Samuel Mahelona Memorial Hospital

All Charges

Charge

Type

Setting

Price

sterile water for irrig 500 ml [HHSC]

Facility

$9.34

Service Code	HCPCS A4217
Hospital Charge Code	2500796
Hospital Revenue Code	250
Min. Negotiated Rate	$7.94
Max. Negotiated Rate	$9.06
Rate for Payer: Cash Price	$6.07
Rate for Payer: Health Management Network Commercial	$7.94
Rate for Payer: Kaiser Permanente Commercial	$8.41
Rate for Payer: MDX Hawaii PPO	$9.06

sterile water for irrig 500 ml [HHSC]

Facility

$9.34

Service Code	HCPCS A4217
Hospital Charge Code	2500796
Hospital Revenue Code	272
Min. Negotiated Rate	$2.43
Max. Negotiated Rate	$9.06
Rate for Payer: AlohaCare Medicaid	$4.67
Rate for Payer: AlohaCare Medicare	$4.67
Rate for Payer: Cash Price	$6.07
Rate for Payer: Cash Price	$6.07
Rate for Payer: Devoted Health Medicare	$5.14
Rate for Payer: Hawaii Medical Service Association Medicare	$4.67
Rate for Payer: Hawaii Western Management Group Commercial	$8.87
Rate for Payer: Health Management Network Commercial	$7.94
Rate for Payer: Humana Medicare	$4.67
Rate for Payer: Kaiser Permanente Commercial	$8.41
Rate for Payer: Kaiser Permanente Medicaid	$4.76
Rate for Payer: Kaiser Permanente Medicare	$4.67
Rate for Payer: MDX Hawaii PPO	$9.06
Rate for Payer: Ohana Health Plan Medicaid	$4.67
Rate for Payer: Ohana Health Plan Medicare	$4.67
Rate for Payer: UnitedHealthcare Medicaid	$2.43
Rate for Payer: UnitedHealthcare Medicare	$4.67
Rate for Payer: University Health Alliance Commercial	$6.81

STOCKINETTE PROTOUCH 2X25YD COTTON NS EA

Facility

$77.00

Hospital Charge Code	12954856
Hospital Revenue Code	272
Min. Negotiated Rate	$65.45
Max. Negotiated Rate	$74.69
Rate for Payer: Cash Price	$50.05
Rate for Payer: Health Management Network Commercial	$65.45
Rate for Payer: Kaiser Permanente Commercial	$69.30
Rate for Payer: MDX Hawaii PPO	$74.69

STOCKINETTE PROTOUCH 2X25YD COTTON NS EA

Facility

$77.00

Hospital Charge Code	12954856
Hospital Revenue Code	272
Min. Negotiated Rate	$38.50
Max. Negotiated Rate	$74.69
Rate for Payer: AlohaCare Medicaid	$38.50
Rate for Payer: AlohaCare Medicare	$38.50
Rate for Payer: Cash Price	$50.05
Rate for Payer: Devoted Health Medicare	$42.35
Rate for Payer: Hawaii Medical Service Association Medicare	$38.50
Rate for Payer: Hawaii Western Management Group Commercial	$73.15
Rate for Payer: Health Management Network Commercial	$65.45
Rate for Payer: Humana Medicare	$38.50
Rate for Payer: Kaiser Permanente Commercial	$69.30
Rate for Payer: Kaiser Permanente Medicaid	$39.27
Rate for Payer: Kaiser Permanente Medicare	$38.50
Rate for Payer: MDX Hawaii PPO	$74.69
Rate for Payer: Ohana Health Plan Medicaid	$38.50
Rate for Payer: Ohana Health Plan Medicare	$38.50
Rate for Payer: UnitedHealthcare Medicare	$38.50
Rate for Payer: University Health Alliance Commercial	$56.13

STOCKINETTE PROTOUCH 2X25YD COTTON NS EA

Professional

Both

$77.00

Hospital Charge Code	12954856
Hospital Revenue Code	272
Min. Negotiated Rate	$65.45
Max. Negotiated Rate	$65.45
Rate for Payer: Cash Price	$50.05
Rate for Payer: Health Management Network Commercial	$65.45

