Samuel Mahelona Memorial Hospital

All Charges

Charge

Type

Setting

Price

P9032 Platelet Irradiated Ea [HHSC]

Facility

$673.00

Service Code	HCPCS P9032
Hospital Charge Code	13359456
Hospital Revenue Code	380
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

P9033 Platelet Leukored Irrd Ea

Facility

$591.00

Service Code	HCPCS P9033
Hospital Charge Code	8258894
Hospital Revenue Code	390
Min. Negotiated Rate	$154.04
Max. Negotiated Rate	$573.27
Rate for Payer: AlohaCare Medicaid	$295.50
Rate for Payer: AlohaCare Medicare	$295.50
Rate for Payer: Cash Price	$384.15
Rate for Payer: Cash Price	$384.15
Rate for Payer: Devoted Health Medicare	$325.05
Rate for Payer: Hawaii Medical Service Association Commercial	$236.99
Rate for Payer: Hawaii Medical Service Association Medicare	$295.50
Rate for Payer: Hawaii Western Management Group Commercial	$561.45
Rate for Payer: Health Management Network Commercial	$502.35
Rate for Payer: Humana Medicare	$295.50
Rate for Payer: Kaiser Permanente Commercial	$531.90
Rate for Payer: Kaiser Permanente Medicaid	$301.41
Rate for Payer: Kaiser Permanente Medicare	$295.50
Rate for Payer: MDX Hawaii PPO	$573.27
Rate for Payer: Ohana Health Plan Medicaid	$295.50
Rate for Payer: Ohana Health Plan Medicare	$295.50
Rate for Payer: UnitedHealthcare Medicaid	$154.04
Rate for Payer: UnitedHealthcare Medicare	$295.50
Rate for Payer: University Health Alliance Commercial	$330.96

P9033 Platelet Leukored Irrd Ea

Facility

$591.00

Service Code	HCPCS P9033
Hospital Charge Code	8258894
Hospital Revenue Code	390
Min. Negotiated Rate	$502.35
Max. Negotiated Rate	$573.27
Rate for Payer: Cash Price	$384.15
Rate for Payer: Health Management Network Commercial	$502.35
Rate for Payer: Kaiser Permanente Commercial	$531.90
Rate for Payer: MDX Hawaii PPO	$573.27

P9033 Platelet Leukored Irrd Ea [HHSC]

Facility

$591.00

Service Code	HCPCS P9033
Hospital Charge Code	13359457
Hospital Revenue Code	380
Min. Negotiated Rate	$502.35
Max. Negotiated Rate	$573.27
Rate for Payer: Cash Price	$384.15
Rate for Payer: Health Management Network Commercial	$502.35
Rate for Payer: Kaiser Permanente Commercial	$531.90
Rate for Payer: MDX Hawaii PPO	$573.27

P9033 Platelet Leukored Irrd Ea [HHSC]

Facility

$591.00

Service Code	HCPCS P9033
Hospital Charge Code	13359457
Hospital Revenue Code	380
Min. Negotiated Rate	$154.04
Max. Negotiated Rate	$573.27
Rate for Payer: AlohaCare Medicaid	$295.50
Rate for Payer: AlohaCare Medicare	$295.50
Rate for Payer: Cash Price	$384.15
Rate for Payer: Cash Price	$384.15
Rate for Payer: Devoted Health Medicare	$325.05
Rate for Payer: Hawaii Medical Service Association Commercial	$236.99
Rate for Payer: Hawaii Medical Service Association Medicare	$295.50
Rate for Payer: Hawaii Western Management Group Commercial	$561.45
Rate for Payer: Health Management Network Commercial	$502.35
Rate for Payer: Humana Medicare	$295.50
Rate for Payer: Kaiser Permanente Commercial	$531.90
Rate for Payer: Kaiser Permanente Medicaid	$301.41
Rate for Payer: Kaiser Permanente Medicare	$295.50
Rate for Payer: MDX Hawaii PPO	$573.27
Rate for Payer: Ohana Health Plan Medicaid	$295.50
Rate for Payer: Ohana Health Plan Medicare	$295.50
Rate for Payer: UnitedHealthcare Medicaid	$154.04
Rate for Payer: UnitedHealthcare Medicare	$295.50
Rate for Payer: University Health Alliance Commercial	$330.96

