Samuel Mahelona Memorial Hospital

All Charges

Charge

Type

Setting

Price

RETROGRADE FEMORAL NAIL, 13MM X 38CM

Facility

$5,030.00

Service Code	HCPCS C1713
Hospital Charge Code	12991367
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

RETROGRADE FEMORAL NAIL, 13MM X 38CM

Facility

$5,030.00

Service Code	HCPCS C1713
Hospital Charge Code	12991367
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, 13MM X 42CM

Facility

$5,030.00

Service Code	HCPCS C1713
Hospital Charge Code	12991376
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, 13MM X 42CM

Facility

$5,030.00

Service Code	HCPCS C1713
Hospital Charge Code	12991376
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

Reverse Triiodothyronine, RT3 FSI

Facility

$179.00

Service Code	HCPCS 84482
Hospital Charge Code	8118033
Hospital Revenue Code	301
Min. Negotiated Rate	$15.76
Max. Negotiated Rate	$173.63
Rate for Payer: AlohaCare Medicaid	$89.50
Rate for Payer: AlohaCare Medicare	$89.50
Rate for Payer: Cash Price	$116.35
Rate for Payer: Cash Price	$116.35
Rate for Payer: Devoted Health Medicare	$98.45
Rate for Payer: Hawaii Medical Service Association ABD	$21.78
Rate for Payer: Hawaii Medical Service Association Commercial	$19.70
Rate for Payer: Hawaii Medical Service Association Medicare	$89.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$22.87
Rate for Payer: Hawaii Western Management Group Commercial	$15.76
Rate for Payer: Health Management Network Commercial	$152.15
Rate for Payer: Humana Medicare	$89.50
Rate for Payer: Kaiser Permanente Commercial	$161.10
Rate for Payer: Kaiser Permanente Medicaid	$91.29
Rate for Payer: Kaiser Permanente Medicare	$89.50
Rate for Payer: MDX Hawaii PPO	$173.63
Rate for Payer: Ohana Health Plan Medicaid	$89.50
Rate for Payer: Ohana Health Plan Medicare	$89.50
Rate for Payer: UnitedHealthcare Medicaid	$21.78
Rate for Payer: UnitedHealthcare Medicare	$89.50
Rate for Payer: University Health Alliance Commercial	$40.74

Reverse Triiodothyronine, RT3 FSI

Facility

$179.00

Service Code	HCPCS 84482
Hospital Charge Code	8118033
Hospital Revenue Code	301
Min. Negotiated Rate	$152.15
Max. Negotiated Rate	$173.63
Rate for Payer: Cash Price	$116.35
Rate for Payer: Health Management Network Commercial	$152.15
Rate for Payer: Kaiser Permanente Commercial	$161.10
Rate for Payer: MDX Hawaii PPO	$173.63

REVISION OF HIP OR KNEE REPLACEMENT WITH CC

Facility

$56,576.67

Service Code	MSDRG 467
Min. Negotiated Rate	$56,576.67
Max. Negotiated Rate	$56,576.67
Rate for Payer: Hawaii Medical Service Association Commercial	$56,576.67

REVISION OF HIP OR KNEE REPLACEMENT WITH MCC

Facility

$56,576.67

Service Code	MSDRG 466
Min. Negotiated Rate	$56,576.67
Max. Negotiated Rate	$56,576.67
Rate for Payer: Hawaii Medical Service Association Commercial	$56,576.67

REVISION OF HIP OR KNEE REPLACEMENT WITHOUT CC/MCC

Facility

$56,576.67

Service Code	MSDRG 468
Min. Negotiated Rate	$56,576.67
Max. Negotiated Rate	$56,576.67
Rate for Payer: Hawaii Medical Service Association Commercial	$56,576.67

