Samuel Mahelona Memorial Hospital

All Charges

Charge

Type

Setting

Price

PADDING CAST SPECIALIST COTTON/ RAYON LIMB 3X4YD WH LF 12RL/CA, 6 BG/CA

Facility

$6.00

Hospital Charge Code	12954852
Hospital Revenue Code	270
Min. Negotiated Rate	$5.10
Max. Negotiated Rate	$5.82
Rate for Payer: Cash Price	$3.90
Rate for Payer: Health Management Network Commercial	$5.10
Rate for Payer: Kaiser Permanente Commercial	$5.40
Rate for Payer: MDX Hawaii PPO	$5.82

PADDING CAST SPECIALIST COTTON/ RAYON LIMB 4X4YD WH LF 12RL/CA, 6 BG/CA

Facility

$7.00

Hospital Charge Code	12954853
Hospital Revenue Code	270
Min. Negotiated Rate	$3.50
Max. Negotiated Rate	$6.79
Rate for Payer: AlohaCare Medicaid	$3.50
Rate for Payer: AlohaCare Medicare	$3.50
Rate for Payer: Cash Price	$4.55
Rate for Payer: Devoted Health Medicare	$3.85
Rate for Payer: Hawaii Medical Service Association Medicare	$3.50
Rate for Payer: Hawaii Western Management Group Commercial	$6.65
Rate for Payer: Health Management Network Commercial	$5.95
Rate for Payer: Humana Medicare	$3.50
Rate for Payer: Kaiser Permanente Commercial	$6.30
Rate for Payer: Kaiser Permanente Medicaid	$3.57
Rate for Payer: Kaiser Permanente Medicare	$3.50
Rate for Payer: MDX Hawaii PPO	$6.79
Rate for Payer: Ohana Health Plan Medicaid	$3.50
Rate for Payer: Ohana Health Plan Medicare	$3.50
Rate for Payer: UnitedHealthcare Medicare	$3.50
Rate for Payer: University Health Alliance Commercial	$5.10

PADDING CAST SPECIALIST COTTON/ RAYON LIMB 4X4YD WH LF 12RL/CA, 6 BG/CA

Facility

$7.00

Hospital Charge Code	12954853
Hospital Revenue Code	270
Min. Negotiated Rate	$5.95
Max. Negotiated Rate	$6.79
Rate for Payer: Cash Price	$4.55
Rate for Payer: Health Management Network Commercial	$5.95
Rate for Payer: Kaiser Permanente Commercial	$6.30
Rate for Payer: MDX Hawaii PPO	$6.79

PADDING CAST SPECIALIST COTTON/ RAYON LIMB 4X4YD WH LF 12RL/CA, 6 BG/CA

Professional

Both

$7.00

Hospital Charge Code	12954853
Hospital Revenue Code	270
Min. Negotiated Rate	$5.95
Max. Negotiated Rate	$5.95
Rate for Payer: Cash Price	$4.55
Rate for Payer: Health Management Network Commercial	$5.95

PAIN AND SPINE:PAINTEQ LINQ SACROILIAC JOINT FUSION SYSTEM - UNILATERAL

Facility

$25,000.00

Hospital Charge Code	11221964
Hospital Revenue Code	278
Min. Negotiated Rate	$14,000.00
Max. Negotiated Rate	$24,250.00
Rate for Payer: Cash Price	$16,250.00
Rate for Payer: Hawaii Western Management Group Commercial	$17,500.00
Rate for Payer: Health Management Network Commercial	$21,250.00
Rate for Payer: Kaiser Permanente Commercial	$22,500.00
Rate for Payer: MDX Hawaii PPO	$24,250.00
Rate for Payer: University Health Alliance Commercial	$14,000.00

