Samuel Mahelona Memorial Hospital

All Charges

Charge

Type

Setting

Price

T-PLATE, 2.4MM, 8 HOLE,REINFORCED

Facility

$2,505.00

Service Code	HCPCS C1713
Hospital Charge Code	13000883
Hospital Revenue Code	278
Min. Negotiated Rate	$1,252.50
Max. Negotiated Rate	$2,429.85
Rate for Payer: AlohaCare Medicaid	$1,252.50
Rate for Payer: AlohaCare Medicare	$1,252.50
Rate for Payer: Cash Price	$1,628.25
Rate for Payer: Devoted Health Medicare	$1,377.75
Rate for Payer: Hawaii Medical Service Association Medicare	$1,252.50
Rate for Payer: Hawaii Western Management Group Commercial	$1,753.50
Rate for Payer: Health Management Network Commercial	$2,129.25
Rate for Payer: Humana Medicare	$1,252.50
Rate for Payer: Kaiser Permanente Commercial	$2,254.50
Rate for Payer: Kaiser Permanente Medicaid	$1,277.55
Rate for Payer: Kaiser Permanente Medicare	$1,252.50
Rate for Payer: MDX Hawaii PPO	$2,429.85
Rate for Payer: Ohana Health Plan Medicaid	$1,252.50
Rate for Payer: Ohana Health Plan Medicare	$1,252.50
Rate for Payer: UnitedHealthcare Medicare	$1,252.50
Rate for Payer: University Health Alliance Commercial	$1,402.80

T-PLATE, 2.7MM, 2 HOLE HEAD, 10 HOLE

Facility

$2,510.00

Service Code	HCPCS C1713
Hospital Charge Code	13000884
Hospital Revenue Code	278
Min. Negotiated Rate	$1,405.60
Max. Negotiated Rate	$2,434.70
Rate for Payer: Cash Price	$1,631.50
Rate for Payer: Hawaii Western Management Group Commercial	$1,757.00
Rate for Payer: Health Management Network Commercial	$2,133.50
Rate for Payer: Kaiser Permanente Commercial	$2,259.00
Rate for Payer: MDX Hawaii PPO	$2,434.70
Rate for Payer: University Health Alliance Commercial	$1,405.60

T-PLATE, 2.7MM, 2 HOLE HEAD, 10 HOLE

Facility

$2,510.00

Service Code	HCPCS C1713
Hospital Charge Code	13000884
Hospital Revenue Code	278
Min. Negotiated Rate	$1,255.00
Max. Negotiated Rate	$2,434.70
Rate for Payer: AlohaCare Medicaid	$1,255.00
Rate for Payer: AlohaCare Medicare	$1,255.00
Rate for Payer: Cash Price	$1,631.50
Rate for Payer: Devoted Health Medicare	$1,380.50
Rate for Payer: Hawaii Medical Service Association Medicare	$1,255.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,757.00
Rate for Payer: Health Management Network Commercial	$2,133.50
Rate for Payer: Humana Medicare	$1,255.00
Rate for Payer: Kaiser Permanente Commercial	$2,259.00
Rate for Payer: Kaiser Permanente Medicaid	$1,280.10
Rate for Payer: Kaiser Permanente Medicare	$1,255.00
Rate for Payer: MDX Hawaii PPO	$2,434.70
Rate for Payer: Ohana Health Plan Medicaid	$1,255.00
Rate for Payer: Ohana Health Plan Medicare	$1,255.00
Rate for Payer: UnitedHealthcare Medicare	$1,255.00
Rate for Payer: University Health Alliance Commercial	$1,405.60

T-PLATE, 2.7MM, 2 HOLE HEAD, 6 HOLE

Facility

$2,510.00

Service Code	HCPCS C1713
Hospital Charge Code	13000878
Hospital Revenue Code	278
Min. Negotiated Rate	$1,405.60
Max. Negotiated Rate	$2,434.70
Rate for Payer: Cash Price	$1,631.50
Rate for Payer: Hawaii Western Management Group Commercial	$1,757.00
Rate for Payer: Health Management Network Commercial	$2,133.50
Rate for Payer: Kaiser Permanente Commercial	$2,259.00
Rate for Payer: MDX Hawaii PPO	$2,434.70
Rate for Payer: University Health Alliance Commercial	$1,405.60

