Samuel Mahelona Memorial Hospital

All Charges

Charge

Type

Setting

Price

MINOR SKIN DISORDERS WITHOUT MCC

Facility

$12,538.36

Service Code	MSDRG 607
Min. Negotiated Rate	$12,538.36
Max. Negotiated Rate	$12,538.36
Rate for Payer: Hawaii Medical Service Association Commercial	$12,538.36

MINOR SMALL AND LARGE BOWEL PROCEDURES WITH CC

Facility

$32,448.04

Service Code	MSDRG 345
Min. Negotiated Rate	$32,448.04
Max. Negotiated Rate	$32,448.04
Rate for Payer: Hawaii Medical Service Association Commercial	$32,448.04

MINOR SMALL AND LARGE BOWEL PROCEDURES WITH MCC

Facility

$36,287.76

Service Code	MSDRG 344
Min. Negotiated Rate	$36,287.76
Max. Negotiated Rate	$36,287.76
Rate for Payer: Hawaii Medical Service Association Commercial	$36,287.76

MINOR SMALL AND LARGE BOWEL PROCEDURES WITHOUT CC/MCC

Facility

$26,688.45

Service Code	MSDRG 346
Min. Negotiated Rate	$26,688.45
Max. Negotiated Rate	$26,688.45
Rate for Payer: Hawaii Medical Service Association Commercial	$26,688.45

mirtazapine 15 mg tablet [HHSC]

Facility

$15.06

Service Code	NDC 68084011901
Hospital Charge Code	2500555
Hospital Revenue Code	250
Min. Negotiated Rate	$7.53
Max. Negotiated Rate	$14.61
Rate for Payer: AlohaCare Medicaid	$7.53
Rate for Payer: AlohaCare Medicare	$7.53
Rate for Payer: Cash Price	$9.79
Rate for Payer: Devoted Health Medicare	$8.28
Rate for Payer: Hawaii Medical Service Association Medicare	$7.53
Rate for Payer: Hawaii Western Management Group Commercial	$14.31
Rate for Payer: Health Management Network Commercial	$12.80
Rate for Payer: Humana Medicare	$7.53
Rate for Payer: Kaiser Permanente Commercial	$13.55
Rate for Payer: Kaiser Permanente Medicaid	$7.68
Rate for Payer: Kaiser Permanente Medicare	$7.53
Rate for Payer: MDX Hawaii PPO	$14.61
Rate for Payer: Ohana Health Plan Medicaid	$7.53
Rate for Payer: Ohana Health Plan Medicare	$7.53
Rate for Payer: UnitedHealthcare Medicaid	$9.04
Rate for Payer: UnitedHealthcare Medicare	$7.53
Rate for Payer: University Health Alliance Commercial	$10.98

mirtazapine 15 mg tablet [HHSC]

Facility

$15.90

Service Code	NDC 00904651961
Hospital Charge Code	2500555
Hospital Revenue Code	250
Min. Negotiated Rate	$7.95
Max. Negotiated Rate	$15.42
Rate for Payer: AlohaCare Medicaid	$7.95
Rate for Payer: AlohaCare Medicare	$7.95
Rate for Payer: Cash Price	$10.34
Rate for Payer: Devoted Health Medicare	$8.74
Rate for Payer: Hawaii Medical Service Association Medicare	$7.95
Rate for Payer: Hawaii Western Management Group Commercial	$15.11
Rate for Payer: Health Management Network Commercial	$13.52
Rate for Payer: Humana Medicare	$7.95
Rate for Payer: Kaiser Permanente Commercial	$14.31
Rate for Payer: Kaiser Permanente Medicaid	$8.11
Rate for Payer: Kaiser Permanente Medicare	$7.95
Rate for Payer: MDX Hawaii PPO	$15.42
Rate for Payer: Ohana Health Plan Medicaid	$7.95
Rate for Payer: Ohana Health Plan Medicare	$7.95
Rate for Payer: UnitedHealthcare Medicaid	$9.54
Rate for Payer: UnitedHealthcare Medicare	$7.95
Rate for Payer: University Health Alliance Commercial	$11.59

mirtazapine 15 mg tablet [HHSC]

