Samuel Mahelona Memorial Hospital

All Charges

Charge

Type

Setting

Price

XR Upper GI + KUB - Report

Professional

Both

$126.00

Service Code	HCPCS 74241 26
Hospital Charge Code	613597
Hospital Revenue Code	972
Min. Negotiated Rate	$103.68
Max. Negotiated Rate	$107.10
Rate for Payer: Cash Price	$81.90
Rate for Payer: Cash Price	$81.90
Rate for Payer: Hawaii Western Management Group Commercial	$103.68
Rate for Payer: Health Management Network Commercial	$107.10

XR Upper GI - Report

Professional

Both

$244.00

Service Code	HCPCS 74240 26
Hospital Charge Code	613595
Hospital Revenue Code	972
Min. Negotiated Rate	$38.60
Max. Negotiated Rate	$207.40
Rate for Payer: AlohaCare Medicaid	$81.48
Rate for Payer: AlohaCare Medicare	$38.60
Rate for Payer: Cash Price	$158.60
Rate for Payer: Cash Price	$158.60
Rate for Payer: Devoted Health Medicare	$42.46
Rate for Payer: Hawaii Medical Service Association Medicare	$38.60
Rate for Payer: Hawaii Western Management Group Commercial	$102.44
Rate for Payer: Health Management Network Commercial	$207.40
Rate for Payer: Kaiser Permanente Commercial	$46.32
Rate for Payer: Kaiser Permanente Medicaid	$46.32
Rate for Payer: Kaiser Permanente Medicare	$46.32
Rate for Payer: Ohana Health Plan Medicaid	$81.48
Rate for Payer: Ohana Health Plan Medicare	$38.60
Rate for Payer: UnitedHealthcare Medicaid	$81.48
Rate for Payer: UnitedHealthcare Medicare	$38.60

XR Upper GI w/ Air Contrast

Facility

$1,061.00

Service Code	HCPCS 74246
Hospital Charge Code	1170566
Hospital Revenue Code	320
Min. Negotiated Rate	$54.40
Max. Negotiated Rate	$1,029.17
Rate for Payer: AlohaCare Medicaid	$530.50
Rate for Payer: AlohaCare Medicare	$530.50
Rate for Payer: Cash Price	$689.65
Rate for Payer: Cash Price	$689.65
Rate for Payer: Devoted Health Medicare	$583.55
Rate for Payer: Hawaii Medical Service Association ABD	$54.40
Rate for Payer: Hawaii Medical Service Association Commercial	$224.00
Rate for Payer: Hawaii Medical Service Association Medicare	$530.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$58.79
Rate for Payer: Hawaii Western Management Group Commercial	$179.20
Rate for Payer: Health Management Network Commercial	$901.85
Rate for Payer: Humana Medicare	$530.50
Rate for Payer: Kaiser Permanente Commercial	$954.90
Rate for Payer: Kaiser Permanente Medicaid	$541.11
Rate for Payer: Kaiser Permanente Medicare	$530.50
Rate for Payer: MDX Hawaii PPO	$1,029.17
Rate for Payer: Ohana Health Plan Medicaid	$530.50
Rate for Payer: Ohana Health Plan Medicare	$530.50
Rate for Payer: UnitedHealthcare Medicaid	$54.40
Rate for Payer: UnitedHealthcare Medicare	$530.50
Rate for Payer: University Health Alliance Commercial	$237.13

XR Upper GI w/ Air Contrast

Facility

$1,061.00

Service Code	HCPCS 74246
Hospital Charge Code	1170566
Hospital Revenue Code	320
Min. Negotiated Rate	$901.85
Max. Negotiated Rate	$1,029.17
Rate for Payer: Cash Price	$689.65
Rate for Payer: Health Management Network Commercial	$901.85
Rate for Payer: Kaiser Permanente Commercial	$954.90
Rate for Payer: MDX Hawaii PPO	$1,029.17

