Samuel Mahelona Memorial Hospital

All Charges

Charge

Type

Setting

Price

B. pertussis IgG Immunoblot FSI

Facility

$151.00

Service Code	HCPCS 86615
Hospital Charge Code	9902025
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 Reflex Immunoblot FSI

Facility

$78.00

Service Code	HCPCS 86615
Hospital Charge Code	9902024
Hospital Revenue Code	302
Min. Negotiated Rate	$66.30
Max. Negotiated Rate	$75.66
Rate for Payer: Cash Price	$50.70
Rate for Payer: Health Management Network Commercial	$66.30
Rate for Payer: Kaiser Permanente Commercial	$70.20
Rate for Payer: MDX Hawaii PPO	$75.66

B. pertussis IgG Reflex Immunoblot FSI

Facility

$78.00

Service Code	HCPCS 86615
Hospital Charge Code	9902024
Hospital Revenue Code	302
Min. Negotiated Rate	$11.06
Max. Negotiated Rate	$75.66
Rate for Payer: AlohaCare Medicaid	$39.00
Rate for Payer: AlohaCare Medicare	$39.00
Rate for Payer: Cash Price	$50.70
Rate for Payer: Cash Price	$50.70
Rate for Payer: Devoted Health Medicare	$42.90
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	$39.00
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	$66.30
Rate for Payer: Humana Medicare	$39.00
Rate for Payer: Kaiser Permanente Commercial	$70.20
Rate for Payer: Kaiser Permanente Medicaid	$39.78
Rate for Payer: Kaiser Permanente Medicare	$39.00
Rate for Payer: MDX Hawaii PPO	$75.66
Rate for Payer: Ohana Health Plan Medicaid	$39.00
Rate for Payer: Ohana Health Plan Medicare	$39.00
Rate for Payer: UnitedHealthcare Medicaid	$11.06
Rate for Payer: UnitedHealthcare Medicare	$39.00
Rate for Payer: University Health Alliance Commercial	$34.10

B. pertussis IgM Immunoblot FSI

Facility

$151.00

Service Code	HCPCS 86615
Hospital Charge Code	9916506
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 IgM Immunoblot FSI

Facility

$151.00

Service Code	HCPCS 86615
Hospital Charge Code	9916506
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

BRACE CLAVICLE ADL XLGE

Facility

$54.00

Service Code	HCPCS L3650
Hospital Charge Code	8266934
Hospital Revenue Code	274
Min. Negotiated Rate	$30.24
Max. Negotiated Rate	$52.38
Rate for Payer: Cash Price	$35.10
Rate for Payer: Hawaii Western Management Group Commercial	$37.80
Rate for Payer: Health Management Network Commercial	$45.90
Rate for Payer: Kaiser Permanente Commercial	$48.60
Rate for Payer: MDX Hawaii PPO	$52.38
Rate for Payer: University Health Alliance Commercial	$30.24

BRACE CLAVICLE ADL XLGE

Facility

$54.00

Service Code	HCPCS L3650
Hospital Charge Code	8266934
Hospital Revenue Code	274
Min. Negotiated Rate	$27.00
Max. Negotiated Rate	$52.38
Rate for Payer: AlohaCare Medicaid	$27.00
Rate for Payer: AlohaCare Medicare	$27.00
Rate for Payer: Cash Price	$35.10
Rate for Payer: Cash Price	$35.10
Rate for Payer: Devoted Health Medicare	$29.70
Rate for Payer: Hawaii Medical Service Association Medicare	$27.00
Rate for Payer: Hawaii Western Management Group Commercial	$37.80
Rate for Payer: Health Management Network Commercial	$45.90
Rate for Payer: Humana Medicare	$27.00
Rate for Payer: Kaiser Permanente Commercial	$48.60
Rate for Payer: Kaiser Permanente Medicaid	$27.54
Rate for Payer: Kaiser Permanente Medicare	$27.00
Rate for Payer: MDX Hawaii PPO	$52.38
Rate for Payer: Ohana Health Plan Medicaid	$27.00
Rate for Payer: Ohana Health Plan Medicare	$27.00
Rate for Payer: UnitedHealthcare Medicaid	$41.53
Rate for Payer: UnitedHealthcare Medicare	$27.00
Rate for Payer: University Health Alliance Commercial	$30.24

