Samuel Mahelona Memorial Hospital

All Charges

Charge

Type

Setting

Price

ES TROCH NAIL, RT, 10MM X 39CM X 130

Facility

$6,080.00

Service Code	HCPCS C1713
Hospital Charge Code	12987650
Hospital Revenue Code	278
Min. Negotiated Rate	$3,404.80
Max. Negotiated Rate	$5,897.60
Rate for Payer: Cash Price	$3,952.00
Rate for Payer: Hawaii Western Management Group Commercial	$4,256.00
Rate for Payer: Health Management Network Commercial	$5,168.00
Rate for Payer: Kaiser Permanente Commercial	$5,472.00
Rate for Payer: MDX Hawaii PPO	$5,897.60
Rate for Payer: University Health Alliance Commercial	$3,404.80

ES TROCH NAIL, RT, 10MM X 42CM X 130

Facility

$6,080.00

Service Code	HCPCS C1713
Hospital Charge Code	12987644
Hospital Revenue Code	278
Min. Negotiated Rate	$3,404.80
Max. Negotiated Rate	$5,897.60
Rate for Payer: Cash Price	$3,952.00
Rate for Payer: Hawaii Western Management Group Commercial	$4,256.00
Rate for Payer: Health Management Network Commercial	$5,168.00
Rate for Payer: Kaiser Permanente Commercial	$5,472.00
Rate for Payer: MDX Hawaii PPO	$5,897.60
Rate for Payer: University Health Alliance Commercial	$3,404.80

ES TROCH NAIL, RT, 10MM X 42CM X 130

Facility

$6,080.00

Service Code	HCPCS C1713
Hospital Charge Code	12987644
Hospital Revenue Code	278
Min. Negotiated Rate	$3,040.00
Max. Negotiated Rate	$5,897.60
Rate for Payer: AlohaCare Medicaid	$3,040.00
Rate for Payer: AlohaCare Medicare	$3,040.00
Rate for Payer: Cash Price	$3,952.00
Rate for Payer: Devoted Health Medicare	$3,344.00
Rate for Payer: Hawaii Medical Service Association Medicare	$3,040.00
Rate for Payer: Hawaii Western Management Group Commercial	$4,256.00
Rate for Payer: Health Management Network Commercial	$5,168.00
Rate for Payer: Humana Medicare	$3,040.00
Rate for Payer: Kaiser Permanente Commercial	$5,472.00
Rate for Payer: Kaiser Permanente Medicaid	$3,100.80
Rate for Payer: Kaiser Permanente Medicare	$3,040.00
Rate for Payer: MDX Hawaii PPO	$5,897.60
Rate for Payer: Ohana Health Plan Medicaid	$3,040.00
Rate for Payer: Ohana Health Plan Medicare	$3,040.00
Rate for Payer: UnitedHealthcare Medicare	$3,040.00
Rate for Payer: University Health Alliance Commercial	$3,404.80

ES TROCH NAIL, RT, 10MM X 45CM X 130

Facility

$6,080.00

Service Code	HCPCS C1713
Hospital Charge Code	12987645
Hospital Revenue Code	278
Min. Negotiated Rate	$3,040.00
Max. Negotiated Rate	$5,897.60
Rate for Payer: AlohaCare Medicaid	$3,040.00
Rate for Payer: AlohaCare Medicare	$3,040.00
Rate for Payer: Cash Price	$3,952.00
Rate for Payer: Devoted Health Medicare	$3,344.00
Rate for Payer: Hawaii Medical Service Association Medicare	$3,040.00
Rate for Payer: Hawaii Western Management Group Commercial	$4,256.00
Rate for Payer: Health Management Network Commercial	$5,168.00
Rate for Payer: Humana Medicare	$3,040.00
Rate for Payer: Kaiser Permanente Commercial	$5,472.00
Rate for Payer: Kaiser Permanente Medicaid	$3,100.80
Rate for Payer: Kaiser Permanente Medicare	$3,040.00
Rate for Payer: MDX Hawaii PPO	$5,897.60
Rate for Payer: Ohana Health Plan Medicaid	$3,040.00
Rate for Payer: Ohana Health Plan Medicare	$3,040.00
Rate for Payer: UnitedHealthcare Medicare	$3,040.00
Rate for Payer: University Health Alliance Commercial	$3,404.80

