Samuel Mahelona Memorial Hospital

All Charges

Charge

Type

Setting

Price

SURGERY:SURGICAL BRA MEDIUM

Facility

$355.00

Hospital Charge Code	11757047
Hospital Revenue Code	272
Min. Negotiated Rate	$301.75
Max. Negotiated Rate	$344.35
Rate for Payer: Cash Price	$230.75
Rate for Payer: Health Management Network Commercial	$301.75
Rate for Payer: Kaiser Permanente Commercial	$319.50
Rate for Payer: MDX Hawaii PPO	$344.35

SURGERY:SURGICAL BRA SMALL

Facility

$355.00

Hospital Charge Code	11757049
Hospital Revenue Code	272
Min. Negotiated Rate	$301.75
Max. Negotiated Rate	$344.35
Rate for Payer: Cash Price	$230.75
Rate for Payer: Health Management Network Commercial	$301.75
Rate for Payer: Kaiser Permanente Commercial	$319.50
Rate for Payer: MDX Hawaii PPO	$344.35

SURGERY:SURGICAL BRA SMALL

Facility

$355.00

Hospital Charge Code	11757049
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

SURGERY:SURGICAL BRA XL

Facility

$355.00

Hospital Charge Code	11768967
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

SURGERY:SURGICAL BRA XL

Facility

$355.00

Hospital Charge Code	11768967
Hospital Revenue Code	272
Min. Negotiated Rate	$301.75
Max. Negotiated Rate	$344.35
Rate for Payer: Cash Price	$230.75
Rate for Payer: Health Management Network Commercial	$301.75
Rate for Payer: Kaiser Permanente Commercial	$319.50
Rate for Payer: MDX Hawaii PPO	$344.35

SURGICEL STERILE 4X8 INCH ABSORBABLE HEMOSTAT

Facility

$432.00

Hospital Charge Code	8348096
Hospital Revenue Code	270
Min. Negotiated Rate	$216.00
Max. Negotiated Rate	$419.04
Rate for Payer: AlohaCare Medicaid	$216.00
Rate for Payer: AlohaCare Medicare	$216.00
Rate for Payer: Cash Price	$280.80
Rate for Payer: Devoted Health Medicare	$237.60
Rate for Payer: Hawaii Medical Service Association Medicare	$216.00
Rate for Payer: Hawaii Western Management Group Commercial	$410.40
Rate for Payer: Health Management Network Commercial	$367.20
Rate for Payer: Humana Medicare	$216.00
Rate for Payer: Kaiser Permanente Commercial	$388.80
Rate for Payer: Kaiser Permanente Medicaid	$220.32
Rate for Payer: Kaiser Permanente Medicare	$216.00
Rate for Payer: MDX Hawaii PPO	$419.04
Rate for Payer: Ohana Health Plan Medicaid	$216.00
Rate for Payer: Ohana Health Plan Medicare	$216.00
Rate for Payer: UnitedHealthcare Medicare	$216.00
Rate for Payer: University Health Alliance Commercial	$314.88

SURGICEL STERILE 4X8 INCH ABSORBABLE HEMOSTAT

Facility

$432.00

Hospital Charge Code	8348096
Hospital Revenue Code	270
Min. Negotiated Rate	$367.20
Max. Negotiated Rate	$419.04
Rate for Payer: Cash Price	$280.80
Rate for Payer: Health Management Network Commercial	$367.20
Rate for Payer: Kaiser Permanente Commercial	$388.80
Rate for Payer: MDX Hawaii PPO	$419.04

SURGIFOAM ABSORBABLE GELATIN SPONGE 2CM X 6CM

Facility

$43.00

Hospital Charge Code	8904678
Hospital Revenue Code	272
Min. Negotiated Rate	$21.50
Max. Negotiated Rate	$41.71
Rate for Payer: AlohaCare Medicaid	$21.50
Rate for Payer: AlohaCare Medicare	$21.50
Rate for Payer: Cash Price	$27.95
Rate for Payer: Devoted Health Medicare	$23.65
Rate for Payer: Hawaii Medical Service Association Medicare	$21.50
Rate for Payer: Hawaii Western Management Group Commercial	$40.85
Rate for Payer: Health Management Network Commercial	$36.55
Rate for Payer: Humana Medicare	$21.50
Rate for Payer: Kaiser Permanente Commercial	$38.70
Rate for Payer: Kaiser Permanente Medicaid	$21.93
Rate for Payer: Kaiser Permanente Medicare	$21.50
Rate for Payer: MDX Hawaii PPO	$41.71
Rate for Payer: Ohana Health Plan Medicaid	$21.50
Rate for Payer: Ohana Health Plan Medicare	$21.50
Rate for Payer: UnitedHealthcare Medicare	$21.50
Rate for Payer: University Health Alliance Commercial	$31.34

