Samuel Mahelona Memorial Hospital

All Charges

Charge

Type

Setting

Price

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	$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 TENMO EVOLUTION 18GX15CM (CT)

Facility

$220.00

Hospital Charge Code	9469091
Hospital Revenue Code	272
Min. Negotiated Rate	$187.00
Max. Negotiated Rate	$213.40
Rate for Payer: Cash Price	$143.00
Rate for Payer: Health Management Network Commercial	$187.00
Rate for Payer: Kaiser Permanente Commercial	$198.00
Rate for Payer: MDX Hawaii PPO	$213.40

HHSC TENMO EVOLUTION 18GX15CM (CT)

Facility

$220.00

Hospital Charge Code	9469091
Hospital Revenue Code	272
Min. Negotiated Rate	$110.00
Max. Negotiated Rate	$213.40
Rate for Payer: AlohaCare Medicaid	$110.00
Rate for Payer: AlohaCare Medicare	$110.00
Rate for Payer: Cash Price	$143.00
Rate for Payer: Devoted Health Medicare	$121.00
Rate for Payer: Hawaii Medical Service Association Medicare	$110.00
Rate for Payer: Hawaii Western Management Group Commercial	$209.00
Rate for Payer: Health Management Network Commercial	$187.00
Rate for Payer: Humana Medicare	$110.00
Rate for Payer: Kaiser Permanente Commercial	$198.00
Rate for Payer: Kaiser Permanente Medicaid	$112.20
Rate for Payer: Kaiser Permanente Medicare	$110.00
Rate for Payer: MDX Hawaii PPO	$213.40
Rate for Payer: Ohana Health Plan Medicaid	$110.00
Rate for Payer: Ohana Health Plan Medicare	$110.00
Rate for Payer: UnitedHealthcare Medicare	$110.00
Rate for Payer: University Health Alliance Commercial	$160.36

HHSC TENMO EVOLUTION 18GX15CM (US)

Facility

$220.00

Hospital Charge Code	9469310
Hospital Revenue Code	272
Min. Negotiated Rate	$187.00
Max. Negotiated Rate	$213.40
Rate for Payer: Cash Price	$143.00
Rate for Payer: Health Management Network Commercial	$187.00
Rate for Payer: Kaiser Permanente Commercial	$198.00
Rate for Payer: MDX Hawaii PPO	$213.40

HHSC TENMO EVOLUTION 18GX15CM (US)

Facility

$220.00

Hospital Charge Code	9469310
Hospital Revenue Code	272
Min. Negotiated Rate	$110.00
Max. Negotiated Rate	$213.40
Rate for Payer: AlohaCare Medicaid	$110.00
Rate for Payer: AlohaCare Medicare	$110.00
Rate for Payer: Cash Price	$143.00
Rate for Payer: Devoted Health Medicare	$121.00
Rate for Payer: Hawaii Medical Service Association Medicare	$110.00
Rate for Payer: Hawaii Western Management Group Commercial	$209.00
Rate for Payer: Health Management Network Commercial	$187.00
Rate for Payer: Humana Medicare	$110.00
Rate for Payer: Kaiser Permanente Commercial	$198.00
Rate for Payer: Kaiser Permanente Medicaid	$112.20
Rate for Payer: Kaiser Permanente Medicare	$110.00
Rate for Payer: MDX Hawaii PPO	$213.40
Rate for Payer: Ohana Health Plan Medicaid	$110.00
Rate for Payer: Ohana Health Plan Medicare	$110.00
Rate for Payer: UnitedHealthcare Medicare	$110.00
Rate for Payer: University Health Alliance Commercial	$160.36

HHSC TENMO EVOLUTION 18GX15CM (XR/MAMMO)

