Samuel Mahelona Memorial Hospital

All Charges

Charge

Type

Setting

Price

CATHETER FOLEY 20FR 5CC 2-WAY SILICONE LATEX FREE

Facility

$23.00

Service Code	HCPCS A4312
Hospital Charge Code	8266928
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	$15.02
Rate for Payer: UnitedHealthcare Medicare	$11.50
Rate for Payer: University Health Alliance Commercial	$16.76

CATHETER FOLEY 20FR 5CC 2-WAY SILICONE LATEX FREE

Facility

$23.00

Service Code	HCPCS A4312
Hospital Charge Code	8266928
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 22FR 30CC 2 WAY

Facility

$44.00

Service Code	HCPCS A4311
Hospital Charge Code	8266294
Hospital Revenue Code	272
Min. Negotiated Rate	$37.40
Max. Negotiated Rate	$42.68
Rate for Payer: Cash Price	$28.60
Rate for Payer: Health Management Network Commercial	$37.40
Rate for Payer: Kaiser Permanente Commercial	$39.60
Rate for Payer: MDX Hawaii PPO	$42.68

CATHETER FOLEY 22FR 30CC 2 WAY

Facility

$44.00

Service Code	HCPCS A4311
Hospital Charge Code	8266294
Hospital Revenue Code	272
Min. Negotiated Rate	$14.13
Max. Negotiated Rate	$42.68
Rate for Payer: AlohaCare Medicaid	$22.00
Rate for Payer: AlohaCare Medicare	$22.00
Rate for Payer: Cash Price	$28.60
Rate for Payer: Cash Price	$28.60
Rate for Payer: Devoted Health Medicare	$24.20
Rate for Payer: Hawaii Medical Service Association Medicare	$22.00
Rate for Payer: Hawaii Western Management Group Commercial	$41.80
Rate for Payer: Health Management Network Commercial	$37.40
Rate for Payer: Humana Medicare	$22.00
Rate for Payer: Kaiser Permanente Commercial	$39.60
Rate for Payer: Kaiser Permanente Medicaid	$22.44
Rate for Payer: Kaiser Permanente Medicare	$22.00
Rate for Payer: MDX Hawaii PPO	$42.68
Rate for Payer: Ohana Health Plan Medicaid	$22.00
Rate for Payer: Ohana Health Plan Medicare	$22.00
Rate for Payer: UnitedHealthcare Medicaid	$14.13
Rate for Payer: UnitedHealthcare Medicare	$22.00
Rate for Payer: University Health Alliance Commercial	$32.07

CATHETER FOLEY 22FR 5CC 2 WAY

Facility

$18.00

Service Code	HCPCS A4311
Hospital Charge Code	8266916
Hospital Revenue Code	272
Min. Negotiated Rate	$15.30
Max. Negotiated Rate	$17.46
Rate for Payer: Cash Price	$11.70
Rate for Payer: Health Management Network Commercial	$15.30
Rate for Payer: Kaiser Permanente Commercial	$16.20
Rate for Payer: MDX Hawaii PPO	$17.46

CATHETER FOLEY 22FR 5CC 2 WAY

Facility

$18.00

Service Code	HCPCS A4311
Hospital Charge Code	8266916
Hospital Revenue Code	272
Min. Negotiated Rate	$9.00
Max. Negotiated Rate	$17.46
Rate for Payer: AlohaCare Medicaid	$9.00
Rate for Payer: AlohaCare Medicare	$9.00
Rate for Payer: Cash Price	$11.70
Rate for Payer: Cash Price	$11.70
Rate for Payer: Devoted Health Medicare	$9.90
Rate for Payer: Hawaii Medical Service Association Medicare	$9.00
Rate for Payer: Hawaii Western Management Group Commercial	$17.10
Rate for Payer: Health Management Network Commercial	$15.30
Rate for Payer: Humana Medicare	$9.00
Rate for Payer: Kaiser Permanente Commercial	$16.20
Rate for Payer: Kaiser Permanente Medicaid	$9.18
Rate for Payer: Kaiser Permanente Medicare	$9.00
Rate for Payer: MDX Hawaii PPO	$17.46
Rate for Payer: Ohana Health Plan Medicaid	$9.00
Rate for Payer: Ohana Health Plan Medicare	$9.00
Rate for Payer: UnitedHealthcare Medicaid	$14.13
Rate for Payer: UnitedHealthcare Medicare	$9.00
Rate for Payer: University Health Alliance Commercial	$13.12

