Samuel Mahelona Memorial Hospital

All Charges

Charge

Type

Setting

Price

HHSC COAXIAL TEMNO BIOPSY SYST 18Gx15CM

Facility

$731.00

Service Code	HCPCS C1729
Hospital Charge Code	8223440
Hospital Revenue Code	272
Min. Negotiated Rate	$621.35
Max. Negotiated Rate	$709.07
Rate for Payer: Cash Price	$475.15
Rate for Payer: Health Management Network Commercial	$621.35
Rate for Payer: Kaiser Permanente Commercial	$657.90
Rate for Payer: MDX Hawaii PPO	$709.07

HHSC COAXIAL TEMNO BIOPSY SYST 18Gx15CM

Facility

$731.00

Service Code	HCPCS C1729
Hospital Charge Code	8223440
Hospital Revenue Code	272
Min. Negotiated Rate	$365.50
Max. Negotiated Rate	$709.07
Rate for Payer: AlohaCare Medicaid	$365.50
Rate for Payer: AlohaCare Medicare	$365.50
Rate for Payer: Cash Price	$475.15
Rate for Payer: Devoted Health Medicare	$402.05
Rate for Payer: Hawaii Medical Service Association Medicare	$365.50
Rate for Payer: Hawaii Western Management Group Commercial	$694.45
Rate for Payer: Health Management Network Commercial	$621.35
Rate for Payer: Humana Medicare	$365.50
Rate for Payer: Kaiser Permanente Commercial	$657.90
Rate for Payer: Kaiser Permanente Medicaid	$372.81
Rate for Payer: Kaiser Permanente Medicare	$365.50
Rate for Payer: MDX Hawaii PPO	$709.07
Rate for Payer: Ohana Health Plan Medicaid	$365.50
Rate for Payer: Ohana Health Plan Medicare	$365.50
Rate for Payer: UnitedHealthcare Medicare	$365.50
Rate for Payer: University Health Alliance Commercial	$532.83

HHSC CONNECT TUBE WITH DRAIN BAG CONNECT

Facility

$90.00

Hospital Charge Code	8223460
Hospital Revenue Code	272
Min. Negotiated Rate	$76.50
Max. Negotiated Rate	$87.30
Rate for Payer: Cash Price	$58.50
Rate for Payer: Health Management Network Commercial	$76.50
Rate for Payer: Kaiser Permanente Commercial	$81.00
Rate for Payer: MDX Hawaii PPO	$87.30

HHSC CONNECT TUBE WITH DRAIN BAG CONNECT

Facility

$90.00

Hospital Charge Code	8223460
Hospital Revenue Code	272
Min. Negotiated Rate	$45.00
Max. Negotiated Rate	$87.30
Rate for Payer: AlohaCare Medicaid	$45.00
Rate for Payer: AlohaCare Medicare	$45.00
Rate for Payer: Cash Price	$58.50
Rate for Payer: Devoted Health Medicare	$49.50
Rate for Payer: Hawaii Medical Service Association Medicare	$45.00
Rate for Payer: Hawaii Western Management Group Commercial	$85.50
Rate for Payer: Health Management Network Commercial	$76.50
Rate for Payer: Humana Medicare	$45.00
Rate for Payer: Kaiser Permanente Commercial	$81.00
Rate for Payer: Kaiser Permanente Medicaid	$45.90
Rate for Payer: Kaiser Permanente Medicare	$45.00
Rate for Payer: MDX Hawaii PPO	$87.30
Rate for Payer: Ohana Health Plan Medicaid	$45.00
Rate for Payer: Ohana Health Plan Medicare	$45.00
Rate for Payer: UnitedHealthcare Medicare	$45.00
Rate for Payer: University Health Alliance Commercial	$65.60

HHSC CT 3D Rendering w/o Postprocess

Facility

$243.00

Service Code	HCPCS 76376
Hospital Charge Code	8223470
Hospital Revenue Code	350
Min. Negotiated Rate	$206.55
Max. Negotiated Rate	$235.71
Rate for Payer: Cash Price	$157.95
Rate for Payer: Health Management Network Commercial	$206.55
Rate for Payer: Kaiser Permanente Commercial	$218.70
Rate for Payer: MDX Hawaii PPO	$235.71

