Samuel Mahelona Memorial Hospital

All Charges

Charge

Type

Setting

Price

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	$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 40MM

Facility

$310.00

Service Code	HCPCS C1713
Hospital Charge Code	13002439
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 40MM

Facility

$310.00

Service Code	HCPCS C1713
Hospital Charge Code	13002439
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 42MM

Facility

$310.00

Service Code	HCPCS C1713
Hospital Charge Code	13002444
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 42MM

Facility

$310.00

Service Code	HCPCS C1713
Hospital Charge Code	13002444
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 44MM

Facility

$310.00

Service Code	HCPCS C1713
Hospital Charge Code	13002431
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 44MM

Facility

$310.00

Service Code	HCPCS C1713
Hospital Charge Code	13002431
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 46MM

Facility

$310.00

Service Code	HCPCS C1713
Hospital Charge Code	13002445
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 46MM

Facility

$310.00

Service Code	HCPCS C1713
Hospital Charge Code	13002445
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 48MM

Facility

$310.00

Service Code	HCPCS C1713
Hospital Charge Code	13002446
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 48MM

Facility

$310.00

Service Code	HCPCS C1713
Hospital Charge Code	13002446
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 65MM

Facility

$310.00

Service Code	HCPCS C1713
Hospital Charge Code	13007972
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 65MM

Facility

$310.00

Service Code	HCPCS C1713
Hospital Charge Code	13007972
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 6MM

Facility

$310.00

Service Code	HCPCS C1713
Hospital Charge Code	13007973
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 6MM

Facility

$310.00

Service Code	HCPCS C1713
Hospital Charge Code	13007973
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 70MM

Facility

$310.00

Service Code	HCPCS C1713
Hospital Charge Code	13007974
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 70MM

Facility

$310.00

Service Code	HCPCS C1713
Hospital Charge Code	13007974
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 75MM

Facility

$310.00

Service Code	HCPCS C1713
Hospital Charge Code	13007975
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 75MM

Facility

$310.00

Service Code	HCPCS C1713
Hospital Charge Code	13007975
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 7MM

Facility

$310.00

Service Code	HCPCS C1713
Hospital Charge Code	13007976
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 7MM

Facility

$310.00

Service Code	HCPCS C1713
Hospital Charge Code	13007976
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 80MM

Facility

$310.00

Service Code	HCPCS C1713
Hospital Charge Code	13007969
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 80MM

Facility

$310.00

Service Code	HCPCS C1713
Hospital Charge Code	13007969
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 8MM

Facility

$310.00

Service Code	HCPCS C1713
Hospital Charge Code	13007970
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 8MM

Facility

$310.00

Service Code	HCPCS C1713
Hospital Charge Code	13007970
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