PAIN AND SPINE:PAINTEQ LINQ SACROILIAC JOINT FUSION SYSTEM - UNILATERAL

Facility

$25,000.00

Hospital Charge Code	11221964
Hospital Revenue Code	278
Min. Negotiated Rate	$12,500.00
Max. Negotiated Rate	$24,250.00
Rate for Payer: AlohaCare Medicaid	$12,500.00
Rate for Payer: AlohaCare Medicare	$12,500.00
Rate for Payer: Cash Price	$16,250.00
Rate for Payer: Devoted Health Medicare	$13,750.00
Rate for Payer: Hawaii Medical Service Association Medicare	$12,500.00
Rate for Payer: Hawaii Western Management Group Commercial	$17,500.00
Rate for Payer: Health Management Network Commercial	$21,250.00
Rate for Payer: Humana Medicare	$12,500.00
Rate for Payer: Kaiser Permanente Commercial	$22,500.00
Rate for Payer: Kaiser Permanente Medicaid	$12,750.00
Rate for Payer: Kaiser Permanente Medicare	$12,500.00
Rate for Payer: MDX Hawaii PPO	$24,250.00
Rate for Payer: Ohana Health Plan Medicaid	$12,500.00
Rate for Payer: Ohana Health Plan Medicare	$12,500.00
Rate for Payer: UnitedHealthcare Medicare	$12,500.00
Rate for Payer: University Health Alliance Commercial	$14,000.00

Pain Management Profile w/ Oxycodone and Rfx Confirm FSI

Facility

$1,384.00

Service Code	HCPCS 80307
Hospital Charge Code	8729403
Hospital Revenue Code	301
Min. Negotiated Rate	$47.89
Max. Negotiated Rate	$1,342.48
Rate for Payer: AlohaCare Medicaid	$692.00
Rate for Payer: AlohaCare Medicare	$692.00
Rate for Payer: Cash Price	$899.60
Rate for Payer: Cash Price	$899.60
Rate for Payer: Devoted Health Medicare	$761.20
Rate for Payer: Hawaii Medical Service Association ABD	$59.38
Rate for Payer: Hawaii Medical Service Association Commercial	$77.67
Rate for Payer: Hawaii Medical Service Association Medicare	$692.00
Rate for Payer: Hawaii Medical Service Association Non-ABD	$59.38
Rate for Payer: Hawaii Western Management Group Commercial	$62.14
Rate for Payer: Health Management Network Commercial	$1,176.40
Rate for Payer: Humana Medicare	$692.00
Rate for Payer: Kaiser Permanente Commercial	$1,245.60
Rate for Payer: Kaiser Permanente Medicaid	$705.84
Rate for Payer: Kaiser Permanente Medicare	$692.00
Rate for Payer: MDX Hawaii PPO	$1,342.48
Rate for Payer: Ohana Health Plan Medicaid	$692.00
Rate for Payer: Ohana Health Plan Medicare	$692.00
Rate for Payer: UnitedHealthcare Medicaid	$47.89
Rate for Payer: UnitedHealthcare Medicare	$692.00
Rate for Payer: University Health Alliance Commercial	$147.65

Pain Management Profile w/ Oxycodone and Rfx Confirm FSI

Facility

$1,384.00

Service Code	HCPCS 80307
Hospital Charge Code	8729403
Hospital Revenue Code	301
Min. Negotiated Rate	$1,176.40
Max. Negotiated Rate	$1,342.48
Rate for Payer: Cash Price	$899.60
Rate for Payer: Health Management Network Commercial	$1,176.40
Rate for Payer: Kaiser Permanente Commercial	$1,245.60
Rate for Payer: MDX Hawaii PPO	$1,342.48

Pain Management Profile w/ Oxycodone FSI

Facility

$1,384.00

Service Code	HCPCS 80307
Hospital Charge Code	8728935
Hospital Revenue Code	301
Min. Negotiated Rate	$1,176.40
Max. Negotiated Rate	$1,342.48
Rate for Payer: Cash Price	$899.60
Rate for Payer: Health Management Network Commercial	$1,176.40
Rate for Payer: Kaiser Permanente Commercial	$1,245.60
Rate for Payer: MDX Hawaii PPO	$1,342.48

