Samuel Mahelona Memorial Hospital

All Charges

Charge

Type

Setting

Price

multivitamin with minerals tablet [HHSC]

Facility

$3.00

Service Code	NDC 00536466110
Hospital Charge Code	2500819
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

multivitamin with minerals tablet [HHSC]

Facility

$3.00

Service Code	NDC 40985022368
Hospital Charge Code	2500819
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

multivitamin with minerals tablet [HHSC]

Facility

$3.00

Service Code	NDC 00904549261
Hospital Charge Code	2500819
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

Mumps Antibody, IgG REF

Facility

$128.00

Service Code	HCPCS 86735
Hospital Charge Code	8118000
Hospital Revenue Code	302
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

Mumps Antibody, IgG REF

Facility

$128.00

Service Code	HCPCS 86735
Hospital Charge Code	8118000
Hospital Revenue Code	302
Min. Negotiated Rate	$13.05
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: Cash Price	$83.20
Rate for Payer: Devoted Health Medicare	$70.40
Rate for Payer: Hawaii Medical Service Association ABD	$18.03
Rate for Payer: Hawaii Medical Service Association Commercial	$16.31
Rate for Payer: Hawaii Medical Service Association Medicare	$64.00
Rate for Payer: Hawaii Medical Service Association Non-ABD	$18.93
Rate for Payer: Hawaii Western Management Group Commercial	$13.05
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	$18.03
Rate for Payer: UnitedHealthcare Medicare	$64.00
Rate for Payer: University Health Alliance Commercial	$33.73

Mumps PCR to DOH FSI

Facility

$149.00

Service Code	HCPCS 86735
Hospital Charge Code	8228900
Hospital Revenue Code	302
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

Mumps PCR to DOH FSI

Facility

$149.00

Service Code	HCPCS 86735
Hospital Charge Code	8228900
Hospital Revenue Code	302
Min. Negotiated Rate	$13.05
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 ABD	$18.03
Rate for Payer: Hawaii Medical Service Association Commercial	$16.31
Rate for Payer: Hawaii Medical Service Association Medicare	$74.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$18.93
Rate for Payer: Hawaii Western Management Group Commercial	$13.05
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	$18.03
Rate for Payer: UnitedHealthcare Medicare	$74.50
Rate for Payer: University Health Alliance Commercial	$33.73

Mumps Virus Ab (IgM) REF

Facility

$149.00

Service Code	HCPCS 86735
Hospital Charge Code	8160296
Hospital Revenue Code	302
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

Mumps Virus Ab (IgM) REF

Facility

$149.00

Service Code	HCPCS 86735
Hospital Charge Code	8160296
Hospital Revenue Code	302
Min. Negotiated Rate	$13.05
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 ABD	$18.03
Rate for Payer: Hawaii Medical Service Association Commercial	$16.31
Rate for Payer: Hawaii Medical Service Association Medicare	$74.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$18.93
Rate for Payer: Hawaii Western Management Group Commercial	$13.05
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	$18.03
Rate for Payer: UnitedHealthcare Medicare	$74.50
Rate for Payer: University Health Alliance Commercial	$33.73

mupirocin 2% ointment 22gm [HHSC]

Facility

$196.85

Service Code	NDC 68462018022
Hospital Charge Code	2500571
Hospital Revenue Code	250
Min. Negotiated Rate	$167.32
Max. Negotiated Rate	$190.94
Rate for Payer: Cash Price	$127.95
Rate for Payer: Health Management Network Commercial	$167.32
Rate for Payer: Kaiser Permanente Commercial	$177.16
Rate for Payer: MDX Hawaii PPO	$190.94

mupirocin 2% ointment 22gm [HHSC]

Facility

$196.85

Service Code	NDC 68462018022
Hospital Charge Code	2500571
Hospital Revenue Code	250
Min. Negotiated Rate	$98.42
Max. Negotiated Rate	$190.94
Rate for Payer: AlohaCare Medicaid	$98.42
Rate for Payer: AlohaCare Medicare	$98.42
Rate for Payer: Cash Price	$127.95
Rate for Payer: Devoted Health Medicare	$108.27
Rate for Payer: Hawaii Medical Service Association Medicare	$98.42
Rate for Payer: Hawaii Western Management Group Commercial	$187.01
Rate for Payer: Health Management Network Commercial	$167.32
Rate for Payer: Humana Medicare	$98.42
Rate for Payer: Kaiser Permanente Commercial	$177.16
Rate for Payer: Kaiser Permanente Medicaid	$100.39
Rate for Payer: Kaiser Permanente Medicare	$98.42
Rate for Payer: MDX Hawaii PPO	$190.94
Rate for Payer: Ohana Health Plan Medicaid	$98.42
Rate for Payer: Ohana Health Plan Medicare	$98.42
Rate for Payer: UnitedHealthcare Medicaid	$118.11
Rate for Payer: UnitedHealthcare Medicare	$98.42
Rate for Payer: University Health Alliance Commercial	$143.48

mupirocin 2% ointment 22gm [HHSC]

