Samuel Mahelona Memorial Hospital

All Charges

Charge

Type

Setting

Price

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

CATHETER POWERPORT 8FR IMPLANTABLE PORT

Facility

$1,015.00

Service Code	HCPCS C1788
Hospital Charge Code	9089383
Hospital Revenue Code	278
Min. Negotiated Rate	$568.40
Max. Negotiated Rate	$984.55
Rate for Payer: Cash Price	$659.75
Rate for Payer: Hawaii Western Management Group Commercial	$710.50
Rate for Payer: Health Management Network Commercial	$862.75
Rate for Payer: Kaiser Permanente Commercial	$913.50
Rate for Payer: MDX Hawaii PPO	$984.55
Rate for Payer: University Health Alliance Commercial	$568.40

CATHETER POWERPORT 8FR IMPLANTABLE PORT

Facility

$1,015.00

Service Code	HCPCS C1788
Hospital Charge Code	9089383
Hospital Revenue Code	278
Min. Negotiated Rate	$507.50
Max. Negotiated Rate	$984.55
Rate for Payer: AlohaCare Medicaid	$507.50
Rate for Payer: AlohaCare Medicare	$507.50
Rate for Payer: Cash Price	$659.75
Rate for Payer: Devoted Health Medicare	$558.25
Rate for Payer: Hawaii Medical Service Association Medicare	$507.50
Rate for Payer: Hawaii Western Management Group Commercial	$710.50
Rate for Payer: Health Management Network Commercial	$862.75
Rate for Payer: Humana Medicare	$507.50
Rate for Payer: Kaiser Permanente Commercial	$913.50
Rate for Payer: Kaiser Permanente Medicaid	$517.65
Rate for Payer: Kaiser Permanente Medicare	$507.50
Rate for Payer: MDX Hawaii PPO	$984.55
Rate for Payer: Ohana Health Plan Medicaid	$507.50
Rate for Payer: Ohana Health Plan Medicare	$507.50
Rate for Payer: UnitedHealthcare Medicare	$507.50
Rate for Payer: University Health Alliance Commercial	$568.40

CATHETER PUREWICK FEMALE EXTERNAL

Facility

$72.00

Hospital Charge Code	9250726
Hospital Revenue Code	272
Min. Negotiated Rate	$36.00
Max. Negotiated Rate	$69.84
Rate for Payer: AlohaCare Medicaid	$36.00
Rate for Payer: AlohaCare Medicare	$36.00
Rate for Payer: Cash Price	$46.80
Rate for Payer: Devoted Health Medicare	$39.60
Rate for Payer: Hawaii Medical Service Association Medicare	$36.00
Rate for Payer: Hawaii Western Management Group Commercial	$68.40
Rate for Payer: Health Management Network Commercial	$61.20
Rate for Payer: Humana Medicare	$36.00
Rate for Payer: Kaiser Permanente Commercial	$64.80
Rate for Payer: Kaiser Permanente Medicaid	$36.72
Rate for Payer: Kaiser Permanente Medicare	$36.00
Rate for Payer: MDX Hawaii PPO	$69.84
Rate for Payer: Ohana Health Plan Medicaid	$36.00
Rate for Payer: Ohana Health Plan Medicare	$36.00
Rate for Payer: UnitedHealthcare Medicare	$36.00
Rate for Payer: University Health Alliance Commercial	$52.48

CATHETER PUREWICK FEMALE EXTERNAL

Facility

$72.00

Hospital Charge Code	9250726
Hospital Revenue Code	272
Min. Negotiated Rate	$61.20
Max. Negotiated Rate	$69.84
Rate for Payer: Cash Price	$46.80
Rate for Payer: Health Management Network Commercial	$61.20
Rate for Payer: Kaiser Permanente Commercial	$64.80
Rate for Payer: MDX Hawaii PPO	$69.84

CATHETER RABINOV SIALOGRAPHY 0.016IN (CT)

Facility

$227.00

Service Code	HCPCS C1887
Hospital Charge Code	8886991
Hospital Revenue Code	272
Min. Negotiated Rate	$192.95
Max. Negotiated Rate	$220.19
Rate for Payer: Cash Price	$147.55
Rate for Payer: Health Management Network Commercial	$192.95
Rate for Payer: Kaiser Permanente Commercial	$204.30
Rate for Payer: MDX Hawaii PPO	$220.19

CATHETER RABINOV SIALOGRAPHY 0.016IN (CT)

