Samuel Mahelona Memorial Hospital

All Charges

Charge

Type

Setting

Price

ORTHO: TWINFIX ULTRA 5.5MM ANCHOR

Facility

$1,873.00

Service Code	HCPCS C1713
Hospital Charge Code	11545380
Hospital Revenue Code	278
Min. Negotiated Rate	$1,048.88
Max. Negotiated Rate	$1,816.81
Rate for Payer: Cash Price	$1,217.45
Rate for Payer: Hawaii Western Management Group Commercial	$1,311.10
Rate for Payer: Health Management Network Commercial	$1,592.05
Rate for Payer: Kaiser Permanente Commercial	$1,685.70
Rate for Payer: MDX Hawaii PPO	$1,816.81
Rate for Payer: University Health Alliance Commercial	$1,048.88

ORTHO: TWINFIX ULTRA 5.5MM ANCHOR

Facility

$1,873.00

Service Code	HCPCS C1713
Hospital Charge Code	11545380
Hospital Revenue Code	278
Min. Negotiated Rate	$936.50
Max. Negotiated Rate	$1,816.81
Rate for Payer: AlohaCare Medicaid	$936.50
Rate for Payer: AlohaCare Medicare	$936.50
Rate for Payer: Cash Price	$1,217.45
Rate for Payer: Devoted Health Medicare	$1,030.15
Rate for Payer: Hawaii Medical Service Association Medicare	$936.50
Rate for Payer: Hawaii Western Management Group Commercial	$1,311.10
Rate for Payer: Health Management Network Commercial	$1,592.05
Rate for Payer: Humana Medicare	$936.50
Rate for Payer: Kaiser Permanente Commercial	$1,685.70
Rate for Payer: Kaiser Permanente Medicaid	$955.23
Rate for Payer: Kaiser Permanente Medicare	$936.50
Rate for Payer: MDX Hawaii PPO	$1,816.81
Rate for Payer: Ohana Health Plan Medicaid	$936.50
Rate for Payer: Ohana Health Plan Medicare	$936.50
Rate for Payer: UnitedHealthcare Medicare	$936.50
Rate for Payer: University Health Alliance Commercial	$1,048.88

ORTHO ULTRA SLING SHOULDER BRACE LARGE

Facility

$204.00

Hospital Charge Code	8336040
Hospital Revenue Code	271
Min. Negotiated Rate	$173.40
Max. Negotiated Rate	$197.88
Rate for Payer: Cash Price	$132.60
Rate for Payer: Health Management Network Commercial	$173.40
Rate for Payer: Kaiser Permanente Commercial	$183.60
Rate for Payer: MDX Hawaii PPO	$197.88

ORTHO ULTRA SLING SHOULDER BRACE LARGE

Facility

$204.00

Hospital Charge Code	8336040
Hospital Revenue Code	271
Min. Negotiated Rate	$102.00
Max. Negotiated Rate	$197.88
Rate for Payer: AlohaCare Medicaid	$102.00
Rate for Payer: AlohaCare Medicare	$102.00
Rate for Payer: Cash Price	$132.60
Rate for Payer: Devoted Health Medicare	$112.20
Rate for Payer: Hawaii Medical Service Association Medicare	$102.00
Rate for Payer: Hawaii Western Management Group Commercial	$193.80
Rate for Payer: Health Management Network Commercial	$173.40
Rate for Payer: Humana Medicare	$102.00
Rate for Payer: Kaiser Permanente Commercial	$183.60
Rate for Payer: Kaiser Permanente Medicaid	$104.04
Rate for Payer: Kaiser Permanente Medicare	$102.00
Rate for Payer: MDX Hawaii PPO	$197.88
Rate for Payer: Ohana Health Plan Medicaid	$102.00
Rate for Payer: Ohana Health Plan Medicare	$102.00
Rate for Payer: UnitedHealthcare Medicare	$102.00
Rate for Payer: University Health Alliance Commercial	$148.70

