Kona Community Hospital

All Charges

Charge

Type

Setting

Price

HCHG VITAMIN B2

Facility

$190.00

Service Code	HCPCS 84252
Hospital Charge Code	H3011284
Hospital Revenue Code	301
Min. Negotiated Rate	$161.50
Max. Negotiated Rate	$184.30
Rate for Payer: Cash Price	$123.50
Rate for Payer: Health Management Network Commercial	$161.50
Rate for Payer: MDX Hawaii PPO	$184.30

HCHG VITAMIN B3 NIACIN

Facility

$202.00

Service Code	HCPCS 84591
Hospital Charge Code	H3011755
Hospital Revenue Code	301
Min. Negotiated Rate	$9.72
Max. Negotiated Rate	$195.94
Rate for Payer: AlohaCare Medicaid	$17.06
Rate for Payer: AlohaCare Medicare	$17.06
Rate for Payer: Cash Price	$131.30
Rate for Payer: Cash Price	$131.30
Rate for Payer: Devoted Health Medicare	$18.77
Rate for Payer: Hawaii Medical Service Association ABD	$9.72
Rate for Payer: Hawaii Medical Service Association Commercial	$21.32
Rate for Payer: Hawaii Medical Service Association Medicare	$17.06
Rate for Payer: Hawaii Medical Service Association Non-ABD	$16.01
Rate for Payer: Hawaii Western Management Group Commercial	$17.06
Rate for Payer: Health Management Network Commercial	$171.70
Rate for Payer: Humana Medicare	$17.06
Rate for Payer: Kaiser Permanente Commercial	$127.26
Rate for Payer: Kaiser Permanente Medicaid	$103.02
Rate for Payer: Kaiser Permanente Medicare	$17.06
Rate for Payer: MDX Hawaii PPO	$195.94
Rate for Payer: Ohana Health Plan Medicaid	$18.77
Rate for Payer: Ohana Health Plan Medicare	$17.06
Rate for Payer: UnitedHealthcare Medicaid	$9.72
Rate for Payer: UnitedHealthcare Medicare	$17.06
Rate for Payer: University Health Alliance Commercial	$29.97

HCHG VITAMIN B3 NIACIN

Facility

$202.00

Service Code	HCPCS 84591
Hospital Charge Code	H3011755
Hospital Revenue Code	301
Min. Negotiated Rate	$171.70
Max. Negotiated Rate	$195.94
Rate for Payer: Cash Price	$131.30
Rate for Payer: Health Management Network Commercial	$171.70
Rate for Payer: MDX Hawaii PPO	$195.94

HCHG VITAMIN B6

Facility

$196.00

Service Code	HCPCS 84207
Hospital Charge Code	H3011286
Hospital Revenue Code	301
Min. Negotiated Rate	$26.36
Max. Negotiated Rate	$190.12
Rate for Payer: AlohaCare Medicaid	$28.10
Rate for Payer: AlohaCare Medicare	$28.10
Rate for Payer: Cash Price	$127.40
Rate for Payer: Cash Price	$127.40
Rate for Payer: Devoted Health Medicare	$30.91
Rate for Payer: Hawaii Medical Service Association ABD	$26.36
Rate for Payer: Hawaii Medical Service Association Commercial	$35.12
Rate for Payer: Hawaii Medical Service Association Medicare	$28.10
Rate for Payer: Hawaii Medical Service Association Non-ABD	$27.68
Rate for Payer: Hawaii Western Management Group Commercial	$28.10
Rate for Payer: Health Management Network Commercial	$166.60
Rate for Payer: Humana Medicare	$28.10
Rate for Payer: Kaiser Permanente Commercial	$123.48
Rate for Payer: Kaiser Permanente Medicaid	$99.96
Rate for Payer: Kaiser Permanente Medicare	$28.10
Rate for Payer: MDX Hawaii PPO	$190.12
Rate for Payer: Ohana Health Plan Medicaid	$30.91
Rate for Payer: Ohana Health Plan Medicare	$28.10
Rate for Payer: UnitedHealthcare Medicaid	$26.36
Rate for Payer: UnitedHealthcare Medicare	$28.10
Rate for Payer: University Health Alliance Commercial	$49.30

