Samuel Mahelona Memorial Hospital

All Charges

Charge

Type

Setting

Price

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	$34.85
Max. Negotiated Rate	$39.77
Rate for Payer: Cash Price	$26.65
Rate for Payer: Health Management Network Commercial	$34.85
Rate for Payer: Kaiser Permanente Commercial	$36.90
Rate for Payer: MDX Hawaii PPO	$39.77

TAPE FLASHCAST ELITE POLY 2X4YD 5-7 MIN LF DINOSAURS 10/BX

Professional

Both

$41.00

Hospital Charge Code	12954859
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

TAPE FLASHCAST ELITE POLY 2X4YD 5-7 MIN LF DINOSAURS 10/BX

Facility

$41.00

Hospital Charge Code	12954859
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 FLASHCAST ELITE POLY 2X4YD 5-7 MIN LF DINOSAURS 10/BX

Facility

$41.00

Hospital Charge Code	12954859
Hospital Revenue Code	272
Min. Negotiated Rate	$34.85
Max. Negotiated Rate	$39.77
Rate for Payer: Cash Price	$26.65
Rate for Payer: Health Management Network Commercial	$34.85
Rate for Payer: Kaiser Permanente Commercial	$36.90
Rate for Payer: MDX Hawaii PPO	$39.77

TAPE, UMBILICAL TAPE 8619-03

Facility

$75.00

Hospital Charge Code	8274339
Hospital Revenue Code	272
Min. Negotiated Rate	$63.75
Max. Negotiated Rate	$72.75
Rate for Payer: Cash Price	$48.75
Rate for Payer: Health Management Network Commercial	$63.75
Rate for Payer: Kaiser Permanente Commercial	$67.50
Rate for Payer: MDX Hawaii PPO	$72.75

TAPE, UMBILICAL TAPE 8619-03

Facility

$75.00

Hospital Charge Code	8274339
Hospital Revenue Code	272
Min. Negotiated Rate	$37.50
Max. Negotiated Rate	$72.75
Rate for Payer: AlohaCare Medicaid	$37.50
Rate for Payer: AlohaCare Medicare	$37.50
Rate for Payer: Cash Price	$48.75
Rate for Payer: Devoted Health Medicare	$41.25
Rate for Payer: Hawaii Medical Service Association Medicare	$37.50
Rate for Payer: Hawaii Western Management Group Commercial	$71.25
Rate for Payer: Health Management Network Commercial	$63.75
Rate for Payer: Humana Medicare	$37.50
Rate for Payer: Kaiser Permanente Commercial	$67.50
Rate for Payer: Kaiser Permanente Medicaid	$38.25
Rate for Payer: Kaiser Permanente Medicare	$37.50
Rate for Payer: MDX Hawaii PPO	$72.75
Rate for Payer: Ohana Health Plan Medicaid	$37.50
Rate for Payer: Ohana Health Plan Medicare	$37.50
Rate for Payer: UnitedHealthcare Medicare	$37.50
Rate for Payer: University Health Alliance Commercial	$54.67

TB Screen

Facility

$111.00

Service Code	HCPCS 86580
Hospital Charge Code	5413083
Hospital Revenue Code	302
Min. Negotiated Rate	$94.35
Max. Negotiated Rate	$107.67
Rate for Payer: Cash Price	$72.15
Rate for Payer: Health Management Network Commercial	$94.35
Rate for Payer: Kaiser Permanente Commercial	$99.90
Rate for Payer: MDX Hawaii PPO	$107.67

TB Screen

Facility

$111.00

Service Code	HCPCS 86580
Hospital Charge Code	5413083
Hospital Revenue Code	302
Min. Negotiated Rate	$6.68
Max. Negotiated Rate	$107.67
Rate for Payer: AlohaCare Medicaid	$55.50
Rate for Payer: AlohaCare Medicare	$55.50
Rate for Payer: Cash Price	$72.15
Rate for Payer: Cash Price	$72.15
Rate for Payer: Devoted Health Medicare	$61.05
Rate for Payer: Hawaii Medical Service Association ABD	$6.68
Rate for Payer: Hawaii Medical Service Association Commercial	$36.94
Rate for Payer: Hawaii Medical Service Association Medicare	$55.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$11.23
Rate for Payer: Hawaii Western Management Group Commercial	$29.55
Rate for Payer: Health Management Network Commercial	$94.35
Rate for Payer: Humana Medicare	$55.50
Rate for Payer: Kaiser Permanente Commercial	$99.90
Rate for Payer: Kaiser Permanente Medicaid	$56.61
Rate for Payer: Kaiser Permanente Medicare	$55.50
Rate for Payer: MDX Hawaii PPO	$107.67
Rate for Payer: Ohana Health Plan Medicaid	$55.50
Rate for Payer: Ohana Health Plan Medicare	$55.50
Rate for Payer: UnitedHealthcare Medicaid	$6.68
Rate for Payer: UnitedHealthcare Medicare	$55.50
Rate for Payer: University Health Alliance Commercial	$17.04