HHSC CT 3D Rendering w/o Postprocess

Facility

$243.00

Service Code	HCPCS 76376
Hospital Charge Code	8223470
Hospital Revenue Code	350
Min. Negotiated Rate	$40.37
Max. Negotiated Rate	$235.71
Rate for Payer: AlohaCare Medicaid	$121.50
Rate for Payer: AlohaCare Medicare	$121.50
Rate for Payer: Cash Price	$157.95
Rate for Payer: Cash Price	$157.95
Rate for Payer: Devoted Health Medicare	$133.65
Rate for Payer: Hawaii Medical Service Association ABD	$98.13
Rate for Payer: Hawaii Medical Service Association Medicare	$121.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$40.37
Rate for Payer: Hawaii Western Management Group Commercial	$230.85
Rate for Payer: Health Management Network Commercial	$206.55
Rate for Payer: Humana Medicare	$121.50
Rate for Payer: Kaiser Permanente Commercial	$218.70
Rate for Payer: Kaiser Permanente Medicaid	$123.93
Rate for Payer: Kaiser Permanente Medicare	$121.50
Rate for Payer: MDX Hawaii PPO	$235.71
Rate for Payer: Ohana Health Plan Medicaid	$121.50
Rate for Payer: Ohana Health Plan Medicare	$121.50
Rate for Payer: UnitedHealthcare Medicaid	$98.13
Rate for Payer: UnitedHealthcare Medicare	$121.50
Rate for Payer: University Health Alliance Commercial	$214.08

HHSC CT 3D Rendering w/ Postprocess

Facility

$436.00

Service Code	HCPCS 76377
Hospital Charge Code	8223468
Hospital Revenue Code	350
Min. Negotiated Rate	$370.60
Max. Negotiated Rate	$422.92
Rate for Payer: Cash Price	$283.40
Rate for Payer: Health Management Network Commercial	$370.60
Rate for Payer: Kaiser Permanente Commercial	$392.40
Rate for Payer: MDX Hawaii PPO	$422.92

HHSC CT 3D Rendering w/ Postprocess

Facility

$436.00

Service Code	HCPCS 76377
Hospital Charge Code	8223468
Hospital Revenue Code	350
Min. Negotiated Rate	$38.91
Max. Negotiated Rate	$422.92
Rate for Payer: AlohaCare Medicaid	$218.00
Rate for Payer: AlohaCare Medicare	$218.00
Rate for Payer: Cash Price	$283.40
Rate for Payer: Cash Price	$283.40
Rate for Payer: Devoted Health Medicare	$239.80
Rate for Payer: Hawaii Medical Service Association ABD	$102.78
Rate for Payer: Hawaii Medical Service Association Medicare	$218.00
Rate for Payer: Hawaii Medical Service Association Non-ABD	$38.91
Rate for Payer: Hawaii Western Management Group Commercial	$414.20
Rate for Payer: Health Management Network Commercial	$370.60
Rate for Payer: Humana Medicare	$218.00
Rate for Payer: Kaiser Permanente Commercial	$392.40
Rate for Payer: Kaiser Permanente Medicaid	$222.36
Rate for Payer: Kaiser Permanente Medicare	$218.00
Rate for Payer: MDX Hawaii PPO	$422.92
Rate for Payer: Ohana Health Plan Medicaid	$218.00
Rate for Payer: Ohana Health Plan Medicare	$218.00
Rate for Payer: UnitedHealthcare Medicaid	$102.78
Rate for Payer: UnitedHealthcare Medicare	$218.00
Rate for Payer: University Health Alliance Commercial	$272.82

HHSC CT Guided FNA Addl

Facility

$1,331.00

Service Code	HCPCS 10010
Hospital Charge Code	8223488
Hospital Revenue Code	361
Min. Negotiated Rate	$69.17
Max. Negotiated Rate	$2,837.00
Rate for Payer: AlohaCare Medicaid	$665.50
Rate for Payer: AlohaCare Medicare	$665.50
Rate for Payer: Cash Price	$865.15
Rate for Payer: Cash Price	$865.15
Rate for Payer: Cash Price	$865.15
Rate for Payer: Devoted Health Medicare	$732.05
Rate for Payer: Hawaii Medical Service Association Medicare	$665.50
Rate for Payer: Health Management Network Commercial	$1,131.35
Rate for Payer: Humana Medicare	$665.50
Rate for Payer: Kaiser Permanente Commercial	$1,197.90
Rate for Payer: Kaiser Permanente Medicaid	$2,837.00
Rate for Payer: Kaiser Permanente Medicare	$665.50
Rate for Payer: MDX Hawaii PPO	$1,291.07
Rate for Payer: Ohana Health Plan Medicaid	$665.50
Rate for Payer: Ohana Health Plan Medicare	$665.50
Rate for Payer: UnitedHealthcare Medicaid	$69.17
Rate for Payer: UnitedHealthcare Medicare	$665.50
Rate for Payer: University Health Alliance Commercial	$745.36

