Samuel Mahelona Memorial Hospital

All Charges

Charge

Type

Setting

Price

RBC Antigens 6

Facility

$133.00

Service Code	HCPCS 86905
Hospital Charge Code	12517900
Hospital Revenue Code	302
Min. Negotiated Rate	$113.05
Max. Negotiated Rate	$129.01
Rate for Payer: Cash Price	$86.45
Rate for Payer: Health Management Network Commercial	$113.05
Rate for Payer: Kaiser Permanente Commercial	$119.70
Rate for Payer: MDX Hawaii PPO	$129.01

RBC Antigens 6

Facility

$133.00

Service Code	HCPCS 86905
Hospital Charge Code	12517900
Hospital Revenue Code	302
Min. Negotiated Rate	$3.83
Max. Negotiated Rate	$129.01
Rate for Payer: AlohaCare Medicaid	$66.50
Rate for Payer: AlohaCare Medicare	$66.50
Rate for Payer: Cash Price	$86.45
Rate for Payer: Cash Price	$86.45
Rate for Payer: Devoted Health Medicare	$73.15
Rate for Payer: Hawaii Medical Service Association ABD	$5.28
Rate for Payer: Hawaii Medical Service Association Commercial	$4.79
Rate for Payer: Hawaii Medical Service Association Medicare	$66.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$5.54
Rate for Payer: Hawaii Western Management Group Commercial	$3.83
Rate for Payer: Health Management Network Commercial	$113.05
Rate for Payer: Humana Medicare	$66.50
Rate for Payer: Kaiser Permanente Commercial	$119.70
Rate for Payer: Kaiser Permanente Medicaid	$67.83
Rate for Payer: Kaiser Permanente Medicare	$66.50
Rate for Payer: MDX Hawaii PPO	$129.01
Rate for Payer: Ohana Health Plan Medicaid	$66.50
Rate for Payer: Ohana Health Plan Medicare	$66.50
Rate for Payer: UnitedHealthcare Medicaid	$5.28
Rate for Payer: UnitedHealthcare Medicare	$66.50
Rate for Payer: University Health Alliance Commercial	$9.88

RBC Antigens 7

Facility

$154.00

Service Code	HCPCS 86905
Hospital Charge Code	12517901
Hospital Revenue Code	302
Min. Negotiated Rate	$130.90
Max. Negotiated Rate	$149.38
Rate for Payer: Cash Price	$100.10
Rate for Payer: Health Management Network Commercial	$130.90
Rate for Payer: Kaiser Permanente Commercial	$138.60
Rate for Payer: MDX Hawaii PPO	$149.38

RBC Antigens 7

Facility

$154.00

Service Code	HCPCS 86905
Hospital Charge Code	12517901
Hospital Revenue Code	302
Min. Negotiated Rate	$3.83
Max. Negotiated Rate	$149.38
Rate for Payer: AlohaCare Medicaid	$77.00
Rate for Payer: AlohaCare Medicare	$77.00
Rate for Payer: Cash Price	$100.10
Rate for Payer: Cash Price	$100.10
Rate for Payer: Devoted Health Medicare	$84.70
Rate for Payer: Hawaii Medical Service Association ABD	$5.28
Rate for Payer: Hawaii Medical Service Association Commercial	$4.79
Rate for Payer: Hawaii Medical Service Association Medicare	$77.00
Rate for Payer: Hawaii Medical Service Association Non-ABD	$5.54
Rate for Payer: Hawaii Western Management Group Commercial	$3.83
Rate for Payer: Health Management Network Commercial	$130.90
Rate for Payer: Humana Medicare	$77.00
Rate for Payer: Kaiser Permanente Commercial	$138.60
Rate for Payer: Kaiser Permanente Medicaid	$78.54
Rate for Payer: Kaiser Permanente Medicare	$77.00
Rate for Payer: MDX Hawaii PPO	$149.38
Rate for Payer: Ohana Health Plan Medicaid	$77.00
Rate for Payer: Ohana Health Plan Medicare	$77.00
Rate for Payer: UnitedHealthcare Medicaid	$5.28
Rate for Payer: UnitedHealthcare Medicare	$77.00
Rate for Payer: University Health Alliance Commercial	$9.88

RBC Antigens 8

Facility

$175.00

Service Code	HCPCS 86905
Hospital Charge Code	12540274
Hospital Revenue Code	302
Min. Negotiated Rate	$148.75
Max. Negotiated Rate	$169.75
Rate for Payer: Cash Price	$113.75
Rate for Payer: Health Management Network Commercial	$148.75
Rate for Payer: Kaiser Permanente Commercial	$157.50
Rate for Payer: MDX Hawaii PPO	$169.75

