Leahi Hospital

All Charges

Charge

Type

Setting

Price

Moderna - Spikevax single

Facility

$341.00

Service Code	HCPCS 91322
Hospital Charge Code	Mod -Spike
Hospital Revenue Code	636
Min. Negotiated Rate	$153.14
Max. Negotiated Rate	$330.77
Rate for Payer: AlohaCare Medicaid	$170.50
Rate for Payer: Cash Price	$221.65
Rate for Payer: Cash Price	$221.65
Rate for Payer: Hawaii Medical Service Association ABD	$153.14
Rate for Payer: Hawaii Medical Service Association Non-ABD	$153.14
Rate for Payer: Hawaii Western Management Group Commercial	$323.95
Rate for Payer: Health Management Network Commercial	$289.85
Rate for Payer: Kaiser Permanente Commercial	$306.90
Rate for Payer: Kaiser Permanente Medicaid	$173.91
Rate for Payer: MDX Hawaii PPO	$330.77
Rate for Payer: UnitedHealthcare Medicaid	$204.60
Rate for Payer: University Health Alliance Commercial	$248.55

Moderna - Spikevax single

Facility

$341.00

Service Code	HCPCS 91322
Hospital Charge Code	Mod -Spike
Hospital Revenue Code	636
Min. Negotiated Rate	$289.85
Max. Negotiated Rate	$330.77
Rate for Payer: Cash Price	$221.65
Rate for Payer: Health Management Network Commercial	$289.85
Rate for Payer: Kaiser Permanente Commercial	$306.90
Rate for Payer: MDX Hawaii PPO	$330.77

MOUTH PROCEDURES WITH CC/MCC

Facility

$59,776.44

Service Code	MSDRG 137
Min. Negotiated Rate	$15,151.85
Max. Negotiated Rate	$59,776.44
Rate for Payer: AlohaCare Medicare	$15,151.85
Rate for Payer: Hawaii Medical Service Association Commercial	$59,776.44
Rate for Payer: Hawaii Medical Service Association Medicare	$15,151.85
Rate for Payer: Humana Medicare	$15,151.85
Rate for Payer: Kaiser Permanente Medicare	$15,151.85
Rate for Payer: Ohana Health Plan Medicare	$15,151.85
Rate for Payer: UnitedHealthcare Medicare	$15,151.85

MOUTH PROCEDURES WITHOUT CC/MCC

Facility

$31,760.68

Service Code	MSDRG 138
Min. Negotiated Rate	$9,169.64
Max. Negotiated Rate	$31,760.68
Rate for Payer: AlohaCare Medicare	$9,169.64
Rate for Payer: Hawaii Medical Service Association Commercial	$31,760.68
Rate for Payer: Hawaii Medical Service Association Medicare	$9,169.64
Rate for Payer: Humana Medicare	$9,169.64
Rate for Payer: Kaiser Permanente Medicare	$9,169.64
Rate for Payer: Ohana Health Plan Medicare	$9,169.64
Rate for Payer: UnitedHealthcare Medicare	$9,169.64

MTB direct probe

Facility

$342.00

Service Code	HCPCS 87555
Hospital Charge Code	87555
Hospital Revenue Code	306
Min. Negotiated Rate	$26.88
Max. Negotiated Rate	$331.74
Rate for Payer: AlohaCare Medicaid	$171.00
Rate for Payer: Cash Price	$222.30
Rate for Payer: Cash Price	$222.30
Rate for Payer: Hawaii Medical Service Association ABD	$27.71
Rate for Payer: Hawaii Medical Service Association Commercial	$33.60
Rate for Payer: Hawaii Medical Service Association Non-ABD	$29.10
Rate for Payer: Hawaii Western Management Group Commercial	$26.88
Rate for Payer: Health Management Network Commercial	$290.70
Rate for Payer: Kaiser Permanente Commercial	$307.80
Rate for Payer: Kaiser Permanente Medicaid	$174.42
Rate for Payer: MDX Hawaii PPO	$331.74
Rate for Payer: UnitedHealthcare Medicaid	$27.71
Rate for Payer: University Health Alliance Commercial	$51.84

MTB direct probe

Facility

$342.00

Service Code	HCPCS 87555
Hospital Charge Code	87555
Hospital Revenue Code	306
Min. Negotiated Rate	$290.70
Max. Negotiated Rate	$331.74
Rate for Payer: Cash Price	$222.30
Rate for Payer: Health Management Network Commercial	$290.70
Rate for Payer: Kaiser Permanente Commercial	$307.80
Rate for Payer: MDX Hawaii PPO	$331.74

