Samuel Mahelona Memorial Hospital

All Charges

Charge

Type

Setting

Price

MENSTRUAL AND OTHER FEMALE REPRODUCTIVE SYSTEM DISORDERS WITH CC/MCC

Facility

$11,993.21

Service Code	MSDRG 760
Min. Negotiated Rate	$11,993.21
Max. Negotiated Rate	$11,993.21
Rate for Payer: Hawaii Medical Service Association Commercial	$11,993.21

MENSTRUAL AND OTHER FEMALE REPRODUCTIVE SYSTEM DISORDERS WITHOUT CC/MCC

Facility

$11,993.21

Service Code	MSDRG 761
Min. Negotiated Rate	$11,993.21
Max. Negotiated Rate	$11,993.21
Rate for Payer: Hawaii Medical Service Association Commercial	$11,993.21

Mercury, Blood FSI

Facility

$185.00

Service Code	HCPCS 83825
Hospital Charge Code	8117991
Hospital Revenue Code	301
Min. Negotiated Rate	$157.25
Max. Negotiated Rate	$179.45
Rate for Payer: Cash Price	$120.25
Rate for Payer: Health Management Network Commercial	$157.25
Rate for Payer: Kaiser Permanente Commercial	$166.50
Rate for Payer: MDX Hawaii PPO	$179.45

Mercury, Blood FSI

Facility

$185.00

Service Code	HCPCS 83825
Hospital Charge Code	8117991
Hospital Revenue Code	301
Min. Negotiated Rate	$16.26
Max. Negotiated Rate	$179.45
Rate for Payer: AlohaCare Medicaid	$92.50
Rate for Payer: AlohaCare Medicare	$92.50
Rate for Payer: Cash Price	$120.25
Rate for Payer: Cash Price	$120.25
Rate for Payer: Devoted Health Medicare	$101.75
Rate for Payer: Hawaii Medical Service Association ABD	$22.47
Rate for Payer: Hawaii Medical Service Association Commercial	$20.32
Rate for Payer: Hawaii Medical Service Association Medicare	$92.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$23.59
Rate for Payer: Hawaii Western Management Group Commercial	$16.26
Rate for Payer: Health Management Network Commercial	$157.25
Rate for Payer: Humana Medicare	$92.50
Rate for Payer: Kaiser Permanente Commercial	$166.50
Rate for Payer: Kaiser Permanente Medicaid	$94.35
Rate for Payer: Kaiser Permanente Medicare	$92.50
Rate for Payer: MDX Hawaii PPO	$179.45
Rate for Payer: Ohana Health Plan Medicaid	$92.50
Rate for Payer: Ohana Health Plan Medicare	$92.50
Rate for Payer: UnitedHealthcare Medicaid	$22.47
Rate for Payer: UnitedHealthcare Medicare	$92.50
Rate for Payer: University Health Alliance Commercial	$42.03

Mercury Level, Urine FSI

Facility

$185.00

Service Code	HCPCS 83825
Hospital Charge Code	8934462
Hospital Revenue Code	301
Min. Negotiated Rate	$16.26
Max. Negotiated Rate	$179.45
Rate for Payer: AlohaCare Medicaid	$92.50
Rate for Payer: AlohaCare Medicare	$92.50
Rate for Payer: Cash Price	$120.25
Rate for Payer: Cash Price	$120.25
Rate for Payer: Devoted Health Medicare	$101.75
Rate for Payer: Hawaii Medical Service Association ABD	$22.47
Rate for Payer: Hawaii Medical Service Association Commercial	$20.32
Rate for Payer: Hawaii Medical Service Association Medicare	$92.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$23.59
Rate for Payer: Hawaii Western Management Group Commercial	$16.26
Rate for Payer: Health Management Network Commercial	$157.25
Rate for Payer: Humana Medicare	$92.50
Rate for Payer: Kaiser Permanente Commercial	$166.50
Rate for Payer: Kaiser Permanente Medicaid	$94.35
Rate for Payer: Kaiser Permanente Medicare	$92.50
Rate for Payer: MDX Hawaii PPO	$179.45
Rate for Payer: Ohana Health Plan Medicaid	$92.50
Rate for Payer: Ohana Health Plan Medicare	$92.50
Rate for Payer: UnitedHealthcare Medicaid	$22.47
Rate for Payer: UnitedHealthcare Medicare	$92.50
Rate for Payer: University Health Alliance Commercial	$42.03

