Samuel Mahelona Memorial Hospital

All Charges

Charge

Type

Setting

Price

PAIN & SPINE LEAD 977A275 3MM SUBCOMPACT 1X8 MRI

Facility

$4,400.00

Service Code	HCPCS C1778
Hospital Charge Code	8806229
Hospital Revenue Code	278
Min. Negotiated Rate	$2,200.00
Max. Negotiated Rate	$4,268.00
Rate for Payer: AlohaCare Medicaid	$2,200.00
Rate for Payer: AlohaCare Medicare	$2,200.00
Rate for Payer: Cash Price	$2,860.00
Rate for Payer: Devoted Health Medicare	$2,420.00
Rate for Payer: Hawaii Medical Service Association Medicare	$2,200.00
Rate for Payer: Hawaii Western Management Group Commercial	$3,080.00
Rate for Payer: Health Management Network Commercial	$3,740.00
Rate for Payer: Humana Medicare	$2,200.00
Rate for Payer: Kaiser Permanente Commercial	$3,960.00
Rate for Payer: Kaiser Permanente Medicaid	$2,244.00
Rate for Payer: Kaiser Permanente Medicare	$2,200.00
Rate for Payer: MDX Hawaii PPO	$4,268.00
Rate for Payer: Ohana Health Plan Medicaid	$2,200.00
Rate for Payer: Ohana Health Plan Medicare	$2,200.00
Rate for Payer: UnitedHealthcare Medicare	$2,200.00
Rate for Payer: University Health Alliance Commercial	$2,464.00

PAIN & SPINE LEAD 977A290 3MM SUBCOMPACT 1X8 MRI

Facility

$4,400.00

Service Code	HCPCS C1778
Hospital Charge Code	8806230
Hospital Revenue Code	278
Min. Negotiated Rate	$2,464.00
Max. Negotiated Rate	$4,268.00
Rate for Payer: Cash Price	$2,860.00
Rate for Payer: Hawaii Western Management Group Commercial	$3,080.00
Rate for Payer: Health Management Network Commercial	$3,740.00
Rate for Payer: Kaiser Permanente Commercial	$3,960.00
Rate for Payer: MDX Hawaii PPO	$4,268.00
Rate for Payer: University Health Alliance Commercial	$2,464.00

PAIN & SPINE LEAD 977A290 3MM SUBCOMPACT 1X8 MRI

Facility

$4,400.00

Service Code	HCPCS C1778
Hospital Charge Code	8806230
Hospital Revenue Code	278
Min. Negotiated Rate	$2,200.00
Max. Negotiated Rate	$4,268.00
Rate for Payer: AlohaCare Medicaid	$2,200.00
Rate for Payer: AlohaCare Medicare	$2,200.00
Rate for Payer: Cash Price	$2,860.00
Rate for Payer: Devoted Health Medicare	$2,420.00
Rate for Payer: Hawaii Medical Service Association Medicare	$2,200.00
Rate for Payer: Hawaii Western Management Group Commercial	$3,080.00
Rate for Payer: Health Management Network Commercial	$3,740.00
Rate for Payer: Humana Medicare	$2,200.00
Rate for Payer: Kaiser Permanente Commercial	$3,960.00
Rate for Payer: Kaiser Permanente Medicaid	$2,244.00
Rate for Payer: Kaiser Permanente Medicare	$2,200.00
Rate for Payer: MDX Hawaii PPO	$4,268.00
Rate for Payer: Ohana Health Plan Medicaid	$2,200.00
Rate for Payer: Ohana Health Plan Medicare	$2,200.00
Rate for Payer: UnitedHealthcare Medicare	$2,200.00
Rate for Payer: University Health Alliance Commercial	$2,464.00

PAIN & SPINE LEAD 977C165 SPECIFY SURESCAN MRI 5-6-5

Facility

$14,000.00

Service Code	HCPCS C1778
Hospital Charge Code	8806210
Hospital Revenue Code	278
Min. Negotiated Rate	$7,840.00
Max. Negotiated Rate	$13,580.00
Rate for Payer: Cash Price	$9,100.00
Rate for Payer: Hawaii Western Management Group Commercial	$9,800.00
Rate for Payer: Health Management Network Commercial	$11,900.00
Rate for Payer: Kaiser Permanente Commercial	$12,600.00
Rate for Payer: MDX Hawaii PPO	$13,580.00
Rate for Payer: University Health Alliance Commercial	$7,840.00

