Samuel Mahelona Memorial Hospital

All Charges

Charge

Type

Setting

Price

tuberculin-ppd 5 TU/0.1 ml vial [HHSC]

Facility

$54.97

Service Code	NDC 49281075221
Hospital Charge Code	2500843
Hospital Revenue Code	250
Min. Negotiated Rate	$46.72
Max. Negotiated Rate	$53.32
Rate for Payer: Cash Price	$35.73
Rate for Payer: Health Management Network Commercial	$46.72
Rate for Payer: Kaiser Permanente Commercial	$49.47
Rate for Payer: MDX Hawaii PPO	$53.32

tuberculin-ppd 5 TU/0.1 ml vial [HHSC]

Facility

$52.37

Service Code	NDC 49281075222
Hospital Charge Code	2500843
Hospital Revenue Code	250
Min. Negotiated Rate	$44.51
Max. Negotiated Rate	$50.80
Rate for Payer: Cash Price	$34.04
Rate for Payer: Health Management Network Commercial	$44.51
Rate for Payer: Kaiser Permanente Commercial	$47.13
Rate for Payer: MDX Hawaii PPO	$50.80

tuberculin-ppd 5 TU/0.1 ml vial [HHSC]

Facility

$54.97

Service Code	NDC 49281075221
Hospital Charge Code	2500843
Hospital Revenue Code	250
Min. Negotiated Rate	$27.48
Max. Negotiated Rate	$53.32
Rate for Payer: AlohaCare Medicaid	$27.48
Rate for Payer: AlohaCare Medicare	$27.48
Rate for Payer: Cash Price	$35.73
Rate for Payer: Devoted Health Medicare	$30.23
Rate for Payer: Hawaii Medical Service Association Medicare	$27.48
Rate for Payer: Hawaii Western Management Group Commercial	$52.22
Rate for Payer: Health Management Network Commercial	$46.72
Rate for Payer: Humana Medicare	$27.48
Rate for Payer: Kaiser Permanente Commercial	$49.47
Rate for Payer: Kaiser Permanente Medicaid	$28.03
Rate for Payer: Kaiser Permanente Medicare	$27.48
Rate for Payer: MDX Hawaii PPO	$53.32
Rate for Payer: Ohana Health Plan Medicaid	$27.48
Rate for Payer: Ohana Health Plan Medicare	$27.48
Rate for Payer: UnitedHealthcare Medicaid	$32.98
Rate for Payer: UnitedHealthcare Medicare	$27.48
Rate for Payer: University Health Alliance Commercial	$40.07

TUBE TRACHEOSTOMY XLT CUFFED SIZE 8 105MM

Facility

$260.00

Hospital Charge Code	9832360
Hospital Revenue Code	272
Min. Negotiated Rate	$221.00
Max. Negotiated Rate	$252.20
Rate for Payer: Cash Price	$169.00
Rate for Payer: Health Management Network Commercial	$221.00
Rate for Payer: Kaiser Permanente Commercial	$234.00
Rate for Payer: MDX Hawaii PPO	$252.20

TUBE TRACHEOSTOMY XLT CUFFED SIZE 8 105MM

Facility

$260.00

Hospital Charge Code	9832360
Hospital Revenue Code	272
Min. Negotiated Rate	$130.00
Max. Negotiated Rate	$252.20
Rate for Payer: AlohaCare Medicaid	$130.00
Rate for Payer: AlohaCare Medicare	$130.00
Rate for Payer: Cash Price	$169.00
Rate for Payer: Devoted Health Medicare	$143.00
Rate for Payer: Hawaii Medical Service Association Medicare	$130.00
Rate for Payer: Hawaii Western Management Group Commercial	$247.00
Rate for Payer: Health Management Network Commercial	$221.00
Rate for Payer: Humana Medicare	$130.00
Rate for Payer: Kaiser Permanente Commercial	$234.00
Rate for Payer: Kaiser Permanente Medicaid	$132.60
Rate for Payer: Kaiser Permanente Medicare	$130.00
Rate for Payer: MDX Hawaii PPO	$252.20
Rate for Payer: Ohana Health Plan Medicaid	$130.00
Rate for Payer: Ohana Health Plan Medicare	$130.00
Rate for Payer: UnitedHealthcare Medicare	$130.00
Rate for Payer: University Health Alliance Commercial	$189.51

