Samuel Mahelona Memorial Hospital

All Charges

Charge

Type

Setting

Price

GENERAL:CANISTER 45 ML 7.2 X 6

Facility

$214.00

Hospital Charge Code	12818174
Hospital Revenue Code	272
Min. Negotiated Rate	$107.00
Max. Negotiated Rate	$207.58
Rate for Payer: AlohaCare Medicaid	$107.00
Rate for Payer: AlohaCare Medicare	$107.00
Rate for Payer: Cash Price	$139.10
Rate for Payer: Devoted Health Medicare	$117.70
Rate for Payer: Hawaii Medical Service Association Medicare	$107.00
Rate for Payer: Hawaii Western Management Group Commercial	$203.30
Rate for Payer: Health Management Network Commercial	$181.90
Rate for Payer: Humana Medicare	$107.00
Rate for Payer: Kaiser Permanente Commercial	$192.60
Rate for Payer: Kaiser Permanente Medicaid	$109.14
Rate for Payer: Kaiser Permanente Medicare	$107.00
Rate for Payer: MDX Hawaii PPO	$207.58
Rate for Payer: Ohana Health Plan Medicaid	$107.00
Rate for Payer: Ohana Health Plan Medicare	$107.00
Rate for Payer: UnitedHealthcare Medicare	$107.00
Rate for Payer: University Health Alliance Commercial	$155.98

GENERAL:CARTER-THOMASON 12MM

Facility

$658.00

Hospital Charge Code	13217011
Hospital Revenue Code	272
Min. Negotiated Rate	$559.30
Max. Negotiated Rate	$638.26
Rate for Payer: Cash Price	$427.70
Rate for Payer: Health Management Network Commercial	$559.30
Rate for Payer: Kaiser Permanente Commercial	$592.20
Rate for Payer: MDX Hawaii PPO	$638.26

GENERAL:CARTER-THOMASON 12MM

Facility

$658.00

Hospital Charge Code	13217011
Hospital Revenue Code	272
Min. Negotiated Rate	$329.00
Max. Negotiated Rate	$638.26
Rate for Payer: AlohaCare Medicaid	$329.00
Rate for Payer: AlohaCare Medicare	$329.00
Rate for Payer: Cash Price	$427.70
Rate for Payer: Devoted Health Medicare	$361.90
Rate for Payer: Hawaii Medical Service Association Medicare	$329.00
Rate for Payer: Hawaii Western Management Group Commercial	$625.10
Rate for Payer: Health Management Network Commercial	$559.30
Rate for Payer: Humana Medicare	$329.00
Rate for Payer: Kaiser Permanente Commercial	$592.20
Rate for Payer: Kaiser Permanente Medicaid	$335.58
Rate for Payer: Kaiser Permanente Medicare	$329.00
Rate for Payer: MDX Hawaii PPO	$638.26
Rate for Payer: Ohana Health Plan Medicaid	$329.00
Rate for Payer: Ohana Health Plan Medicare	$329.00
Rate for Payer: UnitedHealthcare Medicare	$329.00
Rate for Payer: University Health Alliance Commercial	$479.62

GENERAL:COMPOSITE MESH 42 X 32 CM

Facility

$3,614.00

Service Code	HCPCS C1781
Hospital Charge Code	13021712
Hospital Revenue Code	278
Min. Negotiated Rate	$1,807.00
Max. Negotiated Rate	$3,505.58
Rate for Payer: AlohaCare Medicaid	$1,807.00
Rate for Payer: AlohaCare Medicare	$1,807.00
Rate for Payer: Cash Price	$2,349.10
Rate for Payer: Devoted Health Medicare	$1,987.70
Rate for Payer: Hawaii Medical Service Association Medicare	$1,807.00
Rate for Payer: Hawaii Western Management Group Commercial	$2,529.80
Rate for Payer: Health Management Network Commercial	$3,071.90
Rate for Payer: Humana Medicare	$1,807.00
Rate for Payer: Kaiser Permanente Commercial	$3,252.60
Rate for Payer: Kaiser Permanente Medicaid	$1,843.14
Rate for Payer: Kaiser Permanente Medicare	$1,807.00
Rate for Payer: MDX Hawaii PPO	$3,505.58
Rate for Payer: Ohana Health Plan Medicaid	$1,807.00
Rate for Payer: Ohana Health Plan Medicare	$1,807.00
Rate for Payer: UnitedHealthcare Medicare	$1,807.00
Rate for Payer: University Health Alliance Commercial	$2,023.84

