Kona Community Hospital

All Charges

Charge

Type

Setting

Price

HCHG MANDIBLE COMP MIN 4 VIEWS

Facility

$710.00

Service Code	HCPCS 70110
Hospital Charge Code	H3200556
Hospital Revenue Code	320
Min. Negotiated Rate	$20.40
Max. Negotiated Rate	$688.70
Rate for Payer: AlohaCare Medicaid	$123.50
Rate for Payer: AlohaCare Medicare	$123.50
Rate for Payer: Cash Price	$461.50
Rate for Payer: Cash Price	$461.50
Rate for Payer: Devoted Health Medicare	$135.85
Rate for Payer: Hawaii Medical Service Association ABD	$20.40
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	$22.35
Rate for Payer: Hawaii Western Management Group Commercial	$123.50
Rate for Payer: Health Management Network Commercial	$603.50
Rate for Payer: Humana Medicare	$123.50
Rate for Payer: Kaiser Permanente Commercial	$447.30
Rate for Payer: Kaiser Permanente Medicaid	$362.10
Rate for Payer: Kaiser Permanente Medicare	$123.50
Rate for Payer: MDX Hawaii PPO	$688.70
Rate for Payer: Ohana Health Plan Medicaid	$135.85
Rate for Payer: Ohana Health Plan Medicare	$123.50
Rate for Payer: UnitedHealthcare Medicaid	$20.40
Rate for Payer: UnitedHealthcare Medicare	$123.50
Rate for Payer: University Health Alliance Commercial	$78.16

HCHG MANDIBLE COMP MIN 4 VIEWS

Facility

$710.00

Service Code	HCPCS 70110
Hospital Charge Code	H3200556
Hospital Revenue Code	320
Min. Negotiated Rate	$603.50
Max. Negotiated Rate	$688.70
Rate for Payer: Cash Price	$461.50
Rate for Payer: Health Management Network Commercial	$603.50
Rate for Payer: MDX Hawaii PPO	$688.70

HCHG MANIPULATION CHEST WALL INITIAL

Facility

$344.00

Service Code	HCPCS 94667
Hospital Charge Code	H4100278
Hospital Revenue Code	410
Min. Negotiated Rate	$20.34
Max. Negotiated Rate	$333.68
Rate for Payer: AlohaCare Medicaid	$157.18
Rate for Payer: AlohaCare Medicare	$157.18
Rate for Payer: Cash Price	$223.60
Rate for Payer: Cash Price	$223.60
Rate for Payer: Devoted Health Medicare	$172.90
Rate for Payer: Hawaii Medical Service Association Commercial	$196.47
Rate for Payer: Hawaii Medical Service Association Medicare	$157.18
Rate for Payer: Hawaii Western Management Group Commercial	$326.80
Rate for Payer: Health Management Network Commercial	$292.40
Rate for Payer: Humana Medicare	$157.18
Rate for Payer: Kaiser Permanente Commercial	$216.72
Rate for Payer: Kaiser Permanente Medicaid	$175.44
Rate for Payer: Kaiser Permanente Medicare	$157.18
Rate for Payer: MDX Hawaii PPO	$333.68
Rate for Payer: Ohana Health Plan Medicaid	$172.90
Rate for Payer: Ohana Health Plan Medicare	$157.18
Rate for Payer: UnitedHealthcare Medicaid	$20.34
Rate for Payer: UnitedHealthcare Medicare	$157.18
Rate for Payer: University Health Alliance Commercial	$250.74

HCHG MANIPULATION CHEST WALL INITIAL

Facility

$344.00

Service Code	HCPCS 94667
Hospital Charge Code	H4100278
Hospital Revenue Code	410
Min. Negotiated Rate	$292.40
Max. Negotiated Rate	$333.68
Rate for Payer: Cash Price	$223.60
Rate for Payer: Health Management Network Commercial	$292.40
Rate for Payer: MDX Hawaii PPO	$333.68

