Samuel Mahelona Memorial Hospital

All Charges

Charge

Type

Setting

Price

Urine Pregnancy Test POC

Professional

Both

$64.00

Service Code	HCPCS 81025 QW
Hospital Charge Code	8080540
Hospital Revenue Code	307
Min. Negotiated Rate	$8.74
Max. Negotiated Rate	$54.40
Rate for Payer: AlohaCare Medicaid	$8.74
Rate for Payer: Cash Price	$41.60
Rate for Payer: Cash Price	$41.60
Rate for Payer: Hawaii Western Management Group Commercial	$8.75
Rate for Payer: Health Management Network Commercial	$54.40
Rate for Payer: Ohana Health Plan Medicaid	$8.74
Rate for Payer: UnitedHealthcare Medicaid	$8.74

Urine Pregnancy Test POC

Facility

$85.00

Service Code	HCPCS 81025 QW
Hospital Charge Code	607612
Hospital Revenue Code	307
Min. Negotiated Rate	$72.25
Max. Negotiated Rate	$82.45
Rate for Payer: Cash Price	$55.25
Rate for Payer: Health Management Network Commercial	$72.25
Rate for Payer: Kaiser Permanente Commercial	$76.50
Rate for Payer: MDX Hawaii PPO	$82.45

Urine Pregnancy Test POC

Facility

$85.00

Service Code	HCPCS 81025 QW
Hospital Charge Code	607612
Hospital Revenue Code	307
Min. Negotiated Rate	$8.74
Max. Negotiated Rate	$82.45
Rate for Payer: AlohaCare Medicaid	$42.50
Rate for Payer: AlohaCare Medicare	$42.50
Rate for Payer: Cash Price	$55.25
Rate for Payer: Cash Price	$55.25
Rate for Payer: Devoted Health Medicare	$46.75
Rate for Payer: Hawaii Medical Service Association ABD	$8.74
Rate for Payer: Hawaii Medical Service Association Medicare	$42.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$9.18
Rate for Payer: Hawaii Western Management Group Commercial	$80.75
Rate for Payer: Health Management Network Commercial	$72.25
Rate for Payer: Humana Medicare	$42.50
Rate for Payer: Kaiser Permanente Commercial	$76.50
Rate for Payer: Kaiser Permanente Medicaid	$43.35
Rate for Payer: Kaiser Permanente Medicare	$42.50
Rate for Payer: MDX Hawaii PPO	$82.45
Rate for Payer: Ohana Health Plan Medicaid	$42.50
Rate for Payer: Ohana Health Plan Medicare	$42.50
Rate for Payer: UnitedHealthcare Medicaid	$8.74
Rate for Payer: UnitedHealthcare Medicare	$42.50
Rate for Payer: University Health Alliance Commercial	$16.35

.Urine Propoxyphene Confirmation FSI

Facility

$200.00

Service Code	HCPCS 80102
Hospital Charge Code	8728203
Hospital Revenue Code	301
Min. Negotiated Rate	$170.00
Max. Negotiated Rate	$194.00
Rate for Payer: Cash Price	$130.00
Rate for Payer: Health Management Network Commercial	$170.00
Rate for Payer: Kaiser Permanente Commercial	$180.00
Rate for Payer: MDX Hawaii PPO	$194.00

.Urine Propoxyphene Confirmation FSI

Facility

$200.00

Service Code	HCPCS 80102
Hospital Charge Code	8728203
Hospital Revenue Code	301
Min. Negotiated Rate	$34.24
Max. Negotiated Rate	$194.00
Rate for Payer: AlohaCare Medicaid	$100.00
Rate for Payer: AlohaCare Medicare	$100.00
Rate for Payer: Cash Price	$130.00
Rate for Payer: Cash Price	$130.00
Rate for Payer: Devoted Health Medicare	$110.00
Rate for Payer: Hawaii Medical Service Association Medicare	$100.00
Rate for Payer: Hawaii Western Management Group Commercial	$190.00
Rate for Payer: Health Management Network Commercial	$170.00
Rate for Payer: Humana Medicare	$100.00
Rate for Payer: Kaiser Permanente Commercial	$180.00
Rate for Payer: Kaiser Permanente Medicaid	$102.00
Rate for Payer: Kaiser Permanente Medicare	$100.00
Rate for Payer: MDX Hawaii PPO	$194.00
Rate for Payer: Ohana Health Plan Medicaid	$100.00
Rate for Payer: Ohana Health Plan Medicare	$100.00
Rate for Payer: UnitedHealthcare Medicare	$100.00
Rate for Payer: University Health Alliance Commercial	$34.24

