Samuel Mahelona Memorial Hospital

All Charges

Charge

Type

Setting

Price

Newborn Hearing Screening OAE

Facility

$767.00

Service Code	HCPCS 92587
Hospital Charge Code	11435594
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

Newborn Hearing Screening OAE

Facility

$767.00

Service Code	HCPCS 92587
Hospital Charge Code	11435594
Hospital Revenue Code	471
Min. Negotiated Rate	$43.74
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 ABD	$43.74
Rate for Payer: Hawaii Medical Service Association Commercial	$275.75
Rate for Payer: Hawaii Medical Service Association Medicare	$383.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$47.25
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	$43.74
Rate for Payer: UnitedHealthcare Medicare	$383.50
Rate for Payer: University Health Alliance Commercial	$429.52

Newborn Metabolic Screen

Facility

$396.00

Hospital Charge Code	8069132
Hospital Revenue Code	272
Min. Negotiated Rate	$198.00
Max. Negotiated Rate	$384.12
Rate for Payer: AlohaCare Medicaid	$198.00
Rate for Payer: AlohaCare Medicare	$198.00
Rate for Payer: Cash Price	$257.40
Rate for Payer: Devoted Health Medicare	$217.80
Rate for Payer: Hawaii Medical Service Association Medicare	$198.00
Rate for Payer: Hawaii Western Management Group Commercial	$376.20
Rate for Payer: Health Management Network Commercial	$336.60
Rate for Payer: Humana Medicare	$198.00
Rate for Payer: Kaiser Permanente Commercial	$356.40
Rate for Payer: Kaiser Permanente Medicaid	$201.96
Rate for Payer: Kaiser Permanente Medicare	$198.00
Rate for Payer: MDX Hawaii PPO	$384.12
Rate for Payer: Ohana Health Plan Medicaid	$198.00
Rate for Payer: Ohana Health Plan Medicare	$198.00
Rate for Payer: UnitedHealthcare Medicare	$198.00
Rate for Payer: University Health Alliance Commercial	$288.64

Newborn Metabolic Screen

Facility

$396.00

Hospital Charge Code	8069132
Hospital Revenue Code	272
Min. Negotiated Rate	$336.60
Max. Negotiated Rate	$384.12
Rate for Payer: Cash Price	$257.40
Rate for Payer: Health Management Network Commercial	$336.60
Rate for Payer: Kaiser Permanente Commercial	$356.40
Rate for Payer: MDX Hawaii PPO	$384.12

Newborn Resuscitation Charge

Facility

$1,373.00

Service Code	HCPCS 99465
Hospital Charge Code	8268528
Hospital Revenue Code	480
Min. Negotiated Rate	$122.74
Max. Negotiated Rate	$1,331.81
Rate for Payer: AlohaCare Medicaid	$686.50
Rate for Payer: AlohaCare Medicare	$686.50
Rate for Payer: Cash Price	$892.45
Rate for Payer: Cash Price	$892.45
Rate for Payer: Devoted Health Medicare	$755.15
Rate for Payer: Hawaii Medical Service Association Commercial	$844.08
Rate for Payer: Hawaii Medical Service Association Medicare	$686.50
Rate for Payer: Hawaii Western Management Group Commercial	$1,304.35
Rate for Payer: Health Management Network Commercial	$1,167.05
Rate for Payer: Humana Medicare	$686.50
Rate for Payer: Kaiser Permanente Commercial	$1,235.70
Rate for Payer: Kaiser Permanente Medicaid	$700.23
Rate for Payer: Kaiser Permanente Medicare	$686.50
Rate for Payer: MDX Hawaii PPO	$1,331.81
Rate for Payer: Ohana Health Plan Medicaid	$686.50
Rate for Payer: Ohana Health Plan Medicare	$686.50
Rate for Payer: UnitedHealthcare Medicaid	$122.74
Rate for Payer: UnitedHealthcare Medicare	$686.50
Rate for Payer: University Health Alliance Commercial	$768.88

Newborn Resuscitation Charge

Facility

$1,373.00

Service Code	HCPCS 99465
Hospital Charge Code	8268528
Hospital Revenue Code	480
Min. Negotiated Rate	$1,167.05
Max. Negotiated Rate	$1,331.81
Rate for Payer: Cash Price	$892.45
Rate for Payer: Health Management Network Commercial	$1,167.05
Rate for Payer: Kaiser Permanente Commercial	$1,235.70
Rate for Payer: MDX Hawaii PPO	$1,331.81

