Samuel Mahelona Memorial Hospital

All Charges

Charge

Type

Setting

Price

Attended E-Stim Charges

Facility

$112.00

Service Code	HCPCS 97032 GP,CQ
Hospital Charge Code	8111684
Hospital Revenue Code	420
Min. Negotiated Rate	$95.20
Max. Negotiated Rate	$108.64
Rate for Payer: Cash Price	$72.80
Rate for Payer: Health Management Network Commercial	$95.20
Rate for Payer: Kaiser Permanente Commercial	$100.80
Rate for Payer: MDX Hawaii PPO	$108.64

Attended E-Stim Charges

Facility

$112.00

Service Code	HCPCS 97032 GP,CQ
Hospital Charge Code	8123823
Hospital Revenue Code	430
Min. Negotiated Rate	$13.64
Max. Negotiated Rate	$108.64
Rate for Payer: AlohaCare Medicaid	$56.00
Rate for Payer: AlohaCare Medicare	$56.00
Rate for Payer: Cash Price	$72.80
Rate for Payer: Cash Price	$72.80
Rate for Payer: Devoted Health Medicare	$61.60
Rate for Payer: Hawaii Medical Service Association Medicare	$56.00
Rate for Payer: Hawaii Western Management Group Commercial	$106.40
Rate for Payer: Health Management Network Commercial	$95.20
Rate for Payer: Humana Medicare	$56.00
Rate for Payer: Kaiser Permanente Commercial	$100.80
Rate for Payer: Kaiser Permanente Medicaid	$57.12
Rate for Payer: Kaiser Permanente Medicare	$56.00
Rate for Payer: MDX Hawaii PPO	$108.64
Rate for Payer: Ohana Health Plan Medicaid	$56.00
Rate for Payer: Ohana Health Plan Medicare	$56.00
Rate for Payer: UnitedHealthcare Medicaid	$13.64
Rate for Payer: UnitedHealthcare Medicare	$56.00
Rate for Payer: University Health Alliance Commercial	$62.72

Attended E-Stim Charges

Facility

$112.00

Service Code	HCPCS 97032 GP,CQ
Hospital Charge Code	8123823
Hospital Revenue Code	430
Min. Negotiated Rate	$95.20
Max. Negotiated Rate	$108.64
Rate for Payer: Cash Price	$72.80
Rate for Payer: Health Management Network Commercial	$95.20
Rate for Payer: Kaiser Permanente Commercial	$100.80
Rate for Payer: MDX Hawaii PPO	$108.64

Auditory brainstem response - Newborn Hearing Test Type

Facility

$767.00

Service Code	HCPCS 92651
Hospital Charge Code	8347418
Hospital Revenue Code	471
Min. Negotiated Rate	$88.91
Max. Negotiated Rate	$743.99
Rate for Payer: AlohaCare Medicaid	$383.50
Rate for Payer: AlohaCare Medicare	$383.50
Rate for Payer: Cash Price	$498.55
Rate for Payer: Cash Price	$498.55
Rate for Payer: Devoted Health Medicare	$421.85
Rate for Payer: Hawaii Medical Service Association Commercial	$275.75
Rate for Payer: Hawaii Medical Service Association Medicare	$383.50
Rate for Payer: Hawaii Western Management Group Commercial	$728.65
Rate for Payer: Health Management Network Commercial	$651.95
Rate for Payer: Humana Medicare	$383.50
Rate for Payer: Kaiser Permanente Commercial	$690.30
Rate for Payer: Kaiser Permanente Medicaid	$391.17
Rate for Payer: Kaiser Permanente Medicare	$383.50
Rate for Payer: MDX Hawaii PPO	$743.99
Rate for Payer: Ohana Health Plan Medicaid	$383.50
Rate for Payer: Ohana Health Plan Medicare	$383.50
Rate for Payer: UnitedHealthcare Medicaid	$88.91
Rate for Payer: UnitedHealthcare Medicare	$383.50
Rate for Payer: University Health Alliance Commercial	$429.52

Auditory brainstem response - Newborn Hearing Test Type

Facility

$767.00

Service Code	HCPCS 92651
Hospital Charge Code	8347418
Hospital Revenue Code	471
Min. Negotiated Rate	$651.95
Max. Negotiated Rate	$743.99
Rate for Payer: Cash Price	$498.55
Rate for Payer: Health Management Network Commercial	$651.95
Rate for Payer: Kaiser Permanente Commercial	$690.30
Rate for Payer: MDX Hawaii PPO	$743.99

