Samuel Mahelona Memorial Hospital

All Charges

Charge

Type

Setting

Price

OPTH PLAIN GUT 6-0 1735G

Facility

$143.00

Hospital Charge Code	9024308
Hospital Revenue Code	272
Min. Negotiated Rate	$71.50
Max. Negotiated Rate	$138.71
Rate for Payer: AlohaCare Medicaid	$71.50
Rate for Payer: AlohaCare Medicare	$71.50
Rate for Payer: Cash Price	$92.95
Rate for Payer: Devoted Health Medicare	$78.65
Rate for Payer: Hawaii Medical Service Association Medicare	$71.50
Rate for Payer: Hawaii Western Management Group Commercial	$135.85
Rate for Payer: Health Management Network Commercial	$121.55
Rate for Payer: Humana Medicare	$71.50
Rate for Payer: Kaiser Permanente Commercial	$128.70
Rate for Payer: Kaiser Permanente Medicaid	$72.93
Rate for Payer: Kaiser Permanente Medicare	$71.50
Rate for Payer: MDX Hawaii PPO	$138.71
Rate for Payer: Ohana Health Plan Medicaid	$71.50
Rate for Payer: Ohana Health Plan Medicare	$71.50
Rate for Payer: UnitedHealthcare Medicare	$71.50
Rate for Payer: University Health Alliance Commercial	$104.23

OPTH PLAIN GUT 6-0 1735G

Facility

$143.00

Hospital Charge Code	9024308
Hospital Revenue Code	272
Min. Negotiated Rate	$121.55
Max. Negotiated Rate	$138.71
Rate for Payer: Cash Price	$92.95
Rate for Payer: Health Management Network Commercial	$121.55
Rate for Payer: Kaiser Permanente Commercial	$128.70
Rate for Payer: MDX Hawaii PPO	$138.71

OPTH:PROKERA TISSUE

Facility

$2,098.00

Service Code	HCPCS V2790
Hospital Charge Code	9691484
Hospital Revenue Code	278
Min. Negotiated Rate	$1,174.88
Max. Negotiated Rate	$2,035.06
Rate for Payer: Cash Price	$1,363.70
Rate for Payer: Hawaii Western Management Group Commercial	$1,468.60
Rate for Payer: Health Management Network Commercial	$1,783.30
Rate for Payer: Kaiser Permanente Commercial	$1,888.20
Rate for Payer: MDX Hawaii PPO	$2,035.06
Rate for Payer: University Health Alliance Commercial	$1,174.88

OPTH:PROKERA TISSUE

Facility

$2,098.00

Service Code	HCPCS V2790
Hospital Charge Code	9691484
Hospital Revenue Code	278
Min. Negotiated Rate	$1,049.00
Max. Negotiated Rate	$2,035.06
Rate for Payer: AlohaCare Medicaid	$1,049.00
Rate for Payer: AlohaCare Medicare	$1,049.00
Rate for Payer: Cash Price	$1,363.70
Rate for Payer: Devoted Health Medicare	$1,153.90
Rate for Payer: Hawaii Medical Service Association Medicare	$1,049.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,468.60
Rate for Payer: Health Management Network Commercial	$1,783.30
Rate for Payer: Humana Medicare	$1,049.00
Rate for Payer: Kaiser Permanente Commercial	$1,888.20
Rate for Payer: Kaiser Permanente Medicaid	$1,069.98
Rate for Payer: Kaiser Permanente Medicare	$1,049.00
Rate for Payer: MDX Hawaii PPO	$2,035.06
Rate for Payer: Ohana Health Plan Medicaid	$1,049.00
Rate for Payer: Ohana Health Plan Medicare	$1,049.00
Rate for Payer: UnitedHealthcare Medicare	$1,049.00
Rate for Payer: University Health Alliance Commercial	$1,174.88

OPTH:PROLENE BLU 4-0 PS-2

Facility

$50.00

Hospital Charge Code	12706880
Hospital Revenue Code	272
Min. Negotiated Rate	$42.50
Max. Negotiated Rate	$48.50
Rate for Payer: Cash Price	$32.50
Rate for Payer: Health Management Network Commercial	$42.50
Rate for Payer: Kaiser Permanente Commercial	$45.00
Rate for Payer: MDX Hawaii PPO	$48.50

