Samuel Mahelona Memorial Hospital

All Charges

Charge

Type

Setting

Price

LAPAROSCOPIC TROCAR BLADELESS 11MM XCEL 100MM DISPOSABLE STERILE

Facility

$782.00

Hospital Charge Code	8274238
Hospital Revenue Code	272
Min. Negotiated Rate	$664.70
Max. Negotiated Rate	$758.54
Rate for Payer: Cash Price	$508.30
Rate for Payer: Health Management Network Commercial	$664.70
Rate for Payer: Kaiser Permanente Commercial	$703.80
Rate for Payer: MDX Hawaii PPO	$758.54

LAPAROSCOPIC TROCAR BLADELESS 11MM XCEL 100MM DISPOSABLE STERILE

Facility

$782.00

Hospital Charge Code	8274238
Hospital Revenue Code	272
Min. Negotiated Rate	$391.00
Max. Negotiated Rate	$758.54
Rate for Payer: AlohaCare Medicaid	$391.00
Rate for Payer: AlohaCare Medicare	$391.00
Rate for Payer: Cash Price	$508.30
Rate for Payer: Devoted Health Medicare	$430.10
Rate for Payer: Hawaii Medical Service Association Medicare	$391.00
Rate for Payer: Hawaii Western Management Group Commercial	$742.90
Rate for Payer: Health Management Network Commercial	$664.70
Rate for Payer: Humana Medicare	$391.00
Rate for Payer: Kaiser Permanente Commercial	$703.80
Rate for Payer: Kaiser Permanente Medicaid	$398.82
Rate for Payer: Kaiser Permanente Medicare	$391.00
Rate for Payer: MDX Hawaii PPO	$758.54
Rate for Payer: Ohana Health Plan Medicaid	$391.00
Rate for Payer: Ohana Health Plan Medicare	$391.00
Rate for Payer: UnitedHealthcare Medicare	$391.00
Rate for Payer: University Health Alliance Commercial	$570.00

LAPAROSCOPIC TROCAR BLADELESS 5MM XCEL100MM LENGTH

Facility

$609.00

Hospital Charge Code	8274239
Hospital Revenue Code	272
Min. Negotiated Rate	$517.65
Max. Negotiated Rate	$590.73
Rate for Payer: Cash Price	$395.85
Rate for Payer: Health Management Network Commercial	$517.65
Rate for Payer: Kaiser Permanente Commercial	$548.10
Rate for Payer: MDX Hawaii PPO	$590.73

LAPAROSCOPIC TROCAR BLADELESS 5MM XCEL100MM LENGTH

Facility

$609.00

Hospital Charge Code	8274239
Hospital Revenue Code	272
Min. Negotiated Rate	$304.50
Max. Negotiated Rate	$590.73
Rate for Payer: AlohaCare Medicaid	$304.50
Rate for Payer: AlohaCare Medicare	$304.50
Rate for Payer: Cash Price	$395.85
Rate for Payer: Devoted Health Medicare	$334.95
Rate for Payer: Hawaii Medical Service Association Medicare	$304.50
Rate for Payer: Hawaii Western Management Group Commercial	$578.55
Rate for Payer: Health Management Network Commercial	$517.65
Rate for Payer: Humana Medicare	$304.50
Rate for Payer: Kaiser Permanente Commercial	$548.10
Rate for Payer: Kaiser Permanente Medicaid	$310.59
Rate for Payer: Kaiser Permanente Medicare	$304.50
Rate for Payer: MDX Hawaii PPO	$590.73
Rate for Payer: Ohana Health Plan Medicaid	$304.50
Rate for Payer: Ohana Health Plan Medicare	$304.50
Rate for Payer: UnitedHealthcare Medicare	$304.50
Rate for Payer: University Health Alliance Commercial	$443.90

