Samuel Mahelona Memorial Hospital

All Charges

Charge

Type

Setting

Price

Parathyroid Hormone (PTH) Intact Molecule FSI

Facility

$461.00

Service Code	HCPCS 83970
Hospital Charge Code	8118009
Hospital Revenue Code	301
Min. Negotiated Rate	$41.28
Max. Negotiated Rate	$447.17
Rate for Payer: AlohaCare Medicaid	$230.50
Rate for Payer: AlohaCare Medicare	$230.50
Rate for Payer: Cash Price	$299.65
Rate for Payer: Cash Price	$299.65
Rate for Payer: Devoted Health Medicare	$253.55
Rate for Payer: Hawaii Medical Service Association ABD	$57.04
Rate for Payer: Hawaii Medical Service Association Commercial	$51.60
Rate for Payer: Hawaii Medical Service Association Medicare	$230.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$59.89
Rate for Payer: Hawaii Western Management Group Commercial	$41.28
Rate for Payer: Health Management Network Commercial	$391.85
Rate for Payer: Humana Medicare	$230.50
Rate for Payer: Kaiser Permanente Commercial	$414.90
Rate for Payer: Kaiser Permanente Medicaid	$235.11
Rate for Payer: Kaiser Permanente Medicare	$230.50
Rate for Payer: MDX Hawaii PPO	$447.17
Rate for Payer: Ohana Health Plan Medicaid	$230.50
Rate for Payer: Ohana Health Plan Medicare	$230.50
Rate for Payer: UnitedHealthcare Medicaid	$57.04
Rate for Payer: UnitedHealthcare Medicare	$230.50
Rate for Payer: University Health Alliance Commercial	$106.69

Parathyroid Hormone (PTH) Intact Molecule FSI

Facility

$461.00

Service Code	HCPCS 83970
Hospital Charge Code	8118009
Hospital Revenue Code	301
Min. Negotiated Rate	$391.85
Max. Negotiated Rate	$447.17
Rate for Payer: Cash Price	$299.65
Rate for Payer: Health Management Network Commercial	$391.85
Rate for Payer: Kaiser Permanente Commercial	$414.90
Rate for Payer: MDX Hawaii PPO	$447.17

PARoxetine 10 mg tablet [HHSC]

Facility

$14.86

Service Code	NDC 68084004401
Hospital Charge Code	2500636
Hospital Revenue Code	250
Min. Negotiated Rate	$7.43
Max. Negotiated Rate	$14.41
Rate for Payer: AlohaCare Medicaid	$7.43
Rate for Payer: AlohaCare Medicare	$7.43
Rate for Payer: Cash Price	$9.66
Rate for Payer: Devoted Health Medicare	$8.17
Rate for Payer: Hawaii Medical Service Association Medicare	$7.43
Rate for Payer: Hawaii Western Management Group Commercial	$14.12
Rate for Payer: Health Management Network Commercial	$12.63
Rate for Payer: Humana Medicare	$7.43
Rate for Payer: Kaiser Permanente Commercial	$13.37
Rate for Payer: Kaiser Permanente Medicaid	$7.58
Rate for Payer: Kaiser Permanente Medicare	$7.43
Rate for Payer: MDX Hawaii PPO	$14.41
Rate for Payer: Ohana Health Plan Medicaid	$7.43
Rate for Payer: Ohana Health Plan Medicare	$7.43
Rate for Payer: UnitedHealthcare Medicaid	$8.92
Rate for Payer: UnitedHealthcare Medicare	$7.43
Rate for Payer: University Health Alliance Commercial	$10.83

PARoxetine 10 mg tablet [HHSC]

Facility

$14.56

Service Code	NDC 68382009706
Hospital Charge Code	2500636
Hospital Revenue Code	250
Min. Negotiated Rate	$12.38
Max. Negotiated Rate	$14.12
Rate for Payer: Cash Price	$9.46
Rate for Payer: Health Management Network Commercial	$12.38
Rate for Payer: Kaiser Permanente Commercial	$13.10
Rate for Payer: MDX Hawaii PPO	$14.12

PARoxetine 10 mg tablet [HHSC]

