Samuel Mahelona Memorial Hospital

All Charges

Charge

Type

Setting

Price

MG Breast Tissue Specimen Surgical Right

Facility

$4,054.00

Service Code	HCPCS 76098 RT
Hospital Charge Code	969780
Hospital Revenue Code	320
Min. Negotiated Rate	$3,445.90
Max. Negotiated Rate	$3,932.38
Rate for Payer: Cash Price	$2,635.10
Rate for Payer: Health Management Network Commercial	$3,445.90
Rate for Payer: Kaiser Permanente Commercial	$3,648.60
Rate for Payer: MDX Hawaii PPO	$3,932.38

MG Device Plcmnt w/ Mammo Guide Left

Facility

$4,879.00

Service Code	HCPCS 19281 LT
Hospital Charge Code	969773
Hospital Revenue Code	361
Min. Negotiated Rate	$4,147.15
Max. Negotiated Rate	$4,732.63
Rate for Payer: Cash Price	$3,171.35
Rate for Payer: Health Management Network Commercial	$4,147.15
Rate for Payer: Kaiser Permanente Commercial	$4,391.10
Rate for Payer: MDX Hawaii PPO	$4,732.63

MG Device Plcmnt w/ Mammo Guide Left

Facility

$4,879.00

Service Code	HCPCS 19281 LT
Hospital Charge Code	969773
Hospital Revenue Code	361
Min. Negotiated Rate	$456.03
Max. Negotiated Rate	$4,732.63
Rate for Payer: AlohaCare Medicaid	$2,439.50
Rate for Payer: AlohaCare Medicare	$2,439.50
Rate for Payer: Cash Price	$3,171.35
Rate for Payer: Cash Price	$3,171.35
Rate for Payer: Devoted Health Medicare	$2,683.45
Rate for Payer: Hawaii Medical Service Association Medicare	$2,439.50
Rate for Payer: Health Management Network Commercial	$4,147.15
Rate for Payer: Humana Medicare	$2,439.50
Rate for Payer: Kaiser Permanente Commercial	$4,391.10
Rate for Payer: Kaiser Permanente Medicaid	$2,837.00
Rate for Payer: Kaiser Permanente Medicare	$2,439.50
Rate for Payer: MDX Hawaii PPO	$4,732.63
Rate for Payer: Ohana Health Plan Medicaid	$2,439.50
Rate for Payer: Ohana Health Plan Medicare	$2,439.50
Rate for Payer: UnitedHealthcare Medicaid	$456.03
Rate for Payer: UnitedHealthcare Medicare	$2,439.50
Rate for Payer: University Health Alliance Commercial	$2,732.24

MG Device Plcmnt w/ Mammo Guide Left - Report

Professional

Both

$1,100.00

Service Code	HCPCS 19281 26,LT
Hospital Charge Code	627713
Hospital Revenue Code	972
Min. Negotiated Rate	$97.09
Max. Negotiated Rate	$935.00
Rate for Payer: AlohaCare Medicaid	$97.09
Rate for Payer: Cash Price	$715.00
Rate for Payer: Cash Price	$715.00
Rate for Payer: Hawaii Medical Service Association ABD	$97.09
Rate for Payer: Hawaii Medical Service Association Commercial	$165.43
Rate for Payer: Hawaii Medical Service Association Non-ABD	$97.09
Rate for Payer: Hawaii Western Management Group Commercial	$270.14
Rate for Payer: Health Management Network Commercial	$935.00
Rate for Payer: Ohana Health Plan Medicaid	$97.09
Rate for Payer: UnitedHealthcare Medicaid	$97.09
Rate for Payer: University Health Alliance Commercial	$105.35

