Samuel Mahelona Memorial Hospital

All Charges

Charge

Type

Setting

Price

MRI LE Joint w/o Contrast Right - Report

Professional

Both

$332.00

Service Code	HCPCS 73721 26,RT
Hospital Charge Code	8211754
Hospital Revenue Code	972
Min. Negotiated Rate	$138.35
Max. Negotiated Rate	$565.39
Rate for Payer: AlohaCare Medicaid	$138.35
Rate for Payer: Cash Price	$215.80
Rate for Payer: Cash Price	$215.80
Rate for Payer: Hawaii Western Management Group Commercial	$565.39
Rate for Payer: Health Management Network Commercial	$282.20
Rate for Payer: Ohana Health Plan Medicaid	$138.35
Rate for Payer: UnitedHealthcare Medicaid	$138.35

MRI LE Joint w/ + w/o Contrast Lt

Facility

$2,934.00

Service Code	HCPCS 73723 LT
Hospital Charge Code	8110601
Hospital Revenue Code	610
Min. Negotiated Rate	$2,493.90
Max. Negotiated Rate	$2,845.98
Rate for Payer: Cash Price	$1,907.10
Rate for Payer: Health Management Network Commercial	$2,493.90
Rate for Payer: Kaiser Permanente Commercial	$2,640.60
Rate for Payer: MDX Hawaii PPO	$2,845.98

MRI LE Joint w/ + w/o Contrast Lt

Facility

$2,934.00

Service Code	HCPCS 73723 LT
Hospital Charge Code	8110601
Hospital Revenue Code	610
Min. Negotiated Rate	$707.76
Max. Negotiated Rate	$2,845.98
Rate for Payer: AlohaCare Medicaid	$1,467.00
Rate for Payer: AlohaCare Medicare	$1,467.00
Rate for Payer: Cash Price	$1,907.10
Rate for Payer: Cash Price	$1,907.10
Rate for Payer: Devoted Health Medicare	$1,613.70
Rate for Payer: Hawaii Medical Service Association ABD	$707.76
Rate for Payer: Hawaii Medical Service Association Medicare	$1,467.00
Rate for Payer: Hawaii Medical Service Association Non-ABD	$880.75
Rate for Payer: Hawaii Western Management Group Commercial	$2,787.30
Rate for Payer: Health Management Network Commercial	$2,493.90
Rate for Payer: Humana Medicare	$1,467.00
Rate for Payer: Kaiser Permanente Commercial	$2,640.60
Rate for Payer: Kaiser Permanente Medicaid	$1,496.34
Rate for Payer: Kaiser Permanente Medicare	$1,467.00
Rate for Payer: MDX Hawaii PPO	$2,845.98
Rate for Payer: Ohana Health Plan Medicaid	$1,467.00
Rate for Payer: Ohana Health Plan Medicare	$1,467.00
Rate for Payer: UnitedHealthcare Medicaid	$707.76
Rate for Payer: UnitedHealthcare Medicare	$1,467.00
Rate for Payer: University Health Alliance Commercial	$1,286.32

MRI LE Joint w/ + w/o Contrast Lt - Report

Professional

Both

$543.00

Service Code	HCPCS 73723 26,LT
Hospital Charge Code	8110603
Hospital Revenue Code	972
Min. Negotiated Rate	$265.04
Max. Negotiated Rate	$1,201.84
Rate for Payer: AlohaCare Medicaid	$265.04
Rate for Payer: Cash Price	$352.95
Rate for Payer: Cash Price	$352.95
Rate for Payer: Hawaii Western Management Group Commercial	$1,201.84
Rate for Payer: Health Management Network Commercial	$461.55
Rate for Payer: Ohana Health Plan Medicaid	$265.04
Rate for Payer: UnitedHealthcare Medicaid	$265.04

