Samuel Mahelona Memorial Hospital

All Charges

Charge

Type

Setting

Price

STOCKING ANTI-EMBOLISM THIGH LARGE

Facility

$51.00

Hospital Charge Code	8266975
Hospital Revenue Code	270
Min. Negotiated Rate	$43.35
Max. Negotiated Rate	$49.47
Rate for Payer: Cash Price	$33.15
Rate for Payer: Health Management Network Commercial	$43.35
Rate for Payer: Kaiser Permanente Commercial	$45.90
Rate for Payer: MDX Hawaii PPO	$49.47

STOCKING ANTI-EMBOLISM THIGH MEDIUM

Facility

$51.00

Hospital Charge Code	8266971
Hospital Revenue Code	270
Min. Negotiated Rate	$25.50
Max. Negotiated Rate	$49.47
Rate for Payer: AlohaCare Medicaid	$25.50
Rate for Payer: AlohaCare Medicare	$25.50
Rate for Payer: Cash Price	$33.15
Rate for Payer: Devoted Health Medicare	$28.05
Rate for Payer: Hawaii Medical Service Association Medicare	$25.50
Rate for Payer: Hawaii Western Management Group Commercial	$48.45
Rate for Payer: Health Management Network Commercial	$43.35
Rate for Payer: Humana Medicare	$25.50
Rate for Payer: Kaiser Permanente Commercial	$45.90
Rate for Payer: Kaiser Permanente Medicaid	$26.01
Rate for Payer: Kaiser Permanente Medicare	$25.50
Rate for Payer: MDX Hawaii PPO	$49.47
Rate for Payer: Ohana Health Plan Medicaid	$25.50
Rate for Payer: Ohana Health Plan Medicare	$25.50
Rate for Payer: UnitedHealthcare Medicare	$25.50
Rate for Payer: University Health Alliance Commercial	$37.17

STOCKING ANTI-EMBOLISM THIGH MEDIUM

Facility

$51.00

Hospital Charge Code	8266971
Hospital Revenue Code	270
Min. Negotiated Rate	$43.35
Max. Negotiated Rate	$49.47
Rate for Payer: Cash Price	$33.15
Rate for Payer: Health Management Network Commercial	$43.35
Rate for Payer: Kaiser Permanente Commercial	$45.90
Rate for Payer: MDX Hawaii PPO	$49.47

STOCKING ANTI-EMBOLISM THIGH SMALL

Facility

$51.00

Hospital Charge Code	8266987
Hospital Revenue Code	270
Min. Negotiated Rate	$25.50
Max. Negotiated Rate	$49.47
Rate for Payer: AlohaCare Medicaid	$25.50
Rate for Payer: AlohaCare Medicare	$25.50
Rate for Payer: Cash Price	$33.15
Rate for Payer: Devoted Health Medicare	$28.05
Rate for Payer: Hawaii Medical Service Association Medicare	$25.50
Rate for Payer: Hawaii Western Management Group Commercial	$48.45
Rate for Payer: Health Management Network Commercial	$43.35
Rate for Payer: Humana Medicare	$25.50
Rate for Payer: Kaiser Permanente Commercial	$45.90
Rate for Payer: Kaiser Permanente Medicaid	$26.01
Rate for Payer: Kaiser Permanente Medicare	$25.50
Rate for Payer: MDX Hawaii PPO	$49.47
Rate for Payer: Ohana Health Plan Medicaid	$25.50
Rate for Payer: Ohana Health Plan Medicare	$25.50
Rate for Payer: UnitedHealthcare Medicare	$25.50
Rate for Payer: University Health Alliance Commercial	$37.17

STOCKING ANTI-EMBOLISM THIGH SMALL

Facility

$51.00

Hospital Charge Code	8266987
Hospital Revenue Code	270
Min. Negotiated Rate	$43.35
Max. Negotiated Rate	$49.47
Rate for Payer: Cash Price	$33.15
Rate for Payer: Health Management Network Commercial	$43.35
Rate for Payer: Kaiser Permanente Commercial	$45.90
Rate for Payer: MDX Hawaii PPO	$49.47

