Samuel Mahelona Memorial Hospital

All Charges

Charge

Type

Setting

Price

AFP4, Quad Screen FSI

Facility

$403.00

Service Code	HCPCS 82105
Hospital Charge Code	8117767
Hospital Revenue Code	300
Min. Negotiated Rate	$342.55
Max. Negotiated Rate	$390.91
Rate for Payer: Cash Price	$261.95
Rate for Payer: Health Management Network Commercial	$342.55
Rate for Payer: Kaiser Permanente Commercial	$362.70
Rate for Payer: MDX Hawaii PPO	$390.91

AFP (Alpha Fetoprotein) Maternal Serum FSI

Facility

$192.00

Service Code	HCPCS 82105
Hospital Charge Code	8117765
Hospital Revenue Code	301
Min. Negotiated Rate	$16.77
Max. Negotiated Rate	$186.24
Rate for Payer: AlohaCare Medicaid	$96.00
Rate for Payer: AlohaCare Medicare	$96.00
Rate for Payer: Cash Price	$124.80
Rate for Payer: Cash Price	$124.80
Rate for Payer: Devoted Health Medicare	$105.60
Rate for Payer: Hawaii Medical Service Association ABD	$23.18
Rate for Payer: Hawaii Medical Service Association Commercial	$20.96
Rate for Payer: Hawaii Medical Service Association Medicare	$96.00
Rate for Payer: Hawaii Medical Service Association Non-ABD	$24.34
Rate for Payer: Hawaii Western Management Group Commercial	$16.77
Rate for Payer: Health Management Network Commercial	$163.20
Rate for Payer: Humana Medicare	$96.00
Rate for Payer: Kaiser Permanente Commercial	$172.80
Rate for Payer: Kaiser Permanente Medicaid	$97.92
Rate for Payer: Kaiser Permanente Medicare	$96.00
Rate for Payer: MDX Hawaii PPO	$186.24
Rate for Payer: Ohana Health Plan Medicaid	$96.00
Rate for Payer: Ohana Health Plan Medicare	$96.00
Rate for Payer: UnitedHealthcare Medicaid	$23.18
Rate for Payer: UnitedHealthcare Medicare	$96.00
Rate for Payer: University Health Alliance Commercial	$43.36

AFP (Alpha Fetoprotein) Maternal Serum FSI

Facility

$192.00

Service Code	HCPCS 82105
Hospital Charge Code	8117765
Hospital Revenue Code	301
Min. Negotiated Rate	$163.20
Max. Negotiated Rate	$186.24
Rate for Payer: Cash Price	$124.80
Rate for Payer: Health Management Network Commercial	$163.20
Rate for Payer: Kaiser Permanente Commercial	$172.80
Rate for Payer: MDX Hawaii PPO	$186.24

AFP, Alphafetoprotein NTD Only FSI

Facility

$192.00

Service Code	HCPCS 82105
Hospital Charge Code	12426505
Hospital Revenue Code	301
Min. Negotiated Rate	$163.20
Max. Negotiated Rate	$186.24
Rate for Payer: Cash Price	$124.80
Rate for Payer: Health Management Network Commercial	$163.20
Rate for Payer: Kaiser Permanente Commercial	$172.80
Rate for Payer: MDX Hawaii PPO	$186.24

