Samuel Mahelona Memorial Hospital

All Charges

Charge

Type

Setting

Price

ANAL AND STOMAL PROCEDURES WITH CC

Facility

$22,872.43

Service Code	MSDRG 348
Min. Negotiated Rate	$22,872.43
Max. Negotiated Rate	$22,872.43
Rate for Payer: Hawaii Medical Service Association Commercial	$22,872.43

ANAL AND STOMAL PROCEDURES WITH MCC

Facility

$28,513.51

Service Code	MSDRG 347
Min. Negotiated Rate	$28,513.51
Max. Negotiated Rate	$28,513.51
Rate for Payer: Hawaii Medical Service Association Commercial	$28,513.51

ANAL AND STOMAL PROCEDURES WITHOUT CC/MCC

Facility

$14,197.50

Service Code	MSDRG 349
Min. Negotiated Rate	$14,197.50
Max. Negotiated Rate	$14,197.50
Rate for Payer: Hawaii Medical Service Association Commercial	$14,197.50

ANA Screen Rfx Titer FSI

Facility

$173.00

Service Code	HCPCS 86038
Hospital Charge Code	8117841
Hospital Revenue Code	302
Min. Negotiated Rate	$12.09
Max. Negotiated Rate	$167.81
Rate for Payer: AlohaCare Medicaid	$86.50
Rate for Payer: AlohaCare Medicare	$86.50
Rate for Payer: Cash Price	$112.45
Rate for Payer: Cash Price	$112.45
Rate for Payer: Devoted Health Medicare	$95.15
Rate for Payer: Hawaii Medical Service Association ABD	$16.70
Rate for Payer: Hawaii Medical Service Association Commercial	$15.11
Rate for Payer: Hawaii Medical Service Association Medicare	$86.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$17.54
Rate for Payer: Hawaii Western Management Group Commercial	$12.09
Rate for Payer: Health Management Network Commercial	$147.05
Rate for Payer: Humana Medicare	$86.50
Rate for Payer: Kaiser Permanente Commercial	$155.70
Rate for Payer: Kaiser Permanente Medicaid	$88.23
Rate for Payer: Kaiser Permanente Medicare	$86.50
Rate for Payer: MDX Hawaii PPO	$167.81
Rate for Payer: Ohana Health Plan Medicaid	$86.50
Rate for Payer: Ohana Health Plan Medicare	$86.50
Rate for Payer: UnitedHealthcare Medicaid	$16.70
Rate for Payer: UnitedHealthcare Medicare	$86.50
Rate for Payer: University Health Alliance Commercial	$31.25

ANA Screen Rfx Titer FSI

Facility

$173.00

Service Code	HCPCS 86038
Hospital Charge Code	8117841
Hospital Revenue Code	302
Min. Negotiated Rate	$147.05
Max. Negotiated Rate	$167.81
Rate for Payer: Cash Price	$112.45
Rate for Payer: Health Management Network Commercial	$147.05
Rate for Payer: Kaiser Permanente Commercial	$155.70
Rate for Payer: MDX Hawaii PPO	$167.81

ANES ARTHRS HUMERAL H/N STRNCLAV & SHOULDER NOS

Professional

Both

$191.00

Hospital Charge Code	8522126
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

ANES ENDO RETRO CHOLANGIOPANCREATOGRAPHY- 00732

Professional

Both

$400.00

Hospital Charge Code	9365277
Hospital Revenue Code	964
Min. Negotiated Rate	$340.00
Max. Negotiated Rate	$340.00
Rate for Payer: Cash Price	$260.00
Rate for Payer: Health Management Network Commercial	$340.00

ANES NERVE MUSCLE TDN FASCIA&BURSA FOREARM WRIST

Professional

Both

$191.00

Hospital Charge Code	8541860
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

ANES NERVE MUSC TENDON FASCIA&BURSA KNEE&/POPLT

Professional

Both

$191.00

Hospital Charge Code	8802598
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

Anesthesia Closed Procedures Humerus & Elbow

Professional

Both

$191.00

Hospital Charge Code	9560898
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

ANESTHESIA EXTENSIVE SPINE & SPINAL CORD

Professional

Both

$191.00

Hospital Charge Code	9536033
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

ANGINA PECTORIS

Facility

$12,704.27

Service Code	MSDRG 311
Min. Negotiated Rate	$12,704.27
Max. Negotiated Rate	$12,704.27
Rate for Payer: Hawaii Medical Service Association Commercial	$12,704.27

