Samuel Mahelona Memorial Hospital

All Charges

Charge

Type

Setting

Price

SUTURE, SURGIPRO 2-0 SC-2 BLUE 30 KS 60MM

Facility

$34.00

Hospital Charge Code	8428814
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

SUTURE, SURGIPRO 2-0 SC-2 BLUE 30 KS 60MM

Facility

$34.00

Hospital Charge Code	8428814
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

SUTURE SURGIPRO 2-0 V-20 VP-523

Facility

$38.00

Hospital Charge Code	8274423
Hospital Revenue Code	272
Min. Negotiated Rate	$19.00
Max. Negotiated Rate	$36.86
Rate for Payer: AlohaCare Medicaid	$19.00
Rate for Payer: AlohaCare Medicare	$19.00
Rate for Payer: Cash Price	$24.70
Rate for Payer: Devoted Health Medicare	$20.90
Rate for Payer: Hawaii Medical Service Association Medicare	$19.00
Rate for Payer: Hawaii Western Management Group Commercial	$36.10
Rate for Payer: Health Management Network Commercial	$32.30
Rate for Payer: Humana Medicare	$19.00
Rate for Payer: Kaiser Permanente Commercial	$34.20
Rate for Payer: Kaiser Permanente Medicaid	$19.38
Rate for Payer: Kaiser Permanente Medicare	$19.00
Rate for Payer: MDX Hawaii PPO	$36.86
Rate for Payer: Ohana Health Plan Medicaid	$19.00
Rate for Payer: Ohana Health Plan Medicare	$19.00
Rate for Payer: UnitedHealthcare Medicare	$19.00
Rate for Payer: University Health Alliance Commercial	$27.70

SUTURE SURGIPRO 2-0 V-20 VP-523

Facility

$38.00

Hospital Charge Code	8274423
Hospital Revenue Code	272
Min. Negotiated Rate	$32.30
Max. Negotiated Rate	$36.86
Rate for Payer: Cash Price	$24.70
Rate for Payer: Health Management Network Commercial	$32.30
Rate for Payer: Kaiser Permanente Commercial	$34.20
Rate for Payer: MDX Hawaii PPO	$36.86

SUTURE, SURGIPRO 2-0 VP151 VF-20

Facility

$26.00

Hospital Charge Code	8274422
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, SURGIPRO 2-0 VP151 VF-20

Facility

$26.00

Hospital Charge Code	8274422
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, SURGIPRO 2 GS-18 LR BLUE 30 77MM

Facility

$35.00

Hospital Charge Code	8428812
Hospital Revenue Code	272
Min. Negotiated Rate	$29.75
Max. Negotiated Rate	$33.95
Rate for Payer: Cash Price	$22.75
Rate for Payer: Health Management Network Commercial	$29.75
Rate for Payer: Kaiser Permanente Commercial	$31.50
Rate for Payer: MDX Hawaii PPO	$33.95

SUTURE, SURGIPRO 2 GS-18 LR BLUE 30 77MM

Facility

$35.00

Hospital Charge Code	8428812
Hospital Revenue Code	272
Min. Negotiated Rate	$17.50
Max. Negotiated Rate	$33.95
Rate for Payer: AlohaCare Medicaid	$17.50
Rate for Payer: AlohaCare Medicare	$17.50
Rate for Payer: Cash Price	$22.75
Rate for Payer: Devoted Health Medicare	$19.25
Rate for Payer: Hawaii Medical Service Association Medicare	$17.50
Rate for Payer: Hawaii Western Management Group Commercial	$33.25
Rate for Payer: Health Management Network Commercial	$29.75
Rate for Payer: Humana Medicare	$17.50
Rate for Payer: Kaiser Permanente Commercial	$31.50
Rate for Payer: Kaiser Permanente Medicaid	$17.85
Rate for Payer: Kaiser Permanente Medicare	$17.50
Rate for Payer: MDX Hawaii PPO	$33.95
Rate for Payer: Ohana Health Plan Medicaid	$17.50
Rate for Payer: Ohana Health Plan Medicare	$17.50
Rate for Payer: UnitedHealthcare Medicare	$17.50
Rate for Payer: University Health Alliance Commercial	$25.51

