Samuel Mahelona Memorial Hospital

All Charges

Charge

Type

Setting

Price

Blood Gas Venous FSI

Facility

$341.00

Service Code	HCPCS 82805
Hospital Charge Code	8395711
Hospital Revenue Code	301
Min. Negotiated Rate	$289.85
Max. Negotiated Rate	$330.77
Rate for Payer: Cash Price	$221.65
Rate for Payer: Health Management Network Commercial	$289.85
Rate for Payer: Kaiser Permanente Commercial	$306.90
Rate for Payer: MDX Hawaii PPO	$330.77

Blood Glucose Monitoring POC

Facility

$36.00

Service Code	HCPCS 82962
Hospital Charge Code	607609
Hospital Revenue Code	301
Min. Negotiated Rate	$2.50
Max. Negotiated Rate	$34.92
Rate for Payer: AlohaCare Medicaid	$18.00
Rate for Payer: AlohaCare Medicare	$18.00
Rate for Payer: Cash Price	$23.40
Rate for Payer: Cash Price	$23.40
Rate for Payer: Devoted Health Medicare	$19.80
Rate for Payer: Hawaii Medical Service Association ABD	$2.50
Rate for Payer: Hawaii Medical Service Association Commercial	$4.10
Rate for Payer: Hawaii Medical Service Association Medicare	$18.00
Rate for Payer: Hawaii Medical Service Association Non-ABD	$3.10
Rate for Payer: Hawaii Western Management Group Commercial	$3.28
Rate for Payer: Health Management Network Commercial	$30.60
Rate for Payer: Humana Medicare	$18.00
Rate for Payer: Kaiser Permanente Commercial	$32.40
Rate for Payer: Kaiser Permanente Medicaid	$18.36
Rate for Payer: Kaiser Permanente Medicare	$18.00
Rate for Payer: MDX Hawaii PPO	$34.92
Rate for Payer: Ohana Health Plan Medicaid	$18.00
Rate for Payer: Ohana Health Plan Medicare	$18.00
Rate for Payer: UnitedHealthcare Medicaid	$2.50
Rate for Payer: UnitedHealthcare Medicare	$18.00
Rate for Payer: University Health Alliance Commercial	$4.68

Blood Glucose Monitoring POC

Facility

$36.00

Service Code	HCPCS 82962
Hospital Charge Code	607609
Hospital Revenue Code	301
Min. Negotiated Rate	$30.60
Max. Negotiated Rate	$34.92
Rate for Payer: Cash Price	$23.40
Rate for Payer: Health Management Network Commercial	$30.60
Rate for Payer: Kaiser Permanente Commercial	$32.40
Rate for Payer: MDX Hawaii PPO	$34.92

Blood Glucose Monitoring Repeat

Facility

$36.00

Service Code	HCPCS 82962 91
Hospital Charge Code	8408865
Hospital Revenue Code	301
Min. Negotiated Rate	$30.60
Max. Negotiated Rate	$34.92
Rate for Payer: Cash Price	$23.40
Rate for Payer: Health Management Network Commercial	$30.60
Rate for Payer: Kaiser Permanente Commercial	$32.40
Rate for Payer: MDX Hawaii PPO	$34.92

Blood Glucose Monitoring Repeat

Facility

$36.00

Service Code	HCPCS 82962 91
Hospital Charge Code	8408865
Hospital Revenue Code	301
Min. Negotiated Rate	$2.50
Max. Negotiated Rate	$34.92
Rate for Payer: AlohaCare Medicaid	$18.00
Rate for Payer: AlohaCare Medicare	$18.00
Rate for Payer: Cash Price	$23.40
Rate for Payer: Cash Price	$23.40
Rate for Payer: Devoted Health Medicare	$19.80
Rate for Payer: Hawaii Medical Service Association ABD	$2.50
Rate for Payer: Hawaii Medical Service Association Medicare	$18.00
Rate for Payer: Hawaii Medical Service Association Non-ABD	$3.10
Rate for Payer: Hawaii Western Management Group Commercial	$34.20
Rate for Payer: Health Management Network Commercial	$30.60
Rate for Payer: Humana Medicare	$18.00
Rate for Payer: Kaiser Permanente Commercial	$32.40
Rate for Payer: Kaiser Permanente Medicaid	$18.36
Rate for Payer: Kaiser Permanente Medicare	$18.00
Rate for Payer: MDX Hawaii PPO	$34.92
Rate for Payer: Ohana Health Plan Medicaid	$18.00
Rate for Payer: Ohana Health Plan Medicare	$18.00
Rate for Payer: UnitedHealthcare Medicaid	$2.50
Rate for Payer: UnitedHealthcare Medicare	$18.00
Rate for Payer: University Health Alliance Commercial	$4.68