ES TROCH NAIL, RT, 10MM X 45CM X 130

Facility

$6,080.00

Service Code	HCPCS C1713
Hospital Charge Code	12987645
Hospital Revenue Code	278
Min. Negotiated Rate	$3,404.80
Max. Negotiated Rate	$5,897.60
Rate for Payer: Cash Price	$3,952.00
Rate for Payer: Hawaii Western Management Group Commercial	$4,256.00
Rate for Payer: Health Management Network Commercial	$5,168.00
Rate for Payer: Kaiser Permanente Commercial	$5,472.00
Rate for Payer: MDX Hawaii PPO	$5,897.60
Rate for Payer: University Health Alliance Commercial	$3,404.80

ES TROCH NAIL, RT, 11MM X 30CM X 130

Facility

$6,080.00

Service Code	HCPCS C1713
Hospital Charge Code	12987653
Hospital Revenue Code	278
Min. Negotiated Rate	$3,404.80
Max. Negotiated Rate	$5,897.60
Rate for Payer: Cash Price	$3,952.00
Rate for Payer: Hawaii Western Management Group Commercial	$4,256.00
Rate for Payer: Health Management Network Commercial	$5,168.00
Rate for Payer: Kaiser Permanente Commercial	$5,472.00
Rate for Payer: MDX Hawaii PPO	$5,897.60
Rate for Payer: University Health Alliance Commercial	$3,404.80

ES TROCH NAIL, RT, 11MM X 30CM X 130

Facility

$6,080.00

Service Code	HCPCS C1713
Hospital Charge Code	12987653
Hospital Revenue Code	278
Min. Negotiated Rate	$3,040.00
Max. Negotiated Rate	$5,897.60
Rate for Payer: AlohaCare Medicaid	$3,040.00
Rate for Payer: AlohaCare Medicare	$3,040.00
Rate for Payer: Cash Price	$3,952.00
Rate for Payer: Devoted Health Medicare	$3,344.00
Rate for Payer: Hawaii Medical Service Association Medicare	$3,040.00
Rate for Payer: Hawaii Western Management Group Commercial	$4,256.00
Rate for Payer: Health Management Network Commercial	$5,168.00
Rate for Payer: Humana Medicare	$3,040.00
Rate for Payer: Kaiser Permanente Commercial	$5,472.00
Rate for Payer: Kaiser Permanente Medicaid	$3,100.80
Rate for Payer: Kaiser Permanente Medicare	$3,040.00
Rate for Payer: MDX Hawaii PPO	$5,897.60
Rate for Payer: Ohana Health Plan Medicaid	$3,040.00
Rate for Payer: Ohana Health Plan Medicare	$3,040.00
Rate for Payer: UnitedHealthcare Medicare	$3,040.00
Rate for Payer: University Health Alliance Commercial	$3,404.80

ES TROCH NAIL, RT, 11MM X 33CM X 130

Facility

$6,080.00

Service Code	HCPCS C1713
Hospital Charge Code	12987646
Hospital Revenue Code	278
Min. Negotiated Rate	$3,404.80
Max. Negotiated Rate	$5,897.60
Rate for Payer: Cash Price	$3,952.00
Rate for Payer: Hawaii Western Management Group Commercial	$4,256.00
Rate for Payer: Health Management Network Commercial	$5,168.00
Rate for Payer: Kaiser Permanente Commercial	$5,472.00
Rate for Payer: MDX Hawaii PPO	$5,897.60
Rate for Payer: University Health Alliance Commercial	$3,404.80

