Samuel Mahelona Memorial Hospital

All Charges

Charge

Type

Setting

Price

COMPLICATIONS OF TREATMENT WITH CC

Facility

$27,826.15

Service Code	MSDRG 920
Min. Negotiated Rate	$27,826.15
Max. Negotiated Rate	$27,826.15
Rate for Payer: Hawaii Medical Service Association Commercial	$27,826.15

COMPLICATIONS OF TREATMENT WITH MCC

Facility

$27,826.15

Service Code	MSDRG 919
Min. Negotiated Rate	$27,826.15
Max. Negotiated Rate	$27,826.15
Rate for Payer: Hawaii Medical Service Association Commercial	$27,826.15

COMPLICATIONS OF TREATMENT WITHOUT CC/MCC

Facility

$15,761.83

Service Code	MSDRG 921
Min. Negotiated Rate	$15,761.83
Max. Negotiated Rate	$15,761.83
Rate for Payer: Hawaii Medical Service Association Commercial	$15,761.83

Comprehensive Metabolic Panel (CMP) FSI

Facility

$141.00

Service Code	HCPCS 80053
Hospital Charge Code	8117889
Hospital Revenue Code	301
Min. Negotiated Rate	$119.85
Max. Negotiated Rate	$136.77
Rate for Payer: Cash Price	$91.65
Rate for Payer: Health Management Network Commercial	$119.85
Rate for Payer: Kaiser Permanente Commercial	$126.90
Rate for Payer: MDX Hawaii PPO	$136.77

Comprehensive Metabolic Panel (CMP) FSI

Facility

$141.00

Service Code	HCPCS 80053
Hospital Charge Code	8117889
Hospital Revenue Code	301
Min. Negotiated Rate	$10.56
Max. Negotiated Rate	$136.77
Rate for Payer: AlohaCare Medicaid	$70.50
Rate for Payer: AlohaCare Medicare	$70.50
Rate for Payer: Cash Price	$91.65
Rate for Payer: Cash Price	$91.65
Rate for Payer: Devoted Health Medicare	$77.55
Rate for Payer: Hawaii Medical Service Association ABD	$14.61
Rate for Payer: Hawaii Medical Service Association Commercial	$13.20
Rate for Payer: Hawaii Medical Service Association Medicare	$70.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$15.34
Rate for Payer: Hawaii Western Management Group Commercial	$10.56
Rate for Payer: Health Management Network Commercial	$119.85
Rate for Payer: Humana Medicare	$70.50
Rate for Payer: Kaiser Permanente Commercial	$126.90
Rate for Payer: Kaiser Permanente Medicaid	$71.91
Rate for Payer: Kaiser Permanente Medicare	$70.50
Rate for Payer: MDX Hawaii PPO	$136.77
Rate for Payer: Ohana Health Plan Medicaid	$70.50
Rate for Payer: Ohana Health Plan Medicare	$70.50
Rate for Payer: UnitedHealthcare Medicaid	$14.61
Rate for Payer: UnitedHealthcare Medicare	$70.50
Rate for Payer: University Health Alliance Commercial	$27.32

CONCOMITANT AORTIC AND MITRAL VALVE PROCEDURES

Facility

$127,540.46

Service Code	MSDRG 212
Min. Negotiated Rate	$127,540.46
Max. Negotiated Rate	$127,540.46
Rate for Payer: Hawaii Medical Service Association Commercial	$127,540.46

CONCUSSION WITH CC

Facility

$22,493.20

Service Code	MSDRG 089
Min. Negotiated Rate	$22,493.20
Max. Negotiated Rate	$22,493.20
Rate for Payer: Hawaii Medical Service Association Commercial	$22,493.20

CONCUSSION WITH MCC

Facility

$22,493.20

Service Code	MSDRG 088
Min. Negotiated Rate	$22,493.20
Max. Negotiated Rate	$22,493.20
Rate for Payer: Hawaii Medical Service Association Commercial	$22,493.20

CONCUSSION WITHOUT CC/MCC

Facility

$16,781.02

Service Code	MSDRG 090
Min. Negotiated Rate	$16,781.02
Max. Negotiated Rate	$16,781.02
Rate for Payer: Hawaii Medical Service Association Commercial	$16,781.02

CONNECTIVE TISSUE DISORDERS WITH CC

Facility

$34,652.32

Service Code	MSDRG 546
Min. Negotiated Rate	$34,652.32
Max. Negotiated Rate	$34,652.32
Rate for Payer: Hawaii Medical Service Association Commercial	$34,652.32