Facility

$15.06

Service Code	NDC 68084011901
Hospital Charge Code	2500555
Hospital Revenue Code	250
Min. Negotiated Rate	$12.80
Max. Negotiated Rate	$14.61
Rate for Payer: Cash Price	$9.79
Rate for Payer: Health Management Network Commercial	$12.80
Rate for Payer: Kaiser Permanente Commercial	$13.55
Rate for Payer: MDX Hawaii PPO	$14.61

mirtazapine 15 mg tablet [HHSC]

Facility

$15.90

Service Code	NDC 00904651961
Hospital Charge Code	2500555
Hospital Revenue Code	250
Min. Negotiated Rate	$13.52
Max. Negotiated Rate	$15.42
Rate for Payer: Cash Price	$10.34
Rate for Payer: Health Management Network Commercial	$13.52
Rate for Payer: Kaiser Permanente Commercial	$14.31
Rate for Payer: MDX Hawaii PPO	$15.42

Miscellaneous Culture FSI

Facility

$127.00

Service Code	HCPCS 87070
Hospital Charge Code	8117996
Hospital Revenue Code	306
Min. Negotiated Rate	$8.62
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 ABD	$11.90
Rate for Payer: Hawaii Medical Service Association Commercial	$10.78
Rate for Payer: Hawaii Medical Service Association Medicare	$63.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$12.50
Rate for Payer: Hawaii Western Management Group Commercial	$8.62
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	$11.90
Rate for Payer: UnitedHealthcare Medicare	$63.50
Rate for Payer: University Health Alliance Commercial	$22.26

Miscellaneous Culture FSI

Facility

$127.00

Service Code	HCPCS 87070
Hospital Charge Code	8117996
Hospital Revenue Code	306
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

MISCELLANEOUS DISORDERS OF NUTRITION, METABOLISM, FLUIDS AND ELECTROLYTES WITH MCC

Facility

$20,217.81

Service Code	MSDRG 640
Min. Negotiated Rate	$20,217.81
Max. Negotiated Rate	$20,217.81
Rate for Payer: Hawaii Medical Service Association Commercial	$20,217.81

MISCELLANEOUS DISORDERS OF NUTRITION, METABOLISM, FLUIDS AND ELECTROLYTES WITHOUT MCC

Facility

$15,738.13

Service Code	MSDRG 641
Min. Negotiated Rate	$15,738.13
Max. Negotiated Rate	$15,738.13
Rate for Payer: Hawaii Medical Service Association Commercial	$15,738.13

Moderna Vaccine 1st Dose: 0011A - 100mcg - Moderna Vaccine Admin Charge

Facility

$142.00

Service Code	HCPCS 0011A
Hospital Charge Code	9250681
Hospital Revenue Code	771
Min. Negotiated Rate	$71.00
Max. Negotiated Rate	$137.74
Rate for Payer: AlohaCare Medicaid	$71.00
Rate for Payer: AlohaCare Medicare	$71.00
Rate for Payer: Cash Price	$92.30
Rate for Payer: Devoted Health Medicare	$78.10
Rate for Payer: Hawaii Medical Service Association Medicare	$71.00
Rate for Payer: Hawaii Western Management Group Commercial	$134.90
Rate for Payer: Health Management Network Commercial	$120.70
Rate for Payer: Humana Medicare	$71.00
Rate for Payer: Kaiser Permanente Commercial	$127.80
Rate for Payer: Kaiser Permanente Medicaid	$72.42
Rate for Payer: Kaiser Permanente Medicare	$71.00
Rate for Payer: MDX Hawaii PPO	$137.74
Rate for Payer: Ohana Health Plan Medicaid	$71.00
Rate for Payer: Ohana Health Plan Medicare	$71.00
Rate for Payer: UnitedHealthcare Medicare	$71.00
Rate for Payer: University Health Alliance Commercial	$79.52

