Samuel Mahelona Memorial Hospital

All Charges

Charge

Type

Setting

Price

Cardiolipin Ab, IgM

Facility

$142.00

Service Code	HCPCS 86147
Hospital Charge Code	12516676
Hospital Revenue Code	302
Min. Negotiated Rate	$120.70
Max. Negotiated Rate	$137.74
Rate for Payer: Cash Price	$92.30
Rate for Payer: Health Management Network Commercial	$120.70
Rate for Payer: Kaiser Permanente Commercial	$127.80
Rate for Payer: MDX Hawaii PPO	$137.74

Cardiolipin Ab, IgM FSI

Facility

$142.00

Service Code	HCPCS 86147
Hospital Charge Code	12478234
Hospital Revenue Code	302
Min. Negotiated Rate	$25.45
Max. Negotiated Rate	$137.74
Rate for Payer: AlohaCare Medicaid	$71.00
Rate for Payer: AlohaCare Medicare	$71.00
Rate for Payer: Cash Price	$92.30
Rate for Payer: Cash Price	$92.30
Rate for Payer: Devoted Health Medicare	$78.10
Rate for Payer: Hawaii Medical Service Association ABD	$35.16
Rate for Payer: Hawaii Medical Service Association Commercial	$31.81
Rate for Payer: Hawaii Medical Service Association Medicare	$71.00
Rate for Payer: Hawaii Medical Service Association Non-ABD	$36.92
Rate for Payer: Hawaii Western Management Group Commercial	$25.45
Rate for Payer: Health Management Network Commercial	$120.70
Rate for Payer: Humana Medicare	$71.00
Rate for Payer: Kaiser Permanente Commercial	$127.80
Rate for Payer: Kaiser Permanente Medicaid	$72.42
Rate for Payer: Kaiser Permanente Medicare	$71.00
Rate for Payer: MDX Hawaii PPO	$137.74
Rate for Payer: Ohana Health Plan Medicaid	$71.00
Rate for Payer: Ohana Health Plan Medicare	$71.00
Rate for Payer: UnitedHealthcare Medicaid	$35.16
Rate for Payer: UnitedHealthcare Medicare	$71.00
Rate for Payer: University Health Alliance Commercial	$65.75

Cardiolipin Ab, IgM FSI

Facility

$142.00

Service Code	HCPCS 86147
Hospital Charge Code	12478234
Hospital Revenue Code	302
Min. Negotiated Rate	$120.70
Max. Negotiated Rate	$137.74
Rate for Payer: Cash Price	$92.30
Rate for Payer: Health Management Network Commercial	$120.70
Rate for Payer: Kaiser Permanente Commercial	$127.80
Rate for Payer: MDX Hawaii PPO	$137.74

Cardiopulmonary Exercise Test

Facility

$188.00

Service Code	HCPCS 94621
Hospital Charge Code	10856784
Hospital Revenue Code	976
Min. Negotiated Rate	$46.54
Max. Negotiated Rate	$476.55
Rate for Payer: AlohaCare Medicaid	$94.00
Rate for Payer: AlohaCare Medicare	$94.00
Rate for Payer: Cash Price	$122.20
Rate for Payer: Cash Price	$122.20
Rate for Payer: Devoted Health Medicare	$103.40
Rate for Payer: Hawaii Medical Service Association ABD	$46.54
Rate for Payer: Hawaii Medical Service Association Commercial	$476.55
Rate for Payer: Hawaii Medical Service Association Medicare	$94.00
Rate for Payer: Hawaii Medical Service Association Non-ABD	$55.57
Rate for Payer: Hawaii Western Management Group Commercial	$178.60
Rate for Payer: Health Management Network Commercial	$159.80
Rate for Payer: Humana Medicare	$94.00
Rate for Payer: Kaiser Permanente Commercial	$169.20
Rate for Payer: Kaiser Permanente Medicaid	$95.88
Rate for Payer: Kaiser Permanente Medicare	$94.00
Rate for Payer: MDX Hawaii PPO	$182.36
Rate for Payer: Ohana Health Plan Medicaid	$94.00
Rate for Payer: Ohana Health Plan Medicare	$94.00
Rate for Payer: UnitedHealthcare Medicaid	$46.54
Rate for Payer: UnitedHealthcare Medicare	$94.00
Rate for Payer: University Health Alliance Commercial	$105.28

