Samuel Mahelona Memorial Hospital

All Charges

Charge

Type

Setting

Price

UROLOGY: CASCADE URETERAL STENT 6FR X 20CM

Facility

$205.00

Service Code	HCPCS C2625
Hospital Charge Code	10048329
Hospital Revenue Code	278
Min. Negotiated Rate	$102.50
Max. Negotiated Rate	$198.85
Rate for Payer: AlohaCare Medicaid	$102.50
Rate for Payer: AlohaCare Medicare	$102.50
Rate for Payer: Cash Price	$133.25
Rate for Payer: Devoted Health Medicare	$112.75
Rate for Payer: Hawaii Medical Service Association Medicare	$102.50
Rate for Payer: Hawaii Western Management Group Commercial	$143.50
Rate for Payer: Health Management Network Commercial	$174.25
Rate for Payer: Humana Medicare	$102.50
Rate for Payer: Kaiser Permanente Commercial	$184.50
Rate for Payer: Kaiser Permanente Medicaid	$104.55
Rate for Payer: Kaiser Permanente Medicare	$102.50
Rate for Payer: MDX Hawaii PPO	$198.85
Rate for Payer: Ohana Health Plan Medicaid	$102.50
Rate for Payer: Ohana Health Plan Medicare	$102.50
Rate for Payer: UnitedHealthcare Medicare	$102.50
Rate for Payer: University Health Alliance Commercial	$114.80

UROLOGY: CASCADE URETERAL STENT 6FR X 20CM

Facility

$205.00

Service Code	HCPCS C2625
Hospital Charge Code	10048329
Hospital Revenue Code	278
Min. Negotiated Rate	$114.80
Max. Negotiated Rate	$198.85
Rate for Payer: Cash Price	$133.25
Rate for Payer: Hawaii Western Management Group Commercial	$143.50
Rate for Payer: Health Management Network Commercial	$174.25
Rate for Payer: Kaiser Permanente Commercial	$184.50
Rate for Payer: MDX Hawaii PPO	$198.85
Rate for Payer: University Health Alliance Commercial	$114.80

UROLOGY: CASCADE URETERAL STENT 6FR X 22CM

Facility

$205.00

Service Code	HCPCS C1758
Hospital Charge Code	10048330
Hospital Revenue Code	272
Min. Negotiated Rate	$102.50
Max. Negotiated Rate	$198.85
Rate for Payer: AlohaCare Medicaid	$102.50
Rate for Payer: AlohaCare Medicare	$102.50
Rate for Payer: Cash Price	$133.25
Rate for Payer: Devoted Health Medicare	$112.75
Rate for Payer: Hawaii Medical Service Association Medicare	$102.50
Rate for Payer: Hawaii Western Management Group Commercial	$194.75
Rate for Payer: Health Management Network Commercial	$174.25
Rate for Payer: Humana Medicare	$102.50
Rate for Payer: Kaiser Permanente Commercial	$184.50
Rate for Payer: Kaiser Permanente Medicaid	$104.55
Rate for Payer: Kaiser Permanente Medicare	$102.50
Rate for Payer: MDX Hawaii PPO	$198.85
Rate for Payer: Ohana Health Plan Medicaid	$102.50
Rate for Payer: Ohana Health Plan Medicare	$102.50
Rate for Payer: UnitedHealthcare Medicare	$102.50
Rate for Payer: University Health Alliance Commercial	$149.42

UROLOGY: CASCADE URETERAL STENT 6FR X 22CM

Facility

$205.00

Service Code	HCPCS C1758
Hospital Charge Code	10048330
Hospital Revenue Code	272
Min. Negotiated Rate	$174.25
Max. Negotiated Rate	$198.85
Rate for Payer: Cash Price	$133.25
Rate for Payer: Health Management Network Commercial	$174.25
Rate for Payer: Kaiser Permanente Commercial	$184.50
Rate for Payer: MDX Hawaii PPO	$198.85

