Samuel Mahelona Memorial Hospital

All Charges

Charge

Type

Setting

Price

OPTH SUTURE ETHICON 6-0 NYLON C-2

Facility

$16.00

Hospital Charge Code	8998364
Hospital Revenue Code	272
Min. Negotiated Rate	$8.00
Max. Negotiated Rate	$15.52
Rate for Payer: AlohaCare Medicaid	$8.00
Rate for Payer: AlohaCare Medicare	$8.00
Rate for Payer: Cash Price	$10.40
Rate for Payer: Devoted Health Medicare	$8.80
Rate for Payer: Hawaii Medical Service Association Medicare	$8.00
Rate for Payer: Hawaii Western Management Group Commercial	$15.20
Rate for Payer: Health Management Network Commercial	$13.60
Rate for Payer: Humana Medicare	$8.00
Rate for Payer: Kaiser Permanente Commercial	$14.40
Rate for Payer: Kaiser Permanente Medicaid	$8.16
Rate for Payer: Kaiser Permanente Medicare	$8.00
Rate for Payer: MDX Hawaii PPO	$15.52
Rate for Payer: Ohana Health Plan Medicaid	$8.00
Rate for Payer: Ohana Health Plan Medicare	$8.00
Rate for Payer: UnitedHealthcare Medicare	$8.00
Rate for Payer: University Health Alliance Commercial	$11.66

OPTH SUTURE ETHICON 6-0 NYLON C-2

Facility

$16.00

Hospital Charge Code	8998364
Hospital Revenue Code	272
Min. Negotiated Rate	$13.60
Max. Negotiated Rate	$15.52
Rate for Payer: Cash Price	$10.40
Rate for Payer: Health Management Network Commercial	$13.60
Rate for Payer: Kaiser Permanente Commercial	$14.40
Rate for Payer: MDX Hawaii PPO	$15.52

OPTH SUTURE ETHICON 6-0 P-1

Facility

$36.00

Hospital Charge Code	8998365
Hospital Revenue Code	272
Min. Negotiated Rate	$30.60
Max. Negotiated Rate	$34.92
Rate for Payer: Cash Price	$23.40
Rate for Payer: Health Management Network Commercial	$30.60
Rate for Payer: Kaiser Permanente Commercial	$32.40
Rate for Payer: MDX Hawaii PPO	$34.92

OPTH SUTURE ETHICON 6-0 P-1

Facility

$36.00

Hospital Charge Code	8998365
Hospital Revenue Code	272
Min. Negotiated Rate	$18.00
Max. Negotiated Rate	$34.92
Rate for Payer: AlohaCare Medicaid	$18.00
Rate for Payer: AlohaCare Medicare	$18.00
Rate for Payer: Cash Price	$23.40
Rate for Payer: Devoted Health Medicare	$19.80
Rate for Payer: Hawaii Medical Service Association Medicare	$18.00
Rate for Payer: Hawaii Western Management Group Commercial	$34.20
Rate for Payer: Health Management Network Commercial	$30.60
Rate for Payer: Humana Medicare	$18.00
Rate for Payer: Kaiser Permanente Commercial	$32.40
Rate for Payer: Kaiser Permanente Medicaid	$18.36
Rate for Payer: Kaiser Permanente Medicare	$18.00
Rate for Payer: MDX Hawaii PPO	$34.92
Rate for Payer: Ohana Health Plan Medicaid	$18.00
Rate for Payer: Ohana Health Plan Medicare	$18.00
Rate for Payer: UnitedHealthcare Medicare	$18.00
Rate for Payer: University Health Alliance Commercial	$26.24

