Samuel Mahelona Memorial Hospital

All Charges

Charge

Type

Setting

Price

PAIN & SPINE EXTENSION 3708220 8-2-4 OCTAPOLAR 20CM

Facility

$2,985.00

Service Code	HCPCS C1883
Hospital Charge Code	8806219
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 EXTENSION 3708220 8-2-4 OCTAPOLAR 20CM

Facility

$2,985.00

Service Code	HCPCS C1883
Hospital Charge Code	8806219
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 EXTENSION 3708240 8-2-4 OCTAPOLAR 40CM

Facility

$2,985.00

Service Code	HCPCS C1883
Hospital Charge Code	8806220
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 EXTENSION 3708240 8-2-4 OCTAPOLAR 40CM

Facility

$2,985.00

Service Code	HCPCS C1883
Hospital Charge Code	8806220
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 EXTENSION 3708260 8-2-4 OCTAPOLAR 60CM

Facility

$2,985.00

Service Code	HCPCS C1883
Hospital Charge Code	8806221
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 EXTENSION 3708260 8-2-4 OCTAPOLAR 60CM

Facility

$2,985.00

Service Code	HCPCS C1883
Hospital Charge Code	8806221
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 EXTENSION 3708320 4X8 LZ .110SP 20CM

Facility

$2,085.00

Service Code	HCPCS C1883
Hospital Charge Code	8806222
Hospital Revenue Code	278
Min. Negotiated Rate	$1,167.60
Max. Negotiated Rate	$2,022.45
Rate for Payer: Cash Price	$1,355.25
Rate for Payer: Hawaii Western Management Group Commercial	$1,459.50
Rate for Payer: Health Management Network Commercial	$1,772.25
Rate for Payer: Kaiser Permanente Commercial	$1,876.50
Rate for Payer: MDX Hawaii PPO	$2,022.45
Rate for Payer: University Health Alliance Commercial	$1,167.60

PAIN & SPINE EXTENSION 3708320 4X8 LZ .110SP 20CM

Facility

$2,085.00

Service Code	HCPCS C1883
Hospital Charge Code	8806222
Hospital Revenue Code	278
Min. Negotiated Rate	$1,042.50
Max. Negotiated Rate	$2,022.45
Rate for Payer: AlohaCare Medicaid	$1,042.50
Rate for Payer: AlohaCare Medicare	$1,042.50
Rate for Payer: Cash Price	$1,355.25
Rate for Payer: Devoted Health Medicare	$1,146.75
Rate for Payer: Hawaii Medical Service Association Medicare	$1,042.50
Rate for Payer: Hawaii Western Management Group Commercial	$1,459.50
Rate for Payer: Health Management Network Commercial	$1,772.25
Rate for Payer: Humana Medicare	$1,042.50
Rate for Payer: Kaiser Permanente Commercial	$1,876.50
Rate for Payer: Kaiser Permanente Medicaid	$1,063.35
Rate for Payer: Kaiser Permanente Medicare	$1,042.50
Rate for Payer: MDX Hawaii PPO	$2,022.45
Rate for Payer: Ohana Health Plan Medicaid	$1,042.50
Rate for Payer: Ohana Health Plan Medicare	$1,042.50
Rate for Payer: UnitedHealthcare Medicare	$1,042.50
Rate for Payer: University Health Alliance Commercial	$1,167.60

PAIN & SPINE EXTENSION 3708340 4X8 LZ .110SP 40CM

Facility

$2,085.00

Service Code	HCPCS C1883
Hospital Charge Code	8806223
Hospital Revenue Code	278
Min. Negotiated Rate	$1,167.60
Max. Negotiated Rate	$2,022.45
Rate for Payer: Cash Price	$1,355.25
Rate for Payer: Hawaii Western Management Group Commercial	$1,459.50
Rate for Payer: Health Management Network Commercial	$1,772.25
Rate for Payer: Kaiser Permanente Commercial	$1,876.50
Rate for Payer: MDX Hawaii PPO	$2,022.45
Rate for Payer: University Health Alliance Commercial	$1,167.60

