Samuel Mahelona Memorial Hospital

All Charges

Charge

Type

Setting

Price

Wound Culture Aerobic, Anaerobic FSI

Facility

$127.00

Service Code	HCPCS 87070
Hospital Charge Code	8118088
Hospital Revenue Code	306
Min. Negotiated Rate	$8.62
Max. Negotiated Rate	$123.19
Rate for Payer: AlohaCare Medicaid	$63.50
Rate for Payer: AlohaCare Medicare	$63.50
Rate for Payer: Cash Price	$82.55
Rate for Payer: Cash Price	$82.55
Rate for Payer: Devoted Health Medicare	$69.85
Rate for Payer: Hawaii Medical Service Association ABD	$11.90
Rate for Payer: Hawaii Medical Service Association Commercial	$10.78
Rate for Payer: Hawaii Medical Service Association Medicare	$63.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$12.50
Rate for Payer: Hawaii Western Management Group Commercial	$8.62
Rate for Payer: Health Management Network Commercial	$107.95
Rate for Payer: Humana Medicare	$63.50
Rate for Payer: Kaiser Permanente Commercial	$114.30
Rate for Payer: Kaiser Permanente Medicaid	$64.77
Rate for Payer: Kaiser Permanente Medicare	$63.50
Rate for Payer: MDX Hawaii PPO	$123.19
Rate for Payer: Ohana Health Plan Medicaid	$63.50
Rate for Payer: Ohana Health Plan Medicare	$63.50
Rate for Payer: UnitedHealthcare Medicaid	$11.90
Rate for Payer: UnitedHealthcare Medicare	$63.50
Rate for Payer: University Health Alliance Commercial	$22.26

Wound Culture Aerobic, Anaerobic FSI

Facility

$127.00

Service Code	HCPCS 87070
Hospital Charge Code	8118088
Hospital Revenue Code	306
Min. Negotiated Rate	$107.95
Max. Negotiated Rate	$123.19
Rate for Payer: Cash Price	$82.55
Rate for Payer: Health Management Network Commercial	$107.95
Rate for Payer: Kaiser Permanente Commercial	$114.30
Rate for Payer: MDX Hawaii PPO	$123.19

Wound Culture Aerobic FSI

Facility

$127.00

Service Code	HCPCS 87070
Hospital Charge Code	8118087
Hospital Revenue Code	306
Min. Negotiated Rate	$8.62
Max. Negotiated Rate	$123.19
Rate for Payer: AlohaCare Medicaid	$63.50
Rate for Payer: AlohaCare Medicare	$63.50
Rate for Payer: Cash Price	$82.55
Rate for Payer: Cash Price	$82.55
Rate for Payer: Devoted Health Medicare	$69.85
Rate for Payer: Hawaii Medical Service Association ABD	$11.90
Rate for Payer: Hawaii Medical Service Association Commercial	$10.78
Rate for Payer: Hawaii Medical Service Association Medicare	$63.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$12.50
Rate for Payer: Hawaii Western Management Group Commercial	$8.62
Rate for Payer: Health Management Network Commercial	$107.95
Rate for Payer: Humana Medicare	$63.50
Rate for Payer: Kaiser Permanente Commercial	$114.30
Rate for Payer: Kaiser Permanente Medicaid	$64.77
Rate for Payer: Kaiser Permanente Medicare	$63.50
Rate for Payer: MDX Hawaii PPO	$123.19
Rate for Payer: Ohana Health Plan Medicaid	$63.50
Rate for Payer: Ohana Health Plan Medicare	$63.50
Rate for Payer: UnitedHealthcare Medicaid	$11.90
Rate for Payer: UnitedHealthcare Medicare	$63.50
Rate for Payer: University Health Alliance Commercial	$22.26

Wound Culture Aerobic FSI

Facility

$127.00

Service Code	HCPCS 87070
Hospital Charge Code	8118087
Hospital Revenue Code	306
Min. Negotiated Rate	$107.95
Max. Negotiated Rate	$123.19
Rate for Payer: Cash Price	$82.55
Rate for Payer: Health Management Network Commercial	$107.95
Rate for Payer: Kaiser Permanente Commercial	$114.30
Rate for Payer: MDX Hawaii PPO	$123.19

