Samuel Mahelona Memorial Hospital

All Charges

Charge

Type

Setting

Price

Hep C Ab Rfx Quant, Rfx Genotype FSI

Facility

$163.00

Service Code	HCPCS 86803
Hospital Charge Code	8228881
Hospital Revenue Code	302
Min. Negotiated Rate	$138.55
Max. Negotiated Rate	$158.11
Rate for Payer: Cash Price	$105.95
Rate for Payer: Health Management Network Commercial	$138.55
Rate for Payer: Kaiser Permanente Commercial	$146.70
Rate for Payer: MDX Hawaii PPO	$158.11

HERNIA PROCEDURES EXCEPT INGUINAL AND FEMORAL WITH CC

Facility

$31,950.30

Service Code	MSDRG 354
Min. Negotiated Rate	$31,950.30
Max. Negotiated Rate	$31,950.30
Rate for Payer: Hawaii Medical Service Association Commercial	$31,950.30

HERNIA PROCEDURES EXCEPT INGUINAL AND FEMORAL WITH MCC

Facility

$41,407.39

Service Code	MSDRG 353
Min. Negotiated Rate	$41,407.39
Max. Negotiated Rate	$41,407.39
Rate for Payer: Hawaii Medical Service Association Commercial	$41,407.39

HERNIA PROCEDURES EXCEPT INGUINAL AND FEMORAL WITHOUT CC/MCC

Facility

$23,607.19

Service Code	MSDRG 355
Min. Negotiated Rate	$23,607.19
Max. Negotiated Rate	$23,607.19
Rate for Payer: Hawaii Medical Service Association Commercial	$23,607.19

Herpes Simplex HSV 1,2 DNA by PCR FSI

Facility

$392.00

Service Code	HCPCS 87529
Hospital Charge Code	8117954
Hospital Revenue Code	306
Min. Negotiated Rate	$35.09
Max. Negotiated Rate	$380.24
Rate for Payer: AlohaCare Medicaid	$196.00
Rate for Payer: AlohaCare Medicare	$196.00
Rate for Payer: Cash Price	$254.80
Rate for Payer: Cash Price	$254.80
Rate for Payer: Devoted Health Medicare	$215.60
Rate for Payer: Hawaii Medical Service Association ABD	$46.44
Rate for Payer: Hawaii Medical Service Association Commercial	$43.86
Rate for Payer: Hawaii Medical Service Association Medicare	$196.00
Rate for Payer: Hawaii Medical Service Association Non-ABD	$48.76
Rate for Payer: Hawaii Western Management Group Commercial	$35.09
Rate for Payer: Health Management Network Commercial	$333.20
Rate for Payer: Humana Medicare	$196.00
Rate for Payer: Kaiser Permanente Commercial	$352.80
Rate for Payer: Kaiser Permanente Medicaid	$199.92
Rate for Payer: Kaiser Permanente Medicare	$196.00
Rate for Payer: MDX Hawaii PPO	$380.24
Rate for Payer: Ohana Health Plan Medicaid	$196.00
Rate for Payer: Ohana Health Plan Medicare	$196.00
Rate for Payer: UnitedHealthcare Medicaid	$46.44
Rate for Payer: UnitedHealthcare Medicare	$196.00
Rate for Payer: University Health Alliance Commercial	$90.72

Herpes Simplex HSV 1,2 DNA by PCR FSI

Facility

$392.00

Service Code	HCPCS 87529
Hospital Charge Code	8117954
Hospital Revenue Code	306
Min. Negotiated Rate	$333.20
Max. Negotiated Rate	$380.24
Rate for Payer: Cash Price	$254.80
Rate for Payer: Health Management Network Commercial	$333.20
Rate for Payer: Kaiser Permanente Commercial	$352.80
Rate for Payer: MDX Hawaii PPO	$380.24

