Samuel Mahelona Memorial Hospital

All Charges

Charge

Type

Setting

Price

RAPID RHINO 4.5 CM

Facility

$235.00

Hospital Charge Code	9230672
Hospital Revenue Code	272
Min. Negotiated Rate	$117.50
Max. Negotiated Rate	$227.95
Rate for Payer: AlohaCare Medicaid	$117.50
Rate for Payer: AlohaCare Medicare	$117.50
Rate for Payer: Cash Price	$152.75
Rate for Payer: Devoted Health Medicare	$129.25
Rate for Payer: Hawaii Medical Service Association Medicare	$117.50
Rate for Payer: Hawaii Western Management Group Commercial	$223.25
Rate for Payer: Health Management Network Commercial	$199.75
Rate for Payer: Humana Medicare	$117.50
Rate for Payer: Kaiser Permanente Commercial	$211.50
Rate for Payer: Kaiser Permanente Medicaid	$119.85
Rate for Payer: Kaiser Permanente Medicare	$117.50
Rate for Payer: MDX Hawaii PPO	$227.95
Rate for Payer: Ohana Health Plan Medicaid	$117.50
Rate for Payer: Ohana Health Plan Medicare	$117.50
Rate for Payer: UnitedHealthcare Medicare	$117.50
Rate for Payer: University Health Alliance Commercial	$171.29

RAPID RHINO 5.5 CM

Facility

$208.00

Hospital Charge Code	9230674
Hospital Revenue Code	272
Min. Negotiated Rate	$176.80
Max. Negotiated Rate	$201.76
Rate for Payer: Cash Price	$135.20
Rate for Payer: Health Management Network Commercial	$176.80
Rate for Payer: Kaiser Permanente Commercial	$187.20
Rate for Payer: MDX Hawaii PPO	$201.76

RAPID RHINO 5.5 CM

Facility

$208.00

Hospital Charge Code	9230674
Hospital Revenue Code	272
Min. Negotiated Rate	$104.00
Max. Negotiated Rate	$201.76
Rate for Payer: AlohaCare Medicaid	$104.00
Rate for Payer: AlohaCare Medicare	$104.00
Rate for Payer: Cash Price	$135.20
Rate for Payer: Devoted Health Medicare	$114.40
Rate for Payer: Hawaii Medical Service Association Medicare	$104.00
Rate for Payer: Hawaii Western Management Group Commercial	$197.60
Rate for Payer: Health Management Network Commercial	$176.80
Rate for Payer: Humana Medicare	$104.00
Rate for Payer: Kaiser Permanente Commercial	$187.20
Rate for Payer: Kaiser Permanente Medicaid	$106.08
Rate for Payer: Kaiser Permanente Medicare	$104.00
Rate for Payer: MDX Hawaii PPO	$201.76
Rate for Payer: Ohana Health Plan Medicaid	$104.00
Rate for Payer: Ohana Health Plan Medicare	$104.00
Rate for Payer: UnitedHealthcare Medicare	$104.00
Rate for Payer: University Health Alliance Commercial	$151.61

RAPID RHINO 7.5 CM

Facility

$242.00

Hospital Charge Code	9230673
Hospital Revenue Code	272
Min. Negotiated Rate	$121.00
Max. Negotiated Rate	$234.74
Rate for Payer: AlohaCare Medicaid	$121.00
Rate for Payer: AlohaCare Medicare	$121.00
Rate for Payer: Cash Price	$157.30
Rate for Payer: Devoted Health Medicare	$133.10
Rate for Payer: Hawaii Medical Service Association Medicare	$121.00
Rate for Payer: Hawaii Western Management Group Commercial	$229.90
Rate for Payer: Health Management Network Commercial	$205.70
Rate for Payer: Humana Medicare	$121.00
Rate for Payer: Kaiser Permanente Commercial	$217.80
Rate for Payer: Kaiser Permanente Medicaid	$123.42
Rate for Payer: Kaiser Permanente Medicare	$121.00
Rate for Payer: MDX Hawaii PPO	$234.74
Rate for Payer: Ohana Health Plan Medicaid	$121.00
Rate for Payer: Ohana Health Plan Medicare	$121.00
Rate for Payer: UnitedHealthcare Medicare	$121.00
Rate for Payer: University Health Alliance Commercial	$176.39

