Samuel Mahelona Memorial Hospital

All Charges

Charge

Type

Setting

Price

TAPE CAST DELTA ELITE PLYSTR 3X4YD 10/BX

Professional

Both

$30.00

Hospital Charge Code	12957409
Hospital Revenue Code	270
Min. Negotiated Rate	$25.50
Max. Negotiated Rate	$25.50
Rate for Payer: Cash Price	$19.50
Rate for Payer: Health Management Network Commercial	$25.50

TAPE CAST DELTA ELITE PLYSTR 3X4YD 10/BX

Facility

$30.00

Hospital Charge Code	12957409
Hospital Revenue Code	270
Min. Negotiated Rate	$15.00
Max. Negotiated Rate	$29.10
Rate for Payer: AlohaCare Medicaid	$15.00
Rate for Payer: AlohaCare Medicare	$15.00
Rate for Payer: Cash Price	$19.50
Rate for Payer: Devoted Health Medicare	$16.50
Rate for Payer: Hawaii Medical Service Association Medicare	$15.00
Rate for Payer: Hawaii Western Management Group Commercial	$28.50
Rate for Payer: Health Management Network Commercial	$25.50
Rate for Payer: Humana Medicare	$15.00
Rate for Payer: Kaiser Permanente Commercial	$27.00
Rate for Payer: Kaiser Permanente Medicaid	$15.30
Rate for Payer: Kaiser Permanente Medicare	$15.00
Rate for Payer: MDX Hawaii PPO	$29.10
Rate for Payer: Ohana Health Plan Medicaid	$15.00
Rate for Payer: Ohana Health Plan Medicare	$15.00
Rate for Payer: UnitedHealthcare Medicare	$15.00
Rate for Payer: University Health Alliance Commercial	$21.87

TAPE CAST DELTA ELITE PLYSTR 3X4YD 10/BX

Facility

$30.00

Hospital Charge Code	12957409
Hospital Revenue Code	270
Min. Negotiated Rate	$25.50
Max. Negotiated Rate	$29.10
Rate for Payer: Cash Price	$19.50
Rate for Payer: Health Management Network Commercial	$25.50
Rate for Payer: Kaiser Permanente Commercial	$27.00
Rate for Payer: MDX Hawaii PPO	$29.10

TAPE CASTING DELTA-LITE PLUS FBGLS 2X4YD LF DEEP BLUE 10/BX

Facility

$15.00

Hospital Charge Code	12954869
Hospital Revenue Code	272
Min. Negotiated Rate	$12.75
Max. Negotiated Rate	$14.55
Rate for Payer: Cash Price	$9.75
Rate for Payer: Health Management Network Commercial	$12.75
Rate for Payer: Kaiser Permanente Commercial	$13.50
Rate for Payer: MDX Hawaii PPO	$14.55

TAPE CASTING DELTA-LITE PLUS FBGLS 2X4YD LF DEEP BLUE 10/BX

Professional

Both

$15.00

Hospital Charge Code	12954869
Hospital Revenue Code	272
Min. Negotiated Rate	$12.75
Max. Negotiated Rate	$12.75
Rate for Payer: Cash Price	$9.75
Rate for Payer: Health Management Network Commercial	$12.75

TAPE CASTING DELTA-LITE PLUS FBGLS 2X4YD LF DEEP BLUE 10/BX

Facility

$15.00

Hospital Charge Code	12954869
Hospital Revenue Code	272
Min. Negotiated Rate	$7.50
Max. Negotiated Rate	$14.55
Rate for Payer: AlohaCare Medicaid	$7.50
Rate for Payer: AlohaCare Medicare	$7.50
Rate for Payer: Cash Price	$9.75
Rate for Payer: Devoted Health Medicare	$8.25
Rate for Payer: Hawaii Medical Service Association Medicare	$7.50
Rate for Payer: Hawaii Western Management Group Commercial	$14.25
Rate for Payer: Health Management Network Commercial	$12.75
Rate for Payer: Humana Medicare	$7.50
Rate for Payer: Kaiser Permanente Commercial	$13.50
Rate for Payer: Kaiser Permanente Medicaid	$7.65
Rate for Payer: Kaiser Permanente Medicare	$7.50
Rate for Payer: MDX Hawaii PPO	$14.55
Rate for Payer: Ohana Health Plan Medicaid	$7.50
Rate for Payer: Ohana Health Plan Medicare	$7.50
Rate for Payer: UnitedHealthcare Medicare	$7.50
Rate for Payer: University Health Alliance Commercial	$10.93

