Samuel Mahelona Memorial Hospital

All Charges

Charge

Type

Setting

Price

HHSC NDLE BRST WIRE 20GX5.7CM (XR/MAMMO)

Facility

$165.00

Service Code	HCPCS C1819
Hospital Charge Code	9468989
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

HHSC NDLE BRST WIRE 20GX5.7CM (XR/MAMMO)

Facility

$165.00

Service Code	HCPCS C1819
Hospital Charge Code	9468989
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 NDL FRNSN LUNG BX 22G/5CM (CT)

Facility

$263.00

Hospital Charge Code	9469097
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 NDL FRNSN LUNG BX 22G/5CM (CT)

Facility

$263.00

Hospital Charge Code	9469097
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 FRNSN LUNG BX 22G/5CM(US)

Facility

$236.00

Hospital Charge Code	9469327
Hospital Revenue Code	272
Min. Negotiated Rate	$200.60
Max. Negotiated Rate	$228.92
Rate for Payer: Cash Price	$153.40
Rate for Payer: Health Management Network Commercial	$200.60
Rate for Payer: Kaiser Permanente Commercial	$212.40
Rate for Payer: MDX Hawaii PPO	$228.92

HHSC NDL FRNSN LUNG BX 22G/5CM(US)

Facility

$236.00

Hospital Charge Code	9469327
Hospital Revenue Code	272
Min. Negotiated Rate	$118.00
Max. Negotiated Rate	$228.92
Rate for Payer: AlohaCare Medicaid	$118.00
Rate for Payer: AlohaCare Medicare	$118.00
Rate for Payer: Cash Price	$153.40
Rate for Payer: Devoted Health Medicare	$129.80
Rate for Payer: Hawaii Medical Service Association Medicare	$118.00
Rate for Payer: Hawaii Western Management Group Commercial	$224.20
Rate for Payer: Health Management Network Commercial	$200.60
Rate for Payer: Humana Medicare	$118.00
Rate for Payer: Kaiser Permanente Commercial	$212.40
Rate for Payer: Kaiser Permanente Medicaid	$120.36
Rate for Payer: Kaiser Permanente Medicare	$118.00
Rate for Payer: MDX Hawaii PPO	$228.92
Rate for Payer: Ohana Health Plan Medicaid	$118.00
Rate for Payer: Ohana Health Plan Medicare	$118.00
Rate for Payer: UnitedHealthcare Medicare	$118.00
Rate for Payer: University Health Alliance Commercial	$172.02

HHSC NDL FRNSN LUNG BX 22G/5CM(XR/MAMMO)

Facility

$232.00

Hospital Charge Code	9469002
Hospital Revenue Code	272
Min. Negotiated Rate	$116.00
Max. Negotiated Rate	$225.04
Rate for Payer: AlohaCare Medicaid	$116.00
Rate for Payer: AlohaCare Medicare	$116.00
Rate for Payer: Cash Price	$150.80
Rate for Payer: Devoted Health Medicare	$127.60
Rate for Payer: Hawaii Medical Service Association Medicare	$116.00
Rate for Payer: Hawaii Western Management Group Commercial	$220.40
Rate for Payer: Health Management Network Commercial	$197.20
Rate for Payer: Humana Medicare	$116.00
Rate for Payer: Kaiser Permanente Commercial	$208.80
Rate for Payer: Kaiser Permanente Medicaid	$118.32
Rate for Payer: Kaiser Permanente Medicare	$116.00
Rate for Payer: MDX Hawaii PPO	$225.04
Rate for Payer: Ohana Health Plan Medicaid	$116.00
Rate for Payer: Ohana Health Plan Medicare	$116.00
Rate for Payer: UnitedHealthcare Medicare	$116.00
Rate for Payer: University Health Alliance Commercial	$169.10

HHSC NDL FRNSN LUNG BX 22G/5CM(XR/MAMMO)

Facility

$232.00

Hospital Charge Code	9469002
Hospital Revenue Code	272
Min. Negotiated Rate	$197.20
Max. Negotiated Rate	$225.04
Rate for Payer: Cash Price	$150.80
Rate for Payer: Health Management Network Commercial	$197.20
Rate for Payer: Kaiser Permanente Commercial	$208.80
Rate for Payer: MDX Hawaii PPO	$225.04

HHSC NDL TENMO BX SYS 18GX15CM (US)

Facility

$263.00

Hospital Charge Code	9469318
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 NDL TENMO BX SYS 18GX15CM (US)

Facility

$263.00

Hospital Charge Code	9469318
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 TENMO BX SYS 18GX15CM(XR/MAMMO)

Facility

$263.00

Hospital Charge Code	9468994
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 TENMO BX SYS 18GX15CM(XR/MAMMO)

Facility

$263.00

Hospital Charge Code	9468994
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 NDL YUEH 5FR/7CM (CT)

Facility

$96.00

Hospital Charge Code	9469105
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

HHSC NDL YUEH 5FR/7CM (CT)

Facility

$96.00

Hospital Charge Code	9469105
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

HHSC NDL YUEH 5FR/7CM (US)

