Samuel Mahelona Memorial Hospital

All Charges

Charge

Type

Setting

Price

NEEDLE 18G BONE MARROW

Facility

$66.00

Hospital Charge Code	8266676
Hospital Revenue Code	272
Min. Negotiated Rate	$33.00
Max. Negotiated Rate	$64.02
Rate for Payer: AlohaCare Medicaid	$33.00
Rate for Payer: AlohaCare Medicare	$33.00
Rate for Payer: Cash Price	$42.90
Rate for Payer: Devoted Health Medicare	$36.30
Rate for Payer: Hawaii Medical Service Association Medicare	$33.00
Rate for Payer: Hawaii Western Management Group Commercial	$62.70
Rate for Payer: Health Management Network Commercial	$56.10
Rate for Payer: Humana Medicare	$33.00
Rate for Payer: Kaiser Permanente Commercial	$59.40
Rate for Payer: Kaiser Permanente Medicaid	$33.66
Rate for Payer: Kaiser Permanente Medicare	$33.00
Rate for Payer: MDX Hawaii PPO	$64.02
Rate for Payer: Ohana Health Plan Medicaid	$33.00
Rate for Payer: Ohana Health Plan Medicare	$33.00
Rate for Payer: UnitedHealthcare Medicare	$33.00
Rate for Payer: University Health Alliance Commercial	$48.11

NEEDLE 18G BONE MARROW

Facility

$66.00

Hospital Charge Code	8266676
Hospital Revenue Code	272
Min. Negotiated Rate	$56.10
Max. Negotiated Rate	$64.02
Rate for Payer: Cash Price	$42.90
Rate for Payer: Health Management Network Commercial	$56.10
Rate for Payer: Kaiser Permanente Commercial	$59.40
Rate for Payer: MDX Hawaii PPO	$64.02

NEEDLE BREAST WIRE LOCALIZATION 20G X 5.7CM (US)

Facility

$165.00

Service Code	HCPCS A4648
Hospital Charge Code	8880959
Hospital Revenue Code	278
Min. Negotiated Rate	$82.50
Max. Negotiated Rate	$160.05
Rate for Payer: AlohaCare Medicaid	$82.50
Rate for Payer: AlohaCare Medicare	$82.50
Rate for Payer: Cash Price	$107.25
Rate for Payer: Devoted Health Medicare	$90.75
Rate for Payer: Hawaii Medical Service Association Medicare	$82.50
Rate for Payer: Hawaii Western Management Group Commercial	$115.50
Rate for Payer: Health Management Network Commercial	$140.25
Rate for Payer: Humana Medicare	$82.50
Rate for Payer: Kaiser Permanente Commercial	$148.50
Rate for Payer: Kaiser Permanente Medicaid	$84.15
Rate for Payer: Kaiser Permanente Medicare	$82.50
Rate for Payer: MDX Hawaii PPO	$160.05
Rate for Payer: Ohana Health Plan Medicaid	$82.50
Rate for Payer: Ohana Health Plan Medicare	$82.50
Rate for Payer: UnitedHealthcare Medicare	$82.50
Rate for Payer: University Health Alliance Commercial	$92.40

NEEDLE BREAST WIRE LOCALIZATION 20G X 5.7CM (US)

Facility

$165.00

Service Code	HCPCS A4648
Hospital Charge Code	8880959
Hospital Revenue Code	278
Min. Negotiated Rate	$92.40
Max. Negotiated Rate	$160.05
Rate for Payer: Cash Price	$107.25
Rate for Payer: Hawaii Western Management Group Commercial	$115.50
Rate for Payer: Health Management Network Commercial	$140.25
Rate for Payer: Kaiser Permanente Commercial	$148.50
Rate for Payer: MDX Hawaii PPO	$160.05
Rate for Payer: University Health Alliance Commercial	$92.40

NEEDLE BREAST WIRE LOCALIZATION 20G X 5.7CM (XR/MAMMO)

Facility

$115.00

Service Code	HCPCS A4648
Hospital Charge Code	8880960
Hospital Revenue Code	278
Min. Negotiated Rate	$64.40
Max. Negotiated Rate	$111.55
Rate for Payer: Cash Price	$74.75
Rate for Payer: Hawaii Western Management Group Commercial	$80.50
Rate for Payer: Health Management Network Commercial	$97.75
Rate for Payer: Kaiser Permanente Commercial	$103.50
Rate for Payer: MDX Hawaii PPO	$111.55
Rate for Payer: University Health Alliance Commercial	$64.40

