Samuel Mahelona Memorial Hospital

All Charges

Charge

Type

Setting

Price

ORTHO, BUR BARRELL 6 FLUTE F-SERIES 5.0 MM

Facility

$237.00

Hospital Charge Code	8528415
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, BUR BARRELL 6 FLUTE F-SERIES 5.0 MM

Facility

$237.00

Hospital Charge Code	8528415
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:BUR FLAME 6.0MM

Facility

$246.00

Hospital Charge Code	12815066
Hospital Revenue Code	272
Min. Negotiated Rate	$123.00
Max. Negotiated Rate	$238.62
Rate for Payer: AlohaCare Medicaid	$123.00
Rate for Payer: AlohaCare Medicare	$123.00
Rate for Payer: Cash Price	$159.90
Rate for Payer: Devoted Health Medicare	$135.30
Rate for Payer: Hawaii Medical Service Association Medicare	$123.00
Rate for Payer: Hawaii Western Management Group Commercial	$233.70
Rate for Payer: Health Management Network Commercial	$209.10
Rate for Payer: Humana Medicare	$123.00
Rate for Payer: Kaiser Permanente Commercial	$221.40
Rate for Payer: Kaiser Permanente Medicaid	$125.46
Rate for Payer: Kaiser Permanente Medicare	$123.00
Rate for Payer: MDX Hawaii PPO	$238.62
Rate for Payer: Ohana Health Plan Medicaid	$123.00
Rate for Payer: Ohana Health Plan Medicare	$123.00
Rate for Payer: UnitedHealthcare Medicare	$123.00
Rate for Payer: University Health Alliance Commercial	$179.31

ORTHO:BUR FLAME 6.0MM

Facility

$246.00

Hospital Charge Code	12815066
Hospital Revenue Code	272
Min. Negotiated Rate	$209.10
Max. Negotiated Rate	$238.62
Rate for Payer: Cash Price	$159.90
Rate for Payer: Health Management Network Commercial	$209.10
Rate for Payer: Kaiser Permanente Commercial	$221.40
Rate for Payer: MDX Hawaii PPO	$238.62

ORTHO, BUR FORMULA AGGRESSIVE 6-FLUTE BARREL 4.0MMX125MM

Facility

$236.00

Hospital Charge Code	8528424
Hospital Revenue Code	272
Min. Negotiated Rate	$118.00
Max. Negotiated Rate	$228.92
Rate for Payer: AlohaCare Medicaid	$118.00
Rate for Payer: AlohaCare Medicare	$118.00
Rate for Payer: Cash Price	$153.40
Rate for Payer: Devoted Health Medicare	$129.80
Rate for Payer: Hawaii Medical Service Association Medicare	$118.00
Rate for Payer: Hawaii Western Management Group Commercial	$224.20
Rate for Payer: Health Management Network Commercial	$200.60
Rate for Payer: Humana Medicare	$118.00
Rate for Payer: Kaiser Permanente Commercial	$212.40
Rate for Payer: Kaiser Permanente Medicaid	$120.36
Rate for Payer: Kaiser Permanente Medicare	$118.00
Rate for Payer: MDX Hawaii PPO	$228.92
Rate for Payer: Ohana Health Plan Medicaid	$118.00
Rate for Payer: Ohana Health Plan Medicare	$118.00
Rate for Payer: UnitedHealthcare Medicare	$118.00
Rate for Payer: University Health Alliance Commercial	$172.02

ORTHO, BUR FORMULA AGGRESSIVE 6-FLUTE BARREL 4.0MMX125MM

Facility

$236.00

Hospital Charge Code	8528424
Hospital Revenue Code	272
Min. Negotiated Rate	$200.60
Max. Negotiated Rate	$228.92
Rate for Payer: Cash Price	$153.40
Rate for Payer: Health Management Network Commercial	$200.60
Rate for Payer: Kaiser Permanente Commercial	$212.40
Rate for Payer: MDX Hawaii PPO	$228.92

