Samuel Mahelona Memorial Hospital

All Charges

Charge

Type

Setting

Price

US Upper Extrem Non Vasc LT POC

Facility

$758.00

Service Code	HCPCS 76882
Hospital Charge Code	10234951
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 Commercial	$133.51
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	$106.81
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 Upper Extrem Non Vasc LT POC

Facility

$758.00

Service Code	HCPCS 76882
Hospital Charge Code	10234951
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 Upper Extrem Non Vasc RT POC

Facility

$758.00

Service Code	HCPCS 76882
Hospital Charge Code	10234952
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 Upper Extrem Non Vasc RT POC

Facility

$758.00

Service Code	HCPCS 76882
Hospital Charge Code	10234952
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 Commercial	$133.51
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	$106.81
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 Upper Extrem Venous Duplex LT POC

Facility

$761.00

Service Code	HCPCS 93971
Hospital Charge Code	10239192
Hospital Revenue Code	921
Min. Negotiated Rate	$646.85
Max. Negotiated Rate	$738.17
Rate for Payer: Cash Price	$494.65
Rate for Payer: Health Management Network Commercial	$646.85
Rate for Payer: Kaiser Permanente Commercial	$684.90
Rate for Payer: MDX Hawaii PPO	$738.17

US Upper Extrem Venous Duplex LT POC

Facility

$761.00

Service Code	HCPCS 93971
Hospital Charge Code	10239192
Hospital Revenue Code	921
Min. Negotiated Rate	$93.10
Max. Negotiated Rate	$738.17
Rate for Payer: AlohaCare Medicaid	$380.50
Rate for Payer: AlohaCare Medicare	$380.50
Rate for Payer: Cash Price	$494.65
Rate for Payer: Cash Price	$494.65
Rate for Payer: Devoted Health Medicare	$418.55
Rate for Payer: Hawaii Medical Service Association ABD	$93.10
Rate for Payer: Hawaii Medical Service Association Commercial	$133.51
Rate for Payer: Hawaii Medical Service Association Medicare	$380.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$109.94
Rate for Payer: Hawaii Western Management Group Commercial	$722.95
Rate for Payer: Health Management Network Commercial	$646.85
Rate for Payer: Humana Medicare	$380.50
Rate for Payer: Kaiser Permanente Commercial	$684.90
Rate for Payer: Kaiser Permanente Medicaid	$388.11
Rate for Payer: Kaiser Permanente Medicare	$380.50
Rate for Payer: MDX Hawaii PPO	$738.17
Rate for Payer: Ohana Health Plan Medicaid	$380.50
Rate for Payer: Ohana Health Plan Medicare	$380.50
Rate for Payer: UnitedHealthcare Medicaid	$93.10
Rate for Payer: UnitedHealthcare Medicare	$380.50
Rate for Payer: University Health Alliance Commercial	$426.16

US Upper Extrem Venous Duplex RT POC

Facility

$761.00

Service Code	HCPCS 93971
Hospital Charge Code	10234946
Hospital Revenue Code	921
Min. Negotiated Rate	$646.85
Max. Negotiated Rate	$738.17
Rate for Payer: Cash Price	$494.65
Rate for Payer: Health Management Network Commercial	$646.85
Rate for Payer: Kaiser Permanente Commercial	$684.90
Rate for Payer: MDX Hawaii PPO	$738.17

US Upper Extrem Venous Duplex RT POC

Facility

$761.00

Service Code	HCPCS 93971
Hospital Charge Code	10234946
Hospital Revenue Code	921
Min. Negotiated Rate	$93.10
Max. Negotiated Rate	$738.17
Rate for Payer: AlohaCare Medicaid	$380.50
Rate for Payer: AlohaCare Medicare	$380.50
Rate for Payer: Cash Price	$494.65
Rate for Payer: Cash Price	$494.65
Rate for Payer: Devoted Health Medicare	$418.55
Rate for Payer: Hawaii Medical Service Association ABD	$93.10
Rate for Payer: Hawaii Medical Service Association Commercial	$133.51
Rate for Payer: Hawaii Medical Service Association Medicare	$380.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$109.94
Rate for Payer: Hawaii Western Management Group Commercial	$722.95
Rate for Payer: Health Management Network Commercial	$646.85
Rate for Payer: Humana Medicare	$380.50
Rate for Payer: Kaiser Permanente Commercial	$684.90
Rate for Payer: Kaiser Permanente Medicaid	$388.11
Rate for Payer: Kaiser Permanente Medicare	$380.50
Rate for Payer: MDX Hawaii PPO	$738.17
Rate for Payer: Ohana Health Plan Medicaid	$380.50
Rate for Payer: Ohana Health Plan Medicare	$380.50
Rate for Payer: UnitedHealthcare Medicaid	$93.10
Rate for Payer: UnitedHealthcare Medicare	$380.50
Rate for Payer: University Health Alliance Commercial	$426.16