BRACE CLAVICLE ADULT LGE

Facility

$56.00

Service Code	HCPCS L3650
Hospital Charge Code	8267012
Hospital Revenue Code	274
Min. Negotiated Rate	$31.36
Max. Negotiated Rate	$54.32
Rate for Payer: Cash Price	$36.40
Rate for Payer: Hawaii Western Management Group Commercial	$39.20
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
Rate for Payer: University Health Alliance Commercial	$31.36

BRACE CLAVICLE ADULT LGE

Facility

$56.00

Service Code	HCPCS L3650
Hospital Charge Code	8267012
Hospital Revenue Code	274
Min. Negotiated Rate	$28.00
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 Medicare	$28.00
Rate for Payer: Hawaii Western Management Group Commercial	$39.20
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	$41.53
Rate for Payer: UnitedHealthcare Medicare	$28.00
Rate for Payer: University Health Alliance Commercial	$31.36

BRACE CLAVICLE ADULT MED

Facility

$54.00

Service Code	HCPCS L3650
Hospital Charge Code	8267011
Hospital Revenue Code	274
Min. Negotiated Rate	$30.24
Max. Negotiated Rate	$52.38
Rate for Payer: Cash Price	$35.10
Rate for Payer: Hawaii Western Management Group Commercial	$37.80
Rate for Payer: Health Management Network Commercial	$45.90
Rate for Payer: Kaiser Permanente Commercial	$48.60
Rate for Payer: MDX Hawaii PPO	$52.38
Rate for Payer: University Health Alliance Commercial	$30.24

BRACE CLAVICLE ADULT MED

Facility

$54.00

Service Code	HCPCS L3650
Hospital Charge Code	8267011
Hospital Revenue Code	274
Min. Negotiated Rate	$27.00
Max. Negotiated Rate	$52.38
Rate for Payer: AlohaCare Medicaid	$27.00
Rate for Payer: AlohaCare Medicare	$27.00
Rate for Payer: Cash Price	$35.10
Rate for Payer: Cash Price	$35.10
Rate for Payer: Devoted Health Medicare	$29.70
Rate for Payer: Hawaii Medical Service Association Medicare	$27.00
Rate for Payer: Hawaii Western Management Group Commercial	$37.80
Rate for Payer: Health Management Network Commercial	$45.90
Rate for Payer: Humana Medicare	$27.00
Rate for Payer: Kaiser Permanente Commercial	$48.60
Rate for Payer: Kaiser Permanente Medicaid	$27.54
Rate for Payer: Kaiser Permanente Medicare	$27.00
Rate for Payer: MDX Hawaii PPO	$52.38
Rate for Payer: Ohana Health Plan Medicaid	$27.00
Rate for Payer: Ohana Health Plan Medicare	$27.00
Rate for Payer: UnitedHealthcare Medicaid	$41.53
Rate for Payer: UnitedHealthcare Medicare	$27.00
Rate for Payer: University Health Alliance Commercial	$30.24

BRACE CLAVICLE ADULT SML

Facility

$54.00

Service Code	HCPCS L3650
Hospital Charge Code	8266869
Hospital Revenue Code	274
Min. Negotiated Rate	$30.24
Max. Negotiated Rate	$52.38
Rate for Payer: Cash Price	$35.10
Rate for Payer: Hawaii Western Management Group Commercial	$37.80
Rate for Payer: Health Management Network Commercial	$45.90
Rate for Payer: Kaiser Permanente Commercial	$48.60
Rate for Payer: MDX Hawaii PPO	$52.38
Rate for Payer: University Health Alliance Commercial	$30.24

