Samuel Mahelona Memorial Hospital

All Charges

Charge

Type

Setting

Price

VAL KREULOCK SCREW, TI, 2.4 X 15MM

Facility

$310.00

Service Code	HCPCS C1713
Hospital Charge Code	13002430
Hospital Revenue Code	278
Min. Negotiated Rate	$173.60
Max. Negotiated Rate	$300.70
Rate for Payer: Cash Price	$201.50
Rate for Payer: Hawaii Western Management Group Commercial	$217.00
Rate for Payer: Health Management Network Commercial	$263.50
Rate for Payer: Kaiser Permanente Commercial	$279.00
Rate for Payer: MDX Hawaii PPO	$300.70
Rate for Payer: University Health Alliance Commercial	$173.60

VAL KREULOCK SCREW, TI, 2.4 X 15MM

Facility

$310.00

Service Code	HCPCS C1713
Hospital Charge Code	13002430
Hospital Revenue Code	278
Min. Negotiated Rate	$155.00
Max. Negotiated Rate	$300.70
Rate for Payer: AlohaCare Medicaid	$155.00
Rate for Payer: AlohaCare Medicare	$155.00
Rate for Payer: Cash Price	$201.50
Rate for Payer: Devoted Health Medicare	$170.50
Rate for Payer: Hawaii Medical Service Association Medicare	$155.00
Rate for Payer: Hawaii Western Management Group Commercial	$217.00
Rate for Payer: Health Management Network Commercial	$263.50
Rate for Payer: Humana Medicare	$155.00
Rate for Payer: Kaiser Permanente Commercial	$279.00
Rate for Payer: Kaiser Permanente Medicaid	$158.10
Rate for Payer: Kaiser Permanente Medicare	$155.00
Rate for Payer: MDX Hawaii PPO	$300.70
Rate for Payer: Ohana Health Plan Medicaid	$155.00
Rate for Payer: Ohana Health Plan Medicare	$155.00
Rate for Payer: UnitedHealthcare Medicare	$155.00
Rate for Payer: University Health Alliance Commercial	$173.60

VAL KREULOCK SCREW, TI, 2.4 X 16MM

Facility

$310.00

Service Code	HCPCS C1713
Hospital Charge Code	13002428
Hospital Revenue Code	278
Min. Negotiated Rate	$155.00
Max. Negotiated Rate	$300.70
Rate for Payer: AlohaCare Medicaid	$155.00
Rate for Payer: AlohaCare Medicare	$155.00
Rate for Payer: Cash Price	$201.50
Rate for Payer: Devoted Health Medicare	$170.50
Rate for Payer: Hawaii Medical Service Association Medicare	$155.00
Rate for Payer: Hawaii Western Management Group Commercial	$217.00
Rate for Payer: Health Management Network Commercial	$263.50
Rate for Payer: Humana Medicare	$155.00
Rate for Payer: Kaiser Permanente Commercial	$279.00
Rate for Payer: Kaiser Permanente Medicaid	$158.10
Rate for Payer: Kaiser Permanente Medicare	$155.00
Rate for Payer: MDX Hawaii PPO	$300.70
Rate for Payer: Ohana Health Plan Medicaid	$155.00
Rate for Payer: Ohana Health Plan Medicare	$155.00
Rate for Payer: UnitedHealthcare Medicare	$155.00
Rate for Payer: University Health Alliance Commercial	$173.60

VAL KREULOCK SCREW, TI, 2.4 X 16MM

Facility

$310.00

Service Code	HCPCS C1713
Hospital Charge Code	13002428
Hospital Revenue Code	278
Min. Negotiated Rate	$173.60
Max. Negotiated Rate	$300.70
Rate for Payer: Cash Price	$201.50
Rate for Payer: Hawaii Western Management Group Commercial	$217.00
Rate for Payer: Health Management Network Commercial	$263.50
Rate for Payer: Kaiser Permanente Commercial	$279.00
Rate for Payer: MDX Hawaii PPO	$300.70
Rate for Payer: University Health Alliance Commercial	$173.60