GENERAL:COMPOSITE MESH 42 X 32 CM

Facility

$3,614.00

Service Code	HCPCS C1781
Hospital Charge Code	13021712
Hospital Revenue Code	278
Min. Negotiated Rate	$2,023.84
Max. Negotiated Rate	$3,505.58
Rate for Payer: Cash Price	$2,349.10
Rate for Payer: Hawaii Western Management Group Commercial	$2,529.80
Rate for Payer: Health Management Network Commercial	$3,071.90
Rate for Payer: Kaiser Permanente Commercial	$3,252.60
Rate for Payer: MDX Hawaii PPO	$3,505.58
Rate for Payer: University Health Alliance Commercial	$2,023.84

GENERAL: DERMABOND MINI

Facility

$72.00

Hospital Charge Code	13287182
Hospital Revenue Code	272
Min. Negotiated Rate	$61.20
Max. Negotiated Rate	$69.84
Rate for Payer: Cash Price	$46.80
Rate for Payer: Health Management Network Commercial	$61.20
Rate for Payer: Kaiser Permanente Commercial	$64.80
Rate for Payer: MDX Hawaii PPO	$69.84

GENERAL: DERMABOND MINI

Facility

$72.00

Hospital Charge Code	13287182
Hospital Revenue Code	272
Min. Negotiated Rate	$36.00
Max. Negotiated Rate	$69.84
Rate for Payer: AlohaCare Medicaid	$36.00
Rate for Payer: AlohaCare Medicare	$36.00
Rate for Payer: Cash Price	$46.80
Rate for Payer: Devoted Health Medicare	$39.60
Rate for Payer: Hawaii Medical Service Association Medicare	$36.00
Rate for Payer: Hawaii Western Management Group Commercial	$68.40
Rate for Payer: Health Management Network Commercial	$61.20
Rate for Payer: Humana Medicare	$36.00
Rate for Payer: Kaiser Permanente Commercial	$64.80
Rate for Payer: Kaiser Permanente Medicaid	$36.72
Rate for Payer: Kaiser Permanente Medicare	$36.00
Rate for Payer: MDX Hawaii PPO	$69.84
Rate for Payer: Ohana Health Plan Medicaid	$36.00
Rate for Payer: Ohana Health Plan Medicare	$36.00
Rate for Payer: UnitedHealthcare Medicare	$36.00
Rate for Payer: University Health Alliance Commercial	$52.48

GENERAL:DRESSING ADAPTIC

Facility

$18.00

Hospital Charge Code	12818173
Hospital Revenue Code	272
Min. Negotiated Rate	$9.00
Max. Negotiated Rate	$17.46
Rate for Payer: AlohaCare Medicaid	$9.00
Rate for Payer: AlohaCare Medicare	$9.00
Rate for Payer: Cash Price	$11.70
Rate for Payer: Devoted Health Medicare	$9.90
Rate for Payer: Hawaii Medical Service Association Medicare	$9.00
Rate for Payer: Hawaii Western Management Group Commercial	$17.10
Rate for Payer: Health Management Network Commercial	$15.30
Rate for Payer: Humana Medicare	$9.00
Rate for Payer: Kaiser Permanente Commercial	$16.20
Rate for Payer: Kaiser Permanente Medicaid	$9.18
Rate for Payer: Kaiser Permanente Medicare	$9.00
Rate for Payer: MDX Hawaii PPO	$17.46
Rate for Payer: Ohana Health Plan Medicaid	$9.00
Rate for Payer: Ohana Health Plan Medicare	$9.00
Rate for Payer: UnitedHealthcare Medicare	$9.00
Rate for Payer: University Health Alliance Commercial	$13.12

