Leahi Hospital

All Charges

Charge

Type

Setting

Price

AMPUTATION OF LOWER LIMB FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS WITH CC

Facility

$71,603.74

Service Code	MSDRG 617
Min. Negotiated Rate	$18,868.31
Max. Negotiated Rate	$71,603.74
Rate for Payer: AlohaCare Medicare	$18,868.31
Rate for Payer: Hawaii Medical Service Association Commercial	$71,603.74
Rate for Payer: Hawaii Medical Service Association Medicare	$18,868.31
Rate for Payer: Humana Medicare	$18,868.31
Rate for Payer: Kaiser Permanente Medicare	$18,868.31
Rate for Payer: Ohana Health Plan Medicare	$18,868.31
Rate for Payer: UnitedHealthcare Medicare	$18,868.31

AMPUTATION OF LOWER LIMB FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS WITH MCC

Facility

$71,603.74

Service Code	MSDRG 616
Min. Negotiated Rate	$34,805.41
Max. Negotiated Rate	$71,603.74
Rate for Payer: AlohaCare Medicare	$34,805.41
Rate for Payer: Hawaii Medical Service Association Commercial	$71,603.74
Rate for Payer: Hawaii Medical Service Association Medicare	$34,805.41
Rate for Payer: Humana Medicare	$34,805.41
Rate for Payer: Kaiser Permanente Medicare	$34,805.41
Rate for Payer: Ohana Health Plan Medicare	$34,805.41
Rate for Payer: UnitedHealthcare Medicare	$34,805.41

AMPUTATION OF LOWER LIMB FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS WITHOUT CC/MCC

Facility

$71,603.74

Service Code	MSDRG 618
Min. Negotiated Rate	$14,413.69
Max. Negotiated Rate	$71,603.74
Rate for Payer: AlohaCare Medicare	$14,413.69
Rate for Payer: Hawaii Medical Service Association Commercial	$71,603.74
Rate for Payer: Hawaii Medical Service Association Medicare	$14,413.69
Rate for Payer: Humana Medicare	$14,413.69
Rate for Payer: Kaiser Permanente Medicare	$14,413.69
Rate for Payer: Ohana Health Plan Medicare	$14,413.69
Rate for Payer: UnitedHealthcare Medicare	$14,413.69

ANAL AND STOMAL PROCEDURES WITH CC

Facility

$22,872.43

Service Code	MSDRG 348
Min. Negotiated Rate	$13,334.52
Max. Negotiated Rate	$22,872.43
Rate for Payer: AlohaCare Medicare	$13,334.52
Rate for Payer: Hawaii Medical Service Association Commercial	$22,872.43
Rate for Payer: Hawaii Medical Service Association Medicare	$13,334.52
Rate for Payer: Humana Medicare	$13,334.52
Rate for Payer: Kaiser Permanente Medicare	$13,334.52
Rate for Payer: Ohana Health Plan Medicare	$13,334.52
Rate for Payer: UnitedHealthcare Medicare	$13,334.52

ANAL AND STOMAL PROCEDURES WITH MCC

Facility

$28,513.51

Service Code	MSDRG 347
Min. Negotiated Rate	$23,059.79
Max. Negotiated Rate	$28,513.51
Rate for Payer: AlohaCare Medicare	$23,059.79
Rate for Payer: Hawaii Medical Service Association Commercial	$28,513.51
Rate for Payer: Hawaii Medical Service Association Medicare	$23,059.79
Rate for Payer: Humana Medicare	$23,059.79
Rate for Payer: Kaiser Permanente Medicare	$23,059.79
Rate for Payer: Ohana Health Plan Medicare	$23,059.79
Rate for Payer: UnitedHealthcare Medicare	$23,059.79

ANAL AND STOMAL PROCEDURES WITHOUT CC/MCC

Facility

$14,197.50

Service Code	MSDRG 349
Min. Negotiated Rate	$9,015.91
Max. Negotiated Rate	$14,197.50
Rate for Payer: AlohaCare Medicare	$9,015.91
Rate for Payer: Hawaii Medical Service Association Commercial	$14,197.50
Rate for Payer: Hawaii Medical Service Association Medicare	$9,015.91
Rate for Payer: Humana Medicare	$9,015.91
Rate for Payer: Kaiser Permanente Medicare	$9,015.91
Rate for Payer: Ohana Health Plan Medicare	$9,015.91
Rate for Payer: UnitedHealthcare Medicare	$9,015.91

