Samuel Mahelona Memorial Hospital

All Charges

Charge

Type

Setting

Price

SPINE & PAIN: BOSTON SCIENTIFIC COVEREDGE 32 SURGICAL LEAD KIT 50 CM

Facility

$22,250.00

Service Code	HCPCS C1778
Hospital Charge Code	9456770
Hospital Revenue Code	278
Min. Negotiated Rate	$12,460.00
Max. Negotiated Rate	$21,582.50
Rate for Payer: Cash Price	$14,462.50
Rate for Payer: Hawaii Western Management Group Commercial	$15,575.00
Rate for Payer: Health Management Network Commercial	$18,912.50
Rate for Payer: Kaiser Permanente Commercial	$20,025.00
Rate for Payer: MDX Hawaii PPO	$21,582.50
Rate for Payer: University Health Alliance Commercial	$12,460.00

SPINE & PAIN: BOSTON SCIENTIFIC COVEREDGE 32 SURGICAL LEAD KIT 50 CM

Facility

$22,250.00

Service Code	HCPCS C1778
Hospital Charge Code	9456770
Hospital Revenue Code	278
Min. Negotiated Rate	$11,125.00
Max. Negotiated Rate	$21,582.50
Rate for Payer: AlohaCare Medicaid	$11,125.00
Rate for Payer: AlohaCare Medicare	$11,125.00
Rate for Payer: Cash Price	$14,462.50
Rate for Payer: Devoted Health Medicare	$12,237.50
Rate for Payer: Hawaii Medical Service Association Medicare	$11,125.00
Rate for Payer: Hawaii Western Management Group Commercial	$15,575.00
Rate for Payer: Health Management Network Commercial	$18,912.50
Rate for Payer: Humana Medicare	$11,125.00
Rate for Payer: Kaiser Permanente Commercial	$20,025.00
Rate for Payer: Kaiser Permanente Medicaid	$11,347.50
Rate for Payer: Kaiser Permanente Medicare	$11,125.00
Rate for Payer: MDX Hawaii PPO	$21,582.50
Rate for Payer: Ohana Health Plan Medicaid	$11,125.00
Rate for Payer: Ohana Health Plan Medicare	$11,125.00
Rate for Payer: UnitedHealthcare Medicare	$11,125.00
Rate for Payer: University Health Alliance Commercial	$12,460.00

SPINE & PAIN: BOSTON SCIENTIFIC COVEREDGE 32 SURGICAL LEAD KIT 70 CM

Facility

$22,250.00

Service Code	HCPCS C1778
Hospital Charge Code	9456771
Hospital Revenue Code	278
Min. Negotiated Rate	$12,460.00
Max. Negotiated Rate	$21,582.50
Rate for Payer: Cash Price	$14,462.50
Rate for Payer: Hawaii Western Management Group Commercial	$15,575.00
Rate for Payer: Health Management Network Commercial	$18,912.50
Rate for Payer: Kaiser Permanente Commercial	$20,025.00
Rate for Payer: MDX Hawaii PPO	$21,582.50
Rate for Payer: University Health Alliance Commercial	$12,460.00

SPINE & PAIN: BOSTON SCIENTIFIC COVEREDGE 32 SURGICAL LEAD KIT 70 CM

Facility

$22,250.00

Service Code	HCPCS C1778
Hospital Charge Code	9456771
Hospital Revenue Code	278
Min. Negotiated Rate	$11,125.00
Max. Negotiated Rate	$21,582.50
Rate for Payer: AlohaCare Medicaid	$11,125.00
Rate for Payer: AlohaCare Medicare	$11,125.00
Rate for Payer: Cash Price	$14,462.50
Rate for Payer: Devoted Health Medicare	$12,237.50
Rate for Payer: Hawaii Medical Service Association Medicare	$11,125.00
Rate for Payer: Hawaii Western Management Group Commercial	$15,575.00
Rate for Payer: Health Management Network Commercial	$18,912.50
Rate for Payer: Humana Medicare	$11,125.00
Rate for Payer: Kaiser Permanente Commercial	$20,025.00
Rate for Payer: Kaiser Permanente Medicaid	$11,347.50
Rate for Payer: Kaiser Permanente Medicare	$11,125.00
Rate for Payer: MDX Hawaii PPO	$21,582.50
Rate for Payer: Ohana Health Plan Medicaid	$11,125.00
Rate for Payer: Ohana Health Plan Medicare	$11,125.00
Rate for Payer: UnitedHealthcare Medicare	$11,125.00
Rate for Payer: University Health Alliance Commercial	$12,460.00

