Samuel Mahelona Memorial Hospital

All Charges

Charge

Type

Setting

Price

KIT TROCAR CATHETER 20FR

Facility

$145.00

Hospital Charge Code	8266641
Hospital Revenue Code	272
Min. Negotiated Rate	$123.25
Max. Negotiated Rate	$140.65
Rate for Payer: Cash Price	$94.25
Rate for Payer: Health Management Network Commercial	$123.25
Rate for Payer: Kaiser Permanente Commercial	$130.50
Rate for Payer: MDX Hawaii PPO	$140.65

KIT TROCAR CATHETER 20FR

Facility

$145.00

Hospital Charge Code	8266641
Hospital Revenue Code	272
Min. Negotiated Rate	$72.50
Max. Negotiated Rate	$140.65
Rate for Payer: AlohaCare Medicaid	$72.50
Rate for Payer: AlohaCare Medicare	$72.50
Rate for Payer: Cash Price	$94.25
Rate for Payer: Devoted Health Medicare	$79.75
Rate for Payer: Hawaii Medical Service Association Medicare	$72.50
Rate for Payer: Hawaii Western Management Group Commercial	$137.75
Rate for Payer: Health Management Network Commercial	$123.25
Rate for Payer: Humana Medicare	$72.50
Rate for Payer: Kaiser Permanente Commercial	$130.50
Rate for Payer: Kaiser Permanente Medicaid	$73.95
Rate for Payer: Kaiser Permanente Medicare	$72.50
Rate for Payer: MDX Hawaii PPO	$140.65
Rate for Payer: Ohana Health Plan Medicaid	$72.50
Rate for Payer: Ohana Health Plan Medicare	$72.50
Rate for Payer: UnitedHealthcare Medicare	$72.50
Rate for Payer: University Health Alliance Commercial	$105.69

KIWI OMNI CUP

Facility

$176.00

Hospital Charge Code	8274464
Hospital Revenue Code	272
Min. Negotiated Rate	$149.60
Max. Negotiated Rate	$170.72
Rate for Payer: Cash Price	$114.40
Rate for Payer: Health Management Network Commercial	$149.60
Rate for Payer: Kaiser Permanente Commercial	$158.40
Rate for Payer: MDX Hawaii PPO	$170.72

KIWI OMNI CUP

Facility

$176.00

Hospital Charge Code	8274464
Hospital Revenue Code	272
Min. Negotiated Rate	$88.00
Max. Negotiated Rate	$170.72
Rate for Payer: AlohaCare Medicaid	$88.00
Rate for Payer: AlohaCare Medicare	$88.00
Rate for Payer: Cash Price	$114.40
Rate for Payer: Devoted Health Medicare	$96.80
Rate for Payer: Hawaii Medical Service Association Medicare	$88.00
Rate for Payer: Hawaii Western Management Group Commercial	$167.20
Rate for Payer: Health Management Network Commercial	$149.60
Rate for Payer: Humana Medicare	$88.00
Rate for Payer: Kaiser Permanente Commercial	$158.40
Rate for Payer: Kaiser Permanente Medicaid	$89.76
Rate for Payer: Kaiser Permanente Medicare	$88.00
Rate for Payer: MDX Hawaii PPO	$170.72
Rate for Payer: Ohana Health Plan Medicaid	$88.00
Rate for Payer: Ohana Health Plan Medicare	$88.00
Rate for Payer: UnitedHealthcare Medicare	$88.00
Rate for Payer: University Health Alliance Commercial	$128.29

