Samuel Mahelona Memorial Hospital

All Charges

Charge

Type

Setting

Price

CANNULATED CANC SCREW, FT, 7.0X75MM

Facility

$519.00

Service Code	HCPCS C1713
Hospital Charge Code	12974117
Hospital Revenue Code	278
Min. Negotiated Rate	$290.64
Max. Negotiated Rate	$503.43
Rate for Payer: Cash Price	$337.35
Rate for Payer: Hawaii Western Management Group Commercial	$363.30
Rate for Payer: Health Management Network Commercial	$441.15
Rate for Payer: Kaiser Permanente Commercial	$467.10
Rate for Payer: MDX Hawaii PPO	$503.43
Rate for Payer: University Health Alliance Commercial	$290.64

CANNULATED CANC SCREW, FT, 7.0X75MM

Facility

$519.00

Service Code	HCPCS C1713
Hospital Charge Code	12974117
Hospital Revenue Code	278
Min. Negotiated Rate	$259.50
Max. Negotiated Rate	$503.43
Rate for Payer: AlohaCare Medicaid	$259.50
Rate for Payer: AlohaCare Medicare	$259.50
Rate for Payer: Cash Price	$337.35
Rate for Payer: Devoted Health Medicare	$285.45
Rate for Payer: Hawaii Medical Service Association Medicare	$259.50
Rate for Payer: Hawaii Western Management Group Commercial	$363.30
Rate for Payer: Health Management Network Commercial	$441.15
Rate for Payer: Humana Medicare	$259.50
Rate for Payer: Kaiser Permanente Commercial	$467.10
Rate for Payer: Kaiser Permanente Medicaid	$264.69
Rate for Payer: Kaiser Permanente Medicare	$259.50
Rate for Payer: MDX Hawaii PPO	$503.43
Rate for Payer: Ohana Health Plan Medicaid	$259.50
Rate for Payer: Ohana Health Plan Medicare	$259.50
Rate for Payer: UnitedHealthcare Medicare	$259.50
Rate for Payer: University Health Alliance Commercial	$290.64

CANNULATED CANC SCREW, FT, 7.0X80MM

Facility

$519.00

Service Code	HCPCS C1713
Hospital Charge Code	12974118
Hospital Revenue Code	278
Min. Negotiated Rate	$290.64
Max. Negotiated Rate	$503.43
Rate for Payer: Cash Price	$337.35
Rate for Payer: Hawaii Western Management Group Commercial	$363.30
Rate for Payer: Health Management Network Commercial	$441.15
Rate for Payer: Kaiser Permanente Commercial	$467.10
Rate for Payer: MDX Hawaii PPO	$503.43
Rate for Payer: University Health Alliance Commercial	$290.64

CANNULATED CANC SCREW, FT, 7.0X80MM

Facility

$519.00

Service Code	HCPCS C1713
Hospital Charge Code	12974118
Hospital Revenue Code	278
Min. Negotiated Rate	$259.50
Max. Negotiated Rate	$503.43
Rate for Payer: AlohaCare Medicaid	$259.50
Rate for Payer: AlohaCare Medicare	$259.50
Rate for Payer: Cash Price	$337.35
Rate for Payer: Devoted Health Medicare	$285.45
Rate for Payer: Hawaii Medical Service Association Medicare	$259.50
Rate for Payer: Hawaii Western Management Group Commercial	$363.30
Rate for Payer: Health Management Network Commercial	$441.15
Rate for Payer: Humana Medicare	$259.50
Rate for Payer: Kaiser Permanente Commercial	$467.10
Rate for Payer: Kaiser Permanente Medicaid	$264.69
Rate for Payer: Kaiser Permanente Medicare	$259.50
Rate for Payer: MDX Hawaii PPO	$503.43
Rate for Payer: Ohana Health Plan Medicaid	$259.50
Rate for Payer: Ohana Health Plan Medicare	$259.50
Rate for Payer: UnitedHealthcare Medicare	$259.50
Rate for Payer: University Health Alliance Commercial	$290.64