ES TROCH NAIL, RT, 11MM X 33CM X 130

Facility

$6,080.00

Service Code	HCPCS C1713
Hospital Charge Code	12987646
Hospital Revenue Code	278
Min. Negotiated Rate	$3,040.00
Max. Negotiated Rate	$5,897.60
Rate for Payer: AlohaCare Medicaid	$3,040.00
Rate for Payer: AlohaCare Medicare	$3,040.00
Rate for Payer: Cash Price	$3,952.00
Rate for Payer: Devoted Health Medicare	$3,344.00
Rate for Payer: Hawaii Medical Service Association Medicare	$3,040.00
Rate for Payer: Hawaii Western Management Group Commercial	$4,256.00
Rate for Payer: Health Management Network Commercial	$5,168.00
Rate for Payer: Humana Medicare	$3,040.00
Rate for Payer: Kaiser Permanente Commercial	$5,472.00
Rate for Payer: Kaiser Permanente Medicaid	$3,100.80
Rate for Payer: Kaiser Permanente Medicare	$3,040.00
Rate for Payer: MDX Hawaii PPO	$5,897.60
Rate for Payer: Ohana Health Plan Medicaid	$3,040.00
Rate for Payer: Ohana Health Plan Medicare	$3,040.00
Rate for Payer: UnitedHealthcare Medicare	$3,040.00
Rate for Payer: University Health Alliance Commercial	$3,404.80

ES TROCH NAIL, RT, 11MM X 36CM X 130

Facility

$6,080.00

Service Code	HCPCS C1713
Hospital Charge Code	12987654
Hospital Revenue Code	278
Min. Negotiated Rate	$3,040.00
Max. Negotiated Rate	$5,897.60
Rate for Payer: AlohaCare Medicaid	$3,040.00
Rate for Payer: AlohaCare Medicare	$3,040.00
Rate for Payer: Cash Price	$3,952.00
Rate for Payer: Devoted Health Medicare	$3,344.00
Rate for Payer: Hawaii Medical Service Association Medicare	$3,040.00
Rate for Payer: Hawaii Western Management Group Commercial	$4,256.00
Rate for Payer: Health Management Network Commercial	$5,168.00
Rate for Payer: Humana Medicare	$3,040.00
Rate for Payer: Kaiser Permanente Commercial	$5,472.00
Rate for Payer: Kaiser Permanente Medicaid	$3,100.80
Rate for Payer: Kaiser Permanente Medicare	$3,040.00
Rate for Payer: MDX Hawaii PPO	$5,897.60
Rate for Payer: Ohana Health Plan Medicaid	$3,040.00
Rate for Payer: Ohana Health Plan Medicare	$3,040.00
Rate for Payer: UnitedHealthcare Medicare	$3,040.00
Rate for Payer: University Health Alliance Commercial	$3,404.80

ES TROCH NAIL, RT, 11MM X 36CM X 130

Facility

$6,080.00

Service Code	HCPCS C1713
Hospital Charge Code	12987654
Hospital Revenue Code	278
Min. Negotiated Rate	$3,404.80
Max. Negotiated Rate	$5,897.60
Rate for Payer: Cash Price	$3,952.00
Rate for Payer: Hawaii Western Management Group Commercial	$4,256.00
Rate for Payer: Health Management Network Commercial	$5,168.00
Rate for Payer: Kaiser Permanente Commercial	$5,472.00
Rate for Payer: MDX Hawaii PPO	$5,897.60
Rate for Payer: University Health Alliance Commercial	$3,404.80

ES TROCH NAIL, RT, 11MM X 42CM X 130

Facility

$6,080.00

Service Code	HCPCS C1713
Hospital Charge Code	12987656
Hospital Revenue Code	278
Min. Negotiated Rate	$3,404.80
Max. Negotiated Rate	$5,897.60
Rate for Payer: Cash Price	$3,952.00
Rate for Payer: Hawaii Western Management Group Commercial	$4,256.00
Rate for Payer: Health Management Network Commercial	$5,168.00
Rate for Payer: Kaiser Permanente Commercial	$5,472.00
Rate for Payer: MDX Hawaii PPO	$5,897.60
Rate for Payer: University Health Alliance Commercial	$3,404.80

