Samuel Mahelona Memorial Hospital

All Charges

Charge

Type

Setting

Price

0042T CT BRAIN PERFUSION

Facility

$1,321.00

Service Code	HCPCS 0042T
Hospital Charge Code	10060832
Hospital Revenue Code	975
Min. Negotiated Rate	$660.50
Max. Negotiated Rate	$1,281.37
Rate for Payer: AlohaCare Medicaid	$660.50
Rate for Payer: AlohaCare Medicare	$660.50
Rate for Payer: Cash Price	$858.65
Rate for Payer: Devoted Health Medicare	$726.55
Rate for Payer: Hawaii Medical Service Association Medicare	$660.50
Rate for Payer: Hawaii Western Management Group Commercial	$1,254.95
Rate for Payer: Health Management Network Commercial	$1,122.85
Rate for Payer: Humana Medicare	$660.50
Rate for Payer: Kaiser Permanente Commercial	$1,188.90
Rate for Payer: Kaiser Permanente Medicaid	$673.71
Rate for Payer: Kaiser Permanente Medicare	$660.50
Rate for Payer: MDX Hawaii PPO	$1,281.37
Rate for Payer: Ohana Health Plan Medicaid	$660.50
Rate for Payer: Ohana Health Plan Medicare	$660.50
Rate for Payer: UnitedHealthcare Medicare	$660.50
Rate for Payer: University Health Alliance Commercial	$739.76

0042T CT BRAIN PERFUSION

Facility

$1,321.00

Service Code	HCPCS 0042T
Hospital Charge Code	10060832
Hospital Revenue Code	975
Min. Negotiated Rate	$1,122.85
Max. Negotiated Rate	$1,281.37
Rate for Payer: Cash Price	$858.65
Rate for Payer: Health Management Network Commercial	$1,122.85
Rate for Payer: Kaiser Permanente Commercial	$1,188.90
Rate for Payer: MDX Hawaii PPO	$1,281.37

0042T CT BRAIN PERFUSION - DO NOT USE

Facility

$1,554.00

Service Code	HCPCS 0042T
Hospital Charge Code	10060831
Hospital Revenue Code	975
Min. Negotiated Rate	$777.00
Max. Negotiated Rate	$1,507.38
Rate for Payer: AlohaCare Medicaid	$777.00
Rate for Payer: AlohaCare Medicare	$777.00
Rate for Payer: Cash Price	$1,010.10
Rate for Payer: Devoted Health Medicare	$854.70
Rate for Payer: Hawaii Medical Service Association Medicare	$777.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,476.30
Rate for Payer: Health Management Network Commercial	$1,320.90
Rate for Payer: Humana Medicare	$777.00
Rate for Payer: Kaiser Permanente Commercial	$1,398.60
Rate for Payer: Kaiser Permanente Medicaid	$792.54
Rate for Payer: Kaiser Permanente Medicare	$777.00
Rate for Payer: MDX Hawaii PPO	$1,507.38
Rate for Payer: Ohana Health Plan Medicaid	$777.00
Rate for Payer: Ohana Health Plan Medicare	$777.00
Rate for Payer: UnitedHealthcare Medicare	$777.00
Rate for Payer: University Health Alliance Commercial	$870.24

0042T CT BRAIN PERFUSION - DO NOT USE

Facility

$1,554.00

Service Code	HCPCS 0042T
Hospital Charge Code	10060831
Hospital Revenue Code	975
Min. Negotiated Rate	$1,320.90
Max. Negotiated Rate	$1,507.38
Rate for Payer: Cash Price	$1,010.10
Rate for Payer: Health Management Network Commercial	$1,320.90
Rate for Payer: Kaiser Permanente Commercial	$1,398.60
Rate for Payer: MDX Hawaii PPO	$1,507.38

0071A Pfizer-BioNTech Covid-19 Pediatric Vaccine - Administration - First dose

Professional

Both

$75.00

Service Code	HCPCS 0071A
Hospital Charge Code	9795712
Hospital Revenue Code	771
Min. Negotiated Rate	$63.75
Max. Negotiated Rate	$63.75
Rate for Payer: Cash Price	$48.75
Rate for Payer: Health Management Network Commercial	$63.75

0072A Pfizer-BioNTech Covid-19 Pediatric Vaccine - Administration - Second dose

Professional

Both

$75.00

Service Code	HCPCS 0072A
Hospital Charge Code	9795713
Hospital Revenue Code	771
Min. Negotiated Rate	$63.75
Max. Negotiated Rate	$63.75
Rate for Payer: Cash Price	$48.75
Rate for Payer: Health Management Network Commercial	$63.75