Herpes Simplex HSV 1,2 IgG FSI

Facility

$139.00

Service Code	HCPCS 86695
Hospital Charge Code	8117955
Hospital Revenue Code	300
Min. Negotiated Rate	$13.19
Max. Negotiated Rate	$134.83
Rate for Payer: AlohaCare Medicaid	$69.50
Rate for Payer: AlohaCare Medicare	$69.50
Rate for Payer: Cash Price	$90.35
Rate for Payer: Cash Price	$90.35
Rate for Payer: Devoted Health Medicare	$76.45
Rate for Payer: Hawaii Medical Service Association ABD	$18.23
Rate for Payer: Hawaii Medical Service Association Commercial	$16.49
Rate for Payer: Hawaii Medical Service Association Medicare	$69.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$19.14
Rate for Payer: Hawaii Western Management Group Commercial	$13.19
Rate for Payer: Health Management Network Commercial	$118.15
Rate for Payer: Humana Medicare	$69.50
Rate for Payer: Kaiser Permanente Commercial	$125.10
Rate for Payer: Kaiser Permanente Medicaid	$70.89
Rate for Payer: Kaiser Permanente Medicare	$69.50
Rate for Payer: MDX Hawaii PPO	$134.83
Rate for Payer: Ohana Health Plan Medicaid	$69.50
Rate for Payer: Ohana Health Plan Medicare	$69.50
Rate for Payer: UnitedHealthcare Medicaid	$18.23
Rate for Payer: UnitedHealthcare Medicare	$69.50
Rate for Payer: University Health Alliance Commercial	$34.10

Herpes Simplex HSV 1,2 IgG FSI

Facility

$139.00

Service Code	HCPCS 86695
Hospital Charge Code	8117955
Hospital Revenue Code	300
Min. Negotiated Rate	$118.15
Max. Negotiated Rate	$134.83
Rate for Payer: Cash Price	$90.35
Rate for Payer: Health Management Network Commercial	$118.15
Rate for Payer: Kaiser Permanente Commercial	$125.10
Rate for Payer: MDX Hawaii PPO	$134.83

Herpes Simplex HSV 2 IgG FSI

Facility

$138.00

Service Code	HCPCS 86696
Hospital Charge Code	8117957
Hospital Revenue Code	300
Min. Negotiated Rate	$19.35
Max. Negotiated Rate	$133.86
Rate for Payer: AlohaCare Medicaid	$69.00
Rate for Payer: AlohaCare Medicare	$69.00
Rate for Payer: Cash Price	$89.70
Rate for Payer: Cash Price	$89.70
Rate for Payer: Devoted Health Medicare	$75.90
Rate for Payer: Hawaii Medical Service Association ABD	$27.05
Rate for Payer: Hawaii Medical Service Association Commercial	$24.19
Rate for Payer: Hawaii Medical Service Association Medicare	$69.00
Rate for Payer: Hawaii Medical Service Association Non-ABD	$28.40
Rate for Payer: Hawaii Western Management Group Commercial	$19.35
Rate for Payer: Health Management Network Commercial	$117.30
Rate for Payer: Humana Medicare	$69.00
Rate for Payer: Kaiser Permanente Commercial	$124.20
Rate for Payer: Kaiser Permanente Medicaid	$70.38
Rate for Payer: Kaiser Permanente Medicare	$69.00
Rate for Payer: MDX Hawaii PPO	$133.86
Rate for Payer: Ohana Health Plan Medicaid	$69.00
Rate for Payer: Ohana Health Plan Medicare	$69.00
Rate for Payer: UnitedHealthcare Medicaid	$27.05
Rate for Payer: UnitedHealthcare Medicare	$69.00
Rate for Payer: University Health Alliance Commercial	$50.04

Herpes Simplex HSV 2 IgG FSI

Facility

$138.00

Service Code	HCPCS 86696
Hospital Charge Code	8117957
Hospital Revenue Code	300
Min. Negotiated Rate	$117.30
Max. Negotiated Rate	$133.86
Rate for Payer: Cash Price	$89.70
Rate for Payer: Health Management Network Commercial	$117.30
Rate for Payer: Kaiser Permanente Commercial	$124.20
Rate for Payer: MDX Hawaii PPO	$133.86

Herpes Simplex PCR Reflex to Subtype 1, 2 (Blood and Fluid other than CSF) FSI

Facility

$392.00

Service Code	HCPCS 87529
Hospital Charge Code	8117959
Hospital Revenue Code	306
Min. Negotiated Rate	$333.20
Max. Negotiated Rate	$380.24
Rate for Payer: Cash Price	$254.80
Rate for Payer: Health Management Network Commercial	$333.20
Rate for Payer: Kaiser Permanente Commercial	$352.80
Rate for Payer: MDX Hawaii PPO	$380.24

