Samuel Mahelona Memorial Hospital

All Charges

Charge

Type

Setting

Price

SARS-CoV-2 (COVID-19) IgG Antibody, Qual FSI

Facility

$109.00

Service Code	HCPCS 86769
Hospital Charge Code	8879007
Hospital Revenue Code	302
Min. Negotiated Rate	$92.65
Max. Negotiated Rate	$105.73
Rate for Payer: Cash Price	$70.85
Rate for Payer: Health Management Network Commercial	$92.65
Rate for Payer: Kaiser Permanente Commercial	$98.10
Rate for Payer: MDX Hawaii PPO	$105.73

SARS-Cov-2 (COVID -19) PCR, Cepheid FSI

Facility

$265.00

Service Code	HCPCS 87635
Hospital Charge Code	12930674
Hospital Revenue Code	306
Min. Negotiated Rate	$51.31
Max. Negotiated Rate	$257.05
Rate for Payer: AlohaCare Medicaid	$132.50
Rate for Payer: AlohaCare Medicare	$132.50
Rate for Payer: Cash Price	$172.25
Rate for Payer: Cash Price	$172.25
Rate for Payer: Devoted Health Medicare	$145.75
Rate for Payer: Hawaii Medical Service Association ABD	$51.31
Rate for Payer: Hawaii Medical Service Association Commercial	$64.14
Rate for Payer: Hawaii Medical Service Association Medicare	$132.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$51.31
Rate for Payer: Hawaii Western Management Group Commercial	$51.31
Rate for Payer: Health Management Network Commercial	$225.25
Rate for Payer: Humana Medicare	$132.50
Rate for Payer: Kaiser Permanente Commercial	$238.50
Rate for Payer: Kaiser Permanente Medicaid	$135.15
Rate for Payer: Kaiser Permanente Medicare	$132.50
Rate for Payer: MDX Hawaii PPO	$257.05
Rate for Payer: Ohana Health Plan Medicaid	$132.50
Rate for Payer: Ohana Health Plan Medicare	$132.50
Rate for Payer: UnitedHealthcare Medicaid	$51.31
Rate for Payer: UnitedHealthcare Medicare	$132.50
Rate for Payer: University Health Alliance Commercial	$94.96

SARS-Cov-2 (COVID -19) PCR, Cepheid FSI

Facility

$265.00

Service Code	HCPCS 87635
Hospital Charge Code	12930674
Hospital Revenue Code	306
Min. Negotiated Rate	$225.25
Max. Negotiated Rate	$257.05
Rate for Payer: Cash Price	$172.25
Rate for Payer: Health Management Network Commercial	$225.25
Rate for Payer: Kaiser Permanente Commercial	$238.50
Rate for Payer: MDX Hawaii PPO	$257.05

SARS-CoV-2 (COVID-19) Rapid (ID Now) FSI

Facility

$179.00

Service Code	HCPCS 87635 QW
Hospital Charge Code	9256869
Hospital Revenue Code	306
Min. Negotiated Rate	$51.31
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	$51.31
Rate for Payer: Hawaii Medical Service Association Commercial	$64.14
Rate for Payer: Hawaii Medical Service Association Medicare	$89.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$51.31
Rate for Payer: Hawaii Western Management Group Commercial	$51.31
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	$51.31
Rate for Payer: UnitedHealthcare Medicare	$89.50
Rate for Payer: University Health Alliance Commercial	$94.96

SARS-CoV-2 (COVID-19) Rapid (ID Now) FSI

Facility

$179.00

Service Code	HCPCS 87635 QW
Hospital Charge Code	9256869
Hospital Revenue Code	306
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

SARS-CoV-2 (COVID-19) RNA by TMA FSI

Facility

$179.00

Service Code	HCPCS 87635
Hospital Charge Code	8896718
Hospital Revenue Code	306
Min. Negotiated Rate	$51.31
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	$51.31
Rate for Payer: Hawaii Medical Service Association Commercial	$64.14
Rate for Payer: Hawaii Medical Service Association Medicare	$89.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$51.31
Rate for Payer: Hawaii Western Management Group Commercial	$51.31
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	$51.31
Rate for Payer: UnitedHealthcare Medicare	$89.50
Rate for Payer: University Health Alliance Commercial	$94.96

SARS-CoV-2 (COVID-19) RNA by TMA FSI

Facility

$179.00

Service Code	HCPCS 87635
Hospital Charge Code	8896718
Hospital Revenue Code	306
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

