Samuel Mahelona Memorial Hospital

All Charges

Charge

Type

Setting

Price

OTHER O.R. PROCEDURES FOR MULTIPLE SIGNIFICANT TRAUMA WITH MCC

Facility

$152,759.39

Service Code	MSDRG 957
Min. Negotiated Rate	$152,759.39
Max. Negotiated Rate	$152,759.39
Rate for Payer: Hawaii Medical Service Association Commercial	$152,759.39

OTHER O.R. PROCEDURES FOR MULTIPLE SIGNIFICANT TRAUMA WITHOUT CC/MCC

Facility

$152,759.39

Service Code	MSDRG 959
Min. Negotiated Rate	$152,759.39
Max. Negotiated Rate	$152,759.39
Rate for Payer: Hawaii Medical Service Association Commercial	$152,759.39

OTHER O.R. PROCEDURES OF THE BLOOD AND BLOOD FORMING ORGANS WITH CC

Facility

$42,260.67

Service Code	MSDRG 803
Min. Negotiated Rate	$42,260.67
Max. Negotiated Rate	$42,260.67
Rate for Payer: Hawaii Medical Service Association Commercial	$42,260.67

OTHER O.R. PROCEDURES OF THE BLOOD AND BLOOD FORMING ORGANS WITH MCC

Facility

$42,260.67

Service Code	MSDRG 802
Min. Negotiated Rate	$42,260.67
Max. Negotiated Rate	$42,260.67
Rate for Payer: Hawaii Medical Service Association Commercial	$42,260.67

OTHER O.R. PROCEDURES OF THE BLOOD AND BLOOD FORMING ORGANS WITHOUT CC/MCC

Facility

$42,260.67

Service Code	MSDRG 804
Min. Negotiated Rate	$42,260.67
Max. Negotiated Rate	$42,260.67
Rate for Payer: Hawaii Medical Service Association Commercial	$42,260.67

OTHER RESPIRATORY SYSTEM DIAGNOSES WITH MCC

Facility

$20,454.83

Service Code	MSDRG 205
Min. Negotiated Rate	$20,454.83
Max. Negotiated Rate	$20,454.83
Rate for Payer: Hawaii Medical Service Association Commercial	$20,454.83

OTHER RESPIRATORY SYSTEM DIAGNOSES WITHOUT MCC

Facility

$17,634.29

Service Code	MSDRG 206
Min. Negotiated Rate	$17,634.29
Max. Negotiated Rate	$17,634.29
Rate for Payer: Hawaii Medical Service Association Commercial	$17,634.29

OTHER RESPIRATORY SYSTEM O.R. PROCEDURES WITH CC

Facility

$60,511.21

Service Code	MSDRG 167
Min. Negotiated Rate	$60,511.21
Max. Negotiated Rate	$60,511.21
Rate for Payer: Hawaii Medical Service Association Commercial	$60,511.21

OTHER RESPIRATORY SYSTEM O.R. PROCEDURES WITH MCC

Facility

$63,497.66

Service Code	MSDRG 166
Min. Negotiated Rate	$63,497.66
Max. Negotiated Rate	$63,497.66
Rate for Payer: Hawaii Medical Service Association Commercial	$63,497.66

OTHER RESPIRATORY SYSTEM O.R. PROCEDURES WITHOUT CC/MCC

Facility

$43,232.45

Service Code	MSDRG 168
Min. Negotiated Rate	$43,232.45
Max. Negotiated Rate	$43,232.45
Rate for Payer: Hawaii Medical Service Association Commercial	$43,232.45

OTHER SKIN, SUBCUTANEOUS TISSUE AND BREAST PROCEDURES WITH CC

Facility

$29,295.67

Service Code	MSDRG 580
Min. Negotiated Rate	$29,295.67
Max. Negotiated Rate	$29,295.67
Rate for Payer: Hawaii Medical Service Association Commercial	$29,295.67

OTHER SKIN, SUBCUTANEOUS TISSUE AND BREAST PROCEDURES WITH MCC

Facility

$46,811.45

Service Code	MSDRG 579
Min. Negotiated Rate	$46,811.45
Max. Negotiated Rate	$46,811.45
Rate for Payer: Hawaii Medical Service Association Commercial	$46,811.45

OTHER SKIN, SUBCUTANEOUS TISSUE AND BREAST PROCEDURES WITHOUT CC/MCC

Facility

$24,057.53

Service Code	MSDRG 581
Min. Negotiated Rate	$24,057.53
Max. Negotiated Rate	$24,057.53
Rate for Payer: Hawaii Medical Service Association Commercial	$24,057.53

