Samuel Mahelona Memorial Hospital

All Charges

Charge

Type

Setting

Price

U Urealyticum Amp Probe

Facility

$365.00

Service Code	HCPCS 87798
Hospital Charge Code	10023501
Hospital Revenue Code	306
Min. Negotiated Rate	$35.09
Max. Negotiated Rate	$354.05
Rate for Payer: AlohaCare Medicaid	$182.50
Rate for Payer: AlohaCare Medicare	$182.50
Rate for Payer: Cash Price	$237.25
Rate for Payer: Cash Price	$237.25
Rate for Payer: Devoted Health Medicare	$200.75
Rate for Payer: Hawaii Medical Service Association ABD	$48.50
Rate for Payer: Hawaii Medical Service Association Commercial	$43.86
Rate for Payer: Hawaii Medical Service Association Medicare	$182.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$50.93
Rate for Payer: Hawaii Western Management Group Commercial	$35.09
Rate for Payer: Health Management Network Commercial	$310.25
Rate for Payer: Humana Medicare	$182.50
Rate for Payer: Kaiser Permanente Commercial	$328.50
Rate for Payer: Kaiser Permanente Medicaid	$186.15
Rate for Payer: Kaiser Permanente Medicare	$182.50
Rate for Payer: MDX Hawaii PPO	$354.05
Rate for Payer: Ohana Health Plan Medicaid	$182.50
Rate for Payer: Ohana Health Plan Medicare	$182.50
Rate for Payer: UnitedHealthcare Medicaid	$48.50
Rate for Payer: UnitedHealthcare Medicare	$182.50
Rate for Payer: University Health Alliance Commercial	$90.72

U Urealyticum Amp Probe

Facility

$365.00

Service Code	HCPCS 87798
Hospital Charge Code	10023501
Hospital Revenue Code	306
Min. Negotiated Rate	$310.25
Max. Negotiated Rate	$354.05
Rate for Payer: Cash Price	$237.25
Rate for Payer: Health Management Network Commercial	$310.25
Rate for Payer: Kaiser Permanente Commercial	$328.50
Rate for Payer: MDX Hawaii PPO	$354.05

Vag Delivery Recov Lvl 1 Charge

Facility

$3,194.00

Hospital Charge Code	8140424
Hospital Revenue Code	722
Min. Negotiated Rate	$1,597.00
Max. Negotiated Rate	$3,098.18
Rate for Payer: AlohaCare Medicaid	$1,597.00
Rate for Payer: AlohaCare Medicare	$1,597.00
Rate for Payer: Cash Price	$2,076.10
Rate for Payer: Devoted Health Medicare	$1,756.70
Rate for Payer: Hawaii Medical Service Association Medicare	$1,597.00
Rate for Payer: Hawaii Western Management Group Commercial	$3,034.30
Rate for Payer: Health Management Network Commercial	$2,714.90
Rate for Payer: Humana Medicare	$1,597.00
Rate for Payer: Kaiser Permanente Commercial	$2,874.60
Rate for Payer: Kaiser Permanente Medicaid	$1,628.94
Rate for Payer: Kaiser Permanente Medicare	$1,597.00
Rate for Payer: MDX Hawaii PPO	$3,098.18
Rate for Payer: Ohana Health Plan Medicaid	$1,597.00
Rate for Payer: Ohana Health Plan Medicare	$1,597.00
Rate for Payer: UnitedHealthcare Medicare	$1,597.00
Rate for Payer: University Health Alliance Commercial	$1,788.64

Vag Delivery Recov Lvl 1 Charge

Facility

$3,194.00

Hospital Charge Code	8140424
Hospital Revenue Code	722
Min. Negotiated Rate	$2,714.90
Max. Negotiated Rate	$3,098.18
Rate for Payer: Cash Price	$2,076.10
Rate for Payer: Health Management Network Commercial	$2,714.90
Rate for Payer: Kaiser Permanente Commercial	$2,874.60
Rate for Payer: MDX Hawaii PPO	$3,098.18