GENERAL:DRESSING ADAPTIC

Facility

$18.00

Hospital Charge Code	12818173
Hospital Revenue Code	272
Min. Negotiated Rate	$15.30
Max. Negotiated Rate	$17.46
Rate for Payer: Cash Price	$11.70
Rate for Payer: Health Management Network Commercial	$15.30
Rate for Payer: Kaiser Permanente Commercial	$16.20
Rate for Payer: MDX Hawaii PPO	$17.46

GENERAL:ENDOCLOSE TROCAR SITE CLOSURE

Facility

$134.00

Hospital Charge Code	13217014
Hospital Revenue Code	272
Min. Negotiated Rate	$67.00
Max. Negotiated Rate	$129.98
Rate for Payer: AlohaCare Medicaid	$67.00
Rate for Payer: AlohaCare Medicare	$67.00
Rate for Payer: Cash Price	$87.10
Rate for Payer: Devoted Health Medicare	$73.70
Rate for Payer: Hawaii Medical Service Association Medicare	$67.00
Rate for Payer: Hawaii Western Management Group Commercial	$127.30
Rate for Payer: Health Management Network Commercial	$113.90
Rate for Payer: Humana Medicare	$67.00
Rate for Payer: Kaiser Permanente Commercial	$120.60
Rate for Payer: Kaiser Permanente Medicaid	$68.34
Rate for Payer: Kaiser Permanente Medicare	$67.00
Rate for Payer: MDX Hawaii PPO	$129.98
Rate for Payer: Ohana Health Plan Medicaid	$67.00
Rate for Payer: Ohana Health Plan Medicare	$67.00
Rate for Payer: UnitedHealthcare Medicare	$67.00
Rate for Payer: University Health Alliance Commercial	$97.67

GENERAL:ENDOCLOSE TROCAR SITE CLOSURE

Facility

$134.00

Hospital Charge Code	13217014
Hospital Revenue Code	272
Min. Negotiated Rate	$113.90
Max. Negotiated Rate	$129.98
Rate for Payer: Cash Price	$87.10
Rate for Payer: Health Management Network Commercial	$113.90
Rate for Payer: Kaiser Permanente Commercial	$120.60
Rate for Payer: MDX Hawaii PPO	$129.98

GENERAL:GASTROSTOMY PEG 20FR

Facility

$354.00

Hospital Charge Code	8274193
Hospital Revenue Code	272
Min. Negotiated Rate	$177.00
Max. Negotiated Rate	$343.38
Rate for Payer: AlohaCare Medicaid	$177.00
Rate for Payer: AlohaCare Medicare	$177.00
Rate for Payer: Cash Price	$230.10
Rate for Payer: Devoted Health Medicare	$194.70
Rate for Payer: Hawaii Medical Service Association Medicare	$177.00
Rate for Payer: Hawaii Western Management Group Commercial	$336.30
Rate for Payer: Health Management Network Commercial	$300.90
Rate for Payer: Humana Medicare	$177.00
Rate for Payer: Kaiser Permanente Commercial	$318.60
Rate for Payer: Kaiser Permanente Medicaid	$180.54
Rate for Payer: Kaiser Permanente Medicare	$177.00
Rate for Payer: MDX Hawaii PPO	$343.38
Rate for Payer: Ohana Health Plan Medicaid	$177.00
Rate for Payer: Ohana Health Plan Medicare	$177.00
Rate for Payer: UnitedHealthcare Medicare	$177.00
Rate for Payer: University Health Alliance Commercial	$258.03