MULTIPLE LEVEL COMBINED ANTERIOR AND POSTERIOR SPINAL FUSION EXCEPT CERVICAL WITH CC

Facility

$115,594.65

Service Code	MSDRG 427
Min. Negotiated Rate	$71,577.72
Max. Negotiated Rate	$115,594.65
Rate for Payer: AlohaCare Medicare	$71,577.72
Rate for Payer: Hawaii Medical Service Association Commercial	$115,594.65
Rate for Payer: Hawaii Medical Service Association Medicare	$71,577.72
Rate for Payer: Humana Medicare	$71,577.72
Rate for Payer: Kaiser Permanente Medicare	$71,577.72
Rate for Payer: Ohana Health Plan Medicare	$71,577.72
Rate for Payer: UnitedHealthcare Medicare	$71,577.72

MULTIPLE LEVEL COMBINED ANTERIOR AND POSTERIOR SPINAL FUSION EXCEPT CERVICAL WITH MCC OR CUSTOM-MADE ANATOMICALLY DESIGNED INTERBODY FUSION DEVICE

Facility

$115,594.65

Service Code	MSDRG 426
Min. Negotiated Rate	$109,053.70
Max. Negotiated Rate	$115,594.65
Rate for Payer: AlohaCare Medicare	$109,053.70
Rate for Payer: Hawaii Medical Service Association Commercial	$115,594.65
Rate for Payer: Hawaii Medical Service Association Medicare	$109,053.70
Rate for Payer: Humana Medicare	$109,053.70
Rate for Payer: Kaiser Permanente Medicare	$109,053.70
Rate for Payer: Ohana Health Plan Medicare	$109,053.70
Rate for Payer: UnitedHealthcare Medicare	$109,053.70

MULTIPLE LEVEL COMBINED ANTERIOR AND POSTERIOR SPINAL FUSION EXCEPT CERVICAL WITHOUT CC/MCC

Facility

$115,594.65

Service Code	MSDRG 428
Min. Negotiated Rate	$55,842.65
Max. Negotiated Rate	$115,594.65
Rate for Payer: AlohaCare Medicare	$55,842.65
Rate for Payer: Hawaii Medical Service Association Commercial	$115,594.65
Rate for Payer: Hawaii Medical Service Association Medicare	$55,842.65
Rate for Payer: Humana Medicare	$55,842.65
Rate for Payer: Kaiser Permanente Medicare	$55,842.65
Rate for Payer: Ohana Health Plan Medicare	$55,842.65
Rate for Payer: UnitedHealthcare Medicare	$55,842.65

MULTIPLE LEVEL SPINAL FUSION EXCEPT CERVICAL WITH MCC OR CUSTOM-MADE ANATOMICALLY DESIGNED INTERBODY FUSION DEVICE

Facility

$84,260.61

Service Code	MSDRG 447
Min. Negotiated Rate	$66,285.39
Max. Negotiated Rate	$84,260.61
Rate for Payer: AlohaCare Medicare	$66,285.39
Rate for Payer: Hawaii Medical Service Association Commercial	$84,260.61
Rate for Payer: Hawaii Medical Service Association Medicare	$66,285.39
Rate for Payer: Humana Medicare	$66,285.39
Rate for Payer: Kaiser Permanente Medicare	$66,285.39
Rate for Payer: Ohana Health Plan Medicare	$66,285.39
Rate for Payer: UnitedHealthcare Medicare	$66,285.39

MULTIPLE LEVEL SPINAL FUSION EXCEPT CERVICAL WITHOUT MCC

Facility

$79,283.19

Service Code	MSDRG 448
Min. Negotiated Rate	$42,230.43
Max. Negotiated Rate	$79,283.19
Rate for Payer: AlohaCare Medicare	$42,230.43
Rate for Payer: Hawaii Medical Service Association Commercial	$79,283.19
Rate for Payer: Hawaii Medical Service Association Medicare	$42,230.43
Rate for Payer: Humana Medicare	$42,230.43
Rate for Payer: Kaiser Permanente Medicare	$42,230.43
Rate for Payer: Ohana Health Plan Medicare	$42,230.43
Rate for Payer: UnitedHealthcare Medicare	$42,230.43

MULTIPLE SCLEROSIS AND CEREBELLAR ATAXIA WITH CC

Facility

$20,170.40

Service Code	MSDRG 059
Min. Negotiated Rate	$12,665.34
Max. Negotiated Rate	$20,170.40
Rate for Payer: AlohaCare Medicare	$12,665.34
Rate for Payer: Hawaii Medical Service Association Commercial	$20,170.40
Rate for Payer: Hawaii Medical Service Association Medicare	$12,665.34
Rate for Payer: Humana Medicare	$12,665.34
Rate for Payer: Kaiser Permanente Medicare	$12,665.34
Rate for Payer: Ohana Health Plan Medicare	$12,665.34
Rate for Payer: UnitedHealthcare Medicare	$12,665.34

