Samuel Mahelona Memorial Hospital

All Charges

Charge

Type

Setting

Price

ORTHO 4.0 ACROMIONZER BURR

Facility

$232.00

Hospital Charge Code	8336023
Hospital Revenue Code	272
Min. Negotiated Rate	$197.20
Max. Negotiated Rate	$225.04
Rate for Payer: Cash Price	$150.80
Rate for Payer: Health Management Network Commercial	$197.20
Rate for Payer: Kaiser Permanente Commercial	$208.80
Rate for Payer: MDX Hawaii PPO	$225.04

ORTHO 4.5 INCISOR PLUS

Facility

$107.00

Hospital Charge Code	8336028
Hospital Revenue Code	272
Min. Negotiated Rate	$53.50
Max. Negotiated Rate	$103.79
Rate for Payer: AlohaCare Medicaid	$53.50
Rate for Payer: AlohaCare Medicare	$53.50
Rate for Payer: Cash Price	$69.55
Rate for Payer: Devoted Health Medicare	$58.85
Rate for Payer: Hawaii Medical Service Association Medicare	$53.50
Rate for Payer: Hawaii Western Management Group Commercial	$101.65
Rate for Payer: Health Management Network Commercial	$90.95
Rate for Payer: Humana Medicare	$53.50
Rate for Payer: Kaiser Permanente Commercial	$96.30
Rate for Payer: Kaiser Permanente Medicaid	$54.57
Rate for Payer: Kaiser Permanente Medicare	$53.50
Rate for Payer: MDX Hawaii PPO	$103.79
Rate for Payer: Ohana Health Plan Medicaid	$53.50
Rate for Payer: Ohana Health Plan Medicare	$53.50
Rate for Payer: UnitedHealthcare Medicare	$53.50
Rate for Payer: University Health Alliance Commercial	$77.99

ORTHO 4.5 INCISOR PLUS

Facility

$107.00

Hospital Charge Code	8336028
Hospital Revenue Code	272
Min. Negotiated Rate	$90.95
Max. Negotiated Rate	$103.79
Rate for Payer: Cash Price	$69.55
Rate for Payer: Health Management Network Commercial	$90.95
Rate for Payer: Kaiser Permanente Commercial	$96.30
Rate for Payer: MDX Hawaii PPO	$103.79

ORTHO, 50-S SWEEP SERFAS

Facility

$1,269.00

Hospital Charge Code	8528413
Hospital Revenue Code	272
Min. Negotiated Rate	$634.50
Max. Negotiated Rate	$1,230.93
Rate for Payer: AlohaCare Medicaid	$634.50
Rate for Payer: AlohaCare Medicare	$634.50
Rate for Payer: Cash Price	$824.85
Rate for Payer: Devoted Health Medicare	$697.95
Rate for Payer: Hawaii Medical Service Association Medicare	$634.50
Rate for Payer: Hawaii Western Management Group Commercial	$1,205.55
Rate for Payer: Health Management Network Commercial	$1,078.65
Rate for Payer: Humana Medicare	$634.50
Rate for Payer: Kaiser Permanente Commercial	$1,142.10
Rate for Payer: Kaiser Permanente Medicaid	$647.19
Rate for Payer: Kaiser Permanente Medicare	$634.50
Rate for Payer: MDX Hawaii PPO	$1,230.93
Rate for Payer: Ohana Health Plan Medicaid	$634.50
Rate for Payer: Ohana Health Plan Medicare	$634.50
Rate for Payer: UnitedHealthcare Medicare	$634.50
Rate for Payer: University Health Alliance Commercial	$924.97

ORTHO, 50-S SWEEP SERFAS

Facility

$1,269.00

Hospital Charge Code	8528413
Hospital Revenue Code	272
Min. Negotiated Rate	$1,078.65
Max. Negotiated Rate	$1,230.93
Rate for Payer: Cash Price	$824.85
Rate for Payer: Health Management Network Commercial	$1,078.65
Rate for Payer: Kaiser Permanente Commercial	$1,142.10
Rate for Payer: MDX Hawaii PPO	$1,230.93

ORTHO, 90-S CRUISE SUCTION PROBE

Facility

$751.00

Hospital Charge Code	8528414
Hospital Revenue Code	272
Min. Negotiated Rate	$638.35
Max. Negotiated Rate	$728.47
Rate for Payer: Cash Price	$488.15
Rate for Payer: Health Management Network Commercial	$638.35
Rate for Payer: Kaiser Permanente Commercial	$675.90
Rate for Payer: MDX Hawaii PPO	$728.47

