Samuel Mahelona Memorial Hospital

All Charges

Charge

Type

Setting

Price

TUBE 10FR SALEM NASOGASTRIC SUMP WITH PREVENT ANTI-REFLUX FILTER

Facility

$26.00

Hospital Charge Code	8266438
Hospital Revenue Code	270
Min. Negotiated Rate	$22.10
Max. Negotiated Rate	$25.22
Rate for Payer: Cash Price	$16.90
Rate for Payer: Health Management Network Commercial	$22.10
Rate for Payer: Kaiser Permanente Commercial	$23.40
Rate for Payer: MDX Hawaii PPO	$25.22

TUBE 10FR SALEM NASOGASTRIC SUMP WITH PREVENT ANTI-REFLUX FILTER

Facility

$26.00

Hospital Charge Code	8266438
Hospital Revenue Code	270
Min. Negotiated Rate	$13.00
Max. Negotiated Rate	$25.22
Rate for Payer: AlohaCare Medicaid	$13.00
Rate for Payer: AlohaCare Medicare	$13.00
Rate for Payer: Cash Price	$16.90
Rate for Payer: Devoted Health Medicare	$14.30
Rate for Payer: Hawaii Medical Service Association Medicare	$13.00
Rate for Payer: Hawaii Western Management Group Commercial	$24.70
Rate for Payer: Health Management Network Commercial	$22.10
Rate for Payer: Humana Medicare	$13.00
Rate for Payer: Kaiser Permanente Commercial	$23.40
Rate for Payer: Kaiser Permanente Medicaid	$13.26
Rate for Payer: Kaiser Permanente Medicare	$13.00
Rate for Payer: MDX Hawaii PPO	$25.22
Rate for Payer: Ohana Health Plan Medicaid	$13.00
Rate for Payer: Ohana Health Plan Medicare	$13.00
Rate for Payer: UnitedHealthcare Medicare	$13.00
Rate for Payer: University Health Alliance Commercial	$18.95

TUBE 12FR SALEM NASOGASTRIC SUMP WITH PREVENT ANTI-REFLUX VALVE

Facility

$25.00

Hospital Charge Code	8266302
Hospital Revenue Code	270
Min. Negotiated Rate	$12.50
Max. Negotiated Rate	$24.25
Rate for Payer: AlohaCare Medicaid	$12.50
Rate for Payer: AlohaCare Medicare	$12.50
Rate for Payer: Cash Price	$16.25
Rate for Payer: Devoted Health Medicare	$13.75
Rate for Payer: Hawaii Medical Service Association Medicare	$12.50
Rate for Payer: Hawaii Western Management Group Commercial	$23.75
Rate for Payer: Health Management Network Commercial	$21.25
Rate for Payer: Humana Medicare	$12.50
Rate for Payer: Kaiser Permanente Commercial	$22.50
Rate for Payer: Kaiser Permanente Medicaid	$12.75
Rate for Payer: Kaiser Permanente Medicare	$12.50
Rate for Payer: MDX Hawaii PPO	$24.25
Rate for Payer: Ohana Health Plan Medicaid	$12.50
Rate for Payer: Ohana Health Plan Medicare	$12.50
Rate for Payer: UnitedHealthcare Medicare	$12.50
Rate for Payer: University Health Alliance Commercial	$18.22

TUBE 12FR SALEM NASOGASTRIC SUMP WITH PREVENT ANTI-REFLUX VALVE

Facility

$25.00

Hospital Charge Code	8266302
Hospital Revenue Code	270
Min. Negotiated Rate	$21.25
Max. Negotiated Rate	$24.25
Rate for Payer: Cash Price	$16.25
Rate for Payer: Health Management Network Commercial	$21.25
Rate for Payer: Kaiser Permanente Commercial	$22.50
Rate for Payer: MDX Hawaii PPO	$24.25

TUBE 12FR SALEM SUMP

Facility

$250.00

Hospital Charge Code	8266931
Hospital Revenue Code	270
Min. Negotiated Rate	$212.50
Max. Negotiated Rate	$242.50
Rate for Payer: Cash Price	$162.50
Rate for Payer: Health Management Network Commercial	$212.50
Rate for Payer: Kaiser Permanente Commercial	$225.00
Rate for Payer: MDX Hawaii PPO	$242.50

