Samuel Mahelona Memorial Hospital

All Charges

Charge

Type

Setting

Price

OT Therapeutic Activities Charges

Facility

$246.00

Service Code	HCPCS 97530 GO
Hospital Charge Code	750903
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 Exercise Assistant units

Facility

$199.00

Service Code	HCPCS 97110 GO,CO
Hospital Charge Code	8725595
Hospital Revenue Code	430
Min. Negotiated Rate	$169.15
Max. Negotiated Rate	$193.03
Rate for Payer: Cash Price	$129.35
Rate for Payer: Health Management Network Commercial	$169.15
Rate for Payer: Kaiser Permanente Commercial	$179.10
Rate for Payer: MDX Hawaii PPO	$193.03

OT Therapeutic Exercise Assistant units

Facility

$199.00

Service Code	HCPCS 97110 GO,CO
Hospital Charge Code	8725595
Hospital Revenue Code	430
Min. Negotiated Rate	$17.65
Max. Negotiated Rate	$193.03
Rate for Payer: AlohaCare Medicaid	$99.50
Rate for Payer: AlohaCare Medicare	$99.50
Rate for Payer: Cash Price	$129.35
Rate for Payer: Cash Price	$129.35
Rate for Payer: Devoted Health Medicare	$109.45
Rate for Payer: Hawaii Medical Service Association Medicare	$99.50
Rate for Payer: Hawaii Western Management Group Commercial	$189.05
Rate for Payer: Health Management Network Commercial	$169.15
Rate for Payer: Humana Medicare	$99.50
Rate for Payer: Kaiser Permanente Commercial	$179.10
Rate for Payer: Kaiser Permanente Medicaid	$101.49
Rate for Payer: Kaiser Permanente Medicare	$99.50
Rate for Payer: MDX Hawaii PPO	$193.03
Rate for Payer: Ohana Health Plan Medicaid	$99.50
Rate for Payer: Ohana Health Plan Medicare	$99.50
Rate for Payer: UnitedHealthcare Medicaid	$17.65
Rate for Payer: UnitedHealthcare Medicare	$99.50
Rate for Payer: University Health Alliance Commercial	$111.44

OT Therapeutic Exercise Charges

Facility

$199.00

Service Code	HCPCS 97110 GO
Hospital Charge Code	750901
Hospital Revenue Code	430
Min. Negotiated Rate	$169.15
Max. Negotiated Rate	$193.03
Rate for Payer: Cash Price	$129.35
Rate for Payer: Health Management Network Commercial	$169.15
Rate for Payer: Kaiser Permanente Commercial	$179.10
Rate for Payer: MDX Hawaii PPO	$193.03

OT Therapeutic Exercise Charges

Facility

$199.00

Service Code	HCPCS 97110 GO
Hospital Charge Code	750901
Hospital Revenue Code	430
Min. Negotiated Rate	$17.65
Max. Negotiated Rate	$193.03
Rate for Payer: AlohaCare Medicaid	$99.50
Rate for Payer: AlohaCare Medicare	$99.50
Rate for Payer: Cash Price	$129.35
Rate for Payer: Cash Price	$129.35
Rate for Payer: Devoted Health Medicare	$109.45
Rate for Payer: Hawaii Medical Service Association Medicare	$99.50
Rate for Payer: Hawaii Western Management Group Commercial	$189.05
Rate for Payer: Health Management Network Commercial	$169.15
Rate for Payer: Humana Medicare	$99.50
Rate for Payer: Kaiser Permanente Commercial	$179.10
Rate for Payer: Kaiser Permanente Medicaid	$101.49
Rate for Payer: Kaiser Permanente Medicare	$99.50
Rate for Payer: MDX Hawaii PPO	$193.03
Rate for Payer: Ohana Health Plan Medicaid	$99.50
Rate for Payer: Ohana Health Plan Medicare	$99.50
Rate for Payer: UnitedHealthcare Medicaid	$17.65
Rate for Payer: UnitedHealthcare Medicare	$99.50
Rate for Payer: University Health Alliance Commercial	$111.44

