Samuel Mahelona Memorial Hospital

All Charges

Charge

Type

Setting

Price

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	$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	$2,835.75
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	$2,175.77

PAIN & SPINE COMM HANDSET KIT TH09T01 TDD PROX MYPTM

Facility

$1,500.00

Hospital Charge Code	8805349
Hospital Revenue Code	272
Min. Negotiated Rate	$1,275.00
Max. Negotiated Rate	$1,455.00
Rate for Payer: Cash Price	$975.00
Rate for Payer: Health Management Network Commercial	$1,275.00
Rate for Payer: Kaiser Permanente Commercial	$1,350.00
Rate for Payer: MDX Hawaii PPO	$1,455.00

PAIN & SPINE COMM HANDSET KIT TH09T01 TDD PROX MYPTM

Facility

$1,500.00

Hospital Charge Code	8805349
Hospital Revenue Code	272
Min. Negotiated Rate	$750.00
Max. Negotiated Rate	$1,455.00
Rate for Payer: AlohaCare Medicaid	$750.00
Rate for Payer: AlohaCare Medicare	$750.00
Rate for Payer: Cash Price	$975.00
Rate for Payer: Devoted Health Medicare	$825.00
Rate for Payer: Hawaii Medical Service Association Medicare	$750.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,425.00
Rate for Payer: Health Management Network Commercial	$1,275.00
Rate for Payer: Humana Medicare	$750.00
Rate for Payer: Kaiser Permanente Commercial	$1,350.00
Rate for Payer: Kaiser Permanente Medicaid	$765.00
Rate for Payer: Kaiser Permanente Medicare	$750.00
Rate for Payer: MDX Hawaii PPO	$1,455.00
Rate for Payer: Ohana Health Plan Medicaid	$750.00
Rate for Payer: Ohana Health Plan Medicare	$750.00
Rate for Payer: UnitedHealthcare Medicare	$750.00
Rate for Payer: University Health Alliance Commercial	$1,093.35

PAIN & SPINE COOLED RADIOFREQUENCY 2MM KIT 50MM LENGTH

Facility

$2,250.00

Hospital Charge Code	9134128
Hospital Revenue Code	272
Min. Negotiated Rate	$1,912.50
Max. Negotiated Rate	$2,182.50
Rate for Payer: Cash Price	$1,462.50
Rate for Payer: Health Management Network Commercial	$1,912.50
Rate for Payer: Kaiser Permanente Commercial	$2,025.00
Rate for Payer: MDX Hawaii PPO	$2,182.50

PAIN & SPINE COOLED RADIOFREQUENCY 2MM KIT 50MM LENGTH

Facility

$2,250.00

Hospital Charge Code	9134128
Hospital Revenue Code	272
Min. Negotiated Rate	$1,125.00
Max. Negotiated Rate	$2,182.50
Rate for Payer: AlohaCare Medicaid	$1,125.00
Rate for Payer: AlohaCare Medicare	$1,125.00
Rate for Payer: Cash Price	$1,462.50
Rate for Payer: Devoted Health Medicare	$1,237.50
Rate for Payer: Hawaii Medical Service Association Medicare	$1,125.00
Rate for Payer: Hawaii Western Management Group Commercial	$2,137.50
Rate for Payer: Health Management Network Commercial	$1,912.50
Rate for Payer: Humana Medicare	$1,125.00
Rate for Payer: Kaiser Permanente Commercial	$2,025.00
Rate for Payer: Kaiser Permanente Medicaid	$1,147.50
Rate for Payer: Kaiser Permanente Medicare	$1,125.00
Rate for Payer: MDX Hawaii PPO	$2,182.50
Rate for Payer: Ohana Health Plan Medicaid	$1,125.00
Rate for Payer: Ohana Health Plan Medicare	$1,125.00
Rate for Payer: UnitedHealthcare Medicare	$1,125.00
Rate for Payer: University Health Alliance Commercial	$1,640.03

