Samuel Mahelona Memorial Hospital

All Charges

Charge

Type

Setting

Price

MRSA PCR Surveillance FSI

Facility

$373.00

Service Code	HCPCS 87641
Hospital Charge Code	8228899
Hospital Revenue Code	306
Min. Negotiated Rate	$317.05
Max. Negotiated Rate	$361.81
Rate for Payer: Cash Price	$242.45
Rate for Payer: Health Management Network Commercial	$317.05
Rate for Payer: Kaiser Permanente Commercial	$335.70
Rate for Payer: MDX Hawaii PPO	$361.81

MRSA PCR Surveillance FSI

Facility

$373.00

Service Code	HCPCS 87641
Hospital Charge Code	8228899
Hospital Revenue Code	306
Min. Negotiated Rate	$35.09
Max. Negotiated Rate	$361.81
Rate for Payer: AlohaCare Medicaid	$186.50
Rate for Payer: AlohaCare Medicare	$186.50
Rate for Payer: Cash Price	$242.45
Rate for Payer: Cash Price	$242.45
Rate for Payer: Devoted Health Medicare	$205.15
Rate for Payer: Hawaii Medical Service Association ABD	$49.04
Rate for Payer: Hawaii Medical Service Association Commercial	$43.86
Rate for Payer: Hawaii Medical Service Association Medicare	$186.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$51.49
Rate for Payer: Hawaii Western Management Group Commercial	$35.09
Rate for Payer: Health Management Network Commercial	$317.05
Rate for Payer: Humana Medicare	$186.50
Rate for Payer: Kaiser Permanente Commercial	$335.70
Rate for Payer: Kaiser Permanente Medicaid	$190.23
Rate for Payer: Kaiser Permanente Medicare	$186.50
Rate for Payer: MDX Hawaii PPO	$361.81
Rate for Payer: Ohana Health Plan Medicaid	$186.50
Rate for Payer: Ohana Health Plan Medicare	$186.50
Rate for Payer: UnitedHealthcare Medicaid	$49.04
Rate for Payer: UnitedHealthcare Medicare	$186.50
Rate for Payer: University Health Alliance Commercial	$90.72

MRSA, Rapid Test

Facility

$87.00

Service Code	HCPCS 87147
Hospital Charge Code	12499894
Hospital Revenue Code	306
Min. Negotiated Rate	$73.95
Max. Negotiated Rate	$84.39
Rate for Payer: Cash Price	$56.55
Rate for Payer: Health Management Network Commercial	$73.95
Rate for Payer: Kaiser Permanente Commercial	$78.30
Rate for Payer: MDX Hawaii PPO	$84.39

MRSA, Rapid Test

Facility

$87.00

Service Code	HCPCS 87147
Hospital Charge Code	12499894
Hospital Revenue Code	306
Min. Negotiated Rate	$5.18
Max. Negotiated Rate	$84.39
Rate for Payer: AlohaCare Medicaid	$43.50
Rate for Payer: AlohaCare Medicare	$43.50
Rate for Payer: Cash Price	$56.55
Rate for Payer: Cash Price	$56.55
Rate for Payer: Devoted Health Medicare	$47.85
Rate for Payer: Hawaii Medical Service Association ABD	$7.15
Rate for Payer: Hawaii Medical Service Association Commercial	$6.47
Rate for Payer: Hawaii Medical Service Association Medicare	$43.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$7.51
Rate for Payer: Hawaii Western Management Group Commercial	$5.18
Rate for Payer: Health Management Network Commercial	$73.95
Rate for Payer: Humana Medicare	$43.50
Rate for Payer: Kaiser Permanente Commercial	$78.30
Rate for Payer: Kaiser Permanente Medicaid	$44.37
Rate for Payer: Kaiser Permanente Medicare	$43.50
Rate for Payer: MDX Hawaii PPO	$84.39
Rate for Payer: Ohana Health Plan Medicaid	$43.50
Rate for Payer: Ohana Health Plan Medicare	$43.50
Rate for Payer: UnitedHealthcare Medicaid	$7.15
Rate for Payer: UnitedHealthcare Medicare	$43.50
Rate for Payer: University Health Alliance Commercial	$13.38

