Samuel Mahelona Memorial Hospital

All Charges

Charge

Type

Setting

Price

HIP REPLACEMENT WITH PRINCIPAL DIAGNOSIS OF HIP FRACTURE WITH MCC

Facility

$50,580.07

Service Code	MSDRG 521
Min. Negotiated Rate	$50,580.07
Max. Negotiated Rate	$50,580.07
Rate for Payer: Hawaii Medical Service Association Commercial	$50,580.07

HIP REPLACEMENT WITH PRINCIPAL DIAGNOSIS OF HIP FRACTURE WITHOUT MCC

Facility

$36,880.31

Service Code	MSDRG 522
Min. Negotiated Rate	$36,880.31
Max. Negotiated Rate	$36,880.31
Rate for Payer: Hawaii Medical Service Association Commercial	$36,880.31

Histone Antibody, IgG FSI

Facility

$699.00

Service Code	HCPCS 83516
Hospital Charge Code	8117960
Hospital Revenue Code	301
Min. Negotiated Rate	$594.15
Max. Negotiated Rate	$678.03
Rate for Payer: Cash Price	$454.35
Rate for Payer: Health Management Network Commercial	$594.15
Rate for Payer: Kaiser Permanente Commercial	$629.10
Rate for Payer: MDX Hawaii PPO	$678.03

Histone Antibody, IgG FSI

Facility

$699.00

Service Code	HCPCS 83516
Hospital Charge Code	8117960
Hospital Revenue Code	301
Min. Negotiated Rate	$11.53
Max. Negotiated Rate	$678.03
Rate for Payer: AlohaCare Medicaid	$349.50
Rate for Payer: AlohaCare Medicare	$349.50
Rate for Payer: Cash Price	$454.35
Rate for Payer: Cash Price	$454.35
Rate for Payer: Devoted Health Medicare	$384.45
Rate for Payer: Hawaii Medical Service Association ABD	$15.95
Rate for Payer: Hawaii Medical Service Association Commercial	$14.41
Rate for Payer: Hawaii Medical Service Association Medicare	$349.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$16.75
Rate for Payer: Hawaii Western Management Group Commercial	$11.53
Rate for Payer: Health Management Network Commercial	$594.15
Rate for Payer: Humana Medicare	$349.50
Rate for Payer: Kaiser Permanente Commercial	$629.10
Rate for Payer: Kaiser Permanente Medicaid	$356.49
Rate for Payer: Kaiser Permanente Medicare	$349.50
Rate for Payer: MDX Hawaii PPO	$678.03
Rate for Payer: Ohana Health Plan Medicaid	$349.50
Rate for Payer: Ohana Health Plan Medicare	$349.50
Rate for Payer: UnitedHealthcare Medicaid	$15.95
Rate for Payer: UnitedHealthcare Medicare	$349.50
Rate for Payer: University Health Alliance Commercial	$29.82

Histoplasma Antibody FSI

Facility

$490.00

Service Code	HCPCS 86698
Hospital Charge Code	10592882
Hospital Revenue Code	306
Min. Negotiated Rate	$416.50
Max. Negotiated Rate	$475.30
Rate for Payer: Cash Price	$318.50
Rate for Payer: Health Management Network Commercial	$416.50
Rate for Payer: Kaiser Permanente Commercial	$441.00
Rate for Payer: MDX Hawaii PPO	$475.30

