Kona Community Hospital

All Charges

Charge

Type

Setting

Price

HCHG COMPATIB BLD INC 1 UNIT

Facility

$1,017.00

Service Code	HCPCS 86921
Hospital Charge Code	H3900152
Hospital Revenue Code	302
Min. Negotiated Rate	$864.45
Max. Negotiated Rate	$986.49
Rate for Payer: Cash Price	$661.05
Rate for Payer: Health Management Network Commercial	$864.45
Rate for Payer: MDX Hawaii PPO	$986.49

HCHG COMPATIB BLD INC 1 UNIT

Facility

$1,017.00

Service Code	HCPCS 86921
Hospital Charge Code	H3900152
Hospital Revenue Code	302
Min. Negotiated Rate	$20.80
Max. Negotiated Rate	$986.49
Rate for Payer: AlohaCare Medicaid	$201.27
Rate for Payer: AlohaCare Medicare	$201.27
Rate for Payer: Cash Price	$661.05
Rate for Payer: Cash Price	$661.05
Rate for Payer: Devoted Health Medicare	$221.40
Rate for Payer: Hawaii Medical Service Association ABD	$20.80
Rate for Payer: Hawaii Medical Service Association Commercial	$251.59
Rate for Payer: Hawaii Medical Service Association Medicare	$201.27
Rate for Payer: Hawaii Medical Service Association Non-ABD	$27.97
Rate for Payer: Hawaii Western Management Group Commercial	$201.27
Rate for Payer: Health Management Network Commercial	$864.45
Rate for Payer: Humana Medicare	$201.27
Rate for Payer: Kaiser Permanente Commercial	$640.71
Rate for Payer: Kaiser Permanente Medicaid	$518.67
Rate for Payer: Kaiser Permanente Medicare	$201.27
Rate for Payer: MDX Hawaii PPO	$986.49
Rate for Payer: Ohana Health Plan Medicaid	$221.40
Rate for Payer: Ohana Health Plan Medicare	$201.27
Rate for Payer: UnitedHealthcare Medicaid	$20.80
Rate for Payer: UnitedHealthcare Medicare	$201.27
Rate for Payer: University Health Alliance Commercial	$741.29

HCHG COMPLEMENT C2

Facility

$163.00

Service Code	HCPCS 86160
Hospital Charge Code	H3020438
Hospital Revenue Code	302
Min. Negotiated Rate	$12.00
Max. Negotiated Rate	$158.11
Rate for Payer: AlohaCare Medicaid	$12.00
Rate for Payer: AlohaCare Medicare	$12.00
Rate for Payer: Cash Price	$105.95
Rate for Payer: Cash Price	$105.95
Rate for Payer: Devoted Health Medicare	$13.20
Rate for Payer: Hawaii Medical Service Association ABD	$16.59
Rate for Payer: Hawaii Medical Service Association Commercial	$15.00
Rate for Payer: Hawaii Medical Service Association Medicare	$12.00
Rate for Payer: Hawaii Medical Service Association Non-ABD	$17.42
Rate for Payer: Hawaii Western Management Group Commercial	$12.00
Rate for Payer: Health Management Network Commercial	$138.55
Rate for Payer: Humana Medicare	$12.00
Rate for Payer: Kaiser Permanente Commercial	$102.69
Rate for Payer: Kaiser Permanente Medicaid	$83.13
Rate for Payer: Kaiser Permanente Medicare	$12.00
Rate for Payer: MDX Hawaii PPO	$158.11
Rate for Payer: Ohana Health Plan Medicaid	$13.20
Rate for Payer: Ohana Health Plan Medicare	$12.00
Rate for Payer: UnitedHealthcare Medicaid	$16.59
Rate for Payer: UnitedHealthcare Medicare	$12.00
Rate for Payer: University Health Alliance Commercial	$31.04

HCHG COMPLEMENT C2

Facility

$163.00

Service Code	HCPCS 86160
Hospital Charge Code	H3020438
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

HCHG COMPLEMENT C3

Facility

$163.00

Service Code	HCPCS 86160
Hospital Charge Code	H3020440
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