HHSC CT Guided FNA Addl

Facility

$1,331.00

Service Code	HCPCS 10010
Hospital Charge Code	8223488
Hospital Revenue Code	361
Min. Negotiated Rate	$1,131.35
Max. Negotiated Rate	$1,291.07
Rate for Payer: Cash Price	$865.15
Rate for Payer: Health Management Network Commercial	$1,131.35
Rate for Payer: Kaiser Permanente Commercial	$1,197.90
Rate for Payer: MDX Hawaii PPO	$1,291.07

HHSC Doppler Color Flow Addon

Facility

$511.00

Service Code	HCPCS 93325
Hospital Charge Code	8223480
Hospital Revenue Code	483
Min. Negotiated Rate	$40.70
Max. Negotiated Rate	$495.67
Rate for Payer: AlohaCare Medicaid	$255.50
Rate for Payer: AlohaCare Medicare	$255.50
Rate for Payer: Cash Price	$332.15
Rate for Payer: Cash Price	$332.15
Rate for Payer: Devoted Health Medicare	$281.05
Rate for Payer: Hawaii Medical Service Association ABD	$96.84
Rate for Payer: Hawaii Medical Service Association Medicare	$255.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$40.70
Rate for Payer: Hawaii Western Management Group Commercial	$485.45
Rate for Payer: Health Management Network Commercial	$434.35
Rate for Payer: Humana Medicare	$255.50
Rate for Payer: Kaiser Permanente Commercial	$459.90
Rate for Payer: Kaiser Permanente Medicaid	$260.61
Rate for Payer: Kaiser Permanente Medicare	$255.50
Rate for Payer: MDX Hawaii PPO	$495.67
Rate for Payer: Ohana Health Plan Medicaid	$255.50
Rate for Payer: Ohana Health Plan Medicare	$255.50
Rate for Payer: UnitedHealthcare Medicaid	$96.84
Rate for Payer: UnitedHealthcare Medicare	$255.50
Rate for Payer: University Health Alliance Commercial	$286.16

HHSC Doppler Color Flow Addon

Facility

$511.00

Service Code	HCPCS 93325
Hospital Charge Code	8223480
Hospital Revenue Code	483
Min. Negotiated Rate	$434.35
Max. Negotiated Rate	$495.67
Rate for Payer: Cash Price	$332.15
Rate for Payer: Health Management Network Commercial	$434.35
Rate for Payer: Kaiser Permanente Commercial	$459.90
Rate for Payer: MDX Hawaii PPO	$495.67

HHSC Doppler Echo Exam Heart

Facility

$597.00

Service Code	HCPCS 93320
Hospital Charge Code	8223484
Hospital Revenue Code	483
Min. Negotiated Rate	$57.09
Max. Negotiated Rate	$579.09
Rate for Payer: AlohaCare Medicaid	$298.50
Rate for Payer: AlohaCare Medicare	$298.50
Rate for Payer: Cash Price	$388.05
Rate for Payer: Cash Price	$388.05
Rate for Payer: Devoted Health Medicare	$328.35
Rate for Payer: Hawaii Medical Service Association ABD	$57.09
Rate for Payer: Hawaii Medical Service Association Medicare	$298.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$59.94
Rate for Payer: Hawaii Western Management Group Commercial	$567.15
Rate for Payer: Health Management Network Commercial	$507.45
Rate for Payer: Humana Medicare	$298.50
Rate for Payer: Kaiser Permanente Commercial	$537.30
Rate for Payer: Kaiser Permanente Medicaid	$304.47
Rate for Payer: Kaiser Permanente Medicare	$298.50
Rate for Payer: MDX Hawaii PPO	$579.09
Rate for Payer: Ohana Health Plan Medicaid	$298.50
Rate for Payer: Ohana Health Plan Medicare	$298.50
Rate for Payer: UnitedHealthcare Medicaid	$57.09
Rate for Payer: UnitedHealthcare Medicare	$298.50
Rate for Payer: University Health Alliance Commercial	$334.32

