Samuel Mahelona Memorial Hospital

All Charges

Charge

Type

Setting

Price

Bill Only In Situ Hybridization Add'l

Facility

$320.00

Service Code	HCPCS 88364 TC
Hospital Charge Code	8409284
Hospital Revenue Code	310
Min. Negotiated Rate	$272.00
Max. Negotiated Rate	$310.40
Rate for Payer: Cash Price	$208.00
Rate for Payer: Health Management Network Commercial	$272.00
Rate for Payer: Kaiser Permanente Commercial	$288.00
Rate for Payer: MDX Hawaii PPO	$310.40

Bill Only In Situ Hybridization Add'l

Facility

$320.00

Service Code	HCPCS 88364 TC
Hospital Charge Code	8409284
Hospital Revenue Code	310
Min. Negotiated Rate	$56.73
Max. Negotiated Rate	$310.40
Rate for Payer: AlohaCare Medicaid	$160.00
Rate for Payer: AlohaCare Medicare	$160.00
Rate for Payer: Cash Price	$208.00
Rate for Payer: Cash Price	$208.00
Rate for Payer: Devoted Health Medicare	$176.00
Rate for Payer: Hawaii Medical Service Association ABD	$113.46
Rate for Payer: Hawaii Medical Service Association Medicare	$160.00
Rate for Payer: Hawaii Medical Service Association Non-ABD	$56.73
Rate for Payer: Hawaii Western Management Group Commercial	$304.00
Rate for Payer: Health Management Network Commercial	$272.00
Rate for Payer: Humana Medicare	$160.00
Rate for Payer: Kaiser Permanente Commercial	$288.00
Rate for Payer: Kaiser Permanente Medicaid	$163.20
Rate for Payer: Kaiser Permanente Medicare	$160.00
Rate for Payer: MDX Hawaii PPO	$310.40
Rate for Payer: Ohana Health Plan Medicaid	$160.00
Rate for Payer: Ohana Health Plan Medicare	$160.00
Rate for Payer: UnitedHealthcare Medicaid	$89.48
Rate for Payer: UnitedHealthcare Medicare	$160.00
Rate for Payer: University Health Alliance Commercial	$150.48

Bill Only Iron Liver Tissue

Facility

$171.00

Service Code	HCPCS 83540
Hospital Charge Code	8409270
Hospital Revenue Code	301
Min. Negotiated Rate	$6.47
Max. Negotiated Rate	$165.87
Rate for Payer: AlohaCare Medicaid	$85.50
Rate for Payer: AlohaCare Medicare	$85.50
Rate for Payer: Cash Price	$111.15
Rate for Payer: Cash Price	$111.15
Rate for Payer: Devoted Health Medicare	$94.05
Rate for Payer: Hawaii Medical Service Association ABD	$8.95
Rate for Payer: Hawaii Medical Service Association Commercial	$8.09
Rate for Payer: Hawaii Medical Service Association Medicare	$85.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$9.40
Rate for Payer: Hawaii Western Management Group Commercial	$6.47
Rate for Payer: Health Management Network Commercial	$145.35
Rate for Payer: Humana Medicare	$85.50
Rate for Payer: Kaiser Permanente Commercial	$153.90
Rate for Payer: Kaiser Permanente Medicaid	$87.21
Rate for Payer: Kaiser Permanente Medicare	$85.50
Rate for Payer: MDX Hawaii PPO	$165.87
Rate for Payer: Ohana Health Plan Medicaid	$85.50
Rate for Payer: Ohana Health Plan Medicare	$85.50
Rate for Payer: UnitedHealthcare Medicaid	$8.95
Rate for Payer: UnitedHealthcare Medicare	$85.50
Rate for Payer: University Health Alliance Commercial	$16.74

