Samuel Mahelona Memorial Hospital

All Charges

Charge

Type

Setting

Price

Hand finger orthosis, w/o joint, prefab (CMC brace; 3 R)

Facility

$368.00

Service Code	HCPCS L3924
Hospital Charge Code	13372150
Hospital Revenue Code	274
Min. Negotiated Rate	$206.08
Max. Negotiated Rate	$356.96
Rate for Payer: Cash Price	$239.20
Rate for Payer: Hawaii Western Management Group Commercial	$257.60
Rate for Payer: Health Management Network Commercial	$312.80
Rate for Payer: Kaiser Permanente Commercial	$331.20
Rate for Payer: MDX Hawaii PPO	$356.96
Rate for Payer: University Health Alliance Commercial	$206.08

Hand finger orthosis, w/o joint, prefab (CMC brace; 3 R)

Facility

$368.00

Service Code	HCPCS L3924
Hospital Charge Code	13372150
Hospital Revenue Code	274
Min. Negotiated Rate	$7.95
Max. Negotiated Rate	$356.96
Rate for Payer: AlohaCare Medicaid	$184.00
Rate for Payer: AlohaCare Medicare	$184.00
Rate for Payer: Cash Price	$239.20
Rate for Payer: Cash Price	$239.20
Rate for Payer: Devoted Health Medicare	$202.40
Rate for Payer: Hawaii Medical Service Association Medicare	$184.00
Rate for Payer: Hawaii Western Management Group Commercial	$257.60
Rate for Payer: Health Management Network Commercial	$312.80
Rate for Payer: Humana Medicare	$184.00
Rate for Payer: Kaiser Permanente Commercial	$331.20
Rate for Payer: Kaiser Permanente Medicaid	$187.68
Rate for Payer: Kaiser Permanente Medicare	$184.00
Rate for Payer: MDX Hawaii PPO	$356.96
Rate for Payer: Ohana Health Plan Medicaid	$184.00
Rate for Payer: Ohana Health Plan Medicare	$184.00
Rate for Payer: UnitedHealthcare Medicaid	$7.95
Rate for Payer: UnitedHealthcare Medicare	$184.00
Rate for Payer: University Health Alliance Commercial	$206.08

Hand finger orthosis, w/o joint, prefab (palm guard: L)

Facility

$94.00

Service Code	HCPCS L3924
Hospital Charge Code	13381793
Hospital Revenue Code	274
Min. Negotiated Rate	$52.64
Max. Negotiated Rate	$91.18
Rate for Payer: Cash Price	$61.10
Rate for Payer: Hawaii Western Management Group Commercial	$65.80
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
Rate for Payer: University Health Alliance Commercial	$52.64

Hand finger orthosis, w/o joint, prefab (palm guard: L)

Facility

$94.00

Service Code	HCPCS L3924
Hospital Charge Code	13381793
Hospital Revenue Code	274
Min. Negotiated Rate	$7.95
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 Medicare	$47.00
Rate for Payer: Hawaii Western Management Group Commercial	$65.80
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	$7.95
Rate for Payer: UnitedHealthcare Medicare	$47.00
Rate for Payer: University Health Alliance Commercial	$52.64

Hand finger orthosis, w/o joint, prefab (palm guard; R)

Facility

$187.00

Service Code	HCPCS L3924
Hospital Charge Code	13381790
Hospital Revenue Code	274
Min. Negotiated Rate	$104.72
Max. Negotiated Rate	$181.39
Rate for Payer: Cash Price	$121.55
Rate for Payer: Hawaii Western Management Group Commercial	$130.90
Rate for Payer: Health Management Network Commercial	$158.95
Rate for Payer: Kaiser Permanente Commercial	$168.30
Rate for Payer: MDX Hawaii PPO	$181.39
Rate for Payer: University Health Alliance Commercial	$104.72

Hand finger orthosis, w/o joint, prefab (palm guard; R)