Blood Glucose Monitor POCT

Facility

$36.00

Service Code	HCPCS 82962
Hospital Charge Code	10543502
Hospital Revenue Code	301
Min. Negotiated Rate	$2.50
Max. Negotiated Rate	$34.92
Rate for Payer: AlohaCare Medicaid	$18.00
Rate for Payer: AlohaCare Medicare	$18.00
Rate for Payer: Cash Price	$23.40
Rate for Payer: Cash Price	$23.40
Rate for Payer: Devoted Health Medicare	$19.80
Rate for Payer: Hawaii Medical Service Association ABD	$2.50
Rate for Payer: Hawaii Medical Service Association Commercial	$4.10
Rate for Payer: Hawaii Medical Service Association Medicare	$18.00
Rate for Payer: Hawaii Medical Service Association Non-ABD	$3.10
Rate for Payer: Hawaii Western Management Group Commercial	$3.28
Rate for Payer: Health Management Network Commercial	$30.60
Rate for Payer: Humana Medicare	$18.00
Rate for Payer: Kaiser Permanente Commercial	$32.40
Rate for Payer: Kaiser Permanente Medicaid	$18.36
Rate for Payer: Kaiser Permanente Medicare	$18.00
Rate for Payer: MDX Hawaii PPO	$34.92
Rate for Payer: Ohana Health Plan Medicaid	$18.00
Rate for Payer: Ohana Health Plan Medicare	$18.00
Rate for Payer: UnitedHealthcare Medicaid	$2.50
Rate for Payer: UnitedHealthcare Medicare	$18.00
Rate for Payer: University Health Alliance Commercial	$4.68

Blood Glucose Monitor POCT

Facility

$36.00

Service Code	HCPCS 82962
Hospital Charge Code	10543502
Hospital Revenue Code	301
Min. Negotiated Rate	$30.60
Max. Negotiated Rate	$34.92
Rate for Payer: Cash Price	$23.40
Rate for Payer: Health Management Network Commercial	$30.60
Rate for Payer: Kaiser Permanente Commercial	$32.40
Rate for Payer: MDX Hawaii PPO	$34.92

Blood Type FSI

Facility

$94.00

Service Code	HCPCS 86900
Hospital Charge Code	8117864
Hospital Revenue Code	300
Min. Negotiated Rate	$2.99
Max. Negotiated Rate	$91.18
Rate for Payer: AlohaCare Medicaid	$47.00
Rate for Payer: AlohaCare Medicare	$47.00
Rate for Payer: Cash Price	$61.10
Rate for Payer: Cash Price	$61.10
Rate for Payer: Devoted Health Medicare	$51.70
Rate for Payer: Hawaii Medical Service Association ABD	$4.12
Rate for Payer: Hawaii Medical Service Association Commercial	$3.74
Rate for Payer: Hawaii Medical Service Association Medicare	$47.00
Rate for Payer: Hawaii Medical Service Association Non-ABD	$4.33
Rate for Payer: Hawaii Western Management Group Commercial	$2.99
Rate for Payer: Health Management Network Commercial	$79.90
Rate for Payer: Humana Medicare	$47.00
Rate for Payer: Kaiser Permanente Commercial	$84.60
Rate for Payer: Kaiser Permanente Medicaid	$47.94
Rate for Payer: Kaiser Permanente Medicare	$47.00
Rate for Payer: MDX Hawaii PPO	$91.18
Rate for Payer: Ohana Health Plan Medicaid	$47.00
Rate for Payer: Ohana Health Plan Medicare	$47.00
Rate for Payer: UnitedHealthcare Medicaid	$4.12
Rate for Payer: UnitedHealthcare Medicare	$47.00
Rate for Payer: University Health Alliance Commercial	$7.71

