Samuel Mahelona Memorial Hospital

All Charges

Charge

Type

Setting

Price

IV KCL 10 MEQ DEX5% .45NACL 1000ML

Facility

$26.00

Hospital Charge Code	8266642
Hospital Revenue Code	258
Min. Negotiated Rate	$22.10
Max. Negotiated Rate	$25.22
Rate for Payer: Cash Price	$16.90
Rate for Payer: Health Management Network Commercial	$22.10
Rate for Payer: Kaiser Permanente Commercial	$23.40
Rate for Payer: MDX Hawaii PPO	$25.22

IV KCL 10 MEQ DEX5% .45NACL 1000ML

Facility

$26.00

Hospital Charge Code	8266642
Hospital Revenue Code	258
Min. Negotiated Rate	$13.00
Max. Negotiated Rate	$25.22
Rate for Payer: AlohaCare Medicaid	$13.00
Rate for Payer: AlohaCare Medicare	$13.00
Rate for Payer: Cash Price	$16.90
Rate for Payer: Devoted Health Medicare	$14.30
Rate for Payer: Hawaii Medical Service Association Medicare	$13.00
Rate for Payer: Hawaii Western Management Group Commercial	$24.70
Rate for Payer: Health Management Network Commercial	$22.10
Rate for Payer: Humana Medicare	$13.00
Rate for Payer: Kaiser Permanente Commercial	$23.40
Rate for Payer: Kaiser Permanente Medicaid	$13.26
Rate for Payer: Kaiser Permanente Medicare	$13.00
Rate for Payer: MDX Hawaii PPO	$25.22
Rate for Payer: Ohana Health Plan Medicaid	$13.00
Rate for Payer: Ohana Health Plan Medicare	$13.00
Rate for Payer: UnitedHealthcare Medicare	$13.00
Rate for Payer: University Health Alliance Commercial	$14.56

IV KCL 20 MEQ .9% NACL 1000ML

Facility

$15.00

Hospital Charge Code	8266512
Hospital Revenue Code	258
Min. Negotiated Rate	$7.50
Max. Negotiated Rate	$14.55
Rate for Payer: AlohaCare Medicaid	$7.50
Rate for Payer: AlohaCare Medicare	$7.50
Rate for Payer: Cash Price	$9.75
Rate for Payer: Devoted Health Medicare	$8.25
Rate for Payer: Hawaii Medical Service Association Medicare	$7.50
Rate for Payer: Hawaii Western Management Group Commercial	$14.25
Rate for Payer: Health Management Network Commercial	$12.75
Rate for Payer: Humana Medicare	$7.50
Rate for Payer: Kaiser Permanente Commercial	$13.50
Rate for Payer: Kaiser Permanente Medicaid	$7.65
Rate for Payer: Kaiser Permanente Medicare	$7.50
Rate for Payer: MDX Hawaii PPO	$14.55
Rate for Payer: Ohana Health Plan Medicaid	$7.50
Rate for Payer: Ohana Health Plan Medicare	$7.50
Rate for Payer: UnitedHealthcare Medicare	$7.50
Rate for Payer: University Health Alliance Commercial	$8.40

IV KCL 20 MEQ .9% NACL 1000ML

Facility

$15.00

Hospital Charge Code	8266512
Hospital Revenue Code	258
Min. Negotiated Rate	$12.75
Max. Negotiated Rate	$14.55
Rate for Payer: Cash Price	$9.75
Rate for Payer: Health Management Network Commercial	$12.75
Rate for Payer: Kaiser Permanente Commercial	$13.50
Rate for Payer: MDX Hawaii PPO	$14.55

IV KCL 20MEQ DEX5% .45%NACL 1000ML

Facility

$15.00

Hospital Charge Code	8266506
Hospital Revenue Code	258
Min. Negotiated Rate	$7.50
Max. Negotiated Rate	$14.55
Rate for Payer: AlohaCare Medicaid	$7.50
Rate for Payer: AlohaCare Medicare	$7.50
Rate for Payer: Cash Price	$9.75
Rate for Payer: Devoted Health Medicare	$8.25
Rate for Payer: Hawaii Medical Service Association Medicare	$7.50
Rate for Payer: Hawaii Western Management Group Commercial	$14.25
Rate for Payer: Health Management Network Commercial	$12.75
Rate for Payer: Humana Medicare	$7.50
Rate for Payer: Kaiser Permanente Commercial	$13.50
Rate for Payer: Kaiser Permanente Medicaid	$7.65
Rate for Payer: Kaiser Permanente Medicare	$7.50
Rate for Payer: MDX Hawaii PPO	$14.55
Rate for Payer: Ohana Health Plan Medicaid	$7.50
Rate for Payer: Ohana Health Plan Medicare	$7.50
Rate for Payer: UnitedHealthcare Medicare	$7.50
Rate for Payer: University Health Alliance Commercial	$8.40

