Samuel Mahelona Memorial Hospital

All Charges

Charge

Type

Setting

Price

ANTI-ROTATION SCREW, 5.0 MM X 80 MM

Facility

$1,600.00

Service Code	HCPCS C1713
Hospital Charge Code	12974039
Hospital Revenue Code	278
Min. Negotiated Rate	$896.00
Max. Negotiated Rate	$1,552.00
Rate for Payer: Cash Price	$1,040.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,120.00
Rate for Payer: Health Management Network Commercial	$1,360.00
Rate for Payer: Kaiser Permanente Commercial	$1,440.00
Rate for Payer: MDX Hawaii PPO	$1,552.00
Rate for Payer: University Health Alliance Commercial	$896.00

ANTI-ROTATION SCREW, 5.0 MM X 80 MM

Facility

$1,600.00

Service Code	HCPCS C1713
Hospital Charge Code	12974039
Hospital Revenue Code	278
Min. Negotiated Rate	$800.00
Max. Negotiated Rate	$1,552.00
Rate for Payer: AlohaCare Medicaid	$800.00
Rate for Payer: AlohaCare Medicare	$800.00
Rate for Payer: Cash Price	$1,040.00
Rate for Payer: Devoted Health Medicare	$880.00
Rate for Payer: Hawaii Medical Service Association Medicare	$800.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,120.00
Rate for Payer: Health Management Network Commercial	$1,360.00
Rate for Payer: Humana Medicare	$800.00
Rate for Payer: Kaiser Permanente Commercial	$1,440.00
Rate for Payer: Kaiser Permanente Medicaid	$816.00
Rate for Payer: Kaiser Permanente Medicare	$800.00
Rate for Payer: MDX Hawaii PPO	$1,552.00
Rate for Payer: Ohana Health Plan Medicaid	$800.00
Rate for Payer: Ohana Health Plan Medicare	$800.00
Rate for Payer: UnitedHealthcare Medicare	$800.00
Rate for Payer: University Health Alliance Commercial	$896.00

ANTI-ROTATION SCREW, 5.0 MM X 85 MM

Facility

$1,600.00

Service Code	HCPCS C1713
Hospital Charge Code	12974037
Hospital Revenue Code	278
Min. Negotiated Rate	$800.00
Max. Negotiated Rate	$1,552.00
Rate for Payer: AlohaCare Medicaid	$800.00
Rate for Payer: AlohaCare Medicare	$800.00
Rate for Payer: Cash Price	$1,040.00
Rate for Payer: Devoted Health Medicare	$880.00
Rate for Payer: Hawaii Medical Service Association Medicare	$800.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,120.00
Rate for Payer: Health Management Network Commercial	$1,360.00
Rate for Payer: Humana Medicare	$800.00
Rate for Payer: Kaiser Permanente Commercial	$1,440.00
Rate for Payer: Kaiser Permanente Medicaid	$816.00
Rate for Payer: Kaiser Permanente Medicare	$800.00
Rate for Payer: MDX Hawaii PPO	$1,552.00
Rate for Payer: Ohana Health Plan Medicaid	$800.00
Rate for Payer: Ohana Health Plan Medicare	$800.00
Rate for Payer: UnitedHealthcare Medicare	$800.00
Rate for Payer: University Health Alliance Commercial	$896.00

ANTI-ROTATION SCREW, 5.0 MM X 85 MM

Facility

$1,600.00

Service Code	HCPCS C1713
Hospital Charge Code	12974037
Hospital Revenue Code	278
Min. Negotiated Rate	$896.00
Max. Negotiated Rate	$1,552.00
Rate for Payer: Cash Price	$1,040.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,120.00
Rate for Payer: Health Management Network Commercial	$1,360.00
Rate for Payer: Kaiser Permanente Commercial	$1,440.00
Rate for Payer: MDX Hawaii PPO	$1,552.00
Rate for Payer: University Health Alliance Commercial	$896.00