ORTHO ULTRA SLING SHOULDER BRACE MEDIUM

Facility

$223.00

Service Code	HCPCS A4565
Hospital Charge Code	9218920
Hospital Revenue Code	271
Min. Negotiated Rate	$189.55
Max. Negotiated Rate	$216.31
Rate for Payer: Cash Price	$144.95
Rate for Payer: Health Management Network Commercial	$189.55
Rate for Payer: Kaiser Permanente Commercial	$200.70
Rate for Payer: MDX Hawaii PPO	$216.31

ORTHO ULTRA SLING SHOULDER BRACE MEDIUM

Facility

$223.00

Service Code	HCPCS A4565
Hospital Charge Code	9218920
Hospital Revenue Code	271
Min. Negotiated Rate	$10.40
Max. Negotiated Rate	$216.31
Rate for Payer: AlohaCare Medicaid	$111.50
Rate for Payer: AlohaCare Medicare	$111.50
Rate for Payer: Cash Price	$144.95
Rate for Payer: Cash Price	$144.95
Rate for Payer: Devoted Health Medicare	$122.65
Rate for Payer: Hawaii Medical Service Association Medicare	$111.50
Rate for Payer: Hawaii Western Management Group Commercial	$211.85
Rate for Payer: Health Management Network Commercial	$189.55
Rate for Payer: Humana Medicare	$111.50
Rate for Payer: Kaiser Permanente Commercial	$200.70
Rate for Payer: Kaiser Permanente Medicaid	$113.73
Rate for Payer: Kaiser Permanente Medicare	$111.50
Rate for Payer: MDX Hawaii PPO	$216.31
Rate for Payer: Ohana Health Plan Medicaid	$111.50
Rate for Payer: Ohana Health Plan Medicare	$111.50
Rate for Payer: UnitedHealthcare Medicaid	$10.40
Rate for Payer: UnitedHealthcare Medicare	$111.50
Rate for Payer: University Health Alliance Commercial	$162.54

oseltamivir 6 mg/1ml 60ml [HHSC]

Facility

$584.82

Service Code	NDC 70710116506
Hospital Charge Code	2500618
Hospital Revenue Code	250
Min. Negotiated Rate	$292.41
Max. Negotiated Rate	$567.28
Rate for Payer: AlohaCare Medicaid	$292.41
Rate for Payer: AlohaCare Medicare	$292.41
Rate for Payer: Cash Price	$380.13
Rate for Payer: Devoted Health Medicare	$321.65
Rate for Payer: Hawaii Medical Service Association Medicare	$292.41
Rate for Payer: Hawaii Western Management Group Commercial	$555.58
Rate for Payer: Health Management Network Commercial	$497.10
Rate for Payer: Humana Medicare	$292.41
Rate for Payer: Kaiser Permanente Commercial	$526.34
Rate for Payer: Kaiser Permanente Medicaid	$298.26
Rate for Payer: Kaiser Permanente Medicare	$292.41
Rate for Payer: MDX Hawaii PPO	$567.28
Rate for Payer: Ohana Health Plan Medicaid	$292.41
Rate for Payer: Ohana Health Plan Medicare	$292.41
Rate for Payer: UnitedHealthcare Medicaid	$350.89
Rate for Payer: UnitedHealthcare Medicare	$292.41
Rate for Payer: University Health Alliance Commercial	$426.28

oseltamivir 6 mg/1ml 60ml [HHSC]

Facility

$584.22

Service Code	NDC 68180067801
Hospital Charge Code	2500618
Hospital Revenue Code	250
Min. Negotiated Rate	$496.59
Max. Negotiated Rate	$566.69
Rate for Payer: Cash Price	$379.74
Rate for Payer: Health Management Network Commercial	$496.59
Rate for Payer: Kaiser Permanente Commercial	$525.80
Rate for Payer: MDX Hawaii PPO	$566.69

oseltamivir 6 mg/1ml 60ml [HHSC]