TELESCOPING LAG SCREW, 10.5 MM X 100 MM

Facility

$1,645.00

Service Code	HCPCS C1713
Hospital Charge Code	13000625
Hospital Revenue Code	278
Min. Negotiated Rate	$822.50
Max. Negotiated Rate	$1,595.65
Rate for Payer: AlohaCare Medicaid	$822.50
Rate for Payer: AlohaCare Medicare	$822.50
Rate for Payer: Cash Price	$1,069.25
Rate for Payer: Devoted Health Medicare	$904.75
Rate for Payer: Hawaii Medical Service Association Medicare	$822.50
Rate for Payer: Hawaii Western Management Group Commercial	$1,151.50
Rate for Payer: Health Management Network Commercial	$1,398.25
Rate for Payer: Humana Medicare	$822.50
Rate for Payer: Kaiser Permanente Commercial	$1,480.50
Rate for Payer: Kaiser Permanente Medicaid	$838.95
Rate for Payer: Kaiser Permanente Medicare	$822.50
Rate for Payer: MDX Hawaii PPO	$1,595.65
Rate for Payer: Ohana Health Plan Medicaid	$822.50
Rate for Payer: Ohana Health Plan Medicare	$822.50
Rate for Payer: UnitedHealthcare Medicare	$822.50
Rate for Payer: University Health Alliance Commercial	$921.20

TELESCOPING LAG SCREW, 10.5 MM X 100 MM

Facility

$1,645.00

Service Code	HCPCS C1713
Hospital Charge Code	13000625
Hospital Revenue Code	278
Min. Negotiated Rate	$921.20
Max. Negotiated Rate	$1,595.65
Rate for Payer: Cash Price	$1,069.25
Rate for Payer: Hawaii Western Management Group Commercial	$1,151.50
Rate for Payer: Health Management Network Commercial	$1,398.25
Rate for Payer: Kaiser Permanente Commercial	$1,480.50
Rate for Payer: MDX Hawaii PPO	$1,595.65
Rate for Payer: University Health Alliance Commercial	$921.20

TELESCOPING LAG SCREW, 10.5 MM X 105 MM

Facility

$1,645.00

Service Code	HCPCS C1713
Hospital Charge Code	13000623
Hospital Revenue Code	278
Min. Negotiated Rate	$921.20
Max. Negotiated Rate	$1,595.65
Rate for Payer: Cash Price	$1,069.25
Rate for Payer: Hawaii Western Management Group Commercial	$1,151.50
Rate for Payer: Health Management Network Commercial	$1,398.25
Rate for Payer: Kaiser Permanente Commercial	$1,480.50
Rate for Payer: MDX Hawaii PPO	$1,595.65
Rate for Payer: University Health Alliance Commercial	$921.20

TELESCOPING LAG SCREW, 10.5 MM X 105 MM

Facility

$1,645.00

Service Code	HCPCS C1713
Hospital Charge Code	13000623
Hospital Revenue Code	278
Min. Negotiated Rate	$822.50
Max. Negotiated Rate	$1,595.65
Rate for Payer: AlohaCare Medicaid	$822.50
Rate for Payer: AlohaCare Medicare	$822.50
Rate for Payer: Cash Price	$1,069.25
Rate for Payer: Devoted Health Medicare	$904.75
Rate for Payer: Hawaii Medical Service Association Medicare	$822.50
Rate for Payer: Hawaii Western Management Group Commercial	$1,151.50
Rate for Payer: Health Management Network Commercial	$1,398.25
Rate for Payer: Humana Medicare	$822.50
Rate for Payer: Kaiser Permanente Commercial	$1,480.50
Rate for Payer: Kaiser Permanente Medicaid	$838.95
Rate for Payer: Kaiser Permanente Medicare	$822.50
Rate for Payer: MDX Hawaii PPO	$1,595.65
Rate for Payer: Ohana Health Plan Medicaid	$822.50
Rate for Payer: Ohana Health Plan Medicare	$822.50
Rate for Payer: UnitedHealthcare Medicare	$822.50
Rate for Payer: University Health Alliance Commercial	$921.20

