Samuel Mahelona Memorial Hospital

All Charges

Charge

Type

Setting

Price

Gentamicin Trough FSI

Facility

$172.00

Service Code	HCPCS 80170
Hospital Charge Code	8451089
Hospital Revenue Code	300
Min. Negotiated Rate	$146.20
Max. Negotiated Rate	$166.84
Rate for Payer: Cash Price	$111.80
Rate for Payer: Health Management Network Commercial	$146.20
Rate for Payer: Kaiser Permanente Commercial	$154.80
Rate for Payer: MDX Hawaii PPO	$166.84

GGTP (GGT) FSI

Facility

$86.00

Service Code	HCPCS 82977
Hospital Charge Code	8117922
Hospital Revenue Code	301
Min. Negotiated Rate	$7.20
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 ABD	$9.95
Rate for Payer: Hawaii Medical Service Association Commercial	$9.00
Rate for Payer: Hawaii Medical Service Association Medicare	$43.00
Rate for Payer: Hawaii Medical Service Association Non-ABD	$10.45
Rate for Payer: Hawaii Western Management Group Commercial	$7.20
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	$9.95
Rate for Payer: UnitedHealthcare Medicare	$43.00
Rate for Payer: University Health Alliance Commercial	$18.61

GGTP (GGT) FSI

Facility

$86.00

Service Code	HCPCS 82977
Hospital Charge Code	8117922
Hospital Revenue Code	301
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

GHB Screen, Urine w/ Rfx Cnfrm FSI

Facility

$1,384.00

Service Code	HCPCS 80307
Hospital Charge Code	8859124
Hospital Revenue Code	300
Min. Negotiated Rate	$47.89
Max. Negotiated Rate	$1,342.48
Rate for Payer: AlohaCare Medicaid	$692.00
Rate for Payer: AlohaCare Medicare	$692.00
Rate for Payer: Cash Price	$899.60
Rate for Payer: Cash Price	$899.60
Rate for Payer: Devoted Health Medicare	$761.20
Rate for Payer: Hawaii Medical Service Association ABD	$59.38
Rate for Payer: Hawaii Medical Service Association Commercial	$77.67
Rate for Payer: Hawaii Medical Service Association Medicare	$692.00
Rate for Payer: Hawaii Medical Service Association Non-ABD	$59.38
Rate for Payer: Hawaii Western Management Group Commercial	$62.14
Rate for Payer: Health Management Network Commercial	$1,176.40
Rate for Payer: Humana Medicare	$692.00
Rate for Payer: Kaiser Permanente Commercial	$1,245.60
Rate for Payer: Kaiser Permanente Medicaid	$705.84
Rate for Payer: Kaiser Permanente Medicare	$692.00
Rate for Payer: MDX Hawaii PPO	$1,342.48
Rate for Payer: Ohana Health Plan Medicaid	$692.00
Rate for Payer: Ohana Health Plan Medicare	$692.00
Rate for Payer: UnitedHealthcare Medicaid	$47.89
Rate for Payer: UnitedHealthcare Medicare	$692.00
Rate for Payer: University Health Alliance Commercial	$147.65

GHB Screen, Urine w/ Rfx Cnfrm FSI

Facility

$1,384.00

Service Code	HCPCS 80307
Hospital Charge Code	8859124
Hospital Revenue Code	300
Min. Negotiated Rate	$1,176.40
Max. Negotiated Rate	$1,342.48
Rate for Payer: Cash Price	$899.60
Rate for Payer: Health Management Network Commercial	$1,176.40
Rate for Payer: Kaiser Permanente Commercial	$1,245.60
Rate for Payer: MDX Hawaii PPO	$1,342.48

