Samuel Mahelona Memorial Hospital

All Charges

Charge

Type

Setting

Price

sodium phosphates enema 133 mL [HHSC]

Facility

$5.73

Service Code	NDC 00536741551
Hospital Charge Code	2500758
Hospital Revenue Code	250
Min. Negotiated Rate	$4.87
Max. Negotiated Rate	$5.56
Rate for Payer: Cash Price	$3.72
Rate for Payer: Health Management Network Commercial	$4.87
Rate for Payer: Kaiser Permanente Commercial	$5.16
Rate for Payer: MDX Hawaii PPO	$5.56

sodium phosphates enema 133 mL [HHSC]

Facility

$9.45

Service Code	NDC 00904632078
Hospital Charge Code	2500758
Hospital Revenue Code	250
Min. Negotiated Rate	$4.72
Max. Negotiated Rate	$9.17
Rate for Payer: AlohaCare Medicaid	$4.72
Rate for Payer: AlohaCare Medicare	$4.72
Rate for Payer: Cash Price	$6.14
Rate for Payer: Devoted Health Medicare	$5.20
Rate for Payer: Hawaii Medical Service Association Medicare	$4.72
Rate for Payer: Hawaii Western Management Group Commercial	$8.98
Rate for Payer: Health Management Network Commercial	$8.03
Rate for Payer: Humana Medicare	$4.72
Rate for Payer: Kaiser Permanente Commercial	$8.51
Rate for Payer: Kaiser Permanente Medicaid	$4.82
Rate for Payer: Kaiser Permanente Medicare	$4.72
Rate for Payer: MDX Hawaii PPO	$9.17
Rate for Payer: Ohana Health Plan Medicaid	$4.72
Rate for Payer: Ohana Health Plan Medicare	$4.72
Rate for Payer: UnitedHealthcare Medicaid	$5.67
Rate for Payer: UnitedHealthcare Medicare	$4.72
Rate for Payer: University Health Alliance Commercial	$6.89

sodium phosphates enema 133 mL [HHSC]

Facility

$5.73

Service Code	NDC 00536741551
Hospital Charge Code	2500758
Hospital Revenue Code	250
Min. Negotiated Rate	$2.87
Max. Negotiated Rate	$5.56
Rate for Payer: AlohaCare Medicaid	$2.87
Rate for Payer: AlohaCare Medicare	$2.87
Rate for Payer: Cash Price	$3.72
Rate for Payer: Devoted Health Medicare	$3.15
Rate for Payer: Hawaii Medical Service Association Medicare	$2.87
Rate for Payer: Hawaii Western Management Group Commercial	$5.44
Rate for Payer: Health Management Network Commercial	$4.87
Rate for Payer: Humana Medicare	$2.87
Rate for Payer: Kaiser Permanente Commercial	$5.16
Rate for Payer: Kaiser Permanente Medicaid	$2.92
Rate for Payer: Kaiser Permanente Medicare	$2.87
Rate for Payer: MDX Hawaii PPO	$5.56
Rate for Payer: Ohana Health Plan Medicaid	$2.87
Rate for Payer: Ohana Health Plan Medicare	$2.87
Rate for Payer: UnitedHealthcare Medicaid	$3.44
Rate for Payer: UnitedHealthcare Medicare	$2.87
Rate for Payer: University Health Alliance Commercial	$4.18

sodium phosphates peds enema 66ml [HHSC]

