Samuel Mahelona Memorial Hospital

All Charges

Charge

Type

Setting

Price

magnesium-swfi 2 gm/50 mL premix [HHSC]

Facility

$102.17

Service Code	HCPCS J3475
Hospital Charge Code	2500510
Hospital Revenue Code	636
Min. Negotiated Rate	$0.50
Max. Negotiated Rate	$99.10
Rate for Payer: AlohaCare Medicaid	$51.09
Rate for Payer: AlohaCare Medicaid	$49.30
Rate for Payer: AlohaCare Medicaid	$45.64
Rate for Payer: AlohaCare Medicare	$45.64
Rate for Payer: AlohaCare Medicare	$51.09
Rate for Payer: AlohaCare Medicare	$49.30
Rate for Payer: Cash Price	$59.33
Rate for Payer: Cash Price	$64.10
Rate for Payer: Cash Price	$59.33
Rate for Payer: Cash Price	$66.41
Rate for Payer: Cash Price	$66.41
Rate for Payer: Cash Price	$64.10
Rate for Payer: Devoted Health Medicare	$56.19
Rate for Payer: Devoted Health Medicare	$54.24
Rate for Payer: Devoted Health Medicare	$50.20
Rate for Payer: Hawaii Medical Service Association ABD	$0.50
Rate for Payer: Hawaii Medical Service Association ABD	$0.50
Rate for Payer: Hawaii Medical Service Association ABD	$0.50
Rate for Payer: Hawaii Medical Service Association Medicare	$51.09
Rate for Payer: Hawaii Medical Service Association Medicare	$49.30
Rate for Payer: Hawaii Medical Service Association Medicare	$45.64
Rate for Payer: Hawaii Medical Service Association Non-ABD	$0.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$0.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$0.50
Rate for Payer: Hawaii Western Management Group Commercial	$86.72
Rate for Payer: Hawaii Western Management Group Commercial	$97.06
Rate for Payer: Hawaii Western Management Group Commercial	$93.68
Rate for Payer: Health Management Network Commercial	$83.82
Rate for Payer: Health Management Network Commercial	$86.84
Rate for Payer: Health Management Network Commercial	$77.59
Rate for Payer: Humana Medicare	$51.09
Rate for Payer: Humana Medicare	$45.64
Rate for Payer: Humana Medicare	$49.30
Rate for Payer: Kaiser Permanente Commercial	$91.95
Rate for Payer: Kaiser Permanente Commercial	$82.15
Rate for Payer: Kaiser Permanente Commercial	$88.75
Rate for Payer: Kaiser Permanente Medicaid	$50.29
Rate for Payer: Kaiser Permanente Medicaid	$46.55
Rate for Payer: Kaiser Permanente Medicaid	$52.11
Rate for Payer: Kaiser Permanente Medicare	$51.09
Rate for Payer: Kaiser Permanente Medicare	$45.64
Rate for Payer: Kaiser Permanente Medicare	$49.30
Rate for Payer: MDX Hawaii PPO	$95.65
Rate for Payer: MDX Hawaii PPO	$88.54
Rate for Payer: MDX Hawaii PPO	$99.10
Rate for Payer: Ohana Health Plan Medicaid	$45.64
Rate for Payer: Ohana Health Plan Medicaid	$51.09
Rate for Payer: Ohana Health Plan Medicaid	$49.30
Rate for Payer: Ohana Health Plan Medicare	$45.64
Rate for Payer: Ohana Health Plan Medicare	$51.09
Rate for Payer: Ohana Health Plan Medicare	$49.30
Rate for Payer: UnitedHealthcare Medicaid	$54.77
Rate for Payer: UnitedHealthcare Medicaid	$61.30
Rate for Payer: UnitedHealthcare Medicaid	$59.17
Rate for Payer: UnitedHealthcare Medicare	$45.64
Rate for Payer: UnitedHealthcare Medicare	$51.09
Rate for Payer: UnitedHealthcare Medicare	$49.30
Rate for Payer: University Health Alliance Commercial	$74.47
Rate for Payer: University Health Alliance Commercial	$66.53
Rate for Payer: University Health Alliance Commercial	$71.88

Magnesium Urine Timed FSI

Facility

$94.00

Service Code	HCPCS 83735
Hospital Charge Code	8228892
Hospital Revenue Code	301
Min. Negotiated Rate	$79.90
Max. Negotiated Rate	$91.18
Rate for Payer: Cash Price	$61.10
Rate for Payer: Health Management Network Commercial	$79.90
Rate for Payer: Kaiser Permanente Commercial	$84.60
Rate for Payer: MDX Hawaii PPO	$91.18