MRI LE Joint w/ + w/o Contrast Rt

Facility

$2,934.00

Service Code	HCPCS 73723 RT
Hospital Charge Code	8110604
Hospital Revenue Code	610
Min. Negotiated Rate	$2,493.90
Max. Negotiated Rate	$2,845.98
Rate for Payer: Cash Price	$1,907.10
Rate for Payer: Health Management Network Commercial	$2,493.90
Rate for Payer: Kaiser Permanente Commercial	$2,640.60
Rate for Payer: MDX Hawaii PPO	$2,845.98

MRI LE Joint w/ + w/o Contrast Rt

Facility

$2,934.00

Service Code	HCPCS 73723 RT
Hospital Charge Code	8110604
Hospital Revenue Code	610
Min. Negotiated Rate	$707.76
Max. Negotiated Rate	$2,845.98
Rate for Payer: AlohaCare Medicaid	$1,467.00
Rate for Payer: AlohaCare Medicare	$1,467.00
Rate for Payer: Cash Price	$1,907.10
Rate for Payer: Cash Price	$1,907.10
Rate for Payer: Devoted Health Medicare	$1,613.70
Rate for Payer: Hawaii Medical Service Association ABD	$707.76
Rate for Payer: Hawaii Medical Service Association Medicare	$1,467.00
Rate for Payer: Hawaii Medical Service Association Non-ABD	$880.75
Rate for Payer: Hawaii Western Management Group Commercial	$2,787.30
Rate for Payer: Health Management Network Commercial	$2,493.90
Rate for Payer: Humana Medicare	$1,467.00
Rate for Payer: Kaiser Permanente Commercial	$2,640.60
Rate for Payer: Kaiser Permanente Medicaid	$1,496.34
Rate for Payer: Kaiser Permanente Medicare	$1,467.00
Rate for Payer: MDX Hawaii PPO	$2,845.98
Rate for Payer: Ohana Health Plan Medicaid	$1,467.00
Rate for Payer: Ohana Health Plan Medicare	$1,467.00
Rate for Payer: UnitedHealthcare Medicaid	$707.76
Rate for Payer: UnitedHealthcare Medicare	$1,467.00
Rate for Payer: University Health Alliance Commercial	$1,286.32

MRI LE Joint w/ + w/o Contrast Rt - Report

Professional

Both

$543.00

Service Code	HCPCS 73723 26,RT
Hospital Charge Code	8110606
Hospital Revenue Code	972
Min. Negotiated Rate	$265.04
Max. Negotiated Rate	$1,201.84
Rate for Payer: AlohaCare Medicaid	$265.04
Rate for Payer: Cash Price	$352.95
Rate for Payer: Cash Price	$352.95
Rate for Payer: Hawaii Western Management Group Commercial	$1,201.84
Rate for Payer: Health Management Network Commercial	$461.55
Rate for Payer: Ohana Health Plan Medicaid	$265.04
Rate for Payer: UnitedHealthcare Medicaid	$265.04

MRI LE Non Joint w/ Contrast Lt

Facility

$2,465.00

Service Code	HCPCS 73719 LT
Hospital Charge Code	1169014
Hospital Revenue Code	610
Min. Negotiated Rate	$2,095.25
Max. Negotiated Rate	$2,391.05
Rate for Payer: Cash Price	$1,602.25
Rate for Payer: Health Management Network Commercial	$2,095.25
Rate for Payer: Kaiser Permanente Commercial	$2,218.50
Rate for Payer: MDX Hawaii PPO	$2,391.05

