Samuel Mahelona Memorial Hospital

All Charges

Charge

Type

Setting

Price

STAPLER, GEN DST SERIES EEA 28MM

Facility

$999.00

Hospital Charge Code	8274185
Hospital Revenue Code	272
Min. Negotiated Rate	$499.50
Max. Negotiated Rate	$969.03
Rate for Payer: AlohaCare Medicaid	$499.50
Rate for Payer: AlohaCare Medicare	$499.50
Rate for Payer: Cash Price	$649.35
Rate for Payer: Devoted Health Medicare	$549.45
Rate for Payer: Hawaii Medical Service Association Medicare	$499.50
Rate for Payer: Hawaii Western Management Group Commercial	$949.05
Rate for Payer: Health Management Network Commercial	$849.15
Rate for Payer: Humana Medicare	$499.50
Rate for Payer: Kaiser Permanente Commercial	$899.10
Rate for Payer: Kaiser Permanente Medicaid	$509.49
Rate for Payer: Kaiser Permanente Medicare	$499.50
Rate for Payer: MDX Hawaii PPO	$969.03
Rate for Payer: Ohana Health Plan Medicaid	$499.50
Rate for Payer: Ohana Health Plan Medicare	$499.50
Rate for Payer: UnitedHealthcare Medicare	$499.50
Rate for Payer: University Health Alliance Commercial	$728.17

STAPLER, GEN DST SERIES EEA 31MM

Facility

$999.00

Hospital Charge Code	8274186
Hospital Revenue Code	272
Min. Negotiated Rate	$849.15
Max. Negotiated Rate	$969.03
Rate for Payer: Cash Price	$649.35
Rate for Payer: Health Management Network Commercial	$849.15
Rate for Payer: Kaiser Permanente Commercial	$899.10
Rate for Payer: MDX Hawaii PPO	$969.03

STAPLER, GEN DST SERIES EEA 31MM

Facility

$999.00

Hospital Charge Code	8274186
Hospital Revenue Code	272
Min. Negotiated Rate	$499.50
Max. Negotiated Rate	$969.03
Rate for Payer: AlohaCare Medicaid	$499.50
Rate for Payer: AlohaCare Medicare	$499.50
Rate for Payer: Cash Price	$649.35
Rate for Payer: Devoted Health Medicare	$549.45
Rate for Payer: Hawaii Medical Service Association Medicare	$499.50
Rate for Payer: Hawaii Western Management Group Commercial	$949.05
Rate for Payer: Health Management Network Commercial	$849.15
Rate for Payer: Humana Medicare	$499.50
Rate for Payer: Kaiser Permanente Commercial	$899.10
Rate for Payer: Kaiser Permanente Medicaid	$509.49
Rate for Payer: Kaiser Permanente Medicare	$499.50
Rate for Payer: MDX Hawaii PPO	$969.03
Rate for Payer: Ohana Health Plan Medicaid	$499.50
Rate for Payer: Ohana Health Plan Medicare	$499.50
Rate for Payer: UnitedHealthcare Medicare	$499.50
Rate for Payer: University Health Alliance Commercial	$728.17

STAPLER, GEN DST SERIES EEA 35MM

Facility

$921.00

Hospital Charge Code	8274187
Hospital Revenue Code	272
Min. Negotiated Rate	$460.50
Max. Negotiated Rate	$893.37
Rate for Payer: AlohaCare Medicaid	$460.50
Rate for Payer: AlohaCare Medicare	$460.50
Rate for Payer: Cash Price	$598.65
Rate for Payer: Devoted Health Medicare	$506.55
Rate for Payer: Hawaii Medical Service Association Medicare	$460.50
Rate for Payer: Hawaii Western Management Group Commercial	$874.95
Rate for Payer: Health Management Network Commercial	$782.85
Rate for Payer: Humana Medicare	$460.50
Rate for Payer: Kaiser Permanente Commercial	$828.90
Rate for Payer: Kaiser Permanente Medicaid	$469.71
Rate for Payer: Kaiser Permanente Medicare	$460.50
Rate for Payer: MDX Hawaii PPO	$893.37
Rate for Payer: Ohana Health Plan Medicaid	$460.50
Rate for Payer: Ohana Health Plan Medicare	$460.50
Rate for Payer: UnitedHealthcare Medicare	$460.50
Rate for Payer: University Health Alliance Commercial	$671.32

