Kona Community Hospital

All Charges

Charge

Type

Setting

Price

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

HCHG VARICELLA-ZOSTER AB IGG

Facility

$159.00

Service Code	HCPCS 86787
Hospital Charge Code	H3020798
Hospital Revenue Code	302
Min. Negotiated Rate	$12.88
Max. Negotiated Rate	$154.23
Rate for Payer: AlohaCare Medicaid	$12.88
Rate for Payer: AlohaCare Medicare	$12.88
Rate for Payer: Cash Price	$103.35
Rate for Payer: Cash Price	$103.35
Rate for Payer: Devoted Health Medicare	$14.17
Rate for Payer: Hawaii Medical Service Association ABD	$17.81
Rate for Payer: Hawaii Medical Service Association Commercial	$16.10
Rate for Payer: Hawaii Medical Service Association Medicare	$12.88
Rate for Payer: Hawaii Medical Service Association Non-ABD	$18.70
Rate for Payer: Hawaii Western Management Group Commercial	$12.88
Rate for Payer: Health Management Network Commercial	$135.15
Rate for Payer: Humana Medicare	$12.88
Rate for Payer: Kaiser Permanente Commercial	$100.17
Rate for Payer: Kaiser Permanente Medicaid	$81.09
Rate for Payer: Kaiser Permanente Medicare	$12.88
Rate for Payer: MDX Hawaii PPO	$154.23
Rate for Payer: Ohana Health Plan Medicaid	$14.17
Rate for Payer: Ohana Health Plan Medicare	$12.88
Rate for Payer: UnitedHealthcare Medicaid	$17.81
Rate for Payer: UnitedHealthcare Medicare	$12.88
Rate for Payer: University Health Alliance Commercial	$33.30

HCHG VARICELLA-ZOSTER AB IGG

Facility

$159.00

Service Code	HCPCS 86787
Hospital Charge Code	H3020798
Hospital Revenue Code	302
Min. Negotiated Rate	$135.15
Max. Negotiated Rate	$154.23
Rate for Payer: Cash Price	$103.35
Rate for Payer: Health Management Network Commercial	$135.15
Rate for Payer: MDX Hawaii PPO	$154.23

HCHG VARICELLA-ZOSTER AB IGM 90

Facility

$159.00

Service Code	HCPCS 86787
Hospital Charge Code	H3020800
Hospital Revenue Code	302
Min. Negotiated Rate	$12.88
Max. Negotiated Rate	$154.23
Rate for Payer: AlohaCare Medicaid	$12.88
Rate for Payer: AlohaCare Medicare	$12.88
Rate for Payer: Cash Price	$103.35
Rate for Payer: Cash Price	$103.35
Rate for Payer: Devoted Health Medicare	$14.17
Rate for Payer: Hawaii Medical Service Association ABD	$17.81
Rate for Payer: Hawaii Medical Service Association Commercial	$16.10
Rate for Payer: Hawaii Medical Service Association Medicare	$12.88
Rate for Payer: Hawaii Medical Service Association Non-ABD	$18.70
Rate for Payer: Hawaii Western Management Group Commercial	$12.88
Rate for Payer: Health Management Network Commercial	$135.15
Rate for Payer: Humana Medicare	$12.88
Rate for Payer: Kaiser Permanente Commercial	$100.17
Rate for Payer: Kaiser Permanente Medicaid	$81.09
Rate for Payer: Kaiser Permanente Medicare	$12.88
Rate for Payer: MDX Hawaii PPO	$154.23
Rate for Payer: Ohana Health Plan Medicaid	$14.17
Rate for Payer: Ohana Health Plan Medicare	$12.88
Rate for Payer: UnitedHealthcare Medicaid	$17.81
Rate for Payer: UnitedHealthcare Medicare	$12.88
Rate for Payer: University Health Alliance Commercial	$33.30

HCHG VARICELLA-ZOSTER AB IGM 90

Facility

$159.00

Service Code	HCPCS 86787
Hospital Charge Code	H3020800
Hospital Revenue Code	302
Min. Negotiated Rate	$135.15
Max. Negotiated Rate	$154.23
Rate for Payer: Cash Price	$103.35
Rate for Payer: Health Management Network Commercial	$135.15
Rate for Payer: MDX Hawaii PPO	$154.23

