Leahi Hospital

All Charges

Charge

Type

Setting

Price

Orthotic mgmnt & traing

Facility

$228.00

Service Code	HCPCS 97760 GO
Hospital Charge Code	OT97760
Hospital Revenue Code	430
Min. Negotiated Rate	$193.80
Max. Negotiated Rate	$221.16
Rate for Payer: Cash Price	$148.20
Rate for Payer: Health Management Network Commercial	$193.80
Rate for Payer: Kaiser Permanente Commercial	$205.20
Rate for Payer: MDX Hawaii PPO	$221.16

Orthotic mgmnt & traing

Facility

$228.00

Service Code	HCPCS 97760 GO
Hospital Charge Code	OT97760
Hospital Revenue Code	430
Min. Negotiated Rate	$17.21
Max. Negotiated Rate	$221.16
Rate for Payer: AlohaCare Medicaid	$114.00
Rate for Payer: Cash Price	$148.20
Rate for Payer: Cash Price	$148.20
Rate for Payer: Hawaii Western Management Group Commercial	$216.60
Rate for Payer: Health Management Network Commercial	$193.80
Rate for Payer: Kaiser Permanente Commercial	$205.20
Rate for Payer: Kaiser Permanente Medicaid	$116.28
Rate for Payer: MDX Hawaii PPO	$221.16
Rate for Payer: UnitedHealthcare Medicaid	$17.21
Rate for Payer: University Health Alliance Commercial	$166.19

Orthotic mgmt & traing

Facility

$228.00

Service Code	HCPCS 97760 GN
Hospital Charge Code	ST97760
Hospital Revenue Code	440
Min. Negotiated Rate	$193.80
Max. Negotiated Rate	$221.16
Rate for Payer: Cash Price	$148.20
Rate for Payer: Health Management Network Commercial	$193.80
Rate for Payer: Kaiser Permanente Commercial	$205.20
Rate for Payer: MDX Hawaii PPO	$221.16

Orthotic mgmt & traing

Facility

$228.00

Service Code	HCPCS 97760 GN
Hospital Charge Code	ST97760
Hospital Revenue Code	440
Min. Negotiated Rate	$17.21
Max. Negotiated Rate	$221.16
Rate for Payer: AlohaCare Medicaid	$114.00
Rate for Payer: Cash Price	$148.20
Rate for Payer: Cash Price	$148.20
Rate for Payer: Hawaii Western Management Group Commercial	$216.60
Rate for Payer: Health Management Network Commercial	$193.80
Rate for Payer: Kaiser Permanente Commercial	$205.20
Rate for Payer: Kaiser Permanente Medicaid	$116.28
Rate for Payer: MDX Hawaii PPO	$221.16
Rate for Payer: UnitedHealthcare Medicaid	$17.21
Rate for Payer: University Health Alliance Commercial	$166.19

Orthotic mgmt & traing

Facility

$228.00

Service Code	HCPCS 97760 GP
Hospital Charge Code	PT97760
Hospital Revenue Code	420
Min. Negotiated Rate	$17.21
Max. Negotiated Rate	$221.16
Rate for Payer: AlohaCare Medicaid	$114.00
Rate for Payer: Cash Price	$148.20
Rate for Payer: Cash Price	$148.20
Rate for Payer: Hawaii Western Management Group Commercial	$216.60
Rate for Payer: Health Management Network Commercial	$193.80
Rate for Payer: Kaiser Permanente Commercial	$205.20
Rate for Payer: Kaiser Permanente Medicaid	$116.28
Rate for Payer: MDX Hawaii PPO	$221.16
Rate for Payer: UnitedHealthcare Medicaid	$17.21
Rate for Payer: University Health Alliance Commercial	$166.19

Orthotic mgmt & traing

Facility

$228.00

Service Code	HCPCS 97760 GP
Hospital Charge Code	PT97760
Hospital Revenue Code	420
Min. Negotiated Rate	$193.80
Max. Negotiated Rate	$221.16
Rate for Payer: Cash Price	$148.20
Rate for Payer: Health Management Network Commercial	$193.80
Rate for Payer: Kaiser Permanente Commercial	$205.20
Rate for Payer: MDX Hawaii PPO	$221.16

