Samuel Mahelona Memorial Hospital

All Charges

Charge

Type

Setting

Price

Lyme Disease Borrelia burgdorferi, IgG IgM by Western Blot FSI

Facility

$177.00

Service Code	HCPCS 86617
Hospital Charge Code	8117987
Hospital Revenue Code	302
Min. Negotiated Rate	$15.49
Max. Negotiated Rate	$171.69
Rate for Payer: AlohaCare Medicaid	$88.50
Rate for Payer: AlohaCare Medicare	$88.50
Rate for Payer: Cash Price	$115.05
Rate for Payer: Cash Price	$115.05
Rate for Payer: Devoted Health Medicare	$97.35
Rate for Payer: Hawaii Medical Service Association ABD	$21.40
Rate for Payer: Hawaii Medical Service Association Commercial	$19.36
Rate for Payer: Hawaii Medical Service Association Medicare	$88.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$22.47
Rate for Payer: Hawaii Western Management Group Commercial	$15.49
Rate for Payer: Health Management Network Commercial	$150.45
Rate for Payer: Humana Medicare	$88.50
Rate for Payer: Kaiser Permanente Commercial	$159.30
Rate for Payer: Kaiser Permanente Medicaid	$90.27
Rate for Payer: Kaiser Permanente Medicare	$88.50
Rate for Payer: MDX Hawaii PPO	$171.69
Rate for Payer: Ohana Health Plan Medicaid	$88.50
Rate for Payer: Ohana Health Plan Medicare	$88.50
Rate for Payer: UnitedHealthcare Medicaid	$21.40
Rate for Payer: UnitedHealthcare Medicare	$88.50
Rate for Payer: University Health Alliance Commercial	$40.03

Lyme Disease Borrelia burgdorferi, IgG IgM by Western Blot FSI

Facility

$177.00

Service Code	HCPCS 86617
Hospital Charge Code	8117987
Hospital Revenue Code	302
Min. Negotiated Rate	$150.45
Max. Negotiated Rate	$171.69
Rate for Payer: Cash Price	$115.05
Rate for Payer: Health Management Network Commercial	$150.45
Rate for Payer: Kaiser Permanente Commercial	$159.30
Rate for Payer: MDX Hawaii PPO	$171.69

Lyme Immunoblot IgG FSI

Facility

$177.00

Service Code	HCPCS 86617
Hospital Charge Code	11240962
Hospital Revenue Code	302
Min. Negotiated Rate	$150.45
Max. Negotiated Rate	$171.69
Rate for Payer: Cash Price	$115.05
Rate for Payer: Health Management Network Commercial	$150.45
Rate for Payer: Kaiser Permanente Commercial	$159.30
Rate for Payer: MDX Hawaii PPO	$171.69

Lyme Immunoblot IgG FSI

Facility

$177.00

Service Code	HCPCS 86617
Hospital Charge Code	11240962
Hospital Revenue Code	302
Min. Negotiated Rate	$15.49
Max. Negotiated Rate	$171.69
Rate for Payer: AlohaCare Medicaid	$88.50
Rate for Payer: AlohaCare Medicare	$88.50
Rate for Payer: Cash Price	$115.05
Rate for Payer: Cash Price	$115.05
Rate for Payer: Devoted Health Medicare	$97.35
Rate for Payer: Hawaii Medical Service Association ABD	$21.40
Rate for Payer: Hawaii Medical Service Association Commercial	$19.36
Rate for Payer: Hawaii Medical Service Association Medicare	$88.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$22.47
Rate for Payer: Hawaii Western Management Group Commercial	$15.49
Rate for Payer: Health Management Network Commercial	$150.45
Rate for Payer: Humana Medicare	$88.50
Rate for Payer: Kaiser Permanente Commercial	$159.30
Rate for Payer: Kaiser Permanente Medicaid	$90.27
Rate for Payer: Kaiser Permanente Medicare	$88.50
Rate for Payer: MDX Hawaii PPO	$171.69
Rate for Payer: Ohana Health Plan Medicaid	$88.50
Rate for Payer: Ohana Health Plan Medicare	$88.50
Rate for Payer: UnitedHealthcare Medicaid	$21.40
Rate for Payer: UnitedHealthcare Medicare	$88.50
Rate for Payer: University Health Alliance Commercial	$40.03