WOUND DEBRIDEMENT AND SKIN GRAFT EXCEPT HAND FOR MUSCULOSKELETAL AND CONNECTIVE TISSUE DISORDERS WITH CC

Facility

$101,136.43

Service Code	MSDRG 464
Min. Negotiated Rate	$101,136.43
Max. Negotiated Rate	$101,136.43
Rate for Payer: Hawaii Medical Service Association Commercial	$101,136.43

WOUND DEBRIDEMENT AND SKIN GRAFT EXCEPT HAND FOR MUSCULOSKELETAL AND CONNECTIVE TISSUE DISORDERS WITH MCC

Facility

$101,136.43

Service Code	MSDRG 463
Min. Negotiated Rate	$101,136.43
Max. Negotiated Rate	$101,136.43
Rate for Payer: Hawaii Medical Service Association Commercial	$101,136.43

WOUND DEBRIDEMENT AND SKIN GRAFT EXCEPT HAND FOR MUSCULOSKELETAL AND CONNECTIVE TISSUE DISORDERS WITHOUT CC/MCC

Facility

$101,136.43

Service Code	MSDRG 465
Min. Negotiated Rate	$101,136.43
Max. Negotiated Rate	$101,136.43
Rate for Payer: Hawaii Medical Service Association Commercial	$101,136.43

WOUND DEBRIDEMENTS FOR INJURIES WITH CC

Facility

$28,086.87

Service Code	MSDRG 902
Min. Negotiated Rate	$28,086.87
Max. Negotiated Rate	$28,086.87
Rate for Payer: Hawaii Medical Service Association Commercial	$28,086.87

WOUND DEBRIDEMENTS FOR INJURIES WITH MCC

Facility

$28,086.87

Service Code	MSDRG 901
Min. Negotiated Rate	$28,086.87
Max. Negotiated Rate	$28,086.87
Rate for Payer: Hawaii Medical Service Association Commercial	$28,086.87

WOUND DEBRIDEMENTS FOR INJURIES WITHOUT CC/MCC

Facility

$28,086.87

Service Code	MSDRG 903
Min. Negotiated Rate	$28,086.87
Max. Negotiated Rate	$28,086.87
Rate for Payer: Hawaii Medical Service Association Commercial	$28,086.87

Wright's Stain FSI

Facility

$67.00

Service Code	HCPCS 87205
Hospital Charge Code	8228945
Hospital Revenue Code	306
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

Wright's Stain FSI

Facility

$67.00

Service Code	HCPCS 87205
Hospital Charge Code	8228945
Hospital Revenue Code	306
Min. Negotiated Rate	$4.27
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	$5.90
Rate for Payer: Hawaii Medical Service Association Commercial	$5.34
Rate for Payer: Hawaii Medical Service Association Medicare	$33.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$6.20
Rate for Payer: Hawaii Western Management Group Commercial	$4.27
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	$5.90
Rate for Payer: UnitedHealthcare Medicare	$33.50
Rate for Payer: University Health Alliance Commercial	$11.03

Wrist Hand finger Orthosis, w/o joint, prefab, customized (resting hand; L L)

Facility

$580.00

Service Code	HCPCS L3807
Hospital Charge Code	13369812
Hospital Revenue Code	274
Min. Negotiated Rate	$107.29
Max. Negotiated Rate	$562.60
Rate for Payer: AlohaCare Medicaid	$290.00
Rate for Payer: AlohaCare Medicare	$290.00
Rate for Payer: Cash Price	$377.00
Rate for Payer: Cash Price	$377.00
Rate for Payer: Devoted Health Medicare	$319.00
Rate for Payer: Hawaii Medical Service Association Medicare	$290.00
Rate for Payer: Hawaii Western Management Group Commercial	$406.00
Rate for Payer: Health Management Network Commercial	$493.00
Rate for Payer: Humana Medicare	$290.00
Rate for Payer: Kaiser Permanente Commercial	$522.00
Rate for Payer: Kaiser Permanente Medicaid	$295.80
Rate for Payer: Kaiser Permanente Medicare	$290.00
Rate for Payer: MDX Hawaii PPO	$562.60
Rate for Payer: Ohana Health Plan Medicaid	$290.00
Rate for Payer: Ohana Health Plan Medicare	$290.00
Rate for Payer: UnitedHealthcare Medicaid	$107.29
Rate for Payer: UnitedHealthcare Medicare	$290.00
Rate for Payer: University Health Alliance Commercial	$324.80

