Samuel Mahelona Memorial Hospital

All Charges

Charge

Type

Setting

Price

CORONARY BYPASS WITH PTCA WITHOUT MCC

Facility

$140,505.46

Service Code	MSDRG 232
Min. Negotiated Rate	$140,505.46
Max. Negotiated Rate	$140,505.46
Rate for Payer: Hawaii Medical Service Association Commercial	$140,505.46

CORONARY INTRAVASCULAR LITHOTRIPSY WITH INTRALUMINAL DEVICE WITH MCC

Facility

$40,483.02

Service Code	MSDRG 323
Min. Negotiated Rate	$40,483.02
Max. Negotiated Rate	$40,483.02
Rate for Payer: Hawaii Medical Service Association Commercial	$40,483.02

CORONARY INTRAVASCULAR LITHOTRIPSY WITH INTRALUMINAL DEVICE WITHOUT MCC

Facility

$40,483.02

Service Code	MSDRG 324
Min. Negotiated Rate	$40,483.02
Max. Negotiated Rate	$40,483.02
Rate for Payer: Hawaii Medical Service Association Commercial	$40,483.02

CORONARY INTRAVASCULAR LITHOTRIPSY WITHOUT INTRALUMINAL DEVICE

Facility

$38,112.82

Service Code	MSDRG 325
Min. Negotiated Rate	$38,112.82
Max. Negotiated Rate	$38,112.82
Rate for Payer: Hawaii Medical Service Association Commercial	$38,112.82

CORONAVIRUS AG IA POC

Professional

Both

$83.00

Service Code	HCPCS 87426 QW
Hospital Charge Code	9464998
Hospital Revenue Code	306
Min. Negotiated Rate	$35.33
Max. Negotiated Rate	$70.55
Rate for Payer: AlohaCare Medicaid	$35.33
Rate for Payer: AlohaCare Medicare	$35.33
Rate for Payer: Cash Price	$53.95
Rate for Payer: Cash Price	$53.95
Rate for Payer: Devoted Health Medicare	$38.86
Rate for Payer: Hawaii Medical Service Association Medicare	$35.33
Rate for Payer: Hawaii Western Management Group Commercial	$45.23
Rate for Payer: Health Management Network Commercial	$70.55
Rate for Payer: Kaiser Permanente Commercial	$42.40
Rate for Payer: Kaiser Permanente Medicaid	$42.40
Rate for Payer: Kaiser Permanente Medicare	$42.40
Rate for Payer: Ohana Health Plan Medicaid	$35.33
Rate for Payer: Ohana Health Plan Medicare	$35.33
Rate for Payer: UnitedHealthcare Medicaid	$35.33
Rate for Payer: UnitedHealthcare Medicare	$35.33

CORTEX SCREW, TI, 2.4 X 10MM

Facility

$193.00

Service Code	HCPCS C1713
Hospital Charge Code	12974372
Hospital Revenue Code	278
Min. Negotiated Rate	$108.08
Max. Negotiated Rate	$187.21
Rate for Payer: Cash Price	$125.45
Rate for Payer: Hawaii Western Management Group Commercial	$135.10
Rate for Payer: Health Management Network Commercial	$164.05
Rate for Payer: Kaiser Permanente Commercial	$173.70
Rate for Payer: MDX Hawaii PPO	$187.21
Rate for Payer: University Health Alliance Commercial	$108.08

CORTEX SCREW, TI, 2.4 X 10MM

Facility

$193.00

Service Code	HCPCS C1713
Hospital Charge Code	12974372
Hospital Revenue Code	278
Min. Negotiated Rate	$96.50
Max. Negotiated Rate	$187.21
Rate for Payer: AlohaCare Medicaid	$96.50
Rate for Payer: AlohaCare Medicare	$96.50
Rate for Payer: Cash Price	$125.45
Rate for Payer: Devoted Health Medicare	$106.15
Rate for Payer: Hawaii Medical Service Association Medicare	$96.50
Rate for Payer: Hawaii Western Management Group Commercial	$135.10
Rate for Payer: Health Management Network Commercial	$164.05
Rate for Payer: Humana Medicare	$96.50
Rate for Payer: Kaiser Permanente Commercial	$173.70
Rate for Payer: Kaiser Permanente Medicaid	$98.43
Rate for Payer: Kaiser Permanente Medicare	$96.50
Rate for Payer: MDX Hawaii PPO	$187.21
Rate for Payer: Ohana Health Plan Medicaid	$96.50
Rate for Payer: Ohana Health Plan Medicare	$96.50
Rate for Payer: UnitedHealthcare Medicare	$96.50
Rate for Payer: University Health Alliance Commercial	$108.08