ORTHO, BUR HOODED ABRASION SMALL JOINT F-SERIES

Facility

$1,035.00

Hospital Charge Code	8528417
Hospital Revenue Code	272
Min. Negotiated Rate	$879.75
Max. Negotiated Rate	$1,003.95
Rate for Payer: Cash Price	$672.75
Rate for Payer: Health Management Network Commercial	$879.75
Rate for Payer: Kaiser Permanente Commercial	$931.50
Rate for Payer: MDX Hawaii PPO	$1,003.95

ORTHO, BUR HOODED ABRASION SMALL JOINT F-SERIES

Facility

$1,035.00

Hospital Charge Code	8528417
Hospital Revenue Code	272
Min. Negotiated Rate	$517.50
Max. Negotiated Rate	$1,003.95
Rate for Payer: AlohaCare Medicaid	$517.50
Rate for Payer: AlohaCare Medicare	$517.50
Rate for Payer: Cash Price	$672.75
Rate for Payer: Devoted Health Medicare	$569.25
Rate for Payer: Hawaii Medical Service Association Medicare	$517.50
Rate for Payer: Hawaii Western Management Group Commercial	$983.25
Rate for Payer: Health Management Network Commercial	$879.75
Rate for Payer: Humana Medicare	$517.50
Rate for Payer: Kaiser Permanente Commercial	$931.50
Rate for Payer: Kaiser Permanente Medicaid	$527.85
Rate for Payer: Kaiser Permanente Medicare	$517.50
Rate for Payer: MDX Hawaii PPO	$1,003.95
Rate for Payer: Ohana Health Plan Medicaid	$517.50
Rate for Payer: Ohana Health Plan Medicare	$517.50
Rate for Payer: UnitedHealthcare Medicare	$517.50
Rate for Payer: University Health Alliance Commercial	$754.41

ORTHO, BUR SLAP 6 FLUTE F-SERIES 4.0MM

Facility

$1,151.00

Hospital Charge Code	8528416
Hospital Revenue Code	272
Min. Negotiated Rate	$978.35
Max. Negotiated Rate	$1,116.47
Rate for Payer: Cash Price	$748.15
Rate for Payer: Health Management Network Commercial	$978.35
Rate for Payer: Kaiser Permanente Commercial	$1,035.90
Rate for Payer: MDX Hawaii PPO	$1,116.47

ORTHO, BUR SLAP 6 FLUTE F-SERIES 4.0MM

Facility

$1,151.00

Hospital Charge Code	8528416
Hospital Revenue Code	272
Min. Negotiated Rate	$575.50
Max. Negotiated Rate	$1,116.47
Rate for Payer: AlohaCare Medicaid	$575.50
Rate for Payer: AlohaCare Medicare	$575.50
Rate for Payer: Cash Price	$748.15
Rate for Payer: Devoted Health Medicare	$633.05
Rate for Payer: Hawaii Medical Service Association Medicare	$575.50
Rate for Payer: Hawaii Western Management Group Commercial	$1,093.45
Rate for Payer: Health Management Network Commercial	$978.35
Rate for Payer: Humana Medicare	$575.50
Rate for Payer: Kaiser Permanente Commercial	$1,035.90
Rate for Payer: Kaiser Permanente Medicaid	$587.01
Rate for Payer: Kaiser Permanente Medicare	$575.50
Rate for Payer: MDX Hawaii PPO	$1,116.47
Rate for Payer: Ohana Health Plan Medicaid	$575.50
Rate for Payer: Ohana Health Plan Medicare	$575.50
Rate for Payer: UnitedHealthcare Medicare	$575.50
Rate for Payer: University Health Alliance Commercial	$838.96

ORTHO CANNULA GEMINI 8

Facility

$160.00

Hospital Charge Code	8336029
Hospital Revenue Code	270
Min. Negotiated Rate	$136.00
Max. Negotiated Rate	$155.20
Rate for Payer: Cash Price	$104.00
Rate for Payer: Health Management Network Commercial	$136.00
Rate for Payer: Kaiser Permanente Commercial	$144.00
Rate for Payer: MDX Hawaii PPO	$155.20

