Kona Community Hospital

All Charges

Charge

Type

Setting

Price

HCHG EVAL OF FNA FIRST EPISODE

Facility

$491.00

Service Code	HCPCS 88172
Hospital Charge Code	K3110001
Hospital Revenue Code	311
Min. Negotiated Rate	$417.35
Max. Negotiated Rate	$476.27
Rate for Payer: Cash Price	$319.15
Rate for Payer: Health Management Network Commercial	$417.35
Rate for Payer: MDX Hawaii PPO	$476.27

HCHG EVAL OF FNA FIRST EPISODE

Facility

$491.00

Service Code	HCPCS 88172
Hospital Charge Code	K3110001
Hospital Revenue Code	311
Min. Negotiated Rate	$22.64
Max. Negotiated Rate	$476.27
Rate for Payer: AlohaCare Medicaid	$201.27
Rate for Payer: AlohaCare Medicare	$201.27
Rate for Payer: Cash Price	$319.15
Rate for Payer: Cash Price	$319.15
Rate for Payer: Devoted Health Medicare	$221.40
Rate for Payer: Hawaii Medical Service Association ABD	$39.40
Rate for Payer: Hawaii Medical Service Association Commercial	$251.59
Rate for Payer: Hawaii Medical Service Association Medicare	$201.27
Rate for Payer: Hawaii Medical Service Association Non-ABD	$22.64
Rate for Payer: Hawaii Western Management Group Commercial	$201.27
Rate for Payer: Health Management Network Commercial	$417.35
Rate for Payer: Humana Medicare	$201.27
Rate for Payer: Kaiser Permanente Commercial	$309.33
Rate for Payer: Kaiser Permanente Medicaid	$250.41
Rate for Payer: Kaiser Permanente Medicare	$201.27
Rate for Payer: MDX Hawaii PPO	$476.27
Rate for Payer: Ohana Health Plan Medicaid	$221.40
Rate for Payer: Ohana Health Plan Medicare	$201.27
Rate for Payer: UnitedHealthcare Medicaid	$39.40
Rate for Payer: UnitedHealthcare Medicare	$201.27
Rate for Payer: University Health Alliance Commercial	$101.12

HCHG EXAM SURG SPECIMEN

Facility

$2,905.00

Service Code	HCPCS 76098
Hospital Charge Code	H3200346
Hospital Revenue Code	320
Min. Negotiated Rate	$16.29
Max. Negotiated Rate	$2,817.85
Rate for Payer: AlohaCare Medicaid	$645.50
Rate for Payer: AlohaCare Medicare	$645.50
Rate for Payer: Cash Price	$1,888.25
Rate for Payer: Cash Price	$1,888.25
Rate for Payer: Devoted Health Medicare	$710.05
Rate for Payer: Hawaii Medical Service Association ABD	$16.47
Rate for Payer: Hawaii Medical Service Association Commercial	$806.88
Rate for Payer: Hawaii Medical Service Association Medicare	$645.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$16.29
Rate for Payer: Hawaii Western Management Group Commercial	$645.50
Rate for Payer: Health Management Network Commercial	$2,469.25
Rate for Payer: Humana Medicare	$645.50
Rate for Payer: Kaiser Permanente Commercial	$1,830.15
Rate for Payer: Kaiser Permanente Medicaid	$1,481.55
Rate for Payer: Kaiser Permanente Medicare	$645.50
Rate for Payer: MDX Hawaii PPO	$2,817.85
Rate for Payer: Ohana Health Plan Medicaid	$710.05
Rate for Payer: Ohana Health Plan Medicare	$645.50
Rate for Payer: UnitedHealthcare Medicaid	$16.47
Rate for Payer: UnitedHealthcare Medicare	$645.50
Rate for Payer: University Health Alliance Commercial	$42.66

