Samuel Mahelona Memorial Hospital

All Charges

Charge

Type

Setting

Price

OTITIS MEDIA AND URI WITHOUT MCC

Facility

$10,547.39

Service Code	MSDRG 153
Min. Negotiated Rate	$10,547.39
Max. Negotiated Rate	$10,547.39
Rate for Payer: Hawaii Medical Service Association Commercial	$10,547.39

OT Low Complex Units

Facility

$516.00

Service Code	HCPCS 97165 GO,CO
Hospital Charge Code	9663481
Hospital Revenue Code	434
Min. Negotiated Rate	$107.85
Max. Negotiated Rate	$500.52
Rate for Payer: AlohaCare Medicaid	$258.00
Rate for Payer: AlohaCare Medicare	$258.00
Rate for Payer: Cash Price	$335.40
Rate for Payer: Cash Price	$335.40
Rate for Payer: Devoted Health Medicare	$283.80
Rate for Payer: Hawaii Medical Service Association Medicare	$258.00
Rate for Payer: Hawaii Western Management Group Commercial	$490.20
Rate for Payer: Health Management Network Commercial	$438.60
Rate for Payer: Humana Medicare	$258.00
Rate for Payer: Kaiser Permanente Commercial	$464.40
Rate for Payer: Kaiser Permanente Medicaid	$263.16
Rate for Payer: Kaiser Permanente Medicare	$258.00
Rate for Payer: MDX Hawaii PPO	$500.52
Rate for Payer: Ohana Health Plan Medicaid	$258.00
Rate for Payer: Ohana Health Plan Medicare	$258.00
Rate for Payer: UnitedHealthcare Medicaid	$107.85
Rate for Payer: UnitedHealthcare Medicare	$258.00
Rate for Payer: University Health Alliance Commercial	$288.96

OT Low Complex Units

Facility

$516.00

Service Code	HCPCS 97165 GO
Hospital Charge Code	8123903
Hospital Revenue Code	434
Min. Negotiated Rate	$107.85
Max. Negotiated Rate	$500.52
Rate for Payer: AlohaCare Medicaid	$258.00
Rate for Payer: AlohaCare Medicare	$258.00
Rate for Payer: Cash Price	$335.40
Rate for Payer: Cash Price	$335.40
Rate for Payer: Devoted Health Medicare	$283.80
Rate for Payer: Hawaii Medical Service Association Medicare	$258.00
Rate for Payer: Hawaii Western Management Group Commercial	$490.20
Rate for Payer: Health Management Network Commercial	$438.60
Rate for Payer: Humana Medicare	$258.00
Rate for Payer: Kaiser Permanente Commercial	$464.40
Rate for Payer: Kaiser Permanente Medicaid	$263.16
Rate for Payer: Kaiser Permanente Medicare	$258.00
Rate for Payer: MDX Hawaii PPO	$500.52
Rate for Payer: Ohana Health Plan Medicaid	$258.00
Rate for Payer: Ohana Health Plan Medicare	$258.00
Rate for Payer: UnitedHealthcare Medicaid	$107.85
Rate for Payer: UnitedHealthcare Medicare	$258.00
Rate for Payer: University Health Alliance Commercial	$288.96

OT Low Complex Units

Facility

$516.00

Service Code	HCPCS 97165 GO
Hospital Charge Code	8123903
Hospital Revenue Code	434
Min. Negotiated Rate	$438.60
Max. Negotiated Rate	$500.52
Rate for Payer: Cash Price	$335.40
Rate for Payer: Health Management Network Commercial	$438.60
Rate for Payer: Kaiser Permanente Commercial	$464.40
Rate for Payer: MDX Hawaii PPO	$500.52

OT Low Complex Units

Facility

$516.00

Service Code	HCPCS 97165 GO,CO
Hospital Charge Code	9663481
Hospital Revenue Code	434
Min. Negotiated Rate	$438.60
Max. Negotiated Rate	$500.52
Rate for Payer: Cash Price	$335.40
Rate for Payer: Health Management Network Commercial	$438.60
Rate for Payer: Kaiser Permanente Commercial	$464.40
Rate for Payer: MDX Hawaii PPO	$500.52

