Samuel Mahelona Memorial Hospital

All Charges

Charge

Type

Setting

Price

Plasma Metanephrines, Free FSI

Facility

$194.00

Service Code	HCPCS 83835
Hospital Charge Code	10756334
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

Platelet Count FSI

Facility

$61.00

Service Code	HCPCS 85049
Hospital Charge Code	8128140
Hospital Revenue Code	305
Min. Negotiated Rate	$4.48
Max. Negotiated Rate	$59.17
Rate for Payer: AlohaCare Medicaid	$30.50
Rate for Payer: AlohaCare Medicare	$30.50
Rate for Payer: Cash Price	$39.65
Rate for Payer: Cash Price	$39.65
Rate for Payer: Devoted Health Medicare	$33.55
Rate for Payer: Hawaii Medical Service Association ABD	$6.25
Rate for Payer: Hawaii Medical Service Association Commercial	$5.60
Rate for Payer: Hawaii Medical Service Association Medicare	$30.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$6.56
Rate for Payer: Hawaii Western Management Group Commercial	$4.48
Rate for Payer: Health Management Network Commercial	$51.85
Rate for Payer: Humana Medicare	$30.50
Rate for Payer: Kaiser Permanente Commercial	$54.90
Rate for Payer: Kaiser Permanente Medicaid	$31.11
Rate for Payer: Kaiser Permanente Medicare	$30.50
Rate for Payer: MDX Hawaii PPO	$59.17
Rate for Payer: Ohana Health Plan Medicaid	$30.50
Rate for Payer: Ohana Health Plan Medicare	$30.50
Rate for Payer: UnitedHealthcare Medicaid	$6.25
Rate for Payer: UnitedHealthcare Medicare	$30.50
Rate for Payer: University Health Alliance Commercial	$11.56

Platelet Count FSI

Facility

$61.00

Service Code	HCPCS 85049
Hospital Charge Code	8128140
Hospital Revenue Code	305
Min. Negotiated Rate	$51.85
Max. Negotiated Rate	$59.17
Rate for Payer: Cash Price	$39.65
Rate for Payer: Health Management Network Commercial	$51.85
Rate for Payer: Kaiser Permanente Commercial	$54.90
Rate for Payer: MDX Hawaii PPO	$59.17

PLEURAL EFFUSION WITH CC

Facility

$27,565.43

Service Code	MSDRG 187
Min. Negotiated Rate	$27,565.43
Max. Negotiated Rate	$27,565.43
Rate for Payer: Hawaii Medical Service Association Commercial	$27,565.43

PLEURAL EFFUSION WITH MCC

Facility

$28,205.38

Service Code	MSDRG 186
Min. Negotiated Rate	$28,205.38
Max. Negotiated Rate	$28,205.38
Rate for Payer: Hawaii Medical Service Association Commercial	$28,205.38

PLEURAL EFFUSION WITHOUT CC/MCC

Facility

$22,516.90

Service Code	MSDRG 188
Min. Negotiated Rate	$22,516.90
Max. Negotiated Rate	$22,516.90
Rate for Payer: Hawaii Medical Service Association Commercial	$22,516.90

pneumoc 20-val conj vacc 0.5 mL [HHSC]