GENERAL:GASTROSTOMY PEG 20FR

Facility

$354.00

Hospital Charge Code	8274193
Hospital Revenue Code	272
Min. Negotiated Rate	$300.90
Max. Negotiated Rate	$343.38
Rate for Payer: Cash Price	$230.10
Rate for Payer: Health Management Network Commercial	$300.90
Rate for Payer: Kaiser Permanente Commercial	$318.60
Rate for Payer: MDX Hawaii PPO	$343.38

General Health Panel FSI

Facility

$389.00

Service Code	HCPCS 80050
Hospital Charge Code	8681141
Hospital Revenue Code	305
Min. Negotiated Rate	$41.19
Max. Negotiated Rate	$377.33
Rate for Payer: AlohaCare Medicaid	$194.50
Rate for Payer: AlohaCare Medicare	$194.50
Rate for Payer: Cash Price	$252.85
Rate for Payer: Cash Price	$252.85
Rate for Payer: Devoted Health Medicare	$213.95
Rate for Payer: Hawaii Medical Service Association ABD	$41.19
Rate for Payer: Hawaii Medical Service Association Medicare	$194.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$49.16
Rate for Payer: Hawaii Western Management Group Commercial	$369.55
Rate for Payer: Health Management Network Commercial	$330.65
Rate for Payer: Humana Medicare	$194.50
Rate for Payer: Kaiser Permanente Commercial	$350.10
Rate for Payer: Kaiser Permanente Medicaid	$198.39
Rate for Payer: Kaiser Permanente Medicare	$194.50
Rate for Payer: MDX Hawaii PPO	$377.33
Rate for Payer: Ohana Health Plan Medicaid	$194.50
Rate for Payer: Ohana Health Plan Medicare	$194.50
Rate for Payer: UnitedHealthcare Medicaid	$41.19
Rate for Payer: UnitedHealthcare Medicare	$194.50
Rate for Payer: University Health Alliance Commercial	$92.74

General Health Panel FSI

Facility

$389.00

Service Code	HCPCS 80050
Hospital Charge Code	8681141
Hospital Revenue Code	305
Min. Negotiated Rate	$330.65
Max. Negotiated Rate	$377.33
Rate for Payer: Cash Price	$252.85
Rate for Payer: Health Management Network Commercial	$330.65
Rate for Payer: Kaiser Permanente Commercial	$350.10
Rate for Payer: MDX Hawaii PPO	$377.33

GENERAL:KANGAROO GTUBE 18FR20CC

Facility

$127.00

Hospital Charge Code	13126205
Hospital Revenue Code	272
Min. Negotiated Rate	$63.50
Max. Negotiated Rate	$123.19
Rate for Payer: AlohaCare Medicaid	$63.50
Rate for Payer: AlohaCare Medicare	$63.50
Rate for Payer: Cash Price	$82.55
Rate for Payer: Devoted Health Medicare	$69.85
Rate for Payer: Hawaii Medical Service Association Medicare	$63.50
Rate for Payer: Hawaii Western Management Group Commercial	$120.65
Rate for Payer: Health Management Network Commercial	$107.95
Rate for Payer: Humana Medicare	$63.50
Rate for Payer: Kaiser Permanente Commercial	$114.30
Rate for Payer: Kaiser Permanente Medicaid	$64.77
Rate for Payer: Kaiser Permanente Medicare	$63.50
Rate for Payer: MDX Hawaii PPO	$123.19
Rate for Payer: Ohana Health Plan Medicaid	$63.50
Rate for Payer: Ohana Health Plan Medicare	$63.50
Rate for Payer: UnitedHealthcare Medicare	$63.50
Rate for Payer: University Health Alliance Commercial	$92.57

GENERAL:KANGAROO GTUBE 18FR20CC

Facility

$127.00

Hospital Charge Code	13126205
Hospital Revenue Code	272
Min. Negotiated Rate	$107.95
Max. Negotiated Rate	$123.19
Rate for Payer: Cash Price	$82.55
Rate for Payer: Health Management Network Commercial	$107.95
Rate for Payer: Kaiser Permanente Commercial	$114.30
Rate for Payer: MDX Hawaii PPO	$123.19