STOCKINETTE PROTOUCH 3X25YD COTTON EA

Facility

$93.00

Hospital Charge Code	12954864
Hospital Revenue Code	272
Min. Negotiated Rate	$79.05
Max. Negotiated Rate	$90.21
Rate for Payer: Cash Price	$60.45
Rate for Payer: Health Management Network Commercial	$79.05
Rate for Payer: Kaiser Permanente Commercial	$83.70
Rate for Payer: MDX Hawaii PPO	$90.21

STOCKINETTE PROTOUCH 3X25YD COTTON EA

Facility

$93.00

Hospital Charge Code	12954864
Hospital Revenue Code	272
Min. Negotiated Rate	$46.50
Max. Negotiated Rate	$90.21
Rate for Payer: AlohaCare Medicaid	$46.50
Rate for Payer: AlohaCare Medicare	$46.50
Rate for Payer: Cash Price	$60.45
Rate for Payer: Devoted Health Medicare	$51.15
Rate for Payer: Hawaii Medical Service Association Medicare	$46.50
Rate for Payer: Hawaii Western Management Group Commercial	$88.35
Rate for Payer: Health Management Network Commercial	$79.05
Rate for Payer: Humana Medicare	$46.50
Rate for Payer: Kaiser Permanente Commercial	$83.70
Rate for Payer: Kaiser Permanente Medicaid	$47.43
Rate for Payer: Kaiser Permanente Medicare	$46.50
Rate for Payer: MDX Hawaii PPO	$90.21
Rate for Payer: Ohana Health Plan Medicaid	$46.50
Rate for Payer: Ohana Health Plan Medicare	$46.50
Rate for Payer: UnitedHealthcare Medicare	$46.50
Rate for Payer: University Health Alliance Commercial	$67.79

STOCKINETTE PROTOUCH 3X25YD COTTON EA

Professional

Both

$93.00

Hospital Charge Code	12954864
Hospital Revenue Code	272
Min. Negotiated Rate	$79.05
Max. Negotiated Rate	$79.05
Rate for Payer: Cash Price	$60.45
Rate for Payer: Health Management Network Commercial	$79.05

STOCKINETTE PROTOUCH TUBULAR 4X25YD COTTON WHITE EA

Facility

$119.00

Hospital Charge Code	12954865
Hospital Revenue Code	272
Min. Negotiated Rate	$101.15
Max. Negotiated Rate	$115.43
Rate for Payer: Cash Price	$77.35
Rate for Payer: Health Management Network Commercial	$101.15
Rate for Payer: Kaiser Permanente Commercial	$107.10
Rate for Payer: MDX Hawaii PPO	$115.43

STOCKINETTE PROTOUCH TUBULAR 4X25YD COTTON WHITE EA

Professional

Both

$119.00

Hospital Charge Code	12954865
Hospital Revenue Code	272
Min. Negotiated Rate	$101.15
Max. Negotiated Rate	$101.15
Rate for Payer: Cash Price	$77.35
Rate for Payer: Health Management Network Commercial	$101.15

STOCKINETTE PROTOUCH TUBULAR 4X25YD COTTON WHITE EA

Facility

$119.00

Hospital Charge Code	12954865
Hospital Revenue Code	272
Min. Negotiated Rate	$59.50
Max. Negotiated Rate	$115.43
Rate for Payer: AlohaCare Medicaid	$59.50
Rate for Payer: AlohaCare Medicare	$59.50
Rate for Payer: Cash Price	$77.35
Rate for Payer: Devoted Health Medicare	$65.45
Rate for Payer: Hawaii Medical Service Association Medicare	$59.50
Rate for Payer: Hawaii Western Management Group Commercial	$113.05
Rate for Payer: Health Management Network Commercial	$101.15
Rate for Payer: Humana Medicare	$59.50
Rate for Payer: Kaiser Permanente Commercial	$107.10
Rate for Payer: Kaiser Permanente Medicaid	$60.69
Rate for Payer: Kaiser Permanente Medicare	$59.50
Rate for Payer: MDX Hawaii PPO	$115.43
Rate for Payer: Ohana Health Plan Medicaid	$59.50
Rate for Payer: Ohana Health Plan Medicare	$59.50
Rate for Payer: UnitedHealthcare Medicare	$59.50
Rate for Payer: University Health Alliance Commercial	$86.74

