Kohala Hospital

All Charges

Charge

Type

Setting

Price

HCHG PT (INHIBITOR SCRN)

Facility

$59.00

Service Code	HCPCS 85610
Hospital Charge Code	H3000372
Hospital Revenue Code	300
Min. Negotiated Rate	$50.15
Max. Negotiated Rate	$57.23
Rate for Payer: Cash Price	$38.35
Rate for Payer: Health Management Network Commercial	$50.15
Rate for Payer: Kaiser Permanente Commercial	$53.10
Rate for Payer: MDX Hawaii PPO	$57.23

HCHG PT INIT EVAL HIGH

Facility

$620.00

Service Code	HCPCS 97163
Hospital Charge Code	H4240140
Hospital Revenue Code	424
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 PT INIT EVAL HIGH

Facility

$620.00

Service Code	HCPCS 97163
Hospital Charge Code	H4240140
Hospital Revenue Code	424
Min. Negotiated Rate	$106.70
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	$106.70
Rate for Payer: UnitedHealthcare Medicare	$558.00
Rate for Payer: University Health Alliance Commercial	$451.92

HCHG PT INIT EVAL LOW

Facility

$620.00

Service Code	HCPCS 97161
Hospital Charge Code	H4240135
Hospital Revenue Code	424
Min. Negotiated Rate	$106.70
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	$106.70
Rate for Payer: UnitedHealthcare Medicare	$558.00
Rate for Payer: University Health Alliance Commercial	$451.92

HCHG PT INIT EVAL LOW

Facility

$620.00

Service Code	HCPCS 97161
Hospital Charge Code	H4240135
Hospital Revenue Code	424
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 PT INIT EVAL MOD

Facility

$620.00

Service Code	HCPCS 97162
Hospital Charge Code	H4240137
Hospital Revenue Code	424
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 PT INIT EVAL MOD

Facility

$620.00

Service Code	HCPCS 97162
Hospital Charge Code	H4240137
Hospital Revenue Code	424
Min. Negotiated Rate	$106.70
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	$106.70
Rate for Payer: UnitedHealthcare Medicare	$558.00
Rate for Payer: University Health Alliance Commercial	$451.92

HCHG PT MANUAL THERAPY 15 MIN

Facility

$197.00

Service Code	HCPCS 97140
Hospital Charge Code	H4200108
Hospital Revenue Code	420
Min. Negotiated Rate	$167.45
Max. Negotiated Rate	$191.09
Rate for Payer: Cash Price	$128.05
Rate for Payer: Health Management Network Commercial	$167.45
Rate for Payer: Kaiser Permanente Commercial	$177.30
Rate for Payer: MDX Hawaii PPO	$191.09

HCHG PT MANUAL THERAPY 15 MIN

Facility

$197.00

Service Code	HCPCS 97140
Hospital Charge Code	H4200108
Hospital Revenue Code	420
Min. Negotiated Rate	$20.55
Max. Negotiated Rate	$195.03
Rate for Payer: AlohaCare Medicaid	$98.50
Rate for Payer: AlohaCare Medicare	$177.30
Rate for Payer: Cash Price	$128.05
Rate for Payer: Cash Price	$128.05
Rate for Payer: Devoted Health Medicare	$195.03
Rate for Payer: Hawaii Medical Service Association Medicare	$177.30
Rate for Payer: Hawaii Western Management Group Commercial	$187.15
Rate for Payer: Health Management Network Commercial	$167.45
Rate for Payer: Humana Medicare	$177.30
Rate for Payer: Kaiser Permanente Commercial	$177.30
Rate for Payer: Kaiser Permanente Medicaid	$100.47
Rate for Payer: Kaiser Permanente Medicare	$177.30
Rate for Payer: MDX Hawaii PPO	$191.09
Rate for Payer: Ohana Health Plan Medicaid	$177.30
Rate for Payer: Ohana Health Plan Medicare	$177.30
Rate for Payer: UnitedHealthcare Medicaid	$20.55
Rate for Payer: UnitedHealthcare Medicare	$177.30
Rate for Payer: University Health Alliance Commercial	$143.59

HCHG PT MASSAGE 15 MIN

Facility

$208.00

Service Code	HCPCS 97124
Hospital Charge Code	H4200148
Hospital Revenue Code	420
Min. Negotiated Rate	$176.80
Max. Negotiated Rate	$201.76
Rate for Payer: Cash Price	$135.20
Rate for Payer: Health Management Network Commercial	$176.80
Rate for Payer: Kaiser Permanente Commercial	$187.20
Rate for Payer: MDX Hawaii PPO	$201.76

