Samuel Mahelona Memorial Hospital

All Charges

Charge

Type

Setting

Price

PODIATRY: 6.1MM BARREL BUR

Facility

$246.00

Hospital Charge Code	11224323
Hospital Revenue Code	272
Min. Negotiated Rate	$123.00
Max. Negotiated Rate	$238.62
Rate for Payer: AlohaCare Medicaid	$123.00
Rate for Payer: AlohaCare Medicare	$123.00
Rate for Payer: Cash Price	$159.90
Rate for Payer: Devoted Health Medicare	$135.30
Rate for Payer: Hawaii Medical Service Association Medicare	$123.00
Rate for Payer: Hawaii Western Management Group Commercial	$233.70
Rate for Payer: Health Management Network Commercial	$209.10
Rate for Payer: Humana Medicare	$123.00
Rate for Payer: Kaiser Permanente Commercial	$221.40
Rate for Payer: Kaiser Permanente Medicaid	$125.46
Rate for Payer: Kaiser Permanente Medicare	$123.00
Rate for Payer: MDX Hawaii PPO	$238.62
Rate for Payer: Ohana Health Plan Medicaid	$123.00
Rate for Payer: Ohana Health Plan Medicare	$123.00
Rate for Payer: UnitedHealthcare Medicare	$123.00
Rate for Payer: University Health Alliance Commercial	$179.31

PODIATRY:BIT WIRE PASS DRILL 1.5MM

Facility

$257.00

Hospital Charge Code	13214887
Hospital Revenue Code	272
Min. Negotiated Rate	$218.45
Max. Negotiated Rate	$249.29
Rate for Payer: Cash Price	$167.05
Rate for Payer: Health Management Network Commercial	$218.45
Rate for Payer: Kaiser Permanente Commercial	$231.30
Rate for Payer: MDX Hawaii PPO	$249.29

PODIATRY:BIT WIRE PASS DRILL 1.5MM

Facility

$257.00

Hospital Charge Code	13214887
Hospital Revenue Code	272
Min. Negotiated Rate	$128.50
Max. Negotiated Rate	$249.29
Rate for Payer: AlohaCare Medicaid	$128.50
Rate for Payer: AlohaCare Medicare	$128.50
Rate for Payer: Cash Price	$167.05
Rate for Payer: Devoted Health Medicare	$141.35
Rate for Payer: Hawaii Medical Service Association Medicare	$128.50
Rate for Payer: Hawaii Western Management Group Commercial	$244.15
Rate for Payer: Health Management Network Commercial	$218.45
Rate for Payer: Humana Medicare	$128.50
Rate for Payer: Kaiser Permanente Commercial	$231.30
Rate for Payer: Kaiser Permanente Medicaid	$131.07
Rate for Payer: Kaiser Permanente Medicare	$128.50
Rate for Payer: MDX Hawaii PPO	$249.29
Rate for Payer: Ohana Health Plan Medicaid	$128.50
Rate for Payer: Ohana Health Plan Medicare	$128.50
Rate for Payer: UnitedHealthcare Medicare	$128.50
Rate for Payer: University Health Alliance Commercial	$187.33

PODIATRY:BLADE THIN 27.0 X 0.38MM

Facility

$331.00

Hospital Charge Code	12684503
Hospital Revenue Code	272
Min. Negotiated Rate	$165.50
Max. Negotiated Rate	$321.07
Rate for Payer: AlohaCare Medicaid	$165.50
Rate for Payer: AlohaCare Medicare	$165.50
Rate for Payer: Cash Price	$215.15
Rate for Payer: Devoted Health Medicare	$182.05
Rate for Payer: Hawaii Medical Service Association Medicare	$165.50
Rate for Payer: Hawaii Western Management Group Commercial	$314.45
Rate for Payer: Health Management Network Commercial	$281.35
Rate for Payer: Humana Medicare	$165.50
Rate for Payer: Kaiser Permanente Commercial	$297.90
Rate for Payer: Kaiser Permanente Medicaid	$168.81
Rate for Payer: Kaiser Permanente Medicare	$165.50
Rate for Payer: MDX Hawaii PPO	$321.07
Rate for Payer: Ohana Health Plan Medicaid	$165.50
Rate for Payer: Ohana Health Plan Medicare	$165.50
Rate for Payer: UnitedHealthcare Medicare	$165.50
Rate for Payer: University Health Alliance Commercial	$241.27

PODIATRY:BLADE THIN 27.0 X 0.38MM

Facility

$331.00

Hospital Charge Code	12684503
Hospital Revenue Code	272
Min. Negotiated Rate	$281.35
Max. Negotiated Rate	$321.07
Rate for Payer: Cash Price	$215.15
Rate for Payer: Health Management Network Commercial	$281.35
Rate for Payer: Kaiser Permanente Commercial	$297.90
Rate for Payer: MDX Hawaii PPO	$321.07