Other Thermal Charge

Facility

$95.00

Service Code	HCPCS 97010 GP,CQ
Hospital Charge Code	8111704
Hospital Revenue Code	420
Min. Negotiated Rate	$80.75
Max. Negotiated Rate	$92.15
Rate for Payer: Cash Price	$61.75
Rate for Payer: Health Management Network Commercial	$80.75
Rate for Payer: Kaiser Permanente Commercial	$85.50
Rate for Payer: MDX Hawaii PPO	$92.15

Other Thermal Charge

Facility

$95.00

Service Code	HCPCS 97010 GP,CQ
Hospital Charge Code	8111704
Hospital Revenue Code	420
Min. Negotiated Rate	$10.08
Max. Negotiated Rate	$92.15
Rate for Payer: AlohaCare Medicaid	$47.50
Rate for Payer: AlohaCare Medicare	$47.50
Rate for Payer: Cash Price	$61.75
Rate for Payer: Cash Price	$61.75
Rate for Payer: Devoted Health Medicare	$52.25
Rate for Payer: Hawaii Medical Service Association Medicare	$47.50
Rate for Payer: Hawaii Western Management Group Commercial	$90.25
Rate for Payer: Health Management Network Commercial	$80.75
Rate for Payer: Humana Medicare	$47.50
Rate for Payer: Kaiser Permanente Commercial	$85.50
Rate for Payer: Kaiser Permanente Medicaid	$48.45
Rate for Payer: Kaiser Permanente Medicare	$47.50
Rate for Payer: MDX Hawaii PPO	$92.15
Rate for Payer: Ohana Health Plan Medicaid	$47.50
Rate for Payer: Ohana Health Plan Medicare	$47.50
Rate for Payer: UnitedHealthcare Medicaid	$10.08
Rate for Payer: UnitedHealthcare Medicare	$47.50
Rate for Payer: University Health Alliance Commercial	$53.20

OTHER VASCULAR PROCEDURES WITH CC

Facility

$67,550.70

Service Code	MSDRG 253
Min. Negotiated Rate	$67,550.70
Max. Negotiated Rate	$67,550.70
Rate for Payer: Hawaii Medical Service Association Commercial	$67,550.70

OTHER VASCULAR PROCEDURES WITH MCC

Facility

$71,911.87

Service Code	MSDRG 252
Min. Negotiated Rate	$71,911.87
Max. Negotiated Rate	$71,911.87
Rate for Payer: Hawaii Medical Service Association Commercial	$71,911.87

OTHER VASCULAR PROCEDURES WITHOUT CC/MCC

Facility

$48,826.12

Service Code	MSDRG 254
Min. Negotiated Rate	$48,826.12
Max. Negotiated Rate	$48,826.12
Rate for Payer: Hawaii Medical Service Association Commercial	$48,826.12

OT High Complex Units

Facility

$604.00

Service Code	HCPCS 97167 RT,52
Hospital Charge Code	8123907
Hospital Revenue Code	434
Min. Negotiated Rate	$513.40
Max. Negotiated Rate	$585.88
Rate for Payer: Cash Price	$392.60
Rate for Payer: Health Management Network Commercial	$513.40
Rate for Payer: Kaiser Permanente Commercial	$543.60
Rate for Payer: MDX Hawaii PPO	$585.88

OT High Complex Units

Facility

$604.00

Service Code	HCPCS 97167 RT,52
Hospital Charge Code	8123907
Hospital Revenue Code	434
Min. Negotiated Rate	$107.85
Max. Negotiated Rate	$585.88
Rate for Payer: AlohaCare Medicaid	$302.00
Rate for Payer: AlohaCare Medicare	$302.00
Rate for Payer: Cash Price	$392.60
Rate for Payer: Cash Price	$392.60
Rate for Payer: Devoted Health Medicare	$332.20
Rate for Payer: Hawaii Medical Service Association Medicare	$302.00
Rate for Payer: Hawaii Western Management Group Commercial	$573.80
Rate for Payer: Health Management Network Commercial	$513.40
Rate for Payer: Humana Medicare	$302.00
Rate for Payer: Kaiser Permanente Commercial	$543.60
Rate for Payer: Kaiser Permanente Medicaid	$308.04
Rate for Payer: Kaiser Permanente Medicare	$302.00
Rate for Payer: MDX Hawaii PPO	$585.88
Rate for Payer: Ohana Health Plan Medicaid	$302.00
Rate for Payer: Ohana Health Plan Medicare	$302.00
Rate for Payer: UnitedHealthcare Medicaid	$107.85
Rate for Payer: UnitedHealthcare Medicare	$302.00
Rate for Payer: University Health Alliance Commercial	$338.24