Facility

$14.56

Service Code	NDC 68382009706
Hospital Charge Code	2500636
Hospital Revenue Code	250
Min. Negotiated Rate	$7.28
Max. Negotiated Rate	$14.12
Rate for Payer: AlohaCare Medicaid	$7.28
Rate for Payer: AlohaCare Medicare	$7.28
Rate for Payer: Cash Price	$9.46
Rate for Payer: Devoted Health Medicare	$8.01
Rate for Payer: Hawaii Medical Service Association Medicare	$7.28
Rate for Payer: Hawaii Western Management Group Commercial	$13.83
Rate for Payer: Health Management Network Commercial	$12.38
Rate for Payer: Humana Medicare	$7.28
Rate for Payer: Kaiser Permanente Commercial	$13.10
Rate for Payer: Kaiser Permanente Medicaid	$7.43
Rate for Payer: Kaiser Permanente Medicare	$7.28
Rate for Payer: MDX Hawaii PPO	$14.12
Rate for Payer: Ohana Health Plan Medicaid	$7.28
Rate for Payer: Ohana Health Plan Medicare	$7.28
Rate for Payer: UnitedHealthcare Medicaid	$8.74
Rate for Payer: UnitedHealthcare Medicare	$7.28
Rate for Payer: University Health Alliance Commercial	$10.61

PARoxetine 10 mg tablet [HHSC]

Facility

$14.86

Service Code	NDC 68084004401
Hospital Charge Code	2500636
Hospital Revenue Code	250
Min. Negotiated Rate	$12.63
Max. Negotiated Rate	$14.41
Rate for Payer: Cash Price	$9.66
Rate for Payer: Health Management Network Commercial	$12.63
Rate for Payer: Kaiser Permanente Commercial	$13.37
Rate for Payer: MDX Hawaii PPO	$14.41

Parvovirus B19, IgG, IgM FSI

Facility

$241.00

Service Code	HCPCS 86747
Hospital Charge Code	8118010
Hospital Revenue Code	300
Min. Negotiated Rate	$204.85
Max. Negotiated Rate	$233.77
Rate for Payer: Cash Price	$156.65
Rate for Payer: Health Management Network Commercial	$204.85
Rate for Payer: Kaiser Permanente Commercial	$216.90
Rate for Payer: MDX Hawaii PPO	$233.77

Parvovirus B19, IgG, IgM FSI

Facility

$241.00

Service Code	HCPCS 86747
Hospital Charge Code	8118010
Hospital Revenue Code	300
Min. Negotiated Rate	$15.03
Max. Negotiated Rate	$233.77
Rate for Payer: AlohaCare Medicaid	$120.50
Rate for Payer: AlohaCare Medicare	$120.50
Rate for Payer: Cash Price	$156.65
Rate for Payer: Cash Price	$156.65
Rate for Payer: Devoted Health Medicare	$132.55
Rate for Payer: Hawaii Medical Service Association ABD	$20.77
Rate for Payer: Hawaii Medical Service Association Commercial	$18.79
Rate for Payer: Hawaii Medical Service Association Medicare	$120.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$21.81
Rate for Payer: Hawaii Western Management Group Commercial	$15.03
Rate for Payer: Health Management Network Commercial	$204.85
Rate for Payer: Humana Medicare	$120.50
Rate for Payer: Kaiser Permanente Commercial	$216.90
Rate for Payer: Kaiser Permanente Medicaid	$122.91
Rate for Payer: Kaiser Permanente Medicare	$120.50
Rate for Payer: MDX Hawaii PPO	$233.77
Rate for Payer: Ohana Health Plan Medicaid	$120.50
Rate for Payer: Ohana Health Plan Medicare	$120.50
Rate for Payer: UnitedHealthcare Medicaid	$20.77
Rate for Payer: UnitedHealthcare Medicare	$120.50
Rate for Payer: University Health Alliance Commercial	$38.85

Parvovirus B19, IgM FSI

Facility

$172.00

Service Code	HCPCS 86747
Hospital Charge Code	8118011
Hospital Revenue Code	302
Min. Negotiated Rate	$15.03
Max. Negotiated Rate	$166.84
Rate for Payer: AlohaCare Medicaid	$86.00
Rate for Payer: AlohaCare Medicare	$86.00
Rate for Payer: Cash Price	$111.80
Rate for Payer: Cash Price	$111.80
Rate for Payer: Devoted Health Medicare	$94.60
Rate for Payer: Hawaii Medical Service Association ABD	$20.77
Rate for Payer: Hawaii Medical Service Association Commercial	$18.79
Rate for Payer: Hawaii Medical Service Association Medicare	$86.00
Rate for Payer: Hawaii Medical Service Association Non-ABD	$21.81
Rate for Payer: Hawaii Western Management Group Commercial	$15.03
Rate for Payer: Health Management Network Commercial	$146.20
Rate for Payer: Humana Medicare	$86.00
Rate for Payer: Kaiser Permanente Commercial	$154.80
Rate for Payer: Kaiser Permanente Medicaid	$87.72
Rate for Payer: Kaiser Permanente Medicare	$86.00
Rate for Payer: MDX Hawaii PPO	$166.84
Rate for Payer: Ohana Health Plan Medicaid	$86.00
Rate for Payer: Ohana Health Plan Medicare	$86.00
Rate for Payer: UnitedHealthcare Medicaid	$20.77
Rate for Payer: UnitedHealthcare Medicare	$86.00
Rate for Payer: University Health Alliance Commercial	$38.85