NEWBORN SCREENING PKU KIT CHARGE

Facility

$416.00

Hospital Charge Code	8280924
Hospital Revenue Code	272
Min. Negotiated Rate	$208.00
Max. Negotiated Rate	$403.52
Rate for Payer: AlohaCare Medicaid	$208.00
Rate for Payer: AlohaCare Medicare	$208.00
Rate for Payer: Cash Price	$270.40
Rate for Payer: Devoted Health Medicare	$228.80
Rate for Payer: Hawaii Medical Service Association Medicare	$208.00
Rate for Payer: Hawaii Western Management Group Commercial	$395.20
Rate for Payer: Health Management Network Commercial	$353.60
Rate for Payer: Humana Medicare	$208.00
Rate for Payer: Kaiser Permanente Commercial	$374.40
Rate for Payer: Kaiser Permanente Medicaid	$212.16
Rate for Payer: Kaiser Permanente Medicare	$208.00
Rate for Payer: MDX Hawaii PPO	$403.52
Rate for Payer: Ohana Health Plan Medicaid	$208.00
Rate for Payer: Ohana Health Plan Medicare	$208.00
Rate for Payer: UnitedHealthcare Medicare	$208.00
Rate for Payer: University Health Alliance Commercial	$303.22

NEWBORN SCREENING PKU KIT CHARGE

Facility

$416.00

Hospital Charge Code	8280924
Hospital Revenue Code	272
Min. Negotiated Rate	$353.60
Max. Negotiated Rate	$403.52
Rate for Payer: Cash Price	$270.40
Rate for Payer: Health Management Network Commercial	$353.60
Rate for Payer: Kaiser Permanente Commercial	$374.40
Rate for Payer: MDX Hawaii PPO	$403.52

niCARdipine 25 mg/10 ml vial [HHSC]

Facility

$119.01

Service Code	NDC 00143968910
Hospital Charge Code	2500579
Hospital Revenue Code	250
Min. Negotiated Rate	$101.16
Max. Negotiated Rate	$115.44
Rate for Payer: Cash Price	$77.36
Rate for Payer: Health Management Network Commercial	$101.16
Rate for Payer: Kaiser Permanente Commercial	$107.11
Rate for Payer: MDX Hawaii PPO	$115.44

niCARdipine 25 mg/10 ml vial [HHSC]

Facility

$119.18

Service Code	NDC 00143959310
Hospital Charge Code	2500579
Hospital Revenue Code	250
Min. Negotiated Rate	$59.59
Max. Negotiated Rate	$115.60
Rate for Payer: AlohaCare Medicaid	$59.59
Rate for Payer: AlohaCare Medicare	$59.59
Rate for Payer: Cash Price	$77.47
Rate for Payer: Devoted Health Medicare	$65.55
Rate for Payer: Hawaii Medical Service Association Medicare	$59.59
Rate for Payer: Hawaii Western Management Group Commercial	$113.22
Rate for Payer: Health Management Network Commercial	$101.30
Rate for Payer: Humana Medicare	$59.59
Rate for Payer: Kaiser Permanente Commercial	$107.26
Rate for Payer: Kaiser Permanente Medicaid	$60.78
Rate for Payer: Kaiser Permanente Medicare	$59.59
Rate for Payer: MDX Hawaii PPO	$115.60
Rate for Payer: Ohana Health Plan Medicaid	$59.59
Rate for Payer: Ohana Health Plan Medicare	$59.59
Rate for Payer: UnitedHealthcare Medicaid	$71.51
Rate for Payer: UnitedHealthcare Medicare	$59.59
Rate for Payer: University Health Alliance Commercial	$86.87

niCARdipine 25 mg/10 ml vial [HHSC]

