Samuel Mahelona Memorial Hospital

All Charges

Charge

Type

Setting

Price

Varicella zoster PCR FSI

Facility

$365.00

Service Code	HCPCS 87798
Hospital Charge Code	8118078
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

Vasopneumatic Device Charge

Facility

$92.00

Service Code	HCPCS 97016 GP
Hospital Charge Code	8111719
Hospital Revenue Code	420
Min. Negotiated Rate	$78.20
Max. Negotiated Rate	$89.24
Rate for Payer: Cash Price	$59.80
Rate for Payer: Health Management Network Commercial	$78.20
Rate for Payer: Kaiser Permanente Commercial	$82.80
Rate for Payer: MDX Hawaii PPO	$89.24

Vasopneumatic Device Charge

Facility

$92.00

Service Code	HCPCS 97016 GP
Hospital Charge Code	8111719
Hospital Revenue Code	420
Min. Negotiated Rate	$12.49
Max. Negotiated Rate	$89.24
Rate for Payer: AlohaCare Medicaid	$46.00
Rate for Payer: AlohaCare Medicare	$46.00
Rate for Payer: Cash Price	$59.80
Rate for Payer: Cash Price	$59.80
Rate for Payer: Devoted Health Medicare	$50.60
Rate for Payer: Hawaii Medical Service Association Medicare	$46.00
Rate for Payer: Hawaii Western Management Group Commercial	$87.40
Rate for Payer: Health Management Network Commercial	$78.20
Rate for Payer: Humana Medicare	$46.00
Rate for Payer: Kaiser Permanente Commercial	$82.80
Rate for Payer: Kaiser Permanente Medicaid	$46.92
Rate for Payer: Kaiser Permanente Medicare	$46.00
Rate for Payer: MDX Hawaii PPO	$89.24
Rate for Payer: Ohana Health Plan Medicaid	$46.00
Rate for Payer: Ohana Health Plan Medicare	$46.00
Rate for Payer: UnitedHealthcare Medicaid	$12.49
Rate for Payer: UnitedHealthcare Medicare	$46.00
Rate for Payer: University Health Alliance Commercial	$51.52

Vasopneumatic Device Charge

Facility

$92.00

Service Code	HCPCS 97016 GO
Hospital Charge Code	8123852
Hospital Revenue Code	430
Min. Negotiated Rate	$78.20
Max. Negotiated Rate	$89.24
Rate for Payer: Cash Price	$59.80
Rate for Payer: Health Management Network Commercial	$78.20
Rate for Payer: Kaiser Permanente Commercial	$82.80
Rate for Payer: MDX Hawaii PPO	$89.24

Vasopneumatic Device Charge

Facility

$92.00

Service Code	HCPCS 97016 GO
Hospital Charge Code	8123852
Hospital Revenue Code	430
Min. Negotiated Rate	$12.49
Max. Negotiated Rate	$89.24
Rate for Payer: AlohaCare Medicaid	$46.00
Rate for Payer: AlohaCare Medicare	$46.00
Rate for Payer: Cash Price	$59.80
Rate for Payer: Cash Price	$59.80
Rate for Payer: Devoted Health Medicare	$50.60
Rate for Payer: Hawaii Medical Service Association Medicare	$46.00
Rate for Payer: Hawaii Western Management Group Commercial	$87.40
Rate for Payer: Health Management Network Commercial	$78.20
Rate for Payer: Humana Medicare	$46.00
Rate for Payer: Kaiser Permanente Commercial	$82.80
Rate for Payer: Kaiser Permanente Medicaid	$46.92
Rate for Payer: Kaiser Permanente Medicare	$46.00
Rate for Payer: MDX Hawaii PPO	$89.24
Rate for Payer: Ohana Health Plan Medicaid	$46.00
Rate for Payer: Ohana Health Plan Medicare	$46.00
Rate for Payer: UnitedHealthcare Medicaid	$12.49
Rate for Payer: UnitedHealthcare Medicare	$46.00
Rate for Payer: University Health Alliance Commercial	$51.52

vasopressin 20 units/mL vial [HHSC]