Facility

$220.00

Hospital Charge Code	9468984
Hospital Revenue Code	272
Min. Negotiated Rate	$110.00
Max. Negotiated Rate	$213.40
Rate for Payer: AlohaCare Medicaid	$110.00
Rate for Payer: AlohaCare Medicare	$110.00
Rate for Payer: Cash Price	$143.00
Rate for Payer: Devoted Health Medicare	$121.00
Rate for Payer: Hawaii Medical Service Association Medicare	$110.00
Rate for Payer: Hawaii Western Management Group Commercial	$209.00
Rate for Payer: Health Management Network Commercial	$187.00
Rate for Payer: Humana Medicare	$110.00
Rate for Payer: Kaiser Permanente Commercial	$198.00
Rate for Payer: Kaiser Permanente Medicaid	$112.20
Rate for Payer: Kaiser Permanente Medicare	$110.00
Rate for Payer: MDX Hawaii PPO	$213.40
Rate for Payer: Ohana Health Plan Medicaid	$110.00
Rate for Payer: Ohana Health Plan Medicare	$110.00
Rate for Payer: UnitedHealthcare Medicare	$110.00
Rate for Payer: University Health Alliance Commercial	$160.36

HHSC TENMO EVOLUTION 18GX15CM (XR/MAMMO)

Facility

$220.00

Hospital Charge Code	9468984
Hospital Revenue Code	272
Min. Negotiated Rate	$187.00
Max. Negotiated Rate	$213.40
Rate for Payer: Cash Price	$143.00
Rate for Payer: Health Management Network Commercial	$187.00
Rate for Payer: Kaiser Permanente Commercial	$198.00
Rate for Payer: MDX Hawaii PPO	$213.40

HHSC TENMO EVOLUTION 18GX6CM (CT)

Facility

$291.00

Hospital Charge Code	9469089
Hospital Revenue Code	272
Min. Negotiated Rate	$247.35
Max. Negotiated Rate	$282.27
Rate for Payer: Cash Price	$189.15
Rate for Payer: Health Management Network Commercial	$247.35
Rate for Payer: Kaiser Permanente Commercial	$261.90
Rate for Payer: MDX Hawaii PPO	$282.27

HHSC TENMO EVOLUTION 18GX6CM (CT)

Facility

$291.00

Hospital Charge Code	9469089
Hospital Revenue Code	272
Min. Negotiated Rate	$145.50
Max. Negotiated Rate	$282.27
Rate for Payer: AlohaCare Medicaid	$145.50
Rate for Payer: AlohaCare Medicare	$145.50
Rate for Payer: Cash Price	$189.15
Rate for Payer: Devoted Health Medicare	$160.05
Rate for Payer: Hawaii Medical Service Association Medicare	$145.50
Rate for Payer: Hawaii Western Management Group Commercial	$276.45
Rate for Payer: Health Management Network Commercial	$247.35
Rate for Payer: Humana Medicare	$145.50
Rate for Payer: Kaiser Permanente Commercial	$261.90
Rate for Payer: Kaiser Permanente Medicaid	$148.41
Rate for Payer: Kaiser Permanente Medicare	$145.50
Rate for Payer: MDX Hawaii PPO	$282.27
Rate for Payer: Ohana Health Plan Medicaid	$145.50
Rate for Payer: Ohana Health Plan Medicare	$145.50
Rate for Payer: UnitedHealthcare Medicare	$145.50
Rate for Payer: University Health Alliance Commercial	$212.11

HHSC TENMO EVOLUTION 18GX6CM (US)

Facility

$291.00

Hospital Charge Code	9469129
Hospital Revenue Code	272
Min. Negotiated Rate	$247.35
Max. Negotiated Rate	$282.27
Rate for Payer: Cash Price	$189.15
Rate for Payer: Health Management Network Commercial	$247.35
Rate for Payer: Kaiser Permanente Commercial	$261.90
Rate for Payer: MDX Hawaii PPO	$282.27

HHSC TENMO EVOLUTION 18GX6CM (US)

Facility

$291.00

Hospital Charge Code	9469129
Hospital Revenue Code	272
Min. Negotiated Rate	$145.50
Max. Negotiated Rate	$282.27
Rate for Payer: AlohaCare Medicaid	$145.50
Rate for Payer: AlohaCare Medicare	$145.50
Rate for Payer: Cash Price	$189.15
Rate for Payer: Devoted Health Medicare	$160.05
Rate for Payer: Hawaii Medical Service Association Medicare	$145.50
Rate for Payer: Hawaii Western Management Group Commercial	$276.45
Rate for Payer: Health Management Network Commercial	$247.35
Rate for Payer: Humana Medicare	$145.50
Rate for Payer: Kaiser Permanente Commercial	$261.90
Rate for Payer: Kaiser Permanente Medicaid	$148.41
Rate for Payer: Kaiser Permanente Medicare	$145.50
Rate for Payer: MDX Hawaii PPO	$282.27
Rate for Payer: Ohana Health Plan Medicaid	$145.50
Rate for Payer: Ohana Health Plan Medicare	$145.50
Rate for Payer: UnitedHealthcare Medicare	$145.50
Rate for Payer: University Health Alliance Commercial	$212.11

