Samuel Mahelona Memorial Hospital

All Charges

Charge

Type

Setting

Price

ACUTE AND SUBACUTE ENDOCARDITIS WITH CC

Facility

$47,996.55

Service Code	MSDRG 289
Min. Negotiated Rate	$47,996.55
Max. Negotiated Rate	$47,996.55
Rate for Payer: Hawaii Medical Service Association Commercial	$47,996.55

ACUTE AND SUBACUTE ENDOCARDITIS WITH MCC

Facility

$47,996.55

Service Code	MSDRG 288
Min. Negotiated Rate	$47,996.55
Max. Negotiated Rate	$47,996.55
Rate for Payer: Hawaii Medical Service Association Commercial	$47,996.55

ACUTE AND SUBACUTE ENDOCARDITIS WITHOUT CC/MCC

Facility

$47,996.55

Service Code	MSDRG 290
Min. Negotiated Rate	$47,996.55
Max. Negotiated Rate	$47,996.55
Rate for Payer: Hawaii Medical Service Association Commercial	$47,996.55

Acute Hepatitis Panel FSI

Facility

$587.00

Service Code	HCPCS 80074
Hospital Charge Code	8117762
Hospital Revenue Code	301
Min. Negotiated Rate	$47.63
Max. Negotiated Rate	$569.39
Rate for Payer: AlohaCare Medicaid	$293.50
Rate for Payer: AlohaCare Medicare	$293.50
Rate for Payer: Cash Price	$381.55
Rate for Payer: Cash Price	$381.55
Rate for Payer: Devoted Health Medicare	$322.85
Rate for Payer: Hawaii Medical Service Association ABD	$65.82
Rate for Payer: Hawaii Medical Service Association Commercial	$59.54
Rate for Payer: Hawaii Medical Service Association Medicare	$293.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$69.11
Rate for Payer: Hawaii Western Management Group Commercial	$47.63
Rate for Payer: Health Management Network Commercial	$498.95
Rate for Payer: Humana Medicare	$293.50
Rate for Payer: Kaiser Permanente Commercial	$528.30
Rate for Payer: Kaiser Permanente Medicaid	$299.37
Rate for Payer: Kaiser Permanente Medicare	$293.50
Rate for Payer: MDX Hawaii PPO	$569.39
Rate for Payer: Ohana Health Plan Medicaid	$293.50
Rate for Payer: Ohana Health Plan Medicare	$293.50
Rate for Payer: UnitedHealthcare Medicaid	$65.82
Rate for Payer: UnitedHealthcare Medicare	$293.50
Rate for Payer: University Health Alliance Commercial	$123.10

Acute Hepatitis Panel FSI

Facility

$587.00

Service Code	HCPCS 80074
Hospital Charge Code	8117762
Hospital Revenue Code	301
Min. Negotiated Rate	$498.95
Max. Negotiated Rate	$569.39
Rate for Payer: Cash Price	$381.55
Rate for Payer: Health Management Network Commercial	$498.95
Rate for Payer: Kaiser Permanente Commercial	$528.30
Rate for Payer: MDX Hawaii PPO	$569.39

ACUTE LEUKEMIA WITH CC

Facility

$139,699.59

Service Code	MSDRG 835
Min. Negotiated Rate	$139,699.59
Max. Negotiated Rate	$139,699.59
Rate for Payer: Hawaii Medical Service Association Commercial	$139,699.59

ACUTE LEUKEMIA WITH MCC

Facility

$139,699.59

Service Code	MSDRG 834
Min. Negotiated Rate	$139,699.59
Max. Negotiated Rate	$139,699.59
Rate for Payer: Hawaii Medical Service Association Commercial	$139,699.59

ACUTE LEUKEMIA WITH OTHER PROCEDURES

Facility

$139,699.59

Service Code	MSDRG 850
Min. Negotiated Rate	$139,699.59
Max. Negotiated Rate	$139,699.59
Rate for Payer: Hawaii Medical Service Association Commercial	$139,699.59

ACUTE LEUKEMIA WITHOUT CC/MCC

Facility

$139,699.59

Service Code	MSDRG 836
Min. Negotiated Rate	$139,699.59
Max. Negotiated Rate	$139,699.59
Rate for Payer: Hawaii Medical Service Association Commercial	$139,699.59

ACUTE MAJOR EYE INFECTIONS WITH CC/MCC

Facility

$9,125.27

Service Code	MSDRG 121
Min. Negotiated Rate	$9,125.27
Max. Negotiated Rate	$9,125.27
Rate for Payer: Hawaii Medical Service Association Commercial	$9,125.27

