Samuel Mahelona Memorial Hospital

All Charges

Charge

Type

Setting

Price

SKIN ULCERS WITH CC

Facility

$23,038.34

Service Code	MSDRG 593
Min. Negotiated Rate	$23,038.34
Max. Negotiated Rate	$23,038.34
Rate for Payer: Hawaii Medical Service Association Commercial	$23,038.34

SKIN ULCERS WITH MCC

Facility

$23,038.34

Service Code	MSDRG 592
Min. Negotiated Rate	$23,038.34
Max. Negotiated Rate	$23,038.34
Rate for Payer: Hawaii Medical Service Association Commercial	$23,038.34

SKIN ULCERS WITHOUT CC/MCC

Facility

$23,038.34

Service Code	MSDRG 594
Min. Negotiated Rate	$23,038.34
Max. Negotiated Rate	$23,038.34
Rate for Payer: Hawaii Medical Service Association Commercial	$23,038.34

SLEEP STUDY UNATT RESP EFFT CHARGE

Facility

$1,288.00

Service Code	HCPCS 95806
Hospital Charge Code	8243396
Hospital Revenue Code	740
Min. Negotiated Rate	$114.38
Max. Negotiated Rate	$1,249.36
Rate for Payer: AlohaCare Medicaid	$644.00
Rate for Payer: AlohaCare Medicare	$644.00
Rate for Payer: Cash Price	$837.20
Rate for Payer: Cash Price	$837.20
Rate for Payer: Devoted Health Medicare	$708.40
Rate for Payer: Hawaii Medical Service Association ABD	$114.38
Rate for Payer: Hawaii Medical Service Association Commercial	$275.75
Rate for Payer: Hawaii Medical Service Association Medicare	$644.00
Rate for Payer: Hawaii Medical Service Association Non-ABD	$121.44
Rate for Payer: Hawaii Western Management Group Commercial	$1,223.60
Rate for Payer: Health Management Network Commercial	$1,094.80
Rate for Payer: Humana Medicare	$644.00
Rate for Payer: Kaiser Permanente Commercial	$1,159.20
Rate for Payer: Kaiser Permanente Medicaid	$656.88
Rate for Payer: Kaiser Permanente Medicare	$644.00
Rate for Payer: MDX Hawaii PPO	$1,249.36
Rate for Payer: Ohana Health Plan Medicaid	$644.00
Rate for Payer: Ohana Health Plan Medicare	$644.00
Rate for Payer: UnitedHealthcare Medicaid	$114.38
Rate for Payer: UnitedHealthcare Medicare	$644.00
Rate for Payer: University Health Alliance Commercial	$721.28

SLEEP STUDY UNATT RESP EFFT CHARGE

Facility

$1,288.00

Service Code	HCPCS 95806
Hospital Charge Code	8243396
Hospital Revenue Code	740
Min. Negotiated Rate	$1,094.80
Max. Negotiated Rate	$1,249.36
Rate for Payer: Cash Price	$837.20
Rate for Payer: Health Management Network Commercial	$1,094.80
Rate for Payer: Kaiser Permanente Commercial	$1,159.20
Rate for Payer: MDX Hawaii PPO	$1,249.36

SLING ARM LGE

Facility

$27.00

Hospital Charge Code	8266533
Hospital Revenue Code	271
Min. Negotiated Rate	$13.50
Max. Negotiated Rate	$26.19
Rate for Payer: AlohaCare Medicaid	$13.50
Rate for Payer: AlohaCare Medicare	$13.50
Rate for Payer: Cash Price	$17.55
Rate for Payer: Devoted Health Medicare	$14.85
Rate for Payer: Hawaii Medical Service Association Medicare	$13.50
Rate for Payer: Hawaii Western Management Group Commercial	$25.65
Rate for Payer: Health Management Network Commercial	$22.95
Rate for Payer: Humana Medicare	$13.50
Rate for Payer: Kaiser Permanente Commercial	$24.30
Rate for Payer: Kaiser Permanente Medicaid	$13.77
Rate for Payer: Kaiser Permanente Medicare	$13.50
Rate for Payer: MDX Hawaii PPO	$26.19
Rate for Payer: Ohana Health Plan Medicaid	$13.50
Rate for Payer: Ohana Health Plan Medicare	$13.50
Rate for Payer: UnitedHealthcare Medicare	$13.50
Rate for Payer: University Health Alliance Commercial	$19.68