AFP, Alphafetoprotein NTD Only FSI

Facility

$192.00

Service Code	HCPCS 82105
Hospital Charge Code	12426505
Hospital Revenue Code	301
Min. Negotiated Rate	$16.77
Max. Negotiated Rate	$186.24
Rate for Payer: AlohaCare Medicaid	$96.00
Rate for Payer: AlohaCare Medicare	$96.00
Rate for Payer: Cash Price	$124.80
Rate for Payer: Cash Price	$124.80
Rate for Payer: Devoted Health Medicare	$105.60
Rate for Payer: Hawaii Medical Service Association ABD	$23.18
Rate for Payer: Hawaii Medical Service Association Commercial	$20.96
Rate for Payer: Hawaii Medical Service Association Medicare	$96.00
Rate for Payer: Hawaii Medical Service Association Non-ABD	$24.34
Rate for Payer: Hawaii Western Management Group Commercial	$16.77
Rate for Payer: Health Management Network Commercial	$163.20
Rate for Payer: Humana Medicare	$96.00
Rate for Payer: Kaiser Permanente Commercial	$172.80
Rate for Payer: Kaiser Permanente Medicaid	$97.92
Rate for Payer: Kaiser Permanente Medicare	$96.00
Rate for Payer: MDX Hawaii PPO	$186.24
Rate for Payer: Ohana Health Plan Medicaid	$96.00
Rate for Payer: Ohana Health Plan Medicare	$96.00
Rate for Payer: UnitedHealthcare Medicaid	$23.18
Rate for Payer: UnitedHealthcare Medicare	$96.00
Rate for Payer: University Health Alliance Commercial	$43.36

AFP Alphafetoprotein Tumor Marker FSI

Facility

$192.00

Service Code	HCPCS 82105
Hospital Charge Code	8117766
Hospital Revenue Code	301
Min. Negotiated Rate	$163.20
Max. Negotiated Rate	$186.24
Rate for Payer: Cash Price	$124.80
Rate for Payer: Health Management Network Commercial	$163.20
Rate for Payer: Kaiser Permanente Commercial	$172.80
Rate for Payer: MDX Hawaii PPO	$186.24

AFP Alphafetoprotein Tumor Marker FSI

Facility

$192.00

Service Code	HCPCS 82105
Hospital Charge Code	8117766
Hospital Revenue Code	301
Min. Negotiated Rate	$16.77
Max. Negotiated Rate	$186.24
Rate for Payer: AlohaCare Medicaid	$96.00
Rate for Payer: AlohaCare Medicare	$96.00
Rate for Payer: Cash Price	$124.80
Rate for Payer: Cash Price	$124.80
Rate for Payer: Devoted Health Medicare	$105.60
Rate for Payer: Hawaii Medical Service Association ABD	$23.18
Rate for Payer: Hawaii Medical Service Association Commercial	$20.96
Rate for Payer: Hawaii Medical Service Association Medicare	$96.00
Rate for Payer: Hawaii Medical Service Association Non-ABD	$24.34
Rate for Payer: Hawaii Western Management Group Commercial	$16.77
Rate for Payer: Health Management Network Commercial	$163.20
Rate for Payer: Humana Medicare	$96.00
Rate for Payer: Kaiser Permanente Commercial	$172.80
Rate for Payer: Kaiser Permanente Medicaid	$97.92
Rate for Payer: Kaiser Permanente Medicare	$96.00
Rate for Payer: MDX Hawaii PPO	$186.24
Rate for Payer: Ohana Health Plan Medicaid	$96.00
Rate for Payer: Ohana Health Plan Medicare	$96.00
Rate for Payer: UnitedHealthcare Medicaid	$23.18
Rate for Payer: UnitedHealthcare Medicare	$96.00
Rate for Payer: University Health Alliance Commercial	$43.36

AFTERCARE, MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH CC

Facility

$16,567.70

Service Code	MSDRG 560
Min. Negotiated Rate	$16,567.70
Max. Negotiated Rate	$16,567.70
Rate for Payer: Hawaii Medical Service Association Commercial	$16,567.70

AFTERCARE, MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH MCC

Facility

$16,567.70

Service Code	MSDRG 559
Min. Negotiated Rate	$16,567.70
Max. Negotiated Rate	$16,567.70
Rate for Payer: Hawaii Medical Service Association Commercial	$16,567.70

AFTERCARE, MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITHOUT CC/MCC

Facility

$16,567.70

Service Code	MSDRG 561
Min. Negotiated Rate	$16,567.70
Max. Negotiated Rate	$16,567.70
Rate for Payer: Hawaii Medical Service Association Commercial	$16,567.70

AFTERCARE WITH CC/MCC

Facility

$17,610.59

Service Code	MSDRG 949
Min. Negotiated Rate	$17,610.59
Max. Negotiated Rate	$17,610.59
Rate for Payer: Hawaii Medical Service Association Commercial	$17,610.59

