Samuel Mahelona Memorial Hospital

All Charges

Charge

Type

Setting

Price

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	$769.50
Max. Negotiated Rate	$1,492.83
Rate for Payer: AlohaCare Medicaid	$769.50
Rate for Payer: AlohaCare Medicare	$769.50
Rate for Payer: Cash Price	$1,000.35
Rate for Payer: Devoted Health Medicare	$846.45
Rate for Payer: Hawaii Medical Service Association Medicare	$769.50
Rate for Payer: Hawaii Western Management Group Commercial	$1,077.30
Rate for Payer: Health Management Network Commercial	$1,308.15
Rate for Payer: Humana Medicare	$769.50
Rate for Payer: Kaiser Permanente Commercial	$1,385.10
Rate for Payer: Kaiser Permanente Medicaid	$784.89
Rate for Payer: Kaiser Permanente Medicare	$769.50
Rate for Payer: MDX Hawaii PPO	$1,492.83
Rate for Payer: Ohana Health Plan Medicaid	$769.50
Rate for Payer: Ohana Health Plan Medicare	$769.50
Rate for Payer: UnitedHealthcare Medicare	$769.50
Rate for Payer: University Health Alliance Commercial	$861.84

ORTHO SHOULDER KIT QFIX 2.8 DISP

Facility

$1,656.00

Service Code	HCPCS C1713
Hospital Charge Code	8336034
Hospital Revenue Code	278
Min. Negotiated Rate	$927.36
Max. Negotiated Rate	$1,606.32
Rate for Payer: Cash Price	$1,076.40
Rate for Payer: Hawaii Western Management Group Commercial	$1,159.20
Rate for Payer: Health Management Network Commercial	$1,407.60
Rate for Payer: Kaiser Permanente Commercial	$1,490.40
Rate for Payer: MDX Hawaii PPO	$1,606.32
Rate for Payer: University Health Alliance Commercial	$927.36

ORTHO SHOULDER KIT QFIX 2.8 DISP

Facility

$1,656.00

Service Code	HCPCS C1713
Hospital Charge Code	8336034
Hospital Revenue Code	278
Min. Negotiated Rate	$828.00
Max. Negotiated Rate	$1,606.32
Rate for Payer: AlohaCare Medicaid	$828.00
Rate for Payer: AlohaCare Medicare	$828.00
Rate for Payer: Cash Price	$1,076.40
Rate for Payer: Devoted Health Medicare	$910.80
Rate for Payer: Hawaii Medical Service Association Medicare	$828.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,159.20
Rate for Payer: Health Management Network Commercial	$1,407.60
Rate for Payer: Humana Medicare	$828.00
Rate for Payer: Kaiser Permanente Commercial	$1,490.40
Rate for Payer: Kaiser Permanente Medicaid	$844.56
Rate for Payer: Kaiser Permanente Medicare	$828.00
Rate for Payer: MDX Hawaii PPO	$1,606.32
Rate for Payer: Ohana Health Plan Medicaid	$828.00
Rate for Payer: Ohana Health Plan Medicare	$828.00
Rate for Payer: UnitedHealthcare Medicare	$828.00
Rate for Payer: University Health Alliance Commercial	$927.36

ORTHO SHUTTLE RELAY DISP SUT PASSING SYS

Facility

$268.00

Hospital Charge Code	8348098
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 SHUTTLE RELAY DISP SUT PASSING SYS

Facility

$268.00

Hospital Charge Code	8348098
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: SMITH & NEPHEW HEALICOIL 5.5 SUTURE ANCHOR

Facility

$2,704.00

Service Code	HCPCS C1713
Hospital Charge Code	9335982
Hospital Revenue Code	278
Min. Negotiated Rate	$1,352.00
Max. Negotiated Rate	$2,622.88
Rate for Payer: AlohaCare Medicaid	$1,352.00
Rate for Payer: AlohaCare Medicare	$1,352.00
Rate for Payer: Cash Price	$1,757.60
Rate for Payer: Devoted Health Medicare	$1,487.20
Rate for Payer: Hawaii Medical Service Association Medicare	$1,352.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,892.80
Rate for Payer: Health Management Network Commercial	$2,298.40
Rate for Payer: Humana Medicare	$1,352.00
Rate for Payer: Kaiser Permanente Commercial	$2,433.60
Rate for Payer: Kaiser Permanente Medicaid	$1,379.04
Rate for Payer: Kaiser Permanente Medicare	$1,352.00
Rate for Payer: MDX Hawaii PPO	$2,622.88
Rate for Payer: Ohana Health Plan Medicaid	$1,352.00
Rate for Payer: Ohana Health Plan Medicare	$1,352.00
Rate for Payer: UnitedHealthcare Medicare	$1,352.00
Rate for Payer: University Health Alliance Commercial	$1,514.24