UROLOGY - 0.25 ZIPWIRE (GLIDE TYPE)

Facility

$183.00

Hospital Charge Code	9816306
Hospital Revenue Code	272
Min. Negotiated Rate	$155.55
Max. Negotiated Rate	$177.51
Rate for Payer: Cash Price	$118.95
Rate for Payer: Health Management Network Commercial	$155.55
Rate for Payer: Kaiser Permanente Commercial	$164.70
Rate for Payer: MDX Hawaii PPO	$177.51

UROLOGY - 0.25 ZIPWIRE (GLIDE TYPE)

Facility

$183.00

Hospital Charge Code	9816306
Hospital Revenue Code	272
Min. Negotiated Rate	$91.50
Max. Negotiated Rate	$177.51
Rate for Payer: AlohaCare Medicaid	$91.50
Rate for Payer: AlohaCare Medicare	$91.50
Rate for Payer: Cash Price	$118.95
Rate for Payer: Devoted Health Medicare	$100.65
Rate for Payer: Hawaii Medical Service Association Medicare	$91.50
Rate for Payer: Hawaii Western Management Group Commercial	$173.85
Rate for Payer: Health Management Network Commercial	$155.55
Rate for Payer: Humana Medicare	$91.50
Rate for Payer: Kaiser Permanente Commercial	$164.70
Rate for Payer: Kaiser Permanente Medicaid	$93.33
Rate for Payer: Kaiser Permanente Medicare	$91.50
Rate for Payer: MDX Hawaii PPO	$177.51
Rate for Payer: Ohana Health Plan Medicaid	$91.50
Rate for Payer: Ohana Health Plan Medicare	$91.50
Rate for Payer: UnitedHealthcare Medicare	$91.50
Rate for Payer: University Health Alliance Commercial	$133.39

UROLOGY:3 WAY 18 FR / 30CC CATH

Facility

$84.00

Hospital Charge Code	10047497
Hospital Revenue Code	272
Min. Negotiated Rate	$71.40
Max. Negotiated Rate	$81.48
Rate for Payer: Cash Price	$54.60
Rate for Payer: Health Management Network Commercial	$71.40
Rate for Payer: Kaiser Permanente Commercial	$75.60
Rate for Payer: MDX Hawaii PPO	$81.48

UROLOGY:3 WAY 18 FR / 30CC CATH

Facility

$84.00

Hospital Charge Code	10047497
Hospital Revenue Code	272
Min. Negotiated Rate	$42.00
Max. Negotiated Rate	$81.48
Rate for Payer: AlohaCare Medicaid	$42.00
Rate for Payer: AlohaCare Medicare	$42.00
Rate for Payer: Cash Price	$54.60
Rate for Payer: Devoted Health Medicare	$46.20
Rate for Payer: Hawaii Medical Service Association Medicare	$42.00
Rate for Payer: Hawaii Western Management Group Commercial	$79.80
Rate for Payer: Health Management Network Commercial	$71.40
Rate for Payer: Humana Medicare	$42.00
Rate for Payer: Kaiser Permanente Commercial	$75.60
Rate for Payer: Kaiser Permanente Medicaid	$42.84
Rate for Payer: Kaiser Permanente Medicare	$42.00
Rate for Payer: MDX Hawaii PPO	$81.48
Rate for Payer: Ohana Health Plan Medicaid	$42.00
Rate for Payer: Ohana Health Plan Medicare	$42.00
Rate for Payer: UnitedHealthcare Medicare	$42.00
Rate for Payer: University Health Alliance Commercial	$61.23

UROLOGY: 3 WAY 20 FR / 30CC CATH

Facility

$123.00

Hospital Charge Code	10047562
Hospital Revenue Code	272
Min. Negotiated Rate	$61.50
Max. Negotiated Rate	$119.31
Rate for Payer: AlohaCare Medicaid	$61.50
Rate for Payer: AlohaCare Medicare	$61.50
Rate for Payer: Cash Price	$79.95
Rate for Payer: Devoted Health Medicare	$67.65
Rate for Payer: Hawaii Medical Service Association Medicare	$61.50
Rate for Payer: Hawaii Western Management Group Commercial	$116.85
Rate for Payer: Health Management Network Commercial	$104.55
Rate for Payer: Humana Medicare	$61.50
Rate for Payer: Kaiser Permanente Commercial	$110.70
Rate for Payer: Kaiser Permanente Medicaid	$62.73
Rate for Payer: Kaiser Permanente Medicare	$61.50
Rate for Payer: MDX Hawaii PPO	$119.31
Rate for Payer: Ohana Health Plan Medicaid	$61.50
Rate for Payer: Ohana Health Plan Medicare	$61.50
Rate for Payer: UnitedHealthcare Medicare	$61.50
Rate for Payer: University Health Alliance Commercial	$89.65