Giardia Lamblia Ag FSI

Facility

$139.00

Service Code	HCPCS 87329
Hospital Charge Code	9345653
Hospital Revenue Code	306
Min. Negotiated Rate	$11.98
Max. Negotiated Rate	$134.83
Rate for Payer: AlohaCare Medicaid	$69.50
Rate for Payer: AlohaCare Medicare	$69.50
Rate for Payer: Cash Price	$90.35
Rate for Payer: Cash Price	$90.35
Rate for Payer: Devoted Health Medicare	$76.45
Rate for Payer: Hawaii Medical Service Association ABD	$12.02
Rate for Payer: Hawaii Medical Service Association Commercial	$14.97
Rate for Payer: Hawaii Medical Service Association Medicare	$69.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$16.57
Rate for Payer: Hawaii Western Management Group Commercial	$11.98
Rate for Payer: Health Management Network Commercial	$118.15
Rate for Payer: Humana Medicare	$69.50
Rate for Payer: Kaiser Permanente Commercial	$125.10
Rate for Payer: Kaiser Permanente Medicaid	$70.89
Rate for Payer: Kaiser Permanente Medicare	$69.50
Rate for Payer: MDX Hawaii PPO	$134.83
Rate for Payer: Ohana Health Plan Medicaid	$69.50
Rate for Payer: Ohana Health Plan Medicare	$69.50
Rate for Payer: UnitedHealthcare Medicaid	$12.02
Rate for Payer: UnitedHealthcare Medicare	$69.50
Rate for Payer: University Health Alliance Commercial	$31.01

Giardia Lamblia Ag FSI

Facility

$139.00

Service Code	HCPCS 87329
Hospital Charge Code	9345653
Hospital Revenue Code	306
Min. Negotiated Rate	$118.15
Max. Negotiated Rate	$134.83
Rate for Payer: Cash Price	$90.35
Rate for Payer: Health Management Network Commercial	$118.15
Rate for Payer: Kaiser Permanente Commercial	$125.10
Rate for Payer: MDX Hawaii PPO	$134.83

GI CATHETER, NEEDLE INTERJECT

Facility

$152.00

Hospital Charge Code	8274152
Hospital Revenue Code	272
Min. Negotiated Rate	$129.20
Max. Negotiated Rate	$147.44
Rate for Payer: Cash Price	$98.80
Rate for Payer: Health Management Network Commercial	$129.20
Rate for Payer: Kaiser Permanente Commercial	$136.80
Rate for Payer: MDX Hawaii PPO	$147.44

GI CATHETER, NEEDLE INTERJECT

Facility

$152.00

Hospital Charge Code	8274152
Hospital Revenue Code	272
Min. Negotiated Rate	$76.00
Max. Negotiated Rate	$147.44
Rate for Payer: AlohaCare Medicaid	$76.00
Rate for Payer: AlohaCare Medicare	$76.00
Rate for Payer: Cash Price	$98.80
Rate for Payer: Devoted Health Medicare	$83.60
Rate for Payer: Hawaii Medical Service Association Medicare	$76.00
Rate for Payer: Hawaii Western Management Group Commercial	$144.40
Rate for Payer: Health Management Network Commercial	$129.20
Rate for Payer: Humana Medicare	$76.00
Rate for Payer: Kaiser Permanente Commercial	$136.80
Rate for Payer: Kaiser Permanente Medicaid	$77.52
Rate for Payer: Kaiser Permanente Medicare	$76.00
Rate for Payer: MDX Hawaii PPO	$147.44
Rate for Payer: Ohana Health Plan Medicaid	$76.00
Rate for Payer: Ohana Health Plan Medicare	$76.00
Rate for Payer: UnitedHealthcare Medicare	$76.00
Rate for Payer: University Health Alliance Commercial	$110.79

GI ENDOSCOPY BIOPSY FORCEP/COLD 160

Facility

$64.00

Hospital Charge Code	8274429
Hospital Revenue Code	272
Min. Negotiated Rate	$32.00
Max. Negotiated Rate	$62.08
Rate for Payer: AlohaCare Medicaid	$32.00
Rate for Payer: AlohaCare Medicare	$32.00
Rate for Payer: Cash Price	$41.60
Rate for Payer: Devoted Health Medicare	$35.20
Rate for Payer: Hawaii Medical Service Association Medicare	$32.00
Rate for Payer: Hawaii Western Management Group Commercial	$60.80
Rate for Payer: Health Management Network Commercial	$54.40
Rate for Payer: Humana Medicare	$32.00
Rate for Payer: Kaiser Permanente Commercial	$57.60
Rate for Payer: Kaiser Permanente Medicaid	$32.64
Rate for Payer: Kaiser Permanente Medicare	$32.00
Rate for Payer: MDX Hawaii PPO	$62.08
Rate for Payer: Ohana Health Plan Medicaid	$32.00
Rate for Payer: Ohana Health Plan Medicare	$32.00
Rate for Payer: UnitedHealthcare Medicare	$32.00
Rate for Payer: University Health Alliance Commercial	$46.65

