Kohala Hospital

All Charges

Charge

Type

Setting

Price

HCHG OT ADAPT ORTHO FABRICA 15 MIN

Facility

$329.00

Service Code	HCPCS 97760
Hospital Charge Code	H4300122
Hospital Revenue Code	430
Min. Negotiated Rate	$17.21
Max. Negotiated Rate	$325.71
Rate for Payer: AlohaCare Medicaid	$164.50
Rate for Payer: AlohaCare Medicare	$296.10
Rate for Payer: Cash Price	$213.85
Rate for Payer: Cash Price	$213.85
Rate for Payer: Devoted Health Medicare	$325.71
Rate for Payer: Hawaii Medical Service Association Medicare	$296.10
Rate for Payer: Hawaii Western Management Group Commercial	$312.55
Rate for Payer: Health Management Network Commercial	$279.65
Rate for Payer: Humana Medicare	$296.10
Rate for Payer: Kaiser Permanente Commercial	$296.10
Rate for Payer: Kaiser Permanente Medicaid	$167.79
Rate for Payer: Kaiser Permanente Medicare	$296.10
Rate for Payer: MDX Hawaii PPO	$319.13
Rate for Payer: Ohana Health Plan Medicaid	$296.10
Rate for Payer: Ohana Health Plan Medicare	$296.10
Rate for Payer: UnitedHealthcare Medicaid	$17.21
Rate for Payer: UnitedHealthcare Medicare	$296.10
Rate for Payer: University Health Alliance Commercial	$239.81

HCHG OT ADAPT ORTHO FABRICA 15 MIN

Facility

$329.00

Service Code	HCPCS 97760
Hospital Charge Code	H4300122
Hospital Revenue Code	430
Min. Negotiated Rate	$279.65
Max. Negotiated Rate	$319.13
Rate for Payer: Cash Price	$213.85
Rate for Payer: Health Management Network Commercial	$279.65
Rate for Payer: Kaiser Permanente Commercial	$296.10
Rate for Payer: MDX Hawaii PPO	$319.13

HCHG OT AQUATIC THRPY 15M

Facility

$289.00

Service Code	HCPCS 97113
Hospital Charge Code	K4300002
Hospital Revenue Code	430
Min. Negotiated Rate	$20.09
Max. Negotiated Rate	$286.11
Rate for Payer: AlohaCare Medicaid	$144.50
Rate for Payer: AlohaCare Medicare	$260.10
Rate for Payer: Cash Price	$187.85
Rate for Payer: Cash Price	$187.85
Rate for Payer: Devoted Health Medicare	$286.11
Rate for Payer: Hawaii Medical Service Association Medicare	$260.10
Rate for Payer: Hawaii Western Management Group Commercial	$274.55
Rate for Payer: Health Management Network Commercial	$245.65
Rate for Payer: Humana Medicare	$260.10
Rate for Payer: Kaiser Permanente Commercial	$260.10
Rate for Payer: Kaiser Permanente Medicaid	$147.39
Rate for Payer: Kaiser Permanente Medicare	$260.10
Rate for Payer: MDX Hawaii PPO	$280.33
Rate for Payer: Ohana Health Plan Medicaid	$260.10
Rate for Payer: Ohana Health Plan Medicare	$260.10
Rate for Payer: UnitedHealthcare Medicaid	$20.09
Rate for Payer: UnitedHealthcare Medicare	$260.10
Rate for Payer: University Health Alliance Commercial	$210.65

HCHG OT AQUATIC THRPY 15M

Facility

$289.00

Service Code	HCPCS 97113
Hospital Charge Code	K4300002
Hospital Revenue Code	430
Min. Negotiated Rate	$245.65
Max. Negotiated Rate	$280.33
Rate for Payer: Cash Price	$187.85
Rate for Payer: Health Management Network Commercial	$245.65
Rate for Payer: Kaiser Permanente Commercial	$260.10
Rate for Payer: MDX Hawaii PPO	$280.33

