Samuel Mahelona Memorial Hospital

All Charges

Charge

Type

Setting

Price

J2003 Injection, lidocaine hcl, 1 mg

Professional

Both

$65.00

Service Code	HCPCS J2003
Hospital Charge Code	8041337
Hospital Revenue Code	636
Min. Negotiated Rate	$55.25
Max. Negotiated Rate	$55.25
Rate for Payer: Cash Price	$42.25
Rate for Payer: Health Management Network Commercial	$55.25

J2405 Injection, ondansetron hydrochloride, per 1 mg

Professional

Both

$61.00

Service Code	HCPCS J2405
Hospital Charge Code	8041345
Hospital Revenue Code	636
Min. Negotiated Rate	$0.09
Max. Negotiated Rate	$51.85
Rate for Payer: AlohaCare Medicare	$0.09
Rate for Payer: Cash Price	$39.65
Rate for Payer: Cash Price	$39.65
Rate for Payer: Devoted Health Medicare	$0.10
Rate for Payer: Hawaii Medical Service Association Medicare	$0.09
Rate for Payer: Hawaii Western Management Group Commercial	$9.34
Rate for Payer: Health Management Network Commercial	$51.85
Rate for Payer: Kaiser Permanente Commercial	$0.11
Rate for Payer: Kaiser Permanente Medicaid	$0.11
Rate for Payer: Kaiser Permanente Medicare	$0.11
Rate for Payer: Ohana Health Plan Medicare	$0.09
Rate for Payer: UnitedHealthcare Medicare	$0.09

J2550 Injection, promethazine hcl, up to 50 mg

Professional

Both

$20.00

Service Code	HCPCS J2550
Hospital Charge Code	8041350
Hospital Revenue Code	636
Min. Negotiated Rate	$1.87
Max. Negotiated Rate	$17.00
Rate for Payer: AlohaCare Medicare	$3.34
Rate for Payer: Cash Price	$13.00
Rate for Payer: Cash Price	$13.00
Rate for Payer: Devoted Health Medicare	$3.67
Rate for Payer: Hawaii Medical Service Association Medicare	$3.34
Rate for Payer: Hawaii Western Management Group Commercial	$1.87
Rate for Payer: Health Management Network Commercial	$17.00
Rate for Payer: Kaiser Permanente Commercial	$4.01
Rate for Payer: Kaiser Permanente Medicaid	$4.01
Rate for Payer: Kaiser Permanente Medicare	$4.01
Rate for Payer: Ohana Health Plan Medicare	$3.34
Rate for Payer: UnitedHealthcare Medicare	$3.34

J2765 Injection, metoclopramide hcl, up to 10 mg

Professional

Both

$0.01

Service Code	HCPCS J2765
Hospital Charge Code	8041352
Hospital Revenue Code	636
Min. Negotiated Rate	$0.01
Max. Negotiated Rate	$3.00
Rate for Payer: AlohaCare Medicare	$0.95
Rate for Payer: Cash Price	$0.01
Rate for Payer: Cash Price	$0.01
Rate for Payer: Devoted Health Medicare	$1.04
Rate for Payer: Hawaii Medical Service Association Medicare	$0.95
Rate for Payer: Hawaii Western Management Group Commercial	$3.00
Rate for Payer: Health Management Network Commercial	$0.01
Rate for Payer: Kaiser Permanente Commercial	$1.14
Rate for Payer: Kaiser Permanente Medicaid	$1.14
Rate for Payer: Kaiser Permanente Medicare	$1.14
Rate for Payer: Ohana Health Plan Medicare	$0.95
Rate for Payer: UnitedHealthcare Medicare	$0.95

