Samuel Mahelona Memorial Hospital

All Charges

Charge

Type

Setting

Price

Pfizer vaccine 3rd dose: 0003A - 30mcg - Pfizer Vaccine Admin Charge

Facility

$142.00

Service Code	HCPCS 0003A
Hospital Charge Code	9740276
Hospital Revenue Code	771
Min. Negotiated Rate	$71.00
Max. Negotiated Rate	$137.74
Rate for Payer: AlohaCare Medicaid	$71.00
Rate for Payer: AlohaCare Medicare	$71.00
Rate for Payer: Cash Price	$92.30
Rate for Payer: Devoted Health Medicare	$78.10
Rate for Payer: Hawaii Medical Service Association Medicare	$71.00
Rate for Payer: Hawaii Western Management Group Commercial	$134.90
Rate for Payer: Health Management Network Commercial	$120.70
Rate for Payer: Humana Medicare	$71.00
Rate for Payer: Kaiser Permanente Commercial	$127.80
Rate for Payer: Kaiser Permanente Medicaid	$72.42
Rate for Payer: Kaiser Permanente Medicare	$71.00
Rate for Payer: MDX Hawaii PPO	$137.74
Rate for Payer: Ohana Health Plan Medicaid	$71.00
Rate for Payer: Ohana Health Plan Medicare	$71.00
Rate for Payer: UnitedHealthcare Medicare	$71.00
Rate for Payer: University Health Alliance Commercial	$79.52

Pfizer vaccine 3rd dose: 0003A - 30mcg - Pfizer Vaccine Admin Charge

Facility

$142.00

Service Code	HCPCS 0003A
Hospital Charge Code	9740276
Hospital Revenue Code	771
Min. Negotiated Rate	$120.70
Max. Negotiated Rate	$137.74
Rate for Payer: Cash Price	$92.30
Rate for Payer: Health Management Network Commercial	$120.70
Rate for Payer: Kaiser Permanente Commercial	$127.80
Rate for Payer: MDX Hawaii PPO	$137.74

Pfizer vaccine Administration 1st dose: 0001A - 30mcg - Pfizer Vaccine Admin Charge

Facility

$142.00

Service Code	HCPCS 0001A
Hospital Charge Code	9250670
Hospital Revenue Code	771
Min. Negotiated Rate	$120.70
Max. Negotiated Rate	$137.74
Rate for Payer: Cash Price	$92.30
Rate for Payer: Health Management Network Commercial	$120.70
Rate for Payer: Kaiser Permanente Commercial	$127.80
Rate for Payer: MDX Hawaii PPO	$137.74

Pfizer vaccine Administration 1st dose: 0001A - 30mcg - Pfizer Vaccine Admin Charge

Facility

$142.00

Service Code	HCPCS 0001A
Hospital Charge Code	9250670
Hospital Revenue Code	771
Min. Negotiated Rate	$71.00
Max. Negotiated Rate	$137.74
Rate for Payer: AlohaCare Medicaid	$71.00
Rate for Payer: AlohaCare Medicare	$71.00
Rate for Payer: Cash Price	$92.30
Rate for Payer: Devoted Health Medicare	$78.10
Rate for Payer: Hawaii Medical Service Association Medicare	$71.00
Rate for Payer: Hawaii Western Management Group Commercial	$134.90
Rate for Payer: Health Management Network Commercial	$120.70
Rate for Payer: Humana Medicare	$71.00
Rate for Payer: Kaiser Permanente Commercial	$127.80
Rate for Payer: Kaiser Permanente Medicaid	$72.42
Rate for Payer: Kaiser Permanente Medicare	$71.00
Rate for Payer: MDX Hawaii PPO	$137.74
Rate for Payer: Ohana Health Plan Medicaid	$71.00
Rate for Payer: Ohana Health Plan Medicare	$71.00
Rate for Payer: UnitedHealthcare Medicare	$71.00
Rate for Payer: University Health Alliance Commercial	$79.52

phenazopyridine 200 mg tablet [HHSC]