Facility

$187.00

Service Code	HCPCS L3924
Hospital Charge Code	13381790
Hospital Revenue Code	274
Min. Negotiated Rate	$7.95
Max. Negotiated Rate	$181.39
Rate for Payer: AlohaCare Medicaid	$93.50
Rate for Payer: AlohaCare Medicare	$93.50
Rate for Payer: Cash Price	$121.55
Rate for Payer: Cash Price	$121.55
Rate for Payer: Devoted Health Medicare	$102.85
Rate for Payer: Hawaii Medical Service Association Medicare	$93.50
Rate for Payer: Hawaii Western Management Group Commercial	$130.90
Rate for Payer: Health Management Network Commercial	$158.95
Rate for Payer: Humana Medicare	$93.50
Rate for Payer: Kaiser Permanente Commercial	$168.30
Rate for Payer: Kaiser Permanente Medicaid	$95.37
Rate for Payer: Kaiser Permanente Medicare	$93.50
Rate for Payer: MDX Hawaii PPO	$181.39
Rate for Payer: Ohana Health Plan Medicaid	$93.50
Rate for Payer: Ohana Health Plan Medicare	$93.50
Rate for Payer: UnitedHealthcare Medicaid	$7.95
Rate for Payer: UnitedHealthcare Medicare	$93.50
Rate for Payer: University Health Alliance Commercial	$104.72

HAND OR WRIST PROCEDURES, EXCEPT MAJOR THUMB OR JOINT PROCEDURES WITH CC/MCC

Facility

$26,641.05

Service Code	MSDRG 513
Min. Negotiated Rate	$26,641.05
Max. Negotiated Rate	$26,641.05
Rate for Payer: Hawaii Medical Service Association Commercial	$26,641.05

HAND OR WRIST PROCEDURES, EXCEPT MAJOR THUMB OR JOINT PROCEDURES WITHOUT CC/MCC

Facility

$18,416.45

Service Code	MSDRG 514
Min. Negotiated Rate	$18,416.45
Max. Negotiated Rate	$18,416.45
Rate for Payer: Hawaii Medical Service Association Commercial	$18,416.45

HAND PROCEDURES FOR INJURIES

Facility

$22,161.37

Service Code	MSDRG 906
Min. Negotiated Rate	$22,161.37
Max. Negotiated Rate	$22,161.37
Rate for Payer: Hawaii Medical Service Association Commercial	$22,161.37

Haptoglobin REF

Facility

$178.00

Service Code	HCPCS 83010
Hospital Charge Code	8159950
Hospital Revenue Code	301
Min. Negotiated Rate	$151.30
Max. Negotiated Rate	$172.66
Rate for Payer: Cash Price	$115.70
Rate for Payer: Health Management Network Commercial	$151.30
Rate for Payer: Kaiser Permanente Commercial	$160.20
Rate for Payer: MDX Hawaii PPO	$172.66

Haptoglobin REF

Facility

$178.00

Service Code	HCPCS 83010
Hospital Charge Code	8159950
Hospital Revenue Code	301
Min. Negotiated Rate	$12.58
Max. Negotiated Rate	$172.66
Rate for Payer: AlohaCare Medicaid	$89.00
Rate for Payer: AlohaCare Medicare	$89.00
Rate for Payer: Cash Price	$115.70
Rate for Payer: Cash Price	$115.70
Rate for Payer: Devoted Health Medicare	$97.90
Rate for Payer: Hawaii Medical Service Association ABD	$17.38
Rate for Payer: Hawaii Medical Service Association Commercial	$15.72
Rate for Payer: Hawaii Medical Service Association Medicare	$89.00
Rate for Payer: Hawaii Medical Service Association Non-ABD	$18.25
Rate for Payer: Hawaii Western Management Group Commercial	$12.58
Rate for Payer: Health Management Network Commercial	$151.30
Rate for Payer: Humana Medicare	$89.00
Rate for Payer: Kaiser Permanente Commercial	$160.20
Rate for Payer: Kaiser Permanente Medicaid	$90.78
Rate for Payer: Kaiser Permanente Medicare	$89.00
Rate for Payer: MDX Hawaii PPO	$172.66
Rate for Payer: Ohana Health Plan Medicaid	$89.00
Rate for Payer: Ohana Health Plan Medicare	$89.00
Rate for Payer: UnitedHealthcare Medicaid	$17.38
Rate for Payer: UnitedHealthcare Medicare	$89.00
Rate for Payer: University Health Alliance Commercial	$32.52