HCHG VITAMIN B6

Facility

$196.00

Service Code	HCPCS 84207
Hospital Charge Code	H3011286
Hospital Revenue Code	301
Min. Negotiated Rate	$166.60
Max. Negotiated Rate	$190.12
Rate for Payer: Cash Price	$127.40
Rate for Payer: Health Management Network Commercial	$166.60
Rate for Payer: MDX Hawaii PPO	$190.12

HCHG VITAMIN C 90

Facility

$122.00

Service Code	HCPCS 82180
Hospital Charge Code	H3011288
Hospital Revenue Code	301
Min. Negotiated Rate	$103.70
Max. Negotiated Rate	$118.34
Rate for Payer: Cash Price	$79.30
Rate for Payer: Health Management Network Commercial	$103.70
Rate for Payer: MDX Hawaii PPO	$118.34

HCHG VITAMIN C 90

Facility

$122.00

Service Code	HCPCS 82180
Hospital Charge Code	H3011288
Hospital Revenue Code	301
Min. Negotiated Rate	$9.89
Max. Negotiated Rate	$118.34
Rate for Payer: AlohaCare Medicaid	$9.89
Rate for Payer: AlohaCare Medicare	$9.89
Rate for Payer: Cash Price	$79.30
Rate for Payer: Cash Price	$79.30
Rate for Payer: Devoted Health Medicare	$10.88
Rate for Payer: Hawaii Medical Service Association ABD	$13.66
Rate for Payer: Hawaii Medical Service Association Commercial	$12.36
Rate for Payer: Hawaii Medical Service Association Medicare	$9.89
Rate for Payer: Hawaii Medical Service Association Non-ABD	$14.34
Rate for Payer: Hawaii Western Management Group Commercial	$9.89
Rate for Payer: Health Management Network Commercial	$103.70
Rate for Payer: Humana Medicare	$9.89
Rate for Payer: Kaiser Permanente Commercial	$76.86
Rate for Payer: Kaiser Permanente Medicaid	$62.22
Rate for Payer: Kaiser Permanente Medicare	$9.89
Rate for Payer: MDX Hawaii PPO	$118.34
Rate for Payer: Ohana Health Plan Medicaid	$10.88
Rate for Payer: Ohana Health Plan Medicare	$9.89
Rate for Payer: UnitedHealthcare Medicaid	$13.66
Rate for Payer: UnitedHealthcare Medicare	$9.89
Rate for Payer: University Health Alliance Commercial	$25.55

HCHG VITAMIN D (1 25 DIHYDROXY) 90

Facility

$474.00

Service Code	HCPCS 82652
Hospital Charge Code	H3011290
Hospital Revenue Code	301
Min. Negotiated Rate	$38.50
Max. Negotiated Rate	$459.78
Rate for Payer: AlohaCare Medicaid	$38.50
Rate for Payer: AlohaCare Medicare	$38.50
Rate for Payer: Cash Price	$308.10
Rate for Payer: Cash Price	$308.10
Rate for Payer: Devoted Health Medicare	$42.35
Rate for Payer: Hawaii Medical Service Association ABD	$53.19
Rate for Payer: Hawaii Medical Service Association Commercial	$48.12
Rate for Payer: Hawaii Medical Service Association Medicare	$38.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$55.85
Rate for Payer: Hawaii Western Management Group Commercial	$38.50
Rate for Payer: Health Management Network Commercial	$402.90
Rate for Payer: Humana Medicare	$38.50
Rate for Payer: Kaiser Permanente Commercial	$298.62
Rate for Payer: Kaiser Permanente Medicaid	$241.74
Rate for Payer: Kaiser Permanente Medicare	$38.50
Rate for Payer: MDX Hawaii PPO	$459.78
Rate for Payer: Ohana Health Plan Medicaid	$42.35
Rate for Payer: Ohana Health Plan Medicare	$38.50
Rate for Payer: UnitedHealthcare Medicaid	$53.19
Rate for Payer: UnitedHealthcare Medicare	$38.50
Rate for Payer: University Health Alliance Commercial	$99.49

