Kona Community Hospital

All Charges

Charge

Type

Setting

Price

HCHG US SCROTAL DOPPLER

Facility

$670.00

Service Code	HCPCS 93980
Hospital Charge Code	K9210001
Hospital Revenue Code	402
Min. Negotiated Rate	$569.50
Max. Negotiated Rate	$649.90
Rate for Payer: Cash Price	$435.50
Rate for Payer: Health Management Network Commercial	$569.50
Rate for Payer: MDX Hawaii PPO	$649.90

HCHG US SCROTAL DOPPLER

Facility

$670.00

Service Code	HCPCS 93980
Hospital Charge Code	K9210001
Hospital Revenue Code	402
Min. Negotiated Rate	$113.69
Max. Negotiated Rate	$649.90
Rate for Payer: AlohaCare Medicaid	$123.50
Rate for Payer: AlohaCare Medicare	$123.50
Rate for Payer: Cash Price	$435.50
Rate for Payer: Cash Price	$435.50
Rate for Payer: Devoted Health Medicare	$135.85
Rate for Payer: Hawaii Medical Service Association ABD	$113.69
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	$119.37
Rate for Payer: Hawaii Western Management Group Commercial	$636.50
Rate for Payer: Health Management Network Commercial	$569.50
Rate for Payer: Humana Medicare	$123.50
Rate for Payer: Kaiser Permanente Commercial	$422.10
Rate for Payer: Kaiser Permanente Medicaid	$341.70
Rate for Payer: Kaiser Permanente Medicare	$123.50
Rate for Payer: MDX Hawaii PPO	$649.90
Rate for Payer: Ohana Health Plan Medicaid	$135.85
Rate for Payer: Ohana Health Plan Medicare	$123.50
Rate for Payer: UnitedHealthcare Medicaid	$113.69
Rate for Payer: UnitedHealthcare Medicare	$123.50
Rate for Payer: University Health Alliance Commercial	$488.36

HCHG U/S SCROTUM

Facility

$758.00

Service Code	HCPCS 76870
Hospital Charge Code	H4020184
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	$228.81

HCHG U/S SCROTUM

Facility

$758.00

Service Code	HCPCS 76870
Hospital Charge Code	H4020184
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 SOFT TISS HEAD/NECK/THYRD

Facility

$708.00

Service Code	HCPCS 76536
Hospital Charge Code	H4020246
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	$211.12

HCHG U/S SOFT TISS HEAD/NECK/THYRD

Facility

$708.00

Service Code	HCPCS 76536
Hospital Charge Code	H4020246
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 SOFT TISS NECK

Facility

$708.00

Service Code	HCPCS 76536
Hospital Charge Code	H4020281
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 SOFT TISS NECK

Facility

$708.00

Service Code	HCPCS 76536
Hospital Charge Code	H4020281
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	$211.12

HCHG U/S SPINE

Facility

$708.00

Service Code	HCPCS 76800
Hospital Charge Code	H4020248
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 SPINE

Facility

$708.00

Service Code	HCPCS 76800
Hospital Charge Code	H4020248
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	$239.82

HCHG US TRANSPLANT KIDNEY (INCL DOPPLER)

Facility

$708.00

Service Code	HCPCS 76776
Hospital Charge Code	H4020282
Hospital Revenue Code	402
Min. Negotiated Rate	$67.84
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	$67.84
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	$71.23
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	$67.84
Rate for Payer: UnitedHealthcare Medicare	$123.50
Rate for Payer: University Health Alliance Commercial	$281.14

HCHG US TRANSPLANT KIDNEY (INCL DOPPLER)

Facility

$708.00

Service Code	HCPCS 76776
Hospital Charge Code	H4020282
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 US URINE CAPACITY MEASURE

Facility

$428.00

Service Code	HCPCS 51798
Hospital Charge Code	H4500887
Hospital Revenue Code	450
Min. Negotiated Rate	$69.69
Max. Negotiated Rate	$2,833.00
Rate for Payer: AlohaCare Medicaid	$69.69
Rate for Payer: AlohaCare Medicare	$69.69
Rate for Payer: Cash Price	$278.20
Rate for Payer: Cash Price	$278.20
Rate for Payer: Cash Price	$278.20
Rate for Payer: Devoted Health Medicare	$76.66
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	$69.69
Rate for Payer: Hawaii Medical Service Association Non-ABD	$407.95
Rate for Payer: Hawaii Western Management Group Commercial	$406.60
Rate for Payer: Health Management Network Commercial	$363.80
Rate for Payer: Humana Medicare	$69.69
Rate for Payer: Kaiser Permanente Commercial	$269.64
Rate for Payer: Kaiser Permanente Medicaid	$937.50
Rate for Payer: Kaiser Permanente Medicare	$69.69
Rate for Payer: MDX Hawaii PPO	$415.16
Rate for Payer: Ohana Health Plan Medicaid	$76.66
Rate for Payer: Ohana Health Plan Medicare	$69.69
Rate for Payer: UnitedHealthcare Medicare	$69.69
Rate for Payer: University Health Alliance Commercial	$311.97