RBC Antigens 8

Facility

$175.00

Service Code	HCPCS 86905
Hospital Charge Code	12540274
Hospital Revenue Code	302
Min. Negotiated Rate	$3.83
Max. Negotiated Rate	$169.75
Rate for Payer: AlohaCare Medicaid	$87.50
Rate for Payer: AlohaCare Medicare	$87.50
Rate for Payer: Cash Price	$113.75
Rate for Payer: Cash Price	$113.75
Rate for Payer: Devoted Health Medicare	$96.25
Rate for Payer: Hawaii Medical Service Association ABD	$5.28
Rate for Payer: Hawaii Medical Service Association Commercial	$4.79
Rate for Payer: Hawaii Medical Service Association Medicare	$87.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$5.54
Rate for Payer: Hawaii Western Management Group Commercial	$3.83
Rate for Payer: Health Management Network Commercial	$148.75
Rate for Payer: Humana Medicare	$87.50
Rate for Payer: Kaiser Permanente Commercial	$157.50
Rate for Payer: Kaiser Permanente Medicaid	$89.25
Rate for Payer: Kaiser Permanente Medicare	$87.50
Rate for Payer: MDX Hawaii PPO	$169.75
Rate for Payer: Ohana Health Plan Medicaid	$87.50
Rate for Payer: Ohana Health Plan Medicare	$87.50
Rate for Payer: UnitedHealthcare Medicaid	$5.28
Rate for Payer: UnitedHealthcare Medicare	$87.50
Rate for Payer: University Health Alliance Commercial	$9.88

RECTAL RESECTION WITH CC

Facility

$71,224.51

Service Code	MSDRG 333
Min. Negotiated Rate	$71,224.51
Max. Negotiated Rate	$71,224.51
Rate for Payer: Hawaii Medical Service Association Commercial	$71,224.51

RECTAL RESECTION WITH MCC

Facility

$71,224.51

Service Code	MSDRG 332
Min. Negotiated Rate	$71,224.51
Max. Negotiated Rate	$71,224.51
Rate for Payer: Hawaii Medical Service Association Commercial	$71,224.51

RECTAL RESECTION WITHOUT CC/MCC

Facility

$34,083.48

Service Code	MSDRG 334
Min. Negotiated Rate	$34,083.48
Max. Negotiated Rate	$34,083.48
Rate for Payer: Hawaii Medical Service Association Commercial	$34,083.48

RED BLOOD CELL DISORDERS WITH MCC

Facility

$31,049.62

Service Code	MSDRG 811
Min. Negotiated Rate	$31,049.62
Max. Negotiated Rate	$31,049.62
Rate for Payer: Hawaii Medical Service Association Commercial	$31,049.62

RED BLOOD CELL DISORDERS WITHOUT MCC

Facility

$16,638.80

Service Code	MSDRG 812
Min. Negotiated Rate	$16,638.80
Max. Negotiated Rate	$16,638.80
Rate for Payer: Hawaii Medical Service Association Commercial	$16,638.80

REHABILITATION WITH CC/MCC

Facility

$9,765.22

Service Code	MSDRG 945
Min. Negotiated Rate	$9,765.22
Max. Negotiated Rate	$9,765.22
Rate for Payer: Hawaii Medical Service Association Commercial	$9,765.22

REHABILITATION WITHOUT CC/MCC

Facility

$9,765.22

Service Code	MSDRG 946
Min. Negotiated Rate	$9,765.22
Max. Negotiated Rate	$9,765.22
Rate for Payer: Hawaii Medical Service Association Commercial	$9,765.22

Removal of sutures and staples w/o anesthesia

Facility

$17.00

Service Code	HCPCS 15853
Hospital Charge Code	8762515
Hospital Revenue Code	999
Min. Negotiated Rate	$14.45
Max. Negotiated Rate	$16.49
Rate for Payer: Cash Price	$11.05
Rate for Payer: Health Management Network Commercial	$14.45
Rate for Payer: Kaiser Permanente Commercial	$15.30
Rate for Payer: MDX Hawaii PPO	$16.49

Removal of sutures and staples w/o anesthesia

Facility

$17.00

Service Code	HCPCS 15853
Hospital Charge Code	8762515
Hospital Revenue Code	999
Min. Negotiated Rate	$8.50
Max. Negotiated Rate	$16.49
Rate for Payer: AlohaCare Medicaid	$8.50
Rate for Payer: AlohaCare Medicare	$8.50
Rate for Payer: Cash Price	$11.05
Rate for Payer: Cash Price	$11.05
Rate for Payer: Devoted Health Medicare	$9.35
Rate for Payer: Hawaii Medical Service Association Medicare	$8.50
Rate for Payer: Hawaii Western Management Group Commercial	$16.15
Rate for Payer: Health Management Network Commercial	$14.45
Rate for Payer: Humana Medicare	$8.50
Rate for Payer: Kaiser Permanente Commercial	$15.30
Rate for Payer: Kaiser Permanente Medicaid	$8.67
Rate for Payer: Kaiser Permanente Medicare	$8.50
Rate for Payer: MDX Hawaii PPO	$16.49
Rate for Payer: Ohana Health Plan Medicaid	$8.50
Rate for Payer: Ohana Health Plan Medicare	$8.50
Rate for Payer: UnitedHealthcare Medicaid	$13.19
Rate for Payer: UnitedHealthcare Medicare	$8.50
Rate for Payer: University Health Alliance Commercial	$9.52