HCHG EXAM SURG SPECIMEN

Facility

$2,905.00

Service Code	HCPCS 76098
Hospital Charge Code	H3200346
Hospital Revenue Code	320
Min. Negotiated Rate	$2,469.25
Max. Negotiated Rate	$2,817.85
Rate for Payer: Cash Price	$1,888.25
Rate for Payer: Health Management Network Commercial	$2,469.25
Rate for Payer: MDX Hawaii PPO	$2,817.85

HCHG EXC B9 LES MRGN XCP SK TG T/A/L 0.5 CM/<

Facility

$3,819.00

Service Code	HCPCS 11400
Hospital Charge Code	H4501067
Hospital Revenue Code	450
Min. Negotiated Rate	$3,246.15
Max. Negotiated Rate	$3,704.43
Rate for Payer: Cash Price	$2,482.35
Rate for Payer: Health Management Network Commercial	$3,246.15
Rate for Payer: MDX Hawaii PPO	$3,704.43

HCHG EXC B9 LES MRGN XCP SK TG T/A/L 0.5 CM/<

Facility

$3,819.00

Service Code	HCPCS 11400
Hospital Charge Code	H4501067
Hospital Revenue Code	450
Min. Negotiated Rate	$340.18
Max. Negotiated Rate	$4,035.20
Rate for Payer: AlohaCare Medicaid	$836.55
Rate for Payer: AlohaCare Medicare	$836.55
Rate for Payer: Cash Price	$2,482.35
Rate for Payer: Cash Price	$2,482.35
Rate for Payer: Cash Price	$2,482.35
Rate for Payer: Cash Price	$2,482.35
Rate for Payer: Devoted Health Medicare	$920.21
Rate for Payer: Hawaii Medical Service Association ABD	$560.00
Rate for Payer: Hawaii Medical Service Association Commercial	$1,600.00
Rate for Payer: Hawaii Medical Service Association Medicare	$836.55
Rate for Payer: Hawaii Medical Service Association Non-ABD	$520.00
Rate for Payer: Hawaii Western Management Group Commercial	$3,628.05
Rate for Payer: Health Management Network Commercial	$3,246.15
Rate for Payer: Humana Medicare	$836.55
Rate for Payer: Kaiser Permanente Commercial	$2,405.97
Rate for Payer: Kaiser Permanente Medicaid	$937.50
Rate for Payer: Kaiser Permanente Medicare	$836.55
Rate for Payer: MDX Hawaii PPO	$3,704.43
Rate for Payer: Ohana Health Plan Medicaid	$920.21
Rate for Payer: Ohana Health Plan Medicare	$836.55
Rate for Payer: UnitedHealthcare Medicaid	$340.18
Rate for Payer: UnitedHealthcare Medicare	$836.55
Rate for Payer: University Health Alliance Commercial	$4,035.20

HCHG EXC TR EXT B9+MARG 0.5 < CM

Facility

$3,819.00

Service Code	HCPCS 11400
Hospital Charge Code	H3610853
Hospital Revenue Code	361
Min. Negotiated Rate	$340.18
Max. Negotiated Rate	$4,035.20
Rate for Payer: AlohaCare Medicaid	$836.55
Rate for Payer: AlohaCare Medicare	$836.55
Rate for Payer: Cash Price	$2,482.35
Rate for Payer: Cash Price	$2,482.35
Rate for Payer: Cash Price	$2,482.35
Rate for Payer: Devoted Health Medicare	$920.21
Rate for Payer: Hawaii Medical Service Association Commercial	$1,045.69
Rate for Payer: Hawaii Medical Service Association Medicare	$836.55
Rate for Payer: Health Management Network Commercial	$3,246.15
Rate for Payer: Humana Medicare	$836.55
Rate for Payer: Kaiser Permanente Commercial	$2,405.97
Rate for Payer: Kaiser Permanente Medicaid	$2,837.00
Rate for Payer: Kaiser Permanente Medicare	$836.55
Rate for Payer: MDX Hawaii PPO	$3,704.43
Rate for Payer: Ohana Health Plan Medicaid	$920.21
Rate for Payer: Ohana Health Plan Medicare	$836.55
Rate for Payer: UnitedHealthcare Medicaid	$340.18
Rate for Payer: UnitedHealthcare Medicare	$836.55
Rate for Payer: University Health Alliance Commercial	$4,035.20

