Samuel Mahelona Memorial Hospital

All Charges

Charge

Type

Setting

Price

moxifloxacin 0.5% ophth 3ml [HHSC]

Facility

$591.76

Service Code	NDC 68180042201
Hospital Charge Code	2500567
Hospital Revenue Code	250
Min. Negotiated Rate	$295.88
Max. Negotiated Rate	$574.01
Rate for Payer: AlohaCare Medicaid	$295.88
Rate for Payer: AlohaCare Medicare	$295.88
Rate for Payer: Cash Price	$384.64
Rate for Payer: Devoted Health Medicare	$325.47
Rate for Payer: Hawaii Medical Service Association Medicare	$295.88
Rate for Payer: Hawaii Western Management Group Commercial	$562.17
Rate for Payer: Health Management Network Commercial	$503.00
Rate for Payer: Humana Medicare	$295.88
Rate for Payer: Kaiser Permanente Commercial	$532.58
Rate for Payer: Kaiser Permanente Medicaid	$301.80
Rate for Payer: Kaiser Permanente Medicare	$295.88
Rate for Payer: MDX Hawaii PPO	$574.01
Rate for Payer: Ohana Health Plan Medicaid	$295.88
Rate for Payer: Ohana Health Plan Medicare	$295.88
Rate for Payer: UnitedHealthcare Medicaid	$355.06
Rate for Payer: UnitedHealthcare Medicare	$295.88
Rate for Payer: University Health Alliance Commercial	$431.33

moxifloxacin 0.5% ophth 3ml [HHSC]

Facility

$76.34

Service Code	NDC 72266015801
Hospital Charge Code	2500567
Hospital Revenue Code	250
Min. Negotiated Rate	$38.17
Max. Negotiated Rate	$74.05
Rate for Payer: AlohaCare Medicaid	$38.17
Rate for Payer: AlohaCare Medicare	$38.17
Rate for Payer: Cash Price	$49.62
Rate for Payer: Devoted Health Medicare	$41.99
Rate for Payer: Hawaii Medical Service Association Medicare	$38.17
Rate for Payer: Hawaii Western Management Group Commercial	$72.52
Rate for Payer: Health Management Network Commercial	$64.89
Rate for Payer: Humana Medicare	$38.17
Rate for Payer: Kaiser Permanente Commercial	$68.71
Rate for Payer: Kaiser Permanente Medicaid	$38.93
Rate for Payer: Kaiser Permanente Medicare	$38.17
Rate for Payer: MDX Hawaii PPO	$74.05
Rate for Payer: Ohana Health Plan Medicaid	$38.17
Rate for Payer: Ohana Health Plan Medicare	$38.17
Rate for Payer: UnitedHealthcare Medicaid	$45.80
Rate for Payer: UnitedHealthcare Medicare	$38.17
Rate for Payer: University Health Alliance Commercial	$55.64

moxifloxacin 0.5% ophth 3ml [HHSC]

Facility

$591.70

Service Code	NDC 62332050503
Hospital Charge Code	2500567
Hospital Revenue Code	250
Min. Negotiated Rate	$502.94
Max. Negotiated Rate	$573.95
Rate for Payer: Cash Price	$384.60
Rate for Payer: Health Management Network Commercial	$502.94
Rate for Payer: Kaiser Permanente Commercial	$532.53
Rate for Payer: MDX Hawaii PPO	$573.95

moxifloxacin 0.5% ophth 3ml [HHSC]

Facility

$591.76

Service Code	NDC 60505058204
Hospital Charge Code	2500567
Hospital Revenue Code	250
Min. Negotiated Rate	$295.88
Max. Negotiated Rate	$574.01
Rate for Payer: AlohaCare Medicaid	$295.88
Rate for Payer: AlohaCare Medicare	$295.88
Rate for Payer: Cash Price	$384.64
Rate for Payer: Devoted Health Medicare	$325.47
Rate for Payer: Hawaii Medical Service Association Medicare	$295.88
Rate for Payer: Hawaii Western Management Group Commercial	$562.17
Rate for Payer: Health Management Network Commercial	$503.00
Rate for Payer: Humana Medicare	$295.88
Rate for Payer: Kaiser Permanente Commercial	$532.58
Rate for Payer: Kaiser Permanente Medicaid	$301.80
Rate for Payer: Kaiser Permanente Medicare	$295.88
Rate for Payer: MDX Hawaii PPO	$574.01
Rate for Payer: Ohana Health Plan Medicaid	$295.88
Rate for Payer: Ohana Health Plan Medicare	$295.88
Rate for Payer: UnitedHealthcare Medicaid	$355.06
Rate for Payer: UnitedHealthcare Medicare	$295.88
Rate for Payer: University Health Alliance Commercial	$431.33

moxifloxacin 0.5% ophth 3ml [HHSC]

