Samuel Mahelona Memorial Hospital

All Charges

Charge

Type

Setting

Price

Wheelchair Charge

Facility

$257.00

Service Code	HCPCS 97542 GO
Hospital Charge Code	8123841
Hospital Revenue Code	430
Min. Negotiated Rate	$17.54
Max. Negotiated Rate	$249.29
Rate for Payer: AlohaCare Medicaid	$128.50
Rate for Payer: AlohaCare Medicare	$128.50
Rate for Payer: Cash Price	$167.05
Rate for Payer: Cash Price	$167.05
Rate for Payer: Devoted Health Medicare	$141.35
Rate for Payer: Hawaii Medical Service Association Medicare	$128.50
Rate for Payer: Hawaii Western Management Group Commercial	$244.15
Rate for Payer: Health Management Network Commercial	$218.45
Rate for Payer: Humana Medicare	$128.50
Rate for Payer: Kaiser Permanente Commercial	$231.30
Rate for Payer: Kaiser Permanente Medicaid	$131.07
Rate for Payer: Kaiser Permanente Medicare	$128.50
Rate for Payer: MDX Hawaii PPO	$249.29
Rate for Payer: Ohana Health Plan Medicaid	$128.50
Rate for Payer: Ohana Health Plan Medicare	$128.50
Rate for Payer: UnitedHealthcare Medicaid	$17.54
Rate for Payer: UnitedHealthcare Medicare	$128.50
Rate for Payer: University Health Alliance Commercial	$143.92

Wheelchair Management Charges

Facility

$257.00

Service Code	HCPCS 97542 GO
Hospital Charge Code	8111696
Hospital Revenue Code	420
Min. Negotiated Rate	$17.54
Max. Negotiated Rate	$249.29
Rate for Payer: AlohaCare Medicaid	$128.50
Rate for Payer: AlohaCare Medicare	$128.50
Rate for Payer: Cash Price	$167.05
Rate for Payer: Cash Price	$167.05
Rate for Payer: Devoted Health Medicare	$141.35
Rate for Payer: Hawaii Medical Service Association Medicare	$128.50
Rate for Payer: Hawaii Western Management Group Commercial	$244.15
Rate for Payer: Health Management Network Commercial	$218.45
Rate for Payer: Humana Medicare	$128.50
Rate for Payer: Kaiser Permanente Commercial	$231.30
Rate for Payer: Kaiser Permanente Medicaid	$131.07
Rate for Payer: Kaiser Permanente Medicare	$128.50
Rate for Payer: MDX Hawaii PPO	$249.29
Rate for Payer: Ohana Health Plan Medicaid	$128.50
Rate for Payer: Ohana Health Plan Medicare	$128.50
Rate for Payer: UnitedHealthcare Medicaid	$17.54
Rate for Payer: UnitedHealthcare Medicare	$128.50
Rate for Payer: University Health Alliance Commercial	$143.92

Wheelchair Management Charges

Facility

$257.00

Service Code	HCPCS 97542 GO
Hospital Charge Code	8111696
Hospital Revenue Code	420
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

Whirlpool Extremity Charge

Facility

$126.00

Service Code	HCPCS 97022 GO
Hospital Charge Code	8123848
Hospital Revenue Code	430
Min. Negotiated Rate	$11.89
Max. Negotiated Rate	$122.22
Rate for Payer: AlohaCare Medicaid	$63.00
Rate for Payer: AlohaCare Medicare	$63.00
Rate for Payer: Cash Price	$81.90
Rate for Payer: Cash Price	$81.90
Rate for Payer: Devoted Health Medicare	$69.30
Rate for Payer: Hawaii Medical Service Association Medicare	$63.00
Rate for Payer: Hawaii Western Management Group Commercial	$119.70
Rate for Payer: Health Management Network Commercial	$107.10
Rate for Payer: Humana Medicare	$63.00
Rate for Payer: Kaiser Permanente Commercial	$113.40
Rate for Payer: Kaiser Permanente Medicaid	$64.26
Rate for Payer: Kaiser Permanente Medicare	$63.00
Rate for Payer: MDX Hawaii PPO	$122.22
Rate for Payer: Ohana Health Plan Medicaid	$63.00
Rate for Payer: Ohana Health Plan Medicare	$63.00
Rate for Payer: UnitedHealthcare Medicaid	$11.89
Rate for Payer: UnitedHealthcare Medicare	$63.00
Rate for Payer: University Health Alliance Commercial	$70.56

