Samuel Mahelona Memorial Hospital

All Charges

Charge

Type

Setting

Price

BRIDGE PLATE, STRAIGHT, 2.4MM, 6 HOLE

Facility

$1,462.00

Service Code	HCPCS C1713
Hospital Charge Code	12970973
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

BRIDGE PLATE, STRAIGHT, 2.4MM, 6 HOLE

Facility

$1,462.00

Service Code	HCPCS C1713
Hospital Charge Code	12970973
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

brimonidine 0.15% ophth soln 5 mL [HHSC]

Facility

$642.61

Service Code	NDC 60505056401
Hospital Charge Code	2501083
Hospital Revenue Code	250
Min. Negotiated Rate	$546.22
Max. Negotiated Rate	$623.33
Rate for Payer: Cash Price	$417.70
Rate for Payer: Health Management Network Commercial	$546.22
Rate for Payer: Kaiser Permanente Commercial	$578.35
Rate for Payer: MDX Hawaii PPO	$623.33

brimonidine 0.15% ophth soln 5 mL [HHSC]

Facility

$642.61

Service Code	NDC 60505056401
Hospital Charge Code	2501083
Hospital Revenue Code	250
Min. Negotiated Rate	$321.31
Max. Negotiated Rate	$623.33
Rate for Payer: AlohaCare Medicaid	$321.31
Rate for Payer: AlohaCare Medicare	$321.31
Rate for Payer: Cash Price	$417.70
Rate for Payer: Devoted Health Medicare	$353.44
Rate for Payer: Hawaii Medical Service Association Medicare	$321.31
Rate for Payer: Hawaii Western Management Group Commercial	$610.48
Rate for Payer: Health Management Network Commercial	$546.22
Rate for Payer: Humana Medicare	$321.31
Rate for Payer: Kaiser Permanente Commercial	$578.35
Rate for Payer: Kaiser Permanente Medicaid	$327.73
Rate for Payer: Kaiser Permanente Medicare	$321.31
Rate for Payer: MDX Hawaii PPO	$623.33
Rate for Payer: Ohana Health Plan Medicaid	$321.31
Rate for Payer: Ohana Health Plan Medicare	$321.31
Rate for Payer: UnitedHealthcare Medicaid	$385.57
Rate for Payer: UnitedHealthcare Medicare	$321.31
Rate for Payer: University Health Alliance Commercial	$468.40

brimonidine 0.15% ophth soln 5 mL [HHSC]

Facility

$642.61

Service Code	NDC 61314014405
Hospital Charge Code	2501083
Hospital Revenue Code	250
Min. Negotiated Rate	$321.31
Max. Negotiated Rate	$623.33
Rate for Payer: AlohaCare Medicaid	$321.31
Rate for Payer: AlohaCare Medicare	$321.31
Rate for Payer: Cash Price	$417.70
Rate for Payer: Devoted Health Medicare	$353.44
Rate for Payer: Hawaii Medical Service Association Medicare	$321.31
Rate for Payer: Hawaii Western Management Group Commercial	$610.48
Rate for Payer: Health Management Network Commercial	$546.22
Rate for Payer: Humana Medicare	$321.31
Rate for Payer: Kaiser Permanente Commercial	$578.35
Rate for Payer: Kaiser Permanente Medicaid	$327.73
Rate for Payer: Kaiser Permanente Medicare	$321.31
Rate for Payer: MDX Hawaii PPO	$623.33
Rate for Payer: Ohana Health Plan Medicaid	$321.31
Rate for Payer: Ohana Health Plan Medicare	$321.31
Rate for Payer: UnitedHealthcare Medicaid	$385.57
Rate for Payer: UnitedHealthcare Medicare	$321.31
Rate for Payer: University Health Alliance Commercial	$468.40

brimonidine 0.15% ophth soln 5 mL [HHSC]