Pain Management Profile w/ Oxycodone FSI

Facility

$1,384.00

Service Code	HCPCS 80307
Hospital Charge Code	8728935
Hospital Revenue Code	301
Min. Negotiated Rate	$47.89
Max. Negotiated Rate	$1,342.48
Rate for Payer: AlohaCare Medicaid	$692.00
Rate for Payer: AlohaCare Medicare	$692.00
Rate for Payer: Cash Price	$899.60
Rate for Payer: Cash Price	$899.60
Rate for Payer: Devoted Health Medicare	$761.20
Rate for Payer: Hawaii Medical Service Association ABD	$59.38
Rate for Payer: Hawaii Medical Service Association Commercial	$77.67
Rate for Payer: Hawaii Medical Service Association Medicare	$692.00
Rate for Payer: Hawaii Medical Service Association Non-ABD	$59.38
Rate for Payer: Hawaii Western Management Group Commercial	$62.14
Rate for Payer: Health Management Network Commercial	$1,176.40
Rate for Payer: Humana Medicare	$692.00
Rate for Payer: Kaiser Permanente Commercial	$1,245.60
Rate for Payer: Kaiser Permanente Medicaid	$705.84
Rate for Payer: Kaiser Permanente Medicare	$692.00
Rate for Payer: MDX Hawaii PPO	$1,342.48
Rate for Payer: Ohana Health Plan Medicaid	$692.00
Rate for Payer: Ohana Health Plan Medicare	$692.00
Rate for Payer: UnitedHealthcare Medicaid	$47.89
Rate for Payer: UnitedHealthcare Medicare	$692.00
Rate for Payer: University Health Alliance Commercial	$147.65

Pain Mgmt Profile w/ Oxycodone and Alcohol FSI

Facility

$1,384.00

Service Code	HCPCS 80307
Hospital Charge Code	8729547
Hospital Revenue Code	301
Min. Negotiated Rate	$47.89
Max. Negotiated Rate	$1,342.48
Rate for Payer: AlohaCare Medicaid	$692.00
Rate for Payer: AlohaCare Medicare	$692.00
Rate for Payer: Cash Price	$899.60
Rate for Payer: Cash Price	$899.60
Rate for Payer: Devoted Health Medicare	$761.20
Rate for Payer: Hawaii Medical Service Association ABD	$59.38
Rate for Payer: Hawaii Medical Service Association Commercial	$77.67
Rate for Payer: Hawaii Medical Service Association Medicare	$692.00
Rate for Payer: Hawaii Medical Service Association Non-ABD	$59.38
Rate for Payer: Hawaii Western Management Group Commercial	$62.14
Rate for Payer: Health Management Network Commercial	$1,176.40
Rate for Payer: Humana Medicare	$692.00
Rate for Payer: Kaiser Permanente Commercial	$1,245.60
Rate for Payer: Kaiser Permanente Medicaid	$705.84
Rate for Payer: Kaiser Permanente Medicare	$692.00
Rate for Payer: MDX Hawaii PPO	$1,342.48
Rate for Payer: Ohana Health Plan Medicaid	$692.00
Rate for Payer: Ohana Health Plan Medicare	$692.00
Rate for Payer: UnitedHealthcare Medicaid	$47.89
Rate for Payer: UnitedHealthcare Medicare	$692.00
Rate for Payer: University Health Alliance Commercial	$147.65

Pain Mgmt Profile w/ Oxycodone and Alcohol FSI

Facility

$1,384.00

Service Code	HCPCS 80307
Hospital Charge Code	8729547
Hospital Revenue Code	301
Min. Negotiated Rate	$1,176.40
Max. Negotiated Rate	$1,342.48
Rate for Payer: Cash Price	$899.60
Rate for Payer: Health Management Network Commercial	$1,176.40
Rate for Payer: Kaiser Permanente Commercial	$1,245.60
Rate for Payer: MDX Hawaii PPO	$1,342.48

Pain Mgmt Prof w/ Oxy, Alcohol and Rfx Confirm FSI

Facility

$1,384.00

Service Code	HCPCS 80307
Hospital Charge Code	8729548
Hospital Revenue Code	301
Min. Negotiated Rate	$1,176.40
Max. Negotiated Rate	$1,342.48
Rate for Payer: Cash Price	$899.60
Rate for Payer: Health Management Network Commercial	$1,176.40
Rate for Payer: Kaiser Permanente Commercial	$1,245.60
Rate for Payer: MDX Hawaii PPO	$1,342.48

