Kona Community Hospital

All Charges

Charge

Type

Setting

Price

HCHG SODIUM SERUM/PLASMA/WHOLE BLOOD

Facility

$65.00

Service Code	HCPCS 84295
Hospital Charge Code	H3011158
Hospital Revenue Code	301
Min. Negotiated Rate	$55.25
Max. Negotiated Rate	$63.05
Rate for Payer: Cash Price	$42.25
Rate for Payer: Health Management Network Commercial	$55.25
Rate for Payer: MDX Hawaii PPO	$63.05

HCHG SODIUM-URINE

Facility

$66.00

Service Code	HCPCS 84300
Hospital Charge Code	H3011168
Hospital Revenue Code	301
Min. Negotiated Rate	$5.06
Max. Negotiated Rate	$64.02
Rate for Payer: AlohaCare Medicaid	$5.06
Rate for Payer: AlohaCare Medicare	$5.06
Rate for Payer: Cash Price	$42.90
Rate for Payer: Cash Price	$42.90
Rate for Payer: Devoted Health Medicare	$5.57
Rate for Payer: Hawaii Medical Service Association ABD	$6.72
Rate for Payer: Hawaii Medical Service Association Commercial	$6.33
Rate for Payer: Hawaii Medical Service Association Medicare	$5.06
Rate for Payer: Hawaii Medical Service Association Non-ABD	$7.06
Rate for Payer: Hawaii Western Management Group Commercial	$5.06
Rate for Payer: Health Management Network Commercial	$56.10
Rate for Payer: Humana Medicare	$5.06
Rate for Payer: Kaiser Permanente Commercial	$41.58
Rate for Payer: Kaiser Permanente Medicaid	$33.66
Rate for Payer: Kaiser Permanente Medicare	$5.06
Rate for Payer: MDX Hawaii PPO	$64.02
Rate for Payer: Ohana Health Plan Medicaid	$5.57
Rate for Payer: Ohana Health Plan Medicare	$5.06
Rate for Payer: UnitedHealthcare Medicaid	$6.72
Rate for Payer: UnitedHealthcare Medicare	$5.06
Rate for Payer: University Health Alliance Commercial	$12.56

HCHG SODIUM-URINE

Facility

$66.00

Service Code	HCPCS 84300
Hospital Charge Code	H3011168
Hospital Revenue Code	301
Min. Negotiated Rate	$56.10
Max. Negotiated Rate	$64.02
Rate for Payer: Cash Price	$42.90
Rate for Payer: Health Management Network Commercial	$56.10
Rate for Payer: MDX Hawaii PPO	$64.02

HCHG SOLUBLE LIVER AG IGG

Facility

$160.00

Service Code	HCPCS 83520
Hospital Charge Code	H3011170
Hospital Revenue Code	301
Min. Negotiated Rate	$17.27
Max. Negotiated Rate	$155.20
Rate for Payer: AlohaCare Medicaid	$17.27
Rate for Payer: AlohaCare Medicare	$17.27
Rate for Payer: Cash Price	$104.00
Rate for Payer: Cash Price	$104.00
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	$136.00
Rate for Payer: Humana Medicare	$17.27
Rate for Payer: Kaiser Permanente Commercial	$100.80
Rate for Payer: Kaiser Permanente Medicaid	$81.60
Rate for Payer: Kaiser Permanente Medicare	$17.27
Rate for Payer: MDX Hawaii PPO	$155.20
Rate for Payer: Ohana Health Plan Medicaid	$19.00
Rate for Payer: Ohana Health Plan Medicare	$17.27
Rate for Payer: UnitedHealthcare Medicaid	$17.89
Rate for Payer: UnitedHealthcare Medicare	$17.27
Rate for Payer: University Health Alliance Commercial	$33.47

HCHG SOLUBLE LIVER AG IGG

Facility

$160.00

Service Code	HCPCS 83520
Hospital Charge Code	H3011170
Hospital Revenue Code	301
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 SP CLINICAL SWALLOW EVAL

Facility

$630.00

Service Code	HCPCS 92610
Hospital Charge Code	H4440102
Hospital Revenue Code	444
Min. Negotiated Rate	$535.50
Max. Negotiated Rate	$611.10
Rate for Payer: Cash Price	$409.50
Rate for Payer: Health Management Network Commercial	$535.50
Rate for Payer: MDX Hawaii PPO	$611.10