LAPAROSCOPIC TROCAR BLUNT TIP 12MM XCEL 100MM LENGTH

Facility

$922.00

Hospital Charge Code	8274240
Hospital Revenue Code	272
Min. Negotiated Rate	$783.70
Max. Negotiated Rate	$894.34
Rate for Payer: Cash Price	$599.30
Rate for Payer: Health Management Network Commercial	$783.70
Rate for Payer: Kaiser Permanente Commercial	$829.80
Rate for Payer: MDX Hawaii PPO	$894.34

LAPAROSCOPIC TROCAR BLUNT TIP 12MM XCEL 100MM LENGTH

Facility

$922.00

Hospital Charge Code	8274240
Hospital Revenue Code	272
Min. Negotiated Rate	$461.00
Max. Negotiated Rate	$894.34
Rate for Payer: AlohaCare Medicaid	$461.00
Rate for Payer: AlohaCare Medicare	$461.00
Rate for Payer: Cash Price	$599.30
Rate for Payer: Devoted Health Medicare	$507.10
Rate for Payer: Hawaii Medical Service Association Medicare	$461.00
Rate for Payer: Hawaii Western Management Group Commercial	$875.90
Rate for Payer: Health Management Network Commercial	$783.70
Rate for Payer: Humana Medicare	$461.00
Rate for Payer: Kaiser Permanente Commercial	$829.80
Rate for Payer: Kaiser Permanente Medicaid	$470.22
Rate for Payer: Kaiser Permanente Medicare	$461.00
Rate for Payer: MDX Hawaii PPO	$894.34
Rate for Payer: Ohana Health Plan Medicaid	$461.00
Rate for Payer: Ohana Health Plan Medicare	$461.00
Rate for Payer: UnitedHealthcare Medicare	$461.00
Rate for Payer: University Health Alliance Commercial	$672.05

LAPAROSCOPIC, TROCAR STABILITY SLEEVES 11MM

Facility

$427.00

Hospital Charge Code	8274234
Hospital Revenue Code	272
Min. Negotiated Rate	$213.50
Max. Negotiated Rate	$414.19
Rate for Payer: AlohaCare Medicaid	$213.50
Rate for Payer: AlohaCare Medicare	$213.50
Rate for Payer: Cash Price	$277.55
Rate for Payer: Devoted Health Medicare	$234.85
Rate for Payer: Hawaii Medical Service Association Medicare	$213.50
Rate for Payer: Hawaii Western Management Group Commercial	$405.65
Rate for Payer: Health Management Network Commercial	$362.95
Rate for Payer: Humana Medicare	$213.50
Rate for Payer: Kaiser Permanente Commercial	$384.30
Rate for Payer: Kaiser Permanente Medicaid	$217.77
Rate for Payer: Kaiser Permanente Medicare	$213.50
Rate for Payer: MDX Hawaii PPO	$414.19
Rate for Payer: Ohana Health Plan Medicaid	$213.50
Rate for Payer: Ohana Health Plan Medicare	$213.50
Rate for Payer: UnitedHealthcare Medicare	$213.50
Rate for Payer: University Health Alliance Commercial	$311.24

LAPAROSCOPIC, TROCAR STABILITY SLEEVES 11MM

Facility

$427.00

Hospital Charge Code	8274234
Hospital Revenue Code	272
Min. Negotiated Rate	$362.95
Max. Negotiated Rate	$414.19
Rate for Payer: Cash Price	$277.55
Rate for Payer: Health Management Network Commercial	$362.95
Rate for Payer: Kaiser Permanente Commercial	$384.30
Rate for Payer: MDX Hawaii PPO	$414.19

LAPAROSCOPIC TROCAR STABILITY SLEEVES 5MM X 100MM

Facility

$361.00

Hospital Charge Code	8274235
Hospital Revenue Code	272
Min. Negotiated Rate	$306.85
Max. Negotiated Rate	$350.17
Rate for Payer: Cash Price	$234.65
Rate for Payer: Health Management Network Commercial	$306.85
Rate for Payer: Kaiser Permanente Commercial	$324.90
Rate for Payer: MDX Hawaii PPO	$350.17

