Kona Community Hospital

All Charges

Charge

Type

Setting

Price

HCHG OT THERAPEUTIC ACTIVITY 15 MIN

Facility

$246.00

Service Code	HCPCS 97530
Hospital Charge Code	H4300196
Hospital Revenue Code	430
Min. Negotiated Rate	$209.10
Max. Negotiated Rate	$238.62
Rate for Payer: Cash Price	$159.90
Rate for Payer: Health Management Network Commercial	$209.10
Rate for Payer: MDX Hawaii PPO	$238.62

HCHG OT THERAPEUTIC EXERCISE 15 MIN

Facility

$209.00

Service Code	HCPCS 97110
Hospital Charge Code	H4300206
Hospital Revenue Code	430
Min. Negotiated Rate	$17.65
Max. Negotiated Rate	$202.73
Rate for Payer: Cash Price	$135.85
Rate for Payer: Cash Price	$135.85
Rate for Payer: Hawaii Western Management Group Commercial	$198.55
Rate for Payer: Health Management Network Commercial	$177.65
Rate for Payer: Kaiser Permanente Commercial	$131.67
Rate for Payer: Kaiser Permanente Medicaid	$106.59
Rate for Payer: MDX Hawaii PPO	$202.73
Rate for Payer: UnitedHealthcare Medicaid	$17.65
Rate for Payer: University Health Alliance Commercial	$152.34

HCHG OT THERAPEUTIC EXERCISE 15 MIN

Facility

$209.00

Service Code	HCPCS 97110
Hospital Charge Code	H4300206
Hospital Revenue Code	430
Min. Negotiated Rate	$177.65
Max. Negotiated Rate	$202.73
Rate for Payer: Cash Price	$135.85
Rate for Payer: Health Management Network Commercial	$177.65
Rate for Payer: MDX Hawaii PPO	$202.73

HCHG OVA & PARASITES CONC & ID

Facility

$150.00

Service Code	HCPCS 87177
Hospital Charge Code	H3060342
Hospital Revenue Code	306
Min. Negotiated Rate	$127.50
Max. Negotiated Rate	$145.50
Rate for Payer: Cash Price	$97.50
Rate for Payer: Health Management Network Commercial	$127.50
Rate for Payer: MDX Hawaii PPO	$145.50

HCHG OVA & PARASITES CONC & ID

Facility

$150.00

Service Code	HCPCS 87177
Hospital Charge Code	H3060342
Hospital Revenue Code	306
Min. Negotiated Rate	$8.90
Max. Negotiated Rate	$145.50
Rate for Payer: AlohaCare Medicaid	$8.90
Rate for Payer: AlohaCare Medicare	$8.90
Rate for Payer: Cash Price	$97.50
Rate for Payer: Cash Price	$97.50
Rate for Payer: Devoted Health Medicare	$9.79
Rate for Payer: Hawaii Medical Service Association ABD	$12.30
Rate for Payer: Hawaii Medical Service Association Commercial	$11.12
Rate for Payer: Hawaii Medical Service Association Medicare	$8.90
Rate for Payer: Hawaii Medical Service Association Non-ABD	$12.92
Rate for Payer: Hawaii Western Management Group Commercial	$8.90
Rate for Payer: Health Management Network Commercial	$127.50
Rate for Payer: Humana Medicare	$8.90
Rate for Payer: Kaiser Permanente Commercial	$94.50
Rate for Payer: Kaiser Permanente Medicaid	$76.50
Rate for Payer: Kaiser Permanente Medicare	$8.90
Rate for Payer: MDX Hawaii PPO	$145.50
Rate for Payer: Ohana Health Plan Medicaid	$9.79
Rate for Payer: Ohana Health Plan Medicare	$8.90
Rate for Payer: UnitedHealthcare Medicaid	$12.30
Rate for Payer: UnitedHealthcare Medicare	$8.90
Rate for Payer: University Health Alliance Commercial	$23.00

