Samuel Mahelona Memorial Hospital

All Charges

Charge

Type

Setting

Price

LOCAL EXCISION AND REMOVAL OF INTERNAL FIXATION DEVICES EXCEPT HIP AND FEMUR WITH MCC

Facility

$38,278.73

Service Code	MSDRG 495
Min. Negotiated Rate	$38,278.73
Max. Negotiated Rate	$38,278.73
Rate for Payer: Hawaii Medical Service Association Commercial	$38,278.73

LOCAL EXCISION AND REMOVAL OF INTERNAL FIXATION DEVICES EXCEPT HIP AND FEMUR WITHOUT CC/MCC

Facility

$24,673.78

Service Code	MSDRG 497
Min. Negotiated Rate	$24,673.78
Max. Negotiated Rate	$24,673.78
Rate for Payer: Hawaii Medical Service Association Commercial	$24,673.78

LOCAL EXCISION AND REMOVAL OF INTERNAL FIXATION DEVICES OF HIP AND FEMUR WITH CC/MCC

Facility

$42,971.73

Service Code	MSDRG 498
Min. Negotiated Rate	$42,971.73
Max. Negotiated Rate	$42,971.73
Rate for Payer: Hawaii Medical Service Association Commercial	$42,971.73

LOCAL EXCISION AND REMOVAL OF INTERNAL FIXATION DEVICES OF HIP AND FEMUR WITHOUT CC/MCC

Facility

$42,971.73

Service Code	MSDRG 499
Min. Negotiated Rate	$42,971.73
Max. Negotiated Rate	$42,971.73
Rate for Payer: Hawaii Medical Service Association Commercial	$42,971.73

LOCK END CAP, RECON LOCK,0MM,ANTE NAIL

Facility

$1,453.00

Service Code	HCPCS C1713
Hospital Charge Code	12987704
Hospital Revenue Code	278
Min. Negotiated Rate	$813.68
Max. Negotiated Rate	$1,409.41
Rate for Payer: Cash Price	$944.45
Rate for Payer: Hawaii Western Management Group Commercial	$1,017.10
Rate for Payer: Health Management Network Commercial	$1,235.05
Rate for Payer: Kaiser Permanente Commercial	$1,307.70
Rate for Payer: MDX Hawaii PPO	$1,409.41
Rate for Payer: University Health Alliance Commercial	$813.68

LOCK END CAP, RECON LOCK,0MM,ANTE NAIL

Facility

$1,453.00

Service Code	HCPCS C1713
Hospital Charge Code	12987704
Hospital Revenue Code	278
Min. Negotiated Rate	$726.50
Max. Negotiated Rate	$1,409.41
Rate for Payer: AlohaCare Medicaid	$726.50
Rate for Payer: AlohaCare Medicare	$726.50
Rate for Payer: Cash Price	$944.45
Rate for Payer: Devoted Health Medicare	$799.15
Rate for Payer: Hawaii Medical Service Association Medicare	$726.50
Rate for Payer: Hawaii Western Management Group Commercial	$1,017.10
Rate for Payer: Health Management Network Commercial	$1,235.05
Rate for Payer: Humana Medicare	$726.50
Rate for Payer: Kaiser Permanente Commercial	$1,307.70
Rate for Payer: Kaiser Permanente Medicaid	$741.03
Rate for Payer: Kaiser Permanente Medicare	$726.50
Rate for Payer: MDX Hawaii PPO	$1,409.41
Rate for Payer: Ohana Health Plan Medicaid	$726.50
Rate for Payer: Ohana Health Plan Medicare	$726.50
Rate for Payer: UnitedHealthcare Medicare	$726.50
Rate for Payer: University Health Alliance Commercial	$813.68

