Samuel Mahelona Memorial Hospital

All Charges

Charge

Type

Setting

Price

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

Facility

$1,800.00

Hospital Charge Code	8813157
Hospital Revenue Code	272
Min. Negotiated Rate	$1,530.00
Max. Negotiated Rate	$1,746.00
Rate for Payer: Cash Price	$1,170.00
Rate for Payer: Health Management Network Commercial	$1,530.00
Rate for Payer: Kaiser Permanente Commercial	$1,620.00
Rate for Payer: MDX Hawaii PPO	$1,746.00

PAIN & SPINE: BOSTON SCIENTIFIC LINEAR 3-4 LEAD 50CM

Facility

$6,160.00

Service Code	HCPCS C1778
Hospital Charge Code	8882340
Hospital Revenue Code	278
Min. Negotiated Rate	$3,449.60
Max. Negotiated Rate	$5,975.20
Rate for Payer: Cash Price	$4,004.00
Rate for Payer: Hawaii Western Management Group Commercial	$4,312.00
Rate for Payer: Health Management Network Commercial	$5,236.00
Rate for Payer: Kaiser Permanente Commercial	$5,544.00
Rate for Payer: MDX Hawaii PPO	$5,975.20
Rate for Payer: University Health Alliance Commercial	$3,449.60

PAIN & SPINE: BOSTON SCIENTIFIC LINEAR 3-4 LEAD 50CM

Facility

$6,160.00

Service Code	HCPCS C1778
Hospital Charge Code	8882340
Hospital Revenue Code	278
Min. Negotiated Rate	$3,080.00
Max. Negotiated Rate	$5,975.20
Rate for Payer: AlohaCare Medicaid	$3,080.00
Rate for Payer: AlohaCare Medicare	$3,080.00
Rate for Payer: Cash Price	$4,004.00
Rate for Payer: Devoted Health Medicare	$3,388.00
Rate for Payer: Hawaii Medical Service Association Medicare	$3,080.00
Rate for Payer: Hawaii Western Management Group Commercial	$4,312.00
Rate for Payer: Health Management Network Commercial	$5,236.00
Rate for Payer: Humana Medicare	$3,080.00
Rate for Payer: Kaiser Permanente Commercial	$5,544.00
Rate for Payer: Kaiser Permanente Medicaid	$3,141.60
Rate for Payer: Kaiser Permanente Medicare	$3,080.00
Rate for Payer: MDX Hawaii PPO	$5,975.20
Rate for Payer: Ohana Health Plan Medicaid	$3,080.00
Rate for Payer: Ohana Health Plan Medicare	$3,080.00
Rate for Payer: UnitedHealthcare Medicare	$3,080.00
Rate for Payer: University Health Alliance Commercial	$3,449.60

PAIN & SPINE: BOSTON SCIENTIFIC PATIENT TRIAL KIT

Facility

$432.00

Hospital Charge Code	9558775
Hospital Revenue Code	272
Min. Negotiated Rate	$367.20
Max. Negotiated Rate	$419.04
Rate for Payer: Cash Price	$280.80
Rate for Payer: Health Management Network Commercial	$367.20
Rate for Payer: Kaiser Permanente Commercial	$388.80
Rate for Payer: MDX Hawaii PPO	$419.04

PAIN & SPINE: BOSTON SCIENTIFIC PATIENT TRIAL KIT

Facility

$432.00

Hospital Charge Code	9558775
Hospital Revenue Code	272
Min. Negotiated Rate	$216.00
Max. Negotiated Rate	$419.04
Rate for Payer: AlohaCare Medicaid	$216.00
Rate for Payer: AlohaCare Medicare	$216.00
Rate for Payer: Cash Price	$280.80
Rate for Payer: Devoted Health Medicare	$237.60
Rate for Payer: Hawaii Medical Service Association Medicare	$216.00
Rate for Payer: Hawaii Western Management Group Commercial	$410.40
Rate for Payer: Health Management Network Commercial	$367.20
Rate for Payer: Humana Medicare	$216.00
Rate for Payer: Kaiser Permanente Commercial	$388.80
Rate for Payer: Kaiser Permanente Medicaid	$220.32
Rate for Payer: Kaiser Permanente Medicare	$216.00
Rate for Payer: MDX Hawaii PPO	$419.04
Rate for Payer: Ohana Health Plan Medicaid	$216.00
Rate for Payer: Ohana Health Plan Medicare	$216.00
Rate for Payer: UnitedHealthcare Medicare	$216.00
Rate for Payer: University Health Alliance Commercial	$314.88

