Samuel Mahelona Memorial Hospital

All Charges

Charge

Type

Setting

Price

US Encephalogram - Report

Professional

Both

$154.00

Service Code	HCPCS 76506 26
Hospital Charge Code	631057
Hospital Revenue Code	972
Min. Negotiated Rate	$29.88
Max. Negotiated Rate	$130.90
Rate for Payer: AlohaCare Medicaid	$75.10
Rate for Payer: AlohaCare Medicare	$29.88
Rate for Payer: Cash Price	$100.10
Rate for Payer: Cash Price	$100.10
Rate for Payer: Devoted Health Medicare	$32.87
Rate for Payer: Hawaii Medical Service Association Medicare	$29.88
Rate for Payer: Hawaii Western Management Group Commercial	$97.36
Rate for Payer: Health Management Network Commercial	$130.90
Rate for Payer: Kaiser Permanente Commercial	$35.86
Rate for Payer: Kaiser Permanente Medicaid	$35.86
Rate for Payer: Kaiser Permanente Medicare	$35.86
Rate for Payer: Ohana Health Plan Medicaid	$75.10
Rate for Payer: Ohana Health Plan Medicare	$29.88
Rate for Payer: UnitedHealthcare Medicaid	$75.10
Rate for Payer: UnitedHealthcare Medicare	$29.88

US Extracranial Carotid Duplex Left

Facility

$800.00

Service Code	HCPCS 93882 LT
Hospital Charge Code	8207960
Hospital Revenue Code	921
Min. Negotiated Rate	$89.14
Max. Negotiated Rate	$776.00
Rate for Payer: AlohaCare Medicaid	$400.00
Rate for Payer: AlohaCare Medicare	$400.00
Rate for Payer: Cash Price	$520.00
Rate for Payer: Cash Price	$520.00
Rate for Payer: Devoted Health Medicare	$440.00
Rate for Payer: Hawaii Medical Service Association ABD	$89.14
Rate for Payer: Hawaii Medical Service Association Medicare	$400.00
Rate for Payer: Hawaii Medical Service Association Non-ABD	$106.44
Rate for Payer: Hawaii Western Management Group Commercial	$760.00
Rate for Payer: Health Management Network Commercial	$680.00
Rate for Payer: Humana Medicare	$400.00
Rate for Payer: Kaiser Permanente Commercial	$720.00
Rate for Payer: Kaiser Permanente Medicaid	$408.00
Rate for Payer: Kaiser Permanente Medicare	$400.00
Rate for Payer: MDX Hawaii PPO	$776.00
Rate for Payer: Ohana Health Plan Medicaid	$400.00
Rate for Payer: Ohana Health Plan Medicare	$400.00
Rate for Payer: UnitedHealthcare Medicaid	$89.14
Rate for Payer: UnitedHealthcare Medicare	$400.00
Rate for Payer: University Health Alliance Commercial	$448.00

US Extracranial Carotid Duplex Left

Facility

$800.00

Service Code	HCPCS 93882 LT
Hospital Charge Code	8207960
Hospital Revenue Code	921
Min. Negotiated Rate	$680.00
Max. Negotiated Rate	$776.00
Rate for Payer: Cash Price	$520.00
Rate for Payer: Health Management Network Commercial	$680.00
Rate for Payer: Kaiser Permanente Commercial	$720.00
Rate for Payer: MDX Hawaii PPO	$776.00

US Extracranial Carotid Duplex Left - Report

Professional

Both

$264.00

Service Code	HCPCS 93882 26,LT
Hospital Charge Code	8207962
Hospital Revenue Code	972
Min. Negotiated Rate	$72.15
Max. Negotiated Rate	$224.40
Rate for Payer: AlohaCare Medicaid	$139.00
Rate for Payer: Cash Price	$171.60
Rate for Payer: Cash Price	$171.60
Rate for Payer: Hawaii Western Management Group Commercial	$72.15
Rate for Payer: Health Management Network Commercial	$224.40
Rate for Payer: Ohana Health Plan Medicaid	$139.00
Rate for Payer: UnitedHealthcare Medicaid	$139.00

