Kona Community Hospital

All Charges

Charge

Type

Setting

Price

HCHG INJ DIAG/THER SUB LUMB/SAC W/O IMG GDE

Facility

$2,617.00

Service Code	HCPCS 62322
Hospital Charge Code	H3610661
Hospital Revenue Code	361
Min. Negotiated Rate	$2,224.45
Max. Negotiated Rate	$2,538.49
Rate for Payer: Cash Price	$1,701.05
Rate for Payer: Health Management Network Commercial	$2,224.45
Rate for Payer: MDX Hawaii PPO	$2,538.49

HCHG INJECTION FOR HIP X-RAY

Facility

$246.00

Service Code	HCPCS 27095
Hospital Charge Code	H3610848
Hospital Revenue Code	361
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 INJECTION FOR HIP X-RAY

Facility

$246.00

Service Code	HCPCS 27095
Hospital Charge Code	H3610848
Hospital Revenue Code	361
Min. Negotiated Rate	$65.12
Max. Negotiated Rate	$2,837.00
Rate for Payer: Cash Price	$159.90
Rate for Payer: Cash Price	$159.90
Rate for Payer: Cash Price	$159.90
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 Non-ABD	$407.95
Rate for Payer: Health Management Network Commercial	$209.10
Rate for Payer: Kaiser Permanente Commercial	$154.98
Rate for Payer: Kaiser Permanente Medicaid	$2,837.00
Rate for Payer: MDX Hawaii PPO	$238.62
Rate for Payer: UnitedHealthcare Medicaid	$65.12
Rate for Payer: University Health Alliance Commercial	$179.31

HCHG INJECTION PX FOR ANTEGRADE NEPHOSTROGRAM/URETEROGRAM

Facility

$3,382.00

Service Code	HCPCS 50431
Hospital Charge Code	H3610232
Hospital Revenue Code	361
Min. Negotiated Rate	$340.18
Max. Negotiated Rate	$6,183.00
Rate for Payer: AlohaCare Medicaid	$823.75
Rate for Payer: AlohaCare Medicare	$823.75
Rate for Payer: Cash Price	$2,198.30
Rate for Payer: Cash Price	$2,198.30
Rate for Payer: Cash Price	$2,198.30
Rate for Payer: Devoted Health Medicare	$906.12
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	$823.75
Rate for Payer: Hawaii Medical Service Association Non-ABD	$700.72
Rate for Payer: Health Management Network Commercial	$2,874.70
Rate for Payer: Humana Medicare	$823.75
Rate for Payer: Kaiser Permanente Commercial	$2,130.66
Rate for Payer: Kaiser Permanente Medicaid	$2,837.00
Rate for Payer: Kaiser Permanente Medicare	$823.75
Rate for Payer: MDX Hawaii PPO	$3,280.54
Rate for Payer: Ohana Health Plan Medicaid	$906.12
Rate for Payer: Ohana Health Plan Medicare	$823.75
Rate for Payer: UnitedHealthcare Medicaid	$340.18
Rate for Payer: UnitedHealthcare Medicare	$823.75
Rate for Payer: University Health Alliance Commercial	$2,465.14

HCHG INJECTION PX FOR ANTEGRADE NEPHOSTROGRAM/URETEROGRAM

Facility

$3,382.00

Service Code	HCPCS 50431
Hospital Charge Code	H3610232
Hospital Revenue Code	361
Min. Negotiated Rate	$2,874.70
Max. Negotiated Rate	$3,280.54
Rate for Payer: Cash Price	$2,198.30
Rate for Payer: Health Management Network Commercial	$2,874.70
Rate for Payer: MDX Hawaii PPO	$3,280.54

HCHG INJECTION SINGLE TENDON SHEATH

Facility

$1,232.00

Service Code	HCPCS 20550
Hospital Charge Code	H3601089
Hospital Revenue Code	360
Min. Negotiated Rate	$1,047.20
Max. Negotiated Rate	$1,195.04
Rate for Payer: Cash Price	$800.80
Rate for Payer: Health Management Network Commercial	$1,047.20
Rate for Payer: MDX Hawaii PPO	$1,195.04