HCHG OT E-STIM ATTENDED 15 MIN

Facility

$131.00

Service Code	HCPCS 97032
Hospital Charge Code	H4300108
Hospital Revenue Code	430
Min. Negotiated Rate	$13.64
Max. Negotiated Rate	$129.69
Rate for Payer: AlohaCare Medicaid	$65.50
Rate for Payer: AlohaCare Medicare	$117.90
Rate for Payer: Cash Price	$85.15
Rate for Payer: Cash Price	$85.15
Rate for Payer: Devoted Health Medicare	$129.69
Rate for Payer: Hawaii Medical Service Association Medicare	$117.90
Rate for Payer: Hawaii Western Management Group Commercial	$124.45
Rate for Payer: Health Management Network Commercial	$111.35
Rate for Payer: Humana Medicare	$117.90
Rate for Payer: Kaiser Permanente Commercial	$117.90
Rate for Payer: Kaiser Permanente Medicaid	$66.81
Rate for Payer: Kaiser Permanente Medicare	$117.90
Rate for Payer: MDX Hawaii PPO	$127.07
Rate for Payer: Ohana Health Plan Medicaid	$117.90
Rate for Payer: Ohana Health Plan Medicare	$117.90
Rate for Payer: UnitedHealthcare Medicaid	$13.64
Rate for Payer: UnitedHealthcare Medicare	$117.90
Rate for Payer: University Health Alliance Commercial	$95.49

HCHG OT E-STIM ATTENDED 15 MIN

Facility

$131.00

Service Code	HCPCS 97032
Hospital Charge Code	H4300108
Hospital Revenue Code	430
Min. Negotiated Rate	$111.35
Max. Negotiated Rate	$127.07
Rate for Payer: Cash Price	$85.15
Rate for Payer: Health Management Network Commercial	$111.35
Rate for Payer: Kaiser Permanente Commercial	$117.90
Rate for Payer: MDX Hawaii PPO	$127.07

HCHG OT E-STIM UNATTENDED

Facility

$127.00

Service Code	HCPCS 97014
Hospital Charge Code	H4300110
Hospital Revenue Code	430
Min. Negotiated Rate	$107.95
Max. Negotiated Rate	$123.19
Rate for Payer: Cash Price	$82.55
Rate for Payer: Health Management Network Commercial	$107.95
Rate for Payer: Kaiser Permanente Commercial	$114.30
Rate for Payer: MDX Hawaii PPO	$123.19

HCHG OT E-STIM UNATTENDED

Facility

$127.00

Service Code	HCPCS 97014
Hospital Charge Code	H4300110
Hospital Revenue Code	430
Min. Negotiated Rate	$11.85
Max. Negotiated Rate	$125.73
Rate for Payer: AlohaCare Medicaid	$63.50
Rate for Payer: AlohaCare Medicare	$114.30
Rate for Payer: Cash Price	$82.55
Rate for Payer: Cash Price	$82.55
Rate for Payer: Devoted Health Medicare	$125.73
Rate for Payer: Hawaii Medical Service Association Medicare	$114.30
Rate for Payer: Hawaii Western Management Group Commercial	$120.65
Rate for Payer: Health Management Network Commercial	$107.95
Rate for Payer: Humana Medicare	$114.30
Rate for Payer: Kaiser Permanente Commercial	$114.30
Rate for Payer: Kaiser Permanente Medicaid	$64.77
Rate for Payer: Kaiser Permanente Medicare	$114.30
Rate for Payer: MDX Hawaii PPO	$123.19
Rate for Payer: Ohana Health Plan Medicaid	$114.30
Rate for Payer: Ohana Health Plan Medicare	$114.30
Rate for Payer: UnitedHealthcare Medicaid	$11.85
Rate for Payer: UnitedHealthcare Medicare	$114.30
Rate for Payer: University Health Alliance Commercial	$92.57