OPTH:SUTURE MERSILENE 5-0 S-14 1760G

Facility

$112.00

Hospital Charge Code	8274311
Hospital Revenue Code	272
Min. Negotiated Rate	$56.00
Max. Negotiated Rate	$108.64
Rate for Payer: AlohaCare Medicaid	$56.00
Rate for Payer: AlohaCare Medicare	$56.00
Rate for Payer: Cash Price	$72.80
Rate for Payer: Devoted Health Medicare	$61.60
Rate for Payer: Hawaii Medical Service Association Medicare	$56.00
Rate for Payer: Hawaii Western Management Group Commercial	$106.40
Rate for Payer: Health Management Network Commercial	$95.20
Rate for Payer: Humana Medicare	$56.00
Rate for Payer: Kaiser Permanente Commercial	$100.80
Rate for Payer: Kaiser Permanente Medicaid	$57.12
Rate for Payer: Kaiser Permanente Medicare	$56.00
Rate for Payer: MDX Hawaii PPO	$108.64
Rate for Payer: Ohana Health Plan Medicaid	$56.00
Rate for Payer: Ohana Health Plan Medicare	$56.00
Rate for Payer: UnitedHealthcare Medicare	$56.00
Rate for Payer: University Health Alliance Commercial	$81.64

OPTH:SUTURE MERSILENE 5-0 S-14 1760G

Facility

$112.00

Hospital Charge Code	8274311
Hospital Revenue Code	272
Min. Negotiated Rate	$95.20
Max. Negotiated Rate	$108.64
Rate for Payer: Cash Price	$72.80
Rate for Payer: Health Management Network Commercial	$95.20
Rate for Payer: Kaiser Permanente Commercial	$100.80
Rate for Payer: MDX Hawaii PPO	$108.64

OPTH:SUTURE MONOSOF 5-0 P10

Facility

$23.00

Hospital Charge Code	8274312
Hospital Revenue Code	272
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

OPTH:SUTURE MONOSOF 5-0 P10

Facility

$23.00

Hospital Charge Code	8274312
Hospital Revenue Code	272
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

OPTH:SUTURE MONOSOF 8-0 SE-175-H

Facility

$122.00

Hospital Charge Code	8274314
Hospital Revenue Code	272
Min. Negotiated Rate	$61.00
Max. Negotiated Rate	$118.34
Rate for Payer: AlohaCare Medicaid	$61.00
Rate for Payer: AlohaCare Medicare	$61.00
Rate for Payer: Cash Price	$79.30
Rate for Payer: Devoted Health Medicare	$67.10
Rate for Payer: Hawaii Medical Service Association Medicare	$61.00
Rate for Payer: Hawaii Western Management Group Commercial	$115.90
Rate for Payer: Health Management Network Commercial	$103.70
Rate for Payer: Humana Medicare	$61.00
Rate for Payer: Kaiser Permanente Commercial	$109.80
Rate for Payer: Kaiser Permanente Medicaid	$62.22
Rate for Payer: Kaiser Permanente Medicare	$61.00
Rate for Payer: MDX Hawaii PPO	$118.34
Rate for Payer: Ohana Health Plan Medicaid	$61.00
Rate for Payer: Ohana Health Plan Medicare	$61.00
Rate for Payer: UnitedHealthcare Medicare	$61.00
Rate for Payer: University Health Alliance Commercial	$88.93

OPTH:SUTURE MONOSOF 8-0 SE-175-H

Facility

$122.00

Hospital Charge Code	8274314
Hospital Revenue Code	272
Min. Negotiated Rate	$103.70
Max. Negotiated Rate	$118.34
Rate for Payer: Cash Price	$79.30
Rate for Payer: Health Management Network Commercial	$103.70
Rate for Payer: Kaiser Permanente Commercial	$109.80
Rate for Payer: MDX Hawaii PPO	$118.34

OPTH SUTURE NYLON 10-0 CU-5

Facility

$200.00

Hospital Charge Code	8274315
Hospital Revenue Code	272
Min. Negotiated Rate	$100.00
Max. Negotiated Rate	$194.00
Rate for Payer: AlohaCare Medicaid	$100.00
Rate for Payer: AlohaCare Medicare	$100.00
Rate for Payer: Cash Price	$130.00
Rate for Payer: Devoted Health Medicare	$110.00
Rate for Payer: Hawaii Medical Service Association Medicare	$100.00
Rate for Payer: Hawaii Western Management Group Commercial	$190.00
Rate for Payer: Health Management Network Commercial	$170.00
Rate for Payer: Humana Medicare	$100.00
Rate for Payer: Kaiser Permanente Commercial	$180.00
Rate for Payer: Kaiser Permanente Medicaid	$102.00
Rate for Payer: Kaiser Permanente Medicare	$100.00
Rate for Payer: MDX Hawaii PPO	$194.00
Rate for Payer: Ohana Health Plan Medicaid	$100.00
Rate for Payer: Ohana Health Plan Medicare	$100.00
Rate for Payer: UnitedHealthcare Medicare	$100.00
Rate for Payer: University Health Alliance Commercial	$145.78

