Samuel Mahelona Memorial Hospital

All Charges

Charge

Type

Setting

Price

HHSC SET 8.5F M/P DRNGE CATH(XR/MAMMO)

Facility

$741.00

Hospital Charge Code	9469004
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(XR/MAMMO)

Facility

$741.00

Hospital Charge Code	9469004
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 HSG CATHETER 5F (US)

Facility

$150.00

Hospital Charge Code	9469345
Hospital Revenue Code	272
Min. Negotiated Rate	$75.00
Max. Negotiated Rate	$145.50
Rate for Payer: AlohaCare Medicaid	$75.00
Rate for Payer: AlohaCare Medicare	$75.00
Rate for Payer: Cash Price	$97.50
Rate for Payer: Devoted Health Medicare	$82.50
Rate for Payer: Hawaii Medical Service Association Medicare	$75.00
Rate for Payer: Hawaii Western Management Group Commercial	$142.50
Rate for Payer: Health Management Network Commercial	$127.50
Rate for Payer: Humana Medicare	$75.00
Rate for Payer: Kaiser Permanente Commercial	$135.00
Rate for Payer: Kaiser Permanente Medicaid	$76.50
Rate for Payer: Kaiser Permanente Medicare	$75.00
Rate for Payer: MDX Hawaii PPO	$145.50
Rate for Payer: Ohana Health Plan Medicaid	$75.00
Rate for Payer: Ohana Health Plan Medicare	$75.00
Rate for Payer: UnitedHealthcare Medicare	$75.00
Rate for Payer: University Health Alliance Commercial	$109.33

HHSC SET HSG CATHETER 5F (US)

Facility

$150.00

Hospital Charge Code	9469345
Hospital Revenue Code	272
Min. Negotiated Rate	$127.50
Max. Negotiated Rate	$145.50
Rate for Payer: Cash Price	$97.50
Rate for Payer: Health Management Network Commercial	$127.50
Rate for Payer: Kaiser Permanente Commercial	$135.00
Rate for Payer: MDX Hawaii PPO	$145.50

HHSC SET HSG CATHETER 5F (XR/MAMMO)

Facility

$150.00

Hospital Charge Code	9469081
Hospital Revenue Code	272
Min. Negotiated Rate	$127.50
Max. Negotiated Rate	$145.50
Rate for Payer: Cash Price	$97.50
Rate for Payer: Health Management Network Commercial	$127.50
Rate for Payer: Kaiser Permanente Commercial	$135.00
Rate for Payer: MDX Hawaii PPO	$145.50

HHSC SET HSG CATHETER 5F (XR/MAMMO)

Facility

$150.00

Hospital Charge Code	9469081
Hospital Revenue Code	272
Min. Negotiated Rate	$75.00
Max. Negotiated Rate	$145.50
Rate for Payer: AlohaCare Medicaid	$75.00
Rate for Payer: AlohaCare Medicare	$75.00
Rate for Payer: Cash Price	$97.50
Rate for Payer: Devoted Health Medicare	$82.50
Rate for Payer: Hawaii Medical Service Association Medicare	$75.00
Rate for Payer: Hawaii Western Management Group Commercial	$142.50
Rate for Payer: Health Management Network Commercial	$127.50
Rate for Payer: Humana Medicare	$75.00
Rate for Payer: Kaiser Permanente Commercial	$135.00
Rate for Payer: Kaiser Permanente Medicaid	$76.50
Rate for Payer: Kaiser Permanente Medicare	$75.00
Rate for Payer: MDX Hawaii PPO	$145.50
Rate for Payer: Ohana Health Plan Medicaid	$75.00
Rate for Payer: Ohana Health Plan Medicare	$75.00
Rate for Payer: UnitedHealthcare Medicare	$75.00
Rate for Payer: University Health Alliance Commercial	$109.33

HHSC SET INTRO TIP PNEUMOTHORAX (CT)

Facility

$523.00

Service Code	HCPCS C1729
Hospital Charge Code	9469107
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 SET INTRO TIP PNEUMOTHORAX (CT)

Facility

$523.00

Service Code	HCPCS C1729
Hospital Charge Code	9469107
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 SET INTRO TIP PNEUMOTHORAX (US)

Facility

$523.00

Service Code	HCPCS C1729
Hospital Charge Code	9469339
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 SET INTRO TIP PNEUMOTHORAX (US)