J2765 metoclopramide 10 mg/2 ml vial [HHSC

Professional

Both

$9.00

Service Code	HCPCS J2765
Hospital Charge Code	9364856
Hospital Revenue Code	636
Min. Negotiated Rate	$0.95
Max. Negotiated Rate	$7.65
Rate for Payer: AlohaCare Medicare	$0.95
Rate for Payer: Cash Price	$5.85
Rate for Payer: Cash Price	$5.85
Rate for Payer: Devoted Health Medicare	$1.04
Rate for Payer: Hawaii Medical Service Association Medicare	$0.95
Rate for Payer: Hawaii Western Management Group Commercial	$3.00
Rate for Payer: Health Management Network Commercial	$7.65
Rate for Payer: Kaiser Permanente Commercial	$1.14
Rate for Payer: Kaiser Permanente Medicaid	$1.14
Rate for Payer: Kaiser Permanente Medicare	$1.14
Rate for Payer: Ohana Health Plan Medicare	$0.95
Rate for Payer: UnitedHealthcare Medicare	$0.95

J2790 Injection, rho d immune globulin, human, full dose, 300 micrograms (1500 i.u.)

Professional

Both

$211.00

Service Code	HCPCS J2790
Hospital Charge Code	8041357
Hospital Revenue Code	636
Min. Negotiated Rate	$55.00
Max. Negotiated Rate	$179.35
Rate for Payer: AlohaCare Medicare	$78.90
Rate for Payer: Cash Price	$137.15
Rate for Payer: Cash Price	$137.15
Rate for Payer: Devoted Health Medicare	$86.79
Rate for Payer: Hawaii Medical Service Association Medicare	$78.90
Rate for Payer: Hawaii Western Management Group Commercial	$55.00
Rate for Payer: Health Management Network Commercial	$179.35
Rate for Payer: Kaiser Permanente Commercial	$94.68
Rate for Payer: Kaiser Permanente Medicaid	$94.68
Rate for Payer: Kaiser Permanente Medicare	$94.68
Rate for Payer: Ohana Health Plan Medicare	$78.90
Rate for Payer: UnitedHealthcare Medicare	$78.90

J2919 Injection, methylprednisolone sodium succina

Professional

Both

$28.00

Service Code	HCPCS J2919
Hospital Charge Code	8041361
Hospital Revenue Code	636
Min. Negotiated Rate	$0.24
Max. Negotiated Rate	$23.80
Rate for Payer: AlohaCare Medicare	$0.24
Rate for Payer: Cash Price	$18.20
Rate for Payer: Cash Price	$18.20
Rate for Payer: Devoted Health Medicare	$0.26
Rate for Payer: Hawaii Medical Service Association Medicare	$0.24
Rate for Payer: Health Management Network Commercial	$23.80
Rate for Payer: Kaiser Permanente Commercial	$0.29
Rate for Payer: Kaiser Permanente Medicaid	$0.29
Rate for Payer: Kaiser Permanente Medicare	$0.29
Rate for Payer: Ohana Health Plan Medicare	$0.24
Rate for Payer: UnitedHealthcare Medicare	$0.24

J2919 Methylprednisolone Sodium Succinate 125mg

Professional

Both

$2.00

Service Code	HCPCS J2919
Hospital Charge Code	11915212
Hospital Revenue Code	636
Min. Negotiated Rate	$0.24
Max. Negotiated Rate	$1.70
Rate for Payer: AlohaCare Medicare	$0.24
Rate for Payer: Cash Price	$1.30
Rate for Payer: Cash Price	$1.30
Rate for Payer: Devoted Health Medicare	$0.26
Rate for Payer: Hawaii Medical Service Association Medicare	$0.24
Rate for Payer: Health Management Network Commercial	$1.70
Rate for Payer: Kaiser Permanente Commercial	$0.29
Rate for Payer: Kaiser Permanente Medicaid	$0.29
Rate for Payer: Kaiser Permanente Medicare	$0.29
Rate for Payer: Ohana Health Plan Medicare	$0.24
Rate for Payer: UnitedHealthcare Medicare	$0.24

J3111 injection, Evenity 1mg (105mg per 1.17ml)

