Samuel Mahelona Memorial Hospital

All Charges

Charge

Type

Setting

Price

PT NonSelective Debride Assist Unit

Facility

$488.00

Service Code	HCPCS 97602 GP,CQ
Hospital Charge Code	8736298
Hospital Revenue Code	420
Min. Negotiated Rate	$20.46
Max. Negotiated Rate	$473.36
Rate for Payer: AlohaCare Medicaid	$244.00
Rate for Payer: AlohaCare Medicare	$244.00
Rate for Payer: Cash Price	$317.20
Rate for Payer: Cash Price	$317.20
Rate for Payer: Devoted Health Medicare	$268.40
Rate for Payer: Hawaii Medical Service Association Medicare	$244.00
Rate for Payer: Hawaii Western Management Group Commercial	$463.60
Rate for Payer: Health Management Network Commercial	$414.80
Rate for Payer: Humana Medicare	$244.00
Rate for Payer: Kaiser Permanente Commercial	$439.20
Rate for Payer: Kaiser Permanente Medicaid	$248.88
Rate for Payer: Kaiser Permanente Medicare	$244.00
Rate for Payer: MDX Hawaii PPO	$473.36
Rate for Payer: Ohana Health Plan Medicaid	$244.00
Rate for Payer: Ohana Health Plan Medicare	$244.00
Rate for Payer: UnitedHealthcare Medicaid	$20.46
Rate for Payer: UnitedHealthcare Medicare	$244.00
Rate for Payer: University Health Alliance Commercial	$273.28

PT NonSelective Debride Assist Unit

Facility

$488.00

Service Code	HCPCS 97602 GP,CQ
Hospital Charge Code	8736298
Hospital Revenue Code	420
Min. Negotiated Rate	$414.80
Max. Negotiated Rate	$473.36
Rate for Payer: Cash Price	$317.20
Rate for Payer: Health Management Network Commercial	$414.80
Rate for Payer: Kaiser Permanente Commercial	$439.20
Rate for Payer: MDX Hawaii PPO	$473.36

PT Non-Selective Debrid w/o Anes units

Facility

$488.00

Service Code	HCPCS 97602 GP,CQ
Hospital Charge Code	8309538
Hospital Revenue Code	420
Min. Negotiated Rate	$20.46
Max. Negotiated Rate	$473.36
Rate for Payer: AlohaCare Medicaid	$244.00
Rate for Payer: AlohaCare Medicare	$244.00
Rate for Payer: Cash Price	$317.20
Rate for Payer: Cash Price	$317.20
Rate for Payer: Devoted Health Medicare	$268.40
Rate for Payer: Hawaii Medical Service Association Medicare	$244.00
Rate for Payer: Hawaii Western Management Group Commercial	$463.60
Rate for Payer: Health Management Network Commercial	$414.80
Rate for Payer: Humana Medicare	$244.00
Rate for Payer: Kaiser Permanente Commercial	$439.20
Rate for Payer: Kaiser Permanente Medicaid	$248.88
Rate for Payer: Kaiser Permanente Medicare	$244.00
Rate for Payer: MDX Hawaii PPO	$473.36
Rate for Payer: Ohana Health Plan Medicaid	$244.00
Rate for Payer: Ohana Health Plan Medicare	$244.00
Rate for Payer: UnitedHealthcare Medicaid	$20.46
Rate for Payer: UnitedHealthcare Medicare	$244.00
Rate for Payer: University Health Alliance Commercial	$273.28

PT Non-Selective Debrid w/o Anes units

Facility

$488.00

Service Code	HCPCS 97602 GP,CQ
Hospital Charge Code	8309538
Hospital Revenue Code	420
Min. Negotiated Rate	$414.80
Max. Negotiated Rate	$473.36
Rate for Payer: Cash Price	$317.20
Rate for Payer: Health Management Network Commercial	$414.80
Rate for Payer: Kaiser Permanente Commercial	$439.20
Rate for Payer: MDX Hawaii PPO	$473.36

PT Orthotic Mgmt, Train Assistant Units

Facility

$282.00

Service Code	HCPCS 97760 GP,CQ
Hospital Charge Code	8720460
Hospital Revenue Code	420
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