Facility

$413.63

Service Code	NDC 55150037024
Hospital Charge Code	2500896
Hospital Revenue Code	250
Min. Negotiated Rate	$351.59
Max. Negotiated Rate	$401.22
Rate for Payer: Cash Price	$268.86
Rate for Payer: Health Management Network Commercial	$351.59
Rate for Payer: Kaiser Permanente Commercial	$372.27
Rate for Payer: MDX Hawaii PPO	$401.22

vasopressin 20 units/mL vial [HHSC]

Facility

$438.69

Service Code	NDC 42023016410
Hospital Charge Code	2500896
Hospital Revenue Code	250
Min. Negotiated Rate	$219.34
Max. Negotiated Rate	$425.53
Rate for Payer: AlohaCare Medicaid	$219.34
Rate for Payer: AlohaCare Medicare	$219.34
Rate for Payer: Cash Price	$285.15
Rate for Payer: Devoted Health Medicare	$241.28
Rate for Payer: Hawaii Medical Service Association Medicare	$219.34
Rate for Payer: Hawaii Western Management Group Commercial	$416.76
Rate for Payer: Health Management Network Commercial	$372.89
Rate for Payer: Humana Medicare	$219.34
Rate for Payer: Kaiser Permanente Commercial	$394.82
Rate for Payer: Kaiser Permanente Medicaid	$223.73
Rate for Payer: Kaiser Permanente Medicare	$219.34
Rate for Payer: MDX Hawaii PPO	$425.53
Rate for Payer: Ohana Health Plan Medicaid	$219.34
Rate for Payer: Ohana Health Plan Medicare	$219.34
Rate for Payer: UnitedHealthcare Medicaid	$263.21
Rate for Payer: UnitedHealthcare Medicare	$219.34
Rate for Payer: University Health Alliance Commercial	$319.76

vasopressin 20 units/mL vial [HHSC]

Facility

$438.69

Service Code	NDC 42023016425
Hospital Charge Code	2500896
Hospital Revenue Code	250
Min. Negotiated Rate	$372.89
Max. Negotiated Rate	$425.53
Rate for Payer: Cash Price	$285.15
Rate for Payer: Health Management Network Commercial	$372.89
Rate for Payer: Kaiser Permanente Commercial	$394.82
Rate for Payer: MDX Hawaii PPO	$425.53

vasopressin 20 units/mL vial [HHSC]

Facility

$438.69

Service Code	NDC 42023016425
Hospital Charge Code	2500896
Hospital Revenue Code	250
Min. Negotiated Rate	$219.34
Max. Negotiated Rate	$425.53
Rate for Payer: AlohaCare Medicaid	$219.34
Rate for Payer: AlohaCare Medicare	$219.34
Rate for Payer: Cash Price	$285.15
Rate for Payer: Devoted Health Medicare	$241.28
Rate for Payer: Hawaii Medical Service Association Medicare	$219.34
Rate for Payer: Hawaii Western Management Group Commercial	$416.76
Rate for Payer: Health Management Network Commercial	$372.89
Rate for Payer: Humana Medicare	$219.34
Rate for Payer: Kaiser Permanente Commercial	$394.82
Rate for Payer: Kaiser Permanente Medicaid	$223.73
Rate for Payer: Kaiser Permanente Medicare	$219.34
Rate for Payer: MDX Hawaii PPO	$425.53
Rate for Payer: Ohana Health Plan Medicaid	$219.34
Rate for Payer: Ohana Health Plan Medicare	$219.34
Rate for Payer: UnitedHealthcare Medicaid	$263.21
Rate for Payer: UnitedHealthcare Medicare	$219.34
Rate for Payer: University Health Alliance Commercial	$319.76

vasopressin 20 units/mL vial [HHSC]

