Samuel Mahelona Memorial Hospital

All Charges

Charge

Type

Setting

Price

SPINE & PAIN: BOSTON SCIENTIFIC ST LINEAR TRIAL LEAD WITH PRELOADED 0.014 STYLET 50 CM

Facility

$2,000.00

Service Code	HCPCS C1897
Hospital Charge Code	9456260
Hospital Revenue Code	278
Min. Negotiated Rate	$1,000.00
Max. Negotiated Rate	$1,940.00
Rate for Payer: AlohaCare Medicaid	$1,000.00
Rate for Payer: AlohaCare Medicare	$1,000.00
Rate for Payer: Cash Price	$1,300.00
Rate for Payer: Devoted Health Medicare	$1,100.00
Rate for Payer: Hawaii Medical Service Association Medicare	$1,000.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,400.00
Rate for Payer: Health Management Network Commercial	$1,700.00
Rate for Payer: Humana Medicare	$1,000.00
Rate for Payer: Kaiser Permanente Commercial	$1,800.00
Rate for Payer: Kaiser Permanente Medicaid	$1,020.00
Rate for Payer: Kaiser Permanente Medicare	$1,000.00
Rate for Payer: MDX Hawaii PPO	$1,940.00
Rate for Payer: Ohana Health Plan Medicaid	$1,000.00
Rate for Payer: Ohana Health Plan Medicare	$1,000.00
Rate for Payer: UnitedHealthcare Medicare	$1,000.00
Rate for Payer: University Health Alliance Commercial	$1,120.00

SPINE & PAIN: BOSTON SCIENTIFIC ST LINEAR TRIAL LEAD WITH PRELOADED 0.014 STYLET 70 CM

Facility

$3,630.00

Service Code	HCPCS C1897
Hospital Charge Code	9456261
Hospital Revenue Code	278
Min. Negotiated Rate	$1,815.00
Max. Negotiated Rate	$3,521.10
Rate for Payer: AlohaCare Medicaid	$1,815.00
Rate for Payer: AlohaCare Medicare	$1,815.00
Rate for Payer: Cash Price	$2,359.50
Rate for Payer: Devoted Health Medicare	$1,996.50
Rate for Payer: Hawaii Medical Service Association Medicare	$1,815.00
Rate for Payer: Hawaii Western Management Group Commercial	$2,541.00
Rate for Payer: Health Management Network Commercial	$3,085.50
Rate for Payer: Humana Medicare	$1,815.00
Rate for Payer: Kaiser Permanente Commercial	$3,267.00
Rate for Payer: Kaiser Permanente Medicaid	$1,851.30
Rate for Payer: Kaiser Permanente Medicare	$1,815.00
Rate for Payer: MDX Hawaii PPO	$3,521.10
Rate for Payer: Ohana Health Plan Medicaid	$1,815.00
Rate for Payer: Ohana Health Plan Medicare	$1,815.00
Rate for Payer: UnitedHealthcare Medicare	$1,815.00
Rate for Payer: University Health Alliance Commercial	$2,032.80

SPINE & PAIN: BOSTON SCIENTIFIC ST LINEAR TRIAL LEAD WITH PRELOADED 0.014 STYLET 70 CM

Facility

$3,630.00

Service Code	HCPCS C1897
Hospital Charge Code	9456261
Hospital Revenue Code	278
Min. Negotiated Rate	$2,032.80
Max. Negotiated Rate	$3,521.10
Rate for Payer: Cash Price	$2,359.50
Rate for Payer: Hawaii Western Management Group Commercial	$2,541.00
Rate for Payer: Health Management Network Commercial	$3,085.50
Rate for Payer: Kaiser Permanente Commercial	$3,267.00
Rate for Payer: MDX Hawaii PPO	$3,521.10
Rate for Payer: University Health Alliance Commercial	$2,032.80

SPINE & PAIN: BOSTON SCIENTIFIC STRAW TUNNELING TOOL (28 CM)

