Samuel Mahelona Memorial Hospital

All Charges

Charge

Type

Setting

Price

SET INTRO TIP PNEUMOTHORAX (US)

Facility

$523.00

Hospital Charge Code	8890001
Hospital Revenue Code	272
Min. Negotiated Rate	$444.55
Max. Negotiated Rate	$507.31
Rate for Payer: Cash Price	$339.95
Rate for Payer: Health Management Network Commercial	$444.55
Rate for Payer: Kaiser Permanente Commercial	$470.70
Rate for Payer: MDX Hawaii PPO	$507.31

SET INTRO TIP PNEUMOTHORAX (US)

Facility

$523.00

Hospital Charge Code	8890001
Hospital Revenue Code	272
Min. Negotiated Rate	$261.50
Max. Negotiated Rate	$507.31
Rate for Payer: AlohaCare Medicaid	$261.50
Rate for Payer: AlohaCare Medicare	$261.50
Rate for Payer: Cash Price	$339.95
Rate for Payer: Devoted Health Medicare	$287.65
Rate for Payer: Hawaii Medical Service Association Medicare	$261.50
Rate for Payer: Hawaii Western Management Group Commercial	$496.85
Rate for Payer: Health Management Network Commercial	$444.55
Rate for Payer: Humana Medicare	$261.50
Rate for Payer: Kaiser Permanente Commercial	$470.70
Rate for Payer: Kaiser Permanente Medicaid	$266.73
Rate for Payer: Kaiser Permanente Medicare	$261.50
Rate for Payer: MDX Hawaii PPO	$507.31
Rate for Payer: Ohana Health Plan Medicaid	$261.50
Rate for Payer: Ohana Health Plan Medicare	$261.50
Rate for Payer: UnitedHealthcare Medicare	$261.50
Rate for Payer: University Health Alliance Commercial	$381.21

SET INTRO TIP PNEUMOTHORAX (XR/MAMMO)

Facility

$449.00

Hospital Charge Code	8890003
Hospital Revenue Code	272
Min. Negotiated Rate	$224.50
Max. Negotiated Rate	$435.53
Rate for Payer: AlohaCare Medicaid	$224.50
Rate for Payer: AlohaCare Medicare	$224.50
Rate for Payer: Cash Price	$291.85
Rate for Payer: Devoted Health Medicare	$246.95
Rate for Payer: Hawaii Medical Service Association Medicare	$224.50
Rate for Payer: Hawaii Western Management Group Commercial	$426.55
Rate for Payer: Health Management Network Commercial	$381.65
Rate for Payer: Humana Medicare	$224.50
Rate for Payer: Kaiser Permanente Commercial	$404.10
Rate for Payer: Kaiser Permanente Medicaid	$228.99
Rate for Payer: Kaiser Permanente Medicare	$224.50
Rate for Payer: MDX Hawaii PPO	$435.53
Rate for Payer: Ohana Health Plan Medicaid	$224.50
Rate for Payer: Ohana Health Plan Medicare	$224.50
Rate for Payer: UnitedHealthcare Medicare	$224.50
Rate for Payer: University Health Alliance Commercial	$327.28

SET INTRO TIP PNEUMOTHORAX (XR/MAMMO)

Facility

$449.00

Hospital Charge Code	8890003
Hospital Revenue Code	272
Min. Negotiated Rate	$381.65
Max. Negotiated Rate	$435.53
Rate for Payer: Cash Price	$291.85
Rate for Payer: Health Management Network Commercial	$381.65
Rate for Payer: Kaiser Permanente Commercial	$404.10
Rate for Payer: MDX Hawaii PPO	$435.53

SET MULTI-PURPOSE DRAINAGE 12FR

Facility

$746.00

Hospital Charge Code	10189804
Hospital Revenue Code	272
Min. Negotiated Rate	$634.10
Max. Negotiated Rate	$723.62
Rate for Payer: Cash Price	$484.90
Rate for Payer: Health Management Network Commercial	$634.10
Rate for Payer: Kaiser Permanente Commercial	$671.40
Rate for Payer: MDX Hawaii PPO	$723.62