HCHG OT GROUP IOP

Facility

$135.00

Service Code	HCPCS 97150
Hospital Charge Code	H4300164
Hospital Revenue Code	433
Min. Negotiated Rate	$14.78
Max. Negotiated Rate	$133.65
Rate for Payer: AlohaCare Medicaid	$67.50
Rate for Payer: AlohaCare Medicare	$121.50
Rate for Payer: Cash Price	$87.75
Rate for Payer: Cash Price	$87.75
Rate for Payer: Devoted Health Medicare	$133.65
Rate for Payer: Hawaii Medical Service Association Medicare	$121.50
Rate for Payer: Hawaii Western Management Group Commercial	$128.25
Rate for Payer: Health Management Network Commercial	$114.75
Rate for Payer: Humana Medicare	$121.50
Rate for Payer: Kaiser Permanente Commercial	$121.50
Rate for Payer: Kaiser Permanente Medicaid	$68.85
Rate for Payer: Kaiser Permanente Medicare	$121.50
Rate for Payer: MDX Hawaii PPO	$130.95
Rate for Payer: Ohana Health Plan Medicaid	$121.50
Rate for Payer: Ohana Health Plan Medicare	$121.50
Rate for Payer: UnitedHealthcare Medicaid	$14.78
Rate for Payer: UnitedHealthcare Medicare	$121.50
Rate for Payer: University Health Alliance Commercial	$98.40

HCHG OT GROUP IOP

Facility

$135.00

Service Code	HCPCS 97150
Hospital Charge Code	H4300164
Hospital Revenue Code	433
Min. Negotiated Rate	$114.75
Max. Negotiated Rate	$130.95
Rate for Payer: Cash Price	$87.75
Rate for Payer: Health Management Network Commercial	$114.75
Rate for Payer: Kaiser Permanente Commercial	$121.50
Rate for Payer: MDX Hawaii PPO	$130.95

HCHG OT IND DAILY LIV SKILLS 15 MIN

Facility

$235.00

Service Code	HCPCS 97535
Hospital Charge Code	H4300186
Hospital Revenue Code	430
Min. Negotiated Rate	$19.20
Max. Negotiated Rate	$232.65
Rate for Payer: AlohaCare Medicaid	$117.50
Rate for Payer: AlohaCare Medicare	$211.50
Rate for Payer: Cash Price	$152.75
Rate for Payer: Cash Price	$152.75
Rate for Payer: Devoted Health Medicare	$232.65
Rate for Payer: Hawaii Medical Service Association Medicare	$211.50
Rate for Payer: Hawaii Western Management Group Commercial	$223.25
Rate for Payer: Health Management Network Commercial	$199.75
Rate for Payer: Humana Medicare	$211.50
Rate for Payer: Kaiser Permanente Commercial	$211.50
Rate for Payer: Kaiser Permanente Medicaid	$119.85
Rate for Payer: Kaiser Permanente Medicare	$211.50
Rate for Payer: MDX Hawaii PPO	$227.95
Rate for Payer: Ohana Health Plan Medicaid	$211.50
Rate for Payer: Ohana Health Plan Medicare	$211.50
Rate for Payer: UnitedHealthcare Medicaid	$19.20
Rate for Payer: UnitedHealthcare Medicare	$211.50
Rate for Payer: University Health Alliance Commercial	$171.29

HCHG OT IND DAILY LIV SKILLS 15 MIN

Facility

$235.00

Service Code	HCPCS 97535
Hospital Charge Code	H4300186
Hospital Revenue Code	430
Min. Negotiated Rate	$199.75
Max. Negotiated Rate	$227.95
Rate for Payer: Cash Price	$152.75
Rate for Payer: Health Management Network Commercial	$199.75
Rate for Payer: Kaiser Permanente Commercial	$211.50
Rate for Payer: MDX Hawaii PPO	$227.95