CANNULATED CANC SCREW, FT, 7.0X85MM

Facility

$519.00

Service Code	HCPCS C1713
Hospital Charge Code	12974129
Hospital Revenue Code	278
Min. Negotiated Rate	$259.50
Max. Negotiated Rate	$503.43
Rate for Payer: AlohaCare Medicaid	$259.50
Rate for Payer: AlohaCare Medicare	$259.50
Rate for Payer: Cash Price	$337.35
Rate for Payer: Devoted Health Medicare	$285.45
Rate for Payer: Hawaii Medical Service Association Medicare	$259.50
Rate for Payer: Hawaii Western Management Group Commercial	$363.30
Rate for Payer: Health Management Network Commercial	$441.15
Rate for Payer: Humana Medicare	$259.50
Rate for Payer: Kaiser Permanente Commercial	$467.10
Rate for Payer: Kaiser Permanente Medicaid	$264.69
Rate for Payer: Kaiser Permanente Medicare	$259.50
Rate for Payer: MDX Hawaii PPO	$503.43
Rate for Payer: Ohana Health Plan Medicaid	$259.50
Rate for Payer: Ohana Health Plan Medicare	$259.50
Rate for Payer: UnitedHealthcare Medicare	$259.50
Rate for Payer: University Health Alliance Commercial	$290.64

CANNULATED CANC SCREW, FT, 7.0X85MM

Facility

$519.00

Service Code	HCPCS C1713
Hospital Charge Code	12974129
Hospital Revenue Code	278
Min. Negotiated Rate	$290.64
Max. Negotiated Rate	$503.43
Rate for Payer: Cash Price	$337.35
Rate for Payer: Hawaii Western Management Group Commercial	$363.30
Rate for Payer: Health Management Network Commercial	$441.15
Rate for Payer: Kaiser Permanente Commercial	$467.10
Rate for Payer: MDX Hawaii PPO	$503.43
Rate for Payer: University Health Alliance Commercial	$290.64

CANNULATED CANC SCREW, FT, 7.0X90MM

Facility

$519.00

Service Code	HCPCS C1713
Hospital Charge Code	12974119
Hospital Revenue Code	278
Min. Negotiated Rate	$259.50
Max. Negotiated Rate	$503.43
Rate for Payer: AlohaCare Medicaid	$259.50
Rate for Payer: AlohaCare Medicare	$259.50
Rate for Payer: Cash Price	$337.35
Rate for Payer: Devoted Health Medicare	$285.45
Rate for Payer: Hawaii Medical Service Association Medicare	$259.50
Rate for Payer: Hawaii Western Management Group Commercial	$363.30
Rate for Payer: Health Management Network Commercial	$441.15
Rate for Payer: Humana Medicare	$259.50
Rate for Payer: Kaiser Permanente Commercial	$467.10
Rate for Payer: Kaiser Permanente Medicaid	$264.69
Rate for Payer: Kaiser Permanente Medicare	$259.50
Rate for Payer: MDX Hawaii PPO	$503.43
Rate for Payer: Ohana Health Plan Medicaid	$259.50
Rate for Payer: Ohana Health Plan Medicare	$259.50
Rate for Payer: UnitedHealthcare Medicare	$259.50
Rate for Payer: University Health Alliance Commercial	$290.64

CANNULATED CANC SCREW, FT, 7.0X90MM

Facility

$519.00

Service Code	HCPCS C1713
Hospital Charge Code	12974119
Hospital Revenue Code	278
Min. Negotiated Rate	$290.64
Max. Negotiated Rate	$503.43
Rate for Payer: Cash Price	$337.35
Rate for Payer: Hawaii Western Management Group Commercial	$363.30
Rate for Payer: Health Management Network Commercial	$441.15
Rate for Payer: Kaiser Permanente Commercial	$467.10
Rate for Payer: MDX Hawaii PPO	$503.43
Rate for Payer: University Health Alliance Commercial	$290.64