SPINE & PAIN: BOSTON SCIENTIFIC COVEREDGE X 32 SURGICAL LEAD KIT 50 CM

Facility

$22,250.00

Service Code	HCPCS C1778
Hospital Charge Code	9456772
Hospital Revenue Code	278
Min. Negotiated Rate	$12,460.00
Max. Negotiated Rate	$21,582.50
Rate for Payer: Cash Price	$14,462.50
Rate for Payer: Hawaii Western Management Group Commercial	$15,575.00
Rate for Payer: Health Management Network Commercial	$18,912.50
Rate for Payer: Kaiser Permanente Commercial	$20,025.00
Rate for Payer: MDX Hawaii PPO	$21,582.50
Rate for Payer: University Health Alliance Commercial	$12,460.00

SPINE & PAIN: BOSTON SCIENTIFIC COVEREDGE X 32 SURGICAL LEAD KIT 50 CM

Facility

$22,250.00

Service Code	HCPCS C1778
Hospital Charge Code	9456772
Hospital Revenue Code	278
Min. Negotiated Rate	$11,125.00
Max. Negotiated Rate	$21,582.50
Rate for Payer: AlohaCare Medicaid	$11,125.00
Rate for Payer: AlohaCare Medicare	$11,125.00
Rate for Payer: Cash Price	$14,462.50
Rate for Payer: Devoted Health Medicare	$12,237.50
Rate for Payer: Hawaii Medical Service Association Medicare	$11,125.00
Rate for Payer: Hawaii Western Management Group Commercial	$15,575.00
Rate for Payer: Health Management Network Commercial	$18,912.50
Rate for Payer: Humana Medicare	$11,125.00
Rate for Payer: Kaiser Permanente Commercial	$20,025.00
Rate for Payer: Kaiser Permanente Medicaid	$11,347.50
Rate for Payer: Kaiser Permanente Medicare	$11,125.00
Rate for Payer: MDX Hawaii PPO	$21,582.50
Rate for Payer: Ohana Health Plan Medicaid	$11,125.00
Rate for Payer: Ohana Health Plan Medicare	$11,125.00
Rate for Payer: UnitedHealthcare Medicare	$11,125.00
Rate for Payer: University Health Alliance Commercial	$12,460.00

SPINE & PAIN: BOSTON SCIENTIFIC COVEREDGE X 32 SURGICAL LEAD KIT 70 CM

Facility

$22,250.00

Service Code	HCPCS C1778
Hospital Charge Code	9456773
Hospital Revenue Code	278
Min. Negotiated Rate	$12,460.00
Max. Negotiated Rate	$21,582.50
Rate for Payer: Cash Price	$14,462.50
Rate for Payer: Hawaii Western Management Group Commercial	$15,575.00
Rate for Payer: Health Management Network Commercial	$18,912.50
Rate for Payer: Kaiser Permanente Commercial	$20,025.00
Rate for Payer: MDX Hawaii PPO	$21,582.50
Rate for Payer: University Health Alliance Commercial	$12,460.00