STAPLER, GEN DST SERIES EEA 35MM

Facility

$921.00

Hospital Charge Code	8274187
Hospital Revenue Code	272
Min. Negotiated Rate	$782.85
Max. Negotiated Rate	$893.37
Rate for Payer: Cash Price	$598.65
Rate for Payer: Health Management Network Commercial	$782.85
Rate for Payer: Kaiser Permanente Commercial	$828.90
Rate for Payer: MDX Hawaii PPO	$893.37

STAPLER SKIN DISP 35W

Facility

$34.00

Hospital Charge Code	8266346
Hospital Revenue Code	272
Min. Negotiated Rate	$17.00
Max. Negotiated Rate	$32.98
Rate for Payer: AlohaCare Medicaid	$17.00
Rate for Payer: AlohaCare Medicare	$17.00
Rate for Payer: Cash Price	$22.10
Rate for Payer: Devoted Health Medicare	$18.70
Rate for Payer: Hawaii Medical Service Association Medicare	$17.00
Rate for Payer: Hawaii Western Management Group Commercial	$32.30
Rate for Payer: Health Management Network Commercial	$28.90
Rate for Payer: Humana Medicare	$17.00
Rate for Payer: Kaiser Permanente Commercial	$30.60
Rate for Payer: Kaiser Permanente Medicaid	$17.34
Rate for Payer: Kaiser Permanente Medicare	$17.00
Rate for Payer: MDX Hawaii PPO	$32.98
Rate for Payer: Ohana Health Plan Medicaid	$17.00
Rate for Payer: Ohana Health Plan Medicare	$17.00
Rate for Payer: UnitedHealthcare Medicare	$17.00
Rate for Payer: University Health Alliance Commercial	$24.78

STAPLER SKIN DISP 35W

Facility

$34.00

Hospital Charge Code	8266346
Hospital Revenue Code	272
Min. Negotiated Rate	$28.90
Max. Negotiated Rate	$32.98
Rate for Payer: Cash Price	$22.10
Rate for Payer: Health Management Network Commercial	$28.90
Rate for Payer: Kaiser Permanente Commercial	$30.60
Rate for Payer: MDX Hawaii PPO	$32.98

STAPLER, SKIN SUBCUTICULAR GYN INSORB

Facility

$330.00

Hospital Charge Code	8274440
Hospital Revenue Code	272
Min. Negotiated Rate	$280.50
Max. Negotiated Rate	$320.10
Rate for Payer: Cash Price	$214.50
Rate for Payer: Health Management Network Commercial	$280.50
Rate for Payer: Kaiser Permanente Commercial	$297.00
Rate for Payer: MDX Hawaii PPO	$320.10

STAPLER, SKIN SUBCUTICULAR GYN INSORB

Facility

$330.00

Hospital Charge Code	8274440
Hospital Revenue Code	272
Min. Negotiated Rate	$165.00
Max. Negotiated Rate	$320.10
Rate for Payer: AlohaCare Medicaid	$165.00
Rate for Payer: AlohaCare Medicare	$165.00
Rate for Payer: Cash Price	$214.50
Rate for Payer: Devoted Health Medicare	$181.50
Rate for Payer: Hawaii Medical Service Association Medicare	$165.00
Rate for Payer: Hawaii Western Management Group Commercial	$313.50
Rate for Payer: Health Management Network Commercial	$280.50
Rate for Payer: Humana Medicare	$165.00
Rate for Payer: Kaiser Permanente Commercial	$297.00
Rate for Payer: Kaiser Permanente Medicaid	$168.30
Rate for Payer: Kaiser Permanente Medicare	$165.00
Rate for Payer: MDX Hawaii PPO	$320.10
Rate for Payer: Ohana Health Plan Medicaid	$165.00
Rate for Payer: Ohana Health Plan Medicare	$165.00
Rate for Payer: UnitedHealthcare Medicare	$165.00
Rate for Payer: University Health Alliance Commercial	$240.54

STAPLER TA 30

Facility

$330.00

Hospital Charge Code	8336013
Hospital Revenue Code	272
Min. Negotiated Rate	$280.50
Max. Negotiated Rate	$320.10
Rate for Payer: Cash Price	$214.50
Rate for Payer: Health Management Network Commercial	$280.50
Rate for Payer: Kaiser Permanente Commercial	$297.00
Rate for Payer: MDX Hawaii PPO	$320.10