BRACE CLAVICLE ADULT SML

Facility

$54.00

Service Code	HCPCS L3650
Hospital Charge Code	8266869
Hospital Revenue Code	274
Min. Negotiated Rate	$27.00
Max. Negotiated Rate	$52.38
Rate for Payer: AlohaCare Medicaid	$27.00
Rate for Payer: AlohaCare Medicare	$27.00
Rate for Payer: Cash Price	$35.10
Rate for Payer: Cash Price	$35.10
Rate for Payer: Devoted Health Medicare	$29.70
Rate for Payer: Hawaii Medical Service Association Medicare	$27.00
Rate for Payer: Hawaii Western Management Group Commercial	$37.80
Rate for Payer: Health Management Network Commercial	$45.90
Rate for Payer: Humana Medicare	$27.00
Rate for Payer: Kaiser Permanente Commercial	$48.60
Rate for Payer: Kaiser Permanente Medicaid	$27.54
Rate for Payer: Kaiser Permanente Medicare	$27.00
Rate for Payer: MDX Hawaii PPO	$52.38
Rate for Payer: Ohana Health Plan Medicaid	$27.00
Rate for Payer: Ohana Health Plan Medicare	$27.00
Rate for Payer: UnitedHealthcare Medicaid	$41.53
Rate for Payer: UnitedHealthcare Medicare	$27.00
Rate for Payer: University Health Alliance Commercial	$30.24

BRACE LUMB ORTHO RIGID A&P PANEL PREFAB

Facility

$1,651.00

Service Code	HCPCS L0627
Hospital Charge Code	9568326
Hospital Revenue Code	274
Min. Negotiated Rate	$924.56
Max. Negotiated Rate	$1,601.47
Rate for Payer: Cash Price	$1,073.15
Rate for Payer: Hawaii Western Management Group Commercial	$1,155.70
Rate for Payer: Health Management Network Commercial	$1,403.35
Rate for Payer: Kaiser Permanente Commercial	$1,485.90
Rate for Payer: MDX Hawaii PPO	$1,601.47
Rate for Payer: University Health Alliance Commercial	$924.56

BRACE LUMB ORTHO RIGID A&P PANEL PREFAB

Facility

$1,651.00

Service Code	HCPCS L0627
Hospital Charge Code	9568326
Hospital Revenue Code	274
Min. Negotiated Rate	$193.79
Max. Negotiated Rate	$1,601.47
Rate for Payer: Ohana Health Plan Medicaid	$825.50
Rate for Payer: AlohaCare Medicaid	$825.50
Rate for Payer: AlohaCare Medicare	$825.50
Rate for Payer: Cash Price	$1,073.15
Rate for Payer: Cash Price	$1,073.15
Rate for Payer: Devoted Health Medicare	$908.05
Rate for Payer: Hawaii Medical Service Association Medicare	$825.50
Rate for Payer: Hawaii Western Management Group Commercial	$1,155.70
Rate for Payer: Health Management Network Commercial	$1,403.35
Rate for Payer: Humana Medicare	$825.50
Rate for Payer: Kaiser Permanente Commercial	$1,485.90
Rate for Payer: Kaiser Permanente Medicaid	$842.01
Rate for Payer: Kaiser Permanente Medicare	$825.50
Rate for Payer: MDX Hawaii PPO	$1,601.47
Rate for Payer: Ohana Health Plan Medicare	$825.50
Rate for Payer: UnitedHealthcare Medicaid	$193.79
Rate for Payer: UnitedHealthcare Medicare	$825.50
Rate for Payer: University Health Alliance Commercial	$924.56