Facility

$133.00

Hospital Charge Code	9469337
Hospital Revenue Code	272
Min. Negotiated Rate	$66.50
Max. Negotiated Rate	$129.01
Rate for Payer: AlohaCare Medicaid	$66.50
Rate for Payer: AlohaCare Medicare	$66.50
Rate for Payer: Cash Price	$86.45
Rate for Payer: Devoted Health Medicare	$73.15
Rate for Payer: Hawaii Medical Service Association Medicare	$66.50
Rate for Payer: Hawaii Western Management Group Commercial	$126.35
Rate for Payer: Health Management Network Commercial	$113.05
Rate for Payer: Humana Medicare	$66.50
Rate for Payer: Kaiser Permanente Commercial	$119.70
Rate for Payer: Kaiser Permanente Medicaid	$67.83
Rate for Payer: Kaiser Permanente Medicare	$66.50
Rate for Payer: MDX Hawaii PPO	$129.01
Rate for Payer: Ohana Health Plan Medicaid	$66.50
Rate for Payer: Ohana Health Plan Medicare	$66.50
Rate for Payer: UnitedHealthcare Medicare	$66.50
Rate for Payer: University Health Alliance Commercial	$96.94

HHSC NDL YUEH 5FR/7CM (US)

Facility

$133.00

Hospital Charge Code	9469337
Hospital Revenue Code	272
Min. Negotiated Rate	$113.05
Max. Negotiated Rate	$129.01
Rate for Payer: Cash Price	$86.45
Rate for Payer: Health Management Network Commercial	$113.05
Rate for Payer: Kaiser Permanente Commercial	$119.70
Rate for Payer: MDX Hawaii PPO	$129.01

HHSC NDL YUEH 5FR/7CM (XR/MAMMO)

Facility

$133.00

Hospital Charge Code	9469070
Hospital Revenue Code	272
Min. Negotiated Rate	$66.50
Max. Negotiated Rate	$129.01
Rate for Payer: AlohaCare Medicaid	$66.50
Rate for Payer: AlohaCare Medicare	$66.50
Rate for Payer: Cash Price	$86.45
Rate for Payer: Devoted Health Medicare	$73.15
Rate for Payer: Hawaii Medical Service Association Medicare	$66.50
Rate for Payer: Hawaii Western Management Group Commercial	$126.35
Rate for Payer: Health Management Network Commercial	$113.05
Rate for Payer: Humana Medicare	$66.50
Rate for Payer: Kaiser Permanente Commercial	$119.70
Rate for Payer: Kaiser Permanente Medicaid	$67.83
Rate for Payer: Kaiser Permanente Medicare	$66.50
Rate for Payer: MDX Hawaii PPO	$129.01
Rate for Payer: Ohana Health Plan Medicaid	$66.50
Rate for Payer: Ohana Health Plan Medicare	$66.50
Rate for Payer: UnitedHealthcare Medicare	$66.50
Rate for Payer: University Health Alliance Commercial	$96.94

HHSC NDL YUEH 5FR/7CM (XR/MAMMO)

Facility

$133.00

Hospital Charge Code	9469070
Hospital Revenue Code	272
Min. Negotiated Rate	$113.05
Max. Negotiated Rate	$129.01
Rate for Payer: Cash Price	$86.45
Rate for Payer: Health Management Network Commercial	$113.05
Rate for Payer: Kaiser Permanente Commercial	$119.70
Rate for Payer: MDX Hawaii PPO	$129.01

HHSC NDL YUEH CATH 5FR/10CM (CT)

Facility

$133.00

Service Code	HCPCS C1887
Hospital Charge Code	9469103
Hospital Revenue Code	272
Min. Negotiated Rate	$66.50
Max. Negotiated Rate	$129.01
Rate for Payer: AlohaCare Medicaid	$66.50
Rate for Payer: AlohaCare Medicare	$66.50
Rate for Payer: Cash Price	$86.45
Rate for Payer: Devoted Health Medicare	$73.15
Rate for Payer: Hawaii Medical Service Association Medicare	$66.50
Rate for Payer: Hawaii Western Management Group Commercial	$126.35
Rate for Payer: Health Management Network Commercial	$113.05
Rate for Payer: Humana Medicare	$66.50
Rate for Payer: Kaiser Permanente Commercial	$119.70
Rate for Payer: Kaiser Permanente Medicaid	$67.83
Rate for Payer: Kaiser Permanente Medicare	$66.50
Rate for Payer: MDX Hawaii PPO	$129.01
Rate for Payer: Ohana Health Plan Medicaid	$66.50
Rate for Payer: Ohana Health Plan Medicare	$66.50
Rate for Payer: UnitedHealthcare Medicare	$66.50
Rate for Payer: University Health Alliance Commercial	$96.94

HHSC NDL YUEH CATH 5FR/10CM (CT)

Facility

$133.00

Service Code	HCPCS C1887
Hospital Charge Code	9469103
Hospital Revenue Code	272
Min. Negotiated Rate	$113.05
Max. Negotiated Rate	$129.01
Rate for Payer: Cash Price	$86.45
Rate for Payer: Health Management Network Commercial	$113.05
Rate for Payer: Kaiser Permanente Commercial	$119.70
Rate for Payer: MDX Hawaii PPO	$129.01