Blood Type FSI

Facility

$94.00

Service Code	HCPCS 86900
Hospital Charge Code	8117864
Hospital Revenue Code	300
Min. Negotiated Rate	$79.90
Max. Negotiated Rate	$91.18
Rate for Payer: Cash Price	$61.10
Rate for Payer: Health Management Network Commercial	$79.90
Rate for Payer: Kaiser Permanente Commercial	$84.60
Rate for Payer: MDX Hawaii PPO	$91.18

BLOOD VESSEL REPAIR† - 00770

Professional

Both

$191.00

Hospital Charge Code	8970814
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

BONE DISEASES AND ARTHROPATHIES WITH MCC

Facility

$12,490.95

Service Code	MSDRG 553
Min. Negotiated Rate	$12,490.95
Max. Negotiated Rate	$12,490.95
Rate for Payer: Hawaii Medical Service Association Commercial	$12,490.95

BONE DISEASES AND ARTHROPATHIES WITHOUT MCC

Facility

$12,396.15

Service Code	MSDRG 554
Min. Negotiated Rate	$12,396.15
Max. Negotiated Rate	$12,396.15
Rate for Payer: Hawaii Medical Service Association Commercial	$12,396.15

BOOT PODUS STANDARD

Facility

$226.00

Service Code	HCPCS L4397
Hospital Charge Code	8266834
Hospital Revenue Code	274
Min. Negotiated Rate	$126.56
Max. Negotiated Rate	$219.22
Rate for Payer: Cash Price	$146.90
Rate for Payer: Hawaii Western Management Group Commercial	$158.20
Rate for Payer: Health Management Network Commercial	$192.10
Rate for Payer: Kaiser Permanente Commercial	$203.40
Rate for Payer: MDX Hawaii PPO	$219.22
Rate for Payer: University Health Alliance Commercial	$126.56

BOOT PODUS STANDARD

Facility

$226.00

Service Code	HCPCS L4397
Hospital Charge Code	8266834
Hospital Revenue Code	274
Min. Negotiated Rate	$113.00
Max. Negotiated Rate	$219.22
Rate for Payer: AlohaCare Medicaid	$113.00
Rate for Payer: AlohaCare Medicare	$113.00
Rate for Payer: Cash Price	$146.90
Rate for Payer: Cash Price	$146.90
Rate for Payer: Devoted Health Medicare	$124.30
Rate for Payer: Hawaii Medical Service Association Medicare	$113.00
Rate for Payer: Hawaii Western Management Group Commercial	$158.20
Rate for Payer: Health Management Network Commercial	$192.10
Rate for Payer: Humana Medicare	$113.00
Rate for Payer: Kaiser Permanente Commercial	$203.40
Rate for Payer: Kaiser Permanente Medicaid	$115.26
Rate for Payer: Kaiser Permanente Medicare	$113.00
Rate for Payer: MDX Hawaii PPO	$219.22
Rate for Payer: Ohana Health Plan Medicaid	$113.00
Rate for Payer: Ohana Health Plan Medicare	$113.00
Rate for Payer: UnitedHealthcare Medicaid	$151.87
Rate for Payer: UnitedHealthcare Medicare	$113.00
Rate for Payer: University Health Alliance Commercial	$126.56

BOOT PODUS XL

Facility

$224.00

Service Code	HCPCS L4397
Hospital Charge Code	8266835
Hospital Revenue Code	274
Min. Negotiated Rate	$112.00
Max. Negotiated Rate	$217.28
Rate for Payer: AlohaCare Medicaid	$112.00
Rate for Payer: AlohaCare Medicare	$112.00
Rate for Payer: Cash Price	$145.60
Rate for Payer: Cash Price	$145.60
Rate for Payer: Devoted Health Medicare	$123.20
Rate for Payer: Hawaii Medical Service Association Medicare	$112.00
Rate for Payer: Hawaii Western Management Group Commercial	$156.80
Rate for Payer: Health Management Network Commercial	$190.40
Rate for Payer: Humana Medicare	$112.00
Rate for Payer: Kaiser Permanente Commercial	$201.60
Rate for Payer: Kaiser Permanente Medicaid	$114.24
Rate for Payer: Kaiser Permanente Medicare	$112.00
Rate for Payer: MDX Hawaii PPO	$217.28
Rate for Payer: Ohana Health Plan Medicaid	$112.00
Rate for Payer: Ohana Health Plan Medicare	$112.00
Rate for Payer: UnitedHealthcare Medicaid	$151.87
Rate for Payer: UnitedHealthcare Medicare	$112.00
Rate for Payer: University Health Alliance Commercial	$125.44

