Samuel Mahelona Memorial Hospital

All Charges

Charge

Type

Setting

Price

Selective Debridement Addition Charge

Facility

$275.00

Service Code	HCPCS 97598 GP
Hospital Charge Code	8111738
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

Selective Debridement Addition Charge

Facility

$275.00

Service Code	HCPCS 97598 GO
Hospital Charge Code	8123857
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 Charge

Facility

$693.00

Service Code	HCPCS 97597 GP
Hospital Charge Code	8111711
Hospital Revenue Code	761
Min. Negotiated Rate	$589.05
Max. Negotiated Rate	$672.21
Rate for Payer: Cash Price	$450.45
Rate for Payer: Health Management Network Commercial	$589.05
Rate for Payer: Kaiser Permanente Commercial	$623.70
Rate for Payer: MDX Hawaii PPO	$672.21

Selective Debridement Charge

Facility

$693.00

Service Code	HCPCS 97597 GO
Hospital Charge Code	8123849
Hospital Revenue Code	761
Min. Negotiated Rate	$37.07
Max. Negotiated Rate	$672.21
Rate for Payer: AlohaCare Medicaid	$346.50
Rate for Payer: AlohaCare Medicare	$346.50
Rate for Payer: Cash Price	$450.45
Rate for Payer: Cash Price	$450.45
Rate for Payer: Devoted Health Medicare	$381.15
Rate for Payer: Hawaii Medical Service Association Medicare	$346.50
Rate for Payer: Hawaii Western Management Group Commercial	$658.35
Rate for Payer: Health Management Network Commercial	$589.05
Rate for Payer: Humana Medicare	$346.50
Rate for Payer: Kaiser Permanente Commercial	$623.70
Rate for Payer: Kaiser Permanente Medicaid	$353.43
Rate for Payer: Kaiser Permanente Medicare	$346.50
Rate for Payer: MDX Hawaii PPO	$672.21
Rate for Payer: Ohana Health Plan Medicaid	$346.50
Rate for Payer: Ohana Health Plan Medicare	$346.50
Rate for Payer: UnitedHealthcare Medicaid	$37.07
Rate for Payer: UnitedHealthcare Medicare	$346.50
Rate for Payer: University Health Alliance Commercial	$388.08

Selective Debridement Charge

Facility

$693.00

Service Code	HCPCS 97597 GO
Hospital Charge Code	8123849
Hospital Revenue Code	761
Min. Negotiated Rate	$589.05
Max. Negotiated Rate	$672.21
Rate for Payer: Cash Price	$450.45
Rate for Payer: Health Management Network Commercial	$589.05
Rate for Payer: Kaiser Permanente Commercial	$623.70
Rate for Payer: MDX Hawaii PPO	$672.21

Selective Debridement Charge

Facility

$693.00

Service Code	HCPCS 97597 GP
Hospital Charge Code	8111711
Hospital Revenue Code	761
Min. Negotiated Rate	$37.07
Max. Negotiated Rate	$672.21
Rate for Payer: AlohaCare Medicaid	$346.50
Rate for Payer: AlohaCare Medicare	$346.50
Rate for Payer: Cash Price	$450.45
Rate for Payer: Cash Price	$450.45
Rate for Payer: Devoted Health Medicare	$381.15
Rate for Payer: Hawaii Medical Service Association Medicare	$346.50
Rate for Payer: Hawaii Western Management Group Commercial	$658.35
Rate for Payer: Health Management Network Commercial	$589.05
Rate for Payer: Humana Medicare	$346.50
Rate for Payer: Kaiser Permanente Commercial	$623.70
Rate for Payer: Kaiser Permanente Medicaid	$353.43
Rate for Payer: Kaiser Permanente Medicare	$346.50
Rate for Payer: MDX Hawaii PPO	$672.21
Rate for Payer: Ohana Health Plan Medicaid	$346.50
Rate for Payer: Ohana Health Plan Medicare	$346.50
Rate for Payer: UnitedHealthcare Medicaid	$37.07
Rate for Payer: UnitedHealthcare Medicare	$346.50
Rate for Payer: University Health Alliance Commercial	$388.08

