Samuel Mahelona Memorial Hospital

All Charges

Charge

Type

Setting

Price

XR Arthrogram Hip Left

Facility

$1,520.00

Service Code	HCPCS 73525
Hospital Charge Code	8127591
Hospital Revenue Code	322
Min. Negotiated Rate	$69.25
Max. Negotiated Rate	$1,474.40
Rate for Payer: AlohaCare Medicaid	$760.00
Rate for Payer: AlohaCare Medicare	$760.00
Rate for Payer: Cash Price	$988.00
Rate for Payer: Cash Price	$988.00
Rate for Payer: Devoted Health Medicare	$836.00
Rate for Payer: Hawaii Medical Service Association ABD	$69.25
Rate for Payer: Hawaii Medical Service Association Commercial	$445.54
Rate for Payer: Hawaii Medical Service Association Medicare	$760.00
Rate for Payer: Hawaii Medical Service Association Non-ABD	$75.32
Rate for Payer: Hawaii Western Management Group Commercial	$356.43
Rate for Payer: Health Management Network Commercial	$1,292.00
Rate for Payer: Humana Medicare	$760.00
Rate for Payer: Kaiser Permanente Commercial	$1,368.00
Rate for Payer: Kaiser Permanente Medicaid	$775.20
Rate for Payer: Kaiser Permanente Medicare	$760.00
Rate for Payer: MDX Hawaii PPO	$1,474.40
Rate for Payer: Ohana Health Plan Medicaid	$760.00
Rate for Payer: Ohana Health Plan Medicare	$760.00
Rate for Payer: UnitedHealthcare Medicaid	$69.25
Rate for Payer: UnitedHealthcare Medicare	$760.00
Rate for Payer: University Health Alliance Commercial	$206.57

XR Arthrogram Hip Left

Facility

$1,520.00

Service Code	HCPCS 73525
Hospital Charge Code	8127591
Hospital Revenue Code	322
Min. Negotiated Rate	$1,292.00
Max. Negotiated Rate	$1,474.40
Rate for Payer: Cash Price	$988.00
Rate for Payer: Health Management Network Commercial	$1,292.00
Rate for Payer: Kaiser Permanente Commercial	$1,368.00
Rate for Payer: MDX Hawaii PPO	$1,474.40

XR Arthrogram Hip Right

Facility

$1,520.00

Service Code	HCPCS 73525
Hospital Charge Code	8127594
Hospital Revenue Code	322
Min. Negotiated Rate	$69.25
Max. Negotiated Rate	$1,474.40
Rate for Payer: AlohaCare Medicaid	$760.00
Rate for Payer: AlohaCare Medicare	$760.00
Rate for Payer: Cash Price	$988.00
Rate for Payer: Cash Price	$988.00
Rate for Payer: Devoted Health Medicare	$836.00
Rate for Payer: Hawaii Medical Service Association ABD	$69.25
Rate for Payer: Hawaii Medical Service Association Commercial	$445.54
Rate for Payer: Hawaii Medical Service Association Medicare	$760.00
Rate for Payer: Hawaii Medical Service Association Non-ABD	$75.32
Rate for Payer: Hawaii Western Management Group Commercial	$356.43
Rate for Payer: Health Management Network Commercial	$1,292.00
Rate for Payer: Humana Medicare	$760.00
Rate for Payer: Kaiser Permanente Commercial	$1,368.00
Rate for Payer: Kaiser Permanente Medicaid	$775.20
Rate for Payer: Kaiser Permanente Medicare	$760.00
Rate for Payer: MDX Hawaii PPO	$1,474.40
Rate for Payer: Ohana Health Plan Medicaid	$760.00
Rate for Payer: Ohana Health Plan Medicare	$760.00
Rate for Payer: UnitedHealthcare Medicaid	$69.25
Rate for Payer: UnitedHealthcare Medicare	$760.00
Rate for Payer: University Health Alliance Commercial	$206.57

XR Arthrogram Hip Right

Facility

$1,520.00

Service Code	HCPCS 73525
Hospital Charge Code	8127594
Hospital Revenue Code	322
Min. Negotiated Rate	$1,292.00
Max. Negotiated Rate	$1,474.40
Rate for Payer: Cash Price	$988.00
Rate for Payer: Health Management Network Commercial	$1,292.00
Rate for Payer: Kaiser Permanente Commercial	$1,368.00
Rate for Payer: MDX Hawaii PPO	$1,474.40

