Samuel Mahelona Memorial Hospital

All Charges

Charge

Type

Setting

Price

Bill Only Suscept Enz Detect x1

Facility

$41.00

Service Code	HCPCS 87185
Hospital Charge Code	8301490
Hospital Revenue Code	306
Min. Negotiated Rate	$2.57
Max. Negotiated Rate	$39.77
Rate for Payer: AlohaCare Medicaid	$20.50
Rate for Payer: AlohaCare Medicare	$20.50
Rate for Payer: Cash Price	$26.65
Rate for Payer: Cash Price	$26.65
Rate for Payer: Devoted Health Medicare	$22.55
Rate for Payer: Hawaii Medical Service Association ABD	$2.57
Rate for Payer: Hawaii Medical Service Association Commercial	$5.94
Rate for Payer: Hawaii Medical Service Association Medicare	$20.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$2.70
Rate for Payer: Hawaii Western Management Group Commercial	$4.75
Rate for Payer: Health Management Network Commercial	$34.85
Rate for Payer: Humana Medicare	$20.50
Rate for Payer: Kaiser Permanente Commercial	$36.90
Rate for Payer: Kaiser Permanente Medicaid	$20.91
Rate for Payer: Kaiser Permanente Medicare	$20.50
Rate for Payer: MDX Hawaii PPO	$39.77
Rate for Payer: Ohana Health Plan Medicaid	$20.50
Rate for Payer: Ohana Health Plan Medicare	$20.50
Rate for Payer: UnitedHealthcare Medicaid	$2.57
Rate for Payer: UnitedHealthcare Medicare	$20.50
Rate for Payer: University Health Alliance Commercial	$4.81

Bill Only Suscept Enz Detect x1

Facility

$41.00

Service Code	HCPCS 87185
Hospital Charge Code	8301490
Hospital Revenue Code	306
Min. Negotiated Rate	$34.85
Max. Negotiated Rate	$39.77
Rate for Payer: Cash Price	$26.65
Rate for Payer: Health Management Network Commercial	$34.85
Rate for Payer: Kaiser Permanente Commercial	$36.90
Rate for Payer: MDX Hawaii PPO	$39.77

Bill Only Suscept Single Drug

Facility

$167.00

Service Code	HCPCS 87186
Hospital Charge Code	8301476
Hospital Revenue Code	306
Min. Negotiated Rate	$8.65
Max. Negotiated Rate	$161.99
Rate for Payer: AlohaCare Medicaid	$83.50
Rate for Payer: AlohaCare Medicare	$83.50
Rate for Payer: Cash Price	$108.55
Rate for Payer: Cash Price	$108.55
Rate for Payer: Devoted Health Medicare	$91.85
Rate for Payer: Hawaii Medical Service Association ABD	$11.94
Rate for Payer: Hawaii Medical Service Association Commercial	$10.81
Rate for Payer: Hawaii Medical Service Association Medicare	$83.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$12.54
Rate for Payer: Hawaii Western Management Group Commercial	$8.65
Rate for Payer: Health Management Network Commercial	$141.95
Rate for Payer: Humana Medicare	$83.50
Rate for Payer: Kaiser Permanente Commercial	$150.30
Rate for Payer: Kaiser Permanente Medicaid	$85.17
Rate for Payer: Kaiser Permanente Medicare	$83.50
Rate for Payer: MDX Hawaii PPO	$161.99
Rate for Payer: Ohana Health Plan Medicaid	$83.50
Rate for Payer: Ohana Health Plan Medicare	$83.50
Rate for Payer: UnitedHealthcare Medicaid	$11.94
Rate for Payer: UnitedHealthcare Medicare	$83.50
Rate for Payer: University Health Alliance Commercial	$22.35

Bill Only Suscept Single Drug

Facility

$167.00

Service Code	HCPCS 87186
Hospital Charge Code	8301476
Hospital Revenue Code	306
Min. Negotiated Rate	$141.95
Max. Negotiated Rate	$161.99
Rate for Payer: Cash Price	$108.55
Rate for Payer: Health Management Network Commercial	$141.95
Rate for Payer: Kaiser Permanente Commercial	$150.30
Rate for Payer: MDX Hawaii PPO	$161.99

