Samuel Mahelona Memorial Hospital

All Charges

Charge

Type

Setting

Price

GASTROINTESTINAL HEMORRHAGE WITHOUT CC/MCC

Facility

$16,378.08

Service Code	MSDRG 379
Min. Negotiated Rate	$16,378.08
Max. Negotiated Rate	$16,378.08
Rate for Payer: Hawaii Medical Service Association Commercial	$16,378.08

GASTROINTESTINAL OBSTRUCTION WITH CC

Facility

$16,662.51

Service Code	MSDRG 389
Min. Negotiated Rate	$16,662.51
Max. Negotiated Rate	$16,662.51
Rate for Payer: Hawaii Medical Service Association Commercial	$16,662.51

GASTROINTESTINAL OBSTRUCTION WITH MCC

Facility

$18,771.98

Service Code	MSDRG 388
Min. Negotiated Rate	$18,771.98
Max. Negotiated Rate	$18,771.98
Rate for Payer: Hawaii Medical Service Association Commercial	$18,771.98

GASTROINTESTINAL OBSTRUCTION WITHOUT CC/MCC

Facility

$13,273.12

Service Code	MSDRG 390
Min. Negotiated Rate	$13,273.12
Max. Negotiated Rate	$13,273.12
Rate for Payer: Hawaii Medical Service Association Commercial	$13,273.12

GASTROSTOMY 20FR. 50738 KIT

Facility

$282.00

Hospital Charge Code	8274194
Hospital Revenue Code	272
Min. Negotiated Rate	$141.00
Max. Negotiated Rate	$273.54
Rate for Payer: AlohaCare Medicaid	$141.00
Rate for Payer: AlohaCare Medicare	$141.00
Rate for Payer: Cash Price	$183.30
Rate for Payer: Devoted Health Medicare	$155.10
Rate for Payer: Hawaii Medical Service Association Medicare	$141.00
Rate for Payer: Hawaii Western Management Group Commercial	$267.90
Rate for Payer: Health Management Network Commercial	$239.70
Rate for Payer: Humana Medicare	$141.00
Rate for Payer: Kaiser Permanente Commercial	$253.80
Rate for Payer: Kaiser Permanente Medicaid	$143.82
Rate for Payer: Kaiser Permanente Medicare	$141.00
Rate for Payer: MDX Hawaii PPO	$273.54
Rate for Payer: Ohana Health Plan Medicaid	$141.00
Rate for Payer: Ohana Health Plan Medicare	$141.00
Rate for Payer: UnitedHealthcare Medicare	$141.00
Rate for Payer: University Health Alliance Commercial	$205.55

GASTROSTOMY 20FR. 50738 KIT

Facility

$282.00

Hospital Charge Code	8274194
Hospital Revenue Code	272
Min. Negotiated Rate	$239.70
Max. Negotiated Rate	$273.54
Rate for Payer: Cash Price	$183.30
Rate for Payer: Health Management Network Commercial	$239.70
Rate for Payer: Kaiser Permanente Commercial	$253.80
Rate for Payer: MDX Hawaii PPO	$273.54

GASTROSTOMY 20FR. 52354 KIT

Facility

$280.00

Hospital Charge Code	8274195
Hospital Revenue Code	272
Min. Negotiated Rate	$140.00
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: Devoted Health Medicare	$154.00
Rate for Payer: Hawaii Medical Service Association Medicare	$140.00
Rate for Payer: Hawaii Western Management Group Commercial	$266.00
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 Medicare	$140.00
Rate for Payer: University Health Alliance Commercial	$204.09

GASTROSTOMY 20FR. 52354 KIT

Facility

$280.00

Hospital Charge Code	8274195
Hospital Revenue Code	272
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