HCHG INJECTION SINGLE TENDON SHEATH

Facility

$1,232.00

Service Code	HCPCS 20550
Hospital Charge Code	H3601089
Hospital Revenue Code	360
Min. Negotiated Rate	$39.27
Max. Negotiated Rate	$2,837.00
Rate for Payer: AlohaCare Medicaid	$362.62
Rate for Payer: AlohaCare Medicare	$362.62
Rate for Payer: Cash Price	$800.80
Rate for Payer: Cash Price	$800.80
Rate for Payer: Cash Price	$800.80
Rate for Payer: Devoted Health Medicare	$398.88
Rate for Payer: Hawaii Medical Service Association Commercial	$453.27
Rate for Payer: Hawaii Medical Service Association Medicare	$362.62
Rate for Payer: Health Management Network Commercial	$1,047.20
Rate for Payer: Humana Medicare	$362.62
Rate for Payer: Kaiser Permanente Commercial	$776.16
Rate for Payer: Kaiser Permanente Medicaid	$2,837.00
Rate for Payer: Kaiser Permanente Medicare	$362.62
Rate for Payer: MDX Hawaii PPO	$1,195.04
Rate for Payer: Ohana Health Plan Medicaid	$398.88
Rate for Payer: Ohana Health Plan Medicare	$362.62
Rate for Payer: UnitedHealthcare Medicaid	$39.27
Rate for Payer: UnitedHealthcare Medicare	$362.62
Rate for Payer: University Health Alliance Commercial	$898.00

HCHG INJECT TRIGGER POINTS, =/> 3

Facility

$1,721.00

Service Code	HCPCS 20553
Hospital Charge Code	H4500930
Hospital Revenue Code	450
Min. Negotiated Rate	$362.62
Max. Negotiated Rate	$1,669.37
Rate for Payer: AlohaCare Medicaid	$362.62
Rate for Payer: AlohaCare Medicare	$362.62
Rate for Payer: Cash Price	$1,118.65
Rate for Payer: Cash Price	$1,118.65
Rate for Payer: Cash Price	$1,118.65
Rate for Payer: Cash Price	$1,118.65
Rate for Payer: Devoted Health Medicare	$398.88
Rate for Payer: Hawaii Medical Service Association ABD	$560.00
Rate for Payer: Hawaii Medical Service Association Commercial	$1,600.00
Rate for Payer: Hawaii Medical Service Association Medicare	$362.62
Rate for Payer: Hawaii Medical Service Association Non-ABD	$520.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,634.95
Rate for Payer: Health Management Network Commercial	$1,462.85
Rate for Payer: Humana Medicare	$362.62
Rate for Payer: Kaiser Permanente Commercial	$1,084.23
Rate for Payer: Kaiser Permanente Medicaid	$937.50
Rate for Payer: Kaiser Permanente Medicare	$362.62
Rate for Payer: MDX Hawaii PPO	$1,669.37
Rate for Payer: Ohana Health Plan Medicaid	$398.88
Rate for Payer: Ohana Health Plan Medicare	$362.62
Rate for Payer: UnitedHealthcare Medicare	$362.62
Rate for Payer: University Health Alliance Commercial	$1,254.44

HCHG INJECT TRIGGER POINTS, =/> 3

Facility

$1,721.00

Service Code	HCPCS 20553
Hospital Charge Code	H4500930
Hospital Revenue Code	450
Min. Negotiated Rate	$1,462.85
Max. Negotiated Rate	$1,669.37
Rate for Payer: Cash Price	$1,118.65
Rate for Payer: Health Management Network Commercial	$1,462.85
Rate for Payer: MDX Hawaii PPO	$1,669.37