Facility

$22.24

Service Code	NDC 51293081101
Hospital Charge Code	2500645
Hospital Revenue Code	250
Min. Negotiated Rate	$11.12
Max. Negotiated Rate	$21.57
Rate for Payer: AlohaCare Medicaid	$11.12
Rate for Payer: AlohaCare Medicare	$11.12
Rate for Payer: Cash Price	$14.46
Rate for Payer: Devoted Health Medicare	$12.23
Rate for Payer: Hawaii Medical Service Association Medicare	$11.12
Rate for Payer: Hawaii Western Management Group Commercial	$21.13
Rate for Payer: Health Management Network Commercial	$18.90
Rate for Payer: Humana Medicare	$11.12
Rate for Payer: Kaiser Permanente Commercial	$20.02
Rate for Payer: Kaiser Permanente Medicaid	$11.34
Rate for Payer: Kaiser Permanente Medicare	$11.12
Rate for Payer: MDX Hawaii PPO	$21.57
Rate for Payer: Ohana Health Plan Medicaid	$11.12
Rate for Payer: Ohana Health Plan Medicare	$11.12
Rate for Payer: UnitedHealthcare Medicaid	$13.34
Rate for Payer: UnitedHealthcare Medicare	$11.12
Rate for Payer: University Health Alliance Commercial	$16.21

phenazopyridine 200 mg tablet [HHSC]

Facility

$22.24

Service Code	NDC 51293081101
Hospital Charge Code	2500645
Hospital Revenue Code	250
Min. Negotiated Rate	$18.90
Max. Negotiated Rate	$21.57
Rate for Payer: Cash Price	$14.46
Rate for Payer: Health Management Network Commercial	$18.90
Rate for Payer: Kaiser Permanente Commercial	$20.02
Rate for Payer: MDX Hawaii PPO	$21.57

phenazopyridine 200 mg tablet [HHSC]

Facility

$22.24

Service Code	NDC 69367016304
Hospital Charge Code	2500645
Hospital Revenue Code	250
Min. Negotiated Rate	$18.90
Max. Negotiated Rate	$21.57
Rate for Payer: Cash Price	$14.46
Rate for Payer: Health Management Network Commercial	$18.90
Rate for Payer: Kaiser Permanente Commercial	$20.02
Rate for Payer: MDX Hawaii PPO	$21.57

phenazopyridine 200 mg tablet [HHSC]

Facility

$22.24

Service Code	NDC 69367016304
Hospital Charge Code	2500645
Hospital Revenue Code	250
Min. Negotiated Rate	$11.12
Max. Negotiated Rate	$21.57
Rate for Payer: AlohaCare Medicaid	$11.12
Rate for Payer: AlohaCare Medicare	$11.12
Rate for Payer: Cash Price	$14.46
Rate for Payer: Devoted Health Medicare	$12.23
Rate for Payer: Hawaii Medical Service Association Medicare	$11.12
Rate for Payer: Hawaii Western Management Group Commercial	$21.13
Rate for Payer: Health Management Network Commercial	$18.90
Rate for Payer: Humana Medicare	$11.12
Rate for Payer: Kaiser Permanente Commercial	$20.02
Rate for Payer: Kaiser Permanente Medicaid	$11.34
Rate for Payer: Kaiser Permanente Medicare	$11.12
Rate for Payer: MDX Hawaii PPO	$21.57
Rate for Payer: Ohana Health Plan Medicaid	$11.12
Rate for Payer: Ohana Health Plan Medicare	$11.12
Rate for Payer: UnitedHealthcare Medicaid	$13.34
Rate for Payer: UnitedHealthcare Medicare	$11.12
Rate for Payer: University Health Alliance Commercial	$16.21

phenazopyridine 200 mg tablet [HHSC]

