Samuel Mahelona Memorial Hospital

All Charges

Charge

Type

Setting

Price

lido-prilocaine 2.5%-2.5% cream topical [HHSC]

Facility

$54.39

Service Code	NDC 62332058204
Hospital Charge Code	2500487
Hospital Revenue Code	250
Min. Negotiated Rate	$27.20
Max. Negotiated Rate	$52.76
Rate for Payer: AlohaCare Medicaid	$27.20
Rate for Payer: AlohaCare Medicare	$27.20
Rate for Payer: Cash Price	$35.35
Rate for Payer: Devoted Health Medicare	$29.91
Rate for Payer: Hawaii Medical Service Association Medicare	$27.20
Rate for Payer: Hawaii Western Management Group Commercial	$51.67
Rate for Payer: Health Management Network Commercial	$46.23
Rate for Payer: Humana Medicare	$27.20
Rate for Payer: Kaiser Permanente Commercial	$48.95
Rate for Payer: Kaiser Permanente Medicaid	$27.74
Rate for Payer: Kaiser Permanente Medicare	$27.20
Rate for Payer: MDX Hawaii PPO	$52.76
Rate for Payer: Ohana Health Plan Medicaid	$27.20
Rate for Payer: Ohana Health Plan Medicare	$27.20
Rate for Payer: UnitedHealthcare Medicaid	$32.63
Rate for Payer: UnitedHealthcare Medicare	$27.20
Rate for Payer: University Health Alliance Commercial	$39.64

lido-prilocaine 2.5%-2.5% cream topical [HHSC]

Facility

$48.83

Service Code	NDC 00115146860
Hospital Charge Code	2500487
Hospital Revenue Code	250
Min. Negotiated Rate	$24.41
Max. Negotiated Rate	$47.37
Rate for Payer: AlohaCare Medicaid	$24.41
Rate for Payer: AlohaCare Medicare	$24.41
Rate for Payer: Cash Price	$31.74
Rate for Payer: Devoted Health Medicare	$26.86
Rate for Payer: Hawaii Medical Service Association Medicare	$24.41
Rate for Payer: Hawaii Western Management Group Commercial	$46.39
Rate for Payer: Health Management Network Commercial	$41.51
Rate for Payer: Humana Medicare	$24.41
Rate for Payer: Kaiser Permanente Commercial	$43.95
Rate for Payer: Kaiser Permanente Medicaid	$24.90
Rate for Payer: Kaiser Permanente Medicare	$24.41
Rate for Payer: MDX Hawaii PPO	$47.37
Rate for Payer: Ohana Health Plan Medicaid	$24.41
Rate for Payer: Ohana Health Plan Medicare	$24.41
Rate for Payer: UnitedHealthcare Medicaid	$29.30
Rate for Payer: UnitedHealthcare Medicare	$24.41
Rate for Payer: University Health Alliance Commercial	$35.59

lido-prilocaine 2.5%-2.5% cream topical [HHSC]

Facility

$52.81

Service Code	NDC 00591207072
Hospital Charge Code	2500487
Hospital Revenue Code	250
Min. Negotiated Rate	$26.41
Max. Negotiated Rate	$51.23
Rate for Payer: AlohaCare Medicaid	$26.41
Rate for Payer: AlohaCare Medicare	$26.41
Rate for Payer: Cash Price	$34.33
Rate for Payer: Devoted Health Medicare	$29.05
Rate for Payer: Hawaii Medical Service Association Medicare	$26.41
Rate for Payer: Hawaii Western Management Group Commercial	$50.17
Rate for Payer: Health Management Network Commercial	$44.89
Rate for Payer: Humana Medicare	$26.41
Rate for Payer: Kaiser Permanente Commercial	$47.53
Rate for Payer: Kaiser Permanente Medicaid	$26.93
Rate for Payer: Kaiser Permanente Medicare	$26.41
Rate for Payer: MDX Hawaii PPO	$51.23
Rate for Payer: Ohana Health Plan Medicaid	$26.41
Rate for Payer: Ohana Health Plan Medicare	$26.41
Rate for Payer: UnitedHealthcare Medicaid	$31.69
Rate for Payer: UnitedHealthcare Medicare	$26.41
Rate for Payer: University Health Alliance Commercial	$38.49

lido-prilocaine 2.5%-2.5% cream topical [HHSC]

