Samuel Mahelona Memorial Hospital

All Charges

Charge

Type

Setting

Price

P9012 Cryoprecipitate Ea Unit [HHSC]

Facility

$229.00

Service Code	HCPCS P9012
Hospital Charge Code	13369155
Hospital Revenue Code	380
Min. Negotiated Rate	$47.68
Max. Negotiated Rate	$222.13
Rate for Payer: AlohaCare Medicaid	$114.50
Rate for Payer: AlohaCare Medicare	$114.50
Rate for Payer: Cash Price	$148.85
Rate for Payer: Cash Price	$148.85
Rate for Payer: Devoted Health Medicare	$125.95
Rate for Payer: Hawaii Medical Service Association Commercial	$89.94
Rate for Payer: Hawaii Medical Service Association Medicare	$114.50
Rate for Payer: Hawaii Western Management Group Commercial	$217.55
Rate for Payer: Health Management Network Commercial	$194.65
Rate for Payer: Humana Medicare	$114.50
Rate for Payer: Kaiser Permanente Commercial	$206.10
Rate for Payer: Kaiser Permanente Medicaid	$116.79
Rate for Payer: Kaiser Permanente Medicare	$114.50
Rate for Payer: MDX Hawaii PPO	$222.13
Rate for Payer: Ohana Health Plan Medicaid	$114.50
Rate for Payer: Ohana Health Plan Medicare	$114.50
Rate for Payer: UnitedHealthcare Medicaid	$47.68
Rate for Payer: UnitedHealthcare Medicare	$114.50
Rate for Payer: University Health Alliance Commercial	$128.24

P9012 Cryoprecipitate Ea Unit [HHSC]

Facility

$229.00

Service Code	HCPCS P9012
Hospital Charge Code	13369155
Hospital Revenue Code	380
Min. Negotiated Rate	$194.65
Max. Negotiated Rate	$222.13
Rate for Payer: Cash Price	$148.85
Rate for Payer: Health Management Network Commercial	$194.65
Rate for Payer: Kaiser Permanente Commercial	$206.10
Rate for Payer: MDX Hawaii PPO	$222.13

P9016 PACKED CELLS

Facility

$797.00

Service Code	HCPCS P9016
Hospital Charge Code	8258887
Hospital Revenue Code	390
Min. Negotiated Rate	$677.45
Max. Negotiated Rate	$773.09
Rate for Payer: Cash Price	$518.05
Rate for Payer: Health Management Network Commercial	$677.45
Rate for Payer: Kaiser Permanente Commercial	$717.30
Rate for Payer: MDX Hawaii PPO	$773.09

P9016 PACKED CELLS

Facility

$797.00

Service Code	HCPCS P9016
Hospital Charge Code	8258887
Hospital Revenue Code	390
Min. Negotiated Rate	$136.50
Max. Negotiated Rate	$773.09
Rate for Payer: AlohaCare Medicaid	$398.50
Rate for Payer: AlohaCare Medicare	$398.50
Rate for Payer: Cash Price	$518.05
Rate for Payer: Cash Price	$518.05
Rate for Payer: Devoted Health Medicare	$438.35
Rate for Payer: Hawaii Medical Service Association Commercial	$231.14
Rate for Payer: Hawaii Medical Service Association Medicare	$398.50
Rate for Payer: Hawaii Western Management Group Commercial	$757.15
Rate for Payer: Health Management Network Commercial	$677.45
Rate for Payer: Humana Medicare	$398.50
Rate for Payer: Kaiser Permanente Commercial	$717.30
Rate for Payer: Kaiser Permanente Medicaid	$406.47
Rate for Payer: Kaiser Permanente Medicare	$398.50
Rate for Payer: MDX Hawaii PPO	$773.09
Rate for Payer: Ohana Health Plan Medicaid	$398.50
Rate for Payer: Ohana Health Plan Medicare	$398.50
Rate for Payer: UnitedHealthcare Medicaid	$136.50
Rate for Payer: UnitedHealthcare Medicare	$398.50
Rate for Payer: University Health Alliance Commercial	$446.32

P9016 PACKED CELLS [HHSC]