STAPLER TA 30

Facility

$330.00

Hospital Charge Code	8336013
Hospital Revenue Code	272
Min. Negotiated Rate	$165.00
Max. Negotiated Rate	$320.10
Rate for Payer: AlohaCare Medicaid	$165.00
Rate for Payer: AlohaCare Medicare	$165.00
Rate for Payer: Cash Price	$214.50
Rate for Payer: Devoted Health Medicare	$181.50
Rate for Payer: Hawaii Medical Service Association Medicare	$165.00
Rate for Payer: Hawaii Western Management Group Commercial	$313.50
Rate for Payer: Health Management Network Commercial	$280.50
Rate for Payer: Humana Medicare	$165.00
Rate for Payer: Kaiser Permanente Commercial	$297.00
Rate for Payer: Kaiser Permanente Medicaid	$168.30
Rate for Payer: Kaiser Permanente Medicare	$165.00
Rate for Payer: MDX Hawaii PPO	$320.10
Rate for Payer: Ohana Health Plan Medicaid	$165.00
Rate for Payer: Ohana Health Plan Medicare	$165.00
Rate for Payer: UnitedHealthcare Medicare	$165.00
Rate for Payer: University Health Alliance Commercial	$240.54

STAPLER TA 60

Facility

$299.00

Hospital Charge Code	8336015
Hospital Revenue Code	272
Min. Negotiated Rate	$149.50
Max. Negotiated Rate	$290.03
Rate for Payer: AlohaCare Medicaid	$149.50
Rate for Payer: AlohaCare Medicare	$149.50
Rate for Payer: Cash Price	$194.35
Rate for Payer: Devoted Health Medicare	$164.45
Rate for Payer: Hawaii Medical Service Association Medicare	$149.50
Rate for Payer: Hawaii Western Management Group Commercial	$284.05
Rate for Payer: Health Management Network Commercial	$254.15
Rate for Payer: Humana Medicare	$149.50
Rate for Payer: Kaiser Permanente Commercial	$269.10
Rate for Payer: Kaiser Permanente Medicaid	$152.49
Rate for Payer: Kaiser Permanente Medicare	$149.50
Rate for Payer: MDX Hawaii PPO	$290.03
Rate for Payer: Ohana Health Plan Medicaid	$149.50
Rate for Payer: Ohana Health Plan Medicare	$149.50
Rate for Payer: UnitedHealthcare Medicare	$149.50
Rate for Payer: University Health Alliance Commercial	$217.94

STAPLER TA 60

Facility

$299.00

Hospital Charge Code	8336015
Hospital Revenue Code	272
Min. Negotiated Rate	$254.15
Max. Negotiated Rate	$290.03
Rate for Payer: Cash Price	$194.35
Rate for Payer: Health Management Network Commercial	$254.15
Rate for Payer: Kaiser Permanente Commercial	$269.10
Rate for Payer: MDX Hawaii PPO	$290.03

STAPLER TA 90

Facility

$314.00

Hospital Charge Code	8336022
Hospital Revenue Code	272
Min. Negotiated Rate	$157.00
Max. Negotiated Rate	$304.58
Rate for Payer: AlohaCare Medicaid	$157.00
Rate for Payer: AlohaCare Medicare	$157.00
Rate for Payer: Cash Price	$204.10
Rate for Payer: Devoted Health Medicare	$172.70
Rate for Payer: Hawaii Medical Service Association Medicare	$157.00
Rate for Payer: Hawaii Western Management Group Commercial	$298.30
Rate for Payer: Health Management Network Commercial	$266.90
Rate for Payer: Humana Medicare	$157.00
Rate for Payer: Kaiser Permanente Commercial	$282.60
Rate for Payer: Kaiser Permanente Medicaid	$160.14
Rate for Payer: Kaiser Permanente Medicare	$157.00
Rate for Payer: MDX Hawaii PPO	$304.58
Rate for Payer: Ohana Health Plan Medicaid	$157.00
Rate for Payer: Ohana Health Plan Medicare	$157.00
Rate for Payer: UnitedHealthcare Medicare	$157.00
Rate for Payer: University Health Alliance Commercial	$228.87

STAPLER TA 90

Facility

$314.00

Hospital Charge Code	8336022
Hospital Revenue Code	272
Min. Negotiated Rate	$266.90
Max. Negotiated Rate	$304.58
Rate for Payer: Cash Price	$204.10
Rate for Payer: Health Management Network Commercial	$266.90
Rate for Payer: Kaiser Permanente Commercial	$282.60
Rate for Payer: MDX Hawaii PPO	$304.58