Vag Delivery Recov Lvl 2 Charge

Facility

$3,833.00

Hospital Charge Code	8140427
Hospital Revenue Code	722
Min. Negotiated Rate	$1,916.50
Max. Negotiated Rate	$3,718.01
Rate for Payer: AlohaCare Medicaid	$1,916.50
Rate for Payer: AlohaCare Medicare	$1,916.50
Rate for Payer: Cash Price	$2,491.45
Rate for Payer: Devoted Health Medicare	$2,108.15
Rate for Payer: Hawaii Medical Service Association Medicare	$1,916.50
Rate for Payer: Hawaii Western Management Group Commercial	$3,641.35
Rate for Payer: Health Management Network Commercial	$3,258.05
Rate for Payer: Humana Medicare	$1,916.50
Rate for Payer: Kaiser Permanente Commercial	$3,449.70
Rate for Payer: Kaiser Permanente Medicaid	$1,954.83
Rate for Payer: Kaiser Permanente Medicare	$1,916.50
Rate for Payer: MDX Hawaii PPO	$3,718.01
Rate for Payer: Ohana Health Plan Medicaid	$1,916.50
Rate for Payer: Ohana Health Plan Medicare	$1,916.50
Rate for Payer: UnitedHealthcare Medicare	$1,916.50
Rate for Payer: University Health Alliance Commercial	$2,146.48

Vag Delivery Recov Lvl 2 Charge

Facility

$3,833.00

Hospital Charge Code	8140427
Hospital Revenue Code	722
Min. Negotiated Rate	$3,258.05
Max. Negotiated Rate	$3,718.01
Rate for Payer: Cash Price	$2,491.45
Rate for Payer: Health Management Network Commercial	$3,258.05
Rate for Payer: Kaiser Permanente Commercial	$3,449.70
Rate for Payer: MDX Hawaii PPO	$3,718.01

VAGINA, CERVIX AND VULVA PROCEDURES WITH CC/MCC

Facility

$26,451.43

Service Code	MSDRG 746
Min. Negotiated Rate	$26,451.43
Max. Negotiated Rate	$26,451.43
Rate for Payer: Hawaii Medical Service Association Commercial	$26,451.43

VAGINA, CERVIX AND VULVA PROCEDURES WITHOUT CC/MCC

Facility

$26,451.43

Service Code	MSDRG 747
Min. Negotiated Rate	$26,451.43
Max. Negotiated Rate	$26,451.43
Rate for Payer: Hawaii Medical Service Association Commercial	$26,451.43

VAGINAL DELIVERY WITH O.R. PROCEDURES EXCEPT STERILIZATION AND/OR D&C

Facility

$12,490.95

Service Code	MSDRG 768
Min. Negotiated Rate	$7,300.00
Max. Negotiated Rate	$12,490.95
Rate for Payer: Hawaii Medical Service Association Commercial	$12,490.95
Rate for Payer: Hawaii Western Management Group Commercial	$7,300.00
Rate for Payer: University Health Alliance Commercial	$7,760.00

VAGINAL DELIVERY WITHOUT STERILIZATION OR D&C WITH CC

Facility

$10,120.75

Service Code	MSDRG 806
Min. Negotiated Rate	$7,300.00
Max. Negotiated Rate	$10,120.75
Rate for Payer: Hawaii Medical Service Association Commercial	$10,120.75
Rate for Payer: Hawaii Western Management Group Commercial	$7,300.00
Rate for Payer: University Health Alliance Commercial	$7,760.00

VAGINAL DELIVERY WITHOUT STERILIZATION OR D&C WITH MCC

Facility

$10,120.75

Service Code	MSDRG 805
Min. Negotiated Rate	$7,300.00
Max. Negotiated Rate	$10,120.75
Rate for Payer: Hawaii Medical Service Association Commercial	$10,120.75
Rate for Payer: Hawaii Western Management Group Commercial	$7,300.00
Rate for Payer: University Health Alliance Commercial	$7,760.00