Facility

$797.00

Service Code	HCPCS P9016
Hospital Charge Code	13369156
Hospital Revenue Code	380
Min. Negotiated Rate	$677.45
Max. Negotiated Rate	$773.09
Rate for Payer: Cash Price	$518.05
Rate for Payer: Health Management Network Commercial	$677.45
Rate for Payer: Kaiser Permanente Commercial	$717.30
Rate for Payer: MDX Hawaii PPO	$773.09

P9016 PACKED CELLS [HHSC]

Facility

$797.00

Service Code	HCPCS P9016
Hospital Charge Code	13369156
Hospital Revenue Code	380
Min. Negotiated Rate	$136.50
Max. Negotiated Rate	$773.09
Rate for Payer: AlohaCare Medicaid	$398.50
Rate for Payer: AlohaCare Medicare	$398.50
Rate for Payer: Cash Price	$518.05
Rate for Payer: Cash Price	$518.05
Rate for Payer: Devoted Health Medicare	$438.35
Rate for Payer: Hawaii Medical Service Association Commercial	$231.14
Rate for Payer: Hawaii Medical Service Association Medicare	$398.50
Rate for Payer: Hawaii Western Management Group Commercial	$757.15
Rate for Payer: Health Management Network Commercial	$677.45
Rate for Payer: Humana Medicare	$398.50
Rate for Payer: Kaiser Permanente Commercial	$717.30
Rate for Payer: Kaiser Permanente Medicaid	$406.47
Rate for Payer: Kaiser Permanente Medicare	$398.50
Rate for Payer: MDX Hawaii PPO	$773.09
Rate for Payer: Ohana Health Plan Medicaid	$398.50
Rate for Payer: Ohana Health Plan Medicare	$398.50
Rate for Payer: UnitedHealthcare Medicaid	$136.50
Rate for Payer: UnitedHealthcare Medicare	$398.50
Rate for Payer: University Health Alliance Commercial	$446.32

P9017 FFP Ea Unit

Facility

$344.00

Service Code	HCPCS P9017
Hospital Charge Code	8258888
Hospital Revenue Code	390
Min. Negotiated Rate	$59.50
Max. Negotiated Rate	$333.68
Rate for Payer: AlohaCare Medicaid	$172.00
Rate for Payer: AlohaCare Medicare	$172.00
Rate for Payer: Cash Price	$223.60
Rate for Payer: Cash Price	$223.60
Rate for Payer: Devoted Health Medicare	$189.20
Rate for Payer: Hawaii Medical Service Association Commercial	$107.47
Rate for Payer: Hawaii Medical Service Association Medicare	$172.00
Rate for Payer: Hawaii Western Management Group Commercial	$326.80
Rate for Payer: Health Management Network Commercial	$292.40
Rate for Payer: Humana Medicare	$172.00
Rate for Payer: Kaiser Permanente Commercial	$309.60
Rate for Payer: Kaiser Permanente Medicaid	$175.44
Rate for Payer: Kaiser Permanente Medicare	$172.00
Rate for Payer: MDX Hawaii PPO	$333.68
Rate for Payer: Ohana Health Plan Medicaid	$172.00
Rate for Payer: Ohana Health Plan Medicare	$172.00
Rate for Payer: UnitedHealthcare Medicaid	$59.50
Rate for Payer: UnitedHealthcare Medicare	$172.00
Rate for Payer: University Health Alliance Commercial	$192.64

P9017 FFP Ea Unit

Facility

$344.00

Service Code	HCPCS P9017
Hospital Charge Code	8258888
Hospital Revenue Code	390
Min. Negotiated Rate	$292.40
Max. Negotiated Rate	$333.68
Rate for Payer: Cash Price	$223.60
Rate for Payer: Health Management Network Commercial	$292.40
Rate for Payer: Kaiser Permanente Commercial	$309.60
Rate for Payer: MDX Hawaii PPO	$333.68

P9017 FFP Ea Unit [HHSC]