HCHG INJ EPIDURAL BLD/CLOT

Facility

$3,543.00

Service Code	HCPCS 62273
Hospital Charge Code	H4500510
Hospital Revenue Code	450
Min. Negotiated Rate	$340.18
Max. Negotiated Rate	$4,035.20
Rate for Payer: AlohaCare Medicaid	$833.89
Rate for Payer: AlohaCare Medicare	$833.89
Rate for Payer: Cash Price	$2,302.95
Rate for Payer: Cash Price	$2,302.95
Rate for Payer: Cash Price	$2,302.95
Rate for Payer: Devoted Health Medicare	$917.28
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	$833.89
Rate for Payer: Hawaii Medical Service Association Non-ABD	$407.95
Rate for Payer: Hawaii Western Management Group Commercial	$3,365.85
Rate for Payer: Health Management Network Commercial	$3,011.55
Rate for Payer: Humana Medicare	$833.89
Rate for Payer: Kaiser Permanente Commercial	$2,232.09
Rate for Payer: Kaiser Permanente Medicaid	$937.50
Rate for Payer: Kaiser Permanente Medicare	$833.89
Rate for Payer: MDX Hawaii PPO	$3,436.71
Rate for Payer: Ohana Health Plan Medicaid	$917.28
Rate for Payer: Ohana Health Plan Medicare	$833.89
Rate for Payer: UnitedHealthcare Medicaid	$340.18
Rate for Payer: UnitedHealthcare Medicare	$833.89
Rate for Payer: University Health Alliance Commercial	$4,035.20

HCHG INJ EPIDURAL BLD/CLOT

Facility

$3,543.00

Service Code	HCPCS 62273
Hospital Charge Code	H4500510
Hospital Revenue Code	450
Min. Negotiated Rate	$3,011.55
Max. Negotiated Rate	$3,436.71
Rate for Payer: Cash Price	$2,302.95
Rate for Payer: Health Management Network Commercial	$3,011.55
Rate for Payer: MDX Hawaii PPO	$3,436.71

HCHG INJ FERMORAL NERVE/CATH PLCMNT

Facility

$2,781.00

Service Code	HCPCS 64448
Hospital Charge Code	H3610477
Hospital Revenue Code	361
Min. Negotiated Rate	$2,363.85
Max. Negotiated Rate	$2,697.57
Rate for Payer: Cash Price	$1,807.65
Rate for Payer: Health Management Network Commercial	$2,363.85
Rate for Payer: MDX Hawaii PPO	$2,697.57

HCHG INJ FERMORAL NERVE/CATH PLCMNT

Facility

$2,781.00

Service Code	HCPCS 64448
Hospital Charge Code	H3610477
Hospital Revenue Code	361
Min. Negotiated Rate	$340.18
Max. Negotiated Rate	$2,837.00
Rate for Payer: AlohaCare Medicaid	$1,044.87
Rate for Payer: AlohaCare Medicare	$1,044.87
Rate for Payer: Cash Price	$1,807.65
Rate for Payer: Cash Price	$1,807.65
Rate for Payer: Cash Price	$1,807.65
Rate for Payer: Devoted Health Medicare	$1,149.36
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	$1,044.87
Rate for Payer: Hawaii Medical Service Association Non-ABD	$407.95
Rate for Payer: Health Management Network Commercial	$2,363.85
Rate for Payer: Humana Medicare	$1,044.87
Rate for Payer: Kaiser Permanente Commercial	$1,752.03
Rate for Payer: Kaiser Permanente Medicaid	$2,837.00
Rate for Payer: Kaiser Permanente Medicare	$1,044.87
Rate for Payer: MDX Hawaii PPO	$2,697.57
Rate for Payer: Ohana Health Plan Medicaid	$1,149.36
Rate for Payer: Ohana Health Plan Medicare	$1,044.87
Rate for Payer: UnitedHealthcare Medicaid	$340.18
Rate for Payer: UnitedHealthcare Medicare	$1,044.87
Rate for Payer: University Health Alliance Commercial	$2,027.07

