Samuel Mahelona Memorial Hospital

All Charges

Charge

Type

Setting

Price

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

Professional

Both

$17.00

Hospital Charge Code	12954886
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 PURPLE 10/BX

Facility

$17.00

Hospital Charge Code	12954886
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 WHITE 10/BX

Facility

$17.00

Hospital Charge Code	12954883
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 WHITE 10/BX

Facility

$17.00

Hospital Charge Code	12954883
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 WHITE 10/BX

Professional

Both

$17.00

Hospital Charge Code	12954883
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 ROLL LF RED 10/BX

Professional

Both

$17.00

Hospital Charge Code	12954890
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 ROLL LF RED 10/BX

Facility

$17.00

Hospital Charge Code	12954890
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 ROLL LF RED 10/BX

Facility

$17.00

Hospital Charge Code	12954890
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 4X4YD LF PURPLE 10/BX

Facility

$23.00

Hospital Charge Code	12954871
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 FIBERGLASS 4X4YD LF PURPLE 10/BX

Professional

Both

$23.00

Hospital Charge Code	12954871
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 FIBERGLASS 4X4YD LF PURPLE 10/BX

Facility

$23.00

Hospital Charge Code	12954871
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 4X4YD LF WHITE 10/BX

Professional

Both

$23.00

Hospital Charge Code	12954884
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 FIBERGLASS 4X4YD LF WHITE 10/BX

Facility

$23.00

Hospital Charge Code	12954884
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 FIBERGLASS 4X4YD LF WHITE 10/BX

Facility

$23.00

Hospital Charge Code	12954884
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 4X4YD ROLL LF RED 10/BX

Facility

$23.00

Hospital Charge Code	12954887
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 4X4YD ROLL LF RED 10/BX

Facility

$23.00

Hospital Charge Code	12954887
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 FIBERGLASS 4X4YD ROLL LF RED 10/BX

Professional

Both

$23.00

Hospital Charge Code	12954887
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 FIBERGLASS 5X4YD LF GREEN 10/BX

Professional

Both

$34.00

Hospital Charge Code	12954872
Hospital Revenue Code	272
Min. Negotiated Rate	$28.90
Max. Negotiated Rate	$28.90
Rate for Payer: Cash Price	$22.10
Rate for Payer: Health Management Network Commercial	$28.90

TAPE CASTING DELTA-LITE PLUS FIBERGLASS 5X4YD LF GREEN 10/BX

Facility

$34.00

Hospital Charge Code	12954872
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

TAPE CASTING DELTA-LITE PLUS FIBERGLASS 5X4YD LF GREEN 10/BX

Facility

$34.00

Hospital Charge Code	12954872
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

TAPE DELTA-CAST POLYESTER 2 PINK CAMO 10RL/BX

Facility

$28.00

Hospital Charge Code	12954880
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

TAPE DELTA-CAST POLYESTER 2 PINK CAMO 10RL/BX

Professional

Both

$28.00

Hospital Charge Code	12954880
Hospital Revenue Code	272
Min. Negotiated Rate	$23.80
Max. Negotiated Rate	$23.80
Rate for Payer: Cash Price	$18.20
Rate for Payer: Health Management Network Commercial	$23.80

TAPE DELTA-CAST POLYESTER 2 PINK CAMO 10RL/BX

Facility

$28.00

Hospital Charge Code	12954880
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

TAPE DELTA-CAST PRINTS POLY 2X4YD 3-5 MIN LF PASTEL 10/BX

Facility

$41.00

Hospital Charge Code	12954866
Hospital Revenue Code	272
Min. Negotiated Rate	$20.50
Max. Negotiated Rate	$39.77
Rate for Payer: AlohaCare Medicaid	$20.50
Rate for Payer: AlohaCare Medicare	$20.50
Rate for Payer: Cash Price	$26.65
Rate for Payer: Devoted Health Medicare	$22.55
Rate for Payer: Hawaii Medical Service Association Medicare	$20.50
Rate for Payer: Hawaii Western Management Group Commercial	$38.95
Rate for Payer: Health Management Network Commercial	$34.85
Rate for Payer: Humana Medicare	$20.50
Rate for Payer: Kaiser Permanente Commercial	$36.90
Rate for Payer: Kaiser Permanente Medicaid	$20.91
Rate for Payer: Kaiser Permanente Medicare	$20.50
Rate for Payer: MDX Hawaii PPO	$39.77
Rate for Payer: Ohana Health Plan Medicaid	$20.50
Rate for Payer: Ohana Health Plan Medicare	$20.50
Rate for Payer: UnitedHealthcare Medicare	$20.50
Rate for Payer: University Health Alliance Commercial	$29.88

TAPE DELTA-CAST PRINTS POLY 2X4YD 3-5 MIN LF PASTEL 10/BX

Professional

Both

$41.00

Hospital Charge Code	12954866
Hospital Revenue Code	272
Min. Negotiated Rate	$34.85
Max. Negotiated Rate	$34.85
Rate for Payer: Cash Price	$26.65
Rate for Payer: Health Management Network Commercial	$34.85

Know your out-of-pocket cost for care.

All Charges