Samuel Mahelona Memorial Hospital

All Charges

Charge

Type

Setting

Price

DRESSING, CAST PADDING STERILE 6

Facility

$28.00

Hospital Charge Code	8274376
Hospital Revenue Code	272
Min. Negotiated Rate	$23.80
Max. Negotiated Rate	$27.16
Rate for Payer: Cash Price	$18.20
Rate for Payer: Health Management Network Commercial	$23.80
Rate for Payer: Kaiser Permanente Commercial	$25.20
Rate for Payer: MDX Hawaii PPO	$27.16

DRESSING, CAST PADDING STERILE 6

Facility

$28.00

Hospital Charge Code	8274376
Hospital Revenue Code	272
Min. Negotiated Rate	$14.00
Max. Negotiated Rate	$27.16
Rate for Payer: AlohaCare Medicaid	$14.00
Rate for Payer: AlohaCare Medicare	$14.00
Rate for Payer: Cash Price	$18.20
Rate for Payer: Devoted Health Medicare	$15.40
Rate for Payer: Hawaii Medical Service Association Medicare	$14.00
Rate for Payer: Hawaii Western Management Group Commercial	$26.60
Rate for Payer: Health Management Network Commercial	$23.80
Rate for Payer: Humana Medicare	$14.00
Rate for Payer: Kaiser Permanente Commercial	$25.20
Rate for Payer: Kaiser Permanente Medicaid	$14.28
Rate for Payer: Kaiser Permanente Medicare	$14.00
Rate for Payer: MDX Hawaii PPO	$27.16
Rate for Payer: Ohana Health Plan Medicaid	$14.00
Rate for Payer: Ohana Health Plan Medicare	$14.00
Rate for Payer: UnitedHealthcare Medicare	$14.00
Rate for Payer: University Health Alliance Commercial	$20.41

DRESSING GRANUFOAM BRIDGE KCI

Facility

$360.00

Hospital Charge Code	8653686
Hospital Revenue Code	272
Min. Negotiated Rate	$180.00
Max. Negotiated Rate	$349.20
Rate for Payer: AlohaCare Medicaid	$180.00
Rate for Payer: AlohaCare Medicare	$180.00
Rate for Payer: Cash Price	$234.00
Rate for Payer: Devoted Health Medicare	$198.00
Rate for Payer: Hawaii Medical Service Association Medicare	$180.00
Rate for Payer: Hawaii Western Management Group Commercial	$342.00
Rate for Payer: Health Management Network Commercial	$306.00
Rate for Payer: Humana Medicare	$180.00
Rate for Payer: Kaiser Permanente Commercial	$324.00
Rate for Payer: Kaiser Permanente Medicaid	$183.60
Rate for Payer: Kaiser Permanente Medicare	$180.00
Rate for Payer: MDX Hawaii PPO	$349.20
Rate for Payer: Ohana Health Plan Medicaid	$180.00
Rate for Payer: Ohana Health Plan Medicare	$180.00
Rate for Payer: UnitedHealthcare Medicare	$180.00
Rate for Payer: University Health Alliance Commercial	$262.40

DRESSING GRANUFOAM BRIDGE KCI

Facility

$360.00

Hospital Charge Code	8653686
Hospital Revenue Code	272
Min. Negotiated Rate	$306.00
Max. Negotiated Rate	$349.20
Rate for Payer: Cash Price	$234.00
Rate for Payer: Health Management Network Commercial	$306.00
Rate for Payer: Kaiser Permanente Commercial	$324.00
Rate for Payer: MDX Hawaii PPO	$349.20

DRESSING GRANUFOAM MEDIUM

Facility

$204.00

Hospital Charge Code	8444768
Hospital Revenue Code	272
Min. Negotiated Rate	$173.40
Max. Negotiated Rate	$197.88
Rate for Payer: Cash Price	$132.60
Rate for Payer: Health Management Network Commercial	$173.40
Rate for Payer: Kaiser Permanente Commercial	$183.60
Rate for Payer: MDX Hawaii PPO	$197.88