KIWI PROCUP COMPLETE VACUUM DELIVERY SYSTEM

Facility

$163.00

Hospital Charge Code	9297535
Hospital Revenue Code	272
Min. Negotiated Rate	$81.50
Max. Negotiated Rate	$158.11
Rate for Payer: AlohaCare Medicaid	$81.50
Rate for Payer: AlohaCare Medicare	$81.50
Rate for Payer: Cash Price	$105.95
Rate for Payer: Devoted Health Medicare	$89.65
Rate for Payer: Hawaii Medical Service Association Medicare	$81.50
Rate for Payer: Hawaii Western Management Group Commercial	$154.85
Rate for Payer: Health Management Network Commercial	$138.55
Rate for Payer: Humana Medicare	$81.50
Rate for Payer: Kaiser Permanente Commercial	$146.70
Rate for Payer: Kaiser Permanente Medicaid	$83.13
Rate for Payer: Kaiser Permanente Medicare	$81.50
Rate for Payer: MDX Hawaii PPO	$158.11
Rate for Payer: Ohana Health Plan Medicaid	$81.50
Rate for Payer: Ohana Health Plan Medicare	$81.50
Rate for Payer: UnitedHealthcare Medicare	$81.50
Rate for Payer: University Health Alliance Commercial	$118.81

KIWI PROCUP COMPLETE VACUUM DELIVERY SYSTEM

Facility

$163.00

Hospital Charge Code	9297535
Hospital Revenue Code	272
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

Kleihauer-Betke (Fetal Cell Screen) FSI

Facility

$93.00

Service Code	HCPCS 85460
Hospital Charge Code	12231266
Hospital Revenue Code	305
Min. Negotiated Rate	$79.05
Max. Negotiated Rate	$90.21
Rate for Payer: Cash Price	$60.45
Rate for Payer: Health Management Network Commercial	$79.05
Rate for Payer: Kaiser Permanente Commercial	$83.70
Rate for Payer: MDX Hawaii PPO	$90.21

Kleihauer-Betke (Fetal Cell Screen) FSI

Facility

$93.00

Service Code	HCPCS 85460
Hospital Charge Code	12231266
Hospital Revenue Code	305
Min. Negotiated Rate	$7.73
Max. Negotiated Rate	$90.21
Rate for Payer: AlohaCare Medicaid	$46.50
Rate for Payer: AlohaCare Medicare	$46.50
Rate for Payer: Cash Price	$60.45
Rate for Payer: Cash Price	$60.45
Rate for Payer: Devoted Health Medicare	$51.15
Rate for Payer: Hawaii Medical Service Association ABD	$10.69
Rate for Payer: Hawaii Medical Service Association Commercial	$9.66
Rate for Payer: Hawaii Medical Service Association Medicare	$46.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$11.22
Rate for Payer: Hawaii Western Management Group Commercial	$7.73
Rate for Payer: Health Management Network Commercial	$79.05
Rate for Payer: Humana Medicare	$46.50
Rate for Payer: Kaiser Permanente Commercial	$83.70
Rate for Payer: Kaiser Permanente Medicaid	$47.43
Rate for Payer: Kaiser Permanente Medicare	$46.50
Rate for Payer: MDX Hawaii PPO	$90.21
Rate for Payer: Ohana Health Plan Medicaid	$46.50
Rate for Payer: Ohana Health Plan Medicare	$46.50
Rate for Payer: UnitedHealthcare Medicaid	$10.69
Rate for Payer: UnitedHealthcare Medicare	$46.50
Rate for Payer: University Health Alliance Commercial	$20.00

KNEE BRACE REDDIE MEDIUM

Facility

$222.00

Service Code	HCPCS L1820
Hospital Charge Code	9361881
Hospital Revenue Code	274
Min. Negotiated Rate	$124.32
Max. Negotiated Rate	$215.34
Rate for Payer: Cash Price	$144.30
Rate for Payer: Hawaii Western Management Group Commercial	$155.40
Rate for Payer: Health Management Network Commercial	$188.70
Rate for Payer: Kaiser Permanente Commercial	$199.80
Rate for Payer: MDX Hawaii PPO	$215.34
Rate for Payer: University Health Alliance Commercial	$124.32

