Samuel Mahelona Memorial Hospital

All Charges

Charge

Type

Setting

Price

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

Facility

$788.00

Hospital Charge Code	11579938
Hospital Revenue Code	272
Min. Negotiated Rate	$669.80
Max. Negotiated Rate	$764.36
Rate for Payer: Cash Price	$512.20
Rate for Payer: Health Management Network Commercial	$669.80
Rate for Payer: Kaiser Permanente Commercial	$709.20
Rate for Payer: MDX Hawaii PPO	$764.36

HHSC NEEDLE BIOPINCE BIOPSY 16G X 10CM

Facility

$240.00

Hospital Charge Code	11576614
Hospital Revenue Code	272
Min. Negotiated Rate	$120.00
Max. Negotiated Rate	$232.80
Rate for Payer: AlohaCare Medicaid	$120.00
Rate for Payer: AlohaCare Medicare	$120.00
Rate for Payer: Cash Price	$156.00
Rate for Payer: Devoted Health Medicare	$132.00
Rate for Payer: Hawaii Medical Service Association Medicare	$120.00
Rate for Payer: Hawaii Western Management Group Commercial	$228.00
Rate for Payer: Health Management Network Commercial	$204.00
Rate for Payer: Humana Medicare	$120.00
Rate for Payer: Kaiser Permanente Commercial	$216.00
Rate for Payer: Kaiser Permanente Medicaid	$122.40
Rate for Payer: Kaiser Permanente Medicare	$120.00
Rate for Payer: MDX Hawaii PPO	$232.80
Rate for Payer: Ohana Health Plan Medicaid	$120.00
Rate for Payer: Ohana Health Plan Medicare	$120.00
Rate for Payer: UnitedHealthcare Medicare	$120.00
Rate for Payer: University Health Alliance Commercial	$174.94

HHSC NEEDLE BIOPINCE BIOPSY 16G X 10CM

Facility

$240.00

Hospital Charge Code	11576614
Hospital Revenue Code	272
Min. Negotiated Rate	$204.00
Max. Negotiated Rate	$232.80
Rate for Payer: Cash Price	$156.00
Rate for Payer: Health Management Network Commercial	$204.00
Rate for Payer: Kaiser Permanente Commercial	$216.00
Rate for Payer: MDX Hawaii PPO	$232.80

HHSC NEEDLE BIOPINCE BIOPSY 16G X 10CM W/COAX

Facility

$372.00

Hospital Charge Code	11576616
Hospital Revenue Code	272
Min. Negotiated Rate	$186.00
Max. Negotiated Rate	$360.84
Rate for Payer: AlohaCare Medicaid	$186.00
Rate for Payer: AlohaCare Medicare	$186.00
Rate for Payer: Cash Price	$241.80
Rate for Payer: Devoted Health Medicare	$204.60
Rate for Payer: Hawaii Medical Service Association Medicare	$186.00
Rate for Payer: Hawaii Western Management Group Commercial	$353.40
Rate for Payer: Health Management Network Commercial	$316.20
Rate for Payer: Humana Medicare	$186.00
Rate for Payer: Kaiser Permanente Commercial	$334.80
Rate for Payer: Kaiser Permanente Medicaid	$189.72
Rate for Payer: Kaiser Permanente Medicare	$186.00
Rate for Payer: MDX Hawaii PPO	$360.84
Rate for Payer: Ohana Health Plan Medicaid	$186.00
Rate for Payer: Ohana Health Plan Medicare	$186.00
Rate for Payer: UnitedHealthcare Medicare	$186.00
Rate for Payer: University Health Alliance Commercial	$271.15

HHSC NEEDLE BIOPINCE BIOPSY 16G X 10CM W/COAX

Facility

$372.00

Hospital Charge Code	11576616
Hospital Revenue Code	272
Min. Negotiated Rate	$316.20
Max. Negotiated Rate	$360.84
Rate for Payer: Cash Price	$241.80
Rate for Payer: Health Management Network Commercial	$316.20
Rate for Payer: Kaiser Permanente Commercial	$334.80
Rate for Payer: MDX Hawaii PPO	$360.84