Angiotensin Converting Enzyme ACE FSI

Facility

$166.00

Service Code	HCPCS 82164
Hospital Charge Code	8117842
Hospital Revenue Code	301
Min. Negotiated Rate	$14.60
Max. Negotiated Rate	$161.02
Rate for Payer: AlohaCare Medicaid	$83.00
Rate for Payer: AlohaCare Medicare	$83.00
Rate for Payer: Cash Price	$107.90
Rate for Payer: Cash Price	$107.90
Rate for Payer: Devoted Health Medicare	$91.30
Rate for Payer: Hawaii Medical Service Association ABD	$20.17
Rate for Payer: Hawaii Medical Service Association Commercial	$18.25
Rate for Payer: Hawaii Medical Service Association Medicare	$83.00
Rate for Payer: Hawaii Medical Service Association Non-ABD	$21.18
Rate for Payer: Hawaii Western Management Group Commercial	$14.60
Rate for Payer: Health Management Network Commercial	$141.10
Rate for Payer: Humana Medicare	$83.00
Rate for Payer: Kaiser Permanente Commercial	$149.40
Rate for Payer: Kaiser Permanente Medicaid	$84.66
Rate for Payer: Kaiser Permanente Medicare	$83.00
Rate for Payer: MDX Hawaii PPO	$161.02
Rate for Payer: Ohana Health Plan Medicaid	$83.00
Rate for Payer: Ohana Health Plan Medicare	$83.00
Rate for Payer: UnitedHealthcare Medicaid	$20.17
Rate for Payer: UnitedHealthcare Medicare	$83.00
Rate for Payer: University Health Alliance Commercial	$37.72

Angiotensin Converting Enzyme ACE FSI

Facility

$166.00

Service Code	HCPCS 82164
Hospital Charge Code	8117842
Hospital Revenue Code	301
Min. Negotiated Rate	$141.10
Max. Negotiated Rate	$161.02
Rate for Payer: Cash Price	$107.90
Rate for Payer: Health Management Network Commercial	$141.10
Rate for Payer: Kaiser Permanente Commercial	$149.40
Rate for Payer: MDX Hawaii PPO	$161.02

ANTEGRADE FEMORAL NAIL, LT, 10MM X 30CM

Facility

$4,610.00

Service Code	HCPCS C1713
Hospital Charge Code	12969392
Hospital Revenue Code	278
Min. Negotiated Rate	$2,305.00
Max. Negotiated Rate	$4,471.70
Rate for Payer: AlohaCare Medicaid	$2,305.00
Rate for Payer: AlohaCare Medicare	$2,305.00
Rate for Payer: Cash Price	$2,996.50
Rate for Payer: Devoted Health Medicare	$2,535.50
Rate for Payer: Hawaii Medical Service Association Medicare	$2,305.00
Rate for Payer: Hawaii Western Management Group Commercial	$3,227.00
Rate for Payer: Health Management Network Commercial	$3,918.50
Rate for Payer: Humana Medicare	$2,305.00
Rate for Payer: Kaiser Permanente Commercial	$4,149.00
Rate for Payer: Kaiser Permanente Medicaid	$2,351.10
Rate for Payer: Kaiser Permanente Medicare	$2,305.00
Rate for Payer: MDX Hawaii PPO	$4,471.70
Rate for Payer: Ohana Health Plan Medicaid	$2,305.00
Rate for Payer: Ohana Health Plan Medicare	$2,305.00
Rate for Payer: UnitedHealthcare Medicare	$2,305.00
Rate for Payer: University Health Alliance Commercial	$2,581.60

ANTEGRADE FEMORAL NAIL, LT, 10MM X 30CM

Facility

$4,610.00

Service Code	HCPCS C1713
Hospital Charge Code	12969392
Hospital Revenue Code	278
Min. Negotiated Rate	$2,581.60
Max. Negotiated Rate	$4,471.70
Rate for Payer: Cash Price	$2,996.50
Rate for Payer: Hawaii Western Management Group Commercial	$3,227.00
Rate for Payer: Health Management Network Commercial	$3,918.50
Rate for Payer: Kaiser Permanente Commercial	$4,149.00
Rate for Payer: MDX Hawaii PPO	$4,471.70
Rate for Payer: University Health Alliance Commercial	$2,581.60

