Samuel Mahelona Memorial Hospital

All Charges

Charge

Type

Setting

Price

SPINAL DISORDERS AND INJURIES WITH CC/MCC

Facility

$34,581.22

Service Code	MSDRG 052
Min. Negotiated Rate	$34,581.22
Max. Negotiated Rate	$34,581.22
Rate for Payer: Hawaii Medical Service Association Commercial	$34,581.22

SPINAL DISORDERS AND INJURIES WITHOUT CC/MCC

Facility

$34,581.22

Service Code	MSDRG 053
Min. Negotiated Rate	$34,581.22
Max. Negotiated Rate	$34,581.22
Rate for Payer: Hawaii Medical Service Association Commercial	$34,581.22

SPINAL FUSION EXCEPT CERVICAL WITH SPINAL CURVATURE, MALIGNANCY, INFECTION OR EXTENSIVE FUSIONS WITH CC

Facility

$137,281.98

Service Code	MSDRG 457
Min. Negotiated Rate	$137,281.98
Max. Negotiated Rate	$137,281.98
Rate for Payer: Hawaii Medical Service Association Commercial	$137,281.98

SPINAL FUSION EXCEPT CERVICAL WITH SPINAL CURVATURE, MALIGNANCY, INFECTION OR EXTENSIVE FUSIONS WITH MCC

Facility

$137,281.98

Service Code	MSDRG 456
Min. Negotiated Rate	$137,281.98
Max. Negotiated Rate	$137,281.98
Rate for Payer: Hawaii Medical Service Association Commercial	$137,281.98

SPINAL FUSION EXCEPT CERVICAL WITH SPINAL CURVATURE, MALIGNANCY, INFECTION OR EXTENSIVE FUSIONS WITHOUT CC/MCC

Facility

$137,281.98

Service Code	MSDRG 458
Min. Negotiated Rate	$137,281.98
Max. Negotiated Rate	$137,281.98
Rate for Payer: Hawaii Medical Service Association Commercial	$137,281.98

SPINAL PROCEDURES WITH CC OR SPINAL NEUROSTIMULATORS

Facility

$71,177.11

Service Code	MSDRG 029
Min. Negotiated Rate	$10,400.00
Max. Negotiated Rate	$71,177.11
Rate for Payer: Hawaii Medical Service Association Commercial	$71,177.11
Rate for Payer: University Health Alliance Commercial	$10,400.00

SPINAL PROCEDURES WITH MCC

Facility

$86,038.26

Service Code	MSDRG 028
Min. Negotiated Rate	$10,400.00
Max. Negotiated Rate	$86,038.26
Rate for Payer: Hawaii Medical Service Association Commercial	$86,038.26
Rate for Payer: University Health Alliance Commercial	$10,400.00

SPINAL PROCEDURES WITHOUT CC/MCC

Facility

$47,190.68

Service Code	MSDRG 030
Min. Negotiated Rate	$10,400.00
Max. Negotiated Rate	$47,190.68
Rate for Payer: Hawaii Medical Service Association Commercial	$47,190.68
Rate for Payer: University Health Alliance Commercial	$10,400.00

SPINE & PAIN: BOSTON SCCIENTIFIC 2X4 SPLITTER D4 25 CM

Facility

$3,360.00

Service Code	HCPCS C1883
Hospital Charge Code	9458554
Hospital Revenue Code	278
Min. Negotiated Rate	$1,881.60
Max. Negotiated Rate	$3,259.20
Rate for Payer: Cash Price	$2,184.00
Rate for Payer: Hawaii Western Management Group Commercial	$2,352.00
Rate for Payer: Health Management Network Commercial	$2,856.00
Rate for Payer: Kaiser Permanente Commercial	$3,024.00
Rate for Payer: MDX Hawaii PPO	$3,259.20
Rate for Payer: University Health Alliance Commercial	$1,881.60