Facility

$413.63

Service Code	NDC 55150037024
Hospital Charge Code	2500896
Hospital Revenue Code	250
Min. Negotiated Rate	$206.81
Max. Negotiated Rate	$401.22
Rate for Payer: AlohaCare Medicaid	$206.81
Rate for Payer: AlohaCare Medicare	$206.81
Rate for Payer: Cash Price	$268.86
Rate for Payer: Devoted Health Medicare	$227.50
Rate for Payer: Hawaii Medical Service Association Medicare	$206.81
Rate for Payer: Hawaii Western Management Group Commercial	$392.95
Rate for Payer: Health Management Network Commercial	$351.59
Rate for Payer: Humana Medicare	$206.81
Rate for Payer: Kaiser Permanente Commercial	$372.27
Rate for Payer: Kaiser Permanente Medicaid	$210.95
Rate for Payer: Kaiser Permanente Medicare	$206.81
Rate for Payer: MDX Hawaii PPO	$401.22
Rate for Payer: Ohana Health Plan Medicaid	$206.81
Rate for Payer: Ohana Health Plan Medicare	$206.81
Rate for Payer: UnitedHealthcare Medicaid	$248.18
Rate for Payer: UnitedHealthcare Medicare	$206.81
Rate for Payer: University Health Alliance Commercial	$301.49

vasopressin 20 units/mL vial [HHSC]

Facility

$438.69

Service Code	NDC 42023016410
Hospital Charge Code	2500896
Hospital Revenue Code	250
Min. Negotiated Rate	$372.89
Max. Negotiated Rate	$425.53
Rate for Payer: Cash Price	$285.15
Rate for Payer: Health Management Network Commercial	$372.89
Rate for Payer: Kaiser Permanente Commercial	$394.82
Rate for Payer: MDX Hawaii PPO	$425.53

vasopressin 20 units/mL vial [HHSC]

Facility

$413.63

Service Code	NDC 55150037025
Hospital Charge Code	2500896
Hospital Revenue Code	250
Min. Negotiated Rate	$206.81
Max. Negotiated Rate	$401.22
Rate for Payer: AlohaCare Medicaid	$206.81
Rate for Payer: AlohaCare Medicare	$206.81
Rate for Payer: Cash Price	$268.86
Rate for Payer: Devoted Health Medicare	$227.50
Rate for Payer: Hawaii Medical Service Association Medicare	$206.81
Rate for Payer: Hawaii Western Management Group Commercial	$392.95
Rate for Payer: Health Management Network Commercial	$351.59
Rate for Payer: Humana Medicare	$206.81
Rate for Payer: Kaiser Permanente Commercial	$372.27
Rate for Payer: Kaiser Permanente Medicaid	$210.95
Rate for Payer: Kaiser Permanente Medicare	$206.81
Rate for Payer: MDX Hawaii PPO	$401.22
Rate for Payer: Ohana Health Plan Medicaid	$206.81
Rate for Payer: Ohana Health Plan Medicare	$206.81
Rate for Payer: UnitedHealthcare Medicaid	$248.18
Rate for Payer: UnitedHealthcare Medicare	$206.81
Rate for Payer: University Health Alliance Commercial	$301.49

vasopressin 20 units/mL vial [HHSC]

Facility

$413.63

Service Code	NDC 55150037025
Hospital Charge Code	2500896
Hospital Revenue Code	250
Min. Negotiated Rate	$351.59
Max. Negotiated Rate	$401.22
Rate for Payer: Cash Price	$268.86
Rate for Payer: Health Management Network Commercial	$351.59
Rate for Payer: Kaiser Permanente Commercial	$372.27
Rate for Payer: MDX Hawaii PPO	$401.22

VDRL, CSF Reflex to Titer FSI

Facility

$57.00

Service Code	HCPCS 86592
Hospital Charge Code	12656212
Hospital Revenue Code	302
Min. Negotiated Rate	$4.27
Max. Negotiated Rate	$55.29
Rate for Payer: AlohaCare Medicaid	$28.50
Rate for Payer: AlohaCare Medicare	$28.50
Rate for Payer: Cash Price	$37.05
Rate for Payer: Cash Price	$37.05
Rate for Payer: Devoted Health Medicare	$31.35
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	$28.50
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	$48.45
Rate for Payer: Humana Medicare	$28.50
Rate for Payer: Kaiser Permanente Commercial	$51.30
Rate for Payer: Kaiser Permanente Medicaid	$29.07
Rate for Payer: Kaiser Permanente Medicare	$28.50
Rate for Payer: MDX Hawaii PPO	$55.29
Rate for Payer: Ohana Health Plan Medicaid	$28.50
Rate for Payer: Ohana Health Plan Medicare	$28.50
Rate for Payer: UnitedHealthcare Medicaid	$5.90
Rate for Payer: UnitedHealthcare Medicare	$28.50
Rate for Payer: University Health Alliance Commercial	$11.03

