Samuel Mahelona Memorial Hospital

All Charges

Charge

Type

Setting

Price

sulfameth-trimeth 800-160 mg tablet [HHSC]

Facility

$3.00

Service Code	NDC 68084023001
Hospital Charge Code	2500804
Hospital Revenue Code	250
Min. Negotiated Rate	$1.50
Max. Negotiated Rate	$2.91
Rate for Payer: AlohaCare Medicaid	$1.50
Rate for Payer: AlohaCare Medicare	$1.50
Rate for Payer: Cash Price	$1.95
Rate for Payer: Devoted Health Medicare	$1.65
Rate for Payer: Hawaii Medical Service Association Medicare	$1.50
Rate for Payer: Hawaii Western Management Group Commercial	$2.85
Rate for Payer: Health Management Network Commercial	$2.55
Rate for Payer: Humana Medicare	$1.50
Rate for Payer: Kaiser Permanente Commercial	$2.70
Rate for Payer: Kaiser Permanente Medicaid	$1.53
Rate for Payer: Kaiser Permanente Medicare	$1.50
Rate for Payer: MDX Hawaii PPO	$2.91
Rate for Payer: Ohana Health Plan Medicaid	$1.50
Rate for Payer: Ohana Health Plan Medicare	$1.50
Rate for Payer: UnitedHealthcare Medicaid	$1.80
Rate for Payer: UnitedHealthcare Medicare	$1.50
Rate for Payer: University Health Alliance Commercial	$2.19

sulfameth-trimeth 800-160 mg tablet [HHSC]

Facility

$8.01

Service Code	NDC 00603578121
Hospital Charge Code	2500804
Hospital Revenue Code	250
Min. Negotiated Rate	$4.00
Max. Negotiated Rate	$7.77
Rate for Payer: AlohaCare Medicaid	$4.00
Rate for Payer: AlohaCare Medicare	$4.00
Rate for Payer: Cash Price	$5.21
Rate for Payer: Devoted Health Medicare	$4.41
Rate for Payer: Hawaii Medical Service Association Medicare	$4.00
Rate for Payer: Hawaii Western Management Group Commercial	$7.61
Rate for Payer: Health Management Network Commercial	$6.81
Rate for Payer: Humana Medicare	$4.00
Rate for Payer: Kaiser Permanente Commercial	$7.21
Rate for Payer: Kaiser Permanente Medicaid	$4.09
Rate for Payer: Kaiser Permanente Medicare	$4.00
Rate for Payer: MDX Hawaii PPO	$7.77
Rate for Payer: Ohana Health Plan Medicaid	$4.00
Rate for Payer: Ohana Health Plan Medicare	$4.00
Rate for Payer: UnitedHealthcare Medicaid	$4.81
Rate for Payer: UnitedHealthcare Medicare	$4.00
Rate for Payer: University Health Alliance Commercial	$5.84

sulfameth-trimeth 800-160 mg tablet [HHSC]

Facility

$6.42

Service Code	NDC 65862042001
Hospital Charge Code	2500804
Hospital Revenue Code	250
Min. Negotiated Rate	$5.46
Max. Negotiated Rate	$6.23
Rate for Payer: Cash Price	$4.17
Rate for Payer: Health Management Network Commercial	$5.46
Rate for Payer: Kaiser Permanente Commercial	$5.78
Rate for Payer: MDX Hawaii PPO	$6.23

sulfameth-trimeth 800-160 mg tablet [HHSC]

Facility

$3.00

Service Code	NDC 60687061401
Hospital Charge Code	2500804
Hospital Revenue Code	250
Min. Negotiated Rate	$2.55
Max. Negotiated Rate	$2.91
Rate for Payer: Cash Price	$1.95
Rate for Payer: Health Management Network Commercial	$2.55
Rate for Payer: Kaiser Permanente Commercial	$2.70
Rate for Payer: MDX Hawaii PPO	$2.91

SUMAtriptan 6 mg/0.5 ml vial [HHSC]