RH (D) Type FSI

Facility

$124.00

Service Code	HCPCS 86901
Hospital Charge Code	8118034
Hospital Revenue Code	300
Min. Negotiated Rate	$2.99
Max. Negotiated Rate	$120.28
Rate for Payer: AlohaCare Medicaid	$62.00
Rate for Payer: AlohaCare Medicare	$62.00
Rate for Payer: Cash Price	$80.60
Rate for Payer: Cash Price	$80.60
Rate for Payer: Devoted Health Medicare	$68.20
Rate for Payer: Hawaii Medical Service Association ABD	$8.22
Rate for Payer: Hawaii Medical Service Association Commercial	$3.74
Rate for Payer: Hawaii Medical Service Association Medicare	$62.00
Rate for Payer: Hawaii Medical Service Association Non-ABD	$8.63
Rate for Payer: Hawaii Western Management Group Commercial	$2.99
Rate for Payer: Health Management Network Commercial	$105.40
Rate for Payer: Humana Medicare	$62.00
Rate for Payer: Kaiser Permanente Commercial	$111.60
Rate for Payer: Kaiser Permanente Medicaid	$63.24
Rate for Payer: Kaiser Permanente Medicare	$62.00
Rate for Payer: MDX Hawaii PPO	$120.28
Rate for Payer: Ohana Health Plan Medicaid	$62.00
Rate for Payer: Ohana Health Plan Medicare	$62.00
Rate for Payer: UnitedHealthcare Medicaid	$8.22
Rate for Payer: UnitedHealthcare Medicare	$62.00
Rate for Payer: University Health Alliance Commercial	$7.71

RH (D) Type FSI

Facility

$124.00

Service Code	HCPCS 86901
Hospital Charge Code	8118034
Hospital Revenue Code	300
Min. Negotiated Rate	$105.40
Max. Negotiated Rate	$120.28
Rate for Payer: Cash Price	$80.60
Rate for Payer: Health Management Network Commercial	$105.40
Rate for Payer: Kaiser Permanente Commercial	$111.60
Rate for Payer: MDX Hawaii PPO	$120.28

Rheumatoid (RA) Factor Quantitative FSI

Facility

$63.00

Service Code	HCPCS 86431
Hospital Charge Code	8118035
Hospital Revenue Code	302
Min. Negotiated Rate	$53.55
Max. Negotiated Rate	$61.11
Rate for Payer: Cash Price	$40.95
Rate for Payer: Health Management Network Commercial	$53.55
Rate for Payer: Kaiser Permanente Commercial	$56.70
Rate for Payer: MDX Hawaii PPO	$61.11

Rheumatoid (RA) Factor Quantitative FSI

Facility

$63.00

Service Code	HCPCS 86431
Hospital Charge Code	8118035
Hospital Revenue Code	302
Min. Negotiated Rate	$5.67
Max. Negotiated Rate	$61.11
Rate for Payer: AlohaCare Medicaid	$31.50
Rate for Payer: AlohaCare Medicare	$31.50
Rate for Payer: Cash Price	$40.95
Rate for Payer: Cash Price	$40.95
Rate for Payer: Devoted Health Medicare	$34.65
Rate for Payer: Hawaii Medical Service Association ABD	$7.85
Rate for Payer: Hawaii Medical Service Association Commercial	$7.09
Rate for Payer: Hawaii Medical Service Association Medicare	$31.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$8.24
Rate for Payer: Hawaii Western Management Group Commercial	$5.67
Rate for Payer: Health Management Network Commercial	$53.55
Rate for Payer: Humana Medicare	$31.50
Rate for Payer: Kaiser Permanente Commercial	$56.70
Rate for Payer: Kaiser Permanente Medicaid	$32.13
Rate for Payer: Kaiser Permanente Medicare	$31.50
Rate for Payer: MDX Hawaii PPO	$61.11
Rate for Payer: Ohana Health Plan Medicaid	$31.50
Rate for Payer: Ohana Health Plan Medicare	$31.50
Rate for Payer: UnitedHealthcare Medicaid	$7.85
Rate for Payer: UnitedHealthcare Medicare	$31.50
Rate for Payer: University Health Alliance Commercial	$14.67

