Samuel Mahelona Memorial Hospital

All Charges

Charge

Type

Setting

Price

MALIGNANT BREAST DISORDERS WITHOUT CC/MCC

Facility

$1,753.95

Service Code	MSDRG 599
Min. Negotiated Rate	$1,753.95
Max. Negotiated Rate	$1,753.95
Rate for Payer: Hawaii Medical Service Association Commercial	$1,753.95

MANIPULATOR / INJECTOR UTERINE (LUMIN)

Facility

$154.00

Hospital Charge Code	8274257
Hospital Revenue Code	272
Min. Negotiated Rate	$130.90
Max. Negotiated Rate	$149.38
Rate for Payer: Cash Price	$100.10
Rate for Payer: Health Management Network Commercial	$130.90
Rate for Payer: Kaiser Permanente Commercial	$138.60
Rate for Payer: MDX Hawaii PPO	$149.38

MANIPULATOR / INJECTOR UTERINE (LUMIN)

Facility

$154.00

Hospital Charge Code	8274257
Hospital Revenue Code	272
Min. Negotiated Rate	$77.00
Max. Negotiated Rate	$149.38
Rate for Payer: AlohaCare Medicaid	$77.00
Rate for Payer: AlohaCare Medicare	$77.00
Rate for Payer: Cash Price	$100.10
Rate for Payer: Devoted Health Medicare	$84.70
Rate for Payer: Hawaii Medical Service Association Medicare	$77.00
Rate for Payer: Hawaii Western Management Group Commercial	$146.30
Rate for Payer: Health Management Network Commercial	$130.90
Rate for Payer: Humana Medicare	$77.00
Rate for Payer: Kaiser Permanente Commercial	$138.60
Rate for Payer: Kaiser Permanente Medicaid	$78.54
Rate for Payer: Kaiser Permanente Medicare	$77.00
Rate for Payer: MDX Hawaii PPO	$149.38
Rate for Payer: Ohana Health Plan Medicaid	$77.00
Rate for Payer: Ohana Health Plan Medicare	$77.00
Rate for Payer: UnitedHealthcare Medicare	$77.00
Rate for Payer: University Health Alliance Commercial	$112.25

mannitol 20% 100gm/ 500 ml [HHSC]

Facility

$97.78

Service Code	NDC 00409771503
Hospital Charge Code	2500513
Hospital Revenue Code	250
Min. Negotiated Rate	$48.89
Max. Negotiated Rate	$94.85
Rate for Payer: AlohaCare Medicaid	$48.89
Rate for Payer: AlohaCare Medicare	$48.89
Rate for Payer: Cash Price	$63.56
Rate for Payer: Devoted Health Medicare	$53.78
Rate for Payer: Hawaii Medical Service Association Medicare	$48.89
Rate for Payer: Hawaii Western Management Group Commercial	$92.89
Rate for Payer: Health Management Network Commercial	$83.11
Rate for Payer: Humana Medicare	$48.89
Rate for Payer: Kaiser Permanente Commercial	$88.00
Rate for Payer: Kaiser Permanente Medicaid	$49.87
Rate for Payer: Kaiser Permanente Medicare	$48.89
Rate for Payer: MDX Hawaii PPO	$94.85
Rate for Payer: Ohana Health Plan Medicaid	$48.89
Rate for Payer: Ohana Health Plan Medicare	$48.89
Rate for Payer: UnitedHealthcare Medicaid	$58.67
Rate for Payer: UnitedHealthcare Medicare	$48.89
Rate for Payer: University Health Alliance Commercial	$71.27

mannitol 20% 100gm/ 500 ml [HHSC]

Facility

$101.48

Service Code	NDC 00264757810
Hospital Charge Code	2500513
Hospital Revenue Code	250
Min. Negotiated Rate	$86.26
Max. Negotiated Rate	$98.44
Rate for Payer: Cash Price	$65.96
Rate for Payer: Health Management Network Commercial	$86.26
Rate for Payer: Kaiser Permanente Commercial	$91.33
Rate for Payer: MDX Hawaii PPO	$98.44

mannitol 20% 100gm/ 500 ml [HHSC]

