Samuel Mahelona Memorial Hospital

All Charges

Charge

Type

Setting

Price

CAUTERY, ELECTRODES LEEP 15MM X 12MM LOOP

Facility

$76.00

Hospital Charge Code	8274265
Hospital Revenue Code	272
Min. Negotiated Rate	$64.60
Max. Negotiated Rate	$73.72
Rate for Payer: Cash Price	$49.40
Rate for Payer: Health Management Network Commercial	$64.60
Rate for Payer: Kaiser Permanente Commercial	$68.40
Rate for Payer: MDX Hawaii PPO	$73.72

CAUTERY, ELECTRODES LEEP 20MM X 12MM LOOP

Facility

$95.00

Hospital Charge Code	8274261
Hospital Revenue Code	272
Min. Negotiated Rate	$80.75
Max. Negotiated Rate	$92.15
Rate for Payer: Cash Price	$61.75
Rate for Payer: Health Management Network Commercial	$80.75
Rate for Payer: Kaiser Permanente Commercial	$85.50
Rate for Payer: MDX Hawaii PPO	$92.15

CAUTERY, ELECTRODES LEEP 20MM X 12MM LOOP

Facility

$95.00

Hospital Charge Code	8274261
Hospital Revenue Code	272
Min. Negotiated Rate	$47.50
Max. Negotiated Rate	$92.15
Rate for Payer: AlohaCare Medicaid	$47.50
Rate for Payer: AlohaCare Medicare	$47.50
Rate for Payer: Cash Price	$61.75
Rate for Payer: Devoted Health Medicare	$52.25
Rate for Payer: Hawaii Medical Service Association Medicare	$47.50
Rate for Payer: Hawaii Western Management Group Commercial	$90.25
Rate for Payer: Health Management Network Commercial	$80.75
Rate for Payer: Humana Medicare	$47.50
Rate for Payer: Kaiser Permanente Commercial	$85.50
Rate for Payer: Kaiser Permanente Medicaid	$48.45
Rate for Payer: Kaiser Permanente Medicare	$47.50
Rate for Payer: MDX Hawaii PPO	$92.15
Rate for Payer: Ohana Health Plan Medicaid	$47.50
Rate for Payer: Ohana Health Plan Medicare	$47.50
Rate for Payer: UnitedHealthcare Medicare	$47.50
Rate for Payer: University Health Alliance Commercial	$69.25

CAUTERY, ELECTRODES LEEP 20MMX15MM LOOP

Facility

$76.00

Hospital Charge Code	8274262
Hospital Revenue Code	272
Min. Negotiated Rate	$38.00
Max. Negotiated Rate	$73.72
Rate for Payer: AlohaCare Medicaid	$38.00
Rate for Payer: AlohaCare Medicare	$38.00
Rate for Payer: Cash Price	$49.40
Rate for Payer: Devoted Health Medicare	$41.80
Rate for Payer: Hawaii Medical Service Association Medicare	$38.00
Rate for Payer: Hawaii Western Management Group Commercial	$72.20
Rate for Payer: Health Management Network Commercial	$64.60
Rate for Payer: Humana Medicare	$38.00
Rate for Payer: Kaiser Permanente Commercial	$68.40
Rate for Payer: Kaiser Permanente Medicaid	$38.76
Rate for Payer: Kaiser Permanente Medicare	$38.00
Rate for Payer: MDX Hawaii PPO	$73.72
Rate for Payer: Ohana Health Plan Medicaid	$38.00
Rate for Payer: Ohana Health Plan Medicare	$38.00
Rate for Payer: UnitedHealthcare Medicare	$38.00
Rate for Payer: University Health Alliance Commercial	$55.40

CAUTERY, ELECTRODES LEEP 20MMX15MM LOOP

Facility

$76.00

Hospital Charge Code	8274262
Hospital Revenue Code	272
Min. Negotiated Rate	$64.60
Max. Negotiated Rate	$73.72
Rate for Payer: Cash Price	$49.40
Rate for Payer: Health Management Network Commercial	$64.60
Rate for Payer: Kaiser Permanente Commercial	$68.40
Rate for Payer: MDX Hawaii PPO	$73.72