Mercury Level, Urine FSI

Facility

$185.00

Service Code	HCPCS 83825
Hospital Charge Code	8934462
Hospital Revenue Code	301
Min. Negotiated Rate	$157.25
Max. Negotiated Rate	$179.45
Rate for Payer: Cash Price	$120.25
Rate for Payer: Health Management Network Commercial	$157.25
Rate for Payer: Kaiser Permanente Commercial	$166.50
Rate for Payer: MDX Hawaii PPO	$179.45

MESH, PERFIX PLUG LARGE

Facility

$1,097.00

Service Code	HCPCS C1781
Hospital Charge Code	8274198
Hospital Revenue Code	278
Min. Negotiated Rate	$548.50
Max. Negotiated Rate	$1,064.09
Rate for Payer: AlohaCare Medicaid	$548.50
Rate for Payer: AlohaCare Medicare	$548.50
Rate for Payer: Cash Price	$713.05
Rate for Payer: Devoted Health Medicare	$603.35
Rate for Payer: Hawaii Medical Service Association Medicare	$548.50
Rate for Payer: Hawaii Western Management Group Commercial	$767.90
Rate for Payer: Health Management Network Commercial	$932.45
Rate for Payer: Humana Medicare	$548.50
Rate for Payer: Kaiser Permanente Commercial	$987.30
Rate for Payer: Kaiser Permanente Medicaid	$559.47
Rate for Payer: Kaiser Permanente Medicare	$548.50
Rate for Payer: MDX Hawaii PPO	$1,064.09
Rate for Payer: Ohana Health Plan Medicaid	$548.50
Rate for Payer: Ohana Health Plan Medicare	$548.50
Rate for Payer: UnitedHealthcare Medicare	$548.50
Rate for Payer: University Health Alliance Commercial	$614.32

MESH, PERFIX PLUG LARGE

Facility

$1,097.00

Service Code	HCPCS C1781
Hospital Charge Code	8274198
Hospital Revenue Code	278
Min. Negotiated Rate	$614.32
Max. Negotiated Rate	$1,064.09
Rate for Payer: Cash Price	$713.05
Rate for Payer: Hawaii Western Management Group Commercial	$767.90
Rate for Payer: Health Management Network Commercial	$932.45
Rate for Payer: Kaiser Permanente Commercial	$987.30
Rate for Payer: MDX Hawaii PPO	$1,064.09
Rate for Payer: University Health Alliance Commercial	$614.32

MESH, PERFIX PLUG MEDIUM

Facility

$814.00

Service Code	HCPCS C1781
Hospital Charge Code	8274199
Hospital Revenue Code	278
Min. Negotiated Rate	$455.84
Max. Negotiated Rate	$789.58
Rate for Payer: Cash Price	$529.10
Rate for Payer: Hawaii Western Management Group Commercial	$569.80
Rate for Payer: Health Management Network Commercial	$691.90
Rate for Payer: Kaiser Permanente Commercial	$732.60
Rate for Payer: MDX Hawaii PPO	$789.58
Rate for Payer: University Health Alliance Commercial	$455.84

MESH, PERFIX PLUG MEDIUM

Facility

$814.00

Service Code	HCPCS C1781
Hospital Charge Code	8274199
Hospital Revenue Code	278
Min. Negotiated Rate	$407.00
Max. Negotiated Rate	$789.58
Rate for Payer: AlohaCare Medicaid	$407.00
Rate for Payer: AlohaCare Medicare	$407.00
Rate for Payer: Cash Price	$529.10
Rate for Payer: Devoted Health Medicare	$447.70
Rate for Payer: Hawaii Medical Service Association Medicare	$407.00
Rate for Payer: Hawaii Western Management Group Commercial	$569.80
Rate for Payer: Health Management Network Commercial	$691.90
Rate for Payer: Humana Medicare	$407.00
Rate for Payer: Kaiser Permanente Commercial	$732.60
Rate for Payer: Kaiser Permanente Medicaid	$415.14
Rate for Payer: Kaiser Permanente Medicare	$407.00
Rate for Payer: MDX Hawaii PPO	$789.58
Rate for Payer: Ohana Health Plan Medicaid	$407.00
Rate for Payer: Ohana Health Plan Medicare	$407.00
Rate for Payer: UnitedHealthcare Medicare	$407.00
Rate for Payer: University Health Alliance Commercial	$455.84

