Kahuku Medical Center

All Charges

Charge

Type

Setting

Price

OTHER PT/OT GOAL STATUS

Professional

Both

$0.01

Service Code	HCPCS G8991
Hospital Revenue Code	420
Min. Negotiated Rate	$0.01
Max. Negotiated Rate	$0.01
Rate for Payer: Cash Price	$0.01
Rate for Payer: Health Management Network Commercial	$0.01

OTHER PT/OT GOAL STATUS Occupational

Facility

$2.00

Service Code	HCPCS G8991 GO
Hospital Charge Code	426G89910
Hospital Revenue Code	430
Min. Negotiated Rate	$0.84
Max. Negotiated Rate	$1.94
Rate for Payer: AlohaCare Medicaid	$1.00
Rate for Payer: AlohaCare Medicare	$0.84
Rate for Payer: Cash Price	$1.30
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$1.84
Rate for Payer: Devoted Health Medicare	$0.84
Rate for Payer: Hawaii Medical Service Association Medicare	$0.84
Rate for Payer: Hawaii Western Management Group Commercial	$1.90
Rate for Payer: Health Management Network Commercial	$1.70
Rate for Payer: Humana Medicare	$0.84
Rate for Payer: Kaiser Permanente Commercial	$1.80
Rate for Payer: Kaiser Permanente Medicaid	$1.02
Rate for Payer: Kaiser Permanente Medicare	$0.84
Rate for Payer: MDX Hawaii PPO	$1.94
Rate for Payer: Ohana Health Plan Medicaid	$0.84
Rate for Payer: Ohana Health Plan Medicare	$0.84
Rate for Payer: UnitedHealthcare Medicare	$0.84
Rate for Payer: University Health Alliance Commercial	$1.46

OTHER PT/OT GOAL STATUS Occupational

Facility

$2.00

Service Code	HCPCS G8991 GO
Hospital Charge Code	426G89910
Hospital Revenue Code	430
Min. Negotiated Rate	$1.70
Max. Negotiated Rate	$1.94
Rate for Payer: Cash Price	$1.30
Rate for Payer: Health Management Network Commercial	$1.70
Rate for Payer: Kaiser Permanente Commercial	$1.80
Rate for Payer: MDX Hawaii PPO	$1.94

OTHER PT/OT GOAL STATUS Physical

Facility

$1.00

Service Code	HCPCS G8991 GP
Hospital Charge Code	432G89910
Hospital Revenue Code	420
Min. Negotiated Rate	$0.42
Max. Negotiated Rate	$0.97
Rate for Payer: AlohaCare Medicaid	$0.50
Rate for Payer: AlohaCare Medicare	$0.42
Rate for Payer: Cash Price	$0.65
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$0.92
Rate for Payer: Devoted Health Medicare	$0.42
Rate for Payer: Hawaii Medical Service Association Medicare	$0.42
Rate for Payer: Hawaii Western Management Group Commercial	$0.95
Rate for Payer: Health Management Network Commercial	$0.85
Rate for Payer: Humana Medicare	$0.42
Rate for Payer: Kaiser Permanente Commercial	$0.90
Rate for Payer: Kaiser Permanente Medicaid	$0.51
Rate for Payer: Kaiser Permanente Medicare	$0.42
Rate for Payer: MDX Hawaii PPO	$0.97
Rate for Payer: Ohana Health Plan Medicaid	$0.42
Rate for Payer: Ohana Health Plan Medicare	$0.42
Rate for Payer: UnitedHealthcare Medicare	$0.42
Rate for Payer: University Health Alliance Commercial	$0.73

OTHER PT/OT GOAL STATUS Physical

Facility

$1.00

Service Code	HCPCS G8991 GP
Hospital Charge Code	432G89910
Hospital Revenue Code	420
Min. Negotiated Rate	$0.85
Max. Negotiated Rate	$0.97
Rate for Payer: Cash Price	$0.65
Rate for Payer: Health Management Network Commercial	$0.85
Rate for Payer: Kaiser Permanente Commercial	$0.90
Rate for Payer: MDX Hawaii PPO	$0.97