ANTI-ROTATION SCREW, 5.0 MM X 90 MM

Facility

$1,600.00

Service Code	HCPCS C1713
Hospital Charge Code	12974038
Hospital Revenue Code	278
Min. Negotiated Rate	$800.00
Max. Negotiated Rate	$1,552.00
Rate for Payer: Kaiser Permanente Medicare	$800.00
Rate for Payer: AlohaCare Medicaid	$800.00
Rate for Payer: AlohaCare Medicare	$800.00
Rate for Payer: Cash Price	$1,040.00
Rate for Payer: Devoted Health Medicare	$880.00
Rate for Payer: Hawaii Medical Service Association Medicare	$800.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,120.00
Rate for Payer: Health Management Network Commercial	$1,360.00
Rate for Payer: Humana Medicare	$800.00
Rate for Payer: Kaiser Permanente Commercial	$1,440.00
Rate for Payer: Kaiser Permanente Medicaid	$816.00
Rate for Payer: MDX Hawaii PPO	$1,552.00
Rate for Payer: Ohana Health Plan Medicaid	$800.00
Rate for Payer: Ohana Health Plan Medicare	$800.00
Rate for Payer: UnitedHealthcare Medicare	$800.00
Rate for Payer: University Health Alliance Commercial	$896.00

ANTI-ROTATION SCREW, 5.0 MM X 90 MM

Facility

$1,600.00

Service Code	HCPCS C1713
Hospital Charge Code	12974038
Hospital Revenue Code	278
Min. Negotiated Rate	$896.00
Max. Negotiated Rate	$1,552.00
Rate for Payer: Cash Price	$1,040.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,120.00
Rate for Payer: Health Management Network Commercial	$1,360.00
Rate for Payer: Kaiser Permanente Commercial	$1,440.00
Rate for Payer: MDX Hawaii PPO	$1,552.00
Rate for Payer: University Health Alliance Commercial	$896.00

ANTI-ROTATION SCREW, 5.0 MM X 95 MM

Facility

$1,600.00

Service Code	HCPCS C1713
Hospital Charge Code	12974040
Hospital Revenue Code	278
Min. Negotiated Rate	$800.00
Max. Negotiated Rate	$1,552.00
Rate for Payer: AlohaCare Medicaid	$800.00
Rate for Payer: AlohaCare Medicare	$800.00
Rate for Payer: Cash Price	$1,040.00
Rate for Payer: Devoted Health Medicare	$880.00
Rate for Payer: Hawaii Medical Service Association Medicare	$800.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,120.00
Rate for Payer: Health Management Network Commercial	$1,360.00
Rate for Payer: Humana Medicare	$800.00
Rate for Payer: Kaiser Permanente Commercial	$1,440.00
Rate for Payer: Kaiser Permanente Medicaid	$816.00
Rate for Payer: Kaiser Permanente Medicare	$800.00
Rate for Payer: MDX Hawaii PPO	$1,552.00
Rate for Payer: Ohana Health Plan Medicaid	$800.00
Rate for Payer: Ohana Health Plan Medicare	$800.00
Rate for Payer: UnitedHealthcare Medicare	$800.00
Rate for Payer: University Health Alliance Commercial	$896.00

ANTI-ROTATION SCREW, 5.0 MM X 95 MM

Facility

$1,600.00

Service Code	HCPCS C1713
Hospital Charge Code	12974040
Hospital Revenue Code	278
Min. Negotiated Rate	$896.00
Max. Negotiated Rate	$1,552.00
Rate for Payer: Cash Price	$1,040.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,120.00
Rate for Payer: Health Management Network Commercial	$1,360.00
Rate for Payer: Kaiser Permanente Commercial	$1,440.00
Rate for Payer: MDX Hawaii PPO	$1,552.00
Rate for Payer: University Health Alliance Commercial	$896.00

