Samuel Mahelona Memorial Hospital

All Charges

Charge

Type

Setting

Price

DRESSING PETROLATUM GAUZE 3 X 18

Facility

$5.00

Hospital Charge Code	8266739
Hospital Revenue Code	272
Min. Negotiated Rate	$4.25
Max. Negotiated Rate	$4.85
Rate for Payer: Cash Price	$3.25
Rate for Payer: Health Management Network Commercial	$4.25
Rate for Payer: Kaiser Permanente Commercial	$4.50
Rate for Payer: MDX Hawaii PPO	$4.85

DRESSING WHITEFOAM KCI

Facility

$34.00

Service Code	HCPCS A6550
Hospital Charge Code	8528315
Hospital Revenue Code	272
Min. Negotiated Rate	$28.90
Max. Negotiated Rate	$32.98
Rate for Payer: Cash Price	$22.10
Rate for Payer: Health Management Network Commercial	$28.90
Rate for Payer: Kaiser Permanente Commercial	$30.60
Rate for Payer: MDX Hawaii PPO	$32.98

DRESSING WHITEFOAM KCI

Facility

$34.00

Service Code	HCPCS A6550
Hospital Charge Code	8528315
Hospital Revenue Code	272
Min. Negotiated Rate	$17.00
Max. Negotiated Rate	$32.98
Rate for Payer: AlohaCare Medicaid	$17.00
Rate for Payer: AlohaCare Medicare	$17.00
Rate for Payer: Cash Price	$22.10
Rate for Payer: Cash Price	$22.10
Rate for Payer: Devoted Health Medicare	$18.70
Rate for Payer: Hawaii Medical Service Association Medicare	$17.00
Rate for Payer: Hawaii Western Management Group Commercial	$32.30
Rate for Payer: Health Management Network Commercial	$28.90
Rate for Payer: Humana Medicare	$17.00
Rate for Payer: Kaiser Permanente Commercial	$30.60
Rate for Payer: Kaiser Permanente Medicaid	$17.34
Rate for Payer: Kaiser Permanente Medicare	$17.00
Rate for Payer: MDX Hawaii PPO	$32.98
Rate for Payer: Ohana Health Plan Medicaid	$17.00
Rate for Payer: Ohana Health Plan Medicare	$17.00
Rate for Payer: UnitedHealthcare Medicaid	$24.82
Rate for Payer: UnitedHealthcare Medicare	$17.00
Rate for Payer: University Health Alliance Commercial	$24.78

DRILL, A-O STYLE, 4.0MM X 165MM

Facility

$386.00

Hospital Charge Code	12985795
Hospital Revenue Code	272
Min. Negotiated Rate	$193.00
Max. Negotiated Rate	$374.42
Rate for Payer: AlohaCare Medicaid	$193.00
Rate for Payer: AlohaCare Medicare	$193.00
Rate for Payer: Cash Price	$250.90
Rate for Payer: Devoted Health Medicare	$212.30
Rate for Payer: Hawaii Medical Service Association Medicare	$193.00
Rate for Payer: Hawaii Western Management Group Commercial	$366.70
Rate for Payer: Health Management Network Commercial	$328.10
Rate for Payer: Humana Medicare	$193.00
Rate for Payer: Kaiser Permanente Commercial	$347.40
Rate for Payer: Kaiser Permanente Medicaid	$196.86
Rate for Payer: Kaiser Permanente Medicare	$193.00
Rate for Payer: MDX Hawaii PPO	$374.42
Rate for Payer: Ohana Health Plan Medicaid	$193.00
Rate for Payer: Ohana Health Plan Medicare	$193.00
Rate for Payer: UnitedHealthcare Medicare	$193.00
Rate for Payer: University Health Alliance Commercial	$281.36

DRILL, A-O STYLE, 4.0MM X 165MM

Facility

$386.00

Hospital Charge Code	12985795
Hospital Revenue Code	272
Min. Negotiated Rate	$328.10
Max. Negotiated Rate	$374.42
Rate for Payer: Cash Price	$250.90
Rate for Payer: Health Management Network Commercial	$328.10
Rate for Payer: Kaiser Permanente Commercial	$347.40
Rate for Payer: MDX Hawaii PPO	$374.42