BRACE TLSO FLEX TRUNK

Facility

$2,262.00

Service Code	HCPCS L0456
Hospital Charge Code	9533608
Hospital Revenue Code	274
Min. Negotiated Rate	$468.91
Max. Negotiated Rate	$2,194.14
Rate for Payer: AlohaCare Medicaid	$1,131.00
Rate for Payer: AlohaCare Medicare	$1,131.00
Rate for Payer: Cash Price	$1,470.30
Rate for Payer: Cash Price	$1,470.30
Rate for Payer: Devoted Health Medicare	$1,244.10
Rate for Payer: Hawaii Medical Service Association Medicare	$1,131.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,583.40
Rate for Payer: Health Management Network Commercial	$1,922.70
Rate for Payer: Humana Medicare	$1,131.00
Rate for Payer: Kaiser Permanente Commercial	$2,035.80
Rate for Payer: Kaiser Permanente Medicaid	$1,153.62
Rate for Payer: Kaiser Permanente Medicare	$1,131.00
Rate for Payer: MDX Hawaii PPO	$2,194.14
Rate for Payer: Ohana Health Plan Medicaid	$1,131.00
Rate for Payer: Ohana Health Plan Medicare	$1,131.00
Rate for Payer: UnitedHealthcare Medicaid	$468.91
Rate for Payer: UnitedHealthcare Medicare	$1,131.00
Rate for Payer: University Health Alliance Commercial	$1,266.72

BRACE TLSO FLEX TRUNK

Facility

$2,262.00

Service Code	HCPCS L0456
Hospital Charge Code	9533608
Hospital Revenue Code	274
Min. Negotiated Rate	$1,266.72
Max. Negotiated Rate	$2,194.14
Rate for Payer: Cash Price	$1,470.30
Rate for Payer: Hawaii Western Management Group Commercial	$1,583.40
Rate for Payer: Health Management Network Commercial	$1,922.70
Rate for Payer: Kaiser Permanente Commercial	$2,035.80
Rate for Payer: MDX Hawaii PPO	$2,194.14
Rate for Payer: University Health Alliance Commercial	$1,266.72

Brain Natriuretic Peptide BNP FSI

Facility

$878.00

Service Code	HCPCS 83880
Hospital Charge Code	8117866
Hospital Revenue Code	301
Min. Negotiated Rate	$746.30
Max. Negotiated Rate	$851.66
Rate for Payer: Cash Price	$570.70
Rate for Payer: Health Management Network Commercial	$746.30
Rate for Payer: Kaiser Permanente Commercial	$790.20
Rate for Payer: MDX Hawaii PPO	$851.66

Brain Natriuretic Peptide BNP FSI

Facility

$878.00

Service Code	HCPCS 83880
Hospital Charge Code	8117866
Hospital Revenue Code	301
Min. Negotiated Rate	$28.46
Max. Negotiated Rate	$851.66
Rate for Payer: AlohaCare Medicaid	$439.00
Rate for Payer: AlohaCare Medicare	$439.00
Rate for Payer: Cash Price	$570.70
Rate for Payer: Cash Price	$570.70
Rate for Payer: Devoted Health Medicare	$482.90
Rate for Payer: Hawaii Medical Service Association ABD	$28.46
Rate for Payer: Hawaii Medical Service Association Commercial	$49.08
Rate for Payer: Hawaii Medical Service Association Medicare	$439.00
Rate for Payer: Hawaii Medical Service Association Non-ABD	$46.89
Rate for Payer: Hawaii Western Management Group Commercial	$39.26
Rate for Payer: Health Management Network Commercial	$746.30
Rate for Payer: Humana Medicare	$439.00
Rate for Payer: Kaiser Permanente Commercial	$790.20
Rate for Payer: Kaiser Permanente Medicaid	$447.78
Rate for Payer: Kaiser Permanente Medicare	$439.00
Rate for Payer: MDX Hawaii PPO	$851.66
Rate for Payer: Ohana Health Plan Medicaid	$439.00
Rate for Payer: Ohana Health Plan Medicare	$439.00
Rate for Payer: UnitedHealthcare Medicaid	$28.46
Rate for Payer: UnitedHealthcare Medicare	$439.00
Rate for Payer: University Health Alliance Commercial	$87.75

BREAST BIOPSY, LOCAL EXCISION AND OTHER BREAST PROCEDURES WITH CC/MCC

Facility

$25,171.52

Service Code	MSDRG 584
Min. Negotiated Rate	$25,171.52
Max. Negotiated Rate	$25,171.52
Rate for Payer: Hawaii Medical Service Association Commercial	$25,171.52