MG Device Plcmnt w/ Mammo Guide Right

Facility

$4,879.00

Service Code	HCPCS 19281 RT
Hospital Charge Code	969775
Hospital Revenue Code	361
Min. Negotiated Rate	$456.03
Max. Negotiated Rate	$4,732.63
Rate for Payer: AlohaCare Medicaid	$2,439.50
Rate for Payer: AlohaCare Medicare	$2,439.50
Rate for Payer: Cash Price	$3,171.35
Rate for Payer: Cash Price	$3,171.35
Rate for Payer: Devoted Health Medicare	$2,683.45
Rate for Payer: Hawaii Medical Service Association Medicare	$2,439.50
Rate for Payer: Health Management Network Commercial	$4,147.15
Rate for Payer: Humana Medicare	$2,439.50
Rate for Payer: Kaiser Permanente Commercial	$4,391.10
Rate for Payer: Kaiser Permanente Medicaid	$2,837.00
Rate for Payer: Kaiser Permanente Medicare	$2,439.50
Rate for Payer: MDX Hawaii PPO	$4,732.63
Rate for Payer: Ohana Health Plan Medicaid	$2,439.50
Rate for Payer: Ohana Health Plan Medicare	$2,439.50
Rate for Payer: UnitedHealthcare Medicaid	$456.03
Rate for Payer: UnitedHealthcare Medicare	$2,439.50
Rate for Payer: University Health Alliance Commercial	$2,732.24

MG Device Plcmnt w/ Mammo Guide Right

Facility

$4,879.00

Service Code	HCPCS 19281 RT
Hospital Charge Code	969775
Hospital Revenue Code	361
Min. Negotiated Rate	$4,147.15
Max. Negotiated Rate	$4,732.63
Rate for Payer: Cash Price	$3,171.35
Rate for Payer: Health Management Network Commercial	$4,147.15
Rate for Payer: Kaiser Permanente Commercial	$4,391.10
Rate for Payer: MDX Hawaii PPO	$4,732.63

MG Device Plcmnt w/ Mammo Guide Right - Report

Professional

Both

$1,100.00

Service Code	HCPCS 19281 26,RT
Hospital Charge Code	627715
Hospital Revenue Code	972
Min. Negotiated Rate	$97.09
Max. Negotiated Rate	$935.00
Rate for Payer: AlohaCare Medicaid	$97.09
Rate for Payer: Cash Price	$715.00
Rate for Payer: Cash Price	$715.00
Rate for Payer: Hawaii Medical Service Association ABD	$97.09
Rate for Payer: Hawaii Medical Service Association Commercial	$165.43
Rate for Payer: Hawaii Medical Service Association Non-ABD	$97.09
Rate for Payer: Hawaii Western Management Group Commercial	$270.14
Rate for Payer: Health Management Network Commercial	$935.00
Rate for Payer: Ohana Health Plan Medicaid	$97.09
Rate for Payer: UnitedHealthcare Medicaid	$97.09
Rate for Payer: University Health Alliance Commercial	$105.35

MG Dev Plcmt w/ Mam Guide Add Lesion Lt

Facility

$3,780.00

Service Code	HCPCS 19282
Hospital Charge Code	9042494
Hospital Revenue Code	361
Min. Negotiated Rate	$3,213.00
Max. Negotiated Rate	$3,666.60
Rate for Payer: Cash Price	$2,457.00
Rate for Payer: Health Management Network Commercial	$3,213.00
Rate for Payer: Kaiser Permanente Commercial	$3,402.00
Rate for Payer: MDX Hawaii PPO	$3,666.60

MG Dev Plcmt w/ Mam Guide Add Lesion Lt

Facility

$3,780.00

Service Code	HCPCS 19282
Hospital Charge Code	9042494
Hospital Revenue Code	361
Min. Negotiated Rate	$48.74
Max. Negotiated Rate	$3,666.60
Rate for Payer: AlohaCare Medicaid	$1,890.00
Rate for Payer: AlohaCare Medicare	$1,890.00
Rate for Payer: Cash Price	$2,457.00
Rate for Payer: Cash Price	$2,457.00
Rate for Payer: Cash Price	$2,457.00
Rate for Payer: Devoted Health Medicare	$2,079.00
Rate for Payer: Hawaii Medical Service Association Medicare	$1,890.00
Rate for Payer: Health Management Network Commercial	$3,213.00
Rate for Payer: Humana Medicare	$1,890.00
Rate for Payer: Kaiser Permanente Commercial	$3,402.00
Rate for Payer: Kaiser Permanente Medicaid	$2,837.00
Rate for Payer: Kaiser Permanente Medicare	$1,890.00
Rate for Payer: MDX Hawaii PPO	$3,666.60
Rate for Payer: Ohana Health Plan Medicaid	$1,890.00
Rate for Payer: Ohana Health Plan Medicare	$1,890.00
Rate for Payer: UnitedHealthcare Medicaid	$48.74
Rate for Payer: UnitedHealthcare Medicare	$1,890.00
Rate for Payer: University Health Alliance Commercial	$2,116.80