HCHG SP CLINICAL SWALLOW EVAL

Facility

$630.00

Service Code	HCPCS 92610
Hospital Charge Code	H4440102
Hospital Revenue Code	444
Min. Negotiated Rate	$88.36
Max. Negotiated Rate	$611.10
Rate for Payer: Cash Price	$409.50
Rate for Payer: Cash Price	$409.50
Rate for Payer: Hawaii Western Management Group Commercial	$598.50
Rate for Payer: Health Management Network Commercial	$535.50
Rate for Payer: Kaiser Permanente Commercial	$396.90
Rate for Payer: Kaiser Permanente Medicaid	$321.30
Rate for Payer: MDX Hawaii PPO	$611.10
Rate for Payer: UnitedHealthcare Medicaid	$88.36
Rate for Payer: University Health Alliance Commercial	$459.21

HCHG SPCL STN GROUP I

Facility

$269.00

Service Code	HCPCS 88312
Hospital Charge Code	H3120308
Hospital Revenue Code	312
Min. Negotiated Rate	$228.65
Max. Negotiated Rate	$260.93
Rate for Payer: Cash Price	$174.85
Rate for Payer: Health Management Network Commercial	$228.65
Rate for Payer: MDX Hawaii PPO	$260.93

HCHG SPCL STN GROUP I

Facility

$269.00

Service Code	HCPCS 88312
Hospital Charge Code	H3120308
Hospital Revenue Code	312
Min. Negotiated Rate	$32.77
Max. Negotiated Rate	$260.93
Rate for Payer: AlohaCare Medicaid	$61.56
Rate for Payer: AlohaCare Medicare	$61.56
Rate for Payer: Cash Price	$174.85
Rate for Payer: Cash Price	$174.85
Rate for Payer: Devoted Health Medicare	$67.72
Rate for Payer: Hawaii Medical Service Association ABD	$32.77
Rate for Payer: Hawaii Medical Service Association Commercial	$76.95
Rate for Payer: Hawaii Medical Service Association Medicare	$61.56
Rate for Payer: Hawaii Medical Service Association Non-ABD	$41.86
Rate for Payer: Hawaii Western Management Group Commercial	$61.56
Rate for Payer: Health Management Network Commercial	$228.65
Rate for Payer: Humana Medicare	$61.56
Rate for Payer: Kaiser Permanente Commercial	$169.47
Rate for Payer: Kaiser Permanente Medicaid	$137.19
Rate for Payer: Kaiser Permanente Medicare	$61.56
Rate for Payer: MDX Hawaii PPO	$260.93
Rate for Payer: Ohana Health Plan Medicaid	$67.72
Rate for Payer: Ohana Health Plan Medicare	$61.56
Rate for Payer: UnitedHealthcare Medicaid	$32.77
Rate for Payer: UnitedHealthcare Medicare	$61.56
Rate for Payer: University Health Alliance Commercial	$187.61

HCHG SPCL STN GROUP II ALL OTHER

Facility

$513.00

Service Code	HCPCS 88313
Hospital Charge Code	H3120309
Hospital Revenue Code	312
Min. Negotiated Rate	$37.18
Max. Negotiated Rate	$497.61
Rate for Payer: AlohaCare Medicaid	$157.18
Rate for Payer: AlohaCare Medicare	$157.18
Rate for Payer: Cash Price	$333.45
Rate for Payer: Cash Price	$333.45
Rate for Payer: Devoted Health Medicare	$172.90
Rate for Payer: Hawaii Medical Service Association ABD	$37.43
Rate for Payer: Hawaii Medical Service Association Commercial	$196.47
Rate for Payer: Hawaii Medical Service Association Medicare	$157.18
Rate for Payer: Hawaii Medical Service Association Non-ABD	$37.18
Rate for Payer: Hawaii Western Management Group Commercial	$157.18
Rate for Payer: Health Management Network Commercial	$436.05
Rate for Payer: Humana Medicare	$157.18
Rate for Payer: Kaiser Permanente Commercial	$323.19
Rate for Payer: Kaiser Permanente Medicaid	$261.63
Rate for Payer: Kaiser Permanente Medicare	$157.18
Rate for Payer: MDX Hawaii PPO	$497.61
Rate for Payer: Ohana Health Plan Medicaid	$172.90
Rate for Payer: Ohana Health Plan Medicare	$157.18
Rate for Payer: UnitedHealthcare Medicaid	$37.43
Rate for Payer: UnitedHealthcare Medicare	$157.18
Rate for Payer: University Health Alliance Commercial	$144.02

