Samuel Mahelona Memorial Hospital

All Charges

Charge

Type

Setting

Price

HHSC Transvaginal

Facility

$758.00

Service Code	HCPCS 76830
Hospital Charge Code	8265283
Hospital Revenue Code	402
Min. Negotiated Rate	$50.35
Max. Negotiated Rate	$735.26
Rate for Payer: AlohaCare Medicaid	$379.00
Rate for Payer: AlohaCare Medicare	$379.00
Rate for Payer: Cash Price	$492.70
Rate for Payer: Cash Price	$492.70
Rate for Payer: Devoted Health Medicare	$416.90
Rate for Payer: Hawaii Medical Service Association ABD	$50.35
Rate for Payer: Hawaii Medical Service Association Commercial	$133.51
Rate for Payer: Hawaii Medical Service Association Medicare	$379.00
Rate for Payer: Hawaii Medical Service Association Non-ABD	$54.65
Rate for Payer: Hawaii Western Management Group Commercial	$106.81
Rate for Payer: Health Management Network Commercial	$644.30
Rate for Payer: Humana Medicare	$379.00
Rate for Payer: Kaiser Permanente Commercial	$682.20
Rate for Payer: Kaiser Permanente Medicaid	$386.58
Rate for Payer: Kaiser Permanente Medicare	$379.00
Rate for Payer: MDX Hawaii PPO	$735.26
Rate for Payer: Ohana Health Plan Medicaid	$379.00
Rate for Payer: Ohana Health Plan Medicare	$379.00
Rate for Payer: UnitedHealthcare Medicaid	$50.35
Rate for Payer: UnitedHealthcare Medicare	$379.00
Rate for Payer: University Health Alliance Commercial	$230.73

HHSC Transvaginal

Facility

$758.00

Service Code	HCPCS 76830
Hospital Charge Code	8265283
Hospital Revenue Code	402
Min. Negotiated Rate	$644.30
Max. Negotiated Rate	$735.26
Rate for Payer: Cash Price	$492.70
Rate for Payer: Health Management Network Commercial	$644.30
Rate for Payer: Kaiser Permanente Commercial	$682.20
Rate for Payer: MDX Hawaii PPO	$735.26

HHSC TRAY SAFETY SOFT TISSUE BIOPSY

Facility

$122.00

Hospital Charge Code	11576618
Hospital Revenue Code	272
Min. Negotiated Rate	$61.00
Max. Negotiated Rate	$118.34
Rate for Payer: AlohaCare Medicaid	$61.00
Rate for Payer: AlohaCare Medicare	$61.00
Rate for Payer: Cash Price	$79.30
Rate for Payer: Devoted Health Medicare	$67.10
Rate for Payer: Hawaii Medical Service Association Medicare	$61.00
Rate for Payer: Hawaii Western Management Group Commercial	$115.90
Rate for Payer: Health Management Network Commercial	$103.70
Rate for Payer: Humana Medicare	$61.00
Rate for Payer: Kaiser Permanente Commercial	$109.80
Rate for Payer: Kaiser Permanente Medicaid	$62.22
Rate for Payer: Kaiser Permanente Medicare	$61.00
Rate for Payer: MDX Hawaii PPO	$118.34
Rate for Payer: Ohana Health Plan Medicaid	$61.00
Rate for Payer: Ohana Health Plan Medicare	$61.00
Rate for Payer: UnitedHealthcare Medicare	$61.00
Rate for Payer: University Health Alliance Commercial	$88.93

HHSC TRAY SAFETY SOFT TISSUE BIOPSY

Facility

$122.00

Hospital Charge Code	11576618
Hospital Revenue Code	272
Min. Negotiated Rate	$103.70
Max. Negotiated Rate	$118.34
Rate for Payer: Cash Price	$79.30
Rate for Payer: Health Management Network Commercial	$103.70
Rate for Payer: Kaiser Permanente Commercial	$109.80
Rate for Payer: MDX Hawaii PPO	$118.34

HHSC TRAY STANDARD CUSTOM BIOPSY (CT)