Facility

$8.34

Service Code	NDC 00132020220
Hospital Charge Code	2500759
Hospital Revenue Code	250
Min. Negotiated Rate	$4.17
Max. Negotiated Rate	$8.09
Rate for Payer: AlohaCare Medicaid	$4.17
Rate for Payer: AlohaCare Medicare	$4.17
Rate for Payer: Cash Price	$5.42
Rate for Payer: Devoted Health Medicare	$4.59
Rate for Payer: Hawaii Medical Service Association Medicare	$4.17
Rate for Payer: Hawaii Western Management Group Commercial	$7.92
Rate for Payer: Health Management Network Commercial	$7.09
Rate for Payer: Humana Medicare	$4.17
Rate for Payer: Kaiser Permanente Commercial	$7.51
Rate for Payer: Kaiser Permanente Medicaid	$4.25
Rate for Payer: Kaiser Permanente Medicare	$4.17
Rate for Payer: MDX Hawaii PPO	$8.09
Rate for Payer: Ohana Health Plan Medicaid	$4.17
Rate for Payer: Ohana Health Plan Medicare	$4.17
Rate for Payer: UnitedHealthcare Medicaid	$5.00
Rate for Payer: UnitedHealthcare Medicare	$4.17
Rate for Payer: University Health Alliance Commercial	$6.08

sodium phosphates peds enema 66ml [HHSC]

Facility

$8.34

Service Code	NDC 00132020220
Hospital Charge Code	2500759
Hospital Revenue Code	250
Min. Negotiated Rate	$7.09
Max. Negotiated Rate	$8.09
Rate for Payer: Cash Price	$5.42
Rate for Payer: Health Management Network Commercial	$7.09
Rate for Payer: Kaiser Permanente Commercial	$7.51
Rate for Payer: MDX Hawaii PPO	$8.09

Sodium Urine Random FSI

Facility

$68.00

Service Code	HCPCS 84300
Hospital Charge Code	8228918
Hospital Revenue Code	301
Min. Negotiated Rate	$5.06
Max. Negotiated Rate	$65.96
Rate for Payer: AlohaCare Medicaid	$34.00
Rate for Payer: AlohaCare Medicare	$34.00
Rate for Payer: Cash Price	$44.20
Rate for Payer: Cash Price	$44.20
Rate for Payer: Devoted Health Medicare	$37.40
Rate for Payer: Hawaii Medical Service Association ABD	$6.72
Rate for Payer: Hawaii Medical Service Association Commercial	$6.33
Rate for Payer: Hawaii Medical Service Association Medicare	$34.00
Rate for Payer: Hawaii Medical Service Association Non-ABD	$7.06
Rate for Payer: Hawaii Western Management Group Commercial	$5.06
Rate for Payer: Health Management Network Commercial	$57.80
Rate for Payer: Humana Medicare	$34.00
Rate for Payer: Kaiser Permanente Commercial	$61.20
Rate for Payer: Kaiser Permanente Medicaid	$34.68
Rate for Payer: Kaiser Permanente Medicare	$34.00
Rate for Payer: MDX Hawaii PPO	$65.96
Rate for Payer: Ohana Health Plan Medicaid	$34.00
Rate for Payer: Ohana Health Plan Medicare	$34.00
Rate for Payer: UnitedHealthcare Medicaid	$6.72
Rate for Payer: UnitedHealthcare Medicare	$34.00
Rate for Payer: University Health Alliance Commercial	$12.56

Sodium Urine Random FSI

Facility

$68.00

Service Code	HCPCS 84300
Hospital Charge Code	8228918
Hospital Revenue Code	301
Min. Negotiated Rate	$57.80
Max. Negotiated Rate	$65.96
Rate for Payer: Cash Price	$44.20
Rate for Payer: Health Management Network Commercial	$57.80
Rate for Payer: Kaiser Permanente Commercial	$61.20
Rate for Payer: MDX Hawaii PPO	$65.96

Sodium Urine Timed FSI

Facility

$68.00

Service Code	HCPCS 84300
Hospital Charge Code	8228919
Hospital Revenue Code	301
Min. Negotiated Rate	$57.80
Max. Negotiated Rate	$65.96
Rate for Payer: Cash Price	$44.20
Rate for Payer: Health Management Network Commercial	$57.80
Rate for Payer: Kaiser Permanente Commercial	$61.20
Rate for Payer: MDX Hawaii PPO	$65.96