Facility

$114.01

Service Code	NDC 55150018311
Hospital Charge Code	2500579
Hospital Revenue Code	250
Min. Negotiated Rate	$57.01
Max. Negotiated Rate	$110.59
Rate for Payer: AlohaCare Medicaid	$57.01
Rate for Payer: AlohaCare Medicare	$57.01
Rate for Payer: Cash Price	$74.11
Rate for Payer: Devoted Health Medicare	$62.71
Rate for Payer: Hawaii Medical Service Association Medicare	$57.01
Rate for Payer: Hawaii Western Management Group Commercial	$108.31
Rate for Payer: Health Management Network Commercial	$96.91
Rate for Payer: Humana Medicare	$57.01
Rate for Payer: Kaiser Permanente Commercial	$102.61
Rate for Payer: Kaiser Permanente Medicaid	$58.15
Rate for Payer: Kaiser Permanente Medicare	$57.01
Rate for Payer: MDX Hawaii PPO	$110.59
Rate for Payer: Ohana Health Plan Medicaid	$57.01
Rate for Payer: Ohana Health Plan Medicare	$57.01
Rate for Payer: UnitedHealthcare Medicaid	$68.41
Rate for Payer: UnitedHealthcare Medicare	$57.01
Rate for Payer: University Health Alliance Commercial	$83.10

niCARdipine 25 mg/10 ml vial [HHSC]

Facility

$114.01

Service Code	NDC 55150018311
Hospital Charge Code	2500579
Hospital Revenue Code	250
Min. Negotiated Rate	$96.91
Max. Negotiated Rate	$110.59
Rate for Payer: Cash Price	$74.11
Rate for Payer: Health Management Network Commercial	$96.91
Rate for Payer: Kaiser Permanente Commercial	$102.61
Rate for Payer: MDX Hawaii PPO	$110.59

niCARdipine 25 mg/10 ml vial [HHSC]

Facility

$119.01

Service Code	NDC 00143968910
Hospital Charge Code	2500579
Hospital Revenue Code	250
Min. Negotiated Rate	$59.51
Max. Negotiated Rate	$115.44
Rate for Payer: AlohaCare Medicaid	$59.51
Rate for Payer: AlohaCare Medicare	$59.51
Rate for Payer: Cash Price	$77.36
Rate for Payer: Devoted Health Medicare	$65.46
Rate for Payer: Hawaii Medical Service Association Medicare	$59.51
Rate for Payer: Hawaii Western Management Group Commercial	$113.06
Rate for Payer: Health Management Network Commercial	$101.16
Rate for Payer: Humana Medicare	$59.51
Rate for Payer: Kaiser Permanente Commercial	$107.11
Rate for Payer: Kaiser Permanente Medicaid	$60.70
Rate for Payer: Kaiser Permanente Medicare	$59.51
Rate for Payer: MDX Hawaii PPO	$115.44
Rate for Payer: Ohana Health Plan Medicaid	$59.51
Rate for Payer: Ohana Health Plan Medicare	$59.51
Rate for Payer: UnitedHealthcare Medicaid	$71.41
Rate for Payer: UnitedHealthcare Medicare	$59.51
Rate for Payer: University Health Alliance Commercial	$86.75

niCARdipine 25 mg/10 ml vial [HHSC]

Facility

$124.67

Service Code	NDC 55150018310
Hospital Charge Code	2500579
Hospital Revenue Code	250
Min. Negotiated Rate	$62.34
Max. Negotiated Rate	$120.93
Rate for Payer: AlohaCare Medicaid	$62.34
Rate for Payer: AlohaCare Medicare	$62.34
Rate for Payer: Cash Price	$81.04
Rate for Payer: Devoted Health Medicare	$68.57
Rate for Payer: Hawaii Medical Service Association Medicare	$62.34
Rate for Payer: Hawaii Western Management Group Commercial	$118.44
Rate for Payer: Health Management Network Commercial	$105.97
Rate for Payer: Humana Medicare	$62.34
Rate for Payer: Kaiser Permanente Commercial	$112.20
Rate for Payer: Kaiser Permanente Medicaid	$63.58
Rate for Payer: Kaiser Permanente Medicare	$62.34
Rate for Payer: MDX Hawaii PPO	$120.93
Rate for Payer: Ohana Health Plan Medicaid	$62.34
Rate for Payer: Ohana Health Plan Medicare	$62.34
Rate for Payer: UnitedHealthcare Medicaid	$74.80
Rate for Payer: UnitedHealthcare Medicare	$62.34
Rate for Payer: University Health Alliance Commercial	$90.87

niCARdipine 25 mg/10 ml vial [HHSC]

Facility

$119.18

Service Code	NDC 00143959310
Hospital Charge Code	2500579
Hospital Revenue Code	250
Min. Negotiated Rate	$101.30
Max. Negotiated Rate	$115.60
Rate for Payer: Cash Price	$77.47
Rate for Payer: Health Management Network Commercial	$101.30
Rate for Payer: Kaiser Permanente Commercial	$107.26
Rate for Payer: MDX Hawaii PPO	$115.60

niCARdipine 25 mg/10 ml vial [HHSC]