OPTH:PROLENE BLU 4-0 PS-2

Facility

$50.00

Hospital Charge Code	12706880
Hospital Revenue Code	272
Min. Negotiated Rate	$25.00
Max. Negotiated Rate	$48.50
Rate for Payer: MDX Hawaii PPO	$48.50
Rate for Payer: AlohaCare Medicaid	$25.00
Rate for Payer: AlohaCare Medicare	$25.00
Rate for Payer: Cash Price	$32.50
Rate for Payer: Devoted Health Medicare	$27.50
Rate for Payer: Hawaii Medical Service Association Medicare	$25.00
Rate for Payer: Hawaii Western Management Group Commercial	$47.50
Rate for Payer: Health Management Network Commercial	$42.50
Rate for Payer: Humana Medicare	$25.00
Rate for Payer: Kaiser Permanente Commercial	$45.00
Rate for Payer: Kaiser Permanente Medicaid	$25.50
Rate for Payer: Kaiser Permanente Medicare	$25.00
Rate for Payer: Ohana Health Plan Medicaid	$25.00
Rate for Payer: Ohana Health Plan Medicare	$25.00
Rate for Payer: UnitedHealthcare Medicare	$25.00
Rate for Payer: University Health Alliance Commercial	$36.45

OPTH:PROVISC 0.55 ML

Facility

$209.00

Hospital Charge Code	8274166
Hospital Revenue Code	272
Min. Negotiated Rate	$104.50
Max. Negotiated Rate	$202.73
Rate for Payer: AlohaCare Medicaid	$104.50
Rate for Payer: AlohaCare Medicare	$104.50
Rate for Payer: Cash Price	$135.85
Rate for Payer: Devoted Health Medicare	$114.95
Rate for Payer: Hawaii Medical Service Association Medicare	$104.50
Rate for Payer: Hawaii Western Management Group Commercial	$198.55
Rate for Payer: Health Management Network Commercial	$177.65
Rate for Payer: Humana Medicare	$104.50
Rate for Payer: Kaiser Permanente Commercial	$188.10
Rate for Payer: Kaiser Permanente Medicaid	$106.59
Rate for Payer: Kaiser Permanente Medicare	$104.50
Rate for Payer: MDX Hawaii PPO	$202.73
Rate for Payer: Ohana Health Plan Medicaid	$104.50
Rate for Payer: Ohana Health Plan Medicare	$104.50
Rate for Payer: UnitedHealthcare Medicare	$104.50
Rate for Payer: University Health Alliance Commercial	$152.34

OPTH:PROVISC 0.55 ML

Facility

$209.00

Hospital Charge Code	8274166
Hospital Revenue Code	272
Min. Negotiated Rate	$177.65
Max. Negotiated Rate	$202.73
Rate for Payer: Cash Price	$135.85
Rate for Payer: Health Management Network Commercial	$177.65
Rate for Payer: Kaiser Permanente Commercial	$188.10
Rate for Payer: MDX Hawaii PPO	$202.73

OPTH:PUNCH, DONOR 7.0MM

Facility

$324.00

Hospital Charge Code	8274172
Hospital Revenue Code	272
Min. Negotiated Rate	$275.40
Max. Negotiated Rate	$314.28
Rate for Payer: Cash Price	$210.60
Rate for Payer: Health Management Network Commercial	$275.40
Rate for Payer: Kaiser Permanente Commercial	$291.60
Rate for Payer: MDX Hawaii PPO	$314.28

OPTH:PUNCH, DONOR 7.0MM

Facility

$324.00

Hospital Charge Code	8274172
Hospital Revenue Code	272
Min. Negotiated Rate	$162.00
Max. Negotiated Rate	$314.28
Rate for Payer: AlohaCare Medicaid	$162.00
Rate for Payer: AlohaCare Medicare	$162.00
Rate for Payer: Cash Price	$210.60
Rate for Payer: Devoted Health Medicare	$178.20
Rate for Payer: Hawaii Medical Service Association Medicare	$162.00
Rate for Payer: Hawaii Western Management Group Commercial	$307.80
Rate for Payer: Health Management Network Commercial	$275.40
Rate for Payer: Humana Medicare	$162.00
Rate for Payer: Kaiser Permanente Commercial	$291.60
Rate for Payer: Kaiser Permanente Medicaid	$165.24
Rate for Payer: Kaiser Permanente Medicare	$162.00
Rate for Payer: MDX Hawaii PPO	$314.28
Rate for Payer: Ohana Health Plan Medicaid	$162.00
Rate for Payer: Ohana Health Plan Medicare	$162.00
Rate for Payer: UnitedHealthcare Medicare	$162.00
Rate for Payer: University Health Alliance Commercial	$236.16