CATHETER FOLEY 24FR 30CC 2 WAY

Facility

$33.00

Service Code	HCPCS A4311
Hospital Charge Code	8266291
Hospital Revenue Code	272
Min. Negotiated Rate	$28.05
Max. Negotiated Rate	$32.01
Rate for Payer: Cash Price	$21.45
Rate for Payer: Health Management Network Commercial	$28.05
Rate for Payer: Kaiser Permanente Commercial	$29.70
Rate for Payer: MDX Hawaii PPO	$32.01

CATHETER FOLEY 24FR 30CC 2 WAY

Facility

$33.00

Service Code	HCPCS A4311
Hospital Charge Code	8266291
Hospital Revenue Code	272
Min. Negotiated Rate	$14.13
Max. Negotiated Rate	$32.01
Rate for Payer: AlohaCare Medicaid	$16.50
Rate for Payer: AlohaCare Medicare	$16.50
Rate for Payer: Cash Price	$21.45
Rate for Payer: Cash Price	$21.45
Rate for Payer: Devoted Health Medicare	$18.15
Rate for Payer: Hawaii Medical Service Association Medicare	$16.50
Rate for Payer: Hawaii Western Management Group Commercial	$31.35
Rate for Payer: Health Management Network Commercial	$28.05
Rate for Payer: Humana Medicare	$16.50
Rate for Payer: Kaiser Permanente Commercial	$29.70
Rate for Payer: Kaiser Permanente Medicaid	$16.83
Rate for Payer: Kaiser Permanente Medicare	$16.50
Rate for Payer: MDX Hawaii PPO	$32.01
Rate for Payer: Ohana Health Plan Medicaid	$16.50
Rate for Payer: Ohana Health Plan Medicare	$16.50
Rate for Payer: UnitedHealthcare Medicaid	$14.13
Rate for Payer: UnitedHealthcare Medicare	$16.50
Rate for Payer: University Health Alliance Commercial	$24.05

CATHETER FOLEY 24FR 30CC 3 WAY

Facility

$86.00

Service Code	HCPCS A4313
Hospital Charge Code	8266956
Hospital Revenue Code	272
Min. Negotiated Rate	$17.05
Max. Negotiated Rate	$83.42
Rate for Payer: AlohaCare Medicaid	$43.00
Rate for Payer: AlohaCare Medicare	$43.00
Rate for Payer: Cash Price	$55.90
Rate for Payer: Cash Price	$55.90
Rate for Payer: Devoted Health Medicare	$47.30
Rate for Payer: Hawaii Medical Service Association Medicare	$43.00
Rate for Payer: Hawaii Western Management Group Commercial	$81.70
Rate for Payer: Health Management Network Commercial	$73.10
Rate for Payer: Humana Medicare	$43.00
Rate for Payer: Kaiser Permanente Commercial	$77.40
Rate for Payer: Kaiser Permanente Medicaid	$43.86
Rate for Payer: Kaiser Permanente Medicare	$43.00
Rate for Payer: MDX Hawaii PPO	$83.42
Rate for Payer: Ohana Health Plan Medicaid	$43.00
Rate for Payer: Ohana Health Plan Medicare	$43.00
Rate for Payer: UnitedHealthcare Medicaid	$17.05
Rate for Payer: UnitedHealthcare Medicare	$43.00
Rate for Payer: University Health Alliance Commercial	$62.69

CATHETER FOLEY 24FR 30CC 3 WAY

Facility

$86.00

Service Code	HCPCS A4313
Hospital Charge Code	8266956
Hospital Revenue Code	272
Min. Negotiated Rate	$73.10
Max. Negotiated Rate	$83.42
Rate for Payer: Cash Price	$55.90
Rate for Payer: Health Management Network Commercial	$73.10
Rate for Payer: Kaiser Permanente Commercial	$77.40
Rate for Payer: MDX Hawaii PPO	$83.42

CATHETER FOLEY 24FR 5CC 2 WAY

Facility

$9.00

Service Code	HCPCS A4311
Hospital Charge Code	8266879
Hospital Revenue Code	272
Min. Negotiated Rate	$7.65
Max. Negotiated Rate	$8.73
Rate for Payer: Cash Price	$5.85
Rate for Payer: Health Management Network Commercial	$7.65
Rate for Payer: Kaiser Permanente Commercial	$8.10
Rate for Payer: MDX Hawaii PPO	$8.73

