Samuel Mahelona Memorial Hospital

All Charges

Charge

Type

Setting

Price

TRAY 20G 10CM POWERGLIDE

Facility

$424.00

Service Code	HCPCS C1751
Hospital Charge Code	8266278
Hospital Revenue Code	272
Min. Negotiated Rate	$212.00
Max. Negotiated Rate	$411.28
Rate for Payer: AlohaCare Medicaid	$212.00
Rate for Payer: AlohaCare Medicare	$212.00
Rate for Payer: Cash Price	$275.60
Rate for Payer: Devoted Health Medicare	$233.20
Rate for Payer: Hawaii Medical Service Association Medicare	$212.00
Rate for Payer: Hawaii Western Management Group Commercial	$402.80
Rate for Payer: Health Management Network Commercial	$360.40
Rate for Payer: Humana Medicare	$212.00
Rate for Payer: Kaiser Permanente Commercial	$381.60
Rate for Payer: Kaiser Permanente Medicaid	$216.24
Rate for Payer: Kaiser Permanente Medicare	$212.00
Rate for Payer: MDX Hawaii PPO	$411.28
Rate for Payer: Ohana Health Plan Medicaid	$212.00
Rate for Payer: Ohana Health Plan Medicare	$212.00
Rate for Payer: UnitedHealthcare Medicare	$212.00
Rate for Payer: University Health Alliance Commercial	$309.05

TRAY CATHETER FOLEY 14FR

Facility

$98.00

Hospital Charge Code	8266282
Hospital Revenue Code	272
Min. Negotiated Rate	$49.00
Max. Negotiated Rate	$95.06
Rate for Payer: AlohaCare Medicaid	$49.00
Rate for Payer: AlohaCare Medicare	$49.00
Rate for Payer: Cash Price	$63.70
Rate for Payer: Devoted Health Medicare	$53.90
Rate for Payer: Hawaii Medical Service Association Medicare	$49.00
Rate for Payer: Hawaii Western Management Group Commercial	$93.10
Rate for Payer: Health Management Network Commercial	$83.30
Rate for Payer: Humana Medicare	$49.00
Rate for Payer: Kaiser Permanente Commercial	$88.20
Rate for Payer: Kaiser Permanente Medicaid	$49.98
Rate for Payer: Kaiser Permanente Medicare	$49.00
Rate for Payer: MDX Hawaii PPO	$95.06
Rate for Payer: Ohana Health Plan Medicaid	$49.00
Rate for Payer: Ohana Health Plan Medicare	$49.00
Rate for Payer: UnitedHealthcare Medicare	$49.00
Rate for Payer: University Health Alliance Commercial	$71.43

TRAY CATHETER FOLEY 14FR

Facility

$98.00

Hospital Charge Code	8266282
Hospital Revenue Code	272
Min. Negotiated Rate	$83.30
Max. Negotiated Rate	$95.06
Rate for Payer: Cash Price	$63.70
Rate for Payer: Health Management Network Commercial	$83.30
Rate for Payer: Kaiser Permanente Commercial	$88.20
Rate for Payer: MDX Hawaii PPO	$95.06

TRAY CATHETER FOLEY 16FR

Facility

$128.00

Hospital Charge Code	8266283
Hospital Revenue Code	272
Min. Negotiated Rate	$108.80
Max. Negotiated Rate	$124.16
Rate for Payer: Cash Price	$83.20
Rate for Payer: Health Management Network Commercial	$108.80
Rate for Payer: Kaiser Permanente Commercial	$115.20
Rate for Payer: MDX Hawaii PPO	$124.16

TRAY CATHETER FOLEY 16FR

Facility

$128.00

Hospital Charge Code	8266283
Hospital Revenue Code	272
Min. Negotiated Rate	$64.00
Max. Negotiated Rate	$124.16
Rate for Payer: AlohaCare Medicaid	$64.00
Rate for Payer: AlohaCare Medicare	$64.00
Rate for Payer: Cash Price	$83.20
Rate for Payer: Devoted Health Medicare	$70.40
Rate for Payer: Hawaii Medical Service Association Medicare	$64.00
Rate for Payer: Hawaii Western Management Group Commercial	$121.60
Rate for Payer: Health Management Network Commercial	$108.80
Rate for Payer: Humana Medicare	$64.00
Rate for Payer: Kaiser Permanente Commercial	$115.20
Rate for Payer: Kaiser Permanente Medicaid	$65.28
Rate for Payer: Kaiser Permanente Medicare	$64.00
Rate for Payer: MDX Hawaii PPO	$124.16
Rate for Payer: Ohana Health Plan Medicaid	$64.00
Rate for Payer: Ohana Health Plan Medicare	$64.00
Rate for Payer: UnitedHealthcare Medicare	$64.00
Rate for Payer: University Health Alliance Commercial	$93.30