Facility

$642.61

Service Code	NDC 61314014405
Hospital Charge Code	2501083
Hospital Revenue Code	250
Min. Negotiated Rate	$546.22
Max. Negotiated Rate	$623.33
Rate for Payer: Cash Price	$417.70
Rate for Payer: Health Management Network Commercial	$546.22
Rate for Payer: Kaiser Permanente Commercial	$578.35
Rate for Payer: MDX Hawaii PPO	$623.33

BRONCHITIS AND ASTHMA WITH CC/MCC

Facility

$17,800.20

Service Code	MSDRG 202
Min. Negotiated Rate	$17,800.20
Max. Negotiated Rate	$17,800.20
Rate for Payer: Hawaii Medical Service Association Commercial	$17,800.20

BRONCHITIS AND ASTHMA WITHOUT CC/MCC

Facility

$13,533.84

Service Code	MSDRG 203
Min. Negotiated Rate	$13,533.84
Max. Negotiated Rate	$13,533.84
Rate for Payer: Hawaii Medical Service Association Commercial	$13,533.84

BRONCHOSPASM EVALUATION CHARGE

Facility

$664.00

Service Code	HCPCS 94060
Hospital Charge Code	8243039
Hospital Revenue Code	460
Min. Negotiated Rate	$31.20
Max. Negotiated Rate	$644.08
Rate for Payer: AlohaCare Medicaid	$332.00
Rate for Payer: AlohaCare Medicare	$332.00
Rate for Payer: Cash Price	$431.60
Rate for Payer: Cash Price	$431.60
Rate for Payer: Devoted Health Medicare	$365.20
Rate for Payer: Hawaii Medical Service Association ABD	$31.20
Rate for Payer: Hawaii Medical Service Association Commercial	$476.55
Rate for Payer: Hawaii Medical Service Association Medicare	$332.00
Rate for Payer: Hawaii Medical Service Association Non-ABD	$32.76
Rate for Payer: Hawaii Western Management Group Commercial	$630.80
Rate for Payer: Health Management Network Commercial	$564.40
Rate for Payer: Humana Medicare	$332.00
Rate for Payer: Kaiser Permanente Commercial	$597.60
Rate for Payer: Kaiser Permanente Medicaid	$338.64
Rate for Payer: Kaiser Permanente Medicare	$332.00
Rate for Payer: MDX Hawaii PPO	$644.08
Rate for Payer: Ohana Health Plan Medicaid	$332.00
Rate for Payer: Ohana Health Plan Medicare	$332.00
Rate for Payer: UnitedHealthcare Medicaid	$31.20
Rate for Payer: UnitedHealthcare Medicare	$332.00
Rate for Payer: University Health Alliance Commercial	$371.84

BRONCHOSPASM EVALUATION CHARGE

Facility

$664.00

Service Code	HCPCS 94060
Hospital Charge Code	8243039
Hospital Revenue Code	460
Min. Negotiated Rate	$564.40
Max. Negotiated Rate	$644.08
Rate for Payer: Cash Price	$431.60
Rate for Payer: Health Management Network Commercial	$564.40
Rate for Payer: Kaiser Permanente Commercial	$597.60
Rate for Payer: MDX Hawaii PPO	$644.08

BSS 500 ML Bag

Facility

$119.00

Hospital Charge Code	8527570
Hospital Revenue Code	272
Min. Negotiated Rate	$59.50
Max. Negotiated Rate	$115.43
Rate for Payer: AlohaCare Medicaid	$59.50
Rate for Payer: AlohaCare Medicare	$59.50
Rate for Payer: Cash Price	$77.35
Rate for Payer: Devoted Health Medicare	$65.45
Rate for Payer: Hawaii Medical Service Association Medicare	$59.50
Rate for Payer: Hawaii Western Management Group Commercial	$113.05
Rate for Payer: Health Management Network Commercial	$101.15
Rate for Payer: Humana Medicare	$59.50
Rate for Payer: Kaiser Permanente Commercial	$107.10
Rate for Payer: Kaiser Permanente Medicaid	$60.69
Rate for Payer: Kaiser Permanente Medicare	$59.50
Rate for Payer: MDX Hawaii PPO	$115.43
Rate for Payer: Ohana Health Plan Medicaid	$59.50
Rate for Payer: Ohana Health Plan Medicare	$59.50
Rate for Payer: UnitedHealthcare Medicare	$59.50
Rate for Payer: University Health Alliance Commercial	$86.74