OT Ultrasound Assistant Units

Facility

$104.00

Service Code	HCPCS 97035 GO,CO
Hospital Charge Code	8725592
Hospital Revenue Code	430
Min. Negotiated Rate	$9.52
Max. Negotiated Rate	$100.88
Rate for Payer: AlohaCare Medicaid	$52.00
Rate for Payer: AlohaCare Medicare	$52.00
Rate for Payer: Cash Price	$67.60
Rate for Payer: Cash Price	$67.60
Rate for Payer: Devoted Health Medicare	$57.20
Rate for Payer: Hawaii Medical Service Association Medicare	$52.00
Rate for Payer: Hawaii Western Management Group Commercial	$98.80
Rate for Payer: Health Management Network Commercial	$88.40
Rate for Payer: Humana Medicare	$52.00
Rate for Payer: Kaiser Permanente Commercial	$93.60
Rate for Payer: Kaiser Permanente Medicaid	$53.04
Rate for Payer: Kaiser Permanente Medicare	$52.00
Rate for Payer: MDX Hawaii PPO	$100.88
Rate for Payer: Ohana Health Plan Medicaid	$52.00
Rate for Payer: Ohana Health Plan Medicare	$52.00
Rate for Payer: UnitedHealthcare Medicaid	$9.52
Rate for Payer: UnitedHealthcare Medicare	$52.00
Rate for Payer: University Health Alliance Commercial	$58.24

OT Ultrasound Assistant Units

Facility

$104.00

Service Code	HCPCS 97035 GO,CO
Hospital Charge Code	8725592
Hospital Revenue Code	430
Min. Negotiated Rate	$88.40
Max. Negotiated Rate	$100.88
Rate for Payer: Cash Price	$67.60
Rate for Payer: Health Management Network Commercial	$88.40
Rate for Payer: Kaiser Permanente Commercial	$93.60
Rate for Payer: MDX Hawaii PPO	$100.88

OT Ultrasound Units

Facility

$104.00

Service Code	HCPCS 97035 GO
Hospital Charge Code	1373448
Hospital Revenue Code	430
Min. Negotiated Rate	$88.40
Max. Negotiated Rate	$100.88
Rate for Payer: Cash Price	$67.60
Rate for Payer: Health Management Network Commercial	$88.40
Rate for Payer: Kaiser Permanente Commercial	$93.60
Rate for Payer: MDX Hawaii PPO	$100.88

OT Ultrasound Units

Facility

$104.00

Service Code	HCPCS 97035 GO
Hospital Charge Code	1373448
Hospital Revenue Code	430
Min. Negotiated Rate	$9.52
Max. Negotiated Rate	$100.88
Rate for Payer: AlohaCare Medicaid	$52.00
Rate for Payer: AlohaCare Medicare	$52.00
Rate for Payer: Cash Price	$67.60
Rate for Payer: Cash Price	$67.60
Rate for Payer: Devoted Health Medicare	$57.20
Rate for Payer: Hawaii Medical Service Association Medicare	$52.00
Rate for Payer: Hawaii Western Management Group Commercial	$98.80
Rate for Payer: Health Management Network Commercial	$88.40
Rate for Payer: Humana Medicare	$52.00
Rate for Payer: Kaiser Permanente Commercial	$93.60
Rate for Payer: Kaiser Permanente Medicaid	$53.04
Rate for Payer: Kaiser Permanente Medicare	$52.00
Rate for Payer: MDX Hawaii PPO	$100.88
Rate for Payer: Ohana Health Plan Medicaid	$52.00
Rate for Payer: Ohana Health Plan Medicare	$52.00
Rate for Payer: UnitedHealthcare Medicaid	$9.52
Rate for Payer: UnitedHealthcare Medicare	$52.00
Rate for Payer: University Health Alliance Commercial	$58.24

OT Unattended E-stim Assistant Units

Facility

$100.00

Service Code	HCPCS 97014 GO,CO
Hospital Charge Code	8720888
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 Unattended E-stim Assistant Units

Facility

$100.00

Service Code	HCPCS 97014 GO,CO
Hospital Charge Code	8720888
Hospital Revenue Code	430
Min. Negotiated Rate	$11.85
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	$11.85
Rate for Payer: UnitedHealthcare Medicare	$50.00
Rate for Payer: University Health Alliance Commercial	$56.00

OT Vasopneumatic Devices Assistant Units

Facility

$92.00

Service Code	HCPCS 97016 GO,CO
Hospital Charge Code	8720890
Hospital Revenue Code	430
Min. Negotiated Rate	$78.20
Max. Negotiated Rate	$89.24
Rate for Payer: Cash Price	$59.80
Rate for Payer: Health Management Network Commercial	$78.20
Rate for Payer: Kaiser Permanente Commercial	$82.80
Rate for Payer: MDX Hawaii PPO	$89.24