XR Upper GI w/ Air Contrast + KUB

Facility

$635.00

Hospital Charge Code	1170568
Hospital Revenue Code	320
Min. Negotiated Rate	$317.50
Max. Negotiated Rate	$615.95
Rate for Payer: AlohaCare Medicaid	$317.50
Rate for Payer: AlohaCare Medicare	$317.50
Rate for Payer: Cash Price	$412.75
Rate for Payer: Devoted Health Medicare	$349.25
Rate for Payer: Hawaii Medical Service Association Medicare	$317.50
Rate for Payer: Hawaii Western Management Group Commercial	$603.25
Rate for Payer: Health Management Network Commercial	$539.75
Rate for Payer: Humana Medicare	$317.50
Rate for Payer: Kaiser Permanente Commercial	$571.50
Rate for Payer: Kaiser Permanente Medicaid	$323.85
Rate for Payer: Kaiser Permanente Medicare	$317.50
Rate for Payer: MDX Hawaii PPO	$615.95
Rate for Payer: Ohana Health Plan Medicaid	$317.50
Rate for Payer: Ohana Health Plan Medicare	$317.50
Rate for Payer: UnitedHealthcare Medicare	$317.50
Rate for Payer: University Health Alliance Commercial	$355.60

XR Upper GI w/ Air Contrast + KUB

Facility

$635.00

Hospital Charge Code	1170568
Hospital Revenue Code	320
Min. Negotiated Rate	$539.75
Max. Negotiated Rate	$615.95
Rate for Payer: Cash Price	$412.75
Rate for Payer: Health Management Network Commercial	$539.75
Rate for Payer: Kaiser Permanente Commercial	$571.50
Rate for Payer: MDX Hawaii PPO	$615.95

XR Upper GI w/ Air Contrast + KUB - Report

Professional

Both

$128.00

Service Code	HCPCS 74247 26
Hospital Charge Code	613601
Hospital Revenue Code	972
Min. Negotiated Rate	$108.80
Max. Negotiated Rate	$112.45
Rate for Payer: Cash Price	$83.20
Rate for Payer: Cash Price	$83.20
Rate for Payer: Hawaii Western Management Group Commercial	$112.45
Rate for Payer: Health Management Network Commercial	$108.80

XR Upper GI w/ Air Contrast - Report

Professional

Both

$244.00

Service Code	HCPCS 74246 26
Hospital Charge Code	613599
Hospital Revenue Code	972
Min. Negotiated Rate	$42.51
Max. Negotiated Rate	$207.40
Rate for Payer: AlohaCare Medicaid	$92.31
Rate for Payer: AlohaCare Medicare	$42.51
Rate for Payer: Cash Price	$158.60
Rate for Payer: Cash Price	$158.60
Rate for Payer: Devoted Health Medicare	$46.76
Rate for Payer: Hawaii Medical Service Association Medicare	$42.51
Rate for Payer: Hawaii Western Management Group Commercial	$110.48
Rate for Payer: Health Management Network Commercial	$207.40
Rate for Payer: Kaiser Permanente Commercial	$51.01
Rate for Payer: Kaiser Permanente Medicaid	$51.01
Rate for Payer: Kaiser Permanente Medicare	$51.01
Rate for Payer: Ohana Health Plan Medicaid	$92.31
Rate for Payer: Ohana Health Plan Medicare	$42.51
Rate for Payer: UnitedHealthcare Medicaid	$92.31
Rate for Payer: UnitedHealthcare Medicare	$42.51

XR Upper GI w/ Air w/ Small Bowel

Facility

$880.00

Service Code	HCPCS 74240
Hospital Charge Code	1170570
Hospital Revenue Code	320
Min. Negotiated Rate	$48.23
Max. Negotiated Rate	$853.60
Rate for Payer: AlohaCare Medicaid	$440.00
Rate for Payer: AlohaCare Medicare	$440.00
Rate for Payer: Cash Price	$572.00
Rate for Payer: Cash Price	$572.00
Rate for Payer: Devoted Health Medicare	$484.00
Rate for Payer: Hawaii Medical Service Association ABD	$48.23
Rate for Payer: Hawaii Medical Service Association Commercial	$224.00
Rate for Payer: Hawaii Medical Service Association Medicare	$440.00
Rate for Payer: Hawaii Medical Service Association Non-ABD	$52.32
Rate for Payer: Hawaii Western Management Group Commercial	$179.20
Rate for Payer: Health Management Network Commercial	$748.00
Rate for Payer: Humana Medicare	$440.00
Rate for Payer: Kaiser Permanente Commercial	$792.00
Rate for Payer: Kaiser Permanente Medicaid	$448.80
Rate for Payer: Kaiser Permanente Medicare	$440.00
Rate for Payer: MDX Hawaii PPO	$853.60
Rate for Payer: Ohana Health Plan Medicaid	$440.00
Rate for Payer: Ohana Health Plan Medicare	$440.00
Rate for Payer: UnitedHealthcare Medicaid	$48.23
Rate for Payer: UnitedHealthcare Medicare	$440.00
Rate for Payer: University Health Alliance Commercial	$208.88

