Kona Community Hospital

All Charges

Charge

Type

Setting

Price

HCHG US, EXTREMITY, NONVAS, RT W IMAGE DOC, LIM

Facility

$758.00

Service Code	HCPCS 76882
Hospital Charge Code	H4020285
Hospital Revenue Code	402
Min. Negotiated Rate	$7.22
Max. Negotiated Rate	$735.26
Rate for Payer: AlohaCare Medicaid	$123.50
Rate for Payer: AlohaCare Medicare	$123.50
Rate for Payer: Cash Price	$492.70
Rate for Payer: Cash Price	$492.70
Rate for Payer: Devoted Health Medicare	$135.85
Rate for Payer: Hawaii Medical Service Association ABD	$7.22
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	$10.72
Rate for Payer: Hawaii Western Management Group Commercial	$123.50
Rate for Payer: Health Management Network Commercial	$644.30
Rate for Payer: Humana Medicare	$123.50
Rate for Payer: Kaiser Permanente Commercial	$477.54
Rate for Payer: Kaiser Permanente Medicaid	$386.58
Rate for Payer: Kaiser Permanente Medicare	$123.50
Rate for Payer: MDX Hawaii PPO	$735.26
Rate for Payer: Ohana Health Plan Medicaid	$135.85
Rate for Payer: Ohana Health Plan Medicare	$123.50
Rate for Payer: UnitedHealthcare Medicaid	$7.22
Rate for Payer: UnitedHealthcare Medicare	$123.50
Rate for Payer: University Health Alliance Commercial	$60.62

HCHG US, EXTREMITY, NONVAS, RT W IMAGE DOC, LIM

Facility

$758.00

Service Code	HCPCS 76882
Hospital Charge Code	H4020285
Hospital Revenue Code	402
Min. Negotiated Rate	$644.30
Max. Negotiated Rate	$735.26
Rate for Payer: Cash Price	$492.70
Rate for Payer: Health Management Network Commercial	$644.30
Rate for Payer: MDX Hawaii PPO	$735.26

HCHG US GUIDE CATHET FLUID DRAINAGE

Facility

$3,028.00

Service Code	HCPCS 10030
Hospital Charge Code	H3610846
Hospital Revenue Code	361
Min. Negotiated Rate	$2,573.80
Max. Negotiated Rate	$2,937.16
Rate for Payer: Cash Price	$1,968.20
Rate for Payer: Health Management Network Commercial	$2,573.80
Rate for Payer: MDX Hawaii PPO	$2,937.16

HCHG US GUIDE CATHET FLUID DRAINAGE

Facility

$3,028.00

Service Code	HCPCS 10030
Hospital Charge Code	H3610846
Hospital Revenue Code	361
Min. Negotiated Rate	$340.18
Max. Negotiated Rate	$4,035.20
Rate for Payer: AlohaCare Medicaid	$836.55
Rate for Payer: AlohaCare Medicare	$836.55
Rate for Payer: Cash Price	$1,968.20
Rate for Payer: Cash Price	$1,968.20
Rate for Payer: Cash Price	$1,968.20
Rate for Payer: Devoted Health Medicare	$920.21
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	$836.55
Rate for Payer: Hawaii Medical Service Association Non-ABD	$407.95
Rate for Payer: Health Management Network Commercial	$2,573.80
Rate for Payer: Humana Medicare	$836.55
Rate for Payer: Kaiser Permanente Commercial	$1,907.64
Rate for Payer: Kaiser Permanente Medicaid	$2,837.00
Rate for Payer: Kaiser Permanente Medicare	$836.55
Rate for Payer: MDX Hawaii PPO	$2,937.16
Rate for Payer: Ohana Health Plan Medicaid	$920.21
Rate for Payer: Ohana Health Plan Medicare	$836.55
Rate for Payer: UnitedHealthcare Medicaid	$340.18
Rate for Payer: UnitedHealthcare Medicare	$836.55
Rate for Payer: University Health Alliance Commercial	$4,035.20

HCHG U/S GUIDE INTRAOP

Facility

$290.00

Service Code	HCPCS 76998
Hospital Charge Code	H4020170
Hospital Revenue Code	402
Min. Negotiated Rate	$246.50
Max. Negotiated Rate	$281.30
Rate for Payer: Cash Price	$188.50
Rate for Payer: Health Management Network Commercial	$246.50
Rate for Payer: MDX Hawaii PPO	$281.30