Selenium FSI

Facility

$291.00

Service Code	HCPCS 84255
Hospital Charge Code	8118043
Hospital Revenue Code	301
Min. Negotiated Rate	$25.53
Max. Negotiated Rate	$282.27
Rate for Payer: AlohaCare Medicaid	$145.50
Rate for Payer: AlohaCare Medicare	$145.50
Rate for Payer: Cash Price	$189.15
Rate for Payer: Cash Price	$189.15
Rate for Payer: Devoted Health Medicare	$160.05
Rate for Payer: Hawaii Medical Service Association ABD	$35.28
Rate for Payer: Hawaii Medical Service Association Commercial	$31.91
Rate for Payer: Hawaii Medical Service Association Medicare	$145.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$37.04
Rate for Payer: Hawaii Western Management Group Commercial	$25.53
Rate for Payer: Health Management Network Commercial	$247.35
Rate for Payer: Humana Medicare	$145.50
Rate for Payer: Kaiser Permanente Commercial	$261.90
Rate for Payer: Kaiser Permanente Medicaid	$148.41
Rate for Payer: Kaiser Permanente Medicare	$145.50
Rate for Payer: MDX Hawaii PPO	$282.27
Rate for Payer: Ohana Health Plan Medicaid	$145.50
Rate for Payer: Ohana Health Plan Medicare	$145.50
Rate for Payer: UnitedHealthcare Medicaid	$35.28
Rate for Payer: UnitedHealthcare Medicare	$145.50
Rate for Payer: University Health Alliance Commercial	$65.99

Selenium FSI

Facility

$291.00

Service Code	HCPCS 84255
Hospital Charge Code	8118043
Hospital Revenue Code	301
Min. Negotiated Rate	$247.35
Max. Negotiated Rate	$282.27
Rate for Payer: Cash Price	$189.15
Rate for Payer: Health Management Network Commercial	$247.35
Rate for Payer: Kaiser Permanente Commercial	$261.90
Rate for Payer: MDX Hawaii PPO	$282.27

senna 8.6 mg tablet [HHSC]

Facility

$3.00

Service Code	NDC 00904652261
Hospital Charge Code	2500736
Hospital Revenue Code	250
Min. Negotiated Rate	$1.50
Max. Negotiated Rate	$2.91
Rate for Payer: AlohaCare Medicaid	$1.50
Rate for Payer: AlohaCare Medicare	$1.50
Rate for Payer: Cash Price	$1.95
Rate for Payer: Devoted Health Medicare	$1.65
Rate for Payer: Hawaii Medical Service Association Medicare	$1.50
Rate for Payer: Hawaii Western Management Group Commercial	$2.85
Rate for Payer: Health Management Network Commercial	$2.55
Rate for Payer: Humana Medicare	$1.50
Rate for Payer: Kaiser Permanente Commercial	$2.70
Rate for Payer: Kaiser Permanente Medicaid	$1.53
Rate for Payer: Kaiser Permanente Medicare	$1.50
Rate for Payer: MDX Hawaii PPO	$2.91
Rate for Payer: Ohana Health Plan Medicaid	$1.50
Rate for Payer: Ohana Health Plan Medicare	$1.50
Rate for Payer: UnitedHealthcare Medicaid	$1.80
Rate for Payer: UnitedHealthcare Medicare	$1.50
Rate for Payer: University Health Alliance Commercial	$2.19

senna 8.6 mg tablet [HHSC]

