Leahi Hospital

All Charges

Charge

Type

Setting

Price

Elec stim stage iii/iv w

Facility

$106.00

Service Code	HCPCS G0281 GP
Hospital Charge Code	PTG0281
Hospital Revenue Code	420
Min. Negotiated Rate	$90.10
Max. Negotiated Rate	$102.82
Rate for Payer: Cash Price	$68.90
Rate for Payer: Health Management Network Commercial	$90.10
Rate for Payer: Kaiser Permanente Commercial	$95.40
Rate for Payer: MDX Hawaii PPO	$102.82

ENDOCRINE DISORDERS WITH CC

Facility

$19,388.24

Service Code	MSDRG 644
Min. Negotiated Rate	$10,537.56
Max. Negotiated Rate	$19,388.24
Rate for Payer: AlohaCare Medicare	$10,537.56
Rate for Payer: Hawaii Medical Service Association Commercial	$19,388.24
Rate for Payer: Hawaii Medical Service Association Medicare	$10,537.56
Rate for Payer: Humana Medicare	$10,537.56
Rate for Payer: Kaiser Permanente Medicare	$10,537.56
Rate for Payer: Ohana Health Plan Medicare	$10,537.56
Rate for Payer: UnitedHealthcare Medicare	$10,537.56

ENDOCRINE DISORDERS WITH MCC

Facility

$19,388.24

Service Code	MSDRG 643
Min. Negotiated Rate	$16,658.74
Max. Negotiated Rate	$19,388.24
Rate for Payer: AlohaCare Medicare	$16,658.74
Rate for Payer: Hawaii Medical Service Association Commercial	$19,388.24
Rate for Payer: Hawaii Medical Service Association Medicare	$16,658.74
Rate for Payer: Humana Medicare	$16,658.74
Rate for Payer: Kaiser Permanente Medicare	$16,658.74
Rate for Payer: Ohana Health Plan Medicare	$16,658.74
Rate for Payer: UnitedHealthcare Medicare	$16,658.74

ENDOCRINE DISORDERS WITHOUT CC/MCC

Facility

$16,781.02

Service Code	MSDRG 645
Min. Negotiated Rate	$8,007.70
Max. Negotiated Rate	$16,781.02
Rate for Payer: AlohaCare Medicare	$8,007.70
Rate for Payer: Hawaii Medical Service Association Commercial	$16,781.02
Rate for Payer: Hawaii Medical Service Association Medicare	$8,007.70
Rate for Payer: Humana Medicare	$8,007.70
Rate for Payer: Kaiser Permanente Medicare	$8,007.70
Rate for Payer: Ohana Health Plan Medicare	$8,007.70
Rate for Payer: UnitedHealthcare Medicare	$8,007.70

ENDOVASCULAR ABDOMINAL AORTA WITH ILIAC BRANCH PROCEDURES

Facility

$96,040.50

Service Code	MSDRG 213
Min. Negotiated Rate	$56,679.38
Max. Negotiated Rate	$96,040.50
Rate for Payer: AlohaCare Medicare	$56,679.38
Rate for Payer: Hawaii Medical Service Association Commercial	$96,040.50
Rate for Payer: Hawaii Medical Service Association Medicare	$56,679.38
Rate for Payer: Humana Medicare	$56,679.38
Rate for Payer: Kaiser Permanente Medicare	$56,679.38
Rate for Payer: Ohana Health Plan Medicare	$56,679.38
Rate for Payer: UnitedHealthcare Medicare	$56,679.38

ENDOVASCULAR CARDIAC VALVE REPLACEMENT AND SUPPLEMENT PROCEDURES WITH MCC

Facility

$92,366.69

Service Code	MSDRG 266
Min. Negotiated Rate	$60,833.40
Max. Negotiated Rate	$92,366.69
Rate for Payer: AlohaCare Medicare	$60,833.40
Rate for Payer: Hawaii Medical Service Association Commercial	$92,366.69
Rate for Payer: Hawaii Medical Service Association Medicare	$60,833.40
Rate for Payer: Humana Medicare	$60,833.40
Rate for Payer: Kaiser Permanente Medicare	$60,833.40
Rate for Payer: Ohana Health Plan Medicare	$60,833.40
Rate for Payer: UnitedHealthcare Medicare	$60,833.40