CONNECTIVE TISSUE DISORDERS WITH MCC

Facility

$40,032.68

Service Code	MSDRG 545
Min. Negotiated Rate	$40,032.68
Max. Negotiated Rate	$40,032.68
Rate for Payer: Hawaii Medical Service Association Commercial	$40,032.68

CONNECTIVE TISSUE DISORDERS WITHOUT CC/MCC

Facility

$29,295.67

Service Code	MSDRG 547
Min. Negotiated Rate	$29,295.67
Max. Negotiated Rate	$29,295.67
Rate for Payer: Hawaii Medical Service Association Commercial	$29,295.67

Copper, Serum FSI

Facility

$280.00

Service Code	HCPCS 82525
Hospital Charge Code	8117890
Hospital Revenue Code	301
Min. Negotiated Rate	$238.00
Max. Negotiated Rate	$271.60
Rate for Payer: Cash Price	$182.00
Rate for Payer: Health Management Network Commercial	$238.00
Rate for Payer: Kaiser Permanente Commercial	$252.00
Rate for Payer: MDX Hawaii PPO	$271.60

Copper, Serum FSI

Facility

$280.00

Service Code	HCPCS 82525
Hospital Charge Code	8117890
Hospital Revenue Code	301
Min. Negotiated Rate	$12.41
Max. Negotiated Rate	$271.60
Rate for Payer: AlohaCare Medicaid	$140.00
Rate for Payer: AlohaCare Medicare	$140.00
Rate for Payer: Cash Price	$182.00
Rate for Payer: Cash Price	$182.00
Rate for Payer: Devoted Health Medicare	$154.00
Rate for Payer: Hawaii Medical Service Association ABD	$17.15
Rate for Payer: Hawaii Medical Service Association Commercial	$15.51
Rate for Payer: Hawaii Medical Service Association Medicare	$140.00
Rate for Payer: Hawaii Medical Service Association Non-ABD	$18.01
Rate for Payer: Hawaii Western Management Group Commercial	$12.41
Rate for Payer: Health Management Network Commercial	$238.00
Rate for Payer: Humana Medicare	$140.00
Rate for Payer: Kaiser Permanente Commercial	$252.00
Rate for Payer: Kaiser Permanente Medicaid	$142.80
Rate for Payer: Kaiser Permanente Medicare	$140.00
Rate for Payer: MDX Hawaii PPO	$271.60
Rate for Payer: Ohana Health Plan Medicaid	$140.00
Rate for Payer: Ohana Health Plan Medicare	$140.00
Rate for Payer: UnitedHealthcare Medicaid	$17.15
Rate for Payer: UnitedHealthcare Medicare	$140.00
Rate for Payer: University Health Alliance Commercial	$32.08

Cord Blood Gas, Arterial

Facility

$434.00

Service Code	HCPCS 82803
Hospital Charge Code	12499889
Hospital Revenue Code	301
Min. Negotiated Rate	$368.90
Max. Negotiated Rate	$420.98
Rate for Payer: Cash Price	$282.10
Rate for Payer: Health Management Network Commercial	$368.90
Rate for Payer: Kaiser Permanente Commercial	$390.60
Rate for Payer: MDX Hawaii PPO	$420.98

Cord Blood Gas, Arterial

Facility

$434.00

Service Code	HCPCS 82803
Hospital Charge Code	12499889
Hospital Revenue Code	301
Min. Negotiated Rate	$26.07
Max. Negotiated Rate	$420.98
Rate for Payer: AlohaCare Medicaid	$217.00
Rate for Payer: AlohaCare Medicare	$217.00
Rate for Payer: Cash Price	$282.10
Rate for Payer: Cash Price	$282.10
Rate for Payer: Devoted Health Medicare	$238.70
Rate for Payer: Hawaii Medical Service Association ABD	$26.74
Rate for Payer: Hawaii Medical Service Association Commercial	$32.59
Rate for Payer: Hawaii Medical Service Association Medicare	$217.00
Rate for Payer: Hawaii Medical Service Association Non-ABD	$28.08
Rate for Payer: Hawaii Western Management Group Commercial	$26.07
Rate for Payer: Health Management Network Commercial	$368.90
Rate for Payer: Humana Medicare	$217.00
Rate for Payer: Kaiser Permanente Commercial	$390.60
Rate for Payer: Kaiser Permanente Medicaid	$221.34
Rate for Payer: Kaiser Permanente Medicare	$217.00
Rate for Payer: MDX Hawaii PPO	$420.98
Rate for Payer: Ohana Health Plan Medicaid	$217.00
Rate for Payer: Ohana Health Plan Medicare	$217.00
Rate for Payer: UnitedHealthcare Medicaid	$26.74
Rate for Payer: UnitedHealthcare Medicare	$217.00
Rate for Payer: University Health Alliance Commercial	$50.02