Facility

$523.00

Service Code	HCPCS C1729
Hospital Charge Code	9469339
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 SET INTRO TIP PNEUMO (XR/MAMMO)

Facility

$449.00

Service Code	HCPCS C1729
Hospital Charge Code	9469074
Hospital Revenue Code	272
Min. Negotiated Rate	$381.65
Max. Negotiated Rate	$435.53
Rate for Payer: Cash Price	$291.85
Rate for Payer: Health Management Network Commercial	$381.65
Rate for Payer: Kaiser Permanente Commercial	$404.10
Rate for Payer: MDX Hawaii PPO	$435.53

HHSC SET INTRO TIP PNEUMO (XR/MAMMO)

Facility

$449.00

Service Code	HCPCS C1729
Hospital Charge Code	9469074
Hospital Revenue Code	272
Min. Negotiated Rate	$224.50
Max. Negotiated Rate	$435.53
Rate for Payer: AlohaCare Medicaid	$224.50
Rate for Payer: AlohaCare Medicare	$224.50
Rate for Payer: Cash Price	$291.85
Rate for Payer: Devoted Health Medicare	$246.95
Rate for Payer: Hawaii Medical Service Association Medicare	$224.50
Rate for Payer: Hawaii Western Management Group Commercial	$426.55
Rate for Payer: Health Management Network Commercial	$381.65
Rate for Payer: Humana Medicare	$224.50
Rate for Payer: Kaiser Permanente Commercial	$404.10
Rate for Payer: Kaiser Permanente Medicaid	$228.99
Rate for Payer: Kaiser Permanente Medicare	$224.50
Rate for Payer: MDX Hawaii PPO	$435.53
Rate for Payer: Ohana Health Plan Medicaid	$224.50
Rate for Payer: Ohana Health Plan Medicare	$224.50
Rate for Payer: UnitedHealthcare Medicare	$224.50
Rate for Payer: University Health Alliance Commercial	$327.28

HHSC SET MULTI-PURPOSE DRAINAGE 12 FR

Facility

$743.00

Hospital Charge Code	11579942
Hospital Revenue Code	272
Min. Negotiated Rate	$631.55
Max. Negotiated Rate	$720.71
Rate for Payer: Cash Price	$482.95
Rate for Payer: Health Management Network Commercial	$631.55
Rate for Payer: Kaiser Permanente Commercial	$668.70
Rate for Payer: MDX Hawaii PPO	$720.71

HHSC SET MULTI-PURPOSE DRAINAGE 12 FR

Facility

$743.00

Hospital Charge Code	11579942
Hospital Revenue Code	272
Min. Negotiated Rate	$371.50
Max. Negotiated Rate	$720.71
Rate for Payer: AlohaCare Medicaid	$371.50
Rate for Payer: AlohaCare Medicare	$371.50
Rate for Payer: Cash Price	$482.95
Rate for Payer: Devoted Health Medicare	$408.65
Rate for Payer: Hawaii Medical Service Association Medicare	$371.50
Rate for Payer: Hawaii Western Management Group Commercial	$705.85
Rate for Payer: Health Management Network Commercial	$631.55
Rate for Payer: Humana Medicare	$371.50
Rate for Payer: Kaiser Permanente Commercial	$668.70
Rate for Payer: Kaiser Permanente Medicaid	$378.93
Rate for Payer: Kaiser Permanente Medicare	$371.50
Rate for Payer: MDX Hawaii PPO	$720.71
Rate for Payer: Ohana Health Plan Medicaid	$371.50
Rate for Payer: Ohana Health Plan Medicare	$371.50
Rate for Payer: UnitedHealthcare Medicare	$371.50
Rate for Payer: University Health Alliance Commercial	$541.57

HHSC SET UNI CURVED DRNGE CATH (CT)

Facility

$354.00

Hospital Charge Code	9469111
Hospital Revenue Code	272
Min. Negotiated Rate	$300.90
Max. Negotiated Rate	$343.38
Rate for Payer: Cash Price	$230.10
Rate for Payer: Health Management Network Commercial	$300.90
Rate for Payer: Kaiser Permanente Commercial	$318.60
Rate for Payer: MDX Hawaii PPO	$343.38

HHSC SET UNI CURVED DRNGE CATH (CT)