STOMACH, ESOPHAGEAL AND DUODENAL PROCEDURES WITH CC

Facility

$89,640.96

Service Code	MSDRG 327
Min. Negotiated Rate	$89,640.96
Max. Negotiated Rate	$89,640.96
Rate for Payer: Hawaii Medical Service Association Commercial	$89,640.96

STOMACH, ESOPHAGEAL AND DUODENAL PROCEDURES WITH MCC

Facility

$126,639.79

Service Code	MSDRG 326
Min. Negotiated Rate	$126,639.79
Max. Negotiated Rate	$126,639.79
Rate for Payer: Hawaii Medical Service Association Commercial	$126,639.79

STOMACH, ESOPHAGEAL AND DUODENAL PROCEDURES WITHOUT CC/MCC

Facility

$38,373.54

Service Code	MSDRG 328
Min. Negotiated Rate	$38,373.54
Max. Negotiated Rate	$38,373.54
Rate for Payer: Hawaii Medical Service Association Commercial	$38,373.54

STOMACH EVACUATOR/LAVAGE TUBE 28FR

Facility

$64.00

Hospital Charge Code	8266684
Hospital Revenue Code	272
Min. Negotiated Rate	$54.40
Max. Negotiated Rate	$62.08
Rate for Payer: Cash Price	$41.60
Rate for Payer: Health Management Network Commercial	$54.40
Rate for Payer: Kaiser Permanente Commercial	$57.60
Rate for Payer: MDX Hawaii PPO	$62.08

STOMACH EVACUATOR/LAVAGE TUBE 28FR

Facility

$64.00

Hospital Charge Code	8266684
Hospital Revenue Code	272
Min. Negotiated Rate	$32.00
Max. Negotiated Rate	$62.08
Rate for Payer: AlohaCare Medicaid	$32.00
Rate for Payer: AlohaCare Medicare	$32.00
Rate for Payer: Cash Price	$41.60
Rate for Payer: Devoted Health Medicare	$35.20
Rate for Payer: Hawaii Medical Service Association Medicare	$32.00
Rate for Payer: Hawaii Western Management Group Commercial	$60.80
Rate for Payer: Health Management Network Commercial	$54.40
Rate for Payer: Humana Medicare	$32.00
Rate for Payer: Kaiser Permanente Commercial	$57.60
Rate for Payer: Kaiser Permanente Medicaid	$32.64
Rate for Payer: Kaiser Permanente Medicare	$32.00
Rate for Payer: MDX Hawaii PPO	$62.08
Rate for Payer: Ohana Health Plan Medicaid	$32.00
Rate for Payer: Ohana Health Plan Medicare	$32.00
Rate for Payer: UnitedHealthcare Medicare	$32.00
Rate for Payer: University Health Alliance Commercial	$46.65

STOMAHESIVE PASTE

Facility

$34.00

Hospital Charge Code	8266930
Hospital Revenue Code	271
Min. Negotiated Rate	$28.90
Max. Negotiated Rate	$32.98
Rate for Payer: Cash Price	$22.10
Rate for Payer: Health Management Network Commercial	$28.90
Rate for Payer: Kaiser Permanente Commercial	$30.60
Rate for Payer: MDX Hawaii PPO	$32.98

STOMAHESIVE PASTE

Facility

$34.00

Hospital Charge Code	8266930
Hospital Revenue Code	271
Min. Negotiated Rate	$17.00
Max. Negotiated Rate	$32.98
Rate for Payer: AlohaCare Medicaid	$17.00
Rate for Payer: AlohaCare Medicare	$17.00
Rate for Payer: Cash Price	$22.10
Rate for Payer: Devoted Health Medicare	$18.70
Rate for Payer: Hawaii Medical Service Association Medicare	$17.00
Rate for Payer: Hawaii Western Management Group Commercial	$32.30
Rate for Payer: Health Management Network Commercial	$28.90
Rate for Payer: Humana Medicare	$17.00
Rate for Payer: Kaiser Permanente Commercial	$30.60
Rate for Payer: Kaiser Permanente Medicaid	$17.34
Rate for Payer: Kaiser Permanente Medicare	$17.00
Rate for Payer: MDX Hawaii PPO	$32.98
Rate for Payer: Ohana Health Plan Medicaid	$17.00
Rate for Payer: Ohana Health Plan Medicare	$17.00
Rate for Payer: UnitedHealthcare Medicare	$17.00
Rate for Payer: University Health Alliance Commercial	$24.78

