Kona Community Hospital

All Charges

Charge

Type

Setting

Price

HCHG T3 FREE

Facility

$209.00

Service Code	HCPCS 84481
Hospital Charge Code	H3011192
Hospital Revenue Code	301
Min. Negotiated Rate	$16.94
Max. Negotiated Rate	$202.73
Rate for Payer: AlohaCare Medicaid	$16.94
Rate for Payer: AlohaCare Medicare	$16.94
Rate for Payer: Cash Price	$135.85
Rate for Payer: Cash Price	$135.85
Rate for Payer: Devoted Health Medicare	$18.63
Rate for Payer: Hawaii Medical Service Association ABD	$23.41
Rate for Payer: Hawaii Medical Service Association Commercial	$21.18
Rate for Payer: Hawaii Medical Service Association Medicare	$16.94
Rate for Payer: Hawaii Medical Service Association Non-ABD	$24.58
Rate for Payer: Hawaii Western Management Group Commercial	$16.94
Rate for Payer: Health Management Network Commercial	$177.65
Rate for Payer: Humana Medicare	$16.94
Rate for Payer: Kaiser Permanente Commercial	$131.67
Rate for Payer: Kaiser Permanente Medicaid	$106.59
Rate for Payer: Kaiser Permanente Medicare	$16.94
Rate for Payer: MDX Hawaii PPO	$202.73
Rate for Payer: Ohana Health Plan Medicaid	$18.63
Rate for Payer: Ohana Health Plan Medicare	$16.94
Rate for Payer: UnitedHealthcare Medicaid	$23.41
Rate for Payer: UnitedHealthcare Medicare	$16.94
Rate for Payer: University Health Alliance Commercial	$43.79

HCHG T3 TOT

Facility

$218.00

Service Code	HCPCS 84480
Hospital Charge Code	H3011194
Hospital Revenue Code	301
Min. Negotiated Rate	$185.30
Max. Negotiated Rate	$211.46
Rate for Payer: Cash Price	$141.70
Rate for Payer: Health Management Network Commercial	$185.30
Rate for Payer: MDX Hawaii PPO	$211.46

HCHG T3 TOT

Facility

$218.00

Service Code	HCPCS 84480
Hospital Charge Code	H3011194
Hospital Revenue Code	301
Min. Negotiated Rate	$14.18
Max. Negotiated Rate	$211.46
Rate for Payer: AlohaCare Medicaid	$14.18
Rate for Payer: AlohaCare Medicare	$14.18
Rate for Payer: Cash Price	$141.70
Rate for Payer: Cash Price	$141.70
Rate for Payer: Devoted Health Medicare	$15.60
Rate for Payer: Hawaii Medical Service Association ABD	$19.60
Rate for Payer: Hawaii Medical Service Association Commercial	$17.73
Rate for Payer: Hawaii Medical Service Association Medicare	$14.18
Rate for Payer: Hawaii Medical Service Association Non-ABD	$20.58
Rate for Payer: Hawaii Western Management Group Commercial	$14.18
Rate for Payer: Health Management Network Commercial	$185.30
Rate for Payer: Humana Medicare	$14.18
Rate for Payer: Kaiser Permanente Commercial	$137.34
Rate for Payer: Kaiser Permanente Medicaid	$111.18
Rate for Payer: Kaiser Permanente Medicare	$14.18
Rate for Payer: MDX Hawaii PPO	$211.46
Rate for Payer: Ohana Health Plan Medicaid	$15.60
Rate for Payer: Ohana Health Plan Medicare	$14.18
Rate for Payer: UnitedHealthcare Medicaid	$19.60
Rate for Payer: UnitedHealthcare Medicare	$14.18
Rate for Payer: University Health Alliance Commercial	$36.65

HCHG T3 UPTAKE

Facility

$110.00

Service Code	HCPCS 84479
Hospital Charge Code	H3011198
Hospital Revenue Code	301
Min. Negotiated Rate	$93.50
Max. Negotiated Rate	$106.70
Rate for Payer: Cash Price	$71.50
Rate for Payer: Health Management Network Commercial	$93.50
Rate for Payer: MDX Hawaii PPO	$106.70