Facility

$877.06

Service Code	HCPCS 90677
Hospital Charge Code	2501119
Hospital Revenue Code	636
Min. Negotiated Rate	$298.04
Max. Negotiated Rate	$850.75
Rate for Payer: AlohaCare Medicaid	$438.53
Rate for Payer: AlohaCare Medicaid	$459.12
Rate for Payer: AlohaCare Medicare	$459.12
Rate for Payer: AlohaCare Medicare	$438.53
Rate for Payer: Cash Price	$596.86
Rate for Payer: Cash Price	$570.09
Rate for Payer: Cash Price	$570.09
Rate for Payer: Cash Price	$596.86
Rate for Payer: Devoted Health Medicare	$482.38
Rate for Payer: Devoted Health Medicare	$505.03
Rate for Payer: Hawaii Medical Service Association ABD	$298.04
Rate for Payer: Hawaii Medical Service Association ABD	$298.04
Rate for Payer: Hawaii Medical Service Association Medicare	$459.12
Rate for Payer: Hawaii Medical Service Association Medicare	$438.53
Rate for Payer: Hawaii Medical Service Association Non-ABD	$298.04
Rate for Payer: Hawaii Medical Service Association Non-ABD	$298.04
Rate for Payer: Hawaii Western Management Group Commercial	$833.21
Rate for Payer: Hawaii Western Management Group Commercial	$872.33
Rate for Payer: Health Management Network Commercial	$780.50
Rate for Payer: Health Management Network Commercial	$745.50
Rate for Payer: Humana Medicare	$438.53
Rate for Payer: Humana Medicare	$459.12
Rate for Payer: Kaiser Permanente Commercial	$789.35
Rate for Payer: Kaiser Permanente Commercial	$826.42
Rate for Payer: Kaiser Permanente Medicaid	$468.30
Rate for Payer: Kaiser Permanente Medicaid	$447.30
Rate for Payer: Kaiser Permanente Medicare	$438.53
Rate for Payer: Kaiser Permanente Medicare	$459.12
Rate for Payer: MDX Hawaii PPO	$850.75
Rate for Payer: MDX Hawaii PPO	$890.69
Rate for Payer: Ohana Health Plan Medicaid	$459.12
Rate for Payer: Ohana Health Plan Medicaid	$438.53
Rate for Payer: Ohana Health Plan Medicare	$438.53
Rate for Payer: Ohana Health Plan Medicare	$459.12
Rate for Payer: UnitedHealthcare Medicaid	$550.94
Rate for Payer: UnitedHealthcare Medicaid	$526.24
Rate for Payer: UnitedHealthcare Medicare	$438.53
Rate for Payer: UnitedHealthcare Medicare	$459.12
Rate for Payer: University Health Alliance Commercial	$491.15
Rate for Payer: University Health Alliance Commercial	$514.21

pneumoc 20-val conj vacc 0.5 mL [HHSC]

Facility

$877.06

Service Code	HCPCS 90677
Hospital Charge Code	2501119
Hospital Revenue Code	250
Min. Negotiated Rate	$745.50
Max. Negotiated Rate	$850.75
Rate for Payer: Cash Price	$570.09
Rate for Payer: Cash Price	$596.86
Rate for Payer: Health Management Network Commercial	$745.50
Rate for Payer: Health Management Network Commercial	$780.50
Rate for Payer: Kaiser Permanente Commercial	$789.35
Rate for Payer: Kaiser Permanente Commercial	$826.42
Rate for Payer: MDX Hawaii PPO	$890.69
Rate for Payer: MDX Hawaii PPO	$850.75

PNEUMOCLEAR HEATED HUMIDIFIED SMOKE EVACUATION INSUFFLATOR TUBE SET

Facility

$801.00

Hospital Charge Code	8879044
Hospital Revenue Code	272
Min. Negotiated Rate	$680.85
Max. Negotiated Rate	$776.97
Rate for Payer: Cash Price	$520.65
Rate for Payer: Health Management Network Commercial	$680.85
Rate for Payer: Kaiser Permanente Commercial	$720.90
Rate for Payer: MDX Hawaii PPO	$776.97

PNEUMOCLEAR HEATED HUMIDIFIED SMOKE EVACUATION INSUFFLATOR TUBE SET

Facility

$801.00

Hospital Charge Code	8879044
Hospital Revenue Code	272
Min. Negotiated Rate	$400.50
Max. Negotiated Rate	$776.97
Rate for Payer: AlohaCare Medicaid	$400.50
Rate for Payer: AlohaCare Medicare	$400.50
Rate for Payer: Cash Price	$520.65
Rate for Payer: Devoted Health Medicare	$440.55
Rate for Payer: Hawaii Medical Service Association Medicare	$400.50
Rate for Payer: Hawaii Western Management Group Commercial	$760.95
Rate for Payer: Health Management Network Commercial	$680.85
Rate for Payer: Humana Medicare	$400.50
Rate for Payer: Kaiser Permanente Commercial	$720.90
Rate for Payer: Kaiser Permanente Medicaid	$408.51
Rate for Payer: Kaiser Permanente Medicare	$400.50
Rate for Payer: MDX Hawaii PPO	$776.97
Rate for Payer: Ohana Health Plan Medicaid	$400.50
Rate for Payer: Ohana Health Plan Medicare	$400.50
Rate for Payer: UnitedHealthcare Medicare	$400.50
Rate for Payer: University Health Alliance Commercial	$583.85

