Samuel Mahelona Memorial Hospital

All Charges

Charge

Type

Setting

Price

HHSC XR Inj Ankle Arthro

Facility

$214.00

Service Code	HCPCS 27648
Hospital Charge Code	8224268
Hospital Revenue Code	361
Min. Negotiated Rate	$181.90
Max. Negotiated Rate	$207.58
Rate for Payer: Cash Price	$139.10
Rate for Payer: Health Management Network Commercial	$181.90
Rate for Payer: Kaiser Permanente Commercial	$192.60
Rate for Payer: MDX Hawaii PPO	$207.58

HHSC XR Inj Hysterosalpingogram

Facility

$442.00

Service Code	HCPCS 58340
Hospital Charge Code	8224266
Hospital Revenue Code	361
Min. Negotiated Rate	$38.69
Max. Negotiated Rate	$2,837.00
Rate for Payer: AlohaCare Medicaid	$221.00
Rate for Payer: AlohaCare Medicare	$221.00
Rate for Payer: Cash Price	$287.30
Rate for Payer: Cash Price	$287.30
Rate for Payer: Cash Price	$287.30
Rate for Payer: Devoted Health Medicare	$243.10
Rate for Payer: Hawaii Medical Service Association Medicare	$221.00
Rate for Payer: Health Management Network Commercial	$375.70
Rate for Payer: Humana Medicare	$221.00
Rate for Payer: Kaiser Permanente Commercial	$397.80
Rate for Payer: Kaiser Permanente Medicaid	$2,837.00
Rate for Payer: Kaiser Permanente Medicare	$221.00
Rate for Payer: MDX Hawaii PPO	$428.74
Rate for Payer: Ohana Health Plan Medicaid	$221.00
Rate for Payer: Ohana Health Plan Medicare	$221.00
Rate for Payer: UnitedHealthcare Medicaid	$38.69
Rate for Payer: UnitedHealthcare Medicare	$221.00
Rate for Payer: University Health Alliance Commercial	$247.52

HHSC XR Inj Hysterosalpingogram

Facility

$442.00

Service Code	HCPCS 58340
Hospital Charge Code	8224266
Hospital Revenue Code	361
Min. Negotiated Rate	$375.70
Max. Negotiated Rate	$428.74
Rate for Payer: Cash Price	$287.30
Rate for Payer: Health Management Network Commercial	$375.70
Rate for Payer: Kaiser Permanente Commercial	$397.80
Rate for Payer: MDX Hawaii PPO	$428.74

HHSC XR Inj Knee Arthro

Facility

$214.00

Service Code	HCPCS 27370
Hospital Charge Code	8224260
Hospital Revenue Code	361
Min. Negotiated Rate	$107.00
Max. Negotiated Rate	$2,837.00
Rate for Payer: AlohaCare Medicaid	$107.00
Rate for Payer: AlohaCare Medicare	$107.00
Rate for Payer: Cash Price	$139.10
Rate for Payer: Cash Price	$139.10
Rate for Payer: Devoted Health Medicare	$117.70
Rate for Payer: Hawaii Medical Service Association Medicare	$107.00
Rate for Payer: Health Management Network Commercial	$181.90
Rate for Payer: Humana Medicare	$107.00
Rate for Payer: Kaiser Permanente Commercial	$192.60
Rate for Payer: Kaiser Permanente Medicaid	$2,837.00
Rate for Payer: Kaiser Permanente Medicare	$107.00
Rate for Payer: MDX Hawaii PPO	$207.58
Rate for Payer: Ohana Health Plan Medicaid	$107.00
Rate for Payer: Ohana Health Plan Medicare	$107.00
Rate for Payer: UnitedHealthcare Medicare	$107.00
Rate for Payer: University Health Alliance Commercial	$119.84

HHSC XR Inj Knee Arthro

Facility

$214.00

Service Code	HCPCS 27370
Hospital Charge Code	8224260
Hospital Revenue Code	361
Min. Negotiated Rate	$181.90
Max. Negotiated Rate	$207.58
Rate for Payer: Cash Price	$139.10
Rate for Payer: Health Management Network Commercial	$181.90
Rate for Payer: Kaiser Permanente Commercial	$192.60
Rate for Payer: MDX Hawaii PPO	$207.58

