Kau Hospital

All Charges

Charge

Type

Setting

Price

HC OT OCCUPATIONAL THERAPY EVAL LOW COMPLEX 30 MINS

Facility

$490.00

Service Code	HCPCS 97165 GO
Hospital Charge Code	4349716501
Hospital Revenue Code	434
Min. Negotiated Rate	$107.85
Max. Negotiated Rate	$475.30
Rate for Payer: AlohaCare Medicaid	$245.00
Rate for Payer: AlohaCare Medicare	$151.90
Rate for Payer: Cash Price	$294.00
Rate for Payer: Cash Price	$294.00
Rate for Payer: Devoted Health Medicare	$166.60
Rate for Payer: Hawaii Medical Service Association Medicare	$151.90
Rate for Payer: Hawaii Western Management Group Commercial	$465.50
Rate for Payer: Health Management Network Commercial	$416.50
Rate for Payer: Humana Medicare	$151.90
Rate for Payer: Kaiser Permanente Commercial	$441.00
Rate for Payer: Kaiser Permanente Medicaid	$249.90
Rate for Payer: Kaiser Permanente Medicare	$151.90
Rate for Payer: MDX Hawaii PPO	$475.30
Rate for Payer: Ohana Health Plan Medicaid	$151.90
Rate for Payer: Ohana Health Plan Medicare	$151.90
Rate for Payer: UnitedHealthcare Medicaid	$107.85
Rate for Payer: UnitedHealthcare Medicare	$151.90
Rate for Payer: University Health Alliance Commercial	$357.16

HC OT OCCUPATIONAL THERAPY EVAL LOW COMPLEX 30 MINS

Facility

$490.00

Service Code	HCPCS 97165 GO
Hospital Charge Code	4349716501
Hospital Revenue Code	434
Min. Negotiated Rate	$416.50
Max. Negotiated Rate	$475.30
Rate for Payer: Cash Price	$294.00
Rate for Payer: Health Management Network Commercial	$416.50
Rate for Payer: Kaiser Permanente Commercial	$441.00
Rate for Payer: MDX Hawaii PPO	$475.30

HC OT OCCUPATIONAL THERAPY EVAL MOD COMPLEX 45 MINS

Facility

$490.00

Service Code	HCPCS 97166 GO
Hospital Charge Code	4349716601
Hospital Revenue Code	434
Min. Negotiated Rate	$416.50
Max. Negotiated Rate	$475.30
Rate for Payer: Cash Price	$294.00
Rate for Payer: Health Management Network Commercial	$416.50
Rate for Payer: Kaiser Permanente Commercial	$441.00
Rate for Payer: MDX Hawaii PPO	$475.30

HC OT OCCUPATIONAL THERAPY EVAL MOD COMPLEX 45 MINS

Facility

$490.00

Service Code	HCPCS 97166 GO
Hospital Charge Code	4349716601
Hospital Revenue Code	434
Min. Negotiated Rate	$107.85
Max. Negotiated Rate	$475.30
Rate for Payer: AlohaCare Medicaid	$245.00
Rate for Payer: AlohaCare Medicare	$151.90
Rate for Payer: Cash Price	$294.00
Rate for Payer: Cash Price	$294.00
Rate for Payer: Devoted Health Medicare	$166.60
Rate for Payer: Hawaii Medical Service Association Medicare	$151.90
Rate for Payer: Hawaii Western Management Group Commercial	$465.50
Rate for Payer: Health Management Network Commercial	$416.50
Rate for Payer: Humana Medicare	$151.90
Rate for Payer: Kaiser Permanente Commercial	$441.00
Rate for Payer: Kaiser Permanente Medicaid	$249.90
Rate for Payer: Kaiser Permanente Medicare	$151.90
Rate for Payer: MDX Hawaii PPO	$475.30
Rate for Payer: Ohana Health Plan Medicaid	$151.90
Rate for Payer: Ohana Health Plan Medicare	$151.90
Rate for Payer: UnitedHealthcare Medicaid	$107.85
Rate for Payer: UnitedHealthcare Medicare	$151.90
Rate for Payer: University Health Alliance Commercial	$357.16