Facility

$52.81

Service Code	NDC 00591207072
Hospital Charge Code	2500487
Hospital Revenue Code	250
Min. Negotiated Rate	$44.89
Max. Negotiated Rate	$51.23
Rate for Payer: Cash Price	$34.33
Rate for Payer: Health Management Network Commercial	$44.89
Rate for Payer: Kaiser Permanente Commercial	$47.53
Rate for Payer: MDX Hawaii PPO	$51.23

lido-prilocaine 2.5%-2.5% cream topical [HHSC]

Facility

$48.83

Service Code	NDC 00115146860
Hospital Charge Code	2500487
Hospital Revenue Code	250
Min. Negotiated Rate	$41.51
Max. Negotiated Rate	$47.37
Rate for Payer: Cash Price	$31.74
Rate for Payer: Health Management Network Commercial	$41.51
Rate for Payer: Kaiser Permanente Commercial	$43.95
Rate for Payer: MDX Hawaii PPO	$47.37

lido-prilocaine 2.5%-2.5% cream topical [HHSC]

Facility

$57.97

Service Code	NDC 00168035755
Hospital Charge Code	2500487
Hospital Revenue Code	250
Min. Negotiated Rate	$49.27
Max. Negotiated Rate	$56.23
Rate for Payer: Cash Price	$37.68
Rate for Payer: Health Management Network Commercial	$49.27
Rate for Payer: Kaiser Permanente Commercial	$52.17
Rate for Payer: MDX Hawaii PPO	$56.23

lido-prilocaine 2.5%-2.5% cream topical [HHSC]

Facility

$54.39

Service Code	NDC 62332058204
Hospital Charge Code	2500487
Hospital Revenue Code	250
Min. Negotiated Rate	$46.23
Max. Negotiated Rate	$52.76
Rate for Payer: Cash Price	$35.35
Rate for Payer: Health Management Network Commercial	$46.23
Rate for Payer: Kaiser Permanente Commercial	$48.95
Rate for Payer: MDX Hawaii PPO	$52.76

LIGASURE 10MM

Facility

$1,241.00

Hospital Charge Code	8428815
Hospital Revenue Code	272
Min. Negotiated Rate	$620.50
Max. Negotiated Rate	$1,203.77
Rate for Payer: AlohaCare Medicaid	$620.50
Rate for Payer: AlohaCare Medicare	$620.50
Rate for Payer: Cash Price	$806.65
Rate for Payer: Devoted Health Medicare	$682.55
Rate for Payer: Hawaii Medical Service Association Medicare	$620.50
Rate for Payer: Hawaii Western Management Group Commercial	$1,178.95
Rate for Payer: Health Management Network Commercial	$1,054.85
Rate for Payer: Humana Medicare	$620.50
Rate for Payer: Kaiser Permanente Commercial	$1,116.90
Rate for Payer: Kaiser Permanente Medicaid	$632.91
Rate for Payer: Kaiser Permanente Medicare	$620.50
Rate for Payer: MDX Hawaii PPO	$1,203.77
Rate for Payer: Ohana Health Plan Medicaid	$620.50
Rate for Payer: Ohana Health Plan Medicare	$620.50
Rate for Payer: UnitedHealthcare Medicare	$620.50
Rate for Payer: University Health Alliance Commercial	$904.56

LIGASURE 10MM

Facility

$1,241.00

Hospital Charge Code	8428815
Hospital Revenue Code	272
Min. Negotiated Rate	$1,054.85
Max. Negotiated Rate	$1,203.77
Rate for Payer: Cash Price	$806.65
Rate for Payer: Health Management Network Commercial	$1,054.85
Rate for Payer: Kaiser Permanente Commercial	$1,116.90
Rate for Payer: MDX Hawaii PPO	$1,203.77

LIGASURE, IMPACT SEALER/DIVIDER LF 4418

Facility

$1,768.00

Hospital Charge Code	8274241
Hospital Revenue Code	272
Min. Negotiated Rate	$884.00
Max. Negotiated Rate	$1,714.96
Rate for Payer: AlohaCare Medicaid	$884.00
Rate for Payer: AlohaCare Medicare	$884.00
Rate for Payer: Cash Price	$1,149.20
Rate for Payer: Devoted Health Medicare	$972.40
Rate for Payer: Hawaii Medical Service Association Medicare	$884.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,679.60
Rate for Payer: Health Management Network Commercial	$1,502.80
Rate for Payer: Humana Medicare	$884.00
Rate for Payer: Kaiser Permanente Commercial	$1,591.20
Rate for Payer: Kaiser Permanente Medicaid	$901.68
Rate for Payer: Kaiser Permanente Medicare	$884.00
Rate for Payer: MDX Hawaii PPO	$1,714.96
Rate for Payer: Ohana Health Plan Medicaid	$884.00
Rate for Payer: Ohana Health Plan Medicare	$884.00
Rate for Payer: UnitedHealthcare Medicare	$884.00
Rate for Payer: University Health Alliance Commercial	$1,288.70