DRESSING GRANUFOAM MEDIUM

Facility

$204.00

Hospital Charge Code	8444768
Hospital Revenue Code	272
Min. Negotiated Rate	$102.00
Max. Negotiated Rate	$197.88
Rate for Payer: AlohaCare Medicaid	$102.00
Rate for Payer: AlohaCare Medicare	$102.00
Rate for Payer: Cash Price	$132.60
Rate for Payer: Devoted Health Medicare	$112.20
Rate for Payer: Hawaii Medical Service Association Medicare	$102.00
Rate for Payer: Hawaii Western Management Group Commercial	$193.80
Rate for Payer: Health Management Network Commercial	$173.40
Rate for Payer: Humana Medicare	$102.00
Rate for Payer: Kaiser Permanente Commercial	$183.60
Rate for Payer: Kaiser Permanente Medicaid	$104.04
Rate for Payer: Kaiser Permanente Medicare	$102.00
Rate for Payer: MDX Hawaii PPO	$197.88
Rate for Payer: Ohana Health Plan Medicaid	$102.00
Rate for Payer: Ohana Health Plan Medicare	$102.00
Rate for Payer: UnitedHealthcare Medicare	$102.00
Rate for Payer: University Health Alliance Commercial	$148.70

DRESSING GRANUFOAM SMALL

Facility

$162.00

Hospital Charge Code	8444767
Hospital Revenue Code	272
Min. Negotiated Rate	$137.70
Max. Negotiated Rate	$157.14
Rate for Payer: Cash Price	$105.30
Rate for Payer: Health Management Network Commercial	$137.70
Rate for Payer: Kaiser Permanente Commercial	$145.80
Rate for Payer: MDX Hawaii PPO	$157.14

DRESSING GRANUFOAM SMALL

Facility

$162.00

Hospital Charge Code	8444767
Hospital Revenue Code	272
Min. Negotiated Rate	$81.00
Max. Negotiated Rate	$157.14
Rate for Payer: AlohaCare Medicaid	$81.00
Rate for Payer: AlohaCare Medicare	$81.00
Rate for Payer: Cash Price	$105.30
Rate for Payer: Devoted Health Medicare	$89.10
Rate for Payer: Hawaii Medical Service Association Medicare	$81.00
Rate for Payer: Hawaii Western Management Group Commercial	$153.90
Rate for Payer: Health Management Network Commercial	$137.70
Rate for Payer: Humana Medicare	$81.00
Rate for Payer: Kaiser Permanente Commercial	$145.80
Rate for Payer: Kaiser Permanente Medicaid	$82.62
Rate for Payer: Kaiser Permanente Medicare	$81.00
Rate for Payer: MDX Hawaii PPO	$157.14
Rate for Payer: Ohana Health Plan Medicaid	$81.00
Rate for Payer: Ohana Health Plan Medicare	$81.00
Rate for Payer: UnitedHealthcare Medicare	$81.00
Rate for Payer: University Health Alliance Commercial	$118.08

DRESSING GRANUFOAM SMALL 5

Facility

$179.00

Hospital Charge Code	8444770
Hospital Revenue Code	272
Min. Negotiated Rate	$152.15
Max. Negotiated Rate	$173.63
Rate for Payer: Cash Price	$116.35
Rate for Payer: Health Management Network Commercial	$152.15
Rate for Payer: Kaiser Permanente Commercial	$161.10
Rate for Payer: MDX Hawaii PPO	$173.63

DRESSING GRANUFOAM SMALL 5

Facility

$179.00

Hospital Charge Code	8444770
Hospital Revenue Code	272
Min. Negotiated Rate	$89.50
Max. Negotiated Rate	$173.63
Rate for Payer: AlohaCare Medicaid	$89.50
Rate for Payer: AlohaCare Medicare	$89.50
Rate for Payer: Cash Price	$116.35
Rate for Payer: Devoted Health Medicare	$98.45
Rate for Payer: Hawaii Medical Service Association Medicare	$89.50
Rate for Payer: Hawaii Western Management Group Commercial	$170.05
Rate for Payer: Health Management Network Commercial	$152.15
Rate for Payer: Humana Medicare	$89.50
Rate for Payer: Kaiser Permanente Commercial	$161.10
Rate for Payer: Kaiser Permanente Medicaid	$91.29
Rate for Payer: Kaiser Permanente Medicare	$89.50
Rate for Payer: MDX Hawaii PPO	$173.63
Rate for Payer: Ohana Health Plan Medicaid	$89.50
Rate for Payer: Ohana Health Plan Medicare	$89.50
Rate for Payer: UnitedHealthcare Medicare	$89.50
Rate for Payer: University Health Alliance Commercial	$130.47