HCHG US URINE CAPACITY MEASURE

Facility

$428.00

Service Code	HCPCS 51798
Hospital Charge Code	H4500887
Hospital Revenue Code	450
Min. Negotiated Rate	$363.80
Max. Negotiated Rate	$415.16
Rate for Payer: Cash Price	$278.20
Rate for Payer: Health Management Network Commercial	$363.80
Rate for Payer: MDX Hawaii PPO	$415.16

HCHG VAD DECLOT THROMBO AGENT

Facility

$1,360.00

Service Code	HCPCS 36593
Hospital Charge Code	H3600226
Hospital Revenue Code	360
Min. Negotiated Rate	$19.39
Max. Negotiated Rate	$2,837.00
Rate for Payer: AlohaCare Medicaid	$390.20
Rate for Payer: AlohaCare Medicare	$390.20
Rate for Payer: Cash Price	$884.00
Rate for Payer: Cash Price	$884.00
Rate for Payer: Cash Price	$884.00
Rate for Payer: Devoted Health Medicare	$429.22
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	$390.20
Rate for Payer: Hawaii Medical Service Association Non-ABD	$407.95
Rate for Payer: Health Management Network Commercial	$1,156.00
Rate for Payer: Humana Medicare	$390.20
Rate for Payer: Kaiser Permanente Commercial	$856.80
Rate for Payer: Kaiser Permanente Medicaid	$2,837.00
Rate for Payer: Kaiser Permanente Medicare	$390.20
Rate for Payer: MDX Hawaii PPO	$1,319.20
Rate for Payer: Ohana Health Plan Medicaid	$429.22
Rate for Payer: Ohana Health Plan Medicare	$390.20
Rate for Payer: UnitedHealthcare Medicaid	$19.39
Rate for Payer: UnitedHealthcare Medicare	$390.20
Rate for Payer: University Health Alliance Commercial	$991.30

HCHG VAD DECLOT THROMBO AGENT

Facility

$1,360.00

Service Code	HCPCS 36593
Hospital Charge Code	H3600226
Hospital Revenue Code	360
Min. Negotiated Rate	$1,156.00
Max. Negotiated Rate	$1,319.20
Rate for Payer: Cash Price	$884.00
Rate for Payer: Health Management Network Commercial	$1,156.00
Rate for Payer: MDX Hawaii PPO	$1,319.20

HCHG VAG DELIVERY RECOV LVL 1

Facility

$5,315.00

Hospital Charge Code	K7220000
Hospital Revenue Code	722
Min. Negotiated Rate	$2,710.65
Max. Negotiated Rate	$5,155.55
Rate for Payer: Cash Price	$3,454.75
Rate for Payer: Hawaii Western Management Group Commercial	$5,049.25
Rate for Payer: Health Management Network Commercial	$4,517.75
Rate for Payer: Kaiser Permanente Commercial	$3,348.45
Rate for Payer: Kaiser Permanente Medicaid	$2,710.65
Rate for Payer: MDX Hawaii PPO	$5,155.55
Rate for Payer: University Health Alliance Commercial	$3,874.10

HCHG VAG DELIVERY RECOV LVL 1

Facility

$5,315.00

Hospital Charge Code	K7220000
Hospital Revenue Code	722
Min. Negotiated Rate	$4,517.75
Max. Negotiated Rate	$5,155.55
Rate for Payer: Cash Price	$3,454.75
Rate for Payer: Health Management Network Commercial	$4,517.75
Rate for Payer: MDX Hawaii PPO	$5,155.55

HCHG VAG DELIVERY RECOV LVL 2

Facility

$5,952.00

Hospital Charge Code	K7220001
Hospital Revenue Code	722
Min. Negotiated Rate	$5,059.20
Max. Negotiated Rate	$5,773.44
Rate for Payer: Cash Price	$3,868.80
Rate for Payer: Health Management Network Commercial	$5,059.20
Rate for Payer: MDX Hawaii PPO	$5,773.44

HCHG VAG DELIVERY RECOV LVL 2

Facility

$5,952.00

Hospital Charge Code	K7220001
Hospital Revenue Code	722
Min. Negotiated Rate	$3,035.52
Max. Negotiated Rate	$5,773.44
Rate for Payer: Cash Price	$3,868.80
Rate for Payer: Hawaii Western Management Group Commercial	$5,654.40
Rate for Payer: Health Management Network Commercial	$5,059.20
Rate for Payer: Kaiser Permanente Commercial	$3,749.76
Rate for Payer: Kaiser Permanente Medicaid	$3,035.52
Rate for Payer: MDX Hawaii PPO	$5,773.44
Rate for Payer: University Health Alliance Commercial	$4,338.41