P9034 Platelet Pheresis Ea Unit

Facility

$2,120.00

Service Code	HCPCS P9034
Hospital Charge Code	8258895
Hospital Revenue Code	390
Min. Negotiated Rate	$386.20
Max. Negotiated Rate	$2,056.40
Rate for Payer: AlohaCare Medicaid	$1,060.00
Rate for Payer: AlohaCare Medicare	$1,060.00
Rate for Payer: Cash Price	$1,378.00
Rate for Payer: Cash Price	$1,378.00
Rate for Payer: Devoted Health Medicare	$1,166.00
Rate for Payer: Hawaii Medical Service Association Commercial	$386.20
Rate for Payer: Hawaii Medical Service Association Medicare	$1,060.00
Rate for Payer: Hawaii Western Management Group Commercial	$2,014.00
Rate for Payer: Health Management Network Commercial	$1,802.00
Rate for Payer: Humana Medicare	$1,060.00
Rate for Payer: Kaiser Permanente Commercial	$1,908.00
Rate for Payer: Kaiser Permanente Medicaid	$1,081.20
Rate for Payer: Kaiser Permanente Medicare	$1,060.00
Rate for Payer: MDX Hawaii PPO	$2,056.40
Rate for Payer: Ohana Health Plan Medicaid	$1,060.00
Rate for Payer: Ohana Health Plan Medicare	$1,060.00
Rate for Payer: UnitedHealthcare Medicaid	$575.00
Rate for Payer: UnitedHealthcare Medicare	$1,060.00
Rate for Payer: University Health Alliance Commercial	$1,187.20

P9034 Platelet Pheresis Ea Unit

Facility

$2,120.00

Service Code	HCPCS P9034
Hospital Charge Code	8258895
Hospital Revenue Code	390
Min. Negotiated Rate	$1,802.00
Max. Negotiated Rate	$2,056.40
Rate for Payer: Cash Price	$1,378.00
Rate for Payer: Health Management Network Commercial	$1,802.00
Rate for Payer: Kaiser Permanente Commercial	$1,908.00
Rate for Payer: MDX Hawaii PPO	$2,056.40

P9034 Platelet Pheresis Ea Unit [HHSC]

Facility

$2,120.00

Service Code	HCPCS P9034
Hospital Charge Code	13369167
Hospital Revenue Code	380
Min. Negotiated Rate	$386.20
Max. Negotiated Rate	$2,056.40
Rate for Payer: AlohaCare Medicaid	$1,060.00
Rate for Payer: AlohaCare Medicare	$1,060.00
Rate for Payer: Cash Price	$1,378.00
Rate for Payer: Cash Price	$1,378.00
Rate for Payer: Devoted Health Medicare	$1,166.00
Rate for Payer: Hawaii Medical Service Association Commercial	$386.20
Rate for Payer: Hawaii Medical Service Association Medicare	$1,060.00
Rate for Payer: Hawaii Western Management Group Commercial	$2,014.00
Rate for Payer: Health Management Network Commercial	$1,802.00
Rate for Payer: Humana Medicare	$1,060.00
Rate for Payer: Kaiser Permanente Commercial	$1,908.00
Rate for Payer: Kaiser Permanente Medicaid	$1,081.20
Rate for Payer: Kaiser Permanente Medicare	$1,060.00
Rate for Payer: MDX Hawaii PPO	$2,056.40
Rate for Payer: Ohana Health Plan Medicaid	$1,060.00
Rate for Payer: Ohana Health Plan Medicare	$1,060.00
Rate for Payer: UnitedHealthcare Medicaid	$575.00
Rate for Payer: UnitedHealthcare Medicare	$1,060.00
Rate for Payer: University Health Alliance Commercial	$1,187.20

P9034 Platelet Pheresis Ea Unit [HHSC]

Facility

$2,120.00

Service Code	HCPCS P9034
Hospital Charge Code	13369167
Hospital Revenue Code	380
Min. Negotiated Rate	$1,802.00
Max. Negotiated Rate	$2,056.40
Rate for Payer: Cash Price	$1,378.00
Rate for Payer: Health Management Network Commercial	$1,802.00
Rate for Payer: Kaiser Permanente Commercial	$1,908.00
Rate for Payer: MDX Hawaii PPO	$2,056.40