HCHG EXC TR EXT B9+MARG 0.5 < CM

Facility

$3,819.00

Service Code	HCPCS 11400
Hospital Charge Code	H3610853
Hospital Revenue Code	361
Min. Negotiated Rate	$3,246.15
Max. Negotiated Rate	$3,704.43
Rate for Payer: Cash Price	$2,482.35
Rate for Payer: Health Management Network Commercial	$3,246.15
Rate for Payer: MDX Hawaii PPO	$3,704.43

HCHG EXPL PENETR WOUND ABD

Facility

$7,918.00

Service Code	HCPCS 20102
Hospital Charge Code	H4500442
Hospital Revenue Code	450
Min. Negotiated Rate	$456.03
Max. Negotiated Rate	$9,416.00
Rate for Payer: AlohaCare Medicaid	$2,437.45
Rate for Payer: AlohaCare Medicare	$2,437.45
Rate for Payer: Cash Price	$5,146.70
Rate for Payer: Cash Price	$5,146.70
Rate for Payer: Cash Price	$5,146.70
Rate for Payer: Devoted Health Medicare	$2,681.20
Rate for Payer: Hawaii Medical Service Association ABD	$848.00
Rate for Payer: Hawaii Medical Service Association Commercial	$9,416.00
Rate for Payer: Hawaii Medical Service Association Medicare	$2,437.45
Rate for Payer: Hawaii Medical Service Association Non-ABD	$849.21
Rate for Payer: Hawaii Western Management Group Commercial	$7,522.10
Rate for Payer: Health Management Network Commercial	$6,730.30
Rate for Payer: Humana Medicare	$2,437.45
Rate for Payer: Kaiser Permanente Commercial	$4,988.34
Rate for Payer: Kaiser Permanente Medicaid	$937.50
Rate for Payer: Kaiser Permanente Medicare	$2,437.45
Rate for Payer: MDX Hawaii PPO	$7,680.46
Rate for Payer: Ohana Health Plan Medicaid	$2,681.20
Rate for Payer: Ohana Health Plan Medicare	$2,437.45
Rate for Payer: UnitedHealthcare Medicaid	$456.03
Rate for Payer: UnitedHealthcare Medicare	$2,437.45
Rate for Payer: University Health Alliance Commercial	$5,160.40

HCHG EXPL PENETR WOUND ABD

Facility

$7,918.00

Service Code	HCPCS 20102
Hospital Charge Code	H4500442
Hospital Revenue Code	450
Min. Negotiated Rate	$6,730.30
Max. Negotiated Rate	$7,680.46
Rate for Payer: Cash Price	$5,146.70
Rate for Payer: Health Management Network Commercial	$6,730.30
Rate for Payer: MDX Hawaii PPO	$7,680.46