HCHG VALPROIC ACID

Facility

$185.00

Service Code	HCPCS 80164
Hospital Charge Code	H3011272
Hospital Revenue Code	301
Min. Negotiated Rate	$157.25
Max. Negotiated Rate	$179.45
Rate for Payer: Cash Price	$120.25
Rate for Payer: Health Management Network Commercial	$157.25
Rate for Payer: MDX Hawaii PPO	$179.45

HCHG VALPROIC ACID

Facility

$185.00

Service Code	HCPCS 80164
Hospital Charge Code	H3011272
Hospital Revenue Code	301
Min. Negotiated Rate	$13.54
Max. Negotiated Rate	$179.45
Rate for Payer: AlohaCare Medicaid	$13.54
Rate for Payer: AlohaCare Medicare	$13.54
Rate for Payer: Cash Price	$120.25
Rate for Payer: Cash Price	$120.25
Rate for Payer: Devoted Health Medicare	$14.89
Rate for Payer: Hawaii Medical Service Association ABD	$18.72
Rate for Payer: Hawaii Medical Service Association Commercial	$16.93
Rate for Payer: Hawaii Medical Service Association Medicare	$13.54
Rate for Payer: Hawaii Medical Service Association Non-ABD	$19.66
Rate for Payer: Hawaii Western Management Group Commercial	$13.54
Rate for Payer: Health Management Network Commercial	$157.25
Rate for Payer: Humana Medicare	$13.54
Rate for Payer: Kaiser Permanente Commercial	$116.55
Rate for Payer: Kaiser Permanente Medicaid	$94.35
Rate for Payer: Kaiser Permanente Medicare	$13.54
Rate for Payer: MDX Hawaii PPO	$179.45
Rate for Payer: Ohana Health Plan Medicaid	$14.89
Rate for Payer: Ohana Health Plan Medicare	$13.54
Rate for Payer: UnitedHealthcare Medicaid	$18.72
Rate for Payer: UnitedHealthcare Medicare	$13.54
Rate for Payer: University Health Alliance Commercial	$35.02

HCHG VALPROIC ACID FREE SO

Facility

$226.00

Service Code	HCPCS 80299
Hospital Charge Code	K3010003
Hospital Revenue Code	301
Min. Negotiated Rate	$192.10
Max. Negotiated Rate	$219.22
Rate for Payer: Cash Price	$146.90
Rate for Payer: Health Management Network Commercial	$192.10
Rate for Payer: MDX Hawaii PPO	$219.22

HCHG VALPROIC ACID FREE SO

Facility

$226.00

Service Code	HCPCS 80299
Hospital Charge Code	K3010003
Hospital Revenue Code	301
Min. Negotiated Rate	$18.64
Max. Negotiated Rate	$219.22
Rate for Payer: AlohaCare Medicaid	$18.64
Rate for Payer: AlohaCare Medicare	$18.64
Rate for Payer: Cash Price	$146.90
Rate for Payer: Cash Price	$146.90
Rate for Payer: Devoted Health Medicare	$20.50
Rate for Payer: Hawaii Medical Service Association ABD	$18.92
Rate for Payer: Hawaii Medical Service Association Commercial	$23.30
Rate for Payer: Hawaii Medical Service Association Medicare	$18.64
Rate for Payer: Hawaii Medical Service Association Non-ABD	$19.87
Rate for Payer: Hawaii Western Management Group Commercial	$18.64
Rate for Payer: Health Management Network Commercial	$192.10
Rate for Payer: Humana Medicare	$18.64
Rate for Payer: Kaiser Permanente Commercial	$142.38
Rate for Payer: Kaiser Permanente Medicaid	$115.26
Rate for Payer: Kaiser Permanente Medicare	$18.64
Rate for Payer: MDX Hawaii PPO	$219.22
Rate for Payer: Ohana Health Plan Medicaid	$20.50
Rate for Payer: Ohana Health Plan Medicare	$18.64
Rate for Payer: UnitedHealthcare Medicaid	$18.92
Rate for Payer: UnitedHealthcare Medicare	$18.64
Rate for Payer: University Health Alliance Commercial	$35.39

HCHG VANCOMYCIN LEVEL

Facility

$185.00

Service Code	HCPCS 80202
Hospital Charge Code	H3011274
Hospital Revenue Code	301
Min. Negotiated Rate	$157.25
Max. Negotiated Rate	$179.45
Rate for Payer: Cash Price	$120.25
Rate for Payer: Health Management Network Commercial	$157.25
Rate for Payer: MDX Hawaii PPO	$179.45

Know your out-of-pocket cost for care.

All Charges