Samuel Mahelona Memorial Hospital

All Charges

Charge

Type

Setting

Price

PADDING CAST SOF-ROL NEEDLE-LOOMED RAYON LMB 4X4YD WH LF 12RL/CA, 6 BG/CA

Professional

Both

$6.00

Hospital Charge Code	12954854
Hospital Revenue Code	270
Min. Negotiated Rate	$5.10
Max. Negotiated Rate	$5.10
Rate for Payer: Cash Price	$3.90
Rate for Payer: Health Management Network Commercial	$5.10

PADDING CAST SOF-ROL NEEDLE-LOOMED RAYON LMB 4X4YD WH LF 12RL/CA, 6 BG/CA

Facility

$6.00

Hospital Charge Code	12954854
Hospital Revenue Code	270
Min. Negotiated Rate	$5.10
Max. Negotiated Rate	$5.82
Rate for Payer: Cash Price	$3.90
Rate for Payer: Health Management Network Commercial	$5.10
Rate for Payer: Kaiser Permanente Commercial	$5.40
Rate for Payer: MDX Hawaii PPO	$5.82

PADDING CAST SOF-ROL RAYON LIMB 2X4YD WHITE LF 24RL/CA, 6 BG/CA

Professional

Both

$4.00

Hospital Charge Code	12954874
Hospital Revenue Code	270
Min. Negotiated Rate	$3.40
Max. Negotiated Rate	$3.40
Rate for Payer: Cash Price	$2.60
Rate for Payer: Health Management Network Commercial	$3.40

PADDING CAST SOF-ROL RAYON LIMB 2X4YD WHITE LF 24RL/CA, 6 BG/CA

Facility

$4.00

Hospital Charge Code	12954874
Hospital Revenue Code	270
Min. Negotiated Rate	$3.40
Max. Negotiated Rate	$3.88
Rate for Payer: Cash Price	$2.60
Rate for Payer: Health Management Network Commercial	$3.40
Rate for Payer: Kaiser Permanente Commercial	$3.60
Rate for Payer: MDX Hawaii PPO	$3.88

PADDING CAST SOF-ROL RAYON LIMB 2X4YD WHITE LF 24RL/CA, 6 BG/CA

Facility

$4.00

Hospital Charge Code	12954874
Hospital Revenue Code	270
Min. Negotiated Rate	$2.00
Max. Negotiated Rate	$3.88
Rate for Payer: AlohaCare Medicaid	$2.00
Rate for Payer: AlohaCare Medicare	$2.00
Rate for Payer: Cash Price	$2.60
Rate for Payer: Devoted Health Medicare	$2.20
Rate for Payer: Hawaii Medical Service Association Medicare	$2.00
Rate for Payer: Hawaii Western Management Group Commercial	$3.80
Rate for Payer: Health Management Network Commercial	$3.40
Rate for Payer: Humana Medicare	$2.00
Rate for Payer: Kaiser Permanente Commercial	$3.60
Rate for Payer: Kaiser Permanente Medicaid	$2.04
Rate for Payer: Kaiser Permanente Medicare	$2.00
Rate for Payer: MDX Hawaii PPO	$3.88
Rate for Payer: Ohana Health Plan Medicaid	$2.00
Rate for Payer: Ohana Health Plan Medicare	$2.00
Rate for Payer: UnitedHealthcare Medicare	$2.00
Rate for Payer: University Health Alliance Commercial	$2.92

PADDING CAST SPECIALIST 100 COTTON LIMB 2X4YD WHITE LF 24RL/CA, 6 BG/CA

Facility

$6.00

Hospital Charge Code	12954879
Hospital Revenue Code	272
Min. Negotiated Rate	$5.10
Max. Negotiated Rate	$5.82
Rate for Payer: Cash Price	$3.90
Rate for Payer: Health Management Network Commercial	$5.10
Rate for Payer: Kaiser Permanente Commercial	$5.40
Rate for Payer: MDX Hawaii PPO	$5.82

PADDING CAST SPECIALIST 100 COTTON LIMB 2X4YD WHITE LF 24RL/CA, 6 BG/CA

Facility

$6.00

Hospital Charge Code	12954879
Hospital Revenue Code	272
Min. Negotiated Rate	$3.00
Max. Negotiated Rate	$5.82
Rate for Payer: AlohaCare Medicaid	$3.00
Rate for Payer: AlohaCare Medicare	$3.00
Rate for Payer: Cash Price	$3.90
Rate for Payer: Devoted Health Medicare	$3.30
Rate for Payer: Hawaii Medical Service Association Medicare	$3.00
Rate for Payer: Hawaii Western Management Group Commercial	$5.70
Rate for Payer: Health Management Network Commercial	$5.10
Rate for Payer: Humana Medicare	$3.00
Rate for Payer: Kaiser Permanente Commercial	$5.40
Rate for Payer: Kaiser Permanente Medicaid	$3.06
Rate for Payer: Kaiser Permanente Medicare	$3.00
Rate for Payer: MDX Hawaii PPO	$5.82
Rate for Payer: Ohana Health Plan Medicaid	$3.00
Rate for Payer: Ohana Health Plan Medicare	$3.00
Rate for Payer: UnitedHealthcare Medicare	$3.00
Rate for Payer: University Health Alliance Commercial	$4.37

