Samuel Mahelona Memorial Hospital

All Charges

Charge

Type

Setting

Price

TENMO EVOLUTION 14GX11CM (US)

Facility

$220.00

Hospital Charge Code	9800835
Hospital Revenue Code	272
Min. Negotiated Rate	$110.00
Max. Negotiated Rate	$213.40
Rate for Payer: AlohaCare Medicaid	$110.00
Rate for Payer: AlohaCare Medicare	$110.00
Rate for Payer: Cash Price	$143.00
Rate for Payer: Devoted Health Medicare	$121.00
Rate for Payer: Hawaii Medical Service Association Medicare	$110.00
Rate for Payer: Hawaii Western Management Group Commercial	$209.00
Rate for Payer: Health Management Network Commercial	$187.00
Rate for Payer: Humana Medicare	$110.00
Rate for Payer: Kaiser Permanente Commercial	$198.00
Rate for Payer: Kaiser Permanente Medicaid	$112.20
Rate for Payer: Kaiser Permanente Medicare	$110.00
Rate for Payer: MDX Hawaii PPO	$213.40
Rate for Payer: Ohana Health Plan Medicaid	$110.00
Rate for Payer: Ohana Health Plan Medicare	$110.00
Rate for Payer: UnitedHealthcare Medicare	$110.00
Rate for Payer: University Health Alliance Commercial	$160.36

TENMO EVOLUTION 14GX11CM (US)

Facility

$220.00

Hospital Charge Code	9800835
Hospital Revenue Code	272
Min. Negotiated Rate	$187.00
Max. Negotiated Rate	$213.40
Rate for Payer: Cash Price	$143.00
Rate for Payer: Health Management Network Commercial	$187.00
Rate for Payer: Kaiser Permanente Commercial	$198.00
Rate for Payer: MDX Hawaii PPO	$213.40

TENMO EVOLUTION 14GX6CM (CT)

Facility

$220.00

Hospital Charge Code	9800829
Hospital Revenue Code	272
Min. Negotiated Rate	$110.00
Max. Negotiated Rate	$213.40
Rate for Payer: AlohaCare Medicaid	$110.00
Rate for Payer: AlohaCare Medicare	$110.00
Rate for Payer: Cash Price	$143.00
Rate for Payer: Devoted Health Medicare	$121.00
Rate for Payer: Hawaii Medical Service Association Medicare	$110.00
Rate for Payer: Hawaii Western Management Group Commercial	$209.00
Rate for Payer: Health Management Network Commercial	$187.00
Rate for Payer: Humana Medicare	$110.00
Rate for Payer: Kaiser Permanente Commercial	$198.00
Rate for Payer: Kaiser Permanente Medicaid	$112.20
Rate for Payer: Kaiser Permanente Medicare	$110.00
Rate for Payer: MDX Hawaii PPO	$213.40
Rate for Payer: Ohana Health Plan Medicaid	$110.00
Rate for Payer: Ohana Health Plan Medicare	$110.00
Rate for Payer: UnitedHealthcare Medicare	$110.00
Rate for Payer: University Health Alliance Commercial	$160.36

TENMO EVOLUTION 14GX6CM (CT)

Facility

$220.00

Hospital Charge Code	9800829
Hospital Revenue Code	272
Min. Negotiated Rate	$187.00
Max. Negotiated Rate	$213.40
Rate for Payer: Cash Price	$143.00
Rate for Payer: Health Management Network Commercial	$187.00
Rate for Payer: Kaiser Permanente Commercial	$198.00
Rate for Payer: MDX Hawaii PPO	$213.40

TENMO EVOLUTION 14GX6CM (US)

Facility

$220.00

Hospital Charge Code	9800834
Hospital Revenue Code	272
Min. Negotiated Rate	$187.00
Max. Negotiated Rate	$213.40
Rate for Payer: Cash Price	$143.00
Rate for Payer: Health Management Network Commercial	$187.00
Rate for Payer: Kaiser Permanente Commercial	$198.00
Rate for Payer: MDX Hawaii PPO	$213.40

TENMO EVOLUTION 14GX6CM (US)