VAGINAL DELIVERY WITHOUT STERILIZATION OR D&C WITHOUT CC/MCC

Facility

$9,125.27

Service Code	MSDRG 807
Min. Negotiated Rate	$7,300.00
Max. Negotiated Rate	$9,125.27
Rate for Payer: Hawaii Medical Service Association Commercial	$9,125.27
Rate for Payer: Hawaii Western Management Group Commercial	$7,300.00
Rate for Payer: University Health Alliance Commercial	$7,760.00

VAGINAL DELIVERY WITH STERILIZATION AND/OR D&C WITH CC

Facility

$14,695.24

Service Code	MSDRG 797
Min. Negotiated Rate	$7,300.00
Max. Negotiated Rate	$14,695.24
Rate for Payer: Hawaii Medical Service Association Commercial	$14,695.24
Rate for Payer: Hawaii Western Management Group Commercial	$7,300.00
Rate for Payer: University Health Alliance Commercial	$7,760.00

VAGINAL DELIVERY WITH STERILIZATION AND/OR D&C WITH MCC

Facility

$14,695.24

Service Code	MSDRG 796
Min. Negotiated Rate	$7,300.00
Max. Negotiated Rate	$14,695.24
Rate for Payer: Hawaii Medical Service Association Commercial	$14,695.24
Rate for Payer: Hawaii Western Management Group Commercial	$7,300.00
Rate for Payer: University Health Alliance Commercial	$7,760.00

VAGINAL DELIVERY WITH STERILIZATION AND/OR D&C WITHOUT CC/MCC

Facility

$14,695.24

Service Code	MSDRG 798
Min. Negotiated Rate	$7,300.00
Max. Negotiated Rate	$14,695.24
Rate for Payer: Hawaii Medical Service Association Commercial	$14,695.24
Rate for Payer: Hawaii Western Management Group Commercial	$7,300.00
Rate for Payer: University Health Alliance Commercial	$7,760.00

Vaginitis Panel NAAT FSI

Facility

$374.00

Service Code	HCPCS 87661
Hospital Charge Code	11185799
Hospital Revenue Code	306
Min. Negotiated Rate	$28.72
Max. Negotiated Rate	$362.78
Rate for Payer: AlohaCare Medicaid	$187.00
Rate for Payer: AlohaCare Medicare	$187.00
Rate for Payer: Cash Price	$243.10
Rate for Payer: Cash Price	$243.10
Rate for Payer: Devoted Health Medicare	$205.70
Rate for Payer: Hawaii Medical Service Association Commercial	$43.86
Rate for Payer: Hawaii Medical Service Association Medicare	$187.00
Rate for Payer: Hawaii Medical Service Association Non-ABD	$48.48
Rate for Payer: Hawaii Western Management Group Commercial	$35.09
Rate for Payer: Health Management Network Commercial	$317.90
Rate for Payer: Humana Medicare	$187.00
Rate for Payer: Kaiser Permanente Commercial	$336.60
Rate for Payer: Kaiser Permanente Medicaid	$190.74
Rate for Payer: Kaiser Permanente Medicare	$187.00
Rate for Payer: MDX Hawaii PPO	$362.78
Rate for Payer: Ohana Health Plan Medicaid	$187.00
Rate for Payer: Ohana Health Plan Medicare	$187.00
Rate for Payer: UnitedHealthcare Medicaid	$28.72
Rate for Payer: UnitedHealthcare Medicare	$187.00
Rate for Payer: University Health Alliance Commercial	$88.56

Vaginitis Panel NAAT FSI

Facility

$374.00

Service Code	HCPCS 87661
Hospital Charge Code	11185799
Hospital Revenue Code	306
Min. Negotiated Rate	$317.90
Max. Negotiated Rate	$362.78
Rate for Payer: Cash Price	$243.10
Rate for Payer: Health Management Network Commercial	$317.90
Rate for Payer: Kaiser Permanente Commercial	$336.60
Rate for Payer: MDX Hawaii PPO	$362.78