TUBING PORTER MED BREATHER CIRCUIT 6 FT

Facility

$149.00

Hospital Charge Code	9827775
Hospital Revenue Code	270
Min. Negotiated Rate	$126.65
Max. Negotiated Rate	$144.53
Rate for Payer: Cash Price	$96.85
Rate for Payer: Health Management Network Commercial	$126.65
Rate for Payer: Kaiser Permanente Commercial	$134.10
Rate for Payer: MDX Hawaii PPO	$144.53

TUBING PORTER MED BREATHER CIRCUIT 6 FT

Facility

$149.00

Hospital Charge Code	9827775
Hospital Revenue Code	270
Min. Negotiated Rate	$74.50
Max. Negotiated Rate	$144.53
Rate for Payer: AlohaCare Medicaid	$74.50
Rate for Payer: AlohaCare Medicare	$74.50
Rate for Payer: Cash Price	$96.85
Rate for Payer: Devoted Health Medicare	$81.95
Rate for Payer: Hawaii Medical Service Association Medicare	$74.50
Rate for Payer: Hawaii Western Management Group Commercial	$141.55
Rate for Payer: Health Management Network Commercial	$126.65
Rate for Payer: Humana Medicare	$74.50
Rate for Payer: Kaiser Permanente Commercial	$134.10
Rate for Payer: Kaiser Permanente Medicaid	$75.99
Rate for Payer: Kaiser Permanente Medicare	$74.50
Rate for Payer: MDX Hawaii PPO	$144.53
Rate for Payer: Ohana Health Plan Medicaid	$74.50
Rate for Payer: Ohana Health Plan Medicare	$74.50
Rate for Payer: UnitedHealthcare Medicare	$74.50
Rate for Payer: University Health Alliance Commercial	$108.61

Turmeric IgE FSI

Facility

$149.00

Service Code	HCPCS 86003
Hospital Charge Code	8712420
Hospital Revenue Code	302
Min. Negotiated Rate	$5.22
Max. Negotiated Rate	$144.53
Rate for Payer: AlohaCare Medicaid	$74.50
Rate for Payer: AlohaCare Medicare	$74.50
Rate for Payer: Cash Price	$96.85
Rate for Payer: Cash Price	$96.85
Rate for Payer: Devoted Health Medicare	$81.95
Rate for Payer: Hawaii Medical Service Association ABD	$7.22
Rate for Payer: Hawaii Medical Service Association Commercial	$6.53
Rate for Payer: Hawaii Medical Service Association Medicare	$74.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$7.58
Rate for Payer: Hawaii Western Management Group Commercial	$5.22
Rate for Payer: Health Management Network Commercial	$126.65
Rate for Payer: Humana Medicare	$74.50
Rate for Payer: Kaiser Permanente Commercial	$134.10
Rate for Payer: Kaiser Permanente Medicaid	$75.99
Rate for Payer: Kaiser Permanente Medicare	$74.50
Rate for Payer: MDX Hawaii PPO	$144.53
Rate for Payer: Ohana Health Plan Medicaid	$74.50
Rate for Payer: Ohana Health Plan Medicare	$74.50
Rate for Payer: UnitedHealthcare Medicaid	$7.22
Rate for Payer: UnitedHealthcare Medicare	$74.50
Rate for Payer: University Health Alliance Commercial	$13.51

Turmeric IgE FSI

Facility

$149.00

Service Code	HCPCS 86003
Hospital Charge Code	8712420
Hospital Revenue Code	302
Min. Negotiated Rate	$126.65
Max. Negotiated Rate	$144.53
Rate for Payer: Cash Price	$96.85
Rate for Payer: Health Management Network Commercial	$126.65
Rate for Payer: Kaiser Permanente Commercial	$134.10
Rate for Payer: MDX Hawaii PPO	$144.53