HCHG MANIPULATION CHEST WALL SUBSQ

Facility

$250.00

Service Code	HCPCS 94668
Hospital Charge Code	H4100275
Hospital Revenue Code	410
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 MANIPULATION CHEST WALL SUBSQ

Facility

$250.00

Service Code	HCPCS 94668
Hospital Charge Code	H4100275
Hospital Revenue Code	410
Min. Negotiated Rate	$16.41
Max. Negotiated Rate	$242.50
Rate for Payer: AlohaCare Medicaid	$157.18
Rate for Payer: AlohaCare Medicare	$157.18
Rate for Payer: Cash Price	$162.50
Rate for Payer: Cash Price	$162.50
Rate for Payer: Devoted Health Medicare	$172.90
Rate for Payer: Hawaii Medical Service Association Commercial	$196.47
Rate for Payer: Hawaii Medical Service Association Medicare	$157.18
Rate for Payer: Hawaii Western Management Group Commercial	$237.50
Rate for Payer: Health Management Network Commercial	$212.50
Rate for Payer: Humana Medicare	$157.18
Rate for Payer: Kaiser Permanente Commercial	$157.50
Rate for Payer: Kaiser Permanente Medicaid	$127.50
Rate for Payer: Kaiser Permanente Medicare	$157.18
Rate for Payer: MDX Hawaii PPO	$242.50
Rate for Payer: Ohana Health Plan Medicaid	$172.90
Rate for Payer: Ohana Health Plan Medicare	$157.18
Rate for Payer: UnitedHealthcare Medicaid	$16.41
Rate for Payer: UnitedHealthcare Medicare	$157.18
Rate for Payer: University Health Alliance Commercial	$182.22

HCHG MANUAL DIFF

Facility

$46.00

Service Code	HCPCS 85007
Hospital Charge Code	K3050002
Hospital Revenue Code	305
Min. Negotiated Rate	$3.80
Max. Negotiated Rate	$44.62
Rate for Payer: AlohaCare Medicaid	$3.80
Rate for Payer: AlohaCare Medicare	$3.80
Rate for Payer: Cash Price	$29.90
Rate for Payer: Cash Price	$29.90
Rate for Payer: Devoted Health Medicare	$4.18
Rate for Payer: Hawaii Medical Service Association ABD	$4.76
Rate for Payer: Hawaii Medical Service Association Commercial	$4.75
Rate for Payer: Hawaii Medical Service Association Medicare	$3.80
Rate for Payer: Hawaii Medical Service Association Non-ABD	$5.00
Rate for Payer: Hawaii Western Management Group Commercial	$3.80
Rate for Payer: Health Management Network Commercial	$39.10
Rate for Payer: Humana Medicare	$3.80
Rate for Payer: Kaiser Permanente Commercial	$28.98
Rate for Payer: Kaiser Permanente Medicaid	$23.46
Rate for Payer: Kaiser Permanente Medicare	$3.80
Rate for Payer: MDX Hawaii PPO	$44.62
Rate for Payer: Ohana Health Plan Medicaid	$4.18
Rate for Payer: Ohana Health Plan Medicare	$3.80
Rate for Payer: UnitedHealthcare Medicaid	$4.76
Rate for Payer: UnitedHealthcare Medicare	$3.80
Rate for Payer: University Health Alliance Commercial	$8.90

HCHG MANUAL DIFF

Facility

$46.00

Service Code	HCPCS 85007
Hospital Charge Code	K3050002
Hospital Revenue Code	305
Min. Negotiated Rate	$39.10
Max. Negotiated Rate	$44.62
Rate for Payer: Cash Price	$29.90
Rate for Payer: Health Management Network Commercial	$39.10
Rate for Payer: MDX Hawaii PPO	$44.62