Histoplasma Antibody FSI

Facility

$490.00

Service Code	HCPCS 86698
Hospital Charge Code	10592882
Hospital Revenue Code	306
Min. Negotiated Rate	$10.48
Max. Negotiated Rate	$475.30
Rate for Payer: AlohaCare Medicaid	$245.00
Rate for Payer: AlohaCare Medicare	$245.00
Rate for Payer: Cash Price	$318.50
Rate for Payer: Cash Price	$318.50
Rate for Payer: Devoted Health Medicare	$269.50
Rate for Payer: Hawaii Medical Service Association ABD	$10.48
Rate for Payer: Hawaii Medical Service Association Commercial	$17.24
Rate for Payer: Hawaii Medical Service Association Medicare	$245.00
Rate for Payer: Hawaii Medical Service Association Non-ABD	$17.26
Rate for Payer: Hawaii Western Management Group Commercial	$13.79
Rate for Payer: Health Management Network Commercial	$416.50
Rate for Payer: Humana Medicare	$245.00
Rate for Payer: Kaiser Permanente Commercial	$441.00
Rate for Payer: Kaiser Permanente Medicaid	$249.90
Rate for Payer: Kaiser Permanente Medicare	$245.00
Rate for Payer: MDX Hawaii PPO	$475.30
Rate for Payer: Ohana Health Plan Medicaid	$245.00
Rate for Payer: Ohana Health Plan Medicare	$245.00
Rate for Payer: UnitedHealthcare Medicaid	$10.48
Rate for Payer: UnitedHealthcare Medicare	$245.00
Rate for Payer: University Health Alliance Commercial	$32.30

HIV 1, 2 Antigen/Antibody FSI

Facility

$287.00

Service Code	HCPCS 87389
Hospital Charge Code	8117963
Hospital Revenue Code	306
Min. Negotiated Rate	$24.08
Max. Negotiated Rate	$278.39
Rate for Payer: AlohaCare Medicaid	$143.50
Rate for Payer: AlohaCare Medicare	$143.50
Rate for Payer: Cash Price	$186.55
Rate for Payer: Cash Price	$186.55
Rate for Payer: Devoted Health Medicare	$157.85
Rate for Payer: Hawaii Medical Service Association ABD	$34.12
Rate for Payer: Hawaii Medical Service Association Commercial	$30.10
Rate for Payer: Hawaii Medical Service Association Medicare	$143.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$30.90
Rate for Payer: Hawaii Western Management Group Commercial	$24.08
Rate for Payer: Health Management Network Commercial	$243.95
Rate for Payer: Humana Medicare	$143.50
Rate for Payer: Kaiser Permanente Commercial	$258.30
Rate for Payer: Kaiser Permanente Medicaid	$146.37
Rate for Payer: Kaiser Permanente Medicare	$143.50
Rate for Payer: MDX Hawaii PPO	$278.39
Rate for Payer: Ohana Health Plan Medicaid	$143.50
Rate for Payer: Ohana Health Plan Medicare	$143.50
Rate for Payer: UnitedHealthcare Medicaid	$34.12
Rate for Payer: UnitedHealthcare Medicare	$143.50
Rate for Payer: University Health Alliance Commercial	$63.12

HIV 1, 2 Antigen/Antibody FSI

Facility

$287.00

Service Code	HCPCS 87389
Hospital Charge Code	8117963
Hospital Revenue Code	306
Min. Negotiated Rate	$243.95
Max. Negotiated Rate	$278.39
Rate for Payer: Cash Price	$186.55
Rate for Payer: Health Management Network Commercial	$243.95
Rate for Payer: Kaiser Permanente Commercial	$258.30
Rate for Payer: MDX Hawaii PPO	$278.39

HIV 1, 2 Antigen/Antibody Prenatal FSI

Facility

$287.00

Service Code	HCPCS 87389
Hospital Charge Code	8117964
Hospital Revenue Code	306
Min. Negotiated Rate	$24.08
Max. Negotiated Rate	$278.39
Rate for Payer: AlohaCare Medicaid	$143.50
Rate for Payer: AlohaCare Medicare	$143.50
Rate for Payer: Cash Price	$186.55
Rate for Payer: Cash Price	$186.55
Rate for Payer: Devoted Health Medicare	$157.85
Rate for Payer: Hawaii Medical Service Association ABD	$34.12
Rate for Payer: Hawaii Medical Service Association Commercial	$30.10
Rate for Payer: Hawaii Medical Service Association Medicare	$143.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$30.90
Rate for Payer: Hawaii Western Management Group Commercial	$24.08
Rate for Payer: Health Management Network Commercial	$243.95
Rate for Payer: Humana Medicare	$143.50
Rate for Payer: Kaiser Permanente Commercial	$258.30
Rate for Payer: Kaiser Permanente Medicaid	$146.37
Rate for Payer: Kaiser Permanente Medicare	$143.50
Rate for Payer: MDX Hawaii PPO	$278.39
Rate for Payer: Ohana Health Plan Medicaid	$143.50
Rate for Payer: Ohana Health Plan Medicare	$143.50
Rate for Payer: UnitedHealthcare Medicaid	$34.12
Rate for Payer: UnitedHealthcare Medicare	$143.50
Rate for Payer: University Health Alliance Commercial	$63.12