Whirlpool Extremity Charge

Facility

$126.00

Service Code	HCPCS 97022 GO
Hospital Charge Code	8123848
Hospital Revenue Code	430
Min. Negotiated Rate	$107.10
Max. Negotiated Rate	$122.22
Rate for Payer: Cash Price	$81.90
Rate for Payer: Health Management Network Commercial	$107.10
Rate for Payer: Kaiser Permanente Commercial	$113.40
Rate for Payer: MDX Hawaii PPO	$122.22

Whirlpool Full Body Charge

Facility

$126.00

Service Code	HCPCS 97022 GP
Hospital Charge Code	8111729
Hospital Revenue Code	420
Min. Negotiated Rate	$107.10
Max. Negotiated Rate	$122.22
Rate for Payer: Cash Price	$81.90
Rate for Payer: Health Management Network Commercial	$107.10
Rate for Payer: Kaiser Permanente Commercial	$113.40
Rate for Payer: MDX Hawaii PPO	$122.22

Whirlpool Full Body Charge

Facility

$126.00

Service Code	HCPCS 97022 GP
Hospital Charge Code	8111729
Hospital Revenue Code	420
Min. Negotiated Rate	$11.89
Max. Negotiated Rate	$122.22
Rate for Payer: AlohaCare Medicaid	$63.00
Rate for Payer: AlohaCare Medicare	$63.00
Rate for Payer: Cash Price	$81.90
Rate for Payer: Cash Price	$81.90
Rate for Payer: Devoted Health Medicare	$69.30
Rate for Payer: Hawaii Medical Service Association Medicare	$63.00
Rate for Payer: Hawaii Western Management Group Commercial	$119.70
Rate for Payer: Health Management Network Commercial	$107.10
Rate for Payer: Humana Medicare	$63.00
Rate for Payer: Kaiser Permanente Commercial	$113.40
Rate for Payer: Kaiser Permanente Medicaid	$64.26
Rate for Payer: Kaiser Permanente Medicare	$63.00
Rate for Payer: MDX Hawaii PPO	$122.22
Rate for Payer: Ohana Health Plan Medicaid	$63.00
Rate for Payer: Ohana Health Plan Medicare	$63.00
Rate for Payer: UnitedHealthcare Medicaid	$11.89
Rate for Payer: UnitedHealthcare Medicare	$63.00
Rate for Payer: University Health Alliance Commercial	$70.56

WIDE T-PLATE, 2.0MM, 10 HOLE

Facility

$2,505.00

Service Code	HCPCS C1713
Hospital Charge Code	13006748
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

WIDE T-PLATE, 2.0MM, 10 HOLE

Facility

$2,505.00

Service Code	HCPCS C1713
Hospital Charge Code	13006748
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

WIDE T-PLATE, 2.0MM, 6 HOLE

Facility

$1,462.00

Service Code	HCPCS C1713
Hospital Charge Code	13006749
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

WIDE T-PLATE, 2.0MM, 6 HOLE

Facility

$1,462.00

Service Code	HCPCS C1713
Hospital Charge Code	13006749
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

WIDE T-PLATE, 2.4MM, 10 HOLE

Facility

$2,505.00

Service Code	HCPCS C1713
Hospital Charge Code	13006752
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

WIDE T-PLATE, 2.4MM, 10 HOLE

Facility

$2,505.00

Service Code	HCPCS C1713
Hospital Charge Code	13006752
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

WIDE T-PLATE, 2.4MM, 6 HOLE

Facility

$1,462.00

Service Code	HCPCS C1713
Hospital Charge Code	13006750
Hospital Revenue Code	278
Min. Negotiated Rate	$818.72
Max. Negotiated Rate	$1,418.14
Rate for Payer: MDX Hawaii PPO	$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: University Health Alliance Commercial	$818.72

WIDE T-PLATE, 2.4MM, 6 HOLE

Facility

$1,462.00

Service Code	HCPCS C1713
Hospital Charge Code	13006750
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

WIDE T-PLATE, 2.7MM, 10 HOLE

Facility

$2,510.00

Service Code	HCPCS C1713
Hospital Charge Code	13006751
Hospital Revenue Code	278
Min. Negotiated Rate	$1,255.00
Max. Negotiated Rate	$2,434.70
Rate for Payer: AlohaCare Medicaid	$1,255.00
Rate for Payer: AlohaCare Medicare	$1,255.00
Rate for Payer: Cash Price	$1,631.50
Rate for Payer: Devoted Health Medicare	$1,380.50
Rate for Payer: Hawaii Medical Service Association Medicare	$1,255.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,757.00
Rate for Payer: Health Management Network Commercial	$2,133.50
Rate for Payer: Humana Medicare	$1,255.00
Rate for Payer: Kaiser Permanente Commercial	$2,259.00
Rate for Payer: Kaiser Permanente Medicaid	$1,280.10
Rate for Payer: Kaiser Permanente Medicare	$1,255.00
Rate for Payer: MDX Hawaii PPO	$2,434.70
Rate for Payer: Ohana Health Plan Medicaid	$1,255.00
Rate for Payer: Ohana Health Plan Medicare	$1,255.00
Rate for Payer: UnitedHealthcare Medicare	$1,255.00
Rate for Payer: University Health Alliance Commercial	$1,405.60