Wrist Hand finger Orthosis, w/o joint, prefab, customized (resting hand; L L)

Facility

$580.00

Service Code	HCPCS L3807
Hospital Charge Code	13369812
Hospital Revenue Code	274
Min. Negotiated Rate	$324.80
Max. Negotiated Rate	$562.60
Rate for Payer: Cash Price	$377.00
Rate for Payer: Hawaii Western Management Group Commercial	$406.00
Rate for Payer: Health Management Network Commercial	$493.00
Rate for Payer: Kaiser Permanente Commercial	$522.00
Rate for Payer: MDX Hawaii PPO	$562.60
Rate for Payer: University Health Alliance Commercial	$324.80

Wrist Hand finger Orthosis, w/o joint, prefab, customized (resting hand; L R)

Facility

$580.00

Service Code	HCPCS L3807
Hospital Charge Code	13369798
Hospital Revenue Code	274
Min. Negotiated Rate	$324.80
Max. Negotiated Rate	$562.60
Rate for Payer: Cash Price	$377.00
Rate for Payer: Hawaii Western Management Group Commercial	$406.00
Rate for Payer: Health Management Network Commercial	$493.00
Rate for Payer: Kaiser Permanente Commercial	$522.00
Rate for Payer: MDX Hawaii PPO	$562.60
Rate for Payer: University Health Alliance Commercial	$324.80

Wrist Hand finger Orthosis, w/o joint, prefab, customized (resting hand; L R)

Facility

$580.00

Service Code	HCPCS L3807
Hospital Charge Code	13369798
Hospital Revenue Code	274
Min. Negotiated Rate	$107.29
Max. Negotiated Rate	$562.60
Rate for Payer: AlohaCare Medicaid	$290.00
Rate for Payer: AlohaCare Medicare	$290.00
Rate for Payer: Cash Price	$377.00
Rate for Payer: Cash Price	$377.00
Rate for Payer: Devoted Health Medicare	$319.00
Rate for Payer: Hawaii Medical Service Association Medicare	$290.00
Rate for Payer: Hawaii Western Management Group Commercial	$406.00
Rate for Payer: Health Management Network Commercial	$493.00
Rate for Payer: Humana Medicare	$290.00
Rate for Payer: Kaiser Permanente Commercial	$522.00
Rate for Payer: Kaiser Permanente Medicaid	$295.80
Rate for Payer: Kaiser Permanente Medicare	$290.00
Rate for Payer: MDX Hawaii PPO	$562.60
Rate for Payer: Ohana Health Plan Medicaid	$290.00
Rate for Payer: Ohana Health Plan Medicare	$290.00
Rate for Payer: UnitedHealthcare Medicaid	$107.29
Rate for Payer: UnitedHealthcare Medicare	$290.00
Rate for Payer: University Health Alliance Commercial	$324.80

Wrist Hand finger Orthosis, w/o joint, prefab, customized (resting hand; M L)

Facility

$580.00

Service Code	HCPCS L3807
Hospital Charge Code	13369805
Hospital Revenue Code	274
Min. Negotiated Rate	$324.80
Max. Negotiated Rate	$562.60
Rate for Payer: Cash Price	$377.00
Rate for Payer: Hawaii Western Management Group Commercial	$406.00
Rate for Payer: Health Management Network Commercial	$493.00
Rate for Payer: Kaiser Permanente Commercial	$522.00
Rate for Payer: MDX Hawaii PPO	$562.60
Rate for Payer: University Health Alliance Commercial	$324.80

Wrist Hand finger Orthosis, w/o joint, prefab, customized (resting hand; M L)