US Upper Ext Venous Duplex Bilateral

Facility

$1,527.00

Service Code	HCPCS 93970
Hospital Charge Code	1169901
Hospital Revenue Code	921
Min. Negotiated Rate	$139.85
Max. Negotiated Rate	$1,481.19
Rate for Payer: AlohaCare Medicaid	$763.50
Rate for Payer: AlohaCare Medicare	$763.50
Rate for Payer: Cash Price	$992.55
Rate for Payer: Cash Price	$992.55
Rate for Payer: Devoted Health Medicare	$839.85
Rate for Payer: Hawaii Medical Service Association ABD	$139.85
Rate for Payer: Hawaii Medical Service Association Commercial	$304.71
Rate for Payer: Hawaii Medical Service Association Medicare	$763.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$160.42
Rate for Payer: Hawaii Western Management Group Commercial	$1,450.65
Rate for Payer: Health Management Network Commercial	$1,297.95
Rate for Payer: Humana Medicare	$763.50
Rate for Payer: Kaiser Permanente Commercial	$1,374.30
Rate for Payer: Kaiser Permanente Medicaid	$778.77
Rate for Payer: Kaiser Permanente Medicare	$763.50
Rate for Payer: MDX Hawaii PPO	$1,481.19
Rate for Payer: Ohana Health Plan Medicaid	$763.50
Rate for Payer: Ohana Health Plan Medicare	$763.50
Rate for Payer: UnitedHealthcare Medicaid	$139.85
Rate for Payer: UnitedHealthcare Medicare	$763.50
Rate for Payer: University Health Alliance Commercial	$855.12

US Upper Ext Venous Duplex Bilateral

Facility

$1,527.00

Service Code	HCPCS 93970
Hospital Charge Code	1169901
Hospital Revenue Code	921
Min. Negotiated Rate	$1,297.95
Max. Negotiated Rate	$1,481.19
Rate for Payer: Cash Price	$992.55
Rate for Payer: Health Management Network Commercial	$1,297.95
Rate for Payer: Kaiser Permanente Commercial	$1,374.30
Rate for Payer: MDX Hawaii PPO	$1,481.19

US Upper Ext Venous Duplex Bilateral - Report

Professional

Both

$321.00

Service Code	HCPCS 93970 26
Hospital Charge Code	630808
Hospital Revenue Code	972
Min. Negotiated Rate	$32.23
Max. Negotiated Rate	$272.85
Rate for Payer: AlohaCare Medicaid	$209.33
Rate for Payer: AlohaCare Medicare	$32.23
Rate for Payer: Cash Price	$208.65
Rate for Payer: Cash Price	$208.65
Rate for Payer: Devoted Health Medicare	$35.45
Rate for Payer: Hawaii Medical Service Association Medicare	$32.23
Rate for Payer: Hawaii Western Management Group Commercial	$161.05
Rate for Payer: Health Management Network Commercial	$272.85
Rate for Payer: Kaiser Permanente Commercial	$38.68
Rate for Payer: Kaiser Permanente Medicaid	$38.68
Rate for Payer: Kaiser Permanente Medicare	$38.68
Rate for Payer: Ohana Health Plan Medicaid	$209.33
Rate for Payer: Ohana Health Plan Medicare	$32.23
Rate for Payer: UnitedHealthcare Medicaid	$209.33
Rate for Payer: UnitedHealthcare Medicare	$32.23