OPTH:PUNCH, DONOR 7.25MM

Facility

$276.00

Hospital Charge Code	8274173
Hospital Revenue Code	272
Min. Negotiated Rate	$234.60
Max. Negotiated Rate	$267.72
Rate for Payer: Cash Price	$179.40
Rate for Payer: Health Management Network Commercial	$234.60
Rate for Payer: Kaiser Permanente Commercial	$248.40
Rate for Payer: MDX Hawaii PPO	$267.72

OPTH:PUNCH, DONOR 7.25MM

Facility

$276.00

Hospital Charge Code	8274173
Hospital Revenue Code	272
Min. Negotiated Rate	$138.00
Max. Negotiated Rate	$267.72
Rate for Payer: Kaiser Permanente Commercial	$248.40
Rate for Payer: AlohaCare Medicaid	$138.00
Rate for Payer: AlohaCare Medicare	$138.00
Rate for Payer: Cash Price	$179.40
Rate for Payer: Devoted Health Medicare	$151.80
Rate for Payer: Hawaii Medical Service Association Medicare	$138.00
Rate for Payer: Hawaii Western Management Group Commercial	$262.20
Rate for Payer: Health Management Network Commercial	$234.60
Rate for Payer: Humana Medicare	$138.00
Rate for Payer: Kaiser Permanente Medicaid	$140.76
Rate for Payer: Kaiser Permanente Medicare	$138.00
Rate for Payer: MDX Hawaii PPO	$267.72
Rate for Payer: Ohana Health Plan Medicaid	$138.00
Rate for Payer: Ohana Health Plan Medicare	$138.00
Rate for Payer: UnitedHealthcare Medicare	$138.00
Rate for Payer: University Health Alliance Commercial	$201.18

OPTH:PUNCH, DONOR 7.50MM

Facility

$324.00

Hospital Charge Code	8274174
Hospital Revenue Code	272
Min. Negotiated Rate	$162.00
Max. Negotiated Rate	$314.28
Rate for Payer: AlohaCare Medicaid	$162.00
Rate for Payer: AlohaCare Medicare	$162.00
Rate for Payer: Cash Price	$210.60
Rate for Payer: Devoted Health Medicare	$178.20
Rate for Payer: Hawaii Medical Service Association Medicare	$162.00
Rate for Payer: Hawaii Western Management Group Commercial	$307.80
Rate for Payer: Health Management Network Commercial	$275.40
Rate for Payer: Humana Medicare	$162.00
Rate for Payer: Kaiser Permanente Commercial	$291.60
Rate for Payer: Kaiser Permanente Medicaid	$165.24
Rate for Payer: Kaiser Permanente Medicare	$162.00
Rate for Payer: MDX Hawaii PPO	$314.28
Rate for Payer: Ohana Health Plan Medicaid	$162.00
Rate for Payer: Ohana Health Plan Medicare	$162.00
Rate for Payer: UnitedHealthcare Medicare	$162.00
Rate for Payer: University Health Alliance Commercial	$236.16

OPTH:PUNCH, DONOR 7.50MM

Facility

$324.00

Hospital Charge Code	8274174
Hospital Revenue Code	272
Min. Negotiated Rate	$275.40
Max. Negotiated Rate	$314.28
Rate for Payer: Cash Price	$210.60
Rate for Payer: Health Management Network Commercial	$275.40
Rate for Payer: Kaiser Permanente Commercial	$291.60
Rate for Payer: MDX Hawaii PPO	$314.28

OPTH:PUNCH, DONOR 7.75MM

Facility

$276.00

Hospital Charge Code	8274175
Hospital Revenue Code	272
Min. Negotiated Rate	$234.60
Max. Negotiated Rate	$267.72
Rate for Payer: Cash Price	$179.40
Rate for Payer: Health Management Network Commercial	$234.60
Rate for Payer: Kaiser Permanente Commercial	$248.40
Rate for Payer: MDX Hawaii PPO	$267.72