HCHG COMPLEMENT C3

Facility

$163.00

Service Code	HCPCS 86160
Hospital Charge Code	H3020440
Hospital Revenue Code	302
Min. Negotiated Rate	$12.00
Max. Negotiated Rate	$158.11
Rate for Payer: AlohaCare Medicaid	$12.00
Rate for Payer: AlohaCare Medicare	$12.00
Rate for Payer: Cash Price	$105.95
Rate for Payer: Cash Price	$105.95
Rate for Payer: Devoted Health Medicare	$13.20
Rate for Payer: Hawaii Medical Service Association ABD	$16.59
Rate for Payer: Hawaii Medical Service Association Commercial	$15.00
Rate for Payer: Hawaii Medical Service Association Medicare	$12.00
Rate for Payer: Hawaii Medical Service Association Non-ABD	$17.42
Rate for Payer: Hawaii Western Management Group Commercial	$12.00
Rate for Payer: Health Management Network Commercial	$138.55
Rate for Payer: Humana Medicare	$12.00
Rate for Payer: Kaiser Permanente Commercial	$102.69
Rate for Payer: Kaiser Permanente Medicaid	$83.13
Rate for Payer: Kaiser Permanente Medicare	$12.00
Rate for Payer: MDX Hawaii PPO	$158.11
Rate for Payer: Ohana Health Plan Medicaid	$13.20
Rate for Payer: Ohana Health Plan Medicare	$12.00
Rate for Payer: UnitedHealthcare Medicaid	$16.59
Rate for Payer: UnitedHealthcare Medicare	$12.00
Rate for Payer: University Health Alliance Commercial	$31.04

HCHG COMPLEMENT C4

Facility

$163.00

Service Code	HCPCS 86160
Hospital Charge Code	H3020442
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

HCHG COMPLEMENT C4

Facility

$163.00

Service Code	HCPCS 86160
Hospital Charge Code	H3020442
Hospital Revenue Code	302
Min. Negotiated Rate	$12.00
Max. Negotiated Rate	$158.11
Rate for Payer: AlohaCare Medicaid	$12.00
Rate for Payer: AlohaCare Medicare	$12.00
Rate for Payer: Cash Price	$105.95
Rate for Payer: Cash Price	$105.95
Rate for Payer: Devoted Health Medicare	$13.20
Rate for Payer: Hawaii Medical Service Association ABD	$16.59
Rate for Payer: Hawaii Medical Service Association Commercial	$15.00
Rate for Payer: Hawaii Medical Service Association Medicare	$12.00
Rate for Payer: Hawaii Medical Service Association Non-ABD	$17.42
Rate for Payer: Hawaii Western Management Group Commercial	$12.00
Rate for Payer: Health Management Network Commercial	$138.55
Rate for Payer: Humana Medicare	$12.00
Rate for Payer: Kaiser Permanente Commercial	$102.69
Rate for Payer: Kaiser Permanente Medicaid	$83.13
Rate for Payer: Kaiser Permanente Medicare	$12.00
Rate for Payer: MDX Hawaii PPO	$158.11
Rate for Payer: Ohana Health Plan Medicaid	$13.20
Rate for Payer: Ohana Health Plan Medicare	$12.00
Rate for Payer: UnitedHealthcare Medicaid	$16.59
Rate for Payer: UnitedHealthcare Medicare	$12.00
Rate for Payer: University Health Alliance Commercial	$31.04

HCHG COMPLEX DRAINAGE, WOUND

Facility

$7,263.00

Service Code	HCPCS 10180
Hospital Charge Code	H4500920
Hospital Revenue Code	450
Min. Negotiated Rate	$6,173.55
Max. Negotiated Rate	$7,045.11
Rate for Payer: Cash Price	$4,720.95
Rate for Payer: Health Management Network Commercial	$6,173.55
Rate for Payer: MDX Hawaii PPO	$7,045.11

HCHG COMPLEX DRAINAGE, WOUND

Facility

$7,263.00

Service Code	HCPCS 10180
Hospital Charge Code	H4500920
Hospital Revenue Code	450
Min. Negotiated Rate	$456.03
Max. Negotiated Rate	$7,045.11
Rate for Payer: AlohaCare Medicaid	$3,431.47
Rate for Payer: AlohaCare Medicare	$3,431.47
Rate for Payer: Cash Price	$4,720.95
Rate for Payer: Cash Price	$4,720.95
Rate for Payer: Cash Price	$4,720.95
Rate for Payer: Devoted Health Medicare	$3,774.62
Rate for Payer: Hawaii Medical Service Association ABD	$695.00
Rate for Payer: Hawaii Medical Service Association Commercial	$6,183.00
Rate for Payer: Hawaii Medical Service Association Medicare	$3,431.47
Rate for Payer: Hawaii Medical Service Association Non-ABD	$700.72
Rate for Payer: Hawaii Western Management Group Commercial	$6,899.85
Rate for Payer: Health Management Network Commercial	$6,173.55
Rate for Payer: Humana Medicare	$3,431.47
Rate for Payer: Kaiser Permanente Commercial	$4,575.69
Rate for Payer: Kaiser Permanente Medicaid	$937.50
Rate for Payer: Kaiser Permanente Medicare	$3,431.47
Rate for Payer: MDX Hawaii PPO	$7,045.11
Rate for Payer: Ohana Health Plan Medicaid	$3,774.62
Rate for Payer: Ohana Health Plan Medicare	$3,431.47
Rate for Payer: UnitedHealthcare Medicaid	$456.03
Rate for Payer: UnitedHealthcare Medicare	$3,431.47
Rate for Payer: University Health Alliance Commercial	$5,160.40

