Samuel Mahelona Memorial Hospital

All Charges

Charge

Type

Setting

Price

PAIN & SPINE: PROBE APSC04 50MM 12MM ENHANCED

Facility

$1,860.00

Hospital Charge Code	9586300
Hospital Revenue Code	272
Min. Negotiated Rate	$1,581.00
Max. Negotiated Rate	$1,804.20
Rate for Payer: Cash Price	$1,209.00
Rate for Payer: Health Management Network Commercial	$1,581.00
Rate for Payer: Kaiser Permanente Commercial	$1,674.00
Rate for Payer: MDX Hawaii PPO	$1,804.20

PAIN & SPINE: PROBE APSC05 100MM 12MM ENHANCED

Facility

$1,860.00

Hospital Charge Code	9583513
Hospital Revenue Code	272
Min. Negotiated Rate	$930.00
Max. Negotiated Rate	$1,804.20
Rate for Payer: AlohaCare Medicaid	$930.00
Rate for Payer: AlohaCare Medicare	$930.00
Rate for Payer: Cash Price	$1,209.00
Rate for Payer: Devoted Health Medicare	$1,023.00
Rate for Payer: Hawaii Medical Service Association Medicare	$930.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,767.00
Rate for Payer: Health Management Network Commercial	$1,581.00
Rate for Payer: Humana Medicare	$930.00
Rate for Payer: Kaiser Permanente Commercial	$1,674.00
Rate for Payer: Kaiser Permanente Medicaid	$948.60
Rate for Payer: Kaiser Permanente Medicare	$930.00
Rate for Payer: MDX Hawaii PPO	$1,804.20
Rate for Payer: Ohana Health Plan Medicaid	$930.00
Rate for Payer: Ohana Health Plan Medicare	$930.00
Rate for Payer: UnitedHealthcare Medicare	$930.00
Rate for Payer: University Health Alliance Commercial	$1,355.75

PAIN & SPINE: PROBE APSC05 100MM 12MM ENHANCED

Facility

$1,860.00

Hospital Charge Code	9583513
Hospital Revenue Code	272
Min. Negotiated Rate	$1,581.00
Max. Negotiated Rate	$1,804.20
Rate for Payer: Cash Price	$1,209.00
Rate for Payer: Health Management Network Commercial	$1,581.00
Rate for Payer: Kaiser Permanente Commercial	$1,674.00
Rate for Payer: MDX Hawaii PPO	$1,804.20

PAIN & SPINE: PROBE APSC06 150MM 12MM ENHANCED

Facility

$1,860.00

Hospital Charge Code	9586301
Hospital Revenue Code	272
Min. Negotiated Rate	$930.00
Max. Negotiated Rate	$1,804.20
Rate for Payer: AlohaCare Medicaid	$930.00
Rate for Payer: AlohaCare Medicare	$930.00
Rate for Payer: Cash Price	$1,209.00
Rate for Payer: Devoted Health Medicare	$1,023.00
Rate for Payer: Hawaii Medical Service Association Medicare	$930.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,767.00
Rate for Payer: Health Management Network Commercial	$1,581.00
Rate for Payer: Humana Medicare	$930.00
Rate for Payer: Kaiser Permanente Commercial	$1,674.00
Rate for Payer: Kaiser Permanente Medicaid	$948.60
Rate for Payer: Kaiser Permanente Medicare	$930.00
Rate for Payer: MDX Hawaii PPO	$1,804.20
Rate for Payer: Ohana Health Plan Medicaid	$930.00
Rate for Payer: Ohana Health Plan Medicare	$930.00
Rate for Payer: UnitedHealthcare Medicare	$930.00
Rate for Payer: University Health Alliance Commercial	$1,355.75

PAIN & SPINE: PROBE APSC06 150MM 12MM ENHANCED

Facility

$1,860.00

Hospital Charge Code	9586301
Hospital Revenue Code	272
Min. Negotiated Rate	$1,581.00
Max. Negotiated Rate	$1,804.20
Rate for Payer: Cash Price	$1,209.00
Rate for Payer: Health Management Network Commercial	$1,581.00
Rate for Payer: Kaiser Permanente Commercial	$1,674.00
Rate for Payer: MDX Hawaii PPO	$1,804.20

