Samuel Mahelona Memorial Hospital

All Charges

Charge

Type

Setting

Price

ULNAR NERVE CUSHION

Facility

$25.00

Service Code	HCPCS E0190
Hospital Charge Code	11511782
Hospital Revenue Code	272
Min. Negotiated Rate	$12.50
Max. Negotiated Rate	$24.25
Rate for Payer: AlohaCare Medicaid	$12.50
Rate for Payer: AlohaCare Medicare	$12.50
Rate for Payer: Cash Price	$16.25
Rate for Payer: Devoted Health Medicare	$13.75
Rate for Payer: Hawaii Medical Service Association Medicare	$12.50
Rate for Payer: Hawaii Western Management Group Commercial	$23.75
Rate for Payer: Health Management Network Commercial	$21.25
Rate for Payer: Humana Medicare	$12.50
Rate for Payer: Kaiser Permanente Commercial	$22.50
Rate for Payer: Kaiser Permanente Medicaid	$12.75
Rate for Payer: Kaiser Permanente Medicare	$12.50
Rate for Payer: MDX Hawaii PPO	$24.25
Rate for Payer: Ohana Health Plan Medicaid	$12.50
Rate for Payer: Ohana Health Plan Medicare	$12.50
Rate for Payer: UnitedHealthcare Medicare	$12.50
Rate for Payer: University Health Alliance Commercial	$18.22

ULNAR NERVE CUSHION

Facility

$25.00

Service Code	HCPCS E0190
Hospital Charge Code	11511782
Hospital Revenue Code	272
Min. Negotiated Rate	$21.25
Max. Negotiated Rate	$24.25
Rate for Payer: Cash Price	$16.25
Rate for Payer: Health Management Network Commercial	$21.25
Rate for Payer: Kaiser Permanente Commercial	$22.50
Rate for Payer: MDX Hawaii PPO	$24.25

ULTRASOUND ACCELERATED AND OTHER THROMBOLYSIS OF PERIPHERAL VASCULAR STRUCTURES WITH MCC

Facility

$71,911.87

Service Code	MSDRG 278
Min. Negotiated Rate	$71,911.87
Max. Negotiated Rate	$71,911.87
Rate for Payer: Hawaii Medical Service Association Commercial	$71,911.87

ULTRASOUND ACCELERATED AND OTHER THROMBOLYSIS OF PERIPHERAL VASCULAR STRUCTURES WITHOUT MCC

Facility

$71,911.87

Service Code	MSDRG 279
Min. Negotiated Rate	$71,911.87
Max. Negotiated Rate	$71,911.87
Rate for Payer: Hawaii Medical Service Association Commercial	$71,911.87

Ultrasound Charges

Facility

$104.00

Service Code	HCPCS 97035 GP
Hospital Charge Code	8111698
Hospital Revenue Code	420
Min. Negotiated Rate	$88.40
Max. Negotiated Rate	$100.88
Rate for Payer: Cash Price	$67.60
Rate for Payer: Health Management Network Commercial	$88.40
Rate for Payer: Kaiser Permanente Commercial	$93.60
Rate for Payer: MDX Hawaii PPO	$100.88

Ultrasound Charges

Facility

$104.00

Service Code	HCPCS 97035 GP
Hospital Charge Code	8111698
Hospital Revenue Code	420
Min. Negotiated Rate	$9.52
Max. Negotiated Rate	$100.88
Rate for Payer: AlohaCare Medicaid	$52.00
Rate for Payer: AlohaCare Medicare	$52.00
Rate for Payer: Cash Price	$67.60
Rate for Payer: Cash Price	$67.60
Rate for Payer: Devoted Health Medicare	$57.20
Rate for Payer: Hawaii Medical Service Association Medicare	$52.00
Rate for Payer: Hawaii Western Management Group Commercial	$98.80
Rate for Payer: Health Management Network Commercial	$88.40
Rate for Payer: Humana Medicare	$52.00
Rate for Payer: Kaiser Permanente Commercial	$93.60
Rate for Payer: Kaiser Permanente Medicaid	$53.04
Rate for Payer: Kaiser Permanente Medicare	$52.00
Rate for Payer: MDX Hawaii PPO	$100.88
Rate for Payer: Ohana Health Plan Medicaid	$52.00
Rate for Payer: Ohana Health Plan Medicare	$52.00
Rate for Payer: UnitedHealthcare Medicaid	$9.52
Rate for Payer: UnitedHealthcare Medicare	$52.00
Rate for Payer: University Health Alliance Commercial	$58.24