OT Manual Therapy Assistant Units

Facility

$231.00

Service Code	HCPCS 97140 GO,CO
Hospital Charge Code	8725602
Hospital Revenue Code	430
Min. Negotiated Rate	$196.35
Max. Negotiated Rate	$224.07
Rate for Payer: Cash Price	$150.15
Rate for Payer: Health Management Network Commercial	$196.35
Rate for Payer: Kaiser Permanente Commercial	$207.90
Rate for Payer: MDX Hawaii PPO	$224.07

OT Manual Therapy Assistant Units

Facility

$231.00

Service Code	HCPCS 97140 GO,CO
Hospital Charge Code	8725602
Hospital Revenue Code	430
Min. Negotiated Rate	$20.55
Max. Negotiated Rate	$224.07
Rate for Payer: AlohaCare Medicaid	$115.50
Rate for Payer: AlohaCare Medicare	$115.50
Rate for Payer: Cash Price	$150.15
Rate for Payer: Cash Price	$150.15
Rate for Payer: Devoted Health Medicare	$127.05
Rate for Payer: Hawaii Medical Service Association Medicare	$115.50
Rate for Payer: Hawaii Western Management Group Commercial	$219.45
Rate for Payer: Health Management Network Commercial	$196.35
Rate for Payer: Humana Medicare	$115.50
Rate for Payer: Kaiser Permanente Commercial	$207.90
Rate for Payer: Kaiser Permanente Medicaid	$117.81
Rate for Payer: Kaiser Permanente Medicare	$115.50
Rate for Payer: MDX Hawaii PPO	$224.07
Rate for Payer: Ohana Health Plan Medicaid	$115.50
Rate for Payer: Ohana Health Plan Medicare	$115.50
Rate for Payer: UnitedHealthcare Medicaid	$20.55
Rate for Payer: UnitedHealthcare Medicare	$115.50
Rate for Payer: University Health Alliance Commercial	$129.36

OT Manual Therapy Charge Units

Facility

$231.00

Service Code	HCPCS 97140 GO
Hospital Charge Code	750909
Hospital Revenue Code	430
Min. Negotiated Rate	$196.35
Max. Negotiated Rate	$224.07
Rate for Payer: Cash Price	$150.15
Rate for Payer: Health Management Network Commercial	$196.35
Rate for Payer: Kaiser Permanente Commercial	$207.90
Rate for Payer: MDX Hawaii PPO	$224.07

OT Manual Therapy Charge Units

Facility

$231.00

Service Code	HCPCS 97140 GO
Hospital Charge Code	750909
Hospital Revenue Code	430
Min. Negotiated Rate	$20.55
Max. Negotiated Rate	$224.07
Rate for Payer: AlohaCare Medicaid	$115.50
Rate for Payer: AlohaCare Medicare	$115.50
Rate for Payer: Cash Price	$150.15
Rate for Payer: Cash Price	$150.15
Rate for Payer: Devoted Health Medicare	$127.05
Rate for Payer: Hawaii Medical Service Association Medicare	$115.50
Rate for Payer: Hawaii Western Management Group Commercial	$219.45
Rate for Payer: Health Management Network Commercial	$196.35
Rate for Payer: Humana Medicare	$115.50
Rate for Payer: Kaiser Permanente Commercial	$207.90
Rate for Payer: Kaiser Permanente Medicaid	$117.81
Rate for Payer: Kaiser Permanente Medicare	$115.50
Rate for Payer: MDX Hawaii PPO	$224.07
Rate for Payer: Ohana Health Plan Medicaid	$115.50
Rate for Payer: Ohana Health Plan Medicare	$115.50
Rate for Payer: UnitedHealthcare Medicaid	$20.55
Rate for Payer: UnitedHealthcare Medicare	$115.50
Rate for Payer: University Health Alliance Commercial	$129.36

