Samuel Mahelona Memorial Hospital

All Charges

Charge

Type

Setting

Price

JADA SYSTEM 2.0

Facility

$2,700.00

Hospital Charge Code	10039741
Hospital Revenue Code	272
Min. Negotiated Rate	$1,350.00
Max. Negotiated Rate	$2,619.00
Rate for Payer: AlohaCare Medicaid	$1,350.00
Rate for Payer: AlohaCare Medicare	$1,350.00
Rate for Payer: Cash Price	$1,755.00
Rate for Payer: Devoted Health Medicare	$1,485.00
Rate for Payer: Hawaii Medical Service Association Medicare	$1,350.00
Rate for Payer: Hawaii Western Management Group Commercial	$2,565.00
Rate for Payer: Health Management Network Commercial	$2,295.00
Rate for Payer: Humana Medicare	$1,350.00
Rate for Payer: Kaiser Permanente Commercial	$2,430.00
Rate for Payer: Kaiser Permanente Medicaid	$1,377.00
Rate for Payer: Kaiser Permanente Medicare	$1,350.00
Rate for Payer: MDX Hawaii PPO	$2,619.00
Rate for Payer: Ohana Health Plan Medicaid	$1,350.00
Rate for Payer: Ohana Health Plan Medicare	$1,350.00
Rate for Payer: UnitedHealthcare Medicare	$1,350.00
Rate for Payer: University Health Alliance Commercial	$1,968.03

JAK2 Exon 12 Mutation Analysis

Facility

$1,360.00

Service Code	HCPCS 81279
Hospital Charge Code	12514691
Hospital Revenue Code	300
Min. Negotiated Rate	$1,156.00
Max. Negotiated Rate	$1,319.20
Rate for Payer: Cash Price	$884.00
Rate for Payer: Health Management Network Commercial	$1,156.00
Rate for Payer: Kaiser Permanente Commercial	$1,224.00
Rate for Payer: MDX Hawaii PPO	$1,319.20

JAK2 Exon 12 Mutation Analysis

Facility

$1,360.00

Service Code	HCPCS 81279
Hospital Charge Code	12514691
Hospital Revenue Code	300
Min. Negotiated Rate	$111.12
Max. Negotiated Rate	$1,319.20
Rate for Payer: AlohaCare Medicaid	$680.00
Rate for Payer: AlohaCare Medicare	$680.00
Rate for Payer: Cash Price	$884.00
Rate for Payer: Cash Price	$884.00
Rate for Payer: Devoted Health Medicare	$748.00
Rate for Payer: Hawaii Medical Service Association ABD	$185.20
Rate for Payer: Hawaii Medical Service Association Commercial	$231.50
Rate for Payer: Hawaii Medical Service Association Medicare	$680.00
Rate for Payer: Hawaii Medical Service Association Non-ABD	$185.20
Rate for Payer: Hawaii Western Management Group Commercial	$185.20
Rate for Payer: Health Management Network Commercial	$1,156.00
Rate for Payer: Humana Medicare	$680.00
Rate for Payer: Kaiser Permanente Commercial	$1,224.00
Rate for Payer: Kaiser Permanente Medicaid	$693.60
Rate for Payer: Kaiser Permanente Medicare	$680.00
Rate for Payer: MDX Hawaii PPO	$1,319.20
Rate for Payer: Ohana Health Plan Medicaid	$680.00
Rate for Payer: Ohana Health Plan Medicare	$680.00
Rate for Payer: UnitedHealthcare Medicaid	$111.12
Rate for Payer: UnitedHealthcare Medicare	$680.00
Rate for Payer: University Health Alliance Commercial	$761.60