HHSC Doppler Echo Exam Heart

Facility

$597.00

Service Code	HCPCS 93320
Hospital Charge Code	8223484
Hospital Revenue Code	483
Min. Negotiated Rate	$507.45
Max. Negotiated Rate	$579.09
Rate for Payer: Cash Price	$388.05
Rate for Payer: Health Management Network Commercial	$507.45
Rate for Payer: Kaiser Permanente Commercial	$537.30
Rate for Payer: MDX Hawaii PPO	$579.09

HHSC Doppler Echo Exam Heart Ltd

Facility

$439.00

Service Code	HCPCS 93321
Hospital Charge Code	8223482
Hospital Revenue Code	483
Min. Negotiated Rate	$373.15
Max. Negotiated Rate	$425.83
Rate for Payer: Cash Price	$285.35
Rate for Payer: Health Management Network Commercial	$373.15
Rate for Payer: Kaiser Permanente Commercial	$395.10
Rate for Payer: MDX Hawaii PPO	$425.83

HHSC Doppler Echo Exam Heart Ltd

Facility

$439.00

Service Code	HCPCS 93321
Hospital Charge Code	8223482
Hospital Revenue Code	483
Min. Negotiated Rate	$37.31
Max. Negotiated Rate	$425.83
Rate for Payer: AlohaCare Medicaid	$219.50
Rate for Payer: AlohaCare Medicare	$219.50
Rate for Payer: Cash Price	$285.35
Rate for Payer: Cash Price	$285.35
Rate for Payer: Devoted Health Medicare	$241.45
Rate for Payer: Hawaii Medical Service Association ABD	$37.31
Rate for Payer: Hawaii Medical Service Association Medicare	$219.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$39.18
Rate for Payer: Hawaii Western Management Group Commercial	$417.05
Rate for Payer: Health Management Network Commercial	$373.15
Rate for Payer: Humana Medicare	$219.50
Rate for Payer: Kaiser Permanente Commercial	$395.10
Rate for Payer: Kaiser Permanente Medicaid	$223.89
Rate for Payer: Kaiser Permanente Medicare	$219.50
Rate for Payer: MDX Hawaii PPO	$425.83
Rate for Payer: Ohana Health Plan Medicaid	$219.50
Rate for Payer: Ohana Health Plan Medicare	$219.50
Rate for Payer: UnitedHealthcare Medicaid	$37.31
Rate for Payer: UnitedHealthcare Medicare	$219.50
Rate for Payer: University Health Alliance Commercial	$245.84

HHSC EVIVA BREAST BX NEEDLE, PETITE 9GX10CM

Facility

$1,078.00

Hospital Charge Code	13019998
Hospital Revenue Code	272
Min. Negotiated Rate	$916.30
Max. Negotiated Rate	$1,045.66
Rate for Payer: Cash Price	$700.70
Rate for Payer: Health Management Network Commercial	$916.30
Rate for Payer: Kaiser Permanente Commercial	$970.20
Rate for Payer: MDX Hawaii PPO	$1,045.66

HHSC EVIVA BREAST BX NEEDLE, PETITE 9GX10CM

Facility

$1,078.00

Hospital Charge Code	13019998
Hospital Revenue Code	272
Min. Negotiated Rate	$539.00
Max. Negotiated Rate	$1,045.66
Rate for Payer: AlohaCare Medicaid	$539.00
Rate for Payer: AlohaCare Medicare	$539.00
Rate for Payer: Cash Price	$700.70
Rate for Payer: Devoted Health Medicare	$592.90
Rate for Payer: Hawaii Medical Service Association Medicare	$539.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,024.10
Rate for Payer: Health Management Network Commercial	$916.30
Rate for Payer: Humana Medicare	$539.00
Rate for Payer: Kaiser Permanente Commercial	$970.20
Rate for Payer: Kaiser Permanente Medicaid	$549.78
Rate for Payer: Kaiser Permanente Medicare	$539.00
Rate for Payer: MDX Hawaii PPO	$1,045.66
Rate for Payer: Ohana Health Plan Medicaid	$539.00
Rate for Payer: Ohana Health Plan Medicare	$539.00
Rate for Payer: UnitedHealthcare Medicare	$539.00
Rate for Payer: University Health Alliance Commercial	$785.75