Facility

$101.48

Service Code	NDC 00264757810
Hospital Charge Code	2500513
Hospital Revenue Code	250
Min. Negotiated Rate	$50.74
Max. Negotiated Rate	$98.44
Rate for Payer: AlohaCare Medicaid	$50.74
Rate for Payer: AlohaCare Medicare	$50.74
Rate for Payer: Cash Price	$65.96
Rate for Payer: Devoted Health Medicare	$55.81
Rate for Payer: Hawaii Medical Service Association Medicare	$50.74
Rate for Payer: Hawaii Western Management Group Commercial	$96.41
Rate for Payer: Health Management Network Commercial	$86.26
Rate for Payer: Humana Medicare	$50.74
Rate for Payer: Kaiser Permanente Commercial	$91.33
Rate for Payer: Kaiser Permanente Medicaid	$51.75
Rate for Payer: Kaiser Permanente Medicare	$50.74
Rate for Payer: MDX Hawaii PPO	$98.44
Rate for Payer: Ohana Health Plan Medicaid	$50.74
Rate for Payer: Ohana Health Plan Medicare	$50.74
Rate for Payer: UnitedHealthcare Medicaid	$60.89
Rate for Payer: UnitedHealthcare Medicare	$50.74
Rate for Payer: University Health Alliance Commercial	$73.97

mannitol 20% 100gm/ 500 ml [HHSC]

Facility

$113.70

Service Code	NDC 00990771503
Hospital Charge Code	2500513
Hospital Revenue Code	250
Min. Negotiated Rate	$56.85
Max. Negotiated Rate	$110.29
Rate for Payer: AlohaCare Medicaid	$56.85
Rate for Payer: AlohaCare Medicare	$56.85
Rate for Payer: Cash Price	$73.90
Rate for Payer: Devoted Health Medicare	$62.53
Rate for Payer: Hawaii Medical Service Association Medicare	$56.85
Rate for Payer: Hawaii Western Management Group Commercial	$108.02
Rate for Payer: Health Management Network Commercial	$96.64
Rate for Payer: Humana Medicare	$56.85
Rate for Payer: Kaiser Permanente Commercial	$102.33
Rate for Payer: Kaiser Permanente Medicaid	$57.99
Rate for Payer: Kaiser Permanente Medicare	$56.85
Rate for Payer: MDX Hawaii PPO	$110.29
Rate for Payer: Ohana Health Plan Medicaid	$56.85
Rate for Payer: Ohana Health Plan Medicare	$56.85
Rate for Payer: UnitedHealthcare Medicaid	$68.22
Rate for Payer: UnitedHealthcare Medicare	$56.85
Rate for Payer: University Health Alliance Commercial	$82.88

mannitol 20% 100gm/ 500 ml [HHSC]

Facility

$113.70

Service Code	NDC 00990771503
Hospital Charge Code	2500513
Hospital Revenue Code	250
Min. Negotiated Rate	$96.64
Max. Negotiated Rate	$110.29
Rate for Payer: Cash Price	$73.90
Rate for Payer: Health Management Network Commercial	$96.64
Rate for Payer: Kaiser Permanente Commercial	$102.33
Rate for Payer: MDX Hawaii PPO	$110.29

mannitol 20% 100gm/ 500 ml [HHSC]

Facility

$330.46

Service Code	NDC 00338035703
Hospital Charge Code	2500513
Hospital Revenue Code	250
Min. Negotiated Rate	$280.89
Max. Negotiated Rate	$320.55
Rate for Payer: Cash Price	$214.80
Rate for Payer: Health Management Network Commercial	$280.89
Rate for Payer: Kaiser Permanente Commercial	$297.41
Rate for Payer: MDX Hawaii PPO	$320.55

mannitol 20% 100gm/ 500 ml [HHSC]

Facility

$330.46

Service Code	NDC 00338035703
Hospital Charge Code	2500513
Hospital Revenue Code	250
Min. Negotiated Rate	$165.23
Max. Negotiated Rate	$320.55
Rate for Payer: AlohaCare Medicaid	$165.23
Rate for Payer: AlohaCare Medicare	$165.23
Rate for Payer: Cash Price	$214.80
Rate for Payer: Devoted Health Medicare	$181.75
Rate for Payer: Hawaii Medical Service Association Medicare	$165.23
Rate for Payer: Hawaii Western Management Group Commercial	$313.94
Rate for Payer: Health Management Network Commercial	$280.89
Rate for Payer: Humana Medicare	$165.23
Rate for Payer: Kaiser Permanente Commercial	$297.41
Rate for Payer: Kaiser Permanente Medicaid	$168.53
Rate for Payer: Kaiser Permanente Medicare	$165.23
Rate for Payer: MDX Hawaii PPO	$320.55
Rate for Payer: Ohana Health Plan Medicaid	$165.23
Rate for Payer: Ohana Health Plan Medicare	$165.23
Rate for Payer: UnitedHealthcare Medicaid	$198.28
Rate for Payer: UnitedHealthcare Medicare	$165.23
Rate for Payer: University Health Alliance Commercial	$240.87

mannitol 20% 100gm/ 500 ml [HHSC]