ORTHO CANNULA GEMINI 8

Facility

$160.00

Hospital Charge Code	8336029
Hospital Revenue Code	270
Min. Negotiated Rate	$80.00
Max. Negotiated Rate	$155.20
Rate for Payer: AlohaCare Medicaid	$80.00
Rate for Payer: AlohaCare Medicare	$80.00
Rate for Payer: Cash Price	$104.00
Rate for Payer: Devoted Health Medicare	$88.00
Rate for Payer: Hawaii Medical Service Association Medicare	$80.00
Rate for Payer: Hawaii Western Management Group Commercial	$152.00
Rate for Payer: Health Management Network Commercial	$136.00
Rate for Payer: Humana Medicare	$80.00
Rate for Payer: Kaiser Permanente Commercial	$144.00
Rate for Payer: Kaiser Permanente Medicaid	$81.60
Rate for Payer: Kaiser Permanente Medicare	$80.00
Rate for Payer: MDX Hawaii PPO	$155.20
Rate for Payer: Ohana Health Plan Medicaid	$80.00
Rate for Payer: Ohana Health Plan Medicare	$80.00
Rate for Payer: UnitedHealthcare Medicare	$80.00
Rate for Payer: University Health Alliance Commercial	$116.62

ORTHO CLEAR TRAC CANN 7.0 X 72

Facility

$173.00

Hospital Charge Code	8336031
Hospital Revenue Code	272
Min. Negotiated Rate	$86.50
Max. Negotiated Rate	$167.81
Rate for Payer: AlohaCare Medicaid	$86.50
Rate for Payer: AlohaCare Medicare	$86.50
Rate for Payer: Cash Price	$112.45
Rate for Payer: Devoted Health Medicare	$95.15
Rate for Payer: Hawaii Medical Service Association Medicare	$86.50
Rate for Payer: Hawaii Western Management Group Commercial	$164.35
Rate for Payer: Health Management Network Commercial	$147.05
Rate for Payer: Humana Medicare	$86.50
Rate for Payer: Kaiser Permanente Commercial	$155.70
Rate for Payer: Kaiser Permanente Medicaid	$88.23
Rate for Payer: Kaiser Permanente Medicare	$86.50
Rate for Payer: MDX Hawaii PPO	$167.81
Rate for Payer: Ohana Health Plan Medicaid	$86.50
Rate for Payer: Ohana Health Plan Medicare	$86.50
Rate for Payer: UnitedHealthcare Medicare	$86.50
Rate for Payer: University Health Alliance Commercial	$126.10

ORTHO CLEAR TRAC CANN 7.0 X 72

Facility

$173.00

Hospital Charge Code	8336031
Hospital Revenue Code	272
Min. Negotiated Rate	$147.05
Max. Negotiated Rate	$167.81
Rate for Payer: Cash Price	$112.45
Rate for Payer: Health Management Network Commercial	$147.05
Rate for Payer: Kaiser Permanente Commercial	$155.70
Rate for Payer: MDX Hawaii PPO	$167.81

ORTHO CLEAR TRAC CANN 8.5 X 45

Facility

$165.00

Hospital Charge Code	8336032
Hospital Revenue Code	272
Min. Negotiated Rate	$140.25
Max. Negotiated Rate	$160.05
Rate for Payer: Cash Price	$107.25
Rate for Payer: Health Management Network Commercial	$140.25
Rate for Payer: Kaiser Permanente Commercial	$148.50
Rate for Payer: MDX Hawaii PPO	$160.05

ORTHO CLEAR TRAC CANN 8.5 X 45

Facility

$165.00

Hospital Charge Code	8336032
Hospital Revenue Code	272
Min. Negotiated Rate	$82.50
Max. Negotiated Rate	$160.05
Rate for Payer: AlohaCare Medicaid	$82.50
Rate for Payer: AlohaCare Medicare	$82.50
Rate for Payer: Cash Price	$107.25
Rate for Payer: Devoted Health Medicare	$90.75
Rate for Payer: Hawaii Medical Service Association Medicare	$82.50
Rate for Payer: Hawaii Western Management Group Commercial	$156.75
Rate for Payer: Health Management Network Commercial	$140.25
Rate for Payer: Humana Medicare	$82.50
Rate for Payer: Kaiser Permanente Commercial	$148.50
Rate for Payer: Kaiser Permanente Medicaid	$84.15
Rate for Payer: Kaiser Permanente Medicare	$82.50
Rate for Payer: MDX Hawaii PPO	$160.05
Rate for Payer: Ohana Health Plan Medicaid	$82.50
Rate for Payer: Ohana Health Plan Medicare	$82.50
Rate for Payer: UnitedHealthcare Medicare	$82.50
Rate for Payer: University Health Alliance Commercial	$120.27

