Samuel Mahelona Memorial Hospital

All Charges

Charge

Type

Setting

Price

KIDNEY TRANSPLANT WITH HEMODIALYSIS WITHOUT MCC

Facility

$154,726.66

Service Code	MSDRG 651
Min. Negotiated Rate	$154,726.66
Max. Negotiated Rate	$154,726.66
Rate for Payer: Hawaii Medical Service Association Commercial	$154,726.66

KIT 20G ARTERIAL LINE

Facility

$376.00

Hospital Charge Code	8266520
Hospital Revenue Code	272
Min. Negotiated Rate	$319.60
Max. Negotiated Rate	$364.72
Rate for Payer: Cash Price	$244.40
Rate for Payer: Health Management Network Commercial	$319.60
Rate for Payer: Kaiser Permanente Commercial	$338.40
Rate for Payer: MDX Hawaii PPO	$364.72

KIT 20G ARTERIAL LINE

Facility

$376.00

Hospital Charge Code	8266520
Hospital Revenue Code	272
Min. Negotiated Rate	$188.00
Max. Negotiated Rate	$364.72
Rate for Payer: AlohaCare Medicaid	$188.00
Rate for Payer: AlohaCare Medicare	$188.00
Rate for Payer: Cash Price	$244.40
Rate for Payer: Devoted Health Medicare	$206.80
Rate for Payer: Hawaii Medical Service Association Medicare	$188.00
Rate for Payer: Hawaii Western Management Group Commercial	$357.20
Rate for Payer: Health Management Network Commercial	$319.60
Rate for Payer: Humana Medicare	$188.00
Rate for Payer: Kaiser Permanente Commercial	$338.40
Rate for Payer: Kaiser Permanente Medicaid	$191.76
Rate for Payer: Kaiser Permanente Medicare	$188.00
Rate for Payer: MDX Hawaii PPO	$364.72
Rate for Payer: Ohana Health Plan Medicaid	$188.00
Rate for Payer: Ohana Health Plan Medicare	$188.00
Rate for Payer: UnitedHealthcare Medicare	$188.00
Rate for Payer: University Health Alliance Commercial	$274.07

KIT ARTERIAL LINE 18G X 3

Facility

$250.00

Hospital Charge Code	8266569
Hospital Revenue Code	272
Min. Negotiated Rate	$212.50
Max. Negotiated Rate	$242.50
Rate for Payer: Cash Price	$162.50
Rate for Payer: Health Management Network Commercial	$212.50
Rate for Payer: Kaiser Permanente Commercial	$225.00
Rate for Payer: MDX Hawaii PPO	$242.50

KIT ARTERIAL LINE 18G X 3

Facility

$250.00

Hospital Charge Code	8266569
Hospital Revenue Code	272
Min. Negotiated Rate	$125.00
Max. Negotiated Rate	$242.50
Rate for Payer: AlohaCare Medicaid	$125.00
Rate for Payer: AlohaCare Medicare	$125.00
Rate for Payer: Cash Price	$162.50
Rate for Payer: Devoted Health Medicare	$137.50
Rate for Payer: Hawaii Medical Service Association Medicare	$125.00
Rate for Payer: Hawaii Western Management Group Commercial	$237.50
Rate for Payer: Health Management Network Commercial	$212.50
Rate for Payer: Humana Medicare	$125.00
Rate for Payer: Kaiser Permanente Commercial	$225.00
Rate for Payer: Kaiser Permanente Medicaid	$127.50
Rate for Payer: Kaiser Permanente Medicare	$125.00
Rate for Payer: MDX Hawaii PPO	$242.50
Rate for Payer: Ohana Health Plan Medicaid	$125.00
Rate for Payer: Ohana Health Plan Medicare	$125.00
Rate for Payer: UnitedHealthcare Medicare	$125.00
Rate for Payer: University Health Alliance Commercial	$182.22

