Samuel Mahelona Memorial Hospital

All Charges

Charge

Type

Setting

Price

KOH Preparation FSI

Facility

$65.00

Service Code	HCPCS 87220
Hospital Charge Code	8228887
Hospital Revenue Code	306
Min. Negotiated Rate	$4.27
Max. Negotiated Rate	$63.05
Rate for Payer: AlohaCare Medicaid	$32.50
Rate for Payer: AlohaCare Medicare	$32.50
Rate for Payer: Cash Price	$42.25
Rate for Payer: Cash Price	$42.25
Rate for Payer: Devoted Health Medicare	$35.75
Rate for Payer: Hawaii Medical Service Association ABD	$5.90
Rate for Payer: Hawaii Medical Service Association Commercial	$5.34
Rate for Payer: Hawaii Medical Service Association Medicare	$32.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$6.20
Rate for Payer: Hawaii Western Management Group Commercial	$4.27
Rate for Payer: Health Management Network Commercial	$55.25
Rate for Payer: Humana Medicare	$32.50
Rate for Payer: Kaiser Permanente Commercial	$58.50
Rate for Payer: Kaiser Permanente Medicaid	$33.15
Rate for Payer: Kaiser Permanente Medicare	$32.50
Rate for Payer: MDX Hawaii PPO	$63.05
Rate for Payer: Ohana Health Plan Medicaid	$32.50
Rate for Payer: Ohana Health Plan Medicare	$32.50
Rate for Payer: UnitedHealthcare Medicaid	$5.90
Rate for Payer: UnitedHealthcare Medicare	$32.50
Rate for Payer: University Health Alliance Commercial	$11.03

KOH Preparation FSI

Facility

$65.00

Service Code	HCPCS 87220
Hospital Charge Code	8228887
Hospital Revenue Code	306
Min. Negotiated Rate	$55.25
Max. Negotiated Rate	$63.05
Rate for Payer: Cash Price	$42.25
Rate for Payer: Health Management Network Commercial	$55.25
Rate for Payer: Kaiser Permanente Commercial	$58.50
Rate for Payer: MDX Hawaii PPO	$63.05

KOOL KIT WRAPS

Facility

$846.00

Hospital Charge Code	8274457
Hospital Revenue Code	272
Min. Negotiated Rate	$719.10
Max. Negotiated Rate	$820.62
Rate for Payer: Cash Price	$549.90
Rate for Payer: Health Management Network Commercial	$719.10
Rate for Payer: Kaiser Permanente Commercial	$761.40
Rate for Payer: MDX Hawaii PPO	$820.62

KOOL KIT WRAPS

Facility

$846.00

Hospital Charge Code	8274457
Hospital Revenue Code	272
Min. Negotiated Rate	$423.00
Max. Negotiated Rate	$820.62
Rate for Payer: AlohaCare Medicaid	$423.00
Rate for Payer: AlohaCare Medicare	$423.00
Rate for Payer: Cash Price	$549.90
Rate for Payer: Devoted Health Medicare	$465.30
Rate for Payer: Hawaii Medical Service Association Medicare	$423.00
Rate for Payer: Hawaii Western Management Group Commercial	$803.70
Rate for Payer: Health Management Network Commercial	$719.10
Rate for Payer: Humana Medicare	$423.00
Rate for Payer: Kaiser Permanente Commercial	$761.40
Rate for Payer: Kaiser Permanente Medicaid	$431.46
Rate for Payer: Kaiser Permanente Medicare	$423.00
Rate for Payer: MDX Hawaii PPO	$820.62
Rate for Payer: Ohana Health Plan Medicaid	$423.00
Rate for Payer: Ohana Health Plan Medicare	$423.00
Rate for Payer: UnitedHealthcare Medicare	$423.00
Rate for Payer: University Health Alliance Commercial	$616.65