ENDOVASCULAR CARDIAC VALVE REPLACEMENT AND SUPPLEMENT PROCEDURES WITHOUT MCC

Facility

$80,444.59

Service Code	MSDRG 267
Min. Negotiated Rate	$47,355.22
Max. Negotiated Rate	$80,444.59
Rate for Payer: AlohaCare Medicare	$47,355.22
Rate for Payer: Hawaii Medical Service Association Commercial	$80,444.59
Rate for Payer: Hawaii Medical Service Association Medicare	$47,355.22
Rate for Payer: Humana Medicare	$47,355.22
Rate for Payer: Kaiser Permanente Medicare	$47,355.22
Rate for Payer: Ohana Health Plan Medicare	$47,355.22
Rate for Payer: UnitedHealthcare Medicare	$47,355.22

EPISTAXIS WITH MCC

Facility

$13,558.23

Service Code	MSDRG 150
Min. Negotiated Rate	$10,405.18
Max. Negotiated Rate	$13,558.23
Rate for Payer: AlohaCare Medicare	$13,558.23
Rate for Payer: Hawaii Medical Service Association Commercial	$10,405.18
Rate for Payer: Hawaii Medical Service Association Medicare	$13,558.23
Rate for Payer: Humana Medicare	$13,558.23
Rate for Payer: Kaiser Permanente Medicare	$13,558.23
Rate for Payer: Ohana Health Plan Medicare	$13,558.23
Rate for Payer: UnitedHealthcare Medicare	$13,558.23

EPISTAXIS WITHOUT MCC

Facility

$10,405.18

Service Code	MSDRG 151
Min. Negotiated Rate	$7,669.66
Max. Negotiated Rate	$10,405.18
Rate for Payer: AlohaCare Medicare	$7,669.66
Rate for Payer: Hawaii Medical Service Association Commercial	$10,405.18
Rate for Payer: Hawaii Medical Service Association Medicare	$7,669.66
Rate for Payer: Humana Medicare	$7,669.66
Rate for Payer: Kaiser Permanente Medicare	$7,669.66
Rate for Payer: Ohana Health Plan Medicare	$7,669.66
Rate for Payer: UnitedHealthcare Medicare	$7,669.66

ESOPHAGITIS, GASTROENTERITIS AND MISCELLANEOUS DIGESTIVE DISORDERS WITH MCC

Facility

$16,923.23

Service Code	MSDRG 391
Min. Negotiated Rate	$12,935.38
Max. Negotiated Rate	$16,923.23
Rate for Payer: AlohaCare Medicare	$12,935.38
Rate for Payer: Hawaii Medical Service Association Commercial	$16,923.23
Rate for Payer: Hawaii Medical Service Association Medicare	$12,935.38
Rate for Payer: Humana Medicare	$12,935.38
Rate for Payer: Kaiser Permanente Medicare	$12,935.38
Rate for Payer: Ohana Health Plan Medicare	$12,935.38
Rate for Payer: UnitedHealthcare Medicare	$12,935.38

ESOPHAGITIS, GASTROENTERITIS AND MISCELLANEOUS DIGESTIVE DISORDERS WITHOUT MCC

Facility

$14,553.03

Service Code	MSDRG 392
Min. Negotiated Rate	$8,119.07
Max. Negotiated Rate	$14,553.03
Rate for Payer: AlohaCare Medicare	$8,119.07
Rate for Payer: Hawaii Medical Service Association Commercial	$14,553.03
Rate for Payer: Hawaii Medical Service Association Medicare	$8,119.07
Rate for Payer: Humana Medicare	$8,119.07
Rate for Payer: Kaiser Permanente Medicare	$8,119.07
Rate for Payer: Ohana Health Plan Medicare	$8,119.07
Rate for Payer: UnitedHealthcare Medicare	$8,119.07

ESR

Facility

$81.00

Service Code	HCPCS 85651
Hospital Charge Code	85651
Hospital Revenue Code	305
Min. Negotiated Rate	$68.85
Max. Negotiated Rate	$78.57
Rate for Payer: Cash Price	$52.65
Rate for Payer: Health Management Network Commercial	$68.85
Rate for Payer: Kaiser Permanente Commercial	$72.90
Rate for Payer: MDX Hawaii PPO	$78.57