HHSC XR Inj Mamm Duct Galact

Facility

$214.00

Service Code	HCPCS 19030
Hospital Charge Code	8224256
Hospital Revenue Code	361
Min. Negotiated Rate	$181.90
Max. Negotiated Rate	$207.58
Rate for Payer: Cash Price	$139.10
Rate for Payer: Health Management Network Commercial	$181.90
Rate for Payer: Kaiser Permanente Commercial	$192.60
Rate for Payer: MDX Hawaii PPO	$207.58

HHSC XR Inj Mamm Duct Galact

Facility

$214.00

Service Code	HCPCS 19030
Hospital Charge Code	8224256
Hospital Revenue Code	361
Min. Negotiated Rate	$56.73
Max. Negotiated Rate	$2,837.00
Rate for Payer: AlohaCare Medicaid	$107.00
Rate for Payer: AlohaCare Medicare	$107.00
Rate for Payer: Cash Price	$139.10
Rate for Payer: Cash Price	$139.10
Rate for Payer: Cash Price	$139.10
Rate for Payer: Devoted Health Medicare	$117.70
Rate for Payer: Hawaii Medical Service Association Medicare	$107.00
Rate for Payer: Health Management Network Commercial	$181.90
Rate for Payer: Humana Medicare	$107.00
Rate for Payer: Kaiser Permanente Commercial	$192.60
Rate for Payer: Kaiser Permanente Medicaid	$2,837.00
Rate for Payer: Kaiser Permanente Medicare	$107.00
Rate for Payer: MDX Hawaii PPO	$207.58
Rate for Payer: Ohana Health Plan Medicaid	$107.00
Rate for Payer: Ohana Health Plan Medicare	$107.00
Rate for Payer: UnitedHealthcare Medicaid	$56.73
Rate for Payer: UnitedHealthcare Medicare	$107.00
Rate for Payer: University Health Alliance Commercial	$119.84

HHSC XR Inj Shoulder Arthro

Facility

$351.00

Service Code	HCPCS 23350
Hospital Charge Code	8224262
Hospital Revenue Code	361
Min. Negotiated Rate	$298.35
Max. Negotiated Rate	$340.47
Rate for Payer: Cash Price	$228.15
Rate for Payer: Health Management Network Commercial	$298.35
Rate for Payer: Kaiser Permanente Commercial	$315.90
Rate for Payer: MDX Hawaii PPO	$340.47

HHSC XR Inj Shoulder Arthro

Facility

$351.00

Service Code	HCPCS 23350
Hospital Charge Code	8224262
Hospital Revenue Code	361
Min. Negotiated Rate	$40.41
Max. Negotiated Rate	$2,837.00
Rate for Payer: AlohaCare Medicaid	$175.50
Rate for Payer: AlohaCare Medicare	$175.50
Rate for Payer: Cash Price	$228.15
Rate for Payer: Cash Price	$228.15
Rate for Payer: Cash Price	$228.15
Rate for Payer: Devoted Health Medicare	$193.05
Rate for Payer: Hawaii Medical Service Association Medicare	$175.50
Rate for Payer: Health Management Network Commercial	$298.35
Rate for Payer: Humana Medicare	$175.50
Rate for Payer: Kaiser Permanente Commercial	$315.90
Rate for Payer: Kaiser Permanente Medicaid	$2,837.00
Rate for Payer: Kaiser Permanente Medicare	$175.50
Rate for Payer: MDX Hawaii PPO	$340.47
Rate for Payer: Ohana Health Plan Medicaid	$175.50
Rate for Payer: Ohana Health Plan Medicare	$175.50
Rate for Payer: UnitedHealthcare Medicaid	$40.41
Rate for Payer: UnitedHealthcare Medicare	$175.50
Rate for Payer: University Health Alliance Commercial	$196.56

HHSC XR Inj Wrist Arthro

Facility

$214.00

Service Code	HCPCS 25246
Hospital Charge Code	8224264
Hospital Revenue Code	361
Min. Negotiated Rate	$54.32
Max. Negotiated Rate	$2,837.00
Rate for Payer: AlohaCare Medicaid	$107.00
Rate for Payer: AlohaCare Medicare	$107.00
Rate for Payer: Cash Price	$139.10
Rate for Payer: Cash Price	$139.10
Rate for Payer: Cash Price	$139.10
Rate for Payer: Devoted Health Medicare	$117.70
Rate for Payer: Hawaii Medical Service Association Medicare	$107.00
Rate for Payer: Health Management Network Commercial	$181.90
Rate for Payer: Humana Medicare	$107.00
Rate for Payer: Kaiser Permanente Commercial	$192.60
Rate for Payer: Kaiser Permanente Medicaid	$2,837.00
Rate for Payer: Kaiser Permanente Medicare	$107.00
Rate for Payer: MDX Hawaii PPO	$207.58
Rate for Payer: Ohana Health Plan Medicaid	$107.00
Rate for Payer: Ohana Health Plan Medicare	$107.00
Rate for Payer: UnitedHealthcare Medicaid	$54.32
Rate for Payer: UnitedHealthcare Medicare	$107.00
Rate for Payer: University Health Alliance Commercial	$119.84