Facility

$392.00

Hospital Charge Code	8882697
Hospital Revenue Code	272
Min. Negotiated Rate	$196.00
Max. Negotiated Rate	$380.24
Rate for Payer: AlohaCare Medicaid	$196.00
Rate for Payer: AlohaCare Medicare	$196.00
Rate for Payer: Cash Price	$254.80
Rate for Payer: Devoted Health Medicare	$215.60
Rate for Payer: Hawaii Medical Service Association Medicare	$196.00
Rate for Payer: Hawaii Western Management Group Commercial	$372.40
Rate for Payer: Health Management Network Commercial	$333.20
Rate for Payer: Humana Medicare	$196.00
Rate for Payer: Kaiser Permanente Commercial	$352.80
Rate for Payer: Kaiser Permanente Medicaid	$199.92
Rate for Payer: Kaiser Permanente Medicare	$196.00
Rate for Payer: MDX Hawaii PPO	$380.24
Rate for Payer: Ohana Health Plan Medicaid	$196.00
Rate for Payer: Ohana Health Plan Medicare	$196.00
Rate for Payer: UnitedHealthcare Medicare	$196.00
Rate for Payer: University Health Alliance Commercial	$285.73

SPINE & PAIN: BOSTON SCIENTIFIC STRAW TUNNELING TOOL (28 CM)

Facility

$392.00

Hospital Charge Code	8882697
Hospital Revenue Code	272
Min. Negotiated Rate	$333.20
Max. Negotiated Rate	$380.24
Rate for Payer: Cash Price	$254.80
Rate for Payer: Health Management Network Commercial	$333.20
Rate for Payer: Kaiser Permanente Commercial	$352.80
Rate for Payer: MDX Hawaii PPO	$380.24

SPINE & PAIN: BOSTON SCIENTIFIC STYLET KIT W/ STEERING CAP - 30 CM

Facility

$694.00

Hospital Charge Code	8882702
Hospital Revenue Code	272
Min. Negotiated Rate	$347.00
Max. Negotiated Rate	$673.18
Rate for Payer: AlohaCare Medicaid	$347.00
Rate for Payer: AlohaCare Medicare	$347.00
Rate for Payer: Cash Price	$451.10
Rate for Payer: Devoted Health Medicare	$381.70
Rate for Payer: Hawaii Medical Service Association Medicare	$347.00
Rate for Payer: Hawaii Western Management Group Commercial	$659.30
Rate for Payer: Health Management Network Commercial	$589.90
Rate for Payer: Humana Medicare	$347.00
Rate for Payer: Kaiser Permanente Commercial	$624.60
Rate for Payer: Kaiser Permanente Medicaid	$353.94
Rate for Payer: Kaiser Permanente Medicare	$347.00
Rate for Payer: MDX Hawaii PPO	$673.18
Rate for Payer: Ohana Health Plan Medicaid	$347.00
Rate for Payer: Ohana Health Plan Medicare	$347.00
Rate for Payer: UnitedHealthcare Medicare	$347.00
Rate for Payer: University Health Alliance Commercial	$505.86

SPINE & PAIN: BOSTON SCIENTIFIC STYLET KIT W/ STEERING CAP - 30 CM

Facility

$694.00

Hospital Charge Code	8882702
Hospital Revenue Code	272
Min. Negotiated Rate	$589.90
Max. Negotiated Rate	$673.18
Rate for Payer: Cash Price	$451.10
Rate for Payer: Health Management Network Commercial	$589.90
Rate for Payer: Kaiser Permanente Commercial	$624.60
Rate for Payer: MDX Hawaii PPO	$673.18

SPINE & PAIN: BOSTON SCIENTIFIC STYLET KIT W/ STEERING CAP - 50 CM

Facility

$694.00

Hospital Charge Code	8882703
Hospital Revenue Code	272
Min. Negotiated Rate	$347.00
Max. Negotiated Rate	$673.18
Rate for Payer: AlohaCare Medicaid	$347.00
Rate for Payer: AlohaCare Medicare	$347.00
Rate for Payer: Cash Price	$451.10
Rate for Payer: Devoted Health Medicare	$381.70
Rate for Payer: Hawaii Medical Service Association Medicare	$347.00
Rate for Payer: Hawaii Western Management Group Commercial	$659.30
Rate for Payer: Health Management Network Commercial	$589.90
Rate for Payer: Humana Medicare	$347.00
Rate for Payer: Kaiser Permanente Commercial	$624.60
Rate for Payer: Kaiser Permanente Medicaid	$353.94
Rate for Payer: Kaiser Permanente Medicare	$347.00
Rate for Payer: MDX Hawaii PPO	$673.18
Rate for Payer: Ohana Health Plan Medicaid	$347.00
Rate for Payer: Ohana Health Plan Medicare	$347.00
Rate for Payer: UnitedHealthcare Medicare	$347.00
Rate for Payer: University Health Alliance Commercial	$505.86

