Kohala Hospital

All Charges

Charge

Type

Setting

Price

HCHG IV INFUSION HYDRATION EA ADDL HR (IN ED)

Facility

$304.00

Service Code	HCPCS 96361
Hospital Charge Code	H4500864
Hospital Revenue Code	450
Min. Negotiated Rate	$258.40
Max. Negotiated Rate	$294.88
Rate for Payer: Cash Price	$197.60
Rate for Payer: Health Management Network Commercial	$258.40
Rate for Payer: Kaiser Permanente Commercial	$273.60
Rate for Payer: MDX Hawaii PPO	$294.88

HCHG IV INFUSION INITIAL PUSH

Facility

$499.00

Service Code	HCPCS 96374
Hospital Charge Code	H9400112
Hospital Revenue Code	940
Min. Negotiated Rate	$36.88
Max. Negotiated Rate	$494.01
Rate for Payer: AlohaCare Medicaid	$249.50
Rate for Payer: AlohaCare Medicare	$449.10
Rate for Payer: Cash Price	$324.35
Rate for Payer: Cash Price	$324.35
Rate for Payer: Devoted Health Medicare	$494.01
Rate for Payer: Hawaii Medical Service Association Commercial	$271.64
Rate for Payer: Hawaii Medical Service Association Medicare	$449.10
Rate for Payer: Hawaii Western Management Group Commercial	$474.05
Rate for Payer: Health Management Network Commercial	$424.15
Rate for Payer: Humana Medicare	$449.10
Rate for Payer: Kaiser Permanente Commercial	$449.10
Rate for Payer: Kaiser Permanente Medicaid	$254.49
Rate for Payer: Kaiser Permanente Medicare	$449.10
Rate for Payer: MDX Hawaii PPO	$484.03
Rate for Payer: Ohana Health Plan Medicaid	$449.10
Rate for Payer: Ohana Health Plan Medicare	$449.10
Rate for Payer: UnitedHealthcare Medicaid	$36.88
Rate for Payer: UnitedHealthcare Medicare	$449.10
Rate for Payer: University Health Alliance Commercial	$363.72

HCHG IV INFUSION INITIAL PUSH

Facility

$499.00

Service Code	HCPCS 96374
Hospital Charge Code	H9400112
Hospital Revenue Code	940
Min. Negotiated Rate	$424.15
Max. Negotiated Rate	$484.03
Rate for Payer: Cash Price	$324.35
Rate for Payer: Health Management Network Commercial	$424.15
Rate for Payer: Kaiser Permanente Commercial	$449.10
Rate for Payer: MDX Hawaii PPO	$484.03

HCHG IV INFUSION THERAPY EA ADDL HR

Facility

$318.00

Service Code	HCPCS 96366
Hospital Charge Code	H2600010
Hospital Revenue Code	260
Min. Negotiated Rate	$14.27
Max. Negotiated Rate	$314.82
Rate for Payer: AlohaCare Medicaid	$159.00
Rate for Payer: AlohaCare Medicare	$286.20
Rate for Payer: Cash Price	$206.70
Rate for Payer: Cash Price	$206.70
Rate for Payer: Devoted Health Medicare	$314.82
Rate for Payer: Hawaii Medical Service Association Commercial	$59.80
Rate for Payer: Hawaii Medical Service Association Medicare	$286.20
Rate for Payer: Hawaii Western Management Group Commercial	$302.10
Rate for Payer: Health Management Network Commercial	$270.30
Rate for Payer: Humana Medicare	$286.20
Rate for Payer: Kaiser Permanente Commercial	$286.20
Rate for Payer: Kaiser Permanente Medicaid	$162.18
Rate for Payer: Kaiser Permanente Medicare	$286.20
Rate for Payer: MDX Hawaii PPO	$308.46
Rate for Payer: Ohana Health Plan Medicaid	$286.20
Rate for Payer: Ohana Health Plan Medicare	$286.20
Rate for Payer: UnitedHealthcare Medicaid	$14.27
Rate for Payer: UnitedHealthcare Medicare	$286.20
Rate for Payer: University Health Alliance Commercial	$231.79