OSTEOMYELITIS WITH CC

Facility

$39,013.49

Service Code	MSDRG 540
Min. Negotiated Rate	$13,211.32
Max. Negotiated Rate	$39,013.49
Rate for Payer: AlohaCare Medicare	$13,211.32
Rate for Payer: Hawaii Medical Service Association Commercial	$39,013.49
Rate for Payer: Hawaii Medical Service Association Medicare	$13,211.32
Rate for Payer: Humana Medicare	$13,211.32
Rate for Payer: Kaiser Permanente Medicare	$13,211.32
Rate for Payer: Ohana Health Plan Medicare	$13,211.32
Rate for Payer: UnitedHealthcare Medicare	$13,211.32

OSTEOMYELITIS WITH MCC

Facility

$39,013.49

Service Code	MSDRG 539
Min. Negotiated Rate	$19,847.92
Max. Negotiated Rate	$39,013.49
Rate for Payer: AlohaCare Medicare	$19,847.92
Rate for Payer: Hawaii Medical Service Association Commercial	$39,013.49
Rate for Payer: Hawaii Medical Service Association Medicare	$19,847.92
Rate for Payer: Humana Medicare	$19,847.92
Rate for Payer: Kaiser Permanente Medicare	$19,847.92
Rate for Payer: Ohana Health Plan Medicare	$19,847.92
Rate for Payer: UnitedHealthcare Medicare	$19,847.92

OSTEOMYELITIS WITHOUT CC/MCC

Facility

$39,013.49

Service Code	MSDRG 541
Min. Negotiated Rate	$8,195.93
Max. Negotiated Rate	$39,013.49
Rate for Payer: AlohaCare Medicare	$8,195.93
Rate for Payer: Hawaii Medical Service Association Commercial	$39,013.49
Rate for Payer: Hawaii Medical Service Association Medicare	$8,195.93
Rate for Payer: Humana Medicare	$8,195.93
Rate for Payer: Kaiser Permanente Medicare	$8,195.93
Rate for Payer: Ohana Health Plan Medicare	$8,195.93
Rate for Payer: UnitedHealthcare Medicare	$8,195.93

OT Eval High Complex 60 Min

Facility

$552.00

Service Code	HCPCS 97167 GO
Hospital Charge Code	OT97167
Hospital Revenue Code	434
Min. Negotiated Rate	$107.85
Max. Negotiated Rate	$535.44
Rate for Payer: AlohaCare Medicaid	$276.00
Rate for Payer: Cash Price	$358.80
Rate for Payer: Cash Price	$358.80
Rate for Payer: Hawaii Western Management Group Commercial	$524.40
Rate for Payer: Health Management Network Commercial	$469.20
Rate for Payer: Kaiser Permanente Commercial	$496.80
Rate for Payer: Kaiser Permanente Medicaid	$281.52
Rate for Payer: MDX Hawaii PPO	$535.44
Rate for Payer: UnitedHealthcare Medicaid	$107.85
Rate for Payer: University Health Alliance Commercial	$402.35

OT Eval High Complex 60 Min

Facility

$552.00

Service Code	HCPCS 97167 GO
Hospital Charge Code	OT97167
Hospital Revenue Code	434
Min. Negotiated Rate	$469.20
Max. Negotiated Rate	$535.44
Rate for Payer: Cash Price	$358.80
Rate for Payer: Health Management Network Commercial	$469.20
Rate for Payer: Kaiser Permanente Commercial	$496.80
Rate for Payer: MDX Hawaii PPO	$535.44

OT Eval Low Complex 30 Min

Facility

$626.00

Service Code	HCPCS 97165 GO
Hospital Charge Code	OT97165
Hospital Revenue Code	434
Min. Negotiated Rate	$532.10
Max. Negotiated Rate	$607.22
Rate for Payer: Cash Price	$406.90
Rate for Payer: Health Management Network Commercial	$532.10
Rate for Payer: Kaiser Permanente Commercial	$563.40
Rate for Payer: MDX Hawaii PPO	$607.22

OT Eval Low Complex 30 Min

Facility

$626.00

Service Code	HCPCS 97165 GO
Hospital Charge Code	OT97165
Hospital Revenue Code	434
Min. Negotiated Rate	$107.85
Max. Negotiated Rate	$607.22
Rate for Payer: AlohaCare Medicaid	$313.00
Rate for Payer: Cash Price	$406.90
Rate for Payer: Cash Price	$406.90
Rate for Payer: Hawaii Western Management Group Commercial	$594.70
Rate for Payer: Health Management Network Commercial	$532.10
Rate for Payer: Kaiser Permanente Commercial	$563.40
Rate for Payer: Kaiser Permanente Medicaid	$319.26
Rate for Payer: MDX Hawaii PPO	$607.22
Rate for Payer: UnitedHealthcare Medicaid	$107.85
Rate for Payer: University Health Alliance Commercial	$456.29