PADDING CAST SPECIALIST 100 COTTON LIMB 2X4YD WHITE LF 24RL/CA, 6 BG/CA

Professional

Both

$6.00

Hospital Charge Code	12954879
Hospital Revenue Code	272
Min. Negotiated Rate	$5.10
Max. Negotiated Rate	$5.10
Rate for Payer: Cash Price	$3.90
Rate for Payer: Health Management Network Commercial	$5.10

PADDING CAST SPECIALIST 100 COTTON LIMB 3X4YD WHITE LF 12RL/CA, 6 BG/CA

Facility

$8.00

Hospital Charge Code	12954857
Hospital Revenue Code	272
Min. Negotiated Rate	$4.00
Max. Negotiated Rate	$7.76
Rate for Payer: AlohaCare Medicaid	$4.00
Rate for Payer: AlohaCare Medicare	$4.00
Rate for Payer: Cash Price	$5.20
Rate for Payer: Devoted Health Medicare	$4.40
Rate for Payer: Hawaii Medical Service Association Medicare	$4.00
Rate for Payer: Hawaii Western Management Group Commercial	$7.60
Rate for Payer: Health Management Network Commercial	$6.80
Rate for Payer: Humana Medicare	$4.00
Rate for Payer: Kaiser Permanente Commercial	$7.20
Rate for Payer: Kaiser Permanente Medicaid	$4.08
Rate for Payer: Kaiser Permanente Medicare	$4.00
Rate for Payer: MDX Hawaii PPO	$7.76
Rate for Payer: Ohana Health Plan Medicaid	$4.00
Rate for Payer: Ohana Health Plan Medicare	$4.00
Rate for Payer: UnitedHealthcare Medicare	$4.00
Rate for Payer: University Health Alliance Commercial	$5.83

PADDING CAST SPECIALIST 100 COTTON LIMB 3X4YD WHITE LF 12RL/CA, 6 BG/CA

Facility

$8.00

Hospital Charge Code	12954857
Hospital Revenue Code	272
Min. Negotiated Rate	$6.80
Max. Negotiated Rate	$7.76
Rate for Payer: Cash Price	$5.20
Rate for Payer: Health Management Network Commercial	$6.80
Rate for Payer: Kaiser Permanente Commercial	$7.20
Rate for Payer: MDX Hawaii PPO	$7.76

PADDING CAST SPECIALIST 100 COTTON LIMB 3X4YD WHITE LF 12RL/CA, 6 BG/CA

Professional

Both

$8.00

Hospital Charge Code	12954857
Hospital Revenue Code	272
Min. Negotiated Rate	$6.80
Max. Negotiated Rate	$6.80
Rate for Payer: Cash Price	$5.20
Rate for Payer: Health Management Network Commercial	$6.80

PADDING CAST SPECIALIST 100 COTTON LIMB RL 3X4YD WHITE LF 50/CA

Professional

Both

$12.00

Hospital Charge Code	12954873
Hospital Revenue Code	270
Min. Negotiated Rate	$10.20
Max. Negotiated Rate	$10.20
Rate for Payer: Cash Price	$7.80
Rate for Payer: Health Management Network Commercial	$10.20

PADDING CAST SPECIALIST 100 COTTON LIMB RL 3X4YD WHITE LF 50/CA

Facility

$12.00

Hospital Charge Code	12954873
Hospital Revenue Code	270
Min. Negotiated Rate	$10.20
Max. Negotiated Rate	$11.64
Rate for Payer: Cash Price	$7.80
Rate for Payer: Health Management Network Commercial	$10.20
Rate for Payer: Kaiser Permanente Commercial	$10.80
Rate for Payer: MDX Hawaii PPO	$11.64

