Samuel Mahelona Memorial Hospital

All Charges

Charge

Type

Setting

Price

ORTHO 1.3 CORTEX SCREW SLF-TPNG T4 SD REC 9

Facility

$388.00

Service Code	HCPCS C1713
Hospital Charge Code	9522325
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 9

Facility

$388.00

Service Code	HCPCS C1713
Hospital Charge Code	9522325
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 LOCKING SCREW SLF-TPNG T4 SD RECESS 5

Facility

$803.00

Service Code	HCPCS C1713
Hospital Charge Code	9522332
Hospital Revenue Code	278
Min. Negotiated Rate	$401.50
Max. Negotiated Rate	$778.91
Rate for Payer: AlohaCare Medicaid	$401.50
Rate for Payer: AlohaCare Medicare	$401.50
Rate for Payer: Cash Price	$521.95
Rate for Payer: Devoted Health Medicare	$441.65
Rate for Payer: Hawaii Medical Service Association Medicare	$401.50
Rate for Payer: Hawaii Western Management Group Commercial	$562.10
Rate for Payer: Health Management Network Commercial	$682.55
Rate for Payer: Humana Medicare	$401.50
Rate for Payer: Kaiser Permanente Commercial	$722.70
Rate for Payer: Kaiser Permanente Medicaid	$409.53
Rate for Payer: Kaiser Permanente Medicare	$401.50
Rate for Payer: MDX Hawaii PPO	$778.91
Rate for Payer: Ohana Health Plan Medicaid	$401.50
Rate for Payer: Ohana Health Plan Medicare	$401.50
Rate for Payer: UnitedHealthcare Medicare	$401.50
Rate for Payer: University Health Alliance Commercial	$449.68

ORTHO 1.3 LOCKING SCREW SLF-TPNG T4 SD RECESS 5

Facility

$803.00

Service Code	HCPCS C1713
Hospital Charge Code	9522332
Hospital Revenue Code	278
Min. Negotiated Rate	$449.68
Max. Negotiated Rate	$778.91
Rate for Payer: Cash Price	$521.95
Rate for Payer: Hawaii Western Management Group Commercial	$562.10
Rate for Payer: Health Management Network Commercial	$682.55
Rate for Payer: Kaiser Permanente Commercial	$722.70
Rate for Payer: MDX Hawaii PPO	$778.91
Rate for Payer: University Health Alliance Commercial	$449.68

ORTHO 1.3 LOCKING SCREW SLF-TPNG T4 SD RECESS 6

Facility

$803.00

Service Code	HCPCS C1713
Hospital Charge Code	9522331
Hospital Revenue Code	278
Min. Negotiated Rate	$401.50
Max. Negotiated Rate	$778.91
Rate for Payer: AlohaCare Medicaid	$401.50
Rate for Payer: AlohaCare Medicare	$401.50
Rate for Payer: Cash Price	$521.95
Rate for Payer: Devoted Health Medicare	$441.65
Rate for Payer: Hawaii Medical Service Association Medicare	$401.50
Rate for Payer: Hawaii Western Management Group Commercial	$562.10
Rate for Payer: Health Management Network Commercial	$682.55
Rate for Payer: Humana Medicare	$401.50
Rate for Payer: Kaiser Permanente Commercial	$722.70
Rate for Payer: Kaiser Permanente Medicaid	$409.53
Rate for Payer: Kaiser Permanente Medicare	$401.50
Rate for Payer: MDX Hawaii PPO	$778.91
Rate for Payer: Ohana Health Plan Medicaid	$401.50
Rate for Payer: Ohana Health Plan Medicare	$401.50
Rate for Payer: UnitedHealthcare Medicare	$401.50
Rate for Payer: University Health Alliance Commercial	$449.68

