Samuel Mahelona Memorial Hospital

All Charges

Charge

Type

Setting

Price

PEG 3350 powder 17gm [HHSC]

Facility

$5.46

Service Code	NDC 11523726803
Hospital Charge Code	2500671
Hospital Revenue Code	250
Min. Negotiated Rate	$4.64
Max. Negotiated Rate	$5.30
Rate for Payer: Cash Price	$3.55
Rate for Payer: Health Management Network Commercial	$4.64
Rate for Payer: Kaiser Permanente Commercial	$4.91
Rate for Payer: MDX Hawaii PPO	$5.30

PEG 3350 powder 17gm [HHSC]

Facility

$10.39

Service Code	NDC 00904642281
Hospital Charge Code	2500671
Hospital Revenue Code	250
Min. Negotiated Rate	$5.20
Max. Negotiated Rate	$10.08
Rate for Payer: AlohaCare Medicaid	$5.20
Rate for Payer: AlohaCare Medicare	$5.20
Rate for Payer: Cash Price	$6.75
Rate for Payer: Devoted Health Medicare	$5.71
Rate for Payer: Hawaii Medical Service Association Medicare	$5.20
Rate for Payer: Hawaii Western Management Group Commercial	$9.87
Rate for Payer: Health Management Network Commercial	$8.83
Rate for Payer: Humana Medicare	$5.20
Rate for Payer: Kaiser Permanente Commercial	$9.35
Rate for Payer: Kaiser Permanente Medicaid	$5.30
Rate for Payer: Kaiser Permanente Medicare	$5.20
Rate for Payer: MDX Hawaii PPO	$10.08
Rate for Payer: Ohana Health Plan Medicaid	$5.20
Rate for Payer: Ohana Health Plan Medicare	$5.20
Rate for Payer: UnitedHealthcare Medicaid	$6.23
Rate for Payer: UnitedHealthcare Medicare	$5.20
Rate for Payer: University Health Alliance Commercial	$7.57

PEG 3350 powder 17gm [HHSC]

Facility

$15.47

Service Code	NDC 60687043198
Hospital Charge Code	2500671
Hospital Revenue Code	250
Min. Negotiated Rate	$7.74
Max. Negotiated Rate	$15.01
Rate for Payer: AlohaCare Medicaid	$7.74
Rate for Payer: AlohaCare Medicare	$7.74
Rate for Payer: Cash Price	$10.06
Rate for Payer: Devoted Health Medicare	$8.51
Rate for Payer: Hawaii Medical Service Association Medicare	$7.74
Rate for Payer: Hawaii Western Management Group Commercial	$14.70
Rate for Payer: Health Management Network Commercial	$13.15
Rate for Payer: Humana Medicare	$7.74
Rate for Payer: Kaiser Permanente Commercial	$13.92
Rate for Payer: Kaiser Permanente Medicaid	$7.89
Rate for Payer: Kaiser Permanente Medicare	$7.74
Rate for Payer: MDX Hawaii PPO	$15.01
Rate for Payer: Ohana Health Plan Medicaid	$7.74
Rate for Payer: Ohana Health Plan Medicare	$7.74
Rate for Payer: UnitedHealthcare Medicaid	$9.28
Rate for Payer: UnitedHealthcare Medicare	$7.74
Rate for Payer: University Health Alliance Commercial	$11.28

PEG 3350 powder 17gm [HHSC]