LAPAROSCOPIC TROCAR STABILITY SLEEVES 5MM X 100MM

Facility

$361.00

Hospital Charge Code	8274235
Hospital Revenue Code	272
Min. Negotiated Rate	$180.50
Max. Negotiated Rate	$350.17
Rate for Payer: AlohaCare Medicaid	$180.50
Rate for Payer: AlohaCare Medicare	$180.50
Rate for Payer: Cash Price	$234.65
Rate for Payer: Devoted Health Medicare	$198.55
Rate for Payer: Hawaii Medical Service Association Medicare	$180.50
Rate for Payer: Hawaii Western Management Group Commercial	$342.95
Rate for Payer: Health Management Network Commercial	$306.85
Rate for Payer: Humana Medicare	$180.50
Rate for Payer: Kaiser Permanente Commercial	$324.90
Rate for Payer: Kaiser Permanente Medicaid	$184.11
Rate for Payer: Kaiser Permanente Medicare	$180.50
Rate for Payer: MDX Hawaii PPO	$350.17
Rate for Payer: Ohana Health Plan Medicaid	$180.50
Rate for Payer: Ohana Health Plan Medicare	$180.50
Rate for Payer: UnitedHealthcare Medicare	$180.50
Rate for Payer: University Health Alliance Commercial	$263.13

LAPAROSCOPIC, TROCAR XCEL BLADELESS 12MM

Facility

$851.00

Hospital Charge Code	8274236
Hospital Revenue Code	272
Min. Negotiated Rate	$723.35
Max. Negotiated Rate	$825.47
Rate for Payer: Cash Price	$553.15
Rate for Payer: Health Management Network Commercial	$723.35
Rate for Payer: Kaiser Permanente Commercial	$765.90
Rate for Payer: MDX Hawaii PPO	$825.47

LAPAROSCOPIC, TROCAR XCEL BLADELESS 12MM

Facility

$851.00

Hospital Charge Code	8274236
Hospital Revenue Code	272
Min. Negotiated Rate	$425.50
Max. Negotiated Rate	$825.47
Rate for Payer: AlohaCare Medicaid	$425.50
Rate for Payer: AlohaCare Medicare	$425.50
Rate for Payer: Cash Price	$553.15
Rate for Payer: Devoted Health Medicare	$468.05
Rate for Payer: Hawaii Medical Service Association Medicare	$425.50
Rate for Payer: Hawaii Western Management Group Commercial	$808.45
Rate for Payer: Health Management Network Commercial	$723.35
Rate for Payer: Humana Medicare	$425.50
Rate for Payer: Kaiser Permanente Commercial	$765.90
Rate for Payer: Kaiser Permanente Medicaid	$434.01
Rate for Payer: Kaiser Permanente Medicare	$425.50
Rate for Payer: MDX Hawaii PPO	$825.47
Rate for Payer: Ohana Health Plan Medicaid	$425.50
Rate for Payer: Ohana Health Plan Medicare	$425.50
Rate for Payer: UnitedHealthcare Medicare	$425.50
Rate for Payer: University Health Alliance Commercial	$620.29

LAPAROSCOPIC TROCAR XCEL BLADELESS 5MM 150MM

Facility

$662.00

Hospital Charge Code	8274237
Hospital Revenue Code	272
Min. Negotiated Rate	$562.70
Max. Negotiated Rate	$642.14
Rate for Payer: Cash Price	$430.30
Rate for Payer: Health Management Network Commercial	$562.70
Rate for Payer: Kaiser Permanente Commercial	$595.80
Rate for Payer: MDX Hawaii PPO	$642.14