P9035 Plateletphersis Leukoredu

Facility

$2,325.00

Service Code	HCPCS P9035
Hospital Charge Code	8258896
Hospital Revenue Code	390
Min. Negotiated Rate	$1,976.25
Max. Negotiated Rate	$2,255.25
Rate for Payer: Cash Price	$1,511.25
Rate for Payer: Health Management Network Commercial	$1,976.25
Rate for Payer: Kaiser Permanente Commercial	$2,092.50
Rate for Payer: MDX Hawaii PPO	$2,255.25

P9035 Plateletphersis Leukoredu

Facility

$2,325.00

Service Code	HCPCS P9035
Hospital Charge Code	8258896
Hospital Revenue Code	390
Min. Negotiated Rate	$580.00
Max. Negotiated Rate	$2,255.25
Rate for Payer: AlohaCare Medicaid	$1,162.50
Rate for Payer: AlohaCare Medicare	$1,162.50
Rate for Payer: Cash Price	$1,511.25
Rate for Payer: Cash Price	$1,511.25
Rate for Payer: Devoted Health Medicare	$1,278.75
Rate for Payer: Hawaii Medical Service Association Commercial	$639.49
Rate for Payer: Hawaii Medical Service Association Medicare	$1,162.50
Rate for Payer: Hawaii Western Management Group Commercial	$2,208.75
Rate for Payer: Health Management Network Commercial	$1,976.25
Rate for Payer: Humana Medicare	$1,162.50
Rate for Payer: Kaiser Permanente Commercial	$2,092.50
Rate for Payer: Kaiser Permanente Medicaid	$1,185.75
Rate for Payer: Kaiser Permanente Medicare	$1,162.50
Rate for Payer: MDX Hawaii PPO	$2,255.25
Rate for Payer: Ohana Health Plan Medicaid	$1,162.50
Rate for Payer: Ohana Health Plan Medicare	$1,162.50
Rate for Payer: UnitedHealthcare Medicaid	$580.00
Rate for Payer: UnitedHealthcare Medicare	$1,162.50
Rate for Payer: University Health Alliance Commercial	$1,302.00

P9035 Plateletphersis Leukoredu [HHSC]

Facility

$2,325.00

Service Code	HCPCS P9035
Hospital Charge Code	13369168
Hospital Revenue Code	380
Min. Negotiated Rate	$1,976.25
Max. Negotiated Rate	$2,255.25
Rate for Payer: Cash Price	$1,511.25
Rate for Payer: Health Management Network Commercial	$1,976.25
Rate for Payer: Kaiser Permanente Commercial	$2,092.50
Rate for Payer: MDX Hawaii PPO	$2,255.25

P9035 Plateletphersis Leukoredu [HHSC]

Facility

$2,325.00

Service Code	HCPCS P9035
Hospital Charge Code	13369168
Hospital Revenue Code	380
Min. Negotiated Rate	$580.00
Max. Negotiated Rate	$2,255.25
Rate for Payer: AlohaCare Medicaid	$1,162.50
Rate for Payer: AlohaCare Medicare	$1,162.50
Rate for Payer: Cash Price	$1,511.25
Rate for Payer: Cash Price	$1,511.25
Rate for Payer: Devoted Health Medicare	$1,278.75
Rate for Payer: Hawaii Medical Service Association Commercial	$639.49
Rate for Payer: Hawaii Medical Service Association Medicare	$1,162.50
Rate for Payer: Hawaii Western Management Group Commercial	$2,208.75
Rate for Payer: Health Management Network Commercial	$1,976.25
Rate for Payer: Humana Medicare	$1,162.50
Rate for Payer: Kaiser Permanente Commercial	$2,092.50
Rate for Payer: Kaiser Permanente Medicaid	$1,185.75
Rate for Payer: Kaiser Permanente Medicare	$1,162.50
Rate for Payer: MDX Hawaii PPO	$2,255.25
Rate for Payer: Ohana Health Plan Medicaid	$1,162.50
Rate for Payer: Ohana Health Plan Medicare	$1,162.50
Rate for Payer: UnitedHealthcare Medicaid	$580.00
Rate for Payer: UnitedHealthcare Medicare	$1,162.50
Rate for Payer: University Health Alliance Commercial	$1,302.00