Facility

$15.47

Service Code	NDC 68084043098
Hospital Charge Code	2500671
Hospital Revenue Code	250
Min. Negotiated Rate	$7.74
Max. Negotiated Rate	$15.01
Rate for Payer: AlohaCare Medicaid	$7.74
Rate for Payer: AlohaCare Medicare	$7.74
Rate for Payer: Cash Price	$10.06
Rate for Payer: Devoted Health Medicare	$8.51
Rate for Payer: Hawaii Medical Service Association Medicare	$7.74
Rate for Payer: Hawaii Western Management Group Commercial	$14.70
Rate for Payer: Health Management Network Commercial	$13.15
Rate for Payer: Humana Medicare	$7.74
Rate for Payer: Kaiser Permanente Commercial	$13.92
Rate for Payer: Kaiser Permanente Medicaid	$7.89
Rate for Payer: Kaiser Permanente Medicare	$7.74
Rate for Payer: MDX Hawaii PPO	$15.01
Rate for Payer: Ohana Health Plan Medicaid	$7.74
Rate for Payer: Ohana Health Plan Medicare	$7.74
Rate for Payer: UnitedHealthcare Medicaid	$9.28
Rate for Payer: UnitedHealthcare Medicare	$7.74
Rate for Payer: University Health Alliance Commercial	$11.28

PEG 3350 powder 17gm [HHSC]

Facility

$15.47

Service Code	NDC 68084043098
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

$10.39

Service Code	NDC 00904642281
Hospital Charge Code	2500671
Hospital Revenue Code	250
Min. Negotiated Rate	$8.83
Max. Negotiated Rate	$10.08
Rate for Payer: Cash Price	$6.75
Rate for Payer: Health Management Network Commercial	$8.83
Rate for Payer: Kaiser Permanente Commercial	$9.35
Rate for Payer: MDX Hawaii PPO	$10.08

PELVIC EVISCERATION, RADICAL HYSTERECTOMY AND RADICAL VULVECTOMY WITH CC/MCC

Facility

$39,487.53

Service Code	MSDRG 734
Min. Negotiated Rate	$39,487.53
Max. Negotiated Rate	$39,487.53
Rate for Payer: Hawaii Medical Service Association Commercial	$39,487.53

PELVIC EVISCERATION, RADICAL HYSTERECTOMY AND RADICAL VULVECTOMY WITHOUT CC/MCC

Facility

$39,487.53

Service Code	MSDRG 735
Min. Negotiated Rate	$39,487.53
Max. Negotiated Rate	$39,487.53
Rate for Payer: Hawaii Medical Service Association Commercial	$39,487.53

penicillin G benzathine 1200000 unit/2 ml syringe [HHSC]

Facility

$1,167.54

Service Code	HCPCS J0561
Hospital Charge Code	2500638
Hospital Revenue Code	636
Min. Negotiated Rate	$29.30
Max. Negotiated Rate	$1,132.51
Rate for Payer: AlohaCare Medicaid	$583.77
Rate for Payer: AlohaCare Medicare	$583.77
Rate for Payer: Cash Price	$758.90
Rate for Payer: Cash Price	$758.90
Rate for Payer: Devoted Health Medicare	$642.15
Rate for Payer: Hawaii Medical Service Association ABD	$29.30
Rate for Payer: Hawaii Medical Service Association Commercial	$39.34
Rate for Payer: Hawaii Medical Service Association Medicare	$583.77
Rate for Payer: Hawaii Medical Service Association Non-ABD	$29.30
Rate for Payer: Hawaii Western Management Group Commercial	$1,109.16
Rate for Payer: Health Management Network Commercial	$992.41
Rate for Payer: Humana Medicare	$583.77
Rate for Payer: Kaiser Permanente Commercial	$1,050.79
Rate for Payer: Kaiser Permanente Medicaid	$595.45
Rate for Payer: Kaiser Permanente Medicare	$583.77
Rate for Payer: MDX Hawaii PPO	$1,132.51
Rate for Payer: Ohana Health Plan Medicaid	$583.77
Rate for Payer: Ohana Health Plan Medicare	$583.77
Rate for Payer: UnitedHealthcare Medicaid	$700.52
Rate for Payer: UnitedHealthcare Medicare	$583.77
Rate for Payer: University Health Alliance Commercial	$851.02

penicillin G benzathine 1200000 unit/2 ml syringe [HHSC]