Facility

$396.23

Service Code	HCPCS J3030
Hospital Charge Code	2500805
Hospital Revenue Code	637
Min. Negotiated Rate	$79.64
Max. Negotiated Rate	$384.34
Rate for Payer: AlohaCare Medicaid	$198.12
Rate for Payer: AlohaCare Medicaid	$36.66
Rate for Payer: AlohaCare Medicaid	$39.17
Rate for Payer: AlohaCare Medicare	$39.17
Rate for Payer: AlohaCare Medicare	$198.12
Rate for Payer: AlohaCare Medicare	$36.66
Rate for Payer: Cash Price	$257.55
Rate for Payer: Cash Price	$257.55
Rate for Payer: Cash Price	$47.66
Rate for Payer: Cash Price	$47.66
Rate for Payer: Cash Price	$50.92
Rate for Payer: Cash Price	$50.92
Rate for Payer: Devoted Health Medicare	$43.09
Rate for Payer: Devoted Health Medicare	$217.93
Rate for Payer: Devoted Health Medicare	$40.33
Rate for Payer: Hawaii Medical Service Association ABD	$79.64
Rate for Payer: Hawaii Medical Service Association ABD	$79.64
Rate for Payer: Hawaii Medical Service Association ABD	$79.64
Rate for Payer: Hawaii Medical Service Association Medicare	$36.66
Rate for Payer: Hawaii Medical Service Association Medicare	$198.12
Rate for Payer: Hawaii Medical Service Association Medicare	$39.17
Rate for Payer: Hawaii Medical Service Association Non-ABD	$79.64
Rate for Payer: Hawaii Medical Service Association Non-ABD	$79.64
Rate for Payer: Hawaii Medical Service Association Non-ABD	$79.64
Rate for Payer: Hawaii Western Management Group Commercial	$74.42
Rate for Payer: Hawaii Western Management Group Commercial	$376.42
Rate for Payer: Hawaii Western Management Group Commercial	$69.66
Rate for Payer: Health Management Network Commercial	$62.33
Rate for Payer: Health Management Network Commercial	$336.80
Rate for Payer: Health Management Network Commercial	$66.59
Rate for Payer: Humana Medicare	$198.12
Rate for Payer: Humana Medicare	$36.66
Rate for Payer: Humana Medicare	$39.17
Rate for Payer: Kaiser Permanente Commercial	$66.00
Rate for Payer: Kaiser Permanente Commercial	$356.61
Rate for Payer: Kaiser Permanente Commercial	$70.51
Rate for Payer: Kaiser Permanente Medicaid	$202.08
Rate for Payer: Kaiser Permanente Medicaid	$37.40
Rate for Payer: Kaiser Permanente Medicaid	$39.95
Rate for Payer: Kaiser Permanente Medicare	$36.66
Rate for Payer: Kaiser Permanente Medicare	$198.12
Rate for Payer: Kaiser Permanente Medicare	$39.17
Rate for Payer: MDX Hawaii PPO	$384.34
Rate for Payer: MDX Hawaii PPO	$71.13
Rate for Payer: MDX Hawaii PPO	$75.99
Rate for Payer: Ohana Health Plan Medicaid	$39.17
Rate for Payer: Ohana Health Plan Medicaid	$36.66
Rate for Payer: Ohana Health Plan Medicaid	$198.12
Rate for Payer: Ohana Health Plan Medicare	$36.66
Rate for Payer: Ohana Health Plan Medicare	$198.12
Rate for Payer: Ohana Health Plan Medicare	$39.17
Rate for Payer: UnitedHealthcare Medicare	$39.17
Rate for Payer: UnitedHealthcare Medicare	$198.12
Rate for Payer: UnitedHealthcare Medicare	$36.66
Rate for Payer: University Health Alliance Commercial	$288.81
Rate for Payer: University Health Alliance Commercial	$53.45
Rate for Payer: University Health Alliance Commercial	$57.10

SUMAtriptan 6 mg/0.5 ml vial [HHSC]