Facility

$124.67

Service Code	NDC 55150018310
Hospital Charge Code	2500579
Hospital Revenue Code	250
Min. Negotiated Rate	$105.97
Max. Negotiated Rate	$120.93
Rate for Payer: Cash Price	$81.04
Rate for Payer: Health Management Network Commercial	$105.97
Rate for Payer: Kaiser Permanente Commercial	$112.20
Rate for Payer: MDX Hawaii PPO	$120.93

niCARdipine 25 mg/10 ml vial [HHSC]

Facility

$135.19

Service Code	NDC 72485011610
Hospital Charge Code	2500579
Hospital Revenue Code	250
Min. Negotiated Rate	$114.91
Max. Negotiated Rate	$131.13
Rate for Payer: Cash Price	$87.87
Rate for Payer: Health Management Network Commercial	$114.91
Rate for Payer: Kaiser Permanente Commercial	$121.67
Rate for Payer: MDX Hawaii PPO	$131.13

niCARdipine 25 mg/10 ml vial [HHSC]

Facility

$135.19

Service Code	NDC 72485011610
Hospital Charge Code	2500579
Hospital Revenue Code	250
Min. Negotiated Rate	$67.59
Max. Negotiated Rate	$131.13
Rate for Payer: AlohaCare Medicaid	$67.59
Rate for Payer: AlohaCare Medicare	$67.59
Rate for Payer: Cash Price	$87.87
Rate for Payer: Devoted Health Medicare	$74.35
Rate for Payer: Hawaii Medical Service Association Medicare	$67.59
Rate for Payer: Hawaii Western Management Group Commercial	$128.43
Rate for Payer: Health Management Network Commercial	$114.91
Rate for Payer: Humana Medicare	$67.59
Rate for Payer: Kaiser Permanente Commercial	$121.67
Rate for Payer: Kaiser Permanente Medicaid	$68.95
Rate for Payer: Kaiser Permanente Medicare	$67.59
Rate for Payer: MDX Hawaii PPO	$131.13
Rate for Payer: Ohana Health Plan Medicaid	$67.59
Rate for Payer: Ohana Health Plan Medicare	$67.59
Rate for Payer: UnitedHealthcare Medicaid	$81.11
Rate for Payer: UnitedHealthcare Medicare	$67.59
Rate for Payer: University Health Alliance Commercial	$98.54

niCARdipine 25 mg/10 ml vial [HHSC]

Facility

$124.69

Service Code	NDC 71288020411
Hospital Charge Code	2500579
Hospital Revenue Code	250
Min. Negotiated Rate	$62.34
Max. Negotiated Rate	$120.95
Rate for Payer: AlohaCare Medicaid	$62.34
Rate for Payer: AlohaCare Medicare	$62.34
Rate for Payer: Cash Price	$81.05
Rate for Payer: Devoted Health Medicare	$68.58
Rate for Payer: Hawaii Medical Service Association Medicare	$62.34
Rate for Payer: Hawaii Western Management Group Commercial	$118.46
Rate for Payer: Health Management Network Commercial	$105.99
Rate for Payer: Humana Medicare	$62.34
Rate for Payer: Kaiser Permanente Commercial	$112.22
Rate for Payer: Kaiser Permanente Medicaid	$63.59
Rate for Payer: Kaiser Permanente Medicare	$62.34
Rate for Payer: MDX Hawaii PPO	$120.95
Rate for Payer: Ohana Health Plan Medicaid	$62.34
Rate for Payer: Ohana Health Plan Medicare	$62.34
Rate for Payer: UnitedHealthcare Medicaid	$74.81
Rate for Payer: UnitedHealthcare Medicare	$62.34
Rate for Payer: University Health Alliance Commercial	$90.89

niCARdipine 25 mg/10 ml vial [HHSC]

Facility

$124.69

Service Code	NDC 71288020411
Hospital Charge Code	2500579
Hospital Revenue Code	250
Min. Negotiated Rate	$105.99
Max. Negotiated Rate	$120.95
Rate for Payer: Cash Price	$81.05
Rate for Payer: Health Management Network Commercial	$105.99
Rate for Payer: Kaiser Permanente Commercial	$112.22
Rate for Payer: MDX Hawaii PPO	$120.95

nicotine 14 mg/24 hr patch [HHSC]