PODIATRY:POST OP SHOE SMALL

Facility

$98.00

Hospital Charge Code	11768968
Hospital Revenue Code	272
Min. Negotiated Rate	$83.30
Max. Negotiated Rate	$95.06
Rate for Payer: Cash Price	$63.70
Rate for Payer: Health Management Network Commercial	$83.30
Rate for Payer: Kaiser Permanente Commercial	$88.20
Rate for Payer: MDX Hawaii PPO	$95.06

PODIATRY:POST OP SHOE SMALL

Facility

$98.00

Hospital Charge Code	11768968
Hospital Revenue Code	272
Min. Negotiated Rate	$49.00
Max. Negotiated Rate	$95.06
Rate for Payer: AlohaCare Medicaid	$49.00
Rate for Payer: AlohaCare Medicare	$49.00
Rate for Payer: Cash Price	$63.70
Rate for Payer: Devoted Health Medicare	$53.90
Rate for Payer: Hawaii Medical Service Association Medicare	$49.00
Rate for Payer: Hawaii Western Management Group Commercial	$93.10
Rate for Payer: Health Management Network Commercial	$83.30
Rate for Payer: Humana Medicare	$49.00
Rate for Payer: Kaiser Permanente Commercial	$88.20
Rate for Payer: Kaiser Permanente Medicaid	$49.98
Rate for Payer: Kaiser Permanente Medicare	$49.00
Rate for Payer: MDX Hawaii PPO	$95.06
Rate for Payer: Ohana Health Plan Medicaid	$49.00
Rate for Payer: Ohana Health Plan Medicare	$49.00
Rate for Payer: UnitedHealthcare Medicare	$49.00
Rate for Payer: University Health Alliance Commercial	$71.43

PODIATRY: PRECISION 7X.38X18.5mm

Facility

$148.00

Hospital Charge Code	10302076
Hospital Revenue Code	272
Min. Negotiated Rate	$125.80
Max. Negotiated Rate	$143.56
Rate for Payer: Cash Price	$96.20
Rate for Payer: Health Management Network Commercial	$125.80
Rate for Payer: Kaiser Permanente Commercial	$133.20
Rate for Payer: MDX Hawaii PPO	$143.56

PODIATRY: PRECISION 7X.38X18.5mm

Facility

$148.00

Hospital Charge Code	10302076
Hospital Revenue Code	272
Min. Negotiated Rate	$74.00
Max. Negotiated Rate	$143.56
Rate for Payer: AlohaCare Medicaid	$74.00
Rate for Payer: AlohaCare Medicare	$74.00
Rate for Payer: Cash Price	$96.20
Rate for Payer: Devoted Health Medicare	$81.40
Rate for Payer: Hawaii Medical Service Association Medicare	$74.00
Rate for Payer: Hawaii Western Management Group Commercial	$140.60
Rate for Payer: Health Management Network Commercial	$125.80
Rate for Payer: Humana Medicare	$74.00
Rate for Payer: Kaiser Permanente Commercial	$133.20
Rate for Payer: Kaiser Permanente Medicaid	$75.48
Rate for Payer: Kaiser Permanente Medicare	$74.00
Rate for Payer: MDX Hawaii PPO	$143.56
Rate for Payer: Ohana Health Plan Medicaid	$74.00
Rate for Payer: Ohana Health Plan Medicare	$74.00
Rate for Payer: UnitedHealthcare Medicare	$74.00
Rate for Payer: University Health Alliance Commercial	$107.88

PODIATRY: PRECISION THIN (5.5 X 0.38 X 11.5MM)

Facility

$190.00

Hospital Charge Code	12728299
Hospital Revenue Code	272
Min. Negotiated Rate	$95.00
Max. Negotiated Rate	$184.30
Rate for Payer: AlohaCare Medicaid	$95.00
Rate for Payer: AlohaCare Medicare	$95.00
Rate for Payer: Cash Price	$123.50
Rate for Payer: Devoted Health Medicare	$104.50
Rate for Payer: Hawaii Medical Service Association Medicare	$95.00
Rate for Payer: Hawaii Western Management Group Commercial	$180.50
Rate for Payer: Health Management Network Commercial	$161.50
Rate for Payer: Humana Medicare	$95.00
Rate for Payer: Kaiser Permanente Commercial	$171.00
Rate for Payer: Kaiser Permanente Medicaid	$96.90
Rate for Payer: Kaiser Permanente Medicare	$95.00
Rate for Payer: MDX Hawaii PPO	$184.30
Rate for Payer: Ohana Health Plan Medicaid	$95.00
Rate for Payer: Ohana Health Plan Medicare	$95.00
Rate for Payer: UnitedHealthcare Medicare	$95.00
Rate for Payer: University Health Alliance Commercial	$138.49

