Samuel Mahelona Memorial Hospital

All Charges

Charge

Type

Setting

Price

INFLATION DEVICE DISPOSABLE FOR EBD

Facility

$228.00

Hospital Charge Code	9552699
Hospital Revenue Code	272
Min. Negotiated Rate	$114.00
Max. Negotiated Rate	$221.16
Rate for Payer: AlohaCare Medicaid	$114.00
Rate for Payer: AlohaCare Medicare	$114.00
Rate for Payer: Cash Price	$148.20
Rate for Payer: Devoted Health Medicare	$125.40
Rate for Payer: Hawaii Medical Service Association Medicare	$114.00
Rate for Payer: Hawaii Western Management Group Commercial	$216.60
Rate for Payer: Health Management Network Commercial	$193.80
Rate for Payer: Humana Medicare	$114.00
Rate for Payer: Kaiser Permanente Commercial	$205.20
Rate for Payer: Kaiser Permanente Medicaid	$116.28
Rate for Payer: Kaiser Permanente Medicare	$114.00
Rate for Payer: MDX Hawaii PPO	$221.16
Rate for Payer: Ohana Health Plan Medicaid	$114.00
Rate for Payer: Ohana Health Plan Medicare	$114.00
Rate for Payer: UnitedHealthcare Medicare	$114.00
Rate for Payer: University Health Alliance Commercial	$166.19

INFLATION DEVICE DISPOSABLE FOR EBD

Facility

$228.00

Hospital Charge Code	9552699
Hospital Revenue Code	272
Min. Negotiated Rate	$193.80
Max. Negotiated Rate	$221.16
Rate for Payer: Cash Price	$148.20
Rate for Payer: Health Management Network Commercial	$193.80
Rate for Payer: Kaiser Permanente Commercial	$205.20
Rate for Payer: MDX Hawaii PPO	$221.16

Influenza A/B POC.

Professional

Both

$80.00

Service Code	HCPCS 87804 QW
Hospital Charge Code	8041486
Hospital Revenue Code	306
Min. Negotiated Rate	$16.55
Max. Negotiated Rate	$68.00
Rate for Payer: AlohaCare Medicaid	$16.58
Rate for Payer: AlohaCare Medicare	$16.55
Rate for Payer: Cash Price	$52.00
Rate for Payer: Cash Price	$52.00
Rate for Payer: Devoted Health Medicare	$18.20
Rate for Payer: Hawaii Medical Service Association Medicare	$16.55
Rate for Payer: Hawaii Western Management Group Commercial	$16.58
Rate for Payer: Health Management Network Commercial	$68.00
Rate for Payer: Kaiser Permanente Commercial	$19.86
Rate for Payer: Kaiser Permanente Medicaid	$19.86
Rate for Payer: Kaiser Permanente Medicare	$19.86
Rate for Payer: Ohana Health Plan Medicaid	$16.58
Rate for Payer: Ohana Health Plan Medicare	$16.55
Rate for Payer: UnitedHealthcare Medicaid	$16.58
Rate for Payer: UnitedHealthcare Medicare	$16.55

Influenza A/B POC.

Facility

$76.00

Service Code	HCPCS 87804 QW
Hospital Charge Code	8041486
Hospital Revenue Code	306
Min. Negotiated Rate	$16.55
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: Cash Price	$49.40
Rate for Payer: Devoted Health Medicare	$41.80
Rate for Payer: Hawaii Medical Service Association ABD	$16.58
Rate for Payer: Hawaii Medical Service Association Commercial	$20.69
Rate for Payer: Hawaii Medical Service Association Medicare	$38.00
Rate for Payer: Hawaii Medical Service Association Non-ABD	$17.41
Rate for Payer: Hawaii Western Management Group Commercial	$16.55
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 Medicaid	$16.58
Rate for Payer: UnitedHealthcare Medicare	$38.00
Rate for Payer: University Health Alliance Commercial	$31.01

Influenza A/B POC.