0081A Pfizer Pediatric First Dose

Facility

$134.00

Service Code	HCPCS 0171A
Hospital Charge Code	10656900
Hospital Revenue Code	771
Min. Negotiated Rate	$67.00
Max. Negotiated Rate	$129.98
Rate for Payer: AlohaCare Medicaid	$67.00
Rate for Payer: AlohaCare Medicare	$67.00
Rate for Payer: Cash Price	$87.10
Rate for Payer: Devoted Health Medicare	$73.70
Rate for Payer: Hawaii Medical Service Association Medicare	$67.00
Rate for Payer: Hawaii Western Management Group Commercial	$127.30
Rate for Payer: Health Management Network Commercial	$113.90
Rate for Payer: Humana Medicare	$67.00
Rate for Payer: Kaiser Permanente Commercial	$120.60
Rate for Payer: Kaiser Permanente Medicaid	$68.34
Rate for Payer: Kaiser Permanente Medicare	$67.00
Rate for Payer: MDX Hawaii PPO	$129.98
Rate for Payer: Ohana Health Plan Medicaid	$67.00
Rate for Payer: Ohana Health Plan Medicare	$67.00
Rate for Payer: UnitedHealthcare Medicare	$67.00
Rate for Payer: University Health Alliance Commercial	$75.04

0081A Pfizer Pediatric First Dose

Facility

$134.00

Service Code	HCPCS 0171A
Hospital Charge Code	10656900
Hospital Revenue Code	771
Min. Negotiated Rate	$113.90
Max. Negotiated Rate	$129.98
Rate for Payer: Cash Price	$87.10
Rate for Payer: Health Management Network Commercial	$113.90
Rate for Payer: Kaiser Permanente Commercial	$120.60
Rate for Payer: MDX Hawaii PPO	$129.98

0082A PFIZER COVID VACCINE ADMIN 6M-5YRS, 2ND DOSE

Professional

Both

$75.00

Service Code	HCPCS 0082A
Hospital Charge Code	9929133
Hospital Revenue Code	771
Min. Negotiated Rate	$63.75
Max. Negotiated Rate	$63.75
Rate for Payer: Cash Price	$48.75
Rate for Payer: Health Management Network Commercial	$63.75

0082A Pfizer Pediatric Second Dose

Facility

$134.00

Service Code	HCPCS 0172A
Hospital Charge Code	10655402
Hospital Revenue Code	771
Min. Negotiated Rate	$67.00
Max. Negotiated Rate	$129.98
Rate for Payer: AlohaCare Medicaid	$67.00
Rate for Payer: AlohaCare Medicare	$67.00
Rate for Payer: Cash Price	$87.10
Rate for Payer: Devoted Health Medicare	$73.70
Rate for Payer: Hawaii Medical Service Association Medicare	$67.00
Rate for Payer: Hawaii Western Management Group Commercial	$127.30
Rate for Payer: Health Management Network Commercial	$113.90
Rate for Payer: Humana Medicare	$67.00
Rate for Payer: Kaiser Permanente Commercial	$120.60
Rate for Payer: Kaiser Permanente Medicaid	$68.34
Rate for Payer: Kaiser Permanente Medicare	$67.00
Rate for Payer: MDX Hawaii PPO	$129.98
Rate for Payer: Ohana Health Plan Medicaid	$67.00
Rate for Payer: Ohana Health Plan Medicare	$67.00
Rate for Payer: UnitedHealthcare Medicare	$67.00
Rate for Payer: University Health Alliance Commercial	$75.04

0082A Pfizer Pediatric Second Dose

Facility

$134.00

Service Code	HCPCS 0172A
Hospital Charge Code	10655402
Hospital Revenue Code	771
Min. Negotiated Rate	$113.90
Max. Negotiated Rate	$129.98
Rate for Payer: Cash Price	$87.10
Rate for Payer: Health Management Network Commercial	$113.90
Rate for Payer: Kaiser Permanente Commercial	$120.60
Rate for Payer: MDX Hawaii PPO	$129.98

0083A Pfizer-BioNTech Covid-19 Pediatric Vaccine (6mo - 4yr) Admin - 3rd dose

Professional

Both

$75.00

Service Code	HCPCS 0083A
Hospital Charge Code	10494972
Hospital Revenue Code	771
Min. Negotiated Rate	$63.75
Max. Negotiated Rate	$63.75
Rate for Payer: Cash Price	$48.75
Rate for Payer: Health Management Network Commercial	$63.75

00840 LAPOROSCOPY LOWER ENDOSCOPY ANES PRO FEE

Professional

Both

$191.00

Hospital Charge Code	8759950
Hospital Revenue Code	963
Min. Negotiated Rate	$162.35
Max. Negotiated Rate	$162.35
Rate for Payer: Cash Price	$124.15
Rate for Payer: Health Management Network Commercial	$162.35