Professional

Both

$39.00

Service Code	HCPCS J3111
Hospital Charge Code	10140104
Hospital Revenue Code	636
Min. Negotiated Rate	$12.19
Max. Negotiated Rate	$33.15
Rate for Payer: AlohaCare Medicare	$12.19
Rate for Payer: Cash Price	$25.35
Rate for Payer: Cash Price	$25.35
Rate for Payer: Devoted Health Medicare	$13.41
Rate for Payer: Hawaii Medical Service Association Medicare	$12.19
Rate for Payer: Health Management Network Commercial	$33.15
Rate for Payer: Kaiser Permanente Commercial	$14.63
Rate for Payer: Kaiser Permanente Medicaid	$14.63
Rate for Payer: Kaiser Permanente Medicare	$14.63
Rate for Payer: Ohana Health Plan Medicare	$12.19
Rate for Payer: UnitedHealthcare Medicare	$12.19

J3301 Injection, triamcinolone acetonide, not otherwise specified, 10 mg

Professional

Both

$26.00

Service Code	HCPCS J3301
Hospital Charge Code	8041368
Hospital Revenue Code	636
Min. Negotiated Rate	$0.90
Max. Negotiated Rate	$22.10
Rate for Payer: AlohaCare Medicare	$0.90
Rate for Payer: Cash Price	$16.90
Rate for Payer: Cash Price	$16.90
Rate for Payer: Devoted Health Medicare	$0.99
Rate for Payer: Hawaii Medical Service Association Medicare	$0.90
Rate for Payer: Hawaii Western Management Group Commercial	$6.69
Rate for Payer: Health Management Network Commercial	$22.10
Rate for Payer: Kaiser Permanente Commercial	$1.08
Rate for Payer: Kaiser Permanente Medicaid	$1.08
Rate for Payer: Kaiser Permanente Medicare	$1.08
Rate for Payer: Ohana Health Plan Medicare	$0.90
Rate for Payer: UnitedHealthcare Medicare	$0.90

J3410 Injection, hydroxyzine hcl, up to 25 mg

Professional

Both

$23.00

Service Code	HCPCS J3410
Hospital Charge Code	8041373
Hospital Revenue Code	636
Min. Negotiated Rate	$1.03
Max. Negotiated Rate	$19.55
Rate for Payer: AlohaCare Medicare	$15.17
Rate for Payer: Cash Price	$14.95
Rate for Payer: Cash Price	$14.95
Rate for Payer: Devoted Health Medicare	$16.69
Rate for Payer: Hawaii Medical Service Association Medicare	$15.17
Rate for Payer: Hawaii Western Management Group Commercial	$1.03
Rate for Payer: Health Management Network Commercial	$19.55
Rate for Payer: Kaiser Permanente Commercial	$18.20
Rate for Payer: Kaiser Permanente Medicaid	$18.20
Rate for Payer: Kaiser Permanente Medicare	$18.20
Rate for Payer: Ohana Health Plan Medicare	$15.17
Rate for Payer: UnitedHealthcare Medicare	$15.17

J3420 Injection, vitamin b-12, up to 1000mcg

Professional

Both

$23.00

Service Code	HCPCS J3420
Hospital Charge Code	8041375
Hospital Revenue Code	636
Min. Negotiated Rate	$0.67
Max. Negotiated Rate	$19.55
Rate for Payer: AlohaCare Medicare	$0.67
Rate for Payer: Cash Price	$14.95
Rate for Payer: Cash Price	$14.95
Rate for Payer: Devoted Health Medicare	$0.74
Rate for Payer: Hawaii Medical Service Association Medicare	$0.67
Rate for Payer: Hawaii Western Management Group Commercial	$1.13
Rate for Payer: Health Management Network Commercial	$19.55
Rate for Payer: Kaiser Permanente Commercial	$0.80
Rate for Payer: Kaiser Permanente Medicaid	$0.80
Rate for Payer: Kaiser Permanente Medicare	$0.80
Rate for Payer: Ohana Health Plan Medicare	$0.67
Rate for Payer: UnitedHealthcare Medicare	$0.67

J7040 Infusion, normal saline solution, sterile (500 ml=1 unit)