HCHG U/S GUIDE INTRAOP

Facility

$290.00

Service Code	HCPCS 76998
Hospital Charge Code	H4020170
Hospital Revenue Code	402
Min. Negotiated Rate	$93.99
Max. Negotiated Rate	$281.30
Rate for Payer: Cash Price	$188.50
Rate for Payer: Cash Price	$188.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$93.99
Rate for Payer: Hawaii Western Management Group Commercial	$275.50
Rate for Payer: Health Management Network Commercial	$246.50
Rate for Payer: Kaiser Permanente Commercial	$182.70
Rate for Payer: Kaiser Permanente Medicaid	$147.90
Rate for Payer: MDX Hawaii PPO	$281.30
Rate for Payer: University Health Alliance Commercial	$211.38

HCHG U/S GUID EXAM, FOR NDL PLCMT

Facility

$350.00

Service Code	HCPCS 76942
Hospital Charge Code	H4020194
Hospital Revenue Code	402
Min. Negotiated Rate	$73.06
Max. Negotiated Rate	$361.51
Rate for Payer: Cash Price	$227.50
Rate for Payer: Cash Price	$227.50
Rate for Payer: Hawaii Medical Service Association ABD	$73.06
Rate for Payer: Hawaii Medical Service Association Non-ABD	$104.75
Rate for Payer: Hawaii Western Management Group Commercial	$332.50
Rate for Payer: Health Management Network Commercial	$297.50
Rate for Payer: Kaiser Permanente Commercial	$220.50
Rate for Payer: Kaiser Permanente Medicaid	$178.50
Rate for Payer: MDX Hawaii PPO	$339.50
Rate for Payer: UnitedHealthcare Medicaid	$73.06
Rate for Payer: University Health Alliance Commercial	$361.51

HCHG U/S GUID EXAM, FOR NDL PLCMT

Facility

$350.00

Service Code	HCPCS 76942
Hospital Charge Code	H4020194
Hospital Revenue Code	402
Min. Negotiated Rate	$297.50
Max. Negotiated Rate	$339.50
Rate for Payer: Cash Price	$227.50
Rate for Payer: Health Management Network Commercial	$297.50
Rate for Payer: MDX Hawaii PPO	$339.50

HCHG U/S GUID PERC DRAIN

Facility

$939.00

Service Code	HCPCS 75989
Hospital Charge Code	H4020188
Hospital Revenue Code	402
Min. Negotiated Rate	$103.94
Max. Negotiated Rate	$910.83
Rate for Payer: Cash Price	$610.35
Rate for Payer: Cash Price	$610.35
Rate for Payer: Hawaii Medical Service Association ABD	$103.94
Rate for Payer: Hawaii Medical Service Association Non-ABD	$112.58
Rate for Payer: Hawaii Western Management Group Commercial	$892.05
Rate for Payer: Health Management Network Commercial	$798.15
Rate for Payer: Kaiser Permanente Commercial	$591.57
Rate for Payer: Kaiser Permanente Medicaid	$478.89
Rate for Payer: MDX Hawaii PPO	$910.83
Rate for Payer: UnitedHealthcare Medicaid	$103.94
Rate for Payer: University Health Alliance Commercial	$317.64

HCHG U/S GUID PERC DRAIN

Facility

$939.00

Service Code	HCPCS 75989
Hospital Charge Code	H4020188
Hospital Revenue Code	402
Min. Negotiated Rate	$798.15
Max. Negotiated Rate	$910.83
Rate for Payer: Cash Price	$610.35
Rate for Payer: Health Management Network Commercial	$798.15
Rate for Payer: MDX Hawaii PPO	$910.83

HCHG U/S GUID VASC ACSS SITE PERM

Facility

$436.00

Service Code	HCPCS 76937
Hospital Charge Code	H4020216
Hospital Revenue Code	402
Min. Negotiated Rate	$370.60
Max. Negotiated Rate	$422.92
Rate for Payer: Cash Price	$283.40
Rate for Payer: Health Management Network Commercial	$370.60
Rate for Payer: MDX Hawaii PPO	$422.92