TELESCOPING LAG SCREW, 10.5 MM X 85 MM

Facility

$2,820.00

Service Code	HCPCS C1713
Hospital Charge Code	13005002
Hospital Revenue Code	278
Min. Negotiated Rate	$1,579.20
Max. Negotiated Rate	$2,735.40
Rate for Payer: Cash Price	$1,833.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,974.00
Rate for Payer: Health Management Network Commercial	$2,397.00
Rate for Payer: Kaiser Permanente Commercial	$2,538.00
Rate for Payer: MDX Hawaii PPO	$2,735.40
Rate for Payer: University Health Alliance Commercial	$1,579.20

TELESCOPING LAG SCREW, 10.5 MM X 85 MM

Facility

$2,820.00

Service Code	HCPCS C1713
Hospital Charge Code	13005002
Hospital Revenue Code	278
Min. Negotiated Rate	$1,410.00
Max. Negotiated Rate	$2,735.40
Rate for Payer: AlohaCare Medicaid	$1,410.00
Rate for Payer: AlohaCare Medicare	$1,410.00
Rate for Payer: Cash Price	$1,833.00
Rate for Payer: Devoted Health Medicare	$1,551.00
Rate for Payer: Hawaii Medical Service Association Medicare	$1,410.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,974.00
Rate for Payer: Health Management Network Commercial	$2,397.00
Rate for Payer: Humana Medicare	$1,410.00
Rate for Payer: Kaiser Permanente Commercial	$2,538.00
Rate for Payer: Kaiser Permanente Medicaid	$1,438.20
Rate for Payer: Kaiser Permanente Medicare	$1,410.00
Rate for Payer: MDX Hawaii PPO	$2,735.40
Rate for Payer: Ohana Health Plan Medicaid	$1,410.00
Rate for Payer: Ohana Health Plan Medicare	$1,410.00
Rate for Payer: UnitedHealthcare Medicare	$1,410.00
Rate for Payer: University Health Alliance Commercial	$1,579.20

TELESCOPING LAG SCREW, 10.5 MM X 90 MM

Facility

$1,645.00

Service Code	HCPCS C1713
Hospital Charge Code	13005004
Hospital Revenue Code	278
Min. Negotiated Rate	$921.20
Max. Negotiated Rate	$1,595.65
Rate for Payer: Cash Price	$1,069.25
Rate for Payer: Hawaii Western Management Group Commercial	$1,151.50
Rate for Payer: Health Management Network Commercial	$1,398.25
Rate for Payer: Kaiser Permanente Commercial	$1,480.50
Rate for Payer: MDX Hawaii PPO	$1,595.65
Rate for Payer: University Health Alliance Commercial	$921.20

TELESCOPING LAG SCREW, 10.5 MM X 90 MM

Facility

$1,645.00

Service Code	HCPCS C1713
Hospital Charge Code	13005004
Hospital Revenue Code	278
Min. Negotiated Rate	$822.50
Max. Negotiated Rate	$1,595.65
Rate for Payer: AlohaCare Medicaid	$822.50
Rate for Payer: AlohaCare Medicare	$822.50
Rate for Payer: Cash Price	$1,069.25
Rate for Payer: Devoted Health Medicare	$904.75
Rate for Payer: Hawaii Medical Service Association Medicare	$822.50
Rate for Payer: Hawaii Western Management Group Commercial	$1,151.50
Rate for Payer: Health Management Network Commercial	$1,398.25
Rate for Payer: Humana Medicare	$822.50
Rate for Payer: Kaiser Permanente Commercial	$1,480.50
Rate for Payer: Kaiser Permanente Medicaid	$838.95
Rate for Payer: Kaiser Permanente Medicare	$822.50
Rate for Payer: MDX Hawaii PPO	$1,595.65
Rate for Payer: Ohana Health Plan Medicaid	$822.50
Rate for Payer: Ohana Health Plan Medicare	$822.50
Rate for Payer: UnitedHealthcare Medicare	$822.50
Rate for Payer: University Health Alliance Commercial	$921.20

TELESCOPING LAG SCREW, 10.5 MM X 95 MM

Facility

$1,645.00

Service Code	HCPCS C1713
Hospital Charge Code	13005005
Hospital Revenue Code	278
Min. Negotiated Rate	$921.20
Max. Negotiated Rate	$1,595.65
Rate for Payer: Cash Price	$1,069.25
Rate for Payer: Hawaii Western Management Group Commercial	$1,151.50
Rate for Payer: Health Management Network Commercial	$1,398.25
Rate for Payer: Kaiser Permanente Commercial	$1,480.50
Rate for Payer: MDX Hawaii PPO	$1,595.65
Rate for Payer: University Health Alliance Commercial	$921.20

