Samuel Mahelona Memorial Hospital

All Charges

Charge

Type

Setting

Price

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	$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 Measurements and Report Charges

Facility

$100.00

Service Code	HCPCS 95851 GP,CQ
Hospital Charge Code	8111825
Hospital Revenue Code	420
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

PT ROM Measurements and Report Charges

Facility

$100.00

Service Code	HCPCS 95851 GP,CQ
Hospital Charge Code	8111825
Hospital Revenue Code	420
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

PT ROM Measurements/Reports Assist

Facility

$100.00

Service Code	HCPCS 95851 GP,CQ
Hospital Charge Code	8736095
Hospital Revenue Code	420
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

PT ROM Measurements/Reports Assist

Facility

$100.00

Service Code	HCPCS 95851 GP,CQ
Hospital Charge Code	8736095
Hospital Revenue Code	420
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

PT Selective Debridement <20 Units

Facility

$693.00

Service Code	HCPCS 97597 GP,CQ
Hospital Charge Code	10656046
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

PT Selective Debridement <20 Units

Facility

$693.00

Service Code	HCPCS 97597 GP,CQ
Hospital Charge Code	10656046
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

PT Selective Debridement Add Assist Unit

Facility

$275.00

Service Code	HCPCS 97598 GP,CQ
Hospital Charge Code	8736296
Hospital Revenue Code	420
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

PT Selective Debridement Add Assist Unit

Facility

$275.00

Service Code	HCPCS 97598 GP,CQ
Hospital Charge Code	8736296
Hospital Revenue Code	420
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

PT Selective Debridement Assistant Units

Facility

$693.00

Service Code	HCPCS 97597 GP,CQ
Hospital Charge Code	8736289
Hospital Revenue Code	420
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

PT Selective Debridement Assistant Units

Facility

$693.00

Service Code	HCPCS 97597 GP,CQ
Hospital Charge Code	8736289
Hospital Revenue Code	420
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

PTT FSI

Facility

$83.00

Service Code	HCPCS 85730
Hospital Charge Code	8118030
Hospital Revenue Code	305
Min. Negotiated Rate	$6.01
Max. Negotiated Rate	$80.51
Rate for Payer: AlohaCare Medicaid	$41.50
Rate for Payer: AlohaCare Medicare	$41.50
Rate for Payer: Cash Price	$53.95
Rate for Payer: Cash Price	$53.95
Rate for Payer: Devoted Health Medicare	$45.65
Rate for Payer: Hawaii Medical Service Association ABD	$8.30
Rate for Payer: Hawaii Medical Service Association Commercial	$7.51
Rate for Payer: Hawaii Medical Service Association Medicare	$41.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$8.72
Rate for Payer: Hawaii Western Management Group Commercial	$6.01
Rate for Payer: Health Management Network Commercial	$70.55
Rate for Payer: Humana Medicare	$41.50
Rate for Payer: Kaiser Permanente Commercial	$74.70
Rate for Payer: Kaiser Permanente Medicaid	$42.33
Rate for Payer: Kaiser Permanente Medicare	$41.50
Rate for Payer: MDX Hawaii PPO	$80.51
Rate for Payer: Ohana Health Plan Medicaid	$41.50
Rate for Payer: Ohana Health Plan Medicare	$41.50
Rate for Payer: UnitedHealthcare Medicaid	$8.30
Rate for Payer: UnitedHealthcare Medicare	$41.50
Rate for Payer: University Health Alliance Commercial	$15.50

PTT FSI

Facility

$83.00

Service Code	HCPCS 85730
Hospital Charge Code	8118030
Hospital Revenue Code	305
Min. Negotiated Rate	$70.55
Max. Negotiated Rate	$80.51
Rate for Payer: Cash Price	$53.95
Rate for Payer: Health Management Network Commercial	$70.55
Rate for Payer: Kaiser Permanente Commercial	$74.70
Rate for Payer: MDX Hawaii PPO	$80.51

PT Therapeutic Activity Assistant Units

Facility

$246.00

Service Code	HCPCS 97530 GP,CQ
Hospital Charge Code	8720444
Hospital Revenue Code	420
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

PT Therapeutic Activity Assistant Units

Facility

$246.00

Service Code	HCPCS 97530 GP,CQ
Hospital Charge Code	8720444
Hospital Revenue Code	420
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

PT Therapeutic Exercise Assit Units

Facility

$199.00

Service Code	HCPCS 97110 GP,CQ
Hospital Charge Code	8735279
Hospital Revenue Code	420
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

PT Therapeutic Exercise Assit Units

Facility

$199.00

Service Code	HCPCS 97110 GP,CQ
Hospital Charge Code	8735279
Hospital Revenue Code	420
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

PT Ultrasound Assistant Units

Facility

$104.00

Service Code	HCPCS 97035 GP,CQ
Hospital Charge Code	8720430
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 Ultrasound Assistant Units

Facility

$104.00

Service Code	HCPCS 97035 GP,CQ
Hospital Charge Code	8720430
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 Ultrasound Units

Facility

$104.00

Service Code	HCPCS 97035 GP,CQ
Hospital Charge Code	1374021
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 Ultrasound Units

Facility

$104.00

Service Code	HCPCS 97035 GP,CQ
Hospital Charge Code	1374021
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 Unattended E-Stim Assistant Units

Facility

$100.00

Service Code	HCPCS 97014 GP,CO
Hospital Charge Code	8720394
Hospital Revenue Code	420
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

PT Unattended E-Stim Assistant Units

Facility

$100.00

Service Code	HCPCS 97014 GP,CO
Hospital Charge Code	8720394
Hospital Revenue Code	420
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

PT Unattended E-Stim Units

Facility

$100.00

Service Code	HCPCS 97014 GP,CQ
Hospital Charge Code	1374022
Hospital Revenue Code	420
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

PT Unattended E-Stim Units

Facility

$100.00

Service Code	HCPCS 97014 GP,CQ
Hospital Charge Code	1374022
Hospital Revenue Code	420
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

Know your out-of-pocket cost for care.

All Charges