CORTEX SCREW, TI, 2.4 X 12MM

Facility

$193.00

Service Code	HCPCS C1713
Hospital Charge Code	12974373
Hospital Revenue Code	278
Min. Negotiated Rate	$96.50
Max. Negotiated Rate	$187.21
Rate for Payer: AlohaCare Medicaid	$96.50
Rate for Payer: AlohaCare Medicare	$96.50
Rate for Payer: Cash Price	$125.45
Rate for Payer: Devoted Health Medicare	$106.15
Rate for Payer: Hawaii Medical Service Association Medicare	$96.50
Rate for Payer: Hawaii Western Management Group Commercial	$135.10
Rate for Payer: Health Management Network Commercial	$164.05
Rate for Payer: Humana Medicare	$96.50
Rate for Payer: Kaiser Permanente Commercial	$173.70
Rate for Payer: Kaiser Permanente Medicaid	$98.43
Rate for Payer: Kaiser Permanente Medicare	$96.50
Rate for Payer: MDX Hawaii PPO	$187.21
Rate for Payer: Ohana Health Plan Medicaid	$96.50
Rate for Payer: Ohana Health Plan Medicare	$96.50
Rate for Payer: UnitedHealthcare Medicare	$96.50
Rate for Payer: University Health Alliance Commercial	$108.08

CORTEX SCREW, TI, 2.4 X 12MM

Facility

$193.00

Service Code	HCPCS C1713
Hospital Charge Code	12974373
Hospital Revenue Code	278
Min. Negotiated Rate	$108.08
Max. Negotiated Rate	$187.21
Rate for Payer: Cash Price	$125.45
Rate for Payer: Hawaii Western Management Group Commercial	$135.10
Rate for Payer: Health Management Network Commercial	$164.05
Rate for Payer: Kaiser Permanente Commercial	$173.70
Rate for Payer: MDX Hawaii PPO	$187.21
Rate for Payer: University Health Alliance Commercial	$108.08

CORTEX SCREW, TI, 2.4 X 16MM

Facility

$193.00

Service Code	HCPCS C1713
Hospital Charge Code	12974374
Hospital Revenue Code	278
Min. Negotiated Rate	$96.50
Max. Negotiated Rate	$187.21
Rate for Payer: AlohaCare Medicaid	$96.50
Rate for Payer: AlohaCare Medicare	$96.50
Rate for Payer: Cash Price	$125.45
Rate for Payer: Devoted Health Medicare	$106.15
Rate for Payer: Hawaii Medical Service Association Medicare	$96.50
Rate for Payer: Hawaii Western Management Group Commercial	$135.10
Rate for Payer: Health Management Network Commercial	$164.05
Rate for Payer: Humana Medicare	$96.50
Rate for Payer: Kaiser Permanente Commercial	$173.70
Rate for Payer: Kaiser Permanente Medicaid	$98.43
Rate for Payer: Kaiser Permanente Medicare	$96.50
Rate for Payer: MDX Hawaii PPO	$187.21
Rate for Payer: Ohana Health Plan Medicaid	$96.50
Rate for Payer: Ohana Health Plan Medicare	$96.50
Rate for Payer: UnitedHealthcare Medicare	$96.50
Rate for Payer: University Health Alliance Commercial	$108.08

CORTEX SCREW, TI, 2.4 X 16MM

Facility

$193.00

Service Code	HCPCS C1713
Hospital Charge Code	12974374
Hospital Revenue Code	278
Min. Negotiated Rate	$108.08
Max. Negotiated Rate	$187.21
Rate for Payer: Cash Price	$125.45
Rate for Payer: Hawaii Western Management Group Commercial	$135.10
Rate for Payer: Health Management Network Commercial	$164.05
Rate for Payer: Kaiser Permanente Commercial	$173.70
Rate for Payer: MDX Hawaii PPO	$187.21
Rate for Payer: University Health Alliance Commercial	$108.08

