Samuel Mahelona Memorial Hospital

All Charges

Charge

Type

Setting

Price

VAL NEAR CORTEX SCREW, TI, 2.4 X 30MM

Facility

$184.00

Service Code	HCPCS C1713
Hospital Charge Code	13002814
Hospital Revenue Code	278
Min. Negotiated Rate	$92.00
Max. Negotiated Rate	$178.48
Rate for Payer: AlohaCare Medicaid	$92.00
Rate for Payer: AlohaCare Medicare	$92.00
Rate for Payer: Cash Price	$119.60
Rate for Payer: Devoted Health Medicare	$101.20
Rate for Payer: Hawaii Medical Service Association Medicare	$92.00
Rate for Payer: Hawaii Western Management Group Commercial	$128.80
Rate for Payer: Health Management Network Commercial	$156.40
Rate for Payer: Humana Medicare	$92.00
Rate for Payer: Kaiser Permanente Commercial	$165.60
Rate for Payer: Kaiser Permanente Medicaid	$93.84
Rate for Payer: Kaiser Permanente Medicare	$92.00
Rate for Payer: MDX Hawaii PPO	$178.48
Rate for Payer: Ohana Health Plan Medicaid	$92.00
Rate for Payer: Ohana Health Plan Medicare	$92.00
Rate for Payer: UnitedHealthcare Medicare	$92.00
Rate for Payer: University Health Alliance Commercial	$103.04

VAL NEAR CORTEX SCREW, TI, 2.4 X 8MM

Facility

$184.00

Service Code	HCPCS C1713
Hospital Charge Code	13008201
Hospital Revenue Code	278
Min. Negotiated Rate	$103.04
Max. Negotiated Rate	$178.48
Rate for Payer: Cash Price	$119.60
Rate for Payer: Hawaii Western Management Group Commercial	$128.80
Rate for Payer: Health Management Network Commercial	$156.40
Rate for Payer: Kaiser Permanente Commercial	$165.60
Rate for Payer: MDX Hawaii PPO	$178.48
Rate for Payer: University Health Alliance Commercial	$103.04

VAL NEAR CORTEX SCREW, TI, 2.4 X 8MM

Facility

$184.00

Service Code	HCPCS C1713
Hospital Charge Code	13008201
Hospital Revenue Code	278
Min. Negotiated Rate	$92.00
Max. Negotiated Rate	$178.48
Rate for Payer: AlohaCare Medicaid	$92.00
Rate for Payer: AlohaCare Medicare	$92.00
Rate for Payer: Cash Price	$119.60
Rate for Payer: Devoted Health Medicare	$101.20
Rate for Payer: Hawaii Medical Service Association Medicare	$92.00
Rate for Payer: Hawaii Western Management Group Commercial	$128.80
Rate for Payer: Health Management Network Commercial	$156.40
Rate for Payer: Humana Medicare	$92.00
Rate for Payer: Kaiser Permanente Commercial	$165.60
Rate for Payer: Kaiser Permanente Medicaid	$93.84
Rate for Payer: Kaiser Permanente Medicare	$92.00
Rate for Payer: MDX Hawaii PPO	$178.48
Rate for Payer: Ohana Health Plan Medicaid	$92.00
Rate for Payer: Ohana Health Plan Medicare	$92.00
Rate for Payer: UnitedHealthcare Medicare	$92.00
Rate for Payer: University Health Alliance Commercial	$103.04

Valproic Acid FSI

Facility

$155.00

Service Code	HCPCS 80164
Hospital Charge Code	8118077
Hospital Revenue Code	301
Min. Negotiated Rate	$131.75
Max. Negotiated Rate	$150.35
Rate for Payer: Cash Price	$100.75
Rate for Payer: Health Management Network Commercial	$131.75
Rate for Payer: Kaiser Permanente Commercial	$139.50
Rate for Payer: MDX Hawaii PPO	$150.35

Valproic Acid FSI

Facility

$155.00

Service Code	HCPCS 80164
Hospital Charge Code	8118077
Hospital Revenue Code	301
Min. Negotiated Rate	$13.54
Max. Negotiated Rate	$150.35
Rate for Payer: AlohaCare Medicaid	$77.50
Rate for Payer: AlohaCare Medicare	$77.50
Rate for Payer: Cash Price	$100.75
Rate for Payer: Cash Price	$100.75
Rate for Payer: Devoted Health Medicare	$85.25
Rate for Payer: Hawaii Medical Service Association ABD	$18.72
Rate for Payer: Hawaii Medical Service Association Commercial	$16.93
Rate for Payer: Hawaii Medical Service Association Medicare	$77.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$19.66
Rate for Payer: Hawaii Western Management Group Commercial	$13.54
Rate for Payer: Health Management Network Commercial	$131.75
Rate for Payer: Humana Medicare	$77.50
Rate for Payer: Kaiser Permanente Commercial	$139.50
Rate for Payer: Kaiser Permanente Medicaid	$79.05
Rate for Payer: Kaiser Permanente Medicare	$77.50
Rate for Payer: MDX Hawaii PPO	$150.35
Rate for Payer: Ohana Health Plan Medicaid	$77.50
Rate for Payer: Ohana Health Plan Medicare	$77.50
Rate for Payer: UnitedHealthcare Medicaid	$18.72
Rate for Payer: UnitedHealthcare Medicare	$77.50
Rate for Payer: University Health Alliance Commercial	$35.02