SPINE & PAIN: BOSTON SCCIENTIFIC 2X4 SPLITTER D4 25 CM

Facility

$3,360.00

Service Code	HCPCS C1883
Hospital Charge Code	9458554
Hospital Revenue Code	278
Min. Negotiated Rate	$1,680.00
Max. Negotiated Rate	$3,259.20
Rate for Payer: AlohaCare Medicaid	$1,680.00
Rate for Payer: AlohaCare Medicare	$1,680.00
Rate for Payer: Cash Price	$2,184.00
Rate for Payer: Devoted Health Medicare	$1,848.00
Rate for Payer: Hawaii Medical Service Association Medicare	$1,680.00
Rate for Payer: Hawaii Western Management Group Commercial	$2,352.00
Rate for Payer: Health Management Network Commercial	$2,856.00
Rate for Payer: Humana Medicare	$1,680.00
Rate for Payer: Kaiser Permanente Commercial	$3,024.00
Rate for Payer: Kaiser Permanente Medicaid	$1,713.60
Rate for Payer: Kaiser Permanente Medicare	$1,680.00
Rate for Payer: MDX Hawaii PPO	$3,259.20
Rate for Payer: Ohana Health Plan Medicaid	$1,680.00
Rate for Payer: Ohana Health Plan Medicare	$1,680.00
Rate for Payer: UnitedHealthcare Medicare	$1,680.00
Rate for Payer: University Health Alliance Commercial	$1,881.60

SPINE & PAIN: BOSTON SCCIENTIFIC 2X4 SPLITTER W4 25 CM

Facility

$3,360.00

Service Code	HCPCS C1883
Hospital Charge Code	9458555
Hospital Revenue Code	278
Min. Negotiated Rate	$1,680.00
Max. Negotiated Rate	$3,259.20
Rate for Payer: AlohaCare Medicaid	$1,680.00
Rate for Payer: AlohaCare Medicare	$1,680.00
Rate for Payer: Cash Price	$2,184.00
Rate for Payer: Devoted Health Medicare	$1,848.00
Rate for Payer: Hawaii Medical Service Association Medicare	$1,680.00
Rate for Payer: Hawaii Western Management Group Commercial	$2,352.00
Rate for Payer: Health Management Network Commercial	$2,856.00
Rate for Payer: Humana Medicare	$1,680.00
Rate for Payer: Kaiser Permanente Commercial	$3,024.00
Rate for Payer: Kaiser Permanente Medicaid	$1,713.60
Rate for Payer: Kaiser Permanente Medicare	$1,680.00
Rate for Payer: MDX Hawaii PPO	$3,259.20
Rate for Payer: Ohana Health Plan Medicaid	$1,680.00
Rate for Payer: Ohana Health Plan Medicare	$1,680.00
Rate for Payer: UnitedHealthcare Medicare	$1,680.00
Rate for Payer: University Health Alliance Commercial	$1,881.60

SPINE & PAIN: BOSTON SCCIENTIFIC 2X4 SPLITTER W4 25 CM

Facility

$3,360.00

Service Code	HCPCS C1883
Hospital Charge Code	9458555
Hospital Revenue Code	278
Min. Negotiated Rate	$1,881.60
Max. Negotiated Rate	$3,259.20
Rate for Payer: Cash Price	$2,184.00
Rate for Payer: Hawaii Western Management Group Commercial	$2,352.00
Rate for Payer: Health Management Network Commercial	$2,856.00
Rate for Payer: Kaiser Permanente Commercial	$3,024.00
Rate for Payer: MDX Hawaii PPO	$3,259.20
Rate for Payer: University Health Alliance Commercial	$1,881.60