UROLOGY: CASCADE URETERAL STENT 6FR X 24CM

Facility

$205.00

Hospital Charge Code	10048331
Hospital Revenue Code	272
Min. Negotiated Rate	$102.50
Max. Negotiated Rate	$198.85
Rate for Payer: AlohaCare Medicaid	$102.50
Rate for Payer: AlohaCare Medicare	$102.50
Rate for Payer: Cash Price	$133.25
Rate for Payer: Devoted Health Medicare	$112.75
Rate for Payer: Hawaii Medical Service Association Medicare	$102.50
Rate for Payer: Hawaii Western Management Group Commercial	$194.75
Rate for Payer: Health Management Network Commercial	$174.25
Rate for Payer: Humana Medicare	$102.50
Rate for Payer: Kaiser Permanente Commercial	$184.50
Rate for Payer: Kaiser Permanente Medicaid	$104.55
Rate for Payer: Kaiser Permanente Medicare	$102.50
Rate for Payer: MDX Hawaii PPO	$198.85
Rate for Payer: Ohana Health Plan Medicaid	$102.50
Rate for Payer: Ohana Health Plan Medicare	$102.50
Rate for Payer: UnitedHealthcare Medicare	$102.50
Rate for Payer: University Health Alliance Commercial	$149.42

UROLOGY: CASCADE URETERAL STENT 6FR X 24CM

Facility

$205.00

Hospital Charge Code	10048331
Hospital Revenue Code	272
Min. Negotiated Rate	$174.25
Max. Negotiated Rate	$198.85
Rate for Payer: Cash Price	$133.25
Rate for Payer: Health Management Network Commercial	$174.25
Rate for Payer: Kaiser Permanente Commercial	$184.50
Rate for Payer: MDX Hawaii PPO	$198.85

UROLOGY: CASCADE URETERAL STENT 6FR X 26CM

Facility

$205.00

Hospital Charge Code	10048332
Hospital Revenue Code	272
Min. Negotiated Rate	$174.25
Max. Negotiated Rate	$198.85
Rate for Payer: Cash Price	$133.25
Rate for Payer: Health Management Network Commercial	$174.25
Rate for Payer: Kaiser Permanente Commercial	$184.50
Rate for Payer: MDX Hawaii PPO	$198.85

UROLOGY: CASCADE URETERAL STENT 6FR X 26CM

Facility

$205.00

Hospital Charge Code	10048332
Hospital Revenue Code	272
Min. Negotiated Rate	$102.50
Max. Negotiated Rate	$198.85
Rate for Payer: AlohaCare Medicaid	$102.50
Rate for Payer: AlohaCare Medicare	$102.50
Rate for Payer: Cash Price	$133.25
Rate for Payer: Devoted Health Medicare	$112.75
Rate for Payer: Hawaii Medical Service Association Medicare	$102.50
Rate for Payer: Hawaii Western Management Group Commercial	$194.75
Rate for Payer: Health Management Network Commercial	$174.25
Rate for Payer: Humana Medicare	$102.50
Rate for Payer: Kaiser Permanente Commercial	$184.50
Rate for Payer: Kaiser Permanente Medicaid	$104.55
Rate for Payer: Kaiser Permanente Medicare	$102.50
Rate for Payer: MDX Hawaii PPO	$198.85
Rate for Payer: Ohana Health Plan Medicaid	$102.50
Rate for Payer: Ohana Health Plan Medicare	$102.50
Rate for Payer: UnitedHealthcare Medicare	$102.50
Rate for Payer: University Health Alliance Commercial	$149.42