Facility

$1,167.54

Service Code	HCPCS J0561
Hospital Charge Code	2500638
Hospital Revenue Code	250
Min. Negotiated Rate	$992.41
Max. Negotiated Rate	$1,132.51
Rate for Payer: Cash Price	$758.90
Rate for Payer: Health Management Network Commercial	$992.41
Rate for Payer: Kaiser Permanente Commercial	$1,050.79
Rate for Payer: MDX Hawaii PPO	$1,132.51

penicillin VK 500 mg tablet [HHSC]

Facility

$4.32

Service Code	NDC 57237004101
Hospital Charge Code	2500641
Hospital Revenue Code	250
Min. Negotiated Rate	$2.16
Max. Negotiated Rate	$4.19
Rate for Payer: AlohaCare Medicaid	$2.16
Rate for Payer: AlohaCare Medicare	$2.16
Rate for Payer: Cash Price	$2.81
Rate for Payer: Devoted Health Medicare	$2.38
Rate for Payer: Hawaii Medical Service Association Medicare	$2.16
Rate for Payer: Hawaii Western Management Group Commercial	$4.10
Rate for Payer: Health Management Network Commercial	$3.67
Rate for Payer: Humana Medicare	$2.16
Rate for Payer: Kaiser Permanente Commercial	$3.89
Rate for Payer: Kaiser Permanente Medicaid	$2.20
Rate for Payer: Kaiser Permanente Medicare	$2.16
Rate for Payer: MDX Hawaii PPO	$4.19
Rate for Payer: Ohana Health Plan Medicaid	$2.16
Rate for Payer: Ohana Health Plan Medicare	$2.16
Rate for Payer: UnitedHealthcare Medicaid	$2.59
Rate for Payer: UnitedHealthcare Medicare	$2.16
Rate for Payer: University Health Alliance Commercial	$3.15

penicillin VK 500 mg tablet [HHSC]

Facility

$6.49

Service Code	NDC 00781165501
Hospital Charge Code	2500641
Hospital Revenue Code	250
Min. Negotiated Rate	$3.25
Max. Negotiated Rate	$6.30
Rate for Payer: AlohaCare Medicaid	$3.25
Rate for Payer: AlohaCare Medicare	$3.25
Rate for Payer: Cash Price	$4.22
Rate for Payer: Devoted Health Medicare	$3.57
Rate for Payer: Hawaii Medical Service Association Medicare	$3.25
Rate for Payer: Hawaii Western Management Group Commercial	$6.17
Rate for Payer: Health Management Network Commercial	$5.52
Rate for Payer: Humana Medicare	$3.25
Rate for Payer: Kaiser Permanente Commercial	$5.84
Rate for Payer: Kaiser Permanente Medicaid	$3.31
Rate for Payer: Kaiser Permanente Medicare	$3.25
Rate for Payer: MDX Hawaii PPO	$6.30
Rate for Payer: Ohana Health Plan Medicaid	$3.25
Rate for Payer: Ohana Health Plan Medicare	$3.25
Rate for Payer: UnitedHealthcare Medicaid	$3.89
Rate for Payer: UnitedHealthcare Medicare	$3.25
Rate for Payer: University Health Alliance Commercial	$4.73

penicillin VK 500 mg tablet [HHSC]

Facility

$6.49

Service Code	NDC 00781165501
Hospital Charge Code	2500641
Hospital Revenue Code	250
Min. Negotiated Rate	$5.52
Max. Negotiated Rate	$6.30
Rate for Payer: Cash Price	$4.22
Rate for Payer: Health Management Network Commercial	$5.52
Rate for Payer: Kaiser Permanente Commercial	$5.84
Rate for Payer: MDX Hawaii PPO	$6.30

penicillin VK 500 mg tablet [HHSC]

Facility

$4.32

Service Code	NDC 57237004101
Hospital Charge Code	2500641
Hospital Revenue Code	250
Min. Negotiated Rate	$3.67
Max. Negotiated Rate	$4.19
Rate for Payer: Cash Price	$2.81
Rate for Payer: Health Management Network Commercial	$3.67
Rate for Payer: Kaiser Permanente Commercial	$3.89
Rate for Payer: MDX Hawaii PPO	$4.19