XR Upper GI w/ Air w/ Small Bowel

Facility

$880.00

Service Code	HCPCS 74240
Hospital Charge Code	1170570
Hospital Revenue Code	320
Min. Negotiated Rate	$748.00
Max. Negotiated Rate	$853.60
Rate for Payer: Cash Price	$572.00
Rate for Payer: Health Management Network Commercial	$748.00
Rate for Payer: Kaiser Permanente Commercial	$792.00
Rate for Payer: MDX Hawaii PPO	$853.60

XR Upper GI w/ Air w/ Small Bowel - Report

Professional

Both

$244.00

Service Code	HCPCS 74240 26
Hospital Charge Code	613603
Hospital Revenue Code	972
Min. Negotiated Rate	$38.60
Max. Negotiated Rate	$207.40
Rate for Payer: AlohaCare Medicaid	$81.48
Rate for Payer: AlohaCare Medicare	$38.60
Rate for Payer: Cash Price	$158.60
Rate for Payer: Cash Price	$158.60
Rate for Payer: Devoted Health Medicare	$42.46
Rate for Payer: Hawaii Medical Service Association Medicare	$38.60
Rate for Payer: Hawaii Western Management Group Commercial	$102.44
Rate for Payer: Health Management Network Commercial	$207.40
Rate for Payer: Kaiser Permanente Commercial	$46.32
Rate for Payer: Kaiser Permanente Medicaid	$46.32
Rate for Payer: Kaiser Permanente Medicare	$46.32
Rate for Payer: Ohana Health Plan Medicaid	$81.48
Rate for Payer: Ohana Health Plan Medicare	$38.60
Rate for Payer: UnitedHealthcare Medicaid	$81.48
Rate for Payer: UnitedHealthcare Medicare	$38.60

XR Upper GI w/ Small Bowel

Facility

$880.00

Service Code	HCPCS 74240
Hospital Charge Code	1170574
Hospital Revenue Code	320
Min. Negotiated Rate	$748.00
Max. Negotiated Rate	$853.60
Rate for Payer: Cash Price	$572.00
Rate for Payer: Health Management Network Commercial	$748.00
Rate for Payer: Kaiser Permanente Commercial	$792.00
Rate for Payer: MDX Hawaii PPO	$853.60

XR Upper GI w/ Small Bowel

Facility

$880.00

Service Code	HCPCS 74240
Hospital Charge Code	1170574
Hospital Revenue Code	320
Min. Negotiated Rate	$48.23
Max. Negotiated Rate	$853.60
Rate for Payer: AlohaCare Medicaid	$440.00
Rate for Payer: AlohaCare Medicare	$440.00
Rate for Payer: Cash Price	$572.00
Rate for Payer: Cash Price	$572.00
Rate for Payer: Devoted Health Medicare	$484.00
Rate for Payer: Hawaii Medical Service Association ABD	$48.23
Rate for Payer: Hawaii Medical Service Association Commercial	$224.00
Rate for Payer: Hawaii Medical Service Association Medicare	$440.00
Rate for Payer: Hawaii Medical Service Association Non-ABD	$52.32
Rate for Payer: Hawaii Western Management Group Commercial	$179.20
Rate for Payer: Health Management Network Commercial	$748.00
Rate for Payer: Humana Medicare	$440.00
Rate for Payer: Kaiser Permanente Commercial	$792.00
Rate for Payer: Kaiser Permanente Medicaid	$448.80
Rate for Payer: Kaiser Permanente Medicare	$440.00
Rate for Payer: MDX Hawaii PPO	$853.60
Rate for Payer: Ohana Health Plan Medicaid	$440.00
Rate for Payer: Ohana Health Plan Medicare	$440.00
Rate for Payer: UnitedHealthcare Medicaid	$48.23
Rate for Payer: UnitedHealthcare Medicare	$440.00
Rate for Payer: University Health Alliance Commercial	$208.88