Facility

$344.00

Service Code	HCPCS P9017
Hospital Charge Code	13359442
Hospital Revenue Code	380
Min. Negotiated Rate	$59.50
Max. Negotiated Rate	$333.68
Rate for Payer: AlohaCare Medicaid	$172.00
Rate for Payer: AlohaCare Medicare	$172.00
Rate for Payer: Cash Price	$223.60
Rate for Payer: Cash Price	$223.60
Rate for Payer: Devoted Health Medicare	$189.20
Rate for Payer: Hawaii Medical Service Association Commercial	$107.47
Rate for Payer: Hawaii Medical Service Association Medicare	$172.00
Rate for Payer: Hawaii Western Management Group Commercial	$326.80
Rate for Payer: Health Management Network Commercial	$292.40
Rate for Payer: Humana Medicare	$172.00
Rate for Payer: Kaiser Permanente Commercial	$309.60
Rate for Payer: Kaiser Permanente Medicaid	$175.44
Rate for Payer: Kaiser Permanente Medicare	$172.00
Rate for Payer: MDX Hawaii PPO	$333.68
Rate for Payer: Ohana Health Plan Medicaid	$172.00
Rate for Payer: Ohana Health Plan Medicare	$172.00
Rate for Payer: UnitedHealthcare Medicaid	$59.50
Rate for Payer: UnitedHealthcare Medicare	$172.00
Rate for Payer: University Health Alliance Commercial	$192.64

P9017 FFP Ea Unit [HHSC]

Facility

$344.00

Service Code	HCPCS P9017
Hospital Charge Code	13359442
Hospital Revenue Code	380
Min. Negotiated Rate	$292.40
Max. Negotiated Rate	$333.68
Rate for Payer: Cash Price	$223.60
Rate for Payer: Health Management Network Commercial	$292.40
Rate for Payer: Kaiser Permanente Commercial	$309.60
Rate for Payer: MDX Hawaii PPO	$333.68

P9019 Platelet Ea Unit

Facility

$252.00

Service Code	HCPCS P9019
Hospital Charge Code	8258889
Hospital Revenue Code	390
Min. Negotiated Rate	$214.20
Max. Negotiated Rate	$244.44
Rate for Payer: Cash Price	$163.80
Rate for Payer: Health Management Network Commercial	$214.20
Rate for Payer: Kaiser Permanente Commercial	$226.80
Rate for Payer: MDX Hawaii PPO	$244.44

P9019 Platelet Ea Unit

Facility

$252.00

Service Code	HCPCS P9019
Hospital Charge Code	8258889
Hospital Revenue Code	390
Min. Negotiated Rate	$59.50
Max. Negotiated Rate	$244.44
Rate for Payer: AlohaCare Medicaid	$126.00
Rate for Payer: AlohaCare Medicare	$126.00
Rate for Payer: Cash Price	$163.80
Rate for Payer: Cash Price	$163.80
Rate for Payer: Devoted Health Medicare	$138.60
Rate for Payer: Hawaii Medical Service Association Commercial	$66.46
Rate for Payer: Hawaii Medical Service Association Medicare	$126.00
Rate for Payer: Hawaii Western Management Group Commercial	$239.40
Rate for Payer: Health Management Network Commercial	$214.20
Rate for Payer: Humana Medicare	$126.00
Rate for Payer: Kaiser Permanente Commercial	$226.80
Rate for Payer: Kaiser Permanente Medicaid	$128.52
Rate for Payer: Kaiser Permanente Medicare	$126.00
Rate for Payer: MDX Hawaii PPO	$244.44
Rate for Payer: Ohana Health Plan Medicaid	$126.00
Rate for Payer: Ohana Health Plan Medicare	$126.00
Rate for Payer: UnitedHealthcare Medicaid	$59.50
Rate for Payer: UnitedHealthcare Medicare	$126.00
Rate for Payer: University Health Alliance Commercial	$141.12

P9019 Platelet Ea Unit [HHSC]

Facility

$252.00

Service Code	HCPCS P9019
Hospital Charge Code	13357628
Hospital Revenue Code	380
Min. Negotiated Rate	$214.20
Max. Negotiated Rate	$244.44
Rate for Payer: Cash Price	$163.80
Rate for Payer: Health Management Network Commercial	$214.20
Rate for Payer: Kaiser Permanente Commercial	$226.80
Rate for Payer: MDX Hawaii PPO	$244.44

P9019 Platelet Ea Unit [HHSC]