OT Hot, Cold Pack Assistant units

Facility

$95.00

Service Code	HCPCS 97010 GO,CO
Hospital Charge Code	8720886
Hospital Revenue Code	430
Min. Negotiated Rate	$10.08
Max. Negotiated Rate	$92.15
Rate for Payer: AlohaCare Medicaid	$47.50
Rate for Payer: AlohaCare Medicare	$47.50
Rate for Payer: Cash Price	$61.75
Rate for Payer: Cash Price	$61.75
Rate for Payer: Devoted Health Medicare	$52.25
Rate for Payer: Hawaii Medical Service Association Medicare	$47.50
Rate for Payer: Hawaii Western Management Group Commercial	$90.25
Rate for Payer: Health Management Network Commercial	$80.75
Rate for Payer: Humana Medicare	$47.50
Rate for Payer: Kaiser Permanente Commercial	$85.50
Rate for Payer: Kaiser Permanente Medicaid	$48.45
Rate for Payer: Kaiser Permanente Medicare	$47.50
Rate for Payer: MDX Hawaii PPO	$92.15
Rate for Payer: Ohana Health Plan Medicaid	$47.50
Rate for Payer: Ohana Health Plan Medicare	$47.50
Rate for Payer: UnitedHealthcare Medicaid	$10.08
Rate for Payer: UnitedHealthcare Medicare	$47.50
Rate for Payer: University Health Alliance Commercial	$53.20

OT Hot, Cold Pack Assistant units

Facility

$95.00

Service Code	HCPCS 97010 GO,CO
Hospital Charge Code	8720886
Hospital Revenue Code	430
Min. Negotiated Rate	$80.75
Max. Negotiated Rate	$92.15
Rate for Payer: Cash Price	$61.75
Rate for Payer: Health Management Network Commercial	$80.75
Rate for Payer: Kaiser Permanente Commercial	$85.50
Rate for Payer: MDX Hawaii PPO	$92.15

OT Iontophoresis Assistant Units

Facility

$141.00

Service Code	HCPCS 97033 GO,CO
Hospital Charge Code	8720927
Hospital Revenue Code	430
Min. Negotiated Rate	$13.64
Max. Negotiated Rate	$136.77
Rate for Payer: AlohaCare Medicaid	$70.50
Rate for Payer: AlohaCare Medicare	$70.50
Rate for Payer: Cash Price	$91.65
Rate for Payer: Cash Price	$91.65
Rate for Payer: Devoted Health Medicare	$77.55
Rate for Payer: Hawaii Medical Service Association Medicare	$70.50
Rate for Payer: Hawaii Western Management Group Commercial	$133.95
Rate for Payer: Health Management Network Commercial	$119.85
Rate for Payer: Humana Medicare	$70.50
Rate for Payer: Kaiser Permanente Commercial	$126.90
Rate for Payer: Kaiser Permanente Medicaid	$71.91
Rate for Payer: Kaiser Permanente Medicare	$70.50
Rate for Payer: MDX Hawaii PPO	$136.77
Rate for Payer: Ohana Health Plan Medicaid	$70.50
Rate for Payer: Ohana Health Plan Medicare	$70.50
Rate for Payer: UnitedHealthcare Medicaid	$13.64
Rate for Payer: UnitedHealthcare Medicare	$70.50
Rate for Payer: University Health Alliance Commercial	$78.96

OT Iontophoresis Assistant Units

Facility

$141.00

Service Code	HCPCS 97033 GO,CO
Hospital Charge Code	8720927
Hospital Revenue Code	430
Min. Negotiated Rate	$119.85
Max. Negotiated Rate	$136.77
Rate for Payer: Cash Price	$91.65
Rate for Payer: Health Management Network Commercial	$119.85
Rate for Payer: Kaiser Permanente Commercial	$126.90
Rate for Payer: MDX Hawaii PPO	$136.77

OTITIS MEDIA AND URI WITH MCC

Facility

$12,182.83

Service Code	MSDRG 152
Min. Negotiated Rate	$12,182.83
Max. Negotiated Rate	$12,182.83
Rate for Payer: Hawaii Medical Service Association Commercial	$12,182.83

Know your out-of-pocket cost for care.

All Charges