Samuel Mahelona Memorial Hospital

All Charges

Charge

Type

Setting

Price

neomy/polyb/HC 10ml otic drops [HHSC]

Facility

$450.80

Service Code	NDC 61314064511
Hospital Charge Code	2500396
Hospital Revenue Code	250
Min. Negotiated Rate	$383.18
Max. Negotiated Rate	$437.28
Rate for Payer: Cash Price	$293.02
Rate for Payer: Health Management Network Commercial	$383.18
Rate for Payer: Kaiser Permanente Commercial	$405.72
Rate for Payer: MDX Hawaii PPO	$437.28

neomy/polyb/HC 10ml otic drops [HHSC]

Facility

$450.80

Service Code	NDC 61314064511
Hospital Charge Code	2500396
Hospital Revenue Code	250
Min. Negotiated Rate	$225.40
Max. Negotiated Rate	$437.28
Rate for Payer: AlohaCare Medicaid	$225.40
Rate for Payer: AlohaCare Medicare	$225.40
Rate for Payer: Cash Price	$293.02
Rate for Payer: Devoted Health Medicare	$247.94
Rate for Payer: Hawaii Medical Service Association Medicare	$225.40
Rate for Payer: Hawaii Western Management Group Commercial	$428.26
Rate for Payer: Health Management Network Commercial	$383.18
Rate for Payer: Humana Medicare	$225.40
Rate for Payer: Kaiser Permanente Commercial	$405.72
Rate for Payer: Kaiser Permanente Medicaid	$229.91
Rate for Payer: Kaiser Permanente Medicare	$225.40
Rate for Payer: MDX Hawaii PPO	$437.28
Rate for Payer: Ohana Health Plan Medicaid	$225.40
Rate for Payer: Ohana Health Plan Medicare	$225.40
Rate for Payer: UnitedHealthcare Medicaid	$270.48
Rate for Payer: UnitedHealthcare Medicare	$225.40
Rate for Payer: University Health Alliance Commercial	$328.59

neomy/polyb/HC 10ml otic drops [HHSC]

Facility

$450.80

Service Code	NDC 24208063562
Hospital Charge Code	2500396
Hospital Revenue Code	250
Min. Negotiated Rate	$383.18
Max. Negotiated Rate	$437.28
Rate for Payer: Cash Price	$293.02
Rate for Payer: Health Management Network Commercial	$383.18
Rate for Payer: Kaiser Permanente Commercial	$405.72
Rate for Payer: MDX Hawaii PPO	$437.28

NEONATES, DIED OR TRANSFERRED TO ANOTHER ACUTE CARE FACILITY

Facility

$64,422.04

Service Code	MSDRG 789
Min. Negotiated Rate	$64,422.04
Max. Negotiated Rate	$64,422.04
Rate for Payer: Hawaii Medical Service Association Commercial	$64,422.04

NEONATE WITH OTHER SIGNIFICANT PROBLEMS

Facility

$4,029.34

Service Code	MSDRG 794
Min. Negotiated Rate	$4,029.34
Max. Negotiated Rate	$4,029.34
Rate for Payer: Hawaii Medical Service Association Commercial	$4,029.34

NERVOUS SYSTEM NEOPLASMS WITH MCC

Facility

$23,915.32

Service Code	MSDRG 054
Min. Negotiated Rate	$23,915.32
Max. Negotiated Rate	$23,915.32
Rate for Payer: Hawaii Medical Service Association Commercial	$23,915.32

NERVOUS SYSTEM NEOPLASMS WITHOUT MCC

Facility

$23,678.30

Service Code	MSDRG 055
Min. Negotiated Rate	$23,678.30
Max. Negotiated Rate	$23,678.30
Rate for Payer: Hawaii Medical Service Association Commercial	$23,678.30

NET CLOSURE DELTA TERRY DISP DSPNSR BX ADH HK WHITE 1X10YD 1RL

Professional

Both

$108.00

Hospital Charge Code	12957405
Hospital Revenue Code	270
Min. Negotiated Rate	$91.80
Max. Negotiated Rate	$91.80
Rate for Payer: Cash Price	$70.20
Rate for Payer: Health Management Network Commercial	$91.80

NET CLOSURE DELTA TERRY DISP DSPNSR BX ADH HK WHITE 1X10YD 1RL

Facility

$108.00

Hospital Charge Code	12957405
Hospital Revenue Code	270
Min. Negotiated Rate	$91.80
Max. Negotiated Rate	$104.76
Rate for Payer: Cash Price	$70.20
Rate for Payer: Health Management Network Commercial	$91.80
Rate for Payer: Kaiser Permanente Commercial	$97.20
Rate for Payer: MDX Hawaii PPO	$104.76