OPTH:PUNCH, DONOR 7.75MM

Facility

$276.00

Hospital Charge Code	8274175
Hospital Revenue Code	272
Min. Negotiated Rate	$138.00
Max. Negotiated Rate	$267.72
Rate for Payer: AlohaCare Medicaid	$138.00
Rate for Payer: AlohaCare Medicare	$138.00
Rate for Payer: Cash Price	$179.40
Rate for Payer: Devoted Health Medicare	$151.80
Rate for Payer: Hawaii Medical Service Association Medicare	$138.00
Rate for Payer: Hawaii Western Management Group Commercial	$262.20
Rate for Payer: Health Management Network Commercial	$234.60
Rate for Payer: Humana Medicare	$138.00
Rate for Payer: Kaiser Permanente Commercial	$248.40
Rate for Payer: Kaiser Permanente Medicaid	$140.76
Rate for Payer: Kaiser Permanente Medicare	$138.00
Rate for Payer: MDX Hawaii PPO	$267.72
Rate for Payer: Ohana Health Plan Medicaid	$138.00
Rate for Payer: Ohana Health Plan Medicare	$138.00
Rate for Payer: UnitedHealthcare Medicare	$138.00
Rate for Payer: University Health Alliance Commercial	$201.18

OPTH:PUNCH DONOR 8.0MM

Facility

$324.00

Hospital Charge Code	8274167
Hospital Revenue Code	272
Min. Negotiated Rate	$275.40
Max. Negotiated Rate	$314.28
Rate for Payer: Cash Price	$210.60
Rate for Payer: Health Management Network Commercial	$275.40
Rate for Payer: Kaiser Permanente Commercial	$291.60
Rate for Payer: MDX Hawaii PPO	$314.28

OPTH:PUNCH DONOR 8.0MM

Facility

$324.00

Hospital Charge Code	8274167
Hospital Revenue Code	272
Min. Negotiated Rate	$162.00
Max. Negotiated Rate	$314.28
Rate for Payer: AlohaCare Medicaid	$162.00
Rate for Payer: AlohaCare Medicare	$162.00
Rate for Payer: Cash Price	$210.60
Rate for Payer: Devoted Health Medicare	$178.20
Rate for Payer: Hawaii Medical Service Association Medicare	$162.00
Rate for Payer: Hawaii Western Management Group Commercial	$307.80
Rate for Payer: Health Management Network Commercial	$275.40
Rate for Payer: Humana Medicare	$162.00
Rate for Payer: Kaiser Permanente Commercial	$291.60
Rate for Payer: Kaiser Permanente Medicaid	$165.24
Rate for Payer: Kaiser Permanente Medicare	$162.00
Rate for Payer: MDX Hawaii PPO	$314.28
Rate for Payer: Ohana Health Plan Medicaid	$162.00
Rate for Payer: Ohana Health Plan Medicare	$162.00
Rate for Payer: UnitedHealthcare Medicare	$162.00
Rate for Payer: University Health Alliance Commercial	$236.16

OPTH:PUNCH, DONOR 8.25MM

Facility

$276.00

Hospital Charge Code	8274176
Hospital Revenue Code	272
Min. Negotiated Rate	$234.60
Max. Negotiated Rate	$267.72
Rate for Payer: Cash Price	$179.40
Rate for Payer: Health Management Network Commercial	$234.60
Rate for Payer: Kaiser Permanente Commercial	$248.40
Rate for Payer: MDX Hawaii PPO	$267.72

OPTH:PUNCH, DONOR 8.25MM

Facility

$276.00

Hospital Charge Code	8274176
Hospital Revenue Code	272
Min. Negotiated Rate	$138.00
Max. Negotiated Rate	$267.72
Rate for Payer: AlohaCare Medicaid	$138.00
Rate for Payer: AlohaCare Medicare	$138.00
Rate for Payer: Cash Price	$179.40
Rate for Payer: Devoted Health Medicare	$151.80
Rate for Payer: Hawaii Medical Service Association Medicare	$138.00
Rate for Payer: Hawaii Western Management Group Commercial	$262.20
Rate for Payer: Health Management Network Commercial	$234.60
Rate for Payer: Humana Medicare	$138.00
Rate for Payer: Kaiser Permanente Commercial	$248.40
Rate for Payer: Kaiser Permanente Medicaid	$140.76
Rate for Payer: Kaiser Permanente Medicare	$138.00
Rate for Payer: MDX Hawaii PPO	$267.72
Rate for Payer: Ohana Health Plan Medicaid	$138.00
Rate for Payer: Ohana Health Plan Medicare	$138.00
Rate for Payer: UnitedHealthcare Medicare	$138.00
Rate for Payer: University Health Alliance Commercial	$201.18

OPTH:PUNCH DONOR 8.5MM

Facility

$324.00

Hospital Charge Code	8274168
Hospital Revenue Code	272
Min. Negotiated Rate	$275.40
Max. Negotiated Rate	$314.28
Rate for Payer: Cash Price	$210.60
Rate for Payer: Health Management Network Commercial	$275.40
Rate for Payer: Kaiser Permanente Commercial	$291.60
Rate for Payer: MDX Hawaii PPO	$314.28

