Samuel Mahelona Memorial Hospital

All Charges

Charge

Type

Setting

Price

vancomycin 1500 mg vial [HHSC]

Facility

$140.30

Service Code	HCPCS J3370
Hospital Charge Code	2501192
Hospital Revenue Code	636
Min. Negotiated Rate	$8.20
Max. Negotiated Rate	$136.09
Rate for Payer: AlohaCare Medicaid	$70.15
Rate for Payer: AlohaCare Medicare	$70.15
Rate for Payer: Cash Price	$91.20
Rate for Payer: Cash Price	$91.20
Rate for Payer: Devoted Health Medicare	$77.17
Rate for Payer: Hawaii Medical Service Association ABD	$8.20
Rate for Payer: Hawaii Medical Service Association Medicare	$70.15
Rate for Payer: Hawaii Medical Service Association Non-ABD	$8.20
Rate for Payer: Hawaii Western Management Group Commercial	$133.28
Rate for Payer: Health Management Network Commercial	$119.25
Rate for Payer: Humana Medicare	$70.15
Rate for Payer: Kaiser Permanente Commercial	$126.27
Rate for Payer: Kaiser Permanente Medicaid	$71.55
Rate for Payer: Kaiser Permanente Medicare	$70.15
Rate for Payer: MDX Hawaii PPO	$136.09
Rate for Payer: Ohana Health Plan Medicaid	$70.15
Rate for Payer: Ohana Health Plan Medicare	$70.15
Rate for Payer: UnitedHealthcare Medicaid	$84.18
Rate for Payer: UnitedHealthcare Medicare	$70.15
Rate for Payer: University Health Alliance Commercial	$102.26

vancomycin 1500 mg vial [HHSC]

Facility

$140.30

Service Code	HCPCS J3370
Hospital Charge Code	2501192
Hospital Revenue Code	250
Min. Negotiated Rate	$119.25
Max. Negotiated Rate	$136.09
Rate for Payer: Cash Price	$91.20
Rate for Payer: Health Management Network Commercial	$119.25
Rate for Payer: Kaiser Permanente Commercial	$126.27
Rate for Payer: MDX Hawaii PPO	$136.09

vancomycin 1750 mg vial [HHSC]

Facility

$206.01

Service Code	HCPCS J3371
Hospital Charge Code	2501193
Hospital Revenue Code	636
Min. Negotiated Rate	$6.31
Max. Negotiated Rate	$199.83
Rate for Payer: AlohaCare Medicaid	$103.00
Rate for Payer: AlohaCare Medicare	$103.00
Rate for Payer: Cash Price	$133.91
Rate for Payer: Cash Price	$133.91
Rate for Payer: Devoted Health Medicare	$113.31
Rate for Payer: Hawaii Medical Service Association ABD	$6.31
Rate for Payer: Hawaii Medical Service Association Medicare	$103.00
Rate for Payer: Hawaii Medical Service Association Non-ABD	$6.31
Rate for Payer: Hawaii Western Management Group Commercial	$195.71
Rate for Payer: Health Management Network Commercial	$175.11
Rate for Payer: Humana Medicare	$103.00
Rate for Payer: Kaiser Permanente Commercial	$185.41
Rate for Payer: Kaiser Permanente Medicaid	$105.07
Rate for Payer: Kaiser Permanente Medicare	$103.00
Rate for Payer: MDX Hawaii PPO	$199.83
Rate for Payer: Ohana Health Plan Medicaid	$103.00
Rate for Payer: Ohana Health Plan Medicare	$103.00
Rate for Payer: UnitedHealthcare Medicaid	$123.61
Rate for Payer: UnitedHealthcare Medicare	$103.00
Rate for Payer: University Health Alliance Commercial	$150.16

vancomycin 1750 mg vial [HHSC]

Facility

$206.01

Service Code	HCPCS J3371
Hospital Charge Code	2501193
Hospital Revenue Code	250
Min. Negotiated Rate	$175.11
Max. Negotiated Rate	$199.83
Rate for Payer: Cash Price	$133.91
Rate for Payer: Health Management Network Commercial	$175.11
Rate for Payer: Kaiser Permanente Commercial	$185.41
Rate for Payer: MDX Hawaii PPO	$199.83

vancomycin 2000mg/400mL-SWFI premix [HHSC]