VAL SCREW, TI, 2.4 X 8MM

Facility

$184.00

Service Code	HCPCS C1713
Hospital Charge Code	13008202
Hospital Revenue Code	278
Min. Negotiated Rate	$92.00
Max. Negotiated Rate	$178.48
Rate for Payer: AlohaCare Medicaid	$92.00
Rate for Payer: AlohaCare Medicare	$92.00
Rate for Payer: Cash Price	$119.60
Rate for Payer: Devoted Health Medicare	$101.20
Rate for Payer: Hawaii Medical Service Association Medicare	$92.00
Rate for Payer: Hawaii Western Management Group Commercial	$128.80
Rate for Payer: Health Management Network Commercial	$156.40
Rate for Payer: Humana Medicare	$92.00
Rate for Payer: Kaiser Permanente Commercial	$165.60
Rate for Payer: Kaiser Permanente Medicaid	$93.84
Rate for Payer: Kaiser Permanente Medicare	$92.00
Rate for Payer: MDX Hawaii PPO	$178.48
Rate for Payer: Ohana Health Plan Medicaid	$92.00
Rate for Payer: Ohana Health Plan Medicare	$92.00
Rate for Payer: UnitedHealthcare Medicare	$92.00
Rate for Payer: University Health Alliance Commercial	$103.04

VAL SCREW, TI, 2.4 X 8MM

Facility

$184.00

Service Code	HCPCS C1713
Hospital Charge Code	13008202
Hospital Revenue Code	278
Min. Negotiated Rate	$103.04
Max. Negotiated Rate	$178.48
Rate for Payer: Cash Price	$119.60
Rate for Payer: Hawaii Western Management Group Commercial	$128.80
Rate for Payer: Health Management Network Commercial	$156.40
Rate for Payer: Kaiser Permanente Commercial	$165.60
Rate for Payer: MDX Hawaii PPO	$178.48
Rate for Payer: University Health Alliance Commercial	$103.04

VAL VAL KREULOCK SCREW, TI, 2.7 MM X 10 MM

Facility

$310.00

Service Code	HCPCS C1713
Hospital Charge Code	13002822
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 VAL KREULOCK SCREW, TI, 2.7 MM X 10 MM

Facility

$310.00

Service Code	HCPCS C1713
Hospital Charge Code	13002822
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 VAL KREULOCK SCREW, TI, 2.7 MM X 11 MM

Facility

$310.00

Service Code	HCPCS C1713
Hospital Charge Code	13002823
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 VAL KREULOCK SCREW, TI, 2.7 MM X 11 MM

Facility

$310.00

Service Code	HCPCS C1713
Hospital Charge Code	13002823
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 VAL KREULOCK SCREW, TI, 2.7 MM X 12 MM

Facility

$310.00

Service Code	HCPCS C1713
Hospital Charge Code	13002824
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 VAL KREULOCK SCREW, TI, 2.7 MM X 12 MM

Facility

$310.00

Service Code	HCPCS C1713
Hospital Charge Code	13002824
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 VAL KREULOCK SCREW, TI, 2.7 MM X 13 MM

Facility

$310.00

Service Code	HCPCS C1713
Hospital Charge Code	13002821
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 VAL KREULOCK SCREW, TI, 2.7 MM X 13 MM

Facility

$310.00

Service Code	HCPCS C1713
Hospital Charge Code	13002821
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 VAL KREULOCK SCREW, TI, 2.7 MM X 18 MM

Facility

$310.00

Service Code	HCPCS C1713
Hospital Charge Code	13017651
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 VAL KREULOCK SCREW, TI, 2.7 MM X 18 MM

Facility

$310.00

Service Code	HCPCS C1713
Hospital Charge Code	13017651
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 VAL KREULOCK SCREW, TI, 2.7 MM X 20 MM

Facility

$310.00

Service Code	HCPCS C1713
Hospital Charge Code	13017652
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 VAL KREULOCK SCREW, TI, 2.7 MM X 20 MM

Facility

$310.00

Service Code	HCPCS C1713
Hospital Charge Code	13017652
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 VAL KREULOCK SCREW, TI, 2.7 MM X 22 MM

Facility

$310.00

Service Code	HCPCS C1713
Hospital Charge Code	13017650
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 VAL KREULOCK SCREW, TI, 2.7 MM X 22 MM

Facility

$310.00

Service Code	HCPCS C1713
Hospital Charge Code	13017650
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 VAL KREULOCK SCREW, TI, 2.7 MM X 24 MM

Facility

$310.00

Service Code	HCPCS C1713
Hospital Charge Code	13017659
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 VAL KREULOCK SCREW, TI, 2.7 MM X 24 MM

Facility

$310.00

Service Code	HCPCS C1713
Hospital Charge Code	13017659
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 VAL KREULOCK SCREW, TI, 2.7 MM X 36 MM

Facility

$310.00

Service Code	HCPCS C1713
Hospital Charge Code	13017675
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 VAL KREULOCK SCREW, TI, 2.7 MM X 36 MM

Facility

$310.00

Service Code	HCPCS C1713
Hospital Charge Code	13017675
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

Know your out-of-pocket cost for care.

All Charges