Samuel Mahelona Memorial Hospital

All Charges

Charge

Type

Setting

Price

MG Mammo Diagnostic Right w/ Tomo

Facility

$576.00

Service Code	HCPCS 77065 RT
Hospital Charge Code	8033185
Hospital Revenue Code	401
Min. Negotiated Rate	$489.60
Max. Negotiated Rate	$558.72
Rate for Payer: Cash Price	$374.40
Rate for Payer: Health Management Network Commercial	$489.60
Rate for Payer: Kaiser Permanente Commercial	$518.40
Rate for Payer: MDX Hawaii PPO	$558.72

MG Mammo Diagnostic Right w/ Tomo

Facility

$576.00

Service Code	HCPCS 77065 RT
Hospital Charge Code	8420281
Hospital Revenue Code	401
Min. Negotiated Rate	$489.60
Max. Negotiated Rate	$558.72
Rate for Payer: Cash Price	$374.40
Rate for Payer: Health Management Network Commercial	$489.60
Rate for Payer: Kaiser Permanente Commercial	$518.40
Rate for Payer: MDX Hawaii PPO	$558.72

MG Mammo Diagnostic Right w/ Tomo

Facility

$576.00

Service Code	HCPCS 77065 RT
Hospital Charge Code	8420281
Hospital Revenue Code	401
Min. Negotiated Rate	$64.13
Max. Negotiated Rate	$558.72
Rate for Payer: AlohaCare Medicaid	$288.00
Rate for Payer: AlohaCare Medicare	$288.00
Rate for Payer: Cash Price	$374.40
Rate for Payer: Cash Price	$374.40
Rate for Payer: Devoted Health Medicare	$316.80
Rate for Payer: Hawaii Medical Service Association ABD	$64.13
Rate for Payer: Hawaii Medical Service Association Medicare	$288.00
Rate for Payer: Hawaii Medical Service Association Non-ABD	$85.82
Rate for Payer: Hawaii Western Management Group Commercial	$547.20
Rate for Payer: Health Management Network Commercial	$489.60
Rate for Payer: Humana Medicare	$288.00
Rate for Payer: Kaiser Permanente Commercial	$518.40
Rate for Payer: Kaiser Permanente Medicaid	$293.76
Rate for Payer: Kaiser Permanente Medicare	$288.00
Rate for Payer: MDX Hawaii PPO	$558.72
Rate for Payer: Ohana Health Plan Medicaid	$288.00
Rate for Payer: Ohana Health Plan Medicare	$288.00
Rate for Payer: UnitedHealthcare Medicaid	$83.29
Rate for Payer: UnitedHealthcare Medicare	$288.00
Rate for Payer: University Health Alliance Commercial	$277.78

MG Mammo Diagnostic Right w/ Tomo - Report

Professional

Both

$108.00

Service Code	HCPCS 77065 RT
Hospital Charge Code	8420283
Hospital Revenue Code	972
Min. Negotiated Rate	$83.29
Max. Negotiated Rate	$141.22
Rate for Payer: AlohaCare Medicaid	$83.29
Rate for Payer: Cash Price	$70.20
Rate for Payer: Cash Price	$70.20
Rate for Payer: Hawaii Western Management Group Commercial	$141.22
Rate for Payer: Health Management Network Commercial	$91.80
Rate for Payer: Ohana Health Plan Medicaid	$83.29
Rate for Payer: UnitedHealthcare Medicaid	$83.29

MG Mammo Diagnostic Right w/ Tomo - Report

Professional

Both

$108.00

Service Code	HCPCS 77065 26,RT
Hospital Charge Code	8033187
Hospital Revenue Code	972
Min. Negotiated Rate	$83.29
Max. Negotiated Rate	$141.22
Rate for Payer: AlohaCare Medicaid	$83.29
Rate for Payer: Cash Price	$70.20
Rate for Payer: Cash Price	$70.20
Rate for Payer: Hawaii Western Management Group Commercial	$141.22
Rate for Payer: Health Management Network Commercial	$91.80
Rate for Payer: Ohana Health Plan Medicaid	$83.29
Rate for Payer: UnitedHealthcare Medicaid	$83.29

MG Mammo Digital Diagnostic Bilat.