STOMAHESIVE WAFER 38MM 1 1/2 INCH FLANGE 4 IN X 4 IN

Facility

$12.00

Hospital Charge Code	8266895
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

STOMAHESIVE WAFER 38MM 1 1/2 INCH FLANGE 4 IN X 4 IN

Facility

$12.00

Hospital Charge Code	8266895
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

STOMAHESIVE WAFER 45MM 1 3/4 INCH FLANGE 4 IN X 4 IN

Facility

$12.00

Hospital Charge Code	8266349
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

STOMAHESIVE WAFER 45MM 1 3/4 INCH FLANGE 4 IN X 4 IN

Facility

$12.00

Hospital Charge Code	8266349
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

Stone/Crystal Analysis FSI

Facility

$215.00

Service Code	HCPCS 82365
Hospital Charge Code	8118051
Hospital Revenue Code	301
Min. Negotiated Rate	$182.75
Max. Negotiated Rate	$208.55
Rate for Payer: Cash Price	$139.75
Rate for Payer: Health Management Network Commercial	$182.75
Rate for Payer: Kaiser Permanente Commercial	$193.50
Rate for Payer: MDX Hawaii PPO	$208.55

Stone/Crystal Analysis FSI

Facility

$215.00

Service Code	HCPCS 82365
Hospital Charge Code	8118051
Hospital Revenue Code	301
Min. Negotiated Rate	$11.44
Max. Negotiated Rate	$208.55
Rate for Payer: AlohaCare Medicaid	$107.50
Rate for Payer: AlohaCare Medicare	$107.50
Rate for Payer: Cash Price	$139.75
Rate for Payer: Cash Price	$139.75
Rate for Payer: Devoted Health Medicare	$118.25
Rate for Payer: Hawaii Medical Service Association ABD	$11.44
Rate for Payer: Hawaii Medical Service Association Commercial	$16.12
Rate for Payer: Hawaii Medical Service Association Medicare	$107.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$12.01
Rate for Payer: Hawaii Western Management Group Commercial	$12.90
Rate for Payer: Health Management Network Commercial	$182.75
Rate for Payer: Humana Medicare	$107.50
Rate for Payer: Kaiser Permanente Commercial	$193.50
Rate for Payer: Kaiser Permanente Medicaid	$109.65
Rate for Payer: Kaiser Permanente Medicare	$107.50
Rate for Payer: MDX Hawaii PPO	$208.55
Rate for Payer: Ohana Health Plan Medicaid	$107.50
Rate for Payer: Ohana Health Plan Medicare	$107.50
Rate for Payer: UnitedHealthcare Medicaid	$11.44
Rate for Payer: UnitedHealthcare Medicare	$107.50
Rate for Payer: University Health Alliance Commercial	$21.40

Stool Culture Bill Only

Facility

$125.00

Hospital Charge Code	13145597
Hospital Revenue Code	306
Min. Negotiated Rate	$62.50
Max. Negotiated Rate	$121.25
Rate for Payer: AlohaCare Medicaid	$62.50
Rate for Payer: AlohaCare Medicare	$62.50
Rate for Payer: Cash Price	$81.25
Rate for Payer: Devoted Health Medicare	$68.75
Rate for Payer: Hawaii Medical Service Association Medicare	$62.50
Rate for Payer: Hawaii Western Management Group Commercial	$118.75
Rate for Payer: Health Management Network Commercial	$106.25
Rate for Payer: Humana Medicare	$62.50
Rate for Payer: Kaiser Permanente Commercial	$112.50
Rate for Payer: Kaiser Permanente Medicaid	$63.75
Rate for Payer: Kaiser Permanente Medicare	$62.50
Rate for Payer: MDX Hawaii PPO	$121.25
Rate for Payer: Ohana Health Plan Medicaid	$62.50
Rate for Payer: Ohana Health Plan Medicare	$62.50
Rate for Payer: UnitedHealthcare Medicare	$62.50
Rate for Payer: University Health Alliance Commercial	$70.00

