Samuel Mahelona Memorial Hospital

All Charges

Charge

Type

Setting

Price

ORTHO:PATELLA SUTPLT II STAR S STRL

Facility

$5,870.00

Service Code	HCPCS C1713
Hospital Charge Code	13241684
Hospital Revenue Code	278
Min. Negotiated Rate	$2,935.00
Max. Negotiated Rate	$5,693.90
Rate for Payer: AlohaCare Medicaid	$2,935.00
Rate for Payer: AlohaCare Medicare	$2,935.00
Rate for Payer: Cash Price	$3,815.50
Rate for Payer: Devoted Health Medicare	$3,228.50
Rate for Payer: Hawaii Medical Service Association Medicare	$2,935.00
Rate for Payer: Hawaii Western Management Group Commercial	$4,109.00
Rate for Payer: Health Management Network Commercial	$4,989.50
Rate for Payer: Humana Medicare	$2,935.00
Rate for Payer: Kaiser Permanente Commercial	$5,283.00
Rate for Payer: Kaiser Permanente Medicaid	$2,993.70
Rate for Payer: Kaiser Permanente Medicare	$2,935.00
Rate for Payer: MDX Hawaii PPO	$5,693.90
Rate for Payer: Ohana Health Plan Medicaid	$2,935.00
Rate for Payer: Ohana Health Plan Medicare	$2,935.00
Rate for Payer: UnitedHealthcare Medicare	$2,935.00
Rate for Payer: University Health Alliance Commercial	$3,287.20

ORTHO:PATELLA SUTPLT II STAR S STRL

Facility

$5,870.00

Service Code	HCPCS C1713
Hospital Charge Code	13241684
Hospital Revenue Code	278
Min. Negotiated Rate	$3,287.20
Max. Negotiated Rate	$5,693.90
Rate for Payer: Cash Price	$3,815.50
Rate for Payer: Hawaii Western Management Group Commercial	$4,109.00
Rate for Payer: Health Management Network Commercial	$4,989.50
Rate for Payer: Kaiser Permanente Commercial	$5,283.00
Rate for Payer: MDX Hawaii PPO	$5,693.90
Rate for Payer: University Health Alliance Commercial	$3,287.20

ORTHO, PROXIMAL TENODESIS IMPLANT SYSTEM REV: 0

Facility

$2,895.00

Service Code	HCPCS C1713
Hospital Charge Code	8743133
Hospital Revenue Code	278
Min. Negotiated Rate	$1,447.50
Max. Negotiated Rate	$2,808.15
Rate for Payer: AlohaCare Medicaid	$1,447.50
Rate for Payer: AlohaCare Medicare	$1,447.50
Rate for Payer: Cash Price	$1,881.75
Rate for Payer: Devoted Health Medicare	$1,592.25
Rate for Payer: Hawaii Medical Service Association Medicare	$1,447.50
Rate for Payer: Hawaii Western Management Group Commercial	$2,026.50
Rate for Payer: Health Management Network Commercial	$2,460.75
Rate for Payer: Humana Medicare	$1,447.50
Rate for Payer: Kaiser Permanente Commercial	$2,605.50
Rate for Payer: Kaiser Permanente Medicaid	$1,476.45
Rate for Payer: Kaiser Permanente Medicare	$1,447.50
Rate for Payer: MDX Hawaii PPO	$2,808.15
Rate for Payer: Ohana Health Plan Medicaid	$1,447.50
Rate for Payer: Ohana Health Plan Medicare	$1,447.50
Rate for Payer: UnitedHealthcare Medicare	$1,447.50
Rate for Payer: University Health Alliance Commercial	$1,621.20