PAIN & SPINE LEAD 977C165 SPECIFY SURESCAN MRI 5-6-5

Facility

$14,000.00

Service Code	HCPCS C1778
Hospital Charge Code	8806210
Hospital Revenue Code	278
Min. Negotiated Rate	$7,000.00
Max. Negotiated Rate	$13,580.00
Rate for Payer: AlohaCare Medicaid	$7,000.00
Rate for Payer: AlohaCare Medicare	$7,000.00
Rate for Payer: Cash Price	$9,100.00
Rate for Payer: Devoted Health Medicare	$7,700.00
Rate for Payer: Hawaii Medical Service Association Medicare	$7,000.00
Rate for Payer: Hawaii Western Management Group Commercial	$9,800.00
Rate for Payer: Health Management Network Commercial	$11,900.00
Rate for Payer: Humana Medicare	$7,000.00
Rate for Payer: Kaiser Permanente Commercial	$12,600.00
Rate for Payer: Kaiser Permanente Medicaid	$7,140.00
Rate for Payer: Kaiser Permanente Medicare	$7,000.00
Rate for Payer: MDX Hawaii PPO	$13,580.00
Rate for Payer: Ohana Health Plan Medicaid	$7,000.00
Rate for Payer: Ohana Health Plan Medicare	$7,000.00
Rate for Payer: UnitedHealthcare Medicare	$7,000.00
Rate for Payer: University Health Alliance Commercial	$7,840.00

PAIN & SPINE LEAD 977C190 SPECIFY SURESCAN MRI 5-6-5

Facility

$14,000.00

Service Code	HCPCS C1778
Hospital Charge Code	8806211
Hospital Revenue Code	278
Min. Negotiated Rate	$7,000.00
Max. Negotiated Rate	$13,580.00
Rate for Payer: AlohaCare Medicaid	$7,000.00
Rate for Payer: AlohaCare Medicare	$7,000.00
Rate for Payer: Cash Price	$9,100.00
Rate for Payer: Devoted Health Medicare	$7,700.00
Rate for Payer: Hawaii Medical Service Association Medicare	$7,000.00
Rate for Payer: Hawaii Western Management Group Commercial	$9,800.00
Rate for Payer: Health Management Network Commercial	$11,900.00
Rate for Payer: Humana Medicare	$7,000.00
Rate for Payer: Kaiser Permanente Commercial	$12,600.00
Rate for Payer: Kaiser Permanente Medicaid	$7,140.00
Rate for Payer: Kaiser Permanente Medicare	$7,000.00
Rate for Payer: MDX Hawaii PPO	$13,580.00
Rate for Payer: Ohana Health Plan Medicaid	$7,000.00
Rate for Payer: Ohana Health Plan Medicare	$7,000.00
Rate for Payer: UnitedHealthcare Medicare	$7,000.00
Rate for Payer: University Health Alliance Commercial	$7,840.00

PAIN & SPINE LEAD 977C190 SPECIFY SURESCAN MRI 5-6-5

Facility

$14,000.00

Service Code	HCPCS C1778
Hospital Charge Code	8806211
Hospital Revenue Code	278
Min. Negotiated Rate	$7,840.00
Max. Negotiated Rate	$13,580.00
Rate for Payer: Cash Price	$9,100.00
Rate for Payer: Hawaii Western Management Group Commercial	$9,800.00
Rate for Payer: Health Management Network Commercial	$11,900.00
Rate for Payer: Kaiser Permanente Commercial	$12,600.00
Rate for Payer: MDX Hawaii PPO	$13,580.00
Rate for Payer: University Health Alliance Commercial	$7,840.00

PAIN & SPINE LEAD 977C265 SPECIFY SURESCAN MRI 2X8

Facility

$14,000.00

Service Code	HCPCS C1778
Hospital Charge Code	8806212
Hospital Revenue Code	278
Min. Negotiated Rate	$7,840.00
Max. Negotiated Rate	$13,580.00
Rate for Payer: Cash Price	$9,100.00
Rate for Payer: Hawaii Western Management Group Commercial	$9,800.00
Rate for Payer: Health Management Network Commercial	$11,900.00
Rate for Payer: Kaiser Permanente Commercial	$12,600.00
Rate for Payer: MDX Hawaii PPO	$13,580.00
Rate for Payer: University Health Alliance Commercial	$7,840.00