Facility

$79.00

Hospital Charge Code	9469119
Hospital Revenue Code	272
Min. Negotiated Rate	$39.50
Max. Negotiated Rate	$76.63
Rate for Payer: AlohaCare Medicaid	$39.50
Rate for Payer: AlohaCare Medicare	$39.50
Rate for Payer: Cash Price	$51.35
Rate for Payer: Devoted Health Medicare	$43.45
Rate for Payer: Hawaii Medical Service Association Medicare	$39.50
Rate for Payer: Hawaii Western Management Group Commercial	$75.05
Rate for Payer: Health Management Network Commercial	$67.15
Rate for Payer: Humana Medicare	$39.50
Rate for Payer: Kaiser Permanente Commercial	$71.10
Rate for Payer: Kaiser Permanente Medicaid	$40.29
Rate for Payer: Kaiser Permanente Medicare	$39.50
Rate for Payer: MDX Hawaii PPO	$76.63
Rate for Payer: Ohana Health Plan Medicaid	$39.50
Rate for Payer: Ohana Health Plan Medicare	$39.50
Rate for Payer: UnitedHealthcare Medicare	$39.50
Rate for Payer: University Health Alliance Commercial	$57.58

HHSC TRAY STANDARD CUSTOM BIOPSY (CT)

Facility

$79.00

Hospital Charge Code	9469119
Hospital Revenue Code	272
Min. Negotiated Rate	$67.15
Max. Negotiated Rate	$76.63
Rate for Payer: Cash Price	$51.35
Rate for Payer: Health Management Network Commercial	$67.15
Rate for Payer: Kaiser Permanente Commercial	$71.10
Rate for Payer: MDX Hawaii PPO	$76.63

HHSC TRAY STANDARD CUSTOM BIOPSY (US)

Facility

$79.00

Hospital Charge Code	9469362
Hospital Revenue Code	272
Min. Negotiated Rate	$67.15
Max. Negotiated Rate	$76.63
Rate for Payer: Cash Price	$51.35
Rate for Payer: Health Management Network Commercial	$67.15
Rate for Payer: Kaiser Permanente Commercial	$71.10
Rate for Payer: MDX Hawaii PPO	$76.63

HHSC TRAY STANDARD CUSTOM BIOPSY (US)

Facility

$79.00

Hospital Charge Code	9469362
Hospital Revenue Code	272
Min. Negotiated Rate	$39.50
Max. Negotiated Rate	$76.63
Rate for Payer: AlohaCare Medicaid	$39.50
Rate for Payer: AlohaCare Medicare	$39.50
Rate for Payer: Cash Price	$51.35
Rate for Payer: Devoted Health Medicare	$43.45
Rate for Payer: Hawaii Medical Service Association Medicare	$39.50
Rate for Payer: Hawaii Western Management Group Commercial	$75.05
Rate for Payer: Health Management Network Commercial	$67.15
Rate for Payer: Humana Medicare	$39.50
Rate for Payer: Kaiser Permanente Commercial	$71.10
Rate for Payer: Kaiser Permanente Medicaid	$40.29
Rate for Payer: Kaiser Permanente Medicare	$39.50
Rate for Payer: MDX Hawaii PPO	$76.63
Rate for Payer: Ohana Health Plan Medicaid	$39.50
Rate for Payer: Ohana Health Plan Medicare	$39.50
Rate for Payer: UnitedHealthcare Medicare	$39.50
Rate for Payer: University Health Alliance Commercial	$57.58

HHSC TRAY STANDARD CUSTOM BX (XR/MAMMO)

Facility

$79.00

Hospital Charge Code	9469083
Hospital Revenue Code	272
Min. Negotiated Rate	$39.50
Max. Negotiated Rate	$76.63
Rate for Payer: AlohaCare Medicaid	$39.50
Rate for Payer: AlohaCare Medicare	$39.50
Rate for Payer: Cash Price	$51.35
Rate for Payer: Devoted Health Medicare	$43.45
Rate for Payer: Hawaii Medical Service Association Medicare	$39.50
Rate for Payer: Hawaii Western Management Group Commercial	$75.05
Rate for Payer: Health Management Network Commercial	$67.15
Rate for Payer: Humana Medicare	$39.50
Rate for Payer: Kaiser Permanente Commercial	$71.10
Rate for Payer: Kaiser Permanente Medicaid	$40.29
Rate for Payer: Kaiser Permanente Medicare	$39.50
Rate for Payer: MDX Hawaii PPO	$76.63
Rate for Payer: Ohana Health Plan Medicaid	$39.50
Rate for Payer: Ohana Health Plan Medicare	$39.50
Rate for Payer: UnitedHealthcare Medicare	$39.50
Rate for Payer: University Health Alliance Commercial	$57.58

HHSC TRAY STANDARD CUSTOM BX (XR/MAMMO)