ORTHO, PROXIMAL TENODESIS IMPLANT SYSTEM REV: 0

Facility

$2,895.00

Service Code	HCPCS C1713
Hospital Charge Code	8743133
Hospital Revenue Code	278
Min. Negotiated Rate	$1,621.20
Max. Negotiated Rate	$2,808.15
Rate for Payer: Cash Price	$1,881.75
Rate for Payer: Hawaii Western Management Group Commercial	$2,026.50
Rate for Payer: Health Management Network Commercial	$2,460.75
Rate for Payer: Kaiser Permanente Commercial	$2,605.50
Rate for Payer: MDX Hawaii PPO	$2,808.15
Rate for Payer: University Health Alliance Commercial	$1,621.20

ORTHO, REAMER, LOW PROFILE

Facility

$977.00

Hospital Charge Code	8743130
Hospital Revenue Code	272
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, REAMER, LOW PROFILE

Facility

$977.00

Hospital Charge Code	8743130
Hospital Revenue Code	272
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 SCREW 1.5MM CORTEX SLF/TPNG WITH T4 STARDRIVE RECESS

Facility

$447.00

Service Code	HCPCS C1713
Hospital Charge Code	9121733
Hospital Revenue Code	278
Min. Negotiated Rate	$223.50
Max. Negotiated Rate	$433.59
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: Kaiser Permanente Medicare	$223.50
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 SCREW 1.5MM CORTEX SLF/TPNG WITH T4 STARDRIVE RECESS

Facility

$447.00

Service Code	HCPCS C1713
Hospital Charge Code	9121733
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 SCREW 1.5MM VA-LCKING SLF/TPNG WITH T4 STARDRIVE RECESS 13MM

Facility

$2,928.00

Service Code	HCPCS C1713
Hospital Charge Code	9121742
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 SCREW 1.5MM VA-LCKING SLF/TPNG WITH T4 STARDRIVE RECESS 13MM

Facility

$2,928.00

Service Code	HCPCS C1713
Hospital Charge Code	9121742
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 SCREW 4.0MM CANNULATED SHORT THREAD 28MM

Facility

$1,337.00

Service Code	HCPCS C1713
Hospital Charge Code	9134127
Hospital Revenue Code	278
Min. Negotiated Rate	$748.72
Max. Negotiated Rate	$1,296.89
Rate for Payer: Cash Price	$869.05
Rate for Payer: Hawaii Western Management Group Commercial	$935.90
Rate for Payer: Health Management Network Commercial	$1,136.45
Rate for Payer: Kaiser Permanente Commercial	$1,203.30
Rate for Payer: MDX Hawaii PPO	$1,296.89
Rate for Payer: University Health Alliance Commercial	$748.72

ORTHO SCREW 4.0MM CANNULATED SHORT THREAD 28MM

Facility

$1,337.00

Service Code	HCPCS C1713
Hospital Charge Code	9134127
Hospital Revenue Code	278
Min. Negotiated Rate	$668.50
Max. Negotiated Rate	$1,296.89
Rate for Payer: AlohaCare Medicaid	$668.50
Rate for Payer: AlohaCare Medicare	$668.50
Rate for Payer: Cash Price	$869.05
Rate for Payer: Devoted Health Medicare	$735.35
Rate for Payer: Hawaii Medical Service Association Medicare	$668.50
Rate for Payer: Hawaii Western Management Group Commercial	$935.90
Rate for Payer: Health Management Network Commercial	$1,136.45
Rate for Payer: Humana Medicare	$668.50
Rate for Payer: Kaiser Permanente Commercial	$1,203.30
Rate for Payer: Kaiser Permanente Medicaid	$681.87
Rate for Payer: Kaiser Permanente Medicare	$668.50
Rate for Payer: MDX Hawaii PPO	$1,296.89
Rate for Payer: Ohana Health Plan Medicaid	$668.50
Rate for Payer: Ohana Health Plan Medicare	$668.50
Rate for Payer: UnitedHealthcare Medicare	$668.50
Rate for Payer: University Health Alliance Commercial	$748.72

