Samuel Mahelona Memorial Hospital

All Charges

Charge

Type

Setting

Price

V- PLATE, 2.4MM, 10 HOLE

Facility

$2,505.00

Service Code	HCPCS C1713
Hospital Charge Code	13005603
Hospital Revenue Code	278
Min. Negotiated Rate	$1,252.50
Max. Negotiated Rate	$2,429.85
Rate for Payer: AlohaCare Medicaid	$1,252.50
Rate for Payer: AlohaCare Medicare	$1,252.50
Rate for Payer: Cash Price	$1,628.25
Rate for Payer: Devoted Health Medicare	$1,377.75
Rate for Payer: Hawaii Medical Service Association Medicare	$1,252.50
Rate for Payer: Hawaii Western Management Group Commercial	$1,753.50
Rate for Payer: Health Management Network Commercial	$2,129.25
Rate for Payer: Humana Medicare	$1,252.50
Rate for Payer: Kaiser Permanente Commercial	$2,254.50
Rate for Payer: Kaiser Permanente Medicaid	$1,277.55
Rate for Payer: Kaiser Permanente Medicare	$1,252.50
Rate for Payer: MDX Hawaii PPO	$2,429.85
Rate for Payer: Ohana Health Plan Medicaid	$1,252.50
Rate for Payer: Ohana Health Plan Medicare	$1,252.50
Rate for Payer: UnitedHealthcare Medicare	$1,252.50
Rate for Payer: University Health Alliance Commercial	$1,402.80

V- PLATE, 2.4MM, 10 HOLE

Facility

$2,505.00

Service Code	HCPCS C1713
Hospital Charge Code	13005603
Hospital Revenue Code	278
Min. Negotiated Rate	$1,402.80
Max. Negotiated Rate	$2,429.85
Rate for Payer: Cash Price	$1,628.25
Rate for Payer: Hawaii Western Management Group Commercial	$1,753.50
Rate for Payer: Health Management Network Commercial	$2,129.25
Rate for Payer: Kaiser Permanente Commercial	$2,254.50
Rate for Payer: MDX Hawaii PPO	$2,429.85
Rate for Payer: University Health Alliance Commercial	$1,402.80

V- PLATE, 2.4MM, 6 HOLE

Facility

$1,462.00

Service Code	HCPCS C1713
Hospital Charge Code	13005605
Hospital Revenue Code	278
Min. Negotiated Rate	$731.00
Max. Negotiated Rate	$1,418.14
Rate for Payer: AlohaCare Medicaid	$731.00
Rate for Payer: AlohaCare Medicare	$731.00
Rate for Payer: Cash Price	$950.30
Rate for Payer: Devoted Health Medicare	$804.10
Rate for Payer: Hawaii Medical Service Association Medicare	$731.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,023.40
Rate for Payer: Health Management Network Commercial	$1,242.70
Rate for Payer: Humana Medicare	$731.00
Rate for Payer: Kaiser Permanente Commercial	$1,315.80
Rate for Payer: Kaiser Permanente Medicaid	$745.62
Rate for Payer: Kaiser Permanente Medicare	$731.00
Rate for Payer: MDX Hawaii PPO	$1,418.14
Rate for Payer: Ohana Health Plan Medicaid	$731.00
Rate for Payer: Ohana Health Plan Medicare	$731.00
Rate for Payer: UnitedHealthcare Medicare	$731.00
Rate for Payer: University Health Alliance Commercial	$818.72

V- PLATE, 2.4MM, 6 HOLE

Facility

$1,462.00

Service Code	HCPCS C1713
Hospital Charge Code	13005605
Hospital Revenue Code	278
Min. Negotiated Rate	$818.72
Max. Negotiated Rate	$1,418.14
Rate for Payer: Cash Price	$950.30
Rate for Payer: Hawaii Western Management Group Commercial	$1,023.40
Rate for Payer: Health Management Network Commercial	$1,242.70
Rate for Payer: Kaiser Permanente Commercial	$1,315.80
Rate for Payer: MDX Hawaii PPO	$1,418.14
Rate for Payer: University Health Alliance Commercial	$818.72

warfarin 1 mg tablet [HHSC]