XR Upper GI w/ Small Bowel - Report

Professional

Both

$244.00

Service Code	HCPCS 74240 26
Hospital Charge Code	613605
Hospital Revenue Code	972
Min. Negotiated Rate	$38.60
Max. Negotiated Rate	$207.40
Rate for Payer: AlohaCare Medicaid	$81.48
Rate for Payer: AlohaCare Medicare	$38.60
Rate for Payer: Cash Price	$158.60
Rate for Payer: Cash Price	$158.60
Rate for Payer: Devoted Health Medicare	$42.46
Rate for Payer: Hawaii Medical Service Association Medicare	$38.60
Rate for Payer: Hawaii Western Management Group Commercial	$102.44
Rate for Payer: Health Management Network Commercial	$207.40
Rate for Payer: Kaiser Permanente Commercial	$46.32
Rate for Payer: Kaiser Permanente Medicaid	$46.32
Rate for Payer: Kaiser Permanente Medicare	$46.32
Rate for Payer: Ohana Health Plan Medicaid	$81.48
Rate for Payer: Ohana Health Plan Medicare	$38.60
Rate for Payer: UnitedHealthcare Medicaid	$81.48
Rate for Payer: UnitedHealthcare Medicare	$38.60

XR Urethrocystography Retrograde

Facility

$1,234.00

Service Code	HCPCS 74450 TC
Hospital Charge Code	1170578
Hospital Revenue Code	320
Min. Negotiated Rate	$48.23
Max. Negotiated Rate	$1,196.98
Rate for Payer: AlohaCare Medicaid	$617.00
Rate for Payer: AlohaCare Medicare	$617.00
Rate for Payer: Cash Price	$802.10
Rate for Payer: Cash Price	$802.10
Rate for Payer: Devoted Health Medicare	$678.70
Rate for Payer: Hawaii Medical Service Association ABD	$48.23
Rate for Payer: Hawaii Medical Service Association Medicare	$617.00
Rate for Payer: Hawaii Medical Service Association Non-ABD	$52.32
Rate for Payer: Hawaii Western Management Group Commercial	$1,172.30
Rate for Payer: Health Management Network Commercial	$1,048.90
Rate for Payer: Humana Medicare	$617.00
Rate for Payer: Kaiser Permanente Commercial	$1,110.60
Rate for Payer: Kaiser Permanente Medicaid	$629.34
Rate for Payer: Kaiser Permanente Medicare	$617.00
Rate for Payer: MDX Hawaii PPO	$1,196.98
Rate for Payer: Ohana Health Plan Medicaid	$617.00
Rate for Payer: Ohana Health Plan Medicare	$617.00
Rate for Payer: UnitedHealthcare Medicaid	$48.23
Rate for Payer: UnitedHealthcare Medicare	$617.00
Rate for Payer: University Health Alliance Commercial	$691.04

XR Urethrocystography Retrograde

Facility

$1,234.00

Service Code	HCPCS 74450 TC
Hospital Charge Code	1170578
Hospital Revenue Code	320
Min. Negotiated Rate	$1,048.90
Max. Negotiated Rate	$1,196.98
Rate for Payer: Cash Price	$802.10
Rate for Payer: Health Management Network Commercial	$1,048.90
Rate for Payer: Kaiser Permanente Commercial	$1,110.60
Rate for Payer: MDX Hawaii PPO	$1,196.98

XR Urethrocystography Retrograde - Report

Professional

Both

$96.00

Service Code	HCPCS 74450 26
Hospital Charge Code	613607
Hospital Revenue Code	972
Min. Negotiated Rate	$15.63
Max. Negotiated Rate	$82.41
Rate for Payer: AlohaCare Medicaid	$61.21
Rate for Payer: AlohaCare Medicare	$15.63
Rate for Payer: Cash Price	$62.40
Rate for Payer: Cash Price	$62.40
Rate for Payer: Devoted Health Medicare	$17.19
Rate for Payer: Hawaii Medical Service Association Medicare	$15.63
Rate for Payer: Hawaii Western Management Group Commercial	$82.41
Rate for Payer: Health Management Network Commercial	$81.60
Rate for Payer: Kaiser Permanente Commercial	$18.76
Rate for Payer: Kaiser Permanente Medicaid	$18.76
Rate for Payer: Kaiser Permanente Medicare	$18.76
Rate for Payer: Ohana Health Plan Medicaid	$61.21
Rate for Payer: Ohana Health Plan Medicare	$15.63
Rate for Payer: UnitedHealthcare Medicaid	$61.21
Rate for Payer: UnitedHealthcare Medicare	$15.63