Bill Only Iron Liver Tissue

Facility

$171.00

Service Code	HCPCS 83540
Hospital Charge Code	8409270
Hospital Revenue Code	301
Min. Negotiated Rate	$145.35
Max. Negotiated Rate	$165.87
Rate for Payer: Cash Price	$111.15
Rate for Payer: Health Management Network Commercial	$145.35
Rate for Payer: Kaiser Permanente Commercial	$153.90
Rate for Payer: MDX Hawaii PPO	$165.87

Bill Only Lactic Acid Reflex

Facility

$83.00

Service Code	HCPCS 83605
Hospital Charge Code	12929194
Hospital Revenue Code	301
Min. Negotiated Rate	$70.55
Max. Negotiated Rate	$80.51
Rate for Payer: Cash Price	$53.95
Rate for Payer: Health Management Network Commercial	$70.55
Rate for Payer: Kaiser Permanente Commercial	$74.70
Rate for Payer: MDX Hawaii PPO	$80.51

Bill Only Lactic Acid Reflex

Facility

$83.00

Service Code	HCPCS 83605
Hospital Charge Code	12929194
Hospital Revenue Code	301
Min. Negotiated Rate	$11.57
Max. Negotiated Rate	$80.51
Rate for Payer: AlohaCare Medicaid	$41.50
Rate for Payer: AlohaCare Medicare	$41.50
Rate for Payer: Cash Price	$53.95
Rate for Payer: Cash Price	$53.95
Rate for Payer: Devoted Health Medicare	$45.65
Rate for Payer: Hawaii Medical Service Association ABD	$14.76
Rate for Payer: Hawaii Medical Service Association Commercial	$14.46
Rate for Payer: Hawaii Medical Service Association Medicare	$41.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$15.50
Rate for Payer: Hawaii Western Management Group Commercial	$11.57
Rate for Payer: Health Management Network Commercial	$70.55
Rate for Payer: Humana Medicare	$41.50
Rate for Payer: Kaiser Permanente Commercial	$74.70
Rate for Payer: Kaiser Permanente Medicaid	$42.33
Rate for Payer: Kaiser Permanente Medicare	$41.50
Rate for Payer: MDX Hawaii PPO	$80.51
Rate for Payer: Ohana Health Plan Medicaid	$41.50
Rate for Payer: Ohana Health Plan Medicare	$41.50
Rate for Payer: UnitedHealthcare Medicaid	$14.76
Rate for Payer: UnitedHealthcare Medicare	$41.50
Rate for Payer: University Health Alliance Commercial	$27.60

Bill Only Lupus 1:1 Mix

Facility

$77.00

Service Code	HCPCS 85732
Hospital Charge Code	8301498
Hospital Revenue Code	305
Min. Negotiated Rate	$65.45
Max. Negotiated Rate	$74.69
Rate for Payer: Cash Price	$50.05
Rate for Payer: Health Management Network Commercial	$65.45
Rate for Payer: Kaiser Permanente Commercial	$69.30
Rate for Payer: MDX Hawaii PPO	$74.69

Bill Only Lupus 1:1 Mix

Facility

$77.00

Service Code	HCPCS 85732
Hospital Charge Code	8301498
Hospital Revenue Code	305
Min. Negotiated Rate	$6.47
Max. Negotiated Rate	$74.69
Rate for Payer: AlohaCare Medicaid	$38.50
Rate for Payer: AlohaCare Medicare	$38.50
Rate for Payer: Cash Price	$50.05
Rate for Payer: Cash Price	$50.05
Rate for Payer: Devoted Health Medicare	$42.35
Rate for Payer: Hawaii Medical Service Association ABD	$8.95
Rate for Payer: Hawaii Medical Service Association Commercial	$8.09
Rate for Payer: Hawaii Medical Service Association Medicare	$38.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$9.40
Rate for Payer: Hawaii Western Management Group Commercial	$6.47
Rate for Payer: Health Management Network Commercial	$65.45
Rate for Payer: Humana Medicare	$38.50
Rate for Payer: Kaiser Permanente Commercial	$69.30
Rate for Payer: Kaiser Permanente Medicaid	$39.27
Rate for Payer: Kaiser Permanente Medicare	$38.50
Rate for Payer: MDX Hawaii PPO	$74.69
Rate for Payer: Ohana Health Plan Medicaid	$38.50
Rate for Payer: Ohana Health Plan Medicare	$38.50
Rate for Payer: UnitedHealthcare Medicaid	$8.95
Rate for Payer: UnitedHealthcare Medicare	$38.50
Rate for Payer: University Health Alliance Commercial	$16.72

