Samuel Mahelona Memorial Hospital

All Charges

Charge

Type

Setting

Price

MAX BREATHING CAPACITY CHARGE

Facility

$346.00

Service Code	HCPCS 94200
Hospital Charge Code	8243391
Hospital Revenue Code	460
Min. Negotiated Rate	$294.10
Max. Negotiated Rate	$335.62
Rate for Payer: Cash Price	$224.90
Rate for Payer: Health Management Network Commercial	$294.10
Rate for Payer: Kaiser Permanente Commercial	$311.40
Rate for Payer: MDX Hawaii PPO	$335.62

MAX BREATHING CAPACITY CHARGE

Facility

$346.00

Service Code	HCPCS 94200
Hospital Charge Code	8243391
Hospital Revenue Code	460
Min. Negotiated Rate	$10.72
Max. Negotiated Rate	$335.62
Rate for Payer: AlohaCare Medicaid	$173.00
Rate for Payer: AlohaCare Medicare	$173.00
Rate for Payer: Cash Price	$224.90
Rate for Payer: Cash Price	$224.90
Rate for Payer: Devoted Health Medicare	$190.30
Rate for Payer: Hawaii Medical Service Association ABD	$10.72
Rate for Payer: Hawaii Medical Service Association Commercial	$75.34
Rate for Payer: Hawaii Medical Service Association Medicare	$173.00
Rate for Payer: Hawaii Medical Service Association Non-ABD	$12.81
Rate for Payer: Hawaii Western Management Group Commercial	$328.70
Rate for Payer: Health Management Network Commercial	$294.10
Rate for Payer: Humana Medicare	$173.00
Rate for Payer: Kaiser Permanente Commercial	$311.40
Rate for Payer: Kaiser Permanente Medicaid	$176.46
Rate for Payer: Kaiser Permanente Medicare	$173.00
Rate for Payer: MDX Hawaii PPO	$335.62
Rate for Payer: Ohana Health Plan Medicaid	$173.00
Rate for Payer: Ohana Health Plan Medicare	$173.00
Rate for Payer: UnitedHealthcare Medicaid	$10.72
Rate for Payer: UnitedHealthcare Medicare	$173.00
Rate for Payer: University Health Alliance Commercial	$193.76

MDI TREATMENT CHARGE

Facility

$428.00

Service Code	HCPCS 94640
Hospital Charge Code	8243392
Hospital Revenue Code	410
Min. Negotiated Rate	$363.80
Max. Negotiated Rate	$415.16
Rate for Payer: Cash Price	$278.20
Rate for Payer: Health Management Network Commercial	$363.80
Rate for Payer: Kaiser Permanente Commercial	$385.20
Rate for Payer: MDX Hawaii PPO	$415.16

MDI TREATMENT CHARGE

Facility

$428.00

Service Code	HCPCS 94640
Hospital Charge Code	8243392
Hospital Revenue Code	410
Min. Negotiated Rate	$13.32
Max. Negotiated Rate	$415.16
Rate for Payer: AlohaCare Medicaid	$214.00
Rate for Payer: AlohaCare Medicare	$214.00
Rate for Payer: Cash Price	$278.20
Rate for Payer: Cash Price	$278.20
Rate for Payer: Devoted Health Medicare	$235.40
Rate for Payer: Hawaii Medical Service Association Commercial	$279.65
Rate for Payer: Hawaii Medical Service Association Medicare	$214.00
Rate for Payer: Hawaii Western Management Group Commercial	$406.60
Rate for Payer: Health Management Network Commercial	$363.80
Rate for Payer: Humana Medicare	$214.00
Rate for Payer: Kaiser Permanente Commercial	$385.20
Rate for Payer: Kaiser Permanente Medicaid	$218.28
Rate for Payer: Kaiser Permanente Medicare	$214.00
Rate for Payer: MDX Hawaii PPO	$415.16
Rate for Payer: Ohana Health Plan Medicaid	$214.00
Rate for Payer: Ohana Health Plan Medicare	$214.00
Rate for Payer: UnitedHealthcare Medicaid	$13.32
Rate for Payer: UnitedHealthcare Medicare	$214.00
Rate for Payer: University Health Alliance Commercial	$239.68