HCHG PT MASSAGE 15 MIN

Facility

$208.00

Service Code	HCPCS 97124
Hospital Charge Code	H4200148
Hospital Revenue Code	420
Min. Negotiated Rate	$15.39
Max. Negotiated Rate	$205.92
Rate for Payer: AlohaCare Medicaid	$104.00
Rate for Payer: AlohaCare Medicare	$187.20
Rate for Payer: Cash Price	$135.20
Rate for Payer: Cash Price	$135.20
Rate for Payer: Devoted Health Medicare	$205.92
Rate for Payer: Hawaii Medical Service Association Medicare	$187.20
Rate for Payer: Hawaii Western Management Group Commercial	$197.60
Rate for Payer: Health Management Network Commercial	$176.80
Rate for Payer: Humana Medicare	$187.20
Rate for Payer: Kaiser Permanente Commercial	$187.20
Rate for Payer: Kaiser Permanente Medicaid	$106.08
Rate for Payer: Kaiser Permanente Medicare	$187.20
Rate for Payer: MDX Hawaii PPO	$201.76
Rate for Payer: Ohana Health Plan Medicaid	$187.20
Rate for Payer: Ohana Health Plan Medicare	$187.20
Rate for Payer: UnitedHealthcare Medicaid	$15.39
Rate for Payer: UnitedHealthcare Medicare	$187.20
Rate for Payer: University Health Alliance Commercial	$151.61

HCHG PT NEUROMUSC RE-ED 15 MIN

Facility

$237.00

Service Code	HCPCS 97112
Hospital Charge Code	H4200260
Hospital Revenue Code	420
Min. Negotiated Rate	$18.58
Max. Negotiated Rate	$234.63
Rate for Payer: AlohaCare Medicaid	$118.50
Rate for Payer: AlohaCare Medicare	$213.30
Rate for Payer: Cash Price	$154.05
Rate for Payer: Cash Price	$154.05
Rate for Payer: Devoted Health Medicare	$234.63
Rate for Payer: Hawaii Medical Service Association Medicare	$213.30
Rate for Payer: Hawaii Western Management Group Commercial	$225.15
Rate for Payer: Health Management Network Commercial	$201.45
Rate for Payer: Humana Medicare	$213.30
Rate for Payer: Kaiser Permanente Commercial	$213.30
Rate for Payer: Kaiser Permanente Medicaid	$120.87
Rate for Payer: Kaiser Permanente Medicare	$213.30
Rate for Payer: MDX Hawaii PPO	$229.89
Rate for Payer: Ohana Health Plan Medicaid	$213.30
Rate for Payer: Ohana Health Plan Medicare	$213.30
Rate for Payer: UnitedHealthcare Medicaid	$18.58
Rate for Payer: UnitedHealthcare Medicare	$213.30
Rate for Payer: University Health Alliance Commercial	$172.75

HCHG PT NEUROMUSC RE-ED 15 MIN

Facility

$237.00

Service Code	HCPCS 97112
Hospital Charge Code	H4200260
Hospital Revenue Code	420
Min. Negotiated Rate	$201.45
Max. Negotiated Rate	$229.89
Rate for Payer: Cash Price	$154.05
Rate for Payer: Health Management Network Commercial	$201.45
Rate for Payer: Kaiser Permanente Commercial	$213.30
Rate for Payer: MDX Hawaii PPO	$229.89

HCHG PT PROSTHETIC TRAINING 15 MIN

Facility

$220.00

Service Code	HCPCS 97761
Hospital Charge Code	H4200465
Hospital Revenue Code	420
Min. Negotiated Rate	$17.70
Max. Negotiated Rate	$217.80
Rate for Payer: AlohaCare Medicaid	$110.00
Rate for Payer: AlohaCare Medicare	$198.00
Rate for Payer: Cash Price	$143.00
Rate for Payer: Cash Price	$143.00
Rate for Payer: Devoted Health Medicare	$217.80
Rate for Payer: Hawaii Medical Service Association Medicare	$198.00
Rate for Payer: Hawaii Western Management Group Commercial	$209.00
Rate for Payer: Health Management Network Commercial	$187.00
Rate for Payer: Humana Medicare	$198.00
Rate for Payer: Kaiser Permanente Commercial	$198.00
Rate for Payer: Kaiser Permanente Medicaid	$112.20
Rate for Payer: Kaiser Permanente Medicare	$198.00
Rate for Payer: MDX Hawaii PPO	$213.40
Rate for Payer: Ohana Health Plan Medicaid	$198.00
Rate for Payer: Ohana Health Plan Medicare	$198.00
Rate for Payer: UnitedHealthcare Medicaid	$17.70
Rate for Payer: UnitedHealthcare Medicare	$198.00
Rate for Payer: University Health Alliance Commercial	$160.36

