Samuel Mahelona Memorial Hospital

All Charges

Charge

Type

Setting

Price

OT Orthotic Mgmt/Train Est Assist Units

Facility

$283.00

Service Code	HCPCS 97763 GO,CO
Hospital Charge Code	8744286
Hospital Revenue Code	430
Min. Negotiated Rate	$240.55
Max. Negotiated Rate	$274.51
Rate for Payer: Cash Price	$183.95
Rate for Payer: Health Management Network Commercial	$240.55
Rate for Payer: Kaiser Permanente Commercial	$254.70
Rate for Payer: MDX Hawaii PPO	$274.51

OT Orthotic Mgmt/Train Est Assist Units

Facility

$283.00

Service Code	HCPCS 97763 GO,CO
Hospital Charge Code	8744286
Hospital Revenue Code	430
Min. Negotiated Rate	$57.47
Max. Negotiated Rate	$274.51
Rate for Payer: AlohaCare Medicaid	$141.50
Rate for Payer: AlohaCare Medicare	$141.50
Rate for Payer: Cash Price	$183.95
Rate for Payer: Cash Price	$183.95
Rate for Payer: Devoted Health Medicare	$155.65
Rate for Payer: Hawaii Medical Service Association Medicare	$141.50
Rate for Payer: Hawaii Western Management Group Commercial	$268.85
Rate for Payer: Health Management Network Commercial	$240.55
Rate for Payer: Humana Medicare	$141.50
Rate for Payer: Kaiser Permanente Commercial	$254.70
Rate for Payer: Kaiser Permanente Medicaid	$144.33
Rate for Payer: Kaiser Permanente Medicare	$141.50
Rate for Payer: MDX Hawaii PPO	$274.51
Rate for Payer: Ohana Health Plan Medicaid	$141.50
Rate for Payer: Ohana Health Plan Medicare	$141.50
Rate for Payer: UnitedHealthcare Medicaid	$57.47
Rate for Payer: UnitedHealthcare Medicare	$141.50
Rate for Payer: University Health Alliance Commercial	$158.48

OT Paraffin Bath Assistant Units

Facility

$56.00

Service Code	HCPCS 97018 GO,CO
Hospital Charge Code	8720893
Hospital Revenue Code	430
Min. Negotiated Rate	$6.82
Max. Negotiated Rate	$54.32
Rate for Payer: AlohaCare Medicaid	$28.00
Rate for Payer: AlohaCare Medicare	$28.00
Rate for Payer: Cash Price	$36.40
Rate for Payer: Cash Price	$36.40
Rate for Payer: Devoted Health Medicare	$30.80
Rate for Payer: Hawaii Medical Service Association Medicare	$28.00
Rate for Payer: Hawaii Western Management Group Commercial	$53.20
Rate for Payer: Health Management Network Commercial	$47.60
Rate for Payer: Humana Medicare	$28.00
Rate for Payer: Kaiser Permanente Commercial	$50.40
Rate for Payer: Kaiser Permanente Medicaid	$28.56
Rate for Payer: Kaiser Permanente Medicare	$28.00
Rate for Payer: MDX Hawaii PPO	$54.32
Rate for Payer: Ohana Health Plan Medicaid	$28.00
Rate for Payer: Ohana Health Plan Medicare	$28.00
Rate for Payer: UnitedHealthcare Medicaid	$6.82
Rate for Payer: UnitedHealthcare Medicare	$28.00
Rate for Payer: University Health Alliance Commercial	$31.36

OT Paraffin Bath Assistant Units

Facility

$56.00

Service Code	HCPCS 97018 GO,CO
Hospital Charge Code	8720893
Hospital Revenue Code	430
Min. Negotiated Rate	$47.60
Max. Negotiated Rate	$54.32
Rate for Payer: Cash Price	$36.40
Rate for Payer: Health Management Network Commercial	$47.60
Rate for Payer: Kaiser Permanente Commercial	$50.40
Rate for Payer: MDX Hawaii PPO	$54.32