Lyme Immunoblot IgM FSI

Facility

$177.00

Service Code	HCPCS 86617
Hospital Charge Code	11240951
Hospital Revenue Code	302
Min. Negotiated Rate	$15.49
Max. Negotiated Rate	$171.69
Rate for Payer: AlohaCare Medicaid	$88.50
Rate for Payer: AlohaCare Medicare	$88.50
Rate for Payer: Cash Price	$115.05
Rate for Payer: Cash Price	$115.05
Rate for Payer: Devoted Health Medicare	$97.35
Rate for Payer: Hawaii Medical Service Association ABD	$21.40
Rate for Payer: Hawaii Medical Service Association Commercial	$19.36
Rate for Payer: Hawaii Medical Service Association Medicare	$88.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$22.47
Rate for Payer: Hawaii Western Management Group Commercial	$15.49
Rate for Payer: Health Management Network Commercial	$150.45
Rate for Payer: Humana Medicare	$88.50
Rate for Payer: Kaiser Permanente Commercial	$159.30
Rate for Payer: Kaiser Permanente Medicaid	$90.27
Rate for Payer: Kaiser Permanente Medicare	$88.50
Rate for Payer: MDX Hawaii PPO	$171.69
Rate for Payer: Ohana Health Plan Medicaid	$88.50
Rate for Payer: Ohana Health Plan Medicare	$88.50
Rate for Payer: UnitedHealthcare Medicaid	$21.40
Rate for Payer: UnitedHealthcare Medicare	$88.50
Rate for Payer: University Health Alliance Commercial	$40.03

Lyme Immunoblot IgM FSI

Facility

$177.00

Service Code	HCPCS 86617
Hospital Charge Code	11240951
Hospital Revenue Code	302
Min. Negotiated Rate	$150.45
Max. Negotiated Rate	$171.69
Rate for Payer: Cash Price	$115.05
Rate for Payer: Health Management Network Commercial	$150.45
Rate for Payer: Kaiser Permanente Commercial	$159.30
Rate for Payer: MDX Hawaii PPO	$171.69

Lymphocyte Subset Panel 3 (CD4,CD3,CD8) FSI

Facility

$353.00

Service Code	HCPCS 86359
Hospital Charge Code	8228891
Hospital Revenue Code	302
Min. Negotiated Rate	$37.73
Max. Negotiated Rate	$342.41
Rate for Payer: AlohaCare Medicaid	$176.50
Rate for Payer: AlohaCare Medicare	$176.50
Rate for Payer: Cash Price	$229.45
Rate for Payer: Cash Price	$229.45
Rate for Payer: Devoted Health Medicare	$194.15
Rate for Payer: Hawaii Medical Service Association ABD	$52.13
Rate for Payer: Hawaii Medical Service Association Commercial	$47.16
Rate for Payer: Hawaii Medical Service Association Medicare	$176.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$54.74
Rate for Payer: Hawaii Western Management Group Commercial	$37.73
Rate for Payer: Health Management Network Commercial	$300.05
Rate for Payer: Humana Medicare	$176.50
Rate for Payer: Kaiser Permanente Commercial	$317.70
Rate for Payer: Kaiser Permanente Medicaid	$180.03
Rate for Payer: Kaiser Permanente Medicare	$176.50
Rate for Payer: MDX Hawaii PPO	$342.41
Rate for Payer: Ohana Health Plan Medicaid	$176.50
Rate for Payer: Ohana Health Plan Medicare	$176.50
Rate for Payer: UnitedHealthcare Medicaid	$52.13
Rate for Payer: UnitedHealthcare Medicare	$176.50
Rate for Payer: University Health Alliance Commercial	$97.50