HCHG COMPREHENSIVE METABOLIC PROF

Facility

$169.00

Service Code	HCPCS 80053
Hospital Charge Code	H3010410
Hospital Revenue Code	301
Min. Negotiated Rate	$10.56
Max. Negotiated Rate	$163.93
Rate for Payer: AlohaCare Medicaid	$10.56
Rate for Payer: AlohaCare Medicare	$10.56
Rate for Payer: Cash Price	$109.85
Rate for Payer: Cash Price	$109.85
Rate for Payer: Devoted Health Medicare	$11.62
Rate for Payer: Hawaii Medical Service Association ABD	$14.61
Rate for Payer: Hawaii Medical Service Association Commercial	$13.20
Rate for Payer: Hawaii Medical Service Association Medicare	$10.56
Rate for Payer: Hawaii Medical Service Association Non-ABD	$15.34
Rate for Payer: Hawaii Western Management Group Commercial	$10.56
Rate for Payer: Health Management Network Commercial	$143.65
Rate for Payer: Humana Medicare	$10.56
Rate for Payer: Kaiser Permanente Commercial	$106.47
Rate for Payer: Kaiser Permanente Medicaid	$86.19
Rate for Payer: Kaiser Permanente Medicare	$10.56
Rate for Payer: MDX Hawaii PPO	$163.93
Rate for Payer: Ohana Health Plan Medicaid	$11.62
Rate for Payer: Ohana Health Plan Medicare	$10.56
Rate for Payer: UnitedHealthcare Medicaid	$14.61
Rate for Payer: UnitedHealthcare Medicare	$10.56
Rate for Payer: University Health Alliance Commercial	$27.32

HCHG COMPREHENSIVE METABOLIC PROF

Facility

$169.00

Service Code	HCPCS 80053
Hospital Charge Code	H3010410
Hospital Revenue Code	301
Min. Negotiated Rate	$143.65
Max. Negotiated Rate	$163.93
Rate for Payer: Cash Price	$109.85
Rate for Payer: Health Management Network Commercial	$143.65
Rate for Payer: MDX Hawaii PPO	$163.93

HCHG COMPUTED TOMOGRAPHY THORAX LW DOSE LNG CA SCR C-

Facility

$845.00

Service Code	HCPCS 71271
Hospital Charge Code	H3520248
Hospital Revenue Code	352
Min. Negotiated Rate	$92.52
Max. Negotiated Rate	$819.65
Rate for Payer: AlohaCare Medicaid	$123.50
Rate for Payer: AlohaCare Medicare	$123.50
Rate for Payer: Cash Price	$549.25
Rate for Payer: Cash Price	$549.25
Rate for Payer: Devoted Health Medicare	$135.85
Rate for Payer: Hawaii Medical Service Association Commercial	$154.38
Rate for Payer: Hawaii Medical Service Association Medicare	$123.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$92.52
Rate for Payer: Hawaii Western Management Group Commercial	$123.50
Rate for Payer: Health Management Network Commercial	$718.25
Rate for Payer: Humana Medicare	$123.50
Rate for Payer: Kaiser Permanente Commercial	$532.35
Rate for Payer: Kaiser Permanente Medicaid	$430.95
Rate for Payer: Kaiser Permanente Medicare	$123.50
Rate for Payer: MDX Hawaii PPO	$819.65
Rate for Payer: Ohana Health Plan Medicaid	$135.85
Rate for Payer: Ohana Health Plan Medicare	$123.50
Rate for Payer: UnitedHealthcare Medicaid	$92.92
Rate for Payer: UnitedHealthcare Medicare	$123.50
Rate for Payer: University Health Alliance Commercial	$307.65