Pain Mgmt Prof w/ Oxy, Alcohol and Rfx Confirm FSI

Facility

$1,384.00

Service Code	HCPCS 80307
Hospital Charge Code	8729548
Hospital Revenue Code	301
Min. Negotiated Rate	$47.89
Max. Negotiated Rate	$1,342.48
Rate for Payer: AlohaCare Medicaid	$692.00
Rate for Payer: AlohaCare Medicare	$692.00
Rate for Payer: Cash Price	$899.60
Rate for Payer: Cash Price	$899.60
Rate for Payer: Devoted Health Medicare	$761.20
Rate for Payer: Hawaii Medical Service Association ABD	$59.38
Rate for Payer: Hawaii Medical Service Association Commercial	$77.67
Rate for Payer: Hawaii Medical Service Association Medicare	$692.00
Rate for Payer: Hawaii Medical Service Association Non-ABD	$59.38
Rate for Payer: Hawaii Western Management Group Commercial	$62.14
Rate for Payer: Health Management Network Commercial	$1,176.40
Rate for Payer: Humana Medicare	$692.00
Rate for Payer: Kaiser Permanente Commercial	$1,245.60
Rate for Payer: Kaiser Permanente Medicaid	$705.84
Rate for Payer: Kaiser Permanente Medicare	$692.00
Rate for Payer: MDX Hawaii PPO	$1,342.48
Rate for Payer: Ohana Health Plan Medicaid	$692.00
Rate for Payer: Ohana Health Plan Medicare	$692.00
Rate for Payer: UnitedHealthcare Medicaid	$47.89
Rate for Payer: UnitedHealthcare Medicare	$692.00
Rate for Payer: University Health Alliance Commercial	$147.65

PAIN & SPINE: AutoPlex System Cement Mixer W/ Vertaplex HV Cement

Facility

$2,625.00

Hospital Charge Code	11525539
Hospital Revenue Code	272
Min. Negotiated Rate	$2,231.25
Max. Negotiated Rate	$2,546.25
Rate for Payer: Cash Price	$1,706.25
Rate for Payer: Health Management Network Commercial	$2,231.25
Rate for Payer: Kaiser Permanente Commercial	$2,362.50
Rate for Payer: MDX Hawaii PPO	$2,546.25

PAIN & SPINE: AutoPlex System Cement Mixer W/ Vertaplex HV Cement

Facility

$2,625.00

Hospital Charge Code	11525539
Hospital Revenue Code	272
Min. Negotiated Rate	$1,312.50
Max. Negotiated Rate	$2,546.25
Rate for Payer: AlohaCare Medicaid	$1,312.50
Rate for Payer: AlohaCare Medicare	$1,312.50
Rate for Payer: Cash Price	$1,706.25
Rate for Payer: Devoted Health Medicare	$1,443.75
Rate for Payer: Hawaii Medical Service Association Medicare	$1,312.50
Rate for Payer: Hawaii Western Management Group Commercial	$2,493.75
Rate for Payer: Health Management Network Commercial	$2,231.25
Rate for Payer: Humana Medicare	$1,312.50
Rate for Payer: Kaiser Permanente Commercial	$2,362.50
Rate for Payer: Kaiser Permanente Medicaid	$1,338.75
Rate for Payer: Kaiser Permanente Medicare	$1,312.50
Rate for Payer: MDX Hawaii PPO	$2,546.25
Rate for Payer: Ohana Health Plan Medicaid	$1,312.50
Rate for Payer: Ohana Health Plan Medicare	$1,312.50
Rate for Payer: UnitedHealthcare Medicare	$1,312.50
Rate for Payer: University Health Alliance Commercial	$1,913.36

PAIN & SPINE: BALLOON KYPHOPLASTY ESSENTIALS KIT

Facility

$7,030.00

Service Code	HCPCS C1062
Hospital Charge Code	10994942
Hospital Revenue Code	278
Min. Negotiated Rate	$3,936.80
Max. Negotiated Rate	$6,819.10
Rate for Payer: Cash Price	$4,569.50
Rate for Payer: Hawaii Western Management Group Commercial	$4,921.00
Rate for Payer: Health Management Network Commercial	$5,975.50
Rate for Payer: Kaiser Permanente Commercial	$6,327.00
Rate for Payer: MDX Hawaii PPO	$6,819.10
Rate for Payer: University Health Alliance Commercial	$3,936.80

