Samuel Mahelona Memorial Hospital

All Charges

Charge

Type

Setting

Price

SPLINT SYSTEM CASTING ORTHO-GLASS 3X15' ROLL LF WHITE EA, 2 RL/CA

Facility

$168.00

Hospital Charge Code	12954867
Hospital Revenue Code	272
Min. Negotiated Rate	$84.00
Max. Negotiated Rate	$162.96
Rate for Payer: AlohaCare Medicaid	$84.00
Rate for Payer: AlohaCare Medicare	$84.00
Rate for Payer: Cash Price	$109.20
Rate for Payer: Devoted Health Medicare	$92.40
Rate for Payer: Hawaii Medical Service Association Medicare	$84.00
Rate for Payer: Hawaii Western Management Group Commercial	$159.60
Rate for Payer: Health Management Network Commercial	$142.80
Rate for Payer: Humana Medicare	$84.00
Rate for Payer: Kaiser Permanente Commercial	$151.20
Rate for Payer: Kaiser Permanente Medicaid	$85.68
Rate for Payer: Kaiser Permanente Medicare	$84.00
Rate for Payer: MDX Hawaii PPO	$162.96
Rate for Payer: Ohana Health Plan Medicaid	$84.00
Rate for Payer: Ohana Health Plan Medicare	$84.00
Rate for Payer: UnitedHealthcare Medicare	$84.00
Rate for Payer: University Health Alliance Commercial	$122.46

SPLINT SYSTEM CASTING ORTHO-GLASS 3X15' ROLL LF WHITE EA, 2 RL/CA

Facility

$168.00

Hospital Charge Code	12954867
Hospital Revenue Code	272
Min. Negotiated Rate	$142.80
Max. Negotiated Rate	$162.96
Rate for Payer: Cash Price	$109.20
Rate for Payer: Health Management Network Commercial	$142.80
Rate for Payer: Kaiser Permanente Commercial	$151.20
Rate for Payer: MDX Hawaii PPO	$162.96

SPLINT SYSTEM CASTING ORTHO-GLASS 3X15' ROLL LF WHITE EA, 2 RL/CA

Professional

Both

$168.00

Hospital Charge Code	12954867
Hospital Revenue Code	272
Min. Negotiated Rate	$142.80
Max. Negotiated Rate	$142.80
Rate for Payer: Cash Price	$109.20
Rate for Payer: Health Management Network Commercial	$142.80

SPLINT SYSTEM CASTING ORTHO-GLASS 4X15' ROLL LF WHITE EA, 2 RL/CA

Professional

Both

$202.00

Hospital Charge Code	12954861
Hospital Revenue Code	272
Min. Negotiated Rate	$171.70
Max. Negotiated Rate	$171.70
Rate for Payer: Cash Price	$131.30
Rate for Payer: Health Management Network Commercial	$171.70

SPLINT SYSTEM CASTING ORTHO-GLASS 4X15' ROLL LF WHITE EA, 2 RL/CA

Facility

$202.00

Hospital Charge Code	12954861
Hospital Revenue Code	272
Min. Negotiated Rate	$101.00
Max. Negotiated Rate	$195.94
Rate for Payer: AlohaCare Medicaid	$101.00
Rate for Payer: AlohaCare Medicare	$101.00
Rate for Payer: Cash Price	$131.30
Rate for Payer: Devoted Health Medicare	$111.10
Rate for Payer: Hawaii Medical Service Association Medicare	$101.00
Rate for Payer: Hawaii Western Management Group Commercial	$191.90
Rate for Payer: Health Management Network Commercial	$171.70
Rate for Payer: Humana Medicare	$101.00
Rate for Payer: Kaiser Permanente Commercial	$181.80
Rate for Payer: Kaiser Permanente Medicaid	$103.02
Rate for Payer: Kaiser Permanente Medicare	$101.00
Rate for Payer: MDX Hawaii PPO	$195.94
Rate for Payer: Ohana Health Plan Medicaid	$101.00
Rate for Payer: Ohana Health Plan Medicare	$101.00
Rate for Payer: UnitedHealthcare Medicare	$101.00
Rate for Payer: University Health Alliance Commercial	$147.24