LOCK LAT HOOK PLATE, TI, 3H

Facility

$2,913.00

Service Code	HCPCS C1713
Hospital Charge Code	12955903
Hospital Revenue Code	278
Min. Negotiated Rate	$1,456.50
Max. Negotiated Rate	$2,825.61
Rate for Payer: AlohaCare Medicaid	$1,456.50
Rate for Payer: AlohaCare Medicare	$1,456.50
Rate for Payer: Cash Price	$1,893.45
Rate for Payer: Devoted Health Medicare	$1,602.15
Rate for Payer: Hawaii Medical Service Association Medicare	$1,456.50
Rate for Payer: Hawaii Western Management Group Commercial	$2,039.10
Rate for Payer: Health Management Network Commercial	$2,476.05
Rate for Payer: Humana Medicare	$1,456.50
Rate for Payer: Kaiser Permanente Commercial	$2,621.70
Rate for Payer: Kaiser Permanente Medicaid	$1,485.63
Rate for Payer: Kaiser Permanente Medicare	$1,456.50
Rate for Payer: MDX Hawaii PPO	$2,825.61
Rate for Payer: Ohana Health Plan Medicaid	$1,456.50
Rate for Payer: Ohana Health Plan Medicare	$1,456.50
Rate for Payer: UnitedHealthcare Medicare	$1,456.50
Rate for Payer: University Health Alliance Commercial	$1,631.28

LOCK LAT HOOK PLATE, TI, 3H

Facility

$2,913.00

Service Code	HCPCS C1713
Hospital Charge Code	12955903
Hospital Revenue Code	278
Min. Negotiated Rate	$1,631.28
Max. Negotiated Rate	$2,825.61
Rate for Payer: Cash Price	$1,893.45
Rate for Payer: Hawaii Western Management Group Commercial	$2,039.10
Rate for Payer: Health Management Network Commercial	$2,476.05
Rate for Payer: Kaiser Permanente Commercial	$2,621.70
Rate for Payer: MDX Hawaii PPO	$2,825.61
Rate for Payer: University Health Alliance Commercial	$1,631.28

loperamide 2 mg capsule [HHSC]

Facility

$4.86

Service Code	NDC 51079069020
Hospital Charge Code	2500496
Hospital Revenue Code	250
Min. Negotiated Rate	$4.13
Max. Negotiated Rate	$4.71
Rate for Payer: Cash Price	$3.16
Rate for Payer: Health Management Network Commercial	$4.13
Rate for Payer: Kaiser Permanente Commercial	$4.37
Rate for Payer: MDX Hawaii PPO	$4.71

loperamide 2 mg capsule [HHSC]

Facility

$4.88

Service Code	NDC 60687022901
Hospital Charge Code	2500496
Hospital Revenue Code	250
Min. Negotiated Rate	$4.15
Max. Negotiated Rate	$4.73
Rate for Payer: Cash Price	$3.17
Rate for Payer: Health Management Network Commercial	$4.15
Rate for Payer: Kaiser Permanente Commercial	$4.39
Rate for Payer: MDX Hawaii PPO	$4.73

loperamide 2 mg capsule [HHSC]

Facility

$4.86

Service Code	NDC 51079069020
Hospital Charge Code	2500496
Hospital Revenue Code	250
Min. Negotiated Rate	$2.43
Max. Negotiated Rate	$4.71
Rate for Payer: AlohaCare Medicaid	$2.43
Rate for Payer: AlohaCare Medicare	$2.43
Rate for Payer: Cash Price	$3.16
Rate for Payer: Devoted Health Medicare	$2.67
Rate for Payer: Hawaii Medical Service Association Medicare	$2.43
Rate for Payer: Hawaii Western Management Group Commercial	$4.62
Rate for Payer: Health Management Network Commercial	$4.13
Rate for Payer: Humana Medicare	$2.43
Rate for Payer: Kaiser Permanente Commercial	$4.37
Rate for Payer: Kaiser Permanente Medicaid	$2.48
Rate for Payer: Kaiser Permanente Medicare	$2.43
Rate for Payer: MDX Hawaii PPO	$4.71
Rate for Payer: Ohana Health Plan Medicaid	$2.43
Rate for Payer: Ohana Health Plan Medicare	$2.43
Rate for Payer: UnitedHealthcare Medicaid	$2.92
Rate for Payer: UnitedHealthcare Medicare	$2.43
Rate for Payer: University Health Alliance Commercial	$3.54

loperamide 2 mg capsule [HHSC]

