Samuel Mahelona Memorial Hospital

All Charges

Charge

Type

Setting

Price

RESPIRATORY INFECTIONS AND INFLAMMATIONS WITHOUT CC/MCC

Facility

$33,277.61

Service Code	MSDRG 179
Min. Negotiated Rate	$33,277.61
Max. Negotiated Rate	$33,277.61
Rate for Payer: Hawaii Medical Service Association Commercial	$33,277.61

RESPIRATORY NEOPLASMS WITH CC

Facility

$35,932.23

Service Code	MSDRG 181
Min. Negotiated Rate	$35,932.23
Max. Negotiated Rate	$35,932.23
Rate for Payer: Hawaii Medical Service Association Commercial	$35,932.23

RESPIRATORY NEOPLASMS WITH MCC

Facility

$35,932.23

Service Code	MSDRG 180
Min. Negotiated Rate	$35,932.23
Max. Negotiated Rate	$35,932.23
Rate for Payer: Hawaii Medical Service Association Commercial	$35,932.23

RESPIRATORY NEOPLASMS WITHOUT CC/MCC

Facility

$35,932.23

Service Code	MSDRG 182
Min. Negotiated Rate	$35,932.23
Max. Negotiated Rate	$35,932.23
Rate for Payer: Hawaii Medical Service Association Commercial	$35,932.23

Respiratory Panel PCR FSI

Facility

$2,729.00

Service Code	HCPCS 0202U
Hospital Charge Code	8228914
Hospital Revenue Code	306
Min. Negotiated Rate	$2,319.65
Max. Negotiated Rate	$2,647.13
Rate for Payer: Cash Price	$1,773.85
Rate for Payer: Health Management Network Commercial	$2,319.65
Rate for Payer: Kaiser Permanente Commercial	$2,456.10
Rate for Payer: MDX Hawaii PPO	$2,647.13

Respiratory Panel PCR FSI

Facility

$2,729.00

Service Code	HCPCS 0202U
Hospital Charge Code	8228914
Hospital Revenue Code	306
Min. Negotiated Rate	$416.78
Max. Negotiated Rate	$2,647.13
Rate for Payer: AlohaCare Medicaid	$1,364.50
Rate for Payer: AlohaCare Medicare	$1,364.50
Rate for Payer: Cash Price	$1,773.85
Rate for Payer: Cash Price	$1,773.85
Rate for Payer: Devoted Health Medicare	$1,500.95
Rate for Payer: Hawaii Medical Service Association Commercial	$520.98
Rate for Payer: Hawaii Medical Service Association Medicare	$1,364.50
Rate for Payer: Hawaii Western Management Group Commercial	$2,592.55
Rate for Payer: Health Management Network Commercial	$2,319.65
Rate for Payer: Humana Medicare	$1,364.50
Rate for Payer: Kaiser Permanente Commercial	$2,456.10
Rate for Payer: Kaiser Permanente Medicaid	$1,391.79
Rate for Payer: Kaiser Permanente Medicare	$1,364.50
Rate for Payer: MDX Hawaii PPO	$2,647.13
Rate for Payer: Ohana Health Plan Medicaid	$1,364.50
Rate for Payer: Ohana Health Plan Medicare	$1,364.50
Rate for Payer: UnitedHealthcare Medicaid	$416.78
Rate for Payer: UnitedHealthcare Medicare	$1,364.50
Rate for Payer: University Health Alliance Commercial	$1,528.24

RESPIRATORY SIGNS AND SYMPTOMS

Facility

$13,486.44

Service Code	MSDRG 204
Min. Negotiated Rate	$13,486.44
Max. Negotiated Rate	$13,486.44
Rate for Payer: Hawaii Medical Service Association Commercial	$13,486.44

RESPIRATORY SYSTEM DIAGNOSIS WITH VENTILATOR SUPPORT <=96 HOURS

Facility

$70,205.32

Service Code	MSDRG 208
Min. Negotiated Rate	$70,205.32
Max. Negotiated Rate	$70,205.32
Rate for Payer: Hawaii Medical Service Association Commercial	$70,205.32

RESPIRATORY SYSTEM DIAGNOSIS WITH VENTILATOR SUPPORT >96 HOURS

Facility

$185,231.13

Service Code	MSDRG 207
Min. Negotiated Rate	$185,231.13
Max. Negotiated Rate	$185,231.13
Rate for Payer: Hawaii Medical Service Association Commercial	$185,231.13