CAUTERY, ELECTRODES LEEP 3MM BALL

Facility

$76.00

Hospital Charge Code	8274263
Hospital Revenue Code	272
Min. Negotiated Rate	$64.60
Max. Negotiated Rate	$73.72
Rate for Payer: Cash Price	$49.40
Rate for Payer: Health Management Network Commercial	$64.60
Rate for Payer: Kaiser Permanente Commercial	$68.40
Rate for Payer: MDX Hawaii PPO	$73.72

CAUTERY, ELECTRODES LEEP 3MM BALL

Facility

$76.00

Hospital Charge Code	8274263
Hospital Revenue Code	272
Min. Negotiated Rate	$38.00
Max. Negotiated Rate	$73.72
Rate for Payer: AlohaCare Medicaid	$38.00
Rate for Payer: AlohaCare Medicare	$38.00
Rate for Payer: Cash Price	$49.40
Rate for Payer: Devoted Health Medicare	$41.80
Rate for Payer: Hawaii Medical Service Association Medicare	$38.00
Rate for Payer: Hawaii Western Management Group Commercial	$72.20
Rate for Payer: Health Management Network Commercial	$64.60
Rate for Payer: Humana Medicare	$38.00
Rate for Payer: Kaiser Permanente Commercial	$68.40
Rate for Payer: Kaiser Permanente Medicaid	$38.76
Rate for Payer: Kaiser Permanente Medicare	$38.00
Rate for Payer: MDX Hawaii PPO	$73.72
Rate for Payer: Ohana Health Plan Medicaid	$38.00
Rate for Payer: Ohana Health Plan Medicare	$38.00
Rate for Payer: UnitedHealthcare Medicare	$38.00
Rate for Payer: University Health Alliance Commercial	$55.40

CAUTERY, HANDSWITCHING PENCIL

Facility

$36.00

Hospital Charge Code	8274434
Hospital Revenue Code	270
Min. Negotiated Rate	$18.00
Max. Negotiated Rate	$34.92
Rate for Payer: AlohaCare Medicaid	$18.00
Rate for Payer: AlohaCare Medicare	$18.00
Rate for Payer: Cash Price	$23.40
Rate for Payer: Devoted Health Medicare	$19.80
Rate for Payer: Hawaii Medical Service Association Medicare	$18.00
Rate for Payer: Hawaii Western Management Group Commercial	$34.20
Rate for Payer: Health Management Network Commercial	$30.60
Rate for Payer: Humana Medicare	$18.00
Rate for Payer: Kaiser Permanente Commercial	$32.40
Rate for Payer: Kaiser Permanente Medicaid	$18.36
Rate for Payer: Kaiser Permanente Medicare	$18.00
Rate for Payer: MDX Hawaii PPO	$34.92
Rate for Payer: Ohana Health Plan Medicaid	$18.00
Rate for Payer: Ohana Health Plan Medicare	$18.00
Rate for Payer: UnitedHealthcare Medicare	$18.00
Rate for Payer: University Health Alliance Commercial	$26.24

CAUTERY, HANDSWITCHING PENCIL

Facility

$36.00

Hospital Charge Code	8274434
Hospital Revenue Code	270
Min. Negotiated Rate	$30.60
Max. Negotiated Rate	$34.92
Rate for Payer: Cash Price	$23.40
Rate for Payer: Health Management Network Commercial	$30.60
Rate for Payer: Kaiser Permanente Commercial	$32.40
Rate for Payer: MDX Hawaii PPO	$34.92

CAUTERY INSULATED ELECTRODE SPATULA (MASTECTOMY)