ANTI-ROTATION SET SCREW

Facility

$1,453.00

Service Code	HCPCS C1713
Hospital Charge Code	12974042
Hospital Revenue Code	278
Min. Negotiated Rate	$813.68
Max. Negotiated Rate	$1,409.41
Rate for Payer: Cash Price	$944.45
Rate for Payer: Hawaii Western Management Group Commercial	$1,017.10
Rate for Payer: Health Management Network Commercial	$1,235.05
Rate for Payer: Kaiser Permanente Commercial	$1,307.70
Rate for Payer: MDX Hawaii PPO	$1,409.41
Rate for Payer: University Health Alliance Commercial	$813.68

ANTI-ROTATION SET SCREW

Facility

$1,453.00

Service Code	HCPCS C1713
Hospital Charge Code	12974042
Hospital Revenue Code	278
Min. Negotiated Rate	$726.50
Max. Negotiated Rate	$1,409.41
Rate for Payer: AlohaCare Medicaid	$726.50
Rate for Payer: AlohaCare Medicare	$726.50
Rate for Payer: Cash Price	$944.45
Rate for Payer: Devoted Health Medicare	$799.15
Rate for Payer: Hawaii Medical Service Association Medicare	$726.50
Rate for Payer: Hawaii Western Management Group Commercial	$1,017.10
Rate for Payer: Health Management Network Commercial	$1,235.05
Rate for Payer: Humana Medicare	$726.50
Rate for Payer: Kaiser Permanente Commercial	$1,307.70
Rate for Payer: Kaiser Permanente Medicaid	$741.03
Rate for Payer: Kaiser Permanente Medicare	$726.50
Rate for Payer: MDX Hawaii PPO	$1,409.41
Rate for Payer: Ohana Health Plan Medicaid	$726.50
Rate for Payer: Ohana Health Plan Medicare	$726.50
Rate for Payer: UnitedHealthcare Medicare	$726.50
Rate for Payer: University Health Alliance Commercial	$813.68

Anti SARS CoV-2 (COVID-19) Spike FSI

Facility

$143.00

Service Code	HCPCS 86769
Hospital Charge Code	9539263
Hospital Revenue Code	302
Min. Negotiated Rate	$121.55
Max. Negotiated Rate	$138.71
Rate for Payer: Cash Price	$92.95
Rate for Payer: Health Management Network Commercial	$121.55
Rate for Payer: Kaiser Permanente Commercial	$128.70
Rate for Payer: MDX Hawaii PPO	$138.71

Anti SARS CoV-2 (COVID-19) Spike FSI

Facility

$143.00

Service Code	HCPCS 86769
Hospital Charge Code	9539263
Hospital Revenue Code	302
Min. Negotiated Rate	$42.13
Max. Negotiated Rate	$138.71
Rate for Payer: AlohaCare Medicaid	$71.50
Rate for Payer: AlohaCare Medicare	$71.50
Rate for Payer: Cash Price	$92.95
Rate for Payer: Cash Price	$92.95
Rate for Payer: Devoted Health Medicare	$78.65
Rate for Payer: Hawaii Medical Service Association ABD	$42.13
Rate for Payer: Hawaii Medical Service Association Commercial	$52.66
Rate for Payer: Hawaii Medical Service Association Medicare	$71.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$42.13
Rate for Payer: Hawaii Western Management Group Commercial	$42.13
Rate for Payer: Health Management Network Commercial	$121.55
Rate for Payer: Humana Medicare	$71.50
Rate for Payer: Kaiser Permanente Commercial	$128.70
Rate for Payer: Kaiser Permanente Medicaid	$72.93
Rate for Payer: Kaiser Permanente Medicare	$71.50
Rate for Payer: MDX Hawaii PPO	$138.71
Rate for Payer: Ohana Health Plan Medicaid	$71.50
Rate for Payer: Ohana Health Plan Medicare	$71.50
Rate for Payer: UnitedHealthcare Medicaid	$42.13
Rate for Payer: UnitedHealthcare Medicare	$71.50
Rate for Payer: University Health Alliance Commercial	$80.08