HCHG T3 UPTAKE

Facility

$110.00

Service Code	HCPCS 84479
Hospital Charge Code	H3011198
Hospital Revenue Code	301
Min. Negotiated Rate	$6.47
Max. Negotiated Rate	$106.70
Rate for Payer: AlohaCare Medicaid	$6.47
Rate for Payer: AlohaCare Medicare	$6.47
Rate for Payer: Cash Price	$71.50
Rate for Payer: Cash Price	$71.50
Rate for Payer: Devoted Health Medicare	$7.12
Rate for Payer: Hawaii Medical Service Association ABD	$8.95
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	$9.40
Rate for Payer: Hawaii Western Management Group Commercial	$6.47
Rate for Payer: Health Management Network Commercial	$93.50
Rate for Payer: Humana Medicare	$6.47
Rate for Payer: Kaiser Permanente Commercial	$69.30
Rate for Payer: Kaiser Permanente Medicaid	$56.10
Rate for Payer: Kaiser Permanente Medicare	$6.47
Rate for Payer: MDX Hawaii PPO	$106.70
Rate for Payer: Ohana Health Plan Medicaid	$7.12
Rate for Payer: Ohana Health Plan Medicare	$6.47
Rate for Payer: UnitedHealthcare Medicaid	$8.95
Rate for Payer: UnitedHealthcare Medicare	$6.47
Rate for Payer: University Health Alliance Commercial	$16.72

HCHG T4 TOTAL

Facility

$118.00

Service Code	HCPCS 84436
Hospital Charge Code	H3011456
Hospital Revenue Code	301
Min. Negotiated Rate	$100.30
Max. Negotiated Rate	$114.46
Rate for Payer: Cash Price	$76.70
Rate for Payer: Health Management Network Commercial	$100.30
Rate for Payer: MDX Hawaii PPO	$114.46

HCHG T4 TOTAL

Facility

$118.00

Service Code	HCPCS 84436
Hospital Charge Code	H3011456
Hospital Revenue Code	301
Min. Negotiated Rate	$6.87
Max. Negotiated Rate	$114.46
Rate for Payer: AlohaCare Medicaid	$6.87
Rate for Payer: AlohaCare Medicare	$6.87
Rate for Payer: Cash Price	$76.70
Rate for Payer: Cash Price	$76.70
Rate for Payer: Devoted Health Medicare	$7.56
Rate for Payer: Hawaii Medical Service Association ABD	$9.50
Rate for Payer: Hawaii Medical Service Association Commercial	$8.59
Rate for Payer: Hawaii Medical Service Association Medicare	$6.87
Rate for Payer: Hawaii Medical Service Association Non-ABD	$9.98
Rate for Payer: Hawaii Western Management Group Commercial	$6.87
Rate for Payer: Health Management Network Commercial	$100.30
Rate for Payer: Humana Medicare	$6.87
Rate for Payer: Kaiser Permanente Commercial	$74.34
Rate for Payer: Kaiser Permanente Medicaid	$60.18
Rate for Payer: Kaiser Permanente Medicare	$6.87
Rate for Payer: MDX Hawaii PPO	$114.46
Rate for Payer: Ohana Health Plan Medicaid	$7.56
Rate for Payer: Ohana Health Plan Medicare	$6.87
Rate for Payer: UnitedHealthcare Medicaid	$9.50
Rate for Payer: UnitedHealthcare Medicare	$6.87
Rate for Payer: University Health Alliance Commercial	$17.78

HCHG TACROLIMUS

Facility

$169.00

Service Code	HCPCS 80197
Hospital Charge Code	H3000384
Hospital Revenue Code	301
Min. Negotiated Rate	$13.73
Max. Negotiated Rate	$163.93
Rate for Payer: AlohaCare Medicaid	$13.73
Rate for Payer: AlohaCare Medicare	$13.73
Rate for Payer: Cash Price	$109.85
Rate for Payer: Cash Price	$109.85
Rate for Payer: Devoted Health Medicare	$15.10
Rate for Payer: Hawaii Medical Service Association ABD	$18.97
Rate for Payer: Hawaii Medical Service Association Commercial	$17.16
Rate for Payer: Hawaii Medical Service Association Medicare	$13.73
Rate for Payer: Hawaii Medical Service Association Non-ABD	$19.92
Rate for Payer: Hawaii Western Management Group Commercial	$13.73
Rate for Payer: Health Management Network Commercial	$143.65
Rate for Payer: Humana Medicare	$13.73
Rate for Payer: Kaiser Permanente Commercial	$106.47
Rate for Payer: Kaiser Permanente Medicaid	$86.19
Rate for Payer: Kaiser Permanente Medicare	$13.73
Rate for Payer: MDX Hawaii PPO	$163.93
Rate for Payer: Ohana Health Plan Medicaid	$15.10
Rate for Payer: Ohana Health Plan Medicare	$13.73
Rate for Payer: UnitedHealthcare Medicaid	$18.97
Rate for Payer: UnitedHealthcare Medicare	$13.73
Rate for Payer: University Health Alliance Commercial	$35.46