01200 Anesthesia for all closed procedures involving hip joint

Professional

Both

$191.00

Hospital Charge Code	13073793
Hospital Revenue Code	963
Min. Negotiated Rate	$162.35
Max. Negotiated Rate	$162.35
Rate for Payer: Cash Price	$124.15
Rate for Payer: Health Management Network Commercial	$162.35

01210-OPN PROC HIP JOINT. ProFee

Professional

Both

$210.00

Hospital Charge Code	11251411
Hospital Revenue Code	975
Min. Negotiated Rate	$178.50
Max. Negotiated Rate	$178.50
Rate for Payer: Cash Price	$136.50
Rate for Payer: Health Management Network Commercial	$178.50

0154A Pfizer-BioNTech Vaccine (5yr-11yr)

Professional

Both

$75.00

Service Code	HCPCS 0154A
Hospital Charge Code	10660833
Hospital Revenue Code	771
Min. Negotiated Rate	$43.32
Max. Negotiated Rate	$63.75
Rate for Payer: AlohaCare Medicaid	$43.32
Rate for Payer: Cash Price	$48.75
Rate for Payer: Cash Price	$48.75
Rate for Payer: Health Management Network Commercial	$63.75
Rate for Payer: Ohana Health Plan Medicaid	$43.32
Rate for Payer: UnitedHealthcare Medicaid	$43.32

0171A -ADM SARSCV2 BVL 3MCG/0.2ML 1

Professional

Both

$160.00

Service Code	HCPCS 0171A
Hospital Charge Code	11617416
Hospital Revenue Code	771
Min. Negotiated Rate	$136.00
Max. Negotiated Rate	$136.00
Rate for Payer: Cash Price	$104.00
Rate for Payer: Health Management Network Commercial	$136.00

0171T Insertion of posterior spinous process distraction device, lumbar; single level

Professional

Both

$2,103.00

Service Code	HCPCS 0171T
Hospital Charge Code	8037046
Hospital Revenue Code	521
Min. Negotiated Rate	$181.39
Max. Negotiated Rate	$1,787.55
Rate for Payer: Kaiser Permanente Medicare	$339.46
Rate for Payer: Cash Price	$1,366.95
Rate for Payer: Cash Price	$1,366.95
Rate for Payer: Cash Price	$1,366.95
Rate for Payer: Hawaii Medical Service Association ABD	$434.26
Rate for Payer: Hawaii Medical Service Association Medicare	$303.73
Rate for Payer: Hawaii Medical Service Association Medicare	$181.39
Rate for Payer: Hawaii Medical Service Association Medicare	$209.49
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	$339.46
Rate for Payer: Hawaii Medical Service Association Non-ABD	$434.26
Rate for Payer: Hawaii Western Management Group Commercial	$788.06
Rate for Payer: Health Management Network Commercial	$1,787.55
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 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 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: UnitedHealthcare Medicaid	$434.26
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	$265.97
Rate for Payer: UnitedHealthcare Medicare	$303.73
Rate for Payer: UnitedHealthcare Medicare	$339.46

0172A- IMM ADMN SARSCOV2 BIVALENT 3 MCG/0.2 ML 2ND

Professional

Both

$160.00

Service Code	HCPCS 0172A
Hospital Charge Code	11616425
Hospital Revenue Code	771
Min. Negotiated Rate	$136.00
Max. Negotiated Rate	$136.00
Rate for Payer: Cash Price	$104.00
Rate for Payer: Health Management Network Commercial	$136.00

0172T Insertion of posterior spinous process distraction device, lumbar; each additional level

Professional

Both

$1,051.00

Service Code	HCPCS 0172T
Hospital Charge Code	8037047
Hospital Revenue Code	521
Min. Negotiated Rate	$181.39
Max. Negotiated Rate	$893.35
Rate for Payer: Cash Price	$683.15
Rate for Payer: Cash Price	$683.15
Rate for Payer: Cash Price	$683.15
Rate for Payer: Hawaii Medical Service Association ABD	$434.26
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	$303.73
Rate for Payer: Hawaii Medical Service Association Medicare	$265.97
Rate for Payer: Hawaii Medical Service Association Medicare	$339.46
Rate for Payer: Hawaii Medical Service Association Medicare	$181.39
Rate for Payer: Hawaii Medical Service Association Medicare	$209.49
Rate for Payer: Hawaii Medical Service Association Non-ABD	$434.26
Rate for Payer: Hawaii Western Management Group Commercial	$393.90
Rate for Payer: Health Management Network Commercial	$893.35
Rate for Payer: Kaiser Permanente Commercial	$265.97
Rate for Payer: Kaiser Permanente Commercial	$181.39
Rate for Payer: Kaiser Permanente Commercial	$209.49
Rate for Payer: Kaiser Permanente Commercial	$237.64
Rate for Payer: Kaiser Permanente Commercial	$246.64
Rate for Payer: Kaiser Permanente Commercial	$303.73
Rate for Payer: Kaiser Permanente Commercial	$339.46
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	$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	$265.97
Rate for Payer: UnitedHealthcare Medicare	$303.73
Rate for Payer: UnitedHealthcare Medicare	$339.46