PAIN & SPINE CABLE 355531 MULTI LEAD TRIALING

Facility

$750.00

Service Code	HCPCS C1897
Hospital Charge Code	8806215
Hospital Revenue Code	278
Min. Negotiated Rate	$420.00
Max. Negotiated Rate	$727.50
Rate for Payer: Cash Price	$487.50
Rate for Payer: Hawaii Western Management Group Commercial	$525.00
Rate for Payer: Health Management Network Commercial	$637.50
Rate for Payer: Kaiser Permanente Commercial	$675.00
Rate for Payer: MDX Hawaii PPO	$727.50
Rate for Payer: University Health Alliance Commercial	$420.00

PAIN & SPINE CABLE 355531 MULTI LEAD TRIALING

Facility

$750.00

Service Code	HCPCS C1897
Hospital Charge Code	8806215
Hospital Revenue Code	278
Min. Negotiated Rate	$375.00
Max. Negotiated Rate	$727.50
Rate for Payer: AlohaCare Medicaid	$375.00
Rate for Payer: AlohaCare Medicare	$375.00
Rate for Payer: Cash Price	$487.50
Rate for Payer: Devoted Health Medicare	$412.50
Rate for Payer: Hawaii Medical Service Association Medicare	$375.00
Rate for Payer: Hawaii Western Management Group Commercial	$525.00
Rate for Payer: Health Management Network Commercial	$637.50
Rate for Payer: Humana Medicare	$375.00
Rate for Payer: Kaiser Permanente Commercial	$675.00
Rate for Payer: Kaiser Permanente Medicaid	$382.50
Rate for Payer: Kaiser Permanente Medicare	$375.00
Rate for Payer: MDX Hawaii PPO	$727.50
Rate for Payer: Ohana Health Plan Medicaid	$375.00
Rate for Payer: Ohana Health Plan Medicare	$375.00
Rate for Payer: UnitedHealthcare Medicare	$375.00
Rate for Payer: University Health Alliance Commercial	$420.00

PAIN & SPINE: CANNULA AC0001 50MM 16G 10MM CS

Facility

$563.00

Hospital Charge Code	9589766
Hospital Revenue Code	272
Min. Negotiated Rate	$281.50
Max. Negotiated Rate	$546.11
Rate for Payer: AlohaCare Medicaid	$281.50
Rate for Payer: AlohaCare Medicare	$281.50
Rate for Payer: Cash Price	$365.95
Rate for Payer: Devoted Health Medicare	$309.65
Rate for Payer: Hawaii Medical Service Association Medicare	$281.50
Rate for Payer: Hawaii Western Management Group Commercial	$534.85
Rate for Payer: Health Management Network Commercial	$478.55
Rate for Payer: Humana Medicare	$281.50
Rate for Payer: Kaiser Permanente Commercial	$506.70
Rate for Payer: Kaiser Permanente Medicaid	$287.13
Rate for Payer: Kaiser Permanente Medicare	$281.50
Rate for Payer: MDX Hawaii PPO	$546.11
Rate for Payer: Ohana Health Plan Medicaid	$281.50
Rate for Payer: Ohana Health Plan Medicare	$281.50
Rate for Payer: UnitedHealthcare Medicare	$281.50
Rate for Payer: University Health Alliance Commercial	$410.37

PAIN & SPINE: CANNULA AC0001 50MM 16G 10MM CS

Facility

$563.00

Hospital Charge Code	9589766
Hospital Revenue Code	272
Min. Negotiated Rate	$478.55
Max. Negotiated Rate	$546.11
Rate for Payer: Cash Price	$365.95
Rate for Payer: Health Management Network Commercial	$478.55
Rate for Payer: Kaiser Permanente Commercial	$506.70
Rate for Payer: MDX Hawaii PPO	$546.11

PAIN & SPINE: CANNULA AC0002 100MM 16G 10MM CS

Facility

$563.00

Hospital Charge Code	9589767
Hospital Revenue Code	272
Min. Negotiated Rate	$281.50
Max. Negotiated Rate	$546.11
Rate for Payer: AlohaCare Medicaid	$281.50
Rate for Payer: AlohaCare Medicare	$281.50
Rate for Payer: Cash Price	$365.95
Rate for Payer: Devoted Health Medicare	$309.65
Rate for Payer: Hawaii Medical Service Association Medicare	$281.50
Rate for Payer: Hawaii Western Management Group Commercial	$534.85
Rate for Payer: Health Management Network Commercial	$478.55
Rate for Payer: Humana Medicare	$281.50
Rate for Payer: Kaiser Permanente Commercial	$506.70
Rate for Payer: Kaiser Permanente Medicaid	$287.13
Rate for Payer: Kaiser Permanente Medicare	$281.50
Rate for Payer: MDX Hawaii PPO	$546.11
Rate for Payer: Ohana Health Plan Medicaid	$281.50
Rate for Payer: Ohana Health Plan Medicare	$281.50
Rate for Payer: UnitedHealthcare Medicare	$281.50
Rate for Payer: University Health Alliance Commercial	$410.37