PAIN & SPINE EXTENSION 3708340 4X8 LZ .110SP 40CM

Facility

$2,085.00

Service Code	HCPCS C1883
Hospital Charge Code	8806223
Hospital Revenue Code	278
Min. Negotiated Rate	$1,042.50
Max. Negotiated Rate	$2,022.45
Rate for Payer: AlohaCare Medicaid	$1,042.50
Rate for Payer: AlohaCare Medicare	$1,042.50
Rate for Payer: Cash Price	$1,355.25
Rate for Payer: Devoted Health Medicare	$1,146.75
Rate for Payer: Hawaii Medical Service Association Medicare	$1,042.50
Rate for Payer: Hawaii Western Management Group Commercial	$1,459.50
Rate for Payer: Health Management Network Commercial	$1,772.25
Rate for Payer: Humana Medicare	$1,042.50
Rate for Payer: Kaiser Permanente Commercial	$1,876.50
Rate for Payer: Kaiser Permanente Medicaid	$1,063.35
Rate for Payer: Kaiser Permanente Medicare	$1,042.50
Rate for Payer: MDX Hawaii PPO	$2,022.45
Rate for Payer: Ohana Health Plan Medicaid	$1,042.50
Rate for Payer: Ohana Health Plan Medicare	$1,042.50
Rate for Payer: UnitedHealthcare Medicare	$1,042.50
Rate for Payer: University Health Alliance Commercial	$1,167.60

PAIN & SPINE EXTENSION 3708360 4X8 LZ .110SP 60CM

Facility

$2,085.00

Service Code	HCPCS C1883
Hospital Charge Code	8806224
Hospital Revenue Code	278
Min. Negotiated Rate	$1,042.50
Max. Negotiated Rate	$2,022.45
Rate for Payer: AlohaCare Medicaid	$1,042.50
Rate for Payer: AlohaCare Medicare	$1,042.50
Rate for Payer: Cash Price	$1,355.25
Rate for Payer: Devoted Health Medicare	$1,146.75
Rate for Payer: Hawaii Medical Service Association Medicare	$1,042.50
Rate for Payer: Hawaii Western Management Group Commercial	$1,459.50
Rate for Payer: Health Management Network Commercial	$1,772.25
Rate for Payer: Humana Medicare	$1,042.50
Rate for Payer: Kaiser Permanente Commercial	$1,876.50
Rate for Payer: Kaiser Permanente Medicaid	$1,063.35
Rate for Payer: Kaiser Permanente Medicare	$1,042.50
Rate for Payer: MDX Hawaii PPO	$2,022.45
Rate for Payer: Ohana Health Plan Medicaid	$1,042.50
Rate for Payer: Ohana Health Plan Medicare	$1,042.50
Rate for Payer: UnitedHealthcare Medicare	$1,042.50
Rate for Payer: University Health Alliance Commercial	$1,167.60

PAIN & SPINE EXTENSION 3708360 4X8 LZ .110SP 60CM

Facility

$2,085.00

Service Code	HCPCS C1883
Hospital Charge Code	8806224
Hospital Revenue Code	278
Min. Negotiated Rate	$1,167.60
Max. Negotiated Rate	$2,022.45
Rate for Payer: Cash Price	$1,355.25
Rate for Payer: Hawaii Western Management Group Commercial	$1,459.50
Rate for Payer: Health Management Network Commercial	$1,772.25
Rate for Payer: Kaiser Permanente Commercial	$1,876.50
Rate for Payer: MDX Hawaii PPO	$2,022.45
Rate for Payer: University Health Alliance Commercial	$1,167.60

PAIN & SPINE: Injector Transfer Tube 4.2MM

Facility

$242.00

Hospital Charge Code	11525537
Hospital Revenue Code	272
Min. Negotiated Rate	$205.70
Max. Negotiated Rate	$234.74
Rate for Payer: Cash Price	$157.30
Rate for Payer: Health Management Network Commercial	$205.70
Rate for Payer: Kaiser Permanente Commercial	$217.80
Rate for Payer: MDX Hawaii PPO	$234.74

PAIN & SPINE: Injector Transfer Tube 4.2MM

Facility

$242.00

Hospital Charge Code	11525537
Hospital Revenue Code	272
Min. Negotiated Rate	$121.00
Max. Negotiated Rate	$234.74
Rate for Payer: AlohaCare Medicaid	$121.00
Rate for Payer: AlohaCare Medicare	$121.00
Rate for Payer: Cash Price	$157.30
Rate for Payer: Devoted Health Medicare	$133.10
Rate for Payer: Hawaii Medical Service Association Medicare	$121.00
Rate for Payer: Hawaii Western Management Group Commercial	$229.90
Rate for Payer: Health Management Network Commercial	$205.70
Rate for Payer: Humana Medicare	$121.00
Rate for Payer: Kaiser Permanente Commercial	$217.80
Rate for Payer: Kaiser Permanente Medicaid	$123.42
Rate for Payer: Kaiser Permanente Medicare	$121.00
Rate for Payer: MDX Hawaii PPO	$234.74
Rate for Payer: Ohana Health Plan Medicaid	$121.00
Rate for Payer: Ohana Health Plan Medicare	$121.00
Rate for Payer: UnitedHealthcare Medicare	$121.00
Rate for Payer: University Health Alliance Commercial	$176.39

