Kona Community Hospital

All Charges

Charge

Type

Setting

Price

HCHG CEA LEVEL RIA

Facility

$192.00

Service Code	HCPCS 82378
Hospital Charge Code	H3010336
Hospital Revenue Code	301
Min. Negotiated Rate	$18.96
Max. Negotiated Rate	$186.24
Rate for Payer: AlohaCare Medicaid	$18.96
Rate for Payer: AlohaCare Medicare	$18.96
Rate for Payer: Cash Price	$124.80
Rate for Payer: Cash Price	$124.80
Rate for Payer: Devoted Health Medicare	$20.86
Rate for Payer: Hawaii Medical Service Association ABD	$26.22
Rate for Payer: Hawaii Medical Service Association Commercial	$23.70
Rate for Payer: Hawaii Medical Service Association Medicare	$18.96
Rate for Payer: Hawaii Medical Service Association Non-ABD	$27.53
Rate for Payer: Hawaii Western Management Group Commercial	$18.96
Rate for Payer: Health Management Network Commercial	$163.20
Rate for Payer: Humana Medicare	$18.96
Rate for Payer: Kaiser Permanente Commercial	$120.96
Rate for Payer: Kaiser Permanente Medicaid	$97.92
Rate for Payer: Kaiser Permanente Medicare	$18.96
Rate for Payer: MDX Hawaii PPO	$186.24
Rate for Payer: Ohana Health Plan Medicaid	$20.86
Rate for Payer: Ohana Health Plan Medicare	$18.96
Rate for Payer: UnitedHealthcare Medicaid	$26.22
Rate for Payer: UnitedHealthcare Medicare	$18.96
Rate for Payer: University Health Alliance Commercial	$49.04

HCHG CELL COUNT-BODY FLD

Facility

$84.00

Service Code	HCPCS 89051
Hospital Charge Code	H3090106
Hospital Revenue Code	309
Min. Negotiated Rate	$71.40
Max. Negotiated Rate	$81.48
Rate for Payer: Cash Price	$54.60
Rate for Payer: Health Management Network Commercial	$71.40
Rate for Payer: MDX Hawaii PPO	$81.48

HCHG CELL COUNT-BODY FLD

Facility

$84.00

Service Code	HCPCS 89051
Hospital Charge Code	H3090106
Hospital Revenue Code	309
Min. Negotiated Rate	$5.60
Max. Negotiated Rate	$81.48
Rate for Payer: AlohaCare Medicaid	$5.60
Rate for Payer: AlohaCare Medicare	$5.60
Rate for Payer: Cash Price	$54.60
Rate for Payer: Cash Price	$54.60
Rate for Payer: Devoted Health Medicare	$6.16
Rate for Payer: Hawaii Medical Service Association ABD	$7.61
Rate for Payer: Hawaii Medical Service Association Commercial	$7.00
Rate for Payer: Hawaii Medical Service Association Medicare	$5.60
Rate for Payer: Hawaii Medical Service Association Non-ABD	$7.99
Rate for Payer: Hawaii Western Management Group Commercial	$5.60
Rate for Payer: Health Management Network Commercial	$71.40
Rate for Payer: Humana Medicare	$5.60
Rate for Payer: Kaiser Permanente Commercial	$52.92
Rate for Payer: Kaiser Permanente Medicaid	$42.84
Rate for Payer: Kaiser Permanente Medicare	$5.60
Rate for Payer: MDX Hawaii PPO	$81.48
Rate for Payer: Ohana Health Plan Medicaid	$6.16
Rate for Payer: Ohana Health Plan Medicare	$5.60
Rate for Payer: UnitedHealthcare Medicaid	$7.61
Rate for Payer: UnitedHealthcare Medicare	$5.60
Rate for Payer: University Health Alliance Commercial	$14.24