Moderna Vaccine 1st Dose: 0011A - 100mcg - Moderna Vaccine Admin Charge

Facility

$142.00

Service Code	HCPCS 0011A
Hospital Charge Code	9250681
Hospital Revenue Code	771
Min. Negotiated Rate	$120.70
Max. Negotiated Rate	$137.74
Rate for Payer: Cash Price	$92.30
Rate for Payer: Health Management Network Commercial	$120.70
Rate for Payer: Kaiser Permanente Commercial	$127.80
Rate for Payer: MDX Hawaii PPO	$137.74

Moderna Vaccine 2nd dose: 0012A - 100mcg - Moderna Vaccine Admin Charge

Facility

$142.00

Service Code	HCPCS 0012A
Hospital Charge Code	9250680
Hospital Revenue Code	771
Min. Negotiated Rate	$120.70
Max. Negotiated Rate	$137.74
Rate for Payer: Cash Price	$92.30
Rate for Payer: Health Management Network Commercial	$120.70
Rate for Payer: Kaiser Permanente Commercial	$127.80
Rate for Payer: MDX Hawaii PPO	$137.74

Moderna Vaccine 2nd dose: 0012A - 100mcg - Moderna Vaccine Admin Charge

Facility

$142.00

Service Code	HCPCS 0012A
Hospital Charge Code	9250680
Hospital Revenue Code	771
Min. Negotiated Rate	$71.00
Max. Negotiated Rate	$137.74
Rate for Payer: AlohaCare Medicaid	$71.00
Rate for Payer: AlohaCare Medicare	$71.00
Rate for Payer: Cash Price	$92.30
Rate for Payer: Devoted Health Medicare	$78.10
Rate for Payer: Hawaii Medical Service Association Medicare	$71.00
Rate for Payer: Hawaii Western Management Group Commercial	$134.90
Rate for Payer: Health Management Network Commercial	$120.70
Rate for Payer: Humana Medicare	$71.00
Rate for Payer: Kaiser Permanente Commercial	$127.80
Rate for Payer: Kaiser Permanente Medicaid	$72.42
Rate for Payer: Kaiser Permanente Medicare	$71.00
Rate for Payer: MDX Hawaii PPO	$137.74
Rate for Payer: Ohana Health Plan Medicaid	$71.00
Rate for Payer: Ohana Health Plan Medicare	$71.00
Rate for Payer: UnitedHealthcare Medicare	$71.00
Rate for Payer: University Health Alliance Commercial	$79.52

Moderna Vaccine 3rd Dose: 0013A - 100mcg - Moderna Vaccine Admin Charge

Facility

$142.00

Service Code	HCPCS 0013A
Hospital Charge Code	9687165
Hospital Revenue Code	771
Min. Negotiated Rate	$120.70
Max. Negotiated Rate	$137.74
Rate for Payer: Cash Price	$92.30
Rate for Payer: Health Management Network Commercial	$120.70
Rate for Payer: Kaiser Permanente Commercial	$127.80
Rate for Payer: MDX Hawaii PPO	$137.74

Moderna Vaccine 3rd Dose: 0013A - 100mcg - Moderna Vaccine Admin Charge

Facility

$142.00

Service Code	HCPCS 0013A
Hospital Charge Code	9687165
Hospital Revenue Code	771
Min. Negotiated Rate	$71.00
Max. Negotiated Rate	$137.74
Rate for Payer: AlohaCare Medicaid	$71.00
Rate for Payer: AlohaCare Medicare	$71.00
Rate for Payer: Cash Price	$92.30
Rate for Payer: Devoted Health Medicare	$78.10
Rate for Payer: Hawaii Medical Service Association Medicare	$71.00
Rate for Payer: Hawaii Western Management Group Commercial	$134.90
Rate for Payer: Health Management Network Commercial	$120.70
Rate for Payer: Humana Medicare	$71.00
Rate for Payer: Kaiser Permanente Commercial	$127.80
Rate for Payer: Kaiser Permanente Medicaid	$72.42
Rate for Payer: Kaiser Permanente Medicare	$71.00
Rate for Payer: MDX Hawaii PPO	$137.74
Rate for Payer: Ohana Health Plan Medicaid	$71.00
Rate for Payer: Ohana Health Plan Medicare	$71.00
Rate for Payer: UnitedHealthcare Medicare	$71.00
Rate for Payer: University Health Alliance Commercial	$79.52