Magnesium Urine Timed FSI

Facility

$94.00

Service Code	HCPCS 83735
Hospital Charge Code	8228892
Hospital Revenue Code	301
Min. Negotiated Rate	$6.70
Max. Negotiated Rate	$91.18
Rate for Payer: AlohaCare Medicaid	$47.00
Rate for Payer: AlohaCare Medicare	$47.00
Rate for Payer: Cash Price	$61.10
Rate for Payer: Cash Price	$61.10
Rate for Payer: Devoted Health Medicare	$51.70
Rate for Payer: Hawaii Medical Service Association ABD	$9.26
Rate for Payer: Hawaii Medical Service Association Commercial	$8.38
Rate for Payer: Hawaii Medical Service Association Medicare	$47.00
Rate for Payer: Hawaii Medical Service Association Non-ABD	$9.72
Rate for Payer: Hawaii Western Management Group Commercial	$6.70
Rate for Payer: Health Management Network Commercial	$79.90
Rate for Payer: Humana Medicare	$47.00
Rate for Payer: Kaiser Permanente Commercial	$84.60
Rate for Payer: Kaiser Permanente Medicaid	$47.94
Rate for Payer: Kaiser Permanente Medicare	$47.00
Rate for Payer: MDX Hawaii PPO	$91.18
Rate for Payer: Ohana Health Plan Medicaid	$47.00
Rate for Payer: Ohana Health Plan Medicare	$47.00
Rate for Payer: UnitedHealthcare Medicaid	$9.26
Rate for Payer: UnitedHealthcare Medicare	$47.00
Rate for Payer: University Health Alliance Commercial	$17.32

MAJOR BLADDER PROCEDURES WITH CC

Facility

$45,792.26

Service Code	MSDRG 654
Min. Negotiated Rate	$45,792.26
Max. Negotiated Rate	$45,792.26
Rate for Payer: Hawaii Medical Service Association Commercial	$45,792.26

MAJOR BLADDER PROCEDURES WITH MCC

Facility

$45,792.26

Service Code	MSDRG 653
Min. Negotiated Rate	$45,792.26
Max. Negotiated Rate	$45,792.26
Rate for Payer: Hawaii Medical Service Association Commercial	$45,792.26

MAJOR BLADDER PROCEDURES WITHOUT CC/MCC

Facility

$45,792.26

Service Code	MSDRG 655
Min. Negotiated Rate	$45,792.26
Max. Negotiated Rate	$45,792.26
Rate for Payer: Hawaii Medical Service Association Commercial	$45,792.26

MAJOR CHEST PROCEDURES WITH CC

Facility

$63,213.23

Service Code	MSDRG 164
Min. Negotiated Rate	$63,213.23
Max. Negotiated Rate	$63,213.23
Rate for Payer: Hawaii Medical Service Association Commercial	$63,213.23

MAJOR CHEST PROCEDURES WITH MCC

Facility

$63,450.25

Service Code	MSDRG 163
Min. Negotiated Rate	$63,450.25
Max. Negotiated Rate	$63,450.25
Rate for Payer: Hawaii Medical Service Association Commercial	$63,450.25

MAJOR CHEST PROCEDURES WITHOUT CC/MCC

Facility

$45,436.73

Service Code	MSDRG 165
Min. Negotiated Rate	$45,436.73
Max. Negotiated Rate	$45,436.73
Rate for Payer: Hawaii Medical Service Association Commercial	$45,436.73

MAJOR CHEST TRAUMA WITH CC

Facility

$19,767.47

Service Code	MSDRG 184
Min. Negotiated Rate	$19,767.47
Max. Negotiated Rate	$19,767.47
Rate for Payer: Hawaii Medical Service Association Commercial	$19,767.47

MAJOR CHEST TRAUMA WITH MCC

Facility

$21,521.42

Service Code	MSDRG 183
Min. Negotiated Rate	$21,521.42
Max. Negotiated Rate	$21,521.42
Rate for Payer: Hawaii Medical Service Association Commercial	$21,521.42

MAJOR CHEST TRAUMA WITHOUT CC/MCC

Facility

$18,890.49

Service Code	MSDRG 185
Min. Negotiated Rate	$18,890.49
Max. Negotiated Rate	$18,890.49
Rate for Payer: Hawaii Medical Service Association Commercial	$18,890.49

MAJOR ESOPHAGEAL DISORDERS WITH CC

Facility

$19,340.83

Service Code	MSDRG 369
Min. Negotiated Rate	$19,340.83
Max. Negotiated Rate	$19,340.83
Rate for Payer: Hawaii Medical Service Association Commercial	$19,340.83