HCHG CELL COUNT-CSF

Facility

$84.00

Service Code	HCPCS 89051
Hospital Charge Code	H3090108
Hospital Revenue Code	309
Min. Negotiated Rate	$5.60
Max. Negotiated Rate	$81.48
Rate for Payer: AlohaCare Medicaid	$5.60
Rate for Payer: AlohaCare Medicare	$5.60
Rate for Payer: Cash Price	$54.60
Rate for Payer: Cash Price	$54.60
Rate for Payer: Devoted Health Medicare	$6.16
Rate for Payer: Hawaii Medical Service Association ABD	$7.61
Rate for Payer: Hawaii Medical Service Association Commercial	$7.00
Rate for Payer: Hawaii Medical Service Association Medicare	$5.60
Rate for Payer: Hawaii Medical Service Association Non-ABD	$7.99
Rate for Payer: Hawaii Western Management Group Commercial	$5.60
Rate for Payer: Health Management Network Commercial	$71.40
Rate for Payer: Humana Medicare	$5.60
Rate for Payer: Kaiser Permanente Commercial	$52.92
Rate for Payer: Kaiser Permanente Medicaid	$42.84
Rate for Payer: Kaiser Permanente Medicare	$5.60
Rate for Payer: MDX Hawaii PPO	$81.48
Rate for Payer: Ohana Health Plan Medicaid	$6.16
Rate for Payer: Ohana Health Plan Medicare	$5.60
Rate for Payer: UnitedHealthcare Medicaid	$7.61
Rate for Payer: UnitedHealthcare Medicare	$5.60
Rate for Payer: University Health Alliance Commercial	$14.24

HCHG CELL COUNT-CSF

Facility

$84.00

Service Code	HCPCS 89051
Hospital Charge Code	H3090108
Hospital Revenue Code	309
Min. Negotiated Rate	$71.40
Max. Negotiated Rate	$81.48
Rate for Payer: Cash Price	$54.60
Rate for Payer: Health Management Network Commercial	$71.40
Rate for Payer: MDX Hawaii PPO	$81.48

HCHG CELL COUNTS CHROMOSOME ADL 90

Facility

$207.00

Service Code	HCPCS 88285
Hospital Charge Code	H3110122
Hospital Revenue Code	311
Min. Negotiated Rate	$175.95
Max. Negotiated Rate	$200.79
Rate for Payer: Cash Price	$134.55
Rate for Payer: Health Management Network Commercial	$175.95
Rate for Payer: MDX Hawaii PPO	$200.79

HCHG CELL COUNTS CHROMOSOME ADL 90

Facility

$207.00

Service Code	HCPCS 88285
Hospital Charge Code	H3110122
Hospital Revenue Code	311
Min. Negotiated Rate	$15.92
Max. Negotiated Rate	$200.79
Rate for Payer: AlohaCare Medicaid	$26.91
Rate for Payer: AlohaCare Medicare	$26.91
Rate for Payer: Cash Price	$134.55
Rate for Payer: Cash Price	$134.55
Rate for Payer: Devoted Health Medicare	$29.60
Rate for Payer: Hawaii Medical Service Association ABD	$15.92
Rate for Payer: Hawaii Medical Service Association Commercial	$33.64
Rate for Payer: Hawaii Medical Service Association Medicare	$26.91
Rate for Payer: Hawaii Medical Service Association Non-ABD	$26.24
Rate for Payer: Hawaii Western Management Group Commercial	$26.91
Rate for Payer: Health Management Network Commercial	$175.95
Rate for Payer: Humana Medicare	$26.91
Rate for Payer: Kaiser Permanente Commercial	$130.41
Rate for Payer: Kaiser Permanente Medicaid	$105.57
Rate for Payer: Kaiser Permanente Medicare	$26.91
Rate for Payer: MDX Hawaii PPO	$200.79
Rate for Payer: Ohana Health Plan Medicaid	$29.60
Rate for Payer: Ohana Health Plan Medicare	$26.91
Rate for Payer: UnitedHealthcare Medicaid	$15.92
Rate for Payer: UnitedHealthcare Medicare	$26.91
Rate for Payer: University Health Alliance Commercial	$49.10

HCHG CERULOPLASMIN

Facility

$132.00

Service Code	HCPCS 82390
Hospital Charge Code	H3010338
Hospital Revenue Code	301
Min. Negotiated Rate	$10.74
Max. Negotiated Rate	$128.04
Rate for Payer: AlohaCare Medicaid	$10.74
Rate for Payer: AlohaCare Medicare	$10.74
Rate for Payer: Cash Price	$85.80
Rate for Payer: Cash Price	$85.80
Rate for Payer: Devoted Health Medicare	$11.81
Rate for Payer: Hawaii Medical Service Association ABD	$14.84
Rate for Payer: Hawaii Medical Service Association Commercial	$13.43
Rate for Payer: Hawaii Medical Service Association Medicare	$10.74
Rate for Payer: Hawaii Medical Service Association Non-ABD	$15.58
Rate for Payer: Hawaii Western Management Group Commercial	$10.74
Rate for Payer: Health Management Network Commercial	$112.20
Rate for Payer: Humana Medicare	$10.74
Rate for Payer: Kaiser Permanente Commercial	$83.16
Rate for Payer: Kaiser Permanente Medicaid	$67.32
Rate for Payer: Kaiser Permanente Medicare	$10.74
Rate for Payer: MDX Hawaii PPO	$128.04
Rate for Payer: Ohana Health Plan Medicaid	$11.81
Rate for Payer: Ohana Health Plan Medicare	$10.74
Rate for Payer: UnitedHealthcare Medicaid	$14.84
Rate for Payer: UnitedHealthcare Medicare	$10.74
Rate for Payer: University Health Alliance Commercial	$27.77