HC OT ORTHOTIC MGMT AND TRAINING, EACH 15 MIN

Facility

$175.00

Service Code	HCPCS 97760 GO
Hospital Charge Code	4309776001
Hospital Revenue Code	730
Min. Negotiated Rate	$17.21
Max. Negotiated Rate	$169.75
Rate for Payer: AlohaCare Medicaid	$87.50
Rate for Payer: AlohaCare Medicare	$54.25
Rate for Payer: Cash Price	$105.00
Rate for Payer: Cash Price	$105.00
Rate for Payer: Devoted Health Medicare	$59.50
Rate for Payer: Hawaii Medical Service Association Medicare	$54.25
Rate for Payer: Hawaii Western Management Group Commercial	$166.25
Rate for Payer: Health Management Network Commercial	$148.75
Rate for Payer: Humana Medicare	$54.25
Rate for Payer: Kaiser Permanente Commercial	$157.50
Rate for Payer: Kaiser Permanente Medicaid	$89.25
Rate for Payer: Kaiser Permanente Medicare	$54.25
Rate for Payer: MDX Hawaii PPO	$169.75
Rate for Payer: Ohana Health Plan Medicaid	$54.25
Rate for Payer: Ohana Health Plan Medicare	$54.25
Rate for Payer: UnitedHealthcare Medicaid	$17.21
Rate for Payer: UnitedHealthcare Medicare	$54.25
Rate for Payer: University Health Alliance Commercial	$127.56

HC OT ORTHOTIC MGMT AND TRAINING, EACH 15 MIN

Facility

$175.00

Service Code	HCPCS 97760 GO
Hospital Charge Code	4309776001
Hospital Revenue Code	730
Min. Negotiated Rate	$148.75
Max. Negotiated Rate	$169.75
Rate for Payer: Cash Price	$105.00
Rate for Payer: Health Management Network Commercial	$148.75
Rate for Payer: Kaiser Permanente Commercial	$157.50
Rate for Payer: MDX Hawaii PPO	$169.75

HC OT ORTHOTICS/PROSTH MGMT &/TRAINJ SBSQ ENCTR 15 MIN

Facility

$262.00

Service Code	HCPCS 97763 GO
Hospital Charge Code	4309776301
Hospital Revenue Code	430
Min. Negotiated Rate	$222.70
Max. Negotiated Rate	$254.14
Rate for Payer: Cash Price	$157.20
Rate for Payer: Health Management Network Commercial	$222.70
Rate for Payer: Kaiser Permanente Commercial	$235.80
Rate for Payer: MDX Hawaii PPO	$254.14

HC OT ORTHOTICS/PROSTH MGMT &/TRAINJ SBSQ ENCTR 15 MIN

Facility

$262.00

Service Code	HCPCS 97763 GO
Hospital Charge Code	4309776301
Hospital Revenue Code	430
Min. Negotiated Rate	$57.47
Max. Negotiated Rate	$254.14
Rate for Payer: AlohaCare Medicaid	$131.00
Rate for Payer: AlohaCare Medicare	$81.22
Rate for Payer: Cash Price	$157.20
Rate for Payer: Cash Price	$157.20
Rate for Payer: Devoted Health Medicare	$89.08
Rate for Payer: Hawaii Medical Service Association Medicare	$81.22
Rate for Payer: Hawaii Western Management Group Commercial	$248.90
Rate for Payer: Health Management Network Commercial	$222.70
Rate for Payer: Humana Medicare	$81.22
Rate for Payer: Kaiser Permanente Commercial	$235.80
Rate for Payer: Kaiser Permanente Medicaid	$133.62
Rate for Payer: Kaiser Permanente Medicare	$81.22
Rate for Payer: MDX Hawaii PPO	$254.14
Rate for Payer: Ohana Health Plan Medicaid	$81.22
Rate for Payer: Ohana Health Plan Medicare	$81.22
Rate for Payer: UnitedHealthcare Medicaid	$57.47
Rate for Payer: UnitedHealthcare Medicare	$81.22
Rate for Payer: University Health Alliance Commercial	$190.97