P9036 Platelet Pheres Irrad Ea

Facility

$1,603.00

Service Code	HCPCS P9036
Hospital Charge Code	8258897
Hospital Revenue Code	390
Min. Negotiated Rate	$440.74
Max. Negotiated Rate	$1,554.91
Rate for Payer: AlohaCare Medicaid	$801.50
Rate for Payer: AlohaCare Medicare	$801.50
Rate for Payer: Cash Price	$1,041.95
Rate for Payer: Cash Price	$1,041.95
Rate for Payer: Devoted Health Medicare	$881.65
Rate for Payer: Hawaii Medical Service Association Commercial	$1,186.41
Rate for Payer: Hawaii Medical Service Association Medicare	$801.50
Rate for Payer: Hawaii Western Management Group Commercial	$1,522.85
Rate for Payer: Health Management Network Commercial	$1,362.55
Rate for Payer: Humana Medicare	$801.50
Rate for Payer: Kaiser Permanente Commercial	$1,442.70
Rate for Payer: Kaiser Permanente Medicaid	$817.53
Rate for Payer: Kaiser Permanente Medicare	$801.50
Rate for Payer: MDX Hawaii PPO	$1,554.91
Rate for Payer: Ohana Health Plan Medicaid	$801.50
Rate for Payer: Ohana Health Plan Medicare	$801.50
Rate for Payer: UnitedHealthcare Medicaid	$440.74
Rate for Payer: UnitedHealthcare Medicare	$801.50
Rate for Payer: University Health Alliance Commercial	$897.68

P9036 Platelet Pheres Irrad Ea

Facility

$1,603.00

Service Code	HCPCS P9036
Hospital Charge Code	8258897
Hospital Revenue Code	390
Min. Negotiated Rate	$1,362.55
Max. Negotiated Rate	$1,554.91
Rate for Payer: Cash Price	$1,041.95
Rate for Payer: Health Management Network Commercial	$1,362.55
Rate for Payer: Kaiser Permanente Commercial	$1,442.70
Rate for Payer: MDX Hawaii PPO	$1,554.91

P9036 Platelet Pheres Irrad Ea [HHSC]

Facility

$1,603.00

Service Code	HCPCS P9036
Hospital Charge Code	13369169
Hospital Revenue Code	380
Min. Negotiated Rate	$440.74
Max. Negotiated Rate	$1,554.91
Rate for Payer: AlohaCare Medicaid	$801.50
Rate for Payer: AlohaCare Medicare	$801.50
Rate for Payer: Cash Price	$1,041.95
Rate for Payer: Cash Price	$1,041.95
Rate for Payer: Devoted Health Medicare	$881.65
Rate for Payer: Hawaii Medical Service Association Commercial	$1,186.41
Rate for Payer: Hawaii Medical Service Association Medicare	$801.50
Rate for Payer: Hawaii Western Management Group Commercial	$1,522.85
Rate for Payer: Health Management Network Commercial	$1,362.55
Rate for Payer: Humana Medicare	$801.50
Rate for Payer: Kaiser Permanente Commercial	$1,442.70
Rate for Payer: Kaiser Permanente Medicaid	$817.53
Rate for Payer: Kaiser Permanente Medicare	$801.50
Rate for Payer: MDX Hawaii PPO	$1,554.91
Rate for Payer: Ohana Health Plan Medicaid	$801.50
Rate for Payer: Ohana Health Plan Medicare	$801.50
Rate for Payer: UnitedHealthcare Medicaid	$440.74
Rate for Payer: UnitedHealthcare Medicare	$801.50
Rate for Payer: University Health Alliance Commercial	$897.68

P9036 Platelet Pheres Irrad Ea [HHSC]

