Kona Community Hospital

All Charges

Charge

Type

Setting

Price

HCHG PROTEIN ELECTROPHORESIS

Facility

$129.00

Service Code	HCPCS 83521
Hospital Charge Code	H3011686
Hospital Revenue Code	301
Min. Negotiated Rate	$109.65
Max. Negotiated Rate	$125.13
Rate for Payer: Cash Price	$83.85
Rate for Payer: Health Management Network Commercial	$109.65
Rate for Payer: MDX Hawaii PPO	$125.13

HCHG PROTEIN ELECTROPHORESIS

Facility

$129.00

Service Code	HCPCS 83521
Hospital Charge Code	H3011686
Hospital Revenue Code	301
Min. Negotiated Rate	$10.36
Max. Negotiated Rate	$125.13
Rate for Payer: AlohaCare Medicaid	$17.27
Rate for Payer: AlohaCare Medicare	$17.27
Rate for Payer: Cash Price	$83.85
Rate for Payer: Cash Price	$83.85
Rate for Payer: Devoted Health Medicare	$19.00
Rate for Payer: Hawaii Medical Service Association ABD	$17.89
Rate for Payer: Hawaii Medical Service Association Commercial	$21.59
Rate for Payer: Hawaii Medical Service Association Medicare	$17.27
Rate for Payer: Hawaii Medical Service Association Non-ABD	$18.78
Rate for Payer: Hawaii Western Management Group Commercial	$17.27
Rate for Payer: Health Management Network Commercial	$109.65
Rate for Payer: Humana Medicare	$17.27
Rate for Payer: Kaiser Permanente Commercial	$81.27
Rate for Payer: Kaiser Permanente Medicaid	$65.79
Rate for Payer: Kaiser Permanente Medicare	$17.27
Rate for Payer: MDX Hawaii PPO	$125.13
Rate for Payer: Ohana Health Plan Medicaid	$19.00
Rate for Payer: Ohana Health Plan Medicare	$17.27
Rate for Payer: UnitedHealthcare Medicaid	$10.36
Rate for Payer: UnitedHealthcare Medicare	$17.27
Rate for Payer: University Health Alliance Commercial	$94.03

HCHG PROTEIN ELP SERUM

Facility

$132.00

Service Code	HCPCS 84165
Hospital Charge Code	H3011102
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 PROTEIN ELP SERUM

Facility

$132.00

Service Code	HCPCS 84165
Hospital Charge Code	H3011102
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 PROTEIN ELP URINE

Facility

$219.00

Service Code	HCPCS 84166
Hospital Charge Code	H3011104
Hospital Revenue Code	301
Min. Negotiated Rate	$17.83
Max. Negotiated Rate	$212.43
Rate for Payer: AlohaCare Medicaid	$17.83
Rate for Payer: AlohaCare Medicare	$17.83
Rate for Payer: Cash Price	$142.35
Rate for Payer: Cash Price	$142.35
Rate for Payer: Devoted Health Medicare	$19.61
Rate for Payer: Hawaii Medical Service Association ABD	$24.92
Rate for Payer: Hawaii Medical Service Association Commercial	$22.29
Rate for Payer: Hawaii Medical Service Association Medicare	$17.83
Rate for Payer: Hawaii Medical Service Association Non-ABD	$26.17
Rate for Payer: Hawaii Western Management Group Commercial	$17.83
Rate for Payer: Health Management Network Commercial	$186.15
Rate for Payer: Humana Medicare	$17.83
Rate for Payer: Kaiser Permanente Commercial	$137.97
Rate for Payer: Kaiser Permanente Medicaid	$111.69
Rate for Payer: Kaiser Permanente Medicare	$17.83
Rate for Payer: MDX Hawaii PPO	$212.43
Rate for Payer: Ohana Health Plan Medicaid	$19.61
Rate for Payer: Ohana Health Plan Medicare	$17.83
Rate for Payer: UnitedHealthcare Medicaid	$24.92
Rate for Payer: UnitedHealthcare Medicare	$17.83
Rate for Payer: University Health Alliance Commercial	$46.10

HCHG PROTEIN ELP URINE

Facility

$219.00

Service Code	HCPCS 84166
Hospital Charge Code	H3011104
Hospital Revenue Code	301
Min. Negotiated Rate	$186.15
Max. Negotiated Rate	$212.43
Rate for Payer: Cash Price	$142.35
Rate for Payer: Health Management Network Commercial	$186.15
Rate for Payer: MDX Hawaii PPO	$212.43