Facility

$580.00

Service Code	HCPCS L3807
Hospital Charge Code	13369805
Hospital Revenue Code	274
Min. Negotiated Rate	$107.29
Max. Negotiated Rate	$562.60
Rate for Payer: AlohaCare Medicaid	$290.00
Rate for Payer: AlohaCare Medicare	$290.00
Rate for Payer: Cash Price	$377.00
Rate for Payer: Cash Price	$377.00
Rate for Payer: Devoted Health Medicare	$319.00
Rate for Payer: Hawaii Medical Service Association Medicare	$290.00
Rate for Payer: Hawaii Western Management Group Commercial	$406.00
Rate for Payer: Health Management Network Commercial	$493.00
Rate for Payer: Humana Medicare	$290.00
Rate for Payer: Kaiser Permanente Commercial	$522.00
Rate for Payer: Kaiser Permanente Medicaid	$295.80
Rate for Payer: Kaiser Permanente Medicare	$290.00
Rate for Payer: MDX Hawaii PPO	$562.60
Rate for Payer: Ohana Health Plan Medicaid	$290.00
Rate for Payer: Ohana Health Plan Medicare	$290.00
Rate for Payer: UnitedHealthcare Medicaid	$107.29
Rate for Payer: UnitedHealthcare Medicare	$290.00
Rate for Payer: University Health Alliance Commercial	$324.80

Wrist Hand finger Orthosis, w/o joint, prefab, customized (resting hand; M R)

Facility

$580.00

Service Code	HCPCS L3807
Hospital Charge Code	13369799
Hospital Revenue Code	274
Min. Negotiated Rate	$324.80
Max. Negotiated Rate	$562.60
Rate for Payer: Cash Price	$377.00
Rate for Payer: Hawaii Western Management Group Commercial	$406.00
Rate for Payer: Health Management Network Commercial	$493.00
Rate for Payer: Kaiser Permanente Commercial	$522.00
Rate for Payer: MDX Hawaii PPO	$562.60
Rate for Payer: University Health Alliance Commercial	$324.80

Wrist Hand finger Orthosis, w/o joint, prefab, customized (resting hand; M R)

Facility

$580.00

Service Code	HCPCS L3807
Hospital Charge Code	13369799
Hospital Revenue Code	274
Min. Negotiated Rate	$107.29
Max. Negotiated Rate	$562.60
Rate for Payer: AlohaCare Medicaid	$290.00
Rate for Payer: AlohaCare Medicare	$290.00
Rate for Payer: Cash Price	$377.00
Rate for Payer: Cash Price	$377.00
Rate for Payer: Devoted Health Medicare	$319.00
Rate for Payer: Hawaii Medical Service Association Medicare	$290.00
Rate for Payer: Hawaii Western Management Group Commercial	$406.00
Rate for Payer: Health Management Network Commercial	$493.00
Rate for Payer: Humana Medicare	$290.00
Rate for Payer: Kaiser Permanente Commercial	$522.00
Rate for Payer: Kaiser Permanente Medicaid	$295.80
Rate for Payer: Kaiser Permanente Medicare	$290.00
Rate for Payer: MDX Hawaii PPO	$562.60
Rate for Payer: Ohana Health Plan Medicaid	$290.00
Rate for Payer: Ohana Health Plan Medicare	$290.00
Rate for Payer: UnitedHealthcare Medicaid	$107.29
Rate for Payer: UnitedHealthcare Medicare	$290.00
Rate for Payer: University Health Alliance Commercial	$324.80

Wrist Hand finger Orthosis, w/o joint, prefab, customized (resting hand; S L)

Facility

$580.00

Service Code	HCPCS L3807
Hospital Charge Code	13369800
Hospital Revenue Code	274
Min. Negotiated Rate	$324.80
Max. Negotiated Rate	$562.60
Rate for Payer: Cash Price	$377.00
Rate for Payer: Hawaii Western Management Group Commercial	$406.00
Rate for Payer: Health Management Network Commercial	$493.00
Rate for Payer: Kaiser Permanente Commercial	$522.00
Rate for Payer: MDX Hawaii PPO	$562.60
Rate for Payer: University Health Alliance Commercial	$324.80

Wrist Hand finger Orthosis, w/o joint, prefab, customized (resting hand; S L)