HC OT SELF-CARE/HOME MGMT TRAINING EACH 15 MINUTES

Facility

$159.00

Service Code	HCPCS 97535 GO
Hospital Charge Code	4309753501
Hospital Revenue Code	430
Min. Negotiated Rate	$135.15
Max. Negotiated Rate	$154.23
Rate for Payer: Cash Price	$95.40
Rate for Payer: Health Management Network Commercial	$135.15
Rate for Payer: Kaiser Permanente Commercial	$143.10
Rate for Payer: MDX Hawaii PPO	$154.23

HC OT SELF-CARE/HOME MGMT TRAINING EACH 15 MINUTES

Facility

$159.00

Service Code	HCPCS 97535 GO
Hospital Charge Code	4309753501
Hospital Revenue Code	430
Min. Negotiated Rate	$19.20
Max. Negotiated Rate	$154.23
Rate for Payer: AlohaCare Medicaid	$79.50
Rate for Payer: AlohaCare Medicare	$49.29
Rate for Payer: Cash Price	$95.40
Rate for Payer: Cash Price	$95.40
Rate for Payer: Devoted Health Medicare	$54.06
Rate for Payer: Hawaii Medical Service Association Medicare	$49.29
Rate for Payer: Hawaii Western Management Group Commercial	$151.05
Rate for Payer: Health Management Network Commercial	$135.15
Rate for Payer: Humana Medicare	$49.29
Rate for Payer: Kaiser Permanente Commercial	$143.10
Rate for Payer: Kaiser Permanente Medicaid	$81.09
Rate for Payer: Kaiser Permanente Medicare	$49.29
Rate for Payer: MDX Hawaii PPO	$154.23
Rate for Payer: Ohana Health Plan Medicaid	$49.29
Rate for Payer: Ohana Health Plan Medicare	$49.29
Rate for Payer: UnitedHealthcare Medicaid	$19.20
Rate for Payer: UnitedHealthcare Medicare	$49.29
Rate for Payer: University Health Alliance Commercial	$115.90

HC OT THERAPEUT ACTVITY DIRECT PT CONTACT EACH 15 MIN

Facility

$181.00

Service Code	HCPCS 97530 GO
Hospital Charge Code	4309753001
Hospital Revenue Code	430
Min. Negotiated Rate	$153.85
Max. Negotiated Rate	$175.57
Rate for Payer: Cash Price	$108.60
Rate for Payer: Health Management Network Commercial	$153.85
Rate for Payer: Kaiser Permanente Commercial	$162.90
Rate for Payer: MDX Hawaii PPO	$175.57

HC OT THERAPEUT ACTVITY DIRECT PT CONTACT EACH 15 MIN

Facility

$181.00

Service Code	HCPCS 97530 GO
Hospital Charge Code	4309753001
Hospital Revenue Code	430
Min. Negotiated Rate	$18.32
Max. Negotiated Rate	$175.57
Rate for Payer: AlohaCare Medicaid	$90.50
Rate for Payer: AlohaCare Medicare	$56.11
Rate for Payer: Cash Price	$108.60
Rate for Payer: Cash Price	$108.60
Rate for Payer: Devoted Health Medicare	$61.54
Rate for Payer: Hawaii Medical Service Association Medicare	$56.11
Rate for Payer: Hawaii Western Management Group Commercial	$171.95
Rate for Payer: Health Management Network Commercial	$153.85
Rate for Payer: Humana Medicare	$56.11
Rate for Payer: Kaiser Permanente Commercial	$162.90
Rate for Payer: Kaiser Permanente Medicaid	$92.31
Rate for Payer: Kaiser Permanente Medicare	$56.11
Rate for Payer: MDX Hawaii PPO	$175.57
Rate for Payer: Ohana Health Plan Medicaid	$56.11
Rate for Payer: Ohana Health Plan Medicare	$56.11
Rate for Payer: UnitedHealthcare Medicaid	$18.32
Rate for Payer: UnitedHealthcare Medicare	$56.11
Rate for Payer: University Health Alliance Commercial	$131.93