ACUTE MAJOR EYE INFECTIONS WITHOUT CC/MCC

Facility

$9,125.27

Service Code	MSDRG 122
Min. Negotiated Rate	$9,125.27
Max. Negotiated Rate	$9,125.27
Rate for Payer: Hawaii Medical Service Association Commercial	$9,125.27

ACUTE MYOCARDIAL INFARCTION, DISCHARGED ALIVE WITH CC

Facility

$28,940.14

Service Code	MSDRG 281
Min. Negotiated Rate	$28,940.14
Max. Negotiated Rate	$28,940.14
Rate for Payer: Hawaii Medical Service Association Commercial	$28,940.14

ACUTE MYOCARDIAL INFARCTION, DISCHARGED ALIVE WITH MCC

Facility

$33,467.22

Service Code	MSDRG 280
Min. Negotiated Rate	$33,467.22
Max. Negotiated Rate	$33,467.22
Rate for Payer: Hawaii Medical Service Association Commercial	$33,467.22

ACUTE MYOCARDIAL INFARCTION, DISCHARGED ALIVE WITHOUT CC/MCC

Facility

$25,337.44

Service Code	MSDRG 282
Min. Negotiated Rate	$25,337.44
Max. Negotiated Rate	$25,337.44
Rate for Payer: Hawaii Medical Service Association Commercial	$25,337.44

ACUTE MYOCARDIAL INFARCTION, EXPIRED WITH CC

Facility

$55,913.02

Service Code	MSDRG 284
Min. Negotiated Rate	$55,913.02
Max. Negotiated Rate	$55,913.02
Rate for Payer: Hawaii Medical Service Association Commercial	$55,913.02

ACUTE MYOCARDIAL INFARCTION, EXPIRED WITH MCC

Facility

$55,913.02

Service Code	MSDRG 283
Min. Negotiated Rate	$55,913.02
Max. Negotiated Rate	$55,913.02
Rate for Payer: Hawaii Medical Service Association Commercial	$55,913.02

ACUTE MYOCARDIAL INFARCTION, EXPIRED WITHOUT CC/MCC

Facility

$55,913.02

Service Code	MSDRG 285
Min. Negotiated Rate	$55,913.02
Max. Negotiated Rate	$55,913.02
Rate for Payer: Hawaii Medical Service Association Commercial	$55,913.02

Add-On Anti Smith/Rnp SO FSI

Facility

$205.00

Service Code	HCPCS 86235
Hospital Charge Code	8301511
Hospital Revenue Code	302
Min. Negotiated Rate	$174.25
Max. Negotiated Rate	$198.85
Rate for Payer: Cash Price	$133.25
Rate for Payer: Health Management Network Commercial	$174.25
Rate for Payer: Kaiser Permanente Commercial	$184.50
Rate for Payer: MDX Hawaii PPO	$198.85

Add-On Anti Smith/Rnp SO FSI

Facility

$205.00

Service Code	HCPCS 86235
Hospital Charge Code	8301511
Hospital Revenue Code	302
Min. Negotiated Rate	$17.93
Max. Negotiated Rate	$198.85
Rate for Payer: AlohaCare Medicaid	$102.50
Rate for Payer: AlohaCare Medicare	$102.50
Rate for Payer: Cash Price	$133.25
Rate for Payer: Cash Price	$133.25
Rate for Payer: Devoted Health Medicare	$112.75
Rate for Payer: Hawaii Medical Service Association ABD	$24.78
Rate for Payer: Hawaii Medical Service Association Commercial	$22.41
Rate for Payer: Hawaii Medical Service Association Medicare	$102.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$26.02
Rate for Payer: Hawaii Western Management Group Commercial	$17.93
Rate for Payer: Health Management Network Commercial	$174.25
Rate for Payer: Humana Medicare	$102.50
Rate for Payer: Kaiser Permanente Commercial	$184.50
Rate for Payer: Kaiser Permanente Medicaid	$104.55
Rate for Payer: Kaiser Permanente Medicare	$102.50
Rate for Payer: MDX Hawaii PPO	$198.85
Rate for Payer: Ohana Health Plan Medicaid	$102.50
Rate for Payer: Ohana Health Plan Medicare	$102.50
Rate for Payer: UnitedHealthcare Medicaid	$24.78
Rate for Payer: UnitedHealthcare Medicare	$102.50
Rate for Payer: University Health Alliance Commercial	$46.36