Cord Blood Gas, Venous

Facility

$434.00

Service Code	HCPCS 82803
Hospital Charge Code	12514268
Hospital Revenue Code	301
Min. Negotiated Rate	$26.07
Max. Negotiated Rate	$420.98
Rate for Payer: AlohaCare Medicaid	$217.00
Rate for Payer: AlohaCare Medicare	$217.00
Rate for Payer: Cash Price	$282.10
Rate for Payer: Cash Price	$282.10
Rate for Payer: Devoted Health Medicare	$238.70
Rate for Payer: Hawaii Medical Service Association ABD	$26.74
Rate for Payer: Hawaii Medical Service Association Commercial	$32.59
Rate for Payer: Hawaii Medical Service Association Medicare	$217.00
Rate for Payer: Hawaii Medical Service Association Non-ABD	$28.08
Rate for Payer: Hawaii Western Management Group Commercial	$26.07
Rate for Payer: Health Management Network Commercial	$368.90
Rate for Payer: Humana Medicare	$217.00
Rate for Payer: Kaiser Permanente Commercial	$390.60
Rate for Payer: Kaiser Permanente Medicaid	$221.34
Rate for Payer: Kaiser Permanente Medicare	$217.00
Rate for Payer: MDX Hawaii PPO	$420.98
Rate for Payer: Ohana Health Plan Medicaid	$217.00
Rate for Payer: Ohana Health Plan Medicare	$217.00
Rate for Payer: UnitedHealthcare Medicaid	$26.74
Rate for Payer: UnitedHealthcare Medicare	$217.00
Rate for Payer: University Health Alliance Commercial	$50.02

Cord Blood Gas, Venous

Facility

$434.00

Service Code	HCPCS 82803
Hospital Charge Code	12514268
Hospital Revenue Code	301
Min. Negotiated Rate	$368.90
Max. Negotiated Rate	$420.98
Rate for Payer: Cash Price	$282.10
Rate for Payer: Health Management Network Commercial	$368.90
Rate for Payer: Kaiser Permanente Commercial	$390.60
Rate for Payer: MDX Hawaii PPO	$420.98

Cord Blood Workup FSI

Facility

$94.00

Service Code	HCPCS 86900
Hospital Charge Code	8228860
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

Cord Blood Workup FSI

Facility

$94.00

Service Code	HCPCS 86900
Hospital Charge Code	8228860
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

CORONARY BYPASS WITH CARDIAC CATHETERIZATION OR OPEN ABLATION WITH MCC

Facility

$127,327.14

Service Code	MSDRG 233
Min. Negotiated Rate	$127,327.14
Max. Negotiated Rate	$127,327.14
Rate for Payer: Hawaii Medical Service Association Commercial	$127,327.14

CORONARY BYPASS WITH CARDIAC CATHETERIZATION OR OPEN ABLATION WITHOUT MCC

Facility

$111,754.93

Service Code	MSDRG 234
Min. Negotiated Rate	$111,754.93
Max. Negotiated Rate	$111,754.93
Rate for Payer: Hawaii Medical Service Association Commercial	$111,754.93

CORONARY BYPASS WITHOUT CARDIAC CATHETERIZATION WITH MCC

Facility

$97,201.90

Service Code	MSDRG 235
Min. Negotiated Rate	$97,201.90
Max. Negotiated Rate	$97,201.90
Rate for Payer: Hawaii Medical Service Association Commercial	$97,201.90

CORONARY BYPASS WITHOUT CARDIAC CATHETERIZATION WITHOUT MCC

Facility

$90,375.73

Service Code	MSDRG 236
Min. Negotiated Rate	$90,375.73
Max. Negotiated Rate	$90,375.73
Rate for Payer: Hawaii Medical Service Association Commercial	$90,375.73

CORONARY BYPASS WITH PTCA WITH MCC

Facility

$140,505.46

Service Code	MSDRG 231
Min. Negotiated Rate	$140,505.46
Max. Negotiated Rate	$140,505.46
Rate for Payer: Hawaii Medical Service Association Commercial	$140,505.46

Know your out-of-pocket cost for care.

All Charges