Samuel Mahelona Memorial Hospital

All Charges

Charge

Type

Setting

Price

CAST SCOTCHCAST 2 IN

Facility

$15.00

Hospital Charge Code	8266611
Hospital Revenue Code	270
Min. Negotiated Rate	$12.75
Max. Negotiated Rate	$14.55
Rate for Payer: Cash Price	$9.75
Rate for Payer: Health Management Network Commercial	$12.75
Rate for Payer: Kaiser Permanente Commercial	$13.50
Rate for Payer: MDX Hawaii PPO	$14.55

CAST SCOTCHCAST 2 IN

Facility

$15.00

Hospital Charge Code	8266611
Hospital Revenue Code	270
Min. Negotiated Rate	$7.50
Max. Negotiated Rate	$14.55
Rate for Payer: AlohaCare Medicaid	$7.50
Rate for Payer: AlohaCare Medicare	$7.50
Rate for Payer: Cash Price	$9.75
Rate for Payer: Devoted Health Medicare	$8.25
Rate for Payer: Hawaii Medical Service Association Medicare	$7.50
Rate for Payer: Hawaii Western Management Group Commercial	$14.25
Rate for Payer: Health Management Network Commercial	$12.75
Rate for Payer: Humana Medicare	$7.50
Rate for Payer: Kaiser Permanente Commercial	$13.50
Rate for Payer: Kaiser Permanente Medicaid	$7.65
Rate for Payer: Kaiser Permanente Medicare	$7.50
Rate for Payer: MDX Hawaii PPO	$14.55
Rate for Payer: Ohana Health Plan Medicaid	$7.50
Rate for Payer: Ohana Health Plan Medicare	$7.50
Rate for Payer: UnitedHealthcare Medicare	$7.50
Rate for Payer: University Health Alliance Commercial	$10.93

CAST SCOTCHCAST 3 IN

Facility

$17.00

Hospital Charge Code	8266612
Hospital Revenue Code	270
Min. Negotiated Rate	$14.45
Max. Negotiated Rate	$16.49
Rate for Payer: Cash Price	$11.05
Rate for Payer: Health Management Network Commercial	$14.45
Rate for Payer: Kaiser Permanente Commercial	$15.30
Rate for Payer: MDX Hawaii PPO	$16.49

CAST SCOTCHCAST 3 IN

Facility

$17.00

Hospital Charge Code	8266612
Hospital Revenue Code	270
Min. Negotiated Rate	$8.50
Max. Negotiated Rate	$16.49
Rate for Payer: AlohaCare Medicaid	$8.50
Rate for Payer: AlohaCare Medicare	$8.50
Rate for Payer: Cash Price	$11.05
Rate for Payer: Devoted Health Medicare	$9.35
Rate for Payer: Hawaii Medical Service Association Medicare	$8.50
Rate for Payer: Hawaii Western Management Group Commercial	$16.15
Rate for Payer: Health Management Network Commercial	$14.45
Rate for Payer: Humana Medicare	$8.50
Rate for Payer: Kaiser Permanente Commercial	$15.30
Rate for Payer: Kaiser Permanente Medicaid	$8.67
Rate for Payer: Kaiser Permanente Medicare	$8.50
Rate for Payer: MDX Hawaii PPO	$16.49
Rate for Payer: Ohana Health Plan Medicaid	$8.50
Rate for Payer: Ohana Health Plan Medicare	$8.50
Rate for Payer: UnitedHealthcare Medicare	$8.50
Rate for Payer: University Health Alliance Commercial	$12.39

CAST SCOTCHCAST 4 IN

Facility

$22.00

Hospital Charge Code	8266613
Hospital Revenue Code	270
Min. Negotiated Rate	$18.70
Max. Negotiated Rate	$21.34
Rate for Payer: Cash Price	$14.30
Rate for Payer: Health Management Network Commercial	$18.70
Rate for Payer: Kaiser Permanente Commercial	$19.80
Rate for Payer: MDX Hawaii PPO	$21.34