WIDE T-PLATE, 2.7MM, 10 HOLE

Facility

$2,510.00

Service Code	HCPCS C1713
Hospital Charge Code	13006751
Hospital Revenue Code	278
Min. Negotiated Rate	$1,405.60
Max. Negotiated Rate	$2,434.70
Rate for Payer: Cash Price	$1,631.50
Rate for Payer: Hawaii Western Management Group Commercial	$1,757.00
Rate for Payer: Health Management Network Commercial	$2,133.50
Rate for Payer: Kaiser Permanente Commercial	$2,259.00
Rate for Payer: MDX Hawaii PPO	$2,434.70
Rate for Payer: University Health Alliance Commercial	$1,405.60

WIDE T-PLATE, 2.7MM, 20 HOLE

Facility

$3,140.00

Service Code	HCPCS C1713
Hospital Charge Code	13006753
Hospital Revenue Code	278
Min. Negotiated Rate	$1,758.40
Max. Negotiated Rate	$3,045.80
Rate for Payer: Cash Price	$2,041.00
Rate for Payer: Hawaii Western Management Group Commercial	$2,198.00
Rate for Payer: Health Management Network Commercial	$2,669.00
Rate for Payer: Kaiser Permanente Commercial	$2,826.00
Rate for Payer: MDX Hawaii PPO	$3,045.80
Rate for Payer: University Health Alliance Commercial	$1,758.40

WIDE T-PLATE, 2.7MM, 20 HOLE

Facility

$3,140.00

Service Code	HCPCS C1713
Hospital Charge Code	13006753
Hospital Revenue Code	278
Min. Negotiated Rate	$1,570.00
Max. Negotiated Rate	$3,045.80
Rate for Payer: AlohaCare Medicaid	$1,570.00
Rate for Payer: AlohaCare Medicare	$1,570.00
Rate for Payer: Cash Price	$2,041.00
Rate for Payer: Devoted Health Medicare	$1,727.00
Rate for Payer: Hawaii Medical Service Association Medicare	$1,570.00
Rate for Payer: Hawaii Western Management Group Commercial	$2,198.00
Rate for Payer: Health Management Network Commercial	$2,669.00
Rate for Payer: Humana Medicare	$1,570.00
Rate for Payer: Kaiser Permanente Commercial	$2,826.00
Rate for Payer: Kaiser Permanente Medicaid	$1,601.40
Rate for Payer: Kaiser Permanente Medicare	$1,570.00
Rate for Payer: MDX Hawaii PPO	$3,045.80
Rate for Payer: Ohana Health Plan Medicaid	$1,570.00
Rate for Payer: Ohana Health Plan Medicare	$1,570.00
Rate for Payer: UnitedHealthcare Medicare	$1,570.00
Rate for Payer: University Health Alliance Commercial	$1,758.40

WIDE T-PLATE, 2.7MM, 6 HOLE

Facility

$1,883.00

Service Code	HCPCS C1713
Hospital Charge Code	13006754
Hospital Revenue Code	278
Min. Negotiated Rate	$941.50
Max. Negotiated Rate	$1,826.51
Rate for Payer: AlohaCare Medicaid	$941.50
Rate for Payer: AlohaCare Medicare	$941.50
Rate for Payer: Cash Price	$1,223.95
Rate for Payer: Devoted Health Medicare	$1,035.65
Rate for Payer: Hawaii Medical Service Association Medicare	$941.50
Rate for Payer: Hawaii Western Management Group Commercial	$1,318.10
Rate for Payer: Health Management Network Commercial	$1,600.55
Rate for Payer: Humana Medicare	$941.50
Rate for Payer: Kaiser Permanente Commercial	$1,694.70
Rate for Payer: Kaiser Permanente Medicaid	$960.33
Rate for Payer: Kaiser Permanente Medicare	$941.50
Rate for Payer: MDX Hawaii PPO	$1,826.51
Rate for Payer: Ohana Health Plan Medicaid	$941.50
Rate for Payer: Ohana Health Plan Medicare	$941.50
Rate for Payer: UnitedHealthcare Medicare	$941.50
Rate for Payer: University Health Alliance Commercial	$1,054.48