KIT CENTRAL LINE DRESSING

Facility

$96.00

Hospital Charge Code	8266496
Hospital Revenue Code	272
Min. Negotiated Rate	$48.00
Max. Negotiated Rate	$93.12
Rate for Payer: AlohaCare Medicaid	$48.00
Rate for Payer: AlohaCare Medicare	$48.00
Rate for Payer: Cash Price	$62.40
Rate for Payer: Devoted Health Medicare	$52.80
Rate for Payer: Hawaii Medical Service Association Medicare	$48.00
Rate for Payer: Hawaii Western Management Group Commercial	$91.20
Rate for Payer: Health Management Network Commercial	$81.60
Rate for Payer: Humana Medicare	$48.00
Rate for Payer: Kaiser Permanente Commercial	$86.40
Rate for Payer: Kaiser Permanente Medicaid	$48.96
Rate for Payer: Kaiser Permanente Medicare	$48.00
Rate for Payer: MDX Hawaii PPO	$93.12
Rate for Payer: Ohana Health Plan Medicaid	$48.00
Rate for Payer: Ohana Health Plan Medicare	$48.00
Rate for Payer: UnitedHealthcare Medicare	$48.00
Rate for Payer: University Health Alliance Commercial	$69.97

KIT CENTRAL LINE DRESSING

Facility

$96.00

Hospital Charge Code	8266496
Hospital Revenue Code	272
Min. Negotiated Rate	$81.60
Max. Negotiated Rate	$93.12
Rate for Payer: Cash Price	$62.40
Rate for Payer: Health Management Network Commercial	$81.60
Rate for Payer: Kaiser Permanente Commercial	$86.40
Rate for Payer: MDX Hawaii PPO	$93.12

KIT EZ-IO 25MM 15G NEEDLE+STABLIZER

Facility

$577.00

Hospital Charge Code	8500827
Hospital Revenue Code	272
Min. Negotiated Rate	$288.50
Max. Negotiated Rate	$559.69
Rate for Payer: AlohaCare Medicaid	$288.50
Rate for Payer: AlohaCare Medicare	$288.50
Rate for Payer: Cash Price	$375.05
Rate for Payer: Devoted Health Medicare	$317.35
Rate for Payer: Hawaii Medical Service Association Medicare	$288.50
Rate for Payer: Hawaii Western Management Group Commercial	$548.15
Rate for Payer: Health Management Network Commercial	$490.45
Rate for Payer: Humana Medicare	$288.50
Rate for Payer: Kaiser Permanente Commercial	$519.30
Rate for Payer: Kaiser Permanente Medicaid	$294.27
Rate for Payer: Kaiser Permanente Medicare	$288.50
Rate for Payer: MDX Hawaii PPO	$559.69
Rate for Payer: Ohana Health Plan Medicaid	$288.50
Rate for Payer: Ohana Health Plan Medicare	$288.50
Rate for Payer: UnitedHealthcare Medicare	$288.50
Rate for Payer: University Health Alliance Commercial	$420.58

KIT EZ-IO 25MM 15G NEEDLE+STABLIZER

Facility

$577.00

Hospital Charge Code	8500827
Hospital Revenue Code	272
Min. Negotiated Rate	$490.45
Max. Negotiated Rate	$559.69
Rate for Payer: Cash Price	$375.05
Rate for Payer: Health Management Network Commercial	$490.45
Rate for Payer: Kaiser Permanente Commercial	$519.30
Rate for Payer: MDX Hawaii PPO	$559.69

KIT EZ-IO 45MM NEEDLE+STABILIZER

Facility

$535.00

Hospital Charge Code	8500828
Hospital Revenue Code	272
Min. Negotiated Rate	$267.50
Max. Negotiated Rate	$518.95
Rate for Payer: AlohaCare Medicaid	$267.50
Rate for Payer: AlohaCare Medicare	$267.50
Rate for Payer: Cash Price	$347.75
Rate for Payer: Devoted Health Medicare	$294.25
Rate for Payer: Hawaii Medical Service Association Medicare	$267.50
Rate for Payer: Hawaii Western Management Group Commercial	$508.25
Rate for Payer: Health Management Network Commercial	$454.75
Rate for Payer: Humana Medicare	$267.50
Rate for Payer: Kaiser Permanente Commercial	$481.50
Rate for Payer: Kaiser Permanente Medicaid	$272.85
Rate for Payer: Kaiser Permanente Medicare	$267.50
Rate for Payer: MDX Hawaii PPO	$518.95
Rate for Payer: Ohana Health Plan Medicaid	$267.50
Rate for Payer: Ohana Health Plan Medicare	$267.50
Rate for Payer: UnitedHealthcare Medicare	$267.50
Rate for Payer: University Health Alliance Commercial	$389.96