Sodium Urine Timed FSI

Facility

$68.00

Service Code	HCPCS 84300
Hospital Charge Code	8228919
Hospital Revenue Code	301
Min. Negotiated Rate	$5.06
Max. Negotiated Rate	$65.96
Rate for Payer: AlohaCare Medicaid	$34.00
Rate for Payer: AlohaCare Medicare	$34.00
Rate for Payer: Cash Price	$44.20
Rate for Payer: Cash Price	$44.20
Rate for Payer: Devoted Health Medicare	$37.40
Rate for Payer: Hawaii Medical Service Association ABD	$6.72
Rate for Payer: Hawaii Medical Service Association Commercial	$6.33
Rate for Payer: Hawaii Medical Service Association Medicare	$34.00
Rate for Payer: Hawaii Medical Service Association Non-ABD	$7.06
Rate for Payer: Hawaii Western Management Group Commercial	$5.06
Rate for Payer: Health Management Network Commercial	$57.80
Rate for Payer: Humana Medicare	$34.00
Rate for Payer: Kaiser Permanente Commercial	$61.20
Rate for Payer: Kaiser Permanente Medicaid	$34.68
Rate for Payer: Kaiser Permanente Medicare	$34.00
Rate for Payer: MDX Hawaii PPO	$65.96
Rate for Payer: Ohana Health Plan Medicaid	$34.00
Rate for Payer: Ohana Health Plan Medicare	$34.00
Rate for Payer: UnitedHealthcare Medicaid	$6.72
Rate for Payer: UnitedHealthcare Medicare	$34.00
Rate for Payer: University Health Alliance Commercial	$12.56

Sodium (Venous) POCT

Facility

$225.00

Service Code	HCPCS 84295
Hospital Charge Code	9364728
Hospital Revenue Code	301
Min. Negotiated Rate	$191.25
Max. Negotiated Rate	$218.25
Rate for Payer: Cash Price	$146.25
Rate for Payer: Health Management Network Commercial	$191.25
Rate for Payer: Kaiser Permanente Commercial	$202.50
Rate for Payer: MDX Hawaii PPO	$218.25

Sodium (Venous) POCT

Facility

$225.00

Service Code	HCPCS 84295
Hospital Charge Code	9364728
Hospital Revenue Code	301
Min. Negotiated Rate	$4.81
Max. Negotiated Rate	$218.25
Rate for Payer: AlohaCare Medicaid	$112.50
Rate for Payer: AlohaCare Medicare	$112.50
Rate for Payer: Cash Price	$146.25
Rate for Payer: Cash Price	$146.25
Rate for Payer: Devoted Health Medicare	$123.75
Rate for Payer: Hawaii Medical Service Association ABD	$6.65
Rate for Payer: Hawaii Medical Service Association Commercial	$6.01
Rate for Payer: Hawaii Medical Service Association Medicare	$112.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$6.98
Rate for Payer: Hawaii Western Management Group Commercial	$4.81
Rate for Payer: Health Management Network Commercial	$191.25
Rate for Payer: Humana Medicare	$112.50
Rate for Payer: Kaiser Permanente Commercial	$202.50
Rate for Payer: Kaiser Permanente Medicaid	$114.75
Rate for Payer: Kaiser Permanente Medicare	$112.50
Rate for Payer: MDX Hawaii PPO	$218.25
Rate for Payer: Ohana Health Plan Medicaid	$112.50
Rate for Payer: Ohana Health Plan Medicare	$112.50
Rate for Payer: UnitedHealthcare Medicaid	$6.65
Rate for Payer: UnitedHealthcare Medicare	$112.50
Rate for Payer: University Health Alliance Commercial	$12.43

sodium zirconium cyclosilicate 10 g packet [HHSC]