AUTOLOGOUS BONE MARROW TRANSPLANT WITH CC/MCC

Facility

$228,961.32

Service Code	MSDRG 016
Min. Negotiated Rate	$10,400.00
Max. Negotiated Rate	$228,961.32
Rate for Payer: Hawaii Medical Service Association Commercial	$228,961.32
Rate for Payer: University Health Alliance Commercial	$10,400.00

AUTOLOGOUS BONE MARROW TRANSPLANT WITHOUT CC/MCC

Facility

$228,961.32

Service Code	MSDRG 017
Min. Negotiated Rate	$10,400.00
Max. Negotiated Rate	$228,961.32
Rate for Payer: Hawaii Medical Service Association Commercial	$228,961.32
Rate for Payer: University Health Alliance Commercial	$10,400.00

AUTO SUTURE, AUTO EEA 25 MM

Facility

$1,019.00

Hospital Charge Code	8274148
Hospital Revenue Code	272
Min. Negotiated Rate	$866.15
Max. Negotiated Rate	$988.43
Rate for Payer: Cash Price	$662.35
Rate for Payer: Health Management Network Commercial	$866.15
Rate for Payer: Kaiser Permanente Commercial	$917.10
Rate for Payer: MDX Hawaii PPO	$988.43

AUTO SUTURE, AUTO EEA 25 MM

Facility

$1,019.00

Hospital Charge Code	8274148
Hospital Revenue Code	272
Min. Negotiated Rate	$509.50
Max. Negotiated Rate	$988.43
Rate for Payer: AlohaCare Medicaid	$509.50
Rate for Payer: AlohaCare Medicare	$509.50
Rate for Payer: Cash Price	$662.35
Rate for Payer: Devoted Health Medicare	$560.45
Rate for Payer: Hawaii Medical Service Association Medicare	$509.50
Rate for Payer: Hawaii Western Management Group Commercial	$968.05
Rate for Payer: Health Management Network Commercial	$866.15
Rate for Payer: Humana Medicare	$509.50
Rate for Payer: Kaiser Permanente Commercial	$917.10
Rate for Payer: Kaiser Permanente Medicaid	$519.69
Rate for Payer: Kaiser Permanente Medicare	$509.50
Rate for Payer: MDX Hawaii PPO	$988.43
Rate for Payer: Ohana Health Plan Medicaid	$509.50
Rate for Payer: Ohana Health Plan Medicare	$509.50
Rate for Payer: UnitedHealthcare Medicare	$509.50
Rate for Payer: University Health Alliance Commercial	$742.75

AUTO SUTURE, AUTO TA 60; 3.5 MM RELOADABLE STAPLER

Facility

$429.00

Hospital Charge Code	8274205
Hospital Revenue Code	272
Min. Negotiated Rate	$364.65
Max. Negotiated Rate	$416.13
Rate for Payer: Cash Price	$278.85
Rate for Payer: Health Management Network Commercial	$364.65
Rate for Payer: Kaiser Permanente Commercial	$386.10
Rate for Payer: MDX Hawaii PPO	$416.13

AUTO SUTURE, AUTO TA 60; 3.5 MM RELOADABLE STAPLER

Facility

$429.00

Hospital Charge Code	8274205
Hospital Revenue Code	272
Min. Negotiated Rate	$214.50
Max. Negotiated Rate	$416.13
Rate for Payer: AlohaCare Medicaid	$214.50
Rate for Payer: AlohaCare Medicare	$214.50
Rate for Payer: Cash Price	$278.85
Rate for Payer: Devoted Health Medicare	$235.95
Rate for Payer: Hawaii Medical Service Association Medicare	$214.50
Rate for Payer: Hawaii Western Management Group Commercial	$407.55
Rate for Payer: Health Management Network Commercial	$364.65
Rate for Payer: Humana Medicare	$214.50
Rate for Payer: Kaiser Permanente Commercial	$386.10
Rate for Payer: Kaiser Permanente Medicaid	$218.79
Rate for Payer: Kaiser Permanente Medicare	$214.50
Rate for Payer: MDX Hawaii PPO	$416.13
Rate for Payer: Ohana Health Plan Medicaid	$214.50
Rate for Payer: Ohana Health Plan Medicare	$214.50
Rate for Payer: UnitedHealthcare Medicare	$214.50
Rate for Payer: University Health Alliance Commercial	$312.70