HCHG U/S GUID VASC ACSS SITE PERM

Facility

$436.00

Service Code	HCPCS 76937
Hospital Charge Code	H4020216
Hospital Revenue Code	402
Min. Negotiated Rate	$13.38
Max. Negotiated Rate	$422.92
Rate for Payer: Cash Price	$283.40
Rate for Payer: Cash Price	$283.40
Rate for Payer: Hawaii Medical Service Association ABD	$13.38
Rate for Payer: Hawaii Medical Service Association Non-ABD	$15.63
Rate for Payer: Hawaii Western Management Group Commercial	$414.20
Rate for Payer: Health Management Network Commercial	$370.60
Rate for Payer: Kaiser Permanente Commercial	$274.68
Rate for Payer: Kaiser Permanente Medicaid	$222.36
Rate for Payer: MDX Hawaii PPO	$422.92
Rate for Payer: UnitedHealthcare Medicaid	$13.38
Rate for Payer: University Health Alliance Commercial	$69.04

HCHG U/S HYSTERO

Facility

$1,450.00

Service Code	HCPCS 76831
Hospital Charge Code	H4020132
Hospital Revenue Code	402
Min. Negotiated Rate	$50.35
Max. Negotiated Rate	$1,406.50
Rate for Payer: AlohaCare Medicaid	$281.87
Rate for Payer: AlohaCare Medicare	$281.87
Rate for Payer: Cash Price	$942.50
Rate for Payer: Cash Price	$942.50
Rate for Payer: Devoted Health Medicare	$310.06
Rate for Payer: Hawaii Medical Service Association ABD	$50.35
Rate for Payer: Hawaii Medical Service Association Commercial	$352.34
Rate for Payer: Hawaii Medical Service Association Medicare	$281.87
Rate for Payer: Hawaii Medical Service Association Non-ABD	$54.65
Rate for Payer: Hawaii Western Management Group Commercial	$281.87
Rate for Payer: Health Management Network Commercial	$1,232.50
Rate for Payer: Humana Medicare	$281.87
Rate for Payer: Kaiser Permanente Commercial	$913.50
Rate for Payer: Kaiser Permanente Medicaid	$739.50
Rate for Payer: Kaiser Permanente Medicare	$281.87
Rate for Payer: MDX Hawaii PPO	$1,406.50
Rate for Payer: Ohana Health Plan Medicaid	$310.06
Rate for Payer: Ohana Health Plan Medicare	$281.87
Rate for Payer: UnitedHealthcare Medicaid	$50.35
Rate for Payer: UnitedHealthcare Medicare	$281.87
Rate for Payer: University Health Alliance Commercial	$231.34

HCHG U/S HYSTERO

Facility

$1,450.00

Service Code	HCPCS 76831
Hospital Charge Code	H4020132
Hospital Revenue Code	402
Min. Negotiated Rate	$1,232.50
Max. Negotiated Rate	$1,406.50
Rate for Payer: Cash Price	$942.50
Rate for Payer: Health Management Network Commercial	$1,232.50
Rate for Payer: MDX Hawaii PPO	$1,406.50

HCHG U/S LIVER BX

Facility

$350.00

Service Code	HCPCS 76942
Hospital Charge Code	H4020202
Hospital Revenue Code	402
Min. Negotiated Rate	$297.50
Max. Negotiated Rate	$339.50
Rate for Payer: Cash Price	$227.50
Rate for Payer: Health Management Network Commercial	$297.50
Rate for Payer: MDX Hawaii PPO	$339.50

HCHG U/S LIVER BX

Facility

$350.00

Service Code	HCPCS 76942
Hospital Charge Code	H4020202
Hospital Revenue Code	402
Min. Negotiated Rate	$73.06
Max. Negotiated Rate	$361.51
Rate for Payer: Cash Price	$227.50
Rate for Payer: Cash Price	$227.50
Rate for Payer: Hawaii Medical Service Association ABD	$73.06
Rate for Payer: Hawaii Medical Service Association Non-ABD	$104.75
Rate for Payer: Hawaii Western Management Group Commercial	$332.50
Rate for Payer: Health Management Network Commercial	$297.50
Rate for Payer: Kaiser Permanente Commercial	$220.50
Rate for Payer: Kaiser Permanente Medicaid	$178.50
Rate for Payer: MDX Hawaii PPO	$339.50
Rate for Payer: UnitedHealthcare Medicaid	$73.06
Rate for Payer: University Health Alliance Commercial	$361.51