.JAK2 Exon 12 Mutations FSI

Facility

$514.00

Service Code	HCPCS 81279
Hospital Charge Code	10593921
Hospital Revenue Code	310
Min. Negotiated Rate	$111.12
Max. Negotiated Rate	$498.58
Rate for Payer: AlohaCare Medicaid	$257.00
Rate for Payer: AlohaCare Medicare	$257.00
Rate for Payer: Cash Price	$334.10
Rate for Payer: Cash Price	$334.10
Rate for Payer: Devoted Health Medicare	$282.70
Rate for Payer: Hawaii Medical Service Association ABD	$185.20
Rate for Payer: Hawaii Medical Service Association Commercial	$231.50
Rate for Payer: Hawaii Medical Service Association Medicare	$257.00
Rate for Payer: Hawaii Medical Service Association Non-ABD	$185.20
Rate for Payer: Hawaii Western Management Group Commercial	$185.20
Rate for Payer: Health Management Network Commercial	$436.90
Rate for Payer: Humana Medicare	$257.00
Rate for Payer: Kaiser Permanente Commercial	$462.60
Rate for Payer: Kaiser Permanente Medicaid	$262.14
Rate for Payer: Kaiser Permanente Medicare	$257.00
Rate for Payer: MDX Hawaii PPO	$498.58
Rate for Payer: Ohana Health Plan Medicaid	$257.00
Rate for Payer: Ohana Health Plan Medicare	$257.00
Rate for Payer: UnitedHealthcare Medicaid	$111.12
Rate for Payer: UnitedHealthcare Medicare	$257.00
Rate for Payer: University Health Alliance Commercial	$287.84

.JAK2 Exon 12 Mutations FSI

Facility

$514.00

Service Code	HCPCS 81279
Hospital Charge Code	10593921
Hospital Revenue Code	310
Min. Negotiated Rate	$436.90
Max. Negotiated Rate	$498.58
Rate for Payer: Cash Price	$334.10
Rate for Payer: Health Management Network Commercial	$436.90
Rate for Payer: Kaiser Permanente Commercial	$462.60
Rate for Payer: MDX Hawaii PPO	$498.58

JAK2 Mut Rfx CALR MPL FSI

Facility

$520.00

Service Code	HCPCS 81270
Hospital Charge Code	10596933
Hospital Revenue Code	310
Min. Negotiated Rate	$442.00
Max. Negotiated Rate	$504.40
Rate for Payer: Cash Price	$338.00
Rate for Payer: Health Management Network Commercial	$442.00
Rate for Payer: Kaiser Permanente Commercial	$468.00
Rate for Payer: MDX Hawaii PPO	$504.40

JAK2 Mut Rfx CALR MPL FSI

Facility

$520.00

Service Code	HCPCS 81270
Hospital Charge Code	10596933
Hospital Revenue Code	310
Min. Negotiated Rate	$49.73
Max. Negotiated Rate	$504.40
Rate for Payer: AlohaCare Medicaid	$260.00
Rate for Payer: AlohaCare Medicare	$260.00
Rate for Payer: Cash Price	$338.00
Rate for Payer: Cash Price	$338.00
Rate for Payer: Devoted Health Medicare	$286.00
Rate for Payer: Hawaii Medical Service Association ABD	$122.70
Rate for Payer: Hawaii Medical Service Association Commercial	$114.58
Rate for Payer: Hawaii Medical Service Association Medicare	$260.00
Rate for Payer: Hawaii Medical Service Association Non-ABD	$122.70
Rate for Payer: Hawaii Western Management Group Commercial	$91.66
Rate for Payer: Health Management Network Commercial	$442.00
Rate for Payer: Humana Medicare	$260.00
Rate for Payer: Kaiser Permanente Commercial	$468.00
Rate for Payer: Kaiser Permanente Medicaid	$265.20
Rate for Payer: Kaiser Permanente Medicare	$260.00
Rate for Payer: MDX Hawaii PPO	$504.40
Rate for Payer: Ohana Health Plan Medicaid	$260.00
Rate for Payer: Ohana Health Plan Medicare	$260.00
Rate for Payer: UnitedHealthcare Medicaid	$49.73
Rate for Payer: UnitedHealthcare Medicare	$260.00
Rate for Payer: University Health Alliance Commercial	$230.79