Facility

$227.00

Service Code	HCPCS C1887
Hospital Charge Code	8886991
Hospital Revenue Code	272
Min. Negotiated Rate	$113.50
Max. Negotiated Rate	$220.19
Rate for Payer: AlohaCare Medicaid	$113.50
Rate for Payer: AlohaCare Medicare	$113.50
Rate for Payer: Cash Price	$147.55
Rate for Payer: Devoted Health Medicare	$124.85
Rate for Payer: Hawaii Medical Service Association Medicare	$113.50
Rate for Payer: Hawaii Western Management Group Commercial	$215.65
Rate for Payer: Health Management Network Commercial	$192.95
Rate for Payer: Humana Medicare	$113.50
Rate for Payer: Kaiser Permanente Commercial	$204.30
Rate for Payer: Kaiser Permanente Medicaid	$115.77
Rate for Payer: Kaiser Permanente Medicare	$113.50
Rate for Payer: MDX Hawaii PPO	$220.19
Rate for Payer: Ohana Health Plan Medicaid	$113.50
Rate for Payer: Ohana Health Plan Medicare	$113.50
Rate for Payer: UnitedHealthcare Medicare	$113.50
Rate for Payer: University Health Alliance Commercial	$165.46

CATHETER RABINOV SIALOGRAPHY 0.016IN (US)

Facility

$227.00

Service Code	HCPCS C1887
Hospital Charge Code	8886990
Hospital Revenue Code	272
Min. Negotiated Rate	$192.95
Max. Negotiated Rate	$220.19
Rate for Payer: Cash Price	$147.55
Rate for Payer: Health Management Network Commercial	$192.95
Rate for Payer: Kaiser Permanente Commercial	$204.30
Rate for Payer: MDX Hawaii PPO	$220.19

CATHETER RABINOV SIALOGRAPHY 0.016IN (US)

Facility

$227.00

Service Code	HCPCS C1887
Hospital Charge Code	8886990
Hospital Revenue Code	272
Min. Negotiated Rate	$113.50
Max. Negotiated Rate	$220.19
Rate for Payer: AlohaCare Medicaid	$113.50
Rate for Payer: AlohaCare Medicare	$113.50
Rate for Payer: Cash Price	$147.55
Rate for Payer: Devoted Health Medicare	$124.85
Rate for Payer: Hawaii Medical Service Association Medicare	$113.50
Rate for Payer: Hawaii Western Management Group Commercial	$215.65
Rate for Payer: Health Management Network Commercial	$192.95
Rate for Payer: Humana Medicare	$113.50
Rate for Payer: Kaiser Permanente Commercial	$204.30
Rate for Payer: Kaiser Permanente Medicaid	$115.77
Rate for Payer: Kaiser Permanente Medicare	$113.50
Rate for Payer: MDX Hawaii PPO	$220.19
Rate for Payer: Ohana Health Plan Medicaid	$113.50
Rate for Payer: Ohana Health Plan Medicare	$113.50
Rate for Payer: UnitedHealthcare Medicare	$113.50
Rate for Payer: University Health Alliance Commercial	$165.46

CATHETER RABINOV SIALOGRAPHY 0.016IN (XR/MAMMO)

Facility

$227.00

Service Code	HCPCS C1887
Hospital Charge Code	8886992
Hospital Revenue Code	272
Min. Negotiated Rate	$113.50
Max. Negotiated Rate	$220.19
Rate for Payer: AlohaCare Medicaid	$113.50
Rate for Payer: AlohaCare Medicare	$113.50
Rate for Payer: Cash Price	$147.55
Rate for Payer: Devoted Health Medicare	$124.85
Rate for Payer: Hawaii Medical Service Association Medicare	$113.50
Rate for Payer: Hawaii Western Management Group Commercial	$215.65
Rate for Payer: Health Management Network Commercial	$192.95
Rate for Payer: Humana Medicare	$113.50
Rate for Payer: Kaiser Permanente Commercial	$204.30
Rate for Payer: Kaiser Permanente Medicaid	$115.77
Rate for Payer: Kaiser Permanente Medicare	$113.50
Rate for Payer: MDX Hawaii PPO	$220.19
Rate for Payer: Ohana Health Plan Medicaid	$113.50
Rate for Payer: Ohana Health Plan Medicare	$113.50
Rate for Payer: UnitedHealthcare Medicare	$113.50
Rate for Payer: University Health Alliance Commercial	$165.46