Facility

$802.00

Service Code	HCPCS 77066
Hospital Charge Code	8033188
Hospital Revenue Code	401
Min. Negotiated Rate	$77.83
Max. Negotiated Rate	$777.94
Rate for Payer: AlohaCare Medicaid	$401.00
Rate for Payer: AlohaCare Medicare	$401.00
Rate for Payer: Cash Price	$521.30
Rate for Payer: Cash Price	$521.30
Rate for Payer: Devoted Health Medicare	$441.10
Rate for Payer: Hawaii Medical Service Association ABD	$77.83
Rate for Payer: Hawaii Medical Service Association Medicare	$401.00
Rate for Payer: Hawaii Medical Service Association Non-ABD	$104.42
Rate for Payer: Hawaii Western Management Group Commercial	$761.90
Rate for Payer: Health Management Network Commercial	$681.70
Rate for Payer: Humana Medicare	$401.00
Rate for Payer: Kaiser Permanente Commercial	$721.80
Rate for Payer: Kaiser Permanente Medicaid	$409.02
Rate for Payer: Kaiser Permanente Medicare	$401.00
Rate for Payer: MDX Hawaii PPO	$777.94
Rate for Payer: Ohana Health Plan Medicaid	$401.00
Rate for Payer: Ohana Health Plan Medicare	$401.00
Rate for Payer: UnitedHealthcare Medicaid	$105.44
Rate for Payer: UnitedHealthcare Medicare	$401.00
Rate for Payer: University Health Alliance Commercial	$352.89

MG Mammo Digital Diagnostic Bilat.

Facility

$802.00

Service Code	HCPCS 77066
Hospital Charge Code	8033188
Hospital Revenue Code	401
Min. Negotiated Rate	$681.70
Max. Negotiated Rate	$777.94
Rate for Payer: Cash Price	$521.30
Rate for Payer: Health Management Network Commercial	$681.70
Rate for Payer: Kaiser Permanente Commercial	$721.80
Rate for Payer: MDX Hawaii PPO	$777.94

MG Mammo Digital Diagnostic Bilat. - Report

Professional

Both

$156.00

Service Code	HCPCS 77066 26
Hospital Charge Code	8033190
Hospital Revenue Code	972
Min. Negotiated Rate	$47.19
Max. Negotiated Rate	$161.84
Rate for Payer: AlohaCare Medicaid	$105.44
Rate for Payer: AlohaCare Medicare	$47.19
Rate for Payer: Cash Price	$101.40
Rate for Payer: Cash Price	$101.40
Rate for Payer: Devoted Health Medicare	$51.91
Rate for Payer: Hawaii Medical Service Association Medicare	$47.19
Rate for Payer: Hawaii Western Management Group Commercial	$161.84
Rate for Payer: Health Management Network Commercial	$132.60
Rate for Payer: Kaiser Permanente Commercial	$56.63
Rate for Payer: Kaiser Permanente Medicaid	$56.63
Rate for Payer: Kaiser Permanente Medicare	$56.63
Rate for Payer: Ohana Health Plan Medicaid	$105.44
Rate for Payer: Ohana Health Plan Medicare	$47.19
Rate for Payer: UnitedHealthcare Medicaid	$105.44
Rate for Payer: UnitedHealthcare Medicare	$47.19

