Samuel Mahelona Memorial Hospital

All Charges

Charge

Type

Setting

Price

Transfuse Platelet Product

Facility

$2,059.00

Service Code	HCPCS 36430
Hospital Charge Code	7894719
Hospital Revenue Code	391
Min. Negotiated Rate	$33.38
Max. Negotiated Rate	$1,997.23
Rate for Payer: AlohaCare Medicaid	$1,029.50
Rate for Payer: AlohaCare Medicare	$1,029.50
Rate for Payer: Cash Price	$1,338.35
Rate for Payer: Cash Price	$1,338.35
Rate for Payer: Devoted Health Medicare	$1,132.45
Rate for Payer: Hawaii Medical Service Association Commercial	$563.41
Rate for Payer: Hawaii Medical Service Association Medicare	$1,029.50
Rate for Payer: Hawaii Western Management Group Commercial	$1,956.05
Rate for Payer: Health Management Network Commercial	$1,750.15
Rate for Payer: Humana Medicare	$1,029.50
Rate for Payer: Kaiser Permanente Commercial	$1,853.10
Rate for Payer: Kaiser Permanente Medicaid	$1,050.09
Rate for Payer: Kaiser Permanente Medicare	$1,029.50
Rate for Payer: MDX Hawaii PPO	$1,997.23
Rate for Payer: Ohana Health Plan Medicaid	$1,029.50
Rate for Payer: Ohana Health Plan Medicare	$1,029.50
Rate for Payer: UnitedHealthcare Medicaid	$33.38
Rate for Payer: UnitedHealthcare Medicare	$1,029.50
Rate for Payer: University Health Alliance Commercial	$1,153.04

Transfuse Platelet Product

Facility

$2,059.00

Service Code	HCPCS 36430
Hospital Charge Code	7894719
Hospital Revenue Code	391
Min. Negotiated Rate	$1,750.15
Max. Negotiated Rate	$1,997.23
Rate for Payer: Cash Price	$1,338.35
Rate for Payer: Health Management Network Commercial	$1,750.15
Rate for Payer: Kaiser Permanente Commercial	$1,853.10
Rate for Payer: MDX Hawaii PPO	$1,997.23

Transfuse Red Blood Cells

Facility

$2,059.00

Service Code	HCPCS 36430
Hospital Charge Code	8199385
Hospital Revenue Code	391
Min. Negotiated Rate	$1,750.15
Max. Negotiated Rate	$1,997.23
Rate for Payer: Cash Price	$1,338.35
Rate for Payer: Health Management Network Commercial	$1,750.15
Rate for Payer: Kaiser Permanente Commercial	$1,853.10
Rate for Payer: MDX Hawaii PPO	$1,997.23

Transfuse Red Blood Cells

Facility

$2,059.00

Service Code	HCPCS 36430
Hospital Charge Code	8199385
Hospital Revenue Code	391
Min. Negotiated Rate	$33.38
Max. Negotiated Rate	$1,997.23
Rate for Payer: AlohaCare Medicaid	$1,029.50
Rate for Payer: AlohaCare Medicare	$1,029.50
Rate for Payer: Cash Price	$1,338.35
Rate for Payer: Cash Price	$1,338.35
Rate for Payer: Devoted Health Medicare	$1,132.45
Rate for Payer: Hawaii Medical Service Association Commercial	$563.41
Rate for Payer: Hawaii Medical Service Association Medicare	$1,029.50
Rate for Payer: Hawaii Western Management Group Commercial	$1,956.05
Rate for Payer: Health Management Network Commercial	$1,750.15
Rate for Payer: Humana Medicare	$1,029.50
Rate for Payer: Kaiser Permanente Commercial	$1,853.10
Rate for Payer: Kaiser Permanente Medicaid	$1,050.09
Rate for Payer: Kaiser Permanente Medicare	$1,029.50
Rate for Payer: MDX Hawaii PPO	$1,997.23
Rate for Payer: Ohana Health Plan Medicaid	$1,029.50
Rate for Payer: Ohana Health Plan Medicare	$1,029.50
Rate for Payer: UnitedHealthcare Medicaid	$33.38
Rate for Payer: UnitedHealthcare Medicare	$1,029.50
Rate for Payer: University Health Alliance Commercial	$1,153.04

Transfuse Red Blood Cells Leukoreduced

Facility

$2,059.00

Service Code	HCPCS 36430
Hospital Charge Code	7894724
Hospital Revenue Code	391
Min. Negotiated Rate	$1,750.15
Max. Negotiated Rate	$1,997.23
Rate for Payer: Cash Price	$1,338.35
Rate for Payer: Health Management Network Commercial	$1,750.15
Rate for Payer: Kaiser Permanente Commercial	$1,853.10
Rate for Payer: MDX Hawaii PPO	$1,997.23