MRI LE Non Joint w/ Contrast Lt

Facility

$2,465.00

Service Code	HCPCS 73719 LT
Hospital Charge Code	1169014
Hospital Revenue Code	610
Min. Negotiated Rate	$382.28
Max. Negotiated Rate	$2,391.05
Rate for Payer: AlohaCare Medicaid	$1,232.50
Rate for Payer: AlohaCare Medicare	$1,232.50
Rate for Payer: Cash Price	$1,602.25
Rate for Payer: Cash Price	$1,602.25
Rate for Payer: Devoted Health Medicare	$1,355.75
Rate for Payer: Hawaii Medical Service Association ABD	$382.28
Rate for Payer: Hawaii Medical Service Association Medicare	$1,232.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$475.88
Rate for Payer: Hawaii Western Management Group Commercial	$2,341.75
Rate for Payer: Health Management Network Commercial	$2,095.25
Rate for Payer: Humana Medicare	$1,232.50
Rate for Payer: Kaiser Permanente Commercial	$2,218.50
Rate for Payer: Kaiser Permanente Medicaid	$1,257.15
Rate for Payer: Kaiser Permanente Medicare	$1,232.50
Rate for Payer: MDX Hawaii PPO	$2,391.05
Rate for Payer: Ohana Health Plan Medicaid	$1,232.50
Rate for Payer: Ohana Health Plan Medicare	$1,232.50
Rate for Payer: UnitedHealthcare Medicaid	$382.28
Rate for Payer: UnitedHealthcare Medicare	$1,232.50
Rate for Payer: University Health Alliance Commercial	$974.25

MRI LE Non Joint w/ Contrast Lt - Report

Professional

Both

$486.00

Service Code	HCPCS 73719 26,LT
Hospital Charge Code	631177
Hospital Revenue Code	972
Min. Negotiated Rate	$180.23
Max. Negotiated Rate	$666.83
Rate for Payer: AlohaCare Medicaid	$180.23
Rate for Payer: Cash Price	$315.90
Rate for Payer: Cash Price	$315.90
Rate for Payer: Hawaii Western Management Group Commercial	$666.83
Rate for Payer: Health Management Network Commercial	$413.10
Rate for Payer: Ohana Health Plan Medicaid	$180.23
Rate for Payer: UnitedHealthcare Medicaid	$180.23

MRI LE Non Joint w/ Contrast Rt

Facility

$2,465.00

Service Code	HCPCS 73719 RT
Hospital Charge Code	631179
Hospital Revenue Code	610
Min. Negotiated Rate	$382.28
Max. Negotiated Rate	$2,391.05
Rate for Payer: AlohaCare Medicaid	$1,232.50
Rate for Payer: AlohaCare Medicare	$1,232.50
Rate for Payer: Cash Price	$1,602.25
Rate for Payer: Cash Price	$1,602.25
Rate for Payer: Devoted Health Medicare	$1,355.75
Rate for Payer: Hawaii Medical Service Association ABD	$382.28
Rate for Payer: Hawaii Medical Service Association Medicare	$1,232.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$475.88
Rate for Payer: Hawaii Western Management Group Commercial	$2,341.75
Rate for Payer: Health Management Network Commercial	$2,095.25
Rate for Payer: Humana Medicare	$1,232.50
Rate for Payer: Kaiser Permanente Commercial	$2,218.50
Rate for Payer: Kaiser Permanente Medicaid	$1,257.15
Rate for Payer: Kaiser Permanente Medicare	$1,232.50
Rate for Payer: MDX Hawaii PPO	$2,391.05
Rate for Payer: Ohana Health Plan Medicaid	$1,232.50
Rate for Payer: Ohana Health Plan Medicare	$1,232.50
Rate for Payer: UnitedHealthcare Medicaid	$382.28
Rate for Payer: UnitedHealthcare Medicare	$1,232.50
Rate for Payer: University Health Alliance Commercial	$974.25

MRI LE Non Joint w/ Contrast Rt

Facility

$2,465.00

Service Code	HCPCS 73719 RT
Hospital Charge Code	631179
Hospital Revenue Code	610
Min. Negotiated Rate	$2,095.25
Max. Negotiated Rate	$2,391.05
Rate for Payer: Cash Price	$1,602.25
Rate for Payer: Health Management Network Commercial	$2,095.25
Rate for Payer: Kaiser Permanente Commercial	$2,218.50
Rate for Payer: MDX Hawaii PPO	$2,391.05