Herpes Simplex PCR Reflex to Subtype 1, 2 (Blood and Fluid other than CSF) FSI

Facility

$392.00

Service Code	HCPCS 87529
Hospital Charge Code	8117959
Hospital Revenue Code	306
Min. Negotiated Rate	$35.09
Max. Negotiated Rate	$380.24
Rate for Payer: AlohaCare Medicaid	$196.00
Rate for Payer: AlohaCare Medicare	$196.00
Rate for Payer: Cash Price	$254.80
Rate for Payer: Cash Price	$254.80
Rate for Payer: Devoted Health Medicare	$215.60
Rate for Payer: Hawaii Medical Service Association ABD	$46.44
Rate for Payer: Hawaii Medical Service Association Commercial	$43.86
Rate for Payer: Hawaii Medical Service Association Medicare	$196.00
Rate for Payer: Hawaii Medical Service Association Non-ABD	$48.76
Rate for Payer: Hawaii Western Management Group Commercial	$35.09
Rate for Payer: Health Management Network Commercial	$333.20
Rate for Payer: Humana Medicare	$196.00
Rate for Payer: Kaiser Permanente Commercial	$352.80
Rate for Payer: Kaiser Permanente Medicaid	$199.92
Rate for Payer: Kaiser Permanente Medicare	$196.00
Rate for Payer: MDX Hawaii PPO	$380.24
Rate for Payer: Ohana Health Plan Medicaid	$196.00
Rate for Payer: Ohana Health Plan Medicare	$196.00
Rate for Payer: UnitedHealthcare Medicaid	$46.44
Rate for Payer: UnitedHealthcare Medicare	$196.00
Rate for Payer: University Health Alliance Commercial	$90.72

hetastarch-ns 6% 500ml [HHSC]

Facility

$86.16

Service Code	NDC 00264196510
Hospital Charge Code	2500384
Hospital Revenue Code	250
Min. Negotiated Rate	$43.08
Max. Negotiated Rate	$83.58
Rate for Payer: AlohaCare Medicaid	$43.08
Rate for Payer: AlohaCare Medicare	$43.08
Rate for Payer: Cash Price	$56.00
Rate for Payer: Devoted Health Medicare	$47.39
Rate for Payer: Hawaii Medical Service Association Medicare	$43.08
Rate for Payer: Hawaii Western Management Group Commercial	$81.85
Rate for Payer: Health Management Network Commercial	$73.24
Rate for Payer: Humana Medicare	$43.08
Rate for Payer: Kaiser Permanente Commercial	$77.54
Rate for Payer: Kaiser Permanente Medicaid	$43.94
Rate for Payer: Kaiser Permanente Medicare	$43.08
Rate for Payer: MDX Hawaii PPO	$83.58
Rate for Payer: Ohana Health Plan Medicaid	$43.08
Rate for Payer: Ohana Health Plan Medicare	$43.08
Rate for Payer: UnitedHealthcare Medicaid	$51.70
Rate for Payer: UnitedHealthcare Medicare	$43.08
Rate for Payer: University Health Alliance Commercial	$62.80

hetastarch-ns 6% 500ml [HHSC]

Facility

$94.58

Service Code	NDC 00409724803
Hospital Charge Code	2500384
Hospital Revenue Code	250
Min. Negotiated Rate	$80.39
Max. Negotiated Rate	$91.74
Rate for Payer: Cash Price	$61.48
Rate for Payer: Health Management Network Commercial	$80.39
Rate for Payer: Kaiser Permanente Commercial	$85.12
Rate for Payer: MDX Hawaii PPO	$91.74

hetastarch-ns 6% 500ml [HHSC]

Facility

$94.58

Service Code	NDC 00409724803
Hospital Charge Code	2500384
Hospital Revenue Code	250
Min. Negotiated Rate	$47.29
Max. Negotiated Rate	$91.74
Rate for Payer: AlohaCare Medicaid	$47.29
Rate for Payer: AlohaCare Medicare	$47.29
Rate for Payer: Cash Price	$61.48
Rate for Payer: Devoted Health Medicare	$52.02
Rate for Payer: Hawaii Medical Service Association Medicare	$47.29
Rate for Payer: Hawaii Western Management Group Commercial	$89.85
Rate for Payer: Health Management Network Commercial	$80.39
Rate for Payer: Humana Medicare	$47.29
Rate for Payer: Kaiser Permanente Commercial	$85.12
Rate for Payer: Kaiser Permanente Medicaid	$48.24
Rate for Payer: Kaiser Permanente Medicare	$47.29
Rate for Payer: MDX Hawaii PPO	$91.74
Rate for Payer: Ohana Health Plan Medicaid	$47.29
Rate for Payer: Ohana Health Plan Medicare	$47.29
Rate for Payer: UnitedHealthcare Medicaid	$56.75
Rate for Payer: UnitedHealthcare Medicare	$47.29
Rate for Payer: University Health Alliance Commercial	$68.94

hetastarch-ns 6% 500ml [HHSC]

