Samuel Mahelona Memorial Hospital

All Charges

Charge

Type

Setting

Price

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

CATHETER DRAINAGE (US)

Facility

$453.00

Service Code	HCPCS C1729
Hospital Charge Code	8890007
Hospital Revenue Code	272
Min. Negotiated Rate	$385.05
Max. Negotiated Rate	$439.41
Rate for Payer: Cash Price	$294.45
Rate for Payer: Health Management Network Commercial	$385.05
Rate for Payer: Kaiser Permanente Commercial	$407.70
Rate for Payer: MDX Hawaii PPO	$439.41

CATHETER DRAINAGE (US)

Facility

$453.00

Service Code	HCPCS C1729
Hospital Charge Code	8890007
Hospital Revenue Code	272
Min. Negotiated Rate	$226.50
Max. Negotiated Rate	$439.41
Rate for Payer: AlohaCare Medicaid	$226.50
Rate for Payer: AlohaCare Medicare	$226.50
Rate for Payer: Cash Price	$294.45
Rate for Payer: Devoted Health Medicare	$249.15
Rate for Payer: Hawaii Medical Service Association Medicare	$226.50
Rate for Payer: Hawaii Western Management Group Commercial	$430.35
Rate for Payer: Health Management Network Commercial	$385.05
Rate for Payer: Humana Medicare	$226.50
Rate for Payer: Kaiser Permanente Commercial	$407.70
Rate for Payer: Kaiser Permanente Medicaid	$231.03
Rate for Payer: Kaiser Permanente Medicare	$226.50
Rate for Payer: MDX Hawaii PPO	$439.41
Rate for Payer: Ohana Health Plan Medicaid	$226.50
Rate for Payer: Ohana Health Plan Medicare	$226.50
Rate for Payer: UnitedHealthcare Medicare	$226.50
Rate for Payer: University Health Alliance Commercial	$330.19

CATHETER DRAINAGE (XR/MAMMO)

Facility

$400.00

Service Code	HCPCS C1729
Hospital Charge Code	8890078
Hospital Revenue Code	272
Min. Negotiated Rate	$200.00
Max. Negotiated Rate	$388.00
Rate for Payer: AlohaCare Medicaid	$200.00
Rate for Payer: AlohaCare Medicare	$200.00
Rate for Payer: Cash Price	$260.00
Rate for Payer: Devoted Health Medicare	$220.00
Rate for Payer: Hawaii Medical Service Association Medicare	$200.00
Rate for Payer: Hawaii Western Management Group Commercial	$380.00
Rate for Payer: Health Management Network Commercial	$340.00
Rate for Payer: Humana Medicare	$200.00
Rate for Payer: Kaiser Permanente Commercial	$360.00
Rate for Payer: Kaiser Permanente Medicaid	$204.00
Rate for Payer: Kaiser Permanente Medicare	$200.00
Rate for Payer: MDX Hawaii PPO	$388.00
Rate for Payer: Ohana Health Plan Medicaid	$200.00
Rate for Payer: Ohana Health Plan Medicare	$200.00
Rate for Payer: UnitedHealthcare Medicare	$200.00
Rate for Payer: University Health Alliance Commercial	$291.56

CATHETER DRAINAGE (XR/MAMMO)

Facility

$400.00

Service Code	HCPCS C1729
Hospital Charge Code	8890078
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

CATHETER EXTERNAL MALE LARGE

Facility

$7.00

Service Code	HCPCS C1758
Hospital Charge Code	8266863
Hospital Revenue Code	270
Min. Negotiated Rate	$5.95
Max. Negotiated Rate	$6.79
Rate for Payer: Cash Price	$4.55
Rate for Payer: Health Management Network Commercial	$5.95
Rate for Payer: Kaiser Permanente Commercial	$6.30
Rate for Payer: MDX Hawaii PPO	$6.79

CATHETER EXTERNAL MALE LARGE

Facility

$7.00

Service Code	HCPCS C1758
Hospital Charge Code	8266863
Hospital Revenue Code	270
Min. Negotiated Rate	$3.50
Max. Negotiated Rate	$6.79
Rate for Payer: AlohaCare Medicaid	$3.50
Rate for Payer: AlohaCare Medicare	$3.50
Rate for Payer: Cash Price	$4.55
Rate for Payer: Devoted Health Medicare	$3.85
Rate for Payer: Hawaii Medical Service Association Medicare	$3.50
Rate for Payer: Hawaii Western Management Group Commercial	$6.65
Rate for Payer: Health Management Network Commercial	$5.95
Rate for Payer: Humana Medicare	$3.50
Rate for Payer: Kaiser Permanente Commercial	$6.30
Rate for Payer: Kaiser Permanente Medicaid	$3.57
Rate for Payer: Kaiser Permanente Medicare	$3.50
Rate for Payer: MDX Hawaii PPO	$6.79
Rate for Payer: Ohana Health Plan Medicaid	$3.50
Rate for Payer: Ohana Health Plan Medicare	$3.50
Rate for Payer: UnitedHealthcare Medicare	$3.50
Rate for Payer: University Health Alliance Commercial	$5.10