HCHG CERULOPLASMIN

Facility

$132.00

Service Code	HCPCS 82390
Hospital Charge Code	H3010338
Hospital Revenue Code	301
Min. Negotiated Rate	$112.20
Max. Negotiated Rate	$128.04
Rate for Payer: Cash Price	$85.80
Rate for Payer: Health Management Network Commercial	$112.20
Rate for Payer: MDX Hawaii PPO	$128.04

HCHG CERVICAL SPINE WITHOUT AND WITH CONTRAST

Facility

$1,958.00

Service Code	HCPCS 72127
Hospital Charge Code	H3520235
Hospital Revenue Code	352
Min. Negotiated Rate	$1,664.30
Max. Negotiated Rate	$1,899.26
Rate for Payer: Cash Price	$1,272.70
Rate for Payer: Health Management Network Commercial	$1,664.30
Rate for Payer: MDX Hawaii PPO	$1,899.26

HCHG CERVICAL SPINE WITHOUT AND WITH CONTRAST

Facility

$1,958.00

Service Code	HCPCS 72127
Hospital Charge Code	H3520235
Hospital Revenue Code	352
Min. Negotiated Rate	$207.21
Max. Negotiated Rate	$1,899.26
Rate for Payer: AlohaCare Medicaid	$207.21
Rate for Payer: AlohaCare Medicare	$207.21
Rate for Payer: Cash Price	$1,272.70
Rate for Payer: Cash Price	$1,272.70
Rate for Payer: Devoted Health Medicare	$227.93
Rate for Payer: Hawaii Medical Service Association ABD	$291.10
Rate for Payer: Hawaii Medical Service Association Commercial	$259.01
Rate for Payer: Hawaii Medical Service Association Medicare	$207.21
Rate for Payer: Hawaii Medical Service Association Non-ABD	$316.52
Rate for Payer: Hawaii Western Management Group Commercial	$207.21
Rate for Payer: Health Management Network Commercial	$1,664.30
Rate for Payer: Humana Medicare	$207.21
Rate for Payer: Kaiser Permanente Commercial	$1,233.54
Rate for Payer: Kaiser Permanente Medicaid	$998.58
Rate for Payer: Kaiser Permanente Medicare	$207.21
Rate for Payer: MDX Hawaii PPO	$1,899.26
Rate for Payer: Ohana Health Plan Medicaid	$227.93
Rate for Payer: Ohana Health Plan Medicare	$207.21
Rate for Payer: UnitedHealthcare Medicaid	$291.10
Rate for Payer: UnitedHealthcare Medicare	$207.21
Rate for Payer: University Health Alliance Commercial	$789.62

HCHG CHANGE OF CYSTOSTOMY TUBE SIMPLE

Facility

$1,410.00

Service Code	HCPCS 51705
Hospital Charge Code	H4500164
Hospital Revenue Code	450
Min. Negotiated Rate	$295.16
Max. Negotiated Rate	$2,833.00
Rate for Payer: AlohaCare Medicaid	$295.16
Rate for Payer: AlohaCare Medicare	$295.16
Rate for Payer: Cash Price	$916.50
Rate for Payer: Cash Price	$916.50
Rate for Payer: Cash Price	$916.50
Rate for Payer: Devoted Health Medicare	$324.68
Rate for Payer: Hawaii Medical Service Association ABD	$393.00
Rate for Payer: Hawaii Medical Service Association Commercial	$2,833.00
Rate for Payer: Hawaii Medical Service Association Medicare	$295.16
Rate for Payer: Hawaii Medical Service Association Non-ABD	$407.95
Rate for Payer: Hawaii Western Management Group Commercial	$1,339.50
Rate for Payer: Health Management Network Commercial	$1,198.50
Rate for Payer: Humana Medicare	$295.16
Rate for Payer: Kaiser Permanente Commercial	$888.30
Rate for Payer: Kaiser Permanente Medicaid	$937.50
Rate for Payer: Kaiser Permanente Medicare	$295.16
Rate for Payer: MDX Hawaii PPO	$1,367.70
Rate for Payer: Ohana Health Plan Medicaid	$324.68
Rate for Payer: Ohana Health Plan Medicare	$295.16
Rate for Payer: UnitedHealthcare Medicare	$295.16
Rate for Payer: University Health Alliance Commercial	$1,027.75