LAPAROSCOPIC TROCAR XCEL BLADELESS 5MM 150MM

Facility

$662.00

Hospital Charge Code	8274237
Hospital Revenue Code	272
Min. Negotiated Rate	$331.00
Max. Negotiated Rate	$642.14
Rate for Payer: AlohaCare Medicaid	$331.00
Rate for Payer: AlohaCare Medicare	$331.00
Rate for Payer: Cash Price	$430.30
Rate for Payer: Devoted Health Medicare	$364.10
Rate for Payer: Hawaii Medical Service Association Medicare	$331.00
Rate for Payer: Hawaii Western Management Group Commercial	$628.90
Rate for Payer: Health Management Network Commercial	$562.70
Rate for Payer: Humana Medicare	$331.00
Rate for Payer: Kaiser Permanente Commercial	$595.80
Rate for Payer: Kaiser Permanente Medicaid	$337.62
Rate for Payer: Kaiser Permanente Medicare	$331.00
Rate for Payer: MDX Hawaii PPO	$642.14
Rate for Payer: Ohana Health Plan Medicaid	$331.00
Rate for Payer: Ohana Health Plan Medicare	$331.00
Rate for Payer: UnitedHealthcare Medicare	$331.00
Rate for Payer: University Health Alliance Commercial	$482.53

LAPAROSCOPIC, TUBING; INSUFFLATION

Facility

$98.00

Hospital Charge Code	8274162
Hospital Revenue Code	272
Min. Negotiated Rate	$49.00
Max. Negotiated Rate	$95.06
Rate for Payer: AlohaCare Medicaid	$49.00
Rate for Payer: AlohaCare Medicare	$49.00
Rate for Payer: Cash Price	$63.70
Rate for Payer: Devoted Health Medicare	$53.90
Rate for Payer: Hawaii Medical Service Association Medicare	$49.00
Rate for Payer: Hawaii Western Management Group Commercial	$93.10
Rate for Payer: Health Management Network Commercial	$83.30
Rate for Payer: Humana Medicare	$49.00
Rate for Payer: Kaiser Permanente Commercial	$88.20
Rate for Payer: Kaiser Permanente Medicaid	$49.98
Rate for Payer: Kaiser Permanente Medicare	$49.00
Rate for Payer: MDX Hawaii PPO	$95.06
Rate for Payer: Ohana Health Plan Medicaid	$49.00
Rate for Payer: Ohana Health Plan Medicare	$49.00
Rate for Payer: UnitedHealthcare Medicare	$49.00
Rate for Payer: University Health Alliance Commercial	$71.43

LAPAROSCOPIC, TUBING; INSUFFLATION

Facility

$98.00

Hospital Charge Code	8274162
Hospital Revenue Code	272
Min. Negotiated Rate	$83.30
Max. Negotiated Rate	$95.06
Rate for Payer: Cash Price	$63.70
Rate for Payer: Health Management Network Commercial	$83.30
Rate for Payer: Kaiser Permanente Commercial	$88.20
Rate for Payer: MDX Hawaii PPO	$95.06

LAP PROGRIP ANATOMIC LEFT 10 X 15

Facility

$1,598.00

Service Code	HCPCS C1781
Hospital Charge Code	10166861
Hospital Revenue Code	278
Min. Negotiated Rate	$894.88
Max. Negotiated Rate	$1,550.06
Rate for Payer: Cash Price	$1,038.70
Rate for Payer: Hawaii Western Management Group Commercial	$1,118.60
Rate for Payer: Health Management Network Commercial	$1,358.30
Rate for Payer: Kaiser Permanente Commercial	$1,438.20
Rate for Payer: MDX Hawaii PPO	$1,550.06
Rate for Payer: University Health Alliance Commercial	$894.88