VAL KREULOCK SCREW, TI, 2.4 X 18MM

Facility

$248.00

Service Code	HCPCS C1713
Hospital Charge Code	13002432
Hospital Revenue Code	278
Min. Negotiated Rate	$124.00
Max. Negotiated Rate	$240.56
Rate for Payer: AlohaCare Medicaid	$124.00
Rate for Payer: AlohaCare Medicare	$124.00
Rate for Payer: Cash Price	$161.20
Rate for Payer: Devoted Health Medicare	$136.40
Rate for Payer: Hawaii Medical Service Association Medicare	$124.00
Rate for Payer: Hawaii Western Management Group Commercial	$173.60
Rate for Payer: Health Management Network Commercial	$210.80
Rate for Payer: Humana Medicare	$124.00
Rate for Payer: Kaiser Permanente Commercial	$223.20
Rate for Payer: Kaiser Permanente Medicaid	$126.48
Rate for Payer: Kaiser Permanente Medicare	$124.00
Rate for Payer: MDX Hawaii PPO	$240.56
Rate for Payer: Ohana Health Plan Medicaid	$124.00
Rate for Payer: Ohana Health Plan Medicare	$124.00
Rate for Payer: UnitedHealthcare Medicare	$124.00
Rate for Payer: University Health Alliance Commercial	$138.88

VAL KREULOCK SCREW, TI, 2.4 X 18MM

Facility

$248.00

Service Code	HCPCS C1713
Hospital Charge Code	13002432
Hospital Revenue Code	278
Min. Negotiated Rate	$138.88
Max. Negotiated Rate	$240.56
Rate for Payer: Cash Price	$161.20
Rate for Payer: Hawaii Western Management Group Commercial	$173.60
Rate for Payer: Health Management Network Commercial	$210.80
Rate for Payer: Kaiser Permanente Commercial	$223.20
Rate for Payer: MDX Hawaii PPO	$240.56
Rate for Payer: University Health Alliance Commercial	$138.88

VAL KREULOCK SCREW, TI, 2.4 X 20MM

Facility

$248.00

Service Code	HCPCS C1713
Hospital Charge Code	13002433
Hospital Revenue Code	278
Min. Negotiated Rate	$138.88
Max. Negotiated Rate	$240.56
Rate for Payer: Cash Price	$161.20
Rate for Payer: Hawaii Western Management Group Commercial	$173.60
Rate for Payer: Health Management Network Commercial	$210.80
Rate for Payer: Kaiser Permanente Commercial	$223.20
Rate for Payer: MDX Hawaii PPO	$240.56
Rate for Payer: University Health Alliance Commercial	$138.88

VAL KREULOCK SCREW, TI, 2.4 X 20MM

Facility

$248.00

Service Code	HCPCS C1713
Hospital Charge Code	13002433
Hospital Revenue Code	278
Min. Negotiated Rate	$124.00
Max. Negotiated Rate	$240.56
Rate for Payer: AlohaCare Medicaid	$124.00
Rate for Payer: AlohaCare Medicare	$124.00
Rate for Payer: Cash Price	$161.20
Rate for Payer: Devoted Health Medicare	$136.40
Rate for Payer: Hawaii Medical Service Association Medicare	$124.00
Rate for Payer: Hawaii Western Management Group Commercial	$173.60
Rate for Payer: Health Management Network Commercial	$210.80
Rate for Payer: Humana Medicare	$124.00
Rate for Payer: Kaiser Permanente Commercial	$223.20
Rate for Payer: Kaiser Permanente Medicaid	$126.48
Rate for Payer: Kaiser Permanente Medicare	$124.00
Rate for Payer: MDX Hawaii PPO	$240.56
Rate for Payer: Ohana Health Plan Medicaid	$124.00
Rate for Payer: Ohana Health Plan Medicare	$124.00
Rate for Payer: UnitedHealthcare Medicare	$124.00
Rate for Payer: University Health Alliance Commercial	$138.88