Facility

$86.16

Service Code	NDC 00264196510
Hospital Charge Code	2500384
Hospital Revenue Code	250
Min. Negotiated Rate	$73.24
Max. Negotiated Rate	$83.58
Rate for Payer: Cash Price	$56.00
Rate for Payer: Health Management Network Commercial	$73.24
Rate for Payer: Kaiser Permanente Commercial	$77.54
Rate for Payer: MDX Hawaii PPO	$83.58

Hgb/Hct iSTAT

Facility

$97.00

Service Code	HCPCS 85014 QW
Hospital Charge Code	8293266
Hospital Revenue Code	305
Min. Negotiated Rate	$82.45
Max. Negotiated Rate	$94.09
Rate for Payer: Cash Price	$63.05
Rate for Payer: Health Management Network Commercial	$82.45
Rate for Payer: Kaiser Permanente Commercial	$87.30
Rate for Payer: MDX Hawaii PPO	$94.09

Hgb/Hct iSTAT

Facility

$97.00

Service Code	HCPCS 85014 QW
Hospital Charge Code	8293266
Hospital Revenue Code	305
Min. Negotiated Rate	$2.37
Max. Negotiated Rate	$94.09
Rate for Payer: AlohaCare Medicaid	$48.50
Rate for Payer: AlohaCare Medicare	$48.50
Rate for Payer: Cash Price	$63.05
Rate for Payer: Cash Price	$63.05
Rate for Payer: Devoted Health Medicare	$53.35
Rate for Payer: Hawaii Medical Service Association ABD	$3.27
Rate for Payer: Hawaii Medical Service Association Commercial	$2.96
Rate for Payer: Hawaii Medical Service Association Medicare	$48.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$3.43
Rate for Payer: Hawaii Western Management Group Commercial	$2.37
Rate for Payer: Health Management Network Commercial	$82.45
Rate for Payer: Humana Medicare	$48.50
Rate for Payer: Kaiser Permanente Commercial	$87.30
Rate for Payer: Kaiser Permanente Medicaid	$49.47
Rate for Payer: Kaiser Permanente Medicare	$48.50
Rate for Payer: MDX Hawaii PPO	$94.09
Rate for Payer: Ohana Health Plan Medicaid	$48.50
Rate for Payer: Ohana Health Plan Medicare	$48.50
Rate for Payer: UnitedHealthcare Medicaid	$3.27
Rate for Payer: UnitedHealthcare Medicare	$48.50
Rate for Payer: University Health Alliance Commercial	$6.12

HHSC AMNIOCENTESIS TRAYS

Facility

$109.00

Hospital Charge Code	8223464
Hospital Revenue Code	272
Min. Negotiated Rate	$92.65
Max. Negotiated Rate	$105.73
Rate for Payer: Cash Price	$70.85
Rate for Payer: Health Management Network Commercial	$92.65
Rate for Payer: Kaiser Permanente Commercial	$98.10
Rate for Payer: MDX Hawaii PPO	$105.73

HHSC AMNIOCENTESIS TRAYS

Facility

$109.00

Hospital Charge Code	8223464
Hospital Revenue Code	272
Min. Negotiated Rate	$54.50
Max. Negotiated Rate	$105.73
Rate for Payer: AlohaCare Medicaid	$54.50
Rate for Payer: AlohaCare Medicare	$54.50
Rate for Payer: Cash Price	$70.85
Rate for Payer: Devoted Health Medicare	$59.95
Rate for Payer: Hawaii Medical Service Association Medicare	$54.50
Rate for Payer: Hawaii Western Management Group Commercial	$103.55
Rate for Payer: Health Management Network Commercial	$92.65
Rate for Payer: Humana Medicare	$54.50
Rate for Payer: Kaiser Permanente Commercial	$98.10
Rate for Payer: Kaiser Permanente Medicaid	$55.59
Rate for Payer: Kaiser Permanente Medicare	$54.50
Rate for Payer: MDX Hawaii PPO	$105.73
Rate for Payer: Ohana Health Plan Medicaid	$54.50
Rate for Payer: Ohana Health Plan Medicare	$54.50
Rate for Payer: UnitedHealthcare Medicare	$54.50
Rate for Payer: University Health Alliance Commercial	$79.45