Facility

$158.60

Service Code	HCPCS J3375
Hospital Charge Code	2501029
Hospital Revenue Code	250
Min. Negotiated Rate	$134.81
Max. Negotiated Rate	$153.84
Rate for Payer: Cash Price	$103.09
Rate for Payer: Health Management Network Commercial	$134.81
Rate for Payer: Kaiser Permanente Commercial	$142.74
Rate for Payer: MDX Hawaii PPO	$153.84

vancomycin 2000mg/400mL-SWFI premix [HHSC]

Facility

$158.60

Service Code	HCPCS J3375
Hospital Charge Code	2501029
Hospital Revenue Code	636
Min. Negotiated Rate	$0.13
Max. Negotiated Rate	$153.84
Rate for Payer: AlohaCare Medicaid	$79.30
Rate for Payer: AlohaCare Medicare	$79.30
Rate for Payer: Cash Price	$103.09
Rate for Payer: Cash Price	$103.09
Rate for Payer: Devoted Health Medicare	$87.23
Rate for Payer: Hawaii Medical Service Association ABD	$0.13
Rate for Payer: Hawaii Medical Service Association Medicare	$79.30
Rate for Payer: Hawaii Medical Service Association Non-ABD	$0.13
Rate for Payer: Hawaii Western Management Group Commercial	$150.67
Rate for Payer: Health Management Network Commercial	$134.81
Rate for Payer: Humana Medicare	$79.30
Rate for Payer: Kaiser Permanente Commercial	$142.74
Rate for Payer: Kaiser Permanente Medicaid	$80.89
Rate for Payer: Kaiser Permanente Medicare	$79.30
Rate for Payer: MDX Hawaii PPO	$153.84
Rate for Payer: Ohana Health Plan Medicaid	$79.30
Rate for Payer: Ohana Health Plan Medicare	$79.30
Rate for Payer: UnitedHealthcare Medicaid	$95.16
Rate for Payer: UnitedHealthcare Medicare	$79.30
Rate for Payer: University Health Alliance Commercial	$115.60

vancomycin 2000 mg vial [HHSC]

Facility

$279.17

Service Code	HCPCS J3371
Hospital Charge Code	2501194
Hospital Revenue Code	250
Min. Negotiated Rate	$237.29
Max. Negotiated Rate	$270.79
Rate for Payer: Cash Price	$181.46
Rate for Payer: Health Management Network Commercial	$237.29
Rate for Payer: Kaiser Permanente Commercial	$251.25
Rate for Payer: MDX Hawaii PPO	$270.79

vancomycin 2000 mg vial [HHSC]

Facility

$279.17

Service Code	HCPCS J3371
Hospital Charge Code	2501194
Hospital Revenue Code	636
Min. Negotiated Rate	$6.31
Max. Negotiated Rate	$270.79
Rate for Payer: AlohaCare Medicaid	$139.59
Rate for Payer: AlohaCare Medicare	$139.59
Rate for Payer: Cash Price	$181.46
Rate for Payer: Cash Price	$181.46
Rate for Payer: Devoted Health Medicare	$153.54
Rate for Payer: Hawaii Medical Service Association ABD	$6.31
Rate for Payer: Hawaii Medical Service Association Medicare	$139.59
Rate for Payer: Hawaii Medical Service Association Non-ABD	$6.31
Rate for Payer: Hawaii Western Management Group Commercial	$265.21
Rate for Payer: Health Management Network Commercial	$237.29
Rate for Payer: Humana Medicare	$139.59
Rate for Payer: Kaiser Permanente Commercial	$251.25
Rate for Payer: Kaiser Permanente Medicaid	$142.38
Rate for Payer: Kaiser Permanente Medicare	$139.59
Rate for Payer: MDX Hawaii PPO	$270.79
Rate for Payer: Ohana Health Plan Medicaid	$139.59
Rate for Payer: Ohana Health Plan Medicare	$139.59
Rate for Payer: UnitedHealthcare Medicaid	$167.50
Rate for Payer: UnitedHealthcare Medicare	$139.59
Rate for Payer: University Health Alliance Commercial	$203.49

vancomycin 750 mg vial [HHSC]