ORTHO 1.3 LOCKING SCREW SLF-TPNG T4 SD RECESS 6

Facility

$803.00

Service Code	HCPCS C1713
Hospital Charge Code	9522331
Hospital Revenue Code	278
Min. Negotiated Rate	$449.68
Max. Negotiated Rate	$778.91
Rate for Payer: Cash Price	$521.95
Rate for Payer: Hawaii Western Management Group Commercial	$562.10
Rate for Payer: Health Management Network Commercial	$682.55
Rate for Payer: Kaiser Permanente Commercial	$722.70
Rate for Payer: MDX Hawaii PPO	$778.91
Rate for Payer: University Health Alliance Commercial	$449.68

ORTHO 1.3 LOCKING SCREW SLF-TPNG T4 SD RECESS 9

Facility

$803.00

Service Code	HCPCS C1713
Hospital Charge Code	9522330
Hospital Revenue Code	278
Min. Negotiated Rate	$449.68
Max. Negotiated Rate	$778.91
Rate for Payer: Cash Price	$521.95
Rate for Payer: Hawaii Western Management Group Commercial	$562.10
Rate for Payer: Health Management Network Commercial	$682.55
Rate for Payer: Kaiser Permanente Commercial	$722.70
Rate for Payer: MDX Hawaii PPO	$778.91
Rate for Payer: University Health Alliance Commercial	$449.68

ORTHO 1.3 LOCKING SCREW SLF-TPNG T4 SD RECESS 9

Facility

$803.00

Service Code	HCPCS C1713
Hospital Charge Code	9522330
Hospital Revenue Code	278
Min. Negotiated Rate	$401.50
Max. Negotiated Rate	$778.91
Rate for Payer: AlohaCare Medicaid	$401.50
Rate for Payer: AlohaCare Medicare	$401.50
Rate for Payer: Cash Price	$521.95
Rate for Payer: Devoted Health Medicare	$441.65
Rate for Payer: Hawaii Medical Service Association Medicare	$401.50
Rate for Payer: Hawaii Western Management Group Commercial	$562.10
Rate for Payer: Health Management Network Commercial	$682.55
Rate for Payer: Humana Medicare	$401.50
Rate for Payer: Kaiser Permanente Commercial	$722.70
Rate for Payer: Kaiser Permanente Medicaid	$409.53
Rate for Payer: Kaiser Permanente Medicare	$401.50
Rate for Payer: MDX Hawaii PPO	$778.91
Rate for Payer: Ohana Health Plan Medicaid	$401.50
Rate for Payer: Ohana Health Plan Medicare	$401.50
Rate for Payer: UnitedHealthcare Medicare	$401.50
Rate for Payer: University Health Alliance Commercial	$449.68

ORTHO 1.5 CORTEX SREW SLF-TPNG T4 SD REC 10

Facility

$447.00

Service Code	HCPCS C1713
Hospital Charge Code	9522329
Hospital Revenue Code	278
Min. Negotiated Rate	$250.32
Max. Negotiated Rate	$433.59
Rate for Payer: Cash Price	$290.55
Rate for Payer: Hawaii Western Management Group Commercial	$312.90
Rate for Payer: Health Management Network Commercial	$379.95
Rate for Payer: Kaiser Permanente Commercial	$402.30
Rate for Payer: MDX Hawaii PPO	$433.59
Rate for Payer: University Health Alliance Commercial	$250.32