Vaginitis Rapid DNA FSI

Facility

$230.00

Service Code	HCPCS 87480
Hospital Charge Code	8118076
Hospital Revenue Code	306
Min. Negotiated Rate	$195.50
Max. Negotiated Rate	$223.10
Rate for Payer: Cash Price	$149.50
Rate for Payer: Health Management Network Commercial	$195.50
Rate for Payer: Kaiser Permanente Commercial	$207.00
Rate for Payer: MDX Hawaii PPO	$223.10

Vaginitis Rapid DNA FSI

Facility

$230.00

Service Code	HCPCS 87480
Hospital Charge Code	8118076
Hospital Revenue Code	306
Min. Negotiated Rate	$20.05
Max. Negotiated Rate	$223.10
Rate for Payer: AlohaCare Medicaid	$115.00
Rate for Payer: AlohaCare Medicare	$115.00
Rate for Payer: Cash Price	$149.50
Rate for Payer: Cash Price	$149.50
Rate for Payer: Devoted Health Medicare	$126.50
Rate for Payer: Hawaii Medical Service Association ABD	$27.71
Rate for Payer: Hawaii Medical Service Association Commercial	$25.06
Rate for Payer: Hawaii Medical Service Association Medicare	$115.00
Rate for Payer: Hawaii Medical Service Association Non-ABD	$29.10
Rate for Payer: Hawaii Western Management Group Commercial	$20.05
Rate for Payer: Health Management Network Commercial	$195.50
Rate for Payer: Humana Medicare	$115.00
Rate for Payer: Kaiser Permanente Commercial	$207.00
Rate for Payer: Kaiser Permanente Medicaid	$117.30
Rate for Payer: Kaiser Permanente Medicare	$115.00
Rate for Payer: MDX Hawaii PPO	$223.10
Rate for Payer: Ohana Health Plan Medicaid	$115.00
Rate for Payer: Ohana Health Plan Medicare	$115.00
Rate for Payer: UnitedHealthcare Medicaid	$27.71
Rate for Payer: UnitedHealthcare Medicare	$115.00
Rate for Payer: University Health Alliance Commercial	$51.84

valACYclovir 500 mg tablet [HHSC]