MRI LE Non Joint w/ Contrast Rt

Facility

$2,465.00

Service Code	HCPCS 73719 RT
Hospital Charge Code	1169016
Hospital Revenue Code	610
Min. Negotiated Rate	$2,095.25
Max. Negotiated Rate	$2,391.05
Rate for Payer: Cash Price	$1,602.25
Rate for Payer: Health Management Network Commercial	$2,095.25
Rate for Payer: Kaiser Permanente Commercial	$2,218.50
Rate for Payer: MDX Hawaii PPO	$2,391.05

MRI LE Non Joint w/ Contrast Rt

Facility

$2,465.00

Service Code	HCPCS 73719 RT
Hospital Charge Code	1169016
Hospital Revenue Code	610
Min. Negotiated Rate	$382.28
Max. Negotiated Rate	$2,391.05
Rate for Payer: AlohaCare Medicaid	$1,232.50
Rate for Payer: AlohaCare Medicare	$1,232.50
Rate for Payer: Cash Price	$1,602.25
Rate for Payer: Cash Price	$1,602.25
Rate for Payer: Devoted Health Medicare	$1,355.75
Rate for Payer: Hawaii Medical Service Association ABD	$382.28
Rate for Payer: Hawaii Medical Service Association Medicare	$1,232.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$475.88
Rate for Payer: Hawaii Western Management Group Commercial	$2,341.75
Rate for Payer: Health Management Network Commercial	$2,095.25
Rate for Payer: Humana Medicare	$1,232.50
Rate for Payer: Kaiser Permanente Commercial	$2,218.50
Rate for Payer: Kaiser Permanente Medicaid	$1,257.15
Rate for Payer: Kaiser Permanente Medicare	$1,232.50
Rate for Payer: MDX Hawaii PPO	$2,391.05
Rate for Payer: Ohana Health Plan Medicaid	$1,232.50
Rate for Payer: Ohana Health Plan Medicare	$1,232.50
Rate for Payer: UnitedHealthcare Medicaid	$382.28
Rate for Payer: UnitedHealthcare Medicare	$1,232.50
Rate for Payer: University Health Alliance Commercial	$974.25

MRI LE Non Joint w/ Contrast Rt - Report

Professional

Both

$486.00

Service Code	HCPCS 73719 26,RT
Hospital Charge Code	631180
Hospital Revenue Code	972
Min. Negotiated Rate	$180.23
Max. Negotiated Rate	$666.83
Rate for Payer: AlohaCare Medicaid	$180.23
Rate for Payer: Cash Price	$315.90
Rate for Payer: Cash Price	$315.90
Rate for Payer: Hawaii Western Management Group Commercial	$666.83
Rate for Payer: Health Management Network Commercial	$413.10
Rate for Payer: Ohana Health Plan Medicaid	$180.23
Rate for Payer: UnitedHealthcare Medicaid	$180.23

MRI LE Non Joint w/o Contrast Lt

Facility

$2,322.00

Service Code	HCPCS 73718 LT
Hospital Charge Code	1169020
Hospital Revenue Code	610
Min. Negotiated Rate	$318.66
Max. Negotiated Rate	$2,252.34
Rate for Payer: AlohaCare Medicaid	$1,161.00
Rate for Payer: AlohaCare Medicare	$1,161.00
Rate for Payer: Cash Price	$1,509.30
Rate for Payer: Cash Price	$1,509.30
Rate for Payer: Devoted Health Medicare	$1,277.10
Rate for Payer: Hawaii Medical Service Association ABD	$318.66
Rate for Payer: Hawaii Medical Service Association Medicare	$1,161.00
Rate for Payer: Hawaii Medical Service Association Non-ABD	$396.79
Rate for Payer: Hawaii Western Management Group Commercial	$2,205.90
Rate for Payer: Health Management Network Commercial	$1,973.70
Rate for Payer: Humana Medicare	$1,161.00
Rate for Payer: Kaiser Permanente Commercial	$2,089.80
Rate for Payer: Kaiser Permanente Medicaid	$1,184.22
Rate for Payer: Kaiser Permanente Medicare	$1,161.00
Rate for Payer: MDX Hawaii PPO	$2,252.34
Rate for Payer: Ohana Health Plan Medicaid	$1,161.00
Rate for Payer: Ohana Health Plan Medicare	$1,161.00
Rate for Payer: UnitedHealthcare Medicaid	$318.66
Rate for Payer: UnitedHealthcare Medicare	$1,161.00
Rate for Payer: University Health Alliance Commercial	$837.87