DRILL BIT, .059 (1.5MM), AO

Facility

$368.00

Hospital Charge Code	12985759
Hospital Revenue Code	272
Min. Negotiated Rate	$312.80
Max. Negotiated Rate	$356.96
Rate for Payer: Cash Price	$239.20
Rate for Payer: Health Management Network Commercial	$312.80
Rate for Payer: Kaiser Permanente Commercial	$331.20
Rate for Payer: MDX Hawaii PPO	$356.96

DRILL BIT, .059 (1.5MM), AO

Facility

$368.00

Hospital Charge Code	12985759
Hospital Revenue Code	272
Min. Negotiated Rate	$184.00
Max. Negotiated Rate	$356.96
Rate for Payer: AlohaCare Medicaid	$184.00
Rate for Payer: AlohaCare Medicare	$184.00
Rate for Payer: Cash Price	$239.20
Rate for Payer: Devoted Health Medicare	$202.40
Rate for Payer: Hawaii Medical Service Association Medicare	$184.00
Rate for Payer: Hawaii Western Management Group Commercial	$349.60
Rate for Payer: Health Management Network Commercial	$312.80
Rate for Payer: Humana Medicare	$184.00
Rate for Payer: Kaiser Permanente Commercial	$331.20
Rate for Payer: Kaiser Permanente Medicaid	$187.68
Rate for Payer: Kaiser Permanente Medicare	$184.00
Rate for Payer: MDX Hawaii PPO	$356.96
Rate for Payer: Ohana Health Plan Medicaid	$184.00
Rate for Payer: Ohana Health Plan Medicare	$184.00
Rate for Payer: UnitedHealthcare Medicare	$184.00
Rate for Payer: University Health Alliance Commercial	$268.24

DRILL BIT, 1.7MM

Facility

$394.00

Hospital Charge Code	12985794
Hospital Revenue Code	272
Min. Negotiated Rate	$197.00
Max. Negotiated Rate	$382.18
Rate for Payer: AlohaCare Medicaid	$197.00
Rate for Payer: AlohaCare Medicare	$197.00
Rate for Payer: Cash Price	$256.10
Rate for Payer: Devoted Health Medicare	$216.70
Rate for Payer: Hawaii Medical Service Association Medicare	$197.00
Rate for Payer: Hawaii Western Management Group Commercial	$374.30
Rate for Payer: Health Management Network Commercial	$334.90
Rate for Payer: Humana Medicare	$197.00
Rate for Payer: Kaiser Permanente Commercial	$354.60
Rate for Payer: Kaiser Permanente Medicaid	$200.94
Rate for Payer: Kaiser Permanente Medicare	$197.00
Rate for Payer: MDX Hawaii PPO	$382.18
Rate for Payer: Ohana Health Plan Medicaid	$197.00
Rate for Payer: Ohana Health Plan Medicare	$197.00
Rate for Payer: UnitedHealthcare Medicare	$197.00
Rate for Payer: University Health Alliance Commercial	$287.19

DRILL BIT, 1.7MM

Facility

$394.00

Hospital Charge Code	12985794
Hospital Revenue Code	272
Min. Negotiated Rate	$334.90
Max. Negotiated Rate	$382.18
Rate for Payer: Cash Price	$256.10
Rate for Payer: Health Management Network Commercial	$334.90
Rate for Payer: Kaiser Permanente Commercial	$354.60
Rate for Payer: MDX Hawaii PPO	$382.18

DRILL BIT, 1.7MM, LONG

Facility

$394.00

Hospital Charge Code	12985793
Hospital Revenue Code	272
Min. Negotiated Rate	$197.00
Max. Negotiated Rate	$382.18
Rate for Payer: AlohaCare Medicaid	$197.00
Rate for Payer: AlohaCare Medicare	$197.00
Rate for Payer: Cash Price	$256.10
Rate for Payer: Devoted Health Medicare	$216.70
Rate for Payer: Hawaii Medical Service Association Medicare	$197.00
Rate for Payer: Hawaii Western Management Group Commercial	$374.30
Rate for Payer: Health Management Network Commercial	$334.90
Rate for Payer: Humana Medicare	$197.00
Rate for Payer: Kaiser Permanente Commercial	$354.60
Rate for Payer: Kaiser Permanente Medicaid	$200.94
Rate for Payer: Kaiser Permanente Medicare	$197.00
Rate for Payer: MDX Hawaii PPO	$382.18
Rate for Payer: Ohana Health Plan Medicaid	$197.00
Rate for Payer: Ohana Health Plan Medicare	$197.00
Rate for Payer: UnitedHealthcare Medicare	$197.00
Rate for Payer: University Health Alliance Commercial	$287.19