PADDING CAST SPECIALIST 100 COTTON LIMB RL 3X4YD WHITE LF 50/CA

Facility

$12.00

Hospital Charge Code	12954873
Hospital Revenue Code	270
Min. Negotiated Rate	$6.00
Max. Negotiated Rate	$11.64
Rate for Payer: AlohaCare Medicaid	$6.00
Rate for Payer: AlohaCare Medicare	$6.00
Rate for Payer: Cash Price	$7.80
Rate for Payer: Devoted Health Medicare	$6.60
Rate for Payer: Hawaii Medical Service Association Medicare	$6.00
Rate for Payer: Hawaii Western Management Group Commercial	$11.40
Rate for Payer: Health Management Network Commercial	$10.20
Rate for Payer: Humana Medicare	$6.00
Rate for Payer: Kaiser Permanente Commercial	$10.80
Rate for Payer: Kaiser Permanente Medicaid	$6.12
Rate for Payer: Kaiser Permanente Medicare	$6.00
Rate for Payer: MDX Hawaii PPO	$11.64
Rate for Payer: Ohana Health Plan Medicaid	$6.00
Rate for Payer: Ohana Health Plan Medicare	$6.00
Rate for Payer: UnitedHealthcare Medicare	$6.00
Rate for Payer: University Health Alliance Commercial	$8.75

PADDING CAST SPECIALIST COTTON 2X4 LF 50/CA

Facility

$10.00

Hospital Charge Code	12957410
Hospital Revenue Code	270
Min. Negotiated Rate	$8.50
Max. Negotiated Rate	$9.70
Rate for Payer: Cash Price	$6.50
Rate for Payer: Health Management Network Commercial	$8.50
Rate for Payer: Kaiser Permanente Commercial	$9.00
Rate for Payer: MDX Hawaii PPO	$9.70

PADDING CAST SPECIALIST COTTON 2X4 LF 50/CA

Facility

$10.00

Hospital Charge Code	12957410
Hospital Revenue Code	270
Min. Negotiated Rate	$5.00
Max. Negotiated Rate	$9.70
Rate for Payer: AlohaCare Medicaid	$5.00
Rate for Payer: AlohaCare Medicare	$5.00
Rate for Payer: Cash Price	$6.50
Rate for Payer: Devoted Health Medicare	$5.50
Rate for Payer: Hawaii Medical Service Association Medicare	$5.00
Rate for Payer: Hawaii Western Management Group Commercial	$9.50
Rate for Payer: Health Management Network Commercial	$8.50
Rate for Payer: Humana Medicare	$5.00
Rate for Payer: Kaiser Permanente Commercial	$9.00
Rate for Payer: Kaiser Permanente Medicaid	$5.10
Rate for Payer: Kaiser Permanente Medicare	$5.00
Rate for Payer: MDX Hawaii PPO	$9.70
Rate for Payer: Ohana Health Plan Medicaid	$5.00
Rate for Payer: Ohana Health Plan Medicare	$5.00
Rate for Payer: UnitedHealthcare Medicare	$5.00
Rate for Payer: University Health Alliance Commercial	$7.29

PADDING CAST SPECIALIST COTTON 2X4 LF 50/CA

Professional

Both

$10.00

Hospital Charge Code	12957410
Hospital Revenue Code	270
Min. Negotiated Rate	$8.50
Max. Negotiated Rate	$8.50
Rate for Payer: Cash Price	$6.50
Rate for Payer: Health Management Network Commercial	$8.50

PADDING CAST SPECIALIST COTTON 4X4 LF 25/CA

Facility

$16.00

Hospital Charge Code	12954850
Hospital Revenue Code	270
Min. Negotiated Rate	$13.60
Max. Negotiated Rate	$15.52
Rate for Payer: Cash Price	$10.40
Rate for Payer: Health Management Network Commercial	$13.60
Rate for Payer: Kaiser Permanente Commercial	$14.40
Rate for Payer: MDX Hawaii PPO	$15.52

PADDING CAST SPECIALIST COTTON 4X4 LF 25/CA

Professional

Both

$16.00

Hospital Charge Code	12954850
Hospital Revenue Code	270
Min. Negotiated Rate	$13.60
Max. Negotiated Rate	$13.60
Rate for Payer: Cash Price	$10.40
Rate for Payer: Health Management Network Commercial	$13.60

PADDING CAST SPECIALIST COTTON 4X4 LF 25/CA

Facility

$16.00

Hospital Charge Code	12954850
Hospital Revenue Code	270
Min. Negotiated Rate	$8.00
Max. Negotiated Rate	$15.52
Rate for Payer: AlohaCare Medicaid	$8.00
Rate for Payer: AlohaCare Medicare	$8.00
Rate for Payer: Cash Price	$10.40
Rate for Payer: Devoted Health Medicare	$8.80
Rate for Payer: Hawaii Medical Service Association Medicare	$8.00
Rate for Payer: Hawaii Western Management Group Commercial	$15.20
Rate for Payer: Health Management Network Commercial	$13.60
Rate for Payer: Humana Medicare	$8.00
Rate for Payer: Kaiser Permanente Commercial	$14.40
Rate for Payer: Kaiser Permanente Medicaid	$8.16
Rate for Payer: Kaiser Permanente Medicare	$8.00
Rate for Payer: MDX Hawaii PPO	$15.52
Rate for Payer: Ohana Health Plan Medicaid	$8.00
Rate for Payer: Ohana Health Plan Medicare	$8.00
Rate for Payer: UnitedHealthcare Medicare	$8.00
Rate for Payer: University Health Alliance Commercial	$11.66