ORTHO, CROSSFLOW INFLOW CASSETTE TUBING BLUE

Facility

$245.00

Hospital Charge Code	8528419
Hospital Revenue Code	272
Min. Negotiated Rate	$208.25
Max. Negotiated Rate	$237.65
Rate for Payer: Cash Price	$159.25
Rate for Payer: Health Management Network Commercial	$208.25
Rate for Payer: Kaiser Permanente Commercial	$220.50
Rate for Payer: MDX Hawaii PPO	$237.65

ORTHO, CROSSFLOW INFLOW CASSETTE TUBING BLUE

Facility

$245.00

Hospital Charge Code	8528419
Hospital Revenue Code	272
Min. Negotiated Rate	$122.50
Max. Negotiated Rate	$237.65
Rate for Payer: AlohaCare Medicaid	$122.50
Rate for Payer: AlohaCare Medicare	$122.50
Rate for Payer: Cash Price	$159.25
Rate for Payer: Devoted Health Medicare	$134.75
Rate for Payer: Hawaii Medical Service Association Medicare	$122.50
Rate for Payer: Hawaii Western Management Group Commercial	$232.75
Rate for Payer: Health Management Network Commercial	$208.25
Rate for Payer: Humana Medicare	$122.50
Rate for Payer: Kaiser Permanente Commercial	$220.50
Rate for Payer: Kaiser Permanente Medicaid	$124.95
Rate for Payer: Kaiser Permanente Medicare	$122.50
Rate for Payer: MDX Hawaii PPO	$237.65
Rate for Payer: Ohana Health Plan Medicaid	$122.50
Rate for Payer: Ohana Health Plan Medicare	$122.50
Rate for Payer: UnitedHealthcare Medicare	$122.50
Rate for Payer: University Health Alliance Commercial	$178.58

ORTHO, CROSSFLOW INTEGRATED CASSETTE TUBING

Facility

$393.00

Hospital Charge Code	8528418
Hospital Revenue Code	272
Min. Negotiated Rate	$334.05
Max. Negotiated Rate	$381.21
Rate for Payer: Cash Price	$255.45
Rate for Payer: Health Management Network Commercial	$334.05
Rate for Payer: Kaiser Permanente Commercial	$353.70
Rate for Payer: MDX Hawaii PPO	$381.21

ORTHO, CROSSFLOW INTEGRATED CASSETTE TUBING

Facility

$393.00

Hospital Charge Code	8528418
Hospital Revenue Code	272
Min. Negotiated Rate	$196.50
Max. Negotiated Rate	$381.21
Rate for Payer: AlohaCare Medicaid	$196.50
Rate for Payer: AlohaCare Medicare	$196.50
Rate for Payer: Cash Price	$255.45
Rate for Payer: Devoted Health Medicare	$216.15
Rate for Payer: Hawaii Medical Service Association Medicare	$196.50
Rate for Payer: Hawaii Western Management Group Commercial	$373.35
Rate for Payer: Health Management Network Commercial	$334.05
Rate for Payer: Humana Medicare	$196.50
Rate for Payer: Kaiser Permanente Commercial	$353.70
Rate for Payer: Kaiser Permanente Medicaid	$200.43
Rate for Payer: Kaiser Permanente Medicare	$196.50
Rate for Payer: MDX Hawaii PPO	$381.21
Rate for Payer: Ohana Health Plan Medicaid	$196.50
Rate for Payer: Ohana Health Plan Medicare	$196.50
Rate for Payer: UnitedHealthcare Medicare	$196.50
Rate for Payer: University Health Alliance Commercial	$286.46