Parvovirus B19, IgM FSI

Facility

$172.00

Service Code	HCPCS 86747
Hospital Charge Code	8118011
Hospital Revenue Code	302
Min. Negotiated Rate	$146.20
Max. Negotiated Rate	$166.84
Rate for Payer: Cash Price	$111.80
Rate for Payer: Health Management Network Commercial	$146.20
Rate for Payer: Kaiser Permanente Commercial	$154.80
Rate for Payer: MDX Hawaii PPO	$166.84

PATCH, HERNIA AUTOSUTURE ABSORBATACK

Facility

$2,709.00

Hospital Charge Code	8274184
Hospital Revenue Code	272
Min. Negotiated Rate	$1,354.50
Max. Negotiated Rate	$2,627.73
Rate for Payer: AlohaCare Medicaid	$1,354.50
Rate for Payer: AlohaCare Medicare	$1,354.50
Rate for Payer: Cash Price	$1,760.85
Rate for Payer: Devoted Health Medicare	$1,489.95
Rate for Payer: Hawaii Medical Service Association Medicare	$1,354.50
Rate for Payer: Hawaii Western Management Group Commercial	$2,573.55
Rate for Payer: Health Management Network Commercial	$2,302.65
Rate for Payer: Humana Medicare	$1,354.50
Rate for Payer: Kaiser Permanente Commercial	$2,438.10
Rate for Payer: Kaiser Permanente Medicaid	$1,381.59
Rate for Payer: Kaiser Permanente Medicare	$1,354.50
Rate for Payer: MDX Hawaii PPO	$2,627.73
Rate for Payer: Ohana Health Plan Medicaid	$1,354.50
Rate for Payer: Ohana Health Plan Medicare	$1,354.50
Rate for Payer: UnitedHealthcare Medicare	$1,354.50
Rate for Payer: University Health Alliance Commercial	$1,974.59

PATCH, HERNIA AUTOSUTURE ABSORBATACK

Facility

$2,709.00

Hospital Charge Code	8274184
Hospital Revenue Code	272
Min. Negotiated Rate	$2,302.65
Max. Negotiated Rate	$2,627.73
Rate for Payer: Cash Price	$1,760.85
Rate for Payer: Health Management Network Commercial	$2,302.65
Rate for Payer: Kaiser Permanente Commercial	$2,438.10
Rate for Payer: MDX Hawaii PPO	$2,627.73

PATHOLOGICAL FRACTURES AND MUSCULOSKELETAL AND CONNECTIVE TISSUE MALIGNANCY WITH CC

Facility

$32,874.67

Service Code	MSDRG 543
Min. Negotiated Rate	$32,874.67
Max. Negotiated Rate	$32,874.67
Rate for Payer: Hawaii Medical Service Association Commercial	$32,874.67

PATHOLOGICAL FRACTURES AND MUSCULOSKELETAL AND CONNECTIVE TISSUE MALIGNANCY WITH MCC

Facility

$32,874.67

Service Code	MSDRG 542
Min. Negotiated Rate	$32,874.67
Max. Negotiated Rate	$32,874.67
Rate for Payer: Hawaii Medical Service Association Commercial	$32,874.67

PATHOLOGICAL FRACTURES AND MUSCULOSKELETAL AND CONNECTIVE TISSUE MALIGNANCY WITHOUT CC/MCC

Facility

$32,874.67

Service Code	MSDRG 544
Min. Negotiated Rate	$32,874.67
Max. Negotiated Rate	$32,874.67
Rate for Payer: Hawaii Medical Service Association Commercial	$32,874.67