HHSC EVIVA BREAST BX NEEDLE, STANDARD 9GX13CM

Facility

$1,078.00

Hospital Charge Code	13031469
Hospital Revenue Code	272
Min. Negotiated Rate	$539.00
Max. Negotiated Rate	$1,045.66
Rate for Payer: AlohaCare Medicaid	$539.00
Rate for Payer: AlohaCare Medicare	$539.00
Rate for Payer: Cash Price	$700.70
Rate for Payer: Devoted Health Medicare	$592.90
Rate for Payer: Hawaii Medical Service Association Medicare	$539.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,024.10
Rate for Payer: Health Management Network Commercial	$916.30
Rate for Payer: Humana Medicare	$539.00
Rate for Payer: Kaiser Permanente Commercial	$970.20
Rate for Payer: Kaiser Permanente Medicaid	$549.78
Rate for Payer: Kaiser Permanente Medicare	$539.00
Rate for Payer: MDX Hawaii PPO	$1,045.66
Rate for Payer: Ohana Health Plan Medicaid	$539.00
Rate for Payer: Ohana Health Plan Medicare	$539.00
Rate for Payer: UnitedHealthcare Medicare	$539.00
Rate for Payer: University Health Alliance Commercial	$785.75

HHSC EVIVA BREAST BX NEEDLE, STANDARD 9GX13CM

Facility

$1,078.00

Hospital Charge Code	13031469
Hospital Revenue Code	272
Min. Negotiated Rate	$916.30
Max. Negotiated Rate	$1,045.66
Rate for Payer: Cash Price	$700.70
Rate for Payer: Health Management Network Commercial	$916.30
Rate for Payer: Kaiser Permanente Commercial	$970.20
Rate for Payer: MDX Hawaii PPO	$1,045.66

HHSC FIXED CORE WIRE GUIDE SAFE TJ CURVE

Facility

$138.00

Hospital Charge Code	8223458
Hospital Revenue Code	272
Min. Negotiated Rate	$117.30
Max. Negotiated Rate	$133.86
Rate for Payer: Cash Price	$89.70
Rate for Payer: Health Management Network Commercial	$117.30
Rate for Payer: Kaiser Permanente Commercial	$124.20
Rate for Payer: MDX Hawaii PPO	$133.86

HHSC FIXED CORE WIRE GUIDE SAFE TJ CURVE

Facility

$138.00

Hospital Charge Code	8223458
Hospital Revenue Code	272
Min. Negotiated Rate	$69.00
Max. Negotiated Rate	$133.86
Rate for Payer: AlohaCare Medicaid	$69.00
Rate for Payer: AlohaCare Medicare	$69.00
Rate for Payer: Cash Price	$89.70
Rate for Payer: Devoted Health Medicare	$75.90
Rate for Payer: Hawaii Medical Service Association Medicare	$69.00
Rate for Payer: Hawaii Western Management Group Commercial	$131.10
Rate for Payer: Health Management Network Commercial	$117.30
Rate for Payer: Humana Medicare	$69.00
Rate for Payer: Kaiser Permanente Commercial	$124.20
Rate for Payer: Kaiser Permanente Medicaid	$70.38
Rate for Payer: Kaiser Permanente Medicare	$69.00
Rate for Payer: MDX Hawaii PPO	$133.86
Rate for Payer: Ohana Health Plan Medicaid	$69.00
Rate for Payer: Ohana Health Plan Medicare	$69.00
Rate for Payer: UnitedHealthcare Medicare	$69.00
Rate for Payer: University Health Alliance Commercial	$100.59

HHSC FRANSN LNG BX NDL-22-5.0-U 22G/5CM

Facility

$160.00

Hospital Charge Code	8223452
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

HHSC FRANSN LNG BX NDL-22-5.0-U 22G/5CM

Facility

$160.00

Hospital Charge Code	8223452
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

HHSC G/W FIXED CORE SAFE TJ CURVE (CT)

Facility

$84.00

Service Code	HCPCS C1769
Hospital Charge Code	9469095
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

Know your out-of-pocket cost for care.

All Charges