Samuel Mahelona Memorial Hospital

All Charges

Charge

Type

Setting

Price

HHSC AUTOMATIC BX NEEDLE 18GX15CM

Facility

$76.00

Hospital Charge Code	8223444
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

HHSC BCE 20610 Arthrocentesis, aspiration and/or injection, major joint or bursa; without ultrasound

Facility

$717.00

Service Code	HCPCS 20610
Hospital Charge Code	8529434
Hospital Revenue Code	450
Min. Negotiated Rate	$358.50
Max. Negotiated Rate	$4,035.20
Rate for Payer: AlohaCare Medicaid	$358.50
Rate for Payer: AlohaCare Medicare	$358.50
Rate for Payer: Cash Price	$466.05
Rate for Payer: Cash Price	$466.05
Rate for Payer: Devoted Health Medicare	$394.35
Rate for Payer: Hawaii Medical Service Association ABD	$469.00
Rate for Payer: Hawaii Medical Service Association Commercial	$1,600.00
Rate for Payer: Hawaii Medical Service Association Medicare	$358.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$450.00
Rate for Payer: Hawaii Western Management Group Commercial	$681.15
Rate for Payer: Health Management Network Commercial	$609.45
Rate for Payer: Humana Medicare	$358.50
Rate for Payer: Kaiser Permanente Commercial	$645.30
Rate for Payer: Kaiser Permanente Medicaid	$937.50
Rate for Payer: Kaiser Permanente Medicare	$358.50
Rate for Payer: MDX Hawaii PPO	$695.49
Rate for Payer: Ohana Health Plan Medicaid	$358.50
Rate for Payer: Ohana Health Plan Medicare	$358.50
Rate for Payer: UnitedHealthcare Medicare	$358.50
Rate for Payer: University Health Alliance Commercial	$4,035.20

HHSC BCE 20610 Arthrocentesis, aspiration and/or injection, major joint or bursa; without ultrasound

Facility

$717.00

Service Code	HCPCS 20610
Hospital Charge Code	8529434
Hospital Revenue Code	450
Min. Negotiated Rate	$609.45
Max. Negotiated Rate	$695.49
Rate for Payer: Cash Price	$466.05
Rate for Payer: Health Management Network Commercial	$609.45
Rate for Payer: Kaiser Permanente Commercial	$645.30
Rate for Payer: MDX Hawaii PPO	$695.49

HHSC BIOPSY TRAYS

Facility

$131.00

Hospital Charge Code	8223462
Hospital Revenue Code	272
Min. Negotiated Rate	$111.35
Max. Negotiated Rate	$127.07
Rate for Payer: Cash Price	$85.15
Rate for Payer: Health Management Network Commercial	$111.35
Rate for Payer: Kaiser Permanente Commercial	$117.90
Rate for Payer: MDX Hawaii PPO	$127.07

HHSC BIOPSY TRAYS

Facility

$131.00

Hospital Charge Code	8223462
Hospital Revenue Code	272
Min. Negotiated Rate	$65.50
Max. Negotiated Rate	$127.07
Rate for Payer: AlohaCare Medicaid	$65.50
Rate for Payer: AlohaCare Medicare	$65.50
Rate for Payer: Cash Price	$85.15
Rate for Payer: Devoted Health Medicare	$72.05
Rate for Payer: Hawaii Medical Service Association Medicare	$65.50
Rate for Payer: Hawaii Western Management Group Commercial	$124.45
Rate for Payer: Health Management Network Commercial	$111.35
Rate for Payer: Humana Medicare	$65.50
Rate for Payer: Kaiser Permanente Commercial	$117.90
Rate for Payer: Kaiser Permanente Medicaid	$66.81
Rate for Payer: Kaiser Permanente Medicare	$65.50
Rate for Payer: MDX Hawaii PPO	$127.07
Rate for Payer: Ohana Health Plan Medicaid	$65.50
Rate for Payer: Ohana Health Plan Medicare	$65.50
Rate for Payer: UnitedHealthcare Medicare	$65.50
Rate for Payer: University Health Alliance Commercial	$95.49