TAPE CASTING DELTA-LITE PLUS FBGLS 4X4YD LF DEEP BLUE 10/BX

Professional

Both

$23.00

Hospital Charge Code	12954870
Hospital Revenue Code	272
Min. Negotiated Rate	$19.55
Max. Negotiated Rate	$19.55
Rate for Payer: Cash Price	$14.95
Rate for Payer: Health Management Network Commercial	$19.55

TAPE CASTING DELTA-LITE PLUS FBGLS 4X4YD LF DEEP BLUE 10/BX

Facility

$23.00

Hospital Charge Code	12954870
Hospital Revenue Code	272
Min. Negotiated Rate	$19.55
Max. Negotiated Rate	$22.31
Rate for Payer: Cash Price	$14.95
Rate for Payer: Health Management Network Commercial	$19.55
Rate for Payer: Kaiser Permanente Commercial	$20.70
Rate for Payer: MDX Hawaii PPO	$22.31

TAPE CASTING DELTA-LITE PLUS FBGLS 4X4YD LF DEEP BLUE 10/BX

Facility

$23.00

Hospital Charge Code	12954870
Hospital Revenue Code	272
Min. Negotiated Rate	$11.50
Max. Negotiated Rate	$22.31
Rate for Payer: AlohaCare Medicaid	$11.50
Rate for Payer: AlohaCare Medicare	$11.50
Rate for Payer: Cash Price	$14.95
Rate for Payer: Devoted Health Medicare	$12.65
Rate for Payer: Hawaii Medical Service Association Medicare	$11.50
Rate for Payer: Hawaii Western Management Group Commercial	$21.85
Rate for Payer: Health Management Network Commercial	$19.55
Rate for Payer: Humana Medicare	$11.50
Rate for Payer: Kaiser Permanente Commercial	$20.70
Rate for Payer: Kaiser Permanente Medicaid	$11.73
Rate for Payer: Kaiser Permanente Medicare	$11.50
Rate for Payer: MDX Hawaii PPO	$22.31
Rate for Payer: Ohana Health Plan Medicaid	$11.50
Rate for Payer: Ohana Health Plan Medicare	$11.50
Rate for Payer: UnitedHealthcare Medicare	$11.50
Rate for Payer: University Health Alliance Commercial	$16.76

TAPE CASTING DELTA-LITE PLUS FIBERGLASS 2X4YD LF GREEN 10/BX

Professional

Both

$15.00

Hospital Charge Code	12954888
Hospital Revenue Code	272
Min. Negotiated Rate	$12.75
Max. Negotiated Rate	$12.75
Rate for Payer: Cash Price	$9.75
Rate for Payer: Health Management Network Commercial	$12.75

TAPE CASTING DELTA-LITE PLUS FIBERGLASS 2X4YD LF GREEN 10/BX

Facility

$15.00

Hospital Charge Code	12954888
Hospital Revenue Code	272
Min. Negotiated Rate	$7.50
Max. Negotiated Rate	$14.55
Rate for Payer: AlohaCare Medicaid	$7.50
Rate for Payer: AlohaCare Medicare	$7.50
Rate for Payer: Cash Price	$9.75
Rate for Payer: Devoted Health Medicare	$8.25
Rate for Payer: Hawaii Medical Service Association Medicare	$7.50
Rate for Payer: Hawaii Western Management Group Commercial	$14.25
Rate for Payer: Health Management Network Commercial	$12.75
Rate for Payer: Humana Medicare	$7.50
Rate for Payer: Kaiser Permanente Commercial	$13.50
Rate for Payer: Kaiser Permanente Medicaid	$7.65
Rate for Payer: Kaiser Permanente Medicare	$7.50
Rate for Payer: MDX Hawaii PPO	$14.55
Rate for Payer: Ohana Health Plan Medicaid	$7.50
Rate for Payer: Ohana Health Plan Medicare	$7.50
Rate for Payer: UnitedHealthcare Medicare	$7.50
Rate for Payer: University Health Alliance Commercial	$10.93