Tx of Speech/Lang/Voice/Comm/Auditory Chg

Facility

$411.00

Service Code	HCPCS 92507 GP,CQ
Hospital Charge Code	8169572
Hospital Revenue Code	440
Min. Negotiated Rate	$349.35
Max. Negotiated Rate	$398.67
Rate for Payer: Cash Price	$267.15
Rate for Payer: Health Management Network Commercial	$349.35
Rate for Payer: Kaiser Permanente Commercial	$369.90
Rate for Payer: MDX Hawaii PPO	$398.67

Tx of Speech/Lang/Voice/Comm/Auditory Chg

Facility

$411.00

Service Code	HCPCS 92507 GP,CQ
Hospital Charge Code	8169572
Hospital Revenue Code	440
Min. Negotiated Rate	$21.05
Max. Negotiated Rate	$398.67
Rate for Payer: AlohaCare Medicaid	$205.50
Rate for Payer: AlohaCare Medicare	$205.50
Rate for Payer: Cash Price	$267.15
Rate for Payer: Cash Price	$267.15
Rate for Payer: Devoted Health Medicare	$226.05
Rate for Payer: Hawaii Medical Service Association Medicare	$205.50
Rate for Payer: Hawaii Western Management Group Commercial	$390.45
Rate for Payer: Health Management Network Commercial	$349.35
Rate for Payer: Humana Medicare	$205.50
Rate for Payer: Kaiser Permanente Commercial	$369.90
Rate for Payer: Kaiser Permanente Medicaid	$209.61
Rate for Payer: Kaiser Permanente Medicare	$205.50
Rate for Payer: MDX Hawaii PPO	$398.67
Rate for Payer: Ohana Health Plan Medicaid	$205.50
Rate for Payer: Ohana Health Plan Medicare	$205.50
Rate for Payer: UnitedHealthcare Medicaid	$21.05
Rate for Payer: UnitedHealthcare Medicare	$205.50
Rate for Payer: University Health Alliance Commercial	$230.16

Tx of Speech/Lang/Voice/Comm/Auditory Chg Medicaid

Facility

$411.00

Service Code	HCPCS 92507 GP,CQ
Hospital Charge Code	8169604
Hospital Revenue Code	440
Min. Negotiated Rate	$349.35
Max. Negotiated Rate	$398.67
Rate for Payer: Cash Price	$267.15
Rate for Payer: Health Management Network Commercial	$349.35
Rate for Payer: Kaiser Permanente Commercial	$369.90
Rate for Payer: MDX Hawaii PPO	$398.67

Tx of Speech/Lang/Voice/Comm/Auditory Chg Medicaid

Facility

$411.00

Service Code	HCPCS 92507 GP,CQ
Hospital Charge Code	8169604
Hospital Revenue Code	440
Min. Negotiated Rate	$21.05
Max. Negotiated Rate	$398.67
Rate for Payer: AlohaCare Medicaid	$205.50
Rate for Payer: AlohaCare Medicare	$205.50
Rate for Payer: Cash Price	$267.15
Rate for Payer: Cash Price	$267.15
Rate for Payer: Devoted Health Medicare	$226.05
Rate for Payer: Hawaii Medical Service Association Medicare	$205.50
Rate for Payer: Hawaii Western Management Group Commercial	$390.45
Rate for Payer: Health Management Network Commercial	$349.35
Rate for Payer: Humana Medicare	$205.50
Rate for Payer: Kaiser Permanente Commercial	$369.90
Rate for Payer: Kaiser Permanente Medicaid	$209.61
Rate for Payer: Kaiser Permanente Medicare	$205.50
Rate for Payer: MDX Hawaii PPO	$398.67
Rate for Payer: Ohana Health Plan Medicaid	$205.50
Rate for Payer: Ohana Health Plan Medicare	$205.50
Rate for Payer: UnitedHealthcare Medicaid	$21.05
Rate for Payer: UnitedHealthcare Medicare	$205.50
Rate for Payer: University Health Alliance Commercial	$230.16

