Samuel Mahelona Memorial Hospital

All Charges

Charge

Type

Setting

Price

COLLAR CERVICAL LGE

Facility

$23.00

Service Code	HCPCS L0120
Hospital Charge Code	8266530
Hospital Revenue Code	274
Min. Negotiated Rate	$11.50
Max. Negotiated Rate	$23.71
Rate for Payer: AlohaCare Medicaid	$11.50
Rate for Payer: AlohaCare Medicare	$11.50
Rate for Payer: Cash Price	$14.95
Rate for Payer: Cash Price	$14.95
Rate for Payer: Devoted Health Medicare	$12.65
Rate for Payer: Hawaii Medical Service Association Medicare	$11.50
Rate for Payer: Hawaii Western Management Group Commercial	$16.10
Rate for Payer: Health Management Network Commercial	$19.55
Rate for Payer: Humana Medicare	$11.50
Rate for Payer: Kaiser Permanente Commercial	$20.70
Rate for Payer: Kaiser Permanente Medicaid	$11.73
Rate for Payer: Kaiser Permanente Medicare	$11.50
Rate for Payer: MDX Hawaii PPO	$22.31
Rate for Payer: Ohana Health Plan Medicaid	$11.50
Rate for Payer: Ohana Health Plan Medicare	$11.50
Rate for Payer: UnitedHealthcare Medicaid	$23.71
Rate for Payer: UnitedHealthcare Medicare	$11.50
Rate for Payer: University Health Alliance Commercial	$12.88

COLLAR CERVICAL LGE

Facility

$23.00

Service Code	HCPCS L0120
Hospital Charge Code	8266530
Hospital Revenue Code	274
Min. Negotiated Rate	$12.88
Max. Negotiated Rate	$22.31
Rate for Payer: Cash Price	$14.95
Rate for Payer: Hawaii Western Management Group Commercial	$16.10
Rate for Payer: Health Management Network Commercial	$19.55
Rate for Payer: Kaiser Permanente Commercial	$20.70
Rate for Payer: MDX Hawaii PPO	$22.31
Rate for Payer: University Health Alliance Commercial	$12.88

COLLAR CERVICAL MEDIUM

Facility

$22.00

Service Code	HCPCS L0120
Hospital Charge Code	8266517
Hospital Revenue Code	274
Min. Negotiated Rate	$12.32
Max. Negotiated Rate	$21.34
Rate for Payer: Kaiser Permanente Commercial	$19.80
Rate for Payer: Cash Price	$14.30
Rate for Payer: Hawaii Western Management Group Commercial	$15.40
Rate for Payer: Health Management Network Commercial	$18.70
Rate for Payer: MDX Hawaii PPO	$21.34
Rate for Payer: University Health Alliance Commercial	$12.32

COLLAR CERVICAL MEDIUM

Facility

$22.00

Service Code	HCPCS L0120
Hospital Charge Code	8266517
Hospital Revenue Code	274
Min. Negotiated Rate	$11.00
Max. Negotiated Rate	$23.71
Rate for Payer: AlohaCare Medicaid	$11.00
Rate for Payer: AlohaCare Medicare	$11.00
Rate for Payer: Cash Price	$14.30
Rate for Payer: Cash Price	$14.30
Rate for Payer: Devoted Health Medicare	$12.10
Rate for Payer: Hawaii Medical Service Association Medicare	$11.00
Rate for Payer: Hawaii Western Management Group Commercial	$15.40
Rate for Payer: Health Management Network Commercial	$18.70
Rate for Payer: Humana Medicare	$11.00
Rate for Payer: Kaiser Permanente Commercial	$19.80
Rate for Payer: Kaiser Permanente Medicaid	$11.22
Rate for Payer: Kaiser Permanente Medicare	$11.00
Rate for Payer: MDX Hawaii PPO	$21.34
Rate for Payer: Ohana Health Plan Medicaid	$11.00
Rate for Payer: Ohana Health Plan Medicare	$11.00
Rate for Payer: UnitedHealthcare Medicaid	$23.71
Rate for Payer: UnitedHealthcare Medicare	$11.00
Rate for Payer: University Health Alliance Commercial	$12.32

