Samuel Mahelona Memorial Hospital

All Charges

Charge

Type

Setting

Price

Urea Nitrogen Urine Random FSI

Facility

$67.00

Service Code	HCPCS 84540
Hospital Charge Code	8228934
Hospital Revenue Code	301
Min. Negotiated Rate	$5.56
Max. Negotiated Rate	$64.99
Rate for Payer: AlohaCare Medicaid	$33.50
Rate for Payer: AlohaCare Medicare	$33.50
Rate for Payer: Cash Price	$43.55
Rate for Payer: Cash Price	$43.55
Rate for Payer: Devoted Health Medicare	$36.85
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	$33.50
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	$56.95
Rate for Payer: Humana Medicare	$33.50
Rate for Payer: Kaiser Permanente Commercial	$60.30
Rate for Payer: Kaiser Permanente Medicaid	$34.17
Rate for Payer: Kaiser Permanente Medicare	$33.50
Rate for Payer: MDX Hawaii PPO	$64.99
Rate for Payer: Ohana Health Plan Medicaid	$33.50
Rate for Payer: Ohana Health Plan Medicare	$33.50
Rate for Payer: UnitedHealthcare Medicaid	$6.56
Rate for Payer: UnitedHealthcare Medicare	$33.50
Rate for Payer: University Health Alliance Commercial	$12.28

Urea Nitrogen Urine Random FSI

Facility

$67.00

Service Code	HCPCS 84540
Hospital Charge Code	8228934
Hospital Revenue Code	301
Min. Negotiated Rate	$56.95
Max. Negotiated Rate	$64.99
Rate for Payer: Cash Price	$43.55
Rate for Payer: Health Management Network Commercial	$56.95
Rate for Payer: Kaiser Permanente Commercial	$60.30
Rate for Payer: MDX Hawaii PPO	$64.99

URETHRAL PROCEDURES WITH CC/MCC

Facility

$35,505.60

Service Code	MSDRG 671
Min. Negotiated Rate	$35,505.60
Max. Negotiated Rate	$35,505.60
Rate for Payer: Hawaii Medical Service Association Commercial	$35,505.60

URETHRAL PROCEDURES WITHOUT CC/MCC

Facility

$35,505.60

Service Code	MSDRG 672
Min. Negotiated Rate	$35,505.60
Max. Negotiated Rate	$35,505.60
Rate for Payer: Hawaii Medical Service Association Commercial	$35,505.60

URETHRAL STRICTURE

Facility

$5,190.74

Service Code	MSDRG 697
Min. Negotiated Rate	$5,190.74
Max. Negotiated Rate	$5,190.74
Rate for Payer: Hawaii Medical Service Association Commercial	$5,190.74

Uric Acid, Fluid FSI

Facility

$97.00

Service Code	HCPCS 84560
Hospital Charge Code	8404522
Hospital Revenue Code	301
Min. Negotiated Rate	$5.08
Max. Negotiated Rate	$94.09
Rate for Payer: AlohaCare Medicaid	$48.50
Rate for Payer: AlohaCare Medicare	$48.50
Rate for Payer: Cash Price	$63.05
Rate for Payer: Cash Price	$63.05
Rate for Payer: Devoted Health Medicare	$53.35
Rate for Payer: Hawaii Medical Service Association ABD	$6.56
Rate for Payer: Hawaii Medical Service Association Commercial	$6.35
Rate for Payer: Hawaii Medical Service Association Medicare	$48.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$6.89
Rate for Payer: Hawaii Western Management Group Commercial	$5.08
Rate for Payer: Health Management Network Commercial	$82.45
Rate for Payer: Humana Medicare	$48.50
Rate for Payer: Kaiser Permanente Commercial	$87.30
Rate for Payer: Kaiser Permanente Medicaid	$49.47
Rate for Payer: Kaiser Permanente Medicare	$48.50
Rate for Payer: MDX Hawaii PPO	$94.09
Rate for Payer: Ohana Health Plan Medicaid	$48.50
Rate for Payer: Ohana Health Plan Medicare	$48.50
Rate for Payer: UnitedHealthcare Medicaid	$6.56
Rate for Payer: UnitedHealthcare Medicare	$48.50
Rate for Payer: University Health Alliance Commercial	$12.28

Uric Acid, Fluid FSI

Facility

$97.00

Service Code	HCPCS 84560
Hospital Charge Code	8404522
Hospital Revenue Code	301
Min. Negotiated Rate	$82.45
Max. Negotiated Rate	$94.09
Rate for Payer: Cash Price	$63.05
Rate for Payer: Health Management Network Commercial	$82.45
Rate for Payer: Kaiser Permanente Commercial	$87.30
Rate for Payer: MDX Hawaii PPO	$94.09

