Samuel Mahelona Memorial Hospital

All Charges

Charge

Type

Setting

Price

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	$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

HHSC GWIRE FXD CORE TJ CURVE(US)

Facility

$84.00

Service Code	HCPCS C1769
Hospital Charge Code	9469323
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

HHSC GWIRE FXD CORE TJ CURVE(US)

Facility

$84.00

Service Code	HCPCS C1769
Hospital Charge Code	9469323
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

HHSC GWIRE FXD CORE TJ CURVE(XR/MAMMO)

Facility

$84.00

Service Code	HCPCS C1769
Hospital Charge Code	9468999
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

HHSC GWIRE FXD CORE TJ CURVE(XR/MAMMO)

Facility

$84.00

Service Code	HCPCS C1769
Hospital Charge Code	9468999
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

HHSC HSG CATHETER SET 5F

Facility

$235.00

Service Code	HCPCS C1887
Hospital Charge Code	8223454
Hospital Revenue Code	272
Min. Negotiated Rate	$199.75
Max. Negotiated Rate	$227.95
Rate for Payer: Cash Price	$152.75
Rate for Payer: Health Management Network Commercial	$199.75
Rate for Payer: Kaiser Permanente Commercial	$211.50
Rate for Payer: MDX Hawaii PPO	$227.95

HHSC HSG CATHETER SET 5F

Facility

$235.00

Service Code	HCPCS C1887
Hospital Charge Code	8223454
Hospital Revenue Code	272
Min. Negotiated Rate	$117.50
Max. Negotiated Rate	$227.95
Rate for Payer: AlohaCare Medicaid	$117.50
Rate for Payer: AlohaCare Medicare	$117.50
Rate for Payer: Cash Price	$152.75
Rate for Payer: Devoted Health Medicare	$129.25
Rate for Payer: Hawaii Medical Service Association Medicare	$117.50
Rate for Payer: Hawaii Western Management Group Commercial	$223.25
Rate for Payer: Health Management Network Commercial	$199.75
Rate for Payer: Humana Medicare	$117.50
Rate for Payer: Kaiser Permanente Commercial	$211.50
Rate for Payer: Kaiser Permanente Medicaid	$119.85
Rate for Payer: Kaiser Permanente Medicare	$117.50
Rate for Payer: MDX Hawaii PPO	$227.95
Rate for Payer: Ohana Health Plan Medicaid	$117.50
Rate for Payer: Ohana Health Plan Medicare	$117.50
Rate for Payer: UnitedHealthcare Medicare	$117.50
Rate for Payer: University Health Alliance Commercial	$171.29

HHSC INTRO TIP PNEUMOTHORAX SET

Facility

$523.00

Hospital Charge Code	8223466
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

HHSC INTRO TIP PNEUMOTHORAX SET

Facility

$523.00

Hospital Charge Code	8223466
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

HHSC MARKER BREAST BIOPSY TUMARK VISION 10CM

Facility

$480.00

Hospital Charge Code	11579936
Hospital Revenue Code	272
Min. Negotiated Rate	$240.00
Max. Negotiated Rate	$465.60
Rate for Payer: AlohaCare Medicaid	$240.00
Rate for Payer: AlohaCare Medicare	$240.00
Rate for Payer: Cash Price	$312.00
Rate for Payer: Devoted Health Medicare	$264.00
Rate for Payer: Hawaii Medical Service Association Medicare	$240.00
Rate for Payer: Hawaii Western Management Group Commercial	$456.00
Rate for Payer: Health Management Network Commercial	$408.00
Rate for Payer: Humana Medicare	$240.00
Rate for Payer: Kaiser Permanente Commercial	$432.00
Rate for Payer: Kaiser Permanente Medicaid	$244.80
Rate for Payer: Kaiser Permanente Medicare	$240.00
Rate for Payer: MDX Hawaii PPO	$465.60
Rate for Payer: Ohana Health Plan Medicaid	$240.00
Rate for Payer: Ohana Health Plan Medicare	$240.00
Rate for Payer: UnitedHealthcare Medicare	$240.00
Rate for Payer: University Health Alliance Commercial	$349.87

