Kona Community Hospital

All Charges

Charge

Type

Setting

Price

HCHG IV INFUS ADDL SEQ INFUS UP TO 1 HR

Facility

$270.00

Service Code	HCPCS 96367
Hospital Charge Code	H4500865
Hospital Revenue Code	450
Min. Negotiated Rate	$229.50
Max. Negotiated Rate	$261.90
Rate for Payer: Cash Price	$175.50
Rate for Payer: Health Management Network Commercial	$229.50
Rate for Payer: MDX Hawaii PPO	$261.90

HCHG IV INFUS ADDL SEQ INFUS UP TO 1 HR

Facility

$270.00

Service Code	HCPCS 96367
Hospital Charge Code	H4500865
Hospital Revenue Code	450
Min. Negotiated Rate	$85.06
Max. Negotiated Rate	$1,600.00
Rate for Payer: AlohaCare Medicaid	$85.06
Rate for Payer: AlohaCare Medicare	$85.06
Rate for Payer: Cash Price	$175.50
Rate for Payer: Cash Price	$175.50
Rate for Payer: Cash Price	$175.50
Rate for Payer: Cash Price	$175.50
Rate for Payer: Devoted Health Medicare	$93.57
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	$85.06
Rate for Payer: Hawaii Medical Service Association Non-ABD	$520.00
Rate for Payer: Hawaii Western Management Group Commercial	$256.50
Rate for Payer: Health Management Network Commercial	$229.50
Rate for Payer: Humana Medicare	$85.06
Rate for Payer: Kaiser Permanente Commercial	$170.10
Rate for Payer: Kaiser Permanente Medicaid	$937.50
Rate for Payer: Kaiser Permanente Medicare	$85.06
Rate for Payer: MDX Hawaii PPO	$261.90
Rate for Payer: Ohana Health Plan Medicaid	$93.57
Rate for Payer: Ohana Health Plan Medicare	$85.06
Rate for Payer: UnitedHealthcare Medicare	$85.06
Rate for Payer: University Health Alliance Commercial	$196.80

HCHG IV INFUS CONCURRENT INFUS

Facility

$149.00

Service Code	HCPCS 96368
Hospital Charge Code	H4500866
Hospital Revenue Code	450
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 IV INFUS CONCURRENT INFUS

Facility

$149.00

Service Code	HCPCS 96368
Hospital Charge Code	H9400140
Hospital Revenue Code	940
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 IV INFUS CONCURRENT INFUS

Facility

$149.00

Service Code	HCPCS 96368
Hospital Charge Code	H9400140
Hospital Revenue Code	940
Min. Negotiated Rate	$13.30
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	$13.30
Rate for Payer: University Health Alliance Commercial	$108.61

HCHG IV INFUS CONCURRENT INFUS

Facility

$149.00

Service Code	HCPCS 96368
Hospital Charge Code	H4500866
Hospital Revenue Code	450
Min. Negotiated Rate	$93.87
Max. Negotiated Rate	$1,600.00
Rate for Payer: Cash Price	$96.85
Rate for Payer: Cash Price	$96.85
Rate for Payer: Cash Price	$96.85
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 Non-ABD	$520.00
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	$937.50
Rate for Payer: MDX Hawaii PPO	$144.53
Rate for Payer: University Health Alliance Commercial	$108.61

HCHG IV INFUSION EA ADDL PUSH

Facility

$355.00

Service Code	HCPCS 96375
Hospital Charge Code	H3310112
Hospital Revenue Code	260
Min. Negotiated Rate	$301.75
Max. Negotiated Rate	$344.35
Rate for Payer: Cash Price	$230.75
Rate for Payer: Health Management Network Commercial	$301.75
Rate for Payer: MDX Hawaii PPO	$344.35

HCHG IV INFUSION EA ADDL PUSH

Facility

$355.00

Service Code	HCPCS 96375
Hospital Charge Code	H9400137
Hospital Revenue Code	940
Min. Negotiated Rate	$301.75
Max. Negotiated Rate	$344.35
Rate for Payer: Cash Price	$230.75
Rate for Payer: Health Management Network Commercial	$301.75
Rate for Payer: MDX Hawaii PPO	$344.35