TUBE 12FR SALEM SUMP

Facility

$250.00

Hospital Charge Code	8266931
Hospital Revenue Code	270
Min. Negotiated Rate	$125.00
Max. Negotiated Rate	$242.50
Rate for Payer: AlohaCare Medicaid	$125.00
Rate for Payer: AlohaCare Medicare	$125.00
Rate for Payer: Cash Price	$162.50
Rate for Payer: Devoted Health Medicare	$137.50
Rate for Payer: Hawaii Medical Service Association Medicare	$125.00
Rate for Payer: Hawaii Western Management Group Commercial	$237.50
Rate for Payer: Health Management Network Commercial	$212.50
Rate for Payer: Humana Medicare	$125.00
Rate for Payer: Kaiser Permanente Commercial	$225.00
Rate for Payer: Kaiser Permanente Medicaid	$127.50
Rate for Payer: Kaiser Permanente Medicare	$125.00
Rate for Payer: MDX Hawaii PPO	$242.50
Rate for Payer: Ohana Health Plan Medicaid	$125.00
Rate for Payer: Ohana Health Plan Medicare	$125.00
Rate for Payer: UnitedHealthcare Medicare	$125.00
Rate for Payer: University Health Alliance Commercial	$182.22

TUBE 14FR SALEM NASOGASTRIC SUMP WITH PREVENT ANTI-REFLUX VALVE

Facility

$24.00

Hospital Charge Code	8266290
Hospital Revenue Code	270
Min. Negotiated Rate	$12.00
Max. Negotiated Rate	$23.28
Rate for Payer: AlohaCare Medicaid	$12.00
Rate for Payer: AlohaCare Medicare	$12.00
Rate for Payer: Cash Price	$15.60
Rate for Payer: Devoted Health Medicare	$13.20
Rate for Payer: Hawaii Medical Service Association Medicare	$12.00
Rate for Payer: Hawaii Western Management Group Commercial	$22.80
Rate for Payer: Health Management Network Commercial	$20.40
Rate for Payer: Humana Medicare	$12.00
Rate for Payer: Kaiser Permanente Commercial	$21.60
Rate for Payer: Kaiser Permanente Medicaid	$12.24
Rate for Payer: Kaiser Permanente Medicare	$12.00
Rate for Payer: MDX Hawaii PPO	$23.28
Rate for Payer: Ohana Health Plan Medicaid	$12.00
Rate for Payer: Ohana Health Plan Medicare	$12.00
Rate for Payer: UnitedHealthcare Medicare	$12.00
Rate for Payer: University Health Alliance Commercial	$17.49

TUBE 14FR SALEM NASOGASTRIC SUMP WITH PREVENT ANTI-REFLUX VALVE

Facility

$24.00

Hospital Charge Code	8266290
Hospital Revenue Code	270
Min. Negotiated Rate	$20.40
Max. Negotiated Rate	$23.28
Rate for Payer: Kaiser Permanente Commercial	$21.60
Rate for Payer: Cash Price	$15.60
Rate for Payer: Health Management Network Commercial	$20.40
Rate for Payer: MDX Hawaii PPO	$23.28

TUBE 14FR STOMACH LEVIN

Facility

$30.00

Hospital Charge Code	8266565
Hospital Revenue Code	272
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

TUBE 14FR STOMACH LEVIN

Facility

$30.00

Hospital Charge Code	8266565
Hospital Revenue Code	272
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