DRESSING HEAVY DRAINAGE PACK

Facility

$11.00

Hospital Charge Code	8266783
Hospital Revenue Code	272
Min. Negotiated Rate	$9.35
Max. Negotiated Rate	$10.67
Rate for Payer: Cash Price	$7.15
Rate for Payer: Health Management Network Commercial	$9.35
Rate for Payer: Kaiser Permanente Commercial	$9.90
Rate for Payer: MDX Hawaii PPO	$10.67

DRESSING HEAVY DRAINAGE PACK

Facility

$11.00

Hospital Charge Code	8266783
Hospital Revenue Code	272
Min. Negotiated Rate	$5.50
Max. Negotiated Rate	$10.67
Rate for Payer: AlohaCare Medicaid	$5.50
Rate for Payer: AlohaCare Medicare	$5.50
Rate for Payer: Cash Price	$7.15
Rate for Payer: Devoted Health Medicare	$6.05
Rate for Payer: Hawaii Medical Service Association Medicare	$5.50
Rate for Payer: Hawaii Western Management Group Commercial	$10.45
Rate for Payer: Health Management Network Commercial	$9.35
Rate for Payer: Humana Medicare	$5.50
Rate for Payer: Kaiser Permanente Commercial	$9.90
Rate for Payer: Kaiser Permanente Medicaid	$5.61
Rate for Payer: Kaiser Permanente Medicare	$5.50
Rate for Payer: MDX Hawaii PPO	$10.67
Rate for Payer: Ohana Health Plan Medicaid	$5.50
Rate for Payer: Ohana Health Plan Medicare	$5.50
Rate for Payer: UnitedHealthcare Medicare	$5.50
Rate for Payer: University Health Alliance Commercial	$8.02

DRESSING LARGE

Facility

$74.00

Hospital Charge Code	13034587
Hospital Revenue Code	272
Min. Negotiated Rate	$37.00
Max. Negotiated Rate	$71.78
Rate for Payer: AlohaCare Medicaid	$37.00
Rate for Payer: AlohaCare Medicare	$37.00
Rate for Payer: Cash Price	$48.10
Rate for Payer: Devoted Health Medicare	$40.70
Rate for Payer: Hawaii Medical Service Association Medicare	$37.00
Rate for Payer: Hawaii Western Management Group Commercial	$70.30
Rate for Payer: Health Management Network Commercial	$62.90
Rate for Payer: Humana Medicare	$37.00
Rate for Payer: Kaiser Permanente Commercial	$66.60
Rate for Payer: Kaiser Permanente Medicaid	$37.74
Rate for Payer: Kaiser Permanente Medicare	$37.00
Rate for Payer: MDX Hawaii PPO	$71.78
Rate for Payer: Ohana Health Plan Medicaid	$37.00
Rate for Payer: Ohana Health Plan Medicare	$37.00
Rate for Payer: UnitedHealthcare Medicare	$37.00
Rate for Payer: University Health Alliance Commercial	$53.94

DRESSING LARGE

Facility

$74.00

Hospital Charge Code	13034587
Hospital Revenue Code	272
Min. Negotiated Rate	$62.90
Max. Negotiated Rate	$71.78
Rate for Payer: Cash Price	$48.10
Rate for Payer: Health Management Network Commercial	$62.90
Rate for Payer: Kaiser Permanente Commercial	$66.60
Rate for Payer: MDX Hawaii PPO	$71.78

DRESSING NASAL TAMPON 8 CM

Facility

$55.00

Hospital Charge Code	8266699
Hospital Revenue Code	272
Min. Negotiated Rate	$27.50
Max. Negotiated Rate	$53.35
Rate for Payer: AlohaCare Medicaid	$27.50
Rate for Payer: AlohaCare Medicare	$27.50
Rate for Payer: Cash Price	$35.75
Rate for Payer: Devoted Health Medicare	$30.25
Rate for Payer: Hawaii Medical Service Association Medicare	$27.50
Rate for Payer: Hawaii Western Management Group Commercial	$52.25
Rate for Payer: Health Management Network Commercial	$46.75
Rate for Payer: Humana Medicare	$27.50
Rate for Payer: Kaiser Permanente Commercial	$49.50
Rate for Payer: Kaiser Permanente Medicaid	$28.05
Rate for Payer: Kaiser Permanente Medicare	$27.50
Rate for Payer: MDX Hawaii PPO	$53.35
Rate for Payer: Ohana Health Plan Medicaid	$27.50
Rate for Payer: Ohana Health Plan Medicare	$27.50
Rate for Payer: UnitedHealthcare Medicare	$27.50
Rate for Payer: University Health Alliance Commercial	$40.09