HCHG IV INFUSION THERAPY EA ADDL HR

Facility

$318.00

Service Code	HCPCS 96366
Hospital Charge Code	H2600010
Hospital Revenue Code	260
Min. Negotiated Rate	$270.30
Max. Negotiated Rate	$308.46
Rate for Payer: Cash Price	$206.70
Rate for Payer: Health Management Network Commercial	$270.30
Rate for Payer: Kaiser Permanente Commercial	$286.20
Rate for Payer: MDX Hawaii PPO	$308.46

HCHG IV INFUSION THERAPY EA ADDL HR

Facility

$318.00

Service Code	HCPCS 96366
Hospital Charge Code	H4500851
Hospital Revenue Code	450
Min. Negotiated Rate	$159.00
Max. Negotiated Rate	$1,600.00
Rate for Payer: AlohaCare Medicaid	$159.00
Rate for Payer: AlohaCare Medicare	$286.20
Rate for Payer: Cash Price	$206.70
Rate for Payer: Cash Price	$206.70
Rate for Payer: Devoted Health Medicare	$314.82
Rate for Payer: Hawaii Medical Service Association ABD	$469.00
Rate for Payer: Hawaii Medical Service Association Commercial	$1,600.00
Rate for Payer: Hawaii Medical Service Association Medicare	$286.20
Rate for Payer: Hawaii Medical Service Association Non-ABD	$450.00
Rate for Payer: Hawaii Western Management Group Commercial	$302.10
Rate for Payer: Health Management Network Commercial	$270.30
Rate for Payer: Humana Medicare	$286.20
Rate for Payer: Kaiser Permanente Commercial	$286.20
Rate for Payer: Kaiser Permanente Medicaid	$937.50
Rate for Payer: Kaiser Permanente Medicare	$286.20
Rate for Payer: MDX Hawaii PPO	$308.46
Rate for Payer: Ohana Health Plan Medicaid	$286.20
Rate for Payer: Ohana Health Plan Medicare	$286.20
Rate for Payer: UnitedHealthcare Medicare	$286.20
Rate for Payer: University Health Alliance Commercial	$231.79

HCHG IV INFUSION THERAPY EA ADDL HR

Facility

$318.00

Service Code	HCPCS 96366
Hospital Charge Code	H4500851
Hospital Revenue Code	450
Min. Negotiated Rate	$270.30
Max. Negotiated Rate	$308.46
Rate for Payer: Cash Price	$206.70
Rate for Payer: Health Management Network Commercial	$270.30
Rate for Payer: Kaiser Permanente Commercial	$286.20
Rate for Payer: MDX Hawaii PPO	$308.46

HCHG IV INFUSION THERAPY UP TO 1 HR

Facility

$1,251.00

Service Code	HCPCS 96365
Hospital Charge Code	H4500500
Hospital Revenue Code	450
Min. Negotiated Rate	$1,063.35
Max. Negotiated Rate	$1,213.47
Rate for Payer: Cash Price	$813.15
Rate for Payer: Health Management Network Commercial	$1,063.35
Rate for Payer: Kaiser Permanente Commercial	$1,125.90
Rate for Payer: MDX Hawaii PPO	$1,213.47

HCHG IV INFUSION THERAPY UP TO 1 HR

Facility

$1,251.00

Service Code	HCPCS 96365
Hospital Charge Code	H4500500
Hospital Revenue Code	450
Min. Negotiated Rate	$450.00
Max. Negotiated Rate	$1,600.00
Rate for Payer: AlohaCare Medicaid	$625.50
Rate for Payer: AlohaCare Medicare	$1,125.90
Rate for Payer: Cash Price	$813.15
Rate for Payer: Cash Price	$813.15
Rate for Payer: Devoted Health Medicare	$1,238.49
Rate for Payer: Hawaii Medical Service Association ABD	$469.00
Rate for Payer: Hawaii Medical Service Association Commercial	$1,600.00
Rate for Payer: Hawaii Medical Service Association Medicare	$1,125.90
Rate for Payer: Hawaii Medical Service Association Non-ABD	$450.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,188.45
Rate for Payer: Health Management Network Commercial	$1,063.35
Rate for Payer: Humana Medicare	$1,125.90
Rate for Payer: Kaiser Permanente Commercial	$1,125.90
Rate for Payer: Kaiser Permanente Medicaid	$937.50
Rate for Payer: Kaiser Permanente Medicare	$1,125.90
Rate for Payer: MDX Hawaii PPO	$1,213.47
Rate for Payer: Ohana Health Plan Medicaid	$1,125.90
Rate for Payer: Ohana Health Plan Medicare	$1,125.90
Rate for Payer: UnitedHealthcare Medicare	$1,125.90
Rate for Payer: University Health Alliance Commercial	$911.85