ESR

Facility

$81.00

Service Code	HCPCS 85651
Hospital Charge Code	85651
Hospital Revenue Code	305
Min. Negotiated Rate	$4.27
Max. Negotiated Rate	$78.57
Rate for Payer: AlohaCare Medicaid	$40.50
Rate for Payer: Cash Price	$52.65
Rate for Payer: Cash Price	$52.65
Rate for Payer: Hawaii Medical Service Association ABD	$4.91
Rate for Payer: Hawaii Medical Service Association Commercial	$5.34
Rate for Payer: Hawaii Medical Service Association Non-ABD	$5.16
Rate for Payer: Hawaii Western Management Group Commercial	$4.27
Rate for Payer: Health Management Network Commercial	$68.85
Rate for Payer: Kaiser Permanente Commercial	$72.90
Rate for Payer: Kaiser Permanente Medicaid	$41.31
Rate for Payer: MDX Hawaii PPO	$78.57
Rate for Payer: UnitedHealthcare Medicaid	$4.91
Rate for Payer: University Health Alliance Commercial	$9.18

Eval of Speech sound with language

Facility

$769.00

Service Code	HCPCS 92523 GN
Hospital Charge Code	ST92523
Hospital Revenue Code	444
Min. Negotiated Rate	$240.61
Max. Negotiated Rate	$745.93
Rate for Payer: AlohaCare Medicaid	$384.50
Rate for Payer: Cash Price	$499.85
Rate for Payer: Cash Price	$499.85
Rate for Payer: Hawaii Western Management Group Commercial	$730.55
Rate for Payer: Health Management Network Commercial	$653.65
Rate for Payer: Kaiser Permanente Commercial	$692.10
Rate for Payer: Kaiser Permanente Medicaid	$392.19
Rate for Payer: MDX Hawaii PPO	$745.93
Rate for Payer: UnitedHealthcare Medicaid	$240.61
Rate for Payer: University Health Alliance Commercial	$560.52

Eval of Speech sound with language

Facility

$769.00

Service Code	HCPCS 92523 GN
Hospital Charge Code	ST92523
Hospital Revenue Code	444
Min. Negotiated Rate	$653.65
Max. Negotiated Rate	$745.93
Rate for Payer: Cash Price	$499.85
Rate for Payer: Health Management Network Commercial	$653.65
Rate for Payer: Kaiser Permanente Commercial	$692.10
Rate for Payer: MDX Hawaii PPO	$745.93

Evaluation of Speech Fluency

Facility

$769.00

Service Code	HCPCS 92521 GN
Hospital Charge Code	ST92521
Hospital Revenue Code	444
Min. Negotiated Rate	$140.32
Max. Negotiated Rate	$745.93
Rate for Payer: AlohaCare Medicaid	$384.50
Rate for Payer: Cash Price	$499.85
Rate for Payer: Cash Price	$499.85
Rate for Payer: Hawaii Western Management Group Commercial	$730.55
Rate for Payer: Health Management Network Commercial	$653.65
Rate for Payer: Kaiser Permanente Commercial	$692.10
Rate for Payer: Kaiser Permanente Medicaid	$392.19
Rate for Payer: MDX Hawaii PPO	$745.93
Rate for Payer: UnitedHealthcare Medicaid	$140.32
Rate for Payer: University Health Alliance Commercial	$560.52

Evaluation of Speech Fluency

Facility

$769.00

Service Code	HCPCS 92521 GN
Hospital Charge Code	ST92521
Hospital Revenue Code	444
Min. Negotiated Rate	$653.65
Max. Negotiated Rate	$745.93
Rate for Payer: Cash Price	$499.85
Rate for Payer: Health Management Network Commercial	$653.65
Rate for Payer: Kaiser Permanente Commercial	$692.10
Rate for Payer: MDX Hawaii PPO	$745.93

Evaluation of speech sound producti

Facility

$769.00

Service Code	HCPCS 92522 GN
Hospital Charge Code	ST92522
Hospital Revenue Code	444
Min. Negotiated Rate	$653.65
Max. Negotiated Rate	$745.93
Rate for Payer: Cash Price	$499.85
Rate for Payer: Health Management Network Commercial	$653.65
Rate for Payer: Kaiser Permanente Commercial	$692.10
Rate for Payer: MDX Hawaii PPO	$745.93

Evaluation of speech sound producti

Facility

$769.00

Service Code	HCPCS 92522 GN
Hospital Charge Code	ST92522
Hospital Revenue Code	444
Min. Negotiated Rate	$116.85
Max. Negotiated Rate	$745.93
Rate for Payer: AlohaCare Medicaid	$384.50
Rate for Payer: Cash Price	$499.85
Rate for Payer: Cash Price	$499.85
Rate for Payer: Hawaii Western Management Group Commercial	$730.55
Rate for Payer: Health Management Network Commercial	$653.65
Rate for Payer: Kaiser Permanente Commercial	$692.10
Rate for Payer: Kaiser Permanente Medicaid	$392.19
Rate for Payer: MDX Hawaii PPO	$745.93
Rate for Payer: UnitedHealthcare Medicaid	$116.85
Rate for Payer: University Health Alliance Commercial	$560.52