UROLOGY: CASCADE URETERAL STENT 6FR X 28CM

Facility

$205.00

Hospital Charge Code	10048333
Hospital Revenue Code	272
Min. Negotiated Rate	$102.50
Max. Negotiated Rate	$198.85
Rate for Payer: AlohaCare Medicaid	$102.50
Rate for Payer: AlohaCare Medicare	$102.50
Rate for Payer: Cash Price	$133.25
Rate for Payer: Devoted Health Medicare	$112.75
Rate for Payer: Hawaii Medical Service Association Medicare	$102.50
Rate for Payer: Hawaii Western Management Group Commercial	$194.75
Rate for Payer: Health Management Network Commercial	$174.25
Rate for Payer: Humana Medicare	$102.50
Rate for Payer: Kaiser Permanente Commercial	$184.50
Rate for Payer: Kaiser Permanente Medicaid	$104.55
Rate for Payer: Kaiser Permanente Medicare	$102.50
Rate for Payer: MDX Hawaii PPO	$198.85
Rate for Payer: Ohana Health Plan Medicaid	$102.50
Rate for Payer: Ohana Health Plan Medicare	$102.50
Rate for Payer: UnitedHealthcare Medicare	$102.50
Rate for Payer: University Health Alliance Commercial	$149.42

UROLOGY: CASCADE URETERAL STENT 6FR X 28CM

Facility

$205.00

Hospital Charge Code	10048333
Hospital Revenue Code	272
Min. Negotiated Rate	$174.25
Max. Negotiated Rate	$198.85
Rate for Payer: Cash Price	$133.25
Rate for Payer: Health Management Network Commercial	$174.25
Rate for Payer: Kaiser Permanente Commercial	$184.50
Rate for Payer: MDX Hawaii PPO	$198.85

UROLOGY: CASCADE URETERAL STENT 7FR X 26CM

Facility

$205.00

Service Code	HCPCS C2617
Hospital Charge Code	10048337
Hospital Revenue Code	278
Min. Negotiated Rate	$114.80
Max. Negotiated Rate	$198.85
Rate for Payer: Cash Price	$133.25
Rate for Payer: Hawaii Western Management Group Commercial	$143.50
Rate for Payer: Health Management Network Commercial	$174.25
Rate for Payer: Kaiser Permanente Commercial	$184.50
Rate for Payer: MDX Hawaii PPO	$198.85
Rate for Payer: University Health Alliance Commercial	$114.80

UROLOGY: CASCADE URETERAL STENT 7FR X 26CM

Facility

$205.00

Service Code	HCPCS C2617
Hospital Charge Code	10048337
Hospital Revenue Code	278
Min. Negotiated Rate	$102.50
Max. Negotiated Rate	$198.85
Rate for Payer: AlohaCare Medicaid	$102.50
Rate for Payer: AlohaCare Medicare	$102.50
Rate for Payer: Cash Price	$133.25
Rate for Payer: Devoted Health Medicare	$112.75
Rate for Payer: Hawaii Medical Service Association Medicare	$102.50
Rate for Payer: Hawaii Western Management Group Commercial	$143.50
Rate for Payer: Health Management Network Commercial	$174.25
Rate for Payer: Humana Medicare	$102.50
Rate for Payer: Kaiser Permanente Commercial	$184.50
Rate for Payer: Kaiser Permanente Medicaid	$104.55
Rate for Payer: Kaiser Permanente Medicare	$102.50
Rate for Payer: MDX Hawaii PPO	$198.85
Rate for Payer: Ohana Health Plan Medicaid	$102.50
Rate for Payer: Ohana Health Plan Medicare	$102.50
Rate for Payer: UnitedHealthcare Medicare	$102.50
Rate for Payer: University Health Alliance Commercial	$114.80

UROLOGY: DAKOTA W/OPENSURE 8MM BASKET

Facility

$765.00

Hospital Charge Code	9882921
Hospital Revenue Code	270
Min. Negotiated Rate	$650.25
Max. Negotiated Rate	$742.05
Rate for Payer: Cash Price	$497.25
Rate for Payer: Health Management Network Commercial	$650.25
Rate for Payer: Kaiser Permanente Commercial	$688.50
Rate for Payer: MDX Hawaii PPO	$742.05

