Samuel Mahelona Memorial Hospital

All Charges

Charge

Type

Setting

Price

PAIN & SPINE: CANNULA AC0010 100MM 20G 10MM SS

Facility

$563.00

Hospital Charge Code	9589857
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 AC0010 100MM 20G 10MM SS

Facility

$563.00

Hospital Charge Code	9589857
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 AC0011 100MM 20G 10MM CB

Facility

$563.00

Hospital Charge Code	9589858
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 AC0011 100MM 20G 10MM CB

Facility

$563.00

Hospital Charge Code	9589858
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 AC0012 150MM 20G 10MM CS

Facility

$563.00

Hospital Charge Code	9589859
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 AC0012 150MM 20G 10MM CS

Facility

$563.00

Hospital Charge Code	9589859
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 AC0013 150MM 20G 10MM SS

Facility

$563.00

Hospital Charge Code	9589860
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 AC0013 150MM 20G 10MM SS

Facility

$563.00

Hospital Charge Code	9589860
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 AC0014 150MM 20G 10MM CB

Facility

$563.00

Hospital Charge Code	9589861
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 AC0014 150MM 20G 10MM CB

Facility

$563.00

Hospital Charge Code	9589861
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 AC0015 50MM 22G 5MM CS

Facility

$563.00

Hospital Charge Code	9589862
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 AC0015 50MM 22G 5MM CS

Facility

$563.00

Hospital Charge Code	9589862
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 AC0016 100MM 22G 5MM CS

Facility

$563.00

Hospital Charge Code	9589863
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 AC0016 100MM 22G 5MM CS

Facility

$563.00

Hospital Charge Code	9589863
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 AC0017 100MM 22G 5MM SS

Facility

$563.00

Hospital Charge Code	9589864
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 AC0017 100MM 22G 5MM SS

Facility

$563.00

Hospital Charge Code	9589864
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 AC0018 100MM 22G 10MM CS

Facility

$563.00

Hospital Charge Code	9589865
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 AC0018 100MM 22G 10MM CS

Facility

$563.00

Hospital Charge Code	9589865
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 AC0019 100MM 22G 10MM SS

Facility

$563.00

Hospital Charge Code	9589866
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 AC0019 100MM 22G 10MM SS

Facility

$563.00

Hospital Charge Code	9589866
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 AC0020 100MM 22G 10MM CB

Facility

$563.00

Hospital Charge Code	9589867
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 AC0020 100MM 22G 10MM CB

Facility

$563.00

Hospital Charge Code	9589867
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 CATHETER ASCENDA INTRATHECAL 114CM

Facility

$2,985.00

Service Code	HCPCS C1755
Hospital Charge Code	8805346
Hospital Revenue Code	278
Min. Negotiated Rate	$1,492.50
Max. Negotiated Rate	$2,895.45
Rate for Payer: AlohaCare Medicaid	$1,492.50
Rate for Payer: AlohaCare Medicare	$1,492.50
Rate for Payer: Cash Price	$1,940.25
Rate for Payer: Devoted Health Medicare	$1,641.75
Rate for Payer: Hawaii Medical Service Association Medicare	$1,492.50
Rate for Payer: Hawaii Western Management Group Commercial	$2,089.50
Rate for Payer: Health Management Network Commercial	$2,537.25
Rate for Payer: Humana Medicare	$1,492.50
Rate for Payer: Kaiser Permanente Commercial	$2,686.50
Rate for Payer: Kaiser Permanente Medicaid	$1,522.35
Rate for Payer: Kaiser Permanente Medicare	$1,492.50
Rate for Payer: MDX Hawaii PPO	$2,895.45
Rate for Payer: Ohana Health Plan Medicaid	$1,492.50
Rate for Payer: Ohana Health Plan Medicare	$1,492.50
Rate for Payer: UnitedHealthcare Medicare	$1,492.50
Rate for Payer: University Health Alliance Commercial	$1,671.60

PAIN & SPINE CATHETER ASCENDA INTRATHECAL 114CM

Facility

$2,985.00

Service Code	HCPCS C1755
Hospital Charge Code	8805346
Hospital Revenue Code	278
Min. Negotiated Rate	$1,671.60
Max. Negotiated Rate	$2,895.45
Rate for Payer: Cash Price	$1,940.25
Rate for Payer: Hawaii Western Management Group Commercial	$2,089.50
Rate for Payer: Health Management Network Commercial	$2,537.25
Rate for Payer: Kaiser Permanente Commercial	$2,686.50
Rate for Payer: MDX Hawaii PPO	$2,895.45
Rate for Payer: University Health Alliance Commercial	$1,671.60

PAIN & SPINE CATHETER ASCENDA INTRATHECAL 140CM

Facility

$2,985.00

Service Code	HCPCS C1755
Hospital Charge Code	8805347
Hospital Revenue Code	272
Min. Negotiated Rate	$2,537.25
Max. Negotiated Rate	$2,895.45
Rate for Payer: Cash Price	$1,940.25
Rate for Payer: Health Management Network Commercial	$2,537.25
Rate for Payer: Kaiser Permanente Commercial	$2,686.50
Rate for Payer: MDX Hawaii PPO	$2,895.45

Know your out-of-pocket cost for care.

All Charges