Samuel Mahelona Memorial Hospital

All Charges

Charge

Type

Setting

Price

SUTURE POLYSORB 2-0 GU-46 UL 878

Facility

$17.00

Hospital Charge Code	8274408
Hospital Revenue Code	272
Min. Negotiated Rate	$8.50
Max. Negotiated Rate	$16.49
Rate for Payer: AlohaCare Medicaid	$8.50
Rate for Payer: AlohaCare Medicare	$8.50
Rate for Payer: Cash Price	$11.05
Rate for Payer: Devoted Health Medicare	$9.35
Rate for Payer: Hawaii Medical Service Association Medicare	$8.50
Rate for Payer: Hawaii Western Management Group Commercial	$16.15
Rate for Payer: Health Management Network Commercial	$14.45
Rate for Payer: Humana Medicare	$8.50
Rate for Payer: Kaiser Permanente Commercial	$15.30
Rate for Payer: Kaiser Permanente Medicaid	$8.67
Rate for Payer: Kaiser Permanente Medicare	$8.50
Rate for Payer: MDX Hawaii PPO	$16.49
Rate for Payer: Ohana Health Plan Medicaid	$8.50
Rate for Payer: Ohana Health Plan Medicare	$8.50
Rate for Payer: UnitedHealthcare Medicare	$8.50
Rate for Payer: University Health Alliance Commercial	$12.39

SUTURE, POLYSORB 2-0 TIES L113

Facility

$19.00

Hospital Charge Code	8274407
Hospital Revenue Code	272
Min. Negotiated Rate	$16.15
Max. Negotiated Rate	$18.43
Rate for Payer: Cash Price	$12.35
Rate for Payer: Health Management Network Commercial	$16.15
Rate for Payer: Kaiser Permanente Commercial	$17.10
Rate for Payer: MDX Hawaii PPO	$18.43

SUTURE, POLYSORB 2-0 TIES L113

Facility

$19.00

Hospital Charge Code	8274407
Hospital Revenue Code	272
Min. Negotiated Rate	$9.50
Max. Negotiated Rate	$18.43
Rate for Payer: AlohaCare Medicaid	$9.50
Rate for Payer: AlohaCare Medicare	$9.50
Rate for Payer: Cash Price	$12.35
Rate for Payer: Devoted Health Medicare	$10.45
Rate for Payer: Hawaii Medical Service Association Medicare	$9.50
Rate for Payer: Hawaii Western Management Group Commercial	$18.05
Rate for Payer: Health Management Network Commercial	$16.15
Rate for Payer: Humana Medicare	$9.50
Rate for Payer: Kaiser Permanente Commercial	$17.10
Rate for Payer: Kaiser Permanente Medicaid	$9.69
Rate for Payer: Kaiser Permanente Medicare	$9.50
Rate for Payer: MDX Hawaii PPO	$18.43
Rate for Payer: Ohana Health Plan Medicaid	$9.50
Rate for Payer: Ohana Health Plan Medicare	$9.50
Rate for Payer: UnitedHealthcare Medicare	$9.50
Rate for Payer: University Health Alliance Commercial	$13.85

SUTURE, POLYSORB 2-0 UNDYED 30 V-20 SH 26MM

Facility

$13.00

Hospital Charge Code	8428809
Hospital Revenue Code	272
Min. Negotiated Rate	$6.50
Max. Negotiated Rate	$12.61
Rate for Payer: AlohaCare Medicaid	$6.50
Rate for Payer: AlohaCare Medicare	$6.50
Rate for Payer: Cash Price	$8.45
Rate for Payer: Devoted Health Medicare	$7.15
Rate for Payer: Hawaii Medical Service Association Medicare	$6.50
Rate for Payer: Hawaii Western Management Group Commercial	$12.35
Rate for Payer: Health Management Network Commercial	$11.05
Rate for Payer: Humana Medicare	$6.50
Rate for Payer: Kaiser Permanente Commercial	$11.70
Rate for Payer: Kaiser Permanente Medicaid	$6.63
Rate for Payer: Kaiser Permanente Medicare	$6.50
Rate for Payer: MDX Hawaii PPO	$12.61
Rate for Payer: Ohana Health Plan Medicaid	$6.50
Rate for Payer: Ohana Health Plan Medicare	$6.50
Rate for Payer: UnitedHealthcare Medicare	$6.50
Rate for Payer: University Health Alliance Commercial	$9.48

SUTURE, POLYSORB 2-0 UNDYED 30 V-20 SH 26MM

Facility

$13.00

Hospital Charge Code	8428809
Hospital Revenue Code	272
Min. Negotiated Rate	$11.05
Max. Negotiated Rate	$12.61
Rate for Payer: Cash Price	$8.45
Rate for Payer: Health Management Network Commercial	$11.05
Rate for Payer: Kaiser Permanente Commercial	$11.70
Rate for Payer: MDX Hawaii PPO	$12.61