OTHER RESPIRATORY SYSTEM DIAGNOSES WITH MCC

Facility

$20,454.83

Service Code	MSDRG 205
Min. Negotiated Rate	$20,454.83
Max. Negotiated Rate	$20,454.83
Rate for Payer: Hawaii Medical Service Association Commercial	$20,454.83

OTHER RESPIRATORY SYSTEM DIAGNOSES WITHOUT MCC

Facility

$17,634.29

Service Code	MSDRG 206
Min. Negotiated Rate	$17,634.29
Max. Negotiated Rate	$17,634.29
Rate for Payer: Hawaii Medical Service Association Commercial	$17,634.29

OTHER RESPIRATORY SYSTEM O.R. PROCEDURES WITH CC

Facility

$60,511.21

Service Code	MSDRG 167
Min. Negotiated Rate	$60,511.21
Max. Negotiated Rate	$60,511.21
Rate for Payer: Hawaii Medical Service Association Commercial	$60,511.21

OTHER RESPIRATORY SYSTEM O.R. PROCEDURES WITH MCC

Facility

$63,497.66

Service Code	MSDRG 166
Min. Negotiated Rate	$63,497.66
Max. Negotiated Rate	$63,497.66
Rate for Payer: Hawaii Medical Service Association Commercial	$63,497.66

OTHER RESPIRATORY SYSTEM O.R. PROCEDURES WITHOUT CC/MCC

Facility

$43,232.45

Service Code	MSDRG 168
Min. Negotiated Rate	$43,232.45
Max. Negotiated Rate	$43,232.45
Rate for Payer: Hawaii Medical Service Association Commercial	$43,232.45

OTHER SKIN, SUBCUTANEOUS TISSUE AND BREAST PROCEDURES WITH CC

Facility

$29,295.67

Service Code	MSDRG 580
Min. Negotiated Rate	$29,295.67
Max. Negotiated Rate	$29,295.67
Rate for Payer: Hawaii Medical Service Association Commercial	$29,295.67

OTHER SKIN, SUBCUTANEOUS TISSUE AND BREAST PROCEDURES WITH MCC

Facility

$46,811.45

Service Code	MSDRG 579
Min. Negotiated Rate	$46,811.45
Max. Negotiated Rate	$46,811.45
Rate for Payer: Hawaii Medical Service Association Commercial	$46,811.45

OTHER SKIN, SUBCUTANEOUS TISSUE AND BREAST PROCEDURES WITHOUT CC/MCC

Facility

$24,057.53

Service Code	MSDRG 581
Min. Negotiated Rate	$24,057.53
Max. Negotiated Rate	$24,057.53
Rate for Payer: Hawaii Medical Service Association Commercial	$24,057.53

OTHER VASCULAR PROCEDURES WITH CC

Facility

$67,550.70

Service Code	MSDRG 253
Min. Negotiated Rate	$67,550.70
Max. Negotiated Rate	$67,550.70
Rate for Payer: Hawaii Medical Service Association Commercial	$67,550.70

OTHER VASCULAR PROCEDURES WITH MCC

Facility

$71,911.87

Service Code	MSDRG 252
Min. Negotiated Rate	$71,911.87
Max. Negotiated Rate	$71,911.87
Rate for Payer: Hawaii Medical Service Association Commercial	$71,911.87

OTHER VASCULAR PROCEDURES WITHOUT CC/MCC

Facility

$48,826.12

Service Code	MSDRG 254
Min. Negotiated Rate	$48,826.12
Max. Negotiated Rate	$48,826.12
Rate for Payer: Hawaii Medical Service Association Commercial	$48,826.12