HCHG EXPL PENETR WOUND EXTREM

Facility

$4,919.00

Service Code	HCPCS 20103
Hospital Charge Code	H4500446
Hospital Revenue Code	450
Min. Negotiated Rate	$340.18
Max. Negotiated Rate	$6,183.00
Rate for Payer: AlohaCare Medicaid	$1,951.11
Rate for Payer: AlohaCare Medicare	$1,951.11
Rate for Payer: Cash Price	$3,197.35
Rate for Payer: Cash Price	$3,197.35
Rate for Payer: Cash Price	$3,197.35
Rate for Payer: Devoted Health Medicare	$2,146.22
Rate for Payer: Hawaii Medical Service Association ABD	$695.00
Rate for Payer: Hawaii Medical Service Association Commercial	$6,183.00
Rate for Payer: Hawaii Medical Service Association Medicare	$1,951.11
Rate for Payer: Hawaii Medical Service Association Non-ABD	$700.72
Rate for Payer: Hawaii Western Management Group Commercial	$4,673.05
Rate for Payer: Health Management Network Commercial	$4,181.15
Rate for Payer: Humana Medicare	$1,951.11
Rate for Payer: Kaiser Permanente Commercial	$3,098.97
Rate for Payer: Kaiser Permanente Medicaid	$937.50
Rate for Payer: Kaiser Permanente Medicare	$1,951.11
Rate for Payer: MDX Hawaii PPO	$4,771.43
Rate for Payer: Ohana Health Plan Medicaid	$2,146.22
Rate for Payer: Ohana Health Plan Medicare	$1,951.11
Rate for Payer: UnitedHealthcare Medicaid	$340.18
Rate for Payer: UnitedHealthcare Medicare	$1,951.11
Rate for Payer: University Health Alliance Commercial	$3,585.46

HCHG EXPL PENETR WOUND EXTREM

Facility

$4,919.00

Service Code	HCPCS 20103
Hospital Charge Code	H4500446
Hospital Revenue Code	450
Min. Negotiated Rate	$4,181.15
Max. Negotiated Rate	$4,771.43
Rate for Payer: Cash Price	$3,197.35
Rate for Payer: Health Management Network Commercial	$4,181.15
Rate for Payer: MDX Hawaii PPO	$4,771.43

HCHG EXTENDED KRAS

Facility

$1,051.00

Service Code	HCPCS 81276
Hospital Charge Code	H3011609
Hospital Revenue Code	310
Min. Negotiated Rate	$893.35
Max. Negotiated Rate	$1,019.47
Rate for Payer: Cash Price	$683.15
Rate for Payer: Health Management Network Commercial	$893.35
Rate for Payer: MDX Hawaii PPO	$1,019.47

HCHG EXTENDED KRAS

Facility

$1,051.00

Service Code	HCPCS 81276
Hospital Charge Code	H3011609
Hospital Revenue Code	310
Min. Negotiated Rate	$118.31
Max. Negotiated Rate	$1,019.47
Rate for Payer: AlohaCare Medicaid	$193.25
Rate for Payer: AlohaCare Medicare	$193.25
Rate for Payer: Cash Price	$683.15
Rate for Payer: Cash Price	$683.15
Rate for Payer: Devoted Health Medicare	$212.57
Rate for Payer: Hawaii Medical Service Association ABD	$145.92
Rate for Payer: Hawaii Medical Service Association Commercial	$241.56
Rate for Payer: Hawaii Medical Service Association Medicare	$193.25
Rate for Payer: Hawaii Medical Service Association Non-ABD	$145.92
Rate for Payer: Hawaii Western Management Group Commercial	$193.25
Rate for Payer: Health Management Network Commercial	$893.35
Rate for Payer: Humana Medicare	$193.25
Rate for Payer: Kaiser Permanente Commercial	$662.13
Rate for Payer: Kaiser Permanente Medicaid	$536.01
Rate for Payer: Kaiser Permanente Medicare	$193.25
Rate for Payer: MDX Hawaii PPO	$1,019.47
Rate for Payer: Ohana Health Plan Medicaid	$212.57
Rate for Payer: Ohana Health Plan Medicare	$193.25
Rate for Payer: UnitedHealthcare Medicaid	$118.31
Rate for Payer: UnitedHealthcare Medicare	$193.25
Rate for Payer: University Health Alliance Commercial	$766.07

HCHG EXTERNAL VERSION

Facility

$6,555.00

Service Code	HCPCS 59412
Hospital Charge Code	H7200175
Hospital Revenue Code	720
Min. Negotiated Rate	$5,571.75
Max. Negotiated Rate	$6,358.35
Rate for Payer: Cash Price	$4,260.75
Rate for Payer: Health Management Network Commercial	$5,571.75
Rate for Payer: MDX Hawaii PPO	$6,358.35