SPINE & PAIN: BOSTON SCIENTIFIC STYLET KIT W/ STEERING CAP - 50 CM

Facility

$694.00

Hospital Charge Code	8882703
Hospital Revenue Code	272
Min. Negotiated Rate	$589.90
Max. Negotiated Rate	$673.18
Rate for Payer: Cash Price	$451.10
Rate for Payer: Health Management Network Commercial	$589.90
Rate for Payer: Kaiser Permanente Commercial	$624.60
Rate for Payer: MDX Hawaii PPO	$673.18

SPINE & PAIN: BOSTON SCIENTIFIC STYLET KIT W/ STEERING CAP -70 CM

Facility

$694.00

Hospital Charge Code	8882704
Hospital Revenue Code	272
Min. Negotiated Rate	$589.90
Max. Negotiated Rate	$673.18
Rate for Payer: Cash Price	$451.10
Rate for Payer: Health Management Network Commercial	$589.90
Rate for Payer: Kaiser Permanente Commercial	$624.60
Rate for Payer: MDX Hawaii PPO	$673.18

SPINE & PAIN: BOSTON SCIENTIFIC STYLET KIT W/ STEERING CAP -70 CM

Facility

$694.00

Hospital Charge Code	8882704
Hospital Revenue Code	272
Min. Negotiated Rate	$347.00
Max. Negotiated Rate	$673.18
Rate for Payer: AlohaCare Medicaid	$347.00
Rate for Payer: AlohaCare Medicare	$347.00
Rate for Payer: Cash Price	$451.10
Rate for Payer: Devoted Health Medicare	$381.70
Rate for Payer: Hawaii Medical Service Association Medicare	$347.00
Rate for Payer: Hawaii Western Management Group Commercial	$659.30
Rate for Payer: Health Management Network Commercial	$589.90
Rate for Payer: Humana Medicare	$347.00
Rate for Payer: Kaiser Permanente Commercial	$624.60
Rate for Payer: Kaiser Permanente Medicaid	$353.94
Rate for Payer: Kaiser Permanente Medicare	$347.00
Rate for Payer: MDX Hawaii PPO	$673.18
Rate for Payer: Ohana Health Plan Medicaid	$347.00
Rate for Payer: Ohana Health Plan Medicare	$347.00
Rate for Payer: UnitedHealthcare Medicare	$347.00
Rate for Payer: University Health Alliance Commercial	$505.86

SPINE & PAIN: BOSTON SCIENTIFIC STYLET KIT W/ STEERING CAP AND STIFFER STYLET - 30 CM

Facility

$694.00

Hospital Charge Code	8882705
Hospital Revenue Code	272
Min. Negotiated Rate	$347.00
Max. Negotiated Rate	$673.18
Rate for Payer: AlohaCare Medicaid	$347.00
Rate for Payer: AlohaCare Medicare	$347.00
Rate for Payer: Cash Price	$451.10
Rate for Payer: Devoted Health Medicare	$381.70
Rate for Payer: Hawaii Medical Service Association Medicare	$347.00
Rate for Payer: Hawaii Western Management Group Commercial	$659.30
Rate for Payer: Health Management Network Commercial	$589.90
Rate for Payer: Humana Medicare	$347.00
Rate for Payer: Kaiser Permanente Commercial	$624.60
Rate for Payer: Kaiser Permanente Medicaid	$353.94
Rate for Payer: Kaiser Permanente Medicare	$347.00
Rate for Payer: MDX Hawaii PPO	$673.18
Rate for Payer: Ohana Health Plan Medicaid	$347.00
Rate for Payer: Ohana Health Plan Medicare	$347.00
Rate for Payer: UnitedHealthcare Medicare	$347.00
Rate for Payer: University Health Alliance Commercial	$505.86