HIV 1, 2 Antigen/Antibody Prenatal FSI

Facility

$287.00

Service Code	HCPCS 87389
Hospital Charge Code	8117964
Hospital Revenue Code	306
Min. Negotiated Rate	$243.95
Max. Negotiated Rate	$278.39
Rate for Payer: Cash Price	$186.55
Rate for Payer: Health Management Network Commercial	$243.95
Rate for Payer: Kaiser Permanente Commercial	$258.30
Rate for Payer: MDX Hawaii PPO	$278.39

HIV 1, 2 Antigen/Antibody Reflex Western Blot FSI

Facility

$28.00

Service Code	HCPCS 87389
Hospital Charge Code	8117965
Hospital Revenue Code	306
Min. Negotiated Rate	$14.00
Max. Negotiated Rate	$63.12
Rate for Payer: AlohaCare Medicaid	$14.00
Rate for Payer: AlohaCare Medicare	$14.00
Rate for Payer: Cash Price	$18.20
Rate for Payer: Cash Price	$18.20
Rate for Payer: Devoted Health Medicare	$15.40
Rate for Payer: Hawaii Medical Service Association ABD	$34.12
Rate for Payer: Hawaii Medical Service Association Commercial	$30.10
Rate for Payer: Hawaii Medical Service Association Medicare	$14.00
Rate for Payer: Hawaii Medical Service Association Non-ABD	$30.90
Rate for Payer: Hawaii Western Management Group Commercial	$24.08
Rate for Payer: Health Management Network Commercial	$23.80
Rate for Payer: Humana Medicare	$14.00
Rate for Payer: Kaiser Permanente Commercial	$25.20
Rate for Payer: Kaiser Permanente Medicaid	$14.28
Rate for Payer: Kaiser Permanente Medicare	$14.00
Rate for Payer: MDX Hawaii PPO	$27.16
Rate for Payer: Ohana Health Plan Medicaid	$14.00
Rate for Payer: Ohana Health Plan Medicare	$14.00
Rate for Payer: UnitedHealthcare Medicaid	$34.12
Rate for Payer: UnitedHealthcare Medicare	$14.00
Rate for Payer: University Health Alliance Commercial	$63.12

HIV 1, 2 Antigen/Antibody Reflex Western Blot FSI

Facility

$28.00

Service Code	HCPCS 87389
Hospital Charge Code	8117965
Hospital Revenue Code	306
Min. Negotiated Rate	$23.80
Max. Negotiated Rate	$27.16
Rate for Payer: Cash Price	$18.20
Rate for Payer: Health Management Network Commercial	$23.80
Rate for Payer: Kaiser Permanente Commercial	$25.20
Rate for Payer: MDX Hawaii PPO	$27.16