HCHG IV INFUSION THERAPY UP TO 1 HR

Facility

$1,251.00

Service Code	HCPCS 96365
Hospital Charge Code	H2600000
Hospital Revenue Code	260
Min. Negotiated Rate	$46.51
Max. Negotiated Rate	$1,238.49
Rate for Payer: AlohaCare Medicaid	$625.50
Rate for Payer: AlohaCare Medicare	$1,125.90
Rate for Payer: Cash Price	$813.15
Rate for Payer: Cash Price	$813.15
Rate for Payer: Devoted Health Medicare	$1,238.49
Rate for Payer: Hawaii Medical Service Association Commercial	$271.64
Rate for Payer: Hawaii Medical Service Association Medicare	$1,125.90
Rate for Payer: Hawaii Western Management Group Commercial	$1,188.45
Rate for Payer: Health Management Network Commercial	$1,063.35
Rate for Payer: Humana Medicare	$1,125.90
Rate for Payer: Kaiser Permanente Commercial	$1,125.90
Rate for Payer: Kaiser Permanente Medicaid	$638.01
Rate for Payer: Kaiser Permanente Medicare	$1,125.90
Rate for Payer: MDX Hawaii PPO	$1,213.47
Rate for Payer: Ohana Health Plan Medicaid	$1,125.90
Rate for Payer: Ohana Health Plan Medicare	$1,125.90
Rate for Payer: UnitedHealthcare Medicaid	$46.51
Rate for Payer: UnitedHealthcare Medicare	$1,125.90
Rate for Payer: University Health Alliance Commercial	$911.85

HCHG IV INFUSION THERAPY UP TO 1 HR

Facility

$1,251.00

Service Code	HCPCS 96365
Hospital Charge Code	H2600000
Hospital Revenue Code	260
Min. Negotiated Rate	$1,063.35
Max. Negotiated Rate	$1,213.47
Rate for Payer: Cash Price	$813.15
Rate for Payer: Health Management Network Commercial	$1,063.35
Rate for Payer: Kaiser Permanente Commercial	$1,125.90
Rate for Payer: MDX Hawaii PPO	$1,213.47

HCHG IV INFUSION TX EA ADDL HR

Facility

$318.00

Service Code	HCPCS 96366
Hospital Charge Code	H3310116
Hospital Revenue Code	260
Min. Negotiated Rate	$270.30
Max. Negotiated Rate	$308.46
Rate for Payer: Cash Price	$206.70
Rate for Payer: Health Management Network Commercial	$270.30
Rate for Payer: Kaiser Permanente Commercial	$286.20
Rate for Payer: MDX Hawaii PPO	$308.46

HCHG IV INFUSION TX EA ADDL HR

Facility

$318.00

Service Code	HCPCS 96366
Hospital Charge Code	H3310116
Hospital Revenue Code	260
Min. Negotiated Rate	$14.27
Max. Negotiated Rate	$314.82
Rate for Payer: AlohaCare Medicaid	$159.00
Rate for Payer: AlohaCare Medicare	$286.20
Rate for Payer: Cash Price	$206.70
Rate for Payer: Cash Price	$206.70
Rate for Payer: Devoted Health Medicare	$314.82
Rate for Payer: Hawaii Medical Service Association Commercial	$59.80
Rate for Payer: Hawaii Medical Service Association Medicare	$286.20
Rate for Payer: Hawaii Western Management Group Commercial	$302.10
Rate for Payer: Health Management Network Commercial	$270.30
Rate for Payer: Humana Medicare	$286.20
Rate for Payer: Kaiser Permanente Commercial	$286.20
Rate for Payer: Kaiser Permanente Medicaid	$162.18
Rate for Payer: Kaiser Permanente Medicare	$286.20
Rate for Payer: MDX Hawaii PPO	$308.46
Rate for Payer: Ohana Health Plan Medicaid	$286.20
Rate for Payer: Ohana Health Plan Medicare	$286.20
Rate for Payer: UnitedHealthcare Medicaid	$14.27
Rate for Payer: UnitedHealthcare Medicare	$286.20
Rate for Payer: University Health Alliance Commercial	$231.79

