Kona Community Hospital

All Charges

Charge

Type

Setting

Price

HCHG OT COMM REINT TRNG 15 MIN

Facility

$213.00

Service Code	HCPCS 97537
Hospital Charge Code	H4300144
Hospital Revenue Code	430
Min. Negotiated Rate	$18.95
Max. Negotiated Rate	$206.61
Rate for Payer: Cash Price	$138.45
Rate for Payer: Cash Price	$138.45
Rate for Payer: Hawaii Western Management Group Commercial	$202.35
Rate for Payer: Health Management Network Commercial	$181.05
Rate for Payer: Kaiser Permanente Commercial	$134.19
Rate for Payer: Kaiser Permanente Medicaid	$108.63
Rate for Payer: MDX Hawaii PPO	$206.61
Rate for Payer: UnitedHealthcare Medicaid	$18.95
Rate for Payer: University Health Alliance Commercial	$155.26

HCHG OT COMM REINT TRNG 15 MIN

Facility

$213.00

Service Code	HCPCS 97537
Hospital Charge Code	H4300144
Hospital Revenue Code	430
Min. Negotiated Rate	$181.05
Max. Negotiated Rate	$206.61
Rate for Payer: Cash Price	$138.45
Rate for Payer: Health Management Network Commercial	$181.05
Rate for Payer: MDX Hawaii PPO	$206.61

HCHG OT EACH ADDITIONAL COGNITIVE 15 MINUTES

Facility

$149.00

Service Code	HCPCS 97130
Hospital Charge Code	H4300480
Hospital Revenue Code	430
Min. Negotiated Rate	$126.65
Max. Negotiated Rate	$144.53
Rate for Payer: Cash Price	$96.85
Rate for Payer: Health Management Network Commercial	$126.65
Rate for Payer: MDX Hawaii PPO	$144.53

HCHG OT EACH ADDITIONAL COGNITIVE 15 MINUTES

Facility

$149.00

Service Code	HCPCS 97130
Hospital Charge Code	H4300480
Hospital Revenue Code	430
Min. Negotiated Rate	$21.52
Max. Negotiated Rate	$144.53
Rate for Payer: Cash Price	$96.85
Rate for Payer: Cash Price	$96.85
Rate for Payer: Hawaii Western Management Group Commercial	$141.55
Rate for Payer: Health Management Network Commercial	$126.65
Rate for Payer: Kaiser Permanente Commercial	$93.87
Rate for Payer: Kaiser Permanente Medicaid	$75.99
Rate for Payer: MDX Hawaii PPO	$144.53
Rate for Payer: UnitedHealthcare Medicaid	$21.52
Rate for Payer: University Health Alliance Commercial	$108.61

HCHG OT E-STIM ATTENDED 15 MIN

Facility

$105.00

Service Code	HCPCS 97032
Hospital Charge Code	H4300108
Hospital Revenue Code	430
Min. Negotiated Rate	$13.64
Max. Negotiated Rate	$101.85
Rate for Payer: Cash Price	$68.25
Rate for Payer: Cash Price	$68.25
Rate for Payer: Hawaii Western Management Group Commercial	$99.75
Rate for Payer: Health Management Network Commercial	$89.25
Rate for Payer: Kaiser Permanente Commercial	$66.15
Rate for Payer: Kaiser Permanente Medicaid	$53.55
Rate for Payer: MDX Hawaii PPO	$101.85
Rate for Payer: UnitedHealthcare Medicaid	$13.64
Rate for Payer: University Health Alliance Commercial	$76.53

HCHG OT E-STIM ATTENDED 15 MIN

Facility

$105.00

Service Code	HCPCS 97032
Hospital Charge Code	H4300108
Hospital Revenue Code	430
Min. Negotiated Rate	$89.25
Max. Negotiated Rate	$101.85
Rate for Payer: Cash Price	$68.25
Rate for Payer: Health Management Network Commercial	$89.25
Rate for Payer: MDX Hawaii PPO	$101.85

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	$123.19
Rate for Payer: Cash Price	$82.55
Rate for Payer: Cash Price	$82.55
Rate for Payer: Hawaii Western Management Group Commercial	$120.65
Rate for Payer: Health Management Network Commercial	$107.95
Rate for Payer: Kaiser Permanente Commercial	$80.01
Rate for Payer: Kaiser Permanente Medicaid	$64.77
Rate for Payer: MDX Hawaii PPO	$123.19
Rate for Payer: UnitedHealthcare Medicaid	$11.85
Rate for Payer: University Health Alliance Commercial	$92.57