HCHG MANUAL THERAPY 15 MIN

Facility

$194.00

Service Code	HCPCS 97140
Hospital Charge Code	H4300116
Hospital Revenue Code	430
Min. Negotiated Rate	$20.55
Max. Negotiated Rate	$188.18
Rate for Payer: Cash Price	$126.10
Rate for Payer: Cash Price	$126.10
Rate for Payer: Hawaii Western Management Group Commercial	$184.30
Rate for Payer: Health Management Network Commercial	$164.90
Rate for Payer: Kaiser Permanente Commercial	$122.22
Rate for Payer: Kaiser Permanente Medicaid	$98.94
Rate for Payer: MDX Hawaii PPO	$188.18
Rate for Payer: UnitedHealthcare Medicaid	$20.55
Rate for Payer: University Health Alliance Commercial	$141.41

HCHG MANUAL THERAPY 15 MIN

Facility

$194.00

Service Code	HCPCS 97140
Hospital Charge Code	H4300116
Hospital Revenue Code	430
Min. Negotiated Rate	$164.90
Max. Negotiated Rate	$188.18
Rate for Payer: Cash Price	$126.10
Rate for Payer: Health Management Network Commercial	$164.90
Rate for Payer: MDX Hawaii PPO	$188.18

HCHG MASS SPEC QUANT EA SO

Facility

$296.00

Service Code	HCPCS 83789
Hospital Charge Code	K3010040
Hospital Revenue Code	301
Min. Negotiated Rate	$24.11
Max. Negotiated Rate	$287.12
Rate for Payer: AlohaCare Medicaid	$24.11
Rate for Payer: AlohaCare Medicare	$24.11
Rate for Payer: Cash Price	$192.40
Rate for Payer: Cash Price	$192.40
Rate for Payer: Devoted Health Medicare	$26.52
Rate for Payer: Hawaii Medical Service Association ABD	$24.96
Rate for Payer: Hawaii Medical Service Association Commercial	$30.14
Rate for Payer: Hawaii Medical Service Association Medicare	$24.11
Rate for Payer: Hawaii Medical Service Association Non-ABD	$26.21
Rate for Payer: Hawaii Western Management Group Commercial	$24.11
Rate for Payer: Health Management Network Commercial	$251.60
Rate for Payer: Humana Medicare	$24.11
Rate for Payer: Kaiser Permanente Commercial	$186.48
Rate for Payer: Kaiser Permanente Medicaid	$150.96
Rate for Payer: Kaiser Permanente Medicare	$24.11
Rate for Payer: MDX Hawaii PPO	$287.12
Rate for Payer: Ohana Health Plan Medicaid	$26.52
Rate for Payer: Ohana Health Plan Medicare	$24.11
Rate for Payer: UnitedHealthcare Medicaid	$24.96
Rate for Payer: UnitedHealthcare Medicare	$24.11
Rate for Payer: University Health Alliance Commercial	$46.68

HCHG MASS SPEC QUANT EA SO

Facility

$296.00

Service Code	HCPCS 83789
Hospital Charge Code	K3010040
Hospital Revenue Code	301
Min. Negotiated Rate	$251.60
Max. Negotiated Rate	$287.12
Rate for Payer: Cash Price	$192.40
Rate for Payer: Health Management Network Commercial	$251.60
Rate for Payer: MDX Hawaii PPO	$287.12