US Upper Ext Venous Duplex Left

Facility

$761.00

Service Code	HCPCS 93971 LT
Hospital Charge Code	1169903
Hospital Revenue Code	921
Min. Negotiated Rate	$93.10
Max. Negotiated Rate	$738.17
Rate for Payer: AlohaCare Medicaid	$380.50
Rate for Payer: AlohaCare Medicare	$380.50
Rate for Payer: Cash Price	$494.65
Rate for Payer: Cash Price	$494.65
Rate for Payer: Devoted Health Medicare	$418.55
Rate for Payer: Hawaii Medical Service Association ABD	$93.10
Rate for Payer: Hawaii Medical Service Association Medicare	$380.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$109.94
Rate for Payer: Hawaii Western Management Group Commercial	$722.95
Rate for Payer: Health Management Network Commercial	$646.85
Rate for Payer: Humana Medicare	$380.50
Rate for Payer: Kaiser Permanente Commercial	$684.90
Rate for Payer: Kaiser Permanente Medicaid	$388.11
Rate for Payer: Kaiser Permanente Medicare	$380.50
Rate for Payer: MDX Hawaii PPO	$738.17
Rate for Payer: Ohana Health Plan Medicaid	$380.50
Rate for Payer: Ohana Health Plan Medicare	$380.50
Rate for Payer: UnitedHealthcare Medicaid	$93.10
Rate for Payer: UnitedHealthcare Medicare	$380.50
Rate for Payer: University Health Alliance Commercial	$426.16

US Upper Ext Venous Duplex Left

Facility

$761.00

Service Code	HCPCS 93971 LT
Hospital Charge Code	1169903
Hospital Revenue Code	921
Min. Negotiated Rate	$646.85
Max. Negotiated Rate	$738.17
Rate for Payer: Cash Price	$494.65
Rate for Payer: Health Management Network Commercial	$646.85
Rate for Payer: Kaiser Permanente Commercial	$684.90
Rate for Payer: MDX Hawaii PPO	$738.17

US Upper Ext Venous Duplex Left - Report

Professional

Both

$145.00

Service Code	HCPCS 93971 26,LT
Hospital Charge Code	630806
Hospital Revenue Code	972
Min. Negotiated Rate	$123.25
Max. Negotiated Rate	$133.33
Rate for Payer: AlohaCare Medicaid	$133.33
Rate for Payer: Cash Price	$94.25
Rate for Payer: Cash Price	$94.25
Rate for Payer: Hawaii Western Management Group Commercial	$130.82
Rate for Payer: Health Management Network Commercial	$123.25
Rate for Payer: Ohana Health Plan Medicaid	$133.33
Rate for Payer: UnitedHealthcare Medicaid	$133.33

US Upper Ext Venous Duplex Right

Facility

$761.00

Service Code	HCPCS 93971 RT
Hospital Charge Code	1169905
Hospital Revenue Code	921
Min. Negotiated Rate	$646.85
Max. Negotiated Rate	$738.17
Rate for Payer: Cash Price	$494.65
Rate for Payer: Health Management Network Commercial	$646.85
Rate for Payer: Kaiser Permanente Commercial	$684.90
Rate for Payer: MDX Hawaii PPO	$738.17

US Upper Ext Venous Duplex Right

Facility

$761.00

Service Code	HCPCS 93971 RT
Hospital Charge Code	1169905
Hospital Revenue Code	921
Min. Negotiated Rate	$93.10
Max. Negotiated Rate	$738.17
Rate for Payer: AlohaCare Medicaid	$380.50
Rate for Payer: AlohaCare Medicare	$380.50
Rate for Payer: Cash Price	$494.65
Rate for Payer: Cash Price	$494.65
Rate for Payer: Devoted Health Medicare	$418.55
Rate for Payer: Hawaii Medical Service Association ABD	$93.10
Rate for Payer: Hawaii Medical Service Association Medicare	$380.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$109.94
Rate for Payer: Hawaii Western Management Group Commercial	$722.95
Rate for Payer: Health Management Network Commercial	$646.85
Rate for Payer: Humana Medicare	$380.50
Rate for Payer: Kaiser Permanente Commercial	$684.90
Rate for Payer: Kaiser Permanente Medicaid	$388.11
Rate for Payer: Kaiser Permanente Medicare	$380.50
Rate for Payer: MDX Hawaii PPO	$738.17
Rate for Payer: Ohana Health Plan Medicaid	$380.50
Rate for Payer: Ohana Health Plan Medicare	$380.50
Rate for Payer: UnitedHealthcare Medicaid	$93.10
Rate for Payer: UnitedHealthcare Medicare	$380.50
Rate for Payer: University Health Alliance Commercial	$426.16

