Samuel Mahelona Memorial Hospital

All Charges

Charge

Type

Setting

Price

SLP Evaluation LTC

Facility

$505.00

Service Code	HCPCS 92610 GP,CQ
Hospital Charge Code	7282548
Hospital Revenue Code	444
Min. Negotiated Rate	$429.25
Max. Negotiated Rate	$489.85
Rate for Payer: Cash Price	$328.25
Rate for Payer: Health Management Network Commercial	$429.25
Rate for Payer: Kaiser Permanente Commercial	$454.50
Rate for Payer: MDX Hawaii PPO	$489.85

SLP Evaluation LTC

Facility

$505.00

Service Code	HCPCS 92610 GP,CQ
Hospital Charge Code	7282548
Hospital Revenue Code	444
Min. Negotiated Rate	$88.36
Max. Negotiated Rate	$489.85
Rate for Payer: AlohaCare Medicaid	$252.50
Rate for Payer: AlohaCare Medicare	$252.50
Rate for Payer: Cash Price	$328.25
Rate for Payer: Cash Price	$328.25
Rate for Payer: Devoted Health Medicare	$277.75
Rate for Payer: Hawaii Medical Service Association Medicare	$252.50
Rate for Payer: Hawaii Western Management Group Commercial	$479.75
Rate for Payer: Health Management Network Commercial	$429.25
Rate for Payer: Humana Medicare	$252.50
Rate for Payer: Kaiser Permanente Commercial	$454.50
Rate for Payer: Kaiser Permanente Medicaid	$257.55
Rate for Payer: Kaiser Permanente Medicare	$252.50
Rate for Payer: MDX Hawaii PPO	$489.85
Rate for Payer: Ohana Health Plan Medicaid	$252.50
Rate for Payer: Ohana Health Plan Medicare	$252.50
Rate for Payer: UnitedHealthcare Medicaid	$88.36
Rate for Payer: UnitedHealthcare Medicare	$252.50
Rate for Payer: University Health Alliance Commercial	$282.80

SLP Evaluation of Speech Fluency Units

Facility

$778.00

Service Code	HCPCS 92521 GO,CO
Hospital Charge Code	7146947
Hospital Revenue Code	444
Min. Negotiated Rate	$140.32
Max. Negotiated Rate	$754.66
Rate for Payer: AlohaCare Medicaid	$389.00
Rate for Payer: AlohaCare Medicare	$389.00
Rate for Payer: Cash Price	$505.70
Rate for Payer: Cash Price	$505.70
Rate for Payer: Devoted Health Medicare	$427.90
Rate for Payer: Hawaii Medical Service Association Medicare	$389.00
Rate for Payer: Hawaii Western Management Group Commercial	$739.10
Rate for Payer: Health Management Network Commercial	$661.30
Rate for Payer: Humana Medicare	$389.00
Rate for Payer: Kaiser Permanente Commercial	$700.20
Rate for Payer: Kaiser Permanente Medicaid	$396.78
Rate for Payer: Kaiser Permanente Medicare	$389.00
Rate for Payer: MDX Hawaii PPO	$754.66
Rate for Payer: Ohana Health Plan Medicaid	$389.00
Rate for Payer: Ohana Health Plan Medicare	$389.00
Rate for Payer: UnitedHealthcare Medicaid	$140.32
Rate for Payer: UnitedHealthcare Medicare	$389.00
Rate for Payer: University Health Alliance Commercial	$435.68

SLP Evaluation of Speech Fluency Units

Facility

$778.00

Service Code	HCPCS 92521 GO,CO
Hospital Charge Code	7146947
Hospital Revenue Code	444
Min. Negotiated Rate	$661.30
Max. Negotiated Rate	$754.66
Rate for Payer: Cash Price	$505.70
Rate for Payer: Health Management Network Commercial	$661.30
Rate for Payer: Kaiser Permanente Commercial	$700.20
Rate for Payer: MDX Hawaii PPO	$754.66