Facility

$252.00

Service Code	HCPCS P9019
Hospital Charge Code	13357628
Hospital Revenue Code	380
Min. Negotiated Rate	$59.50
Max. Negotiated Rate	$244.44
Rate for Payer: AlohaCare Medicaid	$126.00
Rate for Payer: AlohaCare Medicare	$126.00
Rate for Payer: Cash Price	$163.80
Rate for Payer: Cash Price	$163.80
Rate for Payer: Devoted Health Medicare	$138.60
Rate for Payer: Hawaii Medical Service Association Commercial	$66.46
Rate for Payer: Hawaii Medical Service Association Medicare	$126.00
Rate for Payer: Hawaii Western Management Group Commercial	$239.40
Rate for Payer: Health Management Network Commercial	$214.20
Rate for Payer: Humana Medicare	$126.00
Rate for Payer: Kaiser Permanente Commercial	$226.80
Rate for Payer: Kaiser Permanente Medicaid	$128.52
Rate for Payer: Kaiser Permanente Medicare	$126.00
Rate for Payer: MDX Hawaii PPO	$244.44
Rate for Payer: Ohana Health Plan Medicaid	$126.00
Rate for Payer: Ohana Health Plan Medicare	$126.00
Rate for Payer: UnitedHealthcare Medicaid	$59.50
Rate for Payer: UnitedHealthcare Medicare	$126.00
Rate for Payer: University Health Alliance Commercial	$141.12

P9021 RBC Ea Unit

Facility

$592.00

Service Code	HCPCS P9021
Hospital Charge Code	8258890
Hospital Revenue Code	390
Min. Negotiated Rate	$503.20
Max. Negotiated Rate	$574.24
Rate for Payer: Cash Price	$384.80
Rate for Payer: Health Management Network Commercial	$503.20
Rate for Payer: Kaiser Permanente Commercial	$532.80
Rate for Payer: MDX Hawaii PPO	$574.24

P9021 RBC Ea Unit

Facility

$592.00

Service Code	HCPCS P9021
Hospital Charge Code	8258890
Hospital Revenue Code	390
Min. Negotiated Rate	$94.00
Max. Negotiated Rate	$574.24
Rate for Payer: AlohaCare Medicaid	$296.00
Rate for Payer: AlohaCare Medicare	$296.00
Rate for Payer: Cash Price	$384.80
Rate for Payer: Cash Price	$384.80
Rate for Payer: Devoted Health Medicare	$325.60
Rate for Payer: Hawaii Medical Service Association Commercial	$188.21
Rate for Payer: Hawaii Medical Service Association Medicare	$296.00
Rate for Payer: Hawaii Western Management Group Commercial	$562.40
Rate for Payer: Health Management Network Commercial	$503.20
Rate for Payer: Humana Medicare	$296.00
Rate for Payer: Kaiser Permanente Commercial	$532.80
Rate for Payer: Kaiser Permanente Medicaid	$301.92
Rate for Payer: Kaiser Permanente Medicare	$296.00
Rate for Payer: MDX Hawaii PPO	$574.24
Rate for Payer: Ohana Health Plan Medicaid	$296.00
Rate for Payer: Ohana Health Plan Medicare	$296.00
Rate for Payer: UnitedHealthcare Medicaid	$94.00
Rate for Payer: UnitedHealthcare Medicare	$296.00
Rate for Payer: University Health Alliance Commercial	$331.52

P9021 RBC Ea Unit [HHSC]

Facility

$592.00

Service Code	HCPCS P9021
Hospital Charge Code	13369165
Hospital Revenue Code	380
Min. Negotiated Rate	$503.20
Max. Negotiated Rate	$574.24
Rate for Payer: Cash Price	$384.80
Rate for Payer: Health Management Network Commercial	$503.20
Rate for Payer: Kaiser Permanente Commercial	$532.80
Rate for Payer: MDX Hawaii PPO	$574.24

P9021 RBC Ea Unit [HHSC]