HHSC NEEDLE BIOPINCE BIOPSY 18G X 10CM W/COAX

Facility

$372.00

Hospital Charge Code	11579940
Hospital Revenue Code	272
Min. Negotiated Rate	$316.20
Max. Negotiated Rate	$360.84
Rate for Payer: Cash Price	$241.80
Rate for Payer: Health Management Network Commercial	$316.20
Rate for Payer: Kaiser Permanente Commercial	$334.80
Rate for Payer: MDX Hawaii PPO	$360.84

HHSC NEEDLE BIOPINCE BIOPSY 18G X 10CM W/COAX

Facility

$372.00

Hospital Charge Code	11579940
Hospital Revenue Code	272
Min. Negotiated Rate	$186.00
Max. Negotiated Rate	$360.84
Rate for Payer: AlohaCare Medicaid	$186.00
Rate for Payer: AlohaCare Medicare	$186.00
Rate for Payer: Cash Price	$241.80
Rate for Payer: Devoted Health Medicare	$204.60
Rate for Payer: Hawaii Medical Service Association Medicare	$186.00
Rate for Payer: Hawaii Western Management Group Commercial	$353.40
Rate for Payer: Health Management Network Commercial	$316.20
Rate for Payer: Humana Medicare	$186.00
Rate for Payer: Kaiser Permanente Commercial	$334.80
Rate for Payer: Kaiser Permanente Medicaid	$189.72
Rate for Payer: Kaiser Permanente Medicare	$186.00
Rate for Payer: MDX Hawaii PPO	$360.84
Rate for Payer: Ohana Health Plan Medicaid	$186.00
Rate for Payer: Ohana Health Plan Medicare	$186.00
Rate for Payer: UnitedHealthcare Medicare	$186.00
Rate for Payer: University Health Alliance Commercial	$271.15

HHSC NEEDLE GUIDES FOR EVIVA 9G

Facility

$73.00

Hospital Charge Code	13021601
Hospital Revenue Code	272
Min. Negotiated Rate	$62.05
Max. Negotiated Rate	$70.81
Rate for Payer: Cash Price	$47.45
Rate for Payer: Health Management Network Commercial	$62.05
Rate for Payer: Kaiser Permanente Commercial	$65.70
Rate for Payer: MDX Hawaii PPO	$70.81

HHSC NEEDLE GUIDES FOR EVIVA 9G

Facility

$73.00

Hospital Charge Code	13021601
Hospital Revenue Code	272
Min. Negotiated Rate	$36.50
Max. Negotiated Rate	$70.81
Rate for Payer: AlohaCare Medicaid	$36.50
Rate for Payer: AlohaCare Medicare	$36.50
Rate for Payer: Cash Price	$47.45
Rate for Payer: Devoted Health Medicare	$40.15
Rate for Payer: Hawaii Medical Service Association Medicare	$36.50
Rate for Payer: Hawaii Western Management Group Commercial	$69.35
Rate for Payer: Health Management Network Commercial	$62.05
Rate for Payer: Humana Medicare	$36.50
Rate for Payer: Kaiser Permanente Commercial	$65.70
Rate for Payer: Kaiser Permanente Medicaid	$37.23
Rate for Payer: Kaiser Permanente Medicare	$36.50
Rate for Payer: MDX Hawaii PPO	$70.81
Rate for Payer: Ohana Health Plan Medicaid	$36.50
Rate for Payer: Ohana Health Plan Medicare	$36.50
Rate for Payer: UnitedHealthcare Medicare	$36.50
Rate for Payer: University Health Alliance Commercial	$53.21

HHSC NEEDLE KOPANS MODIFIED BREAST LOCALIZATION

Facility

$210.00

Hospital Charge Code	11583904
Hospital Revenue Code	272
Min. Negotiated Rate	$178.50
Max. Negotiated Rate	$203.70
Rate for Payer: Cash Price	$136.50
Rate for Payer: Health Management Network Commercial	$178.50
Rate for Payer: Kaiser Permanente Commercial	$189.00
Rate for Payer: MDX Hawaii PPO	$203.70