PNEUMONEEDLE 150MM (VERES)

Facility

$240.00

Hospital Charge Code	9952985
Hospital Revenue Code	272
Min. Negotiated Rate	$120.00
Max. Negotiated Rate	$232.80
Rate for Payer: AlohaCare Medicaid	$120.00
Rate for Payer: AlohaCare Medicare	$120.00
Rate for Payer: Cash Price	$156.00
Rate for Payer: Devoted Health Medicare	$132.00
Rate for Payer: Hawaii Medical Service Association Medicare	$120.00
Rate for Payer: Hawaii Western Management Group Commercial	$228.00
Rate for Payer: Health Management Network Commercial	$204.00
Rate for Payer: Humana Medicare	$120.00
Rate for Payer: Kaiser Permanente Commercial	$216.00
Rate for Payer: Kaiser Permanente Medicaid	$122.40
Rate for Payer: Kaiser Permanente Medicare	$120.00
Rate for Payer: MDX Hawaii PPO	$232.80
Rate for Payer: Ohana Health Plan Medicaid	$120.00
Rate for Payer: Ohana Health Plan Medicare	$120.00
Rate for Payer: UnitedHealthcare Medicare	$120.00
Rate for Payer: University Health Alliance Commercial	$174.94

PNEUMONEEDLE 150MM (VERES)

Facility

$240.00

Hospital Charge Code	9952985
Hospital Revenue Code	272
Min. Negotiated Rate	$204.00
Max. Negotiated Rate	$232.80
Rate for Payer: Cash Price	$156.00
Rate for Payer: Health Management Network Commercial	$204.00
Rate for Payer: Kaiser Permanente Commercial	$216.00
Rate for Payer: MDX Hawaii PPO	$232.80

PNEUMOTHORAX WITH CC

Facility

$17,373.57

Service Code	MSDRG 200
Min. Negotiated Rate	$17,373.57
Max. Negotiated Rate	$17,373.57
Rate for Payer: Hawaii Medical Service Association Commercial	$17,373.57

PNEUMOTHORAX WITH MCC

Facility

$18,321.65

Service Code	MSDRG 199
Min. Negotiated Rate	$18,321.65
Max. Negotiated Rate	$18,321.65
Rate for Payer: Hawaii Medical Service Association Commercial	$18,321.65

PNEUMOTHORAX WITHOUT CC/MCC

Facility

$13,770.86

Service Code	MSDRG 201
Min. Negotiated Rate	$13,770.86
Max. Negotiated Rate	$13,770.86
Rate for Payer: Hawaii Medical Service Association Commercial	$13,770.86

POCT Urine Pregnancy Test

Facility

$85.00

Service Code	HCPCS 81025
Hospital Charge Code	10541462
Hospital Revenue Code	307
Min. Negotiated Rate	$72.25
Max. Negotiated Rate	$82.45
Rate for Payer: Cash Price	$55.25
Rate for Payer: Health Management Network Commercial	$72.25
Rate for Payer: Kaiser Permanente Commercial	$76.50
Rate for Payer: MDX Hawaii PPO	$82.45

