Samuel Mahelona Memorial Hospital

All Charges

Charge

Type

Setting

Price

venlafaxine ER 75 mg capsule [HHSC]

Facility

$23.33

Service Code	NDC 68084070901
Hospital Charge Code	2500850
Hospital Revenue Code	250
Min. Negotiated Rate	$19.83
Max. Negotiated Rate	$22.63
Rate for Payer: Cash Price	$15.16
Rate for Payer: Health Management Network Commercial	$19.83
Rate for Payer: Kaiser Permanente Commercial	$21.00
Rate for Payer: MDX Hawaii PPO	$22.63

Venous Blood Gas

Facility

$434.00

Service Code	HCPCS 82803
Hospital Charge Code	12516222
Hospital Revenue Code	301
Min. Negotiated Rate	$368.90
Max. Negotiated Rate	$420.98
Rate for Payer: Cash Price	$282.10
Rate for Payer: Health Management Network Commercial	$368.90
Rate for Payer: Kaiser Permanente Commercial	$390.60
Rate for Payer: MDX Hawaii PPO	$420.98

Venous Blood Gas

Facility

$434.00

Service Code	HCPCS 82803
Hospital Charge Code	12516222
Hospital Revenue Code	301
Min. Negotiated Rate	$26.07
Max. Negotiated Rate	$420.98
Rate for Payer: AlohaCare Medicaid	$217.00
Rate for Payer: AlohaCare Medicare	$217.00
Rate for Payer: Cash Price	$282.10
Rate for Payer: Cash Price	$282.10
Rate for Payer: Devoted Health Medicare	$238.70
Rate for Payer: Hawaii Medical Service Association ABD	$26.74
Rate for Payer: Hawaii Medical Service Association Commercial	$32.59
Rate for Payer: Hawaii Medical Service Association Medicare	$217.00
Rate for Payer: Hawaii Medical Service Association Non-ABD	$28.08
Rate for Payer: Hawaii Western Management Group Commercial	$26.07
Rate for Payer: Health Management Network Commercial	$368.90
Rate for Payer: Humana Medicare	$217.00
Rate for Payer: Kaiser Permanente Commercial	$390.60
Rate for Payer: Kaiser Permanente Medicaid	$221.34
Rate for Payer: Kaiser Permanente Medicare	$217.00
Rate for Payer: MDX Hawaii PPO	$420.98
Rate for Payer: Ohana Health Plan Medicaid	$217.00
Rate for Payer: Ohana Health Plan Medicare	$217.00
Rate for Payer: UnitedHealthcare Medicaid	$26.74
Rate for Payer: UnitedHealthcare Medicare	$217.00
Rate for Payer: University Health Alliance Commercial	$50.02

VENT MANAGEMENT IP INITIAL DAY CHARGE

Facility

$2,791.00

Service Code	HCPCS 94002
Hospital Charge Code	8243400
Hospital Revenue Code	410
Min. Negotiated Rate	$2,372.35
Max. Negotiated Rate	$2,707.27
Rate for Payer: Cash Price	$1,814.15
Rate for Payer: Health Management Network Commercial	$2,372.35
Rate for Payer: Kaiser Permanente Commercial	$2,511.90
Rate for Payer: MDX Hawaii PPO	$2,707.27

VENT MANAGEMENT IP INITIAL DAY CHARGE

Facility

$2,791.00

Service Code	HCPCS 94002
Hospital Charge Code	8243400
Hospital Revenue Code	410
Min. Negotiated Rate	$59.64
Max. Negotiated Rate	$2,707.27
Rate for Payer: AlohaCare Medicaid	$1,395.50
Rate for Payer: AlohaCare Medicare	$1,395.50
Rate for Payer: Cash Price	$1,814.15
Rate for Payer: Cash Price	$1,814.15
Rate for Payer: Devoted Health Medicare	$1,535.05
Rate for Payer: Hawaii Medical Service Association Commercial	$788.96
Rate for Payer: Hawaii Medical Service Association Medicare	$1,395.50
Rate for Payer: Hawaii Western Management Group Commercial	$2,651.45
Rate for Payer: Health Management Network Commercial	$2,372.35
Rate for Payer: Humana Medicare	$1,395.50
Rate for Payer: Kaiser Permanente Commercial	$2,511.90
Rate for Payer: Kaiser Permanente Medicaid	$1,423.41
Rate for Payer: Kaiser Permanente Medicare	$1,395.50
Rate for Payer: MDX Hawaii PPO	$2,707.27
Rate for Payer: Ohana Health Plan Medicaid	$1,395.50
Rate for Payer: Ohana Health Plan Medicare	$1,395.50
Rate for Payer: UnitedHealthcare Medicaid	$59.64
Rate for Payer: UnitedHealthcare Medicare	$1,395.50
Rate for Payer: University Health Alliance Commercial	$1,562.96