RESPIRATORY TREATMENT CHARGE

Facility

$522.00

Service Code	HCPCS 94640
Hospital Charge Code	8243406
Hospital Revenue Code	410
Min. Negotiated Rate	$13.32
Max. Negotiated Rate	$506.34
Rate for Payer: AlohaCare Medicaid	$261.00
Rate for Payer: AlohaCare Medicare	$261.00
Rate for Payer: Cash Price	$339.30
Rate for Payer: Cash Price	$339.30
Rate for Payer: Devoted Health Medicare	$287.10
Rate for Payer: Hawaii Medical Service Association Commercial	$279.65
Rate for Payer: Hawaii Medical Service Association Medicare	$261.00
Rate for Payer: Hawaii Western Management Group Commercial	$495.90
Rate for Payer: Health Management Network Commercial	$443.70
Rate for Payer: Humana Medicare	$261.00
Rate for Payer: Kaiser Permanente Commercial	$469.80
Rate for Payer: Kaiser Permanente Medicaid	$266.22
Rate for Payer: Kaiser Permanente Medicare	$261.00
Rate for Payer: MDX Hawaii PPO	$506.34
Rate for Payer: Ohana Health Plan Medicaid	$261.00
Rate for Payer: Ohana Health Plan Medicare	$261.00
Rate for Payer: UnitedHealthcare Medicaid	$13.32
Rate for Payer: UnitedHealthcare Medicare	$261.00
Rate for Payer: University Health Alliance Commercial	$292.32

RESPIRATORY TREATMENT CHARGE

Facility

$522.00

Service Code	HCPCS 94640
Hospital Charge Code	8243406
Hospital Revenue Code	410
Min. Negotiated Rate	$443.70
Max. Negotiated Rate	$506.34
Rate for Payer: Cash Price	$339.30
Rate for Payer: Health Management Network Commercial	$443.70
Rate for Payer: Kaiser Permanente Commercial	$469.80
Rate for Payer: MDX Hawaii PPO	$506.34

RESPIRATORY TREATMENT SUBSEQUENT CHARGE

Facility

$522.00

Service Code	HCPCS 94640
Hospital Charge Code	8243407
Hospital Revenue Code	410
Min. Negotiated Rate	$443.70
Max. Negotiated Rate	$506.34
Rate for Payer: Cash Price	$339.30
Rate for Payer: Health Management Network Commercial	$443.70
Rate for Payer: Kaiser Permanente Commercial	$469.80
Rate for Payer: MDX Hawaii PPO	$506.34

RESPIRATORY TREATMENT SUBSEQUENT CHARGE

Facility

$522.00

Service Code	HCPCS 94640
Hospital Charge Code	8243407
Hospital Revenue Code	410
Min. Negotiated Rate	$13.32
Max. Negotiated Rate	$506.34
Rate for Payer: AlohaCare Medicaid	$261.00
Rate for Payer: AlohaCare Medicare	$261.00
Rate for Payer: Cash Price	$339.30
Rate for Payer: Cash Price	$339.30
Rate for Payer: Devoted Health Medicare	$287.10
Rate for Payer: Hawaii Medical Service Association Commercial	$279.65
Rate for Payer: Hawaii Medical Service Association Medicare	$261.00
Rate for Payer: Hawaii Western Management Group Commercial	$495.90
Rate for Payer: Health Management Network Commercial	$443.70
Rate for Payer: Humana Medicare	$261.00
Rate for Payer: Kaiser Permanente Commercial	$469.80
Rate for Payer: Kaiser Permanente Medicaid	$266.22
Rate for Payer: Kaiser Permanente Medicare	$261.00
Rate for Payer: MDX Hawaii PPO	$506.34
Rate for Payer: Ohana Health Plan Medicaid	$261.00
Rate for Payer: Ohana Health Plan Medicare	$261.00
Rate for Payer: UnitedHealthcare Medicaid	$13.32
Rate for Payer: UnitedHealthcare Medicare	$261.00
Rate for Payer: University Health Alliance Commercial	$292.32

REST KNEE VINYL EA

Facility

$262.00

Hospital Charge Code	12954862
Hospital Revenue Code	272
Min. Negotiated Rate	$222.70
Max. Negotiated Rate	$254.14
Rate for Payer: Cash Price	$170.30
Rate for Payer: Health Management Network Commercial	$222.70
Rate for Payer: Kaiser Permanente Commercial	$235.80
Rate for Payer: MDX Hawaii PPO	$254.14