HHSC BREAST WIRE LOCAL 20G X 5.7CM NDL

Facility

$239.00

Hospital Charge Code	8223456
Hospital Revenue Code	272
Min. Negotiated Rate	$119.50
Max. Negotiated Rate	$231.83
Rate for Payer: AlohaCare Medicaid	$119.50
Rate for Payer: AlohaCare Medicare	$119.50
Rate for Payer: Cash Price	$155.35
Rate for Payer: Devoted Health Medicare	$131.45
Rate for Payer: Hawaii Medical Service Association Medicare	$119.50
Rate for Payer: Hawaii Western Management Group Commercial	$227.05
Rate for Payer: Health Management Network Commercial	$203.15
Rate for Payer: Humana Medicare	$119.50
Rate for Payer: Kaiser Permanente Commercial	$215.10
Rate for Payer: Kaiser Permanente Medicaid	$121.89
Rate for Payer: Kaiser Permanente Medicare	$119.50
Rate for Payer: MDX Hawaii PPO	$231.83
Rate for Payer: Ohana Health Plan Medicaid	$119.50
Rate for Payer: Ohana Health Plan Medicare	$119.50
Rate for Payer: UnitedHealthcare Medicare	$119.50
Rate for Payer: University Health Alliance Commercial	$174.21

HHSC BREAST WIRE LOCAL 20G X 5.7CM NDL

Facility

$239.00

Hospital Charge Code	8223456
Hospital Revenue Code	272
Min. Negotiated Rate	$203.15
Max. Negotiated Rate	$231.83
Rate for Payer: Cash Price	$155.35
Rate for Payer: Health Management Network Commercial	$203.15
Rate for Payer: Kaiser Permanente Commercial	$215.10
Rate for Payer: MDX Hawaii PPO	$231.83

HHSC CATHETER DRAINAGE (CT)

Facility

$453.00

Service Code	HCPCS C1729
Hospital Charge Code	9469115
Hospital Revenue Code	272
Min. Negotiated Rate	$226.50
Max. Negotiated Rate	$439.41
Rate for Payer: AlohaCare Medicaid	$226.50
Rate for Payer: AlohaCare Medicare	$226.50
Rate for Payer: Cash Price	$294.45
Rate for Payer: Devoted Health Medicare	$249.15
Rate for Payer: Hawaii Medical Service Association Medicare	$226.50
Rate for Payer: Hawaii Western Management Group Commercial	$430.35
Rate for Payer: Health Management Network Commercial	$385.05
Rate for Payer: Humana Medicare	$226.50
Rate for Payer: Kaiser Permanente Commercial	$407.70
Rate for Payer: Kaiser Permanente Medicaid	$231.03
Rate for Payer: Kaiser Permanente Medicare	$226.50
Rate for Payer: MDX Hawaii PPO	$439.41
Rate for Payer: Ohana Health Plan Medicaid	$226.50
Rate for Payer: Ohana Health Plan Medicare	$226.50
Rate for Payer: UnitedHealthcare Medicare	$226.50
Rate for Payer: University Health Alliance Commercial	$330.19

HHSC CATHETER DRAINAGE (CT)

Facility

$453.00

Service Code	HCPCS C1729
Hospital Charge Code	9469115
Hospital Revenue Code	272
Min. Negotiated Rate	$385.05
Max. Negotiated Rate	$439.41
Rate for Payer: Cash Price	$294.45
Rate for Payer: Health Management Network Commercial	$385.05
Rate for Payer: Kaiser Permanente Commercial	$407.70
Rate for Payer: MDX Hawaii PPO	$439.41

HHSC CATHETER DRAINAGE (US)

Facility

$453.00

Service Code	HCPCS C1729
Hospital Charge Code	9469343
Hospital Revenue Code	272
Min. Negotiated Rate	$226.50
Max. Negotiated Rate	$439.41
Rate for Payer: AlohaCare Medicaid	$226.50
Rate for Payer: AlohaCare Medicare	$226.50
Rate for Payer: Cash Price	$294.45
Rate for Payer: Devoted Health Medicare	$249.15
Rate for Payer: Hawaii Medical Service Association Medicare	$226.50
Rate for Payer: Hawaii Western Management Group Commercial	$430.35
Rate for Payer: Health Management Network Commercial	$385.05
Rate for Payer: Humana Medicare	$226.50
Rate for Payer: Kaiser Permanente Commercial	$407.70
Rate for Payer: Kaiser Permanente Medicaid	$231.03
Rate for Payer: Kaiser Permanente Medicare	$226.50
Rate for Payer: MDX Hawaii PPO	$439.41
Rate for Payer: Ohana Health Plan Medicaid	$226.50
Rate for Payer: Ohana Health Plan Medicare	$226.50
Rate for Payer: UnitedHealthcare Medicare	$226.50
Rate for Payer: University Health Alliance Commercial	$330.19