OT Vasopneumatic Devices Assistant Units

Facility

$92.00

Service Code	HCPCS 97016 GO,CO
Hospital Charge Code	8720890
Hospital Revenue Code	430
Min. Negotiated Rate	$12.49
Max. Negotiated Rate	$89.24
Rate for Payer: AlohaCare Medicaid	$46.00
Rate for Payer: AlohaCare Medicare	$46.00
Rate for Payer: Cash Price	$59.80
Rate for Payer: Cash Price	$59.80
Rate for Payer: Devoted Health Medicare	$50.60
Rate for Payer: Hawaii Medical Service Association Medicare	$46.00
Rate for Payer: Hawaii Western Management Group Commercial	$87.40
Rate for Payer: Health Management Network Commercial	$78.20
Rate for Payer: Humana Medicare	$46.00
Rate for Payer: Kaiser Permanente Commercial	$82.80
Rate for Payer: Kaiser Permanente Medicaid	$46.92
Rate for Payer: Kaiser Permanente Medicare	$46.00
Rate for Payer: MDX Hawaii PPO	$89.24
Rate for Payer: Ohana Health Plan Medicaid	$46.00
Rate for Payer: Ohana Health Plan Medicare	$46.00
Rate for Payer: UnitedHealthcare Medicaid	$12.49
Rate for Payer: UnitedHealthcare Medicare	$46.00
Rate for Payer: University Health Alliance Commercial	$51.52

OT Vasopneumatic Devices Units

Facility

$92.00

Service Code	HCPCS 97016 GO
Hospital Charge Code	1373553
Hospital Revenue Code	430
Min. Negotiated Rate	$78.20
Max. Negotiated Rate	$89.24
Rate for Payer: Cash Price	$59.80
Rate for Payer: Health Management Network Commercial	$78.20
Rate for Payer: Kaiser Permanente Commercial	$82.80
Rate for Payer: MDX Hawaii PPO	$89.24

OT Vasopneumatic Devices Units

Facility

$92.00

Service Code	HCPCS 97016 GO
Hospital Charge Code	1373553
Hospital Revenue Code	430
Min. Negotiated Rate	$12.49
Max. Negotiated Rate	$89.24
Rate for Payer: AlohaCare Medicaid	$46.00
Rate for Payer: AlohaCare Medicare	$46.00
Rate for Payer: Cash Price	$59.80
Rate for Payer: Cash Price	$59.80
Rate for Payer: Devoted Health Medicare	$50.60
Rate for Payer: Hawaii Medical Service Association Medicare	$46.00
Rate for Payer: Hawaii Western Management Group Commercial	$87.40
Rate for Payer: Health Management Network Commercial	$78.20
Rate for Payer: Humana Medicare	$46.00
Rate for Payer: Kaiser Permanente Commercial	$82.80
Rate for Payer: Kaiser Permanente Medicaid	$46.92
Rate for Payer: Kaiser Permanente Medicare	$46.00
Rate for Payer: MDX Hawaii PPO	$89.24
Rate for Payer: Ohana Health Plan Medicaid	$46.00
Rate for Payer: Ohana Health Plan Medicare	$46.00
Rate for Payer: UnitedHealthcare Medicaid	$12.49
Rate for Payer: UnitedHealthcare Medicare	$46.00
Rate for Payer: University Health Alliance Commercial	$51.52

OT Wheelchair Management Assistant Units

Facility

$257.00

Service Code	HCPCS 97542 GO,CO
Hospital Charge Code	8725617
Hospital Revenue Code	430
Min. Negotiated Rate	$17.54
Max. Negotiated Rate	$249.29
Rate for Payer: AlohaCare Medicaid	$128.50
Rate for Payer: AlohaCare Medicare	$128.50
Rate for Payer: Cash Price	$167.05
Rate for Payer: Cash Price	$167.05
Rate for Payer: Devoted Health Medicare	$141.35
Rate for Payer: Hawaii Medical Service Association Medicare	$128.50
Rate for Payer: Hawaii Western Management Group Commercial	$244.15
Rate for Payer: Health Management Network Commercial	$218.45
Rate for Payer: Humana Medicare	$128.50
Rate for Payer: Kaiser Permanente Commercial	$231.30
Rate for Payer: Kaiser Permanente Medicaid	$131.07
Rate for Payer: Kaiser Permanente Medicare	$128.50
Rate for Payer: MDX Hawaii PPO	$249.29
Rate for Payer: Ohana Health Plan Medicaid	$128.50
Rate for Payer: Ohana Health Plan Medicare	$128.50
Rate for Payer: UnitedHealthcare Medicaid	$17.54
Rate for Payer: UnitedHealthcare Medicare	$128.50
Rate for Payer: University Health Alliance Commercial	$143.92