ORTHO SCREW 4.0MM CANNULATED SHORT THREAD 32MM

Facility

$1,337.00

Service Code	HCPCS C1713
Hospital Charge Code	9134126
Hospital Revenue Code	278
Min. Negotiated Rate	$668.50
Max. Negotiated Rate	$1,296.89
Rate for Payer: AlohaCare Medicaid	$668.50
Rate for Payer: AlohaCare Medicare	$668.50
Rate for Payer: Cash Price	$869.05
Rate for Payer: Devoted Health Medicare	$735.35
Rate for Payer: Hawaii Medical Service Association Medicare	$668.50
Rate for Payer: Hawaii Western Management Group Commercial	$935.90
Rate for Payer: Health Management Network Commercial	$1,136.45
Rate for Payer: Humana Medicare	$668.50
Rate for Payer: Kaiser Permanente Commercial	$1,203.30
Rate for Payer: Kaiser Permanente Medicaid	$681.87
Rate for Payer: Kaiser Permanente Medicare	$668.50
Rate for Payer: MDX Hawaii PPO	$1,296.89
Rate for Payer: Ohana Health Plan Medicaid	$668.50
Rate for Payer: Ohana Health Plan Medicare	$668.50
Rate for Payer: UnitedHealthcare Medicare	$668.50
Rate for Payer: University Health Alliance Commercial	$748.72

ORTHO SCREW 4.0MM CANNULATED SHORT THREAD 32MM

Facility

$1,337.00

Service Code	HCPCS C1713
Hospital Charge Code	9134126
Hospital Revenue Code	278
Min. Negotiated Rate	$748.72
Max. Negotiated Rate	$1,296.89
Rate for Payer: Cash Price	$869.05
Rate for Payer: Hawaii Western Management Group Commercial	$935.90
Rate for Payer: Health Management Network Commercial	$1,136.45
Rate for Payer: Kaiser Permanente Commercial	$1,203.30
Rate for Payer: MDX Hawaii PPO	$1,296.89
Rate for Payer: University Health Alliance Commercial	$748.72

ORTHO SHAVER 3.5 FULL RADIUS SMITH & NEPHEW

Facility

$268.00

Hospital Charge Code	8348099
Hospital Revenue Code	272
Min. Negotiated Rate	$227.80
Max. Negotiated Rate	$259.96
Rate for Payer: Cash Price	$174.20
Rate for Payer: Health Management Network Commercial	$227.80
Rate for Payer: Kaiser Permanente Commercial	$241.20
Rate for Payer: MDX Hawaii PPO	$259.96

ORTHO SHAVER 3.5 FULL RADIUS SMITH & NEPHEW

Facility

$268.00

Hospital Charge Code	8348099
Hospital Revenue Code	272
Min. Negotiated Rate	$134.00
Max. Negotiated Rate	$259.96
Rate for Payer: AlohaCare Medicaid	$134.00
Rate for Payer: AlohaCare Medicare	$134.00
Rate for Payer: Cash Price	$174.20
Rate for Payer: Devoted Health Medicare	$147.40
Rate for Payer: Hawaii Medical Service Association Medicare	$134.00
Rate for Payer: Hawaii Western Management Group Commercial	$254.60
Rate for Payer: Health Management Network Commercial	$227.80
Rate for Payer: Humana Medicare	$134.00
Rate for Payer: Kaiser Permanente Commercial	$241.20
Rate for Payer: Kaiser Permanente Medicaid	$136.68
Rate for Payer: Kaiser Permanente Medicare	$134.00
Rate for Payer: MDX Hawaii PPO	$259.96
Rate for Payer: Ohana Health Plan Medicaid	$134.00
Rate for Payer: Ohana Health Plan Medicare	$134.00
Rate for Payer: UnitedHealthcare Medicare	$134.00
Rate for Payer: University Health Alliance Commercial	$195.35

