Samuel Mahelona Memorial Hospital

All Charges

Charge

Type

Setting

Price

GI: RADIAL JAW (HOT) 240CM

Facility

$115.00

Hospital Charge Code	9953068
Hospital Revenue Code	272
Min. Negotiated Rate	$57.50
Max. Negotiated Rate	$111.55
Rate for Payer: AlohaCare Medicaid	$57.50
Rate for Payer: AlohaCare Medicare	$57.50
Rate for Payer: Cash Price	$74.75
Rate for Payer: Devoted Health Medicare	$63.25
Rate for Payer: Hawaii Medical Service Association Medicare	$57.50
Rate for Payer: Hawaii Western Management Group Commercial	$109.25
Rate for Payer: Health Management Network Commercial	$97.75
Rate for Payer: Humana Medicare	$57.50
Rate for Payer: Kaiser Permanente Commercial	$103.50
Rate for Payer: Kaiser Permanente Medicaid	$58.65
Rate for Payer: Kaiser Permanente Medicare	$57.50
Rate for Payer: MDX Hawaii PPO	$111.55
Rate for Payer: Ohana Health Plan Medicaid	$57.50
Rate for Payer: Ohana Health Plan Medicare	$57.50
Rate for Payer: UnitedHealthcare Medicare	$57.50
Rate for Payer: University Health Alliance Commercial	$83.82

GI: RADIAL JAW (HOT) 240CM

Facility

$115.00

Hospital Charge Code	9953068
Hospital Revenue Code	272
Min. Negotiated Rate	$97.75
Max. Negotiated Rate	$111.55
Rate for Payer: Cash Price	$74.75
Rate for Payer: Health Management Network Commercial	$97.75
Rate for Payer: Kaiser Permanente Commercial	$103.50
Rate for Payer: MDX Hawaii PPO	$111.55

GI: RESOLUTION CLIP 360 - 235CM

Facility

$822.00

Hospital Charge Code	9953046
Hospital Revenue Code	272
Min. Negotiated Rate	$698.70
Max. Negotiated Rate	$797.34
Rate for Payer: Cash Price	$534.30
Rate for Payer: Health Management Network Commercial	$698.70
Rate for Payer: Kaiser Permanente Commercial	$739.80
Rate for Payer: MDX Hawaii PPO	$797.34

GI: RESOLUTION CLIP 360 - 235CM

Facility

$822.00

Hospital Charge Code	9953046
Hospital Revenue Code	272
Min. Negotiated Rate	$411.00
Max. Negotiated Rate	$797.34
Rate for Payer: AlohaCare Medicaid	$411.00
Rate for Payer: AlohaCare Medicare	$411.00
Rate for Payer: Cash Price	$534.30
Rate for Payer: Devoted Health Medicare	$452.10
Rate for Payer: Hawaii Medical Service Association Medicare	$411.00
Rate for Payer: Hawaii Western Management Group Commercial	$780.90
Rate for Payer: Health Management Network Commercial	$698.70
Rate for Payer: Humana Medicare	$411.00
Rate for Payer: Kaiser Permanente Commercial	$739.80
Rate for Payer: Kaiser Permanente Medicaid	$419.22
Rate for Payer: Kaiser Permanente Medicare	$411.00
Rate for Payer: MDX Hawaii PPO	$797.34
Rate for Payer: Ohana Health Plan Medicaid	$411.00
Rate for Payer: Ohana Health Plan Medicare	$411.00
Rate for Payer: UnitedHealthcare Medicare	$411.00
Rate for Payer: University Health Alliance Commercial	$599.16

GI SNARE CAPTIVATION LARGE 30MM

Facility

$24.00

Hospital Charge Code	9542824
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: 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 Medicare	$12.00
Rate for Payer: University Health Alliance Commercial	$17.49

GI SNARE CAPTIVATION LARGE 30MM

Facility

$24.00

Hospital Charge Code	9542824
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

GI SNARE CAPTIVATOR LARGE OVAL (THIN WIRE) 30MM LARGE SNARE

Facility

$523.00

Hospital Charge Code	9595418
Hospital Revenue Code	272
Min. Negotiated Rate	$261.50
Max. Negotiated Rate	$507.31
Rate for Payer: AlohaCare Medicaid	$261.50
Rate for Payer: AlohaCare Medicare	$261.50
Rate for Payer: Cash Price	$339.95
Rate for Payer: Devoted Health Medicare	$287.65
Rate for Payer: Hawaii Medical Service Association Medicare	$261.50
Rate for Payer: Hawaii Western Management Group Commercial	$496.85
Rate for Payer: Health Management Network Commercial	$444.55
Rate for Payer: Humana Medicare	$261.50
Rate for Payer: Kaiser Permanente Commercial	$470.70
Rate for Payer: Kaiser Permanente Medicaid	$266.73
Rate for Payer: Kaiser Permanente Medicare	$261.50
Rate for Payer: MDX Hawaii PPO	$507.31
Rate for Payer: Ohana Health Plan Medicaid	$261.50
Rate for Payer: Ohana Health Plan Medicare	$261.50
Rate for Payer: UnitedHealthcare Medicare	$261.50
Rate for Payer: University Health Alliance Commercial	$381.21