Bill Only Thrombin Time

Facility

$61.00

Service Code	HCPCS 85670
Hospital Charge Code	8301487
Hospital Revenue Code	305
Min. Negotiated Rate	$5.77
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	$7.98
Rate for Payer: Hawaii Medical Service Association Commercial	$7.21
Rate for Payer: Hawaii Medical Service Association Medicare	$30.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$8.38
Rate for Payer: Hawaii Western Management Group Commercial	$5.77
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	$7.98
Rate for Payer: UnitedHealthcare Medicare	$30.50
Rate for Payer: University Health Alliance Commercial	$14.93

Bill Only Thrombin Time

Facility

$61.00

Service Code	HCPCS 85670
Hospital Charge Code	8301487
Hospital Revenue Code	305
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

Bill Only Ur Cult ID

Facility

$86.00

Service Code	HCPCS 87088
Hospital Charge Code	8301496
Hospital Revenue Code	306
Min. Negotiated Rate	$8.09
Max. Negotiated Rate	$83.42
Rate for Payer: AlohaCare Medicaid	$43.00
Rate for Payer: AlohaCare Medicare	$43.00
Rate for Payer: Cash Price	$55.90
Rate for Payer: Cash Price	$55.90
Rate for Payer: Devoted Health Medicare	$47.30
Rate for Payer: Hawaii Medical Service Association ABD	$10.55
Rate for Payer: Hawaii Medical Service Association Commercial	$10.11
Rate for Payer: Hawaii Medical Service Association Medicare	$43.00
Rate for Payer: Hawaii Medical Service Association Non-ABD	$11.08
Rate for Payer: Hawaii Western Management Group Commercial	$8.09
Rate for Payer: Health Management Network Commercial	$73.10
Rate for Payer: Humana Medicare	$43.00
Rate for Payer: Kaiser Permanente Commercial	$77.40
Rate for Payer: Kaiser Permanente Medicaid	$43.86
Rate for Payer: Kaiser Permanente Medicare	$43.00
Rate for Payer: MDX Hawaii PPO	$83.42
Rate for Payer: Ohana Health Plan Medicaid	$43.00
Rate for Payer: Ohana Health Plan Medicare	$43.00
Rate for Payer: UnitedHealthcare Medicaid	$10.55
Rate for Payer: UnitedHealthcare Medicare	$43.00
Rate for Payer: University Health Alliance Commercial	$19.74

Bill Only Ur Cult ID

Facility

$86.00

Service Code	HCPCS 87088
Hospital Charge Code	8301496
Hospital Revenue Code	306
Min. Negotiated Rate	$73.10
Max. Negotiated Rate	$83.42
Rate for Payer: Cash Price	$55.90
Rate for Payer: Health Management Network Commercial	$73.10
Rate for Payer: Kaiser Permanente Commercial	$77.40
Rate for Payer: MDX Hawaii PPO	$83.42

Bill Only Urea Nitrogen, 24 Hr Urine

Facility

$40.00

Service Code	HCPCS 84540
Hospital Charge Code	12929193
Hospital Revenue Code	301
Min. Negotiated Rate	$5.56
Max. Negotiated Rate	$38.80
Rate for Payer: AlohaCare Medicaid	$20.00
Rate for Payer: AlohaCare Medicare	$20.00
Rate for Payer: Cash Price	$26.00
Rate for Payer: Cash Price	$26.00
Rate for Payer: Devoted Health Medicare	$22.00
Rate for Payer: Hawaii Medical Service Association ABD	$6.56
Rate for Payer: Hawaii Medical Service Association Commercial	$6.95
Rate for Payer: Hawaii Medical Service Association Medicare	$20.00
Rate for Payer: Hawaii Medical Service Association Non-ABD	$6.89
Rate for Payer: Hawaii Western Management Group Commercial	$5.56
Rate for Payer: Health Management Network Commercial	$34.00
Rate for Payer: Humana Medicare	$20.00
Rate for Payer: Kaiser Permanente Commercial	$36.00
Rate for Payer: Kaiser Permanente Medicaid	$20.40
Rate for Payer: Kaiser Permanente Medicare	$20.00
Rate for Payer: MDX Hawaii PPO	$38.80
Rate for Payer: Ohana Health Plan Medicaid	$20.00
Rate for Payer: Ohana Health Plan Medicare	$20.00
Rate for Payer: UnitedHealthcare Medicaid	$6.56
Rate for Payer: UnitedHealthcare Medicare	$20.00
Rate for Payer: University Health Alliance Commercial	$12.28

