Samuel Mahelona Memorial Hospital

All Charges

Charge

Type

Setting

Price

QUEtiapine 300 mg tablet [HHSC]

Facility

$89.47

Service Code	NDC 67877024760
Hospital Charge Code	2500721
Hospital Revenue Code	250
Min. Negotiated Rate	$44.73
Max. Negotiated Rate	$86.79
Rate for Payer: AlohaCare Medicaid	$44.73
Rate for Payer: AlohaCare Medicare	$44.73
Rate for Payer: Cash Price	$58.16
Rate for Payer: Devoted Health Medicare	$49.21
Rate for Payer: Hawaii Medical Service Association Medicare	$44.73
Rate for Payer: Hawaii Western Management Group Commercial	$85.00
Rate for Payer: Health Management Network Commercial	$76.05
Rate for Payer: Humana Medicare	$44.73
Rate for Payer: Kaiser Permanente Commercial	$80.52
Rate for Payer: Kaiser Permanente Medicaid	$45.63
Rate for Payer: Kaiser Permanente Medicare	$44.73
Rate for Payer: MDX Hawaii PPO	$86.79
Rate for Payer: Ohana Health Plan Medicaid	$44.73
Rate for Payer: Ohana Health Plan Medicare	$44.73
Rate for Payer: UnitedHealthcare Medicaid	$53.68
Rate for Payer: UnitedHealthcare Medicare	$44.73
Rate for Payer: University Health Alliance Commercial	$65.21

QUEtiapine 300 mg tablet [HHSC]

Facility

$59.10

Service Code	NDC 50268063415
Hospital Charge Code	2500721
Hospital Revenue Code	250
Min. Negotiated Rate	$29.55
Max. Negotiated Rate	$57.33
Rate for Payer: AlohaCare Medicaid	$29.55
Rate for Payer: AlohaCare Medicare	$29.55
Rate for Payer: Cash Price	$38.42
Rate for Payer: Devoted Health Medicare	$32.51
Rate for Payer: Hawaii Medical Service Association Medicare	$29.55
Rate for Payer: Hawaii Western Management Group Commercial	$56.15
Rate for Payer: Health Management Network Commercial	$50.23
Rate for Payer: Humana Medicare	$29.55
Rate for Payer: Kaiser Permanente Commercial	$53.19
Rate for Payer: Kaiser Permanente Medicaid	$30.14
Rate for Payer: Kaiser Permanente Medicare	$29.55
Rate for Payer: MDX Hawaii PPO	$57.33
Rate for Payer: Ohana Health Plan Medicaid	$29.55
Rate for Payer: Ohana Health Plan Medicare	$29.55
Rate for Payer: UnitedHealthcare Medicaid	$35.46
Rate for Payer: UnitedHealthcare Medicare	$29.55
Rate for Payer: University Health Alliance Commercial	$43.08

racepinephrine 2.25% neb soln [HHSC]

Facility

$5.56

Service Code	NDC 00487278401
Hospital Charge Code	2500723
Hospital Revenue Code	250
Min. Negotiated Rate	$2.78
Max. Negotiated Rate	$5.39
Rate for Payer: AlohaCare Medicaid	$2.78
Rate for Payer: AlohaCare Medicare	$2.78
Rate for Payer: Cash Price	$3.61
Rate for Payer: Devoted Health Medicare	$3.06
Rate for Payer: Hawaii Medical Service Association Medicare	$2.78
Rate for Payer: Hawaii Western Management Group Commercial	$5.28
Rate for Payer: Health Management Network Commercial	$4.73
Rate for Payer: Humana Medicare	$2.78
Rate for Payer: Kaiser Permanente Commercial	$5.00
Rate for Payer: Kaiser Permanente Medicaid	$2.84
Rate for Payer: Kaiser Permanente Medicare	$2.78
Rate for Payer: MDX Hawaii PPO	$5.39
Rate for Payer: Ohana Health Plan Medicaid	$2.78
Rate for Payer: Ohana Health Plan Medicare	$2.78
Rate for Payer: UnitedHealthcare Medicaid	$3.34
Rate for Payer: UnitedHealthcare Medicare	$2.78
Rate for Payer: University Health Alliance Commercial	$4.05

racepinephrine 2.25% neb soln [HHSC]