Mechanical Traction Charge

Facility

$127.00

Service Code	HCPCS 97012 GP,CQ
Hospital Charge Code	8111701
Hospital Revenue Code	420
Min. Negotiated Rate	$13.69
Max. Negotiated Rate	$123.19
Rate for Payer: AlohaCare Medicaid	$63.50
Rate for Payer: AlohaCare Medicare	$63.50
Rate for Payer: Cash Price	$82.55
Rate for Payer: Cash Price	$82.55
Rate for Payer: Devoted Health Medicare	$69.85
Rate for Payer: Hawaii Medical Service Association Medicare	$63.50
Rate for Payer: Hawaii Western Management Group Commercial	$120.65
Rate for Payer: Health Management Network Commercial	$107.95
Rate for Payer: Humana Medicare	$63.50
Rate for Payer: Kaiser Permanente Commercial	$114.30
Rate for Payer: Kaiser Permanente Medicaid	$64.77
Rate for Payer: Kaiser Permanente Medicare	$63.50
Rate for Payer: MDX Hawaii PPO	$123.19
Rate for Payer: Ohana Health Plan Medicaid	$63.50
Rate for Payer: Ohana Health Plan Medicare	$63.50
Rate for Payer: UnitedHealthcare Medicaid	$13.69
Rate for Payer: UnitedHealthcare Medicare	$63.50
Rate for Payer: University Health Alliance Commercial	$71.12

Mechanical Traction Charge

Facility

$127.00

Service Code	HCPCS 97012 GP,CQ
Hospital Charge Code	8111701
Hospital Revenue Code	420
Min. Negotiated Rate	$107.95
Max. Negotiated Rate	$123.19
Rate for Payer: Cash Price	$82.55
Rate for Payer: Health Management Network Commercial	$107.95
Rate for Payer: Kaiser Permanente Commercial	$114.30
Rate for Payer: MDX Hawaii PPO	$123.19

meclizine 25 mg tablet [HHSC]

Facility

$4.76

Service Code	NDC 60687073001
Hospital Charge Code	2500515
Hospital Revenue Code	250
Min. Negotiated Rate	$4.05
Max. Negotiated Rate	$4.62
Rate for Payer: Cash Price	$3.09
Rate for Payer: Health Management Network Commercial	$4.05
Rate for Payer: Kaiser Permanente Commercial	$4.28
Rate for Payer: MDX Hawaii PPO	$4.62

meclizine 25 mg tablet [HHSC]

Facility

$4.76

Service Code	NDC 68084049101
Hospital Charge Code	2500515
Hospital Revenue Code	250
Min. Negotiated Rate	$2.38
Max. Negotiated Rate	$4.62
Rate for Payer: AlohaCare Medicaid	$2.38
Rate for Payer: AlohaCare Medicare	$2.38
Rate for Payer: Cash Price	$3.09
Rate for Payer: Devoted Health Medicare	$2.62
Rate for Payer: Hawaii Medical Service Association Medicare	$2.38
Rate for Payer: Hawaii Western Management Group Commercial	$4.52
Rate for Payer: Health Management Network Commercial	$4.05
Rate for Payer: Humana Medicare	$2.38
Rate for Payer: Kaiser Permanente Commercial	$4.28
Rate for Payer: Kaiser Permanente Medicaid	$2.43
Rate for Payer: Kaiser Permanente Medicare	$2.38
Rate for Payer: MDX Hawaii PPO	$4.62
Rate for Payer: Ohana Health Plan Medicaid	$2.38
Rate for Payer: Ohana Health Plan Medicare	$2.38
Rate for Payer: UnitedHealthcare Medicaid	$2.86
Rate for Payer: UnitedHealthcare Medicare	$2.38
Rate for Payer: University Health Alliance Commercial	$3.47

meclizine 25 mg tablet [HHSC]

Facility

$3.00

Service Code	NDC 59746012106
Hospital Charge Code	2500515
Hospital Revenue Code	250
Min. Negotiated Rate	$2.55
Max. Negotiated Rate	$2.91
Rate for Payer: Cash Price	$1.95
Rate for Payer: Health Management Network Commercial	$2.55
Rate for Payer: Kaiser Permanente Commercial	$2.70
Rate for Payer: MDX Hawaii PPO	$2.91

meclizine 25 mg tablet [HHSC]