SLP Fluoroscopic Evaluation Units

Facility

$581.00

Service Code	HCPCS 92611 GO,CO
Hospital Charge Code	1373839
Hospital Revenue Code	444
Min. Negotiated Rate	$88.36
Max. Negotiated Rate	$563.57
Rate for Payer: AlohaCare Medicaid	$290.50
Rate for Payer: AlohaCare Medicare	$290.50
Rate for Payer: Cash Price	$377.65
Rate for Payer: Cash Price	$377.65
Rate for Payer: Devoted Health Medicare	$319.55
Rate for Payer: Hawaii Medical Service Association Medicare	$290.50
Rate for Payer: Hawaii Western Management Group Commercial	$551.95
Rate for Payer: Health Management Network Commercial	$493.85
Rate for Payer: Humana Medicare	$290.50
Rate for Payer: Kaiser Permanente Commercial	$522.90
Rate for Payer: Kaiser Permanente Medicaid	$296.31
Rate for Payer: Kaiser Permanente Medicare	$290.50
Rate for Payer: MDX Hawaii PPO	$563.57
Rate for Payer: Ohana Health Plan Medicaid	$290.50
Rate for Payer: Ohana Health Plan Medicare	$290.50
Rate for Payer: UnitedHealthcare Medicaid	$88.36
Rate for Payer: UnitedHealthcare Medicare	$290.50
Rate for Payer: University Health Alliance Commercial	$325.36

SLP Fluoroscopic Evaluation Units

Facility

$581.00

Service Code	HCPCS 92611 GO,CO
Hospital Charge Code	1373839
Hospital Revenue Code	444
Min. Negotiated Rate	$493.85
Max. Negotiated Rate	$563.57
Rate for Payer: Cash Price	$377.65
Rate for Payer: Health Management Network Commercial	$493.85
Rate for Payer: Kaiser Permanente Commercial	$522.90
Rate for Payer: MDX Hawaii PPO	$563.57

SLP Group Therapy Units

Facility

$177.00

Service Code	HCPCS 92508 GO,CO
Hospital Charge Code	1373850
Hospital Revenue Code	440
Min. Negotiated Rate	$150.45
Max. Negotiated Rate	$171.69
Rate for Payer: Cash Price	$115.05
Rate for Payer: Health Management Network Commercial	$150.45
Rate for Payer: Kaiser Permanente Commercial	$159.30
Rate for Payer: MDX Hawaii PPO	$171.69

SLP Group Therapy Units

Facility

$177.00

Service Code	HCPCS 92508 GO,CO
Hospital Charge Code	1373850
Hospital Revenue Code	440
Min. Negotiated Rate	$11.15
Max. Negotiated Rate	$171.69
Rate for Payer: AlohaCare Medicaid	$88.50
Rate for Payer: AlohaCare Medicare	$88.50
Rate for Payer: Cash Price	$115.05
Rate for Payer: Cash Price	$115.05
Rate for Payer: Devoted Health Medicare	$97.35
Rate for Payer: Hawaii Medical Service Association Medicare	$88.50
Rate for Payer: Hawaii Western Management Group Commercial	$168.15
Rate for Payer: Health Management Network Commercial	$150.45
Rate for Payer: Humana Medicare	$88.50
Rate for Payer: Kaiser Permanente Commercial	$159.30
Rate for Payer: Kaiser Permanente Medicaid	$90.27
Rate for Payer: Kaiser Permanente Medicare	$88.50
Rate for Payer: MDX Hawaii PPO	$171.69
Rate for Payer: Ohana Health Plan Medicaid	$88.50
Rate for Payer: Ohana Health Plan Medicare	$88.50
Rate for Payer: UnitedHealthcare Medicaid	$11.15
Rate for Payer: UnitedHealthcare Medicare	$88.50
Rate for Payer: University Health Alliance Commercial	$99.12

SLP Non-Speech AAC Device Eval Units

Facility

$257.00

Service Code	HCPCS 92605 GO,CO
Hospital Charge Code	1373847
Hospital Revenue Code	444
Min. Negotiated Rate	$62.11
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	$62.11
Rate for Payer: UnitedHealthcare Medicare	$128.50
Rate for Payer: University Health Alliance Commercial	$143.92

SLP Non-Speech AAC Device Eval Units

Facility

$257.00

Service Code	HCPCS 92605 GO,CO
Hospital Charge Code	1373847
Hospital Revenue Code	444
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