HC OT THERAPEUTIC EXERCISES

Facility

$140.00

Service Code	HCPCS 97110 GO
Hospital Charge Code	4309711001
Hospital Revenue Code	430
Min. Negotiated Rate	$17.65
Max. Negotiated Rate	$135.80
Rate for Payer: AlohaCare Medicaid	$70.00
Rate for Payer: AlohaCare Medicare	$43.40
Rate for Payer: Cash Price	$84.00
Rate for Payer: Cash Price	$84.00
Rate for Payer: Devoted Health Medicare	$47.60
Rate for Payer: Hawaii Medical Service Association Medicare	$43.40
Rate for Payer: Hawaii Western Management Group Commercial	$133.00
Rate for Payer: Health Management Network Commercial	$119.00
Rate for Payer: Humana Medicare	$43.40
Rate for Payer: Kaiser Permanente Commercial	$126.00
Rate for Payer: Kaiser Permanente Medicaid	$71.40
Rate for Payer: Kaiser Permanente Medicare	$43.40
Rate for Payer: MDX Hawaii PPO	$135.80
Rate for Payer: Ohana Health Plan Medicaid	$43.40
Rate for Payer: Ohana Health Plan Medicare	$43.40
Rate for Payer: UnitedHealthcare Medicaid	$17.65
Rate for Payer: UnitedHealthcare Medicare	$43.40
Rate for Payer: University Health Alliance Commercial	$102.05

HC OT THERAPEUTIC EXERCISES

Facility

$140.00

Service Code	HCPCS 97110 GO
Hospital Charge Code	4309711001
Hospital Revenue Code	430
Min. Negotiated Rate	$119.00
Max. Negotiated Rate	$135.80
Rate for Payer: Cash Price	$84.00
Rate for Payer: Health Management Network Commercial	$119.00
Rate for Payer: Kaiser Permanente Commercial	$126.00
Rate for Payer: MDX Hawaii PPO	$135.80

HC OVA AND PARASITES SMEARS - OVA AND PARASITE EXAMINATION

Facility

$75.00

Service Code	HCPCS 87177
Hospital Charge Code	3068717701
Hospital Revenue Code	306
Min. Negotiated Rate	$63.75
Max. Negotiated Rate	$72.75
Rate for Payer: Cash Price	$45.00
Rate for Payer: Health Management Network Commercial	$63.75
Rate for Payer: Kaiser Permanente Commercial	$67.50
Rate for Payer: MDX Hawaii PPO	$72.75

HC OVA AND PARASITES SMEARS - OVA AND PARASITE EXAMINATION

Facility

$75.00

Service Code	HCPCS 87177
Hospital Charge Code	3068717701
Hospital Revenue Code	306
Min. Negotiated Rate	$8.90
Max. Negotiated Rate	$72.75
Rate for Payer: AlohaCare Medicaid	$37.50
Rate for Payer: AlohaCare Medicare	$23.25
Rate for Payer: Cash Price	$45.00
Rate for Payer: Cash Price	$45.00
Rate for Payer: Devoted Health Medicare	$25.50
Rate for Payer: Hawaii Medical Service Association ABD	$12.30
Rate for Payer: Hawaii Medical Service Association Commercial	$11.12
Rate for Payer: Hawaii Medical Service Association Medicare	$23.25
Rate for Payer: Hawaii Medical Service Association Non-ABD	$12.92
Rate for Payer: Hawaii Western Management Group Commercial	$8.90
Rate for Payer: Health Management Network Commercial	$63.75
Rate for Payer: Humana Medicare	$23.25
Rate for Payer: Kaiser Permanente Commercial	$67.50
Rate for Payer: Kaiser Permanente Medicaid	$38.25
Rate for Payer: Kaiser Permanente Medicare	$23.25
Rate for Payer: MDX Hawaii PPO	$72.75
Rate for Payer: Ohana Health Plan Medicaid	$23.25
Rate for Payer: Ohana Health Plan Medicare	$23.25
Rate for Payer: UnitedHealthcare Medicaid	$12.30
Rate for Payer: UnitedHealthcare Medicare	$23.25
Rate for Payer: University Health Alliance Commercial	$23.00