DRILL BIT, 1.7MM, LONG

Facility

$394.00

Hospital Charge Code	12985793
Hospital Revenue Code	272
Min. Negotiated Rate	$334.90
Max. Negotiated Rate	$382.18
Rate for Payer: Cash Price	$256.10
Rate for Payer: Health Management Network Commercial	$334.90
Rate for Payer: Kaiser Permanente Commercial	$354.60
Rate for Payer: MDX Hawaii PPO	$382.18

DRILL BIT, 2.0MM, LONG (AO)

Facility

$394.00

Hospital Charge Code	12985796
Hospital Revenue Code	272
Min. Negotiated Rate	$334.90
Max. Negotiated Rate	$382.18
Rate for Payer: Cash Price	$256.10
Rate for Payer: Health Management Network Commercial	$334.90
Rate for Payer: Kaiser Permanente Commercial	$354.60
Rate for Payer: MDX Hawaii PPO	$382.18

DRILL BIT, 2.0MM, LONG (AO)

Facility

$394.00

Hospital Charge Code	12985796
Hospital Revenue Code	272
Min. Negotiated Rate	$197.00
Max. Negotiated Rate	$382.18
Rate for Payer: AlohaCare Medicaid	$197.00
Rate for Payer: AlohaCare Medicare	$197.00
Rate for Payer: Cash Price	$256.10
Rate for Payer: Devoted Health Medicare	$216.70
Rate for Payer: Hawaii Medical Service Association Medicare	$197.00
Rate for Payer: Hawaii Western Management Group Commercial	$374.30
Rate for Payer: Health Management Network Commercial	$334.90
Rate for Payer: Humana Medicare	$197.00
Rate for Payer: Kaiser Permanente Commercial	$354.60
Rate for Payer: Kaiser Permanente Medicaid	$200.94
Rate for Payer: Kaiser Permanente Medicare	$197.00
Rate for Payer: MDX Hawaii PPO	$382.18
Rate for Payer: Ohana Health Plan Medicaid	$197.00
Rate for Payer: Ohana Health Plan Medicare	$197.00
Rate for Payer: UnitedHealthcare Medicare	$197.00
Rate for Payer: University Health Alliance Commercial	$287.19

DRILL BIT, 2.0MM, SHORT (AO)

Facility

$336.00

Hospital Charge Code	12985797
Hospital Revenue Code	272
Min. Negotiated Rate	$168.00
Max. Negotiated Rate	$325.92
Rate for Payer: AlohaCare Medicaid	$168.00
Rate for Payer: AlohaCare Medicare	$168.00
Rate for Payer: Cash Price	$218.40
Rate for Payer: Devoted Health Medicare	$184.80
Rate for Payer: Hawaii Medical Service Association Medicare	$168.00
Rate for Payer: Hawaii Western Management Group Commercial	$319.20
Rate for Payer: Health Management Network Commercial	$285.60
Rate for Payer: Humana Medicare	$168.00
Rate for Payer: Kaiser Permanente Commercial	$302.40
Rate for Payer: Kaiser Permanente Medicaid	$171.36
Rate for Payer: Kaiser Permanente Medicare	$168.00
Rate for Payer: MDX Hawaii PPO	$325.92
Rate for Payer: Ohana Health Plan Medicaid	$168.00
Rate for Payer: Ohana Health Plan Medicare	$168.00
Rate for Payer: UnitedHealthcare Medicare	$168.00
Rate for Payer: University Health Alliance Commercial	$244.91

DRILL BIT, 2.0MM, SHORT (AO)

Facility

$336.00

Hospital Charge Code	12985797
Hospital Revenue Code	272
Min. Negotiated Rate	$285.60
Max. Negotiated Rate	$325.92
Rate for Payer: Cash Price	$218.40
Rate for Payer: Health Management Network Commercial	$285.60
Rate for Payer: Kaiser Permanente Commercial	$302.40
Rate for Payer: MDX Hawaii PPO	$325.92