HCG Qualitative, Serum FSI

Facility

$110.00

Service Code	HCPCS 84703
Hospital Charge Code	8117933
Hospital Revenue Code	301
Min. Negotiated Rate	$7.52
Max. Negotiated Rate	$106.70
Rate for Payer: AlohaCare Medicaid	$55.00
Rate for Payer: AlohaCare Medicare	$55.00
Rate for Payer: Cash Price	$71.50
Rate for Payer: Cash Price	$71.50
Rate for Payer: Devoted Health Medicare	$60.50
Rate for Payer: Hawaii Medical Service Association ABD	$10.38
Rate for Payer: Hawaii Medical Service Association Commercial	$9.40
Rate for Payer: Hawaii Medical Service Association Medicare	$55.00
Rate for Payer: Hawaii Medical Service Association Non-ABD	$10.90
Rate for Payer: Hawaii Western Management Group Commercial	$7.52
Rate for Payer: Health Management Network Commercial	$93.50
Rate for Payer: Humana Medicare	$55.00
Rate for Payer: Kaiser Permanente Commercial	$99.00
Rate for Payer: Kaiser Permanente Medicaid	$56.10
Rate for Payer: Kaiser Permanente Medicare	$55.00
Rate for Payer: MDX Hawaii PPO	$106.70
Rate for Payer: Ohana Health Plan Medicaid	$55.00
Rate for Payer: Ohana Health Plan Medicare	$55.00
Rate for Payer: UnitedHealthcare Medicaid	$10.38
Rate for Payer: UnitedHealthcare Medicare	$55.00
Rate for Payer: University Health Alliance Commercial	$19.41

HCG Qualitative, Serum FSI

Facility

$110.00

Service Code	HCPCS 84703
Hospital Charge Code	8117933
Hospital Revenue Code	301
Min. Negotiated Rate	$93.50
Max. Negotiated Rate	$106.70
Rate for Payer: Cash Price	$71.50
Rate for Payer: Health Management Network Commercial	$93.50
Rate for Payer: Kaiser Permanente Commercial	$99.00
Rate for Payer: MDX Hawaii PPO	$106.70

HCG Qualitative, Urine FSI

Facility

$110.00

Service Code	HCPCS 84703
Hospital Charge Code	8228876
Hospital Revenue Code	301
Min. Negotiated Rate	$93.50
Max. Negotiated Rate	$106.70
Rate for Payer: Cash Price	$71.50
Rate for Payer: Health Management Network Commercial	$93.50
Rate for Payer: Kaiser Permanente Commercial	$99.00
Rate for Payer: MDX Hawaii PPO	$106.70

HCG Qualitative, Urine FSI

Facility

$110.00

Service Code	HCPCS 84703
Hospital Charge Code	8228876
Hospital Revenue Code	301
Min. Negotiated Rate	$7.52
Max. Negotiated Rate	$106.70
Rate for Payer: AlohaCare Medicaid	$55.00
Rate for Payer: AlohaCare Medicare	$55.00
Rate for Payer: Cash Price	$71.50
Rate for Payer: Cash Price	$71.50
Rate for Payer: Devoted Health Medicare	$60.50
Rate for Payer: Hawaii Medical Service Association ABD	$10.38
Rate for Payer: Hawaii Medical Service Association Commercial	$9.40
Rate for Payer: Hawaii Medical Service Association Medicare	$55.00
Rate for Payer: Hawaii Medical Service Association Non-ABD	$10.90
Rate for Payer: Hawaii Western Management Group Commercial	$7.52
Rate for Payer: Health Management Network Commercial	$93.50
Rate for Payer: Humana Medicare	$55.00
Rate for Payer: Kaiser Permanente Commercial	$99.00
Rate for Payer: Kaiser Permanente Medicaid	$56.10
Rate for Payer: Kaiser Permanente Medicare	$55.00
Rate for Payer: MDX Hawaii PPO	$106.70
Rate for Payer: Ohana Health Plan Medicaid	$55.00
Rate for Payer: Ohana Health Plan Medicare	$55.00
Rate for Payer: UnitedHealthcare Medicaid	$10.38
Rate for Payer: UnitedHealthcare Medicare	$55.00
Rate for Payer: University Health Alliance Commercial	$19.41

HCG, Quant Tumor Marker FSI

Facility

$172.00

Service Code	HCPCS 84704
Hospital Charge Code	10368184
Hospital Revenue Code	301
Min. Negotiated Rate	$15.29
Max. Negotiated Rate	$166.84
Rate for Payer: AlohaCare Medicaid	$86.00
Rate for Payer: AlohaCare Medicare	$86.00
Rate for Payer: Cash Price	$111.80
Rate for Payer: Cash Price	$111.80
Rate for Payer: Devoted Health Medicare	$94.60
Rate for Payer: Hawaii Medical Service Association ABD	$21.03
Rate for Payer: Hawaii Medical Service Association Commercial	$19.11
Rate for Payer: Hawaii Medical Service Association Medicare	$86.00
Rate for Payer: Hawaii Medical Service Association Non-ABD	$22.08
Rate for Payer: Hawaii Western Management Group Commercial	$15.29
Rate for Payer: Health Management Network Commercial	$146.20
Rate for Payer: Humana Medicare	$86.00
Rate for Payer: Kaiser Permanente Commercial	$154.80
Rate for Payer: Kaiser Permanente Medicaid	$87.72
Rate for Payer: Kaiser Permanente Medicare	$86.00
Rate for Payer: MDX Hawaii PPO	$166.84
Rate for Payer: Ohana Health Plan Medicaid	$86.00
Rate for Payer: Ohana Health Plan Medicare	$86.00
Rate for Payer: UnitedHealthcare Medicaid	$21.03
Rate for Payer: UnitedHealthcare Medicare	$86.00
Rate for Payer: University Health Alliance Commercial	$38.91