Lymphocyte Subset Panel 3 (CD4,CD3,CD8) FSI

Facility

$353.00

Service Code	HCPCS 86359
Hospital Charge Code	8228891
Hospital Revenue Code	302
Min. Negotiated Rate	$300.05
Max. Negotiated Rate	$342.41
Rate for Payer: Cash Price	$229.45
Rate for Payer: Health Management Network Commercial	$300.05
Rate for Payer: Kaiser Permanente Commercial	$317.70
Rate for Payer: MDX Hawaii PPO	$342.41

Lymphocyte Subset Panel (CD3, CD4, CD8, CD19) FSI

Facility

$753.00

Service Code	HCPCS 86355
Hospital Charge Code	12409515
Hospital Revenue Code	302
Min. Negotiated Rate	$36.89
Max. Negotiated Rate	$730.41
Rate for Payer: AlohaCare Medicaid	$376.50
Rate for Payer: AlohaCare Medicare	$376.50
Rate for Payer: Cash Price	$489.45
Rate for Payer: Cash Price	$489.45
Rate for Payer: Devoted Health Medicare	$414.15
Rate for Payer: Hawaii Medical Service Association ABD	$36.89
Rate for Payer: Hawaii Medical Service Association Commercial	$47.16
Rate for Payer: Hawaii Medical Service Association Medicare	$376.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$52.10
Rate for Payer: Hawaii Western Management Group Commercial	$37.73
Rate for Payer: Health Management Network Commercial	$640.05
Rate for Payer: Humana Medicare	$376.50
Rate for Payer: Kaiser Permanente Commercial	$677.70
Rate for Payer: Kaiser Permanente Medicaid	$384.03
Rate for Payer: Kaiser Permanente Medicare	$376.50
Rate for Payer: MDX Hawaii PPO	$730.41
Rate for Payer: Ohana Health Plan Medicaid	$376.50
Rate for Payer: Ohana Health Plan Medicare	$376.50
Rate for Payer: UnitedHealthcare Medicaid	$36.89
Rate for Payer: UnitedHealthcare Medicare	$376.50
Rate for Payer: University Health Alliance Commercial	$97.50

Lymphocyte Subset Panel (CD3, CD4, CD8, CD19) FSI

Facility

$753.00

Service Code	HCPCS 86355
Hospital Charge Code	12409515
Hospital Revenue Code	302
Min. Negotiated Rate	$640.05
Max. Negotiated Rate	$730.41
Rate for Payer: Cash Price	$489.45
Rate for Payer: Health Management Network Commercial	$640.05
Rate for Payer: Kaiser Permanente Commercial	$677.70
Rate for Payer: MDX Hawaii PPO	$730.41

LYMPHOMA AND LEUKEMIA WITH MAJOR O.R. PROCEDURES WITH CC

Facility

$76,510.06

Service Code	MSDRG 821
Min. Negotiated Rate	$76,510.06
Max. Negotiated Rate	$76,510.06
Rate for Payer: Hawaii Medical Service Association Commercial	$76,510.06

LYMPHOMA AND LEUKEMIA WITH MAJOR O.R. PROCEDURES WITH MCC

Facility

$76,510.06

Service Code	MSDRG 820
Min. Negotiated Rate	$76,510.06
Max. Negotiated Rate	$76,510.06
Rate for Payer: Hawaii Medical Service Association Commercial	$76,510.06

LYMPHOMA AND LEUKEMIA WITH MAJOR O.R. PROCEDURES WITHOUT CC/MCC

Facility

$30,646.69

Service Code	MSDRG 822
Min. Negotiated Rate	$30,646.69
Max. Negotiated Rate	$30,646.69
Rate for Payer: Hawaii Medical Service Association Commercial	$30,646.69