CANNULATED CANC SCREW, FT, 7.0X95MM

Facility

$519.00

Service Code	HCPCS C1713
Hospital Charge Code	12974125
Hospital Revenue Code	278
Min. Negotiated Rate	$290.64
Max. Negotiated Rate	$503.43
Rate for Payer: Cash Price	$337.35
Rate for Payer: Hawaii Western Management Group Commercial	$363.30
Rate for Payer: Health Management Network Commercial	$441.15
Rate for Payer: Kaiser Permanente Commercial	$467.10
Rate for Payer: MDX Hawaii PPO	$503.43
Rate for Payer: University Health Alliance Commercial	$290.64

CANNULATED CANC SCREW, FT, 7.0X95MM

Facility

$519.00

Service Code	HCPCS C1713
Hospital Charge Code	12974125
Hospital Revenue Code	278
Min. Negotiated Rate	$259.50
Max. Negotiated Rate	$503.43
Rate for Payer: AlohaCare Medicaid	$259.50
Rate for Payer: AlohaCare Medicare	$259.50
Rate for Payer: Cash Price	$337.35
Rate for Payer: Devoted Health Medicare	$285.45
Rate for Payer: Hawaii Medical Service Association Medicare	$259.50
Rate for Payer: Hawaii Western Management Group Commercial	$363.30
Rate for Payer: Health Management Network Commercial	$441.15
Rate for Payer: Humana Medicare	$259.50
Rate for Payer: Kaiser Permanente Commercial	$467.10
Rate for Payer: Kaiser Permanente Medicaid	$264.69
Rate for Payer: Kaiser Permanente Medicare	$259.50
Rate for Payer: MDX Hawaii PPO	$503.43
Rate for Payer: Ohana Health Plan Medicaid	$259.50
Rate for Payer: Ohana Health Plan Medicare	$259.50
Rate for Payer: UnitedHealthcare Medicare	$259.50
Rate for Payer: University Health Alliance Commercial	$290.64

CANNULA TRACHEOSTOMY TUBE 7.6MM SHILEY INNER CANNULA DCT 79MM LENGHTH

Facility

$192.00

Hospital Charge Code	8266673
Hospital Revenue Code	270
Min. Negotiated Rate	$163.20
Max. Negotiated Rate	$186.24
Rate for Payer: Cash Price	$124.80
Rate for Payer: Health Management Network Commercial	$163.20
Rate for Payer: Kaiser Permanente Commercial	$172.80
Rate for Payer: MDX Hawaii PPO	$186.24

CANNULA TRACHEOSTOMY TUBE 7.6MM SHILEY INNER CANNULA DCT 79MM LENGHTH

Facility

$192.00

Hospital Charge Code	8266673
Hospital Revenue Code	270
Min. Negotiated Rate	$96.00
Max. Negotiated Rate	$186.24
Rate for Payer: AlohaCare Medicaid	$96.00
Rate for Payer: AlohaCare Medicare	$96.00
Rate for Payer: Cash Price	$124.80
Rate for Payer: Devoted Health Medicare	$105.60
Rate for Payer: Hawaii Medical Service Association Medicare	$96.00
Rate for Payer: Hawaii Western Management Group Commercial	$182.40
Rate for Payer: Health Management Network Commercial	$163.20
Rate for Payer: Humana Medicare	$96.00
Rate for Payer: Kaiser Permanente Commercial	$172.80
Rate for Payer: Kaiser Permanente Medicaid	$97.92
Rate for Payer: Kaiser Permanente Medicare	$96.00
Rate for Payer: MDX Hawaii PPO	$186.24
Rate for Payer: Ohana Health Plan Medicaid	$96.00
Rate for Payer: Ohana Health Plan Medicare	$96.00
Rate for Payer: UnitedHealthcare Medicare	$96.00
Rate for Payer: University Health Alliance Commercial	$139.95