SURGIFOAM ABSORBABLE GELATIN SPONGE 2CM X 6CM

Facility

$43.00

Hospital Charge Code	8904678
Hospital Revenue Code	272
Min. Negotiated Rate	$36.55
Max. Negotiated Rate	$41.71
Rate for Payer: Cash Price	$27.95
Rate for Payer: Health Management Network Commercial	$36.55
Rate for Payer: Kaiser Permanente Commercial	$38.70
Rate for Payer: MDX Hawaii PPO	$41.71

surgilube lubricant 3gm [HHSC]

Facility

$3.00

Service Code	NDC 00281020543
Hospital Charge Code	2500281
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

surgilube lubricant 3gm [HHSC]

Facility

$3.00

Service Code	NDC 00281020543
Hospital Charge Code	2500281
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

SUTURE, 0 TICRON BLUE 30 GS-22

Facility

$26.00

Hospital Charge Code	8711297
Hospital Revenue Code	272
Min. Negotiated Rate	$13.00
Max. Negotiated Rate	$25.22
Rate for Payer: AlohaCare Medicaid	$13.00
Rate for Payer: AlohaCare Medicare	$13.00
Rate for Payer: Cash Price	$16.90
Rate for Payer: Devoted Health Medicare	$14.30
Rate for Payer: Hawaii Medical Service Association Medicare	$13.00
Rate for Payer: Hawaii Western Management Group Commercial	$24.70
Rate for Payer: Health Management Network Commercial	$22.10
Rate for Payer: Humana Medicare	$13.00
Rate for Payer: Kaiser Permanente Commercial	$23.40
Rate for Payer: Kaiser Permanente Medicaid	$13.26
Rate for Payer: Kaiser Permanente Medicare	$13.00
Rate for Payer: MDX Hawaii PPO	$25.22
Rate for Payer: Ohana Health Plan Medicaid	$13.00
Rate for Payer: Ohana Health Plan Medicare	$13.00
Rate for Payer: UnitedHealthcare Medicare	$13.00
Rate for Payer: University Health Alliance Commercial	$18.95

SUTURE, 0 TICRON BLUE 30 GS-22

Facility

$26.00

Hospital Charge Code	8711297
Hospital Revenue Code	272
Min. Negotiated Rate	$22.10
Max. Negotiated Rate	$25.22
Rate for Payer: Cash Price	$16.90
Rate for Payer: Health Management Network Commercial	$22.10
Rate for Payer: Kaiser Permanente Commercial	$23.40
Rate for Payer: MDX Hawaii PPO	$25.22

SUTURE, 0 TICRON BLUE 5X18 HGS-23 DT

Facility

$60.00

Hospital Charge Code	8711299
Hospital Revenue Code	272
Min. Negotiated Rate	$51.00
Max. Negotiated Rate	$58.20
Rate for Payer: Cash Price	$39.00
Rate for Payer: Health Management Network Commercial	$51.00
Rate for Payer: Kaiser Permanente Commercial	$54.00
Rate for Payer: MDX Hawaii PPO	$58.20

SUTURE, 0 TICRON BLUE 5X18 HGS-23 DT

Facility

$60.00

Hospital Charge Code	8711299
Hospital Revenue Code	272
Min. Negotiated Rate	$30.00
Max. Negotiated Rate	$58.20
Rate for Payer: AlohaCare Medicaid	$30.00
Rate for Payer: AlohaCare Medicare	$30.00
Rate for Payer: Cash Price	$39.00
Rate for Payer: Devoted Health Medicare	$33.00
Rate for Payer: Hawaii Medical Service Association Medicare	$30.00
Rate for Payer: Hawaii Western Management Group Commercial	$57.00
Rate for Payer: Health Management Network Commercial	$51.00
Rate for Payer: Humana Medicare	$30.00
Rate for Payer: Kaiser Permanente Commercial	$54.00
Rate for Payer: Kaiser Permanente Medicaid	$30.60
Rate for Payer: Kaiser Permanente Medicare	$30.00
Rate for Payer: MDX Hawaii PPO	$58.20
Rate for Payer: Ohana Health Plan Medicaid	$30.00
Rate for Payer: Ohana Health Plan Medicare	$30.00
Rate for Payer: UnitedHealthcare Medicare	$30.00
Rate for Payer: University Health Alliance Commercial	$43.73