Facility

$4.88

Service Code	NDC 60687022901
Hospital Charge Code	2500496
Hospital Revenue Code	250
Min. Negotiated Rate	$2.44
Max. Negotiated Rate	$4.73
Rate for Payer: AlohaCare Medicaid	$2.44
Rate for Payer: AlohaCare Medicare	$2.44
Rate for Payer: Cash Price	$3.17
Rate for Payer: Devoted Health Medicare	$2.68
Rate for Payer: Hawaii Medical Service Association Medicare	$2.44
Rate for Payer: Hawaii Western Management Group Commercial	$4.64
Rate for Payer: Health Management Network Commercial	$4.15
Rate for Payer: Humana Medicare	$2.44
Rate for Payer: Kaiser Permanente Commercial	$4.39
Rate for Payer: Kaiser Permanente Medicaid	$2.49
Rate for Payer: Kaiser Permanente Medicare	$2.44
Rate for Payer: MDX Hawaii PPO	$4.73
Rate for Payer: Ohana Health Plan Medicaid	$2.44
Rate for Payer: Ohana Health Plan Medicare	$2.44
Rate for Payer: UnitedHealthcare Medicaid	$2.93
Rate for Payer: UnitedHealthcare Medicare	$2.44
Rate for Payer: University Health Alliance Commercial	$3.56

LO-PRO SCRW,TI,3.5MMX 14MM

Facility

$95.00

Service Code	HCPCS C1713
Hospital Charge Code	12942903
Hospital Revenue Code	278
Min. Negotiated Rate	$47.50
Max. Negotiated Rate	$92.15
Rate for Payer: AlohaCare Medicaid	$47.50
Rate for Payer: AlohaCare Medicare	$47.50
Rate for Payer: Cash Price	$61.75
Rate for Payer: Devoted Health Medicare	$52.25
Rate for Payer: Hawaii Medical Service Association Medicare	$47.50
Rate for Payer: Hawaii Western Management Group Commercial	$66.50
Rate for Payer: Health Management Network Commercial	$80.75
Rate for Payer: Humana Medicare	$47.50
Rate for Payer: Kaiser Permanente Commercial	$85.50
Rate for Payer: Kaiser Permanente Medicaid	$48.45
Rate for Payer: Kaiser Permanente Medicare	$47.50
Rate for Payer: MDX Hawaii PPO	$92.15
Rate for Payer: Ohana Health Plan Medicaid	$47.50
Rate for Payer: Ohana Health Plan Medicare	$47.50
Rate for Payer: UnitedHealthcare Medicare	$47.50
Rate for Payer: University Health Alliance Commercial	$53.20

LO-PRO SCRW,TI,3.5MMX 14MM

Facility

$95.00

Service Code	HCPCS C1713
Hospital Charge Code	12942903
Hospital Revenue Code	278
Min. Negotiated Rate	$53.20
Max. Negotiated Rate	$92.15
Rate for Payer: Cash Price	$61.75
Rate for Payer: Hawaii Western Management Group Commercial	$66.50
Rate for Payer: Health Management Network Commercial	$80.75
Rate for Payer: Kaiser Permanente Commercial	$85.50
Rate for Payer: MDX Hawaii PPO	$92.15
Rate for Payer: University Health Alliance Commercial	$53.20

LO-PRO SCRW,TI,4.0MMX 22MM

Facility

$126.00

Service Code	HCPCS C1713
Hospital Charge Code	12957940
Hospital Revenue Code	278
Min. Negotiated Rate	$63.00
Max. Negotiated Rate	$122.22
Rate for Payer: AlohaCare Medicaid	$63.00
Rate for Payer: AlohaCare Medicare	$63.00
Rate for Payer: Cash Price	$81.90
Rate for Payer: Devoted Health Medicare	$69.30
Rate for Payer: Hawaii Medical Service Association Medicare	$63.00
Rate for Payer: Hawaii Western Management Group Commercial	$88.20
Rate for Payer: Health Management Network Commercial	$107.10
Rate for Payer: Humana Medicare	$63.00
Rate for Payer: Kaiser Permanente Commercial	$113.40
Rate for Payer: Kaiser Permanente Medicaid	$64.26
Rate for Payer: Kaiser Permanente Medicare	$63.00
Rate for Payer: MDX Hawaii PPO	$122.22
Rate for Payer: Ohana Health Plan Medicaid	$63.00
Rate for Payer: Ohana Health Plan Medicare	$63.00
Rate for Payer: UnitedHealthcare Medicare	$63.00
Rate for Payer: University Health Alliance Commercial	$70.56