HCHG IV INFUSION EA ADDL PUSH

Facility

$355.00

Service Code	HCPCS 96375
Hospital Charge Code	H9400137
Hospital Revenue Code	940
Min. Negotiated Rate	$15.80
Max. Negotiated Rate	$344.35
Rate for Payer: AlohaCare Medicaid	$55.32
Rate for Payer: AlohaCare Medicare	$55.32
Rate for Payer: Cash Price	$230.75
Rate for Payer: Cash Price	$230.75
Rate for Payer: Devoted Health Medicare	$60.85
Rate for Payer: Hawaii Medical Service Association Commercial	$69.15
Rate for Payer: Hawaii Medical Service Association Medicare	$55.32
Rate for Payer: Hawaii Western Management Group Commercial	$337.25
Rate for Payer: Health Management Network Commercial	$301.75
Rate for Payer: Humana Medicare	$55.32
Rate for Payer: Kaiser Permanente Commercial	$223.65
Rate for Payer: Kaiser Permanente Medicaid	$181.05
Rate for Payer: Kaiser Permanente Medicare	$55.32
Rate for Payer: MDX Hawaii PPO	$344.35
Rate for Payer: Ohana Health Plan Medicaid	$60.85
Rate for Payer: Ohana Health Plan Medicare	$55.32
Rate for Payer: UnitedHealthcare Medicaid	$15.80
Rate for Payer: UnitedHealthcare Medicare	$55.32
Rate for Payer: University Health Alliance Commercial	$258.76

HCHG IV INFUSION EA ADDL PUSH

Facility

$355.00

Service Code	HCPCS 96375
Hospital Charge Code	H3310112
Hospital Revenue Code	260
Min. Negotiated Rate	$15.80
Max. Negotiated Rate	$344.35
Rate for Payer: AlohaCare Medicaid	$55.32
Rate for Payer: AlohaCare Medicare	$55.32
Rate for Payer: Cash Price	$230.75
Rate for Payer: Cash Price	$230.75
Rate for Payer: Devoted Health Medicare	$60.85
Rate for Payer: Hawaii Medical Service Association Commercial	$69.15
Rate for Payer: Hawaii Medical Service Association Medicare	$55.32
Rate for Payer: Hawaii Western Management Group Commercial	$337.25
Rate for Payer: Health Management Network Commercial	$301.75
Rate for Payer: Humana Medicare	$55.32
Rate for Payer: Kaiser Permanente Commercial	$223.65
Rate for Payer: Kaiser Permanente Medicaid	$181.05
Rate for Payer: Kaiser Permanente Medicare	$55.32
Rate for Payer: MDX Hawaii PPO	$344.35
Rate for Payer: Ohana Health Plan Medicaid	$60.85
Rate for Payer: Ohana Health Plan Medicare	$55.32
Rate for Payer: UnitedHealthcare Medicaid	$15.80
Rate for Payer: UnitedHealthcare Medicare	$55.32
Rate for Payer: University Health Alliance Commercial	$258.76

HCHG IV INFUSION HYDRATION 1ST HR

Facility

$1,060.00

Service Code	HCPCS 96360
Hospital Charge Code	H2600116
Hospital Revenue Code	260
Min. Negotiated Rate	$901.00
Max. Negotiated Rate	$1,028.20
Rate for Payer: Cash Price	$689.00
Rate for Payer: Health Management Network Commercial	$901.00
Rate for Payer: MDX Hawaii PPO	$1,028.20

HCHG IV INFUSION HYDRATION 1ST HR

Facility

$1,060.00

Service Code	HCPCS 96360
Hospital Charge Code	H2600116
Hospital Revenue Code	260
Min. Negotiated Rate	$38.10
Max. Negotiated Rate	$1,028.20
Rate for Payer: AlohaCare Medicaid	$251.28
Rate for Payer: AlohaCare Medicare	$251.28
Rate for Payer: Cash Price	$689.00
Rate for Payer: Cash Price	$689.00
Rate for Payer: Devoted Health Medicare	$276.41
Rate for Payer: Hawaii Medical Service Association Commercial	$314.10
Rate for Payer: Hawaii Medical Service Association Medicare	$251.28
Rate for Payer: Hawaii Western Management Group Commercial	$1,007.00
Rate for Payer: Health Management Network Commercial	$901.00
Rate for Payer: Humana Medicare	$251.28
Rate for Payer: Kaiser Permanente Commercial	$667.80
Rate for Payer: Kaiser Permanente Medicaid	$540.60
Rate for Payer: Kaiser Permanente Medicare	$251.28
Rate for Payer: MDX Hawaii PPO	$1,028.20
Rate for Payer: Ohana Health Plan Medicaid	$276.41
Rate for Payer: Ohana Health Plan Medicare	$251.28
Rate for Payer: UnitedHealthcare Medicaid	$38.10
Rate for Payer: UnitedHealthcare Medicare	$251.28
Rate for Payer: University Health Alliance Commercial	$772.63