Uric Acid FSI

Facility

$78.00

Service Code	HCPCS 84550
Hospital Charge Code	8118069
Hospital Revenue Code	301
Min. Negotiated Rate	$66.30
Max. Negotiated Rate	$75.66
Rate for Payer: Cash Price	$50.70
Rate for Payer: Health Management Network Commercial	$66.30
Rate for Payer: Kaiser Permanente Commercial	$70.20
Rate for Payer: MDX Hawaii PPO	$75.66

Uric Acid FSI

Facility

$78.00

Service Code	HCPCS 84550
Hospital Charge Code	8118069
Hospital Revenue Code	301
Min. Negotiated Rate	$4.52
Max. Negotiated Rate	$75.66
Rate for Payer: AlohaCare Medicaid	$39.00
Rate for Payer: AlohaCare Medicare	$39.00
Rate for Payer: Cash Price	$50.70
Rate for Payer: Cash Price	$50.70
Rate for Payer: Devoted Health Medicare	$42.90
Rate for Payer: Hawaii Medical Service Association ABD	$6.25
Rate for Payer: Hawaii Medical Service Association Commercial	$5.65
Rate for Payer: Hawaii Medical Service Association Medicare	$39.00
Rate for Payer: Hawaii Medical Service Association Non-ABD	$6.56
Rate for Payer: Hawaii Western Management Group Commercial	$4.52
Rate for Payer: Health Management Network Commercial	$66.30
Rate for Payer: Humana Medicare	$39.00
Rate for Payer: Kaiser Permanente Commercial	$70.20
Rate for Payer: Kaiser Permanente Medicaid	$39.78
Rate for Payer: Kaiser Permanente Medicare	$39.00
Rate for Payer: MDX Hawaii PPO	$75.66
Rate for Payer: Ohana Health Plan Medicaid	$39.00
Rate for Payer: Ohana Health Plan Medicare	$39.00
Rate for Payer: UnitedHealthcare Medicaid	$6.25
Rate for Payer: UnitedHealthcare Medicare	$39.00
Rate for Payer: University Health Alliance Commercial	$11.67

Uric Acid Urine Timed FSI

Facility

$97.00

Service Code	HCPCS 84560
Hospital Charge Code	8228935
Hospital Revenue Code	301
Min. Negotiated Rate	$5.08
Max. Negotiated Rate	$94.09
Rate for Payer: AlohaCare Medicaid	$48.50
Rate for Payer: AlohaCare Medicare	$48.50
Rate for Payer: Cash Price	$63.05
Rate for Payer: Cash Price	$63.05
Rate for Payer: Devoted Health Medicare	$53.35
Rate for Payer: Hawaii Medical Service Association ABD	$6.56
Rate for Payer: Hawaii Medical Service Association Commercial	$6.35
Rate for Payer: Hawaii Medical Service Association Medicare	$48.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$6.89
Rate for Payer: Hawaii Western Management Group Commercial	$5.08
Rate for Payer: Health Management Network Commercial	$82.45
Rate for Payer: Humana Medicare	$48.50
Rate for Payer: Kaiser Permanente Commercial	$87.30
Rate for Payer: Kaiser Permanente Medicaid	$49.47
Rate for Payer: Kaiser Permanente Medicare	$48.50
Rate for Payer: MDX Hawaii PPO	$94.09
Rate for Payer: Ohana Health Plan Medicaid	$48.50
Rate for Payer: Ohana Health Plan Medicare	$48.50
Rate for Payer: UnitedHealthcare Medicaid	$6.56
Rate for Payer: UnitedHealthcare Medicare	$48.50
Rate for Payer: University Health Alliance Commercial	$12.28

Uric Acid Urine Timed FSI

Facility

$97.00

Service Code	HCPCS 84560
Hospital Charge Code	8228935
Hospital Revenue Code	301
Min. Negotiated Rate	$82.45
Max. Negotiated Rate	$94.09
Rate for Payer: Cash Price	$63.05
Rate for Payer: Health Management Network Commercial	$82.45
Rate for Payer: Kaiser Permanente Commercial	$87.30
Rate for Payer: MDX Hawaii PPO	$94.09

Urinalysis (Clinitek) POC

Facility

$67.00

Service Code	HCPCS 81003 QW
Hospital Charge Code	13033435
Hospital Revenue Code	307
Min. Negotiated Rate	$56.95
Max. Negotiated Rate	$64.99
Rate for Payer: Cash Price	$43.55
Rate for Payer: Health Management Network Commercial	$56.95
Rate for Payer: Kaiser Permanente Commercial	$60.30
Rate for Payer: MDX Hawaii PPO	$64.99