ANGINA PECTORIS

Facility

$12,704.27

Service Code	MSDRG 311
Min. Negotiated Rate	$7,353.30
Max. Negotiated Rate	$12,704.27
Rate for Payer: AlohaCare Medicare	$7,353.30
Rate for Payer: Hawaii Medical Service Association Commercial	$12,704.27
Rate for Payer: Hawaii Medical Service Association Medicare	$7,353.30
Rate for Payer: Humana Medicare	$7,353.30
Rate for Payer: Kaiser Permanente Medicare	$7,353.30
Rate for Payer: Ohana Health Plan Medicare	$7,353.30
Rate for Payer: UnitedHealthcare Medicare	$7,353.30

AORTIC AND HEART ASSIST PROCEDURES EXCEPT PULSATION BALLOON WITH MCC

Facility

$111,280.89

Service Code	MSDRG 268
Min. Negotiated Rate	$68,220.00
Max. Negotiated Rate	$111,280.89
Rate for Payer: AlohaCare Medicare	$68,220.00
Rate for Payer: Hawaii Medical Service Association Commercial	$111,280.89
Rate for Payer: Hawaii Medical Service Association Medicare	$68,220.00
Rate for Payer: Humana Medicare	$68,220.00
Rate for Payer: Kaiser Permanente Medicare	$68,220.00
Rate for Payer: Ohana Health Plan Medicare	$68,220.00
Rate for Payer: UnitedHealthcare Medicare	$68,220.00

AORTIC AND HEART ASSIST PROCEDURES EXCEPT PULSATION BALLOON WITHOUT MCC

Facility

$96,040.50

Service Code	MSDRG 269
Min. Negotiated Rate	$42,056.99
Max. Negotiated Rate	$96,040.50
Rate for Payer: AlohaCare Medicare	$42,056.99
Rate for Payer: Hawaii Medical Service Association Commercial	$96,040.50
Rate for Payer: Hawaii Medical Service Association Medicare	$42,056.99
Rate for Payer: Humana Medicare	$42,056.99
Rate for Payer: Kaiser Permanente Medicare	$42,056.99
Rate for Payer: Ohana Health Plan Medicare	$42,056.99
Rate for Payer: UnitedHealthcare Medicare	$42,056.99

APPENDIX PROCEDURES WITH CC

Facility

$31,689.57

Service Code	MSDRG 398
Min. Negotiated Rate	$15,352.90
Max. Negotiated Rate	$31,689.57
Rate for Payer: AlohaCare Medicare	$15,352.90
Rate for Payer: Hawaii Medical Service Association Commercial	$31,689.57
Rate for Payer: Hawaii Medical Service Association Medicare	$15,352.90
Rate for Payer: Humana Medicare	$15,352.90
Rate for Payer: Kaiser Permanente Medicare	$15,352.90
Rate for Payer: Ohana Health Plan Medicare	$15,352.90
Rate for Payer: UnitedHealthcare Medicare	$15,352.90

APPENDIX PROCEDURES WITH MCC

Facility

$34,320.50

Service Code	MSDRG 397
Min. Negotiated Rate	$24,038.42
Max. Negotiated Rate	$34,320.50
Rate for Payer: AlohaCare Medicare	$24,038.42
Rate for Payer: Hawaii Medical Service Association Commercial	$34,320.50
Rate for Payer: Hawaii Medical Service Association Medicare	$24,038.42
Rate for Payer: Humana Medicare	$24,038.42
Rate for Payer: Kaiser Permanente Medicare	$24,038.42
Rate for Payer: Ohana Health Plan Medicare	$24,038.42
Rate for Payer: UnitedHealthcare Medicare	$24,038.42

APPENDIX PROCEDURES WITHOUT CC/MCC

Facility

$23,654.60

Service Code	MSDRG 399
Min. Negotiated Rate	$11,717.26
Max. Negotiated Rate	$23,654.60
Rate for Payer: AlohaCare Medicare	$11,717.26
Rate for Payer: Hawaii Medical Service Association Commercial	$23,654.60
Rate for Payer: Hawaii Medical Service Association Medicare	$11,717.26
Rate for Payer: Humana Medicare	$11,717.26
Rate for Payer: Kaiser Permanente Medicare	$11,717.26
Rate for Payer: Ohana Health Plan Medicare	$11,717.26
Rate for Payer: UnitedHealthcare Medicare	$11,717.26