Cardiopulmonary Exercise Test

Facility

$188.00

Service Code	HCPCS 94621
Hospital Charge Code	10856784
Hospital Revenue Code	976
Min. Negotiated Rate	$159.80
Max. Negotiated Rate	$182.36
Rate for Payer: Cash Price	$122.20
Rate for Payer: Health Management Network Commercial	$159.80
Rate for Payer: Kaiser Permanente Commercial	$169.20
Rate for Payer: MDX Hawaii PPO	$182.36

CARDIOVASCULAR STRESS TEST CHARGE

Facility

$1,329.00

Service Code	HCPCS 93017
Hospital Charge Code	8282438
Hospital Revenue Code	482
Min. Negotiated Rate	$1,129.65
Max. Negotiated Rate	$1,289.13
Rate for Payer: Cash Price	$863.85
Rate for Payer: Health Management Network Commercial	$1,129.65
Rate for Payer: Kaiser Permanente Commercial	$1,196.10
Rate for Payer: MDX Hawaii PPO	$1,289.13

CARDIOVASCULAR STRESS TEST CHARGE

Facility

$1,329.00

Service Code	HCPCS 93017
Hospital Charge Code	8282438
Hospital Revenue Code	482
Min. Negotiated Rate	$55.90
Max. Negotiated Rate	$1,289.13
Rate for Payer: AlohaCare Medicaid	$664.50
Rate for Payer: AlohaCare Medicare	$664.50
Rate for Payer: Cash Price	$863.85
Rate for Payer: Cash Price	$863.85
Rate for Payer: Devoted Health Medicare	$730.95
Rate for Payer: Hawaii Medical Service Association Commercial	$275.75
Rate for Payer: Hawaii Medical Service Association Medicare	$664.50
Rate for Payer: Hawaii Western Management Group Commercial	$1,262.55
Rate for Payer: Health Management Network Commercial	$1,129.65
Rate for Payer: Humana Medicare	$664.50
Rate for Payer: Kaiser Permanente Commercial	$1,196.10
Rate for Payer: Kaiser Permanente Medicaid	$677.79
Rate for Payer: Kaiser Permanente Medicare	$664.50
Rate for Payer: MDX Hawaii PPO	$1,289.13
Rate for Payer: Ohana Health Plan Medicaid	$664.50
Rate for Payer: Ohana Health Plan Medicare	$664.50
Rate for Payer: UnitedHealthcare Medicaid	$55.90
Rate for Payer: UnitedHealthcare Medicare	$664.50
Rate for Payer: University Health Alliance Commercial	$744.24

cariprazine 1.5 mg capsule [HHSC]

Facility

$283.07

Service Code	NDC 61874011520
Hospital Charge Code	2501088
Hospital Revenue Code	250
Min. Negotiated Rate	$240.61
Max. Negotiated Rate	$274.58
Rate for Payer: Cash Price	$184.00
Rate for Payer: Health Management Network Commercial	$240.61
Rate for Payer: Kaiser Permanente Commercial	$254.76
Rate for Payer: MDX Hawaii PPO	$274.58

cariprazine 1.5 mg capsule [HHSC]

Facility

$292.20

Service Code	NDC 61874011530
Hospital Charge Code	2501088
Hospital Revenue Code	250
Min. Negotiated Rate	$146.10
Max. Negotiated Rate	$283.43
Rate for Payer: Ohana Health Plan Medicare	$146.10
Rate for Payer: AlohaCare Medicaid	$146.10
Rate for Payer: AlohaCare Medicare	$146.10
Rate for Payer: Cash Price	$189.93
Rate for Payer: Devoted Health Medicare	$160.71
Rate for Payer: Hawaii Medical Service Association Medicare	$146.10
Rate for Payer: Hawaii Western Management Group Commercial	$277.59
Rate for Payer: Health Management Network Commercial	$248.37
Rate for Payer: Humana Medicare	$146.10
Rate for Payer: Kaiser Permanente Commercial	$262.98
Rate for Payer: Kaiser Permanente Medicaid	$149.02
Rate for Payer: Kaiser Permanente Medicare	$146.10
Rate for Payer: MDX Hawaii PPO	$283.43
Rate for Payer: Ohana Health Plan Medicaid	$146.10
Rate for Payer: UnitedHealthcare Medicaid	$175.32
Rate for Payer: UnitedHealthcare Medicare	$146.10
Rate for Payer: University Health Alliance Commercial	$212.98

cariprazine 1.5 mg capsule [HHSC]