UROLOGY: DAKOTA W/OPENSURE 8MM BASKET

Facility

$765.00

Hospital Charge Code	9882921
Hospital Revenue Code	270
Min. Negotiated Rate	$382.50
Max. Negotiated Rate	$742.05
Rate for Payer: AlohaCare Medicaid	$382.50
Rate for Payer: AlohaCare Medicare	$382.50
Rate for Payer: Cash Price	$497.25
Rate for Payer: Devoted Health Medicare	$420.75
Rate for Payer: Hawaii Medical Service Association Medicare	$382.50
Rate for Payer: Hawaii Western Management Group Commercial	$726.75
Rate for Payer: Health Management Network Commercial	$650.25
Rate for Payer: Humana Medicare	$382.50
Rate for Payer: Kaiser Permanente Commercial	$688.50
Rate for Payer: Kaiser Permanente Medicaid	$390.15
Rate for Payer: Kaiser Permanente Medicare	$382.50
Rate for Payer: MDX Hawaii PPO	$742.05
Rate for Payer: Ohana Health Plan Medicaid	$382.50
Rate for Payer: Ohana Health Plan Medicare	$382.50
Rate for Payer: UnitedHealthcare Medicare	$382.50
Rate for Payer: University Health Alliance Commercial	$557.61

UROLOGY:DORNIER SINGLEFLEX 200 HIGH ENERGY

Facility

$1,080.00

Hospital Charge Code	12137722
Hospital Revenue Code	272
Min. Negotiated Rate	$540.00
Max. Negotiated Rate	$1,047.60
Rate for Payer: AlohaCare Medicaid	$540.00
Rate for Payer: AlohaCare Medicare	$540.00
Rate for Payer: Cash Price	$702.00
Rate for Payer: Devoted Health Medicare	$594.00
Rate for Payer: Hawaii Medical Service Association Medicare	$540.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,026.00
Rate for Payer: Health Management Network Commercial	$918.00
Rate for Payer: Humana Medicare	$540.00
Rate for Payer: Kaiser Permanente Commercial	$972.00
Rate for Payer: Kaiser Permanente Medicaid	$550.80
Rate for Payer: Kaiser Permanente Medicare	$540.00
Rate for Payer: MDX Hawaii PPO	$1,047.60
Rate for Payer: Ohana Health Plan Medicaid	$540.00
Rate for Payer: Ohana Health Plan Medicare	$540.00
Rate for Payer: UnitedHealthcare Medicare	$540.00
Rate for Payer: University Health Alliance Commercial	$787.21

UROLOGY:DORNIER SINGLEFLEX 200 HIGH ENERGY

Facility

$1,080.00

Hospital Charge Code	12137722
Hospital Revenue Code	272
Min. Negotiated Rate	$918.00
Max. Negotiated Rate	$1,047.60
Rate for Payer: Cash Price	$702.00
Rate for Payer: Health Management Network Commercial	$918.00
Rate for Payer: Kaiser Permanente Commercial	$972.00
Rate for Payer: MDX Hawaii PPO	$1,047.60

UROLOGY: DORNIER SINGLEFLEX 400 HIGH ENERGY SINGLE USE

Facility

$927.00

Hospital Charge Code	10048400
Hospital Revenue Code	272
Min. Negotiated Rate	$463.50
Max. Negotiated Rate	$899.19
Rate for Payer: AlohaCare Medicaid	$463.50
Rate for Payer: AlohaCare Medicare	$463.50
Rate for Payer: Cash Price	$602.55
Rate for Payer: Devoted Health Medicare	$509.85
Rate for Payer: Hawaii Medical Service Association Medicare	$463.50
Rate for Payer: Hawaii Western Management Group Commercial	$880.65
Rate for Payer: Health Management Network Commercial	$787.95
Rate for Payer: Humana Medicare	$463.50
Rate for Payer: Kaiser Permanente Commercial	$834.30
Rate for Payer: Kaiser Permanente Medicaid	$472.77
Rate for Payer: Kaiser Permanente Medicare	$463.50
Rate for Payer: MDX Hawaii PPO	$899.19
Rate for Payer: Ohana Health Plan Medicaid	$463.50
Rate for Payer: Ohana Health Plan Medicare	$463.50
Rate for Payer: UnitedHealthcare Medicare	$463.50
Rate for Payer: University Health Alliance Commercial	$675.69