PENIS PROCEDURES WITH CC/MCC

Facility

$24,958.21

Service Code	MSDRG 709
Min. Negotiated Rate	$24,958.21
Max. Negotiated Rate	$24,958.21
Rate for Payer: Hawaii Medical Service Association Commercial	$24,958.21

PENIS PROCEDURES WITHOUT CC/MCC

Facility

$24,958.21

Service Code	MSDRG 710
Min. Negotiated Rate	$24,958.21
Max. Negotiated Rate	$24,958.21
Rate for Payer: Hawaii Medical Service Association Commercial	$24,958.21

PERCUTANEOUS AND OTHER INTRACARDIAC PROCEDURES WITH MCC

Facility

$53,400.61

Service Code	MSDRG 273
Min. Negotiated Rate	$53,400.61
Max. Negotiated Rate	$53,400.61
Rate for Payer: Hawaii Medical Service Association Commercial	$53,400.61

PERCUTANEOUS AND OTHER INTRACARDIAC PROCEDURES WITHOUT MCC

Facility

$37,591.37

Service Code	MSDRG 274
Min. Negotiated Rate	$37,591.37
Max. Negotiated Rate	$37,591.37
Rate for Payer: Hawaii Medical Service Association Commercial	$37,591.37

PERCUTANEOUS CARDIOVASCULAR PROCEDURES WITH INTRALUMINAL DEVICE WITH MCC OR 4+ ARTERIES/INTRALUMINAL DEVICES

Facility

$57,050.71

Service Code	MSDRG 321
Min. Negotiated Rate	$57,050.71
Max. Negotiated Rate	$57,050.71
Rate for Payer: Hawaii Medical Service Association Commercial	$57,050.71

PERCUTANEOUS CARDIOVASCULAR PROCEDURES WITH INTRALUMINAL DEVICE WITHOUT MCC

Facility

$40,483.02

Service Code	MSDRG 322
Min. Negotiated Rate	$40,483.02
Max. Negotiated Rate	$40,483.02
Rate for Payer: Hawaii Medical Service Association Commercial	$40,483.02

PERCUTANEOUS CARDIOVASCULAR PROCEDURES WITHOUT INTRALUMINAL DEVICE WITH MCC

Facility

$47,996.55

Service Code	MSDRG 250
Min. Negotiated Rate	$47,996.55
Max. Negotiated Rate	$47,996.55
Rate for Payer: Hawaii Medical Service Association Commercial	$47,996.55

PERCUTANEOUS CARDIOVASCULAR PROCEDURES WITHOUT INTRALUMINAL DEVICE WITHOUT MCC

Facility

$35,742.62

Service Code	MSDRG 251
Min. Negotiated Rate	$35,742.62
Max. Negotiated Rate	$35,742.62
Rate for Payer: Hawaii Medical Service Association Commercial	$35,742.62

PERCUTANEOUS CORONARY ATHERECTOMY WITH INTRALUMINAL DEVICE WITH MCC

Facility

$57,050.71

Service Code	MSDRG 359
Min. Negotiated Rate	$57,050.71
Max. Negotiated Rate	$57,050.71
Rate for Payer: Hawaii Medical Service Association Commercial	$57,050.71

PERCUTANEOUS CORONARY ATHERECTOMY WITH INTRALUMINAL DEVICE WITHOUT MCC

Facility

$40,483.02

Service Code	MSDRG 360
Min. Negotiated Rate	$40,483.02
Max. Negotiated Rate	$40,483.02
Rate for Payer: Hawaii Medical Service Association Commercial	$40,483.02

PERCUTANEOUS CORONARY ATHERECTOMY WITHOUT INTRALUMINAL DEVICE

Facility

$47,996.55

Service Code	MSDRG 318
Min. Negotiated Rate	$47,996.55
Max. Negotiated Rate	$47,996.55
Rate for Payer: Hawaii Medical Service Association Commercial	$47,996.55

Know your out-of-pocket cost for care.

All Charges