ORTHO 1.5 CORTEX SREW SLF-TPNG T4 SD REC 10

Facility

$447.00

Service Code	HCPCS C1713
Hospital Charge Code	9522329
Hospital Revenue Code	278
Min. Negotiated Rate	$223.50
Max. Negotiated Rate	$433.59
Rate for Payer: Kaiser Permanente Medicare	$223.50
Rate for Payer: AlohaCare Medicaid	$223.50
Rate for Payer: AlohaCare Medicare	$223.50
Rate for Payer: Cash Price	$290.55
Rate for Payer: Devoted Health Medicare	$245.85
Rate for Payer: Hawaii Medical Service Association Medicare	$223.50
Rate for Payer: Hawaii Western Management Group Commercial	$312.90
Rate for Payer: Health Management Network Commercial	$379.95
Rate for Payer: Humana Medicare	$223.50
Rate for Payer: Kaiser Permanente Commercial	$402.30
Rate for Payer: Kaiser Permanente Medicaid	$227.97
Rate for Payer: MDX Hawaii PPO	$433.59
Rate for Payer: Ohana Health Plan Medicaid	$223.50
Rate for Payer: Ohana Health Plan Medicare	$223.50
Rate for Payer: UnitedHealthcare Medicare	$223.50
Rate for Payer: University Health Alliance Commercial	$250.32

ORTHO 1.5MM VAL CONDYLAR PLATE 2 HOLES HD-6 HOLES SHAFT

Facility

$2,928.00

Service Code	HCPCS C1713
Hospital Charge Code	9121745
Hospital Revenue Code	278
Min. Negotiated Rate	$1,464.00
Max. Negotiated Rate	$2,840.16
Rate for Payer: AlohaCare Medicaid	$1,464.00
Rate for Payer: AlohaCare Medicare	$1,464.00
Rate for Payer: Cash Price	$1,903.20
Rate for Payer: Devoted Health Medicare	$1,610.40
Rate for Payer: Hawaii Medical Service Association Medicare	$1,464.00
Rate for Payer: Hawaii Western Management Group Commercial	$2,049.60
Rate for Payer: Health Management Network Commercial	$2,488.80
Rate for Payer: Humana Medicare	$1,464.00
Rate for Payer: Kaiser Permanente Commercial	$2,635.20
Rate for Payer: Kaiser Permanente Medicaid	$1,493.28
Rate for Payer: Kaiser Permanente Medicare	$1,464.00
Rate for Payer: MDX Hawaii PPO	$2,840.16
Rate for Payer: Ohana Health Plan Medicaid	$1,464.00
Rate for Payer: Ohana Health Plan Medicare	$1,464.00
Rate for Payer: UnitedHealthcare Medicare	$1,464.00
Rate for Payer: University Health Alliance Commercial	$1,639.68

ORTHO 1.5MM VAL CONDYLAR PLATE 2 HOLES HD-6 HOLES SHAFT

Facility

$2,928.00

Service Code	HCPCS C1713
Hospital Charge Code	9121745
Hospital Revenue Code	278
Min. Negotiated Rate	$1,639.68
Max. Negotiated Rate	$2,840.16
Rate for Payer: Cash Price	$1,903.20
Rate for Payer: Hawaii Western Management Group Commercial	$2,049.60
Rate for Payer: Health Management Network Commercial	$2,488.80
Rate for Payer: Kaiser Permanente Commercial	$2,635.20
Rate for Payer: MDX Hawaii PPO	$2,840.16
Rate for Payer: University Health Alliance Commercial	$1,639.68

ORTHO: 2.0MM DRILL BIT/QC/125MM

Facility

$612.00

Hospital Charge Code	9595029
Hospital Revenue Code	272
Min. Negotiated Rate	$520.20
Max. Negotiated Rate	$593.64
Rate for Payer: Cash Price	$397.80
Rate for Payer: Health Management Network Commercial	$520.20
Rate for Payer: Kaiser Permanente Commercial	$550.80
Rate for Payer: MDX Hawaii PPO	$593.64