HCHG IV INFUSION HYDRATION 1ST HR

Facility

$1,060.00

Service Code	HCPCS 96360
Hospital Charge Code	H4500863
Hospital Revenue Code	450
Min. Negotiated Rate	$901.00
Max. Negotiated Rate	$1,028.20
Rate for Payer: Cash Price	$689.00
Rate for Payer: Health Management Network Commercial	$901.00
Rate for Payer: MDX Hawaii PPO	$1,028.20

HCHG IV INFUSION HYDRATION 1ST HR

Facility

$1,060.00

Service Code	HCPCS 96360
Hospital Charge Code	H4500863
Hospital Revenue Code	450
Min. Negotiated Rate	$251.28
Max. Negotiated Rate	$1,600.00
Rate for Payer: AlohaCare Medicaid	$251.28
Rate for Payer: AlohaCare Medicare	$251.28
Rate for Payer: Cash Price	$689.00
Rate for Payer: Cash Price	$689.00
Rate for Payer: Cash Price	$689.00
Rate for Payer: Cash Price	$689.00
Rate for Payer: Devoted Health Medicare	$276.41
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	$251.28
Rate for Payer: Hawaii Medical Service Association Non-ABD	$520.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,007.00
Rate for Payer: Health Management Network Commercial	$901.00
Rate for Payer: Humana Medicare	$251.28
Rate for Payer: Kaiser Permanente Commercial	$667.80
Rate for Payer: Kaiser Permanente Medicaid	$937.50
Rate for Payer: Kaiser Permanente Medicare	$251.28
Rate for Payer: MDX Hawaii PPO	$1,028.20
Rate for Payer: Ohana Health Plan Medicaid	$276.41
Rate for Payer: Ohana Health Plan Medicare	$251.28
Rate for Payer: UnitedHealthcare Medicare	$251.28
Rate for Payer: University Health Alliance Commercial	$772.63

HCHG IV INFUSION HYDRATION EA ADDL HR

Facility

$226.00

Service Code	HCPCS 96361
Hospital Charge Code	H2600118
Hospital Revenue Code	260
Min. Negotiated Rate	$10.81
Max. Negotiated Rate	$219.22
Rate for Payer: AlohaCare Medicaid	$55.32
Rate for Payer: AlohaCare Medicare	$55.32
Rate for Payer: Cash Price	$146.90
Rate for Payer: Cash Price	$146.90
Rate for Payer: Devoted Health Medicare	$60.85
Rate for Payer: Hawaii Medical Service Association Commercial	$69.15
Rate for Payer: Hawaii Medical Service Association Medicare	$55.32
Rate for Payer: Hawaii Western Management Group Commercial	$214.70
Rate for Payer: Health Management Network Commercial	$192.10
Rate for Payer: Humana Medicare	$55.32
Rate for Payer: Kaiser Permanente Commercial	$142.38
Rate for Payer: Kaiser Permanente Medicaid	$115.26
Rate for Payer: Kaiser Permanente Medicare	$55.32
Rate for Payer: MDX Hawaii PPO	$219.22
Rate for Payer: Ohana Health Plan Medicaid	$60.85
Rate for Payer: Ohana Health Plan Medicare	$55.32
Rate for Payer: UnitedHealthcare Medicaid	$10.81
Rate for Payer: UnitedHealthcare Medicare	$55.32
Rate for Payer: University Health Alliance Commercial	$164.73

HCHG IV INFUSION HYDRATION EA ADDL HR

Facility

$226.00

Service Code	HCPCS 96361
Hospital Charge Code	H2600118
Hospital Revenue Code	260
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 IV INFUSION HYDRATION EA ADDL HR (IN ED)

Facility

$226.00

Service Code	HCPCS 96361
Hospital Charge Code	H4500864
Hospital Revenue Code	450
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 IV INFUSION HYDRATION EA ADDL HR (IN ED)