PODIATRY: PRECISION THIN (5.5 X 0.38 X 11.5MM)

Facility

$190.00

Hospital Charge Code	12728299
Hospital Revenue Code	272
Min. Negotiated Rate	$161.50
Max. Negotiated Rate	$184.30
Rate for Payer: Cash Price	$123.50
Rate for Payer: Health Management Network Commercial	$161.50
Rate for Payer: Kaiser Permanente Commercial	$171.00
Rate for Payer: MDX Hawaii PPO	$184.30

POISONING AND TOXIC EFFECTS OF DRUGS WITH MCC

Facility

$20,597.04

Service Code	MSDRG 917
Min. Negotiated Rate	$20,597.04
Max. Negotiated Rate	$20,597.04
Rate for Payer: Hawaii Medical Service Association Commercial	$20,597.04

POISONING AND TOXIC EFFECTS OF DRUGS WITHOUT MCC

Facility

$15,714.43

Service Code	MSDRG 918
Min. Negotiated Rate	$15,714.43
Max. Negotiated Rate	$15,714.43
Rate for Payer: Hawaii Medical Service Association Commercial	$15,714.43

Polio Antibody Titer FSI

Facility

$101.00

Service Code	HCPCS 86658
Hospital Charge Code	9300194
Hospital Revenue Code	300
Min. Negotiated Rate	$85.85
Max. Negotiated Rate	$97.97
Rate for Payer: Cash Price	$65.65
Rate for Payer: Health Management Network Commercial	$85.85
Rate for Payer: Kaiser Permanente Commercial	$90.90
Rate for Payer: MDX Hawaii PPO	$97.97

Polio Antibody Titer FSI

Facility

$101.00

Service Code	HCPCS 86658
Hospital Charge Code	9300194
Hospital Revenue Code	300
Min. Negotiated Rate	$10.92
Max. Negotiated Rate	$97.97
Rate for Payer: AlohaCare Medicaid	$50.50
Rate for Payer: AlohaCare Medicare	$50.50
Rate for Payer: Cash Price	$65.65
Rate for Payer: Cash Price	$65.65
Rate for Payer: Devoted Health Medicare	$55.55
Rate for Payer: Hawaii Medical Service Association ABD	$10.92
Rate for Payer: Hawaii Medical Service Association Commercial	$16.29
Rate for Payer: Hawaii Medical Service Association Medicare	$50.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$17.99
Rate for Payer: Hawaii Western Management Group Commercial	$13.03
Rate for Payer: Health Management Network Commercial	$85.85
Rate for Payer: Humana Medicare	$50.50
Rate for Payer: Kaiser Permanente Commercial	$90.90
Rate for Payer: Kaiser Permanente Medicaid	$51.51
Rate for Payer: Kaiser Permanente Medicare	$50.50
Rate for Payer: MDX Hawaii PPO	$97.97
Rate for Payer: Ohana Health Plan Medicaid	$50.50
Rate for Payer: Ohana Health Plan Medicare	$50.50
Rate for Payer: UnitedHealthcare Medicaid	$10.92
Rate for Payer: UnitedHealthcare Medicare	$50.50
Rate for Payer: University Health Alliance Commercial	$33.67

Porphobilinogen FSI

Facility

$103.00

Service Code	HCPCS 84110
Hospital Charge Code	11480498
Hospital Revenue Code	301
Min. Negotiated Rate	$87.55
Max. Negotiated Rate	$99.91
Rate for Payer: Cash Price	$66.95
Rate for Payer: Health Management Network Commercial	$87.55
Rate for Payer: Kaiser Permanente Commercial	$92.70
Rate for Payer: MDX Hawaii PPO	$99.91

Porphobilinogen FSI

Facility

$103.00

Service Code	HCPCS 84110
Hospital Charge Code	11480498
Hospital Revenue Code	301
Min. Negotiated Rate	$8.44
Max. Negotiated Rate	$99.91
Rate for Payer: AlohaCare Medicaid	$51.50
Rate for Payer: AlohaCare Medicare	$51.50
Rate for Payer: Cash Price	$66.95
Rate for Payer: Cash Price	$66.95
Rate for Payer: Devoted Health Medicare	$56.65
Rate for Payer: Hawaii Medical Service Association ABD	$11.68
Rate for Payer: Hawaii Medical Service Association Commercial	$10.55
Rate for Payer: Hawaii Medical Service Association Medicare	$51.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$12.26
Rate for Payer: Hawaii Western Management Group Commercial	$8.44
Rate for Payer: Health Management Network Commercial	$87.55
Rate for Payer: Humana Medicare	$51.50
Rate for Payer: Kaiser Permanente Commercial	$92.70
Rate for Payer: Kaiser Permanente Medicaid	$52.53
Rate for Payer: Kaiser Permanente Medicare	$51.50
Rate for Payer: MDX Hawaii PPO	$99.91
Rate for Payer: Ohana Health Plan Medicaid	$51.50
Rate for Payer: Ohana Health Plan Medicare	$51.50
Rate for Payer: UnitedHealthcare Medicaid	$11.68
Rate for Payer: UnitedHealthcare Medicare	$51.50
Rate for Payer: University Health Alliance Commercial	$21.83