PT Orthotic Mgmt, Train Assistant Units

Facility

$282.00

Service Code	HCPCS 97760 GP,CQ
Hospital Charge Code	8720460
Hospital Revenue Code	420
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

PT Orthotic Mgmt/Train Establish Charge

Facility

$353.00

Service Code	HCPCS 97763 GP,CQ
Hospital Charge Code	8111857
Hospital Revenue Code	420
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

PT Orthotic Mgmt/Train Establish Charge

Facility

$353.00

Service Code	HCPCS 97763 GP,CQ
Hospital Charge Code	8111857
Hospital Revenue Code	420
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

PT Orthotic Mgmt/Train Establish Rehab Units

Facility

$353.00

Service Code	HCPCS 97763 GP,CQ
Hospital Charge Code	8309611
Hospital Revenue Code	420
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

PT Orthotic Mgmt/Train Establish Rehab Units

Facility

$353.00

Service Code	HCPCS 97763 GP,CQ
Hospital Charge Code	8309611
Hospital Revenue Code	420
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

PT Other Thermal Assitant Units

Facility

$95.00

Service Code	HCPCS 97010 GP,CQ
Hospital Charge Code	8735302
Hospital Revenue Code	420
Min. Negotiated Rate	$80.75
Max. Negotiated Rate	$92.15
Rate for Payer: Cash Price	$61.75
Rate for Payer: Health Management Network Commercial	$80.75
Rate for Payer: Kaiser Permanente Commercial	$85.50
Rate for Payer: MDX Hawaii PPO	$92.15

PT Other Thermal Assitant Units

Facility

$95.00

Service Code	HCPCS 97010 GP,CQ
Hospital Charge Code	8735302
Hospital Revenue Code	420
Min. Negotiated Rate	$10.08
Max. Negotiated Rate	$92.15
Rate for Payer: AlohaCare Medicaid	$47.50
Rate for Payer: AlohaCare Medicare	$47.50
Rate for Payer: Cash Price	$61.75
Rate for Payer: Cash Price	$61.75
Rate for Payer: Devoted Health Medicare	$52.25
Rate for Payer: Hawaii Medical Service Association Medicare	$47.50
Rate for Payer: Hawaii Western Management Group Commercial	$90.25
Rate for Payer: Health Management Network Commercial	$80.75
Rate for Payer: Humana Medicare	$47.50
Rate for Payer: Kaiser Permanente Commercial	$85.50
Rate for Payer: Kaiser Permanente Medicaid	$48.45
Rate for Payer: Kaiser Permanente Medicare	$47.50
Rate for Payer: MDX Hawaii PPO	$92.15
Rate for Payer: Ohana Health Plan Medicaid	$47.50
Rate for Payer: Ohana Health Plan Medicare	$47.50
Rate for Payer: UnitedHealthcare Medicaid	$10.08
Rate for Payer: UnitedHealthcare Medicare	$47.50
Rate for Payer: University Health Alliance Commercial	$53.20

PT Paraffin Assistant Units

Facility

$56.00

Service Code	HCPCS 97018 GO,59
Hospital Charge Code	8720398
Hospital Revenue Code	420
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

PT Paraffin Assistant Units

Facility

$56.00

Service Code	HCPCS 97018 GO,59
Hospital Charge Code	8720398
Hospital Revenue Code	420
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

PT Paraffin Units

Facility

$56.00

Service Code	HCPCS 97018 GP,CQ
Hospital Charge Code	1373914
Hospital Revenue Code	420
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

PT Paraffin Units

Facility

$56.00

Service Code	HCPCS 97018 GP,CQ
Hospital Charge Code	1373914
Hospital Revenue Code	420
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

PT Phonophoresis Assitant Units

Facility

$104.00

Service Code	HCPCS 97035 GP,CQ
Hospital Charge Code	8735300
Hospital Revenue Code	420
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

PT Phonophoresis Assitant Units

Facility

$104.00

Service Code	HCPCS 97035 GP,CQ
Hospital Charge Code	8735300
Hospital Revenue Code	420
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