MG Mammo Digital Diagnostic Left

Facility

$576.00

Service Code	HCPCS 77065 LT
Hospital Charge Code	969801
Hospital Revenue Code	401
Min. Negotiated Rate	$64.13
Max. Negotiated Rate	$558.72
Rate for Payer: AlohaCare Medicaid	$288.00
Rate for Payer: AlohaCare Medicare	$288.00
Rate for Payer: Cash Price	$374.40
Rate for Payer: Cash Price	$374.40
Rate for Payer: Devoted Health Medicare	$316.80
Rate for Payer: Hawaii Medical Service Association ABD	$64.13
Rate for Payer: Hawaii Medical Service Association Medicare	$288.00
Rate for Payer: Hawaii Medical Service Association Non-ABD	$85.82
Rate for Payer: Hawaii Western Management Group Commercial	$547.20
Rate for Payer: Health Management Network Commercial	$489.60
Rate for Payer: Humana Medicare	$288.00
Rate for Payer: Kaiser Permanente Commercial	$518.40
Rate for Payer: Kaiser Permanente Medicaid	$293.76
Rate for Payer: Kaiser Permanente Medicare	$288.00
Rate for Payer: MDX Hawaii PPO	$558.72
Rate for Payer: Ohana Health Plan Medicaid	$288.00
Rate for Payer: Ohana Health Plan Medicare	$288.00
Rate for Payer: UnitedHealthcare Medicaid	$83.29
Rate for Payer: UnitedHealthcare Medicare	$288.00
Rate for Payer: University Health Alliance Commercial	$277.78

MG Mammo Digital Diagnostic Left

Facility

$576.00

Service Code	HCPCS 77065 LT
Hospital Charge Code	969801
Hospital Revenue Code	401
Min. Negotiated Rate	$489.60
Max. Negotiated Rate	$558.72
Rate for Payer: Cash Price	$374.40
Rate for Payer: Health Management Network Commercial	$489.60
Rate for Payer: Kaiser Permanente Commercial	$518.40
Rate for Payer: MDX Hawaii PPO	$558.72

MG Mammo Digital Diagnostic Left.

Facility

$576.00

Service Code	HCPCS 77065 LT
Hospital Charge Code	8033191
Hospital Revenue Code	401
Min. Negotiated Rate	$489.60
Max. Negotiated Rate	$558.72
Rate for Payer: Cash Price	$374.40
Rate for Payer: Health Management Network Commercial	$489.60
Rate for Payer: Kaiser Permanente Commercial	$518.40
Rate for Payer: MDX Hawaii PPO	$558.72

MG Mammo Digital Diagnostic Left.

Facility

$576.00

Service Code	HCPCS 77065 LT
Hospital Charge Code	8033191
Hospital Revenue Code	401
Min. Negotiated Rate	$64.13
Max. Negotiated Rate	$558.72
Rate for Payer: AlohaCare Medicaid	$288.00
Rate for Payer: AlohaCare Medicare	$288.00
Rate for Payer: Cash Price	$374.40
Rate for Payer: Cash Price	$374.40
Rate for Payer: Devoted Health Medicare	$316.80
Rate for Payer: Hawaii Medical Service Association ABD	$64.13
Rate for Payer: Hawaii Medical Service Association Medicare	$288.00
Rate for Payer: Hawaii Medical Service Association Non-ABD	$85.82
Rate for Payer: Hawaii Western Management Group Commercial	$547.20
Rate for Payer: Health Management Network Commercial	$489.60
Rate for Payer: Humana Medicare	$288.00
Rate for Payer: Kaiser Permanente Commercial	$518.40
Rate for Payer: Kaiser Permanente Medicaid	$293.76
Rate for Payer: Kaiser Permanente Medicare	$288.00
Rate for Payer: MDX Hawaii PPO	$558.72
Rate for Payer: Ohana Health Plan Medicaid	$288.00
Rate for Payer: Ohana Health Plan Medicare	$288.00
Rate for Payer: UnitedHealthcare Medicaid	$83.29
Rate for Payer: UnitedHealthcare Medicare	$288.00
Rate for Payer: University Health Alliance Commercial	$277.78

MG Mammo Digital Diagnostic Left. - Report

Professional

Both

$128.00

Service Code	HCPCS 77065 26,LT
Hospital Charge Code	8033193
Hospital Revenue Code	972
Min. Negotiated Rate	$83.29
Max. Negotiated Rate	$141.22
Rate for Payer: AlohaCare Medicaid	$83.29
Rate for Payer: Cash Price	$83.20
Rate for Payer: Cash Price	$83.20
Rate for Payer: Hawaii Western Management Group Commercial	$141.22
Rate for Payer: Health Management Network Commercial	$108.80
Rate for Payer: Ohana Health Plan Medicaid	$83.29
Rate for Payer: UnitedHealthcare Medicaid	$83.29

MG Mammo Digital Diagnostic Right.