BOOT PODUS XL

Facility

$224.00

Service Code	HCPCS L4397
Hospital Charge Code	8266835
Hospital Revenue Code	274
Min. Negotiated Rate	$125.44
Max. Negotiated Rate	$217.28
Rate for Payer: Cash Price	$145.60
Rate for Payer: Hawaii Western Management Group Commercial	$156.80
Rate for Payer: Health Management Network Commercial	$190.40
Rate for Payer: Kaiser Permanente Commercial	$201.60
Rate for Payer: MDX Hawaii PPO	$217.28
Rate for Payer: University Health Alliance Commercial	$125.44

Bordatella pertussis/parapertussis DNA FSI

Facility

$758.00

Service Code	HCPCS 87798
Hospital Charge Code	8228845
Hospital Revenue Code	300
Min. Negotiated Rate	$35.09
Max. Negotiated Rate	$735.26
Rate for Payer: AlohaCare Medicaid	$379.00
Rate for Payer: AlohaCare Medicare	$379.00
Rate for Payer: Cash Price	$492.70
Rate for Payer: Cash Price	$492.70
Rate for Payer: Devoted Health Medicare	$416.90
Rate for Payer: Hawaii Medical Service Association ABD	$48.50
Rate for Payer: Hawaii Medical Service Association Commercial	$43.86
Rate for Payer: Hawaii Medical Service Association Medicare	$379.00
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	$644.30
Rate for Payer: Humana Medicare	$379.00
Rate for Payer: Kaiser Permanente Commercial	$682.20
Rate for Payer: Kaiser Permanente Medicaid	$386.58
Rate for Payer: Kaiser Permanente Medicare	$379.00
Rate for Payer: MDX Hawaii PPO	$735.26
Rate for Payer: Ohana Health Plan Medicaid	$379.00
Rate for Payer: Ohana Health Plan Medicare	$379.00
Rate for Payer: UnitedHealthcare Medicaid	$48.50
Rate for Payer: UnitedHealthcare Medicare	$379.00
Rate for Payer: University Health Alliance Commercial	$90.72

Bordatella pertussis/parapertussis DNA FSI

Facility

$758.00

Service Code	HCPCS 87798
Hospital Charge Code	8228845
Hospital Revenue Code	300
Min. Negotiated Rate	$644.30
Max. Negotiated Rate	$735.26
Rate for Payer: Cash Price	$492.70
Rate for Payer: Health Management Network Commercial	$644.30
Rate for Payer: Kaiser Permanente Commercial	$682.20
Rate for Payer: MDX Hawaii PPO	$735.26

Bordetella pertussis DNA FSI

Facility

$86.00

Service Code	HCPCS 86140
Hospital Charge Code	8117865
Hospital Revenue Code	306
Min. Negotiated Rate	$5.18
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	$7.15
Rate for Payer: Hawaii Medical Service Association Commercial	$6.47
Rate for Payer: Hawaii Medical Service Association Medicare	$43.00
Rate for Payer: Hawaii Medical Service Association Non-ABD	$7.51
Rate for Payer: Hawaii Western Management Group Commercial	$5.18
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	$7.15
Rate for Payer: UnitedHealthcare Medicare	$43.00
Rate for Payer: University Health Alliance Commercial	$13.38

Bordetella pertussis DNA FSI

Facility

$86.00

Service Code	HCPCS 86140
Hospital Charge Code	8117865
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

B. pertussis IgA Immunoblot FSI

Facility

$151.00

Service Code	HCPCS 86615
Hospital Charge Code	9916507
Hospital Revenue Code	302
Min. Negotiated Rate	$128.35
Max. Negotiated Rate	$146.47
Rate for Payer: Cash Price	$98.15
Rate for Payer: Health Management Network Commercial	$128.35
Rate for Payer: Kaiser Permanente Commercial	$135.90
Rate for Payer: MDX Hawaii PPO	$146.47