HCHG TACROLIMUS

Facility

$169.00

Service Code	HCPCS 80197
Hospital Charge Code	H3000384
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 TAP BLOCK UNIL BY INJECTION

Facility

$923.00

Service Code	HCPCS 64486
Hospital Charge Code	H3610852
Hospital Revenue Code	361
Min. Negotiated Rate	$784.55
Max. Negotiated Rate	$895.31
Rate for Payer: Cash Price	$599.95
Rate for Payer: Health Management Network Commercial	$784.55
Rate for Payer: MDX Hawaii PPO	$895.31

HCHG TAP BLOCK UNIL BY INJECTION

Facility

$923.00

Service Code	HCPCS 64486
Hospital Charge Code	H3610852
Hospital Revenue Code	361
Min. Negotiated Rate	$53.89
Max. Negotiated Rate	$2,837.00
Rate for Payer: Cash Price	$599.95
Rate for Payer: Cash Price	$599.95
Rate for Payer: Cash Price	$599.95
Rate for Payer: Health Management Network Commercial	$784.55
Rate for Payer: Kaiser Permanente Commercial	$581.49
Rate for Payer: Kaiser Permanente Medicaid	$2,837.00
Rate for Payer: MDX Hawaii PPO	$895.31
Rate for Payer: UnitedHealthcare Medicaid	$53.89
Rate for Payer: University Health Alliance Commercial	$672.77

HCHG TB, AMP PROBE - 90

Facility

$361.00

Service Code	HCPCS 87556
Hospital Charge Code	H3060771
Hospital Revenue Code	306
Min. Negotiated Rate	$41.68
Max. Negotiated Rate	$350.17
Rate for Payer: AlohaCare Medicaid	$41.68
Rate for Payer: AlohaCare Medicare	$41.68
Rate for Payer: Cash Price	$234.65
Rate for Payer: Cash Price	$234.65
Rate for Payer: Devoted Health Medicare	$45.85
Rate for Payer: Hawaii Medical Service Association ABD	$48.50
Rate for Payer: Hawaii Medical Service Association Commercial	$52.10
Rate for Payer: Hawaii Medical Service Association Medicare	$41.68
Rate for Payer: Hawaii Medical Service Association Non-ABD	$50.93
Rate for Payer: Hawaii Western Management Group Commercial	$41.68
Rate for Payer: Health Management Network Commercial	$306.85
Rate for Payer: Humana Medicare	$41.68
Rate for Payer: Kaiser Permanente Commercial	$227.43
Rate for Payer: Kaiser Permanente Medicaid	$184.11
Rate for Payer: Kaiser Permanente Medicare	$41.68
Rate for Payer: MDX Hawaii PPO	$350.17
Rate for Payer: Ohana Health Plan Medicaid	$45.85
Rate for Payer: Ohana Health Plan Medicare	$41.68
Rate for Payer: UnitedHealthcare Medicaid	$48.50
Rate for Payer: UnitedHealthcare Medicare	$41.68
Rate for Payer: University Health Alliance Commercial	$90.72

HCHG TB, AMP PROBE - 90

Facility

$361.00

Service Code	HCPCS 87556
Hospital Charge Code	H3060771
Hospital Revenue Code	306
Min. Negotiated Rate	$306.85
Max. Negotiated Rate	$350.17
Rate for Payer: Cash Price	$234.65
Rate for Payer: Health Management Network Commercial	$306.85
Rate for Payer: MDX Hawaii PPO	$350.17