SPINE & PAIN: BOSTON SCIENTIFIC STYLET KIT W/ STEERING CAP AND STIFFER STYLET - 30 CM

Facility

$694.00

Hospital Charge Code	8882705
Hospital Revenue Code	272
Min. Negotiated Rate	$589.90
Max. Negotiated Rate	$673.18
Rate for Payer: Cash Price	$451.10
Rate for Payer: Health Management Network Commercial	$589.90
Rate for Payer: Kaiser Permanente Commercial	$624.60
Rate for Payer: MDX Hawaii PPO	$673.18

SPINE & PAIN: BOSTON SCIENTIFIC STYLET KIT W/ STEERING CAP AND STIFFER STYLET - 50 CM

Facility

$694.00

Hospital Charge Code	8882706
Hospital Revenue Code	272
Min. Negotiated Rate	$347.00
Max. Negotiated Rate	$673.18
Rate for Payer: AlohaCare Medicaid	$347.00
Rate for Payer: AlohaCare Medicare	$347.00
Rate for Payer: Cash Price	$451.10
Rate for Payer: Devoted Health Medicare	$381.70
Rate for Payer: Hawaii Medical Service Association Medicare	$347.00
Rate for Payer: Hawaii Western Management Group Commercial	$659.30
Rate for Payer: Health Management Network Commercial	$589.90
Rate for Payer: Humana Medicare	$347.00
Rate for Payer: Kaiser Permanente Commercial	$624.60
Rate for Payer: Kaiser Permanente Medicaid	$353.94
Rate for Payer: Kaiser Permanente Medicare	$347.00
Rate for Payer: MDX Hawaii PPO	$673.18
Rate for Payer: Ohana Health Plan Medicaid	$347.00
Rate for Payer: Ohana Health Plan Medicare	$347.00
Rate for Payer: UnitedHealthcare Medicare	$347.00
Rate for Payer: University Health Alliance Commercial	$505.86

SPINE & PAIN: BOSTON SCIENTIFIC STYLET KIT W/ STEERING CAP AND STIFFER STYLET - 50 CM

Facility

$694.00

Hospital Charge Code	8882706
Hospital Revenue Code	272
Min. Negotiated Rate	$589.90
Max. Negotiated Rate	$673.18
Rate for Payer: Cash Price	$451.10
Rate for Payer: Health Management Network Commercial	$589.90
Rate for Payer: Kaiser Permanente Commercial	$624.60
Rate for Payer: MDX Hawaii PPO	$673.18

SPINE & PAIN: BOSTON SCIENTIFIC STYLET KIT W/ STEERING CAP AND STIFFER STYLET - 70 CM

Facility

$694.00

Hospital Charge Code	8882390
Hospital Revenue Code	272
Min. Negotiated Rate	$589.90
Max. Negotiated Rate	$673.18
Rate for Payer: Cash Price	$451.10
Rate for Payer: Health Management Network Commercial	$589.90
Rate for Payer: Kaiser Permanente Commercial	$624.60
Rate for Payer: MDX Hawaii PPO	$673.18

SPINE & PAIN: BOSTON SCIENTIFIC STYLET KIT W/ STEERING CAP AND STIFFER STYLET - 70 CM

Facility

$694.00

Hospital Charge Code	8882390
Hospital Revenue Code	272
Min. Negotiated Rate	$347.00
Max. Negotiated Rate	$673.18
Rate for Payer: AlohaCare Medicaid	$347.00
Rate for Payer: AlohaCare Medicare	$347.00
Rate for Payer: Cash Price	$451.10
Rate for Payer: Devoted Health Medicare	$381.70
Rate for Payer: Hawaii Medical Service Association Medicare	$347.00
Rate for Payer: Hawaii Western Management Group Commercial	$659.30
Rate for Payer: Health Management Network Commercial	$589.90
Rate for Payer: Humana Medicare	$347.00
Rate for Payer: Kaiser Permanente Commercial	$624.60
Rate for Payer: Kaiser Permanente Medicaid	$353.94
Rate for Payer: Kaiser Permanente Medicare	$347.00
Rate for Payer: MDX Hawaii PPO	$673.18
Rate for Payer: Ohana Health Plan Medicaid	$347.00
Rate for Payer: Ohana Health Plan Medicare	$347.00
Rate for Payer: UnitedHealthcare Medicare	$347.00
Rate for Payer: University Health Alliance Commercial	$505.86