MRSA, Rapid Test-Bill Only

Facility

$87.00

Service Code	HCPCS 87147
Hospital Charge Code	12528425
Hospital Revenue Code	306
Min. Negotiated Rate	$5.18
Max. Negotiated Rate	$84.39
Rate for Payer: AlohaCare Medicaid	$43.50
Rate for Payer: AlohaCare Medicare	$43.50
Rate for Payer: Cash Price	$56.55
Rate for Payer: Cash Price	$56.55
Rate for Payer: Devoted Health Medicare	$47.85
Rate for Payer: Hawaii Medical Service Association ABD	$7.15
Rate for Payer: Hawaii Medical Service Association Commercial	$6.47
Rate for Payer: Hawaii Medical Service Association Medicare	$43.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$7.51
Rate for Payer: Hawaii Western Management Group Commercial	$5.18
Rate for Payer: Health Management Network Commercial	$73.95
Rate for Payer: Humana Medicare	$43.50
Rate for Payer: Kaiser Permanente Commercial	$78.30
Rate for Payer: Kaiser Permanente Medicaid	$44.37
Rate for Payer: Kaiser Permanente Medicare	$43.50
Rate for Payer: MDX Hawaii PPO	$84.39
Rate for Payer: Ohana Health Plan Medicaid	$43.50
Rate for Payer: Ohana Health Plan Medicare	$43.50
Rate for Payer: UnitedHealthcare Medicaid	$7.15
Rate for Payer: UnitedHealthcare Medicare	$43.50
Rate for Payer: University Health Alliance Commercial	$13.38

MRSA, Rapid Test-Bill Only

Facility

$87.00

Service Code	HCPCS 87147
Hospital Charge Code	12528425
Hospital Revenue Code	306
Min. Negotiated Rate	$73.95
Max. Negotiated Rate	$84.39
Rate for Payer: Cash Price	$56.55
Rate for Payer: Health Management Network Commercial	$73.95
Rate for Payer: Kaiser Permanente Commercial	$78.30
Rate for Payer: MDX Hawaii PPO	$84.39

MRSA, Rapid Test FSI

Facility

$6.00

Service Code	HCPCS 87147
Hospital Charge Code	13393665
Hospital Revenue Code	306
Min. Negotiated Rate	$5.10
Max. Negotiated Rate	$5.82
Rate for Payer: Cash Price	$3.90
Rate for Payer: Health Management Network Commercial	$5.10
Rate for Payer: Kaiser Permanente Commercial	$5.40
Rate for Payer: MDX Hawaii PPO	$5.82

MRSA, Rapid Test FSI

Facility

$6.00

Service Code	HCPCS 87147
Hospital Charge Code	13393665
Hospital Revenue Code	306
Min. Negotiated Rate	$3.00
Max. Negotiated Rate	$13.38
Rate for Payer: AlohaCare Medicaid	$3.00
Rate for Payer: AlohaCare Medicare	$3.00
Rate for Payer: Cash Price	$3.90
Rate for Payer: Cash Price	$3.90
Rate for Payer: Devoted Health Medicare	$3.30
Rate for Payer: Hawaii Medical Service Association ABD	$7.15
Rate for Payer: Hawaii Medical Service Association Commercial	$6.47
Rate for Payer: Hawaii Medical Service Association Medicare	$3.00
Rate for Payer: Hawaii Medical Service Association Non-ABD	$7.51
Rate for Payer: Hawaii Western Management Group Commercial	$5.18
Rate for Payer: Health Management Network Commercial	$5.10
Rate for Payer: Humana Medicare	$3.00
Rate for Payer: Kaiser Permanente Commercial	$5.40
Rate for Payer: Kaiser Permanente Medicaid	$3.06
Rate for Payer: Kaiser Permanente Medicare	$3.00
Rate for Payer: MDX Hawaii PPO	$5.82
Rate for Payer: Ohana Health Plan Medicaid	$3.00
Rate for Payer: Ohana Health Plan Medicare	$3.00
Rate for Payer: UnitedHealthcare Medicaid	$7.15
Rate for Payer: UnitedHealthcare Medicare	$3.00
Rate for Payer: University Health Alliance Commercial	$13.38