UROLOGY: 3 WAY 20 FR / 30CC CATH

Facility

$123.00

Hospital Charge Code	10047562
Hospital Revenue Code	272
Min. Negotiated Rate	$104.55
Max. Negotiated Rate	$119.31
Rate for Payer: Cash Price	$79.95
Rate for Payer: Health Management Network Commercial	$104.55
Rate for Payer: Kaiser Permanente Commercial	$110.70
Rate for Payer: MDX Hawaii PPO	$119.31

UROLOGY: 5 FRENCH CONE TIP CATH

Facility

$62.00

Hospital Charge Code	9882802
Hospital Revenue Code	270
Min. Negotiated Rate	$31.00
Max. Negotiated Rate	$60.14
Rate for Payer: AlohaCare Medicaid	$31.00
Rate for Payer: AlohaCare Medicare	$31.00
Rate for Payer: Cash Price	$40.30
Rate for Payer: Devoted Health Medicare	$34.10
Rate for Payer: Hawaii Medical Service Association Medicare	$31.00
Rate for Payer: Hawaii Western Management Group Commercial	$58.90
Rate for Payer: Health Management Network Commercial	$52.70
Rate for Payer: Humana Medicare	$31.00
Rate for Payer: Kaiser Permanente Commercial	$55.80
Rate for Payer: Kaiser Permanente Medicaid	$31.62
Rate for Payer: Kaiser Permanente Medicare	$31.00
Rate for Payer: MDX Hawaii PPO	$60.14
Rate for Payer: Ohana Health Plan Medicaid	$31.00
Rate for Payer: Ohana Health Plan Medicare	$31.00
Rate for Payer: UnitedHealthcare Medicare	$31.00
Rate for Payer: University Health Alliance Commercial	$45.19

UROLOGY: 5 FRENCH CONE TIP CATH

Facility

$62.00

Hospital Charge Code	9882802
Hospital Revenue Code	270
Min. Negotiated Rate	$52.70
Max. Negotiated Rate	$60.14
Rate for Payer: Cash Price	$40.30
Rate for Payer: Health Management Network Commercial	$52.70
Rate for Payer: Kaiser Permanente Commercial	$55.80
Rate for Payer: MDX Hawaii PPO	$60.14

UROLOGY - 5 OR 6 FRENCH OPEN-ENDED CATH

Facility

$705.00

Hospital Charge Code	9816308
Hospital Revenue Code	272
Min. Negotiated Rate	$599.25
Max. Negotiated Rate	$683.85
Rate for Payer: Cash Price	$458.25
Rate for Payer: Health Management Network Commercial	$599.25
Rate for Payer: Kaiser Permanente Commercial	$634.50
Rate for Payer: MDX Hawaii PPO	$683.85

UROLOGY - 5 OR 6 FRENCH OPEN-ENDED CATH

Facility

$705.00

Hospital Charge Code	9816308
Hospital Revenue Code	272
Min. Negotiated Rate	$352.50
Max. Negotiated Rate	$683.85
Rate for Payer: AlohaCare Medicaid	$352.50
Rate for Payer: AlohaCare Medicare	$352.50
Rate for Payer: Cash Price	$458.25
Rate for Payer: Devoted Health Medicare	$387.75
Rate for Payer: Hawaii Medical Service Association Medicare	$352.50
Rate for Payer: Hawaii Western Management Group Commercial	$669.75
Rate for Payer: Health Management Network Commercial	$599.25
Rate for Payer: Humana Medicare	$352.50
Rate for Payer: Kaiser Permanente Commercial	$634.50
Rate for Payer: Kaiser Permanente Medicaid	$359.55
Rate for Payer: Kaiser Permanente Medicare	$352.50
Rate for Payer: MDX Hawaii PPO	$683.85
Rate for Payer: Ohana Health Plan Medicaid	$352.50
Rate for Payer: Ohana Health Plan Medicare	$352.50
Rate for Payer: UnitedHealthcare Medicare	$352.50
Rate for Payer: University Health Alliance Commercial	$513.87