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: MDX Hawaii PPO	$123.19

HCHG OT GROUP IOP

Facility

$111.00

Service Code	HCPCS 97150
Hospital Charge Code	H4300164
Hospital Revenue Code	433
Min. Negotiated Rate	$14.78
Max. Negotiated Rate	$107.67
Rate for Payer: Cash Price	$72.15
Rate for Payer: Cash Price	$72.15
Rate for Payer: Hawaii Western Management Group Commercial	$105.45
Rate for Payer: Health Management Network Commercial	$94.35
Rate for Payer: Kaiser Permanente Commercial	$69.93
Rate for Payer: Kaiser Permanente Medicaid	$56.61
Rate for Payer: MDX Hawaii PPO	$107.67
Rate for Payer: UnitedHealthcare Medicaid	$14.78
Rate for Payer: University Health Alliance Commercial	$80.91

HCHG OT GROUP IOP

Facility

$111.00

Service Code	HCPCS 97150
Hospital Charge Code	H4300164
Hospital Revenue Code	433
Min. Negotiated Rate	$94.35
Max. Negotiated Rate	$107.67
Rate for Payer: Cash Price	$72.15
Rate for Payer: Health Management Network Commercial	$94.35
Rate for Payer: MDX Hawaii PPO	$107.67

HCHG OT IND DAILY LIV SKILLS 15 MIN

Facility

$226.00

Service Code	HCPCS 97535
Hospital Charge Code	H4300186
Hospital Revenue Code	430
Min. Negotiated Rate	$192.10
Max. Negotiated Rate	$219.22
Rate for Payer: Cash Price	$146.90
Rate for Payer: Health Management Network Commercial	$192.10
Rate for Payer: MDX Hawaii PPO	$219.22

HCHG OT IND DAILY LIV SKILLS 15 MIN

Facility

$226.00

Service Code	HCPCS 97535
Hospital Charge Code	H4300186
Hospital Revenue Code	430
Min. Negotiated Rate	$19.20
Max. Negotiated Rate	$219.22
Rate for Payer: Cash Price	$146.90
Rate for Payer: Cash Price	$146.90
Rate for Payer: Hawaii Western Management Group Commercial	$214.70
Rate for Payer: Health Management Network Commercial	$192.10
Rate for Payer: Kaiser Permanente Commercial	$142.38
Rate for Payer: Kaiser Permanente Medicaid	$115.26
Rate for Payer: MDX Hawaii PPO	$219.22
Rate for Payer: UnitedHealthcare Medicaid	$19.20
Rate for Payer: University Health Alliance Commercial	$164.73

HCHG OT INITIAL COGNITIVE 15 MINUTES

Facility

$155.00

Service Code	HCPCS 97129
Hospital Charge Code	H4300479
Hospital Revenue Code	430
Min. Negotiated Rate	$131.75
Max. Negotiated Rate	$150.35
Rate for Payer: Cash Price	$100.75
Rate for Payer: Health Management Network Commercial	$131.75
Rate for Payer: MDX Hawaii PPO	$150.35

HCHG OT INITIAL COGNITIVE 15 MINUTES

Facility

$155.00

Service Code	HCPCS 97129
Hospital Charge Code	H4300479
Hospital Revenue Code	430
Min. Negotiated Rate	$22.57
Max. Negotiated Rate	$150.35
Rate for Payer: Cash Price	$100.75
Rate for Payer: Cash Price	$100.75
Rate for Payer: Hawaii Western Management Group Commercial	$147.25
Rate for Payer: Health Management Network Commercial	$131.75
Rate for Payer: Kaiser Permanente Commercial	$97.65
Rate for Payer: Kaiser Permanente Medicaid	$79.05
Rate for Payer: MDX Hawaii PPO	$150.35
Rate for Payer: UnitedHealthcare Medicaid	$22.57
Rate for Payer: University Health Alliance Commercial	$112.98

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	$601.40
Rate for Payer: Cash Price	$403.00
Rate for Payer: Cash Price	$403.00
Rate for Payer: Hawaii Western Management Group Commercial	$589.00
Rate for Payer: Health Management Network Commercial	$527.00
Rate for Payer: Kaiser Permanente Commercial	$390.60
Rate for Payer: Kaiser Permanente Medicaid	$316.20
Rate for Payer: MDX Hawaii PPO	$601.40
Rate for Payer: UnitedHealthcare Medicaid	$107.85
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: MDX Hawaii PPO	$601.40

HCHG OT MED-SURG EVAL LOW

Facility

$604.00

Service Code	HCPCS 97165
Hospital Charge Code	H4340125
Hospital Revenue Code	434
Min. Negotiated Rate	$107.85
Max. Negotiated Rate	$585.88
Rate for Payer: Cash Price	$392.60
Rate for Payer: Cash Price	$392.60
Rate for Payer: Hawaii Western Management Group Commercial	$573.80
Rate for Payer: Health Management Network Commercial	$513.40
Rate for Payer: Kaiser Permanente Commercial	$380.52
Rate for Payer: Kaiser Permanente Medicaid	$308.04
Rate for Payer: MDX Hawaii PPO	$585.88
Rate for Payer: UnitedHealthcare Medicaid	$107.85
Rate for Payer: University Health Alliance Commercial	$440.26