Facility

$3.00

Service Code	NDC 00904725261
Hospital Charge Code	2500736
Hospital Revenue Code	250
Min. Negotiated Rate	$1.50
Max. Negotiated Rate	$2.91
Rate for Payer: AlohaCare Medicaid	$1.50
Rate for Payer: AlohaCare Medicare	$1.50
Rate for Payer: Cash Price	$1.95
Rate for Payer: Devoted Health Medicare	$1.65
Rate for Payer: Hawaii Medical Service Association Medicare	$1.50
Rate for Payer: Hawaii Western Management Group Commercial	$2.85
Rate for Payer: Health Management Network Commercial	$2.55
Rate for Payer: Humana Medicare	$1.50
Rate for Payer: Kaiser Permanente Commercial	$2.70
Rate for Payer: Kaiser Permanente Medicaid	$1.53
Rate for Payer: Kaiser Permanente Medicare	$1.50
Rate for Payer: MDX Hawaii PPO	$2.91
Rate for Payer: Ohana Health Plan Medicaid	$1.50
Rate for Payer: Ohana Health Plan Medicare	$1.50
Rate for Payer: UnitedHealthcare Medicaid	$1.80
Rate for Payer: UnitedHealthcare Medicare	$1.50
Rate for Payer: University Health Alliance Commercial	$2.19

senna 8.6 mg tablet [HHSC]

Facility

$3.00

Service Code	NDC 00904725261
Hospital Charge Code	2500736
Hospital Revenue Code	250
Min. Negotiated Rate	$2.55
Max. Negotiated Rate	$2.91
Rate for Payer: Cash Price	$1.95
Rate for Payer: Health Management Network Commercial	$2.55
Rate for Payer: Kaiser Permanente Commercial	$2.70
Rate for Payer: MDX Hawaii PPO	$2.91

senna 8.6 mg tablet [HHSC]

Facility

$3.00

Service Code	NDC 00904672559
Hospital Charge Code	2500736
Hospital Revenue Code	250
Min. Negotiated Rate	$1.50
Max. Negotiated Rate	$2.91
Rate for Payer: AlohaCare Medicaid	$1.50
Rate for Payer: AlohaCare Medicare	$1.50
Rate for Payer: Cash Price	$1.95
Rate for Payer: Devoted Health Medicare	$1.65
Rate for Payer: Hawaii Medical Service Association Medicare	$1.50
Rate for Payer: Hawaii Western Management Group Commercial	$2.85
Rate for Payer: Health Management Network Commercial	$2.55
Rate for Payer: Humana Medicare	$1.50
Rate for Payer: Kaiser Permanente Commercial	$2.70
Rate for Payer: Kaiser Permanente Medicaid	$1.53
Rate for Payer: Kaiser Permanente Medicare	$1.50
Rate for Payer: MDX Hawaii PPO	$2.91
Rate for Payer: Ohana Health Plan Medicaid	$1.50
Rate for Payer: Ohana Health Plan Medicare	$1.50
Rate for Payer: UnitedHealthcare Medicaid	$1.80
Rate for Payer: UnitedHealthcare Medicare	$1.50
Rate for Payer: University Health Alliance Commercial	$2.19

senna 8.6 mg tablet [HHSC]

Facility

$3.00

Service Code	NDC 00904672559
Hospital Charge Code	2500736
Hospital Revenue Code	250
Min. Negotiated Rate	$2.55
Max. Negotiated Rate	$2.91
Rate for Payer: Cash Price	$1.95
Rate for Payer: Health Management Network Commercial	$2.55
Rate for Payer: Kaiser Permanente Commercial	$2.70
Rate for Payer: MDX Hawaii PPO	$2.91

senna 8.6 mg tablet [HHSC]

Facility

$3.00

Service Code	NDC 71399824503
Hospital Charge Code	2500736
Hospital Revenue Code	250
Min. Negotiated Rate	$2.55
Max. Negotiated Rate	$2.91
Rate for Payer: Cash Price	$1.95
Rate for Payer: Health Management Network Commercial	$2.55
Rate for Payer: Kaiser Permanente Commercial	$2.70
Rate for Payer: MDX Hawaii PPO	$2.91

senna 8.6 mg tablet [HHSC]

Facility

$3.00

Service Code	NDC 00904652261
Hospital Charge Code	2500736
Hospital Revenue Code	250
Min. Negotiated Rate	$2.55
Max. Negotiated Rate	$2.91
Rate for Payer: Cash Price	$1.95
Rate for Payer: Health Management Network Commercial	$2.55
Rate for Payer: Kaiser Permanente Commercial	$2.70
Rate for Payer: MDX Hawaii PPO	$2.91

senna 8.6 mg tablet [HHSC]