PEAK FLOW METER CHARGE

Facility

$74.00

Service Code	HCPCS A4614
Hospital Charge Code	8243411
Hospital Revenue Code	272
Min. Negotiated Rate	$23.59
Max. Negotiated Rate	$71.78
Rate for Payer: AlohaCare Medicaid	$37.00
Rate for Payer: AlohaCare Medicare	$37.00
Rate for Payer: Cash Price	$48.10
Rate for Payer: Cash Price	$48.10
Rate for Payer: Devoted Health Medicare	$40.70
Rate for Payer: Hawaii Medical Service Association Medicare	$37.00
Rate for Payer: Hawaii Western Management Group Commercial	$70.30
Rate for Payer: Health Management Network Commercial	$62.90
Rate for Payer: Humana Medicare	$37.00
Rate for Payer: Kaiser Permanente Commercial	$66.60
Rate for Payer: Kaiser Permanente Medicaid	$37.74
Rate for Payer: Kaiser Permanente Medicare	$37.00
Rate for Payer: MDX Hawaii PPO	$71.78
Rate for Payer: Ohana Health Plan Medicaid	$37.00
Rate for Payer: Ohana Health Plan Medicare	$37.00
Rate for Payer: UnitedHealthcare Medicaid	$23.59
Rate for Payer: UnitedHealthcare Medicare	$37.00
Rate for Payer: University Health Alliance Commercial	$53.94

PEAK FLOW METER CHARGE

Facility

$74.00

Service Code	HCPCS A4614
Hospital Charge Code	8243411
Hospital Revenue Code	272
Min. Negotiated Rate	$62.90
Max. Negotiated Rate	$71.78
Rate for Payer: Cash Price	$48.10
Rate for Payer: Health Management Network Commercial	$62.90
Rate for Payer: Kaiser Permanente Commercial	$66.60
Rate for Payer: MDX Hawaii PPO	$71.78

.Ped Drugs Urine Panel FSI

Facility

$1,384.00

Service Code	HCPCS 80307
Hospital Charge Code	8395736
Hospital Revenue Code	301
Min. Negotiated Rate	$1,176.40
Max. Negotiated Rate	$1,342.48
Rate for Payer: Cash Price	$899.60
Rate for Payer: Health Management Network Commercial	$1,176.40
Rate for Payer: Kaiser Permanente Commercial	$1,245.60
Rate for Payer: MDX Hawaii PPO	$1,342.48

.Ped Drugs Urine Panel FSI

Facility

$1,384.00

Service Code	HCPCS 80307
Hospital Charge Code	8395736
Hospital Revenue Code	301
Min. Negotiated Rate	$47.89
Max. Negotiated Rate	$1,342.48
Rate for Payer: AlohaCare Medicaid	$692.00
Rate for Payer: AlohaCare Medicare	$692.00
Rate for Payer: Cash Price	$899.60
Rate for Payer: Cash Price	$899.60
Rate for Payer: Devoted Health Medicare	$761.20
Rate for Payer: Hawaii Medical Service Association ABD	$59.38
Rate for Payer: Hawaii Medical Service Association Commercial	$77.67
Rate for Payer: Hawaii Medical Service Association Medicare	$692.00
Rate for Payer: Hawaii Medical Service Association Non-ABD	$59.38
Rate for Payer: Hawaii Western Management Group Commercial	$62.14
Rate for Payer: Health Management Network Commercial	$1,176.40
Rate for Payer: Humana Medicare	$692.00
Rate for Payer: Kaiser Permanente Commercial	$1,245.60
Rate for Payer: Kaiser Permanente Medicaid	$705.84
Rate for Payer: Kaiser Permanente Medicare	$692.00
Rate for Payer: MDX Hawaii PPO	$1,342.48
Rate for Payer: Ohana Health Plan Medicaid	$692.00
Rate for Payer: Ohana Health Plan Medicare	$692.00
Rate for Payer: UnitedHealthcare Medicaid	$47.89
Rate for Payer: UnitedHealthcare Medicare	$692.00
Rate for Payer: University Health Alliance Commercial	$147.65

PEG 3350 powder 17gm [HHSC]

Facility

$6.36

Service Code	NDC 11523726808
Hospital Charge Code	2500671
Hospital Revenue Code	250
Min. Negotiated Rate	$5.41
Max. Negotiated Rate	$6.17
Rate for Payer: Cash Price	$4.13
Rate for Payer: Health Management Network Commercial	$5.41
Rate for Payer: Kaiser Permanente Commercial	$5.72
Rate for Payer: MDX Hawaii PPO	$6.17

PEG 3350 powder 17gm [HHSC]

Facility

$15.47

Service Code	NDC 60687043198
Hospital Charge Code	2500671
Hospital Revenue Code	250
Min. Negotiated Rate	$13.15
Max. Negotiated Rate	$15.01
Rate for Payer: Cash Price	$10.06
Rate for Payer: Health Management Network Commercial	$13.15
Rate for Payer: Kaiser Permanente Commercial	$13.92
Rate for Payer: MDX Hawaii PPO	$15.01

PEG 3350 powder 17gm [HHSC]