Facility

$76.00

Service Code	HCPCS 87804 QW
Hospital Charge Code	8041486
Hospital Revenue Code	306
Min. Negotiated Rate	$64.60
Max. Negotiated Rate	$73.72
Rate for Payer: Cash Price	$49.40
Rate for Payer: Health Management Network Commercial	$64.60
Rate for Payer: Kaiser Permanente Commercial	$68.40
Rate for Payer: MDX Hawaii PPO	$73.72

Influenza A/B POCT

Facility

$61.00

Service Code	HCPCS 87084
Hospital Charge Code	9578814
Hospital Revenue Code	306
Min. Negotiated Rate	$51.85
Max. Negotiated Rate	$59.17
Rate for Payer: Cash Price	$39.65
Rate for Payer: Health Management Network Commercial	$51.85
Rate for Payer: Kaiser Permanente Commercial	$54.90
Rate for Payer: MDX Hawaii PPO	$59.17

Influenza A/B POCT

Facility

$61.00

Service Code	HCPCS 87084
Hospital Charge Code	9578814
Hospital Revenue Code	306
Min. Negotiated Rate	$11.90
Max. Negotiated Rate	$59.17
Rate for Payer: AlohaCare Medicaid	$30.50
Rate for Payer: AlohaCare Medicare	$30.50
Rate for Payer: Cash Price	$39.65
Rate for Payer: Cash Price	$39.65
Rate for Payer: Devoted Health Medicare	$33.55
Rate for Payer: Hawaii Medical Service Association ABD	$11.90
Rate for Payer: Hawaii Medical Service Association Commercial	$33.84
Rate for Payer: Hawaii Medical Service Association Medicare	$30.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$12.50
Rate for Payer: Hawaii Western Management Group Commercial	$27.07
Rate for Payer: Health Management Network Commercial	$51.85
Rate for Payer: Humana Medicare	$30.50
Rate for Payer: Kaiser Permanente Commercial	$54.90
Rate for Payer: Kaiser Permanente Medicaid	$31.11
Rate for Payer: Kaiser Permanente Medicare	$30.50
Rate for Payer: MDX Hawaii PPO	$59.17
Rate for Payer: Ohana Health Plan Medicaid	$30.50
Rate for Payer: Ohana Health Plan Medicare	$30.50
Rate for Payer: UnitedHealthcare Medicaid	$11.90
Rate for Payer: UnitedHealthcare Medicare	$30.50
Rate for Payer: University Health Alliance Commercial	$22.26

Influenza Testing to DOH FSI

Facility

$139.00

Service Code	HCPCS 87804 QW
Hospital Charge Code	8228884
Hospital Revenue Code	306
Min. Negotiated Rate	$16.55
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	$16.58
Rate for Payer: Hawaii Medical Service Association Commercial	$20.69
Rate for Payer: Hawaii Medical Service Association Medicare	$69.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$17.41
Rate for Payer: Hawaii Western Management Group Commercial	$16.55
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	$16.58
Rate for Payer: UnitedHealthcare Medicare	$69.50
Rate for Payer: University Health Alliance Commercial	$31.01

Influenza Testing to DOH FSI

Facility

$139.00

Service Code	HCPCS 87804 QW
Hospital Charge Code	8228884
Hospital Revenue Code	306
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

Influenza Virus Flu A/B PCR FSI

Facility

$947.00

Service Code	HCPCS 87502
Hospital Charge Code	8228885
Hospital Revenue Code	306
Min. Negotiated Rate	$95.80
Max. Negotiated Rate	$918.59
Rate for Payer: AlohaCare Medicaid	$473.50
Rate for Payer: AlohaCare Medicare	$473.50
Rate for Payer: Cash Price	$615.55
Rate for Payer: Cash Price	$615.55
Rate for Payer: Devoted Health Medicare	$520.85
Rate for Payer: Hawaii Medical Service Association ABD	$119.75
Rate for Payer: Hawaii Medical Service Association Commercial	$119.75
Rate for Payer: Hawaii Medical Service Association Medicare	$473.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$117.54
Rate for Payer: Hawaii Western Management Group Commercial	$95.80
Rate for Payer: Health Management Network Commercial	$804.95
Rate for Payer: Humana Medicare	$473.50
Rate for Payer: Kaiser Permanente Commercial	$852.30
Rate for Payer: Kaiser Permanente Medicaid	$482.97
Rate for Payer: Kaiser Permanente Medicare	$473.50
Rate for Payer: MDX Hawaii PPO	$918.59
Rate for Payer: Ohana Health Plan Medicaid	$473.50
Rate for Payer: Ohana Health Plan Medicare	$473.50
Rate for Payer: UnitedHealthcare Medicaid	$119.75
Rate for Payer: UnitedHealthcare Medicare	$473.50
Rate for Payer: University Health Alliance Commercial	$221.54