CORTEX SCREW, TI, 2.4 X 18MM

Facility

$193.00

Service Code	HCPCS C1713
Hospital Charge Code	12974366
Hospital Revenue Code	278
Min. Negotiated Rate	$96.50
Max. Negotiated Rate	$187.21
Rate for Payer: AlohaCare Medicaid	$96.50
Rate for Payer: AlohaCare Medicare	$96.50
Rate for Payer: Cash Price	$125.45
Rate for Payer: Devoted Health Medicare	$106.15
Rate for Payer: Hawaii Medical Service Association Medicare	$96.50
Rate for Payer: Hawaii Western Management Group Commercial	$135.10
Rate for Payer: Health Management Network Commercial	$164.05
Rate for Payer: Humana Medicare	$96.50
Rate for Payer: Kaiser Permanente Commercial	$173.70
Rate for Payer: Kaiser Permanente Medicaid	$98.43
Rate for Payer: Kaiser Permanente Medicare	$96.50
Rate for Payer: MDX Hawaii PPO	$187.21
Rate for Payer: Ohana Health Plan Medicaid	$96.50
Rate for Payer: Ohana Health Plan Medicare	$96.50
Rate for Payer: UnitedHealthcare Medicare	$96.50
Rate for Payer: University Health Alliance Commercial	$108.08

CORTEX SCREW, TI, 2.4 X 18MM

Facility

$193.00

Service Code	HCPCS C1713
Hospital Charge Code	12974366
Hospital Revenue Code	278
Min. Negotiated Rate	$108.08
Max. Negotiated Rate	$187.21
Rate for Payer: Cash Price	$125.45
Rate for Payer: Hawaii Western Management Group Commercial	$135.10
Rate for Payer: Health Management Network Commercial	$164.05
Rate for Payer: Kaiser Permanente Commercial	$173.70
Rate for Payer: MDX Hawaii PPO	$187.21
Rate for Payer: University Health Alliance Commercial	$108.08

CORTEX SCREW, TI, 2.4 X 20MM

Facility

$193.00

Service Code	HCPCS C1713
Hospital Charge Code	12974369
Hospital Revenue Code	278
Min. Negotiated Rate	$96.50
Max. Negotiated Rate	$187.21
Rate for Payer: AlohaCare Medicaid	$96.50
Rate for Payer: AlohaCare Medicare	$96.50
Rate for Payer: Cash Price	$125.45
Rate for Payer: Devoted Health Medicare	$106.15
Rate for Payer: Hawaii Medical Service Association Medicare	$96.50
Rate for Payer: Hawaii Western Management Group Commercial	$135.10
Rate for Payer: Health Management Network Commercial	$164.05
Rate for Payer: Humana Medicare	$96.50
Rate for Payer: Kaiser Permanente Commercial	$173.70
Rate for Payer: Kaiser Permanente Medicaid	$98.43
Rate for Payer: Kaiser Permanente Medicare	$96.50
Rate for Payer: MDX Hawaii PPO	$187.21
Rate for Payer: Ohana Health Plan Medicaid	$96.50
Rate for Payer: Ohana Health Plan Medicare	$96.50
Rate for Payer: UnitedHealthcare Medicare	$96.50
Rate for Payer: University Health Alliance Commercial	$108.08

CORTEX SCREW, TI, 2.4 X 20MM

Facility

$193.00

Service Code	HCPCS C1713
Hospital Charge Code	12974369
Hospital Revenue Code	278
Min. Negotiated Rate	$108.08
Max. Negotiated Rate	$187.21
Rate for Payer: Cash Price	$125.45
Rate for Payer: Hawaii Western Management Group Commercial	$135.10
Rate for Payer: Health Management Network Commercial	$164.05
Rate for Payer: Kaiser Permanente Commercial	$173.70
Rate for Payer: MDX Hawaii PPO	$187.21
Rate for Payer: University Health Alliance Commercial	$108.08

CORTEX SCREW, TI, 2.4 X 22MM

Facility

$193.00

Service Code	HCPCS C1713
Hospital Charge Code	12974370
Hospital Revenue Code	278
Min. Negotiated Rate	$96.50
Max. Negotiated Rate	$187.21
Rate for Payer: AlohaCare Medicaid	$96.50
Rate for Payer: AlohaCare Medicare	$96.50
Rate for Payer: Cash Price	$125.45
Rate for Payer: Devoted Health Medicare	$106.15
Rate for Payer: Hawaii Medical Service Association Medicare	$96.50
Rate for Payer: Hawaii Western Management Group Commercial	$135.10
Rate for Payer: Health Management Network Commercial	$164.05
Rate for Payer: Humana Medicare	$96.50
Rate for Payer: Kaiser Permanente Commercial	$173.70
Rate for Payer: Kaiser Permanente Medicaid	$98.43
Rate for Payer: Kaiser Permanente Medicare	$96.50
Rate for Payer: MDX Hawaii PPO	$187.21
Rate for Payer: Ohana Health Plan Medicaid	$96.50
Rate for Payer: Ohana Health Plan Medicare	$96.50
Rate for Payer: UnitedHealthcare Medicare	$96.50
Rate for Payer: University Health Alliance Commercial	$108.08