Type and Screen FSI

Facility

$160.00

Service Code	HCPCS 86850
Hospital Charge Code	8128089
Hospital Revenue Code	300
Min. Negotiated Rate	$9.77
Max. Negotiated Rate	$155.20
Rate for Payer: AlohaCare Medicaid	$80.00
Rate for Payer: AlohaCare Medicare	$80.00
Rate for Payer: Cash Price	$104.00
Rate for Payer: Cash Price	$104.00
Rate for Payer: Devoted Health Medicare	$88.00
Rate for Payer: Hawaii Medical Service Association ABD	$19.65
Rate for Payer: Hawaii Medical Service Association Commercial	$12.21
Rate for Payer: Hawaii Medical Service Association Medicare	$80.00
Rate for Payer: Hawaii Medical Service Association Non-ABD	$23.51
Rate for Payer: Hawaii Western Management Group Commercial	$9.77
Rate for Payer: Health Management Network Commercial	$136.00
Rate for Payer: Humana Medicare	$80.00
Rate for Payer: Kaiser Permanente Commercial	$144.00
Rate for Payer: Kaiser Permanente Medicaid	$81.60
Rate for Payer: Kaiser Permanente Medicare	$80.00
Rate for Payer: MDX Hawaii PPO	$155.20
Rate for Payer: Ohana Health Plan Medicaid	$80.00
Rate for Payer: Ohana Health Plan Medicare	$80.00
Rate for Payer: UnitedHealthcare Medicaid	$19.65
Rate for Payer: UnitedHealthcare Medicare	$80.00
Rate for Payer: University Health Alliance Commercial	$50.88

Type and Screen FSI

Facility

$160.00

Service Code	HCPCS 86850
Hospital Charge Code	8128089
Hospital Revenue Code	300
Min. Negotiated Rate	$136.00
Max. Negotiated Rate	$155.20
Rate for Payer: Cash Price	$104.00
Rate for Payer: Health Management Network Commercial	$136.00
Rate for Payer: Kaiser Permanente Commercial	$144.00
Rate for Payer: MDX Hawaii PPO	$155.20

.Type and Screen, XM Convertible FSI

Facility

$160.00

Service Code	HCPCS 86850
Hospital Charge Code	8228932
Hospital Revenue Code	300
Min. Negotiated Rate	$9.77
Max. Negotiated Rate	$155.20
Rate for Payer: AlohaCare Medicaid	$80.00
Rate for Payer: AlohaCare Medicare	$80.00
Rate for Payer: Cash Price	$104.00
Rate for Payer: Cash Price	$104.00
Rate for Payer: Devoted Health Medicare	$88.00
Rate for Payer: Hawaii Medical Service Association ABD	$19.65
Rate for Payer: Hawaii Medical Service Association Commercial	$12.21
Rate for Payer: Hawaii Medical Service Association Medicare	$80.00
Rate for Payer: Hawaii Medical Service Association Non-ABD	$23.51
Rate for Payer: Hawaii Western Management Group Commercial	$9.77
Rate for Payer: Health Management Network Commercial	$136.00
Rate for Payer: Humana Medicare	$80.00
Rate for Payer: Kaiser Permanente Commercial	$144.00
Rate for Payer: Kaiser Permanente Medicaid	$81.60
Rate for Payer: Kaiser Permanente Medicare	$80.00
Rate for Payer: MDX Hawaii PPO	$155.20
Rate for Payer: Ohana Health Plan Medicaid	$80.00
Rate for Payer: Ohana Health Plan Medicare	$80.00
Rate for Payer: UnitedHealthcare Medicaid	$19.65
Rate for Payer: UnitedHealthcare Medicare	$80.00
Rate for Payer: University Health Alliance Commercial	$50.88

.Type and Screen, XM Convertible FSI

Facility

$160.00

Service Code	HCPCS 86850
Hospital Charge Code	8228932
Hospital Revenue Code	300
Min. Negotiated Rate	$136.00
Max. Negotiated Rate	$155.20
Rate for Payer: Cash Price	$104.00
Rate for Payer: Health Management Network Commercial	$136.00
Rate for Payer: Kaiser Permanente Commercial	$144.00
Rate for Payer: MDX Hawaii PPO	$155.20