TRAY EPIDURAL 17G 3 1/2

Facility

$201.00

Hospital Charge Code	9818956
Hospital Revenue Code	272
Min. Negotiated Rate	$170.85
Max. Negotiated Rate	$194.97
Rate for Payer: Cash Price	$130.65
Rate for Payer: Health Management Network Commercial	$170.85
Rate for Payer: Kaiser Permanente Commercial	$180.90
Rate for Payer: MDX Hawaii PPO	$194.97

TRAY EPIDURAL 17G 3 1/2

Facility

$201.00

Hospital Charge Code	9818956
Hospital Revenue Code	272
Min. Negotiated Rate	$100.50
Max. Negotiated Rate	$194.97
Rate for Payer: AlohaCare Medicaid	$100.50
Rate for Payer: AlohaCare Medicare	$100.50
Rate for Payer: Cash Price	$130.65
Rate for Payer: Devoted Health Medicare	$110.55
Rate for Payer: Hawaii Medical Service Association Medicare	$100.50
Rate for Payer: Hawaii Western Management Group Commercial	$190.95
Rate for Payer: Health Management Network Commercial	$170.85
Rate for Payer: Humana Medicare	$100.50
Rate for Payer: Kaiser Permanente Commercial	$180.90
Rate for Payer: Kaiser Permanente Medicaid	$102.51
Rate for Payer: Kaiser Permanente Medicare	$100.50
Rate for Payer: MDX Hawaii PPO	$194.97
Rate for Payer: Ohana Health Plan Medicaid	$100.50
Rate for Payer: Ohana Health Plan Medicare	$100.50
Rate for Payer: UnitedHealthcare Medicare	$100.50
Rate for Payer: University Health Alliance Commercial	$146.51

TRAY EPIDURAL ANESTHESIA PERIFIX FX CONTINUOUS

Facility

$160.00

Hospital Charge Code	9078108
Hospital Revenue Code	272
Min. Negotiated Rate	$80.00
Max. Negotiated Rate	$155.20
Rate for Payer: AlohaCare Medicaid	$80.00
Rate for Payer: AlohaCare Medicare	$80.00
Rate for Payer: Cash Price	$104.00
Rate for Payer: Devoted Health Medicare	$88.00
Rate for Payer: Hawaii Medical Service Association Medicare	$80.00
Rate for Payer: Hawaii Western Management Group Commercial	$152.00
Rate for Payer: Health Management Network Commercial	$136.00
Rate for Payer: Humana Medicare	$80.00
Rate for Payer: Kaiser Permanente Commercial	$144.00
Rate for Payer: Kaiser Permanente Medicaid	$81.60
Rate for Payer: Kaiser Permanente Medicare	$80.00
Rate for Payer: MDX Hawaii PPO	$155.20
Rate for Payer: Ohana Health Plan Medicaid	$80.00
Rate for Payer: Ohana Health Plan Medicare	$80.00
Rate for Payer: UnitedHealthcare Medicare	$80.00
Rate for Payer: University Health Alliance Commercial	$116.62

TRAY EPIDURAL ANESTHESIA PERIFIX FX CONTINUOUS

Facility

$160.00

Hospital Charge Code	9078108
Hospital Revenue Code	272
Min. Negotiated Rate	$136.00
Max. Negotiated Rate	$155.20
Rate for Payer: Cash Price	$104.00
Rate for Payer: Health Management Network Commercial	$136.00
Rate for Payer: Kaiser Permanente Commercial	$144.00
Rate for Payer: MDX Hawaii PPO	$155.20