OT Paraffin Bath Units

Facility

$56.00

Service Code	HCPCS 97018 GO
Hospital Charge Code	1373447
Hospital Revenue Code	430
Min. Negotiated Rate	$6.82
Max. Negotiated Rate	$54.32
Rate for Payer: AlohaCare Medicaid	$28.00
Rate for Payer: AlohaCare Medicare	$28.00
Rate for Payer: Cash Price	$36.40
Rate for Payer: Cash Price	$36.40
Rate for Payer: Devoted Health Medicare	$30.80
Rate for Payer: Hawaii Medical Service Association Medicare	$28.00
Rate for Payer: Hawaii Western Management Group Commercial	$53.20
Rate for Payer: Health Management Network Commercial	$47.60
Rate for Payer: Humana Medicare	$28.00
Rate for Payer: Kaiser Permanente Commercial	$50.40
Rate for Payer: Kaiser Permanente Medicaid	$28.56
Rate for Payer: Kaiser Permanente Medicare	$28.00
Rate for Payer: MDX Hawaii PPO	$54.32
Rate for Payer: Ohana Health Plan Medicaid	$28.00
Rate for Payer: Ohana Health Plan Medicare	$28.00
Rate for Payer: UnitedHealthcare Medicaid	$6.82
Rate for Payer: UnitedHealthcare Medicare	$28.00
Rate for Payer: University Health Alliance Commercial	$31.36

OT Paraffin Bath Units

Facility

$56.00

Service Code	HCPCS 97018 GO
Hospital Charge Code	1373447
Hospital Revenue Code	430
Min. Negotiated Rate	$47.60
Max. Negotiated Rate	$54.32
Rate for Payer: Cash Price	$36.40
Rate for Payer: Health Management Network Commercial	$47.60
Rate for Payer: Kaiser Permanente Commercial	$50.40
Rate for Payer: MDX Hawaii PPO	$54.32

OT Physical Performance Test Charges

Facility

$229.00

Service Code	HCPCS 97750 GO
Hospital Charge Code	8123873
Hospital Revenue Code	430
Min. Negotiated Rate	$19.83
Max. Negotiated Rate	$222.13
Rate for Payer: AlohaCare Medicaid	$114.50
Rate for Payer: AlohaCare Medicare	$114.50
Rate for Payer: Cash Price	$148.85
Rate for Payer: Cash Price	$148.85
Rate for Payer: Devoted Health Medicare	$125.95
Rate for Payer: Hawaii Medical Service Association Medicare	$114.50
Rate for Payer: Hawaii Western Management Group Commercial	$217.55
Rate for Payer: Health Management Network Commercial	$194.65
Rate for Payer: Humana Medicare	$114.50
Rate for Payer: Kaiser Permanente Commercial	$206.10
Rate for Payer: Kaiser Permanente Medicaid	$116.79
Rate for Payer: Kaiser Permanente Medicare	$114.50
Rate for Payer: MDX Hawaii PPO	$222.13
Rate for Payer: Ohana Health Plan Medicaid	$114.50
Rate for Payer: Ohana Health Plan Medicare	$114.50
Rate for Payer: UnitedHealthcare Medicaid	$19.83
Rate for Payer: UnitedHealthcare Medicare	$114.50
Rate for Payer: University Health Alliance Commercial	$128.24

OT Physical Performance Test Charges

Facility

$229.00

Service Code	HCPCS 97750 GO
Hospital Charge Code	8123873
Hospital Revenue Code	430
Min. Negotiated Rate	$194.65
Max. Negotiated Rate	$222.13
Rate for Payer: Cash Price	$148.85
Rate for Payer: Health Management Network Commercial	$194.65
Rate for Payer: Kaiser Permanente Commercial	$206.10
Rate for Payer: MDX Hawaii PPO	$222.13