Facility

$41.00

Hospital Charge Code	8274151
Hospital Revenue Code	272
Min. Negotiated Rate	$20.50
Max. Negotiated Rate	$39.77
Rate for Payer: AlohaCare Medicaid	$20.50
Rate for Payer: AlohaCare Medicare	$20.50
Rate for Payer: Cash Price	$26.65
Rate for Payer: Devoted Health Medicare	$22.55
Rate for Payer: Hawaii Medical Service Association Medicare	$20.50
Rate for Payer: Hawaii Western Management Group Commercial	$38.95
Rate for Payer: Health Management Network Commercial	$34.85
Rate for Payer: Humana Medicare	$20.50
Rate for Payer: Kaiser Permanente Commercial	$36.90
Rate for Payer: Kaiser Permanente Medicaid	$20.91
Rate for Payer: Kaiser Permanente Medicare	$20.50
Rate for Payer: MDX Hawaii PPO	$39.77
Rate for Payer: Ohana Health Plan Medicaid	$20.50
Rate for Payer: Ohana Health Plan Medicare	$20.50
Rate for Payer: UnitedHealthcare Medicare	$20.50
Rate for Payer: University Health Alliance Commercial	$29.88

CAUTERY INSULATED ELECTRODE SPATULA (MASTECTOMY)

Facility

$41.00

Hospital Charge Code	8274151
Hospital Revenue Code	272
Min. Negotiated Rate	$34.85
Max. Negotiated Rate	$39.77
Rate for Payer: Cash Price	$26.65
Rate for Payer: Health Management Network Commercial	$34.85
Rate for Payer: Kaiser Permanente Commercial	$36.90
Rate for Payer: MDX Hawaii PPO	$39.77

CAUTERY INSULATED NEEDLE TIP

Facility

$29.00

Hospital Charge Code	8274435
Hospital Revenue Code	272
Min. Negotiated Rate	$14.50
Max. Negotiated Rate	$28.13
Rate for Payer: AlohaCare Medicaid	$14.50
Rate for Payer: AlohaCare Medicare	$14.50
Rate for Payer: Cash Price	$18.85
Rate for Payer: Devoted Health Medicare	$15.95
Rate for Payer: Hawaii Medical Service Association Medicare	$14.50
Rate for Payer: Hawaii Western Management Group Commercial	$27.55
Rate for Payer: Health Management Network Commercial	$24.65
Rate for Payer: Humana Medicare	$14.50
Rate for Payer: Kaiser Permanente Commercial	$26.10
Rate for Payer: Kaiser Permanente Medicaid	$14.79
Rate for Payer: Kaiser Permanente Medicare	$14.50
Rate for Payer: MDX Hawaii PPO	$28.13
Rate for Payer: Ohana Health Plan Medicaid	$14.50
Rate for Payer: Ohana Health Plan Medicare	$14.50
Rate for Payer: UnitedHealthcare Medicare	$14.50
Rate for Payer: University Health Alliance Commercial	$21.14

CAUTERY INSULATED NEEDLE TIP

Facility

$29.00

Hospital Charge Code	8274435
Hospital Revenue Code	272
Min. Negotiated Rate	$24.65
Max. Negotiated Rate	$28.13
Rate for Payer: Cash Price	$18.85
Rate for Payer: Health Management Network Commercial	$24.65
Rate for Payer: Kaiser Permanente Commercial	$26.10
Rate for Payer: MDX Hawaii PPO	$28.13

CBC Complete Blood Count w/ Diff FSI

Facility

$114.00

Service Code	HCPCS 85025
Hospital Charge Code	8117875
Hospital Revenue Code	305
Min. Negotiated Rate	$96.90
Max. Negotiated Rate	$110.58
Rate for Payer: Cash Price	$74.10
Rate for Payer: Health Management Network Commercial	$96.90
Rate for Payer: Kaiser Permanente Commercial	$102.60
Rate for Payer: MDX Hawaii PPO	$110.58

