Samuel Mahelona Memorial Hospital

All Charges

Charge

Type

Setting

Price

MG Mammo Screening Bilateral w/ Tomo

Facility

$464.00

Service Code	HCPCS 77067
Hospital Charge Code	8352756
Hospital Revenue Code	403
Min. Negotiated Rate	$394.40
Max. Negotiated Rate	$450.08
Rate for Payer: Cash Price	$301.60
Rate for Payer: Health Management Network Commercial	$394.40
Rate for Payer: Kaiser Permanente Commercial	$417.60
Rate for Payer: MDX Hawaii PPO	$450.08

MG Mammo Screening Bilateral w/ Tomo

Facility

$464.00

Service Code	HCPCS 77067
Hospital Charge Code	8352756
Hospital Revenue Code	403
Min. Negotiated Rate	$80.77
Max. Negotiated Rate	$450.08
Rate for Payer: AlohaCare Medicaid	$232.00
Rate for Payer: AlohaCare Medicare	$232.00
Rate for Payer: Cash Price	$301.60
Rate for Payer: Cash Price	$301.60
Rate for Payer: Devoted Health Medicare	$255.20
Rate for Payer: Hawaii Medical Service Association ABD	$80.77
Rate for Payer: Hawaii Medical Service Association Medicare	$232.00
Rate for Payer: Hawaii Medical Service Association Non-ABD	$106.74
Rate for Payer: Hawaii Western Management Group Commercial	$440.80
Rate for Payer: Health Management Network Commercial	$394.40
Rate for Payer: Humana Medicare	$232.00
Rate for Payer: Kaiser Permanente Commercial	$417.60
Rate for Payer: Kaiser Permanente Medicaid	$236.64
Rate for Payer: Kaiser Permanente Medicare	$232.00
Rate for Payer: MDX Hawaii PPO	$450.08
Rate for Payer: Ohana Health Plan Medicaid	$232.00
Rate for Payer: Ohana Health Plan Medicare	$232.00
Rate for Payer: UnitedHealthcare Medicaid	$85.27
Rate for Payer: UnitedHealthcare Medicare	$232.00
Rate for Payer: University Health Alliance Commercial	$285.53

MG Mammo Screening Bilateral w/ Tomo - Report

Professional

Both

$114.00

Service Code	HCPCS 77067
Hospital Charge Code	8352758
Hospital Revenue Code	972
Min. Negotiated Rate	$85.27
Max. Negotiated Rate	$167.08
Rate for Payer: AlohaCare Medicaid	$85.27
Rate for Payer: AlohaCare Medicare	$139.23
Rate for Payer: Cash Price	$74.10
Rate for Payer: Cash Price	$74.10
Rate for Payer: Devoted Health Medicare	$153.15
Rate for Payer: Hawaii Medical Service Association Medicare	$139.23
Rate for Payer: Hawaii Western Management Group Commercial	$156.36
Rate for Payer: Health Management Network Commercial	$96.90
Rate for Payer: Kaiser Permanente Commercial	$167.08
Rate for Payer: Kaiser Permanente Medicaid	$167.08
Rate for Payer: Kaiser Permanente Medicare	$167.08
Rate for Payer: Ohana Health Plan Medicaid	$85.27
Rate for Payer: Ohana Health Plan Medicare	$139.23
Rate for Payer: UnitedHealthcare Medicaid	$85.27
Rate for Payer: UnitedHealthcare Medicare	$139.23

MG Mammo Screening Bilateral w/ Tomo - Report

Professional

Both

$114.00

Service Code	HCPCS 77067 26
Hospital Charge Code	8033242
Hospital Revenue Code	972
Min. Negotiated Rate	$35.74
Max. Negotiated Rate	$156.36
Rate for Payer: AlohaCare Medicaid	$85.27
Rate for Payer: AlohaCare Medicare	$35.74
Rate for Payer: Cash Price	$74.10
Rate for Payer: Cash Price	$74.10
Rate for Payer: Devoted Health Medicare	$39.31
Rate for Payer: Hawaii Medical Service Association Medicare	$35.74
Rate for Payer: Hawaii Western Management Group Commercial	$156.36
Rate for Payer: Health Management Network Commercial	$96.90
Rate for Payer: Kaiser Permanente Commercial	$42.89
Rate for Payer: Kaiser Permanente Medicaid	$42.89
Rate for Payer: Kaiser Permanente Medicare	$42.89
Rate for Payer: Ohana Health Plan Medicaid	$85.27
Rate for Payer: Ohana Health Plan Medicare	$35.74
Rate for Payer: UnitedHealthcare Medicaid	$85.27
Rate for Payer: UnitedHealthcare Medicare	$35.74