OT ReEval Units

Facility

$451.00

Service Code	HCPCS 97168 GO
Hospital Charge Code	8123910
Hospital Revenue Code	434
Min. Negotiated Rate	$383.35
Max. Negotiated Rate	$437.47
Rate for Payer: Cash Price	$293.15
Rate for Payer: Health Management Network Commercial	$383.35
Rate for Payer: Kaiser Permanente Commercial	$405.90
Rate for Payer: MDX Hawaii PPO	$437.47

OT ReEval Units

Facility

$451.00

Service Code	HCPCS 97168 GO
Hospital Charge Code	8123910
Hospital Revenue Code	434
Min. Negotiated Rate	$74.97
Max. Negotiated Rate	$437.47
Rate for Payer: AlohaCare Medicaid	$225.50
Rate for Payer: AlohaCare Medicare	$225.50
Rate for Payer: Cash Price	$293.15
Rate for Payer: Cash Price	$293.15
Rate for Payer: Devoted Health Medicare	$248.05
Rate for Payer: Hawaii Medical Service Association Medicare	$225.50
Rate for Payer: Hawaii Western Management Group Commercial	$428.45
Rate for Payer: Health Management Network Commercial	$383.35
Rate for Payer: Humana Medicare	$225.50
Rate for Payer: Kaiser Permanente Commercial	$405.90
Rate for Payer: Kaiser Permanente Medicaid	$230.01
Rate for Payer: Kaiser Permanente Medicare	$225.50
Rate for Payer: MDX Hawaii PPO	$437.47
Rate for Payer: Ohana Health Plan Medicaid	$225.50
Rate for Payer: Ohana Health Plan Medicare	$225.50
Rate for Payer: UnitedHealthcare Medicaid	$74.97
Rate for Payer: UnitedHealthcare Medicare	$225.50
Rate for Payer: University Health Alliance Commercial	$252.56

OT ROM Each Ex/Trunk Assist Units

Facility

$100.00

Service Code	HCPCS 95851 GO,CO
Hospital Charge Code	8743921
Hospital Revenue Code	430
Min. Negotiated Rate	$85.00
Max. Negotiated Rate	$97.00
Rate for Payer: Cash Price	$65.00
Rate for Payer: Health Management Network Commercial	$85.00
Rate for Payer: Kaiser Permanente Commercial	$90.00
Rate for Payer: MDX Hawaii PPO	$97.00

OT ROM Each Ex/Trunk Assist Units

Facility

$100.00

Service Code	HCPCS 95851 GO,CO
Hospital Charge Code	8743921
Hospital Revenue Code	430
Min. Negotiated Rate	$7.89
Max. Negotiated Rate	$97.00
Rate for Payer: AlohaCare Medicaid	$50.00
Rate for Payer: AlohaCare Medicare	$50.00
Rate for Payer: Cash Price	$65.00
Rate for Payer: Cash Price	$65.00
Rate for Payer: Devoted Health Medicare	$55.00
Rate for Payer: Hawaii Medical Service Association Medicare	$50.00
Rate for Payer: Hawaii Western Management Group Commercial	$95.00
Rate for Payer: Health Management Network Commercial	$85.00
Rate for Payer: Humana Medicare	$50.00
Rate for Payer: Kaiser Permanente Commercial	$90.00
Rate for Payer: Kaiser Permanente Medicaid	$51.00
Rate for Payer: Kaiser Permanente Medicare	$50.00
Rate for Payer: MDX Hawaii PPO	$97.00
Rate for Payer: Ohana Health Plan Medicaid	$50.00
Rate for Payer: Ohana Health Plan Medicare	$50.00
Rate for Payer: UnitedHealthcare Medicaid	$7.89
Rate for Payer: UnitedHealthcare Medicare	$50.00
Rate for Payer: University Health Alliance Commercial	$56.00