OT Wheelchair Management Assistant Units

Facility

$257.00

Service Code	HCPCS 97542 GO,CO
Hospital Charge Code	8725617
Hospital Revenue Code	430
Min. Negotiated Rate	$218.45
Max. Negotiated Rate	$249.29
Rate for Payer: Cash Price	$167.05
Rate for Payer: Health Management Network Commercial	$218.45
Rate for Payer: Kaiser Permanente Commercial	$231.30
Rate for Payer: MDX Hawaii PPO	$249.29

OT Whirlpool, Fluidotherapy Units

Facility

$126.00

Service Code	HCPCS 97022 GO
Hospital Charge Code	1373554
Hospital Revenue Code	430
Min. Negotiated Rate	$11.89
Max. Negotiated Rate	$122.22
Rate for Payer: AlohaCare Medicaid	$63.00
Rate for Payer: AlohaCare Medicare	$63.00
Rate for Payer: Cash Price	$81.90
Rate for Payer: Cash Price	$81.90
Rate for Payer: Devoted Health Medicare	$69.30
Rate for Payer: Hawaii Medical Service Association Medicare	$63.00
Rate for Payer: Hawaii Western Management Group Commercial	$119.70
Rate for Payer: Health Management Network Commercial	$107.10
Rate for Payer: Humana Medicare	$63.00
Rate for Payer: Kaiser Permanente Commercial	$113.40
Rate for Payer: Kaiser Permanente Medicaid	$64.26
Rate for Payer: Kaiser Permanente Medicare	$63.00
Rate for Payer: MDX Hawaii PPO	$122.22
Rate for Payer: Ohana Health Plan Medicaid	$63.00
Rate for Payer: Ohana Health Plan Medicare	$63.00
Rate for Payer: UnitedHealthcare Medicaid	$11.89
Rate for Payer: UnitedHealthcare Medicare	$63.00
Rate for Payer: University Health Alliance Commercial	$70.56

OT Whirlpool, Fluidotherapy Units

Facility

$126.00

Service Code	HCPCS 97022 GO
Hospital Charge Code	1373554
Hospital Revenue Code	430
Min. Negotiated Rate	$107.10
Max. Negotiated Rate	$122.22
Rate for Payer: Cash Price	$81.90
Rate for Payer: Health Management Network Commercial	$107.10
Rate for Payer: Kaiser Permanente Commercial	$113.40
Rate for Payer: MDX Hawaii PPO	$122.22

OT Whirlpool Therapy Assistant Units

Facility

$126.00

Service Code	HCPCS 97022 GO,CO
Hospital Charge Code	8740047
Hospital Revenue Code	430
Min. Negotiated Rate	$11.89
Max. Negotiated Rate	$122.22
Rate for Payer: AlohaCare Medicaid	$63.00
Rate for Payer: AlohaCare Medicare	$63.00
Rate for Payer: Cash Price	$81.90
Rate for Payer: Cash Price	$81.90
Rate for Payer: Devoted Health Medicare	$69.30
Rate for Payer: Hawaii Medical Service Association Medicare	$63.00
Rate for Payer: Hawaii Western Management Group Commercial	$119.70
Rate for Payer: Health Management Network Commercial	$107.10
Rate for Payer: Humana Medicare	$63.00
Rate for Payer: Kaiser Permanente Commercial	$113.40
Rate for Payer: Kaiser Permanente Medicaid	$64.26
Rate for Payer: Kaiser Permanente Medicare	$63.00
Rate for Payer: MDX Hawaii PPO	$122.22
Rate for Payer: Ohana Health Plan Medicaid	$63.00
Rate for Payer: Ohana Health Plan Medicare	$63.00
Rate for Payer: UnitedHealthcare Medicaid	$11.89
Rate for Payer: UnitedHealthcare Medicare	$63.00
Rate for Payer: University Health Alliance Commercial	$70.56