CANNULA TRACH TUBE 5.0MM SHILEY

Facility

$258.00

Hospital Charge Code	8266671
Hospital Revenue Code	270
Min. Negotiated Rate	$129.00
Max. Negotiated Rate	$250.26
Rate for Payer: AlohaCare Medicaid	$129.00
Rate for Payer: AlohaCare Medicare	$129.00
Rate for Payer: Cash Price	$167.70
Rate for Payer: Devoted Health Medicare	$141.90
Rate for Payer: Hawaii Medical Service Association Medicare	$129.00
Rate for Payer: Hawaii Western Management Group Commercial	$245.10
Rate for Payer: Health Management Network Commercial	$219.30
Rate for Payer: Humana Medicare	$129.00
Rate for Payer: Kaiser Permanente Commercial	$232.20
Rate for Payer: Kaiser Permanente Medicaid	$131.58
Rate for Payer: Kaiser Permanente Medicare	$129.00
Rate for Payer: MDX Hawaii PPO	$250.26
Rate for Payer: Ohana Health Plan Medicaid	$129.00
Rate for Payer: Ohana Health Plan Medicare	$129.00
Rate for Payer: UnitedHealthcare Medicare	$129.00
Rate for Payer: University Health Alliance Commercial	$188.06

CANNULA TRACH TUBE 5.0MM SHILEY

Facility

$258.00

Hospital Charge Code	8266671
Hospital Revenue Code	270
Min. Negotiated Rate	$219.30
Max. Negotiated Rate	$250.26
Rate for Payer: Cash Price	$167.70
Rate for Payer: Health Management Network Commercial	$219.30
Rate for Payer: Kaiser Permanente Commercial	$232.20
Rate for Payer: MDX Hawaii PPO	$250.26

CANNULA TRACH TUBE 6.4MM SHILEY

Facility

$22.00

Hospital Charge Code	8266672
Hospital Revenue Code	270
Min. Negotiated Rate	$11.00
Max. Negotiated Rate	$21.34
Rate for Payer: AlohaCare Medicaid	$11.00
Rate for Payer: AlohaCare Medicare	$11.00
Rate for Payer: Cash Price	$14.30
Rate for Payer: Devoted Health Medicare	$12.10
Rate for Payer: Hawaii Medical Service Association Medicare	$11.00
Rate for Payer: Hawaii Western Management Group Commercial	$20.90
Rate for Payer: Health Management Network Commercial	$18.70
Rate for Payer: Humana Medicare	$11.00
Rate for Payer: Kaiser Permanente Commercial	$19.80
Rate for Payer: Kaiser Permanente Medicaid	$11.22
Rate for Payer: Kaiser Permanente Medicare	$11.00
Rate for Payer: MDX Hawaii PPO	$21.34
Rate for Payer: Ohana Health Plan Medicaid	$11.00
Rate for Payer: Ohana Health Plan Medicare	$11.00
Rate for Payer: UnitedHealthcare Medicare	$11.00
Rate for Payer: University Health Alliance Commercial	$16.04

CANNULA TRACH TUBE 6.4MM SHILEY

Facility

$22.00

Hospital Charge Code	8266672
Hospital Revenue Code	270
Min. Negotiated Rate	$18.70
Max. Negotiated Rate	$21.34
Rate for Payer: Cash Price	$14.30
Rate for Payer: Health Management Network Commercial	$18.70
Rate for Payer: Kaiser Permanente Commercial	$19.80
Rate for Payer: MDX Hawaii PPO	$21.34

Capillary Blood Draw Nursing

Facility

$405.00

Service Code	HCPCS 36591
Hospital Charge Code	11934637
Hospital Revenue Code	300
Min. Negotiated Rate	$12.68
Max. Negotiated Rate	$392.85
Rate for Payer: AlohaCare Medicaid	$202.50
Rate for Payer: AlohaCare Medicare	$202.50
Rate for Payer: Cash Price	$263.25
Rate for Payer: Cash Price	$263.25
Rate for Payer: Devoted Health Medicare	$222.75
Rate for Payer: Hawaii Medical Service Association Commercial	$169.91
Rate for Payer: Hawaii Medical Service Association Medicare	$202.50
Rate for Payer: Hawaii Western Management Group Commercial	$384.75
Rate for Payer: Health Management Network Commercial	$344.25
Rate for Payer: Humana Medicare	$202.50
Rate for Payer: Kaiser Permanente Commercial	$364.50
Rate for Payer: Kaiser Permanente Medicaid	$206.55
Rate for Payer: Kaiser Permanente Medicare	$202.50
Rate for Payer: MDX Hawaii PPO	$392.85
Rate for Payer: Ohana Health Plan Medicaid	$202.50
Rate for Payer: Ohana Health Plan Medicare	$202.50
Rate for Payer: UnitedHealthcare Medicaid	$12.68
Rate for Payer: UnitedHealthcare Medicare	$202.50
Rate for Payer: University Health Alliance Commercial	$226.80