Facility

$591.76

Service Code	NDC 00378543035
Hospital Charge Code	2500567
Hospital Revenue Code	250
Min. Negotiated Rate	$295.88
Max. Negotiated Rate	$574.01
Rate for Payer: AlohaCare Medicaid	$295.88
Rate for Payer: AlohaCare Medicare	$295.88
Rate for Payer: Cash Price	$384.64
Rate for Payer: Devoted Health Medicare	$325.47
Rate for Payer: Hawaii Medical Service Association Medicare	$295.88
Rate for Payer: Hawaii Western Management Group Commercial	$562.17
Rate for Payer: Health Management Network Commercial	$503.00
Rate for Payer: Humana Medicare	$295.88
Rate for Payer: Kaiser Permanente Commercial	$532.58
Rate for Payer: Kaiser Permanente Medicaid	$301.80
Rate for Payer: Kaiser Permanente Medicare	$295.88
Rate for Payer: MDX Hawaii PPO	$574.01
Rate for Payer: Ohana Health Plan Medicaid	$295.88
Rate for Payer: Ohana Health Plan Medicare	$295.88
Rate for Payer: UnitedHealthcare Medicaid	$355.06
Rate for Payer: UnitedHealthcare Medicare	$295.88
Rate for Payer: University Health Alliance Commercial	$431.33

moxifloxacin 0.5% ophth 3ml [HHSC]

Facility

$634.36

Service Code	NDC 00065401303
Hospital Charge Code	2500567
Hospital Revenue Code	250
Min. Negotiated Rate	$317.18
Max. Negotiated Rate	$615.33
Rate for Payer: AlohaCare Medicaid	$317.18
Rate for Payer: AlohaCare Medicare	$317.18
Rate for Payer: Cash Price	$412.33
Rate for Payer: Devoted Health Medicare	$348.90
Rate for Payer: Hawaii Medical Service Association Medicare	$317.18
Rate for Payer: Hawaii Western Management Group Commercial	$602.64
Rate for Payer: Health Management Network Commercial	$539.21
Rate for Payer: Humana Medicare	$317.18
Rate for Payer: Kaiser Permanente Commercial	$570.92
Rate for Payer: Kaiser Permanente Medicaid	$323.52
Rate for Payer: Kaiser Permanente Medicare	$317.18
Rate for Payer: MDX Hawaii PPO	$615.33
Rate for Payer: Ohana Health Plan Medicaid	$317.18
Rate for Payer: Ohana Health Plan Medicare	$317.18
Rate for Payer: UnitedHealthcare Medicaid	$380.62
Rate for Payer: UnitedHealthcare Medicare	$317.18
Rate for Payer: University Health Alliance Commercial	$462.39

moxifloxacin 0.5% ophth 3ml [HHSC]

Facility

$634.36

Service Code	NDC 00065401303
Hospital Charge Code	2500567
Hospital Revenue Code	250
Min. Negotiated Rate	$539.21
Max. Negotiated Rate	$615.33
Rate for Payer: Cash Price	$412.33
Rate for Payer: Health Management Network Commercial	$539.21
Rate for Payer: Kaiser Permanente Commercial	$570.92
Rate for Payer: MDX Hawaii PPO	$615.33

moxifloxacin 0.5% ophth 3ml [HHSC]

Facility

$76.34

Service Code	NDC 72266015801
Hospital Charge Code	2500567
Hospital Revenue Code	250
Min. Negotiated Rate	$64.89
Max. Negotiated Rate	$74.05
Rate for Payer: Cash Price	$49.62
Rate for Payer: Health Management Network Commercial	$64.89
Rate for Payer: Kaiser Permanente Commercial	$68.71
Rate for Payer: MDX Hawaii PPO	$74.05

moxifloxacin 0.5% ophth 3ml [HHSC]