XR Arthrogram Injection Ankle Left

Facility

$1,520.00

Service Code	HCPCS 73615 LT
Hospital Charge Code	1169950
Hospital Revenue Code	320
Min. Negotiated Rate	$69.25
Max. Negotiated Rate	$1,474.40
Rate for Payer: AlohaCare Medicaid	$760.00
Rate for Payer: AlohaCare Medicare	$760.00
Rate for Payer: Cash Price	$988.00
Rate for Payer: Cash Price	$988.00
Rate for Payer: Devoted Health Medicare	$836.00
Rate for Payer: Hawaii Medical Service Association ABD	$69.25
Rate for Payer: Hawaii Medical Service Association Medicare	$760.00
Rate for Payer: Hawaii Medical Service Association Non-ABD	$75.32
Rate for Payer: Hawaii Western Management Group Commercial	$1,444.00
Rate for Payer: Health Management Network Commercial	$1,292.00
Rate for Payer: Humana Medicare	$760.00
Rate for Payer: Kaiser Permanente Commercial	$1,368.00
Rate for Payer: Kaiser Permanente Medicaid	$775.20
Rate for Payer: Kaiser Permanente Medicare	$760.00
Rate for Payer: MDX Hawaii PPO	$1,474.40
Rate for Payer: Ohana Health Plan Medicaid	$760.00
Rate for Payer: Ohana Health Plan Medicare	$760.00
Rate for Payer: UnitedHealthcare Medicaid	$69.25
Rate for Payer: UnitedHealthcare Medicare	$760.00
Rate for Payer: University Health Alliance Commercial	$212.97

XR Arthrogram Injection Ankle Left

Facility

$1,520.00

Service Code	HCPCS 73615 LT
Hospital Charge Code	1169950
Hospital Revenue Code	320
Min. Negotiated Rate	$1,292.00
Max. Negotiated Rate	$1,474.40
Rate for Payer: Cash Price	$988.00
Rate for Payer: Health Management Network Commercial	$1,292.00
Rate for Payer: Kaiser Permanente Commercial	$1,368.00
Rate for Payer: MDX Hawaii PPO	$1,474.40

XR Arthrogram Injection Ankle Right

Facility

$1,520.00

Service Code	HCPCS 73615 RT
Hospital Charge Code	1169952
Hospital Revenue Code	320
Min. Negotiated Rate	$69.25
Max. Negotiated Rate	$1,474.40
Rate for Payer: AlohaCare Medicaid	$760.00
Rate for Payer: AlohaCare Medicare	$760.00
Rate for Payer: Cash Price	$988.00
Rate for Payer: Cash Price	$988.00
Rate for Payer: Devoted Health Medicare	$836.00
Rate for Payer: Hawaii Medical Service Association ABD	$69.25
Rate for Payer: Hawaii Medical Service Association Medicare	$760.00
Rate for Payer: Hawaii Medical Service Association Non-ABD	$75.32
Rate for Payer: Hawaii Western Management Group Commercial	$1,444.00
Rate for Payer: Health Management Network Commercial	$1,292.00
Rate for Payer: Humana Medicare	$760.00
Rate for Payer: Kaiser Permanente Commercial	$1,368.00
Rate for Payer: Kaiser Permanente Medicaid	$775.20
Rate for Payer: Kaiser Permanente Medicare	$760.00
Rate for Payer: MDX Hawaii PPO	$1,474.40
Rate for Payer: Ohana Health Plan Medicaid	$760.00
Rate for Payer: Ohana Health Plan Medicare	$760.00
Rate for Payer: UnitedHealthcare Medicaid	$69.25
Rate for Payer: UnitedHealthcare Medicare	$760.00
Rate for Payer: University Health Alliance Commercial	$212.97

XR Arthrogram Injection Ankle Right

Facility

$1,520.00

Service Code	HCPCS 73615 RT
Hospital Charge Code	1169952
Hospital Revenue Code	320
Min. Negotiated Rate	$1,292.00
Max. Negotiated Rate	$1,474.40
Rate for Payer: Cash Price	$988.00
Rate for Payer: Health Management Network Commercial	$1,292.00
Rate for Payer: Kaiser Permanente Commercial	$1,368.00
Rate for Payer: MDX Hawaii PPO	$1,474.40