CATHETER FOLEY 10FR 3CC 2 WAY

Facility

$24.00

Service Code	HCPCS A4311
Hospital Charge Code	8266305
Hospital Revenue Code	272
Min. Negotiated Rate	$20.40
Max. Negotiated Rate	$23.28
Rate for Payer: Cash Price	$15.60
Rate for Payer: Health Management Network Commercial	$20.40
Rate for Payer: Kaiser Permanente Commercial	$21.60
Rate for Payer: MDX Hawaii PPO	$23.28

CATHETER FOLEY 10FR 3CC 2 WAY

Facility

$24.00

Service Code	HCPCS A4311
Hospital Charge Code	8266305
Hospital Revenue Code	272
Min. Negotiated Rate	$12.00
Max. Negotiated Rate	$23.28
Rate for Payer: AlohaCare Medicaid	$12.00
Rate for Payer: AlohaCare Medicare	$12.00
Rate for Payer: Cash Price	$15.60
Rate for Payer: Cash Price	$15.60
Rate for Payer: Devoted Health Medicare	$13.20
Rate for Payer: Hawaii Medical Service Association Medicare	$12.00
Rate for Payer: Hawaii Western Management Group Commercial	$22.80
Rate for Payer: Health Management Network Commercial	$20.40
Rate for Payer: Humana Medicare	$12.00
Rate for Payer: Kaiser Permanente Commercial	$21.60
Rate for Payer: Kaiser Permanente Medicaid	$12.24
Rate for Payer: Kaiser Permanente Medicare	$12.00
Rate for Payer: MDX Hawaii PPO	$23.28
Rate for Payer: Ohana Health Plan Medicaid	$12.00
Rate for Payer: Ohana Health Plan Medicare	$12.00
Rate for Payer: UnitedHealthcare Medicaid	$14.13
Rate for Payer: UnitedHealthcare Medicare	$12.00
Rate for Payer: University Health Alliance Commercial	$17.49

CATHETER FOLEY 12FR 5CC 2 WAY

Facility

$23.00

Service Code	HCPCS A4311
Hospital Charge Code	8266289
Hospital Revenue Code	272
Min. Negotiated Rate	$19.55
Max. Negotiated Rate	$22.31
Rate for Payer: Cash Price	$14.95
Rate for Payer: Health Management Network Commercial	$19.55
Rate for Payer: Kaiser Permanente Commercial	$20.70
Rate for Payer: MDX Hawaii PPO	$22.31

CATHETER FOLEY 12FR 5CC 2 WAY

Facility

$23.00

Service Code	HCPCS A4311
Hospital Charge Code	8266289
Hospital Revenue Code	272
Min. Negotiated Rate	$11.50
Max. Negotiated Rate	$22.31
Rate for Payer: AlohaCare Medicaid	$11.50
Rate for Payer: AlohaCare Medicare	$11.50
Rate for Payer: Cash Price	$14.95
Rate for Payer: Cash Price	$14.95
Rate for Payer: Devoted Health Medicare	$12.65
Rate for Payer: Hawaii Medical Service Association Medicare	$11.50
Rate for Payer: Hawaii Western Management Group Commercial	$21.85
Rate for Payer: Health Management Network Commercial	$19.55
Rate for Payer: Humana Medicare	$11.50
Rate for Payer: Kaiser Permanente Commercial	$20.70
Rate for Payer: Kaiser Permanente Medicaid	$11.73
Rate for Payer: Kaiser Permanente Medicare	$11.50
Rate for Payer: MDX Hawaii PPO	$22.31
Rate for Payer: Ohana Health Plan Medicaid	$11.50
Rate for Payer: Ohana Health Plan Medicare	$11.50
Rate for Payer: UnitedHealthcare Medicaid	$14.13
Rate for Payer: UnitedHealthcare Medicare	$11.50
Rate for Payer: University Health Alliance Commercial	$16.76