Facility

$13.76

Service Code	NDC 00056016975
Hospital Charge Code	2500858
Hospital Revenue Code	250
Min. Negotiated Rate	$11.70
Max. Negotiated Rate	$13.35
Rate for Payer: Cash Price	$8.94
Rate for Payer: Health Management Network Commercial	$11.70
Rate for Payer: Kaiser Permanente Commercial	$12.38
Rate for Payer: MDX Hawaii PPO	$13.35

warfarin 1 mg tablet [HHSC]

Facility

$3.42

Service Code	NDC 00832121100
Hospital Charge Code	2500858
Hospital Revenue Code	250
Min. Negotiated Rate	$2.91
Max. Negotiated Rate	$3.32
Rate for Payer: Cash Price	$2.22
Rate for Payer: Health Management Network Commercial	$2.91
Rate for Payer: Kaiser Permanente Commercial	$3.08
Rate for Payer: MDX Hawaii PPO	$3.32

warfarin 1 mg tablet [HHSC]

Facility

$3.42

Service Code	NDC 00832121100
Hospital Charge Code	2500858
Hospital Revenue Code	250
Min. Negotiated Rate	$1.71
Max. Negotiated Rate	$3.32
Rate for Payer: AlohaCare Medicaid	$1.71
Rate for Payer: AlohaCare Medicare	$1.71
Rate for Payer: Cash Price	$2.22
Rate for Payer: Devoted Health Medicare	$1.88
Rate for Payer: Hawaii Medical Service Association Medicare	$1.71
Rate for Payer: Hawaii Western Management Group Commercial	$3.25
Rate for Payer: Health Management Network Commercial	$2.91
Rate for Payer: Humana Medicare	$1.71
Rate for Payer: Kaiser Permanente Commercial	$3.08
Rate for Payer: Kaiser Permanente Medicaid	$1.74
Rate for Payer: Kaiser Permanente Medicare	$1.71
Rate for Payer: MDX Hawaii PPO	$3.32
Rate for Payer: Ohana Health Plan Medicaid	$1.71
Rate for Payer: Ohana Health Plan Medicare	$1.71
Rate for Payer: UnitedHealthcare Medicaid	$2.05
Rate for Payer: UnitedHealthcare Medicare	$1.71
Rate for Payer: University Health Alliance Commercial	$2.49

warfarin 1 mg tablet [HHSC]

Facility

$13.76

Service Code	NDC 00056016975
Hospital Charge Code	2500858
Hospital Revenue Code	250
Min. Negotiated Rate	$6.88
Max. Negotiated Rate	$13.35
Rate for Payer: AlohaCare Medicaid	$6.88
Rate for Payer: AlohaCare Medicare	$6.88
Rate for Payer: Cash Price	$8.94
Rate for Payer: Devoted Health Medicare	$7.57
Rate for Payer: Hawaii Medical Service Association Medicare	$6.88
Rate for Payer: Hawaii Western Management Group Commercial	$13.07
Rate for Payer: Health Management Network Commercial	$11.70
Rate for Payer: Humana Medicare	$6.88
Rate for Payer: Kaiser Permanente Commercial	$12.38
Rate for Payer: Kaiser Permanente Medicaid	$7.02
Rate for Payer: Kaiser Permanente Medicare	$6.88
Rate for Payer: MDX Hawaii PPO	$13.35
Rate for Payer: Ohana Health Plan Medicaid	$6.88
Rate for Payer: Ohana Health Plan Medicare	$6.88
Rate for Payer: UnitedHealthcare Medicaid	$8.26
Rate for Payer: UnitedHealthcare Medicare	$6.88
Rate for Payer: University Health Alliance Commercial	$10.03

warfarin 1 mg tablet [HHSC]