TUBE 16FR SALEM NASOGASTRIC SUMP WITH PREVENT ANTI-REFLUX VALVE

Facility

$25.00

Hospital Charge Code	8266954
Hospital Revenue Code	270
Min. Negotiated Rate	$12.50
Max. Negotiated Rate	$24.25
Rate for Payer: AlohaCare Medicaid	$12.50
Rate for Payer: AlohaCare Medicare	$12.50
Rate for Payer: Cash Price	$16.25
Rate for Payer: Devoted Health Medicare	$13.75
Rate for Payer: Hawaii Medical Service Association Medicare	$12.50
Rate for Payer: Hawaii Western Management Group Commercial	$23.75
Rate for Payer: Health Management Network Commercial	$21.25
Rate for Payer: Humana Medicare	$12.50
Rate for Payer: Kaiser Permanente Commercial	$22.50
Rate for Payer: Kaiser Permanente Medicaid	$12.75
Rate for Payer: Kaiser Permanente Medicare	$12.50
Rate for Payer: MDX Hawaii PPO	$24.25
Rate for Payer: Ohana Health Plan Medicaid	$12.50
Rate for Payer: Ohana Health Plan Medicare	$12.50
Rate for Payer: UnitedHealthcare Medicare	$12.50
Rate for Payer: University Health Alliance Commercial	$18.22

TUBE 16FR SALEM NASOGASTRIC SUMP WITH PREVENT ANTI-REFLUX VALVE

Facility

$25.00

Hospital Charge Code	8266954
Hospital Revenue Code	270
Min. Negotiated Rate	$21.25
Max. Negotiated Rate	$24.25
Rate for Payer: Cash Price	$16.25
Rate for Payer: Health Management Network Commercial	$21.25
Rate for Payer: Kaiser Permanente Commercial	$22.50
Rate for Payer: MDX Hawaii PPO	$24.25

TUBE 16FR STOMACH LEVIN

Facility

$6.00

Hospital Charge Code	8266358
Hospital Revenue Code	272
Min. Negotiated Rate	$5.10
Max. Negotiated Rate	$5.82
Rate for Payer: Cash Price	$3.90
Rate for Payer: Health Management Network Commercial	$5.10
Rate for Payer: Kaiser Permanente Commercial	$5.40
Rate for Payer: MDX Hawaii PPO	$5.82

TUBE 16FR STOMACH LEVIN

Facility

$6.00

Hospital Charge Code	8266358
Hospital Revenue Code	272
Min. Negotiated Rate	$3.00
Max. Negotiated Rate	$5.82
Rate for Payer: AlohaCare Medicaid	$3.00
Rate for Payer: AlohaCare Medicare	$3.00
Rate for Payer: Cash Price	$3.90
Rate for Payer: Devoted Health Medicare	$3.30
Rate for Payer: Hawaii Medical Service Association Medicare	$3.00
Rate for Payer: Hawaii Western Management Group Commercial	$5.70
Rate for Payer: Health Management Network Commercial	$5.10
Rate for Payer: Humana Medicare	$3.00
Rate for Payer: Kaiser Permanente Commercial	$5.40
Rate for Payer: Kaiser Permanente Medicaid	$3.06
Rate for Payer: Kaiser Permanente Medicare	$3.00
Rate for Payer: MDX Hawaii PPO	$5.82
Rate for Payer: Ohana Health Plan Medicaid	$3.00
Rate for Payer: Ohana Health Plan Medicare	$3.00
Rate for Payer: UnitedHealthcare Medicare	$3.00
Rate for Payer: University Health Alliance Commercial	$4.37

TUBE 18FR SALEM NASOGASTRIC SUMP WITH ANTI-REFLUX VALVE

Facility

$25.00

Hospital Charge Code	8266968
Hospital Revenue Code	270
Min. Negotiated Rate	$21.25
Max. Negotiated Rate	$24.25
Rate for Payer: Cash Price	$16.25
Rate for Payer: Health Management Network Commercial	$21.25
Rate for Payer: Kaiser Permanente Commercial	$22.50
Rate for Payer: MDX Hawaii PPO	$24.25