SLING ARM LGE

Facility

$27.00

Hospital Charge Code	8266533
Hospital Revenue Code	271
Min. Negotiated Rate	$22.95
Max. Negotiated Rate	$26.19
Rate for Payer: Cash Price	$17.55
Rate for Payer: Health Management Network Commercial	$22.95
Rate for Payer: Kaiser Permanente Commercial	$24.30
Rate for Payer: MDX Hawaii PPO	$26.19

SLING ARM MED

Facility

$13.00

Hospital Charge Code	8266532
Hospital Revenue Code	271
Min. Negotiated Rate	$11.05
Max. Negotiated Rate	$12.61
Rate for Payer: Cash Price	$8.45
Rate for Payer: Health Management Network Commercial	$11.05
Rate for Payer: Kaiser Permanente Commercial	$11.70
Rate for Payer: MDX Hawaii PPO	$12.61

SLING ARM MED

Facility

$13.00

Hospital Charge Code	8266532
Hospital Revenue Code	271
Min. Negotiated Rate	$6.50
Max. Negotiated Rate	$12.61
Rate for Payer: AlohaCare Medicaid	$6.50
Rate for Payer: AlohaCare Medicare	$6.50
Rate for Payer: Cash Price	$8.45
Rate for Payer: Devoted Health Medicare	$7.15
Rate for Payer: Hawaii Medical Service Association Medicare	$6.50
Rate for Payer: Hawaii Western Management Group Commercial	$12.35
Rate for Payer: Health Management Network Commercial	$11.05
Rate for Payer: Humana Medicare	$6.50
Rate for Payer: Kaiser Permanente Commercial	$11.70
Rate for Payer: Kaiser Permanente Medicaid	$6.63
Rate for Payer: Kaiser Permanente Medicare	$6.50
Rate for Payer: MDX Hawaii PPO	$12.61
Rate for Payer: Ohana Health Plan Medicaid	$6.50
Rate for Payer: Ohana Health Plan Medicare	$6.50
Rate for Payer: UnitedHealthcare Medicare	$6.50
Rate for Payer: University Health Alliance Commercial	$9.48

SLING ARM SML

Facility

$13.00

Hospital Charge Code	8266531
Hospital Revenue Code	271
Min. Negotiated Rate	$6.50
Max. Negotiated Rate	$12.61
Rate for Payer: AlohaCare Medicaid	$6.50
Rate for Payer: AlohaCare Medicare	$6.50
Rate for Payer: Cash Price	$8.45
Rate for Payer: Devoted Health Medicare	$7.15
Rate for Payer: Hawaii Medical Service Association Medicare	$6.50
Rate for Payer: Hawaii Western Management Group Commercial	$12.35
Rate for Payer: Health Management Network Commercial	$11.05
Rate for Payer: Humana Medicare	$6.50
Rate for Payer: Kaiser Permanente Commercial	$11.70
Rate for Payer: Kaiser Permanente Medicaid	$6.63
Rate for Payer: Kaiser Permanente Medicare	$6.50
Rate for Payer: MDX Hawaii PPO	$12.61
Rate for Payer: Ohana Health Plan Medicaid	$6.50
Rate for Payer: Ohana Health Plan Medicare	$6.50
Rate for Payer: UnitedHealthcare Medicare	$6.50
Rate for Payer: University Health Alliance Commercial	$9.48

SLING ARM SML

Facility

$13.00

Hospital Charge Code	8266531
Hospital Revenue Code	271
Min. Negotiated Rate	$11.05
Max. Negotiated Rate	$12.61
Rate for Payer: Cash Price	$8.45
Rate for Payer: Health Management Network Commercial	$11.05
Rate for Payer: Kaiser Permanente Commercial	$11.70
Rate for Payer: MDX Hawaii PPO	$12.61

SLING ARM XLG

Facility

$12.00

Hospital Charge Code	8266534
Hospital Revenue Code	271
Min. Negotiated Rate	$10.20
Max. Negotiated Rate	$11.64
Rate for Payer: Cash Price	$7.80
Rate for Payer: Health Management Network Commercial	$10.20
Rate for Payer: Kaiser Permanente Commercial	$10.80
Rate for Payer: MDX Hawaii PPO	$11.64