Facility

$591.76

Service Code	NDC 65862084003
Hospital Charge Code	2500567
Hospital Revenue Code	250
Min. Negotiated Rate	$295.88
Max. Negotiated Rate	$574.01
Rate for Payer: AlohaCare Medicaid	$295.88
Rate for Payer: AlohaCare Medicare	$295.88
Rate for Payer: Cash Price	$384.64
Rate for Payer: Devoted Health Medicare	$325.47
Rate for Payer: Hawaii Medical Service Association Medicare	$295.88
Rate for Payer: Hawaii Western Management Group Commercial	$562.17
Rate for Payer: Health Management Network Commercial	$503.00
Rate for Payer: Humana Medicare	$295.88
Rate for Payer: Kaiser Permanente Commercial	$532.58
Rate for Payer: Kaiser Permanente Medicaid	$301.80
Rate for Payer: Kaiser Permanente Medicare	$295.88
Rate for Payer: MDX Hawaii PPO	$574.01
Rate for Payer: Ohana Health Plan Medicaid	$295.88
Rate for Payer: Ohana Health Plan Medicare	$295.88
Rate for Payer: UnitedHealthcare Medicaid	$355.06
Rate for Payer: UnitedHealthcare Medicare	$295.88
Rate for Payer: University Health Alliance Commercial	$431.33

moxifloxacin 0.5% ophth 3ml [HHSC]

Facility

$591.76

Service Code	NDC 60505058204
Hospital Charge Code	2500567
Hospital Revenue Code	250
Min. Negotiated Rate	$503.00
Max. Negotiated Rate	$574.01
Rate for Payer: Cash Price	$384.64
Rate for Payer: Health Management Network Commercial	$503.00
Rate for Payer: Kaiser Permanente Commercial	$532.58
Rate for Payer: MDX Hawaii PPO	$574.01

.MPL Codon 515 Mutation FSI

Facility

$515.00

Service Code	HCPCS 81338
Hospital Charge Code	10593929
Hospital Revenue Code	310
Min. Negotiated Rate	$437.75
Max. Negotiated Rate	$499.55
Rate for Payer: Cash Price	$334.75
Rate for Payer: Health Management Network Commercial	$437.75
Rate for Payer: Kaiser Permanente Commercial	$463.50
Rate for Payer: MDX Hawaii PPO	$499.55

.MPL Codon 515 Mutation FSI

Facility

$515.00

Service Code	HCPCS 81338
Hospital Charge Code	10593929
Hospital Revenue Code	310
Min. Negotiated Rate	$90.20
Max. Negotiated Rate	$499.55
Rate for Payer: AlohaCare Medicaid	$257.50
Rate for Payer: AlohaCare Medicare	$257.50
Rate for Payer: Cash Price	$334.75
Rate for Payer: Cash Price	$334.75
Rate for Payer: Devoted Health Medicare	$283.25
Rate for Payer: Hawaii Medical Service Association ABD	$150.33
Rate for Payer: Hawaii Medical Service Association Commercial	$187.91
Rate for Payer: Hawaii Medical Service Association Medicare	$257.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$150.33
Rate for Payer: Hawaii Western Management Group Commercial	$150.33
Rate for Payer: Health Management Network Commercial	$437.75
Rate for Payer: Humana Medicare	$257.50
Rate for Payer: Kaiser Permanente Commercial	$463.50
Rate for Payer: Kaiser Permanente Medicaid	$262.65
Rate for Payer: Kaiser Permanente Medicare	$257.50
Rate for Payer: MDX Hawaii PPO	$499.55
Rate for Payer: Ohana Health Plan Medicaid	$257.50
Rate for Payer: Ohana Health Plan Medicare	$257.50
Rate for Payer: UnitedHealthcare Medicaid	$90.20
Rate for Payer: UnitedHealthcare Medicare	$257.50
Rate for Payer: University Health Alliance Commercial	$288.40