SPINE & PAIN: BOSTON SCIENTIFIC 1 CM SPLIT SUTURE SLEEVE SET OF 1

Facility

$300.00

Hospital Charge Code	9458967
Hospital Revenue Code	272
Min. Negotiated Rate	$150.00
Max. Negotiated Rate	$291.00
Rate for Payer: AlohaCare Medicaid	$150.00
Rate for Payer: AlohaCare Medicare	$150.00
Rate for Payer: Cash Price	$195.00
Rate for Payer: Devoted Health Medicare	$165.00
Rate for Payer: Hawaii Medical Service Association Medicare	$150.00
Rate for Payer: Hawaii Western Management Group Commercial	$285.00
Rate for Payer: Health Management Network Commercial	$255.00
Rate for Payer: Humana Medicare	$150.00
Rate for Payer: Kaiser Permanente Commercial	$270.00
Rate for Payer: Kaiser Permanente Medicaid	$153.00
Rate for Payer: Kaiser Permanente Medicare	$150.00
Rate for Payer: MDX Hawaii PPO	$291.00
Rate for Payer: Ohana Health Plan Medicaid	$150.00
Rate for Payer: Ohana Health Plan Medicare	$150.00
Rate for Payer: UnitedHealthcare Medicare	$150.00
Rate for Payer: University Health Alliance Commercial	$218.67

SPINE & PAIN: BOSTON SCIENTIFIC 1 CM SPLIT SUTURE SLEEVE SET OF 1

Facility

$300.00

Hospital Charge Code	9458967
Hospital Revenue Code	272
Min. Negotiated Rate	$255.00
Max. Negotiated Rate	$291.00
Rate for Payer: Cash Price	$195.00
Rate for Payer: Health Management Network Commercial	$255.00
Rate for Payer: Kaiser Permanente Commercial	$270.00
Rate for Payer: MDX Hawaii PPO	$291.00

SPINE & PAIN: BOSTON SCIENTIFIC 1 CM SUTURE SLEEVE SET OF 1

Facility

$300.00

Hospital Charge Code	9458966
Hospital Revenue Code	272
Min. Negotiated Rate	$255.00
Max. Negotiated Rate	$291.00
Rate for Payer: Cash Price	$195.00
Rate for Payer: Health Management Network Commercial	$255.00
Rate for Payer: Kaiser Permanente Commercial	$270.00
Rate for Payer: MDX Hawaii PPO	$291.00

SPINE & PAIN: BOSTON SCIENTIFIC 1 CM SUTURE SLEEVE SET OF 1

Facility

$300.00

Hospital Charge Code	9458966
Hospital Revenue Code	272
Min. Negotiated Rate	$150.00
Max. Negotiated Rate	$291.00
Rate for Payer: AlohaCare Medicaid	$150.00
Rate for Payer: AlohaCare Medicare	$150.00
Rate for Payer: Cash Price	$195.00
Rate for Payer: Devoted Health Medicare	$165.00
Rate for Payer: Hawaii Medical Service Association Medicare	$150.00
Rate for Payer: Hawaii Western Management Group Commercial	$285.00
Rate for Payer: Health Management Network Commercial	$255.00
Rate for Payer: Humana Medicare	$150.00
Rate for Payer: Kaiser Permanente Commercial	$270.00
Rate for Payer: Kaiser Permanente Medicaid	$153.00
Rate for Payer: Kaiser Permanente Medicare	$150.00
Rate for Payer: MDX Hawaii PPO	$291.00
Rate for Payer: Ohana Health Plan Medicaid	$150.00
Rate for Payer: Ohana Health Plan Medicare	$150.00
Rate for Payer: UnitedHealthcare Medicare	$150.00
Rate for Payer: University Health Alliance Commercial	$218.67

SPINE & PAIN: BOSTON SCIENTIFIC 2.3 CM SUTURE SLEEVE SET OF 1

Facility

$300.00

Hospital Charge Code	9458969
Hospital Revenue Code	272
Min. Negotiated Rate	$150.00
Max. Negotiated Rate	$291.00
Rate for Payer: AlohaCare Medicaid	$150.00
Rate for Payer: AlohaCare Medicare	$150.00
Rate for Payer: Cash Price	$195.00
Rate for Payer: Devoted Health Medicare	$165.00
Rate for Payer: Hawaii Medical Service Association Medicare	$150.00
Rate for Payer: Hawaii Western Management Group Commercial	$285.00
Rate for Payer: Health Management Network Commercial	$255.00
Rate for Payer: Humana Medicare	$150.00
Rate for Payer: Kaiser Permanente Commercial	$270.00
Rate for Payer: Kaiser Permanente Medicaid	$153.00
Rate for Payer: Kaiser Permanente Medicare	$150.00
Rate for Payer: MDX Hawaii PPO	$291.00
Rate for Payer: Ohana Health Plan Medicaid	$150.00
Rate for Payer: Ohana Health Plan Medicare	$150.00
Rate for Payer: UnitedHealthcare Medicare	$150.00
Rate for Payer: University Health Alliance Commercial	$218.67