Transfuse Red Blood Cells Leukoreduced

Facility

$2,059.00

Service Code	HCPCS 36430
Hospital Charge Code	7894720
Hospital Revenue Code	391
Min. Negotiated Rate	$1,750.15
Max. Negotiated Rate	$1,997.23
Rate for Payer: Cash Price	$1,338.35
Rate for Payer: Health Management Network Commercial	$1,750.15
Rate for Payer: Kaiser Permanente Commercial	$1,853.10
Rate for Payer: MDX Hawaii PPO	$1,997.23

Transfuse Red Blood Cells Leukoreduced

Facility

$2,059.00

Service Code	HCPCS 36430
Hospital Charge Code	7894724
Hospital Revenue Code	391
Min. Negotiated Rate	$33.38
Max. Negotiated Rate	$1,997.23
Rate for Payer: AlohaCare Medicaid	$1,029.50
Rate for Payer: AlohaCare Medicare	$1,029.50
Rate for Payer: Cash Price	$1,338.35
Rate for Payer: Cash Price	$1,338.35
Rate for Payer: Devoted Health Medicare	$1,132.45
Rate for Payer: Hawaii Medical Service Association Commercial	$563.41
Rate for Payer: Hawaii Medical Service Association Medicare	$1,029.50
Rate for Payer: Hawaii Western Management Group Commercial	$1,956.05
Rate for Payer: Health Management Network Commercial	$1,750.15
Rate for Payer: Humana Medicare	$1,029.50
Rate for Payer: Kaiser Permanente Commercial	$1,853.10
Rate for Payer: Kaiser Permanente Medicaid	$1,050.09
Rate for Payer: Kaiser Permanente Medicare	$1,029.50
Rate for Payer: MDX Hawaii PPO	$1,997.23
Rate for Payer: Ohana Health Plan Medicaid	$1,029.50
Rate for Payer: Ohana Health Plan Medicare	$1,029.50
Rate for Payer: UnitedHealthcare Medicaid	$33.38
Rate for Payer: UnitedHealthcare Medicare	$1,029.50
Rate for Payer: University Health Alliance Commercial	$1,153.04

Transfuse Red Blood Cells Leukoreduced

Facility

$2,059.00

Service Code	HCPCS 36430
Hospital Charge Code	7894720
Hospital Revenue Code	391
Min. Negotiated Rate	$33.38
Max. Negotiated Rate	$1,997.23
Rate for Payer: AlohaCare Medicaid	$1,029.50
Rate for Payer: AlohaCare Medicare	$1,029.50
Rate for Payer: Cash Price	$1,338.35
Rate for Payer: Cash Price	$1,338.35
Rate for Payer: Devoted Health Medicare	$1,132.45
Rate for Payer: Hawaii Medical Service Association Commercial	$563.41
Rate for Payer: Hawaii Medical Service Association Medicare	$1,029.50
Rate for Payer: Hawaii Western Management Group Commercial	$1,956.05
Rate for Payer: Health Management Network Commercial	$1,750.15
Rate for Payer: Humana Medicare	$1,029.50
Rate for Payer: Kaiser Permanente Commercial	$1,853.10
Rate for Payer: Kaiser Permanente Medicaid	$1,050.09
Rate for Payer: Kaiser Permanente Medicare	$1,029.50
Rate for Payer: MDX Hawaii PPO	$1,997.23
Rate for Payer: Ohana Health Plan Medicaid	$1,029.50
Rate for Payer: Ohana Health Plan Medicare	$1,029.50
Rate for Payer: UnitedHealthcare Medicaid	$33.38
Rate for Payer: UnitedHealthcare Medicare	$1,029.50
Rate for Payer: University Health Alliance Commercial	$1,153.04

TRANSIENT ISCHEMIA WITHOUT THROMBOLYTIC

Facility

$17,468.37

Service Code	MSDRG 069
Min. Negotiated Rate	$17,468.37
Max. Negotiated Rate	$17,468.37
Rate for Payer: Hawaii Medical Service Association Commercial	$17,468.37

TRANSURETHRAL PROCEDURES WITH CC

Facility

$21,165.89

Service Code	MSDRG 669
Min. Negotiated Rate	$21,165.89
Max. Negotiated Rate	$21,165.89
Rate for Payer: Hawaii Medical Service Association Commercial	$21,165.89

TRANSURETHRAL PROCEDURES WITH MCC

Facility

$21,165.89

Service Code	MSDRG 668
Min. Negotiated Rate	$21,165.89
Max. Negotiated Rate	$21,165.89
Rate for Payer: Hawaii Medical Service Association Commercial	$21,165.89