SLING ARM XLG

Facility

$12.00

Hospital Charge Code	8266534
Hospital Revenue Code	271
Min. Negotiated Rate	$6.00
Max. Negotiated Rate	$11.64
Rate for Payer: AlohaCare Medicaid	$6.00
Rate for Payer: AlohaCare Medicare	$6.00
Rate for Payer: Cash Price	$7.80
Rate for Payer: Devoted Health Medicare	$6.60
Rate for Payer: Hawaii Medical Service Association Medicare	$6.00
Rate for Payer: Hawaii Western Management Group Commercial	$11.40
Rate for Payer: Health Management Network Commercial	$10.20
Rate for Payer: Humana Medicare	$6.00
Rate for Payer: Kaiser Permanente Commercial	$10.80
Rate for Payer: Kaiser Permanente Medicaid	$6.12
Rate for Payer: Kaiser Permanente Medicare	$6.00
Rate for Payer: MDX Hawaii PPO	$11.64
Rate for Payer: Ohana Health Plan Medicaid	$6.00
Rate for Payer: Ohana Health Plan Medicare	$6.00
Rate for Payer: UnitedHealthcare Medicare	$6.00
Rate for Payer: University Health Alliance Commercial	$8.75

SLP Assessment of Aphasia Units

Facility

$591.00

Service Code	HCPCS 96105 GO,CO
Hospital Charge Code	1373853
Hospital Revenue Code	444
Min. Negotiated Rate	$59.90
Max. Negotiated Rate	$573.27
Rate for Payer: AlohaCare Medicaid	$295.50
Rate for Payer: AlohaCare Medicare	$295.50
Rate for Payer: Cash Price	$384.15
Rate for Payer: Cash Price	$384.15
Rate for Payer: Devoted Health Medicare	$325.05
Rate for Payer: Hawaii Medical Service Association Medicare	$295.50
Rate for Payer: Hawaii Western Management Group Commercial	$561.45
Rate for Payer: Health Management Network Commercial	$502.35
Rate for Payer: Humana Medicare	$295.50
Rate for Payer: Kaiser Permanente Commercial	$531.90
Rate for Payer: Kaiser Permanente Medicaid	$301.41
Rate for Payer: Kaiser Permanente Medicare	$295.50
Rate for Payer: MDX Hawaii PPO	$573.27
Rate for Payer: Ohana Health Plan Medicaid	$295.50
Rate for Payer: Ohana Health Plan Medicare	$295.50
Rate for Payer: UnitedHealthcare Medicaid	$59.90
Rate for Payer: UnitedHealthcare Medicare	$295.50
Rate for Payer: University Health Alliance Commercial	$330.96

SLP Assessment of Aphasia Units

Facility

$591.00

Service Code	HCPCS 96105 GO,CO
Hospital Charge Code	1373853
Hospital Revenue Code	444
Min. Negotiated Rate	$502.35
Max. Negotiated Rate	$573.27
Rate for Payer: Cash Price	$384.15
Rate for Payer: Health Management Network Commercial	$502.35
Rate for Payer: Kaiser Permanente Commercial	$531.90
Rate for Payer: MDX Hawaii PPO	$573.27

SLP Auditory Processing Tx Units

Facility

$411.00

Service Code	HCPCS 92507 GO,CO
Hospital Charge Code	1373841
Hospital Revenue Code	440
Min. Negotiated Rate	$21.05
Max. Negotiated Rate	$398.67
Rate for Payer: AlohaCare Medicaid	$205.50
Rate for Payer: AlohaCare Medicare	$205.50
Rate for Payer: Cash Price	$267.15
Rate for Payer: Cash Price	$267.15
Rate for Payer: Devoted Health Medicare	$226.05
Rate for Payer: Hawaii Medical Service Association Medicare	$205.50
Rate for Payer: Hawaii Western Management Group Commercial	$390.45
Rate for Payer: Health Management Network Commercial	$349.35
Rate for Payer: Humana Medicare	$205.50
Rate for Payer: Kaiser Permanente Commercial	$369.90
Rate for Payer: Kaiser Permanente Medicaid	$209.61
Rate for Payer: Kaiser Permanente Medicare	$205.50
Rate for Payer: MDX Hawaii PPO	$398.67
Rate for Payer: Ohana Health Plan Medicaid	$205.50
Rate for Payer: Ohana Health Plan Medicare	$205.50
Rate for Payer: UnitedHealthcare Medicaid	$21.05
Rate for Payer: UnitedHealthcare Medicare	$205.50
Rate for Payer: University Health Alliance Commercial	$230.16