Professional

Both

$28.00

Service Code	HCPCS J7040
Hospital Charge Code	8041381
Hospital Revenue Code	636
Min. Negotiated Rate	$1.36
Max. Negotiated Rate	$23.80
Rate for Payer: AlohaCare Medicare	$1.36
Rate for Payer: Cash Price	$18.20
Rate for Payer: Cash Price	$18.20
Rate for Payer: Devoted Health Medicare	$1.50
Rate for Payer: Hawaii Medical Service Association Medicare	$1.36
Rate for Payer: Hawaii Western Management Group Commercial	$1.62
Rate for Payer: Health Management Network Commercial	$23.80
Rate for Payer: Kaiser Permanente Commercial	$1.63
Rate for Payer: Kaiser Permanente Medicaid	$1.63
Rate for Payer: Kaiser Permanente Medicare	$1.63
Rate for Payer: Ohana Health Plan Medicare	$1.36
Rate for Payer: UnitedHealthcare Medicare	$1.36

J7298 Levonorgestrel-releasing intrauterine contraceptive system, 52 mg

Professional

Both

$2,921.00

Service Code	HCPCS J7298
Hospital Charge Code	8041387
Hospital Revenue Code	636
Min. Negotiated Rate	$981.68
Max. Negotiated Rate	$2,482.85
Rate for Payer: Cash Price	$1,898.65
Rate for Payer: Cash Price	$1,898.65
Rate for Payer: Hawaii Western Management Group Commercial	$981.68
Rate for Payer: Health Management Network Commercial	$2,482.85

J7300 Intrauterine copper contraceptive

Professional

Both

$1,140.00

Service Code	HCPCS J7300
Hospital Charge Code	8041388
Hospital Revenue Code	636
Min. Negotiated Rate	$873.18
Max. Negotiated Rate	$969.00
Rate for Payer: Cash Price	$741.00
Rate for Payer: Cash Price	$741.00
Rate for Payer: Hawaii Western Management Group Commercial	$873.18
Rate for Payer: Health Management Network Commercial	$969.00

J7307 Etonogestrel (contraceptive) implant system, including implant and supplies

Facility

$1,729.00

Service Code	HCPCS J7307
Hospital Charge Code	8041390
Hospital Revenue Code	250
Min. Negotiated Rate	$864.50
Max. Negotiated Rate	$1,677.13
Rate for Payer: AlohaCare Medicaid	$864.50
Rate for Payer: AlohaCare Medicare	$864.50
Rate for Payer: Cash Price	$1,123.85
Rate for Payer: Cash Price	$1,123.85
Rate for Payer: Devoted Health Medicare	$950.95
Rate for Payer: Hawaii Medical Service Association ABD	$1,214.63
Rate for Payer: Hawaii Medical Service Association Medicare	$864.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$1,214.63
Rate for Payer: Hawaii Western Management Group Commercial	$1,642.55
Rate for Payer: Health Management Network Commercial	$1,469.65
Rate for Payer: Humana Medicare	$864.50
Rate for Payer: Kaiser Permanente Commercial	$1,556.10
Rate for Payer: Kaiser Permanente Medicaid	$881.79
Rate for Payer: Kaiser Permanente Medicare	$864.50
Rate for Payer: MDX Hawaii PPO	$1,677.13
Rate for Payer: Ohana Health Plan Medicaid	$864.50
Rate for Payer: Ohana Health Plan Medicare	$864.50
Rate for Payer: UnitedHealthcare Medicaid	$1,037.40
Rate for Payer: UnitedHealthcare Medicare	$864.50
Rate for Payer: University Health Alliance Commercial	$1,260.27

J7307 Etonogestrel (contraceptive) implant system, including implant and supplies

Facility

$1,729.00

Service Code	HCPCS J7307
Hospital Charge Code	8041390
Hospital Revenue Code	250
Min. Negotiated Rate	$1,469.65
Max. Negotiated Rate	$1,677.13
Rate for Payer: Cash Price	$1,123.85
Rate for Payer: Health Management Network Commercial	$1,469.65
Rate for Payer: Kaiser Permanente Commercial	$1,556.10
Rate for Payer: MDX Hawaii PPO	$1,677.13