Bill Only Urea Nitrogen, 24 Hr Urine

Facility

$40.00

Service Code	HCPCS 84540
Hospital Charge Code	12929193
Hospital Revenue Code	301
Min. Negotiated Rate	$34.00
Max. Negotiated Rate	$38.80
Rate for Payer: Cash Price	$26.00
Rate for Payer: Health Management Network Commercial	$34.00
Rate for Payer: Kaiser Permanente Commercial	$36.00
Rate for Payer: MDX Hawaii PPO	$38.80

Bill Only Urine Protein

Facility

$56.00

Service Code	HCPCS 84156
Hospital Charge Code	12925323
Hospital Revenue Code	301
Min. Negotiated Rate	$47.60
Max. Negotiated Rate	$54.32
Rate for Payer: Cash Price	$36.40
Rate for Payer: Health Management Network Commercial	$47.60
Rate for Payer: Kaiser Permanente Commercial	$50.40
Rate for Payer: MDX Hawaii PPO	$54.32

Bill Only Urine Protein

Facility

$56.00

Service Code	HCPCS 84156
Hospital Charge Code	12925323
Hospital Revenue Code	301
Min. Negotiated Rate	$3.67
Max. Negotiated Rate	$54.32
Rate for Payer: AlohaCare Medicaid	$28.00
Rate for Payer: AlohaCare Medicare	$28.00
Rate for Payer: Cash Price	$36.40
Rate for Payer: Cash Price	$36.40
Rate for Payer: Devoted Health Medicare	$30.80
Rate for Payer: Hawaii Medical Service Association ABD	$3.69
Rate for Payer: Hawaii Medical Service Association Commercial	$4.59
Rate for Payer: Hawaii Medical Service Association Medicare	$28.00
Rate for Payer: Hawaii Medical Service Association Non-ABD	$5.06
Rate for Payer: Hawaii Western Management Group Commercial	$3.67
Rate for Payer: Health Management Network Commercial	$47.60
Rate for Payer: Humana Medicare	$28.00
Rate for Payer: Kaiser Permanente Commercial	$50.40
Rate for Payer: Kaiser Permanente Medicaid	$28.56
Rate for Payer: Kaiser Permanente Medicare	$28.00
Rate for Payer: MDX Hawaii PPO	$54.32
Rate for Payer: Ohana Health Plan Medicaid	$28.00
Rate for Payer: Ohana Health Plan Medicare	$28.00
Rate for Payer: UnitedHealthcare Medicaid	$3.69
Rate for Payer: UnitedHealthcare Medicare	$28.00
Rate for Payer: University Health Alliance Commercial	$9.47

Bill Only Vancomycin (Peak)

Facility

$168.00

Service Code	HCPCS 80202
Hospital Charge Code	12927332
Hospital Revenue Code	301
Min. Negotiated Rate	$142.80
Max. Negotiated Rate	$162.96
Rate for Payer: Cash Price	$109.20
Rate for Payer: Health Management Network Commercial	$142.80
Rate for Payer: Kaiser Permanente Commercial	$151.20
Rate for Payer: MDX Hawaii PPO	$162.96

Bill Only Vancomycin (Peak)

Facility

$168.00

Service Code	HCPCS 80202
Hospital Charge Code	12927332
Hospital Revenue Code	301
Min. Negotiated Rate	$13.54
Max. Negotiated Rate	$162.96
Rate for Payer: AlohaCare Medicaid	$84.00
Rate for Payer: AlohaCare Medicare	$84.00
Rate for Payer: Cash Price	$109.20
Rate for Payer: Cash Price	$109.20
Rate for Payer: Devoted Health Medicare	$92.40
Rate for Payer: Hawaii Medical Service Association ABD	$18.72
Rate for Payer: Hawaii Medical Service Association Commercial	$16.93
Rate for Payer: Hawaii Medical Service Association Medicare	$84.00
Rate for Payer: Hawaii Medical Service Association Non-ABD	$19.66
Rate for Payer: Hawaii Western Management Group Commercial	$13.54
Rate for Payer: Health Management Network Commercial	$142.80
Rate for Payer: Humana Medicare	$84.00
Rate for Payer: Kaiser Permanente Commercial	$151.20
Rate for Payer: Kaiser Permanente Medicaid	$85.68
Rate for Payer: Kaiser Permanente Medicare	$84.00
Rate for Payer: MDX Hawaii PPO	$162.96
Rate for Payer: Ohana Health Plan Medicaid	$84.00
Rate for Payer: Ohana Health Plan Medicare	$84.00
Rate for Payer: UnitedHealthcare Medicaid	$18.72
Rate for Payer: UnitedHealthcare Medicare	$84.00
Rate for Payer: University Health Alliance Commercial	$35.02