ORTHO: SMITH & NEPHEW HEALICOIL 5.5 SUTURE ANCHOR

Facility

$2,704.00

Service Code	HCPCS C1713
Hospital Charge Code	9335982
Hospital Revenue Code	278
Min. Negotiated Rate	$1,514.24
Max. Negotiated Rate	$2,622.88
Rate for Payer: Cash Price	$1,757.60
Rate for Payer: Hawaii Western Management Group Commercial	$1,892.80
Rate for Payer: Health Management Network Commercial	$2,298.40
Rate for Payer: Kaiser Permanente Commercial	$2,433.60
Rate for Payer: MDX Hawaii PPO	$2,622.88
Rate for Payer: University Health Alliance Commercial	$1,514.24

ORTHO SUTURE ANCHOR 1.8MM

Facility

$2,310.00

Hospital Charge Code	8336035
Hospital Revenue Code	272
Min. Negotiated Rate	$1,155.00
Max. Negotiated Rate	$2,240.70
Rate for Payer: AlohaCare Medicaid	$1,155.00
Rate for Payer: AlohaCare Medicare	$1,155.00
Rate for Payer: Cash Price	$1,501.50
Rate for Payer: Devoted Health Medicare	$1,270.50
Rate for Payer: Hawaii Medical Service Association Medicare	$1,155.00
Rate for Payer: Hawaii Western Management Group Commercial	$2,194.50
Rate for Payer: Health Management Network Commercial	$1,963.50
Rate for Payer: Humana Medicare	$1,155.00
Rate for Payer: Kaiser Permanente Commercial	$2,079.00
Rate for Payer: Kaiser Permanente Medicaid	$1,178.10
Rate for Payer: Kaiser Permanente Medicare	$1,155.00
Rate for Payer: MDX Hawaii PPO	$2,240.70
Rate for Payer: Ohana Health Plan Medicaid	$1,155.00
Rate for Payer: Ohana Health Plan Medicare	$1,155.00
Rate for Payer: UnitedHealthcare Medicare	$1,155.00
Rate for Payer: University Health Alliance Commercial	$1,683.76

ORTHO SUTURE ANCHOR 1.8MM

Facility

$2,310.00

Hospital Charge Code	8336035
Hospital Revenue Code	272
Min. Negotiated Rate	$1,963.50
Max. Negotiated Rate	$2,240.70
Rate for Payer: Cash Price	$1,501.50
Rate for Payer: Health Management Network Commercial	$1,963.50
Rate for Payer: Kaiser Permanente Commercial	$2,079.00
Rate for Payer: MDX Hawaii PPO	$2,240.70

ORTHO SUTURE ANCHOR 2.8MM

Facility

$1,659.00

Hospital Charge Code	8336036
Hospital Revenue Code	272
Min. Negotiated Rate	$1,410.15
Max. Negotiated Rate	$1,609.23
Rate for Payer: Cash Price	$1,078.35
Rate for Payer: Health Management Network Commercial	$1,410.15
Rate for Payer: Kaiser Permanente Commercial	$1,493.10
Rate for Payer: MDX Hawaii PPO	$1,609.23

ORTHO SUTURE ANCHOR 2.8MM

Facility

$1,659.00

Hospital Charge Code	8336036
Hospital Revenue Code	272
Min. Negotiated Rate	$829.50
Max. Negotiated Rate	$1,609.23
Rate for Payer: AlohaCare Medicaid	$829.50
Rate for Payer: AlohaCare Medicare	$829.50
Rate for Payer: Cash Price	$1,078.35
Rate for Payer: Devoted Health Medicare	$912.45
Rate for Payer: Hawaii Medical Service Association Medicare	$829.50
Rate for Payer: Hawaii Western Management Group Commercial	$1,576.05
Rate for Payer: Health Management Network Commercial	$1,410.15
Rate for Payer: Humana Medicare	$829.50
Rate for Payer: Kaiser Permanente Commercial	$1,493.10
Rate for Payer: Kaiser Permanente Medicaid	$846.09
Rate for Payer: Kaiser Permanente Medicare	$829.50
Rate for Payer: MDX Hawaii PPO	$1,609.23
Rate for Payer: Ohana Health Plan Medicaid	$829.50
Rate for Payer: Ohana Health Plan Medicare	$829.50
Rate for Payer: UnitedHealthcare Medicare	$829.50
Rate for Payer: University Health Alliance Commercial	$1,209.25