Facility

$73.33

Service Code	HCPCS J3030
Hospital Charge Code	2500805
Hospital Revenue Code	250
Min. Negotiated Rate	$62.33
Max. Negotiated Rate	$71.13
Rate for Payer: Cash Price	$47.66
Rate for Payer: Cash Price	$257.55
Rate for Payer: Cash Price	$50.92
Rate for Payer: Health Management Network Commercial	$66.59
Rate for Payer: Health Management Network Commercial	$336.80
Rate for Payer: Health Management Network Commercial	$62.33
Rate for Payer: Kaiser Permanente Commercial	$70.51
Rate for Payer: Kaiser Permanente Commercial	$356.61
Rate for Payer: Kaiser Permanente Commercial	$66.00
Rate for Payer: MDX Hawaii PPO	$71.13
Rate for Payer: MDX Hawaii PPO	$384.34
Rate for Payer: MDX Hawaii PPO	$75.99

SUPPORT ABDOMINAL 10 IN

Facility

$67.00

Hospital Charge Code	8266516
Hospital Revenue Code	271
Min. Negotiated Rate	$33.50
Max. Negotiated Rate	$64.99
Rate for Payer: AlohaCare Medicaid	$33.50
Rate for Payer: AlohaCare Medicare	$33.50
Rate for Payer: Cash Price	$43.55
Rate for Payer: Devoted Health Medicare	$36.85
Rate for Payer: Hawaii Medical Service Association Medicare	$33.50
Rate for Payer: Hawaii Western Management Group Commercial	$63.65
Rate for Payer: Health Management Network Commercial	$56.95
Rate for Payer: Humana Medicare	$33.50
Rate for Payer: Kaiser Permanente Commercial	$60.30
Rate for Payer: Kaiser Permanente Medicaid	$34.17
Rate for Payer: Kaiser Permanente Medicare	$33.50
Rate for Payer: MDX Hawaii PPO	$64.99
Rate for Payer: Ohana Health Plan Medicaid	$33.50
Rate for Payer: Ohana Health Plan Medicare	$33.50
Rate for Payer: UnitedHealthcare Medicare	$33.50
Rate for Payer: University Health Alliance Commercial	$48.84

SUPPORT ABDOMINAL 10 IN

Facility

$67.00

Hospital Charge Code	8266516
Hospital Revenue Code	271
Min. Negotiated Rate	$56.95
Max. Negotiated Rate	$64.99
Rate for Payer: Cash Price	$43.55
Rate for Payer: Health Management Network Commercial	$56.95
Rate for Payer: Kaiser Permanente Commercial	$60.30
Rate for Payer: MDX Hawaii PPO	$64.99

SUPPORT, BREAST MEDIUM BRA SURGI MEDIUM LATEX FREE

Facility

$241.00

Hospital Charge Code	9764543
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

SUPPORT, BREAST MEDIUM BRA SURGI MEDIUM LATEX FREE

Facility

$241.00

Hospital Charge Code	9764543
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

SUPRACONDYLAR FEMORAL NAIL, 10MM X 22CM

Facility

$5,030.00

Service Code	HCPCS C1713
Hospital Charge Code	13000619
Hospital Revenue Code	278
Min. Negotiated Rate	$2,515.00
Max. Negotiated Rate	$4,879.10
Rate for Payer: AlohaCare Medicaid	$2,515.00
Rate for Payer: AlohaCare Medicare	$2,515.00
Rate for Payer: Cash Price	$3,269.50
Rate for Payer: Devoted Health Medicare	$2,766.50
Rate for Payer: Hawaii Medical Service Association Medicare	$2,515.00
Rate for Payer: Hawaii Western Management Group Commercial	$3,521.00
Rate for Payer: Health Management Network Commercial	$4,275.50
Rate for Payer: Humana Medicare	$2,515.00
Rate for Payer: Kaiser Permanente Commercial	$4,527.00
Rate for Payer: Kaiser Permanente Medicaid	$2,565.30
Rate for Payer: Kaiser Permanente Medicare	$2,515.00
Rate for Payer: MDX Hawaii PPO	$4,879.10
Rate for Payer: Ohana Health Plan Medicaid	$2,515.00
Rate for Payer: Ohana Health Plan Medicare	$2,515.00
Rate for Payer: UnitedHealthcare Medicare	$2,515.00
Rate for Payer: University Health Alliance Commercial	$2,816.80