J7307 Etonogestrel (contraceptive) implant system, including implant and supplies

Professional

Both

$2,495.00

Service Code	HCPCS J7307
Hospital Charge Code	8041390
Hospital Revenue Code	636
Min. Negotiated Rate	$915.73
Max. Negotiated Rate	$2,120.75
Rate for Payer: Cash Price	$1,621.75
Rate for Payer: Cash Price	$1,621.75
Rate for Payer: Hawaii Western Management Group Commercial	$915.73
Rate for Payer: Health Management Network Commercial	$2,120.75

J7321 PT SUPPLIED Injections, Hyaluronan or derivative, hyalgan or supartz, intra-articular, per dos

Professional

Both

$0.01

Service Code	HCPCS J7321
Hospital Charge Code	13323475
Hospital Revenue Code	636
Min. Negotiated Rate	$0.01
Max. Negotiated Rate	$143.46
Rate for Payer: AlohaCare Medicaid	$102.06
Rate for Payer: AlohaCare Medicare	$74.43
Rate for Payer: Cash Price	$0.01
Rate for Payer: Cash Price	$0.01
Rate for Payer: Devoted Health Medicare	$81.87
Rate for Payer: Hawaii Medical Service Association Medicare	$74.43
Rate for Payer: Hawaii Western Management Group Commercial	$143.46
Rate for Payer: Health Management Network Commercial	$0.01
Rate for Payer: Kaiser Permanente Commercial	$89.32
Rate for Payer: Kaiser Permanente Medicaid	$89.32
Rate for Payer: Kaiser Permanente Medicare	$89.32
Rate for Payer: Ohana Health Plan Medicaid	$102.06
Rate for Payer: Ohana Health Plan Medicare	$74.43
Rate for Payer: UnitedHealthcare Medicaid	$102.06
Rate for Payer: UnitedHealthcare Medicare	$74.43

J7323 PT SUPPLIED Injection, Hyaluronan or derivative, euflexxa, intra-articular, per dose

Professional

Both

$0.01

Service Code	HCPCS J7323
Hospital Charge Code	13303114
Hospital Revenue Code	636
Min. Negotiated Rate	$0.01
Max. Negotiated Rate	$269.81
Rate for Payer: AlohaCare Medicaid	$110.87
Rate for Payer: AlohaCare Medicare	$105.58
Rate for Payer: Cash Price	$0.01
Rate for Payer: Cash Price	$0.01
Rate for Payer: Devoted Health Medicare	$116.14
Rate for Payer: Hawaii Medical Service Association Medicare	$105.58
Rate for Payer: Hawaii Western Management Group Commercial	$269.81
Rate for Payer: Health Management Network Commercial	$0.01
Rate for Payer: Kaiser Permanente Commercial	$126.70
Rate for Payer: Kaiser Permanente Medicaid	$126.70
Rate for Payer: Kaiser Permanente Medicare	$126.70
Rate for Payer: Ohana Health Plan Medicaid	$110.87
Rate for Payer: Ohana Health Plan Medicare	$105.58
Rate for Payer: UnitedHealthcare Medicaid	$110.87
Rate for Payer: UnitedHealthcare Medicare	$105.58

J7325 PT SUPPLIED Hyaluronan or derivative, synvisc or synvisc-one, for intra-articular injection, 1

Professional

Both

$0.01

Service Code	HCPCS J7325
Hospital Charge Code	13323474
Hospital Revenue Code	636
Min. Negotiated Rate	$0.01
Max. Negotiated Rate	$26.66
Rate for Payer: AlohaCare Medicare	$6.96
Rate for Payer: Cash Price	$0.01
Rate for Payer: Cash Price	$0.01
Rate for Payer: Devoted Health Medicare	$7.66
Rate for Payer: Hawaii Medical Service Association Medicare	$6.96
Rate for Payer: Hawaii Western Management Group Commercial	$26.66
Rate for Payer: Health Management Network Commercial	$0.01
Rate for Payer: Kaiser Permanente Commercial	$8.35
Rate for Payer: Kaiser Permanente Medicaid	$8.35
Rate for Payer: Kaiser Permanente Medicare	$8.35
Rate for Payer: Ohana Health Plan Medicare	$6.96
Rate for Payer: UnitedHealthcare Medicare	$6.96