Facility

$22.24

Service Code	NDC 65162068210
Hospital Charge Code	2500645
Hospital Revenue Code	250
Min. Negotiated Rate	$11.12
Max. Negotiated Rate	$21.57
Rate for Payer: AlohaCare Medicaid	$11.12
Rate for Payer: AlohaCare Medicare	$11.12
Rate for Payer: Cash Price	$14.46
Rate for Payer: Devoted Health Medicare	$12.23
Rate for Payer: Hawaii Medical Service Association Medicare	$11.12
Rate for Payer: Hawaii Western Management Group Commercial	$21.13
Rate for Payer: Health Management Network Commercial	$18.90
Rate for Payer: Humana Medicare	$11.12
Rate for Payer: Kaiser Permanente Commercial	$20.02
Rate for Payer: Kaiser Permanente Medicaid	$11.34
Rate for Payer: Kaiser Permanente Medicare	$11.12
Rate for Payer: MDX Hawaii PPO	$21.57
Rate for Payer: Ohana Health Plan Medicaid	$11.12
Rate for Payer: Ohana Health Plan Medicare	$11.12
Rate for Payer: UnitedHealthcare Medicaid	$13.34
Rate for Payer: UnitedHealthcare Medicare	$11.12
Rate for Payer: University Health Alliance Commercial	$16.21

phenazopyridine 200 mg tablet [HHSC]

Facility

$22.24

Service Code	NDC 65162068210
Hospital Charge Code	2500645
Hospital Revenue Code	250
Min. Negotiated Rate	$18.90
Max. Negotiated Rate	$21.57
Rate for Payer: Cash Price	$14.46
Rate for Payer: Health Management Network Commercial	$18.90
Rate for Payer: Kaiser Permanente Commercial	$20.02
Rate for Payer: MDX Hawaii PPO	$21.57

.Phencyclidine, Ur Confrm FSI

Facility

$220.00

Service Code	HCPCS 83992
Hospital Charge Code	8728229
Hospital Revenue Code	301
Min. Negotiated Rate	$12.32
Max. Negotiated Rate	$213.40
Rate for Payer: AlohaCare Medicaid	$110.00
Rate for Payer: AlohaCare Medicare	$110.00
Rate for Payer: Cash Price	$143.00
Rate for Payer: Cash Price	$143.00
Rate for Payer: Devoted Health Medicare	$121.00
Rate for Payer: Hawaii Medical Service Association ABD	$12.32
Rate for Payer: Hawaii Medical Service Association Medicare	$110.00
Rate for Payer: Hawaii Medical Service Association Non-ABD	$20.31
Rate for Payer: Hawaii Western Management Group Commercial	$209.00
Rate for Payer: Health Management Network Commercial	$187.00
Rate for Payer: Humana Medicare	$110.00
Rate for Payer: Kaiser Permanente Commercial	$198.00
Rate for Payer: Kaiser Permanente Medicaid	$112.20
Rate for Payer: Kaiser Permanente Medicare	$110.00
Rate for Payer: MDX Hawaii PPO	$213.40
Rate for Payer: Ohana Health Plan Medicaid	$110.00
Rate for Payer: Ohana Health Plan Medicare	$110.00
Rate for Payer: UnitedHealthcare Medicaid	$12.32
Rate for Payer: UnitedHealthcare Medicare	$110.00
Rate for Payer: University Health Alliance Commercial	$38.00

.Phencyclidine, Ur Confrm FSI

Facility

$220.00

Service Code	HCPCS 83992
Hospital Charge Code	8728229
Hospital Revenue Code	301
Min. Negotiated Rate	$187.00
Max. Negotiated Rate	$213.40
Rate for Payer: Cash Price	$143.00
Rate for Payer: Health Management Network Commercial	$187.00
Rate for Payer: Kaiser Permanente Commercial	$198.00
Rate for Payer: MDX Hawaii PPO	$213.40

Phencyclidine, Urine Screen FSI

Facility

$1,384.00

Service Code	HCPCS 80307
Hospital Charge Code	8228907
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