Facility

$292.20

Service Code	NDC 61874011530
Hospital Charge Code	2501088
Hospital Revenue Code	250
Min. Negotiated Rate	$248.37
Max. Negotiated Rate	$283.43
Rate for Payer: Cash Price	$189.93
Rate for Payer: Health Management Network Commercial	$248.37
Rate for Payer: Kaiser Permanente Commercial	$262.98
Rate for Payer: MDX Hawaii PPO	$283.43

cariprazine 1.5 mg capsule [HHSC]

Facility

$283.07

Service Code	NDC 61874011520
Hospital Charge Code	2501088
Hospital Revenue Code	250
Min. Negotiated Rate	$141.53
Max. Negotiated Rate	$274.58
Rate for Payer: AlohaCare Medicaid	$141.53
Rate for Payer: AlohaCare Medicare	$141.53
Rate for Payer: Cash Price	$184.00
Rate for Payer: Devoted Health Medicare	$155.69
Rate for Payer: Hawaii Medical Service Association Medicare	$141.53
Rate for Payer: Hawaii Western Management Group Commercial	$268.92
Rate for Payer: Health Management Network Commercial	$240.61
Rate for Payer: Humana Medicare	$141.53
Rate for Payer: Kaiser Permanente Commercial	$254.76
Rate for Payer: Kaiser Permanente Medicaid	$144.37
Rate for Payer: Kaiser Permanente Medicare	$141.53
Rate for Payer: MDX Hawaii PPO	$274.58
Rate for Payer: Ohana Health Plan Medicaid	$141.53
Rate for Payer: Ohana Health Plan Medicare	$141.53
Rate for Payer: UnitedHealthcare Medicaid	$169.84
Rate for Payer: UnitedHealthcare Medicare	$141.53
Rate for Payer: University Health Alliance Commercial	$206.33

cariprazine 3 mg capsule [HHSC]

Facility

$283.07

Service Code	NDC 61874013020
Hospital Charge Code	2501089
Hospital Revenue Code	250
Min. Negotiated Rate	$141.53
Max. Negotiated Rate	$274.58
Rate for Payer: AlohaCare Medicaid	$141.53
Rate for Payer: AlohaCare Medicare	$141.53
Rate for Payer: Cash Price	$184.00
Rate for Payer: Devoted Health Medicare	$155.69
Rate for Payer: Hawaii Medical Service Association Medicare	$141.53
Rate for Payer: Hawaii Western Management Group Commercial	$268.92
Rate for Payer: Health Management Network Commercial	$240.61
Rate for Payer: Humana Medicare	$141.53
Rate for Payer: Kaiser Permanente Commercial	$254.76
Rate for Payer: Kaiser Permanente Medicaid	$144.37
Rate for Payer: Kaiser Permanente Medicare	$141.53
Rate for Payer: MDX Hawaii PPO	$274.58
Rate for Payer: Ohana Health Plan Medicaid	$141.53
Rate for Payer: Ohana Health Plan Medicare	$141.53
Rate for Payer: UnitedHealthcare Medicaid	$169.84
Rate for Payer: UnitedHealthcare Medicare	$141.53
Rate for Payer: University Health Alliance Commercial	$206.33

cariprazine 3 mg capsule [HHSC]

Facility

$283.07

Service Code	NDC 61874013020
Hospital Charge Code	2501089
Hospital Revenue Code	250
Min. Negotiated Rate	$240.61
Max. Negotiated Rate	$274.58
Rate for Payer: Cash Price	$184.00
Rate for Payer: Health Management Network Commercial	$240.61
Rate for Payer: Kaiser Permanente Commercial	$254.76
Rate for Payer: MDX Hawaii PPO	$274.58

carmex lip balm 10gm [HHSC]

Facility

$4.11

Service Code	NDC 83078011214
Hospital Charge Code	2500283
Hospital Revenue Code	250
Min. Negotiated Rate	$2.06
Max. Negotiated Rate	$3.99
Rate for Payer: AlohaCare Medicaid	$2.06
Rate for Payer: AlohaCare Medicare	$2.06
Rate for Payer: Cash Price	$2.67
Rate for Payer: Devoted Health Medicare	$2.26
Rate for Payer: Hawaii Medical Service Association Medicare	$2.06
Rate for Payer: Hawaii Western Management Group Commercial	$3.90
Rate for Payer: Health Management Network Commercial	$3.49
Rate for Payer: Humana Medicare	$2.06
Rate for Payer: Kaiser Permanente Commercial	$3.70
Rate for Payer: Kaiser Permanente Medicaid	$2.10
Rate for Payer: Kaiser Permanente Medicare	$2.06
Rate for Payer: MDX Hawaii PPO	$3.99
Rate for Payer: Ohana Health Plan Medicaid	$2.06
Rate for Payer: Ohana Health Plan Medicare	$2.06
Rate for Payer: UnitedHealthcare Medicaid	$2.47
Rate for Payer: UnitedHealthcare Medicare	$2.06
Rate for Payer: University Health Alliance Commercial	$3.00

carmex lip balm 10gm [HHSC]