B. pertussis IgA Immunoblot FSI

Facility

$151.00

Service Code	HCPCS 86615
Hospital Charge Code	9916507
Hospital Revenue Code	302
Min. Negotiated Rate	$11.06
Max. Negotiated Rate	$146.47
Rate for Payer: AlohaCare Medicaid	$75.50
Rate for Payer: AlohaCare Medicare	$75.50
Rate for Payer: Cash Price	$98.15
Rate for Payer: Cash Price	$98.15
Rate for Payer: Devoted Health Medicare	$83.05
Rate for Payer: Hawaii Medical Service Association ABD	$11.06
Rate for Payer: Hawaii Medical Service Association Commercial	$16.49
Rate for Payer: Hawaii Medical Service Association Medicare	$75.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$18.22
Rate for Payer: Hawaii Western Management Group Commercial	$13.19
Rate for Payer: Health Management Network Commercial	$128.35
Rate for Payer: Humana Medicare	$75.50
Rate for Payer: Kaiser Permanente Commercial	$135.90
Rate for Payer: Kaiser Permanente Medicaid	$77.01
Rate for Payer: Kaiser Permanente Medicare	$75.50
Rate for Payer: MDX Hawaii PPO	$146.47
Rate for Payer: Ohana Health Plan Medicaid	$75.50
Rate for Payer: Ohana Health Plan Medicare	$75.50
Rate for Payer: UnitedHealthcare Medicaid	$11.06
Rate for Payer: UnitedHealthcare Medicare	$75.50
Rate for Payer: University Health Alliance Commercial	$34.10

B. pertussis IgG, IgM, IgA with Rfx Immunoblot FSI

Facility

$151.00

Service Code	HCPCS 86615
Hospital Charge Code	9916508
Hospital Revenue Code	302
Min. Negotiated Rate	$128.35
Max. Negotiated Rate	$146.47
Rate for Payer: Cash Price	$98.15
Rate for Payer: Health Management Network Commercial	$128.35
Rate for Payer: Kaiser Permanente Commercial	$135.90
Rate for Payer: MDX Hawaii PPO	$146.47

B. pertussis IgG, IgM, IgA with Rfx Immunoblot FSI

Facility

$151.00

Service Code	HCPCS 86615
Hospital Charge Code	9916508
Hospital Revenue Code	302
Min. Negotiated Rate	$11.06
Max. Negotiated Rate	$146.47
Rate for Payer: AlohaCare Medicaid	$75.50
Rate for Payer: AlohaCare Medicare	$75.50
Rate for Payer: Cash Price	$98.15
Rate for Payer: Cash Price	$98.15
Rate for Payer: Devoted Health Medicare	$83.05
Rate for Payer: Hawaii Medical Service Association ABD	$11.06
Rate for Payer: Hawaii Medical Service Association Commercial	$16.49
Rate for Payer: Hawaii Medical Service Association Medicare	$75.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$18.22
Rate for Payer: Hawaii Western Management Group Commercial	$13.19
Rate for Payer: Health Management Network Commercial	$128.35
Rate for Payer: Humana Medicare	$75.50
Rate for Payer: Kaiser Permanente Commercial	$135.90
Rate for Payer: Kaiser Permanente Medicaid	$77.01
Rate for Payer: Kaiser Permanente Medicare	$75.50
Rate for Payer: MDX Hawaii PPO	$146.47
Rate for Payer: Ohana Health Plan Medicaid	$75.50
Rate for Payer: Ohana Health Plan Medicare	$75.50
Rate for Payer: UnitedHealthcare Medicaid	$11.06
Rate for Payer: UnitedHealthcare Medicare	$75.50
Rate for Payer: University Health Alliance Commercial	$34.10

B. pertussis IgG Immunoblot FSI

Facility

$151.00

Service Code	HCPCS 86615
Hospital Charge Code	9902025
Hospital Revenue Code	302
Min. Negotiated Rate	$128.35
Max. Negotiated Rate	$146.47
Rate for Payer: Cash Price	$98.15
Rate for Payer: Health Management Network Commercial	$128.35
Rate for Payer: Kaiser Permanente Commercial	$135.90
Rate for Payer: MDX Hawaii PPO	$146.47

Know your out-of-pocket cost for care.

All Charges