HHSC AT0912-12 9X12,12MM HP HOLO BRST BX

Facility

$155.00

Hospital Charge Code	8223446
Hospital Revenue Code	272
Min. Negotiated Rate	$77.50
Max. Negotiated Rate	$150.35
Rate for Payer: AlohaCare Medicaid	$77.50
Rate for Payer: AlohaCare Medicare	$77.50
Rate for Payer: Cash Price	$100.75
Rate for Payer: Devoted Health Medicare	$85.25
Rate for Payer: Hawaii Medical Service Association Medicare	$77.50
Rate for Payer: Hawaii Western Management Group Commercial	$147.25
Rate for Payer: Health Management Network Commercial	$131.75
Rate for Payer: Humana Medicare	$77.50
Rate for Payer: Kaiser Permanente Commercial	$139.50
Rate for Payer: Kaiser Permanente Medicaid	$79.05
Rate for Payer: Kaiser Permanente Medicare	$77.50
Rate for Payer: MDX Hawaii PPO	$150.35
Rate for Payer: Ohana Health Plan Medicaid	$77.50
Rate for Payer: Ohana Health Plan Medicare	$77.50
Rate for Payer: UnitedHealthcare Medicare	$77.50
Rate for Payer: University Health Alliance Commercial	$112.98

HHSC AT0912-12 9X12,12MM HP HOLO BRST BX

Facility

$155.00

Hospital Charge Code	8223446
Hospital Revenue Code	272
Min. Negotiated Rate	$131.75
Max. Negotiated Rate	$150.35
Rate for Payer: Cash Price	$100.75
Rate for Payer: Health Management Network Commercial	$131.75
Rate for Payer: Kaiser Permanente Commercial	$139.50
Rate for Payer: MDX Hawaii PPO	$150.35

HHSC AT0912-20 9X12,20MM HP HOLO BRST BX

Facility

$110.00

Hospital Charge Code	8223448
Hospital Revenue Code	272
Min. Negotiated Rate	$55.00
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: Devoted Health Medicare	$60.50
Rate for Payer: Hawaii Medical Service Association Medicare	$55.00
Rate for Payer: Hawaii Western Management Group Commercial	$104.50
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 Medicare	$55.00
Rate for Payer: University Health Alliance Commercial	$80.18

HHSC AT0912-20 9X12,20MM HP HOLO BRST BX

Facility

$110.00

Hospital Charge Code	8223448
Hospital Revenue Code	272
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

HHSC AUTOMATIC BX NEEDLE 18GX15CM

Facility

$76.00

Hospital Charge Code	8223444
Hospital Revenue Code	272
Min. Negotiated Rate	$38.00
Max. Negotiated Rate	$73.72
Rate for Payer: AlohaCare Medicaid	$38.00
Rate for Payer: AlohaCare Medicare	$38.00
Rate for Payer: Cash Price	$49.40
Rate for Payer: Devoted Health Medicare	$41.80
Rate for Payer: Hawaii Medical Service Association Medicare	$38.00
Rate for Payer: Hawaii Western Management Group Commercial	$72.20
Rate for Payer: Health Management Network Commercial	$64.60
Rate for Payer: Humana Medicare	$38.00
Rate for Payer: Kaiser Permanente Commercial	$68.40
Rate for Payer: Kaiser Permanente Medicaid	$38.76
Rate for Payer: Kaiser Permanente Medicare	$38.00
Rate for Payer: MDX Hawaii PPO	$73.72
Rate for Payer: Ohana Health Plan Medicaid	$38.00
Rate for Payer: Ohana Health Plan Medicare	$38.00
Rate for Payer: UnitedHealthcare Medicare	$38.00
Rate for Payer: University Health Alliance Commercial	$55.40

Know your out-of-pocket cost for care.

All Charges