Samuel Mahelona Memorial Hospital

All Charges

Charge

Type

Setting

Price

TUBE ENDOTRACH 3.0 UNCUFFED

Facility

$10.00

Hospital Charge Code	8266473
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 3.5 UNCUFFED

Facility

$8.00

Hospital Charge Code	8266488
Hospital Revenue Code	270
Min. Negotiated Rate	$4.00
Max. Negotiated Rate	$7.76
Rate for Payer: AlohaCare Medicaid	$4.00
Rate for Payer: AlohaCare Medicare	$4.00
Rate for Payer: Cash Price	$5.20
Rate for Payer: Devoted Health Medicare	$4.40
Rate for Payer: Hawaii Medical Service Association Medicare	$4.00
Rate for Payer: Hawaii Western Management Group Commercial	$7.60
Rate for Payer: Health Management Network Commercial	$6.80
Rate for Payer: Humana Medicare	$4.00
Rate for Payer: Kaiser Permanente Commercial	$7.20
Rate for Payer: Kaiser Permanente Medicaid	$4.08
Rate for Payer: Kaiser Permanente Medicare	$4.00
Rate for Payer: MDX Hawaii PPO	$7.76
Rate for Payer: Ohana Health Plan Medicaid	$4.00
Rate for Payer: Ohana Health Plan Medicare	$4.00
Rate for Payer: UnitedHealthcare Medicare	$4.00
Rate for Payer: University Health Alliance Commercial	$5.83

TUBE ENDOTRACH 3.5 UNCUFFED

Facility

$8.00

Hospital Charge Code	8266488
Hospital Revenue Code	270
Min. Negotiated Rate	$6.80
Max. Negotiated Rate	$7.76
Rate for Payer: Cash Price	$5.20
Rate for Payer: Health Management Network Commercial	$6.80
Rate for Payer: Kaiser Permanente Commercial	$7.20
Rate for Payer: MDX Hawaii PPO	$7.76

TUBE ENDOTRACH 4.0 CUFFED

Facility

$18.00

Hospital Charge Code	8266828
Hospital Revenue Code	270
Min. Negotiated Rate	$15.30
Max. Negotiated Rate	$17.46
Rate for Payer: Cash Price	$11.70
Rate for Payer: Health Management Network Commercial	$15.30
Rate for Payer: Kaiser Permanente Commercial	$16.20
Rate for Payer: MDX Hawaii PPO	$17.46

TUBE ENDOTRACH 4.0 CUFFED

Facility

$18.00

Hospital Charge Code	8266828
Hospital Revenue Code	270
Min. Negotiated Rate	$9.00
Max. Negotiated Rate	$17.46
Rate for Payer: AlohaCare Medicaid	$9.00
Rate for Payer: AlohaCare Medicare	$9.00
Rate for Payer: Cash Price	$11.70
Rate for Payer: Devoted Health Medicare	$9.90
Rate for Payer: Hawaii Medical Service Association Medicare	$9.00
Rate for Payer: Hawaii Western Management Group Commercial	$17.10
Rate for Payer: Health Management Network Commercial	$15.30
Rate for Payer: Humana Medicare	$9.00
Rate for Payer: Kaiser Permanente Commercial	$16.20
Rate for Payer: Kaiser Permanente Medicaid	$9.18
Rate for Payer: Kaiser Permanente Medicare	$9.00
Rate for Payer: MDX Hawaii PPO	$17.46
Rate for Payer: Ohana Health Plan Medicaid	$9.00
Rate for Payer: Ohana Health Plan Medicare	$9.00
Rate for Payer: UnitedHealthcare Medicare	$9.00
Rate for Payer: University Health Alliance Commercial	$13.12

TUBE ENDOTRACH 4.0 UNCUFFED

Facility

$9.00

Hospital Charge Code	8266489
Hospital Revenue Code	270
Min. Negotiated Rate	$7.65
Max. Negotiated Rate	$8.73
Rate for Payer: Cash Price	$5.85
Rate for Payer: Health Management Network Commercial	$7.65
Rate for Payer: Kaiser Permanente Commercial	$8.10
Rate for Payer: MDX Hawaii PPO	$8.73