HCHG VARICELLA-ZOSTER VIRUS, RAPID CULT - 90

Facility

$139.00

Service Code	HCPCS 87254
Hospital Charge Code	H3060538
Hospital Revenue Code	306
Min. Negotiated Rate	$118.15
Max. Negotiated Rate	$134.83
Rate for Payer: Cash Price	$90.35
Rate for Payer: Health Management Network Commercial	$118.15
Rate for Payer: MDX Hawaii PPO	$134.83

HCHG VARICELLA-ZOSTER VIRUS, RAPID CULT - 90

Facility

$139.00

Service Code	HCPCS 87254
Hospital Charge Code	H3060538
Hospital Revenue Code	306
Min. Negotiated Rate	$16.39
Max. Negotiated Rate	$134.83
Rate for Payer: AlohaCare Medicaid	$19.56
Rate for Payer: AlohaCare Medicare	$19.56
Rate for Payer: Cash Price	$90.35
Rate for Payer: Cash Price	$90.35
Rate for Payer: Devoted Health Medicare	$21.52
Rate for Payer: Hawaii Medical Service Association ABD	$16.39
Rate for Payer: Hawaii Medical Service Association Commercial	$24.45
Rate for Payer: Hawaii Medical Service Association Medicare	$19.56
Rate for Payer: Hawaii Medical Service Association Non-ABD	$26.20
Rate for Payer: Hawaii Western Management Group Commercial	$19.56
Rate for Payer: Health Management Network Commercial	$118.15
Rate for Payer: Humana Medicare	$19.56
Rate for Payer: Kaiser Permanente Commercial	$87.57
Rate for Payer: Kaiser Permanente Medicaid	$70.89
Rate for Payer: Kaiser Permanente Medicare	$19.56
Rate for Payer: MDX Hawaii PPO	$134.83
Rate for Payer: Ohana Health Plan Medicaid	$21.52
Rate for Payer: Ohana Health Plan Medicare	$19.56
Rate for Payer: UnitedHealthcare Medicaid	$16.39
Rate for Payer: UnitedHealthcare Medicare	$19.56
Rate for Payer: University Health Alliance Commercial	$50.54

HCHG VDRL-CSF

Facility

$59.00

Service Code	HCPCS 86592
Hospital Charge Code	H3020802
Hospital Revenue Code	302
Min. Negotiated Rate	$4.27
Max. Negotiated Rate	$57.23
Rate for Payer: AlohaCare Medicaid	$4.27
Rate for Payer: AlohaCare Medicare	$4.27
Rate for Payer: Cash Price	$38.35
Rate for Payer: Cash Price	$38.35
Rate for Payer: Devoted Health Medicare	$4.70
Rate for Payer: Hawaii Medical Service Association ABD	$5.90
Rate for Payer: Hawaii Medical Service Association Commercial	$5.34
Rate for Payer: Hawaii Medical Service Association Medicare	$4.27
Rate for Payer: Hawaii Medical Service Association Non-ABD	$6.20
Rate for Payer: Hawaii Western Management Group Commercial	$4.27
Rate for Payer: Health Management Network Commercial	$50.15
Rate for Payer: Humana Medicare	$4.27
Rate for Payer: Kaiser Permanente Commercial	$37.17
Rate for Payer: Kaiser Permanente Medicaid	$30.09
Rate for Payer: Kaiser Permanente Medicare	$4.27
Rate for Payer: MDX Hawaii PPO	$57.23
Rate for Payer: Ohana Health Plan Medicaid	$4.70
Rate for Payer: Ohana Health Plan Medicare	$4.27
Rate for Payer: UnitedHealthcare Medicaid	$5.90
Rate for Payer: UnitedHealthcare Medicare	$4.27
Rate for Payer: University Health Alliance Commercial	$11.03

HCHG VDRL-CSF

Facility

$59.00

Service Code	HCPCS 86592
Hospital Charge Code	H3020802
Hospital Revenue Code	302
Min. Negotiated Rate	$50.15
Max. Negotiated Rate	$57.23
Rate for Payer: Cash Price	$38.35
Rate for Payer: Health Management Network Commercial	$50.15
Rate for Payer: MDX Hawaii PPO	$57.23

HCHG VDRL QUAL SERUM SO

Facility

$59.00

Service Code	HCPCS 86592
Hospital Charge Code	K3020008
Hospital Revenue Code	302
Min. Negotiated Rate	$50.15
Max. Negotiated Rate	$57.23
Rate for Payer: Cash Price	$38.35
Rate for Payer: Health Management Network Commercial	$50.15
Rate for Payer: MDX Hawaii PPO	$57.23