Facility

$226.00

Service Code	HCPCS 96361
Hospital Charge Code	H4500864
Hospital Revenue Code	450
Min. Negotiated Rate	$55.32
Max. Negotiated Rate	$1,600.00
Rate for Payer: AlohaCare Medicaid	$55.32
Rate for Payer: AlohaCare Medicare	$55.32
Rate for Payer: Cash Price	$146.90
Rate for Payer: Cash Price	$146.90
Rate for Payer: Cash Price	$146.90
Rate for Payer: Cash Price	$146.90
Rate for Payer: Devoted Health Medicare	$60.85
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	$55.32
Rate for Payer: Hawaii Medical Service Association Non-ABD	$520.00
Rate for Payer: Hawaii Western Management Group Commercial	$214.70
Rate for Payer: Health Management Network Commercial	$192.10
Rate for Payer: Humana Medicare	$55.32
Rate for Payer: Kaiser Permanente Commercial	$142.38
Rate for Payer: Kaiser Permanente Medicaid	$937.50
Rate for Payer: Kaiser Permanente Medicare	$55.32
Rate for Payer: MDX Hawaii PPO	$219.22
Rate for Payer: Ohana Health Plan Medicaid	$60.85
Rate for Payer: Ohana Health Plan Medicare	$55.32
Rate for Payer: UnitedHealthcare Medicare	$55.32
Rate for Payer: University Health Alliance Commercial	$164.73

HCHG IV INFUSION INITIAL PUSH

Facility

$423.00

Service Code	HCPCS 96374
Hospital Charge Code	H9400112
Hospital Revenue Code	940
Min. Negotiated Rate	$36.88
Max. Negotiated Rate	$410.31
Rate for Payer: AlohaCare Medicaid	$251.28
Rate for Payer: AlohaCare Medicare	$251.28
Rate for Payer: Cash Price	$274.95
Rate for Payer: Cash Price	$274.95
Rate for Payer: Devoted Health Medicare	$276.41
Rate for Payer: Hawaii Medical Service Association Commercial	$314.10
Rate for Payer: Hawaii Medical Service Association Medicare	$251.28
Rate for Payer: Hawaii Western Management Group Commercial	$401.85
Rate for Payer: Health Management Network Commercial	$359.55
Rate for Payer: Humana Medicare	$251.28
Rate for Payer: Kaiser Permanente Commercial	$266.49
Rate for Payer: Kaiser Permanente Medicaid	$215.73
Rate for Payer: Kaiser Permanente Medicare	$251.28
Rate for Payer: MDX Hawaii PPO	$410.31
Rate for Payer: Ohana Health Plan Medicaid	$276.41
Rate for Payer: Ohana Health Plan Medicare	$251.28
Rate for Payer: UnitedHealthcare Medicaid	$36.88
Rate for Payer: UnitedHealthcare Medicare	$251.28
Rate for Payer: University Health Alliance Commercial	$308.32

HCHG IV INFUSION INITIAL PUSH

Facility

$423.00

Service Code	HCPCS 96374
Hospital Charge Code	H9400112
Hospital Revenue Code	940
Min. Negotiated Rate	$359.55
Max. Negotiated Rate	$410.31
Rate for Payer: Cash Price	$274.95
Rate for Payer: Health Management Network Commercial	$359.55
Rate for Payer: MDX Hawaii PPO	$410.31

HCHG IV INFUSION THERAPY EA ADDL HR

Facility

$268.00

Service Code	HCPCS 96366
Hospital Charge Code	H4500851
Hospital Revenue Code	450
Min. Negotiated Rate	$227.80
Max. Negotiated Rate	$259.96
Rate for Payer: Cash Price	$174.20
Rate for Payer: Health Management Network Commercial	$227.80
Rate for Payer: MDX Hawaii PPO	$259.96