SLP Auditory Processing Tx Units

Facility

$411.00

Service Code	HCPCS 92507 GO,CO
Hospital Charge Code	1373841
Hospital Revenue Code	440
Min. Negotiated Rate	$349.35
Max. Negotiated Rate	$398.67
Rate for Payer: Cash Price	$267.15
Rate for Payer: Health Management Network Commercial	$349.35
Rate for Payer: Kaiser Permanente Commercial	$369.90
Rate for Payer: MDX Hawaii PPO	$398.67

SLP Cog Ther Intervent1st 15min Unit

Facility

$152.00

Service Code	HCPCS 97129 GO,CO
Hospital Charge Code	8740039
Hospital Revenue Code	440
Min. Negotiated Rate	$129.20
Max. Negotiated Rate	$147.44
Rate for Payer: Cash Price	$98.80
Rate for Payer: Health Management Network Commercial	$129.20
Rate for Payer: Kaiser Permanente Commercial	$136.80
Rate for Payer: MDX Hawaii PPO	$147.44

SLP Cog Ther Intervent1st 15min Unit

Facility

$152.00

Service Code	HCPCS 97129 GO,CO
Hospital Charge Code	8740039
Hospital Revenue Code	440
Min. Negotiated Rate	$22.57
Max. Negotiated Rate	$147.44
Rate for Payer: AlohaCare Medicaid	$76.00
Rate for Payer: AlohaCare Medicare	$76.00
Rate for Payer: Cash Price	$98.80
Rate for Payer: Cash Price	$98.80
Rate for Payer: Devoted Health Medicare	$83.60
Rate for Payer: Hawaii Medical Service Association Medicare	$76.00
Rate for Payer: Hawaii Western Management Group Commercial	$144.40
Rate for Payer: Health Management Network Commercial	$129.20
Rate for Payer: Humana Medicare	$76.00
Rate for Payer: Kaiser Permanente Commercial	$136.80
Rate for Payer: Kaiser Permanente Medicaid	$77.52
Rate for Payer: Kaiser Permanente Medicare	$76.00
Rate for Payer: MDX Hawaii PPO	$147.44
Rate for Payer: Ohana Health Plan Medicaid	$76.00
Rate for Payer: Ohana Health Plan Medicare	$76.00
Rate for Payer: UnitedHealthcare Medicaid	$22.57
Rate for Payer: UnitedHealthcare Medicare	$76.00
Rate for Payer: University Health Alliance Commercial	$85.12

SLP Cog Ther Intervent, Addl 15 Units

Facility

$149.00

Service Code	HCPCS 97130 GO,CO
Hospital Charge Code	8740043
Hospital Revenue Code	440
Min. Negotiated Rate	$126.65
Max. Negotiated Rate	$144.53
Rate for Payer: Cash Price	$96.85
Rate for Payer: Health Management Network Commercial	$126.65
Rate for Payer: Kaiser Permanente Commercial	$134.10
Rate for Payer: MDX Hawaii PPO	$144.53

SLP Cog Ther Intervent, Addl 15 Units

Facility

$149.00

Service Code	HCPCS 97130 GO,CO
Hospital Charge Code	8740043
Hospital Revenue Code	440
Min. Negotiated Rate	$21.52
Max. Negotiated Rate	$144.53
Rate for Payer: AlohaCare Medicaid	$74.50
Rate for Payer: AlohaCare Medicare	$74.50
Rate for Payer: Cash Price	$96.85
Rate for Payer: Cash Price	$96.85
Rate for Payer: Devoted Health Medicare	$81.95
Rate for Payer: Hawaii Medical Service Association Medicare	$74.50
Rate for Payer: Hawaii Western Management Group Commercial	$141.55
Rate for Payer: Health Management Network Commercial	$126.65
Rate for Payer: Humana Medicare	$74.50
Rate for Payer: Kaiser Permanente Commercial	$134.10
Rate for Payer: Kaiser Permanente Medicaid	$75.99
Rate for Payer: Kaiser Permanente Medicare	$74.50
Rate for Payer: MDX Hawaii PPO	$144.53
Rate for Payer: Ohana Health Plan Medicaid	$74.50
Rate for Payer: Ohana Health Plan Medicare	$74.50
Rate for Payer: UnitedHealthcare Medicaid	$21.52
Rate for Payer: UnitedHealthcare Medicare	$74.50
Rate for Payer: University Health Alliance Commercial	$83.44