PAIN & SPINE: PROBE APSD050 SINGLE USE SS 50MM 16-22G

Facility

$488.00

Hospital Charge Code	9586302
Hospital Revenue Code	272
Min. Negotiated Rate	$244.00
Max. Negotiated Rate	$473.36
Rate for Payer: AlohaCare Medicaid	$244.00
Rate for Payer: AlohaCare Medicare	$244.00
Rate for Payer: Cash Price	$317.20
Rate for Payer: Devoted Health Medicare	$268.40
Rate for Payer: Hawaii Medical Service Association Medicare	$244.00
Rate for Payer: Hawaii Western Management Group Commercial	$463.60
Rate for Payer: Health Management Network Commercial	$414.80
Rate for Payer: Humana Medicare	$244.00
Rate for Payer: Kaiser Permanente Commercial	$439.20
Rate for Payer: Kaiser Permanente Medicaid	$248.88
Rate for Payer: Kaiser Permanente Medicare	$244.00
Rate for Payer: MDX Hawaii PPO	$473.36
Rate for Payer: Ohana Health Plan Medicaid	$244.00
Rate for Payer: Ohana Health Plan Medicare	$244.00
Rate for Payer: UnitedHealthcare Medicare	$244.00
Rate for Payer: University Health Alliance Commercial	$355.70

PAIN & SPINE: PROBE APSD050 SINGLE USE SS 50MM 16-22G

Facility

$488.00

Hospital Charge Code	9586302
Hospital Revenue Code	272
Min. Negotiated Rate	$414.80
Max. Negotiated Rate	$473.36
Rate for Payer: Cash Price	$317.20
Rate for Payer: Health Management Network Commercial	$414.80
Rate for Payer: Kaiser Permanente Commercial	$439.20
Rate for Payer: MDX Hawaii PPO	$473.36

PAIN & SPINE: PROBE APSD100 SINGLE USE SS 100MM 16-22G

Facility

$488.00

Hospital Charge Code	9586332
Hospital Revenue Code	272
Min. Negotiated Rate	$414.80
Max. Negotiated Rate	$473.36
Rate for Payer: Cash Price	$317.20
Rate for Payer: Health Management Network Commercial	$414.80
Rate for Payer: Kaiser Permanente Commercial	$439.20
Rate for Payer: MDX Hawaii PPO	$473.36

PAIN & SPINE: PROBE APSD100 SINGLE USE SS 100MM 16-22G

Facility

$488.00

Hospital Charge Code	9586332
Hospital Revenue Code	272
Min. Negotiated Rate	$244.00
Max. Negotiated Rate	$473.36
Rate for Payer: AlohaCare Medicaid	$244.00
Rate for Payer: AlohaCare Medicare	$244.00
Rate for Payer: Cash Price	$317.20
Rate for Payer: Devoted Health Medicare	$268.40
Rate for Payer: Hawaii Medical Service Association Medicare	$244.00
Rate for Payer: Hawaii Western Management Group Commercial	$463.60
Rate for Payer: Health Management Network Commercial	$414.80
Rate for Payer: Humana Medicare	$244.00
Rate for Payer: Kaiser Permanente Commercial	$439.20
Rate for Payer: Kaiser Permanente Medicaid	$248.88
Rate for Payer: Kaiser Permanente Medicare	$244.00
Rate for Payer: MDX Hawaii PPO	$473.36
Rate for Payer: Ohana Health Plan Medicaid	$244.00
Rate for Payer: Ohana Health Plan Medicare	$244.00
Rate for Payer: UnitedHealthcare Medicare	$244.00
Rate for Payer: University Health Alliance Commercial	$355.70

PAIN & SPINE: PROBE APSD150 SINGLE USE SS 150MM 16-22G

Facility

$488.00

Hospital Charge Code	9586333
Hospital Revenue Code	272
Min. Negotiated Rate	$244.00
Max. Negotiated Rate	$473.36
Rate for Payer: AlohaCare Medicaid	$244.00
Rate for Payer: AlohaCare Medicare	$244.00
Rate for Payer: Cash Price	$317.20
Rate for Payer: Devoted Health Medicare	$268.40
Rate for Payer: Hawaii Medical Service Association Medicare	$244.00
Rate for Payer: Hawaii Western Management Group Commercial	$463.60
Rate for Payer: Health Management Network Commercial	$414.80
Rate for Payer: Humana Medicare	$244.00
Rate for Payer: Kaiser Permanente Commercial	$439.20
Rate for Payer: Kaiser Permanente Medicaid	$248.88
Rate for Payer: Kaiser Permanente Medicare	$244.00
Rate for Payer: MDX Hawaii PPO	$473.36
Rate for Payer: Ohana Health Plan Medicaid	$244.00
Rate for Payer: Ohana Health Plan Medicare	$244.00
Rate for Payer: UnitedHealthcare Medicare	$244.00
Rate for Payer: University Health Alliance Commercial	$355.70