CATHETER RABINOV SIALOGRAPHY 0.016IN (XR/MAMMO)

Facility

$227.00

Service Code	HCPCS C1887
Hospital Charge Code	8886992
Hospital Revenue Code	272
Min. Negotiated Rate	$192.95
Max. Negotiated Rate	$220.19
Rate for Payer: Cash Price	$147.55
Rate for Payer: Health Management Network Commercial	$192.95
Rate for Payer: Kaiser Permanente Commercial	$204.30
Rate for Payer: MDX Hawaii PPO	$220.19

CATHETER ROB-NEL 10FR

Facility

$3.00

Service Code	HCPCS C1758
Hospital Charge Code	8266614
Hospital Revenue Code	270
Min. Negotiated Rate	$1.50
Max. Negotiated Rate	$2.91
Rate for Payer: AlohaCare Medicaid	$1.50
Rate for Payer: AlohaCare Medicare	$1.50
Rate for Payer: Cash Price	$1.95
Rate for Payer: Devoted Health Medicare	$1.65
Rate for Payer: Hawaii Medical Service Association Medicare	$1.50
Rate for Payer: Hawaii Western Management Group Commercial	$2.85
Rate for Payer: Health Management Network Commercial	$2.55
Rate for Payer: Humana Medicare	$1.50
Rate for Payer: Kaiser Permanente Commercial	$2.70
Rate for Payer: Kaiser Permanente Medicaid	$1.53
Rate for Payer: Kaiser Permanente Medicare	$1.50
Rate for Payer: MDX Hawaii PPO	$2.91
Rate for Payer: Ohana Health Plan Medicaid	$1.50
Rate for Payer: Ohana Health Plan Medicare	$1.50
Rate for Payer: UnitedHealthcare Medicare	$1.50
Rate for Payer: University Health Alliance Commercial	$2.19

CATHETER ROB-NEL 10FR

Facility

$3.00

Service Code	HCPCS C1758
Hospital Charge Code	8266614
Hospital Revenue Code	270
Min. Negotiated Rate	$2.55
Max. Negotiated Rate	$2.91
Rate for Payer: Cash Price	$1.95
Rate for Payer: Health Management Network Commercial	$2.55
Rate for Payer: Kaiser Permanente Commercial	$2.70
Rate for Payer: MDX Hawaii PPO	$2.91

CATHETER ROB-NEL 12FR

Facility

$4.00

Service Code	HCPCS C1758
Hospital Charge Code	8266615
Hospital Revenue Code	270
Min. Negotiated Rate	$3.40
Max. Negotiated Rate	$3.88
Rate for Payer: Cash Price	$2.60
Rate for Payer: Health Management Network Commercial	$3.40
Rate for Payer: Kaiser Permanente Commercial	$3.60
Rate for Payer: MDX Hawaii PPO	$3.88

CATHETER ROB-NEL 12FR

Facility

$4.00

Service Code	HCPCS C1758
Hospital Charge Code	8266615
Hospital Revenue Code	270
Min. Negotiated Rate	$2.00
Max. Negotiated Rate	$3.88
Rate for Payer: AlohaCare Medicaid	$2.00
Rate for Payer: AlohaCare Medicare	$2.00
Rate for Payer: Cash Price	$2.60
Rate for Payer: Devoted Health Medicare	$2.20
Rate for Payer: Hawaii Medical Service Association Medicare	$2.00
Rate for Payer: Hawaii Western Management Group Commercial	$3.80
Rate for Payer: Health Management Network Commercial	$3.40
Rate for Payer: Humana Medicare	$2.00
Rate for Payer: Kaiser Permanente Commercial	$3.60
Rate for Payer: Kaiser Permanente Medicaid	$2.04
Rate for Payer: Kaiser Permanente Medicare	$2.00
Rate for Payer: MDX Hawaii PPO	$3.88
Rate for Payer: Ohana Health Plan Medicaid	$2.00
Rate for Payer: Ohana Health Plan Medicare	$2.00
Rate for Payer: UnitedHealthcare Medicare	$2.00
Rate for Payer: University Health Alliance Commercial	$2.92