Anti-Streptolysin O REF

Facility

$89.00

Service Code	HCPCS 86060
Hospital Charge Code	8159914
Hospital Revenue Code	302
Min. Negotiated Rate	$75.65
Max. Negotiated Rate	$86.33
Rate for Payer: Cash Price	$57.85
Rate for Payer: Health Management Network Commercial	$75.65
Rate for Payer: Kaiser Permanente Commercial	$80.10
Rate for Payer: MDX Hawaii PPO	$86.33

Anti-Streptolysin O REF

Facility

$89.00

Service Code	HCPCS 86060
Hospital Charge Code	8159914
Hospital Revenue Code	302
Min. Negotiated Rate	$7.30
Max. Negotiated Rate	$86.33
Rate for Payer: AlohaCare Medicaid	$44.50
Rate for Payer: AlohaCare Medicare	$44.50
Rate for Payer: Cash Price	$57.85
Rate for Payer: Cash Price	$57.85
Rate for Payer: Devoted Health Medicare	$48.95
Rate for Payer: Hawaii Medical Service Association ABD	$10.09
Rate for Payer: Hawaii Medical Service Association Commercial	$9.12
Rate for Payer: Hawaii Medical Service Association Medicare	$44.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$10.59
Rate for Payer: Hawaii Western Management Group Commercial	$7.30
Rate for Payer: Health Management Network Commercial	$75.65
Rate for Payer: Humana Medicare	$44.50
Rate for Payer: Kaiser Permanente Commercial	$80.10
Rate for Payer: Kaiser Permanente Medicaid	$45.39
Rate for Payer: Kaiser Permanente Medicare	$44.50
Rate for Payer: MDX Hawaii PPO	$86.33
Rate for Payer: Ohana Health Plan Medicaid	$44.50
Rate for Payer: Ohana Health Plan Medicare	$44.50
Rate for Payer: UnitedHealthcare Medicaid	$10.09
Rate for Payer: UnitedHealthcare Medicare	$44.50
Rate for Payer: University Health Alliance Commercial	$18.87

Anti-Thyroglobulin and Anti-Thyroid Peroxidase Antibody FSI

Facility

$183.00

Service Code	HCPCS 86800
Hospital Charge Code	8117851
Hospital Revenue Code	302
Min. Negotiated Rate	$15.91
Max. Negotiated Rate	$177.51
Rate for Payer: AlohaCare Medicaid	$91.50
Rate for Payer: AlohaCare Medicare	$91.50
Rate for Payer: Cash Price	$118.95
Rate for Payer: Cash Price	$118.95
Rate for Payer: Devoted Health Medicare	$100.65
Rate for Payer: Hawaii Medical Service Association ABD	$21.98
Rate for Payer: Hawaii Medical Service Association Commercial	$19.89
Rate for Payer: Hawaii Medical Service Association Medicare	$91.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$23.08
Rate for Payer: Hawaii Western Management Group Commercial	$15.91
Rate for Payer: Health Management Network Commercial	$155.55
Rate for Payer: Humana Medicare	$91.50
Rate for Payer: Kaiser Permanente Commercial	$164.70
Rate for Payer: Kaiser Permanente Medicaid	$93.33
Rate for Payer: Kaiser Permanente Medicare	$91.50
Rate for Payer: MDX Hawaii PPO	$177.51
Rate for Payer: Ohana Health Plan Medicaid	$91.50
Rate for Payer: Ohana Health Plan Medicare	$91.50
Rate for Payer: UnitedHealthcare Medicaid	$21.98
Rate for Payer: UnitedHealthcare Medicare	$91.50
Rate for Payer: University Health Alliance Commercial	$41.11

Anti-Thyroglobulin and Anti-Thyroid Peroxidase Antibody FSI

Facility

$183.00

Service Code	HCPCS 86800
Hospital Charge Code	8117851
Hospital Revenue Code	302
Min. Negotiated Rate	$155.55
Max. Negotiated Rate	$177.51
Rate for Payer: Cash Price	$118.95
Rate for Payer: Health Management Network Commercial	$155.55
Rate for Payer: Kaiser Permanente Commercial	$164.70
Rate for Payer: MDX Hawaii PPO	$177.51