Facility

$568.68

Service Code	NDC 00004082205
Hospital Charge Code	2500618
Hospital Revenue Code	250
Min. Negotiated Rate	$483.38
Max. Negotiated Rate	$551.62
Rate for Payer: Cash Price	$369.64
Rate for Payer: Health Management Network Commercial	$483.38
Rate for Payer: Kaiser Permanente Commercial	$511.81
Rate for Payer: MDX Hawaii PPO	$551.62

oseltamivir 6 mg/1ml 60ml [HHSC]

Facility

$584.22

Service Code	NDC 68180067801
Hospital Charge Code	2500618
Hospital Revenue Code	250
Min. Negotiated Rate	$292.11
Max. Negotiated Rate	$566.69
Rate for Payer: AlohaCare Medicaid	$292.11
Rate for Payer: AlohaCare Medicare	$292.11
Rate for Payer: Cash Price	$379.74
Rate for Payer: Devoted Health Medicare	$321.32
Rate for Payer: Hawaii Medical Service Association Medicare	$292.11
Rate for Payer: Hawaii Western Management Group Commercial	$555.01
Rate for Payer: Health Management Network Commercial	$496.59
Rate for Payer: Humana Medicare	$292.11
Rate for Payer: Kaiser Permanente Commercial	$525.80
Rate for Payer: Kaiser Permanente Medicaid	$297.95
Rate for Payer: Kaiser Permanente Medicare	$292.11
Rate for Payer: MDX Hawaii PPO	$566.69
Rate for Payer: Ohana Health Plan Medicaid	$292.11
Rate for Payer: Ohana Health Plan Medicare	$292.11
Rate for Payer: UnitedHealthcare Medicaid	$350.53
Rate for Payer: UnitedHealthcare Medicare	$292.11
Rate for Payer: University Health Alliance Commercial	$425.84

oseltamivir 6 mg/1ml 60ml [HHSC]

Facility

$584.82

Service Code	NDC 70710116506
Hospital Charge Code	2500618
Hospital Revenue Code	250
Min. Negotiated Rate	$497.10
Max. Negotiated Rate	$567.28
Rate for Payer: Cash Price	$380.13
Rate for Payer: Health Management Network Commercial	$497.10
Rate for Payer: Kaiser Permanente Commercial	$526.34
Rate for Payer: MDX Hawaii PPO	$567.28

oseltamivir 6 mg/1ml 60ml [HHSC]

Facility

$568.68

Service Code	NDC 00004082205
Hospital Charge Code	2500618
Hospital Revenue Code	250
Min. Negotiated Rate	$284.34
Max. Negotiated Rate	$551.62
Rate for Payer: AlohaCare Medicaid	$284.34
Rate for Payer: AlohaCare Medicare	$284.34
Rate for Payer: Cash Price	$369.64
Rate for Payer: Devoted Health Medicare	$312.77
Rate for Payer: Hawaii Medical Service Association Medicare	$284.34
Rate for Payer: Hawaii Western Management Group Commercial	$540.25
Rate for Payer: Health Management Network Commercial	$483.38
Rate for Payer: Humana Medicare	$284.34
Rate for Payer: Kaiser Permanente Commercial	$511.81
Rate for Payer: Kaiser Permanente Medicaid	$290.03
Rate for Payer: Kaiser Permanente Medicare	$284.34
Rate for Payer: MDX Hawaii PPO	$551.62
Rate for Payer: Ohana Health Plan Medicaid	$284.34
Rate for Payer: Ohana Health Plan Medicare	$284.34
Rate for Payer: UnitedHealthcare Medicaid	$341.21
Rate for Payer: UnitedHealthcare Medicare	$284.34
Rate for Payer: University Health Alliance Commercial	$414.51

oseltamivir 6 mg/1ml 60ml [HHSC]

Facility

$584.82

Service Code	NDC 27241013909
Hospital Charge Code	2500618
Hospital Revenue Code	250
Min. Negotiated Rate	$497.10
Max. Negotiated Rate	$567.28
Rate for Payer: Cash Price	$380.13
Rate for Payer: Health Management Network Commercial	$497.10
Rate for Payer: Kaiser Permanente Commercial	$526.34
Rate for Payer: MDX Hawaii PPO	$567.28

oseltamivir 6 mg/1ml 60ml [HHSC]