VAL KREULOCK SCREW, TI, 2.4 X 22MM

Facility

$248.00

Service Code	HCPCS C1713
Hospital Charge Code	13002434
Hospital Revenue Code	278
Min. Negotiated Rate	$138.88
Max. Negotiated Rate	$240.56
Rate for Payer: Cash Price	$161.20
Rate for Payer: Hawaii Western Management Group Commercial	$173.60
Rate for Payer: Health Management Network Commercial	$210.80
Rate for Payer: Kaiser Permanente Commercial	$223.20
Rate for Payer: MDX Hawaii PPO	$240.56
Rate for Payer: University Health Alliance Commercial	$138.88

VAL KREULOCK SCREW, TI, 2.4 X 22MM

Facility

$248.00

Service Code	HCPCS C1713
Hospital Charge Code	13002434
Hospital Revenue Code	278
Min. Negotiated Rate	$124.00
Max. Negotiated Rate	$240.56
Rate for Payer: AlohaCare Medicaid	$124.00
Rate for Payer: AlohaCare Medicare	$124.00
Rate for Payer: Cash Price	$161.20
Rate for Payer: Devoted Health Medicare	$136.40
Rate for Payer: Hawaii Medical Service Association Medicare	$124.00
Rate for Payer: Hawaii Western Management Group Commercial	$173.60
Rate for Payer: Health Management Network Commercial	$210.80
Rate for Payer: Humana Medicare	$124.00
Rate for Payer: Kaiser Permanente Commercial	$223.20
Rate for Payer: Kaiser Permanente Medicaid	$126.48
Rate for Payer: Kaiser Permanente Medicare	$124.00
Rate for Payer: MDX Hawaii PPO	$240.56
Rate for Payer: Ohana Health Plan Medicaid	$124.00
Rate for Payer: Ohana Health Plan Medicare	$124.00
Rate for Payer: UnitedHealthcare Medicare	$124.00
Rate for Payer: University Health Alliance Commercial	$138.88

VAL KREULOCK SCREW, TI, 2.4 X 24MM

Facility

$248.00

Service Code	HCPCS C1713
Hospital Charge Code	13002435
Hospital Revenue Code	278
Min. Negotiated Rate	$138.88
Max. Negotiated Rate	$240.56
Rate for Payer: Cash Price	$161.20
Rate for Payer: Hawaii Western Management Group Commercial	$173.60
Rate for Payer: Health Management Network Commercial	$210.80
Rate for Payer: Kaiser Permanente Commercial	$223.20
Rate for Payer: MDX Hawaii PPO	$240.56
Rate for Payer: University Health Alliance Commercial	$138.88

VAL KREULOCK SCREW, TI, 2.4 X 24MM

Facility

$248.00

Service Code	HCPCS C1713
Hospital Charge Code	13002435
Hospital Revenue Code	278
Min. Negotiated Rate	$124.00
Max. Negotiated Rate	$240.56
Rate for Payer: AlohaCare Medicaid	$124.00
Rate for Payer: AlohaCare Medicare	$124.00
Rate for Payer: Cash Price	$161.20
Rate for Payer: Devoted Health Medicare	$136.40
Rate for Payer: Hawaii Medical Service Association Medicare	$124.00
Rate for Payer: Hawaii Western Management Group Commercial	$173.60
Rate for Payer: Health Management Network Commercial	$210.80
Rate for Payer: Humana Medicare	$124.00
Rate for Payer: Kaiser Permanente Commercial	$223.20
Rate for Payer: Kaiser Permanente Medicaid	$126.48
Rate for Payer: Kaiser Permanente Medicare	$124.00
Rate for Payer: MDX Hawaii PPO	$240.56
Rate for Payer: Ohana Health Plan Medicaid	$124.00
Rate for Payer: Ohana Health Plan Medicare	$124.00
Rate for Payer: UnitedHealthcare Medicare	$124.00
Rate for Payer: University Health Alliance Commercial	$138.88