AUTO SUTURE, AUTO TA 90; 3.5 MM RELOADABLE STAPLER

Facility

$429.00

Hospital Charge Code	8274206
Hospital Revenue Code	272
Min. Negotiated Rate	$214.50
Max. Negotiated Rate	$416.13
Rate for Payer: AlohaCare Medicaid	$214.50
Rate for Payer: AlohaCare Medicare	$214.50
Rate for Payer: Cash Price	$278.85
Rate for Payer: Devoted Health Medicare	$235.95
Rate for Payer: Hawaii Medical Service Association Medicare	$214.50
Rate for Payer: Hawaii Western Management Group Commercial	$407.55
Rate for Payer: Health Management Network Commercial	$364.65
Rate for Payer: Humana Medicare	$214.50
Rate for Payer: Kaiser Permanente Commercial	$386.10
Rate for Payer: Kaiser Permanente Medicaid	$218.79
Rate for Payer: Kaiser Permanente Medicare	$214.50
Rate for Payer: MDX Hawaii PPO	$416.13
Rate for Payer: Ohana Health Plan Medicaid	$214.50
Rate for Payer: Ohana Health Plan Medicare	$214.50
Rate for Payer: UnitedHealthcare Medicare	$214.50
Rate for Payer: University Health Alliance Commercial	$312.70

AUTO SUTURE, AUTO TA 90; 3.5 MM RELOADABLE STAPLER

Facility

$429.00

Hospital Charge Code	8274206
Hospital Revenue Code	272
Min. Negotiated Rate	$364.65
Max. Negotiated Rate	$416.13
Rate for Payer: Cash Price	$278.85
Rate for Payer: Health Management Network Commercial	$364.65
Rate for Payer: Kaiser Permanente Commercial	$386.10
Rate for Payer: MDX Hawaii PPO	$416.13

AUTO SUTURE GIA 80 RELOADS

Facility

$241.00

Hospital Charge Code	8274219
Hospital Revenue Code	272
Min. Negotiated Rate	$120.50
Max. Negotiated Rate	$233.77
Rate for Payer: AlohaCare Medicaid	$120.50
Rate for Payer: AlohaCare Medicare	$120.50
Rate for Payer: Cash Price	$156.65
Rate for Payer: Devoted Health Medicare	$132.55
Rate for Payer: Hawaii Medical Service Association Medicare	$120.50
Rate for Payer: Hawaii Western Management Group Commercial	$228.95
Rate for Payer: Health Management Network Commercial	$204.85
Rate for Payer: Humana Medicare	$120.50
Rate for Payer: Kaiser Permanente Commercial	$216.90
Rate for Payer: Kaiser Permanente Medicaid	$122.91
Rate for Payer: Kaiser Permanente Medicare	$120.50
Rate for Payer: MDX Hawaii PPO	$233.77
Rate for Payer: Ohana Health Plan Medicaid	$120.50
Rate for Payer: Ohana Health Plan Medicare	$120.50
Rate for Payer: UnitedHealthcare Medicare	$120.50
Rate for Payer: University Health Alliance Commercial	$175.66

AUTO SUTURE GIA 80 RELOADS

Facility

$241.00

Hospital Charge Code	8274219
Hospital Revenue Code	272
Min. Negotiated Rate	$204.85
Max. Negotiated Rate	$233.77
Rate for Payer: Cash Price	$156.65
Rate for Payer: Health Management Network Commercial	$204.85
Rate for Payer: Kaiser Permanente Commercial	$216.90
Rate for Payer: MDX Hawaii PPO	$233.77