ORTHO SUTURE FIRST PASSER DISP

Facility

$1,530.00

Hospital Charge Code	8336037
Hospital Revenue Code	272
Min. Negotiated Rate	$1,300.50
Max. Negotiated Rate	$1,484.10
Rate for Payer: Cash Price	$994.50
Rate for Payer: Health Management Network Commercial	$1,300.50
Rate for Payer: Kaiser Permanente Commercial	$1,377.00
Rate for Payer: MDX Hawaii PPO	$1,484.10

ORTHO SUTURE FIRST PASSER DISP

Facility

$1,530.00

Hospital Charge Code	8336037
Hospital Revenue Code	272
Min. Negotiated Rate	$765.00
Max. Negotiated Rate	$1,484.10
Rate for Payer: AlohaCare Medicaid	$765.00
Rate for Payer: AlohaCare Medicare	$765.00
Rate for Payer: Cash Price	$994.50
Rate for Payer: Devoted Health Medicare	$841.50
Rate for Payer: Hawaii Medical Service Association Medicare	$765.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,453.50
Rate for Payer: Health Management Network Commercial	$1,300.50
Rate for Payer: Humana Medicare	$765.00
Rate for Payer: Kaiser Permanente Commercial	$1,377.00
Rate for Payer: Kaiser Permanente Medicaid	$780.30
Rate for Payer: Kaiser Permanente Medicare	$765.00
Rate for Payer: MDX Hawaii PPO	$1,484.10
Rate for Payer: Ohana Health Plan Medicaid	$765.00
Rate for Payer: Ohana Health Plan Medicare	$765.00
Rate for Payer: UnitedHealthcare Medicare	$765.00
Rate for Payer: University Health Alliance Commercial	$1,115.22

ORTHO SUTURE ULTRABRAID II BLUE

Facility

$374.00

Hospital Charge Code	8348092
Hospital Revenue Code	272
Min. Negotiated Rate	$317.90
Max. Negotiated Rate	$362.78
Rate for Payer: Cash Price	$243.10
Rate for Payer: Health Management Network Commercial	$317.90
Rate for Payer: Kaiser Permanente Commercial	$336.60
Rate for Payer: MDX Hawaii PPO	$362.78

ORTHO SUTURE ULTRABRAID II BLUE

Facility

$374.00

Hospital Charge Code	8348092
Hospital Revenue Code	272
Min. Negotiated Rate	$187.00
Max. Negotiated Rate	$362.78
Rate for Payer: AlohaCare Medicaid	$187.00
Rate for Payer: AlohaCare Medicare	$187.00
Rate for Payer: Cash Price	$243.10
Rate for Payer: Devoted Health Medicare	$205.70
Rate for Payer: Hawaii Medical Service Association Medicare	$187.00
Rate for Payer: Hawaii Western Management Group Commercial	$355.30
Rate for Payer: Health Management Network Commercial	$317.90
Rate for Payer: Humana Medicare	$187.00
Rate for Payer: Kaiser Permanente Commercial	$336.60
Rate for Payer: Kaiser Permanente Medicaid	$190.74
Rate for Payer: Kaiser Permanente Medicare	$187.00
Rate for Payer: MDX Hawaii PPO	$362.78
Rate for Payer: Ohana Health Plan Medicaid	$187.00
Rate for Payer: Ohana Health Plan Medicare	$187.00
Rate for Payer: UnitedHealthcare Medicare	$187.00
Rate for Payer: University Health Alliance Commercial	$272.61

Orthotic Mgmt and Training Charges

Facility

$282.00

Service Code	HCPCS 97760 GP,CQ
Hospital Charge Code	8111694
Hospital Revenue Code	420
Min. Negotiated Rate	$239.70
Max. Negotiated Rate	$273.54
Rate for Payer: Cash Price	$183.30
Rate for Payer: Health Management Network Commercial	$239.70
Rate for Payer: Kaiser Permanente Commercial	$253.80
Rate for Payer: MDX Hawaii PPO	$273.54