PAIN & SPINE: CANNULA AC0002 100MM 16G 10MM CS

Facility

$563.00

Hospital Charge Code	9589767
Hospital Revenue Code	272
Min. Negotiated Rate	$478.55
Max. Negotiated Rate	$546.11
Rate for Payer: Cash Price	$365.95
Rate for Payer: Health Management Network Commercial	$478.55
Rate for Payer: Kaiser Permanente Commercial	$506.70
Rate for Payer: MDX Hawaii PPO	$546.11

PAIN & SPINE: CANNULA AC0003 150MM 16G 10MM CS

Facility

$563.00

Hospital Charge Code	9589768
Hospital Revenue Code	272
Min. Negotiated Rate	$478.55
Max. Negotiated Rate	$546.11
Rate for Payer: Cash Price	$365.95
Rate for Payer: Health Management Network Commercial	$478.55
Rate for Payer: Kaiser Permanente Commercial	$506.70
Rate for Payer: MDX Hawaii PPO	$546.11

PAIN & SPINE: CANNULA AC0003 150MM 16G 10MM CS

Facility

$563.00

Hospital Charge Code	9589768
Hospital Revenue Code	272
Min. Negotiated Rate	$281.50
Max. Negotiated Rate	$546.11
Rate for Payer: AlohaCare Medicaid	$281.50
Rate for Payer: AlohaCare Medicare	$281.50
Rate for Payer: Cash Price	$365.95
Rate for Payer: Devoted Health Medicare	$309.65
Rate for Payer: Hawaii Medical Service Association Medicare	$281.50
Rate for Payer: Hawaii Western Management Group Commercial	$534.85
Rate for Payer: Health Management Network Commercial	$478.55
Rate for Payer: Humana Medicare	$281.50
Rate for Payer: Kaiser Permanente Commercial	$506.70
Rate for Payer: Kaiser Permanente Medicaid	$287.13
Rate for Payer: Kaiser Permanente Medicare	$281.50
Rate for Payer: MDX Hawaii PPO	$546.11
Rate for Payer: Ohana Health Plan Medicaid	$281.50
Rate for Payer: Ohana Health Plan Medicare	$281.50
Rate for Payer: UnitedHealthcare Medicare	$281.50
Rate for Payer: University Health Alliance Commercial	$410.37

PAIN & SPINE: CANNULA AC0004 50MM 18G 10MM CS

Facility

$563.00

Hospital Charge Code	9589769
Hospital Revenue Code	272
Min. Negotiated Rate	$281.50
Max. Negotiated Rate	$546.11
Rate for Payer: AlohaCare Medicaid	$281.50
Rate for Payer: AlohaCare Medicare	$281.50
Rate for Payer: Cash Price	$365.95
Rate for Payer: Devoted Health Medicare	$309.65
Rate for Payer: Hawaii Medical Service Association Medicare	$281.50
Rate for Payer: Hawaii Western Management Group Commercial	$534.85
Rate for Payer: Health Management Network Commercial	$478.55
Rate for Payer: Humana Medicare	$281.50
Rate for Payer: Kaiser Permanente Commercial	$506.70
Rate for Payer: Kaiser Permanente Medicaid	$287.13
Rate for Payer: Kaiser Permanente Medicare	$281.50
Rate for Payer: MDX Hawaii PPO	$546.11
Rate for Payer: Ohana Health Plan Medicaid	$281.50
Rate for Payer: Ohana Health Plan Medicare	$281.50
Rate for Payer: UnitedHealthcare Medicare	$281.50
Rate for Payer: University Health Alliance Commercial	$410.37

PAIN & SPINE: CANNULA AC0004 50MM 18G 10MM CS

Facility

$563.00

Hospital Charge Code	9589769
Hospital Revenue Code	272
Min. Negotiated Rate	$478.55
Max. Negotiated Rate	$546.11
Rate for Payer: Cash Price	$365.95
Rate for Payer: Health Management Network Commercial	$478.55
Rate for Payer: Kaiser Permanente Commercial	$506.70
Rate for Payer: MDX Hawaii PPO	$546.11