HCHG IV INFUSION TX UP TO 1 HR

Facility

$1,251.00

Service Code	HCPCS 96365
Hospital Charge Code	H3310114
Hospital Revenue Code	260
Min. Negotiated Rate	$46.51
Max. Negotiated Rate	$1,238.49
Rate for Payer: AlohaCare Medicaid	$625.50
Rate for Payer: AlohaCare Medicare	$1,125.90
Rate for Payer: Cash Price	$813.15
Rate for Payer: Cash Price	$813.15
Rate for Payer: Devoted Health Medicare	$1,238.49
Rate for Payer: Hawaii Medical Service Association Commercial	$271.64
Rate for Payer: Hawaii Medical Service Association Medicare	$1,125.90
Rate for Payer: Hawaii Western Management Group Commercial	$1,188.45
Rate for Payer: Health Management Network Commercial	$1,063.35
Rate for Payer: Humana Medicare	$1,125.90
Rate for Payer: Kaiser Permanente Commercial	$1,125.90
Rate for Payer: Kaiser Permanente Medicaid	$638.01
Rate for Payer: Kaiser Permanente Medicare	$1,125.90
Rate for Payer: MDX Hawaii PPO	$1,213.47
Rate for Payer: Ohana Health Plan Medicaid	$1,125.90
Rate for Payer: Ohana Health Plan Medicare	$1,125.90
Rate for Payer: UnitedHealthcare Medicaid	$46.51
Rate for Payer: UnitedHealthcare Medicare	$1,125.90
Rate for Payer: University Health Alliance Commercial	$911.85

HCHG IV INFUSION TX UP TO 1 HR

Facility

$1,251.00

Service Code	HCPCS 96365
Hospital Charge Code	H3310114
Hospital Revenue Code	260
Min. Negotiated Rate	$1,063.35
Max. Negotiated Rate	$1,213.47
Rate for Payer: Cash Price	$813.15
Rate for Payer: Health Management Network Commercial	$1,063.35
Rate for Payer: Kaiser Permanente Commercial	$1,125.90
Rate for Payer: MDX Hawaii PPO	$1,213.47

HCHG IV INFUS SEQ INFUS UP TO 1HR

Facility

$320.00

Service Code	HCPCS 96367
Hospital Charge Code	H9400139
Hospital Revenue Code	940
Min. Negotiated Rate	$272.00
Max. Negotiated Rate	$310.40
Rate for Payer: Cash Price	$208.00
Rate for Payer: Health Management Network Commercial	$272.00
Rate for Payer: Kaiser Permanente Commercial	$288.00
Rate for Payer: MDX Hawaii PPO	$310.40

HCHG IV INFUS SEQ INFUS UP TO 1HR

Facility

$320.00

Service Code	HCPCS 96367
Hospital Charge Code	H9400139
Hospital Revenue Code	940
Min. Negotiated Rate	$23.03
Max. Negotiated Rate	$316.80
Rate for Payer: AlohaCare Medicaid	$160.00
Rate for Payer: AlohaCare Medicare	$288.00
Rate for Payer: Cash Price	$208.00
Rate for Payer: Cash Price	$208.00
Rate for Payer: Devoted Health Medicare	$316.80
Rate for Payer: Hawaii Medical Service Association Commercial	$91.95
Rate for Payer: Hawaii Medical Service Association Medicare	$288.00
Rate for Payer: Hawaii Western Management Group Commercial	$304.00
Rate for Payer: Health Management Network Commercial	$272.00
Rate for Payer: Humana Medicare	$288.00
Rate for Payer: Kaiser Permanente Commercial	$288.00
Rate for Payer: Kaiser Permanente Medicaid	$163.20
Rate for Payer: Kaiser Permanente Medicare	$288.00
Rate for Payer: MDX Hawaii PPO	$310.40
Rate for Payer: Ohana Health Plan Medicaid	$288.00
Rate for Payer: Ohana Health Plan Medicare	$288.00
Rate for Payer: UnitedHealthcare Medicaid	$23.03
Rate for Payer: UnitedHealthcare Medicare	$288.00
Rate for Payer: University Health Alliance Commercial	$233.25