Facility

$65.17

Service Code	NDC 45802011222
Hospital Charge Code	2500571
Hospital Revenue Code	250
Min. Negotiated Rate	$55.39
Max. Negotiated Rate	$63.21
Rate for Payer: Cash Price	$42.36
Rate for Payer: Health Management Network Commercial	$55.39
Rate for Payer: Kaiser Permanente Commercial	$58.65
Rate for Payer: MDX Hawaii PPO	$63.21

mupirocin 2% ointment 22gm [HHSC]

Facility

$65.17

Service Code	NDC 45802011222
Hospital Charge Code	2500571
Hospital Revenue Code	250
Min. Negotiated Rate	$32.59
Max. Negotiated Rate	$63.21
Rate for Payer: AlohaCare Medicaid	$32.59
Rate for Payer: AlohaCare Medicare	$32.59
Rate for Payer: Cash Price	$42.36
Rate for Payer: Devoted Health Medicare	$35.84
Rate for Payer: Hawaii Medical Service Association Medicare	$32.59
Rate for Payer: Hawaii Western Management Group Commercial	$61.91
Rate for Payer: Health Management Network Commercial	$55.39
Rate for Payer: Humana Medicare	$32.59
Rate for Payer: Kaiser Permanente Commercial	$58.65
Rate for Payer: Kaiser Permanente Medicaid	$33.24
Rate for Payer: Kaiser Permanente Medicare	$32.59
Rate for Payer: MDX Hawaii PPO	$63.21
Rate for Payer: Ohana Health Plan Medicaid	$32.59
Rate for Payer: Ohana Health Plan Medicare	$32.59
Rate for Payer: UnitedHealthcare Medicaid	$39.10
Rate for Payer: UnitedHealthcare Medicare	$32.59
Rate for Payer: University Health Alliance Commercial	$47.50

MVI, adult w/ vit K 10ml vial [HHSC]

Facility

$68.89

Service Code	NDC 54643900701
Hospital Charge Code	2500568
Hospital Revenue Code	250
Min. Negotiated Rate	$58.56
Max. Negotiated Rate	$66.82
Rate for Payer: Cash Price	$44.78
Rate for Payer: Health Management Network Commercial	$58.56
Rate for Payer: Kaiser Permanente Commercial	$62.00
Rate for Payer: MDX Hawaii PPO	$66.82

MVI, adult w/ vit K 10ml vial [HHSC]

Facility

$221.13

Service Code	NDC 54643564901
Hospital Charge Code	2500568
Hospital Revenue Code	250
Min. Negotiated Rate	$187.96
Max. Negotiated Rate	$214.50
Rate for Payer: Cash Price	$143.73
Rate for Payer: Health Management Network Commercial	$187.96
Rate for Payer: Kaiser Permanente Commercial	$199.02
Rate for Payer: MDX Hawaii PPO	$214.50

MVI, adult w/ vit K 10ml vial [HHSC]

Facility

$221.13

Service Code	NDC 54643564901
Hospital Charge Code	2500568
Hospital Revenue Code	250
Min. Negotiated Rate	$110.56
Max. Negotiated Rate	$214.50
Rate for Payer: AlohaCare Medicaid	$110.56
Rate for Payer: AlohaCare Medicare	$110.56
Rate for Payer: Cash Price	$143.73
Rate for Payer: Devoted Health Medicare	$121.62
Rate for Payer: Hawaii Medical Service Association Medicare	$110.56
Rate for Payer: Hawaii Western Management Group Commercial	$210.07
Rate for Payer: Health Management Network Commercial	$187.96
Rate for Payer: Humana Medicare	$110.56
Rate for Payer: Kaiser Permanente Commercial	$199.02
Rate for Payer: Kaiser Permanente Medicaid	$112.78
Rate for Payer: Kaiser Permanente Medicare	$110.56
Rate for Payer: MDX Hawaii PPO	$214.50
Rate for Payer: Ohana Health Plan Medicaid	$110.56
Rate for Payer: Ohana Health Plan Medicare	$110.56
Rate for Payer: UnitedHealthcare Medicaid	$132.68
Rate for Payer: UnitedHealthcare Medicare	$110.56
Rate for Payer: University Health Alliance Commercial	$161.18