OT Massage Assistant Units

Facility

$207.00

Service Code	HCPCS 97124 GO,CO
Hospital Charge Code	8725599
Hospital Revenue Code	430
Min. Negotiated Rate	$15.39
Max. Negotiated Rate	$200.79
Rate for Payer: AlohaCare Medicaid	$103.50
Rate for Payer: AlohaCare Medicare	$103.50
Rate for Payer: Cash Price	$134.55
Rate for Payer: Cash Price	$134.55
Rate for Payer: Devoted Health Medicare	$113.85
Rate for Payer: Hawaii Medical Service Association Medicare	$103.50
Rate for Payer: Hawaii Western Management Group Commercial	$196.65
Rate for Payer: Health Management Network Commercial	$175.95
Rate for Payer: Humana Medicare	$103.50
Rate for Payer: Kaiser Permanente Commercial	$186.30
Rate for Payer: Kaiser Permanente Medicaid	$105.57
Rate for Payer: Kaiser Permanente Medicare	$103.50
Rate for Payer: MDX Hawaii PPO	$200.79
Rate for Payer: Ohana Health Plan Medicaid	$103.50
Rate for Payer: Ohana Health Plan Medicare	$103.50
Rate for Payer: UnitedHealthcare Medicaid	$15.39
Rate for Payer: UnitedHealthcare Medicare	$103.50
Rate for Payer: University Health Alliance Commercial	$115.92

OT Massage Assistant Units

Facility

$207.00

Service Code	HCPCS 97124 GO,CO
Hospital Charge Code	8725599
Hospital Revenue Code	430
Min. Negotiated Rate	$175.95
Max. Negotiated Rate	$200.79
Rate for Payer: Cash Price	$134.55
Rate for Payer: Health Management Network Commercial	$175.95
Rate for Payer: Kaiser Permanente Commercial	$186.30
Rate for Payer: MDX Hawaii PPO	$200.79

OT Massage Charge Units

Facility

$207.00

Service Code	HCPCS 97124 GO
Hospital Charge Code	1041799
Hospital Revenue Code	430
Min. Negotiated Rate	$15.39
Max. Negotiated Rate	$200.79
Rate for Payer: AlohaCare Medicaid	$103.50
Rate for Payer: AlohaCare Medicare	$103.50
Rate for Payer: Cash Price	$134.55
Rate for Payer: Cash Price	$134.55
Rate for Payer: Devoted Health Medicare	$113.85
Rate for Payer: Hawaii Medical Service Association Medicare	$103.50
Rate for Payer: Hawaii Western Management Group Commercial	$196.65
Rate for Payer: Health Management Network Commercial	$175.95
Rate for Payer: Humana Medicare	$103.50
Rate for Payer: Kaiser Permanente Commercial	$186.30
Rate for Payer: Kaiser Permanente Medicaid	$105.57
Rate for Payer: Kaiser Permanente Medicare	$103.50
Rate for Payer: MDX Hawaii PPO	$200.79
Rate for Payer: Ohana Health Plan Medicaid	$103.50
Rate for Payer: Ohana Health Plan Medicare	$103.50
Rate for Payer: UnitedHealthcare Medicaid	$15.39
Rate for Payer: UnitedHealthcare Medicare	$103.50
Rate for Payer: University Health Alliance Commercial	$115.92

OT Massage Charge Units

Facility

$207.00

Service Code	HCPCS 97124 GO
Hospital Charge Code	1041799
Hospital Revenue Code	430
Min. Negotiated Rate	$175.95
Max. Negotiated Rate	$200.79
Rate for Payer: Cash Price	$134.55
Rate for Payer: Health Management Network Commercial	$175.95
Rate for Payer: Kaiser Permanente Commercial	$186.30
Rate for Payer: MDX Hawaii PPO	$200.79