Facility

$592.00

Service Code	HCPCS P9021
Hospital Charge Code	13369165
Hospital Revenue Code	380
Min. Negotiated Rate	$94.00
Max. Negotiated Rate	$574.24
Rate for Payer: AlohaCare Medicaid	$296.00
Rate for Payer: AlohaCare Medicare	$296.00
Rate for Payer: Cash Price	$384.80
Rate for Payer: Cash Price	$384.80
Rate for Payer: Devoted Health Medicare	$325.60
Rate for Payer: Hawaii Medical Service Association Commercial	$188.21
Rate for Payer: Hawaii Medical Service Association Medicare	$296.00
Rate for Payer: Hawaii Western Management Group Commercial	$562.40
Rate for Payer: Health Management Network Commercial	$503.20
Rate for Payer: Humana Medicare	$296.00
Rate for Payer: Kaiser Permanente Commercial	$532.80
Rate for Payer: Kaiser Permanente Medicaid	$301.92
Rate for Payer: Kaiser Permanente Medicare	$296.00
Rate for Payer: MDX Hawaii PPO	$574.24
Rate for Payer: Ohana Health Plan Medicaid	$296.00
Rate for Payer: Ohana Health Plan Medicare	$296.00
Rate for Payer: UnitedHealthcare Medicaid	$94.00
Rate for Payer: UnitedHealthcare Medicare	$296.00
Rate for Payer: University Health Alliance Commercial	$331.52

P9031 Platelets Leuko Reduc Ea

Facility

$469.00

Service Code	HCPCS P9031
Hospital Charge Code	8258891
Hospital Revenue Code	390
Min. Negotiated Rate	$398.65
Max. Negotiated Rate	$454.93
Rate for Payer: Cash Price	$304.85
Rate for Payer: Health Management Network Commercial	$398.65
Rate for Payer: Kaiser Permanente Commercial	$422.10
Rate for Payer: MDX Hawaii PPO	$454.93

P9031 Platelets Leuko Reduc Ea

Facility

$469.00

Service Code	HCPCS P9031
Hospital Charge Code	8258891
Hospital Revenue Code	390
Min. Negotiated Rate	$94.33
Max. Negotiated Rate	$454.93
Rate for Payer: AlohaCare Medicaid	$234.50
Rate for Payer: AlohaCare Medicare	$234.50
Rate for Payer: Cash Price	$304.85
Rate for Payer: Cash Price	$304.85
Rate for Payer: Devoted Health Medicare	$257.95
Rate for Payer: Hawaii Medical Service Association Commercial	$180.32
Rate for Payer: Hawaii Medical Service Association Medicare	$234.50
Rate for Payer: Hawaii Western Management Group Commercial	$445.55
Rate for Payer: Health Management Network Commercial	$398.65
Rate for Payer: Humana Medicare	$234.50
Rate for Payer: Kaiser Permanente Commercial	$422.10
Rate for Payer: Kaiser Permanente Medicaid	$239.19
Rate for Payer: Kaiser Permanente Medicare	$234.50
Rate for Payer: MDX Hawaii PPO	$454.93
Rate for Payer: Ohana Health Plan Medicaid	$234.50
Rate for Payer: Ohana Health Plan Medicare	$234.50
Rate for Payer: UnitedHealthcare Medicaid	$94.33
Rate for Payer: UnitedHealthcare Medicare	$234.50
Rate for Payer: University Health Alliance Commercial	$262.64

P9031 Platelets Leuko Reduc Ea [HHSC]

Facility

$469.00

Service Code	HCPCS P9031
Hospital Charge Code	13369166
Hospital Revenue Code	380
Min. Negotiated Rate	$94.33
Max. Negotiated Rate	$454.93
Rate for Payer: AlohaCare Medicaid	$234.50
Rate for Payer: AlohaCare Medicare	$234.50
Rate for Payer: Cash Price	$304.85
Rate for Payer: Cash Price	$304.85
Rate for Payer: Devoted Health Medicare	$257.95
Rate for Payer: Hawaii Medical Service Association Commercial	$180.32
Rate for Payer: Hawaii Medical Service Association Medicare	$234.50
Rate for Payer: Hawaii Western Management Group Commercial	$445.55
Rate for Payer: Health Management Network Commercial	$398.65
Rate for Payer: Humana Medicare	$234.50
Rate for Payer: Kaiser Permanente Commercial	$422.10
Rate for Payer: Kaiser Permanente Medicaid	$239.19
Rate for Payer: Kaiser Permanente Medicare	$234.50
Rate for Payer: MDX Hawaii PPO	$454.93
Rate for Payer: Ohana Health Plan Medicaid	$234.50
Rate for Payer: Ohana Health Plan Medicare	$234.50
Rate for Payer: UnitedHealthcare Medicaid	$94.33
Rate for Payer: UnitedHealthcare Medicare	$234.50
Rate for Payer: University Health Alliance Commercial	$262.64