LYMPHOMA AND NON-ACUTE LEUKEMIA WITH CC

Facility

$77,718.86

Service Code	MSDRG 841
Min. Negotiated Rate	$77,718.86
Max. Negotiated Rate	$77,718.86
Rate for Payer: Hawaii Medical Service Association Commercial	$77,718.86

LYMPHOMA AND NON-ACUTE LEUKEMIA WITH MCC

Facility

$82,293.34

Service Code	MSDRG 840
Min. Negotiated Rate	$82,293.34
Max. Negotiated Rate	$82,293.34
Rate for Payer: Hawaii Medical Service Association Commercial	$82,293.34

LYMPHOMA AND NON-ACUTE LEUKEMIA WITH OTHER PROCEDURES WITH CC

Facility

$92,532.61

Service Code	MSDRG 824
Min. Negotiated Rate	$92,532.61
Max. Negotiated Rate	$92,532.61
Rate for Payer: Hawaii Medical Service Association Commercial	$92,532.61

LYMPHOMA AND NON-ACUTE LEUKEMIA WITH OTHER PROCEDURES WITH MCC

Facility

$92,532.61

Service Code	MSDRG 823
Min. Negotiated Rate	$92,532.61
Max. Negotiated Rate	$92,532.61
Rate for Payer: Hawaii Medical Service Association Commercial	$92,532.61

LYMPHOMA AND NON-ACUTE LEUKEMIA WITH OTHER PROCEDURES WITHOUT CC/MCC

Facility

$25,053.01

Service Code	MSDRG 825
Min. Negotiated Rate	$25,053.01
Max. Negotiated Rate	$25,053.01
Rate for Payer: Hawaii Medical Service Association Commercial	$25,053.01

LYMPHOMA AND NON-ACUTE LEUKEMIA WITHOUT CC/MCC

Facility

$51,030.41

Service Code	MSDRG 842
Min. Negotiated Rate	$51,030.41
Max. Negotiated Rate	$51,030.41
Rate for Payer: Hawaii Medical Service Association Commercial	$51,030.41

M0222 BEBTELOVIMAB MONOCLONAL INJECTION

Facility

$2,617.00

Service Code	HCPCS M0222
Hospital Charge Code	10023578
Hospital Revenue Code	771
Min. Negotiated Rate	$1,308.50
Max. Negotiated Rate	$2,538.49
Rate for Payer: AlohaCare Medicaid	$1,308.50
Rate for Payer: AlohaCare Medicare	$1,308.50
Rate for Payer: Cash Price	$1,701.05
Rate for Payer: Devoted Health Medicare	$1,439.35
Rate for Payer: Hawaii Medical Service Association Medicare	$1,308.50
Rate for Payer: Hawaii Western Management Group Commercial	$2,486.15
Rate for Payer: Health Management Network Commercial	$2,224.45
Rate for Payer: Humana Medicare	$1,308.50
Rate for Payer: Kaiser Permanente Commercial	$2,355.30
Rate for Payer: Kaiser Permanente Medicaid	$1,334.67
Rate for Payer: Kaiser Permanente Medicare	$1,308.50
Rate for Payer: MDX Hawaii PPO	$2,538.49
Rate for Payer: Ohana Health Plan Medicaid	$1,308.50
Rate for Payer: Ohana Health Plan Medicare	$1,308.50
Rate for Payer: UnitedHealthcare Medicare	$1,308.50
Rate for Payer: University Health Alliance Commercial	$1,465.52

M0222 BEBTELOVIMAB MONOCLONAL INJECTION

Facility

$2,617.00

Service Code	HCPCS M0222
Hospital Charge Code	10023578
Hospital Revenue Code	771
Min. Negotiated Rate	$2,224.45
Max. Negotiated Rate	$2,538.49
Rate for Payer: Cash Price	$1,701.05
Rate for Payer: Health Management Network Commercial	$2,224.45
Rate for Payer: Kaiser Permanente Commercial	$2,355.30
Rate for Payer: MDX Hawaii PPO	$2,538.49