STOCKINETTE UNDERCAST PROTOUCH ROLL 1/BX

Facility

$57.00

Hospital Charge Code	12954855
Hospital Revenue Code	272
Min. Negotiated Rate	$28.50
Max. Negotiated Rate	$55.29
Rate for Payer: AlohaCare Medicaid	$28.50
Rate for Payer: AlohaCare Medicare	$28.50
Rate for Payer: Cash Price	$37.05
Rate for Payer: Devoted Health Medicare	$31.35
Rate for Payer: Hawaii Medical Service Association Medicare	$28.50
Rate for Payer: Hawaii Western Management Group Commercial	$54.15
Rate for Payer: Health Management Network Commercial	$48.45
Rate for Payer: Humana Medicare	$28.50
Rate for Payer: Kaiser Permanente Commercial	$51.30
Rate for Payer: Kaiser Permanente Medicaid	$29.07
Rate for Payer: Kaiser Permanente Medicare	$28.50
Rate for Payer: MDX Hawaii PPO	$55.29
Rate for Payer: Ohana Health Plan Medicaid	$28.50
Rate for Payer: Ohana Health Plan Medicare	$28.50
Rate for Payer: UnitedHealthcare Medicare	$28.50
Rate for Payer: University Health Alliance Commercial	$41.55

STOCKINETTE UNDERCAST PROTOUCH ROLL 1/BX

Facility

$57.00

Hospital Charge Code	12954855
Hospital Revenue Code	272
Min. Negotiated Rate	$48.45
Max. Negotiated Rate	$55.29
Rate for Payer: Cash Price	$37.05
Rate for Payer: Health Management Network Commercial	$48.45
Rate for Payer: Kaiser Permanente Commercial	$51.30
Rate for Payer: MDX Hawaii PPO	$55.29

STOCKINETTE UNDERCAST PROTOUCH ROLL 1/BX

Professional

Both

$57.00

Hospital Charge Code	12954855
Hospital Revenue Code	272
Min. Negotiated Rate	$48.45
Max. Negotiated Rate	$48.45
Rate for Payer: Cash Price	$37.05
Rate for Payer: Health Management Network Commercial	$48.45

STOCKING ANTI-EMBOLISM KNEE EXTRA LARGE

Facility

$27.00

Hospital Charge Code	8266937
Hospital Revenue Code	270
Min. Negotiated Rate	$13.50
Max. Negotiated Rate	$26.19
Rate for Payer: AlohaCare Medicaid	$13.50
Rate for Payer: AlohaCare Medicare	$13.50
Rate for Payer: Cash Price	$17.55
Rate for Payer: Devoted Health Medicare	$14.85
Rate for Payer: Hawaii Medical Service Association Medicare	$13.50
Rate for Payer: Hawaii Western Management Group Commercial	$25.65
Rate for Payer: Health Management Network Commercial	$22.95
Rate for Payer: Humana Medicare	$13.50
Rate for Payer: Kaiser Permanente Commercial	$24.30
Rate for Payer: Kaiser Permanente Medicaid	$13.77
Rate for Payer: Kaiser Permanente Medicare	$13.50
Rate for Payer: MDX Hawaii PPO	$26.19
Rate for Payer: Ohana Health Plan Medicaid	$13.50
Rate for Payer: Ohana Health Plan Medicare	$13.50
Rate for Payer: UnitedHealthcare Medicare	$13.50
Rate for Payer: University Health Alliance Commercial	$19.68

STOCKING ANTI-EMBOLISM KNEE EXTRA LARGE

Facility

$27.00

Hospital Charge Code	8266937
Hospital Revenue Code	270
Min. Negotiated Rate	$22.95
Max. Negotiated Rate	$26.19
Rate for Payer: Cash Price	$17.55
Rate for Payer: Health Management Network Commercial	$22.95
Rate for Payer: Kaiser Permanente Commercial	$24.30
Rate for Payer: MDX Hawaii PPO	$26.19