HCHG OXCARBAZEPINE AS METAOLITE

Facility

$179.00

Service Code	HCPCS 80183
Hospital Charge Code	H3011364
Hospital Revenue Code	301
Min. Negotiated Rate	$10.85
Max. Negotiated Rate	$173.63
Rate for Payer: AlohaCare Medicaid	$13.25
Rate for Payer: AlohaCare Medicare	$13.25
Rate for Payer: Cash Price	$116.35
Rate for Payer: Cash Price	$116.35
Rate for Payer: Devoted Health Medicare	$14.57
Rate for Payer: Hawaii Medical Service Association ABD	$11.11
Rate for Payer: Hawaii Medical Service Association Commercial	$16.56
Rate for Payer: Hawaii Medical Service Association Medicare	$13.25
Rate for Payer: Hawaii Medical Service Association Non-ABD	$17.75
Rate for Payer: Hawaii Western Management Group Commercial	$13.25
Rate for Payer: Health Management Network Commercial	$152.15
Rate for Payer: Humana Medicare	$13.25
Rate for Payer: Kaiser Permanente Commercial	$112.77
Rate for Payer: Kaiser Permanente Medicaid	$91.29
Rate for Payer: Kaiser Permanente Medicare	$13.25
Rate for Payer: MDX Hawaii PPO	$173.63
Rate for Payer: Ohana Health Plan Medicaid	$14.57
Rate for Payer: Ohana Health Plan Medicare	$13.25
Rate for Payer: UnitedHealthcare Medicaid	$10.85
Rate for Payer: UnitedHealthcare Medicare	$13.25
Rate for Payer: University Health Alliance Commercial	$33.47

HCHG OXCARBAZEPINE AS METAOLITE

Facility

$179.00

Service Code	HCPCS 80183
Hospital Charge Code	H3011364
Hospital Revenue Code	301
Min. Negotiated Rate	$152.15
Max. Negotiated Rate	$173.63
Rate for Payer: Cash Price	$116.35
Rate for Payer: Health Management Network Commercial	$152.15
Rate for Payer: MDX Hawaii PPO	$173.63

HCHG OXIMETRY CONTINUOUS

Facility

$529.00

Service Code	HCPCS 94762
Hospital Charge Code	H4600126
Hospital Revenue Code	460
Min. Negotiated Rate	$449.65
Max. Negotiated Rate	$513.13
Rate for Payer: Cash Price	$343.85
Rate for Payer: Health Management Network Commercial	$449.65
Rate for Payer: MDX Hawaii PPO	$513.13

HCHG OXIMETRY CONTINUOUS

Facility

$529.00

Service Code	HCPCS 94762
Hospital Charge Code	H4600126
Hospital Revenue Code	460
Min. Negotiated Rate	$19.84
Max. Negotiated Rate	$513.13
Rate for Payer: AlohaCare Medicaid	$152.01
Rate for Payer: AlohaCare Medicare	$152.01
Rate for Payer: Cash Price	$343.85
Rate for Payer: Cash Price	$343.85
Rate for Payer: Devoted Health Medicare	$167.21
Rate for Payer: Hawaii Medical Service Association Commercial	$190.01
Rate for Payer: Hawaii Medical Service Association Medicare	$152.01
Rate for Payer: Hawaii Western Management Group Commercial	$502.55
Rate for Payer: Health Management Network Commercial	$449.65
Rate for Payer: Humana Medicare	$152.01
Rate for Payer: Kaiser Permanente Commercial	$333.27
Rate for Payer: Kaiser Permanente Medicaid	$269.79
Rate for Payer: Kaiser Permanente Medicare	$152.01
Rate for Payer: MDX Hawaii PPO	$513.13
Rate for Payer: Ohana Health Plan Medicaid	$167.21
Rate for Payer: Ohana Health Plan Medicare	$152.01
Rate for Payer: UnitedHealthcare Medicaid	$19.84
Rate for Payer: UnitedHealthcare Medicare	$152.01
Rate for Payer: University Health Alliance Commercial	$385.59