Facility

$67.48

Service Code	HCPCS J3370
Hospital Charge Code	2501190
Hospital Revenue Code	636
Min. Negotiated Rate	$8.20
Max. Negotiated Rate	$65.46
Rate for Payer: AlohaCare Medicaid	$33.74
Rate for Payer: AlohaCare Medicare	$33.74
Rate for Payer: Cash Price	$43.86
Rate for Payer: Cash Price	$43.86
Rate for Payer: Devoted Health Medicare	$37.11
Rate for Payer: Hawaii Medical Service Association ABD	$8.20
Rate for Payer: Hawaii Medical Service Association Medicare	$33.74
Rate for Payer: Hawaii Medical Service Association Non-ABD	$8.20
Rate for Payer: Hawaii Western Management Group Commercial	$64.11
Rate for Payer: Health Management Network Commercial	$57.36
Rate for Payer: Humana Medicare	$33.74
Rate for Payer: Kaiser Permanente Commercial	$60.73
Rate for Payer: Kaiser Permanente Medicaid	$34.41
Rate for Payer: Kaiser Permanente Medicare	$33.74
Rate for Payer: MDX Hawaii PPO	$65.46
Rate for Payer: Ohana Health Plan Medicaid	$33.74
Rate for Payer: Ohana Health Plan Medicare	$33.74
Rate for Payer: UnitedHealthcare Medicaid	$40.49
Rate for Payer: UnitedHealthcare Medicare	$33.74
Rate for Payer: University Health Alliance Commercial	$49.19

vancomycin 750 mg vial [HHSC]

Facility

$67.48

Service Code	HCPCS J3370
Hospital Charge Code	2501190
Hospital Revenue Code	250
Min. Negotiated Rate	$57.36
Max. Negotiated Rate	$65.46
Rate for Payer: Cash Price	$43.86
Rate for Payer: Health Management Network Commercial	$57.36
Rate for Payer: Kaiser Permanente Commercial	$60.73
Rate for Payer: MDX Hawaii PPO	$65.46

Vancomycin (No Time)

Facility

$169.00

Service Code	HCPCS 80202
Hospital Charge Code	12516218
Hospital Revenue Code	301
Min. Negotiated Rate	$13.54
Max. Negotiated Rate	$163.93
Rate for Payer: AlohaCare Medicaid	$84.50
Rate for Payer: AlohaCare Medicare	$84.50
Rate for Payer: Cash Price	$109.85
Rate for Payer: Cash Price	$109.85
Rate for Payer: Devoted Health Medicare	$92.95
Rate for Payer: Hawaii Medical Service Association ABD	$18.72
Rate for Payer: Hawaii Medical Service Association Commercial	$16.93
Rate for Payer: Hawaii Medical Service Association Medicare	$84.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$19.66
Rate for Payer: Hawaii Western Management Group Commercial	$13.54
Rate for Payer: Health Management Network Commercial	$143.65
Rate for Payer: Humana Medicare	$84.50
Rate for Payer: Kaiser Permanente Commercial	$152.10
Rate for Payer: Kaiser Permanente Medicaid	$86.19
Rate for Payer: Kaiser Permanente Medicare	$84.50
Rate for Payer: MDX Hawaii PPO	$163.93
Rate for Payer: Ohana Health Plan Medicaid	$84.50
Rate for Payer: Ohana Health Plan Medicare	$84.50
Rate for Payer: UnitedHealthcare Medicaid	$18.72
Rate for Payer: UnitedHealthcare Medicare	$84.50
Rate for Payer: University Health Alliance Commercial	$35.02

Vancomycin (No Time)