Facility

$4.69

Service Code	NDC 50268052315
Hospital Charge Code	2500515
Hospital Revenue Code	250
Min. Negotiated Rate	$2.35
Max. Negotiated Rate	$4.55
Rate for Payer: AlohaCare Medicaid	$2.35
Rate for Payer: AlohaCare Medicare	$2.35
Rate for Payer: Cash Price	$3.05
Rate for Payer: Devoted Health Medicare	$2.58
Rate for Payer: Hawaii Medical Service Association Medicare	$2.35
Rate for Payer: Hawaii Western Management Group Commercial	$4.46
Rate for Payer: Health Management Network Commercial	$3.99
Rate for Payer: Humana Medicare	$2.35
Rate for Payer: Kaiser Permanente Commercial	$4.22
Rate for Payer: Kaiser Permanente Medicaid	$2.39
Rate for Payer: Kaiser Permanente Medicare	$2.35
Rate for Payer: MDX Hawaii PPO	$4.55
Rate for Payer: Ohana Health Plan Medicaid	$2.35
Rate for Payer: Ohana Health Plan Medicare	$2.35
Rate for Payer: UnitedHealthcare Medicaid	$2.81
Rate for Payer: UnitedHealthcare Medicare	$2.35
Rate for Payer: University Health Alliance Commercial	$3.42

meclizine 25 mg tablet [HHSC]

Facility

$4.76

Service Code	NDC 68084049101
Hospital Charge Code	2500515
Hospital Revenue Code	250
Min. Negotiated Rate	$4.05
Max. Negotiated Rate	$4.62
Rate for Payer: Cash Price	$3.09
Rate for Payer: Health Management Network Commercial	$4.05
Rate for Payer: Kaiser Permanente Commercial	$4.28
Rate for Payer: MDX Hawaii PPO	$4.62

meclizine 25 mg tablet [HHSC]

Facility

$4.69

Service Code	NDC 50268052315
Hospital Charge Code	2500515
Hospital Revenue Code	250
Min. Negotiated Rate	$3.99
Max. Negotiated Rate	$4.55
Rate for Payer: Cash Price	$3.05
Rate for Payer: Health Management Network Commercial	$3.99
Rate for Payer: Kaiser Permanente Commercial	$4.22
Rate for Payer: MDX Hawaii PPO	$4.55

meclizine 25 mg tablet [HHSC]

Facility

$3.00

Service Code	NDC 16571066101
Hospital Charge Code	2500515
Hospital Revenue Code	250
Min. Negotiated Rate	$1.50
Max. Negotiated Rate	$2.91
Rate for Payer: AlohaCare Medicaid	$1.50
Rate for Payer: AlohaCare Medicare	$1.50
Rate for Payer: Cash Price	$1.95
Rate for Payer: Devoted Health Medicare	$1.65
Rate for Payer: Hawaii Medical Service Association Medicare	$1.50
Rate for Payer: Hawaii Western Management Group Commercial	$2.85
Rate for Payer: Health Management Network Commercial	$2.55
Rate for Payer: Humana Medicare	$1.50
Rate for Payer: Kaiser Permanente Commercial	$2.70
Rate for Payer: Kaiser Permanente Medicaid	$1.53
Rate for Payer: Kaiser Permanente Medicare	$1.50
Rate for Payer: MDX Hawaii PPO	$2.91
Rate for Payer: Ohana Health Plan Medicaid	$1.50
Rate for Payer: Ohana Health Plan Medicare	$1.50
Rate for Payer: UnitedHealthcare Medicaid	$1.80
Rate for Payer: UnitedHealthcare Medicare	$1.50
Rate for Payer: University Health Alliance Commercial	$2.19

meclizine 25 mg tablet [HHSC]

Facility

$3.00

Service Code	NDC 16571066101
Hospital Charge Code	2500515
Hospital Revenue Code	250
Min. Negotiated Rate	$2.55
Max. Negotiated Rate	$2.91
Rate for Payer: Cash Price	$1.95
Rate for Payer: Health Management Network Commercial	$2.55
Rate for Payer: Kaiser Permanente Commercial	$2.70
Rate for Payer: MDX Hawaii PPO	$2.91

meclizine 25 mg tablet [HHSC]

Facility

$3.00

Service Code	NDC 59746012106
Hospital Charge Code	2500515
Hospital Revenue Code	250
Min. Negotiated Rate	$1.50
Max. Negotiated Rate	$2.91
Rate for Payer: AlohaCare Medicaid	$1.50
Rate for Payer: AlohaCare Medicare	$1.50
Rate for Payer: Cash Price	$1.95
Rate for Payer: Devoted Health Medicare	$1.65
Rate for Payer: Hawaii Medical Service Association Medicare	$1.50
Rate for Payer: Hawaii Western Management Group Commercial	$2.85
Rate for Payer: Health Management Network Commercial	$2.55
Rate for Payer: Humana Medicare	$1.50
Rate for Payer: Kaiser Permanente Commercial	$2.70
Rate for Payer: Kaiser Permanente Medicaid	$1.53
Rate for Payer: Kaiser Permanente Medicare	$1.50
Rate for Payer: MDX Hawaii PPO	$2.91
Rate for Payer: Ohana Health Plan Medicaid	$1.50
Rate for Payer: Ohana Health Plan Medicare	$1.50
Rate for Payer: UnitedHealthcare Medicaid	$1.80
Rate for Payer: UnitedHealthcare Medicare	$1.50
Rate for Payer: University Health Alliance Commercial	$2.19

meclizine 25 mg tablet [HHSC]