K-WIRE 0.9 X150MM BLUNT/TROCAR

Facility

$256.00

Hospital Charge Code	10600424
Hospital Revenue Code	272
Min. Negotiated Rate	$128.00
Max. Negotiated Rate	$248.32
Rate for Payer: AlohaCare Medicaid	$128.00
Rate for Payer: AlohaCare Medicare	$128.00
Rate for Payer: Cash Price	$166.40
Rate for Payer: Devoted Health Medicare	$140.80
Rate for Payer: Hawaii Medical Service Association Medicare	$128.00
Rate for Payer: Hawaii Western Management Group Commercial	$243.20
Rate for Payer: Health Management Network Commercial	$217.60
Rate for Payer: Humana Medicare	$128.00
Rate for Payer: Kaiser Permanente Commercial	$230.40
Rate for Payer: Kaiser Permanente Medicaid	$130.56
Rate for Payer: Kaiser Permanente Medicare	$128.00
Rate for Payer: MDX Hawaii PPO	$248.32
Rate for Payer: Ohana Health Plan Medicaid	$128.00
Rate for Payer: Ohana Health Plan Medicare	$128.00
Rate for Payer: UnitedHealthcare Medicare	$128.00
Rate for Payer: University Health Alliance Commercial	$186.60

K-WIRE 0.9 X150MM BLUNT/TROCAR

Facility

$256.00

Hospital Charge Code	10600424
Hospital Revenue Code	272
Min. Negotiated Rate	$217.60
Max. Negotiated Rate	$248.32
Rate for Payer: Cash Price	$166.40
Rate for Payer: Health Management Network Commercial	$217.60
Rate for Payer: Kaiser Permanente Commercial	$230.40
Rate for Payer: MDX Hawaii PPO	$248.32

K-WIRE 1.1 X150MM BLUNT/TROCAR

Facility

$236.00

Service Code	HCPCS C1713
Hospital Charge Code	10600438
Hospital Revenue Code	278
Min. Negotiated Rate	$118.00
Max. Negotiated Rate	$228.92
Rate for Payer: AlohaCare Medicaid	$118.00
Rate for Payer: AlohaCare Medicare	$118.00
Rate for Payer: Cash Price	$153.40
Rate for Payer: Devoted Health Medicare	$129.80
Rate for Payer: Hawaii Medical Service Association Medicare	$118.00
Rate for Payer: Hawaii Western Management Group Commercial	$165.20
Rate for Payer: Health Management Network Commercial	$200.60
Rate for Payer: Humana Medicare	$118.00
Rate for Payer: Kaiser Permanente Commercial	$212.40
Rate for Payer: Kaiser Permanente Medicaid	$120.36
Rate for Payer: Kaiser Permanente Medicare	$118.00
Rate for Payer: MDX Hawaii PPO	$228.92
Rate for Payer: Ohana Health Plan Medicaid	$118.00
Rate for Payer: Ohana Health Plan Medicare	$118.00
Rate for Payer: UnitedHealthcare Medicare	$118.00
Rate for Payer: University Health Alliance Commercial	$132.16

K-WIRE 1.1 X150MM BLUNT/TROCAR

Facility

$236.00

Service Code	HCPCS C1713
Hospital Charge Code	10600438
Hospital Revenue Code	278
Min. Negotiated Rate	$132.16
Max. Negotiated Rate	$228.92
Rate for Payer: Cash Price	$153.40
Rate for Payer: Hawaii Western Management Group Commercial	$165.20
Rate for Payer: Health Management Network Commercial	$200.60
Rate for Payer: Kaiser Permanente Commercial	$212.40
Rate for Payer: MDX Hawaii PPO	$228.92
Rate for Payer: University Health Alliance Commercial	$132.16