HCHG PT PROSTHETIC TRAINING 15 MIN

Facility

$220.00

Service Code	HCPCS 97761
Hospital Charge Code	H4200465
Hospital Revenue Code	420
Min. Negotiated Rate	$187.00
Max. Negotiated Rate	$213.40
Rate for Payer: Cash Price	$143.00
Rate for Payer: Health Management Network Commercial	$187.00
Rate for Payer: Kaiser Permanente Commercial	$198.00
Rate for Payer: MDX Hawaii PPO	$213.40

HCHG PT RE-EVAL

Facility

$425.00

Service Code	HCPCS 97164
Hospital Charge Code	H4240147
Hospital Revenue Code	424
Min. Negotiated Rate	$74.59
Max. Negotiated Rate	$420.75
Rate for Payer: AlohaCare Medicaid	$212.50
Rate for Payer: AlohaCare Medicare	$382.50
Rate for Payer: Cash Price	$276.25
Rate for Payer: Cash Price	$276.25
Rate for Payer: Devoted Health Medicare	$420.75
Rate for Payer: Hawaii Medical Service Association Medicare	$382.50
Rate for Payer: Hawaii Western Management Group Commercial	$403.75
Rate for Payer: Health Management Network Commercial	$361.25
Rate for Payer: Humana Medicare	$382.50
Rate for Payer: Kaiser Permanente Commercial	$382.50
Rate for Payer: Kaiser Permanente Medicaid	$216.75
Rate for Payer: Kaiser Permanente Medicare	$382.50
Rate for Payer: MDX Hawaii PPO	$412.25
Rate for Payer: Ohana Health Plan Medicaid	$382.50
Rate for Payer: Ohana Health Plan Medicare	$382.50
Rate for Payer: UnitedHealthcare Medicaid	$74.59
Rate for Payer: UnitedHealthcare Medicare	$382.50
Rate for Payer: University Health Alliance Commercial	$309.78

HCHG PT RE-EVAL

Facility

$425.00

Service Code	HCPCS 97164
Hospital Charge Code	H4240147
Hospital Revenue Code	424
Min. Negotiated Rate	$361.25
Max. Negotiated Rate	$412.25
Rate for Payer: Cash Price	$276.25
Rate for Payer: Health Management Network Commercial	$361.25
Rate for Payer: Kaiser Permanente Commercial	$382.50
Rate for Payer: MDX Hawaii PPO	$412.25

HCHG PT THER ADAPT FU 15 MIN

Facility

$300.00

Service Code	HCPCS 97763
Hospital Charge Code	H4200483
Hospital Revenue Code	420
Min. Negotiated Rate	$255.00
Max. Negotiated Rate	$291.00
Rate for Payer: Cash Price	$195.00
Rate for Payer: Health Management Network Commercial	$255.00
Rate for Payer: Kaiser Permanente Commercial	$270.00
Rate for Payer: MDX Hawaii PPO	$291.00

HCHG PT THER ADAPT FU 15 MIN

Facility

$300.00

Service Code	HCPCS 97763
Hospital Charge Code	H4200483
Hospital Revenue Code	420
Min. Negotiated Rate	$57.47
Max. Negotiated Rate	$297.00
Rate for Payer: AlohaCare Medicaid	$150.00
Rate for Payer: AlohaCare Medicare	$270.00
Rate for Payer: Cash Price	$195.00
Rate for Payer: Cash Price	$195.00
Rate for Payer: Devoted Health Medicare	$297.00
Rate for Payer: Hawaii Medical Service Association Medicare	$270.00
Rate for Payer: Hawaii Western Management Group Commercial	$285.00
Rate for Payer: Health Management Network Commercial	$255.00
Rate for Payer: Humana Medicare	$270.00
Rate for Payer: Kaiser Permanente Commercial	$270.00
Rate for Payer: Kaiser Permanente Medicaid	$153.00
Rate for Payer: Kaiser Permanente Medicare	$270.00
Rate for Payer: MDX Hawaii PPO	$291.00
Rate for Payer: Ohana Health Plan Medicaid	$270.00
Rate for Payer: Ohana Health Plan Medicare	$270.00
Rate for Payer: UnitedHealthcare Medicaid	$57.47
Rate for Payer: UnitedHealthcare Medicare	$270.00
Rate for Payer: University Health Alliance Commercial	$218.67

HCHG PT THERAPEUTIC ACTIV 15 MIN

Facility

$246.00

Service Code	HCPCS 97530
Hospital Charge Code	H4200268
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

