Kona Community Hospital

All Charges

Charge

Type

Setting

Price

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

HCHG U/S OB AMNIO FLUID

Facility

$708.00

Service Code	HCPCS 76815
Hospital Charge Code	H4020102
Hospital Revenue Code	402
Min. Negotiated Rate	$601.80
Max. Negotiated Rate	$686.76
Rate for Payer: Cash Price	$460.20
Rate for Payer: Health Management Network Commercial	$601.80
Rate for Payer: MDX Hawaii PPO	$686.76

HCHG U/S OB AMNIO FLUID

Facility

$708.00

Service Code	HCPCS 76815
Hospital Charge Code	H4020102
Hospital Revenue Code	402
Min. Negotiated Rate	$46.98
Max. Negotiated Rate	$686.76
Rate for Payer: AlohaCare Medicaid	$123.50
Rate for Payer: AlohaCare Medicare	$123.50
Rate for Payer: Cash Price	$460.20
Rate for Payer: Cash Price	$460.20
Rate for Payer: Devoted Health Medicare	$135.85
Rate for Payer: Hawaii Medical Service Association ABD	$46.98
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	$50.90
Rate for Payer: Hawaii Western Management Group Commercial	$123.50
Rate for Payer: Health Management Network Commercial	$601.80
Rate for Payer: Humana Medicare	$123.50
Rate for Payer: Kaiser Permanente Commercial	$446.04
Rate for Payer: Kaiser Permanente Medicaid	$361.08
Rate for Payer: Kaiser Permanente Medicare	$123.50
Rate for Payer: MDX Hawaii PPO	$686.76
Rate for Payer: Ohana Health Plan Medicaid	$135.85
Rate for Payer: Ohana Health Plan Medicare	$123.50
Rate for Payer: UnitedHealthcare Medicaid	$46.98
Rate for Payer: UnitedHealthcare Medicare	$123.50
Rate for Payer: University Health Alliance Commercial	$183.63

HCHG U/S OB F/U EA GEST

Facility

$598.00

Service Code	HCPCS 76816
Hospital Charge Code	H4020130
Hospital Revenue Code	402
Min. Negotiated Rate	$508.30
Max. Negotiated Rate	$580.06
Rate for Payer: Cash Price	$388.70
Rate for Payer: Health Management Network Commercial	$508.30
Rate for Payer: MDX Hawaii PPO	$580.06

HCHG U/S OB F/U EA GEST

Facility

$598.00

Service Code	HCPCS 76816
Hospital Charge Code	H4020130
Hospital Revenue Code	402
Min. Negotiated Rate	$36.81
Max. Negotiated Rate	$580.06
Rate for Payer: AlohaCare Medicaid	$123.50
Rate for Payer: AlohaCare Medicare	$123.50
Rate for Payer: Cash Price	$388.70
Rate for Payer: Cash Price	$388.70
Rate for Payer: Devoted Health Medicare	$135.85
Rate for Payer: Hawaii Medical Service Association ABD	$36.81
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	$39.59
Rate for Payer: Hawaii Western Management Group Commercial	$123.50
Rate for Payer: Health Management Network Commercial	$508.30
Rate for Payer: Humana Medicare	$123.50
Rate for Payer: Kaiser Permanente Commercial	$376.74
Rate for Payer: Kaiser Permanente Medicaid	$304.98
Rate for Payer: Kaiser Permanente Medicare	$123.50
Rate for Payer: MDX Hawaii PPO	$580.06
Rate for Payer: Ohana Health Plan Medicaid	$135.85
Rate for Payer: Ohana Health Plan Medicare	$123.50
Rate for Payer: UnitedHealthcare Medicaid	$36.81
Rate for Payer: UnitedHealthcare Medicare	$123.50
Rate for Payer: University Health Alliance Commercial	$203.81