Facility

$155.34

Service Code	NDC 00310111030
Hospital Charge Code	2501111
Hospital Revenue Code	250
Min. Negotiated Rate	$132.04
Max. Negotiated Rate	$150.68
Rate for Payer: Cash Price	$100.97
Rate for Payer: Health Management Network Commercial	$132.04
Rate for Payer: Kaiser Permanente Commercial	$139.81
Rate for Payer: MDX Hawaii PPO	$150.68

sodium zirconium cyclosilicate 10 g packet [HHSC]

Facility

$155.34

Service Code	NDC 00310111030
Hospital Charge Code	2501111
Hospital Revenue Code	250
Min. Negotiated Rate	$77.67
Max. Negotiated Rate	$150.68
Rate for Payer: AlohaCare Medicaid	$77.67
Rate for Payer: AlohaCare Medicare	$77.67
Rate for Payer: Cash Price	$100.97
Rate for Payer: Devoted Health Medicare	$85.44
Rate for Payer: Hawaii Medical Service Association Medicare	$77.67
Rate for Payer: Hawaii Western Management Group Commercial	$147.57
Rate for Payer: Health Management Network Commercial	$132.04
Rate for Payer: Humana Medicare	$77.67
Rate for Payer: Kaiser Permanente Commercial	$139.81
Rate for Payer: Kaiser Permanente Medicaid	$79.22
Rate for Payer: Kaiser Permanente Medicare	$77.67
Rate for Payer: MDX Hawaii PPO	$150.68
Rate for Payer: Ohana Health Plan Medicaid	$77.67
Rate for Payer: Ohana Health Plan Medicare	$77.67
Rate for Payer: UnitedHealthcare Medicaid	$93.20
Rate for Payer: UnitedHealthcare Medicare	$77.67
Rate for Payer: University Health Alliance Commercial	$113.23

sodium zirconium cyclosilicate 10 g packet [HHSC]

Facility

$155.34

Service Code	NDC 00310111039
Hospital Charge Code	2501111
Hospital Revenue Code	250
Min. Negotiated Rate	$132.04
Max. Negotiated Rate	$150.68
Rate for Payer: Cash Price	$100.97
Rate for Payer: Health Management Network Commercial	$132.04
Rate for Payer: Kaiser Permanente Commercial	$139.81
Rate for Payer: MDX Hawaii PPO	$150.68

sodium zirconium cyclosilicate 10 g packet [HHSC]

Facility

$155.34

Service Code	NDC 00310111039
Hospital Charge Code	2501111
Hospital Revenue Code	250
Min. Negotiated Rate	$77.67
Max. Negotiated Rate	$150.68
Rate for Payer: AlohaCare Medicaid	$77.67
Rate for Payer: AlohaCare Medicare	$77.67
Rate for Payer: Cash Price	$100.97
Rate for Payer: Devoted Health Medicare	$85.44
Rate for Payer: Hawaii Medical Service Association Medicare	$77.67
Rate for Payer: Hawaii Western Management Group Commercial	$147.57
Rate for Payer: Health Management Network Commercial	$132.04
Rate for Payer: Humana Medicare	$77.67
Rate for Payer: Kaiser Permanente Commercial	$139.81
Rate for Payer: Kaiser Permanente Medicaid	$79.22
Rate for Payer: Kaiser Permanente Medicare	$77.67
Rate for Payer: MDX Hawaii PPO	$150.68
Rate for Payer: Ohana Health Plan Medicaid	$77.67
Rate for Payer: Ohana Health Plan Medicare	$77.67
Rate for Payer: UnitedHealthcare Medicaid	$93.20
Rate for Payer: UnitedHealthcare Medicare	$77.67
Rate for Payer: University Health Alliance Commercial	$113.23

SOFT TISSUE PROCEDURES WITH CC

Facility

$46,408.52

Service Code	MSDRG 501
Min. Negotiated Rate	$46,408.52
Max. Negotiated Rate	$46,408.52
Rate for Payer: Hawaii Medical Service Association Commercial	$46,408.52

SOFT TISSUE PROCEDURES WITH MCC

Facility

$46,408.52

Service Code	MSDRG 500
Min. Negotiated Rate	$46,408.52
Max. Negotiated Rate	$46,408.52
Rate for Payer: Hawaii Medical Service Association Commercial	$46,408.52