ORTHO, 90-S CRUISE SUCTION PROBE

Facility

$751.00

Hospital Charge Code	8528414
Hospital Revenue Code	272
Min. Negotiated Rate	$375.50
Max. Negotiated Rate	$728.47
Rate for Payer: AlohaCare Medicaid	$375.50
Rate for Payer: AlohaCare Medicare	$375.50
Rate for Payer: Cash Price	$488.15
Rate for Payer: Devoted Health Medicare	$413.05
Rate for Payer: Hawaii Medical Service Association Medicare	$375.50
Rate for Payer: Hawaii Western Management Group Commercial	$713.45
Rate for Payer: Health Management Network Commercial	$638.35
Rate for Payer: Humana Medicare	$375.50
Rate for Payer: Kaiser Permanente Commercial	$675.90
Rate for Payer: Kaiser Permanente Medicaid	$383.01
Rate for Payer: Kaiser Permanente Medicare	$375.50
Rate for Payer: MDX Hawaii PPO	$728.47
Rate for Payer: Ohana Health Plan Medicaid	$375.50
Rate for Payer: Ohana Health Plan Medicare	$375.50
Rate for Payer: UnitedHealthcare Medicare	$375.50
Rate for Payer: University Health Alliance Commercial	$547.40

ORTHO ACCU PASS SHUTTLE 45 DEGREE LEFT

Facility

$492.00

Hospital Charge Code	8336024
Hospital Revenue Code	272
Min. Negotiated Rate	$246.00
Max. Negotiated Rate	$477.24
Rate for Payer: AlohaCare Medicaid	$246.00
Rate for Payer: AlohaCare Medicare	$246.00
Rate for Payer: Cash Price	$319.80
Rate for Payer: Devoted Health Medicare	$270.60
Rate for Payer: Hawaii Medical Service Association Medicare	$246.00
Rate for Payer: Hawaii Western Management Group Commercial	$467.40
Rate for Payer: Health Management Network Commercial	$418.20
Rate for Payer: Humana Medicare	$246.00
Rate for Payer: Kaiser Permanente Commercial	$442.80
Rate for Payer: Kaiser Permanente Medicaid	$250.92
Rate for Payer: Kaiser Permanente Medicare	$246.00
Rate for Payer: MDX Hawaii PPO	$477.24
Rate for Payer: Ohana Health Plan Medicaid	$246.00
Rate for Payer: Ohana Health Plan Medicare	$246.00
Rate for Payer: UnitedHealthcare Medicare	$246.00
Rate for Payer: University Health Alliance Commercial	$358.62

ORTHO ACCU PASS SHUTTLE 45 DEGREE LEFT

Facility

$492.00

Hospital Charge Code	8336024
Hospital Revenue Code	272
Min. Negotiated Rate	$418.20
Max. Negotiated Rate	$477.24
Rate for Payer: Cash Price	$319.80
Rate for Payer: Health Management Network Commercial	$418.20
Rate for Payer: Kaiser Permanente Commercial	$442.80
Rate for Payer: MDX Hawaii PPO	$477.24

ORTHO ACCU PASS SHUTTLE 45 DEGREE RIGHT

Facility

$492.00

Hospital Charge Code	8336025
Hospital Revenue Code	272
Min. Negotiated Rate	$418.20
Max. Negotiated Rate	$477.24
Rate for Payer: Cash Price	$319.80
Rate for Payer: Health Management Network Commercial	$418.20
Rate for Payer: Kaiser Permanente Commercial	$442.80
Rate for Payer: MDX Hawaii PPO	$477.24

ORTHO ACCU PASS SHUTTLE 45 DEGREE RIGHT

Facility

$492.00

Hospital Charge Code	8336025
Hospital Revenue Code	272
Min. Negotiated Rate	$246.00
Max. Negotiated Rate	$477.24
Rate for Payer: AlohaCare Medicaid	$246.00
Rate for Payer: AlohaCare Medicare	$246.00
Rate for Payer: Cash Price	$319.80
Rate for Payer: Devoted Health Medicare	$270.60
Rate for Payer: Hawaii Medical Service Association Medicare	$246.00
Rate for Payer: Hawaii Western Management Group Commercial	$467.40
Rate for Payer: Health Management Network Commercial	$418.20
Rate for Payer: Humana Medicare	$246.00
Rate for Payer: Kaiser Permanente Commercial	$442.80
Rate for Payer: Kaiser Permanente Medicaid	$250.92
Rate for Payer: Kaiser Permanente Medicare	$246.00
Rate for Payer: MDX Hawaii PPO	$477.24
Rate for Payer: Ohana Health Plan Medicaid	$246.00
Rate for Payer: Ohana Health Plan Medicare	$246.00
Rate for Payer: UnitedHealthcare Medicare	$246.00
Rate for Payer: University Health Alliance Commercial	$358.62