OT Moderate Complex Units

Facility

$588.00

Service Code	HCPCS 97166 GO
Hospital Charge Code	8123905
Hospital Revenue Code	434
Min. Negotiated Rate	$499.80
Max. Negotiated Rate	$570.36
Rate for Payer: Cash Price	$382.20
Rate for Payer: Health Management Network Commercial	$499.80
Rate for Payer: Kaiser Permanente Commercial	$529.20
Rate for Payer: MDX Hawaii PPO	$570.36

OT Moderate Complex Units

Facility

$588.00

Service Code	HCPCS 97166 GO
Hospital Charge Code	8123905
Hospital Revenue Code	434
Min. Negotiated Rate	$107.85
Max. Negotiated Rate	$570.36
Rate for Payer: AlohaCare Medicaid	$294.00
Rate for Payer: AlohaCare Medicare	$294.00
Rate for Payer: Cash Price	$382.20
Rate for Payer: Cash Price	$382.20
Rate for Payer: Devoted Health Medicare	$323.40
Rate for Payer: Hawaii Medical Service Association Medicare	$294.00
Rate for Payer: Hawaii Western Management Group Commercial	$558.60
Rate for Payer: Health Management Network Commercial	$499.80
Rate for Payer: Humana Medicare	$294.00
Rate for Payer: Kaiser Permanente Commercial	$529.20
Rate for Payer: Kaiser Permanente Medicaid	$299.88
Rate for Payer: Kaiser Permanente Medicare	$294.00
Rate for Payer: MDX Hawaii PPO	$570.36
Rate for Payer: Ohana Health Plan Medicaid	$294.00
Rate for Payer: Ohana Health Plan Medicare	$294.00
Rate for Payer: UnitedHealthcare Medicaid	$107.85
Rate for Payer: UnitedHealthcare Medicare	$294.00
Rate for Payer: University Health Alliance Commercial	$329.28

OT Neuromuscular Reeducation Assist Unit

Facility

$266.00

Service Code	HCPCS 97112 GO,CO
Hospital Charge Code	8725597
Hospital Revenue Code	430
Min. Negotiated Rate	$18.58
Max. Negotiated Rate	$258.02
Rate for Payer: AlohaCare Medicaid	$133.00
Rate for Payer: AlohaCare Medicare	$133.00
Rate for Payer: Cash Price	$172.90
Rate for Payer: Cash Price	$172.90
Rate for Payer: Devoted Health Medicare	$146.30
Rate for Payer: Hawaii Medical Service Association Medicare	$133.00
Rate for Payer: Hawaii Western Management Group Commercial	$252.70
Rate for Payer: Health Management Network Commercial	$226.10
Rate for Payer: Humana Medicare	$133.00
Rate for Payer: Kaiser Permanente Commercial	$239.40
Rate for Payer: Kaiser Permanente Medicaid	$135.66
Rate for Payer: Kaiser Permanente Medicare	$133.00
Rate for Payer: MDX Hawaii PPO	$258.02
Rate for Payer: Ohana Health Plan Medicaid	$133.00
Rate for Payer: Ohana Health Plan Medicare	$133.00
Rate for Payer: UnitedHealthcare Medicaid	$18.58
Rate for Payer: UnitedHealthcare Medicare	$133.00
Rate for Payer: University Health Alliance Commercial	$148.96

OT Neuromuscular Reeducation Assist Unit

Facility

$266.00

Service Code	HCPCS 97112 GO,CO
Hospital Charge Code	8725597
Hospital Revenue Code	430
Min. Negotiated Rate	$226.10
Max. Negotiated Rate	$258.02
Rate for Payer: Cash Price	$172.90
Rate for Payer: Health Management Network Commercial	$226.10
Rate for Payer: Kaiser Permanente Commercial	$239.40
Rate for Payer: MDX Hawaii PPO	$258.02