Ultrasound Charges

Facility

$104.00

Service Code	HCPCS 97035 GO
Hospital Charge Code	8123832
Hospital Revenue Code	430
Min. Negotiated Rate	$88.40
Max. Negotiated Rate	$100.88
Rate for Payer: Cash Price	$67.60
Rate for Payer: Health Management Network Commercial	$88.40
Rate for Payer: Kaiser Permanente Commercial	$93.60
Rate for Payer: MDX Hawaii PPO	$100.88

Ultrasound Charges

Facility

$104.00

Service Code	HCPCS 97035 GO
Hospital Charge Code	8123832
Hospital Revenue Code	430
Min. Negotiated Rate	$9.52
Max. Negotiated Rate	$100.88
Rate for Payer: AlohaCare Medicaid	$52.00
Rate for Payer: AlohaCare Medicare	$52.00
Rate for Payer: Cash Price	$67.60
Rate for Payer: Cash Price	$67.60
Rate for Payer: Devoted Health Medicare	$57.20
Rate for Payer: Hawaii Medical Service Association Medicare	$52.00
Rate for Payer: Hawaii Western Management Group Commercial	$98.80
Rate for Payer: Health Management Network Commercial	$88.40
Rate for Payer: Humana Medicare	$52.00
Rate for Payer: Kaiser Permanente Commercial	$93.60
Rate for Payer: Kaiser Permanente Medicaid	$53.04
Rate for Payer: Kaiser Permanente Medicare	$52.00
Rate for Payer: MDX Hawaii PPO	$100.88
Rate for Payer: Ohana Health Plan Medicaid	$52.00
Rate for Payer: Ohana Health Plan Medicare	$52.00
Rate for Payer: UnitedHealthcare Medicaid	$9.52
Rate for Payer: UnitedHealthcare Medicare	$52.00
Rate for Payer: University Health Alliance Commercial	$58.24

UNCOMPLICATED PEPTIC ULCER WITH MCC

Facility

$19,625.26

Service Code	MSDRG 383
Min. Negotiated Rate	$19,625.26
Max. Negotiated Rate	$19,625.26
Rate for Payer: Hawaii Medical Service Association Commercial	$19,625.26

UNCOMPLICATED PEPTIC ULCER WITHOUT MCC

Facility

$19,625.26

Service Code	MSDRG 384
Min. Negotiated Rate	$19,625.26
Max. Negotiated Rate	$19,625.26
Rate for Payer: Hawaii Medical Service Association Commercial	$19,625.26

UNIVERSAL HOOK PLATE

Facility

$2,913.00

Service Code	HCPCS C1713
Hospital Charge Code	13005600
Hospital Revenue Code	278
Min. Negotiated Rate	$1,631.28
Max. Negotiated Rate	$2,825.61
Rate for Payer: Cash Price	$1,893.45
Rate for Payer: Hawaii Western Management Group Commercial	$2,039.10
Rate for Payer: Health Management Network Commercial	$2,476.05
Rate for Payer: Kaiser Permanente Commercial	$2,621.70
Rate for Payer: MDX Hawaii PPO	$2,825.61
Rate for Payer: University Health Alliance Commercial	$1,631.28

UNIVERSAL HOOK PLATE

Facility

$2,913.00

Service Code	HCPCS C1713
Hospital Charge Code	13005600
Hospital Revenue Code	278
Min. Negotiated Rate	$1,456.50
Max. Negotiated Rate	$2,825.61
Rate for Payer: AlohaCare Medicaid	$1,456.50
Rate for Payer: AlohaCare Medicare	$1,456.50
Rate for Payer: Cash Price	$1,893.45
Rate for Payer: Devoted Health Medicare	$1,602.15
Rate for Payer: Hawaii Medical Service Association Medicare	$1,456.50
Rate for Payer: Hawaii Western Management Group Commercial	$2,039.10
Rate for Payer: Health Management Network Commercial	$2,476.05
Rate for Payer: Humana Medicare	$1,456.50
Rate for Payer: Kaiser Permanente Commercial	$2,621.70
Rate for Payer: Kaiser Permanente Medicaid	$1,485.63
Rate for Payer: Kaiser Permanente Medicare	$1,456.50
Rate for Payer: MDX Hawaii PPO	$2,825.61
Rate for Payer: Ohana Health Plan Medicaid	$1,456.50
Rate for Payer: Ohana Health Plan Medicare	$1,456.50
Rate for Payer: UnitedHealthcare Medicare	$1,456.50
Rate for Payer: University Health Alliance Commercial	$1,631.28