MG Mammo Screening Left w/ Tomo

Facility

$464.00

Service Code	HCPCS 77067 52,LT
Hospital Charge Code	8352759
Hospital Revenue Code	403
Min. Negotiated Rate	$80.77
Max. Negotiated Rate	$450.08
Rate for Payer: AlohaCare Medicaid	$232.00
Rate for Payer: AlohaCare Medicare	$232.00
Rate for Payer: Cash Price	$301.60
Rate for Payer: Cash Price	$301.60
Rate for Payer: Devoted Health Medicare	$255.20
Rate for Payer: Hawaii Medical Service Association ABD	$80.77
Rate for Payer: Hawaii Medical Service Association Medicare	$232.00
Rate for Payer: Hawaii Medical Service Association Non-ABD	$106.74
Rate for Payer: Hawaii Western Management Group Commercial	$440.80
Rate for Payer: Health Management Network Commercial	$394.40
Rate for Payer: Humana Medicare	$232.00
Rate for Payer: Kaiser Permanente Commercial	$417.60
Rate for Payer: Kaiser Permanente Medicaid	$236.64
Rate for Payer: Kaiser Permanente Medicare	$232.00
Rate for Payer: MDX Hawaii PPO	$450.08
Rate for Payer: Ohana Health Plan Medicaid	$232.00
Rate for Payer: Ohana Health Plan Medicare	$232.00
Rate for Payer: UnitedHealthcare Medicaid	$85.27
Rate for Payer: UnitedHealthcare Medicare	$232.00
Rate for Payer: University Health Alliance Commercial	$285.53

MG Mammo Screening Left w/ Tomo

Facility

$464.00

Service Code	HCPCS 77067 52,LT
Hospital Charge Code	8352759
Hospital Revenue Code	403
Min. Negotiated Rate	$394.40
Max. Negotiated Rate	$450.08
Rate for Payer: Cash Price	$301.60
Rate for Payer: Health Management Network Commercial	$394.40
Rate for Payer: Kaiser Permanente Commercial	$417.60
Rate for Payer: MDX Hawaii PPO	$450.08

MG Mammo Screening Left w/ Tomo - Report

Professional

Both

$114.00

Service Code	HCPCS 77067 52,LT
Hospital Charge Code	8033245
Hospital Revenue Code	972
Min. Negotiated Rate	$85.27
Max. Negotiated Rate	$156.36
Rate for Payer: AlohaCare Medicaid	$85.27
Rate for Payer: Cash Price	$74.10
Rate for Payer: Cash Price	$74.10
Rate for Payer: Hawaii Western Management Group Commercial	$156.36
Rate for Payer: Health Management Network Commercial	$96.90
Rate for Payer: Ohana Health Plan Medicaid	$85.27
Rate for Payer: UnitedHealthcare Medicaid	$85.27

MG Mammo Screening Left w/ Tomo - Report

Professional

Both

$114.00

Service Code	HCPCS 77067 52,LT
Hospital Charge Code	8352761
Hospital Revenue Code	972
Min. Negotiated Rate	$85.27
Max. Negotiated Rate	$156.36
Rate for Payer: AlohaCare Medicaid	$85.27
Rate for Payer: Cash Price	$74.10
Rate for Payer: Cash Price	$74.10
Rate for Payer: Hawaii Western Management Group Commercial	$156.36
Rate for Payer: Health Management Network Commercial	$96.90
Rate for Payer: Ohana Health Plan Medicaid	$85.27
Rate for Payer: UnitedHealthcare Medicaid	$85.27

MG Mammo Screening Right w/ Tomo

Facility

$464.00

Service Code	HCPCS 77067 52,RT
Hospital Charge Code	8352762
Hospital Revenue Code	403
Min. Negotiated Rate	$394.40
Max. Negotiated Rate	$450.08
Rate for Payer: Cash Price	$301.60
Rate for Payer: Health Management Network Commercial	$394.40
Rate for Payer: Kaiser Permanente Commercial	$417.60
Rate for Payer: MDX Hawaii PPO	$450.08