VENT MANAGEMENT IP SUB DAY CHARGE

Facility

$2,511.00

Service Code	HCPCS 94003
Hospital Charge Code	8243398
Hospital Revenue Code	410
Min. Negotiated Rate	$43.79
Max. Negotiated Rate	$2,435.67
Rate for Payer: AlohaCare Medicaid	$1,255.50
Rate for Payer: AlohaCare Medicare	$1,255.50
Rate for Payer: Cash Price	$1,632.15
Rate for Payer: Cash Price	$1,632.15
Rate for Payer: Devoted Health Medicare	$1,381.05
Rate for Payer: Hawaii Medical Service Association Commercial	$788.96
Rate for Payer: Hawaii Medical Service Association Medicare	$1,255.50
Rate for Payer: Hawaii Western Management Group Commercial	$2,385.45
Rate for Payer: Health Management Network Commercial	$2,134.35
Rate for Payer: Humana Medicare	$1,255.50
Rate for Payer: Kaiser Permanente Commercial	$2,259.90
Rate for Payer: Kaiser Permanente Medicaid	$1,280.61
Rate for Payer: Kaiser Permanente Medicare	$1,255.50
Rate for Payer: MDX Hawaii PPO	$2,435.67
Rate for Payer: Ohana Health Plan Medicaid	$1,255.50
Rate for Payer: Ohana Health Plan Medicare	$1,255.50
Rate for Payer: UnitedHealthcare Medicaid	$43.79
Rate for Payer: UnitedHealthcare Medicare	$1,255.50
Rate for Payer: University Health Alliance Commercial	$1,406.16

VENT MANAGEMENT IP SUB DAY CHARGE

Facility

$2,511.00

Service Code	HCPCS 94003
Hospital Charge Code	8243398
Hospital Revenue Code	410
Min. Negotiated Rate	$2,134.35
Max. Negotiated Rate	$2,435.67
Rate for Payer: Cash Price	$1,632.15
Rate for Payer: Health Management Network Commercial	$2,134.35
Rate for Payer: Kaiser Permanente Commercial	$2,259.90
Rate for Payer: MDX Hawaii PPO	$2,435.67

VENT MGMT SNF PER DAY CHARGE

Facility

$585.00

Service Code	HCPCS 94004
Hospital Charge Code	8282343
Hospital Revenue Code	410
Min. Negotiated Rate	$31.91
Max. Negotiated Rate	$567.45
Rate for Payer: AlohaCare Medicaid	$292.50
Rate for Payer: AlohaCare Medicare	$292.50
Rate for Payer: Cash Price	$380.25
Rate for Payer: Cash Price	$380.25
Rate for Payer: Devoted Health Medicare	$321.75
Rate for Payer: Hawaii Medical Service Association Medicare	$292.50
Rate for Payer: Hawaii Western Management Group Commercial	$555.75
Rate for Payer: Health Management Network Commercial	$497.25
Rate for Payer: Humana Medicare	$292.50
Rate for Payer: Kaiser Permanente Commercial	$526.50
Rate for Payer: Kaiser Permanente Medicaid	$298.35
Rate for Payer: Kaiser Permanente Medicare	$292.50
Rate for Payer: MDX Hawaii PPO	$567.45
Rate for Payer: Ohana Health Plan Medicaid	$292.50
Rate for Payer: Ohana Health Plan Medicare	$292.50
Rate for Payer: UnitedHealthcare Medicaid	$31.91
Rate for Payer: UnitedHealthcare Medicare	$292.50
Rate for Payer: University Health Alliance Commercial	$327.60

VENT MGMT SNF PER DAY CHARGE

Facility

$585.00

Service Code	HCPCS 94004
Hospital Charge Code	8282343
Hospital Revenue Code	410
Min. Negotiated Rate	$497.25
Max. Negotiated Rate	$567.45
Rate for Payer: Cash Price	$380.25
Rate for Payer: Health Management Network Commercial	$497.25
Rate for Payer: Kaiser Permanente Commercial	$526.50
Rate for Payer: MDX Hawaii PPO	$567.45

VENTRALIGHT ST MESH 8X10IN

Facility

$4,131.00

Service Code	HCPCS C1781
Hospital Charge Code	8500796
Hospital Revenue Code	278
Min. Negotiated Rate	$2,065.50
Max. Negotiated Rate	$4,007.07
Rate for Payer: AlohaCare Medicaid	$2,065.50
Rate for Payer: AlohaCare Medicare	$2,065.50
Rate for Payer: Cash Price	$2,685.15
Rate for Payer: Devoted Health Medicare	$2,272.05
Rate for Payer: Hawaii Medical Service Association Medicare	$2,065.50
Rate for Payer: Hawaii Western Management Group Commercial	$2,891.70
Rate for Payer: Health Management Network Commercial	$3,511.35
Rate for Payer: Humana Medicare	$2,065.50
Rate for Payer: Kaiser Permanente Commercial	$3,717.90
Rate for Payer: Kaiser Permanente Medicaid	$2,106.81
Rate for Payer: Kaiser Permanente Medicare	$2,065.50
Rate for Payer: MDX Hawaii PPO	$4,007.07
Rate for Payer: Ohana Health Plan Medicaid	$2,065.50
Rate for Payer: Ohana Health Plan Medicare	$2,065.50
Rate for Payer: UnitedHealthcare Medicare	$2,065.50
Rate for Payer: University Health Alliance Commercial	$2,313.36