HCHG OXYGEN PER DAY

Facility

$615.00

Hospital Charge Code	K2700001
Hospital Revenue Code	270
Min. Negotiated Rate	$522.75
Max. Negotiated Rate	$596.55
Rate for Payer: Cash Price	$399.75
Rate for Payer: Health Management Network Commercial	$522.75
Rate for Payer: MDX Hawaii PPO	$596.55

HCHG OXYGEN PER DAY

Facility

$615.00

Hospital Charge Code	K2700001
Hospital Revenue Code	270
Min. Negotiated Rate	$313.65
Max. Negotiated Rate	$596.55
Rate for Payer: Cash Price	$399.75
Rate for Payer: Hawaii Western Management Group Commercial	$584.25
Rate for Payer: Health Management Network Commercial	$522.75
Rate for Payer: Kaiser Permanente Commercial	$387.45
Rate for Payer: Kaiser Permanente Medicaid	$313.65
Rate for Payer: MDX Hawaii PPO	$596.55
Rate for Payer: University Health Alliance Commercial	$448.27

HCHG P190 BCR-ABL1

Facility

$792.00

Service Code	HCPCS 81207
Hospital Charge Code	H3011598
Hospital Revenue Code	301
Min. Negotiated Rate	$673.20
Max. Negotiated Rate	$768.24
Rate for Payer: Cash Price	$514.80
Rate for Payer: Health Management Network Commercial	$673.20
Rate for Payer: MDX Hawaii PPO	$768.24

HCHG P190 BCR-ABL1

Facility

$792.00

Service Code	HCPCS 81207
Hospital Charge Code	H3011598
Hospital Revenue Code	301
Min. Negotiated Rate	$54.19
Max. Negotiated Rate	$768.24
Rate for Payer: AlohaCare Medicaid	$144.84
Rate for Payer: AlohaCare Medicare	$144.84
Rate for Payer: Cash Price	$514.80
Rate for Payer: Cash Price	$514.80
Rate for Payer: Devoted Health Medicare	$159.32
Rate for Payer: Hawaii Medical Service Association Commercial	$181.05
Rate for Payer: Hawaii Medical Service Association Medicare	$144.84
Rate for Payer: Hawaii Medical Service Association Non-ABD	$193.87
Rate for Payer: Hawaii Western Management Group Commercial	$144.84
Rate for Payer: Health Management Network Commercial	$673.20
Rate for Payer: Humana Medicare	$144.84
Rate for Payer: Kaiser Permanente Commercial	$498.96
Rate for Payer: Kaiser Permanente Medicaid	$403.92
Rate for Payer: Kaiser Permanente Medicare	$144.84
Rate for Payer: MDX Hawaii PPO	$768.24
Rate for Payer: Ohana Health Plan Medicaid	$159.32
Rate for Payer: Ohana Health Plan Medicare	$144.84
Rate for Payer: UnitedHealthcare Medicaid	$54.19
Rate for Payer: UnitedHealthcare Medicare	$144.84
Rate for Payer: University Health Alliance Commercial	$167.07