MG Mammo Screening Right w/ Tomo

Facility

$464.00

Service Code	HCPCS 77067 52,RT
Hospital Charge Code	8352762
Hospital Revenue Code	403
Min. Negotiated Rate	$80.77
Max. Negotiated Rate	$450.08
Rate for Payer: AlohaCare Medicaid	$232.00
Rate for Payer: AlohaCare Medicare	$232.00
Rate for Payer: Cash Price	$301.60
Rate for Payer: Cash Price	$301.60
Rate for Payer: Devoted Health Medicare	$255.20
Rate for Payer: Hawaii Medical Service Association ABD	$80.77
Rate for Payer: Hawaii Medical Service Association Medicare	$232.00
Rate for Payer: Hawaii Medical Service Association Non-ABD	$106.74
Rate for Payer: Hawaii Western Management Group Commercial	$440.80
Rate for Payer: Health Management Network Commercial	$394.40
Rate for Payer: Humana Medicare	$232.00
Rate for Payer: Kaiser Permanente Commercial	$417.60
Rate for Payer: Kaiser Permanente Medicaid	$236.64
Rate for Payer: Kaiser Permanente Medicare	$232.00
Rate for Payer: MDX Hawaii PPO	$450.08
Rate for Payer: Ohana Health Plan Medicaid	$232.00
Rate for Payer: Ohana Health Plan Medicare	$232.00
Rate for Payer: UnitedHealthcare Medicaid	$85.27
Rate for Payer: UnitedHealthcare Medicare	$232.00
Rate for Payer: University Health Alliance Commercial	$285.53

MG Mammo Screening Right w/ Tomo - Report

Professional

Both

$114.00

Service Code	HCPCS 77067 52,RT
Hospital Charge Code	8352764
Hospital Revenue Code	972
Min. Negotiated Rate	$85.27
Max. Negotiated Rate	$156.36
Rate for Payer: AlohaCare Medicaid	$85.27
Rate for Payer: Cash Price	$74.10
Rate for Payer: Cash Price	$74.10
Rate for Payer: Hawaii Western Management Group Commercial	$156.36
Rate for Payer: Health Management Network Commercial	$96.90
Rate for Payer: Ohana Health Plan Medicaid	$85.27
Rate for Payer: UnitedHealthcare Medicaid	$85.27

MG Mammo Screening Right w/ Tomo - Report

Professional

Both

$114.00

Service Code	HCPCS 77067 52,RT
Hospital Charge Code	8033248
Hospital Revenue Code	972
Min. Negotiated Rate	$85.27
Max. Negotiated Rate	$156.36
Rate for Payer: AlohaCare Medicaid	$85.27
Rate for Payer: Cash Price	$74.10
Rate for Payer: Cash Price	$74.10
Rate for Payer: Hawaii Western Management Group Commercial	$156.36
Rate for Payer: Health Management Network Commercial	$96.90
Rate for Payer: Ohana Health Plan Medicaid	$85.27
Rate for Payer: UnitedHealthcare Medicaid	$85.27

MG Mammo Screening Unilateral w/ Tomo

Facility

$464.00

Service Code	HCPCS 77067 52,RT
Hospital Charge Code	8033246
Hospital Revenue Code	403
Min. Negotiated Rate	$80.77
Max. Negotiated Rate	$450.08
Rate for Payer: AlohaCare Medicaid	$232.00
Rate for Payer: AlohaCare Medicare	$232.00
Rate for Payer: Cash Price	$301.60
Rate for Payer: Cash Price	$301.60
Rate for Payer: Devoted Health Medicare	$255.20
Rate for Payer: Hawaii Medical Service Association ABD	$80.77
Rate for Payer: Hawaii Medical Service Association Medicare	$232.00
Rate for Payer: Hawaii Medical Service Association Non-ABD	$106.74
Rate for Payer: Hawaii Western Management Group Commercial	$440.80
Rate for Payer: Health Management Network Commercial	$394.40
Rate for Payer: Humana Medicare	$232.00
Rate for Payer: Kaiser Permanente Commercial	$417.60
Rate for Payer: Kaiser Permanente Medicaid	$236.64
Rate for Payer: Kaiser Permanente Medicare	$232.00
Rate for Payer: MDX Hawaii PPO	$450.08
Rate for Payer: Ohana Health Plan Medicaid	$232.00
Rate for Payer: Ohana Health Plan Medicare	$232.00
Rate for Payer: UnitedHealthcare Medicaid	$85.27
Rate for Payer: UnitedHealthcare Medicare	$232.00
Rate for Payer: University Health Alliance Commercial	$285.53