UROLOGY: DORNIER SINGLEFLEX 400 HIGH ENERGY SINGLE USE

Facility

$927.00

Hospital Charge Code	10048400
Hospital Revenue Code	272
Min. Negotiated Rate	$787.95
Max. Negotiated Rate	$899.19
Rate for Payer: Cash Price	$602.55
Rate for Payer: Health Management Network Commercial	$787.95
Rate for Payer: Kaiser Permanente Commercial	$834.30
Rate for Payer: MDX Hawaii PPO	$899.19

UROLOGY: DORNIER SINGLEFLEX 600 HIGH ENERGY SINGLE USE

Facility

$1,377.00

Hospital Charge Code	10048401
Hospital Revenue Code	272
Min. Negotiated Rate	$1,170.45
Max. Negotiated Rate	$1,335.69
Rate for Payer: Cash Price	$895.05
Rate for Payer: Health Management Network Commercial	$1,170.45
Rate for Payer: Kaiser Permanente Commercial	$1,239.30
Rate for Payer: MDX Hawaii PPO	$1,335.69

UROLOGY: DORNIER SINGLEFLEX 600 HIGH ENERGY SINGLE USE

Facility

$1,377.00

Hospital Charge Code	10048401
Hospital Revenue Code	272
Min. Negotiated Rate	$688.50
Max. Negotiated Rate	$1,335.69
Rate for Payer: AlohaCare Medicaid	$688.50
Rate for Payer: AlohaCare Medicare	$688.50
Rate for Payer: Cash Price	$895.05
Rate for Payer: Devoted Health Medicare	$757.35
Rate for Payer: Hawaii Medical Service Association Medicare	$688.50
Rate for Payer: Hawaii Western Management Group Commercial	$1,308.15
Rate for Payer: Health Management Network Commercial	$1,170.45
Rate for Payer: Humana Medicare	$688.50
Rate for Payer: Kaiser Permanente Commercial	$1,239.30
Rate for Payer: Kaiser Permanente Medicaid	$702.27
Rate for Payer: Kaiser Permanente Medicare	$688.50
Rate for Payer: MDX Hawaii PPO	$1,335.69
Rate for Payer: Ohana Health Plan Medicaid	$688.50
Rate for Payer: Ohana Health Plan Medicare	$688.50
Rate for Payer: UnitedHealthcare Medicare	$688.50
Rate for Payer: University Health Alliance Commercial	$1,003.70

UROLOGY - DUAL - LUMEN

Facility

$271.00

Hospital Charge Code	9816312
Hospital Revenue Code	272
Min. Negotiated Rate	$230.35
Max. Negotiated Rate	$262.87
Rate for Payer: Cash Price	$176.15
Rate for Payer: Health Management Network Commercial	$230.35
Rate for Payer: Kaiser Permanente Commercial	$243.90
Rate for Payer: MDX Hawaii PPO	$262.87