App finger splint

Facility

$467.00

Service Code	HCPCS 29130 GO
Hospital Charge Code	OT29130
Hospital Revenue Code	430
Min. Negotiated Rate	$18.15
Max. Negotiated Rate	$452.99
Rate for Payer: AlohaCare Medicaid	$233.50
Rate for Payer: Cash Price	$303.55
Rate for Payer: Cash Price	$303.55
Rate for Payer: Hawaii Western Management Group Commercial	$443.65
Rate for Payer: Health Management Network Commercial	$396.95
Rate for Payer: Kaiser Permanente Commercial	$420.30
Rate for Payer: Kaiser Permanente Medicaid	$238.17
Rate for Payer: MDX Hawaii PPO	$452.99
Rate for Payer: UnitedHealthcare Medicaid	$18.15
Rate for Payer: University Health Alliance Commercial	$340.40

App finger splint

Facility

$467.00

Service Code	HCPCS 29130 GO
Hospital Charge Code	OT29130
Hospital Revenue Code	430
Min. Negotiated Rate	$396.95
Max. Negotiated Rate	$452.99
Rate for Payer: Cash Price	$303.55
Rate for Payer: Health Management Network Commercial	$396.95
Rate for Payer: Kaiser Permanente Commercial	$420.30
Rate for Payer: MDX Hawaii PPO	$452.99

App finger splint dynam

Facility

$467.00

Service Code	HCPCS 29131 GO
Hospital Charge Code	OT29131
Hospital Revenue Code	430
Min. Negotiated Rate	$396.95
Max. Negotiated Rate	$452.99
Rate for Payer: Cash Price	$303.55
Rate for Payer: Health Management Network Commercial	$396.95
Rate for Payer: Kaiser Permanente Commercial	$420.30
Rate for Payer: MDX Hawaii PPO	$452.99

App finger splint dynam

Facility

$467.00

Service Code	HCPCS 29131 GO
Hospital Charge Code	OT29131
Hospital Revenue Code	430
Min. Negotiated Rate	$22.28
Max. Negotiated Rate	$452.99
Rate for Payer: AlohaCare Medicaid	$233.50
Rate for Payer: Cash Price	$303.55
Rate for Payer: Cash Price	$303.55
Rate for Payer: Hawaii Western Management Group Commercial	$443.65
Rate for Payer: Health Management Network Commercial	$396.95
Rate for Payer: Kaiser Permanente Commercial	$420.30
Rate for Payer: Kaiser Permanente Medicaid	$238.17
Rate for Payer: MDX Hawaii PPO	$452.99
Rate for Payer: UnitedHealthcare Medicaid	$22.28
Rate for Payer: University Health Alliance Commercial	$340.40

Appl;elbow to finger sa

Facility

$961.00

Service Code	HCPCS 29075 GO
Hospital Charge Code	OT29075
Hospital Revenue Code	430
Min. Negotiated Rate	$37.14
Max. Negotiated Rate	$932.17
Rate for Payer: AlohaCare Medicaid	$480.50
Rate for Payer: Cash Price	$624.65
Rate for Payer: Cash Price	$624.65
Rate for Payer: Hawaii Western Management Group Commercial	$912.95
Rate for Payer: Health Management Network Commercial	$816.85
Rate for Payer: Kaiser Permanente Commercial	$864.90
Rate for Payer: Kaiser Permanente Medicaid	$490.11
Rate for Payer: MDX Hawaii PPO	$932.17
Rate for Payer: UnitedHealthcare Medicaid	$37.14
Rate for Payer: University Health Alliance Commercial	$700.47

Appl;elbow to finger sa

Facility

$961.00

Service Code	HCPCS 29075 GO
Hospital Charge Code	OT29075
Hospital Revenue Code	430
Min. Negotiated Rate	$816.85
Max. Negotiated Rate	$932.17
Rate for Payer: Cash Price	$624.65
Rate for Payer: Health Management Network Commercial	$816.85
Rate for Payer: Kaiser Permanente Commercial	$864.90
Rate for Payer: MDX Hawaii PPO	$932.17