ANTEGRADE FEMORAL NAIL, LT, 10MM X 40CM

Facility

$4,610.00

Service Code	HCPCS C1713
Hospital Charge Code	12969401
Hospital Revenue Code	278
Min. Negotiated Rate	$2,305.00
Max. Negotiated Rate	$4,471.70
Rate for Payer: AlohaCare Medicaid	$2,305.00
Rate for Payer: AlohaCare Medicare	$2,305.00
Rate for Payer: Cash Price	$2,996.50
Rate for Payer: Devoted Health Medicare	$2,535.50
Rate for Payer: Hawaii Medical Service Association Medicare	$2,305.00
Rate for Payer: Hawaii Western Management Group Commercial	$3,227.00
Rate for Payer: Health Management Network Commercial	$3,918.50
Rate for Payer: Humana Medicare	$2,305.00
Rate for Payer: Kaiser Permanente Commercial	$4,149.00
Rate for Payer: Kaiser Permanente Medicaid	$2,351.10
Rate for Payer: Kaiser Permanente Medicare	$2,305.00
Rate for Payer: MDX Hawaii PPO	$4,471.70
Rate for Payer: Ohana Health Plan Medicaid	$2,305.00
Rate for Payer: Ohana Health Plan Medicare	$2,305.00
Rate for Payer: UnitedHealthcare Medicare	$2,305.00
Rate for Payer: University Health Alliance Commercial	$2,581.60

ANTEGRADE FEMORAL NAIL, LT, 10MM X 40CM

Facility

$4,610.00

Service Code	HCPCS C1713
Hospital Charge Code	12969401
Hospital Revenue Code	278
Min. Negotiated Rate	$2,581.60
Max. Negotiated Rate	$4,471.70
Rate for Payer: Cash Price	$2,996.50
Rate for Payer: Hawaii Western Management Group Commercial	$3,227.00
Rate for Payer: Health Management Network Commercial	$3,918.50
Rate for Payer: Kaiser Permanente Commercial	$4,149.00
Rate for Payer: MDX Hawaii PPO	$4,471.70
Rate for Payer: University Health Alliance Commercial	$2,581.60

ANTEGRADE FEMORAL NAIL, LT, 10MM X 42CM

Facility

$4,070.00

Service Code	HCPCS C1713
Hospital Charge Code	12969402
Hospital Revenue Code	278
Min. Negotiated Rate	$2,279.20
Max. Negotiated Rate	$3,947.90
Rate for Payer: Cash Price	$2,645.50
Rate for Payer: Hawaii Western Management Group Commercial	$2,849.00
Rate for Payer: Health Management Network Commercial	$3,459.50
Rate for Payer: Kaiser Permanente Commercial	$3,663.00
Rate for Payer: MDX Hawaii PPO	$3,947.90
Rate for Payer: University Health Alliance Commercial	$2,279.20

ANTEGRADE FEMORAL NAIL, LT, 10MM X 42CM

Facility

$4,070.00

Service Code	HCPCS C1713
Hospital Charge Code	12969402
Hospital Revenue Code	278
Min. Negotiated Rate	$2,035.00
Max. Negotiated Rate	$3,947.90
Rate for Payer: AlohaCare Medicaid	$2,035.00
Rate for Payer: AlohaCare Medicare	$2,035.00
Rate for Payer: Cash Price	$2,645.50
Rate for Payer: Devoted Health Medicare	$2,238.50
Rate for Payer: Hawaii Medical Service Association Medicare	$2,035.00
Rate for Payer: Hawaii Western Management Group Commercial	$2,849.00
Rate for Payer: Health Management Network Commercial	$3,459.50
Rate for Payer: Humana Medicare	$2,035.00
Rate for Payer: Kaiser Permanente Commercial	$3,663.00
Rate for Payer: Kaiser Permanente Medicaid	$2,075.70
Rate for Payer: Kaiser Permanente Medicare	$2,035.00
Rate for Payer: MDX Hawaii PPO	$3,947.90
Rate for Payer: Ohana Health Plan Medicaid	$2,035.00
Rate for Payer: Ohana Health Plan Medicare	$2,035.00
Rate for Payer: UnitedHealthcare Medicare	$2,035.00
Rate for Payer: University Health Alliance Commercial	$2,279.20

ANTEGRADE FEMORAL NAIL, LT, 10MM X 44CM

Facility

$4,610.00

Service Code	HCPCS C1713
Hospital Charge Code	12969400
Hospital Revenue Code	278
Min. Negotiated Rate	$2,305.00
Max. Negotiated Rate	$4,471.70
Rate for Payer: AlohaCare Medicaid	$2,305.00
Rate for Payer: AlohaCare Medicare	$2,305.00
Rate for Payer: Cash Price	$2,996.50
Rate for Payer: Devoted Health Medicare	$2,535.50
Rate for Payer: Hawaii Medical Service Association Medicare	$2,305.00
Rate for Payer: Hawaii Western Management Group Commercial	$3,227.00
Rate for Payer: Health Management Network Commercial	$3,918.50
Rate for Payer: Humana Medicare	$2,305.00
Rate for Payer: Kaiser Permanente Commercial	$4,149.00
Rate for Payer: Kaiser Permanente Medicaid	$2,351.10
Rate for Payer: Kaiser Permanente Medicare	$2,305.00
Rate for Payer: MDX Hawaii PPO	$4,471.70
Rate for Payer: Ohana Health Plan Medicaid	$2,305.00
Rate for Payer: Ohana Health Plan Medicare	$2,305.00
Rate for Payer: UnitedHealthcare Medicare	$2,305.00
Rate for Payer: University Health Alliance Commercial	$2,581.60