HHSC NDL YUEH CATH 5FR/10CM (US)

Facility

$127.00

Service Code	HCPCS C1887
Hospital Charge Code	9469335
Hospital Revenue Code	272
Min. Negotiated Rate	$107.95
Max. Negotiated Rate	$123.19
Rate for Payer: Cash Price	$82.55
Rate for Payer: Health Management Network Commercial	$107.95
Rate for Payer: Kaiser Permanente Commercial	$114.30
Rate for Payer: MDX Hawaii PPO	$123.19

HHSC NDL YUEH CATH 5FR/10CM (US)

Facility

$127.00

Service Code	HCPCS C1887
Hospital Charge Code	9469335
Hospital Revenue Code	272
Min. Negotiated Rate	$63.50
Max. Negotiated Rate	$123.19
Rate for Payer: AlohaCare Medicaid	$63.50
Rate for Payer: AlohaCare Medicare	$63.50
Rate for Payer: Cash Price	$82.55
Rate for Payer: Devoted Health Medicare	$69.85
Rate for Payer: Hawaii Medical Service Association Medicare	$63.50
Rate for Payer: Hawaii Western Management Group Commercial	$120.65
Rate for Payer: Health Management Network Commercial	$107.95
Rate for Payer: Humana Medicare	$63.50
Rate for Payer: Kaiser Permanente Commercial	$114.30
Rate for Payer: Kaiser Permanente Medicaid	$64.77
Rate for Payer: Kaiser Permanente Medicare	$63.50
Rate for Payer: MDX Hawaii PPO	$123.19
Rate for Payer: Ohana Health Plan Medicaid	$63.50
Rate for Payer: Ohana Health Plan Medicare	$63.50
Rate for Payer: UnitedHealthcare Medicare	$63.50
Rate for Payer: University Health Alliance Commercial	$92.57

HHSC NDL YUEH CATH 5FR/10CM (XR/MAMMO)

Facility

$133.00

Service Code	HCPCS C1887
Hospital Charge Code	9469068
Hospital Revenue Code	272
Min. Negotiated Rate	$113.05
Max. Negotiated Rate	$129.01
Rate for Payer: Cash Price	$86.45
Rate for Payer: Health Management Network Commercial	$113.05
Rate for Payer: Kaiser Permanente Commercial	$119.70
Rate for Payer: MDX Hawaii PPO	$129.01

HHSC NDL YUEH CATH 5FR/10CM (XR/MAMMO)

Facility

$133.00

Service Code	HCPCS C1887
Hospital Charge Code	9469068
Hospital Revenue Code	272
Min. Negotiated Rate	$66.50
Max. Negotiated Rate	$129.01
Rate for Payer: AlohaCare Medicaid	$66.50
Rate for Payer: AlohaCare Medicare	$66.50
Rate for Payer: Cash Price	$86.45
Rate for Payer: Devoted Health Medicare	$73.15
Rate for Payer: Hawaii Medical Service Association Medicare	$66.50
Rate for Payer: Hawaii Western Management Group Commercial	$126.35
Rate for Payer: Health Management Network Commercial	$113.05
Rate for Payer: Humana Medicare	$66.50
Rate for Payer: Kaiser Permanente Commercial	$119.70
Rate for Payer: Kaiser Permanente Medicaid	$67.83
Rate for Payer: Kaiser Permanente Medicare	$66.50
Rate for Payer: MDX Hawaii PPO	$129.01
Rate for Payer: Ohana Health Plan Medicaid	$66.50
Rate for Payer: Ohana Health Plan Medicare	$66.50
Rate for Payer: UnitedHealthcare Medicare	$66.50
Rate for Payer: University Health Alliance Commercial	$96.94

HHSC NEEDLE 13G X 10CM OSTEO-SITE BONE BIOPSY SET

Facility

$788.00

Hospital Charge Code	11579938
Hospital Revenue Code	272
Min. Negotiated Rate	$394.00
Max. Negotiated Rate	$764.36
Rate for Payer: AlohaCare Medicaid	$394.00
Rate for Payer: AlohaCare Medicare	$394.00
Rate for Payer: Cash Price	$512.20
Rate for Payer: Devoted Health Medicare	$433.40
Rate for Payer: Hawaii Medical Service Association Medicare	$394.00
Rate for Payer: Hawaii Western Management Group Commercial	$748.60
Rate for Payer: Health Management Network Commercial	$669.80
Rate for Payer: Humana Medicare	$394.00
Rate for Payer: Kaiser Permanente Commercial	$709.20
Rate for Payer: Kaiser Permanente Medicaid	$401.88
Rate for Payer: Kaiser Permanente Medicare	$394.00
Rate for Payer: MDX Hawaii PPO	$764.36
Rate for Payer: Ohana Health Plan Medicaid	$394.00
Rate for Payer: Ohana Health Plan Medicare	$394.00
Rate for Payer: UnitedHealthcare Medicare	$394.00
Rate for Payer: University Health Alliance Commercial	$574.37

Know your out-of-pocket cost for care.

All Charges