PT Prosthetic Mgmt, Train Assistant Units

Facility

$260.00

Service Code	HCPCS 97761 GP,CQ
Hospital Charge Code	8720462
Hospital Revenue Code	420
Min. Negotiated Rate	$221.00
Max. Negotiated Rate	$252.20
Rate for Payer: Cash Price	$169.00
Rate for Payer: Health Management Network Commercial	$221.00
Rate for Payer: Kaiser Permanente Commercial	$234.00
Rate for Payer: MDX Hawaii PPO	$252.20

PT Prosthetic Mgmt, Train Assistant Units

Facility

$260.00

Service Code	HCPCS 97761 GP,CQ
Hospital Charge Code	8720462
Hospital Revenue Code	420
Min. Negotiated Rate	$17.70
Max. Negotiated Rate	$252.20
Rate for Payer: AlohaCare Medicaid	$130.00
Rate for Payer: AlohaCare Medicare	$130.00
Rate for Payer: Cash Price	$169.00
Rate for Payer: Cash Price	$169.00
Rate for Payer: Devoted Health Medicare	$143.00
Rate for Payer: Hawaii Medical Service Association Medicare	$130.00
Rate for Payer: Hawaii Western Management Group Commercial	$247.00
Rate for Payer: Health Management Network Commercial	$221.00
Rate for Payer: Humana Medicare	$130.00
Rate for Payer: Kaiser Permanente Commercial	$234.00
Rate for Payer: Kaiser Permanente Medicaid	$132.60
Rate for Payer: Kaiser Permanente Medicare	$130.00
Rate for Payer: MDX Hawaii PPO	$252.20
Rate for Payer: Ohana Health Plan Medicaid	$130.00
Rate for Payer: Ohana Health Plan Medicare	$130.00
Rate for Payer: UnitedHealthcare Medicaid	$17.70
Rate for Payer: UnitedHealthcare Medicare	$130.00
Rate for Payer: University Health Alliance Commercial	$145.60

PT ReEval Units

Facility

$426.00

Service Code	HCPCS 97164 GP,CQ
Hospital Charge Code	8111855
Hospital Revenue Code	424
Min. Negotiated Rate	$74.59
Max. Negotiated Rate	$413.22
Rate for Payer: AlohaCare Medicaid	$213.00
Rate for Payer: AlohaCare Medicare	$213.00
Rate for Payer: Cash Price	$276.90
Rate for Payer: Cash Price	$276.90
Rate for Payer: Devoted Health Medicare	$234.30
Rate for Payer: Hawaii Medical Service Association Medicare	$213.00
Rate for Payer: Hawaii Western Management Group Commercial	$404.70
Rate for Payer: Health Management Network Commercial	$362.10
Rate for Payer: Humana Medicare	$213.00
Rate for Payer: Kaiser Permanente Commercial	$383.40
Rate for Payer: Kaiser Permanente Medicaid	$217.26
Rate for Payer: Kaiser Permanente Medicare	$213.00
Rate for Payer: MDX Hawaii PPO	$413.22
Rate for Payer: Ohana Health Plan Medicaid	$213.00
Rate for Payer: Ohana Health Plan Medicare	$213.00
Rate for Payer: UnitedHealthcare Medicaid	$74.59
Rate for Payer: UnitedHealthcare Medicare	$213.00
Rate for Payer: University Health Alliance Commercial	$238.56

PT ReEval Units

Facility

$426.00

Service Code	HCPCS 97164 GP,CQ
Hospital Charge Code	8111855
Hospital Revenue Code	424
Min. Negotiated Rate	$362.10
Max. Negotiated Rate	$413.22
Rate for Payer: Cash Price	$276.90
Rate for Payer: Health Management Network Commercial	$362.10
Rate for Payer: Kaiser Permanente Commercial	$383.40
Rate for Payer: MDX Hawaii PPO	$413.22

PT ROm Measurement and Hand Time Charge

Facility

$65.00

Service Code	HCPCS 95852 GP,CQ
Hospital Charge Code	8111827
Hospital Revenue Code	420
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

PT ROm Measurement and Hand Time Charge

Facility

$65.00

Service Code	HCPCS 95852 GP,CQ
Hospital Charge Code	8111827
Hospital Revenue Code	420
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

PT ROM Measurement Hand Assistant Units

Facility

$65.00

Service Code	HCPCS 95852 GP,CQ
Hospital Charge Code	8720416
Hospital Revenue Code	420
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

Know your out-of-pocket cost for care.

All Charges