HCHG PROTEIN S ACTIVITY

Facility

$189.00

Service Code	HCPCS 85306
Hospital Charge Code	H3050216
Hospital Revenue Code	305
Min. Negotiated Rate	$160.65
Max. Negotiated Rate	$183.33
Rate for Payer: Cash Price	$122.85
Rate for Payer: Health Management Network Commercial	$160.65
Rate for Payer: MDX Hawaii PPO	$183.33

HCHG PROTEIN S ACTIVITY

Facility

$189.00

Service Code	HCPCS 85306
Hospital Charge Code	H3050216
Hospital Revenue Code	305
Min. Negotiated Rate	$15.32
Max. Negotiated Rate	$183.33
Rate for Payer: AlohaCare Medicaid	$15.32
Rate for Payer: AlohaCare Medicare	$15.32
Rate for Payer: Cash Price	$122.85
Rate for Payer: Cash Price	$122.85
Rate for Payer: Devoted Health Medicare	$16.85
Rate for Payer: Hawaii Medical Service Association ABD	$21.18
Rate for Payer: Hawaii Medical Service Association Commercial	$19.15
Rate for Payer: Hawaii Medical Service Association Medicare	$15.32
Rate for Payer: Hawaii Medical Service Association Non-ABD	$22.24
Rate for Payer: Hawaii Western Management Group Commercial	$15.32
Rate for Payer: Health Management Network Commercial	$160.65
Rate for Payer: Humana Medicare	$15.32
Rate for Payer: Kaiser Permanente Commercial	$119.07
Rate for Payer: Kaiser Permanente Medicaid	$96.39
Rate for Payer: Kaiser Permanente Medicare	$15.32
Rate for Payer: MDX Hawaii PPO	$183.33
Rate for Payer: Ohana Health Plan Medicaid	$16.85
Rate for Payer: Ohana Health Plan Medicare	$15.32
Rate for Payer: UnitedHealthcare Medicaid	$21.18
Rate for Payer: UnitedHealthcare Medicare	$15.32
Rate for Payer: University Health Alliance Commercial	$39.61

HCHG PROTEIN S TOTAL

Facility

$144.00

Service Code	HCPCS 85305
Hospital Charge Code	H3050214
Hospital Revenue Code	305
Min. Negotiated Rate	$122.40
Max. Negotiated Rate	$139.68
Rate for Payer: Cash Price	$93.60
Rate for Payer: Health Management Network Commercial	$122.40
Rate for Payer: MDX Hawaii PPO	$139.68

HCHG PROTEIN S TOTAL

Facility

$144.00

Service Code	HCPCS 85305
Hospital Charge Code	H3050214
Hospital Revenue Code	305
Min. Negotiated Rate	$11.61
Max. Negotiated Rate	$139.68
Rate for Payer: AlohaCare Medicaid	$11.61
Rate for Payer: AlohaCare Medicare	$11.61
Rate for Payer: Cash Price	$93.60
Rate for Payer: Cash Price	$93.60
Rate for Payer: Devoted Health Medicare	$12.77
Rate for Payer: Hawaii Medical Service Association ABD	$16.02
Rate for Payer: Hawaii Medical Service Association Commercial	$14.51
Rate for Payer: Hawaii Medical Service Association Medicare	$11.61
Rate for Payer: Hawaii Medical Service Association Non-ABD	$16.82
Rate for Payer: Hawaii Western Management Group Commercial	$11.61
Rate for Payer: Health Management Network Commercial	$122.40
Rate for Payer: Humana Medicare	$11.61
Rate for Payer: Kaiser Permanente Commercial	$90.72
Rate for Payer: Kaiser Permanente Medicaid	$73.44
Rate for Payer: Kaiser Permanente Medicare	$11.61
Rate for Payer: MDX Hawaii PPO	$139.68
Rate for Payer: Ohana Health Plan Medicaid	$12.77
Rate for Payer: Ohana Health Plan Medicare	$11.61
Rate for Payer: UnitedHealthcare Medicaid	$16.02
Rate for Payer: UnitedHealthcare Medicare	$11.61
Rate for Payer: University Health Alliance Commercial	$29.97