CATHETER FOLEY 14FR 5CC 2 WAY

Facility

$23.00

Service Code	HCPCS A4311
Hospital Charge Code	8266297
Hospital Revenue Code	272
Min. Negotiated Rate	$11.50
Max. Negotiated Rate	$22.31
Rate for Payer: AlohaCare Medicaid	$11.50
Rate for Payer: AlohaCare Medicare	$11.50
Rate for Payer: Cash Price	$14.95
Rate for Payer: Cash Price	$14.95
Rate for Payer: Devoted Health Medicare	$12.65
Rate for Payer: Hawaii Medical Service Association Medicare	$11.50
Rate for Payer: Hawaii Western Management Group Commercial	$21.85
Rate for Payer: Health Management Network Commercial	$19.55
Rate for Payer: Humana Medicare	$11.50
Rate for Payer: Kaiser Permanente Commercial	$20.70
Rate for Payer: Kaiser Permanente Medicaid	$11.73
Rate for Payer: Kaiser Permanente Medicare	$11.50
Rate for Payer: MDX Hawaii PPO	$22.31
Rate for Payer: Ohana Health Plan Medicaid	$11.50
Rate for Payer: Ohana Health Plan Medicare	$11.50
Rate for Payer: UnitedHealthcare Medicaid	$14.13
Rate for Payer: UnitedHealthcare Medicare	$11.50
Rate for Payer: University Health Alliance Commercial	$16.76

CATHETER FOLEY 14FR 5CC 2 WAY

Facility

$23.00

Service Code	HCPCS A4311
Hospital Charge Code	8266297
Hospital Revenue Code	272
Min. Negotiated Rate	$19.55
Max. Negotiated Rate	$22.31
Rate for Payer: Cash Price	$14.95
Rate for Payer: Health Management Network Commercial	$19.55
Rate for Payer: Kaiser Permanente Commercial	$20.70
Rate for Payer: MDX Hawaii PPO	$22.31

CATHETER FOLEY 16FR 30CC 2 WAY

Facility

$37.00

Service Code	HCPCS A4311
Hospital Charge Code	8266293
Hospital Revenue Code	272
Min. Negotiated Rate	$31.45
Max. Negotiated Rate	$35.89
Rate for Payer: Cash Price	$24.05
Rate for Payer: Health Management Network Commercial	$31.45
Rate for Payer: Kaiser Permanente Commercial	$33.30
Rate for Payer: MDX Hawaii PPO	$35.89

CATHETER FOLEY 16FR 30CC 2 WAY

Facility

$37.00

Service Code	HCPCS A4311
Hospital Charge Code	8266293
Hospital Revenue Code	272
Min. Negotiated Rate	$14.13
Max. Negotiated Rate	$35.89
Rate for Payer: AlohaCare Medicaid	$18.50
Rate for Payer: AlohaCare Medicare	$18.50
Rate for Payer: Cash Price	$24.05
Rate for Payer: Cash Price	$24.05
Rate for Payer: Devoted Health Medicare	$20.35
Rate for Payer: Hawaii Medical Service Association Medicare	$18.50
Rate for Payer: Hawaii Western Management Group Commercial	$35.15
Rate for Payer: Health Management Network Commercial	$31.45
Rate for Payer: Humana Medicare	$18.50
Rate for Payer: Kaiser Permanente Commercial	$33.30
Rate for Payer: Kaiser Permanente Medicaid	$18.87
Rate for Payer: Kaiser Permanente Medicare	$18.50
Rate for Payer: MDX Hawaii PPO	$35.89
Rate for Payer: Ohana Health Plan Medicaid	$18.50
Rate for Payer: Ohana Health Plan Medicare	$18.50
Rate for Payer: UnitedHealthcare Medicaid	$14.13
Rate for Payer: UnitedHealthcare Medicare	$18.50
Rate for Payer: University Health Alliance Commercial	$26.97

CATHETER FOLEY 16FR 5CC 2 WAY

Facility

$28.00

Service Code	HCPCS A4311
Hospital Charge Code	8266298
Hospital Revenue Code	272
Min. Negotiated Rate	$23.80
Max. Negotiated Rate	$27.16
Rate for Payer: Cash Price	$18.20
Rate for Payer: Health Management Network Commercial	$23.80
Rate for Payer: Kaiser Permanente Commercial	$25.20
Rate for Payer: MDX Hawaii PPO	$27.16