Facility

$576.00

Service Code	HCPCS 77065 RT
Hospital Charge Code	8033194
Hospital Revenue Code	401
Min. Negotiated Rate	$489.60
Max. Negotiated Rate	$558.72
Rate for Payer: Cash Price	$374.40
Rate for Payer: Health Management Network Commercial	$489.60
Rate for Payer: Kaiser Permanente Commercial	$518.40
Rate for Payer: MDX Hawaii PPO	$558.72

MG Mammo Digital Diagnostic Right.

Facility

$576.00

Service Code	HCPCS 77065 RT
Hospital Charge Code	8033194
Hospital Revenue Code	401
Min. Negotiated Rate	$64.13
Max. Negotiated Rate	$558.72
Rate for Payer: AlohaCare Medicaid	$288.00
Rate for Payer: AlohaCare Medicare	$288.00
Rate for Payer: Cash Price	$374.40
Rate for Payer: Cash Price	$374.40
Rate for Payer: Devoted Health Medicare	$316.80
Rate for Payer: Hawaii Medical Service Association ABD	$64.13
Rate for Payer: Hawaii Medical Service Association Medicare	$288.00
Rate for Payer: Hawaii Medical Service Association Non-ABD	$85.82
Rate for Payer: Hawaii Western Management Group Commercial	$547.20
Rate for Payer: Health Management Network Commercial	$489.60
Rate for Payer: Humana Medicare	$288.00
Rate for Payer: Kaiser Permanente Commercial	$518.40
Rate for Payer: Kaiser Permanente Medicaid	$293.76
Rate for Payer: Kaiser Permanente Medicare	$288.00
Rate for Payer: MDX Hawaii PPO	$558.72
Rate for Payer: Ohana Health Plan Medicaid	$288.00
Rate for Payer: Ohana Health Plan Medicare	$288.00
Rate for Payer: UnitedHealthcare Medicaid	$83.29
Rate for Payer: UnitedHealthcare Medicare	$288.00
Rate for Payer: University Health Alliance Commercial	$277.78

MG Mammo Digital Diagnostic Right. - Report

Professional

Both

$102.00

Service Code	HCPCS 77065 26,RT
Hospital Charge Code	8033196
Hospital Revenue Code	972
Min. Negotiated Rate	$83.29
Max. Negotiated Rate	$141.22
Rate for Payer: AlohaCare Medicaid	$83.29
Rate for Payer: Cash Price	$66.30
Rate for Payer: Cash Price	$66.30
Rate for Payer: Hawaii Western Management Group Commercial	$141.22
Rate for Payer: Health Management Network Commercial	$86.70
Rate for Payer: Ohana Health Plan Medicaid	$83.29
Rate for Payer: UnitedHealthcare Medicaid	$83.29

MG Mammo Digital Screening Bilateral.

Facility

$464.00

Service Code	HCPCS 77067 TC
Hospital Charge Code	8033197
Hospital Revenue Code	403
Min. Negotiated Rate	$80.77
Max. Negotiated Rate	$450.08
Rate for Payer: AlohaCare Medicaid	$232.00
Rate for Payer: AlohaCare Medicare	$232.00
Rate for Payer: Cash Price	$301.60
Rate for Payer: Cash Price	$301.60
Rate for Payer: Devoted Health Medicare	$255.20
Rate for Payer: Hawaii Medical Service Association ABD	$80.77
Rate for Payer: Hawaii Medical Service Association Medicare	$232.00
Rate for Payer: Hawaii Medical Service Association Non-ABD	$106.74
Rate for Payer: Hawaii Western Management Group Commercial	$440.80
Rate for Payer: Health Management Network Commercial	$394.40
Rate for Payer: Humana Medicare	$232.00
Rate for Payer: Kaiser Permanente Commercial	$417.60
Rate for Payer: Kaiser Permanente Medicaid	$236.64
Rate for Payer: Kaiser Permanente Medicare	$232.00
Rate for Payer: MDX Hawaii PPO	$450.08
Rate for Payer: Ohana Health Plan Medicaid	$232.00
Rate for Payer: Ohana Health Plan Medicare	$232.00
Rate for Payer: UnitedHealthcare Medicaid	$85.27
Rate for Payer: UnitedHealthcare Medicare	$232.00
Rate for Payer: University Health Alliance Commercial	$214.17

MG Mammo Digital Screening Bilateral.