JAK2 V617F Mutation FSI

Facility

$445.00

Service Code	HCPCS 81270
Hospital Charge Code	8808649
Hospital Revenue Code	309
Min. Negotiated Rate	$49.73
Max. Negotiated Rate	$431.65
Rate for Payer: AlohaCare Medicaid	$222.50
Rate for Payer: AlohaCare Medicare	$222.50
Rate for Payer: Cash Price	$289.25
Rate for Payer: Cash Price	$289.25
Rate for Payer: Devoted Health Medicare	$244.75
Rate for Payer: Hawaii Medical Service Association ABD	$122.70
Rate for Payer: Hawaii Medical Service Association Commercial	$114.58
Rate for Payer: Hawaii Medical Service Association Medicare	$222.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$122.70
Rate for Payer: Hawaii Western Management Group Commercial	$91.66
Rate for Payer: Health Management Network Commercial	$378.25
Rate for Payer: Humana Medicare	$222.50
Rate for Payer: Kaiser Permanente Commercial	$400.50
Rate for Payer: Kaiser Permanente Medicaid	$226.95
Rate for Payer: Kaiser Permanente Medicare	$222.50
Rate for Payer: MDX Hawaii PPO	$431.65
Rate for Payer: Ohana Health Plan Medicaid	$222.50
Rate for Payer: Ohana Health Plan Medicare	$222.50
Rate for Payer: UnitedHealthcare Medicaid	$49.73
Rate for Payer: UnitedHealthcare Medicare	$222.50
Rate for Payer: University Health Alliance Commercial	$230.79

JAK2 V617F Mutation FSI

Facility

$445.00

Service Code	HCPCS 81270
Hospital Charge Code	8808649
Hospital Revenue Code	309
Min. Negotiated Rate	$378.25
Max. Negotiated Rate	$431.65
Rate for Payer: Cash Price	$289.25
Rate for Payer: Health Management Network Commercial	$378.25
Rate for Payer: Kaiser Permanente Commercial	$400.50
Rate for Payer: MDX Hawaii PPO	$431.65

JAK2 V617F Rfx Exon 12 FSI

Facility

$630.00

Service Code	HCPCS 81270
Hospital Charge Code	10593920
Hospital Revenue Code	310
Min. Negotiated Rate	$535.50
Max. Negotiated Rate	$611.10
Rate for Payer: Cash Price	$409.50
Rate for Payer: Health Management Network Commercial	$535.50
Rate for Payer: Kaiser Permanente Commercial	$567.00
Rate for Payer: MDX Hawaii PPO	$611.10

JAK2 V617F Rfx Exon 12 FSI

Facility

$630.00

Service Code	HCPCS 81270
Hospital Charge Code	10593920
Hospital Revenue Code	310
Min. Negotiated Rate	$49.73
Max. Negotiated Rate	$611.10
Rate for Payer: AlohaCare Medicaid	$315.00
Rate for Payer: AlohaCare Medicare	$315.00
Rate for Payer: Cash Price	$409.50
Rate for Payer: Cash Price	$409.50
Rate for Payer: Devoted Health Medicare	$346.50
Rate for Payer: Hawaii Medical Service Association ABD	$122.70
Rate for Payer: Hawaii Medical Service Association Commercial	$114.58
Rate for Payer: Hawaii Medical Service Association Medicare	$315.00
Rate for Payer: Hawaii Medical Service Association Non-ABD	$122.70
Rate for Payer: Hawaii Western Management Group Commercial	$91.66
Rate for Payer: Health Management Network Commercial	$535.50
Rate for Payer: Humana Medicare	$315.00
Rate for Payer: Kaiser Permanente Commercial	$567.00
Rate for Payer: Kaiser Permanente Medicaid	$321.30
Rate for Payer: Kaiser Permanente Medicare	$315.00
Rate for Payer: MDX Hawaii PPO	$611.10
Rate for Payer: Ohana Health Plan Medicaid	$315.00
Rate for Payer: Ohana Health Plan Medicare	$315.00
Rate for Payer: UnitedHealthcare Medicaid	$49.73
Rate for Payer: UnitedHealthcare Medicare	$315.00
Rate for Payer: University Health Alliance Commercial	$230.79