HCHG PROTEIN TOT

Facility

$57.00

Service Code	HCPCS 84155
Hospital Charge Code	H3011106
Hospital Revenue Code	301
Min. Negotiated Rate	$3.67
Max. Negotiated Rate	$55.29
Rate for Payer: AlohaCare Medicaid	$3.67
Rate for Payer: AlohaCare Medicare	$3.67
Rate for Payer: Cash Price	$37.05
Rate for Payer: Cash Price	$37.05
Rate for Payer: Devoted Health Medicare	$4.04
Rate for Payer: Hawaii Medical Service Association ABD	$5.06
Rate for Payer: Hawaii Medical Service Association Commercial	$4.59
Rate for Payer: Hawaii Medical Service Association Medicare	$3.67
Rate for Payer: Hawaii Medical Service Association Non-ABD	$5.31
Rate for Payer: Hawaii Western Management Group Commercial	$3.67
Rate for Payer: Health Management Network Commercial	$48.45
Rate for Payer: Humana Medicare	$3.67
Rate for Payer: Kaiser Permanente Commercial	$35.91
Rate for Payer: Kaiser Permanente Medicaid	$29.07
Rate for Payer: Kaiser Permanente Medicare	$3.67
Rate for Payer: MDX Hawaii PPO	$55.29
Rate for Payer: Ohana Health Plan Medicaid	$4.04
Rate for Payer: Ohana Health Plan Medicare	$3.67
Rate for Payer: UnitedHealthcare Medicaid	$5.06
Rate for Payer: UnitedHealthcare Medicare	$3.67
Rate for Payer: University Health Alliance Commercial	$9.47

HCHG PROTEIN TOT

Facility

$57.00

Service Code	HCPCS 84155
Hospital Charge Code	H3011106
Hospital Revenue Code	301
Min. Negotiated Rate	$48.45
Max. Negotiated Rate	$55.29
Rate for Payer: Cash Price	$37.05
Rate for Payer: Health Management Network Commercial	$48.45
Rate for Payer: MDX Hawaii PPO	$55.29

HCHG PROTEIN TOT BODY FLUID

Facility

$63.00

Service Code	HCPCS 84157
Hospital Charge Code	H3011108
Hospital Revenue Code	301
Min. Negotiated Rate	$3.69
Max. Negotiated Rate	$61.11
Rate for Payer: AlohaCare Medicaid	$4.00
Rate for Payer: AlohaCare Medicare	$4.00
Rate for Payer: Cash Price	$40.95
Rate for Payer: Cash Price	$40.95
Rate for Payer: Devoted Health Medicare	$4.40
Rate for Payer: Hawaii Medical Service Association ABD	$3.69
Rate for Payer: Hawaii Medical Service Association Commercial	$5.00
Rate for Payer: Hawaii Medical Service Association Medicare	$4.00
Rate for Payer: Hawaii Medical Service Association Non-ABD	$5.06
Rate for Payer: Hawaii Western Management Group Commercial	$4.00
Rate for Payer: Health Management Network Commercial	$53.55
Rate for Payer: Humana Medicare	$4.00
Rate for Payer: Kaiser Permanente Commercial	$39.69
Rate for Payer: Kaiser Permanente Medicaid	$32.13
Rate for Payer: Kaiser Permanente Medicare	$4.00
Rate for Payer: MDX Hawaii PPO	$61.11
Rate for Payer: Ohana Health Plan Medicaid	$4.40
Rate for Payer: Ohana Health Plan Medicare	$4.00
Rate for Payer: UnitedHealthcare Medicaid	$3.69
Rate for Payer: UnitedHealthcare Medicare	$4.00
Rate for Payer: University Health Alliance Commercial	$9.47

HCHG PROTEIN TOT BODY FLUID

Facility

$63.00

Service Code	HCPCS 84157
Hospital Charge Code	H3011108
Hospital Revenue Code	301
Min. Negotiated Rate	$53.55
Max. Negotiated Rate	$61.11
Rate for Payer: Cash Price	$40.95
Rate for Payer: Health Management Network Commercial	$53.55
Rate for Payer: MDX Hawaii PPO	$61.11