HHSC TENMO EVOLUTION 18GX6CM (XR/MAMMO)

Facility

$291.00

Hospital Charge Code	9468982
Hospital Revenue Code	272
Min. Negotiated Rate	$247.35
Max. Negotiated Rate	$282.27
Rate for Payer: Cash Price	$189.15
Rate for Payer: Health Management Network Commercial	$247.35
Rate for Payer: Kaiser Permanente Commercial	$261.90
Rate for Payer: MDX Hawaii PPO	$282.27

HHSC TENMO EVOLUTION 18GX6CM (XR/MAMMO)

Facility

$291.00

Hospital Charge Code	9468982
Hospital Revenue Code	272
Min. Negotiated Rate	$145.50
Max. Negotiated Rate	$282.27
Rate for Payer: AlohaCare Medicaid	$145.50
Rate for Payer: AlohaCare Medicare	$145.50
Rate for Payer: Cash Price	$189.15
Rate for Payer: Devoted Health Medicare	$160.05
Rate for Payer: Hawaii Medical Service Association Medicare	$145.50
Rate for Payer: Hawaii Western Management Group Commercial	$276.45
Rate for Payer: Health Management Network Commercial	$247.35
Rate for Payer: Humana Medicare	$145.50
Rate for Payer: Kaiser Permanente Commercial	$261.90
Rate for Payer: Kaiser Permanente Medicaid	$148.41
Rate for Payer: Kaiser Permanente Medicare	$145.50
Rate for Payer: MDX Hawaii PPO	$282.27
Rate for Payer: Ohana Health Plan Medicaid	$145.50
Rate for Payer: Ohana Health Plan Medicare	$145.50
Rate for Payer: UnitedHealthcare Medicare	$145.50
Rate for Payer: University Health Alliance Commercial	$212.11

HHSC TENMO EVOLUTION 20GX15CM (CT)

Facility

$220.00

Hospital Charge Code	9469087
Hospital Revenue Code	272
Min. Negotiated Rate	$187.00
Max. Negotiated Rate	$213.40
Rate for Payer: Cash Price	$143.00
Rate for Payer: Health Management Network Commercial	$187.00
Rate for Payer: Kaiser Permanente Commercial	$198.00
Rate for Payer: MDX Hawaii PPO	$213.40

HHSC TENMO EVOLUTION 20GX15CM (CT)

Facility

$220.00

Hospital Charge Code	9469087
Hospital Revenue Code	272
Min. Negotiated Rate	$110.00
Max. Negotiated Rate	$213.40
Rate for Payer: AlohaCare Medicaid	$110.00
Rate for Payer: AlohaCare Medicare	$110.00
Rate for Payer: Cash Price	$143.00
Rate for Payer: Devoted Health Medicare	$121.00
Rate for Payer: Hawaii Medical Service Association Medicare	$110.00
Rate for Payer: Hawaii Western Management Group Commercial	$209.00
Rate for Payer: Health Management Network Commercial	$187.00
Rate for Payer: Humana Medicare	$110.00
Rate for Payer: Kaiser Permanente Commercial	$198.00
Rate for Payer: Kaiser Permanente Medicaid	$112.20
Rate for Payer: Kaiser Permanente Medicare	$110.00
Rate for Payer: MDX Hawaii PPO	$213.40
Rate for Payer: Ohana Health Plan Medicaid	$110.00
Rate for Payer: Ohana Health Plan Medicare	$110.00
Rate for Payer: UnitedHealthcare Medicare	$110.00
Rate for Payer: University Health Alliance Commercial	$160.36

HHSC TENMO EVOLUTION 20GX15CM (US)