SET MULTI-PURPOSE DRAINAGE 12FR

Facility

$746.00

Hospital Charge Code	10189804
Hospital Revenue Code	272
Min. Negotiated Rate	$373.00
Max. Negotiated Rate	$723.62
Rate for Payer: AlohaCare Medicaid	$373.00
Rate for Payer: AlohaCare Medicare	$373.00
Rate for Payer: Cash Price	$484.90
Rate for Payer: Devoted Health Medicare	$410.30
Rate for Payer: Hawaii Medical Service Association Medicare	$373.00
Rate for Payer: Hawaii Western Management Group Commercial	$708.70
Rate for Payer: Health Management Network Commercial	$634.10
Rate for Payer: Humana Medicare	$373.00
Rate for Payer: Kaiser Permanente Commercial	$671.40
Rate for Payer: Kaiser Permanente Medicaid	$380.46
Rate for Payer: Kaiser Permanente Medicare	$373.00
Rate for Payer: MDX Hawaii PPO	$723.62
Rate for Payer: Ohana Health Plan Medicaid	$373.00
Rate for Payer: Ohana Health Plan Medicare	$373.00
Rate for Payer: UnitedHealthcare Medicare	$373.00
Rate for Payer: University Health Alliance Commercial	$543.76

SET PNEUMOCLEAR SMOKE EVACUATION HIGH FLOW INSUFFLATOR TUBE

Facility

$228.00

Hospital Charge Code	8879043
Hospital Revenue Code	272
Min. Negotiated Rate	$193.80
Max. Negotiated Rate	$221.16
Rate for Payer: Cash Price	$148.20
Rate for Payer: Health Management Network Commercial	$193.80
Rate for Payer: Kaiser Permanente Commercial	$205.20
Rate for Payer: MDX Hawaii PPO	$221.16

SET PNEUMOCLEAR SMOKE EVACUATION HIGH FLOW INSUFFLATOR TUBE

Facility

$228.00

Hospital Charge Code	8879043
Hospital Revenue Code	272
Min. Negotiated Rate	$114.00
Max. Negotiated Rate	$221.16
Rate for Payer: AlohaCare Medicaid	$114.00
Rate for Payer: AlohaCare Medicare	$114.00
Rate for Payer: Cash Price	$148.20
Rate for Payer: Devoted Health Medicare	$125.40
Rate for Payer: Hawaii Medical Service Association Medicare	$114.00
Rate for Payer: Hawaii Western Management Group Commercial	$216.60
Rate for Payer: Health Management Network Commercial	$193.80
Rate for Payer: Humana Medicare	$114.00
Rate for Payer: Kaiser Permanente Commercial	$205.20
Rate for Payer: Kaiser Permanente Medicaid	$116.28
Rate for Payer: Kaiser Permanente Medicare	$114.00
Rate for Payer: MDX Hawaii PPO	$221.16
Rate for Payer: Ohana Health Plan Medicaid	$114.00
Rate for Payer: Ohana Health Plan Medicare	$114.00
Rate for Payer: UnitedHealthcare Medicare	$114.00
Rate for Payer: University Health Alliance Commercial	$166.19

SET RADIAL ARTERY CATHERIZATION

Facility

$133.00

Hospital Charge Code	8266662
Hospital Revenue Code	272
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

SET RADIAL ARTERY CATHERIZATION

Facility

$133.00

Hospital Charge Code	8266662
Hospital Revenue Code	272
Min. Negotiated Rate	$66.50
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: Devoted Health Medicare	$73.15
Rate for Payer: Hawaii Medical Service Association Medicare	$66.50
Rate for Payer: Hawaii Western Management Group Commercial	$126.35
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 Medicare	$66.50
Rate for Payer: University Health Alliance Commercial	$96.94

SET UNIVERSAL CURVED DRAINAGE CATHETER (CT)