HCHG MASTOTOMY W EXPL/DRN ABSC, DEEP

Facility

$6,739.00

Service Code	HCPCS 19020
Hospital Charge Code	H4500855
Hospital Revenue Code	450
Min. Negotiated Rate	$456.03
Max. Negotiated Rate	$6,536.83
Rate for Payer: AlohaCare Medicaid	$1,951.11
Rate for Payer: AlohaCare Medicare	$1,951.11
Rate for Payer: Cash Price	$4,380.35
Rate for Payer: Cash Price	$4,380.35
Rate for Payer: Cash Price	$4,380.35
Rate for Payer: Devoted Health Medicare	$2,146.22
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	$1,951.11
Rate for Payer: Hawaii Medical Service Association Non-ABD	$700.72
Rate for Payer: Hawaii Western Management Group Commercial	$6,402.05
Rate for Payer: Health Management Network Commercial	$5,728.15
Rate for Payer: Humana Medicare	$1,951.11
Rate for Payer: Kaiser Permanente Commercial	$4,245.57
Rate for Payer: Kaiser Permanente Medicaid	$937.50
Rate for Payer: Kaiser Permanente Medicare	$1,951.11
Rate for Payer: MDX Hawaii PPO	$6,536.83
Rate for Payer: Ohana Health Plan Medicaid	$2,146.22
Rate for Payer: Ohana Health Plan Medicare	$1,951.11
Rate for Payer: UnitedHealthcare Medicaid	$456.03
Rate for Payer: UnitedHealthcare Medicare	$1,951.11
Rate for Payer: University Health Alliance Commercial	$5,160.40

HCHG MASTOTOMY W EXPL/DRN ABSC, DEEP

Facility

$6,739.00

Service Code	HCPCS 19020
Hospital Charge Code	H4500855
Hospital Revenue Code	450
Min. Negotiated Rate	$5,728.15
Max. Negotiated Rate	$6,536.83
Rate for Payer: Cash Price	$4,380.35
Rate for Payer: Health Management Network Commercial	$5,728.15
Rate for Payer: MDX Hawaii PPO	$6,536.83

HCHG M.AVIUM COMPLEX MIC PANEL

Facility

$194.00

Service Code	HCPCS 87186
Hospital Charge Code	H3060681
Hospital Revenue Code	306
Min. Negotiated Rate	$164.90
Max. Negotiated Rate	$188.18
Rate for Payer: Cash Price	$126.10
Rate for Payer: Health Management Network Commercial	$164.90
Rate for Payer: MDX Hawaii PPO	$188.18

HCHG M.AVIUM COMPLEX MIC PANEL

Facility

$194.00

Service Code	HCPCS 87186
Hospital Charge Code	H3060681
Hospital Revenue Code	306
Min. Negotiated Rate	$8.65
Max. Negotiated Rate	$188.18
Rate for Payer: AlohaCare Medicaid	$8.65
Rate for Payer: AlohaCare Medicare	$8.65
Rate for Payer: Cash Price	$126.10
Rate for Payer: Cash Price	$126.10
Rate for Payer: Devoted Health Medicare	$9.52
Rate for Payer: Hawaii Medical Service Association ABD	$11.94
Rate for Payer: Hawaii Medical Service Association Commercial	$10.81
Rate for Payer: Hawaii Medical Service Association Medicare	$8.65
Rate for Payer: Hawaii Medical Service Association Non-ABD	$12.54
Rate for Payer: Hawaii Western Management Group Commercial	$8.65
Rate for Payer: Health Management Network Commercial	$164.90
Rate for Payer: Humana Medicare	$8.65
Rate for Payer: Kaiser Permanente Commercial	$122.22
Rate for Payer: Kaiser Permanente Medicaid	$98.94
Rate for Payer: Kaiser Permanente Medicare	$8.65
Rate for Payer: MDX Hawaii PPO	$188.18
Rate for Payer: Ohana Health Plan Medicaid	$9.52
Rate for Payer: Ohana Health Plan Medicare	$8.65
Rate for Payer: UnitedHealthcare Medicaid	$11.94
Rate for Payer: UnitedHealthcare Medicare	$8.65
Rate for Payer: University Health Alliance Commercial	$22.35

HCHG MDI TX INIT

Facility

$418.00

Service Code	HCPCS 94664
Hospital Charge Code	H4120208
Hospital Revenue Code	412
Min. Negotiated Rate	$355.30
Max. Negotiated Rate	$405.46
Rate for Payer: Cash Price	$271.70
Rate for Payer: Health Management Network Commercial	$355.30
Rate for Payer: MDX Hawaii PPO	$405.46