Facility

$10.42

Service Code	NDC 00487590199
Hospital Charge Code	2500723
Hospital Revenue Code	250
Min. Negotiated Rate	$5.21
Max. Negotiated Rate	$10.11
Rate for Payer: AlohaCare Medicaid	$5.21
Rate for Payer: AlohaCare Medicare	$5.21
Rate for Payer: Cash Price	$6.77
Rate for Payer: Devoted Health Medicare	$5.73
Rate for Payer: Hawaii Medical Service Association Medicare	$5.21
Rate for Payer: Hawaii Western Management Group Commercial	$9.90
Rate for Payer: Health Management Network Commercial	$8.86
Rate for Payer: Humana Medicare	$5.21
Rate for Payer: Kaiser Permanente Commercial	$9.38
Rate for Payer: Kaiser Permanente Medicaid	$5.31
Rate for Payer: Kaiser Permanente Medicare	$5.21
Rate for Payer: MDX Hawaii PPO	$10.11
Rate for Payer: Ohana Health Plan Medicaid	$5.21
Rate for Payer: Ohana Health Plan Medicare	$5.21
Rate for Payer: UnitedHealthcare Medicaid	$6.25
Rate for Payer: UnitedHealthcare Medicare	$5.21
Rate for Payer: University Health Alliance Commercial	$7.60

racepinephrine 2.25% neb soln [HHSC]

Facility

$10.42

Service Code	NDC 00487590199
Hospital Charge Code	2500723
Hospital Revenue Code	250
Min. Negotiated Rate	$8.86
Max. Negotiated Rate	$10.11
Rate for Payer: Cash Price	$6.77
Rate for Payer: Health Management Network Commercial	$8.86
Rate for Payer: Kaiser Permanente Commercial	$9.38
Rate for Payer: MDX Hawaii PPO	$10.11

racepinephrine 2.25% neb soln [HHSC]

Facility

$5.56

Service Code	NDC 00487278401
Hospital Charge Code	2500723
Hospital Revenue Code	250
Min. Negotiated Rate	$4.73
Max. Negotiated Rate	$5.39
Rate for Payer: Cash Price	$3.61
Rate for Payer: Health Management Network Commercial	$4.73
Rate for Payer: Kaiser Permanente Commercial	$5.00
Rate for Payer: MDX Hawaii PPO	$5.39

RADIOTHERAPY

Facility

$17,373.57

Service Code	MSDRG 849
Min. Negotiated Rate	$17,373.57
Max. Negotiated Rate	$17,373.57
Rate for Payer: Hawaii Medical Service Association Commercial	$17,373.57

raltegravir 400 mg tablet [HHSC]

Facility

$185.08

Service Code	HCPCS J8499
Hospital Charge Code	2501070
Hospital Revenue Code	636
Min. Negotiated Rate	$92.54
Max. Negotiated Rate	$179.53
Rate for Payer: AlohaCare Medicaid	$92.54
Rate for Payer: AlohaCare Medicare	$92.54
Rate for Payer: Cash Price	$120.30
Rate for Payer: Devoted Health Medicare	$101.79
Rate for Payer: Hawaii Medical Service Association Medicare	$92.54
Rate for Payer: Hawaii Western Management Group Commercial	$175.83
Rate for Payer: Health Management Network Commercial	$157.32
Rate for Payer: Humana Medicare	$92.54
Rate for Payer: Kaiser Permanente Commercial	$166.57
Rate for Payer: Kaiser Permanente Medicaid	$94.39
Rate for Payer: Kaiser Permanente Medicare	$92.54
Rate for Payer: MDX Hawaii PPO	$179.53
Rate for Payer: Ohana Health Plan Medicaid	$92.54
Rate for Payer: Ohana Health Plan Medicare	$92.54
Rate for Payer: UnitedHealthcare Medicaid	$111.05
Rate for Payer: UnitedHealthcare Medicare	$92.54
Rate for Payer: University Health Alliance Commercial	$134.90

raltegravir 400 mg tablet [HHSC]