HCHG SPCL STN GROUP II ALL OTHER

Facility

$513.00

Service Code	HCPCS 88313
Hospital Charge Code	H3120309
Hospital Revenue Code	312
Min. Negotiated Rate	$436.05
Max. Negotiated Rate	$497.61
Rate for Payer: Cash Price	$333.45
Rate for Payer: Health Management Network Commercial	$436.05
Rate for Payer: MDX Hawaii PPO	$497.61

HCHG SPCL STN GRP II ALLOTHER QMC90

Facility

$513.00

Service Code	HCPCS 88313
Hospital Charge Code	H3120224
Hospital Revenue Code	312
Min. Negotiated Rate	$436.05
Max. Negotiated Rate	$497.61
Rate for Payer: Cash Price	$333.45
Rate for Payer: Health Management Network Commercial	$436.05
Rate for Payer: MDX Hawaii PPO	$497.61

HCHG SPCL STN GRP II ALLOTHER QMC90

Facility

$513.00

Service Code	HCPCS 88313
Hospital Charge Code	H3120224
Hospital Revenue Code	312
Min. Negotiated Rate	$37.18
Max. Negotiated Rate	$497.61
Rate for Payer: AlohaCare Medicaid	$157.18
Rate for Payer: AlohaCare Medicare	$157.18
Rate for Payer: Cash Price	$333.45
Rate for Payer: Cash Price	$333.45
Rate for Payer: Devoted Health Medicare	$172.90
Rate for Payer: Hawaii Medical Service Association ABD	$37.43
Rate for Payer: Hawaii Medical Service Association Commercial	$196.47
Rate for Payer: Hawaii Medical Service Association Medicare	$157.18
Rate for Payer: Hawaii Medical Service Association Non-ABD	$37.18
Rate for Payer: Hawaii Western Management Group Commercial	$157.18
Rate for Payer: Health Management Network Commercial	$436.05
Rate for Payer: Humana Medicare	$157.18
Rate for Payer: Kaiser Permanente Commercial	$323.19
Rate for Payer: Kaiser Permanente Medicaid	$261.63
Rate for Payer: Kaiser Permanente Medicare	$157.18
Rate for Payer: MDX Hawaii PPO	$497.61
Rate for Payer: Ohana Health Plan Medicaid	$172.90
Rate for Payer: Ohana Health Plan Medicare	$157.18
Rate for Payer: UnitedHealthcare Medicaid	$37.43
Rate for Payer: UnitedHealthcare Medicare	$157.18
Rate for Payer: University Health Alliance Commercial	$144.02

HCHG SPCL STN STOOL

Facility

$305.00

Service Code	HCPCS 87209
Hospital Charge Code	H3120276
Hospital Revenue Code	306
Min. Negotiated Rate	$17.57
Max. Negotiated Rate	$295.85
Rate for Payer: AlohaCare Medicaid	$17.98
Rate for Payer: AlohaCare Medicare	$17.98
Rate for Payer: Cash Price	$198.25
Rate for Payer: Cash Price	$198.25
Rate for Payer: Devoted Health Medicare	$19.78
Rate for Payer: Hawaii Medical Service Association ABD	$17.57
Rate for Payer: Hawaii Medical Service Association Commercial	$22.48
Rate for Payer: Hawaii Medical Service Association Medicare	$17.98
Rate for Payer: Hawaii Medical Service Association Non-ABD	$24.82
Rate for Payer: Hawaii Western Management Group Commercial	$17.98
Rate for Payer: Health Management Network Commercial	$259.25
Rate for Payer: Humana Medicare	$17.98
Rate for Payer: Kaiser Permanente Commercial	$192.15
Rate for Payer: Kaiser Permanente Medicaid	$155.55
Rate for Payer: Kaiser Permanente Medicare	$17.98
Rate for Payer: MDX Hawaii PPO	$295.85
Rate for Payer: Ohana Health Plan Medicaid	$19.78
Rate for Payer: Ohana Health Plan Medicare	$17.98
Rate for Payer: UnitedHealthcare Medicaid	$17.57
Rate for Payer: UnitedHealthcare Medicare	$17.98
Rate for Payer: University Health Alliance Commercial	$46.45