HCHG TB COMPLEX DNA PCR 90

Facility

$361.00

Service Code	HCPCS 87556
Hospital Charge Code	H3060492
Hospital Revenue Code	306
Min. Negotiated Rate	$306.85
Max. Negotiated Rate	$350.17
Rate for Payer: Cash Price	$234.65
Rate for Payer: Health Management Network Commercial	$306.85
Rate for Payer: MDX Hawaii PPO	$350.17

HCHG TB COMPLEX DNA PCR 90

Facility

$361.00

Service Code	HCPCS 87556
Hospital Charge Code	H3060492
Hospital Revenue Code	306
Min. Negotiated Rate	$41.68
Max. Negotiated Rate	$350.17
Rate for Payer: AlohaCare Medicaid	$41.68
Rate for Payer: AlohaCare Medicare	$41.68
Rate for Payer: Cash Price	$234.65
Rate for Payer: Cash Price	$234.65
Rate for Payer: Devoted Health Medicare	$45.85
Rate for Payer: Hawaii Medical Service Association ABD	$48.50
Rate for Payer: Hawaii Medical Service Association Commercial	$52.10
Rate for Payer: Hawaii Medical Service Association Medicare	$41.68
Rate for Payer: Hawaii Medical Service Association Non-ABD	$50.93
Rate for Payer: Hawaii Western Management Group Commercial	$41.68
Rate for Payer: Health Management Network Commercial	$306.85
Rate for Payer: Humana Medicare	$41.68
Rate for Payer: Kaiser Permanente Commercial	$227.43
Rate for Payer: Kaiser Permanente Medicaid	$184.11
Rate for Payer: Kaiser Permanente Medicare	$41.68
Rate for Payer: MDX Hawaii PPO	$350.17
Rate for Payer: Ohana Health Plan Medicaid	$45.85
Rate for Payer: Ohana Health Plan Medicare	$41.68
Rate for Payer: UnitedHealthcare Medicaid	$48.50
Rate for Payer: UnitedHealthcare Medicare	$41.68
Rate for Payer: University Health Alliance Commercial	$90.72

HCHG TBII

Facility

$160.00

Service Code	HCPCS 83519
Hospital Charge Code	H3011206
Hospital Revenue Code	301
Min. Negotiated Rate	$18.40
Max. Negotiated Rate	$155.20
Rate for Payer: AlohaCare Medicaid	$18.40
Rate for Payer: AlohaCare Medicare	$18.40
Rate for Payer: Cash Price	$104.00
Rate for Payer: Cash Price	$104.00
Rate for Payer: Devoted Health Medicare	$20.24
Rate for Payer: Hawaii Medical Service Association ABD	$18.67
Rate for Payer: Hawaii Medical Service Association Commercial	$23.00
Rate for Payer: Hawaii Medical Service Association Medicare	$18.40
Rate for Payer: Hawaii Medical Service Association Non-ABD	$19.60
Rate for Payer: Hawaii Western Management Group Commercial	$18.40
Rate for Payer: Health Management Network Commercial	$136.00
Rate for Payer: Humana Medicare	$18.40
Rate for Payer: Kaiser Permanente Commercial	$100.80
Rate for Payer: Kaiser Permanente Medicaid	$81.60
Rate for Payer: Kaiser Permanente Medicare	$18.40
Rate for Payer: MDX Hawaii PPO	$155.20
Rate for Payer: Ohana Health Plan Medicaid	$20.24
Rate for Payer: Ohana Health Plan Medicare	$18.40
Rate for Payer: UnitedHealthcare Medicaid	$18.67
Rate for Payer: UnitedHealthcare Medicare	$18.40
Rate for Payer: University Health Alliance Commercial	$34.93

HCHG TBII

Facility

$160.00

Service Code	HCPCS 83519
Hospital Charge Code	H3011206
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 TC99M CARDIOLITE/DOSE

Facility

$189.00

Service Code	HCPCS A9500
Hospital Charge Code	H3430126
Hospital Revenue Code	343
Min. Negotiated Rate	$160.65
Max. Negotiated Rate	$183.33
Rate for Payer: Cash Price	$122.85
Rate for Payer: Health Management Network Commercial	$160.65
Rate for Payer: MDX Hawaii PPO	$183.33