RAPID RHINO 7.5 CM

Facility

$242.00

Hospital Charge Code	9230673
Hospital Revenue Code	272
Min. Negotiated Rate	$205.70
Max. Negotiated Rate	$234.74
Rate for Payer: Cash Price	$157.30
Rate for Payer: Health Management Network Commercial	$205.70
Rate for Payer: Kaiser Permanente Commercial	$217.80
Rate for Payer: MDX Hawaii PPO	$234.74

Rapid sequence intubation

Facility

$1,446.00

Service Code	HCPCS 31500
Hospital Charge Code	2636297
Hospital Revenue Code	450
Min. Negotiated Rate	$1,229.10
Max. Negotiated Rate	$1,402.62
Rate for Payer: Cash Price	$939.90
Rate for Payer: Health Management Network Commercial	$1,229.10
Rate for Payer: Kaiser Permanente Commercial	$1,301.40
Rate for Payer: MDX Hawaii PPO	$1,402.62

Rapid sequence intubation

Facility

$1,446.00

Service Code	HCPCS 31500
Hospital Charge Code	2636297
Hospital Revenue Code	450
Min. Negotiated Rate	$450.00
Max. Negotiated Rate	$4,035.20
Rate for Payer: AlohaCare Medicaid	$723.00
Rate for Payer: AlohaCare Medicare	$723.00
Rate for Payer: Cash Price	$939.90
Rate for Payer: Cash Price	$939.90
Rate for Payer: Devoted Health Medicare	$795.30
Rate for Payer: Hawaii Medical Service Association ABD	$469.00
Rate for Payer: Hawaii Medical Service Association Commercial	$1,600.00
Rate for Payer: Hawaii Medical Service Association Medicare	$723.00
Rate for Payer: Hawaii Medical Service Association Non-ABD	$450.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,373.70
Rate for Payer: Health Management Network Commercial	$1,229.10
Rate for Payer: Humana Medicare	$723.00
Rate for Payer: Kaiser Permanente Commercial	$1,301.40
Rate for Payer: Kaiser Permanente Medicaid	$937.50
Rate for Payer: Kaiser Permanente Medicare	$723.00
Rate for Payer: MDX Hawaii PPO	$1,402.62
Rate for Payer: Ohana Health Plan Medicaid	$723.00
Rate for Payer: Ohana Health Plan Medicare	$723.00
Rate for Payer: UnitedHealthcare Medicare	$723.00
Rate for Payer: University Health Alliance Commercial	$4,035.20

Rapid Strep

Facility

$134.00

Service Code	HCPCS 87880 QW
Hospital Charge Code	2836317
Hospital Revenue Code	306
Min. Negotiated Rate	$113.90
Max. Negotiated Rate	$129.98
Rate for Payer: Cash Price	$87.10
Rate for Payer: Health Management Network Commercial	$113.90
Rate for Payer: Kaiser Permanente Commercial	$120.60
Rate for Payer: MDX Hawaii PPO	$129.98

Rapid Strep

Facility

$134.00

Service Code	HCPCS 87880 QW
Hospital Charge Code	2836317
Hospital Revenue Code	306
Min. Negotiated Rate	$16.53
Max. Negotiated Rate	$129.98
Rate for Payer: AlohaCare Medicaid	$67.00
Rate for Payer: AlohaCare Medicare	$67.00
Rate for Payer: Cash Price	$87.10
Rate for Payer: Cash Price	$87.10
Rate for Payer: Devoted Health Medicare	$73.70
Rate for Payer: Hawaii Medical Service Association ABD	$16.58
Rate for Payer: Hawaii Medical Service Association Commercial	$20.66
Rate for Payer: Hawaii Medical Service Association Medicare	$67.00
Rate for Payer: Hawaii Medical Service Association Non-ABD	$17.41
Rate for Payer: Hawaii Western Management Group Commercial	$16.53
Rate for Payer: Health Management Network Commercial	$113.90
Rate for Payer: Humana Medicare	$67.00
Rate for Payer: Kaiser Permanente Commercial	$120.60
Rate for Payer: Kaiser Permanente Medicaid	$68.34
Rate for Payer: Kaiser Permanente Medicare	$67.00
Rate for Payer: MDX Hawaii PPO	$129.98
Rate for Payer: Ohana Health Plan Medicaid	$67.00
Rate for Payer: Ohana Health Plan Medicare	$67.00
Rate for Payer: UnitedHealthcare Medicaid	$16.58
Rate for Payer: UnitedHealthcare Medicare	$67.00
Rate for Payer: University Health Alliance Commercial	$31.01