MULTIPLE SCLEROSIS AND CEREBELLAR ATAXIA WITH MCC

Facility

$20,170.40

Service Code	MSDRG 058
Min. Negotiated Rate	$17,283.56
Max. Negotiated Rate	$20,170.40
Rate for Payer: AlohaCare Medicare	$17,283.56
Rate for Payer: Hawaii Medical Service Association Commercial	$20,170.40
Rate for Payer: Hawaii Medical Service Association Medicare	$17,283.56
Rate for Payer: Humana Medicare	$17,283.56
Rate for Payer: Kaiser Permanente Medicare	$17,283.56
Rate for Payer: Ohana Health Plan Medicare	$17,283.56
Rate for Payer: UnitedHealthcare Medicare	$17,283.56

MULTIPLE SCLEROSIS AND CEREBELLAR ATAXIA WITHOUT CC/MCC

Facility

$20,170.40

Service Code	MSDRG 060
Min. Negotiated Rate	$9,500.79
Max. Negotiated Rate	$20,170.40
Rate for Payer: AlohaCare Medicare	$9,500.79
Rate for Payer: Hawaii Medical Service Association Commercial	$20,170.40
Rate for Payer: Hawaii Medical Service Association Medicare	$9,500.79
Rate for Payer: Humana Medicare	$9,500.79
Rate for Payer: Kaiser Permanente Medicare	$9,500.79
Rate for Payer: Ohana Health Plan Medicare	$9,500.79
Rate for Payer: UnitedHealthcare Medicare	$9,500.79

MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH MAJOR O.R. PROCEDURES WITH CC

Facility

$73,452.50

Service Code	MSDRG 827
Min. Negotiated Rate	$23,213.53
Max. Negotiated Rate	$73,452.50
Rate for Payer: AlohaCare Medicare	$23,213.53
Rate for Payer: Hawaii Medical Service Association Commercial	$73,452.50
Rate for Payer: Hawaii Medical Service Association Medicare	$23,213.53
Rate for Payer: Humana Medicare	$23,213.53
Rate for Payer: Kaiser Permanente Medicare	$23,213.53
Rate for Payer: Ohana Health Plan Medicare	$23,213.53
Rate for Payer: UnitedHealthcare Medicare	$23,213.53

MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH MAJOR O.R. PROCEDURES WITH MCC

Facility

$73,452.50

Service Code	MSDRG 826
Min. Negotiated Rate	$46,537.22
Max. Negotiated Rate	$73,452.50
Rate for Payer: AlohaCare Medicare	$46,537.22
Rate for Payer: Hawaii Medical Service Association Commercial	$73,452.50
Rate for Payer: Hawaii Medical Service Association Medicare	$46,537.22
Rate for Payer: Humana Medicare	$46,537.22
Rate for Payer: Kaiser Permanente Medicare	$46,537.22
Rate for Payer: Ohana Health Plan Medicare	$46,537.22
Rate for Payer: UnitedHealthcare Medicare	$46,537.22

MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH MAJOR O.R. PROCEDURES WITHOUT CC/MCC

Facility

$37,069.93

Service Code	MSDRG 828
Min. Negotiated Rate	$17,227.39
Max. Negotiated Rate	$37,069.93
Rate for Payer: AlohaCare Medicare	$17,227.39
Rate for Payer: Hawaii Medical Service Association Commercial	$37,069.93
Rate for Payer: Hawaii Medical Service Association Medicare	$17,227.39
Rate for Payer: Humana Medicare	$17,227.39
Rate for Payer: Kaiser Permanente Medicare	$17,227.39
Rate for Payer: Ohana Health Plan Medicare	$17,227.39
Rate for Payer: UnitedHealthcare Medicare	$17,227.39

MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH OTHER PROCEDURES WITH CC/MCC

Facility

$46,811.45

Service Code	MSDRG 829
Min. Negotiated Rate	$31,578.75
Max. Negotiated Rate	$46,811.45
Rate for Payer: AlohaCare Medicare	$31,578.75
Rate for Payer: Hawaii Medical Service Association Commercial	$46,811.45
Rate for Payer: Hawaii Medical Service Association Medicare	$31,578.75
Rate for Payer: Humana Medicare	$31,578.75
Rate for Payer: Kaiser Permanente Medicare	$31,578.75
Rate for Payer: Ohana Health Plan Medicare	$31,578.75
Rate for Payer: UnitedHealthcare Medicare	$31,578.75

MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH OTHER PROCEDURES WITHOUT CC/MCC