GASTROSTOMY 24FR FEEDING TUBE SAFETY PEG PULL KIT

Facility

$354.00

Hospital Charge Code	8274196
Hospital Revenue Code	272
Min. Negotiated Rate	$300.90
Max. Negotiated Rate	$343.38
Rate for Payer: Cash Price	$230.10
Rate for Payer: Health Management Network Commercial	$300.90
Rate for Payer: Kaiser Permanente Commercial	$318.60
Rate for Payer: MDX Hawaii PPO	$343.38

GASTROSTOMY 24FR FEEDING TUBE SAFETY PEG PULL KIT

Facility

$354.00

Hospital Charge Code	8274196
Hospital Revenue Code	272
Min. Negotiated Rate	$177.00
Max. Negotiated Rate	$343.38
Rate for Payer: AlohaCare Medicaid	$177.00
Rate for Payer: AlohaCare Medicare	$177.00
Rate for Payer: Cash Price	$230.10
Rate for Payer: Devoted Health Medicare	$194.70
Rate for Payer: Hawaii Medical Service Association Medicare	$177.00
Rate for Payer: Hawaii Western Management Group Commercial	$336.30
Rate for Payer: Health Management Network Commercial	$300.90
Rate for Payer: Humana Medicare	$177.00
Rate for Payer: Kaiser Permanente Commercial	$318.60
Rate for Payer: Kaiser Permanente Medicaid	$180.54
Rate for Payer: Kaiser Permanente Medicare	$177.00
Rate for Payer: MDX Hawaii PPO	$343.38
Rate for Payer: Ohana Health Plan Medicaid	$177.00
Rate for Payer: Ohana Health Plan Medicare	$177.00
Rate for Payer: UnitedHealthcare Medicare	$177.00
Rate for Payer: University Health Alliance Commercial	$258.03

GC Screen

Facility

$66.00

Service Code	HCPCS 87081
Hospital Charge Code	12499896
Hospital Revenue Code	306
Min. Negotiated Rate	$6.63
Max. Negotiated Rate	$64.02
Rate for Payer: AlohaCare Medicaid	$33.00
Rate for Payer: AlohaCare Medicare	$33.00
Rate for Payer: Cash Price	$42.90
Rate for Payer: Cash Price	$42.90
Rate for Payer: Devoted Health Medicare	$36.30
Rate for Payer: Hawaii Medical Service Association ABD	$9.16
Rate for Payer: Hawaii Medical Service Association Commercial	$8.29
Rate for Payer: Hawaii Medical Service Association Medicare	$33.00
Rate for Payer: Hawaii Medical Service Association Non-ABD	$9.62
Rate for Payer: Hawaii Western Management Group Commercial	$6.63
Rate for Payer: Health Management Network Commercial	$56.10
Rate for Payer: Humana Medicare	$33.00
Rate for Payer: Kaiser Permanente Commercial	$59.40
Rate for Payer: Kaiser Permanente Medicaid	$33.66
Rate for Payer: Kaiser Permanente Medicare	$33.00
Rate for Payer: MDX Hawaii PPO	$64.02
Rate for Payer: Ohana Health Plan Medicaid	$33.00
Rate for Payer: Ohana Health Plan Medicare	$33.00
Rate for Payer: UnitedHealthcare Medicaid	$9.16
Rate for Payer: UnitedHealthcare Medicare	$33.00
Rate for Payer: University Health Alliance Commercial	$17.13

GC Screen

Facility

$66.00

Service Code	HCPCS 87081
Hospital Charge Code	12499896
Hospital Revenue Code	306
Min. Negotiated Rate	$56.10
Max. Negotiated Rate	$64.02
Rate for Payer: Cash Price	$42.90
Rate for Payer: Health Management Network Commercial	$56.10
Rate for Payer: Kaiser Permanente Commercial	$59.40
Rate for Payer: MDX Hawaii PPO	$64.02