Porphyrins, Total Serum, FSI

Facility

$104.00

Service Code	HCPCS 84311
Hospital Charge Code	11480510
Hospital Revenue Code	301
Min. Negotiated Rate	$8.10
Max. Negotiated Rate	$100.88
Rate for Payer: AlohaCare Medicaid	$52.00
Rate for Payer: AlohaCare Medicare	$52.00
Rate for Payer: Cash Price	$67.60
Rate for Payer: Cash Price	$67.60
Rate for Payer: Devoted Health Medicare	$57.20
Rate for Payer: Hawaii Medical Service Association ABD	$9.66
Rate for Payer: Hawaii Medical Service Association Commercial	$10.12
Rate for Payer: Hawaii Medical Service Association Medicare	$52.00
Rate for Payer: Hawaii Medical Service Association Non-ABD	$10.14
Rate for Payer: Hawaii Western Management Group Commercial	$8.10
Rate for Payer: Health Management Network Commercial	$88.40
Rate for Payer: Humana Medicare	$52.00
Rate for Payer: Kaiser Permanente Commercial	$93.60
Rate for Payer: Kaiser Permanente Medicaid	$53.04
Rate for Payer: Kaiser Permanente Medicare	$52.00
Rate for Payer: MDX Hawaii PPO	$100.88
Rate for Payer: Ohana Health Plan Medicaid	$52.00
Rate for Payer: Ohana Health Plan Medicare	$52.00
Rate for Payer: UnitedHealthcare Medicaid	$9.66
Rate for Payer: UnitedHealthcare Medicare	$52.00
Rate for Payer: University Health Alliance Commercial	$18.07

Porphyrins, Total Serum, FSI

Facility

$104.00

Service Code	HCPCS 84311
Hospital Charge Code	11480510
Hospital Revenue Code	301
Min. Negotiated Rate	$88.40
Max. Negotiated Rate	$100.88
Rate for Payer: Cash Price	$67.60
Rate for Payer: Health Management Network Commercial	$88.40
Rate for Payer: Kaiser Permanente Commercial	$93.60
Rate for Payer: MDX Hawaii PPO	$100.88

POSTOPERATIVE AND POST-TRAUMATIC INFECTIONS WITH MCC

Facility

$21,545.12

Service Code	MSDRG 862
Min. Negotiated Rate	$21,545.12
Max. Negotiated Rate	$21,545.12
Rate for Payer: Hawaii Medical Service Association Commercial	$21,545.12

POSTOPERATIVE AND POST-TRAUMATIC INFECTIONS WITHOUT MCC

Facility

$21,545.12

Service Code	MSDRG 863
Min. Negotiated Rate	$21,545.12
Max. Negotiated Rate	$21,545.12
Rate for Payer: Hawaii Medical Service Association Commercial	$21,545.12

POSTOPERATIVE OR POST-TRAUMATIC INFECTIONS WITH O.R. PROCEDURES WITH CC

Facility

$37,899.50

Service Code	MSDRG 857
Min. Negotiated Rate	$37,899.50
Max. Negotiated Rate	$37,899.50
Rate for Payer: Hawaii Medical Service Association Commercial	$37,899.50

POSTOPERATIVE OR POST-TRAUMATIC INFECTIONS WITH O.R. PROCEDURES WITH MCC

Facility

$37,899.50

Service Code	MSDRG 856
Min. Negotiated Rate	$37,899.50
Max. Negotiated Rate	$37,899.50
Rate for Payer: Hawaii Medical Service Association Commercial	$37,899.50

POSTOPERATIVE OR POST-TRAUMATIC INFECTIONS WITH O.R. PROCEDURES WITHOUT CC/MCC

Facility

$37,899.50

Service Code	MSDRG 858
Min. Negotiated Rate	$37,899.50
Max. Negotiated Rate	$37,899.50
Rate for Payer: Hawaii Medical Service Association Commercial	$37,899.50

POSTPARTUM AND POST ABORTION DIAGNOSES WITH O.R. PROCEDURES

Facility

$25,124.12

Service Code	MSDRG 769
Min. Negotiated Rate	$25,124.12
Max. Negotiated Rate	$25,124.12
Rate for Payer: Hawaii Medical Service Association Commercial	$25,124.12

Know your out-of-pocket cost for care.

All Charges