HCHG OT INITIAL COGNITIVE 15 MINUTES

Facility

$162.00

Service Code	HCPCS 97129
Hospital Charge Code	H4300479
Hospital Revenue Code	430
Min. Negotiated Rate	$22.57
Max. Negotiated Rate	$160.38
Rate for Payer: AlohaCare Medicaid	$81.00
Rate for Payer: AlohaCare Medicare	$145.80
Rate for Payer: Cash Price	$105.30
Rate for Payer: Cash Price	$105.30
Rate for Payer: Devoted Health Medicare	$160.38
Rate for Payer: Hawaii Medical Service Association Medicare	$145.80
Rate for Payer: Hawaii Western Management Group Commercial	$153.90
Rate for Payer: Health Management Network Commercial	$137.70
Rate for Payer: Humana Medicare	$145.80
Rate for Payer: Kaiser Permanente Commercial	$145.80
Rate for Payer: Kaiser Permanente Medicaid	$82.62
Rate for Payer: Kaiser Permanente Medicare	$145.80
Rate for Payer: MDX Hawaii PPO	$157.14
Rate for Payer: Ohana Health Plan Medicaid	$145.80
Rate for Payer: Ohana Health Plan Medicare	$145.80
Rate for Payer: UnitedHealthcare Medicaid	$22.57
Rate for Payer: UnitedHealthcare Medicare	$145.80
Rate for Payer: University Health Alliance Commercial	$118.08

HCHG OT INITIAL COGNITIVE 15 MINUTES

Facility

$162.00

Service Code	HCPCS 97129
Hospital Charge Code	H4300479
Hospital Revenue Code	430
Min. Negotiated Rate	$137.70
Max. Negotiated Rate	$157.14
Rate for Payer: Cash Price	$105.30
Rate for Payer: Health Management Network Commercial	$137.70
Rate for Payer: Kaiser Permanente Commercial	$145.80
Rate for Payer: MDX Hawaii PPO	$157.14

HCHG OT MED-SURG EVAL HIGH

Facility

$620.00

Service Code	HCPCS 97167
Hospital Charge Code	H4340135
Hospital Revenue Code	434
Min. Negotiated Rate	$107.85
Max. Negotiated Rate	$613.80
Rate for Payer: AlohaCare Medicaid	$310.00
Rate for Payer: AlohaCare Medicare	$558.00
Rate for Payer: Cash Price	$403.00
Rate for Payer: Cash Price	$403.00
Rate for Payer: Devoted Health Medicare	$613.80
Rate for Payer: Hawaii Medical Service Association Medicare	$558.00
Rate for Payer: Hawaii Western Management Group Commercial	$589.00
Rate for Payer: Health Management Network Commercial	$527.00
Rate for Payer: Humana Medicare	$558.00
Rate for Payer: Kaiser Permanente Commercial	$558.00
Rate for Payer: Kaiser Permanente Medicaid	$316.20
Rate for Payer: Kaiser Permanente Medicare	$558.00
Rate for Payer: MDX Hawaii PPO	$601.40
Rate for Payer: Ohana Health Plan Medicaid	$558.00
Rate for Payer: Ohana Health Plan Medicare	$558.00
Rate for Payer: UnitedHealthcare Medicaid	$107.85
Rate for Payer: UnitedHealthcare Medicare	$558.00
Rate for Payer: University Health Alliance Commercial	$451.92

HCHG OT MED-SURG EVAL HIGH

Facility

$620.00

Service Code	HCPCS 97167
Hospital Charge Code	H4340135
Hospital Revenue Code	434
Min. Negotiated Rate	$527.00
Max. Negotiated Rate	$601.40
Rate for Payer: Cash Price	$403.00
Rate for Payer: Health Management Network Commercial	$527.00
Rate for Payer: Kaiser Permanente Commercial	$558.00
Rate for Payer: MDX Hawaii PPO	$601.40

HCHG OT MED-SURG EVAL HIGH 45 MIN

Facility

$620.00

Service Code	HCPCS 97167
Hospital Charge Code	H4340130
Hospital Revenue Code	434
Min. Negotiated Rate	$527.00
Max. Negotiated Rate	$601.40
Rate for Payer: Cash Price	$403.00
Rate for Payer: Health Management Network Commercial	$527.00
Rate for Payer: Kaiser Permanente Commercial	$558.00
Rate for Payer: MDX Hawaii PPO	$601.40