SPLINT SYSTEM CASTING ORTHO-GLASS 4X15' ROLL LF WHITE EA, 2 RL/CA

Facility

$202.00

Hospital Charge Code	12954861
Hospital Revenue Code	272
Min. Negotiated Rate	$171.70
Max. Negotiated Rate	$195.94
Rate for Payer: Cash Price	$131.30
Rate for Payer: Health Management Network Commercial	$171.70
Rate for Payer: Kaiser Permanente Commercial	$181.80
Rate for Payer: MDX Hawaii PPO	$195.94

SPOT ENDOSCOPIC TATTOO

Facility

$190.00

Hospital Charge Code	8939937
Hospital Revenue Code	272
Min. Negotiated Rate	$95.00
Max. Negotiated Rate	$184.30
Rate for Payer: AlohaCare Medicaid	$95.00
Rate for Payer: AlohaCare Medicare	$95.00
Rate for Payer: Cash Price	$123.50
Rate for Payer: Devoted Health Medicare	$104.50
Rate for Payer: Hawaii Medical Service Association Medicare	$95.00
Rate for Payer: Hawaii Western Management Group Commercial	$180.50
Rate for Payer: Health Management Network Commercial	$161.50
Rate for Payer: Humana Medicare	$95.00
Rate for Payer: Kaiser Permanente Commercial	$171.00
Rate for Payer: Kaiser Permanente Medicaid	$96.90
Rate for Payer: Kaiser Permanente Medicare	$95.00
Rate for Payer: MDX Hawaii PPO	$184.30
Rate for Payer: Ohana Health Plan Medicaid	$95.00
Rate for Payer: Ohana Health Plan Medicare	$95.00
Rate for Payer: UnitedHealthcare Medicare	$95.00
Rate for Payer: University Health Alliance Commercial	$138.49

SPOT ENDOSCOPIC TATTOO

Facility

$190.00

Hospital Charge Code	8939937
Hospital Revenue Code	272
Min. Negotiated Rate	$161.50
Max. Negotiated Rate	$184.30
Rate for Payer: Cash Price	$123.50
Rate for Payer: Health Management Network Commercial	$161.50
Rate for Payer: Kaiser Permanente Commercial	$171.00
Rate for Payer: MDX Hawaii PPO	$184.30

SPRAINS, STRAINS, AND DISLOCATIONS OF HIP, PELVIS AND THIGH WITH CC/MCC

Facility

$24,910.80

Service Code	MSDRG 537
Min. Negotiated Rate	$24,910.80
Max. Negotiated Rate	$24,910.80
Rate for Payer: Hawaii Medical Service Association Commercial	$24,910.80

SPRAINS, STRAINS, AND DISLOCATIONS OF HIP, PELVIS AND THIGH WITHOUT CC/MCC

Facility

$24,910.80

Service Code	MSDRG 538
Min. Negotiated Rate	$24,910.80
Max. Negotiated Rate	$24,910.80
Rate for Payer: Hawaii Medical Service Association Commercial	$24,910.80

Sputum Culture FSI

Facility

$127.00

Service Code	HCPCS 87070
Hospital Charge Code	8118049
Hospital Revenue Code	306
Min. Negotiated Rate	$107.95
Max. Negotiated Rate	$123.19
Rate for Payer: Cash Price	$82.55
Rate for Payer: Health Management Network Commercial	$107.95
Rate for Payer: Kaiser Permanente Commercial	$114.30
Rate for Payer: MDX Hawaii PPO	$123.19

Sputum Culture FSI

Facility

$127.00

Service Code	HCPCS 87070
Hospital Charge Code	8118049
Hospital Revenue Code	306
Min. Negotiated Rate	$8.62
Max. Negotiated Rate	$123.19
Rate for Payer: AlohaCare Medicaid	$63.50
Rate for Payer: AlohaCare Medicare	$63.50
Rate for Payer: Cash Price	$82.55
Rate for Payer: Cash Price	$82.55
Rate for Payer: Devoted Health Medicare	$69.85
Rate for Payer: Hawaii Medical Service Association ABD	$11.90
Rate for Payer: Hawaii Medical Service Association Commercial	$10.78
Rate for Payer: Hawaii Medical Service Association Medicare	$63.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$12.50
Rate for Payer: Hawaii Western Management Group Commercial	$8.62
Rate for Payer: Health Management Network Commercial	$107.95
Rate for Payer: Humana Medicare	$63.50
Rate for Payer: Kaiser Permanente Commercial	$114.30
Rate for Payer: Kaiser Permanente Medicaid	$64.77
Rate for Payer: Kaiser Permanente Medicare	$63.50
Rate for Payer: MDX Hawaii PPO	$123.19
Rate for Payer: Ohana Health Plan Medicaid	$63.50
Rate for Payer: Ohana Health Plan Medicare	$63.50
Rate for Payer: UnitedHealthcare Medicaid	$11.90
Rate for Payer: UnitedHealthcare Medicare	$63.50
Rate for Payer: University Health Alliance Commercial	$22.26