Bill Only MAVI Direct Probe Fee

Facility

$230.00

Service Code	HCPCS 87560
Hospital Charge Code	8301499
Hospital Revenue Code	306
Min. Negotiated Rate	$27.29
Max. Negotiated Rate	$223.10
Rate for Payer: AlohaCare Medicaid	$115.00
Rate for Payer: AlohaCare Medicare	$115.00
Rate for Payer: Cash Price	$149.50
Rate for Payer: Cash Price	$149.50
Rate for Payer: Devoted Health Medicare	$126.50
Rate for Payer: Hawaii Medical Service Association ABD	$27.71
Rate for Payer: Hawaii Medical Service Association Commercial	$34.11
Rate for Payer: Hawaii Medical Service Association Medicare	$115.00
Rate for Payer: Hawaii Medical Service Association Non-ABD	$29.10
Rate for Payer: Hawaii Western Management Group Commercial	$27.29
Rate for Payer: Health Management Network Commercial	$195.50
Rate for Payer: Humana Medicare	$115.00
Rate for Payer: Kaiser Permanente Commercial	$207.00
Rate for Payer: Kaiser Permanente Medicaid	$117.30
Rate for Payer: Kaiser Permanente Medicare	$115.00
Rate for Payer: MDX Hawaii PPO	$223.10
Rate for Payer: Ohana Health Plan Medicaid	$115.00
Rate for Payer: Ohana Health Plan Medicare	$115.00
Rate for Payer: UnitedHealthcare Medicaid	$27.71
Rate for Payer: UnitedHealthcare Medicare	$115.00
Rate for Payer: University Health Alliance Commercial	$51.84

Bill Only MAVI Direct Probe Fee

Facility

$230.00

Service Code	HCPCS 87560
Hospital Charge Code	8301499
Hospital Revenue Code	306
Min. Negotiated Rate	$195.50
Max. Negotiated Rate	$223.10
Rate for Payer: Cash Price	$149.50
Rate for Payer: Health Management Network Commercial	$195.50
Rate for Payer: Kaiser Permanente Commercial	$207.00
Rate for Payer: MDX Hawaii PPO	$223.10

Bill Only Microdissection Manual

Facility

$411.00

Service Code	HCPCS 88381 TC
Hospital Charge Code	8409289
Hospital Revenue Code	310
Min. Negotiated Rate	$82.12
Max. Negotiated Rate	$398.67
Rate for Payer: AlohaCare Medicaid	$205.50
Rate for Payer: AlohaCare Medicare	$205.50
Rate for Payer: Cash Price	$267.15
Rate for Payer: Cash Price	$267.15
Rate for Payer: Devoted Health Medicare	$226.05
Rate for Payer: Hawaii Medical Service Association ABD	$101.01
Rate for Payer: Hawaii Medical Service Association Medicare	$205.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$82.12
Rate for Payer: Hawaii Western Management Group Commercial	$390.45
Rate for Payer: Health Management Network Commercial	$349.35
Rate for Payer: Humana Medicare	$205.50
Rate for Payer: Kaiser Permanente Commercial	$369.90
Rate for Payer: Kaiser Permanente Medicaid	$209.61
Rate for Payer: Kaiser Permanente Medicare	$205.50
Rate for Payer: MDX Hawaii PPO	$398.67
Rate for Payer: Ohana Health Plan Medicaid	$205.50
Rate for Payer: Ohana Health Plan Medicare	$205.50
Rate for Payer: UnitedHealthcare Medicaid	$126.26
Rate for Payer: UnitedHealthcare Medicare	$205.50
Rate for Payer: University Health Alliance Commercial	$333.50