SOFT TISSUE PROCEDURES WITHOUT CC/MCC

Facility

$22,896.13

Service Code	MSDRG 502
Min. Negotiated Rate	$22,896.13
Max. Negotiated Rate	$22,896.13
Rate for Payer: Hawaii Medical Service Association Commercial	$22,896.13

SOLID LOCKING LAG SCREW, 10.5 MM X 70 MM

Facility

$2,505.00

Service Code	HCPCS C1713
Hospital Charge Code	13000546
Hospital Revenue Code	278
Min. Negotiated Rate	$1,402.80
Max. Negotiated Rate	$2,429.85
Rate for Payer: Cash Price	$1,628.25
Rate for Payer: Hawaii Western Management Group Commercial	$1,753.50
Rate for Payer: Health Management Network Commercial	$2,129.25
Rate for Payer: Kaiser Permanente Commercial	$2,254.50
Rate for Payer: MDX Hawaii PPO	$2,429.85
Rate for Payer: University Health Alliance Commercial	$1,402.80

SOLID LOCKING LAG SCREW, 10.5 MM X 70 MM

Facility

$2,505.00

Service Code	HCPCS C1713
Hospital Charge Code	13000546
Hospital Revenue Code	278
Min. Negotiated Rate	$1,252.50
Max. Negotiated Rate	$2,429.85
Rate for Payer: AlohaCare Medicaid	$1,252.50
Rate for Payer: AlohaCare Medicare	$1,252.50
Rate for Payer: Cash Price	$1,628.25
Rate for Payer: Devoted Health Medicare	$1,377.75
Rate for Payer: Hawaii Medical Service Association Medicare	$1,252.50
Rate for Payer: Hawaii Western Management Group Commercial	$1,753.50
Rate for Payer: Health Management Network Commercial	$2,129.25
Rate for Payer: Humana Medicare	$1,252.50
Rate for Payer: Kaiser Permanente Commercial	$2,254.50
Rate for Payer: Kaiser Permanente Medicaid	$1,277.55
Rate for Payer: Kaiser Permanente Medicare	$1,252.50
Rate for Payer: MDX Hawaii PPO	$2,429.85
Rate for Payer: Ohana Health Plan Medicaid	$1,252.50
Rate for Payer: Ohana Health Plan Medicare	$1,252.50
Rate for Payer: UnitedHealthcare Medicare	$1,252.50
Rate for Payer: University Health Alliance Commercial	$1,402.80

SOLID LOCKING LAG SCREW, 10.5 MM X 75 MM

Facility

$2,505.00

Service Code	HCPCS C1713
Hospital Charge Code	13000549
Hospital Revenue Code	278
Min. Negotiated Rate	$1,252.50
Max. Negotiated Rate	$2,429.85
Rate for Payer: AlohaCare Medicaid	$1,252.50
Rate for Payer: AlohaCare Medicare	$1,252.50
Rate for Payer: Cash Price	$1,628.25
Rate for Payer: Devoted Health Medicare	$1,377.75
Rate for Payer: Hawaii Medical Service Association Medicare	$1,252.50
Rate for Payer: Hawaii Western Management Group Commercial	$1,753.50
Rate for Payer: Health Management Network Commercial	$2,129.25
Rate for Payer: Humana Medicare	$1,252.50
Rate for Payer: Kaiser Permanente Commercial	$2,254.50
Rate for Payer: Kaiser Permanente Medicaid	$1,277.55
Rate for Payer: Kaiser Permanente Medicare	$1,252.50
Rate for Payer: MDX Hawaii PPO	$2,429.85
Rate for Payer: Ohana Health Plan Medicaid	$1,252.50
Rate for Payer: Ohana Health Plan Medicare	$1,252.50
Rate for Payer: UnitedHealthcare Medicare	$1,252.50
Rate for Payer: University Health Alliance Commercial	$1,402.80