HCHG VITAMIN D (1 25 DIHYDROXY) 90

Facility

$474.00

Service Code	HCPCS 82652
Hospital Charge Code	H3011290
Hospital Revenue Code	301
Min. Negotiated Rate	$402.90
Max. Negotiated Rate	$459.78
Rate for Payer: Cash Price	$308.10
Rate for Payer: Health Management Network Commercial	$402.90
Rate for Payer: MDX Hawaii PPO	$459.78

HCHG VITAMIN D, 25- HYDROXY (D2 &D3)

Facility

$333.00

Service Code	HCPCS 82306
Hospital Charge Code	H3011292
Hospital Revenue Code	301
Min. Negotiated Rate	$29.60
Max. Negotiated Rate	$323.01
Rate for Payer: AlohaCare Medicaid	$29.60
Rate for Payer: AlohaCare Medicare	$29.60
Rate for Payer: Cash Price	$216.45
Rate for Payer: Cash Price	$216.45
Rate for Payer: Devoted Health Medicare	$32.56
Rate for Payer: Hawaii Medical Service Association ABD	$40.91
Rate for Payer: Hawaii Medical Service Association Commercial	$37.00
Rate for Payer: Hawaii Medical Service Association Medicare	$29.60
Rate for Payer: Hawaii Medical Service Association Non-ABD	$42.96
Rate for Payer: Hawaii Western Management Group Commercial	$29.60
Rate for Payer: Health Management Network Commercial	$283.05
Rate for Payer: Humana Medicare	$29.60
Rate for Payer: Kaiser Permanente Commercial	$209.79
Rate for Payer: Kaiser Permanente Medicaid	$169.83
Rate for Payer: Kaiser Permanente Medicare	$29.60
Rate for Payer: MDX Hawaii PPO	$323.01
Rate for Payer: Ohana Health Plan Medicaid	$32.56
Rate for Payer: Ohana Health Plan Medicare	$29.60
Rate for Payer: UnitedHealthcare Medicaid	$40.91
Rate for Payer: UnitedHealthcare Medicare	$29.60
Rate for Payer: University Health Alliance Commercial	$76.52

HCHG VITAMIN D, 25- HYDROXY (D2 &D3)

Facility

$333.00

Service Code	HCPCS 82306
Hospital Charge Code	H3011292
Hospital Revenue Code	301
Min. Negotiated Rate	$283.05
Max. Negotiated Rate	$323.01
Rate for Payer: Cash Price	$216.45
Rate for Payer: Health Management Network Commercial	$283.05
Rate for Payer: MDX Hawaii PPO	$323.01

HCHG VITAMIN D, 25-HYDROXY, TOTAL

Facility

$333.00

Service Code	HCPCS 82306
Hospital Charge Code	H3011403
Hospital Revenue Code	301
Min. Negotiated Rate	$29.60
Max. Negotiated Rate	$323.01
Rate for Payer: AlohaCare Medicaid	$29.60
Rate for Payer: AlohaCare Medicare	$29.60
Rate for Payer: Cash Price	$216.45
Rate for Payer: Cash Price	$216.45
Rate for Payer: Devoted Health Medicare	$32.56
Rate for Payer: Hawaii Medical Service Association ABD	$40.91
Rate for Payer: Hawaii Medical Service Association Commercial	$37.00
Rate for Payer: Hawaii Medical Service Association Medicare	$29.60
Rate for Payer: Hawaii Medical Service Association Non-ABD	$42.96
Rate for Payer: Hawaii Western Management Group Commercial	$29.60
Rate for Payer: Health Management Network Commercial	$283.05
Rate for Payer: Humana Medicare	$29.60
Rate for Payer: Kaiser Permanente Commercial	$209.79
Rate for Payer: Kaiser Permanente Medicaid	$169.83
Rate for Payer: Kaiser Permanente Medicare	$29.60
Rate for Payer: MDX Hawaii PPO	$323.01
Rate for Payer: Ohana Health Plan Medicaid	$32.56
Rate for Payer: Ohana Health Plan Medicare	$29.60
Rate for Payer: UnitedHealthcare Medicaid	$40.91
Rate for Payer: UnitedHealthcare Medicare	$29.60
Rate for Payer: University Health Alliance Commercial	$76.52