Facility

$3.42

Service Code	NDC 00832121101
Hospital Charge Code	2500858
Hospital Revenue Code	250
Min. Negotiated Rate	$1.71
Max. Negotiated Rate	$3.32
Rate for Payer: AlohaCare Medicaid	$1.71
Rate for Payer: AlohaCare Medicare	$1.71
Rate for Payer: Cash Price	$2.22
Rate for Payer: Devoted Health Medicare	$1.88
Rate for Payer: Hawaii Medical Service Association Medicare	$1.71
Rate for Payer: Hawaii Western Management Group Commercial	$3.25
Rate for Payer: Health Management Network Commercial	$2.91
Rate for Payer: Humana Medicare	$1.71
Rate for Payer: Kaiser Permanente Commercial	$3.08
Rate for Payer: Kaiser Permanente Medicaid	$1.74
Rate for Payer: Kaiser Permanente Medicare	$1.71
Rate for Payer: MDX Hawaii PPO	$3.32
Rate for Payer: Ohana Health Plan Medicaid	$1.71
Rate for Payer: Ohana Health Plan Medicare	$1.71
Rate for Payer: UnitedHealthcare Medicaid	$2.05
Rate for Payer: UnitedHealthcare Medicare	$1.71
Rate for Payer: University Health Alliance Commercial	$2.49

warfarin 1 mg tablet [HHSC]

Facility

$3.42

Service Code	NDC 00832121101
Hospital Charge Code	2500858
Hospital Revenue Code	250
Min. Negotiated Rate	$2.91
Max. Negotiated Rate	$3.32
Rate for Payer: Cash Price	$2.22
Rate for Payer: Health Management Network Commercial	$2.91
Rate for Payer: Kaiser Permanente Commercial	$3.08
Rate for Payer: MDX Hawaii PPO	$3.32

water for injection, sterile 10ml [HHSC]

Facility

$5.82

Service Code	NDC 00409488710
Hospital Charge Code	2500793
Hospital Revenue Code	250
Min. Negotiated Rate	$4.95
Max. Negotiated Rate	$5.65
Rate for Payer: Cash Price	$3.78
Rate for Payer: Health Management Network Commercial	$4.95
Rate for Payer: Kaiser Permanente Commercial	$5.24
Rate for Payer: MDX Hawaii PPO	$5.65

water for injection, sterile 10ml [HHSC]

Facility

$5.82

Service Code	NDC 00409488710
Hospital Charge Code	2500793
Hospital Revenue Code	250
Min. Negotiated Rate	$2.91
Max. Negotiated Rate	$5.65
Rate for Payer: AlohaCare Medicaid	$2.91
Rate for Payer: AlohaCare Medicare	$2.91
Rate for Payer: Cash Price	$3.78
Rate for Payer: Devoted Health Medicare	$3.20
Rate for Payer: Hawaii Medical Service Association Medicare	$2.91
Rate for Payer: Hawaii Western Management Group Commercial	$5.53
Rate for Payer: Health Management Network Commercial	$4.95
Rate for Payer: Humana Medicare	$2.91
Rate for Payer: Kaiser Permanente Commercial	$5.24
Rate for Payer: Kaiser Permanente Medicaid	$2.97
Rate for Payer: Kaiser Permanente Medicare	$2.91
Rate for Payer: MDX Hawaii PPO	$5.65
Rate for Payer: Ohana Health Plan Medicaid	$2.91
Rate for Payer: Ohana Health Plan Medicare	$2.91
Rate for Payer: UnitedHealthcare Medicaid	$3.49
Rate for Payer: UnitedHealthcare Medicare	$2.91
Rate for Payer: University Health Alliance Commercial	$4.24

water for injection, sterile 10ml [HHSC]