Type & Cross LR-PRBCís (Lab Order) FSI

Facility

$126.00

Service Code	HCPCS 86880
Hospital Charge Code	8228864
Hospital Revenue Code	302
Min. Negotiated Rate	$5.39
Max. Negotiated Rate	$122.22
Rate for Payer: AlohaCare Medicaid	$63.00
Rate for Payer: AlohaCare Medicare	$63.00
Rate for Payer: Cash Price	$81.90
Rate for Payer: Cash Price	$81.90
Rate for Payer: Devoted Health Medicare	$69.30
Rate for Payer: Hawaii Medical Service Association ABD	$7.42
Rate for Payer: Hawaii Medical Service Association Commercial	$6.74
Rate for Payer: Hawaii Medical Service Association Medicare	$63.00
Rate for Payer: Hawaii Medical Service Association Non-ABD	$7.79
Rate for Payer: Hawaii Western Management Group Commercial	$5.39
Rate for Payer: Health Management Network Commercial	$107.10
Rate for Payer: Humana Medicare	$63.00
Rate for Payer: Kaiser Permanente Commercial	$113.40
Rate for Payer: Kaiser Permanente Medicaid	$64.26
Rate for Payer: Kaiser Permanente Medicare	$63.00
Rate for Payer: MDX Hawaii PPO	$122.22
Rate for Payer: Ohana Health Plan Medicaid	$63.00
Rate for Payer: Ohana Health Plan Medicare	$63.00
Rate for Payer: UnitedHealthcare Medicaid	$7.42
Rate for Payer: UnitedHealthcare Medicare	$63.00
Rate for Payer: University Health Alliance Commercial	$13.88

Type & Cross LR-PRBCís (Lab Order) FSI

Facility

$126.00

Service Code	HCPCS 86880
Hospital Charge Code	8228864
Hospital Revenue Code	302
Min. Negotiated Rate	$107.10
Max. Negotiated Rate	$122.22
Rate for Payer: Cash Price	$81.90
Rate for Payer: Health Management Network Commercial	$107.10
Rate for Payer: Kaiser Permanente Commercial	$113.40
Rate for Payer: MDX Hawaii PPO	$122.22

Typhus Fever, IgG, IgM FSI

Facility

$218.00

Service Code	HCPCS 86757
Hospital Charge Code	8228933
Hospital Revenue Code	302
Min. Negotiated Rate	$185.30
Max. Negotiated Rate	$211.46
Rate for Payer: Cash Price	$141.70
Rate for Payer: Health Management Network Commercial	$185.30
Rate for Payer: Kaiser Permanente Commercial	$196.20
Rate for Payer: MDX Hawaii PPO	$211.46

Typhus Fever, IgG, IgM FSI

Facility

$218.00

Service Code	HCPCS 86757
Hospital Charge Code	8228933
Hospital Revenue Code	302
Min. Negotiated Rate	$19.35
Max. Negotiated Rate	$211.46
Rate for Payer: AlohaCare Medicaid	$109.00
Rate for Payer: AlohaCare Medicare	$109.00
Rate for Payer: Cash Price	$141.70
Rate for Payer: Cash Price	$141.70
Rate for Payer: Devoted Health Medicare	$119.90
Rate for Payer: Hawaii Medical Service Association ABD	$26.75
Rate for Payer: Hawaii Medical Service Association Commercial	$24.19
Rate for Payer: Hawaii Medical Service Association Medicare	$109.00
Rate for Payer: Hawaii Medical Service Association Non-ABD	$28.09
Rate for Payer: Hawaii Western Management Group Commercial	$19.35
Rate for Payer: Health Management Network Commercial	$185.30
Rate for Payer: Humana Medicare	$109.00
Rate for Payer: Kaiser Permanente Commercial	$196.20
Rate for Payer: Kaiser Permanente Medicaid	$111.18
Rate for Payer: Kaiser Permanente Medicare	$109.00
Rate for Payer: MDX Hawaii PPO	$211.46
Rate for Payer: Ohana Health Plan Medicaid	$109.00
Rate for Payer: Ohana Health Plan Medicare	$109.00
Rate for Payer: UnitedHealthcare Medicaid	$26.75
Rate for Payer: UnitedHealthcare Medicare	$109.00
Rate for Payer: University Health Alliance Commercial	$50.04