Appl;hand & lower f/arm

Facility

$467.00

Service Code	HCPCS 29085 GO
Hospital Charge Code	OT29085
Hospital Revenue Code	430
Min. Negotiated Rate	$38.35
Max. Negotiated Rate	$452.99
Rate for Payer: AlohaCare Medicaid	$233.50
Rate for Payer: Cash Price	$303.55
Rate for Payer: Cash Price	$303.55
Rate for Payer: Hawaii Western Management Group Commercial	$443.65
Rate for Payer: Health Management Network Commercial	$396.95
Rate for Payer: Kaiser Permanente Commercial	$420.30
Rate for Payer: Kaiser Permanente Medicaid	$238.17
Rate for Payer: MDX Hawaii PPO	$452.99
Rate for Payer: UnitedHealthcare Medicaid	$38.35
Rate for Payer: University Health Alliance Commercial	$340.40

Appl;hand & lower f/arm

Facility

$467.00

Service Code	HCPCS 29085 GO
Hospital Charge Code	OT29085
Hospital Revenue Code	430
Min. Negotiated Rate	$396.95
Max. Negotiated Rate	$452.99
Rate for Payer: Cash Price	$303.55
Rate for Payer: Health Management Network Commercial	$396.95
Rate for Payer: Kaiser Permanente Commercial	$420.30
Rate for Payer: MDX Hawaii PPO	$452.99

App long arm splint

Facility

$467.00

Service Code	HCPCS 29105 GO
Hospital Charge Code	OT29105
Hospital Revenue Code	430
Min. Negotiated Rate	$34.95
Max. Negotiated Rate	$452.99
Rate for Payer: AlohaCare Medicaid	$233.50
Rate for Payer: Cash Price	$303.55
Rate for Payer: Cash Price	$303.55
Rate for Payer: Hawaii Western Management Group Commercial	$443.65
Rate for Payer: Health Management Network Commercial	$396.95
Rate for Payer: Kaiser Permanente Commercial	$420.30
Rate for Payer: Kaiser Permanente Medicaid	$238.17
Rate for Payer: MDX Hawaii PPO	$452.99
Rate for Payer: UnitedHealthcare Medicaid	$34.95
Rate for Payer: University Health Alliance Commercial	$340.40

App long arm splint

Facility

$467.00

Service Code	HCPCS 29105 GO
Hospital Charge Code	OT29105
Hospital Revenue Code	430
Min. Negotiated Rate	$396.95
Max. Negotiated Rate	$452.99
Rate for Payer: Cash Price	$303.55
Rate for Payer: Health Management Network Commercial	$396.95
Rate for Payer: Kaiser Permanente Commercial	$420.30
Rate for Payer: MDX Hawaii PPO	$452.99

Appl;shoulder to hand la

Facility

$801.00

Service Code	HCPCS 29065 GO
Hospital Charge Code	OT29065
Hospital Revenue Code	430
Min. Negotiated Rate	$41.56
Max. Negotiated Rate	$776.97
Rate for Payer: AlohaCare Medicaid	$400.50
Rate for Payer: Cash Price	$520.65
Rate for Payer: Cash Price	$520.65
Rate for Payer: Hawaii Western Management Group Commercial	$760.95
Rate for Payer: Health Management Network Commercial	$680.85
Rate for Payer: Kaiser Permanente Commercial	$720.90
Rate for Payer: Kaiser Permanente Medicaid	$408.51
Rate for Payer: MDX Hawaii PPO	$776.97
Rate for Payer: UnitedHealthcare Medicaid	$41.56
Rate for Payer: University Health Alliance Commercial	$583.85

Appl;shoulder to hand la

Facility

$801.00

Service Code	HCPCS 29065 GO
Hospital Charge Code	OT29065
Hospital Revenue Code	430
Min. Negotiated Rate	$680.85
Max. Negotiated Rate	$776.97
Rate for Payer: Cash Price	$520.65
Rate for Payer: Health Management Network Commercial	$680.85
Rate for Payer: Kaiser Permanente Commercial	$720.90
Rate for Payer: MDX Hawaii PPO	$776.97

App short arm splint

Facility

$467.00

Service Code	HCPCS 29125 GO
Hospital Charge Code	OT29125
Hospital Revenue Code	430
Min. Negotiated Rate	$396.95
Max. Negotiated Rate	$452.99
Rate for Payer: Cash Price	$303.55
Rate for Payer: Health Management Network Commercial	$396.95
Rate for Payer: Kaiser Permanente Commercial	$420.30
Rate for Payer: MDX Hawaii PPO	$452.99

Know your out-of-pocket cost for care.

All Charges