NEEDLE BREAST WIRE LOCALIZATION 20G X 5.7CM (XR/MAMMO)

Facility

$115.00

Service Code	HCPCS A4648
Hospital Charge Code	8880960
Hospital Revenue Code	278
Min. Negotiated Rate	$57.50
Max. Negotiated Rate	$111.55
Rate for Payer: AlohaCare Medicaid	$57.50
Rate for Payer: AlohaCare Medicare	$57.50
Rate for Payer: Cash Price	$74.75
Rate for Payer: Devoted Health Medicare	$63.25
Rate for Payer: Hawaii Medical Service Association Medicare	$57.50
Rate for Payer: Hawaii Western Management Group Commercial	$80.50
Rate for Payer: Health Management Network Commercial	$97.75
Rate for Payer: Humana Medicare	$57.50
Rate for Payer: Kaiser Permanente Commercial	$103.50
Rate for Payer: Kaiser Permanente Medicaid	$58.65
Rate for Payer: Kaiser Permanente Medicare	$57.50
Rate for Payer: MDX Hawaii PPO	$111.55
Rate for Payer: Ohana Health Plan Medicaid	$57.50
Rate for Payer: Ohana Health Plan Medicare	$57.50
Rate for Payer: UnitedHealthcare Medicare	$57.50
Rate for Payer: University Health Alliance Commercial	$64.40

NEEDLE COAXIAL TENMO BX SYS 18GX15CM (CT)

Facility

$263.00

Hospital Charge Code	8886978
Hospital Revenue Code	272
Min. Negotiated Rate	$223.55
Max. Negotiated Rate	$255.11
Rate for Payer: Cash Price	$170.95
Rate for Payer: Health Management Network Commercial	$223.55
Rate for Payer: Kaiser Permanente Commercial	$236.70
Rate for Payer: MDX Hawaii PPO	$255.11

NEEDLE COAXIAL TENMO BX SYS 18GX15CM (CT)

Facility

$263.00

Hospital Charge Code	8886978
Hospital Revenue Code	272
Min. Negotiated Rate	$131.50
Max. Negotiated Rate	$255.11
Rate for Payer: AlohaCare Medicaid	$131.50
Rate for Payer: AlohaCare Medicare	$131.50
Rate for Payer: Cash Price	$170.95
Rate for Payer: Devoted Health Medicare	$144.65
Rate for Payer: Hawaii Medical Service Association Medicare	$131.50
Rate for Payer: Hawaii Western Management Group Commercial	$249.85
Rate for Payer: Health Management Network Commercial	$223.55
Rate for Payer: Humana Medicare	$131.50
Rate for Payer: Kaiser Permanente Commercial	$236.70
Rate for Payer: Kaiser Permanente Medicaid	$134.13
Rate for Payer: Kaiser Permanente Medicare	$131.50
Rate for Payer: MDX Hawaii PPO	$255.11
Rate for Payer: Ohana Health Plan Medicaid	$131.50
Rate for Payer: Ohana Health Plan Medicare	$131.50
Rate for Payer: UnitedHealthcare Medicare	$131.50
Rate for Payer: University Health Alliance Commercial	$191.70

NEEDLE COAXIAL TENMO BX SYS 18GX15CM (US)

Facility

$263.00

Hospital Charge Code	8886977
Hospital Revenue Code	272
Min. Negotiated Rate	$131.50
Max. Negotiated Rate	$255.11
Rate for Payer: AlohaCare Medicaid	$131.50
Rate for Payer: AlohaCare Medicare	$131.50
Rate for Payer: Cash Price	$170.95
Rate for Payer: Devoted Health Medicare	$144.65
Rate for Payer: Hawaii Medical Service Association Medicare	$131.50
Rate for Payer: Hawaii Western Management Group Commercial	$249.85
Rate for Payer: Health Management Network Commercial	$223.55
Rate for Payer: Humana Medicare	$131.50
Rate for Payer: Kaiser Permanente Commercial	$236.70
Rate for Payer: Kaiser Permanente Medicaid	$134.13
Rate for Payer: Kaiser Permanente Medicare	$131.50
Rate for Payer: MDX Hawaii PPO	$255.11
Rate for Payer: Ohana Health Plan Medicaid	$131.50
Rate for Payer: Ohana Health Plan Medicare	$131.50
Rate for Payer: UnitedHealthcare Medicare	$131.50
Rate for Payer: University Health Alliance Commercial	$191.70

NEEDLE COAXIAL TENMO BX SYS 18GX15CM (US)