Facility

$354.00

Service Code	HCPCS C1729
Hospital Charge Code	8890005
Hospital Revenue Code	272
Min. Negotiated Rate	$300.90
Max. Negotiated Rate	$343.38
Rate for Payer: Cash Price	$230.10
Rate for Payer: Health Management Network Commercial	$300.90
Rate for Payer: Kaiser Permanente Commercial	$318.60
Rate for Payer: MDX Hawaii PPO	$343.38

SET UNIVERSAL CURVED DRAINAGE CATHETER (CT)

Facility

$354.00

Service Code	HCPCS C1729
Hospital Charge Code	8890005
Hospital Revenue Code	272
Min. Negotiated Rate	$177.00
Max. Negotiated Rate	$343.38
Rate for Payer: AlohaCare Medicaid	$177.00
Rate for Payer: AlohaCare Medicare	$177.00
Rate for Payer: Cash Price	$230.10
Rate for Payer: Devoted Health Medicare	$194.70
Rate for Payer: Hawaii Medical Service Association Medicare	$177.00
Rate for Payer: Hawaii Western Management Group Commercial	$336.30
Rate for Payer: Health Management Network Commercial	$300.90
Rate for Payer: Humana Medicare	$177.00
Rate for Payer: Kaiser Permanente Commercial	$318.60
Rate for Payer: Kaiser Permanente Medicaid	$180.54
Rate for Payer: Kaiser Permanente Medicare	$177.00
Rate for Payer: MDX Hawaii PPO	$343.38
Rate for Payer: Ohana Health Plan Medicaid	$177.00
Rate for Payer: Ohana Health Plan Medicare	$177.00
Rate for Payer: UnitedHealthcare Medicare	$177.00
Rate for Payer: University Health Alliance Commercial	$258.03

SET UNIVERSAL CURVED DRAINAGE CATHETER (US)

Facility

$354.00

Service Code	HCPCS C1729
Hospital Charge Code	8890004
Hospital Revenue Code	272
Min. Negotiated Rate	$177.00
Max. Negotiated Rate	$343.38
Rate for Payer: AlohaCare Medicaid	$177.00
Rate for Payer: AlohaCare Medicare	$177.00
Rate for Payer: Cash Price	$230.10
Rate for Payer: Devoted Health Medicare	$194.70
Rate for Payer: Hawaii Medical Service Association Medicare	$177.00
Rate for Payer: Hawaii Western Management Group Commercial	$336.30
Rate for Payer: Health Management Network Commercial	$300.90
Rate for Payer: Humana Medicare	$177.00
Rate for Payer: Kaiser Permanente Commercial	$318.60
Rate for Payer: Kaiser Permanente Medicaid	$180.54
Rate for Payer: Kaiser Permanente Medicare	$177.00
Rate for Payer: MDX Hawaii PPO	$343.38
Rate for Payer: Ohana Health Plan Medicaid	$177.00
Rate for Payer: Ohana Health Plan Medicare	$177.00
Rate for Payer: UnitedHealthcare Medicare	$177.00
Rate for Payer: University Health Alliance Commercial	$258.03

SET UNIVERSAL CURVED DRAINAGE CATHETER (US)

Facility

$354.00

Service Code	HCPCS C1729
Hospital Charge Code	8890004
Hospital Revenue Code	272
Min. Negotiated Rate	$300.90
Max. Negotiated Rate	$343.38
Rate for Payer: Cash Price	$230.10
Rate for Payer: Health Management Network Commercial	$300.90
Rate for Payer: Kaiser Permanente Commercial	$318.60
Rate for Payer: MDX Hawaii PPO	$343.38

SET UNIVERSAL CURVED DRAINAGE CATHETER (XR/MAMMO)