SPINE & PAIN: BOSTON SCIENTIFIC WAVEWRITER ALPHA 16 IPG KIT

Facility

$39,600.00

Service Code	HCPCS C1820
Hospital Charge Code	9468257
Hospital Revenue Code	278
Min. Negotiated Rate	$22,176.00
Max. Negotiated Rate	$38,412.00
Rate for Payer: Cash Price	$25,740.00
Rate for Payer: Hawaii Western Management Group Commercial	$27,720.00
Rate for Payer: Health Management Network Commercial	$33,660.00
Rate for Payer: Kaiser Permanente Commercial	$35,640.00
Rate for Payer: MDX Hawaii PPO	$38,412.00
Rate for Payer: University Health Alliance Commercial	$22,176.00

SPINE & PAIN: BOSTON SCIENTIFIC WAVEWRITER ALPHA 16 IPG KIT

Facility

$39,600.00

Service Code	HCPCS C1820
Hospital Charge Code	9468257
Hospital Revenue Code	278
Min. Negotiated Rate	$19,800.00
Max. Negotiated Rate	$38,412.00
Rate for Payer: AlohaCare Medicaid	$19,800.00
Rate for Payer: AlohaCare Medicare	$19,800.00
Rate for Payer: Cash Price	$25,740.00
Rate for Payer: Devoted Health Medicare	$21,780.00
Rate for Payer: Hawaii Medical Service Association Medicare	$19,800.00
Rate for Payer: Hawaii Western Management Group Commercial	$27,720.00
Rate for Payer: Health Management Network Commercial	$33,660.00
Rate for Payer: Humana Medicare	$19,800.00
Rate for Payer: Kaiser Permanente Commercial	$35,640.00
Rate for Payer: Kaiser Permanente Medicaid	$20,196.00
Rate for Payer: Kaiser Permanente Medicare	$19,800.00
Rate for Payer: MDX Hawaii PPO	$38,412.00
Rate for Payer: Ohana Health Plan Medicaid	$19,800.00
Rate for Payer: Ohana Health Plan Medicare	$19,800.00
Rate for Payer: UnitedHealthcare Medicare	$19,800.00
Rate for Payer: University Health Alliance Commercial	$22,176.00

SPINE & PAIN: BOSTON SCIENTIFIC WAVEWRITER IMPLANTABLE PULSE GENERATOR (IPG)

Facility

$33,942.00

Service Code	HCPCS C1820
Hospital Charge Code	8882699
Hospital Revenue Code	278
Min. Negotiated Rate	$16,971.00
Max. Negotiated Rate	$32,923.74
Rate for Payer: AlohaCare Medicaid	$16,971.00
Rate for Payer: AlohaCare Medicare	$16,971.00
Rate for Payer: Cash Price	$22,062.30
Rate for Payer: Devoted Health Medicare	$18,668.10
Rate for Payer: Hawaii Medical Service Association Medicare	$16,971.00
Rate for Payer: Hawaii Western Management Group Commercial	$23,759.40
Rate for Payer: Health Management Network Commercial	$28,850.70
Rate for Payer: Humana Medicare	$16,971.00
Rate for Payer: Kaiser Permanente Commercial	$30,547.80
Rate for Payer: Kaiser Permanente Medicaid	$17,310.42
Rate for Payer: Kaiser Permanente Medicare	$16,971.00
Rate for Payer: MDX Hawaii PPO	$32,923.74
Rate for Payer: Ohana Health Plan Medicaid	$16,971.00
Rate for Payer: Ohana Health Plan Medicare	$16,971.00
Rate for Payer: UnitedHealthcare Medicare	$16,971.00
Rate for Payer: University Health Alliance Commercial	$19,007.52

SPINE & PAIN: BOSTON SCIENTIFIC WAVEWRITER IMPLANTABLE PULSE GENERATOR (IPG)

Facility

$33,942.00

Service Code	HCPCS C1820
Hospital Charge Code	8882699
Hospital Revenue Code	278
Min. Negotiated Rate	$19,007.52
Max. Negotiated Rate	$32,923.74
Rate for Payer: Cash Price	$22,062.30
Rate for Payer: Hawaii Western Management Group Commercial	$23,759.40
Rate for Payer: Health Management Network Commercial	$28,850.70
Rate for Payer: Kaiser Permanente Commercial	$30,547.80
Rate for Payer: MDX Hawaii PPO	$32,923.74
Rate for Payer: University Health Alliance Commercial	$19,007.52