T-PLATE, 2.7MM, 2 HOLE HEAD, 6 HOLE

Facility

$2,510.00

Service Code	HCPCS C1713
Hospital Charge Code	13000878
Hospital Revenue Code	278
Min. Negotiated Rate	$1,255.00
Max. Negotiated Rate	$2,434.70
Rate for Payer: AlohaCare Medicaid	$1,255.00
Rate for Payer: AlohaCare Medicare	$1,255.00
Rate for Payer: Cash Price	$1,631.50
Rate for Payer: Devoted Health Medicare	$1,380.50
Rate for Payer: Hawaii Medical Service Association Medicare	$1,255.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,757.00
Rate for Payer: Health Management Network Commercial	$2,133.50
Rate for Payer: Humana Medicare	$1,255.00
Rate for Payer: Kaiser Permanente Commercial	$2,259.00
Rate for Payer: Kaiser Permanente Medicaid	$1,280.10
Rate for Payer: Kaiser Permanente Medicare	$1,255.00
Rate for Payer: MDX Hawaii PPO	$2,434.70
Rate for Payer: Ohana Health Plan Medicaid	$1,255.00
Rate for Payer: Ohana Health Plan Medicare	$1,255.00
Rate for Payer: UnitedHealthcare Medicare	$1,255.00
Rate for Payer: University Health Alliance Commercial	$1,405.60

T-PLATE, 2.7MM, 3 HOLE HEAD, 10 HOLE

Facility

$1,883.00

Service Code	HCPCS C1713
Hospital Charge Code	13000881
Hospital Revenue Code	278
Min. Negotiated Rate	$1,054.48
Max. Negotiated Rate	$1,826.51
Rate for Payer: Cash Price	$1,223.95
Rate for Payer: Hawaii Western Management Group Commercial	$1,318.10
Rate for Payer: Health Management Network Commercial	$1,600.55
Rate for Payer: Kaiser Permanente Commercial	$1,694.70
Rate for Payer: MDX Hawaii PPO	$1,826.51
Rate for Payer: University Health Alliance Commercial	$1,054.48

T-PLATE, 2.7MM, 3 HOLE HEAD, 10 HOLE

Facility

$1,883.00

Service Code	HCPCS C1713
Hospital Charge Code	13000881
Hospital Revenue Code	278
Min. Negotiated Rate	$941.50
Max. Negotiated Rate	$1,826.51
Rate for Payer: AlohaCare Medicaid	$941.50
Rate for Payer: AlohaCare Medicare	$941.50
Rate for Payer: Cash Price	$1,223.95
Rate for Payer: Devoted Health Medicare	$1,035.65
Rate for Payer: Hawaii Medical Service Association Medicare	$941.50
Rate for Payer: Hawaii Western Management Group Commercial	$1,318.10
Rate for Payer: Health Management Network Commercial	$1,600.55
Rate for Payer: Humana Medicare	$941.50
Rate for Payer: Kaiser Permanente Commercial	$1,694.70
Rate for Payer: Kaiser Permanente Medicaid	$960.33
Rate for Payer: Kaiser Permanente Medicare	$941.50
Rate for Payer: MDX Hawaii PPO	$1,826.51
Rate for Payer: Ohana Health Plan Medicaid	$941.50
Rate for Payer: Ohana Health Plan Medicare	$941.50
Rate for Payer: UnitedHealthcare Medicare	$941.50
Rate for Payer: University Health Alliance Commercial	$1,054.48

T-PLATE, 2.7MM, 3 HOLE HEAD, 6 HOLE

Facility

$1,883.00

Service Code	HCPCS C1713
Hospital Charge Code	13000879
Hospital Revenue Code	278
Min. Negotiated Rate	$1,054.48
Max. Negotiated Rate	$1,826.51
Rate for Payer: Cash Price	$1,223.95
Rate for Payer: Hawaii Western Management Group Commercial	$1,318.10
Rate for Payer: Health Management Network Commercial	$1,600.55
Rate for Payer: Kaiser Permanente Commercial	$1,694.70
Rate for Payer: MDX Hawaii PPO	$1,826.51
Rate for Payer: University Health Alliance Commercial	$1,054.48