Facility

$263.00

Hospital Charge Code	8886977
Hospital Revenue Code	272
Min. Negotiated Rate	$223.55
Max. Negotiated Rate	$255.11
Rate for Payer: Cash Price	$170.95
Rate for Payer: Health Management Network Commercial	$223.55
Rate for Payer: Kaiser Permanente Commercial	$236.70
Rate for Payer: MDX Hawaii PPO	$255.11

NEEDLE COAXIAL TENMO BX SYS 18GX15CM (XR/MAMMO)

Facility

$263.00

Hospital Charge Code	8886979
Hospital Revenue Code	272
Min. Negotiated Rate	$131.50
Max. Negotiated Rate	$255.11
Rate for Payer: AlohaCare Medicaid	$131.50
Rate for Payer: AlohaCare Medicare	$131.50
Rate for Payer: Cash Price	$170.95
Rate for Payer: Devoted Health Medicare	$144.65
Rate for Payer: Hawaii Medical Service Association Medicare	$131.50
Rate for Payer: Hawaii Western Management Group Commercial	$249.85
Rate for Payer: Health Management Network Commercial	$223.55
Rate for Payer: Humana Medicare	$131.50
Rate for Payer: Kaiser Permanente Commercial	$236.70
Rate for Payer: Kaiser Permanente Medicaid	$134.13
Rate for Payer: Kaiser Permanente Medicare	$131.50
Rate for Payer: MDX Hawaii PPO	$255.11
Rate for Payer: Ohana Health Plan Medicaid	$131.50
Rate for Payer: Ohana Health Plan Medicare	$131.50
Rate for Payer: UnitedHealthcare Medicare	$131.50
Rate for Payer: University Health Alliance Commercial	$191.70

NEEDLE COAXIAL TENMO BX SYS 18GX15CM (XR/MAMMO)

Facility

$263.00

Hospital Charge Code	8886979
Hospital Revenue Code	272
Min. Negotiated Rate	$223.55
Max. Negotiated Rate	$255.11
Rate for Payer: Cash Price	$170.95
Rate for Payer: Health Management Network Commercial	$223.55
Rate for Payer: Kaiser Permanente Commercial	$236.70
Rate for Payer: MDX Hawaii PPO	$255.11

NEEDLE FRANSEEN LUNG BX DFBN-22-5.0-U 22G/5CM (CT)

Facility

$236.00

Hospital Charge Code	8886985
Hospital Revenue Code	272
Min. Negotiated Rate	$200.60
Max. Negotiated Rate	$228.92
Rate for Payer: Cash Price	$153.40
Rate for Payer: Health Management Network Commercial	$200.60
Rate for Payer: Kaiser Permanente Commercial	$212.40
Rate for Payer: MDX Hawaii PPO	$228.92

NEEDLE FRANSEEN LUNG BX DFBN-22-5.0-U 22G/5CM (CT)

Facility

$236.00

Hospital Charge Code	8886985
Hospital Revenue Code	272
Min. Negotiated Rate	$118.00
Max. Negotiated Rate	$228.92
Rate for Payer: AlohaCare Medicaid	$118.00
Rate for Payer: AlohaCare Medicare	$118.00
Rate for Payer: Cash Price	$153.40
Rate for Payer: Devoted Health Medicare	$129.80
Rate for Payer: Hawaii Medical Service Association Medicare	$118.00
Rate for Payer: Hawaii Western Management Group Commercial	$224.20
Rate for Payer: Health Management Network Commercial	$200.60
Rate for Payer: Humana Medicare	$118.00
Rate for Payer: Kaiser Permanente Commercial	$212.40
Rate for Payer: Kaiser Permanente Medicaid	$120.36
Rate for Payer: Kaiser Permanente Medicare	$118.00
Rate for Payer: MDX Hawaii PPO	$228.92
Rate for Payer: Ohana Health Plan Medicaid	$118.00
Rate for Payer: Ohana Health Plan Medicare	$118.00
Rate for Payer: UnitedHealthcare Medicare	$118.00
Rate for Payer: University Health Alliance Commercial	$172.02

NEEDLE FRANSEEN LUNG BX DFBN-22-5.0-U 22G/5CM (US)

Facility

$236.00

Hospital Charge Code	8886984
Hospital Revenue Code	272
Min. Negotiated Rate	$200.60
Max. Negotiated Rate	$228.92
Rate for Payer: Cash Price	$153.40
Rate for Payer: Health Management Network Commercial	$200.60
Rate for Payer: Kaiser Permanente Commercial	$212.40
Rate for Payer: MDX Hawaii PPO	$228.92