Sputum Culture w/ Gram Stain FSI

Facility

$105.00

Service Code	HCPCS 87070
Hospital Charge Code	8118050
Hospital Revenue Code	300
Min. Negotiated Rate	$8.62
Max. Negotiated Rate	$101.85
Rate for Payer: AlohaCare Medicaid	$52.50
Rate for Payer: AlohaCare Medicare	$52.50
Rate for Payer: Cash Price	$68.25
Rate for Payer: Cash Price	$68.25
Rate for Payer: Devoted Health Medicare	$57.75
Rate for Payer: Hawaii Medical Service Association ABD	$11.90
Rate for Payer: Hawaii Medical Service Association Commercial	$10.78
Rate for Payer: Hawaii Medical Service Association Medicare	$52.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$12.50
Rate for Payer: Hawaii Western Management Group Commercial	$8.62
Rate for Payer: Health Management Network Commercial	$89.25
Rate for Payer: Humana Medicare	$52.50
Rate for Payer: Kaiser Permanente Commercial	$94.50
Rate for Payer: Kaiser Permanente Medicaid	$53.55
Rate for Payer: Kaiser Permanente Medicare	$52.50
Rate for Payer: MDX Hawaii PPO	$101.85
Rate for Payer: Ohana Health Plan Medicaid	$52.50
Rate for Payer: Ohana Health Plan Medicare	$52.50
Rate for Payer: UnitedHealthcare Medicaid	$11.90
Rate for Payer: UnitedHealthcare Medicare	$52.50
Rate for Payer: University Health Alliance Commercial	$22.26

Sputum Culture w/ Gram Stain FSI

Facility

$105.00

Service Code	HCPCS 87070
Hospital Charge Code	8118050
Hospital Revenue Code	300
Min. Negotiated Rate	$89.25
Max. Negotiated Rate	$101.85
Rate for Payer: Cash Price	$68.25
Rate for Payer: Health Management Network Commercial	$89.25
Rate for Payer: Kaiser Permanente Commercial	$94.50
Rate for Payer: MDX Hawaii PPO	$101.85

SPUTUM INDUCTION TREATMENT CHARGE

Facility

$378.00

Service Code	HCPCS 89220
Hospital Charge Code	8223119
Hospital Revenue Code	410
Min. Negotiated Rate	$11.23
Max. Negotiated Rate	$366.66
Rate for Payer: AlohaCare Medicaid	$189.00
Rate for Payer: AlohaCare Medicare	$189.00
Rate for Payer: Cash Price	$245.70
Rate for Payer: Cash Price	$245.70
Rate for Payer: Devoted Health Medicare	$207.90
Rate for Payer: Hawaii Medical Service Association ABD	$11.23
Rate for Payer: Hawaii Medical Service Association Commercial	$217.57
Rate for Payer: Hawaii Medical Service Association Medicare	$189.00
Rate for Payer: Hawaii Medical Service Association Non-ABD	$14.80
Rate for Payer: Hawaii Western Management Group Commercial	$174.06
Rate for Payer: Health Management Network Commercial	$321.30
Rate for Payer: Humana Medicare	$189.00
Rate for Payer: Kaiser Permanente Commercial	$340.20
Rate for Payer: Kaiser Permanente Medicaid	$192.78
Rate for Payer: Kaiser Permanente Medicare	$189.00
Rate for Payer: MDX Hawaii PPO	$366.66
Rate for Payer: Ohana Health Plan Medicaid	$189.00
Rate for Payer: Ohana Health Plan Medicare	$189.00
Rate for Payer: UnitedHealthcare Medicaid	$11.23
Rate for Payer: UnitedHealthcare Medicare	$189.00
Rate for Payer: University Health Alliance Commercial	$33.06