Facility

$97.78

Service Code	NDC 00409771503
Hospital Charge Code	2500513
Hospital Revenue Code	250
Min. Negotiated Rate	$83.11
Max. Negotiated Rate	$94.85
Rate for Payer: Cash Price	$63.56
Rate for Payer: Health Management Network Commercial	$83.11
Rate for Payer: Kaiser Permanente Commercial	$88.00
Rate for Payer: MDX Hawaii PPO	$94.85

Manual Diff FSI

Facility

$47.00

Service Code	HCPCS 85007
Hospital Charge Code	8228893
Hospital Revenue Code	305
Min. Negotiated Rate	$3.80
Max. Negotiated Rate	$45.59
Rate for Payer: AlohaCare Medicaid	$23.50
Rate for Payer: AlohaCare Medicare	$23.50
Rate for Payer: Cash Price	$30.55
Rate for Payer: Cash Price	$30.55
Rate for Payer: Devoted Health Medicare	$25.85
Rate for Payer: Hawaii Medical Service Association ABD	$4.76
Rate for Payer: Hawaii Medical Service Association Commercial	$4.75
Rate for Payer: Hawaii Medical Service Association Medicare	$23.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$5.00
Rate for Payer: Hawaii Western Management Group Commercial	$3.80
Rate for Payer: Health Management Network Commercial	$39.95
Rate for Payer: Humana Medicare	$23.50
Rate for Payer: Kaiser Permanente Commercial	$42.30
Rate for Payer: Kaiser Permanente Medicaid	$23.97
Rate for Payer: Kaiser Permanente Medicare	$23.50
Rate for Payer: MDX Hawaii PPO	$45.59
Rate for Payer: Ohana Health Plan Medicaid	$23.50
Rate for Payer: Ohana Health Plan Medicare	$23.50
Rate for Payer: UnitedHealthcare Medicaid	$4.76
Rate for Payer: UnitedHealthcare Medicare	$23.50
Rate for Payer: University Health Alliance Commercial	$8.90

Manual Diff FSI

Facility

$47.00

Service Code	HCPCS 85007
Hospital Charge Code	8228893
Hospital Revenue Code	305
Min. Negotiated Rate	$39.95
Max. Negotiated Rate	$45.59
Rate for Payer: Cash Price	$30.55
Rate for Payer: Health Management Network Commercial	$39.95
Rate for Payer: Kaiser Permanente Commercial	$42.30
Rate for Payer: MDX Hawaii PPO	$45.59

Manual Therapy Charge Units

Facility

$231.00

Service Code	HCPCS 97140 GP,CQ
Hospital Charge Code	8123827
Hospital Revenue Code	430
Min. Negotiated Rate	$196.35
Max. Negotiated Rate	$224.07
Rate for Payer: Cash Price	$150.15
Rate for Payer: Health Management Network Commercial	$196.35
Rate for Payer: Kaiser Permanente Commercial	$207.90
Rate for Payer: MDX Hawaii PPO	$224.07

Manual Therapy Charge Units

Facility

$231.00

Service Code	HCPCS 97140 GP,CQ
Hospital Charge Code	8111688
Hospital Revenue Code	420
Min. Negotiated Rate	$20.55
Max. Negotiated Rate	$224.07
Rate for Payer: AlohaCare Medicaid	$115.50
Rate for Payer: AlohaCare Medicare	$115.50
Rate for Payer: Cash Price	$150.15
Rate for Payer: Cash Price	$150.15
Rate for Payer: Devoted Health Medicare	$127.05
Rate for Payer: Hawaii Medical Service Association Medicare	$115.50
Rate for Payer: Hawaii Western Management Group Commercial	$219.45
Rate for Payer: Health Management Network Commercial	$196.35
Rate for Payer: Humana Medicare	$115.50
Rate for Payer: Kaiser Permanente Commercial	$207.90
Rate for Payer: Kaiser Permanente Medicaid	$117.81
Rate for Payer: Kaiser Permanente Medicare	$115.50
Rate for Payer: MDX Hawaii PPO	$224.07
Rate for Payer: Ohana Health Plan Medicaid	$115.50
Rate for Payer: Ohana Health Plan Medicare	$115.50
Rate for Payer: UnitedHealthcare Medicaid	$20.55
Rate for Payer: UnitedHealthcare Medicare	$115.50
Rate for Payer: University Health Alliance Commercial	$129.36

