Samuel Mahelona Memorial Hospital

All Charges

Charge

Type

Setting

Price

guaiFENesin ER 600 mg tablet [HHSC]

Facility

$5.57

Service Code	NDC 68084057201
Hospital Charge Code	2500369
Hospital Revenue Code	250
Min. Negotiated Rate	$2.79
Max. Negotiated Rate	$5.40
Rate for Payer: AlohaCare Medicaid	$2.79
Rate for Payer: AlohaCare Medicare	$2.79
Rate for Payer: Cash Price	$3.62
Rate for Payer: Devoted Health Medicare	$3.06
Rate for Payer: Hawaii Medical Service Association Medicare	$2.79
Rate for Payer: Hawaii Western Management Group Commercial	$5.29
Rate for Payer: Health Management Network Commercial	$4.73
Rate for Payer: Humana Medicare	$2.79
Rate for Payer: Kaiser Permanente Commercial	$5.01
Rate for Payer: Kaiser Permanente Medicaid	$2.84
Rate for Payer: Kaiser Permanente Medicare	$2.79
Rate for Payer: MDX Hawaii PPO	$5.40
Rate for Payer: Ohana Health Plan Medicaid	$2.79
Rate for Payer: Ohana Health Plan Medicare	$2.79
Rate for Payer: UnitedHealthcare Medicaid	$3.34
Rate for Payer: UnitedHealthcare Medicare	$2.79
Rate for Payer: University Health Alliance Commercial	$4.06

GUIDE PIN, 3.2MM X 330MM

Facility

$245.00

Hospital Charge Code	12984241
Hospital Revenue Code	272
Min. Negotiated Rate	$122.50
Max. Negotiated Rate	$237.65
Rate for Payer: AlohaCare Medicaid	$122.50
Rate for Payer: AlohaCare Medicare	$122.50
Rate for Payer: Cash Price	$159.25
Rate for Payer: Devoted Health Medicare	$134.75
Rate for Payer: Hawaii Medical Service Association Medicare	$122.50
Rate for Payer: Hawaii Western Management Group Commercial	$232.75
Rate for Payer: Health Management Network Commercial	$208.25
Rate for Payer: Humana Medicare	$122.50
Rate for Payer: Kaiser Permanente Commercial	$220.50
Rate for Payer: Kaiser Permanente Medicaid	$124.95
Rate for Payer: Kaiser Permanente Medicare	$122.50
Rate for Payer: MDX Hawaii PPO	$237.65
Rate for Payer: Ohana Health Plan Medicaid	$122.50
Rate for Payer: Ohana Health Plan Medicare	$122.50
Rate for Payer: UnitedHealthcare Medicare	$122.50
Rate for Payer: University Health Alliance Commercial	$178.58

GUIDE PIN, 3.2MM X 330MM

Facility

$245.00

Hospital Charge Code	12984241
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

GUIDE PIN, 3.2MM X 381MM

Facility

$231.00

Hospital Charge Code	12984236
Hospital Revenue Code	272
Min. Negotiated Rate	$115.50
Max. Negotiated Rate	$224.07
Rate for Payer: AlohaCare Medicaid	$115.50
Rate for Payer: AlohaCare Medicare	$115.50
Rate for Payer: Cash Price	$150.15
Rate for Payer: Devoted Health Medicare	$127.05
Rate for Payer: Hawaii Medical Service Association Medicare	$115.50
Rate for Payer: Hawaii Western Management Group Commercial	$219.45
Rate for Payer: Health Management Network Commercial	$196.35
Rate for Payer: Humana Medicare	$115.50
Rate for Payer: Kaiser Permanente Commercial	$207.90
Rate for Payer: Kaiser Permanente Medicaid	$117.81
Rate for Payer: Kaiser Permanente Medicare	$115.50
Rate for Payer: MDX Hawaii PPO	$224.07
Rate for Payer: Ohana Health Plan Medicaid	$115.50
Rate for Payer: Ohana Health Plan Medicare	$115.50
Rate for Payer: UnitedHealthcare Medicare	$115.50
Rate for Payer: University Health Alliance Commercial	$168.38