Facility

$3.00

Service Code	NDC 71399824503
Hospital Charge Code	2500736
Hospital Revenue Code	250
Min. Negotiated Rate	$1.50
Max. Negotiated Rate	$2.91
Rate for Payer: AlohaCare Medicaid	$1.50
Rate for Payer: AlohaCare Medicare	$1.50
Rate for Payer: Cash Price	$1.95
Rate for Payer: Devoted Health Medicare	$1.65
Rate for Payer: Hawaii Medical Service Association Medicare	$1.50
Rate for Payer: Hawaii Western Management Group Commercial	$2.85
Rate for Payer: Health Management Network Commercial	$2.55
Rate for Payer: Humana Medicare	$1.50
Rate for Payer: Kaiser Permanente Commercial	$2.70
Rate for Payer: Kaiser Permanente Medicaid	$1.53
Rate for Payer: Kaiser Permanente Medicare	$1.50
Rate for Payer: MDX Hawaii PPO	$2.91
Rate for Payer: Ohana Health Plan Medicaid	$1.50
Rate for Payer: Ohana Health Plan Medicare	$1.50
Rate for Payer: UnitedHealthcare Medicaid	$1.80
Rate for Payer: UnitedHealthcare Medicare	$1.50
Rate for Payer: University Health Alliance Commercial	$2.19

senna-docusate 8.6 mg-50 mg tablet [HHSC]

Facility

$3.00

Service Code	HCPCS A9270
Hospital Charge Code	2501053
Hospital Revenue Code	250
Min. Negotiated Rate	$2.55
Max. Negotiated Rate	$2.91
Rate for Payer: Cash Price	$1.95
Rate for Payer: Health Management Network Commercial	$2.55
Rate for Payer: Kaiser Permanente Commercial	$2.70
Rate for Payer: MDX Hawaii PPO	$2.91

senna-docusate 8.6 mg-50 mg tablet [HHSC]

Facility

$3.00

Service Code	HCPCS A9270
Hospital Charge Code	2501053
Hospital Revenue Code	637
Min. Negotiated Rate	$1.50
Max. Negotiated Rate	$2.91
Rate for Payer: AlohaCare Medicaid	$1.50
Rate for Payer: AlohaCare Medicare	$1.50
Rate for Payer: Cash Price	$1.95
Rate for Payer: Devoted Health Medicare	$1.65
Rate for Payer: Hawaii Medical Service Association Medicare	$1.50
Rate for Payer: Hawaii Western Management Group Commercial	$2.85
Rate for Payer: Health Management Network Commercial	$2.55
Rate for Payer: Humana Medicare	$1.50
Rate for Payer: Kaiser Permanente Commercial	$2.70
Rate for Payer: Kaiser Permanente Medicaid	$1.53
Rate for Payer: Kaiser Permanente Medicare	$1.50
Rate for Payer: MDX Hawaii PPO	$2.91
Rate for Payer: Ohana Health Plan Medicaid	$1.50
Rate for Payer: Ohana Health Plan Medicare	$1.50
Rate for Payer: UnitedHealthcare Medicare	$1.50
Rate for Payer: University Health Alliance Commercial	$1.68

Sensi D-Dimer (DVT/PE) FSI

Facility

$145.00

Service Code	HCPCS 85379
Hospital Charge Code	8118044
Hospital Revenue Code	305
Min. Negotiated Rate	$123.25
Max. Negotiated Rate	$140.65
Rate for Payer: Cash Price	$94.25
Rate for Payer: Health Management Network Commercial	$123.25
Rate for Payer: Kaiser Permanente Commercial	$130.50
Rate for Payer: MDX Hawaii PPO	$140.65