KIT EZ-IO 45MM NEEDLE+STABILIZER

Facility

$535.00

Hospital Charge Code	8500828
Hospital Revenue Code	272
Min. Negotiated Rate	$454.75
Max. Negotiated Rate	$518.95
Rate for Payer: Cash Price	$347.75
Rate for Payer: Health Management Network Commercial	$454.75
Rate for Payer: Kaiser Permanente Commercial	$481.50
Rate for Payer: MDX Hawaii PPO	$518.95

KIT GASTRIC LAVAGE E VAC 34F

Facility

$243.00

Hospital Charge Code	8266637
Hospital Revenue Code	272
Min. Negotiated Rate	$121.50
Max. Negotiated Rate	$235.71
Rate for Payer: AlohaCare Medicaid	$121.50
Rate for Payer: AlohaCare Medicare	$121.50
Rate for Payer: Cash Price	$157.95
Rate for Payer: Devoted Health Medicare	$133.65
Rate for Payer: Hawaii Medical Service Association Medicare	$121.50
Rate for Payer: Hawaii Western Management Group Commercial	$230.85
Rate for Payer: Health Management Network Commercial	$206.55
Rate for Payer: Humana Medicare	$121.50
Rate for Payer: Kaiser Permanente Commercial	$218.70
Rate for Payer: Kaiser Permanente Medicaid	$123.93
Rate for Payer: Kaiser Permanente Medicare	$121.50
Rate for Payer: MDX Hawaii PPO	$235.71
Rate for Payer: Ohana Health Plan Medicaid	$121.50
Rate for Payer: Ohana Health Plan Medicare	$121.50
Rate for Payer: UnitedHealthcare Medicare	$121.50
Rate for Payer: University Health Alliance Commercial	$177.12

KIT GASTRIC LAVAGE E VAC 34F

Facility

$243.00

Hospital Charge Code	8266637
Hospital Revenue Code	272
Min. Negotiated Rate	$206.55
Max. Negotiated Rate	$235.71
Rate for Payer: Cash Price	$157.95
Rate for Payer: Health Management Network Commercial	$206.55
Rate for Payer: Kaiser Permanente Commercial	$218.70
Rate for Payer: MDX Hawaii PPO	$235.71

KIT MICROINTRODUCER 5FR

Facility

$174.00

Hospital Charge Code	8266279
Hospital Revenue Code	272
Min. Negotiated Rate	$87.00
Max. Negotiated Rate	$168.78
Rate for Payer: AlohaCare Medicaid	$87.00
Rate for Payer: AlohaCare Medicare	$87.00
Rate for Payer: Cash Price	$113.10
Rate for Payer: Devoted Health Medicare	$95.70
Rate for Payer: Hawaii Medical Service Association Medicare	$87.00
Rate for Payer: Hawaii Western Management Group Commercial	$165.30
Rate for Payer: Health Management Network Commercial	$147.90
Rate for Payer: Humana Medicare	$87.00
Rate for Payer: Kaiser Permanente Commercial	$156.60
Rate for Payer: Kaiser Permanente Medicaid	$88.74
Rate for Payer: Kaiser Permanente Medicare	$87.00
Rate for Payer: MDX Hawaii PPO	$168.78
Rate for Payer: Ohana Health Plan Medicaid	$87.00
Rate for Payer: Ohana Health Plan Medicare	$87.00
Rate for Payer: UnitedHealthcare Medicare	$87.00
Rate for Payer: University Health Alliance Commercial	$126.83

KIT MICROINTRODUCER 5FR

Facility

$174.00

Hospital Charge Code	8266279
Hospital Revenue Code	272
Min. Negotiated Rate	$147.90
Max. Negotiated Rate	$168.78
Rate for Payer: Cash Price	$113.10
Rate for Payer: Health Management Network Commercial	$147.90
Rate for Payer: Kaiser Permanente Commercial	$156.60
Rate for Payer: MDX Hawaii PPO	$168.78