Facility

$185.08

Service Code	HCPCS J8499
Hospital Charge Code	2501070
Hospital Revenue Code	250
Min. Negotiated Rate	$157.32
Max. Negotiated Rate	$179.53
Rate for Payer: Cash Price	$120.30
Rate for Payer: Health Management Network Commercial	$157.32
Rate for Payer: Kaiser Permanente Commercial	$166.57
Rate for Payer: MDX Hawaii PPO	$179.53

Rapid EEG - ED Ceribell

Facility

$1,537.00

Service Code	HCPCS 95816
Hospital Charge Code	10095506
Hospital Revenue Code	740
Min. Negotiated Rate	$1,306.45
Max. Negotiated Rate	$1,490.89
Rate for Payer: Cash Price	$999.05
Rate for Payer: Health Management Network Commercial	$1,306.45
Rate for Payer: Kaiser Permanente Commercial	$1,383.30
Rate for Payer: MDX Hawaii PPO	$1,490.89

Rapid EEG - ED Ceribell

Facility

$1,537.00

Service Code	HCPCS 95816
Hospital Charge Code	10095506
Hospital Revenue Code	740
Min. Negotiated Rate	$84.17
Max. Negotiated Rate	$1,490.89
Rate for Payer: AlohaCare Medicaid	$768.50
Rate for Payer: AlohaCare Medicare	$768.50
Rate for Payer: Cash Price	$999.05
Rate for Payer: Cash Price	$999.05
Rate for Payer: Devoted Health Medicare	$845.35
Rate for Payer: Hawaii Medical Service Association ABD	$84.17
Rate for Payer: Hawaii Medical Service Association Commercial	$275.75
Rate for Payer: Hawaii Medical Service Association Medicare	$768.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$145.63
Rate for Payer: Hawaii Western Management Group Commercial	$1,460.15
Rate for Payer: Health Management Network Commercial	$1,306.45
Rate for Payer: Humana Medicare	$768.50
Rate for Payer: Kaiser Permanente Commercial	$1,383.30
Rate for Payer: Kaiser Permanente Medicaid	$783.87
Rate for Payer: Kaiser Permanente Medicare	$768.50
Rate for Payer: MDX Hawaii PPO	$1,490.89
Rate for Payer: Ohana Health Plan Medicaid	$768.50
Rate for Payer: Ohana Health Plan Medicare	$768.50
Rate for Payer: UnitedHealthcare Medicaid	$84.17
Rate for Payer: UnitedHealthcare Medicare	$768.50
Rate for Payer: University Health Alliance Commercial	$860.72

Rapid EEG - ED Ceribell

Professional

Both

$751.00

Service Code	HCPCS 95816
Hospital Charge Code	10095506
Hospital Revenue Code	981
Min. Negotiated Rate	$105.68
Max. Negotiated Rate	$638.35
Rate for Payer: AlohaCare Medicaid	$445.92
Rate for Payer: AlohaCare Medicare	$463.48
Rate for Payer: Cash Price	$488.15
Rate for Payer: Cash Price	$488.15
Rate for Payer: Devoted Health Medicare	$509.83
Rate for Payer: Hawaii Medical Service Association Medicare	$463.48
Rate for Payer: Hawaii Western Management Group Commercial	$105.68
Rate for Payer: Health Management Network Commercial	$638.35
Rate for Payer: Kaiser Permanente Commercial	$556.18
Rate for Payer: Kaiser Permanente Medicaid	$556.18
Rate for Payer: Kaiser Permanente Medicare	$556.18
Rate for Payer: Ohana Health Plan Medicaid	$445.92
Rate for Payer: Ohana Health Plan Medicare	$463.48
Rate for Payer: UnitedHealthcare Medicaid	$445.92
Rate for Payer: UnitedHealthcare Medicare	$463.48

