Samuel Mahelona Memorial Hospital

All Charges

Charge

Type

Setting

Price

SIMPLE PNEUMONIA AND PLEURISY WITH MCC

Facility

$24,626.38

Service Code	MSDRG 193
Min. Negotiated Rate	$24,626.38
Max. Negotiated Rate	$24,626.38
Rate for Payer: Hawaii Medical Service Association Commercial	$24,626.38

SIMPLE PNEUMONIA AND PLEURISY WITHOUT CC/MCC

Facility

$18,937.90

Service Code	MSDRG 195
Min. Negotiated Rate	$18,937.90
Max. Negotiated Rate	$18,937.90
Rate for Payer: Hawaii Medical Service Association Commercial	$18,937.90

SIMULTANEOUS PANCREAS AND KIDNEY TRANSPLANT

Facility

$696,862.50

Service Code	MSDRG 008
Min. Negotiated Rate	$10,400.00
Max. Negotiated Rate	$696,862.50
Rate for Payer: Hawaii Medical Service Association Commercial	$696,862.50
Rate for Payer: University Health Alliance Commercial	$10,400.00

SINGLE LEVEL COMBINED ANTERIOR AND POSTERIOR SPINAL FUSION EXCEPT CERVICAL

Facility

$115,594.65

Service Code	MSDRG 402
Min. Negotiated Rate	$115,594.65
Max. Negotiated Rate	$115,594.65
Rate for Payer: Hawaii Medical Service Association Commercial	$115,594.65

SINGLE TROCAR WIRE 1.6X150MM

Facility

$248.00

Service Code	HCPCS C1713
Hospital Charge Code	10613400
Hospital Revenue Code	278
Min. Negotiated Rate	$124.00
Max. Negotiated Rate	$240.56
Rate for Payer: AlohaCare Medicaid	$124.00
Rate for Payer: AlohaCare Medicare	$124.00
Rate for Payer: Cash Price	$161.20
Rate for Payer: Devoted Health Medicare	$136.40
Rate for Payer: Hawaii Medical Service Association Medicare	$124.00
Rate for Payer: Hawaii Western Management Group Commercial	$173.60
Rate for Payer: Health Management Network Commercial	$210.80
Rate for Payer: Humana Medicare	$124.00
Rate for Payer: Kaiser Permanente Commercial	$223.20
Rate for Payer: Kaiser Permanente Medicaid	$126.48
Rate for Payer: Kaiser Permanente Medicare	$124.00
Rate for Payer: MDX Hawaii PPO	$240.56
Rate for Payer: Ohana Health Plan Medicaid	$124.00
Rate for Payer: Ohana Health Plan Medicare	$124.00
Rate for Payer: UnitedHealthcare Medicare	$124.00
Rate for Payer: University Health Alliance Commercial	$138.88

SINGLE TROCAR WIRE 1.6X150MM

Facility

$248.00

Service Code	HCPCS C1713
Hospital Charge Code	10613400
Hospital Revenue Code	278
Min. Negotiated Rate	$138.88
Max. Negotiated Rate	$240.56
Rate for Payer: Cash Price	$161.20
Rate for Payer: Hawaii Western Management Group Commercial	$173.60
Rate for Payer: Health Management Network Commercial	$210.80
Rate for Payer: Kaiser Permanente Commercial	$223.20
Rate for Payer: MDX Hawaii PPO	$240.56
Rate for Payer: University Health Alliance Commercial	$138.88

SINUS AND MASTOID PROCEDURES WITH CC/MCC

Facility

$25,882.58

Service Code	MSDRG 135
Min. Negotiated Rate	$25,882.58
Max. Negotiated Rate	$25,882.58
Rate for Payer: Hawaii Medical Service Association Commercial	$25,882.58

SINUS AND MASTOID PROCEDURES WITHOUT CC/MCC

Facility

$25,882.58

Service Code	MSDRG 136
Min. Negotiated Rate	$25,882.58
Max. Negotiated Rate	$25,882.58
Rate for Payer: Hawaii Medical Service Association Commercial	$25,882.58

Sjogren's Antibody FSI

Facility

$205.00

Service Code	HCPCS 86235
Hospital Charge Code	8118046
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

Sjogren's Antibody FSI

Facility

$205.00

Service Code	HCPCS 86235
Hospital Charge Code	8118046
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

SKIN DEBRIDEMENT WITH CC

Facility

$57,951.39

Service Code	MSDRG 571
Min. Negotiated Rate	$57,951.39
Max. Negotiated Rate	$57,951.39
Rate for Payer: Hawaii Medical Service Association Commercial	$57,951.39

SKIN DEBRIDEMENT WITH MCC

Facility

$60,795.63

Service Code	MSDRG 570
Min. Negotiated Rate	$60,795.63
Max. Negotiated Rate	$60,795.63
Rate for Payer: Hawaii Medical Service Association Commercial	$60,795.63

SKIN DEBRIDEMENT WITHOUT CC/MCC

Facility

$29,983.03

Service Code	MSDRG 572
Min. Negotiated Rate	$29,983.03
Max. Negotiated Rate	$29,983.03
Rate for Payer: Hawaii Medical Service Association Commercial	$29,983.03