HCHG PROTHROMBIN TIME

Facility

$55.00

Service Code	HCPCS 85610
Hospital Charge Code	H3050218
Hospital Revenue Code	305
Min. Negotiated Rate	$4.29
Max. Negotiated Rate	$53.35
Rate for Payer: AlohaCare Medicaid	$4.29
Rate for Payer: AlohaCare Medicare	$4.29
Rate for Payer: Cash Price	$35.75
Rate for Payer: Cash Price	$35.75
Rate for Payer: Devoted Health Medicare	$4.72
Rate for Payer: Hawaii Medical Service Association ABD	$5.43
Rate for Payer: Hawaii Medical Service Association Commercial	$5.36
Rate for Payer: Hawaii Medical Service Association Medicare	$4.29
Rate for Payer: Hawaii Medical Service Association Non-ABD	$5.70
Rate for Payer: Hawaii Western Management Group Commercial	$4.29
Rate for Payer: Health Management Network Commercial	$46.75
Rate for Payer: Humana Medicare	$4.29
Rate for Payer: Kaiser Permanente Commercial	$34.65
Rate for Payer: Kaiser Permanente Medicaid	$28.05
Rate for Payer: Kaiser Permanente Medicare	$4.29
Rate for Payer: MDX Hawaii PPO	$53.35
Rate for Payer: Ohana Health Plan Medicaid	$4.72
Rate for Payer: Ohana Health Plan Medicare	$4.29
Rate for Payer: UnitedHealthcare Medicaid	$5.43
Rate for Payer: UnitedHealthcare Medicare	$4.29
Rate for Payer: University Health Alliance Commercial	$10.16

HCHG PROTHROMBIN TIME

Facility

$55.00

Service Code	HCPCS 85610
Hospital Charge Code	H3050218
Hospital Revenue Code	305
Min. Negotiated Rate	$46.75
Max. Negotiated Rate	$53.35
Rate for Payer: Cash Price	$35.75
Rate for Payer: Health Management Network Commercial	$46.75
Rate for Payer: MDX Hawaii PPO	$53.35

HCHG PSA TOTAL CA MCR SCREEN

Facility

$135.00

Service Code	HCPCS G0103
Hospital Charge Code	K3010051
Hospital Revenue Code	301
Min. Negotiated Rate	$114.75
Max. Negotiated Rate	$130.95
Rate for Payer: Cash Price	$87.75
Rate for Payer: Health Management Network Commercial	$114.75
Rate for Payer: MDX Hawaii PPO	$130.95

HCHG PSA TOTAL CA MCR SCREEN

Facility

$135.00

Service Code	HCPCS G0103
Hospital Charge Code	K3010051
Hospital Revenue Code	301
Min. Negotiated Rate	$19.31
Max. Negotiated Rate	$130.95
Rate for Payer: AlohaCare Medicaid	$19.31
Rate for Payer: AlohaCare Medicare	$19.31
Rate for Payer: Cash Price	$87.75
Rate for Payer: Cash Price	$87.75
Rate for Payer: Devoted Health Medicare	$21.24
Rate for Payer: Hawaii Medical Service Association Commercial	$24.14
Rate for Payer: Hawaii Medical Service Association Medicare	$19.31
Rate for Payer: Hawaii Western Management Group Commercial	$128.25
Rate for Payer: Health Management Network Commercial	$114.75
Rate for Payer: Humana Medicare	$19.31
Rate for Payer: Kaiser Permanente Commercial	$85.05
Rate for Payer: Kaiser Permanente Medicaid	$68.85
Rate for Payer: Kaiser Permanente Medicare	$19.31
Rate for Payer: MDX Hawaii PPO	$130.95
Rate for Payer: Ohana Health Plan Medicaid	$21.24
Rate for Payer: Ohana Health Plan Medicare	$19.31
Rate for Payer: UnitedHealthcare Medicaid	$25.42
Rate for Payer: UnitedHealthcare Medicare	$19.31
Rate for Payer: University Health Alliance Commercial	$98.40