STAPLE, SURGICLIP PREMIUM MEDIUM

Facility

$212.00

Hospital Charge Code	8274255
Hospital Revenue Code	272
Min. Negotiated Rate	$180.20
Max. Negotiated Rate	$205.64
Rate for Payer: Cash Price	$137.80
Rate for Payer: Health Management Network Commercial	$180.20
Rate for Payer: Kaiser Permanente Commercial	$190.80
Rate for Payer: MDX Hawaii PPO	$205.64

STAPLE, SURGICLIP PREMIUM MEDIUM

Facility

$212.00

Hospital Charge Code	8274255
Hospital Revenue Code	272
Min. Negotiated Rate	$106.00
Max. Negotiated Rate	$205.64
Rate for Payer: AlohaCare Medicaid	$106.00
Rate for Payer: AlohaCare Medicare	$106.00
Rate for Payer: Cash Price	$137.80
Rate for Payer: Devoted Health Medicare	$116.60
Rate for Payer: Hawaii Medical Service Association Medicare	$106.00
Rate for Payer: Hawaii Western Management Group Commercial	$201.40
Rate for Payer: Health Management Network Commercial	$180.20
Rate for Payer: Humana Medicare	$106.00
Rate for Payer: Kaiser Permanente Commercial	$190.80
Rate for Payer: Kaiser Permanente Medicaid	$108.12
Rate for Payer: Kaiser Permanente Medicare	$106.00
Rate for Payer: MDX Hawaii PPO	$205.64
Rate for Payer: Ohana Health Plan Medicaid	$106.00
Rate for Payer: Ohana Health Plan Medicare	$106.00
Rate for Payer: UnitedHealthcare Medicare	$106.00
Rate for Payer: University Health Alliance Commercial	$154.53

STAPLE, SURGICLIP PREMIUM SMALL

Facility

$212.00

Hospital Charge Code	8274256
Hospital Revenue Code	272
Min. Negotiated Rate	$106.00
Max. Negotiated Rate	$205.64
Rate for Payer: AlohaCare Medicaid	$106.00
Rate for Payer: AlohaCare Medicare	$106.00
Rate for Payer: Cash Price	$137.80
Rate for Payer: Devoted Health Medicare	$116.60
Rate for Payer: Hawaii Medical Service Association Medicare	$106.00
Rate for Payer: Hawaii Western Management Group Commercial	$201.40
Rate for Payer: Health Management Network Commercial	$180.20
Rate for Payer: Humana Medicare	$106.00
Rate for Payer: Kaiser Permanente Commercial	$190.80
Rate for Payer: Kaiser Permanente Medicaid	$108.12
Rate for Payer: Kaiser Permanente Medicare	$106.00
Rate for Payer: MDX Hawaii PPO	$205.64
Rate for Payer: Ohana Health Plan Medicaid	$106.00
Rate for Payer: Ohana Health Plan Medicare	$106.00
Rate for Payer: UnitedHealthcare Medicare	$106.00
Rate for Payer: University Health Alliance Commercial	$154.53

STAPLE, SURGICLIP PREMIUM SMALL

Facility

$212.00

Hospital Charge Code	8274256
Hospital Revenue Code	272
Min. Negotiated Rate	$180.20
Max. Negotiated Rate	$205.64
Rate for Payer: Cash Price	$137.80
Rate for Payer: Health Management Network Commercial	$180.20
Rate for Payer: Kaiser Permanente Commercial	$190.80
Rate for Payer: MDX Hawaii PPO	$205.64

STAPLE, SURGICLIP SMALL

Facility

$241.00

Hospital Charge Code	8274289
Hospital Revenue Code	272
Min. Negotiated Rate	$120.50
Max. Negotiated Rate	$233.77
Rate for Payer: AlohaCare Medicaid	$120.50
Rate for Payer: AlohaCare Medicare	$120.50
Rate for Payer: Cash Price	$156.65
Rate for Payer: Devoted Health Medicare	$132.55
Rate for Payer: Hawaii Medical Service Association Medicare	$120.50
Rate for Payer: Hawaii Western Management Group Commercial	$228.95
Rate for Payer: Health Management Network Commercial	$204.85
Rate for Payer: Humana Medicare	$120.50
Rate for Payer: Kaiser Permanente Commercial	$216.90
Rate for Payer: Kaiser Permanente Medicaid	$122.91
Rate for Payer: Kaiser Permanente Medicare	$120.50
Rate for Payer: MDX Hawaii PPO	$233.77
Rate for Payer: Ohana Health Plan Medicaid	$120.50
Rate for Payer: Ohana Health Plan Medicare	$120.50
Rate for Payer: UnitedHealthcare Medicare	$120.50
Rate for Payer: University Health Alliance Commercial	$175.66