L0625 - Brace Back Sup Corfit Sys

Facility

$186.00

Service Code	HCPCS L0625
Hospital Charge Code	8409626
Hospital Revenue Code	274
Min. Negotiated Rate	$43.27
Max. Negotiated Rate	$180.42
Rate for Payer: AlohaCare Medicaid	$93.00
Rate for Payer: AlohaCare Medicare	$93.00
Rate for Payer: Cash Price	$120.90
Rate for Payer: Cash Price	$120.90
Rate for Payer: Devoted Health Medicare	$102.30
Rate for Payer: Hawaii Medical Service Association Medicare	$93.00
Rate for Payer: Hawaii Western Management Group Commercial	$130.20
Rate for Payer: Health Management Network Commercial	$158.10
Rate for Payer: Humana Medicare	$93.00
Rate for Payer: Kaiser Permanente Commercial	$167.40
Rate for Payer: Kaiser Permanente Medicaid	$94.86
Rate for Payer: Kaiser Permanente Medicare	$93.00
Rate for Payer: MDX Hawaii PPO	$180.42
Rate for Payer: Ohana Health Plan Medicaid	$93.00
Rate for Payer: Ohana Health Plan Medicare	$93.00
Rate for Payer: UnitedHealthcare Medicaid	$43.27
Rate for Payer: UnitedHealthcare Medicare	$93.00
Rate for Payer: University Health Alliance Commercial	$104.16

L0625 - Brace Back Sup Corfit Sys

Facility

$186.00

Service Code	HCPCS L0625
Hospital Charge Code	8409626
Hospital Revenue Code	274
Min. Negotiated Rate	$104.16
Max. Negotiated Rate	$180.42
Rate for Payer: Cash Price	$120.90
Rate for Payer: Hawaii Western Management Group Commercial	$130.20
Rate for Payer: Health Management Network Commercial	$158.10
Rate for Payer: Kaiser Permanente Commercial	$167.40
Rate for Payer: MDX Hawaii PPO	$180.42
Rate for Payer: University Health Alliance Commercial	$104.16

L3760 - EO Adj Lcking Jnts Prefab

Facility

$96.00

Service Code	HCPCS L3760
Hospital Charge Code	8409612
Hospital Revenue Code	274
Min. Negotiated Rate	$53.76
Max. Negotiated Rate	$93.12
Rate for Payer: Cash Price	$62.40
Rate for Payer: Hawaii Western Management Group Commercial	$67.20
Rate for Payer: Health Management Network Commercial	$81.60
Rate for Payer: Kaiser Permanente Commercial	$86.40
Rate for Payer: MDX Hawaii PPO	$93.12
Rate for Payer: University Health Alliance Commercial	$53.76

L3760 - EO Adj Lcking Jnts Prefab

Facility

$96.00

Service Code	HCPCS L3760
Hospital Charge Code	8409612
Hospital Revenue Code	274
Min. Negotiated Rate	$48.00
Max. Negotiated Rate	$214.57
Rate for Payer: AlohaCare Medicaid	$48.00
Rate for Payer: AlohaCare Medicare	$48.00
Rate for Payer: Cash Price	$62.40
Rate for Payer: Cash Price	$62.40
Rate for Payer: Devoted Health Medicare	$52.80
Rate for Payer: Hawaii Medical Service Association Medicare	$48.00
Rate for Payer: Hawaii Western Management Group Commercial	$67.20
Rate for Payer: Health Management Network Commercial	$81.60
Rate for Payer: Humana Medicare	$48.00
Rate for Payer: Kaiser Permanente Commercial	$86.40
Rate for Payer: Kaiser Permanente Medicaid	$48.96
Rate for Payer: Kaiser Permanente Medicare	$48.00
Rate for Payer: MDX Hawaii PPO	$93.12
Rate for Payer: Ohana Health Plan Medicaid	$48.00
Rate for Payer: Ohana Health Plan Medicare	$48.00
Rate for Payer: UnitedHealthcare Medicaid	$214.57
Rate for Payer: UnitedHealthcare Medicare	$48.00
Rate for Payer: University Health Alliance Commercial	$53.76

L3760 - EO Custom Fab Elbow Splint

Facility

$319.00

Service Code	HCPCS L3760
Hospital Charge Code	8409611
Hospital Revenue Code	274
Min. Negotiated Rate	$178.64
Max. Negotiated Rate	$309.43
Rate for Payer: Cash Price	$207.35
Rate for Payer: Hawaii Western Management Group Commercial	$223.30
Rate for Payer: Health Management Network Commercial	$271.15
Rate for Payer: Kaiser Permanente Commercial	$287.10
Rate for Payer: MDX Hawaii PPO	$309.43
Rate for Payer: University Health Alliance Commercial	$178.64