XR Arthrogram Injection Elbow Left

Facility

$1,520.00

Service Code	HCPCS 73085 LT
Hospital Charge Code	1169956
Hospital Revenue Code	320
Min. Negotiated Rate	$69.25
Max. Negotiated Rate	$1,474.40
Rate for Payer: AlohaCare Medicaid	$760.00
Rate for Payer: AlohaCare Medicare	$760.00
Rate for Payer: Cash Price	$988.00
Rate for Payer: Cash Price	$988.00
Rate for Payer: Devoted Health Medicare	$836.00
Rate for Payer: Hawaii Medical Service Association ABD	$69.25
Rate for Payer: Hawaii Medical Service Association Medicare	$760.00
Rate for Payer: Hawaii Medical Service Association Non-ABD	$75.32
Rate for Payer: Hawaii Western Management Group Commercial	$1,444.00
Rate for Payer: Health Management Network Commercial	$1,292.00
Rate for Payer: Humana Medicare	$760.00
Rate for Payer: Kaiser Permanente Commercial	$1,368.00
Rate for Payer: Kaiser Permanente Medicaid	$775.20
Rate for Payer: Kaiser Permanente Medicare	$760.00
Rate for Payer: MDX Hawaii PPO	$1,474.40
Rate for Payer: Ohana Health Plan Medicaid	$760.00
Rate for Payer: Ohana Health Plan Medicare	$760.00
Rate for Payer: UnitedHealthcare Medicaid	$69.25
Rate for Payer: UnitedHealthcare Medicare	$760.00
Rate for Payer: University Health Alliance Commercial	$206.85

XR Arthrogram Injection Elbow Left

Facility

$1,520.00

Service Code	HCPCS 73085 LT
Hospital Charge Code	1169956
Hospital Revenue Code	320
Min. Negotiated Rate	$1,292.00
Max. Negotiated Rate	$1,474.40
Rate for Payer: Cash Price	$988.00
Rate for Payer: Health Management Network Commercial	$1,292.00
Rate for Payer: Kaiser Permanente Commercial	$1,368.00
Rate for Payer: MDX Hawaii PPO	$1,474.40

XR Arthrogram Injection Elbow Right

Facility

$1,520.00

Service Code	HCPCS 73085 RT
Hospital Charge Code	1169958
Hospital Revenue Code	320
Min. Negotiated Rate	$1,292.00
Max. Negotiated Rate	$1,474.40
Rate for Payer: Cash Price	$988.00
Rate for Payer: Health Management Network Commercial	$1,292.00
Rate for Payer: Kaiser Permanente Commercial	$1,368.00
Rate for Payer: MDX Hawaii PPO	$1,474.40

XR Arthrogram Injection Elbow Right

Facility

$1,520.00

Service Code	HCPCS 73085 RT
Hospital Charge Code	1169958
Hospital Revenue Code	320
Min. Negotiated Rate	$69.25
Max. Negotiated Rate	$1,474.40
Rate for Payer: AlohaCare Medicaid	$760.00
Rate for Payer: AlohaCare Medicare	$760.00
Rate for Payer: Cash Price	$988.00
Rate for Payer: Cash Price	$988.00
Rate for Payer: Devoted Health Medicare	$836.00
Rate for Payer: Hawaii Medical Service Association ABD	$69.25
Rate for Payer: Hawaii Medical Service Association Medicare	$760.00
Rate for Payer: Hawaii Medical Service Association Non-ABD	$75.32
Rate for Payer: Hawaii Western Management Group Commercial	$1,444.00
Rate for Payer: Health Management Network Commercial	$1,292.00
Rate for Payer: Humana Medicare	$760.00
Rate for Payer: Kaiser Permanente Commercial	$1,368.00
Rate for Payer: Kaiser Permanente Medicaid	$775.20
Rate for Payer: Kaiser Permanente Medicare	$760.00
Rate for Payer: MDX Hawaii PPO	$1,474.40
Rate for Payer: Ohana Health Plan Medicaid	$760.00
Rate for Payer: Ohana Health Plan Medicare	$760.00
Rate for Payer: UnitedHealthcare Medicaid	$69.25
Rate for Payer: UnitedHealthcare Medicare	$760.00
Rate for Payer: University Health Alliance Commercial	$206.85