GUIDE PIN, 3.2MM X 381MM

Facility

$231.00

Hospital Charge Code	12984236
Hospital Revenue Code	272
Min. Negotiated Rate	$196.35
Max. Negotiated Rate	$224.07
Rate for Payer: Cash Price	$150.15
Rate for Payer: Health Management Network Commercial	$196.35
Rate for Payer: Kaiser Permanente Commercial	$207.90
Rate for Payer: MDX Hawaii PPO	$224.07

GUIDEWIRE, DRILL TIP, 1.25MM

Facility

$86.00

Hospital Charge Code	12984242
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

GUIDEWIRE, DRILL TIP, 1.25MM

Facility

$86.00

Hospital Charge Code	12984242
Hospital Revenue Code	272
Min. Negotiated Rate	$43.00
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: 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 Medicare	$43.00
Rate for Payer: University Health Alliance Commercial	$62.69

GUIDEWIRE, DRILL TIP, 1.6MM

Facility

$86.00

Hospital Charge Code	12984237
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

GUIDEWIRE, DRILL TIP, 1.6MM

Facility

$86.00

Hospital Charge Code	12984237
Hospital Revenue Code	272
Min. Negotiated Rate	$43.00
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: 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 Medicare	$43.00
Rate for Payer: University Health Alliance Commercial	$62.69

GUIDEWIRE, DRILL TIP, 2.0MM

Facility

$86.00

Hospital Charge Code	12984243
Hospital Revenue Code	272
Min. Negotiated Rate	$43.00
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: 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 Medicare	$43.00
Rate for Payer: University Health Alliance Commercial	$62.69

GUIDEWIRE, DRILL TIP, 2.0MM

Facility

$86.00

Hospital Charge Code	12984243
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

GUIDE WIRE FIXED CORE SAFE TJ CURVE (CT)

Facility

$84.00

Service Code	HCPCS C1769
Hospital Charge Code	8886982
Hospital Revenue Code	272
Min. Negotiated Rate	$42.00
Max. Negotiated Rate	$81.48
Rate for Payer: AlohaCare Medicaid	$42.00
Rate for Payer: AlohaCare Medicare	$42.00
Rate for Payer: Cash Price	$54.60
Rate for Payer: Devoted Health Medicare	$46.20
Rate for Payer: Hawaii Medical Service Association Medicare	$42.00
Rate for Payer: Hawaii Western Management Group Commercial	$79.80
Rate for Payer: Health Management Network Commercial	$71.40
Rate for Payer: Humana Medicare	$42.00
Rate for Payer: Kaiser Permanente Commercial	$75.60
Rate for Payer: Kaiser Permanente Medicaid	$42.84
Rate for Payer: Kaiser Permanente Medicare	$42.00
Rate for Payer: MDX Hawaii PPO	$81.48
Rate for Payer: Ohana Health Plan Medicaid	$42.00
Rate for Payer: Ohana Health Plan Medicare	$42.00
Rate for Payer: UnitedHealthcare Medicare	$42.00
Rate for Payer: University Health Alliance Commercial	$61.23

GUIDE WIRE FIXED CORE SAFE TJ CURVE (CT)

Facility

$84.00

Service Code	HCPCS C1769
Hospital Charge Code	8886982
Hospital Revenue Code	272
Min. Negotiated Rate	$71.40
Max. Negotiated Rate	$81.48
Rate for Payer: Cash Price	$54.60
Rate for Payer: Health Management Network Commercial	$71.40
Rate for Payer: Kaiser Permanente Commercial	$75.60
Rate for Payer: MDX Hawaii PPO	$81.48

GUIDE WIRE FIXED CORE SAFE TJ CURVE (US)

Facility

$84.00

Service Code	HCPCS C1769
Hospital Charge Code	8886981
Hospital Revenue Code	272
Min. Negotiated Rate	$42.00
Max. Negotiated Rate	$81.48
Rate for Payer: AlohaCare Medicaid	$42.00
Rate for Payer: AlohaCare Medicare	$42.00
Rate for Payer: Cash Price	$54.60
Rate for Payer: Devoted Health Medicare	$46.20
Rate for Payer: Hawaii Medical Service Association Medicare	$42.00
Rate for Payer: Hawaii Western Management Group Commercial	$79.80
Rate for Payer: Health Management Network Commercial	$71.40
Rate for Payer: Humana Medicare	$42.00
Rate for Payer: Kaiser Permanente Commercial	$75.60
Rate for Payer: Kaiser Permanente Medicaid	$42.84
Rate for Payer: Kaiser Permanente Medicare	$42.00
Rate for Payer: MDX Hawaii PPO	$81.48
Rate for Payer: Ohana Health Plan Medicaid	$42.00
Rate for Payer: Ohana Health Plan Medicare	$42.00
Rate for Payer: UnitedHealthcare Medicare	$42.00
Rate for Payer: University Health Alliance Commercial	$61.23