HHSC MARKER BREAST BIOPSY TUMARK VISION 10CM

Facility

$480.00

Hospital Charge Code	11579936
Hospital Revenue Code	272
Min. Negotiated Rate	$408.00
Max. Negotiated Rate	$465.60
Rate for Payer: Cash Price	$312.00
Rate for Payer: Health Management Network Commercial	$408.00
Rate for Payer: Kaiser Permanente Commercial	$432.00
Rate for Payer: MDX Hawaii PPO	$465.60

HHSC MG Bx Breast Add Lesion Strtctc LT

Facility

$719.00

Service Code	HCPCS 19082
Hospital Charge Code	8223498
Hospital Revenue Code	361
Min. Negotiated Rate	$80.28
Max. Negotiated Rate	$2,837.00
Rate for Payer: AlohaCare Medicaid	$359.50
Rate for Payer: AlohaCare Medicare	$359.50
Rate for Payer: Cash Price	$467.35
Rate for Payer: Cash Price	$467.35
Rate for Payer: Cash Price	$467.35
Rate for Payer: Devoted Health Medicare	$395.45
Rate for Payer: Hawaii Medical Service Association Medicare	$359.50
Rate for Payer: Health Management Network Commercial	$611.15
Rate for Payer: Humana Medicare	$359.50
Rate for Payer: Kaiser Permanente Commercial	$647.10
Rate for Payer: Kaiser Permanente Medicaid	$2,837.00
Rate for Payer: Kaiser Permanente Medicare	$359.50
Rate for Payer: MDX Hawaii PPO	$697.43
Rate for Payer: Ohana Health Plan Medicaid	$359.50
Rate for Payer: Ohana Health Plan Medicare	$359.50
Rate for Payer: UnitedHealthcare Medicaid	$80.28
Rate for Payer: UnitedHealthcare Medicare	$359.50
Rate for Payer: University Health Alliance Commercial	$402.64

HHSC MG Bx Breast Add Lesion Strtctc LT

Facility

$719.00

Service Code	HCPCS 19082
Hospital Charge Code	8223498
Hospital Revenue Code	361
Min. Negotiated Rate	$611.15
Max. Negotiated Rate	$697.43
Rate for Payer: Cash Price	$467.35
Rate for Payer: Health Management Network Commercial	$611.15
Rate for Payer: Kaiser Permanente Commercial	$647.10
Rate for Payer: MDX Hawaii PPO	$697.43

HHSC MG Bx Breast Add Lesion Strtctc RT

Facility

$719.00

Service Code	HCPCS 19082
Hospital Charge Code	8223500
Hospital Revenue Code	361
Min. Negotiated Rate	$80.28
Max. Negotiated Rate	$2,837.00
Rate for Payer: AlohaCare Medicaid	$359.50
Rate for Payer: AlohaCare Medicare	$359.50
Rate for Payer: Cash Price	$467.35
Rate for Payer: Cash Price	$467.35
Rate for Payer: Cash Price	$467.35
Rate for Payer: Devoted Health Medicare	$395.45
Rate for Payer: Hawaii Medical Service Association Medicare	$359.50
Rate for Payer: Health Management Network Commercial	$611.15
Rate for Payer: Humana Medicare	$359.50
Rate for Payer: Kaiser Permanente Commercial	$647.10
Rate for Payer: Kaiser Permanente Medicaid	$2,837.00
Rate for Payer: Kaiser Permanente Medicare	$359.50
Rate for Payer: MDX Hawaii PPO	$697.43
Rate for Payer: Ohana Health Plan Medicaid	$359.50
Rate for Payer: Ohana Health Plan Medicare	$359.50
Rate for Payer: UnitedHealthcare Medicaid	$80.28
Rate for Payer: UnitedHealthcare Medicare	$359.50
Rate for Payer: University Health Alliance Commercial	$402.64

HHSC MG Bx Breast Add Lesion Strtctc RT

Facility

$719.00

Service Code	HCPCS 19082
Hospital Charge Code	8223500
Hospital Revenue Code	361
Min. Negotiated Rate	$611.15
Max. Negotiated Rate	$697.43
Rate for Payer: Cash Price	$467.35
Rate for Payer: Health Management Network Commercial	$611.15
Rate for Payer: Kaiser Permanente Commercial	$647.10
Rate for Payer: MDX Hawaii PPO	$697.43