SUPRACONDYLAR FEMORAL NAIL, 10MM X 22CM

Facility

$5,030.00

Service Code	HCPCS C1713
Hospital Charge Code	13000619
Hospital Revenue Code	278
Min. Negotiated Rate	$2,816.80
Max. Negotiated Rate	$4,879.10
Rate for Payer: Cash Price	$3,269.50
Rate for Payer: Hawaii Western Management Group Commercial	$3,521.00
Rate for Payer: Health Management Network Commercial	$4,275.50
Rate for Payer: Kaiser Permanente Commercial	$4,527.00
Rate for Payer: MDX Hawaii PPO	$4,879.10
Rate for Payer: University Health Alliance Commercial	$2,816.80

SUPRACONDYLAR FEMORAL NAIL, 11MM X 22CM

Facility

$5,030.00

Service Code	HCPCS C1713
Hospital Charge Code	13000620
Hospital Revenue Code	278
Min. Negotiated Rate	$2,816.80
Max. Negotiated Rate	$4,879.10
Rate for Payer: Cash Price	$3,269.50
Rate for Payer: Hawaii Western Management Group Commercial	$3,521.00
Rate for Payer: Health Management Network Commercial	$4,275.50
Rate for Payer: Kaiser Permanente Commercial	$4,527.00
Rate for Payer: MDX Hawaii PPO	$4,879.10
Rate for Payer: University Health Alliance Commercial	$2,816.80

SUPRACONDYLAR FEMORAL NAIL, 11MM X 22CM

Facility

$5,030.00

Service Code	HCPCS C1713
Hospital Charge Code	13000620
Hospital Revenue Code	278
Min. Negotiated Rate	$2,515.00
Max. Negotiated Rate	$4,879.10
Rate for Payer: AlohaCare Medicaid	$2,515.00
Rate for Payer: AlohaCare Medicare	$2,515.00
Rate for Payer: Cash Price	$3,269.50
Rate for Payer: Devoted Health Medicare	$2,766.50
Rate for Payer: Hawaii Medical Service Association Medicare	$2,515.00
Rate for Payer: Hawaii Western Management Group Commercial	$3,521.00
Rate for Payer: Health Management Network Commercial	$4,275.50
Rate for Payer: Humana Medicare	$2,515.00
Rate for Payer: Kaiser Permanente Commercial	$4,527.00
Rate for Payer: Kaiser Permanente Medicaid	$2,565.30
Rate for Payer: Kaiser Permanente Medicare	$2,515.00
Rate for Payer: MDX Hawaii PPO	$4,879.10
Rate for Payer: Ohana Health Plan Medicaid	$2,515.00
Rate for Payer: Ohana Health Plan Medicare	$2,515.00
Rate for Payer: UnitedHealthcare Medicare	$2,515.00
Rate for Payer: University Health Alliance Commercial	$2,816.80

SUPRACONDYLAR FEMORAL NAIL, 12MM X 22CM

Facility

$5,030.00

Service Code	HCPCS C1713
Hospital Charge Code	13000622
Hospital Revenue Code	278
Min. Negotiated Rate	$2,515.00
Max. Negotiated Rate	$4,879.10
Rate for Payer: AlohaCare Medicaid	$2,515.00
Rate for Payer: AlohaCare Medicare	$2,515.00
Rate for Payer: Cash Price	$3,269.50
Rate for Payer: Devoted Health Medicare	$2,766.50
Rate for Payer: Hawaii Medical Service Association Medicare	$2,515.00
Rate for Payer: Hawaii Western Management Group Commercial	$3,521.00
Rate for Payer: Health Management Network Commercial	$4,275.50
Rate for Payer: Humana Medicare	$2,515.00
Rate for Payer: Kaiser Permanente Commercial	$4,527.00
Rate for Payer: Kaiser Permanente Medicaid	$2,565.30
Rate for Payer: Kaiser Permanente Medicare	$2,515.00
Rate for Payer: MDX Hawaii PPO	$4,879.10
Rate for Payer: Ohana Health Plan Medicaid	$2,515.00
Rate for Payer: Ohana Health Plan Medicare	$2,515.00
Rate for Payer: UnitedHealthcare Medicare	$2,515.00
Rate for Payer: University Health Alliance Commercial	$2,816.80