TRAY IRRIGATION WITH 60ML PISTON SYRINGE

Facility

$10.00

Hospital Charge Code	8266434
Hospital Revenue Code	272
Min. Negotiated Rate	$5.00
Max. Negotiated Rate	$9.70
Rate for Payer: AlohaCare Medicaid	$5.00
Rate for Payer: AlohaCare Medicare	$5.00
Rate for Payer: Cash Price	$6.50
Rate for Payer: Devoted Health Medicare	$5.50
Rate for Payer: Hawaii Medical Service Association Medicare	$5.00
Rate for Payer: Hawaii Western Management Group Commercial	$9.50
Rate for Payer: Health Management Network Commercial	$8.50
Rate for Payer: Humana Medicare	$5.00
Rate for Payer: Kaiser Permanente Commercial	$9.00
Rate for Payer: Kaiser Permanente Medicaid	$5.10
Rate for Payer: Kaiser Permanente Medicare	$5.00
Rate for Payer: MDX Hawaii PPO	$9.70
Rate for Payer: Ohana Health Plan Medicaid	$5.00
Rate for Payer: Ohana Health Plan Medicare	$5.00
Rate for Payer: UnitedHealthcare Medicare	$5.00
Rate for Payer: University Health Alliance Commercial	$7.29

TRAY IRRIGATION WITH 60ML PISTON SYRINGE

Facility

$10.00

Hospital Charge Code	8266434
Hospital Revenue Code	272
Min. Negotiated Rate	$8.50
Max. Negotiated Rate	$9.70
Rate for Payer: Cash Price	$6.50
Rate for Payer: Health Management Network Commercial	$8.50
Rate for Payer: Kaiser Permanente Commercial	$9.00
Rate for Payer: MDX Hawaii PPO	$9.70

TRAY LACERATION

Facility

$33.00

Hospital Charge Code	8266428
Hospital Revenue Code	272
Min. Negotiated Rate	$16.50
Max. Negotiated Rate	$32.01
Rate for Payer: AlohaCare Medicaid	$16.50
Rate for Payer: AlohaCare Medicare	$16.50
Rate for Payer: Cash Price	$21.45
Rate for Payer: Devoted Health Medicare	$18.15
Rate for Payer: Hawaii Medical Service Association Medicare	$16.50
Rate for Payer: Hawaii Western Management Group Commercial	$31.35
Rate for Payer: Health Management Network Commercial	$28.05
Rate for Payer: Humana Medicare	$16.50
Rate for Payer: Kaiser Permanente Commercial	$29.70
Rate for Payer: Kaiser Permanente Medicaid	$16.83
Rate for Payer: Kaiser Permanente Medicare	$16.50
Rate for Payer: MDX Hawaii PPO	$32.01
Rate for Payer: Ohana Health Plan Medicaid	$16.50
Rate for Payer: Ohana Health Plan Medicare	$16.50
Rate for Payer: UnitedHealthcare Medicare	$16.50
Rate for Payer: University Health Alliance Commercial	$24.05

TRAY LACERATION

Facility

$33.00

Hospital Charge Code	8266428
Hospital Revenue Code	272
Min. Negotiated Rate	$28.05
Max. Negotiated Rate	$32.01
Rate for Payer: Cash Price	$21.45
Rate for Payer: Health Management Network Commercial	$28.05
Rate for Payer: Kaiser Permanente Commercial	$29.70
Rate for Payer: MDX Hawaii PPO	$32.01

TRAY LUMBAR PUNCTURE ADULT

Facility

$101.00

Hospital Charge Code	8266521
Hospital Revenue Code	272
Min. Negotiated Rate	$85.85
Max. Negotiated Rate	$97.97
Rate for Payer: Cash Price	$65.65
Rate for Payer: Health Management Network Commercial	$85.85
Rate for Payer: Kaiser Permanente Commercial	$90.90
Rate for Payer: MDX Hawaii PPO	$97.97

TRAY LUMBAR PUNCTURE ADULT

Facility

$101.00

Hospital Charge Code	8266521
Hospital Revenue Code	272
Min. Negotiated Rate	$50.50
Max. Negotiated Rate	$97.97
Rate for Payer: AlohaCare Medicaid	$50.50
Rate for Payer: AlohaCare Medicare	$50.50
Rate for Payer: Cash Price	$65.65
Rate for Payer: Devoted Health Medicare	$55.55
Rate for Payer: Hawaii Medical Service Association Medicare	$50.50
Rate for Payer: Hawaii Western Management Group Commercial	$95.95
Rate for Payer: Health Management Network Commercial	$85.85
Rate for Payer: Humana Medicare	$50.50
Rate for Payer: Kaiser Permanente Commercial	$90.90
Rate for Payer: Kaiser Permanente Medicaid	$51.51
Rate for Payer: Kaiser Permanente Medicare	$50.50
Rate for Payer: MDX Hawaii PPO	$97.97
Rate for Payer: Ohana Health Plan Medicaid	$50.50
Rate for Payer: Ohana Health Plan Medicare	$50.50
Rate for Payer: UnitedHealthcare Medicare	$50.50
Rate for Payer: University Health Alliance Commercial	$73.62