DRESSING NASAL TAMPON 8 CM

Facility

$55.00

Hospital Charge Code	8266699
Hospital Revenue Code	272
Min. Negotiated Rate	$46.75
Max. Negotiated Rate	$53.35
Rate for Payer: Cash Price	$35.75
Rate for Payer: Health Management Network Commercial	$46.75
Rate for Payer: Kaiser Permanente Commercial	$49.50
Rate for Payer: MDX Hawaii PPO	$53.35

DRESSING OIL EMULSION DRESSING 3 X 3

Facility

$3.00

Hospital Charge Code	8266998
Hospital Revenue Code	272
Min. Negotiated Rate	$1.50
Max. Negotiated Rate	$2.91
Rate for Payer: AlohaCare Medicaid	$1.50
Rate for Payer: AlohaCare Medicare	$1.50
Rate for Payer: Cash Price	$1.95
Rate for Payer: Devoted Health Medicare	$1.65
Rate for Payer: Hawaii Medical Service Association Medicare	$1.50
Rate for Payer: Hawaii Western Management Group Commercial	$2.85
Rate for Payer: Health Management Network Commercial	$2.55
Rate for Payer: Humana Medicare	$1.50
Rate for Payer: Kaiser Permanente Commercial	$2.70
Rate for Payer: Kaiser Permanente Medicaid	$1.53
Rate for Payer: Kaiser Permanente Medicare	$1.50
Rate for Payer: MDX Hawaii PPO	$2.91
Rate for Payer: Ohana Health Plan Medicaid	$1.50
Rate for Payer: Ohana Health Plan Medicare	$1.50
Rate for Payer: UnitedHealthcare Medicare	$1.50
Rate for Payer: University Health Alliance Commercial	$2.19

DRESSING OIL EMULSION DRESSING 3 X 3

Facility

$3.00

Hospital Charge Code	8266998
Hospital Revenue Code	272
Min. Negotiated Rate	$2.55
Max. Negotiated Rate	$2.91
Rate for Payer: Cash Price	$1.95
Rate for Payer: Health Management Network Commercial	$2.55
Rate for Payer: Kaiser Permanente Commercial	$2.70
Rate for Payer: MDX Hawaii PPO	$2.91

DRESSING OIL EMULSION DRESSING 3 X 8

Facility

$7.00

Hospital Charge Code	8266337
Hospital Revenue Code	272
Min. Negotiated Rate	$5.95
Max. Negotiated Rate	$6.79
Rate for Payer: Cash Price	$4.55
Rate for Payer: Health Management Network Commercial	$5.95
Rate for Payer: Kaiser Permanente Commercial	$6.30
Rate for Payer: MDX Hawaii PPO	$6.79

DRESSING OIL EMULSION DRESSING 3 X 8

Facility

$7.00

Hospital Charge Code	8266337
Hospital Revenue Code	272
Min. Negotiated Rate	$3.50
Max. Negotiated Rate	$6.79
Rate for Payer: AlohaCare Medicaid	$3.50
Rate for Payer: AlohaCare Medicare	$3.50
Rate for Payer: Cash Price	$4.55
Rate for Payer: Devoted Health Medicare	$3.85
Rate for Payer: Hawaii Medical Service Association Medicare	$3.50
Rate for Payer: Hawaii Western Management Group Commercial	$6.65
Rate for Payer: Health Management Network Commercial	$5.95
Rate for Payer: Humana Medicare	$3.50
Rate for Payer: Kaiser Permanente Commercial	$6.30
Rate for Payer: Kaiser Permanente Medicaid	$3.57
Rate for Payer: Kaiser Permanente Medicare	$3.50
Rate for Payer: MDX Hawaii PPO	$6.79
Rate for Payer: Ohana Health Plan Medicaid	$3.50
Rate for Payer: Ohana Health Plan Medicare	$3.50
Rate for Payer: UnitedHealthcare Medicare	$3.50
Rate for Payer: University Health Alliance Commercial	$5.10