HCHG EXTERNAL VERSION

Facility

$6,555.00

Service Code	HCPCS 59412
Hospital Charge Code	H7200175
Hospital Revenue Code	720
Min. Negotiated Rate	$393.00
Max. Negotiated Rate	$6,358.35
Rate for Payer: AlohaCare Medicaid	$3,824.16
Rate for Payer: AlohaCare Medicare	$3,824.16
Rate for Payer: Cash Price	$4,260.75
Rate for Payer: Cash Price	$4,260.75
Rate for Payer: Cash Price	$4,260.75
Rate for Payer: Devoted Health Medicare	$4,206.58
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	$3,824.16
Rate for Payer: Hawaii Medical Service Association Non-ABD	$407.95
Rate for Payer: Hawaii Western Management Group Commercial	$6,227.25
Rate for Payer: Health Management Network Commercial	$5,571.75
Rate for Payer: Humana Medicare	$3,824.16
Rate for Payer: Kaiser Permanente Commercial	$4,129.65
Rate for Payer: Kaiser Permanente Medicaid	$3,343.05
Rate for Payer: Kaiser Permanente Medicare	$3,824.16
Rate for Payer: MDX Hawaii PPO	$6,358.35
Rate for Payer: Ohana Health Plan Medicaid	$4,206.58
Rate for Payer: Ohana Health Plan Medicare	$3,824.16
Rate for Payer: UnitedHealthcare Medicaid	$456.03
Rate for Payer: UnitedHealthcare Medicare	$3,824.16
Rate for Payer: University Health Alliance Commercial	$4,035.20

HCHG EXTREM ARTERIAL-VENOUS STUDY

Facility

$758.00

Service Code	HCPCS 93990
Hospital Charge Code	H9200110
Hospital Revenue Code	921
Min. Negotiated Rate	$644.30
Max. Negotiated Rate	$735.26
Rate for Payer: Cash Price	$492.70
Rate for Payer: Health Management Network Commercial	$644.30
Rate for Payer: MDX Hawaii PPO	$735.26

HCHG EXTREM ARTERIAL-VENOUS STUDY

Facility

$758.00

Service Code	HCPCS 93990
Hospital Charge Code	H9200110
Hospital Revenue Code	921
Min. Negotiated Rate	$102.96
Max. Negotiated Rate	$735.26
Rate for Payer: AlohaCare Medicaid	$123.50
Rate for Payer: AlohaCare Medicare	$123.50
Rate for Payer: Cash Price	$492.70
Rate for Payer: Cash Price	$492.70
Rate for Payer: Devoted Health Medicare	$135.85
Rate for Payer: Hawaii Medical Service Association ABD	$102.96
Rate for Payer: Hawaii Medical Service Association Commercial	$154.38
Rate for Payer: Hawaii Medical Service Association Medicare	$123.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$122.94
Rate for Payer: Hawaii Western Management Group Commercial	$720.10
Rate for Payer: Health Management Network Commercial	$644.30
Rate for Payer: Humana Medicare	$123.50
Rate for Payer: Kaiser Permanente Commercial	$477.54
Rate for Payer: Kaiser Permanente Medicaid	$386.58
Rate for Payer: Kaiser Permanente Medicare	$123.50
Rate for Payer: MDX Hawaii PPO	$735.26
Rate for Payer: Ohana Health Plan Medicaid	$135.85
Rate for Payer: Ohana Health Plan Medicare	$123.50
Rate for Payer: UnitedHealthcare Medicaid	$102.96
Rate for Payer: UnitedHealthcare Medicare	$123.50
Rate for Payer: University Health Alliance Commercial	$552.51