MG Mammo Screening Unilateral w/ Tomo

Facility

$464.00

Service Code	HCPCS 77067 52,LT
Hospital Charge Code	8033243
Hospital Revenue Code	403
Min. Negotiated Rate	$394.40
Max. Negotiated Rate	$450.08
Rate for Payer: Cash Price	$301.60
Rate for Payer: Health Management Network Commercial	$394.40
Rate for Payer: Kaiser Permanente Commercial	$417.60
Rate for Payer: MDX Hawaii PPO	$450.08

MG Mammo Screening Unilateral w/ Tomo

Facility

$464.00

Service Code	HCPCS 77067 52,LT
Hospital Charge Code	8033243
Hospital Revenue Code	403
Min. Negotiated Rate	$80.77
Max. Negotiated Rate	$450.08
Rate for Payer: AlohaCare Medicaid	$232.00
Rate for Payer: AlohaCare Medicare	$232.00
Rate for Payer: Cash Price	$301.60
Rate for Payer: Cash Price	$301.60
Rate for Payer: Devoted Health Medicare	$255.20
Rate for Payer: Hawaii Medical Service Association ABD	$80.77
Rate for Payer: Hawaii Medical Service Association Medicare	$232.00
Rate for Payer: Hawaii Medical Service Association Non-ABD	$106.74
Rate for Payer: Hawaii Western Management Group Commercial	$440.80
Rate for Payer: Health Management Network Commercial	$394.40
Rate for Payer: Humana Medicare	$232.00
Rate for Payer: Kaiser Permanente Commercial	$417.60
Rate for Payer: Kaiser Permanente Medicaid	$236.64
Rate for Payer: Kaiser Permanente Medicare	$232.00
Rate for Payer: MDX Hawaii PPO	$450.08
Rate for Payer: Ohana Health Plan Medicaid	$232.00
Rate for Payer: Ohana Health Plan Medicare	$232.00
Rate for Payer: UnitedHealthcare Medicaid	$85.27
Rate for Payer: UnitedHealthcare Medicare	$232.00
Rate for Payer: University Health Alliance Commercial	$285.53

MG Mammo Screening Unilateral w/ Tomo

Facility

$464.00

Service Code	HCPCS 77067 52,RT
Hospital Charge Code	8033246
Hospital Revenue Code	403
Min. Negotiated Rate	$394.40
Max. Negotiated Rate	$450.08
Rate for Payer: Cash Price	$301.60
Rate for Payer: Health Management Network Commercial	$394.40
Rate for Payer: Kaiser Permanente Commercial	$417.60
Rate for Payer: MDX Hawaii PPO	$450.08

M Hominis Amp Probe

Facility

$365.00

Service Code	HCPCS 87798
Hospital Charge Code	10023502
Hospital Revenue Code	306
Min. Negotiated Rate	$310.25
Max. Negotiated Rate	$354.05
Rate for Payer: Cash Price	$237.25
Rate for Payer: Health Management Network Commercial	$310.25
Rate for Payer: Kaiser Permanente Commercial	$328.50
Rate for Payer: MDX Hawaii PPO	$354.05

M Hominis Amp Probe

Facility

$365.00

Service Code	HCPCS 87798
Hospital Charge Code	10023502
Hospital Revenue Code	306
Min. Negotiated Rate	$35.09
Max. Negotiated Rate	$354.05
Rate for Payer: AlohaCare Medicaid	$182.50
Rate for Payer: AlohaCare Medicare	$182.50
Rate for Payer: Cash Price	$237.25
Rate for Payer: Cash Price	$237.25
Rate for Payer: Devoted Health Medicare	$200.75
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	$182.50
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	$310.25
Rate for Payer: Humana Medicare	$182.50
Rate for Payer: Kaiser Permanente Commercial	$328.50
Rate for Payer: Kaiser Permanente Medicaid	$186.15
Rate for Payer: Kaiser Permanente Medicare	$182.50
Rate for Payer: MDX Hawaii PPO	$354.05
Rate for Payer: Ohana Health Plan Medicaid	$182.50
Rate for Payer: Ohana Health Plan Medicare	$182.50
Rate for Payer: UnitedHealthcare Medicaid	$48.50
Rate for Payer: UnitedHealthcare Medicare	$182.50
Rate for Payer: University Health Alliance Commercial	$90.72