Facility

$464.00

Service Code	HCPCS 77067 TC
Hospital Charge Code	8033197
Hospital Revenue Code	403
Min. Negotiated Rate	$394.40
Max. Negotiated Rate	$450.08
Rate for Payer: Cash Price	$301.60
Rate for Payer: Health Management Network Commercial	$394.40
Rate for Payer: Kaiser Permanente Commercial	$417.60
Rate for Payer: MDX Hawaii PPO	$450.08

MG Mammo Digital Screening Bilateral. - Report

Professional

Both

$114.00

Service Code	HCPCS 77067 26
Hospital Charge Code	8033199
Hospital Revenue Code	972
Min. Negotiated Rate	$35.74
Max. Negotiated Rate	$156.36
Rate for Payer: AlohaCare Medicaid	$85.27
Rate for Payer: AlohaCare Medicare	$35.74
Rate for Payer: Cash Price	$74.10
Rate for Payer: Cash Price	$74.10
Rate for Payer: Devoted Health Medicare	$39.31
Rate for Payer: Hawaii Medical Service Association Medicare	$35.74
Rate for Payer: Hawaii Western Management Group Commercial	$156.36
Rate for Payer: Health Management Network Commercial	$96.90
Rate for Payer: Kaiser Permanente Commercial	$42.89
Rate for Payer: Kaiser Permanente Medicaid	$42.89
Rate for Payer: Kaiser Permanente Medicare	$42.89
Rate for Payer: Ohana Health Plan Medicaid	$85.27
Rate for Payer: Ohana Health Plan Medicare	$35.74
Rate for Payer: UnitedHealthcare Medicaid	$85.27
Rate for Payer: UnitedHealthcare Medicare	$35.74

MG Mammo Digital Screening Left.

Facility

$464.00

Service Code	HCPCS 77067 LT
Hospital Charge Code	8033200
Hospital Revenue Code	403
Min. Negotiated Rate	$80.77
Max. Negotiated Rate	$450.08
Rate for Payer: AlohaCare Medicaid	$232.00
Rate for Payer: AlohaCare Medicare	$232.00
Rate for Payer: Cash Price	$301.60
Rate for Payer: Cash Price	$301.60
Rate for Payer: Devoted Health Medicare	$255.20
Rate for Payer: Hawaii Medical Service Association ABD	$80.77
Rate for Payer: Hawaii Medical Service Association Medicare	$232.00
Rate for Payer: Hawaii Medical Service Association Non-ABD	$106.74
Rate for Payer: Hawaii Western Management Group Commercial	$440.80
Rate for Payer: Health Management Network Commercial	$394.40
Rate for Payer: Humana Medicare	$232.00
Rate for Payer: Kaiser Permanente Commercial	$417.60
Rate for Payer: Kaiser Permanente Medicaid	$236.64
Rate for Payer: Kaiser Permanente Medicare	$232.00
Rate for Payer: MDX Hawaii PPO	$450.08
Rate for Payer: Ohana Health Plan Medicaid	$232.00
Rate for Payer: Ohana Health Plan Medicare	$232.00
Rate for Payer: UnitedHealthcare Medicaid	$85.27
Rate for Payer: UnitedHealthcare Medicare	$232.00
Rate for Payer: University Health Alliance Commercial	$285.53

MG Mammo Digital Screening Left.