TELESCOPING LAG SCREW, 10.5 MM X 95 MM

Facility

$1,645.00

Service Code	HCPCS C1713
Hospital Charge Code	13005005
Hospital Revenue Code	278
Min. Negotiated Rate	$822.50
Max. Negotiated Rate	$1,595.65
Rate for Payer: AlohaCare Medicaid	$822.50
Rate for Payer: AlohaCare Medicare	$822.50
Rate for Payer: Cash Price	$1,069.25
Rate for Payer: Devoted Health Medicare	$904.75
Rate for Payer: Hawaii Medical Service Association Medicare	$822.50
Rate for Payer: Hawaii Western Management Group Commercial	$1,151.50
Rate for Payer: Health Management Network Commercial	$1,398.25
Rate for Payer: Humana Medicare	$822.50
Rate for Payer: Kaiser Permanente Commercial	$1,480.50
Rate for Payer: Kaiser Permanente Medicaid	$838.95
Rate for Payer: Kaiser Permanente Medicare	$822.50
Rate for Payer: MDX Hawaii PPO	$1,595.65
Rate for Payer: Ohana Health Plan Medicaid	$822.50
Rate for Payer: Ohana Health Plan Medicare	$822.50
Rate for Payer: UnitedHealthcare Medicare	$822.50
Rate for Payer: University Health Alliance Commercial	$921.20

TELESCOPING LAG SCREW, LT, 10.5 X 105MM

Facility

$2,820.00

Service Code	HCPCS C1713
Hospital Charge Code	13000797
Hospital Revenue Code	278
Min. Negotiated Rate	$1,410.00
Max. Negotiated Rate	$2,735.40
Rate for Payer: AlohaCare Medicaid	$1,410.00
Rate for Payer: AlohaCare Medicare	$1,410.00
Rate for Payer: Cash Price	$1,833.00
Rate for Payer: Devoted Health Medicare	$1,551.00
Rate for Payer: Hawaii Medical Service Association Medicare	$1,410.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,974.00
Rate for Payer: Health Management Network Commercial	$2,397.00
Rate for Payer: Humana Medicare	$1,410.00
Rate for Payer: Kaiser Permanente Commercial	$2,538.00
Rate for Payer: Kaiser Permanente Medicaid	$1,438.20
Rate for Payer: Kaiser Permanente Medicare	$1,410.00
Rate for Payer: MDX Hawaii PPO	$2,735.40
Rate for Payer: Ohana Health Plan Medicaid	$1,410.00
Rate for Payer: Ohana Health Plan Medicare	$1,410.00
Rate for Payer: UnitedHealthcare Medicare	$1,410.00
Rate for Payer: University Health Alliance Commercial	$1,579.20

TELESCOPING LAG SCREW, LT, 10.5 X 105MM

Facility

$2,820.00

Service Code	HCPCS C1713
Hospital Charge Code	13000797
Hospital Revenue Code	278
Min. Negotiated Rate	$1,579.20
Max. Negotiated Rate	$2,735.40
Rate for Payer: Cash Price	$1,833.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,974.00
Rate for Payer: Health Management Network Commercial	$2,397.00
Rate for Payer: Kaiser Permanente Commercial	$2,538.00
Rate for Payer: MDX Hawaii PPO	$2,735.40
Rate for Payer: University Health Alliance Commercial	$1,579.20

TELESCOPING LAG SCREW, LT, 10.5 X 110MM

Facility

$2,820.00

Service Code	HCPCS C1713
Hospital Charge Code	13000798
Hospital Revenue Code	278
Min. Negotiated Rate	$1,579.20
Max. Negotiated Rate	$2,735.40
Rate for Payer: Cash Price	$1,833.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,974.00
Rate for Payer: Health Management Network Commercial	$2,397.00
Rate for Payer: Kaiser Permanente Commercial	$2,538.00
Rate for Payer: MDX Hawaii PPO	$2,735.40
Rate for Payer: University Health Alliance Commercial	$1,579.20