HHSC XR Inj Wrist Arthro

Facility

$214.00

Service Code	HCPCS 25246
Hospital Charge Code	8224264
Hospital Revenue Code	361
Min. Negotiated Rate	$181.90
Max. Negotiated Rate	$207.58
Rate for Payer: Cash Price	$139.10
Rate for Payer: Health Management Network Commercial	$181.90
Rate for Payer: Kaiser Permanente Commercial	$192.60
Rate for Payer: MDX Hawaii PPO	$207.58

HHSC XR Small Bowel

Facility

$647.00

Service Code	HCPCS 74248
Hospital Charge Code	9218290
Hospital Revenue Code	320
Min. Negotiated Rate	$549.95
Max. Negotiated Rate	$627.59
Rate for Payer: Cash Price	$420.55
Rate for Payer: Health Management Network Commercial	$549.95
Rate for Payer: Kaiser Permanente Commercial	$582.30
Rate for Payer: MDX Hawaii PPO	$627.59

HHSC XR Small Bowel

Facility

$647.00

Service Code	HCPCS 74248
Hospital Charge Code	9218290
Hospital Revenue Code	320
Min. Negotiated Rate	$43.61
Max. Negotiated Rate	$627.59
Rate for Payer: AlohaCare Medicaid	$323.50
Rate for Payer: AlohaCare Medicare	$323.50
Rate for Payer: Cash Price	$420.55
Rate for Payer: Cash Price	$420.55
Rate for Payer: Devoted Health Medicare	$355.85
Rate for Payer: Hawaii Medical Service Association ABD	$65.90
Rate for Payer: Hawaii Medical Service Association Medicare	$323.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$43.61
Rate for Payer: Hawaii Western Management Group Commercial	$614.65
Rate for Payer: Health Management Network Commercial	$549.95
Rate for Payer: Humana Medicare	$323.50
Rate for Payer: Kaiser Permanente Commercial	$582.30
Rate for Payer: Kaiser Permanente Medicaid	$329.97
Rate for Payer: Kaiser Permanente Medicare	$323.50
Rate for Payer: MDX Hawaii PPO	$627.59
Rate for Payer: Ohana Health Plan Medicaid	$323.50
Rate for Payer: Ohana Health Plan Medicare	$323.50
Rate for Payer: UnitedHealthcare Medicaid	$54.01
Rate for Payer: UnitedHealthcare Medicare	$323.50
Rate for Payer: University Health Alliance Commercial	$176.51

HHSC XR Small Bowel ProFee

Professional

Both

$111.00

Service Code	HCPCS 74248 26
Hospital Charge Code	9218291
Hospital Revenue Code	972
Min. Negotiated Rate	$32.60
Max. Negotiated Rate	$94.35
Rate for Payer: AlohaCare Medicaid	$54.01
Rate for Payer: AlohaCare Medicare	$32.60
Rate for Payer: Cash Price	$72.15
Rate for Payer: Cash Price	$72.15
Rate for Payer: Devoted Health Medicare	$35.86
Rate for Payer: Hawaii Medical Service Association Medicare	$32.60
Rate for Payer: Hawaii Western Management Group Commercial	$91.74
Rate for Payer: Health Management Network Commercial	$94.35
Rate for Payer: Kaiser Permanente Commercial	$39.12
Rate for Payer: Kaiser Permanente Medicaid	$39.12
Rate for Payer: Kaiser Permanente Medicare	$39.12
Rate for Payer: Ohana Health Plan Medicaid	$54.01
Rate for Payer: Ohana Health Plan Medicare	$32.60
Rate for Payer: UnitedHealthcare Medicaid	$54.01
Rate for Payer: UnitedHealthcare Medicare	$32.60

HHSC YUEH CENT DISP CATH NDL 5 FR/10CM

Facility

$95.00

Service Code	HCPCS A4648
Hospital Charge Code	8223432
Hospital Revenue Code	278
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	$66.50
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	$53.20