HCHG VITAMIN D, 25-HYDROXY, TOTAL

Facility

$333.00

Service Code	HCPCS 82306
Hospital Charge Code	H3011403
Hospital Revenue Code	301
Min. Negotiated Rate	$283.05
Max. Negotiated Rate	$323.01
Rate for Payer: Cash Price	$216.45
Rate for Payer: Health Management Network Commercial	$283.05
Rate for Payer: MDX Hawaii PPO	$323.01

HCHG VITAMIN K PLASMA

Facility

$179.00

Service Code	HCPCS 84597
Hospital Charge Code	H3000400
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 VITAMIN K PLASMA

Facility

$179.00

Service Code	HCPCS 84597
Hospital Charge Code	H3000400
Hospital Revenue Code	301
Min. Negotiated Rate	$13.72
Max. Negotiated Rate	$173.63
Rate for Payer: AlohaCare Medicaid	$13.72
Rate for Payer: AlohaCare Medicare	$13.72
Rate for Payer: Cash Price	$116.35
Rate for Payer: Cash Price	$116.35
Rate for Payer: Devoted Health Medicare	$15.09
Rate for Payer: Hawaii Medical Service Association ABD	$18.94
Rate for Payer: Hawaii Medical Service Association Commercial	$17.15
Rate for Payer: Hawaii Medical Service Association Medicare	$13.72
Rate for Payer: Hawaii Medical Service Association Non-ABD	$19.89
Rate for Payer: Hawaii Western Management Group Commercial	$13.72
Rate for Payer: Health Management Network Commercial	$152.15
Rate for Payer: Humana Medicare	$13.72
Rate for Payer: Kaiser Permanente Commercial	$112.77
Rate for Payer: Kaiser Permanente Medicaid	$91.29
Rate for Payer: Kaiser Permanente Medicare	$13.72
Rate for Payer: MDX Hawaii PPO	$173.63
Rate for Payer: Ohana Health Plan Medicaid	$15.09
Rate for Payer: Ohana Health Plan Medicare	$13.72
Rate for Payer: UnitedHealthcare Medicaid	$18.94
Rate for Payer: UnitedHealthcare Medicare	$13.72
Rate for Payer: University Health Alliance Commercial	$35.43

HCHG VITAMIN K SO

Facility

$179.00

Service Code	HCPCS 84597
Hospital Charge Code	K3010046
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 VITAMIN K SO

Facility

$179.00

Service Code	HCPCS 84597
Hospital Charge Code	K3010046
Hospital Revenue Code	301
Min. Negotiated Rate	$13.72
Max. Negotiated Rate	$173.63
Rate for Payer: AlohaCare Medicaid	$13.72
Rate for Payer: AlohaCare Medicare	$13.72
Rate for Payer: Cash Price	$116.35
Rate for Payer: Cash Price	$116.35
Rate for Payer: Devoted Health Medicare	$15.09
Rate for Payer: Hawaii Medical Service Association ABD	$18.94
Rate for Payer: Hawaii Medical Service Association Commercial	$17.15
Rate for Payer: Hawaii Medical Service Association Medicare	$13.72
Rate for Payer: Hawaii Medical Service Association Non-ABD	$19.89
Rate for Payer: Hawaii Western Management Group Commercial	$13.72
Rate for Payer: Health Management Network Commercial	$152.15
Rate for Payer: Humana Medicare	$13.72
Rate for Payer: Kaiser Permanente Commercial	$112.77
Rate for Payer: Kaiser Permanente Medicaid	$91.29
Rate for Payer: Kaiser Permanente Medicare	$13.72
Rate for Payer: MDX Hawaii PPO	$173.63
Rate for Payer: Ohana Health Plan Medicaid	$15.09
Rate for Payer: Ohana Health Plan Medicare	$13.72
Rate for Payer: UnitedHealthcare Medicaid	$18.94
Rate for Payer: UnitedHealthcare Medicare	$13.72
Rate for Payer: University Health Alliance Commercial	$35.43