MTHFR Mutation Detection FSI

Facility

$410.00

Service Code	HCPCS 81291
Hospital Charge Code	8117999
Hospital Revenue Code	309
Min. Negotiated Rate	$55.75
Max. Negotiated Rate	$397.70
Rate for Payer: AlohaCare Medicaid	$205.00
Rate for Payer: AlohaCare Medicare	$205.00
Rate for Payer: Cash Price	$266.50
Rate for Payer: Cash Price	$266.50
Rate for Payer: Devoted Health Medicare	$225.50
Rate for Payer: Hawaii Medical Service Association Commercial	$81.67
Rate for Payer: Hawaii Medical Service Association Medicare	$205.00
Rate for Payer: Hawaii Medical Service Association Non-ABD	$58.43
Rate for Payer: Hawaii Western Management Group Commercial	$65.34
Rate for Payer: Health Management Network Commercial	$348.50
Rate for Payer: Humana Medicare	$205.00
Rate for Payer: Kaiser Permanente Commercial	$369.00
Rate for Payer: Kaiser Permanente Medicaid	$209.10
Rate for Payer: Kaiser Permanente Medicare	$205.00
Rate for Payer: MDX Hawaii PPO	$397.70
Rate for Payer: Ohana Health Plan Medicaid	$205.00
Rate for Payer: Ohana Health Plan Medicare	$205.00
Rate for Payer: UnitedHealthcare Medicaid	$55.75
Rate for Payer: UnitedHealthcare Medicare	$205.00
Rate for Payer: University Health Alliance Commercial	$110.17

MTHFR Mutation Detection FSI

Facility

$410.00

Service Code	HCPCS 81291
Hospital Charge Code	8117999
Hospital Revenue Code	309
Min. Negotiated Rate	$348.50
Max. Negotiated Rate	$397.70
Rate for Payer: Cash Price	$266.50
Rate for Payer: Health Management Network Commercial	$348.50
Rate for Payer: Kaiser Permanente Commercial	$369.00
Rate for Payer: MDX Hawaii PPO	$397.70

MULTIFOCAL TORIC LENS

Facility

$1,400.00

Service Code	HCPCS V2632 GY
Hospital Charge Code	8770569
Hospital Revenue Code	276
Min. Negotiated Rate	$311.40
Max. Negotiated Rate	$1,358.00
Rate for Payer: AlohaCare Medicaid	$700.00
Rate for Payer: AlohaCare Medicare	$700.00
Rate for Payer: Cash Price	$910.00
Rate for Payer: Cash Price	$910.00
Rate for Payer: Devoted Health Medicare	$770.00
Rate for Payer: Hawaii Medical Service Association Medicare	$700.00
Rate for Payer: Hawaii Western Management Group Commercial	$980.00
Rate for Payer: Health Management Network Commercial	$1,190.00
Rate for Payer: Humana Medicare	$700.00
Rate for Payer: Kaiser Permanente Commercial	$1,260.00
Rate for Payer: Kaiser Permanente Medicaid	$714.00
Rate for Payer: Kaiser Permanente Medicare	$700.00
Rate for Payer: MDX Hawaii PPO	$1,358.00
Rate for Payer: Ohana Health Plan Medicaid	$700.00
Rate for Payer: Ohana Health Plan Medicare	$700.00
Rate for Payer: UnitedHealthcare Medicaid	$311.40
Rate for Payer: UnitedHealthcare Medicare	$700.00
Rate for Payer: University Health Alliance Commercial	$784.00