ORTHO, SHAVER BLADE AGG F-SERIES 4.0MM

Facility

$980.00

Hospital Charge Code	8528425
Hospital Revenue Code	272
Min. Negotiated Rate	$490.00
Max. Negotiated Rate	$950.60
Rate for Payer: AlohaCare Medicaid	$490.00
Rate for Payer: AlohaCare Medicare	$490.00
Rate for Payer: Cash Price	$637.00
Rate for Payer: Devoted Health Medicare	$539.00
Rate for Payer: Hawaii Medical Service Association Medicare	$490.00
Rate for Payer: Hawaii Western Management Group Commercial	$931.00
Rate for Payer: Health Management Network Commercial	$833.00
Rate for Payer: Humana Medicare	$490.00
Rate for Payer: Kaiser Permanente Commercial	$882.00
Rate for Payer: Kaiser Permanente Medicaid	$499.80
Rate for Payer: Kaiser Permanente Medicare	$490.00
Rate for Payer: MDX Hawaii PPO	$950.60
Rate for Payer: Ohana Health Plan Medicaid	$490.00
Rate for Payer: Ohana Health Plan Medicare	$490.00
Rate for Payer: UnitedHealthcare Medicare	$490.00
Rate for Payer: University Health Alliance Commercial	$714.32

ORTHO, SHAVER BLADE AGG F-SERIES 4.0MM

Facility

$980.00

Hospital Charge Code	8528425
Hospital Revenue Code	272
Min. Negotiated Rate	$833.00
Max. Negotiated Rate	$950.60
Rate for Payer: Cash Price	$637.00
Rate for Payer: Health Management Network Commercial	$833.00
Rate for Payer: Kaiser Permanente Commercial	$882.00
Rate for Payer: MDX Hawaii PPO	$950.60

ORTHO, SHAVER BLADE AGGRESSIVE MAX CUTTER 3.5MM

Facility

$361.00

Hospital Charge Code	8528426
Hospital Revenue Code	272
Min. Negotiated Rate	$180.50
Max. Negotiated Rate	$350.17
Rate for Payer: AlohaCare Medicaid	$180.50
Rate for Payer: AlohaCare Medicare	$180.50
Rate for Payer: Cash Price	$234.65
Rate for Payer: Devoted Health Medicare	$198.55
Rate for Payer: Hawaii Medical Service Association Medicare	$180.50
Rate for Payer: Hawaii Western Management Group Commercial	$342.95
Rate for Payer: Health Management Network Commercial	$306.85
Rate for Payer: Humana Medicare	$180.50
Rate for Payer: Kaiser Permanente Commercial	$324.90
Rate for Payer: Kaiser Permanente Medicaid	$184.11
Rate for Payer: Kaiser Permanente Medicare	$180.50
Rate for Payer: MDX Hawaii PPO	$350.17
Rate for Payer: Ohana Health Plan Medicaid	$180.50
Rate for Payer: Ohana Health Plan Medicare	$180.50
Rate for Payer: UnitedHealthcare Medicare	$180.50
Rate for Payer: University Health Alliance Commercial	$263.13

ORTHO, SHAVER BLADE AGGRESSIVE MAX CUTTER 3.5MM

Facility

$361.00

Hospital Charge Code	8528426
Hospital Revenue Code	272
Min. Negotiated Rate	$306.85
Max. Negotiated Rate	$350.17
Rate for Payer: Cash Price	$234.65
Rate for Payer: Health Management Network Commercial	$306.85
Rate for Payer: Kaiser Permanente Commercial	$324.90
Rate for Payer: MDX Hawaii PPO	$350.17