Facility

$1,603.00

Service Code	HCPCS P9036
Hospital Charge Code	13369169
Hospital Revenue Code	380
Min. Negotiated Rate	$1,362.55
Max. Negotiated Rate	$1,554.91
Rate for Payer: Cash Price	$1,041.95
Rate for Payer: Health Management Network Commercial	$1,362.55
Rate for Payer: Kaiser Permanente Commercial	$1,442.70
Rate for Payer: MDX Hawaii PPO	$1,554.91

P9038 RBC Irradiated Ea Unit

Facility

$1,012.00

Service Code	HCPCS P9038
Hospital Charge Code	8258898
Hospital Revenue Code	390
Min. Negotiated Rate	$860.20
Max. Negotiated Rate	$981.64
Rate for Payer: Cash Price	$657.80
Rate for Payer: Health Management Network Commercial	$860.20
Rate for Payer: Kaiser Permanente Commercial	$910.80
Rate for Payer: MDX Hawaii PPO	$981.64

P9038 RBC Irradiated Ea Unit

Facility

$1,012.00

Service Code	HCPCS P9038
Hospital Charge Code	8258898
Hospital Revenue Code	390
Min. Negotiated Rate	$111.92
Max. Negotiated Rate	$981.64
Rate for Payer: AlohaCare Medicaid	$506.00
Rate for Payer: AlohaCare Medicare	$506.00
Rate for Payer: Cash Price	$657.80
Rate for Payer: Cash Price	$657.80
Rate for Payer: Devoted Health Medicare	$556.60
Rate for Payer: Hawaii Medical Service Association Commercial	$181.53
Rate for Payer: Hawaii Medical Service Association Medicare	$506.00
Rate for Payer: Hawaii Western Management Group Commercial	$961.40
Rate for Payer: Health Management Network Commercial	$860.20
Rate for Payer: Humana Medicare	$506.00
Rate for Payer: Kaiser Permanente Commercial	$910.80
Rate for Payer: Kaiser Permanente Medicaid	$516.12
Rate for Payer: Kaiser Permanente Medicare	$506.00
Rate for Payer: MDX Hawaii PPO	$981.64
Rate for Payer: Ohana Health Plan Medicaid	$506.00
Rate for Payer: Ohana Health Plan Medicare	$506.00
Rate for Payer: UnitedHealthcare Medicaid	$111.92
Rate for Payer: UnitedHealthcare Medicare	$506.00
Rate for Payer: University Health Alliance Commercial	$566.72

P9038 RBC Irradiated Ea Unit [HHSC]

Facility

$1,012.00

Service Code	HCPCS P9038
Hospital Charge Code	13359463
Hospital Revenue Code	380
Min. Negotiated Rate	$860.20
Max. Negotiated Rate	$981.64
Rate for Payer: Cash Price	$657.80
Rate for Payer: Health Management Network Commercial	$860.20
Rate for Payer: Kaiser Permanente Commercial	$910.80
Rate for Payer: MDX Hawaii PPO	$981.64

P9038 RBC Irradiated Ea Unit [HHSC]

Facility

$1,012.00

Service Code	HCPCS P9038
Hospital Charge Code	13359463
Hospital Revenue Code	380
Min. Negotiated Rate	$111.92
Max. Negotiated Rate	$981.64
Rate for Payer: AlohaCare Medicaid	$506.00
Rate for Payer: AlohaCare Medicare	$506.00
Rate for Payer: Cash Price	$657.80
Rate for Payer: Cash Price	$657.80
Rate for Payer: Devoted Health Medicare	$556.60
Rate for Payer: Hawaii Medical Service Association Commercial	$181.53
Rate for Payer: Hawaii Medical Service Association Medicare	$506.00
Rate for Payer: Hawaii Western Management Group Commercial	$961.40
Rate for Payer: Health Management Network Commercial	$860.20
Rate for Payer: Humana Medicare	$506.00
Rate for Payer: Kaiser Permanente Commercial	$910.80
Rate for Payer: Kaiser Permanente Medicaid	$516.12
Rate for Payer: Kaiser Permanente Medicare	$506.00
Rate for Payer: MDX Hawaii PPO	$981.64
Rate for Payer: Ohana Health Plan Medicaid	$506.00
Rate for Payer: Ohana Health Plan Medicare	$506.00
Rate for Payer: UnitedHealthcare Medicaid	$111.92
Rate for Payer: UnitedHealthcare Medicare	$506.00
Rate for Payer: University Health Alliance Commercial	$566.72