Facility

$220.00

Hospital Charge Code	9469125
Hospital Revenue Code	272
Min. Negotiated Rate	$110.00
Max. Negotiated Rate	$213.40
Rate for Payer: AlohaCare Medicaid	$110.00
Rate for Payer: AlohaCare Medicare	$110.00
Rate for Payer: Cash Price	$143.00
Rate for Payer: Devoted Health Medicare	$121.00
Rate for Payer: Hawaii Medical Service Association Medicare	$110.00
Rate for Payer: Hawaii Western Management Group Commercial	$209.00
Rate for Payer: Health Management Network Commercial	$187.00
Rate for Payer: Humana Medicare	$110.00
Rate for Payer: Kaiser Permanente Commercial	$198.00
Rate for Payer: Kaiser Permanente Medicaid	$112.20
Rate for Payer: Kaiser Permanente Medicare	$110.00
Rate for Payer: MDX Hawaii PPO	$213.40
Rate for Payer: Ohana Health Plan Medicaid	$110.00
Rate for Payer: Ohana Health Plan Medicare	$110.00
Rate for Payer: UnitedHealthcare Medicare	$110.00
Rate for Payer: University Health Alliance Commercial	$160.36

HHSC TENMO EVOLUTION 20GX15CM (US)

Facility

$220.00

Hospital Charge Code	9469125
Hospital Revenue Code	272
Min. Negotiated Rate	$187.00
Max. Negotiated Rate	$213.40
Rate for Payer: Cash Price	$143.00
Rate for Payer: Health Management Network Commercial	$187.00
Rate for Payer: Kaiser Permanente Commercial	$198.00
Rate for Payer: MDX Hawaii PPO	$213.40

HHSC TENMO EVOLUTION 20GX15CM (XR/MAMMO)

Facility

$220.00

Hospital Charge Code	9468980
Hospital Revenue Code	272
Min. Negotiated Rate	$110.00
Max. Negotiated Rate	$213.40
Rate for Payer: AlohaCare Medicaid	$110.00
Rate for Payer: AlohaCare Medicare	$110.00
Rate for Payer: Cash Price	$143.00
Rate for Payer: Devoted Health Medicare	$121.00
Rate for Payer: Hawaii Medical Service Association Medicare	$110.00
Rate for Payer: Hawaii Western Management Group Commercial	$209.00
Rate for Payer: Health Management Network Commercial	$187.00
Rate for Payer: Humana Medicare	$110.00
Rate for Payer: Kaiser Permanente Commercial	$198.00
Rate for Payer: Kaiser Permanente Medicaid	$112.20
Rate for Payer: Kaiser Permanente Medicare	$110.00
Rate for Payer: MDX Hawaii PPO	$213.40
Rate for Payer: Ohana Health Plan Medicaid	$110.00
Rate for Payer: Ohana Health Plan Medicare	$110.00
Rate for Payer: UnitedHealthcare Medicare	$110.00
Rate for Payer: University Health Alliance Commercial	$160.36

HHSC TENMO EVOLUTION 20GX15CM (XR/MAMMO)

Facility

$220.00

Hospital Charge Code	9468980
Hospital Revenue Code	272
Min. Negotiated Rate	$187.00
Max. Negotiated Rate	$213.40
Rate for Payer: Cash Price	$143.00
Rate for Payer: Health Management Network Commercial	$187.00
Rate for Payer: Kaiser Permanente Commercial	$198.00
Rate for Payer: MDX Hawaii PPO	$213.40

HHSC TENMO EVOLUTION 20G X 6CM (CT)

Facility

$321.00

Hospital Charge Code	9469085
Hospital Revenue Code	272
Min. Negotiated Rate	$160.50
Max. Negotiated Rate	$311.37
Rate for Payer: AlohaCare Medicaid	$160.50
Rate for Payer: AlohaCare Medicare	$160.50
Rate for Payer: Cash Price	$208.65
Rate for Payer: Devoted Health Medicare	$176.55
Rate for Payer: Hawaii Medical Service Association Medicare	$160.50
Rate for Payer: Hawaii Western Management Group Commercial	$304.95
Rate for Payer: Health Management Network Commercial	$272.85
Rate for Payer: Humana Medicare	$160.50
Rate for Payer: Kaiser Permanente Commercial	$288.90
Rate for Payer: Kaiser Permanente Medicaid	$163.71
Rate for Payer: Kaiser Permanente Medicare	$160.50
Rate for Payer: MDX Hawaii PPO	$311.37
Rate for Payer: Ohana Health Plan Medicaid	$160.50
Rate for Payer: Ohana Health Plan Medicare	$160.50
Rate for Payer: UnitedHealthcare Medicare	$160.50
Rate for Payer: University Health Alliance Commercial	$233.98