Add-On Bordetella Pertuss Amp Prb FSI

Facility

$365.00

Service Code	HCPCS 87798
Hospital Charge Code	8301524
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

Add-On Bordetella Pertuss Amp Prb FSI

Facility

$365.00

Service Code	HCPCS 87798
Hospital Charge Code	8301524
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

Add-On Cardiolipin Ab IgG FSI

Facility

$174.00

Service Code	HCPCS 86147
Hospital Charge Code	8335809
Hospital Revenue Code	302
Min. Negotiated Rate	$25.45
Max. Negotiated Rate	$168.78
Rate for Payer: AlohaCare Medicaid	$87.00
Rate for Payer: AlohaCare Medicare	$87.00
Rate for Payer: Cash Price	$113.10
Rate for Payer: Cash Price	$113.10
Rate for Payer: Devoted Health Medicare	$95.70
Rate for Payer: Hawaii Medical Service Association ABD	$35.16
Rate for Payer: Hawaii Medical Service Association Commercial	$31.81
Rate for Payer: Hawaii Medical Service Association Medicare	$87.00
Rate for Payer: Hawaii Medical Service Association Non-ABD	$36.92
Rate for Payer: Hawaii Western Management Group Commercial	$25.45
Rate for Payer: Health Management Network Commercial	$147.90
Rate for Payer: Humana Medicare	$87.00
Rate for Payer: Kaiser Permanente Commercial	$156.60
Rate for Payer: Kaiser Permanente Medicaid	$88.74
Rate for Payer: Kaiser Permanente Medicare	$87.00
Rate for Payer: MDX Hawaii PPO	$168.78
Rate for Payer: Ohana Health Plan Medicaid	$87.00
Rate for Payer: Ohana Health Plan Medicare	$87.00
Rate for Payer: UnitedHealthcare Medicaid	$35.16
Rate for Payer: UnitedHealthcare Medicare	$87.00
Rate for Payer: University Health Alliance Commercial	$65.75

Add-On Cardiolipin Ab IgG FSI

Facility

$174.00

Service Code	HCPCS 86147
Hospital Charge Code	8335809
Hospital Revenue Code	302
Min. Negotiated Rate	$147.90
Max. Negotiated Rate	$168.78
Rate for Payer: Cash Price	$113.10
Rate for Payer: Health Management Network Commercial	$147.90
Rate for Payer: Kaiser Permanente Commercial	$156.60
Rate for Payer: MDX Hawaii PPO	$168.78

Add-On C Difficile GDH AG SO FSI

Facility

$245.00

Service Code	HCPCS 87449
Hospital Charge Code	8301508
Hospital Revenue Code	306
Min. Negotiated Rate	$208.25
Max. Negotiated Rate	$237.65
Rate for Payer: Cash Price	$159.25
Rate for Payer: Health Management Network Commercial	$208.25
Rate for Payer: Kaiser Permanente Commercial	$220.50
Rate for Payer: MDX Hawaii PPO	$237.65

Add-On C Difficile GDH AG SO FSI

Facility

$245.00

Service Code	HCPCS 87449
Hospital Charge Code	8301508
Hospital Revenue Code	306
Min. Negotiated Rate	$11.98
Max. Negotiated Rate	$237.65
Rate for Payer: AlohaCare Medicaid	$122.50
Rate for Payer: AlohaCare Medicare	$122.50
Rate for Payer: Cash Price	$159.25
Rate for Payer: Cash Price	$159.25
Rate for Payer: Devoted Health Medicare	$134.75
Rate for Payer: Hawaii Medical Service Association ABD	$16.58
Rate for Payer: Hawaii Medical Service Association Commercial	$14.97
Rate for Payer: Hawaii Medical Service Association Medicare	$122.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$17.41
Rate for Payer: Hawaii Western Management Group Commercial	$11.98
Rate for Payer: Health Management Network Commercial	$208.25
Rate for Payer: Humana Medicare	$122.50
Rate for Payer: Kaiser Permanente Commercial	$220.50
Rate for Payer: Kaiser Permanente Medicaid	$124.95
Rate for Payer: Kaiser Permanente Medicare	$122.50
Rate for Payer: MDX Hawaii PPO	$237.65
Rate for Payer: Ohana Health Plan Medicaid	$122.50
Rate for Payer: Ohana Health Plan Medicare	$122.50
Rate for Payer: UnitedHealthcare Medicaid	$16.58
Rate for Payer: UnitedHealthcare Medicare	$122.50
Rate for Payer: University Health Alliance Commercial	$31.01

Know your out-of-pocket cost for care.

All Charges