PAIN & SPINE: PROBE APSD150 SINGLE USE SS 150MM 16-22G

Facility

$488.00

Hospital Charge Code	9586333
Hospital Revenue Code	272
Min. Negotiated Rate	$414.80
Max. Negotiated Rate	$473.36
Rate for Payer: Cash Price	$317.20
Rate for Payer: Health Management Network Commercial	$414.80
Rate for Payer: Kaiser Permanente Commercial	$439.20
Rate for Payer: MDX Hawaii PPO	$473.36

PAIN & SPINE: PROBE APSE050 REUSABLE SS 50MM 16-22G

Facility

$2,500.00

Hospital Charge Code	9586069
Hospital Revenue Code	272
Min. Negotiated Rate	$2,125.00
Max. Negotiated Rate	$2,425.00
Rate for Payer: Cash Price	$1,625.00
Rate for Payer: Health Management Network Commercial	$2,125.00
Rate for Payer: Kaiser Permanente Commercial	$2,250.00
Rate for Payer: MDX Hawaii PPO	$2,425.00

PAIN & SPINE: PROBE APSE050 REUSABLE SS 50MM 16-22G

Facility

$2,500.00

Hospital Charge Code	9586069
Hospital Revenue Code	272
Min. Negotiated Rate	$1,250.00
Max. Negotiated Rate	$2,425.00
Rate for Payer: AlohaCare Medicaid	$1,250.00
Rate for Payer: AlohaCare Medicare	$1,250.00
Rate for Payer: Cash Price	$1,625.00
Rate for Payer: Devoted Health Medicare	$1,375.00
Rate for Payer: Hawaii Medical Service Association Medicare	$1,250.00
Rate for Payer: Hawaii Western Management Group Commercial	$2,375.00
Rate for Payer: Health Management Network Commercial	$2,125.00
Rate for Payer: Humana Medicare	$1,250.00
Rate for Payer: Kaiser Permanente Commercial	$2,250.00
Rate for Payer: Kaiser Permanente Medicaid	$1,275.00
Rate for Payer: Kaiser Permanente Medicare	$1,250.00
Rate for Payer: MDX Hawaii PPO	$2,425.00
Rate for Payer: Ohana Health Plan Medicaid	$1,250.00
Rate for Payer: Ohana Health Plan Medicare	$1,250.00
Rate for Payer: UnitedHealthcare Medicare	$1,250.00
Rate for Payer: University Health Alliance Commercial	$1,822.25

PAIN & SPINE: PROBE APSN050 REUSE NITINOL 50MM 16-22G

Facility

$3,000.00

Hospital Charge Code	9586173
Hospital Revenue Code	272
Min. Negotiated Rate	$1,500.00
Max. Negotiated Rate	$2,910.00
Rate for Payer: AlohaCare Medicaid	$1,500.00
Rate for Payer: AlohaCare Medicare	$1,500.00
Rate for Payer: Cash Price	$1,950.00
Rate for Payer: Devoted Health Medicare	$1,650.00
Rate for Payer: Hawaii Medical Service Association Medicare	$1,500.00
Rate for Payer: Hawaii Western Management Group Commercial	$2,850.00
Rate for Payer: Health Management Network Commercial	$2,550.00
Rate for Payer: Humana Medicare	$1,500.00
Rate for Payer: Kaiser Permanente Commercial	$2,700.00
Rate for Payer: Kaiser Permanente Medicaid	$1,530.00
Rate for Payer: Kaiser Permanente Medicare	$1,500.00
Rate for Payer: MDX Hawaii PPO	$2,910.00
Rate for Payer: Ohana Health Plan Medicaid	$1,500.00
Rate for Payer: Ohana Health Plan Medicare	$1,500.00
Rate for Payer: UnitedHealthcare Medicare	$1,500.00
Rate for Payer: University Health Alliance Commercial	$2,186.70