OPTH SUTURE NYLON 10-0 CU-5

Facility

$200.00

Hospital Charge Code	8274315
Hospital Revenue Code	272
Min. Negotiated Rate	$170.00
Max. Negotiated Rate	$194.00
Rate for Payer: Cash Price	$130.00
Rate for Payer: Health Management Network Commercial	$170.00
Rate for Payer: Kaiser Permanente Commercial	$180.00
Rate for Payer: MDX Hawaii PPO	$194.00

OPTH:SUTURE PLAIN GUT 4-0

Facility

$41.00

Hospital Charge Code	8274316
Hospital Revenue Code	272
Min. Negotiated Rate	$20.50
Max. Negotiated Rate	$39.77
Rate for Payer: AlohaCare Medicaid	$20.50
Rate for Payer: AlohaCare Medicare	$20.50
Rate for Payer: Cash Price	$26.65
Rate for Payer: Devoted Health Medicare	$22.55
Rate for Payer: Hawaii Medical Service Association Medicare	$20.50
Rate for Payer: Hawaii Western Management Group Commercial	$38.95
Rate for Payer: Health Management Network Commercial	$34.85
Rate for Payer: Humana Medicare	$20.50
Rate for Payer: Kaiser Permanente Commercial	$36.90
Rate for Payer: Kaiser Permanente Medicaid	$20.91
Rate for Payer: Kaiser Permanente Medicare	$20.50
Rate for Payer: MDX Hawaii PPO	$39.77
Rate for Payer: Ohana Health Plan Medicaid	$20.50
Rate for Payer: Ohana Health Plan Medicare	$20.50
Rate for Payer: UnitedHealthcare Medicare	$20.50
Rate for Payer: University Health Alliance Commercial	$29.88

OPTH:SUTURE PLAIN GUT 4-0

Facility

$41.00

Hospital Charge Code	8274316
Hospital Revenue Code	272
Min. Negotiated Rate	$34.85
Max. Negotiated Rate	$39.77
Rate for Payer: Cash Price	$26.65
Rate for Payer: Health Management Network Commercial	$34.85
Rate for Payer: Kaiser Permanente Commercial	$36.90
Rate for Payer: MDX Hawaii PPO	$39.77

OPTH:SUTURE PLAIN GUT 6-0, P10

Facility

$11.00

Hospital Charge Code	8274378
Hospital Revenue Code	272
Min. Negotiated Rate	$9.35
Max. Negotiated Rate	$10.67
Rate for Payer: Cash Price	$7.15
Rate for Payer: Health Management Network Commercial	$9.35
Rate for Payer: Kaiser Permanente Commercial	$9.90
Rate for Payer: MDX Hawaii PPO	$10.67

OPTH:SUTURE PLAIN GUT 6-0, P10

Facility

$11.00

Hospital Charge Code	8274378
Hospital Revenue Code	272
Min. Negotiated Rate	$5.50
Max. Negotiated Rate	$10.67
Rate for Payer: AlohaCare Medicaid	$5.50
Rate for Payer: AlohaCare Medicare	$5.50
Rate for Payer: Cash Price	$7.15
Rate for Payer: Devoted Health Medicare	$6.05
Rate for Payer: Hawaii Medical Service Association Medicare	$5.50
Rate for Payer: Hawaii Western Management Group Commercial	$10.45
Rate for Payer: Health Management Network Commercial	$9.35
Rate for Payer: Humana Medicare	$5.50
Rate for Payer: Kaiser Permanente Commercial	$9.90
Rate for Payer: Kaiser Permanente Medicaid	$5.61
Rate for Payer: Kaiser Permanente Medicare	$5.50
Rate for Payer: MDX Hawaii PPO	$10.67
Rate for Payer: Ohana Health Plan Medicaid	$5.50
Rate for Payer: Ohana Health Plan Medicare	$5.50
Rate for Payer: UnitedHealthcare Medicare	$5.50
Rate for Payer: University Health Alliance Commercial	$8.02