OT High Complex Units

Facility

$389.00

Service Code	HCPCS 97167 GO
Hospital Charge Code	426971670
Hospital Revenue Code	434
Min. Negotiated Rate	$107.85
Max. Negotiated Rate	$377.33
Rate for Payer: AlohaCare Medicaid	$194.50
Rate for Payer: AlohaCare Medicare	$163.38
Rate for Payer: Cash Price	$252.85
Rate for Payer: Cash Price	$252.85
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$357.88
Rate for Payer: Devoted Health Medicare	$163.38
Rate for Payer: Hawaii Medical Service Association Medicare	$163.38
Rate for Payer: Hawaii Western Management Group Commercial	$369.55
Rate for Payer: Health Management Network Commercial	$330.65
Rate for Payer: Humana Medicare	$163.38
Rate for Payer: Kaiser Permanente Commercial	$350.10
Rate for Payer: Kaiser Permanente Medicaid	$198.39
Rate for Payer: Kaiser Permanente Medicare	$163.38
Rate for Payer: MDX Hawaii PPO	$377.33
Rate for Payer: Ohana Health Plan Medicaid	$163.38
Rate for Payer: Ohana Health Plan Medicare	$163.38
Rate for Payer: UnitedHealthcare Medicaid	$107.85
Rate for Payer: UnitedHealthcare Medicare	$163.38
Rate for Payer: University Health Alliance Commercial	$283.54

OT High Complex Units

Facility

$389.00

Service Code	HCPCS 97167 GO
Hospital Charge Code	426971670
Hospital Revenue Code	434
Min. Negotiated Rate	$330.65
Max. Negotiated Rate	$377.33
Rate for Payer: Cash Price	$252.85
Rate for Payer: Health Management Network Commercial	$330.65
Rate for Payer: Kaiser Permanente Commercial	$350.10
Rate for Payer: MDX Hawaii PPO	$377.33

OTH RESP PROC, GROUP

Professional

Both

$121.00

Service Code	HCPCS G0239
Hospital Revenue Code	410
Min. Negotiated Rate	$14.72
Max. Negotiated Rate	$102.85
Rate for Payer: AlohaCare Medicaid	$14.72
Rate for Payer: AlohaCare Medicare	$16.14
Rate for Payer: Cash Price	$78.65
Rate for Payer: Cash Price	$78.65
Rate for Payer: Devoted Health Medicare	$16.14
Rate for Payer: Hawaii Medical Service Association Medicare	$16.14
Rate for Payer: Health Management Network Commercial	$102.85
Rate for Payer: Kaiser Permanente Commercial	$19.37
Rate for Payer: Kaiser Permanente Medicaid	$19.37
Rate for Payer: Kaiser Permanente Medicare	$19.37
Rate for Payer: Ohana Health Plan Medicaid	$14.72
Rate for Payer: Ohana Health Plan Medicare	$16.14
Rate for Payer: UnitedHealthcare Medicaid	$14.72
Rate for Payer: UnitedHealthcare Medicare	$16.14

OTH RESP PROC, INDIV

Professional

Both

$91.00

Service Code	HCPCS G0238
Hospital Revenue Code	410
Min. Negotiated Rate	$11.66
Max. Negotiated Rate	$77.35
Rate for Payer: AlohaCare Medicaid	$11.66
Rate for Payer: AlohaCare Medicare	$12.73
Rate for Payer: Cash Price	$59.15
Rate for Payer: Cash Price	$59.15
Rate for Payer: Devoted Health Medicare	$12.73
Rate for Payer: Hawaii Medical Service Association Medicare	$12.73
Rate for Payer: Health Management Network Commercial	$77.35
Rate for Payer: Kaiser Permanente Commercial	$15.28
Rate for Payer: Kaiser Permanente Medicaid	$15.28
Rate for Payer: Kaiser Permanente Medicare	$15.28
Rate for Payer: Ohana Health Plan Medicaid	$11.66
Rate for Payer: Ohana Health Plan Medicare	$12.73
Rate for Payer: UnitedHealthcare Medicaid	$11.66
Rate for Payer: UnitedHealthcare Medicare	$12.73