CATHETER FOLEY 24FR 5CC 2 WAY

Facility

$9.00

Service Code	HCPCS A4311
Hospital Charge Code	8266879
Hospital Revenue Code	272
Min. Negotiated Rate	$4.50
Max. Negotiated Rate	$14.13
Rate for Payer: AlohaCare Medicaid	$4.50
Rate for Payer: AlohaCare Medicare	$4.50
Rate for Payer: Cash Price	$5.85
Rate for Payer: Cash Price	$5.85
Rate for Payer: Devoted Health Medicare	$4.95
Rate for Payer: Hawaii Medical Service Association Medicare	$4.50
Rate for Payer: Hawaii Western Management Group Commercial	$8.55
Rate for Payer: Health Management Network Commercial	$7.65
Rate for Payer: Humana Medicare	$4.50
Rate for Payer: Kaiser Permanente Commercial	$8.10
Rate for Payer: Kaiser Permanente Medicaid	$4.59
Rate for Payer: Kaiser Permanente Medicare	$4.50
Rate for Payer: MDX Hawaii PPO	$8.73
Rate for Payer: Ohana Health Plan Medicaid	$4.50
Rate for Payer: Ohana Health Plan Medicare	$4.50
Rate for Payer: UnitedHealthcare Medicaid	$14.13
Rate for Payer: UnitedHealthcare Medicare	$4.50
Rate for Payer: University Health Alliance Commercial	$6.56

CATHETER FOLEY 8FR 3CC 2WAY

Facility

$48.00

Service Code	HCPCS A4311
Hospital Charge Code	8266292
Hospital Revenue Code	272
Min. Negotiated Rate	$40.80
Max. Negotiated Rate	$46.56
Rate for Payer: Cash Price	$31.20
Rate for Payer: Health Management Network Commercial	$40.80
Rate for Payer: Kaiser Permanente Commercial	$43.20
Rate for Payer: MDX Hawaii PPO	$46.56

CATHETER FOLEY 8FR 3CC 2WAY

Facility

$48.00

Service Code	HCPCS A4311
Hospital Charge Code	8266292
Hospital Revenue Code	272
Min. Negotiated Rate	$14.13
Max. Negotiated Rate	$46.56
Rate for Payer: AlohaCare Medicaid	$24.00
Rate for Payer: AlohaCare Medicare	$24.00
Rate for Payer: Cash Price	$31.20
Rate for Payer: Cash Price	$31.20
Rate for Payer: Devoted Health Medicare	$26.40
Rate for Payer: Hawaii Medical Service Association Medicare	$24.00
Rate for Payer: Hawaii Western Management Group Commercial	$45.60
Rate for Payer: Health Management Network Commercial	$40.80
Rate for Payer: Humana Medicare	$24.00
Rate for Payer: Kaiser Permanente Commercial	$43.20
Rate for Payer: Kaiser Permanente Medicaid	$24.48
Rate for Payer: Kaiser Permanente Medicare	$24.00
Rate for Payer: MDX Hawaii PPO	$46.56
Rate for Payer: Ohana Health Plan Medicaid	$24.00
Rate for Payer: Ohana Health Plan Medicare	$24.00
Rate for Payer: UnitedHealthcare Medicaid	$14.13
Rate for Payer: UnitedHealthcare Medicare	$24.00
Rate for Payer: University Health Alliance Commercial	$34.99

CATHETER FOLEY COUDE 14FR 5CC 2-WAY

Facility

$55.00

Service Code	HCPCS A4311
Hospital Charge Code	8266295
Hospital Revenue Code	272
Min. Negotiated Rate	$14.13
Max. Negotiated Rate	$53.35
Rate for Payer: AlohaCare Medicaid	$27.50
Rate for Payer: AlohaCare Medicare	$27.50
Rate for Payer: Cash Price	$35.75
Rate for Payer: Cash Price	$35.75
Rate for Payer: Devoted Health Medicare	$30.25
Rate for Payer: Hawaii Medical Service Association Medicare	$27.50
Rate for Payer: Hawaii Western Management Group Commercial	$52.25
Rate for Payer: Health Management Network Commercial	$46.75
Rate for Payer: Humana Medicare	$27.50
Rate for Payer: Kaiser Permanente Commercial	$49.50
Rate for Payer: Kaiser Permanente Medicaid	$28.05
Rate for Payer: Kaiser Permanente Medicare	$27.50
Rate for Payer: MDX Hawaii PPO	$53.35
Rate for Payer: Ohana Health Plan Medicaid	$27.50
Rate for Payer: Ohana Health Plan Medicare	$27.50
Rate for Payer: UnitedHealthcare Medicaid	$14.13
Rate for Payer: UnitedHealthcare Medicare	$27.50
Rate for Payer: University Health Alliance Commercial	$40.09