Sensi D-Dimer (DVT/PE) FSI

Facility

$145.00

Service Code	HCPCS 85379
Hospital Charge Code	8118044
Hospital Revenue Code	305
Min. Negotiated Rate	$10.18
Max. Negotiated Rate	$140.65
Rate for Payer: AlohaCare Medicaid	$72.50
Rate for Payer: AlohaCare Medicare	$72.50
Rate for Payer: Cash Price	$94.25
Rate for Payer: Cash Price	$94.25
Rate for Payer: Devoted Health Medicare	$79.75
Rate for Payer: Hawaii Medical Service Association ABD	$14.06
Rate for Payer: Hawaii Medical Service Association Commercial	$12.72
Rate for Payer: Hawaii Medical Service Association Medicare	$72.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$14.76
Rate for Payer: Hawaii Western Management Group Commercial	$10.18
Rate for Payer: Health Management Network Commercial	$123.25
Rate for Payer: Humana Medicare	$72.50
Rate for Payer: Kaiser Permanente Commercial	$130.50
Rate for Payer: Kaiser Permanente Medicaid	$73.95
Rate for Payer: Kaiser Permanente Medicare	$72.50
Rate for Payer: MDX Hawaii PPO	$140.65
Rate for Payer: Ohana Health Plan Medicaid	$72.50
Rate for Payer: Ohana Health Plan Medicare	$72.50
Rate for Payer: UnitedHealthcare Medicaid	$14.06
Rate for Payer: UnitedHealthcare Medicare	$72.50
Rate for Payer: University Health Alliance Commercial	$26.31

Sensory Stimulation Charge

Facility

$238.00

Service Code	HCPCS 97533 GO
Hospital Charge Code	8123845
Hospital Revenue Code	430
Min. Negotiated Rate	$202.30
Max. Negotiated Rate	$230.86
Rate for Payer: Cash Price	$154.70
Rate for Payer: Health Management Network Commercial	$202.30
Rate for Payer: Kaiser Permanente Commercial	$214.20
Rate for Payer: MDX Hawaii PPO	$230.86

Sensory Stimulation Charge

Facility

$238.00

Service Code	HCPCS 97533 GO
Hospital Charge Code	8123845
Hospital Revenue Code	430
Min. Negotiated Rate	$17.81
Max. Negotiated Rate	$230.86
Rate for Payer: AlohaCare Medicaid	$119.00
Rate for Payer: AlohaCare Medicare	$119.00
Rate for Payer: Cash Price	$154.70
Rate for Payer: Cash Price	$154.70
Rate for Payer: Devoted Health Medicare	$130.90
Rate for Payer: Hawaii Medical Service Association Medicare	$119.00
Rate for Payer: Hawaii Western Management Group Commercial	$226.10
Rate for Payer: Health Management Network Commercial	$202.30
Rate for Payer: Humana Medicare	$119.00
Rate for Payer: Kaiser Permanente Commercial	$214.20
Rate for Payer: Kaiser Permanente Medicaid	$121.38
Rate for Payer: Kaiser Permanente Medicare	$119.00
Rate for Payer: MDX Hawaii PPO	$230.86
Rate for Payer: Ohana Health Plan Medicaid	$119.00
Rate for Payer: Ohana Health Plan Medicare	$119.00
Rate for Payer: UnitedHealthcare Medicaid	$17.81
Rate for Payer: UnitedHealthcare Medicare	$119.00
Rate for Payer: University Health Alliance Commercial	$133.28

SEPTIC ARTHRITIS WITH CC

Facility

$24,460.46

Service Code	MSDRG 549
Min. Negotiated Rate	$24,460.46
Max. Negotiated Rate	$24,460.46
Rate for Payer: Hawaii Medical Service Association Commercial	$24,460.46

SEPTIC ARTHRITIS WITH MCC

Facility

$24,460.46

Service Code	MSDRG 548
Min. Negotiated Rate	$24,460.46
Max. Negotiated Rate	$24,460.46
Rate for Payer: Hawaii Medical Service Association Commercial	$24,460.46

SEPTIC ARTHRITIS WITHOUT CC/MCC

Facility

$24,460.46

Service Code	MSDRG 550
Min. Negotiated Rate	$24,460.46
Max. Negotiated Rate	$24,460.46
Rate for Payer: Hawaii Medical Service Association Commercial	$24,460.46

Know your out-of-pocket cost for care.

All Charges