OT Eval Mod Complex 45 Min

Facility

$502.00

Service Code	HCPCS 97166 GO
Hospital Charge Code	OT97166
Hospital Revenue Code	434
Min. Negotiated Rate	$426.70
Max. Negotiated Rate	$486.94
Rate for Payer: Cash Price	$326.30
Rate for Payer: Health Management Network Commercial	$426.70
Rate for Payer: Kaiser Permanente Commercial	$451.80
Rate for Payer: MDX Hawaii PPO	$486.94

OT Eval Mod Complex 45 Min

Facility

$502.00

Service Code	HCPCS 97166 GO
Hospital Charge Code	OT97166
Hospital Revenue Code	434
Min. Negotiated Rate	$107.85
Max. Negotiated Rate	$486.94
Rate for Payer: AlohaCare Medicaid	$251.00
Rate for Payer: Cash Price	$326.30
Rate for Payer: Cash Price	$326.30
Rate for Payer: Hawaii Western Management Group Commercial	$476.90
Rate for Payer: Health Management Network Commercial	$426.70
Rate for Payer: Kaiser Permanente Commercial	$451.80
Rate for Payer: Kaiser Permanente Medicaid	$256.02
Rate for Payer: MDX Hawaii PPO	$486.94
Rate for Payer: UnitedHealthcare Medicaid	$107.85
Rate for Payer: University Health Alliance Commercial	$365.91

OTHER ANTEPARTUM DIAGNOSES WITH O.R. PROCEDURES WITH CC

Facility

$11,860.16

Service Code	MSDRG 818
Min. Negotiated Rate	$10,618.50
Max. Negotiated Rate	$11,860.16
Rate for Payer: AlohaCare Medicare	$11,860.16
Rate for Payer: Hawaii Medical Service Association Commercial	$10,618.50
Rate for Payer: Hawaii Medical Service Association Medicare	$11,860.16
Rate for Payer: Humana Medicare	$11,860.16
Rate for Payer: Kaiser Permanente Medicare	$11,860.16
Rate for Payer: Ohana Health Plan Medicare	$11,860.16
Rate for Payer: UnitedHealthcare Medicare	$11,860.16

OTHER ANTEPARTUM DIAGNOSES WITH O.R. PROCEDURES WITH MCC

Facility

$22,921.82

Service Code	MSDRG 817
Min. Negotiated Rate	$10,618.50
Max. Negotiated Rate	$22,921.82
Rate for Payer: AlohaCare Medicare	$22,921.82
Rate for Payer: Hawaii Medical Service Association Commercial	$10,618.50
Rate for Payer: Hawaii Medical Service Association Medicare	$22,921.82
Rate for Payer: Humana Medicare	$22,921.82
Rate for Payer: Kaiser Permanente Medicare	$22,921.82
Rate for Payer: Ohana Health Plan Medicare	$22,921.82
Rate for Payer: UnitedHealthcare Medicare	$22,921.82

OTHER ANTEPARTUM DIAGNOSES WITH O.R. PROCEDURES WITHOUT CC/MCC

Facility

$10,334.07

Service Code	MSDRG 819
Min. Negotiated Rate	$8,910.44
Max. Negotiated Rate	$10,334.07
Rate for Payer: AlohaCare Medicare	$8,910.44
Rate for Payer: Hawaii Medical Service Association Commercial	$10,334.07
Rate for Payer: Hawaii Medical Service Association Medicare	$8,910.44
Rate for Payer: Humana Medicare	$8,910.44
Rate for Payer: Kaiser Permanente Medicare	$8,910.44
Rate for Payer: Ohana Health Plan Medicare	$8,910.44
Rate for Payer: UnitedHealthcare Medicare	$8,910.44

OTHER ANTEPARTUM DIAGNOSES WITHOUT O.R. PROCEDURES WITH CC

Facility

$9,314.89

Service Code	MSDRG 832
Min. Negotiated Rate	$7,547.45
Max. Negotiated Rate	$9,314.89
Rate for Payer: AlohaCare Medicare	$7,547.45
Rate for Payer: Hawaii Medical Service Association Commercial	$9,314.89
Rate for Payer: Hawaii Medical Service Association Medicare	$7,547.45
Rate for Payer: Humana Medicare	$7,547.45
Rate for Payer: Kaiser Permanente Medicare	$7,547.45
Rate for Payer: Ohana Health Plan Medicare	$7,547.45
Rate for Payer: UnitedHealthcare Medicare	$7,547.45