DRESSING OPSITE ADHESIVE WOUND 11 X 6

Facility

$23.00

Hospital Charge Code	8266881
Hospital Revenue Code	272
Min. Negotiated Rate	$11.50
Max. Negotiated Rate	$22.31
Rate for Payer: AlohaCare Medicaid	$11.50
Rate for Payer: AlohaCare Medicare	$11.50
Rate for Payer: Cash Price	$14.95
Rate for Payer: Devoted Health Medicare	$12.65
Rate for Payer: Hawaii Medical Service Association Medicare	$11.50
Rate for Payer: Hawaii Western Management Group Commercial	$21.85
Rate for Payer: Health Management Network Commercial	$19.55
Rate for Payer: Humana Medicare	$11.50
Rate for Payer: Kaiser Permanente Commercial	$20.70
Rate for Payer: Kaiser Permanente Medicaid	$11.73
Rate for Payer: Kaiser Permanente Medicare	$11.50
Rate for Payer: MDX Hawaii PPO	$22.31
Rate for Payer: Ohana Health Plan Medicaid	$11.50
Rate for Payer: Ohana Health Plan Medicare	$11.50
Rate for Payer: UnitedHealthcare Medicare	$11.50
Rate for Payer: University Health Alliance Commercial	$16.76

DRESSING OPSITE ADHESIVE WOUND 11 X 6

Facility

$23.00

Hospital Charge Code	8266881
Hospital Revenue Code	272
Min. Negotiated Rate	$19.55
Max. Negotiated Rate	$22.31
Rate for Payer: Cash Price	$14.95
Rate for Payer: Health Management Network Commercial	$19.55
Rate for Payer: Kaiser Permanente Commercial	$20.70
Rate for Payer: MDX Hawaii PPO	$22.31

DRESSING OPTIFOAM 3.5 X 10 GENTLE AG+ POST-OP STRIP

Facility

$147.00

Hospital Charge Code	8274273
Hospital Revenue Code	272
Min. Negotiated Rate	$124.95
Max. Negotiated Rate	$142.59
Rate for Payer: Cash Price	$95.55
Rate for Payer: Health Management Network Commercial	$124.95
Rate for Payer: Kaiser Permanente Commercial	$132.30
Rate for Payer: MDX Hawaii PPO	$142.59

DRESSING OPTIFOAM 3.5 X 10 GENTLE AG+ POST-OP STRIP

Facility

$147.00

Hospital Charge Code	8274273
Hospital Revenue Code	272
Min. Negotiated Rate	$73.50
Max. Negotiated Rate	$142.59
Rate for Payer: AlohaCare Medicaid	$73.50
Rate for Payer: AlohaCare Medicare	$73.50
Rate for Payer: Cash Price	$95.55
Rate for Payer: Devoted Health Medicare	$80.85
Rate for Payer: Hawaii Medical Service Association Medicare	$73.50
Rate for Payer: Hawaii Western Management Group Commercial	$139.65
Rate for Payer: Health Management Network Commercial	$124.95
Rate for Payer: Humana Medicare	$73.50
Rate for Payer: Kaiser Permanente Commercial	$132.30
Rate for Payer: Kaiser Permanente Medicaid	$74.97
Rate for Payer: Kaiser Permanente Medicare	$73.50
Rate for Payer: MDX Hawaii PPO	$142.59
Rate for Payer: Ohana Health Plan Medicaid	$73.50
Rate for Payer: Ohana Health Plan Medicare	$73.50
Rate for Payer: UnitedHealthcare Medicare	$73.50
Rate for Payer: University Health Alliance Commercial	$107.15

DRESSING PETROLATUM GAUZE 3 X 18

Facility

$5.00

Hospital Charge Code	8266739
Hospital Revenue Code	272
Min. Negotiated Rate	$2.50
Max. Negotiated Rate	$4.85
Rate for Payer: AlohaCare Medicaid	$2.50
Rate for Payer: AlohaCare Medicare	$2.50
Rate for Payer: Cash Price	$3.25
Rate for Payer: Devoted Health Medicare	$2.75
Rate for Payer: Hawaii Medical Service Association Medicare	$2.50
Rate for Payer: Hawaii Western Management Group Commercial	$4.75
Rate for Payer: Health Management Network Commercial	$4.25
Rate for Payer: Humana Medicare	$2.50
Rate for Payer: Kaiser Permanente Commercial	$4.50
Rate for Payer: Kaiser Permanente Medicaid	$2.55
Rate for Payer: Kaiser Permanente Medicare	$2.50
Rate for Payer: MDX Hawaii PPO	$4.85
Rate for Payer: Ohana Health Plan Medicaid	$2.50
Rate for Payer: Ohana Health Plan Medicare	$2.50
Rate for Payer: UnitedHealthcare Medicare	$2.50
Rate for Payer: University Health Alliance Commercial	$3.64

Know your out-of-pocket cost for care.

All Charges