Bill Only Microdissection Manual

Facility

$411.00

Service Code	HCPCS 88381 TC
Hospital Charge Code	8409289
Hospital Revenue Code	310
Min. Negotiated Rate	$349.35
Max. Negotiated Rate	$398.67
Rate for Payer: Cash Price	$267.15
Rate for Payer: Health Management Network Commercial	$349.35
Rate for Payer: Kaiser Permanente Commercial	$369.90
Rate for Payer: MDX Hawaii PPO	$398.67

Bill Only Morph Ana In Situ Add

Facility

$359.00

Service Code	HCPCS 88369
Hospital Charge Code	8728900
Hospital Revenue Code	310
Min. Negotiated Rate	$305.15
Max. Negotiated Rate	$348.23
Rate for Payer: Cash Price	$233.35
Rate for Payer: Health Management Network Commercial	$305.15
Rate for Payer: Kaiser Permanente Commercial	$323.10
Rate for Payer: MDX Hawaii PPO	$348.23

Bill Only Morph Ana In Situ Add

Facility

$359.00

Service Code	HCPCS 88369
Hospital Charge Code	8728900
Hospital Revenue Code	310
Min. Negotiated Rate	$48.59
Max. Negotiated Rate	$348.23
Rate for Payer: AlohaCare Medicaid	$179.50
Rate for Payer: AlohaCare Medicare	$179.50
Rate for Payer: Cash Price	$233.35
Rate for Payer: Cash Price	$233.35
Rate for Payer: Devoted Health Medicare	$197.45
Rate for Payer: Hawaii Medical Service Association Medicare	$179.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$48.59
Rate for Payer: Hawaii Western Management Group Commercial	$341.05
Rate for Payer: Health Management Network Commercial	$305.15
Rate for Payer: Humana Medicare	$179.50
Rate for Payer: Kaiser Permanente Commercial	$323.10
Rate for Payer: Kaiser Permanente Medicaid	$183.09
Rate for Payer: Kaiser Permanente Medicare	$179.50
Rate for Payer: MDX Hawaii PPO	$348.23
Rate for Payer: Ohana Health Plan Medicaid	$179.50
Rate for Payer: Ohana Health Plan Medicare	$179.50
Rate for Payer: UnitedHealthcare Medicaid	$86.03
Rate for Payer: UnitedHealthcare Medicare	$179.50
Rate for Payer: University Health Alliance Commercial	$243.52

Bill Only Morph Analysis In Situ

Facility

$708.00

Service Code	HCPCS 88367 TC
Hospital Charge Code	8409286
Hospital Revenue Code	310
Min. Negotiated Rate	$113.82
Max. Negotiated Rate	$686.76
Rate for Payer: AlohaCare Medicaid	$354.00
Rate for Payer: AlohaCare Medicare	$354.00
Rate for Payer: Cash Price	$460.20
Rate for Payer: Cash Price	$460.20
Rate for Payer: Devoted Health Medicare	$389.40
Rate for Payer: Hawaii Medical Service Association ABD	$113.82
Rate for Payer: Hawaii Medical Service Association Medicare	$354.00
Rate for Payer: Hawaii Medical Service Association Non-ABD	$117.97
Rate for Payer: Hawaii Western Management Group Commercial	$672.60
Rate for Payer: Health Management Network Commercial	$601.80
Rate for Payer: Humana Medicare	$354.00
Rate for Payer: Kaiser Permanente Commercial	$637.20
Rate for Payer: Kaiser Permanente Medicaid	$361.08
Rate for Payer: Kaiser Permanente Medicare	$354.00
Rate for Payer: MDX Hawaii PPO	$686.76
Rate for Payer: Ohana Health Plan Medicaid	$354.00
Rate for Payer: Ohana Health Plan Medicare	$354.00
Rate for Payer: UnitedHealthcare Medicaid	$113.82
Rate for Payer: UnitedHealthcare Medicare	$354.00
Rate for Payer: University Health Alliance Commercial	$341.16