RHo(D) immune glob 300 mcg syringe [HHSC]

Facility

$661.00

Service Code	HCPCS J2791
Hospital Charge Code	2500729
Hospital Revenue Code	250
Min. Negotiated Rate	$561.85
Max. Negotiated Rate	$641.17
Rate for Payer: Cash Price	$429.65
Rate for Payer: Health Management Network Commercial	$561.85
Rate for Payer: Kaiser Permanente Commercial	$594.90
Rate for Payer: MDX Hawaii PPO	$641.17

RHo(D) immune glob 300 mcg syringe [HHSC]

Facility

$661.00

Service Code	HCPCS J2791
Hospital Charge Code	2500729
Hospital Revenue Code	636
Min. Negotiated Rate	$4.97
Max. Negotiated Rate	$641.17
Rate for Payer: AlohaCare Medicaid	$330.50
Rate for Payer: AlohaCare Medicare	$330.50
Rate for Payer: Cash Price	$429.65
Rate for Payer: Cash Price	$429.65
Rate for Payer: Devoted Health Medicare	$363.55
Rate for Payer: Hawaii Medical Service Association ABD	$4.97
Rate for Payer: Hawaii Medical Service Association Medicare	$330.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$4.97
Rate for Payer: Hawaii Western Management Group Commercial	$627.95
Rate for Payer: Health Management Network Commercial	$561.85
Rate for Payer: Humana Medicare	$330.50
Rate for Payer: Kaiser Permanente Commercial	$594.90
Rate for Payer: Kaiser Permanente Medicaid	$337.11
Rate for Payer: Kaiser Permanente Medicare	$330.50
Rate for Payer: MDX Hawaii PPO	$641.17
Rate for Payer: Ohana Health Plan Medicaid	$330.50
Rate for Payer: Ohana Health Plan Medicare	$330.50
Rate for Payer: UnitedHealthcare Medicaid	$396.60
Rate for Payer: UnitedHealthcare Medicare	$330.50
Rate for Payer: University Health Alliance Commercial	$481.80

risperiDONE 1 mg tablet [HHSC]

Facility

$25.31

Service Code	NDC 68382011414
Hospital Charge Code	2500731
Hospital Revenue Code	250
Min. Negotiated Rate	$12.65
Max. Negotiated Rate	$24.55
Rate for Payer: AlohaCare Medicaid	$12.65
Rate for Payer: AlohaCare Medicare	$12.65
Rate for Payer: Cash Price	$16.45
Rate for Payer: Devoted Health Medicare	$13.92
Rate for Payer: Hawaii Medical Service Association Medicare	$12.65
Rate for Payer: Hawaii Western Management Group Commercial	$24.04
Rate for Payer: Health Management Network Commercial	$21.51
Rate for Payer: Humana Medicare	$12.65
Rate for Payer: Kaiser Permanente Commercial	$22.78
Rate for Payer: Kaiser Permanente Medicaid	$12.91
Rate for Payer: Kaiser Permanente Medicare	$12.65
Rate for Payer: MDX Hawaii PPO	$24.55
Rate for Payer: Ohana Health Plan Medicaid	$12.65
Rate for Payer: Ohana Health Plan Medicare	$12.65
Rate for Payer: UnitedHealthcare Medicaid	$15.19
Rate for Payer: UnitedHealthcare Medicare	$12.65
Rate for Payer: University Health Alliance Commercial	$18.45

risperiDONE 1 mg tablet [HHSC]

Facility

$25.31

Service Code	NDC 68382011414
Hospital Charge Code	2500731
Hospital Revenue Code	250
Min. Negotiated Rate	$21.51
Max. Negotiated Rate	$24.55
Rate for Payer: Cash Price	$16.45
Rate for Payer: Health Management Network Commercial	$21.51
Rate for Payer: Kaiser Permanente Commercial	$22.78
Rate for Payer: MDX Hawaii PPO	$24.55

risperiDONE 1 mg tablet [HHSC]