Facility

$220.00

Hospital Charge Code	9800834
Hospital Revenue Code	272
Min. Negotiated Rate	$110.00
Max. Negotiated Rate	$213.40
Rate for Payer: AlohaCare Medicaid	$110.00
Rate for Payer: AlohaCare Medicare	$110.00
Rate for Payer: Cash Price	$143.00
Rate for Payer: Devoted Health Medicare	$121.00
Rate for Payer: Hawaii Medical Service Association Medicare	$110.00
Rate for Payer: Hawaii Western Management Group Commercial	$209.00
Rate for Payer: Health Management Network Commercial	$187.00
Rate for Payer: Humana Medicare	$110.00
Rate for Payer: Kaiser Permanente Commercial	$198.00
Rate for Payer: Kaiser Permanente Medicaid	$112.20
Rate for Payer: Kaiser Permanente Medicare	$110.00
Rate for Payer: MDX Hawaii PPO	$213.40
Rate for Payer: Ohana Health Plan Medicaid	$110.00
Rate for Payer: Ohana Health Plan Medicare	$110.00
Rate for Payer: UnitedHealthcare Medicare	$110.00
Rate for Payer: University Health Alliance Commercial	$160.36

TENMO EVOLUTION 14GX6CM (XR)

Facility

$220.00

Hospital Charge Code	9800799
Hospital Revenue Code	272
Min. Negotiated Rate	$110.00
Max. Negotiated Rate	$213.40
Rate for Payer: AlohaCare Medicaid	$110.00
Rate for Payer: AlohaCare Medicare	$110.00
Rate for Payer: Cash Price	$143.00
Rate for Payer: Devoted Health Medicare	$121.00
Rate for Payer: Hawaii Medical Service Association Medicare	$110.00
Rate for Payer: Hawaii Western Management Group Commercial	$209.00
Rate for Payer: Health Management Network Commercial	$187.00
Rate for Payer: Humana Medicare	$110.00
Rate for Payer: Kaiser Permanente Commercial	$198.00
Rate for Payer: Kaiser Permanente Medicaid	$112.20
Rate for Payer: Kaiser Permanente Medicare	$110.00
Rate for Payer: MDX Hawaii PPO	$213.40
Rate for Payer: Ohana Health Plan Medicaid	$110.00
Rate for Payer: Ohana Health Plan Medicare	$110.00
Rate for Payer: UnitedHealthcare Medicare	$110.00
Rate for Payer: University Health Alliance Commercial	$160.36

TENMO EVOLUTION 14GX6CM (XR)

Facility

$220.00

Hospital Charge Code	9800799
Hospital Revenue Code	272
Min. Negotiated Rate	$187.00
Max. Negotiated Rate	$213.40
Rate for Payer: Cash Price	$143.00
Rate for Payer: Health Management Network Commercial	$187.00
Rate for Payer: Kaiser Permanente Commercial	$198.00
Rate for Payer: MDX Hawaii PPO	$213.40

TENMO EVOLUTION 16GX11CM (CT)

Facility

$220.00

Hospital Charge Code	9800827
Hospital Revenue Code	272
Min. Negotiated Rate	$110.00
Max. Negotiated Rate	$213.40
Rate for Payer: AlohaCare Medicaid	$110.00
Rate for Payer: AlohaCare Medicare	$110.00
Rate for Payer: Cash Price	$143.00
Rate for Payer: Devoted Health Medicare	$121.00
Rate for Payer: Hawaii Medical Service Association Medicare	$110.00
Rate for Payer: Hawaii Western Management Group Commercial	$209.00
Rate for Payer: Health Management Network Commercial	$187.00
Rate for Payer: Humana Medicare	$110.00
Rate for Payer: Kaiser Permanente Commercial	$198.00
Rate for Payer: Kaiser Permanente Medicaid	$112.20
Rate for Payer: Kaiser Permanente Medicare	$110.00
Rate for Payer: MDX Hawaii PPO	$213.40
Rate for Payer: Ohana Health Plan Medicaid	$110.00
Rate for Payer: Ohana Health Plan Medicare	$110.00
Rate for Payer: UnitedHealthcare Medicare	$110.00
Rate for Payer: University Health Alliance Commercial	$160.36

TENMO EVOLUTION 16GX11CM (CT)

Facility

$220.00

Hospital Charge Code	9800827
Hospital Revenue Code	272
Min. Negotiated Rate	$187.00
Max. Negotiated Rate	$213.40
Rate for Payer: Cash Price	$143.00
Rate for Payer: Health Management Network Commercial	$187.00
Rate for Payer: Kaiser Permanente Commercial	$198.00
Rate for Payer: MDX Hawaii PPO	$213.40

TENMO EVOLUTION 16GX11CM (US)