Rapid Strep POCT

Facility

$134.00

Service Code	HCPCS 87880
Hospital Charge Code	9841868
Hospital Revenue Code	306
Min. Negotiated Rate	$113.90
Max. Negotiated Rate	$129.98
Rate for Payer: Cash Price	$87.10
Rate for Payer: Health Management Network Commercial	$113.90
Rate for Payer: Kaiser Permanente Commercial	$120.60
Rate for Payer: MDX Hawaii PPO	$129.98

Rapid Strep POCT

Facility

$134.00

Service Code	HCPCS 87880
Hospital Charge Code	9841868
Hospital Revenue Code	306
Min. Negotiated Rate	$16.53
Max. Negotiated Rate	$129.98
Rate for Payer: AlohaCare Medicaid	$67.00
Rate for Payer: AlohaCare Medicare	$67.00
Rate for Payer: Cash Price	$87.10
Rate for Payer: Cash Price	$87.10
Rate for Payer: Devoted Health Medicare	$73.70
Rate for Payer: Hawaii Medical Service Association ABD	$16.58
Rate for Payer: Hawaii Medical Service Association Commercial	$20.66
Rate for Payer: Hawaii Medical Service Association Medicare	$67.00
Rate for Payer: Hawaii Medical Service Association Non-ABD	$17.41
Rate for Payer: Hawaii Western Management Group Commercial	$16.53
Rate for Payer: Health Management Network Commercial	$113.90
Rate for Payer: Humana Medicare	$67.00
Rate for Payer: Kaiser Permanente Commercial	$120.60
Rate for Payer: Kaiser Permanente Medicaid	$68.34
Rate for Payer: Kaiser Permanente Medicare	$67.00
Rate for Payer: MDX Hawaii PPO	$129.98
Rate for Payer: Ohana Health Plan Medicaid	$67.00
Rate for Payer: Ohana Health Plan Medicare	$67.00
Rate for Payer: UnitedHealthcare Medicaid	$16.58
Rate for Payer: UnitedHealthcare Medicare	$67.00
Rate for Payer: University Health Alliance Commercial	$31.01

RBC 1 Unit FSI

Facility

$339.00

Service Code	HCPCS 86920
Hospital Charge Code	11652600
Hospital Revenue Code	305
Min. Negotiated Rate	$20.80
Max. Negotiated Rate	$328.83
Rate for Payer: AlohaCare Medicaid	$169.50
Rate for Payer: AlohaCare Medicare	$169.50
Rate for Payer: Cash Price	$220.35
Rate for Payer: Cash Price	$220.35
Rate for Payer: Devoted Health Medicare	$186.45
Rate for Payer: Hawaii Medical Service Association ABD	$20.80
Rate for Payer: Hawaii Medical Service Association Commercial	$217.57
Rate for Payer: Hawaii Medical Service Association Medicare	$169.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$27.97
Rate for Payer: Hawaii Western Management Group Commercial	$174.06
Rate for Payer: Health Management Network Commercial	$288.15
Rate for Payer: Humana Medicare	$169.50
Rate for Payer: Kaiser Permanente Commercial	$305.10
Rate for Payer: Kaiser Permanente Medicaid	$172.89
Rate for Payer: Kaiser Permanente Medicare	$169.50
Rate for Payer: MDX Hawaii PPO	$328.83
Rate for Payer: Ohana Health Plan Medicaid	$169.50
Rate for Payer: Ohana Health Plan Medicare	$169.50
Rate for Payer: UnitedHealthcare Medicaid	$20.80
Rate for Payer: UnitedHealthcare Medicare	$169.50
Rate for Payer: University Health Alliance Commercial	$42.35