HHSC NEEDLE KOPANS MODIFIED BREAST LOCALIZATION

Facility

$210.00

Hospital Charge Code	11583904
Hospital Revenue Code	272
Min. Negotiated Rate	$105.00
Max. Negotiated Rate	$203.70
Rate for Payer: AlohaCare Medicaid	$105.00
Rate for Payer: AlohaCare Medicare	$105.00
Rate for Payer: Cash Price	$136.50
Rate for Payer: Devoted Health Medicare	$115.50
Rate for Payer: Hawaii Medical Service Association Medicare	$105.00
Rate for Payer: Hawaii Western Management Group Commercial	$199.50
Rate for Payer: Health Management Network Commercial	$178.50
Rate for Payer: Humana Medicare	$105.00
Rate for Payer: Kaiser Permanente Commercial	$189.00
Rate for Payer: Kaiser Permanente Medicaid	$107.10
Rate for Payer: Kaiser Permanente Medicare	$105.00
Rate for Payer: MDX Hawaii PPO	$203.70
Rate for Payer: Ohana Health Plan Medicaid	$105.00
Rate for Payer: Ohana Health Plan Medicare	$105.00
Rate for Payer: UnitedHealthcare Medicare	$105.00
Rate for Payer: University Health Alliance Commercial	$153.07

HHSC NEEDLE MONOPTY BIOPSY 16G X 9CM

Facility

$34.00

Service Code	HCPCS C1819
Hospital Charge Code	11170699
Hospital Revenue Code	278
Min. Negotiated Rate	$17.00
Max. Negotiated Rate	$32.98
Rate for Payer: AlohaCare Medicaid	$17.00
Rate for Payer: AlohaCare Medicare	$17.00
Rate for Payer: Cash Price	$22.10
Rate for Payer: Devoted Health Medicare	$18.70
Rate for Payer: Hawaii Medical Service Association Medicare	$17.00
Rate for Payer: Hawaii Western Management Group Commercial	$23.80
Rate for Payer: Health Management Network Commercial	$28.90
Rate for Payer: Humana Medicare	$17.00
Rate for Payer: Kaiser Permanente Commercial	$30.60
Rate for Payer: Kaiser Permanente Medicaid	$17.34
Rate for Payer: Kaiser Permanente Medicare	$17.00
Rate for Payer: MDX Hawaii PPO	$32.98
Rate for Payer: Ohana Health Plan Medicaid	$17.00
Rate for Payer: Ohana Health Plan Medicare	$17.00
Rate for Payer: UnitedHealthcare Medicare	$17.00
Rate for Payer: University Health Alliance Commercial	$19.04

HHSC NEEDLE MONOPTY BIOPSY 16G X 9CM

Facility

$34.00

Service Code	HCPCS C1819
Hospital Charge Code	11170699
Hospital Revenue Code	278
Min. Negotiated Rate	$19.04
Max. Negotiated Rate	$32.98
Rate for Payer: Cash Price	$22.10
Rate for Payer: Hawaii Western Management Group Commercial	$23.80
Rate for Payer: Health Management Network Commercial	$28.90
Rate for Payer: Kaiser Permanente Commercial	$30.60
Rate for Payer: MDX Hawaii PPO	$32.98
Rate for Payer: University Health Alliance Commercial	$19.04

HHSC NEEDLE MONOPTY BIOPSY 18G X 9CM

Facility

$28.00

Service Code	HCPCS C1819
Hospital Charge Code	11178177
Hospital Revenue Code	278
Min. Negotiated Rate	$15.68
Max. Negotiated Rate	$27.16
Rate for Payer: Cash Price	$18.20
Rate for Payer: Hawaii Western Management Group Commercial	$19.60
Rate for Payer: Health Management Network Commercial	$23.80
Rate for Payer: Kaiser Permanente Commercial	$25.20
Rate for Payer: MDX Hawaii PPO	$27.16
Rate for Payer: University Health Alliance Commercial	$15.68