US Extracranial Carotid Duplex Right

Facility

$800.00

Service Code	HCPCS 93882 RT
Hospital Charge Code	8207963
Hospital Revenue Code	921
Min. Negotiated Rate	$89.14
Max. Negotiated Rate	$776.00
Rate for Payer: AlohaCare Medicaid	$400.00
Rate for Payer: AlohaCare Medicare	$400.00
Rate for Payer: Cash Price	$520.00
Rate for Payer: Cash Price	$520.00
Rate for Payer: Devoted Health Medicare	$440.00
Rate for Payer: Hawaii Medical Service Association ABD	$89.14
Rate for Payer: Hawaii Medical Service Association Medicare	$400.00
Rate for Payer: Hawaii Medical Service Association Non-ABD	$106.44
Rate for Payer: Hawaii Western Management Group Commercial	$760.00
Rate for Payer: Health Management Network Commercial	$680.00
Rate for Payer: Humana Medicare	$400.00
Rate for Payer: Kaiser Permanente Commercial	$720.00
Rate for Payer: Kaiser Permanente Medicaid	$408.00
Rate for Payer: Kaiser Permanente Medicare	$400.00
Rate for Payer: MDX Hawaii PPO	$776.00
Rate for Payer: Ohana Health Plan Medicaid	$400.00
Rate for Payer: Ohana Health Plan Medicare	$400.00
Rate for Payer: UnitedHealthcare Medicaid	$89.14
Rate for Payer: UnitedHealthcare Medicare	$400.00
Rate for Payer: University Health Alliance Commercial	$448.00

US Extracranial Carotid Duplex Right

Facility

$800.00

Service Code	HCPCS 93882 RT
Hospital Charge Code	8207963
Hospital Revenue Code	921
Min. Negotiated Rate	$680.00
Max. Negotiated Rate	$776.00
Rate for Payer: Cash Price	$520.00
Rate for Payer: Health Management Network Commercial	$680.00
Rate for Payer: Kaiser Permanente Commercial	$720.00
Rate for Payer: MDX Hawaii PPO	$776.00

US Extracranial Carotid Duplex Right - Report

Professional

Both

$145.00

Service Code	HCPCS 93882 26,RT
Hospital Charge Code	8207965
Hospital Revenue Code	972
Min. Negotiated Rate	$72.15
Max. Negotiated Rate	$139.00
Rate for Payer: AlohaCare Medicaid	$139.00
Rate for Payer: Cash Price	$94.25
Rate for Payer: Cash Price	$94.25
Rate for Payer: Hawaii Western Management Group Commercial	$72.15
Rate for Payer: Health Management Network Commercial	$123.25
Rate for Payer: Ohana Health Plan Medicaid	$139.00
Rate for Payer: UnitedHealthcare Medicaid	$139.00

US Extremity Nonvascular Complete Bilat

Facility

$758.00

Service Code	HCPCS 76881 50
Hospital Charge Code	3148320
Hospital Revenue Code	320
Min. Negotiated Rate	$50.90
Max. Negotiated Rate	$735.26
Rate for Payer: AlohaCare Medicaid	$379.00
Rate for Payer: AlohaCare Medicare	$379.00
Rate for Payer: Cash Price	$492.70
Rate for Payer: Cash Price	$492.70
Rate for Payer: Devoted Health Medicare	$416.90
Rate for Payer: Hawaii Medical Service Association ABD	$61.93
Rate for Payer: Hawaii Medical Service Association Medicare	$379.00
Rate for Payer: Hawaii Medical Service Association Non-ABD	$50.90
Rate for Payer: Hawaii Western Management Group Commercial	$720.10
Rate for Payer: Health Management Network Commercial	$644.30
Rate for Payer: Humana Medicare	$379.00
Rate for Payer: Kaiser Permanente Commercial	$682.20
Rate for Payer: Kaiser Permanente Medicaid	$386.58
Rate for Payer: Kaiser Permanente Medicare	$379.00
Rate for Payer: MDX Hawaii PPO	$735.26
Rate for Payer: Ohana Health Plan Medicaid	$379.00
Rate for Payer: Ohana Health Plan Medicare	$379.00
Rate for Payer: UnitedHealthcare Medicaid	$61.93
Rate for Payer: UnitedHealthcare Medicare	$379.00
Rate for Payer: University Health Alliance Commercial	$246.33