SUTURE POLYSORB 2-0 UNDYED 5X18 V-20

Facility

$50.00

Hospital Charge Code	8527155
Hospital Revenue Code	272
Min. Negotiated Rate	$25.00
Max. Negotiated Rate	$48.50
Rate for Payer: AlohaCare Medicaid	$25.00
Rate for Payer: AlohaCare Medicare	$25.00
Rate for Payer: Cash Price	$32.50
Rate for Payer: Devoted Health Medicare	$27.50
Rate for Payer: Hawaii Medical Service Association Medicare	$25.00
Rate for Payer: Hawaii Western Management Group Commercial	$47.50
Rate for Payer: Health Management Network Commercial	$42.50
Rate for Payer: Humana Medicare	$25.00
Rate for Payer: Kaiser Permanente Commercial	$45.00
Rate for Payer: Kaiser Permanente Medicaid	$25.50
Rate for Payer: Kaiser Permanente Medicare	$25.00
Rate for Payer: MDX Hawaii PPO	$48.50
Rate for Payer: Ohana Health Plan Medicaid	$25.00
Rate for Payer: Ohana Health Plan Medicare	$25.00
Rate for Payer: UnitedHealthcare Medicare	$25.00
Rate for Payer: University Health Alliance Commercial	$36.45

SUTURE POLYSORB 2-0 UNDYED 5X18 V-20

Facility

$50.00

Hospital Charge Code	8527155
Hospital Revenue Code	272
Min. Negotiated Rate	$42.50
Max. Negotiated Rate	$48.50
Rate for Payer: Cash Price	$32.50
Rate for Payer: Health Management Network Commercial	$42.50
Rate for Payer: Kaiser Permanente Commercial	$45.00
Rate for Payer: MDX Hawaii PPO	$48.50

SUTURE, POLYSORB 3-0 CV-25 GL192

Facility

$14.00

Hospital Charge Code	8274411
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, POLYSORB 3-0 CV-25 GL192

Facility

$14.00

Hospital Charge Code	8274411
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, POLYSORB 3-0 GS21 CL 922

Facility

$14.00

Hospital Charge Code	8274410
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, POLYSORB 3-0 GS21 CL 922

Facility

$14.00

Hospital Charge Code	8274410
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, POLYSORB 3-0 P12 SL5628G

Facility

$22.00

Hospital Charge Code	8274335
Hospital Revenue Code	272
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

SUTURE, POLYSORB 3-0 P12 SL5628G

Facility

$22.00

Hospital Charge Code	8274335
Hospital Revenue Code	272
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

SUTURE, POLYSORB 3-0, PC-15 SL-1654

Facility

$28.00

Hospital Charge Code	8274412
Hospital Revenue Code	272
Min. Negotiated Rate	$14.00
Max. Negotiated Rate	$27.16
Rate for Payer: AlohaCare Medicaid	$14.00
Rate for Payer: AlohaCare Medicare	$14.00
Rate for Payer: Cash Price	$18.20
Rate for Payer: Devoted Health Medicare	$15.40
Rate for Payer: Hawaii Medical Service Association Medicare	$14.00
Rate for Payer: Hawaii Western Management Group Commercial	$26.60
Rate for Payer: Health Management Network Commercial	$23.80
Rate for Payer: Humana Medicare	$14.00
Rate for Payer: Kaiser Permanente Commercial	$25.20
Rate for Payer: Kaiser Permanente Medicaid	$14.28
Rate for Payer: Kaiser Permanente Medicare	$14.00
Rate for Payer: MDX Hawaii PPO	$27.16
Rate for Payer: Ohana Health Plan Medicaid	$14.00
Rate for Payer: Ohana Health Plan Medicare	$14.00
Rate for Payer: UnitedHealthcare Medicare	$14.00
Rate for Payer: University Health Alliance Commercial	$20.41

SUTURE, POLYSORB 3-0, PC-15 SL-1654

Facility

$28.00

Hospital Charge Code	8274412
Hospital Revenue Code	272
Min. Negotiated Rate	$23.80
Max. Negotiated Rate	$27.16
Rate for Payer: Cash Price	$18.20
Rate for Payer: Health Management Network Commercial	$23.80
Rate for Payer: Kaiser Permanente Commercial	$25.20
Rate for Payer: MDX Hawaii PPO	$27.16

SUTURE, POLYSORB 3-0 TIES L-38

Facility

$43.00

Hospital Charge Code	8274360
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

SUTURE, POLYSORB 3-0 TIES L-38

Facility

$43.00

Hospital Charge Code	8274360
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

SUTURE, POLYSORB 3-0 V-20 UNDYED 30 SH 26MM

Facility

$13.00

Hospital Charge Code	8428810
Hospital Revenue Code	272
Min. Negotiated Rate	$6.50
Max. Negotiated Rate	$12.61
Rate for Payer: AlohaCare Medicaid	$6.50
Rate for Payer: AlohaCare Medicare	$6.50
Rate for Payer: Cash Price	$8.45
Rate for Payer: Devoted Health Medicare	$7.15
Rate for Payer: Hawaii Medical Service Association Medicare	$6.50
Rate for Payer: Hawaii Western Management Group Commercial	$12.35
Rate for Payer: Health Management Network Commercial	$11.05
Rate for Payer: Humana Medicare	$6.50
Rate for Payer: Kaiser Permanente Commercial	$11.70
Rate for Payer: Kaiser Permanente Medicaid	$6.63
Rate for Payer: Kaiser Permanente Medicare	$6.50
Rate for Payer: MDX Hawaii PPO	$12.61
Rate for Payer: Ohana Health Plan Medicaid	$6.50
Rate for Payer: Ohana Health Plan Medicare	$6.50
Rate for Payer: UnitedHealthcare Medicare	$6.50
Rate for Payer: University Health Alliance Commercial	$9.48