TRANSURETHRAL PROCEDURES WITHOUT CC/MCC

Facility

$18,771.98

Service Code	MSDRG 670
Min. Negotiated Rate	$18,771.98
Max. Negotiated Rate	$18,771.98
Rate for Payer: Hawaii Medical Service Association Commercial	$18,771.98

TRANSURETHRAL PROSTATECTOMY WITH CC/MCC

Facility

$17,681.69

Service Code	MSDRG 713
Min. Negotiated Rate	$17,681.69
Max. Negotiated Rate	$17,681.69
Rate for Payer: Hawaii Medical Service Association Commercial	$17,681.69

TRANSURETHRAL PROSTATECTOMY WITHOUT CC/MCC

Facility

$14,007.88

Service Code	MSDRG 714
Min. Negotiated Rate	$14,007.88
Max. Negotiated Rate	$14,007.88
Rate for Payer: Hawaii Medical Service Association Commercial	$14,007.88

TRAUMATIC INJURY WITH MCC

Facility

$14,861.15

Service Code	MSDRG 913
Min. Negotiated Rate	$14,861.15
Max. Negotiated Rate	$14,861.15
Rate for Payer: Hawaii Medical Service Association Commercial	$14,861.15

TRAUMATIC INJURY WITHOUT MCC

Facility

$14,861.15

Service Code	MSDRG 914
Min. Negotiated Rate	$14,861.15
Max. Negotiated Rate	$14,861.15
Rate for Payer: Hawaii Medical Service Association Commercial	$14,861.15

TRAUMATIC STUPOR AND COMA <1 HOUR WITH CC

Facility

$16,709.91

Service Code	MSDRG 086
Min. Negotiated Rate	$16,709.91
Max. Negotiated Rate	$16,709.91
Rate for Payer: Hawaii Medical Service Association Commercial	$16,709.91

TRAUMATIC STUPOR AND COMA >1 HOUR WITH CC

Facility

$37,757.29

Service Code	MSDRG 083
Min. Negotiated Rate	$37,757.29
Max. Negotiated Rate	$37,757.29
Rate for Payer: Hawaii Medical Service Association Commercial	$37,757.29

TRAUMATIC STUPOR AND COMA <1 HOUR WITH MCC

Facility

$58,235.81

Service Code	MSDRG 085
Min. Negotiated Rate	$58,235.81
Max. Negotiated Rate	$58,235.81
Rate for Payer: Hawaii Medical Service Association Commercial	$58,235.81

TRAUMATIC STUPOR AND COMA >1 HOUR WITH MCC

Facility

$37,757.29

Service Code	MSDRG 082
Min. Negotiated Rate	$37,757.29
Max. Negotiated Rate	$37,757.29
Rate for Payer: Hawaii Medical Service Association Commercial	$37,757.29

TRAUMATIC STUPOR AND COMA <1 HOUR WITHOUT CC/MCC

Facility

$15,216.68

Service Code	MSDRG 087
Min. Negotiated Rate	$15,216.68
Max. Negotiated Rate	$15,216.68
Rate for Payer: Hawaii Medical Service Association Commercial	$15,216.68

TRAUMATIC STUPOR AND COMA >1 HOUR WITHOUT CC/MCC

Facility

$37,757.29

Service Code	MSDRG 084
Min. Negotiated Rate	$37,757.29
Max. Negotiated Rate	$37,757.29
Rate for Payer: Hawaii Medical Service Association Commercial	$37,757.29

TRAUMA TO THE SKIN, SUBCUTANEOUS TISSUE AND BREAST WITH MCC

Facility

$17,918.71

Service Code	MSDRG 604
Min. Negotiated Rate	$17,918.71
Max. Negotiated Rate	$17,918.71
Rate for Payer: Hawaii Medical Service Association Commercial	$17,918.71

TRAUMA TO THE SKIN, SUBCUTANEOUS TISSUE AND BREAST WITHOUT MCC

Facility

$14,718.94

Service Code	MSDRG 605
Min. Negotiated Rate	$14,718.94
Max. Negotiated Rate	$14,718.94
Rate for Payer: Hawaii Medical Service Association Commercial	$14,718.94

TRAY 20G 10CM POWERGLIDE

Facility

$424.00

Service Code	HCPCS C1751
Hospital Charge Code	8266278
Hospital Revenue Code	272
Min. Negotiated Rate	$360.40
Max. Negotiated Rate	$411.28
Rate for Payer: Cash Price	$275.60
Rate for Payer: Health Management Network Commercial	$360.40
Rate for Payer: Kaiser Permanente Commercial	$381.60
Rate for Payer: MDX Hawaii PPO	$411.28

Know your out-of-pocket cost for care.

All Charges