NET CLOSURE DELTA TERRY DISP DSPNSR BX ADH HK WHITE 1X10YD 1RL

Facility

$108.00

Hospital Charge Code	12957405
Hospital Revenue Code	270
Min. Negotiated Rate	$54.00
Max. Negotiated Rate	$104.76
Rate for Payer: AlohaCare Medicaid	$54.00
Rate for Payer: AlohaCare Medicare	$54.00
Rate for Payer: Cash Price	$70.20
Rate for Payer: Devoted Health Medicare	$59.40
Rate for Payer: Hawaii Medical Service Association Medicare	$54.00
Rate for Payer: Hawaii Western Management Group Commercial	$102.60
Rate for Payer: Health Management Network Commercial	$91.80
Rate for Payer: Humana Medicare	$54.00
Rate for Payer: Kaiser Permanente Commercial	$97.20
Rate for Payer: Kaiser Permanente Medicaid	$55.08
Rate for Payer: Kaiser Permanente Medicare	$54.00
Rate for Payer: MDX Hawaii PPO	$104.76
Rate for Payer: Ohana Health Plan Medicaid	$54.00
Rate for Payer: Ohana Health Plan Medicare	$54.00
Rate for Payer: UnitedHealthcare Medicare	$54.00
Rate for Payer: University Health Alliance Commercial	$78.72

NET CLOSURE DELTA TERRY DISP DSPNSR BX STRTCH LOOP WHT 1X15 1RL

Professional

Both

$192.00

Hospital Charge Code	12957406
Hospital Revenue Code	270
Min. Negotiated Rate	$163.20
Max. Negotiated Rate	$163.20
Rate for Payer: Cash Price	$124.80
Rate for Payer: Health Management Network Commercial	$163.20

NET CLOSURE DELTA TERRY DISP DSPNSR BX STRTCH LOOP WHT 1X15 1RL

Facility

$192.00

Hospital Charge Code	12957406
Hospital Revenue Code	270
Min. Negotiated Rate	$163.20
Max. Negotiated Rate	$186.24
Rate for Payer: Cash Price	$124.80
Rate for Payer: Health Management Network Commercial	$163.20
Rate for Payer: Kaiser Permanente Commercial	$172.80
Rate for Payer: MDX Hawaii PPO	$186.24

NET CLOSURE DELTA TERRY DISP DSPNSR BX STRTCH LOOP WHT 1X15 1RL

Facility

$192.00

Hospital Charge Code	12957406
Hospital Revenue Code	270
Min. Negotiated Rate	$96.00
Max. Negotiated Rate	$186.24
Rate for Payer: AlohaCare Medicaid	$96.00
Rate for Payer: AlohaCare Medicare	$96.00
Rate for Payer: Cash Price	$124.80
Rate for Payer: Devoted Health Medicare	$105.60
Rate for Payer: Hawaii Medical Service Association Medicare	$96.00
Rate for Payer: Hawaii Western Management Group Commercial	$182.40
Rate for Payer: Health Management Network Commercial	$163.20
Rate for Payer: Humana Medicare	$96.00
Rate for Payer: Kaiser Permanente Commercial	$172.80
Rate for Payer: Kaiser Permanente Medicaid	$97.92
Rate for Payer: Kaiser Permanente Medicare	$96.00
Rate for Payer: MDX Hawaii PPO	$186.24
Rate for Payer: Ohana Health Plan Medicaid	$96.00
Rate for Payer: Ohana Health Plan Medicare	$96.00
Rate for Payer: UnitedHealthcare Medicare	$96.00
Rate for Payer: University Health Alliance Commercial	$139.95

NEUROLOGICAL EYE DISORDERS

Facility

$16,638.80

Service Code	MSDRG 123
Min. Negotiated Rate	$16,638.80
Max. Negotiated Rate	$16,638.80
Rate for Payer: Hawaii Medical Service Association Commercial	$16,638.80

Neuromuscular Reeducation Charges

Facility

$266.00

Service Code	HCPCS 97112 GP,CQ
Hospital Charge Code	8111697
Hospital Revenue Code	420
Min. Negotiated Rate	$18.58
Max. Negotiated Rate	$258.02
Rate for Payer: AlohaCare Medicaid	$133.00
Rate for Payer: AlohaCare Medicare	$133.00
Rate for Payer: Cash Price	$172.90
Rate for Payer: Cash Price	$172.90
Rate for Payer: Devoted Health Medicare	$146.30
Rate for Payer: Hawaii Medical Service Association Medicare	$133.00
Rate for Payer: Hawaii Western Management Group Commercial	$252.70
Rate for Payer: Health Management Network Commercial	$226.10
Rate for Payer: Humana Medicare	$133.00
Rate for Payer: Kaiser Permanente Commercial	$239.40
Rate for Payer: Kaiser Permanente Medicaid	$135.66
Rate for Payer: Kaiser Permanente Medicare	$133.00
Rate for Payer: MDX Hawaii PPO	$258.02
Rate for Payer: Ohana Health Plan Medicaid	$133.00
Rate for Payer: Ohana Health Plan Medicare	$133.00
Rate for Payer: UnitedHealthcare Medicaid	$18.58
Rate for Payer: UnitedHealthcare Medicare	$133.00
Rate for Payer: University Health Alliance Commercial	$148.96