AUTO SUTURE GIA 80 STAPLERS

Facility

$650.00

Hospital Charge Code	8274192
Hospital Revenue Code	272
Min. Negotiated Rate	$325.00
Max. Negotiated Rate	$630.50
Rate for Payer: AlohaCare Medicaid	$325.00
Rate for Payer: AlohaCare Medicare	$325.00
Rate for Payer: Cash Price	$422.50
Rate for Payer: Devoted Health Medicare	$357.50
Rate for Payer: Hawaii Medical Service Association Medicare	$325.00
Rate for Payer: Hawaii Western Management Group Commercial	$617.50
Rate for Payer: Health Management Network Commercial	$552.50
Rate for Payer: Humana Medicare	$325.00
Rate for Payer: Kaiser Permanente Commercial	$585.00
Rate for Payer: Kaiser Permanente Medicaid	$331.50
Rate for Payer: Kaiser Permanente Medicare	$325.00
Rate for Payer: MDX Hawaii PPO	$630.50
Rate for Payer: Ohana Health Plan Medicaid	$325.00
Rate for Payer: Ohana Health Plan Medicare	$325.00
Rate for Payer: UnitedHealthcare Medicare	$325.00
Rate for Payer: University Health Alliance Commercial	$473.79

AUTO SUTURE GIA 80 STAPLERS

Facility

$650.00

Hospital Charge Code	8274192
Hospital Revenue Code	272
Min. Negotiated Rate	$552.50
Max. Negotiated Rate	$630.50
Rate for Payer: Cash Price	$422.50
Rate for Payer: Health Management Network Commercial	$552.50
Rate for Payer: Kaiser Permanente Commercial	$585.00
Rate for Payer: MDX Hawaii PPO	$630.50

AUTO SUTURE, LINEAR GIA 60 PREMIUM STAPLER 3.8 DS

Facility

$314.00

Hospital Charge Code	8274207
Hospital Revenue Code	272
Min. Negotiated Rate	$157.00
Max. Negotiated Rate	$304.58
Rate for Payer: AlohaCare Medicaid	$157.00
Rate for Payer: AlohaCare Medicare	$157.00
Rate for Payer: Cash Price	$204.10
Rate for Payer: Devoted Health Medicare	$172.70
Rate for Payer: Hawaii Medical Service Association Medicare	$157.00
Rate for Payer: Hawaii Western Management Group Commercial	$298.30
Rate for Payer: Health Management Network Commercial	$266.90
Rate for Payer: Humana Medicare	$157.00
Rate for Payer: Kaiser Permanente Commercial	$282.60
Rate for Payer: Kaiser Permanente Medicaid	$160.14
Rate for Payer: Kaiser Permanente Medicare	$157.00
Rate for Payer: MDX Hawaii PPO	$304.58
Rate for Payer: Ohana Health Plan Medicaid	$157.00
Rate for Payer: Ohana Health Plan Medicare	$157.00
Rate for Payer: UnitedHealthcare Medicare	$157.00
Rate for Payer: University Health Alliance Commercial	$228.87

AUTO SUTURE, LINEAR GIA 60 PREMIUM STAPLER 3.8 DS

Facility

$314.00

Hospital Charge Code	8274207
Hospital Revenue Code	272
Min. Negotiated Rate	$266.90
Max. Negotiated Rate	$304.58
Rate for Payer: Cash Price	$204.10
Rate for Payer: Health Management Network Commercial	$266.90
Rate for Payer: Kaiser Permanente Commercial	$282.60
Rate for Payer: MDX Hawaii PPO	$304.58

AUTO SUTURE, LINEAR GIA 60 STAPLER RELOADS DS

Facility

$206.00

Hospital Charge Code	8274220
Hospital Revenue Code	272
Min. Negotiated Rate	$175.10
Max. Negotiated Rate	$199.82
Rate for Payer: Cash Price	$133.90
Rate for Payer: Health Management Network Commercial	$175.10
Rate for Payer: Kaiser Permanente Commercial	$185.40
Rate for Payer: MDX Hawaii PPO	$199.82