HCHG EYE FOREIGN BODY

Facility

$429.00

Service Code	HCPCS 70030
Hospital Charge Code	H3200356
Hospital Revenue Code	320
Min. Negotiated Rate	$13.91
Max. Negotiated Rate	$416.13
Rate for Payer: AlohaCare Medicaid	$102.81
Rate for Payer: AlohaCare Medicare	$102.81
Rate for Payer: Cash Price	$278.85
Rate for Payer: Cash Price	$278.85
Rate for Payer: Devoted Health Medicare	$113.09
Rate for Payer: Hawaii Medical Service Association ABD	$13.91
Rate for Payer: Hawaii Medical Service Association Commercial	$128.51
Rate for Payer: Hawaii Medical Service Association Medicare	$102.81
Rate for Payer: Hawaii Medical Service Association Non-ABD	$15.15
Rate for Payer: Hawaii Western Management Group Commercial	$102.81
Rate for Payer: Health Management Network Commercial	$364.65
Rate for Payer: Humana Medicare	$102.81
Rate for Payer: Kaiser Permanente Commercial	$270.27
Rate for Payer: Kaiser Permanente Medicaid	$218.79
Rate for Payer: Kaiser Permanente Medicare	$102.81
Rate for Payer: MDX Hawaii PPO	$416.13
Rate for Payer: Ohana Health Plan Medicaid	$113.09
Rate for Payer: Ohana Health Plan Medicare	$102.81
Rate for Payer: UnitedHealthcare Medicaid	$13.91
Rate for Payer: UnitedHealthcare Medicare	$102.81
Rate for Payer: University Health Alliance Commercial	$55.37

HCHG EYE FOREIGN BODY

Facility

$429.00

Service Code	HCPCS 70030
Hospital Charge Code	H3200356
Hospital Revenue Code	320
Min. Negotiated Rate	$364.65
Max. Negotiated Rate	$416.13
Rate for Payer: Cash Price	$278.85
Rate for Payer: Health Management Network Commercial	$364.65
Rate for Payer: MDX Hawaii PPO	$416.13

HCHG FACIAL BONES MIN 3 VIEWS

Facility

$685.00

Service Code	HCPCS 70150
Hospital Charge Code	H3200358
Hospital Revenue Code	320
Min. Negotiated Rate	$25.96
Max. Negotiated Rate	$664.45
Rate for Payer: AlohaCare Medicaid	$123.50
Rate for Payer: AlohaCare Medicare	$123.50
Rate for Payer: Cash Price	$445.25
Rate for Payer: Cash Price	$445.25
Rate for Payer: Devoted Health Medicare	$135.85
Rate for Payer: Hawaii Medical Service Association ABD	$25.96
Rate for Payer: Hawaii Medical Service Association Commercial	$154.38
Rate for Payer: Hawaii Medical Service Association Medicare	$123.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$28.19
Rate for Payer: Hawaii Western Management Group Commercial	$123.50
Rate for Payer: Health Management Network Commercial	$582.25
Rate for Payer: Humana Medicare	$123.50
Rate for Payer: Kaiser Permanente Commercial	$431.55
Rate for Payer: Kaiser Permanente Medicaid	$349.35
Rate for Payer: Kaiser Permanente Medicare	$123.50
Rate for Payer: MDX Hawaii PPO	$664.45
Rate for Payer: Ohana Health Plan Medicaid	$135.85
Rate for Payer: Ohana Health Plan Medicare	$123.50
Rate for Payer: UnitedHealthcare Medicaid	$25.96
Rate for Payer: UnitedHealthcare Medicare	$123.50
Rate for Payer: University Health Alliance Commercial	$87.39

HCHG FACIAL BONES MIN 3 VIEWS

Facility

$685.00

Service Code	HCPCS 70150
Hospital Charge Code	H3200358
Hospital Revenue Code	320
Min. Negotiated Rate	$582.25
Max. Negotiated Rate	$664.45
Rate for Payer: Cash Price	$445.25
Rate for Payer: Health Management Network Commercial	$582.25
Rate for Payer: MDX Hawaii PPO	$664.45