HCHG COMPUTED TOMOGRAPHY THORAX LW DOSE LNG CA SCR C-

Facility

$845.00

Service Code	HCPCS 71271
Hospital Charge Code	H3520248
Hospital Revenue Code	352
Min. Negotiated Rate	$718.25
Max. Negotiated Rate	$819.65
Rate for Payer: Cash Price	$549.25
Rate for Payer: Health Management Network Commercial	$718.25
Rate for Payer: MDX Hawaii PPO	$819.65

HCHG CONCENTRATION

Facility

$114.00

Service Code	HCPCS 87015
Hospital Charge Code	H3060132
Hospital Revenue Code	306
Min. Negotiated Rate	$6.68
Max. Negotiated Rate	$110.58
Rate for Payer: AlohaCare Medicaid	$6.68
Rate for Payer: AlohaCare Medicare	$6.68
Rate for Payer: Cash Price	$74.10
Rate for Payer: Cash Price	$74.10
Rate for Payer: Devoted Health Medicare	$7.35
Rate for Payer: Hawaii Medical Service Association ABD	$9.23
Rate for Payer: Hawaii Medical Service Association Commercial	$8.35
Rate for Payer: Hawaii Medical Service Association Medicare	$6.68
Rate for Payer: Hawaii Medical Service Association Non-ABD	$9.69
Rate for Payer: Hawaii Western Management Group Commercial	$6.68
Rate for Payer: Health Management Network Commercial	$96.90
Rate for Payer: Humana Medicare	$6.68
Rate for Payer: Kaiser Permanente Commercial	$71.82
Rate for Payer: Kaiser Permanente Medicaid	$58.14
Rate for Payer: Kaiser Permanente Medicare	$6.68
Rate for Payer: MDX Hawaii PPO	$110.58
Rate for Payer: Ohana Health Plan Medicaid	$7.35
Rate for Payer: Ohana Health Plan Medicare	$6.68
Rate for Payer: UnitedHealthcare Medicaid	$9.23
Rate for Payer: UnitedHealthcare Medicare	$6.68
Rate for Payer: University Health Alliance Commercial	$17.26

HCHG CONCENTRATION

Facility

$114.00

Service Code	HCPCS 87015
Hospital Charge Code	H3060132
Hospital Revenue Code	306
Min. Negotiated Rate	$96.90
Max. Negotiated Rate	$110.58
Rate for Payer: Cash Price	$74.10
Rate for Payer: Health Management Network Commercial	$96.90
Rate for Payer: MDX Hawaii PPO	$110.58

HCHG CONSCIOUS SEDATION 5 YO OR > INITIAL 15 MINS

Facility

$120.00

Service Code	HCPCS 99152
Hospital Charge Code	H3701188
Hospital Revenue Code	370
Min. Negotiated Rate	$11.94
Max. Negotiated Rate	$116.40
Rate for Payer: Cash Price	$78.00
Rate for Payer: Cash Price	$78.00
Rate for Payer: Hawaii Western Management Group Commercial	$114.00
Rate for Payer: Health Management Network Commercial	$102.00
Rate for Payer: Kaiser Permanente Commercial	$75.60
Rate for Payer: Kaiser Permanente Medicaid	$61.20
Rate for Payer: MDX Hawaii PPO	$116.40
Rate for Payer: UnitedHealthcare Medicaid	$11.94
Rate for Payer: University Health Alliance Commercial	$87.47

HCHG CONSCIOUS SEDATION 5 YO OR > INITIAL 15 MINS

Facility

$120.00

Service Code	HCPCS 99152
Hospital Charge Code	H3701188
Hospital Revenue Code	370
Min. Negotiated Rate	$102.00
Max. Negotiated Rate	$116.40
Rate for Payer: Cash Price	$78.00
Rate for Payer: Health Management Network Commercial	$102.00
Rate for Payer: MDX Hawaii PPO	$116.40

HCHG CONSCIOUS SEDATION<5 YRS INITIAL 15 MINS

Facility

$181.00

Service Code	HCPCS 99151
Hospital Charge Code	H3701193
Hospital Revenue Code	370
Min. Negotiated Rate	$17.23
Max. Negotiated Rate	$175.57
Rate for Payer: Cash Price	$117.65
Rate for Payer: Cash Price	$117.65
Rate for Payer: Hawaii Western Management Group Commercial	$171.95
Rate for Payer: Health Management Network Commercial	$153.85
Rate for Payer: Kaiser Permanente Commercial	$114.03
Rate for Payer: Kaiser Permanente Medicaid	$92.31
Rate for Payer: MDX Hawaii PPO	$175.57
Rate for Payer: UnitedHealthcare Medicaid	$17.23
Rate for Payer: University Health Alliance Commercial	$131.93