PAIN & SPINE: COOLED RADIOFREQUENCY KIT 150

Facility

$2,250.00

Hospital Charge Code	9337580
Hospital Revenue Code	272
Min. Negotiated Rate	$1,125.00
Max. Negotiated Rate	$2,182.50
Rate for Payer: AlohaCare Medicaid	$1,125.00
Rate for Payer: AlohaCare Medicare	$1,125.00
Rate for Payer: Cash Price	$1,462.50
Rate for Payer: Devoted Health Medicare	$1,237.50
Rate for Payer: Hawaii Medical Service Association Medicare	$1,125.00
Rate for Payer: Hawaii Western Management Group Commercial	$2,137.50
Rate for Payer: Health Management Network Commercial	$1,912.50
Rate for Payer: Humana Medicare	$1,125.00
Rate for Payer: Kaiser Permanente Commercial	$2,025.00
Rate for Payer: Kaiser Permanente Medicaid	$1,147.50
Rate for Payer: Kaiser Permanente Medicare	$1,125.00
Rate for Payer: MDX Hawaii PPO	$2,182.50
Rate for Payer: Ohana Health Plan Medicaid	$1,125.00
Rate for Payer: Ohana Health Plan Medicare	$1,125.00
Rate for Payer: UnitedHealthcare Medicare	$1,125.00
Rate for Payer: University Health Alliance Commercial	$1,640.03

PAIN & SPINE: COOLED RADIOFREQUENCY KIT 150

Facility

$2,250.00

Hospital Charge Code	9337580
Hospital Revenue Code	272
Min. Negotiated Rate	$1,912.50
Max. Negotiated Rate	$2,182.50
Rate for Payer: Cash Price	$1,462.50
Rate for Payer: Health Management Network Commercial	$1,912.50
Rate for Payer: Kaiser Permanente Commercial	$2,025.00
Rate for Payer: MDX Hawaii PPO	$2,182.50

PAIN & SPINE: COOLED RADIOFREQUENCY KIT 75

Facility

$2,250.00

Hospital Charge Code	8848269
Hospital Revenue Code	272
Min. Negotiated Rate	$1,125.00
Max. Negotiated Rate	$2,182.50
Rate for Payer: AlohaCare Medicaid	$1,125.00
Rate for Payer: AlohaCare Medicare	$1,125.00
Rate for Payer: Cash Price	$1,462.50
Rate for Payer: Devoted Health Medicare	$1,237.50
Rate for Payer: Hawaii Medical Service Association Medicare	$1,125.00
Rate for Payer: Hawaii Western Management Group Commercial	$2,137.50
Rate for Payer: Health Management Network Commercial	$1,912.50
Rate for Payer: Humana Medicare	$1,125.00
Rate for Payer: Kaiser Permanente Commercial	$2,025.00
Rate for Payer: Kaiser Permanente Medicaid	$1,147.50
Rate for Payer: Kaiser Permanente Medicare	$1,125.00
Rate for Payer: MDX Hawaii PPO	$2,182.50
Rate for Payer: Ohana Health Plan Medicaid	$1,125.00
Rate for Payer: Ohana Health Plan Medicare	$1,125.00
Rate for Payer: UnitedHealthcare Medicare	$1,125.00
Rate for Payer: University Health Alliance Commercial	$1,640.03

PAIN & SPINE: COOLED RADIOFREQUENCY KIT 75

Facility

$2,250.00

Hospital Charge Code	8848269
Hospital Revenue Code	272
Min. Negotiated Rate	$1,912.50
Max. Negotiated Rate	$2,182.50
Rate for Payer: Cash Price	$1,462.50
Rate for Payer: Health Management Network Commercial	$1,912.50
Rate for Payer: Kaiser Permanente Commercial	$2,025.00
Rate for Payer: MDX Hawaii PPO	$2,182.50