US Extremity Nonvascular Complete Bilat

Facility

$758.00

Service Code	HCPCS 76881 50
Hospital Charge Code	3148320
Hospital Revenue Code	320
Min. Negotiated Rate	$644.30
Max. Negotiated Rate	$735.26
Rate for Payer: Cash Price	$492.70
Rate for Payer: Health Management Network Commercial	$644.30
Rate for Payer: Kaiser Permanente Commercial	$682.20
Rate for Payer: MDX Hawaii PPO	$735.26

US Extremity Nonvascular Complete Bilat - Report

Professional

Both

$145.00

Service Code	HCPCS 76881 26,50
Hospital Charge Code	3148322
Hospital Revenue Code	972
Min. Negotiated Rate	$33.68
Max. Negotiated Rate	$133.15
Rate for Payer: AlohaCare Medicaid	$33.68
Rate for Payer: Cash Price	$94.25
Rate for Payer: Cash Price	$94.25
Rate for Payer: Hawaii Western Management Group Commercial	$133.15
Rate for Payer: Health Management Network Commercial	$123.25
Rate for Payer: Ohana Health Plan Medicaid	$33.68
Rate for Payer: UnitedHealthcare Medicaid	$33.68

US Extremity Nonvascular Complete Left

Facility

$758.00

Service Code	HCPCS 76881 LT
Hospital Charge Code	2425332
Hospital Revenue Code	320
Min. Negotiated Rate	$644.30
Max. Negotiated Rate	$735.26
Rate for Payer: Cash Price	$492.70
Rate for Payer: Health Management Network Commercial	$644.30
Rate for Payer: Kaiser Permanente Commercial	$682.20
Rate for Payer: MDX Hawaii PPO	$735.26

US Extremity Nonvascular Complete Left

Facility

$758.00

Service Code	HCPCS 76881 LT
Hospital Charge Code	2425332
Hospital Revenue Code	320
Min. Negotiated Rate	$50.90
Max. Negotiated Rate	$735.26
Rate for Payer: AlohaCare Medicaid	$379.00
Rate for Payer: AlohaCare Medicare	$379.00
Rate for Payer: Cash Price	$492.70
Rate for Payer: Cash Price	$492.70
Rate for Payer: Devoted Health Medicare	$416.90
Rate for Payer: Hawaii Medical Service Association ABD	$61.93
Rate for Payer: Hawaii Medical Service Association Medicare	$379.00
Rate for Payer: Hawaii Medical Service Association Non-ABD	$50.90
Rate for Payer: Hawaii Western Management Group Commercial	$720.10
Rate for Payer: Health Management Network Commercial	$644.30
Rate for Payer: Humana Medicare	$379.00
Rate for Payer: Kaiser Permanente Commercial	$682.20
Rate for Payer: Kaiser Permanente Medicaid	$386.58
Rate for Payer: Kaiser Permanente Medicare	$379.00
Rate for Payer: MDX Hawaii PPO	$735.26
Rate for Payer: Ohana Health Plan Medicaid	$379.00
Rate for Payer: Ohana Health Plan Medicare	$379.00
Rate for Payer: UnitedHealthcare Medicaid	$61.93
Rate for Payer: UnitedHealthcare Medicare	$379.00
Rate for Payer: University Health Alliance Commercial	$246.33

US Extremity Nonvascular Complete Left - Report

Professional

Both

$145.00

Service Code	HCPCS 76881 26,LT
Hospital Charge Code	2425334
Hospital Revenue Code	972
Min. Negotiated Rate	$33.68
Max. Negotiated Rate	$133.15
Rate for Payer: AlohaCare Medicaid	$33.68
Rate for Payer: Cash Price	$94.25
Rate for Payer: Cash Price	$94.25
Rate for Payer: Hawaii Western Management Group Commercial	$133.15
Rate for Payer: Health Management Network Commercial	$123.25
Rate for Payer: Ohana Health Plan Medicaid	$33.68
Rate for Payer: UnitedHealthcare Medicaid	$33.68