ORTHO, SHAVER BLADE CROSSBLADE TOMCAT HC 4.0MM ARTHROSCOPIC

Facility

$361.00

Hospital Charge Code	8528422
Hospital Revenue Code	272
Min. Negotiated Rate	$180.50
Max. Negotiated Rate	$350.17
Rate for Payer: AlohaCare Medicaid	$180.50
Rate for Payer: AlohaCare Medicare	$180.50
Rate for Payer: Cash Price	$234.65
Rate for Payer: Devoted Health Medicare	$198.55
Rate for Payer: Hawaii Medical Service Association Medicare	$180.50
Rate for Payer: Hawaii Western Management Group Commercial	$342.95
Rate for Payer: Health Management Network Commercial	$306.85
Rate for Payer: Humana Medicare	$180.50
Rate for Payer: Kaiser Permanente Commercial	$324.90
Rate for Payer: Kaiser Permanente Medicaid	$184.11
Rate for Payer: Kaiser Permanente Medicare	$180.50
Rate for Payer: MDX Hawaii PPO	$350.17
Rate for Payer: Ohana Health Plan Medicaid	$180.50
Rate for Payer: Ohana Health Plan Medicare	$180.50
Rate for Payer: UnitedHealthcare Medicare	$180.50
Rate for Payer: University Health Alliance Commercial	$263.13

ORTHO, SHAVER BLADE CROSSBLADE TOMCAT HC 4.0MM ARTHROSCOPIC

Facility

$361.00

Hospital Charge Code	8528422
Hospital Revenue Code	272
Min. Negotiated Rate	$306.85
Max. Negotiated Rate	$350.17
Rate for Payer: Cash Price	$234.65
Rate for Payer: Health Management Network Commercial	$306.85
Rate for Payer: Kaiser Permanente Commercial	$324.90
Rate for Payer: MDX Hawaii PPO	$350.17

ORTHO, SHAVER BLADE FULL RADIUS SMALL JOINT F-SERIES

Facility

$980.00

Hospital Charge Code	8528427
Hospital Revenue Code	272
Min. Negotiated Rate	$833.00
Max. Negotiated Rate	$950.60
Rate for Payer: Cash Price	$637.00
Rate for Payer: Health Management Network Commercial	$833.00
Rate for Payer: Kaiser Permanente Commercial	$882.00
Rate for Payer: MDX Hawaii PPO	$950.60

ORTHO, SHAVER BLADE FULL RADIUS SMALL JOINT F-SERIES

Facility

$980.00

Hospital Charge Code	8528427
Hospital Revenue Code	272
Min. Negotiated Rate	$490.00
Max. Negotiated Rate	$950.60
Rate for Payer: AlohaCare Medicaid	$490.00
Rate for Payer: AlohaCare Medicare	$490.00
Rate for Payer: Cash Price	$637.00
Rate for Payer: Devoted Health Medicare	$539.00
Rate for Payer: Hawaii Medical Service Association Medicare	$490.00
Rate for Payer: Hawaii Western Management Group Commercial	$931.00
Rate for Payer: Health Management Network Commercial	$833.00
Rate for Payer: Humana Medicare	$490.00
Rate for Payer: Kaiser Permanente Commercial	$882.00
Rate for Payer: Kaiser Permanente Medicaid	$499.80
Rate for Payer: Kaiser Permanente Medicare	$490.00
Rate for Payer: MDX Hawaii PPO	$950.60
Rate for Payer: Ohana Health Plan Medicaid	$490.00
Rate for Payer: Ohana Health Plan Medicare	$490.00
Rate for Payer: UnitedHealthcare Medicare	$490.00
Rate for Payer: University Health Alliance Commercial	$714.32

ORTHO SHOULDER KIT QFIX 1.8 DISP

Facility

$1,539.00

Service Code	HCPCS C1713
Hospital Charge Code	8336033
Hospital Revenue Code	278
Min. Negotiated Rate	$861.84
Max. Negotiated Rate	$1,492.83
Rate for Payer: Cash Price	$1,000.35
Rate for Payer: Hawaii Western Management Group Commercial	$1,077.30
Rate for Payer: Health Management Network Commercial	$1,308.15
Rate for Payer: Kaiser Permanente Commercial	$1,385.10
Rate for Payer: MDX Hawaii PPO	$1,492.83
Rate for Payer: University Health Alliance Commercial	$861.84

Know your out-of-pocket cost for care.

All Charges