Urinalysis (Clinitek) POC

Professional

Both

$67.00

Service Code	HCPCS 81003 QW
Hospital Charge Code	13033435
Hospital Revenue Code	307
Min. Negotiated Rate	$2.25
Max. Negotiated Rate	$56.95
Rate for Payer: AlohaCare Medicaid	$3.10
Rate for Payer: AlohaCare Medicare	$2.25
Rate for Payer: Cash Price	$43.55
Rate for Payer: Cash Price	$43.55
Rate for Payer: Devoted Health Medicare	$2.48
Rate for Payer: Hawaii Medical Service Association Medicare	$2.25
Rate for Payer: Hawaii Western Management Group Commercial	$3.10
Rate for Payer: Health Management Network Commercial	$56.95
Rate for Payer: Kaiser Permanente Commercial	$2.70
Rate for Payer: Kaiser Permanente Medicaid	$2.70
Rate for Payer: Kaiser Permanente Medicare	$2.70
Rate for Payer: Ohana Health Plan Medicaid	$3.10
Rate for Payer: Ohana Health Plan Medicare	$2.25
Rate for Payer: UnitedHealthcare Medicaid	$3.10
Rate for Payer: UnitedHealthcare Medicare	$2.25

Urinalysis (Clinitek) POC

Facility

$67.00

Service Code	HCPCS 81003 QW
Hospital Charge Code	13033435
Hospital Revenue Code	307
Min. Negotiated Rate	$2.25
Max. Negotiated Rate	$64.99
Rate for Payer: AlohaCare Medicaid	$33.50
Rate for Payer: AlohaCare Medicare	$33.50
Rate for Payer: Cash Price	$43.55
Rate for Payer: Cash Price	$43.55
Rate for Payer: Devoted Health Medicare	$36.85
Rate for Payer: Hawaii Medical Service Association ABD	$3.10
Rate for Payer: Hawaii Medical Service Association Commercial	$2.81
Rate for Payer: Hawaii Medical Service Association Medicare	$33.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$3.26
Rate for Payer: Hawaii Western Management Group Commercial	$2.25
Rate for Payer: Health Management Network Commercial	$56.95
Rate for Payer: Humana Medicare	$33.50
Rate for Payer: Kaiser Permanente Commercial	$60.30
Rate for Payer: Kaiser Permanente Medicaid	$34.17
Rate for Payer: Kaiser Permanente Medicare	$33.50
Rate for Payer: MDX Hawaii PPO	$64.99
Rate for Payer: Ohana Health Plan Medicaid	$33.50
Rate for Payer: Ohana Health Plan Medicare	$33.50
Rate for Payer: UnitedHealthcare Medicaid	$3.10
Rate for Payer: UnitedHealthcare Medicare	$33.50
Rate for Payer: University Health Alliance Commercial	$5.81

Urinalysis Complete FSI

Facility

$56.00

Service Code	HCPCS 81001
Hospital Charge Code	8118070
Hospital Revenue Code	307
Min. Negotiated Rate	$47.60
Max. Negotiated Rate	$54.32
Rate for Payer: Cash Price	$36.40
Rate for Payer: Health Management Network Commercial	$47.60
Rate for Payer: Kaiser Permanente Commercial	$50.40
Rate for Payer: MDX Hawaii PPO	$54.32

Urinalysis Complete FSI

Facility

$56.00

Service Code	HCPCS 81001
Hospital Charge Code	8118070
Hospital Revenue Code	307
Min. Negotiated Rate	$3.17
Max. Negotiated Rate	$54.32
Rate for Payer: AlohaCare Medicaid	$28.00
Rate for Payer: AlohaCare Medicare	$28.00
Rate for Payer: Cash Price	$36.40
Rate for Payer: Cash Price	$36.40
Rate for Payer: Devoted Health Medicare	$30.80
Rate for Payer: Hawaii Medical Service Association ABD	$4.37
Rate for Payer: Hawaii Medical Service Association Commercial	$3.96
Rate for Payer: Hawaii Medical Service Association Medicare	$28.00
Rate for Payer: Hawaii Medical Service Association Non-ABD	$4.59
Rate for Payer: Hawaii Western Management Group Commercial	$3.17
Rate for Payer: Health Management Network Commercial	$47.60
Rate for Payer: Humana Medicare	$28.00
Rate for Payer: Kaiser Permanente Commercial	$50.40
Rate for Payer: Kaiser Permanente Medicaid	$28.56
Rate for Payer: Kaiser Permanente Medicare	$28.00
Rate for Payer: MDX Hawaii PPO	$54.32
Rate for Payer: Ohana Health Plan Medicaid	$28.00
Rate for Payer: Ohana Health Plan Medicare	$28.00
Rate for Payer: UnitedHealthcare Medicaid	$4.37
Rate for Payer: UnitedHealthcare Medicare	$28.00
Rate for Payer: University Health Alliance Commercial	$8.20