0173A ADM SARSCV2 BVL 3MCG/0.2ML 3

Professional

Both

$75.00

Service Code	HCPCS 0173A
Hospital Charge Code	10647706
Hospital Revenue Code	771
Min. Negotiated Rate	$63.75
Max. Negotiated Rate	$63.75
Rate for Payer: Cash Price	$48.75
Rate for Payer: Health Management Network Commercial	$63.75

0191T Insertion of anterior segment aqueous drainage device; initial insertion

Professional

Both

$7,406.00

Service Code	HCPCS 66991
Hospital Charge Code	8037048
Hospital Revenue Code	521
Min. Negotiated Rate	$181.39
Max. Negotiated Rate	$6,295.10
Rate for Payer: AlohaCare Medicaid	$716.18
Rate for Payer: AlohaCare Medicare	$607.89
Rate for Payer: Cash Price	$4,813.90
Rate for Payer: Cash Price	$4,813.90
Rate for Payer: Cash Price	$4,813.90
Rate for Payer: Devoted Health Medicare	$668.68
Rate for Payer: Hawaii Medical Service Association ABD	$434.26
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 Medicare	$246.64
Rate for Payer: Hawaii Medical Service Association Medicare	$265.97
Rate for Payer: Hawaii Medical Service Association Medicare	$181.39
Rate for Payer: Hawaii Medical Service Association Medicare	$209.49
Rate for Payer: Hawaii Medical Service Association Medicare	$237.64
Rate for Payer: Hawaii Medical Service Association Non-ABD	$434.26
Rate for Payer: Health Management Network Commercial	$6,295.10
Rate for Payer: Kaiser Permanente Commercial	$237.64
Rate for Payer: Kaiser Permanente Commercial	$729.47
Rate for Payer: Kaiser Permanente Commercial	$181.39
Rate for Payer: Kaiser Permanente Commercial	$209.49
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 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	$265.97
Rate for Payer: Kaiser Permanente Medicare	$303.73
Rate for Payer: Kaiser Permanente Medicare	$339.46
Rate for Payer: Kaiser Permanente Medicare	$246.64
Rate for Payer: Ohana Health Plan Medicaid	$716.18
Rate for Payer: Ohana Health Plan Medicare	$607.89
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

01940 Anesthesia for percutaneous image guided destruction procedures by neurolytic agent on the spi

Professional

Both

$41.00

Hospital Charge Code	9901578
Hospital Revenue Code	963
Min. Negotiated Rate	$34.85
Max. Negotiated Rate	$34.85
Rate for Payer: Cash Price	$26.65
Rate for Payer: Health Management Network Commercial	$34.85

01942 Anesthesia for percutaneos image guilded neuromodulation or intravertebral procedures(eg, kyph

Professional

Both

$191.00

Hospital Charge Code	9901580
Hospital Revenue Code	963
Min. Negotiated Rate	$162.35
Max. Negotiated Rate	$162.35
Rate for Payer: Cash Price	$124.15
Rate for Payer: Health Management Network Commercial	$162.35

0232T Injection(s), Platelet Rich Plasma, any site, including image guidance, harvesting [HHSC]

Professional

Both

$1,365.00

Service Code	HCPCS 0232T
Hospital Charge Code	13000937
Hospital Revenue Code	521
Min. Negotiated Rate	$151.32
Max. Negotiated Rate	$1,160.25
Rate for Payer: Cash Price	$887.25
Rate for Payer: Cash Price	$887.25
Rate for Payer: Cash Price	$887.25
Rate for Payer: Hawaii Medical Service Association ABD	$434.26
Rate for Payer: Hawaii Medical Service Association Medicare	$246.64
Rate for Payer: Hawaii Medical Service Association Medicare	$181.39
Rate for Payer: Hawaii Medical Service Association Medicare	$209.49
Rate for Payer: Hawaii Medical Service Association Medicare	$237.64
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	$151.32
Rate for Payer: Health Management Network Commercial	$1,160.25
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

Know your out-of-pocket cost for care.

All Charges