US Extremity Nonvascular Complete Right

Facility

$758.00

Service Code	HCPCS 76881 RT
Hospital Charge Code	2425335
Hospital Revenue Code	320
Min. Negotiated Rate	$644.30
Max. Negotiated Rate	$735.26
Rate for Payer: Cash Price	$492.70
Rate for Payer: Health Management Network Commercial	$644.30
Rate for Payer: Kaiser Permanente Commercial	$682.20
Rate for Payer: MDX Hawaii PPO	$735.26

US Extremity Nonvascular Complete Right

Facility

$758.00

Service Code	HCPCS 76881 RT
Hospital Charge Code	2425335
Hospital Revenue Code	320
Min. Negotiated Rate	$50.90
Max. Negotiated Rate	$735.26
Rate for Payer: AlohaCare Medicaid	$379.00
Rate for Payer: AlohaCare Medicare	$379.00
Rate for Payer: Cash Price	$492.70
Rate for Payer: Cash Price	$492.70
Rate for Payer: Devoted Health Medicare	$416.90
Rate for Payer: Hawaii Medical Service Association ABD	$61.93
Rate for Payer: Hawaii Medical Service Association Medicare	$379.00
Rate for Payer: Hawaii Medical Service Association Non-ABD	$50.90
Rate for Payer: Hawaii Western Management Group Commercial	$720.10
Rate for Payer: Health Management Network Commercial	$644.30
Rate for Payer: Humana Medicare	$379.00
Rate for Payer: Kaiser Permanente Commercial	$682.20
Rate for Payer: Kaiser Permanente Medicaid	$386.58
Rate for Payer: Kaiser Permanente Medicare	$379.00
Rate for Payer: MDX Hawaii PPO	$735.26
Rate for Payer: Ohana Health Plan Medicaid	$379.00
Rate for Payer: Ohana Health Plan Medicare	$379.00
Rate for Payer: UnitedHealthcare Medicaid	$61.93
Rate for Payer: UnitedHealthcare Medicare	$379.00
Rate for Payer: University Health Alliance Commercial	$246.33

US Extremity Nonvascular Complete Right - Report

Professional

Both

$145.00

Service Code	HCPCS 76881 26,RT
Hospital Charge Code	2425337
Hospital Revenue Code	972
Min. Negotiated Rate	$33.68
Max. Negotiated Rate	$133.15
Rate for Payer: AlohaCare Medicaid	$33.68
Rate for Payer: Cash Price	$94.25
Rate for Payer: Cash Price	$94.25
Rate for Payer: Hawaii Western Management Group Commercial	$133.15
Rate for Payer: Health Management Network Commercial	$123.25
Rate for Payer: Ohana Health Plan Medicaid	$33.68
Rate for Payer: UnitedHealthcare Medicaid	$33.68

US Extremity Nonvascular Limited Left

Facility

$758.00

Service Code	HCPCS 76882 LT
Hospital Charge Code	2425338
Hospital Revenue Code	320
Min. Negotiated Rate	$644.30
Max. Negotiated Rate	$735.26
Rate for Payer: Cash Price	$492.70
Rate for Payer: Health Management Network Commercial	$644.30
Rate for Payer: Kaiser Permanente Commercial	$682.20
Rate for Payer: MDX Hawaii PPO	$735.26