Facility

$301.00

Service Code	HCPCS C1729
Hospital Charge Code	8890006
Hospital Revenue Code	272
Min. Negotiated Rate	$150.50
Max. Negotiated Rate	$291.97
Rate for Payer: AlohaCare Medicaid	$150.50
Rate for Payer: AlohaCare Medicare	$150.50
Rate for Payer: Cash Price	$195.65
Rate for Payer: Devoted Health Medicare	$165.55
Rate for Payer: Hawaii Medical Service Association Medicare	$150.50
Rate for Payer: Hawaii Western Management Group Commercial	$285.95
Rate for Payer: Health Management Network Commercial	$255.85
Rate for Payer: Humana Medicare	$150.50
Rate for Payer: Kaiser Permanente Commercial	$270.90
Rate for Payer: Kaiser Permanente Medicaid	$153.51
Rate for Payer: Kaiser Permanente Medicare	$150.50
Rate for Payer: MDX Hawaii PPO	$291.97
Rate for Payer: Ohana Health Plan Medicaid	$150.50
Rate for Payer: Ohana Health Plan Medicare	$150.50
Rate for Payer: UnitedHealthcare Medicare	$150.50
Rate for Payer: University Health Alliance Commercial	$219.40

SET UNIVERSAL CURVED DRAINAGE CATHETER (XR/MAMMO)

Facility

$301.00

Service Code	HCPCS C1729
Hospital Charge Code	8890006
Hospital Revenue Code	272
Min. Negotiated Rate	$255.85
Max. Negotiated Rate	$291.97
Rate for Payer: Cash Price	$195.65
Rate for Payer: Health Management Network Commercial	$255.85
Rate for Payer: Kaiser Permanente Commercial	$270.90
Rate for Payer: MDX Hawaii PPO	$291.97

SET UROLOGY IRRIGATION T-U-R Y-SET

Facility

$82.00

Service Code	HCPCS A4355
Hospital Charge Code	8879103
Hospital Revenue Code	272
Min. Negotiated Rate	$7.02
Max. Negotiated Rate	$79.54
Rate for Payer: AlohaCare Medicaid	$41.00
Rate for Payer: AlohaCare Medicare	$41.00
Rate for Payer: Cash Price	$53.30
Rate for Payer: Cash Price	$53.30
Rate for Payer: Devoted Health Medicare	$45.10
Rate for Payer: Hawaii Medical Service Association Medicare	$41.00
Rate for Payer: Hawaii Western Management Group Commercial	$77.90
Rate for Payer: Health Management Network Commercial	$69.70
Rate for Payer: Humana Medicare	$41.00
Rate for Payer: Kaiser Permanente Commercial	$73.80
Rate for Payer: Kaiser Permanente Medicaid	$41.82
Rate for Payer: Kaiser Permanente Medicare	$41.00
Rate for Payer: MDX Hawaii PPO	$79.54
Rate for Payer: Ohana Health Plan Medicaid	$41.00
Rate for Payer: Ohana Health Plan Medicare	$41.00
Rate for Payer: UnitedHealthcare Medicaid	$7.02
Rate for Payer: UnitedHealthcare Medicare	$41.00
Rate for Payer: University Health Alliance Commercial	$59.77

SET UROLOGY IRRIGATION T-U-R Y-SET

Facility

$82.00

Service Code	HCPCS A4355
Hospital Charge Code	8879103
Hospital Revenue Code	272
Min. Negotiated Rate	$69.70
Max. Negotiated Rate	$79.54
Rate for Payer: Cash Price	$53.30
Rate for Payer: Health Management Network Commercial	$69.70
Rate for Payer: Kaiser Permanente Commercial	$73.80
Rate for Payer: MDX Hawaii PPO	$79.54

Shiga Toxin Bill Only

Facility

$70.00

Hospital Charge Code	13128084
Hospital Revenue Code	306
Min. Negotiated Rate	$35.00
Max. Negotiated Rate	$67.90
Rate for Payer: AlohaCare Medicaid	$35.00
Rate for Payer: AlohaCare Medicare	$35.00
Rate for Payer: Cash Price	$45.50
Rate for Payer: Devoted Health Medicare	$38.50
Rate for Payer: Hawaii Medical Service Association Medicare	$35.00
Rate for Payer: Hawaii Western Management Group Commercial	$66.50
Rate for Payer: Health Management Network Commercial	$59.50
Rate for Payer: Humana Medicare	$35.00
Rate for Payer: Kaiser Permanente Commercial	$63.00
Rate for Payer: Kaiser Permanente Medicaid	$35.70
Rate for Payer: Kaiser Permanente Medicare	$35.00
Rate for Payer: MDX Hawaii PPO	$67.90
Rate for Payer: Ohana Health Plan Medicaid	$35.00
Rate for Payer: Ohana Health Plan Medicare	$35.00
Rate for Payer: UnitedHealthcare Medicare	$35.00
Rate for Payer: University Health Alliance Commercial	$39.20