COLLAR CERVICAL SML

Facility

$23.00

Service Code	HCPCS L0120
Hospital Charge Code	8266529
Hospital Revenue Code	274
Min. Negotiated Rate	$12.88
Max. Negotiated Rate	$22.31
Rate for Payer: Cash Price	$14.95
Rate for Payer: Hawaii Western Management Group Commercial	$16.10
Rate for Payer: Health Management Network Commercial	$19.55
Rate for Payer: Kaiser Permanente Commercial	$20.70
Rate for Payer: MDX Hawaii PPO	$22.31
Rate for Payer: University Health Alliance Commercial	$12.88

COLLAR CERVICAL SML

Facility

$23.00

Service Code	HCPCS L0120
Hospital Charge Code	8266529
Hospital Revenue Code	274
Min. Negotiated Rate	$11.50
Max. Negotiated Rate	$23.71
Rate for Payer: AlohaCare Medicaid	$11.50
Rate for Payer: AlohaCare Medicare	$11.50
Rate for Payer: Cash Price	$14.95
Rate for Payer: Cash Price	$14.95
Rate for Payer: Devoted Health Medicare	$12.65
Rate for Payer: Hawaii Medical Service Association Medicare	$11.50
Rate for Payer: Hawaii Western Management Group Commercial	$16.10
Rate for Payer: Health Management Network Commercial	$19.55
Rate for Payer: Humana Medicare	$11.50
Rate for Payer: Kaiser Permanente Commercial	$20.70
Rate for Payer: Kaiser Permanente Medicaid	$11.73
Rate for Payer: Kaiser Permanente Medicare	$11.50
Rate for Payer: MDX Hawaii PPO	$22.31
Rate for Payer: Ohana Health Plan Medicaid	$11.50
Rate for Payer: Ohana Health Plan Medicare	$11.50
Rate for Payer: UnitedHealthcare Medicaid	$23.71
Rate for Payer: UnitedHealthcare Medicare	$11.50
Rate for Payer: University Health Alliance Commercial	$12.88

COLLAR EXTRICATION ADULT SHORT

Facility

$46.00

Hospital Charge Code	8266518
Hospital Revenue Code	274
Min. Negotiated Rate	$23.00
Max. Negotiated Rate	$44.62
Rate for Payer: AlohaCare Medicaid	$23.00
Rate for Payer: AlohaCare Medicare	$23.00
Rate for Payer: Cash Price	$29.90
Rate for Payer: Devoted Health Medicare	$25.30
Rate for Payer: Hawaii Medical Service Association Medicare	$23.00
Rate for Payer: Hawaii Western Management Group Commercial	$32.20
Rate for Payer: Health Management Network Commercial	$39.10
Rate for Payer: Humana Medicare	$23.00
Rate for Payer: Kaiser Permanente Commercial	$41.40
Rate for Payer: Kaiser Permanente Medicaid	$23.46
Rate for Payer: Kaiser Permanente Medicare	$23.00
Rate for Payer: MDX Hawaii PPO	$44.62
Rate for Payer: Ohana Health Plan Medicaid	$23.00
Rate for Payer: Ohana Health Plan Medicare	$23.00
Rate for Payer: UnitedHealthcare Medicare	$23.00
Rate for Payer: University Health Alliance Commercial	$25.76

COLLAR EXTRICATION ADULT SHORT

Facility

$46.00

Hospital Charge Code	8266518
Hospital Revenue Code	274
Min. Negotiated Rate	$25.76
Max. Negotiated Rate	$44.62
Rate for Payer: Cash Price	$29.90
Rate for Payer: Hawaii Western Management Group Commercial	$32.20
Rate for Payer: Health Management Network Commercial	$39.10
Rate for Payer: Kaiser Permanente Commercial	$41.40
Rate for Payer: MDX Hawaii PPO	$44.62
Rate for Payer: University Health Alliance Commercial	$25.76