CATHETER ROB-NEL 14FR

Facility

$5.00

Service Code	HCPCS C1758
Hospital Charge Code	8266497
Hospital Revenue Code	270
Min. Negotiated Rate	$2.50
Max. Negotiated Rate	$4.85
Rate for Payer: AlohaCare Medicaid	$2.50
Rate for Payer: AlohaCare Medicare	$2.50
Rate for Payer: Cash Price	$3.25
Rate for Payer: Devoted Health Medicare	$2.75
Rate for Payer: Hawaii Medical Service Association Medicare	$2.50
Rate for Payer: Hawaii Western Management Group Commercial	$4.75
Rate for Payer: Health Management Network Commercial	$4.25
Rate for Payer: Humana Medicare	$2.50
Rate for Payer: Kaiser Permanente Commercial	$4.50
Rate for Payer: Kaiser Permanente Medicaid	$2.55
Rate for Payer: Kaiser Permanente Medicare	$2.50
Rate for Payer: MDX Hawaii PPO	$4.85
Rate for Payer: Ohana Health Plan Medicaid	$2.50
Rate for Payer: Ohana Health Plan Medicare	$2.50
Rate for Payer: UnitedHealthcare Medicare	$2.50
Rate for Payer: University Health Alliance Commercial	$3.64

CATHETER ROB-NEL 14FR

Facility

$5.00

Service Code	HCPCS C1758
Hospital Charge Code	8266497
Hospital Revenue Code	270
Min. Negotiated Rate	$4.25
Max. Negotiated Rate	$4.85
Rate for Payer: Cash Price	$3.25
Rate for Payer: Health Management Network Commercial	$4.25
Rate for Payer: Kaiser Permanente Commercial	$4.50
Rate for Payer: MDX Hawaii PPO	$4.85

CATHETER ROB-NEL 16FR

Facility

$4.00

Service Code	HCPCS C1758
Hospital Charge Code	8266306
Hospital Revenue Code	270
Min. Negotiated Rate	$2.00
Max. Negotiated Rate	$3.88
Rate for Payer: AlohaCare Medicaid	$2.00
Rate for Payer: AlohaCare Medicare	$2.00
Rate for Payer: Cash Price	$2.60
Rate for Payer: Devoted Health Medicare	$2.20
Rate for Payer: Hawaii Medical Service Association Medicare	$2.00
Rate for Payer: Hawaii Western Management Group Commercial	$3.80
Rate for Payer: Health Management Network Commercial	$3.40
Rate for Payer: Humana Medicare	$2.00
Rate for Payer: Kaiser Permanente Commercial	$3.60
Rate for Payer: Kaiser Permanente Medicaid	$2.04
Rate for Payer: Kaiser Permanente Medicare	$2.00
Rate for Payer: MDX Hawaii PPO	$3.88
Rate for Payer: Ohana Health Plan Medicaid	$2.00
Rate for Payer: Ohana Health Plan Medicare	$2.00
Rate for Payer: UnitedHealthcare Medicare	$2.00
Rate for Payer: University Health Alliance Commercial	$2.92

CATHETER ROB-NEL 16FR

Facility

$4.00

Service Code	HCPCS C1758
Hospital Charge Code	8266306
Hospital Revenue Code	270
Min. Negotiated Rate	$3.40
Max. Negotiated Rate	$3.88
Rate for Payer: Cash Price	$2.60
Rate for Payer: Health Management Network Commercial	$3.40
Rate for Payer: Kaiser Permanente Commercial	$3.60
Rate for Payer: MDX Hawaii PPO	$3.88

CATHETER SET, EMERGENCY CRICOIDOTOMY 18 GAUGE

Facility

$1,040.00

Hospital Charge Code	8274454
Hospital Revenue Code	278
Min. Negotiated Rate	$582.40
Max. Negotiated Rate	$1,008.80
Rate for Payer: Cash Price	$676.00
Rate for Payer: Hawaii Western Management Group Commercial	$728.00
Rate for Payer: Health Management Network Commercial	$884.00
Rate for Payer: Kaiser Permanente Commercial	$936.00
Rate for Payer: MDX Hawaii PPO	$1,008.80
Rate for Payer: University Health Alliance Commercial	$582.40