HCHG VMA 24 HR URINE

Facility

$191.00

Service Code	HCPCS 84585
Hospital Charge Code	H3011296
Hospital Revenue Code	301
Min. Negotiated Rate	$162.35
Max. Negotiated Rate	$185.27
Rate for Payer: Cash Price	$124.15
Rate for Payer: Health Management Network Commercial	$162.35
Rate for Payer: MDX Hawaii PPO	$185.27

HCHG VMA 24 HR URINE

Facility

$191.00

Service Code	HCPCS 84585
Hospital Charge Code	H3011296
Hospital Revenue Code	301
Min. Negotiated Rate	$15.50
Max. Negotiated Rate	$185.27
Rate for Payer: AlohaCare Medicaid	$15.50
Rate for Payer: AlohaCare Medicare	$15.50
Rate for Payer: Cash Price	$124.15
Rate for Payer: Cash Price	$124.15
Rate for Payer: Devoted Health Medicare	$17.05
Rate for Payer: Hawaii Medical Service Association ABD	$21.42
Rate for Payer: Hawaii Medical Service Association Commercial	$19.38
Rate for Payer: Hawaii Medical Service Association Medicare	$15.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$22.49
Rate for Payer: Hawaii Western Management Group Commercial	$15.50
Rate for Payer: Health Management Network Commercial	$162.35
Rate for Payer: Humana Medicare	$15.50
Rate for Payer: Kaiser Permanente Commercial	$120.33
Rate for Payer: Kaiser Permanente Medicaid	$97.41
Rate for Payer: Kaiser Permanente Medicare	$15.50
Rate for Payer: MDX Hawaii PPO	$185.27
Rate for Payer: Ohana Health Plan Medicaid	$17.05
Rate for Payer: Ohana Health Plan Medicare	$15.50
Rate for Payer: UnitedHealthcare Medicaid	$21.42
Rate for Payer: UnitedHealthcare Medicare	$15.50
Rate for Payer: University Health Alliance Commercial	$40.07

HCHG VOL MEASURMENT FOR TIMED COLLECTION, EACH

Facility

$28.00

Service Code	HCPCS 81050
Hospital Charge Code	H3070124
Hospital Revenue Code	307
Min. Negotiated Rate	$2.70
Max. Negotiated Rate	$27.16
Rate for Payer: AlohaCare Medicaid	$3.64
Rate for Payer: AlohaCare Medicare	$3.64
Rate for Payer: Cash Price	$18.20
Rate for Payer: Cash Price	$18.20
Rate for Payer: Devoted Health Medicare	$4.00
Rate for Payer: Hawaii Medical Service Association ABD	$2.70
Rate for Payer: Hawaii Medical Service Association Commercial	$4.55
Rate for Payer: Hawaii Medical Service Association Medicare	$3.64
Rate for Payer: Hawaii Medical Service Association Non-ABD	$4.14
Rate for Payer: Hawaii Western Management Group Commercial	$3.64
Rate for Payer: Health Management Network Commercial	$23.80
Rate for Payer: Humana Medicare	$3.64
Rate for Payer: Kaiser Permanente Commercial	$17.64
Rate for Payer: Kaiser Permanente Medicaid	$14.28
Rate for Payer: Kaiser Permanente Medicare	$3.64
Rate for Payer: MDX Hawaii PPO	$27.16
Rate for Payer: Ohana Health Plan Medicaid	$4.00
Rate for Payer: Ohana Health Plan Medicare	$3.64
Rate for Payer: UnitedHealthcare Medicaid	$2.70
Rate for Payer: UnitedHealthcare Medicare	$3.64
Rate for Payer: University Health Alliance Commercial	$7.75

HCHG VOL MEASURMENT FOR TIMED COLLECTION, EACH

Facility

$28.00

Service Code	HCPCS 81050
Hospital Charge Code	H3070124
Hospital Revenue Code	307
Min. Negotiated Rate	$23.80
Max. Negotiated Rate	$27.16
Rate for Payer: Cash Price	$18.20
Rate for Payer: Health Management Network Commercial	$23.80
Rate for Payer: MDX Hawaii PPO	$27.16