P9031 Platelets Leuko Reduc Ea [HHSC]

Facility

$469.00

Service Code	HCPCS P9031
Hospital Charge Code	13369166
Hospital Revenue Code	380
Min. Negotiated Rate	$398.65
Max. Negotiated Rate	$454.93
Rate for Payer: Cash Price	$304.85
Rate for Payer: Health Management Network Commercial	$398.65
Rate for Payer: Kaiser Permanente Commercial	$422.10
Rate for Payer: MDX Hawaii PPO	$454.93

P9032 Platelet Irradiated Ea

Facility

$673.00

Service Code	HCPCS P9032
Hospital Charge Code	8258892
Hospital Revenue Code	390
Min. Negotiated Rate	$101.84
Max. Negotiated Rate	$652.81
Rate for Payer: AlohaCare Medicaid	$336.50
Rate for Payer: AlohaCare Medicare	$336.50
Rate for Payer: Cash Price	$437.45
Rate for Payer: Cash Price	$437.45
Rate for Payer: Devoted Health Medicare	$370.15
Rate for Payer: Hawaii Medical Service Association Commercial	$491.21
Rate for Payer: Hawaii Medical Service Association Medicare	$336.50
Rate for Payer: Hawaii Western Management Group Commercial	$639.35
Rate for Payer: Health Management Network Commercial	$572.05
Rate for Payer: Humana Medicare	$336.50
Rate for Payer: Kaiser Permanente Commercial	$605.70
Rate for Payer: Kaiser Permanente Medicaid	$343.23
Rate for Payer: Kaiser Permanente Medicare	$336.50
Rate for Payer: MDX Hawaii PPO	$652.81
Rate for Payer: Ohana Health Plan Medicaid	$336.50
Rate for Payer: Ohana Health Plan Medicare	$336.50
Rate for Payer: UnitedHealthcare Medicaid	$101.84
Rate for Payer: UnitedHealthcare Medicare	$336.50
Rate for Payer: University Health Alliance Commercial	$376.88

P9032 Platelet Irradiated Ea

Facility

$673.00

Service Code	HCPCS P9032
Hospital Charge Code	8258892
Hospital Revenue Code	390
Min. Negotiated Rate	$572.05
Max. Negotiated Rate	$652.81
Rate for Payer: Cash Price	$437.45
Rate for Payer: Health Management Network Commercial	$572.05
Rate for Payer: Kaiser Permanente Commercial	$605.70
Rate for Payer: MDX Hawaii PPO	$652.81

P9032 Platelet Irradiated Ea [HHSC]

Facility

$673.00

Service Code	HCPCS P9032
Hospital Charge Code	13359456
Hospital Revenue Code	380
Min. Negotiated Rate	$101.84
Max. Negotiated Rate	$652.81
Rate for Payer: AlohaCare Medicaid	$336.50
Rate for Payer: AlohaCare Medicare	$336.50
Rate for Payer: Cash Price	$437.45
Rate for Payer: Cash Price	$437.45
Rate for Payer: Devoted Health Medicare	$370.15
Rate for Payer: Hawaii Medical Service Association Commercial	$491.21
Rate for Payer: Hawaii Medical Service Association Medicare	$336.50
Rate for Payer: Hawaii Western Management Group Commercial	$639.35
Rate for Payer: Health Management Network Commercial	$572.05
Rate for Payer: Humana Medicare	$336.50
Rate for Payer: Kaiser Permanente Commercial	$605.70
Rate for Payer: Kaiser Permanente Medicaid	$343.23
Rate for Payer: Kaiser Permanente Medicare	$336.50
Rate for Payer: MDX Hawaii PPO	$652.81
Rate for Payer: Ohana Health Plan Medicaid	$336.50
Rate for Payer: Ohana Health Plan Medicare	$336.50
Rate for Payer: UnitedHealthcare Medicaid	$101.84
Rate for Payer: UnitedHealthcare Medicare	$336.50
Rate for Payer: University Health Alliance Commercial	$376.88

Know your out-of-pocket cost for care.

All Charges