HCHG IV INFUSION THERAPY EA ADDL HR

Facility

$268.00

Service Code	HCPCS 96366
Hospital Charge Code	H4500851
Hospital Revenue Code	450
Min. Negotiated Rate	$55.32
Max. Negotiated Rate	$1,600.00
Rate for Payer: AlohaCare Medicaid	$55.32
Rate for Payer: AlohaCare Medicare	$55.32
Rate for Payer: Cash Price	$174.20
Rate for Payer: Cash Price	$174.20
Rate for Payer: Cash Price	$174.20
Rate for Payer: Cash Price	$174.20
Rate for Payer: Devoted Health Medicare	$60.85
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	$55.32
Rate for Payer: Hawaii Medical Service Association Non-ABD	$520.00
Rate for Payer: Hawaii Western Management Group Commercial	$254.60
Rate for Payer: Health Management Network Commercial	$227.80
Rate for Payer: Humana Medicare	$55.32
Rate for Payer: Kaiser Permanente Commercial	$168.84
Rate for Payer: Kaiser Permanente Medicaid	$937.50
Rate for Payer: Kaiser Permanente Medicare	$55.32
Rate for Payer: MDX Hawaii PPO	$259.96
Rate for Payer: Ohana Health Plan Medicaid	$60.85
Rate for Payer: Ohana Health Plan Medicare	$55.32
Rate for Payer: UnitedHealthcare Medicare	$55.32
Rate for Payer: University Health Alliance Commercial	$195.35

HCHG IV INFUSION THERAPY EA ADDL HR

Facility

$268.00

Service Code	HCPCS 96366
Hospital Charge Code	H2600010
Hospital Revenue Code	260
Min. Negotiated Rate	$14.27
Max. Negotiated Rate	$259.96
Rate for Payer: AlohaCare Medicaid	$55.32
Rate for Payer: AlohaCare Medicare	$55.32
Rate for Payer: Cash Price	$174.20
Rate for Payer: Cash Price	$174.20
Rate for Payer: Devoted Health Medicare	$60.85
Rate for Payer: Hawaii Medical Service Association Commercial	$69.15
Rate for Payer: Hawaii Medical Service Association Medicare	$55.32
Rate for Payer: Hawaii Western Management Group Commercial	$254.60
Rate for Payer: Health Management Network Commercial	$227.80
Rate for Payer: Humana Medicare	$55.32
Rate for Payer: Kaiser Permanente Commercial	$168.84
Rate for Payer: Kaiser Permanente Medicaid	$136.68
Rate for Payer: Kaiser Permanente Medicare	$55.32
Rate for Payer: MDX Hawaii PPO	$259.96
Rate for Payer: Ohana Health Plan Medicaid	$60.85
Rate for Payer: Ohana Health Plan Medicare	$55.32
Rate for Payer: UnitedHealthcare Medicaid	$14.27
Rate for Payer: UnitedHealthcare Medicare	$55.32
Rate for Payer: University Health Alliance Commercial	$195.35

HCHG IV INFUSION THERAPY EA ADDL HR

Facility

$268.00

Service Code	HCPCS 96366
Hospital Charge Code	H2600010
Hospital Revenue Code	260
Min. Negotiated Rate	$227.80
Max. Negotiated Rate	$259.96
Rate for Payer: Cash Price	$174.20
Rate for Payer: Health Management Network Commercial	$227.80
Rate for Payer: MDX Hawaii PPO	$259.96

HCHG IV INFUSION THERAPY UP TO 1 HR

Facility

$1,060.00

Service Code	HCPCS 96365
Hospital Charge Code	H4500500
Hospital Revenue Code	450
Min. Negotiated Rate	$251.28
Max. Negotiated Rate	$1,600.00
Rate for Payer: AlohaCare Medicaid	$251.28
Rate for Payer: AlohaCare Medicare	$251.28
Rate for Payer: Cash Price	$689.00
Rate for Payer: Cash Price	$689.00
Rate for Payer: Cash Price	$689.00
Rate for Payer: Cash Price	$689.00
Rate for Payer: Devoted Health Medicare	$276.41
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	$251.28
Rate for Payer: Hawaii Medical Service Association Non-ABD	$520.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,007.00
Rate for Payer: Health Management Network Commercial	$901.00
Rate for Payer: Humana Medicare	$251.28
Rate for Payer: Kaiser Permanente Commercial	$667.80
Rate for Payer: Kaiser Permanente Medicaid	$937.50
Rate for Payer: Kaiser Permanente Medicare	$251.28
Rate for Payer: MDX Hawaii PPO	$1,028.20
Rate for Payer: Ohana Health Plan Medicaid	$276.41
Rate for Payer: Ohana Health Plan Medicare	$251.28
Rate for Payer: UnitedHealthcare Medicare	$251.28
Rate for Payer: University Health Alliance Commercial	$772.63

Know your out-of-pocket cost for care.

All Charges