HHSC NEEDLE MONOPTY BIOPSY 18G X 9CM

Facility

$28.00

Service Code	HCPCS C1819
Hospital Charge Code	11178177
Hospital Revenue Code	278
Min. Negotiated Rate	$14.00
Max. Negotiated Rate	$27.16
Rate for Payer: AlohaCare Medicaid	$14.00
Rate for Payer: AlohaCare Medicare	$14.00
Rate for Payer: Cash Price	$18.20
Rate for Payer: Devoted Health Medicare	$15.40
Rate for Payer: Hawaii Medical Service Association Medicare	$14.00
Rate for Payer: Hawaii Western Management Group Commercial	$19.60
Rate for Payer: Health Management Network Commercial	$23.80
Rate for Payer: Humana Medicare	$14.00
Rate for Payer: Kaiser Permanente Commercial	$25.20
Rate for Payer: Kaiser Permanente Medicaid	$14.28
Rate for Payer: Kaiser Permanente Medicare	$14.00
Rate for Payer: MDX Hawaii PPO	$27.16
Rate for Payer: Ohana Health Plan Medicaid	$14.00
Rate for Payer: Ohana Health Plan Medicare	$14.00
Rate for Payer: UnitedHealthcare Medicare	$14.00
Rate for Payer: University Health Alliance Commercial	$15.68

HHSC ProFee BCE 20610 Drain Inj Major JT Bursa Bil

Professional

Both

$427.00

Service Code	HCPCS 20610
Hospital Charge Code	8584504
Hospital Revenue Code	521
Min. Negotiated Rate	$39.25
Max. Negotiated Rate	$434.26
Rate for Payer: AlohaCare Medicaid	$45.55
Rate for Payer: AlohaCare Medicare	$39.25
Rate for Payer: Cash Price	$277.55
Rate for Payer: Cash Price	$277.55
Rate for Payer: Cash Price	$277.55
Rate for Payer: Devoted Health Medicare	$43.17
Rate for Payer: Hawaii Medical Service Association ABD	$434.26
Rate for Payer: Hawaii Medical Service Association Commercial	$70.55
Rate for Payer: Hawaii Medical Service Association Medicare	$246.64
Rate for Payer: Hawaii Medical Service Association Medicare	$181.39
Rate for Payer: Hawaii Medical Service Association Medicare	$209.49
Rate for Payer: Hawaii Medical Service Association Medicare	$237.64
Rate for Payer: Hawaii Medical Service Association Medicare	$265.97
Rate for Payer: Hawaii Medical Service Association Medicare	$303.73
Rate for Payer: Hawaii Medical Service Association Medicare	$339.46
Rate for Payer: Hawaii Medical Service Association Non-ABD	$434.26
Rate for Payer: Hawaii Western Management Group Commercial	$58.76
Rate for Payer: Health Management Network Commercial	$362.95
Rate for Payer: Kaiser Permanente Commercial	$265.97
Rate for Payer: Kaiser Permanente Commercial	$47.10
Rate for Payer: Kaiser Permanente Commercial	$181.39
Rate for Payer: Kaiser Permanente Commercial	$209.49
Rate for Payer: Kaiser Permanente Commercial	$237.64
Rate for Payer: Kaiser Permanente Commercial	$246.64
Rate for Payer: Kaiser Permanente Commercial	$303.73
Rate for Payer: Kaiser Permanente Commercial	$339.46
Rate for Payer: Kaiser Permanente Medicaid	$434.26
Rate for Payer: Kaiser Permanente Medicare	$339.46
Rate for Payer: Kaiser Permanente Medicare	$265.97
Rate for Payer: Kaiser Permanente Medicare	$303.73
Rate for Payer: Kaiser Permanente Medicare	$181.39
Rate for Payer: Kaiser Permanente Medicare	$209.49
Rate for Payer: Kaiser Permanente Medicare	$237.64
Rate for Payer: Kaiser Permanente Medicare	$246.64
Rate for Payer: Ohana Health Plan Medicaid	$45.55
Rate for Payer: Ohana Health Plan Medicare	$39.25
Rate for Payer: UnitedHealthcare Medicaid	$434.26
Rate for Payer: UnitedHealthcare Medicare	$246.64
Rate for Payer: UnitedHealthcare Medicare	$237.64
Rate for Payer: UnitedHealthcare Medicare	$209.49
Rate for Payer: UnitedHealthcare Medicare	$181.39
Rate for Payer: UnitedHealthcare Medicare	$265.97
Rate for Payer: UnitedHealthcare Medicare	$303.73
Rate for Payer: UnitedHealthcare Medicare	$339.46