HCHG VDRL QUAL SERUM SO

Facility

$59.00

Service Code	HCPCS 86592
Hospital Charge Code	K3020008
Hospital Revenue Code	302
Min. Negotiated Rate	$4.27
Max. Negotiated Rate	$57.23
Rate for Payer: AlohaCare Medicaid	$4.27
Rate for Payer: AlohaCare Medicare	$4.27
Rate for Payer: Cash Price	$38.35
Rate for Payer: Cash Price	$38.35
Rate for Payer: Devoted Health Medicare	$4.70
Rate for Payer: Hawaii Medical Service Association ABD	$5.90
Rate for Payer: Hawaii Medical Service Association Commercial	$5.34
Rate for Payer: Hawaii Medical Service Association Medicare	$4.27
Rate for Payer: Hawaii Medical Service Association Non-ABD	$6.20
Rate for Payer: Hawaii Western Management Group Commercial	$4.27
Rate for Payer: Health Management Network Commercial	$50.15
Rate for Payer: Humana Medicare	$4.27
Rate for Payer: Kaiser Permanente Commercial	$37.17
Rate for Payer: Kaiser Permanente Medicaid	$30.09
Rate for Payer: Kaiser Permanente Medicare	$4.27
Rate for Payer: MDX Hawaii PPO	$57.23
Rate for Payer: Ohana Health Plan Medicaid	$4.70
Rate for Payer: Ohana Health Plan Medicare	$4.27
Rate for Payer: UnitedHealthcare Medicaid	$5.90
Rate for Payer: UnitedHealthcare Medicare	$4.27
Rate for Payer: University Health Alliance Commercial	$11.03

HCHG VDRL/RPR QUANT

Facility

$34.00

Service Code	HCPCS 86593
Hospital Charge Code	K3020009
Hospital Revenue Code	302
Min. Negotiated Rate	$28.90
Max. Negotiated Rate	$32.98
Rate for Payer: Cash Price	$22.10
Rate for Payer: Health Management Network Commercial	$28.90
Rate for Payer: MDX Hawaii PPO	$32.98

HCHG VDRL/RPR QUANT

Facility

$34.00

Service Code	HCPCS 86593
Hospital Charge Code	K3020009
Hospital Revenue Code	302
Min. Negotiated Rate	$4.40
Max. Negotiated Rate	$32.98
Rate for Payer: AlohaCare Medicaid	$4.40
Rate for Payer: AlohaCare Medicare	$4.40
Rate for Payer: Cash Price	$22.10
Rate for Payer: Cash Price	$22.10
Rate for Payer: Devoted Health Medicare	$4.84
Rate for Payer: Hawaii Medical Service Association ABD	$6.09
Rate for Payer: Hawaii Medical Service Association Commercial	$5.50
Rate for Payer: Hawaii Medical Service Association Medicare	$4.40
Rate for Payer: Hawaii Medical Service Association Non-ABD	$6.39
Rate for Payer: Hawaii Western Management Group Commercial	$4.40
Rate for Payer: Health Management Network Commercial	$28.90
Rate for Payer: Humana Medicare	$4.40
Rate for Payer: Kaiser Permanente Commercial	$21.42
Rate for Payer: Kaiser Permanente Medicaid	$17.34
Rate for Payer: Kaiser Permanente Medicare	$4.40
Rate for Payer: MDX Hawaii PPO	$32.98
Rate for Payer: Ohana Health Plan Medicaid	$4.84
Rate for Payer: Ohana Health Plan Medicare	$4.40
Rate for Payer: UnitedHealthcare Medicaid	$6.09
Rate for Payer: UnitedHealthcare Medicare	$4.40
Rate for Payer: University Health Alliance Commercial	$11.40

HCHG VEIN MAP IMAGING PERIPH LTD

Facility

$798.00

Service Code	HCPCS 93971
Hospital Charge Code	H9210140
Hospital Revenue Code	921
Min. Negotiated Rate	$93.10
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	$93.10
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	$109.94
Rate for Payer: Hawaii Western Management Group Commercial	$758.10
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	$93.10
Rate for Payer: UnitedHealthcare Medicare	$123.50
Rate for Payer: University Health Alliance Commercial	$581.66