TUBE 18FR SALEM NASOGASTRIC SUMP WITH ANTI-REFLUX VALVE

Facility

$25.00

Hospital Charge Code	8266968
Hospital Revenue Code	270
Min. Negotiated Rate	$12.50
Max. Negotiated Rate	$24.25
Rate for Payer: AlohaCare Medicaid	$12.50
Rate for Payer: AlohaCare Medicare	$12.50
Rate for Payer: Cash Price	$16.25
Rate for Payer: Devoted Health Medicare	$13.75
Rate for Payer: Hawaii Medical Service Association Medicare	$12.50
Rate for Payer: Hawaii Western Management Group Commercial	$23.75
Rate for Payer: Health Management Network Commercial	$21.25
Rate for Payer: Humana Medicare	$12.50
Rate for Payer: Kaiser Permanente Commercial	$22.50
Rate for Payer: Kaiser Permanente Medicaid	$12.75
Rate for Payer: Kaiser Permanente Medicare	$12.50
Rate for Payer: MDX Hawaii PPO	$24.25
Rate for Payer: Ohana Health Plan Medicaid	$12.50
Rate for Payer: Ohana Health Plan Medicare	$12.50
Rate for Payer: UnitedHealthcare Medicare	$12.50
Rate for Payer: University Health Alliance Commercial	$18.22

TUBE 18FR STOMACH LEVIN

Facility

$7.00

Hospital Charge Code	8266635
Hospital Revenue Code	272
Min. Negotiated Rate	$3.50
Max. Negotiated Rate	$6.79
Rate for Payer: AlohaCare Medicaid	$3.50
Rate for Payer: AlohaCare Medicare	$3.50
Rate for Payer: Cash Price	$4.55
Rate for Payer: Devoted Health Medicare	$3.85
Rate for Payer: Hawaii Medical Service Association Medicare	$3.50
Rate for Payer: Hawaii Western Management Group Commercial	$6.65
Rate for Payer: Health Management Network Commercial	$5.95
Rate for Payer: Humana Medicare	$3.50
Rate for Payer: Kaiser Permanente Commercial	$6.30
Rate for Payer: Kaiser Permanente Medicaid	$3.57
Rate for Payer: Kaiser Permanente Medicare	$3.50
Rate for Payer: MDX Hawaii PPO	$6.79
Rate for Payer: Ohana Health Plan Medicaid	$3.50
Rate for Payer: Ohana Health Plan Medicare	$3.50
Rate for Payer: UnitedHealthcare Medicare	$3.50
Rate for Payer: University Health Alliance Commercial	$5.10

TUBE 18FR STOMACH LEVIN

Facility

$7.00

Hospital Charge Code	8266635
Hospital Revenue Code	272
Min. Negotiated Rate	$5.95
Max. Negotiated Rate	$6.79
Rate for Payer: Cash Price	$4.55
Rate for Payer: Health Management Network Commercial	$5.95
Rate for Payer: Kaiser Permanente Commercial	$6.30
Rate for Payer: MDX Hawaii PPO	$6.79

TUBE ENDOTRACH 2.0 UNCUFFED

Facility

$10.00

Hospital Charge Code	8266486
Hospital Revenue Code	270
Min. Negotiated Rate	$5.00
Max. Negotiated Rate	$9.70
Rate for Payer: AlohaCare Medicaid	$5.00
Rate for Payer: AlohaCare Medicare	$5.00
Rate for Payer: Cash Price	$6.50
Rate for Payer: Devoted Health Medicare	$5.50
Rate for Payer: Hawaii Medical Service Association Medicare	$5.00
Rate for Payer: Hawaii Western Management Group Commercial	$9.50
Rate for Payer: Health Management Network Commercial	$8.50
Rate for Payer: Humana Medicare	$5.00
Rate for Payer: Kaiser Permanente Commercial	$9.00
Rate for Payer: Kaiser Permanente Medicaid	$5.10
Rate for Payer: Kaiser Permanente Medicare	$5.00
Rate for Payer: MDX Hawaii PPO	$9.70
Rate for Payer: Ohana Health Plan Medicaid	$5.00
Rate for Payer: Ohana Health Plan Medicare	$5.00
Rate for Payer: UnitedHealthcare Medicare	$5.00
Rate for Payer: University Health Alliance Commercial	$7.29

TUBE ENDOTRACH 2.0 UNCUFFED

Facility

$10.00

Hospital Charge Code	8266486
Hospital Revenue Code	270
Min. Negotiated Rate	$8.50
Max. Negotiated Rate	$9.70
Rate for Payer: Cash Price	$6.50
Rate for Payer: Health Management Network Commercial	$8.50
Rate for Payer: Kaiser Permanente Commercial	$9.00
Rate for Payer: MDX Hawaii PPO	$9.70