STAPLE, SURGICLIP SMALL

Facility

$241.00

Hospital Charge Code	8274289
Hospital Revenue Code	272
Min. Negotiated Rate	$204.85
Max. Negotiated Rate	$233.77
Rate for Payer: Cash Price	$156.65
Rate for Payer: Health Management Network Commercial	$204.85
Rate for Payer: Kaiser Permanente Commercial	$216.90
Rate for Payer: MDX Hawaii PPO	$233.77

STEREOTACTIC BIOPSY MARKER TUMARK Q

Facility

$315.00

Service Code	HCPCS A4648
Hospital Charge Code	13045676
Hospital Revenue Code	278
Min. Negotiated Rate	$176.40
Max. Negotiated Rate	$305.55
Rate for Payer: Cash Price	$204.75
Rate for Payer: Hawaii Western Management Group Commercial	$220.50
Rate for Payer: Health Management Network Commercial	$267.75
Rate for Payer: Kaiser Permanente Commercial	$283.50
Rate for Payer: MDX Hawaii PPO	$305.55
Rate for Payer: University Health Alliance Commercial	$176.40

STEREOTACTIC BIOPSY MARKER TUMARK Q

Facility

$315.00

Service Code	HCPCS A4648
Hospital Charge Code	13045676
Hospital Revenue Code	278
Min. Negotiated Rate	$157.50
Max. Negotiated Rate	$305.55
Rate for Payer: AlohaCare Medicaid	$157.50
Rate for Payer: AlohaCare Medicare	$157.50
Rate for Payer: Cash Price	$204.75
Rate for Payer: Devoted Health Medicare	$173.25
Rate for Payer: Hawaii Medical Service Association Medicare	$157.50
Rate for Payer: Hawaii Western Management Group Commercial	$220.50
Rate for Payer: Health Management Network Commercial	$267.75
Rate for Payer: Humana Medicare	$157.50
Rate for Payer: Kaiser Permanente Commercial	$283.50
Rate for Payer: Kaiser Permanente Medicaid	$160.65
Rate for Payer: Kaiser Permanente Medicare	$157.50
Rate for Payer: MDX Hawaii PPO	$305.55
Rate for Payer: Ohana Health Plan Medicaid	$157.50
Rate for Payer: Ohana Health Plan Medicare	$157.50
Rate for Payer: UnitedHealthcare Medicare	$157.50
Rate for Payer: University Health Alliance Commercial	$176.40

STEREOTACTIC BIOPSY MARKER TUMARK VISION

Facility

$413.00

Service Code	HCPCS A4648
Hospital Charge Code	13034588
Hospital Revenue Code	278
Min. Negotiated Rate	$231.28
Max. Negotiated Rate	$400.61
Rate for Payer: Cash Price	$268.45
Rate for Payer: Hawaii Western Management Group Commercial	$289.10
Rate for Payer: Health Management Network Commercial	$351.05
Rate for Payer: Kaiser Permanente Commercial	$371.70
Rate for Payer: MDX Hawaii PPO	$400.61
Rate for Payer: University Health Alliance Commercial	$231.28

STEREOTACTIC BIOPSY MARKER TUMARK VISION

Facility

$413.00

Service Code	HCPCS A4648
Hospital Charge Code	13034588
Hospital Revenue Code	278
Min. Negotiated Rate	$206.50
Max. Negotiated Rate	$400.61
Rate for Payer: AlohaCare Medicaid	$206.50
Rate for Payer: AlohaCare Medicare	$206.50
Rate for Payer: Cash Price	$268.45
Rate for Payer: Devoted Health Medicare	$227.15
Rate for Payer: Hawaii Medical Service Association Medicare	$206.50
Rate for Payer: Hawaii Western Management Group Commercial	$289.10
Rate for Payer: Health Management Network Commercial	$351.05
Rate for Payer: Humana Medicare	$206.50
Rate for Payer: Kaiser Permanente Commercial	$371.70
Rate for Payer: Kaiser Permanente Medicaid	$210.63
Rate for Payer: Kaiser Permanente Medicare	$206.50
Rate for Payer: MDX Hawaii PPO	$400.61
Rate for Payer: Ohana Health Plan Medicaid	$206.50
Rate for Payer: Ohana Health Plan Medicare	$206.50
Rate for Payer: UnitedHealthcare Medicare	$206.50
Rate for Payer: University Health Alliance Commercial	$231.28

Know your out-of-pocket cost for care.

All Charges