OPTH:SUTURE POLYSORB 4-0

Facility

$20.00

Hospital Charge Code	8274379
Hospital Revenue Code	272
Min. Negotiated Rate	$17.00
Max. Negotiated Rate	$19.40
Rate for Payer: Cash Price	$13.00
Rate for Payer: Health Management Network Commercial	$17.00
Rate for Payer: Kaiser Permanente Commercial	$18.00
Rate for Payer: MDX Hawaii PPO	$19.40

OPTH:SUTURE POLYSORB 4-0

Facility

$20.00

Hospital Charge Code	8274379
Hospital Revenue Code	272
Min. Negotiated Rate	$10.00
Max. Negotiated Rate	$19.40
Rate for Payer: AlohaCare Medicaid	$10.00
Rate for Payer: AlohaCare Medicare	$10.00
Rate for Payer: Cash Price	$13.00
Rate for Payer: Devoted Health Medicare	$11.00
Rate for Payer: Hawaii Medical Service Association Medicare	$10.00
Rate for Payer: Hawaii Western Management Group Commercial	$19.00
Rate for Payer: Health Management Network Commercial	$17.00
Rate for Payer: Humana Medicare	$10.00
Rate for Payer: Kaiser Permanente Commercial	$18.00
Rate for Payer: Kaiser Permanente Medicaid	$10.20
Rate for Payer: Kaiser Permanente Medicare	$10.00
Rate for Payer: MDX Hawaii PPO	$19.40
Rate for Payer: Ohana Health Plan Medicaid	$10.00
Rate for Payer: Ohana Health Plan Medicare	$10.00
Rate for Payer: UnitedHealthcare Medicare	$10.00
Rate for Payer: University Health Alliance Commercial	$14.58

OPTH:SUTURE POLYSORB 5-0 L-1739K

Facility

$34.00

Hospital Charge Code	8274318
Hospital Revenue Code	272
Min. Negotiated Rate	$28.90
Max. Negotiated Rate	$32.98
Rate for Payer: Cash Price	$22.10
Rate for Payer: Health Management Network Commercial	$28.90
Rate for Payer: Kaiser Permanente Commercial	$30.60
Rate for Payer: MDX Hawaii PPO	$32.98

OPTH:SUTURE POLYSORB 5-0 L-1739K

Facility

$34.00

Hospital Charge Code	8274318
Hospital Revenue Code	272
Min. Negotiated Rate	$17.00
Max. Negotiated Rate	$32.98
Rate for Payer: AlohaCare Medicaid	$17.00
Rate for Payer: AlohaCare Medicare	$17.00
Rate for Payer: Cash Price	$22.10
Rate for Payer: Devoted Health Medicare	$18.70
Rate for Payer: Hawaii Medical Service Association Medicare	$17.00
Rate for Payer: Hawaii Western Management Group Commercial	$32.30
Rate for Payer: Health Management Network Commercial	$28.90
Rate for Payer: Humana Medicare	$17.00
Rate for Payer: Kaiser Permanente Commercial	$30.60
Rate for Payer: Kaiser Permanente Medicaid	$17.34
Rate for Payer: Kaiser Permanente Medicare	$17.00
Rate for Payer: MDX Hawaii PPO	$32.98
Rate for Payer: Ohana Health Plan Medicaid	$17.00
Rate for Payer: Ohana Health Plan Medicare	$17.00
Rate for Payer: UnitedHealthcare Medicare	$17.00
Rate for Payer: University Health Alliance Commercial	$24.78