XR Arthrogram Injection Hip Left

Facility

$1,520.00

Service Code	HCPCS 73525 LT
Hospital Charge Code	1169962
Hospital Revenue Code	322
Min. Negotiated Rate	$69.25
Max. Negotiated Rate	$1,474.40
Rate for Payer: AlohaCare Medicaid	$760.00
Rate for Payer: AlohaCare Medicare	$760.00
Rate for Payer: Cash Price	$988.00
Rate for Payer: Cash Price	$988.00
Rate for Payer: Devoted Health Medicare	$836.00
Rate for Payer: Hawaii Medical Service Association ABD	$69.25
Rate for Payer: Hawaii Medical Service Association Medicare	$760.00
Rate for Payer: Hawaii Medical Service Association Non-ABD	$75.32
Rate for Payer: Hawaii Western Management Group Commercial	$1,444.00
Rate for Payer: Health Management Network Commercial	$1,292.00
Rate for Payer: Humana Medicare	$760.00
Rate for Payer: Kaiser Permanente Commercial	$1,368.00
Rate for Payer: Kaiser Permanente Medicaid	$775.20
Rate for Payer: Kaiser Permanente Medicare	$760.00
Rate for Payer: MDX Hawaii PPO	$1,474.40
Rate for Payer: Ohana Health Plan Medicaid	$760.00
Rate for Payer: Ohana Health Plan Medicare	$760.00
Rate for Payer: UnitedHealthcare Medicaid	$69.25
Rate for Payer: UnitedHealthcare Medicare	$760.00
Rate for Payer: University Health Alliance Commercial	$206.57

XR Arthrogram Injection Hip Left

Facility

$1,520.00

Service Code	HCPCS 73525 LT
Hospital Charge Code	1169962
Hospital Revenue Code	322
Min. Negotiated Rate	$1,292.00
Max. Negotiated Rate	$1,474.40
Rate for Payer: Cash Price	$988.00
Rate for Payer: Health Management Network Commercial	$1,292.00
Rate for Payer: Kaiser Permanente Commercial	$1,368.00
Rate for Payer: MDX Hawaii PPO	$1,474.40

XR Arthrogram Injection Hip Right

Facility

$1,520.00

Service Code	HCPCS 73525 RT
Hospital Charge Code	1169964
Hospital Revenue Code	322
Min. Negotiated Rate	$69.25
Max. Negotiated Rate	$1,474.40
Rate for Payer: AlohaCare Medicaid	$760.00
Rate for Payer: AlohaCare Medicare	$760.00
Rate for Payer: Cash Price	$988.00
Rate for Payer: Cash Price	$988.00
Rate for Payer: Devoted Health Medicare	$836.00
Rate for Payer: Hawaii Medical Service Association ABD	$69.25
Rate for Payer: Hawaii Medical Service Association Medicare	$760.00
Rate for Payer: Hawaii Medical Service Association Non-ABD	$75.32
Rate for Payer: Hawaii Western Management Group Commercial	$1,444.00
Rate for Payer: Health Management Network Commercial	$1,292.00
Rate for Payer: Humana Medicare	$760.00
Rate for Payer: Kaiser Permanente Commercial	$1,368.00
Rate for Payer: Kaiser Permanente Medicaid	$775.20
Rate for Payer: Kaiser Permanente Medicare	$760.00
Rate for Payer: MDX Hawaii PPO	$1,474.40
Rate for Payer: Ohana Health Plan Medicaid	$760.00
Rate for Payer: Ohana Health Plan Medicare	$760.00
Rate for Payer: UnitedHealthcare Medicaid	$69.25
Rate for Payer: UnitedHealthcare Medicare	$760.00
Rate for Payer: University Health Alliance Commercial	$206.57

XR Arthrogram Injection Hip Right

Facility

$1,520.00

Service Code	HCPCS 73525 RT
Hospital Charge Code	1169964
Hospital Revenue Code	322
Min. Negotiated Rate	$1,292.00
Max. Negotiated Rate	$1,474.40
Rate for Payer: Cash Price	$988.00
Rate for Payer: Health Management Network Commercial	$1,292.00
Rate for Payer: Kaiser Permanente Commercial	$1,368.00
Rate for Payer: MDX Hawaii PPO	$1,474.40