Facility

$220.00

Hospital Charge Code	9800832
Hospital Revenue Code	272
Min. Negotiated Rate	$110.00
Max. Negotiated Rate	$213.40
Rate for Payer: AlohaCare Medicaid	$110.00
Rate for Payer: AlohaCare Medicare	$110.00
Rate for Payer: Cash Price	$143.00
Rate for Payer: Devoted Health Medicare	$121.00
Rate for Payer: Hawaii Medical Service Association Medicare	$110.00
Rate for Payer: Hawaii Western Management Group Commercial	$209.00
Rate for Payer: Health Management Network Commercial	$187.00
Rate for Payer: Humana Medicare	$110.00
Rate for Payer: Kaiser Permanente Commercial	$198.00
Rate for Payer: Kaiser Permanente Medicaid	$112.20
Rate for Payer: Kaiser Permanente Medicare	$110.00
Rate for Payer: MDX Hawaii PPO	$213.40
Rate for Payer: Ohana Health Plan Medicaid	$110.00
Rate for Payer: Ohana Health Plan Medicare	$110.00
Rate for Payer: UnitedHealthcare Medicare	$110.00
Rate for Payer: University Health Alliance Commercial	$160.36

TENMO EVOLUTION 16GX11CM (US)

Facility

$220.00

Hospital Charge Code	9800832
Hospital Revenue Code	272
Min. Negotiated Rate	$187.00
Max. Negotiated Rate	$213.40
Rate for Payer: Cash Price	$143.00
Rate for Payer: Health Management Network Commercial	$187.00
Rate for Payer: Kaiser Permanente Commercial	$198.00
Rate for Payer: MDX Hawaii PPO	$213.40

TENMO EVOLUTION 16GX11CM (XR)

Facility

$220.00

Hospital Charge Code	9800797
Hospital Revenue Code	272
Min. Negotiated Rate	$110.00
Max. Negotiated Rate	$213.40
Rate for Payer: AlohaCare Medicaid	$110.00
Rate for Payer: AlohaCare Medicare	$110.00
Rate for Payer: Cash Price	$143.00
Rate for Payer: Devoted Health Medicare	$121.00
Rate for Payer: Hawaii Medical Service Association Medicare	$110.00
Rate for Payer: Hawaii Western Management Group Commercial	$209.00
Rate for Payer: Health Management Network Commercial	$187.00
Rate for Payer: Humana Medicare	$110.00
Rate for Payer: Kaiser Permanente Commercial	$198.00
Rate for Payer: Kaiser Permanente Medicaid	$112.20
Rate for Payer: Kaiser Permanente Medicare	$110.00
Rate for Payer: MDX Hawaii PPO	$213.40
Rate for Payer: Ohana Health Plan Medicaid	$110.00
Rate for Payer: Ohana Health Plan Medicare	$110.00
Rate for Payer: UnitedHealthcare Medicare	$110.00
Rate for Payer: University Health Alliance Commercial	$160.36

TENMO EVOLUTION 16GX11CM (XR)

Facility

$220.00

Hospital Charge Code	9800797
Hospital Revenue Code	272
Min. Negotiated Rate	$187.00
Max. Negotiated Rate	$213.40
Rate for Payer: Cash Price	$143.00
Rate for Payer: Health Management Network Commercial	$187.00
Rate for Payer: Kaiser Permanente Commercial	$198.00
Rate for Payer: MDX Hawaii PPO	$213.40

TENMO EVOLUTION 16GX15CM (US)

Facility

$220.00

Hospital Charge Code	9800833
Hospital Revenue Code	272
Min. Negotiated Rate	$187.00
Max. Negotiated Rate	$213.40
Rate for Payer: Cash Price	$143.00
Rate for Payer: Health Management Network Commercial	$187.00
Rate for Payer: Kaiser Permanente Commercial	$198.00
Rate for Payer: MDX Hawaii PPO	$213.40

TENMO EVOLUTION 16GX15CM (US)