SPINE & PAIN: BOSTON SCIENTIFIC COVEREDGE X 32 SURGICAL LEAD KIT 70 CM

Facility

$22,250.00

Service Code	HCPCS C1778
Hospital Charge Code	9456773
Hospital Revenue Code	278
Min. Negotiated Rate	$11,125.00
Max. Negotiated Rate	$21,582.50
Rate for Payer: AlohaCare Medicaid	$11,125.00
Rate for Payer: AlohaCare Medicare	$11,125.00
Rate for Payer: Cash Price	$14,462.50
Rate for Payer: Devoted Health Medicare	$12,237.50
Rate for Payer: Hawaii Medical Service Association Medicare	$11,125.00
Rate for Payer: Hawaii Western Management Group Commercial	$15,575.00
Rate for Payer: Health Management Network Commercial	$18,912.50
Rate for Payer: Humana Medicare	$11,125.00
Rate for Payer: Kaiser Permanente Commercial	$20,025.00
Rate for Payer: Kaiser Permanente Medicaid	$11,347.50
Rate for Payer: Kaiser Permanente Medicare	$11,125.00
Rate for Payer: MDX Hawaii PPO	$21,582.50
Rate for Payer: Ohana Health Plan Medicaid	$11,125.00
Rate for Payer: Ohana Health Plan Medicare	$11,125.00
Rate for Payer: UnitedHealthcare Medicare	$11,125.00
Rate for Payer: University Health Alliance Commercial	$12,460.00

SPINE & PAIN: BOSTON SCIENTIFIC ENTRADA NEEDLE

Facility

$1,383.00

Hospital Charge Code	8882692
Hospital Revenue Code	272
Min. Negotiated Rate	$691.50
Max. Negotiated Rate	$1,341.51
Rate for Payer: AlohaCare Medicaid	$691.50
Rate for Payer: AlohaCare Medicare	$691.50
Rate for Payer: Cash Price	$898.95
Rate for Payer: Devoted Health Medicare	$760.65
Rate for Payer: Hawaii Medical Service Association Medicare	$691.50
Rate for Payer: Hawaii Western Management Group Commercial	$1,313.85
Rate for Payer: Health Management Network Commercial	$1,175.55
Rate for Payer: Humana Medicare	$691.50
Rate for Payer: Kaiser Permanente Commercial	$1,244.70
Rate for Payer: Kaiser Permanente Medicaid	$705.33
Rate for Payer: Kaiser Permanente Medicare	$691.50
Rate for Payer: MDX Hawaii PPO	$1,341.51
Rate for Payer: Ohana Health Plan Medicaid	$691.50
Rate for Payer: Ohana Health Plan Medicare	$691.50
Rate for Payer: UnitedHealthcare Medicare	$691.50
Rate for Payer: University Health Alliance Commercial	$1,008.07

SPINE & PAIN: BOSTON SCIENTIFIC ENTRADA NEEDLE

Facility

$1,383.00

Hospital Charge Code	8882692
Hospital Revenue Code	272
Min. Negotiated Rate	$1,175.55
Max. Negotiated Rate	$1,341.51
Rate for Payer: Cash Price	$898.95
Rate for Payer: Health Management Network Commercial	$1,175.55
Rate for Payer: Kaiser Permanente Commercial	$1,244.70
Rate for Payer: MDX Hawaii PPO	$1,341.51

SPINE & PAIN: BOSTON SCIENTIFIC ENTRADA NEEDLE 11CM (4.5 IN)

Facility

$1,383.00

Hospital Charge Code	8882693
Hospital Revenue Code	272
Min. Negotiated Rate	$691.50
Max. Negotiated Rate	$1,341.51
Rate for Payer: AlohaCare Medicaid	$691.50
Rate for Payer: AlohaCare Medicare	$691.50
Rate for Payer: Cash Price	$898.95
Rate for Payer: Devoted Health Medicare	$760.65
Rate for Payer: Hawaii Medical Service Association Medicare	$691.50
Rate for Payer: Hawaii Western Management Group Commercial	$1,313.85
Rate for Payer: Health Management Network Commercial	$1,175.55
Rate for Payer: Humana Medicare	$691.50
Rate for Payer: Kaiser Permanente Commercial	$1,244.70
Rate for Payer: Kaiser Permanente Medicaid	$705.33
Rate for Payer: Kaiser Permanente Medicare	$691.50
Rate for Payer: MDX Hawaii PPO	$1,341.51
Rate for Payer: Ohana Health Plan Medicaid	$691.50
Rate for Payer: Ohana Health Plan Medicare	$691.50
Rate for Payer: UnitedHealthcare Medicare	$691.50
Rate for Payer: University Health Alliance Commercial	$1,008.07