GC Screen- Bill only

Facility

$66.00

Service Code	HCPCS 87081
Hospital Charge Code	12528424
Hospital Revenue Code	306
Min. Negotiated Rate	$56.10
Max. Negotiated Rate	$64.02
Rate for Payer: Cash Price	$42.90
Rate for Payer: Health Management Network Commercial	$56.10
Rate for Payer: Kaiser Permanente Commercial	$59.40
Rate for Payer: MDX Hawaii PPO	$64.02

GC Screen- Bill only

Facility

$66.00

Service Code	HCPCS 87081
Hospital Charge Code	12528424
Hospital Revenue Code	306
Min. Negotiated Rate	$6.63
Max. Negotiated Rate	$64.02
Rate for Payer: AlohaCare Medicaid	$33.00
Rate for Payer: AlohaCare Medicare	$33.00
Rate for Payer: Cash Price	$42.90
Rate for Payer: Cash Price	$42.90
Rate for Payer: Devoted Health Medicare	$36.30
Rate for Payer: Hawaii Medical Service Association ABD	$9.16
Rate for Payer: Hawaii Medical Service Association Commercial	$8.29
Rate for Payer: Hawaii Medical Service Association Medicare	$33.00
Rate for Payer: Hawaii Medical Service Association Non-ABD	$9.62
Rate for Payer: Hawaii Western Management Group Commercial	$6.63
Rate for Payer: Health Management Network Commercial	$56.10
Rate for Payer: Humana Medicare	$33.00
Rate for Payer: Kaiser Permanente Commercial	$59.40
Rate for Payer: Kaiser Permanente Medicaid	$33.66
Rate for Payer: Kaiser Permanente Medicare	$33.00
Rate for Payer: MDX Hawaii PPO	$64.02
Rate for Payer: Ohana Health Plan Medicaid	$33.00
Rate for Payer: Ohana Health Plan Medicare	$33.00
Rate for Payer: UnitedHealthcare Medicaid	$9.16
Rate for Payer: UnitedHealthcare Medicare	$33.00
Rate for Payer: University Health Alliance Commercial	$17.13

GEN:COMPOSITE MESH 30CM X 20CM

Facility

$3,036.00

Service Code	HCPCS C1781
Hospital Charge Code	12915049
Hospital Revenue Code	278
Min. Negotiated Rate	$1,518.00
Max. Negotiated Rate	$2,944.92
Rate for Payer: AlohaCare Medicaid	$1,518.00
Rate for Payer: AlohaCare Medicare	$1,518.00
Rate for Payer: Cash Price	$1,973.40
Rate for Payer: Devoted Health Medicare	$1,669.80
Rate for Payer: Hawaii Medical Service Association Medicare	$1,518.00
Rate for Payer: Hawaii Western Management Group Commercial	$2,125.20
Rate for Payer: Health Management Network Commercial	$2,580.60
Rate for Payer: Humana Medicare	$1,518.00
Rate for Payer: Kaiser Permanente Commercial	$2,732.40
Rate for Payer: Kaiser Permanente Medicaid	$1,548.36
Rate for Payer: Kaiser Permanente Medicare	$1,518.00
Rate for Payer: MDX Hawaii PPO	$2,944.92
Rate for Payer: Ohana Health Plan Medicaid	$1,518.00
Rate for Payer: Ohana Health Plan Medicare	$1,518.00
Rate for Payer: UnitedHealthcare Medicare	$1,518.00
Rate for Payer: University Health Alliance Commercial	$1,700.16

GEN:COMPOSITE MESH 30CM X 20CM

Facility

$3,036.00

Service Code	HCPCS C1781
Hospital Charge Code	12915049
Hospital Revenue Code	278
Min. Negotiated Rate	$1,700.16
Max. Negotiated Rate	$2,944.92
Rate for Payer: Cash Price	$1,973.40
Rate for Payer: Hawaii Western Management Group Commercial	$2,125.20
Rate for Payer: Health Management Network Commercial	$2,580.60
Rate for Payer: Kaiser Permanente Commercial	$2,732.40
Rate for Payer: MDX Hawaii PPO	$2,944.92
Rate for Payer: University Health Alliance Commercial	$1,700.16