MG Dev Plcmt w/ Mam Guide Add Lesion Lt - Report

Professional

Both

$73.00

Service Code	HCPCS 19282 LT
Hospital Charge Code	9042496
Hospital Revenue Code	972
Min. Negotiated Rate	$48.74
Max. Negotiated Rate	$191.36
Rate for Payer: AlohaCare Medicaid	$48.74
Rate for Payer: Cash Price	$47.45
Rate for Payer: Cash Price	$47.45
Rate for Payer: Hawaii Medical Service Association ABD	$48.74
Rate for Payer: Hawaii Medical Service Association Commercial	$82.71
Rate for Payer: Hawaii Medical Service Association Non-ABD	$48.74
Rate for Payer: Hawaii Western Management Group Commercial	$191.36
Rate for Payer: Health Management Network Commercial	$62.05
Rate for Payer: Ohana Health Plan Medicaid	$48.74
Rate for Payer: UnitedHealthcare Medicaid	$48.74
Rate for Payer: University Health Alliance Commercial	$52.78

MG Dev Plcmt w/ Mam Guide Add Lesion Rt

Facility

$3,780.00

Service Code	HCPCS 19282
Hospital Charge Code	9042497
Hospital Revenue Code	361
Min. Negotiated Rate	$3,213.00
Max. Negotiated Rate	$3,666.60
Rate for Payer: Cash Price	$2,457.00
Rate for Payer: Health Management Network Commercial	$3,213.00
Rate for Payer: Kaiser Permanente Commercial	$3,402.00
Rate for Payer: MDX Hawaii PPO	$3,666.60

MG Dev Plcmt w/ Mam Guide Add Lesion Rt

Facility

$3,780.00

Service Code	HCPCS 19282
Hospital Charge Code	9042497
Hospital Revenue Code	361
Min. Negotiated Rate	$48.74
Max. Negotiated Rate	$3,666.60
Rate for Payer: AlohaCare Medicaid	$1,890.00
Rate for Payer: AlohaCare Medicare	$1,890.00
Rate for Payer: Cash Price	$2,457.00
Rate for Payer: Cash Price	$2,457.00
Rate for Payer: Cash Price	$2,457.00
Rate for Payer: Devoted Health Medicare	$2,079.00
Rate for Payer: Hawaii Medical Service Association Medicare	$1,890.00
Rate for Payer: Health Management Network Commercial	$3,213.00
Rate for Payer: Humana Medicare	$1,890.00
Rate for Payer: Kaiser Permanente Commercial	$3,402.00
Rate for Payer: Kaiser Permanente Medicaid	$2,837.00
Rate for Payer: Kaiser Permanente Medicare	$1,890.00
Rate for Payer: MDX Hawaii PPO	$3,666.60
Rate for Payer: Ohana Health Plan Medicaid	$1,890.00
Rate for Payer: Ohana Health Plan Medicare	$1,890.00
Rate for Payer: UnitedHealthcare Medicaid	$48.74
Rate for Payer: UnitedHealthcare Medicare	$1,890.00
Rate for Payer: University Health Alliance Commercial	$2,116.80