TRAY LUMBAR PUNCTURE PEDIATRIC

Facility

$96.00

Hospital Charge Code	8266972
Hospital Revenue Code	272
Min. Negotiated Rate	$81.60
Max. Negotiated Rate	$93.12
Rate for Payer: Cash Price	$62.40
Rate for Payer: Health Management Network Commercial	$81.60
Rate for Payer: Kaiser Permanente Commercial	$86.40
Rate for Payer: MDX Hawaii PPO	$93.12

TRAY LUMBAR PUNCTURE PEDIATRIC

Facility

$96.00

Hospital Charge Code	8266972
Hospital Revenue Code	272
Min. Negotiated Rate	$48.00
Max. Negotiated Rate	$93.12
Rate for Payer: AlohaCare Medicaid	$48.00
Rate for Payer: AlohaCare Medicare	$48.00
Rate for Payer: Cash Price	$62.40
Rate for Payer: Devoted Health Medicare	$52.80
Rate for Payer: Hawaii Medical Service Association Medicare	$48.00
Rate for Payer: Hawaii Western Management Group Commercial	$91.20
Rate for Payer: Health Management Network Commercial	$81.60
Rate for Payer: Humana Medicare	$48.00
Rate for Payer: Kaiser Permanente Commercial	$86.40
Rate for Payer: Kaiser Permanente Medicaid	$48.96
Rate for Payer: Kaiser Permanente Medicare	$48.00
Rate for Payer: MDX Hawaii PPO	$93.12
Rate for Payer: Ohana Health Plan Medicaid	$48.00
Rate for Payer: Ohana Health Plan Medicare	$48.00
Rate for Payer: UnitedHealthcare Medicare	$48.00
Rate for Payer: University Health Alliance Commercial	$69.97

TRAY SPINAL WHITACRE 25G X 3.5 IN BD WHITACRE SPINAL NEEDLE

Facility

$230.00

Hospital Charge Code	8939030
Hospital Revenue Code	272
Min. Negotiated Rate	$115.00
Max. Negotiated Rate	$223.10
Rate for Payer: AlohaCare Medicaid	$115.00
Rate for Payer: AlohaCare Medicare	$115.00
Rate for Payer: Cash Price	$149.50
Rate for Payer: Devoted Health Medicare	$126.50
Rate for Payer: Hawaii Medical Service Association Medicare	$115.00
Rate for Payer: Hawaii Western Management Group Commercial	$218.50
Rate for Payer: Health Management Network Commercial	$195.50
Rate for Payer: Humana Medicare	$115.00
Rate for Payer: Kaiser Permanente Commercial	$207.00
Rate for Payer: Kaiser Permanente Medicaid	$117.30
Rate for Payer: Kaiser Permanente Medicare	$115.00
Rate for Payer: MDX Hawaii PPO	$223.10
Rate for Payer: Ohana Health Plan Medicaid	$115.00
Rate for Payer: Ohana Health Plan Medicare	$115.00
Rate for Payer: UnitedHealthcare Medicare	$115.00
Rate for Payer: University Health Alliance Commercial	$167.65

TRAY SPINAL WHITACRE 25G X 3.5 IN BD WHITACRE SPINAL NEEDLE

Facility

$230.00

Hospital Charge Code	8939030
Hospital Revenue Code	272
Min. Negotiated Rate	$195.50
Max. Negotiated Rate	$223.10
Rate for Payer: Cash Price	$149.50
Rate for Payer: Health Management Network Commercial	$195.50
Rate for Payer: Kaiser Permanente Commercial	$207.00
Rate for Payer: MDX Hawaii PPO	$223.10

TRAY THORACENTESIS/PARA 8FR CATH 18G

Facility

$402.00

Hospital Charge Code	8266528
Hospital Revenue Code	272
Min. Negotiated Rate	$341.70
Max. Negotiated Rate	$389.94
Rate for Payer: Cash Price	$261.30
Rate for Payer: Health Management Network Commercial	$341.70
Rate for Payer: Kaiser Permanente Commercial	$361.80
Rate for Payer: MDX Hawaii PPO	$389.94