Stool Culture Bill Only

Facility

$125.00

Hospital Charge Code	13145597
Hospital Revenue Code	306
Min. Negotiated Rate	$106.25
Max. Negotiated Rate	$121.25
Rate for Payer: Cash Price	$81.25
Rate for Payer: Health Management Network Commercial	$106.25
Rate for Payer: Kaiser Permanente Commercial	$112.50
Rate for Payer: MDX Hawaii PPO	$121.25

Stool Culture, Campy Antigen, and Shiga Toxin Bill Only

Facility

$238.00

Hospital Charge Code	13135372
Hospital Revenue Code	306
Min. Negotiated Rate	$119.00
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: 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 Medicare	$119.00
Rate for Payer: University Health Alliance Commercial	$133.28

Stool Culture, Campy Antigen, and Shiga Toxin Bill Only

Facility

$238.00

Hospital Charge Code	13135372
Hospital Revenue Code	306
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

Stool Culture FSI

Facility

$124.00

Service Code	HCPCS 87045
Hospital Charge Code	8118052
Hospital Revenue Code	306
Min. Negotiated Rate	$105.40
Max. Negotiated Rate	$120.28
Rate for Payer: Cash Price	$80.60
Rate for Payer: Health Management Network Commercial	$105.40
Rate for Payer: Kaiser Permanente Commercial	$111.60
Rate for Payer: MDX Hawaii PPO	$120.28

Stool Culture FSI

Facility

$124.00

Service Code	HCPCS 87045
Hospital Charge Code	8118052
Hospital Revenue Code	306
Min. Negotiated Rate	$9.44
Max. Negotiated Rate	$120.28
Rate for Payer: AlohaCare Medicaid	$62.00
Rate for Payer: AlohaCare Medicare	$62.00
Rate for Payer: Cash Price	$80.60
Rate for Payer: Cash Price	$80.60
Rate for Payer: Devoted Health Medicare	$68.20
Rate for Payer: Hawaii Medical Service Association ABD	$13.04
Rate for Payer: Hawaii Medical Service Association Commercial	$11.80
Rate for Payer: Hawaii Medical Service Association Medicare	$62.00
Rate for Payer: Hawaii Medical Service Association Non-ABD	$13.69
Rate for Payer: Hawaii Western Management Group Commercial	$9.44
Rate for Payer: Health Management Network Commercial	$105.40
Rate for Payer: Humana Medicare	$62.00
Rate for Payer: Kaiser Permanente Commercial	$111.60
Rate for Payer: Kaiser Permanente Medicaid	$63.24
Rate for Payer: Kaiser Permanente Medicare	$62.00
Rate for Payer: MDX Hawaii PPO	$120.28
Rate for Payer: Ohana Health Plan Medicaid	$62.00
Rate for Payer: Ohana Health Plan Medicare	$62.00
Rate for Payer: UnitedHealthcare Medicaid	$13.04
Rate for Payer: UnitedHealthcare Medicare	$62.00
Rate for Payer: University Health Alliance Commercial	$24.38

Stool For Occult Blood POC

Facility

$37.00

Service Code	HCPCS 82270
Hospital Charge Code	8126219
Hospital Revenue Code	301
Min. Negotiated Rate	$31.45
Max. Negotiated Rate	$35.89
Rate for Payer: Cash Price	$24.05
Rate for Payer: Health Management Network Commercial	$31.45
Rate for Payer: Kaiser Permanente Commercial	$33.30
Rate for Payer: MDX Hawaii PPO	$35.89

Know your out-of-pocket cost for care.

All Charges