MESH, PERFIX PLUG SMALL

Facility

$807.00

Service Code	HCPCS C1781
Hospital Charge Code	8274200
Hospital Revenue Code	278
Min. Negotiated Rate	$403.50
Max. Negotiated Rate	$782.79
Rate for Payer: AlohaCare Medicaid	$403.50
Rate for Payer: AlohaCare Medicare	$403.50
Rate for Payer: Cash Price	$524.55
Rate for Payer: Devoted Health Medicare	$443.85
Rate for Payer: Hawaii Medical Service Association Medicare	$403.50
Rate for Payer: Hawaii Western Management Group Commercial	$564.90
Rate for Payer: Health Management Network Commercial	$685.95
Rate for Payer: Humana Medicare	$403.50
Rate for Payer: Kaiser Permanente Commercial	$726.30
Rate for Payer: Kaiser Permanente Medicaid	$411.57
Rate for Payer: Kaiser Permanente Medicare	$403.50
Rate for Payer: MDX Hawaii PPO	$782.79
Rate for Payer: Ohana Health Plan Medicaid	$403.50
Rate for Payer: Ohana Health Plan Medicare	$403.50
Rate for Payer: UnitedHealthcare Medicare	$403.50
Rate for Payer: University Health Alliance Commercial	$451.92

MESH, PERFIX PLUG SMALL

Facility

$807.00

Service Code	HCPCS C1781
Hospital Charge Code	8274200
Hospital Revenue Code	278
Min. Negotiated Rate	$451.92
Max. Negotiated Rate	$782.79
Rate for Payer: Cash Price	$524.55
Rate for Payer: Hawaii Western Management Group Commercial	$564.90
Rate for Payer: Health Management Network Commercial	$685.95
Rate for Payer: Kaiser Permanente Commercial	$726.30
Rate for Payer: MDX Hawaii PPO	$782.79
Rate for Payer: University Health Alliance Commercial	$451.92

MESH, POLYPROPYLENE MESH 6X 6

Facility

$465.00

Service Code	HCPCS C1781
Hospital Charge Code	8274243
Hospital Revenue Code	278
Min. Negotiated Rate	$260.40
Max. Negotiated Rate	$451.05
Rate for Payer: Cash Price	$302.25
Rate for Payer: Hawaii Western Management Group Commercial	$325.50
Rate for Payer: Health Management Network Commercial	$395.25
Rate for Payer: Kaiser Permanente Commercial	$418.50
Rate for Payer: MDX Hawaii PPO	$451.05
Rate for Payer: University Health Alliance Commercial	$260.40

MESH, POLYPROPYLENE MESH 6X 6

Facility

$465.00

Service Code	HCPCS C1781
Hospital Charge Code	8274243
Hospital Revenue Code	278
Min. Negotiated Rate	$232.50
Max. Negotiated Rate	$451.05
Rate for Payer: AlohaCare Medicaid	$232.50
Rate for Payer: AlohaCare Medicare	$232.50
Rate for Payer: Cash Price	$302.25
Rate for Payer: Devoted Health Medicare	$255.75
Rate for Payer: Hawaii Medical Service Association Medicare	$232.50
Rate for Payer: Hawaii Western Management Group Commercial	$325.50
Rate for Payer: Health Management Network Commercial	$395.25
Rate for Payer: Humana Medicare	$232.50
Rate for Payer: Kaiser Permanente Commercial	$418.50
Rate for Payer: Kaiser Permanente Medicaid	$237.15
Rate for Payer: Kaiser Permanente Medicare	$232.50
Rate for Payer: MDX Hawaii PPO	$451.05
Rate for Payer: Ohana Health Plan Medicaid	$232.50
Rate for Payer: Ohana Health Plan Medicare	$232.50
Rate for Payer: UnitedHealthcare Medicare	$232.50
Rate for Payer: University Health Alliance Commercial	$260.40

