Samuel Mahelona Memorial Hospital

All Charges

Charge

Type

Setting

Price

P9044 Plasma Cryoprecipitate Reduced Ea Unit

Facility

$206.00

Service Code	HCPCS P9044
Hospital Charge Code	8258902
Hospital Revenue Code	390
Min. Negotiated Rate	$103.00
Max. Negotiated Rate	$199.82
Rate for Payer: AlohaCare Medicaid	$103.00
Rate for Payer: AlohaCare Medicare	$103.00
Rate for Payer: Cash Price	$133.90
Rate for Payer: Cash Price	$133.90
Rate for Payer: Devoted Health Medicare	$113.30
Rate for Payer: Hawaii Medical Service Association Commercial	$165.06
Rate for Payer: Hawaii Medical Service Association Medicare	$103.00
Rate for Payer: Hawaii Western Management Group Commercial	$195.70
Rate for Payer: Health Management Network Commercial	$175.10
Rate for Payer: Humana Medicare	$103.00
Rate for Payer: Kaiser Permanente Commercial	$185.40
Rate for Payer: Kaiser Permanente Medicaid	$105.06
Rate for Payer: Kaiser Permanente Medicare	$103.00
Rate for Payer: MDX Hawaii PPO	$199.82
Rate for Payer: Ohana Health Plan Medicaid	$103.00
Rate for Payer: Ohana Health Plan Medicare	$103.00
Rate for Payer: UnitedHealthcare Medicaid	$110.48
Rate for Payer: UnitedHealthcare Medicare	$103.00
Rate for Payer: University Health Alliance Commercial	$115.36

P9044 Plasma Cryoprecipitate Reduced Ea Unit

Facility

$206.00

Service Code	HCPCS P9044
Hospital Charge Code	8258902
Hospital Revenue Code	390
Min. Negotiated Rate	$175.10
Max. Negotiated Rate	$199.82
Rate for Payer: Cash Price	$133.90
Rate for Payer: Health Management Network Commercial	$175.10
Rate for Payer: Kaiser Permanente Commercial	$185.40
Rate for Payer: MDX Hawaii PPO	$199.82

P9044 Plasma Cryoprecipitate Reduced Ea Unit [HHSC]

Facility

$206.00

Service Code	HCPCS P9044
Hospital Charge Code	13369170
Hospital Revenue Code	380
Min. Negotiated Rate	$103.00
Max. Negotiated Rate	$199.82
Rate for Payer: AlohaCare Medicaid	$103.00
Rate for Payer: AlohaCare Medicare	$103.00
Rate for Payer: Cash Price	$133.90
Rate for Payer: Cash Price	$133.90
Rate for Payer: Devoted Health Medicare	$113.30
Rate for Payer: Hawaii Medical Service Association Commercial	$165.06
Rate for Payer: Hawaii Medical Service Association Medicare	$103.00
Rate for Payer: Hawaii Western Management Group Commercial	$195.70
Rate for Payer: Health Management Network Commercial	$175.10
Rate for Payer: Humana Medicare	$103.00
Rate for Payer: Kaiser Permanente Commercial	$185.40
Rate for Payer: Kaiser Permanente Medicaid	$105.06
Rate for Payer: Kaiser Permanente Medicare	$103.00
Rate for Payer: MDX Hawaii PPO	$199.82
Rate for Payer: Ohana Health Plan Medicaid	$103.00
Rate for Payer: Ohana Health Plan Medicare	$103.00
Rate for Payer: UnitedHealthcare Medicaid	$110.48
Rate for Payer: UnitedHealthcare Medicare	$103.00
Rate for Payer: University Health Alliance Commercial	$115.36

P9044 Plasma Cryoprecipitate Reduced Ea Unit [HHSC]

Facility

$206.00

Service Code	HCPCS P9044
Hospital Charge Code	13369170
Hospital Revenue Code	380
Min. Negotiated Rate	$175.10
Max. Negotiated Rate	$199.82
Rate for Payer: Cash Price	$133.90
Rate for Payer: Health Management Network Commercial	$175.10
Rate for Payer: Kaiser Permanente Commercial	$185.40
Rate for Payer: MDX Hawaii PPO	$199.82

P9059 FFP 8-24 Hrs Ea Unit

Facility

$344.00

Service Code	HCPCS P9059
Hospital Charge Code	8258901
Hospital Revenue Code	390
Min. Negotiated Rate	$53.32
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	$92.21
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	$53.32
Rate for Payer: UnitedHealthcare Medicare	$172.00
Rate for Payer: University Health Alliance Commercial	$192.64

P9059 FFP 8-24 Hrs Ea Unit

Facility

$344.00

Service Code	HCPCS P9059
Hospital Charge Code	8258901
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