Unlisted Laparoscopic PX Abd Pertoneum & Omentum

Professional

Both

$898.00

Service Code	HCPCS 49329
Hospital Charge Code	9589980
Hospital Revenue Code	975
Min. Negotiated Rate	$548.58
Max. Negotiated Rate	$763.30
Rate for Payer: AlohaCare Medicaid	$548.58
Rate for Payer: Cash Price	$583.70
Rate for Payer: Cash Price	$583.70
Rate for Payer: Health Management Network Commercial	$763.30
Rate for Payer: Ohana Health Plan Medicaid	$548.58
Rate for Payer: UnitedHealthcare Medicaid	$548.58

Unlisted Laparoscopic PX Abd Pertoneum & Omentum

Professional

Both

$8,414.00

Service Code	HCPCS 49329
Hospital Charge Code	9589980
Hospital Revenue Code	521
Min. Negotiated Rate	$181.39
Max. Negotiated Rate	$7,151.90
Rate for Payer: AlohaCare Medicaid	$548.58
Rate for Payer: Cash Price	$5,469.10
Rate for Payer: Cash Price	$5,469.10
Rate for Payer: Cash Price	$5,469.10
Rate for Payer: Hawaii Medical Service Association ABD	$434.26
Rate for Payer: Hawaii Medical Service Association Medicare	$339.46
Rate for Payer: Hawaii Medical Service Association Medicare	$265.97
Rate for Payer: Hawaii Medical Service Association Medicare	$303.73
Rate for Payer: Hawaii Medical Service Association Medicare	$181.39
Rate for Payer: Hawaii Medical Service Association Medicare	$209.49
Rate for Payer: Hawaii Medical Service Association Medicare	$237.64
Rate for Payer: Hawaii Medical Service Association Medicare	$246.64
Rate for Payer: Hawaii Medical Service Association Non-ABD	$434.26
Rate for Payer: Health Management Network Commercial	$7,151.90
Rate for Payer: Kaiser Permanente Commercial	$209.49
Rate for Payer: Kaiser Permanente Commercial	$181.39
Rate for Payer: Kaiser Permanente Commercial	$237.64
Rate for Payer: Kaiser Permanente Commercial	$246.64
Rate for Payer: Kaiser Permanente Commercial	$265.97
Rate for Payer: Kaiser Permanente Commercial	$303.73
Rate for Payer: Kaiser Permanente Commercial	$339.46
Rate for Payer: Kaiser Permanente Medicaid	$434.26
Rate for Payer: Kaiser Permanente Medicare	$181.39
Rate for Payer: Kaiser Permanente Medicare	$209.49
Rate for Payer: Kaiser Permanente Medicare	$237.64
Rate for Payer: Kaiser Permanente Medicare	$246.64
Rate for Payer: Kaiser Permanente Medicare	$303.73
Rate for Payer: Kaiser Permanente Medicare	$339.46
Rate for Payer: Kaiser Permanente Medicare	$265.97
Rate for Payer: Ohana Health Plan Medicaid	$548.58
Rate for Payer: UnitedHealthcare Medicaid	$434.26
Rate for Payer: UnitedHealthcare Medicare	$303.73
Rate for Payer: UnitedHealthcare Medicare	$181.39
Rate for Payer: UnitedHealthcare Medicare	$209.49
Rate for Payer: UnitedHealthcare Medicare	$237.64
Rate for Payer: UnitedHealthcare Medicare	$246.64
Rate for Payer: UnitedHealthcare Medicare	$265.97
Rate for Payer: UnitedHealthcare Medicare	$339.46