HIV 1 Genotype Drug Resistance FSI

Facility

$2,876.00

Service Code	HCPCS 87901
Hospital Charge Code	8228883
Hospital Revenue Code	306
Min. Negotiated Rate	$257.45
Max. Negotiated Rate	$2,789.72
Rate for Payer: AlohaCare Medicaid	$1,438.00
Rate for Payer: AlohaCare Medicare	$1,438.00
Rate for Payer: Cash Price	$1,869.40
Rate for Payer: Cash Price	$1,869.40
Rate for Payer: Devoted Health Medicare	$1,581.80
Rate for Payer: Hawaii Medical Service Association ABD	$355.78
Rate for Payer: Hawaii Medical Service Association Commercial	$321.81
Rate for Payer: Hawaii Medical Service Association Medicare	$1,438.00
Rate for Payer: Hawaii Medical Service Association Non-ABD	$373.57
Rate for Payer: Hawaii Western Management Group Commercial	$257.45
Rate for Payer: Health Management Network Commercial	$2,444.60
Rate for Payer: Humana Medicare	$1,438.00
Rate for Payer: Kaiser Permanente Commercial	$2,588.40
Rate for Payer: Kaiser Permanente Medicaid	$1,466.76
Rate for Payer: Kaiser Permanente Medicare	$1,438.00
Rate for Payer: MDX Hawaii PPO	$2,789.72
Rate for Payer: Ohana Health Plan Medicaid	$1,438.00
Rate for Payer: Ohana Health Plan Medicare	$1,438.00
Rate for Payer: UnitedHealthcare Medicaid	$355.78
Rate for Payer: UnitedHealthcare Medicare	$1,438.00
Rate for Payer: University Health Alliance Commercial	$665.43

HIV 1 Genotype Drug Resistance FSI

Facility

$2,876.00

Service Code	HCPCS 87901
Hospital Charge Code	8228883
Hospital Revenue Code	306
Min. Negotiated Rate	$2,444.60
Max. Negotiated Rate	$2,789.72
Rate for Payer: Cash Price	$1,869.40
Rate for Payer: Health Management Network Commercial	$2,444.60
Rate for Payer: Kaiser Permanente Commercial	$2,588.40
Rate for Payer: MDX Hawaii PPO	$2,789.72

HIV 1 Quantitative PCR FSI

Facility

$950.00

Service Code	HCPCS 87536
Hospital Charge Code	8117961
Hospital Revenue Code	306
Min. Negotiated Rate	$85.10
Max. Negotiated Rate	$921.50
Rate for Payer: AlohaCare Medicaid	$475.00
Rate for Payer: AlohaCare Medicare	$475.00
Rate for Payer: Cash Price	$617.50
Rate for Payer: Cash Price	$617.50
Rate for Payer: Devoted Health Medicare	$522.50
Rate for Payer: Hawaii Medical Service Association ABD	$117.59
Rate for Payer: Hawaii Medical Service Association Commercial	$106.38
Rate for Payer: Hawaii Medical Service Association Medicare	$475.00
Rate for Payer: Hawaii Medical Service Association Non-ABD	$123.47
Rate for Payer: Hawaii Western Management Group Commercial	$85.10
Rate for Payer: Health Management Network Commercial	$807.50
Rate for Payer: Humana Medicare	$475.00
Rate for Payer: Kaiser Permanente Commercial	$855.00
Rate for Payer: Kaiser Permanente Medicaid	$484.50
Rate for Payer: Kaiser Permanente Medicare	$475.00
Rate for Payer: MDX Hawaii PPO	$921.50
Rate for Payer: Ohana Health Plan Medicaid	$475.00
Rate for Payer: Ohana Health Plan Medicare	$475.00
Rate for Payer: UnitedHealthcare Medicaid	$117.59
Rate for Payer: UnitedHealthcare Medicare	$475.00
Rate for Payer: University Health Alliance Commercial	$219.95

HIV 1 Quantitative PCR FSI

Facility

$950.00

Service Code	HCPCS 87536
Hospital Charge Code	8117961
Hospital Revenue Code	306
Min. Negotiated Rate	$807.50
Max. Negotiated Rate	$921.50
Rate for Payer: Cash Price	$617.50
Rate for Payer: Health Management Network Commercial	$807.50
Rate for Payer: Kaiser Permanente Commercial	$855.00
Rate for Payer: MDX Hawaii PPO	$921.50

HIV WITH EXTENSIVE O.R. PROCEDURES WITH MCC

Facility

$99,074.36

Service Code	MSDRG 969
Min. Negotiated Rate	$99,074.36
Max. Negotiated Rate	$99,074.36
Rate for Payer: Hawaii Medical Service Association Commercial	$99,074.36