Influenza Virus Flu A/B PCR FSI

Facility

$947.00

Service Code	HCPCS 87502
Hospital Charge Code	8228885
Hospital Revenue Code	306
Min. Negotiated Rate	$804.95
Max. Negotiated Rate	$918.59
Rate for Payer: Cash Price	$615.55
Rate for Payer: Health Management Network Commercial	$804.95
Rate for Payer: Kaiser Permanente Commercial	$852.30
Rate for Payer: MDX Hawaii PPO	$918.59

Infrared-Light Therapy Charge

Facility

$45.00

Service Code	HCPCS 97026 GP,CQ
Hospital Charge Code	8111743
Hospital Revenue Code	420
Min. Negotiated Rate	$38.25
Max. Negotiated Rate	$43.65
Rate for Payer: Cash Price	$29.25
Rate for Payer: Health Management Network Commercial	$38.25
Rate for Payer: Kaiser Permanente Commercial	$40.50
Rate for Payer: MDX Hawaii PPO	$43.65

Infrared-Light Therapy Charge

Facility

$45.00

Service Code	HCPCS 97026 GP,CQ
Hospital Charge Code	8111743
Hospital Revenue Code	420
Min. Negotiated Rate	$4.50
Max. Negotiated Rate	$43.65
Rate for Payer: AlohaCare Medicaid	$22.50
Rate for Payer: AlohaCare Medicare	$22.50
Rate for Payer: Cash Price	$29.25
Rate for Payer: Cash Price	$29.25
Rate for Payer: Devoted Health Medicare	$24.75
Rate for Payer: Hawaii Medical Service Association Medicare	$22.50
Rate for Payer: Hawaii Western Management Group Commercial	$42.75
Rate for Payer: Health Management Network Commercial	$38.25
Rate for Payer: Humana Medicare	$22.50
Rate for Payer: Kaiser Permanente Commercial	$40.50
Rate for Payer: Kaiser Permanente Medicaid	$22.95
Rate for Payer: Kaiser Permanente Medicare	$22.50
Rate for Payer: MDX Hawaii PPO	$43.65
Rate for Payer: Ohana Health Plan Medicaid	$22.50
Rate for Payer: Ohana Health Plan Medicare	$22.50
Rate for Payer: UnitedHealthcare Medicaid	$4.50
Rate for Payer: UnitedHealthcare Medicare	$22.50
Rate for Payer: University Health Alliance Commercial	$25.20

Infusion, normal saline solution 1,000 cc

Facility

$10.00

Service Code	HCPCS J7030
Hospital Charge Code	8764248
Hospital Revenue Code	636
Min. Negotiated Rate	$8.50
Max. Negotiated Rate	$9.70
Rate for Payer: Cash Price	$6.50
Rate for Payer: Health Management Network Commercial	$8.50
Rate for Payer: Kaiser Permanente Commercial	$9.00
Rate for Payer: MDX Hawaii PPO	$9.70

Infusion, normal saline solution 1,000 cc

Professional

Both

$9.00

Service Code	HCPCS J7030
Hospital Charge Code	8764248
Hospital Revenue Code	636
Min. Negotiated Rate	$2.19
Max. Negotiated Rate	$12.00
Rate for Payer: AlohaCare Medicare	$2.19
Rate for Payer: Cash Price	$5.85
Rate for Payer: Cash Price	$5.85
Rate for Payer: Devoted Health Medicare	$2.41
Rate for Payer: Hawaii Medical Service Association Medicare	$2.19
Rate for Payer: Hawaii Western Management Group Commercial	$12.00
Rate for Payer: Health Management Network Commercial	$7.65
Rate for Payer: Kaiser Permanente Commercial	$2.63
Rate for Payer: Kaiser Permanente Medicaid	$2.63
Rate for Payer: Kaiser Permanente Medicare	$2.63
Rate for Payer: Ohana Health Plan Medicare	$2.19
Rate for Payer: UnitedHealthcare Medicare	$2.19