Microalbumin, U Only FSI

Facility

$81.00

Service Code	HCPCS 82043
Hospital Charge Code	8228898
Hospital Revenue Code	301
Min. Negotiated Rate	$5.78
Max. Negotiated Rate	$78.57
Rate for Payer: AlohaCare Medicaid	$40.50
Rate for Payer: AlohaCare Medicare	$40.50
Rate for Payer: Cash Price	$52.65
Rate for Payer: Cash Price	$52.65
Rate for Payer: Devoted Health Medicare	$44.55
Rate for Payer: Hawaii Medical Service Association ABD	$8.00
Rate for Payer: Hawaii Medical Service Association Commercial	$7.22
Rate for Payer: Hawaii Medical Service Association Medicare	$40.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$8.40
Rate for Payer: Hawaii Western Management Group Commercial	$5.78
Rate for Payer: Health Management Network Commercial	$68.85
Rate for Payer: Humana Medicare	$40.50
Rate for Payer: Kaiser Permanente Commercial	$72.90
Rate for Payer: Kaiser Permanente Medicaid	$41.31
Rate for Payer: Kaiser Permanente Medicare	$40.50
Rate for Payer: MDX Hawaii PPO	$78.57
Rate for Payer: Ohana Health Plan Medicaid	$40.50
Rate for Payer: Ohana Health Plan Medicare	$40.50
Rate for Payer: UnitedHealthcare Medicaid	$8.00
Rate for Payer: UnitedHealthcare Medicare	$40.50
Rate for Payer: University Health Alliance Commercial	$14.97

Microalbumin, U Only FSI

Facility

$81.00

Service Code	HCPCS 82043
Hospital Charge Code	8228898
Hospital Revenue Code	301
Min. Negotiated Rate	$68.85
Max. Negotiated Rate	$78.57
Rate for Payer: Cash Price	$52.65
Rate for Payer: Health Management Network Commercial	$68.85
Rate for Payer: Kaiser Permanente Commercial	$72.90
Rate for Payer: MDX Hawaii PPO	$78.57

Microscan MIC Susceptibility

Facility

$104.00

Service Code	HCPCS 87186
Hospital Charge Code	12516217
Hospital Revenue Code	306
Min. Negotiated Rate	$88.40
Max. Negotiated Rate	$100.88
Rate for Payer: Cash Price	$67.60
Rate for Payer: Health Management Network Commercial	$88.40
Rate for Payer: Kaiser Permanente Commercial	$93.60
Rate for Payer: MDX Hawaii PPO	$100.88

Microscan MIC Susceptibility

Facility

$104.00

Service Code	HCPCS 87186
Hospital Charge Code	12516217
Hospital Revenue Code	306
Min. Negotiated Rate	$8.65
Max. Negotiated Rate	$100.88
Rate for Payer: AlohaCare Medicaid	$52.00
Rate for Payer: AlohaCare Medicare	$52.00
Rate for Payer: Cash Price	$67.60
Rate for Payer: Cash Price	$67.60
Rate for Payer: Devoted Health Medicare	$57.20
Rate for Payer: Hawaii Medical Service Association ABD	$11.94
Rate for Payer: Hawaii Medical Service Association Commercial	$10.81
Rate for Payer: Hawaii Medical Service Association Medicare	$52.00
Rate for Payer: Hawaii Medical Service Association Non-ABD	$12.54
Rate for Payer: Hawaii Western Management Group Commercial	$8.65
Rate for Payer: Health Management Network Commercial	$88.40
Rate for Payer: Humana Medicare	$52.00
Rate for Payer: Kaiser Permanente Commercial	$93.60
Rate for Payer: Kaiser Permanente Medicaid	$53.04
Rate for Payer: Kaiser Permanente Medicare	$52.00
Rate for Payer: MDX Hawaii PPO	$100.88
Rate for Payer: Ohana Health Plan Medicaid	$52.00
Rate for Payer: Ohana Health Plan Medicare	$52.00
Rate for Payer: UnitedHealthcare Medicaid	$11.94
Rate for Payer: UnitedHealthcare Medicare	$52.00
Rate for Payer: University Health Alliance Commercial	$22.35

midazolam 10 mg/2 ml vial [HHSC]