HHSC YUEH CENT DISP CATH NDL 5 FR/10CM

Facility

$95.00

Service Code	HCPCS A4648
Hospital Charge Code	8223432
Hospital Revenue Code	278
Min. Negotiated Rate	$53.20
Max. Negotiated Rate	$92.15
Rate for Payer: Cash Price	$61.75
Rate for Payer: Hawaii Western Management Group Commercial	$66.50
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
Rate for Payer: University Health Alliance Commercial	$53.20

HHSC YUEH CENT DISP CATH NDL 5 FR/7CM

Facility

$95.00

Service Code	HCPCS A4648
Hospital Charge Code	8223430
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 YUEH CENT DISP CATH NDL 5 FR/7CM

Facility

$95.00

Service Code	HCPCS A4648
Hospital Charge Code	8223430
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 YUEH CENT DISP CATH NDL 5 FR/9CM

Facility

$95.00

Service Code	HCPCS A4648
Hospital Charge Code	8223428
Hospital Revenue Code	278
Min. Negotiated Rate	$53.20
Max. Negotiated Rate	$92.15
Rate for Payer: Cash Price	$61.75
Rate for Payer: Hawaii Western Management Group Commercial	$66.50
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
Rate for Payer: University Health Alliance Commercial	$53.20

HHSC YUEH CENT DISP CATH NDL 5 FR/9CM

Facility

$95.00

Service Code	HCPCS A4648
Hospital Charge Code	8223428
Hospital Revenue Code	278
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	$66.50
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	$53.20

High Sensitivity Troponin iSTAT POCT

Facility

$125.00

Service Code	HCPCS 84484 QW
Hospital Charge Code	13230888
Hospital Revenue Code	301
Min. Negotiated Rate	$106.25
Max. Negotiated Rate	$121.25
Rate for Payer: Cash Price	$81.25
Rate for Payer: Health Management Network Commercial	$106.25
Rate for Payer: Kaiser Permanente Commercial	$112.50
Rate for Payer: MDX Hawaii PPO	$121.25

High Sensitivity Troponin iSTAT POCT

Facility

$125.00

Service Code	HCPCS 84484 QW
Hospital Charge Code	13230888
Hospital Revenue Code	301
Min. Negotiated Rate	$13.60
Max. Negotiated Rate	$121.25
Rate for Payer: AlohaCare Medicaid	$62.50
Rate for Payer: AlohaCare Medicare	$62.50
Rate for Payer: Cash Price	$81.25
Rate for Payer: Cash Price	$81.25
Rate for Payer: Devoted Health Medicare	$68.75
Rate for Payer: Hawaii Medical Service Association ABD	$13.60
Rate for Payer: Hawaii Medical Service Association Medicare	$62.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$14.28
Rate for Payer: Hawaii Western Management Group Commercial	$118.75
Rate for Payer: Health Management Network Commercial	$106.25
Rate for Payer: Humana Medicare	$62.50
Rate for Payer: Kaiser Permanente Commercial	$112.50
Rate for Payer: Kaiser Permanente Medicaid	$63.75
Rate for Payer: Kaiser Permanente Medicare	$62.50
Rate for Payer: MDX Hawaii PPO	$121.25
Rate for Payer: Ohana Health Plan Medicaid	$62.50
Rate for Payer: Ohana Health Plan Medicare	$62.50
Rate for Payer: UnitedHealthcare Medicaid	$13.60
Rate for Payer: UnitedHealthcare Medicare	$62.50
Rate for Payer: University Health Alliance Commercial	$25.44

HIP AND FEMUR PROCEDURES EXCEPT MAJOR JOINT WITH CC

Facility

$48,517.99

Service Code	MSDRG 481
Min. Negotiated Rate	$48,517.99
Max. Negotiated Rate	$48,517.99
Rate for Payer: Hawaii Medical Service Association Commercial	$48,517.99

HIP AND FEMUR PROCEDURES EXCEPT MAJOR JOINT WITH MCC

Facility

$49,750.50

Service Code	MSDRG 480
Min. Negotiated Rate	$49,750.50
Max. Negotiated Rate	$49,750.50
Rate for Payer: Hawaii Medical Service Association Commercial	$49,750.50

HIP AND FEMUR PROCEDURES EXCEPT MAJOR JOINT WITHOUT CC/MCC

Facility

$34,960.45

Service Code	MSDRG 482
Min. Negotiated Rate	$34,960.45
Max. Negotiated Rate	$34,960.45
Rate for Payer: Hawaii Medical Service Association Commercial	$34,960.45

Know your out-of-pocket cost for care.

All Charges