Facility

$23.29

Service Code	NDC 63323018510
Hospital Charge Code	2500793
Hospital Revenue Code	250
Min. Negotiated Rate	$11.64
Max. Negotiated Rate	$22.59
Rate for Payer: AlohaCare Medicaid	$11.64
Rate for Payer: AlohaCare Medicare	$11.64
Rate for Payer: Cash Price	$15.14
Rate for Payer: Devoted Health Medicare	$12.81
Rate for Payer: Hawaii Medical Service Association Medicare	$11.64
Rate for Payer: Hawaii Western Management Group Commercial	$22.13
Rate for Payer: Health Management Network Commercial	$19.80
Rate for Payer: Humana Medicare	$11.64
Rate for Payer: Kaiser Permanente Commercial	$20.96
Rate for Payer: Kaiser Permanente Medicaid	$11.88
Rate for Payer: Kaiser Permanente Medicare	$11.64
Rate for Payer: MDX Hawaii PPO	$22.59
Rate for Payer: Ohana Health Plan Medicaid	$11.64
Rate for Payer: Ohana Health Plan Medicare	$11.64
Rate for Payer: UnitedHealthcare Medicaid	$13.97
Rate for Payer: UnitedHealthcare Medicare	$11.64
Rate for Payer: University Health Alliance Commercial	$16.98

water for injection, sterile 10ml [HHSC]

Facility

$40.13

Service Code	NDC 00641614725
Hospital Charge Code	2500793
Hospital Revenue Code	250
Min. Negotiated Rate	$20.07
Max. Negotiated Rate	$38.93
Rate for Payer: AlohaCare Medicaid	$20.07
Rate for Payer: AlohaCare Medicare	$20.07
Rate for Payer: Cash Price	$26.08
Rate for Payer: Devoted Health Medicare	$22.07
Rate for Payer: Hawaii Medical Service Association Medicare	$20.07
Rate for Payer: Hawaii Western Management Group Commercial	$38.12
Rate for Payer: Health Management Network Commercial	$34.11
Rate for Payer: Humana Medicare	$20.07
Rate for Payer: Kaiser Permanente Commercial	$36.12
Rate for Payer: Kaiser Permanente Medicaid	$20.47
Rate for Payer: Kaiser Permanente Medicare	$20.07
Rate for Payer: MDX Hawaii PPO	$38.93
Rate for Payer: Ohana Health Plan Medicaid	$20.07
Rate for Payer: Ohana Health Plan Medicare	$20.07
Rate for Payer: UnitedHealthcare Medicaid	$24.08
Rate for Payer: UnitedHealthcare Medicare	$20.07
Rate for Payer: University Health Alliance Commercial	$29.25

water for injection, sterile 10ml [HHSC]

Facility

$20.82

Service Code	NDC 00641614710
Hospital Charge Code	2500793
Hospital Revenue Code	250
Min. Negotiated Rate	$10.41
Max. Negotiated Rate	$20.20
Rate for Payer: AlohaCare Medicaid	$10.41
Rate for Payer: AlohaCare Medicare	$10.41
Rate for Payer: Cash Price	$13.53
Rate for Payer: Devoted Health Medicare	$11.45
Rate for Payer: Hawaii Medical Service Association Medicare	$10.41
Rate for Payer: Hawaii Western Management Group Commercial	$19.78
Rate for Payer: Health Management Network Commercial	$17.70
Rate for Payer: Humana Medicare	$10.41
Rate for Payer: Kaiser Permanente Commercial	$18.74
Rate for Payer: Kaiser Permanente Medicaid	$10.62
Rate for Payer: Kaiser Permanente Medicare	$10.41
Rate for Payer: MDX Hawaii PPO	$20.20
Rate for Payer: Ohana Health Plan Medicaid	$10.41
Rate for Payer: Ohana Health Plan Medicare	$10.41
Rate for Payer: UnitedHealthcare Medicaid	$12.49
Rate for Payer: UnitedHealthcare Medicare	$10.41
Rate for Payer: University Health Alliance Commercial	$15.18

water for injection, sterile 10ml [HHSC]