PAIN & SPINE: Injector Transfer Tube 5.0MM/ 5.8MM

Facility

$242.00

Hospital Charge Code	11525538
Hospital Revenue Code	272
Min. Negotiated Rate	$121.00
Max. Negotiated Rate	$234.74
Rate for Payer: AlohaCare Medicaid	$121.00
Rate for Payer: AlohaCare Medicare	$121.00
Rate for Payer: Cash Price	$157.30
Rate for Payer: Devoted Health Medicare	$133.10
Rate for Payer: Hawaii Medical Service Association Medicare	$121.00
Rate for Payer: Hawaii Western Management Group Commercial	$229.90
Rate for Payer: Health Management Network Commercial	$205.70
Rate for Payer: Humana Medicare	$121.00
Rate for Payer: Kaiser Permanente Commercial	$217.80
Rate for Payer: Kaiser Permanente Medicaid	$123.42
Rate for Payer: Kaiser Permanente Medicare	$121.00
Rate for Payer: MDX Hawaii PPO	$234.74
Rate for Payer: Ohana Health Plan Medicaid	$121.00
Rate for Payer: Ohana Health Plan Medicare	$121.00
Rate for Payer: UnitedHealthcare Medicare	$121.00
Rate for Payer: University Health Alliance Commercial	$176.39

PAIN & SPINE: Injector Transfer Tube 5.0MM/ 5.8MM

Facility

$242.00

Hospital Charge Code	11525538
Hospital Revenue Code	272
Min. Negotiated Rate	$205.70
Max. Negotiated Rate	$234.74
Rate for Payer: Cash Price	$157.30
Rate for Payer: Health Management Network Commercial	$205.70
Rate for Payer: Kaiser Permanente Commercial	$217.80
Rate for Payer: MDX Hawaii PPO	$234.74

PAIN & SPINE: INJEX BI-WING ANCHOR-ACCESSORY KIT

Facility

$1,117.00

Hospital Charge Code	11213637
Hospital Revenue Code	278
Min. Negotiated Rate	$625.52
Max. Negotiated Rate	$1,083.49
Rate for Payer: Cash Price	$726.05
Rate for Payer: Hawaii Western Management Group Commercial	$781.90
Rate for Payer: Health Management Network Commercial	$949.45
Rate for Payer: Kaiser Permanente Commercial	$1,005.30
Rate for Payer: MDX Hawaii PPO	$1,083.49
Rate for Payer: University Health Alliance Commercial	$625.52

PAIN & SPINE: INJEX BI-WING ANCHOR-ACCESSORY KIT

Facility

$1,117.00

Hospital Charge Code	11213637
Hospital Revenue Code	278
Min. Negotiated Rate	$558.50
Max. Negotiated Rate	$1,083.49
Rate for Payer: AlohaCare Medicaid	$558.50
Rate for Payer: AlohaCare Medicare	$558.50
Rate for Payer: Cash Price	$726.05
Rate for Payer: Devoted Health Medicare	$614.35
Rate for Payer: Hawaii Medical Service Association Medicare	$558.50
Rate for Payer: Hawaii Western Management Group Commercial	$781.90
Rate for Payer: Health Management Network Commercial	$949.45
Rate for Payer: Humana Medicare	$558.50
Rate for Payer: Kaiser Permanente Commercial	$1,005.30
Rate for Payer: Kaiser Permanente Medicaid	$569.67
Rate for Payer: Kaiser Permanente Medicare	$558.50
Rate for Payer: MDX Hawaii PPO	$1,083.49
Rate for Payer: Ohana Health Plan Medicaid	$558.50
Rate for Payer: Ohana Health Plan Medicare	$558.50
Rate for Payer: UnitedHealthcare Medicare	$558.50
Rate for Payer: University Health Alliance Commercial	$625.52

PAIN & SPINE INS 97702 PRIME ADVANCED MRI

Facility

$25,000.00

Service Code	HCPCS C1767
Hospital Charge Code	8806231
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 & SPINE INS 97702 PRIME ADVANCED MRI