REST KNEE VINYL EA

Professional

Both

$262.00

Hospital Charge Code	12954862
Hospital Revenue Code	272
Min. Negotiated Rate	$222.70
Max. Negotiated Rate	$222.70
Rate for Payer: Cash Price	$170.30
Rate for Payer: Health Management Network Commercial	$222.70

REST KNEE VINYL EA

Facility

$262.00

Hospital Charge Code	12954862
Hospital Revenue Code	272
Min. Negotiated Rate	$131.00
Max. Negotiated Rate	$254.14
Rate for Payer: AlohaCare Medicaid	$131.00
Rate for Payer: AlohaCare Medicare	$131.00
Rate for Payer: Cash Price	$170.30
Rate for Payer: Devoted Health Medicare	$144.10
Rate for Payer: Hawaii Medical Service Association Medicare	$131.00
Rate for Payer: Hawaii Western Management Group Commercial	$248.90
Rate for Payer: Health Management Network Commercial	$222.70
Rate for Payer: Humana Medicare	$131.00
Rate for Payer: Kaiser Permanente Commercial	$235.80
Rate for Payer: Kaiser Permanente Medicaid	$133.62
Rate for Payer: Kaiser Permanente Medicare	$131.00
Rate for Payer: MDX Hawaii PPO	$254.14
Rate for Payer: Ohana Health Plan Medicaid	$131.00
Rate for Payer: Ohana Health Plan Medicare	$131.00
Rate for Payer: UnitedHealthcare Medicare	$131.00
Rate for Payer: University Health Alliance Commercial	$190.97

Resuscitation at Birth:

Facility

$1,305.00

Service Code	HCPCS 99465
Hospital Charge Code	1370565
Hospital Revenue Code	480
Min. Negotiated Rate	$122.74
Max. Negotiated Rate	$1,265.85
Rate for Payer: AlohaCare Medicaid	$652.50
Rate for Payer: AlohaCare Medicare	$652.50
Rate for Payer: Cash Price	$848.25
Rate for Payer: Cash Price	$848.25
Rate for Payer: Devoted Health Medicare	$717.75
Rate for Payer: Hawaii Medical Service Association Commercial	$844.08
Rate for Payer: Hawaii Medical Service Association Medicare	$652.50
Rate for Payer: Hawaii Western Management Group Commercial	$1,239.75
Rate for Payer: Health Management Network Commercial	$1,109.25
Rate for Payer: Humana Medicare	$652.50
Rate for Payer: Kaiser Permanente Commercial	$1,174.50
Rate for Payer: Kaiser Permanente Medicaid	$665.55
Rate for Payer: Kaiser Permanente Medicare	$652.50
Rate for Payer: MDX Hawaii PPO	$1,265.85
Rate for Payer: Ohana Health Plan Medicaid	$652.50
Rate for Payer: Ohana Health Plan Medicare	$652.50
Rate for Payer: UnitedHealthcare Medicaid	$122.74
Rate for Payer: UnitedHealthcare Medicare	$652.50
Rate for Payer: University Health Alliance Commercial	$730.80

Resuscitation at Birth:

Facility

$1,305.00

Service Code	HCPCS 99465
Hospital Charge Code	1370565
Hospital Revenue Code	480
Min. Negotiated Rate	$1,109.25
Max. Negotiated Rate	$1,265.85
Rate for Payer: Cash Price	$848.25
Rate for Payer: Health Management Network Commercial	$1,109.25
Rate for Payer: Kaiser Permanente Commercial	$1,174.50
Rate for Payer: MDX Hawaii PPO	$1,265.85