UROLOGY: 6 FRENCH OPEN-ENDED CATH

Facility

$62.00

Hospital Charge Code	9882801
Hospital Revenue Code	270
Min. Negotiated Rate	$31.00
Max. Negotiated Rate	$60.14
Rate for Payer: AlohaCare Medicaid	$31.00
Rate for Payer: AlohaCare Medicare	$31.00
Rate for Payer: Cash Price	$40.30
Rate for Payer: Devoted Health Medicare	$34.10
Rate for Payer: Hawaii Medical Service Association Medicare	$31.00
Rate for Payer: Hawaii Western Management Group Commercial	$58.90
Rate for Payer: Health Management Network Commercial	$52.70
Rate for Payer: Humana Medicare	$31.00
Rate for Payer: Kaiser Permanente Commercial	$55.80
Rate for Payer: Kaiser Permanente Medicaid	$31.62
Rate for Payer: Kaiser Permanente Medicare	$31.00
Rate for Payer: MDX Hawaii PPO	$60.14
Rate for Payer: Ohana Health Plan Medicaid	$31.00
Rate for Payer: Ohana Health Plan Medicare	$31.00
Rate for Payer: UnitedHealthcare Medicare	$31.00
Rate for Payer: University Health Alliance Commercial	$45.19

UROLOGY: 6 FRENCH OPEN-ENDED CATH

Facility

$62.00

Hospital Charge Code	9882801
Hospital Revenue Code	270
Min. Negotiated Rate	$52.70
Max. Negotiated Rate	$60.14
Rate for Payer: Cash Price	$40.30
Rate for Payer: Health Management Network Commercial	$52.70
Rate for Payer: Kaiser Permanente Commercial	$55.80
Rate for Payer: MDX Hawaii PPO	$60.14

UROLOGY:BIOPSY PORT (DISP)

Facility

$99.00

Hospital Charge Code	10171264
Hospital Revenue Code	270
Min. Negotiated Rate	$84.15
Max. Negotiated Rate	$96.03
Rate for Payer: Cash Price	$64.35
Rate for Payer: Health Management Network Commercial	$84.15
Rate for Payer: Kaiser Permanente Commercial	$89.10
Rate for Payer: MDX Hawaii PPO	$96.03

UROLOGY:BIOPSY PORT (DISP)

Facility

$99.00

Hospital Charge Code	10171264
Hospital Revenue Code	270
Min. Negotiated Rate	$49.50
Max. Negotiated Rate	$96.03
Rate for Payer: AlohaCare Medicaid	$49.50
Rate for Payer: AlohaCare Medicare	$49.50
Rate for Payer: Cash Price	$64.35
Rate for Payer: Devoted Health Medicare	$54.45
Rate for Payer: Hawaii Medical Service Association Medicare	$49.50
Rate for Payer: Hawaii Western Management Group Commercial	$94.05
Rate for Payer: Health Management Network Commercial	$84.15
Rate for Payer: Humana Medicare	$49.50
Rate for Payer: Kaiser Permanente Commercial	$89.10
Rate for Payer: Kaiser Permanente Medicaid	$50.49
Rate for Payer: Kaiser Permanente Medicare	$49.50
Rate for Payer: MDX Hawaii PPO	$96.03
Rate for Payer: Ohana Health Plan Medicaid	$49.50
Rate for Payer: Ohana Health Plan Medicare	$49.50
Rate for Payer: UnitedHealthcare Medicare	$49.50
Rate for Payer: University Health Alliance Commercial	$72.16

UROLOGY: BIPOLAR 30 DEGREE LARGE LOOP ELECTRODE

Facility

$1,091.00

Hospital Charge Code	10048447
Hospital Revenue Code	270
Min. Negotiated Rate	$927.35
Max. Negotiated Rate	$1,058.27
Rate for Payer: Cash Price	$709.15
Rate for Payer: Health Management Network Commercial	$927.35
Rate for Payer: Kaiser Permanente Commercial	$981.90
Rate for Payer: MDX Hawaii PPO	$1,058.27