GI ENDOSCOPY BIOPSY FORCEP/COLD 160

Facility

$64.00

Hospital Charge Code	8274429
Hospital Revenue Code	272
Min. Negotiated Rate	$54.40
Max. Negotiated Rate	$62.08
Rate for Payer: Cash Price	$41.60
Rate for Payer: Health Management Network Commercial	$54.40
Rate for Payer: Kaiser Permanente Commercial	$57.60
Rate for Payer: MDX Hawaii PPO	$62.08

GI ENDOSCOPY BIOPSY FORCEP/COLD 240

Facility

$92.00

Hospital Charge Code	8274216
Hospital Revenue Code	272
Min. Negotiated Rate	$78.20
Max. Negotiated Rate	$89.24
Rate for Payer: Cash Price	$59.80
Rate for Payer: Health Management Network Commercial	$78.20
Rate for Payer: Kaiser Permanente Commercial	$82.80
Rate for Payer: MDX Hawaii PPO	$89.24

GI ENDOSCOPY BIOPSY FORCEP/COLD 240

Facility

$92.00

Hospital Charge Code	8274216
Hospital Revenue Code	272
Min. Negotiated Rate	$46.00
Max. Negotiated Rate	$89.24
Rate for Payer: AlohaCare Medicaid	$46.00
Rate for Payer: AlohaCare Medicare	$46.00
Rate for Payer: Cash Price	$59.80
Rate for Payer: Devoted Health Medicare	$50.60
Rate for Payer: Hawaii Medical Service Association Medicare	$46.00
Rate for Payer: Hawaii Western Management Group Commercial	$87.40
Rate for Payer: Health Management Network Commercial	$78.20
Rate for Payer: Humana Medicare	$46.00
Rate for Payer: Kaiser Permanente Commercial	$82.80
Rate for Payer: Kaiser Permanente Medicaid	$46.92
Rate for Payer: Kaiser Permanente Medicare	$46.00
Rate for Payer: MDX Hawaii PPO	$89.24
Rate for Payer: Ohana Health Plan Medicaid	$46.00
Rate for Payer: Ohana Health Plan Medicare	$46.00
Rate for Payer: UnitedHealthcare Medicare	$46.00
Rate for Payer: University Health Alliance Commercial	$67.06

GI ENDOSCOPY INJECTION GOLD PROBE 7 FRENCH

Facility

$788.00

Hospital Charge Code	8274153
Hospital Revenue Code	272
Min. Negotiated Rate	$669.80
Max. Negotiated Rate	$764.36
Rate for Payer: Cash Price	$512.20
Rate for Payer: Health Management Network Commercial	$669.80
Rate for Payer: Kaiser Permanente Commercial	$709.20
Rate for Payer: MDX Hawaii PPO	$764.36

GI ENDOSCOPY INJECTION GOLD PROBE 7 FRENCH

Facility

$788.00

Hospital Charge Code	8274153
Hospital Revenue Code	272
Min. Negotiated Rate	$394.00
Max. Negotiated Rate	$764.36
Rate for Payer: AlohaCare Medicaid	$394.00
Rate for Payer: AlohaCare Medicare	$394.00
Rate for Payer: Cash Price	$512.20
Rate for Payer: Devoted Health Medicare	$433.40
Rate for Payer: Hawaii Medical Service Association Medicare	$394.00
Rate for Payer: Hawaii Western Management Group Commercial	$748.60
Rate for Payer: Health Management Network Commercial	$669.80
Rate for Payer: Humana Medicare	$394.00
Rate for Payer: Kaiser Permanente Commercial	$709.20
Rate for Payer: Kaiser Permanente Medicaid	$401.88
Rate for Payer: Kaiser Permanente Medicare	$394.00
Rate for Payer: MDX Hawaii PPO	$764.36
Rate for Payer: Ohana Health Plan Medicaid	$394.00
Rate for Payer: Ohana Health Plan Medicare	$394.00
Rate for Payer: UnitedHealthcare Medicare	$394.00
Rate for Payer: University Health Alliance Commercial	$574.37

GI ENDOSCOPY RESCUE NET RETRIEVAL

Facility

$340.00

Hospital Charge Code	10510251
Hospital Revenue Code	272
Min. Negotiated Rate	$289.00
Max. Negotiated Rate	$329.80
Rate for Payer: Cash Price	$221.00
Rate for Payer: Health Management Network Commercial	$289.00
Rate for Payer: Kaiser Permanente Commercial	$306.00
Rate for Payer: MDX Hawaii PPO	$329.80