Neuromuscular Reeducation Charges

Facility

$266.00

Service Code	HCPCS 97112 GP,CQ
Hospital Charge Code	8123830
Hospital Revenue Code	430
Min. Negotiated Rate	$18.58
Max. Negotiated Rate	$258.02
Rate for Payer: AlohaCare Medicaid	$133.00
Rate for Payer: AlohaCare Medicare	$133.00
Rate for Payer: Cash Price	$172.90
Rate for Payer: Cash Price	$172.90
Rate for Payer: Devoted Health Medicare	$146.30
Rate for Payer: Hawaii Medical Service Association Medicare	$133.00
Rate for Payer: Hawaii Western Management Group Commercial	$252.70
Rate for Payer: Health Management Network Commercial	$226.10
Rate for Payer: Humana Medicare	$133.00
Rate for Payer: Kaiser Permanente Commercial	$239.40
Rate for Payer: Kaiser Permanente Medicaid	$135.66
Rate for Payer: Kaiser Permanente Medicare	$133.00
Rate for Payer: MDX Hawaii PPO	$258.02
Rate for Payer: Ohana Health Plan Medicaid	$133.00
Rate for Payer: Ohana Health Plan Medicare	$133.00
Rate for Payer: UnitedHealthcare Medicaid	$18.58
Rate for Payer: UnitedHealthcare Medicare	$133.00
Rate for Payer: University Health Alliance Commercial	$148.96

Neuromuscular Reeducation Charges

Facility

$266.00

Service Code	HCPCS 97112 GP,CQ
Hospital Charge Code	8123830
Hospital Revenue Code	430
Min. Negotiated Rate	$226.10
Max. Negotiated Rate	$258.02
Rate for Payer: Cash Price	$172.90
Rate for Payer: Health Management Network Commercial	$226.10
Rate for Payer: Kaiser Permanente Commercial	$239.40
Rate for Payer: MDX Hawaii PPO	$258.02

Neuromuscular Reeducation Charges

Facility

$266.00

Service Code	HCPCS 97112 GP,CQ
Hospital Charge Code	8111697
Hospital Revenue Code	420
Min. Negotiated Rate	$226.10
Max. Negotiated Rate	$258.02
Rate for Payer: Cash Price	$172.90
Rate for Payer: Health Management Network Commercial	$226.10
Rate for Payer: Kaiser Permanente Commercial	$239.40
Rate for Payer: MDX Hawaii PPO	$258.02

Neuron Specific Enolase FSI

Facility

$158.00

Service Code	HCPCS 86316
Hospital Charge Code	9904291
Hospital Revenue Code	302
Min. Negotiated Rate	$134.30
Max. Negotiated Rate	$153.26
Rate for Payer: Cash Price	$102.70
Rate for Payer: Health Management Network Commercial	$134.30
Rate for Payer: Kaiser Permanente Commercial	$142.20
Rate for Payer: MDX Hawaii PPO	$153.26

Neuron Specific Enolase FSI

Facility

$158.00

Service Code	HCPCS 86316
Hospital Charge Code	9904291
Hospital Revenue Code	302
Min. Negotiated Rate	$20.81
Max. Negotiated Rate	$153.26
Rate for Payer: AlohaCare Medicaid	$79.00
Rate for Payer: AlohaCare Medicare	$79.00
Rate for Payer: Cash Price	$102.70
Rate for Payer: Cash Price	$102.70
Rate for Payer: Devoted Health Medicare	$86.90
Rate for Payer: Hawaii Medical Service Association ABD	$28.76
Rate for Payer: Hawaii Medical Service Association Commercial	$26.01
Rate for Payer: Hawaii Medical Service Association Medicare	$79.00
Rate for Payer: Hawaii Medical Service Association Non-ABD	$30.20
Rate for Payer: Hawaii Western Management Group Commercial	$20.81
Rate for Payer: Health Management Network Commercial	$134.30
Rate for Payer: Humana Medicare	$79.00
Rate for Payer: Kaiser Permanente Commercial	$142.20
Rate for Payer: Kaiser Permanente Medicaid	$80.58
Rate for Payer: Kaiser Permanente Medicare	$79.00
Rate for Payer: MDX Hawaii PPO	$153.26
Rate for Payer: Ohana Health Plan Medicaid	$79.00
Rate for Payer: Ohana Health Plan Medicare	$79.00
Rate for Payer: UnitedHealthcare Medicaid	$28.76
Rate for Payer: UnitedHealthcare Medicare	$79.00
Rate for Payer: University Health Alliance Commercial	$53.78