PADDING CAST SPECIALIST COTTON/ RAYON LIMB 2X4YD WH LF 24RL/CA, 6 BG/CA

Facility

$4.00

Hospital Charge Code	12954851
Hospital Revenue Code	270
Min. Negotiated Rate	$3.40
Max. Negotiated Rate	$3.88
Rate for Payer: Cash Price	$2.60
Rate for Payer: Health Management Network Commercial	$3.40
Rate for Payer: Kaiser Permanente Commercial	$3.60
Rate for Payer: MDX Hawaii PPO	$3.88

PADDING CAST SPECIALIST COTTON/ RAYON LIMB 2X4YD WH LF 24RL/CA, 6 BG/CA

Facility

$4.00

Hospital Charge Code	12954851
Hospital Revenue Code	270
Min. Negotiated Rate	$2.00
Max. Negotiated Rate	$3.88
Rate for Payer: AlohaCare Medicaid	$2.00
Rate for Payer: AlohaCare Medicare	$2.00
Rate for Payer: Cash Price	$2.60
Rate for Payer: Devoted Health Medicare	$2.20
Rate for Payer: Hawaii Medical Service Association Medicare	$2.00
Rate for Payer: Hawaii Western Management Group Commercial	$3.80
Rate for Payer: Health Management Network Commercial	$3.40
Rate for Payer: Humana Medicare	$2.00
Rate for Payer: Kaiser Permanente Commercial	$3.60
Rate for Payer: Kaiser Permanente Medicaid	$2.04
Rate for Payer: Kaiser Permanente Medicare	$2.00
Rate for Payer: MDX Hawaii PPO	$3.88
Rate for Payer: Ohana Health Plan Medicaid	$2.00
Rate for Payer: Ohana Health Plan Medicare	$2.00
Rate for Payer: UnitedHealthcare Medicare	$2.00
Rate for Payer: University Health Alliance Commercial	$2.92

PADDING CAST SPECIALIST COTTON/ RAYON LIMB 2X4YD WH LF 24RL/CA, 6 BG/CA

Professional

Both

$4.00

Hospital Charge Code	12954851
Hospital Revenue Code	270
Min. Negotiated Rate	$3.40
Max. Negotiated Rate	$3.40
Rate for Payer: Cash Price	$2.60
Rate for Payer: Health Management Network Commercial	$3.40

PADDING CAST SPECIALIST COTTON/ RAYON LIMB 3X4YD WH LF 12RL/CA, 6 BG/CA

Facility

$6.00

Hospital Charge Code	12954852
Hospital Revenue Code	270
Min. Negotiated Rate	$3.00
Max. Negotiated Rate	$5.82
Rate for Payer: AlohaCare Medicaid	$3.00
Rate for Payer: AlohaCare Medicare	$3.00
Rate for Payer: Cash Price	$3.90
Rate for Payer: Devoted Health Medicare	$3.30
Rate for Payer: Hawaii Medical Service Association Medicare	$3.00
Rate for Payer: Hawaii Western Management Group Commercial	$5.70
Rate for Payer: Health Management Network Commercial	$5.10
Rate for Payer: Humana Medicare	$3.00
Rate for Payer: Kaiser Permanente Commercial	$5.40
Rate for Payer: Kaiser Permanente Medicaid	$3.06
Rate for Payer: Kaiser Permanente Medicare	$3.00
Rate for Payer: MDX Hawaii PPO	$5.82
Rate for Payer: Ohana Health Plan Medicaid	$3.00
Rate for Payer: Ohana Health Plan Medicare	$3.00
Rate for Payer: UnitedHealthcare Medicare	$3.00
Rate for Payer: University Health Alliance Commercial	$4.37

PADDING CAST SPECIALIST COTTON/ RAYON LIMB 3X4YD WH LF 12RL/CA, 6 BG/CA

Professional

Both

$6.00

Hospital Charge Code	12954852
Hospital Revenue Code	270
Min. Negotiated Rate	$5.10
Max. Negotiated Rate	$5.10
Rate for Payer: Cash Price	$3.90
Rate for Payer: Health Management Network Commercial	$5.10

Know your out-of-pocket cost for care.

All Charges