Capillary Blood Draw Nursing

Facility

$405.00

Service Code	HCPCS 36591
Hospital Charge Code	11934637
Hospital Revenue Code	300
Min. Negotiated Rate	$344.25
Max. Negotiated Rate	$392.85
Rate for Payer: Cash Price	$263.25
Rate for Payer: Health Management Network Commercial	$344.25
Rate for Payer: Kaiser Permanente Commercial	$364.50
Rate for Payer: MDX Hawaii PPO	$392.85

CAPILLARY BLOOD DRAW NURSING CHARGE

Facility

$12.00

Service Code	HCPCS 36416
Hospital Charge Code	8280949
Hospital Revenue Code	300
Min. Negotiated Rate	$10.20
Max. Negotiated Rate	$11.64
Rate for Payer: Cash Price	$7.80
Rate for Payer: Health Management Network Commercial	$10.20
Rate for Payer: Kaiser Permanente Commercial	$10.80
Rate for Payer: MDX Hawaii PPO	$11.64

CAPILLARY BLOOD DRAW NURSING CHARGE

Facility

$12.00

Service Code	HCPCS 36416
Hospital Charge Code	8280949
Hospital Revenue Code	300
Min. Negotiated Rate	$6.00
Max. Negotiated Rate	$11.64
Rate for Payer: AlohaCare Medicaid	$6.00
Rate for Payer: AlohaCare Medicare	$6.00
Rate for Payer: Cash Price	$7.80
Rate for Payer: Devoted Health Medicare	$6.60
Rate for Payer: Hawaii Medical Service Association Medicare	$6.00
Rate for Payer: Hawaii Western Management Group Commercial	$11.40
Rate for Payer: Health Management Network Commercial	$10.20
Rate for Payer: Humana Medicare	$6.00
Rate for Payer: Kaiser Permanente Commercial	$10.80
Rate for Payer: Kaiser Permanente Medicaid	$6.12
Rate for Payer: Kaiser Permanente Medicare	$6.00
Rate for Payer: MDX Hawaii PPO	$11.64
Rate for Payer: Ohana Health Plan Medicaid	$6.00
Rate for Payer: Ohana Health Plan Medicare	$6.00
Rate for Payer: UnitedHealthcare Medicare	$6.00
Rate for Payer: University Health Alliance Commercial	$6.72

carBAMazepine 200 mg tablet [HHSC]

Facility

$9.14

Service Code	NDC 68084044401
Hospital Charge Code	2500142
Hospital Revenue Code	250
Min. Negotiated Rate	$4.57
Max. Negotiated Rate	$8.87
Rate for Payer: AlohaCare Medicaid	$4.57
Rate for Payer: AlohaCare Medicare	$4.57
Rate for Payer: Cash Price	$5.94
Rate for Payer: Devoted Health Medicare	$5.03
Rate for Payer: Hawaii Medical Service Association Medicare	$4.57
Rate for Payer: Hawaii Western Management Group Commercial	$8.68
Rate for Payer: Health Management Network Commercial	$7.77
Rate for Payer: Humana Medicare	$4.57
Rate for Payer: Kaiser Permanente Commercial	$8.23
Rate for Payer: Kaiser Permanente Medicaid	$4.66
Rate for Payer: Kaiser Permanente Medicare	$4.57
Rate for Payer: MDX Hawaii PPO	$8.87
Rate for Payer: Ohana Health Plan Medicaid	$4.57
Rate for Payer: Ohana Health Plan Medicare	$4.57
Rate for Payer: UnitedHealthcare Medicaid	$5.48
Rate for Payer: UnitedHealthcare Medicare	$4.57
Rate for Payer: University Health Alliance Commercial	$6.66

carBAMazepine 200 mg tablet [HHSC]