CATHETER FOLEY 16FR 5CC 2 WAY

Facility

$28.00

Service Code	HCPCS A4311
Hospital Charge Code	8266298
Hospital Revenue Code	272
Min. Negotiated Rate	$14.00
Max. Negotiated Rate	$27.16
Rate for Payer: AlohaCare Medicaid	$14.00
Rate for Payer: AlohaCare Medicare	$14.00
Rate for Payer: Cash Price	$18.20
Rate for Payer: Cash Price	$18.20
Rate for Payer: Devoted Health Medicare	$15.40
Rate for Payer: Hawaii Medical Service Association Medicare	$14.00
Rate for Payer: Hawaii Western Management Group Commercial	$26.60
Rate for Payer: Health Management Network Commercial	$23.80
Rate for Payer: Humana Medicare	$14.00
Rate for Payer: Kaiser Permanente Commercial	$25.20
Rate for Payer: Kaiser Permanente Medicaid	$14.28
Rate for Payer: Kaiser Permanente Medicare	$14.00
Rate for Payer: MDX Hawaii PPO	$27.16
Rate for Payer: Ohana Health Plan Medicaid	$14.00
Rate for Payer: Ohana Health Plan Medicare	$14.00
Rate for Payer: UnitedHealthcare Medicaid	$14.13
Rate for Payer: UnitedHealthcare Medicare	$14.00
Rate for Payer: University Health Alliance Commercial	$20.41

CATHETER FOLEY 18FR 30CC 2 WAY

Facility

$27.00

Service Code	HCPCS A4311
Hospital Charge Code	8266304
Hospital Revenue Code	272
Min. Negotiated Rate	$13.50
Max. Negotiated Rate	$26.19
Rate for Payer: AlohaCare Medicaid	$13.50
Rate for Payer: AlohaCare Medicare	$13.50
Rate for Payer: Cash Price	$17.55
Rate for Payer: Cash Price	$17.55
Rate for Payer: Devoted Health Medicare	$14.85
Rate for Payer: Hawaii Medical Service Association Medicare	$13.50
Rate for Payer: Hawaii Western Management Group Commercial	$25.65
Rate for Payer: Health Management Network Commercial	$22.95
Rate for Payer: Humana Medicare	$13.50
Rate for Payer: Kaiser Permanente Commercial	$24.30
Rate for Payer: Kaiser Permanente Medicaid	$13.77
Rate for Payer: Kaiser Permanente Medicare	$13.50
Rate for Payer: MDX Hawaii PPO	$26.19
Rate for Payer: Ohana Health Plan Medicaid	$13.50
Rate for Payer: Ohana Health Plan Medicare	$13.50
Rate for Payer: UnitedHealthcare Medicaid	$14.13
Rate for Payer: UnitedHealthcare Medicare	$13.50
Rate for Payer: University Health Alliance Commercial	$19.68

CATHETER FOLEY 18FR 30CC 2 WAY

Facility

$27.00

Service Code	HCPCS A4311
Hospital Charge Code	8266304
Hospital Revenue Code	272
Min. Negotiated Rate	$22.95
Max. Negotiated Rate	$26.19
Rate for Payer: Cash Price	$17.55
Rate for Payer: Health Management Network Commercial	$22.95
Rate for Payer: Kaiser Permanente Commercial	$24.30
Rate for Payer: MDX Hawaii PPO	$26.19

CATHETER FOLEY 18FR 5CC 2 WAY

Facility

$23.00

Service Code	HCPCS A4311
Hospital Charge Code	8266299
Hospital Revenue Code	272
Min. Negotiated Rate	$19.55
Max. Negotiated Rate	$22.31
Rate for Payer: Cash Price	$14.95
Rate for Payer: Health Management Network Commercial	$19.55
Rate for Payer: Kaiser Permanente Commercial	$20.70
Rate for Payer: MDX Hawaii PPO	$22.31

CATHETER FOLEY 18FR 5CC 2 WAY

Facility

$23.00

Service Code	HCPCS A4311
Hospital Charge Code	8266299
Hospital Revenue Code	272
Min. Negotiated Rate	$11.50
Max. Negotiated Rate	$22.31
Rate for Payer: AlohaCare Medicaid	$11.50
Rate for Payer: AlohaCare Medicare	$11.50
Rate for Payer: Cash Price	$14.95
Rate for Payer: Cash Price	$14.95
Rate for Payer: Devoted Health Medicare	$12.65
Rate for Payer: Hawaii Medical Service Association Medicare	$11.50
Rate for Payer: Hawaii Western Management Group Commercial	$21.85
Rate for Payer: Health Management Network Commercial	$19.55
Rate for Payer: Humana Medicare	$11.50
Rate for Payer: Kaiser Permanente Commercial	$20.70
Rate for Payer: Kaiser Permanente Medicaid	$11.73
Rate for Payer: Kaiser Permanente Medicare	$11.50
Rate for Payer: MDX Hawaii PPO	$22.31
Rate for Payer: Ohana Health Plan Medicaid	$11.50
Rate for Payer: Ohana Health Plan Medicare	$11.50
Rate for Payer: UnitedHealthcare Medicaid	$14.13
Rate for Payer: UnitedHealthcare Medicare	$11.50
Rate for Payer: University Health Alliance Commercial	$16.76