HCHG U/S NON OB TRANSVAG

Facility

$758.00

Service Code	HCPCS 76830
Hospital Charge Code	H4020218
Hospital Revenue Code	402
Min. Negotiated Rate	$644.30
Max. Negotiated Rate	$735.26
Rate for Payer: Cash Price	$492.70
Rate for Payer: Health Management Network Commercial	$644.30
Rate for Payer: MDX Hawaii PPO	$735.26

HCHG U/S NON OB TRANSVAG

Facility

$758.00

Service Code	HCPCS 76830
Hospital Charge Code	H4020218
Hospital Revenue Code	402
Min. Negotiated Rate	$50.35
Max. Negotiated Rate	$735.26
Rate for Payer: AlohaCare Medicaid	$123.50
Rate for Payer: AlohaCare Medicare	$123.50
Rate for Payer: Cash Price	$492.70
Rate for Payer: Cash Price	$492.70
Rate for Payer: Devoted Health Medicare	$135.85
Rate for Payer: Hawaii Medical Service Association ABD	$50.35
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	$54.65
Rate for Payer: Hawaii Western Management Group Commercial	$123.50
Rate for Payer: Health Management Network Commercial	$644.30
Rate for Payer: Humana Medicare	$123.50
Rate for Payer: Kaiser Permanente Commercial	$477.54
Rate for Payer: Kaiser Permanente Medicaid	$386.58
Rate for Payer: Kaiser Permanente Medicare	$123.50
Rate for Payer: MDX Hawaii PPO	$735.26
Rate for Payer: Ohana Health Plan Medicaid	$135.85
Rate for Payer: Ohana Health Plan Medicare	$123.50
Rate for Payer: UnitedHealthcare Medicaid	$50.35
Rate for Payer: UnitedHealthcare Medicare	$123.50
Rate for Payer: University Health Alliance Commercial	$230.73

HCHG U/S OB>14WK 1 GEST

Facility

$798.00

Service Code	HCPCS 76805
Hospital Charge Code	H4020142
Hospital Revenue Code	402
Min. Negotiated Rate	$61.23
Max. Negotiated Rate	$774.06
Rate for Payer: AlohaCare Medicaid	$123.50
Rate for Payer: AlohaCare Medicare	$123.50
Rate for Payer: Cash Price	$518.70
Rate for Payer: Cash Price	$518.70
Rate for Payer: Devoted Health Medicare	$135.85
Rate for Payer: Hawaii Medical Service Association ABD	$61.23
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	$75.32
Rate for Payer: Hawaii Western Management Group Commercial	$123.50
Rate for Payer: Health Management Network Commercial	$678.30
Rate for Payer: Humana Medicare	$123.50
Rate for Payer: Kaiser Permanente Commercial	$502.74
Rate for Payer: Kaiser Permanente Medicaid	$406.98
Rate for Payer: Kaiser Permanente Medicare	$123.50
Rate for Payer: MDX Hawaii PPO	$774.06
Rate for Payer: Ohana Health Plan Medicaid	$135.85
Rate for Payer: Ohana Health Plan Medicare	$123.50
Rate for Payer: UnitedHealthcare Medicaid	$61.23
Rate for Payer: UnitedHealthcare Medicare	$123.50
Rate for Payer: University Health Alliance Commercial	$287.45

HCHG U/S OB>14WK 1 GEST

Facility

$798.00

Service Code	HCPCS 76805
Hospital Charge Code	H4020142
Hospital Revenue Code	402
Min. Negotiated Rate	$678.30
Max. Negotiated Rate	$774.06
Rate for Payer: Cash Price	$518.70
Rate for Payer: Health Management Network Commercial	$678.30
Rate for Payer: MDX Hawaii PPO	$774.06