Facility

$7.62

Service Code	NDC 00409002410
Hospital Charge Code	2500793
Hospital Revenue Code	250
Min. Negotiated Rate	$3.81
Max. Negotiated Rate	$7.39
Rate for Payer: AlohaCare Medicaid	$3.81
Rate for Payer: AlohaCare Medicare	$3.81
Rate for Payer: Cash Price	$4.95
Rate for Payer: Devoted Health Medicare	$4.19
Rate for Payer: Hawaii Medical Service Association Medicare	$3.81
Rate for Payer: Hawaii Western Management Group Commercial	$7.24
Rate for Payer: Health Management Network Commercial	$6.48
Rate for Payer: Humana Medicare	$3.81
Rate for Payer: Kaiser Permanente Commercial	$6.86
Rate for Payer: Kaiser Permanente Medicaid	$3.89
Rate for Payer: Kaiser Permanente Medicare	$3.81
Rate for Payer: MDX Hawaii PPO	$7.39
Rate for Payer: Ohana Health Plan Medicaid	$3.81
Rate for Payer: Ohana Health Plan Medicare	$3.81
Rate for Payer: UnitedHealthcare Medicaid	$4.57
Rate for Payer: UnitedHealthcare Medicare	$3.81
Rate for Payer: University Health Alliance Commercial	$5.55

water for injection, sterile 10ml [HHSC]

Facility

$7.62

Service Code	NDC 00409002410
Hospital Charge Code	2500793
Hospital Revenue Code	250
Min. Negotiated Rate	$6.48
Max. Negotiated Rate	$7.39
Rate for Payer: Cash Price	$4.95
Rate for Payer: Health Management Network Commercial	$6.48
Rate for Payer: Kaiser Permanente Commercial	$6.86
Rate for Payer: MDX Hawaii PPO	$7.39

water for injection, sterile 10ml [HHSC]

Facility

$23.29

Service Code	NDC 63323018510
Hospital Charge Code	2500793
Hospital Revenue Code	250
Min. Negotiated Rate	$19.80
Max. Negotiated Rate	$22.59
Rate for Payer: Cash Price	$15.14
Rate for Payer: Health Management Network Commercial	$19.80
Rate for Payer: Kaiser Permanente Commercial	$20.96
Rate for Payer: MDX Hawaii PPO	$22.59

water for injection, sterile 10ml [HHSC]

Facility

$40.13

Service Code	NDC 00641614725
Hospital Charge Code	2500793
Hospital Revenue Code	250
Min. Negotiated Rate	$34.11
Max. Negotiated Rate	$38.93
Rate for Payer: Cash Price	$26.08
Rate for Payer: Health Management Network Commercial	$34.11
Rate for Payer: Kaiser Permanente Commercial	$36.12
Rate for Payer: MDX Hawaii PPO	$38.93

water for injection, sterile 10ml [HHSC]

Facility

$20.82

Service Code	NDC 00641614710
Hospital Charge Code	2500793
Hospital Revenue Code	250
Min. Negotiated Rate	$17.70
Max. Negotiated Rate	$20.20
Rate for Payer: Cash Price	$13.53
Rate for Payer: Health Management Network Commercial	$17.70
Rate for Payer: Kaiser Permanente Commercial	$18.74
Rate for Payer: MDX Hawaii PPO	$20.20

WBC Count FSI

Facility

$37.00

Service Code	HCPCS 85048
Hospital Charge Code	8128161
Hospital Revenue Code	305
Min. Negotiated Rate	$31.45
Max. Negotiated Rate	$35.89
Rate for Payer: Cash Price	$24.05
Rate for Payer: Health Management Network Commercial	$31.45
Rate for Payer: Kaiser Permanente Commercial	$33.30
Rate for Payer: MDX Hawaii PPO	$35.89