SARS-COV2/Flu A, B PCR FSI

Facility

$561.00

Service Code	HCPCS 87636 QW
Hospital Charge Code	10058644
Hospital Revenue Code	306
Min. Negotiated Rate	$476.85
Max. Negotiated Rate	$544.17
Rate for Payer: Cash Price	$364.65
Rate for Payer: Health Management Network Commercial	$476.85
Rate for Payer: Kaiser Permanente Commercial	$504.90
Rate for Payer: MDX Hawaii PPO	$544.17

SARS-COV2/Flu A, B PCR FSI

Facility

$561.00

Service Code	HCPCS 87636 QW
Hospital Charge Code	10058644
Hospital Revenue Code	306
Min. Negotiated Rate	$142.63
Max. Negotiated Rate	$544.17
Rate for Payer: AlohaCare Medicaid	$280.50
Rate for Payer: AlohaCare Medicare	$280.50
Rate for Payer: Cash Price	$364.65
Rate for Payer: Cash Price	$364.65
Rate for Payer: Devoted Health Medicare	$308.55
Rate for Payer: Hawaii Medical Service Association ABD	$142.63
Rate for Payer: Hawaii Medical Service Association Commercial	$178.29
Rate for Payer: Hawaii Medical Service Association Medicare	$280.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$142.63
Rate for Payer: Hawaii Western Management Group Commercial	$142.63
Rate for Payer: Health Management Network Commercial	$476.85
Rate for Payer: Humana Medicare	$280.50
Rate for Payer: Kaiser Permanente Commercial	$504.90
Rate for Payer: Kaiser Permanente Medicaid	$286.11
Rate for Payer: Kaiser Permanente Medicare	$280.50
Rate for Payer: MDX Hawaii PPO	$544.17
Rate for Payer: Ohana Health Plan Medicaid	$280.50
Rate for Payer: Ohana Health Plan Medicare	$280.50
Rate for Payer: UnitedHealthcare Medicaid	$142.63
Rate for Payer: UnitedHealthcare Medicare	$280.50
Rate for Payer: University Health Alliance Commercial	$314.16

SARS CoV-2 RNA (For International Travel Only) FSI

Facility

$179.00

Service Code	HCPCS 87635
Hospital Charge Code	9335642
Hospital Revenue Code	306
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

SARS CoV-2 RNA (For International Travel Only) FSI

Facility

$179.00

Service Code	HCPCS 87635
Hospital Charge Code	9335642
Hospital Revenue Code	306
Min. Negotiated Rate	$51.31
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	$51.31
Rate for Payer: Hawaii Medical Service Association Commercial	$64.14
Rate for Payer: Hawaii Medical Service Association Medicare	$89.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$51.31
Rate for Payer: Hawaii Western Management Group Commercial	$51.31
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	$51.31
Rate for Payer: UnitedHealthcare Medicare	$89.50
Rate for Payer: University Health Alliance Commercial	$94.96

SARS ñ CoV-2 Flu A/B, RSV PCR FSI

Facility

$579.00

Service Code	HCPCS 87637 QW
Hospital Charge Code	10026082
Hospital Revenue Code	306
Min. Negotiated Rate	$492.15
Max. Negotiated Rate	$561.63
Rate for Payer: Cash Price	$376.35
Rate for Payer: Health Management Network Commercial	$492.15
Rate for Payer: Kaiser Permanente Commercial	$521.10
Rate for Payer: MDX Hawaii PPO	$561.63

SARS ñ CoV-2 Flu A/B, RSV PCR FSI

Facility

$579.00

Service Code	HCPCS 87637 QW
Hospital Charge Code	10026082
Hospital Revenue Code	306
Min. Negotiated Rate	$142.63
Max. Negotiated Rate	$561.63
Rate for Payer: AlohaCare Medicaid	$289.50
Rate for Payer: AlohaCare Medicare	$289.50
Rate for Payer: Cash Price	$376.35
Rate for Payer: Cash Price	$376.35
Rate for Payer: Devoted Health Medicare	$318.45
Rate for Payer: Hawaii Medical Service Association ABD	$142.63
Rate for Payer: Hawaii Medical Service Association Commercial	$178.29
Rate for Payer: Hawaii Medical Service Association Medicare	$289.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$142.63
Rate for Payer: Hawaii Western Management Group Commercial	$142.63
Rate for Payer: Health Management Network Commercial	$492.15
Rate for Payer: Humana Medicare	$289.50
Rate for Payer: Kaiser Permanente Commercial	$521.10
Rate for Payer: Kaiser Permanente Medicaid	$295.29
Rate for Payer: Kaiser Permanente Medicare	$289.50
Rate for Payer: MDX Hawaii PPO	$561.63
Rate for Payer: Ohana Health Plan Medicaid	$289.50
Rate for Payer: Ohana Health Plan Medicare	$289.50
Rate for Payer: UnitedHealthcare Medicaid	$142.63
Rate for Payer: UnitedHealthcare Medicare	$289.50
Rate for Payer: University Health Alliance Commercial	$324.24

