Samuel Mahelona Memorial Hospital

All Charges

Charge

Type

Setting

Price

PAIN & SPINE: INTRACEPT ADDITIONAL LEVEL ACCESS INTRUMENTS

Facility

$1,995.00

Hospital Charge Code	10114995
Hospital Revenue Code	272
Min. Negotiated Rate	$997.50
Max. Negotiated Rate	$1,935.15
Rate for Payer: AlohaCare Medicaid	$997.50
Rate for Payer: AlohaCare Medicare	$997.50
Rate for Payer: Cash Price	$1,296.75
Rate for Payer: Devoted Health Medicare	$1,097.25
Rate for Payer: Hawaii Medical Service Association Medicare	$997.50
Rate for Payer: Hawaii Western Management Group Commercial	$1,895.25
Rate for Payer: Health Management Network Commercial	$1,695.75
Rate for Payer: Humana Medicare	$997.50
Rate for Payer: Kaiser Permanente Commercial	$1,795.50
Rate for Payer: Kaiser Permanente Medicaid	$1,017.45
Rate for Payer: Kaiser Permanente Medicare	$997.50
Rate for Payer: MDX Hawaii PPO	$1,935.15
Rate for Payer: Ohana Health Plan Medicaid	$997.50
Rate for Payer: Ohana Health Plan Medicare	$997.50
Rate for Payer: UnitedHealthcare Medicare	$997.50
Rate for Payer: University Health Alliance Commercial	$1,454.16

PAIN & SPINE: INTRACEPT RADIOFREQUENCY GENERATOR PROC FEE

Facility

$963.00

Hospital Charge Code	10114994
Hospital Revenue Code	272
Min. Negotiated Rate	$818.55
Max. Negotiated Rate	$934.11
Rate for Payer: Cash Price	$625.95
Rate for Payer: Health Management Network Commercial	$818.55
Rate for Payer: Kaiser Permanente Commercial	$866.70
Rate for Payer: MDX Hawaii PPO	$934.11

PAIN & SPINE: INTRACEPT RADIOFREQUENCY GENERATOR PROC FEE

Facility

$963.00

Hospital Charge Code	10114994
Hospital Revenue Code	272
Min. Negotiated Rate	$481.50
Max. Negotiated Rate	$934.11
Rate for Payer: AlohaCare Medicaid	$481.50
Rate for Payer: AlohaCare Medicare	$481.50
Rate for Payer: Cash Price	$625.95
Rate for Payer: Devoted Health Medicare	$529.65
Rate for Payer: Hawaii Medical Service Association Medicare	$481.50
Rate for Payer: Hawaii Western Management Group Commercial	$914.85
Rate for Payer: Health Management Network Commercial	$818.55
Rate for Payer: Humana Medicare	$481.50
Rate for Payer: Kaiser Permanente Commercial	$866.70
Rate for Payer: Kaiser Permanente Medicaid	$491.13
Rate for Payer: Kaiser Permanente Medicare	$481.50
Rate for Payer: MDX Hawaii PPO	$934.11
Rate for Payer: Ohana Health Plan Medicaid	$481.50
Rate for Payer: Ohana Health Plan Medicare	$481.50
Rate for Payer: UnitedHealthcare Medicare	$481.50
Rate for Payer: University Health Alliance Commercial	$701.93

PAIN & SPINE: INTRACEPT RADIOFREQUENCY PROBE

Facility

$8,400.00

Hospital Charge Code	10114997
Hospital Revenue Code	272
Min. Negotiated Rate	$4,200.00
Max. Negotiated Rate	$8,148.00
Rate for Payer: AlohaCare Medicaid	$4,200.00
Rate for Payer: AlohaCare Medicare	$4,200.00
Rate for Payer: Cash Price	$5,460.00
Rate for Payer: Devoted Health Medicare	$4,620.00
Rate for Payer: Hawaii Medical Service Association Medicare	$4,200.00
Rate for Payer: Hawaii Western Management Group Commercial	$7,980.00
Rate for Payer: Health Management Network Commercial	$7,140.00
Rate for Payer: Humana Medicare	$4,200.00
Rate for Payer: Kaiser Permanente Commercial	$7,560.00
Rate for Payer: Kaiser Permanente Medicaid	$4,284.00
Rate for Payer: Kaiser Permanente Medicare	$4,200.00
Rate for Payer: MDX Hawaii PPO	$8,148.00
Rate for Payer: Ohana Health Plan Medicaid	$4,200.00
Rate for Payer: Ohana Health Plan Medicare	$4,200.00
Rate for Payer: UnitedHealthcare Medicare	$4,200.00
Rate for Payer: University Health Alliance Commercial	$6,122.76