ORTHO AMBIENT TURBOVAC 90

Facility

$1,054.00

Hospital Charge Code	8336030
Hospital Revenue Code	272
Min. Negotiated Rate	$527.00
Max. Negotiated Rate	$1,022.38
Rate for Payer: AlohaCare Medicaid	$527.00
Rate for Payer: AlohaCare Medicare	$527.00
Rate for Payer: Cash Price	$685.10
Rate for Payer: Devoted Health Medicare	$579.70
Rate for Payer: Hawaii Medical Service Association Medicare	$527.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,001.30
Rate for Payer: Health Management Network Commercial	$895.90
Rate for Payer: Humana Medicare	$527.00
Rate for Payer: Kaiser Permanente Commercial	$948.60
Rate for Payer: Kaiser Permanente Medicaid	$537.54
Rate for Payer: Kaiser Permanente Medicare	$527.00
Rate for Payer: MDX Hawaii PPO	$1,022.38
Rate for Payer: Ohana Health Plan Medicaid	$527.00
Rate for Payer: Ohana Health Plan Medicare	$527.00
Rate for Payer: UnitedHealthcare Medicare	$527.00
Rate for Payer: University Health Alliance Commercial	$768.26

ORTHO AMBIENT TURBOVAC 90

Facility

$1,054.00

Hospital Charge Code	8336030
Hospital Revenue Code	272
Min. Negotiated Rate	$895.90
Max. Negotiated Rate	$1,022.38
Rate for Payer: Cash Price	$685.10
Rate for Payer: Health Management Network Commercial	$895.90
Rate for Payer: Kaiser Permanente Commercial	$948.60
Rate for Payer: MDX Hawaii PPO	$1,022.38

ORTHO: ARTHREX FIBERWIRE #2 AR-7200 SUTURE

Facility

$132.00

Hospital Charge Code	9335983
Hospital Revenue Code	272
Min. Negotiated Rate	$66.00
Max. Negotiated Rate	$128.04
Rate for Payer: AlohaCare Medicaid	$66.00
Rate for Payer: AlohaCare Medicare	$66.00
Rate for Payer: Cash Price	$85.80
Rate for Payer: Devoted Health Medicare	$72.60
Rate for Payer: Hawaii Medical Service Association Medicare	$66.00
Rate for Payer: Hawaii Western Management Group Commercial	$125.40
Rate for Payer: Health Management Network Commercial	$112.20
Rate for Payer: Humana Medicare	$66.00
Rate for Payer: Kaiser Permanente Commercial	$118.80
Rate for Payer: Kaiser Permanente Medicaid	$67.32
Rate for Payer: Kaiser Permanente Medicare	$66.00
Rate for Payer: MDX Hawaii PPO	$128.04
Rate for Payer: Ohana Health Plan Medicaid	$66.00
Rate for Payer: Ohana Health Plan Medicare	$66.00
Rate for Payer: UnitedHealthcare Medicare	$66.00
Rate for Payer: University Health Alliance Commercial	$96.21

ORTHO: ARTHREX FIBERWIRE #2 AR-7200 SUTURE

Facility

$132.00

Hospital Charge Code	9335983
Hospital Revenue Code	272
Min. Negotiated Rate	$112.20
Max. Negotiated Rate	$128.04
Rate for Payer: Cash Price	$85.80
Rate for Payer: Health Management Network Commercial	$112.20
Rate for Payer: Kaiser Permanente Commercial	$118.80
Rate for Payer: MDX Hawaii PPO	$128.04