SPINE & PAIN: BOSTON SCIENTIFIC ENTRADA NEEDLE 11CM (4.5 IN)

Facility

$1,383.00

Hospital Charge Code	8882693
Hospital Revenue Code	272
Min. Negotiated Rate	$1,175.55
Max. Negotiated Rate	$1,341.51
Rate for Payer: Cash Price	$898.95
Rate for Payer: Health Management Network Commercial	$1,175.55
Rate for Payer: Kaiser Permanente Commercial	$1,244.70
Rate for Payer: MDX Hawaii PPO	$1,341.51

SPINE & PAIN: BOSTON SCIENTIFIC ENTRADA NEEDLE 15CM (6.0 IN)

Facility

$1,383.00

Hospital Charge Code	8882694
Hospital Revenue Code	272
Min. Negotiated Rate	$1,175.55
Max. Negotiated Rate	$1,341.51
Rate for Payer: Cash Price	$898.95
Rate for Payer: Health Management Network Commercial	$1,175.55
Rate for Payer: Kaiser Permanente Commercial	$1,244.70
Rate for Payer: MDX Hawaii PPO	$1,341.51

SPINE & PAIN: BOSTON SCIENTIFIC ENTRADA NEEDLE 15CM (6.0 IN)

Facility

$1,383.00

Hospital Charge Code	8882694
Hospital Revenue Code	272
Min. Negotiated Rate	$691.50
Max. Negotiated Rate	$1,341.51
Rate for Payer: AlohaCare Medicaid	$691.50
Rate for Payer: AlohaCare Medicare	$691.50
Rate for Payer: Cash Price	$898.95
Rate for Payer: Devoted Health Medicare	$760.65
Rate for Payer: Hawaii Medical Service Association Medicare	$691.50
Rate for Payer: Hawaii Western Management Group Commercial	$1,313.85
Rate for Payer: Health Management Network Commercial	$1,175.55
Rate for Payer: Humana Medicare	$691.50
Rate for Payer: Kaiser Permanente Commercial	$1,244.70
Rate for Payer: Kaiser Permanente Medicaid	$705.33
Rate for Payer: Kaiser Permanente Medicare	$691.50
Rate for Payer: MDX Hawaii PPO	$1,341.51
Rate for Payer: Ohana Health Plan Medicaid	$691.50
Rate for Payer: Ohana Health Plan Medicare	$691.50
Rate for Payer: UnitedHealthcare Medicare	$691.50
Rate for Payer: University Health Alliance Commercial	$1,008.07

SPINE & PAIN: BOSTON SCIENTIFIC ENTRADA SPARE SHEATH 11CM (4.5 IN)

Facility

$380.00

Hospital Charge Code	8882695
Hospital Revenue Code	272
Min. Negotiated Rate	$323.00
Max. Negotiated Rate	$368.60
Rate for Payer: Cash Price	$247.00
Rate for Payer: Health Management Network Commercial	$323.00
Rate for Payer: Kaiser Permanente Commercial	$342.00
Rate for Payer: MDX Hawaii PPO	$368.60

SPINE & PAIN: BOSTON SCIENTIFIC ENTRADA SPARE SHEATH 11CM (4.5 IN)