UROLOGY: BIPOLAR 30 DEGREE LARGE LOOP ELECTRODE

Facility

$1,091.00

Hospital Charge Code	10048447
Hospital Revenue Code	270
Min. Negotiated Rate	$545.50
Max. Negotiated Rate	$1,058.27
Rate for Payer: AlohaCare Medicaid	$545.50
Rate for Payer: AlohaCare Medicare	$545.50
Rate for Payer: Cash Price	$709.15
Rate for Payer: Devoted Health Medicare	$600.05
Rate for Payer: Hawaii Medical Service Association Medicare	$545.50
Rate for Payer: Hawaii Western Management Group Commercial	$1,036.45
Rate for Payer: Health Management Network Commercial	$927.35
Rate for Payer: Humana Medicare	$545.50
Rate for Payer: Kaiser Permanente Commercial	$981.90
Rate for Payer: Kaiser Permanente Medicaid	$556.41
Rate for Payer: Kaiser Permanente Medicare	$545.50
Rate for Payer: MDX Hawaii PPO	$1,058.27
Rate for Payer: Ohana Health Plan Medicaid	$545.50
Rate for Payer: Ohana Health Plan Medicare	$545.50
Rate for Payer: UnitedHealthcare Medicare	$545.50
Rate for Payer: University Health Alliance Commercial	$795.23

UROLOGY: BIPOLAR CABLE, ESG-400 GENERATOR

Facility

$200.00

Hospital Charge Code	10048446
Hospital Revenue Code	270
Min. Negotiated Rate	$100.00
Max. Negotiated Rate	$194.00
Rate for Payer: AlohaCare Medicaid	$100.00
Rate for Payer: AlohaCare Medicare	$100.00
Rate for Payer: Cash Price	$130.00
Rate for Payer: Devoted Health Medicare	$110.00
Rate for Payer: Hawaii Medical Service Association Medicare	$100.00
Rate for Payer: Hawaii Western Management Group Commercial	$190.00
Rate for Payer: Health Management Network Commercial	$170.00
Rate for Payer: Humana Medicare	$100.00
Rate for Payer: Kaiser Permanente Commercial	$180.00
Rate for Payer: Kaiser Permanente Medicaid	$102.00
Rate for Payer: Kaiser Permanente Medicare	$100.00
Rate for Payer: MDX Hawaii PPO	$194.00
Rate for Payer: Ohana Health Plan Medicaid	$100.00
Rate for Payer: Ohana Health Plan Medicare	$100.00
Rate for Payer: UnitedHealthcare Medicare	$100.00
Rate for Payer: University Health Alliance Commercial	$145.78

UROLOGY: BIPOLAR CABLE, ESG-400 GENERATOR

Facility

$200.00

Hospital Charge Code	10048446
Hospital Revenue Code	270
Min. Negotiated Rate	$170.00
Max. Negotiated Rate	$194.00
Rate for Payer: Cash Price	$130.00
Rate for Payer: Health Management Network Commercial	$170.00
Rate for Payer: Kaiser Permanente Commercial	$180.00
Rate for Payer: MDX Hawaii PPO	$194.00

UROLOGY: BIPOLAR PLASMA DISC (BUTTON) ELECTRODE

Facility

$1,091.00

Hospital Charge Code	10048445
Hospital Revenue Code	270
Min. Negotiated Rate	$545.50
Max. Negotiated Rate	$1,058.27
Rate for Payer: AlohaCare Medicaid	$545.50
Rate for Payer: AlohaCare Medicare	$545.50
Rate for Payer: Cash Price	$709.15
Rate for Payer: Devoted Health Medicare	$600.05
Rate for Payer: Hawaii Medical Service Association Medicare	$545.50
Rate for Payer: Hawaii Western Management Group Commercial	$1,036.45
Rate for Payer: Health Management Network Commercial	$927.35
Rate for Payer: Humana Medicare	$545.50
Rate for Payer: Kaiser Permanente Commercial	$981.90
Rate for Payer: Kaiser Permanente Medicaid	$556.41
Rate for Payer: Kaiser Permanente Medicare	$545.50
Rate for Payer: MDX Hawaii PPO	$1,058.27
Rate for Payer: Ohana Health Plan Medicaid	$545.50
Rate for Payer: Ohana Health Plan Medicare	$545.50
Rate for Payer: UnitedHealthcare Medicare	$545.50
Rate for Payer: University Health Alliance Commercial	$795.23

UROLOGY: BIPOLAR PLASMA DISC (BUTTON) ELECTRODE

Facility

$1,091.00

Hospital Charge Code	10048445
Hospital Revenue Code	270
Min. Negotiated Rate	$927.35
Max. Negotiated Rate	$1,058.27
Rate for Payer: Cash Price	$709.15
Rate for Payer: Health Management Network Commercial	$927.35
Rate for Payer: Kaiser Permanente Commercial	$981.90
Rate for Payer: MDX Hawaii PPO	$1,058.27

Know your out-of-pocket cost for care.

All Charges