Facility

$44.86

Service Code	HCPCS J8499
Hospital Charge Code	2501050
Hospital Revenue Code	637
Min. Negotiated Rate	$22.43
Max. Negotiated Rate	$43.51
Rate for Payer: AlohaCare Medicaid	$22.43
Rate for Payer: AlohaCare Medicaid	$16.59
Rate for Payer: AlohaCare Medicaid	$10.31
Rate for Payer: AlohaCare Medicaid	$11.04
Rate for Payer: AlohaCare Medicare	$11.04
Rate for Payer: AlohaCare Medicare	$10.31
Rate for Payer: AlohaCare Medicare	$22.43
Rate for Payer: AlohaCare Medicare	$16.59
Rate for Payer: Cash Price	$13.40
Rate for Payer: Cash Price	$21.57
Rate for Payer: Cash Price	$14.36
Rate for Payer: Cash Price	$29.16
Rate for Payer: Devoted Health Medicare	$12.15
Rate for Payer: Devoted Health Medicare	$24.67
Rate for Payer: Devoted Health Medicare	$11.34
Rate for Payer: Devoted Health Medicare	$18.25
Rate for Payer: Hawaii Medical Service Association Medicare	$22.43
Rate for Payer: Hawaii Medical Service Association Medicare	$10.31
Rate for Payer: Hawaii Medical Service Association Medicare	$11.04
Rate for Payer: Hawaii Medical Service Association Medicare	$16.59
Rate for Payer: Hawaii Western Management Group Commercial	$31.53
Rate for Payer: Hawaii Western Management Group Commercial	$19.59
Rate for Payer: Hawaii Western Management Group Commercial	$20.99
Rate for Payer: Hawaii Western Management Group Commercial	$42.62
Rate for Payer: Health Management Network Commercial	$18.78
Rate for Payer: Health Management Network Commercial	$17.53
Rate for Payer: Health Management Network Commercial	$28.21
Rate for Payer: Health Management Network Commercial	$38.13
Rate for Payer: Humana Medicare	$16.59
Rate for Payer: Humana Medicare	$11.04
Rate for Payer: Humana Medicare	$10.31
Rate for Payer: Humana Medicare	$22.43
Rate for Payer: Kaiser Permanente Commercial	$40.37
Rate for Payer: Kaiser Permanente Commercial	$18.56
Rate for Payer: Kaiser Permanente Commercial	$29.87
Rate for Payer: Kaiser Permanente Commercial	$19.88
Rate for Payer: Kaiser Permanente Medicaid	$22.88
Rate for Payer: Kaiser Permanente Medicaid	$11.27
Rate for Payer: Kaiser Permanente Medicaid	$16.93
Rate for Payer: Kaiser Permanente Medicaid	$10.52
Rate for Payer: Kaiser Permanente Medicare	$11.04
Rate for Payer: Kaiser Permanente Medicare	$16.59
Rate for Payer: Kaiser Permanente Medicare	$10.31
Rate for Payer: Kaiser Permanente Medicare	$22.43
Rate for Payer: MDX Hawaii PPO	$21.43
Rate for Payer: MDX Hawaii PPO	$32.19
Rate for Payer: MDX Hawaii PPO	$43.51
Rate for Payer: MDX Hawaii PPO	$20.00
Rate for Payer: Ohana Health Plan Medicaid	$22.43
Rate for Payer: Ohana Health Plan Medicaid	$16.59
Rate for Payer: Ohana Health Plan Medicaid	$11.04
Rate for Payer: Ohana Health Plan Medicaid	$10.31
Rate for Payer: Ohana Health Plan Medicare	$22.43
Rate for Payer: Ohana Health Plan Medicare	$10.31
Rate for Payer: Ohana Health Plan Medicare	$11.04
Rate for Payer: Ohana Health Plan Medicare	$16.59
Rate for Payer: UnitedHealthcare Medicare	$11.04
Rate for Payer: UnitedHealthcare Medicare	$16.59
Rate for Payer: UnitedHealthcare Medicare	$22.43
Rate for Payer: UnitedHealthcare Medicare	$10.31
Rate for Payer: University Health Alliance Commercial	$24.19
Rate for Payer: University Health Alliance Commercial	$16.10
Rate for Payer: University Health Alliance Commercial	$32.70
Rate for Payer: University Health Alliance Commercial	$15.03

valACYclovir 500 mg tablet [HHSC]

Facility

$22.09

Service Code	HCPCS J8499
Hospital Charge Code	2501050
Hospital Revenue Code	250
Min. Negotiated Rate	$18.78
Max. Negotiated Rate	$21.43
Rate for Payer: Cash Price	$14.36
Rate for Payer: Cash Price	$13.40
Rate for Payer: Cash Price	$29.16
Rate for Payer: Cash Price	$21.57
Rate for Payer: Health Management Network Commercial	$17.53
Rate for Payer: Health Management Network Commercial	$18.78
Rate for Payer: Health Management Network Commercial	$28.21
Rate for Payer: Health Management Network Commercial	$38.13
Rate for Payer: Kaiser Permanente Commercial	$18.56
Rate for Payer: Kaiser Permanente Commercial	$29.87
Rate for Payer: Kaiser Permanente Commercial	$19.88
Rate for Payer: Kaiser Permanente Commercial	$40.37
Rate for Payer: MDX Hawaii PPO	$21.43
Rate for Payer: MDX Hawaii PPO	$32.19
Rate for Payer: MDX Hawaii PPO	$43.51
Rate for Payer: MDX Hawaii PPO	$20.00

valbenazine tosylate 40 mg capsule [HHSC]