Urinalysis Complete Reflex Culture FSI

Facility

$56.00

Service Code	HCPCS 81001
Hospital Charge Code	8118071
Hospital Revenue Code	307
Min. Negotiated Rate	$3.17
Max. Negotiated Rate	$54.32
Rate for Payer: AlohaCare Medicaid	$28.00
Rate for Payer: AlohaCare Medicare	$28.00
Rate for Payer: Cash Price	$36.40
Rate for Payer: Cash Price	$36.40
Rate for Payer: Devoted Health Medicare	$30.80
Rate for Payer: Hawaii Medical Service Association ABD	$4.37
Rate for Payer: Hawaii Medical Service Association Commercial	$3.96
Rate for Payer: Hawaii Medical Service Association Medicare	$28.00
Rate for Payer: Hawaii Medical Service Association Non-ABD	$4.59
Rate for Payer: Hawaii Western Management Group Commercial	$3.17
Rate for Payer: Health Management Network Commercial	$47.60
Rate for Payer: Humana Medicare	$28.00
Rate for Payer: Kaiser Permanente Commercial	$50.40
Rate for Payer: Kaiser Permanente Medicaid	$28.56
Rate for Payer: Kaiser Permanente Medicare	$28.00
Rate for Payer: MDX Hawaii PPO	$54.32
Rate for Payer: Ohana Health Plan Medicaid	$28.00
Rate for Payer: Ohana Health Plan Medicare	$28.00
Rate for Payer: UnitedHealthcare Medicaid	$4.37
Rate for Payer: UnitedHealthcare Medicare	$28.00
Rate for Payer: University Health Alliance Commercial	$8.20

Urinalysis Complete Reflex Culture FSI

Facility

$56.00

Service Code	HCPCS 81001
Hospital Charge Code	8118071
Hospital Revenue Code	307
Min. Negotiated Rate	$47.60
Max. Negotiated Rate	$54.32
Rate for Payer: Cash Price	$36.40
Rate for Payer: Health Management Network Commercial	$47.60
Rate for Payer: Kaiser Permanente Commercial	$50.40
Rate for Payer: MDX Hawaii PPO	$54.32

Urinalysis Macroscopic FSI

Facility

$37.00

Service Code	HCPCS 81003
Hospital Charge Code	8118072
Hospital Revenue Code	307
Min. Negotiated Rate	$2.25
Max. Negotiated Rate	$35.89
Rate for Payer: AlohaCare Medicaid	$18.50
Rate for Payer: AlohaCare Medicare	$18.50
Rate for Payer: Cash Price	$24.05
Rate for Payer: Cash Price	$24.05
Rate for Payer: Devoted Health Medicare	$20.35
Rate for Payer: Hawaii Medical Service Association ABD	$3.10
Rate for Payer: Hawaii Medical Service Association Commercial	$2.81
Rate for Payer: Hawaii Medical Service Association Medicare	$18.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$3.26
Rate for Payer: Hawaii Western Management Group Commercial	$2.25
Rate for Payer: Health Management Network Commercial	$31.45
Rate for Payer: Humana Medicare	$18.50
Rate for Payer: Kaiser Permanente Commercial	$33.30
Rate for Payer: Kaiser Permanente Medicaid	$18.87
Rate for Payer: Kaiser Permanente Medicare	$18.50
Rate for Payer: MDX Hawaii PPO	$35.89
Rate for Payer: Ohana Health Plan Medicaid	$18.50
Rate for Payer: Ohana Health Plan Medicare	$18.50
Rate for Payer: UnitedHealthcare Medicaid	$3.10
Rate for Payer: UnitedHealthcare Medicare	$18.50
Rate for Payer: University Health Alliance Commercial	$5.81

Urinalysis Macroscopic FSI

Facility

$37.00

Service Code	HCPCS 81003
Hospital Charge Code	8118072
Hospital Revenue Code	307
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