T-PLATE, 2.7MM, 3 HOLE HEAD, 6 HOLE

Facility

$1,883.00

Service Code	HCPCS C1713
Hospital Charge Code	13000879
Hospital Revenue Code	278
Min. Negotiated Rate	$941.50
Max. Negotiated Rate	$1,826.51
Rate for Payer: AlohaCare Medicaid	$941.50
Rate for Payer: AlohaCare Medicare	$941.50
Rate for Payer: Cash Price	$1,223.95
Rate for Payer: Devoted Health Medicare	$1,035.65
Rate for Payer: Hawaii Medical Service Association Medicare	$941.50
Rate for Payer: Hawaii Western Management Group Commercial	$1,318.10
Rate for Payer: Health Management Network Commercial	$1,600.55
Rate for Payer: Humana Medicare	$941.50
Rate for Payer: Kaiser Permanente Commercial	$1,694.70
Rate for Payer: Kaiser Permanente Medicaid	$960.33
Rate for Payer: Kaiser Permanente Medicare	$941.50
Rate for Payer: MDX Hawaii PPO	$1,826.51
Rate for Payer: Ohana Health Plan Medicaid	$941.50
Rate for Payer: Ohana Health Plan Medicare	$941.50
Rate for Payer: UnitedHealthcare Medicare	$941.50
Rate for Payer: University Health Alliance Commercial	$1,054.48

T-PLATE, 2.7MM,3 HOLE HEAD,REINF,10 HOLE

Facility

$1,883.00

Service Code	HCPCS C1713
Hospital Charge Code	13001598
Hospital Revenue Code	278
Min. Negotiated Rate	$941.50
Max. Negotiated Rate	$1,826.51
Rate for Payer: AlohaCare Medicaid	$941.50
Rate for Payer: AlohaCare Medicare	$941.50
Rate for Payer: Cash Price	$1,223.95
Rate for Payer: Devoted Health Medicare	$1,035.65
Rate for Payer: Hawaii Medical Service Association Medicare	$941.50
Rate for Payer: Hawaii Western Management Group Commercial	$1,318.10
Rate for Payer: Health Management Network Commercial	$1,600.55
Rate for Payer: Humana Medicare	$941.50
Rate for Payer: Kaiser Permanente Commercial	$1,694.70
Rate for Payer: Kaiser Permanente Medicaid	$960.33
Rate for Payer: Kaiser Permanente Medicare	$941.50
Rate for Payer: MDX Hawaii PPO	$1,826.51
Rate for Payer: Ohana Health Plan Medicaid	$941.50
Rate for Payer: Ohana Health Plan Medicare	$941.50
Rate for Payer: UnitedHealthcare Medicare	$941.50
Rate for Payer: University Health Alliance Commercial	$1,054.48

T-PLATE, 2.7MM,3 HOLE HEAD,REINF,10 HOLE

Facility

$1,883.00

Service Code	HCPCS C1713
Hospital Charge Code	13001598
Hospital Revenue Code	278
Min. Negotiated Rate	$1,054.48
Max. Negotiated Rate	$1,826.51
Rate for Payer: Cash Price	$1,223.95
Rate for Payer: Hawaii Western Management Group Commercial	$1,318.10
Rate for Payer: Health Management Network Commercial	$1,600.55
Rate for Payer: Kaiser Permanente Commercial	$1,694.70
Rate for Payer: MDX Hawaii PPO	$1,826.51
Rate for Payer: University Health Alliance Commercial	$1,054.48