GI SNARE CAPTIVATOR LARGE OVAL (THIN WIRE) 30MM LARGE SNARE

Facility

$523.00

Hospital Charge Code	9595418
Hospital Revenue Code	272
Min. Negotiated Rate	$444.55
Max. Negotiated Rate	$507.31
Rate for Payer: Cash Price	$339.95
Rate for Payer: Health Management Network Commercial	$444.55
Rate for Payer: Kaiser Permanente Commercial	$470.70
Rate for Payer: MDX Hawaii PPO	$507.31

GI SNARE, COLONOSCOPY ROTATABLE

Facility

$96.00

Hospital Charge Code	8274288
Hospital Revenue Code	272
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

GI SNARE, COLONOSCOPY ROTATABLE

Facility

$96.00

Hospital Charge Code	8274288
Hospital Revenue Code	272
Min. Negotiated Rate	$48.00
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: Devoted Health Medicare	$52.80
Rate for Payer: Hawaii Medical Service Association Medicare	$48.00
Rate for Payer: Hawaii Western Management Group Commercial	$91.20
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 Medicare	$48.00
Rate for Payer: University Health Alliance Commercial	$69.97

GI SNARE, ENDOSCOPY 240 CAPTIVATOR LARGE OVAL THIN WIRE FLEXIBLE 30MM

Facility

$89.00

Hospital Charge Code	8274444
Hospital Revenue Code	272
Min. Negotiated Rate	$75.65
Max. Negotiated Rate	$86.33
Rate for Payer: Cash Price	$57.85
Rate for Payer: Health Management Network Commercial	$75.65
Rate for Payer: Kaiser Permanente Commercial	$80.10
Rate for Payer: MDX Hawaii PPO	$86.33

GI SNARE, ENDOSCOPY 240 CAPTIVATOR LARGE OVAL THIN WIRE FLEXIBLE 30MM

Facility

$89.00

Hospital Charge Code	8274444
Hospital Revenue Code	272
Min. Negotiated Rate	$44.50
Max. Negotiated Rate	$86.33
Rate for Payer: AlohaCare Medicaid	$44.50
Rate for Payer: AlohaCare Medicare	$44.50
Rate for Payer: Cash Price	$57.85
Rate for Payer: Devoted Health Medicare	$48.95
Rate for Payer: Hawaii Medical Service Association Medicare	$44.50
Rate for Payer: Hawaii Western Management Group Commercial	$84.55
Rate for Payer: Health Management Network Commercial	$75.65
Rate for Payer: Humana Medicare	$44.50
Rate for Payer: Kaiser Permanente Commercial	$80.10
Rate for Payer: Kaiser Permanente Medicaid	$45.39
Rate for Payer: Kaiser Permanente Medicare	$44.50
Rate for Payer: MDX Hawaii PPO	$86.33
Rate for Payer: Ohana Health Plan Medicaid	$44.50
Rate for Payer: Ohana Health Plan Medicare	$44.50
Rate for Payer: UnitedHealthcare Medicare	$44.50
Rate for Payer: University Health Alliance Commercial	$64.87

GI SNARE, MASTER

Facility

$72.00

Hospital Charge Code	8274301
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

GI SNARE, MASTER

Facility

$72.00

Hospital Charge Code	8274301
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

GI: SNARE, MEDIUM

Facility

$108.00

Hospital Charge Code	9953069
Hospital Revenue Code	272
Min. Negotiated Rate	$54.00
Max. Negotiated Rate	$104.76
Rate for Payer: AlohaCare Medicaid	$54.00
Rate for Payer: AlohaCare Medicare	$54.00
Rate for Payer: Cash Price	$70.20
Rate for Payer: Devoted Health Medicare	$59.40
Rate for Payer: Hawaii Medical Service Association Medicare	$54.00
Rate for Payer: Hawaii Western Management Group Commercial	$102.60
Rate for Payer: Health Management Network Commercial	$91.80
Rate for Payer: Humana Medicare	$54.00
Rate for Payer: Kaiser Permanente Commercial	$97.20
Rate for Payer: Kaiser Permanente Medicaid	$55.08
Rate for Payer: Kaiser Permanente Medicare	$54.00
Rate for Payer: MDX Hawaii PPO	$104.76
Rate for Payer: Ohana Health Plan Medicaid	$54.00
Rate for Payer: Ohana Health Plan Medicare	$54.00
Rate for Payer: UnitedHealthcare Medicare	$54.00
Rate for Payer: University Health Alliance Commercial	$78.72

GI: SNARE, MEDIUM

Facility

$108.00

Hospital Charge Code	9953069
Hospital Revenue Code	272
Min. Negotiated Rate	$91.80
Max. Negotiated Rate	$104.76
Rate for Payer: Cash Price	$70.20
Rate for Payer: Health Management Network Commercial	$91.80
Rate for Payer: Kaiser Permanente Commercial	$97.20
Rate for Payer: MDX Hawaii PPO	$104.76

glipiZIDE 5 mg tablet [HHSC]