Facility

$464.00

Service Code	HCPCS 77067 LT
Hospital Charge Code	8033200
Hospital Revenue Code	403
Min. Negotiated Rate	$394.40
Max. Negotiated Rate	$450.08
Rate for Payer: Cash Price	$301.60
Rate for Payer: Health Management Network Commercial	$394.40
Rate for Payer: Kaiser Permanente Commercial	$417.60
Rate for Payer: MDX Hawaii PPO	$450.08

MG Mammo Digital Screening Left. - Report

Professional

Both

$128.00

Service Code	HCPCS 77067 26,52
Hospital Charge Code	8033202
Hospital Revenue Code	972
Min. Negotiated Rate	$85.27
Max. Negotiated Rate	$156.36
Rate for Payer: AlohaCare Medicaid	$85.27
Rate for Payer: Cash Price	$83.20
Rate for Payer: Cash Price	$83.20
Rate for Payer: Hawaii Western Management Group Commercial	$156.36
Rate for Payer: Health Management Network Commercial	$108.80
Rate for Payer: Ohana Health Plan Medicaid	$85.27
Rate for Payer: UnitedHealthcare Medicaid	$85.27

MG Mammo Digital Screening Right.

Facility

$464.00

Service Code	HCPCS 77067 TC
Hospital Charge Code	8033203
Hospital Revenue Code	403
Min. Negotiated Rate	$394.40
Max. Negotiated Rate	$450.08
Rate for Payer: Cash Price	$301.60
Rate for Payer: Health Management Network Commercial	$394.40
Rate for Payer: Kaiser Permanente Commercial	$417.60
Rate for Payer: MDX Hawaii PPO	$450.08

MG Mammo Digital Screening Right.

Facility

$464.00

Service Code	HCPCS 77067 TC
Hospital Charge Code	8033203
Hospital Revenue Code	403
Min. Negotiated Rate	$80.77
Max. Negotiated Rate	$450.08
Rate for Payer: AlohaCare Medicaid	$232.00
Rate for Payer: AlohaCare Medicare	$232.00
Rate for Payer: Cash Price	$301.60
Rate for Payer: Cash Price	$301.60
Rate for Payer: Devoted Health Medicare	$255.20
Rate for Payer: Hawaii Medical Service Association ABD	$80.77
Rate for Payer: Hawaii Medical Service Association Medicare	$232.00
Rate for Payer: Hawaii Medical Service Association Non-ABD	$106.74
Rate for Payer: Hawaii Western Management Group Commercial	$440.80
Rate for Payer: Health Management Network Commercial	$394.40
Rate for Payer: Humana Medicare	$232.00
Rate for Payer: Kaiser Permanente Commercial	$417.60
Rate for Payer: Kaiser Permanente Medicaid	$236.64
Rate for Payer: Kaiser Permanente Medicare	$232.00
Rate for Payer: MDX Hawaii PPO	$450.08
Rate for Payer: Ohana Health Plan Medicaid	$232.00
Rate for Payer: Ohana Health Plan Medicare	$232.00
Rate for Payer: UnitedHealthcare Medicaid	$85.27
Rate for Payer: UnitedHealthcare Medicare	$232.00
Rate for Payer: University Health Alliance Commercial	$214.17

MG Mammo Digital Screening Right. - Report

Professional

Both

$128.00

Service Code	HCPCS 77067 26
Hospital Charge Code	8033205
Hospital Revenue Code	972
Min. Negotiated Rate	$35.74
Max. Negotiated Rate	$156.36
Rate for Payer: AlohaCare Medicaid	$85.27
Rate for Payer: AlohaCare Medicare	$35.74
Rate for Payer: Cash Price	$83.20
Rate for Payer: Cash Price	$83.20
Rate for Payer: Devoted Health Medicare	$39.31
Rate for Payer: Hawaii Medical Service Association Medicare	$35.74
Rate for Payer: Hawaii Western Management Group Commercial	$156.36
Rate for Payer: Health Management Network Commercial	$108.80
Rate for Payer: Kaiser Permanente Commercial	$42.89
Rate for Payer: Kaiser Permanente Medicaid	$42.89
Rate for Payer: Kaiser Permanente Medicare	$42.89
Rate for Payer: Ohana Health Plan Medicaid	$85.27
Rate for Payer: Ohana Health Plan Medicare	$35.74
Rate for Payer: UnitedHealthcare Medicaid	$85.27
Rate for Payer: UnitedHealthcare Medicare	$35.74

Know your out-of-pocket cost for care.

All Charges