ANTEGRADE FEMORAL NAIL, LT, 10MM X 44CM

Facility

$4,610.00

Service Code	HCPCS C1713
Hospital Charge Code	12969400
Hospital Revenue Code	278
Min. Negotiated Rate	$2,581.60
Max. Negotiated Rate	$4,471.70
Rate for Payer: Cash Price	$2,996.50
Rate for Payer: Hawaii Western Management Group Commercial	$3,227.00
Rate for Payer: Health Management Network Commercial	$3,918.50
Rate for Payer: Kaiser Permanente Commercial	$4,149.00
Rate for Payer: MDX Hawaii PPO	$4,471.70
Rate for Payer: University Health Alliance Commercial	$2,581.60

ANTEGRADE FEMORAL NAIL, LT, 10MM X 46CM

Facility

$4,070.00

Service Code	HCPCS C1713
Hospital Charge Code	12969403
Hospital Revenue Code	278
Min. Negotiated Rate	$2,279.20
Max. Negotiated Rate	$3,947.90
Rate for Payer: Cash Price	$2,645.50
Rate for Payer: Hawaii Western Management Group Commercial	$2,849.00
Rate for Payer: Health Management Network Commercial	$3,459.50
Rate for Payer: Kaiser Permanente Commercial	$3,663.00
Rate for Payer: MDX Hawaii PPO	$3,947.90
Rate for Payer: University Health Alliance Commercial	$2,279.20

ANTEGRADE FEMORAL NAIL, LT, 10MM X 46CM

Facility

$4,070.00

Service Code	HCPCS C1713
Hospital Charge Code	12969403
Hospital Revenue Code	278
Min. Negotiated Rate	$2,035.00
Max. Negotiated Rate	$3,947.90
Rate for Payer: AlohaCare Medicaid	$2,035.00
Rate for Payer: AlohaCare Medicare	$2,035.00
Rate for Payer: Cash Price	$2,645.50
Rate for Payer: Devoted Health Medicare	$2,238.50
Rate for Payer: Hawaii Medical Service Association Medicare	$2,035.00
Rate for Payer: Hawaii Western Management Group Commercial	$2,849.00
Rate for Payer: Health Management Network Commercial	$3,459.50
Rate for Payer: Humana Medicare	$2,035.00
Rate for Payer: Kaiser Permanente Commercial	$3,663.00
Rate for Payer: Kaiser Permanente Medicaid	$2,075.70
Rate for Payer: Kaiser Permanente Medicare	$2,035.00
Rate for Payer: MDX Hawaii PPO	$3,947.90
Rate for Payer: Ohana Health Plan Medicaid	$2,035.00
Rate for Payer: Ohana Health Plan Medicare	$2,035.00
Rate for Payer: UnitedHealthcare Medicare	$2,035.00
Rate for Payer: University Health Alliance Commercial	$2,279.20

ANTEGRADE FEMORAL NAIL, LT, 11MM X 30CM

Facility

$4,610.00

Service Code	HCPCS C1713
Hospital Charge Code	12969404
Hospital Revenue Code	278
Min. Negotiated Rate	$2,305.00
Max. Negotiated Rate	$4,471.70
Rate for Payer: AlohaCare Medicaid	$2,305.00
Rate for Payer: AlohaCare Medicare	$2,305.00
Rate for Payer: Cash Price	$2,996.50
Rate for Payer: Devoted Health Medicare	$2,535.50
Rate for Payer: Hawaii Medical Service Association Medicare	$2,305.00
Rate for Payer: Hawaii Western Management Group Commercial	$3,227.00
Rate for Payer: Health Management Network Commercial	$3,918.50
Rate for Payer: Humana Medicare	$2,305.00
Rate for Payer: Kaiser Permanente Commercial	$4,149.00
Rate for Payer: Kaiser Permanente Medicaid	$2,351.10
Rate for Payer: Kaiser Permanente Medicare	$2,305.00
Rate for Payer: MDX Hawaii PPO	$4,471.70
Rate for Payer: Ohana Health Plan Medicaid	$2,305.00
Rate for Payer: Ohana Health Plan Medicare	$2,305.00
Rate for Payer: UnitedHealthcare Medicare	$2,305.00
Rate for Payer: University Health Alliance Commercial	$2,581.60

Know your out-of-pocket cost for care.

All Charges