Manual Therapy Charge Units

Facility

$231.00

Service Code	HCPCS 97140 GP,CQ
Hospital Charge Code	8123827
Hospital Revenue Code	430
Min. Negotiated Rate	$20.55
Max. Negotiated Rate	$224.07
Rate for Payer: AlohaCare Medicaid	$115.50
Rate for Payer: AlohaCare Medicare	$115.50
Rate for Payer: Cash Price	$150.15
Rate for Payer: Cash Price	$150.15
Rate for Payer: Devoted Health Medicare	$127.05
Rate for Payer: Hawaii Medical Service Association Medicare	$115.50
Rate for Payer: Hawaii Western Management Group Commercial	$219.45
Rate for Payer: Health Management Network Commercial	$196.35
Rate for Payer: Humana Medicare	$115.50
Rate for Payer: Kaiser Permanente Commercial	$207.90
Rate for Payer: Kaiser Permanente Medicaid	$117.81
Rate for Payer: Kaiser Permanente Medicare	$115.50
Rate for Payer: MDX Hawaii PPO	$224.07
Rate for Payer: Ohana Health Plan Medicaid	$115.50
Rate for Payer: Ohana Health Plan Medicare	$115.50
Rate for Payer: UnitedHealthcare Medicaid	$20.55
Rate for Payer: UnitedHealthcare Medicare	$115.50
Rate for Payer: University Health Alliance Commercial	$129.36

Manual Therapy Charge Units

Facility

$231.00

Service Code	HCPCS 97140 GP,CQ
Hospital Charge Code	8111688
Hospital Revenue Code	420
Min. Negotiated Rate	$196.35
Max. Negotiated Rate	$224.07
Rate for Payer: Cash Price	$150.15
Rate for Payer: Health Management Network Commercial	$196.35
Rate for Payer: Kaiser Permanente Commercial	$207.90
Rate for Payer: MDX Hawaii PPO	$224.07

MASK ANESTHESIA FLEXIBLE ADULT SIZE 5

Facility

$11.00

Hospital Charge Code	9868289
Hospital Revenue Code	270
Min. Negotiated Rate	$9.35
Max. Negotiated Rate	$10.67
Rate for Payer: Cash Price	$7.15
Rate for Payer: Health Management Network Commercial	$9.35
Rate for Payer: Kaiser Permanente Commercial	$9.90
Rate for Payer: MDX Hawaii PPO	$10.67

MASK ANESTHESIA FLEXIBLE ADULT SIZE 5

Facility

$11.00

Hospital Charge Code	9868289
Hospital Revenue Code	270
Min. Negotiated Rate	$5.50
Max. Negotiated Rate	$10.67
Rate for Payer: AlohaCare Medicaid	$5.50
Rate for Payer: AlohaCare Medicare	$5.50
Rate for Payer: Cash Price	$7.15
Rate for Payer: Devoted Health Medicare	$6.05
Rate for Payer: Hawaii Medical Service Association Medicare	$5.50
Rate for Payer: Hawaii Western Management Group Commercial	$10.45
Rate for Payer: Health Management Network Commercial	$9.35
Rate for Payer: Humana Medicare	$5.50
Rate for Payer: Kaiser Permanente Commercial	$9.90
Rate for Payer: Kaiser Permanente Medicaid	$5.61
Rate for Payer: Kaiser Permanente Medicare	$5.50
Rate for Payer: MDX Hawaii PPO	$10.67
Rate for Payer: Ohana Health Plan Medicaid	$5.50
Rate for Payer: Ohana Health Plan Medicare	$5.50
Rate for Payer: UnitedHealthcare Medicare	$5.50
Rate for Payer: University Health Alliance Commercial	$8.02