RENAL FAILURE WITH CC

Facility

$30,006.73

Service Code	MSDRG 683
Min. Negotiated Rate	$30,006.73
Max. Negotiated Rate	$30,006.73
Rate for Payer: Hawaii Medical Service Association Commercial	$30,006.73

RENAL FAILURE WITH MCC

Facility

$30,006.73

Service Code	MSDRG 682
Min. Negotiated Rate	$30,006.73
Max. Negotiated Rate	$30,006.73
Rate for Payer: Hawaii Medical Service Association Commercial	$30,006.73

RENAL FAILURE WITHOUT CC/MCC

Facility

$30,006.73

Service Code	MSDRG 684
Min. Negotiated Rate	$30,006.73
Max. Negotiated Rate	$30,006.73
Rate for Payer: Hawaii Medical Service Association Commercial	$30,006.73

Renal Function Panel FSI

Facility

$113.00

Service Code	HCPCS 80069
Hospital Charge Code	8118031
Hospital Revenue Code	301
Min. Negotiated Rate	$96.05
Max. Negotiated Rate	$109.61
Rate for Payer: Cash Price	$73.45
Rate for Payer: Health Management Network Commercial	$96.05
Rate for Payer: Kaiser Permanente Commercial	$101.70
Rate for Payer: MDX Hawaii PPO	$109.61

Renal Function Panel FSI

Facility

$113.00

Service Code	HCPCS 80069
Hospital Charge Code	8118031
Hospital Revenue Code	301
Min. Negotiated Rate	$8.68
Max. Negotiated Rate	$109.61
Rate for Payer: AlohaCare Medicaid	$56.50
Rate for Payer: AlohaCare Medicare	$56.50
Rate for Payer: Cash Price	$73.45
Rate for Payer: Cash Price	$73.45
Rate for Payer: Devoted Health Medicare	$62.15
Rate for Payer: Hawaii Medical Service Association ABD	$12.00
Rate for Payer: Hawaii Medical Service Association Commercial	$10.85
Rate for Payer: Hawaii Medical Service Association Medicare	$56.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$12.60
Rate for Payer: Hawaii Western Management Group Commercial	$8.68
Rate for Payer: Health Management Network Commercial	$96.05
Rate for Payer: Humana Medicare	$56.50
Rate for Payer: Kaiser Permanente Commercial	$101.70
Rate for Payer: Kaiser Permanente Medicaid	$57.63
Rate for Payer: Kaiser Permanente Medicare	$56.50
Rate for Payer: MDX Hawaii PPO	$109.61
Rate for Payer: Ohana Health Plan Medicaid	$56.50
Rate for Payer: Ohana Health Plan Medicare	$56.50
Rate for Payer: UnitedHealthcare Medicaid	$12.00
Rate for Payer: UnitedHealthcare Medicare	$56.50
Rate for Payer: University Health Alliance Commercial	$22.44

Replace G-tube per RN Charge

Facility

$1,722.00

Service Code	HCPCS 43762
Hospital Charge Code	8386886
Hospital Revenue Code	450
Min. Negotiated Rate	$450.00
Max. Negotiated Rate	$1,670.34
Rate for Payer: AlohaCare Medicaid	$861.00
Rate for Payer: AlohaCare Medicare	$861.00
Rate for Payer: Cash Price	$1,119.30
Rate for Payer: Cash Price	$1,119.30
Rate for Payer: Devoted Health Medicare	$947.10
Rate for Payer: Hawaii Medical Service Association ABD	$469.00
Rate for Payer: Hawaii Medical Service Association Commercial	$1,600.00
Rate for Payer: Hawaii Medical Service Association Medicare	$861.00
Rate for Payer: Hawaii Medical Service Association Non-ABD	$450.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,635.90
Rate for Payer: Health Management Network Commercial	$1,463.70
Rate for Payer: Humana Medicare	$861.00
Rate for Payer: Kaiser Permanente Commercial	$1,549.80
Rate for Payer: Kaiser Permanente Medicaid	$937.50
Rate for Payer: Kaiser Permanente Medicare	$861.00
Rate for Payer: MDX Hawaii PPO	$1,670.34
Rate for Payer: Ohana Health Plan Medicaid	$861.00
Rate for Payer: Ohana Health Plan Medicare	$861.00
Rate for Payer: UnitedHealthcare Medicare	$861.00
Rate for Payer: University Health Alliance Commercial	$1,255.17