CAST SCOTCHCAST 4 IN

Facility

$22.00

Hospital Charge Code	8266613
Hospital Revenue Code	270
Min. Negotiated Rate	$11.00
Max. Negotiated Rate	$21.34
Rate for Payer: AlohaCare Medicaid	$11.00
Rate for Payer: AlohaCare Medicare	$11.00
Rate for Payer: Cash Price	$14.30
Rate for Payer: Devoted Health Medicare	$12.10
Rate for Payer: Hawaii Medical Service Association Medicare	$11.00
Rate for Payer: Hawaii Western Management Group Commercial	$20.90
Rate for Payer: Health Management Network Commercial	$18.70
Rate for Payer: Humana Medicare	$11.00
Rate for Payer: Kaiser Permanente Commercial	$19.80
Rate for Payer: Kaiser Permanente Medicaid	$11.22
Rate for Payer: Kaiser Permanente Medicare	$11.00
Rate for Payer: MDX Hawaii PPO	$21.34
Rate for Payer: Ohana Health Plan Medicaid	$11.00
Rate for Payer: Ohana Health Plan Medicare	$11.00
Rate for Payer: UnitedHealthcare Medicare	$11.00
Rate for Payer: University Health Alliance Commercial	$16.04

CAST SCOTCHCAST 5 IN

Facility

$93.00

Hospital Charge Code	8266736
Hospital Revenue Code	270
Min. Negotiated Rate	$79.05
Max. Negotiated Rate	$90.21
Rate for Payer: Cash Price	$60.45
Rate for Payer: Health Management Network Commercial	$79.05
Rate for Payer: Kaiser Permanente Commercial	$83.70
Rate for Payer: MDX Hawaii PPO	$90.21

CAST SCOTCHCAST 5 IN

Facility

$93.00

Hospital Charge Code	8266736
Hospital Revenue Code	270
Min. Negotiated Rate	$46.50
Max. Negotiated Rate	$90.21
Rate for Payer: AlohaCare Medicaid	$46.50
Rate for Payer: AlohaCare Medicare	$46.50
Rate for Payer: Cash Price	$60.45
Rate for Payer: Devoted Health Medicare	$51.15
Rate for Payer: Hawaii Medical Service Association Medicare	$46.50
Rate for Payer: Hawaii Western Management Group Commercial	$88.35
Rate for Payer: Health Management Network Commercial	$79.05
Rate for Payer: Humana Medicare	$46.50
Rate for Payer: Kaiser Permanente Commercial	$83.70
Rate for Payer: Kaiser Permanente Medicaid	$47.43
Rate for Payer: Kaiser Permanente Medicare	$46.50
Rate for Payer: MDX Hawaii PPO	$90.21
Rate for Payer: Ohana Health Plan Medicaid	$46.50
Rate for Payer: Ohana Health Plan Medicare	$46.50
Rate for Payer: UnitedHealthcare Medicare	$46.50
Rate for Payer: University Health Alliance Commercial	$67.79

Catecholamines Urine 24 Hour FSI

Facility

$287.00

Service Code	HCPCS 82384
Hospital Charge Code	8117874
Hospital Revenue Code	301
Min. Negotiated Rate	$243.95
Max. Negotiated Rate	$278.39
Rate for Payer: Cash Price	$186.55
Rate for Payer: Health Management Network Commercial	$243.95
Rate for Payer: Kaiser Permanente Commercial	$258.30
Rate for Payer: MDX Hawaii PPO	$278.39

Catecholamines Urine 24 Hour FSI

Facility

$287.00

Service Code	HCPCS 82384
Hospital Charge Code	8117874
Hospital Revenue Code	301
Min. Negotiated Rate	$25.25
Max. Negotiated Rate	$278.39
Rate for Payer: AlohaCare Medicaid	$143.50
Rate for Payer: AlohaCare Medicare	$143.50
Rate for Payer: Cash Price	$186.55
Rate for Payer: Cash Price	$186.55
Rate for Payer: Devoted Health Medicare	$157.85
Rate for Payer: Hawaii Medical Service Association ABD	$34.90
Rate for Payer: Hawaii Medical Service Association Commercial	$31.56
Rate for Payer: Hawaii Medical Service Association Medicare	$143.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$36.65
Rate for Payer: Hawaii Western Management Group Commercial	$25.25
Rate for Payer: Health Management Network Commercial	$243.95
Rate for Payer: Humana Medicare	$143.50
Rate for Payer: Kaiser Permanente Commercial	$258.30
Rate for Payer: Kaiser Permanente Medicaid	$146.37
Rate for Payer: Kaiser Permanente Medicare	$143.50
Rate for Payer: MDX Hawaii PPO	$278.39
Rate for Payer: Ohana Health Plan Medicaid	$143.50
Rate for Payer: Ohana Health Plan Medicare	$143.50
Rate for Payer: UnitedHealthcare Medicaid	$34.90
Rate for Payer: UnitedHealthcare Medicare	$143.50
Rate for Payer: University Health Alliance Commercial	$65.27