HCHG VON WILLEBRAND FACTOR AG

Facility

$282.00

Service Code	HCPCS 85246
Hospital Charge Code	H3050260
Hospital Revenue Code	305
Min. Negotiated Rate	$22.94
Max. Negotiated Rate	$273.54
Rate for Payer: AlohaCare Medicaid	$22.94
Rate for Payer: AlohaCare Medicare	$22.94
Rate for Payer: Cash Price	$183.30
Rate for Payer: Cash Price	$183.30
Rate for Payer: Devoted Health Medicare	$25.23
Rate for Payer: Hawaii Medical Service Association ABD	$31.72
Rate for Payer: Hawaii Medical Service Association Commercial	$28.68
Rate for Payer: Hawaii Medical Service Association Medicare	$22.94
Rate for Payer: Hawaii Medical Service Association Non-ABD	$33.31
Rate for Payer: Hawaii Western Management Group Commercial	$22.94
Rate for Payer: Health Management Network Commercial	$239.70
Rate for Payer: Humana Medicare	$22.94
Rate for Payer: Kaiser Permanente Commercial	$177.66
Rate for Payer: Kaiser Permanente Medicaid	$143.82
Rate for Payer: Kaiser Permanente Medicare	$22.94
Rate for Payer: MDX Hawaii PPO	$273.54
Rate for Payer: Ohana Health Plan Medicaid	$25.23
Rate for Payer: Ohana Health Plan Medicare	$22.94
Rate for Payer: UnitedHealthcare Medicaid	$31.72
Rate for Payer: UnitedHealthcare Medicare	$22.94
Rate for Payer: University Health Alliance Commercial	$59.31

HCHG VON WILLEBRAND FACTOR AG

Facility

$282.00

Service Code	HCPCS 85246
Hospital Charge Code	H3050260
Hospital Revenue Code	305
Min. Negotiated Rate	$239.70
Max. Negotiated Rate	$273.54
Rate for Payer: Cash Price	$183.30
Rate for Payer: Health Management Network Commercial	$239.70
Rate for Payer: MDX Hawaii PPO	$273.54

HCHG WBC & DIFF

Facility

$88.00

Service Code	HCPCS 85004
Hospital Charge Code	H3050262
Hospital Revenue Code	305
Min. Negotiated Rate	$74.80
Max. Negotiated Rate	$85.36
Rate for Payer: Cash Price	$57.20
Rate for Payer: Health Management Network Commercial	$74.80
Rate for Payer: MDX Hawaii PPO	$85.36

HCHG WBC & DIFF

Facility

$88.00

Service Code	HCPCS 85004
Hospital Charge Code	H3050262
Hospital Revenue Code	305
Min. Negotiated Rate	$6.47
Max. Negotiated Rate	$85.36
Rate for Payer: AlohaCare Medicaid	$6.47
Rate for Payer: AlohaCare Medicare	$6.47
Rate for Payer: Cash Price	$57.20
Rate for Payer: Cash Price	$57.20
Rate for Payer: Devoted Health Medicare	$7.12
Rate for Payer: Hawaii Medical Service Association ABD	$9.04
Rate for Payer: Hawaii Medical Service Association Commercial	$8.09
Rate for Payer: Hawaii Medical Service Association Medicare	$6.47
Rate for Payer: Hawaii Medical Service Association Non-ABD	$9.49
Rate for Payer: Hawaii Western Management Group Commercial	$6.47
Rate for Payer: Health Management Network Commercial	$74.80
Rate for Payer: Humana Medicare	$6.47
Rate for Payer: Kaiser Permanente Commercial	$55.44
Rate for Payer: Kaiser Permanente Medicaid	$44.88
Rate for Payer: Kaiser Permanente Medicare	$6.47
Rate for Payer: MDX Hawaii PPO	$85.36
Rate for Payer: Ohana Health Plan Medicaid	$7.12
Rate for Payer: Ohana Health Plan Medicare	$6.47
Rate for Payer: UnitedHealthcare Medicaid	$9.04
Rate for Payer: UnitedHealthcare Medicare	$6.47
Rate for Payer: University Health Alliance Commercial	$16.72

Know your out-of-pocket cost for care.

All Charges