SUTURE, 0 TICRON BLUE 5X18 T-12GS-DT

Facility

$112.00

Hospital Charge Code	8711301
Hospital Revenue Code	272
Min. Negotiated Rate	$95.20
Max. Negotiated Rate	$108.64
Rate for Payer: Cash Price	$72.80
Rate for Payer: Health Management Network Commercial	$95.20
Rate for Payer: Kaiser Permanente Commercial	$100.80
Rate for Payer: MDX Hawaii PPO	$108.64

SUTURE, 0 TICRON BLUE 5X18 T-12GS-DT

Facility

$112.00

Hospital Charge Code	8711301
Hospital Revenue Code	272
Min. Negotiated Rate	$56.00
Max. Negotiated Rate	$108.64
Rate for Payer: AlohaCare Medicaid	$56.00
Rate for Payer: AlohaCare Medicare	$56.00
Rate for Payer: Cash Price	$72.80
Rate for Payer: Devoted Health Medicare	$61.60
Rate for Payer: Hawaii Medical Service Association Medicare	$56.00
Rate for Payer: Hawaii Western Management Group Commercial	$106.40
Rate for Payer: Health Management Network Commercial	$95.20
Rate for Payer: Humana Medicare	$56.00
Rate for Payer: Kaiser Permanente Commercial	$100.80
Rate for Payer: Kaiser Permanente Medicaid	$57.12
Rate for Payer: Kaiser Permanente Medicare	$56.00
Rate for Payer: MDX Hawaii PPO	$108.64
Rate for Payer: Ohana Health Plan Medicaid	$56.00
Rate for Payer: Ohana Health Plan Medicare	$56.00
Rate for Payer: UnitedHealthcare Medicare	$56.00
Rate for Payer: University Health Alliance Commercial	$81.64

SUTURE 2-0 CHROMIC GUT GS-21

Facility

$24.00

Hospital Charge Code	8274528
Hospital Revenue Code	272
Min. Negotiated Rate	$20.40
Max. Negotiated Rate	$23.28
Rate for Payer: Cash Price	$15.60
Rate for Payer: Health Management Network Commercial	$20.40
Rate for Payer: Kaiser Permanente Commercial	$21.60
Rate for Payer: MDX Hawaii PPO	$23.28

SUTURE 2-0 CHROMIC GUT GS-21

Facility

$24.00

Hospital Charge Code	8274528
Hospital Revenue Code	272
Min. Negotiated Rate	$12.00
Max. Negotiated Rate	$23.28
Rate for Payer: AlohaCare Medicaid	$12.00
Rate for Payer: AlohaCare Medicare	$12.00
Rate for Payer: Cash Price	$15.60
Rate for Payer: Devoted Health Medicare	$13.20
Rate for Payer: Hawaii Medical Service Association Medicare	$12.00
Rate for Payer: Hawaii Western Management Group Commercial	$22.80
Rate for Payer: Health Management Network Commercial	$20.40
Rate for Payer: Humana Medicare	$12.00
Rate for Payer: Kaiser Permanente Commercial	$21.60
Rate for Payer: Kaiser Permanente Medicaid	$12.24
Rate for Payer: Kaiser Permanente Medicare	$12.00
Rate for Payer: MDX Hawaii PPO	$23.28
Rate for Payer: Ohana Health Plan Medicaid	$12.00
Rate for Payer: Ohana Health Plan Medicare	$12.00
Rate for Payer: UnitedHealthcare Medicare	$12.00
Rate for Payer: University Health Alliance Commercial	$17.49

SUTURE, 2-0 PDS SH

Facility

$153.00

Hospital Charge Code	12728303
Hospital Revenue Code	272
Min. Negotiated Rate	$76.50
Max. Negotiated Rate	$148.41
Rate for Payer: AlohaCare Medicaid	$76.50
Rate for Payer: AlohaCare Medicare	$76.50
Rate for Payer: Cash Price	$99.45
Rate for Payer: Devoted Health Medicare	$84.15
Rate for Payer: Hawaii Medical Service Association Medicare	$76.50
Rate for Payer: Hawaii Western Management Group Commercial	$145.35
Rate for Payer: Health Management Network Commercial	$130.05
Rate for Payer: Humana Medicare	$76.50
Rate for Payer: Kaiser Permanente Commercial	$137.70
Rate for Payer: Kaiser Permanente Medicaid	$78.03
Rate for Payer: Kaiser Permanente Medicare	$76.50
Rate for Payer: MDX Hawaii PPO	$148.41
Rate for Payer: Ohana Health Plan Medicaid	$76.50
Rate for Payer: Ohana Health Plan Medicare	$76.50
Rate for Payer: UnitedHealthcare Medicare	$76.50
Rate for Payer: University Health Alliance Commercial	$111.52