HCHG PAMG 1

Facility

$912.00

Service Code	HCPCS 84112
Hospital Charge Code	K3010043
Hospital Revenue Code	301
Min. Negotiated Rate	$86.99
Max. Negotiated Rate	$884.64
Rate for Payer: AlohaCare Medicaid	$98.11
Rate for Payer: AlohaCare Medicare	$98.11
Rate for Payer: Cash Price	$592.80
Rate for Payer: Cash Price	$592.80
Rate for Payer: Devoted Health Medicare	$107.92
Rate for Payer: Hawaii Medical Service Association ABD	$90.64
Rate for Payer: Hawaii Medical Service Association Commercial	$122.64
Rate for Payer: Hawaii Medical Service Association Medicare	$98.11
Rate for Payer: Hawaii Medical Service Association Non-ABD	$86.99
Rate for Payer: Hawaii Western Management Group Commercial	$98.11
Rate for Payer: Health Management Network Commercial	$775.20
Rate for Payer: Humana Medicare	$98.11
Rate for Payer: Kaiser Permanente Commercial	$574.56
Rate for Payer: Kaiser Permanente Medicaid	$465.12
Rate for Payer: Kaiser Permanente Medicare	$98.11
Rate for Payer: MDX Hawaii PPO	$884.64
Rate for Payer: Ohana Health Plan Medicaid	$107.92
Rate for Payer: Ohana Health Plan Medicare	$98.11
Rate for Payer: UnitedHealthcare Medicaid	$90.64
Rate for Payer: UnitedHealthcare Medicare	$98.11
Rate for Payer: University Health Alliance Commercial	$167.68

HCHG PAMG 1

Facility

$912.00

Service Code	HCPCS 84112
Hospital Charge Code	K3010043
Hospital Revenue Code	301
Min. Negotiated Rate	$775.20
Max. Negotiated Rate	$884.64
Rate for Payer: Cash Price	$592.80
Rate for Payer: Health Management Network Commercial	$775.20
Rate for Payer: MDX Hawaii PPO	$884.64

HCHG PANCREATIC ELASTASE-1

Facility

$425.00

Service Code	HCPCS 82653
Hospital Charge Code	H3011688
Hospital Revenue Code	301
Min. Negotiated Rate	$13.78
Max. Negotiated Rate	$412.25
Rate for Payer: AlohaCare Medicaid	$22.97
Rate for Payer: AlohaCare Medicare	$22.97
Rate for Payer: Cash Price	$276.25
Rate for Payer: Cash Price	$276.25
Rate for Payer: Devoted Health Medicare	$25.27
Rate for Payer: Hawaii Medical Service Association ABD	$23.79
Rate for Payer: Hawaii Medical Service Association Commercial	$28.71
Rate for Payer: Hawaii Medical Service Association Medicare	$22.97
Rate for Payer: Hawaii Medical Service Association Non-ABD	$24.98
Rate for Payer: Hawaii Western Management Group Commercial	$22.97
Rate for Payer: Health Management Network Commercial	$361.25
Rate for Payer: Humana Medicare	$22.97
Rate for Payer: Kaiser Permanente Commercial	$267.75
Rate for Payer: Kaiser Permanente Medicaid	$216.75
Rate for Payer: Kaiser Permanente Medicare	$22.97
Rate for Payer: MDX Hawaii PPO	$412.25
Rate for Payer: Ohana Health Plan Medicaid	$25.27
Rate for Payer: Ohana Health Plan Medicare	$22.97
Rate for Payer: UnitedHealthcare Medicaid	$13.78
Rate for Payer: UnitedHealthcare Medicare	$22.97
Rate for Payer: University Health Alliance Commercial	$309.78

HCHG PANCREATIC ELASTASE-1

Facility

$425.00

Service Code	HCPCS 82653
Hospital Charge Code	H3011688
Hospital Revenue Code	301
Min. Negotiated Rate	$361.25
Max. Negotiated Rate	$412.25
Rate for Payer: Cash Price	$276.25
Rate for Payer: Health Management Network Commercial	$361.25
Rate for Payer: MDX Hawaii PPO	$412.25

HCHG PAP IN FLD(NEOPATH/MAN RESCRN)