HCHG PT THERAPEUTIC ACTIV 15 MIN

Facility

$246.00

Service Code	HCPCS 97530
Hospital Charge Code	H4200268
Hospital Revenue Code	420
Min. Negotiated Rate	$18.32
Max. Negotiated Rate	$243.54
Rate for Payer: AlohaCare Medicaid	$123.00
Rate for Payer: AlohaCare Medicare	$221.40
Rate for Payer: Cash Price	$159.90
Rate for Payer: Cash Price	$159.90
Rate for Payer: Devoted Health Medicare	$243.54
Rate for Payer: Hawaii Medical Service Association Medicare	$221.40
Rate for Payer: Hawaii Western Management Group Commercial	$233.70
Rate for Payer: Health Management Network Commercial	$209.10
Rate for Payer: Humana Medicare	$221.40
Rate for Payer: Kaiser Permanente Commercial	$221.40
Rate for Payer: Kaiser Permanente Medicaid	$125.46
Rate for Payer: Kaiser Permanente Medicare	$221.40
Rate for Payer: MDX Hawaii PPO	$238.62
Rate for Payer: Ohana Health Plan Medicaid	$221.40
Rate for Payer: Ohana Health Plan Medicare	$221.40
Rate for Payer: UnitedHealthcare Medicaid	$18.32
Rate for Payer: UnitedHealthcare Medicare	$221.40
Rate for Payer: University Health Alliance Commercial	$179.31

HCHG PTT (INHIBITOR SCRN)

Facility

$89.00

Service Code	HCPCS 85730
Hospital Charge Code	H3050234
Hospital Revenue Code	305
Min. Negotiated Rate	$75.65
Max. Negotiated Rate	$86.33
Rate for Payer: Cash Price	$57.85
Rate for Payer: Health Management Network Commercial	$75.65
Rate for Payer: Kaiser Permanente Commercial	$80.10
Rate for Payer: MDX Hawaii PPO	$86.33

HCHG PTT (INHIBITOR SCRN)

Facility

$89.00

Service Code	HCPCS 85730
Hospital Charge Code	H3050234
Hospital Revenue Code	305
Min. Negotiated Rate	$6.01
Max. Negotiated Rate	$88.11
Rate for Payer: AlohaCare Medicaid	$44.50
Rate for Payer: AlohaCare Medicare	$80.10
Rate for Payer: Cash Price	$57.85
Rate for Payer: Cash Price	$57.85
Rate for Payer: Devoted Health Medicare	$88.11
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	$80.10
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	$75.65
Rate for Payer: Humana Medicare	$80.10
Rate for Payer: Kaiser Permanente Commercial	$80.10
Rate for Payer: Kaiser Permanente Medicaid	$45.39
Rate for Payer: Kaiser Permanente Medicare	$80.10
Rate for Payer: MDX Hawaii PPO	$86.33
Rate for Payer: Ohana Health Plan Medicaid	$80.10
Rate for Payer: Ohana Health Plan Medicare	$80.10
Rate for Payer: UnitedHealthcare Medicaid	$8.30
Rate for Payer: UnitedHealthcare Medicare	$80.10
Rate for Payer: University Health Alliance Commercial	$15.50

HCHG PT WHEELCHAIR MGT 15 MIN

Facility

$228.00

Service Code	HCPCS 97542
Hospital Charge Code	H4200288
Hospital Revenue Code	420
Min. Negotiated Rate	$17.54
Max. Negotiated Rate	$225.72
Rate for Payer: AlohaCare Medicaid	$114.00
Rate for Payer: AlohaCare Medicare	$205.20
Rate for Payer: Cash Price	$148.20
Rate for Payer: Cash Price	$148.20
Rate for Payer: Devoted Health Medicare	$225.72
Rate for Payer: Hawaii Medical Service Association Medicare	$205.20
Rate for Payer: Hawaii Western Management Group Commercial	$216.60
Rate for Payer: Health Management Network Commercial	$193.80
Rate for Payer: Humana Medicare	$205.20
Rate for Payer: Kaiser Permanente Commercial	$205.20
Rate for Payer: Kaiser Permanente Medicaid	$116.28
Rate for Payer: Kaiser Permanente Medicare	$205.20
Rate for Payer: MDX Hawaii PPO	$221.16
Rate for Payer: Ohana Health Plan Medicaid	$205.20
Rate for Payer: Ohana Health Plan Medicare	$205.20
Rate for Payer: UnitedHealthcare Medicaid	$17.54
Rate for Payer: UnitedHealthcare Medicare	$205.20
Rate for Payer: University Health Alliance Commercial	$166.19

HCHG PT WHEELCHAIR MGT 15 MIN

Facility

$228.00

Service Code	HCPCS 97542
Hospital Charge Code	H4200288
Hospital Revenue Code	420
Min. Negotiated Rate	$193.80
Max. Negotiated Rate	$221.16
Rate for Payer: Cash Price	$148.20
Rate for Payer: Health Management Network Commercial	$193.80
Rate for Payer: Kaiser Permanente Commercial	$205.20
Rate for Payer: MDX Hawaii PPO	$221.16

Know your out-of-pocket cost for care.

All Charges