Facility

$4.76

Service Code	NDC 60687073001
Hospital Charge Code	2500515
Hospital Revenue Code	250
Min. Negotiated Rate	$2.38
Max. Negotiated Rate	$4.62
Rate for Payer: AlohaCare Medicaid	$2.38
Rate for Payer: AlohaCare Medicare	$2.38
Rate for Payer: Cash Price	$3.09
Rate for Payer: Devoted Health Medicare	$2.62
Rate for Payer: Hawaii Medical Service Association Medicare	$2.38
Rate for Payer: Hawaii Western Management Group Commercial	$4.52
Rate for Payer: Health Management Network Commercial	$4.05
Rate for Payer: Humana Medicare	$2.38
Rate for Payer: Kaiser Permanente Commercial	$4.28
Rate for Payer: Kaiser Permanente Medicaid	$2.43
Rate for Payer: Kaiser Permanente Medicare	$2.38
Rate for Payer: MDX Hawaii PPO	$4.62
Rate for Payer: Ohana Health Plan Medicaid	$2.38
Rate for Payer: Ohana Health Plan Medicare	$2.38
Rate for Payer: UnitedHealthcare Medicaid	$2.86
Rate for Payer: UnitedHealthcare Medicare	$2.38
Rate for Payer: University Health Alliance Commercial	$3.47

.Meconium Drug Screen FSI

Facility

$1,384.00

Service Code	HCPCS 80307
Hospital Charge Code	8395735
Hospital Revenue Code	301
Min. Negotiated Rate	$47.89
Max. Negotiated Rate	$1,342.48
Rate for Payer: AlohaCare Medicaid	$692.00
Rate for Payer: AlohaCare Medicare	$692.00
Rate for Payer: Cash Price	$899.60
Rate for Payer: Cash Price	$899.60
Rate for Payer: Devoted Health Medicare	$761.20
Rate for Payer: Hawaii Medical Service Association ABD	$59.38
Rate for Payer: Hawaii Medical Service Association Commercial	$77.67
Rate for Payer: Hawaii Medical Service Association Medicare	$692.00
Rate for Payer: Hawaii Medical Service Association Non-ABD	$59.38
Rate for Payer: Hawaii Western Management Group Commercial	$62.14
Rate for Payer: Health Management Network Commercial	$1,176.40
Rate for Payer: Humana Medicare	$692.00
Rate for Payer: Kaiser Permanente Commercial	$1,245.60
Rate for Payer: Kaiser Permanente Medicaid	$705.84
Rate for Payer: Kaiser Permanente Medicare	$692.00
Rate for Payer: MDX Hawaii PPO	$1,342.48
Rate for Payer: Ohana Health Plan Medicaid	$692.00
Rate for Payer: Ohana Health Plan Medicare	$692.00
Rate for Payer: UnitedHealthcare Medicaid	$47.89
Rate for Payer: UnitedHealthcare Medicare	$692.00
Rate for Payer: University Health Alliance Commercial	$147.65

.Meconium Drug Screen FSI

Facility

$1,384.00

Service Code	HCPCS 80307
Hospital Charge Code	8395735
Hospital Revenue Code	301
Min. Negotiated Rate	$1,176.40
Max. Negotiated Rate	$1,342.48
Rate for Payer: Cash Price	$899.60
Rate for Payer: Health Management Network Commercial	$1,176.40
Rate for Payer: Kaiser Permanente Commercial	$1,245.60
Rate for Payer: MDX Hawaii PPO	$1,342.48

MEDICAL BACK PROBLEMS WITH MCC

Facility

$14,647.84

Service Code	MSDRG 551
Min. Negotiated Rate	$14,647.84
Max. Negotiated Rate	$14,647.84
Rate for Payer: Hawaii Medical Service Association Commercial	$14,647.84

MEDICAL BACK PROBLEMS WITHOUT MCC

Facility

$14,647.84

Service Code	MSDRG 552
Min. Negotiated Rate	$14,647.84
Max. Negotiated Rate	$14,647.84
Rate for Payer: Hawaii Medical Service Association Commercial	$14,647.84