GEN ENDOSCOPIC: ECHELON 45MM RELOAD

Facility

$2,417.00

Hospital Charge Code	10050580
Hospital Revenue Code	272
Min. Negotiated Rate	$2,054.45
Max. Negotiated Rate	$2,344.49
Rate for Payer: Cash Price	$1,571.05
Rate for Payer: Health Management Network Commercial	$2,054.45
Rate for Payer: Kaiser Permanente Commercial	$2,175.30
Rate for Payer: MDX Hawaii PPO	$2,344.49

GEN ENDOSCOPIC: ECHELON 45MM RELOAD

Facility

$2,417.00

Hospital Charge Code	10050580
Hospital Revenue Code	272
Min. Negotiated Rate	$1,208.50
Max. Negotiated Rate	$2,344.49
Rate for Payer: AlohaCare Medicaid	$1,208.50
Rate for Payer: AlohaCare Medicare	$1,208.50
Rate for Payer: Cash Price	$1,571.05
Rate for Payer: Devoted Health Medicare	$1,329.35
Rate for Payer: Hawaii Medical Service Association Medicare	$1,208.50
Rate for Payer: Hawaii Western Management Group Commercial	$2,296.15
Rate for Payer: Health Management Network Commercial	$2,054.45
Rate for Payer: Humana Medicare	$1,208.50
Rate for Payer: Kaiser Permanente Commercial	$2,175.30
Rate for Payer: Kaiser Permanente Medicaid	$1,232.67
Rate for Payer: Kaiser Permanente Medicare	$1,208.50
Rate for Payer: MDX Hawaii PPO	$2,344.49
Rate for Payer: Ohana Health Plan Medicaid	$1,208.50
Rate for Payer: Ohana Health Plan Medicare	$1,208.50
Rate for Payer: UnitedHealthcare Medicare	$1,208.50
Rate for Payer: University Health Alliance Commercial	$1,761.75

GEN ENDOSCOPIC: ENDOLOOP PDS II LIGATURE 18

Facility

$767.00

Hospital Charge Code	10050581
Hospital Revenue Code	272
Min. Negotiated Rate	$651.95
Max. Negotiated Rate	$743.99
Rate for Payer: Cash Price	$498.55
Rate for Payer: Health Management Network Commercial	$651.95
Rate for Payer: Kaiser Permanente Commercial	$690.30
Rate for Payer: MDX Hawaii PPO	$743.99

GEN ENDOSCOPIC: ENDOLOOP PDS II LIGATURE 18

Facility

$767.00

Hospital Charge Code	10050581
Hospital Revenue Code	272
Min. Negotiated Rate	$383.50
Max. Negotiated Rate	$743.99
Rate for Payer: AlohaCare Medicaid	$383.50
Rate for Payer: AlohaCare Medicare	$383.50
Rate for Payer: Cash Price	$498.55
Rate for Payer: Devoted Health Medicare	$421.85
Rate for Payer: Hawaii Medical Service Association Medicare	$383.50
Rate for Payer: Hawaii Western Management Group Commercial	$728.65
Rate for Payer: Health Management Network Commercial	$651.95
Rate for Payer: Humana Medicare	$383.50
Rate for Payer: Kaiser Permanente Commercial	$690.30
Rate for Payer: Kaiser Permanente Medicaid	$391.17
Rate for Payer: Kaiser Permanente Medicare	$383.50
Rate for Payer: MDX Hawaii PPO	$743.99
Rate for Payer: Ohana Health Plan Medicaid	$383.50
Rate for Payer: Ohana Health Plan Medicare	$383.50
Rate for Payer: UnitedHealthcare Medicare	$383.50
Rate for Payer: University Health Alliance Commercial	$559.07