HCHG U/S OB POSITION

Facility

$708.00

Service Code	HCPCS 76815
Hospital Charge Code	H4020134
Hospital Revenue Code	402
Min. Negotiated Rate	$46.98
Max. Negotiated Rate	$686.76
Rate for Payer: AlohaCare Medicaid	$123.50
Rate for Payer: AlohaCare Medicare	$123.50
Rate for Payer: Cash Price	$460.20
Rate for Payer: Cash Price	$460.20
Rate for Payer: Devoted Health Medicare	$135.85
Rate for Payer: Hawaii Medical Service Association ABD	$46.98
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	$50.90
Rate for Payer: Hawaii Western Management Group Commercial	$123.50
Rate for Payer: Health Management Network Commercial	$601.80
Rate for Payer: Humana Medicare	$123.50
Rate for Payer: Kaiser Permanente Commercial	$446.04
Rate for Payer: Kaiser Permanente Medicaid	$361.08
Rate for Payer: Kaiser Permanente Medicare	$123.50
Rate for Payer: MDX Hawaii PPO	$686.76
Rate for Payer: Ohana Health Plan Medicaid	$135.85
Rate for Payer: Ohana Health Plan Medicare	$123.50
Rate for Payer: UnitedHealthcare Medicaid	$46.98
Rate for Payer: UnitedHealthcare Medicare	$123.50
Rate for Payer: University Health Alliance Commercial	$183.63

HCHG U/S OB POSITION

Facility

$708.00

Service Code	HCPCS 76815
Hospital Charge Code	H4020134
Hospital Revenue Code	402
Min. Negotiated Rate	$601.80
Max. Negotiated Rate	$686.76
Rate for Payer: Cash Price	$460.20
Rate for Payer: Health Management Network Commercial	$601.80
Rate for Payer: MDX Hawaii PPO	$686.76

HCHG U/S OBS TRANSVAGINAL

Facility

$758.00

Service Code	HCPCS 76817
Hospital Charge Code	H4020224
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 OBS TRANSVAGINAL

Facility

$758.00

Service Code	HCPCS 76817
Hospital Charge Code	H4020224
Hospital Revenue Code	402
Min. Negotiated Rate	$46.06
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	$46.06
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	$53.86
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	$46.06
Rate for Payer: UnitedHealthcare Medicare	$123.50
Rate for Payer: University Health Alliance Commercial	$193.75

HCHG U/S OB TRANSVAG

Facility

$758.00

Service Code	HCPCS 76817
Hospital Charge Code	H4020140
Hospital Revenue Code	402
Min. Negotiated Rate	$46.06
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	$46.06
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	$53.86
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	$46.06
Rate for Payer: UnitedHealthcare Medicare	$123.50
Rate for Payer: University Health Alliance Commercial	$193.75

HCHG U/S OB TRANSVAG

Facility

$758.00

Service Code	HCPCS 76817
Hospital Charge Code	H4020140
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 W DETAIL EA ADDL

Facility

$258.00

Service Code	HCPCS 76812
Hospital Charge Code	H4020138
Hospital Revenue Code	402
Min. Negotiated Rate	$38.47
Max. Negotiated Rate	$282.24
Rate for Payer: Cash Price	$167.70
Rate for Payer: Cash Price	$167.70
Rate for Payer: Hawaii Medical Service Association ABD	$38.47
Rate for Payer: Hawaii Medical Service Association Non-ABD	$44.99
Rate for Payer: Hawaii Western Management Group Commercial	$245.10
Rate for Payer: Health Management Network Commercial	$219.30
Rate for Payer: Kaiser Permanente Commercial	$162.54
Rate for Payer: Kaiser Permanente Medicaid	$131.58
Rate for Payer: MDX Hawaii PPO	$250.26
Rate for Payer: UnitedHealthcare Medicaid	$38.47
Rate for Payer: University Health Alliance Commercial	$282.24

HCHG U/S OB W DETAIL EA ADDL

Facility

$258.00

Service Code	HCPCS 76812
Hospital Charge Code	H4020138
Hospital Revenue Code	402
Min. Negotiated Rate	$219.30
Max. Negotiated Rate	$250.26
Rate for Payer: Cash Price	$167.70
Rate for Payer: Health Management Network Commercial	$219.30
Rate for Payer: MDX Hawaii PPO	$250.26

HCHG U/S OB W DETAIL SINGLE

Facility

$514.00

Service Code	HCPCS 76811
Hospital Charge Code	H4020136
Hospital Revenue Code	402
Min. Negotiated Rate	$436.90
Max. Negotiated Rate	$498.58
Rate for Payer: Cash Price	$334.10
Rate for Payer: Health Management Network Commercial	$436.90
Rate for Payer: MDX Hawaii PPO	$498.58