DRILL BIT, 2.4 MM

Facility

$550.00

Hospital Charge Code	12985798
Hospital Revenue Code	272
Min. Negotiated Rate	$467.50
Max. Negotiated Rate	$533.50
Rate for Payer: Cash Price	$357.50
Rate for Payer: Health Management Network Commercial	$467.50
Rate for Payer: Kaiser Permanente Commercial	$495.00
Rate for Payer: MDX Hawaii PPO	$533.50

DRILL BIT, 2.4 MM

Facility

$550.00

Hospital Charge Code	12985798
Hospital Revenue Code	272
Min. Negotiated Rate	$275.00
Max. Negotiated Rate	$533.50
Rate for Payer: AlohaCare Medicaid	$275.00
Rate for Payer: AlohaCare Medicare	$275.00
Rate for Payer: Cash Price	$357.50
Rate for Payer: Devoted Health Medicare	$302.50
Rate for Payer: Hawaii Medical Service Association Medicare	$275.00
Rate for Payer: Hawaii Western Management Group Commercial	$522.50
Rate for Payer: Health Management Network Commercial	$467.50
Rate for Payer: Humana Medicare	$275.00
Rate for Payer: Kaiser Permanente Commercial	$495.00
Rate for Payer: Kaiser Permanente Medicaid	$280.50
Rate for Payer: Kaiser Permanente Medicare	$275.00
Rate for Payer: MDX Hawaii PPO	$533.50
Rate for Payer: Ohana Health Plan Medicaid	$275.00
Rate for Payer: Ohana Health Plan Medicare	$275.00
Rate for Payer: UnitedHealthcare Medicare	$275.00
Rate for Payer: University Health Alliance Commercial	$400.89

DRILL BIT, 2.7MM, (AO)

Facility

$336.00

Hospital Charge Code	12985799
Hospital Revenue Code	272
Min. Negotiated Rate	$168.00
Max. Negotiated Rate	$325.92
Rate for Payer: AlohaCare Medicaid	$168.00
Rate for Payer: AlohaCare Medicare	$168.00
Rate for Payer: Cash Price	$218.40
Rate for Payer: Devoted Health Medicare	$184.80
Rate for Payer: Hawaii Medical Service Association Medicare	$168.00
Rate for Payer: Hawaii Western Management Group Commercial	$319.20
Rate for Payer: Health Management Network Commercial	$285.60
Rate for Payer: Humana Medicare	$168.00
Rate for Payer: Kaiser Permanente Commercial	$302.40
Rate for Payer: Kaiser Permanente Medicaid	$171.36
Rate for Payer: Kaiser Permanente Medicare	$168.00
Rate for Payer: MDX Hawaii PPO	$325.92
Rate for Payer: Ohana Health Plan Medicaid	$168.00
Rate for Payer: Ohana Health Plan Medicare	$168.00
Rate for Payer: UnitedHealthcare Medicare	$168.00
Rate for Payer: University Health Alliance Commercial	$244.91

DRILL BIT, 2.7MM, (AO)

Facility

$336.00

Hospital Charge Code	12985799
Hospital Revenue Code	272
Min. Negotiated Rate	$285.60
Max. Negotiated Rate	$325.92
Rate for Payer: Cash Price	$218.40
Rate for Payer: Health Management Network Commercial	$285.60
Rate for Payer: Kaiser Permanente Commercial	$302.40
Rate for Payer: MDX Hawaii PPO	$325.92

DRILL BIT 3.0MM CANNULATED

Facility

$1,544.00

Hospital Charge Code	10600423
Hospital Revenue Code	272
Min. Negotiated Rate	$1,312.40
Max. Negotiated Rate	$1,497.68
Rate for Payer: Cash Price	$1,003.60
Rate for Payer: Health Management Network Commercial	$1,312.40
Rate for Payer: Kaiser Permanente Commercial	$1,389.60
Rate for Payer: MDX Hawaii PPO	$1,497.68