Mod Sed Different Phys, ea addtl 15 min, 5/> years Charge

Facility

$87.00

Service Code	HCPCS 99157
Hospital Charge Code	8704044
Hospital Revenue Code	370
Min. Negotiated Rate	$43.50
Max. Negotiated Rate	$84.39
Rate for Payer: AlohaCare Medicaid	$43.50
Rate for Payer: AlohaCare Medicare	$43.50
Rate for Payer: Cash Price	$56.55
Rate for Payer: Cash Price	$56.55
Rate for Payer: Devoted Health Medicare	$47.85
Rate for Payer: Hawaii Medical Service Association Medicare	$43.50
Rate for Payer: Hawaii Western Management Group Commercial	$82.65
Rate for Payer: Health Management Network Commercial	$73.95
Rate for Payer: Humana Medicare	$43.50
Rate for Payer: Kaiser Permanente Commercial	$78.30
Rate for Payer: Kaiser Permanente Medicaid	$44.37
Rate for Payer: Kaiser Permanente Medicare	$43.50
Rate for Payer: MDX Hawaii PPO	$84.39
Rate for Payer: Ohana Health Plan Medicaid	$43.50
Rate for Payer: Ohana Health Plan Medicare	$43.50
Rate for Payer: UnitedHealthcare Medicaid	$58.96
Rate for Payer: UnitedHealthcare Medicare	$43.50
Rate for Payer: University Health Alliance Commercial	$48.72

Mod Sed Different Phys, ea addtl 15 min, 5/> years Charge

Facility

$87.00

Service Code	HCPCS 99157
Hospital Charge Code	8704044
Hospital Revenue Code	370
Min. Negotiated Rate	$73.95
Max. Negotiated Rate	$84.39
Rate for Payer: Cash Price	$56.55
Rate for Payer: Health Management Network Commercial	$73.95
Rate for Payer: Kaiser Permanente Commercial	$78.30
Rate for Payer: MDX Hawaii PPO	$84.39

Mod Sed Different Phys, initial 15 min, 5/> years charge

Facility

$149.00

Service Code	HCPCS 99156
Hospital Charge Code	8704043
Hospital Revenue Code	370
Min. Negotiated Rate	$53.37
Max. Negotiated Rate	$144.53
Rate for Payer: AlohaCare Medicaid	$74.50
Rate for Payer: AlohaCare Medicare	$74.50
Rate for Payer: Cash Price	$96.85
Rate for Payer: Cash Price	$96.85
Rate for Payer: Devoted Health Medicare	$81.95
Rate for Payer: Hawaii Medical Service Association Medicare	$74.50
Rate for Payer: Hawaii Western Management Group Commercial	$141.55
Rate for Payer: Health Management Network Commercial	$126.65
Rate for Payer: Humana Medicare	$74.50
Rate for Payer: Kaiser Permanente Commercial	$134.10
Rate for Payer: Kaiser Permanente Medicaid	$75.99
Rate for Payer: Kaiser Permanente Medicare	$74.50
Rate for Payer: MDX Hawaii PPO	$144.53
Rate for Payer: Ohana Health Plan Medicaid	$74.50
Rate for Payer: Ohana Health Plan Medicare	$74.50
Rate for Payer: UnitedHealthcare Medicaid	$53.37
Rate for Payer: UnitedHealthcare Medicare	$74.50
Rate for Payer: University Health Alliance Commercial	$83.44