T-PLATE, 2.7MM, 3 HOLE HEAD,REINF,6 HOLE

Facility

$1,883.00

Service Code	HCPCS C1713
Hospital Charge Code	13001593
Hospital Revenue Code	278
Min. Negotiated Rate	$941.50
Max. Negotiated Rate	$1,826.51
Rate for Payer: AlohaCare Medicaid	$941.50
Rate for Payer: AlohaCare Medicare	$941.50
Rate for Payer: Cash Price	$1,223.95
Rate for Payer: Devoted Health Medicare	$1,035.65
Rate for Payer: Hawaii Medical Service Association Medicare	$941.50
Rate for Payer: Hawaii Western Management Group Commercial	$1,318.10
Rate for Payer: Health Management Network Commercial	$1,600.55
Rate for Payer: Humana Medicare	$941.50
Rate for Payer: Kaiser Permanente Commercial	$1,694.70
Rate for Payer: Kaiser Permanente Medicaid	$960.33
Rate for Payer: Kaiser Permanente Medicare	$941.50
Rate for Payer: MDX Hawaii PPO	$1,826.51
Rate for Payer: Ohana Health Plan Medicaid	$941.50
Rate for Payer: Ohana Health Plan Medicare	$941.50
Rate for Payer: UnitedHealthcare Medicare	$941.50
Rate for Payer: University Health Alliance Commercial	$1,054.48

T-PLATE, 2.7MM, 3 HOLE HEAD,REINF,6 HOLE

Facility

$1,883.00

Service Code	HCPCS C1713
Hospital Charge Code	13001593
Hospital Revenue Code	278
Min. Negotiated Rate	$1,054.48
Max. Negotiated Rate	$1,826.51
Rate for Payer: Cash Price	$1,223.95
Rate for Payer: Hawaii Western Management Group Commercial	$1,318.10
Rate for Payer: Health Management Network Commercial	$1,600.55
Rate for Payer: Kaiser Permanente Commercial	$1,694.70
Rate for Payer: MDX Hawaii PPO	$1,826.51
Rate for Payer: University Health Alliance Commercial	$1,054.48

T-PLATE ROTATION CORRECTION,2.0MM,5 HOLE

Facility

$1,462.00

Service Code	HCPCS C1713
Hospital Charge Code	13000862
Hospital Revenue Code	278
Min. Negotiated Rate	$818.72
Max. Negotiated Rate	$1,418.14
Rate for Payer: Cash Price	$950.30
Rate for Payer: Hawaii Western Management Group Commercial	$1,023.40
Rate for Payer: Health Management Network Commercial	$1,242.70
Rate for Payer: Kaiser Permanente Commercial	$1,315.80
Rate for Payer: MDX Hawaii PPO	$1,418.14
Rate for Payer: University Health Alliance Commercial	$818.72

T-PLATE ROTATION CORRECTION,2.0MM,5 HOLE

Facility

$1,462.00

Service Code	HCPCS C1713
Hospital Charge Code	13000862
Hospital Revenue Code	278
Min. Negotiated Rate	$731.00
Max. Negotiated Rate	$1,418.14
Rate for Payer: AlohaCare Medicaid	$731.00
Rate for Payer: AlohaCare Medicare	$731.00
Rate for Payer: Cash Price	$950.30
Rate for Payer: Devoted Health Medicare	$804.10
Rate for Payer: Hawaii Medical Service Association Medicare	$731.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,023.40
Rate for Payer: Health Management Network Commercial	$1,242.70
Rate for Payer: Humana Medicare	$731.00
Rate for Payer: Kaiser Permanente Commercial	$1,315.80
Rate for Payer: Kaiser Permanente Medicaid	$745.62
Rate for Payer: Kaiser Permanente Medicare	$731.00
Rate for Payer: MDX Hawaii PPO	$1,418.14
Rate for Payer: Ohana Health Plan Medicaid	$731.00
Rate for Payer: Ohana Health Plan Medicare	$731.00
Rate for Payer: UnitedHealthcare Medicare	$731.00
Rate for Payer: University Health Alliance Commercial	$818.72

TRACHEOSTOMY FOR FACE, MOUTH AND NECK DIAGNOSES OR LARYNGECTOMY WITH CC

Facility

$83,122.91

Service Code	MSDRG 012
Min. Negotiated Rate	$10,400.00
Max. Negotiated Rate	$83,122.91
Rate for Payer: Hawaii Medical Service Association Commercial	$83,122.91
Rate for Payer: University Health Alliance Commercial	$10,400.00