Facility

$8.89

Service Code	NDC 75834022101
Hospital Charge Code	2500142
Hospital Revenue Code	250
Min. Negotiated Rate	$7.56
Max. Negotiated Rate	$8.62
Rate for Payer: Cash Price	$5.78
Rate for Payer: Health Management Network Commercial	$7.56
Rate for Payer: Kaiser Permanente Commercial	$8.00
Rate for Payer: MDX Hawaii PPO	$8.62

carBAMazepine 200 mg tablet [HHSC]

Facility

$9.14

Service Code	NDC 68084044401
Hospital Charge Code	2500142
Hospital Revenue Code	250
Min. Negotiated Rate	$7.77
Max. Negotiated Rate	$8.87
Rate for Payer: Cash Price	$5.94
Rate for Payer: Health Management Network Commercial	$7.77
Rate for Payer: Kaiser Permanente Commercial	$8.23
Rate for Payer: MDX Hawaii PPO	$8.87

carBAMazepine 200 mg tablet [HHSC]

Facility

$8.89

Service Code	NDC 51672400501
Hospital Charge Code	2500142
Hospital Revenue Code	250
Min. Negotiated Rate	$4.45
Max. Negotiated Rate	$8.62
Rate for Payer: AlohaCare Medicaid	$4.45
Rate for Payer: AlohaCare Medicare	$4.45
Rate for Payer: Cash Price	$5.78
Rate for Payer: Devoted Health Medicare	$4.89
Rate for Payer: Hawaii Medical Service Association Medicare	$4.45
Rate for Payer: Hawaii Western Management Group Commercial	$8.45
Rate for Payer: Health Management Network Commercial	$7.56
Rate for Payer: Humana Medicare	$4.45
Rate for Payer: Kaiser Permanente Commercial	$8.00
Rate for Payer: Kaiser Permanente Medicaid	$4.53
Rate for Payer: Kaiser Permanente Medicare	$4.45
Rate for Payer: MDX Hawaii PPO	$8.62
Rate for Payer: Ohana Health Plan Medicaid	$4.45
Rate for Payer: Ohana Health Plan Medicare	$4.45
Rate for Payer: UnitedHealthcare Medicaid	$5.33
Rate for Payer: UnitedHealthcare Medicare	$4.45
Rate for Payer: University Health Alliance Commercial	$6.48

carBAMazepine 200 mg tablet [HHSC]

Facility

$8.89

Service Code	NDC 60505018300
Hospital Charge Code	2500142
Hospital Revenue Code	250
Min. Negotiated Rate	$4.45
Max. Negotiated Rate	$8.62
Rate for Payer: AlohaCare Medicaid	$4.45
Rate for Payer: AlohaCare Medicare	$4.45
Rate for Payer: Cash Price	$5.78
Rate for Payer: Devoted Health Medicare	$4.89
Rate for Payer: Hawaii Medical Service Association Medicare	$4.45
Rate for Payer: Hawaii Western Management Group Commercial	$8.45
Rate for Payer: Health Management Network Commercial	$7.56
Rate for Payer: Humana Medicare	$4.45
Rate for Payer: Kaiser Permanente Commercial	$8.00
Rate for Payer: Kaiser Permanente Medicaid	$4.53
Rate for Payer: Kaiser Permanente Medicare	$4.45
Rate for Payer: MDX Hawaii PPO	$8.62
Rate for Payer: Ohana Health Plan Medicaid	$4.45
Rate for Payer: Ohana Health Plan Medicare	$4.45
Rate for Payer: UnitedHealthcare Medicaid	$5.33
Rate for Payer: UnitedHealthcare Medicare	$4.45
Rate for Payer: University Health Alliance Commercial	$6.48

Know your out-of-pocket cost for care.

All Charges