Rapid Flu A/B Antigen FSI

Facility

$139.00

Service Code	HCPCS 87804 QW
Hospital Charge Code	8225272
Hospital Revenue Code	306
Min. Negotiated Rate	$16.55
Max. Negotiated Rate	$134.83
Rate for Payer: AlohaCare Medicaid	$69.50
Rate for Payer: AlohaCare Medicare	$69.50
Rate for Payer: Cash Price	$90.35
Rate for Payer: Cash Price	$90.35
Rate for Payer: Devoted Health Medicare	$76.45
Rate for Payer: Hawaii Medical Service Association ABD	$16.58
Rate for Payer: Hawaii Medical Service Association Commercial	$20.69
Rate for Payer: Hawaii Medical Service Association Medicare	$69.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$17.41
Rate for Payer: Hawaii Western Management Group Commercial	$16.55
Rate for Payer: Health Management Network Commercial	$118.15
Rate for Payer: Humana Medicare	$69.50
Rate for Payer: Kaiser Permanente Commercial	$125.10
Rate for Payer: Kaiser Permanente Medicaid	$70.89
Rate for Payer: Kaiser Permanente Medicare	$69.50
Rate for Payer: MDX Hawaii PPO	$134.83
Rate for Payer: Ohana Health Plan Medicaid	$69.50
Rate for Payer: Ohana Health Plan Medicare	$69.50
Rate for Payer: UnitedHealthcare Medicaid	$16.58
Rate for Payer: UnitedHealthcare Medicare	$69.50
Rate for Payer: University Health Alliance Commercial	$31.01

Rapid Flu A/B Antigen FSI

Facility

$139.00

Service Code	HCPCS 87804 QW
Hospital Charge Code	8225272
Hospital Revenue Code	306
Min. Negotiated Rate	$118.15
Max. Negotiated Rate	$134.83
Rate for Payer: Cash Price	$90.35
Rate for Payer: Health Management Network Commercial	$118.15
Rate for Payer: Kaiser Permanente Commercial	$125.10
Rate for Payer: MDX Hawaii PPO	$134.83

Rapid Flu Rfx CoV-2 FSI

Facility

$139.00

Service Code	HCPCS 87804 QW
Hospital Charge Code	8860988
Hospital Revenue Code	300
Min. Negotiated Rate	$16.55
Max. Negotiated Rate	$134.83
Rate for Payer: AlohaCare Medicaid	$69.50
Rate for Payer: AlohaCare Medicare	$69.50
Rate for Payer: Cash Price	$90.35
Rate for Payer: Cash Price	$90.35
Rate for Payer: Devoted Health Medicare	$76.45
Rate for Payer: Hawaii Medical Service Association ABD	$16.58
Rate for Payer: Hawaii Medical Service Association Commercial	$20.69
Rate for Payer: Hawaii Medical Service Association Medicare	$69.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$17.41
Rate for Payer: Hawaii Western Management Group Commercial	$16.55
Rate for Payer: Health Management Network Commercial	$118.15
Rate for Payer: Humana Medicare	$69.50
Rate for Payer: Kaiser Permanente Commercial	$125.10
Rate for Payer: Kaiser Permanente Medicaid	$70.89
Rate for Payer: Kaiser Permanente Medicare	$69.50
Rate for Payer: MDX Hawaii PPO	$134.83
Rate for Payer: Ohana Health Plan Medicaid	$69.50
Rate for Payer: Ohana Health Plan Medicare	$69.50
Rate for Payer: UnitedHealthcare Medicaid	$16.58
Rate for Payer: UnitedHealthcare Medicare	$69.50
Rate for Payer: University Health Alliance Commercial	$31.01

Rapid Flu Rfx CoV-2 FSI

Facility

$139.00

Service Code	HCPCS 87804 QW
Hospital Charge Code	8860988
Hospital Revenue Code	300
Min. Negotiated Rate	$118.15
Max. Negotiated Rate	$134.83
Rate for Payer: Cash Price	$90.35
Rate for Payer: Health Management Network Commercial	$118.15
Rate for Payer: Kaiser Permanente Commercial	$125.10
Rate for Payer: MDX Hawaii PPO	$134.83