Bill Only Morph Analysis In Situ

Facility

$708.00

Service Code	HCPCS 88367 TC
Hospital Charge Code	8409286
Hospital Revenue Code	310
Min. Negotiated Rate	$601.80
Max. Negotiated Rate	$686.76
Rate for Payer: Cash Price	$460.20
Rate for Payer: Health Management Network Commercial	$601.80
Rate for Payer: Kaiser Permanente Commercial	$637.20
Rate for Payer: MDX Hawaii PPO	$686.76

Bill Only Morph Ana Manual Multi

Facility

$1,075.00

Service Code	HCPCS 88377 TC
Hospital Charge Code	8409288
Hospital Revenue Code	310
Min. Negotiated Rate	$913.75
Max. Negotiated Rate	$1,042.75
Rate for Payer: Cash Price	$698.75
Rate for Payer: Health Management Network Commercial	$913.75
Rate for Payer: Kaiser Permanente Commercial	$967.50
Rate for Payer: MDX Hawaii PPO	$1,042.75

Bill Only Morph Ana Manual Multi

Facility

$1,075.00

Service Code	HCPCS 88377 TC
Hospital Charge Code	8409288
Hospital Revenue Code	310
Min. Negotiated Rate	$148.91
Max. Negotiated Rate	$1,042.75
Rate for Payer: AlohaCare Medicaid	$537.50
Rate for Payer: AlohaCare Medicare	$537.50
Rate for Payer: Cash Price	$698.75
Rate for Payer: Cash Price	$698.75
Rate for Payer: Devoted Health Medicare	$591.25
Rate for Payer: Hawaii Medical Service Association ABD	$475.14
Rate for Payer: Hawaii Medical Service Association Medicare	$537.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$148.91
Rate for Payer: Hawaii Western Management Group Commercial	$1,021.25
Rate for Payer: Health Management Network Commercial	$913.75
Rate for Payer: Humana Medicare	$537.50
Rate for Payer: Kaiser Permanente Commercial	$967.50
Rate for Payer: Kaiser Permanente Medicaid	$548.25
Rate for Payer: Kaiser Permanente Medicare	$537.50
Rate for Payer: MDX Hawaii PPO	$1,042.75
Rate for Payer: Ohana Health Plan Medicaid	$537.50
Rate for Payer: Ohana Health Plan Medicare	$537.50
Rate for Payer: UnitedHealthcare Medicaid	$267.53
Rate for Payer: UnitedHealthcare Medicare	$537.50
Rate for Payer: University Health Alliance Commercial	$760.83

Bill Only Morph Ana Multiplex Each

Facility

$1,349.00

Service Code	HCPCS 88374 TC
Hospital Charge Code	8409287
Hospital Revenue Code	310
Min. Negotiated Rate	$28.79
Max. Negotiated Rate	$1,308.53
Rate for Payer: AlohaCare Medicaid	$674.50
Rate for Payer: AlohaCare Medicare	$674.50
Rate for Payer: Cash Price	$876.85
Rate for Payer: Cash Price	$876.85
Rate for Payer: Devoted Health Medicare	$741.95
Rate for Payer: Hawaii Medical Service Association ABD	$28.79
Rate for Payer: Hawaii Medical Service Association Medicare	$674.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$160.01
Rate for Payer: Hawaii Western Management Group Commercial	$1,281.55
Rate for Payer: Health Management Network Commercial	$1,146.65
Rate for Payer: Humana Medicare	$674.50
Rate for Payer: Kaiser Permanente Commercial	$1,214.10
Rate for Payer: Kaiser Permanente Medicaid	$687.99
Rate for Payer: Kaiser Permanente Medicare	$674.50
Rate for Payer: MDX Hawaii PPO	$1,308.53
Rate for Payer: Ohana Health Plan Medicaid	$674.50
Rate for Payer: Ohana Health Plan Medicare	$674.50
Rate for Payer: UnitedHealthcare Medicaid	$195.04
Rate for Payer: UnitedHealthcare Medicare	$674.50
Rate for Payer: University Health Alliance Commercial	$651.94