P9059 FFP 8-24 Hrs Ea Unit [HHSC]

Facility

$344.00

Service Code	HCPCS P9059
Hospital Charge Code	13369171
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

P9059 FFP 8-24 Hrs Ea Unit [HHSC]

Facility

$344.00

Service Code	HCPCS P9059
Hospital Charge Code	13369171
Hospital Revenue Code	380
Min. Negotiated Rate	$53.32
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	$92.21
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	$53.32
Rate for Payer: UnitedHealthcare Medicare	$172.00
Rate for Payer: University Health Alliance Commercial	$192.64

PADDING CAST DELTA-DRY OPEN KNIT LIMB 00000-00 2X2.6YD 12RL/PK

Facility

$54.00

Service Code	HCPCS A9270
Hospital Charge Code	12954863
Hospital Revenue Code	270
Min. Negotiated Rate	$45.90
Max. Negotiated Rate	$52.38
Rate for Payer: Cash Price	$35.10
Rate for Payer: Health Management Network Commercial	$45.90
Rate for Payer: Kaiser Permanente Commercial	$48.60
Rate for Payer: MDX Hawaii PPO	$52.38

PADDING CAST DELTA-DRY OPEN KNIT LIMB 00000-00 2X2.6YD 12RL/PK

Professional

Both

$54.00

Service Code	HCPCS A9270
Hospital Charge Code	12954863
Hospital Revenue Code	270
Min. Negotiated Rate	$45.90
Max. Negotiated Rate	$45.90
Rate for Payer: Cash Price	$35.10
Rate for Payer: Health Management Network Commercial	$45.90

PADDING CAST DELTA-DRY OPEN KNIT LIMB 00000-00 2X2.6YD 12RL/PK

Facility

$54.00

Service Code	HCPCS A9270
Hospital Charge Code	12954863
Hospital Revenue Code	270
Min. Negotiated Rate	$27.00
Max. Negotiated Rate	$52.38
Rate for Payer: AlohaCare Medicaid	$27.00
Rate for Payer: AlohaCare Medicare	$27.00
Rate for Payer: Cash Price	$35.10
Rate for Payer: Devoted Health Medicare	$29.70
Rate for Payer: Hawaii Medical Service Association Medicare	$27.00
Rate for Payer: Hawaii Western Management Group Commercial	$51.30
Rate for Payer: Health Management Network Commercial	$45.90
Rate for Payer: Humana Medicare	$27.00
Rate for Payer: Kaiser Permanente Commercial	$48.60
Rate for Payer: Kaiser Permanente Medicaid	$27.54
Rate for Payer: Kaiser Permanente Medicare	$27.00
Rate for Payer: MDX Hawaii PPO	$52.38
Rate for Payer: Ohana Health Plan Medicaid	$27.00
Rate for Payer: Ohana Health Plan Medicare	$27.00
Rate for Payer: UnitedHealthcare Medicare	$27.00
Rate for Payer: University Health Alliance Commercial	$39.36

PADDING CAST DELTA-DRY OPEN KNIT LIMB 00001-00 3X2.6YD 12RL/PK

Professional

Both

$58.00

Service Code	HCPCS A9270 GY
Hospital Charge Code	12954868
Hospital Revenue Code	272
Min. Negotiated Rate	$49.30
Max. Negotiated Rate	$49.30
Rate for Payer: Cash Price	$37.70
Rate for Payer: Health Management Network Commercial	$49.30

PADDING CAST DELTA-DRY OPEN KNIT LIMB 00001-00 3X2.6YD 12RL/PK

Facility

$58.00

Service Code	HCPCS A9270 GY
Hospital Charge Code	12954868
Hospital Revenue Code	272
Min. Negotiated Rate	$29.00
Max. Negotiated Rate	$56.26
Rate for Payer: AlohaCare Medicaid	$29.00
Rate for Payer: AlohaCare Medicare	$29.00
Rate for Payer: Cash Price	$37.70
Rate for Payer: Devoted Health Medicare	$31.90
Rate for Payer: Hawaii Medical Service Association Medicare	$29.00
Rate for Payer: Hawaii Western Management Group Commercial	$55.10
Rate for Payer: Health Management Network Commercial	$49.30
Rate for Payer: Humana Medicare	$29.00
Rate for Payer: Kaiser Permanente Commercial	$52.20
Rate for Payer: Kaiser Permanente Medicaid	$29.58
Rate for Payer: Kaiser Permanente Medicare	$29.00
Rate for Payer: MDX Hawaii PPO	$56.26
Rate for Payer: Ohana Health Plan Medicaid	$29.00
Rate for Payer: Ohana Health Plan Medicare	$29.00
Rate for Payer: UnitedHealthcare Medicare	$29.00
Rate for Payer: University Health Alliance Commercial	$42.28