Rapid Flu Rfx PCR Rfx CoV-2 FSI

Facility

$139.00

Service Code	HCPCS 87804 QW
Hospital Charge Code	8860989
Hospital Revenue Code	300
Min. Negotiated Rate	$16.55
Max. Negotiated Rate	$134.83
Rate for Payer: AlohaCare Medicaid	$69.50
Rate for Payer: AlohaCare Medicare	$69.50
Rate for Payer: Cash Price	$90.35
Rate for Payer: Cash Price	$90.35
Rate for Payer: Devoted Health Medicare	$76.45
Rate for Payer: Hawaii Medical Service Association ABD	$16.58
Rate for Payer: Hawaii Medical Service Association Commercial	$20.69
Rate for Payer: Hawaii Medical Service Association Medicare	$69.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$17.41
Rate for Payer: Hawaii Western Management Group Commercial	$16.55
Rate for Payer: Health Management Network Commercial	$118.15
Rate for Payer: Humana Medicare	$69.50
Rate for Payer: Kaiser Permanente Commercial	$125.10
Rate for Payer: Kaiser Permanente Medicaid	$70.89
Rate for Payer: Kaiser Permanente Medicare	$69.50
Rate for Payer: MDX Hawaii PPO	$134.83
Rate for Payer: Ohana Health Plan Medicaid	$69.50
Rate for Payer: Ohana Health Plan Medicare	$69.50
Rate for Payer: UnitedHealthcare Medicaid	$16.58
Rate for Payer: UnitedHealthcare Medicare	$69.50
Rate for Payer: University Health Alliance Commercial	$31.01

Rapid Flu Rfx PCR Rfx CoV-2 FSI

Facility

$139.00

Service Code	HCPCS 87804 QW
Hospital Charge Code	8860989
Hospital Revenue Code	300
Min. Negotiated Rate	$118.15
Max. Negotiated Rate	$134.83
Rate for Payer: Cash Price	$90.35
Rate for Payer: Health Management Network Commercial	$118.15
Rate for Payer: Kaiser Permanente Commercial	$125.10
Rate for Payer: MDX Hawaii PPO	$134.83

Rapid Influenza A/B NAAT FSI

Facility

$947.00

Service Code	HCPCS 87502
Hospital Charge Code	9905084
Hospital Revenue Code	306
Min. Negotiated Rate	$95.80
Max. Negotiated Rate	$918.59
Rate for Payer: AlohaCare Medicaid	$473.50
Rate for Payer: AlohaCare Medicare	$473.50
Rate for Payer: Cash Price	$615.55
Rate for Payer: Cash Price	$615.55
Rate for Payer: Devoted Health Medicare	$520.85
Rate for Payer: Hawaii Medical Service Association ABD	$119.75
Rate for Payer: Hawaii Medical Service Association Commercial	$119.75
Rate for Payer: Hawaii Medical Service Association Medicare	$473.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$117.54
Rate for Payer: Hawaii Western Management Group Commercial	$95.80
Rate for Payer: Health Management Network Commercial	$804.95
Rate for Payer: Humana Medicare	$473.50
Rate for Payer: Kaiser Permanente Commercial	$852.30
Rate for Payer: Kaiser Permanente Medicaid	$482.97
Rate for Payer: Kaiser Permanente Medicare	$473.50
Rate for Payer: MDX Hawaii PPO	$918.59
Rate for Payer: Ohana Health Plan Medicaid	$473.50
Rate for Payer: Ohana Health Plan Medicare	$473.50
Rate for Payer: UnitedHealthcare Medicaid	$119.75
Rate for Payer: UnitedHealthcare Medicare	$473.50
Rate for Payer: University Health Alliance Commercial	$221.54

Rapid Influenza A/B NAAT FSI

Facility

$947.00

Service Code	HCPCS 87502
Hospital Charge Code	9905084
Hospital Revenue Code	306
Min. Negotiated Rate	$804.95
Max. Negotiated Rate	$918.59
Rate for Payer: Cash Price	$615.55
Rate for Payer: Health Management Network Commercial	$804.95
Rate for Payer: Kaiser Permanente Commercial	$852.30
Rate for Payer: MDX Hawaii PPO	$918.59

Rapid Molecular MRSA Screen (Nasal)

Facility

$210.00

Service Code	HCPCS 87641
Hospital Charge Code	12514759
Hospital Revenue Code	306
Min. Negotiated Rate	$178.50
Max. Negotiated Rate	$203.70
Rate for Payer: Cash Price	$136.50
Rate for Payer: Health Management Network Commercial	$178.50
Rate for Payer: Kaiser Permanente Commercial	$189.00
Rate for Payer: MDX Hawaii PPO	$203.70

Rapid Molecular MRSA Screen (Nasal)