SLP Non-Speech AAC Device Tx Units

Facility

$223.00

Service Code	HCPCS 92606 GO,CO
Hospital Charge Code	1373848
Hospital Revenue Code	444
Min. Negotiated Rate	$45.54
Max. Negotiated Rate	$216.31
Rate for Payer: AlohaCare Medicaid	$111.50
Rate for Payer: AlohaCare Medicare	$111.50
Rate for Payer: Cash Price	$144.95
Rate for Payer: Cash Price	$144.95
Rate for Payer: Devoted Health Medicare	$122.65
Rate for Payer: Hawaii Medical Service Association Medicare	$111.50
Rate for Payer: Hawaii Western Management Group Commercial	$211.85
Rate for Payer: Health Management Network Commercial	$189.55
Rate for Payer: Humana Medicare	$111.50
Rate for Payer: Kaiser Permanente Commercial	$200.70
Rate for Payer: Kaiser Permanente Medicaid	$113.73
Rate for Payer: Kaiser Permanente Medicare	$111.50
Rate for Payer: MDX Hawaii PPO	$216.31
Rate for Payer: Ohana Health Plan Medicaid	$111.50
Rate for Payer: Ohana Health Plan Medicare	$111.50
Rate for Payer: UnitedHealthcare Medicaid	$45.54
Rate for Payer: UnitedHealthcare Medicare	$111.50
Rate for Payer: University Health Alliance Commercial	$124.88

SLP Non-Speech AAC Device Tx Units

Facility

$223.00

Service Code	HCPCS 92606 GO,CO
Hospital Charge Code	1373848
Hospital Revenue Code	444
Min. Negotiated Rate	$189.55
Max. Negotiated Rate	$216.31
Rate for Payer: Cash Price	$144.95
Rate for Payer: Health Management Network Commercial	$189.55
Rate for Payer: Kaiser Permanente Commercial	$200.70
Rate for Payer: MDX Hawaii PPO	$216.31

SLP Outpatient Daily Documentation

Facility

$533.00

Service Code	HCPCS 92526 GP,CQ
Hospital Charge Code	1397804
Hospital Revenue Code	440
Min. Negotiated Rate	$22.46
Max. Negotiated Rate	$517.01
Rate for Payer: AlohaCare Medicaid	$266.50
Rate for Payer: AlohaCare Medicare	$266.50
Rate for Payer: Cash Price	$346.45
Rate for Payer: Cash Price	$346.45
Rate for Payer: Devoted Health Medicare	$293.15
Rate for Payer: Hawaii Medical Service Association Medicare	$266.50
Rate for Payer: Hawaii Western Management Group Commercial	$506.35
Rate for Payer: Health Management Network Commercial	$453.05
Rate for Payer: Humana Medicare	$266.50
Rate for Payer: Kaiser Permanente Commercial	$479.70
Rate for Payer: Kaiser Permanente Medicaid	$271.83
Rate for Payer: Kaiser Permanente Medicare	$266.50
Rate for Payer: MDX Hawaii PPO	$517.01
Rate for Payer: Ohana Health Plan Medicaid	$266.50
Rate for Payer: Ohana Health Plan Medicare	$266.50
Rate for Payer: UnitedHealthcare Medicaid	$22.46
Rate for Payer: UnitedHealthcare Medicare	$266.50
Rate for Payer: University Health Alliance Commercial	$298.48

SLP Outpatient Daily Documentation

Facility

$533.00

Service Code	HCPCS 92526 GP,CQ
Hospital Charge Code	1397804
Hospital Revenue Code	440
Min. Negotiated Rate	$453.05
Max. Negotiated Rate	$517.01
Rate for Payer: Cash Price	$346.45
Rate for Payer: Health Management Network Commercial	$453.05
Rate for Payer: Kaiser Permanente Commercial	$479.70
Rate for Payer: MDX Hawaii PPO	$517.01

SLP Pharyngeal Swallow Eval Units

Facility

$521.00

Service Code	HCPCS 92610 GO,CO
Hospital Charge Code	1373843
Hospital Revenue Code	444
Min. Negotiated Rate	$88.36
Max. Negotiated Rate	$505.37
Rate for Payer: AlohaCare Medicaid	$260.50
Rate for Payer: AlohaCare Medicare	$260.50
Rate for Payer: Cash Price	$338.65
Rate for Payer: Cash Price	$338.65
Rate for Payer: Devoted Health Medicare	$286.55
Rate for Payer: Hawaii Medical Service Association Medicare	$260.50
Rate for Payer: Hawaii Western Management Group Commercial	$494.95
Rate for Payer: Health Management Network Commercial	$442.85
Rate for Payer: Humana Medicare	$260.50
Rate for Payer: Kaiser Permanente Commercial	$468.90
Rate for Payer: Kaiser Permanente Medicaid	$265.71
Rate for Payer: Kaiser Permanente Medicare	$260.50
Rate for Payer: MDX Hawaii PPO	$505.37
Rate for Payer: Ohana Health Plan Medicaid	$260.50
Rate for Payer: Ohana Health Plan Medicare	$260.50
Rate for Payer: UnitedHealthcare Medicaid	$88.36
Rate for Payer: UnitedHealthcare Medicare	$260.50
Rate for Payer: University Health Alliance Commercial	$291.76

