Samuel Mahelona Memorial Hospital

All Charges

Charge

Type

Setting

Price

O.R. PROCEDURES FOR OBESITY WITHOUT CC/MCC

Facility

$51,504.45

Service Code	MSDRG 621
Min. Negotiated Rate	$51,504.45
Max. Negotiated Rate	$51,504.45
Rate for Payer: Hawaii Medical Service Association Commercial	$51,504.45

O.R. PROCEDURES WITH DIAGNOSES OF OTHER CONTACT WITH HEALTH SERVICES WITH CC

Facility

$38,586.86

Service Code	MSDRG 940
Min. Negotiated Rate	$38,586.86
Max. Negotiated Rate	$38,586.86
Rate for Payer: Hawaii Medical Service Association Commercial	$38,586.86

O.R. PROCEDURES WITH DIAGNOSES OF OTHER CONTACT WITH HEALTH SERVICES WITH MCC

Facility

$38,586.86

Service Code	MSDRG 939
Min. Negotiated Rate	$38,586.86
Max. Negotiated Rate	$38,586.86
Rate for Payer: Hawaii Medical Service Association Commercial	$38,586.86

O.R. PROCEDURES WITH DIAGNOSES OF OTHER CONTACT WITH HEALTH SERVICES WITHOUT CC/MCC

Facility

$38,586.86

Service Code	MSDRG 941
Min. Negotiated Rate	$38,586.86
Max. Negotiated Rate	$38,586.86
Rate for Payer: Hawaii Medical Service Association Commercial	$38,586.86

O.R. PROCEDURES WITH PRINCIPAL DIAGNOSIS OF MENTAL ILLNESS

Facility

$85,990.86

Service Code	MSDRG 876
Min. Negotiated Rate	$85,990.86
Max. Negotiated Rate	$85,990.86
Rate for Payer: Hawaii Medical Service Association Commercial	$85,990.86

OR:SURGICAL WOUND PROTECTOR LARGE

Facility

$316.00

Hospital Charge Code	12507048
Hospital Revenue Code	272
Min. Negotiated Rate	$158.00
Max. Negotiated Rate	$306.52
Rate for Payer: AlohaCare Medicaid	$158.00
Rate for Payer: AlohaCare Medicare	$158.00
Rate for Payer: Cash Price	$205.40
Rate for Payer: Devoted Health Medicare	$173.80
Rate for Payer: Hawaii Medical Service Association Medicare	$158.00
Rate for Payer: Hawaii Western Management Group Commercial	$300.20
Rate for Payer: Health Management Network Commercial	$268.60
Rate for Payer: Humana Medicare	$158.00
Rate for Payer: Kaiser Permanente Commercial	$284.40
Rate for Payer: Kaiser Permanente Medicaid	$161.16
Rate for Payer: Kaiser Permanente Medicare	$158.00
Rate for Payer: MDX Hawaii PPO	$306.52
Rate for Payer: Ohana Health Plan Medicaid	$158.00
Rate for Payer: Ohana Health Plan Medicare	$158.00
Rate for Payer: UnitedHealthcare Medicare	$158.00
Rate for Payer: University Health Alliance Commercial	$230.33

OR:SURGICAL WOUND PROTECTOR LARGE

Facility

$316.00

Hospital Charge Code	12507048
Hospital Revenue Code	272
Min. Negotiated Rate	$268.60
Max. Negotiated Rate	$306.52
Rate for Payer: Cash Price	$205.40
Rate for Payer: Health Management Network Commercial	$268.60
Rate for Payer: Kaiser Permanente Commercial	$284.40
Rate for Payer: MDX Hawaii PPO	$306.52

ORTHO 1.0 DRILL BIT/K-WIRE ATTACHMT THRD H/75

Facility

$952.00

Hospital Charge Code	9522334
Hospital Revenue Code	272
Min. Negotiated Rate	$476.00
Max. Negotiated Rate	$923.44
Rate for Payer: AlohaCare Medicaid	$476.00
Rate for Payer: AlohaCare Medicare	$476.00
Rate for Payer: Cash Price	$618.80
Rate for Payer: Devoted Health Medicare	$523.60
Rate for Payer: Hawaii Medical Service Association Medicare	$476.00
Rate for Payer: Hawaii Western Management Group Commercial	$904.40
Rate for Payer: Health Management Network Commercial	$809.20
Rate for Payer: Humana Medicare	$476.00
Rate for Payer: Kaiser Permanente Commercial	$856.80
Rate for Payer: Kaiser Permanente Medicaid	$485.52
Rate for Payer: Kaiser Permanente Medicare	$476.00
Rate for Payer: MDX Hawaii PPO	$923.44
Rate for Payer: Ohana Health Plan Medicaid	$476.00
Rate for Payer: Ohana Health Plan Medicare	$476.00
Rate for Payer: UnitedHealthcare Medicare	$476.00
Rate for Payer: University Health Alliance Commercial	$693.91