SUTURE, 2-0 PDS SH

Facility

$153.00

Hospital Charge Code	12728303
Hospital Revenue Code	272
Min. Negotiated Rate	$130.05
Max. Negotiated Rate	$148.41
Rate for Payer: Cash Price	$99.45
Rate for Payer: Health Management Network Commercial	$130.05
Rate for Payer: Kaiser Permanente Commercial	$137.70
Rate for Payer: MDX Hawaii PPO	$148.41

SUTURE 2-0 POLYSORB GS-21 TAPER

Facility

$14.00

Hospital Charge Code	8274566
Hospital Revenue Code	272
Min. Negotiated Rate	$7.00
Max. Negotiated Rate	$13.58
Rate for Payer: AlohaCare Medicaid	$7.00
Rate for Payer: AlohaCare Medicare	$7.00
Rate for Payer: Cash Price	$9.10
Rate for Payer: Devoted Health Medicare	$7.70
Rate for Payer: Hawaii Medical Service Association Medicare	$7.00
Rate for Payer: Hawaii Western Management Group Commercial	$13.30
Rate for Payer: Health Management Network Commercial	$11.90
Rate for Payer: Humana Medicare	$7.00
Rate for Payer: Kaiser Permanente Commercial	$12.60
Rate for Payer: Kaiser Permanente Medicaid	$7.14
Rate for Payer: Kaiser Permanente Medicare	$7.00
Rate for Payer: MDX Hawaii PPO	$13.58
Rate for Payer: Ohana Health Plan Medicaid	$7.00
Rate for Payer: Ohana Health Plan Medicare	$7.00
Rate for Payer: UnitedHealthcare Medicare	$7.00
Rate for Payer: University Health Alliance Commercial	$10.20

SUTURE 2-0 POLYSORB GS-21 TAPER

Facility

$14.00

Hospital Charge Code	8274566
Hospital Revenue Code	272
Min. Negotiated Rate	$11.90
Max. Negotiated Rate	$13.58
Rate for Payer: Cash Price	$9.10
Rate for Payer: Health Management Network Commercial	$11.90
Rate for Payer: Kaiser Permanente Commercial	$12.60
Rate for Payer: MDX Hawaii PPO	$13.58

SUTURE, 2-0 POLYSORB UD 18 GS-21 DT

Facility

$47.00

Hospital Charge Code	8711305
Hospital Revenue Code	272
Min. Negotiated Rate	$23.50
Max. Negotiated Rate	$45.59
Rate for Payer: AlohaCare Medicaid	$23.50
Rate for Payer: AlohaCare Medicare	$23.50
Rate for Payer: Cash Price	$30.55
Rate for Payer: Devoted Health Medicare	$25.85
Rate for Payer: Hawaii Medical Service Association Medicare	$23.50
Rate for Payer: Hawaii Western Management Group Commercial	$44.65
Rate for Payer: Health Management Network Commercial	$39.95
Rate for Payer: Humana Medicare	$23.50
Rate for Payer: Kaiser Permanente Commercial	$42.30
Rate for Payer: Kaiser Permanente Medicaid	$23.97
Rate for Payer: Kaiser Permanente Medicare	$23.50
Rate for Payer: MDX Hawaii PPO	$45.59
Rate for Payer: Ohana Health Plan Medicaid	$23.50
Rate for Payer: Ohana Health Plan Medicare	$23.50
Rate for Payer: UnitedHealthcare Medicare	$23.50
Rate for Payer: University Health Alliance Commercial	$34.26

SUTURE, 2-0 POLYSORB UD 18 GS-21 DT

Facility

$47.00

Hospital Charge Code	8711305
Hospital Revenue Code	272
Min. Negotiated Rate	$39.95
Max. Negotiated Rate	$45.59
Rate for Payer: Cash Price	$30.55
Rate for Payer: Health Management Network Commercial	$39.95
Rate for Payer: Kaiser Permanente Commercial	$42.30
Rate for Payer: MDX Hawaii PPO	$45.59

Know your out-of-pocket cost for care.

All Charges