HCG, Quant Tumor Marker FSI

Facility

$172.00

Service Code	HCPCS 84704
Hospital Charge Code	10368184
Hospital Revenue Code	301
Min. Negotiated Rate	$146.20
Max. Negotiated Rate	$166.84
Rate for Payer: Cash Price	$111.80
Rate for Payer: Health Management Network Commercial	$146.20
Rate for Payer: Kaiser Permanente Commercial	$154.80
Rate for Payer: MDX Hawaii PPO	$166.84

HDL Cholesterol FSI

Facility

$120.00

Service Code	HCPCS 83718
Hospital Charge Code	8117934
Hospital Revenue Code	301
Min. Negotiated Rate	$102.00
Max. Negotiated Rate	$116.40
Rate for Payer: Cash Price	$78.00
Rate for Payer: Health Management Network Commercial	$102.00
Rate for Payer: Kaiser Permanente Commercial	$108.00
Rate for Payer: MDX Hawaii PPO	$116.40

HDL Cholesterol FSI

Facility

$120.00

Service Code	HCPCS 83718
Hospital Charge Code	8117934
Hospital Revenue Code	301
Min. Negotiated Rate	$8.19
Max. Negotiated Rate	$116.40
Rate for Payer: AlohaCare Medicaid	$60.00
Rate for Payer: AlohaCare Medicare	$60.00
Rate for Payer: Cash Price	$78.00
Rate for Payer: Cash Price	$78.00
Rate for Payer: Devoted Health Medicare	$66.00
Rate for Payer: Hawaii Medical Service Association ABD	$11.31
Rate for Payer: Hawaii Medical Service Association Commercial	$10.24
Rate for Payer: Hawaii Medical Service Association Medicare	$60.00
Rate for Payer: Hawaii Medical Service Association Non-ABD	$11.88
Rate for Payer: Hawaii Western Management Group Commercial	$8.19
Rate for Payer: Health Management Network Commercial	$102.00
Rate for Payer: Humana Medicare	$60.00
Rate for Payer: Kaiser Permanente Commercial	$108.00
Rate for Payer: Kaiser Permanente Medicaid	$61.20
Rate for Payer: Kaiser Permanente Medicare	$60.00
Rate for Payer: MDX Hawaii PPO	$116.40
Rate for Payer: Ohana Health Plan Medicaid	$60.00
Rate for Payer: Ohana Health Plan Medicare	$60.00
Rate for Payer: UnitedHealthcare Medicaid	$11.31
Rate for Payer: UnitedHealthcare Medicare	$60.00
Rate for Payer: University Health Alliance Commercial	$21.16

HEADACHES WITH MCC

Facility

$15,667.02

Service Code	MSDRG 102
Min. Negotiated Rate	$15,667.02
Max. Negotiated Rate	$15,667.02
Rate for Payer: Hawaii Medical Service Association Commercial	$15,667.02

HEADACHES WITHOUT MCC

Facility

$15,667.02

Service Code	MSDRG 103
Min. Negotiated Rate	$15,667.02
Max. Negotiated Rate	$15,667.02
Rate for Payer: Hawaii Medical Service Association Commercial	$15,667.02

HEADED SCREW 4.0MM X 14MM

Facility

$1,733.00

Service Code	HCPCS C1713
Hospital Charge Code	10613398
Hospital Revenue Code	278
Min. Negotiated Rate	$866.50
Max. Negotiated Rate	$1,681.01
Rate for Payer: AlohaCare Medicaid	$866.50
Rate for Payer: AlohaCare Medicare	$866.50
Rate for Payer: Cash Price	$1,126.45
Rate for Payer: Devoted Health Medicare	$953.15
Rate for Payer: Hawaii Medical Service Association Medicare	$866.50
Rate for Payer: Hawaii Western Management Group Commercial	$1,213.10
Rate for Payer: Health Management Network Commercial	$1,473.05
Rate for Payer: Humana Medicare	$866.50
Rate for Payer: Kaiser Permanente Commercial	$1,559.70
Rate for Payer: Kaiser Permanente Medicaid	$883.83
Rate for Payer: Kaiser Permanente Medicare	$866.50
Rate for Payer: MDX Hawaii PPO	$1,681.01
Rate for Payer: Ohana Health Plan Medicaid	$866.50
Rate for Payer: Ohana Health Plan Medicare	$866.50
Rate for Payer: UnitedHealthcare Medicare	$866.50
Rate for Payer: University Health Alliance Commercial	$970.48