Massage Charge Units

Facility

$207.00

Service Code	HCPCS 97124 GP,CO
Hospital Charge Code	8111689
Hospital Revenue Code	420
Min. Negotiated Rate	$175.95
Max. Negotiated Rate	$200.79
Rate for Payer: Cash Price	$134.55
Rate for Payer: Health Management Network Commercial	$175.95
Rate for Payer: Kaiser Permanente Commercial	$186.30
Rate for Payer: MDX Hawaii PPO	$200.79

Massage Charge Units

Facility

$207.00

Service Code	HCPCS 97124 GP,CQ
Hospital Charge Code	8123828
Hospital Revenue Code	430
Min. Negotiated Rate	$175.95
Max. Negotiated Rate	$200.79
Rate for Payer: Cash Price	$134.55
Rate for Payer: Health Management Network Commercial	$175.95
Rate for Payer: Kaiser Permanente Commercial	$186.30
Rate for Payer: MDX Hawaii PPO	$200.79

Massage Charge Units

Facility

$207.00

Service Code	HCPCS 97124 GP,CO
Hospital Charge Code	8111689
Hospital Revenue Code	420
Min. Negotiated Rate	$15.39
Max. Negotiated Rate	$200.79
Rate for Payer: AlohaCare Medicaid	$103.50
Rate for Payer: AlohaCare Medicare	$103.50
Rate for Payer: Cash Price	$134.55
Rate for Payer: Cash Price	$134.55
Rate for Payer: Devoted Health Medicare	$113.85
Rate for Payer: Hawaii Medical Service Association Medicare	$103.50
Rate for Payer: Hawaii Western Management Group Commercial	$196.65
Rate for Payer: Health Management Network Commercial	$175.95
Rate for Payer: Humana Medicare	$103.50
Rate for Payer: Kaiser Permanente Commercial	$186.30
Rate for Payer: Kaiser Permanente Medicaid	$105.57
Rate for Payer: Kaiser Permanente Medicare	$103.50
Rate for Payer: MDX Hawaii PPO	$200.79
Rate for Payer: Ohana Health Plan Medicaid	$103.50
Rate for Payer: Ohana Health Plan Medicare	$103.50
Rate for Payer: UnitedHealthcare Medicaid	$15.39
Rate for Payer: UnitedHealthcare Medicare	$103.50
Rate for Payer: University Health Alliance Commercial	$115.92

Massage Charge Units

Facility

$207.00

Service Code	HCPCS 97124 GP,CQ
Hospital Charge Code	8123828
Hospital Revenue Code	430
Min. Negotiated Rate	$15.39
Max. Negotiated Rate	$200.79
Rate for Payer: AlohaCare Medicaid	$103.50
Rate for Payer: AlohaCare Medicare	$103.50
Rate for Payer: Cash Price	$134.55
Rate for Payer: Cash Price	$134.55
Rate for Payer: Devoted Health Medicare	$113.85
Rate for Payer: Hawaii Medical Service Association Medicare	$103.50
Rate for Payer: Hawaii Western Management Group Commercial	$196.65
Rate for Payer: Health Management Network Commercial	$175.95
Rate for Payer: Humana Medicare	$103.50
Rate for Payer: Kaiser Permanente Commercial	$186.30
Rate for Payer: Kaiser Permanente Medicaid	$105.57
Rate for Payer: Kaiser Permanente Medicare	$103.50
Rate for Payer: MDX Hawaii PPO	$200.79
Rate for Payer: Ohana Health Plan Medicaid	$103.50
Rate for Payer: Ohana Health Plan Medicare	$103.50
Rate for Payer: UnitedHealthcare Medicaid	$15.39
Rate for Payer: UnitedHealthcare Medicare	$103.50
Rate for Payer: University Health Alliance Commercial	$115.92

MASTECTOMY FOR MALIGNANCY WITH CC/MCC

Facility

$25,029.31

Service Code	MSDRG 582
Min. Negotiated Rate	$25,029.31
Max. Negotiated Rate	$25,029.31
Rate for Payer: Hawaii Medical Service Association Commercial	$25,029.31

MASTECTOMY FOR MALIGNANCY WITHOUT CC/MCC

Facility

$22,848.73

Service Code	MSDRG 583
Min. Negotiated Rate	$22,848.73
Max. Negotiated Rate	$22,848.73
Rate for Payer: Hawaii Medical Service Association Commercial	$22,848.73

Know your out-of-pocket cost for care.

All Charges