WIDE T-PLATE, 2.7MM, 6 HOLE

Facility

$1,883.00

Service Code	HCPCS C1713
Hospital Charge Code	13006754
Hospital Revenue Code	278
Min. Negotiated Rate	$1,054.48
Max. Negotiated Rate	$1,826.51
Rate for Payer: Cash Price	$1,223.95
Rate for Payer: Hawaii Western Management Group Commercial	$1,318.10
Rate for Payer: Health Management Network Commercial	$1,600.55
Rate for Payer: Kaiser Permanente Commercial	$1,694.70
Rate for Payer: MDX Hawaii PPO	$1,826.51
Rate for Payer: University Health Alliance Commercial	$1,054.48

Work Reconditioning Additional Hours Charge

Facility

$102.00

Service Code	HCPCS 97546 GO
Hospital Charge Code	8123851
Hospital Revenue Code	430
Min. Negotiated Rate	$86.70
Max. Negotiated Rate	$98.94
Rate for Payer: Cash Price	$66.30
Rate for Payer: Health Management Network Commercial	$86.70
Rate for Payer: Kaiser Permanente Commercial	$91.80
Rate for Payer: MDX Hawaii PPO	$98.94

Work Reconditioning Additional Hours Charge

Facility

$102.00

Service Code	HCPCS 97546 GO
Hospital Charge Code	8123851
Hospital Revenue Code	430
Min. Negotiated Rate	$51.00
Max. Negotiated Rate	$98.94
Rate for Payer: AlohaCare Medicaid	$51.00
Rate for Payer: AlohaCare Medicare	$51.00
Rate for Payer: Cash Price	$66.30
Rate for Payer: Devoted Health Medicare	$56.10
Rate for Payer: Hawaii Medical Service Association Medicare	$51.00
Rate for Payer: Hawaii Western Management Group Commercial	$96.90
Rate for Payer: Health Management Network Commercial	$86.70
Rate for Payer: Humana Medicare	$51.00
Rate for Payer: Kaiser Permanente Commercial	$91.80
Rate for Payer: Kaiser Permanente Medicaid	$52.02
Rate for Payer: Kaiser Permanente Medicare	$51.00
Rate for Payer: MDX Hawaii PPO	$98.94
Rate for Payer: Ohana Health Plan Medicaid	$51.00
Rate for Payer: Ohana Health Plan Medicare	$51.00
Rate for Payer: UnitedHealthcare Medicare	$51.00
Rate for Payer: University Health Alliance Commercial	$57.12

Work Reconditioning Charge

Facility

$307.00

Service Code	HCPCS 97545 GO
Hospital Charge Code	8123850
Hospital Revenue Code	430
Min. Negotiated Rate	$260.95
Max. Negotiated Rate	$297.79
Rate for Payer: Cash Price	$199.55
Rate for Payer: Health Management Network Commercial	$260.95
Rate for Payer: Kaiser Permanente Commercial	$276.30
Rate for Payer: MDX Hawaii PPO	$297.79

Work Reconditioning Charge

Facility

$307.00

Service Code	HCPCS 97545 GO
Hospital Charge Code	8123850
Hospital Revenue Code	430
Min. Negotiated Rate	$153.50
Max. Negotiated Rate	$297.79
Rate for Payer: AlohaCare Medicaid	$153.50
Rate for Payer: AlohaCare Medicare	$153.50
Rate for Payer: Cash Price	$199.55
Rate for Payer: Devoted Health Medicare	$168.85
Rate for Payer: Hawaii Medical Service Association Medicare	$153.50
Rate for Payer: Hawaii Western Management Group Commercial	$291.65
Rate for Payer: Health Management Network Commercial	$260.95
Rate for Payer: Humana Medicare	$153.50
Rate for Payer: Kaiser Permanente Commercial	$276.30
Rate for Payer: Kaiser Permanente Medicaid	$156.57
Rate for Payer: Kaiser Permanente Medicare	$153.50
Rate for Payer: MDX Hawaii PPO	$297.79
Rate for Payer: Ohana Health Plan Medicaid	$153.50
Rate for Payer: Ohana Health Plan Medicare	$153.50
Rate for Payer: UnitedHealthcare Medicare	$153.50
Rate for Payer: University Health Alliance Commercial	$171.92

Know your out-of-pocket cost for care.

All Charges