HCHG OT MED-SURG EVAL HIGH 45 MIN

Facility

$620.00

Service Code	HCPCS 97167
Hospital Charge Code	H4340130
Hospital Revenue Code	434
Min. Negotiated Rate	$107.85
Max. Negotiated Rate	$613.80
Rate for Payer: AlohaCare Medicaid	$310.00
Rate for Payer: AlohaCare Medicare	$558.00
Rate for Payer: Cash Price	$403.00
Rate for Payer: Cash Price	$403.00
Rate for Payer: Devoted Health Medicare	$613.80
Rate for Payer: Hawaii Medical Service Association Medicare	$558.00
Rate for Payer: Hawaii Western Management Group Commercial	$589.00
Rate for Payer: Health Management Network Commercial	$527.00
Rate for Payer: Humana Medicare	$558.00
Rate for Payer: Kaiser Permanente Commercial	$558.00
Rate for Payer: Kaiser Permanente Medicaid	$316.20
Rate for Payer: Kaiser Permanente Medicare	$558.00
Rate for Payer: MDX Hawaii PPO	$601.40
Rate for Payer: Ohana Health Plan Medicaid	$558.00
Rate for Payer: Ohana Health Plan Medicare	$558.00
Rate for Payer: UnitedHealthcare Medicaid	$107.85
Rate for Payer: UnitedHealthcare Medicare	$558.00
Rate for Payer: University Health Alliance Commercial	$451.92

HCHG OT MED-SURG EVAL LOW

Facility

$620.00

Service Code	HCPCS 97165
Hospital Charge Code	H4340125
Hospital Revenue Code	434
Min. Negotiated Rate	$527.00
Max. Negotiated Rate	$601.40
Rate for Payer: Cash Price	$403.00
Rate for Payer: Health Management Network Commercial	$527.00
Rate for Payer: Kaiser Permanente Commercial	$558.00
Rate for Payer: MDX Hawaii PPO	$601.40

HCHG OT MED-SURG EVAL LOW

Facility

$620.00

Service Code	HCPCS 97165
Hospital Charge Code	H4340125
Hospital Revenue Code	434
Min. Negotiated Rate	$107.85
Max. Negotiated Rate	$613.80
Rate for Payer: AlohaCare Medicaid	$310.00
Rate for Payer: AlohaCare Medicare	$558.00
Rate for Payer: Cash Price	$403.00
Rate for Payer: Cash Price	$403.00
Rate for Payer: Devoted Health Medicare	$613.80
Rate for Payer: Hawaii Medical Service Association Medicare	$558.00
Rate for Payer: Hawaii Western Management Group Commercial	$589.00
Rate for Payer: Health Management Network Commercial	$527.00
Rate for Payer: Humana Medicare	$558.00
Rate for Payer: Kaiser Permanente Commercial	$558.00
Rate for Payer: Kaiser Permanente Medicaid	$316.20
Rate for Payer: Kaiser Permanente Medicare	$558.00
Rate for Payer: MDX Hawaii PPO	$601.40
Rate for Payer: Ohana Health Plan Medicaid	$558.00
Rate for Payer: Ohana Health Plan Medicare	$558.00
Rate for Payer: UnitedHealthcare Medicaid	$107.85
Rate for Payer: UnitedHealthcare Medicare	$558.00
Rate for Payer: University Health Alliance Commercial	$451.92