XR Venogram Extremity Left

Facility

$3,143.00

Service Code	HCPCS 75820 LT
Hospital Charge Code	8211788
Hospital Revenue Code	320
Min. Negotiated Rate	$2,671.55
Max. Negotiated Rate	$3,048.71
Rate for Payer: Cash Price	$2,042.95
Rate for Payer: Health Management Network Commercial	$2,671.55
Rate for Payer: Kaiser Permanente Commercial	$2,828.70
Rate for Payer: MDX Hawaii PPO	$3,048.71

XR Venogram Extremity Left

Facility

$3,143.00

Service Code	HCPCS 75820 LT
Hospital Charge Code	8211788
Hospital Revenue Code	320
Min. Negotiated Rate	$31.51
Max. Negotiated Rate	$3,048.71
Rate for Payer: AlohaCare Medicaid	$1,571.50
Rate for Payer: AlohaCare Medicare	$1,571.50
Rate for Payer: Cash Price	$2,042.95
Rate for Payer: Cash Price	$2,042.95
Rate for Payer: Devoted Health Medicare	$1,728.65
Rate for Payer: Hawaii Medical Service Association ABD	$31.51
Rate for Payer: Hawaii Medical Service Association Medicare	$1,571.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$34.37
Rate for Payer: Hawaii Western Management Group Commercial	$2,985.85
Rate for Payer: Health Management Network Commercial	$2,671.55
Rate for Payer: Humana Medicare	$1,571.50
Rate for Payer: Kaiser Permanente Commercial	$2,828.70
Rate for Payer: Kaiser Permanente Medicaid	$1,602.93
Rate for Payer: Kaiser Permanente Medicare	$1,571.50
Rate for Payer: MDX Hawaii PPO	$3,048.71
Rate for Payer: Ohana Health Plan Medicaid	$1,571.50
Rate for Payer: Ohana Health Plan Medicare	$1,571.50
Rate for Payer: UnitedHealthcare Medicaid	$31.51
Rate for Payer: UnitedHealthcare Medicare	$1,571.50
Rate for Payer: University Health Alliance Commercial	$215.77

XR Venogram Extremity Left - Report

Professional

Both

$219.00

Service Code	HCPCS 75820 26,LT
Hospital Charge Code	8211790
Hospital Revenue Code	972
Min. Negotiated Rate	$69.94
Max. Negotiated Rate	$186.15
Rate for Payer: AlohaCare Medicaid	$69.94
Rate for Payer: Cash Price	$142.35
Rate for Payer: Cash Price	$142.35
Rate for Payer: Hawaii Western Management Group Commercial	$80.24
Rate for Payer: Health Management Network Commercial	$186.15
Rate for Payer: Ohana Health Plan Medicaid	$69.94
Rate for Payer: UnitedHealthcare Medicaid	$69.94

XR Venogram Extremity Right

Facility

$3,143.00

Service Code	HCPCS 75820 RT
Hospital Charge Code	8211791
Hospital Revenue Code	320
Min. Negotiated Rate	$2,671.55
Max. Negotiated Rate	$3,048.71
Rate for Payer: Cash Price	$2,042.95
Rate for Payer: Health Management Network Commercial	$2,671.55
Rate for Payer: Kaiser Permanente Commercial	$2,828.70
Rate for Payer: MDX Hawaii PPO	$3,048.71