SLP Pharyngeal Swallow Eval Units

Facility

$521.00

Service Code	HCPCS 92610 GO,CO
Hospital Charge Code	1373843
Hospital Revenue Code	444
Min. Negotiated Rate	$442.85
Max. Negotiated Rate	$505.37
Rate for Payer: Cash Price	$338.65
Rate for Payer: Health Management Network Commercial	$442.85
Rate for Payer: Kaiser Permanente Commercial	$468.90
Rate for Payer: MDX Hawaii PPO	$505.37

SLP Speech AAC Eval Addl Half Hour Units

Facility

$227.00

Service Code	HCPCS 92608 GO,CO
Hospital Charge Code	1373854
Hospital Revenue Code	444
Min. Negotiated Rate	$192.95
Max. Negotiated Rate	$220.19
Rate for Payer: Cash Price	$147.55
Rate for Payer: Health Management Network Commercial	$192.95
Rate for Payer: Kaiser Permanente Commercial	$204.30
Rate for Payer: MDX Hawaii PPO	$220.19

SLP Speech AAC Eval Addl Half Hour Units

Facility

$227.00

Service Code	HCPCS 92608 GO,CO
Hospital Charge Code	1373854
Hospital Revenue Code	444
Min. Negotiated Rate	$17.26
Max. Negotiated Rate	$220.19
Rate for Payer: AlohaCare Medicaid	$113.50
Rate for Payer: AlohaCare Medicare	$113.50
Rate for Payer: Cash Price	$147.55
Rate for Payer: Cash Price	$147.55
Rate for Payer: Devoted Health Medicare	$124.85
Rate for Payer: Hawaii Medical Service Association Medicare	$113.50
Rate for Payer: Hawaii Western Management Group Commercial	$215.65
Rate for Payer: Health Management Network Commercial	$192.95
Rate for Payer: Humana Medicare	$113.50
Rate for Payer: Kaiser Permanente Commercial	$204.30
Rate for Payer: Kaiser Permanente Medicaid	$115.77
Rate for Payer: Kaiser Permanente Medicare	$113.50
Rate for Payer: MDX Hawaii PPO	$220.19
Rate for Payer: Ohana Health Plan Medicaid	$113.50
Rate for Payer: Ohana Health Plan Medicare	$113.50
Rate for Payer: UnitedHealthcare Medicaid	$17.26
Rate for Payer: UnitedHealthcare Medicare	$113.50
Rate for Payer: University Health Alliance Commercial	$127.12

SLP Speech AAC Eval First Hour Units

Facility

$413.00

Service Code	HCPCS 92607 GO,CO
Hospital Charge Code	1373852
Hospital Revenue Code	444
Min. Negotiated Rate	$88.11
Max. Negotiated Rate	$400.61
Rate for Payer: AlohaCare Medicaid	$206.50
Rate for Payer: AlohaCare Medicare	$206.50
Rate for Payer: Cash Price	$268.45
Rate for Payer: Cash Price	$268.45
Rate for Payer: Devoted Health Medicare	$227.15
Rate for Payer: Hawaii Medical Service Association Medicare	$206.50
Rate for Payer: Hawaii Western Management Group Commercial	$392.35
Rate for Payer: Health Management Network Commercial	$351.05
Rate for Payer: Humana Medicare	$206.50
Rate for Payer: Kaiser Permanente Commercial	$371.70
Rate for Payer: Kaiser Permanente Medicaid	$210.63
Rate for Payer: Kaiser Permanente Medicare	$206.50
Rate for Payer: MDX Hawaii PPO	$400.61
Rate for Payer: Ohana Health Plan Medicaid	$206.50
Rate for Payer: Ohana Health Plan Medicare	$206.50
Rate for Payer: UnitedHealthcare Medicaid	$88.11
Rate for Payer: UnitedHealthcare Medicare	$206.50
Rate for Payer: University Health Alliance Commercial	$231.28

SLP Speech AAC Eval First Hour Units

Facility

$413.00

Service Code	HCPCS 92607 GO,CO
Hospital Charge Code	1373852
Hospital Revenue Code	444
Min. Negotiated Rate	$351.05
Max. Negotiated Rate	$400.61
Rate for Payer: Cash Price	$268.45
Rate for Payer: Health Management Network Commercial	$351.05
Rate for Payer: Kaiser Permanente Commercial	$371.70
Rate for Payer: MDX Hawaii PPO	$400.61