PAIN & SPINE: COOLED RF KIT 17G/100MM/4MM

Facility

$2,250.00

Hospital Charge Code	9080178
Hospital Revenue Code	272
Min. Negotiated Rate	$1,912.50
Max. Negotiated Rate	$2,182.50
Rate for Payer: Cash Price	$1,462.50
Rate for Payer: Health Management Network Commercial	$1,912.50
Rate for Payer: Kaiser Permanente Commercial	$2,025.00
Rate for Payer: MDX Hawaii PPO	$2,182.50

PAIN & SPINE: COOLED RF KIT 17G/100MM/4MM

Facility

$2,250.00

Hospital Charge Code	9080178
Hospital Revenue Code	272
Min. Negotiated Rate	$1,125.00
Max. Negotiated Rate	$2,182.50
Rate for Payer: AlohaCare Medicaid	$1,125.00
Rate for Payer: AlohaCare Medicare	$1,125.00
Rate for Payer: Cash Price	$1,462.50
Rate for Payer: Devoted Health Medicare	$1,237.50
Rate for Payer: Hawaii Medical Service Association Medicare	$1,125.00
Rate for Payer: Hawaii Western Management Group Commercial	$2,137.50
Rate for Payer: Health Management Network Commercial	$1,912.50
Rate for Payer: Humana Medicare	$1,125.00
Rate for Payer: Kaiser Permanente Commercial	$2,025.00
Rate for Payer: Kaiser Permanente Medicaid	$1,147.50
Rate for Payer: Kaiser Permanente Medicare	$1,125.00
Rate for Payer: MDX Hawaii PPO	$2,182.50
Rate for Payer: Ohana Health Plan Medicaid	$1,125.00
Rate for Payer: Ohana Health Plan Medicare	$1,125.00
Rate for Payer: UnitedHealthcare Medicare	$1,125.00
Rate for Payer: University Health Alliance Commercial	$1,640.03

PAIN & SPINE: COOLED RF KIT 17G/150MM/4MM

Facility

$2,250.00

Hospital Charge Code	10721827
Hospital Revenue Code	272
Min. Negotiated Rate	$1,912.50
Max. Negotiated Rate	$2,182.50
Rate for Payer: Cash Price	$1,462.50
Rate for Payer: Health Management Network Commercial	$1,912.50
Rate for Payer: Kaiser Permanente Commercial	$2,025.00
Rate for Payer: MDX Hawaii PPO	$2,182.50

PAIN & SPINE: COOLED RF KIT 17G/150MM/4MM

Facility

$2,250.00

Hospital Charge Code	10721827
Hospital Revenue Code	272
Min. Negotiated Rate	$1,125.00
Max. Negotiated Rate	$2,182.50
Rate for Payer: AlohaCare Medicaid	$1,125.00
Rate for Payer: AlohaCare Medicare	$1,125.00
Rate for Payer: Cash Price	$1,462.50
Rate for Payer: Devoted Health Medicare	$1,237.50
Rate for Payer: Hawaii Medical Service Association Medicare	$1,125.00
Rate for Payer: Hawaii Western Management Group Commercial	$2,137.50
Rate for Payer: Health Management Network Commercial	$1,912.50
Rate for Payer: Humana Medicare	$1,125.00
Rate for Payer: Kaiser Permanente Commercial	$2,025.00
Rate for Payer: Kaiser Permanente Medicaid	$1,147.50
Rate for Payer: Kaiser Permanente Medicare	$1,125.00
Rate for Payer: MDX Hawaii PPO	$2,182.50
Rate for Payer: Ohana Health Plan Medicaid	$1,125.00
Rate for Payer: Ohana Health Plan Medicare	$1,125.00
Rate for Payer: UnitedHealthcare Medicare	$1,125.00
Rate for Payer: University Health Alliance Commercial	$1,640.03