Facility

$380.00

Hospital Charge Code	8882695
Hospital Revenue Code	272
Min. Negotiated Rate	$190.00
Max. Negotiated Rate	$368.60
Rate for Payer: AlohaCare Medicaid	$190.00
Rate for Payer: AlohaCare Medicare	$190.00
Rate for Payer: Cash Price	$247.00
Rate for Payer: Devoted Health Medicare	$209.00
Rate for Payer: Hawaii Medical Service Association Medicare	$190.00
Rate for Payer: Hawaii Western Management Group Commercial	$361.00
Rate for Payer: Health Management Network Commercial	$323.00
Rate for Payer: Humana Medicare	$190.00
Rate for Payer: Kaiser Permanente Commercial	$342.00
Rate for Payer: Kaiser Permanente Medicaid	$193.80
Rate for Payer: Kaiser Permanente Medicare	$190.00
Rate for Payer: MDX Hawaii PPO	$368.60
Rate for Payer: Ohana Health Plan Medicaid	$190.00
Rate for Payer: Ohana Health Plan Medicare	$190.00
Rate for Payer: UnitedHealthcare Medicare	$190.00
Rate for Payer: University Health Alliance Commercial	$276.98

SPINE & PAIN: BOSTON SCIENTIFIC ENTRADA SPARE SHEATH 15CM (6.0 IN)

Facility

$380.00

Hospital Charge Code	8882696
Hospital Revenue Code	272
Min. Negotiated Rate	$323.00
Max. Negotiated Rate	$368.60
Rate for Payer: Cash Price	$247.00
Rate for Payer: Health Management Network Commercial	$323.00
Rate for Payer: Kaiser Permanente Commercial	$342.00
Rate for Payer: MDX Hawaii PPO	$368.60

SPINE & PAIN: BOSTON SCIENTIFIC ENTRADA SPARE SHEATH 15CM (6.0 IN)

Facility

$380.00

Hospital Charge Code	8882696
Hospital Revenue Code	272
Min. Negotiated Rate	$190.00
Max. Negotiated Rate	$368.60
Rate for Payer: AlohaCare Medicaid	$190.00
Rate for Payer: AlohaCare Medicare	$190.00
Rate for Payer: Cash Price	$247.00
Rate for Payer: Devoted Health Medicare	$209.00
Rate for Payer: Hawaii Medical Service Association Medicare	$190.00
Rate for Payer: Hawaii Western Management Group Commercial	$361.00
Rate for Payer: Health Management Network Commercial	$323.00
Rate for Payer: Humana Medicare	$190.00
Rate for Payer: Kaiser Permanente Commercial	$342.00
Rate for Payer: Kaiser Permanente Medicaid	$193.80
Rate for Payer: Kaiser Permanente Medicare	$190.00
Rate for Payer: MDX Hawaii PPO	$368.60
Rate for Payer: Ohana Health Plan Medicaid	$190.00
Rate for Payer: Ohana Health Plan Medicare	$190.00
Rate for Payer: UnitedHealthcare Medicare	$190.00
Rate for Payer: University Health Alliance Commercial	$276.98

SPINE & PAIN: BOSTON SCIENTIFIC EPIMED CURVED NEEDLE

Facility

$300.00

Hospital Charge Code	8882691
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 EPIMED CURVED NEEDLE

Facility

$300.00

Hospital Charge Code	8882691
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 FREELINK REMOTE CONTROL KIT

Facility

$3,580.00

Service Code	HCPCS C1787
Hospital Charge Code	8882334
Hospital Revenue Code	278
Min. Negotiated Rate	$1,790.00
Max. Negotiated Rate	$3,472.60
Rate for Payer: AlohaCare Medicaid	$1,790.00
Rate for Payer: AlohaCare Medicare	$1,790.00
Rate for Payer: Cash Price	$2,327.00
Rate for Payer: Devoted Health Medicare	$1,969.00
Rate for Payer: Hawaii Medical Service Association Medicare	$1,790.00
Rate for Payer: Hawaii Western Management Group Commercial	$2,506.00
Rate for Payer: Health Management Network Commercial	$3,043.00
Rate for Payer: Humana Medicare	$1,790.00
Rate for Payer: Kaiser Permanente Commercial	$3,222.00
Rate for Payer: Kaiser Permanente Medicaid	$1,825.80
Rate for Payer: Kaiser Permanente Medicare	$1,790.00
Rate for Payer: MDX Hawaii PPO	$3,472.60
Rate for Payer: Ohana Health Plan Medicaid	$1,790.00
Rate for Payer: Ohana Health Plan Medicare	$1,790.00
Rate for Payer: UnitedHealthcare Medicare	$1,790.00
Rate for Payer: University Health Alliance Commercial	$2,004.80