Facility

$9.76

Service Code	NDC 60687043127
Hospital Charge Code	2500671
Hospital Revenue Code	250
Min. Negotiated Rate	$4.88
Max. Negotiated Rate	$9.47
Rate for Payer: AlohaCare Medicaid	$4.88
Rate for Payer: AlohaCare Medicare	$4.88
Rate for Payer: Cash Price	$6.34
Rate for Payer: Devoted Health Medicare	$5.37
Rate for Payer: Hawaii Medical Service Association Medicare	$4.88
Rate for Payer: Hawaii Western Management Group Commercial	$9.27
Rate for Payer: Health Management Network Commercial	$8.30
Rate for Payer: Humana Medicare	$4.88
Rate for Payer: Kaiser Permanente Commercial	$8.78
Rate for Payer: Kaiser Permanente Medicaid	$4.98
Rate for Payer: Kaiser Permanente Medicare	$4.88
Rate for Payer: MDX Hawaii PPO	$9.47
Rate for Payer: Ohana Health Plan Medicaid	$4.88
Rate for Payer: Ohana Health Plan Medicare	$4.88
Rate for Payer: UnitedHealthcare Medicaid	$5.86
Rate for Payer: UnitedHealthcare Medicare	$4.88
Rate for Payer: University Health Alliance Commercial	$7.11

PEG 3350 powder 17gm [HHSC]

Facility

$9.76

Service Code	NDC 60687043127
Hospital Charge Code	2500671
Hospital Revenue Code	250
Min. Negotiated Rate	$8.30
Max. Negotiated Rate	$9.47
Rate for Payer: Cash Price	$6.34
Rate for Payer: Health Management Network Commercial	$8.30
Rate for Payer: Kaiser Permanente Commercial	$8.78
Rate for Payer: MDX Hawaii PPO	$9.47

PEG 3350 powder 17gm [HHSC]

Facility

$6.36

Service Code	NDC 11523726808
Hospital Charge Code	2500671
Hospital Revenue Code	250
Min. Negotiated Rate	$3.18
Max. Negotiated Rate	$6.17
Rate for Payer: AlohaCare Medicaid	$3.18
Rate for Payer: AlohaCare Medicare	$3.18
Rate for Payer: Cash Price	$4.13
Rate for Payer: Devoted Health Medicare	$3.50
Rate for Payer: Hawaii Medical Service Association Medicare	$3.18
Rate for Payer: Hawaii Western Management Group Commercial	$6.04
Rate for Payer: Health Management Network Commercial	$5.41
Rate for Payer: Humana Medicare	$3.18
Rate for Payer: Kaiser Permanente Commercial	$5.72
Rate for Payer: Kaiser Permanente Medicaid	$3.24
Rate for Payer: Kaiser Permanente Medicare	$3.18
Rate for Payer: MDX Hawaii PPO	$6.17
Rate for Payer: Ohana Health Plan Medicaid	$3.18
Rate for Payer: Ohana Health Plan Medicare	$3.18
Rate for Payer: UnitedHealthcare Medicaid	$3.82
Rate for Payer: UnitedHealthcare Medicare	$3.18
Rate for Payer: University Health Alliance Commercial	$4.64

PEG 3350 powder 17gm [HHSC]

Facility

$5.46

Service Code	NDC 11523726803
Hospital Charge Code	2500671
Hospital Revenue Code	250
Min. Negotiated Rate	$2.73
Max. Negotiated Rate	$5.30
Rate for Payer: AlohaCare Medicaid	$2.73
Rate for Payer: AlohaCare Medicare	$2.73
Rate for Payer: Cash Price	$3.55
Rate for Payer: Devoted Health Medicare	$3.00
Rate for Payer: Hawaii Medical Service Association Medicare	$2.73
Rate for Payer: Hawaii Western Management Group Commercial	$5.19
Rate for Payer: Health Management Network Commercial	$4.64
Rate for Payer: Humana Medicare	$2.73
Rate for Payer: Kaiser Permanente Commercial	$4.91
Rate for Payer: Kaiser Permanente Medicaid	$2.78
Rate for Payer: Kaiser Permanente Medicare	$2.73
Rate for Payer: MDX Hawaii PPO	$5.30
Rate for Payer: Ohana Health Plan Medicaid	$2.73
Rate for Payer: Ohana Health Plan Medicare	$2.73
Rate for Payer: UnitedHealthcare Medicaid	$3.28
Rate for Payer: UnitedHealthcare Medicare	$2.73
Rate for Payer: University Health Alliance Commercial	$3.98

Know your out-of-pocket cost for care.

All Charges