LIGASURE, IMPACT SEALER/DIVIDER LF 4418

Facility

$1,768.00

Hospital Charge Code	8274241
Hospital Revenue Code	272
Min. Negotiated Rate	$1,502.80
Max. Negotiated Rate	$1,714.96
Rate for Payer: Cash Price	$1,149.20
Rate for Payer: Health Management Network Commercial	$1,502.80
Rate for Payer: Kaiser Permanente Commercial	$1,591.20
Rate for Payer: MDX Hawaii PPO	$1,714.96

LIGASURE, TISSUE FUSION LS1020

Facility

$1,190.00

Hospital Charge Code	8274242
Hospital Revenue Code	272
Min. Negotiated Rate	$595.00
Max. Negotiated Rate	$1,154.30
Rate for Payer: AlohaCare Medicaid	$595.00
Rate for Payer: AlohaCare Medicare	$595.00
Rate for Payer: Cash Price	$773.50
Rate for Payer: Devoted Health Medicare	$654.50
Rate for Payer: Hawaii Medical Service Association Medicare	$595.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,130.50
Rate for Payer: Health Management Network Commercial	$1,011.50
Rate for Payer: Humana Medicare	$595.00
Rate for Payer: Kaiser Permanente Commercial	$1,071.00
Rate for Payer: Kaiser Permanente Medicaid	$606.90
Rate for Payer: Kaiser Permanente Medicare	$595.00
Rate for Payer: MDX Hawaii PPO	$1,154.30
Rate for Payer: Ohana Health Plan Medicaid	$595.00
Rate for Payer: Ohana Health Plan Medicare	$595.00
Rate for Payer: UnitedHealthcare Medicare	$595.00
Rate for Payer: University Health Alliance Commercial	$867.39

LIGASURE, TISSUE FUSION LS1020

Facility

$1,190.00

Hospital Charge Code	8274242
Hospital Revenue Code	272
Min. Negotiated Rate	$1,011.50
Max. Negotiated Rate	$1,154.30
Rate for Payer: Cash Price	$773.50
Rate for Payer: Health Management Network Commercial	$1,011.50
Rate for Payer: Kaiser Permanente Commercial	$1,071.00
Rate for Payer: MDX Hawaii PPO	$1,154.30

LIMB REATTACHMENT, HIP AND FEMUR PROCEDURES FOR MULTIPLE SIGNIFICANT TRAUMA

Facility

$214,242.38

Service Code	MSDRG 956
Min. Negotiated Rate	$214,242.38
Max. Negotiated Rate	$214,242.38
Rate for Payer: Hawaii Medical Service Association Commercial	$214,242.38

LINER ARM DELTA TERRY-NET SYNTH 3X19 WHITE F/ THUMB SPICA 10/CA

Professional

Both

$23.00

Hospital Charge Code	12957407
Hospital Revenue Code	270
Min. Negotiated Rate	$19.55
Max. Negotiated Rate	$19.55
Rate for Payer: Cash Price	$14.95
Rate for Payer: Health Management Network Commercial	$19.55

LINER ARM DELTA TERRY-NET SYNTH 3X19 WHITE F/ THUMB SPICA 10/CA

Facility

$23.00

Hospital Charge Code	12957407
Hospital Revenue Code	270
Min. Negotiated Rate	$11.50
Max. Negotiated Rate	$22.31
Rate for Payer: AlohaCare Medicaid	$11.50
Rate for Payer: AlohaCare Medicare	$11.50
Rate for Payer: Cash Price	$14.95
Rate for Payer: Devoted Health Medicare	$12.65
Rate for Payer: Hawaii Medical Service Association Medicare	$11.50
Rate for Payer: Hawaii Western Management Group Commercial	$21.85
Rate for Payer: Health Management Network Commercial	$19.55
Rate for Payer: Humana Medicare	$11.50
Rate for Payer: Kaiser Permanente Commercial	$20.70
Rate for Payer: Kaiser Permanente Medicaid	$11.73
Rate for Payer: Kaiser Permanente Medicare	$11.50
Rate for Payer: MDX Hawaii PPO	$22.31
Rate for Payer: Ohana Health Plan Medicaid	$11.50
Rate for Payer: Ohana Health Plan Medicare	$11.50
Rate for Payer: UnitedHealthcare Medicare	$11.50
Rate for Payer: University Health Alliance Commercial	$16.76