HCHG OT MED-SURG EVAL LOW

Facility

$604.00

Service Code	HCPCS 97165
Hospital Charge Code	H4340125
Hospital Revenue Code	434
Min. Negotiated Rate	$513.40
Max. Negotiated Rate	$585.88
Rate for Payer: Cash Price	$392.60
Rate for Payer: Health Management Network Commercial	$513.40
Rate for Payer: MDX Hawaii PPO	$585.88

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	$601.40
Rate for Payer: Cash Price	$403.00
Rate for Payer: Cash Price	$403.00
Rate for Payer: Hawaii Western Management Group Commercial	$589.00
Rate for Payer: Health Management Network Commercial	$527.00
Rate for Payer: Kaiser Permanente Commercial	$390.60
Rate for Payer: Kaiser Permanente Medicaid	$316.20
Rate for Payer: MDX Hawaii PPO	$601.40
Rate for Payer: UnitedHealthcare Medicaid	$107.85
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: MDX Hawaii PPO	$601.40

HCHG OT MED-SURG RE-EVAL

Facility

$398.00

Service Code	HCPCS 97168
Hospital Charge Code	H4340137
Hospital Revenue Code	434
Min. Negotiated Rate	$338.30
Max. Negotiated Rate	$386.06
Rate for Payer: Cash Price	$258.70
Rate for Payer: Health Management Network Commercial	$338.30
Rate for Payer: MDX Hawaii PPO	$386.06

HCHG OT MED-SURG RE-EVAL

Facility

$398.00

Service Code	HCPCS 97168
Hospital Charge Code	H4340137
Hospital Revenue Code	434
Min. Negotiated Rate	$74.97
Max. Negotiated Rate	$386.06
Rate for Payer: Cash Price	$258.70
Rate for Payer: Cash Price	$258.70
Rate for Payer: Hawaii Western Management Group Commercial	$378.10
Rate for Payer: Health Management Network Commercial	$338.30
Rate for Payer: Kaiser Permanente Commercial	$250.74
Rate for Payer: Kaiser Permanente Medicaid	$202.98
Rate for Payer: MDX Hawaii PPO	$386.06
Rate for Payer: UnitedHealthcare Medicaid	$74.97
Rate for Payer: University Health Alliance Commercial	$290.10

HCHG OT THER ADAPT FU 15 MIN

Facility

$261.00

Service Code	HCPCS 97763
Hospital Charge Code	H4300272
Hospital Revenue Code	430
Min. Negotiated Rate	$221.85
Max. Negotiated Rate	$253.17
Rate for Payer: Cash Price	$169.65
Rate for Payer: Health Management Network Commercial	$221.85
Rate for Payer: MDX Hawaii PPO	$253.17

HCHG OT THER ADAPT FU 15 MIN

Facility

$261.00

Service Code	HCPCS 97763
Hospital Charge Code	H4300272
Hospital Revenue Code	430
Min. Negotiated Rate	$57.47
Max. Negotiated Rate	$253.17
Rate for Payer: Cash Price	$169.65
Rate for Payer: Cash Price	$169.65
Rate for Payer: Hawaii Western Management Group Commercial	$247.95
Rate for Payer: Health Management Network Commercial	$221.85
Rate for Payer: Kaiser Permanente Commercial	$164.43
Rate for Payer: Kaiser Permanente Medicaid	$133.11
Rate for Payer: MDX Hawaii PPO	$253.17
Rate for Payer: UnitedHealthcare Medicaid	$57.47
Rate for Payer: University Health Alliance Commercial	$190.24

HCHG OT THERAPEUTIC ACTIVITY 15 MIN

Facility

$246.00

Service Code	HCPCS 97530
Hospital Charge Code	H4300196
Hospital Revenue Code	430
Min. Negotiated Rate	$18.32
Max. Negotiated Rate	$238.62
Rate for Payer: Cash Price	$159.90
Rate for Payer: Cash Price	$159.90
Rate for Payer: Hawaii Western Management Group Commercial	$233.70
Rate for Payer: Health Management Network Commercial	$209.10
Rate for Payer: Kaiser Permanente Commercial	$154.98
Rate for Payer: Kaiser Permanente Medicaid	$125.46
Rate for Payer: MDX Hawaii PPO	$238.62
Rate for Payer: UnitedHealthcare Medicaid	$18.32
Rate for Payer: University Health Alliance Commercial	$179.31

Know your out-of-pocket cost for care.

All Charges