L3760 - EO Custom Fab Elbow Splint

Facility

$319.00

Service Code	HCPCS L3760
Hospital Charge Code	8409611
Hospital Revenue Code	274
Min. Negotiated Rate	$159.50
Max. Negotiated Rate	$309.43
Rate for Payer: AlohaCare Medicaid	$159.50
Rate for Payer: AlohaCare Medicare	$159.50
Rate for Payer: Cash Price	$207.35
Rate for Payer: Cash Price	$207.35
Rate for Payer: Devoted Health Medicare	$175.45
Rate for Payer: Hawaii Medical Service Association Medicare	$159.50
Rate for Payer: Hawaii Western Management Group Commercial	$223.30
Rate for Payer: Health Management Network Commercial	$271.15
Rate for Payer: Humana Medicare	$159.50
Rate for Payer: Kaiser Permanente Commercial	$287.10
Rate for Payer: Kaiser Permanente Medicaid	$162.69
Rate for Payer: Kaiser Permanente Medicare	$159.50
Rate for Payer: MDX Hawaii PPO	$309.43
Rate for Payer: Ohana Health Plan Medicaid	$159.50
Rate for Payer: Ohana Health Plan Medicare	$159.50
Rate for Payer: UnitedHealthcare Medicaid	$214.57
Rate for Payer: UnitedHealthcare Medicare	$159.50
Rate for Payer: University Health Alliance Commercial	$178.64

L3807 - Splint Aqua Plast Sm

Facility

$45.00

Service Code	HCPCS L3807
Hospital Charge Code	8409605
Hospital Revenue Code	274
Min. Negotiated Rate	$22.50
Max. Negotiated Rate	$107.29
Rate for Payer: AlohaCare Medicaid	$22.50
Rate for Payer: AlohaCare Medicare	$22.50
Rate for Payer: Cash Price	$29.25
Rate for Payer: Cash Price	$29.25
Rate for Payer: Devoted Health Medicare	$24.75
Rate for Payer: Hawaii Medical Service Association Medicare	$22.50
Rate for Payer: Hawaii Western Management Group Commercial	$31.50
Rate for Payer: Health Management Network Commercial	$38.25
Rate for Payer: Humana Medicare	$22.50
Rate for Payer: Kaiser Permanente Commercial	$40.50
Rate for Payer: Kaiser Permanente Medicaid	$22.95
Rate for Payer: Kaiser Permanente Medicare	$22.50
Rate for Payer: MDX Hawaii PPO	$43.65
Rate for Payer: Ohana Health Plan Medicaid	$22.50
Rate for Payer: Ohana Health Plan Medicare	$22.50
Rate for Payer: UnitedHealthcare Medicaid	$107.29
Rate for Payer: UnitedHealthcare Medicare	$22.50
Rate for Payer: University Health Alliance Commercial	$25.20

L3807 - Splint Aqua Plast Sm

Facility

$45.00

Service Code	HCPCS L3807
Hospital Charge Code	8409605
Hospital Revenue Code	274
Min. Negotiated Rate	$25.20
Max. Negotiated Rate	$43.65
Rate for Payer: Cash Price	$29.25
Rate for Payer: Hawaii Western Management Group Commercial	$31.50
Rate for Payer: Health Management Network Commercial	$38.25
Rate for Payer: Kaiser Permanente Commercial	$40.50
Rate for Payer: MDX Hawaii PPO	$43.65
Rate for Payer: University Health Alliance Commercial	$25.20

L3807 - Splint Aqua Plast Sm/Med

Facility

$45.00

Service Code	HCPCS L3807
Hospital Charge Code	8409606
Hospital Revenue Code	274
Min. Negotiated Rate	$25.20
Max. Negotiated Rate	$43.65
Rate for Payer: Cash Price	$29.25
Rate for Payer: Hawaii Western Management Group Commercial	$31.50
Rate for Payer: Health Management Network Commercial	$38.25
Rate for Payer: Kaiser Permanente Commercial	$40.50
Rate for Payer: MDX Hawaii PPO	$43.65
Rate for Payer: University Health Alliance Commercial	$25.20