ORTHO AWL TAPERED 3.8 MM DISP

Facility

$198.00

Hospital Charge Code	8336043
Hospital Revenue Code	272
Min. Negotiated Rate	$99.00
Max. Negotiated Rate	$192.06
Rate for Payer: AlohaCare Medicaid	$99.00
Rate for Payer: AlohaCare Medicare	$99.00
Rate for Payer: Cash Price	$128.70
Rate for Payer: Devoted Health Medicare	$108.90
Rate for Payer: Hawaii Medical Service Association Medicare	$99.00
Rate for Payer: Hawaii Western Management Group Commercial	$188.10
Rate for Payer: Health Management Network Commercial	$168.30
Rate for Payer: Humana Medicare	$99.00
Rate for Payer: Kaiser Permanente Commercial	$178.20
Rate for Payer: Kaiser Permanente Medicaid	$100.98
Rate for Payer: Kaiser Permanente Medicare	$99.00
Rate for Payer: MDX Hawaii PPO	$192.06
Rate for Payer: Ohana Health Plan Medicaid	$99.00
Rate for Payer: Ohana Health Plan Medicare	$99.00
Rate for Payer: UnitedHealthcare Medicare	$99.00
Rate for Payer: University Health Alliance Commercial	$144.32

ORTHO AWL TAPERED 3.8 MM DISP

Facility

$198.00

Hospital Charge Code	8336043
Hospital Revenue Code	272
Min. Negotiated Rate	$168.30
Max. Negotiated Rate	$192.06
Rate for Payer: Cash Price	$128.70
Rate for Payer: Health Management Network Commercial	$168.30
Rate for Payer: Kaiser Permanente Commercial	$178.20
Rate for Payer: MDX Hawaii PPO	$192.06

ORTHO, BARREL BUR 12 FLUTE 5.0MM

Facility

$237.00

Hospital Charge Code	8585243
Hospital Revenue Code	272
Min. Negotiated Rate	$118.50
Max. Negotiated Rate	$229.89
Rate for Payer: AlohaCare Medicaid	$118.50
Rate for Payer: AlohaCare Medicare	$118.50
Rate for Payer: Cash Price	$154.05
Rate for Payer: Devoted Health Medicare	$130.35
Rate for Payer: Hawaii Medical Service Association Medicare	$118.50
Rate for Payer: Hawaii Western Management Group Commercial	$225.15
Rate for Payer: Health Management Network Commercial	$201.45
Rate for Payer: Humana Medicare	$118.50
Rate for Payer: Kaiser Permanente Commercial	$213.30
Rate for Payer: Kaiser Permanente Medicaid	$120.87
Rate for Payer: Kaiser Permanente Medicare	$118.50
Rate for Payer: MDX Hawaii PPO	$229.89
Rate for Payer: Ohana Health Plan Medicaid	$118.50
Rate for Payer: Ohana Health Plan Medicare	$118.50
Rate for Payer: UnitedHealthcare Medicare	$118.50
Rate for Payer: University Health Alliance Commercial	$172.75

ORTHO, BARREL BUR 12 FLUTE 5.0MM

Facility

$237.00

Hospital Charge Code	8585243
Hospital Revenue Code	272
Min. Negotiated Rate	$201.45
Max. Negotiated Rate	$229.89
Rate for Payer: Cash Price	$154.05
Rate for Payer: Health Management Network Commercial	$201.45
Rate for Payer: Kaiser Permanente Commercial	$213.30
Rate for Payer: MDX Hawaii PPO	$229.89

ORTHO, BIOCOMP-TENO SWIVELOCK 6.25 X 15 VES

Facility

$1,737.00

Service Code	HCPCS C1713
Hospital Charge Code	8743131
Hospital Revenue Code	278
Min. Negotiated Rate	$972.72
Max. Negotiated Rate	$1,684.89
Rate for Payer: Cash Price	$1,129.05
Rate for Payer: Hawaii Western Management Group Commercial	$1,215.90
Rate for Payer: Health Management Network Commercial	$1,476.45
Rate for Payer: Kaiser Permanente Commercial	$1,563.30
Rate for Payer: MDX Hawaii PPO	$1,684.89
Rate for Payer: University Health Alliance Commercial	$972.72