CBC Complete Blood Count w/ Diff FSI

Facility

$114.00

Service Code	HCPCS 85025
Hospital Charge Code	8117875
Hospital Revenue Code	305
Min. Negotiated Rate	$7.77
Max. Negotiated Rate	$110.58
Rate for Payer: AlohaCare Medicaid	$57.00
Rate for Payer: AlohaCare Medicare	$57.00
Rate for Payer: Cash Price	$74.10
Rate for Payer: Cash Price	$74.10
Rate for Payer: Devoted Health Medicare	$62.70
Rate for Payer: Hawaii Medical Service Association ABD	$10.74
Rate for Payer: Hawaii Medical Service Association Commercial	$9.71
Rate for Payer: Hawaii Medical Service Association Medicare	$57.00
Rate for Payer: Hawaii Medical Service Association Non-ABD	$11.28
Rate for Payer: Hawaii Western Management Group Commercial	$7.77
Rate for Payer: Health Management Network Commercial	$96.90
Rate for Payer: Humana Medicare	$57.00
Rate for Payer: Kaiser Permanente Commercial	$102.60
Rate for Payer: Kaiser Permanente Medicaid	$58.14
Rate for Payer: Kaiser Permanente Medicare	$57.00
Rate for Payer: MDX Hawaii PPO	$110.58
Rate for Payer: Ohana Health Plan Medicaid	$57.00
Rate for Payer: Ohana Health Plan Medicare	$57.00
Rate for Payer: UnitedHealthcare Medicaid	$10.74
Rate for Payer: UnitedHealthcare Medicare	$57.00
Rate for Payer: University Health Alliance Commercial	$20.09

CBC Complete Blood Count w/ Manual Diff FSI

Facility

$96.00

Service Code	HCPCS 85027
Hospital Charge Code	8117876
Hospital Revenue Code	305
Min. Negotiated Rate	$81.60
Max. Negotiated Rate	$93.12
Rate for Payer: Cash Price	$62.40
Rate for Payer: Health Management Network Commercial	$81.60
Rate for Payer: Kaiser Permanente Commercial	$86.40
Rate for Payer: MDX Hawaii PPO	$93.12

CBC Complete Blood Count w/ Manual Diff FSI

Facility

$96.00

Service Code	HCPCS 85027
Hospital Charge Code	8117876
Hospital Revenue Code	305
Min. Negotiated Rate	$6.47
Max. Negotiated Rate	$93.12
Rate for Payer: AlohaCare Medicaid	$48.00
Rate for Payer: AlohaCare Medicare	$48.00
Rate for Payer: Cash Price	$62.40
Rate for Payer: Cash Price	$62.40
Rate for Payer: Devoted Health Medicare	$52.80
Rate for Payer: Hawaii Medical Service Association ABD	$8.95
Rate for Payer: Hawaii Medical Service Association Commercial	$8.09
Rate for Payer: Hawaii Medical Service Association Medicare	$48.00
Rate for Payer: Hawaii Medical Service Association Non-ABD	$9.40
Rate for Payer: Hawaii Western Management Group Commercial	$6.47
Rate for Payer: Health Management Network Commercial	$81.60
Rate for Payer: Humana Medicare	$48.00
Rate for Payer: Kaiser Permanente Commercial	$86.40
Rate for Payer: Kaiser Permanente Medicaid	$48.96
Rate for Payer: Kaiser Permanente Medicare	$48.00
Rate for Payer: MDX Hawaii PPO	$93.12
Rate for Payer: Ohana Health Plan Medicaid	$48.00
Rate for Payer: Ohana Health Plan Medicare	$48.00
Rate for Payer: UnitedHealthcare Medicaid	$8.95
Rate for Payer: UnitedHealthcare Medicare	$48.00
Rate for Payer: University Health Alliance Commercial	$16.72