OTITIS MEDIA AND URI WITH MCC

Facility

$12,182.83

Service Code	MSDRG 152
Min. Negotiated Rate	$12,182.83
Max. Negotiated Rate	$12,182.83
Rate for Payer: Hawaii Medical Service Association Commercial	$12,182.83

OTITIS MEDIA AND URI WITHOUT MCC

Facility

$10,547.39

Service Code	MSDRG 153
Min. Negotiated Rate	$10,547.39
Max. Negotiated Rate	$10,547.39
Rate for Payer: Hawaii Medical Service Association Commercial	$10,547.39

OT Low Complex Units

Facility

$389.00

Service Code	HCPCS 97165 GO
Hospital Charge Code	426971650
Hospital Revenue Code	434
Min. Negotiated Rate	$107.85
Max. Negotiated Rate	$377.33
Rate for Payer: AlohaCare Medicaid	$194.50
Rate for Payer: AlohaCare Medicare	$163.38
Rate for Payer: Cash Price	$252.85
Rate for Payer: Cash Price	$252.85
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$357.88
Rate for Payer: Devoted Health Medicare	$163.38
Rate for Payer: Hawaii Medical Service Association Medicare	$163.38
Rate for Payer: Hawaii Western Management Group Commercial	$369.55
Rate for Payer: Health Management Network Commercial	$330.65
Rate for Payer: Humana Medicare	$163.38
Rate for Payer: Kaiser Permanente Commercial	$350.10
Rate for Payer: Kaiser Permanente Medicaid	$198.39
Rate for Payer: Kaiser Permanente Medicare	$163.38
Rate for Payer: MDX Hawaii PPO	$377.33
Rate for Payer: Ohana Health Plan Medicaid	$163.38
Rate for Payer: Ohana Health Plan Medicare	$163.38
Rate for Payer: UnitedHealthcare Medicaid	$107.85
Rate for Payer: UnitedHealthcare Medicare	$163.38
Rate for Payer: University Health Alliance Commercial	$283.54

OT Low Complex Units

Facility

$389.00

Service Code	HCPCS 97165 GO
Hospital Charge Code	426971650
Hospital Revenue Code	434
Min. Negotiated Rate	$330.65
Max. Negotiated Rate	$377.33
Rate for Payer: Cash Price	$252.85
Rate for Payer: Health Management Network Commercial	$330.65
Rate for Payer: Kaiser Permanente Commercial	$350.10
Rate for Payer: MDX Hawaii PPO	$377.33

OT Moderate Complex Units

Facility

$389.00

Service Code	HCPCS 97166 GO
Hospital Charge Code	426971660
Hospital Revenue Code	434
Min. Negotiated Rate	$107.85
Max. Negotiated Rate	$377.33
Rate for Payer: AlohaCare Medicaid	$194.50
Rate for Payer: AlohaCare Medicare	$163.38
Rate for Payer: Cash Price	$252.85
Rate for Payer: Cash Price	$252.85
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$357.88
Rate for Payer: Devoted Health Medicare	$163.38
Rate for Payer: Hawaii Medical Service Association Medicare	$163.38
Rate for Payer: Hawaii Western Management Group Commercial	$369.55
Rate for Payer: Health Management Network Commercial	$330.65
Rate for Payer: Humana Medicare	$163.38
Rate for Payer: Kaiser Permanente Commercial	$350.10
Rate for Payer: Kaiser Permanente Medicaid	$198.39
Rate for Payer: Kaiser Permanente Medicare	$163.38
Rate for Payer: MDX Hawaii PPO	$377.33
Rate for Payer: Ohana Health Plan Medicaid	$163.38
Rate for Payer: Ohana Health Plan Medicare	$163.38
Rate for Payer: UnitedHealthcare Medicaid	$107.85
Rate for Payer: UnitedHealthcare Medicare	$163.38
Rate for Payer: University Health Alliance Commercial	$283.54

Know your out-of-pocket cost for care.

All Charges