PAIN & SPINE LEAD 977C265 SPECIFY SURESCAN MRI 2X8

Facility

$14,000.00

Service Code	HCPCS C1778
Hospital Charge Code	8806212
Hospital Revenue Code	278
Min. Negotiated Rate	$7,000.00
Max. Negotiated Rate	$13,580.00
Rate for Payer: AlohaCare Medicaid	$7,000.00
Rate for Payer: AlohaCare Medicare	$7,000.00
Rate for Payer: Cash Price	$9,100.00
Rate for Payer: Devoted Health Medicare	$7,700.00
Rate for Payer: Hawaii Medical Service Association Medicare	$7,000.00
Rate for Payer: Hawaii Western Management Group Commercial	$9,800.00
Rate for Payer: Health Management Network Commercial	$11,900.00
Rate for Payer: Humana Medicare	$7,000.00
Rate for Payer: Kaiser Permanente Commercial	$12,600.00
Rate for Payer: Kaiser Permanente Medicaid	$7,140.00
Rate for Payer: Kaiser Permanente Medicare	$7,000.00
Rate for Payer: MDX Hawaii PPO	$13,580.00
Rate for Payer: Ohana Health Plan Medicaid	$7,000.00
Rate for Payer: Ohana Health Plan Medicare	$7,000.00
Rate for Payer: UnitedHealthcare Medicare	$7,000.00
Rate for Payer: University Health Alliance Commercial	$7,840.00

PAIN & SPINE LEAD 977C290 SPECIFY SURESCAN MRI 2X8

Facility

$14,000.00

Service Code	HCPCS C1778
Hospital Charge Code	8806213
Hospital Revenue Code	278
Min. Negotiated Rate	$7,000.00
Max. Negotiated Rate	$13,580.00
Rate for Payer: AlohaCare Medicaid	$7,000.00
Rate for Payer: AlohaCare Medicare	$7,000.00
Rate for Payer: Cash Price	$9,100.00
Rate for Payer: Devoted Health Medicare	$7,700.00
Rate for Payer: Hawaii Medical Service Association Medicare	$7,000.00
Rate for Payer: Hawaii Western Management Group Commercial	$9,800.00
Rate for Payer: Health Management Network Commercial	$11,900.00
Rate for Payer: Humana Medicare	$7,000.00
Rate for Payer: Kaiser Permanente Commercial	$12,600.00
Rate for Payer: Kaiser Permanente Medicaid	$7,140.00
Rate for Payer: Kaiser Permanente Medicare	$7,000.00
Rate for Payer: MDX Hawaii PPO	$13,580.00
Rate for Payer: Ohana Health Plan Medicaid	$7,000.00
Rate for Payer: Ohana Health Plan Medicare	$7,000.00
Rate for Payer: UnitedHealthcare Medicare	$7,000.00
Rate for Payer: University Health Alliance Commercial	$7,840.00

PAIN & SPINE LEAD 977C290 SPECIFY SURESCAN MRI 2X8

Facility

$14,000.00

Service Code	HCPCS C1778
Hospital Charge Code	8806213
Hospital Revenue Code	278
Min. Negotiated Rate	$7,840.00
Max. Negotiated Rate	$13,580.00
Rate for Payer: Cash Price	$9,100.00
Rate for Payer: Hawaii Western Management Group Commercial	$9,800.00
Rate for Payer: Health Management Network Commercial	$11,900.00
Rate for Payer: Kaiser Permanente Commercial	$12,600.00
Rate for Payer: MDX Hawaii PPO	$13,580.00
Rate for Payer: University Health Alliance Commercial	$7,840.00

PAIN & SPINE LEAD 977D160 TRIAL 3MM SUBCOMPACT 1X8

Facility

$2,700.00

Service Code	HCPCS C1778
Hospital Charge Code	8806202
Hospital Revenue Code	278
Min. Negotiated Rate	$1,512.00
Max. Negotiated Rate	$2,619.00
Rate for Payer: Cash Price	$1,755.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,890.00
Rate for Payer: Health Management Network Commercial	$2,295.00
Rate for Payer: Kaiser Permanente Commercial	$2,430.00
Rate for Payer: MDX Hawaii PPO	$2,619.00
Rate for Payer: University Health Alliance Commercial	$1,512.00