AFTERCARE WITHOUT CC/MCC

Facility

$5,214.44

Service Code	MSDRG 950
Min. Negotiated Rate	$5,214.44
Max. Negotiated Rate	$5,214.44
Rate for Payer: Hawaii Medical Service Association Commercial	$5,214.44

AICD GENERATOR PROCEDURES

Facility

$77,315.92

Service Code	MSDRG 245
Min. Negotiated Rate	$77,315.92
Max. Negotiated Rate	$77,315.92
Rate for Payer: Hawaii Medical Service Association Commercial	$77,315.92

AICD LEAD PROCEDURES

Facility

$77,315.92

Service Code	MSDRG 265
Min. Negotiated Rate	$77,315.92
Max. Negotiated Rate	$77,315.92
Rate for Payer: Hawaii Medical Service Association Commercial	$77,315.92

AIRWAY LARYNGEAL MASK LMA GASTRO ADULT SIZE 4 CUFFED BLUE/WHITE

Facility

$175.00

Hospital Charge Code	9884519
Hospital Revenue Code	270
Min. Negotiated Rate	$148.75
Max. Negotiated Rate	$169.75
Rate for Payer: Cash Price	$113.75
Rate for Payer: Health Management Network Commercial	$148.75
Rate for Payer: Kaiser Permanente Commercial	$157.50
Rate for Payer: MDX Hawaii PPO	$169.75

AIRWAY LARYNGEAL MASK LMA GASTRO ADULT SIZE 4 CUFFED BLUE/WHITE

Facility

$175.00

Hospital Charge Code	9884519
Hospital Revenue Code	270
Min. Negotiated Rate	$87.50
Max. Negotiated Rate	$169.75
Rate for Payer: AlohaCare Medicaid	$87.50
Rate for Payer: AlohaCare Medicare	$87.50
Rate for Payer: Cash Price	$113.75
Rate for Payer: Devoted Health Medicare	$96.25
Rate for Payer: Hawaii Medical Service Association Medicare	$87.50
Rate for Payer: Hawaii Western Management Group Commercial	$166.25
Rate for Payer: Health Management Network Commercial	$148.75
Rate for Payer: Humana Medicare	$87.50
Rate for Payer: Kaiser Permanente Commercial	$157.50
Rate for Payer: Kaiser Permanente Medicaid	$89.25
Rate for Payer: Kaiser Permanente Medicare	$87.50
Rate for Payer: MDX Hawaii PPO	$169.75
Rate for Payer: Ohana Health Plan Medicaid	$87.50
Rate for Payer: Ohana Health Plan Medicare	$87.50
Rate for Payer: UnitedHealthcare Medicare	$87.50
Rate for Payer: University Health Alliance Commercial	$127.56

AIRWAY LARYNGEAL MASK LMA GASTRO ADULT SIZE 5 CUFFED BLUE/WHITE

Facility

$175.00

Hospital Charge Code	9884520
Hospital Revenue Code	270
Min. Negotiated Rate	$87.50
Max. Negotiated Rate	$169.75
Rate for Payer: AlohaCare Medicaid	$87.50
Rate for Payer: AlohaCare Medicare	$87.50
Rate for Payer: Cash Price	$113.75
Rate for Payer: Devoted Health Medicare	$96.25
Rate for Payer: Hawaii Medical Service Association Medicare	$87.50
Rate for Payer: Hawaii Western Management Group Commercial	$166.25
Rate for Payer: Health Management Network Commercial	$148.75
Rate for Payer: Humana Medicare	$87.50
Rate for Payer: Kaiser Permanente Commercial	$157.50
Rate for Payer: Kaiser Permanente Medicaid	$89.25
Rate for Payer: Kaiser Permanente Medicare	$87.50
Rate for Payer: MDX Hawaii PPO	$169.75
Rate for Payer: Ohana Health Plan Medicaid	$87.50
Rate for Payer: Ohana Health Plan Medicare	$87.50
Rate for Payer: UnitedHealthcare Medicare	$87.50
Rate for Payer: University Health Alliance Commercial	$127.56