HHSC ProFee BCE 20610 Drain Inj Major JT Bursa Bil

Professional

Both

$427.00

Service Code	HCPCS 20610
Hospital Charge Code	8584504
Hospital Revenue Code	972
Min. Negotiated Rate	$39.25
Max. Negotiated Rate	$362.95
Rate for Payer: AlohaCare Medicaid	$45.55
Rate for Payer: AlohaCare Medicare	$39.25
Rate for Payer: Cash Price	$277.55
Rate for Payer: Cash Price	$277.55
Rate for Payer: Devoted Health Medicare	$43.17
Rate for Payer: Hawaii Medical Service Association ABD	$45.55
Rate for Payer: Hawaii Medical Service Association Commercial	$70.55
Rate for Payer: Hawaii Medical Service Association Medicare	$39.25
Rate for Payer: Hawaii Medical Service Association Non-ABD	$45.55
Rate for Payer: Hawaii Western Management Group Commercial	$58.76
Rate for Payer: Health Management Network Commercial	$362.95
Rate for Payer: Kaiser Permanente Commercial	$47.10
Rate for Payer: Kaiser Permanente Medicaid	$47.10
Rate for Payer: Kaiser Permanente Medicare	$47.10
Rate for Payer: Ohana Health Plan Medicaid	$45.55
Rate for Payer: Ohana Health Plan Medicare	$39.25
Rate for Payer: UnitedHealthcare Medicaid	$45.55
Rate for Payer: UnitedHealthcare Medicare	$39.25

HHSC RABINOV SIALOGRAPHY CATH .016 INCH

Facility

$95.00

Service Code	HCPCS C1729
Hospital Charge Code	8223436
Hospital Revenue Code	272
Min. Negotiated Rate	$47.50
Max. Negotiated Rate	$92.15
Rate for Payer: AlohaCare Medicaid	$47.50
Rate for Payer: AlohaCare Medicare	$47.50
Rate for Payer: Cash Price	$61.75
Rate for Payer: Devoted Health Medicare	$52.25
Rate for Payer: Hawaii Medical Service Association Medicare	$47.50
Rate for Payer: Hawaii Western Management Group Commercial	$90.25
Rate for Payer: Health Management Network Commercial	$80.75
Rate for Payer: Humana Medicare	$47.50
Rate for Payer: Kaiser Permanente Commercial	$85.50
Rate for Payer: Kaiser Permanente Medicaid	$48.45
Rate for Payer: Kaiser Permanente Medicare	$47.50
Rate for Payer: MDX Hawaii PPO	$92.15
Rate for Payer: Ohana Health Plan Medicaid	$47.50
Rate for Payer: Ohana Health Plan Medicare	$47.50
Rate for Payer: UnitedHealthcare Medicare	$47.50
Rate for Payer: University Health Alliance Commercial	$69.25

HHSC RABINOV SIALOGRAPHY CATH .016 INCH

Facility

$95.00

Service Code	HCPCS C1729
Hospital Charge Code	8223436
Hospital Revenue Code	272
Min. Negotiated Rate	$80.75
Max. Negotiated Rate	$92.15
Rate for Payer: Cash Price	$61.75
Rate for Payer: Health Management Network Commercial	$80.75
Rate for Payer: Kaiser Permanente Commercial	$85.50
Rate for Payer: MDX Hawaii PPO	$92.15

HHSC Securmark SS Biopsy Site Marker

Facility

$318.00

Service Code	HCPCS A4648
Hospital Charge Code	8223474
Hospital Revenue Code	278
Min. Negotiated Rate	$159.00
Max. Negotiated Rate	$308.46
Rate for Payer: AlohaCare Medicaid	$159.00
Rate for Payer: AlohaCare Medicare	$159.00
Rate for Payer: Cash Price	$206.70
Rate for Payer: Devoted Health Medicare	$174.90
Rate for Payer: Hawaii Medical Service Association Medicare	$159.00
Rate for Payer: Hawaii Western Management Group Commercial	$222.60
Rate for Payer: Health Management Network Commercial	$270.30
Rate for Payer: Humana Medicare	$159.00
Rate for Payer: Kaiser Permanente Commercial	$286.20
Rate for Payer: Kaiser Permanente Medicaid	$162.18
Rate for Payer: Kaiser Permanente Medicare	$159.00
Rate for Payer: MDX Hawaii PPO	$308.46
Rate for Payer: Ohana Health Plan Medicaid	$159.00
Rate for Payer: Ohana Health Plan Medicare	$159.00
Rate for Payer: UnitedHealthcare Medicare	$159.00
Rate for Payer: University Health Alliance Commercial	$178.08