Janssen Vaccine 0031A - Janssen Vaccine Admin Charge

Facility

$101.00

Service Code	HCPCS 0031A
Hospital Charge Code	9628231
Hospital Revenue Code	771
Min. Negotiated Rate	$50.50
Max. Negotiated Rate	$97.97
Rate for Payer: AlohaCare Medicaid	$50.50
Rate for Payer: AlohaCare Medicare	$50.50
Rate for Payer: Cash Price	$65.65
Rate for Payer: Devoted Health Medicare	$55.55
Rate for Payer: Hawaii Medical Service Association Medicare	$50.50
Rate for Payer: Hawaii Western Management Group Commercial	$95.95
Rate for Payer: Health Management Network Commercial	$85.85
Rate for Payer: Humana Medicare	$50.50
Rate for Payer: Kaiser Permanente Commercial	$90.90
Rate for Payer: Kaiser Permanente Medicaid	$51.51
Rate for Payer: Kaiser Permanente Medicare	$50.50
Rate for Payer: MDX Hawaii PPO	$97.97
Rate for Payer: Ohana Health Plan Medicaid	$50.50
Rate for Payer: Ohana Health Plan Medicare	$50.50
Rate for Payer: UnitedHealthcare Medicare	$50.50
Rate for Payer: University Health Alliance Commercial	$56.56

Janssen Vaccine 0031A - Janssen Vaccine Admin Charge

Facility

$101.00

Service Code	HCPCS 0031A
Hospital Charge Code	9628231
Hospital Revenue Code	771
Min. Negotiated Rate	$85.85
Max. Negotiated Rate	$97.97
Rate for Payer: Cash Price	$65.65
Rate for Payer: Health Management Network Commercial	$85.85
Rate for Payer: Kaiser Permanente Commercial	$90.90
Rate for Payer: MDX Hawaii PPO	$97.97

JP DRAIN 15F ROUND

Facility

$39.00

Hospital Charge Code	8479432
Hospital Revenue Code	272
Min. Negotiated Rate	$33.15
Max. Negotiated Rate	$37.83
Rate for Payer: Cash Price	$25.35
Rate for Payer: Health Management Network Commercial	$33.15
Rate for Payer: Kaiser Permanente Commercial	$35.10
Rate for Payer: MDX Hawaii PPO	$37.83

JP DRAIN 15F ROUND

Facility

$39.00

Hospital Charge Code	8479432
Hospital Revenue Code	272
Min. Negotiated Rate	$19.50
Max. Negotiated Rate	$37.83
Rate for Payer: AlohaCare Medicaid	$19.50
Rate for Payer: AlohaCare Medicare	$19.50
Rate for Payer: Cash Price	$25.35
Rate for Payer: Devoted Health Medicare	$21.45
Rate for Payer: Hawaii Medical Service Association Medicare	$19.50
Rate for Payer: Hawaii Western Management Group Commercial	$37.05
Rate for Payer: Health Management Network Commercial	$33.15
Rate for Payer: Humana Medicare	$19.50
Rate for Payer: Kaiser Permanente Commercial	$35.10
Rate for Payer: Kaiser Permanente Medicaid	$19.89
Rate for Payer: Kaiser Permanente Medicare	$19.50
Rate for Payer: MDX Hawaii PPO	$37.83
Rate for Payer: Ohana Health Plan Medicaid	$19.50
Rate for Payer: Ohana Health Plan Medicare	$19.50
Rate for Payer: UnitedHealthcare Medicare	$19.50
Rate for Payer: University Health Alliance Commercial	$28.43

JP RESERVOIR 100ML

Facility

$55.00

Hospital Charge Code	8479433
Hospital Revenue Code	272
Min. Negotiated Rate	$27.50
Max. Negotiated Rate	$53.35
Rate for Payer: AlohaCare Medicaid	$27.50
Rate for Payer: AlohaCare Medicare	$27.50
Rate for Payer: Cash Price	$35.75
Rate for Payer: Devoted Health Medicare	$30.25
Rate for Payer: Hawaii Medical Service Association Medicare	$27.50
Rate for Payer: Hawaii Western Management Group Commercial	$52.25
Rate for Payer: Health Management Network Commercial	$46.75
Rate for Payer: Humana Medicare	$27.50
Rate for Payer: Kaiser Permanente Commercial	$49.50
Rate for Payer: Kaiser Permanente Medicaid	$28.05
Rate for Payer: Kaiser Permanente Medicare	$27.50
Rate for Payer: MDX Hawaii PPO	$53.35
Rate for Payer: Ohana Health Plan Medicaid	$27.50
Rate for Payer: Ohana Health Plan Medicare	$27.50
Rate for Payer: UnitedHealthcare Medicare	$27.50
Rate for Payer: University Health Alliance Commercial	$40.09