PAIN & SPINE LEAD 977D160 TRIAL 3MM SUBCOMPACT 1X8

Facility

$2,700.00

Service Code	HCPCS C1778
Hospital Charge Code	8806202
Hospital Revenue Code	278
Min. Negotiated Rate	$1,350.00
Max. Negotiated Rate	$2,619.00
Rate for Payer: AlohaCare Medicaid	$1,350.00
Rate for Payer: AlohaCare Medicare	$1,350.00
Rate for Payer: Cash Price	$1,755.00
Rate for Payer: Devoted Health Medicare	$1,485.00
Rate for Payer: Hawaii Medical Service Association Medicare	$1,350.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,890.00
Rate for Payer: Health Management Network Commercial	$2,295.00
Rate for Payer: Humana Medicare	$1,350.00
Rate for Payer: Kaiser Permanente Commercial	$2,430.00
Rate for Payer: Kaiser Permanente Medicaid	$1,377.00
Rate for Payer: Kaiser Permanente Medicare	$1,350.00
Rate for Payer: MDX Hawaii PPO	$2,619.00
Rate for Payer: Ohana Health Plan Medicaid	$1,350.00
Rate for Payer: Ohana Health Plan Medicare	$1,350.00
Rate for Payer: UnitedHealthcare Medicare	$1,350.00
Rate for Payer: University Health Alliance Commercial	$1,512.00

PAIN & SPINE LEAD 977D260 TRIAL 5MM COMPACT 1X8

Facility

$2,970.00

Service Code	HCPCS C1778
Hospital Charge Code	8806203
Hospital Revenue Code	278
Min. Negotiated Rate	$1,663.20
Max. Negotiated Rate	$2,880.90
Rate for Payer: Cash Price	$1,930.50
Rate for Payer: Hawaii Western Management Group Commercial	$2,079.00
Rate for Payer: Health Management Network Commercial	$2,524.50
Rate for Payer: Kaiser Permanente Commercial	$2,673.00
Rate for Payer: MDX Hawaii PPO	$2,880.90
Rate for Payer: University Health Alliance Commercial	$1,663.20

PAIN & SPINE LEAD 977D260 TRIAL 5MM COMPACT 1X8

Facility

$2,970.00

Service Code	HCPCS C1778
Hospital Charge Code	8806203
Hospital Revenue Code	278
Min. Negotiated Rate	$1,485.00
Max. Negotiated Rate	$2,880.90
Rate for Payer: AlohaCare Medicaid	$1,485.00
Rate for Payer: AlohaCare Medicare	$1,485.00
Rate for Payer: Cash Price	$1,930.50
Rate for Payer: Devoted Health Medicare	$1,633.50
Rate for Payer: Hawaii Medical Service Association Medicare	$1,485.00
Rate for Payer: Hawaii Western Management Group Commercial	$2,079.00
Rate for Payer: Health Management Network Commercial	$2,524.50
Rate for Payer: Humana Medicare	$1,485.00
Rate for Payer: Kaiser Permanente Commercial	$2,673.00
Rate for Payer: Kaiser Permanente Medicaid	$1,514.70
Rate for Payer: Kaiser Permanente Medicare	$1,485.00
Rate for Payer: MDX Hawaii PPO	$2,880.90
Rate for Payer: Ohana Health Plan Medicaid	$1,485.00
Rate for Payer: Ohana Health Plan Medicare	$1,485.00
Rate for Payer: UnitedHealthcare Medicare	$1,485.00
Rate for Payer: University Health Alliance Commercial	$1,663.20

PAIN & SPINE: LEAD KIT 60CM

Facility

$5,106.00

Service Code	HCPCS C1778
Hospital Charge Code	8743137
Hospital Revenue Code	278
Min. Negotiated Rate	$2,859.36
Max. Negotiated Rate	$4,952.82
Rate for Payer: Cash Price	$3,318.90
Rate for Payer: Hawaii Western Management Group Commercial	$3,574.20
Rate for Payer: Health Management Network Commercial	$4,340.10
Rate for Payer: Kaiser Permanente Commercial	$4,595.40
Rate for Payer: MDX Hawaii PPO	$4,952.82
Rate for Payer: University Health Alliance Commercial	$2,859.36