Facility

$8.34

Service Code	HCPCS J2250
Hospital Charge Code	2500551
Hospital Revenue Code	636
Min. Negotiated Rate	$0.16
Max. Negotiated Rate	$8.09
Rate for Payer: AlohaCare Medicaid	$4.17
Rate for Payer: AlohaCare Medicaid	$21.32
Rate for Payer: AlohaCare Medicare	$21.32
Rate for Payer: AlohaCare Medicare	$4.17
Rate for Payer: Cash Price	$27.72
Rate for Payer: Cash Price	$27.72
Rate for Payer: Cash Price	$5.42
Rate for Payer: Cash Price	$5.42
Rate for Payer: Devoted Health Medicare	$23.46
Rate for Payer: Devoted Health Medicare	$4.59
Rate for Payer: Hawaii Medical Service Association ABD	$0.16
Rate for Payer: Hawaii Medical Service Association ABD	$0.16
Rate for Payer: Hawaii Medical Service Association Medicare	$21.32
Rate for Payer: Hawaii Medical Service Association Medicare	$4.17
Rate for Payer: Hawaii Medical Service Association Non-ABD	$0.16
Rate for Payer: Hawaii Medical Service Association Non-ABD	$0.16
Rate for Payer: Hawaii Western Management Group Commercial	$40.52
Rate for Payer: Hawaii Western Management Group Commercial	$7.92
Rate for Payer: Health Management Network Commercial	$36.25
Rate for Payer: Health Management Network Commercial	$7.09
Rate for Payer: Humana Medicare	$21.32
Rate for Payer: Humana Medicare	$4.17
Rate for Payer: Kaiser Permanente Commercial	$7.51
Rate for Payer: Kaiser Permanente Commercial	$38.38
Rate for Payer: Kaiser Permanente Medicaid	$21.75
Rate for Payer: Kaiser Permanente Medicaid	$4.25
Rate for Payer: Kaiser Permanente Medicare	$21.32
Rate for Payer: Kaiser Permanente Medicare	$4.17
Rate for Payer: MDX Hawaii PPO	$41.37
Rate for Payer: MDX Hawaii PPO	$8.09
Rate for Payer: Ohana Health Plan Medicaid	$4.17
Rate for Payer: Ohana Health Plan Medicaid	$21.32
Rate for Payer: Ohana Health Plan Medicare	$21.32
Rate for Payer: Ohana Health Plan Medicare	$4.17
Rate for Payer: UnitedHealthcare Medicaid	$25.59
Rate for Payer: UnitedHealthcare Medicaid	$5.00
Rate for Payer: UnitedHealthcare Medicare	$4.17
Rate for Payer: UnitedHealthcare Medicare	$21.32
Rate for Payer: University Health Alliance Commercial	$31.09
Rate for Payer: University Health Alliance Commercial	$6.08

midazolam 10 mg/2 ml vial [HHSC]

Facility

$42.65

Service Code	HCPCS J2250
Hospital Charge Code	2500551
Hospital Revenue Code	250
Min. Negotiated Rate	$36.25
Max. Negotiated Rate	$41.37
Rate for Payer: Cash Price	$27.72
Rate for Payer: Cash Price	$5.42
Rate for Payer: Health Management Network Commercial	$7.09
Rate for Payer: Health Management Network Commercial	$36.25
Rate for Payer: Kaiser Permanente Commercial	$38.38
Rate for Payer: Kaiser Permanente Commercial	$7.51
Rate for Payer: MDX Hawaii PPO	$41.37
Rate for Payer: MDX Hawaii PPO	$8.09

midazolam 2 mg/2 ml vial [HHSC]

Facility

$4.27

Service Code	HCPCS J2250
Hospital Charge Code	2500549
Hospital Revenue Code	250
Min. Negotiated Rate	$3.63
Max. Negotiated Rate	$4.14
Rate for Payer: Cash Price	$2.78
Rate for Payer: Cash Price	$1.95
Rate for Payer: Cash Price	$3.81
Rate for Payer: Cash Price	$2.82
Rate for Payer: Health Management Network Commercial	$2.55
Rate for Payer: Health Management Network Commercial	$3.63
Rate for Payer: Health Management Network Commercial	$3.69
Rate for Payer: Health Management Network Commercial	$4.98
Rate for Payer: Kaiser Permanente Commercial	$2.70
Rate for Payer: Kaiser Permanente Commercial	$5.27
Rate for Payer: Kaiser Permanente Commercial	$3.91
Rate for Payer: Kaiser Permanente Commercial	$3.84
Rate for Payer: MDX Hawaii PPO	$2.91
Rate for Payer: MDX Hawaii PPO	$4.21
Rate for Payer: MDX Hawaii PPO	$5.68
Rate for Payer: MDX Hawaii PPO	$4.14

Know your out-of-pocket cost for care.

All Charges