ES TROCH NAIL, RT, 11MM X 42CM X 130

Facility

$6,080.00

Service Code	HCPCS C1713
Hospital Charge Code	12987656
Hospital Revenue Code	278
Min. Negotiated Rate	$3,040.00
Max. Negotiated Rate	$5,897.60
Rate for Payer: AlohaCare Medicaid	$3,040.00
Rate for Payer: AlohaCare Medicare	$3,040.00
Rate for Payer: Cash Price	$3,952.00
Rate for Payer: Devoted Health Medicare	$3,344.00
Rate for Payer: Hawaii Medical Service Association Medicare	$3,040.00
Rate for Payer: Hawaii Western Management Group Commercial	$4,256.00
Rate for Payer: Health Management Network Commercial	$5,168.00
Rate for Payer: Humana Medicare	$3,040.00
Rate for Payer: Kaiser Permanente Commercial	$5,472.00
Rate for Payer: Kaiser Permanente Medicaid	$3,100.80
Rate for Payer: Kaiser Permanente Medicare	$3,040.00
Rate for Payer: MDX Hawaii PPO	$5,897.60
Rate for Payer: Ohana Health Plan Medicaid	$3,040.00
Rate for Payer: Ohana Health Plan Medicare	$3,040.00
Rate for Payer: UnitedHealthcare Medicare	$3,040.00
Rate for Payer: University Health Alliance Commercial	$3,404.80

ES TROCH NAIL, RT, 11MM X 45CM X 130

Facility

$6,080.00

Service Code	HCPCS C1713
Hospital Charge Code	12987651
Hospital Revenue Code	278
Min. Negotiated Rate	$3,040.00
Max. Negotiated Rate	$5,897.60
Rate for Payer: AlohaCare Medicaid	$3,040.00
Rate for Payer: AlohaCare Medicare	$3,040.00
Rate for Payer: Cash Price	$3,952.00
Rate for Payer: Devoted Health Medicare	$3,344.00
Rate for Payer: Hawaii Medical Service Association Medicare	$3,040.00
Rate for Payer: Hawaii Western Management Group Commercial	$4,256.00
Rate for Payer: Health Management Network Commercial	$5,168.00
Rate for Payer: Humana Medicare	$3,040.00
Rate for Payer: Kaiser Permanente Commercial	$5,472.00
Rate for Payer: Kaiser Permanente Medicaid	$3,100.80
Rate for Payer: Kaiser Permanente Medicare	$3,040.00
Rate for Payer: MDX Hawaii PPO	$5,897.60
Rate for Payer: Ohana Health Plan Medicaid	$3,040.00
Rate for Payer: Ohana Health Plan Medicare	$3,040.00
Rate for Payer: UnitedHealthcare Medicare	$3,040.00
Rate for Payer: University Health Alliance Commercial	$3,404.80

ES TROCH NAIL, RT, 11MM X 45CM X 130

Facility

$6,080.00

Service Code	HCPCS C1713
Hospital Charge Code	12987651
Hospital Revenue Code	278
Min. Negotiated Rate	$3,404.80
Max. Negotiated Rate	$5,897.60
Rate for Payer: Cash Price	$3,952.00
Rate for Payer: Hawaii Western Management Group Commercial	$4,256.00
Rate for Payer: Health Management Network Commercial	$5,168.00
Rate for Payer: Kaiser Permanente Commercial	$5,472.00
Rate for Payer: MDX Hawaii PPO	$5,897.60
Rate for Payer: University Health Alliance Commercial	$3,404.80

ES TROCH NAIL, RT, 12.5MM X 30CM X 130

Facility

$6,290.00

Service Code	HCPCS C1713
Hospital Charge Code	12987647
Hospital Revenue Code	278
Min. Negotiated Rate	$3,522.40
Max. Negotiated Rate	$6,101.30
Rate for Payer: Cash Price	$4,088.50
Rate for Payer: Hawaii Western Management Group Commercial	$4,403.00
Rate for Payer: Health Management Network Commercial	$5,346.50
Rate for Payer: Kaiser Permanente Commercial	$5,661.00
Rate for Payer: MDX Hawaii PPO	$6,101.30
Rate for Payer: University Health Alliance Commercial	$3,522.40