CORTEX SCREW, TI, 2.4 X 22MM

Facility

$193.00

Service Code	HCPCS C1713
Hospital Charge Code	12974370
Hospital Revenue Code	278
Min. Negotiated Rate	$108.08
Max. Negotiated Rate	$187.21
Rate for Payer: Cash Price	$125.45
Rate for Payer: Hawaii Western Management Group Commercial	$135.10
Rate for Payer: Health Management Network Commercial	$164.05
Rate for Payer: Kaiser Permanente Commercial	$173.70
Rate for Payer: MDX Hawaii PPO	$187.21
Rate for Payer: University Health Alliance Commercial	$108.08

CORTEX SCREW, TI, 2.4 X 24MM

Facility

$193.00

Service Code	HCPCS C1713
Hospital Charge Code	12974367
Hospital Revenue Code	278
Min. Negotiated Rate	$96.50
Max. Negotiated Rate	$187.21
Rate for Payer: AlohaCare Medicaid	$96.50
Rate for Payer: AlohaCare Medicare	$96.50
Rate for Payer: Cash Price	$125.45
Rate for Payer: Devoted Health Medicare	$106.15
Rate for Payer: Hawaii Medical Service Association Medicare	$96.50
Rate for Payer: Hawaii Western Management Group Commercial	$135.10
Rate for Payer: Health Management Network Commercial	$164.05
Rate for Payer: Humana Medicare	$96.50
Rate for Payer: Kaiser Permanente Commercial	$173.70
Rate for Payer: Kaiser Permanente Medicaid	$98.43
Rate for Payer: Kaiser Permanente Medicare	$96.50
Rate for Payer: MDX Hawaii PPO	$187.21
Rate for Payer: Ohana Health Plan Medicaid	$96.50
Rate for Payer: Ohana Health Plan Medicare	$96.50
Rate for Payer: UnitedHealthcare Medicare	$96.50
Rate for Payer: University Health Alliance Commercial	$108.08

CORTEX SCREW, TI, 2.4 X 24MM

Facility

$193.00

Service Code	HCPCS C1713
Hospital Charge Code	12974367
Hospital Revenue Code	278
Min. Negotiated Rate	$108.08
Max. Negotiated Rate	$187.21
Rate for Payer: MDX Hawaii PPO	$187.21
Rate for Payer: Cash Price	$125.45
Rate for Payer: Hawaii Western Management Group Commercial	$135.10
Rate for Payer: Health Management Network Commercial	$164.05
Rate for Payer: Kaiser Permanente Commercial	$173.70
Rate for Payer: University Health Alliance Commercial	$108.08

CORTEX SCREW, TI, 2.4 X 26MM

Facility

$193.00

Service Code	HCPCS C1713
Hospital Charge Code	12974375
Hospital Revenue Code	278
Min. Negotiated Rate	$96.50
Max. Negotiated Rate	$187.21
Rate for Payer: AlohaCare Medicaid	$96.50
Rate for Payer: AlohaCare Medicare	$96.50
Rate for Payer: Cash Price	$125.45
Rate for Payer: Devoted Health Medicare	$106.15
Rate for Payer: Hawaii Medical Service Association Medicare	$96.50
Rate for Payer: Hawaii Western Management Group Commercial	$135.10
Rate for Payer: Health Management Network Commercial	$164.05
Rate for Payer: Humana Medicare	$96.50
Rate for Payer: Kaiser Permanente Commercial	$173.70
Rate for Payer: Kaiser Permanente Medicaid	$98.43
Rate for Payer: Kaiser Permanente Medicare	$96.50
Rate for Payer: MDX Hawaii PPO	$187.21
Rate for Payer: Ohana Health Plan Medicaid	$96.50
Rate for Payer: Ohana Health Plan Medicare	$96.50
Rate for Payer: UnitedHealthcare Medicare	$96.50
Rate for Payer: University Health Alliance Commercial	$108.08