Facility

$46,811.45

Service Code	MSDRG 830
Min. Negotiated Rate	$15,268.15
Max. Negotiated Rate	$46,811.45
Rate for Payer: AlohaCare Medicare	$15,268.15
Rate for Payer: Hawaii Medical Service Association Commercial	$46,811.45
Rate for Payer: Hawaii Medical Service Association Medicare	$15,268.15
Rate for Payer: Humana Medicare	$15,268.15
Rate for Payer: Kaiser Permanente Medicare	$15,268.15
Rate for Payer: Ohana Health Plan Medicare	$15,268.15
Rate for Payer: UnitedHealthcare Medicare	$15,268.15

Natriuretic peptide

Facility

$607.00

Service Code	HCPCS 83880
Hospital Charge Code	83880
Hospital Revenue Code	301
Min. Negotiated Rate	$515.95
Max. Negotiated Rate	$588.79
Rate for Payer: Cash Price	$394.55
Rate for Payer: Health Management Network Commercial	$515.95
Rate for Payer: Kaiser Permanente Commercial	$546.30
Rate for Payer: MDX Hawaii PPO	$588.79

Natriuretic peptide

Facility

$607.00

Service Code	HCPCS 83880
Hospital Charge Code	83880
Hospital Revenue Code	301
Min. Negotiated Rate	$28.46
Max. Negotiated Rate	$588.79
Rate for Payer: AlohaCare Medicaid	$303.50
Rate for Payer: Cash Price	$394.55
Rate for Payer: Cash Price	$394.55
Rate for Payer: Hawaii Medical Service Association ABD	$28.46
Rate for Payer: Hawaii Medical Service Association Commercial	$49.08
Rate for Payer: Hawaii Medical Service Association Non-ABD	$46.89
Rate for Payer: Hawaii Western Management Group Commercial	$39.26
Rate for Payer: Health Management Network Commercial	$515.95
Rate for Payer: Kaiser Permanente Commercial	$546.30
Rate for Payer: Kaiser Permanente Medicaid	$309.57
Rate for Payer: MDX Hawaii PPO	$588.79
Rate for Payer: UnitedHealthcare Medicaid	$28.46
Rate for Payer: University Health Alliance Commercial	$87.75

Neg Pressure Wound TX

Facility

$947.00

Service Code	HCPCS 97607 GP
Hospital Charge Code	PT97607
Hospital Revenue Code	420
Min. Negotiated Rate	$20.89
Max. Negotiated Rate	$918.59
Rate for Payer: AlohaCare Medicaid	$473.50
Rate for Payer: Cash Price	$615.55
Rate for Payer: Cash Price	$615.55
Rate for Payer: Hawaii Western Management Group Commercial	$899.65
Rate for Payer: Health Management Network Commercial	$804.95
Rate for Payer: Kaiser Permanente Commercial	$852.30
Rate for Payer: Kaiser Permanente Medicaid	$482.97
Rate for Payer: MDX Hawaii PPO	$918.59
Rate for Payer: UnitedHealthcare Medicaid	$20.89
Rate for Payer: University Health Alliance Commercial	$690.27

Neg Pressure Wound TX

Facility

$947.00

Service Code	HCPCS 97607 GO
Hospital Charge Code	OT97607
Hospital Revenue Code	430
Min. Negotiated Rate	$804.95
Max. Negotiated Rate	$918.59
Rate for Payer: Cash Price	$615.55
Rate for Payer: Health Management Network Commercial	$804.95
Rate for Payer: Kaiser Permanente Commercial	$852.30
Rate for Payer: MDX Hawaii PPO	$918.59

Neg Pressure Wound TX

Facility

$947.00

Service Code	HCPCS 97607 GP
Hospital Charge Code	PT97607
Hospital Revenue Code	420
Min. Negotiated Rate	$804.95
Max. Negotiated Rate	$918.59
Rate for Payer: Cash Price	$615.55
Rate for Payer: Health Management Network Commercial	$804.95
Rate for Payer: Kaiser Permanente Commercial	$852.30
Rate for Payer: MDX Hawaii PPO	$918.59

Neg Pressure Wound TX

Facility

$947.00

Service Code	HCPCS 97607 GO
Hospital Charge Code	OT97607
Hospital Revenue Code	430
Min. Negotiated Rate	$20.89
Max. Negotiated Rate	$918.59
Rate for Payer: AlohaCare Medicaid	$473.50
Rate for Payer: Cash Price	$615.55
Rate for Payer: Cash Price	$615.55
Rate for Payer: Hawaii Western Management Group Commercial	$899.65
Rate for Payer: Health Management Network Commercial	$804.95
Rate for Payer: Kaiser Permanente Commercial	$852.30
Rate for Payer: Kaiser Permanente Medicaid	$482.97
Rate for Payer: MDX Hawaii PPO	$918.59
Rate for Payer: UnitedHealthcare Medicaid	$20.89
Rate for Payer: University Health Alliance Commercial	$690.27

Know your out-of-pocket cost for care.

All Charges