HCHG U/S OB<14 WK 1ST GEST

Facility

$758.00

Service Code	HCPCS 76801
Hospital Charge Code	H4020234
Hospital Revenue Code	402
Min. Negotiated Rate	$644.30
Max. Negotiated Rate	$735.26
Rate for Payer: Cash Price	$492.70
Rate for Payer: Health Management Network Commercial	$644.30
Rate for Payer: MDX Hawaii PPO	$735.26

HCHG U/S OB<14 WK 1ST GEST

Facility

$758.00

Service Code	HCPCS 76801
Hospital Charge Code	H4020234
Hospital Revenue Code	402
Min. Negotiated Rate	$55.49
Max. Negotiated Rate	$735.26
Rate for Payer: AlohaCare Medicaid	$123.50
Rate for Payer: AlohaCare Medicare	$123.50
Rate for Payer: Cash Price	$492.70
Rate for Payer: Cash Price	$492.70
Rate for Payer: Devoted Health Medicare	$135.85
Rate for Payer: Hawaii Medical Service Association ABD	$55.49
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	$66.25
Rate for Payer: Hawaii Western Management Group Commercial	$123.50
Rate for Payer: Health Management Network Commercial	$644.30
Rate for Payer: Humana Medicare	$123.50
Rate for Payer: Kaiser Permanente Commercial	$477.54
Rate for Payer: Kaiser Permanente Medicaid	$386.58
Rate for Payer: Kaiser Permanente Medicare	$123.50
Rate for Payer: MDX Hawaii PPO	$735.26
Rate for Payer: Ohana Health Plan Medicaid	$135.85
Rate for Payer: Ohana Health Plan Medicare	$123.50
Rate for Payer: UnitedHealthcare Medicaid	$55.49
Rate for Payer: UnitedHealthcare Medicare	$123.50
Rate for Payer: University Health Alliance Commercial	$265.83

HCHG U/S OB>14WK ADD GEST

Facility

$604.00

Service Code	HCPCS 76810
Hospital Charge Code	H4020110
Hospital Revenue Code	402
Min. Negotiated Rate	$513.40
Max. Negotiated Rate	$585.88
Rate for Payer: Cash Price	$392.60
Rate for Payer: Health Management Network Commercial	$513.40
Rate for Payer: MDX Hawaii PPO	$585.88

HCHG U/S OB>14WK ADD GEST

Facility

$604.00

Service Code	HCPCS 76810
Hospital Charge Code	H4020110
Hospital Revenue Code	402
Min. Negotiated Rate	$48.52
Max. Negotiated Rate	$585.88
Rate for Payer: Cash Price	$392.60
Rate for Payer: Cash Price	$392.60
Rate for Payer: Hawaii Medical Service Association ABD	$48.52
Rate for Payer: Hawaii Medical Service Association Non-ABD	$64.55
Rate for Payer: Hawaii Western Management Group Commercial	$573.80
Rate for Payer: Health Management Network Commercial	$513.40
Rate for Payer: Kaiser Permanente Commercial	$380.52
Rate for Payer: Kaiser Permanente Medicaid	$308.04
Rate for Payer: MDX Hawaii PPO	$585.88
Rate for Payer: UnitedHealthcare Medicaid	$48.52
Rate for Payer: University Health Alliance Commercial	$195.73

HCHG US OB<14WK ADDL GEST

Facility

$378.00

Service Code	HCPCS 76802
Hospital Charge Code	H4020168
Hospital Revenue Code	402
Min. Negotiated Rate	$28.71
Max. Negotiated Rate	$366.66
Rate for Payer: Cash Price	$245.70
Rate for Payer: Cash Price	$245.70
Rate for Payer: Hawaii Medical Service Association ABD	$28.71
Rate for Payer: Hawaii Medical Service Association Non-ABD	$34.28
Rate for Payer: Hawaii Western Management Group Commercial	$359.10
Rate for Payer: Health Management Network Commercial	$321.30
Rate for Payer: Kaiser Permanente Commercial	$238.14
Rate for Payer: Kaiser Permanente Medicaid	$192.78
Rate for Payer: MDX Hawaii PPO	$366.66
Rate for Payer: UnitedHealthcare Medicaid	$28.71
Rate for Payer: University Health Alliance Commercial	$152.61

Know your out-of-pocket cost for care.

All Charges