SPINE & PAIN: BOSTON SCIENTIFIC FREELINK REMOTE CONTROL KIT

Facility

$3,580.00

Service Code	HCPCS C1787
Hospital Charge Code	8882334
Hospital Revenue Code	278
Min. Negotiated Rate	$2,004.80
Max. Negotiated Rate	$3,472.60
Rate for Payer: Cash Price	$2,327.00
Rate for Payer: Hawaii Western Management Group Commercial	$2,506.00
Rate for Payer: Health Management Network Commercial	$3,043.00
Rate for Payer: Kaiser Permanente Commercial	$3,222.00
Rate for Payer: MDX Hawaii PPO	$3,472.60
Rate for Payer: University Health Alliance Commercial	$2,004.80

SPINE & PAIN: BOSTON SCIENTIFIC- FREELINK REMOTE CONTROL KIT

Facility

$3,580.00

Service Code	HCPCS C1787
Hospital Charge Code	8882395
Hospital Revenue Code	278
Min. Negotiated Rate	$1,790.00
Max. Negotiated Rate	$3,472.60
Rate for Payer: AlohaCare Medicaid	$1,790.00
Rate for Payer: AlohaCare Medicare	$1,790.00
Rate for Payer: Cash Price	$2,327.00
Rate for Payer: Devoted Health Medicare	$1,969.00
Rate for Payer: Hawaii Medical Service Association Medicare	$1,790.00
Rate for Payer: Hawaii Western Management Group Commercial	$2,506.00
Rate for Payer: Health Management Network Commercial	$3,043.00
Rate for Payer: Humana Medicare	$1,790.00
Rate for Payer: Kaiser Permanente Commercial	$3,222.00
Rate for Payer: Kaiser Permanente Medicaid	$1,825.80
Rate for Payer: Kaiser Permanente Medicare	$1,790.00
Rate for Payer: MDX Hawaii PPO	$3,472.60
Rate for Payer: Ohana Health Plan Medicaid	$1,790.00
Rate for Payer: Ohana Health Plan Medicare	$1,790.00
Rate for Payer: UnitedHealthcare Medicare	$1,790.00
Rate for Payer: University Health Alliance Commercial	$2,004.80

SPINE & PAIN: BOSTON SCIENTIFIC- FREELINK REMOTE CONTROL KIT

Facility

$3,580.00

Service Code	HCPCS C1787
Hospital Charge Code	8882395
Hospital Revenue Code	278
Min. Negotiated Rate	$2,004.80
Max. Negotiated Rate	$3,472.60
Rate for Payer: Cash Price	$2,327.00
Rate for Payer: Hawaii Western Management Group Commercial	$2,506.00
Rate for Payer: Health Management Network Commercial	$3,043.00
Rate for Payer: Kaiser Permanente Commercial	$3,222.00
Rate for Payer: MDX Hawaii PPO	$3,472.60
Rate for Payer: University Health Alliance Commercial	$2,004.80

SPINE & PAIN: BOSTON SCIENTIFIC FREELINK REMOTE CONTROL KIT-SPECTRA, NOVI, AND MONTAGE MRI

Facility

$3,580.00

Service Code	HCPCS C1787
Hospital Charge Code	8882396
Hospital Revenue Code	278
Min. Negotiated Rate	$2,004.80
Max. Negotiated Rate	$3,472.60
Rate for Payer: Cash Price	$2,327.00
Rate for Payer: Hawaii Western Management Group Commercial	$2,506.00
Rate for Payer: Health Management Network Commercial	$3,043.00
Rate for Payer: Kaiser Permanente Commercial	$3,222.00
Rate for Payer: MDX Hawaii PPO	$3,472.60
Rate for Payer: University Health Alliance Commercial	$2,004.80

Know your out-of-pocket cost for care.

All Charges