BSS 500 ML Bag

Facility

$119.00

Hospital Charge Code	8527570
Hospital Revenue Code	272
Min. Negotiated Rate	$101.15
Max. Negotiated Rate	$115.43
Rate for Payer: Cash Price	$77.35
Rate for Payer: Health Management Network Commercial	$101.15
Rate for Payer: Kaiser Permanente Commercial	$107.10
Rate for Payer: MDX Hawaii PPO	$115.43

BUCKET CAST PLASTIC EA

Professional

Both

$43.00

Hospital Charge Code	12954881
Hospital Revenue Code	272
Min. Negotiated Rate	$36.55
Max. Negotiated Rate	$36.55
Rate for Payer: Cash Price	$27.95
Rate for Payer: Health Management Network Commercial	$36.55

BUCKET CAST PLASTIC EA

Facility

$43.00

Hospital Charge Code	12954881
Hospital Revenue Code	272
Min. Negotiated Rate	$36.55
Max. Negotiated Rate	$41.71
Rate for Payer: Cash Price	$27.95
Rate for Payer: Health Management Network Commercial	$36.55
Rate for Payer: Kaiser Permanente Commercial	$38.70
Rate for Payer: MDX Hawaii PPO	$41.71

BUCKET CAST PLASTIC EA

Facility

$43.00

Hospital Charge Code	12954881
Hospital Revenue Code	272
Min. Negotiated Rate	$21.50
Max. Negotiated Rate	$41.71
Rate for Payer: AlohaCare Medicaid	$21.50
Rate for Payer: AlohaCare Medicare	$21.50
Rate for Payer: Cash Price	$27.95
Rate for Payer: Devoted Health Medicare	$23.65
Rate for Payer: Hawaii Medical Service Association Medicare	$21.50
Rate for Payer: Hawaii Western Management Group Commercial	$40.85
Rate for Payer: Health Management Network Commercial	$36.55
Rate for Payer: Humana Medicare	$21.50
Rate for Payer: Kaiser Permanente Commercial	$38.70
Rate for Payer: Kaiser Permanente Medicaid	$21.93
Rate for Payer: Kaiser Permanente Medicare	$21.50
Rate for Payer: MDX Hawaii PPO	$41.71
Rate for Payer: Ohana Health Plan Medicaid	$21.50
Rate for Payer: Ohana Health Plan Medicare	$21.50
Rate for Payer: UnitedHealthcare Medicare	$21.50
Rate for Payer: University Health Alliance Commercial	$31.34

BUGBEE ELECTRODE 5 FR 58CM L DISPOSABLE STERILE

Facility

$340.00

Hospital Charge Code	9816284
Hospital Revenue Code	272
Min. Negotiated Rate	$289.00
Max. Negotiated Rate	$329.80
Rate for Payer: Cash Price	$221.00
Rate for Payer: Health Management Network Commercial	$289.00
Rate for Payer: Kaiser Permanente Commercial	$306.00
Rate for Payer: MDX Hawaii PPO	$329.80