MVI, adult w/ vit K 10ml vial [HHSC]

Facility

$68.89

Service Code	NDC 54643900701
Hospital Charge Code	2500568
Hospital Revenue Code	250
Min. Negotiated Rate	$34.45
Max. Negotiated Rate	$66.82
Rate for Payer: AlohaCare Medicaid	$34.45
Rate for Payer: AlohaCare Medicare	$34.45
Rate for Payer: Cash Price	$44.78
Rate for Payer: Devoted Health Medicare	$37.89
Rate for Payer: Hawaii Medical Service Association Medicare	$34.45
Rate for Payer: Hawaii Western Management Group Commercial	$65.45
Rate for Payer: Health Management Network Commercial	$58.56
Rate for Payer: Humana Medicare	$34.45
Rate for Payer: Kaiser Permanente Commercial	$62.00
Rate for Payer: Kaiser Permanente Medicaid	$35.13
Rate for Payer: Kaiser Permanente Medicare	$34.45
Rate for Payer: MDX Hawaii PPO	$66.82
Rate for Payer: Ohana Health Plan Medicaid	$34.45
Rate for Payer: Ohana Health Plan Medicare	$34.45
Rate for Payer: UnitedHealthcare Medicaid	$41.33
Rate for Payer: UnitedHealthcare Medicare	$34.45
Rate for Payer: University Health Alliance Commercial	$50.21

Mycoplasma Culture, Genital FSI

Facility

$321.00

Service Code	HCPCS 87109
Hospital Charge Code	12428711
Hospital Revenue Code	306
Min. Negotiated Rate	$272.85
Max. Negotiated Rate	$311.37
Rate for Payer: Cash Price	$208.65
Rate for Payer: Health Management Network Commercial	$272.85
Rate for Payer: Kaiser Permanente Commercial	$288.90
Rate for Payer: MDX Hawaii PPO	$311.37

Mycoplasma Culture, Genital FSI

Facility

$321.00

Service Code	HCPCS 87109
Hospital Charge Code	12428711
Hospital Revenue Code	306
Min. Negotiated Rate	$15.39
Max. Negotiated Rate	$311.37
Rate for Payer: AlohaCare Medicaid	$160.50
Rate for Payer: AlohaCare Medicare	$160.50
Rate for Payer: Cash Price	$208.65
Rate for Payer: Cash Price	$208.65
Rate for Payer: Devoted Health Medicare	$176.55
Rate for Payer: Hawaii Medical Service Association ABD	$21.26
Rate for Payer: Hawaii Medical Service Association Commercial	$19.24
Rate for Payer: Hawaii Medical Service Association Medicare	$160.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$22.32
Rate for Payer: Hawaii Western Management Group Commercial	$15.39
Rate for Payer: Health Management Network Commercial	$272.85
Rate for Payer: Humana Medicare	$160.50
Rate for Payer: Kaiser Permanente Commercial	$288.90
Rate for Payer: Kaiser Permanente Medicaid	$163.71
Rate for Payer: Kaiser Permanente Medicare	$160.50
Rate for Payer: MDX Hawaii PPO	$311.37
Rate for Payer: Ohana Health Plan Medicaid	$160.50
Rate for Payer: Ohana Health Plan Medicare	$160.50
Rate for Payer: UnitedHealthcare Medicaid	$21.26
Rate for Payer: UnitedHealthcare Medicare	$160.50
Rate for Payer: University Health Alliance Commercial	$39.77

Mycoplasma genitalium by NAAT FSI

Facility

$236.00

Service Code	HCPCS 87563
Hospital Charge Code	11447739
Hospital Revenue Code	306
Min. Negotiated Rate	$200.60
Max. Negotiated Rate	$228.92
Rate for Payer: Cash Price	$153.40
Rate for Payer: Health Management Network Commercial	$200.60
Rate for Payer: Kaiser Permanente Commercial	$212.40
Rate for Payer: MDX Hawaii PPO	$228.92