LO-PRO SCRW,TI,4.0MMX 22MM

Facility

$126.00

Service Code	HCPCS C1713
Hospital Charge Code	12957940
Hospital Revenue Code	278
Min. Negotiated Rate	$70.56
Max. Negotiated Rate	$122.22
Rate for Payer: Cash Price	$81.90
Rate for Payer: Hawaii Western Management Group Commercial	$88.20
Rate for Payer: Health Management Network Commercial	$107.10
Rate for Payer: Kaiser Permanente Commercial	$113.40
Rate for Payer: MDX Hawaii PPO	$122.22
Rate for Payer: University Health Alliance Commercial	$70.56

LO-PRO SCRW,TI,4.0MMX 24MM

Facility

$126.00

Service Code	HCPCS C1713
Hospital Charge Code	12957941
Hospital Revenue Code	278
Min. Negotiated Rate	$70.56
Max. Negotiated Rate	$122.22
Rate for Payer: Cash Price	$81.90
Rate for Payer: Hawaii Western Management Group Commercial	$88.20
Rate for Payer: Health Management Network Commercial	$107.10
Rate for Payer: Kaiser Permanente Commercial	$113.40
Rate for Payer: MDX Hawaii PPO	$122.22
Rate for Payer: University Health Alliance Commercial	$70.56

LO-PRO SCRW,TI,4.0MMX 24MM

Facility

$126.00

Service Code	HCPCS C1713
Hospital Charge Code	12957941
Hospital Revenue Code	278
Min. Negotiated Rate	$63.00
Max. Negotiated Rate	$122.22
Rate for Payer: AlohaCare Medicaid	$63.00
Rate for Payer: AlohaCare Medicare	$63.00
Rate for Payer: Cash Price	$81.90
Rate for Payer: Devoted Health Medicare	$69.30
Rate for Payer: Hawaii Medical Service Association Medicare	$63.00
Rate for Payer: Hawaii Western Management Group Commercial	$88.20
Rate for Payer: Health Management Network Commercial	$107.10
Rate for Payer: Humana Medicare	$63.00
Rate for Payer: Kaiser Permanente Commercial	$113.40
Rate for Payer: Kaiser Permanente Medicaid	$64.26
Rate for Payer: Kaiser Permanente Medicare	$63.00
Rate for Payer: MDX Hawaii PPO	$122.22
Rate for Payer: Ohana Health Plan Medicaid	$63.00
Rate for Payer: Ohana Health Plan Medicare	$63.00
Rate for Payer: UnitedHealthcare Medicare	$63.00
Rate for Payer: University Health Alliance Commercial	$70.56

loratadine 10 mg tablet [HHSC]

Facility

$3.90

Service Code	NDC 68084024801
Hospital Charge Code	2500497
Hospital Revenue Code	250
Min. Negotiated Rate	$3.31
Max. Negotiated Rate	$3.78
Rate for Payer: Cash Price	$2.54
Rate for Payer: Health Management Network Commercial	$3.31
Rate for Payer: Kaiser Permanente Commercial	$3.51
Rate for Payer: MDX Hawaii PPO	$3.78

loratadine 10 mg tablet [HHSC]

Facility

$3.90

Service Code	NDC 68001043896
Hospital Charge Code	2500497
Hospital Revenue Code	250
Min. Negotiated Rate	$3.31
Max. Negotiated Rate	$3.78
Rate for Payer: Cash Price	$2.54
Rate for Payer: Health Management Network Commercial	$3.31
Rate for Payer: Kaiser Permanente Commercial	$3.51
Rate for Payer: MDX Hawaii PPO	$3.78

loratadine 10 mg tablet [HHSC]

Facility

$3.90

Service Code	NDC 68084024801
Hospital Charge Code	2500497
Hospital Revenue Code	250
Min. Negotiated Rate	$1.95
Max. Negotiated Rate	$3.78
Rate for Payer: AlohaCare Medicaid	$1.95
Rate for Payer: AlohaCare Medicare	$1.95
Rate for Payer: Cash Price	$2.54
Rate for Payer: Devoted Health Medicare	$2.15
Rate for Payer: Hawaii Medical Service Association Medicare	$1.95
Rate for Payer: Hawaii Western Management Group Commercial	$3.71
Rate for Payer: Health Management Network Commercial	$3.31
Rate for Payer: Humana Medicare	$1.95
Rate for Payer: Kaiser Permanente Commercial	$3.51
Rate for Payer: Kaiser Permanente Medicaid	$1.99
Rate for Payer: Kaiser Permanente Medicare	$1.95
Rate for Payer: MDX Hawaii PPO	$3.78
Rate for Payer: Ohana Health Plan Medicaid	$1.95
Rate for Payer: Ohana Health Plan Medicare	$1.95
Rate for Payer: UnitedHealthcare Medicaid	$2.34
Rate for Payer: UnitedHealthcare Medicare	$1.95
Rate for Payer: University Health Alliance Commercial	$2.84

loratadine 10 mg tablet [HHSC]