KNEE BRACE REDDIE MEDIUM

Facility

$222.00

Service Code	HCPCS L1820
Hospital Charge Code	9361881
Hospital Revenue Code	274
Min. Negotiated Rate	$76.34
Max. Negotiated Rate	$215.34
Rate for Payer: AlohaCare Medicaid	$111.00
Rate for Payer: AlohaCare Medicare	$111.00
Rate for Payer: Cash Price	$144.30
Rate for Payer: Cash Price	$144.30
Rate for Payer: Devoted Health Medicare	$122.10
Rate for Payer: Hawaii Medical Service Association Medicare	$111.00
Rate for Payer: Hawaii Western Management Group Commercial	$155.40
Rate for Payer: Health Management Network Commercial	$188.70
Rate for Payer: Humana Medicare	$111.00
Rate for Payer: Kaiser Permanente Commercial	$199.80
Rate for Payer: Kaiser Permanente Medicaid	$113.22
Rate for Payer: Kaiser Permanente Medicare	$111.00
Rate for Payer: MDX Hawaii PPO	$215.34
Rate for Payer: Ohana Health Plan Medicaid	$111.00
Rate for Payer: Ohana Health Plan Medicare	$111.00
Rate for Payer: UnitedHealthcare Medicaid	$76.34
Rate for Payer: UnitedHealthcare Medicare	$111.00
Rate for Payer: University Health Alliance Commercial	$124.32

KNEE PROCEDURES WITHOUT PRINCIPAL DIAGNOSIS OF INFECTION WITH CC/MCC

Facility

$24,934.50

Service Code	MSDRG 488
Min. Negotiated Rate	$24,934.50
Max. Negotiated Rate	$24,934.50
Rate for Payer: Hawaii Medical Service Association Commercial	$24,934.50

KNEE PROCEDURES WITHOUT PRINCIPAL DIAGNOSIS OF INFECTION WITHOUT CC/MCC

Facility

$24,934.50

Service Code	MSDRG 489
Min. Negotiated Rate	$24,934.50
Max. Negotiated Rate	$24,934.50
Rate for Payer: Hawaii Medical Service Association Commercial	$24,934.50

KNEE PROCEDURES WITH PRINCIPAL DIAGNOSIS OF INFECTION WITH CC

Facility

$44,156.83

Service Code	MSDRG 486
Min. Negotiated Rate	$44,156.83
Max. Negotiated Rate	$44,156.83
Rate for Payer: Hawaii Medical Service Association Commercial	$44,156.83

KNEE PROCEDURES WITH PRINCIPAL DIAGNOSIS OF INFECTION WITH MCC

Facility

$44,156.83

Service Code	MSDRG 485
Min. Negotiated Rate	$44,156.83
Max. Negotiated Rate	$44,156.83
Rate for Payer: Hawaii Medical Service Association Commercial	$44,156.83

KNEE PROCEDURES WITH PRINCIPAL DIAGNOSIS OF INFECTION WITHOUT CC/MCC

Facility

$31,547.36

Service Code	MSDRG 487
Min. Negotiated Rate	$31,547.36
Max. Negotiated Rate	$31,547.36
Rate for Payer: Hawaii Medical Service Association Commercial	$31,547.36

KOALA INTRAUTERINE PRESSURE MONITORING

Facility

$141.00

Hospital Charge Code	9002340
Hospital Revenue Code	272
Min. Negotiated Rate	$119.85
Max. Negotiated Rate	$136.77
Rate for Payer: Cash Price	$91.65
Rate for Payer: Health Management Network Commercial	$119.85
Rate for Payer: Kaiser Permanente Commercial	$126.90
Rate for Payer: MDX Hawaii PPO	$136.77