GI ENDOSCOPY RESCUE NET RETRIEVAL

Facility

$340.00

Hospital Charge Code	10510251
Hospital Revenue Code	272
Min. Negotiated Rate	$170.00
Max. Negotiated Rate	$329.80
Rate for Payer: AlohaCare Medicaid	$170.00
Rate for Payer: AlohaCare Medicare	$170.00
Rate for Payer: Cash Price	$221.00
Rate for Payer: Devoted Health Medicare	$187.00
Rate for Payer: Hawaii Medical Service Association Medicare	$170.00
Rate for Payer: Hawaii Western Management Group Commercial	$323.00
Rate for Payer: Health Management Network Commercial	$289.00
Rate for Payer: Humana Medicare	$170.00
Rate for Payer: Kaiser Permanente Commercial	$306.00
Rate for Payer: Kaiser Permanente Medicaid	$173.40
Rate for Payer: Kaiser Permanente Medicare	$170.00
Rate for Payer: MDX Hawaii PPO	$329.80
Rate for Payer: Ohana Health Plan Medicaid	$170.00
Rate for Payer: Ohana Health Plan Medicare	$170.00
Rate for Payer: UnitedHealthcare Medicare	$170.00
Rate for Payer: University Health Alliance Commercial	$247.83

GI GASTRO POLYP TRAP

Facility

$14.00

Hospital Charge Code	8274346
Hospital Revenue Code	272
Min. Negotiated Rate	$7.00
Max. Negotiated Rate	$13.58
Rate for Payer: AlohaCare Medicaid	$7.00
Rate for Payer: AlohaCare Medicare	$7.00
Rate for Payer: Cash Price	$9.10
Rate for Payer: Devoted Health Medicare	$7.70
Rate for Payer: Hawaii Medical Service Association Medicare	$7.00
Rate for Payer: Hawaii Western Management Group Commercial	$13.30
Rate for Payer: Health Management Network Commercial	$11.90
Rate for Payer: Humana Medicare	$7.00
Rate for Payer: Kaiser Permanente Commercial	$12.60
Rate for Payer: Kaiser Permanente Medicaid	$7.14
Rate for Payer: Kaiser Permanente Medicare	$7.00
Rate for Payer: MDX Hawaii PPO	$13.58
Rate for Payer: Ohana Health Plan Medicaid	$7.00
Rate for Payer: Ohana Health Plan Medicare	$7.00
Rate for Payer: UnitedHealthcare Medicare	$7.00
Rate for Payer: University Health Alliance Commercial	$10.20

GI GASTRO POLYP TRAP

Facility

$14.00

Hospital Charge Code	8274346
Hospital Revenue Code	272
Min. Negotiated Rate	$11.90
Max. Negotiated Rate	$13.58
Rate for Payer: Cash Price	$9.10
Rate for Payer: Health Management Network Commercial	$11.90
Rate for Payer: Kaiser Permanente Commercial	$12.60
Rate for Payer: MDX Hawaii PPO	$13.58

GI: INFLATOR FOR BALLOON 60CC

Facility

$190.00

Hospital Charge Code	9953066
Hospital Revenue Code	272
Min. Negotiated Rate	$95.00
Max. Negotiated Rate	$184.30
Rate for Payer: AlohaCare Medicaid	$95.00
Rate for Payer: AlohaCare Medicare	$95.00
Rate for Payer: Cash Price	$123.50
Rate for Payer: Devoted Health Medicare	$104.50
Rate for Payer: Hawaii Medical Service Association Medicare	$95.00
Rate for Payer: Hawaii Western Management Group Commercial	$180.50
Rate for Payer: Health Management Network Commercial	$161.50
Rate for Payer: Humana Medicare	$95.00
Rate for Payer: Kaiser Permanente Commercial	$171.00
Rate for Payer: Kaiser Permanente Medicaid	$96.90
Rate for Payer: Kaiser Permanente Medicare	$95.00
Rate for Payer: MDX Hawaii PPO	$184.30
Rate for Payer: Ohana Health Plan Medicaid	$95.00
Rate for Payer: Ohana Health Plan Medicare	$95.00
Rate for Payer: UnitedHealthcare Medicare	$95.00
Rate for Payer: University Health Alliance Commercial	$138.49