ORTHO: 2.0MM DRILL BIT/QC/125MM

Facility

$612.00

Hospital Charge Code	9595029
Hospital Revenue Code	272
Min. Negotiated Rate	$306.00
Max. Negotiated Rate	$593.64
Rate for Payer: AlohaCare Medicaid	$306.00
Rate for Payer: AlohaCare Medicare	$306.00
Rate for Payer: Cash Price	$397.80
Rate for Payer: Devoted Health Medicare	$336.60
Rate for Payer: Hawaii Medical Service Association Medicare	$306.00
Rate for Payer: Hawaii Western Management Group Commercial	$581.40
Rate for Payer: Health Management Network Commercial	$520.20
Rate for Payer: Humana Medicare	$306.00
Rate for Payer: Kaiser Permanente Commercial	$550.80
Rate for Payer: Kaiser Permanente Medicaid	$312.12
Rate for Payer: Kaiser Permanente Medicare	$306.00
Rate for Payer: MDX Hawaii PPO	$593.64
Rate for Payer: Ohana Health Plan Medicaid	$306.00
Rate for Payer: Ohana Health Plan Medicare	$306.00
Rate for Payer: UnitedHealthcare Medicare	$306.00
Rate for Payer: University Health Alliance Commercial	$446.09

ORTHO: 2.5MM DRILL BIT/QC/GOLD/110MM

Facility

$540.00

Hospital Charge Code	9595028
Hospital Revenue Code	272
Min. Negotiated Rate	$270.00
Max. Negotiated Rate	$523.80
Rate for Payer: Ohana Health Plan Medicare	$270.00
Rate for Payer: AlohaCare Medicaid	$270.00
Rate for Payer: AlohaCare Medicare	$270.00
Rate for Payer: Cash Price	$351.00
Rate for Payer: Devoted Health Medicare	$297.00
Rate for Payer: Hawaii Medical Service Association Medicare	$270.00
Rate for Payer: Hawaii Western Management Group Commercial	$513.00
Rate for Payer: Health Management Network Commercial	$459.00
Rate for Payer: Humana Medicare	$270.00
Rate for Payer: Kaiser Permanente Commercial	$486.00
Rate for Payer: Kaiser Permanente Medicaid	$275.40
Rate for Payer: Kaiser Permanente Medicare	$270.00
Rate for Payer: MDX Hawaii PPO	$523.80
Rate for Payer: Ohana Health Plan Medicaid	$270.00
Rate for Payer: UnitedHealthcare Medicare	$270.00
Rate for Payer: University Health Alliance Commercial	$393.61

ORTHO: 2.5MM DRILL BIT/QC/GOLD/110MM

Facility

$540.00

Hospital Charge Code	9595028
Hospital Revenue Code	272
Min. Negotiated Rate	$459.00
Max. Negotiated Rate	$523.80
Rate for Payer: Cash Price	$351.00
Rate for Payer: Health Management Network Commercial	$459.00
Rate for Payer: Kaiser Permanente Commercial	$486.00
Rate for Payer: MDX Hawaii PPO	$523.80

ORTHO: 2.7MM CORTEX SCCREW SELF TAPPING 26MM

Facility

$380.00

Service Code	HCPCS C1713
Hospital Charge Code	9595026
Hospital Revenue Code	278
Min. Negotiated Rate	$212.80
Max. Negotiated Rate	$368.60
Rate for Payer: Cash Price	$247.00
Rate for Payer: Hawaii Western Management Group Commercial	$266.00
Rate for Payer: Health Management Network Commercial	$323.00
Rate for Payer: Kaiser Permanente Commercial	$342.00
Rate for Payer: MDX Hawaii PPO	$368.60
Rate for Payer: University Health Alliance Commercial	$212.80