CATHETER FOLEY COUDE 14FR 5CC 2-WAY

Facility

$55.00

Service Code	HCPCS A4311
Hospital Charge Code	8266295
Hospital Revenue Code	272
Min. Negotiated Rate	$46.75
Max. Negotiated Rate	$53.35
Rate for Payer: Cash Price	$35.75
Rate for Payer: Health Management Network Commercial	$46.75
Rate for Payer: Kaiser Permanente Commercial	$49.50
Rate for Payer: MDX Hawaii PPO	$53.35

CATHETER FOLEY COUDE 16FR 5CC 2-WAY

Facility

$65.00

Service Code	HCPCS A4311
Hospital Charge Code	8266296
Hospital Revenue Code	272
Min. Negotiated Rate	$14.13
Max. Negotiated Rate	$63.05
Rate for Payer: AlohaCare Medicaid	$32.50
Rate for Payer: AlohaCare Medicare	$32.50
Rate for Payer: Cash Price	$42.25
Rate for Payer: Cash Price	$42.25
Rate for Payer: Devoted Health Medicare	$35.75
Rate for Payer: Hawaii Medical Service Association Medicare	$32.50
Rate for Payer: Hawaii Western Management Group Commercial	$61.75
Rate for Payer: Health Management Network Commercial	$55.25
Rate for Payer: Humana Medicare	$32.50
Rate for Payer: Kaiser Permanente Commercial	$58.50
Rate for Payer: Kaiser Permanente Medicaid	$33.15
Rate for Payer: Kaiser Permanente Medicare	$32.50
Rate for Payer: MDX Hawaii PPO	$63.05
Rate for Payer: Ohana Health Plan Medicaid	$32.50
Rate for Payer: Ohana Health Plan Medicare	$32.50
Rate for Payer: UnitedHealthcare Medicaid	$14.13
Rate for Payer: UnitedHealthcare Medicare	$32.50
Rate for Payer: University Health Alliance Commercial	$47.38

CATHETER FOLEY COUDE 16FR 5CC 2-WAY

Facility

$65.00

Service Code	HCPCS A4311
Hospital Charge Code	8266296
Hospital Revenue Code	272
Min. Negotiated Rate	$55.25
Max. Negotiated Rate	$63.05
Rate for Payer: Cash Price	$42.25
Rate for Payer: Health Management Network Commercial	$55.25
Rate for Payer: Kaiser Permanente Commercial	$58.50
Rate for Payer: MDX Hawaii PPO	$63.05

CATHETER, GROSHONG 8.0 FR.

Facility

$2,226.00

Service Code	HCPCS C1751
Hospital Charge Code	8274149
Hospital Revenue Code	272
Min. Negotiated Rate	$1,113.00
Max. Negotiated Rate	$2,159.22
Rate for Payer: AlohaCare Medicaid	$1,113.00
Rate for Payer: AlohaCare Medicare	$1,113.00
Rate for Payer: Cash Price	$1,446.90
Rate for Payer: Devoted Health Medicare	$1,224.30
Rate for Payer: Hawaii Medical Service Association Medicare	$1,113.00
Rate for Payer: Hawaii Western Management Group Commercial	$2,114.70
Rate for Payer: Health Management Network Commercial	$1,892.10
Rate for Payer: Humana Medicare	$1,113.00
Rate for Payer: Kaiser Permanente Commercial	$2,003.40
Rate for Payer: Kaiser Permanente Medicaid	$1,135.26
Rate for Payer: Kaiser Permanente Medicare	$1,113.00
Rate for Payer: MDX Hawaii PPO	$2,159.22
Rate for Payer: Ohana Health Plan Medicaid	$1,113.00
Rate for Payer: Ohana Health Plan Medicare	$1,113.00
Rate for Payer: UnitedHealthcare Medicare	$1,113.00
Rate for Payer: University Health Alliance Commercial	$1,622.53

CATHETER, GROSHONG 8.0 FR.