Catherization for Urine Sample Charge

Facility

$46.00

Service Code	HCPCS P9612
Hospital Charge Code	8422801
Hospital Revenue Code	300
Min. Negotiated Rate	$39.10
Max. Negotiated Rate	$44.62
Rate for Payer: Cash Price	$29.90
Rate for Payer: Health Management Network Commercial	$39.10
Rate for Payer: Kaiser Permanente Commercial	$41.40
Rate for Payer: MDX Hawaii PPO	$44.62

Catherization for Urine Sample Charge

Facility

$46.00

Service Code	HCPCS P9612
Hospital Charge Code	8422801
Hospital Revenue Code	300
Min. Negotiated Rate	$3.00
Max. Negotiated Rate	$44.62
Rate for Payer: AlohaCare Medicaid	$23.00
Rate for Payer: AlohaCare Medicare	$23.00
Rate for Payer: Cash Price	$29.90
Rate for Payer: Cash Price	$29.90
Rate for Payer: Devoted Health Medicare	$25.30
Rate for Payer: Hawaii Medical Service Association ABD	$3.00
Rate for Payer: Hawaii Medical Service Association Commercial	$11.68
Rate for Payer: Hawaii Medical Service Association Medicare	$23.00
Rate for Payer: Hawaii Western Management Group Commercial	$43.70
Rate for Payer: Health Management Network Commercial	$39.10
Rate for Payer: Humana Medicare	$23.00
Rate for Payer: Kaiser Permanente Commercial	$41.40
Rate for Payer: Kaiser Permanente Medicaid	$23.46
Rate for Payer: Kaiser Permanente Medicare	$23.00
Rate for Payer: MDX Hawaii PPO	$44.62
Rate for Payer: Ohana Health Plan Medicaid	$23.00
Rate for Payer: Ohana Health Plan Medicare	$23.00
Rate for Payer: UnitedHealthcare Medicaid	$3.00
Rate for Payer: UnitedHealthcare Medicare	$23.00
Rate for Payer: University Health Alliance Commercial	$25.76

Catherization for Urine Sample Charge [HHSC]

Facility

$46.00

Service Code	HCPCS P9612
Hospital Charge Code	13357626
Hospital Revenue Code	380
Min. Negotiated Rate	$3.00
Max. Negotiated Rate	$44.62
Rate for Payer: AlohaCare Medicaid	$23.00
Rate for Payer: AlohaCare Medicare	$23.00
Rate for Payer: Cash Price	$29.90
Rate for Payer: Cash Price	$29.90
Rate for Payer: Devoted Health Medicare	$25.30
Rate for Payer: Hawaii Medical Service Association ABD	$3.00
Rate for Payer: Hawaii Medical Service Association Commercial	$11.68
Rate for Payer: Hawaii Medical Service Association Medicare	$23.00
Rate for Payer: Hawaii Western Management Group Commercial	$43.70
Rate for Payer: Health Management Network Commercial	$39.10
Rate for Payer: Humana Medicare	$23.00
Rate for Payer: Kaiser Permanente Commercial	$41.40
Rate for Payer: Kaiser Permanente Medicaid	$23.46
Rate for Payer: Kaiser Permanente Medicare	$23.00
Rate for Payer: MDX Hawaii PPO	$44.62
Rate for Payer: Ohana Health Plan Medicaid	$23.00
Rate for Payer: Ohana Health Plan Medicare	$23.00
Rate for Payer: UnitedHealthcare Medicaid	$3.00
Rate for Payer: UnitedHealthcare Medicare	$23.00
Rate for Payer: University Health Alliance Commercial	$25.76

Catherization for Urine Sample Charge [HHSC]

Facility

$46.00

Service Code	HCPCS P9612
Hospital Charge Code	13357626
Hospital Revenue Code	380
Min. Negotiated Rate	$39.10
Max. Negotiated Rate	$44.62
Rate for Payer: Cash Price	$29.90
Rate for Payer: Health Management Network Commercial	$39.10
Rate for Payer: Kaiser Permanente Commercial	$41.40
Rate for Payer: MDX Hawaii PPO	$44.62