SLP Speech-Gen Dev Prog and Mod

Facility

$251.00

Service Code	HCPCS 92609 GO,CO
Hospital Charge Code	8117181
Hospital Revenue Code	440
Min. Negotiated Rate	$47.70
Max. Negotiated Rate	$243.47
Rate for Payer: AlohaCare Medicaid	$125.50
Rate for Payer: AlohaCare Medicare	$125.50
Rate for Payer: Cash Price	$163.15
Rate for Payer: Cash Price	$163.15
Rate for Payer: Devoted Health Medicare	$138.05
Rate for Payer: Hawaii Medical Service Association Medicare	$125.50
Rate for Payer: Hawaii Western Management Group Commercial	$238.45
Rate for Payer: Health Management Network Commercial	$213.35
Rate for Payer: Humana Medicare	$125.50
Rate for Payer: Kaiser Permanente Commercial	$225.90
Rate for Payer: Kaiser Permanente Medicaid	$128.01
Rate for Payer: Kaiser Permanente Medicare	$125.50
Rate for Payer: MDX Hawaii PPO	$243.47
Rate for Payer: Ohana Health Plan Medicaid	$125.50
Rate for Payer: Ohana Health Plan Medicare	$125.50
Rate for Payer: UnitedHealthcare Medicaid	$47.70
Rate for Payer: UnitedHealthcare Medicare	$125.50
Rate for Payer: University Health Alliance Commercial	$140.56

SLP Speech-Gen Dev Prog and Mod

Facility

$251.00

Service Code	HCPCS 92609 GO,CO
Hospital Charge Code	8117181
Hospital Revenue Code	440
Min. Negotiated Rate	$213.35
Max. Negotiated Rate	$243.47
Rate for Payer: Cash Price	$163.15
Rate for Payer: Health Management Network Commercial	$213.35
Rate for Payer: Kaiser Permanente Commercial	$225.90
Rate for Payer: MDX Hawaii PPO	$243.47

SLP Swallow Dysfunction Oral Feed Units

Facility

$533.00

Service Code	HCPCS 92526 GO,CO
Hospital Charge Code	1373842
Hospital Revenue Code	440
Min. Negotiated Rate	$453.05
Max. Negotiated Rate	$517.01
Rate for Payer: Cash Price	$346.45
Rate for Payer: Health Management Network Commercial	$453.05
Rate for Payer: Kaiser Permanente Commercial	$479.70
Rate for Payer: MDX Hawaii PPO	$517.01

SLP Swallow Dysfunction Oral Feed Units

Facility

$533.00

Service Code	HCPCS 92526 GO,CO
Hospital Charge Code	1373842
Hospital Revenue Code	440
Min. Negotiated Rate	$22.46
Max. Negotiated Rate	$517.01
Rate for Payer: AlohaCare Medicaid	$266.50
Rate for Payer: AlohaCare Medicare	$266.50
Rate for Payer: Cash Price	$346.45
Rate for Payer: Cash Price	$346.45
Rate for Payer: Devoted Health Medicare	$293.15
Rate for Payer: Hawaii Medical Service Association Medicare	$266.50
Rate for Payer: Hawaii Western Management Group Commercial	$506.35
Rate for Payer: Health Management Network Commercial	$453.05
Rate for Payer: Humana Medicare	$266.50
Rate for Payer: Kaiser Permanente Commercial	$479.70
Rate for Payer: Kaiser Permanente Medicaid	$271.83
Rate for Payer: Kaiser Permanente Medicare	$266.50
Rate for Payer: MDX Hawaii PPO	$517.01
Rate for Payer: Ohana Health Plan Medicaid	$266.50
Rate for Payer: Ohana Health Plan Medicare	$266.50
Rate for Payer: UnitedHealthcare Medicaid	$22.46
Rate for Payer: UnitedHealthcare Medicare	$266.50
Rate for Payer: University Health Alliance Commercial	$298.48

SLP Tx Generating Device Units

Facility

$251.00

Service Code	HCPCS 92609 GO,CO
Hospital Charge Code	1373849
Hospital Revenue Code	440
Min. Negotiated Rate	$213.35
Max. Negotiated Rate	$243.47
Rate for Payer: Cash Price	$163.15
Rate for Payer: Health Management Network Commercial	$213.35
Rate for Payer: Kaiser Permanente Commercial	$225.90
Rate for Payer: MDX Hawaii PPO	$243.47

Know your out-of-pocket cost for care.

All Charges