AUTO SUTURE, LINEAR GIA 60 STAPLER RELOADS DS

Facility

$206.00

Hospital Charge Code	8274220
Hospital Revenue Code	272
Min. Negotiated Rate	$103.00
Max. Negotiated Rate	$199.82
Rate for Payer: AlohaCare Medicaid	$103.00
Rate for Payer: AlohaCare Medicare	$103.00
Rate for Payer: Cash Price	$133.90
Rate for Payer: Devoted Health Medicare	$113.30
Rate for Payer: Hawaii Medical Service Association Medicare	$103.00
Rate for Payer: Hawaii Western Management Group Commercial	$195.70
Rate for Payer: Health Management Network Commercial	$175.10
Rate for Payer: Humana Medicare	$103.00
Rate for Payer: Kaiser Permanente Commercial	$185.40
Rate for Payer: Kaiser Permanente Medicaid	$105.06
Rate for Payer: Kaiser Permanente Medicare	$103.00
Rate for Payer: MDX Hawaii PPO	$199.82
Rate for Payer: Ohana Health Plan Medicaid	$103.00
Rate for Payer: Ohana Health Plan Medicare	$103.00
Rate for Payer: UnitedHealthcare Medicare	$103.00
Rate for Payer: University Health Alliance Commercial	$150.15

AUTO SUTURE, TA 30, 3.5 MM RELOADS

Facility

$202.00

Hospital Charge Code	8274221
Hospital Revenue Code	272
Min. Negotiated Rate	$101.00
Max. Negotiated Rate	$195.94
Rate for Payer: AlohaCare Medicaid	$101.00
Rate for Payer: AlohaCare Medicare	$101.00
Rate for Payer: Cash Price	$131.30
Rate for Payer: Devoted Health Medicare	$111.10
Rate for Payer: Hawaii Medical Service Association Medicare	$101.00
Rate for Payer: Hawaii Western Management Group Commercial	$191.90
Rate for Payer: Health Management Network Commercial	$171.70
Rate for Payer: Humana Medicare	$101.00
Rate for Payer: Kaiser Permanente Commercial	$181.80
Rate for Payer: Kaiser Permanente Medicaid	$103.02
Rate for Payer: Kaiser Permanente Medicare	$101.00
Rate for Payer: MDX Hawaii PPO	$195.94
Rate for Payer: Ohana Health Plan Medicaid	$101.00
Rate for Payer: Ohana Health Plan Medicare	$101.00
Rate for Payer: UnitedHealthcare Medicare	$101.00
Rate for Payer: University Health Alliance Commercial	$147.24

AUTO SUTURE, TA 30, 3.5 MM RELOADS

Facility

$202.00

Hospital Charge Code	8274221
Hospital Revenue Code	272
Min. Negotiated Rate	$171.70
Max. Negotiated Rate	$195.94
Rate for Payer: Cash Price	$131.30
Rate for Payer: Health Management Network Commercial	$171.70
Rate for Payer: Kaiser Permanente Commercial	$181.80
Rate for Payer: MDX Hawaii PPO	$195.94

AUTO SUTURE, TA 60 3.5 MM RELOADS

Facility

$184.00

Hospital Charge Code	8274222
Hospital Revenue Code	272
Min. Negotiated Rate	$156.40
Max. Negotiated Rate	$178.48
Rate for Payer: Cash Price	$119.60
Rate for Payer: Health Management Network Commercial	$156.40
Rate for Payer: Kaiser Permanente Commercial	$165.60
Rate for Payer: MDX Hawaii PPO	$178.48

AUTO SUTURE, TA 60 3.5 MM RELOADS

Facility

$184.00

Hospital Charge Code	8274222
Hospital Revenue Code	272
Min. Negotiated Rate	$92.00
Max. Negotiated Rate	$178.48
Rate for Payer: AlohaCare Medicaid	$92.00
Rate for Payer: AlohaCare Medicare	$92.00
Rate for Payer: Cash Price	$119.60
Rate for Payer: Devoted Health Medicare	$101.20
Rate for Payer: Hawaii Medical Service Association Medicare	$92.00
Rate for Payer: Hawaii Western Management Group Commercial	$174.80
Rate for Payer: Health Management Network Commercial	$156.40
Rate for Payer: Humana Medicare	$92.00
Rate for Payer: Kaiser Permanente Commercial	$165.60
Rate for Payer: Kaiser Permanente Medicaid	$93.84
Rate for Payer: Kaiser Permanente Medicare	$92.00
Rate for Payer: MDX Hawaii PPO	$178.48
Rate for Payer: Ohana Health Plan Medicaid	$92.00
Rate for Payer: Ohana Health Plan Medicare	$92.00
Rate for Payer: UnitedHealthcare Medicare	$92.00
Rate for Payer: University Health Alliance Commercial	$134.12

Know your out-of-pocket cost for care.

All Charges