MG Dev Plcmt w/ Mam Guide Add Lesion Rt - Report

Professional

Both

$73.00

Service Code	HCPCS 19282 RT
Hospital Charge Code	9042499
Hospital Revenue Code	972
Min. Negotiated Rate	$48.74
Max. Negotiated Rate	$191.36
Rate for Payer: AlohaCare Medicaid	$48.74
Rate for Payer: Cash Price	$47.45
Rate for Payer: Cash Price	$47.45
Rate for Payer: Hawaii Medical Service Association ABD	$48.74
Rate for Payer: Hawaii Medical Service Association Commercial	$82.71
Rate for Payer: Hawaii Medical Service Association Non-ABD	$48.74
Rate for Payer: Hawaii Western Management Group Commercial	$191.36
Rate for Payer: Health Management Network Commercial	$62.05
Rate for Payer: Ohana Health Plan Medicaid	$48.74
Rate for Payer: UnitedHealthcare Medicaid	$48.74
Rate for Payer: University Health Alliance Commercial	$52.78

MG Ductogram or Galactogram Multiple Lt

Facility

$740.00

Service Code	HCPCS 77054
Hospital Charge Code	8099873
Hospital Revenue Code	320
Min. Negotiated Rate	$95.49
Max. Negotiated Rate	$717.80
Rate for Payer: AlohaCare Medicaid	$370.00
Rate for Payer: AlohaCare Medicare	$370.00
Rate for Payer: Cash Price	$481.00
Rate for Payer: Cash Price	$481.00
Rate for Payer: Devoted Health Medicare	$407.00
Rate for Payer: Hawaii Medical Service Association ABD	$95.49
Rate for Payer: Hawaii Medical Service Association Commercial	$304.71
Rate for Payer: Hawaii Medical Service Association Medicare	$370.00
Rate for Payer: Hawaii Medical Service Association Non-ABD	$123.78
Rate for Payer: Hawaii Western Management Group Commercial	$243.77
Rate for Payer: Health Management Network Commercial	$629.00
Rate for Payer: Humana Medicare	$370.00
Rate for Payer: Kaiser Permanente Commercial	$666.00
Rate for Payer: Kaiser Permanente Medicaid	$377.40
Rate for Payer: Kaiser Permanente Medicare	$370.00
Rate for Payer: MDX Hawaii PPO	$717.80
Rate for Payer: Ohana Health Plan Medicaid	$370.00
Rate for Payer: Ohana Health Plan Medicare	$370.00
Rate for Payer: UnitedHealthcare Medicaid	$95.49
Rate for Payer: UnitedHealthcare Medicare	$370.00
Rate for Payer: University Health Alliance Commercial	$258.46

MG Ductogram or Galactogram Multiple Lt

Facility

$740.00

Service Code	HCPCS 77054
Hospital Charge Code	8099873
Hospital Revenue Code	320
Min. Negotiated Rate	$629.00
Max. Negotiated Rate	$717.80
Rate for Payer: Cash Price	$481.00
Rate for Payer: Health Management Network Commercial	$629.00
Rate for Payer: Kaiser Permanente Commercial	$666.00
Rate for Payer: MDX Hawaii PPO	$717.80

MG Ductogram or Galactogram Multiple Lt.

Facility

$740.00

Service Code	HCPCS 77054
Hospital Charge Code	8253562
Hospital Revenue Code	320
Min. Negotiated Rate	$95.49
Max. Negotiated Rate	$717.80
Rate for Payer: Cash Price	$481.00
Rate for Payer: AlohaCare Medicaid	$370.00
Rate for Payer: AlohaCare Medicare	$370.00
Rate for Payer: Cash Price	$481.00
Rate for Payer: Devoted Health Medicare	$407.00
Rate for Payer: Hawaii Medical Service Association ABD	$95.49
Rate for Payer: Hawaii Medical Service Association Commercial	$304.71
Rate for Payer: Hawaii Medical Service Association Medicare	$370.00
Rate for Payer: Hawaii Medical Service Association Non-ABD	$123.78
Rate for Payer: Hawaii Western Management Group Commercial	$243.77
Rate for Payer: Health Management Network Commercial	$629.00
Rate for Payer: Humana Medicare	$370.00
Rate for Payer: Kaiser Permanente Commercial	$666.00
Rate for Payer: Kaiser Permanente Medicaid	$377.40
Rate for Payer: Kaiser Permanente Medicare	$370.00
Rate for Payer: MDX Hawaii PPO	$717.80
Rate for Payer: Ohana Health Plan Medicaid	$370.00
Rate for Payer: Ohana Health Plan Medicare	$370.00
Rate for Payer: UnitedHealthcare Medicaid	$95.49
Rate for Payer: UnitedHealthcare Medicare	$370.00
Rate for Payer: University Health Alliance Commercial	$258.46

MG Ductogram or Galactogram Multiple Lt.