SPINE & PAIN: BOSTON SCIENTIFIC 2.3 CM SUTURE SLEEVE SET OF 1

Facility

$300.00

Hospital Charge Code	9458969
Hospital Revenue Code	272
Min. Negotiated Rate	$255.00
Max. Negotiated Rate	$291.00
Rate for Payer: Cash Price	$195.00
Rate for Payer: Health Management Network Commercial	$255.00
Rate for Payer: Kaiser Permanente Commercial	$270.00
Rate for Payer: MDX Hawaii PPO	$291.00

SPINE & PAIN: BOSTON SCIENTIFIC 2.3 CM SUTURE SLEEVE SET OF 2

Facility

$300.00

Hospital Charge Code	9458968
Hospital Revenue Code	272
Min. Negotiated Rate	$150.00
Max. Negotiated Rate	$291.00
Rate for Payer: AlohaCare Medicaid	$150.00
Rate for Payer: AlohaCare Medicare	$150.00
Rate for Payer: Cash Price	$195.00
Rate for Payer: Devoted Health Medicare	$165.00
Rate for Payer: Hawaii Medical Service Association Medicare	$150.00
Rate for Payer: Hawaii Western Management Group Commercial	$285.00
Rate for Payer: Health Management Network Commercial	$255.00
Rate for Payer: Humana Medicare	$150.00
Rate for Payer: Kaiser Permanente Commercial	$270.00
Rate for Payer: Kaiser Permanente Medicaid	$153.00
Rate for Payer: Kaiser Permanente Medicare	$150.00
Rate for Payer: MDX Hawaii PPO	$291.00
Rate for Payer: Ohana Health Plan Medicaid	$150.00
Rate for Payer: Ohana Health Plan Medicare	$150.00
Rate for Payer: UnitedHealthcare Medicare	$150.00
Rate for Payer: University Health Alliance Commercial	$218.67

SPINE & PAIN: BOSTON SCIENTIFIC 2.3 CM SUTURE SLEEVE SET OF 2

Facility

$300.00

Hospital Charge Code	9458968
Hospital Revenue Code	272
Min. Negotiated Rate	$255.00
Max. Negotiated Rate	$291.00
Rate for Payer: Cash Price	$195.00
Rate for Payer: Health Management Network Commercial	$255.00
Rate for Payer: Kaiser Permanente Commercial	$270.00
Rate for Payer: MDX Hawaii PPO	$291.00

SPINE & PAIN: BOSTON SCIENTIFIC 2 X 8 INFINITION SPLITTER KIT

Facility

$3,740.00

Service Code	HCPCS C1883
Hospital Charge Code	9458961
Hospital Revenue Code	278
Min. Negotiated Rate	$1,870.00
Max. Negotiated Rate	$3,627.80
Rate for Payer: AlohaCare Medicaid	$1,870.00
Rate for Payer: AlohaCare Medicare	$1,870.00
Rate for Payer: Cash Price	$2,431.00
Rate for Payer: Devoted Health Medicare	$2,057.00
Rate for Payer: Hawaii Medical Service Association Medicare	$1,870.00
Rate for Payer: Hawaii Western Management Group Commercial	$2,618.00
Rate for Payer: Health Management Network Commercial	$3,179.00
Rate for Payer: Humana Medicare	$1,870.00
Rate for Payer: Kaiser Permanente Commercial	$3,366.00
Rate for Payer: Kaiser Permanente Medicaid	$1,907.40
Rate for Payer: Kaiser Permanente Medicare	$1,870.00
Rate for Payer: MDX Hawaii PPO	$3,627.80
Rate for Payer: Ohana Health Plan Medicaid	$1,870.00
Rate for Payer: Ohana Health Plan Medicare	$1,870.00
Rate for Payer: UnitedHealthcare Medicare	$1,870.00
Rate for Payer: University Health Alliance Commercial	$2,094.40