MRI LE Non Joint w/o Contrast Lt

Facility

$2,322.00

Service Code	HCPCS 73718 LT
Hospital Charge Code	1169020
Hospital Revenue Code	610
Min. Negotiated Rate	$1,973.70
Max. Negotiated Rate	$2,252.34
Rate for Payer: Cash Price	$1,509.30
Rate for Payer: Health Management Network Commercial	$1,973.70
Rate for Payer: Kaiser Permanente Commercial	$2,089.80
Rate for Payer: MDX Hawaii PPO	$2,252.34

MRI LE Non Joint w/o Contrast Lt - Report

Professional

Both

$314.00

Service Code	HCPCS 73718 26,LT
Hospital Charge Code	631191
Hospital Revenue Code	972
Min. Negotiated Rate	$153.04
Max. Negotiated Rate	$556.53
Rate for Payer: AlohaCare Medicaid	$153.04
Rate for Payer: Cash Price	$204.10
Rate for Payer: Cash Price	$204.10
Rate for Payer: Hawaii Western Management Group Commercial	$556.53
Rate for Payer: Health Management Network Commercial	$266.90
Rate for Payer: Ohana Health Plan Medicaid	$153.04
Rate for Payer: UnitedHealthcare Medicaid	$153.04

MRI LE Non Joint w/o Contrast Rt

Facility

$2,427.00

Service Code	HCPCS 73718 RT
Hospital Charge Code	1169022
Hospital Revenue Code	610
Min. Negotiated Rate	$318.66
Max. Negotiated Rate	$2,354.19
Rate for Payer: AlohaCare Medicaid	$1,213.50
Rate for Payer: AlohaCare Medicare	$1,213.50
Rate for Payer: Cash Price	$1,577.55
Rate for Payer: Cash Price	$1,577.55
Rate for Payer: Devoted Health Medicare	$1,334.85
Rate for Payer: Hawaii Medical Service Association ABD	$318.66
Rate for Payer: Hawaii Medical Service Association Medicare	$1,213.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$396.79
Rate for Payer: Hawaii Western Management Group Commercial	$2,305.65
Rate for Payer: Health Management Network Commercial	$2,062.95
Rate for Payer: Humana Medicare	$1,213.50
Rate for Payer: Kaiser Permanente Commercial	$2,184.30
Rate for Payer: Kaiser Permanente Medicaid	$1,237.77
Rate for Payer: Kaiser Permanente Medicare	$1,213.50
Rate for Payer: MDX Hawaii PPO	$2,354.19
Rate for Payer: Ohana Health Plan Medicaid	$1,213.50
Rate for Payer: Ohana Health Plan Medicare	$1,213.50
Rate for Payer: UnitedHealthcare Medicaid	$318.66
Rate for Payer: UnitedHealthcare Medicare	$1,213.50
Rate for Payer: University Health Alliance Commercial	$837.87

MRI LE Non Joint w/o Contrast Rt

Facility

$2,427.00

Service Code	HCPCS 73718 RT
Hospital Charge Code	1169022
Hospital Revenue Code	610
Min. Negotiated Rate	$2,062.95
Max. Negotiated Rate	$2,354.19
Rate for Payer: Cash Price	$1,577.55
Rate for Payer: Health Management Network Commercial	$2,062.95
Rate for Payer: Kaiser Permanente Commercial	$2,184.30
Rate for Payer: MDX Hawaii PPO	$2,354.19