VAL KREULOCK SCREW, TI, 2.4 X 26MM

Facility

$248.00

Service Code	HCPCS C1713
Hospital Charge Code	13002440
Hospital Revenue Code	278
Min. Negotiated Rate	$138.88
Max. Negotiated Rate	$240.56
Rate for Payer: Cash Price	$161.20
Rate for Payer: Hawaii Western Management Group Commercial	$173.60
Rate for Payer: Health Management Network Commercial	$210.80
Rate for Payer: Kaiser Permanente Commercial	$223.20
Rate for Payer: MDX Hawaii PPO	$240.56
Rate for Payer: University Health Alliance Commercial	$138.88

VAL KREULOCK SCREW, TI, 2.4 X 26MM

Facility

$248.00

Service Code	HCPCS C1713
Hospital Charge Code	13002440
Hospital Revenue Code	278
Min. Negotiated Rate	$124.00
Max. Negotiated Rate	$240.56
Rate for Payer: AlohaCare Medicaid	$124.00
Rate for Payer: AlohaCare Medicare	$124.00
Rate for Payer: Cash Price	$161.20
Rate for Payer: Devoted Health Medicare	$136.40
Rate for Payer: Hawaii Medical Service Association Medicare	$124.00
Rate for Payer: Hawaii Western Management Group Commercial	$173.60
Rate for Payer: Health Management Network Commercial	$210.80
Rate for Payer: Humana Medicare	$124.00
Rate for Payer: Kaiser Permanente Commercial	$223.20
Rate for Payer: Kaiser Permanente Medicaid	$126.48
Rate for Payer: Kaiser Permanente Medicare	$124.00
Rate for Payer: MDX Hawaii PPO	$240.56
Rate for Payer: Ohana Health Plan Medicaid	$124.00
Rate for Payer: Ohana Health Plan Medicare	$124.00
Rate for Payer: UnitedHealthcare Medicare	$124.00
Rate for Payer: University Health Alliance Commercial	$138.88

VAL KREULOCK SCREW, TI, 2.4 X 28MM

Facility

$248.00

Service Code	HCPCS C1713
Hospital Charge Code	13002436
Hospital Revenue Code	278
Min. Negotiated Rate	$138.88
Max. Negotiated Rate	$240.56
Rate for Payer: Cash Price	$161.20
Rate for Payer: Hawaii Western Management Group Commercial	$173.60
Rate for Payer: Health Management Network Commercial	$210.80
Rate for Payer: Kaiser Permanente Commercial	$223.20
Rate for Payer: MDX Hawaii PPO	$240.56
Rate for Payer: University Health Alliance Commercial	$138.88

VAL KREULOCK SCREW, TI, 2.4 X 28MM

Facility

$248.00

Service Code	HCPCS C1713
Hospital Charge Code	13002436
Hospital Revenue Code	278
Min. Negotiated Rate	$124.00
Max. Negotiated Rate	$240.56
Rate for Payer: AlohaCare Medicaid	$124.00
Rate for Payer: AlohaCare Medicare	$124.00
Rate for Payer: Cash Price	$161.20
Rate for Payer: Devoted Health Medicare	$136.40
Rate for Payer: Hawaii Medical Service Association Medicare	$124.00
Rate for Payer: Hawaii Western Management Group Commercial	$173.60
Rate for Payer: Health Management Network Commercial	$210.80
Rate for Payer: Humana Medicare	$124.00
Rate for Payer: Kaiser Permanente Commercial	$223.20
Rate for Payer: Kaiser Permanente Medicaid	$126.48
Rate for Payer: Kaiser Permanente Medicare	$124.00
Rate for Payer: MDX Hawaii PPO	$240.56
Rate for Payer: Ohana Health Plan Medicaid	$124.00
Rate for Payer: Ohana Health Plan Medicare	$124.00
Rate for Payer: UnitedHealthcare Medicare	$124.00
Rate for Payer: University Health Alliance Commercial	$138.88