Facility

$4.11

Service Code	NDC 83078011214
Hospital Charge Code	2500283
Hospital Revenue Code	250
Min. Negotiated Rate	$3.49
Max. Negotiated Rate	$3.99
Rate for Payer: Cash Price	$2.67
Rate for Payer: Health Management Network Commercial	$3.49
Rate for Payer: Kaiser Permanente Commercial	$3.70
Rate for Payer: MDX Hawaii PPO	$3.99

CAROTID ARTERY STENT PROCEDURES WITH CC

Facility

$10,400.00

Service Code	MSDRG 035
Min. Negotiated Rate	$10,400.00
Max. Negotiated Rate	$10,400.00
Rate for Payer: University Health Alliance Commercial	$10,400.00

CAROTID ARTERY STENT PROCEDURES WITH MCC

Facility

$10,400.00

Service Code	MSDRG 034
Min. Negotiated Rate	$10,400.00
Max. Negotiated Rate	$10,400.00
Rate for Payer: University Health Alliance Commercial	$10,400.00

CAROTID ARTERY STENT PROCEDURES WITHOUT CC/MCC

Facility

$10,400.00

Service Code	MSDRG 036
Min. Negotiated Rate	$10,400.00
Max. Negotiated Rate	$10,400.00
Rate for Payer: University Health Alliance Commercial	$10,400.00

CARRIER SKIN GRAFT DERMA CARRIER II 3:1

Facility

$202.00

Hospital Charge Code	8348093
Hospital Revenue Code	270
Min. Negotiated Rate	$101.00
Max. Negotiated Rate	$195.94
Rate for Payer: AlohaCare Medicaid	$101.00
Rate for Payer: AlohaCare Medicare	$101.00
Rate for Payer: Cash Price	$131.30
Rate for Payer: Devoted Health Medicare	$111.10
Rate for Payer: Hawaii Medical Service Association Medicare	$101.00
Rate for Payer: Hawaii Western Management Group Commercial	$191.90
Rate for Payer: Health Management Network Commercial	$171.70
Rate for Payer: Humana Medicare	$101.00
Rate for Payer: Kaiser Permanente Commercial	$181.80
Rate for Payer: Kaiser Permanente Medicaid	$103.02
Rate for Payer: Kaiser Permanente Medicare	$101.00
Rate for Payer: MDX Hawaii PPO	$195.94
Rate for Payer: Ohana Health Plan Medicaid	$101.00
Rate for Payer: Ohana Health Plan Medicare	$101.00
Rate for Payer: UnitedHealthcare Medicare	$101.00
Rate for Payer: University Health Alliance Commercial	$147.24

CARRIER SKIN GRAFT DERMA CARRIER II 3:1

Facility

$202.00

Hospital Charge Code	8348093
Hospital Revenue Code	270
Min. Negotiated Rate	$171.70
Max. Negotiated Rate	$195.94
Rate for Payer: Cash Price	$131.30
Rate for Payer: Health Management Network Commercial	$171.70
Rate for Payer: Kaiser Permanente Commercial	$181.80
Rate for Payer: MDX Hawaii PPO	$195.94

CAR SEAT/ BED TESTING 1ST HOUR CHARGE

Facility

$195.00

Service Code	HCPCS 94780
Hospital Charge Code	8243417
Hospital Revenue Code	410
Min. Negotiated Rate	$14.47
Max. Negotiated Rate	$189.15
Rate for Payer: AlohaCare Medicaid	$97.50
Rate for Payer: AlohaCare Medicare	$97.50
Rate for Payer: Cash Price	$126.75
Rate for Payer: Cash Price	$126.75
Rate for Payer: Devoted Health Medicare	$107.25
Rate for Payer: Hawaii Medical Service Association Commercial	$47.70
Rate for Payer: Hawaii Medical Service Association Medicare	$97.50
Rate for Payer: Hawaii Western Management Group Commercial	$185.25
Rate for Payer: Health Management Network Commercial	$165.75
Rate for Payer: Humana Medicare	$97.50
Rate for Payer: Kaiser Permanente Commercial	$175.50
Rate for Payer: Kaiser Permanente Medicaid	$99.45
Rate for Payer: Kaiser Permanente Medicare	$97.50
Rate for Payer: MDX Hawaii PPO	$189.15
Rate for Payer: Ohana Health Plan Medicaid	$97.50
Rate for Payer: Ohana Health Plan Medicare	$97.50
Rate for Payer: UnitedHealthcare Medicaid	$14.47
Rate for Payer: UnitedHealthcare Medicare	$97.50
Rate for Payer: University Health Alliance Commercial	$109.20