ORTHO, BIOCOMP-TENO SWIVELOCK 6.25 X 15 VES

Facility

$1,737.00

Service Code	HCPCS C1713
Hospital Charge Code	8743131
Hospital Revenue Code	278
Min. Negotiated Rate	$868.50
Max. Negotiated Rate	$1,684.89
Rate for Payer: AlohaCare Medicaid	$868.50
Rate for Payer: AlohaCare Medicare	$868.50
Rate for Payer: Cash Price	$1,129.05
Rate for Payer: Devoted Health Medicare	$955.35
Rate for Payer: Hawaii Medical Service Association Medicare	$868.50
Rate for Payer: Hawaii Western Management Group Commercial	$1,215.90
Rate for Payer: Health Management Network Commercial	$1,476.45
Rate for Payer: Humana Medicare	$868.50
Rate for Payer: Kaiser Permanente Commercial	$1,563.30
Rate for Payer: Kaiser Permanente Medicaid	$885.87
Rate for Payer: Kaiser Permanente Medicare	$868.50
Rate for Payer: MDX Hawaii PPO	$1,684.89
Rate for Payer: Ohana Health Plan Medicaid	$868.50
Rate for Payer: Ohana Health Plan Medicare	$868.50
Rate for Payer: UnitedHealthcare Medicare	$868.50
Rate for Payer: University Health Alliance Commercial	$972.72

ORTHO:BIT DRILL WIRE PASS 1.1MM

Facility

$257.00

Hospital Charge Code	12815063
Hospital Revenue Code	272
Min. Negotiated Rate	$218.45
Max. Negotiated Rate	$249.29
Rate for Payer: Cash Price	$167.05
Rate for Payer: Health Management Network Commercial	$218.45
Rate for Payer: Kaiser Permanente Commercial	$231.30
Rate for Payer: MDX Hawaii PPO	$249.29

ORTHO:BIT DRILL WIRE PASS 1.1MM

Facility

$257.00

Hospital Charge Code	12815063
Hospital Revenue Code	272
Min. Negotiated Rate	$128.50
Max. Negotiated Rate	$249.29
Rate for Payer: AlohaCare Medicaid	$128.50
Rate for Payer: AlohaCare Medicare	$128.50
Rate for Payer: Cash Price	$167.05
Rate for Payer: Devoted Health Medicare	$141.35
Rate for Payer: Hawaii Medical Service Association Medicare	$128.50
Rate for Payer: Hawaii Western Management Group Commercial	$244.15
Rate for Payer: Health Management Network Commercial	$218.45
Rate for Payer: Humana Medicare	$128.50
Rate for Payer: Kaiser Permanente Commercial	$231.30
Rate for Payer: Kaiser Permanente Medicaid	$131.07
Rate for Payer: Kaiser Permanente Medicare	$128.50
Rate for Payer: MDX Hawaii PPO	$249.29
Rate for Payer: Ohana Health Plan Medicaid	$128.50
Rate for Payer: Ohana Health Plan Medicare	$128.50
Rate for Payer: UnitedHealthcare Medicare	$128.50
Rate for Payer: University Health Alliance Commercial	$187.33

ORTHO BLADE 3.5 INCISOR

Facility

$210.00

Hospital Charge Code	8336044
Hospital Revenue Code	272
Min. Negotiated Rate	$105.00
Max. Negotiated Rate	$203.70
Rate for Payer: AlohaCare Medicaid	$105.00
Rate for Payer: AlohaCare Medicare	$105.00
Rate for Payer: Cash Price	$136.50
Rate for Payer: Devoted Health Medicare	$115.50
Rate for Payer: Hawaii Medical Service Association Medicare	$105.00
Rate for Payer: Hawaii Western Management Group Commercial	$199.50
Rate for Payer: Health Management Network Commercial	$178.50
Rate for Payer: Humana Medicare	$105.00
Rate for Payer: Kaiser Permanente Commercial	$189.00
Rate for Payer: Kaiser Permanente Medicaid	$107.10
Rate for Payer: Kaiser Permanente Medicare	$105.00
Rate for Payer: MDX Hawaii PPO	$203.70
Rate for Payer: Ohana Health Plan Medicaid	$105.00
Rate for Payer: Ohana Health Plan Medicare	$105.00
Rate for Payer: UnitedHealthcare Medicare	$105.00
Rate for Payer: University Health Alliance Commercial	$153.07

ORTHO BLADE 3.5 INCISOR

Facility

$210.00

Hospital Charge Code	8336044
Hospital Revenue Code	272
Min. Negotiated Rate	$178.50
Max. Negotiated Rate	$203.70
Rate for Payer: Cash Price	$136.50
Rate for Payer: Health Management Network Commercial	$178.50
Rate for Payer: Kaiser Permanente Commercial	$189.00
Rate for Payer: MDX Hawaii PPO	$203.70

Know your out-of-pocket cost for care.

All Charges