VAL KREULOCK SCREW, TI, 2.4 X 30MM

Facility

$310.00

Service Code	HCPCS C1713
Hospital Charge Code	13002437
Hospital Revenue Code	278
Min. Negotiated Rate	$155.00
Max. Negotiated Rate	$300.70
Rate for Payer: AlohaCare Medicaid	$155.00
Rate for Payer: AlohaCare Medicare	$155.00
Rate for Payer: Cash Price	$201.50
Rate for Payer: Devoted Health Medicare	$170.50
Rate for Payer: Hawaii Medical Service Association Medicare	$155.00
Rate for Payer: Hawaii Western Management Group Commercial	$217.00
Rate for Payer: Health Management Network Commercial	$263.50
Rate for Payer: Humana Medicare	$155.00
Rate for Payer: Kaiser Permanente Commercial	$279.00
Rate for Payer: Kaiser Permanente Medicaid	$158.10
Rate for Payer: Kaiser Permanente Medicare	$155.00
Rate for Payer: MDX Hawaii PPO	$300.70
Rate for Payer: Ohana Health Plan Medicaid	$155.00
Rate for Payer: Ohana Health Plan Medicare	$155.00
Rate for Payer: UnitedHealthcare Medicare	$155.00
Rate for Payer: University Health Alliance Commercial	$173.60

VAL KREULOCK SCREW, TI, 2.4 X 30MM

Facility

$310.00

Service Code	HCPCS C1713
Hospital Charge Code	13002437
Hospital Revenue Code	278
Min. Negotiated Rate	$173.60
Max. Negotiated Rate	$300.70
Rate for Payer: Cash Price	$201.50
Rate for Payer: Hawaii Western Management Group Commercial	$217.00
Rate for Payer: Health Management Network Commercial	$263.50
Rate for Payer: Kaiser Permanente Commercial	$279.00
Rate for Payer: MDX Hawaii PPO	$300.70
Rate for Payer: University Health Alliance Commercial	$173.60

VAL KREULOCK SCREW, TI, 2.4 X 32MM

Facility

$310.00

Service Code	HCPCS C1713
Hospital Charge Code	13002441
Hospital Revenue Code	278
Min. Negotiated Rate	$155.00
Max. Negotiated Rate	$300.70
Rate for Payer: AlohaCare Medicaid	$155.00
Rate for Payer: AlohaCare Medicare	$155.00
Rate for Payer: Cash Price	$201.50
Rate for Payer: Devoted Health Medicare	$170.50
Rate for Payer: Hawaii Medical Service Association Medicare	$155.00
Rate for Payer: Hawaii Western Management Group Commercial	$217.00
Rate for Payer: Health Management Network Commercial	$263.50
Rate for Payer: Humana Medicare	$155.00
Rate for Payer: Kaiser Permanente Commercial	$279.00
Rate for Payer: Kaiser Permanente Medicaid	$158.10
Rate for Payer: Kaiser Permanente Medicare	$155.00
Rate for Payer: MDX Hawaii PPO	$300.70
Rate for Payer: Ohana Health Plan Medicaid	$155.00
Rate for Payer: Ohana Health Plan Medicare	$155.00
Rate for Payer: UnitedHealthcare Medicare	$155.00
Rate for Payer: University Health Alliance Commercial	$173.60

VAL KREULOCK SCREW, TI, 2.4 X 32MM

Facility

$310.00

Service Code	HCPCS C1713
Hospital Charge Code	13002441
Hospital Revenue Code	278
Min. Negotiated Rate	$173.60
Max. Negotiated Rate	$300.70
Rate for Payer: Cash Price	$201.50
Rate for Payer: Hawaii Western Management Group Commercial	$217.00
Rate for Payer: Health Management Network Commercial	$263.50
Rate for Payer: Kaiser Permanente Commercial	$279.00
Rate for Payer: MDX Hawaii PPO	$300.70
Rate for Payer: University Health Alliance Commercial	$173.60

VAL KREULOCK SCREW, TI, 2.4 X 34MM

Facility

$310.00

Service Code	HCPCS C1713
Hospital Charge Code	13002442
Hospital Revenue Code	278
Min. Negotiated Rate	$173.60
Max. Negotiated Rate	$300.70
Rate for Payer: Cash Price	$201.50
Rate for Payer: Hawaii Western Management Group Commercial	$217.00
Rate for Payer: Health Management Network Commercial	$263.50
Rate for Payer: Kaiser Permanente Commercial	$279.00
Rate for Payer: MDX Hawaii PPO	$300.70
Rate for Payer: University Health Alliance Commercial	$173.60