Infusion, normal saline solution 1,000 cc

Facility

$10.00

Service Code	HCPCS J7030
Hospital Charge Code	8764248
Hospital Revenue Code	636
Min. Negotiated Rate	$2.28
Max. Negotiated Rate	$9.70
Rate for Payer: AlohaCare Medicaid	$5.00
Rate for Payer: AlohaCare Medicare	$5.00
Rate for Payer: Cash Price	$6.50
Rate for Payer: Cash Price	$6.50
Rate for Payer: Devoted Health Medicare	$5.50
Rate for Payer: Hawaii Medical Service Association ABD	$2.28
Rate for Payer: Hawaii Medical Service Association Medicare	$5.00
Rate for Payer: Hawaii Medical Service Association Non-ABD	$2.28
Rate for Payer: Hawaii Western Management Group Commercial	$9.50
Rate for Payer: Health Management Network Commercial	$8.50
Rate for Payer: Humana Medicare	$5.00
Rate for Payer: Kaiser Permanente Commercial	$9.00
Rate for Payer: Kaiser Permanente Medicaid	$5.10
Rate for Payer: Kaiser Permanente Medicare	$5.00
Rate for Payer: MDX Hawaii PPO	$9.70
Rate for Payer: Ohana Health Plan Medicaid	$5.00
Rate for Payer: Ohana Health Plan Medicare	$5.00
Rate for Payer: UnitedHealthcare Medicaid	$6.00
Rate for Payer: UnitedHealthcare Medicare	$5.00
Rate for Payer: University Health Alliance Commercial	$7.29

INGUINAL AND FEMORAL HERNIA PROCEDURES WITH CC

Facility

$29,888.22

Service Code	MSDRG 351
Min. Negotiated Rate	$29,888.22
Max. Negotiated Rate	$29,888.22
Rate for Payer: Hawaii Medical Service Association Commercial	$29,888.22

INGUINAL AND FEMORAL HERNIA PROCEDURES WITH MCC

Facility

$37,117.33

Service Code	MSDRG 350
Min. Negotiated Rate	$37,117.33
Max. Negotiated Rate	$37,117.33
Rate for Payer: Hawaii Medical Service Association Commercial	$37,117.33

INGUINAL AND FEMORAL HERNIA PROCEDURES WITHOUT CC/MCC

Facility

$15,453.70

Service Code	MSDRG 352
Min. Negotiated Rate	$15,453.70
Max. Negotiated Rate	$15,453.70
Rate for Payer: Hawaii Medical Service Association Commercial	$15,453.70

Insert Coude Catheter

Facility

$633.00

Service Code	HCPCS 51703
Hospital Charge Code	9259112
Hospital Revenue Code	450
Min. Negotiated Rate	$538.05
Max. Negotiated Rate	$614.01
Rate for Payer: Cash Price	$411.45
Rate for Payer: Health Management Network Commercial	$538.05
Rate for Payer: Kaiser Permanente Commercial	$569.70
Rate for Payer: MDX Hawaii PPO	$614.01

Insert Coude Catheter

Facility

$633.00

Service Code	HCPCS 51703
Hospital Charge Code	9259112
Hospital Revenue Code	450
Min. Negotiated Rate	$316.50
Max. Negotiated Rate	$1,600.00
Rate for Payer: AlohaCare Medicaid	$316.50
Rate for Payer: AlohaCare Medicare	$316.50
Rate for Payer: Cash Price	$411.45
Rate for Payer: Cash Price	$411.45
Rate for Payer: Devoted Health Medicare	$348.15
Rate for Payer: Hawaii Medical Service Association ABD	$469.00
Rate for Payer: Hawaii Medical Service Association Commercial	$1,600.00
Rate for Payer: Hawaii Medical Service Association Medicare	$316.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$450.00
Rate for Payer: Hawaii Western Management Group Commercial	$601.35
Rate for Payer: Health Management Network Commercial	$538.05
Rate for Payer: Humana Medicare	$316.50
Rate for Payer: Kaiser Permanente Commercial	$569.70
Rate for Payer: Kaiser Permanente Medicaid	$937.50
Rate for Payer: Kaiser Permanente Medicare	$316.50
Rate for Payer: MDX Hawaii PPO	$614.01
Rate for Payer: Ohana Health Plan Medicaid	$316.50
Rate for Payer: Ohana Health Plan Medicare	$316.50
Rate for Payer: UnitedHealthcare Medicare	$316.50
Rate for Payer: University Health Alliance Commercial	$461.39