IV KCL 20MEQ DEX5% .45%NACL 1000ML

Facility

$15.00

Hospital Charge Code	8266506
Hospital Revenue Code	258
Min. Negotiated Rate	$12.75
Max. Negotiated Rate	$14.55
Rate for Payer: Cash Price	$9.75
Rate for Payer: Health Management Network Commercial	$12.75
Rate for Payer: Kaiser Permanente Commercial	$13.50
Rate for Payer: MDX Hawaii PPO	$14.55

IV KCL 20 MEQ DEX 5% .9% NACL 1000ML

Facility

$15.00

Hospital Charge Code	8266643
Hospital Revenue Code	258
Min. Negotiated Rate	$12.75
Max. Negotiated Rate	$14.55
Rate for Payer: Cash Price	$9.75
Rate for Payer: Health Management Network Commercial	$12.75
Rate for Payer: Kaiser Permanente Commercial	$13.50
Rate for Payer: MDX Hawaii PPO	$14.55

IV KCL 20 MEQ DEX 5% .9% NACL 1000ML

Facility

$15.00

Hospital Charge Code	8266643
Hospital Revenue Code	258
Min. Negotiated Rate	$7.50
Max. Negotiated Rate	$14.55
Rate for Payer: AlohaCare Medicaid	$7.50
Rate for Payer: AlohaCare Medicare	$7.50
Rate for Payer: Cash Price	$9.75
Rate for Payer: Devoted Health Medicare	$8.25
Rate for Payer: Hawaii Medical Service Association Medicare	$7.50
Rate for Payer: Hawaii Western Management Group Commercial	$14.25
Rate for Payer: Health Management Network Commercial	$12.75
Rate for Payer: Humana Medicare	$7.50
Rate for Payer: Kaiser Permanente Commercial	$13.50
Rate for Payer: Kaiser Permanente Medicaid	$7.65
Rate for Payer: Kaiser Permanente Medicare	$7.50
Rate for Payer: MDX Hawaii PPO	$14.55
Rate for Payer: Ohana Health Plan Medicaid	$7.50
Rate for Payer: Ohana Health Plan Medicare	$7.50
Rate for Payer: UnitedHealthcare Medicare	$7.50
Rate for Payer: University Health Alliance Commercial	$8.40

IV LACTATED RINGER 1000ML

Facility

$11.00

Hospital Charge Code	8266425
Hospital Revenue Code	258
Min. Negotiated Rate	$5.50
Max. Negotiated Rate	$10.67
Rate for Payer: AlohaCare Medicaid	$5.50
Rate for Payer: AlohaCare Medicare	$5.50
Rate for Payer: Cash Price	$7.15
Rate for Payer: Devoted Health Medicare	$6.05
Rate for Payer: Hawaii Medical Service Association Medicare	$5.50
Rate for Payer: Hawaii Western Management Group Commercial	$10.45
Rate for Payer: Health Management Network Commercial	$9.35
Rate for Payer: Humana Medicare	$5.50
Rate for Payer: Kaiser Permanente Commercial	$9.90
Rate for Payer: Kaiser Permanente Medicaid	$5.61
Rate for Payer: Kaiser Permanente Medicare	$5.50
Rate for Payer: MDX Hawaii PPO	$10.67
Rate for Payer: Ohana Health Plan Medicaid	$5.50
Rate for Payer: Ohana Health Plan Medicare	$5.50
Rate for Payer: UnitedHealthcare Medicare	$5.50
Rate for Payer: University Health Alliance Commercial	$6.16

IV LACTATED RINGER 1000ML

Facility

$11.00

Hospital Charge Code	8266425
Hospital Revenue Code	258
Min. Negotiated Rate	$9.35
Max. Negotiated Rate	$10.67
Rate for Payer: Cash Price	$7.15
Rate for Payer: Health Management Network Commercial	$9.35
Rate for Payer: Kaiser Permanente Commercial	$9.90
Rate for Payer: MDX Hawaii PPO	$10.67