Orthotic Mgmt and Training Charges

Facility

$282.00

Service Code	HCPCS 97760 GP,CQ
Hospital Charge Code	8111694
Hospital Revenue Code	420
Min. Negotiated Rate	$17.21
Max. Negotiated Rate	$273.54
Rate for Payer: AlohaCare Medicaid	$141.00
Rate for Payer: AlohaCare Medicare	$141.00
Rate for Payer: Cash Price	$183.30
Rate for Payer: Cash Price	$183.30
Rate for Payer: Devoted Health Medicare	$155.10
Rate for Payer: Hawaii Medical Service Association Medicare	$141.00
Rate for Payer: Hawaii Western Management Group Commercial	$267.90
Rate for Payer: Health Management Network Commercial	$239.70
Rate for Payer: Humana Medicare	$141.00
Rate for Payer: Kaiser Permanente Commercial	$253.80
Rate for Payer: Kaiser Permanente Medicaid	$143.82
Rate for Payer: Kaiser Permanente Medicare	$141.00
Rate for Payer: MDX Hawaii PPO	$273.54
Rate for Payer: Ohana Health Plan Medicaid	$141.00
Rate for Payer: Ohana Health Plan Medicare	$141.00
Rate for Payer: UnitedHealthcare Medicaid	$17.21
Rate for Payer: UnitedHealthcare Medicare	$141.00
Rate for Payer: University Health Alliance Commercial	$157.92

Orthotic Mgmt and Training Charges

Facility

$282.00

Service Code	HCPCS 97760 GO
Hospital Charge Code	8123847
Hospital Revenue Code	430
Min. Negotiated Rate	$239.70
Max. Negotiated Rate	$273.54
Rate for Payer: Cash Price	$183.30
Rate for Payer: Health Management Network Commercial	$239.70
Rate for Payer: Kaiser Permanente Commercial	$253.80
Rate for Payer: MDX Hawaii PPO	$273.54

Orthotic Mgmt and Training Charges

Facility

$282.00

Service Code	HCPCS 97760 GO
Hospital Charge Code	8123847
Hospital Revenue Code	430
Min. Negotiated Rate	$17.21
Max. Negotiated Rate	$273.54
Rate for Payer: AlohaCare Medicaid	$141.00
Rate for Payer: AlohaCare Medicare	$141.00
Rate for Payer: Cash Price	$183.30
Rate for Payer: Cash Price	$183.30
Rate for Payer: Devoted Health Medicare	$155.10
Rate for Payer: Hawaii Medical Service Association Medicare	$141.00
Rate for Payer: Hawaii Western Management Group Commercial	$267.90
Rate for Payer: Health Management Network Commercial	$239.70
Rate for Payer: Humana Medicare	$141.00
Rate for Payer: Kaiser Permanente Commercial	$253.80
Rate for Payer: Kaiser Permanente Medicaid	$143.82
Rate for Payer: Kaiser Permanente Medicare	$141.00
Rate for Payer: MDX Hawaii PPO	$273.54
Rate for Payer: Ohana Health Plan Medicaid	$141.00
Rate for Payer: Ohana Health Plan Medicare	$141.00
Rate for Payer: UnitedHealthcare Medicaid	$17.21
Rate for Payer: UnitedHealthcare Medicare	$141.00
Rate for Payer: University Health Alliance Commercial	$157.92

ORTHO TWINFIX SUTURE ANCHOR 5.5 MM

Facility

$1,209.00

Service Code	HCPCS C1713
Hospital Charge Code	8336041
Hospital Revenue Code	278
Min. Negotiated Rate	$604.50
Max. Negotiated Rate	$1,172.73
Rate for Payer: AlohaCare Medicaid	$604.50
Rate for Payer: AlohaCare Medicare	$604.50
Rate for Payer: Cash Price	$785.85
Rate for Payer: Devoted Health Medicare	$664.95
Rate for Payer: Hawaii Medical Service Association Medicare	$604.50
Rate for Payer: Hawaii Western Management Group Commercial	$846.30
Rate for Payer: Health Management Network Commercial	$1,027.65
Rate for Payer: Humana Medicare	$604.50
Rate for Payer: Kaiser Permanente Commercial	$1,088.10
Rate for Payer: Kaiser Permanente Medicaid	$616.59
Rate for Payer: Kaiser Permanente Medicare	$604.50
Rate for Payer: MDX Hawaii PPO	$1,172.73
Rate for Payer: Ohana Health Plan Medicaid	$604.50
Rate for Payer: Ohana Health Plan Medicare	$604.50
Rate for Payer: UnitedHealthcare Medicare	$604.50
Rate for Payer: University Health Alliance Commercial	$677.04