TUBE ENDOTRACH 4.0 UNCUFFED

Facility

$9.00

Hospital Charge Code	8266489
Hospital Revenue Code	270
Min. Negotiated Rate	$4.50
Max. Negotiated Rate	$8.73
Rate for Payer: AlohaCare Medicaid	$4.50
Rate for Payer: AlohaCare Medicare	$4.50
Rate for Payer: Cash Price	$5.85
Rate for Payer: Devoted Health Medicare	$4.95
Rate for Payer: Hawaii Medical Service Association Medicare	$4.50
Rate for Payer: Hawaii Western Management Group Commercial	$8.55
Rate for Payer: Health Management Network Commercial	$7.65
Rate for Payer: Humana Medicare	$4.50
Rate for Payer: Kaiser Permanente Commercial	$8.10
Rate for Payer: Kaiser Permanente Medicaid	$4.59
Rate for Payer: Kaiser Permanente Medicare	$4.50
Rate for Payer: MDX Hawaii PPO	$8.73
Rate for Payer: Ohana Health Plan Medicaid	$4.50
Rate for Payer: Ohana Health Plan Medicare	$4.50
Rate for Payer: UnitedHealthcare Medicare	$4.50
Rate for Payer: University Health Alliance Commercial	$6.56

TUBE ENDOTRACH 4.5 CUFFED

Facility

$19.00

Hospital Charge Code	8266472
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 4.5 CUFFED

Facility

$19.00

Hospital Charge Code	8266472
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 4.5 UNCUFFED

Facility

$9.00

Hospital Charge Code	8266727
Hospital Revenue Code	270
Min. Negotiated Rate	$7.65
Max. Negotiated Rate	$8.73
Rate for Payer: Cash Price	$5.85
Rate for Payer: Health Management Network Commercial	$7.65
Rate for Payer: Kaiser Permanente Commercial	$8.10
Rate for Payer: MDX Hawaii PPO	$8.73

TUBE ENDOTRACH 4.5 UNCUFFED

Facility

$9.00

Hospital Charge Code	8266727
Hospital Revenue Code	270
Min. Negotiated Rate	$4.50
Max. Negotiated Rate	$8.73
Rate for Payer: AlohaCare Medicaid	$4.50
Rate for Payer: AlohaCare Medicare	$4.50
Rate for Payer: Cash Price	$5.85
Rate for Payer: Devoted Health Medicare	$4.95
Rate for Payer: Hawaii Medical Service Association Medicare	$4.50
Rate for Payer: Hawaii Western Management Group Commercial	$8.55
Rate for Payer: Health Management Network Commercial	$7.65
Rate for Payer: Humana Medicare	$4.50
Rate for Payer: Kaiser Permanente Commercial	$8.10
Rate for Payer: Kaiser Permanente Medicaid	$4.59
Rate for Payer: Kaiser Permanente Medicare	$4.50
Rate for Payer: MDX Hawaii PPO	$8.73
Rate for Payer: Ohana Health Plan Medicaid	$4.50
Rate for Payer: Ohana Health Plan Medicare	$4.50
Rate for Payer: UnitedHealthcare Medicare	$4.50
Rate for Payer: University Health Alliance Commercial	$6.56