COLLAR EXTRICATION PEDIATRIC

Facility

$48.00

Hospital Charge Code	8266519
Hospital Revenue Code	274
Min. Negotiated Rate	$24.00
Max. Negotiated Rate	$46.56
Rate for Payer: AlohaCare Medicaid	$24.00
Rate for Payer: AlohaCare Medicare	$24.00
Rate for Payer: Cash Price	$31.20
Rate for Payer: Devoted Health Medicare	$26.40
Rate for Payer: Hawaii Medical Service Association Medicare	$24.00
Rate for Payer: Hawaii Western Management Group Commercial	$33.60
Rate for Payer: Health Management Network Commercial	$40.80
Rate for Payer: Humana Medicare	$24.00
Rate for Payer: Kaiser Permanente Commercial	$43.20
Rate for Payer: Kaiser Permanente Medicaid	$24.48
Rate for Payer: Kaiser Permanente Medicare	$24.00
Rate for Payer: MDX Hawaii PPO	$46.56
Rate for Payer: Ohana Health Plan Medicaid	$24.00
Rate for Payer: Ohana Health Plan Medicare	$24.00
Rate for Payer: UnitedHealthcare Medicare	$24.00
Rate for Payer: University Health Alliance Commercial	$26.88

COLLAR EXTRICATION PEDIATRIC

Facility

$48.00

Hospital Charge Code	8266519
Hospital Revenue Code	274
Min. Negotiated Rate	$26.88
Max. Negotiated Rate	$46.56
Rate for Payer: Cash Price	$31.20
Rate for Payer: Hawaii Western Management Group Commercial	$33.60
Rate for Payer: Health Management Network Commercial	$40.80
Rate for Payer: Kaiser Permanente Commercial	$43.20
Rate for Payer: MDX Hawaii PPO	$46.56
Rate for Payer: University Health Alliance Commercial	$26.88

COLLAR EXTRICATION REGULAR

Facility

$87.00

Hospital Charge Code	8266522
Hospital Revenue Code	274
Min. Negotiated Rate	$48.72
Max. Negotiated Rate	$84.39
Rate for Payer: Cash Price	$56.55
Rate for Payer: Hawaii Western Management Group Commercial	$60.90
Rate for Payer: Health Management Network Commercial	$73.95
Rate for Payer: Kaiser Permanente Commercial	$78.30
Rate for Payer: MDX Hawaii PPO	$84.39
Rate for Payer: University Health Alliance Commercial	$48.72

COLLAR EXTRICATION REGULAR

Facility

$87.00

Hospital Charge Code	8266522
Hospital Revenue Code	274
Min. Negotiated Rate	$43.50
Max. Negotiated Rate	$84.39
Rate for Payer: AlohaCare Medicaid	$43.50
Rate for Payer: AlohaCare Medicare	$43.50
Rate for Payer: Cash Price	$56.55
Rate for Payer: Devoted Health Medicare	$47.85
Rate for Payer: Hawaii Medical Service Association Medicare	$43.50
Rate for Payer: Hawaii Western Management Group Commercial	$60.90
Rate for Payer: Health Management Network Commercial	$73.95
Rate for Payer: Humana Medicare	$43.50
Rate for Payer: Kaiser Permanente Commercial	$78.30
Rate for Payer: Kaiser Permanente Medicaid	$44.37
Rate for Payer: Kaiser Permanente Medicare	$43.50
Rate for Payer: MDX Hawaii PPO	$84.39
Rate for Payer: Ohana Health Plan Medicaid	$43.50
Rate for Payer: Ohana Health Plan Medicare	$43.50
Rate for Payer: UnitedHealthcare Medicare	$43.50
Rate for Payer: University Health Alliance Commercial	$48.72