SARS ñ CoV-2 RT-PCR CPH FSI

Facility

$179.00

Service Code	HCPCS 87635 QW
Hospital Charge Code	10026135
Hospital Revenue Code	306
Min. Negotiated Rate	$51.31
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	$51.31
Rate for Payer: Hawaii Medical Service Association Commercial	$64.14
Rate for Payer: Hawaii Medical Service Association Medicare	$89.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$51.31
Rate for Payer: Hawaii Western Management Group Commercial	$51.31
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	$51.31
Rate for Payer: UnitedHealthcare Medicare	$89.50
Rate for Payer: University Health Alliance Commercial	$94.96

SARS ñ CoV-2 RT-PCR CPH FSI

Facility

$179.00

Service Code	HCPCS 87635 QW
Hospital Charge Code	10026135
Hospital Revenue Code	306
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

S. cerevisiae IgG/IgA FSI

Facility

$595.00

Service Code	HCPCS 86671
Hospital Charge Code	8331288
Hospital Revenue Code	300
Min. Negotiated Rate	$12.25
Max. Negotiated Rate	$577.15
Rate for Payer: AlohaCare Medicaid	$297.50
Rate for Payer: AlohaCare Medicare	$297.50
Rate for Payer: Cash Price	$386.75
Rate for Payer: Cash Price	$386.75
Rate for Payer: Devoted Health Medicare	$327.25
Rate for Payer: Hawaii Medical Service Association ABD	$16.95
Rate for Payer: Hawaii Medical Service Association Commercial	$15.31
Rate for Payer: Hawaii Medical Service Association Medicare	$297.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$17.80
Rate for Payer: Hawaii Western Management Group Commercial	$12.25
Rate for Payer: Health Management Network Commercial	$505.75
Rate for Payer: Humana Medicare	$297.50
Rate for Payer: Kaiser Permanente Commercial	$535.50
Rate for Payer: Kaiser Permanente Medicaid	$303.45
Rate for Payer: Kaiser Permanente Medicare	$297.50
Rate for Payer: MDX Hawaii PPO	$577.15
Rate for Payer: Ohana Health Plan Medicaid	$297.50
Rate for Payer: Ohana Health Plan Medicare	$297.50
Rate for Payer: UnitedHealthcare Medicaid	$16.95
Rate for Payer: UnitedHealthcare Medicare	$297.50
Rate for Payer: University Health Alliance Commercial	$31.69

S. cerevisiae IgG/IgA FSI

Facility

$595.00

Service Code	HCPCS 86671
Hospital Charge Code	8331288
Hospital Revenue Code	300
Min. Negotiated Rate	$505.75
Max. Negotiated Rate	$577.15
Rate for Payer: Cash Price	$386.75
Rate for Payer: Health Management Network Commercial	$505.75
Rate for Payer: Kaiser Permanente Commercial	$535.50
Rate for Payer: MDX Hawaii PPO	$577.15

SCREW SPACER/COMPRESSION BOLT, FEM NAIL

Facility

$779.00

Service Code	HCPCS C1713
Hospital Charge Code	12991371
Hospital Revenue Code	278
Min. Negotiated Rate	$389.50
Max. Negotiated Rate	$755.63
Rate for Payer: AlohaCare Medicaid	$389.50
Rate for Payer: AlohaCare Medicare	$389.50
Rate for Payer: Cash Price	$506.35
Rate for Payer: Devoted Health Medicare	$428.45
Rate for Payer: Hawaii Medical Service Association Medicare	$389.50
Rate for Payer: Hawaii Western Management Group Commercial	$545.30
Rate for Payer: Health Management Network Commercial	$662.15
Rate for Payer: Humana Medicare	$389.50
Rate for Payer: Kaiser Permanente Commercial	$701.10
Rate for Payer: Kaiser Permanente Medicaid	$397.29
Rate for Payer: Kaiser Permanente Medicare	$389.50
Rate for Payer: MDX Hawaii PPO	$755.63
Rate for Payer: Ohana Health Plan Medicaid	$389.50
Rate for Payer: Ohana Health Plan Medicare	$389.50
Rate for Payer: UnitedHealthcare Medicare	$389.50
Rate for Payer: University Health Alliance Commercial	$436.24