ORTHO 1.0 DRILL BIT/K-WIRE ATTACHMT THRD H/75

Facility

$952.00

Hospital Charge Code	9522334
Hospital Revenue Code	272
Min. Negotiated Rate	$809.20
Max. Negotiated Rate	$923.44
Rate for Payer: Cash Price	$618.80
Rate for Payer: Health Management Network Commercial	$809.20
Rate for Payer: Kaiser Permanente Commercial	$856.80
Rate for Payer: MDX Hawaii PPO	$923.44

ORTHO 1.0 DRILL BIT/MQC FOR THREADED HOLE/61

Facility

$675.00

Hospital Charge Code	9522335
Hospital Revenue Code	272
Min. Negotiated Rate	$573.75
Max. Negotiated Rate	$654.75
Rate for Payer: Cash Price	$438.75
Rate for Payer: Health Management Network Commercial	$573.75
Rate for Payer: Kaiser Permanente Commercial	$607.50
Rate for Payer: MDX Hawaii PPO	$654.75

ORTHO 1.0 DRILL BIT/MQC FOR THREADED HOLE/61

Facility

$675.00

Hospital Charge Code	9522335
Hospital Revenue Code	272
Min. Negotiated Rate	$337.50
Max. Negotiated Rate	$654.75
Rate for Payer: AlohaCare Medicaid	$337.50
Rate for Payer: AlohaCare Medicare	$337.50
Rate for Payer: Cash Price	$438.75
Rate for Payer: Devoted Health Medicare	$371.25
Rate for Payer: Hawaii Medical Service Association Medicare	$337.50
Rate for Payer: Hawaii Western Management Group Commercial	$641.25
Rate for Payer: Health Management Network Commercial	$573.75
Rate for Payer: Humana Medicare	$337.50
Rate for Payer: Kaiser Permanente Commercial	$607.50
Rate for Payer: Kaiser Permanente Medicaid	$344.25
Rate for Payer: Kaiser Permanente Medicare	$337.50
Rate for Payer: MDX Hawaii PPO	$654.75
Rate for Payer: Ohana Health Plan Medicaid	$337.50
Rate for Payer: Ohana Health Plan Medicare	$337.50
Rate for Payer: UnitedHealthcare Medicare	$337.50
Rate for Payer: University Health Alliance Commercial	$492.01

ORTHO 1.25MM K/WIRE W/TROCAR POINT 150MM

Facility

$668.00

Service Code	HCPCS C1713
Hospital Charge Code	9121744
Hospital Revenue Code	278
Min. Negotiated Rate	$374.08
Max. Negotiated Rate	$647.96
Rate for Payer: Cash Price	$434.20
Rate for Payer: Hawaii Western Management Group Commercial	$467.60
Rate for Payer: Health Management Network Commercial	$567.80
Rate for Payer: Kaiser Permanente Commercial	$601.20
Rate for Payer: MDX Hawaii PPO	$647.96
Rate for Payer: University Health Alliance Commercial	$374.08

ORTHO 1.25MM K/WIRE W/TROCAR POINT 150MM

Facility

$668.00

Service Code	HCPCS C1713
Hospital Charge Code	9121744
Hospital Revenue Code	278
Min. Negotiated Rate	$334.00
Max. Negotiated Rate	$647.96
Rate for Payer: AlohaCare Medicaid	$334.00
Rate for Payer: AlohaCare Medicare	$334.00
Rate for Payer: Cash Price	$434.20
Rate for Payer: Devoted Health Medicare	$367.40
Rate for Payer: Hawaii Medical Service Association Medicare	$334.00
Rate for Payer: Hawaii Western Management Group Commercial	$467.60
Rate for Payer: Health Management Network Commercial	$567.80
Rate for Payer: Humana Medicare	$334.00
Rate for Payer: Kaiser Permanente Commercial	$601.20
Rate for Payer: Kaiser Permanente Medicaid	$340.68
Rate for Payer: Kaiser Permanente Medicare	$334.00
Rate for Payer: MDX Hawaii PPO	$647.96
Rate for Payer: Ohana Health Plan Medicaid	$334.00
Rate for Payer: Ohana Health Plan Medicare	$334.00
Rate for Payer: UnitedHealthcare Medicare	$334.00
Rate for Payer: University Health Alliance Commercial	$374.08