HIV WITH EXTENSIVE O.R. PROCEDURES WITHOUT MCC

Facility

$99,074.36

Service Code	MSDRG 970
Min. Negotiated Rate	$99,074.36
Max. Negotiated Rate	$99,074.36
Rate for Payer: Hawaii Medical Service Association Commercial	$99,074.36

HIV WITH MAJOR RELATED CONDITION WITH CC

Facility

$57,643.26

Service Code	MSDRG 975
Min. Negotiated Rate	$57,643.26
Max. Negotiated Rate	$57,643.26
Rate for Payer: Hawaii Medical Service Association Commercial	$57,643.26

HIV WITH MAJOR RELATED CONDITION WITH MCC

Facility

$57,643.26

Service Code	MSDRG 974
Min. Negotiated Rate	$57,643.26
Max. Negotiated Rate	$57,643.26
Rate for Payer: Hawaii Medical Service Association Commercial	$57,643.26

HIV WITH MAJOR RELATED CONDITION WITHOUT CC/MCC

Facility

$57,643.26

Service Code	MSDRG 976
Min. Negotiated Rate	$57,643.26
Max. Negotiated Rate	$57,643.26
Rate for Payer: Hawaii Medical Service Association Commercial	$57,643.26

HIV WITH OR WITHOUT OTHER RELATED CONDITION

Facility

$41,431.10

Service Code	MSDRG 977
Min. Negotiated Rate	$41,431.10
Max. Negotiated Rate	$41,431.10
Rate for Payer: Hawaii Medical Service Association Commercial	$41,431.10

HMGCR Antibody IgG

Facility

$530.00

Service Code	HCPCS 82397
Hospital Charge Code	12514764
Hospital Revenue Code	301
Min. Negotiated Rate	$11.84
Max. Negotiated Rate	$514.10
Rate for Payer: AlohaCare Medicaid	$265.00
Rate for Payer: AlohaCare Medicare	$265.00
Rate for Payer: Cash Price	$344.50
Rate for Payer: Cash Price	$344.50
Rate for Payer: Devoted Health Medicare	$291.50
Rate for Payer: Hawaii Medical Service Association ABD	$11.84
Rate for Payer: Hawaii Medical Service Association Commercial	$17.65
Rate for Payer: Hawaii Medical Service Association Medicare	$265.00
Rate for Payer: Hawaii Medical Service Association Non-ABD	$19.51
Rate for Payer: Hawaii Western Management Group Commercial	$14.12
Rate for Payer: Health Management Network Commercial	$450.50
Rate for Payer: Humana Medicare	$265.00
Rate for Payer: Kaiser Permanente Commercial	$477.00
Rate for Payer: Kaiser Permanente Medicaid	$270.30
Rate for Payer: Kaiser Permanente Medicare	$265.00
Rate for Payer: MDX Hawaii PPO	$514.10
Rate for Payer: Ohana Health Plan Medicaid	$265.00
Rate for Payer: Ohana Health Plan Medicare	$265.00
Rate for Payer: UnitedHealthcare Medicaid	$11.84
Rate for Payer: UnitedHealthcare Medicare	$265.00
Rate for Payer: University Health Alliance Commercial	$36.52

HMGCR Antibody IgG

Facility

$530.00

Service Code	HCPCS 82397
Hospital Charge Code	12514764
Hospital Revenue Code	301
Min. Negotiated Rate	$450.50
Max. Negotiated Rate	$514.10
Rate for Payer: Cash Price	$344.50
Rate for Payer: Health Management Network Commercial	$450.50
Rate for Payer: Kaiser Permanente Commercial	$477.00
Rate for Payer: MDX Hawaii PPO	$514.10

HMGCR Antibody IgG FSI

Facility

$557.00

Service Code	HCPCS 82397
Hospital Charge Code	12332995
Hospital Revenue Code	300
Min. Negotiated Rate	$473.45
Max. Negotiated Rate	$540.29
Rate for Payer: Cash Price	$362.05
Rate for Payer: Health Management Network Commercial	$473.45
Rate for Payer: Kaiser Permanente Commercial	$501.30
Rate for Payer: MDX Hawaii PPO	$540.29

Know your out-of-pocket cost for care.

All Charges