VDRL, CSF Reflex to Titer FSI

Facility

$57.00

Service Code	HCPCS 86592
Hospital Charge Code	12656212
Hospital Revenue Code	302
Min. Negotiated Rate	$48.45
Max. Negotiated Rate	$55.29
Rate for Payer: Cash Price	$37.05
Rate for Payer: Health Management Network Commercial	$48.45
Rate for Payer: Kaiser Permanente Commercial	$51.30
Rate for Payer: MDX Hawaii PPO	$55.29

VDRL, Serum Reflex Titer FSI

Facility

$89.00

Service Code	HCPCS 86592
Hospital Charge Code	8118081
Hospital Revenue Code	302
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

VDRL, Serum Reflex Titer FSI

Facility

$89.00

Service Code	HCPCS 86592
Hospital Charge Code	8118081
Hospital Revenue Code	302
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

VEIN LIGATION AND STRIPPING

Facility

$32,898.38

Service Code	MSDRG 263
Min. Negotiated Rate	$32,898.38
Max. Negotiated Rate	$32,898.38
Rate for Payer: Hawaii Medical Service Association Commercial	$32,898.38

Venipuncture Nursing Blood Draw

Facility

$10.00

Service Code	HCPCS 36416
Hospital Charge Code	11934636
Hospital Revenue Code	300
Min. Negotiated Rate	$5.00
Max. Negotiated Rate	$9.70
Rate for Payer: AlohaCare Medicaid	$5.00
Rate for Payer: AlohaCare Medicare	$5.00
Rate for Payer: Cash Price	$6.50
Rate for Payer: Devoted Health Medicare	$5.50
Rate for Payer: Hawaii Medical Service Association Medicare	$5.00
Rate for Payer: Hawaii Western Management Group Commercial	$9.50
Rate for Payer: Health Management Network Commercial	$8.50
Rate for Payer: Humana Medicare	$5.00
Rate for Payer: Kaiser Permanente Commercial	$9.00
Rate for Payer: Kaiser Permanente Medicaid	$5.10
Rate for Payer: Kaiser Permanente Medicare	$5.00
Rate for Payer: MDX Hawaii PPO	$9.70
Rate for Payer: Ohana Health Plan Medicaid	$5.00
Rate for Payer: Ohana Health Plan Medicare	$5.00
Rate for Payer: UnitedHealthcare Medicare	$5.00
Rate for Payer: University Health Alliance Commercial	$5.60

Venipuncture Nursing Blood Draw

Facility

$10.00

Service Code	HCPCS 36416
Hospital Charge Code	11934636
Hospital Revenue Code	300
Min. Negotiated Rate	$8.50
Max. Negotiated Rate	$9.70
Rate for Payer: Cash Price	$6.50
Rate for Payer: Health Management Network Commercial	$8.50
Rate for Payer: Kaiser Permanente Commercial	$9.00
Rate for Payer: MDX Hawaii PPO	$9.70

venlafaxine ER 37.5 mg capsule [HHSC]

Facility

$23.15

Service Code	NDC 65862052790
Hospital Charge Code	2500849
Hospital Revenue Code	250
Min. Negotiated Rate	$19.68
Max. Negotiated Rate	$22.46
Rate for Payer: Cash Price	$15.05
Rate for Payer: Health Management Network Commercial	$19.68
Rate for Payer: Kaiser Permanente Commercial	$20.84
Rate for Payer: MDX Hawaii PPO	$22.46

venlafaxine ER 37.5 mg capsule [HHSC]