HHSC Securmark SS Biopsy Site Marker

Facility

$318.00

Service Code	HCPCS A4648
Hospital Charge Code	8223474
Hospital Revenue Code	278
Min. Negotiated Rate	$178.08
Max. Negotiated Rate	$308.46
Rate for Payer: Cash Price	$206.70
Rate for Payer: Hawaii Western Management Group Commercial	$222.60
Rate for Payer: Health Management Network Commercial	$270.30
Rate for Payer: Kaiser Permanente Commercial	$286.20
Rate for Payer: MDX Hawaii PPO	$308.46
Rate for Payer: University Health Alliance Commercial	$178.08

HHSC SET 8.5F M/P DRNGE CATH(CT)

Facility

$741.00

Hospital Charge Code	9469099
Hospital Revenue Code	272
Min. Negotiated Rate	$629.85
Max. Negotiated Rate	$718.77
Rate for Payer: Cash Price	$481.65
Rate for Payer: Health Management Network Commercial	$629.85
Rate for Payer: Kaiser Permanente Commercial	$666.90
Rate for Payer: MDX Hawaii PPO	$718.77

HHSC SET 8.5F M/P DRNGE CATH(CT)

Facility

$741.00

Hospital Charge Code	9469099
Hospital Revenue Code	272
Min. Negotiated Rate	$370.50
Max. Negotiated Rate	$718.77
Rate for Payer: AlohaCare Medicaid	$370.50
Rate for Payer: AlohaCare Medicare	$370.50
Rate for Payer: Cash Price	$481.65
Rate for Payer: Devoted Health Medicare	$407.55
Rate for Payer: Hawaii Medical Service Association Medicare	$370.50
Rate for Payer: Hawaii Western Management Group Commercial	$703.95
Rate for Payer: Health Management Network Commercial	$629.85
Rate for Payer: Humana Medicare	$370.50
Rate for Payer: Kaiser Permanente Commercial	$666.90
Rate for Payer: Kaiser Permanente Medicaid	$377.91
Rate for Payer: Kaiser Permanente Medicare	$370.50
Rate for Payer: MDX Hawaii PPO	$718.77
Rate for Payer: Ohana Health Plan Medicaid	$370.50
Rate for Payer: Ohana Health Plan Medicare	$370.50
Rate for Payer: UnitedHealthcare Medicare	$370.50
Rate for Payer: University Health Alliance Commercial	$540.11

HHSC SET 8.5F M/P DRNGE CATH (US)

Facility

$741.00

Hospital Charge Code	9469331
Hospital Revenue Code	272
Min. Negotiated Rate	$629.85
Max. Negotiated Rate	$718.77
Rate for Payer: Cash Price	$481.65
Rate for Payer: Health Management Network Commercial	$629.85
Rate for Payer: Kaiser Permanente Commercial	$666.90
Rate for Payer: MDX Hawaii PPO	$718.77

HHSC SET 8.5F M/P DRNGE CATH (US)

Facility

$741.00

Hospital Charge Code	9469331
Hospital Revenue Code	272
Min. Negotiated Rate	$370.50
Max. Negotiated Rate	$718.77
Rate for Payer: AlohaCare Medicaid	$370.50
Rate for Payer: AlohaCare Medicare	$370.50
Rate for Payer: Cash Price	$481.65
Rate for Payer: Devoted Health Medicare	$407.55
Rate for Payer: Hawaii Medical Service Association Medicare	$370.50
Rate for Payer: Hawaii Western Management Group Commercial	$703.95
Rate for Payer: Health Management Network Commercial	$629.85
Rate for Payer: Humana Medicare	$370.50
Rate for Payer: Kaiser Permanente Commercial	$666.90
Rate for Payer: Kaiser Permanente Medicaid	$377.91
Rate for Payer: Kaiser Permanente Medicare	$370.50
Rate for Payer: MDX Hawaii PPO	$718.77
Rate for Payer: Ohana Health Plan Medicaid	$370.50
Rate for Payer: Ohana Health Plan Medicare	$370.50
Rate for Payer: UnitedHealthcare Medicare	$370.50
Rate for Payer: University Health Alliance Commercial	$540.11

Know your out-of-pocket cost for care.

All Charges