CATHETER FOLEY 20FR 30CC 2 WAY

Facility

$37.00

Service Code	HCPCS A4311
Hospital Charge Code	8266300
Hospital Revenue Code	272
Min. Negotiated Rate	$31.45
Max. Negotiated Rate	$35.89
Rate for Payer: Cash Price	$24.05
Rate for Payer: Health Management Network Commercial	$31.45
Rate for Payer: Kaiser Permanente Commercial	$33.30
Rate for Payer: MDX Hawaii PPO	$35.89

CATHETER FOLEY 20FR 30CC 2 WAY

Facility

$37.00

Service Code	HCPCS A4311
Hospital Charge Code	8266300
Hospital Revenue Code	272
Min. Negotiated Rate	$14.13
Max. Negotiated Rate	$35.89
Rate for Payer: AlohaCare Medicaid	$18.50
Rate for Payer: AlohaCare Medicare	$18.50
Rate for Payer: Cash Price	$24.05
Rate for Payer: Cash Price	$24.05
Rate for Payer: Devoted Health Medicare	$20.35
Rate for Payer: Hawaii Medical Service Association Medicare	$18.50
Rate for Payer: Hawaii Western Management Group Commercial	$35.15
Rate for Payer: Health Management Network Commercial	$31.45
Rate for Payer: Humana Medicare	$18.50
Rate for Payer: Kaiser Permanente Commercial	$33.30
Rate for Payer: Kaiser Permanente Medicaid	$18.87
Rate for Payer: Kaiser Permanente Medicare	$18.50
Rate for Payer: MDX Hawaii PPO	$35.89
Rate for Payer: Ohana Health Plan Medicaid	$18.50
Rate for Payer: Ohana Health Plan Medicare	$18.50
Rate for Payer: UnitedHealthcare Medicaid	$14.13
Rate for Payer: UnitedHealthcare Medicare	$18.50
Rate for Payer: University Health Alliance Commercial	$26.97

CATHETER FOLEY 20FR 30CC 3 WAY SILICONE

Facility

$82.00

Service Code	HCPCS A4313
Hospital Charge Code	8266955
Hospital Revenue Code	272
Min. Negotiated Rate	$17.05
Max. Negotiated Rate	$79.54
Rate for Payer: AlohaCare Medicaid	$41.00
Rate for Payer: AlohaCare Medicare	$41.00
Rate for Payer: Cash Price	$53.30
Rate for Payer: Cash Price	$53.30
Rate for Payer: Devoted Health Medicare	$45.10
Rate for Payer: Hawaii Medical Service Association Medicare	$41.00
Rate for Payer: Hawaii Western Management Group Commercial	$77.90
Rate for Payer: Health Management Network Commercial	$69.70
Rate for Payer: Humana Medicare	$41.00
Rate for Payer: Kaiser Permanente Commercial	$73.80
Rate for Payer: Kaiser Permanente Medicaid	$41.82
Rate for Payer: Kaiser Permanente Medicare	$41.00
Rate for Payer: MDX Hawaii PPO	$79.54
Rate for Payer: Ohana Health Plan Medicaid	$41.00
Rate for Payer: Ohana Health Plan Medicare	$41.00
Rate for Payer: UnitedHealthcare Medicaid	$17.05
Rate for Payer: UnitedHealthcare Medicare	$41.00
Rate for Payer: University Health Alliance Commercial	$59.77

CATHETER FOLEY 20FR 30CC 3 WAY SILICONE

Facility

$82.00

Service Code	HCPCS A4313
Hospital Charge Code	8266955
Hospital Revenue Code	272
Min. Negotiated Rate	$69.70
Max. Negotiated Rate	$79.54
Rate for Payer: Cash Price	$53.30
Rate for Payer: Health Management Network Commercial	$69.70
Rate for Payer: Kaiser Permanente Commercial	$73.80
Rate for Payer: MDX Hawaii PPO	$79.54

Know your out-of-pocket cost for care.

All Charges