COLLAR EXTRICATION TALL

Facility

$61.00

Hospital Charge Code	8266523
Hospital Revenue Code	274
Min. Negotiated Rate	$30.50
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: Devoted Health Medicare	$33.55
Rate for Payer: Hawaii Medical Service Association Medicare	$30.50
Rate for Payer: Hawaii Western Management Group Commercial	$42.70
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 Medicare	$30.50
Rate for Payer: University Health Alliance Commercial	$34.16

COLLAR EXTRICATION TALL

Facility

$61.00

Hospital Charge Code	8266523
Hospital Revenue Code	274
Min. Negotiated Rate	$34.16
Max. Negotiated Rate	$59.17
Rate for Payer: Cash Price	$39.65
Rate for Payer: Hawaii Western Management Group Commercial	$42.70
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
Rate for Payer: University Health Alliance Commercial	$34.16

COLLAR MIAMI J PED 0-6 MO

Facility

$386.00

Service Code	HCPCS L0174
Hospital Charge Code	8500829
Hospital Revenue Code	274
Min. Negotiated Rate	$216.16
Max. Negotiated Rate	$374.42
Rate for Payer: Cash Price	$250.90
Rate for Payer: Hawaii Western Management Group Commercial	$270.20
Rate for Payer: Health Management Network Commercial	$328.10
Rate for Payer: Kaiser Permanente Commercial	$347.40
Rate for Payer: MDX Hawaii PPO	$374.42
Rate for Payer: University Health Alliance Commercial	$216.16

COLLAR MIAMI J PED 0-6 MO

Facility

$386.00

Service Code	HCPCS L0174
Hospital Charge Code	8500829
Hospital Revenue Code	274
Min. Negotiated Rate	$193.00
Max. Negotiated Rate	$374.42
Rate for Payer: AlohaCare Medicaid	$193.00
Rate for Payer: AlohaCare Medicare	$193.00
Rate for Payer: Cash Price	$250.90
Rate for Payer: Cash Price	$250.90
Rate for Payer: Devoted Health Medicare	$212.30
Rate for Payer: Hawaii Medical Service Association Medicare	$193.00
Rate for Payer: Hawaii Western Management Group Commercial	$270.20
Rate for Payer: Health Management Network Commercial	$328.10
Rate for Payer: Humana Medicare	$193.00
Rate for Payer: Kaiser Permanente Commercial	$347.40
Rate for Payer: Kaiser Permanente Medicaid	$196.86
Rate for Payer: Kaiser Permanente Medicare	$193.00
Rate for Payer: MDX Hawaii PPO	$374.42
Rate for Payer: Ohana Health Plan Medicaid	$193.00
Rate for Payer: Ohana Health Plan Medicare	$193.00
Rate for Payer: UnitedHealthcare Medicaid	$211.18
Rate for Payer: UnitedHealthcare Medicare	$193.00
Rate for Payer: University Health Alliance Commercial	$216.16

COLLAR MIAMI J PED 2YR-6YR

Facility

$386.00

Service Code	HCPCS L0174
Hospital Charge Code	8500830
Hospital Revenue Code	274
Min. Negotiated Rate	$216.16
Max. Negotiated Rate	$374.42
Rate for Payer: Cash Price	$250.90
Rate for Payer: Hawaii Western Management Group Commercial	$270.20
Rate for Payer: Health Management Network Commercial	$328.10
Rate for Payer: Kaiser Permanente Commercial	$347.40
Rate for Payer: MDX Hawaii PPO	$374.42
Rate for Payer: University Health Alliance Commercial	$216.16