Facility

$11.64

Service Code	NDC 46122035274
Hospital Charge Code	2500580
Hospital Revenue Code	250
Min. Negotiated Rate	$9.89
Max. Negotiated Rate	$11.29
Rate for Payer: Cash Price	$7.57
Rate for Payer: Health Management Network Commercial	$9.89
Rate for Payer: Kaiser Permanente Commercial	$10.48
Rate for Payer: MDX Hawaii PPO	$11.29

nicotine 14 mg/24 hr patch [HHSC]

Facility

$11.86

Service Code	NDC 43598044774
Hospital Charge Code	2500580
Hospital Revenue Code	250
Min. Negotiated Rate	$5.93
Max. Negotiated Rate	$11.50
Rate for Payer: AlohaCare Medicaid	$5.93
Rate for Payer: AlohaCare Medicare	$5.93
Rate for Payer: Cash Price	$7.71
Rate for Payer: Devoted Health Medicare	$6.52
Rate for Payer: Hawaii Medical Service Association Medicare	$5.93
Rate for Payer: Hawaii Western Management Group Commercial	$11.27
Rate for Payer: Health Management Network Commercial	$10.08
Rate for Payer: Humana Medicare	$5.93
Rate for Payer: Kaiser Permanente Commercial	$10.67
Rate for Payer: Kaiser Permanente Medicaid	$6.05
Rate for Payer: Kaiser Permanente Medicare	$5.93
Rate for Payer: MDX Hawaii PPO	$11.50
Rate for Payer: Ohana Health Plan Medicaid	$5.93
Rate for Payer: Ohana Health Plan Medicare	$5.93
Rate for Payer: UnitedHealthcare Medicaid	$7.12
Rate for Payer: UnitedHealthcare Medicare	$5.93
Rate for Payer: University Health Alliance Commercial	$8.64

nicotine 14 mg/24 hr patch [HHSC]

Facility

$11.91

Service Code	NDC 68001043390
Hospital Charge Code	2500580
Hospital Revenue Code	250
Min. Negotiated Rate	$5.96
Max. Negotiated Rate	$11.55
Rate for Payer: AlohaCare Medicaid	$5.96
Rate for Payer: AlohaCare Medicare	$5.96
Rate for Payer: Cash Price	$7.74
Rate for Payer: Devoted Health Medicare	$6.55
Rate for Payer: Hawaii Medical Service Association Medicare	$5.96
Rate for Payer: Hawaii Western Management Group Commercial	$11.31
Rate for Payer: Health Management Network Commercial	$10.12
Rate for Payer: Humana Medicare	$5.96
Rate for Payer: Kaiser Permanente Commercial	$10.72
Rate for Payer: Kaiser Permanente Medicaid	$6.07
Rate for Payer: Kaiser Permanente Medicare	$5.96
Rate for Payer: MDX Hawaii PPO	$11.55
Rate for Payer: Ohana Health Plan Medicaid	$5.96
Rate for Payer: Ohana Health Plan Medicare	$5.96
Rate for Payer: UnitedHealthcare Medicaid	$7.15
Rate for Payer: UnitedHealthcare Medicare	$5.96
Rate for Payer: University Health Alliance Commercial	$8.68

nicotine 14 mg/24 hr patch [HHSC]

Facility

$11.91

Service Code	NDC 68001043390
Hospital Charge Code	2500580
Hospital Revenue Code	250
Min. Negotiated Rate	$10.12
Max. Negotiated Rate	$11.55
Rate for Payer: Cash Price	$7.74
Rate for Payer: Health Management Network Commercial	$10.12
Rate for Payer: Kaiser Permanente Commercial	$10.72
Rate for Payer: MDX Hawaii PPO	$11.55

nicotine 14 mg/24 hr patch [HHSC]

Facility

$11.91

Service Code	NDC 00536589588
Hospital Charge Code	2500580
Hospital Revenue Code	250
Min. Negotiated Rate	$10.12
Max. Negotiated Rate	$11.55
Rate for Payer: Cash Price	$7.74
Rate for Payer: Health Management Network Commercial	$10.12
Rate for Payer: Kaiser Permanente Commercial	$10.72
Rate for Payer: MDX Hawaii PPO	$11.55

Know your out-of-pocket cost for care.

All Charges