PAIN & SPINE: LEAD KIT 60CM

Facility

$5,106.00

Service Code	HCPCS C1778
Hospital Charge Code	8743137
Hospital Revenue Code	278
Min. Negotiated Rate	$2,553.00
Max. Negotiated Rate	$4,952.82
Rate for Payer: AlohaCare Medicaid	$2,553.00
Rate for Payer: AlohaCare Medicare	$2,553.00
Rate for Payer: Cash Price	$3,318.90
Rate for Payer: Devoted Health Medicare	$2,808.30
Rate for Payer: Hawaii Medical Service Association Medicare	$2,553.00
Rate for Payer: Hawaii Western Management Group Commercial	$3,574.20
Rate for Payer: Health Management Network Commercial	$4,340.10
Rate for Payer: Humana Medicare	$2,553.00
Rate for Payer: Kaiser Permanente Commercial	$4,595.40
Rate for Payer: Kaiser Permanente Medicaid	$2,604.06
Rate for Payer: Kaiser Permanente Medicare	$2,553.00
Rate for Payer: MDX Hawaii PPO	$4,952.82
Rate for Payer: Ohana Health Plan Medicaid	$2,553.00
Rate for Payer: Ohana Health Plan Medicare	$2,553.00
Rate for Payer: UnitedHealthcare Medicare	$2,553.00
Rate for Payer: University Health Alliance Commercial	$2,859.36

PAIN & SPINE: MEDTRONIC 10GA OSTEOCOOL BONE ACCESS KIT

Facility

$1,611.00

Hospital Charge Code	9334136
Hospital Revenue Code	272
Min. Negotiated Rate	$1,369.35
Max. Negotiated Rate	$1,562.67
Rate for Payer: Cash Price	$1,047.15
Rate for Payer: Health Management Network Commercial	$1,369.35
Rate for Payer: Kaiser Permanente Commercial	$1,449.90
Rate for Payer: MDX Hawaii PPO	$1,562.67

PAIN & SPINE: MEDTRONIC 10GA OSTEOCOOL BONE ACCESS KIT

Facility

$1,611.00

Hospital Charge Code	9334136
Hospital Revenue Code	272
Min. Negotiated Rate	$805.50
Max. Negotiated Rate	$1,562.67
Rate for Payer: AlohaCare Medicaid	$805.50
Rate for Payer: AlohaCare Medicare	$805.50
Rate for Payer: Cash Price	$1,047.15
Rate for Payer: Devoted Health Medicare	$886.05
Rate for Payer: Hawaii Medical Service Association Medicare	$805.50
Rate for Payer: Hawaii Western Management Group Commercial	$1,530.45
Rate for Payer: Health Management Network Commercial	$1,369.35
Rate for Payer: Humana Medicare	$805.50
Rate for Payer: Kaiser Permanente Commercial	$1,449.90
Rate for Payer: Kaiser Permanente Medicaid	$821.61
Rate for Payer: Kaiser Permanente Medicare	$805.50
Rate for Payer: MDX Hawaii PPO	$1,562.67
Rate for Payer: Ohana Health Plan Medicaid	$805.50
Rate for Payer: Ohana Health Plan Medicare	$805.50
Rate for Payer: UnitedHealthcare Medicare	$805.50
Rate for Payer: University Health Alliance Commercial	$1,174.26

PAIN & SPINE: MEDTRONIC ACCESSORY KIT

Facility

$220.00

Hospital Charge Code	9533210
Hospital Revenue Code	272
Min. Negotiated Rate	$187.00
Max. Negotiated Rate	$213.40
Rate for Payer: Cash Price	$143.00
Rate for Payer: Health Management Network Commercial	$187.00
Rate for Payer: Kaiser Permanente Commercial	$198.00
Rate for Payer: MDX Hawaii PPO	$213.40

PAIN & SPINE: MEDTRONIC ACCESSORY KIT

Facility

$220.00

Hospital Charge Code	9533210
Hospital Revenue Code	272
Min. Negotiated Rate	$110.00
Max. Negotiated Rate	$213.40
Rate for Payer: AlohaCare Medicaid	$110.00
Rate for Payer: AlohaCare Medicare	$110.00
Rate for Payer: Cash Price	$143.00
Rate for Payer: Devoted Health Medicare	$121.00
Rate for Payer: Hawaii Medical Service Association Medicare	$110.00
Rate for Payer: Hawaii Western Management Group Commercial	$209.00
Rate for Payer: Health Management Network Commercial	$187.00
Rate for Payer: Humana Medicare	$110.00
Rate for Payer: Kaiser Permanente Commercial	$198.00
Rate for Payer: Kaiser Permanente Medicaid	$112.20
Rate for Payer: Kaiser Permanente Medicare	$110.00
Rate for Payer: MDX Hawaii PPO	$213.40
Rate for Payer: Ohana Health Plan Medicaid	$110.00
Rate for Payer: Ohana Health Plan Medicare	$110.00
Rate for Payer: UnitedHealthcare Medicare	$110.00
Rate for Payer: University Health Alliance Commercial	$160.36