TUBE ENDOTRACH 5.0 CUFFED

Facility

$15.00

Hospital Charge Code	8266480
Hospital Revenue Code	270
Min. Negotiated Rate	$7.50
Max. Negotiated Rate	$14.55
Rate for Payer: AlohaCare Medicaid	$7.50
Rate for Payer: AlohaCare Medicare	$7.50
Rate for Payer: Cash Price	$9.75
Rate for Payer: Devoted Health Medicare	$8.25
Rate for Payer: Hawaii Medical Service Association Medicare	$7.50
Rate for Payer: Hawaii Western Management Group Commercial	$14.25
Rate for Payer: Health Management Network Commercial	$12.75
Rate for Payer: Humana Medicare	$7.50
Rate for Payer: Kaiser Permanente Commercial	$13.50
Rate for Payer: Kaiser Permanente Medicaid	$7.65
Rate for Payer: Kaiser Permanente Medicare	$7.50
Rate for Payer: MDX Hawaii PPO	$14.55
Rate for Payer: Ohana Health Plan Medicaid	$7.50
Rate for Payer: Ohana Health Plan Medicare	$7.50
Rate for Payer: UnitedHealthcare Medicare	$7.50
Rate for Payer: University Health Alliance Commercial	$10.93

TUBE ENDOTRACH 5.0 CUFFED

Facility

$15.00

Hospital Charge Code	8266480
Hospital Revenue Code	270
Min. Negotiated Rate	$12.75
Max. Negotiated Rate	$14.55
Rate for Payer: Cash Price	$9.75
Rate for Payer: Health Management Network Commercial	$12.75
Rate for Payer: Kaiser Permanente Commercial	$13.50
Rate for Payer: MDX Hawaii PPO	$14.55

TUBE ENDOTRACH 5.0 UNCUFFED

Facility

$9.00

Hospital Charge Code	8266490
Hospital Revenue Code	270
Min. Negotiated Rate	$7.65
Max. Negotiated Rate	$8.73
Rate for Payer: Cash Price	$5.85
Rate for Payer: Health Management Network Commercial	$7.65
Rate for Payer: Kaiser Permanente Commercial	$8.10
Rate for Payer: MDX Hawaii PPO	$8.73

TUBE ENDOTRACH 5.0 UNCUFFED

Facility

$9.00

Hospital Charge Code	8266490
Hospital Revenue Code	270
Min. Negotiated Rate	$4.50
Max. Negotiated Rate	$8.73
Rate for Payer: AlohaCare Medicaid	$4.50
Rate for Payer: AlohaCare Medicare	$4.50
Rate for Payer: Cash Price	$5.85
Rate for Payer: Devoted Health Medicare	$4.95
Rate for Payer: Hawaii Medical Service Association Medicare	$4.50
Rate for Payer: Hawaii Western Management Group Commercial	$8.55
Rate for Payer: Health Management Network Commercial	$7.65
Rate for Payer: Humana Medicare	$4.50
Rate for Payer: Kaiser Permanente Commercial	$8.10
Rate for Payer: Kaiser Permanente Medicaid	$4.59
Rate for Payer: Kaiser Permanente Medicare	$4.50
Rate for Payer: MDX Hawaii PPO	$8.73
Rate for Payer: Ohana Health Plan Medicaid	$4.50
Rate for Payer: Ohana Health Plan Medicare	$4.50
Rate for Payer: UnitedHealthcare Medicare	$4.50
Rate for Payer: University Health Alliance Commercial	$6.56

TUBE ENDOTRACH 5.5 CUFFED

Facility

$12.00

Hospital Charge Code	8266481
Hospital Revenue Code	270
Min. Negotiated Rate	$10.20
Max. Negotiated Rate	$11.64
Rate for Payer: Cash Price	$7.80
Rate for Payer: Health Management Network Commercial	$10.20
Rate for Payer: Kaiser Permanente Commercial	$10.80
Rate for Payer: MDX Hawaii PPO	$11.64