KIT MULTI LUMEN CVC 7FR

Facility

$459.00

Hospital Charge Code	8266492
Hospital Revenue Code	272
Min. Negotiated Rate	$229.50
Max. Negotiated Rate	$445.23
Rate for Payer: AlohaCare Medicaid	$229.50
Rate for Payer: AlohaCare Medicare	$229.50
Rate for Payer: Cash Price	$298.35
Rate for Payer: Devoted Health Medicare	$252.45
Rate for Payer: Hawaii Medical Service Association Medicare	$229.50
Rate for Payer: Hawaii Western Management Group Commercial	$436.05
Rate for Payer: Health Management Network Commercial	$390.15
Rate for Payer: Humana Medicare	$229.50
Rate for Payer: Kaiser Permanente Commercial	$413.10
Rate for Payer: Kaiser Permanente Medicaid	$234.09
Rate for Payer: Kaiser Permanente Medicare	$229.50
Rate for Payer: MDX Hawaii PPO	$445.23
Rate for Payer: Ohana Health Plan Medicaid	$229.50
Rate for Payer: Ohana Health Plan Medicare	$229.50
Rate for Payer: UnitedHealthcare Medicare	$229.50
Rate for Payer: University Health Alliance Commercial	$334.57

KIT MULTI LUMEN CVC 7FR

Facility

$459.00

Hospital Charge Code	8266492
Hospital Revenue Code	272
Min. Negotiated Rate	$390.15
Max. Negotiated Rate	$445.23
Rate for Payer: Cash Price	$298.35
Rate for Payer: Health Management Network Commercial	$390.15
Rate for Payer: Kaiser Permanente Commercial	$413.10
Rate for Payer: MDX Hawaii PPO	$445.23

KIT PICC DUAL LUMEN 5FR

Facility

$878.00

Service Code	HCPCS C1751
Hospital Charge Code	8266277
Hospital Revenue Code	272
Min. Negotiated Rate	$439.00
Max. Negotiated Rate	$851.66
Rate for Payer: AlohaCare Medicaid	$439.00
Rate for Payer: AlohaCare Medicare	$439.00
Rate for Payer: Cash Price	$570.70
Rate for Payer: Devoted Health Medicare	$482.90
Rate for Payer: Hawaii Medical Service Association Medicare	$439.00
Rate for Payer: Hawaii Western Management Group Commercial	$834.10
Rate for Payer: Health Management Network Commercial	$746.30
Rate for Payer: Humana Medicare	$439.00
Rate for Payer: Kaiser Permanente Commercial	$790.20
Rate for Payer: Kaiser Permanente Medicaid	$447.78
Rate for Payer: Kaiser Permanente Medicare	$439.00
Rate for Payer: MDX Hawaii PPO	$851.66
Rate for Payer: Ohana Health Plan Medicaid	$439.00
Rate for Payer: Ohana Health Plan Medicare	$439.00
Rate for Payer: UnitedHealthcare Medicare	$439.00
Rate for Payer: University Health Alliance Commercial	$639.97

KIT PICC DUAL LUMEN 5FR

Facility

$878.00

Service Code	HCPCS C1751
Hospital Charge Code	8266277
Hospital Revenue Code	272
Min. Negotiated Rate	$746.30
Max. Negotiated Rate	$851.66
Rate for Payer: Cash Price	$570.70
Rate for Payer: Health Management Network Commercial	$746.30
Rate for Payer: Kaiser Permanente Commercial	$790.20
Rate for Payer: MDX Hawaii PPO	$851.66

KIT PICC SINGLE LUMEN 4FR

Facility

$834.00

Service Code	HCPCS C1751
Hospital Charge Code	8266276
Hospital Revenue Code	272
Min. Negotiated Rate	$708.90
Max. Negotiated Rate	$808.98
Rate for Payer: Cash Price	$542.10
Rate for Payer: Health Management Network Commercial	$708.90
Rate for Payer: Kaiser Permanente Commercial	$750.60
Rate for Payer: MDX Hawaii PPO	$808.98