XR Arthrogram Injection Knee Left

Facility

$214.00

Service Code	HCPCS 27370
Hospital Charge Code	1169970
Hospital Revenue Code	361
Min. Negotiated Rate	$107.00
Max. Negotiated Rate	$2,837.00
Rate for Payer: AlohaCare Medicaid	$107.00
Rate for Payer: AlohaCare Medicare	$107.00
Rate for Payer: Cash Price	$139.10
Rate for Payer: Cash Price	$139.10
Rate for Payer: Devoted Health Medicare	$117.70
Rate for Payer: Hawaii Medical Service Association Medicare	$107.00
Rate for Payer: Health Management Network Commercial	$181.90
Rate for Payer: Humana Medicare	$107.00
Rate for Payer: Kaiser Permanente Commercial	$192.60
Rate for Payer: Kaiser Permanente Medicaid	$2,837.00
Rate for Payer: Kaiser Permanente Medicare	$107.00
Rate for Payer: MDX Hawaii PPO	$207.58
Rate for Payer: Ohana Health Plan Medicaid	$107.00
Rate for Payer: Ohana Health Plan Medicare	$107.00
Rate for Payer: UnitedHealthcare Medicare	$107.00
Rate for Payer: University Health Alliance Commercial	$119.84

XR Arthrogram Injection Knee Left

Facility

$214.00

Service Code	HCPCS 27370
Hospital Charge Code	1169970
Hospital Revenue Code	361
Min. Negotiated Rate	$181.90
Max. Negotiated Rate	$207.58
Rate for Payer: Cash Price	$139.10
Rate for Payer: Health Management Network Commercial	$181.90
Rate for Payer: Kaiser Permanente Commercial	$192.60
Rate for Payer: MDX Hawaii PPO	$207.58

XR Arthrogram Injection Knee Right

Facility

$214.00

Service Code	HCPCS 27648
Hospital Charge Code	1169972
Hospital Revenue Code	361
Min. Negotiated Rate	$39.92
Max. Negotiated Rate	$2,837.00
Rate for Payer: AlohaCare Medicaid	$107.00
Rate for Payer: AlohaCare Medicare	$107.00
Rate for Payer: Cash Price	$139.10
Rate for Payer: Cash Price	$139.10
Rate for Payer: Cash Price	$139.10
Rate for Payer: Devoted Health Medicare	$117.70
Rate for Payer: Hawaii Medical Service Association Medicare	$107.00
Rate for Payer: Health Management Network Commercial	$181.90
Rate for Payer: Humana Medicare	$107.00
Rate for Payer: Kaiser Permanente Commercial	$192.60
Rate for Payer: Kaiser Permanente Medicaid	$2,837.00
Rate for Payer: Kaiser Permanente Medicare	$107.00
Rate for Payer: MDX Hawaii PPO	$207.58
Rate for Payer: Ohana Health Plan Medicaid	$107.00
Rate for Payer: Ohana Health Plan Medicare	$107.00
Rate for Payer: UnitedHealthcare Medicaid	$39.92
Rate for Payer: UnitedHealthcare Medicare	$107.00
Rate for Payer: University Health Alliance Commercial	$119.84

XR Arthrogram Injection Knee Right

Facility

$214.00

Service Code	HCPCS 27648
Hospital Charge Code	1169972
Hospital Revenue Code	361
Min. Negotiated Rate	$181.90
Max. Negotiated Rate	$207.58
Rate for Payer: Cash Price	$139.10
Rate for Payer: Health Management Network Commercial	$181.90
Rate for Payer: Kaiser Permanente Commercial	$192.60
Rate for Payer: MDX Hawaii PPO	$207.58