TUBE ENDOTRACH 5.5 CUFFED

Facility

$12.00

Hospital Charge Code	8266481
Hospital Revenue Code	270
Min. Negotiated Rate	$6.00
Max. Negotiated Rate	$11.64
Rate for Payer: AlohaCare Medicaid	$6.00
Rate for Payer: AlohaCare Medicare	$6.00
Rate for Payer: Cash Price	$7.80
Rate for Payer: Devoted Health Medicare	$6.60
Rate for Payer: Hawaii Medical Service Association Medicare	$6.00
Rate for Payer: Hawaii Western Management Group Commercial	$11.40
Rate for Payer: Health Management Network Commercial	$10.20
Rate for Payer: Humana Medicare	$6.00
Rate for Payer: Kaiser Permanente Commercial	$10.80
Rate for Payer: Kaiser Permanente Medicaid	$6.12
Rate for Payer: Kaiser Permanente Medicare	$6.00
Rate for Payer: MDX Hawaii PPO	$11.64
Rate for Payer: Ohana Health Plan Medicaid	$6.00
Rate for Payer: Ohana Health Plan Medicare	$6.00
Rate for Payer: UnitedHealthcare Medicare	$6.00
Rate for Payer: University Health Alliance Commercial	$8.75

TUBE ENDOTRACH 5.5 UNCUFFED

Facility

$11.00

Hospital Charge Code	8266724
Hospital Revenue Code	270
Min. Negotiated Rate	$9.35
Max. Negotiated Rate	$10.67
Rate for Payer: Cash Price	$7.15
Rate for Payer: Health Management Network Commercial	$9.35
Rate for Payer: Kaiser Permanente Commercial	$9.90
Rate for Payer: MDX Hawaii PPO	$10.67

TUBE ENDOTRACH 5.5 UNCUFFED

Facility

$11.00

Hospital Charge Code	8266724
Hospital Revenue Code	270
Min. Negotiated Rate	$5.50
Max. Negotiated Rate	$10.67
Rate for Payer: AlohaCare Medicaid	$5.50
Rate for Payer: AlohaCare Medicare	$5.50
Rate for Payer: Cash Price	$7.15
Rate for Payer: Devoted Health Medicare	$6.05
Rate for Payer: Hawaii Medical Service Association Medicare	$5.50
Rate for Payer: Hawaii Western Management Group Commercial	$10.45
Rate for Payer: Health Management Network Commercial	$9.35
Rate for Payer: Humana Medicare	$5.50
Rate for Payer: Kaiser Permanente Commercial	$9.90
Rate for Payer: Kaiser Permanente Medicaid	$5.61
Rate for Payer: Kaiser Permanente Medicare	$5.50
Rate for Payer: MDX Hawaii PPO	$10.67
Rate for Payer: Ohana Health Plan Medicaid	$5.50
Rate for Payer: Ohana Health Plan Medicare	$5.50
Rate for Payer: UnitedHealthcare Medicare	$5.50
Rate for Payer: University Health Alliance Commercial	$8.02

TUBE ENDOTRACH 6.0 CUFFED

Facility

$12.00

Hospital Charge Code	8266437
Hospital Revenue Code	270
Min. Negotiated Rate	$6.00
Max. Negotiated Rate	$11.64
Rate for Payer: AlohaCare Medicaid	$6.00
Rate for Payer: AlohaCare Medicare	$6.00
Rate for Payer: Cash Price	$7.80
Rate for Payer: Devoted Health Medicare	$6.60
Rate for Payer: Hawaii Medical Service Association Medicare	$6.00
Rate for Payer: Hawaii Western Management Group Commercial	$11.40
Rate for Payer: Health Management Network Commercial	$10.20
Rate for Payer: Humana Medicare	$6.00
Rate for Payer: Kaiser Permanente Commercial	$10.80
Rate for Payer: Kaiser Permanente Medicaid	$6.12
Rate for Payer: Kaiser Permanente Medicare	$6.00
Rate for Payer: MDX Hawaii PPO	$11.64
Rate for Payer: Ohana Health Plan Medicaid	$6.00
Rate for Payer: Ohana Health Plan Medicare	$6.00
Rate for Payer: UnitedHealthcare Medicare	$6.00
Rate for Payer: University Health Alliance Commercial	$8.75