HCHG VEIN MAP IMAGING PERIPH LTD

Facility

$798.00

Service Code	HCPCS 93971
Hospital Charge Code	H9210140
Hospital Revenue Code	921
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 VENIPUNCTURE 3 YRS OR >, PHYS/QHP SKILL

Facility

$127.00

Service Code	HCPCS 36410
Hospital Charge Code	H4501066
Hospital Revenue Code	450
Min. Negotiated Rate	$107.95
Max. Negotiated Rate	$123.19
Rate for Payer: Cash Price	$82.55
Rate for Payer: Health Management Network Commercial	$107.95
Rate for Payer: MDX Hawaii PPO	$123.19

HCHG VENIPUNCTURE 3 YRS OR >, PHYS/QHP SKILL

Facility

$127.00

Service Code	HCPCS 36410
Hospital Charge Code	H4501066
Hospital Revenue Code	450
Min. Negotiated Rate	$80.01
Max. Negotiated Rate	$1,600.00
Rate for Payer: Cash Price	$82.55
Rate for Payer: Cash Price	$82.55
Rate for Payer: Cash Price	$82.55
Rate for Payer: Hawaii Medical Service Association ABD	$560.00
Rate for Payer: Hawaii Medical Service Association Commercial	$1,600.00
Rate for Payer: Hawaii Medical Service Association Non-ABD	$520.00
Rate for Payer: Hawaii Western Management Group Commercial	$120.65
Rate for Payer: Health Management Network Commercial	$107.95
Rate for Payer: Kaiser Permanente Commercial	$80.01
Rate for Payer: Kaiser Permanente Medicaid	$937.50
Rate for Payer: MDX Hawaii PPO	$123.19
Rate for Payer: University Health Alliance Commercial	$92.57

HCHG VENOGRAM EXTREM UPP UNILAT

Facility

$3,133.00

Service Code	HCPCS 75820
Hospital Charge Code	H3200354
Hospital Revenue Code	320
Min. Negotiated Rate	$31.51
Max. Negotiated Rate	$3,039.01
Rate for Payer: AlohaCare Medicaid	$1,859.62
Rate for Payer: AlohaCare Medicare	$1,859.62
Rate for Payer: Cash Price	$2,036.45
Rate for Payer: Cash Price	$2,036.45
Rate for Payer: Devoted Health Medicare	$2,045.58
Rate for Payer: Hawaii Medical Service Association ABD	$31.51
Rate for Payer: Hawaii Medical Service Association Commercial	$2,324.53
Rate for Payer: Hawaii Medical Service Association Medicare	$1,859.62
Rate for Payer: Hawaii Medical Service Association Non-ABD	$34.37
Rate for Payer: Hawaii Western Management Group Commercial	$1,859.62
Rate for Payer: Health Management Network Commercial	$2,663.05
Rate for Payer: Humana Medicare	$1,859.62
Rate for Payer: Kaiser Permanente Commercial	$1,973.79
Rate for Payer: Kaiser Permanente Medicaid	$1,597.83
Rate for Payer: Kaiser Permanente Medicare	$1,859.62
Rate for Payer: MDX Hawaii PPO	$3,039.01
Rate for Payer: Ohana Health Plan Medicaid	$2,045.58
Rate for Payer: Ohana Health Plan Medicare	$1,859.62
Rate for Payer: UnitedHealthcare Medicaid	$31.51
Rate for Payer: UnitedHealthcare Medicare	$1,859.62
Rate for Payer: University Health Alliance Commercial	$215.77

HCHG VENOGRAM EXTREM UPP UNILAT

Facility

$3,133.00

Service Code	HCPCS 75820
Hospital Charge Code	H3200354
Hospital Revenue Code	320
Min. Negotiated Rate	$2,663.05
Max. Negotiated Rate	$3,039.01
Rate for Payer: Cash Price	$2,036.45
Rate for Payer: Health Management Network Commercial	$2,663.05
Rate for Payer: MDX Hawaii PPO	$3,039.01

HCHG VENOUS DPLX IMAGING PERIP

Facility

$1,527.00

Service Code	HCPCS 93970
Hospital Charge Code	H9210144
Hospital Revenue Code	921
Min. Negotiated Rate	$1,297.95
Max. Negotiated Rate	$1,481.19
Rate for Payer: Cash Price	$992.55
Rate for Payer: Health Management Network Commercial	$1,297.95
Rate for Payer: MDX Hawaii PPO	$1,481.19