KOALA INTRAUTERINE PRESSURE MONITORING

Facility

$141.00

Hospital Charge Code	9002340
Hospital Revenue Code	272
Min. Negotiated Rate	$70.50
Max. Negotiated Rate	$136.77
Rate for Payer: AlohaCare Medicaid	$70.50
Rate for Payer: AlohaCare Medicare	$70.50
Rate for Payer: Cash Price	$91.65
Rate for Payer: Devoted Health Medicare	$77.55
Rate for Payer: Hawaii Medical Service Association Medicare	$70.50
Rate for Payer: Hawaii Western Management Group Commercial	$133.95
Rate for Payer: Health Management Network Commercial	$119.85
Rate for Payer: Humana Medicare	$70.50
Rate for Payer: Kaiser Permanente Commercial	$126.90
Rate for Payer: Kaiser Permanente Medicaid	$71.91
Rate for Payer: Kaiser Permanente Medicare	$70.50
Rate for Payer: MDX Hawaii PPO	$136.77
Rate for Payer: Ohana Health Plan Medicaid	$70.50
Rate for Payer: Ohana Health Plan Medicare	$70.50
Rate for Payer: UnitedHealthcare Medicare	$70.50
Rate for Payer: University Health Alliance Commercial	$102.77

KOH EFFICIENT RUMI 2.5 CM FOR ELECTROSURGERY

Facility

$502.00

Hospital Charge Code	9716475
Hospital Revenue Code	272
Min. Negotiated Rate	$251.00
Max. Negotiated Rate	$486.94
Rate for Payer: AlohaCare Medicaid	$251.00
Rate for Payer: AlohaCare Medicare	$251.00
Rate for Payer: Cash Price	$326.30
Rate for Payer: Devoted Health Medicare	$276.10
Rate for Payer: Hawaii Medical Service Association Medicare	$251.00
Rate for Payer: Hawaii Western Management Group Commercial	$476.90
Rate for Payer: Health Management Network Commercial	$426.70
Rate for Payer: Humana Medicare	$251.00
Rate for Payer: Kaiser Permanente Commercial	$451.80
Rate for Payer: Kaiser Permanente Medicaid	$256.02
Rate for Payer: Kaiser Permanente Medicare	$251.00
Rate for Payer: MDX Hawaii PPO	$486.94
Rate for Payer: Ohana Health Plan Medicaid	$251.00
Rate for Payer: Ohana Health Plan Medicare	$251.00
Rate for Payer: UnitedHealthcare Medicare	$251.00
Rate for Payer: University Health Alliance Commercial	$365.91

KOH EFFICIENT RUMI 2.5 CM FOR ELECTROSURGERY

Facility

$502.00

Hospital Charge Code	9716475
Hospital Revenue Code	272
Min. Negotiated Rate	$426.70
Max. Negotiated Rate	$486.94
Rate for Payer: Cash Price	$326.30
Rate for Payer: Health Management Network Commercial	$426.70
Rate for Payer: Kaiser Permanente Commercial	$451.80
Rate for Payer: MDX Hawaii PPO	$486.94

KOH-EFFICIENT RUMI 3.0 CM FOR ELECTROSURGERY

Facility

$739.00

Hospital Charge Code	9723653
Hospital Revenue Code	272
Min. Negotiated Rate	$369.50
Max. Negotiated Rate	$716.83
Rate for Payer: AlohaCare Medicaid	$369.50
Rate for Payer: AlohaCare Medicare	$369.50
Rate for Payer: Cash Price	$480.35
Rate for Payer: Devoted Health Medicare	$406.45
Rate for Payer: Hawaii Medical Service Association Medicare	$369.50
Rate for Payer: Hawaii Western Management Group Commercial	$702.05
Rate for Payer: Health Management Network Commercial	$628.15
Rate for Payer: Humana Medicare	$369.50
Rate for Payer: Kaiser Permanente Commercial	$665.10
Rate for Payer: Kaiser Permanente Medicaid	$376.89
Rate for Payer: Kaiser Permanente Medicare	$369.50
Rate for Payer: MDX Hawaii PPO	$716.83
Rate for Payer: Ohana Health Plan Medicaid	$369.50
Rate for Payer: Ohana Health Plan Medicare	$369.50
Rate for Payer: UnitedHealthcare Medicare	$369.50
Rate for Payer: University Health Alliance Commercial	$538.66