SPUTUM INDUCTION TREATMENT CHARGE

Facility

$378.00

Service Code	HCPCS 89220
Hospital Charge Code	8223119
Hospital Revenue Code	410
Min. Negotiated Rate	$321.30
Max. Negotiated Rate	$366.66
Rate for Payer: Cash Price	$245.70
Rate for Payer: Health Management Network Commercial	$321.30
Rate for Payer: Kaiser Permanente Commercial	$340.20
Rate for Payer: MDX Hawaii PPO	$366.66

SPY DISCOVER: SPYGLASS DISCOVER T/A CATH

Facility

$5,500.00

Hospital Charge Code	10400710
Hospital Revenue Code	272
Min. Negotiated Rate	$4,675.00
Max. Negotiated Rate	$5,335.00
Rate for Payer: Cash Price	$3,575.00
Rate for Payer: Health Management Network Commercial	$4,675.00
Rate for Payer: Kaiser Permanente Commercial	$4,950.00
Rate for Payer: MDX Hawaii PPO	$5,335.00

SPY DISCOVER: SPYGLASS DISCOVER T/A CATH

Facility

$5,500.00

Hospital Charge Code	10400710
Hospital Revenue Code	272
Min. Negotiated Rate	$2,750.00
Max. Negotiated Rate	$5,335.00
Rate for Payer: AlohaCare Medicaid	$2,750.00
Rate for Payer: AlohaCare Medicare	$2,750.00
Rate for Payer: Cash Price	$3,575.00
Rate for Payer: Devoted Health Medicare	$3,025.00
Rate for Payer: Hawaii Medical Service Association Medicare	$2,750.00
Rate for Payer: Hawaii Western Management Group Commercial	$5,225.00
Rate for Payer: Health Management Network Commercial	$4,675.00
Rate for Payer: Humana Medicare	$2,750.00
Rate for Payer: Kaiser Permanente Commercial	$4,950.00
Rate for Payer: Kaiser Permanente Medicaid	$2,805.00
Rate for Payer: Kaiser Permanente Medicare	$2,750.00
Rate for Payer: MDX Hawaii PPO	$5,335.00
Rate for Payer: Ohana Health Plan Medicaid	$2,750.00
Rate for Payer: Ohana Health Plan Medicare	$2,750.00
Rate for Payer: UnitedHealthcare Medicare	$2,750.00
Rate for Payer: University Health Alliance Commercial	$4,008.95

Standardized Cognitive Eval Charge

Facility

$272.00

Service Code	HCPCS 96125 GP,CO
Hospital Charge Code	8173996
Hospital Revenue Code	440
Min. Negotiated Rate	$231.20
Max. Negotiated Rate	$263.84
Rate for Payer: Cash Price	$176.80
Rate for Payer: Health Management Network Commercial	$231.20
Rate for Payer: Kaiser Permanente Commercial	$244.80
Rate for Payer: MDX Hawaii PPO	$263.84

Standardized Cognitive Eval Charge

Facility

$272.00

Service Code	HCPCS 96125 GP,CO
Hospital Charge Code	8173996
Hospital Revenue Code	440
Min. Negotiated Rate	$41.65
Max. Negotiated Rate	$263.84
Rate for Payer: AlohaCare Medicaid	$136.00
Rate for Payer: AlohaCare Medicare	$136.00
Rate for Payer: Cash Price	$176.80
Rate for Payer: Cash Price	$176.80
Rate for Payer: Devoted Health Medicare	$149.60
Rate for Payer: Hawaii Medical Service Association Medicare	$136.00
Rate for Payer: Hawaii Western Management Group Commercial	$258.40
Rate for Payer: Health Management Network Commercial	$231.20
Rate for Payer: Humana Medicare	$136.00
Rate for Payer: Kaiser Permanente Commercial	$244.80
Rate for Payer: Kaiser Permanente Medicaid	$138.72
Rate for Payer: Kaiser Permanente Medicare	$136.00
Rate for Payer: MDX Hawaii PPO	$263.84
Rate for Payer: Ohana Health Plan Medicaid	$136.00
Rate for Payer: Ohana Health Plan Medicare	$136.00
Rate for Payer: UnitedHealthcare Medicaid	$41.65
Rate for Payer: UnitedHealthcare Medicare	$136.00
Rate for Payer: University Health Alliance Commercial	$152.32