TAPE CASTING DELTA-LITE PLUS FIBERGLASS 2X4YD LF GREEN 10/BX

Facility

$15.00

Hospital Charge Code	12954888
Hospital Revenue Code	272
Min. Negotiated Rate	$12.75
Max. Negotiated Rate	$14.55
Rate for Payer: Cash Price	$9.75
Rate for Payer: Health Management Network Commercial	$12.75
Rate for Payer: Kaiser Permanente Commercial	$13.50
Rate for Payer: MDX Hawaii PPO	$14.55

TAPE CASTING DELTA-LITE PLUS FIBERGLASS 2X4YD LF PURPLE 10/BX

Professional

Both

$15.00

Hospital Charge Code	12954885
Hospital Revenue Code	272
Min. Negotiated Rate	$12.75
Max. Negotiated Rate	$12.75
Rate for Payer: Cash Price	$9.75
Rate for Payer: Health Management Network Commercial	$12.75

TAPE CASTING DELTA-LITE PLUS FIBERGLASS 2X4YD LF PURPLE 10/BX

Facility

$15.00

Hospital Charge Code	12954885
Hospital Revenue Code	272
Min. Negotiated Rate	$7.50
Max. Negotiated Rate	$14.55
Rate for Payer: AlohaCare Medicaid	$7.50
Rate for Payer: AlohaCare Medicare	$7.50
Rate for Payer: Cash Price	$9.75
Rate for Payer: Devoted Health Medicare	$8.25
Rate for Payer: Hawaii Medical Service Association Medicare	$7.50
Rate for Payer: Hawaii Western Management Group Commercial	$14.25
Rate for Payer: Health Management Network Commercial	$12.75
Rate for Payer: Humana Medicare	$7.50
Rate for Payer: Kaiser Permanente Commercial	$13.50
Rate for Payer: Kaiser Permanente Medicaid	$7.65
Rate for Payer: Kaiser Permanente Medicare	$7.50
Rate for Payer: MDX Hawaii PPO	$14.55
Rate for Payer: Ohana Health Plan Medicaid	$7.50
Rate for Payer: Ohana Health Plan Medicare	$7.50
Rate for Payer: UnitedHealthcare Medicare	$7.50
Rate for Payer: University Health Alliance Commercial	$10.93

TAPE CASTING DELTA-LITE PLUS FIBERGLASS 2X4YD LF PURPLE 10/BX

Facility

$15.00

Hospital Charge Code	12954885
Hospital Revenue Code	272
Min. Negotiated Rate	$12.75
Max. Negotiated Rate	$14.55
Rate for Payer: Cash Price	$9.75
Rate for Payer: Health Management Network Commercial	$12.75
Rate for Payer: Kaiser Permanente Commercial	$13.50
Rate for Payer: MDX Hawaii PPO	$14.55

TAPE CASTING DELTA-LITE PLUS FIBERGLASS 2X4YD LF WHITE 10/BX

Facility

$15.00

Hospital Charge Code	12954882
Hospital Revenue Code	272
Min. Negotiated Rate	$7.50
Max. Negotiated Rate	$14.55
Rate for Payer: AlohaCare Medicaid	$7.50
Rate for Payer: AlohaCare Medicare	$7.50
Rate for Payer: Cash Price	$9.75
Rate for Payer: Devoted Health Medicare	$8.25
Rate for Payer: Hawaii Medical Service Association Medicare	$7.50
Rate for Payer: Hawaii Western Management Group Commercial	$14.25
Rate for Payer: Health Management Network Commercial	$12.75
Rate for Payer: Humana Medicare	$7.50
Rate for Payer: Kaiser Permanente Commercial	$13.50
Rate for Payer: Kaiser Permanente Medicaid	$7.65
Rate for Payer: Kaiser Permanente Medicare	$7.50
Rate for Payer: MDX Hawaii PPO	$14.55
Rate for Payer: Ohana Health Plan Medicaid	$7.50
Rate for Payer: Ohana Health Plan Medicare	$7.50
Rate for Payer: UnitedHealthcare Medicare	$7.50
Rate for Payer: University Health Alliance Commercial	$10.93