HHSC TENMO EVOLUTION 20G X 6CM (CT)

Facility

$321.00

Hospital Charge Code	9469085
Hospital Revenue Code	272
Min. Negotiated Rate	$272.85
Max. Negotiated Rate	$311.37
Rate for Payer: Cash Price	$208.65
Rate for Payer: Health Management Network Commercial	$272.85
Rate for Payer: Kaiser Permanente Commercial	$288.90
Rate for Payer: MDX Hawaii PPO	$311.37

HHSC TENMO EVOLUTION 20G X 6CM (US)

Facility

$321.00

Hospital Charge Code	9469123
Hospital Revenue Code	272
Min. Negotiated Rate	$160.50
Max. Negotiated Rate	$311.37
Rate for Payer: AlohaCare Medicaid	$160.50
Rate for Payer: AlohaCare Medicare	$160.50
Rate for Payer: Cash Price	$208.65
Rate for Payer: Devoted Health Medicare	$176.55
Rate for Payer: Hawaii Medical Service Association Medicare	$160.50
Rate for Payer: Hawaii Western Management Group Commercial	$304.95
Rate for Payer: Health Management Network Commercial	$272.85
Rate for Payer: Humana Medicare	$160.50
Rate for Payer: Kaiser Permanente Commercial	$288.90
Rate for Payer: Kaiser Permanente Medicaid	$163.71
Rate for Payer: Kaiser Permanente Medicare	$160.50
Rate for Payer: MDX Hawaii PPO	$311.37
Rate for Payer: Ohana Health Plan Medicaid	$160.50
Rate for Payer: Ohana Health Plan Medicare	$160.50
Rate for Payer: UnitedHealthcare Medicare	$160.50
Rate for Payer: University Health Alliance Commercial	$233.98

HHSC TENMO EVOLUTION 20G X 6CM (US)

Facility

$321.00

Hospital Charge Code	9469123
Hospital Revenue Code	272
Min. Negotiated Rate	$272.85
Max. Negotiated Rate	$311.37
Rate for Payer: Cash Price	$208.65
Rate for Payer: Health Management Network Commercial	$272.85
Rate for Payer: Kaiser Permanente Commercial	$288.90
Rate for Payer: MDX Hawaii PPO	$311.37

HHSC TENMO EVOLUTION 20GX6CM (XR/MAMMO)

Facility

$321.00

Hospital Charge Code	9468978
Hospital Revenue Code	272
Min. Negotiated Rate	$272.85
Max. Negotiated Rate	$311.37
Rate for Payer: Cash Price	$208.65
Rate for Payer: Health Management Network Commercial	$272.85
Rate for Payer: Kaiser Permanente Commercial	$288.90
Rate for Payer: MDX Hawaii PPO	$311.37

HHSC TENMO EVOLUTION 20GX6CM (XR/MAMMO)

Facility

$321.00

Hospital Charge Code	9468978
Hospital Revenue Code	272
Min. Negotiated Rate	$160.50
Max. Negotiated Rate	$311.37
Rate for Payer: AlohaCare Medicaid	$160.50
Rate for Payer: AlohaCare Medicare	$160.50
Rate for Payer: Cash Price	$208.65
Rate for Payer: Devoted Health Medicare	$176.55
Rate for Payer: Hawaii Medical Service Association Medicare	$160.50
Rate for Payer: Hawaii Western Management Group Commercial	$304.95
Rate for Payer: Health Management Network Commercial	$272.85
Rate for Payer: Humana Medicare	$160.50
Rate for Payer: Kaiser Permanente Commercial	$288.90
Rate for Payer: Kaiser Permanente Medicaid	$163.71
Rate for Payer: Kaiser Permanente Medicare	$160.50
Rate for Payer: MDX Hawaii PPO	$311.37
Rate for Payer: Ohana Health Plan Medicaid	$160.50
Rate for Payer: Ohana Health Plan Medicare	$160.50
Rate for Payer: UnitedHealthcare Medicare	$160.50
Rate for Payer: University Health Alliance Commercial	$233.98

Know your out-of-pocket cost for care.

All Charges