SUPRACONDYLAR FEMORAL NAIL, 12MM X 22CM

Facility

$5,030.00

Service Code	HCPCS C1713
Hospital Charge Code	13000622
Hospital Revenue Code	278
Min. Negotiated Rate	$2,816.80
Max. Negotiated Rate	$4,879.10
Rate for Payer: Cash Price	$3,269.50
Rate for Payer: Hawaii Western Management Group Commercial	$3,521.00
Rate for Payer: Health Management Network Commercial	$4,275.50
Rate for Payer: Kaiser Permanente Commercial	$4,527.00
Rate for Payer: MDX Hawaii PPO	$4,879.10
Rate for Payer: University Health Alliance Commercial	$2,816.80

SUPRACONDYLAR FEMORAL NAIL, 13MM X 22CM

Facility

$5,030.00

Service Code	HCPCS C1713
Hospital Charge Code	13000624
Hospital Revenue Code	278
Min. Negotiated Rate	$2,515.00
Max. Negotiated Rate	$4,879.10
Rate for Payer: AlohaCare Medicaid	$2,515.00
Rate for Payer: AlohaCare Medicare	$2,515.00
Rate for Payer: Cash Price	$3,269.50
Rate for Payer: Devoted Health Medicare	$2,766.50
Rate for Payer: Hawaii Medical Service Association Medicare	$2,515.00
Rate for Payer: Hawaii Western Management Group Commercial	$3,521.00
Rate for Payer: Health Management Network Commercial	$4,275.50
Rate for Payer: Humana Medicare	$2,515.00
Rate for Payer: Kaiser Permanente Commercial	$4,527.00
Rate for Payer: Kaiser Permanente Medicaid	$2,565.30
Rate for Payer: Kaiser Permanente Medicare	$2,515.00
Rate for Payer: MDX Hawaii PPO	$4,879.10
Rate for Payer: Ohana Health Plan Medicaid	$2,515.00
Rate for Payer: Ohana Health Plan Medicare	$2,515.00
Rate for Payer: UnitedHealthcare Medicare	$2,515.00
Rate for Payer: University Health Alliance Commercial	$2,816.80

SUPRACONDYLAR FEMORAL NAIL, 13MM X 22CM

Facility

$5,030.00

Service Code	HCPCS C1713
Hospital Charge Code	13000624
Hospital Revenue Code	278
Min. Negotiated Rate	$2,816.80
Max. Negotiated Rate	$4,879.10
Rate for Payer: Cash Price	$3,269.50
Rate for Payer: Hawaii Western Management Group Commercial	$3,521.00
Rate for Payer: Health Management Network Commercial	$4,275.50
Rate for Payer: Kaiser Permanente Commercial	$4,527.00
Rate for Payer: MDX Hawaii PPO	$4,879.10
Rate for Payer: University Health Alliance Commercial	$2,816.80

SURFACTANT ADMIN THRU TUBE CHARGE

Facility

$428.00

Service Code	HCPCS 94610
Hospital Charge Code	8243397
Hospital Revenue Code	460
Min. Negotiated Rate	$43.49
Max. Negotiated Rate	$415.16
Rate for Payer: AlohaCare Medicaid	$214.00
Rate for Payer: AlohaCare Medicare	$214.00
Rate for Payer: Cash Price	$278.20
Rate for Payer: Cash Price	$278.20
Rate for Payer: Devoted Health Medicare	$235.40
Rate for Payer: Hawaii Medical Service Association Commercial	$279.65
Rate for Payer: Hawaii Medical Service Association Medicare	$214.00
Rate for Payer: Hawaii Western Management Group Commercial	$406.60
Rate for Payer: Health Management Network Commercial	$363.80
Rate for Payer: Humana Medicare	$214.00
Rate for Payer: Kaiser Permanente Commercial	$385.20
Rate for Payer: Kaiser Permanente Medicaid	$218.28
Rate for Payer: Kaiser Permanente Medicare	$214.00
Rate for Payer: MDX Hawaii PPO	$415.16
Rate for Payer: Ohana Health Plan Medicaid	$214.00
Rate for Payer: Ohana Health Plan Medicare	$214.00
Rate for Payer: UnitedHealthcare Medicaid	$43.49
Rate for Payer: UnitedHealthcare Medicare	$214.00
Rate for Payer: University Health Alliance Commercial	$239.68