GENERAL:KIT 20 CM

Facility

$2,248.00

Hospital Charge Code	12818166
Hospital Revenue Code	272
Min. Negotiated Rate	$1,910.80
Max. Negotiated Rate	$2,180.56
Rate for Payer: Cash Price	$1,461.20
Rate for Payer: Health Management Network Commercial	$1,910.80
Rate for Payer: Kaiser Permanente Commercial	$2,023.20
Rate for Payer: MDX Hawaii PPO	$2,180.56

GENERAL:KIT 20 CM

Facility

$2,248.00

Hospital Charge Code	12818166
Hospital Revenue Code	272
Min. Negotiated Rate	$1,124.00
Max. Negotiated Rate	$2,180.56
Rate for Payer: AlohaCare Medicaid	$1,124.00
Rate for Payer: AlohaCare Medicare	$1,124.00
Rate for Payer: Cash Price	$1,461.20
Rate for Payer: Devoted Health Medicare	$1,236.40
Rate for Payer: Hawaii Medical Service Association Medicare	$1,124.00
Rate for Payer: Hawaii Western Management Group Commercial	$2,135.60
Rate for Payer: Health Management Network Commercial	$1,910.80
Rate for Payer: Humana Medicare	$1,124.00
Rate for Payer: Kaiser Permanente Commercial	$2,023.20
Rate for Payer: Kaiser Permanente Medicaid	$1,146.48
Rate for Payer: Kaiser Permanente Medicare	$1,124.00
Rate for Payer: MDX Hawaii PPO	$2,180.56
Rate for Payer: Ohana Health Plan Medicaid	$1,124.00
Rate for Payer: Ohana Health Plan Medicare	$1,124.00
Rate for Payer: UnitedHealthcare Medicare	$1,124.00
Rate for Payer: University Health Alliance Commercial	$1,638.57

GENERAL:MARYLAND/HOOK LIGASURE

Facility

$1,814.00

Hospital Charge Code	12818170
Hospital Revenue Code	272
Min. Negotiated Rate	$1,541.90
Max. Negotiated Rate	$1,759.58
Rate for Payer: Cash Price	$1,179.10
Rate for Payer: Health Management Network Commercial	$1,541.90
Rate for Payer: Kaiser Permanente Commercial	$1,632.60
Rate for Payer: MDX Hawaii PPO	$1,759.58

GENERAL:MARYLAND/HOOK LIGASURE

Facility

$1,814.00

Hospital Charge Code	12818170
Hospital Revenue Code	272
Min. Negotiated Rate	$907.00
Max. Negotiated Rate	$1,759.58
Rate for Payer: AlohaCare Medicaid	$907.00
Rate for Payer: AlohaCare Medicare	$907.00
Rate for Payer: Cash Price	$1,179.10
Rate for Payer: Devoted Health Medicare	$997.70
Rate for Payer: Hawaii Medical Service Association Medicare	$907.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,723.30
Rate for Payer: Health Management Network Commercial	$1,541.90
Rate for Payer: Humana Medicare	$907.00
Rate for Payer: Kaiser Permanente Commercial	$1,632.60
Rate for Payer: Kaiser Permanente Medicaid	$925.14
Rate for Payer: Kaiser Permanente Medicare	$907.00
Rate for Payer: MDX Hawaii PPO	$1,759.58
Rate for Payer: Ohana Health Plan Medicaid	$907.00
Rate for Payer: Ohana Health Plan Medicare	$907.00
Rate for Payer: UnitedHealthcare Medicare	$907.00
Rate for Payer: University Health Alliance Commercial	$1,322.22