COLLAR MIAMI J PED 2YR-6YR

Facility

$386.00

Service Code	HCPCS L0174
Hospital Charge Code	8500830
Hospital Revenue Code	274
Min. Negotiated Rate	$193.00
Max. Negotiated Rate	$374.42
Rate for Payer: AlohaCare Medicaid	$193.00
Rate for Payer: AlohaCare Medicare	$193.00
Rate for Payer: Cash Price	$250.90
Rate for Payer: Cash Price	$250.90
Rate for Payer: Devoted Health Medicare	$212.30
Rate for Payer: Hawaii Medical Service Association Medicare	$193.00
Rate for Payer: Hawaii Western Management Group Commercial	$270.20
Rate for Payer: Health Management Network Commercial	$328.10
Rate for Payer: Humana Medicare	$193.00
Rate for Payer: Kaiser Permanente Commercial	$347.40
Rate for Payer: Kaiser Permanente Medicaid	$196.86
Rate for Payer: Kaiser Permanente Medicare	$193.00
Rate for Payer: MDX Hawaii PPO	$374.42
Rate for Payer: Ohana Health Plan Medicaid	$193.00
Rate for Payer: Ohana Health Plan Medicare	$193.00
Rate for Payer: UnitedHealthcare Medicaid	$211.18
Rate for Payer: UnitedHealthcare Medicare	$193.00
Rate for Payer: University Health Alliance Commercial	$216.16

COLLAR MIAMI J PED 6MO-2YR

Facility

$386.00

Service Code	HCPCS L0174
Hospital Charge Code	8500831
Hospital Revenue Code	274
Min. Negotiated Rate	$216.16
Max. Negotiated Rate	$374.42
Rate for Payer: Cash Price	$250.90
Rate for Payer: Hawaii Western Management Group Commercial	$270.20
Rate for Payer: Health Management Network Commercial	$328.10
Rate for Payer: Kaiser Permanente Commercial	$347.40
Rate for Payer: MDX Hawaii PPO	$374.42
Rate for Payer: University Health Alliance Commercial	$216.16

COLLAR MIAMI J PED 6MO-2YR

Facility

$386.00

Service Code	HCPCS L0174
Hospital Charge Code	8500831
Hospital Revenue Code	274
Min. Negotiated Rate	$193.00
Max. Negotiated Rate	$374.42
Rate for Payer: AlohaCare Medicaid	$193.00
Rate for Payer: AlohaCare Medicare	$193.00
Rate for Payer: Cash Price	$250.90
Rate for Payer: Cash Price	$250.90
Rate for Payer: Devoted Health Medicare	$212.30
Rate for Payer: Hawaii Medical Service Association Medicare	$193.00
Rate for Payer: Hawaii Western Management Group Commercial	$270.20
Rate for Payer: Health Management Network Commercial	$328.10
Rate for Payer: Humana Medicare	$193.00
Rate for Payer: Kaiser Permanente Commercial	$347.40
Rate for Payer: Kaiser Permanente Medicaid	$196.86
Rate for Payer: Kaiser Permanente Medicare	$193.00
Rate for Payer: MDX Hawaii PPO	$374.42
Rate for Payer: Ohana Health Plan Medicaid	$193.00
Rate for Payer: Ohana Health Plan Medicare	$193.00
Rate for Payer: UnitedHealthcare Medicaid	$211.18
Rate for Payer: UnitedHealthcare Medicare	$193.00
Rate for Payer: University Health Alliance Commercial	$216.16

COLLAR MIAMI J PED 6YR-12YR

Facility

$386.00

Service Code	HCPCS L0174
Hospital Charge Code	8500832
Hospital Revenue Code	274
Min. Negotiated Rate	$216.16
Max. Negotiated Rate	$374.42
Rate for Payer: Cash Price	$250.90
Rate for Payer: Hawaii Western Management Group Commercial	$270.20
Rate for Payer: Health Management Network Commercial	$328.10
Rate for Payer: Kaiser Permanente Commercial	$347.40
Rate for Payer: MDX Hawaii PPO	$374.42
Rate for Payer: University Health Alliance Commercial	$216.16