ORTHO 1.2 LOCKING SRUT PL 8 HOLES-OBLIQUE-RIGHT

Facility

$2,508.00

Service Code	HCPCS C1713
Hospital Charge Code	9522333
Hospital Revenue Code	278
Min. Negotiated Rate	$1,254.00
Max. Negotiated Rate	$2,432.76
Rate for Payer: AlohaCare Medicaid	$1,254.00
Rate for Payer: AlohaCare Medicare	$1,254.00
Rate for Payer: Cash Price	$1,630.20
Rate for Payer: Devoted Health Medicare	$1,379.40
Rate for Payer: Hawaii Medical Service Association Medicare	$1,254.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,755.60
Rate for Payer: Health Management Network Commercial	$2,131.80
Rate for Payer: Humana Medicare	$1,254.00
Rate for Payer: Kaiser Permanente Commercial	$2,257.20
Rate for Payer: Kaiser Permanente Medicaid	$1,279.08
Rate for Payer: Kaiser Permanente Medicare	$1,254.00
Rate for Payer: MDX Hawaii PPO	$2,432.76
Rate for Payer: Ohana Health Plan Medicaid	$1,254.00
Rate for Payer: Ohana Health Plan Medicare	$1,254.00
Rate for Payer: UnitedHealthcare Medicare	$1,254.00
Rate for Payer: University Health Alliance Commercial	$1,404.48

ORTHO 1.2 LOCKING SRUT PL 8 HOLES-OBLIQUE-RIGHT

Facility

$2,508.00

Service Code	HCPCS C1713
Hospital Charge Code	9522333
Hospital Revenue Code	278
Min. Negotiated Rate	$1,404.48
Max. Negotiated Rate	$2,432.76
Rate for Payer: Cash Price	$1,630.20
Rate for Payer: Hawaii Western Management Group Commercial	$1,755.60
Rate for Payer: Health Management Network Commercial	$2,131.80
Rate for Payer: Kaiser Permanente Commercial	$2,257.20
Rate for Payer: MDX Hawaii PPO	$2,432.76
Rate for Payer: University Health Alliance Commercial	$1,404.48

ORTHO 1.3 CORTEX SCREW SLF-TPNG T4 SD REC 10

Facility

$388.00

Service Code	HCPCS C1713
Hospital Charge Code	9522323
Hospital Revenue Code	278
Min. Negotiated Rate	$217.28
Max. Negotiated Rate	$376.36
Rate for Payer: Cash Price	$252.20
Rate for Payer: Hawaii Western Management Group Commercial	$271.60
Rate for Payer: Health Management Network Commercial	$329.80
Rate for Payer: Kaiser Permanente Commercial	$349.20
Rate for Payer: MDX Hawaii PPO	$376.36
Rate for Payer: University Health Alliance Commercial	$217.28

ORTHO 1.3 CORTEX SCREW SLF-TPNG T4 SD REC 10

Facility

$388.00

Service Code	HCPCS C1713
Hospital Charge Code	9522323
Hospital Revenue Code	278
Min. Negotiated Rate	$194.00
Max. Negotiated Rate	$376.36
Rate for Payer: AlohaCare Medicaid	$194.00
Rate for Payer: AlohaCare Medicare	$194.00
Rate for Payer: Cash Price	$252.20
Rate for Payer: Devoted Health Medicare	$213.40
Rate for Payer: Hawaii Medical Service Association Medicare	$194.00
Rate for Payer: Hawaii Western Management Group Commercial	$271.60
Rate for Payer: Health Management Network Commercial	$329.80
Rate for Payer: Humana Medicare	$194.00
Rate for Payer: Kaiser Permanente Commercial	$349.20
Rate for Payer: Kaiser Permanente Medicaid	$197.88
Rate for Payer: Kaiser Permanente Medicare	$194.00
Rate for Payer: MDX Hawaii PPO	$376.36
Rate for Payer: Ohana Health Plan Medicaid	$194.00
Rate for Payer: Ohana Health Plan Medicare	$194.00
Rate for Payer: UnitedHealthcare Medicare	$194.00
Rate for Payer: University Health Alliance Commercial	$217.28