PAIN & SPINE: BALLOON KYPHOPLASTY ESSENTIALS KIT

Facility

$7,030.00

Service Code	HCPCS C1062
Hospital Charge Code	10994942
Hospital Revenue Code	278
Min. Negotiated Rate	$3,515.00
Max. Negotiated Rate	$6,819.10
Rate for Payer: AlohaCare Medicaid	$3,515.00
Rate for Payer: AlohaCare Medicare	$3,515.00
Rate for Payer: Cash Price	$4,569.50
Rate for Payer: Devoted Health Medicare	$3,866.50
Rate for Payer: Hawaii Medical Service Association Medicare	$3,515.00
Rate for Payer: Hawaii Western Management Group Commercial	$4,921.00
Rate for Payer: Health Management Network Commercial	$5,975.50
Rate for Payer: Humana Medicare	$3,515.00
Rate for Payer: Kaiser Permanente Commercial	$6,327.00
Rate for Payer: Kaiser Permanente Medicaid	$3,585.30
Rate for Payer: Kaiser Permanente Medicare	$3,515.00
Rate for Payer: MDX Hawaii PPO	$6,819.10
Rate for Payer: Ohana Health Plan Medicaid	$3,515.00
Rate for Payer: Ohana Health Plan Medicare	$3,515.00
Rate for Payer: UnitedHealthcare Medicare	$3,515.00
Rate for Payer: University Health Alliance Commercial	$3,936.80

PAIN & SPINE BOOT ENS 375003 PAIN DISPOSABLE

Facility

$375.00

Hospital Charge Code	8806233
Hospital Revenue Code	272
Min. Negotiated Rate	$318.75
Max. Negotiated Rate	$363.75
Rate for Payer: Cash Price	$243.75
Rate for Payer: Health Management Network Commercial	$318.75
Rate for Payer: Kaiser Permanente Commercial	$337.50
Rate for Payer: MDX Hawaii PPO	$363.75

PAIN & SPINE BOOT ENS 375003 PAIN DISPOSABLE

Facility

$375.00

Hospital Charge Code	8806233
Hospital Revenue Code	272
Min. Negotiated Rate	$187.50
Max. Negotiated Rate	$363.75
Rate for Payer: AlohaCare Medicaid	$187.50
Rate for Payer: AlohaCare Medicare	$187.50
Rate for Payer: Cash Price	$243.75
Rate for Payer: Devoted Health Medicare	$206.25
Rate for Payer: Hawaii Medical Service Association Medicare	$187.50
Rate for Payer: Hawaii Western Management Group Commercial	$356.25
Rate for Payer: Health Management Network Commercial	$318.75
Rate for Payer: Humana Medicare	$187.50
Rate for Payer: Kaiser Permanente Commercial	$337.50
Rate for Payer: Kaiser Permanente Medicaid	$191.25
Rate for Payer: Kaiser Permanente Medicare	$187.50
Rate for Payer: MDX Hawaii PPO	$363.75
Rate for Payer: Ohana Health Plan Medicaid	$187.50
Rate for Payer: Ohana Health Plan Medicare	$187.50
Rate for Payer: UnitedHealthcare Medicare	$187.50
Rate for Payer: University Health Alliance Commercial	$273.34

PAIN & SPINE: BOSTON SCIENTIFIC AVISTA MRI SAFE LEAD KIT 70 CM

Facility

$9,240.00

Service Code	HCPCS C1778
Hospital Charge Code	9452706
Hospital Revenue Code	278
Min. Negotiated Rate	$5,174.40
Max. Negotiated Rate	$8,962.80
Rate for Payer: Cash Price	$6,006.00
Rate for Payer: Hawaii Western Management Group Commercial	$6,468.00
Rate for Payer: Health Management Network Commercial	$7,854.00
Rate for Payer: Kaiser Permanente Commercial	$8,316.00
Rate for Payer: MDX Hawaii PPO	$8,962.80
Rate for Payer: University Health Alliance Commercial	$5,174.40