US Extremity Nonvascular Limited Left

Facility

$758.00

Service Code	HCPCS 76882 LT
Hospital Charge Code	2425338
Hospital Revenue Code	320
Min. Negotiated Rate	$7.22
Max. Negotiated Rate	$735.26
Rate for Payer: AlohaCare Medicaid	$379.00
Rate for Payer: AlohaCare Medicare	$379.00
Rate for Payer: Cash Price	$492.70
Rate for Payer: Cash Price	$492.70
Rate for Payer: Devoted Health Medicare	$416.90
Rate for Payer: Hawaii Medical Service Association ABD	$7.22
Rate for Payer: Hawaii Medical Service Association Medicare	$379.00
Rate for Payer: Hawaii Medical Service Association Non-ABD	$10.72
Rate for Payer: Hawaii Western Management Group Commercial	$720.10
Rate for Payer: Health Management Network Commercial	$644.30
Rate for Payer: Humana Medicare	$379.00
Rate for Payer: Kaiser Permanente Commercial	$682.20
Rate for Payer: Kaiser Permanente Medicaid	$386.58
Rate for Payer: Kaiser Permanente Medicare	$379.00
Rate for Payer: MDX Hawaii PPO	$735.26
Rate for Payer: Ohana Health Plan Medicaid	$379.00
Rate for Payer: Ohana Health Plan Medicare	$379.00
Rate for Payer: UnitedHealthcare Medicaid	$7.22
Rate for Payer: UnitedHealthcare Medicare	$379.00
Rate for Payer: University Health Alliance Commercial	$60.62

US Extremity Nonvascular Limited Left - Report

Professional

Both

$145.00

Service Code	HCPCS 76882 26,LT
Hospital Charge Code	2425340
Hospital Revenue Code	972
Min. Negotiated Rate	$32.77
Max. Negotiated Rate	$123.25
Rate for Payer: AlohaCare Medicaid	$40.96
Rate for Payer: Cash Price	$94.25
Rate for Payer: Cash Price	$94.25
Rate for Payer: Hawaii Western Management Group Commercial	$32.77
Rate for Payer: Health Management Network Commercial	$123.25
Rate for Payer: Ohana Health Plan Medicaid	$40.96
Rate for Payer: UnitedHealthcare Medicaid	$40.96

US Extremity Nonvascular Limited Right

Facility

$758.00

Service Code	HCPCS 76882 RT
Hospital Charge Code	2425341
Hospital Revenue Code	320
Min. Negotiated Rate	$644.30
Max. Negotiated Rate	$735.26
Rate for Payer: Cash Price	$492.70
Rate for Payer: Health Management Network Commercial	$644.30
Rate for Payer: Kaiser Permanente Commercial	$682.20
Rate for Payer: MDX Hawaii PPO	$735.26

US Extremity Nonvascular Limited Right

Facility

$758.00

Service Code	HCPCS 76882 RT
Hospital Charge Code	2425341
Hospital Revenue Code	320
Min. Negotiated Rate	$7.22
Max. Negotiated Rate	$735.26
Rate for Payer: AlohaCare Medicaid	$379.00
Rate for Payer: AlohaCare Medicare	$379.00
Rate for Payer: Cash Price	$492.70
Rate for Payer: Cash Price	$492.70
Rate for Payer: Devoted Health Medicare	$416.90
Rate for Payer: Hawaii Medical Service Association ABD	$7.22
Rate for Payer: Hawaii Medical Service Association Medicare	$379.00
Rate for Payer: Hawaii Medical Service Association Non-ABD	$10.72
Rate for Payer: Hawaii Western Management Group Commercial	$720.10
Rate for Payer: Health Management Network Commercial	$644.30
Rate for Payer: Humana Medicare	$379.00
Rate for Payer: Kaiser Permanente Commercial	$682.20
Rate for Payer: Kaiser Permanente Medicaid	$386.58
Rate for Payer: Kaiser Permanente Medicare	$379.00
Rate for Payer: MDX Hawaii PPO	$735.26
Rate for Payer: Ohana Health Plan Medicaid	$379.00
Rate for Payer: Ohana Health Plan Medicare	$379.00
Rate for Payer: UnitedHealthcare Medicaid	$7.22
Rate for Payer: UnitedHealthcare Medicare	$379.00
Rate for Payer: University Health Alliance Commercial	$60.62