POCT Urine Pregnancy Test

Facility

$85.00

Service Code	HCPCS 81025
Hospital Charge Code	10541462
Hospital Revenue Code	307
Min. Negotiated Rate	$8.61
Max. Negotiated Rate	$82.45
Rate for Payer: AlohaCare Medicaid	$42.50
Rate for Payer: AlohaCare Medicare	$42.50
Rate for Payer: Cash Price	$55.25
Rate for Payer: Cash Price	$55.25
Rate for Payer: Devoted Health Medicare	$46.75
Rate for Payer: Hawaii Medical Service Association ABD	$8.74
Rate for Payer: Hawaii Medical Service Association Commercial	$10.76
Rate for Payer: Hawaii Medical Service Association Medicare	$42.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$9.18
Rate for Payer: Hawaii Western Management Group Commercial	$8.61
Rate for Payer: Health Management Network Commercial	$72.25
Rate for Payer: Humana Medicare	$42.50
Rate for Payer: Kaiser Permanente Commercial	$76.50
Rate for Payer: Kaiser Permanente Medicaid	$43.35
Rate for Payer: Kaiser Permanente Medicare	$42.50
Rate for Payer: MDX Hawaii PPO	$82.45
Rate for Payer: Ohana Health Plan Medicaid	$42.50
Rate for Payer: Ohana Health Plan Medicare	$42.50
Rate for Payer: UnitedHealthcare Medicaid	$8.74
Rate for Payer: UnitedHealthcare Medicare	$42.50
Rate for Payer: University Health Alliance Commercial	$16.35

POC Ultrasound of eye

Facility

$447.00

Service Code	HCPCS 76512
Hospital Charge Code	12390665
Hospital Revenue Code	402
Min. Negotiated Rate	$379.95
Max. Negotiated Rate	$433.59
Rate for Payer: Cash Price	$290.55
Rate for Payer: Health Management Network Commercial	$379.95
Rate for Payer: Kaiser Permanente Commercial	$402.30
Rate for Payer: MDX Hawaii PPO	$433.59

POC Ultrasound of eye

Facility

$447.00

Service Code	HCPCS 76512
Hospital Charge Code	12390665
Hospital Revenue Code	402
Min. Negotiated Rate	$47.80
Max. Negotiated Rate	$433.59
Rate for Payer: AlohaCare Medicaid	$223.50
Rate for Payer: AlohaCare Medicare	$223.50
Rate for Payer: Cash Price	$290.55
Rate for Payer: Cash Price	$290.55
Rate for Payer: Devoted Health Medicare	$245.85
Rate for Payer: Hawaii Medical Service Association ABD	$47.80
Rate for Payer: Hawaii Medical Service Association Commercial	$133.51
Rate for Payer: Hawaii Medical Service Association Medicare	$223.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$74.09
Rate for Payer: Hawaii Western Management Group Commercial	$106.81
Rate for Payer: Health Management Network Commercial	$379.95
Rate for Payer: Humana Medicare	$223.50
Rate for Payer: Kaiser Permanente Commercial	$402.30
Rate for Payer: Kaiser Permanente Medicaid	$227.97
Rate for Payer: Kaiser Permanente Medicare	$223.50
Rate for Payer: MDX Hawaii PPO	$433.59
Rate for Payer: Ohana Health Plan Medicaid	$223.50
Rate for Payer: Ohana Health Plan Medicare	$223.50
Rate for Payer: UnitedHealthcare Medicaid	$47.80
Rate for Payer: UnitedHealthcare Medicare	$223.50
Rate for Payer: University Health Alliance Commercial	$200.08

POC Ultrasound of eye

Professional

Both

$145.00

Service Code	HCPCS 76512
Hospital Charge Code	12390665
Hospital Revenue Code	972
Min. Negotiated Rate	$31.14
Max. Negotiated Rate	$123.25
Rate for Payer: AlohaCare Medicaid	$31.14
Rate for Payer: AlohaCare Medicare	$52.56
Rate for Payer: Cash Price	$94.25
Rate for Payer: Cash Price	$94.25
Rate for Payer: Devoted Health Medicare	$57.82
Rate for Payer: Hawaii Medical Service Association Medicare	$52.56
Rate for Payer: Hawaii Western Management Group Commercial	$104.92
Rate for Payer: Health Management Network Commercial	$123.25
Rate for Payer: Kaiser Permanente Commercial	$63.07
Rate for Payer: Kaiser Permanente Medicaid	$63.07
Rate for Payer: Kaiser Permanente Medicare	$63.07
Rate for Payer: Ohana Health Plan Medicaid	$31.14
Rate for Payer: Ohana Health Plan Medicare	$52.56
Rate for Payer: UnitedHealthcare Medicaid	$31.14
Rate for Payer: UnitedHealthcare Medicare	$52.56