AIRWAY LARYNGEAL MASK LMA GASTRO ADULT SIZE 5 CUFFED BLUE/WHITE

Facility

$175.00

Hospital Charge Code	9884520
Hospital Revenue Code	270
Min. Negotiated Rate	$148.75
Max. Negotiated Rate	$169.75
Rate for Payer: Cash Price	$113.75
Rate for Payer: Health Management Network Commercial	$148.75
Rate for Payer: Kaiser Permanente Commercial	$157.50
Rate for Payer: MDX Hawaii PPO	$169.75

Albumin, Body Fluid FSI

Facility

$73.00

Service Code	HCPCS 82042
Hospital Charge Code	8228833
Hospital Revenue Code	301
Min. Negotiated Rate	$7.15
Max. Negotiated Rate	$70.81
Rate for Payer: AlohaCare Medicaid	$36.50
Rate for Payer: AlohaCare Medicare	$36.50
Rate for Payer: Cash Price	$47.45
Rate for Payer: Cash Price	$47.45
Rate for Payer: Devoted Health Medicare	$40.15
Rate for Payer: Hawaii Medical Service Association ABD	$7.15
Rate for Payer: Hawaii Medical Service Association Commercial	$9.72
Rate for Payer: Hawaii Medical Service Association Medicare	$36.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$7.51
Rate for Payer: Hawaii Western Management Group Commercial	$7.78
Rate for Payer: Health Management Network Commercial	$62.05
Rate for Payer: Humana Medicare	$36.50
Rate for Payer: Kaiser Permanente Commercial	$65.70
Rate for Payer: Kaiser Permanente Medicaid	$37.23
Rate for Payer: Kaiser Permanente Medicare	$36.50
Rate for Payer: MDX Hawaii PPO	$70.81
Rate for Payer: Ohana Health Plan Medicaid	$36.50
Rate for Payer: Ohana Health Plan Medicare	$36.50
Rate for Payer: UnitedHealthcare Medicaid	$7.15
Rate for Payer: UnitedHealthcare Medicare	$36.50
Rate for Payer: University Health Alliance Commercial	$13.38

Albumin, Body Fluid FSI

Facility

$73.00

Service Code	HCPCS 82042
Hospital Charge Code	8228833
Hospital Revenue Code	301
Min. Negotiated Rate	$62.05
Max. Negotiated Rate	$70.81
Rate for Payer: Cash Price	$47.45
Rate for Payer: Health Management Network Commercial	$62.05
Rate for Payer: Kaiser Permanente Commercial	$65.70
Rate for Payer: MDX Hawaii PPO	$70.81

Albumin/Creatinine Ratio, Urine FSI

Facility

$98.00

Service Code	HCPCS 82043
Hospital Charge Code	8117769
Hospital Revenue Code	300
Min. Negotiated Rate	$83.30
Max. Negotiated Rate	$95.06
Rate for Payer: Cash Price	$63.70
Rate for Payer: Health Management Network Commercial	$83.30
Rate for Payer: Kaiser Permanente Commercial	$88.20
Rate for Payer: MDX Hawaii PPO	$95.06

Albumin/Creatinine Ratio, Urine FSI

Facility

$98.00

Service Code	HCPCS 82043
Hospital Charge Code	8117769
Hospital Revenue Code	300
Min. Negotiated Rate	$5.78
Max. Negotiated Rate	$95.06
Rate for Payer: AlohaCare Medicaid	$49.00
Rate for Payer: AlohaCare Medicare	$49.00
Rate for Payer: Cash Price	$63.70
Rate for Payer: Cash Price	$63.70
Rate for Payer: Devoted Health Medicare	$53.90
Rate for Payer: Hawaii Medical Service Association ABD	$8.00
Rate for Payer: Hawaii Medical Service Association Commercial	$7.22
Rate for Payer: Hawaii Medical Service Association Medicare	$49.00
Rate for Payer: Hawaii Medical Service Association Non-ABD	$8.40
Rate for Payer: Hawaii Western Management Group Commercial	$5.78
Rate for Payer: Health Management Network Commercial	$83.30
Rate for Payer: Humana Medicare	$49.00
Rate for Payer: Kaiser Permanente Commercial	$88.20
Rate for Payer: Kaiser Permanente Medicaid	$49.98
Rate for Payer: Kaiser Permanente Medicare	$49.00
Rate for Payer: MDX Hawaii PPO	$95.06
Rate for Payer: Ohana Health Plan Medicaid	$49.00
Rate for Payer: Ohana Health Plan Medicare	$49.00
Rate for Payer: UnitedHealthcare Medicaid	$8.00
Rate for Payer: UnitedHealthcare Medicare	$49.00
Rate for Payer: University Health Alliance Commercial	$14.97