PAIN & SPINE: COOLED RF KIT 17G/50MM/4MM

Facility

$2,250.00

Hospital Charge Code	10500432
Hospital Revenue Code	272
Min. Negotiated Rate	$1,125.00
Max. Negotiated Rate	$2,182.50
Rate for Payer: AlohaCare Medicaid	$1,125.00
Rate for Payer: AlohaCare Medicare	$1,125.00
Rate for Payer: Cash Price	$1,462.50
Rate for Payer: Devoted Health Medicare	$1,237.50
Rate for Payer: Hawaii Medical Service Association Medicare	$1,125.00
Rate for Payer: Hawaii Western Management Group Commercial	$2,137.50
Rate for Payer: Health Management Network Commercial	$1,912.50
Rate for Payer: Humana Medicare	$1,125.00
Rate for Payer: Kaiser Permanente Commercial	$2,025.00
Rate for Payer: Kaiser Permanente Medicaid	$1,147.50
Rate for Payer: Kaiser Permanente Medicare	$1,125.00
Rate for Payer: MDX Hawaii PPO	$2,182.50
Rate for Payer: Ohana Health Plan Medicaid	$1,125.00
Rate for Payer: Ohana Health Plan Medicare	$1,125.00
Rate for Payer: UnitedHealthcare Medicare	$1,125.00
Rate for Payer: University Health Alliance Commercial	$1,640.03

PAIN & SPINE: COOLED RF KIT 17G/50MM/4MM

Facility

$2,250.00

Hospital Charge Code	10500432
Hospital Revenue Code	272
Min. Negotiated Rate	$1,912.50
Max. Negotiated Rate	$2,182.50
Rate for Payer: Cash Price	$1,462.50
Rate for Payer: Health Management Network Commercial	$1,912.50
Rate for Payer: Kaiser Permanente Commercial	$2,025.00
Rate for Payer: MDX Hawaii PPO	$2,182.50

PAIN & SPINE COOLIEF COOLED RADIOFREQUENCY KIT 50

Facility

$2,250.00

Hospital Charge Code	9036238
Hospital Revenue Code	272
Min. Negotiated Rate	$1,125.00
Max. Negotiated Rate	$2,182.50
Rate for Payer: AlohaCare Medicaid	$1,125.00
Rate for Payer: AlohaCare Medicare	$1,125.00
Rate for Payer: Cash Price	$1,462.50
Rate for Payer: Devoted Health Medicare	$1,237.50
Rate for Payer: Hawaii Medical Service Association Medicare	$1,125.00
Rate for Payer: Hawaii Western Management Group Commercial	$2,137.50
Rate for Payer: Health Management Network Commercial	$1,912.50
Rate for Payer: Humana Medicare	$1,125.00
Rate for Payer: Kaiser Permanente Commercial	$2,025.00
Rate for Payer: Kaiser Permanente Medicaid	$1,147.50
Rate for Payer: Kaiser Permanente Medicare	$1,125.00
Rate for Payer: MDX Hawaii PPO	$2,182.50
Rate for Payer: Ohana Health Plan Medicaid	$1,125.00
Rate for Payer: Ohana Health Plan Medicare	$1,125.00
Rate for Payer: UnitedHealthcare Medicare	$1,125.00
Rate for Payer: University Health Alliance Commercial	$1,640.03

PAIN & SPINE COOLIEF COOLED RADIOFREQUENCY KIT 50

Facility

$2,250.00

Hospital Charge Code	9036238
Hospital Revenue Code	272
Min. Negotiated Rate	$1,912.50
Max. Negotiated Rate	$2,182.50
Rate for Payer: Cash Price	$1,462.50
Rate for Payer: Health Management Network Commercial	$1,912.50
Rate for Payer: Kaiser Permanente Commercial	$2,025.00
Rate for Payer: MDX Hawaii PPO	$2,182.50