Facility

$25.25

Service Code	NDC 68084027201
Hospital Charge Code	2500731
Hospital Revenue Code	250
Min. Negotiated Rate	$21.46
Max. Negotiated Rate	$24.49
Rate for Payer: Cash Price	$16.41
Rate for Payer: Health Management Network Commercial	$21.46
Rate for Payer: Kaiser Permanente Commercial	$22.73
Rate for Payer: MDX Hawaii PPO	$24.49

risperiDONE 1 mg tablet [HHSC]

Facility

$25.25

Service Code	NDC 68084027201
Hospital Charge Code	2500731
Hospital Revenue Code	250
Min. Negotiated Rate	$12.62
Max. Negotiated Rate	$24.49
Rate for Payer: AlohaCare Medicaid	$12.62
Rate for Payer: AlohaCare Medicare	$12.62
Rate for Payer: Cash Price	$16.41
Rate for Payer: Devoted Health Medicare	$13.89
Rate for Payer: Hawaii Medical Service Association Medicare	$12.62
Rate for Payer: Hawaii Western Management Group Commercial	$23.99
Rate for Payer: Health Management Network Commercial	$21.46
Rate for Payer: Humana Medicare	$12.62
Rate for Payer: Kaiser Permanente Commercial	$22.73
Rate for Payer: Kaiser Permanente Medicaid	$12.88
Rate for Payer: Kaiser Permanente Medicare	$12.62
Rate for Payer: MDX Hawaii PPO	$24.49
Rate for Payer: Ohana Health Plan Medicaid	$12.62
Rate for Payer: Ohana Health Plan Medicare	$12.62
Rate for Payer: UnitedHealthcare Medicaid	$15.15
Rate for Payer: UnitedHealthcare Medicare	$12.62
Rate for Payer: University Health Alliance Commercial	$18.40

risperiDONE 3 mg tablet [HHSC]

Facility

$53.19

Service Code	NDC 68382011614
Hospital Charge Code	2500732
Hospital Revenue Code	250
Min. Negotiated Rate	$45.21
Max. Negotiated Rate	$51.59
Rate for Payer: Cash Price	$34.57
Rate for Payer: Health Management Network Commercial	$45.21
Rate for Payer: Kaiser Permanente Commercial	$47.87
Rate for Payer: MDX Hawaii PPO	$51.59

risperiDONE 3 mg tablet [HHSC]

Facility

$53.09

Service Code	NDC 68084027401
Hospital Charge Code	2500732
Hospital Revenue Code	250
Min. Negotiated Rate	$26.55
Max. Negotiated Rate	$51.50
Rate for Payer: AlohaCare Medicaid	$26.55
Rate for Payer: AlohaCare Medicare	$26.55
Rate for Payer: Cash Price	$34.51
Rate for Payer: Devoted Health Medicare	$29.20
Rate for Payer: Hawaii Medical Service Association Medicare	$26.55
Rate for Payer: Hawaii Western Management Group Commercial	$50.44
Rate for Payer: Health Management Network Commercial	$45.13
Rate for Payer: Humana Medicare	$26.55
Rate for Payer: Kaiser Permanente Commercial	$47.78
Rate for Payer: Kaiser Permanente Medicaid	$27.08
Rate for Payer: Kaiser Permanente Medicare	$26.55
Rate for Payer: MDX Hawaii PPO	$51.50
Rate for Payer: Ohana Health Plan Medicaid	$26.55
Rate for Payer: Ohana Health Plan Medicare	$26.55
Rate for Payer: UnitedHealthcare Medicaid	$31.85
Rate for Payer: UnitedHealthcare Medicare	$26.55
Rate for Payer: University Health Alliance Commercial	$38.70

risperiDONE 3 mg tablet [HHSC]