GENERAL:MESH 5 X 5 CM

Facility

$6,160.00

Service Code	HCPCS A2007
Hospital Charge Code	12706882
Hospital Revenue Code	278
Min. Negotiated Rate	$3,449.60
Max. Negotiated Rate	$5,975.20
Rate for Payer: Cash Price	$4,004.00
Rate for Payer: Hawaii Western Management Group Commercial	$4,312.00
Rate for Payer: Health Management Network Commercial	$5,236.00
Rate for Payer: Kaiser Permanente Commercial	$5,544.00
Rate for Payer: MDX Hawaii PPO	$5,975.20
Rate for Payer: University Health Alliance Commercial	$3,449.60

GENERAL:MESH 5 X 5 CM

Facility

$6,160.00

Service Code	HCPCS A2007
Hospital Charge Code	12706882
Hospital Revenue Code	278
Min. Negotiated Rate	$158.93
Max. Negotiated Rate	$5,975.20
Rate for Payer: AlohaCare Medicaid	$3,080.00
Rate for Payer: AlohaCare Medicare	$3,080.00
Rate for Payer: Cash Price	$4,004.00
Rate for Payer: Cash Price	$4,004.00
Rate for Payer: Devoted Health Medicare	$3,388.00
Rate for Payer: Hawaii Medical Service Association Commercial	$158.93
Rate for Payer: Hawaii Medical Service Association Medicare	$3,080.00
Rate for Payer: Hawaii Western Management Group Commercial	$4,312.00
Rate for Payer: Health Management Network Commercial	$5,236.00
Rate for Payer: Humana Medicare	$3,080.00
Rate for Payer: Kaiser Permanente Commercial	$5,544.00
Rate for Payer: Kaiser Permanente Medicaid	$3,141.60
Rate for Payer: Kaiser Permanente Medicare	$3,080.00
Rate for Payer: MDX Hawaii PPO	$5,975.20
Rate for Payer: Ohana Health Plan Medicaid	$3,080.00
Rate for Payer: Ohana Health Plan Medicare	$3,080.00
Rate for Payer: UnitedHealthcare Medicare	$3,080.00
Rate for Payer: University Health Alliance Commercial	$3,449.60

GENERAL:MIC-KEY GASTROSTOMY F. KIT

Facility

$412.00

Hospital Charge Code	12650976
Hospital Revenue Code	272
Min. Negotiated Rate	$206.00
Max. Negotiated Rate	$399.64
Rate for Payer: AlohaCare Medicaid	$206.00
Rate for Payer: AlohaCare Medicare	$206.00
Rate for Payer: Cash Price	$267.80
Rate for Payer: Devoted Health Medicare	$226.60
Rate for Payer: Hawaii Medical Service Association Medicare	$206.00
Rate for Payer: Hawaii Western Management Group Commercial	$391.40
Rate for Payer: Health Management Network Commercial	$350.20
Rate for Payer: Humana Medicare	$206.00
Rate for Payer: Kaiser Permanente Commercial	$370.80
Rate for Payer: Kaiser Permanente Medicaid	$210.12
Rate for Payer: Kaiser Permanente Medicare	$206.00
Rate for Payer: MDX Hawaii PPO	$399.64
Rate for Payer: Ohana Health Plan Medicaid	$206.00
Rate for Payer: Ohana Health Plan Medicare	$206.00
Rate for Payer: UnitedHealthcare Medicare	$206.00
Rate for Payer: University Health Alliance Commercial	$300.31

GENERAL:MIC-KEY GASTROSTOMY F. KIT

Facility

$412.00

Hospital Charge Code	12650976
Hospital Revenue Code	272
Min. Negotiated Rate	$350.20
Max. Negotiated Rate	$399.64
Rate for Payer: Cash Price	$267.80
Rate for Payer: Health Management Network Commercial	$350.20
Rate for Payer: Kaiser Permanente Commercial	$370.80
Rate for Payer: MDX Hawaii PPO	$399.64

Know your out-of-pocket cost for care.

All Charges