SUTURE, SURGIPRO 3-0 C14 SP-684

Facility

$35.00

Hospital Charge Code	8274424
Hospital Revenue Code	272
Min. Negotiated Rate	$17.50
Max. Negotiated Rate	$33.95
Rate for Payer: AlohaCare Medicaid	$17.50
Rate for Payer: AlohaCare Medicare	$17.50
Rate for Payer: Cash Price	$22.75
Rate for Payer: Devoted Health Medicare	$19.25
Rate for Payer: Hawaii Medical Service Association Medicare	$17.50
Rate for Payer: Hawaii Western Management Group Commercial	$33.25
Rate for Payer: Health Management Network Commercial	$29.75
Rate for Payer: Humana Medicare	$17.50
Rate for Payer: Kaiser Permanente Commercial	$31.50
Rate for Payer: Kaiser Permanente Medicaid	$17.85
Rate for Payer: Kaiser Permanente Medicare	$17.50
Rate for Payer: MDX Hawaii PPO	$33.95
Rate for Payer: Ohana Health Plan Medicaid	$17.50
Rate for Payer: Ohana Health Plan Medicare	$17.50
Rate for Payer: UnitedHealthcare Medicare	$17.50
Rate for Payer: University Health Alliance Commercial	$25.51

SUTURE, SURGIPRO 3-0 C14 SP-684

Facility

$35.00

Hospital Charge Code	8274424
Hospital Revenue Code	272
Min. Negotiated Rate	$29.75
Max. Negotiated Rate	$33.95
Rate for Payer: Cash Price	$22.75
Rate for Payer: Health Management Network Commercial	$29.75
Rate for Payer: Kaiser Permanente Commercial	$31.50
Rate for Payer: MDX Hawaii PPO	$33.95

SUTURE SURGIPRO 4-0 18 BL CV23 VP-757-X

Facility

$39.00

Hospital Charge Code	8274425
Hospital Revenue Code	272
Min. Negotiated Rate	$19.50
Max. Negotiated Rate	$37.83
Rate for Payer: AlohaCare Medicaid	$19.50
Rate for Payer: AlohaCare Medicare	$19.50
Rate for Payer: Cash Price	$25.35
Rate for Payer: Devoted Health Medicare	$21.45
Rate for Payer: Hawaii Medical Service Association Medicare	$19.50
Rate for Payer: Hawaii Western Management Group Commercial	$37.05
Rate for Payer: Health Management Network Commercial	$33.15
Rate for Payer: Humana Medicare	$19.50
Rate for Payer: Kaiser Permanente Commercial	$35.10
Rate for Payer: Kaiser Permanente Medicaid	$19.89
Rate for Payer: Kaiser Permanente Medicare	$19.50
Rate for Payer: MDX Hawaii PPO	$37.83
Rate for Payer: Ohana Health Plan Medicaid	$19.50
Rate for Payer: Ohana Health Plan Medicare	$19.50
Rate for Payer: UnitedHealthcare Medicare	$19.50
Rate for Payer: University Health Alliance Commercial	$28.43

SUTURE SURGIPRO 4-0 18 BL CV23 VP-757-X

Facility

$39.00

Hospital Charge Code	8274425
Hospital Revenue Code	272
Min. Negotiated Rate	$33.15
Max. Negotiated Rate	$37.83
Rate for Payer: Cash Price	$25.35
Rate for Payer: Health Management Network Commercial	$33.15
Rate for Payer: Kaiser Permanente Commercial	$35.10
Rate for Payer: MDX Hawaii PPO	$37.83

SUTURE, SURGIPRO 5-0, CV-11 VP 719X

Facility

$26.00

Hospital Charge Code	8274426
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, SURGIPRO 5-0, CV-11 VP 719X

Facility

$26.00

Hospital Charge Code	8274426
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, SURGIPRO 6-0 CV-11 VP-718-X

Facility

$26.00

Hospital Charge Code	8274427
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, SURGIPRO 6-0 CV-11 VP-718-X

Facility

$26.00

Hospital Charge Code	8274427
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, TICRON 1 GS21 3090-71

Facility

$8.00

Hospital Charge Code	8274428
Hospital Revenue Code	272
Min. Negotiated Rate	$6.80
Max. Negotiated Rate	$7.76
Rate for Payer: Cash Price	$5.20
Rate for Payer: Health Management Network Commercial	$6.80
Rate for Payer: Kaiser Permanente Commercial	$7.20
Rate for Payer: MDX Hawaii PPO	$7.76