PADDING CAST DELTA-DRY OPEN KNIT LIMB 00001-00 3X2.6YD 12RL/PK

Facility

$58.00

Service Code	HCPCS A9270 GY
Hospital Charge Code	12954868
Hospital Revenue Code	272
Min. Negotiated Rate	$49.30
Max. Negotiated Rate	$56.26
Rate for Payer: Cash Price	$37.70
Rate for Payer: Health Management Network Commercial	$49.30
Rate for Payer: Kaiser Permanente Commercial	$52.20
Rate for Payer: MDX Hawaii PPO	$56.26

PADDING CAST PROTOUCH NATURAL 3 X 4 YD 12/PK

Facility

$7.00

Hospital Charge Code	12954878
Hospital Revenue Code	272
Min. Negotiated Rate	$5.95
Max. Negotiated Rate	$6.79
Rate for Payer: Cash Price	$4.55
Rate for Payer: Health Management Network Commercial	$5.95
Rate for Payer: Kaiser Permanente Commercial	$6.30
Rate for Payer: MDX Hawaii PPO	$6.79

PADDING CAST PROTOUCH NATURAL 3 X 4 YD 12/PK

Professional

Both

$7.00

Hospital Charge Code	12954878
Hospital Revenue Code	272
Min. Negotiated Rate	$5.95
Max. Negotiated Rate	$5.95
Rate for Payer: Cash Price	$4.55
Rate for Payer: Health Management Network Commercial	$5.95

PADDING CAST PROTOUCH NATURAL 3 X 4 YD 12/PK

Facility

$7.00

Hospital Charge Code	12954878
Hospital Revenue Code	272
Min. Negotiated Rate	$3.50
Max. Negotiated Rate	$6.79
Rate for Payer: AlohaCare Medicaid	$3.50
Rate for Payer: AlohaCare Medicare	$3.50
Rate for Payer: Cash Price	$4.55
Rate for Payer: Devoted Health Medicare	$3.85
Rate for Payer: Hawaii Medical Service Association Medicare	$3.50
Rate for Payer: Hawaii Western Management Group Commercial	$6.65
Rate for Payer: Health Management Network Commercial	$5.95
Rate for Payer: Humana Medicare	$3.50
Rate for Payer: Kaiser Permanente Commercial	$6.30
Rate for Payer: Kaiser Permanente Medicaid	$3.57
Rate for Payer: Kaiser Permanente Medicare	$3.50
Rate for Payer: MDX Hawaii PPO	$6.79
Rate for Payer: Ohana Health Plan Medicaid	$3.50
Rate for Payer: Ohana Health Plan Medicare	$3.50
Rate for Payer: UnitedHealthcare Medicare	$3.50
Rate for Payer: University Health Alliance Commercial	$5.10

PADDING CAST PROTOUCH NATURAL/ RAYON LIMB 2X4YD WHITE 12RL/PK

Facility

$5.00

Hospital Charge Code	12954877
Hospital Revenue Code	272
Min. Negotiated Rate	$4.25
Max. Negotiated Rate	$4.85
Rate for Payer: Cash Price	$3.25
Rate for Payer: Health Management Network Commercial	$4.25
Rate for Payer: Kaiser Permanente Commercial	$4.50
Rate for Payer: MDX Hawaii PPO	$4.85

PADDING CAST PROTOUCH NATURAL/ RAYON LIMB 2X4YD WHITE 12RL/PK

Facility

$5.00

Hospital Charge Code	12954877
Hospital Revenue Code	272
Min. Negotiated Rate	$2.50
Max. Negotiated Rate	$4.85
Rate for Payer: AlohaCare Medicaid	$2.50
Rate for Payer: AlohaCare Medicare	$2.50
Rate for Payer: Cash Price	$3.25
Rate for Payer: Devoted Health Medicare	$2.75
Rate for Payer: Hawaii Medical Service Association Medicare	$2.50
Rate for Payer: Hawaii Western Management Group Commercial	$4.75
Rate for Payer: Health Management Network Commercial	$4.25
Rate for Payer: Humana Medicare	$2.50
Rate for Payer: Kaiser Permanente Commercial	$4.50
Rate for Payer: Kaiser Permanente Medicaid	$2.55
Rate for Payer: Kaiser Permanente Medicare	$2.50
Rate for Payer: MDX Hawaii PPO	$4.85
Rate for Payer: Ohana Health Plan Medicaid	$2.50
Rate for Payer: Ohana Health Plan Medicare	$2.50
Rate for Payer: UnitedHealthcare Medicare	$2.50
Rate for Payer: University Health Alliance Commercial	$3.64