ORTHO TWINFIX SUTURE ANCHOR 5.5 MM

Facility

$1,209.00

Service Code	HCPCS C1713
Hospital Charge Code	8336041
Hospital Revenue Code	278
Min. Negotiated Rate	$677.04
Max. Negotiated Rate	$1,172.73
Rate for Payer: Cash Price	$785.85
Rate for Payer: Hawaii Western Management Group Commercial	$846.30
Rate for Payer: Health Management Network Commercial	$1,027.65
Rate for Payer: Kaiser Permanente Commercial	$1,088.10
Rate for Payer: MDX Hawaii PPO	$1,172.73
Rate for Payer: University Health Alliance Commercial	$677.04

ORTHO TWINFIX SUTURE ANCHOR 6.5 MM

Facility

$1,209.00

Service Code	HCPCS C1713
Hospital Charge Code	8336042
Hospital Revenue Code	278
Min. Negotiated Rate	$604.50
Max. Negotiated Rate	$1,172.73
Rate for Payer: AlohaCare Medicaid	$604.50
Rate for Payer: AlohaCare Medicare	$604.50
Rate for Payer: Cash Price	$785.85
Rate for Payer: Devoted Health Medicare	$664.95
Rate for Payer: Hawaii Medical Service Association Medicare	$604.50
Rate for Payer: Hawaii Western Management Group Commercial	$846.30
Rate for Payer: Health Management Network Commercial	$1,027.65
Rate for Payer: Humana Medicare	$604.50
Rate for Payer: Kaiser Permanente Commercial	$1,088.10
Rate for Payer: Kaiser Permanente Medicaid	$616.59
Rate for Payer: Kaiser Permanente Medicare	$604.50
Rate for Payer: MDX Hawaii PPO	$1,172.73
Rate for Payer: Ohana Health Plan Medicaid	$604.50
Rate for Payer: Ohana Health Plan Medicare	$604.50
Rate for Payer: UnitedHealthcare Medicare	$604.50
Rate for Payer: University Health Alliance Commercial	$677.04

ORTHO TWINFIX SUTURE ANCHOR 6.5 MM

Facility

$1,209.00

Service Code	HCPCS C1713
Hospital Charge Code	8336042
Hospital Revenue Code	278
Min. Negotiated Rate	$677.04
Max. Negotiated Rate	$1,172.73
Rate for Payer: Cash Price	$785.85
Rate for Payer: Hawaii Western Management Group Commercial	$846.30
Rate for Payer: Health Management Network Commercial	$1,027.65
Rate for Payer: Kaiser Permanente Commercial	$1,088.10
Rate for Payer: MDX Hawaii PPO	$1,172.73
Rate for Payer: University Health Alliance Commercial	$677.04

ORTHO: TWINFIX ULTRA 4.5MM ANCHOR

Facility

$2,222.00

Service Code	HCPCS C1713
Hospital Charge Code	11545381
Hospital Revenue Code	278
Min. Negotiated Rate	$1,244.32
Max. Negotiated Rate	$2,155.34
Rate for Payer: Cash Price	$1,444.30
Rate for Payer: Hawaii Western Management Group Commercial	$1,555.40
Rate for Payer: Health Management Network Commercial	$1,888.70
Rate for Payer: Kaiser Permanente Commercial	$1,999.80
Rate for Payer: MDX Hawaii PPO	$2,155.34
Rate for Payer: University Health Alliance Commercial	$1,244.32

ORTHO: TWINFIX ULTRA 4.5MM ANCHOR

Facility

$2,222.00

Service Code	HCPCS C1713
Hospital Charge Code	11545381
Hospital Revenue Code	278
Min. Negotiated Rate	$1,111.00
Max. Negotiated Rate	$2,155.34
Rate for Payer: AlohaCare Medicaid	$1,111.00
Rate for Payer: AlohaCare Medicare	$1,111.00
Rate for Payer: Cash Price	$1,444.30
Rate for Payer: Devoted Health Medicare	$1,222.10
Rate for Payer: Hawaii Medical Service Association Medicare	$1,111.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,555.40
Rate for Payer: Health Management Network Commercial	$1,888.70
Rate for Payer: Humana Medicare	$1,111.00
Rate for Payer: Kaiser Permanente Commercial	$1,999.80
Rate for Payer: Kaiser Permanente Medicaid	$1,133.22
Rate for Payer: Kaiser Permanente Medicare	$1,111.00
Rate for Payer: MDX Hawaii PPO	$2,155.34
Rate for Payer: Ohana Health Plan Medicaid	$1,111.00
Rate for Payer: Ohana Health Plan Medicare	$1,111.00
Rate for Payer: UnitedHealthcare Medicare	$1,111.00
Rate for Payer: University Health Alliance Commercial	$1,244.32

Know your out-of-pocket cost for care.

All Charges