Replace G-tube per RN Charge

Facility

$1,722.00

Service Code	HCPCS 43762
Hospital Charge Code	8386886
Hospital Revenue Code	450
Min. Negotiated Rate	$1,463.70
Max. Negotiated Rate	$1,670.34
Rate for Payer: Cash Price	$1,119.30
Rate for Payer: Health Management Network Commercial	$1,463.70
Rate for Payer: Kaiser Permanente Commercial	$1,549.80
Rate for Payer: MDX Hawaii PPO	$1,670.34

Replantation, digit, excluding thumb, complete amputation

Professional

Both

$4,730.00

Service Code	HCPCS 20822
Hospital Charge Code	8037416
Hospital Revenue Code	521
Min. Negotiated Rate	$181.39
Max. Negotiated Rate	$4,020.50
Rate for Payer: AlohaCare Medicaid	$1,796.21
Rate for Payer: AlohaCare Medicare	$1,599.95
Rate for Payer: Cash Price	$3,074.50
Rate for Payer: Cash Price	$3,074.50
Rate for Payer: Cash Price	$3,074.50
Rate for Payer: Devoted Health Medicare	$1,759.94
Rate for Payer: Hawaii Medical Service Association ABD	$434.26
Rate for Payer: Hawaii Medical Service Association Medicare	$265.97
Rate for Payer: Hawaii Medical Service Association Medicare	$339.46
Rate for Payer: Hawaii Medical Service Association Medicare	$237.64
Rate for Payer: Hawaii Medical Service Association Medicare	$246.64
Rate for Payer: Hawaii Medical Service Association Medicare	$303.73
Rate for Payer: Hawaii Medical Service Association Medicare	$181.39
Rate for Payer: Hawaii Medical Service Association Medicare	$209.49
Rate for Payer: Hawaii Medical Service Association Non-ABD	$434.26
Rate for Payer: Hawaii Western Management Group Commercial	$1,593.28
Rate for Payer: Health Management Network Commercial	$4,020.50
Rate for Payer: Kaiser Permanente Commercial	$339.46
Rate for Payer: Kaiser Permanente Commercial	$1,919.94
Rate for Payer: Kaiser Permanente Commercial	$181.39
Rate for Payer: Kaiser Permanente Commercial	$209.49
Rate for Payer: Kaiser Permanente Commercial	$237.64
Rate for Payer: Kaiser Permanente Commercial	$246.64
Rate for Payer: Kaiser Permanente Commercial	$265.97
Rate for Payer: Kaiser Permanente Commercial	$303.73
Rate for Payer: Kaiser Permanente Medicaid	$434.26
Rate for Payer: Kaiser Permanente Medicare	$339.46
Rate for Payer: Kaiser Permanente Medicare	$181.39
Rate for Payer: Kaiser Permanente Medicare	$209.49
Rate for Payer: Kaiser Permanente Medicare	$237.64
Rate for Payer: Kaiser Permanente Medicare	$246.64
Rate for Payer: Kaiser Permanente Medicare	$303.73
Rate for Payer: Kaiser Permanente Medicare	$265.97
Rate for Payer: Ohana Health Plan Medicaid	$1,796.21
Rate for Payer: Ohana Health Plan Medicare	$1,599.95
Rate for Payer: UnitedHealthcare Medicaid	$434.26
Rate for Payer: UnitedHealthcare Medicare	$303.73
Rate for Payer: UnitedHealthcare Medicare	$181.39
Rate for Payer: UnitedHealthcare Medicare	$209.49
Rate for Payer: UnitedHealthcare Medicare	$237.64
Rate for Payer: UnitedHealthcare Medicare	$246.64
Rate for Payer: UnitedHealthcare Medicare	$265.97
Rate for Payer: UnitedHealthcare Medicare	$339.46

RESPIRATORY INFECTIONS AND INFLAMMATIONS WITH CC

Facility

$42,142.16

Service Code	MSDRG 178
Min. Negotiated Rate	$42,142.16
Max. Negotiated Rate	$42,142.16
Rate for Payer: Hawaii Medical Service Association Commercial	$42,142.16

RESPIRATORY INFECTIONS AND INFLAMMATIONS WITH MCC

Facility

$42,142.16

Service Code	MSDRG 177
Min. Negotiated Rate	$42,142.16
Max. Negotiated Rate	$42,142.16
Rate for Payer: Hawaii Medical Service Association Commercial	$42,142.16

Know your out-of-pocket cost for care.

All Charges