J0171 Injection, adrenalin, epinephrine

Professional

Both

$25.00

Service Code	HCPCS J0171
Hospital Charge Code	8041275
Hospital Revenue Code	636
Min. Negotiated Rate	$0.03
Max. Negotiated Rate	$21.25
Rate for Payer: Cash Price	$16.25
Rate for Payer: Cash Price	$16.25
Rate for Payer: Hawaii Western Management Group Commercial	$0.03
Rate for Payer: Health Management Network Commercial	$21.25

J0558 Injection, penicillin g benzathine and penicillin g procaine, 100,000 U

Professional

Both

$0.11

Service Code	HCPCS J0558
Hospital Charge Code	8041281
Hospital Revenue Code	636
Min. Negotiated Rate	$0.09
Max. Negotiated Rate	$23.42
Rate for Payer: AlohaCare Medicare	$19.52
Rate for Payer: Cash Price	$0.07
Rate for Payer: Cash Price	$0.07
Rate for Payer: Devoted Health Medicare	$21.47
Rate for Payer: Hawaii Medical Service Association Medicare	$19.52
Rate for Payer: Hawaii Western Management Group Commercial	$6.18
Rate for Payer: Health Management Network Commercial	$0.09
Rate for Payer: Kaiser Permanente Commercial	$23.42
Rate for Payer: Kaiser Permanente Medicaid	$23.42
Rate for Payer: Kaiser Permanente Medicare	$23.42
Rate for Payer: Ohana Health Plan Medicare	$19.52
Rate for Payer: UnitedHealthcare Medicare	$19.52

J0561 Injection, penicillin g benzathine, 100,000 units

Professional

Both

$58.00

Service Code	HCPCS J0561
Hospital Charge Code	8041282
Hospital Revenue Code	636
Min. Negotiated Rate	$16.36
Max. Negotiated Rate	$49.30
Rate for Payer: AlohaCare Medicare	$31.47
Rate for Payer: Cash Price	$37.70
Rate for Payer: Cash Price	$37.70
Rate for Payer: Devoted Health Medicare	$34.62
Rate for Payer: Hawaii Medical Service Association Medicare	$31.47
Rate for Payer: Hawaii Western Management Group Commercial	$16.36
Rate for Payer: Health Management Network Commercial	$49.30
Rate for Payer: Kaiser Permanente Commercial	$37.76
Rate for Payer: Kaiser Permanente Medicaid	$37.76
Rate for Payer: Kaiser Permanente Medicare	$37.76
Rate for Payer: Ohana Health Plan Medicare	$31.47
Rate for Payer: UnitedHealthcare Medicare	$31.47

J0571 Buprenorphine, oral, 1 mg

Professional

Both

$44.00

Service Code	HCPCS J0571
Hospital Charge Code	8099705
Hospital Revenue Code	636
Min. Negotiated Rate	$37.40
Max. Negotiated Rate	$37.40
Rate for Payer: Cash Price	$28.60
Rate for Payer: Health Management Network Commercial	$37.40

J0696 Injection, ceftriaxone sodium, per 250 mg

Professional

Both

$58.00

Service Code	HCPCS J0696
Hospital Charge Code	8041288
Hospital Revenue Code	636
Min. Negotiated Rate	$0.43
Max. Negotiated Rate	$49.30
Rate for Payer: AlohaCare Medicare	$0.43
Rate for Payer: Cash Price	$37.70
Rate for Payer: Cash Price	$37.70
Rate for Payer: Devoted Health Medicare	$0.47
Rate for Payer: Hawaii Medical Service Association Medicare	$0.43
Rate for Payer: Hawaii Western Management Group Commercial	$10.34
Rate for Payer: Health Management Network Commercial	$49.30
Rate for Payer: Kaiser Permanente Commercial	$0.52
Rate for Payer: Kaiser Permanente Medicaid	$0.52
Rate for Payer: Kaiser Permanente Medicare	$0.52
Rate for Payer: Ohana Health Plan Medicare	$0.43
Rate for Payer: UnitedHealthcare Medicare	$0.43