MAJOR ESOPHAGEAL DISORDERS WITH MCC

Facility

$19,340.83

Service Code	MSDRG 368
Min. Negotiated Rate	$19,340.83
Max. Negotiated Rate	$19,340.83
Rate for Payer: Hawaii Medical Service Association Commercial	$19,340.83

MAJOR ESOPHAGEAL DISORDERS WITHOUT CC/MCC

Facility

$19,340.83

Service Code	MSDRG 370
Min. Negotiated Rate	$19,340.83
Max. Negotiated Rate	$19,340.83
Rate for Payer: Hawaii Medical Service Association Commercial	$19,340.83

MAJOR GASTROINTESTINAL DISORDERS AND PERITONEAL INFECTIONS WITH CC

Facility

$21,995.46

Service Code	MSDRG 372
Min. Negotiated Rate	$21,995.46
Max. Negotiated Rate	$21,995.46
Rate for Payer: Hawaii Medical Service Association Commercial	$21,995.46

MAJOR GASTROINTESTINAL DISORDERS AND PERITONEAL INFECTIONS WITH MCC

Facility

$21,995.46

Service Code	MSDRG 371
Min. Negotiated Rate	$21,995.46
Max. Negotiated Rate	$21,995.46
Rate for Payer: Hawaii Medical Service Association Commercial	$21,995.46

MAJOR GASTROINTESTINAL DISORDERS AND PERITONEAL INFECTIONS WITHOUT CC/MCC

Facility

$21,995.46

Service Code	MSDRG 373
Min. Negotiated Rate	$21,995.46
Max. Negotiated Rate	$21,995.46
Rate for Payer: Hawaii Medical Service Association Commercial	$21,995.46

MAJOR HEAD AND NECK PROCEDURES WITH CC

Facility

$50,390.45

Service Code	MSDRG 141
Min. Negotiated Rate	$50,390.45
Max. Negotiated Rate	$50,390.45
Rate for Payer: Hawaii Medical Service Association Commercial	$50,390.45

MAJOR HEAD AND NECK PROCEDURES WITH MCC

Facility

$61,340.78

Service Code	MSDRG 140
Min. Negotiated Rate	$61,340.78
Max. Negotiated Rate	$61,340.78
Rate for Payer: Hawaii Medical Service Association Commercial	$61,340.78

MAJOR HEAD AND NECK PROCEDURES WITHOUT CC/MCC

Facility

$28,086.87

Service Code	MSDRG 142
Min. Negotiated Rate	$28,086.87
Max. Negotiated Rate	$28,086.87
Rate for Payer: Hawaii Medical Service Association Commercial	$28,086.87

MAJOR HEMATOLOGICAL AND IMMUNOLOGICAL DIAGNOSES EXCEPT SICKLE CELL CRISIS AND COAGULATION DISORDERS WITH CC

Facility

$34,913.05

Service Code	MSDRG 809
Min. Negotiated Rate	$34,913.05
Max. Negotiated Rate	$34,913.05
Rate for Payer: Hawaii Medical Service Association Commercial	$34,913.05

MAJOR HEMATOLOGICAL AND IMMUNOLOGICAL DIAGNOSES EXCEPT SICKLE CELL CRISIS AND COAGULATION DISORDERS WITH MCC

Facility

$34,913.05

Service Code	MSDRG 808
Min. Negotiated Rate	$34,913.05
Max. Negotiated Rate	$34,913.05
Rate for Payer: Hawaii Medical Service Association Commercial	$34,913.05

MAJOR HEMATOLOGICAL AND IMMUNOLOGICAL DIAGNOSES EXCEPT SICKLE CELL CRISIS AND COAGULATION DISORDERS WITHOUT CC/MCC

Facility

$34,913.05

Service Code	MSDRG 810
Min. Negotiated Rate	$34,913.05
Max. Negotiated Rate	$34,913.05
Rate for Payer: Hawaii Medical Service Association Commercial	$34,913.05

MAJOR HIP AND KNEE JOINT REPLACEMENT OR REATTACHMENT OF LOWER EXTREMITY WITH MCC OR TOTAL ANKLE REPLACEMENT

Facility

$40,957.06

Service Code	MSDRG 469
Min. Negotiated Rate	$10,400.00
Max. Negotiated Rate	$40,957.06
Rate for Payer: Hawaii Medical Service Association Commercial	$40,957.06
Rate for Payer: University Health Alliance Commercial	$10,400.00

Know your out-of-pocket cost for care.

All Charges