RBC 1 Unit FSI

Facility

$339.00

Service Code	HCPCS 86920
Hospital Charge Code	11652600
Hospital Revenue Code	305
Min. Negotiated Rate	$288.15
Max. Negotiated Rate	$328.83
Rate for Payer: Cash Price	$220.35
Rate for Payer: Health Management Network Commercial	$288.15
Rate for Payer: Kaiser Permanente Commercial	$305.10
Rate for Payer: MDX Hawaii PPO	$328.83

RBC 2 Units FSI

Facility

$339.00

Service Code	HCPCS 86920
Hospital Charge Code	11641969
Hospital Revenue Code	305
Min. Negotiated Rate	$20.80
Max. Negotiated Rate	$328.83
Rate for Payer: AlohaCare Medicaid	$169.50
Rate for Payer: AlohaCare Medicare	$169.50
Rate for Payer: Cash Price	$220.35
Rate for Payer: Cash Price	$220.35
Rate for Payer: Devoted Health Medicare	$186.45
Rate for Payer: Hawaii Medical Service Association ABD	$20.80
Rate for Payer: Hawaii Medical Service Association Commercial	$217.57
Rate for Payer: Hawaii Medical Service Association Medicare	$169.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$27.97
Rate for Payer: Hawaii Western Management Group Commercial	$174.06
Rate for Payer: Health Management Network Commercial	$288.15
Rate for Payer: Humana Medicare	$169.50
Rate for Payer: Kaiser Permanente Commercial	$305.10
Rate for Payer: Kaiser Permanente Medicaid	$172.89
Rate for Payer: Kaiser Permanente Medicare	$169.50
Rate for Payer: MDX Hawaii PPO	$328.83
Rate for Payer: Ohana Health Plan Medicaid	$169.50
Rate for Payer: Ohana Health Plan Medicare	$169.50
Rate for Payer: UnitedHealthcare Medicaid	$20.80
Rate for Payer: UnitedHealthcare Medicare	$169.50
Rate for Payer: University Health Alliance Commercial	$42.35

RBC 2 Units FSI

Facility

$339.00

Service Code	HCPCS 86920
Hospital Charge Code	11641969
Hospital Revenue Code	305
Min. Negotiated Rate	$288.15
Max. Negotiated Rate	$328.83
Rate for Payer: Cash Price	$220.35
Rate for Payer: Health Management Network Commercial	$288.15
Rate for Payer: Kaiser Permanente Commercial	$305.10
Rate for Payer: MDX Hawaii PPO	$328.83

RBC Antigens 1

Facility

$24.00

Service Code	HCPCS 86905
Hospital Charge Code	12539056
Hospital Revenue Code	302
Min. Negotiated Rate	$3.83
Max. Negotiated Rate	$23.28
Rate for Payer: AlohaCare Medicaid	$12.00
Rate for Payer: AlohaCare Medicare	$12.00
Rate for Payer: Cash Price	$15.60
Rate for Payer: Cash Price	$15.60
Rate for Payer: Devoted Health Medicare	$13.20
Rate for Payer: Hawaii Medical Service Association ABD	$5.28
Rate for Payer: Hawaii Medical Service Association Commercial	$4.79
Rate for Payer: Hawaii Medical Service Association Medicare	$12.00
Rate for Payer: Hawaii Medical Service Association Non-ABD	$5.54
Rate for Payer: Hawaii Western Management Group Commercial	$3.83
Rate for Payer: Health Management Network Commercial	$20.40
Rate for Payer: Humana Medicare	$12.00
Rate for Payer: Kaiser Permanente Commercial	$21.60
Rate for Payer: Kaiser Permanente Medicaid	$12.24
Rate for Payer: Kaiser Permanente Medicare	$12.00
Rate for Payer: MDX Hawaii PPO	$23.28
Rate for Payer: Ohana Health Plan Medicaid	$12.00
Rate for Payer: Ohana Health Plan Medicare	$12.00
Rate for Payer: UnitedHealthcare Medicaid	$5.28
Rate for Payer: UnitedHealthcare Medicare	$12.00
Rate for Payer: University Health Alliance Commercial	$9.88