Facility

$354.00

Hospital Charge Code	9469111
Hospital Revenue Code	272
Min. Negotiated Rate	$177.00
Max. Negotiated Rate	$343.38
Rate for Payer: AlohaCare Medicaid	$177.00
Rate for Payer: AlohaCare Medicare	$177.00
Rate for Payer: Cash Price	$230.10
Rate for Payer: Devoted Health Medicare	$194.70
Rate for Payer: Hawaii Medical Service Association Medicare	$177.00
Rate for Payer: Hawaii Western Management Group Commercial	$336.30
Rate for Payer: Health Management Network Commercial	$300.90
Rate for Payer: Humana Medicare	$177.00
Rate for Payer: Kaiser Permanente Commercial	$318.60
Rate for Payer: Kaiser Permanente Medicaid	$180.54
Rate for Payer: Kaiser Permanente Medicare	$177.00
Rate for Payer: MDX Hawaii PPO	$343.38
Rate for Payer: Ohana Health Plan Medicaid	$177.00
Rate for Payer: Ohana Health Plan Medicare	$177.00
Rate for Payer: UnitedHealthcare Medicare	$177.00
Rate for Payer: University Health Alliance Commercial	$258.03

HHSC SET UNI CURVED DRNGE CATH (US)

Facility

$354.00

Hospital Charge Code	9469341
Hospital Revenue Code	272
Min. Negotiated Rate	$300.90
Max. Negotiated Rate	$343.38
Rate for Payer: Cash Price	$230.10
Rate for Payer: Health Management Network Commercial	$300.90
Rate for Payer: Kaiser Permanente Commercial	$318.60
Rate for Payer: MDX Hawaii PPO	$343.38

HHSC SET UNI CURVED DRNGE CATH (US)

Facility

$354.00

Hospital Charge Code	9469341
Hospital Revenue Code	272
Min. Negotiated Rate	$177.00
Max. Negotiated Rate	$343.38
Rate for Payer: AlohaCare Medicaid	$177.00
Rate for Payer: AlohaCare Medicare	$177.00
Rate for Payer: Cash Price	$230.10
Rate for Payer: Devoted Health Medicare	$194.70
Rate for Payer: Hawaii Medical Service Association Medicare	$177.00
Rate for Payer: Hawaii Western Management Group Commercial	$336.30
Rate for Payer: Health Management Network Commercial	$300.90
Rate for Payer: Humana Medicare	$177.00
Rate for Payer: Kaiser Permanente Commercial	$318.60
Rate for Payer: Kaiser Permanente Medicaid	$180.54
Rate for Payer: Kaiser Permanente Medicare	$177.00
Rate for Payer: MDX Hawaii PPO	$343.38
Rate for Payer: Ohana Health Plan Medicaid	$177.00
Rate for Payer: Ohana Health Plan Medicare	$177.00
Rate for Payer: UnitedHealthcare Medicare	$177.00
Rate for Payer: University Health Alliance Commercial	$258.03

HHSC SET UNI CURVED DRNGE CATH(XR/MAMMO)

Facility

$301.00

Hospital Charge Code	9469077
Hospital Revenue Code	272
Min. Negotiated Rate	$255.85
Max. Negotiated Rate	$291.97
Rate for Payer: Cash Price	$195.65
Rate for Payer: Health Management Network Commercial	$255.85
Rate for Payer: Kaiser Permanente Commercial	$270.90
Rate for Payer: MDX Hawaii PPO	$291.97

HHSC SET UNI CURVED DRNGE CATH(XR/MAMMO)

Facility

$301.00

Hospital Charge Code	9469077
Hospital Revenue Code	272
Min. Negotiated Rate	$150.50
Max. Negotiated Rate	$291.97
Rate for Payer: AlohaCare Medicaid	$150.50
Rate for Payer: AlohaCare Medicare	$150.50
Rate for Payer: Cash Price	$195.65
Rate for Payer: Devoted Health Medicare	$165.55
Rate for Payer: Hawaii Medical Service Association Medicare	$150.50
Rate for Payer: Hawaii Western Management Group Commercial	$285.95
Rate for Payer: Health Management Network Commercial	$255.85
Rate for Payer: Humana Medicare	$150.50
Rate for Payer: Kaiser Permanente Commercial	$270.90
Rate for Payer: Kaiser Permanente Medicaid	$153.51
Rate for Payer: Kaiser Permanente Medicare	$150.50
Rate for Payer: MDX Hawaii PPO	$291.97
Rate for Payer: Ohana Health Plan Medicaid	$150.50
Rate for Payer: Ohana Health Plan Medicare	$150.50
Rate for Payer: UnitedHealthcare Medicare	$150.50
Rate for Payer: University Health Alliance Commercial	$219.40