Facility

$740.00

Service Code	HCPCS 77054
Hospital Charge Code	8253562
Hospital Revenue Code	320
Min. Negotiated Rate	$629.00
Max. Negotiated Rate	$717.80
Rate for Payer: Cash Price	$481.00
Rate for Payer: Health Management Network Commercial	$629.00
Rate for Payer: Kaiser Permanente Commercial	$666.00
Rate for Payer: MDX Hawaii PPO	$717.80

MG Ductogram or Galactogram Multiple Lt - Report

Professional

Both

$332.00

Service Code	HCPCS 77054 26,LT
Hospital Charge Code	8099875
Hospital Revenue Code	972
Min. Negotiated Rate	$46.04
Max. Negotiated Rate	$282.20
Rate for Payer: AlohaCare Medicaid	$46.04
Rate for Payer: Cash Price	$215.80
Rate for Payer: Cash Price	$215.80
Rate for Payer: Health Management Network Commercial	$282.20
Rate for Payer: Ohana Health Plan Medicaid	$46.04
Rate for Payer: UnitedHealthcare Medicaid	$46.04

MG Ductogram or Galactogram Multiple Lt. - Report

Professional

Both

$332.00

Service Code	HCPCS 77054 26
Hospital Charge Code	8253564
Hospital Revenue Code	972
Min. Negotiated Rate	$21.35
Max. Negotiated Rate	$282.20
Rate for Payer: AlohaCare Medicaid	$46.04
Rate for Payer: AlohaCare Medicare	$21.35
Rate for Payer: Cash Price	$215.80
Rate for Payer: Cash Price	$215.80
Rate for Payer: Devoted Health Medicare	$23.48
Rate for Payer: Hawaii Medical Service Association Medicare	$21.35
Rate for Payer: Health Management Network Commercial	$282.20
Rate for Payer: Kaiser Permanente Commercial	$25.62
Rate for Payer: Kaiser Permanente Medicaid	$25.62
Rate for Payer: Kaiser Permanente Medicare	$25.62
Rate for Payer: Ohana Health Plan Medicaid	$46.04
Rate for Payer: Ohana Health Plan Medicare	$21.35
Rate for Payer: UnitedHealthcare Medicaid	$46.04
Rate for Payer: UnitedHealthcare Medicare	$21.35

MG Ductogram or Galactogram Multiple Rt

Facility

$740.00

Service Code	HCPCS 77054 RT
Hospital Charge Code	8099876
Hospital Revenue Code	320
Min. Negotiated Rate	$629.00
Max. Negotiated Rate	$717.80
Rate for Payer: Cash Price	$481.00
Rate for Payer: Health Management Network Commercial	$629.00
Rate for Payer: Kaiser Permanente Commercial	$666.00
Rate for Payer: MDX Hawaii PPO	$717.80

MG Ductogram or Galactogram Multiple Rt

Facility

$740.00

Service Code	HCPCS 77054 RT
Hospital Charge Code	8099876
Hospital Revenue Code	320
Min. Negotiated Rate	$95.49
Max. Negotiated Rate	$717.80
Rate for Payer: AlohaCare Medicaid	$370.00
Rate for Payer: AlohaCare Medicare	$370.00
Rate for Payer: Cash Price	$481.00
Rate for Payer: Cash Price	$481.00
Rate for Payer: Devoted Health Medicare	$407.00
Rate for Payer: Hawaii Medical Service Association ABD	$95.49
Rate for Payer: Hawaii Medical Service Association Medicare	$370.00
Rate for Payer: Hawaii Medical Service Association Non-ABD	$123.78
Rate for Payer: Hawaii Western Management Group Commercial	$703.00
Rate for Payer: Health Management Network Commercial	$629.00
Rate for Payer: Humana Medicare	$370.00
Rate for Payer: Kaiser Permanente Commercial	$666.00
Rate for Payer: Kaiser Permanente Medicaid	$377.40
Rate for Payer: Kaiser Permanente Medicare	$370.00
Rate for Payer: MDX Hawaii PPO	$717.80
Rate for Payer: Ohana Health Plan Medicaid	$370.00
Rate for Payer: Ohana Health Plan Medicare	$370.00
Rate for Payer: UnitedHealthcare Medicaid	$95.49
Rate for Payer: UnitedHealthcare Medicare	$370.00
Rate for Payer: University Health Alliance Commercial	$258.46