Albumin FSI

Facility

$61.00

Service Code	HCPCS 82040
Hospital Charge Code	8117768
Hospital Revenue Code	301
Min. Negotiated Rate	$4.95
Max. Negotiated Rate	$59.17
Rate for Payer: AlohaCare Medicaid	$30.50
Rate for Payer: AlohaCare Medicare	$30.50
Rate for Payer: Cash Price	$39.65
Rate for Payer: Cash Price	$39.65
Rate for Payer: Devoted Health Medicare	$33.55
Rate for Payer: Hawaii Medical Service Association ABD	$6.85
Rate for Payer: Hawaii Medical Service Association Commercial	$6.19
Rate for Payer: Hawaii Medical Service Association Medicare	$30.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$7.19
Rate for Payer: Hawaii Western Management Group Commercial	$4.95
Rate for Payer: Health Management Network Commercial	$51.85
Rate for Payer: Humana Medicare	$30.50
Rate for Payer: Kaiser Permanente Commercial	$54.90
Rate for Payer: Kaiser Permanente Medicaid	$31.11
Rate for Payer: Kaiser Permanente Medicare	$30.50
Rate for Payer: MDX Hawaii PPO	$59.17
Rate for Payer: Ohana Health Plan Medicaid	$30.50
Rate for Payer: Ohana Health Plan Medicare	$30.50
Rate for Payer: UnitedHealthcare Medicaid	$6.85
Rate for Payer: UnitedHealthcare Medicare	$30.50
Rate for Payer: University Health Alliance Commercial	$12.80

Albumin FSI

Facility

$61.00

Service Code	HCPCS 82040
Hospital Charge Code	8117768
Hospital Revenue Code	301
Min. Negotiated Rate	$51.85
Max. Negotiated Rate	$59.17
Rate for Payer: Cash Price	$39.65
Rate for Payer: Health Management Network Commercial	$51.85
Rate for Payer: Kaiser Permanente Commercial	$54.90
Rate for Payer: MDX Hawaii PPO	$59.17

albuterol 2.5mg/3ml neb soln [HHSC]

Facility

$4.45

Service Code	HCPCS J7613
Hospital Charge Code	2500030
Hospital Revenue Code	636
Min. Negotiated Rate	$0.08
Max. Negotiated Rate	$4.32
Rate for Payer: AlohaCare Medicaid	$2.23
Rate for Payer: AlohaCare Medicare	$2.23
Rate for Payer: Cash Price	$2.89
Rate for Payer: Cash Price	$2.89
Rate for Payer: Devoted Health Medicare	$2.45
Rate for Payer: Hawaii Medical Service Association ABD	$0.08
Rate for Payer: Hawaii Medical Service Association Medicare	$2.23
Rate for Payer: Hawaii Medical Service Association Non-ABD	$0.08
Rate for Payer: Hawaii Western Management Group Commercial	$4.23
Rate for Payer: Health Management Network Commercial	$3.78
Rate for Payer: Humana Medicare	$2.23
Rate for Payer: Kaiser Permanente Commercial	$4.00
Rate for Payer: Kaiser Permanente Medicaid	$2.27
Rate for Payer: Kaiser Permanente Medicare	$2.23
Rate for Payer: MDX Hawaii PPO	$4.32
Rate for Payer: Ohana Health Plan Medicaid	$2.23
Rate for Payer: Ohana Health Plan Medicare	$2.23
Rate for Payer: UnitedHealthcare Medicaid	$2.67
Rate for Payer: UnitedHealthcare Medicare	$2.23
Rate for Payer: University Health Alliance Commercial	$3.24

Know your out-of-pocket cost for care.

All Charges