OT Neuromuscular Reeducation Charges

Facility

$266.00

Service Code	HCPCS 97112 GO
Hospital Charge Code	750905
Hospital Revenue Code	430
Min. Negotiated Rate	$18.58
Max. Negotiated Rate	$258.02
Rate for Payer: AlohaCare Medicaid	$133.00
Rate for Payer: AlohaCare Medicare	$133.00
Rate for Payer: Cash Price	$172.90
Rate for Payer: Cash Price	$172.90
Rate for Payer: Devoted Health Medicare	$146.30
Rate for Payer: Hawaii Medical Service Association Medicare	$133.00
Rate for Payer: Hawaii Western Management Group Commercial	$252.70
Rate for Payer: Health Management Network Commercial	$226.10
Rate for Payer: Humana Medicare	$133.00
Rate for Payer: Kaiser Permanente Commercial	$239.40
Rate for Payer: Kaiser Permanente Medicaid	$135.66
Rate for Payer: Kaiser Permanente Medicare	$133.00
Rate for Payer: MDX Hawaii PPO	$258.02
Rate for Payer: Ohana Health Plan Medicaid	$133.00
Rate for Payer: Ohana Health Plan Medicare	$133.00
Rate for Payer: UnitedHealthcare Medicaid	$18.58
Rate for Payer: UnitedHealthcare Medicare	$133.00
Rate for Payer: University Health Alliance Commercial	$148.96

OT Neuromuscular Reeducation Charges

Facility

$266.00

Service Code	HCPCS 97112 GO
Hospital Charge Code	750905
Hospital Revenue Code	430
Min. Negotiated Rate	$226.10
Max. Negotiated Rate	$258.02
Rate for Payer: Cash Price	$172.90
Rate for Payer: Health Management Network Commercial	$226.10
Rate for Payer: Kaiser Permanente Commercial	$239.40
Rate for Payer: MDX Hawaii PPO	$258.02

Otoacoustic emissions - Newborn Hearing Test Type

Facility

$767.00

Service Code	HCPCS 92587
Hospital Charge Code	8347419
Hospital Revenue Code	471
Min. Negotiated Rate	$43.74
Max. Negotiated Rate	$743.99
Rate for Payer: AlohaCare Medicaid	$383.50
Rate for Payer: AlohaCare Medicare	$383.50
Rate for Payer: Cash Price	$498.55
Rate for Payer: Cash Price	$498.55
Rate for Payer: Devoted Health Medicare	$421.85
Rate for Payer: Hawaii Medical Service Association ABD	$43.74
Rate for Payer: Hawaii Medical Service Association Commercial	$275.75
Rate for Payer: Hawaii Medical Service Association Medicare	$383.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$47.25
Rate for Payer: Hawaii Western Management Group Commercial	$728.65
Rate for Payer: Health Management Network Commercial	$651.95
Rate for Payer: Humana Medicare	$383.50
Rate for Payer: Kaiser Permanente Commercial	$690.30
Rate for Payer: Kaiser Permanente Medicaid	$391.17
Rate for Payer: Kaiser Permanente Medicare	$383.50
Rate for Payer: MDX Hawaii PPO	$743.99
Rate for Payer: Ohana Health Plan Medicaid	$383.50
Rate for Payer: Ohana Health Plan Medicare	$383.50
Rate for Payer: UnitedHealthcare Medicaid	$43.74
Rate for Payer: UnitedHealthcare Medicare	$383.50
Rate for Payer: University Health Alliance Commercial	$429.52

Otoacoustic emissions - Newborn Hearing Test Type

Facility

$767.00

Service Code	HCPCS 92587
Hospital Charge Code	8347419
Hospital Revenue Code	471
Min. Negotiated Rate	$651.95
Max. Negotiated Rate	$743.99
Rate for Payer: Cash Price	$498.55
Rate for Payer: Health Management Network Commercial	$651.95
Rate for Payer: Kaiser Permanente Commercial	$690.30
Rate for Payer: MDX Hawaii PPO	$743.99