Phencyclidine, Urine Screen FSI

Facility

$1,384.00

Service Code	HCPCS 80307
Hospital Charge Code	8228907
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

phenobarb-belladonna 32.4mg/10mL [HHSC]

Facility

$131.52

Service Code	NDC 72768901104
Hospital Charge Code	2500086
Hospital Revenue Code	250
Min. Negotiated Rate	$65.76
Max. Negotiated Rate	$127.57
Rate for Payer: AlohaCare Medicaid	$65.76
Rate for Payer: AlohaCare Medicare	$65.76
Rate for Payer: Cash Price	$85.49
Rate for Payer: Devoted Health Medicare	$72.34
Rate for Payer: Hawaii Medical Service Association Medicare	$65.76
Rate for Payer: Hawaii Western Management Group Commercial	$124.94
Rate for Payer: Health Management Network Commercial	$111.79
Rate for Payer: Humana Medicare	$65.76
Rate for Payer: Kaiser Permanente Commercial	$118.37
Rate for Payer: Kaiser Permanente Medicaid	$67.08
Rate for Payer: Kaiser Permanente Medicare	$65.76
Rate for Payer: MDX Hawaii PPO	$127.57
Rate for Payer: Ohana Health Plan Medicaid	$65.76
Rate for Payer: Ohana Health Plan Medicare	$65.76
Rate for Payer: UnitedHealthcare Medicaid	$78.91
Rate for Payer: UnitedHealthcare Medicare	$65.76
Rate for Payer: University Health Alliance Commercial	$95.86

phenobarb-belladonna 32.4mg/10mL [HHSC]

Facility

$106.04

Service Code	NDC 71914016204
Hospital Charge Code	2500086
Hospital Revenue Code	250
Min. Negotiated Rate	$53.02
Max. Negotiated Rate	$102.86
Rate for Payer: AlohaCare Medicaid	$53.02
Rate for Payer: AlohaCare Medicare	$53.02
Rate for Payer: Cash Price	$68.93
Rate for Payer: Devoted Health Medicare	$58.32
Rate for Payer: Hawaii Medical Service Association Medicare	$53.02
Rate for Payer: Hawaii Western Management Group Commercial	$100.74
Rate for Payer: Health Management Network Commercial	$90.13
Rate for Payer: Humana Medicare	$53.02
Rate for Payer: Kaiser Permanente Commercial	$95.44
Rate for Payer: Kaiser Permanente Medicaid	$54.08
Rate for Payer: Kaiser Permanente Medicare	$53.02
Rate for Payer: MDX Hawaii PPO	$102.86
Rate for Payer: Ohana Health Plan Medicaid	$53.02
Rate for Payer: Ohana Health Plan Medicare	$53.02
Rate for Payer: UnitedHealthcare Medicaid	$63.62
Rate for Payer: UnitedHealthcare Medicare	$53.02
Rate for Payer: University Health Alliance Commercial	$77.29

phenobarb-belladonna 32.4mg/10mL [HHSC]

Facility

$154.18

Service Code	NDC 50742066604
Hospital Charge Code	2500086
Hospital Revenue Code	250
Min. Negotiated Rate	$77.09
Max. Negotiated Rate	$149.55
Rate for Payer: AlohaCare Medicaid	$77.09
Rate for Payer: AlohaCare Medicare	$77.09
Rate for Payer: Cash Price	$100.22
Rate for Payer: Devoted Health Medicare	$84.80
Rate for Payer: Hawaii Medical Service Association Medicare	$77.09
Rate for Payer: Hawaii Western Management Group Commercial	$146.47
Rate for Payer: Health Management Network Commercial	$131.05
Rate for Payer: Humana Medicare	$77.09
Rate for Payer: Kaiser Permanente Commercial	$138.76
Rate for Payer: Kaiser Permanente Medicaid	$78.63
Rate for Payer: Kaiser Permanente Medicare	$77.09
Rate for Payer: MDX Hawaii PPO	$149.55
Rate for Payer: Ohana Health Plan Medicaid	$77.09
Rate for Payer: Ohana Health Plan Medicare	$77.09
Rate for Payer: UnitedHealthcare Medicaid	$92.51
Rate for Payer: UnitedHealthcare Medicare	$77.09
Rate for Payer: University Health Alliance Commercial	$112.38

phenobarb-belladonna 32.4mg/10mL [HHSC]