SUTURE, POLYSORB 3-0 V-20 UNDYED 30 SH 26MM

Facility

$13.00

Hospital Charge Code	8428810
Hospital Revenue Code	272
Min. Negotiated Rate	$11.05
Max. Negotiated Rate	$12.61
Rate for Payer: Cash Price	$8.45
Rate for Payer: Health Management Network Commercial	$11.05
Rate for Payer: Kaiser Permanente Commercial	$11.70
Rate for Payer: MDX Hawaii PPO	$12.61

SUTURE POLYSORB 3-0 VIOLET 5X18 CV-23 D-TACH

Facility

$50.00

Hospital Charge Code	8527484
Hospital Revenue Code	272
Min. Negotiated Rate	$25.00
Max. Negotiated Rate	$48.50
Rate for Payer: AlohaCare Medicaid	$25.00
Rate for Payer: AlohaCare Medicare	$25.00
Rate for Payer: Cash Price	$32.50
Rate for Payer: Devoted Health Medicare	$27.50
Rate for Payer: Hawaii Medical Service Association Medicare	$25.00
Rate for Payer: Hawaii Western Management Group Commercial	$47.50
Rate for Payer: Health Management Network Commercial	$42.50
Rate for Payer: Humana Medicare	$25.00
Rate for Payer: Kaiser Permanente Commercial	$45.00
Rate for Payer: Kaiser Permanente Medicaid	$25.50
Rate for Payer: Kaiser Permanente Medicare	$25.00
Rate for Payer: MDX Hawaii PPO	$48.50
Rate for Payer: Ohana Health Plan Medicaid	$25.00
Rate for Payer: Ohana Health Plan Medicare	$25.00
Rate for Payer: UnitedHealthcare Medicare	$25.00
Rate for Payer: University Health Alliance Commercial	$36.45

SUTURE POLYSORB 3-0 VIOLET 5X18 CV-23 D-TACH

Facility

$50.00

Hospital Charge Code	8527484
Hospital Revenue Code	272
Min. Negotiated Rate	$42.50
Max. Negotiated Rate	$48.50
Rate for Payer: Cash Price	$32.50
Rate for Payer: Health Management Network Commercial	$42.50
Rate for Payer: Kaiser Permanente Commercial	$45.00
Rate for Payer: MDX Hawaii PPO	$48.50

SUTURE, POLYSORB 4-0 C-13 UNDYED 20 FS-2 19MM

Facility

$18.00

Hospital Charge Code	8428811
Hospital Revenue Code	272
Min. Negotiated Rate	$9.00
Max. Negotiated Rate	$17.46
Rate for Payer: AlohaCare Medicaid	$9.00
Rate for Payer: AlohaCare Medicare	$9.00
Rate for Payer: Cash Price	$11.70
Rate for Payer: Devoted Health Medicare	$9.90
Rate for Payer: Hawaii Medical Service Association Medicare	$9.00
Rate for Payer: Hawaii Western Management Group Commercial	$17.10
Rate for Payer: Health Management Network Commercial	$15.30
Rate for Payer: Humana Medicare	$9.00
Rate for Payer: Kaiser Permanente Commercial	$16.20
Rate for Payer: Kaiser Permanente Medicaid	$9.18
Rate for Payer: Kaiser Permanente Medicare	$9.00
Rate for Payer: MDX Hawaii PPO	$17.46
Rate for Payer: Ohana Health Plan Medicaid	$9.00
Rate for Payer: Ohana Health Plan Medicare	$9.00
Rate for Payer: UnitedHealthcare Medicare	$9.00
Rate for Payer: University Health Alliance Commercial	$13.12

SUTURE, POLYSORB 4-0 C-13 UNDYED 20 FS-2 19MM

Facility

$18.00

Hospital Charge Code	8428811
Hospital Revenue Code	272
Min. Negotiated Rate	$15.30
Max. Negotiated Rate	$17.46
Rate for Payer: Cash Price	$11.70
Rate for Payer: Health Management Network Commercial	$15.30
Rate for Payer: Kaiser Permanente Commercial	$16.20
Rate for Payer: MDX Hawaii PPO	$17.46

SUTURE, POLYSORB 4-0 CV25 GL-191

Facility

$16.00

Hospital Charge Code	8274413
Hospital Revenue Code	272
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

SUTURE, POLYSORB 4-0 CV25 GL-191

Facility

$16.00

Hospital Charge Code	8274413
Hospital Revenue Code	272
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

Know your out-of-pocket cost for care.

All Charges