MESH SOFT PROLENE 6X6

Facility

$465.00

Service Code	HCPCS C1781
Hospital Charge Code	8348095
Hospital Revenue Code	278
Min. Negotiated Rate	$260.40
Max. Negotiated Rate	$451.05
Rate for Payer: Cash Price	$302.25
Rate for Payer: Hawaii Western Management Group Commercial	$325.50
Rate for Payer: Health Management Network Commercial	$395.25
Rate for Payer: Kaiser Permanente Commercial	$418.50
Rate for Payer: MDX Hawaii PPO	$451.05
Rate for Payer: University Health Alliance Commercial	$260.40

MESH SOFT PROLENE 6X6

Facility

$465.00

Service Code	HCPCS C1781
Hospital Charge Code	8348095
Hospital Revenue Code	278
Min. Negotiated Rate	$232.50
Max. Negotiated Rate	$451.05
Rate for Payer: AlohaCare Medicaid	$232.50
Rate for Payer: AlohaCare Medicare	$232.50
Rate for Payer: Cash Price	$302.25
Rate for Payer: Devoted Health Medicare	$255.75
Rate for Payer: Hawaii Medical Service Association Medicare	$232.50
Rate for Payer: Hawaii Western Management Group Commercial	$325.50
Rate for Payer: Health Management Network Commercial	$395.25
Rate for Payer: Humana Medicare	$232.50
Rate for Payer: Kaiser Permanente Commercial	$418.50
Rate for Payer: Kaiser Permanente Medicaid	$237.15
Rate for Payer: Kaiser Permanente Medicare	$232.50
Rate for Payer: MDX Hawaii PPO	$451.05
Rate for Payer: Ohana Health Plan Medicaid	$232.50
Rate for Payer: Ohana Health Plan Medicare	$232.50
Rate for Payer: UnitedHealthcare Medicare	$232.50
Rate for Payer: University Health Alliance Commercial	$260.40

MESH, VENTRALEX HERNIA PATCH LARGE

Facility

$2,619.00

Service Code	HCPCS C1781
Hospital Charge Code	8274201
Hospital Revenue Code	278
Min. Negotiated Rate	$1,466.64
Max. Negotiated Rate	$2,540.43
Rate for Payer: Cash Price	$1,702.35
Rate for Payer: Hawaii Western Management Group Commercial	$1,833.30
Rate for Payer: Health Management Network Commercial	$2,226.15
Rate for Payer: Kaiser Permanente Commercial	$2,357.10
Rate for Payer: MDX Hawaii PPO	$2,540.43
Rate for Payer: University Health Alliance Commercial	$1,466.64

MESH, VENTRALEX HERNIA PATCH LARGE

Facility

$2,619.00

Service Code	HCPCS C1781
Hospital Charge Code	8274201
Hospital Revenue Code	278
Min. Negotiated Rate	$1,309.50
Max. Negotiated Rate	$2,540.43
Rate for Payer: AlohaCare Medicaid	$1,309.50
Rate for Payer: AlohaCare Medicare	$1,309.50
Rate for Payer: Cash Price	$1,702.35
Rate for Payer: Devoted Health Medicare	$1,440.45
Rate for Payer: Hawaii Medical Service Association Medicare	$1,309.50
Rate for Payer: Hawaii Western Management Group Commercial	$1,833.30
Rate for Payer: Health Management Network Commercial	$2,226.15
Rate for Payer: Humana Medicare	$1,309.50
Rate for Payer: Kaiser Permanente Commercial	$2,357.10
Rate for Payer: Kaiser Permanente Medicaid	$1,335.69
Rate for Payer: Kaiser Permanente Medicare	$1,309.50
Rate for Payer: MDX Hawaii PPO	$2,540.43
Rate for Payer: Ohana Health Plan Medicaid	$1,309.50
Rate for Payer: Ohana Health Plan Medicare	$1,309.50
Rate for Payer: UnitedHealthcare Medicare	$1,309.50
Rate for Payer: University Health Alliance Commercial	$1,466.64