US Extremity Nonvascular Limited Right - Report

Professional

Both

$145.00

Service Code	HCPCS 76882 26,RT
Hospital Charge Code	2425343
Hospital Revenue Code	972
Min. Negotiated Rate	$32.77
Max. Negotiated Rate	$123.25
Rate for Payer: AlohaCare Medicaid	$40.96
Rate for Payer: Cash Price	$94.25
Rate for Payer: Cash Price	$94.25
Rate for Payer: Hawaii Western Management Group Commercial	$32.77
Rate for Payer: Health Management Network Commercial	$123.25
Rate for Payer: Ohana Health Plan Medicaid	$40.96
Rate for Payer: UnitedHealthcare Medicaid	$40.96

US Fetal Biophysical Profile w/o N Str

Facility

$678.00

Service Code	HCPCS 76819
Hospital Charge Code	1169689
Hospital Revenue Code	402
Min. Negotiated Rate	$46.56
Max. Negotiated Rate	$657.66
Rate for Payer: Kaiser Permanente Medicare	$339.00
Rate for Payer: AlohaCare Medicaid	$339.00
Rate for Payer: AlohaCare Medicare	$339.00
Rate for Payer: Cash Price	$440.70
Rate for Payer: Cash Price	$440.70
Rate for Payer: Devoted Health Medicare	$372.90
Rate for Payer: Hawaii Medical Service Association ABD	$46.56
Rate for Payer: Hawaii Medical Service Association Commercial	$133.51
Rate for Payer: Hawaii Medical Service Association Medicare	$339.00
Rate for Payer: Hawaii Medical Service Association Non-ABD	$58.13
Rate for Payer: Hawaii Western Management Group Commercial	$106.81
Rate for Payer: Health Management Network Commercial	$576.30
Rate for Payer: Humana Medicare	$339.00
Rate for Payer: Kaiser Permanente Commercial	$610.20
Rate for Payer: Kaiser Permanente Medicaid	$345.78
Rate for Payer: MDX Hawaii PPO	$657.66
Rate for Payer: Ohana Health Plan Medicaid	$339.00
Rate for Payer: Ohana Health Plan Medicare	$339.00
Rate for Payer: UnitedHealthcare Medicaid	$46.56
Rate for Payer: UnitedHealthcare Medicare	$339.00
Rate for Payer: University Health Alliance Commercial	$195.62

US Fetal Biophysical Profile w/o N Str

Facility

$678.00

Service Code	HCPCS 76819
Hospital Charge Code	1169689
Hospital Revenue Code	402
Min. Negotiated Rate	$576.30
Max. Negotiated Rate	$657.66
Rate for Payer: Cash Price	$440.70
Rate for Payer: Health Management Network Commercial	$576.30
Rate for Payer: Kaiser Permanente Commercial	$610.20
Rate for Payer: MDX Hawaii PPO	$657.66

US Fetal Biophysical Profile w/o N-Str - Report

Professional

Both

$140.00

Service Code	HCPCS 76819 26
Hospital Charge Code	631109
Hospital Revenue Code	972
Min. Negotiated Rate	$37.60
Max. Negotiated Rate	$119.00
Rate for Payer: AlohaCare Medicaid	$56.22
Rate for Payer: AlohaCare Medicare	$37.60
Rate for Payer: Cash Price	$91.00
Rate for Payer: Cash Price	$91.00
Rate for Payer: Devoted Health Medicare	$41.36
Rate for Payer: Hawaii Medical Service Association Medicare	$37.60
Rate for Payer: Hawaii Western Management Group Commercial	$109.03
Rate for Payer: Health Management Network Commercial	$119.00
Rate for Payer: Kaiser Permanente Commercial	$45.12
Rate for Payer: Kaiser Permanente Medicaid	$45.12
Rate for Payer: Kaiser Permanente Medicare	$45.12
Rate for Payer: Ohana Health Plan Medicaid	$56.22
Rate for Payer: Ohana Health Plan Medicare	$37.60
Rate for Payer: UnitedHealthcare Medicaid	$56.22
Rate for Payer: UnitedHealthcare Medicare	$37.60

Know your out-of-pocket cost for care.

All Charges