OPTH:PUNCH DONOR 8.5MM

Facility

$324.00

Hospital Charge Code	8274168
Hospital Revenue Code	272
Min. Negotiated Rate	$162.00
Max. Negotiated Rate	$314.28
Rate for Payer: AlohaCare Medicaid	$162.00
Rate for Payer: AlohaCare Medicare	$162.00
Rate for Payer: Cash Price	$210.60
Rate for Payer: Devoted Health Medicare	$178.20
Rate for Payer: Hawaii Medical Service Association Medicare	$162.00
Rate for Payer: Hawaii Western Management Group Commercial	$307.80
Rate for Payer: Health Management Network Commercial	$275.40
Rate for Payer: Humana Medicare	$162.00
Rate for Payer: Kaiser Permanente Commercial	$291.60
Rate for Payer: Kaiser Permanente Medicaid	$165.24
Rate for Payer: Kaiser Permanente Medicare	$162.00
Rate for Payer: MDX Hawaii PPO	$314.28
Rate for Payer: Ohana Health Plan Medicaid	$162.00
Rate for Payer: Ohana Health Plan Medicare	$162.00
Rate for Payer: UnitedHealthcare Medicare	$162.00
Rate for Payer: University Health Alliance Commercial	$236.16

OPTH:PUNCH DONOR 8.75MM

Facility

$276.00

Hospital Charge Code	8274169
Hospital Revenue Code	272
Min. Negotiated Rate	$234.60
Max. Negotiated Rate	$267.72
Rate for Payer: Cash Price	$179.40
Rate for Payer: Health Management Network Commercial	$234.60
Rate for Payer: Kaiser Permanente Commercial	$248.40
Rate for Payer: MDX Hawaii PPO	$267.72

OPTH:PUNCH DONOR 8.75MM

Facility

$276.00

Hospital Charge Code	8274169
Hospital Revenue Code	272
Min. Negotiated Rate	$138.00
Max. Negotiated Rate	$267.72
Rate for Payer: AlohaCare Medicaid	$138.00
Rate for Payer: AlohaCare Medicare	$138.00
Rate for Payer: Cash Price	$179.40
Rate for Payer: Devoted Health Medicare	$151.80
Rate for Payer: Hawaii Medical Service Association Medicare	$138.00
Rate for Payer: Hawaii Western Management Group Commercial	$262.20
Rate for Payer: Health Management Network Commercial	$234.60
Rate for Payer: Humana Medicare	$138.00
Rate for Payer: Kaiser Permanente Commercial	$248.40
Rate for Payer: Kaiser Permanente Medicaid	$140.76
Rate for Payer: Kaiser Permanente Medicare	$138.00
Rate for Payer: MDX Hawaii PPO	$267.72
Rate for Payer: Ohana Health Plan Medicaid	$138.00
Rate for Payer: Ohana Health Plan Medicare	$138.00
Rate for Payer: UnitedHealthcare Medicare	$138.00
Rate for Payer: University Health Alliance Commercial	$201.18

OPTH:PUNCH DONOR 9.0MM

Facility

$324.00

Hospital Charge Code	8274170
Hospital Revenue Code	272
Min. Negotiated Rate	$162.00
Max. Negotiated Rate	$314.28
Rate for Payer: AlohaCare Medicaid	$162.00
Rate for Payer: AlohaCare Medicare	$162.00
Rate for Payer: Cash Price	$210.60
Rate for Payer: Devoted Health Medicare	$178.20
Rate for Payer: Hawaii Medical Service Association Medicare	$162.00
Rate for Payer: Hawaii Western Management Group Commercial	$307.80
Rate for Payer: Health Management Network Commercial	$275.40
Rate for Payer: Humana Medicare	$162.00
Rate for Payer: Kaiser Permanente Commercial	$291.60
Rate for Payer: Kaiser Permanente Medicaid	$165.24
Rate for Payer: Kaiser Permanente Medicare	$162.00
Rate for Payer: MDX Hawaii PPO	$314.28
Rate for Payer: Ohana Health Plan Medicaid	$162.00
Rate for Payer: Ohana Health Plan Medicare	$162.00
Rate for Payer: UnitedHealthcare Medicare	$162.00
Rate for Payer: University Health Alliance Commercial	$236.16

Know your out-of-pocket cost for care.

All Charges