J0702 Injection, betamethasone acetate 3 mg and betamethasone sodium phosphate 3 mg

Professional

Both

$43.00

Service Code	HCPCS J0702
Hospital Charge Code	8041289
Hospital Revenue Code	636
Min. Negotiated Rate	$6.97
Max. Negotiated Rate	$36.55
Rate for Payer: AlohaCare Medicare	$6.97
Rate for Payer: Cash Price	$27.95
Rate for Payer: Cash Price	$27.95
Rate for Payer: Devoted Health Medicare	$7.67
Rate for Payer: Hawaii Medical Service Association Medicare	$6.97
Rate for Payer: Hawaii Western Management Group Commercial	$7.27
Rate for Payer: Health Management Network Commercial	$36.55
Rate for Payer: Kaiser Permanente Commercial	$8.36
Rate for Payer: Kaiser Permanente Medicaid	$8.36
Rate for Payer: Kaiser Permanente Medicare	$8.36
Rate for Payer: Ohana Health Plan Medicare	$6.97
Rate for Payer: UnitedHealthcare Medicare	$6.97

J0897 Injection, denosumab, 1 mg

Professional

Both

$43.00

Service Code	HCPCS J0897
Hospital Charge Code	8041301
Hospital Revenue Code	636
Min. Negotiated Rate	$17.13
Max. Negotiated Rate	$36.55
Rate for Payer: AlohaCare Medicare	$29.51
Rate for Payer: Cash Price	$27.95
Rate for Payer: Cash Price	$27.95
Rate for Payer: Devoted Health Medicare	$32.46
Rate for Payer: Hawaii Medical Service Association Medicare	$29.51
Rate for Payer: Hawaii Western Management Group Commercial	$17.13
Rate for Payer: Health Management Network Commercial	$36.55
Rate for Payer: Kaiser Permanente Commercial	$35.41
Rate for Payer: Kaiser Permanente Medicaid	$35.41
Rate for Payer: Kaiser Permanente Medicare	$35.41
Rate for Payer: Ohana Health Plan Medicare	$29.51
Rate for Payer: UnitedHealthcare Medicare	$29.51

J1010 Injection, methylprednisolone acetate,40 MG

Professional

Both

$20.00

Service Code	HCPCS J1010
Hospital Charge Code	8041304
Hospital Revenue Code	636
Min. Negotiated Rate	$0.11
Max. Negotiated Rate	$17.00
Rate for Payer: AlohaCare Medicare	$0.11
Rate for Payer: Cash Price	$13.00
Rate for Payer: Cash Price	$13.00
Rate for Payer: Devoted Health Medicare	$0.12
Rate for Payer: Hawaii Medical Service Association Medicare	$0.11
Rate for Payer: Health Management Network Commercial	$17.00
Rate for Payer: Kaiser Permanente Commercial	$0.13
Rate for Payer: Kaiser Permanente Medicaid	$0.13
Rate for Payer: Kaiser Permanente Medicare	$0.13
Rate for Payer: Ohana Health Plan Medicare	$0.11
Rate for Payer: UnitedHealthcare Medicare	$0.11

J1010 Injection, methylprednisolone acetate,80 MG

Professional

Both

$42.00

Service Code	HCPCS J1010
Hospital Charge Code	8041305
Hospital Revenue Code	636
Min. Negotiated Rate	$0.11
Max. Negotiated Rate	$35.70
Rate for Payer: AlohaCare Medicare	$0.11
Rate for Payer: Cash Price	$27.30
Rate for Payer: Cash Price	$27.30
Rate for Payer: Devoted Health Medicare	$0.12
Rate for Payer: Hawaii Medical Service Association Medicare	$0.11
Rate for Payer: Health Management Network Commercial	$35.70
Rate for Payer: Kaiser Permanente Commercial	$0.13
Rate for Payer: Kaiser Permanente Medicaid	$0.13
Rate for Payer: Kaiser Permanente Medicare	$0.13
Rate for Payer: Ohana Health Plan Medicare	$0.11
Rate for Payer: UnitedHealthcare Medicare	$0.11

J1050 Injection, medroxyprogesterone acetate, 1 mg

Professional

Both

$1.00

Service Code	HCPCS J1050
Hospital Charge Code	8041306
Hospital Revenue Code	636
Min. Negotiated Rate	$0.48
Max. Negotiated Rate	$0.85
Rate for Payer: Cash Price	$0.65
Rate for Payer: Cash Price	$0.65
Rate for Payer: Hawaii Western Management Group Commercial	$0.48
Rate for Payer: Health Management Network Commercial	$0.85