TUBE ENDOTRACH 2.5 UNCUFFED

Facility

$10.00

Hospital Charge Code	8266487
Hospital Revenue Code	270
Min. Negotiated Rate	$8.50
Max. Negotiated Rate	$9.70
Rate for Payer: Cash Price	$6.50
Rate for Payer: Health Management Network Commercial	$8.50
Rate for Payer: Kaiser Permanente Commercial	$9.00
Rate for Payer: MDX Hawaii PPO	$9.70

TUBE ENDOTRACH 2.5 UNCUFFED

Facility

$10.00

Hospital Charge Code	8266487
Hospital Revenue Code	270
Min. Negotiated Rate	$5.00
Max. Negotiated Rate	$9.70
Rate for Payer: AlohaCare Medicaid	$5.00
Rate for Payer: AlohaCare Medicare	$5.00
Rate for Payer: Cash Price	$6.50
Rate for Payer: Devoted Health Medicare	$5.50
Rate for Payer: Hawaii Medical Service Association Medicare	$5.00
Rate for Payer: Hawaii Western Management Group Commercial	$9.50
Rate for Payer: Health Management Network Commercial	$8.50
Rate for Payer: Humana Medicare	$5.00
Rate for Payer: Kaiser Permanente Commercial	$9.00
Rate for Payer: Kaiser Permanente Medicaid	$5.10
Rate for Payer: Kaiser Permanente Medicare	$5.00
Rate for Payer: MDX Hawaii PPO	$9.70
Rate for Payer: Ohana Health Plan Medicaid	$5.00
Rate for Payer: Ohana Health Plan Medicare	$5.00
Rate for Payer: UnitedHealthcare Medicare	$5.00
Rate for Payer: University Health Alliance Commercial	$7.29

TUBE ENDOTRACH 3.0 CUFFED

Facility

$19.00

Hospital Charge Code	8266491
Hospital Revenue Code	270
Min. Negotiated Rate	$9.50
Max. Negotiated Rate	$18.43
Rate for Payer: AlohaCare Medicaid	$9.50
Rate for Payer: AlohaCare Medicare	$9.50
Rate for Payer: Cash Price	$12.35
Rate for Payer: Devoted Health Medicare	$10.45
Rate for Payer: Hawaii Medical Service Association Medicare	$9.50
Rate for Payer: Hawaii Western Management Group Commercial	$18.05
Rate for Payer: Health Management Network Commercial	$16.15
Rate for Payer: Humana Medicare	$9.50
Rate for Payer: Kaiser Permanente Commercial	$17.10
Rate for Payer: Kaiser Permanente Medicaid	$9.69
Rate for Payer: Kaiser Permanente Medicare	$9.50
Rate for Payer: MDX Hawaii PPO	$18.43
Rate for Payer: Ohana Health Plan Medicaid	$9.50
Rate for Payer: Ohana Health Plan Medicare	$9.50
Rate for Payer: UnitedHealthcare Medicare	$9.50
Rate for Payer: University Health Alliance Commercial	$13.85

TUBE ENDOTRACH 3.0 CUFFED

Facility

$19.00

Hospital Charge Code	8266491
Hospital Revenue Code	270
Min. Negotiated Rate	$16.15
Max. Negotiated Rate	$18.43
Rate for Payer: Cash Price	$12.35
Rate for Payer: Health Management Network Commercial	$16.15
Rate for Payer: Kaiser Permanente Commercial	$17.10
Rate for Payer: MDX Hawaii PPO	$18.43

TUBE ENDOTRACH 3.0 UNCUFFED

Facility

$10.00

Hospital Charge Code	8266473
Hospital Revenue Code	270
Min. Negotiated Rate	$8.50
Max. Negotiated Rate	$9.70
Rate for Payer: Cash Price	$6.50
Rate for Payer: Health Management Network Commercial	$8.50
Rate for Payer: Kaiser Permanente Commercial	$9.00
Rate for Payer: MDX Hawaii PPO	$9.70

Know your out-of-pocket cost for care.

All Charges