HHSC STEREO BIOPSY MARKER TUMARK Q

Facility

$315.00

Service Code	HCPCS A4648
Hospital Charge Code	13157519
Hospital Revenue Code	278
Min. Negotiated Rate	$176.40
Max. Negotiated Rate	$305.55
Rate for Payer: Cash Price	$204.75
Rate for Payer: Hawaii Western Management Group Commercial	$220.50
Rate for Payer: Health Management Network Commercial	$267.75
Rate for Payer: Kaiser Permanente Commercial	$283.50
Rate for Payer: MDX Hawaii PPO	$305.55
Rate for Payer: University Health Alliance Commercial	$176.40

HHSC STEREO BIOPSY MARKER TUMARK Q

Facility

$315.00

Service Code	HCPCS A4648
Hospital Charge Code	13157519
Hospital Revenue Code	278
Min. Negotiated Rate	$157.50
Max. Negotiated Rate	$305.55
Rate for Payer: AlohaCare Medicaid	$157.50
Rate for Payer: AlohaCare Medicare	$157.50
Rate for Payer: Cash Price	$204.75
Rate for Payer: Devoted Health Medicare	$173.25
Rate for Payer: Hawaii Medical Service Association Medicare	$157.50
Rate for Payer: Hawaii Western Management Group Commercial	$220.50
Rate for Payer: Health Management Network Commercial	$267.75
Rate for Payer: Humana Medicare	$157.50
Rate for Payer: Kaiser Permanente Commercial	$283.50
Rate for Payer: Kaiser Permanente Medicaid	$160.65
Rate for Payer: Kaiser Permanente Medicare	$157.50
Rate for Payer: MDX Hawaii PPO	$305.55
Rate for Payer: Ohana Health Plan Medicaid	$157.50
Rate for Payer: Ohana Health Plan Medicare	$157.50
Rate for Payer: UnitedHealthcare Medicare	$157.50
Rate for Payer: University Health Alliance Commercial	$176.40

HHSC STEREO BIOPSY MARKER TUMARK VISION

Facility

$413.00

Service Code	HCPCS A4648
Hospital Charge Code	13157517
Hospital Revenue Code	278
Min. Negotiated Rate	$231.28
Max. Negotiated Rate	$400.61
Rate for Payer: Cash Price	$268.45
Rate for Payer: Hawaii Western Management Group Commercial	$289.10
Rate for Payer: Health Management Network Commercial	$351.05
Rate for Payer: Kaiser Permanente Commercial	$371.70
Rate for Payer: MDX Hawaii PPO	$400.61
Rate for Payer: University Health Alliance Commercial	$231.28

HHSC STEREO BIOPSY MARKER TUMARK VISION

Facility

$413.00

Service Code	HCPCS A4648
Hospital Charge Code	13157517
Hospital Revenue Code	278
Min. Negotiated Rate	$206.50
Max. Negotiated Rate	$400.61
Rate for Payer: AlohaCare Medicaid	$206.50
Rate for Payer: AlohaCare Medicare	$206.50
Rate for Payer: Cash Price	$268.45
Rate for Payer: Devoted Health Medicare	$227.15
Rate for Payer: Hawaii Medical Service Association Medicare	$206.50
Rate for Payer: Hawaii Western Management Group Commercial	$289.10
Rate for Payer: Health Management Network Commercial	$351.05
Rate for Payer: Humana Medicare	$206.50
Rate for Payer: Kaiser Permanente Commercial	$371.70
Rate for Payer: Kaiser Permanente Medicaid	$210.63
Rate for Payer: Kaiser Permanente Medicare	$206.50
Rate for Payer: MDX Hawaii PPO	$400.61
Rate for Payer: Ohana Health Plan Medicaid	$206.50
Rate for Payer: Ohana Health Plan Medicare	$206.50
Rate for Payer: UnitedHealthcare Medicare	$206.50
Rate for Payer: University Health Alliance Commercial	$231.28

HHSC TEMNO CHIBA FINE NDL ASP 22GX15CM

Facility

$95.00

Service Code	HCPCS C1729
Hospital Charge Code	8223434
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

Know your out-of-pocket cost for care.

All Charges