Shiga Toxin Bill Only

Facility

$70.00

Hospital Charge Code	13128084
Hospital Revenue Code	306
Min. Negotiated Rate	$59.50
Max. Negotiated Rate	$67.90
Rate for Payer: Cash Price	$45.50
Rate for Payer: Health Management Network Commercial	$59.50
Rate for Payer: Kaiser Permanente Commercial	$63.00
Rate for Payer: MDX Hawaii PPO	$67.90

SHOULDER, ELBOW OR FOREARM PROCEDURES, EXCEPT MAJOR JOINT PROCEDURES WITH CC

Facility

$23,180.56

Service Code	MSDRG 511
Min. Negotiated Rate	$23,180.56
Max. Negotiated Rate	$23,180.56
Rate for Payer: Hawaii Medical Service Association Commercial	$23,180.56

SHOULDER, ELBOW OR FOREARM PROCEDURES, EXCEPT MAJOR JOINT PROCEDURES WITH MCC

Facility

$23,180.56

Service Code	MSDRG 510
Min. Negotiated Rate	$23,180.56
Max. Negotiated Rate	$23,180.56
Rate for Payer: Hawaii Medical Service Association Commercial	$23,180.56

SHOULDER, ELBOW OR FOREARM PROCEDURES, EXCEPT MAJOR JOINT PROCEDURES WITHOUT CC/MCC

Facility

$21,782.14

Service Code	MSDRG 512
Min. Negotiated Rate	$21,782.14
Max. Negotiated Rate	$21,782.14
Rate for Payer: Hawaii Medical Service Association Commercial	$21,782.14

Sickle Cell Solubility FSI

Facility

$77.00

Service Code	HCPCS 85660
Hospital Charge Code	8118045
Hospital Revenue Code	305
Min. Negotiated Rate	$5.51
Max. Negotiated Rate	$74.69
Rate for Payer: AlohaCare Medicaid	$38.50
Rate for Payer: AlohaCare Medicare	$38.50
Rate for Payer: Cash Price	$50.05
Rate for Payer: Cash Price	$50.05
Rate for Payer: Devoted Health Medicare	$42.35
Rate for Payer: Hawaii Medical Service Association ABD	$7.63
Rate for Payer: Hawaii Medical Service Association Commercial	$6.89
Rate for Payer: Hawaii Medical Service Association Medicare	$38.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$8.01
Rate for Payer: Hawaii Western Management Group Commercial	$5.51
Rate for Payer: Health Management Network Commercial	$65.45
Rate for Payer: Humana Medicare	$38.50
Rate for Payer: Kaiser Permanente Commercial	$69.30
Rate for Payer: Kaiser Permanente Medicaid	$39.27
Rate for Payer: Kaiser Permanente Medicare	$38.50
Rate for Payer: MDX Hawaii PPO	$74.69
Rate for Payer: Ohana Health Plan Medicaid	$38.50
Rate for Payer: Ohana Health Plan Medicare	$38.50
Rate for Payer: UnitedHealthcare Medicaid	$7.63
Rate for Payer: UnitedHealthcare Medicare	$38.50
Rate for Payer: University Health Alliance Commercial	$14.26

Sickle Cell Solubility FSI

Facility

$77.00

Service Code	HCPCS 85660
Hospital Charge Code	8118045
Hospital Revenue Code	305
Min. Negotiated Rate	$65.45
Max. Negotiated Rate	$74.69
Rate for Payer: Cash Price	$50.05
Rate for Payer: Health Management Network Commercial	$65.45
Rate for Payer: Kaiser Permanente Commercial	$69.30
Rate for Payer: MDX Hawaii PPO	$74.69

Know your out-of-pocket cost for care.

All Charges