TUBE ENDOTRACH 6.0 CUFFED

Facility

$12.00

Hospital Charge Code	8266437
Hospital Revenue Code	270
Min. Negotiated Rate	$10.20
Max. Negotiated Rate	$11.64
Rate for Payer: Cash Price	$7.80
Rate for Payer: Health Management Network Commercial	$10.20
Rate for Payer: Kaiser Permanente Commercial	$10.80
Rate for Payer: MDX Hawaii PPO	$11.64

TUBE ENDOTRACH 6.5 CUFFED

Facility

$12.00

Hospital Charge Code	8266482
Hospital Revenue Code	270
Min. Negotiated Rate	$10.20
Max. Negotiated Rate	$11.64
Rate for Payer: Cash Price	$7.80
Rate for Payer: Health Management Network Commercial	$10.20
Rate for Payer: Kaiser Permanente Commercial	$10.80
Rate for Payer: MDX Hawaii PPO	$11.64

TUBE ENDOTRACH 6.5 CUFFED

Facility

$12.00

Hospital Charge Code	8266482
Hospital Revenue Code	270
Min. Negotiated Rate	$6.00
Max. Negotiated Rate	$11.64
Rate for Payer: AlohaCare Medicaid	$6.00
Rate for Payer: AlohaCare Medicare	$6.00
Rate for Payer: Cash Price	$7.80
Rate for Payer: Devoted Health Medicare	$6.60
Rate for Payer: Hawaii Medical Service Association Medicare	$6.00
Rate for Payer: Hawaii Western Management Group Commercial	$11.40
Rate for Payer: Health Management Network Commercial	$10.20
Rate for Payer: Humana Medicare	$6.00
Rate for Payer: Kaiser Permanente Commercial	$10.80
Rate for Payer: Kaiser Permanente Medicaid	$6.12
Rate for Payer: Kaiser Permanente Medicare	$6.00
Rate for Payer: MDX Hawaii PPO	$11.64
Rate for Payer: Ohana Health Plan Medicaid	$6.00
Rate for Payer: Ohana Health Plan Medicare	$6.00
Rate for Payer: UnitedHealthcare Medicare	$6.00
Rate for Payer: University Health Alliance Commercial	$8.75

TUBE ENDOTRACH 7.0 CUFFED

Facility

$12.00

Hospital Charge Code	8266483
Hospital Revenue Code	270
Min. Negotiated Rate	$10.20
Max. Negotiated Rate	$11.64
Rate for Payer: Cash Price	$7.80
Rate for Payer: Health Management Network Commercial	$10.20
Rate for Payer: Kaiser Permanente Commercial	$10.80
Rate for Payer: MDX Hawaii PPO	$11.64

TUBE ENDOTRACH 7.0 CUFFED

Facility

$12.00

Hospital Charge Code	8266483
Hospital Revenue Code	270
Min. Negotiated Rate	$6.00
Max. Negotiated Rate	$11.64
Rate for Payer: AlohaCare Medicaid	$6.00
Rate for Payer: AlohaCare Medicare	$6.00
Rate for Payer: Cash Price	$7.80
Rate for Payer: Devoted Health Medicare	$6.60
Rate for Payer: Hawaii Medical Service Association Medicare	$6.00
Rate for Payer: Hawaii Western Management Group Commercial	$11.40
Rate for Payer: Health Management Network Commercial	$10.20
Rate for Payer: Humana Medicare	$6.00
Rate for Payer: Kaiser Permanente Commercial	$10.80
Rate for Payer: Kaiser Permanente Medicaid	$6.12
Rate for Payer: Kaiser Permanente Medicare	$6.00
Rate for Payer: MDX Hawaii PPO	$11.64
Rate for Payer: Ohana Health Plan Medicaid	$6.00
Rate for Payer: Ohana Health Plan Medicare	$6.00
Rate for Payer: UnitedHealthcare Medicare	$6.00
Rate for Payer: University Health Alliance Commercial	$8.75

Know your out-of-pocket cost for care.

All Charges