SCREW SPACER/COMPRESSION BOLT, FEM NAIL

Facility

$779.00

Service Code	HCPCS C1713
Hospital Charge Code	12991371
Hospital Revenue Code	278
Min. Negotiated Rate	$436.24
Max. Negotiated Rate	$755.63
Rate for Payer: Cash Price	$506.35
Rate for Payer: Hawaii Western Management Group Commercial	$545.30
Rate for Payer: Health Management Network Commercial	$662.15
Rate for Payer: Kaiser Permanente Commercial	$701.10
Rate for Payer: MDX Hawaii PPO	$755.63
Rate for Payer: University Health Alliance Commercial	$436.24

SEAL SET SINGLE USE

Facility

$67.00

Hospital Charge Code	9390157
Hospital Revenue Code	272
Min. Negotiated Rate	$56.95
Max. Negotiated Rate	$64.99
Rate for Payer: Cash Price	$43.55
Rate for Payer: Health Management Network Commercial	$56.95
Rate for Payer: Kaiser Permanente Commercial	$60.30
Rate for Payer: MDX Hawaii PPO	$64.99

SEAL SET SINGLE USE

Facility

$67.00

Hospital Charge Code	9390157
Hospital Revenue Code	272
Min. Negotiated Rate	$33.50
Max. Negotiated Rate	$64.99
Rate for Payer: AlohaCare Medicaid	$33.50
Rate for Payer: AlohaCare Medicare	$33.50
Rate for Payer: Cash Price	$43.55
Rate for Payer: Devoted Health Medicare	$36.85
Rate for Payer: Hawaii Medical Service Association Medicare	$33.50
Rate for Payer: Hawaii Western Management Group Commercial	$63.65
Rate for Payer: Health Management Network Commercial	$56.95
Rate for Payer: Humana Medicare	$33.50
Rate for Payer: Kaiser Permanente Commercial	$60.30
Rate for Payer: Kaiser Permanente Medicaid	$34.17
Rate for Payer: Kaiser Permanente Medicare	$33.50
Rate for Payer: MDX Hawaii PPO	$64.99
Rate for Payer: Ohana Health Plan Medicaid	$33.50
Rate for Payer: Ohana Health Plan Medicare	$33.50
Rate for Payer: UnitedHealthcare Medicare	$33.50
Rate for Payer: University Health Alliance Commercial	$48.84

SEIZURES WITH MCC

Facility

$22,730.22

Service Code	MSDRG 100
Min. Negotiated Rate	$22,730.22
Max. Negotiated Rate	$22,730.22
Rate for Payer: Hawaii Medical Service Association Commercial	$22,730.22

SEIZURES WITHOUT MCC

Facility

$19,625.26

Service Code	MSDRG 101
Min. Negotiated Rate	$19,625.26
Max. Negotiated Rate	$19,625.26
Rate for Payer: Hawaii Medical Service Association Commercial	$19,625.26

Selective Debridement Addition Charge

Facility

$275.00

Service Code	HCPCS 97598 GP
Hospital Charge Code	8111738
Hospital Revenue Code	761
Min. Negotiated Rate	$233.75
Max. Negotiated Rate	$266.75
Rate for Payer: Cash Price	$178.75
Rate for Payer: Health Management Network Commercial	$233.75
Rate for Payer: Kaiser Permanente Commercial	$247.50
Rate for Payer: MDX Hawaii PPO	$266.75

Selective Debridement Addition Charge

Facility

$275.00

Service Code	HCPCS 97598 GO
Hospital Charge Code	8123857
Hospital Revenue Code	761
Min. Negotiated Rate	$47.04
Max. Negotiated Rate	$266.75
Rate for Payer: AlohaCare Medicaid	$137.50
Rate for Payer: AlohaCare Medicare	$137.50
Rate for Payer: Cash Price	$178.75
Rate for Payer: Cash Price	$178.75
Rate for Payer: Devoted Health Medicare	$151.25
Rate for Payer: Hawaii Medical Service Association Medicare	$137.50
Rate for Payer: Hawaii Western Management Group Commercial	$261.25
Rate for Payer: Health Management Network Commercial	$233.75
Rate for Payer: Humana Medicare	$137.50
Rate for Payer: Kaiser Permanente Commercial	$247.50
Rate for Payer: Kaiser Permanente Medicaid	$140.25
Rate for Payer: Kaiser Permanente Medicare	$137.50
Rate for Payer: MDX Hawaii PPO	$266.75
Rate for Payer: Ohana Health Plan Medicaid	$137.50
Rate for Payer: Ohana Health Plan Medicare	$137.50
Rate for Payer: UnitedHealthcare Medicaid	$47.04
Rate for Payer: UnitedHealthcare Medicare	$137.50
Rate for Payer: University Health Alliance Commercial	$154.00

Know your out-of-pocket cost for care.

All Charges