Facility

$802.04

Service Code	NDC 70370204001
Hospital Charge Code	2501091
Hospital Revenue Code	250
Min. Negotiated Rate	$401.02
Max. Negotiated Rate	$777.98
Rate for Payer: AlohaCare Medicaid	$401.02
Rate for Payer: AlohaCare Medicare	$401.02
Rate for Payer: Cash Price	$521.33
Rate for Payer: Devoted Health Medicare	$441.12
Rate for Payer: Hawaii Medical Service Association Medicare	$401.02
Rate for Payer: Hawaii Western Management Group Commercial	$761.94
Rate for Payer: Health Management Network Commercial	$681.73
Rate for Payer: Humana Medicare	$401.02
Rate for Payer: Kaiser Permanente Commercial	$721.84
Rate for Payer: Kaiser Permanente Medicaid	$409.04
Rate for Payer: Kaiser Permanente Medicare	$401.02
Rate for Payer: MDX Hawaii PPO	$777.98
Rate for Payer: Ohana Health Plan Medicaid	$401.02
Rate for Payer: Ohana Health Plan Medicare	$401.02
Rate for Payer: UnitedHealthcare Medicaid	$481.22
Rate for Payer: UnitedHealthcare Medicare	$401.02
Rate for Payer: University Health Alliance Commercial	$584.61

valbenazine tosylate 40 mg capsule [HHSC]

Facility

$802.04

Service Code	NDC 70370204001
Hospital Charge Code	2501091
Hospital Revenue Code	250
Min. Negotiated Rate	$681.73
Max. Negotiated Rate	$777.98
Rate for Payer: Cash Price	$521.33
Rate for Payer: Health Management Network Commercial	$681.73
Rate for Payer: Kaiser Permanente Commercial	$721.84
Rate for Payer: MDX Hawaii PPO	$777.98

VAL KREULOCK SCREW, TI, 2.0 X 10MM

Facility

$310.00

Service Code	HCPCS C1713
Hospital Charge Code	13005604
Hospital Revenue Code	278
Min. Negotiated Rate	$155.00
Max. Negotiated Rate	$300.70
Rate for Payer: AlohaCare Medicaid	$155.00
Rate for Payer: AlohaCare Medicare	$155.00
Rate for Payer: Cash Price	$201.50
Rate for Payer: Devoted Health Medicare	$170.50
Rate for Payer: Hawaii Medical Service Association Medicare	$155.00
Rate for Payer: Hawaii Western Management Group Commercial	$217.00
Rate for Payer: Health Management Network Commercial	$263.50
Rate for Payer: Humana Medicare	$155.00
Rate for Payer: Kaiser Permanente Commercial	$279.00
Rate for Payer: Kaiser Permanente Medicaid	$158.10
Rate for Payer: Kaiser Permanente Medicare	$155.00
Rate for Payer: MDX Hawaii PPO	$300.70
Rate for Payer: Ohana Health Plan Medicaid	$155.00
Rate for Payer: Ohana Health Plan Medicare	$155.00
Rate for Payer: UnitedHealthcare Medicare	$155.00
Rate for Payer: University Health Alliance Commercial	$173.60

VAL KREULOCK SCREW, TI, 2.0 X 10MM

Facility

$310.00

Service Code	HCPCS C1713
Hospital Charge Code	13005604
Hospital Revenue Code	278
Min. Negotiated Rate	$173.60
Max. Negotiated Rate	$300.70
Rate for Payer: Cash Price	$201.50
Rate for Payer: Hawaii Western Management Group Commercial	$217.00
Rate for Payer: Health Management Network Commercial	$263.50
Rate for Payer: Kaiser Permanente Commercial	$279.00
Rate for Payer: MDX Hawaii PPO	$300.70
Rate for Payer: University Health Alliance Commercial	$173.60

Know your out-of-pocket cost for care.

All Charges