COLLAR MIAMI J PED 6YR-12YR

Facility

$386.00

Service Code	HCPCS L0174
Hospital Charge Code	8500832
Hospital Revenue Code	274
Min. Negotiated Rate	$193.00
Max. Negotiated Rate	$374.42
Rate for Payer: AlohaCare Medicaid	$193.00
Rate for Payer: AlohaCare Medicare	$193.00
Rate for Payer: Cash Price	$250.90
Rate for Payer: Cash Price	$250.90
Rate for Payer: Devoted Health Medicare	$212.30
Rate for Payer: Hawaii Medical Service Association Medicare	$193.00
Rate for Payer: Hawaii Western Management Group Commercial	$270.20
Rate for Payer: Health Management Network Commercial	$328.10
Rate for Payer: Humana Medicare	$193.00
Rate for Payer: Kaiser Permanente Commercial	$347.40
Rate for Payer: Kaiser Permanente Medicaid	$196.86
Rate for Payer: Kaiser Permanente Medicare	$193.00
Rate for Payer: MDX Hawaii PPO	$374.42
Rate for Payer: Ohana Health Plan Medicaid	$193.00
Rate for Payer: Ohana Health Plan Medicare	$193.00
Rate for Payer: UnitedHealthcare Medicaid	$211.18
Rate for Payer: UnitedHealthcare Medicare	$193.00
Rate for Payer: University Health Alliance Commercial	$216.16

COLLAR PHILADELPHIA NO NECK EXTRICATION DEROYAL

Facility

$133.00

Hospital Charge Code	8266932
Hospital Revenue Code	274
Min. Negotiated Rate	$66.50
Max. Negotiated Rate	$129.01
Rate for Payer: AlohaCare Medicaid	$66.50
Rate for Payer: AlohaCare Medicare	$66.50
Rate for Payer: Cash Price	$86.45
Rate for Payer: Devoted Health Medicare	$73.15
Rate for Payer: Hawaii Medical Service Association Medicare	$66.50
Rate for Payer: Hawaii Western Management Group Commercial	$93.10
Rate for Payer: Health Management Network Commercial	$113.05
Rate for Payer: Humana Medicare	$66.50
Rate for Payer: Kaiser Permanente Commercial	$119.70
Rate for Payer: Kaiser Permanente Medicaid	$67.83
Rate for Payer: Kaiser Permanente Medicare	$66.50
Rate for Payer: MDX Hawaii PPO	$129.01
Rate for Payer: Ohana Health Plan Medicaid	$66.50
Rate for Payer: Ohana Health Plan Medicare	$66.50
Rate for Payer: UnitedHealthcare Medicare	$66.50
Rate for Payer: University Health Alliance Commercial	$74.48

COLLAR PHILADELPHIA NO NECK EXTRICATION DEROYAL

Facility

$133.00

Hospital Charge Code	8266932
Hospital Revenue Code	274
Min. Negotiated Rate	$74.48
Max. Negotiated Rate	$129.01
Rate for Payer: Cash Price	$86.45
Rate for Payer: Hawaii Western Management Group Commercial	$93.10
Rate for Payer: Health Management Network Commercial	$113.05
Rate for Payer: Kaiser Permanente Commercial	$119.70
Rate for Payer: MDX Hawaii PPO	$129.01
Rate for Payer: University Health Alliance Commercial	$74.48

COLOSTOMY POUCH

Facility

$4.00

Hospital Charge Code	8266303
Hospital Revenue Code	271
Min. Negotiated Rate	$3.40
Max. Negotiated Rate	$3.88
Rate for Payer: Cash Price	$2.60
Rate for Payer: Health Management Network Commercial	$3.40
Rate for Payer: Kaiser Permanente Commercial	$3.60
Rate for Payer: MDX Hawaii PPO	$3.88

Know your out-of-pocket cost for care.

All Charges