Facility

$23.15

Service Code	NDC 65862052790
Hospital Charge Code	2500849
Hospital Revenue Code	250
Min. Negotiated Rate	$11.57
Max. Negotiated Rate	$22.46
Rate for Payer: AlohaCare Medicaid	$11.57
Rate for Payer: AlohaCare Medicare	$11.57
Rate for Payer: Cash Price	$15.05
Rate for Payer: Devoted Health Medicare	$12.73
Rate for Payer: Hawaii Medical Service Association Medicare	$11.57
Rate for Payer: Hawaii Western Management Group Commercial	$21.99
Rate for Payer: Health Management Network Commercial	$19.68
Rate for Payer: Humana Medicare	$11.57
Rate for Payer: Kaiser Permanente Commercial	$20.84
Rate for Payer: Kaiser Permanente Medicaid	$11.81
Rate for Payer: Kaiser Permanente Medicare	$11.57
Rate for Payer: MDX Hawaii PPO	$22.46
Rate for Payer: Ohana Health Plan Medicaid	$11.57
Rate for Payer: Ohana Health Plan Medicare	$11.57
Rate for Payer: UnitedHealthcare Medicaid	$13.89
Rate for Payer: UnitedHealthcare Medicare	$11.57
Rate for Payer: University Health Alliance Commercial	$16.87

venlafaxine ER 37.5 mg capsule [HHSC]

Facility

$20.81

Service Code	NDC 68084069801
Hospital Charge Code	2500849
Hospital Revenue Code	250
Min. Negotiated Rate	$10.40
Max. Negotiated Rate	$20.19
Rate for Payer: AlohaCare Medicaid	$10.40
Rate for Payer: AlohaCare Medicare	$10.40
Rate for Payer: Cash Price	$13.53
Rate for Payer: Devoted Health Medicare	$11.45
Rate for Payer: Hawaii Medical Service Association Medicare	$10.40
Rate for Payer: Hawaii Western Management Group Commercial	$19.77
Rate for Payer: Health Management Network Commercial	$17.69
Rate for Payer: Humana Medicare	$10.40
Rate for Payer: Kaiser Permanente Commercial	$18.73
Rate for Payer: Kaiser Permanente Medicaid	$10.61
Rate for Payer: Kaiser Permanente Medicare	$10.40
Rate for Payer: MDX Hawaii PPO	$20.19
Rate for Payer: Ohana Health Plan Medicaid	$10.40
Rate for Payer: Ohana Health Plan Medicare	$10.40
Rate for Payer: UnitedHealthcare Medicaid	$12.49
Rate for Payer: UnitedHealthcare Medicare	$10.40
Rate for Payer: University Health Alliance Commercial	$15.17

venlafaxine ER 37.5 mg capsule [HHSC]

Facility

$20.81

Service Code	NDC 68084069801
Hospital Charge Code	2500849
Hospital Revenue Code	250
Min. Negotiated Rate	$17.69
Max. Negotiated Rate	$20.19
Rate for Payer: Cash Price	$13.53
Rate for Payer: Health Management Network Commercial	$17.69
Rate for Payer: Kaiser Permanente Commercial	$18.73
Rate for Payer: MDX Hawaii PPO	$20.19

venlafaxine ER 75 mg capsule [HHSC]

Facility

$23.33

Service Code	NDC 68084070901
Hospital Charge Code	2500850
Hospital Revenue Code	250
Min. Negotiated Rate	$11.66
Max. Negotiated Rate	$22.63
Rate for Payer: AlohaCare Medicaid	$11.66
Rate for Payer: AlohaCare Medicare	$11.66
Rate for Payer: Cash Price	$15.16
Rate for Payer: Devoted Health Medicare	$12.83
Rate for Payer: Hawaii Medical Service Association Medicare	$11.66
Rate for Payer: Hawaii Western Management Group Commercial	$22.16
Rate for Payer: Health Management Network Commercial	$19.83
Rate for Payer: Humana Medicare	$11.66
Rate for Payer: Kaiser Permanente Commercial	$21.00
Rate for Payer: Kaiser Permanente Medicaid	$11.90
Rate for Payer: Kaiser Permanente Medicare	$11.66
Rate for Payer: MDX Hawaii PPO	$22.63
Rate for Payer: Ohana Health Plan Medicaid	$11.66
Rate for Payer: Ohana Health Plan Medicare	$11.66
Rate for Payer: UnitedHealthcare Medicaid	$14.00
Rate for Payer: UnitedHealthcare Medicare	$11.66
Rate for Payer: University Health Alliance Commercial	$17.01

Know your out-of-pocket cost for care.

All Charges