MRI Guided Abdominal Mass Biopsy

Facility

$3,181.00

Service Code	HCPCS 49180
Hospital Charge Code	8211740
Hospital Revenue Code	761
Min. Negotiated Rate	$2,703.85
Max. Negotiated Rate	$3,085.57
Rate for Payer: Cash Price	$2,067.65
Rate for Payer: Health Management Network Commercial	$2,703.85
Rate for Payer: Kaiser Permanente Commercial	$2,862.90
Rate for Payer: MDX Hawaii PPO	$3,085.57

MRI Guided Abdominal Mass Biopsy

Facility

$3,181.00

Service Code	HCPCS 49180
Hospital Charge Code	8211740
Hospital Revenue Code	761
Min. Negotiated Rate	$456.03
Max. Negotiated Rate	$3,085.57
Rate for Payer: AlohaCare Medicaid	$1,590.50
Rate for Payer: AlohaCare Medicare	$1,590.50
Rate for Payer: Cash Price	$2,067.65
Rate for Payer: Cash Price	$2,067.65
Rate for Payer: Cash Price	$2,067.65
Rate for Payer: Devoted Health Medicare	$1,749.55
Rate for Payer: Hawaii Medical Service Association Commercial	$2,109.21
Rate for Payer: Hawaii Medical Service Association Medicare	$1,590.50
Rate for Payer: Hawaii Western Management Group Commercial	$3,021.95
Rate for Payer: Health Management Network Commercial	$2,703.85
Rate for Payer: Humana Medicare	$1,590.50
Rate for Payer: Kaiser Permanente Commercial	$2,862.90
Rate for Payer: Kaiser Permanente Medicaid	$1,622.31
Rate for Payer: Kaiser Permanente Medicare	$1,590.50
Rate for Payer: MDX Hawaii PPO	$3,085.57
Rate for Payer: Ohana Health Plan Medicaid	$1,590.50
Rate for Payer: Ohana Health Plan Medicare	$1,590.50
Rate for Payer: UnitedHealthcare Medicaid	$456.03
Rate for Payer: UnitedHealthcare Medicare	$1,590.50
Rate for Payer: University Health Alliance Commercial	$1,781.36

MRI LE Joint w/ Contrast Left

Facility

$3,679.00

Service Code	HCPCS 73722 LT
Hospital Charge Code	8211743
Hospital Revenue Code	610
Min. Negotiated Rate	$3,127.15
Max. Negotiated Rate	$3,568.63
Rate for Payer: Cash Price	$2,391.35
Rate for Payer: Health Management Network Commercial	$3,127.15
Rate for Payer: Kaiser Permanente Commercial	$3,311.10
Rate for Payer: MDX Hawaii PPO	$3,568.63

MRI LE Joint w/ Contrast Left

Facility

$3,679.00

Service Code	HCPCS 73722 LT
Hospital Charge Code	8211743
Hospital Revenue Code	610
Min. Negotiated Rate	$382.28
Max. Negotiated Rate	$3,568.63
Rate for Payer: AlohaCare Medicaid	$1,839.50
Rate for Payer: AlohaCare Medicare	$1,839.50
Rate for Payer: Cash Price	$2,391.35
Rate for Payer: Cash Price	$2,391.35
Rate for Payer: Devoted Health Medicare	$2,023.45
Rate for Payer: Hawaii Medical Service Association ABD	$382.28
Rate for Payer: Hawaii Medical Service Association Medicare	$1,839.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$475.88
Rate for Payer: Hawaii Western Management Group Commercial	$3,495.05
Rate for Payer: Health Management Network Commercial	$3,127.15
Rate for Payer: Humana Medicare	$1,839.50
Rate for Payer: Kaiser Permanente Commercial	$3,311.10
Rate for Payer: Kaiser Permanente Medicaid	$1,876.29
Rate for Payer: Kaiser Permanente Medicare	$1,839.50
Rate for Payer: MDX Hawaii PPO	$3,568.63
Rate for Payer: Ohana Health Plan Medicaid	$1,839.50
Rate for Payer: Ohana Health Plan Medicare	$1,839.50
Rate for Payer: UnitedHealthcare Medicaid	$382.28
Rate for Payer: UnitedHealthcare Medicare	$1,839.50
Rate for Payer: University Health Alliance Commercial	$973.95