GENERAL:BINDER BREAST LARGE

Facility

$278.00

Hospital Charge Code	11398984
Hospital Revenue Code	272
Min. Negotiated Rate	$236.30
Max. Negotiated Rate	$269.66
Rate for Payer: Cash Price	$180.70
Rate for Payer: Health Management Network Commercial	$236.30
Rate for Payer: Kaiser Permanente Commercial	$250.20
Rate for Payer: MDX Hawaii PPO	$269.66

GENERAL:BINDER BREAST LARGE

Facility

$278.00

Hospital Charge Code	11398984
Hospital Revenue Code	272
Min. Negotiated Rate	$139.00
Max. Negotiated Rate	$269.66
Rate for Payer: AlohaCare Medicaid	$139.00
Rate for Payer: AlohaCare Medicare	$139.00
Rate for Payer: Cash Price	$180.70
Rate for Payer: Devoted Health Medicare	$152.90
Rate for Payer: Hawaii Medical Service Association Medicare	$139.00
Rate for Payer: Hawaii Western Management Group Commercial	$264.10
Rate for Payer: Health Management Network Commercial	$236.30
Rate for Payer: Humana Medicare	$139.00
Rate for Payer: Kaiser Permanente Commercial	$250.20
Rate for Payer: Kaiser Permanente Medicaid	$141.78
Rate for Payer: Kaiser Permanente Medicare	$139.00
Rate for Payer: MDX Hawaii PPO	$269.66
Rate for Payer: Ohana Health Plan Medicaid	$139.00
Rate for Payer: Ohana Health Plan Medicare	$139.00
Rate for Payer: UnitedHealthcare Medicare	$139.00
Rate for Payer: University Health Alliance Commercial	$202.63

GENERAL:CANISTER 150 ML

Facility

$237.00

Hospital Charge Code	12818167
Hospital Revenue Code	272
Min. Negotiated Rate	$201.45
Max. Negotiated Rate	$229.89
Rate for Payer: Cash Price	$154.05
Rate for Payer: Health Management Network Commercial	$201.45
Rate for Payer: Kaiser Permanente Commercial	$213.30
Rate for Payer: MDX Hawaii PPO	$229.89

GENERAL:CANISTER 150 ML

Facility

$237.00

Hospital Charge Code	12818167
Hospital Revenue Code	272
Min. Negotiated Rate	$118.50
Max. Negotiated Rate	$229.89
Rate for Payer: Cash Price	$154.05
Rate for Payer: AlohaCare Medicaid	$118.50
Rate for Payer: AlohaCare Medicare	$118.50
Rate for Payer: Devoted Health Medicare	$130.35
Rate for Payer: Hawaii Medical Service Association Medicare	$118.50
Rate for Payer: Hawaii Western Management Group Commercial	$225.15
Rate for Payer: Health Management Network Commercial	$201.45
Rate for Payer: Humana Medicare	$118.50
Rate for Payer: Kaiser Permanente Commercial	$213.30
Rate for Payer: Kaiser Permanente Medicaid	$120.87
Rate for Payer: Kaiser Permanente Medicare	$118.50
Rate for Payer: MDX Hawaii PPO	$229.89
Rate for Payer: Ohana Health Plan Medicaid	$118.50
Rate for Payer: Ohana Health Plan Medicare	$118.50
Rate for Payer: UnitedHealthcare Medicare	$118.50
Rate for Payer: University Health Alliance Commercial	$172.75

GENERAL:CANISTER 45 ML 7.2 X 6

Facility

$214.00

Hospital Charge Code	12818174
Hospital Revenue Code	272
Min. Negotiated Rate	$181.90
Max. Negotiated Rate	$207.58
Rate for Payer: Cash Price	$139.10
Rate for Payer: Health Management Network Commercial	$181.90
Rate for Payer: Kaiser Permanente Commercial	$192.60
Rate for Payer: MDX Hawaii PPO	$207.58

Know your out-of-pocket cost for care.

All Charges