Facility

$79.00

Hospital Charge Code	9469083
Hospital Revenue Code	272
Min. Negotiated Rate	$67.15
Max. Negotiated Rate	$76.63
Rate for Payer: Cash Price	$51.35
Rate for Payer: Health Management Network Commercial	$67.15
Rate for Payer: Kaiser Permanente Commercial	$71.10
Rate for Payer: MDX Hawaii PPO	$76.63

HHSC Tray Thoracentesis/Para 8Fr Cath 18g

Facility

$495.00

Hospital Charge Code	13095976
Hospital Revenue Code	272
Min. Negotiated Rate	$420.75
Max. Negotiated Rate	$480.15
Rate for Payer: Cash Price	$321.75
Rate for Payer: Health Management Network Commercial	$420.75
Rate for Payer: Kaiser Permanente Commercial	$445.50
Rate for Payer: MDX Hawaii PPO	$480.15

HHSC Tray Thoracentesis/Para 8Fr Cath 18g

Facility

$495.00

Hospital Charge Code	13095976
Hospital Revenue Code	272
Min. Negotiated Rate	$247.50
Max. Negotiated Rate	$480.15
Rate for Payer: AlohaCare Medicaid	$247.50
Rate for Payer: AlohaCare Medicare	$247.50
Rate for Payer: Cash Price	$321.75
Rate for Payer: Devoted Health Medicare	$272.25
Rate for Payer: Hawaii Medical Service Association Medicare	$247.50
Rate for Payer: Hawaii Western Management Group Commercial	$470.25
Rate for Payer: Health Management Network Commercial	$420.75
Rate for Payer: Humana Medicare	$247.50
Rate for Payer: Kaiser Permanente Commercial	$445.50
Rate for Payer: Kaiser Permanente Medicaid	$252.45
Rate for Payer: Kaiser Permanente Medicare	$247.50
Rate for Payer: MDX Hawaii PPO	$480.15
Rate for Payer: Ohana Health Plan Medicaid	$247.50
Rate for Payer: Ohana Health Plan Medicare	$247.50
Rate for Payer: UnitedHealthcare Medicare	$247.50
Rate for Payer: University Health Alliance Commercial	$360.81

HHSC TRAY URESIL TRU-CLOSE PNEUMOTHORAX

Facility

$798.00

Hospital Charge Code	11583907
Hospital Revenue Code	272
Min. Negotiated Rate	$678.30
Max. Negotiated Rate	$774.06
Rate for Payer: Cash Price	$518.70
Rate for Payer: Health Management Network Commercial	$678.30
Rate for Payer: Kaiser Permanente Commercial	$718.20
Rate for Payer: MDX Hawaii PPO	$774.06

HHSC TRAY URESIL TRU-CLOSE PNEUMOTHORAX

Facility

$798.00

Hospital Charge Code	11583907
Hospital Revenue Code	272
Min. Negotiated Rate	$399.00
Max. Negotiated Rate	$774.06
Rate for Payer: AlohaCare Medicaid	$399.00
Rate for Payer: AlohaCare Medicare	$399.00
Rate for Payer: Cash Price	$518.70
Rate for Payer: Devoted Health Medicare	$438.90
Rate for Payer: Hawaii Medical Service Association Medicare	$399.00
Rate for Payer: Hawaii Western Management Group Commercial	$758.10
Rate for Payer: Health Management Network Commercial	$678.30
Rate for Payer: Humana Medicare	$399.00
Rate for Payer: Kaiser Permanente Commercial	$718.20
Rate for Payer: Kaiser Permanente Medicaid	$406.98
Rate for Payer: Kaiser Permanente Medicare	$399.00
Rate for Payer: MDX Hawaii PPO	$774.06
Rate for Payer: Ohana Health Plan Medicaid	$399.00
Rate for Payer: Ohana Health Plan Medicare	$399.00
Rate for Payer: UnitedHealthcare Medicare	$399.00
Rate for Payer: University Health Alliance Commercial	$581.66

HHSC TRU-CUT BIOPSY NEEDLE 18gx11.4CM

Facility

$129.00

Service Code	HCPCS C1729
Hospital Charge Code	8223438
Hospital Revenue Code	272
Min. Negotiated Rate	$109.65
Max. Negotiated Rate	$125.13
Rate for Payer: Cash Price	$83.85
Rate for Payer: Health Management Network Commercial	$109.65
Rate for Payer: Kaiser Permanente Commercial	$116.10
Rate for Payer: MDX Hawaii PPO	$125.13