HEADED SCREW 4.0MM X 14MM

Facility

$1,733.00

Service Code	HCPCS C1713
Hospital Charge Code	10613398
Hospital Revenue Code	278
Min. Negotiated Rate	$970.48
Max. Negotiated Rate	$1,681.01
Rate for Payer: Cash Price	$1,126.45
Rate for Payer: Hawaii Western Management Group Commercial	$1,213.10
Rate for Payer: Health Management Network Commercial	$1,473.05
Rate for Payer: Kaiser Permanente Commercial	$1,559.70
Rate for Payer: MDX Hawaii PPO	$1,681.01
Rate for Payer: University Health Alliance Commercial	$970.48

Hearing Screen POC

Professional

Both

$56.00

Service Code	HCPCS 92551
Hospital Charge Code	1019764
Hospital Revenue Code	521
Min. Negotiated Rate	$12.38
Max. Negotiated Rate	$434.26
Rate for Payer: AlohaCare Medicaid	$14.34
Rate for Payer: Cash Price	$36.40
Rate for Payer: Cash Price	$36.40
Rate for Payer: Cash Price	$36.40
Rate for Payer: Hawaii Medical Service Association ABD	$434.26
Rate for Payer: Hawaii Medical Service Association Medicare	$339.46
Rate for Payer: Hawaii Medical Service Association Medicare	$246.64
Rate for Payer: Hawaii Medical Service Association Medicare	$265.97
Rate for Payer: Hawaii Medical Service Association Medicare	$303.73
Rate for Payer: Hawaii Medical Service Association Medicare	$181.39
Rate for Payer: Hawaii Medical Service Association Medicare	$209.49
Rate for Payer: Hawaii Medical Service Association Medicare	$237.64
Rate for Payer: Hawaii Medical Service Association Non-ABD	$434.26
Rate for Payer: Hawaii Western Management Group Commercial	$12.38
Rate for Payer: Health Management Network Commercial	$47.60
Rate for Payer: Kaiser Permanente Commercial	$246.64
Rate for Payer: Kaiser Permanente Commercial	$181.39
Rate for Payer: Kaiser Permanente Commercial	$209.49
Rate for Payer: Kaiser Permanente Commercial	$237.64
Rate for Payer: Kaiser Permanente Commercial	$265.97
Rate for Payer: Kaiser Permanente Commercial	$303.73
Rate for Payer: Kaiser Permanente Commercial	$339.46
Rate for Payer: Kaiser Permanente Medicaid	$434.26
Rate for Payer: Kaiser Permanente Medicare	$181.39
Rate for Payer: Kaiser Permanente Medicare	$209.49
Rate for Payer: Kaiser Permanente Medicare	$237.64
Rate for Payer: Kaiser Permanente Medicare	$246.64
Rate for Payer: Kaiser Permanente Medicare	$303.73
Rate for Payer: Kaiser Permanente Medicare	$339.46
Rate for Payer: Kaiser Permanente Medicare	$265.97
Rate for Payer: Ohana Health Plan Medicaid	$14.34
Rate for Payer: UnitedHealthcare Medicaid	$434.26
Rate for Payer: UnitedHealthcare Medicare	$303.73
Rate for Payer: UnitedHealthcare Medicare	$181.39
Rate for Payer: UnitedHealthcare Medicare	$209.49
Rate for Payer: UnitedHealthcare Medicare	$237.64
Rate for Payer: UnitedHealthcare Medicare	$246.64
Rate for Payer: UnitedHealthcare Medicare	$265.97
Rate for Payer: UnitedHealthcare Medicare	$339.46

Hearing Screen POC

Facility

$56.00

Service Code	HCPCS 92551
Hospital Charge Code	1083772
Hospital Revenue Code	521
Min. Negotiated Rate	$10.13
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 Medicare	$28.00
Rate for Payer: Hawaii Western Management Group Commercial	$53.20
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	$10.13
Rate for Payer: UnitedHealthcare Medicare	$28.00
Rate for Payer: University Health Alliance Commercial	$31.36

Know your out-of-pocket cost for care.

All Charges