PODIATRY: 2.5 HL 16 MM

Facility

$1,689.00

Hospital Charge Code	10622092
Hospital Revenue Code	272
Min. Negotiated Rate	$844.50
Max. Negotiated Rate	$1,638.33
Rate for Payer: AlohaCare Medicaid	$844.50
Rate for Payer: AlohaCare Medicare	$844.50
Rate for Payer: Cash Price	$1,097.85
Rate for Payer: Devoted Health Medicare	$928.95
Rate for Payer: Hawaii Medical Service Association Medicare	$844.50
Rate for Payer: Hawaii Western Management Group Commercial	$1,604.55
Rate for Payer: Health Management Network Commercial	$1,435.65
Rate for Payer: Humana Medicare	$844.50
Rate for Payer: Kaiser Permanente Commercial	$1,520.10
Rate for Payer: Kaiser Permanente Medicaid	$861.39
Rate for Payer: Kaiser Permanente Medicare	$844.50
Rate for Payer: MDX Hawaii PPO	$1,638.33
Rate for Payer: Ohana Health Plan Medicaid	$844.50
Rate for Payer: Ohana Health Plan Medicare	$844.50
Rate for Payer: UnitedHealthcare Medicare	$844.50
Rate for Payer: University Health Alliance Commercial	$1,231.11

PODIATRY: 2.5 HL 16 MM

Facility

$1,689.00

Hospital Charge Code	10622092
Hospital Revenue Code	272
Min. Negotiated Rate	$1,435.65
Max. Negotiated Rate	$1,638.33
Rate for Payer: Cash Price	$1,097.85
Rate for Payer: Health Management Network Commercial	$1,435.65
Rate for Payer: Kaiser Permanente Commercial	$1,520.10
Rate for Payer: MDX Hawaii PPO	$1,638.33

PODIATRY: 3.0 HL 18 MM

Facility

$1,689.00

Hospital Charge Code	10622090
Hospital Revenue Code	272
Min. Negotiated Rate	$1,435.65
Max. Negotiated Rate	$1,638.33
Rate for Payer: Cash Price	$1,097.85
Rate for Payer: Health Management Network Commercial	$1,435.65
Rate for Payer: Kaiser Permanente Commercial	$1,520.10
Rate for Payer: MDX Hawaii PPO	$1,638.33

PODIATRY: 3.0 HL 18 MM

Facility

$1,689.00

Hospital Charge Code	10622090
Hospital Revenue Code	272
Min. Negotiated Rate	$844.50
Max. Negotiated Rate	$1,638.33
Rate for Payer: AlohaCare Medicaid	$844.50
Rate for Payer: AlohaCare Medicare	$844.50
Rate for Payer: Cash Price	$1,097.85
Rate for Payer: Devoted Health Medicare	$928.95
Rate for Payer: Hawaii Medical Service Association Medicare	$844.50
Rate for Payer: Hawaii Western Management Group Commercial	$1,604.55
Rate for Payer: Health Management Network Commercial	$1,435.65
Rate for Payer: Humana Medicare	$844.50
Rate for Payer: Kaiser Permanente Commercial	$1,520.10
Rate for Payer: Kaiser Permanente Medicaid	$861.39
Rate for Payer: Kaiser Permanente Medicare	$844.50
Rate for Payer: MDX Hawaii PPO	$1,638.33
Rate for Payer: Ohana Health Plan Medicaid	$844.50
Rate for Payer: Ohana Health Plan Medicare	$844.50
Rate for Payer: UnitedHealthcare Medicare	$844.50
Rate for Payer: University Health Alliance Commercial	$1,231.11

PODIATRY: 6.1MM BARREL BUR

Facility

$246.00

Hospital Charge Code	11224323
Hospital Revenue Code	272
Min. Negotiated Rate	$209.10
Max. Negotiated Rate	$238.62
Rate for Payer: Cash Price	$159.90
Rate for Payer: Health Management Network Commercial	$209.10
Rate for Payer: Kaiser Permanente Commercial	$221.40
Rate for Payer: MDX Hawaii PPO	$238.62

Know your out-of-pocket cost for care.

All Charges