Facility

$2,226.00

Service Code	HCPCS C1751
Hospital Charge Code	8274149
Hospital Revenue Code	272
Min. Negotiated Rate	$1,892.10
Max. Negotiated Rate	$2,159.22
Rate for Payer: Cash Price	$1,446.90
Rate for Payer: Health Management Network Commercial	$1,892.10
Rate for Payer: Kaiser Permanente Commercial	$2,003.40
Rate for Payer: MDX Hawaii PPO	$2,159.22

CATHETER, GROSHONG 9.5 DUAL LUMEN

Facility

$1,805.00

Service Code	HCPCS C1751
Hospital Charge Code	8274150
Hospital Revenue Code	272
Min. Negotiated Rate	$902.50
Max. Negotiated Rate	$1,750.85
Rate for Payer: AlohaCare Medicaid	$902.50
Rate for Payer: AlohaCare Medicare	$902.50
Rate for Payer: Cash Price	$1,173.25
Rate for Payer: Devoted Health Medicare	$992.75
Rate for Payer: Hawaii Medical Service Association Medicare	$902.50
Rate for Payer: Hawaii Western Management Group Commercial	$1,714.75
Rate for Payer: Health Management Network Commercial	$1,534.25
Rate for Payer: Humana Medicare	$902.50
Rate for Payer: Kaiser Permanente Commercial	$1,624.50
Rate for Payer: Kaiser Permanente Medicaid	$920.55
Rate for Payer: Kaiser Permanente Medicare	$902.50
Rate for Payer: MDX Hawaii PPO	$1,750.85
Rate for Payer: Ohana Health Plan Medicaid	$902.50
Rate for Payer: Ohana Health Plan Medicare	$902.50
Rate for Payer: UnitedHealthcare Medicare	$902.50
Rate for Payer: University Health Alliance Commercial	$1,315.66

CATHETER, GROSHONG 9.5 DUAL LUMEN

Facility

$1,805.00

Service Code	HCPCS C1751
Hospital Charge Code	8274150
Hospital Revenue Code	272
Min. Negotiated Rate	$1,534.25
Max. Negotiated Rate	$1,750.85
Rate for Payer: Cash Price	$1,173.25
Rate for Payer: Health Management Network Commercial	$1,534.25
Rate for Payer: Kaiser Permanente Commercial	$1,624.50
Rate for Payer: MDX Hawaii PPO	$1,750.85

CATHETER HICKMAN 9.6 FR

Facility

$390.00

Service Code	HCPCS C1750
Hospital Charge Code	8348094
Hospital Revenue Code	272
Min. Negotiated Rate	$331.50
Max. Negotiated Rate	$378.30
Rate for Payer: Cash Price	$253.50
Rate for Payer: Health Management Network Commercial	$331.50
Rate for Payer: Kaiser Permanente Commercial	$351.00
Rate for Payer: MDX Hawaii PPO	$378.30

CATHETER HICKMAN 9.6 FR

Facility

$390.00

Service Code	HCPCS C1750
Hospital Charge Code	8348094
Hospital Revenue Code	272
Min. Negotiated Rate	$195.00
Max. Negotiated Rate	$378.30
Rate for Payer: AlohaCare Medicaid	$195.00
Rate for Payer: AlohaCare Medicare	$195.00
Rate for Payer: Cash Price	$253.50
Rate for Payer: Devoted Health Medicare	$214.50
Rate for Payer: Hawaii Medical Service Association Medicare	$195.00
Rate for Payer: Hawaii Western Management Group Commercial	$370.50
Rate for Payer: Health Management Network Commercial	$331.50
Rate for Payer: Humana Medicare	$195.00
Rate for Payer: Kaiser Permanente Commercial	$351.00
Rate for Payer: Kaiser Permanente Medicaid	$198.90
Rate for Payer: Kaiser Permanente Medicare	$195.00
Rate for Payer: MDX Hawaii PPO	$378.30
Rate for Payer: Ohana Health Plan Medicaid	$195.00
Rate for Payer: Ohana Health Plan Medicare	$195.00
Rate for Payer: UnitedHealthcare Medicare	$195.00
Rate for Payer: University Health Alliance Commercial	$284.27

CATHETERIZATION TRAY

Facility

$245.00

Hospital Charge Code	9589765
Hospital Revenue Code	272
Min. Negotiated Rate	$208.25
Max. Negotiated Rate	$237.65
Rate for Payer: Cash Price	$159.25
Rate for Payer: Health Management Network Commercial	$208.25
Rate for Payer: Kaiser Permanente Commercial	$220.50
Rate for Payer: MDX Hawaii PPO	$237.65

Know your out-of-pocket cost for care.

All Charges