Bill Only Viral ID Charge

Facility

$150.00

Service Code	HCPCS 87253
Hospital Charge Code	8301506
Hospital Revenue Code	306
Min. Negotiated Rate	$127.50
Max. Negotiated Rate	$145.50
Rate for Payer: Cash Price	$97.50
Rate for Payer: Health Management Network Commercial	$127.50
Rate for Payer: Kaiser Permanente Commercial	$135.00
Rate for Payer: MDX Hawaii PPO	$145.50

Bill Only Viral ID Charge

Facility

$150.00

Service Code	HCPCS 87253
Hospital Charge Code	8301506
Hospital Revenue Code	306
Min. Negotiated Rate	$12.39
Max. Negotiated Rate	$145.50
Rate for Payer: AlohaCare Medicaid	$75.00
Rate for Payer: AlohaCare Medicare	$75.00
Rate for Payer: Cash Price	$97.50
Rate for Payer: Cash Price	$97.50
Rate for Payer: Devoted Health Medicare	$82.50
Rate for Payer: Hawaii Medical Service Association ABD	$12.39
Rate for Payer: Hawaii Medical Service Association Commercial	$25.25
Rate for Payer: Hawaii Medical Service Association Medicare	$75.00
Rate for Payer: Hawaii Medical Service Association Non-ABD	$13.01
Rate for Payer: Hawaii Western Management Group Commercial	$20.20
Rate for Payer: Health Management Network Commercial	$127.50
Rate for Payer: Humana Medicare	$75.00
Rate for Payer: Kaiser Permanente Commercial	$135.00
Rate for Payer: Kaiser Permanente Medicaid	$76.50
Rate for Payer: Kaiser Permanente Medicare	$75.00
Rate for Payer: MDX Hawaii PPO	$145.50
Rate for Payer: Ohana Health Plan Medicaid	$75.00
Rate for Payer: Ohana Health Plan Medicare	$75.00
Rate for Payer: UnitedHealthcare Medicaid	$12.39
Rate for Payer: UnitedHealthcare Medicare	$75.00
Rate for Payer: University Health Alliance Commercial	$23.18

Bill Only Yeast Id x1

Facility

$147.00

Service Code	HCPCS 87106
Hospital Charge Code	8301497
Hospital Revenue Code	306
Min. Negotiated Rate	$10.32
Max. Negotiated Rate	$142.59
Rate for Payer: AlohaCare Medicaid	$73.50
Rate for Payer: AlohaCare Medicare	$73.50
Rate for Payer: Cash Price	$95.55
Rate for Payer: Cash Price	$95.55
Rate for Payer: Devoted Health Medicare	$80.85
Rate for Payer: Hawaii Medical Service Association ABD	$14.27
Rate for Payer: Hawaii Medical Service Association Commercial	$12.90
Rate for Payer: Hawaii Medical Service Association Medicare	$73.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$14.98
Rate for Payer: Hawaii Western Management Group Commercial	$10.32
Rate for Payer: Health Management Network Commercial	$124.95
Rate for Payer: Humana Medicare	$73.50
Rate for Payer: Kaiser Permanente Commercial	$132.30
Rate for Payer: Kaiser Permanente Medicaid	$74.97
Rate for Payer: Kaiser Permanente Medicare	$73.50
Rate for Payer: MDX Hawaii PPO	$142.59
Rate for Payer: Ohana Health Plan Medicaid	$73.50
Rate for Payer: Ohana Health Plan Medicare	$73.50
Rate for Payer: UnitedHealthcare Medicaid	$14.27
Rate for Payer: UnitedHealthcare Medicare	$73.50
Rate for Payer: University Health Alliance Commercial	$26.68

Bill Only Yeast Id x1

Facility

$147.00

Service Code	HCPCS 87106
Hospital Charge Code	8301497
Hospital Revenue Code	306
Min. Negotiated Rate	$124.95
Max. Negotiated Rate	$142.59
Rate for Payer: Cash Price	$95.55
Rate for Payer: Health Management Network Commercial	$124.95
Rate for Payer: Kaiser Permanente Commercial	$132.30
Rate for Payer: MDX Hawaii PPO	$142.59