Retic Count Automated FSI

Facility

$56.00

Service Code	HCPCS 85045
Hospital Charge Code	8118032
Hospital Revenue Code	305
Min. Negotiated Rate	$3.99
Max. Negotiated Rate	$54.32
Rate for Payer: AlohaCare Medicaid	$28.00
Rate for Payer: AlohaCare Medicare	$28.00
Rate for Payer: Cash Price	$36.40
Rate for Payer: Cash Price	$36.40
Rate for Payer: Devoted Health Medicare	$30.80
Rate for Payer: Hawaii Medical Service Association ABD	$5.59
Rate for Payer: Hawaii Medical Service Association Commercial	$4.99
Rate for Payer: Hawaii Medical Service Association Medicare	$28.00
Rate for Payer: Hawaii Medical Service Association Non-ABD	$5.87
Rate for Payer: Hawaii Western Management Group Commercial	$3.99
Rate for Payer: Health Management Network Commercial	$47.60
Rate for Payer: Humana Medicare	$28.00
Rate for Payer: Kaiser Permanente Commercial	$50.40
Rate for Payer: Kaiser Permanente Medicaid	$28.56
Rate for Payer: Kaiser Permanente Medicare	$28.00
Rate for Payer: MDX Hawaii PPO	$54.32
Rate for Payer: Ohana Health Plan Medicaid	$28.00
Rate for Payer: Ohana Health Plan Medicare	$28.00
Rate for Payer: UnitedHealthcare Medicaid	$5.59
Rate for Payer: UnitedHealthcare Medicare	$28.00
Rate for Payer: University Health Alliance Commercial	$10.34

Retic Count Automated FSI

Facility

$56.00

Service Code	HCPCS 85045
Hospital Charge Code	8118032
Hospital Revenue Code	305
Min. Negotiated Rate	$47.60
Max. Negotiated Rate	$54.32
Rate for Payer: Cash Price	$36.40
Rate for Payer: Health Management Network Commercial	$47.60
Rate for Payer: Kaiser Permanente Commercial	$50.40
Rate for Payer: MDX Hawaii PPO	$54.32

RETICULOENDOTHELIAL AND IMMUNITY DISORDERS WITH CC

Facility

$15,975.15

Service Code	MSDRG 815
Min. Negotiated Rate	$15,975.15
Max. Negotiated Rate	$15,975.15
Rate for Payer: Hawaii Medical Service Association Commercial	$15,975.15

RETICULOENDOTHELIAL AND IMMUNITY DISORDERS WITH MCC

Facility

$15,975.15

Service Code	MSDRG 814
Min. Negotiated Rate	$15,975.15
Max. Negotiated Rate	$15,975.15
Rate for Payer: Hawaii Medical Service Association Commercial	$15,975.15

RETICULOENDOTHELIAL AND IMMUNITY DISORDERS WITHOUT CC/MCC

Facility

$11,685.09

Service Code	MSDRG 816
Min. Negotiated Rate	$11,685.09
Max. Negotiated Rate	$11,685.09
Rate for Payer: Hawaii Medical Service Association Commercial	$11,685.09

RETROGRADE FEMORAL NAIL, 10MM X 26CM

Facility

$5,030.00

Service Code	HCPCS C1713
Hospital Charge Code	12989598
Hospital Revenue Code	278
Min. Negotiated Rate	$2,816.80
Max. Negotiated Rate	$4,879.10
Rate for Payer: Cash Price	$3,269.50
Rate for Payer: Hawaii Western Management Group Commercial	$3,521.00
Rate for Payer: Health Management Network Commercial	$4,275.50
Rate for Payer: Kaiser Permanente Commercial	$4,527.00
Rate for Payer: MDX Hawaii PPO	$4,879.10
Rate for Payer: University Health Alliance Commercial	$2,816.80

RETROGRADE FEMORAL NAIL, 10MM X 26CM

Facility

$5,030.00

Service Code	HCPCS C1713
Hospital Charge Code	12989598
Hospital Revenue Code	278
Min. Negotiated Rate	$2,515.00
Max. Negotiated Rate	$4,879.10
Rate for Payer: AlohaCare Medicaid	$2,515.00
Rate for Payer: AlohaCare Medicare	$2,515.00
Rate for Payer: Cash Price	$3,269.50
Rate for Payer: Devoted Health Medicare	$2,766.50
Rate for Payer: Hawaii Medical Service Association Medicare	$2,515.00
Rate for Payer: Hawaii Western Management Group Commercial	$3,521.00
Rate for Payer: Health Management Network Commercial	$4,275.50
Rate for Payer: Humana Medicare	$2,515.00
Rate for Payer: Kaiser Permanente Commercial	$4,527.00
Rate for Payer: Kaiser Permanente Medicaid	$2,565.30
Rate for Payer: Kaiser Permanente Medicare	$2,515.00
Rate for Payer: MDX Hawaii PPO	$4,879.10
Rate for Payer: Ohana Health Plan Medicaid	$2,515.00
Rate for Payer: Ohana Health Plan Medicare	$2,515.00
Rate for Payer: UnitedHealthcare Medicare	$2,515.00
Rate for Payer: University Health Alliance Commercial	$2,816.80

Know your out-of-pocket cost for care.

All Charges