AORTIC AND HEART ASSIST PROCEDURES EXCEPT PULSATION BALLOON WITH MCC

Facility

$111,280.89

Service Code	MSDRG 268
Min. Negotiated Rate	$111,280.89
Max. Negotiated Rate	$111,280.89
Rate for Payer: Hawaii Medical Service Association Commercial	$111,280.89

AORTIC AND HEART ASSIST PROCEDURES EXCEPT PULSATION BALLOON WITHOUT MCC

Facility

$96,040.50

Service Code	MSDRG 269
Min. Negotiated Rate	$96,040.50
Max. Negotiated Rate	$96,040.50
Rate for Payer: Hawaii Medical Service Association Commercial	$96,040.50

Aphasia Assessment Charge

Facility

$591.00

Service Code	HCPCS 96105 GO,CO
Hospital Charge Code	8173988
Hospital Revenue Code	444
Min. Negotiated Rate	$502.35
Max. Negotiated Rate	$573.27
Rate for Payer: Cash Price	$384.15
Rate for Payer: Health Management Network Commercial	$502.35
Rate for Payer: Kaiser Permanente Commercial	$531.90
Rate for Payer: MDX Hawaii PPO	$573.27

Aphasia Assessment Charge

Facility

$591.00

Service Code	HCPCS 96105 GO,CO
Hospital Charge Code	8173988
Hospital Revenue Code	444
Min. Negotiated Rate	$59.90
Max. Negotiated Rate	$573.27
Rate for Payer: AlohaCare Medicaid	$295.50
Rate for Payer: AlohaCare Medicare	$295.50
Rate for Payer: Cash Price	$384.15
Rate for Payer: Cash Price	$384.15
Rate for Payer: Devoted Health Medicare	$325.05
Rate for Payer: Hawaii Medical Service Association Medicare	$295.50
Rate for Payer: Hawaii Western Management Group Commercial	$561.45
Rate for Payer: Health Management Network Commercial	$502.35
Rate for Payer: Humana Medicare	$295.50
Rate for Payer: Kaiser Permanente Commercial	$531.90
Rate for Payer: Kaiser Permanente Medicaid	$301.41
Rate for Payer: Kaiser Permanente Medicare	$295.50
Rate for Payer: MDX Hawaii PPO	$573.27
Rate for Payer: Ohana Health Plan Medicaid	$295.50
Rate for Payer: Ohana Health Plan Medicare	$295.50
Rate for Payer: UnitedHealthcare Medicaid	$59.90
Rate for Payer: UnitedHealthcare Medicare	$295.50
Rate for Payer: University Health Alliance Commercial	$330.96

Aphasia Assessment Charges ST

Facility

$591.00

Service Code	HCPCS 96105 GO,CO
Hospital Charge Code	753733
Hospital Revenue Code	444
Min. Negotiated Rate	$502.35
Max. Negotiated Rate	$573.27
Rate for Payer: Cash Price	$384.15
Rate for Payer: Health Management Network Commercial	$502.35
Rate for Payer: Kaiser Permanente Commercial	$531.90
Rate for Payer: MDX Hawaii PPO	$573.27