VAL KREULOCK SCREW, TI, 2.4 X 34MM

Facility

$310.00

Service Code	HCPCS C1713
Hospital Charge Code	13002442
Hospital Revenue Code	278
Min. Negotiated Rate	$155.00
Max. Negotiated Rate	$300.70
Rate for Payer: AlohaCare Medicaid	$155.00
Rate for Payer: AlohaCare Medicare	$155.00
Rate for Payer: Cash Price	$201.50
Rate for Payer: Devoted Health Medicare	$170.50
Rate for Payer: Hawaii Medical Service Association Medicare	$155.00
Rate for Payer: Hawaii Western Management Group Commercial	$217.00
Rate for Payer: Health Management Network Commercial	$263.50
Rate for Payer: Humana Medicare	$155.00
Rate for Payer: Kaiser Permanente Commercial	$279.00
Rate for Payer: Kaiser Permanente Medicaid	$158.10
Rate for Payer: Kaiser Permanente Medicare	$155.00
Rate for Payer: MDX Hawaii PPO	$300.70
Rate for Payer: Ohana Health Plan Medicaid	$155.00
Rate for Payer: Ohana Health Plan Medicare	$155.00
Rate for Payer: UnitedHealthcare Medicare	$155.00
Rate for Payer: University Health Alliance Commercial	$173.60

VAL KREULOCK SCREW, TI, 2.4 X 36MM

Facility

$310.00

Service Code	HCPCS C1713
Hospital Charge Code	13002438
Hospital Revenue Code	278
Min. Negotiated Rate	$155.00
Max. Negotiated Rate	$300.70
Rate for Payer: Kaiser Permanente Medicare	$155.00
Rate for Payer: AlohaCare Medicaid	$155.00
Rate for Payer: AlohaCare Medicare	$155.00
Rate for Payer: Cash Price	$201.50
Rate for Payer: Devoted Health Medicare	$170.50
Rate for Payer: Hawaii Medical Service Association Medicare	$155.00
Rate for Payer: Hawaii Western Management Group Commercial	$217.00
Rate for Payer: Health Management Network Commercial	$263.50
Rate for Payer: Humana Medicare	$155.00
Rate for Payer: Kaiser Permanente Commercial	$279.00
Rate for Payer: Kaiser Permanente Medicaid	$158.10
Rate for Payer: MDX Hawaii PPO	$300.70
Rate for Payer: Ohana Health Plan Medicaid	$155.00
Rate for Payer: Ohana Health Plan Medicare	$155.00
Rate for Payer: UnitedHealthcare Medicare	$155.00
Rate for Payer: University Health Alliance Commercial	$173.60

VAL KREULOCK SCREW, TI, 2.4 X 36MM

Facility

$310.00

Service Code	HCPCS C1713
Hospital Charge Code	13002438
Hospital Revenue Code	278
Min. Negotiated Rate	$173.60
Max. Negotiated Rate	$300.70
Rate for Payer: Cash Price	$201.50
Rate for Payer: Hawaii Western Management Group Commercial	$217.00
Rate for Payer: Health Management Network Commercial	$263.50
Rate for Payer: Kaiser Permanente Commercial	$279.00
Rate for Payer: MDX Hawaii PPO	$300.70
Rate for Payer: University Health Alliance Commercial	$173.60

VAL KREULOCK SCREW, TI, 2.4 X 38MM

Facility

$310.00

Service Code	HCPCS C1713
Hospital Charge Code	13002443
Hospital Revenue Code	278
Min. Negotiated Rate	$173.60
Max. Negotiated Rate	$300.70
Rate for Payer: Cash Price	$201.50
Rate for Payer: Hawaii Western Management Group Commercial	$217.00
Rate for Payer: Health Management Network Commercial	$263.50
Rate for Payer: Kaiser Permanente Commercial	$279.00
Rate for Payer: MDX Hawaii PPO	$300.70
Rate for Payer: University Health Alliance Commercial	$173.60

Know your out-of-pocket cost for care.

All Charges