SKIN GRAFT EXCEPT FOR SKIN ULCER OR CELLULITIS WITH CC

Facility

$59,894.95

Service Code	MSDRG 577
Min. Negotiated Rate	$59,894.95
Max. Negotiated Rate	$59,894.95
Rate for Payer: Hawaii Medical Service Association Commercial	$59,894.95

SKIN GRAFT EXCEPT FOR SKIN ULCER OR CELLULITIS WITH MCC

Facility

$59,894.95

Service Code	MSDRG 576
Min. Negotiated Rate	$59,894.95
Max. Negotiated Rate	$59,894.95
Rate for Payer: Hawaii Medical Service Association Commercial	$59,894.95

SKIN GRAFT EXCEPT FOR SKIN ULCER OR CELLULITIS WITHOUT CC/MCC

Facility

$14,150.09

Service Code	MSDRG 578
Min. Negotiated Rate	$14,150.09
Max. Negotiated Rate	$14,150.09
Rate for Payer: Hawaii Medical Service Association Commercial	$14,150.09

SKIN GRAFT FOR SKIN ULCER OR CELLULITIS WITH CC

Facility

$57,738.07

Service Code	MSDRG 574
Min. Negotiated Rate	$57,738.07
Max. Negotiated Rate	$57,738.07
Rate for Payer: Hawaii Medical Service Association Commercial	$57,738.07

SKIN GRAFT FOR SKIN ULCER OR CELLULITIS WITH MCC

Facility

$60,890.44

Service Code	MSDRG 573
Min. Negotiated Rate	$60,890.44
Max. Negotiated Rate	$60,890.44
Rate for Payer: Hawaii Medical Service Association Commercial	$60,890.44

SKIN GRAFT FOR SKIN ULCER OR CELLULITIS WITHOUT CC/MCC

Facility

$34,984.15

Service Code	MSDRG 575
Min. Negotiated Rate	$34,984.15
Max. Negotiated Rate	$34,984.15
Rate for Payer: Hawaii Medical Service Association Commercial	$34,984.15

Skin Graft Full Thickness

Professional

Both

$2,872.00

Service Code	HCPCS 15240
Hospital Charge Code	8300897
Hospital Revenue Code	975
Min. Negotiated Rate	$606.84
Max. Negotiated Rate	$2,441.20
Rate for Payer: AlohaCare Medicaid	$835.06
Rate for Payer: AlohaCare Medicare	$722.48
Rate for Payer: Cash Price	$1,866.80
Rate for Payer: Cash Price	$1,866.80
Rate for Payer: Devoted Health Medicare	$794.73
Rate for Payer: Hawaii Medical Service Association ABD	$835.06
Rate for Payer: Hawaii Medical Service Association Commercial	$1,273.49
Rate for Payer: Hawaii Medical Service Association Medicare	$722.48
Rate for Payer: Hawaii Medical Service Association Non-ABD	$835.06
Rate for Payer: Hawaii Western Management Group Commercial	$606.84
Rate for Payer: Health Management Network Commercial	$2,441.20
Rate for Payer: Kaiser Permanente Commercial	$866.98
Rate for Payer: Kaiser Permanente Medicaid	$866.98
Rate for Payer: Kaiser Permanente Medicare	$866.98
Rate for Payer: Ohana Health Plan Medicaid	$835.06
Rate for Payer: Ohana Health Plan Medicare	$722.48
Rate for Payer: UnitedHealthcare Medicaid	$835.06
Rate for Payer: UnitedHealthcare Medicare	$722.48
Rate for Payer: University Health Alliance Commercial	$942.38

SKIN GRAFTS AND WOUND DEBRIDEMENT FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS WITH CC

Facility

$46,076.69

Service Code	MSDRG 623
Min. Negotiated Rate	$46,076.69
Max. Negotiated Rate	$46,076.69
Rate for Payer: Hawaii Medical Service Association Commercial	$46,076.69

SKIN GRAFTS AND WOUND DEBRIDEMENT FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS WITH MCC

Facility

$46,076.69

Service Code	MSDRG 622
Min. Negotiated Rate	$46,076.69
Max. Negotiated Rate	$46,076.69
Rate for Payer: Hawaii Medical Service Association Commercial	$46,076.69

SKIN GRAFTS AND WOUND DEBRIDEMENT FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS WITHOUT CC/MCC

Facility

$46,076.69

Service Code	MSDRG 624
Min. Negotiated Rate	$46,076.69
Max. Negotiated Rate	$46,076.69
Rate for Payer: Hawaii Medical Service Association Commercial	$46,076.69

SKIN GRAFTS FOR INJURIES WITH CC/MCC

Facility

$65,061.99

Service Code	MSDRG 904
Min. Negotiated Rate	$65,061.99
Max. Negotiated Rate	$65,061.99
Rate for Payer: Hawaii Medical Service Association Commercial	$65,061.99

SKIN GRAFTS FOR INJURIES WITHOUT CC/MCC

Facility

$65,061.99

Service Code	MSDRG 905
Min. Negotiated Rate	$65,061.99
Max. Negotiated Rate	$65,061.99
Rate for Payer: Hawaii Medical Service Association Commercial	$65,061.99

Know your out-of-pocket cost for care.

All Charges