PAIN & SPINE: INTRACEPT RADIOFREQUENCY PROBE

Facility

$8,400.00

Hospital Charge Code	10114997
Hospital Revenue Code	272
Min. Negotiated Rate	$7,140.00
Max. Negotiated Rate	$8,148.00
Rate for Payer: Cash Price	$5,460.00
Rate for Payer: Health Management Network Commercial	$7,140.00
Rate for Payer: Kaiser Permanente Commercial	$7,560.00
Rate for Payer: MDX Hawaii PPO	$8,148.00

PAIN & SPINE:INTRACEPT RADIOFREQUENCY PROBE (GEN 3)

Facility

$8,840.00

Service Code	HCPCS C1889
Hospital Charge Code	12258024
Hospital Revenue Code	278
Min. Negotiated Rate	$4,420.00
Max. Negotiated Rate	$8,574.80
Rate for Payer: AlohaCare Medicaid	$4,420.00
Rate for Payer: AlohaCare Medicare	$4,420.00
Rate for Payer: Cash Price	$5,746.00
Rate for Payer: Devoted Health Medicare	$4,862.00
Rate for Payer: Hawaii Medical Service Association Medicare	$4,420.00
Rate for Payer: Hawaii Western Management Group Commercial	$6,188.00
Rate for Payer: Health Management Network Commercial	$7,514.00
Rate for Payer: Humana Medicare	$4,420.00
Rate for Payer: Kaiser Permanente Commercial	$7,956.00
Rate for Payer: Kaiser Permanente Medicaid	$4,508.40
Rate for Payer: Kaiser Permanente Medicare	$4,420.00
Rate for Payer: MDX Hawaii PPO	$8,574.80
Rate for Payer: Ohana Health Plan Medicaid	$4,420.00
Rate for Payer: Ohana Health Plan Medicare	$4,420.00
Rate for Payer: UnitedHealthcare Medicare	$4,420.00
Rate for Payer: University Health Alliance Commercial	$4,950.40

PAIN & SPINE:INTRACEPT RADIOFREQUENCY PROBE (GEN 3)

Facility

$8,840.00

Service Code	HCPCS C1889
Hospital Charge Code	12258024
Hospital Revenue Code	278
Min. Negotiated Rate	$4,950.40
Max. Negotiated Rate	$8,574.80
Rate for Payer: Cash Price	$5,746.00
Rate for Payer: Hawaii Western Management Group Commercial	$6,188.00
Rate for Payer: Health Management Network Commercial	$7,514.00
Rate for Payer: Kaiser Permanente Commercial	$7,956.00
Rate for Payer: MDX Hawaii PPO	$8,574.80
Rate for Payer: University Health Alliance Commercial	$4,950.40

PAIN & SPINE INTRODUCER AI0001 50MM 10MM ENHANCED

Facility

$563.00

Hospital Charge Code	9586292
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 INTRODUCER AI0001 50MM 10MM ENHANCED

Facility

$563.00

Hospital Charge Code	9586292
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: INTRODUCER AI0002 100MM 10MM ENHANCED

Facility

$563.00

Hospital Charge Code	9586293
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: INTRODUCER AI0002 100MM 10MM ENHANCED

Facility

$563.00

Hospital Charge Code	9586293
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: INTRODUCER AI0003 150MM 10MM ENHANCED

Facility

$563.00

Hospital Charge Code	9586294
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: INTRODUCER AI0003 150MM 10MM ENHANCED

Facility

$563.00

Hospital Charge Code	9586294
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 INTRODUCER AI0004 50MM 12MM ENHANCED

Facility

$563.00

Hospital Charge Code	9586295
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 INTRODUCER AI0004 50MM 12MM ENHANCED

Facility

$563.00

Hospital Charge Code	9586295
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: INTRODUCER AI0005 100MM 12MM ENHANCED

Facility

$563.00

Hospital Charge Code	9583512
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: INTRODUCER AI0005 100MM 12MM ENHANCED