HCHG U/S OB W DETAIL SINGLE

Facility

$514.00

Service Code	HCPCS 76811
Hospital Charge Code	H4020136
Hospital Revenue Code	402
Min. Negotiated Rate	$112.44
Max. Negotiated Rate	$498.58
Rate for Payer: AlohaCare Medicaid	$281.87
Rate for Payer: AlohaCare Medicare	$281.87
Rate for Payer: Cash Price	$334.10
Rate for Payer: Cash Price	$334.10
Rate for Payer: Devoted Health Medicare	$310.06
Rate for Payer: Hawaii Medical Service Association ABD	$112.44
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	$131.50
Rate for Payer: Hawaii Western Management Group Commercial	$281.87
Rate for Payer: Health Management Network Commercial	$436.90
Rate for Payer: Humana Medicare	$281.87
Rate for Payer: Kaiser Permanente Commercial	$323.82
Rate for Payer: Kaiser Permanente Medicaid	$262.14
Rate for Payer: Kaiser Permanente Medicare	$281.87
Rate for Payer: MDX Hawaii PPO	$498.58
Rate for Payer: Ohana Health Plan Medicaid	$310.06
Rate for Payer: Ohana Health Plan Medicare	$281.87
Rate for Payer: UnitedHealthcare Medicaid	$112.44
Rate for Payer: UnitedHealthcare Medicare	$281.87
Rate for Payer: University Health Alliance Commercial	$436.01

HCHG U/S PELVIC NON-OB LTD

Facility

$708.00

Service Code	HCPCS 76857
Hospital Charge Code	H4020226
Hospital Revenue Code	402
Min. Negotiated Rate	$44.29
Max. Negotiated Rate	$686.76
Rate for Payer: AlohaCare Medicaid	$123.50
Rate for Payer: AlohaCare Medicare	$123.50
Rate for Payer: Cash Price	$460.20
Rate for Payer: Cash Price	$460.20
Rate for Payer: Devoted Health Medicare	$135.85
Rate for Payer: Hawaii Medical Service Association ABD	$44.29
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	$69.53
Rate for Payer: Hawaii Western Management Group Commercial	$123.50
Rate for Payer: Health Management Network Commercial	$601.80
Rate for Payer: Humana Medicare	$123.50
Rate for Payer: Kaiser Permanente Commercial	$446.04
Rate for Payer: Kaiser Permanente Medicaid	$361.08
Rate for Payer: Kaiser Permanente Medicare	$123.50
Rate for Payer: MDX Hawaii PPO	$686.76
Rate for Payer: Ohana Health Plan Medicaid	$135.85
Rate for Payer: Ohana Health Plan Medicare	$123.50
Rate for Payer: UnitedHealthcare Medicaid	$44.29
Rate for Payer: UnitedHealthcare Medicare	$123.50
Rate for Payer: University Health Alliance Commercial	$161.45

HCHG U/S PELVIC NON-OB LTD

Facility

$708.00

Service Code	HCPCS 76857
Hospital Charge Code	H4020226
Hospital Revenue Code	402
Min. Negotiated Rate	$601.80
Max. Negotiated Rate	$686.76
Rate for Payer: Cash Price	$460.20
Rate for Payer: Health Management Network Commercial	$601.80
Rate for Payer: MDX Hawaii PPO	$686.76

HCHG U/S PELVIC SCAN CMPLT

Facility

$758.00

Service Code	HCPCS 76856
Hospital Charge Code	H4020230
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 PELVIC SCAN CMPLT

Facility

$758.00

Service Code	HCPCS 76856
Hospital Charge Code	H4020230
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	$231.53

HCHG U/S PELVIS COMP PORT

Facility

$758.00

Service Code	HCPCS 76856
Hospital Charge Code	H4020232
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	$231.53

HCHG U/S PELVIS COMP PORT

Facility

$758.00

Service Code	HCPCS 76856
Hospital Charge Code	H4020232
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 RENAL,COMPLETE

Facility

$758.00

Service Code	HCPCS 76770
Hospital Charge Code	H4020240
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 RENAL,COMPLETE

Facility

$758.00

Service Code	HCPCS 76770
Hospital Charge Code	H4020240
Hospital Revenue Code	402
Min. Negotiated Rate	$64.94
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	$64.94
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	$70.56
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	$64.94
Rate for Payer: UnitedHealthcare Medicare	$123.50
Rate for Payer: University Health Alliance Commercial	$258.91

HCHG U/S RETROP LTD

Facility

$758.00

Service Code	HCPCS 76775
Hospital Charge Code	H4020244
Hospital Revenue Code	402
Min. Negotiated Rate	$46.98
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	$46.98
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	$50.90
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	$46.98
Rate for Payer: UnitedHealthcare Medicare	$123.50
Rate for Payer: University Health Alliance Commercial	$202.63

HCHG U/S RETROP LTD

Facility

$758.00

Service Code	HCPCS 76775
Hospital Charge Code	H4020244
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

Know your out-of-pocket cost for care.

All Charges