OT ROM, Hand Assistant Units

Facility

$65.00

Service Code	HCPCS 95852 GO,CO
Hospital Charge Code	8720914
Hospital Revenue Code	430
Min. Negotiated Rate	$5.33
Max. Negotiated Rate	$63.05
Rate for Payer: AlohaCare Medicaid	$32.50
Rate for Payer: AlohaCare Medicare	$32.50
Rate for Payer: Cash Price	$42.25
Rate for Payer: Cash Price	$42.25
Rate for Payer: Devoted Health Medicare	$35.75
Rate for Payer: Hawaii Medical Service Association Medicare	$32.50
Rate for Payer: Hawaii Western Management Group Commercial	$61.75
Rate for Payer: Health Management Network Commercial	$55.25
Rate for Payer: Humana Medicare	$32.50
Rate for Payer: Kaiser Permanente Commercial	$58.50
Rate for Payer: Kaiser Permanente Medicaid	$33.15
Rate for Payer: Kaiser Permanente Medicare	$32.50
Rate for Payer: MDX Hawaii PPO	$63.05
Rate for Payer: Ohana Health Plan Medicaid	$32.50
Rate for Payer: Ohana Health Plan Medicare	$32.50
Rate for Payer: UnitedHealthcare Medicaid	$5.33
Rate for Payer: UnitedHealthcare Medicare	$32.50
Rate for Payer: University Health Alliance Commercial	$36.40

OT ROM, Hand Assistant Units

Facility

$65.00

Service Code	HCPCS 95852 GO,CO
Hospital Charge Code	8720914
Hospital Revenue Code	430
Min. Negotiated Rate	$55.25
Max. Negotiated Rate	$63.05
Rate for Payer: Cash Price	$42.25
Rate for Payer: Health Management Network Commercial	$55.25
Rate for Payer: Kaiser Permanente Commercial	$58.50
Rate for Payer: MDX Hawaii PPO	$63.05

OT Selective Debridement Add Assist Unit

Facility

$275.00

Service Code	HCPCS 97598 GO,CO
Hospital Charge Code	8744259
Hospital Revenue Code	430
Min. Negotiated Rate	$233.75
Max. Negotiated Rate	$266.75
Rate for Payer: Cash Price	$178.75
Rate for Payer: Health Management Network Commercial	$233.75
Rate for Payer: Kaiser Permanente Commercial	$247.50
Rate for Payer: MDX Hawaii PPO	$266.75

OT Selective Debridement Add Assist Unit

Facility

$275.00

Service Code	HCPCS 97598 GO,CO
Hospital Charge Code	8744259
Hospital Revenue Code	430
Min. Negotiated Rate	$47.04
Max. Negotiated Rate	$266.75
Rate for Payer: AlohaCare Medicaid	$137.50
Rate for Payer: AlohaCare Medicare	$137.50
Rate for Payer: Cash Price	$178.75
Rate for Payer: Cash Price	$178.75
Rate for Payer: Devoted Health Medicare	$151.25
Rate for Payer: Hawaii Medical Service Association Medicare	$137.50
Rate for Payer: Hawaii Western Management Group Commercial	$261.25
Rate for Payer: Health Management Network Commercial	$233.75
Rate for Payer: Humana Medicare	$137.50
Rate for Payer: Kaiser Permanente Commercial	$247.50
Rate for Payer: Kaiser Permanente Medicaid	$140.25
Rate for Payer: Kaiser Permanente Medicare	$137.50
Rate for Payer: MDX Hawaii PPO	$266.75
Rate for Payer: Ohana Health Plan Medicaid	$137.50
Rate for Payer: Ohana Health Plan Medicare	$137.50
Rate for Payer: UnitedHealthcare Medicaid	$47.04
Rate for Payer: UnitedHealthcare Medicare	$137.50
Rate for Payer: University Health Alliance Commercial	$154.00