Facility

$131.52

Service Code	NDC 72768901104
Hospital Charge Code	2500086
Hospital Revenue Code	250
Min. Negotiated Rate	$111.79
Max. Negotiated Rate	$127.57
Rate for Payer: Cash Price	$85.49
Rate for Payer: Health Management Network Commercial	$111.79
Rate for Payer: Kaiser Permanente Commercial	$118.37
Rate for Payer: MDX Hawaii PPO	$127.57

phenobarb-belladonna 32.4mg/10mL [HHSC]

Facility

$169.31

Service Code	NDC 59212042304
Hospital Charge Code	2500086
Hospital Revenue Code	250
Min. Negotiated Rate	$84.66
Max. Negotiated Rate	$164.23
Rate for Payer: AlohaCare Medicaid	$84.66
Rate for Payer: AlohaCare Medicare	$84.66
Rate for Payer: Cash Price	$110.05
Rate for Payer: Devoted Health Medicare	$93.12
Rate for Payer: Hawaii Medical Service Association Medicare	$84.66
Rate for Payer: Hawaii Western Management Group Commercial	$160.84
Rate for Payer: Health Management Network Commercial	$143.91
Rate for Payer: Humana Medicare	$84.66
Rate for Payer: Kaiser Permanente Commercial	$152.38
Rate for Payer: Kaiser Permanente Medicaid	$86.35
Rate for Payer: Kaiser Permanente Medicare	$84.66
Rate for Payer: MDX Hawaii PPO	$164.23
Rate for Payer: Ohana Health Plan Medicaid	$84.66
Rate for Payer: Ohana Health Plan Medicare	$84.66
Rate for Payer: UnitedHealthcare Medicaid	$101.59
Rate for Payer: UnitedHealthcare Medicare	$84.66
Rate for Payer: University Health Alliance Commercial	$123.41

phenobarb-belladonna 32.4mg/10mL [HHSC]

Facility

$169.31

Service Code	NDC 59212042304
Hospital Charge Code	2500086
Hospital Revenue Code	250
Min. Negotiated Rate	$143.91
Max. Negotiated Rate	$164.23
Rate for Payer: Cash Price	$110.05
Rate for Payer: Health Management Network Commercial	$143.91
Rate for Payer: Kaiser Permanente Commercial	$152.38
Rate for Payer: MDX Hawaii PPO	$164.23

phenobarb-belladonna 32.4mg/10mL [HHSC]

Facility

$154.18

Service Code	NDC 50742066604
Hospital Charge Code	2500086
Hospital Revenue Code	250
Min. Negotiated Rate	$131.05
Max. Negotiated Rate	$149.55
Rate for Payer: Cash Price	$100.22
Rate for Payer: Health Management Network Commercial	$131.05
Rate for Payer: Kaiser Permanente Commercial	$138.76
Rate for Payer: MDX Hawaii PPO	$149.55

phenobarb-belladonna 32.4mg/10mL [HHSC]

Facility

$106.04

Service Code	NDC 71914016204
Hospital Charge Code	2500086
Hospital Revenue Code	250
Min. Negotiated Rate	$90.13
Max. Negotiated Rate	$102.86
Rate for Payer: Cash Price	$68.93
Rate for Payer: Health Management Network Commercial	$90.13
Rate for Payer: Kaiser Permanente Commercial	$95.44
Rate for Payer: MDX Hawaii PPO	$102.86