Unlisted Physical Medicine/Rehab Service Charge

Facility

$114.00

Service Code	HCPCS 97799 GP
Hospital Charge Code	8111829
Hospital Revenue Code	420
Min. Negotiated Rate	$57.00
Max. Negotiated Rate	$110.58
Rate for Payer: AlohaCare Medicaid	$57.00
Rate for Payer: AlohaCare Medicare	$57.00
Rate for Payer: Cash Price	$74.10
Rate for Payer: Devoted Health Medicare	$62.70
Rate for Payer: Hawaii Medical Service Association Medicare	$57.00
Rate for Payer: Hawaii Western Management Group Commercial	$108.30
Rate for Payer: Health Management Network Commercial	$96.90
Rate for Payer: Humana Medicare	$57.00
Rate for Payer: Kaiser Permanente Commercial	$102.60
Rate for Payer: Kaiser Permanente Medicaid	$58.14
Rate for Payer: Kaiser Permanente Medicare	$57.00
Rate for Payer: MDX Hawaii PPO	$110.58
Rate for Payer: Ohana Health Plan Medicaid	$57.00
Rate for Payer: Ohana Health Plan Medicare	$57.00
Rate for Payer: UnitedHealthcare Medicare	$57.00
Rate for Payer: University Health Alliance Commercial	$63.84

Unlisted Physical Medicine/Rehab Service Charge

Facility

$114.00

Service Code	HCPCS 97799 GP
Hospital Charge Code	8111829
Hospital Revenue Code	420
Min. Negotiated Rate	$96.90
Max. Negotiated Rate	$110.58
Rate for Payer: Cash Price	$74.10
Rate for Payer: Health Management Network Commercial	$96.90
Rate for Payer: Kaiser Permanente Commercial	$102.60
Rate for Payer: MDX Hawaii PPO	$110.58

Unlisted Procedure, Vascular Surgery 37799

Facility

$4,140.00

Service Code	HCPCS 37799
Hospital Charge Code	8749388
Hospital Revenue Code	450
Min. Negotiated Rate	$340.18
Max. Negotiated Rate	$4,015.80
Rate for Payer: AlohaCare Medicaid	$2,070.00
Rate for Payer: AlohaCare Medicare	$2,070.00
Rate for Payer: Cash Price	$2,691.00
Rate for Payer: Cash Price	$2,691.00
Rate for Payer: Devoted Health Medicare	$2,277.00
Rate for Payer: Hawaii Medical Service Association ABD	$469.00
Rate for Payer: Hawaii Medical Service Association Commercial	$1,600.00
Rate for Payer: Hawaii Medical Service Association Medicare	$2,070.00
Rate for Payer: Hawaii Medical Service Association Non-ABD	$450.00
Rate for Payer: Hawaii Western Management Group Commercial	$3,933.00
Rate for Payer: Health Management Network Commercial	$3,519.00
Rate for Payer: Humana Medicare	$2,070.00
Rate for Payer: Kaiser Permanente Commercial	$3,726.00
Rate for Payer: Kaiser Permanente Medicaid	$937.50
Rate for Payer: Kaiser Permanente Medicare	$2,070.00
Rate for Payer: MDX Hawaii PPO	$4,015.80
Rate for Payer: Ohana Health Plan Medicaid	$2,070.00
Rate for Payer: Ohana Health Plan Medicare	$2,070.00
Rate for Payer: UnitedHealthcare Medicaid	$340.18
Rate for Payer: UnitedHealthcare Medicare	$2,070.00
Rate for Payer: University Health Alliance Commercial	$3,017.65

Unlisted Procedure, Vascular Surgery 37799

Facility

$4,140.00

Service Code	HCPCS 37799
Hospital Charge Code	8749388
Hospital Revenue Code	450
Min. Negotiated Rate	$3,519.00
Max. Negotiated Rate	$4,015.80
Rate for Payer: Cash Price	$2,691.00
Rate for Payer: Health Management Network Commercial	$3,519.00
Rate for Payer: Kaiser Permanente Commercial	$3,726.00
Rate for Payer: MDX Hawaii PPO	$4,015.80

U Parvum Amp Probe

Facility

$365.00

Service Code	HCPCS 87798
Hospital Charge Code	10023503
Hospital Revenue Code	306
Min. Negotiated Rate	$310.25
Max. Negotiated Rate	$354.05
Rate for Payer: Cash Price	$237.25
Rate for Payer: Health Management Network Commercial	$310.25
Rate for Payer: Kaiser Permanente Commercial	$328.50
Rate for Payer: MDX Hawaii PPO	$354.05