Evaluation of swallowing

Facility

$769.00

Service Code	HCPCS 92611 GN
Hospital Charge Code	ST92611
Hospital Revenue Code	444
Min. Negotiated Rate	$88.36
Max. Negotiated Rate	$745.93
Rate for Payer: AlohaCare Medicaid	$384.50
Rate for Payer: Cash Price	$499.85
Rate for Payer: Cash Price	$499.85
Rate for Payer: Hawaii Western Management Group Commercial	$730.55
Rate for Payer: Health Management Network Commercial	$653.65
Rate for Payer: Kaiser Permanente Commercial	$692.10
Rate for Payer: Kaiser Permanente Medicaid	$392.19
Rate for Payer: MDX Hawaii PPO	$745.93
Rate for Payer: UnitedHealthcare Medicaid	$88.36
Rate for Payer: University Health Alliance Commercial	$560.52

Evaluation of swallowing

Facility

$769.00

Service Code	HCPCS 92611 GN
Hospital Charge Code	ST92611
Hospital Revenue Code	444
Min. Negotiated Rate	$653.65
Max. Negotiated Rate	$745.93
Rate for Payer: Cash Price	$499.85
Rate for Payer: Health Management Network Commercial	$653.65
Rate for Payer: Kaiser Permanente Commercial	$692.10
Rate for Payer: MDX Hawaii PPO	$745.93

EXTENSIVE BURNS OR FULL THICKNESS BURNS WITH MV >96 HOURS WITHOUT SKIN GRAFT

Facility

$61,625.20

Service Code	MSDRG 933
Min. Negotiated Rate	$38,814.56
Max. Negotiated Rate	$61,625.20
Rate for Payer: AlohaCare Medicare	$38,814.56
Rate for Payer: Hawaii Medical Service Association Commercial	$61,625.20
Rate for Payer: Hawaii Medical Service Association Medicare	$38,814.56
Rate for Payer: Humana Medicare	$38,814.56
Rate for Payer: Kaiser Permanente Medicare	$38,814.56
Rate for Payer: Ohana Health Plan Medicare	$38,814.56
Rate for Payer: UnitedHealthcare Medicare	$38,814.56

EXTENSIVE BURNS OR FULL THICKNESS BURNS WITH MV >96 HOURS WITH SKIN GRAFT

Facility

$382,502.88

Service Code	MSDRG 927
Min. Negotiated Rate	$210,852.66
Max. Negotiated Rate	$382,502.88
Rate for Payer: AlohaCare Medicare	$210,852.66
Rate for Payer: Hawaii Medical Service Association Commercial	$382,502.88
Rate for Payer: Hawaii Medical Service Association Medicare	$210,852.66
Rate for Payer: Humana Medicare	$210,852.66
Rate for Payer: Kaiser Permanente Medicare	$210,852.66
Rate for Payer: Ohana Health Plan Medicare	$210,852.66
Rate for Payer: UnitedHealthcare Medicare	$210,852.66

EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH CC

Facility

$45,650.05

Service Code	MSDRG 982
Min. Negotiated Rate	$24,665.23
Max. Negotiated Rate	$45,650.05
Rate for Payer: AlohaCare Medicare	$24,665.23
Rate for Payer: Hawaii Medical Service Association Commercial	$45,650.05
Rate for Payer: Hawaii Medical Service Association Medicare	$24,665.23
Rate for Payer: Humana Medicare	$24,665.23
Rate for Payer: Kaiser Permanente Medicare	$24,665.23
Rate for Payer: Ohana Health Plan Medicare	$24,665.23
Rate for Payer: UnitedHealthcare Medicare	$24,665.23

EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH MCC

Facility

$76,510.06

Service Code	MSDRG 981
Min. Negotiated Rate	$46,675.19
Max. Negotiated Rate	$76,510.06
Rate for Payer: AlohaCare Medicare	$46,675.19
Rate for Payer: Hawaii Medical Service Association Commercial	$76,510.06
Rate for Payer: Hawaii Medical Service Association Medicare	$46,675.19
Rate for Payer: Humana Medicare	$46,675.19
Rate for Payer: Kaiser Permanente Medicare	$46,675.19
Rate for Payer: Ohana Health Plan Medicare	$46,675.19
Rate for Payer: UnitedHealthcare Medicare	$46,675.19

Know your out-of-pocket cost for care.

All Charges