SLP Eval Lang Comprehension,Express Unit

Facility

$572.00

Service Code	HCPCS 92523 GO,CO
Hospital Charge Code	2597754
Hospital Revenue Code	444
Min. Negotiated Rate	$486.20
Max. Negotiated Rate	$554.84
Rate for Payer: Cash Price	$371.80
Rate for Payer: Health Management Network Commercial	$486.20
Rate for Payer: Kaiser Permanente Commercial	$514.80
Rate for Payer: MDX Hawaii PPO	$554.84

SLP Eval Lang Comprehension,Express Unit

Facility

$572.00

Service Code	HCPCS 92523 GO,CO
Hospital Charge Code	2597754
Hospital Revenue Code	444
Min. Negotiated Rate	$240.61
Max. Negotiated Rate	$554.84
Rate for Payer: AlohaCare Medicaid	$286.00
Rate for Payer: AlohaCare Medicare	$286.00
Rate for Payer: Cash Price	$371.80
Rate for Payer: Cash Price	$371.80
Rate for Payer: Devoted Health Medicare	$314.60
Rate for Payer: Hawaii Medical Service Association Medicare	$286.00
Rate for Payer: Hawaii Western Management Group Commercial	$543.40
Rate for Payer: Health Management Network Commercial	$486.20
Rate for Payer: Humana Medicare	$286.00
Rate for Payer: Kaiser Permanente Commercial	$514.80
Rate for Payer: Kaiser Permanente Medicaid	$291.72
Rate for Payer: Kaiser Permanente Medicare	$286.00
Rate for Payer: MDX Hawaii PPO	$554.84
Rate for Payer: Ohana Health Plan Medicaid	$286.00
Rate for Payer: Ohana Health Plan Medicare	$286.00
Rate for Payer: UnitedHealthcare Medicaid	$240.61
Rate for Payer: UnitedHealthcare Medicare	$286.00
Rate for Payer: University Health Alliance Commercial	$320.32

SLP Eval of Speech Sound Prod Units

Facility

$665.00

Service Code	HCPCS 92522 GO,CO
Hospital Charge Code	2597752
Hospital Revenue Code	444
Min. Negotiated Rate	$116.85
Max. Negotiated Rate	$645.05
Rate for Payer: AlohaCare Medicaid	$332.50
Rate for Payer: AlohaCare Medicare	$332.50
Rate for Payer: Cash Price	$432.25
Rate for Payer: Cash Price	$432.25
Rate for Payer: Devoted Health Medicare	$365.75
Rate for Payer: Hawaii Medical Service Association Medicare	$332.50
Rate for Payer: Hawaii Western Management Group Commercial	$631.75
Rate for Payer: Health Management Network Commercial	$565.25
Rate for Payer: Humana Medicare	$332.50
Rate for Payer: Kaiser Permanente Commercial	$598.50
Rate for Payer: Kaiser Permanente Medicaid	$339.15
Rate for Payer: Kaiser Permanente Medicare	$332.50
Rate for Payer: MDX Hawaii PPO	$645.05
Rate for Payer: Ohana Health Plan Medicaid	$332.50
Rate for Payer: Ohana Health Plan Medicare	$332.50
Rate for Payer: UnitedHealthcare Medicaid	$116.85
Rate for Payer: UnitedHealthcare Medicare	$332.50
Rate for Payer: University Health Alliance Commercial	$372.40

SLP Eval of Speech Sound Prod Units

Facility

$665.00

Service Code	HCPCS 92522 GO,CO
Hospital Charge Code	2597752
Hospital Revenue Code	444
Min. Negotiated Rate	$565.25
Max. Negotiated Rate	$645.05
Rate for Payer: Cash Price	$432.25
Rate for Payer: Health Management Network Commercial	$565.25
Rate for Payer: Kaiser Permanente Commercial	$598.50
Rate for Payer: MDX Hawaii PPO	$645.05

Know your out-of-pocket cost for care.

All Charges