CATHERIZATION TRAY UMBILICAL

Facility

$250.00

Hospital Charge Code	8274483
Hospital Revenue Code	272
Min. Negotiated Rate	$125.00
Max. Negotiated Rate	$242.50
Rate for Payer: AlohaCare Medicaid	$125.00
Rate for Payer: AlohaCare Medicare	$125.00
Rate for Payer: Cash Price	$162.50
Rate for Payer: Devoted Health Medicare	$137.50
Rate for Payer: Hawaii Medical Service Association Medicare	$125.00
Rate for Payer: Hawaii Western Management Group Commercial	$237.50
Rate for Payer: Health Management Network Commercial	$212.50
Rate for Payer: Humana Medicare	$125.00
Rate for Payer: Kaiser Permanente Commercial	$225.00
Rate for Payer: Kaiser Permanente Medicaid	$127.50
Rate for Payer: Kaiser Permanente Medicare	$125.00
Rate for Payer: MDX Hawaii PPO	$242.50
Rate for Payer: Ohana Health Plan Medicaid	$125.00
Rate for Payer: Ohana Health Plan Medicare	$125.00
Rate for Payer: UnitedHealthcare Medicare	$125.00
Rate for Payer: University Health Alliance Commercial	$182.22

CATHERIZATION TRAY UMBILICAL

Facility

$250.00

Hospital Charge Code	8274483
Hospital Revenue Code	272
Min. Negotiated Rate	$212.50
Max. Negotiated Rate	$242.50
Rate for Payer: Cash Price	$162.50
Rate for Payer: Health Management Network Commercial	$212.50
Rate for Payer: Kaiser Permanente Commercial	$225.00
Rate for Payer: MDX Hawaii PPO	$242.50

CATHETER 3.5F SINGLE LUMEN UMBILICAL

Facility

$91.00

Service Code	HCPCS C1887
Hospital Charge Code	8891287
Hospital Revenue Code	272
Min. Negotiated Rate	$45.50
Max. Negotiated Rate	$88.27
Rate for Payer: AlohaCare Medicaid	$45.50
Rate for Payer: AlohaCare Medicare	$45.50
Rate for Payer: Cash Price	$59.15
Rate for Payer: Devoted Health Medicare	$50.05
Rate for Payer: Hawaii Medical Service Association Medicare	$45.50
Rate for Payer: Hawaii Western Management Group Commercial	$86.45
Rate for Payer: Health Management Network Commercial	$77.35
Rate for Payer: Humana Medicare	$45.50
Rate for Payer: Kaiser Permanente Commercial	$81.90
Rate for Payer: Kaiser Permanente Medicaid	$46.41
Rate for Payer: Kaiser Permanente Medicare	$45.50
Rate for Payer: MDX Hawaii PPO	$88.27
Rate for Payer: Ohana Health Plan Medicaid	$45.50
Rate for Payer: Ohana Health Plan Medicare	$45.50
Rate for Payer: UnitedHealthcare Medicare	$45.50
Rate for Payer: University Health Alliance Commercial	$66.33

CATHETER 3.5F SINGLE LUMEN UMBILICAL

Facility

$91.00

Service Code	HCPCS C1887
Hospital Charge Code	8891287
Hospital Revenue Code	272
Min. Negotiated Rate	$77.35
Max. Negotiated Rate	$88.27
Rate for Payer: Cash Price	$59.15
Rate for Payer: Health Management Network Commercial	$77.35
Rate for Payer: Kaiser Permanente Commercial	$81.90
Rate for Payer: MDX Hawaii PPO	$88.27

CATHETER ANGIOCATH 14G X 3.25 IN PERIPHERAL VENOUS

Facility

$131.00

Service Code	HCPCS C1751
Hospital Charge Code	9526197
Hospital Revenue Code	272
Min. Negotiated Rate	$111.35
Max. Negotiated Rate	$127.07
Rate for Payer: Cash Price	$85.15
Rate for Payer: Health Management Network Commercial	$111.35
Rate for Payer: Kaiser Permanente Commercial	$117.90
Rate for Payer: MDX Hawaii PPO	$127.07

CATHETER ANGIOCATH 14G X 3.25 IN PERIPHERAL VENOUS

Facility

$131.00

Service Code	HCPCS C1751
Hospital Charge Code	9526197
Hospital Revenue Code	272
Min. Negotiated Rate	$65.50
Max. Negotiated Rate	$127.07
Rate for Payer: AlohaCare Medicaid	$65.50
Rate for Payer: AlohaCare Medicare	$65.50
Rate for Payer: Cash Price	$85.15
Rate for Payer: Devoted Health Medicare	$72.05
Rate for Payer: Hawaii Medical Service Association Medicare	$65.50
Rate for Payer: Hawaii Western Management Group Commercial	$124.45
Rate for Payer: Health Management Network Commercial	$111.35
Rate for Payer: Humana Medicare	$65.50
Rate for Payer: Kaiser Permanente Commercial	$117.90
Rate for Payer: Kaiser Permanente Medicaid	$66.81
Rate for Payer: Kaiser Permanente Medicare	$65.50
Rate for Payer: MDX Hawaii PPO	$127.07
Rate for Payer: Ohana Health Plan Medicaid	$65.50
Rate for Payer: Ohana Health Plan Medicare	$65.50
Rate for Payer: UnitedHealthcare Medicare	$65.50
Rate for Payer: University Health Alliance Commercial	$95.49