CBC without Diff FSI

Facility

$96.00

Service Code	HCPCS 85027
Hospital Charge Code	8117853
Hospital Revenue Code	305
Min. Negotiated Rate	$6.47
Max. Negotiated Rate	$93.12
Rate for Payer: AlohaCare Medicaid	$48.00
Rate for Payer: AlohaCare Medicare	$48.00
Rate for Payer: Cash Price	$62.40
Rate for Payer: Cash Price	$62.40
Rate for Payer: Devoted Health Medicare	$52.80
Rate for Payer: Hawaii Medical Service Association ABD	$8.95
Rate for Payer: Hawaii Medical Service Association Commercial	$8.09
Rate for Payer: Hawaii Medical Service Association Medicare	$48.00
Rate for Payer: Hawaii Medical Service Association Non-ABD	$9.40
Rate for Payer: Hawaii Western Management Group Commercial	$6.47
Rate for Payer: Health Management Network Commercial	$81.60
Rate for Payer: Humana Medicare	$48.00
Rate for Payer: Kaiser Permanente Commercial	$86.40
Rate for Payer: Kaiser Permanente Medicaid	$48.96
Rate for Payer: Kaiser Permanente Medicare	$48.00
Rate for Payer: MDX Hawaii PPO	$93.12
Rate for Payer: Ohana Health Plan Medicaid	$48.00
Rate for Payer: Ohana Health Plan Medicare	$48.00
Rate for Payer: UnitedHealthcare Medicaid	$8.95
Rate for Payer: UnitedHealthcare Medicare	$48.00
Rate for Payer: University Health Alliance Commercial	$16.72

CBC without Diff FSI

Facility

$96.00

Service Code	HCPCS 85027
Hospital Charge Code	8117853
Hospital Revenue Code	305
Min. Negotiated Rate	$81.60
Max. Negotiated Rate	$93.12
Rate for Payer: Cash Price	$62.40
Rate for Payer: Health Management Network Commercial	$81.60
Rate for Payer: Kaiser Permanente Commercial	$86.40
Rate for Payer: MDX Hawaii PPO	$93.12

CBT 1ST HOUR CHARGE

Facility

$375.00

Service Code	HCPCS 94644
Hospital Charge Code	8243382
Hospital Revenue Code	410
Min. Negotiated Rate	$27.58
Max. Negotiated Rate	$363.75
Rate for Payer: AlohaCare Medicaid	$187.50
Rate for Payer: AlohaCare Medicare	$187.50
Rate for Payer: Cash Price	$243.75
Rate for Payer: Cash Price	$243.75
Rate for Payer: Devoted Health Medicare	$206.25
Rate for Payer: Hawaii Medical Service Association Commercial	$169.91
Rate for Payer: Hawaii Medical Service Association Medicare	$187.50
Rate for Payer: Hawaii Western Management Group Commercial	$356.25
Rate for Payer: Health Management Network Commercial	$318.75
Rate for Payer: Humana Medicare	$187.50
Rate for Payer: Kaiser Permanente Commercial	$337.50
Rate for Payer: Kaiser Permanente Medicaid	$191.25
Rate for Payer: Kaiser Permanente Medicare	$187.50
Rate for Payer: MDX Hawaii PPO	$363.75
Rate for Payer: Ohana Health Plan Medicaid	$187.50
Rate for Payer: Ohana Health Plan Medicare	$187.50
Rate for Payer: UnitedHealthcare Medicaid	$27.58
Rate for Payer: UnitedHealthcare Medicare	$187.50
Rate for Payer: University Health Alliance Commercial	$210.00

CBT 1ST HOUR CHARGE

Facility

$375.00

Service Code	HCPCS 94644
Hospital Charge Code	8243382
Hospital Revenue Code	410
Min. Negotiated Rate	$318.75
Max. Negotiated Rate	$363.75
Rate for Payer: Cash Price	$243.75
Rate for Payer: Health Management Network Commercial	$318.75
Rate for Payer: Kaiser Permanente Commercial	$337.50
Rate for Payer: MDX Hawaii PPO	$363.75