RBC Antigens 1

Facility

$24.00

Service Code	HCPCS 86905
Hospital Charge Code	12539056
Hospital Revenue Code	302
Min. Negotiated Rate	$20.40
Max. Negotiated Rate	$23.28
Rate for Payer: Cash Price	$15.60
Rate for Payer: Health Management Network Commercial	$20.40
Rate for Payer: Kaiser Permanente Commercial	$21.60
Rate for Payer: MDX Hawaii PPO	$23.28

RBC Antigens 2

Facility

$53.00

Service Code	HCPCS 86905
Hospital Charge Code	12517897
Hospital Revenue Code	302
Min. Negotiated Rate	$45.05
Max. Negotiated Rate	$51.41
Rate for Payer: Cash Price	$34.45
Rate for Payer: Health Management Network Commercial	$45.05
Rate for Payer: Kaiser Permanente Commercial	$47.70
Rate for Payer: MDX Hawaii PPO	$51.41

RBC Antigens 2

Facility

$53.00

Service Code	HCPCS 86905
Hospital Charge Code	12517897
Hospital Revenue Code	302
Min. Negotiated Rate	$3.83
Max. Negotiated Rate	$51.41
Rate for Payer: AlohaCare Medicaid	$26.50
Rate for Payer: AlohaCare Medicare	$26.50
Rate for Payer: Cash Price	$34.45
Rate for Payer: Cash Price	$34.45
Rate for Payer: Devoted Health Medicare	$29.15
Rate for Payer: Hawaii Medical Service Association ABD	$5.28
Rate for Payer: Hawaii Medical Service Association Commercial	$4.79
Rate for Payer: Hawaii Medical Service Association Medicare	$26.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$5.54
Rate for Payer: Hawaii Western Management Group Commercial	$3.83
Rate for Payer: Health Management Network Commercial	$45.05
Rate for Payer: Humana Medicare	$26.50
Rate for Payer: Kaiser Permanente Commercial	$47.70
Rate for Payer: Kaiser Permanente Medicaid	$27.03
Rate for Payer: Kaiser Permanente Medicare	$26.50
Rate for Payer: MDX Hawaii PPO	$51.41
Rate for Payer: Ohana Health Plan Medicaid	$26.50
Rate for Payer: Ohana Health Plan Medicare	$26.50
Rate for Payer: UnitedHealthcare Medicaid	$5.28
Rate for Payer: UnitedHealthcare Medicare	$26.50
Rate for Payer: University Health Alliance Commercial	$9.88

RBC Antigens 3

Facility

$69.00

Service Code	HCPCS 86905
Hospital Charge Code	12517899
Hospital Revenue Code	302
Min. Negotiated Rate	$58.65
Max. Negotiated Rate	$66.93
Rate for Payer: Cash Price	$44.85
Rate for Payer: Health Management Network Commercial	$58.65
Rate for Payer: Kaiser Permanente Commercial	$62.10
Rate for Payer: MDX Hawaii PPO	$66.93

RBC Antigens 3

Facility

$69.00

Service Code	HCPCS 86905
Hospital Charge Code	12517899
Hospital Revenue Code	302
Min. Negotiated Rate	$3.83
Max. Negotiated Rate	$66.93
Rate for Payer: AlohaCare Medicaid	$34.50
Rate for Payer: AlohaCare Medicare	$34.50
Rate for Payer: Cash Price	$44.85
Rate for Payer: Cash Price	$44.85
Rate for Payer: Devoted Health Medicare	$37.95
Rate for Payer: Hawaii Medical Service Association ABD	$5.28
Rate for Payer: Hawaii Medical Service Association Commercial	$4.79
Rate for Payer: Hawaii Medical Service Association Medicare	$34.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$5.54
Rate for Payer: Hawaii Western Management Group Commercial	$3.83
Rate for Payer: Health Management Network Commercial	$58.65
Rate for Payer: Humana Medicare	$34.50
Rate for Payer: Kaiser Permanente Commercial	$62.10
Rate for Payer: Kaiser Permanente Medicaid	$35.19
Rate for Payer: Kaiser Permanente Medicare	$34.50
Rate for Payer: MDX Hawaii PPO	$66.93
Rate for Payer: Ohana Health Plan Medicaid	$34.50
Rate for Payer: Ohana Health Plan Medicare	$34.50
Rate for Payer: UnitedHealthcare Medicaid	$5.28
Rate for Payer: UnitedHealthcare Medicare	$34.50
Rate for Payer: University Health Alliance Commercial	$9.88