TAPE CASTING DELTA-LITE PLUS FIBERGLASS 2X4YD LF WHITE 10/BX

Facility

$15.00

Hospital Charge Code	12954882
Hospital Revenue Code	272
Min. Negotiated Rate	$12.75
Max. Negotiated Rate	$14.55
Rate for Payer: Cash Price	$9.75
Rate for Payer: Health Management Network Commercial	$12.75
Rate for Payer: Kaiser Permanente Commercial	$13.50
Rate for Payer: MDX Hawaii PPO	$14.55

TAPE CASTING DELTA-LITE PLUS FIBERGLASS 2X4YD LF WHITE 10/BX

Professional

Both

$15.00

Hospital Charge Code	12954882
Hospital Revenue Code	272
Min. Negotiated Rate	$12.75
Max. Negotiated Rate	$12.75
Rate for Payer: Cash Price	$9.75
Rate for Payer: Health Management Network Commercial	$12.75

TAPE CASTING DELTA-LITE PLUS FIBERGLASS 2X4YD ROLL LF RED 10/BX

Professional

Both

$15.00

Hospital Charge Code	12954889
Hospital Revenue Code	272
Min. Negotiated Rate	$12.75
Max. Negotiated Rate	$12.75
Rate for Payer: Cash Price	$9.75
Rate for Payer: Health Management Network Commercial	$12.75

TAPE CASTING DELTA-LITE PLUS FIBERGLASS 2X4YD ROLL LF RED 10/BX

Facility

$15.00

Hospital Charge Code	12954889
Hospital Revenue Code	272
Min. Negotiated Rate	$12.75
Max. Negotiated Rate	$14.55
Rate for Payer: Cash Price	$9.75
Rate for Payer: Health Management Network Commercial	$12.75
Rate for Payer: Kaiser Permanente Commercial	$13.50
Rate for Payer: MDX Hawaii PPO	$14.55

TAPE CASTING DELTA-LITE PLUS FIBERGLASS 2X4YD ROLL LF RED 10/BX

Facility

$15.00

Hospital Charge Code	12954889
Hospital Revenue Code	272
Min. Negotiated Rate	$7.50
Max. Negotiated Rate	$14.55
Rate for Payer: AlohaCare Medicaid	$7.50
Rate for Payer: AlohaCare Medicare	$7.50
Rate for Payer: Cash Price	$9.75
Rate for Payer: Devoted Health Medicare	$8.25
Rate for Payer: Hawaii Medical Service Association Medicare	$7.50
Rate for Payer: Hawaii Western Management Group Commercial	$14.25
Rate for Payer: Health Management Network Commercial	$12.75
Rate for Payer: Humana Medicare	$7.50
Rate for Payer: Kaiser Permanente Commercial	$13.50
Rate for Payer: Kaiser Permanente Medicaid	$7.65
Rate for Payer: Kaiser Permanente Medicare	$7.50
Rate for Payer: MDX Hawaii PPO	$14.55
Rate for Payer: Ohana Health Plan Medicaid	$7.50
Rate for Payer: Ohana Health Plan Medicare	$7.50
Rate for Payer: UnitedHealthcare Medicare	$7.50
Rate for Payer: University Health Alliance Commercial	$10.93

TAPE CASTING DELTA-LITE PLUS FIBERGLASS 3X4YD LF GREEN 10/BX

Facility

$17.00

Hospital Charge Code	12954891
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

TAPE CASTING DELTA-LITE PLUS FIBERGLASS 3X4YD LF GREEN 10/BX

Professional

Both

$17.00

Hospital Charge Code	12954891
Hospital Revenue Code	272
Min. Negotiated Rate	$14.45
Max. Negotiated Rate	$14.45
Rate for Payer: Cash Price	$11.05
Rate for Payer: Health Management Network Commercial	$14.45

TAPE CASTING DELTA-LITE PLUS FIBERGLASS 3X4YD LF GREEN 10/BX

Facility

$17.00

Hospital Charge Code	12954891
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

TAPE CASTING DELTA-LITE PLUS FIBERGLASS 3X4YD LF PURPLE 10/BX

Facility

$17.00

Hospital Charge Code	12954886
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

Know your out-of-pocket cost for care.

All Charges