STOCKING ANTI-EMBOLISM KNEE LARGE

Facility

$27.00

Hospital Charge Code	8266974
Hospital Revenue Code	270
Min. Negotiated Rate	$13.50
Max. Negotiated Rate	$26.19
Rate for Payer: AlohaCare Medicaid	$13.50
Rate for Payer: AlohaCare Medicare	$13.50
Rate for Payer: Cash Price	$17.55
Rate for Payer: Devoted Health Medicare	$14.85
Rate for Payer: Hawaii Medical Service Association Medicare	$13.50
Rate for Payer: Hawaii Western Management Group Commercial	$25.65
Rate for Payer: Health Management Network Commercial	$22.95
Rate for Payer: Humana Medicare	$13.50
Rate for Payer: Kaiser Permanente Commercial	$24.30
Rate for Payer: Kaiser Permanente Medicaid	$13.77
Rate for Payer: Kaiser Permanente Medicare	$13.50
Rate for Payer: MDX Hawaii PPO	$26.19
Rate for Payer: Ohana Health Plan Medicaid	$13.50
Rate for Payer: Ohana Health Plan Medicare	$13.50
Rate for Payer: UnitedHealthcare Medicare	$13.50
Rate for Payer: University Health Alliance Commercial	$19.68

STOCKING ANTI-EMBOLISM KNEE LARGE

Facility

$27.00

Hospital Charge Code	8266974
Hospital Revenue Code	270
Min. Negotiated Rate	$22.95
Max. Negotiated Rate	$26.19
Rate for Payer: Cash Price	$17.55
Rate for Payer: Health Management Network Commercial	$22.95
Rate for Payer: Kaiser Permanente Commercial	$24.30
Rate for Payer: MDX Hawaii PPO	$26.19

STOCKING ANTI-EMBOLISM KNEE MEDIUM

Facility

$27.00

Hospital Charge Code	8266973
Hospital Revenue Code	270
Min. Negotiated Rate	$22.95
Max. Negotiated Rate	$26.19
Rate for Payer: Cash Price	$17.55
Rate for Payer: Health Management Network Commercial	$22.95
Rate for Payer: Kaiser Permanente Commercial	$24.30
Rate for Payer: MDX Hawaii PPO	$26.19

STOCKING ANTI-EMBOLISM KNEE MEDIUM

Facility

$27.00

Hospital Charge Code	8266973
Hospital Revenue Code	270
Min. Negotiated Rate	$13.50
Max. Negotiated Rate	$26.19
Rate for Payer: AlohaCare Medicaid	$13.50
Rate for Payer: AlohaCare Medicare	$13.50
Rate for Payer: Cash Price	$17.55
Rate for Payer: Devoted Health Medicare	$14.85
Rate for Payer: Hawaii Medical Service Association Medicare	$13.50
Rate for Payer: Hawaii Western Management Group Commercial	$25.65
Rate for Payer: Health Management Network Commercial	$22.95
Rate for Payer: Humana Medicare	$13.50
Rate for Payer: Kaiser Permanente Commercial	$24.30
Rate for Payer: Kaiser Permanente Medicaid	$13.77
Rate for Payer: Kaiser Permanente Medicare	$13.50
Rate for Payer: MDX Hawaii PPO	$26.19
Rate for Payer: Ohana Health Plan Medicaid	$13.50
Rate for Payer: Ohana Health Plan Medicare	$13.50
Rate for Payer: UnitedHealthcare Medicare	$13.50
Rate for Payer: University Health Alliance Commercial	$19.68

STOCKING ANTI-EMBOLISM KNEE SMALL

Facility

$22.00

Hospital Charge Code	8266986
Hospital Revenue Code	270
Min. Negotiated Rate	$18.70
Max. Negotiated Rate	$21.34
Rate for Payer: Cash Price	$14.30
Rate for Payer: Health Management Network Commercial	$18.70
Rate for Payer: Kaiser Permanente Commercial	$19.80
Rate for Payer: MDX Hawaii PPO	$21.34