CORTEX SCREW, TI, 2.4 X 26MM

Facility

$193.00

Service Code	HCPCS C1713
Hospital Charge Code	12974375
Hospital Revenue Code	278
Min. Negotiated Rate	$108.08
Max. Negotiated Rate	$187.21
Rate for Payer: Cash Price	$125.45
Rate for Payer: Hawaii Western Management Group Commercial	$135.10
Rate for Payer: Health Management Network Commercial	$164.05
Rate for Payer: Kaiser Permanente Commercial	$173.70
Rate for Payer: MDX Hawaii PPO	$187.21
Rate for Payer: University Health Alliance Commercial	$108.08

CORTEX SCREW, TI, 2.4 X 28MM

Facility

$193.00

Service Code	HCPCS C1713
Hospital Charge Code	12974393
Hospital Revenue Code	278
Min. Negotiated Rate	$96.50
Max. Negotiated Rate	$187.21
Rate for Payer: AlohaCare Medicaid	$96.50
Rate for Payer: AlohaCare Medicare	$96.50
Rate for Payer: Cash Price	$125.45
Rate for Payer: Devoted Health Medicare	$106.15
Rate for Payer: Hawaii Medical Service Association Medicare	$96.50
Rate for Payer: Hawaii Western Management Group Commercial	$135.10
Rate for Payer: Health Management Network Commercial	$164.05
Rate for Payer: Humana Medicare	$96.50
Rate for Payer: Kaiser Permanente Commercial	$173.70
Rate for Payer: Kaiser Permanente Medicaid	$98.43
Rate for Payer: Kaiser Permanente Medicare	$96.50
Rate for Payer: MDX Hawaii PPO	$187.21
Rate for Payer: Ohana Health Plan Medicaid	$96.50
Rate for Payer: Ohana Health Plan Medicare	$96.50
Rate for Payer: UnitedHealthcare Medicare	$96.50
Rate for Payer: University Health Alliance Commercial	$108.08

CORTEX SCREW, TI, 2.4 X 28MM

Facility

$193.00

Service Code	HCPCS C1713
Hospital Charge Code	12974393
Hospital Revenue Code	278
Min. Negotiated Rate	$108.08
Max. Negotiated Rate	$187.21
Rate for Payer: Cash Price	$125.45
Rate for Payer: Hawaii Western Management Group Commercial	$135.10
Rate for Payer: Health Management Network Commercial	$164.05
Rate for Payer: Kaiser Permanente Commercial	$173.70
Rate for Payer: MDX Hawaii PPO	$187.21
Rate for Payer: University Health Alliance Commercial	$108.08

CORTEX SCREW, TI, 2.4 X 30MM

Facility

$193.00

Service Code	HCPCS C1713
Hospital Charge Code	12974394
Hospital Revenue Code	278
Min. Negotiated Rate	$108.08
Max. Negotiated Rate	$187.21
Rate for Payer: Cash Price	$125.45
Rate for Payer: Hawaii Western Management Group Commercial	$135.10
Rate for Payer: Health Management Network Commercial	$164.05
Rate for Payer: Kaiser Permanente Commercial	$173.70
Rate for Payer: MDX Hawaii PPO	$187.21
Rate for Payer: University Health Alliance Commercial	$108.08

CORTEX SCREW, TI, 2.4 X 30MM

Facility

$193.00

Service Code	HCPCS C1713
Hospital Charge Code	12974394
Hospital Revenue Code	278
Min. Negotiated Rate	$96.50
Max. Negotiated Rate	$187.21
Rate for Payer: AlohaCare Medicaid	$96.50
Rate for Payer: AlohaCare Medicare	$96.50
Rate for Payer: Cash Price	$125.45
Rate for Payer: Devoted Health Medicare	$106.15
Rate for Payer: Hawaii Medical Service Association Medicare	$96.50
Rate for Payer: Hawaii Western Management Group Commercial	$135.10
Rate for Payer: Health Management Network Commercial	$164.05
Rate for Payer: Humana Medicare	$96.50
Rate for Payer: Kaiser Permanente Commercial	$173.70
Rate for Payer: Kaiser Permanente Medicaid	$98.43
Rate for Payer: Kaiser Permanente Medicare	$96.50
Rate for Payer: MDX Hawaii PPO	$187.21
Rate for Payer: Ohana Health Plan Medicaid	$96.50
Rate for Payer: Ohana Health Plan Medicare	$96.50
Rate for Payer: UnitedHealthcare Medicare	$96.50
Rate for Payer: University Health Alliance Commercial	$108.08

Know your out-of-pocket cost for care.

All Charges