CMS Price Transparency Data

Tdap vaccine (tetanus, diphtheria, pertussis)

Facility: Samuel Mahelona Memorial Hospital

Billing Code: 90715 (HCPCS)

Factual Cost Summary (Answer Capsule)

CPT Billing Code: 90715
Insurance Median: $149
Cash Discount Price: $184
vs. Medicare Baseline: N/A Medicare

The contracted insurance negotiated median rate for a Tdap vaccine (tetanus, diphtheria, pertussis) at Samuel Mahelona Memorial Hospital is $149. If you are paying out-of-pocket or uninsured, the self-pay cash discount rate is $184. Compared to the federal Medicare reimbursement reference rate of N/A, this hospital’s rate is N/A the Medicare baseline. Located in 4800 Kawaihau Road, Kapaa, HI.

Cash / Self-Pay

$184

Average discount available for prompt cash payment at this facility.

Insurance Median

$149

Median negotiated contract rate across all mapped commercial carriers.

Medicare Reference Rate

N/A

Standard federal government reimbursement rate for this code.

Out-of-Pocket Cost Estimator

Estimate whether it is more economical to use your insurance or pay the upfront self-pay cash rate.

Billing Status

Remaining Deductible ($)

Your Coinsurance Rate (%)

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Commercial Insurance Negotiated Rates

Negotiated contract ranges established by major commercial carriers at this facility.

Carrier / Plan Group	Contract Rate Range	vs. Medicare Reference
Alohacare	$4 - $149	N/A
UnitedHealthcare	$4 - $179	N/A
Ohana Health Plan	$4 - $149	N/A
Hawaii Medical Service Association	$39 - $149	N/A
Devoted Health	$43 - $164	N/A
Kaiser Permanente	$47 - $268	N/A
Hawaii Western Management Group	$47 - $283	N/A
Health Management Network	$94 - $253	N/A
Humana	$142 - $149	N/A
University Health Alliance	$159 - $167	N/A
Mdx Hawaii	$275 - $289	N/A

Self-Pay Upfront Cash Action Plan

Request a "Self-Pay classification" with the billing desk before receiving care.
Ask for a written "Prompt-Pay Discount" agreement quoting the price of $184.
Request and sign a "Waiver of Insurance Submission" to prevent automatic billing.
Verify HCPCS Code matches exactly: 90715.

Insurance In-Network Protection Plan

Contact your insurance company to confirm Samuel Mahelona Memorial Hospital is fully in-network.
Ask your insurer if "Prior Authorization" is required for HCPCS code 90715.
Confirm the specific physician or imaging center is also in-network (not just the hospital building).
Audit your Explanation of Benefits (EOB) against the final itemized hospital invoice.