HCHG CHANGE OF CYSTOSTOMY TUBE SIMPLE

Facility

$1,410.00

Service Code	HCPCS 51705
Hospital Charge Code	H4500164
Hospital Revenue Code	450
Min. Negotiated Rate	$1,198.50
Max. Negotiated Rate	$1,367.70
Rate for Payer: Cash Price	$916.50
Rate for Payer: Health Management Network Commercial	$1,198.50
Rate for Payer: MDX Hawaii PPO	$1,367.70

HCHG CHEMO ADMIN BY INFUS EA ADDL HR

Facility

$450.00

Service Code	HCPCS 96415
Hospital Charge Code	H3350114
Hospital Revenue Code	335
Min. Negotiated Rate	$38.31
Max. Negotiated Rate	$436.50
Rate for Payer: AlohaCare Medicaid	$85.06
Rate for Payer: AlohaCare Medicare	$85.06
Rate for Payer: Cash Price	$292.50
Rate for Payer: Cash Price	$292.50
Rate for Payer: Devoted Health Medicare	$93.57
Rate for Payer: Hawaii Medical Service Association Commercial	$106.33
Rate for Payer: Hawaii Medical Service Association Medicare	$85.06
Rate for Payer: Hawaii Western Management Group Commercial	$427.50
Rate for Payer: Health Management Network Commercial	$382.50
Rate for Payer: Humana Medicare	$85.06
Rate for Payer: Kaiser Permanente Commercial	$283.50
Rate for Payer: Kaiser Permanente Medicaid	$229.50
Rate for Payer: Kaiser Permanente Medicare	$85.06
Rate for Payer: MDX Hawaii PPO	$436.50
Rate for Payer: Ohana Health Plan Medicaid	$93.57
Rate for Payer: Ohana Health Plan Medicare	$85.06
Rate for Payer: UnitedHealthcare Medicaid	$38.31
Rate for Payer: UnitedHealthcare Medicare	$85.06
Rate for Payer: University Health Alliance Commercial	$328.00

HCHG CHEMO ADMIN BY INFUS EA ADDL HR

Facility

$450.00

Service Code	HCPCS 96415
Hospital Charge Code	H3350114
Hospital Revenue Code	335
Min. Negotiated Rate	$382.50
Max. Negotiated Rate	$436.50
Rate for Payer: Cash Price	$292.50
Rate for Payer: Health Management Network Commercial	$382.50
Rate for Payer: MDX Hawaii PPO	$436.50

HCHG CHEMO ADMIN BY INFUS UP TO 1 HR

Facility

$1,641.00

Service Code	HCPCS 96413
Hospital Charge Code	H3350117
Hospital Revenue Code	335
Min. Negotiated Rate	$113.96
Max. Negotiated Rate	$1,591.77
Rate for Payer: AlohaCare Medicaid	$390.20
Rate for Payer: AlohaCare Medicare	$390.20
Rate for Payer: Cash Price	$1,066.65
Rate for Payer: Cash Price	$1,066.65
Rate for Payer: Devoted Health Medicare	$429.22
Rate for Payer: Hawaii Medical Service Association Commercial	$487.75
Rate for Payer: Hawaii Medical Service Association Medicare	$390.20
Rate for Payer: Hawaii Western Management Group Commercial	$1,558.95
Rate for Payer: Health Management Network Commercial	$1,394.85
Rate for Payer: Humana Medicare	$390.20
Rate for Payer: Kaiser Permanente Commercial	$1,033.83
Rate for Payer: Kaiser Permanente Medicaid	$836.91
Rate for Payer: Kaiser Permanente Medicare	$390.20
Rate for Payer: MDX Hawaii PPO	$1,591.77
Rate for Payer: Ohana Health Plan Medicaid	$429.22
Rate for Payer: Ohana Health Plan Medicare	$390.20
Rate for Payer: UnitedHealthcare Medicaid	$113.96
Rate for Payer: UnitedHealthcare Medicare	$390.20
Rate for Payer: University Health Alliance Commercial	$1,196.12