OT Orthotic Mgmt, Train Assistant Units

Facility

$282.00

Service Code	HCPCS 97760 GO,CO
Hospital Charge Code	8725625
Hospital Revenue Code	430
Min. Negotiated Rate	$239.70
Max. Negotiated Rate	$273.54
Rate for Payer: Cash Price	$183.30
Rate for Payer: Health Management Network Commercial	$239.70
Rate for Payer: Kaiser Permanente Commercial	$253.80
Rate for Payer: MDX Hawaii PPO	$273.54

OT Orthotic Mgmt, Train Assistant Units

Facility

$282.00

Service Code	HCPCS 97760 GO,CO
Hospital Charge Code	8725625
Hospital Revenue Code	430
Min. Negotiated Rate	$17.21
Max. Negotiated Rate	$273.54
Rate for Payer: AlohaCare Medicaid	$141.00
Rate for Payer: AlohaCare Medicare	$141.00
Rate for Payer: Cash Price	$183.30
Rate for Payer: Cash Price	$183.30
Rate for Payer: Devoted Health Medicare	$155.10
Rate for Payer: Hawaii Medical Service Association Medicare	$141.00
Rate for Payer: Hawaii Western Management Group Commercial	$267.90
Rate for Payer: Health Management Network Commercial	$239.70
Rate for Payer: Humana Medicare	$141.00
Rate for Payer: Kaiser Permanente Commercial	$253.80
Rate for Payer: Kaiser Permanente Medicaid	$143.82
Rate for Payer: Kaiser Permanente Medicare	$141.00
Rate for Payer: MDX Hawaii PPO	$273.54
Rate for Payer: Ohana Health Plan Medicaid	$141.00
Rate for Payer: Ohana Health Plan Medicare	$141.00
Rate for Payer: UnitedHealthcare Medicaid	$17.21
Rate for Payer: UnitedHealthcare Medicare	$141.00
Rate for Payer: University Health Alliance Commercial	$157.92

OT Orthotic Mgmt/Train Establish Charge

Facility

$353.00

Service Code	HCPCS 97763 GO
Hospital Charge Code	8123922
Hospital Revenue Code	430
Min. Negotiated Rate	$300.05
Max. Negotiated Rate	$342.41
Rate for Payer: Cash Price	$229.45
Rate for Payer: Health Management Network Commercial	$300.05
Rate for Payer: Kaiser Permanente Commercial	$317.70
Rate for Payer: MDX Hawaii PPO	$342.41

OT Orthotic Mgmt/Train Establish Charge

Facility

$353.00

Service Code	HCPCS 97763 GO
Hospital Charge Code	8123922
Hospital Revenue Code	430
Min. Negotiated Rate	$57.47
Max. Negotiated Rate	$342.41
Rate for Payer: AlohaCare Medicaid	$176.50
Rate for Payer: AlohaCare Medicare	$176.50
Rate for Payer: Cash Price	$229.45
Rate for Payer: Cash Price	$229.45
Rate for Payer: Devoted Health Medicare	$194.15
Rate for Payer: Hawaii Medical Service Association Medicare	$176.50
Rate for Payer: Hawaii Western Management Group Commercial	$335.35
Rate for Payer: Health Management Network Commercial	$300.05
Rate for Payer: Humana Medicare	$176.50
Rate for Payer: Kaiser Permanente Commercial	$317.70
Rate for Payer: Kaiser Permanente Medicaid	$180.03
Rate for Payer: Kaiser Permanente Medicare	$176.50
Rate for Payer: MDX Hawaii PPO	$342.41
Rate for Payer: Ohana Health Plan Medicaid	$176.50
Rate for Payer: Ohana Health Plan Medicare	$176.50
Rate for Payer: UnitedHealthcare Medicaid	$57.47
Rate for Payer: UnitedHealthcare Medicare	$176.50
Rate for Payer: University Health Alliance Commercial	$197.68

Know your out-of-pocket cost for care.

All Charges