OTHER ANTEPARTUM DIAGNOSES WITHOUT O.R. PROCEDURES WITH MCC

Facility

$12,286.90

Service Code	MSDRG 831
Min. Negotiated Rate	$9,314.89
Max. Negotiated Rate	$12,286.90
Rate for Payer: AlohaCare Medicare	$12,286.90
Rate for Payer: Hawaii Medical Service Association Commercial	$9,314.89
Rate for Payer: Hawaii Medical Service Association Medicare	$12,286.90
Rate for Payer: Humana Medicare	$12,286.90
Rate for Payer: Kaiser Permanente Medicare	$12,286.90
Rate for Payer: Ohana Health Plan Medicare	$12,286.90
Rate for Payer: UnitedHealthcare Medicare	$12,286.90

OTHER ANTEPARTUM DIAGNOSES WITHOUT O.R. PROCEDURES WITHOUT CC/MCC

Facility

$9,172.67

Service Code	MSDRG 833
Min. Negotiated Rate	$5,589.19
Max. Negotiated Rate	$9,172.67
Rate for Payer: AlohaCare Medicare	$5,589.19
Rate for Payer: Hawaii Medical Service Association Commercial	$9,172.67
Rate for Payer: Hawaii Medical Service Association Medicare	$5,589.19
Rate for Payer: Humana Medicare	$5,589.19
Rate for Payer: Kaiser Permanente Medicare	$5,589.19
Rate for Payer: Ohana Health Plan Medicare	$5,589.19
Rate for Payer: UnitedHealthcare Medicare	$5,589.19

OTHER CARDIOTHORACIC PROCEDURES WITH MCC

Facility

$112,679.31

Service Code	MSDRG 228
Min. Negotiated Rate	$49,194.22
Max. Negotiated Rate	$112,679.31
Rate for Payer: AlohaCare Medicare	$49,194.22
Rate for Payer: Hawaii Medical Service Association Commercial	$112,679.31
Rate for Payer: Hawaii Medical Service Association Medicare	$49,194.22
Rate for Payer: Humana Medicare	$49,194.22
Rate for Payer: Kaiser Permanente Medicare	$49,194.22
Rate for Payer: Ohana Health Plan Medicare	$49,194.22
Rate for Payer: UnitedHealthcare Medicare	$49,194.22

OTHER CARDIOTHORACIC PROCEDURES WITHOUT MCC

Facility

$112,679.31

Service Code	MSDRG 229
Min. Negotiated Rate	$31,475.28
Max. Negotiated Rate	$112,679.31
Rate for Payer: AlohaCare Medicare	$31,475.28
Rate for Payer: Hawaii Medical Service Association Commercial	$112,679.31
Rate for Payer: Hawaii Medical Service Association Medicare	$31,475.28
Rate for Payer: Humana Medicare	$31,475.28
Rate for Payer: Kaiser Permanente Medicare	$31,475.28
Rate for Payer: Ohana Health Plan Medicare	$31,475.28
Rate for Payer: UnitedHealthcare Medicare	$31,475.28

OTHER CEREBROVASCULAR DISORDERS WITH CC

Facility

$26,238.11

Service Code	MSDRG 071
Min. Negotiated Rate	$10,547.42
Max. Negotiated Rate	$26,238.11
Rate for Payer: AlohaCare Medicare	$10,547.42
Rate for Payer: Hawaii Medical Service Association Commercial	$26,238.11
Rate for Payer: Hawaii Medical Service Association Medicare	$10,547.42
Rate for Payer: Humana Medicare	$10,547.42
Rate for Payer: Kaiser Permanente Medicare	$10,547.42
Rate for Payer: Ohana Health Plan Medicare	$10,547.42
Rate for Payer: UnitedHealthcare Medicare	$10,547.42

OTHER CEREBROVASCULAR DISORDERS WITH MCC

Facility

$27,968.36

Service Code	MSDRG 070
Min. Negotiated Rate	$16,843.04
Max. Negotiated Rate	$27,968.36
Rate for Payer: AlohaCare Medicare	$16,843.04
Rate for Payer: Hawaii Medical Service Association Commercial	$27,968.36
Rate for Payer: Hawaii Medical Service Association Medicare	$16,843.04
Rate for Payer: Humana Medicare	$16,843.04
Rate for Payer: Kaiser Permanente Medicare	$16,843.04
Rate for Payer: Ohana Health Plan Medicare	$16,843.04
Rate for Payer: UnitedHealthcare Medicare	$16,843.04

Know your out-of-pocket cost for care.

All Charges