HHSC TRU-CUT BIOPSY NEEDLE 18gx11.4CM

Facility

$129.00

Service Code	HCPCS C1729
Hospital Charge Code	8223438
Hospital Revenue Code	272
Min. Negotiated Rate	$64.50
Max. Negotiated Rate	$125.13
Rate for Payer: AlohaCare Medicaid	$64.50
Rate for Payer: AlohaCare Medicare	$64.50
Rate for Payer: Cash Price	$83.85
Rate for Payer: Devoted Health Medicare	$70.95
Rate for Payer: Hawaii Medical Service Association Medicare	$64.50
Rate for Payer: Hawaii Western Management Group Commercial	$122.55
Rate for Payer: Health Management Network Commercial	$109.65
Rate for Payer: Humana Medicare	$64.50
Rate for Payer: Kaiser Permanente Commercial	$116.10
Rate for Payer: Kaiser Permanente Medicaid	$65.79
Rate for Payer: Kaiser Permanente Medicare	$64.50
Rate for Payer: MDX Hawaii PPO	$125.13
Rate for Payer: Ohana Health Plan Medicaid	$64.50
Rate for Payer: Ohana Health Plan Medicare	$64.50
Rate for Payer: UnitedHealthcare Medicare	$64.50
Rate for Payer: University Health Alliance Commercial	$94.03

HHSC US Aspiration Cyst Brst Addl

Facility

$440.00

Service Code	HCPCS 19001
Hospital Charge Code	8223496
Hospital Revenue Code	361
Min. Negotiated Rate	$374.00
Max. Negotiated Rate	$426.80
Rate for Payer: Cash Price	$286.00
Rate for Payer: Health Management Network Commercial	$374.00
Rate for Payer: Kaiser Permanente Commercial	$396.00
Rate for Payer: MDX Hawaii PPO	$426.80

HHSC US Aspiration Cyst Brst Addl

Facility

$440.00

Service Code	HCPCS 19001
Hospital Charge Code	8223496
Hospital Revenue Code	361
Min. Negotiated Rate	$15.86
Max. Negotiated Rate	$2,837.00
Rate for Payer: AlohaCare Medicaid	$220.00
Rate for Payer: AlohaCare Medicare	$220.00
Rate for Payer: Cash Price	$286.00
Rate for Payer: Cash Price	$286.00
Rate for Payer: Cash Price	$286.00
Rate for Payer: Devoted Health Medicare	$242.00
Rate for Payer: Hawaii Medical Service Association Medicare	$220.00
Rate for Payer: Health Management Network Commercial	$374.00
Rate for Payer: Humana Medicare	$220.00
Rate for Payer: Kaiser Permanente Commercial	$396.00
Rate for Payer: Kaiser Permanente Medicaid	$2,837.00
Rate for Payer: Kaiser Permanente Medicare	$220.00
Rate for Payer: MDX Hawaii PPO	$426.80
Rate for Payer: Ohana Health Plan Medicaid	$220.00
Rate for Payer: Ohana Health Plan Medicare	$220.00
Rate for Payer: UnitedHealthcare Medicaid	$15.86
Rate for Payer: UnitedHealthcare Medicare	$220.00
Rate for Payer: University Health Alliance Commercial	$246.40

HHSC US Breast Marker Clip

Facility

$392.00

Hospital Charge Code	8223486
Hospital Revenue Code	272
Min. Negotiated Rate	$333.20
Max. Negotiated Rate	$380.24
Rate for Payer: Cash Price	$254.80
Rate for Payer: Health Management Network Commercial	$333.20
Rate for Payer: Kaiser Permanente Commercial	$352.80
Rate for Payer: MDX Hawaii PPO	$380.24

HHSC US Breast Marker Clip

Facility

$392.00

Hospital Charge Code	8223486
Hospital Revenue Code	272
Min. Negotiated Rate	$196.00
Max. Negotiated Rate	$380.24
Rate for Payer: AlohaCare Medicaid	$196.00
Rate for Payer: AlohaCare Medicare	$196.00
Rate for Payer: Cash Price	$254.80
Rate for Payer: Devoted Health Medicare	$215.60
Rate for Payer: Hawaii Medical Service Association Medicare	$196.00
Rate for Payer: Hawaii Western Management Group Commercial	$372.40
Rate for Payer: Health Management Network Commercial	$333.20
Rate for Payer: Humana Medicare	$196.00
Rate for Payer: Kaiser Permanente Commercial	$352.80
Rate for Payer: Kaiser Permanente Medicaid	$199.92
Rate for Payer: Kaiser Permanente Medicare	$196.00
Rate for Payer: MDX Hawaii PPO	$380.24
Rate for Payer: Ohana Health Plan Medicaid	$196.00
Rate for Payer: Ohana Health Plan Medicare	$196.00
Rate for Payer: UnitedHealthcare Medicare	$196.00
Rate for Payer: University Health Alliance Commercial	$285.73