PAIN & SPINE: PROBE APSN050 REUSE NITINOL 50MM 16-22G

Facility

$3,000.00

Hospital Charge Code	9586173
Hospital Revenue Code	272
Min. Negotiated Rate	$2,550.00
Max. Negotiated Rate	$2,910.00
Rate for Payer: Cash Price	$1,950.00
Rate for Payer: Health Management Network Commercial	$2,550.00
Rate for Payer: Kaiser Permanente Commercial	$2,700.00
Rate for Payer: MDX Hawaii PPO	$2,910.00

PAIN & SPINE: PROBE APSN100 REUSE NITINOL 100MM 16-22G

Facility

$3,000.00

Hospital Charge Code	9586174
Hospital Revenue Code	272
Min. Negotiated Rate	$2,550.00
Max. Negotiated Rate	$2,910.00
Rate for Payer: Cash Price	$1,950.00
Rate for Payer: Health Management Network Commercial	$2,550.00
Rate for Payer: Kaiser Permanente Commercial	$2,700.00
Rate for Payer: MDX Hawaii PPO	$2,910.00

PAIN & SPINE: PROBE APSN100 REUSE NITINOL 100MM 16-22G

Facility

$3,000.00

Hospital Charge Code	9586174
Hospital Revenue Code	272
Min. Negotiated Rate	$1,500.00
Max. Negotiated Rate	$2,910.00
Rate for Payer: AlohaCare Medicaid	$1,500.00
Rate for Payer: AlohaCare Medicare	$1,500.00
Rate for Payer: Cash Price	$1,950.00
Rate for Payer: Devoted Health Medicare	$1,650.00
Rate for Payer: Hawaii Medical Service Association Medicare	$1,500.00
Rate for Payer: Hawaii Western Management Group Commercial	$2,850.00
Rate for Payer: Health Management Network Commercial	$2,550.00
Rate for Payer: Humana Medicare	$1,500.00
Rate for Payer: Kaiser Permanente Commercial	$2,700.00
Rate for Payer: Kaiser Permanente Medicaid	$1,530.00
Rate for Payer: Kaiser Permanente Medicare	$1,500.00
Rate for Payer: MDX Hawaii PPO	$2,910.00
Rate for Payer: Ohana Health Plan Medicaid	$1,500.00
Rate for Payer: Ohana Health Plan Medicare	$1,500.00
Rate for Payer: UnitedHealthcare Medicare	$1,500.00
Rate for Payer: University Health Alliance Commercial	$2,186.70

PAIN & SPINE: PROBE APSN150 REUSE NITINOL 150MM 16-22G

Facility

$3,000.00

Hospital Charge Code	9586291
Hospital Revenue Code	272
Min. Negotiated Rate	$2,550.00
Max. Negotiated Rate	$2,910.00
Rate for Payer: Cash Price	$1,950.00
Rate for Payer: Health Management Network Commercial	$2,550.00
Rate for Payer: Kaiser Permanente Commercial	$2,700.00
Rate for Payer: MDX Hawaii PPO	$2,910.00

PAIN & SPINE: PROBE APSN150 REUSE NITINOL 150MM 16-22G

Facility

$3,000.00

Hospital Charge Code	9586291
Hospital Revenue Code	272
Min. Negotiated Rate	$1,500.00
Max. Negotiated Rate	$2,910.00
Rate for Payer: AlohaCare Medicaid	$1,500.00
Rate for Payer: AlohaCare Medicare	$1,500.00
Rate for Payer: Cash Price	$1,950.00
Rate for Payer: Devoted Health Medicare	$1,650.00
Rate for Payer: Hawaii Medical Service Association Medicare	$1,500.00
Rate for Payer: Hawaii Western Management Group Commercial	$2,850.00
Rate for Payer: Health Management Network Commercial	$2,550.00
Rate for Payer: Humana Medicare	$1,500.00
Rate for Payer: Kaiser Permanente Commercial	$2,700.00
Rate for Payer: Kaiser Permanente Medicaid	$1,530.00
Rate for Payer: Kaiser Permanente Medicare	$1,500.00
Rate for Payer: MDX Hawaii PPO	$2,910.00
Rate for Payer: Ohana Health Plan Medicaid	$1,500.00
Rate for Payer: Ohana Health Plan Medicare	$1,500.00
Rate for Payer: UnitedHealthcare Medicare	$1,500.00
Rate for Payer: University Health Alliance Commercial	$2,186.70