Facility

$584.82

Service Code	NDC 27241013909
Hospital Charge Code	2500618
Hospital Revenue Code	250
Min. Negotiated Rate	$292.41
Max. Negotiated Rate	$567.28
Rate for Payer: AlohaCare Medicaid	$292.41
Rate for Payer: AlohaCare Medicare	$292.41
Rate for Payer: Cash Price	$380.13
Rate for Payer: Devoted Health Medicare	$321.65
Rate for Payer: Hawaii Medical Service Association Medicare	$292.41
Rate for Payer: Hawaii Western Management Group Commercial	$555.58
Rate for Payer: Health Management Network Commercial	$497.10
Rate for Payer: Humana Medicare	$292.41
Rate for Payer: Kaiser Permanente Commercial	$526.34
Rate for Payer: Kaiser Permanente Medicaid	$298.26
Rate for Payer: Kaiser Permanente Medicare	$292.41
Rate for Payer: MDX Hawaii PPO	$567.28
Rate for Payer: Ohana Health Plan Medicaid	$292.41
Rate for Payer: Ohana Health Plan Medicare	$292.41
Rate for Payer: UnitedHealthcare Medicaid	$350.89
Rate for Payer: UnitedHealthcare Medicare	$292.41
Rate for Payer: University Health Alliance Commercial	$426.28

oseltamivir 75 mg capsule [HHSC]

Facility

$94.33

Service Code	NDC 00004080085
Hospital Charge Code	2500619
Hospital Revenue Code	250
Min. Negotiated Rate	$47.16
Max. Negotiated Rate	$91.50
Rate for Payer: AlohaCare Medicaid	$47.16
Rate for Payer: AlohaCare Medicare	$47.16
Rate for Payer: Cash Price	$61.31
Rate for Payer: Devoted Health Medicare	$51.88
Rate for Payer: Hawaii Medical Service Association Medicare	$47.16
Rate for Payer: Hawaii Western Management Group Commercial	$89.61
Rate for Payer: Health Management Network Commercial	$80.18
Rate for Payer: Humana Medicare	$47.16
Rate for Payer: Kaiser Permanente Commercial	$84.90
Rate for Payer: Kaiser Permanente Medicaid	$48.11
Rate for Payer: Kaiser Permanente Medicare	$47.16
Rate for Payer: MDX Hawaii PPO	$91.50
Rate for Payer: Ohana Health Plan Medicaid	$47.16
Rate for Payer: Ohana Health Plan Medicare	$47.16
Rate for Payer: UnitedHealthcare Medicaid	$56.60
Rate for Payer: UnitedHealthcare Medicare	$47.16
Rate for Payer: University Health Alliance Commercial	$68.76

oseltamivir 75 mg capsule [HHSC]

Facility

$82.76

Service Code	NDC 31722063231
Hospital Charge Code	2500619
Hospital Revenue Code	250
Min. Negotiated Rate	$41.38
Max. Negotiated Rate	$80.28
Rate for Payer: AlohaCare Medicaid	$41.38
Rate for Payer: AlohaCare Medicare	$41.38
Rate for Payer: Cash Price	$53.79
Rate for Payer: Devoted Health Medicare	$45.52
Rate for Payer: Hawaii Medical Service Association Medicare	$41.38
Rate for Payer: Hawaii Western Management Group Commercial	$78.62
Rate for Payer: Health Management Network Commercial	$70.35
Rate for Payer: Humana Medicare	$41.38
Rate for Payer: Kaiser Permanente Commercial	$74.48
Rate for Payer: Kaiser Permanente Medicaid	$42.21
Rate for Payer: Kaiser Permanente Medicare	$41.38
Rate for Payer: MDX Hawaii PPO	$80.28
Rate for Payer: Ohana Health Plan Medicaid	$41.38
Rate for Payer: Ohana Health Plan Medicare	$41.38
Rate for Payer: UnitedHealthcare Medicaid	$49.66
Rate for Payer: UnitedHealthcare Medicare	$41.38
Rate for Payer: University Health Alliance Commercial	$60.32

oseltamivir 75 mg capsule [HHSC]