HCHG SPCL STN STOOL

Facility

$305.00

Service Code	HCPCS 87209
Hospital Charge Code	H3120276
Hospital Revenue Code	306
Min. Negotiated Rate	$259.25
Max. Negotiated Rate	$295.85
Rate for Payer: Cash Price	$198.25
Rate for Payer: Health Management Network Commercial	$259.25
Rate for Payer: MDX Hawaii PPO	$295.85

HCHG SP COGNITIVE EACH ADDITIONAL 15 MINUTES

Facility

$149.00

Service Code	HCPCS 97130
Hospital Charge Code	H4400360
Hospital Revenue Code	440
Min. Negotiated Rate	$21.52
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	$21.52
Rate for Payer: University Health Alliance Commercial	$108.61

HCHG SP COGNITIVE EACH ADDITIONAL 15 MINUTES

Facility

$149.00

Service Code	HCPCS 97130
Hospital Charge Code	H4400360
Hospital Revenue Code	440
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 SP COGNITIVE PERF TESTING PER HR

Facility

$576.00

Service Code	HCPCS 96125
Hospital Charge Code	H4400164
Hospital Revenue Code	440
Min. Negotiated Rate	$489.60
Max. Negotiated Rate	$558.72
Rate for Payer: Cash Price	$374.40
Rate for Payer: Health Management Network Commercial	$489.60
Rate for Payer: MDX Hawaii PPO	$558.72

HCHG SP COGNITIVE PERF TESTING PER HR

Facility

$576.00

Service Code	HCPCS 96125
Hospital Charge Code	H4400164
Hospital Revenue Code	440
Min. Negotiated Rate	$41.65
Max. Negotiated Rate	$558.72
Rate for Payer: Cash Price	$374.40
Rate for Payer: Cash Price	$374.40
Rate for Payer: Hawaii Western Management Group Commercial	$547.20
Rate for Payer: Health Management Network Commercial	$489.60
Rate for Payer: Kaiser Permanente Commercial	$362.88
Rate for Payer: Kaiser Permanente Medicaid	$293.76
Rate for Payer: MDX Hawaii PPO	$558.72
Rate for Payer: UnitedHealthcare Medicaid	$41.65
Rate for Payer: University Health Alliance Commercial	$419.85

HCHG SPECIAL DOSIMETRY

Facility

$858.00

Service Code	HCPCS 77331
Hospital Charge Code	H3330176
Hospital Revenue Code	333
Min. Negotiated Rate	$729.30
Max. Negotiated Rate	$832.26
Rate for Payer: Cash Price	$557.70
Rate for Payer: Health Management Network Commercial	$729.30
Rate for Payer: MDX Hawaii PPO	$832.26

HCHG SPECIAL DOSIMETRY

Facility

$858.00

Service Code	HCPCS 77331
Hospital Charge Code	H3330176
Hospital Revenue Code	333
Min. Negotiated Rate	$18.05
Max. Negotiated Rate	$832.26
Rate for Payer: AlohaCare Medicaid	$158.78
Rate for Payer: AlohaCare Medicare	$158.78
Rate for Payer: Cash Price	$557.70
Rate for Payer: Cash Price	$557.70
Rate for Payer: Devoted Health Medicare	$174.66
Rate for Payer: Hawaii Medical Service Association ABD	$18.05
Rate for Payer: Hawaii Medical Service Association Commercial	$198.47
Rate for Payer: Hawaii Medical Service Association Medicare	$158.78
Rate for Payer: Hawaii Medical Service Association Non-ABD	$18.95
Rate for Payer: Hawaii Western Management Group Commercial	$158.78
Rate for Payer: Health Management Network Commercial	$729.30
Rate for Payer: Humana Medicare	$158.78
Rate for Payer: Kaiser Permanente Commercial	$540.54
Rate for Payer: Kaiser Permanente Medicaid	$437.58
Rate for Payer: Kaiser Permanente Medicare	$158.78
Rate for Payer: MDX Hawaii PPO	$832.26
Rate for Payer: Ohana Health Plan Medicaid	$174.66
Rate for Payer: Ohana Health Plan Medicare	$158.78
Rate for Payer: UnitedHealthcare Medicaid	$18.05
Rate for Payer: UnitedHealthcare Medicare	$158.78
Rate for Payer: University Health Alliance Commercial	$120.68