HCHG MDI TX INIT

Facility

$418.00

Service Code	HCPCS 94664
Hospital Charge Code	H4120208
Hospital Revenue Code	412
Min. Negotiated Rate	$14.35
Max. Negotiated Rate	$405.46
Rate for Payer: AlohaCare Medicaid	$258.69
Rate for Payer: AlohaCare Medicare	$258.69
Rate for Payer: Cash Price	$271.70
Rate for Payer: Cash Price	$271.70
Rate for Payer: Devoted Health Medicare	$284.56
Rate for Payer: Hawaii Medical Service Association Commercial	$323.36
Rate for Payer: Hawaii Medical Service Association Medicare	$258.69
Rate for Payer: Hawaii Western Management Group Commercial	$397.10
Rate for Payer: Health Management Network Commercial	$355.30
Rate for Payer: Humana Medicare	$258.69
Rate for Payer: Kaiser Permanente Commercial	$263.34
Rate for Payer: Kaiser Permanente Medicaid	$213.18
Rate for Payer: Kaiser Permanente Medicare	$258.69
Rate for Payer: MDX Hawaii PPO	$405.46
Rate for Payer: Ohana Health Plan Medicaid	$284.56
Rate for Payer: Ohana Health Plan Medicare	$258.69
Rate for Payer: UnitedHealthcare Medicaid	$14.35
Rate for Payer: UnitedHealthcare Medicare	$258.69
Rate for Payer: University Health Alliance Commercial	$304.68

HCHG MDI TX SUBSEQ

Facility

$1,361.00

Service Code	HCPCS 94640
Hospital Charge Code	H4120210
Hospital Revenue Code	412
Min. Negotiated Rate	$1,156.85
Max. Negotiated Rate	$1,320.17
Rate for Payer: Cash Price	$884.65
Rate for Payer: Health Management Network Commercial	$1,156.85
Rate for Payer: MDX Hawaii PPO	$1,320.17

HCHG MDI TX SUBSEQ

Facility

$1,361.00

Service Code	HCPCS 94640
Hospital Charge Code	H4120210
Hospital Revenue Code	412
Min. Negotiated Rate	$13.32
Max. Negotiated Rate	$2,833.00
Rate for Payer: AlohaCare Medicaid	$258.69
Rate for Payer: AlohaCare Medicare	$258.69
Rate for Payer: Cash Price	$884.65
Rate for Payer: Cash Price	$884.65
Rate for Payer: Cash Price	$884.65
Rate for Payer: Devoted Health Medicare	$284.56
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	$258.69
Rate for Payer: Hawaii Medical Service Association Non-ABD	$407.95
Rate for Payer: Hawaii Western Management Group Commercial	$1,292.95
Rate for Payer: Health Management Network Commercial	$1,156.85
Rate for Payer: Humana Medicare	$258.69
Rate for Payer: Kaiser Permanente Commercial	$857.43
Rate for Payer: Kaiser Permanente Medicaid	$694.11
Rate for Payer: Kaiser Permanente Medicare	$258.69
Rate for Payer: MDX Hawaii PPO	$1,320.17
Rate for Payer: Ohana Health Plan Medicaid	$284.56
Rate for Payer: Ohana Health Plan Medicare	$258.69
Rate for Payer: UnitedHealthcare Medicaid	$13.32
Rate for Payer: UnitedHealthcare Medicare	$258.69
Rate for Payer: University Health Alliance Commercial	$992.03