MRI LE Joint w/ Contrast Left - Report

Professional

Both

$1,091.00

Service Code	HCPCS 73722 26,LT
Hospital Charge Code	8211745
Hospital Revenue Code	972
Min. Negotiated Rate	$216.03
Max. Negotiated Rate	$927.35
Rate for Payer: AlohaCare Medicaid	$216.03
Rate for Payer: Cash Price	$709.15
Rate for Payer: Cash Price	$709.15
Rate for Payer: Hawaii Western Management Group Commercial	$614.42
Rate for Payer: Health Management Network Commercial	$927.35
Rate for Payer: Ohana Health Plan Medicaid	$216.03
Rate for Payer: UnitedHealthcare Medicaid	$216.03

MRI LE Joint w/ Contrast Right

Facility

$3,679.00

Service Code	HCPCS 73722 RT
Hospital Charge Code	8211746
Hospital Revenue Code	610
Min. Negotiated Rate	$382.28
Max. Negotiated Rate	$3,568.63
Rate for Payer: AlohaCare Medicaid	$1,839.50
Rate for Payer: AlohaCare Medicare	$1,839.50
Rate for Payer: Cash Price	$2,391.35
Rate for Payer: Cash Price	$2,391.35
Rate for Payer: Devoted Health Medicare	$2,023.45
Rate for Payer: Hawaii Medical Service Association ABD	$382.28
Rate for Payer: Hawaii Medical Service Association Medicare	$1,839.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$475.88
Rate for Payer: Hawaii Western Management Group Commercial	$3,495.05
Rate for Payer: Health Management Network Commercial	$3,127.15
Rate for Payer: Humana Medicare	$1,839.50
Rate for Payer: Kaiser Permanente Commercial	$3,311.10
Rate for Payer: Kaiser Permanente Medicaid	$1,876.29
Rate for Payer: Kaiser Permanente Medicare	$1,839.50
Rate for Payer: MDX Hawaii PPO	$3,568.63
Rate for Payer: Ohana Health Plan Medicaid	$1,839.50
Rate for Payer: Ohana Health Plan Medicare	$1,839.50
Rate for Payer: UnitedHealthcare Medicaid	$382.28
Rate for Payer: UnitedHealthcare Medicare	$1,839.50
Rate for Payer: University Health Alliance Commercial	$973.95

MRI LE Joint w/ Contrast Right

Facility

$3,679.00

Service Code	HCPCS 73722 RT
Hospital Charge Code	8211746
Hospital Revenue Code	610
Min. Negotiated Rate	$3,127.15
Max. Negotiated Rate	$3,568.63
Rate for Payer: Cash Price	$2,391.35
Rate for Payer: Health Management Network Commercial	$3,127.15
Rate for Payer: Kaiser Permanente Commercial	$3,311.10
Rate for Payer: MDX Hawaii PPO	$3,568.63

MRI LE Joint w/ Contrast Right - Report

Professional

Both

$1,091.00

Service Code	HCPCS 73722 26,RT
Hospital Charge Code	8211748
Hospital Revenue Code	972
Min. Negotiated Rate	$216.03
Max. Negotiated Rate	$927.35
Rate for Payer: AlohaCare Medicaid	$216.03
Rate for Payer: Cash Price	$709.15
Rate for Payer: Cash Price	$709.15
Rate for Payer: Hawaii Western Management Group Commercial	$614.42
Rate for Payer: Health Management Network Commercial	$927.35
Rate for Payer: Ohana Health Plan Medicaid	$216.03
Rate for Payer: UnitedHealthcare Medicaid	$216.03

MRI LE Joint w/o Contrast Left

Facility

$1,741.00

Service Code	HCPCS 73721 LT
Hospital Charge Code	8211749
Hospital Revenue Code	610
Min. Negotiated Rate	$1,479.85
Max. Negotiated Rate	$1,688.77
Rate for Payer: Cash Price	$1,131.65
Rate for Payer: Health Management Network Commercial	$1,479.85
Rate for Payer: Kaiser Permanente Commercial	$1,566.90
Rate for Payer: MDX Hawaii PPO	$1,688.77