HC OXYGEN HOURLY

Facility

$17.00

Hospital Charge Code	2700000026
Hospital Revenue Code	270
Min. Negotiated Rate	$5.27
Max. Negotiated Rate	$16.49
Rate for Payer: AlohaCare Medicaid	$8.50
Rate for Payer: AlohaCare Medicare	$5.27
Rate for Payer: Cash Price	$10.20
Rate for Payer: Devoted Health Medicare	$5.78
Rate for Payer: Hawaii Medical Service Association Medicare	$5.27
Rate for Payer: Hawaii Western Management Group Commercial	$16.15
Rate for Payer: Health Management Network Commercial	$14.45
Rate for Payer: Humana Medicare	$5.27
Rate for Payer: Kaiser Permanente Commercial	$15.30
Rate for Payer: Kaiser Permanente Medicaid	$8.67
Rate for Payer: Kaiser Permanente Medicare	$5.27
Rate for Payer: MDX Hawaii PPO	$16.49
Rate for Payer: Ohana Health Plan Medicaid	$5.27
Rate for Payer: Ohana Health Plan Medicare	$5.27
Rate for Payer: UnitedHealthcare Medicare	$5.27
Rate for Payer: University Health Alliance Commercial	$12.39

HC OXYGEN HOURLY

Facility

$17.00

Hospital Charge Code	2700000026
Hospital Revenue Code	270
Min. Negotiated Rate	$14.45
Max. Negotiated Rate	$16.49
Rate for Payer: Cash Price	$10.20
Rate for Payer: Health Management Network Commercial	$14.45
Rate for Payer: Kaiser Permanente Commercial	$15.30
Rate for Payer: MDX Hawaii PPO	$16.49

HC PBB CLOSED RX CARPAL FX

Facility

$935.00

Service Code	HCPCS 25630
Hospital Charge Code	76125630PB
Hospital Revenue Code	761
Min. Negotiated Rate	$794.75
Max. Negotiated Rate	$906.95
Rate for Payer: Cash Price	$561.00
Rate for Payer: Health Management Network Commercial	$794.75
Rate for Payer: Kaiser Permanente Commercial	$841.50
Rate for Payer: MDX Hawaii PPO	$906.95

HC PBB CLOSED RX CARPAL FX

Facility

$935.00

Service Code	HCPCS 25630
Hospital Charge Code	76125630PB
Hospital Revenue Code	761
Min. Negotiated Rate	$148.52
Max. Negotiated Rate	$906.95
Rate for Payer: AlohaCare Medicaid	$467.50
Rate for Payer: AlohaCare Medicare	$289.85
Rate for Payer: Cash Price	$561.00
Rate for Payer: Cash Price	$561.00
Rate for Payer: Devoted Health Medicare	$317.90
Rate for Payer: Hawaii Medical Service Association Commercial	$315.01
Rate for Payer: Hawaii Medical Service Association Medicare	$289.85
Rate for Payer: Hawaii Western Management Group Commercial	$888.25
Rate for Payer: Health Management Network Commercial	$794.75
Rate for Payer: Humana Medicare	$289.85
Rate for Payer: Kaiser Permanente Commercial	$841.50
Rate for Payer: Kaiser Permanente Medicaid	$476.85
Rate for Payer: Kaiser Permanente Medicare	$289.85
Rate for Payer: MDX Hawaii PPO	$906.95
Rate for Payer: Ohana Health Plan Medicaid	$289.85
Rate for Payer: Ohana Health Plan Medicare	$289.85
Rate for Payer: UnitedHealthcare Medicaid	$148.52
Rate for Payer: UnitedHealthcare Medicare	$289.85
Rate for Payer: University Health Alliance Commercial	$681.52