HCHG IV INJECTION EA ADDL SAME DRUG

Facility

$334.00

Service Code	HCPCS 96376
Hospital Charge Code	H2600128
Hospital Revenue Code	260
Min. Negotiated Rate	$167.00
Max. Negotiated Rate	$330.66
Rate for Payer: AlohaCare Medicaid	$167.00
Rate for Payer: AlohaCare Medicare	$300.60
Rate for Payer: Cash Price	$217.10
Rate for Payer: Devoted Health Medicare	$330.66
Rate for Payer: Hawaii Medical Service Association Medicare	$300.60
Rate for Payer: Hawaii Western Management Group Commercial	$317.30
Rate for Payer: Health Management Network Commercial	$283.90
Rate for Payer: Humana Medicare	$300.60
Rate for Payer: Kaiser Permanente Commercial	$300.60
Rate for Payer: Kaiser Permanente Medicaid	$170.34
Rate for Payer: Kaiser Permanente Medicare	$300.60
Rate for Payer: MDX Hawaii PPO	$323.98
Rate for Payer: Ohana Health Plan Medicaid	$300.60
Rate for Payer: Ohana Health Plan Medicare	$300.60
Rate for Payer: UnitedHealthcare Medicare	$300.60
Rate for Payer: University Health Alliance Commercial	$243.45

HCHG IV INJECTION EA ADDL SAME DRUG

Facility

$334.00

Service Code	HCPCS 96376
Hospital Charge Code	H2600128
Hospital Revenue Code	260
Min. Negotiated Rate	$283.90
Max. Negotiated Rate	$323.98
Rate for Payer: Cash Price	$217.10
Rate for Payer: Health Management Network Commercial	$283.90
Rate for Payer: Kaiser Permanente Commercial	$300.60
Rate for Payer: MDX Hawaii PPO	$323.98

HCHG IV INJ/PUSH EA ADDL

Facility

$368.00

Service Code	HCPCS 96375
Hospital Charge Code	H4500867
Hospital Revenue Code	450
Min. Negotiated Rate	$312.80
Max. Negotiated Rate	$356.96
Rate for Payer: Cash Price	$239.20
Rate for Payer: Health Management Network Commercial	$312.80
Rate for Payer: Kaiser Permanente Commercial	$331.20
Rate for Payer: MDX Hawaii PPO	$356.96

HCHG IV INJ/PUSH EA ADDL

Facility

$368.00

Service Code	HCPCS 96375
Hospital Charge Code	H4500867
Hospital Revenue Code	450
Min. Negotiated Rate	$184.00
Max. Negotiated Rate	$1,600.00
Rate for Payer: AlohaCare Medicaid	$184.00
Rate for Payer: AlohaCare Medicare	$331.20
Rate for Payer: Cash Price	$239.20
Rate for Payer: Cash Price	$239.20
Rate for Payer: Devoted Health Medicare	$364.32
Rate for Payer: Hawaii Medical Service Association ABD	$469.00
Rate for Payer: Hawaii Medical Service Association Commercial	$1,600.00
Rate for Payer: Hawaii Medical Service Association Medicare	$331.20
Rate for Payer: Hawaii Medical Service Association Non-ABD	$450.00
Rate for Payer: Hawaii Western Management Group Commercial	$349.60
Rate for Payer: Health Management Network Commercial	$312.80
Rate for Payer: Humana Medicare	$331.20
Rate for Payer: Kaiser Permanente Commercial	$331.20
Rate for Payer: Kaiser Permanente Medicaid	$937.50
Rate for Payer: Kaiser Permanente Medicare	$331.20
Rate for Payer: MDX Hawaii PPO	$356.96
Rate for Payer: Ohana Health Plan Medicaid	$331.20
Rate for Payer: Ohana Health Plan Medicare	$331.20
Rate for Payer: UnitedHealthcare Medicare	$331.20
Rate for Payer: University Health Alliance Commercial	$268.24