Mycoplasma genitalium by NAAT FSI

Facility

$236.00

Service Code	HCPCS 87563
Hospital Charge Code	11447739
Hospital Revenue Code	306
Min. Negotiated Rate	$21.05
Max. Negotiated Rate	$228.92
Rate for Payer: AlohaCare Medicaid	$118.00
Rate for Payer: AlohaCare Medicare	$118.00
Rate for Payer: Cash Price	$153.40
Rate for Payer: Cash Price	$153.40
Rate for Payer: Devoted Health Medicare	$129.80
Rate for Payer: Hawaii Medical Service Association ABD	$33.68
Rate for Payer: Hawaii Medical Service Association Commercial	$43.86
Rate for Payer: Hawaii Medical Service Association Medicare	$118.00
Rate for Payer: Hawaii Medical Service Association Non-ABD	$33.68
Rate for Payer: Hawaii Western Management Group Commercial	$35.09
Rate for Payer: Health Management Network Commercial	$200.60
Rate for Payer: Humana Medicare	$118.00
Rate for Payer: Kaiser Permanente Commercial	$212.40
Rate for Payer: Kaiser Permanente Medicaid	$120.36
Rate for Payer: Kaiser Permanente Medicare	$118.00
Rate for Payer: MDX Hawaii PPO	$228.92
Rate for Payer: Ohana Health Plan Medicaid	$118.00
Rate for Payer: Ohana Health Plan Medicare	$118.00
Rate for Payer: UnitedHealthcare Medicaid	$21.05
Rate for Payer: UnitedHealthcare Medicare	$118.00
Rate for Payer: University Health Alliance Commercial	$132.16

Mycoplasma/Ureaplasma PCR FSI

Facility

$243.00

Service Code	HCPCS 87563
Hospital Charge Code	10023492
Hospital Revenue Code	306
Min. Negotiated Rate	$21.05
Max. Negotiated Rate	$235.71
Rate for Payer: AlohaCare Medicaid	$121.50
Rate for Payer: AlohaCare Medicare	$121.50
Rate for Payer: Cash Price	$157.95
Rate for Payer: Cash Price	$157.95
Rate for Payer: Devoted Health Medicare	$133.65
Rate for Payer: Hawaii Medical Service Association ABD	$33.68
Rate for Payer: Hawaii Medical Service Association Commercial	$43.86
Rate for Payer: Hawaii Medical Service Association Medicare	$121.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$33.68
Rate for Payer: Hawaii Western Management Group Commercial	$35.09
Rate for Payer: Health Management Network Commercial	$206.55
Rate for Payer: Humana Medicare	$121.50
Rate for Payer: Kaiser Permanente Commercial	$218.70
Rate for Payer: Kaiser Permanente Medicaid	$123.93
Rate for Payer: Kaiser Permanente Medicare	$121.50
Rate for Payer: MDX Hawaii PPO	$235.71
Rate for Payer: Ohana Health Plan Medicaid	$121.50
Rate for Payer: Ohana Health Plan Medicare	$121.50
Rate for Payer: UnitedHealthcare Medicaid	$21.05
Rate for Payer: UnitedHealthcare Medicare	$121.50
Rate for Payer: University Health Alliance Commercial	$136.08

Mycoplasma/Ureaplasma PCR FSI

Facility

$243.00

Service Code	HCPCS 87563
Hospital Charge Code	10023492
Hospital Revenue Code	306
Min. Negotiated Rate	$206.55
Max. Negotiated Rate	$235.71
Rate for Payer: Cash Price	$157.95
Rate for Payer: Health Management Network Commercial	$206.55
Rate for Payer: Kaiser Permanente Commercial	$218.70
Rate for Payer: MDX Hawaii PPO	$235.71

MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH MAJOR O.R. PROCEDURES WITH CC

Facility

$73,452.50

Service Code	MSDRG 827
Min. Negotiated Rate	$73,452.50
Max. Negotiated Rate	$73,452.50
Rate for Payer: Hawaii Medical Service Association Commercial	$73,452.50

MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH MAJOR O.R. PROCEDURES WITH MCC

Facility

$73,452.50

Service Code	MSDRG 826
Min. Negotiated Rate	$73,452.50
Max. Negotiated Rate	$73,452.50
Rate for Payer: Hawaii Medical Service Association Commercial	$73,452.50

Know your out-of-pocket cost for care.

All Charges