Aphasia Assessment Charges ST

Facility

$591.00

Service Code	HCPCS 96105 GO,CO
Hospital Charge Code	753733
Hospital Revenue Code	444
Min. Negotiated Rate	$59.90
Max. Negotiated Rate	$573.27
Rate for Payer: AlohaCare Medicaid	$295.50
Rate for Payer: AlohaCare Medicare	$295.50
Rate for Payer: Cash Price	$384.15
Rate for Payer: Cash Price	$384.15
Rate for Payer: Devoted Health Medicare	$325.05
Rate for Payer: Hawaii Medical Service Association Medicare	$295.50
Rate for Payer: Hawaii Western Management Group Commercial	$561.45
Rate for Payer: Health Management Network Commercial	$502.35
Rate for Payer: Humana Medicare	$295.50
Rate for Payer: Kaiser Permanente Commercial	$531.90
Rate for Payer: Kaiser Permanente Medicaid	$301.41
Rate for Payer: Kaiser Permanente Medicare	$295.50
Rate for Payer: MDX Hawaii PPO	$573.27
Rate for Payer: Ohana Health Plan Medicaid	$295.50
Rate for Payer: Ohana Health Plan Medicare	$295.50
Rate for Payer: UnitedHealthcare Medicaid	$59.90
Rate for Payer: UnitedHealthcare Medicare	$295.50
Rate for Payer: University Health Alliance Commercial	$330.96

apixaban 2.5 mg tablet [HHSC]

Facility

$50.50

Service Code	NDC 00003089331
Hospital Charge Code	2500064
Hospital Revenue Code	250
Min. Negotiated Rate	$42.92
Max. Negotiated Rate	$48.98
Rate for Payer: Cash Price	$32.83
Rate for Payer: Health Management Network Commercial	$42.92
Rate for Payer: Kaiser Permanente Commercial	$45.45
Rate for Payer: MDX Hawaii PPO	$48.98

apixaban 2.5 mg tablet [HHSC]

Facility

$50.50

Service Code	NDC 00003089331
Hospital Charge Code	2500064
Hospital Revenue Code	250
Min. Negotiated Rate	$25.25
Max. Negotiated Rate	$48.98
Rate for Payer: AlohaCare Medicaid	$25.25
Rate for Payer: AlohaCare Medicare	$25.25
Rate for Payer: Cash Price	$32.83
Rate for Payer: Devoted Health Medicare	$27.77
Rate for Payer: Hawaii Medical Service Association Medicare	$25.25
Rate for Payer: Hawaii Western Management Group Commercial	$47.98
Rate for Payer: Health Management Network Commercial	$42.92
Rate for Payer: Humana Medicare	$25.25
Rate for Payer: Kaiser Permanente Commercial	$45.45
Rate for Payer: Kaiser Permanente Medicaid	$25.75
Rate for Payer: Kaiser Permanente Medicare	$25.25
Rate for Payer: MDX Hawaii PPO	$48.98
Rate for Payer: Ohana Health Plan Medicaid	$25.25
Rate for Payer: Ohana Health Plan Medicare	$25.25
Rate for Payer: UnitedHealthcare Medicaid	$30.30
Rate for Payer: UnitedHealthcare Medicare	$25.25
Rate for Payer: University Health Alliance Commercial	$36.81

apixaban 2.5 mg tablet [HHSC]

Facility

$65.03

Service Code	NDC 00003089321
Hospital Charge Code	2500064
Hospital Revenue Code	250
Min. Negotiated Rate	$32.52
Max. Negotiated Rate	$63.08
Rate for Payer: AlohaCare Medicaid	$32.52
Rate for Payer: AlohaCare Medicare	$32.52
Rate for Payer: Cash Price	$42.27
Rate for Payer: Devoted Health Medicare	$35.77
Rate for Payer: Hawaii Medical Service Association Medicare	$32.52
Rate for Payer: Hawaii Western Management Group Commercial	$61.78
Rate for Payer: Health Management Network Commercial	$55.28
Rate for Payer: Humana Medicare	$32.52
Rate for Payer: Kaiser Permanente Commercial	$58.53
Rate for Payer: Kaiser Permanente Medicaid	$33.17
Rate for Payer: Kaiser Permanente Medicare	$32.52
Rate for Payer: MDX Hawaii PPO	$63.08
Rate for Payer: Ohana Health Plan Medicaid	$32.52
Rate for Payer: Ohana Health Plan Medicare	$32.52
Rate for Payer: UnitedHealthcare Medicaid	$39.02
Rate for Payer: UnitedHealthcare Medicare	$32.52
Rate for Payer: University Health Alliance Commercial	$47.40

Know your out-of-pocket cost for care.

All Charges