HCHG CONSCIOUS SEDATION<5 YRS INITIAL 15 MINS

Facility

$181.00

Service Code	HCPCS 99151
Hospital Charge Code	H3701193
Hospital Revenue Code	370
Min. Negotiated Rate	$153.85
Max. Negotiated Rate	$175.57
Rate for Payer: Cash Price	$117.65
Rate for Payer: Health Management Network Commercial	$153.85
Rate for Payer: MDX Hawaii PPO	$175.57

HCHG CONSCIOUS SEDATION EACH ADDITIONAL 15 MIN

Facility

$102.00

Service Code	HCPCS 99153
Hospital Charge Code	H3701189
Hospital Revenue Code	370
Min. Negotiated Rate	$86.70
Max. Negotiated Rate	$98.94
Rate for Payer: Cash Price	$66.30
Rate for Payer: Health Management Network Commercial	$86.70
Rate for Payer: MDX Hawaii PPO	$98.94

HCHG CONSCIOUS SEDATION EACH ADDITIONAL 15 MIN

Facility

$102.00

Service Code	HCPCS 99153
Hospital Charge Code	H3701189
Hospital Revenue Code	370
Min. Negotiated Rate	$13.00
Max. Negotiated Rate	$98.94
Rate for Payer: Cash Price	$66.30
Rate for Payer: Cash Price	$66.30
Rate for Payer: Hawaii Western Management Group Commercial	$96.90
Rate for Payer: Health Management Network Commercial	$86.70
Rate for Payer: Kaiser Permanente Commercial	$64.26
Rate for Payer: Kaiser Permanente Medicaid	$52.02
Rate for Payer: MDX Hawaii PPO	$98.94
Rate for Payer: UnitedHealthcare Medicaid	$13.00
Rate for Payer: University Health Alliance Commercial	$74.35

HCHG CONSULT&RPT ON REFER MATERIAL

Facility

$314.00

Service Code	HCPCS 88323
Hospital Charge Code	H3120126
Hospital Revenue Code	312
Min. Negotiated Rate	$31.88
Max. Negotiated Rate	$304.58
Rate for Payer: AlohaCare Medicaid	$61.56
Rate for Payer: AlohaCare Medicare	$61.56
Rate for Payer: Cash Price	$204.10
Rate for Payer: Cash Price	$204.10
Rate for Payer: Devoted Health Medicare	$67.72
Rate for Payer: Hawaii Medical Service Association ABD	$31.88
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	$39.51
Rate for Payer: Hawaii Western Management Group Commercial	$61.56
Rate for Payer: Health Management Network Commercial	$266.90
Rate for Payer: Humana Medicare	$61.56
Rate for Payer: Kaiser Permanente Commercial	$197.82
Rate for Payer: Kaiser Permanente Medicaid	$160.14
Rate for Payer: Kaiser Permanente Medicare	$61.56
Rate for Payer: MDX Hawaii PPO	$304.58
Rate for Payer: Ohana Health Plan Medicaid	$67.72
Rate for Payer: Ohana Health Plan Medicare	$61.56
Rate for Payer: UnitedHealthcare Medicaid	$31.88
Rate for Payer: UnitedHealthcare Medicare	$61.56
Rate for Payer: University Health Alliance Commercial	$277.37

HCHG CONSULT&RPT ON REFER MATERIAL

Facility

$314.00

Service Code	HCPCS 88323
Hospital Charge Code	H3120126
Hospital Revenue Code	312
Min. Negotiated Rate	$266.90
Max. Negotiated Rate	$304.58
Rate for Payer: Cash Price	$204.10
Rate for Payer: Health Management Network Commercial	$266.90
Rate for Payer: MDX Hawaii PPO	$304.58

HCHG CONT MED PHYSIC PER WEEK OF THPY

Facility

$910.00

Service Code	HCPCS 77336
Hospital Charge Code	H3330114
Hospital Revenue Code	333
Min. Negotiated Rate	$105.25
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	$105.25
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	$110.51
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	$105.25
Rate for Payer: UnitedHealthcare Medicare	$158.78
Rate for Payer: University Health Alliance Commercial	$173.22

Know your out-of-pocket cost for care.

All Charges