HCHG MDI VENT TX DEMO//EVAL

Facility

$418.00

Service Code	HCPCS 94664
Hospital Charge Code	H4100154
Hospital Revenue Code	410
Min. Negotiated Rate	$14.35
Max. Negotiated Rate	$405.46
Rate for Payer: AlohaCare Medicaid	$258.69
Rate for Payer: AlohaCare Medicare	$258.69
Rate for Payer: Cash Price	$271.70
Rate for Payer: Cash Price	$271.70
Rate for Payer: Devoted Health Medicare	$284.56
Rate for Payer: Hawaii Medical Service Association Commercial	$323.36
Rate for Payer: Hawaii Medical Service Association Medicare	$258.69
Rate for Payer: Hawaii Western Management Group Commercial	$397.10
Rate for Payer: Health Management Network Commercial	$355.30
Rate for Payer: Humana Medicare	$258.69
Rate for Payer: Kaiser Permanente Commercial	$263.34
Rate for Payer: Kaiser Permanente Medicaid	$213.18
Rate for Payer: Kaiser Permanente Medicare	$258.69
Rate for Payer: MDX Hawaii PPO	$405.46
Rate for Payer: Ohana Health Plan Medicaid	$284.56
Rate for Payer: Ohana Health Plan Medicare	$258.69
Rate for Payer: UnitedHealthcare Medicaid	$14.35
Rate for Payer: UnitedHealthcare Medicare	$258.69
Rate for Payer: University Health Alliance Commercial	$304.68

HCHG MDI VENT TX DEMO//EVAL

Facility

$418.00

Service Code	HCPCS 94664
Hospital Charge Code	H4100154
Hospital Revenue Code	410
Min. Negotiated Rate	$355.30
Max. Negotiated Rate	$405.46
Rate for Payer: Cash Price	$271.70
Rate for Payer: Health Management Network Commercial	$355.30
Rate for Payer: MDX Hawaii PPO	$405.46

HCHG MECKEL'S

Facility

$1,881.00

Service Code	HCPCS 78290
Hospital Charge Code	H3410222
Hospital Revenue Code	341
Min. Negotiated Rate	$1,598.85
Max. Negotiated Rate	$1,824.57
Rate for Payer: Cash Price	$1,222.65
Rate for Payer: Health Management Network Commercial	$1,598.85
Rate for Payer: MDX Hawaii PPO	$1,824.57

HCHG MECKEL'S

Facility

$1,881.00

Service Code	HCPCS 78290
Hospital Charge Code	H3410222
Hospital Revenue Code	341
Min. Negotiated Rate	$100.26
Max. Negotiated Rate	$1,824.57
Rate for Payer: AlohaCare Medicaid	$472.27
Rate for Payer: AlohaCare Medicare	$472.27
Rate for Payer: Cash Price	$1,222.65
Rate for Payer: Cash Price	$1,222.65
Rate for Payer: Devoted Health Medicare	$519.50
Rate for Payer: Hawaii Medical Service Association ABD	$100.26
Rate for Payer: Hawaii Medical Service Association Commercial	$590.34
Rate for Payer: Hawaii Medical Service Association Medicare	$472.27
Rate for Payer: Hawaii Medical Service Association Non-ABD	$109.20
Rate for Payer: Hawaii Western Management Group Commercial	$472.27
Rate for Payer: Health Management Network Commercial	$1,598.85
Rate for Payer: Humana Medicare	$472.27
Rate for Payer: Kaiser Permanente Commercial	$1,185.03
Rate for Payer: Kaiser Permanente Medicaid	$959.31
Rate for Payer: Kaiser Permanente Medicare	$472.27
Rate for Payer: MDX Hawaii PPO	$1,824.57
Rate for Payer: Ohana Health Plan Medicaid	$519.50
Rate for Payer: Ohana Health Plan Medicare	$472.27
Rate for Payer: UnitedHealthcare Medicaid	$100.26
Rate for Payer: UnitedHealthcare Medicare	$472.27
Rate for Payer: University Health Alliance Commercial	$525.51

HCHG MEDICAL NUTRITION ASSMT&IVNTJ INDIV EACH 15 MI

Facility

$135.00

Service Code	HCPCS 97802
Hospital Charge Code	K9420001
Hospital Revenue Code	942
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

Know your out-of-pocket cost for care.

All Charges