TRACHEOSTOMY FOR FACE, MOUTH AND NECK DIAGNOSES OR LARYNGECTOMY WITH MCC

Facility

$83,122.91

Service Code	MSDRG 011
Min. Negotiated Rate	$10,400.00
Max. Negotiated Rate	$83,122.91
Rate for Payer: Hawaii Medical Service Association Commercial	$83,122.91
Rate for Payer: University Health Alliance Commercial	$10,400.00

TRACHEOSTOMY FOR FACE, MOUTH AND NECK DIAGNOSES OR LARYNGECTOMY WITHOUT CC/MCC

Facility

$83,122.91

Service Code	MSDRG 013
Min. Negotiated Rate	$10,400.00
Max. Negotiated Rate	$83,122.91
Rate for Payer: Hawaii Medical Service Association Commercial	$83,122.91
Rate for Payer: University Health Alliance Commercial	$10,400.00

TRACHEOSTOMY WITH MV >96 HOURS OR PRINCIPAL DIAGNOSIS EXCEPT FACE, MOUTH AND NECK WITHOUT MAJOR O.R. PROCEDURES

Facility

$404,593.14

Service Code	MSDRG 004
Min. Negotiated Rate	$10,400.00
Max. Negotiated Rate	$404,593.14
Rate for Payer: Hawaii Medical Service Association Commercial	$404,593.14
Rate for Payer: University Health Alliance Commercial	$10,400.00

traMADol 50 mg tablet [HHSC]

Facility

$3.00

Service Code	NDC 60687079501
Hospital Charge Code	2500830
Hospital Revenue Code	250
Min. Negotiated Rate	$1.50
Max. Negotiated Rate	$2.91
Rate for Payer: AlohaCare Medicaid	$1.50
Rate for Payer: AlohaCare Medicare	$1.50
Rate for Payer: Cash Price	$1.95
Rate for Payer: Devoted Health Medicare	$1.65
Rate for Payer: Hawaii Medical Service Association Medicare	$1.50
Rate for Payer: Hawaii Western Management Group Commercial	$2.85
Rate for Payer: Health Management Network Commercial	$2.55
Rate for Payer: Humana Medicare	$1.50
Rate for Payer: Kaiser Permanente Commercial	$2.70
Rate for Payer: Kaiser Permanente Medicaid	$1.53
Rate for Payer: Kaiser Permanente Medicare	$1.50
Rate for Payer: MDX Hawaii PPO	$2.91
Rate for Payer: Ohana Health Plan Medicaid	$1.50
Rate for Payer: Ohana Health Plan Medicare	$1.50
Rate for Payer: UnitedHealthcare Medicaid	$1.80
Rate for Payer: UnitedHealthcare Medicare	$1.50
Rate for Payer: University Health Alliance Commercial	$2.19

traMADol 50 mg tablet [HHSC]

Facility

$4.56

Service Code	NDC 68084080801
Hospital Charge Code	2500830
Hospital Revenue Code	250
Min. Negotiated Rate	$2.28
Max. Negotiated Rate	$4.42
Rate for Payer: AlohaCare Medicaid	$2.28
Rate for Payer: AlohaCare Medicare	$2.28
Rate for Payer: Cash Price	$2.96
Rate for Payer: Devoted Health Medicare	$2.51
Rate for Payer: Hawaii Medical Service Association Medicare	$2.28
Rate for Payer: Hawaii Western Management Group Commercial	$4.33
Rate for Payer: Health Management Network Commercial	$3.88
Rate for Payer: Humana Medicare	$2.28
Rate for Payer: Kaiser Permanente Commercial	$4.10
Rate for Payer: Kaiser Permanente Medicaid	$2.33
Rate for Payer: Kaiser Permanente Medicare	$2.28
Rate for Payer: MDX Hawaii PPO	$4.42
Rate for Payer: Ohana Health Plan Medicaid	$2.28
Rate for Payer: Ohana Health Plan Medicare	$2.28
Rate for Payer: UnitedHealthcare Medicaid	$2.74
Rate for Payer: UnitedHealthcare Medicare	$2.28
Rate for Payer: University Health Alliance Commercial	$3.32

traMADol 50 mg tablet [HHSC]