HCHG FACTOR II ACTIVITY CLOTTING

Facility

$160.00

Service Code	HCPCS 85210
Hospital Charge Code	H3000208
Hospital Revenue Code	305
Min. Negotiated Rate	$12.98
Max. Negotiated Rate	$155.20
Rate for Payer: AlohaCare Medicaid	$12.98
Rate for Payer: AlohaCare Medicare	$12.98
Rate for Payer: Cash Price	$104.00
Rate for Payer: Cash Price	$104.00
Rate for Payer: Devoted Health Medicare	$14.28
Rate for Payer: Hawaii Medical Service Association ABD	$17.95
Rate for Payer: Hawaii Medical Service Association Commercial	$16.23
Rate for Payer: Hawaii Medical Service Association Medicare	$12.98
Rate for Payer: Hawaii Medical Service Association Non-ABD	$18.85
Rate for Payer: Hawaii Western Management Group Commercial	$12.98
Rate for Payer: Health Management Network Commercial	$136.00
Rate for Payer: Humana Medicare	$12.98
Rate for Payer: Kaiser Permanente Commercial	$100.80
Rate for Payer: Kaiser Permanente Medicaid	$81.60
Rate for Payer: Kaiser Permanente Medicare	$12.98
Rate for Payer: MDX Hawaii PPO	$155.20
Rate for Payer: Ohana Health Plan Medicaid	$14.28
Rate for Payer: Ohana Health Plan Medicare	$12.98
Rate for Payer: UnitedHealthcare Medicaid	$17.95
Rate for Payer: UnitedHealthcare Medicare	$12.98
Rate for Payer: University Health Alliance Commercial	$33.56

HCHG FACTOR II ACTIVITY CLOTTING

Facility

$160.00

Service Code	HCPCS 85210
Hospital Charge Code	H3000208
Hospital Revenue Code	305
Min. Negotiated Rate	$136.00
Max. Negotiated Rate	$155.20
Rate for Payer: Cash Price	$104.00
Rate for Payer: Health Management Network Commercial	$136.00
Rate for Payer: MDX Hawaii PPO	$155.20

HCHG FACTOR V

Facility

$250.00

Service Code	HCPCS 81241
Hospital Charge Code	H3100155
Hospital Revenue Code	310
Min. Negotiated Rate	$47.03
Max. Negotiated Rate	$242.50
Rate for Payer: AlohaCare Medicaid	$73.37
Rate for Payer: AlohaCare Medicare	$73.37
Rate for Payer: Cash Price	$162.50
Rate for Payer: Cash Price	$162.50
Rate for Payer: Devoted Health Medicare	$80.71
Rate for Payer: Hawaii Medical Service Association ABD	$81.80
Rate for Payer: Hawaii Medical Service Association Commercial	$91.71
Rate for Payer: Hawaii Medical Service Association Medicare	$73.37
Rate for Payer: Hawaii Medical Service Association Non-ABD	$81.80
Rate for Payer: Hawaii Western Management Group Commercial	$73.37
Rate for Payer: Health Management Network Commercial	$212.50
Rate for Payer: Humana Medicare	$73.37
Rate for Payer: Kaiser Permanente Commercial	$157.50
Rate for Payer: Kaiser Permanente Medicaid	$127.50
Rate for Payer: Kaiser Permanente Medicare	$73.37
Rate for Payer: MDX Hawaii PPO	$242.50
Rate for Payer: Ohana Health Plan Medicaid	$80.71
Rate for Payer: Ohana Health Plan Medicare	$73.37
Rate for Payer: UnitedHealthcare Medicaid	$47.03
Rate for Payer: UnitedHealthcare Medicare	$73.37
Rate for Payer: University Health Alliance Commercial	$154.23

Know your out-of-pocket cost for care.

All Charges