Urinalysis Macroscopic Reflex Microscopic FSI

Facility

$41.00

Service Code	HCPCS 81000
Hospital Charge Code	8118073
Hospital Revenue Code	307
Min. Negotiated Rate	$34.85
Max. Negotiated Rate	$39.77
Rate for Payer: Cash Price	$26.65
Rate for Payer: Health Management Network Commercial	$34.85
Rate for Payer: Kaiser Permanente Commercial	$36.90
Rate for Payer: MDX Hawaii PPO	$39.77

Urinalysis Macroscopic Reflex Microscopic FSI

Facility

$41.00

Service Code	HCPCS 81000
Hospital Charge Code	8118073
Hospital Revenue Code	307
Min. Negotiated Rate	$4.02
Max. Negotiated Rate	$39.77
Rate for Payer: AlohaCare Medicaid	$20.50
Rate for Payer: AlohaCare Medicare	$20.50
Rate for Payer: Cash Price	$26.65
Rate for Payer: Cash Price	$26.65
Rate for Payer: Devoted Health Medicare	$22.55
Rate for Payer: Hawaii Medical Service Association ABD	$4.37
Rate for Payer: Hawaii Medical Service Association Commercial	$5.03
Rate for Payer: Hawaii Medical Service Association Medicare	$20.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$4.59
Rate for Payer: Hawaii Western Management Group Commercial	$4.02
Rate for Payer: Health Management Network Commercial	$34.85
Rate for Payer: Humana Medicare	$20.50
Rate for Payer: Kaiser Permanente Commercial	$36.90
Rate for Payer: Kaiser Permanente Medicaid	$20.91
Rate for Payer: Kaiser Permanente Medicare	$20.50
Rate for Payer: MDX Hawaii PPO	$39.77
Rate for Payer: Ohana Health Plan Medicaid	$20.50
Rate for Payer: Ohana Health Plan Medicare	$20.50
Rate for Payer: UnitedHealthcare Medicaid	$4.37
Rate for Payer: UnitedHealthcare Medicare	$20.50
Rate for Payer: University Health Alliance Commercial	$8.20

Urinalysis Macroscopic Reflex Microscropic and Culture/Sensitivity FSI

Facility

$43.00

Service Code	HCPCS 81015
Hospital Charge Code	8118074
Hospital Revenue Code	307
Min. Negotiated Rate	$3.05
Max. Negotiated Rate	$41.71
Rate for Payer: AlohaCare Medicaid	$21.50
Rate for Payer: AlohaCare Medicare	$21.50
Rate for Payer: Cash Price	$27.95
Rate for Payer: Cash Price	$27.95
Rate for Payer: Devoted Health Medicare	$23.65
Rate for Payer: Hawaii Medical Service Association ABD	$4.20
Rate for Payer: Hawaii Medical Service Association Commercial	$3.81
Rate for Payer: Hawaii Medical Service Association Medicare	$21.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$4.41
Rate for Payer: Hawaii Western Management Group Commercial	$3.05
Rate for Payer: Health Management Network Commercial	$36.55
Rate for Payer: Humana Medicare	$21.50
Rate for Payer: Kaiser Permanente Commercial	$38.70
Rate for Payer: Kaiser Permanente Medicaid	$21.93
Rate for Payer: Kaiser Permanente Medicare	$21.50
Rate for Payer: MDX Hawaii PPO	$41.71
Rate for Payer: Ohana Health Plan Medicaid	$21.50
Rate for Payer: Ohana Health Plan Medicare	$21.50
Rate for Payer: UnitedHealthcare Medicaid	$4.20
Rate for Payer: UnitedHealthcare Medicare	$21.50
Rate for Payer: University Health Alliance Commercial	$7.84

Urinalysis Macroscopic Reflex Microscropic and Culture/Sensitivity FSI

Facility

$43.00

Service Code	HCPCS 81015
Hospital Charge Code	8118074
Hospital Revenue Code	307
Min. Negotiated Rate	$36.55
Max. Negotiated Rate	$41.71
Rate for Payer: Cash Price	$27.95
Rate for Payer: Health Management Network Commercial	$36.55
Rate for Payer: Kaiser Permanente Commercial	$38.70
Rate for Payer: MDX Hawaii PPO	$41.71

Urinalysis Microscopic FSI

Facility

$43.00

Service Code	HCPCS 81015
Hospital Charge Code	8404426
Hospital Revenue Code	307
Min. Negotiated Rate	$36.55
Max. Negotiated Rate	$41.71
Rate for Payer: Cash Price	$27.95
Rate for Payer: Health Management Network Commercial	$36.55
Rate for Payer: Kaiser Permanente Commercial	$38.70
Rate for Payer: MDX Hawaii PPO	$41.71

Know your out-of-pocket cost for care.

All Charges