PAIN & SPINE: CANNULA AC0005 100MM 18G 10MM CS

Facility

$563.00

Hospital Charge Code	9589770
Hospital Revenue Code	272
Min. Negotiated Rate	$281.50
Max. Negotiated Rate	$546.11
Rate for Payer: AlohaCare Medicaid	$281.50
Rate for Payer: AlohaCare Medicare	$281.50
Rate for Payer: Cash Price	$365.95
Rate for Payer: Devoted Health Medicare	$309.65
Rate for Payer: Hawaii Medical Service Association Medicare	$281.50
Rate for Payer: Hawaii Western Management Group Commercial	$534.85
Rate for Payer: Health Management Network Commercial	$478.55
Rate for Payer: Humana Medicare	$281.50
Rate for Payer: Kaiser Permanente Commercial	$506.70
Rate for Payer: Kaiser Permanente Medicaid	$287.13
Rate for Payer: Kaiser Permanente Medicare	$281.50
Rate for Payer: MDX Hawaii PPO	$546.11
Rate for Payer: Ohana Health Plan Medicaid	$281.50
Rate for Payer: Ohana Health Plan Medicare	$281.50
Rate for Payer: UnitedHealthcare Medicare	$281.50
Rate for Payer: University Health Alliance Commercial	$410.37

PAIN & SPINE: CANNULA AC0005 100MM 18G 10MM CS

Facility

$563.00

Hospital Charge Code	9589770
Hospital Revenue Code	272
Min. Negotiated Rate	$478.55
Max. Negotiated Rate	$546.11
Rate for Payer: Cash Price	$365.95
Rate for Payer: Health Management Network Commercial	$478.55
Rate for Payer: Kaiser Permanente Commercial	$506.70
Rate for Payer: MDX Hawaii PPO	$546.11

PAIN & SPINE: CANNULA AC0006 100MM 18G 10MM SS

Facility

$563.00

Hospital Charge Code	9589771
Hospital Revenue Code	272
Min. Negotiated Rate	$281.50
Max. Negotiated Rate	$546.11
Rate for Payer: AlohaCare Medicaid	$281.50
Rate for Payer: AlohaCare Medicare	$281.50
Rate for Payer: Cash Price	$365.95
Rate for Payer: Devoted Health Medicare	$309.65
Rate for Payer: Hawaii Medical Service Association Medicare	$281.50
Rate for Payer: Hawaii Western Management Group Commercial	$534.85
Rate for Payer: Health Management Network Commercial	$478.55
Rate for Payer: Humana Medicare	$281.50
Rate for Payer: Kaiser Permanente Commercial	$506.70
Rate for Payer: Kaiser Permanente Medicaid	$287.13
Rate for Payer: Kaiser Permanente Medicare	$281.50
Rate for Payer: MDX Hawaii PPO	$546.11
Rate for Payer: Ohana Health Plan Medicaid	$281.50
Rate for Payer: Ohana Health Plan Medicare	$281.50
Rate for Payer: UnitedHealthcare Medicare	$281.50
Rate for Payer: University Health Alliance Commercial	$410.37

PAIN & SPINE: CANNULA AC0006 100MM 18G 10MM SS

Facility

$563.00

Hospital Charge Code	9589771
Hospital Revenue Code	272
Min. Negotiated Rate	$478.55
Max. Negotiated Rate	$546.11
Rate for Payer: Cash Price	$365.95
Rate for Payer: Health Management Network Commercial	$478.55
Rate for Payer: Kaiser Permanente Commercial	$506.70
Rate for Payer: MDX Hawaii PPO	$546.11

PAIN & SPINE: CANNULA AC0007 150MM 18G 10MM CS

Facility

$563.00

Hospital Charge Code	9589772
Hospital Revenue Code	272
Min. Negotiated Rate	$281.50
Max. Negotiated Rate	$546.11
Rate for Payer: AlohaCare Medicaid	$281.50
Rate for Payer: AlohaCare Medicare	$281.50
Rate for Payer: Cash Price	$365.95
Rate for Payer: Devoted Health Medicare	$309.65
Rate for Payer: Hawaii Medical Service Association Medicare	$281.50
Rate for Payer: Hawaii Western Management Group Commercial	$534.85
Rate for Payer: Health Management Network Commercial	$478.55
Rate for Payer: Humana Medicare	$281.50
Rate for Payer: Kaiser Permanente Commercial	$506.70
Rate for Payer: Kaiser Permanente Medicaid	$287.13
Rate for Payer: Kaiser Permanente Medicare	$281.50
Rate for Payer: MDX Hawaii PPO	$546.11
Rate for Payer: Ohana Health Plan Medicaid	$281.50
Rate for Payer: Ohana Health Plan Medicare	$281.50
Rate for Payer: UnitedHealthcare Medicare	$281.50
Rate for Payer: University Health Alliance Commercial	$410.37