SUTURE, TICRON 1 GS21 3090-71

Facility

$8.00

Hospital Charge Code	8274428
Hospital Revenue Code	272
Min. Negotiated Rate	$4.00
Max. Negotiated Rate	$7.76
Rate for Payer: AlohaCare Medicaid	$4.00
Rate for Payer: AlohaCare Medicare	$4.00
Rate for Payer: Cash Price	$5.20
Rate for Payer: Devoted Health Medicare	$4.40
Rate for Payer: Hawaii Medical Service Association Medicare	$4.00
Rate for Payer: Hawaii Western Management Group Commercial	$7.60
Rate for Payer: Health Management Network Commercial	$6.80
Rate for Payer: Humana Medicare	$4.00
Rate for Payer: Kaiser Permanente Commercial	$7.20
Rate for Payer: Kaiser Permanente Medicaid	$4.08
Rate for Payer: Kaiser Permanente Medicare	$4.00
Rate for Payer: MDX Hawaii PPO	$7.76
Rate for Payer: Ohana Health Plan Medicaid	$4.00
Rate for Payer: Ohana Health Plan Medicare	$4.00
Rate for Payer: UnitedHealthcare Medicare	$4.00
Rate for Payer: University Health Alliance Commercial	$5.83

SUTURE, TICRON 5-0 P13 SCD-2864G

Facility

$37.00

Hospital Charge Code	8274338
Hospital Revenue Code	272
Min. Negotiated Rate	$18.50
Max. Negotiated Rate	$35.89
Rate for Payer: AlohaCare Medicaid	$18.50
Rate for Payer: AlohaCare Medicare	$18.50
Rate for Payer: Cash Price	$24.05
Rate for Payer: Devoted Health Medicare	$20.35
Rate for Payer: Hawaii Medical Service Association Medicare	$18.50
Rate for Payer: Hawaii Western Management Group Commercial	$35.15
Rate for Payer: Health Management Network Commercial	$31.45
Rate for Payer: Humana Medicare	$18.50
Rate for Payer: Kaiser Permanente Commercial	$33.30
Rate for Payer: Kaiser Permanente Medicaid	$18.87
Rate for Payer: Kaiser Permanente Medicare	$18.50
Rate for Payer: MDX Hawaii PPO	$35.89
Rate for Payer: Ohana Health Plan Medicaid	$18.50
Rate for Payer: Ohana Health Plan Medicare	$18.50
Rate for Payer: UnitedHealthcare Medicare	$18.50
Rate for Payer: University Health Alliance Commercial	$26.97

SUTURE, TICRON 5-0 P13 SCD-2864G

Facility

$37.00

Hospital Charge Code	8274338
Hospital Revenue Code	272
Min. Negotiated Rate	$31.45
Max. Negotiated Rate	$35.89
Rate for Payer: Cash Price	$24.05
Rate for Payer: Health Management Network Commercial	$31.45
Rate for Payer: Kaiser Permanente Commercial	$33.30
Rate for Payer: MDX Hawaii PPO	$35.89

SUTURE, VICRYL 0 COATED PLUS UNDYED 1X27 CT-2

Facility

$17.00

Hospital Charge Code	8550235
Hospital Revenue Code	272
Min. Negotiated Rate	$14.45
Max. Negotiated Rate	$16.49
Rate for Payer: Cash Price	$11.05
Rate for Payer: Health Management Network Commercial	$14.45
Rate for Payer: Kaiser Permanente Commercial	$15.30
Rate for Payer: MDX Hawaii PPO	$16.49

SUTURE, VICRYL 0 COATED PLUS UNDYED 1X27 CT-2

Facility

$17.00

Hospital Charge Code	8550235
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 VICRYL 2-0 COATED PLUS UNDYED TAPERPOINT SH 26MM 1 X 27IN/70CM

Facility

$16.00

Hospital Charge Code	8551047
Hospital Revenue Code	270
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 VICRYL 2-0 COATED PLUS UNDYED TAPERPOINT SH 26MM 1 X 27IN/70CM

Facility

$16.00

Hospital Charge Code	8551047
Hospital Revenue Code	270
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

SUTURE, V-LOC 180 0 GREEN 23CM GS-21

Facility

$149.00

Hospital Charge Code	9590126
Hospital Revenue Code	272
Min. Negotiated Rate	$126.65
Max. Negotiated Rate	$144.53
Rate for Payer: Cash Price	$96.85
Rate for Payer: Health Management Network Commercial	$126.65
Rate for Payer: Kaiser Permanente Commercial	$134.10
Rate for Payer: MDX Hawaii PPO	$144.53

Know your out-of-pocket cost for care.

All Charges