Insert Coude or Complicated Foley Insertion Charge

Facility

$631.00

Service Code	HCPCS 51703
Hospital Charge Code	8422800
Hospital Revenue Code	450
Min. Negotiated Rate	$536.35
Max. Negotiated Rate	$612.07
Rate for Payer: Cash Price	$410.15
Rate for Payer: Health Management Network Commercial	$536.35
Rate for Payer: Kaiser Permanente Commercial	$567.90
Rate for Payer: MDX Hawaii PPO	$612.07

Insert Coude or Complicated Foley Insertion Charge

Facility

$631.00

Service Code	HCPCS 51703
Hospital Charge Code	8422800
Hospital Revenue Code	450
Min. Negotiated Rate	$315.50
Max. Negotiated Rate	$1,600.00
Rate for Payer: AlohaCare Medicaid	$315.50
Rate for Payer: AlohaCare Medicare	$315.50
Rate for Payer: Cash Price	$410.15
Rate for Payer: Cash Price	$410.15
Rate for Payer: Devoted Health Medicare	$347.05
Rate for Payer: Hawaii Medical Service Association ABD	$469.00
Rate for Payer: Hawaii Medical Service Association Commercial	$1,600.00
Rate for Payer: Hawaii Medical Service Association Medicare	$315.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$450.00
Rate for Payer: Hawaii Western Management Group Commercial	$599.45
Rate for Payer: Health Management Network Commercial	$536.35
Rate for Payer: Humana Medicare	$315.50
Rate for Payer: Kaiser Permanente Commercial	$567.90
Rate for Payer: Kaiser Permanente Medicaid	$937.50
Rate for Payer: Kaiser Permanente Medicare	$315.50
Rate for Payer: MDX Hawaii PPO	$612.07
Rate for Payer: Ohana Health Plan Medicaid	$315.50
Rate for Payer: Ohana Health Plan Medicare	$315.50
Rate for Payer: UnitedHealthcare Medicare	$315.50
Rate for Payer: University Health Alliance Commercial	$459.94

Insert Foley Catheter Charge

Facility

$451.00

Service Code	HCPCS 51702
Hospital Charge Code	8422799
Hospital Revenue Code	450
Min. Negotiated Rate	$225.50
Max. Negotiated Rate	$1,600.00
Rate for Payer: AlohaCare Medicaid	$225.50
Rate for Payer: AlohaCare Medicare	$225.50
Rate for Payer: Cash Price	$293.15
Rate for Payer: Cash Price	$293.15
Rate for Payer: Devoted Health Medicare	$248.05
Rate for Payer: Hawaii Medical Service Association ABD	$469.00
Rate for Payer: Hawaii Medical Service Association Commercial	$1,600.00
Rate for Payer: Hawaii Medical Service Association Medicare	$225.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$450.00
Rate for Payer: Hawaii Western Management Group Commercial	$428.45
Rate for Payer: Health Management Network Commercial	$383.35
Rate for Payer: Humana Medicare	$225.50
Rate for Payer: Kaiser Permanente Commercial	$405.90
Rate for Payer: Kaiser Permanente Medicaid	$937.50
Rate for Payer: Kaiser Permanente Medicare	$225.50
Rate for Payer: MDX Hawaii PPO	$437.47
Rate for Payer: Ohana Health Plan Medicaid	$225.50
Rate for Payer: Ohana Health Plan Medicare	$225.50
Rate for Payer: UnitedHealthcare Medicare	$225.50
Rate for Payer: University Health Alliance Commercial	$328.73

Insert Foley Catheter Charge

Facility

$451.00

Service Code	HCPCS 51702
Hospital Charge Code	8422799
Hospital Revenue Code	450
Min. Negotiated Rate	$383.35
Max. Negotiated Rate	$437.47
Rate for Payer: Cash Price	$293.15
Rate for Payer: Health Management Network Commercial	$383.35
Rate for Payer: Kaiser Permanente Commercial	$405.90
Rate for Payer: MDX Hawaii PPO	$437.47

Know your out-of-pocket cost for care.

All Charges