KOH-EFFICIENT RUMI 3.0 CM FOR ELECTROSURGERY

Facility

$739.00

Hospital Charge Code	9723653
Hospital Revenue Code	272
Min. Negotiated Rate	$628.15
Max. Negotiated Rate	$716.83
Rate for Payer: Cash Price	$480.35
Rate for Payer: Health Management Network Commercial	$628.15
Rate for Payer: Kaiser Permanente Commercial	$665.10
Rate for Payer: MDX Hawaii PPO	$716.83

KOH-EFFICIENT RUMI 3.5 CM FOR ELECTROSURGERY

Facility

$595.00

Hospital Charge Code	9723654
Hospital Revenue Code	272
Min. Negotiated Rate	$297.50
Max. Negotiated Rate	$577.15
Rate for Payer: AlohaCare Medicaid	$297.50
Rate for Payer: AlohaCare Medicare	$297.50
Rate for Payer: Cash Price	$386.75
Rate for Payer: Devoted Health Medicare	$327.25
Rate for Payer: Hawaii Medical Service Association Medicare	$297.50
Rate for Payer: Hawaii Western Management Group Commercial	$565.25
Rate for Payer: Health Management Network Commercial	$505.75
Rate for Payer: Humana Medicare	$297.50
Rate for Payer: Kaiser Permanente Commercial	$535.50
Rate for Payer: Kaiser Permanente Medicaid	$303.45
Rate for Payer: Kaiser Permanente Medicare	$297.50
Rate for Payer: MDX Hawaii PPO	$577.15
Rate for Payer: Ohana Health Plan Medicaid	$297.50
Rate for Payer: Ohana Health Plan Medicare	$297.50
Rate for Payer: UnitedHealthcare Medicare	$297.50
Rate for Payer: University Health Alliance Commercial	$433.70

KOH-EFFICIENT RUMI 3.5 CM FOR ELECTROSURGERY

Facility

$595.00

Hospital Charge Code	9723654
Hospital Revenue Code	272
Min. Negotiated Rate	$505.75
Max. Negotiated Rate	$577.15
Rate for Payer: Cash Price	$386.75
Rate for Payer: Health Management Network Commercial	$505.75
Rate for Payer: Kaiser Permanente Commercial	$535.50
Rate for Payer: MDX Hawaii PPO	$577.15

KOH-EFFICIENT RUMI 4.0 CM FOR ELECTROSURGERY

Facility

$502.00

Hospital Charge Code	9723655
Hospital Revenue Code	272
Min. Negotiated Rate	$251.00
Max. Negotiated Rate	$486.94
Rate for Payer: AlohaCare Medicaid	$251.00
Rate for Payer: AlohaCare Medicare	$251.00
Rate for Payer: Cash Price	$326.30
Rate for Payer: Devoted Health Medicare	$276.10
Rate for Payer: Hawaii Medical Service Association Medicare	$251.00
Rate for Payer: Hawaii Western Management Group Commercial	$476.90
Rate for Payer: Health Management Network Commercial	$426.70
Rate for Payer: Humana Medicare	$251.00
Rate for Payer: Kaiser Permanente Commercial	$451.80
Rate for Payer: Kaiser Permanente Medicaid	$256.02
Rate for Payer: Kaiser Permanente Medicare	$251.00
Rate for Payer: MDX Hawaii PPO	$486.94
Rate for Payer: Ohana Health Plan Medicaid	$251.00
Rate for Payer: Ohana Health Plan Medicare	$251.00
Rate for Payer: UnitedHealthcare Medicare	$251.00
Rate for Payer: University Health Alliance Commercial	$365.91

KOH-EFFICIENT RUMI 4.0 CM FOR ELECTROSURGERY

Facility

$502.00

Hospital Charge Code	9723655
Hospital Revenue Code	272
Min. Negotiated Rate	$426.70
Max. Negotiated Rate	$486.94
Rate for Payer: Cash Price	$326.30
Rate for Payer: Health Management Network Commercial	$426.70
Rate for Payer: Kaiser Permanente Commercial	$451.80
Rate for Payer: MDX Hawaii PPO	$486.94

Know your out-of-pocket cost for care.

All Charges