DRILL BIT 3.0MM CANNULATED

Facility

$1,544.00

Hospital Charge Code	10600423
Hospital Revenue Code	272
Min. Negotiated Rate	$772.00
Max. Negotiated Rate	$1,497.68
Rate for Payer: AlohaCare Medicaid	$772.00
Rate for Payer: AlohaCare Medicare	$772.00
Rate for Payer: Cash Price	$1,003.60
Rate for Payer: Devoted Health Medicare	$849.20
Rate for Payer: Hawaii Medical Service Association Medicare	$772.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,466.80
Rate for Payer: Health Management Network Commercial	$1,312.40
Rate for Payer: Humana Medicare	$772.00
Rate for Payer: Kaiser Permanente Commercial	$1,389.60
Rate for Payer: Kaiser Permanente Medicaid	$787.44
Rate for Payer: Kaiser Permanente Medicare	$772.00
Rate for Payer: MDX Hawaii PPO	$1,497.68
Rate for Payer: Ohana Health Plan Medicaid	$772.00
Rate for Payer: Ohana Health Plan Medicare	$772.00
Rate for Payer: UnitedHealthcare Medicare	$772.00
Rate for Payer: University Health Alliance Commercial	$1,125.42

DRILL BIT, CANNULATED, 2.6MM

Facility

$368.00

Hospital Charge Code	12944056
Hospital Revenue Code	272
Min. Negotiated Rate	$312.80
Max. Negotiated Rate	$356.96
Rate for Payer: Cash Price	$239.20
Rate for Payer: Health Management Network Commercial	$312.80
Rate for Payer: Kaiser Permanente Commercial	$331.20
Rate for Payer: MDX Hawaii PPO	$356.96

DRILL BIT, CANNULATED, 2.6MM

Facility

$368.00

Hospital Charge Code	12944056
Hospital Revenue Code	272
Min. Negotiated Rate	$184.00
Max. Negotiated Rate	$356.96
Rate for Payer: AlohaCare Medicaid	$184.00
Rate for Payer: AlohaCare Medicare	$184.00
Rate for Payer: Cash Price	$239.20
Rate for Payer: Devoted Health Medicare	$202.40
Rate for Payer: Hawaii Medical Service Association Medicare	$184.00
Rate for Payer: Hawaii Western Management Group Commercial	$349.60
Rate for Payer: Health Management Network Commercial	$312.80
Rate for Payer: Humana Medicare	$184.00
Rate for Payer: Kaiser Permanente Commercial	$331.20
Rate for Payer: Kaiser Permanente Medicaid	$187.68
Rate for Payer: Kaiser Permanente Medicare	$184.00
Rate for Payer: MDX Hawaii PPO	$356.96
Rate for Payer: Ohana Health Plan Medicaid	$184.00
Rate for Payer: Ohana Health Plan Medicare	$184.00
Rate for Payer: UnitedHealthcare Medicare	$184.00
Rate for Payer: University Health Alliance Commercial	$268.24

DRILL, CANNULATED, SMALL HUDSON, 5.0MM

Facility

$1,038.00

Hospital Charge Code	12985800
Hospital Revenue Code	272
Min. Negotiated Rate	$519.00
Max. Negotiated Rate	$1,006.86
Rate for Payer: AlohaCare Medicaid	$519.00
Rate for Payer: AlohaCare Medicare	$519.00
Rate for Payer: Cash Price	$674.70
Rate for Payer: Devoted Health Medicare	$570.90
Rate for Payer: Hawaii Medical Service Association Medicare	$519.00
Rate for Payer: Hawaii Western Management Group Commercial	$986.10
Rate for Payer: Health Management Network Commercial	$882.30
Rate for Payer: Humana Medicare	$519.00
Rate for Payer: Kaiser Permanente Commercial	$934.20
Rate for Payer: Kaiser Permanente Medicaid	$529.38
Rate for Payer: Kaiser Permanente Medicare	$519.00
Rate for Payer: MDX Hawaii PPO	$1,006.86
Rate for Payer: Ohana Health Plan Medicaid	$519.00
Rate for Payer: Ohana Health Plan Medicare	$519.00
Rate for Payer: UnitedHealthcare Medicare	$519.00
Rate for Payer: University Health Alliance Commercial	$756.60

DRILL, CANNULATED, SMALL HUDSON, 5.0MM

Facility

$1,038.00

Hospital Charge Code	12985800
Hospital Revenue Code	272
Min. Negotiated Rate	$882.30
Max. Negotiated Rate	$1,006.86
Rate for Payer: Cash Price	$674.70
Rate for Payer: Health Management Network Commercial	$882.30
Rate for Payer: Kaiser Permanente Commercial	$934.20
Rate for Payer: MDX Hawaii PPO	$1,006.86

Know your out-of-pocket cost for care.

All Charges