HCHG CHEMO ADMIN BY INFUS UP TO 1 HR

Facility

$1,641.00

Service Code	HCPCS 96413
Hospital Charge Code	H3350117
Hospital Revenue Code	335
Min. Negotiated Rate	$1,394.85
Max. Negotiated Rate	$1,591.77
Rate for Payer: Cash Price	$1,066.65
Rate for Payer: Health Management Network Commercial	$1,394.85
Rate for Payer: MDX Hawaii PPO	$1,591.77

HCHG CHEMO ADMIN EA ADDL SEQ INFUSION UP TO 1HR

Facility

$450.00

Service Code	HCPCS 96417
Hospital Charge Code	H9400141
Hospital Revenue Code	940
Min. Negotiated Rate	$55.33
Max. Negotiated Rate	$436.50
Rate for Payer: AlohaCare Medicaid	$85.06
Rate for Payer: AlohaCare Medicare	$85.06
Rate for Payer: Cash Price	$292.50
Rate for Payer: Cash Price	$292.50
Rate for Payer: Devoted Health Medicare	$93.57
Rate for Payer: Hawaii Medical Service Association Commercial	$106.33
Rate for Payer: Hawaii Medical Service Association Medicare	$85.06
Rate for Payer: Hawaii Western Management Group Commercial	$427.50
Rate for Payer: Health Management Network Commercial	$382.50
Rate for Payer: Humana Medicare	$85.06
Rate for Payer: Kaiser Permanente Commercial	$283.50
Rate for Payer: Kaiser Permanente Medicaid	$229.50
Rate for Payer: Kaiser Permanente Medicare	$85.06
Rate for Payer: MDX Hawaii PPO	$436.50
Rate for Payer: Ohana Health Plan Medicaid	$93.57
Rate for Payer: Ohana Health Plan Medicare	$85.06
Rate for Payer: UnitedHealthcare Medicaid	$55.33
Rate for Payer: UnitedHealthcare Medicare	$85.06
Rate for Payer: University Health Alliance Commercial	$328.00

HCHG CHEMO ADMIN EA ADDL SEQ INFUSION UP TO 1HR

Facility

$450.00

Service Code	HCPCS 96417
Hospital Charge Code	H9400141
Hospital Revenue Code	940
Min. Negotiated Rate	$382.50
Max. Negotiated Rate	$436.50
Rate for Payer: Cash Price	$292.50
Rate for Payer: Health Management Network Commercial	$382.50
Rate for Payer: MDX Hawaii PPO	$436.50

HCHG CHEMO ADMIN HORMONAL ANTI-NEO SQ/IM

Facility

$505.00

Service Code	HCPCS 96402
Hospital Charge Code	H3310121
Hospital Revenue Code	331
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: MDX Hawaii PPO	$489.85

HCHG CHEMO ADMIN HORMONAL ANTI-NEO SQ/IM

Facility

$505.00

Service Code	HCPCS 96402
Hospital Charge Code	H3310121
Hospital Revenue Code	331
Min. Negotiated Rate	$30.04
Max. Negotiated Rate	$489.85
Rate for Payer: AlohaCare Medicaid	$85.06
Rate for Payer: AlohaCare Medicare	$85.06
Rate for Payer: Cash Price	$328.25
Rate for Payer: Cash Price	$328.25
Rate for Payer: Devoted Health Medicare	$93.57
Rate for Payer: Hawaii Medical Service Association Commercial	$106.33
Rate for Payer: Hawaii Medical Service Association Medicare	$85.06
Rate for Payer: Hawaii Western Management Group Commercial	$479.75
Rate for Payer: Health Management Network Commercial	$429.25
Rate for Payer: Humana Medicare	$85.06
Rate for Payer: Kaiser Permanente Commercial	$318.15
Rate for Payer: Kaiser Permanente Medicaid	$257.55
Rate for Payer: Kaiser Permanente Medicare	$85.06
Rate for Payer: MDX Hawaii PPO	$489.85
Rate for Payer: Ohana Health Plan Medicaid	$93.57
Rate for Payer: Ohana Health Plan Medicare	$85.06
Rate for Payer: UnitedHealthcare Medicaid	$30.04
Rate for Payer: UnitedHealthcare Medicare	$85.06
Rate for Payer: University Health Alliance Commercial	$368.09