M0240 IV/SubQ Inj REGN-COV2 Addtl

Facility

$1,891.00

Service Code	HCPCS M0240
Hospital Charge Code	9702004
Hospital Revenue Code	771
Min. Negotiated Rate	$945.50
Max. Negotiated Rate	$1,834.27
Rate for Payer: AlohaCare Medicaid	$945.50
Rate for Payer: AlohaCare Medicare	$945.50
Rate for Payer: Cash Price	$1,229.15
Rate for Payer: Devoted Health Medicare	$1,040.05
Rate for Payer: Hawaii Medical Service Association Medicare	$945.50
Rate for Payer: Hawaii Western Management Group Commercial	$1,796.45
Rate for Payer: Health Management Network Commercial	$1,607.35
Rate for Payer: Humana Medicare	$945.50
Rate for Payer: Kaiser Permanente Commercial	$1,701.90
Rate for Payer: Kaiser Permanente Medicaid	$964.41
Rate for Payer: Kaiser Permanente Medicare	$945.50
Rate for Payer: MDX Hawaii PPO	$1,834.27
Rate for Payer: Ohana Health Plan Medicaid	$945.50
Rate for Payer: Ohana Health Plan Medicare	$945.50
Rate for Payer: UnitedHealthcare Medicare	$945.50
Rate for Payer: University Health Alliance Commercial	$1,058.96

M0240 IV/SubQ Inj REGN-COV2 Addtl

Facility

$1,891.00

Service Code	HCPCS M0240
Hospital Charge Code	9702004
Hospital Revenue Code	771
Min. Negotiated Rate	$1,607.35
Max. Negotiated Rate	$1,834.27
Rate for Payer: Cash Price	$1,229.15
Rate for Payer: Health Management Network Commercial	$1,607.35
Rate for Payer: Kaiser Permanente Commercial	$1,701.90
Rate for Payer: MDX Hawaii PPO	$1,834.27

M0244 IV/SubQ Inj REGN-COV2 Initial

Facility

$2,160.00

Service Code	HCPCS M0244
Hospital Charge Code	9702003
Hospital Revenue Code	771
Min. Negotiated Rate	$1,836.00
Max. Negotiated Rate	$2,095.20
Rate for Payer: Cash Price	$1,404.00
Rate for Payer: Health Management Network Commercial	$1,836.00
Rate for Payer: Kaiser Permanente Commercial	$1,944.00
Rate for Payer: MDX Hawaii PPO	$2,095.20

M0244 IV/SubQ Inj REGN-COV2 Initial

Facility

$2,160.00

Service Code	HCPCS M0244
Hospital Charge Code	9702003
Hospital Revenue Code	771
Min. Negotiated Rate	$1,080.00
Max. Negotiated Rate	$2,095.20
Rate for Payer: AlohaCare Medicaid	$1,080.00
Rate for Payer: AlohaCare Medicare	$1,080.00
Rate for Payer: Cash Price	$1,404.00
Rate for Payer: Devoted Health Medicare	$1,188.00
Rate for Payer: Hawaii Medical Service Association Medicare	$1,080.00
Rate for Payer: Hawaii Western Management Group Commercial	$2,052.00
Rate for Payer: Health Management Network Commercial	$1,836.00
Rate for Payer: Humana Medicare	$1,080.00
Rate for Payer: Kaiser Permanente Commercial	$1,944.00
Rate for Payer: Kaiser Permanente Medicaid	$1,101.60
Rate for Payer: Kaiser Permanente Medicare	$1,080.00
Rate for Payer: MDX Hawaii PPO	$2,095.20
Rate for Payer: Ohana Health Plan Medicaid	$1,080.00
Rate for Payer: Ohana Health Plan Medicare	$1,080.00
Rate for Payer: UnitedHealthcare Medicare	$1,080.00
Rate for Payer: University Health Alliance Commercial	$1,209.60

Know your out-of-pocket cost for care.

All Charges