OT Whirlpool Therapy Assistant Units

Facility

$126.00

Service Code	HCPCS 97022 GO,CO
Hospital Charge Code	8740047
Hospital Revenue Code	430
Min. Negotiated Rate	$107.10
Max. Negotiated Rate	$122.22
Rate for Payer: Cash Price	$81.90
Rate for Payer: Health Management Network Commercial	$107.10
Rate for Payer: Kaiser Permanente Commercial	$113.40
Rate for Payer: MDX Hawaii PPO	$122.22

OT Work Hardening-Initial 2 Hours Units

Facility

$307.00

Service Code	HCPCS 97545 GO
Hospital Charge Code	1373571
Hospital Revenue Code	430
Min. Negotiated Rate	$260.95
Max. Negotiated Rate	$297.79
Rate for Payer: Cash Price	$199.55
Rate for Payer: Health Management Network Commercial	$260.95
Rate for Payer: Kaiser Permanente Commercial	$276.30
Rate for Payer: MDX Hawaii PPO	$297.79

OT Work Hardening-Initial 2 Hours Units

Facility

$307.00

Service Code	HCPCS 97545 GO
Hospital Charge Code	1373571
Hospital Revenue Code	430
Min. Negotiated Rate	$153.50
Max. Negotiated Rate	$297.79
Rate for Payer: AlohaCare Medicaid	$153.50
Rate for Payer: AlohaCare Medicare	$153.50
Rate for Payer: Cash Price	$199.55
Rate for Payer: Devoted Health Medicare	$168.85
Rate for Payer: Hawaii Medical Service Association Medicare	$153.50
Rate for Payer: Hawaii Western Management Group Commercial	$291.65
Rate for Payer: Health Management Network Commercial	$260.95
Rate for Payer: Humana Medicare	$153.50
Rate for Payer: Kaiser Permanente Commercial	$276.30
Rate for Payer: Kaiser Permanente Medicaid	$156.57
Rate for Payer: Kaiser Permanente Medicare	$153.50
Rate for Payer: MDX Hawaii PPO	$297.79
Rate for Payer: Ohana Health Plan Medicaid	$153.50
Rate for Payer: Ohana Health Plan Medicare	$153.50
Rate for Payer: UnitedHealthcare Medicare	$153.50
Rate for Payer: University Health Alliance Commercial	$171.92

OT Work Reconditioning Addl Assist Unit

Facility

$102.00

Service Code	HCPCS 97546 GO,CO
Hospital Charge Code	8743917
Hospital Revenue Code	430
Min. Negotiated Rate	$51.00
Max. Negotiated Rate	$98.94
Rate for Payer: AlohaCare Medicaid	$51.00
Rate for Payer: AlohaCare Medicare	$51.00
Rate for Payer: Cash Price	$66.30
Rate for Payer: Devoted Health Medicare	$56.10
Rate for Payer: Hawaii Medical Service Association Medicare	$51.00
Rate for Payer: Hawaii Western Management Group Commercial	$96.90
Rate for Payer: Health Management Network Commercial	$86.70
Rate for Payer: Humana Medicare	$51.00
Rate for Payer: Kaiser Permanente Commercial	$91.80
Rate for Payer: Kaiser Permanente Medicaid	$52.02
Rate for Payer: Kaiser Permanente Medicare	$51.00
Rate for Payer: MDX Hawaii PPO	$98.94
Rate for Payer: Ohana Health Plan Medicaid	$51.00
Rate for Payer: Ohana Health Plan Medicare	$51.00
Rate for Payer: UnitedHealthcare Medicare	$51.00
Rate for Payer: University Health Alliance Commercial	$57.12

OT Work Reconditioning Addl Assist Unit

Facility

$102.00

Service Code	HCPCS 97546 GO,CO
Hospital Charge Code	8743917
Hospital Revenue Code	430
Min. Negotiated Rate	$86.70
Max. Negotiated Rate	$98.94
Rate for Payer: Cash Price	$66.30
Rate for Payer: Health Management Network Commercial	$86.70
Rate for Payer: Kaiser Permanente Commercial	$91.80
Rate for Payer: MDX Hawaii PPO	$98.94

Know your out-of-pocket cost for care.

All Charges