Facility

$53.19

Service Code	NDC 68382011614
Hospital Charge Code	2500732
Hospital Revenue Code	250
Min. Negotiated Rate	$26.59
Max. Negotiated Rate	$51.59
Rate for Payer: AlohaCare Medicaid	$26.59
Rate for Payer: AlohaCare Medicare	$26.59
Rate for Payer: Cash Price	$34.57
Rate for Payer: Devoted Health Medicare	$29.25
Rate for Payer: Hawaii Medical Service Association Medicare	$26.59
Rate for Payer: Hawaii Western Management Group Commercial	$50.53
Rate for Payer: Health Management Network Commercial	$45.21
Rate for Payer: Humana Medicare	$26.59
Rate for Payer: Kaiser Permanente Commercial	$47.87
Rate for Payer: Kaiser Permanente Medicaid	$27.13
Rate for Payer: Kaiser Permanente Medicare	$26.59
Rate for Payer: MDX Hawaii PPO	$51.59
Rate for Payer: Ohana Health Plan Medicaid	$26.59
Rate for Payer: Ohana Health Plan Medicare	$26.59
Rate for Payer: UnitedHealthcare Medicaid	$31.91
Rate for Payer: UnitedHealthcare Medicare	$26.59
Rate for Payer: University Health Alliance Commercial	$38.77

risperiDONE 3 mg tablet [HHSC]

Facility

$53.09

Service Code	NDC 68084027401
Hospital Charge Code	2500732
Hospital Revenue Code	250
Min. Negotiated Rate	$45.13
Max. Negotiated Rate	$51.50
Rate for Payer: Cash Price	$34.51
Rate for Payer: Health Management Network Commercial	$45.13
Rate for Payer: Kaiser Permanente Commercial	$47.78
Rate for Payer: MDX Hawaii PPO	$51.50

RNP (ENA) Ribonucleic Protein, IgG FSI

Facility

$205.00

Service Code	HCPCS 86235
Hospital Charge Code	8118036
Hospital Revenue Code	302
Min. Negotiated Rate	$174.25
Max. Negotiated Rate	$198.85
Rate for Payer: Cash Price	$133.25
Rate for Payer: Health Management Network Commercial	$174.25
Rate for Payer: Kaiser Permanente Commercial	$184.50
Rate for Payer: MDX Hawaii PPO	$198.85

RNP (ENA) Ribonucleic Protein, IgG FSI

Facility

$205.00

Service Code	HCPCS 86235
Hospital Charge Code	8118036
Hospital Revenue Code	302
Min. Negotiated Rate	$17.93
Max. Negotiated Rate	$198.85
Rate for Payer: AlohaCare Medicaid	$102.50
Rate for Payer: AlohaCare Medicare	$102.50
Rate for Payer: Cash Price	$133.25
Rate for Payer: Cash Price	$133.25
Rate for Payer: Devoted Health Medicare	$112.75
Rate for Payer: Hawaii Medical Service Association ABD	$24.78
Rate for Payer: Hawaii Medical Service Association Commercial	$22.41
Rate for Payer: Hawaii Medical Service Association Medicare	$102.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$26.02
Rate for Payer: Hawaii Western Management Group Commercial	$17.93
Rate for Payer: Health Management Network Commercial	$174.25
Rate for Payer: Humana Medicare	$102.50
Rate for Payer: Kaiser Permanente Commercial	$184.50
Rate for Payer: Kaiser Permanente Medicaid	$104.55
Rate for Payer: Kaiser Permanente Medicare	$102.50
Rate for Payer: MDX Hawaii PPO	$198.85
Rate for Payer: Ohana Health Plan Medicaid	$102.50
Rate for Payer: Ohana Health Plan Medicare	$102.50
Rate for Payer: UnitedHealthcare Medicaid	$24.78
Rate for Payer: UnitedHealthcare Medicare	$102.50
Rate for Payer: University Health Alliance Commercial	$46.36

Know your out-of-pocket cost for care.

All Charges