LAP PROGRIP ANATOMIC LEFT 10 X 15

Facility

$1,598.00

Service Code	HCPCS C1781
Hospital Charge Code	10166861
Hospital Revenue Code	278
Min. Negotiated Rate	$799.00
Max. Negotiated Rate	$1,550.06
Rate for Payer: AlohaCare Medicaid	$799.00
Rate for Payer: AlohaCare Medicare	$799.00
Rate for Payer: Cash Price	$1,038.70
Rate for Payer: Devoted Health Medicare	$878.90
Rate for Payer: Hawaii Medical Service Association Medicare	$799.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,118.60
Rate for Payer: Health Management Network Commercial	$1,358.30
Rate for Payer: Humana Medicare	$799.00
Rate for Payer: Kaiser Permanente Commercial	$1,438.20
Rate for Payer: Kaiser Permanente Medicaid	$814.98
Rate for Payer: Kaiser Permanente Medicare	$799.00
Rate for Payer: MDX Hawaii PPO	$1,550.06
Rate for Payer: Ohana Health Plan Medicaid	$799.00
Rate for Payer: Ohana Health Plan Medicare	$799.00
Rate for Payer: UnitedHealthcare Medicare	$799.00
Rate for Payer: University Health Alliance Commercial	$894.88

LAP PROGRIP ANATOMIC RIGHT 10 X 15

Facility

$1,599.00

Service Code	HCPCS C1781
Hospital Charge Code	10166862
Hospital Revenue Code	278
Min. Negotiated Rate	$895.44
Max. Negotiated Rate	$1,551.03
Rate for Payer: Cash Price	$1,039.35
Rate for Payer: Hawaii Western Management Group Commercial	$1,119.30
Rate for Payer: Health Management Network Commercial	$1,359.15
Rate for Payer: Kaiser Permanente Commercial	$1,439.10
Rate for Payer: MDX Hawaii PPO	$1,551.03
Rate for Payer: University Health Alliance Commercial	$895.44

LAP PROGRIP ANATOMIC RIGHT 10 X 15

Facility

$1,599.00

Service Code	HCPCS C1781
Hospital Charge Code	10166862
Hospital Revenue Code	278
Min. Negotiated Rate	$799.50
Max. Negotiated Rate	$1,551.03
Rate for Payer: AlohaCare Medicaid	$799.50
Rate for Payer: AlohaCare Medicare	$799.50
Rate for Payer: Cash Price	$1,039.35
Rate for Payer: Devoted Health Medicare	$879.45
Rate for Payer: Hawaii Medical Service Association Medicare	$799.50
Rate for Payer: Hawaii Western Management Group Commercial	$1,119.30
Rate for Payer: Health Management Network Commercial	$1,359.15
Rate for Payer: Humana Medicare	$799.50
Rate for Payer: Kaiser Permanente Commercial	$1,439.10
Rate for Payer: Kaiser Permanente Medicaid	$815.49
Rate for Payer: Kaiser Permanente Medicare	$799.50
Rate for Payer: MDX Hawaii PPO	$1,551.03
Rate for Payer: Ohana Health Plan Medicaid	$799.50
Rate for Payer: Ohana Health Plan Medicare	$799.50
Rate for Payer: UnitedHealthcare Medicare	$799.50
Rate for Payer: University Health Alliance Commercial	$895.44

LD, Body Fluid FSI

Facility

$92.00

Service Code	HCPCS 83615
Hospital Charge Code	8228889
Hospital Revenue Code	301
Min. Negotiated Rate	$6.04
Max. Negotiated Rate	$89.24
Rate for Payer: AlohaCare Medicaid	$46.00
Rate for Payer: AlohaCare Medicare	$46.00
Rate for Payer: Cash Price	$59.80
Rate for Payer: Cash Price	$59.80
Rate for Payer: Devoted Health Medicare	$50.60
Rate for Payer: Hawaii Medical Service Association ABD	$8.35
Rate for Payer: Hawaii Medical Service Association Commercial	$7.55
Rate for Payer: Hawaii Medical Service Association Medicare	$46.00
Rate for Payer: Hawaii Medical Service Association Non-ABD	$8.77
Rate for Payer: Hawaii Western Management Group Commercial	$6.04
Rate for Payer: Health Management Network Commercial	$78.20
Rate for Payer: Humana Medicare	$46.00
Rate for Payer: Kaiser Permanente Commercial	$82.80
Rate for Payer: Kaiser Permanente Medicaid	$46.92
Rate for Payer: Kaiser Permanente Medicare	$46.00
Rate for Payer: MDX Hawaii PPO	$89.24
Rate for Payer: Ohana Health Plan Medicaid	$46.00
Rate for Payer: Ohana Health Plan Medicare	$46.00
Rate for Payer: UnitedHealthcare Medicaid	$8.35
Rate for Payer: UnitedHealthcare Medicare	$46.00
Rate for Payer: University Health Alliance Commercial	$15.61