J1055 Medroxyprogesterone Acetate for Contraceptive Use 150mg

Professional

Both

$141.00

Hospital Charge Code	8046249
Hospital Revenue Code	636
Min. Negotiated Rate	$119.85
Max. Negotiated Rate	$119.85
Rate for Payer: Cash Price	$91.65
Rate for Payer: Health Management Network Commercial	$119.85

J1100 Injection, dexamethasone sodium phosphate, 1mg

Professional

Both

$25.00

Service Code	HCPCS J1100
Hospital Charge Code	8041308
Hospital Revenue Code	636
Min. Negotiated Rate	$0.07
Max. Negotiated Rate	$21.25
Rate for Payer: AlohaCare Medicare	$0.11
Rate for Payer: Cash Price	$16.25
Rate for Payer: Cash Price	$16.25
Rate for Payer: Devoted Health Medicare	$0.12
Rate for Payer: Hawaii Medical Service Association Medicare	$0.11
Rate for Payer: Hawaii Western Management Group Commercial	$0.07
Rate for Payer: Health Management Network Commercial	$21.25
Rate for Payer: Kaiser Permanente Commercial	$0.13
Rate for Payer: Kaiser Permanente Medicaid	$0.13
Rate for Payer: Kaiser Permanente Medicare	$0.13
Rate for Payer: Ohana Health Plan Medicare	$0.11
Rate for Payer: UnitedHealthcare Medicare	$0.11

J1200 Injection, diphenhydramine hcl, up to 50 mg

Professional

Both

$23.00

Service Code	HCPCS J1200
Hospital Charge Code	8041311
Hospital Revenue Code	636
Min. Negotiated Rate	$0.69
Max. Negotiated Rate	$19.55
Rate for Payer: AlohaCare Medicare	$0.69
Rate for Payer: Cash Price	$14.95
Rate for Payer: Cash Price	$14.95
Rate for Payer: Devoted Health Medicare	$0.76
Rate for Payer: Hawaii Medical Service Association Medicare	$0.69
Rate for Payer: Hawaii Western Management Group Commercial	$1.42
Rate for Payer: Health Management Network Commercial	$19.55
Rate for Payer: Kaiser Permanente Commercial	$0.83
Rate for Payer: Kaiser Permanente Medicaid	$0.83
Rate for Payer: Kaiser Permanente Medicare	$0.83
Rate for Payer: Ohana Health Plan Medicare	$0.69
Rate for Payer: UnitedHealthcare Medicare	$0.69

J1815 Injection, insulin, per 5 units

Professional

Both

$50.00

Service Code	HCPCS J1815
Hospital Charge Code	8084916
Hospital Revenue Code	636
Min. Negotiated Rate	$5.00
Max. Negotiated Rate	$42.50
Rate for Payer: Cash Price	$32.50
Rate for Payer: Cash Price	$32.50
Rate for Payer: Hawaii Western Management Group Commercial	$5.00
Rate for Payer: Health Management Network Commercial	$42.50

J1885 Injection, ketorolac tromethamine, per 15 mg

Professional

Both

$9.00

Service Code	HCPCS J1885
Hospital Charge Code	8041333
Hospital Revenue Code	636
Min. Negotiated Rate	$0.34
Max. Negotiated Rate	$13.19
Rate for Payer: AlohaCare Medicare	$0.34
Rate for Payer: Cash Price	$5.85
Rate for Payer: Cash Price	$5.85
Rate for Payer: Devoted Health Medicare	$0.37
Rate for Payer: Hawaii Medical Service Association Medicare	$0.34
Rate for Payer: Hawaii Western Management Group Commercial	$13.19
Rate for Payer: Health Management Network Commercial	$7.65
Rate for Payer: Kaiser Permanente Commercial	$0.41
Rate for Payer: Kaiser Permanente Medicaid	$0.41
Rate for Payer: Kaiser Permanente Medicare	$0.41
Rate for Payer: Ohana Health Plan Medicare	$0.34
Rate for Payer: UnitedHealthcare Medicare	$0.34

Know your out-of-pocket cost for care.

All Charges