JP RESERVOIR 100ML

Facility

$55.00

Hospital Charge Code	8479433
Hospital Revenue Code	272
Min. Negotiated Rate	$46.75
Max. Negotiated Rate	$53.35
Rate for Payer: Cash Price	$35.75
Rate for Payer: Health Management Network Commercial	$46.75
Rate for Payer: Kaiser Permanente Commercial	$49.50
Rate for Payer: MDX Hawaii PPO	$53.35

KATZ EXTRACTOR

Facility

$260.00

Hospital Charge Code	8802544
Hospital Revenue Code	270
Min. Negotiated Rate	$130.00
Max. Negotiated Rate	$252.20
Rate for Payer: AlohaCare Medicaid	$130.00
Rate for Payer: AlohaCare Medicare	$130.00
Rate for Payer: Cash Price	$169.00
Rate for Payer: Devoted Health Medicare	$143.00
Rate for Payer: Hawaii Medical Service Association Medicare	$130.00
Rate for Payer: Hawaii Western Management Group Commercial	$247.00
Rate for Payer: Health Management Network Commercial	$221.00
Rate for Payer: Humana Medicare	$130.00
Rate for Payer: Kaiser Permanente Commercial	$234.00
Rate for Payer: Kaiser Permanente Medicaid	$132.60
Rate for Payer: Kaiser Permanente Medicare	$130.00
Rate for Payer: MDX Hawaii PPO	$252.20
Rate for Payer: Ohana Health Plan Medicaid	$130.00
Rate for Payer: Ohana Health Plan Medicare	$130.00
Rate for Payer: UnitedHealthcare Medicare	$130.00
Rate for Payer: University Health Alliance Commercial	$189.51

KATZ EXTRACTOR

Facility

$260.00

Hospital Charge Code	8802544
Hospital Revenue Code	270
Min. Negotiated Rate	$221.00
Max. Negotiated Rate	$252.20
Rate for Payer: Cash Price	$169.00
Rate for Payer: Health Management Network Commercial	$221.00
Rate for Payer: Kaiser Permanente Commercial	$234.00
Rate for Payer: MDX Hawaii PPO	$252.20

Keppra (Levetiracetam) FSI

Facility

$126.00

Service Code	HCPCS 80177
Hospital Charge Code	8117977
Hospital Revenue Code	301
Min. Negotiated Rate	$10.85
Max. Negotiated Rate	$122.22
Rate for Payer: AlohaCare Medicaid	$63.00
Rate for Payer: AlohaCare Medicare	$63.00
Rate for Payer: Cash Price	$81.90
Rate for Payer: Cash Price	$81.90
Rate for Payer: Devoted Health Medicare	$69.30
Rate for Payer: Hawaii Medical Service Association ABD	$11.11
Rate for Payer: Hawaii Medical Service Association Commercial	$16.56
Rate for Payer: Hawaii Medical Service Association Medicare	$63.00
Rate for Payer: Hawaii Medical Service Association Non-ABD	$17.75
Rate for Payer: Hawaii Western Management Group Commercial	$13.25
Rate for Payer: Health Management Network Commercial	$107.10
Rate for Payer: Humana Medicare	$63.00
Rate for Payer: Kaiser Permanente Commercial	$113.40
Rate for Payer: Kaiser Permanente Medicaid	$64.26
Rate for Payer: Kaiser Permanente Medicare	$63.00
Rate for Payer: MDX Hawaii PPO	$122.22
Rate for Payer: Ohana Health Plan Medicaid	$63.00
Rate for Payer: Ohana Health Plan Medicare	$63.00
Rate for Payer: UnitedHealthcare Medicaid	$10.85
Rate for Payer: UnitedHealthcare Medicare	$63.00
Rate for Payer: University Health Alliance Commercial	$33.47