RBC Antigens 4

Facility

$93.00

Service Code	HCPCS 86905
Hospital Charge Code	12540273
Hospital Revenue Code	302
Min. Negotiated Rate	$3.83
Max. Negotiated Rate	$90.21
Rate for Payer: AlohaCare Medicaid	$46.50
Rate for Payer: AlohaCare Medicare	$46.50
Rate for Payer: Cash Price	$60.45
Rate for Payer: Cash Price	$60.45
Rate for Payer: Devoted Health Medicare	$51.15
Rate for Payer: Hawaii Medical Service Association ABD	$5.28
Rate for Payer: Hawaii Medical Service Association Commercial	$4.79
Rate for Payer: Hawaii Medical Service Association Medicare	$46.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$5.54
Rate for Payer: Hawaii Western Management Group Commercial	$3.83
Rate for Payer: Health Management Network Commercial	$79.05
Rate for Payer: Humana Medicare	$46.50
Rate for Payer: Kaiser Permanente Commercial	$83.70
Rate for Payer: Kaiser Permanente Medicaid	$47.43
Rate for Payer: Kaiser Permanente Medicare	$46.50
Rate for Payer: MDX Hawaii PPO	$90.21
Rate for Payer: Ohana Health Plan Medicaid	$46.50
Rate for Payer: Ohana Health Plan Medicare	$46.50
Rate for Payer: UnitedHealthcare Medicaid	$5.28
Rate for Payer: UnitedHealthcare Medicare	$46.50
Rate for Payer: University Health Alliance Commercial	$9.88

RBC Antigens 4

Facility

$93.00

Service Code	HCPCS 86905
Hospital Charge Code	12540273
Hospital Revenue Code	302
Min. Negotiated Rate	$79.05
Max. Negotiated Rate	$90.21
Rate for Payer: Cash Price	$60.45
Rate for Payer: Health Management Network Commercial	$79.05
Rate for Payer: Kaiser Permanente Commercial	$83.70
Rate for Payer: MDX Hawaii PPO	$90.21

RBC Antigens 5

Facility

$112.00

Service Code	HCPCS 86905
Hospital Charge Code	12539055
Hospital Revenue Code	302
Min. Negotiated Rate	$95.20
Max. Negotiated Rate	$108.64
Rate for Payer: Cash Price	$72.80
Rate for Payer: Health Management Network Commercial	$95.20
Rate for Payer: Kaiser Permanente Commercial	$100.80
Rate for Payer: MDX Hawaii PPO	$108.64

RBC Antigens 5

Facility

$112.00

Service Code	HCPCS 86905
Hospital Charge Code	12539055
Hospital Revenue Code	302
Min. Negotiated Rate	$3.83
Max. Negotiated Rate	$108.64
Rate for Payer: AlohaCare Medicaid	$56.00
Rate for Payer: AlohaCare Medicare	$56.00
Rate for Payer: Cash Price	$72.80
Rate for Payer: Cash Price	$72.80
Rate for Payer: Devoted Health Medicare	$61.60
Rate for Payer: Hawaii Medical Service Association ABD	$5.28
Rate for Payer: Hawaii Medical Service Association Commercial	$4.79
Rate for Payer: Hawaii Medical Service Association Medicare	$56.00
Rate for Payer: Hawaii Medical Service Association Non-ABD	$5.54
Rate for Payer: Hawaii Western Management Group Commercial	$3.83
Rate for Payer: Health Management Network Commercial	$95.20
Rate for Payer: Humana Medicare	$56.00
Rate for Payer: Kaiser Permanente Commercial	$100.80
Rate for Payer: Kaiser Permanente Medicaid	$57.12
Rate for Payer: Kaiser Permanente Medicare	$56.00
Rate for Payer: MDX Hawaii PPO	$108.64
Rate for Payer: Ohana Health Plan Medicaid	$56.00
Rate for Payer: Ohana Health Plan Medicare	$56.00
Rate for Payer: UnitedHealthcare Medicaid	$5.28
Rate for Payer: UnitedHealthcare Medicare	$56.00
Rate for Payer: University Health Alliance Commercial	$9.88

Know your out-of-pocket cost for care.

All Charges