P9040 Rbc Leuko Reduc Irrad Ea

Facility

$1,208.00

Service Code	HCPCS P9040
Hospital Charge Code	8258899
Hospital Revenue Code	390
Min. Negotiated Rate	$1,026.80
Max. Negotiated Rate	$1,171.76
Rate for Payer: Cash Price	$785.20
Rate for Payer: Health Management Network Commercial	$1,026.80
Rate for Payer: Kaiser Permanente Commercial	$1,087.20
Rate for Payer: MDX Hawaii PPO	$1,171.76

P9040 Rbc Leuko Reduc Irrad Ea

Facility

$1,208.00

Service Code	HCPCS P9040
Hospital Charge Code	8258899
Hospital Revenue Code	390
Min. Negotiated Rate	$191.85
Max. Negotiated Rate	$1,171.76
Rate for Payer: AlohaCare Medicaid	$604.00
Rate for Payer: AlohaCare Medicare	$604.00
Rate for Payer: Cash Price	$785.20
Rate for Payer: Cash Price	$785.20
Rate for Payer: Devoted Health Medicare	$664.40
Rate for Payer: Hawaii Medical Service Association Commercial	$331.76
Rate for Payer: Hawaii Medical Service Association Medicare	$604.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,147.60
Rate for Payer: Health Management Network Commercial	$1,026.80
Rate for Payer: Humana Medicare	$604.00
Rate for Payer: Kaiser Permanente Commercial	$1,087.20
Rate for Payer: Kaiser Permanente Medicaid	$616.08
Rate for Payer: Kaiser Permanente Medicare	$604.00
Rate for Payer: MDX Hawaii PPO	$1,171.76
Rate for Payer: Ohana Health Plan Medicaid	$604.00
Rate for Payer: Ohana Health Plan Medicare	$604.00
Rate for Payer: UnitedHealthcare Medicaid	$191.85
Rate for Payer: UnitedHealthcare Medicare	$604.00
Rate for Payer: University Health Alliance Commercial	$676.48

P9040 Rbc Leuko Reduc Irrad Ea [HHSC]

Facility

$1,208.00

Service Code	HCPCS P9040
Hospital Charge Code	13357629
Hospital Revenue Code	380
Min. Negotiated Rate	$191.85
Max. Negotiated Rate	$1,171.76
Rate for Payer: AlohaCare Medicaid	$604.00
Rate for Payer: AlohaCare Medicare	$604.00
Rate for Payer: Cash Price	$785.20
Rate for Payer: Cash Price	$785.20
Rate for Payer: Devoted Health Medicare	$664.40
Rate for Payer: Hawaii Medical Service Association Commercial	$331.76
Rate for Payer: Hawaii Medical Service Association Medicare	$604.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,147.60
Rate for Payer: Health Management Network Commercial	$1,026.80
Rate for Payer: Humana Medicare	$604.00
Rate for Payer: Kaiser Permanente Commercial	$1,087.20
Rate for Payer: Kaiser Permanente Medicaid	$616.08
Rate for Payer: Kaiser Permanente Medicare	$604.00
Rate for Payer: MDX Hawaii PPO	$1,171.76
Rate for Payer: Ohana Health Plan Medicaid	$604.00
Rate for Payer: Ohana Health Plan Medicare	$604.00
Rate for Payer: UnitedHealthcare Medicaid	$191.85
Rate for Payer: UnitedHealthcare Medicare	$604.00
Rate for Payer: University Health Alliance Commercial	$676.48

P9040 Rbc Leuko Reduc Irrad Ea [HHSC]

Facility

$1,208.00

Service Code	HCPCS P9040
Hospital Charge Code	13357629
Hospital Revenue Code	380
Min. Negotiated Rate	$1,026.80
Max. Negotiated Rate	$1,171.76
Rate for Payer: Cash Price	$785.20
Rate for Payer: Health Management Network Commercial	$1,026.80
Rate for Payer: Kaiser Permanente Commercial	$1,087.20
Rate for Payer: MDX Hawaii PPO	$1,171.76

Know your out-of-pocket cost for care.

All Charges