HCHG PSC/BONE MARROW HARVEST WBC

Facility

$32.00

Service Code	HCPCS 85048
Hospital Charge Code	H3050226
Hospital Revenue Code	305
Min. Negotiated Rate	$2.54
Max. Negotiated Rate	$31.04
Rate for Payer: AlohaCare Medicaid	$2.54
Rate for Payer: AlohaCare Medicare	$2.54
Rate for Payer: Cash Price	$20.80
Rate for Payer: Cash Price	$20.80
Rate for Payer: Devoted Health Medicare	$2.79
Rate for Payer: Hawaii Medical Service Association ABD	$3.52
Rate for Payer: Hawaii Medical Service Association Commercial	$3.17
Rate for Payer: Hawaii Medical Service Association Medicare	$2.54
Rate for Payer: Hawaii Medical Service Association Non-ABD	$3.70
Rate for Payer: Hawaii Western Management Group Commercial	$2.54
Rate for Payer: Health Management Network Commercial	$27.20
Rate for Payer: Humana Medicare	$2.54
Rate for Payer: Kaiser Permanente Commercial	$20.16
Rate for Payer: Kaiser Permanente Medicaid	$16.32
Rate for Payer: Kaiser Permanente Medicare	$2.54
Rate for Payer: MDX Hawaii PPO	$31.04
Rate for Payer: Ohana Health Plan Medicaid	$2.79
Rate for Payer: Ohana Health Plan Medicare	$2.54
Rate for Payer: UnitedHealthcare Medicaid	$3.52
Rate for Payer: UnitedHealthcare Medicare	$2.54
Rate for Payer: University Health Alliance Commercial	$6.57

HCHG PSC/BONE MARROW HARVEST WBC

Facility

$32.00

Service Code	HCPCS 85048
Hospital Charge Code	H3050226
Hospital Revenue Code	305
Min. Negotiated Rate	$27.20
Max. Negotiated Rate	$31.04
Rate for Payer: Cash Price	$20.80
Rate for Payer: Health Management Network Commercial	$27.20
Rate for Payer: MDX Hawaii PPO	$31.04

HCHG PT ADAPT ORTHO FABRICA 15 MIN

Facility

$250.00

Service Code	HCPCS 97760
Hospital Charge Code	H4200450
Hospital Revenue Code	420
Min. Negotiated Rate	$17.21
Max. Negotiated Rate	$242.50
Rate for Payer: Cash Price	$162.50
Rate for Payer: Cash Price	$162.50
Rate for Payer: Hawaii Western Management Group Commercial	$237.50
Rate for Payer: Health Management Network Commercial	$212.50
Rate for Payer: Kaiser Permanente Commercial	$157.50
Rate for Payer: Kaiser Permanente Medicaid	$127.50
Rate for Payer: MDX Hawaii PPO	$242.50
Rate for Payer: UnitedHealthcare Medicaid	$17.21
Rate for Payer: University Health Alliance Commercial	$182.22

HCHG PT ADAPT ORTHO FABRICA 15 MIN

Facility

$250.00

Service Code	HCPCS 97760
Hospital Charge Code	H4200450
Hospital Revenue Code	420
Min. Negotiated Rate	$212.50
Max. Negotiated Rate	$242.50
Rate for Payer: Cash Price	$162.50
Rate for Payer: Health Management Network Commercial	$212.50
Rate for Payer: MDX Hawaii PPO	$242.50

HCHG PT AQUATIC THRPY 15M

Facility

$289.00

Service Code	HCPCS 97113
Hospital Charge Code	H4200455
Hospital Revenue Code	420
Min. Negotiated Rate	$245.65
Max. Negotiated Rate	$280.33
Rate for Payer: Cash Price	$187.85
Rate for Payer: Health Management Network Commercial	$245.65
Rate for Payer: MDX Hawaii PPO	$280.33

HCHG PT AQUATIC THRPY 15M

Facility

$289.00

Service Code	HCPCS 97113
Hospital Charge Code	H4200455
Hospital Revenue Code	420
Min. Negotiated Rate	$20.09
Max. Negotiated Rate	$280.33
Rate for Payer: Cash Price	$187.85
Rate for Payer: Cash Price	$187.85
Rate for Payer: Hawaii Western Management Group Commercial	$274.55
Rate for Payer: Health Management Network Commercial	$245.65
Rate for Payer: Kaiser Permanente Commercial	$182.07
Rate for Payer: Kaiser Permanente Medicaid	$147.39
Rate for Payer: MDX Hawaii PPO	$280.33
Rate for Payer: UnitedHealthcare Medicaid	$20.09
Rate for Payer: University Health Alliance Commercial	$210.65

HCHG PT CANALITH REPOSITIONING PROCEDURE

Facility

$208.00

Service Code	HCPCS 95992
Hospital Charge Code	H4200454
Hospital Revenue Code	420
Min. Negotiated Rate	$176.80
Max. Negotiated Rate	$201.76
Rate for Payer: Cash Price	$135.20
Rate for Payer: Health Management Network Commercial	$176.80
Rate for Payer: MDX Hawaii PPO	$201.76

Know your out-of-pocket cost for care.

All Charges