Facility

$82.76

Service Code	NDC 68180067711
Hospital Charge Code	2500619
Hospital Revenue Code	250
Min. Negotiated Rate	$70.35
Max. Negotiated Rate	$80.28
Rate for Payer: Cash Price	$53.79
Rate for Payer: Health Management Network Commercial	$70.35
Rate for Payer: Kaiser Permanente Commercial	$74.48
Rate for Payer: MDX Hawaii PPO	$80.28

oseltamivir 75 mg capsule [HHSC]

Facility

$82.76

Service Code	NDC 47781047013
Hospital Charge Code	2500619
Hospital Revenue Code	250
Min. Negotiated Rate	$70.35
Max. Negotiated Rate	$80.28
Rate for Payer: Cash Price	$53.79
Rate for Payer: Health Management Network Commercial	$70.35
Rate for Payer: Kaiser Permanente Commercial	$74.48
Rate for Payer: MDX Hawaii PPO	$80.28

oseltamivir 75 mg capsule [HHSC]

Facility

$82.76

Service Code	NDC 69238126601
Hospital Charge Code	2500619
Hospital Revenue Code	250
Min. Negotiated Rate	$70.35
Max. Negotiated Rate	$80.28
Rate for Payer: Cash Price	$53.79
Rate for Payer: Health Management Network Commercial	$70.35
Rate for Payer: Kaiser Permanente Commercial	$74.48
Rate for Payer: MDX Hawaii PPO	$80.28

oseltamivir 75 mg capsule [HHSC]

Facility

$82.76

Service Code	NDC 70710101002
Hospital Charge Code	2500619
Hospital Revenue Code	250
Min. Negotiated Rate	$70.35
Max. Negotiated Rate	$80.28
Rate for Payer: Cash Price	$53.79
Rate for Payer: Health Management Network Commercial	$70.35
Rate for Payer: Kaiser Permanente Commercial	$74.48
Rate for Payer: MDX Hawaii PPO	$80.28

oseltamivir 75 mg capsule [HHSC]

Facility

$82.76

Service Code	NDC 70710101002
Hospital Charge Code	2500619
Hospital Revenue Code	250
Min. Negotiated Rate	$41.38
Max. Negotiated Rate	$80.28
Rate for Payer: AlohaCare Medicaid	$41.38
Rate for Payer: AlohaCare Medicare	$41.38
Rate for Payer: Cash Price	$53.79
Rate for Payer: Devoted Health Medicare	$45.52
Rate for Payer: Hawaii Medical Service Association Medicare	$41.38
Rate for Payer: Hawaii Western Management Group Commercial	$78.62
Rate for Payer: Health Management Network Commercial	$70.35
Rate for Payer: Humana Medicare	$41.38
Rate for Payer: Kaiser Permanente Commercial	$74.48
Rate for Payer: Kaiser Permanente Medicaid	$42.21
Rate for Payer: Kaiser Permanente Medicare	$41.38
Rate for Payer: MDX Hawaii PPO	$80.28
Rate for Payer: Ohana Health Plan Medicaid	$41.38
Rate for Payer: Ohana Health Plan Medicare	$41.38
Rate for Payer: UnitedHealthcare Medicaid	$49.66
Rate for Payer: UnitedHealthcare Medicare	$41.38
Rate for Payer: University Health Alliance Commercial	$60.32

oseltamivir 75 mg capsule [HHSC]