MESH, VENTRALEX HERNIA PATCH MEDIUM

Facility

$2,178.00

Service Code	HCPCS C1781
Hospital Charge Code	8274202
Hospital Revenue Code	278
Min. Negotiated Rate	$1,219.68
Max. Negotiated Rate	$2,112.66
Rate for Payer: Cash Price	$1,415.70
Rate for Payer: Hawaii Western Management Group Commercial	$1,524.60
Rate for Payer: Health Management Network Commercial	$1,851.30
Rate for Payer: Kaiser Permanente Commercial	$1,960.20
Rate for Payer: MDX Hawaii PPO	$2,112.66
Rate for Payer: University Health Alliance Commercial	$1,219.68

MESH, VENTRALEX HERNIA PATCH MEDIUM

Facility

$2,178.00

Service Code	HCPCS C1781
Hospital Charge Code	8274202
Hospital Revenue Code	278
Min. Negotiated Rate	$1,089.00
Max. Negotiated Rate	$2,112.66
Rate for Payer: AlohaCare Medicaid	$1,089.00
Rate for Payer: AlohaCare Medicare	$1,089.00
Rate for Payer: Cash Price	$1,415.70
Rate for Payer: Devoted Health Medicare	$1,197.90
Rate for Payer: Hawaii Medical Service Association Medicare	$1,089.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,524.60
Rate for Payer: Health Management Network Commercial	$1,851.30
Rate for Payer: Humana Medicare	$1,089.00
Rate for Payer: Kaiser Permanente Commercial	$1,960.20
Rate for Payer: Kaiser Permanente Medicaid	$1,110.78
Rate for Payer: Kaiser Permanente Medicare	$1,089.00
Rate for Payer: MDX Hawaii PPO	$2,112.66
Rate for Payer: Ohana Health Plan Medicaid	$1,089.00
Rate for Payer: Ohana Health Plan Medicare	$1,089.00
Rate for Payer: UnitedHealthcare Medicare	$1,089.00
Rate for Payer: University Health Alliance Commercial	$1,219.68

MESH, VENTRALEX HERNIA PATCH SMALL

Facility

$1,969.00

Service Code	HCPCS C1781
Hospital Charge Code	8274203
Hospital Revenue Code	278
Min. Negotiated Rate	$984.50
Max. Negotiated Rate	$1,909.93
Rate for Payer: AlohaCare Medicaid	$984.50
Rate for Payer: AlohaCare Medicare	$984.50
Rate for Payer: Cash Price	$1,279.85
Rate for Payer: Devoted Health Medicare	$1,082.95
Rate for Payer: Hawaii Medical Service Association Medicare	$984.50
Rate for Payer: Hawaii Western Management Group Commercial	$1,378.30
Rate for Payer: Health Management Network Commercial	$1,673.65
Rate for Payer: Humana Medicare	$984.50
Rate for Payer: Kaiser Permanente Commercial	$1,772.10
Rate for Payer: Kaiser Permanente Medicaid	$1,004.19
Rate for Payer: Kaiser Permanente Medicare	$984.50
Rate for Payer: MDX Hawaii PPO	$1,909.93
Rate for Payer: Ohana Health Plan Medicaid	$984.50
Rate for Payer: Ohana Health Plan Medicare	$984.50
Rate for Payer: UnitedHealthcare Medicare	$984.50
Rate for Payer: University Health Alliance Commercial	$1,102.64

MESH, VENTRALEX HERNIA PATCH SMALL

Facility

$1,969.00

Service Code	HCPCS C1781
Hospital Charge Code	8274203
Hospital Revenue Code	278
Min. Negotiated Rate	$1,102.64
Max. Negotiated Rate	$1,909.93
Rate for Payer: Cash Price	$1,279.85
Rate for Payer: Hawaii Western Management Group Commercial	$1,378.30
Rate for Payer: Health Management Network Commercial	$1,673.65
Rate for Payer: Kaiser Permanente Commercial	$1,772.10
Rate for Payer: MDX Hawaii PPO	$1,909.93
Rate for Payer: University Health Alliance Commercial	$1,102.64