HHSC US BREAST MARKER CLIP (US)

Facility

$340.00

Hospital Charge Code	9469355
Hospital Revenue Code	272
Min. Negotiated Rate	$289.00
Max. Negotiated Rate	$329.80
Rate for Payer: Cash Price	$221.00
Rate for Payer: Health Management Network Commercial	$289.00
Rate for Payer: Kaiser Permanente Commercial	$306.00
Rate for Payer: MDX Hawaii PPO	$329.80

HHSC US BREAST MARKER CLIP (US)

Facility

$340.00

Hospital Charge Code	9469355
Hospital Revenue Code	272
Min. Negotiated Rate	$170.00
Max. Negotiated Rate	$329.80
Rate for Payer: AlohaCare Medicaid	$170.00
Rate for Payer: AlohaCare Medicare	$170.00
Rate for Payer: Cash Price	$221.00
Rate for Payer: Devoted Health Medicare	$187.00
Rate for Payer: Hawaii Medical Service Association Medicare	$170.00
Rate for Payer: Hawaii Western Management Group Commercial	$323.00
Rate for Payer: Health Management Network Commercial	$289.00
Rate for Payer: Humana Medicare	$170.00
Rate for Payer: Kaiser Permanente Commercial	$306.00
Rate for Payer: Kaiser Permanente Medicaid	$173.40
Rate for Payer: Kaiser Permanente Medicare	$170.00
Rate for Payer: MDX Hawaii PPO	$329.80
Rate for Payer: Ohana Health Plan Medicaid	$170.00
Rate for Payer: Ohana Health Plan Medicare	$170.00
Rate for Payer: UnitedHealthcare Medicare	$170.00
Rate for Payer: University Health Alliance Commercial	$247.83

HHSC US Bx Breast Add Lesion LT

Facility

$792.00

Service Code	HCPCS 19084
Hospital Charge Code	8223502
Hospital Revenue Code	361
Min. Negotiated Rate	$75.62
Max. Negotiated Rate	$2,837.00
Rate for Payer: AlohaCare Medicaid	$396.00
Rate for Payer: AlohaCare Medicare	$396.00
Rate for Payer: Cash Price	$514.80
Rate for Payer: Cash Price	$514.80
Rate for Payer: Cash Price	$514.80
Rate for Payer: Devoted Health Medicare	$435.60
Rate for Payer: Hawaii Medical Service Association Medicare	$396.00
Rate for Payer: Health Management Network Commercial	$673.20
Rate for Payer: Humana Medicare	$396.00
Rate for Payer: Kaiser Permanente Commercial	$712.80
Rate for Payer: Kaiser Permanente Medicaid	$2,837.00
Rate for Payer: Kaiser Permanente Medicare	$396.00
Rate for Payer: MDX Hawaii PPO	$768.24
Rate for Payer: Ohana Health Plan Medicaid	$396.00
Rate for Payer: Ohana Health Plan Medicare	$396.00
Rate for Payer: UnitedHealthcare Medicaid	$75.62
Rate for Payer: UnitedHealthcare Medicare	$396.00
Rate for Payer: University Health Alliance Commercial	$443.52

HHSC US Bx Breast Add Lesion LT

Facility

$792.00

Service Code	HCPCS 19084
Hospital Charge Code	8223502
Hospital Revenue Code	361
Min. Negotiated Rate	$673.20
Max. Negotiated Rate	$768.24
Rate for Payer: Cash Price	$514.80
Rate for Payer: Health Management Network Commercial	$673.20
Rate for Payer: Kaiser Permanente Commercial	$712.80
Rate for Payer: MDX Hawaii PPO	$768.24

HHSC US Bx Breast Add Lesion RT

Facility

$792.00

Service Code	HCPCS 19084
Hospital Charge Code	8223504
Hospital Revenue Code	361
Min. Negotiated Rate	$673.20
Max. Negotiated Rate	$768.24
Rate for Payer: Cash Price	$514.80
Rate for Payer: Health Management Network Commercial	$673.20
Rate for Payer: Kaiser Permanente Commercial	$712.80
Rate for Payer: MDX Hawaii PPO	$768.24

Know your out-of-pocket cost for care.

All Charges