Facility

$580.00

Service Code	HCPCS L3807
Hospital Charge Code	13369800
Hospital Revenue Code	274
Min. Negotiated Rate	$107.29
Max. Negotiated Rate	$562.60
Rate for Payer: AlohaCare Medicaid	$290.00
Rate for Payer: AlohaCare Medicare	$290.00
Rate for Payer: Cash Price	$377.00
Rate for Payer: Cash Price	$377.00
Rate for Payer: Devoted Health Medicare	$319.00
Rate for Payer: Hawaii Medical Service Association Medicare	$290.00
Rate for Payer: Hawaii Western Management Group Commercial	$406.00
Rate for Payer: Health Management Network Commercial	$493.00
Rate for Payer: Humana Medicare	$290.00
Rate for Payer: Kaiser Permanente Commercial	$522.00
Rate for Payer: Kaiser Permanente Medicaid	$295.80
Rate for Payer: Kaiser Permanente Medicare	$290.00
Rate for Payer: MDX Hawaii PPO	$562.60
Rate for Payer: Ohana Health Plan Medicaid	$290.00
Rate for Payer: Ohana Health Plan Medicare	$290.00
Rate for Payer: UnitedHealthcare Medicaid	$107.29
Rate for Payer: UnitedHealthcare Medicare	$290.00
Rate for Payer: University Health Alliance Commercial	$324.80

Wrist hand finger orthosis, w/o joint, prefab, non-customized (one size - resting hand w/o thumb)

Facility

$253.00

Service Code	HCPCS L3809
Hospital Charge Code	13381765
Hospital Revenue Code	274
Min. Negotiated Rate	$126.50
Max. Negotiated Rate	$245.41
Rate for Payer: AlohaCare Medicaid	$126.50
Rate for Payer: AlohaCare Medicare	$126.50
Rate for Payer: Cash Price	$164.45
Rate for Payer: Cash Price	$164.45
Rate for Payer: Devoted Health Medicare	$139.15
Rate for Payer: Hawaii Medical Service Association Medicare	$126.50
Rate for Payer: Hawaii Western Management Group Commercial	$177.10
Rate for Payer: Health Management Network Commercial	$215.05
Rate for Payer: Humana Medicare	$126.50
Rate for Payer: Kaiser Permanente Commercial	$227.70
Rate for Payer: Kaiser Permanente Medicaid	$129.03
Rate for Payer: Kaiser Permanente Medicare	$126.50
Rate for Payer: MDX Hawaii PPO	$245.41
Rate for Payer: Ohana Health Plan Medicaid	$126.50
Rate for Payer: Ohana Health Plan Medicare	$126.50
Rate for Payer: UnitedHealthcare Medicaid	$209.46
Rate for Payer: UnitedHealthcare Medicare	$126.50
Rate for Payer: University Health Alliance Commercial	$141.68

Wrist hand finger orthosis, w/o joint, prefab, non-customized (one size - resting hand w/o thumb)

Facility

$253.00

Service Code	HCPCS L3809
Hospital Charge Code	13381765
Hospital Revenue Code	274
Min. Negotiated Rate	$141.68
Max. Negotiated Rate	$245.41
Rate for Payer: Cash Price	$164.45
Rate for Payer: Hawaii Western Management Group Commercial	$177.10
Rate for Payer: Health Management Network Commercial	$215.05
Rate for Payer: Kaiser Permanente Commercial	$227.70
Rate for Payer: MDX Hawaii PPO	$245.41
Rate for Payer: University Health Alliance Commercial	$141.68

Wrist hand finger orthosis, w/o joint, prefab, non-customized (thumb spica; L)

Facility

$162.00

Service Code	HCPCS L3809
Hospital Charge Code	13381789
Hospital Revenue Code	274
Min. Negotiated Rate	$90.72
Max. Negotiated Rate	$157.14
Rate for Payer: Cash Price	$105.30
Rate for Payer: Hawaii Western Management Group Commercial	$113.40
Rate for Payer: Health Management Network Commercial	$137.70
Rate for Payer: Kaiser Permanente Commercial	$145.80
Rate for Payer: MDX Hawaii PPO	$157.14
Rate for Payer: University Health Alliance Commercial	$90.72

Know your out-of-pocket cost for care.

All Charges