Facility

$563.00

Hospital Charge Code	9583512
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: INTRODUCER AI0006 150MM 12MM ENHANCED

Facility

$563.00

Hospital Charge Code	9586296
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: INTRODUCER AI0006 150MM 12MM ENHANCED

Facility

$563.00

Hospital Charge Code	9586296
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: iVAS Access Cannula 10g

Facility

$299.00

Hospital Charge Code	11525540
Hospital Revenue Code	272
Min. Negotiated Rate	$149.50
Max. Negotiated Rate	$290.03
Rate for Payer: AlohaCare Medicaid	$149.50
Rate for Payer: AlohaCare Medicare	$149.50
Rate for Payer: Cash Price	$194.35
Rate for Payer: Devoted Health Medicare	$164.45
Rate for Payer: Hawaii Medical Service Association Medicare	$149.50
Rate for Payer: Hawaii Western Management Group Commercial	$284.05
Rate for Payer: Health Management Network Commercial	$254.15
Rate for Payer: Humana Medicare	$149.50
Rate for Payer: Kaiser Permanente Commercial	$269.10
Rate for Payer: Kaiser Permanente Medicaid	$152.49
Rate for Payer: Kaiser Permanente Medicare	$149.50
Rate for Payer: MDX Hawaii PPO	$290.03
Rate for Payer: Ohana Health Plan Medicaid	$149.50
Rate for Payer: Ohana Health Plan Medicare	$149.50
Rate for Payer: UnitedHealthcare Medicare	$149.50
Rate for Payer: University Health Alliance Commercial	$217.94

PAIN & SPINE: iVAS Access Cannula 10g

Facility

$299.00

Hospital Charge Code	11525540
Hospital Revenue Code	272
Min. Negotiated Rate	$254.15
Max. Negotiated Rate	$290.03
Rate for Payer: Cash Price	$194.35
Rate for Payer: Health Management Network Commercial	$254.15
Rate for Payer: Kaiser Permanente Commercial	$269.10
Rate for Payer: MDX Hawaii PPO	$290.03

PAIN & SPINE KIT 8551 SYNCHROMED REFILL PROGRAMABLE PUMP

Facility

$120.00

Hospital Charge Code	8805348
Hospital Revenue Code	272
Min. Negotiated Rate	$60.00
Max. Negotiated Rate	$116.40
Rate for Payer: AlohaCare Medicaid	$60.00
Rate for Payer: AlohaCare Medicare	$60.00
Rate for Payer: Cash Price	$78.00
Rate for Payer: Devoted Health Medicare	$66.00
Rate for Payer: Hawaii Medical Service Association Medicare	$60.00
Rate for Payer: Hawaii Western Management Group Commercial	$114.00
Rate for Payer: Health Management Network Commercial	$102.00
Rate for Payer: Humana Medicare	$60.00
Rate for Payer: Kaiser Permanente Commercial	$108.00
Rate for Payer: Kaiser Permanente Medicaid	$61.20
Rate for Payer: Kaiser Permanente Medicare	$60.00
Rate for Payer: MDX Hawaii PPO	$116.40
Rate for Payer: Ohana Health Plan Medicaid	$60.00
Rate for Payer: Ohana Health Plan Medicare	$60.00
Rate for Payer: UnitedHealthcare Medicare	$60.00
Rate for Payer: University Health Alliance Commercial	$87.47

PAIN & SPINE KIT 8551 SYNCHROMED REFILL PROGRAMABLE PUMP

Facility

$120.00

Hospital Charge Code	8805348
Hospital Revenue Code	272
Min. Negotiated Rate	$102.00
Max. Negotiated Rate	$116.40
Rate for Payer: Cash Price	$78.00
Rate for Payer: Health Management Network Commercial	$102.00
Rate for Payer: Kaiser Permanente Commercial	$108.00
Rate for Payer: MDX Hawaii PPO	$116.40

PAIN & SPINE LEAD 34387-56 PISCES QUAD KIT 56CM

Facility

$2,985.00

Service Code	HCPCS C1778
Hospital Charge Code	8806201
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 LEAD 34387-56 PISCES QUAD KIT 56CM

Facility

$2,985.00

Service Code	HCPCS C1778
Hospital Charge Code	8806201
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

Know your out-of-pocket cost for care.

All Charges