Facility

$358.00

Service Code	HCPCS 88175
Hospital Charge Code	H3110228
Hospital Revenue Code	311
Min. Negotiated Rate	$26.61
Max. Negotiated Rate	$347.26
Rate for Payer: AlohaCare Medicaid	$26.61
Rate for Payer: AlohaCare Medicare	$26.61
Rate for Payer: Cash Price	$232.70
Rate for Payer: Cash Price	$232.70
Rate for Payer: Devoted Health Medicare	$29.27
Rate for Payer: Hawaii Medical Service Association ABD	$37.01
Rate for Payer: Hawaii Medical Service Association Commercial	$33.26
Rate for Payer: Hawaii Medical Service Association Medicare	$26.61
Rate for Payer: Hawaii Medical Service Association Non-ABD	$30.96
Rate for Payer: Hawaii Western Management Group Commercial	$26.61
Rate for Payer: Health Management Network Commercial	$304.30
Rate for Payer: Humana Medicare	$26.61
Rate for Payer: Kaiser Permanente Commercial	$225.54
Rate for Payer: Kaiser Permanente Medicaid	$182.58
Rate for Payer: Kaiser Permanente Medicare	$26.61
Rate for Payer: MDX Hawaii PPO	$347.26
Rate for Payer: Ohana Health Plan Medicaid	$29.27
Rate for Payer: Ohana Health Plan Medicare	$26.61
Rate for Payer: UnitedHealthcare Medicaid	$37.01
Rate for Payer: UnitedHealthcare Medicare	$26.61
Rate for Payer: University Health Alliance Commercial	$68.47

HCHG PAP IN FLD(NEOPATH/MAN RESCRN)

Facility

$358.00

Service Code	HCPCS 88175
Hospital Charge Code	H3110228
Hospital Revenue Code	311
Min. Negotiated Rate	$304.30
Max. Negotiated Rate	$347.26
Rate for Payer: Cash Price	$232.70
Rate for Payer: Health Management Network Commercial	$304.30
Rate for Payer: MDX Hawaii PPO	$347.26

HCHG PAP SYSTEM DAILY

Facility

$1,361.00

Service Code	HCPCS 94640
Hospital Charge Code	H4128107
Hospital Revenue Code	412
Min. Negotiated Rate	$13.32
Max. Negotiated Rate	$2,833.00
Rate for Payer: AlohaCare Medicaid	$258.69
Rate for Payer: AlohaCare Medicare	$258.69
Rate for Payer: Cash Price	$884.65
Rate for Payer: Cash Price	$884.65
Rate for Payer: Cash Price	$884.65
Rate for Payer: Devoted Health Medicare	$284.56
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	$258.69
Rate for Payer: Hawaii Medical Service Association Non-ABD	$407.95
Rate for Payer: Hawaii Western Management Group Commercial	$1,292.95
Rate for Payer: Health Management Network Commercial	$1,156.85
Rate for Payer: Humana Medicare	$258.69
Rate for Payer: Kaiser Permanente Commercial	$857.43
Rate for Payer: Kaiser Permanente Medicaid	$694.11
Rate for Payer: Kaiser Permanente Medicare	$258.69
Rate for Payer: MDX Hawaii PPO	$1,320.17
Rate for Payer: Ohana Health Plan Medicaid	$284.56
Rate for Payer: Ohana Health Plan Medicare	$258.69
Rate for Payer: UnitedHealthcare Medicaid	$13.32
Rate for Payer: UnitedHealthcare Medicare	$258.69
Rate for Payer: University Health Alliance Commercial	$992.03

HCHG PAP SYSTEM DAILY

Facility

$1,361.00

Service Code	HCPCS 94640
Hospital Charge Code	H4128107
Hospital Revenue Code	412
Min. Negotiated Rate	$1,156.85
Max. Negotiated Rate	$1,320.17
Rate for Payer: Cash Price	$884.65
Rate for Payer: Health Management Network Commercial	$1,156.85
Rate for Payer: MDX Hawaii PPO	$1,320.17

HCHG PAP SYSTEM SUBSEQUENT

Facility

$1,361.00

Service Code	HCPCS 94640
Hospital Charge Code	H4128108
Hospital Revenue Code	412
Min. Negotiated Rate	$1,156.85
Max. Negotiated Rate	$1,320.17
Rate for Payer: Cash Price	$884.65
Rate for Payer: Health Management Network Commercial	$1,156.85
Rate for Payer: MDX Hawaii PPO	$1,320.17