GUIDE WIRE FIXED CORE SAFE TJ CURVE (US)

Facility

$84.00

Service Code	HCPCS C1769
Hospital Charge Code	8886981
Hospital Revenue Code	272
Min. Negotiated Rate	$71.40
Max. Negotiated Rate	$81.48
Rate for Payer: Cash Price	$54.60
Rate for Payer: Health Management Network Commercial	$71.40
Rate for Payer: Kaiser Permanente Commercial	$75.60
Rate for Payer: MDX Hawaii PPO	$81.48

GUIDE WIRE FIXED CORE SAFE TJ CURVE (XR/MAMMO)

Facility

$84.00

Service Code	HCPCS C1769
Hospital Charge Code	8886983
Hospital Revenue Code	272
Min. Negotiated Rate	$71.40
Max. Negotiated Rate	$81.48
Rate for Payer: Cash Price	$54.60
Rate for Payer: Health Management Network Commercial	$71.40
Rate for Payer: Kaiser Permanente Commercial	$75.60
Rate for Payer: MDX Hawaii PPO	$81.48

GUIDE WIRE FIXED CORE SAFE TJ CURVE (XR/MAMMO)

Facility

$84.00

Service Code	HCPCS C1769
Hospital Charge Code	8886983
Hospital Revenue Code	272
Min. Negotiated Rate	$42.00
Max. Negotiated Rate	$81.48
Rate for Payer: AlohaCare Medicaid	$42.00
Rate for Payer: AlohaCare Medicare	$42.00
Rate for Payer: Cash Price	$54.60
Rate for Payer: Devoted Health Medicare	$46.20
Rate for Payer: Hawaii Medical Service Association Medicare	$42.00
Rate for Payer: Hawaii Western Management Group Commercial	$79.80
Rate for Payer: Health Management Network Commercial	$71.40
Rate for Payer: Humana Medicare	$42.00
Rate for Payer: Kaiser Permanente Commercial	$75.60
Rate for Payer: Kaiser Permanente Medicaid	$42.84
Rate for Payer: Kaiser Permanente Medicare	$42.00
Rate for Payer: MDX Hawaii PPO	$81.48
Rate for Payer: Ohana Health Plan Medicaid	$42.00
Rate for Payer: Ohana Health Plan Medicare	$42.00
Rate for Payer: UnitedHealthcare Medicare	$42.00
Rate for Payer: University Health Alliance Commercial	$61.23

GUIDE WIRE, TROCAR TIP, 1.35 MM

Facility

$25.00

Service Code	HCPCS C1769
Hospital Charge Code	12944032
Hospital Revenue Code	272
Min. Negotiated Rate	$12.50
Max. Negotiated Rate	$24.25
Rate for Payer: AlohaCare Medicaid	$12.50
Rate for Payer: AlohaCare Medicare	$12.50
Rate for Payer: Cash Price	$16.25
Rate for Payer: Devoted Health Medicare	$13.75
Rate for Payer: Hawaii Medical Service Association Medicare	$12.50
Rate for Payer: Hawaii Western Management Group Commercial	$23.75
Rate for Payer: Health Management Network Commercial	$21.25
Rate for Payer: Humana Medicare	$12.50
Rate for Payer: Kaiser Permanente Commercial	$22.50
Rate for Payer: Kaiser Permanente Medicaid	$12.75
Rate for Payer: Kaiser Permanente Medicare	$12.50
Rate for Payer: MDX Hawaii PPO	$24.25
Rate for Payer: Ohana Health Plan Medicaid	$12.50
Rate for Payer: Ohana Health Plan Medicare	$12.50
Rate for Payer: UnitedHealthcare Medicare	$12.50
Rate for Payer: University Health Alliance Commercial	$18.22