Facility

$169.00

Service Code	HCPCS 80202
Hospital Charge Code	12516218
Hospital Revenue Code	301
Min. Negotiated Rate	$143.65
Max. Negotiated Rate	$163.93
Rate for Payer: Cash Price	$109.85
Rate for Payer: Health Management Network Commercial	$143.65
Rate for Payer: Kaiser Permanente Commercial	$152.10
Rate for Payer: MDX Hawaii PPO	$163.93

Vancomycin Random FSI

Facility

$155.00

Service Code	HCPCS 80202
Hospital Charge Code	8228937
Hospital Revenue Code	301
Min. Negotiated Rate	$13.54
Max. Negotiated Rate	$150.35
Rate for Payer: AlohaCare Medicaid	$77.50
Rate for Payer: AlohaCare Medicare	$77.50
Rate for Payer: Cash Price	$100.75
Rate for Payer: Cash Price	$100.75
Rate for Payer: Devoted Health Medicare	$85.25
Rate for Payer: Hawaii Medical Service Association ABD	$18.72
Rate for Payer: Hawaii Medical Service Association Commercial	$16.93
Rate for Payer: Hawaii Medical Service Association Medicare	$77.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$19.66
Rate for Payer: Hawaii Western Management Group Commercial	$13.54
Rate for Payer: Health Management Network Commercial	$131.75
Rate for Payer: Humana Medicare	$77.50
Rate for Payer: Kaiser Permanente Commercial	$139.50
Rate for Payer: Kaiser Permanente Medicaid	$79.05
Rate for Payer: Kaiser Permanente Medicare	$77.50
Rate for Payer: MDX Hawaii PPO	$150.35
Rate for Payer: Ohana Health Plan Medicaid	$77.50
Rate for Payer: Ohana Health Plan Medicare	$77.50
Rate for Payer: UnitedHealthcare Medicaid	$18.72
Rate for Payer: UnitedHealthcare Medicare	$77.50
Rate for Payer: University Health Alliance Commercial	$35.02

Vancomycin Random FSI

Facility

$155.00

Service Code	HCPCS 80202
Hospital Charge Code	8228937
Hospital Revenue Code	301
Min. Negotiated Rate	$131.75
Max. Negotiated Rate	$150.35
Rate for Payer: Cash Price	$100.75
Rate for Payer: Health Management Network Commercial	$131.75
Rate for Payer: Kaiser Permanente Commercial	$139.50
Rate for Payer: MDX Hawaii PPO	$150.35

Vancomycin Trough FSI

Facility

$155.00

Service Code	HCPCS 80202
Hospital Charge Code	8128160
Hospital Revenue Code	301
Min. Negotiated Rate	$131.75
Max. Negotiated Rate	$150.35
Rate for Payer: Cash Price	$100.75
Rate for Payer: Health Management Network Commercial	$131.75
Rate for Payer: Kaiser Permanente Commercial	$139.50
Rate for Payer: MDX Hawaii PPO	$150.35

Vancomycin Trough FSI

Facility

$155.00

Service Code	HCPCS 80202
Hospital Charge Code	8128160
Hospital Revenue Code	301
Min. Negotiated Rate	$13.54
Max. Negotiated Rate	$150.35
Rate for Payer: AlohaCare Medicaid	$77.50
Rate for Payer: AlohaCare Medicare	$77.50
Rate for Payer: Cash Price	$100.75
Rate for Payer: Cash Price	$100.75
Rate for Payer: Devoted Health Medicare	$85.25
Rate for Payer: Hawaii Medical Service Association ABD	$18.72
Rate for Payer: Hawaii Medical Service Association Commercial	$16.93
Rate for Payer: Hawaii Medical Service Association Medicare	$77.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$19.66
Rate for Payer: Hawaii Western Management Group Commercial	$13.54
Rate for Payer: Health Management Network Commercial	$131.75
Rate for Payer: Humana Medicare	$77.50
Rate for Payer: Kaiser Permanente Commercial	$139.50
Rate for Payer: Kaiser Permanente Medicaid	$79.05
Rate for Payer: Kaiser Permanente Medicare	$77.50
Rate for Payer: MDX Hawaii PPO	$150.35
Rate for Payer: Ohana Health Plan Medicaid	$77.50
Rate for Payer: Ohana Health Plan Medicare	$77.50
Rate for Payer: UnitedHealthcare Medicaid	$18.72
Rate for Payer: UnitedHealthcare Medicare	$77.50
Rate for Payer: University Health Alliance Commercial	$35.02