L3807 - Splint Aqua Plast Sm/Med

Facility

$45.00

Service Code	HCPCS L3807
Hospital Charge Code	8409606
Hospital Revenue Code	274
Min. Negotiated Rate	$22.50
Max. Negotiated Rate	$107.29
Rate for Payer: AlohaCare Medicaid	$22.50
Rate for Payer: AlohaCare Medicare	$22.50
Rate for Payer: Cash Price	$29.25
Rate for Payer: Cash Price	$29.25
Rate for Payer: Devoted Health Medicare	$24.75
Rate for Payer: Hawaii Medical Service Association Medicare	$22.50
Rate for Payer: Hawaii Western Management Group Commercial	$31.50
Rate for Payer: Health Management Network Commercial	$38.25
Rate for Payer: Humana Medicare	$22.50
Rate for Payer: Kaiser Permanente Commercial	$40.50
Rate for Payer: Kaiser Permanente Medicaid	$22.95
Rate for Payer: Kaiser Permanente Medicare	$22.50
Rate for Payer: MDX Hawaii PPO	$43.65
Rate for Payer: Ohana Health Plan Medicaid	$22.50
Rate for Payer: Ohana Health Plan Medicare	$22.50
Rate for Payer: UnitedHealthcare Medicaid	$107.29
Rate for Payer: UnitedHealthcare Medicare	$22.50
Rate for Payer: University Health Alliance Commercial	$25.20

L3807 - WHFO MP Ext Assist

Facility

$32.00

Service Code	HCPCS L3807
Hospital Charge Code	8409598
Hospital Revenue Code	274
Min. Negotiated Rate	$17.92
Max. Negotiated Rate	$31.04
Rate for Payer: Cash Price	$20.80
Rate for Payer: Hawaii Western Management Group Commercial	$22.40
Rate for Payer: Health Management Network Commercial	$27.20
Rate for Payer: Kaiser Permanente Commercial	$28.80
Rate for Payer: MDX Hawaii PPO	$31.04
Rate for Payer: University Health Alliance Commercial	$17.92

L3807 - WHFO MP Ext Assist

Facility

$32.00

Service Code	HCPCS L3807
Hospital Charge Code	8409598
Hospital Revenue Code	274
Min. Negotiated Rate	$16.00
Max. Negotiated Rate	$107.29
Rate for Payer: AlohaCare Medicaid	$16.00
Rate for Payer: AlohaCare Medicare	$16.00
Rate for Payer: Cash Price	$20.80
Rate for Payer: Cash Price	$20.80
Rate for Payer: Devoted Health Medicare	$17.60
Rate for Payer: Hawaii Medical Service Association Medicare	$16.00
Rate for Payer: Hawaii Western Management Group Commercial	$22.40
Rate for Payer: Health Management Network Commercial	$27.20
Rate for Payer: Humana Medicare	$16.00
Rate for Payer: Kaiser Permanente Commercial	$28.80
Rate for Payer: Kaiser Permanente Medicaid	$16.32
Rate for Payer: Kaiser Permanente Medicare	$16.00
Rate for Payer: MDX Hawaii PPO	$31.04
Rate for Payer: Ohana Health Plan Medicaid	$16.00
Rate for Payer: Ohana Health Plan Medicare	$16.00
Rate for Payer: UnitedHealthcare Medicaid	$107.29
Rate for Payer: UnitedHealthcare Medicare	$16.00
Rate for Payer: University Health Alliance Commercial	$17.92

L3808 - Splint Aqua Plast Med

Facility

$72.00

Service Code	HCPCS L3808
Hospital Charge Code	8409628
Hospital Revenue Code	274
Min. Negotiated Rate	$40.32
Max. Negotiated Rate	$69.84
Rate for Payer: Cash Price	$46.80
Rate for Payer: Hawaii Western Management Group Commercial	$50.40
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
Rate for Payer: University Health Alliance Commercial	$40.32