VENTRALIGHT ST MESH 8X10IN

Facility

$4,131.00

Service Code	HCPCS C1781
Hospital Charge Code	8500796
Hospital Revenue Code	278
Min. Negotiated Rate	$2,313.36
Max. Negotiated Rate	$4,007.07
Rate for Payer: Cash Price	$2,685.15
Rate for Payer: Hawaii Western Management Group Commercial	$2,891.70
Rate for Payer: Health Management Network Commercial	$3,511.35
Rate for Payer: Kaiser Permanente Commercial	$3,717.90
Rate for Payer: MDX Hawaii PPO	$4,007.07
Rate for Payer: University Health Alliance Commercial	$2,313.36

VENTRICULAR SHUNT PROCEDURES WITH CC

Facility

$53,827.24

Service Code	MSDRG 032
Min. Negotiated Rate	$10,400.00
Max. Negotiated Rate	$53,827.24
Rate for Payer: Hawaii Medical Service Association Commercial	$53,827.24
Rate for Payer: University Health Alliance Commercial	$10,400.00

VENTRICULAR SHUNT PROCEDURES WITH MCC

Facility

$53,827.24

Service Code	MSDRG 031
Min. Negotiated Rate	$10,400.00
Max. Negotiated Rate	$53,827.24
Rate for Payer: Hawaii Medical Service Association Commercial	$53,827.24
Rate for Payer: University Health Alliance Commercial	$10,400.00

VENTRICULAR SHUNT PROCEDURES WITHOUT CC/MCC

Facility

$37,401.76

Service Code	MSDRG 033
Min. Negotiated Rate	$10,400.00
Max. Negotiated Rate	$37,401.76
Rate for Payer: Hawaii Medical Service Association Commercial	$37,401.76
Rate for Payer: University Health Alliance Commercial	$10,400.00

VFC 90697 DTaP/IPV/HIB/HepB (Vaxelis), for intramuscular use

Professional

Both

$0.01

Service Code	HCPCS 90697
Hospital Charge Code	11151460
Hospital Revenue Code	636
Min. Negotiated Rate	$0.01
Max. Negotiated Rate	$0.01
Rate for Payer: Cash Price	$0.01
Rate for Payer: Health Management Network Commercial	$0.01

VFC 90743 Hepatitis B vaccine (HepB), adolescent, 2 dose schedule, for intramuscular use

Professional

Both

$0.01

Service Code	HCPCS 90743
Hospital Charge Code	8180348
Hospital Revenue Code	636
Min. Negotiated Rate	$0.01
Max. Negotiated Rate	$90.18
Rate for Payer: AlohaCare Medicaid	$4.00
Rate for Payer: AlohaCare Medicare	$75.15
Rate for Payer: Cash Price	$0.01
Rate for Payer: Cash Price	$0.01
Rate for Payer: Devoted Health Medicare	$82.67
Rate for Payer: Hawaii Medical Service Association Medicare	$75.15
Rate for Payer: Hawaii Western Management Group Commercial	$64.48
Rate for Payer: Health Management Network Commercial	$0.01
Rate for Payer: Kaiser Permanente Commercial	$90.18
Rate for Payer: Kaiser Permanente Medicaid	$90.18
Rate for Payer: Kaiser Permanente Medicare	$90.18
Rate for Payer: Ohana Health Plan Medicaid	$4.00
Rate for Payer: Ohana Health Plan Medicare	$75.15
Rate for Payer: UnitedHealthcare Medicaid	$4.00
Rate for Payer: UnitedHealthcare Medicare	$75.15

VFC DTAP-IPV-HIB-HEPB VACCINE IM

Professional

Both

$0.01

Service Code	HCPCS 90697
Hospital Charge Code	11029915
Hospital Revenue Code	636
Min. Negotiated Rate	$0.01
Max. Negotiated Rate	$0.01
Rate for Payer: Cash Price	$0.01
Rate for Payer: Health Management Network Commercial	$0.01