VAPOTHERM CIRCUIT HIGH FLOW DISPOSABLE PATIENT CIRCUIT

Facility

$399.00

Hospital Charge Code	8938950
Hospital Revenue Code	272
Min. Negotiated Rate	$339.15
Max. Negotiated Rate	$387.03
Rate for Payer: Cash Price	$259.35
Rate for Payer: Health Management Network Commercial	$339.15
Rate for Payer: Kaiser Permanente Commercial	$359.10
Rate for Payer: MDX Hawaii PPO	$387.03

VAPOTHERM CIRCUIT HIGH FLOW DISPOSABLE PATIENT CIRCUIT

Facility

$399.00

Hospital Charge Code	8938950
Hospital Revenue Code	272
Min. Negotiated Rate	$199.50
Max. Negotiated Rate	$387.03
Rate for Payer: AlohaCare Medicaid	$199.50
Rate for Payer: AlohaCare Medicare	$199.50
Rate for Payer: Cash Price	$259.35
Rate for Payer: Devoted Health Medicare	$219.45
Rate for Payer: Hawaii Medical Service Association Medicare	$199.50
Rate for Payer: Hawaii Western Management Group Commercial	$379.05
Rate for Payer: Health Management Network Commercial	$339.15
Rate for Payer: Humana Medicare	$199.50
Rate for Payer: Kaiser Permanente Commercial	$359.10
Rate for Payer: Kaiser Permanente Medicaid	$203.49
Rate for Payer: Kaiser Permanente Medicare	$199.50
Rate for Payer: MDX Hawaii PPO	$387.03
Rate for Payer: Ohana Health Plan Medicaid	$199.50
Rate for Payer: Ohana Health Plan Medicare	$199.50
Rate for Payer: UnitedHealthcare Medicare	$199.50
Rate for Payer: University Health Alliance Commercial	$290.83

VAPOTHERM CIRCUIT LOW FLOW DISPOSABLE PATIENT CIRCUIT

Facility

$399.00

Hospital Charge Code	8938951
Hospital Revenue Code	272
Min. Negotiated Rate	$339.15
Max. Negotiated Rate	$387.03
Rate for Payer: Cash Price	$259.35
Rate for Payer: Health Management Network Commercial	$339.15
Rate for Payer: Kaiser Permanente Commercial	$359.10
Rate for Payer: MDX Hawaii PPO	$387.03

VAPOTHERM CIRCUIT LOW FLOW DISPOSABLE PATIENT CIRCUIT

Facility

$399.00

Hospital Charge Code	8938951
Hospital Revenue Code	272
Min. Negotiated Rate	$199.50
Max. Negotiated Rate	$387.03
Rate for Payer: AlohaCare Medicaid	$199.50
Rate for Payer: AlohaCare Medicare	$199.50
Rate for Payer: Cash Price	$259.35
Rate for Payer: Devoted Health Medicare	$219.45
Rate for Payer: Hawaii Medical Service Association Medicare	$199.50
Rate for Payer: Hawaii Western Management Group Commercial	$379.05
Rate for Payer: Health Management Network Commercial	$339.15
Rate for Payer: Humana Medicare	$199.50
Rate for Payer: Kaiser Permanente Commercial	$359.10
Rate for Payer: Kaiser Permanente Medicaid	$203.49
Rate for Payer: Kaiser Permanente Medicare	$199.50
Rate for Payer: MDX Hawaii PPO	$387.03
Rate for Payer: Ohana Health Plan Medicaid	$199.50
Rate for Payer: Ohana Health Plan Medicare	$199.50
Rate for Payer: UnitedHealthcare Medicare	$199.50
Rate for Payer: University Health Alliance Commercial	$290.83