Facility

$82.76

Service Code	NDC 47781047013
Hospital Charge Code	2500619
Hospital Revenue Code	250
Min. Negotiated Rate	$41.38
Max. Negotiated Rate	$80.28
Rate for Payer: AlohaCare Medicaid	$41.38
Rate for Payer: AlohaCare Medicare	$41.38
Rate for Payer: Cash Price	$53.79
Rate for Payer: Devoted Health Medicare	$45.52
Rate for Payer: Hawaii Medical Service Association Medicare	$41.38
Rate for Payer: Hawaii Western Management Group Commercial	$78.62
Rate for Payer: Health Management Network Commercial	$70.35
Rate for Payer: Humana Medicare	$41.38
Rate for Payer: Kaiser Permanente Commercial	$74.48
Rate for Payer: Kaiser Permanente Medicaid	$42.21
Rate for Payer: Kaiser Permanente Medicare	$41.38
Rate for Payer: MDX Hawaii PPO	$80.28
Rate for Payer: Ohana Health Plan Medicaid	$41.38
Rate for Payer: Ohana Health Plan Medicare	$41.38
Rate for Payer: UnitedHealthcare Medicaid	$49.66
Rate for Payer: UnitedHealthcare Medicare	$41.38
Rate for Payer: University Health Alliance Commercial	$60.32

oseltamivir 75 mg capsule [HHSC]

Facility

$82.76

Service Code	NDC 69238126601
Hospital Charge Code	2500619
Hospital Revenue Code	250
Min. Negotiated Rate	$41.38
Max. Negotiated Rate	$80.28
Rate for Payer: AlohaCare Medicaid	$41.38
Rate for Payer: AlohaCare Medicare	$41.38
Rate for Payer: Cash Price	$53.79
Rate for Payer: Devoted Health Medicare	$45.52
Rate for Payer: Hawaii Medical Service Association Medicare	$41.38
Rate for Payer: Hawaii Western Management Group Commercial	$78.62
Rate for Payer: Health Management Network Commercial	$70.35
Rate for Payer: Humana Medicare	$41.38
Rate for Payer: Kaiser Permanente Commercial	$74.48
Rate for Payer: Kaiser Permanente Medicaid	$42.21
Rate for Payer: Kaiser Permanente Medicare	$41.38
Rate for Payer: MDX Hawaii PPO	$80.28
Rate for Payer: Ohana Health Plan Medicaid	$41.38
Rate for Payer: Ohana Health Plan Medicare	$41.38
Rate for Payer: UnitedHealthcare Medicaid	$49.66
Rate for Payer: UnitedHealthcare Medicare	$41.38
Rate for Payer: University Health Alliance Commercial	$60.32

oseltamivir 75 mg capsule [HHSC]

Facility

$82.76

Service Code	NDC 68180067711
Hospital Charge Code	2500619
Hospital Revenue Code	250
Min. Negotiated Rate	$41.38
Max. Negotiated Rate	$80.28
Rate for Payer: AlohaCare Medicaid	$41.38
Rate for Payer: AlohaCare Medicare	$41.38
Rate for Payer: Cash Price	$53.79
Rate for Payer: Devoted Health Medicare	$45.52
Rate for Payer: Hawaii Medical Service Association Medicare	$41.38
Rate for Payer: Hawaii Western Management Group Commercial	$78.62
Rate for Payer: Health Management Network Commercial	$70.35
Rate for Payer: Humana Medicare	$41.38
Rate for Payer: Kaiser Permanente Commercial	$74.48
Rate for Payer: Kaiser Permanente Medicaid	$42.21
Rate for Payer: Kaiser Permanente Medicare	$41.38
Rate for Payer: MDX Hawaii PPO	$80.28
Rate for Payer: Ohana Health Plan Medicaid	$41.38
Rate for Payer: Ohana Health Plan Medicare	$41.38
Rate for Payer: UnitedHealthcare Medicaid	$49.66
Rate for Payer: UnitedHealthcare Medicare	$41.38
Rate for Payer: University Health Alliance Commercial	$60.32

oseltamivir 75 mg capsule [HHSC]

Facility

$94.33

Service Code	NDC 00004080085
Hospital Charge Code	2500619
Hospital Revenue Code	250
Min. Negotiated Rate	$80.18
Max. Negotiated Rate	$91.50
Rate for Payer: Cash Price	$61.31
Rate for Payer: Health Management Network Commercial	$80.18
Rate for Payer: Kaiser Permanente Commercial	$84.90
Rate for Payer: MDX Hawaii PPO	$91.50

Know your out-of-pocket cost for care.

All Charges