LINER ARM DELTA TERRY-NET SYNTH 3X19 WHITE F/ THUMB SPICA 10/CA

Facility

$23.00

Hospital Charge Code	12957407
Hospital Revenue Code	270
Min. Negotiated Rate	$19.55
Max. Negotiated Rate	$22.31
Rate for Payer: Cash Price	$14.95
Rate for Payer: Health Management Network Commercial	$19.55
Rate for Payer: Kaiser Permanente Commercial	$20.70
Rate for Payer: MDX Hawaii PPO	$22.31

LINER PADDING DELTA TERRY-NET CLOTH/ FOAM ADH 23X39 LF 1RL/BX

Facility

$257.00

Hospital Charge Code	12957404
Hospital Revenue Code	270
Min. Negotiated Rate	$218.45
Max. Negotiated Rate	$249.29
Rate for Payer: Cash Price	$167.05
Rate for Payer: Health Management Network Commercial	$218.45
Rate for Payer: Kaiser Permanente Commercial	$231.30
Rate for Payer: MDX Hawaii PPO	$249.29

LINER PADDING DELTA TERRY-NET CLOTH/ FOAM ADH 23X39 LF 1RL/BX

Facility

$257.00

Hospital Charge Code	12957404
Hospital Revenue Code	270
Min. Negotiated Rate	$128.50
Max. Negotiated Rate	$249.29
Rate for Payer: AlohaCare Medicaid	$128.50
Rate for Payer: AlohaCare Medicare	$128.50
Rate for Payer: Cash Price	$167.05
Rate for Payer: Devoted Health Medicare	$141.35
Rate for Payer: Hawaii Medical Service Association Medicare	$128.50
Rate for Payer: Hawaii Western Management Group Commercial	$244.15
Rate for Payer: Health Management Network Commercial	$218.45
Rate for Payer: Humana Medicare	$128.50
Rate for Payer: Kaiser Permanente Commercial	$231.30
Rate for Payer: Kaiser Permanente Medicaid	$131.07
Rate for Payer: Kaiser Permanente Medicare	$128.50
Rate for Payer: MDX Hawaii PPO	$249.29
Rate for Payer: Ohana Health Plan Medicaid	$128.50
Rate for Payer: Ohana Health Plan Medicare	$128.50
Rate for Payer: UnitedHealthcare Medicare	$128.50
Rate for Payer: University Health Alliance Commercial	$187.33

Lipase FSI

Facility

$94.00

Service Code	HCPCS 83690
Hospital Charge Code	8117982
Hospital Revenue Code	301
Min. Negotiated Rate	$79.90
Max. Negotiated Rate	$91.18
Rate for Payer: Cash Price	$61.10
Rate for Payer: Health Management Network Commercial	$79.90
Rate for Payer: Kaiser Permanente Commercial	$84.60
Rate for Payer: MDX Hawaii PPO	$91.18

Lipase FSI

Facility

$94.00

Service Code	HCPCS 83690
Hospital Charge Code	8117982
Hospital Revenue Code	301
Min. Negotiated Rate	$6.89
Max. Negotiated Rate	$91.18
Rate for Payer: AlohaCare Medicaid	$47.00
Rate for Payer: AlohaCare Medicare	$47.00
Rate for Payer: Cash Price	$61.10
Rate for Payer: Cash Price	$61.10
Rate for Payer: Devoted Health Medicare	$51.70
Rate for Payer: Hawaii Medical Service Association ABD	$9.52
Rate for Payer: Hawaii Medical Service Association Commercial	$8.61
Rate for Payer: Hawaii Medical Service Association Medicare	$47.00
Rate for Payer: Hawaii Medical Service Association Non-ABD	$10.00
Rate for Payer: Hawaii Western Management Group Commercial	$6.89
Rate for Payer: Health Management Network Commercial	$79.90
Rate for Payer: Humana Medicare	$47.00
Rate for Payer: Kaiser Permanente Commercial	$84.60
Rate for Payer: Kaiser Permanente Medicaid	$47.94
Rate for Payer: Kaiser Permanente Medicare	$47.00
Rate for Payer: MDX Hawaii PPO	$91.18
Rate for Payer: Ohana Health Plan Medicaid	$47.00
Rate for Payer: Ohana Health Plan Medicare	$47.00
Rate for Payer: UnitedHealthcare Medicaid	$9.52
Rate for Payer: UnitedHealthcare Medicare	$47.00
Rate for Payer: University Health Alliance Commercial	$17.80