CATHETER ANGIOCATH 16G X 3.25 IN PERIPHERAL VENOUS

Facility

$177.00

Service Code	HCPCS C1751
Hospital Charge Code	9526198
Hospital Revenue Code	272
Min. Negotiated Rate	$88.50
Max. Negotiated Rate	$171.69
Rate for Payer: AlohaCare Medicaid	$88.50
Rate for Payer: AlohaCare Medicare	$88.50
Rate for Payer: Cash Price	$115.05
Rate for Payer: Devoted Health Medicare	$97.35
Rate for Payer: Hawaii Medical Service Association Medicare	$88.50
Rate for Payer: Hawaii Western Management Group Commercial	$168.15
Rate for Payer: Health Management Network Commercial	$150.45
Rate for Payer: Humana Medicare	$88.50
Rate for Payer: Kaiser Permanente Commercial	$159.30
Rate for Payer: Kaiser Permanente Medicaid	$90.27
Rate for Payer: Kaiser Permanente Medicare	$88.50
Rate for Payer: MDX Hawaii PPO	$171.69
Rate for Payer: Ohana Health Plan Medicaid	$88.50
Rate for Payer: Ohana Health Plan Medicare	$88.50
Rate for Payer: UnitedHealthcare Medicare	$88.50
Rate for Payer: University Health Alliance Commercial	$129.02

CATHETER ANGIOCATH 16G X 3.25 IN PERIPHERAL VENOUS

Facility

$177.00

Service Code	HCPCS C1751
Hospital Charge Code	9526198
Hospital Revenue Code	272
Min. Negotiated Rate	$150.45
Max. Negotiated Rate	$171.69
Rate for Payer: Cash Price	$115.05
Rate for Payer: Health Management Network Commercial	$150.45
Rate for Payer: Kaiser Permanente Commercial	$159.30
Rate for Payer: MDX Hawaii PPO	$171.69

CATHETER ANGIOCATH 18G X 1.88 IN IV STRAIGHT HUB

Facility

$83.00

Service Code	HCPCS C1751
Hospital Charge Code	9526199
Hospital Revenue Code	272
Min. Negotiated Rate	$41.50
Max. Negotiated Rate	$80.51
Rate for Payer: AlohaCare Medicaid	$41.50
Rate for Payer: AlohaCare Medicare	$41.50
Rate for Payer: Cash Price	$53.95
Rate for Payer: Devoted Health Medicare	$45.65
Rate for Payer: Hawaii Medical Service Association Medicare	$41.50
Rate for Payer: Hawaii Western Management Group Commercial	$78.85
Rate for Payer: Health Management Network Commercial	$70.55
Rate for Payer: Humana Medicare	$41.50
Rate for Payer: Kaiser Permanente Commercial	$74.70
Rate for Payer: Kaiser Permanente Medicaid	$42.33
Rate for Payer: Kaiser Permanente Medicare	$41.50
Rate for Payer: MDX Hawaii PPO	$80.51
Rate for Payer: Ohana Health Plan Medicaid	$41.50
Rate for Payer: Ohana Health Plan Medicare	$41.50
Rate for Payer: UnitedHealthcare Medicare	$41.50
Rate for Payer: University Health Alliance Commercial	$60.50

CATHETER ANGIOCATH 18G X 1.88 IN IV STRAIGHT HUB

Facility

$83.00

Service Code	HCPCS C1751
Hospital Charge Code	9526199
Hospital Revenue Code	272
Min. Negotiated Rate	$70.55
Max. Negotiated Rate	$80.51
Rate for Payer: Cash Price	$53.95
Rate for Payer: Health Management Network Commercial	$70.55
Rate for Payer: Kaiser Permanente Commercial	$74.70
Rate for Payer: MDX Hawaii PPO	$80.51

CATHETER DRAINAGE (CT)

Facility

$400.00

Service Code	HCPCS C1729
Hospital Charge Code	8890008
Hospital Revenue Code	272
Min. Negotiated Rate	$340.00
Max. Negotiated Rate	$388.00
Rate for Payer: Cash Price	$260.00
Rate for Payer: Health Management Network Commercial	$340.00
Rate for Payer: Kaiser Permanente Commercial	$360.00
Rate for Payer: MDX Hawaii PPO	$388.00

Know your out-of-pocket cost for care.

All Charges