PAIN & SPINE: DBM PUTTY 1.0cc

Facility

$807.00

Service Code	HCPCS C9359
Hospital Charge Code	11452143
Hospital Revenue Code	278
Min. Negotiated Rate	$451.92
Max. Negotiated Rate	$782.79
Rate for Payer: Cash Price	$524.55
Rate for Payer: Hawaii Western Management Group Commercial	$564.90
Rate for Payer: Health Management Network Commercial	$685.95
Rate for Payer: Kaiser Permanente Commercial	$726.30
Rate for Payer: MDX Hawaii PPO	$782.79
Rate for Payer: University Health Alliance Commercial	$451.92

PAIN & SPINE: DBM PUTTY 1.0cc

Facility

$807.00

Service Code	HCPCS C9359
Hospital Charge Code	11452143
Hospital Revenue Code	278
Min. Negotiated Rate	$403.50
Max. Negotiated Rate	$782.79
Rate for Payer: AlohaCare Medicaid	$403.50
Rate for Payer: AlohaCare Medicare	$403.50
Rate for Payer: Cash Price	$524.55
Rate for Payer: Devoted Health Medicare	$443.85
Rate for Payer: Hawaii Medical Service Association Medicare	$403.50
Rate for Payer: Hawaii Western Management Group Commercial	$564.90
Rate for Payer: Health Management Network Commercial	$685.95
Rate for Payer: Humana Medicare	$403.50
Rate for Payer: Kaiser Permanente Commercial	$726.30
Rate for Payer: Kaiser Permanente Medicaid	$411.57
Rate for Payer: Kaiser Permanente Medicare	$403.50
Rate for Payer: MDX Hawaii PPO	$782.79
Rate for Payer: Ohana Health Plan Medicaid	$403.50
Rate for Payer: Ohana Health Plan Medicare	$403.50
Rate for Payer: UnitedHealthcare Medicare	$403.50
Rate for Payer: University Health Alliance Commercial	$451.92

PAIN & SPINE EXTENSION 3708120 1X8 20CM

Facility

$1,785.00

Service Code	HCPCS C1883
Hospital Charge Code	8806216
Hospital Revenue Code	278
Min. Negotiated Rate	$999.60
Max. Negotiated Rate	$1,731.45
Rate for Payer: Cash Price	$1,160.25
Rate for Payer: Hawaii Western Management Group Commercial	$1,249.50
Rate for Payer: Health Management Network Commercial	$1,517.25
Rate for Payer: Kaiser Permanente Commercial	$1,606.50
Rate for Payer: MDX Hawaii PPO	$1,731.45
Rate for Payer: University Health Alliance Commercial	$999.60

PAIN & SPINE EXTENSION 3708120 1X8 20CM

Facility

$1,785.00

Service Code	HCPCS C1883
Hospital Charge Code	8806216
Hospital Revenue Code	278
Min. Negotiated Rate	$892.50
Max. Negotiated Rate	$1,731.45
Rate for Payer: AlohaCare Medicaid	$892.50
Rate for Payer: AlohaCare Medicare	$892.50
Rate for Payer: Cash Price	$1,160.25
Rate for Payer: Devoted Health Medicare	$981.75
Rate for Payer: Hawaii Medical Service Association Medicare	$892.50
Rate for Payer: Hawaii Western Management Group Commercial	$1,249.50
Rate for Payer: Health Management Network Commercial	$1,517.25
Rate for Payer: Humana Medicare	$892.50
Rate for Payer: Kaiser Permanente Commercial	$1,606.50
Rate for Payer: Kaiser Permanente Medicaid	$910.35
Rate for Payer: Kaiser Permanente Medicare	$892.50
Rate for Payer: MDX Hawaii PPO	$1,731.45
Rate for Payer: Ohana Health Plan Medicaid	$892.50
Rate for Payer: Ohana Health Plan Medicare	$892.50
Rate for Payer: UnitedHealthcare Medicare	$892.50
Rate for Payer: University Health Alliance Commercial	$999.60