ES TROCH NAIL, RT, 12.5MM X 30CM X 130

Facility

$6,290.00

Service Code	HCPCS C1713
Hospital Charge Code	12987647
Hospital Revenue Code	278
Min. Negotiated Rate	$3,145.00
Max. Negotiated Rate	$6,101.30
Rate for Payer: AlohaCare Medicaid	$3,145.00
Rate for Payer: AlohaCare Medicare	$3,145.00
Rate for Payer: Cash Price	$4,088.50
Rate for Payer: Devoted Health Medicare	$3,459.50
Rate for Payer: Hawaii Medical Service Association Medicare	$3,145.00
Rate for Payer: Hawaii Western Management Group Commercial	$4,403.00
Rate for Payer: Health Management Network Commercial	$5,346.50
Rate for Payer: Humana Medicare	$3,145.00
Rate for Payer: Kaiser Permanente Commercial	$5,661.00
Rate for Payer: Kaiser Permanente Medicaid	$3,207.90
Rate for Payer: Kaiser Permanente Medicare	$3,145.00
Rate for Payer: MDX Hawaii PPO	$6,101.30
Rate for Payer: Ohana Health Plan Medicaid	$3,145.00
Rate for Payer: Ohana Health Plan Medicare	$3,145.00
Rate for Payer: UnitedHealthcare Medicare	$3,145.00
Rate for Payer: University Health Alliance Commercial	$3,522.40

ES TROCH NAIL, RT, 12.5MM X 33CM X 130

Facility

$6,290.00

Service Code	HCPCS C1713
Hospital Charge Code	12987657
Hospital Revenue Code	278
Min. Negotiated Rate	$3,145.00
Max. Negotiated Rate	$6,101.30
Rate for Payer: AlohaCare Medicaid	$3,145.00
Rate for Payer: AlohaCare Medicare	$3,145.00
Rate for Payer: Cash Price	$4,088.50
Rate for Payer: Devoted Health Medicare	$3,459.50
Rate for Payer: Hawaii Medical Service Association Medicare	$3,145.00
Rate for Payer: Hawaii Western Management Group Commercial	$4,403.00
Rate for Payer: Health Management Network Commercial	$5,346.50
Rate for Payer: Humana Medicare	$3,145.00
Rate for Payer: Kaiser Permanente Commercial	$5,661.00
Rate for Payer: Kaiser Permanente Medicaid	$3,207.90
Rate for Payer: Kaiser Permanente Medicare	$3,145.00
Rate for Payer: MDX Hawaii PPO	$6,101.30
Rate for Payer: Ohana Health Plan Medicaid	$3,145.00
Rate for Payer: Ohana Health Plan Medicare	$3,145.00
Rate for Payer: UnitedHealthcare Medicare	$3,145.00
Rate for Payer: University Health Alliance Commercial	$3,522.40

ES TROCH NAIL, RT, 12.5MM X 33CM X 130

Facility

$6,290.00

Service Code	HCPCS C1713
Hospital Charge Code	12987657
Hospital Revenue Code	278
Min. Negotiated Rate	$3,522.40
Max. Negotiated Rate	$6,101.30
Rate for Payer: Cash Price	$4,088.50
Rate for Payer: Hawaii Western Management Group Commercial	$4,403.00
Rate for Payer: Health Management Network Commercial	$5,346.50
Rate for Payer: Kaiser Permanente Commercial	$5,661.00
Rate for Payer: MDX Hawaii PPO	$6,101.30
Rate for Payer: University Health Alliance Commercial	$3,522.40

Estrogens Total Serum FSI

Facility

$112.00

Service Code	HCPCS 82672
Hospital Charge Code	8117907
Hospital Revenue Code	301
Min. Negotiated Rate	$95.20
Max. Negotiated Rate	$108.64
Rate for Payer: Cash Price	$72.80
Rate for Payer: Health Management Network Commercial	$95.20
Rate for Payer: Kaiser Permanente Commercial	$100.80
Rate for Payer: MDX Hawaii PPO	$108.64