GI: INFLATOR FOR BALLOON 60CC

Facility

$190.00

Hospital Charge Code	9953066
Hospital Revenue Code	272
Min. Negotiated Rate	$161.50
Max. Negotiated Rate	$184.30
Rate for Payer: Cash Price	$123.50
Rate for Payer: Health Management Network Commercial	$161.50
Rate for Payer: Kaiser Permanente Commercial	$171.00
Rate for Payer: MDX Hawaii PPO	$184.30

GI Panel PCR FSI

Facility

$3,849.00

Service Code	HCPCS 87999
Hospital Charge Code	8695016
Hospital Revenue Code	306
Min. Negotiated Rate	$7.90
Max. Negotiated Rate	$3,733.53
Rate for Payer: AlohaCare Medicaid	$1,924.50
Rate for Payer: AlohaCare Medicare	$1,924.50
Rate for Payer: Cash Price	$2,501.85
Rate for Payer: Cash Price	$2,501.85
Rate for Payer: Devoted Health Medicare	$2,116.95
Rate for Payer: Hawaii Medical Service Association Medicare	$1,924.50
Rate for Payer: Hawaii Western Management Group Commercial	$3,656.55
Rate for Payer: Health Management Network Commercial	$3,271.65
Rate for Payer: Humana Medicare	$1,924.50
Rate for Payer: Kaiser Permanente Commercial	$3,464.10
Rate for Payer: Kaiser Permanente Medicaid	$1,962.99
Rate for Payer: Kaiser Permanente Medicare	$1,924.50
Rate for Payer: MDX Hawaii PPO	$3,733.53
Rate for Payer: Ohana Health Plan Medicaid	$1,924.50
Rate for Payer: Ohana Health Plan Medicare	$1,924.50
Rate for Payer: UnitedHealthcare Medicaid	$7.90
Rate for Payer: UnitedHealthcare Medicare	$1,924.50
Rate for Payer: University Health Alliance Commercial	$2,155.44

GI Panel PCR FSI

Facility

$3,849.00

Service Code	HCPCS 87999
Hospital Charge Code	8695016
Hospital Revenue Code	306
Min. Negotiated Rate	$3,271.65
Max. Negotiated Rate	$3,733.53
Rate for Payer: Cash Price	$2,501.85
Rate for Payer: Health Management Network Commercial	$3,271.65
Rate for Payer: Kaiser Permanente Commercial	$3,464.10
Rate for Payer: MDX Hawaii PPO	$3,733.53

GI QUICKCLIP PRO

Facility

$735.00

Hospital Charge Code	9952984
Hospital Revenue Code	272
Min. Negotiated Rate	$367.50
Max. Negotiated Rate	$712.95
Rate for Payer: MDX Hawaii PPO	$712.95
Rate for Payer: AlohaCare Medicaid	$367.50
Rate for Payer: AlohaCare Medicare	$367.50
Rate for Payer: Cash Price	$477.75
Rate for Payer: Devoted Health Medicare	$404.25
Rate for Payer: Hawaii Medical Service Association Medicare	$367.50
Rate for Payer: Hawaii Western Management Group Commercial	$698.25
Rate for Payer: Health Management Network Commercial	$624.75
Rate for Payer: Humana Medicare	$367.50
Rate for Payer: Kaiser Permanente Commercial	$661.50
Rate for Payer: Kaiser Permanente Medicaid	$374.85
Rate for Payer: Kaiser Permanente Medicare	$367.50
Rate for Payer: Ohana Health Plan Medicaid	$367.50
Rate for Payer: Ohana Health Plan Medicare	$367.50
Rate for Payer: UnitedHealthcare Medicare	$367.50
Rate for Payer: University Health Alliance Commercial	$535.74

GI QUICKCLIP PRO

Facility

$735.00

Hospital Charge Code	9952984
Hospital Revenue Code	272
Min. Negotiated Rate	$624.75
Max. Negotiated Rate	$712.95
Rate for Payer: Cash Price	$477.75
Rate for Payer: Health Management Network Commercial	$624.75
Rate for Payer: Kaiser Permanente Commercial	$661.50
Rate for Payer: MDX Hawaii PPO	$712.95

Know your out-of-pocket cost for care.

All Charges