TRAY THORACENTESIS/PARA 8FR CATH 18G

Facility

$402.00

Hospital Charge Code	8266528
Hospital Revenue Code	272
Min. Negotiated Rate	$201.00
Max. Negotiated Rate	$389.94
Rate for Payer: AlohaCare Medicaid	$201.00
Rate for Payer: AlohaCare Medicare	$201.00
Rate for Payer: Cash Price	$261.30
Rate for Payer: Devoted Health Medicare	$221.10
Rate for Payer: Hawaii Medical Service Association Medicare	$201.00
Rate for Payer: Hawaii Western Management Group Commercial	$381.90
Rate for Payer: Health Management Network Commercial	$341.70
Rate for Payer: Humana Medicare	$201.00
Rate for Payer: Kaiser Permanente Commercial	$361.80
Rate for Payer: Kaiser Permanente Medicaid	$205.02
Rate for Payer: Kaiser Permanente Medicare	$201.00
Rate for Payer: MDX Hawaii PPO	$389.94
Rate for Payer: Ohana Health Plan Medicaid	$201.00
Rate for Payer: Ohana Health Plan Medicare	$201.00
Rate for Payer: UnitedHealthcare Medicare	$201.00
Rate for Payer: University Health Alliance Commercial	$293.02

TRAY URESIL THORACIC VENT PROCEDURE PNEUMOTHORAX

Facility

$855.00

Hospital Charge Code	8746815
Hospital Revenue Code	272
Min. Negotiated Rate	$427.50
Max. Negotiated Rate	$829.35
Rate for Payer: AlohaCare Medicaid	$427.50
Rate for Payer: AlohaCare Medicare	$427.50
Rate for Payer: Cash Price	$555.75
Rate for Payer: Devoted Health Medicare	$470.25
Rate for Payer: Hawaii Medical Service Association Medicare	$427.50
Rate for Payer: Hawaii Western Management Group Commercial	$812.25
Rate for Payer: Health Management Network Commercial	$726.75
Rate for Payer: Humana Medicare	$427.50
Rate for Payer: Kaiser Permanente Commercial	$769.50
Rate for Payer: Kaiser Permanente Medicaid	$436.05
Rate for Payer: Kaiser Permanente Medicare	$427.50
Rate for Payer: MDX Hawaii PPO	$829.35
Rate for Payer: Ohana Health Plan Medicaid	$427.50
Rate for Payer: Ohana Health Plan Medicare	$427.50
Rate for Payer: UnitedHealthcare Medicare	$427.50
Rate for Payer: University Health Alliance Commercial	$623.21

TRAY URESIL THORACIC VENT PROCEDURE PNEUMOTHORAX

Facility

$855.00

Hospital Charge Code	8746815
Hospital Revenue Code	272
Min. Negotiated Rate	$726.75
Max. Negotiated Rate	$829.35
Rate for Payer: Cash Price	$555.75
Rate for Payer: Health Management Network Commercial	$726.75
Rate for Payer: Kaiser Permanente Commercial	$769.50
Rate for Payer: MDX Hawaii PPO	$829.35

TRAY URETHRAL CATHETER 14FR

Facility

$15.00

Hospital Charge Code	8266280
Hospital Revenue Code	272
Min. Negotiated Rate	$7.50
Max. Negotiated Rate	$14.55
Rate for Payer: AlohaCare Medicaid	$7.50
Rate for Payer: AlohaCare Medicare	$7.50
Rate for Payer: Cash Price	$9.75
Rate for Payer: Devoted Health Medicare	$8.25
Rate for Payer: Hawaii Medical Service Association Medicare	$7.50
Rate for Payer: Hawaii Western Management Group Commercial	$14.25
Rate for Payer: Health Management Network Commercial	$12.75
Rate for Payer: Humana Medicare	$7.50
Rate for Payer: Kaiser Permanente Commercial	$13.50
Rate for Payer: Kaiser Permanente Medicaid	$7.65
Rate for Payer: Kaiser Permanente Medicare	$7.50
Rate for Payer: MDX Hawaii PPO	$14.55
Rate for Payer: Ohana Health Plan Medicaid	$7.50
Rate for Payer: Ohana Health Plan Medicare	$7.50
Rate for Payer: UnitedHealthcare Medicare	$7.50
Rate for Payer: University Health Alliance Commercial	$10.93

TRAY URETHRAL CATHETER 14FR

Facility

$15.00

Hospital Charge Code	8266280
Hospital Revenue Code	272
Min. Negotiated Rate	$12.75
Max. Negotiated Rate	$14.55
Rate for Payer: Cash Price	$9.75
Rate for Payer: Health Management Network Commercial	$12.75
Rate for Payer: Kaiser Permanente Commercial	$13.50
Rate for Payer: MDX Hawaii PPO	$14.55

Know your out-of-pocket cost for care.

All Charges