Facility

$3.00

Service Code	NDC 60687079501
Hospital Charge Code	2500830
Hospital Revenue Code	250
Min. Negotiated Rate	$2.55
Max. Negotiated Rate	$2.91
Rate for Payer: Cash Price	$1.95
Rate for Payer: Health Management Network Commercial	$2.55
Rate for Payer: Kaiser Permanente Commercial	$2.70
Rate for Payer: MDX Hawaii PPO	$2.91

traMADol 50 mg tablet [HHSC]

Facility

$4.56

Service Code	NDC 68084080801
Hospital Charge Code	2500830
Hospital Revenue Code	250
Min. Negotiated Rate	$3.88
Max. Negotiated Rate	$4.42
Rate for Payer: Cash Price	$2.96
Rate for Payer: Health Management Network Commercial	$3.88
Rate for Payer: Kaiser Permanente Commercial	$4.10
Rate for Payer: MDX Hawaii PPO	$4.42

tranexamic acid 1000 mg/10 ml vial [HHSC]

Facility

$25.35

Service Code	NDC 81284061210
Hospital Charge Code	2500831
Hospital Revenue Code	250
Min. Negotiated Rate	$12.68
Max. Negotiated Rate	$24.59
Rate for Payer: AlohaCare Medicaid	$12.68
Rate for Payer: AlohaCare Medicare	$12.68
Rate for Payer: Cash Price	$16.48
Rate for Payer: Devoted Health Medicare	$13.94
Rate for Payer: Hawaii Medical Service Association Medicare	$12.68
Rate for Payer: Hawaii Western Management Group Commercial	$24.08
Rate for Payer: Health Management Network Commercial	$21.55
Rate for Payer: Humana Medicare	$12.68
Rate for Payer: Kaiser Permanente Commercial	$22.82
Rate for Payer: Kaiser Permanente Medicaid	$12.93
Rate for Payer: Kaiser Permanente Medicare	$12.68
Rate for Payer: MDX Hawaii PPO	$24.59
Rate for Payer: Ohana Health Plan Medicaid	$12.68
Rate for Payer: Ohana Health Plan Medicare	$12.68
Rate for Payer: UnitedHealthcare Medicaid	$15.21
Rate for Payer: UnitedHealthcare Medicare	$12.68
Rate for Payer: University Health Alliance Commercial	$18.48

tranexamic acid 1000 mg/10 ml vial [HHSC]

Facility

$122.57

Service Code	NDC 00517096010
Hospital Charge Code	2500831
Hospital Revenue Code	250
Min. Negotiated Rate	$61.28
Max. Negotiated Rate	$118.89
Rate for Payer: AlohaCare Medicaid	$61.28
Rate for Payer: AlohaCare Medicare	$61.28
Rate for Payer: Cash Price	$79.67
Rate for Payer: Devoted Health Medicare	$67.41
Rate for Payer: Hawaii Medical Service Association Medicare	$61.28
Rate for Payer: Hawaii Western Management Group Commercial	$116.44
Rate for Payer: Health Management Network Commercial	$104.18
Rate for Payer: Humana Medicare	$61.28
Rate for Payer: Kaiser Permanente Commercial	$110.31
Rate for Payer: Kaiser Permanente Medicaid	$62.51
Rate for Payer: Kaiser Permanente Medicare	$61.28
Rate for Payer: MDX Hawaii PPO	$118.89
Rate for Payer: Ohana Health Plan Medicaid	$61.28
Rate for Payer: Ohana Health Plan Medicare	$61.28
Rate for Payer: UnitedHealthcare Medicaid	$73.54
Rate for Payer: UnitedHealthcare Medicare	$61.28
Rate for Payer: University Health Alliance Commercial	$89.34

Know your out-of-pocket cost for care.

All Charges