STANDARD PEG KIT 20F

Facility

$240.00

Hospital Charge Code	9952986
Hospital Revenue Code	272
Min. Negotiated Rate	$204.00
Max. Negotiated Rate	$232.80
Rate for Payer: Cash Price	$156.00
Rate for Payer: Health Management Network Commercial	$204.00
Rate for Payer: Kaiser Permanente Commercial	$216.00
Rate for Payer: MDX Hawaii PPO	$232.80

STANDARD PEG KIT 20F

Facility

$240.00

Hospital Charge Code	9952986
Hospital Revenue Code	272
Min. Negotiated Rate	$120.00
Max. Negotiated Rate	$232.80
Rate for Payer: AlohaCare Medicaid	$120.00
Rate for Payer: AlohaCare Medicare	$120.00
Rate for Payer: Cash Price	$156.00
Rate for Payer: Devoted Health Medicare	$132.00
Rate for Payer: Hawaii Medical Service Association Medicare	$120.00
Rate for Payer: Hawaii Western Management Group Commercial	$228.00
Rate for Payer: Health Management Network Commercial	$204.00
Rate for Payer: Humana Medicare	$120.00
Rate for Payer: Kaiser Permanente Commercial	$216.00
Rate for Payer: Kaiser Permanente Medicaid	$122.40
Rate for Payer: Kaiser Permanente Medicare	$120.00
Rate for Payer: MDX Hawaii PPO	$232.80
Rate for Payer: Ohana Health Plan Medicaid	$120.00
Rate for Payer: Ohana Health Plan Medicare	$120.00
Rate for Payer: UnitedHealthcare Medicare	$120.00
Rate for Payer: University Health Alliance Commercial	$174.94

STAPLER CONTOUR CURVED CUTTER

Facility

$394.00

Hospital Charge Code	8348081
Hospital Revenue Code	272
Min. Negotiated Rate	$334.90
Max. Negotiated Rate	$382.18
Rate for Payer: Cash Price	$256.10
Rate for Payer: Health Management Network Commercial	$334.90
Rate for Payer: Kaiser Permanente Commercial	$354.60
Rate for Payer: MDX Hawaii PPO	$382.18

STAPLER CONTOUR CURVED CUTTER

Facility

$394.00

Hospital Charge Code	8348081
Hospital Revenue Code	272
Min. Negotiated Rate	$197.00
Max. Negotiated Rate	$382.18
Rate for Payer: AlohaCare Medicaid	$197.00
Rate for Payer: AlohaCare Medicare	$197.00
Rate for Payer: Cash Price	$256.10
Rate for Payer: Devoted Health Medicare	$216.70
Rate for Payer: Hawaii Medical Service Association Medicare	$197.00
Rate for Payer: Hawaii Western Management Group Commercial	$374.30
Rate for Payer: Health Management Network Commercial	$334.90
Rate for Payer: Humana Medicare	$197.00
Rate for Payer: Kaiser Permanente Commercial	$354.60
Rate for Payer: Kaiser Permanente Medicaid	$200.94
Rate for Payer: Kaiser Permanente Medicare	$197.00
Rate for Payer: MDX Hawaii PPO	$382.18
Rate for Payer: Ohana Health Plan Medicaid	$197.00
Rate for Payer: Ohana Health Plan Medicare	$197.00
Rate for Payer: UnitedHealthcare Medicare	$197.00
Rate for Payer: University Health Alliance Commercial	$287.19

STAPLER, GEN DST SERIES EEA 28MM

Facility

$999.00

Hospital Charge Code	8274185
Hospital Revenue Code	272
Min. Negotiated Rate	$849.15
Max. Negotiated Rate	$969.03
Rate for Payer: Cash Price	$649.35
Rate for Payer: Health Management Network Commercial	$849.15
Rate for Payer: Kaiser Permanente Commercial	$899.10
Rate for Payer: MDX Hawaii PPO	$969.03

Know your out-of-pocket cost for care.

All Charges