U Parvum Amp Probe

Facility

$365.00

Service Code	HCPCS 87798
Hospital Charge Code	10023503
Hospital Revenue Code	306
Min. Negotiated Rate	$35.09
Max. Negotiated Rate	$354.05
Rate for Payer: AlohaCare Medicaid	$182.50
Rate for Payer: AlohaCare Medicare	$182.50
Rate for Payer: Cash Price	$237.25
Rate for Payer: Cash Price	$237.25
Rate for Payer: Devoted Health Medicare	$200.75
Rate for Payer: Hawaii Medical Service Association ABD	$48.50
Rate for Payer: Hawaii Medical Service Association Commercial	$43.86
Rate for Payer: Hawaii Medical Service Association Medicare	$182.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$50.93
Rate for Payer: Hawaii Western Management Group Commercial	$35.09
Rate for Payer: Health Management Network Commercial	$310.25
Rate for Payer: Humana Medicare	$182.50
Rate for Payer: Kaiser Permanente Commercial	$328.50
Rate for Payer: Kaiser Permanente Medicaid	$186.15
Rate for Payer: Kaiser Permanente Medicare	$182.50
Rate for Payer: MDX Hawaii PPO	$354.05
Rate for Payer: Ohana Health Plan Medicaid	$182.50
Rate for Payer: Ohana Health Plan Medicare	$182.50
Rate for Payer: UnitedHealthcare Medicaid	$48.50
Rate for Payer: UnitedHealthcare Medicare	$182.50
Rate for Payer: University Health Alliance Commercial	$90.72

UPPER LIMB AND TOE AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS WITH CC

Facility

$36,643.29

Service Code	MSDRG 256
Min. Negotiated Rate	$36,643.29
Max. Negotiated Rate	$36,643.29
Rate for Payer: Hawaii Medical Service Association Commercial	$36,643.29

UPPER LIMB AND TOE AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS WITH MCC

Facility

$36,643.29

Service Code	MSDRG 255
Min. Negotiated Rate	$36,643.29
Max. Negotiated Rate	$36,643.29
Rate for Payer: Hawaii Medical Service Association Commercial	$36,643.29

UPPER LIMB AND TOE AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS WITHOUT CC/MCC

Facility

$36,643.29

Service Code	MSDRG 257
Min. Negotiated Rate	$36,643.29
Max. Negotiated Rate	$36,643.29
Rate for Payer: Hawaii Medical Service Association Commercial	$36,643.29

Urea Nitrogen, Random Urine FSI

Facility

$19.00

Service Code	HCPCS 84540
Hospital Charge Code	13157352
Hospital Revenue Code	301
Min. Negotiated Rate	$16.15
Max. Negotiated Rate	$18.43
Rate for Payer: Cash Price	$12.35
Rate for Payer: Health Management Network Commercial	$16.15
Rate for Payer: Kaiser Permanente Commercial	$17.10
Rate for Payer: MDX Hawaii PPO	$18.43

Urea Nitrogen, Random Urine FSI

Facility

$19.00

Service Code	HCPCS 84540
Hospital Charge Code	13157352
Hospital Revenue Code	301
Min. Negotiated Rate	$5.56
Max. Negotiated Rate	$18.43
Rate for Payer: AlohaCare Medicaid	$9.50
Rate for Payer: AlohaCare Medicare	$9.50
Rate for Payer: Cash Price	$12.35
Rate for Payer: Cash Price	$12.35
Rate for Payer: Devoted Health Medicare	$10.45
Rate for Payer: Hawaii Medical Service Association ABD	$6.56
Rate for Payer: Hawaii Medical Service Association Commercial	$6.95
Rate for Payer: Hawaii Medical Service Association Medicare	$9.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$6.89
Rate for Payer: Hawaii Western Management Group Commercial	$5.56
Rate for Payer: Health Management Network Commercial	$16.15
Rate for Payer: Humana Medicare	$9.50
Rate for Payer: Kaiser Permanente Commercial	$17.10
Rate for Payer: Kaiser Permanente Medicaid	$9.69
Rate for Payer: Kaiser Permanente Medicare	$9.50
Rate for Payer: MDX Hawaii PPO	$18.43
Rate for Payer: Ohana Health Plan Medicaid	$9.50
Rate for Payer: Ohana Health Plan Medicare	$9.50
Rate for Payer: UnitedHealthcare Medicaid	$6.56
Rate for Payer: UnitedHealthcare Medicare	$9.50
Rate for Payer: University Health Alliance Commercial	$12.28

Know your out-of-pocket cost for care.

All Charges