ORTHO 1.3 CORTEX SCREW SLF-TPNG T4 SD REC 11

Facility

$388.00

Service Code	HCPCS C1713
Hospital Charge Code	9522324
Hospital Revenue Code	278
Min. Negotiated Rate	$217.28
Max. Negotiated Rate	$376.36
Rate for Payer: Cash Price	$252.20
Rate for Payer: Hawaii Western Management Group Commercial	$271.60
Rate for Payer: Health Management Network Commercial	$329.80
Rate for Payer: Kaiser Permanente Commercial	$349.20
Rate for Payer: MDX Hawaii PPO	$376.36
Rate for Payer: University Health Alliance Commercial	$217.28

ORTHO 1.3 CORTEX SCREW SLF-TPNG T4 SD REC 11

Facility

$388.00

Service Code	HCPCS C1713
Hospital Charge Code	9522324
Hospital Revenue Code	278
Min. Negotiated Rate	$194.00
Max. Negotiated Rate	$376.36
Rate for Payer: AlohaCare Medicaid	$194.00
Rate for Payer: AlohaCare Medicare	$194.00
Rate for Payer: Cash Price	$252.20
Rate for Payer: Devoted Health Medicare	$213.40
Rate for Payer: Hawaii Medical Service Association Medicare	$194.00
Rate for Payer: Hawaii Western Management Group Commercial	$271.60
Rate for Payer: Health Management Network Commercial	$329.80
Rate for Payer: Humana Medicare	$194.00
Rate for Payer: Kaiser Permanente Commercial	$349.20
Rate for Payer: Kaiser Permanente Medicaid	$197.88
Rate for Payer: Kaiser Permanente Medicare	$194.00
Rate for Payer: MDX Hawaii PPO	$376.36
Rate for Payer: Ohana Health Plan Medicaid	$194.00
Rate for Payer: Ohana Health Plan Medicare	$194.00
Rate for Payer: UnitedHealthcare Medicare	$194.00
Rate for Payer: University Health Alliance Commercial	$217.28

ORTHO 1.3 CORTEX SCREW SLF-TPNG T4 SD REC 13

Facility

$388.00

Service Code	HCPCS C1713
Hospital Charge Code	9522322
Hospital Revenue Code	278
Min. Negotiated Rate	$194.00
Max. Negotiated Rate	$376.36
Rate for Payer: AlohaCare Medicaid	$194.00
Rate for Payer: AlohaCare Medicare	$194.00
Rate for Payer: Cash Price	$252.20
Rate for Payer: Devoted Health Medicare	$213.40
Rate for Payer: Hawaii Medical Service Association Medicare	$194.00
Rate for Payer: Hawaii Western Management Group Commercial	$271.60
Rate for Payer: Health Management Network Commercial	$329.80
Rate for Payer: Humana Medicare	$194.00
Rate for Payer: Kaiser Permanente Commercial	$349.20
Rate for Payer: Kaiser Permanente Medicaid	$197.88
Rate for Payer: Kaiser Permanente Medicare	$194.00
Rate for Payer: MDX Hawaii PPO	$376.36
Rate for Payer: Ohana Health Plan Medicaid	$194.00
Rate for Payer: Ohana Health Plan Medicare	$194.00
Rate for Payer: UnitedHealthcare Medicare	$194.00
Rate for Payer: University Health Alliance Commercial	$217.28

ORTHO 1.3 CORTEX SCREW SLF-TPNG T4 SD REC 13

Facility

$388.00

Service Code	HCPCS C1713
Hospital Charge Code	9522322
Hospital Revenue Code	278
Min. Negotiated Rate	$217.28
Max. Negotiated Rate	$376.36
Rate for Payer: Cash Price	$252.20
Rate for Payer: Hawaii Western Management Group Commercial	$271.60
Rate for Payer: Health Management Network Commercial	$329.80
Rate for Payer: Kaiser Permanente Commercial	$349.20
Rate for Payer: MDX Hawaii PPO	$376.36
Rate for Payer: University Health Alliance Commercial	$217.28