Varicella zoster, IgG FSI

Facility

$147.00

Service Code	HCPCS 86787
Hospital Charge Code	8118079
Hospital Revenue Code	302
Min. Negotiated Rate	$12.88
Max. Negotiated Rate	$142.59
Rate for Payer: AlohaCare Medicaid	$73.50
Rate for Payer: AlohaCare Medicare	$73.50
Rate for Payer: Cash Price	$95.55
Rate for Payer: Cash Price	$95.55
Rate for Payer: Devoted Health Medicare	$80.85
Rate for Payer: Hawaii Medical Service Association ABD	$17.81
Rate for Payer: Hawaii Medical Service Association Commercial	$16.10
Rate for Payer: Hawaii Medical Service Association Medicare	$73.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$18.70
Rate for Payer: Hawaii Western Management Group Commercial	$12.88
Rate for Payer: Health Management Network Commercial	$124.95
Rate for Payer: Humana Medicare	$73.50
Rate for Payer: Kaiser Permanente Commercial	$132.30
Rate for Payer: Kaiser Permanente Medicaid	$74.97
Rate for Payer: Kaiser Permanente Medicare	$73.50
Rate for Payer: MDX Hawaii PPO	$142.59
Rate for Payer: Ohana Health Plan Medicaid	$73.50
Rate for Payer: Ohana Health Plan Medicare	$73.50
Rate for Payer: UnitedHealthcare Medicaid	$17.81
Rate for Payer: UnitedHealthcare Medicare	$73.50
Rate for Payer: University Health Alliance Commercial	$33.30

Varicella zoster, IgG FSI

Facility

$147.00

Service Code	HCPCS 86787
Hospital Charge Code	8118079
Hospital Revenue Code	302
Min. Negotiated Rate	$124.95
Max. Negotiated Rate	$142.59
Rate for Payer: Cash Price	$95.55
Rate for Payer: Health Management Network Commercial	$124.95
Rate for Payer: Kaiser Permanente Commercial	$132.30
Rate for Payer: MDX Hawaii PPO	$142.59

Varicella zoster IgM FSI

Facility

$147.00

Service Code	HCPCS 86787
Hospital Charge Code	8702605
Hospital Revenue Code	302
Min. Negotiated Rate	$124.95
Max. Negotiated Rate	$142.59
Rate for Payer: Cash Price	$95.55
Rate for Payer: Health Management Network Commercial	$124.95
Rate for Payer: Kaiser Permanente Commercial	$132.30
Rate for Payer: MDX Hawaii PPO	$142.59

Varicella zoster IgM FSI

Facility

$147.00

Service Code	HCPCS 86787
Hospital Charge Code	8702605
Hospital Revenue Code	302
Min. Negotiated Rate	$12.88
Max. Negotiated Rate	$142.59
Rate for Payer: AlohaCare Medicaid	$73.50
Rate for Payer: AlohaCare Medicare	$73.50
Rate for Payer: Cash Price	$95.55
Rate for Payer: Cash Price	$95.55
Rate for Payer: Devoted Health Medicare	$80.85
Rate for Payer: Hawaii Medical Service Association ABD	$17.81
Rate for Payer: Hawaii Medical Service Association Commercial	$16.10
Rate for Payer: Hawaii Medical Service Association Medicare	$73.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$18.70
Rate for Payer: Hawaii Western Management Group Commercial	$12.88
Rate for Payer: Health Management Network Commercial	$124.95
Rate for Payer: Humana Medicare	$73.50
Rate for Payer: Kaiser Permanente Commercial	$132.30
Rate for Payer: Kaiser Permanente Medicaid	$74.97
Rate for Payer: Kaiser Permanente Medicare	$73.50
Rate for Payer: MDX Hawaii PPO	$142.59
Rate for Payer: Ohana Health Plan Medicaid	$73.50
Rate for Payer: Ohana Health Plan Medicare	$73.50
Rate for Payer: UnitedHealthcare Medicaid	$17.81
Rate for Payer: UnitedHealthcare Medicare	$73.50
Rate for Payer: University Health Alliance Commercial	$33.30

Varicella zoster PCR FSI

Facility

$365.00

Service Code	HCPCS 87798
Hospital Charge Code	8118078
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

Know your out-of-pocket cost for care.

All Charges