Keppra (Levetiracetam) FSI

Facility

$126.00

Service Code	HCPCS 80177
Hospital Charge Code	8117977
Hospital Revenue Code	301
Min. Negotiated Rate	$107.10
Max. Negotiated Rate	$122.22
Rate for Payer: Cash Price	$81.90
Rate for Payer: Health Management Network Commercial	$107.10
Rate for Payer: Kaiser Permanente Commercial	$113.40
Rate for Payer: MDX Hawaii PPO	$122.22

ketamine 500 mg/10ml vial [HHSC]

Facility

$44.74

Service Code	NDC 67457000110
Hospital Charge Code	2500436
Hospital Revenue Code	250
Min. Negotiated Rate	$22.37
Max. Negotiated Rate	$43.40
Rate for Payer: AlohaCare Medicaid	$22.37
Rate for Payer: AlohaCare Medicare	$22.37
Rate for Payer: Cash Price	$29.08
Rate for Payer: Devoted Health Medicare	$24.61
Rate for Payer: Hawaii Medical Service Association Medicare	$22.37
Rate for Payer: Hawaii Western Management Group Commercial	$42.50
Rate for Payer: Health Management Network Commercial	$38.03
Rate for Payer: Humana Medicare	$22.37
Rate for Payer: Kaiser Permanente Commercial	$40.27
Rate for Payer: Kaiser Permanente Medicaid	$22.82
Rate for Payer: Kaiser Permanente Medicare	$22.37
Rate for Payer: MDX Hawaii PPO	$43.40
Rate for Payer: Ohana Health Plan Medicaid	$22.37
Rate for Payer: Ohana Health Plan Medicare	$22.37
Rate for Payer: UnitedHealthcare Medicaid	$26.84
Rate for Payer: UnitedHealthcare Medicare	$22.37
Rate for Payer: University Health Alliance Commercial	$32.61

ketamine 500 mg/10ml vial [HHSC]

Facility

$44.74

Service Code	NDC 67457000110
Hospital Charge Code	2500436
Hospital Revenue Code	250
Min. Negotiated Rate	$38.03
Max. Negotiated Rate	$43.40
Rate for Payer: Cash Price	$29.08
Rate for Payer: Health Management Network Commercial	$38.03
Rate for Payer: Kaiser Permanente Commercial	$40.27
Rate for Payer: MDX Hawaii PPO	$43.40

ketamine 500 mg/10ml vial [HHSC]

Facility

$23.35

Service Code	NDC 00143950810
Hospital Charge Code	2500436
Hospital Revenue Code	250
Min. Negotiated Rate	$19.85
Max. Negotiated Rate	$22.65
Rate for Payer: Cash Price	$15.18
Rate for Payer: Health Management Network Commercial	$19.85
Rate for Payer: Kaiser Permanente Commercial	$21.02
Rate for Payer: MDX Hawaii PPO	$22.65

ketamine 500 mg/10ml vial [HHSC]

Facility

$23.35

Service Code	NDC 00143950810
Hospital Charge Code	2500436
Hospital Revenue Code	250
Min. Negotiated Rate	$11.68
Max. Negotiated Rate	$22.65
Rate for Payer: AlohaCare Medicaid	$11.68
Rate for Payer: AlohaCare Medicare	$11.68
Rate for Payer: Cash Price	$15.18
Rate for Payer: Devoted Health Medicare	$12.84
Rate for Payer: Hawaii Medical Service Association Medicare	$11.68
Rate for Payer: Hawaii Western Management Group Commercial	$22.18
Rate for Payer: Health Management Network Commercial	$19.85
Rate for Payer: Humana Medicare	$11.68
Rate for Payer: Kaiser Permanente Commercial	$21.02
Rate for Payer: Kaiser Permanente Medicaid	$11.91
Rate for Payer: Kaiser Permanente Medicare	$11.68
Rate for Payer: MDX Hawaii PPO	$22.65
Rate for Payer: Ohana Health Plan Medicaid	$11.68
Rate for Payer: Ohana Health Plan Medicare	$11.68
Rate for Payer: UnitedHealthcare Medicaid	$14.01
Rate for Payer: UnitedHealthcare Medicare	$11.68
Rate for Payer: University Health Alliance Commercial	$17.02

Know your out-of-pocket cost for care.

All Charges