HCHG INJ FOR CYSTOGM/VCUG

Facility

$202.00

Service Code	HCPCS 51600
Hospital Charge Code	H3610194
Hospital Revenue Code	361
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 INJ FOR CYSTOGM/VCUG

Facility

$202.00

Service Code	HCPCS 51600
Hospital Charge Code	H3610194
Hospital Revenue Code	361
Min. Negotiated Rate	$32.89
Max. Negotiated Rate	$2,837.00
Rate for Payer: Cash Price	$131.30
Rate for Payer: Cash Price	$131.30
Rate for Payer: Cash Price	$131.30
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 Non-ABD	$407.95
Rate for Payer: Health Management Network Commercial	$171.70
Rate for Payer: Kaiser Permanente Commercial	$127.26
Rate for Payer: Kaiser Permanente Medicaid	$2,837.00
Rate for Payer: MDX Hawaii PPO	$195.94
Rate for Payer: UnitedHealthcare Medicaid	$32.89
Rate for Payer: University Health Alliance Commercial	$147.24

HCHG INJ FOR HIP

Facility

$259.00

Service Code	HCPCS 27093
Hospital Charge Code	H3610200
Hospital Revenue Code	361
Min. Negotiated Rate	$220.15
Max. Negotiated Rate	$251.23
Rate for Payer: Cash Price	$168.35
Rate for Payer: Health Management Network Commercial	$220.15
Rate for Payer: MDX Hawaii PPO	$251.23

HCHG INJ FOR HIP

Facility

$259.00

Service Code	HCPCS 27093
Hospital Charge Code	H3610200
Hospital Revenue Code	361
Min. Negotiated Rate	$57.11
Max. Negotiated Rate	$2,837.00
Rate for Payer: Cash Price	$168.35
Rate for Payer: Cash Price	$168.35
Rate for Payer: Cash Price	$168.35
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 Non-ABD	$407.95
Rate for Payer: Health Management Network Commercial	$220.15
Rate for Payer: Kaiser Permanente Commercial	$163.17
Rate for Payer: Kaiser Permanente Medicaid	$2,837.00
Rate for Payer: MDX Hawaii PPO	$251.23
Rate for Payer: UnitedHealthcare Medicaid	$57.11
Rate for Payer: University Health Alliance Commercial	$188.79

HCHG INJ FOR MYELOGRAPHY

Facility

$530.00

Service Code	HCPCS 62284
Hospital Charge Code	H3610204
Hospital Revenue Code	361
Min. Negotiated Rate	$78.52
Max. Negotiated Rate	$2,837.00
Rate for Payer: Cash Price	$344.50
Rate for Payer: Cash Price	$344.50
Rate for Payer: Cash Price	$344.50
Rate for Payer: Health Management Network Commercial	$450.50
Rate for Payer: Kaiser Permanente Commercial	$333.90
Rate for Payer: Kaiser Permanente Medicaid	$2,837.00
Rate for Payer: MDX Hawaii PPO	$514.10
Rate for Payer: UnitedHealthcare Medicaid	$78.52
Rate for Payer: University Health Alliance Commercial	$386.32

HCHG INJ FOR MYELOGRAPHY

Facility

$530.00

Service Code	HCPCS 62284
Hospital Charge Code	H3610204
Hospital Revenue Code	361
Min. Negotiated Rate	$450.50
Max. Negotiated Rate	$514.10
Rate for Payer: Cash Price	$344.50
Rate for Payer: Health Management Network Commercial	$450.50
Rate for Payer: MDX Hawaii PPO	$514.10

HCHG INJ FOR RETRO URETHROCYSTOGRAPHY

Facility

$259.00

Service Code	HCPCS 51610
Hospital Charge Code	H3610234
Hospital Revenue Code	361
Min. Negotiated Rate	$220.15
Max. Negotiated Rate	$251.23
Rate for Payer: Cash Price	$168.35
Rate for Payer: Health Management Network Commercial	$220.15
Rate for Payer: MDX Hawaii PPO	$251.23