MRI LE Joint w/o Contrast Left

Facility

$1,741.00

Service Code	HCPCS 73721 LT
Hospital Charge Code	8211749
Hospital Revenue Code	610
Min. Negotiated Rate	$396.10
Max. Negotiated Rate	$1,688.77
Rate for Payer: AlohaCare Medicaid	$870.50
Rate for Payer: AlohaCare Medicare	$870.50
Rate for Payer: Cash Price	$1,131.65
Rate for Payer: Cash Price	$1,131.65
Rate for Payer: Devoted Health Medicare	$957.55
Rate for Payer: Hawaii Medical Service Association ABD	$396.10
Rate for Payer: Hawaii Medical Service Association Medicare	$870.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$415.91
Rate for Payer: Hawaii Western Management Group Commercial	$1,653.95
Rate for Payer: Health Management Network Commercial	$1,479.85
Rate for Payer: Humana Medicare	$870.50
Rate for Payer: Kaiser Permanente Commercial	$1,566.90
Rate for Payer: Kaiser Permanente Medicaid	$887.91
Rate for Payer: Kaiser Permanente Medicare	$870.50
Rate for Payer: MDX Hawaii PPO	$1,688.77
Rate for Payer: Ohana Health Plan Medicaid	$870.50
Rate for Payer: Ohana Health Plan Medicare	$870.50
Rate for Payer: UnitedHealthcare Medicaid	$396.10
Rate for Payer: UnitedHealthcare Medicare	$870.50
Rate for Payer: University Health Alliance Commercial	$837.57

MRI LE Joint w/o Contrast Left - Report

Professional

Both

$332.00

Service Code	HCPCS 73721 26,LT
Hospital Charge Code	8211751
Hospital Revenue Code	972
Min. Negotiated Rate	$138.35
Max. Negotiated Rate	$565.39
Rate for Payer: AlohaCare Medicaid	$138.35
Rate for Payer: Cash Price	$215.80
Rate for Payer: Cash Price	$215.80
Rate for Payer: Hawaii Western Management Group Commercial	$565.39
Rate for Payer: Health Management Network Commercial	$282.20
Rate for Payer: Ohana Health Plan Medicaid	$138.35
Rate for Payer: UnitedHealthcare Medicaid	$138.35

MRI LE Joint w/o Contrast Right

Facility

$1,741.00

Service Code	HCPCS 73721 RT
Hospital Charge Code	8211752
Hospital Revenue Code	610
Min. Negotiated Rate	$1,479.85
Max. Negotiated Rate	$1,688.77
Rate for Payer: Cash Price	$1,131.65
Rate for Payer: Health Management Network Commercial	$1,479.85
Rate for Payer: Kaiser Permanente Commercial	$1,566.90
Rate for Payer: MDX Hawaii PPO	$1,688.77

MRI LE Joint w/o Contrast Right

Facility

$1,741.00

Service Code	HCPCS 73721 RT
Hospital Charge Code	8211752
Hospital Revenue Code	610
Min. Negotiated Rate	$396.10
Max. Negotiated Rate	$1,688.77
Rate for Payer: AlohaCare Medicaid	$870.50
Rate for Payer: AlohaCare Medicare	$870.50
Rate for Payer: Cash Price	$1,131.65
Rate for Payer: Cash Price	$1,131.65
Rate for Payer: Devoted Health Medicare	$957.55
Rate for Payer: Hawaii Medical Service Association ABD	$396.10
Rate for Payer: Hawaii Medical Service Association Medicare	$870.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$415.91
Rate for Payer: Hawaii Western Management Group Commercial	$1,653.95
Rate for Payer: Health Management Network Commercial	$1,479.85
Rate for Payer: Humana Medicare	$870.50
Rate for Payer: Kaiser Permanente Commercial	$1,566.90
Rate for Payer: Kaiser Permanente Medicaid	$887.91
Rate for Payer: Kaiser Permanente Medicare	$870.50
Rate for Payer: MDX Hawaii PPO	$1,688.77
Rate for Payer: Ohana Health Plan Medicaid	$870.50
Rate for Payer: Ohana Health Plan Medicare	$870.50
Rate for Payer: UnitedHealthcare Medicaid	$396.10
Rate for Payer: UnitedHealthcare Medicare	$870.50
Rate for Payer: University Health Alliance Commercial	$837.57

Know your out-of-pocket cost for care.

All Charges