PAIN & SPINE EXTENSION 3708140 1X8 20CM

Facility

$1,785.00

Service Code	HCPCS C1883
Hospital Charge Code	8806217
Hospital Revenue Code	278
Min. Negotiated Rate	$999.60
Max. Negotiated Rate	$1,731.45
Rate for Payer: Cash Price	$1,160.25
Rate for Payer: Hawaii Western Management Group Commercial	$1,249.50
Rate for Payer: Health Management Network Commercial	$1,517.25
Rate for Payer: Kaiser Permanente Commercial	$1,606.50
Rate for Payer: MDX Hawaii PPO	$1,731.45
Rate for Payer: University Health Alliance Commercial	$999.60

PAIN & SPINE EXTENSION 3708140 1X8 20CM

Facility

$1,785.00

Service Code	HCPCS C1883
Hospital Charge Code	8806217
Hospital Revenue Code	278
Min. Negotiated Rate	$892.50
Max. Negotiated Rate	$1,731.45
Rate for Payer: AlohaCare Medicaid	$892.50
Rate for Payer: AlohaCare Medicare	$892.50
Rate for Payer: Cash Price	$1,160.25
Rate for Payer: Devoted Health Medicare	$981.75
Rate for Payer: Hawaii Medical Service Association Medicare	$892.50
Rate for Payer: Hawaii Western Management Group Commercial	$1,249.50
Rate for Payer: Health Management Network Commercial	$1,517.25
Rate for Payer: Humana Medicare	$892.50
Rate for Payer: Kaiser Permanente Commercial	$1,606.50
Rate for Payer: Kaiser Permanente Medicaid	$910.35
Rate for Payer: Kaiser Permanente Medicare	$892.50
Rate for Payer: MDX Hawaii PPO	$1,731.45
Rate for Payer: Ohana Health Plan Medicaid	$892.50
Rate for Payer: Ohana Health Plan Medicare	$892.50
Rate for Payer: UnitedHealthcare Medicare	$892.50
Rate for Payer: University Health Alliance Commercial	$999.60

PAIN & SPINE EXTENSION 3708160 1X8 60CM

Facility

$1,785.00

Service Code	HCPCS C1883
Hospital Charge Code	8806218
Hospital Revenue Code	278
Min. Negotiated Rate	$892.50
Max. Negotiated Rate	$1,731.45
Rate for Payer: AlohaCare Medicaid	$892.50
Rate for Payer: AlohaCare Medicare	$892.50
Rate for Payer: Cash Price	$1,160.25
Rate for Payer: Devoted Health Medicare	$981.75
Rate for Payer: Hawaii Medical Service Association Medicare	$892.50
Rate for Payer: Hawaii Western Management Group Commercial	$1,249.50
Rate for Payer: Health Management Network Commercial	$1,517.25
Rate for Payer: Humana Medicare	$892.50
Rate for Payer: Kaiser Permanente Commercial	$1,606.50
Rate for Payer: Kaiser Permanente Medicaid	$910.35
Rate for Payer: Kaiser Permanente Medicare	$892.50
Rate for Payer: MDX Hawaii PPO	$1,731.45
Rate for Payer: Ohana Health Plan Medicaid	$892.50
Rate for Payer: Ohana Health Plan Medicare	$892.50
Rate for Payer: UnitedHealthcare Medicare	$892.50
Rate for Payer: University Health Alliance Commercial	$999.60

PAIN & SPINE EXTENSION 3708160 1X8 60CM

Facility

$1,785.00

Service Code	HCPCS C1883
Hospital Charge Code	8806218
Hospital Revenue Code	278
Min. Negotiated Rate	$999.60
Max. Negotiated Rate	$1,731.45
Rate for Payer: Cash Price	$1,160.25
Rate for Payer: Hawaii Western Management Group Commercial	$1,249.50
Rate for Payer: Health Management Network Commercial	$1,517.25
Rate for Payer: Kaiser Permanente Commercial	$1,606.50
Rate for Payer: MDX Hawaii PPO	$1,731.45
Rate for Payer: University Health Alliance Commercial	$999.60

Know your out-of-pocket cost for care.

All Charges