ORTHO, CROSSFLOW OUTFLOW CASSETTE TUBING RED

Facility

$1,834.00

Hospital Charge Code	8528423
Hospital Revenue Code	272
Min. Negotiated Rate	$917.00
Max. Negotiated Rate	$1,778.98
Rate for Payer: AlohaCare Medicaid	$917.00
Rate for Payer: AlohaCare Medicare	$917.00
Rate for Payer: Cash Price	$1,192.10
Rate for Payer: Devoted Health Medicare	$1,008.70
Rate for Payer: Hawaii Medical Service Association Medicare	$917.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,742.30
Rate for Payer: Health Management Network Commercial	$1,558.90
Rate for Payer: Humana Medicare	$917.00
Rate for Payer: Kaiser Permanente Commercial	$1,650.60
Rate for Payer: Kaiser Permanente Medicaid	$935.34
Rate for Payer: Kaiser Permanente Medicare	$917.00
Rate for Payer: MDX Hawaii PPO	$1,778.98
Rate for Payer: Ohana Health Plan Medicaid	$917.00
Rate for Payer: Ohana Health Plan Medicare	$917.00
Rate for Payer: UnitedHealthcare Medicare	$917.00
Rate for Payer: University Health Alliance Commercial	$1,336.80

ORTHO, CROSSFLOW OUTFLOW CASSETTE TUBING RED

Facility

$1,834.00

Hospital Charge Code	8528423
Hospital Revenue Code	272
Min. Negotiated Rate	$1,558.90
Max. Negotiated Rate	$1,778.98
Rate for Payer: Cash Price	$1,192.10
Rate for Payer: Health Management Network Commercial	$1,558.90
Rate for Payer: Kaiser Permanente Commercial	$1,650.60
Rate for Payer: MDX Hawaii PPO	$1,778.98

ORTHO, DISP INSTRUMENT KIT FOR TENO SCREW

Facility

$977.00

Hospital Charge Code	8743132
Hospital Revenue Code	270
Min. Negotiated Rate	$488.50
Max. Negotiated Rate	$947.69
Rate for Payer: AlohaCare Medicaid	$488.50
Rate for Payer: AlohaCare Medicare	$488.50
Rate for Payer: Cash Price	$635.05
Rate for Payer: Devoted Health Medicare	$537.35
Rate for Payer: Hawaii Medical Service Association Medicare	$488.50
Rate for Payer: Hawaii Western Management Group Commercial	$928.15
Rate for Payer: Health Management Network Commercial	$830.45
Rate for Payer: Humana Medicare	$488.50
Rate for Payer: Kaiser Permanente Commercial	$879.30
Rate for Payer: Kaiser Permanente Medicaid	$498.27
Rate for Payer: Kaiser Permanente Medicare	$488.50
Rate for Payer: MDX Hawaii PPO	$947.69
Rate for Payer: Ohana Health Plan Medicaid	$488.50
Rate for Payer: Ohana Health Plan Medicare	$488.50
Rate for Payer: UnitedHealthcare Medicare	$488.50
Rate for Payer: University Health Alliance Commercial	$712.14

ORTHO, DISP INSTRUMENT KIT FOR TENO SCREW

Facility

$977.00

Hospital Charge Code	8743132
Hospital Revenue Code	270
Min. Negotiated Rate	$830.45
Max. Negotiated Rate	$947.69
Rate for Payer: Cash Price	$635.05
Rate for Payer: Health Management Network Commercial	$830.45
Rate for Payer: Kaiser Permanente Commercial	$879.30
Rate for Payer: MDX Hawaii PPO	$947.69

ORTHO DRILL BIT 1.1MM/JC/45MM

Facility

$555.00

Hospital Charge Code	9121743
Hospital Revenue Code	272
Min. Negotiated Rate	$471.75
Max. Negotiated Rate	$538.35
Rate for Payer: Cash Price	$360.75
Rate for Payer: Health Management Network Commercial	$471.75
Rate for Payer: Kaiser Permanente Commercial	$499.50
Rate for Payer: MDX Hawaii PPO	$538.35

Know your out-of-pocket cost for care.

All Charges