ORTHO: 2.7MM CORTEX SCCREW SELF TAPPING 26MM

Facility

$380.00

Service Code	HCPCS C1713
Hospital Charge Code	9595026
Hospital Revenue Code	278
Min. Negotiated Rate	$190.00
Max. Negotiated Rate	$368.60
Rate for Payer: AlohaCare Medicaid	$190.00
Rate for Payer: AlohaCare Medicare	$190.00
Rate for Payer: Cash Price	$247.00
Rate for Payer: Devoted Health Medicare	$209.00
Rate for Payer: Hawaii Medical Service Association Medicare	$190.00
Rate for Payer: Hawaii Western Management Group Commercial	$266.00
Rate for Payer: Health Management Network Commercial	$323.00
Rate for Payer: Humana Medicare	$190.00
Rate for Payer: Kaiser Permanente Commercial	$342.00
Rate for Payer: Kaiser Permanente Medicaid	$193.80
Rate for Payer: Kaiser Permanente Medicare	$190.00
Rate for Payer: MDX Hawaii PPO	$368.60
Rate for Payer: Ohana Health Plan Medicaid	$190.00
Rate for Payer: Ohana Health Plan Medicare	$190.00
Rate for Payer: UnitedHealthcare Medicare	$190.00
Rate for Payer: University Health Alliance Commercial	$212.80

ORTHO: 2.7MM THREE FLUTED DRILL BIT QC/125MM

Facility

$863.00

Hospital Charge Code	9595030
Hospital Revenue Code	272
Min. Negotiated Rate	$431.50
Max. Negotiated Rate	$837.11
Rate for Payer: AlohaCare Medicaid	$431.50
Rate for Payer: AlohaCare Medicare	$431.50
Rate for Payer: Cash Price	$560.95
Rate for Payer: Devoted Health Medicare	$474.65
Rate for Payer: Hawaii Medical Service Association Medicare	$431.50
Rate for Payer: Hawaii Western Management Group Commercial	$819.85
Rate for Payer: Health Management Network Commercial	$733.55
Rate for Payer: Humana Medicare	$431.50
Rate for Payer: Kaiser Permanente Commercial	$776.70
Rate for Payer: Kaiser Permanente Medicaid	$440.13
Rate for Payer: Kaiser Permanente Medicare	$431.50
Rate for Payer: MDX Hawaii PPO	$837.11
Rate for Payer: Ohana Health Plan Medicaid	$431.50
Rate for Payer: Ohana Health Plan Medicare	$431.50
Rate for Payer: UnitedHealthcare Medicare	$431.50
Rate for Payer: University Health Alliance Commercial	$629.04

ORTHO: 2.7MM THREE FLUTED DRILL BIT QC/125MM

Facility

$863.00

Hospital Charge Code	9595030
Hospital Revenue Code	272
Min. Negotiated Rate	$733.55
Max. Negotiated Rate	$837.11
Rate for Payer: Cash Price	$560.95
Rate for Payer: Health Management Network Commercial	$733.55
Rate for Payer: Kaiser Permanente Commercial	$776.70
Rate for Payer: MDX Hawaii PPO	$837.11

ORTHO: 3.5MM CORTEX SCREW SELF TAPPING 12MM

Facility

$256.00

Service Code	HCPCS C1713
Hospital Charge Code	9595024
Hospital Revenue Code	278
Min. Negotiated Rate	$128.00
Max. Negotiated Rate	$248.32
Rate for Payer: AlohaCare Medicaid	$128.00
Rate for Payer: AlohaCare Medicare	$128.00
Rate for Payer: Cash Price	$166.40
Rate for Payer: Devoted Health Medicare	$140.80
Rate for Payer: Hawaii Medical Service Association Medicare	$128.00
Rate for Payer: Hawaii Western Management Group Commercial	$179.20
Rate for Payer: Health Management Network Commercial	$217.60
Rate for Payer: Humana Medicare	$128.00
Rate for Payer: Kaiser Permanente Commercial	$230.40
Rate for Payer: Kaiser Permanente Medicaid	$130.56
Rate for Payer: Kaiser Permanente Medicare	$128.00
Rate for Payer: MDX Hawaii PPO	$248.32
Rate for Payer: Ohana Health Plan Medicaid	$128.00
Rate for Payer: Ohana Health Plan Medicare	$128.00
Rate for Payer: UnitedHealthcare Medicare	$128.00
Rate for Payer: University Health Alliance Commercial	$143.36