J7613 Albuterol, 0.083%, 2.5mg/3mL

Professional

Both

$5.00

Service Code	HCPCS J7613
Hospital Charge Code	8741661
Hospital Revenue Code	636
Min. Negotiated Rate	$0.08
Max. Negotiated Rate	$4.25
Rate for Payer: AlohaCare Medicare	$0.08
Rate for Payer: Cash Price	$3.25
Rate for Payer: Cash Price	$3.25
Rate for Payer: Devoted Health Medicare	$0.09
Rate for Payer: Hawaii Medical Service Association Medicare	$0.08
Rate for Payer: Hawaii Western Management Group Commercial	$2.34
Rate for Payer: Health Management Network Commercial	$4.25
Rate for Payer: Kaiser Permanente Commercial	$0.10
Rate for Payer: Kaiser Permanente Medicaid	$0.10
Rate for Payer: Kaiser Permanente Medicare	$0.10
Rate for Payer: Ohana Health Plan Medicare	$0.08
Rate for Payer: UnitedHealthcare Medicare	$0.08

J7620 Albuterol, up to 2.5 mg and ipratropium bromide, up to 0.5 mg, administered through dme

Professional

Both

$11.00

Service Code	HCPCS J7620
Hospital Charge Code	8041404
Hospital Revenue Code	636
Min. Negotiated Rate	$0.21
Max. Negotiated Rate	$9.35
Rate for Payer: AlohaCare Medicare	$0.21
Rate for Payer: Cash Price	$7.15
Rate for Payer: Cash Price	$7.15
Rate for Payer: Devoted Health Medicare	$0.23
Rate for Payer: Hawaii Medical Service Association Medicare	$0.21
Rate for Payer: Hawaii Western Management Group Commercial	$0.74
Rate for Payer: Health Management Network Commercial	$9.35
Rate for Payer: Kaiser Permanente Commercial	$0.25
Rate for Payer: Kaiser Permanente Medicaid	$0.25
Rate for Payer: Kaiser Permanente Medicare	$0.25
Rate for Payer: Ohana Health Plan Medicare	$0.21
Rate for Payer: UnitedHealthcare Medicare	$0.21

J8540 Dexamethasone, oral, 0.25 mg

Professional

Both

$10.00

Service Code	HCPCS J8540
Hospital Charge Code	8100573
Hospital Revenue Code	636
Min. Negotiated Rate	$0.03
Max. Negotiated Rate	$8.50
Rate for Payer: AlohaCare Medicare	$0.03
Rate for Payer: Cash Price	$6.50
Rate for Payer: Cash Price	$6.50
Rate for Payer: Devoted Health Medicare	$0.03
Rate for Payer: Hawaii Medical Service Association Medicare	$0.03
Rate for Payer: Health Management Network Commercial	$8.50
Rate for Payer: Kaiser Permanente Commercial	$0.04
Rate for Payer: Kaiser Permanente Medicaid	$0.04
Rate for Payer: Kaiser Permanente Medicare	$0.04
Rate for Payer: Ohana Health Plan Medicare	$0.03
Rate for Payer: UnitedHealthcare Medicare	$0.03

JADA SYSTEM 2.0

Facility

$2,700.00

Hospital Charge Code	10039741
Hospital Revenue Code	272
Min. Negotiated Rate	$2,295.00
Max. Negotiated Rate	$2,619.00
Rate for Payer: Cash Price	$1,755.00
Rate for Payer: Health Management Network Commercial	$2,295.00
Rate for Payer: Kaiser Permanente Commercial	$2,430.00
Rate for Payer: MDX Hawaii PPO	$2,619.00

Know your out-of-pocket cost for care.

All Charges