PAIN & SPINE: CANNULA AC0007 150MM 18G 10MM CS

Facility

$563.00

Hospital Charge Code	9589772
Hospital Revenue Code	272
Min. Negotiated Rate	$478.55
Max. Negotiated Rate	$546.11
Rate for Payer: Cash Price	$365.95
Rate for Payer: Health Management Network Commercial	$478.55
Rate for Payer: Kaiser Permanente Commercial	$506.70
Rate for Payer: MDX Hawaii PPO	$546.11

PAIN & SPINE: CANNULA AC0008 50MM 20G 10MM CS

Facility

$563.00

Hospital Charge Code	9589855
Hospital Revenue Code	272
Min. Negotiated Rate	$281.50
Max. Negotiated Rate	$546.11
Rate for Payer: AlohaCare Medicaid	$281.50
Rate for Payer: AlohaCare Medicare	$281.50
Rate for Payer: Cash Price	$365.95
Rate for Payer: Devoted Health Medicare	$309.65
Rate for Payer: Hawaii Medical Service Association Medicare	$281.50
Rate for Payer: Hawaii Western Management Group Commercial	$534.85
Rate for Payer: Health Management Network Commercial	$478.55
Rate for Payer: Humana Medicare	$281.50
Rate for Payer: Kaiser Permanente Commercial	$506.70
Rate for Payer: Kaiser Permanente Medicaid	$287.13
Rate for Payer: Kaiser Permanente Medicare	$281.50
Rate for Payer: MDX Hawaii PPO	$546.11
Rate for Payer: Ohana Health Plan Medicaid	$281.50
Rate for Payer: Ohana Health Plan Medicare	$281.50
Rate for Payer: UnitedHealthcare Medicare	$281.50
Rate for Payer: University Health Alliance Commercial	$410.37

PAIN & SPINE: CANNULA AC0008 50MM 20G 10MM CS

Facility

$563.00

Hospital Charge Code	9589855
Hospital Revenue Code	272
Min. Negotiated Rate	$478.55
Max. Negotiated Rate	$546.11
Rate for Payer: Cash Price	$365.95
Rate for Payer: Health Management Network Commercial	$478.55
Rate for Payer: Kaiser Permanente Commercial	$506.70
Rate for Payer: MDX Hawaii PPO	$546.11

PAIN & SPINE: CANNULA AC0009 100MM 20G 10MM CS

Facility

$563.00

Hospital Charge Code	9589856
Hospital Revenue Code	272
Min. Negotiated Rate	$281.50
Max. Negotiated Rate	$546.11
Rate for Payer: AlohaCare Medicaid	$281.50
Rate for Payer: AlohaCare Medicare	$281.50
Rate for Payer: Cash Price	$365.95
Rate for Payer: Devoted Health Medicare	$309.65
Rate for Payer: Hawaii Medical Service Association Medicare	$281.50
Rate for Payer: Hawaii Western Management Group Commercial	$534.85
Rate for Payer: Health Management Network Commercial	$478.55
Rate for Payer: Humana Medicare	$281.50
Rate for Payer: Kaiser Permanente Commercial	$506.70
Rate for Payer: Kaiser Permanente Medicaid	$287.13
Rate for Payer: Kaiser Permanente Medicare	$281.50
Rate for Payer: MDX Hawaii PPO	$546.11
Rate for Payer: Ohana Health Plan Medicaid	$281.50
Rate for Payer: Ohana Health Plan Medicare	$281.50
Rate for Payer: UnitedHealthcare Medicare	$281.50
Rate for Payer: University Health Alliance Commercial	$410.37

PAIN & SPINE: CANNULA AC0009 100MM 20G 10MM CS

Facility

$563.00

Hospital Charge Code	9589856
Hospital Revenue Code	272
Min. Negotiated Rate	$478.55
Max. Negotiated Rate	$546.11
Rate for Payer: Cash Price	$365.95
Rate for Payer: Health Management Network Commercial	$478.55
Rate for Payer: Kaiser Permanente Commercial	$506.70
Rate for Payer: MDX Hawaii PPO	$546.11

Know your out-of-pocket cost for care.

All Charges