HCHG SPECIAL PHYSICS CONSUL

Facility

$910.00

Service Code	HCPCS 77370
Hospital Charge Code	H3330178
Hospital Revenue Code	333
Min. Negotiated Rate	$773.50
Max. Negotiated Rate	$882.70
Rate for Payer: Cash Price	$591.50
Rate for Payer: Health Management Network Commercial	$773.50
Rate for Payer: MDX Hawaii PPO	$882.70

HCHG SPECIAL PHYSICS CONSUL

Facility

$910.00

Service Code	HCPCS 77370
Hospital Charge Code	H3330178
Hospital Revenue Code	333
Min. Negotiated Rate	$123.30
Max. Negotiated Rate	$882.70
Rate for Payer: AlohaCare Medicaid	$158.78
Rate for Payer: AlohaCare Medicare	$158.78
Rate for Payer: Cash Price	$591.50
Rate for Payer: Cash Price	$591.50
Rate for Payer: Devoted Health Medicare	$174.66
Rate for Payer: Hawaii Medical Service Association ABD	$123.30
Rate for Payer: Hawaii Medical Service Association Commercial	$198.47
Rate for Payer: Hawaii Medical Service Association Medicare	$158.78
Rate for Payer: Hawaii Medical Service Association Non-ABD	$129.47
Rate for Payer: Hawaii Western Management Group Commercial	$158.78
Rate for Payer: Health Management Network Commercial	$773.50
Rate for Payer: Humana Medicare	$158.78
Rate for Payer: Kaiser Permanente Commercial	$573.30
Rate for Payer: Kaiser Permanente Medicaid	$464.10
Rate for Payer: Kaiser Permanente Medicare	$158.78
Rate for Payer: MDX Hawaii PPO	$882.70
Rate for Payer: Ohana Health Plan Medicaid	$174.66
Rate for Payer: Ohana Health Plan Medicare	$158.78
Rate for Payer: UnitedHealthcare Medicaid	$123.30
Rate for Payer: UnitedHealthcare Medicare	$158.78
Rate for Payer: University Health Alliance Commercial	$271.17

HCHG SPECIAL STAIN GRP 2

Facility

$298.00

Service Code	HCPCS 88313
Hospital Charge Code	K3100009
Hospital Revenue Code	310
Min. Negotiated Rate	$253.30
Max. Negotiated Rate	$289.06
Rate for Payer: Cash Price	$193.70
Rate for Payer: Health Management Network Commercial	$253.30
Rate for Payer: MDX Hawaii PPO	$289.06

HCHG SPECIAL STAIN GRP 2

Facility

$298.00

Service Code	HCPCS 88313
Hospital Charge Code	K3100009
Hospital Revenue Code	310
Min. Negotiated Rate	$37.18
Max. Negotiated Rate	$289.06
Rate for Payer: AlohaCare Medicaid	$157.18
Rate for Payer: AlohaCare Medicare	$157.18
Rate for Payer: Cash Price	$193.70
Rate for Payer: Cash Price	$193.70
Rate for Payer: Devoted Health Medicare	$172.90
Rate for Payer: Hawaii Medical Service Association ABD	$37.43
Rate for Payer: Hawaii Medical Service Association Commercial	$196.47
Rate for Payer: Hawaii Medical Service Association Medicare	$157.18
Rate for Payer: Hawaii Medical Service Association Non-ABD	$37.18
Rate for Payer: Hawaii Western Management Group Commercial	$157.18
Rate for Payer: Health Management Network Commercial	$253.30
Rate for Payer: Humana Medicare	$157.18
Rate for Payer: Kaiser Permanente Commercial	$187.74
Rate for Payer: Kaiser Permanente Medicaid	$151.98
Rate for Payer: Kaiser Permanente Medicare	$157.18
Rate for Payer: MDX Hawaii PPO	$289.06
Rate for Payer: Ohana Health Plan Medicaid	$172.90
Rate for Payer: Ohana Health Plan Medicare	$157.18
Rate for Payer: UnitedHealthcare Medicaid	$37.43
Rate for Payer: UnitedHealthcare Medicare	$157.18
Rate for Payer: University Health Alliance Commercial	$144.02

Know your out-of-pocket cost for care.

All Charges