XR Arthrogram Injection Shoulder Left

Facility

$351.00

Service Code	HCPCS 23350
Hospital Charge Code	1169984
Hospital Revenue Code	361
Min. Negotiated Rate	$40.41
Max. Negotiated Rate	$2,837.00
Rate for Payer: AlohaCare Medicaid	$175.50
Rate for Payer: AlohaCare Medicare	$175.50
Rate for Payer: Cash Price	$228.15
Rate for Payer: Cash Price	$228.15
Rate for Payer: Cash Price	$228.15
Rate for Payer: Devoted Health Medicare	$193.05
Rate for Payer: Hawaii Medical Service Association Medicare	$175.50
Rate for Payer: Health Management Network Commercial	$298.35
Rate for Payer: Humana Medicare	$175.50
Rate for Payer: Kaiser Permanente Commercial	$315.90
Rate for Payer: Kaiser Permanente Medicaid	$2,837.00
Rate for Payer: Kaiser Permanente Medicare	$175.50
Rate for Payer: MDX Hawaii PPO	$340.47
Rate for Payer: Ohana Health Plan Medicaid	$175.50
Rate for Payer: Ohana Health Plan Medicare	$175.50
Rate for Payer: UnitedHealthcare Medicaid	$40.41
Rate for Payer: UnitedHealthcare Medicare	$175.50
Rate for Payer: University Health Alliance Commercial	$196.56

XR Arthrogram Injection Shoulder Left

Facility

$351.00

Service Code	HCPCS 23350
Hospital Charge Code	1169984
Hospital Revenue Code	361
Min. Negotiated Rate	$298.35
Max. Negotiated Rate	$340.47
Rate for Payer: Cash Price	$228.15
Rate for Payer: Health Management Network Commercial	$298.35
Rate for Payer: Kaiser Permanente Commercial	$315.90
Rate for Payer: MDX Hawaii PPO	$340.47

XR Arthrogram Injection Shoulder Right

Facility

$1,898.00

Service Code	HCPCS 73040 RT
Hospital Charge Code	1169986
Hospital Revenue Code	322
Min. Negotiated Rate	$69.25
Max. Negotiated Rate	$1,841.06
Rate for Payer: AlohaCare Medicaid	$949.00
Rate for Payer: AlohaCare Medicare	$949.00
Rate for Payer: Cash Price	$1,233.70
Rate for Payer: Cash Price	$1,233.70
Rate for Payer: Devoted Health Medicare	$1,043.90
Rate for Payer: Hawaii Medical Service Association ABD	$69.25
Rate for Payer: Hawaii Medical Service Association Medicare	$949.00
Rate for Payer: Hawaii Medical Service Association Non-ABD	$75.32
Rate for Payer: Hawaii Western Management Group Commercial	$1,803.10
Rate for Payer: Health Management Network Commercial	$1,613.30
Rate for Payer: Humana Medicare	$949.00
Rate for Payer: Kaiser Permanente Commercial	$1,708.20
Rate for Payer: Kaiser Permanente Medicaid	$967.98
Rate for Payer: Kaiser Permanente Medicare	$949.00
Rate for Payer: MDX Hawaii PPO	$1,841.06
Rate for Payer: Ohana Health Plan Medicaid	$949.00
Rate for Payer: Ohana Health Plan Medicare	$949.00
Rate for Payer: UnitedHealthcare Medicaid	$69.25
Rate for Payer: UnitedHealthcare Medicare	$949.00
Rate for Payer: University Health Alliance Commercial	$222.87

XR Arthrogram Injection Shoulder Right

Facility

$1,898.00

Service Code	HCPCS 73040 RT
Hospital Charge Code	1169986
Hospital Revenue Code	322
Min. Negotiated Rate	$1,613.30
Max. Negotiated Rate	$1,841.06
Rate for Payer: Cash Price	$1,233.70
Rate for Payer: Health Management Network Commercial	$1,613.30
Rate for Payer: Kaiser Permanente Commercial	$1,708.20
Rate for Payer: MDX Hawaii PPO	$1,841.06

XR Arthrogram Injection Wrist Left

Facility

$214.00

Service Code	HCPCS 25246
Hospital Charge Code	1169996
Hospital Revenue Code	361
Min. Negotiated Rate	$181.90
Max. Negotiated Rate	$207.58
Rate for Payer: Cash Price	$139.10
Rate for Payer: Health Management Network Commercial	$181.90
Rate for Payer: Kaiser Permanente Commercial	$192.60
Rate for Payer: MDX Hawaii PPO	$207.58

Know your out-of-pocket cost for care.

All Charges