Mod Sed Different Phys, initial 15 min, 5/> years charge

Facility

$149.00

Service Code	HCPCS 99156
Hospital Charge Code	8704043
Hospital Revenue Code	370
Min. Negotiated Rate	$126.65
Max. Negotiated Rate	$144.53
Rate for Payer: Cash Price	$96.85
Rate for Payer: Health Management Network Commercial	$126.65
Rate for Payer: Kaiser Permanente Commercial	$134.10
Rate for Payer: MDX Hawaii PPO	$144.53

Mod Sed Different Phys,, initial 15 mins, less than 5 years old Charge

Facility

$163.00

Service Code	HCPCS 99155
Hospital Charge Code	8704042
Hospital Revenue Code	370
Min. Negotiated Rate	$138.55
Max. Negotiated Rate	$158.11
Rate for Payer: Cash Price	$105.95
Rate for Payer: Health Management Network Commercial	$138.55
Rate for Payer: Kaiser Permanente Commercial	$146.70
Rate for Payer: MDX Hawaii PPO	$158.11

Mod Sed Different Phys,, initial 15 mins, less than 5 years old Charge

Facility

$163.00

Service Code	HCPCS 99155
Hospital Charge Code	8704042
Hospital Revenue Code	370
Min. Negotiated Rate	$59.68
Max. Negotiated Rate	$158.11
Rate for Payer: AlohaCare Medicaid	$81.50
Rate for Payer: AlohaCare Medicare	$81.50
Rate for Payer: Cash Price	$105.95
Rate for Payer: Cash Price	$105.95
Rate for Payer: Devoted Health Medicare	$89.65
Rate for Payer: Hawaii Medical Service Association Medicare	$81.50
Rate for Payer: Hawaii Western Management Group Commercial	$154.85
Rate for Payer: Health Management Network Commercial	$138.55
Rate for Payer: Humana Medicare	$81.50
Rate for Payer: Kaiser Permanente Commercial	$146.70
Rate for Payer: Kaiser Permanente Medicaid	$83.13
Rate for Payer: Kaiser Permanente Medicare	$81.50
Rate for Payer: MDX Hawaii PPO	$158.11
Rate for Payer: Ohana Health Plan Medicaid	$81.50
Rate for Payer: Ohana Health Plan Medicare	$81.50
Rate for Payer: UnitedHealthcare Medicaid	$59.68
Rate for Payer: UnitedHealthcare Medicare	$81.50
Rate for Payer: University Health Alliance Commercial	$91.28

Mod Sed Same Phys, ea addtl 15 min, 5/> years Charge

Facility

$129.00

Service Code	HCPCS 99153
Hospital Charge Code	8386868
Hospital Revenue Code	370
Min. Negotiated Rate	$13.00
Max. Negotiated Rate	$125.13
Rate for Payer: AlohaCare Medicaid	$64.50
Rate for Payer: AlohaCare Medicare	$64.50
Rate for Payer: Cash Price	$83.85
Rate for Payer: Cash Price	$83.85
Rate for Payer: Devoted Health Medicare	$70.95
Rate for Payer: Hawaii Medical Service Association Medicare	$64.50
Rate for Payer: Hawaii Western Management Group Commercial	$122.55
Rate for Payer: Health Management Network Commercial	$109.65
Rate for Payer: Humana Medicare	$64.50
Rate for Payer: Kaiser Permanente Commercial	$116.10
Rate for Payer: Kaiser Permanente Medicaid	$65.79
Rate for Payer: Kaiser Permanente Medicare	$64.50
Rate for Payer: MDX Hawaii PPO	$125.13
Rate for Payer: Ohana Health Plan Medicaid	$64.50
Rate for Payer: Ohana Health Plan Medicare	$64.50
Rate for Payer: UnitedHealthcare Medicaid	$13.00
Rate for Payer: UnitedHealthcare Medicare	$64.50
Rate for Payer: University Health Alliance Commercial	$72.24

Know your out-of-pocket cost for care.

All Charges