ORTHO: 3.5MM CORTEX SCREW SELF TAPPING 12MM

Facility

$256.00

Service Code	HCPCS C1713
Hospital Charge Code	9595024
Hospital Revenue Code	278
Min. Negotiated Rate	$143.36
Max. Negotiated Rate	$248.32
Rate for Payer: Cash Price	$166.40
Rate for Payer: Hawaii Western Management Group Commercial	$179.20
Rate for Payer: Health Management Network Commercial	$217.60
Rate for Payer: Kaiser Permanente Commercial	$230.40
Rate for Payer: MDX Hawaii PPO	$248.32
Rate for Payer: University Health Alliance Commercial	$143.36

ORTHO: 3.5MM CORTEX SCREW SELF TAPPING 14MM

Facility

$256.00

Service Code	HCPCS C1713
Hospital Charge Code	9595025
Hospital Revenue Code	278
Min. Negotiated Rate	$143.36
Max. Negotiated Rate	$248.32
Rate for Payer: Cash Price	$166.40
Rate for Payer: Hawaii Western Management Group Commercial	$179.20
Rate for Payer: Health Management Network Commercial	$217.60
Rate for Payer: Kaiser Permanente Commercial	$230.40
Rate for Payer: MDX Hawaii PPO	$248.32
Rate for Payer: University Health Alliance Commercial	$143.36

ORTHO: 3.5MM CORTEX SCREW SELF TAPPING 14MM

Facility

$256.00

Service Code	HCPCS C1713
Hospital Charge Code	9595025
Hospital Revenue Code	278
Min. Negotiated Rate	$128.00
Max. Negotiated Rate	$248.32
Rate for Payer: AlohaCare Medicaid	$128.00
Rate for Payer: AlohaCare Medicare	$128.00
Rate for Payer: Cash Price	$166.40
Rate for Payer: Devoted Health Medicare	$140.80
Rate for Payer: Hawaii Medical Service Association Medicare	$128.00
Rate for Payer: Hawaii Western Management Group Commercial	$179.20
Rate for Payer: Health Management Network Commercial	$217.60
Rate for Payer: Humana Medicare	$128.00
Rate for Payer: Kaiser Permanente Commercial	$230.40
Rate for Payer: Kaiser Permanente Medicaid	$130.56
Rate for Payer: Kaiser Permanente Medicare	$128.00
Rate for Payer: MDX Hawaii PPO	$248.32
Rate for Payer: Ohana Health Plan Medicaid	$128.00
Rate for Payer: Ohana Health Plan Medicare	$128.00
Rate for Payer: UnitedHealthcare Medicare	$128.00
Rate for Payer: University Health Alliance Commercial	$143.36

ORTHO 4.0 ACROMIONZER BURR

Facility

$232.00

Hospital Charge Code	8336023
Hospital Revenue Code	272
Min. Negotiated Rate	$116.00
Max. Negotiated Rate	$225.04
Rate for Payer: AlohaCare Medicaid	$116.00
Rate for Payer: AlohaCare Medicare	$116.00
Rate for Payer: Cash Price	$150.80
Rate for Payer: Devoted Health Medicare	$127.60
Rate for Payer: Hawaii Medical Service Association Medicare	$116.00
Rate for Payer: Hawaii Western Management Group Commercial	$220.40
Rate for Payer: Health Management Network Commercial	$197.20
Rate for Payer: Humana Medicare	$116.00
Rate for Payer: Kaiser Permanente Commercial	$208.80
Rate for Payer: Kaiser Permanente Medicaid	$118.32
Rate for Payer: Kaiser Permanente Medicare	$116.00
Rate for Payer: MDX Hawaii PPO	$225.04
Rate for Payer: Ohana Health Plan Medicaid	$116.00
Rate for Payer: Ohana Health Plan Medicare	$116.00
Rate for Payer: UnitedHealthcare Medicare	$116.00
Rate for Payer: University Health Alliance Commercial	$169.10

Know your out-of-pocket cost for care.

All Charges