ORTHO 1.3 CORTEX SCREW SLF-TPNG T4 SD REC 7

Facility

$388.00

Service Code	HCPCS C1713
Hospital Charge Code	9522327
Hospital Revenue Code	278
Min. Negotiated Rate	$194.00
Max. Negotiated Rate	$376.36
Rate for Payer: AlohaCare Medicaid	$194.00
Rate for Payer: AlohaCare Medicare	$194.00
Rate for Payer: Cash Price	$252.20
Rate for Payer: Devoted Health Medicare	$213.40
Rate for Payer: Hawaii Medical Service Association Medicare	$194.00
Rate for Payer: Hawaii Western Management Group Commercial	$271.60
Rate for Payer: Health Management Network Commercial	$329.80
Rate for Payer: Humana Medicare	$194.00
Rate for Payer: Kaiser Permanente Commercial	$349.20
Rate for Payer: Kaiser Permanente Medicaid	$197.88
Rate for Payer: Kaiser Permanente Medicare	$194.00
Rate for Payer: MDX Hawaii PPO	$376.36
Rate for Payer: Ohana Health Plan Medicaid	$194.00
Rate for Payer: Ohana Health Plan Medicare	$194.00
Rate for Payer: UnitedHealthcare Medicare	$194.00
Rate for Payer: University Health Alliance Commercial	$217.28

ORTHO 1.3 CORTEX SCREW SLF-TPNG T4 SD REC 7

Facility

$388.00

Service Code	HCPCS C1713
Hospital Charge Code	9522327
Hospital Revenue Code	278
Min. Negotiated Rate	$217.28
Max. Negotiated Rate	$376.36
Rate for Payer: Cash Price	$252.20
Rate for Payer: Hawaii Western Management Group Commercial	$271.60
Rate for Payer: Health Management Network Commercial	$329.80
Rate for Payer: Kaiser Permanente Commercial	$349.20
Rate for Payer: MDX Hawaii PPO	$376.36
Rate for Payer: University Health Alliance Commercial	$217.28

ORTHO 1.3 CORTEX SCREW SLF-TPNG T4 SD REC 8

Facility

$388.00

Service Code	HCPCS C1713
Hospital Charge Code	9522326
Hospital Revenue Code	278
Min. Negotiated Rate	$194.00
Max. Negotiated Rate	$376.36
Rate for Payer: AlohaCare Medicaid	$194.00
Rate for Payer: AlohaCare Medicare	$194.00
Rate for Payer: Cash Price	$252.20
Rate for Payer: Devoted Health Medicare	$213.40
Rate for Payer: Hawaii Medical Service Association Medicare	$194.00
Rate for Payer: Hawaii Western Management Group Commercial	$271.60
Rate for Payer: Health Management Network Commercial	$329.80
Rate for Payer: Humana Medicare	$194.00
Rate for Payer: Kaiser Permanente Commercial	$349.20
Rate for Payer: Kaiser Permanente Medicaid	$197.88
Rate for Payer: Kaiser Permanente Medicare	$194.00
Rate for Payer: MDX Hawaii PPO	$376.36
Rate for Payer: Ohana Health Plan Medicaid	$194.00
Rate for Payer: Ohana Health Plan Medicare	$194.00
Rate for Payer: UnitedHealthcare Medicare	$194.00
Rate for Payer: University Health Alliance Commercial	$217.28

ORTHO 1.3 CORTEX SCREW SLF-TPNG T4 SD REC 8

Facility

$388.00

Service Code	HCPCS C1713
Hospital Charge Code	9522326
Hospital Revenue Code	278
Min. Negotiated Rate	$217.28
Max. Negotiated Rate	$376.36
Rate for Payer: Cash Price	$252.20
Rate for Payer: Hawaii Western Management Group Commercial	$271.60
Rate for Payer: Health Management Network Commercial	$329.80
Rate for Payer: Kaiser Permanente Commercial	$349.20
Rate for Payer: MDX Hawaii PPO	$376.36
Rate for Payer: University Health Alliance Commercial	$217.28

Know your out-of-pocket cost for care.

All Charges