BINDER PELVIC

Facility

$963.00

Hospital Charge Code	8419560
Hospital Revenue Code	270
Min. Negotiated Rate	$481.50
Max. Negotiated Rate	$934.11
Rate for Payer: AlohaCare Medicaid	$481.50
Rate for Payer: AlohaCare Medicare	$481.50
Rate for Payer: Cash Price	$625.95
Rate for Payer: Devoted Health Medicare	$529.65
Rate for Payer: Hawaii Medical Service Association Medicare	$481.50
Rate for Payer: Hawaii Western Management Group Commercial	$914.85
Rate for Payer: Health Management Network Commercial	$818.55
Rate for Payer: Humana Medicare	$481.50
Rate for Payer: Kaiser Permanente Commercial	$866.70
Rate for Payer: Kaiser Permanente Medicaid	$491.13
Rate for Payer: Kaiser Permanente Medicare	$481.50
Rate for Payer: MDX Hawaii PPO	$934.11
Rate for Payer: Ohana Health Plan Medicaid	$481.50
Rate for Payer: Ohana Health Plan Medicare	$481.50
Rate for Payer: UnitedHealthcare Medicare	$481.50
Rate for Payer: University Health Alliance Commercial	$701.93

BINDER PELVIC

Facility

$963.00

Hospital Charge Code	8419560
Hospital Revenue Code	270
Min. Negotiated Rate	$818.55
Max. Negotiated Rate	$934.11
Rate for Payer: Cash Price	$625.95
Rate for Payer: Health Management Network Commercial	$818.55
Rate for Payer: Kaiser Permanente Commercial	$866.70
Rate for Payer: MDX Hawaii PPO	$934.11

BIOPSIES OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH CC

Facility

$47,830.64

Service Code	MSDRG 478
Min. Negotiated Rate	$47,830.64
Max. Negotiated Rate	$47,830.64
Rate for Payer: Hawaii Medical Service Association Commercial	$47,830.64

BIOPSIES OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH MCC

Facility

$47,830.64

Service Code	MSDRG 477
Min. Negotiated Rate	$47,830.64
Max. Negotiated Rate	$47,830.64
Rate for Payer: Hawaii Medical Service Association Commercial	$47,830.64

BIOPSIES OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITHOUT CC/MCC

Facility

$47,830.64

Service Code	MSDRG 479
Min. Negotiated Rate	$47,830.64
Max. Negotiated Rate	$47,830.64
Rate for Payer: Hawaii Medical Service Association Commercial	$47,830.64

BiPAP/ CPAP INITIAL AND SUBSEQUENT CHARGE

Facility

$1,666.00

Service Code	HCPCS 94660
Hospital Charge Code	8243036
Hospital Revenue Code	410
Min. Negotiated Rate	$1,416.10
Max. Negotiated Rate	$1,616.02
Rate for Payer: Cash Price	$1,082.90
Rate for Payer: Health Management Network Commercial	$1,416.10
Rate for Payer: Kaiser Permanente Commercial	$1,499.40
Rate for Payer: MDX Hawaii PPO	$1,616.02

BiPAP/ CPAP INITIAL AND SUBSEQUENT CHARGE

Facility

$1,666.00

Service Code	HCPCS 94660
Hospital Charge Code	8243036
Hospital Revenue Code	410
Min. Negotiated Rate	$39.67
Max. Negotiated Rate	$1,616.02
Rate for Payer: AlohaCare Medicaid	$833.00
Rate for Payer: AlohaCare Medicare	$833.00
Rate for Payer: Cash Price	$1,082.90
Rate for Payer: Cash Price	$1,082.90
Rate for Payer: Devoted Health Medicare	$916.30
Rate for Payer: Hawaii Medical Service Association Commercial	$279.65
Rate for Payer: Hawaii Medical Service Association Medicare	$833.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,582.70
Rate for Payer: Health Management Network Commercial	$1,416.10
Rate for Payer: Humana Medicare	$833.00
Rate for Payer: Kaiser Permanente Commercial	$1,499.40
Rate for Payer: Kaiser Permanente Medicaid	$849.66
Rate for Payer: Kaiser Permanente Medicare	$833.00
Rate for Payer: MDX Hawaii PPO	$1,616.02
Rate for Payer: Ohana Health Plan Medicaid	$833.00
Rate for Payer: Ohana Health Plan Medicare	$833.00
Rate for Payer: UnitedHealthcare Medicaid	$39.67
Rate for Payer: UnitedHealthcare Medicare	$833.00
Rate for Payer: University Health Alliance Commercial	$932.96

Know your out-of-pocket cost for care.

All Charges