L3808 - Splint Aqua Plast Med

Facility

$72.00

Service Code	HCPCS L3808
Hospital Charge Code	8409628
Hospital Revenue Code	274
Min. Negotiated Rate	$18.94
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: 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	$50.40
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 Medicaid	$18.94
Rate for Payer: UnitedHealthcare Medicare	$36.00
Rate for Payer: University Health Alliance Commercial	$40.32

L3900 - WHFO MP Ext Asst MPStp

Facility

$118.00

Service Code	HCPCS L3900
Hospital Charge Code	8409627
Hospital Revenue Code	274
Min. Negotiated Rate	$59.00
Max. Negotiated Rate	$763.00
Rate for Payer: AlohaCare Medicaid	$59.00
Rate for Payer: AlohaCare Medicare	$59.00
Rate for Payer: Cash Price	$76.70
Rate for Payer: Cash Price	$76.70
Rate for Payer: Devoted Health Medicare	$64.90
Rate for Payer: Hawaii Medical Service Association Medicare	$59.00
Rate for Payer: Hawaii Western Management Group Commercial	$82.60
Rate for Payer: Health Management Network Commercial	$100.30
Rate for Payer: Humana Medicare	$59.00
Rate for Payer: Kaiser Permanente Commercial	$106.20
Rate for Payer: Kaiser Permanente Medicaid	$60.18
Rate for Payer: Kaiser Permanente Medicare	$59.00
Rate for Payer: MDX Hawaii PPO	$114.46
Rate for Payer: Ohana Health Plan Medicaid	$59.00
Rate for Payer: Ohana Health Plan Medicare	$59.00
Rate for Payer: UnitedHealthcare Medicaid	$763.00
Rate for Payer: UnitedHealthcare Medicare	$59.00
Rate for Payer: University Health Alliance Commercial	$66.08

L3900 - WHFO MP Ext Asst MPStp

Facility

$118.00

Service Code	HCPCS L3900
Hospital Charge Code	8409627
Hospital Revenue Code	274
Min. Negotiated Rate	$66.08
Max. Negotiated Rate	$114.46
Rate for Payer: Cash Price	$76.70
Rate for Payer: Hawaii Western Management Group Commercial	$82.60
Rate for Payer: Health Management Network Commercial	$100.30
Rate for Payer: Kaiser Permanente Commercial	$106.20
Rate for Payer: MDX Hawaii PPO	$114.46
Rate for Payer: University Health Alliance Commercial	$66.08

L3913 - Gel Shell Roylan Thumb

Facility

$103.00

Service Code	HCPCS L3913
Hospital Charge Code	8409609
Hospital Revenue Code	274
Min. Negotiated Rate	$51.50
Max. Negotiated Rate	$116.21
Rate for Payer: AlohaCare Medicaid	$51.50
Rate for Payer: AlohaCare Medicare	$51.50
Rate for Payer: Cash Price	$66.95
Rate for Payer: Cash Price	$66.95
Rate for Payer: Devoted Health Medicare	$56.65
Rate for Payer: Hawaii Medical Service Association Medicare	$51.50
Rate for Payer: Hawaii Western Management Group Commercial	$72.10
Rate for Payer: Health Management Network Commercial	$87.55
Rate for Payer: Humana Medicare	$51.50
Rate for Payer: Kaiser Permanente Commercial	$92.70
Rate for Payer: Kaiser Permanente Medicaid	$52.53
Rate for Payer: Kaiser Permanente Medicare	$51.50
Rate for Payer: MDX Hawaii PPO	$99.91
Rate for Payer: Ohana Health Plan Medicaid	$51.50
Rate for Payer: Ohana Health Plan Medicare	$51.50
Rate for Payer: UnitedHealthcare Medicaid	$116.21
Rate for Payer: UnitedHealthcare Medicare	$51.50
Rate for Payer: University Health Alliance Commercial	$57.68

Know your out-of-pocket cost for care.

All Charges