TELESCOPING LAG SCREW, LT, 10.5 X 110MM

Facility

$2,820.00

Service Code	HCPCS C1713
Hospital Charge Code	13000798
Hospital Revenue Code	278
Min. Negotiated Rate	$1,410.00
Max. Negotiated Rate	$2,735.40
Rate for Payer: AlohaCare Medicaid	$1,410.00
Rate for Payer: AlohaCare Medicare	$1,410.00
Rate for Payer: Cash Price	$1,833.00
Rate for Payer: Devoted Health Medicare	$1,551.00
Rate for Payer: Hawaii Medical Service Association Medicare	$1,410.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,974.00
Rate for Payer: Health Management Network Commercial	$2,397.00
Rate for Payer: Humana Medicare	$1,410.00
Rate for Payer: Kaiser Permanente Commercial	$2,538.00
Rate for Payer: Kaiser Permanente Medicaid	$1,438.20
Rate for Payer: Kaiser Permanente Medicare	$1,410.00
Rate for Payer: MDX Hawaii PPO	$2,735.40
Rate for Payer: Ohana Health Plan Medicaid	$1,410.00
Rate for Payer: Ohana Health Plan Medicare	$1,410.00
Rate for Payer: UnitedHealthcare Medicare	$1,410.00
Rate for Payer: University Health Alliance Commercial	$1,579.20

TELESCOPING LAG SCREW, LT, 10.5 X 115MM

Facility

$2,820.00

Service Code	HCPCS C1713
Hospital Charge Code	13001559
Hospital Revenue Code	278
Min. Negotiated Rate	$1,410.00
Max. Negotiated Rate	$2,735.40
Rate for Payer: AlohaCare Medicaid	$1,410.00
Rate for Payer: AlohaCare Medicare	$1,410.00
Rate for Payer: Cash Price	$1,833.00
Rate for Payer: Devoted Health Medicare	$1,551.00
Rate for Payer: Hawaii Medical Service Association Medicare	$1,410.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,974.00
Rate for Payer: Health Management Network Commercial	$2,397.00
Rate for Payer: Humana Medicare	$1,410.00
Rate for Payer: Kaiser Permanente Commercial	$2,538.00
Rate for Payer: Kaiser Permanente Medicaid	$1,438.20
Rate for Payer: Kaiser Permanente Medicare	$1,410.00
Rate for Payer: MDX Hawaii PPO	$2,735.40
Rate for Payer: Ohana Health Plan Medicaid	$1,410.00
Rate for Payer: Ohana Health Plan Medicare	$1,410.00
Rate for Payer: UnitedHealthcare Medicare	$1,410.00
Rate for Payer: University Health Alliance Commercial	$1,579.20

TELESCOPING LAG SCREW, LT, 10.5 X 115MM

Facility

$2,820.00

Service Code	HCPCS C1713
Hospital Charge Code	13001559
Hospital Revenue Code	278
Min. Negotiated Rate	$1,579.20
Max. Negotiated Rate	$2,735.40
Rate for Payer: Cash Price	$1,833.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,974.00
Rate for Payer: Health Management Network Commercial	$2,397.00
Rate for Payer: Kaiser Permanente Commercial	$2,538.00
Rate for Payer: MDX Hawaii PPO	$2,735.40
Rate for Payer: University Health Alliance Commercial	$1,579.20

TELESCOPING LAG SCREW, LT, 10.5 X 120MM

Facility

$2,820.00

Service Code	HCPCS C1713
Hospital Charge Code	13001555
Hospital Revenue Code	278
Min. Negotiated Rate	$1,410.00
Max. Negotiated Rate	$2,735.40
Rate for Payer: AlohaCare Medicaid	$1,410.00
Rate for Payer: AlohaCare Medicare	$1,410.00
Rate for Payer: Cash Price	$1,833.00
Rate for Payer: Devoted Health Medicare	$1,551.00
Rate for Payer: Hawaii Medical Service Association Medicare	$1,410.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,974.00
Rate for Payer: Health Management Network Commercial	$2,397.00
Rate for Payer: Humana Medicare	$1,410.00
Rate for Payer: Kaiser Permanente Commercial	$2,538.00
Rate for Payer: Kaiser Permanente Medicaid	$1,438.20
Rate for Payer: Kaiser Permanente Medicare	$1,410.00
Rate for Payer: MDX Hawaii PPO	$2,735.40
Rate for Payer: Ohana Health Plan Medicaid	$1,410.00
Rate for Payer: Ohana Health Plan Medicare	$1,410.00
Rate for Payer: UnitedHealthcare Medicare	$1,410.00
Rate for Payer: University Health Alliance Commercial	$1,579.20

Know your out-of-pocket cost for care.

All Charges