HCHG VENOUS DPLX IMAGING PERIP

Facility

$1,527.00

Service Code	HCPCS 93970
Hospital Charge Code	H9210144
Hospital Revenue Code	921
Min. Negotiated Rate	$139.85
Max. Negotiated Rate	$1,481.19
Rate for Payer: AlohaCare Medicaid	$281.87
Rate for Payer: AlohaCare Medicare	$281.87
Rate for Payer: Cash Price	$992.55
Rate for Payer: Cash Price	$992.55
Rate for Payer: Devoted Health Medicare	$310.06
Rate for Payer: Hawaii Medical Service Association ABD	$139.85
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	$160.42
Rate for Payer: Hawaii Western Management Group Commercial	$1,450.65
Rate for Payer: Health Management Network Commercial	$1,297.95
Rate for Payer: Humana Medicare	$281.87
Rate for Payer: Kaiser Permanente Commercial	$962.01
Rate for Payer: Kaiser Permanente Medicaid	$778.77
Rate for Payer: Kaiser Permanente Medicare	$281.87
Rate for Payer: MDX Hawaii PPO	$1,481.19
Rate for Payer: Ohana Health Plan Medicaid	$310.06
Rate for Payer: Ohana Health Plan Medicare	$281.87
Rate for Payer: UnitedHealthcare Medicaid	$139.85
Rate for Payer: UnitedHealthcare Medicare	$281.87
Rate for Payer: University Health Alliance Commercial	$1,113.03

HCHG VENOUS DPLX IMAGING PERIP F/U

Facility

$798.00

Service Code	HCPCS 93971
Hospital Charge Code	H9210142
Hospital Revenue Code	921
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 VENOUS DPLX IMAGING PERIP F/U

Facility

$798.00

Service Code	HCPCS 93971
Hospital Charge Code	H9210142
Hospital Revenue Code	921
Min. Negotiated Rate	$93.10
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	$93.10
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	$109.94
Rate for Payer: Hawaii Western Management Group Commercial	$758.10
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	$93.10
Rate for Payer: UnitedHealthcare Medicare	$123.50
Rate for Payer: University Health Alliance Commercial	$581.66

HCHG VENT MGMT INITIAL DAY

Facility

$1,660.00

Service Code	HCPCS 94002
Hospital Charge Code	H4100274
Hospital Revenue Code	410
Min. Negotiated Rate	$1,411.00
Max. Negotiated Rate	$1,610.20
Rate for Payer: Cash Price	$1,079.00
Rate for Payer: Health Management Network Commercial	$1,411.00
Rate for Payer: MDX Hawaii PPO	$1,610.20

HCHG VENT MGMT INITIAL DAY

Facility

$1,660.00

Service Code	HCPCS 94002
Hospital Charge Code	H4100274
Hospital Revenue Code	410
Min. Negotiated Rate	$59.64
Max. Negotiated Rate	$1,610.20
Rate for Payer: AlohaCare Medicaid	$729.82
Rate for Payer: AlohaCare Medicare	$729.82
Rate for Payer: Cash Price	$1,079.00
Rate for Payer: Cash Price	$1,079.00
Rate for Payer: Devoted Health Medicare	$802.80
Rate for Payer: Hawaii Medical Service Association Commercial	$912.27
Rate for Payer: Hawaii Medical Service Association Medicare	$729.82
Rate for Payer: Hawaii Western Management Group Commercial	$1,577.00
Rate for Payer: Health Management Network Commercial	$1,411.00
Rate for Payer: Humana Medicare	$729.82
Rate for Payer: Kaiser Permanente Commercial	$1,045.80
Rate for Payer: Kaiser Permanente Medicaid	$846.60
Rate for Payer: Kaiser Permanente Medicare	$729.82
Rate for Payer: MDX Hawaii PPO	$1,610.20
Rate for Payer: Ohana Health Plan Medicaid	$802.80
Rate for Payer: Ohana Health Plan Medicare	$729.82
Rate for Payer: UnitedHealthcare Medicaid	$59.64
Rate for Payer: UnitedHealthcare Medicare	$729.82
Rate for Payer: University Health Alliance Commercial	$1,209.97

Know your out-of-pocket cost for care.

All Charges