HCHG INJ FOR RETRO URETHROCYSTOGRAPHY

Facility

$259.00

Service Code	HCPCS 51610
Hospital Charge Code	H3610234
Hospital Revenue Code	361
Min. Negotiated Rate	$40.43
Max. Negotiated Rate	$2,837.00
Rate for Payer: Cash Price	$168.35
Rate for Payer: Cash Price	$168.35
Rate for Payer: Cash Price	$168.35
Rate for Payer: Health Management Network Commercial	$220.15
Rate for Payer: Kaiser Permanente Commercial	$163.17
Rate for Payer: Kaiser Permanente Medicaid	$2,837.00
Rate for Payer: MDX Hawaii PPO	$251.23
Rate for Payer: UnitedHealthcare Medicaid	$40.43
Rate for Payer: University Health Alliance Commercial	$188.79

HCHG INJ FOR SHOULDER

Facility

$338.00

Service Code	HCPCS 23350
Hospital Charge Code	H3610208
Hospital Revenue Code	361
Min. Negotiated Rate	$40.41
Max. Negotiated Rate	$2,837.00
Rate for Payer: Cash Price	$219.70
Rate for Payer: Cash Price	$219.70
Rate for Payer: Cash Price	$219.70
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 Non-ABD	$407.95
Rate for Payer: Health Management Network Commercial	$287.30
Rate for Payer: Kaiser Permanente Commercial	$212.94
Rate for Payer: Kaiser Permanente Medicaid	$2,837.00
Rate for Payer: MDX Hawaii PPO	$327.86
Rate for Payer: UnitedHealthcare Medicaid	$40.41
Rate for Payer: University Health Alliance Commercial	$246.37

HCHG INJ FOR SHOULDER

Facility

$338.00

Service Code	HCPCS 23350
Hospital Charge Code	H3610208
Hospital Revenue Code	361
Min. Negotiated Rate	$287.30
Max. Negotiated Rate	$327.86
Rate for Payer: Cash Price	$219.70
Rate for Payer: Health Management Network Commercial	$287.30
Rate for Payer: MDX Hawaii PPO	$327.86

HCHG INJ IM/SUBQ

Facility

$220.00

Service Code	HCPCS 96372
Hospital Charge Code	H9400110
Hospital Revenue Code	940
Min. Negotiated Rate	$187.00
Max. Negotiated Rate	$213.40
Rate for Payer: Cash Price	$143.00
Rate for Payer: Health Management Network Commercial	$187.00
Rate for Payer: MDX Hawaii PPO	$213.40

HCHG INJ IM/SUBQ

Facility

$220.00

Service Code	HCPCS 96372
Hospital Charge Code	H9400110
Hospital Revenue Code	940
Min. Negotiated Rate	$13.87
Max. Negotiated Rate	$213.40
Rate for Payer: AlohaCare Medicaid	$85.06
Rate for Payer: AlohaCare Medicare	$85.06
Rate for Payer: Cash Price	$143.00
Rate for Payer: Cash Price	$143.00
Rate for Payer: Devoted Health Medicare	$93.57
Rate for Payer: Hawaii Medical Service Association Commercial	$106.33
Rate for Payer: Hawaii Medical Service Association Medicare	$85.06
Rate for Payer: Hawaii Western Management Group Commercial	$209.00
Rate for Payer: Health Management Network Commercial	$187.00
Rate for Payer: Humana Medicare	$85.06
Rate for Payer: Kaiser Permanente Commercial	$138.60
Rate for Payer: Kaiser Permanente Medicaid	$112.20
Rate for Payer: Kaiser Permanente Medicare	$85.06
Rate for Payer: MDX Hawaii PPO	$213.40
Rate for Payer: Ohana Health Plan Medicaid	$93.57
Rate for Payer: Ohana Health Plan Medicare	$85.06
Rate for Payer: UnitedHealthcare Medicaid	$13.87
Rate for Payer: UnitedHealthcare Medicare	$85.06
Rate for Payer: University Health Alliance Commercial	$160.36

Know your out-of-pocket cost for care.

All Charges