Estrogens Total Serum FSI

Facility

$112.00

Service Code	HCPCS 82672
Hospital Charge Code	8117907
Hospital Revenue Code	301
Min. Negotiated Rate	$21.70
Max. Negotiated Rate	$108.64
Rate for Payer: AlohaCare Medicaid	$56.00
Rate for Payer: AlohaCare Medicare	$56.00
Rate for Payer: Cash Price	$72.80
Rate for Payer: Cash Price	$72.80
Rate for Payer: Devoted Health Medicare	$61.60
Rate for Payer: Hawaii Medical Service Association ABD	$29.97
Rate for Payer: Hawaii Medical Service Association Commercial	$27.12
Rate for Payer: Hawaii Medical Service Association Medicare	$56.00
Rate for Payer: Hawaii Medical Service Association Non-ABD	$31.47
Rate for Payer: Hawaii Western Management Group Commercial	$21.70
Rate for Payer: Health Management Network Commercial	$95.20
Rate for Payer: Humana Medicare	$56.00
Rate for Payer: Kaiser Permanente Commercial	$100.80
Rate for Payer: Kaiser Permanente Medicaid	$57.12
Rate for Payer: Kaiser Permanente Medicare	$56.00
Rate for Payer: MDX Hawaii PPO	$108.64
Rate for Payer: Ohana Health Plan Medicaid	$56.00
Rate for Payer: Ohana Health Plan Medicare	$56.00
Rate for Payer: UnitedHealthcare Medicaid	$29.97
Rate for Payer: UnitedHealthcare Medicare	$56.00
Rate for Payer: University Health Alliance Commercial	$56.05

Ethyl Glucuronide and Ethyl Sulfate Urine w/ Confirmation FSI

Facility

$375.00

Service Code	HCPCS 80321
Hospital Charge Code	8117908
Hospital Revenue Code	300
Min. Negotiated Rate	$318.75
Max. Negotiated Rate	$363.75
Rate for Payer: Cash Price	$243.75
Rate for Payer: Health Management Network Commercial	$318.75
Rate for Payer: Kaiser Permanente Commercial	$337.50
Rate for Payer: MDX Hawaii PPO	$363.75

Ethyl Glucuronide and Ethyl Sulfate Urine w/ Confirmation FSI

Facility

$375.00

Service Code	HCPCS 80321
Hospital Charge Code	8117908
Hospital Revenue Code	300
Min. Negotiated Rate	$14.93
Max. Negotiated Rate	$363.75
Rate for Payer: AlohaCare Medicaid	$187.50
Rate for Payer: AlohaCare Medicare	$187.50
Rate for Payer: Cash Price	$243.75
Rate for Payer: Cash Price	$243.75
Rate for Payer: Devoted Health Medicare	$206.25
Rate for Payer: Hawaii Medical Service Association ABD	$14.93
Rate for Payer: Hawaii Medical Service Association Medicare	$187.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$15.68
Rate for Payer: Hawaii Western Management Group Commercial	$356.25
Rate for Payer: Health Management Network Commercial	$318.75
Rate for Payer: Humana Medicare	$187.50
Rate for Payer: Kaiser Permanente Commercial	$337.50
Rate for Payer: Kaiser Permanente Medicaid	$191.25
Rate for Payer: Kaiser Permanente Medicare	$187.50
Rate for Payer: MDX Hawaii PPO	$363.75
Rate for Payer: Ohana Health Plan Medicaid	$187.50
Rate for Payer: Ohana Health Plan Medicare	$187.50
Rate for Payer: UnitedHealthcare Medicare	$187.50
Rate for Payer: University Health Alliance Commercial	$210.00

etomidate 20 mg/10 ml vial [HHSC]

Facility

$46.03

Service Code	NDC 00143950610
Hospital Charge Code	2500317
Hospital Revenue Code	250
Min. Negotiated Rate	$39.13
Max. Negotiated Rate	$44.65
Rate for Payer: Cash Price	$29.92
Rate for Payer: Health Management Network Commercial	$39.13
Rate for Payer: Kaiser Permanente Commercial	$41.43
Rate for Payer: MDX Hawaii PPO	$44.65

etomidate 20 mg/10 ml vial [HHSC]

Facility

$56.43

Service Code	NDC 55150022110
Hospital Charge Code	2500317
Hospital Revenue Code	250
Min. Negotiated Rate	$47.97
Max. Negotiated Rate	$54.74
Rate for Payer: Cash Price	$36.68
Rate for Payer: Health Management Network Commercial	$47.97
Rate for Payer: Kaiser Permanente Commercial	$50.79
Rate for Payer: MDX Hawaii PPO	$54.74

Know your out-of-pocket cost for care.

All Charges