HCHG PAP SYSTEM SUBSEQUENT

Facility

$1,361.00

Service Code	HCPCS 94640
Hospital Charge Code	H4128108
Hospital Revenue Code	412
Min. Negotiated Rate	$13.32
Max. Negotiated Rate	$2,833.00
Rate for Payer: AlohaCare Medicaid	$258.69
Rate for Payer: AlohaCare Medicare	$258.69
Rate for Payer: Cash Price	$884.65
Rate for Payer: Cash Price	$884.65
Rate for Payer: Cash Price	$884.65
Rate for Payer: Devoted Health Medicare	$284.56
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	$258.69
Rate for Payer: Hawaii Medical Service Association Non-ABD	$407.95
Rate for Payer: Hawaii Western Management Group Commercial	$1,292.95
Rate for Payer: Health Management Network Commercial	$1,156.85
Rate for Payer: Humana Medicare	$258.69
Rate for Payer: Kaiser Permanente Commercial	$857.43
Rate for Payer: Kaiser Permanente Medicaid	$694.11
Rate for Payer: Kaiser Permanente Medicare	$258.69
Rate for Payer: MDX Hawaii PPO	$1,320.17
Rate for Payer: Ohana Health Plan Medicaid	$284.56
Rate for Payer: Ohana Health Plan Medicare	$258.69
Rate for Payer: UnitedHealthcare Medicaid	$13.32
Rate for Payer: UnitedHealthcare Medicare	$258.69
Rate for Payer: University Health Alliance Commercial	$992.03

HCHG PARANEOPLASTIC AUTOANTIBODY EVAL, CSF - 90

Facility

$163.00

Service Code	HCPCS 86255
Hospital Charge Code	H3021079
Hospital Revenue Code	302
Min. Negotiated Rate	$12.05
Max. Negotiated Rate	$158.11
Rate for Payer: AlohaCare Medicaid	$12.05
Rate for Payer: AlohaCare Medicare	$12.05
Rate for Payer: Cash Price	$105.95
Rate for Payer: Cash Price	$105.95
Rate for Payer: Devoted Health Medicare	$13.26
Rate for Payer: Hawaii Medical Service Association ABD	$16.66
Rate for Payer: Hawaii Medical Service Association Commercial	$15.06
Rate for Payer: Hawaii Medical Service Association Medicare	$12.05
Rate for Payer: Hawaii Medical Service Association Non-ABD	$17.49
Rate for Payer: Hawaii Western Management Group Commercial	$12.05
Rate for Payer: Health Management Network Commercial	$138.55
Rate for Payer: Humana Medicare	$12.05
Rate for Payer: Kaiser Permanente Commercial	$102.69
Rate for Payer: Kaiser Permanente Medicaid	$83.13
Rate for Payer: Kaiser Permanente Medicare	$12.05
Rate for Payer: MDX Hawaii PPO	$158.11
Rate for Payer: Ohana Health Plan Medicaid	$13.26
Rate for Payer: Ohana Health Plan Medicare	$12.05
Rate for Payer: UnitedHealthcare Medicaid	$16.66
Rate for Payer: UnitedHealthcare Medicare	$12.05
Rate for Payer: University Health Alliance Commercial	$31.15

HCHG PARANEOPLASTIC AUTOANTIBODY EVAL, CSF - 90

Facility

$163.00

Service Code	HCPCS 86255
Hospital Charge Code	H3021079
Hospital Revenue Code	302
Min. Negotiated Rate	$138.55
Max. Negotiated Rate	$158.11
Rate for Payer: Cash Price	$105.95
Rate for Payer: Health Management Network Commercial	$138.55
Rate for Payer: MDX Hawaii PPO	$158.11

Know your out-of-pocket cost for care.

All Charges