Facility

$220.00

Hospital Charge Code	9800833
Hospital Revenue Code	272
Min. Negotiated Rate	$110.00
Max. Negotiated Rate	$213.40
Rate for Payer: AlohaCare Medicaid	$110.00
Rate for Payer: AlohaCare Medicare	$110.00
Rate for Payer: Cash Price	$143.00
Rate for Payer: Devoted Health Medicare	$121.00
Rate for Payer: Hawaii Medical Service Association Medicare	$110.00
Rate for Payer: Hawaii Western Management Group Commercial	$209.00
Rate for Payer: Health Management Network Commercial	$187.00
Rate for Payer: Humana Medicare	$110.00
Rate for Payer: Kaiser Permanente Commercial	$198.00
Rate for Payer: Kaiser Permanente Medicaid	$112.20
Rate for Payer: Kaiser Permanente Medicare	$110.00
Rate for Payer: MDX Hawaii PPO	$213.40
Rate for Payer: Ohana Health Plan Medicaid	$110.00
Rate for Payer: Ohana Health Plan Medicare	$110.00
Rate for Payer: UnitedHealthcare Medicare	$110.00
Rate for Payer: University Health Alliance Commercial	$160.36

TENMO EVOLUTION 16GX6CM (CT)

Facility

$220.00

Hospital Charge Code	9800826
Hospital Revenue Code	272
Min. Negotiated Rate	$110.00
Max. Negotiated Rate	$213.40
Rate for Payer: AlohaCare Medicaid	$110.00
Rate for Payer: AlohaCare Medicare	$110.00
Rate for Payer: Cash Price	$143.00
Rate for Payer: Devoted Health Medicare	$121.00
Rate for Payer: Hawaii Medical Service Association Medicare	$110.00
Rate for Payer: Hawaii Western Management Group Commercial	$209.00
Rate for Payer: Health Management Network Commercial	$187.00
Rate for Payer: Humana Medicare	$110.00
Rate for Payer: Kaiser Permanente Commercial	$198.00
Rate for Payer: Kaiser Permanente Medicaid	$112.20
Rate for Payer: Kaiser Permanente Medicare	$110.00
Rate for Payer: MDX Hawaii PPO	$213.40
Rate for Payer: Ohana Health Plan Medicaid	$110.00
Rate for Payer: Ohana Health Plan Medicare	$110.00
Rate for Payer: UnitedHealthcare Medicare	$110.00
Rate for Payer: University Health Alliance Commercial	$160.36

TENMO EVOLUTION 16GX6CM (CT)

Facility

$220.00

Hospital Charge Code	9800826
Hospital Revenue Code	272
Min. Negotiated Rate	$187.00
Max. Negotiated Rate	$213.40
Rate for Payer: Cash Price	$143.00
Rate for Payer: Health Management Network Commercial	$187.00
Rate for Payer: Kaiser Permanente Commercial	$198.00
Rate for Payer: MDX Hawaii PPO	$213.40

TENMO EVOLUTION 16GX6CM (US)

Facility

$220.00

Hospital Charge Code	9800831
Hospital Revenue Code	272
Min. Negotiated Rate	$110.00
Max. Negotiated Rate	$213.40
Rate for Payer: AlohaCare Medicaid	$110.00
Rate for Payer: AlohaCare Medicare	$110.00
Rate for Payer: Cash Price	$143.00
Rate for Payer: Devoted Health Medicare	$121.00
Rate for Payer: Hawaii Medical Service Association Medicare	$110.00
Rate for Payer: Hawaii Western Management Group Commercial	$209.00
Rate for Payer: Health Management Network Commercial	$187.00
Rate for Payer: Humana Medicare	$110.00
Rate for Payer: Kaiser Permanente Commercial	$198.00
Rate for Payer: Kaiser Permanente Medicaid	$112.20
Rate for Payer: Kaiser Permanente Medicare	$110.00
Rate for Payer: MDX Hawaii PPO	$213.40
Rate for Payer: Ohana Health Plan Medicaid	$110.00
Rate for Payer: Ohana Health Plan Medicare	$110.00
Rate for Payer: UnitedHealthcare Medicare	$110.00
Rate for Payer: University Health Alliance Commercial	$160.36

TENMO EVOLUTION 16GX6CM (US)

Facility

$220.00

Hospital Charge Code	9800831
Hospital Revenue Code	272
Min. Negotiated Rate	$187.00
Max. Negotiated Rate	$213.40
Rate for Payer: Cash Price	$143.00
Rate for Payer: Health Management Network Commercial	$187.00
Rate for Payer: Kaiser Permanente Commercial	$198.00
Rate for Payer: MDX Hawaii PPO	$213.40

TENMO EVOLUTION 16GX6CM (XR)