Bill Only Morph Ana Multiplex Each

Facility

$1,349.00

Service Code	HCPCS 88374 TC
Hospital Charge Code	8409287
Hospital Revenue Code	310
Min. Negotiated Rate	$1,146.65
Max. Negotiated Rate	$1,308.53
Rate for Payer: Cash Price	$876.85
Rate for Payer: Health Management Network Commercial	$1,146.65
Rate for Payer: Kaiser Permanente Commercial	$1,214.10
Rate for Payer: MDX Hawaii PPO	$1,308.53

Bill Only Morphometric Ana Nerve

Facility

$412.00

Service Code	HCPCS 88356 TC
Hospital Charge Code	8409283
Hospital Revenue Code	310
Min. Negotiated Rate	$350.20
Max. Negotiated Rate	$399.64
Rate for Payer: Cash Price	$267.80
Rate for Payer: Health Management Network Commercial	$350.20
Rate for Payer: Kaiser Permanente Commercial	$370.80
Rate for Payer: MDX Hawaii PPO	$399.64

Bill Only Morphometric Ana Nerve

Facility

$412.00

Service Code	HCPCS 88356 TC
Hospital Charge Code	8409283
Hospital Revenue Code	310
Min. Negotiated Rate	$96.16
Max. Negotiated Rate	$399.64
Rate for Payer: AlohaCare Medicaid	$206.00
Rate for Payer: AlohaCare Medicare	$206.00
Rate for Payer: Cash Price	$267.80
Rate for Payer: Cash Price	$267.80
Rate for Payer: Devoted Health Medicare	$226.60
Rate for Payer: Hawaii Medical Service Association ABD	$178.32
Rate for Payer: Hawaii Medical Service Association Medicare	$206.00
Rate for Payer: Hawaii Medical Service Association Non-ABD	$96.16
Rate for Payer: Hawaii Western Management Group Commercial	$391.40
Rate for Payer: Health Management Network Commercial	$350.20
Rate for Payer: Humana Medicare	$206.00
Rate for Payer: Kaiser Permanente Commercial	$370.80
Rate for Payer: Kaiser Permanente Medicaid	$210.12
Rate for Payer: Kaiser Permanente Medicare	$206.00
Rate for Payer: MDX Hawaii PPO	$399.64
Rate for Payer: Ohana Health Plan Medicaid	$206.00
Rate for Payer: Ohana Health Plan Medicare	$206.00
Rate for Payer: UnitedHealthcare Medicaid	$178.32
Rate for Payer: UnitedHealthcare Medicare	$206.00
Rate for Payer: University Health Alliance Commercial	$312.02

Bill Only MTB Complex Speciation

Facility

$365.00

Service Code	HCPCS 87150
Hospital Charge Code	8301474
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

Bill Only MTB Complex Speciation

Facility

$365.00

Service Code	HCPCS 87150
Hospital Charge Code	8301474
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	$50.27
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	$50.27
Rate for Payer: UnitedHealthcare Medicare	$182.50
Rate for Payer: University Health Alliance Commercial	$91.37

Bill Only M tb Direct Probe Fee

Facility

$230.00

Service Code	HCPCS 87555
Hospital Charge Code	8301500
Hospital Revenue Code	306
Min. Negotiated Rate	$195.50
Max. Negotiated Rate	$223.10
Rate for Payer: Cash Price	$149.50
Rate for Payer: Health Management Network Commercial	$195.50
Rate for Payer: Kaiser Permanente Commercial	$207.00
Rate for Payer: MDX Hawaii PPO	$223.10

Know your out-of-pocket cost for care.

All Charges