GUIDE WIRE, TROCAR TIP, 1.35 MM

Facility

$25.00

Service Code	HCPCS C1769
Hospital Charge Code	12944032
Hospital Revenue Code	272
Min. Negotiated Rate	$21.25
Max. Negotiated Rate	$24.25
Rate for Payer: Cash Price	$16.25
Rate for Payer: Health Management Network Commercial	$21.25
Rate for Payer: Kaiser Permanente Commercial	$22.50
Rate for Payer: MDX Hawaii PPO	$24.25

GYN: ALLY UPS ADAPTER DRAPE

Facility

$617.00

Hospital Charge Code	11584047
Hospital Revenue Code	272
Min. Negotiated Rate	$308.50
Max. Negotiated Rate	$598.49
Rate for Payer: AlohaCare Medicaid	$308.50
Rate for Payer: AlohaCare Medicare	$308.50
Rate for Payer: Cash Price	$401.05
Rate for Payer: Devoted Health Medicare	$339.35
Rate for Payer: Hawaii Medical Service Association Medicare	$308.50
Rate for Payer: Hawaii Western Management Group Commercial	$586.15
Rate for Payer: Health Management Network Commercial	$524.45
Rate for Payer: Humana Medicare	$308.50
Rate for Payer: Kaiser Permanente Commercial	$555.30
Rate for Payer: Kaiser Permanente Medicaid	$314.67
Rate for Payer: Kaiser Permanente Medicare	$308.50
Rate for Payer: MDX Hawaii PPO	$598.49
Rate for Payer: Ohana Health Plan Medicaid	$308.50
Rate for Payer: Ohana Health Plan Medicare	$308.50
Rate for Payer: UnitedHealthcare Medicare	$308.50
Rate for Payer: University Health Alliance Commercial	$449.73

GYN: ALLY UPS ADAPTER DRAPE

Facility

$617.00

Hospital Charge Code	11584047
Hospital Revenue Code	272
Min. Negotiated Rate	$524.45
Max. Negotiated Rate	$598.49
Rate for Payer: Cash Price	$401.05
Rate for Payer: Health Management Network Commercial	$524.45
Rate for Payer: Kaiser Permanente Commercial	$555.30
Rate for Payer: MDX Hawaii PPO	$598.49

GYN BIOPSY PUNCH 5MM

Facility

$160.00

Hospital Charge Code	8274370
Hospital Revenue Code	272
Min. Negotiated Rate	$80.00
Max. Negotiated Rate	$155.20
Rate for Payer: AlohaCare Medicaid	$80.00
Rate for Payer: AlohaCare Medicare	$80.00
Rate for Payer: Cash Price	$104.00
Rate for Payer: Devoted Health Medicare	$88.00
Rate for Payer: Hawaii Medical Service Association Medicare	$80.00
Rate for Payer: Hawaii Western Management Group Commercial	$152.00
Rate for Payer: Health Management Network Commercial	$136.00
Rate for Payer: Humana Medicare	$80.00
Rate for Payer: Kaiser Permanente Commercial	$144.00
Rate for Payer: Kaiser Permanente Medicaid	$81.60
Rate for Payer: Kaiser Permanente Medicare	$80.00
Rate for Payer: MDX Hawaii PPO	$155.20
Rate for Payer: Ohana Health Plan Medicaid	$80.00
Rate for Payer: Ohana Health Plan Medicare	$80.00
Rate for Payer: UnitedHealthcare Medicare	$80.00
Rate for Payer: University Health Alliance Commercial	$116.62

GYN BIOPSY PUNCH 5MM

Facility

$160.00

Hospital Charge Code	8274370
Hospital Revenue Code	272
Min. Negotiated Rate	$136.00
Max. Negotiated Rate	$155.20
Rate for Payer: Cash Price	$104.00
Rate for Payer: Health Management Network Commercial	$136.00
Rate for Payer: Kaiser Permanente Commercial	$144.00
Rate for Payer: MDX Hawaii PPO	$155.20

GYN CAUTERY, ELECTRODES LEEP 10MM X 10MM LOOP

Facility

$76.00

Hospital Charge Code	8274274
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

GYN CAUTERY, ELECTRODES LEEP 10MM X 10MM LOOP

Facility

$76.00

Hospital Charge Code	8274274
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

Know your out-of-pocket cost for care.

All Charges