NEUROSES EXCEPT DEPRESSIVE

Facility

$9,528.20

Service Code	MSDRG 882
Min. Negotiated Rate	$9,528.20
Max. Negotiated Rate	$9,528.20
Rate for Payer: Hawaii Medical Service Association Commercial	$9,528.20

Newborn Discharge Checklist

Facility

$400.00

Service Code	HCPCS 54150
Hospital Charge Code	1666881
Hospital Revenue Code	761
Min. Negotiated Rate	$200.00
Max. Negotiated Rate	$4,035.20
Rate for Payer: AlohaCare Medicaid	$200.00
Rate for Payer: AlohaCare Medicare	$200.00
Rate for Payer: Cash Price	$260.00
Rate for Payer: Cash Price	$260.00
Rate for Payer: Cash Price	$260.00
Rate for Payer: Devoted Health Medicare	$220.00
Rate for Payer: Hawaii Medical Service Association Commercial	$2,669.57
Rate for Payer: Hawaii Medical Service Association Medicare	$200.00
Rate for Payer: Hawaii Western Management Group Commercial	$380.00
Rate for Payer: Health Management Network Commercial	$340.00
Rate for Payer: Humana Medicare	$200.00
Rate for Payer: Kaiser Permanente Commercial	$360.00
Rate for Payer: Kaiser Permanente Medicaid	$204.00
Rate for Payer: Kaiser Permanente Medicare	$200.00
Rate for Payer: MDX Hawaii PPO	$388.00
Rate for Payer: Ohana Health Plan Medicaid	$200.00
Rate for Payer: Ohana Health Plan Medicare	$200.00
Rate for Payer: UnitedHealthcare Medicaid	$456.03
Rate for Payer: UnitedHealthcare Medicare	$200.00
Rate for Payer: University Health Alliance Commercial	$4,035.20

Newborn Discharge Checklist

Facility

$400.00

Service Code	HCPCS 54150
Hospital Charge Code	1666881
Hospital Revenue Code	761
Min. Negotiated Rate	$340.00
Max. Negotiated Rate	$388.00
Rate for Payer: Cash Price	$260.00
Rate for Payer: Health Management Network Commercial	$340.00
Rate for Payer: Kaiser Permanente Commercial	$360.00
Rate for Payer: MDX Hawaii PPO	$388.00

Newborn Hearing Screening ABR

Facility

$767.00

Service Code	HCPCS 92651
Hospital Charge Code	11437355
Hospital Revenue Code	471
Min. Negotiated Rate	$88.91
Max. Negotiated Rate	$743.99
Rate for Payer: AlohaCare Medicaid	$383.50
Rate for Payer: AlohaCare Medicare	$383.50
Rate for Payer: Cash Price	$498.55
Rate for Payer: Cash Price	$498.55
Rate for Payer: Devoted Health Medicare	$421.85
Rate for Payer: Hawaii Medical Service Association Commercial	$275.75
Rate for Payer: Hawaii Medical Service Association Medicare	$383.50
Rate for Payer: Hawaii Western Management Group Commercial	$728.65
Rate for Payer: Health Management Network Commercial	$651.95
Rate for Payer: Humana Medicare	$383.50
Rate for Payer: Kaiser Permanente Commercial	$690.30
Rate for Payer: Kaiser Permanente Medicaid	$391.17
Rate for Payer: Kaiser Permanente Medicare	$383.50
Rate for Payer: MDX Hawaii PPO	$743.99
Rate for Payer: Ohana Health Plan Medicaid	$383.50
Rate for Payer: Ohana Health Plan Medicare	$383.50
Rate for Payer: UnitedHealthcare Medicaid	$88.91
Rate for Payer: UnitedHealthcare Medicare	$383.50
Rate for Payer: University Health Alliance Commercial	$429.52

Newborn Hearing Screening ABR

Facility

$767.00

Service Code	HCPCS 92651
Hospital Charge Code	11437355
Hospital Revenue Code	471
Min. Negotiated Rate	$651.95
Max. Negotiated Rate	$743.99
Rate for Payer: Cash Price	$498.55
Rate for Payer: Health Management Network Commercial	$651.95
Rate for Payer: Kaiser Permanente Commercial	$690.30
Rate for Payer: MDX Hawaii PPO	$743.99

Know your out-of-pocket cost for care.

All Charges