KIT PICC SINGLE LUMEN 4FR

Facility

$834.00

Service Code	HCPCS C1751
Hospital Charge Code	8266276
Hospital Revenue Code	272
Min. Negotiated Rate	$417.00
Max. Negotiated Rate	$808.98
Rate for Payer: AlohaCare Medicaid	$417.00
Rate for Payer: AlohaCare Medicare	$417.00
Rate for Payer: Cash Price	$542.10
Rate for Payer: Devoted Health Medicare	$458.70
Rate for Payer: Hawaii Medical Service Association Medicare	$417.00
Rate for Payer: Hawaii Western Management Group Commercial	$792.30
Rate for Payer: Health Management Network Commercial	$708.90
Rate for Payer: Humana Medicare	$417.00
Rate for Payer: Kaiser Permanente Commercial	$750.60
Rate for Payer: Kaiser Permanente Medicaid	$425.34
Rate for Payer: Kaiser Permanente Medicare	$417.00
Rate for Payer: MDX Hawaii PPO	$808.98
Rate for Payer: Ohana Health Plan Medicaid	$417.00
Rate for Payer: Ohana Health Plan Medicare	$417.00
Rate for Payer: UnitedHealthcare Medicare	$417.00
Rate for Payer: University Health Alliance Commercial	$607.90

KIT TRIMANO BEACH CHAIR

Facility

$300.00

Hospital Charge Code	9080354
Hospital Revenue Code	272
Min. Negotiated Rate	$255.00
Max. Negotiated Rate	$291.00
Rate for Payer: Cash Price	$195.00
Rate for Payer: Health Management Network Commercial	$255.00
Rate for Payer: Kaiser Permanente Commercial	$270.00
Rate for Payer: MDX Hawaii PPO	$291.00

KIT TRIMANO BEACH CHAIR

Facility

$300.00

Hospital Charge Code	9080354
Hospital Revenue Code	272
Min. Negotiated Rate	$150.00
Max. Negotiated Rate	$291.00
Rate for Payer: AlohaCare Medicaid	$150.00
Rate for Payer: AlohaCare Medicare	$150.00
Rate for Payer: Cash Price	$195.00
Rate for Payer: Devoted Health Medicare	$165.00
Rate for Payer: Hawaii Medical Service Association Medicare	$150.00
Rate for Payer: Hawaii Western Management Group Commercial	$285.00
Rate for Payer: Health Management Network Commercial	$255.00
Rate for Payer: Humana Medicare	$150.00
Rate for Payer: Kaiser Permanente Commercial	$270.00
Rate for Payer: Kaiser Permanente Medicaid	$153.00
Rate for Payer: Kaiser Permanente Medicare	$150.00
Rate for Payer: MDX Hawaii PPO	$291.00
Rate for Payer: Ohana Health Plan Medicaid	$150.00
Rate for Payer: Ohana Health Plan Medicare	$150.00
Rate for Payer: UnitedHealthcare Medicare	$150.00
Rate for Payer: University Health Alliance Commercial	$218.67

KIT TRIMANO ELBOW

Facility

$300.00

Hospital Charge Code	9080355
Hospital Revenue Code	272
Min. Negotiated Rate	$150.00
Max. Negotiated Rate	$291.00
Rate for Payer: AlohaCare Medicaid	$150.00
Rate for Payer: AlohaCare Medicare	$150.00
Rate for Payer: Cash Price	$195.00
Rate for Payer: Devoted Health Medicare	$165.00
Rate for Payer: Hawaii Medical Service Association Medicare	$150.00
Rate for Payer: Hawaii Western Management Group Commercial	$285.00
Rate for Payer: Health Management Network Commercial	$255.00
Rate for Payer: Humana Medicare	$150.00
Rate for Payer: Kaiser Permanente Commercial	$270.00
Rate for Payer: Kaiser Permanente Medicaid	$153.00
Rate for Payer: Kaiser Permanente Medicare	$150.00
Rate for Payer: MDX Hawaii PPO	$291.00
Rate for Payer: Ohana Health Plan Medicaid	$150.00
Rate for Payer: Ohana Health Plan Medicare	$150.00
Rate for Payer: UnitedHealthcare Medicare	$150.00
Rate for Payer: University Health Alliance Commercial	$218.67

KIT TRIMANO ELBOW

Facility

$300.00

Hospital Charge Code	9080355
Hospital Revenue Code	272
Min. Negotiated Rate	$255.00
Max. Negotiated Rate	$291.00
Rate for Payer: Cash Price	$195.00
Rate for Payer: Health Management Network Commercial	$255.00
Rate for Payer: Kaiser Permanente Commercial	$270.00
Rate for Payer: MDX Hawaii PPO	$291.00

Know your out-of-pocket cost for care.

All Charges