NEEDLE FRANSEEN LUNG BX DFBN-22-5.0-U 22G/5CM (US)

Facility

$236.00

Hospital Charge Code	8886984
Hospital Revenue Code	272
Min. Negotiated Rate	$118.00
Max. Negotiated Rate	$228.92
Rate for Payer: AlohaCare Medicaid	$118.00
Rate for Payer: AlohaCare Medicare	$118.00
Rate for Payer: Cash Price	$153.40
Rate for Payer: Devoted Health Medicare	$129.80
Rate for Payer: Hawaii Medical Service Association Medicare	$118.00
Rate for Payer: Hawaii Western Management Group Commercial	$224.20
Rate for Payer: Health Management Network Commercial	$200.60
Rate for Payer: Humana Medicare	$118.00
Rate for Payer: Kaiser Permanente Commercial	$212.40
Rate for Payer: Kaiser Permanente Medicaid	$120.36
Rate for Payer: Kaiser Permanente Medicare	$118.00
Rate for Payer: MDX Hawaii PPO	$228.92
Rate for Payer: Ohana Health Plan Medicaid	$118.00
Rate for Payer: Ohana Health Plan Medicare	$118.00
Rate for Payer: UnitedHealthcare Medicare	$118.00
Rate for Payer: University Health Alliance Commercial	$172.02

NEEDLE FRANSEEN LUNG BX DFBN-22-5.0-U 22G/5CM (XR/MAMMO)

Facility

$232.00

Hospital Charge Code	8886986
Hospital Revenue Code	272
Min. Negotiated Rate	$116.00
Max. Negotiated Rate	$225.04
Rate for Payer: AlohaCare Medicaid	$116.00
Rate for Payer: AlohaCare Medicare	$116.00
Rate for Payer: Cash Price	$150.80
Rate for Payer: Devoted Health Medicare	$127.60
Rate for Payer: Hawaii Medical Service Association Medicare	$116.00
Rate for Payer: Hawaii Western Management Group Commercial	$220.40
Rate for Payer: Health Management Network Commercial	$197.20
Rate for Payer: Humana Medicare	$116.00
Rate for Payer: Kaiser Permanente Commercial	$208.80
Rate for Payer: Kaiser Permanente Medicaid	$118.32
Rate for Payer: Kaiser Permanente Medicare	$116.00
Rate for Payer: MDX Hawaii PPO	$225.04
Rate for Payer: Ohana Health Plan Medicaid	$116.00
Rate for Payer: Ohana Health Plan Medicare	$116.00
Rate for Payer: UnitedHealthcare Medicare	$116.00
Rate for Payer: University Health Alliance Commercial	$169.10

NEEDLE FRANSEEN LUNG BX DFBN-22-5.0-U 22G/5CM (XR/MAMMO)

Facility

$232.00

Hospital Charge Code	8886986
Hospital Revenue Code	272
Min. Negotiated Rate	$197.20
Max. Negotiated Rate	$225.04
Rate for Payer: Cash Price	$150.80
Rate for Payer: Health Management Network Commercial	$197.20
Rate for Payer: Kaiser Permanente Commercial	$208.80
Rate for Payer: MDX Hawaii PPO	$225.04

NEEDLE GUIDES FOR EVIVA 9G

Facility

$73.00

Hospital Charge Code	12925599
Hospital Revenue Code	272
Min. Negotiated Rate	$36.50
Max. Negotiated Rate	$70.81
Rate for Payer: AlohaCare Medicaid	$36.50
Rate for Payer: AlohaCare Medicare	$36.50
Rate for Payer: Cash Price	$47.45
Rate for Payer: Devoted Health Medicare	$40.15
Rate for Payer: Hawaii Medical Service Association Medicare	$36.50
Rate for Payer: Hawaii Western Management Group Commercial	$69.35
Rate for Payer: Health Management Network Commercial	$62.05
Rate for Payer: Humana Medicare	$36.50
Rate for Payer: Kaiser Permanente Commercial	$65.70
Rate for Payer: Kaiser Permanente Medicaid	$37.23
Rate for Payer: Kaiser Permanente Medicare	$36.50
Rate for Payer: MDX Hawaii PPO	$70.81
Rate for Payer: Ohana Health Plan Medicaid	$36.50
Rate for Payer: Ohana Health Plan Medicare	$36.50
Rate for Payer: UnitedHealthcare Medicare	$36.50
Rate for Payer: University Health Alliance Commercial	$53.21