MULTIFOCAL TORIC LENS

Facility

$1,400.00

Service Code	HCPCS V2632 GY
Hospital Charge Code	8770569
Hospital Revenue Code	276
Min. Negotiated Rate	$784.00
Max. Negotiated Rate	$1,358.00
Rate for Payer: Cash Price	$910.00
Rate for Payer: Hawaii Western Management Group Commercial	$980.00
Rate for Payer: Health Management Network Commercial	$1,190.00
Rate for Payer: Kaiser Permanente Commercial	$1,260.00
Rate for Payer: MDX Hawaii PPO	$1,358.00
Rate for Payer: University Health Alliance Commercial	$784.00

MULTIPLE LEVEL COMBINED ANTERIOR AND POSTERIOR SPINAL FUSION EXCEPT CERVICAL WITH CC

Facility

$115,594.65

Service Code	MSDRG 427
Min. Negotiated Rate	$115,594.65
Max. Negotiated Rate	$115,594.65
Rate for Payer: Hawaii Medical Service Association Commercial	$115,594.65

MULTIPLE LEVEL COMBINED ANTERIOR AND POSTERIOR SPINAL FUSION EXCEPT CERVICAL WITH MCC OR CUSTOM-MADE ANATOMICALLY DESIGNED INTERBODY FUSION DEVICE

Facility

$115,594.65

Service Code	MSDRG 426
Min. Negotiated Rate	$115,594.65
Max. Negotiated Rate	$115,594.65
Rate for Payer: Hawaii Medical Service Association Commercial	$115,594.65

MULTIPLE LEVEL COMBINED ANTERIOR AND POSTERIOR SPINAL FUSION EXCEPT CERVICAL WITHOUT CC/MCC

Facility

$115,594.65

Service Code	MSDRG 428
Min. Negotiated Rate	$115,594.65
Max. Negotiated Rate	$115,594.65
Rate for Payer: Hawaii Medical Service Association Commercial	$115,594.65

MULTIPLE LEVEL SPINAL FUSION EXCEPT CERVICAL WITH MCC OR CUSTOM-MADE ANATOMICALLY DESIGNED INTERBODY FUSION DEVICE

Facility

$84,260.61

Service Code	MSDRG 447
Min. Negotiated Rate	$84,260.61
Max. Negotiated Rate	$84,260.61
Rate for Payer: Hawaii Medical Service Association Commercial	$84,260.61

MULTIPLE LEVEL SPINAL FUSION EXCEPT CERVICAL WITHOUT MCC

Facility

$79,283.19

Service Code	MSDRG 448
Min. Negotiated Rate	$79,283.19
Max. Negotiated Rate	$79,283.19
Rate for Payer: Hawaii Medical Service Association Commercial	$79,283.19

MULTIPLE SCLEROSIS AND CEREBELLAR ATAXIA WITH CC

Facility

$20,170.40

Service Code	MSDRG 059
Min. Negotiated Rate	$20,170.40
Max. Negotiated Rate	$20,170.40
Rate for Payer: Hawaii Medical Service Association Commercial	$20,170.40

MULTIPLE SCLEROSIS AND CEREBELLAR ATAXIA WITH MCC

Facility

$20,170.40

Service Code	MSDRG 058
Min. Negotiated Rate	$20,170.40
Max. Negotiated Rate	$20,170.40
Rate for Payer: Hawaii Medical Service Association Commercial	$20,170.40

MULTIPLE SCLEROSIS AND CEREBELLAR ATAXIA WITHOUT CC/MCC

Facility

$20,170.40

Service Code	MSDRG 060
Min. Negotiated Rate	$20,170.40
Max. Negotiated Rate	$20,170.40
Rate for Payer: Hawaii Medical Service Association Commercial	$20,170.40

multivitamin tablet [HHSC]