OPTH:SUTURE POLYSORB 5-0 SS-14 L-1792K

Facility

$82.00

Hospital Charge Code	8274317
Hospital Revenue Code	272
Min. Negotiated Rate	$41.00
Max. Negotiated Rate	$79.54
Rate for Payer: AlohaCare Medicaid	$41.00
Rate for Payer: AlohaCare Medicare	$41.00
Rate for Payer: Cash Price	$53.30
Rate for Payer: Devoted Health Medicare	$45.10
Rate for Payer: Hawaii Medical Service Association Medicare	$41.00
Rate for Payer: Hawaii Western Management Group Commercial	$77.90
Rate for Payer: Health Management Network Commercial	$69.70
Rate for Payer: Humana Medicare	$41.00
Rate for Payer: Kaiser Permanente Commercial	$73.80
Rate for Payer: Kaiser Permanente Medicaid	$41.82
Rate for Payer: Kaiser Permanente Medicare	$41.00
Rate for Payer: MDX Hawaii PPO	$79.54
Rate for Payer: Ohana Health Plan Medicaid	$41.00
Rate for Payer: Ohana Health Plan Medicare	$41.00
Rate for Payer: UnitedHealthcare Medicare	$41.00
Rate for Payer: University Health Alliance Commercial	$59.77

OPTH:SUTURE POLYSORB 5-0 SS-14 L-1792K

Facility

$82.00

Hospital Charge Code	8274317
Hospital Revenue Code	272
Min. Negotiated Rate	$69.70
Max. Negotiated Rate	$79.54
Rate for Payer: Cash Price	$53.30
Rate for Payer: Health Management Network Commercial	$69.70
Rate for Payer: Kaiser Permanente Commercial	$73.80
Rate for Payer: MDX Hawaii PPO	$79.54

OPTH:SUTURE POLYSORB 5-0 SS-24 L-2753K

Facility

$41.00

Hospital Charge Code	8274380
Hospital Revenue Code	272
Min. Negotiated Rate	$20.50
Max. Negotiated Rate	$39.77
Rate for Payer: AlohaCare Medicaid	$20.50
Rate for Payer: AlohaCare Medicare	$20.50
Rate for Payer: Cash Price	$26.65
Rate for Payer: Devoted Health Medicare	$22.55
Rate for Payer: Hawaii Medical Service Association Medicare	$20.50
Rate for Payer: Hawaii Western Management Group Commercial	$38.95
Rate for Payer: Health Management Network Commercial	$34.85
Rate for Payer: Humana Medicare	$20.50
Rate for Payer: Kaiser Permanente Commercial	$36.90
Rate for Payer: Kaiser Permanente Medicaid	$20.91
Rate for Payer: Kaiser Permanente Medicare	$20.50
Rate for Payer: MDX Hawaii PPO	$39.77
Rate for Payer: Ohana Health Plan Medicaid	$20.50
Rate for Payer: Ohana Health Plan Medicare	$20.50
Rate for Payer: UnitedHealthcare Medicare	$20.50
Rate for Payer: University Health Alliance Commercial	$29.88

OPTH:SUTURE POLYSORB 5-0 SS-24 L-2753K

Facility

$41.00

Hospital Charge Code	8274380
Hospital Revenue Code	272
Min. Negotiated Rate	$34.85
Max. Negotiated Rate	$39.77
Rate for Payer: Cash Price	$26.65
Rate for Payer: Health Management Network Commercial	$34.85
Rate for Payer: Kaiser Permanente Commercial	$36.90
Rate for Payer: MDX Hawaii PPO	$39.77

OPTH:SUTURE POLYSORB 6-0 SS-28 L-1562K

Facility

$59.00

Hospital Charge Code	8274320
Hospital Revenue Code	272
Min. Negotiated Rate	$50.15
Max. Negotiated Rate	$57.23
Rate for Payer: Cash Price	$38.35
Rate for Payer: Health Management Network Commercial	$50.15
Rate for Payer: Kaiser Permanente Commercial	$53.10
Rate for Payer: MDX Hawaii PPO	$57.23

Know your out-of-pocket cost for care.

All Charges