SPINE & PAIN: BOSTON SCIENTIFIC 2 X 8 INFINITION SPLITTER KIT

Facility

$3,740.00

Service Code	HCPCS C1883
Hospital Charge Code	9458961
Hospital Revenue Code	278
Min. Negotiated Rate	$2,094.40
Max. Negotiated Rate	$3,627.80
Rate for Payer: Cash Price	$2,431.00
Rate for Payer: Hawaii Western Management Group Commercial	$2,618.00
Rate for Payer: Health Management Network Commercial	$3,179.00
Rate for Payer: Kaiser Permanente Commercial	$3,366.00
Rate for Payer: MDX Hawaii PPO	$3,627.80
Rate for Payer: University Health Alliance Commercial	$2,094.40

SPINE & PAIN: BOSTON SCIENTIFIC 4 CM SPLIT SUTURE SLEEVE SET OF 1

Facility

$300.00

Hospital Charge Code	9458971
Hospital Revenue Code	272
Min. Negotiated Rate	$150.00
Max. Negotiated Rate	$291.00
Rate for Payer: AlohaCare Medicaid	$150.00
Rate for Payer: AlohaCare Medicare	$150.00
Rate for Payer: Cash Price	$195.00
Rate for Payer: Devoted Health Medicare	$165.00
Rate for Payer: Hawaii Medical Service Association Medicare	$150.00
Rate for Payer: Hawaii Western Management Group Commercial	$285.00
Rate for Payer: Health Management Network Commercial	$255.00
Rate for Payer: Humana Medicare	$150.00
Rate for Payer: Kaiser Permanente Commercial	$270.00
Rate for Payer: Kaiser Permanente Medicaid	$153.00
Rate for Payer: Kaiser Permanente Medicare	$150.00
Rate for Payer: MDX Hawaii PPO	$291.00
Rate for Payer: Ohana Health Plan Medicaid	$150.00
Rate for Payer: Ohana Health Plan Medicare	$150.00
Rate for Payer: UnitedHealthcare Medicare	$150.00
Rate for Payer: University Health Alliance Commercial	$218.67

SPINE & PAIN: BOSTON SCIENTIFIC 4 CM SPLIT SUTURE SLEEVE SET OF 1

Facility

$300.00

Hospital Charge Code	9458971
Hospital Revenue Code	272
Min. Negotiated Rate	$255.00
Max. Negotiated Rate	$291.00
Rate for Payer: Cash Price	$195.00
Rate for Payer: Health Management Network Commercial	$255.00
Rate for Payer: Kaiser Permanente Commercial	$270.00
Rate for Payer: MDX Hawaii PPO	$291.00

SPINE & PAIN: BOSTON SCIENTIFIC 4 CM SUTURE SLEEVE SET OF 1

Facility

$300.00

Hospital Charge Code	9458970
Hospital Revenue Code	272
Min. Negotiated Rate	$150.00
Max. Negotiated Rate	$291.00
Rate for Payer: AlohaCare Medicaid	$150.00
Rate for Payer: AlohaCare Medicare	$150.00
Rate for Payer: Cash Price	$195.00
Rate for Payer: Devoted Health Medicare	$165.00
Rate for Payer: Hawaii Medical Service Association Medicare	$150.00
Rate for Payer: Hawaii Western Management Group Commercial	$285.00
Rate for Payer: Health Management Network Commercial	$255.00
Rate for Payer: Humana Medicare	$150.00
Rate for Payer: Kaiser Permanente Commercial	$270.00
Rate for Payer: Kaiser Permanente Medicaid	$153.00
Rate for Payer: Kaiser Permanente Medicare	$150.00
Rate for Payer: MDX Hawaii PPO	$291.00
Rate for Payer: Ohana Health Plan Medicaid	$150.00
Rate for Payer: Ohana Health Plan Medicare	$150.00
Rate for Payer: UnitedHealthcare Medicare	$150.00
Rate for Payer: University Health Alliance Commercial	$218.67

Know your out-of-pocket cost for care.

All Charges