HHSC CATHETER DRAINAGE (US)

Facility

$453.00

Service Code	HCPCS C1729
Hospital Charge Code	9469343
Hospital Revenue Code	272
Min. Negotiated Rate	$385.05
Max. Negotiated Rate	$439.41
Rate for Payer: Cash Price	$294.45
Rate for Payer: Health Management Network Commercial	$385.05
Rate for Payer: Kaiser Permanente Commercial	$407.70
Rate for Payer: MDX Hawaii PPO	$439.41

HHSC CATHETER DRAINAGE (XR/MAMMO)

Facility

$400.00

Service Code	HCPCS C1729
Hospital Charge Code	9469079
Hospital Revenue Code	272
Min. Negotiated Rate	$200.00
Max. Negotiated Rate	$388.00
Rate for Payer: AlohaCare Medicaid	$200.00
Rate for Payer: AlohaCare Medicare	$200.00
Rate for Payer: Cash Price	$260.00
Rate for Payer: Devoted Health Medicare	$220.00
Rate for Payer: Hawaii Medical Service Association Medicare	$200.00
Rate for Payer: Hawaii Western Management Group Commercial	$380.00
Rate for Payer: Health Management Network Commercial	$340.00
Rate for Payer: Humana Medicare	$200.00
Rate for Payer: Kaiser Permanente Commercial	$360.00
Rate for Payer: Kaiser Permanente Medicaid	$204.00
Rate for Payer: Kaiser Permanente Medicare	$200.00
Rate for Payer: MDX Hawaii PPO	$388.00
Rate for Payer: Ohana Health Plan Medicaid	$200.00
Rate for Payer: Ohana Health Plan Medicare	$200.00
Rate for Payer: UnitedHealthcare Medicare	$200.00
Rate for Payer: University Health Alliance Commercial	$291.56

HHSC CATHETER DRAINAGE (XR/MAMMO)

Facility

$400.00

Service Code	HCPCS C1729
Hospital Charge Code	9469079
Hospital Revenue Code	272
Min. Negotiated Rate	$340.00
Max. Negotiated Rate	$388.00
Rate for Payer: Cash Price	$260.00
Rate for Payer: Health Management Network Commercial	$340.00
Rate for Payer: Kaiser Permanente Commercial	$360.00
Rate for Payer: MDX Hawaii PPO	$388.00

HHSC CATH RABINOV 0.016IN(CT)

Facility

$227.00

Service Code	HCPCS C1887
Hospital Charge Code	9469101
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

HHSC CATH RABINOV 0.016IN(CT)

Facility

$227.00

Service Code	HCPCS C1887
Hospital Charge Code	9469101
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

HHSC CATH RABINOV 0.016IN (US)

Facility

$227.00

Service Code	HCPCS C1887
Hospital Charge Code	9469333
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

HHSC CATH RABINOV 0.016IN (US)

Facility

$227.00

Service Code	HCPCS C1887
Hospital Charge Code	9469333
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

HHSC CATH RABINOV 0.016IN(XR/MAMMO)

Facility

$227.00

Service Code	HCPCS C1887
Hospital Charge Code	9469006
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

HHSC CATH RABINOV 0.016IN(XR/MAMMO)

Facility

$227.00

Service Code	HCPCS C1887
Hospital Charge Code	9469006
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

HHSC CEL12 SP LOAD CORE BX DEV US GID BX

Facility

$919.00

Service Code	HCPCS C1769
Hospital Charge Code	8223442
Hospital Revenue Code	272
Min. Negotiated Rate	$459.50
Max. Negotiated Rate	$891.43
Rate for Payer: AlohaCare Medicaid	$459.50
Rate for Payer: AlohaCare Medicare	$459.50
Rate for Payer: Cash Price	$597.35
Rate for Payer: Devoted Health Medicare	$505.45
Rate for Payer: Hawaii Medical Service Association Medicare	$459.50
Rate for Payer: Hawaii Western Management Group Commercial	$873.05
Rate for Payer: Health Management Network Commercial	$781.15
Rate for Payer: Humana Medicare	$459.50
Rate for Payer: Kaiser Permanente Commercial	$827.10
Rate for Payer: Kaiser Permanente Medicaid	$468.69
Rate for Payer: Kaiser Permanente Medicare	$459.50
Rate for Payer: MDX Hawaii PPO	$891.43
Rate for Payer: Ohana Health Plan Medicaid	$459.50
Rate for Payer: Ohana Health Plan Medicare	$459.50
Rate for Payer: UnitedHealthcare Medicare	$459.50
Rate for Payer: University Health Alliance Commercial	$669.86