OT Selective Debridement Assist Units

Facility

$555.00

Service Code	HCPCS 97597 GO,CO
Hospital Charge Code	8744257
Hospital Revenue Code	430
Min. Negotiated Rate	$37.07
Max. Negotiated Rate	$538.35
Rate for Payer: AlohaCare Medicaid	$277.50
Rate for Payer: AlohaCare Medicare	$277.50
Rate for Payer: Cash Price	$360.75
Rate for Payer: Cash Price	$360.75
Rate for Payer: Devoted Health Medicare	$305.25
Rate for Payer: Hawaii Medical Service Association Medicare	$277.50
Rate for Payer: Hawaii Western Management Group Commercial	$527.25
Rate for Payer: Health Management Network Commercial	$471.75
Rate for Payer: Humana Medicare	$277.50
Rate for Payer: Kaiser Permanente Commercial	$499.50
Rate for Payer: Kaiser Permanente Medicaid	$283.05
Rate for Payer: Kaiser Permanente Medicare	$277.50
Rate for Payer: MDX Hawaii PPO	$538.35
Rate for Payer: Ohana Health Plan Medicaid	$277.50
Rate for Payer: Ohana Health Plan Medicare	$277.50
Rate for Payer: UnitedHealthcare Medicaid	$37.07
Rate for Payer: UnitedHealthcare Medicare	$277.50
Rate for Payer: University Health Alliance Commercial	$310.80

OT Selective Debridement Assist Units

Facility

$555.00

Service Code	HCPCS 97597 GO,CO
Hospital Charge Code	8744257
Hospital Revenue Code	430
Min. Negotiated Rate	$471.75
Max. Negotiated Rate	$538.35
Rate for Payer: Cash Price	$360.75
Rate for Payer: Health Management Network Commercial	$471.75
Rate for Payer: Kaiser Permanente Commercial	$499.50
Rate for Payer: MDX Hawaii PPO	$538.35

OT Selective Debridement Units

Facility

$693.00

Service Code	HCPCS 97597 GO
Hospital Charge Code	11526563
Hospital Revenue Code	761
Min. Negotiated Rate	$589.05
Max. Negotiated Rate	$672.21
Rate for Payer: Cash Price	$450.45
Rate for Payer: Health Management Network Commercial	$589.05
Rate for Payer: Kaiser Permanente Commercial	$623.70
Rate for Payer: MDX Hawaii PPO	$672.21

OT Selective Debridement Units

Facility

$693.00

Service Code	HCPCS 97597 GO
Hospital Charge Code	11526563
Hospital Revenue Code	761
Min. Negotiated Rate	$37.07
Max. Negotiated Rate	$672.21
Rate for Payer: AlohaCare Medicaid	$346.50
Rate for Payer: AlohaCare Medicare	$346.50
Rate for Payer: Cash Price	$450.45
Rate for Payer: Cash Price	$450.45
Rate for Payer: Devoted Health Medicare	$381.15
Rate for Payer: Hawaii Medical Service Association Medicare	$346.50
Rate for Payer: Hawaii Western Management Group Commercial	$658.35
Rate for Payer: Health Management Network Commercial	$589.05
Rate for Payer: Humana Medicare	$346.50
Rate for Payer: Kaiser Permanente Commercial	$623.70
Rate for Payer: Kaiser Permanente Medicaid	$353.43
Rate for Payer: Kaiser Permanente Medicare	$346.50
Rate for Payer: MDX Hawaii PPO	$672.21
Rate for Payer: Ohana Health Plan Medicaid	$346.50
Rate for Payer: Ohana Health Plan Medicare	$346.50
Rate for Payer: UnitedHealthcare Medicaid	$37.07
Rate for Payer: UnitedHealthcare Medicare	$346.50
Rate for Payer: University Health Alliance Commercial	$388.08