Metanephrines Urine 24 Hour FSI

Facility

$194.00

Service Code	HCPCS 83835
Hospital Charge Code	8117992
Hospital Revenue Code	301
Min. Negotiated Rate	$164.90
Max. Negotiated Rate	$188.18
Rate for Payer: Cash Price	$126.10
Rate for Payer: Health Management Network Commercial	$164.90
Rate for Payer: Kaiser Permanente Commercial	$174.60
Rate for Payer: MDX Hawaii PPO	$188.18

Metanephrines Urine 24 Hour FSI

Facility

$194.00

Service Code	HCPCS 83835
Hospital Charge Code	8117992
Hospital Revenue Code	301
Min. Negotiated Rate	$16.94
Max. Negotiated Rate	$188.18
Rate for Payer: AlohaCare Medicaid	$97.00
Rate for Payer: AlohaCare Medicare	$97.00
Rate for Payer: Cash Price	$126.10
Rate for Payer: Cash Price	$126.10
Rate for Payer: Devoted Health Medicare	$106.70
Rate for Payer: Hawaii Medical Service Association ABD	$23.41
Rate for Payer: Hawaii Medical Service Association Commercial	$21.18
Rate for Payer: Hawaii Medical Service Association Medicare	$97.00
Rate for Payer: Hawaii Medical Service Association Non-ABD	$24.58
Rate for Payer: Hawaii Western Management Group Commercial	$16.94
Rate for Payer: Health Management Network Commercial	$164.90
Rate for Payer: Humana Medicare	$97.00
Rate for Payer: Kaiser Permanente Commercial	$174.60
Rate for Payer: Kaiser Permanente Medicaid	$98.94
Rate for Payer: Kaiser Permanente Medicare	$97.00
Rate for Payer: MDX Hawaii PPO	$188.18
Rate for Payer: Ohana Health Plan Medicaid	$97.00
Rate for Payer: Ohana Health Plan Medicare	$97.00
Rate for Payer: UnitedHealthcare Medicaid	$23.41
Rate for Payer: UnitedHealthcare Medicare	$97.00
Rate for Payer: University Health Alliance Commercial	$43.79

Metanephrines Urine Random FSI

Facility

$194.00

Service Code	HCPCS 83835
Hospital Charge Code	8117993
Hospital Revenue Code	301
Min. Negotiated Rate	$16.94
Max. Negotiated Rate	$188.18
Rate for Payer: AlohaCare Medicaid	$97.00
Rate for Payer: AlohaCare Medicare	$97.00
Rate for Payer: Cash Price	$126.10
Rate for Payer: Cash Price	$126.10
Rate for Payer: Devoted Health Medicare	$106.70
Rate for Payer: Hawaii Medical Service Association ABD	$23.41
Rate for Payer: Hawaii Medical Service Association Commercial	$21.18
Rate for Payer: Hawaii Medical Service Association Medicare	$97.00
Rate for Payer: Hawaii Medical Service Association Non-ABD	$24.58
Rate for Payer: Hawaii Western Management Group Commercial	$16.94
Rate for Payer: Health Management Network Commercial	$164.90
Rate for Payer: Humana Medicare	$97.00
Rate for Payer: Kaiser Permanente Commercial	$174.60
Rate for Payer: Kaiser Permanente Medicaid	$98.94
Rate for Payer: Kaiser Permanente Medicare	$97.00
Rate for Payer: MDX Hawaii PPO	$188.18
Rate for Payer: Ohana Health Plan Medicaid	$97.00
Rate for Payer: Ohana Health Plan Medicare	$97.00
Rate for Payer: UnitedHealthcare Medicaid	$23.41
Rate for Payer: UnitedHealthcare Medicare	$97.00
Rate for Payer: University Health Alliance Commercial	$43.79

Know your out-of-pocket cost for care.

All Charges