SURFACTANT ADMIN THRU TUBE CHARGE

Facility

$428.00

Service Code	HCPCS 94610
Hospital Charge Code	8243397
Hospital Revenue Code	460
Min. Negotiated Rate	$363.80
Max. Negotiated Rate	$415.16
Rate for Payer: Cash Price	$278.20
Rate for Payer: Health Management Network Commercial	$363.80
Rate for Payer: Kaiser Permanente Commercial	$385.20
Rate for Payer: MDX Hawaii PPO	$415.16

SURGERY:LIGASURE HANDHELD DISSECTOR

Facility

$1,521.00

Hospital Charge Code	12324108
Hospital Revenue Code	272
Min. Negotiated Rate	$1,292.85
Max. Negotiated Rate	$1,475.37
Rate for Payer: Cash Price	$988.65
Rate for Payer: Health Management Network Commercial	$1,292.85
Rate for Payer: Kaiser Permanente Commercial	$1,368.90
Rate for Payer: MDX Hawaii PPO	$1,475.37

SURGERY:LIGASURE HANDHELD DISSECTOR

Facility

$1,521.00

Hospital Charge Code	12324108
Hospital Revenue Code	272
Min. Negotiated Rate	$760.50
Max. Negotiated Rate	$1,475.37
Rate for Payer: AlohaCare Medicaid	$760.50
Rate for Payer: AlohaCare Medicare	$760.50
Rate for Payer: Cash Price	$988.65
Rate for Payer: Devoted Health Medicare	$836.55
Rate for Payer: Hawaii Medical Service Association Medicare	$760.50
Rate for Payer: Hawaii Western Management Group Commercial	$1,444.95
Rate for Payer: Health Management Network Commercial	$1,292.85
Rate for Payer: Humana Medicare	$760.50
Rate for Payer: Kaiser Permanente Commercial	$1,368.90
Rate for Payer: Kaiser Permanente Medicaid	$775.71
Rate for Payer: Kaiser Permanente Medicare	$760.50
Rate for Payer: MDX Hawaii PPO	$1,475.37
Rate for Payer: Ohana Health Plan Medicaid	$760.50
Rate for Payer: Ohana Health Plan Medicare	$760.50
Rate for Payer: UnitedHealthcare Medicare	$760.50
Rate for Payer: University Health Alliance Commercial	$1,108.66

SURGERY:SUPPORTER ATHLETIC XL

Facility

$34.00

Hospital Charge Code	11757050
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

SURGERY:SUPPORTER ATHLETIC XL

Facility

$34.00

Hospital Charge Code	11757050
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

SURGERY:SURGICAL BRA MEDIUM

Facility

$355.00

Hospital Charge Code	11757047
Hospital Revenue Code	272
Min. Negotiated Rate	$177.50
Max. Negotiated Rate	$344.35
Rate for Payer: AlohaCare Medicaid	$177.50
Rate for Payer: AlohaCare Medicare	$177.50
Rate for Payer: Cash Price	$230.75
Rate for Payer: Devoted Health Medicare	$195.25
Rate for Payer: Hawaii Medical Service Association Medicare	$177.50
Rate for Payer: Hawaii Western Management Group Commercial	$337.25
Rate for Payer: Health Management Network Commercial	$301.75
Rate for Payer: Humana Medicare	$177.50
Rate for Payer: Kaiser Permanente Commercial	$319.50
Rate for Payer: Kaiser Permanente Medicaid	$181.05
Rate for Payer: Kaiser Permanente Medicare	$177.50
Rate for Payer: MDX Hawaii PPO	$344.35
Rate for Payer: Ohana Health Plan Medicaid	$177.50
Rate for Payer: Ohana Health Plan Medicare	$177.50
Rate for Payer: UnitedHealthcare Medicare	$177.50
Rate for Payer: University Health Alliance Commercial	$258.76

Know your out-of-pocket cost for care.

All Charges