BREAST BIOPSY, LOCAL EXCISION AND OTHER BREAST PROCEDURES WITHOUT CC/MCC

Facility

$24,365.66

Service Code	MSDRG 585
Min. Negotiated Rate	$24,365.66
Max. Negotiated Rate	$24,365.66
Rate for Payer: Hawaii Medical Service Association Commercial	$24,365.66

BREAST PUMP CHARGE

Facility

$181.00

Service Code	HCPCS E0604
Hospital Charge Code	8280923
Hospital Revenue Code	271
Min. Negotiated Rate	$153.85
Max. Negotiated Rate	$175.57
Rate for Payer: Cash Price	$117.65
Rate for Payer: Health Management Network Commercial	$153.85
Rate for Payer: Kaiser Permanente Commercial	$162.90
Rate for Payer: MDX Hawaii PPO	$175.57

BREAST PUMP CHARGE

Facility

$181.00

Service Code	HCPCS E0604
Hospital Charge Code	8280923
Hospital Revenue Code	271
Min. Negotiated Rate	$90.50
Max. Negotiated Rate	$175.57
Rate for Payer: AlohaCare Medicaid	$90.50
Rate for Payer: AlohaCare Medicare	$90.50
Rate for Payer: Cash Price	$117.65
Rate for Payer: Devoted Health Medicare	$99.55
Rate for Payer: Hawaii Medical Service Association Medicare	$90.50
Rate for Payer: Hawaii Western Management Group Commercial	$171.95
Rate for Payer: Health Management Network Commercial	$153.85
Rate for Payer: Humana Medicare	$90.50
Rate for Payer: Kaiser Permanente Commercial	$162.90
Rate for Payer: Kaiser Permanente Medicaid	$92.31
Rate for Payer: Kaiser Permanente Medicare	$90.50
Rate for Payer: MDX Hawaii PPO	$175.57
Rate for Payer: Ohana Health Plan Medicaid	$90.50
Rate for Payer: Ohana Health Plan Medicare	$90.50
Rate for Payer: UnitedHealthcare Medicare	$90.50
Rate for Payer: University Health Alliance Commercial	$131.93

BRIDGE PLATE, STRAIGHT, 2.0MM, 6 HOLE

Facility

$1,462.00

Service Code	HCPCS C1713
Hospital Charge Code	12971938
Hospital Revenue Code	278
Min. Negotiated Rate	$731.00
Max. Negotiated Rate	$1,418.14
Rate for Payer: AlohaCare Medicaid	$731.00
Rate for Payer: AlohaCare Medicare	$731.00
Rate for Payer: Cash Price	$950.30
Rate for Payer: Devoted Health Medicare	$804.10
Rate for Payer: Hawaii Medical Service Association Medicare	$731.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,023.40
Rate for Payer: Health Management Network Commercial	$1,242.70
Rate for Payer: Humana Medicare	$731.00
Rate for Payer: Kaiser Permanente Commercial	$1,315.80
Rate for Payer: Kaiser Permanente Medicaid	$745.62
Rate for Payer: Kaiser Permanente Medicare	$731.00
Rate for Payer: MDX Hawaii PPO	$1,418.14
Rate for Payer: Ohana Health Plan Medicaid	$731.00
Rate for Payer: Ohana Health Plan Medicare	$731.00
Rate for Payer: UnitedHealthcare Medicare	$731.00
Rate for Payer: University Health Alliance Commercial	$818.72

BRIDGE PLATE, STRAIGHT, 2.0MM, 6 HOLE

Facility

$1,462.00

Service Code	HCPCS C1713
Hospital Charge Code	12971938
Hospital Revenue Code	278
Min. Negotiated Rate	$818.72
Max. Negotiated Rate	$1,418.14
Rate for Payer: Cash Price	$950.30
Rate for Payer: Hawaii Western Management Group Commercial	$1,023.40
Rate for Payer: Health Management Network Commercial	$1,242.70
Rate for Payer: Kaiser Permanente Commercial	$1,315.80
Rate for Payer: MDX Hawaii PPO	$1,418.14
Rate for Payer: University Health Alliance Commercial	$818.72

Know your out-of-pocket cost for care.

All Charges