LD, Body Fluid FSI

Facility

$92.00

Service Code	HCPCS 83615
Hospital Charge Code	8228889
Hospital Revenue Code	301
Min. Negotiated Rate	$78.20
Max. Negotiated Rate	$89.24
Rate for Payer: Cash Price	$59.80
Rate for Payer: Health Management Network Commercial	$78.20
Rate for Payer: Kaiser Permanente Commercial	$82.80
Rate for Payer: MDX Hawaii PPO	$89.24

LD (LDH) FSI

Facility

$92.00

Service Code	HCPCS 83615
Hospital Charge Code	8117978
Hospital Revenue Code	301
Min. Negotiated Rate	$78.20
Max. Negotiated Rate	$89.24
Rate for Payer: Cash Price	$59.80
Rate for Payer: Health Management Network Commercial	$78.20
Rate for Payer: Kaiser Permanente Commercial	$82.80
Rate for Payer: MDX Hawaii PPO	$89.24

LD (LDH) FSI

Facility

$92.00

Service Code	HCPCS 83615
Hospital Charge Code	8117978
Hospital Revenue Code	301
Min. Negotiated Rate	$6.04
Max. Negotiated Rate	$89.24
Rate for Payer: AlohaCare Medicaid	$46.00
Rate for Payer: AlohaCare Medicare	$46.00
Rate for Payer: Cash Price	$59.80
Rate for Payer: Cash Price	$59.80
Rate for Payer: Devoted Health Medicare	$50.60
Rate for Payer: Hawaii Medical Service Association ABD	$8.35
Rate for Payer: Hawaii Medical Service Association Commercial	$7.55
Rate for Payer: Hawaii Medical Service Association Medicare	$46.00
Rate for Payer: Hawaii Medical Service Association Non-ABD	$8.77
Rate for Payer: Hawaii Western Management Group Commercial	$6.04
Rate for Payer: Health Management Network Commercial	$78.20
Rate for Payer: Humana Medicare	$46.00
Rate for Payer: Kaiser Permanente Commercial	$82.80
Rate for Payer: Kaiser Permanente Medicaid	$46.92
Rate for Payer: Kaiser Permanente Medicare	$46.00
Rate for Payer: MDX Hawaii PPO	$89.24
Rate for Payer: Ohana Health Plan Medicaid	$46.00
Rate for Payer: Ohana Health Plan Medicare	$46.00
Rate for Payer: UnitedHealthcare Medicaid	$8.35
Rate for Payer: UnitedHealthcare Medicare	$46.00
Rate for Payer: University Health Alliance Commercial	$15.61

Lead Blood (Capillary) FSI

Facility

$140.00

Service Code	HCPCS 83655
Hospital Charge Code	8117979
Hospital Revenue Code	301
Min. Negotiated Rate	$119.00
Max. Negotiated Rate	$135.80
Rate for Payer: Cash Price	$91.00
Rate for Payer: Health Management Network Commercial	$119.00
Rate for Payer: Kaiser Permanente Commercial	$126.00
Rate for Payer: MDX Hawaii PPO	$135.80

Know your out-of-pocket cost for care.

All Charges