PAIN & SPINE: BOSTON SCIENTIFIC AVISTA MRI SAFE LEAD KIT 70 CM

Facility

$9,240.00

Service Code	HCPCS C1778
Hospital Charge Code	9452706
Hospital Revenue Code	278
Min. Negotiated Rate	$4,620.00
Max. Negotiated Rate	$8,962.80
Rate for Payer: AlohaCare Medicaid	$4,620.00
Rate for Payer: AlohaCare Medicare	$4,620.00
Rate for Payer: Cash Price	$6,006.00
Rate for Payer: Devoted Health Medicare	$5,082.00
Rate for Payer: Hawaii Medical Service Association Medicare	$4,620.00
Rate for Payer: Hawaii Western Management Group Commercial	$6,468.00
Rate for Payer: Health Management Network Commercial	$7,854.00
Rate for Payer: Humana Medicare	$4,620.00
Rate for Payer: Kaiser Permanente Commercial	$8,316.00
Rate for Payer: Kaiser Permanente Medicaid	$4,712.40
Rate for Payer: Kaiser Permanente Medicare	$4,620.00
Rate for Payer: MDX Hawaii PPO	$8,962.80
Rate for Payer: Ohana Health Plan Medicaid	$4,620.00
Rate for Payer: Ohana Health Plan Medicare	$4,620.00
Rate for Payer: UnitedHealthcare Medicare	$4,620.00
Rate for Payer: University Health Alliance Commercial	$5,174.40

PAIN & SPINE: BOSTON SCIENTIFIC FIXATE TISSUE BAND (DUAL PACK)

Facility

$3,580.00

Hospital Charge Code	8882333
Hospital Revenue Code	272
Min. Negotiated Rate	$3,043.00
Max. Negotiated Rate	$3,472.60
Rate for Payer: Cash Price	$2,327.00
Rate for Payer: Health Management Network Commercial	$3,043.00
Rate for Payer: Kaiser Permanente Commercial	$3,222.00
Rate for Payer: MDX Hawaii PPO	$3,472.60

PAIN & SPINE: BOSTON SCIENTIFIC FIXATE TISSUE BAND (DUAL PACK)

Facility

$3,580.00

Hospital Charge Code	8882333
Hospital Revenue Code	272
Min. Negotiated Rate	$1,790.00
Max. Negotiated Rate	$3,472.60
Rate for Payer: AlohaCare Medicaid	$1,790.00
Rate for Payer: AlohaCare Medicare	$1,790.00
Rate for Payer: Cash Price	$2,327.00
Rate for Payer: Devoted Health Medicare	$1,969.00
Rate for Payer: Hawaii Medical Service Association Medicare	$1,790.00
Rate for Payer: Hawaii Western Management Group Commercial	$3,401.00
Rate for Payer: Health Management Network Commercial	$3,043.00
Rate for Payer: Humana Medicare	$1,790.00
Rate for Payer: Kaiser Permanente Commercial	$3,222.00
Rate for Payer: Kaiser Permanente Medicaid	$1,825.80
Rate for Payer: Kaiser Permanente Medicare	$1,790.00
Rate for Payer: MDX Hawaii PPO	$3,472.60
Rate for Payer: Ohana Health Plan Medicaid	$1,790.00
Rate for Payer: Ohana Health Plan Medicare	$1,790.00
Rate for Payer: UnitedHealthcare Medicare	$1,790.00
Rate for Payer: University Health Alliance Commercial	$2,609.46

PAIN & SPINE: BOSTON SCIENTIFIC FIXATE TISSUE BAND (SINGLE PACK)

Facility

$1,800.00

Hospital Charge Code	8813157
Hospital Revenue Code	272
Min. Negotiated Rate	$900.00
Max. Negotiated Rate	$1,746.00
Rate for Payer: AlohaCare Medicaid	$900.00
Rate for Payer: AlohaCare Medicare	$900.00
Rate for Payer: Cash Price	$1,170.00
Rate for Payer: Devoted Health Medicare	$990.00
Rate for Payer: Hawaii Medical Service Association Medicare	$900.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,710.00
Rate for Payer: Health Management Network Commercial	$1,530.00
Rate for Payer: Humana Medicare	$900.00
Rate for Payer: Kaiser Permanente Commercial	$1,620.00
Rate for Payer: Kaiser Permanente Medicaid	$918.00
Rate for Payer: Kaiser Permanente Medicare	$900.00
Rate for Payer: MDX Hawaii PPO	$1,746.00
Rate for Payer: Ohana Health Plan Medicaid	$900.00
Rate for Payer: Ohana Health Plan Medicare	$900.00
Rate for Payer: UnitedHealthcare Medicare	$900.00
Rate for Payer: University Health Alliance Commercial	$1,312.02

Know your out-of-pocket cost for care.

All Charges