MRI LE Non Joint w/o Contrast Rt - Report

Professional

Both

$314.00

Service Code	HCPCS 73718 26,RT
Hospital Charge Code	631196
Hospital Revenue Code	972
Min. Negotiated Rate	$153.04
Max. Negotiated Rate	$556.53
Rate for Payer: AlohaCare Medicaid	$153.04
Rate for Payer: Cash Price	$204.10
Rate for Payer: Cash Price	$204.10
Rate for Payer: Hawaii Western Management Group Commercial	$556.53
Rate for Payer: Health Management Network Commercial	$266.90
Rate for Payer: Ohana Health Plan Medicaid	$153.04
Rate for Payer: UnitedHealthcare Medicaid	$153.04

MRI LE Non Joint w/ + w/o Contrast Lt

Facility

$2,524.00

Service Code	HCPCS 73720 LT
Hospital Charge Code	1169008
Hospital Revenue Code	610
Min. Negotiated Rate	$2,145.40
Max. Negotiated Rate	$2,448.28
Rate for Payer: Cash Price	$1,640.60
Rate for Payer: Health Management Network Commercial	$2,145.40
Rate for Payer: Kaiser Permanente Commercial	$2,271.60
Rate for Payer: MDX Hawaii PPO	$2,448.28

MRI LE Non Joint w/ + w/o Contrast Lt

Facility

$2,524.00

Service Code	HCPCS 73720 LT
Hospital Charge Code	1169008
Hospital Revenue Code	610
Min. Negotiated Rate	$645.58
Max. Negotiated Rate	$2,448.28
Rate for Payer: AlohaCare Medicaid	$1,262.00
Rate for Payer: AlohaCare Medicare	$1,262.00
Rate for Payer: Cash Price	$1,640.60
Rate for Payer: Cash Price	$1,640.60
Rate for Payer: Devoted Health Medicare	$1,388.20
Rate for Payer: Hawaii Medical Service Association ABD	$645.58
Rate for Payer: Hawaii Medical Service Association Medicare	$1,262.00
Rate for Payer: Hawaii Medical Service Association Non-ABD	$880.75
Rate for Payer: Hawaii Western Management Group Commercial	$2,397.80
Rate for Payer: Health Management Network Commercial	$2,145.40
Rate for Payer: Humana Medicare	$1,262.00
Rate for Payer: Kaiser Permanente Commercial	$2,271.60
Rate for Payer: Kaiser Permanente Medicaid	$1,287.24
Rate for Payer: Kaiser Permanente Medicare	$1,262.00
Rate for Payer: MDX Hawaii PPO	$2,448.28
Rate for Payer: Ohana Health Plan Medicaid	$1,262.00
Rate for Payer: Ohana Health Plan Medicare	$1,262.00
Rate for Payer: UnitedHealthcare Medicaid	$645.58
Rate for Payer: UnitedHealthcare Medicare	$1,262.00
Rate for Payer: University Health Alliance Commercial	$1,285.82

MRI LE Non Joint w/ + w/o Contrast Lt - Report

Professional

Both

$473.00

Service Code	HCPCS 73720 26,LT
Hospital Charge Code	631160
Hospital Revenue Code	972
Min. Negotiated Rate	$230.62
Max. Negotiated Rate	$574.00
Rate for Payer: AlohaCare Medicaid	$230.62
Rate for Payer: Cash Price	$307.45
Rate for Payer: Cash Price	$307.45
Rate for Payer: Hawaii Western Management Group Commercial	$574.00
Rate for Payer: Health Management Network Commercial	$402.05
Rate for Payer: Ohana Health Plan Medicaid	$230.62
Rate for Payer: UnitedHealthcare Medicaid	$230.62

MRI LE Non Joint w/ + w/o Contrast Rt

Facility

$2,524.00

Service Code	HCPCS 73720 RT
Hospital Charge Code	1169010
Hospital Revenue Code	610
Min. Negotiated Rate	$2,145.40
Max. Negotiated Rate	$2,448.28
Rate for Payer: Cash Price	$1,640.60
Rate for Payer: Health Management Network Commercial	$2,145.40
Rate for Payer: Kaiser Permanente Commercial	$2,271.60
Rate for Payer: MDX Hawaii PPO	$2,448.28

Know your out-of-pocket cost for care.

All Charges