VFC RSV Vaccine (Abrysvo) 0.5ml IM Use

Professional

Both

$0.01

Service Code	HCPCS 90678
Hospital Charge Code	11539223
Hospital Revenue Code	636
Min. Negotiated Rate	$0.01
Max. Negotiated Rate	$0.01
Rate for Payer: Cash Price	$0.01
Rate for Payer: Health Management Network Commercial	$0.01

VIRAL ILLNESS WITH MCC

Facility

$24,341.95

Service Code	MSDRG 865
Min. Negotiated Rate	$24,341.95
Max. Negotiated Rate	$24,341.95
Rate for Payer: Hawaii Medical Service Association Commercial	$24,341.95

VIRAL ILLNESS WITHOUT MCC

Facility

$22,825.03

Service Code	MSDRG 866
Min. Negotiated Rate	$22,825.03
Max. Negotiated Rate	$22,825.03
Rate for Payer: Hawaii Medical Service Association Commercial	$22,825.03

VIRAL MENINGITIS WITH CC/MCC

Facility

$14,102.69

Service Code	MSDRG 075
Min. Negotiated Rate	$14,102.69
Max. Negotiated Rate	$14,102.69
Rate for Payer: Hawaii Medical Service Association Commercial	$14,102.69

VIRAL MENINGITIS WITHOUT CC/MCC

Facility

$14,102.69

Service Code	MSDRG 076
Min. Negotiated Rate	$14,102.69
Max. Negotiated Rate	$14,102.69
Rate for Payer: Hawaii Medical Service Association Commercial	$14,102.69

Vision Testing POC

Facility

$26.00

Service Code	HCPCS 99173
Hospital Charge Code	1019784
Hospital Revenue Code	521
Min. Negotiated Rate	$2.42
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 Medicare	$13.00
Rate for Payer: Hawaii Western Management Group Commercial	$24.70
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	$2.42
Rate for Payer: UnitedHealthcare Medicare	$13.00
Rate for Payer: University Health Alliance Commercial	$14.56

Vision Testing POC

Professional

Both

$26.00

Service Code	HCPCS 99173
Hospital Charge Code	1019785
Hospital Revenue Code	521
Min. Negotiated Rate	$8.20
Max. Negotiated Rate	$434.26
Rate for Payer: Cash Price	$16.90
Rate for Payer: Cash Price	$16.90
Rate for Payer: Cash Price	$16.90
Rate for Payer: Hawaii Medical Service Association ABD	$434.26
Rate for Payer: Hawaii Medical Service Association Medicare	$209.49
Rate for Payer: Hawaii Medical Service Association Medicare	$181.39
Rate for Payer: Hawaii Medical Service Association Medicare	$237.64
Rate for Payer: Hawaii Medical Service Association Medicare	$246.64
Rate for Payer: Hawaii Medical Service Association Medicare	$265.97
Rate for Payer: Hawaii Medical Service Association Medicare	$303.73
Rate for Payer: Hawaii Medical Service Association Medicare	$339.46
Rate for Payer: Hawaii Medical Service Association Non-ABD	$434.26
Rate for Payer: Hawaii Western Management Group Commercial	$8.20
Rate for Payer: Health Management Network Commercial	$22.10
Rate for Payer: Kaiser Permanente Commercial	$237.64
Rate for Payer: Kaiser Permanente Commercial	$246.64
Rate for Payer: Kaiser Permanente Commercial	$265.97
Rate for Payer: Kaiser Permanente Commercial	$303.73
Rate for Payer: Kaiser Permanente Commercial	$339.46
Rate for Payer: Kaiser Permanente Commercial	$181.39
Rate for Payer: Kaiser Permanente Commercial	$209.49
Rate for Payer: Kaiser Permanente Medicaid	$434.26
Rate for Payer: Kaiser Permanente Medicare	$181.39
Rate for Payer: Kaiser Permanente Medicare	$209.49
Rate for Payer: Kaiser Permanente Medicare	$237.64
Rate for Payer: Kaiser Permanente Medicare	$246.64
Rate for Payer: Kaiser Permanente Medicare	$265.97
Rate for Payer: Kaiser Permanente Medicare	$303.73
Rate for Payer: Kaiser Permanente Medicare	$339.46
Rate for Payer: UnitedHealthcare Medicaid	$434.26
Rate for Payer: UnitedHealthcare Medicare	$265.97
Rate for Payer: UnitedHealthcare Medicare	$339.46
Rate for Payer: UnitedHealthcare Medicare	$181.39
Rate for Payer: UnitedHealthcare Medicare	$209.49
Rate for Payer: UnitedHealthcare Medicare	$237.64
Rate for Payer: UnitedHealthcare Medicare	$246.64
Rate for Payer: UnitedHealthcare Medicare	$303.73

Vision Testing POC

Facility

$26.00

Service Code	HCPCS 99173
Hospital Charge Code	1019784
Hospital Revenue Code	521
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

Know your out-of-pocket cost for care.

All Charges