WBC Count FSI

Facility

$37.00

Service Code	HCPCS 85048
Hospital Charge Code	8128161
Hospital Revenue Code	305
Min. Negotiated Rate	$2.54
Max. Negotiated Rate	$35.89
Rate for Payer: Kaiser Permanente Medicaid	$18.87
Rate for Payer: AlohaCare Medicaid	$18.50
Rate for Payer: AlohaCare Medicare	$18.50
Rate for Payer: Cash Price	$24.05
Rate for Payer: Cash Price	$24.05
Rate for Payer: Devoted Health Medicare	$20.35
Rate for Payer: Hawaii Medical Service Association ABD	$3.52
Rate for Payer: Hawaii Medical Service Association Commercial	$3.17
Rate for Payer: Hawaii Medical Service Association Medicare	$18.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$3.70
Rate for Payer: Hawaii Western Management Group Commercial	$2.54
Rate for Payer: Health Management Network Commercial	$31.45
Rate for Payer: Humana Medicare	$18.50
Rate for Payer: Kaiser Permanente Commercial	$33.30
Rate for Payer: Kaiser Permanente Medicare	$18.50
Rate for Payer: MDX Hawaii PPO	$35.89
Rate for Payer: Ohana Health Plan Medicaid	$18.50
Rate for Payer: Ohana Health Plan Medicare	$18.50
Rate for Payer: UnitedHealthcare Medicaid	$3.52
Rate for Payer: UnitedHealthcare Medicare	$18.50
Rate for Payer: University Health Alliance Commercial	$6.57

Wet Prep FSI

Facility

$69.00

Service Code	HCPCS Q0111
Hospital Charge Code	8128163
Hospital Revenue Code	306
Min. Negotiated Rate	$5.90
Max. Negotiated Rate	$66.93
Rate for Payer: AlohaCare Medicaid	$34.50
Rate for Payer: AlohaCare Medicare	$34.50
Rate for Payer: Cash Price	$44.85
Rate for Payer: Cash Price	$44.85
Rate for Payer: Devoted Health Medicare	$37.95
Rate for Payer: Hawaii Medical Service Association Commercial	$23.18
Rate for Payer: Hawaii Medical Service Association Medicare	$34.50
Rate for Payer: Hawaii Western Management Group Commercial	$65.55
Rate for Payer: Health Management Network Commercial	$58.65
Rate for Payer: Humana Medicare	$34.50
Rate for Payer: Kaiser Permanente Commercial	$62.10
Rate for Payer: Kaiser Permanente Medicaid	$35.19
Rate for Payer: Kaiser Permanente Medicare	$34.50
Rate for Payer: MDX Hawaii PPO	$66.93
Rate for Payer: Ohana Health Plan Medicaid	$34.50
Rate for Payer: Ohana Health Plan Medicare	$34.50
Rate for Payer: UnitedHealthcare Medicaid	$5.90
Rate for Payer: UnitedHealthcare Medicare	$34.50
Rate for Payer: University Health Alliance Commercial	$38.64

Wet Prep FSI

Facility

$69.00

Service Code	HCPCS Q0111
Hospital Charge Code	8128163
Hospital Revenue Code	306
Min. Negotiated Rate	$58.65
Max. Negotiated Rate	$66.93
Rate for Payer: Cash Price	$44.85
Rate for Payer: Health Management Network Commercial	$58.65
Rate for Payer: Kaiser Permanente Commercial	$62.10
Rate for Payer: MDX Hawaii PPO	$66.93

Wheelchair Charge

Facility

$257.00

Service Code	HCPCS 97542 GO
Hospital Charge Code	8123841
Hospital Revenue Code	430
Min. Negotiated Rate	$218.45
Max. Negotiated Rate	$249.29
Rate for Payer: Cash Price	$167.05
Rate for Payer: Health Management Network Commercial	$218.45
Rate for Payer: Kaiser Permanente Commercial	$231.30
Rate for Payer: MDX Hawaii PPO	$249.29

Know your out-of-pocket cost for care.

All Charges