US Upper Ext Venous Duplex Right - Report

Professional

Both

$145.00

Service Code	HCPCS 93971 26,RT
Hospital Charge Code	630802
Hospital Revenue Code	972
Min. Negotiated Rate	$123.25
Max. Negotiated Rate	$133.33
Rate for Payer: AlohaCare Medicaid	$133.33
Rate for Payer: Cash Price	$94.25
Rate for Payer: Cash Price	$94.25
Rate for Payer: Hawaii Western Management Group Commercial	$130.82
Rate for Payer: Health Management Network Commercial	$123.25
Rate for Payer: Ohana Health Plan Medicaid	$133.33
Rate for Payer: UnitedHealthcare Medicaid	$133.33

UTERINE AND ADNEXA PROCEDURES FOR NON-MALIGNANCY WITH CC/MCC

Facility

$22,279.88

Service Code	MSDRG 742
Min. Negotiated Rate	$22,279.88
Max. Negotiated Rate	$22,279.88
Rate for Payer: Hawaii Medical Service Association Commercial	$22,279.88

UTERINE AND ADNEXA PROCEDURES FOR NON-MALIGNANCY WITHOUT CC/MCC

Facility

$20,028.19

Service Code	MSDRG 743
Min. Negotiated Rate	$20,028.19
Max. Negotiated Rate	$20,028.19
Rate for Payer: Hawaii Medical Service Association Commercial	$20,028.19

UTERINE AND ADNEXA PROCEDURES FOR NON-OVARIAN AND NON-ADNEXAL MALIGNANCY WITH CC

Facility

$36,074.44

Service Code	MSDRG 740
Min. Negotiated Rate	$36,074.44
Max. Negotiated Rate	$36,074.44
Rate for Payer: Hawaii Medical Service Association Commercial	$36,074.44

UTERINE AND ADNEXA PROCEDURES FOR NON-OVARIAN AND NON-ADNEXAL MALIGNANCY WITH MCC

Facility

$37,496.56

Service Code	MSDRG 739
Min. Negotiated Rate	$37,496.56
Max. Negotiated Rate	$37,496.56
Rate for Payer: Hawaii Medical Service Association Commercial	$37,496.56

UTERINE AND ADNEXA PROCEDURES FOR NON-OVARIAN AND NON-ADNEXAL MALIGNANCY WITHOUT CC/MCC

Facility

$25,835.18

Service Code	MSDRG 741
Min. Negotiated Rate	$25,835.18
Max. Negotiated Rate	$25,835.18
Rate for Payer: Hawaii Medical Service Association Commercial	$25,835.18

UTERINE AND ADNEXA PROCEDURES FOR OVARIAN OR ADNEXAL MALIGNANCY WITH CC

Facility

$45,626.35

Service Code	MSDRG 737
Min. Negotiated Rate	$45,626.35
Max. Negotiated Rate	$45,626.35
Rate for Payer: Hawaii Medical Service Association Commercial	$45,626.35

UTERINE AND ADNEXA PROCEDURES FOR OVARIAN OR ADNEXAL MALIGNANCY WITH MCC

Facility

$45,626.35

Service Code	MSDRG 736
Min. Negotiated Rate	$45,626.35
Max. Negotiated Rate	$45,626.35
Rate for Payer: Hawaii Medical Service Association Commercial	$45,626.35

UTERINE AND ADNEXA PROCEDURES FOR OVARIAN OR ADNEXAL MALIGNANCY WITHOUT CC/MCC

Facility

$45,626.35

Service Code	MSDRG 738
Min. Negotiated Rate	$45,626.35
Max. Negotiated Rate	$45,626.35
Rate for Payer: Hawaii Medical Service Association Commercial	$45,626.35

Know your out-of-pocket cost for care.

All Charges