Lipid Profile FSI

Facility

$154.00

Service Code	HCPCS 80061
Hospital Charge Code	8117983
Hospital Revenue Code	301
Min. Negotiated Rate	$130.90
Max. Negotiated Rate	$149.38
Rate for Payer: Cash Price	$100.10
Rate for Payer: Health Management Network Commercial	$130.90
Rate for Payer: Kaiser Permanente Commercial	$138.60
Rate for Payer: MDX Hawaii PPO	$149.38

Lipid Profile FSI

Facility

$154.00

Service Code	HCPCS 80061
Hospital Charge Code	8117983
Hospital Revenue Code	301
Min. Negotiated Rate	$13.39
Max. Negotiated Rate	$149.38
Rate for Payer: AlohaCare Medicaid	$77.00
Rate for Payer: AlohaCare Medicare	$77.00
Rate for Payer: Cash Price	$100.10
Rate for Payer: Cash Price	$100.10
Rate for Payer: Devoted Health Medicare	$84.70
Rate for Payer: Hawaii Medical Service Association ABD	$18.51
Rate for Payer: Hawaii Medical Service Association Commercial	$16.74
Rate for Payer: Hawaii Medical Service Association Medicare	$77.00
Rate for Payer: Hawaii Medical Service Association Non-ABD	$19.44
Rate for Payer: Hawaii Western Management Group Commercial	$13.39
Rate for Payer: Health Management Network Commercial	$130.90
Rate for Payer: Humana Medicare	$77.00
Rate for Payer: Kaiser Permanente Commercial	$138.60
Rate for Payer: Kaiser Permanente Medicaid	$78.54
Rate for Payer: Kaiser Permanente Medicare	$77.00
Rate for Payer: MDX Hawaii PPO	$149.38
Rate for Payer: Ohana Health Plan Medicaid	$77.00
Rate for Payer: Ohana Health Plan Medicare	$77.00
Rate for Payer: UnitedHealthcare Medicaid	$18.51
Rate for Payer: UnitedHealthcare Medicare	$77.00
Rate for Payer: University Health Alliance Commercial	$34.63

Lipoprotein (a) FSI

Facility

$177.00

Service Code	HCPCS 83695
Hospital Charge Code	8117984
Hospital Revenue Code	301
Min. Negotiated Rate	$12.66
Max. Negotiated Rate	$171.69
Rate for Payer: AlohaCare Medicaid	$88.50
Rate for Payer: AlohaCare Medicare	$88.50
Rate for Payer: Cash Price	$115.05
Rate for Payer: Cash Price	$115.05
Rate for Payer: Devoted Health Medicare	$97.35
Rate for Payer: Hawaii Medical Service Association ABD	$12.66
Rate for Payer: Hawaii Medical Service Association Commercial	$17.90
Rate for Payer: Hawaii Medical Service Association Medicare	$88.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$17.88
Rate for Payer: Hawaii Western Management Group Commercial	$14.32
Rate for Payer: Health Management Network Commercial	$150.45
Rate for Payer: Humana Medicare	$88.50
Rate for Payer: Kaiser Permanente Commercial	$159.30
Rate for Payer: Kaiser Permanente Medicaid	$90.27
Rate for Payer: Kaiser Permanente Medicare	$88.50
Rate for Payer: MDX Hawaii PPO	$171.69
Rate for Payer: Ohana Health Plan Medicaid	$88.50
Rate for Payer: Ohana Health Plan Medicare	$88.50
Rate for Payer: UnitedHealthcare Medicaid	$12.66
Rate for Payer: UnitedHealthcare Medicare	$88.50
Rate for Payer: University Health Alliance Commercial	$33.47

Lipoprotein (a) FSI

Facility

$177.00

Service Code	HCPCS 83695
Hospital Charge Code	8117984
Hospital Revenue Code	301
Min. Negotiated Rate	$150.45
Max. Negotiated Rate	$171.69
Rate for Payer: Cash Price	$115.05
Rate for Payer: Health Management Network Commercial	$150.45
Rate for Payer: Kaiser Permanente Commercial	$159.30
Rate for Payer: MDX Hawaii PPO	$171.69

Know your out-of-pocket cost for care.

All Charges