PAIN & SPINE: PROBE APSR0150 REUABLE SS 150MM 16-22G

Facility

$2,500.00

Hospital Charge Code	9586172
Hospital Revenue Code	272
Min. Negotiated Rate	$2,125.00
Max. Negotiated Rate	$2,425.00
Rate for Payer: Cash Price	$1,625.00
Rate for Payer: Health Management Network Commercial	$2,125.00
Rate for Payer: Kaiser Permanente Commercial	$2,250.00
Rate for Payer: MDX Hawaii PPO	$2,425.00

PAIN & SPINE: PROBE APSR0150 REUABLE SS 150MM 16-22G

Facility

$2,500.00

Hospital Charge Code	9586172
Hospital Revenue Code	272
Min. Negotiated Rate	$1,250.00
Max. Negotiated Rate	$2,425.00
Rate for Payer: AlohaCare Medicaid	$1,250.00
Rate for Payer: AlohaCare Medicare	$1,250.00
Rate for Payer: Cash Price	$1,625.00
Rate for Payer: Devoted Health Medicare	$1,375.00
Rate for Payer: Hawaii Medical Service Association Medicare	$1,250.00
Rate for Payer: Hawaii Western Management Group Commercial	$2,375.00
Rate for Payer: Health Management Network Commercial	$2,125.00
Rate for Payer: Humana Medicare	$1,250.00
Rate for Payer: Kaiser Permanente Commercial	$2,250.00
Rate for Payer: Kaiser Permanente Medicaid	$1,275.00
Rate for Payer: Kaiser Permanente Medicare	$1,250.00
Rate for Payer: MDX Hawaii PPO	$2,425.00
Rate for Payer: Ohana Health Plan Medicaid	$1,250.00
Rate for Payer: Ohana Health Plan Medicare	$1,250.00
Rate for Payer: UnitedHealthcare Medicare	$1,250.00
Rate for Payer: University Health Alliance Commercial	$1,822.25

PAIN & SPINE: PROBE APSR100 REUSABLE SS 100MM 16-22G

Facility

$2,500.00

Hospital Charge Code	9586171
Hospital Revenue Code	272
Min. Negotiated Rate	$2,125.00
Max. Negotiated Rate	$2,425.00
Rate for Payer: Cash Price	$1,625.00
Rate for Payer: Health Management Network Commercial	$2,125.00
Rate for Payer: Kaiser Permanente Commercial	$2,250.00
Rate for Payer: MDX Hawaii PPO	$2,425.00

PAIN & SPINE: PROBE APSR100 REUSABLE SS 100MM 16-22G

Facility

$2,500.00

Hospital Charge Code	9586171
Hospital Revenue Code	272
Min. Negotiated Rate	$1,250.00
Max. Negotiated Rate	$2,425.00
Rate for Payer: AlohaCare Medicaid	$1,250.00
Rate for Payer: AlohaCare Medicare	$1,250.00
Rate for Payer: Cash Price	$1,625.00
Rate for Payer: Devoted Health Medicare	$1,375.00
Rate for Payer: Hawaii Medical Service Association Medicare	$1,250.00
Rate for Payer: Hawaii Western Management Group Commercial	$2,375.00
Rate for Payer: Health Management Network Commercial	$2,125.00
Rate for Payer: Humana Medicare	$1,250.00
Rate for Payer: Kaiser Permanente Commercial	$2,250.00
Rate for Payer: Kaiser Permanente Medicaid	$1,275.00
Rate for Payer: Kaiser Permanente Medicare	$1,250.00
Rate for Payer: MDX Hawaii PPO	$2,425.00
Rate for Payer: Ohana Health Plan Medicaid	$1,250.00
Rate for Payer: Ohana Health Plan Medicare	$1,250.00
Rate for Payer: UnitedHealthcare Medicare	$1,250.00
Rate for Payer: University Health Alliance Commercial	$1,822.25

PAIN & SPINE PROGRAMMER 97740 PATIENT MRICS

Facility

$2,985.00

Service Code	HCPCS C1787
Hospital Charge Code	8806214
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 PROGRAMMER 97740 PATIENT MRICS

Facility

$2,985.00

Service Code	HCPCS C1787
Hospital Charge Code	8806214
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

Know your out-of-pocket cost for care.

All Charges