PADDING CAST PROTOUCH NATURAL/ RAYON LIMB 2X4YD WHITE 12RL/PK

Professional

Both

$5.00

Hospital Charge Code	12954877
Hospital Revenue Code	272
Min. Negotiated Rate	$4.25
Max. Negotiated Rate	$4.25
Rate for Payer: Cash Price	$3.25
Rate for Payer: Health Management Network Commercial	$4.25

PADDING CAST SOF-ROL NEEDLE-LOOMED RAYON LIMB 6X4YD WH LF 6RL/CA, 6 BG/CA

Professional

Both

$9.00

Hospital Charge Code	12954876
Hospital Revenue Code	272
Min. Negotiated Rate	$7.65
Max. Negotiated Rate	$7.65
Rate for Payer: Cash Price	$5.85
Rate for Payer: Health Management Network Commercial	$7.65

PADDING CAST SOF-ROL NEEDLE-LOOMED RAYON LMB 3X4YD WH LF 12RL/CA, 6 BG/CA

Facility

$5.00

Hospital Charge Code	12954875
Hospital Revenue Code	270
Min. Negotiated Rate	$2.50
Max. Negotiated Rate	$4.85
Rate for Payer: AlohaCare Medicaid	$2.50
Rate for Payer: AlohaCare Medicare	$2.50
Rate for Payer: Cash Price	$3.25
Rate for Payer: Devoted Health Medicare	$2.75
Rate for Payer: Hawaii Medical Service Association Medicare	$2.50
Rate for Payer: Hawaii Western Management Group Commercial	$4.75
Rate for Payer: Health Management Network Commercial	$4.25
Rate for Payer: Humana Medicare	$2.50
Rate for Payer: Kaiser Permanente Commercial	$4.50
Rate for Payer: Kaiser Permanente Medicaid	$2.55
Rate for Payer: Kaiser Permanente Medicare	$2.50
Rate for Payer: MDX Hawaii PPO	$4.85
Rate for Payer: Ohana Health Plan Medicaid	$2.50
Rate for Payer: Ohana Health Plan Medicare	$2.50
Rate for Payer: UnitedHealthcare Medicare	$2.50
Rate for Payer: University Health Alliance Commercial	$3.64

PADDING CAST SOF-ROL NEEDLE-LOOMED RAYON LMB 3X4YD WH LF 12RL/CA, 6 BG/CA

Facility

$5.00

Hospital Charge Code	12954875
Hospital Revenue Code	270
Min. Negotiated Rate	$4.25
Max. Negotiated Rate	$4.85
Rate for Payer: Cash Price	$3.25
Rate for Payer: Health Management Network Commercial	$4.25
Rate for Payer: Kaiser Permanente Commercial	$4.50
Rate for Payer: MDX Hawaii PPO	$4.85

PADDING CAST SOF-ROL NEEDLE-LOOMED RAYON LMB 3X4YD WH LF 12RL/CA, 6 BG/CA

Professional

Both

$5.00

Hospital Charge Code	12954875
Hospital Revenue Code	270
Min. Negotiated Rate	$4.25
Max. Negotiated Rate	$4.25
Rate for Payer: Cash Price	$3.25
Rate for Payer: Health Management Network Commercial	$4.25

PADDING CAST SOF-ROL NEEDLE-LOOMED RAYON LMB 4X4YD WH LF 12RL/CA, 6 BG/CA

Facility

$6.00

Hospital Charge Code	12954854
Hospital Revenue Code	270
Min. Negotiated Rate	$3.00
Max. Negotiated Rate	$5.82
Rate for Payer: AlohaCare Medicaid	$3.00
Rate for Payer: AlohaCare Medicare	$3.00
Rate for Payer: Cash Price	$3.90
Rate for Payer: Devoted Health Medicare	$3.30
Rate for Payer: Hawaii Medical Service Association Medicare	$3.00
Rate for Payer: Hawaii Western Management Group Commercial	$5.70
Rate for Payer: Health Management Network Commercial	$5.10
Rate for Payer: Humana Medicare	$3.00
Rate for Payer: Kaiser Permanente Commercial	$5.40
Rate for Payer: Kaiser Permanente Medicaid	$3.06
Rate for Payer: Kaiser Permanente Medicare	$3.00
Rate for Payer: MDX Hawaii PPO	$5.82
Rate for Payer: Ohana Health Plan Medicaid	$3.00
Rate for Payer: Ohana Health Plan Medicare	$3.00
Rate for Payer: UnitedHealthcare Medicare	$3.00
Rate for Payer: University Health Alliance Commercial	$4.37

Know your out-of-pocket cost for care.

All Charges