HCHG IV INJ/PUSH EA ADD SAME SUB

Facility

$334.00

Service Code	HCPCS 96376
Hospital Charge Code	H4500907
Hospital Revenue Code	450
Min. Negotiated Rate	$167.00
Max. Negotiated Rate	$1,600.00
Rate for Payer: AlohaCare Medicaid	$167.00
Rate for Payer: AlohaCare Medicare	$300.60
Rate for Payer: Cash Price	$217.10
Rate for Payer: Cash Price	$217.10
Rate for Payer: Devoted Health Medicare	$330.66
Rate for Payer: Hawaii Medical Service Association ABD	$469.00
Rate for Payer: Hawaii Medical Service Association Commercial	$1,600.00
Rate for Payer: Hawaii Medical Service Association Medicare	$300.60
Rate for Payer: Hawaii Medical Service Association Non-ABD	$450.00
Rate for Payer: Hawaii Western Management Group Commercial	$317.30
Rate for Payer: Health Management Network Commercial	$283.90
Rate for Payer: Humana Medicare	$300.60
Rate for Payer: Kaiser Permanente Commercial	$300.60
Rate for Payer: Kaiser Permanente Medicaid	$937.50
Rate for Payer: Kaiser Permanente Medicare	$300.60
Rate for Payer: MDX Hawaii PPO	$323.98
Rate for Payer: Ohana Health Plan Medicaid	$300.60
Rate for Payer: Ohana Health Plan Medicare	$300.60
Rate for Payer: UnitedHealthcare Medicare	$300.60
Rate for Payer: University Health Alliance Commercial	$243.45

HCHG IV INJ/PUSH EA ADD SAME SUB

Facility

$334.00

Service Code	HCPCS 96376
Hospital Charge Code	H4500907
Hospital Revenue Code	450
Min. Negotiated Rate	$283.90
Max. Negotiated Rate	$323.98
Rate for Payer: Cash Price	$217.10
Rate for Payer: Health Management Network Commercial	$283.90
Rate for Payer: Kaiser Permanente Commercial	$300.60
Rate for Payer: MDX Hawaii PPO	$323.98

HCHG IV INJ/PUSH INITIAL

Facility

$499.00

Service Code	HCPCS 96374
Hospital Charge Code	H4500512
Hospital Revenue Code	450
Min. Negotiated Rate	$249.50
Max. Negotiated Rate	$1,600.00
Rate for Payer: AlohaCare Medicaid	$249.50
Rate for Payer: AlohaCare Medicare	$449.10
Rate for Payer: Cash Price	$324.35
Rate for Payer: Cash Price	$324.35
Rate for Payer: Devoted Health Medicare	$494.01
Rate for Payer: Hawaii Medical Service Association ABD	$469.00
Rate for Payer: Hawaii Medical Service Association Commercial	$1,600.00
Rate for Payer: Hawaii Medical Service Association Medicare	$449.10
Rate for Payer: Hawaii Medical Service Association Non-ABD	$450.00
Rate for Payer: Hawaii Western Management Group Commercial	$474.05
Rate for Payer: Health Management Network Commercial	$424.15
Rate for Payer: Humana Medicare	$449.10
Rate for Payer: Kaiser Permanente Commercial	$449.10
Rate for Payer: Kaiser Permanente Medicaid	$937.50
Rate for Payer: Kaiser Permanente Medicare	$449.10
Rate for Payer: MDX Hawaii PPO	$484.03
Rate for Payer: Ohana Health Plan Medicaid	$449.10
Rate for Payer: Ohana Health Plan Medicare	$449.10
Rate for Payer: UnitedHealthcare Medicare	$449.10
Rate for Payer: University Health Alliance Commercial	$363.72

HCHG IV INJ/PUSH INITIAL

Facility

$499.00

Service Code	HCPCS 96374
Hospital Charge Code	H4500512
Hospital Revenue Code	450
Min. Negotiated Rate	$424.15
Max. Negotiated Rate	$484.03
Rate for Payer: Cash Price	$324.35
Rate for Payer: Health Management Network Commercial	$424.15
Rate for Payer: Kaiser Permanente Commercial	$449.10
Rate for Payer: MDX Hawaii PPO	$484.03

Know your out-of-pocket cost for care.

All Charges