Facility

$3.00

Service Code	NDC 60505014100
Hospital Charge Code	2500357
Hospital Revenue Code	250
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 Medicaid	$1.80
Rate for Payer: UnitedHealthcare Medicare	$1.50
Rate for Payer: University Health Alliance Commercial	$2.19

glipiZIDE 5 mg tablet [HHSC]

Facility

$3.00

Service Code	NDC 50268036115
Hospital Charge Code	2500357
Hospital Revenue Code	250
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 Medicaid	$1.80
Rate for Payer: UnitedHealthcare Medicare	$1.50
Rate for Payer: University Health Alliance Commercial	$2.19

glipiZIDE 5 mg tablet [HHSC]

Facility

$3.00

Service Code	NDC 51079081020
Hospital Charge Code	2500357
Hospital Revenue Code	250
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

glipiZIDE 5 mg tablet [HHSC]

Facility

$3.00

Service Code	NDC 51079081020
Hospital Charge Code	2500357
Hospital Revenue Code	250
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 Medicaid	$1.80
Rate for Payer: UnitedHealthcare Medicare	$1.50
Rate for Payer: University Health Alliance Commercial	$2.19

glipiZIDE 5 mg tablet [HHSC]

Facility

$3.00

Service Code	NDC 60505014100
Hospital Charge Code	2500357
Hospital Revenue Code	250
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

glipiZIDE 5 mg tablet [HHSC]

Facility

$3.00

Service Code	NDC 60687069001
Hospital Charge Code	2500357
Hospital Revenue Code	250
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

glipiZIDE 5 mg tablet [HHSC]

Facility

$3.00

Service Code	NDC 60687069001
Hospital Charge Code	2500357
Hospital Revenue Code	250
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 Medicaid	$1.80
Rate for Payer: UnitedHealthcare Medicare	$1.50
Rate for Payer: University Health Alliance Commercial	$2.19

glipiZIDE 5 mg tablet [HHSC]

Facility

$3.00

Service Code	NDC 50268036115
Hospital Charge Code	2500357
Hospital Revenue Code	250
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

glucagon 1 mg kit [HHSC]

Facility

$944.24

Service Code	HCPCS J1610
Hospital Charge Code	2500358
Hospital Revenue Code	636
Min. Negotiated Rate	$182.91
Max. Negotiated Rate	$915.91
Rate for Payer: AlohaCare Medicaid	$472.12
Rate for Payer: AlohaCare Medicaid	$469.67
Rate for Payer: AlohaCare Medicare	$472.12
Rate for Payer: AlohaCare Medicare	$469.67
Rate for Payer: Cash Price	$610.57
Rate for Payer: Cash Price	$610.57
Rate for Payer: Cash Price	$613.76
Rate for Payer: Cash Price	$613.76
Rate for Payer: Devoted Health Medicare	$519.33
Rate for Payer: Devoted Health Medicare	$516.64
Rate for Payer: Hawaii Medical Service Association ABD	$195.79
Rate for Payer: Hawaii Medical Service Association ABD	$195.79
Rate for Payer: Hawaii Medical Service Association Commercial	$182.91
Rate for Payer: Hawaii Medical Service Association Commercial	$182.91
Rate for Payer: Hawaii Medical Service Association Medicare	$472.12
Rate for Payer: Hawaii Medical Service Association Medicare	$469.67
Rate for Payer: Hawaii Medical Service Association Non-ABD	$195.79
Rate for Payer: Hawaii Medical Service Association Non-ABD	$195.79
Rate for Payer: Hawaii Western Management Group Commercial	$897.03
Rate for Payer: Hawaii Western Management Group Commercial	$892.37
Rate for Payer: Health Management Network Commercial	$802.60
Rate for Payer: Health Management Network Commercial	$798.44
Rate for Payer: Humana Medicare	$469.67
Rate for Payer: Humana Medicare	$472.12
Rate for Payer: Kaiser Permanente Commercial	$849.82
Rate for Payer: Kaiser Permanente Commercial	$845.41
Rate for Payer: Kaiser Permanente Medicaid	$479.06
Rate for Payer: Kaiser Permanente Medicaid	$481.56
Rate for Payer: Kaiser Permanente Medicare	$472.12
Rate for Payer: Kaiser Permanente Medicare	$469.67
Rate for Payer: MDX Hawaii PPO	$915.91
Rate for Payer: MDX Hawaii PPO	$911.16
Rate for Payer: Ohana Health Plan Medicaid	$469.67
Rate for Payer: Ohana Health Plan Medicaid	$472.12
Rate for Payer: Ohana Health Plan Medicare	$469.67
Rate for Payer: Ohana Health Plan Medicare	$472.12
Rate for Payer: UnitedHealthcare Medicaid	$563.60
Rate for Payer: UnitedHealthcare Medicaid	$566.54
Rate for Payer: UnitedHealthcare Medicare	$469.67
Rate for Payer: UnitedHealthcare Medicare	$472.12
Rate for Payer: University Health Alliance Commercial	$688.26
Rate for Payer: University Health Alliance Commercial	$684.68

Know your out-of-pocket cost for care.

All Charges