MG Ductogram or Galactogram Multiple Rt.

Facility

$740.00

Service Code	HCPCS 77054
Hospital Charge Code	8253565
Hospital Revenue Code	320
Min. Negotiated Rate	$629.00
Max. Negotiated Rate	$717.80
Rate for Payer: Cash Price	$481.00
Rate for Payer: Health Management Network Commercial	$629.00
Rate for Payer: Kaiser Permanente Commercial	$666.00
Rate for Payer: MDX Hawaii PPO	$717.80

MG Ductogram or Galactogram Multiple Rt.

Facility

$740.00

Service Code	HCPCS 77054
Hospital Charge Code	8253565
Hospital Revenue Code	320
Min. Negotiated Rate	$95.49
Max. Negotiated Rate	$717.80
Rate for Payer: AlohaCare Medicaid	$370.00
Rate for Payer: AlohaCare Medicare	$370.00
Rate for Payer: Cash Price	$481.00
Rate for Payer: Cash Price	$481.00
Rate for Payer: Devoted Health Medicare	$407.00
Rate for Payer: Hawaii Medical Service Association ABD	$95.49
Rate for Payer: Hawaii Medical Service Association Commercial	$304.71
Rate for Payer: Hawaii Medical Service Association Medicare	$370.00
Rate for Payer: Hawaii Medical Service Association Non-ABD	$123.78
Rate for Payer: Hawaii Western Management Group Commercial	$243.77
Rate for Payer: Health Management Network Commercial	$629.00
Rate for Payer: Humana Medicare	$370.00
Rate for Payer: Kaiser Permanente Commercial	$666.00
Rate for Payer: Kaiser Permanente Medicaid	$377.40
Rate for Payer: Kaiser Permanente Medicare	$370.00
Rate for Payer: MDX Hawaii PPO	$717.80
Rate for Payer: Ohana Health Plan Medicaid	$370.00
Rate for Payer: Ohana Health Plan Medicare	$370.00
Rate for Payer: UnitedHealthcare Medicaid	$95.49
Rate for Payer: UnitedHealthcare Medicare	$370.00
Rate for Payer: University Health Alliance Commercial	$258.46

MG Ductogram or Galactogram Multiple Rt - Report

Professional

Both

$332.00

Service Code	HCPCS 77054 26,RT
Hospital Charge Code	8099878
Hospital Revenue Code	972
Min. Negotiated Rate	$46.04
Max. Negotiated Rate	$282.20
Rate for Payer: AlohaCare Medicaid	$46.04
Rate for Payer: Cash Price	$215.80
Rate for Payer: Cash Price	$215.80
Rate for Payer: Health Management Network Commercial	$282.20
Rate for Payer: Ohana Health Plan Medicaid	$46.04
Rate for Payer: UnitedHealthcare Medicaid	$46.04

MG Ductogram or Galactogram Multiple Rt. - Report

Professional

Both

$332.00

Service Code	HCPCS 77054 26,RT
Hospital Charge Code	8253567
Hospital Revenue Code	972
Min. Negotiated Rate	$46.04
Max. Negotiated Rate	$282.20
Rate for Payer: AlohaCare Medicaid	$46.04
Rate for Payer: Cash Price	$215.80
Rate for Payer: Cash Price	$215.80
Rate for Payer: Health Management Network Commercial	$282.20
Rate for Payer: Ohana Health Plan Medicaid	$46.04
Rate for Payer: UnitedHealthcare Medicaid	$46.04

Know your out-of-pocket cost for care.

All Charges