Facility

$3.00

Service Code	NDC 00904053961
Hospital Charge Code	2500818
Hospital Revenue Code	250
Min. Negotiated Rate	$2.55
Max. Negotiated Rate	$2.91
Rate for Payer: Cash Price	$1.95
Rate for Payer: Health Management Network Commercial	$2.55
Rate for Payer: Kaiser Permanente Commercial	$2.70
Rate for Payer: MDX Hawaii PPO	$2.91

multivitamin tablet [HHSC]

Facility

$3.00

Service Code	NDC 00904053961
Hospital Charge Code	2500818
Hospital Revenue Code	250
Min. Negotiated Rate	$1.50
Max. Negotiated Rate	$2.91
Rate for Payer: AlohaCare Medicaid	$1.50
Rate for Payer: AlohaCare Medicare	$1.50
Rate for Payer: Cash Price	$1.95
Rate for Payer: Devoted Health Medicare	$1.65
Rate for Payer: Hawaii Medical Service Association Medicare	$1.50
Rate for Payer: Hawaii Western Management Group Commercial	$2.85
Rate for Payer: Health Management Network Commercial	$2.55
Rate for Payer: Humana Medicare	$1.50
Rate for Payer: Kaiser Permanente Commercial	$2.70
Rate for Payer: Kaiser Permanente Medicaid	$1.53
Rate for Payer: Kaiser Permanente Medicare	$1.50
Rate for Payer: MDX Hawaii PPO	$2.91
Rate for Payer: Ohana Health Plan Medicaid	$1.50
Rate for Payer: Ohana Health Plan Medicare	$1.50
Rate for Payer: UnitedHealthcare Medicaid	$1.80
Rate for Payer: UnitedHealthcare Medicare	$1.50
Rate for Payer: University Health Alliance Commercial	$2.19

multivitamin with minerals tablet [HHSC]

Facility

$3.00

Service Code	NDC 00904549261
Hospital Charge Code	2500819
Hospital Revenue Code	250
Min. Negotiated Rate	$2.55
Max. Negotiated Rate	$2.91
Rate for Payer: Cash Price	$1.95
Rate for Payer: Health Management Network Commercial	$2.55
Rate for Payer: Kaiser Permanente Commercial	$2.70
Rate for Payer: MDX Hawaii PPO	$2.91

multivitamin with minerals tablet [HHSC]

Facility

$3.00

Service Code	NDC 00536466110
Hospital Charge Code	2500819
Hospital Revenue Code	250
Min. Negotiated Rate	$2.55
Max. Negotiated Rate	$2.91
Rate for Payer: Cash Price	$1.95
Rate for Payer: Health Management Network Commercial	$2.55
Rate for Payer: Kaiser Permanente Commercial	$2.70
Rate for Payer: MDX Hawaii PPO	$2.91

multivitamin with minerals tablet [HHSC]

Facility

$3.00

Service Code	NDC 40985022368
Hospital Charge Code	2500819
Hospital Revenue Code	250
Min. Negotiated Rate	$1.50
Max. Negotiated Rate	$2.91
Rate for Payer: AlohaCare Medicaid	$1.50
Rate for Payer: AlohaCare Medicare	$1.50
Rate for Payer: Cash Price	$1.95
Rate for Payer: Devoted Health Medicare	$1.65
Rate for Payer: Hawaii Medical Service Association Medicare	$1.50
Rate for Payer: Hawaii Western Management Group Commercial	$2.85
Rate for Payer: Health Management Network Commercial	$2.55
Rate for Payer: Humana Medicare	$1.50
Rate for Payer: Kaiser Permanente Commercial	$2.70
Rate for Payer: Kaiser Permanente Medicaid	$1.53
Rate for Payer: Kaiser Permanente Medicare	$1.50
Rate for Payer: MDX Hawaii PPO	$2.91
Rate for Payer: Ohana Health Plan Medicaid	$1.50
Rate for Payer: Ohana Health Plan Medicare	$1.50
Rate for Payer: UnitedHealthcare Medicaid	$1.80
Rate for Payer: UnitedHealthcare Medicare	$1.50
Rate for Payer: University Health Alliance Commercial	$2.19

Know your out-of-pocket cost for care.

All Charges