HCHG TC99M CARDIOLITE/DOSE

Facility

$189.00

Service Code	HCPCS A9500
Hospital Charge Code	H3430126
Hospital Revenue Code	343
Min. Negotiated Rate	$83.20
Max. Negotiated Rate	$183.33
Rate for Payer: Cash Price	$122.85
Rate for Payer: Cash Price	$122.85
Rate for Payer: Hawaii Western Management Group Commercial	$179.55
Rate for Payer: Health Management Network Commercial	$160.65
Rate for Payer: Kaiser Permanente Commercial	$119.07
Rate for Payer: Kaiser Permanente Medicaid	$96.39
Rate for Payer: MDX Hawaii PPO	$183.33
Rate for Payer: UnitedHealthcare Medicaid	$83.20
Rate for Payer: University Health Alliance Commercial	$137.76

HCHG TC99M DTPA, UP 75MCI FOR AEROSOL VENT

Facility

$380.00

Service Code	HCPCS A9567
Hospital Charge Code	H3430216
Hospital Revenue Code	343
Min. Negotiated Rate	$323.00
Max. Negotiated Rate	$368.60
Rate for Payer: Cash Price	$247.00
Rate for Payer: Health Management Network Commercial	$323.00
Rate for Payer: MDX Hawaii PPO	$368.60

HCHG TC99M DTPA, UP 75MCI FOR AEROSOL VENT

Facility

$380.00

Service Code	HCPCS A9567
Hospital Charge Code	H3430216
Hospital Revenue Code	343
Min. Negotiated Rate	$193.80
Max. Negotiated Rate	$368.60
Rate for Payer: Cash Price	$247.00
Rate for Payer: Hawaii Western Management Group Commercial	$361.00
Rate for Payer: Health Management Network Commercial	$323.00
Rate for Payer: Kaiser Permanente Commercial	$239.40
Rate for Payer: Kaiser Permanente Medicaid	$193.80
Rate for Payer: MDX Hawaii PPO	$368.60
Rate for Payer: University Health Alliance Commercial	$276.98

HCHG TC99M DTPA, UP TO 25MCI

Facility

$202.00

Service Code	HCPCS A9539
Hospital Charge Code	H3430128
Hospital Revenue Code	343
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 TC99M DTPA, UP TO 25MCI

Facility

$202.00

Service Code	HCPCS A9539
Hospital Charge Code	H3430128
Hospital Revenue Code	343
Min. Negotiated Rate	$103.02
Max. Negotiated Rate	$195.94
Rate for Payer: Cash Price	$131.30
Rate for Payer: Hawaii Western Management Group Commercial	$191.90
Rate for Payer: Health Management Network Commercial	$171.70
Rate for Payer: Kaiser Permanente Commercial	$127.26
Rate for Payer: Kaiser Permanente Medicaid	$103.02
Rate for Payer: MDX Hawaii PPO	$195.94
Rate for Payer: University Health Alliance Commercial	$147.24

HCHG TC99M HIDA, UP TO 15MCI

Facility

$399.00

Service Code	HCPCS A9510
Hospital Charge Code	H3430134
Hospital Revenue Code	343
Min. Negotiated Rate	$79.17
Max. Negotiated Rate	$387.03
Rate for Payer: Cash Price	$259.35
Rate for Payer: Cash Price	$259.35
Rate for Payer: Hawaii Western Management Group Commercial	$379.05
Rate for Payer: Health Management Network Commercial	$339.15
Rate for Payer: Kaiser Permanente Commercial	$251.37
Rate for Payer: Kaiser Permanente Medicaid	$203.49
Rate for Payer: MDX Hawaii PPO	$387.03
Rate for Payer: UnitedHealthcare Medicaid	$79.17
Rate for Payer: University Health Alliance Commercial	$290.83

HCHG TC99M HIDA, UP TO 15MCI

Facility

$399.00

Service Code	HCPCS A9510
Hospital Charge Code	H3430134
Hospital Revenue Code	343
Min. Negotiated Rate	$339.15
Max. Negotiated Rate	$387.03
Rate for Payer: Cash Price	$259.35
Rate for Payer: Health Management Network Commercial	$339.15
Rate for Payer: MDX Hawaii PPO	$387.03

Know your out-of-pocket cost for care.

All Charges