BUGBEE ELECTRODE 5 FR 58CM L DISPOSABLE STERILE

Facility

$340.00

Hospital Charge Code	9816284
Hospital Revenue Code	272
Min. Negotiated Rate	$170.00
Max. Negotiated Rate	$329.80
Rate for Payer: AlohaCare Medicaid	$170.00
Rate for Payer: AlohaCare Medicare	$170.00
Rate for Payer: Cash Price	$221.00
Rate for Payer: Devoted Health Medicare	$187.00
Rate for Payer: Hawaii Medical Service Association Medicare	$170.00
Rate for Payer: Hawaii Western Management Group Commercial	$323.00
Rate for Payer: Health Management Network Commercial	$289.00
Rate for Payer: Humana Medicare	$170.00
Rate for Payer: Kaiser Permanente Commercial	$306.00
Rate for Payer: Kaiser Permanente Medicaid	$173.40
Rate for Payer: Kaiser Permanente Medicare	$170.00
Rate for Payer: MDX Hawaii PPO	$329.80
Rate for Payer: Ohana Health Plan Medicaid	$170.00
Rate for Payer: Ohana Health Plan Medicare	$170.00
Rate for Payer: UnitedHealthcare Medicare	$170.00
Rate for Payer: University Health Alliance Commercial	$247.83

BUN (Arterial) POCT

Facility

$61.00

Service Code	HCPCS 84520
Hospital Charge Code	9364704
Hospital Revenue Code	301
Min. Negotiated Rate	$3.95
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	$5.45
Rate for Payer: Hawaii Medical Service Association Commercial	$4.94
Rate for Payer: Hawaii Medical Service Association Medicare	$30.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$5.72
Rate for Payer: Hawaii Western Management Group Commercial	$3.95
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	$5.45
Rate for Payer: UnitedHealthcare Medicare	$30.50
Rate for Payer: University Health Alliance Commercial	$10.19

BUN (Arterial) POCT

Facility

$61.00

Service Code	HCPCS 84520
Hospital Charge Code	9364704
Hospital Revenue Code	301
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

BUN FSI

Facility

$61.00

Service Code	HCPCS 84520
Hospital Charge Code	8117867
Hospital Revenue Code	301
Min. Negotiated Rate	$3.95
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	$5.45
Rate for Payer: Hawaii Medical Service Association Commercial	$4.94
Rate for Payer: Hawaii Medical Service Association Medicare	$30.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$5.72
Rate for Payer: Hawaii Western Management Group Commercial	$3.95
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	$5.45
Rate for Payer: UnitedHealthcare Medicare	$30.50
Rate for Payer: University Health Alliance Commercial	$10.19

BUN FSI

Facility

$61.00

Service Code	HCPCS 84520
Hospital Charge Code	8117867
Hospital Revenue Code	301
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

BUN iSTAT

Facility

$56.00

Service Code	HCPCS 84520 QW
Hospital Charge Code	1019789
Hospital Revenue Code	301
Min. Negotiated Rate	$3.95
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	$5.45
Rate for Payer: Hawaii Medical Service Association Commercial	$4.94
Rate for Payer: Hawaii Medical Service Association Medicare	$28.00
Rate for Payer: Hawaii Medical Service Association Non-ABD	$5.72
Rate for Payer: Hawaii Western Management Group Commercial	$3.95
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	$5.45
Rate for Payer: UnitedHealthcare Medicare	$28.00
Rate for Payer: University Health Alliance Commercial	$10.19

BUN iSTAT

Facility

$56.00

Service Code	HCPCS 84520 QW
Hospital Charge Code	1019789
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

BUN (Venous) POCT

Facility

$61.00

Service Code	HCPCS 84520
Hospital Charge Code	9364733
Hospital Revenue Code	301
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

BUN (Venous) POCT

Facility

$61.00

Service Code	HCPCS 84520
Hospital Charge Code	9364733
Hospital Revenue Code	301
Min. Negotiated Rate	$3.95
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	$5.45
Rate for Payer: Hawaii Medical Service Association Commercial	$4.94
Rate for Payer: Hawaii Medical Service Association Medicare	$30.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$5.72
Rate for Payer: Hawaii Western Management Group Commercial	$3.95
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	$5.45
Rate for Payer: UnitedHealthcare Medicare	$30.50
Rate for Payer: University Health Alliance Commercial	$10.19

Know your out-of-pocket cost for care.

All Charges