HC PBB CLOSED RX MANDIBLE FX+DENTAL FIX

Facility

$5,772.00

Service Code	HCPCS 21453
Hospital Charge Code	76121453PB
Hospital Revenue Code	761
Min. Negotiated Rate	$521.33
Max. Negotiated Rate	$7,560.06
Rate for Payer: AlohaCare Medicaid	$2,886.00
Rate for Payer: AlohaCare Medicare	$1,789.32
Rate for Payer: Cash Price	$3,463.20
Rate for Payer: Cash Price	$3,463.20
Rate for Payer: Cash Price	$3,463.20
Rate for Payer: Devoted Health Medicare	$1,962.48
Rate for Payer: Hawaii Medical Service Association Commercial	$7,560.06
Rate for Payer: Hawaii Medical Service Association Medicare	$1,789.32
Rate for Payer: Hawaii Western Management Group Commercial	$5,483.40
Rate for Payer: Health Management Network Commercial	$4,906.20
Rate for Payer: Humana Medicare	$1,789.32
Rate for Payer: Kaiser Permanente Commercial	$5,194.80
Rate for Payer: Kaiser Permanente Medicaid	$2,943.72
Rate for Payer: Kaiser Permanente Medicare	$1,789.32
Rate for Payer: MDX Hawaii PPO	$5,598.84
Rate for Payer: Ohana Health Plan Medicaid	$1,789.32
Rate for Payer: Ohana Health Plan Medicare	$1,789.32
Rate for Payer: UnitedHealthcare Medicaid	$521.33
Rate for Payer: UnitedHealthcare Medicare	$1,789.32
Rate for Payer: University Health Alliance Commercial	$6,743.44

HC PBB CLOSED RX MANDIBLE FX+DENTAL FIX

Facility

$5,772.00

Service Code	HCPCS 21453
Hospital Charge Code	76121453PB
Hospital Revenue Code	761
Min. Negotiated Rate	$4,906.20
Max. Negotiated Rate	$5,598.84
Rate for Payer: Cash Price	$3,463.20
Rate for Payer: Health Management Network Commercial	$4,906.20
Rate for Payer: Kaiser Permanente Commercial	$5,194.80
Rate for Payer: MDX Hawaii PPO	$5,598.84

HC PBB CLOSED RX NASAL SEPTAL FRACTURE

Facility

$12,906.00

Service Code	HCPCS 21337
Hospital Charge Code	76121337PB
Hospital Revenue Code	761
Min. Negotiated Rate	$456.03
Max. Negotiated Rate	$12,518.82
Rate for Payer: AlohaCare Medicaid	$6,453.00
Rate for Payer: AlohaCare Medicare	$4,000.86
Rate for Payer: Cash Price	$7,743.60
Rate for Payer: Cash Price	$7,743.60
Rate for Payer: Cash Price	$7,743.60
Rate for Payer: Devoted Health Medicare	$4,388.04
Rate for Payer: Hawaii Medical Service Association Commercial	$4,234.09
Rate for Payer: Hawaii Medical Service Association Medicare	$4,000.86
Rate for Payer: Hawaii Western Management Group Commercial	$12,260.70
Rate for Payer: Health Management Network Commercial	$10,970.10
Rate for Payer: Humana Medicare	$4,000.86
Rate for Payer: Kaiser Permanente Commercial	$11,615.40
Rate for Payer: Kaiser Permanente Medicaid	$6,582.06
Rate for Payer: Kaiser Permanente Medicare	$4,000.86
Rate for Payer: MDX Hawaii PPO	$12,518.82
Rate for Payer: Ohana Health Plan Medicaid	$4,000.86
Rate for Payer: Ohana Health Plan Medicare	$4,000.86
Rate for Payer: UnitedHealthcare Medicaid	$456.03
Rate for Payer: UnitedHealthcare Medicare	$4,000.86
Rate for Payer: University Health Alliance Commercial	$5,160.40

HC PBB CLOSED RX NASAL SEPTAL FRACTURE

Facility

$12,906.00

Service Code	HCPCS 21337
Hospital Charge Code	76121337PB
Hospital Revenue Code	761
Min. Negotiated Rate	$10,970.10
Max. Negotiated Rate	$12,518.82
Rate for Payer: Cash Price	$7,743.60
Rate for Payer: Health Management Network Commercial	$10,970.10
Rate for Payer: Kaiser Permanente Commercial	$11,615.40
Rate for Payer: MDX Hawaii PPO	$12,518.82

HC PBB CLOSED RX PROX HUMERUS FRACTURE

Facility

$955.00

Service Code	HCPCS 23600
Hospital Charge Code	76123600PB
Hospital Revenue Code	761
Min. Negotiated Rate	$811.75
Max. Negotiated Rate	$926.35
Rate for Payer: Cash Price	$573.00
Rate for Payer: Health Management Network Commercial	$811.75
Rate for Payer: Kaiser Permanente Commercial	$859.50
Rate for Payer: MDX Hawaii PPO	$926.35

Know your out-of-pocket cost for care.

All Charges