STOCKING ANTI-EMBOLISM KNEE SMALL

Facility

$22.00

Hospital Charge Code	8266986
Hospital Revenue Code	270
Min. Negotiated Rate	$11.00
Max. Negotiated Rate	$21.34
Rate for Payer: AlohaCare Medicaid	$11.00
Rate for Payer: AlohaCare Medicare	$11.00
Rate for Payer: Cash Price	$14.30
Rate for Payer: Devoted Health Medicare	$12.10
Rate for Payer: Hawaii Medical Service Association Medicare	$11.00
Rate for Payer: Hawaii Western Management Group Commercial	$20.90
Rate for Payer: Health Management Network Commercial	$18.70
Rate for Payer: Humana Medicare	$11.00
Rate for Payer: Kaiser Permanente Commercial	$19.80
Rate for Payer: Kaiser Permanente Medicaid	$11.22
Rate for Payer: Kaiser Permanente Medicare	$11.00
Rate for Payer: MDX Hawaii PPO	$21.34
Rate for Payer: Ohana Health Plan Medicaid	$11.00
Rate for Payer: Ohana Health Plan Medicare	$11.00
Rate for Payer: UnitedHealthcare Medicare	$11.00
Rate for Payer: University Health Alliance Commercial	$16.04

STOCKING ANTI-EMBOLISM THIGH EXTRA LARGE

Facility

$143.00

Hospital Charge Code	8266249
Hospital Revenue Code	270
Min. Negotiated Rate	$121.55
Max. Negotiated Rate	$138.71
Rate for Payer: Cash Price	$92.95
Rate for Payer: Health Management Network Commercial	$121.55
Rate for Payer: Kaiser Permanente Commercial	$128.70
Rate for Payer: MDX Hawaii PPO	$138.71

STOCKING ANTI-EMBOLISM THIGH EXTRA LARGE

Facility

$143.00

Hospital Charge Code	8266249
Hospital Revenue Code	270
Min. Negotiated Rate	$71.50
Max. Negotiated Rate	$138.71
Rate for Payer: AlohaCare Medicaid	$71.50
Rate for Payer: AlohaCare Medicare	$71.50
Rate for Payer: Cash Price	$92.95
Rate for Payer: Devoted Health Medicare	$78.65
Rate for Payer: Hawaii Medical Service Association Medicare	$71.50
Rate for Payer: Hawaii Western Management Group Commercial	$135.85
Rate for Payer: Health Management Network Commercial	$121.55
Rate for Payer: Humana Medicare	$71.50
Rate for Payer: Kaiser Permanente Commercial	$128.70
Rate for Payer: Kaiser Permanente Medicaid	$72.93
Rate for Payer: Kaiser Permanente Medicare	$71.50
Rate for Payer: MDX Hawaii PPO	$138.71
Rate for Payer: Ohana Health Plan Medicaid	$71.50
Rate for Payer: Ohana Health Plan Medicare	$71.50
Rate for Payer: UnitedHealthcare Medicare	$71.50
Rate for Payer: University Health Alliance Commercial	$104.23

STOCKING ANTI-EMBOLISM THIGH LARGE

Facility

$51.00

Hospital Charge Code	8266975
Hospital Revenue Code	270
Min. Negotiated Rate	$25.50
Max. Negotiated Rate	$49.47
Rate for Payer: AlohaCare Medicaid	$25.50
Rate for Payer: AlohaCare Medicare	$25.50
Rate for Payer: Cash Price	$33.15
Rate for Payer: Devoted Health Medicare	$28.05
Rate for Payer: Hawaii Medical Service Association Medicare	$25.50
Rate for Payer: Hawaii Western Management Group Commercial	$48.45
Rate for Payer: Health Management Network Commercial	$43.35
Rate for Payer: Humana Medicare	$25.50
Rate for Payer: Kaiser Permanente Commercial	$45.90
Rate for Payer: Kaiser Permanente Medicaid	$26.01
Rate for Payer: Kaiser Permanente Medicare	$25.50
Rate for Payer: MDX Hawaii PPO	$49.47
Rate for Payer: Ohana Health Plan Medicaid	$25.50
Rate for Payer: Ohana Health Plan Medicare	$25.50
Rate for Payer: UnitedHealthcare Medicare	$25.50
Rate for Payer: University Health Alliance Commercial	$37.17

Know your out-of-pocket cost for care.

All Charges