SOLID LOCKING LAG SCREW, 10.5 MM X 75 MM

Facility

$2,505.00

Service Code	HCPCS C1713
Hospital Charge Code	13000549
Hospital Revenue Code	278
Min. Negotiated Rate	$1,402.80
Max. Negotiated Rate	$2,429.85
Rate for Payer: Cash Price	$1,628.25
Rate for Payer: Hawaii Western Management Group Commercial	$1,753.50
Rate for Payer: Health Management Network Commercial	$2,129.25
Rate for Payer: Kaiser Permanente Commercial	$2,254.50
Rate for Payer: MDX Hawaii PPO	$2,429.85
Rate for Payer: University Health Alliance Commercial	$1,402.80

Soluble Transferrin Receptor FSI

Facility

$408.00

Service Code	HCPCS 84238
Hospital Charge Code	8118047
Hospital Revenue Code	301
Min. Negotiated Rate	$36.57
Max. Negotiated Rate	$395.76
Rate for Payer: AlohaCare Medicaid	$204.00
Rate for Payer: AlohaCare Medicare	$204.00
Rate for Payer: Cash Price	$265.20
Rate for Payer: Cash Price	$265.20
Rate for Payer: Devoted Health Medicare	$224.40
Rate for Payer: Hawaii Medical Service Association ABD	$50.53
Rate for Payer: Hawaii Medical Service Association Commercial	$45.71
Rate for Payer: Hawaii Medical Service Association Medicare	$204.00
Rate for Payer: Hawaii Medical Service Association Non-ABD	$53.06
Rate for Payer: Hawaii Western Management Group Commercial	$36.57
Rate for Payer: Health Management Network Commercial	$346.80
Rate for Payer: Humana Medicare	$204.00
Rate for Payer: Kaiser Permanente Commercial	$367.20
Rate for Payer: Kaiser Permanente Medicaid	$208.08
Rate for Payer: Kaiser Permanente Medicare	$204.00
Rate for Payer: MDX Hawaii PPO	$395.76
Rate for Payer: Ohana Health Plan Medicaid	$204.00
Rate for Payer: Ohana Health Plan Medicare	$204.00
Rate for Payer: UnitedHealthcare Medicaid	$50.53
Rate for Payer: UnitedHealthcare Medicare	$204.00
Rate for Payer: University Health Alliance Commercial	$94.52

Soluble Transferrin Receptor FSI

Facility

$408.00

Service Code	HCPCS 84238
Hospital Charge Code	8118047
Hospital Revenue Code	301
Min. Negotiated Rate	$346.80
Max. Negotiated Rate	$395.76
Rate for Payer: Cash Price	$265.20
Rate for Payer: Health Management Network Commercial	$346.80
Rate for Payer: Kaiser Permanente Commercial	$367.20
Rate for Payer: MDX Hawaii PPO	$395.76

SOLU-MEDROL 40 MG/UNIT

Professional

Both

$4.00

Service Code	HCPCS J2919
Hospital Charge Code	8041360
Hospital Revenue Code	636
Min. Negotiated Rate	$0.24
Max. Negotiated Rate	$3.40
Rate for Payer: AlohaCare Medicare	$0.24
Rate for Payer: Cash Price	$2.60
Rate for Payer: Cash Price	$2.60
Rate for Payer: Devoted Health Medicare	$0.26
Rate for Payer: Hawaii Medical Service Association Medicare	$0.24
Rate for Payer: Health Management Network Commercial	$3.40
Rate for Payer: Kaiser Permanente Commercial	$0.29
Rate for Payer: Kaiser Permanente Medicaid	$0.29
Rate for Payer: Kaiser Permanente Medicare	$0.29
Rate for Payer: Ohana Health Plan Medicare	$0.24
Rate for Payer: UnitedHealthcare Medicare	$0.24

Know your out-of-pocket cost for care.

All Charges