UROLOGY - DUAL - LUMEN

Facility

$271.00

Hospital Charge Code	9816312
Hospital Revenue Code	272
Min. Negotiated Rate	$135.50
Max. Negotiated Rate	$262.87
Rate for Payer: AlohaCare Medicaid	$135.50
Rate for Payer: AlohaCare Medicare	$135.50
Rate for Payer: Cash Price	$176.15
Rate for Payer: Devoted Health Medicare	$149.05
Rate for Payer: Hawaii Medical Service Association Medicare	$135.50
Rate for Payer: Hawaii Western Management Group Commercial	$257.45
Rate for Payer: Health Management Network Commercial	$230.35
Rate for Payer: Humana Medicare	$135.50
Rate for Payer: Kaiser Permanente Commercial	$243.90
Rate for Payer: Kaiser Permanente Medicaid	$138.21
Rate for Payer: Kaiser Permanente Medicare	$135.50
Rate for Payer: MDX Hawaii PPO	$262.87
Rate for Payer: Ohana Health Plan Medicaid	$135.50
Rate for Payer: Ohana Health Plan Medicare	$135.50
Rate for Payer: UnitedHealthcare Medicare	$135.50
Rate for Payer: University Health Alliance Commercial	$197.53

UROLOGY: ECLIPSE NITINOL STONE RETRIEVAL BASKET, TIPLESS, 1.8FR X 120CM

Facility

$632.00

Hospital Charge Code	10048402
Hospital Revenue Code	272
Min. Negotiated Rate	$537.20
Max. Negotiated Rate	$613.04
Rate for Payer: Cash Price	$410.80
Rate for Payer: Health Management Network Commercial	$537.20
Rate for Payer: Kaiser Permanente Commercial	$568.80
Rate for Payer: MDX Hawaii PPO	$613.04

UROLOGY: ECLIPSE NITINOL STONE RETRIEVAL BASKET, TIPLESS, 1.8FR X 120CM

Facility

$632.00

Hospital Charge Code	10048402
Hospital Revenue Code	272
Min. Negotiated Rate	$316.00
Max. Negotiated Rate	$613.04
Rate for Payer: AlohaCare Medicaid	$316.00
Rate for Payer: AlohaCare Medicare	$316.00
Rate for Payer: Cash Price	$410.80
Rate for Payer: Devoted Health Medicare	$347.60
Rate for Payer: Hawaii Medical Service Association Medicare	$316.00
Rate for Payer: Hawaii Western Management Group Commercial	$600.40
Rate for Payer: Health Management Network Commercial	$537.20
Rate for Payer: Humana Medicare	$316.00
Rate for Payer: Kaiser Permanente Commercial	$568.80
Rate for Payer: Kaiser Permanente Medicaid	$322.32
Rate for Payer: Kaiser Permanente Medicare	$316.00
Rate for Payer: MDX Hawaii PPO	$613.04
Rate for Payer: Ohana Health Plan Medicaid	$316.00
Rate for Payer: Ohana Health Plan Medicare	$316.00
Rate for Payer: UnitedHealthcare Medicare	$316.00
Rate for Payer: University Health Alliance Commercial	$460.66

UROLOGY - EVACUATOR UROVAC BLADDER

Facility

$117.00

Hospital Charge Code	9740163
Hospital Revenue Code	272
Min. Negotiated Rate	$58.50
Max. Negotiated Rate	$113.49
Rate for Payer: AlohaCare Medicaid	$58.50
Rate for Payer: AlohaCare Medicare	$58.50
Rate for Payer: Cash Price	$76.05
Rate for Payer: Devoted Health Medicare	$64.35
Rate for Payer: Hawaii Medical Service Association Medicare	$58.50
Rate for Payer: Hawaii Western Management Group Commercial	$111.15
Rate for Payer: Health Management Network Commercial	$99.45
Rate for Payer: Humana Medicare	$58.50
Rate for Payer: Kaiser Permanente Commercial	$105.30
Rate for Payer: Kaiser Permanente Medicaid	$59.67
Rate for Payer: Kaiser Permanente Medicare	$58.50
Rate for Payer: MDX Hawaii PPO	$113.49
Rate for Payer: Ohana Health Plan Medicaid	$58.50
Rate for Payer: Ohana Health Plan Medicare	$58.50
Rate for Payer: UnitedHealthcare Medicare	$58.50
Rate for Payer: University Health Alliance Commercial	$85.28

Know your out-of-pocket cost for care.

All Charges