CBT EACH ADDL HOUR CHARGE

Facility

$166.00

Service Code	HCPCS 94645
Hospital Charge Code	8243383
Hospital Revenue Code	410
Min. Negotiated Rate	$141.10
Max. Negotiated Rate	$161.02
Rate for Payer: Cash Price	$107.90
Rate for Payer: Health Management Network Commercial	$141.10
Rate for Payer: Kaiser Permanente Commercial	$149.40
Rate for Payer: MDX Hawaii PPO	$161.02

CBT EACH ADDL HOUR CHARGE

Facility

$166.00

Service Code	HCPCS 94645
Hospital Charge Code	8243383
Hospital Revenue Code	410
Min. Negotiated Rate	$10.46
Max. Negotiated Rate	$161.02
Rate for Payer: AlohaCare Medicaid	$83.00
Rate for Payer: AlohaCare Medicare	$83.00
Rate for Payer: Cash Price	$107.90
Rate for Payer: Cash Price	$107.90
Rate for Payer: Devoted Health Medicare	$91.30
Rate for Payer: Hawaii Medical Service Association Medicare	$83.00
Rate for Payer: Hawaii Western Management Group Commercial	$157.70
Rate for Payer: Health Management Network Commercial	$141.10
Rate for Payer: Humana Medicare	$83.00
Rate for Payer: Kaiser Permanente Commercial	$149.40
Rate for Payer: Kaiser Permanente Medicaid	$84.66
Rate for Payer: Kaiser Permanente Medicare	$83.00
Rate for Payer: MDX Hawaii PPO	$161.02
Rate for Payer: Ohana Health Plan Medicaid	$83.00
Rate for Payer: Ohana Health Plan Medicare	$83.00
Rate for Payer: UnitedHealthcare Medicaid	$10.46
Rate for Payer: UnitedHealthcare Medicare	$83.00
Rate for Payer: University Health Alliance Commercial	$92.96

CEA Carcinoembrionic Antigen FSI

Facility

$216.00

Service Code	HCPCS 82378
Hospital Charge Code	8117877
Hospital Revenue Code	301
Min. Negotiated Rate	$18.96
Max. Negotiated Rate	$209.52
Rate for Payer: AlohaCare Medicaid	$108.00
Rate for Payer: AlohaCare Medicare	$108.00
Rate for Payer: Cash Price	$140.40
Rate for Payer: Cash Price	$140.40
Rate for Payer: Devoted Health Medicare	$118.80
Rate for Payer: Hawaii Medical Service Association ABD	$26.22
Rate for Payer: Hawaii Medical Service Association Commercial	$23.70
Rate for Payer: Hawaii Medical Service Association Medicare	$108.00
Rate for Payer: Hawaii Medical Service Association Non-ABD	$27.53
Rate for Payer: Hawaii Western Management Group Commercial	$18.96
Rate for Payer: Health Management Network Commercial	$183.60
Rate for Payer: Humana Medicare	$108.00
Rate for Payer: Kaiser Permanente Commercial	$194.40
Rate for Payer: Kaiser Permanente Medicaid	$110.16
Rate for Payer: Kaiser Permanente Medicare	$108.00
Rate for Payer: MDX Hawaii PPO	$209.52
Rate for Payer: Ohana Health Plan Medicaid	$108.00
Rate for Payer: Ohana Health Plan Medicare	$108.00
Rate for Payer: UnitedHealthcare Medicaid	$26.22
Rate for Payer: UnitedHealthcare Medicare	$108.00
Rate for Payer: University Health Alliance Commercial	$49.04

CEA Carcinoembrionic Antigen FSI

Facility

$216.00

Service Code	HCPCS 82378
Hospital Charge Code	8117877
Hospital Revenue Code	301
Min. Negotiated Rate	$183.60
Max. Negotiated Rate	$209.52
Rate for Payer: Cash Price	$140.40
Rate for Payer: Health Management Network Commercial	$183.60
Rate for Payer: Kaiser Permanente Commercial	$194.40
Rate for Payer: MDX Hawaii PPO	$209.52

Know your out-of-pocket cost for care.

All Charges