HCHG OT MED-SURG EVAL MOD

Facility

$620.00

Service Code	HCPCS 97166
Hospital Charge Code	H4340127
Hospital Revenue Code	434
Min. Negotiated Rate	$107.85
Max. Negotiated Rate	$613.80
Rate for Payer: AlohaCare Medicaid	$310.00
Rate for Payer: AlohaCare Medicare	$558.00
Rate for Payer: Cash Price	$403.00
Rate for Payer: Cash Price	$403.00
Rate for Payer: Devoted Health Medicare	$613.80
Rate for Payer: Hawaii Medical Service Association Medicare	$558.00
Rate for Payer: Hawaii Western Management Group Commercial	$589.00
Rate for Payer: Health Management Network Commercial	$527.00
Rate for Payer: Humana Medicare	$558.00
Rate for Payer: Kaiser Permanente Commercial	$558.00
Rate for Payer: Kaiser Permanente Medicaid	$316.20
Rate for Payer: Kaiser Permanente Medicare	$558.00
Rate for Payer: MDX Hawaii PPO	$601.40
Rate for Payer: Ohana Health Plan Medicaid	$558.00
Rate for Payer: Ohana Health Plan Medicare	$558.00
Rate for Payer: UnitedHealthcare Medicaid	$107.85
Rate for Payer: UnitedHealthcare Medicare	$558.00
Rate for Payer: University Health Alliance Commercial	$451.92

HCHG OT MED-SURG EVAL MOD

Facility

$620.00

Service Code	HCPCS 97166
Hospital Charge Code	H4340127
Hospital Revenue Code	434
Min. Negotiated Rate	$527.00
Max. Negotiated Rate	$601.40
Rate for Payer: Cash Price	$403.00
Rate for Payer: Health Management Network Commercial	$527.00
Rate for Payer: Kaiser Permanente Commercial	$558.00
Rate for Payer: MDX Hawaii PPO	$601.40

HCHG OT MED-SURG RE-EVAL

Facility

$427.00

Service Code	HCPCS 97168
Hospital Charge Code	H4340137
Hospital Revenue Code	434
Min. Negotiated Rate	$362.95
Max. Negotiated Rate	$414.19
Rate for Payer: Cash Price	$277.55
Rate for Payer: Health Management Network Commercial	$362.95
Rate for Payer: Kaiser Permanente Commercial	$384.30
Rate for Payer: MDX Hawaii PPO	$414.19

HCHG OT MED-SURG RE-EVAL

Facility

$427.00

Service Code	HCPCS 97168
Hospital Charge Code	H4340137
Hospital Revenue Code	434
Min. Negotiated Rate	$74.97
Max. Negotiated Rate	$422.73
Rate for Payer: AlohaCare Medicaid	$213.50
Rate for Payer: AlohaCare Medicare	$384.30
Rate for Payer: Cash Price	$277.55
Rate for Payer: Cash Price	$277.55
Rate for Payer: Devoted Health Medicare	$422.73
Rate for Payer: Hawaii Medical Service Association Medicare	$384.30
Rate for Payer: Hawaii Western Management Group Commercial	$405.65
Rate for Payer: Health Management Network Commercial	$362.95
Rate for Payer: Humana Medicare	$384.30
Rate for Payer: Kaiser Permanente Commercial	$384.30
Rate for Payer: Kaiser Permanente Medicaid	$217.77
Rate for Payer: Kaiser Permanente Medicare	$384.30
Rate for Payer: MDX Hawaii PPO	$414.19
Rate for Payer: Ohana Health Plan Medicaid	$384.30
Rate for Payer: Ohana Health Plan Medicare	$384.30
Rate for Payer: UnitedHealthcare Medicaid	$74.97
Rate for Payer: UnitedHealthcare Medicare	$384.30
Rate for Payer: University Health Alliance Commercial	$311.24

HCHG OT THER ADAPT FU 15 MIN

Facility

$241.00

Service Code	HCPCS 97763
Hospital Charge Code	H4300272
Hospital Revenue Code	430
Min. Negotiated Rate	$204.85
Max. Negotiated Rate	$233.77
Rate for Payer: Cash Price	$156.65
Rate for Payer: Health Management Network Commercial	$204.85
Rate for Payer: Kaiser Permanente Commercial	$216.90
Rate for Payer: MDX Hawaii PPO	$233.77

Know your out-of-pocket cost for care.

All Charges