PAIN & SPINE: MEDTRONIC ACCESSORY KIT (TRIAL)

Facility

$220.00

Hospital Charge Code	9390094
Hospital Revenue Code	272
Min. Negotiated Rate	$110.00
Max. Negotiated Rate	$213.40
Rate for Payer: AlohaCare Medicaid	$110.00
Rate for Payer: AlohaCare Medicare	$110.00
Rate for Payer: Cash Price	$143.00
Rate for Payer: Devoted Health Medicare	$121.00
Rate for Payer: Hawaii Medical Service Association Medicare	$110.00
Rate for Payer: Hawaii Western Management Group Commercial	$209.00
Rate for Payer: Health Management Network Commercial	$187.00
Rate for Payer: Humana Medicare	$110.00
Rate for Payer: Kaiser Permanente Commercial	$198.00
Rate for Payer: Kaiser Permanente Medicaid	$112.20
Rate for Payer: Kaiser Permanente Medicare	$110.00
Rate for Payer: MDX Hawaii PPO	$213.40
Rate for Payer: Ohana Health Plan Medicaid	$110.00
Rate for Payer: Ohana Health Plan Medicare	$110.00
Rate for Payer: UnitedHealthcare Medicare	$110.00
Rate for Payer: University Health Alliance Commercial	$160.36

PAIN & SPINE: MEDTRONIC ACCESSORY KIT (TRIAL)

Facility

$220.00

Hospital Charge Code	9390094
Hospital Revenue Code	272
Min. Negotiated Rate	$187.00
Max. Negotiated Rate	$213.40
Rate for Payer: Cash Price	$143.00
Rate for Payer: Health Management Network Commercial	$187.00
Rate for Payer: Kaiser Permanente Commercial	$198.00
Rate for Payer: MDX Hawaii PPO	$213.40

PAIN & SPINE: MEDTRONIC CONTROLLER

Facility

$3,714.00

Hospital Charge Code	8743135
Hospital Revenue Code	272
Min. Negotiated Rate	$3,156.90
Max. Negotiated Rate	$3,602.58
Rate for Payer: Cash Price	$2,414.10
Rate for Payer: Health Management Network Commercial	$3,156.90
Rate for Payer: Kaiser Permanente Commercial	$3,342.60
Rate for Payer: MDX Hawaii PPO	$3,602.58

PAIN & SPINE: MEDTRONIC CONTROLLER

Facility

$3,714.00

Hospital Charge Code	8743135
Hospital Revenue Code	272
Min. Negotiated Rate	$1,857.00
Max. Negotiated Rate	$3,602.58
Rate for Payer: AlohaCare Medicaid	$1,857.00
Rate for Payer: AlohaCare Medicare	$1,857.00
Rate for Payer: Cash Price	$2,414.10
Rate for Payer: Devoted Health Medicare	$2,042.70
Rate for Payer: Hawaii Medical Service Association Medicare	$1,857.00
Rate for Payer: Hawaii Western Management Group Commercial	$3,528.30
Rate for Payer: Health Management Network Commercial	$3,156.90
Rate for Payer: Humana Medicare	$1,857.00
Rate for Payer: Kaiser Permanente Commercial	$3,342.60
Rate for Payer: Kaiser Permanente Medicaid	$1,894.14
Rate for Payer: Kaiser Permanente Medicare	$1,857.00
Rate for Payer: MDX Hawaii PPO	$3,602.58
Rate for Payer: Ohana Health Plan Medicaid	$1,857.00
Rate for Payer: Ohana Health Plan Medicare	$1,857.00
Rate for Payer: UnitedHealthcare Medicare	$1,857.00
Rate for Payer: University Health Alliance Commercial	$2,707.13

Know your out-of-pocket cost for care.

All Charges