SPINE & PAIN: BOSTON SCIENTIFIC WAVEWRITER PATIENT TRIAL KIT (INCLUDES: ETS BELT & ETS BATTERY)

Facility

$432.00

Hospital Charge Code	8882401
Hospital Revenue Code	272
Min. Negotiated Rate	$367.20
Max. Negotiated Rate	$419.04
Rate for Payer: Cash Price	$280.80
Rate for Payer: Health Management Network Commercial	$367.20
Rate for Payer: Kaiser Permanente Commercial	$388.80
Rate for Payer: MDX Hawaii PPO	$419.04

SPINE & PAIN: BOSTON SCIENTIFIC WAVEWRITER PATIENT TRIAL KIT (INCLUDES: ETS BELT & ETS BATTERY)

Facility

$432.00

Hospital Charge Code	8882401
Hospital Revenue Code	272
Min. Negotiated Rate	$216.00
Max. Negotiated Rate	$419.04
Rate for Payer: AlohaCare Medicaid	$216.00
Rate for Payer: AlohaCare Medicare	$216.00
Rate for Payer: Cash Price	$280.80
Rate for Payer: Devoted Health Medicare	$237.60
Rate for Payer: Hawaii Medical Service Association Medicare	$216.00
Rate for Payer: Hawaii Western Management Group Commercial	$410.40
Rate for Payer: Health Management Network Commercial	$367.20
Rate for Payer: Humana Medicare	$216.00
Rate for Payer: Kaiser Permanente Commercial	$388.80
Rate for Payer: Kaiser Permanente Medicaid	$220.32
Rate for Payer: Kaiser Permanente Medicare	$216.00
Rate for Payer: MDX Hawaii PPO	$419.04
Rate for Payer: Ohana Health Plan Medicaid	$216.00
Rate for Payer: Ohana Health Plan Medicare	$216.00
Rate for Payer: UnitedHealthcare Medicare	$216.00
Rate for Payer: University Health Alliance Commercial	$314.88

SPINE & PAIN: COOLIEF COOLED RADIOFREQUENCY PERISTALTIC PUMP UNIT

Facility

$7,000.00

Hospital Charge Code	9036239
Hospital Revenue Code	272
Min. Negotiated Rate	$3,500.00
Max. Negotiated Rate	$6,790.00
Rate for Payer: AlohaCare Medicaid	$3,500.00
Rate for Payer: AlohaCare Medicare	$3,500.00
Rate for Payer: Cash Price	$4,550.00
Rate for Payer: Devoted Health Medicare	$3,850.00
Rate for Payer: Hawaii Medical Service Association Medicare	$3,500.00
Rate for Payer: Hawaii Western Management Group Commercial	$6,650.00
Rate for Payer: Health Management Network Commercial	$5,950.00
Rate for Payer: Humana Medicare	$3,500.00
Rate for Payer: Kaiser Permanente Commercial	$6,300.00
Rate for Payer: Kaiser Permanente Medicaid	$3,570.00
Rate for Payer: Kaiser Permanente Medicare	$3,500.00
Rate for Payer: MDX Hawaii PPO	$6,790.00
Rate for Payer: Ohana Health Plan Medicaid	$3,500.00
Rate for Payer: Ohana Health Plan Medicare	$3,500.00
Rate for Payer: UnitedHealthcare Medicare	$3,500.00
Rate for Payer: University Health Alliance Commercial	$5,102.30

SPINE & PAIN: COOLIEF COOLED RADIOFREQUENCY PERISTALTIC PUMP UNIT

Facility

$7,000.00

Hospital Charge Code	9036239
Hospital Revenue Code	272
Min. Negotiated Rate	$5,950.00
Max. Negotiated Rate	$6,790.00
Rate for Payer: Cash Price	$4,550.00
Rate for Payer: Health Management Network Commercial	$5,950.00
Rate for Payer: Kaiser Permanente Commercial	$6,300.00
Rate for Payer: MDX Hawaii PPO	$6,790.00

Know your out-of-pocket cost for care.

All Charges