XR Venogram Extremity Right

Facility

$3,143.00

Service Code	HCPCS 75820 RT
Hospital Charge Code	8211791
Hospital Revenue Code	320
Min. Negotiated Rate	$31.51
Max. Negotiated Rate	$3,048.71
Rate for Payer: AlohaCare Medicaid	$1,571.50
Rate for Payer: AlohaCare Medicare	$1,571.50
Rate for Payer: Cash Price	$2,042.95
Rate for Payer: Cash Price	$2,042.95
Rate for Payer: Devoted Health Medicare	$1,728.65
Rate for Payer: Hawaii Medical Service Association ABD	$31.51
Rate for Payer: Hawaii Medical Service Association Medicare	$1,571.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$34.37
Rate for Payer: Hawaii Western Management Group Commercial	$2,985.85
Rate for Payer: Health Management Network Commercial	$2,671.55
Rate for Payer: Humana Medicare	$1,571.50
Rate for Payer: Kaiser Permanente Commercial	$2,828.70
Rate for Payer: Kaiser Permanente Medicaid	$1,602.93
Rate for Payer: Kaiser Permanente Medicare	$1,571.50
Rate for Payer: MDX Hawaii PPO	$3,048.71
Rate for Payer: Ohana Health Plan Medicaid	$1,571.50
Rate for Payer: Ohana Health Plan Medicare	$1,571.50
Rate for Payer: UnitedHealthcare Medicaid	$31.51
Rate for Payer: UnitedHealthcare Medicare	$1,571.50
Rate for Payer: University Health Alliance Commercial	$215.77

XR Venogram Extremity Right - Report

Professional

Both

$219.00

Service Code	HCPCS 75820 26,RT
Hospital Charge Code	8211793
Hospital Revenue Code	972
Min. Negotiated Rate	$69.94
Max. Negotiated Rate	$186.15
Rate for Payer: AlohaCare Medicaid	$69.94
Rate for Payer: Cash Price	$142.35
Rate for Payer: Cash Price	$142.35
Rate for Payer: Hawaii Western Management Group Commercial	$80.24
Rate for Payer: Health Management Network Commercial	$186.15
Rate for Payer: Ohana Health Plan Medicaid	$69.94
Rate for Payer: UnitedHealthcare Medicaid	$69.94

XR Venography Extremity Bilateral

Facility

$3,143.00

Service Code	HCPCS 75822
Hospital Charge Code	8221479
Hospital Revenue Code	320
Min. Negotiated Rate	$48.85
Max. Negotiated Rate	$3,048.71
Rate for Payer: AlohaCare Medicaid	$1,571.50
Rate for Payer: AlohaCare Medicare	$1,571.50
Rate for Payer: Cash Price	$2,042.95
Rate for Payer: Cash Price	$2,042.95
Rate for Payer: Devoted Health Medicare	$1,728.65
Rate for Payer: Hawaii Medical Service Association ABD	$48.85
Rate for Payer: Hawaii Medical Service Association Commercial	$2,010.31
Rate for Payer: Hawaii Medical Service Association Medicare	$1,571.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$52.97
Rate for Payer: Hawaii Western Management Group Commercial	$1,608.25
Rate for Payer: Health Management Network Commercial	$2,671.55
Rate for Payer: Humana Medicare	$1,571.50
Rate for Payer: Kaiser Permanente Commercial	$2,828.70
Rate for Payer: Kaiser Permanente Medicaid	$1,602.93
Rate for Payer: Kaiser Permanente Medicare	$1,571.50
Rate for Payer: MDX Hawaii PPO	$3,048.71
Rate for Payer: Ohana Health Plan Medicaid	$1,571.50
Rate for Payer: Ohana Health Plan Medicare	$1,571.50
Rate for Payer: UnitedHealthcare Medicaid	$48.85
Rate for Payer: UnitedHealthcare Medicare	$1,571.50
Rate for Payer: University Health Alliance Commercial	$272.52

XR Venography Extremity Bilateral

Facility

$3,143.00

Service Code	HCPCS 75822
Hospital Charge Code	8221479
Hospital Revenue Code	320
Min. Negotiated Rate	$2,671.55
Max. Negotiated Rate	$3,048.71
Rate for Payer: Cash Price	$2,042.95
Rate for Payer: Health Management Network Commercial	$2,671.55
Rate for Payer: Kaiser Permanente Commercial	$2,828.70
Rate for Payer: MDX Hawaii PPO	$3,048.71

Know your out-of-pocket cost for care.

All Charges