Facility

$210.00

Service Code	HCPCS 87641
Hospital Charge Code	12514759
Hospital Revenue Code	306
Min. Negotiated Rate	$35.09
Max. Negotiated Rate	$203.70
Rate for Payer: AlohaCare Medicaid	$105.00
Rate for Payer: AlohaCare Medicare	$105.00
Rate for Payer: Cash Price	$136.50
Rate for Payer: Cash Price	$136.50
Rate for Payer: Devoted Health Medicare	$115.50
Rate for Payer: Hawaii Medical Service Association ABD	$49.04
Rate for Payer: Hawaii Medical Service Association Commercial	$43.86
Rate for Payer: Hawaii Medical Service Association Medicare	$105.00
Rate for Payer: Hawaii Medical Service Association Non-ABD	$51.49
Rate for Payer: Hawaii Western Management Group Commercial	$35.09
Rate for Payer: Health Management Network Commercial	$178.50
Rate for Payer: Humana Medicare	$105.00
Rate for Payer: Kaiser Permanente Commercial	$189.00
Rate for Payer: Kaiser Permanente Medicaid	$107.10
Rate for Payer: Kaiser Permanente Medicare	$105.00
Rate for Payer: MDX Hawaii PPO	$203.70
Rate for Payer: Ohana Health Plan Medicaid	$105.00
Rate for Payer: Ohana Health Plan Medicare	$105.00
Rate for Payer: UnitedHealthcare Medicaid	$49.04
Rate for Payer: UnitedHealthcare Medicare	$105.00
Rate for Payer: University Health Alliance Commercial	$90.72

Rapid Plasma Reagin with Reflex to Titer

Facility

$89.00

Service Code	HCPCS 86592
Hospital Charge Code	9189930
Hospital Revenue Code	300
Min. Negotiated Rate	$4.27
Max. Negotiated Rate	$86.33
Rate for Payer: AlohaCare Medicaid	$44.50
Rate for Payer: AlohaCare Medicare	$44.50
Rate for Payer: Cash Price	$57.85
Rate for Payer: Cash Price	$57.85
Rate for Payer: Devoted Health Medicare	$48.95
Rate for Payer: Hawaii Medical Service Association ABD	$5.90
Rate for Payer: Hawaii Medical Service Association Commercial	$5.34
Rate for Payer: Hawaii Medical Service Association Medicare	$44.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$6.20
Rate for Payer: Hawaii Western Management Group Commercial	$4.27
Rate for Payer: Health Management Network Commercial	$75.65
Rate for Payer: Humana Medicare	$44.50
Rate for Payer: Kaiser Permanente Commercial	$80.10
Rate for Payer: Kaiser Permanente Medicaid	$45.39
Rate for Payer: Kaiser Permanente Medicare	$44.50
Rate for Payer: MDX Hawaii PPO	$86.33
Rate for Payer: Ohana Health Plan Medicaid	$44.50
Rate for Payer: Ohana Health Plan Medicare	$44.50
Rate for Payer: UnitedHealthcare Medicaid	$5.90
Rate for Payer: UnitedHealthcare Medicare	$44.50
Rate for Payer: University Health Alliance Commercial	$11.03

Rapid Plasma Reagin with Reflex to Titer

Facility

$89.00

Service Code	HCPCS 86592
Hospital Charge Code	9189930
Hospital Revenue Code	300
Min. Negotiated Rate	$75.65
Max. Negotiated Rate	$86.33
Rate for Payer: Cash Price	$57.85
Rate for Payer: Health Management Network Commercial	$75.65
Rate for Payer: Kaiser Permanente Commercial	$80.10
Rate for Payer: MDX Hawaii PPO	$86.33

RAPID RHINO 4.5 CM

Facility

$235.00

Hospital Charge Code	9230672
Hospital Revenue Code	272
Min. Negotiated Rate	$199.75
Max. Negotiated Rate	$227.95
Rate for Payer: Cash Price	$152.75
Rate for Payer: Health Management Network Commercial	$199.75
Rate for Payer: Kaiser Permanente Commercial	$211.50
Rate for Payer: MDX Hawaii PPO	$227.95

Know your out-of-pocket cost for care.

All Charges