UA Microscopic REF

Facility

$26.00

Service Code	HCPCS 81015
Hospital Charge Code	8191172
Hospital Revenue Code	300
Min. Negotiated Rate	$3.05
Max. Negotiated Rate	$25.22
Rate for Payer: AlohaCare Medicaid	$13.00
Rate for Payer: AlohaCare Medicare	$13.00
Rate for Payer: Cash Price	$16.90
Rate for Payer: Cash Price	$16.90
Rate for Payer: Devoted Health Medicare	$14.30
Rate for Payer: Hawaii Medical Service Association ABD	$4.20
Rate for Payer: Hawaii Medical Service Association Commercial	$3.81
Rate for Payer: Hawaii Medical Service Association Medicare	$13.00
Rate for Payer: Hawaii Medical Service Association Non-ABD	$4.41
Rate for Payer: Hawaii Western Management Group Commercial	$3.05
Rate for Payer: Health Management Network Commercial	$22.10
Rate for Payer: Humana Medicare	$13.00
Rate for Payer: Kaiser Permanente Commercial	$23.40
Rate for Payer: Kaiser Permanente Medicaid	$13.26
Rate for Payer: Kaiser Permanente Medicare	$13.00
Rate for Payer: MDX Hawaii PPO	$25.22
Rate for Payer: Ohana Health Plan Medicaid	$13.00
Rate for Payer: Ohana Health Plan Medicare	$13.00
Rate for Payer: UnitedHealthcare Medicaid	$4.20
Rate for Payer: UnitedHealthcare Medicare	$13.00
Rate for Payer: University Health Alliance Commercial	$7.84

UA Microscopic REF

Facility

$26.00

Service Code	HCPCS 81015
Hospital Charge Code	8191172
Hospital Revenue Code	300
Min. Negotiated Rate	$22.10
Max. Negotiated Rate	$25.22
Rate for Payer: Cash Price	$16.90
Rate for Payer: Health Management Network Commercial	$22.10
Rate for Payer: Kaiser Permanente Commercial	$23.40
Rate for Payer: MDX Hawaii PPO	$25.22

UA Micro w Rfx Culture REF

Facility

$56.00

Service Code	HCPCS 81001
Hospital Charge Code	8191173
Hospital Revenue Code	307
Min. Negotiated Rate	$3.17
Max. Negotiated Rate	$54.32
Rate for Payer: AlohaCare Medicaid	$28.00
Rate for Payer: AlohaCare Medicare	$28.00
Rate for Payer: Cash Price	$36.40
Rate for Payer: Cash Price	$36.40
Rate for Payer: Devoted Health Medicare	$30.80
Rate for Payer: Hawaii Medical Service Association ABD	$4.37
Rate for Payer: Hawaii Medical Service Association Commercial	$3.96
Rate for Payer: Hawaii Medical Service Association Medicare	$28.00
Rate for Payer: Hawaii Medical Service Association Non-ABD	$4.59
Rate for Payer: Hawaii Western Management Group Commercial	$3.17
Rate for Payer: Health Management Network Commercial	$47.60
Rate for Payer: Humana Medicare	$28.00
Rate for Payer: Kaiser Permanente Commercial	$50.40
Rate for Payer: Kaiser Permanente Medicaid	$28.56
Rate for Payer: Kaiser Permanente Medicare	$28.00
Rate for Payer: MDX Hawaii PPO	$54.32
Rate for Payer: Ohana Health Plan Medicaid	$28.00
Rate for Payer: Ohana Health Plan Medicare	$28.00
Rate for Payer: UnitedHealthcare Medicaid	$4.37
Rate for Payer: UnitedHealthcare Medicare	$28.00
Rate for Payer: University Health Alliance Commercial	$8.20

UA Micro w Rfx Culture REF

Facility

$56.00

Service Code	HCPCS 81001
Hospital Charge Code	8191173
Hospital Revenue Code	307
Min. Negotiated Rate	$47.60
Max. Negotiated Rate	$54.32
Rate for Payer: Cash Price	$36.40
Rate for Payer: Health Management Network Commercial	$47.60
Rate for Payer: Kaiser Permanente Commercial	$50.40
Rate for Payer: MDX Hawaii PPO	$54.32

Know your out-of-pocket cost for care.

All Charges