NEEDLE GUIDES FOR EVIVA 9G

Facility

$73.00

Hospital Charge Code	12925599
Hospital Revenue Code	272
Min. Negotiated Rate	$62.05
Max. Negotiated Rate	$70.81
Rate for Payer: Cash Price	$47.45
Rate for Payer: Health Management Network Commercial	$62.05
Rate for Payer: Kaiser Permanente Commercial	$65.70
Rate for Payer: MDX Hawaii PPO	$70.81

NEEDLE HUBER 19G X 1 W/EXT SET

Facility

$43.00

Hospital Charge Code	8266731
Hospital Revenue Code	272
Min. Negotiated Rate	$21.50
Max. Negotiated Rate	$41.71
Rate for Payer: AlohaCare Medicaid	$21.50
Rate for Payer: AlohaCare Medicare	$21.50
Rate for Payer: Cash Price	$27.95
Rate for Payer: Devoted Health Medicare	$23.65
Rate for Payer: Hawaii Medical Service Association Medicare	$21.50
Rate for Payer: Hawaii Western Management Group Commercial	$40.85
Rate for Payer: Health Management Network Commercial	$36.55
Rate for Payer: Humana Medicare	$21.50
Rate for Payer: Kaiser Permanente Commercial	$38.70
Rate for Payer: Kaiser Permanente Medicaid	$21.93
Rate for Payer: Kaiser Permanente Medicare	$21.50
Rate for Payer: MDX Hawaii PPO	$41.71
Rate for Payer: Ohana Health Plan Medicaid	$21.50
Rate for Payer: Ohana Health Plan Medicare	$21.50
Rate for Payer: UnitedHealthcare Medicare	$21.50
Rate for Payer: University Health Alliance Commercial	$31.34

NEEDLE HUBER 19G X 1 W/EXT SET

Facility

$43.00

Hospital Charge Code	8266731
Hospital Revenue Code	272
Min. Negotiated Rate	$36.55
Max. Negotiated Rate	$41.71
Rate for Payer: Cash Price	$27.95
Rate for Payer: Health Management Network Commercial	$36.55
Rate for Payer: Kaiser Permanente Commercial	$38.70
Rate for Payer: MDX Hawaii PPO	$41.71

NEEDLE HUBER 20G X 1.5 W/EXT SET

Facility

$54.00

Hospital Charge Code	8266732
Hospital Revenue Code	272
Min. Negotiated Rate	$27.00
Max. Negotiated Rate	$52.38
Rate for Payer: AlohaCare Medicaid	$27.00
Rate for Payer: AlohaCare Medicare	$27.00
Rate for Payer: Cash Price	$35.10
Rate for Payer: Devoted Health Medicare	$29.70
Rate for Payer: Hawaii Medical Service Association Medicare	$27.00
Rate for Payer: Hawaii Western Management Group Commercial	$51.30
Rate for Payer: Health Management Network Commercial	$45.90
Rate for Payer: Humana Medicare	$27.00
Rate for Payer: Kaiser Permanente Commercial	$48.60
Rate for Payer: Kaiser Permanente Medicaid	$27.54
Rate for Payer: Kaiser Permanente Medicare	$27.00
Rate for Payer: MDX Hawaii PPO	$52.38
Rate for Payer: Ohana Health Plan Medicaid	$27.00
Rate for Payer: Ohana Health Plan Medicare	$27.00
Rate for Payer: UnitedHealthcare Medicare	$27.00
Rate for Payer: University Health Alliance Commercial	$39.36

NEEDLE HUBER 20G X 1.5 W/EXT SET

Facility

$54.00

Hospital Charge Code	8266732
Hospital Revenue Code	272
Min. Negotiated Rate	$45.90
Max. Negotiated Rate	$52.38
Rate for Payer: Cash Price	$35.10
Rate for Payer: Health Management Network Commercial	$45.90
Rate for Payer: Kaiser Permanente Commercial	$48.60
Rate for Payer: MDX Hawaii PPO	$52.38

NEEDLE HUBER 20G X 1 W/EXT SET

Facility

$42.00

Hospital Charge Code	8266742
Hospital Revenue Code	272
Min. Negotiated Rate	$35.70
Max. Negotiated Rate	$40.74
Rate for Payer: Cash Price	$27.30
Rate for Payer: Health Management Network Commercial	$35.70
Rate for Payer: Kaiser Permanente Commercial	$37.80
Rate for Payer: MDX Hawaii PPO	$40.74

Know your out-of-pocket cost for care.

All Charges