CAR SEAT/ BED TESTING 1ST HOUR CHARGE

Professional

Both

$52.00

Service Code	HCPCS 94780
Hospital Charge Code	8243417
Hospital Revenue Code	960
Min. Negotiated Rate	$20.41
Max. Negotiated Rate	$44.20
Rate for Payer: AlohaCare Medicaid	$23.42
Rate for Payer: AlohaCare Medicare	$20.41
Rate for Payer: Cash Price	$33.80
Rate for Payer: Cash Price	$33.80
Rate for Payer: Devoted Health Medicare	$22.45
Rate for Payer: Hawaii Medical Service Association ABD	$23.42
Rate for Payer: Hawaii Medical Service Association Medicare	$20.41
Rate for Payer: Hawaii Medical Service Association Non-ABD	$23.42
Rate for Payer: Health Management Network Commercial	$44.20
Rate for Payer: Kaiser Permanente Commercial	$24.49
Rate for Payer: Kaiser Permanente Medicaid	$24.49
Rate for Payer: Kaiser Permanente Medicare	$24.49
Rate for Payer: Ohana Health Plan Medicaid	$23.42
Rate for Payer: Ohana Health Plan Medicare	$20.41
Rate for Payer: UnitedHealthcare Medicaid	$23.42
Rate for Payer: UnitedHealthcare Medicare	$20.41
Rate for Payer: University Health Alliance Commercial	$28.80

CAR SEAT/ BED TESTING 1ST HOUR CHARGE

Facility

$195.00

Service Code	HCPCS 94780
Hospital Charge Code	8243417
Hospital Revenue Code	410
Min. Negotiated Rate	$165.75
Max. Negotiated Rate	$189.15
Rate for Payer: Cash Price	$126.75
Rate for Payer: Health Management Network Commercial	$165.75
Rate for Payer: Kaiser Permanente Commercial	$175.50
Rate for Payer: MDX Hawaii PPO	$189.15

CAR SEAT/ BED TESTING ADDL 30 MIN CHARGE

Professional

Both

$29.00

Service Code	HCPCS 94781
Hospital Charge Code	8243381
Hospital Revenue Code	960
Min. Negotiated Rate	$7.01
Max. Negotiated Rate	$24.65
Rate for Payer: AlohaCare Medicaid	$8.14
Rate for Payer: AlohaCare Medicare	$7.01
Rate for Payer: Cash Price	$18.85
Rate for Payer: Cash Price	$18.85
Rate for Payer: Devoted Health Medicare	$7.71
Rate for Payer: Hawaii Medical Service Association ABD	$8.14
Rate for Payer: Hawaii Medical Service Association Medicare	$7.01
Rate for Payer: Hawaii Medical Service Association Non-ABD	$8.14
Rate for Payer: Health Management Network Commercial	$24.65
Rate for Payer: Kaiser Permanente Commercial	$8.41
Rate for Payer: Kaiser Permanente Medicaid	$8.41
Rate for Payer: Kaiser Permanente Medicare	$8.41
Rate for Payer: Ohana Health Plan Medicaid	$8.14
Rate for Payer: Ohana Health Plan Medicare	$7.01
Rate for Payer: UnitedHealthcare Medicaid	$8.14
Rate for Payer: UnitedHealthcare Medicare	$7.01
Rate for Payer: University Health Alliance Commercial	$9.92

CAR SEAT/ BED TESTING ADDL 30 MIN CHARGE

Facility

$55.00

Service Code	HCPCS 94781
Hospital Charge Code	8243381
Hospital Revenue Code	410
Min. Negotiated Rate	$46.75
Max. Negotiated Rate	$53.35
Rate for Payer: Cash Price	$35.75
Rate for Payer: Health Management Network Commercial	$46.75
Rate for Payer: Kaiser Permanente Commercial	$49.50
Rate for Payer: MDX Hawaii PPO	$53.35

Know your out-of-pocket cost for care.

All Charges