OT Sensory Integrative Tech Assist Units

Facility

$238.00

Service Code	HCPCS 97533 GO,CO
Hospital Charge Code	8725609
Hospital Revenue Code	430
Min. Negotiated Rate	$17.81
Max. Negotiated Rate	$230.86
Rate for Payer: AlohaCare Medicaid	$119.00
Rate for Payer: AlohaCare Medicare	$119.00
Rate for Payer: Cash Price	$154.70
Rate for Payer: Cash Price	$154.70
Rate for Payer: Devoted Health Medicare	$130.90
Rate for Payer: Hawaii Medical Service Association Medicare	$119.00
Rate for Payer: Hawaii Western Management Group Commercial	$226.10
Rate for Payer: Health Management Network Commercial	$202.30
Rate for Payer: Humana Medicare	$119.00
Rate for Payer: Kaiser Permanente Commercial	$214.20
Rate for Payer: Kaiser Permanente Medicaid	$121.38
Rate for Payer: Kaiser Permanente Medicare	$119.00
Rate for Payer: MDX Hawaii PPO	$230.86
Rate for Payer: Ohana Health Plan Medicaid	$119.00
Rate for Payer: Ohana Health Plan Medicare	$119.00
Rate for Payer: UnitedHealthcare Medicaid	$17.81
Rate for Payer: UnitedHealthcare Medicare	$119.00
Rate for Payer: University Health Alliance Commercial	$133.28

OT Sensory Integrative Tech Assist Units

Facility

$238.00

Service Code	HCPCS 97533 GO,CO
Hospital Charge Code	8725609
Hospital Revenue Code	430
Min. Negotiated Rate	$202.30
Max. Negotiated Rate	$230.86
Rate for Payer: Cash Price	$154.70
Rate for Payer: Health Management Network Commercial	$202.30
Rate for Payer: Kaiser Permanente Commercial	$214.20
Rate for Payer: MDX Hawaii PPO	$230.86

OT Therapeutic Activities Assistant Units

Facility

$246.00

Service Code	HCPCS 97530 GO,CO
Hospital Charge Code	8725605
Hospital Revenue Code	430
Min. Negotiated Rate	$18.32
Max. Negotiated Rate	$238.62
Rate for Payer: AlohaCare Medicaid	$123.00
Rate for Payer: AlohaCare Medicare	$123.00
Rate for Payer: Cash Price	$159.90
Rate for Payer: Cash Price	$159.90
Rate for Payer: Devoted Health Medicare	$135.30
Rate for Payer: Hawaii Medical Service Association Medicare	$123.00
Rate for Payer: Hawaii Western Management Group Commercial	$233.70
Rate for Payer: Health Management Network Commercial	$209.10
Rate for Payer: Humana Medicare	$123.00
Rate for Payer: Kaiser Permanente Commercial	$221.40
Rate for Payer: Kaiser Permanente Medicaid	$125.46
Rate for Payer: Kaiser Permanente Medicare	$123.00
Rate for Payer: MDX Hawaii PPO	$238.62
Rate for Payer: Ohana Health Plan Medicaid	$123.00
Rate for Payer: Ohana Health Plan Medicare	$123.00
Rate for Payer: UnitedHealthcare Medicaid	$18.32
Rate for Payer: UnitedHealthcare Medicare	$123.00
Rate for Payer: University Health Alliance Commercial	$137.76

OT Therapeutic Activities Assistant Units

Facility

$246.00

Service Code	HCPCS 97530 GO,CO
Hospital Charge Code	8725605
Hospital Revenue Code	430
Min. Negotiated Rate	$209.10
Max. Negotiated Rate	$238.62
Rate for Payer: Cash Price	$159.90
Rate for Payer: Health Management Network Commercial	$209.10
Rate for Payer: Kaiser Permanente Commercial	$221.40
Rate for Payer: MDX Hawaii PPO	$238.62

OT Therapeutic Activities Charges

Facility

$246.00

Service Code	HCPCS 97530 GO
Hospital Charge Code	750903
Hospital Revenue Code	430
Min. Negotiated Rate	$209.10
Max. Negotiated Rate	$238.62
Rate for Payer: Cash Price	$159.90
Rate for Payer: Health Management Network Commercial	$209.10
Rate for Payer: Kaiser Permanente Commercial	$221.40
Rate for Payer: MDX Hawaii PPO	$238.62

Know your out-of-pocket cost for care.

All Charges