CATHETER SET, EMERGENCY CRICOIDOTOMY 18 GAUGE

Facility

$1,040.00

Hospital Charge Code	8274454
Hospital Revenue Code	278
Min. Negotiated Rate	$520.00
Max. Negotiated Rate	$1,008.80
Rate for Payer: AlohaCare Medicaid	$520.00
Rate for Payer: AlohaCare Medicare	$520.00
Rate for Payer: Cash Price	$676.00
Rate for Payer: Devoted Health Medicare	$572.00
Rate for Payer: Hawaii Medical Service Association Medicare	$520.00
Rate for Payer: Hawaii Western Management Group Commercial	$728.00
Rate for Payer: Health Management Network Commercial	$884.00
Rate for Payer: Humana Medicare	$520.00
Rate for Payer: Kaiser Permanente Commercial	$936.00
Rate for Payer: Kaiser Permanente Medicaid	$530.40
Rate for Payer: Kaiser Permanente Medicare	$520.00
Rate for Payer: MDX Hawaii PPO	$1,008.80
Rate for Payer: Ohana Health Plan Medicaid	$520.00
Rate for Payer: Ohana Health Plan Medicare	$520.00
Rate for Payer: UnitedHealthcare Medicare	$520.00
Rate for Payer: University Health Alliance Commercial	$582.40

CATHETER THORACIC 12FR STRAIGHT

Facility

$45.00

Service Code	HCPCS C1725
Hospital Charge Code	8266618
Hospital Revenue Code	272
Min. Negotiated Rate	$38.25
Max. Negotiated Rate	$43.65
Rate for Payer: Cash Price	$29.25
Rate for Payer: Health Management Network Commercial	$38.25
Rate for Payer: Kaiser Permanente Commercial	$40.50
Rate for Payer: MDX Hawaii PPO	$43.65

CATHETER THORACIC 12FR STRAIGHT

Facility

$45.00

Service Code	HCPCS C1725
Hospital Charge Code	8266618
Hospital Revenue Code	272
Min. Negotiated Rate	$22.50
Max. Negotiated Rate	$43.65
Rate for Payer: AlohaCare Medicaid	$22.50
Rate for Payer: AlohaCare Medicare	$22.50
Rate for Payer: Cash Price	$29.25
Rate for Payer: Devoted Health Medicare	$24.75
Rate for Payer: Hawaii Medical Service Association Medicare	$22.50
Rate for Payer: Hawaii Western Management Group Commercial	$42.75
Rate for Payer: Health Management Network Commercial	$38.25
Rate for Payer: Humana Medicare	$22.50
Rate for Payer: Kaiser Permanente Commercial	$40.50
Rate for Payer: Kaiser Permanente Medicaid	$22.95
Rate for Payer: Kaiser Permanente Medicare	$22.50
Rate for Payer: MDX Hawaii PPO	$43.65
Rate for Payer: Ohana Health Plan Medicaid	$22.50
Rate for Payer: Ohana Health Plan Medicare	$22.50
Rate for Payer: UnitedHealthcare Medicare	$22.50
Rate for Payer: University Health Alliance Commercial	$32.80

CATHETER THORACIC 16FR STRAIGHT

Facility

$49.00

Service Code	HCPCS C1725
Hospital Charge Code	8266524
Hospital Revenue Code	272
Min. Negotiated Rate	$24.50
Max. Negotiated Rate	$47.53
Rate for Payer: AlohaCare Medicaid	$24.50
Rate for Payer: AlohaCare Medicare	$24.50
Rate for Payer: Cash Price	$31.85
Rate for Payer: Devoted Health Medicare	$26.95
Rate for Payer: Hawaii Medical Service Association Medicare	$24.50
Rate for Payer: Hawaii Western Management Group Commercial	$46.55
Rate for Payer: Health Management Network Commercial	$41.65
Rate for Payer: Humana Medicare	$24.50
Rate for Payer: Kaiser Permanente Commercial	$44.10
Rate for Payer: Kaiser Permanente Medicaid	$24.99
Rate for Payer: Kaiser Permanente Medicare	$24.50
Rate for Payer: MDX Hawaii PPO	$47.53
Rate for Payer: Ohana Health Plan Medicaid	$24.50
Rate for Payer: Ohana Health Plan Medicare	$24.50
Rate for Payer: UnitedHealthcare Medicare	$24.50
Rate for Payer: University Health Alliance Commercial	$35.72

CATHETER THORACIC 16FR STRAIGHT

Facility

$49.00

Service Code	HCPCS C1725
Hospital Charge Code	8266524
Hospital Revenue Code	272
Min. Negotiated Rate	$41.65
Max. Negotiated Rate	$47.53
Rate for Payer: Cash Price	$31.85
Rate for Payer: Health Management Network Commercial	$41.65
Rate for Payer: Kaiser Permanente Commercial	$44.10
Rate for Payer: MDX Hawaii PPO	$47.53

Know your out-of-pocket cost for care.

All Charges