Facility

$25,000.00

Service Code	HCPCS C1767
Hospital Charge Code	8806231
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 & SPINE:INTRACEPT ACCESS INSTRUMENT (GEN 3)

Facility

$4,360.00

Hospital Charge Code	12258023
Hospital Revenue Code	272
Min. Negotiated Rate	$2,180.00
Max. Negotiated Rate	$4,229.20
Rate for Payer: AlohaCare Medicaid	$2,180.00
Rate for Payer: AlohaCare Medicare	$2,180.00
Rate for Payer: Cash Price	$2,834.00
Rate for Payer: Devoted Health Medicare	$2,398.00
Rate for Payer: Hawaii Medical Service Association Medicare	$2,180.00
Rate for Payer: Hawaii Western Management Group Commercial	$4,142.00
Rate for Payer: Health Management Network Commercial	$3,706.00
Rate for Payer: Humana Medicare	$2,180.00
Rate for Payer: Kaiser Permanente Commercial	$3,924.00
Rate for Payer: Kaiser Permanente Medicaid	$2,223.60
Rate for Payer: Kaiser Permanente Medicare	$2,180.00
Rate for Payer: MDX Hawaii PPO	$4,229.20
Rate for Payer: Ohana Health Plan Medicaid	$2,180.00
Rate for Payer: Ohana Health Plan Medicare	$2,180.00
Rate for Payer: UnitedHealthcare Medicare	$2,180.00
Rate for Payer: University Health Alliance Commercial	$3,178.00

PAIN & SPINE:INTRACEPT ACCESS INSTRUMENT (GEN 3)

Facility

$4,360.00

Hospital Charge Code	12258023
Hospital Revenue Code	272
Min. Negotiated Rate	$3,706.00
Max. Negotiated Rate	$4,229.20
Rate for Payer: Cash Price	$2,834.00
Rate for Payer: Health Management Network Commercial	$3,706.00
Rate for Payer: Kaiser Permanente Commercial	$3,924.00
Rate for Payer: MDX Hawaii PPO	$4,229.20

PAIN & SPINE: INTRACEPT ACCESS INSTRUMENTS

Facility

$3,600.00

Hospital Charge Code	10114996
Hospital Revenue Code	272
Min. Negotiated Rate	$1,800.00
Max. Negotiated Rate	$3,492.00
Rate for Payer: AlohaCare Medicaid	$1,800.00
Rate for Payer: AlohaCare Medicare	$1,800.00
Rate for Payer: Cash Price	$2,340.00
Rate for Payer: Devoted Health Medicare	$1,980.00
Rate for Payer: Hawaii Medical Service Association Medicare	$1,800.00
Rate for Payer: Hawaii Western Management Group Commercial	$3,420.00
Rate for Payer: Health Management Network Commercial	$3,060.00
Rate for Payer: Humana Medicare	$1,800.00
Rate for Payer: Kaiser Permanente Commercial	$3,240.00
Rate for Payer: Kaiser Permanente Medicaid	$1,836.00
Rate for Payer: Kaiser Permanente Medicare	$1,800.00
Rate for Payer: MDX Hawaii PPO	$3,492.00
Rate for Payer: Ohana Health Plan Medicaid	$1,800.00
Rate for Payer: Ohana Health Plan Medicare	$1,800.00
Rate for Payer: UnitedHealthcare Medicare	$1,800.00
Rate for Payer: University Health Alliance Commercial	$2,624.04

PAIN & SPINE: INTRACEPT ACCESS INSTRUMENTS

Facility

$3,600.00

Hospital Charge Code	10114996
Hospital Revenue Code	272
Min. Negotiated Rate	$3,060.00
Max. Negotiated Rate	$3,492.00
Rate for Payer: Cash Price	$2,340.00
Rate for Payer: Health Management Network Commercial	$3,060.00
Rate for Payer: Kaiser Permanente Commercial	$3,240.00
Rate for Payer: MDX Hawaii PPO	$3,492.00

PAIN & SPINE: INTRACEPT ADDITIONAL LEVEL ACCESS INTRUMENTS

Facility

$1,995.00

Hospital Charge Code	10114995
Hospital Revenue Code	272
Min. Negotiated Rate	$1,695.75
Max. Negotiated Rate	$1,935.15
Rate for Payer: Cash Price	$1,296.75
Rate for Payer: Health Management Network Commercial	$1,695.75
Rate for Payer: Kaiser Permanente Commercial	$1,795.50
Rate for Payer: MDX Hawaii PPO	$1,935.15

Know your out-of-pocket cost for care.

All Charges