Facility

$3.90

Service Code	NDC 68001043896
Hospital Charge Code	2500497
Hospital Revenue Code	250
Min. Negotiated Rate	$1.95
Max. Negotiated Rate	$3.78
Rate for Payer: AlohaCare Medicaid	$1.95
Rate for Payer: AlohaCare Medicare	$1.95
Rate for Payer: Cash Price	$2.54
Rate for Payer: Devoted Health Medicare	$2.15
Rate for Payer: Hawaii Medical Service Association Medicare	$1.95
Rate for Payer: Hawaii Western Management Group Commercial	$3.71
Rate for Payer: Health Management Network Commercial	$3.31
Rate for Payer: Humana Medicare	$1.95
Rate for Payer: Kaiser Permanente Commercial	$3.51
Rate for Payer: Kaiser Permanente Medicaid	$1.99
Rate for Payer: Kaiser Permanente Medicare	$1.95
Rate for Payer: MDX Hawaii PPO	$3.78
Rate for Payer: Ohana Health Plan Medicaid	$1.95
Rate for Payer: Ohana Health Plan Medicare	$1.95
Rate for Payer: UnitedHealthcare Medicaid	$2.34
Rate for Payer: UnitedHealthcare Medicare	$1.95
Rate for Payer: University Health Alliance Commercial	$2.84

LORazepam 0.5 mg tablet [HHSC]

Facility

$3.58

Service Code	NDC 00591024001
Hospital Charge Code	2500498
Hospital Revenue Code	250
Min. Negotiated Rate	$3.04
Max. Negotiated Rate	$3.47
Rate for Payer: Cash Price	$2.33
Rate for Payer: Health Management Network Commercial	$3.04
Rate for Payer: Kaiser Permanente Commercial	$3.22
Rate for Payer: MDX Hawaii PPO	$3.47

LORazepam 0.5 mg tablet [HHSC]

Facility

$3.68

Service Code	NDC 00591024005
Hospital Charge Code	2500498
Hospital Revenue Code	250
Min. Negotiated Rate	$1.84
Max. Negotiated Rate	$3.57
Rate for Payer: AlohaCare Medicaid	$1.84
Rate for Payer: AlohaCare Medicare	$1.84
Rate for Payer: Cash Price	$2.39
Rate for Payer: Devoted Health Medicare	$2.02
Rate for Payer: Hawaii Medical Service Association Medicare	$1.84
Rate for Payer: Hawaii Western Management Group Commercial	$3.50
Rate for Payer: Health Management Network Commercial	$3.13
Rate for Payer: Humana Medicare	$1.84
Rate for Payer: Kaiser Permanente Commercial	$3.31
Rate for Payer: Kaiser Permanente Medicaid	$1.88
Rate for Payer: Kaiser Permanente Medicare	$1.84
Rate for Payer: MDX Hawaii PPO	$3.57
Rate for Payer: Ohana Health Plan Medicaid	$1.84
Rate for Payer: Ohana Health Plan Medicare	$1.84
Rate for Payer: UnitedHealthcare Medicaid	$2.21
Rate for Payer: UnitedHealthcare Medicare	$1.84
Rate for Payer: University Health Alliance Commercial	$2.68

LORazepam 0.5 mg tablet [HHSC]

Facility

$3.00

Service Code	NDC 68084073601
Hospital Charge Code	2500498
Hospital Revenue Code	250
Min. Negotiated Rate	$2.55
Max. Negotiated Rate	$2.91
Rate for Payer: Cash Price	$1.95
Rate for Payer: Health Management Network Commercial	$2.55
Rate for Payer: Kaiser Permanente Commercial	$2.70
Rate for Payer: MDX Hawaii PPO	$2.91

Know your out-of-pocket cost for care.

All Charges