Facility

$220.00

Hospital Charge Code	9800796
Hospital Revenue Code	272
Min. Negotiated Rate	$110.00
Max. Negotiated Rate	$213.40
Rate for Payer: AlohaCare Medicaid	$110.00
Rate for Payer: AlohaCare Medicare	$110.00
Rate for Payer: Cash Price	$143.00
Rate for Payer: Devoted Health Medicare	$121.00
Rate for Payer: Hawaii Medical Service Association Medicare	$110.00
Rate for Payer: Hawaii Western Management Group Commercial	$209.00
Rate for Payer: Health Management Network Commercial	$187.00
Rate for Payer: Humana Medicare	$110.00
Rate for Payer: Kaiser Permanente Commercial	$198.00
Rate for Payer: Kaiser Permanente Medicaid	$112.20
Rate for Payer: Kaiser Permanente Medicare	$110.00
Rate for Payer: MDX Hawaii PPO	$213.40
Rate for Payer: Ohana Health Plan Medicaid	$110.00
Rate for Payer: Ohana Health Plan Medicare	$110.00
Rate for Payer: UnitedHealthcare Medicare	$110.00
Rate for Payer: University Health Alliance Commercial	$160.36

TENMO EVOLUTION 16GX6CM (XR)

Facility

$220.00

Hospital Charge Code	9800796
Hospital Revenue Code	272
Min. Negotiated Rate	$187.00
Max. Negotiated Rate	$213.40
Rate for Payer: Cash Price	$143.00
Rate for Payer: Health Management Network Commercial	$187.00
Rate for Payer: Kaiser Permanente Commercial	$198.00
Rate for Payer: MDX Hawaii PPO	$213.40

TENMO EVOLUTION 16X15CM (CT)

Facility

$220.00

Hospital Charge Code	9800828
Hospital Revenue Code	272
Min. Negotiated Rate	$187.00
Max. Negotiated Rate	$213.40
Rate for Payer: Cash Price	$143.00
Rate for Payer: Health Management Network Commercial	$187.00
Rate for Payer: Kaiser Permanente Commercial	$198.00
Rate for Payer: MDX Hawaii PPO	$213.40

TENMO EVOLUTION 16X15CM (CT)

Facility

$220.00

Hospital Charge Code	9800828
Hospital Revenue Code	272
Min. Negotiated Rate	$110.00
Max. Negotiated Rate	$213.40
Rate for Payer: AlohaCare Medicaid	$110.00
Rate for Payer: AlohaCare Medicare	$110.00
Rate for Payer: Cash Price	$143.00
Rate for Payer: Devoted Health Medicare	$121.00
Rate for Payer: Hawaii Medical Service Association Medicare	$110.00
Rate for Payer: Hawaii Western Management Group Commercial	$209.00
Rate for Payer: Health Management Network Commercial	$187.00
Rate for Payer: Humana Medicare	$110.00
Rate for Payer: Kaiser Permanente Commercial	$198.00
Rate for Payer: Kaiser Permanente Medicaid	$112.20
Rate for Payer: Kaiser Permanente Medicare	$110.00
Rate for Payer: MDX Hawaii PPO	$213.40
Rate for Payer: Ohana Health Plan Medicaid	$110.00
Rate for Payer: Ohana Health Plan Medicare	$110.00
Rate for Payer: UnitedHealthcare Medicare	$110.00
Rate for Payer: University Health Alliance Commercial	$160.36

TENMO EVOLUTION 18GX15CM (CT)

Facility

$220.00

Hospital Charge Code	9023985
Hospital Revenue Code	272
Min. Negotiated Rate	$110.00
Max. Negotiated Rate	$213.40
Rate for Payer: AlohaCare Medicaid	$110.00
Rate for Payer: AlohaCare Medicare	$110.00
Rate for Payer: Cash Price	$143.00
Rate for Payer: Devoted Health Medicare	$121.00
Rate for Payer: Hawaii Medical Service Association Medicare	$110.00
Rate for Payer: Hawaii Western Management Group Commercial	$209.00
Rate for Payer: Health Management Network Commercial	$187.00
Rate for Payer: Humana Medicare	$110.00
Rate for Payer: Kaiser Permanente Commercial	$198.00
Rate for Payer: Kaiser Permanente Medicaid	$112.20
Rate for Payer: Kaiser Permanente Medicare	$110.00
Rate for Payer: MDX Hawaii PPO	$213.40
Rate for Payer: Ohana Health Plan Medicaid	$110.00
Rate for Payer: Ohana Health Plan Medicare	$110.00
Rate for Payer: UnitedHealthcare Medicare	$110.00
Rate for Payer: University Health Alliance Commercial	$160.36

Know your out-of-pocket cost for care.

All Charges