HHSC CEL12 SP LOAD CORE BX DEV US GID BX

Facility

$919.00

Service Code	HCPCS C1769
Hospital Charge Code	8223442
Hospital Revenue Code	272
Min. Negotiated Rate	$781.15
Max. Negotiated Rate	$891.43
Rate for Payer: Cash Price	$597.35
Rate for Payer: Health Management Network Commercial	$781.15
Rate for Payer: Kaiser Permanente Commercial	$827.10
Rate for Payer: MDX Hawaii PPO	$891.43

HHSC CELERO 12 SPRING LOADED CORE BX(US)

Facility

$919.00

Hospital Charge Code	9469347
Hospital Revenue Code	272
Min. Negotiated Rate	$781.15
Max. Negotiated Rate	$891.43
Rate for Payer: Cash Price	$597.35
Rate for Payer: Health Management Network Commercial	$781.15
Rate for Payer: Kaiser Permanente Commercial	$827.10
Rate for Payer: MDX Hawaii PPO	$891.43

HHSC CELERO 12 SPRING LOADED CORE BX(US)

Facility

$919.00

Hospital Charge Code	9469347
Hospital Revenue Code	272
Min. Negotiated Rate	$459.50
Max. Negotiated Rate	$891.43
Rate for Payer: AlohaCare Medicaid	$459.50
Rate for Payer: AlohaCare Medicare	$459.50
Rate for Payer: Cash Price	$597.35
Rate for Payer: Devoted Health Medicare	$505.45
Rate for Payer: Hawaii Medical Service Association Medicare	$459.50
Rate for Payer: Hawaii Western Management Group Commercial	$873.05
Rate for Payer: Health Management Network Commercial	$781.15
Rate for Payer: Humana Medicare	$459.50
Rate for Payer: Kaiser Permanente Commercial	$827.10
Rate for Payer: Kaiser Permanente Medicaid	$468.69
Rate for Payer: Kaiser Permanente Medicare	$459.50
Rate for Payer: MDX Hawaii PPO	$891.43
Rate for Payer: Ohana Health Plan Medicaid	$459.50
Rate for Payer: Ohana Health Plan Medicare	$459.50
Rate for Payer: UnitedHealthcare Medicare	$459.50
Rate for Payer: University Health Alliance Commercial	$669.86

HHSC CK8.5F MPDRNCATHSTCLM-8.5RH-NPAS-NT

Facility

$262.00

Hospital Charge Code	8223450
Hospital Revenue Code	272
Min. Negotiated Rate	$131.00
Max. Negotiated Rate	$254.14
Rate for Payer: AlohaCare Medicaid	$131.00
Rate for Payer: AlohaCare Medicare	$131.00
Rate for Payer: Cash Price	$170.30
Rate for Payer: Devoted Health Medicare	$144.10
Rate for Payer: Hawaii Medical Service Association Medicare	$131.00
Rate for Payer: Hawaii Western Management Group Commercial	$248.90
Rate for Payer: Health Management Network Commercial	$222.70
Rate for Payer: Humana Medicare	$131.00
Rate for Payer: Kaiser Permanente Commercial	$235.80
Rate for Payer: Kaiser Permanente Medicaid	$133.62
Rate for Payer: Kaiser Permanente Medicare	$131.00
Rate for Payer: MDX Hawaii PPO	$254.14
Rate for Payer: Ohana Health Plan Medicaid	$131.00
Rate for Payer: Ohana Health Plan Medicare	$131.00
Rate for Payer: UnitedHealthcare Medicare	$131.00
Rate for Payer: University Health Alliance Commercial	$190.97

HHSC CK8.5F MPDRNCATHSTCLM-8.5RH-NPAS-NT

Facility

$262.00

Hospital Charge Code	8223450
Hospital Revenue Code	272
Min. Negotiated Rate	$222.70
Max. Negotiated Rate	$254.14
Rate for Payer: Cash Price	$170.30
Rate for Payer: Health Management Network Commercial	$222.70
Rate for Payer: Kaiser Permanente Commercial	$235.80
Rate for Payer: MDX Hawaii PPO	$254.14

Know your out-of-pocket cost for care.

All Charges