HHSC MG Perq Device Breast Ea Addl

Facility

$3,780.00

Service Code	HCPCS 19282
Hospital Charge Code	8223506
Hospital Revenue Code	361
Min. Negotiated Rate	$48.74
Max. Negotiated Rate	$3,666.60
Rate for Payer: AlohaCare Medicaid	$1,890.00
Rate for Payer: AlohaCare Medicare	$1,890.00
Rate for Payer: Cash Price	$2,457.00
Rate for Payer: Cash Price	$2,457.00
Rate for Payer: Cash Price	$2,457.00
Rate for Payer: Devoted Health Medicare	$2,079.00
Rate for Payer: Hawaii Medical Service Association Medicare	$1,890.00
Rate for Payer: Health Management Network Commercial	$3,213.00
Rate for Payer: Humana Medicare	$1,890.00
Rate for Payer: Kaiser Permanente Commercial	$3,402.00
Rate for Payer: Kaiser Permanente Medicaid	$2,837.00
Rate for Payer: Kaiser Permanente Medicare	$1,890.00
Rate for Payer: MDX Hawaii PPO	$3,666.60
Rate for Payer: Ohana Health Plan Medicaid	$1,890.00
Rate for Payer: Ohana Health Plan Medicare	$1,890.00
Rate for Payer: UnitedHealthcare Medicaid	$48.74
Rate for Payer: UnitedHealthcare Medicare	$1,890.00
Rate for Payer: University Health Alliance Commercial	$2,116.80

HHSC MG Perq Device Breast Ea Addl

Facility

$3,780.00

Service Code	HCPCS 19282
Hospital Charge Code	8223506
Hospital Revenue Code	361
Min. Negotiated Rate	$3,213.00
Max. Negotiated Rate	$3,666.60
Rate for Payer: Cash Price	$2,457.00
Rate for Payer: Health Management Network Commercial	$3,213.00
Rate for Payer: Kaiser Permanente Commercial	$3,402.00
Rate for Payer: MDX Hawaii PPO	$3,666.60

HHSC Mod Sed 5 Yrs+ 15 min Add

Facility

$70.00

Service Code	HCPCS 99157
Hospital Charge Code	8417759
Hospital Revenue Code	371
Min. Negotiated Rate	$35.00
Max. Negotiated Rate	$67.90
Rate for Payer: AlohaCare Medicaid	$35.00
Rate for Payer: AlohaCare Medicare	$35.00
Rate for Payer: Cash Price	$45.50
Rate for Payer: Cash Price	$45.50
Rate for Payer: Devoted Health Medicare	$38.50
Rate for Payer: Hawaii Medical Service Association Medicare	$35.00
Rate for Payer: Hawaii Western Management Group Commercial	$66.50
Rate for Payer: Health Management Network Commercial	$59.50
Rate for Payer: Humana Medicare	$35.00
Rate for Payer: Kaiser Permanente Commercial	$63.00
Rate for Payer: Kaiser Permanente Medicaid	$35.70
Rate for Payer: Kaiser Permanente Medicare	$35.00
Rate for Payer: MDX Hawaii PPO	$67.90
Rate for Payer: Ohana Health Plan Medicaid	$35.00
Rate for Payer: Ohana Health Plan Medicare	$35.00
Rate for Payer: UnitedHealthcare Medicaid	$58.96
Rate for Payer: UnitedHealthcare Medicare	$35.00
Rate for Payer: University Health Alliance Commercial	$39.20

HHSC Mod Sed 5 Yrs+ 15 min Add

Facility

$70.00

Service Code	HCPCS 99157
Hospital Charge Code	8417759
Hospital Revenue Code	371
Min. Negotiated Rate	$59.50
Max. Negotiated Rate	$67.90
Rate for Payer: Cash Price	$45.50
Rate for Payer: Health Management Network Commercial	$59.50
Rate for Payer: Kaiser Permanente Commercial	$63.00
Rate for Payer: MDX Hawaii PPO	$67.90

HHSC Mod Sed 5 Yrs+ 15 min Init

Facility

$139.00

Service Code	HCPCS 99156
Hospital Charge Code	8417755
Hospital Revenue Code	371
Min. Negotiated Rate	$53.37
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 Medicare	$69.50
Rate for Payer: Hawaii Western Management Group Commercial	$132.05
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	$53.37
Rate for Payer: UnitedHealthcare Medicare	$69.50
Rate for Payer: University Health Alliance Commercial	$77.84