Phenobarbital REF

Facility

$133.00

Service Code	HCPCS 80184
Hospital Charge Code	8159985
Hospital Revenue Code	301
Min. Negotiated Rate	$15.30
Max. Negotiated Rate	$129.01
Rate for Payer: AlohaCare Medicaid	$66.50
Rate for Payer: AlohaCare Medicare	$66.50
Rate for Payer: Cash Price	$86.45
Rate for Payer: Cash Price	$86.45
Rate for Payer: Devoted Health Medicare	$73.15
Rate for Payer: Hawaii Medical Service Association ABD	$15.83
Rate for Payer: Hawaii Medical Service Association Commercial	$19.12
Rate for Payer: Hawaii Medical Service Association Medicare	$66.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$16.62
Rate for Payer: Hawaii Western Management Group Commercial	$15.30
Rate for Payer: Health Management Network Commercial	$113.05
Rate for Payer: Humana Medicare	$66.50
Rate for Payer: Kaiser Permanente Commercial	$119.70
Rate for Payer: Kaiser Permanente Medicaid	$67.83
Rate for Payer: Kaiser Permanente Medicare	$66.50
Rate for Payer: MDX Hawaii PPO	$129.01
Rate for Payer: Ohana Health Plan Medicaid	$66.50
Rate for Payer: Ohana Health Plan Medicare	$66.50
Rate for Payer: UnitedHealthcare Medicaid	$15.83
Rate for Payer: UnitedHealthcare Medicare	$66.50
Rate for Payer: University Health Alliance Commercial	$29.62

Phenobarbital REF

Facility

$133.00

Service Code	HCPCS 80184
Hospital Charge Code	8159985
Hospital Revenue Code	301
Min. Negotiated Rate	$113.05
Max. Negotiated Rate	$129.01
Rate for Payer: Cash Price	$86.45
Rate for Payer: Health Management Network Commercial	$113.05
Rate for Payer: Kaiser Permanente Commercial	$119.70
Rate for Payer: MDX Hawaii PPO	$129.01

phenylephrine 10 mg/ml vial [HHSC]

Facility

$15.29

Service Code	HCPCS J2371
Hospital Charge Code	2500651
Hospital Revenue Code	250
Min. Negotiated Rate	$13.00
Max. Negotiated Rate	$14.83
Rate for Payer: Cash Price	$9.94
Rate for Payer: Cash Price	$13.88
Rate for Payer: Cash Price	$5.21
Rate for Payer: Cash Price	$15.51
Rate for Payer: Cash Price	$29.08
Rate for Payer: Cash Price	$13.53
Rate for Payer: Cash Price	$15.92
Rate for Payer: Health Management Network Commercial	$38.03
Rate for Payer: Health Management Network Commercial	$17.70
Rate for Payer: Health Management Network Commercial	$6.81
Rate for Payer: Health Management Network Commercial	$18.15
Rate for Payer: Health Management Network Commercial	$13.00
Rate for Payer: Health Management Network Commercial	$20.28
Rate for Payer: Health Management Network Commercial	$20.82
Rate for Payer: Kaiser Permanente Commercial	$21.47
Rate for Payer: Kaiser Permanente Commercial	$13.76
Rate for Payer: Kaiser Permanente Commercial	$18.74
Rate for Payer: Kaiser Permanente Commercial	$40.27
Rate for Payer: Kaiser Permanente Commercial	$22.04
Rate for Payer: Kaiser Permanente Commercial	$19.21
Rate for Payer: Kaiser Permanente Commercial	$7.21
Rate for Payer: MDX Hawaii PPO	$23.14
Rate for Payer: MDX Hawaii PPO	$14.83
Rate for Payer: MDX Hawaii PPO	$20.20
Rate for Payer: MDX Hawaii PPO	$20.71
Rate for Payer: MDX Hawaii PPO	$23.76
Rate for Payer: MDX Hawaii PPO	$43.40
Rate for Payer: MDX Hawaii PPO	$7.77

Know your out-of-pocket cost for care.

All Charges