HCHG CHEMO ADMIN INTRALESIONAL UP TO 7

Facility

$408.00

Service Code	HCPCS 96405
Hospital Charge Code	H3310122
Hospital Revenue Code	331
Min. Negotiated Rate	$30.10
Max. Negotiated Rate	$395.76
Rate for Payer: AlohaCare Medicaid	$85.06
Rate for Payer: AlohaCare Medicare	$85.06
Rate for Payer: Cash Price	$265.20
Rate for Payer: Cash Price	$265.20
Rate for Payer: Devoted Health Medicare	$93.57
Rate for Payer: Hawaii Medical Service Association Commercial	$106.33
Rate for Payer: Hawaii Medical Service Association Medicare	$85.06
Rate for Payer: Hawaii Western Management Group Commercial	$387.60
Rate for Payer: Health Management Network Commercial	$346.80
Rate for Payer: Humana Medicare	$85.06
Rate for Payer: Kaiser Permanente Commercial	$257.04
Rate for Payer: Kaiser Permanente Medicaid	$208.08
Rate for Payer: Kaiser Permanente Medicare	$85.06
Rate for Payer: MDX Hawaii PPO	$395.76
Rate for Payer: Ohana Health Plan Medicaid	$93.57
Rate for Payer: Ohana Health Plan Medicare	$85.06
Rate for Payer: UnitedHealthcare Medicaid	$30.10
Rate for Payer: UnitedHealthcare Medicare	$85.06
Rate for Payer: University Health Alliance Commercial	$297.39

HCHG CHEMO ADMIN INTRALESIONAL UP TO 7

Facility

$408.00

Service Code	HCPCS 96405
Hospital Charge Code	H3310122
Hospital Revenue Code	331
Min. Negotiated Rate	$346.80
Max. Negotiated Rate	$395.76
Rate for Payer: Cash Price	$265.20
Rate for Payer: Health Management Network Commercial	$346.80
Rate for Payer: MDX Hawaii PPO	$395.76

HCHG CHEMO ADMIN INTRAVESICAL

Facility

$1,874.00

Service Code	HCPCS 51720
Hospital Charge Code	H3310106
Hospital Revenue Code	761
Min. Negotiated Rate	$68.68
Max. Negotiated Rate	$2,833.00
Rate for Payer: AlohaCare Medicaid	$823.75
Rate for Payer: AlohaCare Medicare	$823.75
Rate for Payer: Cash Price	$1,218.10
Rate for Payer: Cash Price	$1,218.10
Rate for Payer: Cash Price	$1,218.10
Rate for Payer: Devoted Health Medicare	$906.12
Rate for Payer: Hawaii Medical Service Association ABD	$393.00
Rate for Payer: Hawaii Medical Service Association Commercial	$2,833.00
Rate for Payer: Hawaii Medical Service Association Medicare	$823.75
Rate for Payer: Hawaii Medical Service Association Non-ABD	$407.95
Rate for Payer: Hawaii Western Management Group Commercial	$1,780.30
Rate for Payer: Health Management Network Commercial	$1,592.90
Rate for Payer: Humana Medicare	$823.75
Rate for Payer: Kaiser Permanente Commercial	$1,180.62
Rate for Payer: Kaiser Permanente Medicaid	$955.74
Rate for Payer: Kaiser Permanente Medicare	$823.75
Rate for Payer: MDX Hawaii PPO	$1,817.78
Rate for Payer: Ohana Health Plan Medicaid	$906.12
Rate for Payer: Ohana Health Plan Medicare	$823.75
Rate for Payer: UnitedHealthcare Medicaid	$68.68
Rate for Payer: UnitedHealthcare Medicare	$823.75
Rate for Payer: University Health Alliance Commercial	$1,365.96

HCHG CHEMO ADMIN INTRAVESICAL

Facility

$1,874.00

Service Code	HCPCS 51720
Hospital Charge Code	H3310106
Hospital Revenue Code	761
Min. Negotiated Rate	$1,592.90
Max. Negotiated Rate	$1,817.78
Rate for Payer: Cash Price	$1,218.10
Rate for Payer: Health Management Network Commercial	$1,592.90
Rate for Payer: MDX Hawaii PPO	$1,817.78

Know your out-of-pocket cost for care.

All Charges