Medication Charge

Professional

Both

$23.00

Service Code	HCPCS S0119
Hospital Charge Code	13273843
Hospital Revenue Code	637
Min. Negotiated Rate	$19.55
Max. Negotiated Rate	$21.59
Rate for Payer: Cash Price	$14.95
Rate for Payer: Cash Price	$14.95
Rate for Payer: Hawaii Western Management Group Commercial	$21.59
Rate for Payer: Health Management Network Commercial	$19.55

MEDIHONEY HYDROCOLLOID PASTE 1.5 OZ

Facility

$128.00

Hospital Charge Code	8419564
Hospital Revenue Code	250
Min. Negotiated Rate	$108.80
Max. Negotiated Rate	$124.16
Rate for Payer: Cash Price	$83.20
Rate for Payer: Health Management Network Commercial	$108.80
Rate for Payer: Kaiser Permanente Commercial	$115.20
Rate for Payer: MDX Hawaii PPO	$124.16

MEDIHONEY HYDROCOLLOID PASTE 1.5 OZ

Facility

$128.00

Hospital Charge Code	8419564
Hospital Revenue Code	250
Min. Negotiated Rate	$64.00
Max. Negotiated Rate	$124.16
Rate for Payer: AlohaCare Medicaid	$64.00
Rate for Payer: AlohaCare Medicare	$64.00
Rate for Payer: Cash Price	$83.20
Rate for Payer: Devoted Health Medicare	$70.40
Rate for Payer: Hawaii Medical Service Association Medicare	$64.00
Rate for Payer: Hawaii Western Management Group Commercial	$121.60
Rate for Payer: Health Management Network Commercial	$108.80
Rate for Payer: Humana Medicare	$64.00
Rate for Payer: Kaiser Permanente Commercial	$115.20
Rate for Payer: Kaiser Permanente Medicaid	$65.28
Rate for Payer: Kaiser Permanente Medicare	$64.00
Rate for Payer: MDX Hawaii PPO	$124.16
Rate for Payer: Ohana Health Plan Medicaid	$64.00
Rate for Payer: Ohana Health Plan Medicare	$64.00
Rate for Payer: UnitedHealthcare Medicaid	$76.80
Rate for Payer: UnitedHealthcare Medicare	$64.00
Rate for Payer: University Health Alliance Commercial	$93.30

Meningitis/Encephalitis Panel by PCR FSI

Facility

$516.00

Service Code	HCPCS 87496
Hospital Charge Code	8228894
Hospital Revenue Code	300
Min. Negotiated Rate	$438.60
Max. Negotiated Rate	$500.52
Rate for Payer: Cash Price	$335.40
Rate for Payer: Health Management Network Commercial	$438.60
Rate for Payer: Kaiser Permanente Commercial	$464.40
Rate for Payer: MDX Hawaii PPO	$500.52

Meningitis/Encephalitis Panel by PCR FSI

Facility

$516.00

Service Code	HCPCS 87496
Hospital Charge Code	8228894
Hospital Revenue Code	300
Min. Negotiated Rate	$35.09
Max. Negotiated Rate	$500.52
Rate for Payer: AlohaCare Medicaid	$258.00
Rate for Payer: AlohaCare Medicare	$258.00
Rate for Payer: Cash Price	$335.40
Rate for Payer: Cash Price	$335.40
Rate for Payer: Devoted Health Medicare	$283.80
Rate for Payer: Hawaii Medical Service Association ABD	$48.50
Rate for Payer: Hawaii Medical Service Association Commercial	$43.86
Rate for Payer: Hawaii Medical Service Association Medicare	$258.00
Rate for Payer: Hawaii Medical Service Association Non-ABD	$50.93
Rate for Payer: Hawaii Western Management Group Commercial	$35.09
Rate for Payer: Health Management Network Commercial	$438.60
Rate for Payer: Humana Medicare	$258.00
Rate for Payer: Kaiser Permanente Commercial	$464.40
Rate for Payer: Kaiser Permanente Medicaid	$263.16
Rate for Payer: Kaiser Permanente Medicare	$258.00
Rate for Payer: MDX Hawaii PPO	$500.52
Rate for Payer: Ohana Health Plan Medicaid	$258.00
Rate for Payer: Ohana Health Plan Medicare	$258.00
Rate for Payer: UnitedHealthcare Medicaid	$48.50
Rate for Payer: UnitedHealthcare Medicare	$258.00
Rate for Payer: University Health Alliance Commercial	$90.72

Know your out-of-pocket cost for care.

All Charges