HHSC Mod Sed 5 Yrs+ 15 min Init

Facility

$139.00

Service Code	HCPCS 99156
Hospital Charge Code	8417755
Hospital Revenue Code	371
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

HHSC NDL COAX TENMO BX SYS 18GX15CM (CT)

Facility

$263.00

Hospital Charge Code	9469093
Hospital Revenue Code	272
Min. Negotiated Rate	$131.50
Max. Negotiated Rate	$255.11
Rate for Payer: AlohaCare Medicaid	$131.50
Rate for Payer: AlohaCare Medicare	$131.50
Rate for Payer: Cash Price	$170.95
Rate for Payer: Devoted Health Medicare	$144.65
Rate for Payer: Hawaii Medical Service Association Medicare	$131.50
Rate for Payer: Hawaii Western Management Group Commercial	$249.85
Rate for Payer: Health Management Network Commercial	$223.55
Rate for Payer: Humana Medicare	$131.50
Rate for Payer: Kaiser Permanente Commercial	$236.70
Rate for Payer: Kaiser Permanente Medicaid	$134.13
Rate for Payer: Kaiser Permanente Medicare	$131.50
Rate for Payer: MDX Hawaii PPO	$255.11
Rate for Payer: Ohana Health Plan Medicaid	$131.50
Rate for Payer: Ohana Health Plan Medicare	$131.50
Rate for Payer: UnitedHealthcare Medicare	$131.50
Rate for Payer: University Health Alliance Commercial	$191.70

HHSC NDL COAX TENMO BX SYS 18GX15CM (CT)

Facility

$263.00

Hospital Charge Code	9469093
Hospital Revenue Code	272
Min. Negotiated Rate	$223.55
Max. Negotiated Rate	$255.11
Rate for Payer: Cash Price	$170.95
Rate for Payer: Health Management Network Commercial	$223.55
Rate for Payer: Kaiser Permanente Commercial	$236.70
Rate for Payer: MDX Hawaii PPO	$255.11

HHSC NDLE BRST WIRE 20GX5.7CM (US)

Facility

$165.00

Service Code	HCPCS C1819
Hospital Charge Code	9469314
Hospital Revenue Code	278
Min. Negotiated Rate	$82.50
Max. Negotiated Rate	$160.05
Rate for Payer: AlohaCare Medicaid	$82.50
Rate for Payer: AlohaCare Medicare	$82.50
Rate for Payer: Cash Price	$107.25
Rate for Payer: Devoted Health Medicare	$90.75
Rate for Payer: Hawaii Medical Service Association Medicare	$82.50
Rate for Payer: Hawaii Western Management Group Commercial	$115.50
Rate for Payer: Health Management Network Commercial	$140.25
Rate for Payer: Humana Medicare	$82.50
Rate for Payer: Kaiser Permanente Commercial	$148.50
Rate for Payer: Kaiser Permanente Medicaid	$84.15
Rate for Payer: Kaiser Permanente Medicare	$82.50
Rate for Payer: MDX Hawaii PPO	$160.05
Rate for Payer: Ohana Health Plan Medicaid	$82.50
Rate for Payer: Ohana Health Plan Medicare	$82.50
Rate for Payer: UnitedHealthcare Medicare	$82.50
Rate for Payer: University Health Alliance Commercial	$92.40

HHSC NDLE BRST WIRE 20GX5.7CM (US)

Facility

$165.00

Service Code	HCPCS C1819
Hospital Charge Code	9469314
Hospital Revenue Code	278
Min. Negotiated Rate	$92.40
Max. Negotiated Rate	$160.05
Rate for Payer: Cash Price	$107.25
Rate for Payer: Hawaii Western Management Group Commercial	$115.50
Rate for Payer: Health Management Network Commercial	$140.25
Rate for Payer: Kaiser Permanente Commercial	$148.50
Rate for Payer: MDX Hawaii PPO	$160.05
Rate for Payer: University Health Alliance Commercial	$92.40

Know your out-of-pocket cost for care.

All Charges