Kona Community Hospital

All Charges

Charge

Type

Setting

Price

Lap Trocar Xcel Bladeless 15mm B15LT [3640194]

Facility

$875.47

Hospital Charge Code	3640194
Hospital Revenue Code	272
Min. Negotiated Rate	$446.49
Max. Negotiated Rate	$849.21
Rate for Payer: Cash Price	$569.06
Rate for Payer: Hawaii Western Management Group Commercial	$831.70
Rate for Payer: Health Management Network Commercial	$744.15
Rate for Payer: Kaiser Permanente Commercial	$551.55
Rate for Payer: Kaiser Permanente Medicaid	$446.49
Rate for Payer: MDX Hawaii PPO	$849.21
Rate for Payer: University Health Alliance Commercial	$638.13

Lap Trocar Xcel Bladeless 15mm B15LT [3640194]

Facility

$875.47

Hospital Charge Code	3640194
Hospital Revenue Code	272
Min. Negotiated Rate	$744.15
Max. Negotiated Rate	$849.21
Rate for Payer: Cash Price	$569.06
Rate for Payer: Health Management Network Commercial	$744.15
Rate for Payer: MDX Hawaii PPO	$849.21

Lap Trocar Xcel Optiview 12mm 150mm B12XT [3640449]

Facility

$805.37

Hospital Charge Code	3640449
Hospital Revenue Code	272
Min. Negotiated Rate	$684.56
Max. Negotiated Rate	$781.21
Rate for Payer: Cash Price	$523.49
Rate for Payer: Health Management Network Commercial	$684.56
Rate for Payer: MDX Hawaii PPO	$781.21

Lap Trocar Xcel Optiview 12mm 150mm B12XT [3640449]

Facility

$805.37

Hospital Charge Code	3640449
Hospital Revenue Code	272
Min. Negotiated Rate	$410.74
Max. Negotiated Rate	$781.21
Rate for Payer: Cash Price	$523.49
Rate for Payer: Hawaii Western Management Group Commercial	$765.10
Rate for Payer: Health Management Network Commercial	$684.56
Rate for Payer: Kaiser Permanente Commercial	$507.38
Rate for Payer: Kaiser Permanente Medicaid	$410.74
Rate for Payer: MDX Hawaii PPO	$781.21
Rate for Payer: University Health Alliance Commercial	$587.03

Lap Trocar Xcel Optiview 12mm 2B12LT [3640314]

Facility

$1,174.49

Hospital Charge Code	3640314
Hospital Revenue Code	272
Min. Negotiated Rate	$998.32
Max. Negotiated Rate	$1,139.26
Rate for Payer: Cash Price	$763.42
Rate for Payer: Health Management Network Commercial	$998.32
Rate for Payer: MDX Hawaii PPO	$1,139.26

Lap Trocar Xcel Optiview 12mm 2B12LT [3640314]

Facility

$1,174.49

Hospital Charge Code	3640314
Hospital Revenue Code	272
Min. Negotiated Rate	$598.99
Max. Negotiated Rate	$1,139.26
Rate for Payer: Cash Price	$763.42
Rate for Payer: Hawaii Western Management Group Commercial	$1,115.77
Rate for Payer: Health Management Network Commercial	$998.32
Rate for Payer: Kaiser Permanente Commercial	$739.93
Rate for Payer: Kaiser Permanente Medicaid	$598.99
Rate for Payer: MDX Hawaii PPO	$1,139.26
Rate for Payer: University Health Alliance Commercial	$856.09

Lap Trocar Xcel Optiview 5mm 150mm 2B5XT [3640748]

Facility

$1,156.28

Hospital Charge Code	3640748
Hospital Revenue Code	272
Min. Negotiated Rate	$589.70
Max. Negotiated Rate	$1,121.59
Rate for Payer: Cash Price	$751.58
Rate for Payer: Hawaii Western Management Group Commercial	$1,098.47
Rate for Payer: Health Management Network Commercial	$982.84
Rate for Payer: Kaiser Permanente Commercial	$728.46
Rate for Payer: Kaiser Permanente Medicaid	$589.70
Rate for Payer: MDX Hawaii PPO	$1,121.59
Rate for Payer: University Health Alliance Commercial	$842.81

Lap Trocar Xcel Optiview 5mm 150mm 2B5XT [3640748]

Facility

$1,156.28

Hospital Charge Code	3640748
Hospital Revenue Code	272
Min. Negotiated Rate	$982.84
Max. Negotiated Rate	$1,121.59
Rate for Payer: Cash Price	$751.58
Rate for Payer: Health Management Network Commercial	$982.84
Rate for Payer: MDX Hawaii PPO	$1,121.59

Lap Trocar Xcel Optiview 5MM 2B5LT [3603169]

Facility

$1,158.96

Hospital Charge Code	3603169
Hospital Revenue Code	272
Min. Negotiated Rate	$591.07
Max. Negotiated Rate	$1,124.19
Rate for Payer: Cash Price	$753.32
Rate for Payer: Hawaii Western Management Group Commercial	$1,101.01
Rate for Payer: Health Management Network Commercial	$985.12
Rate for Payer: Kaiser Permanente Commercial	$730.14
Rate for Payer: Kaiser Permanente Medicaid	$591.07
Rate for Payer: MDX Hawaii PPO	$1,124.19
Rate for Payer: University Health Alliance Commercial	$844.77

Lap Trocar Xcel Optiview 5MM 2B5LT [3603169]

Facility

$1,158.96

Hospital Charge Code	3603169
Hospital Revenue Code	272
Min. Negotiated Rate	$985.12
Max. Negotiated Rate	$1,124.19
Rate for Payer: Cash Price	$753.32
Rate for Payer: Health Management Network Commercial	$985.12
Rate for Payer: MDX Hawaii PPO	$1,124.19

Lap Versastep 5Mm Long W/Exp Slv VS101505 [3603145]

Facility

$326.69

Hospital Charge Code	3603145
Hospital Revenue Code	272
Min. Negotiated Rate	$166.61
Max. Negotiated Rate	$316.89
Rate for Payer: Cash Price	$212.35
Rate for Payer: Hawaii Western Management Group Commercial	$310.36
Rate for Payer: Health Management Network Commercial	$277.69
Rate for Payer: Kaiser Permanente Commercial	$205.81
Rate for Payer: Kaiser Permanente Medicaid	$166.61
Rate for Payer: MDX Hawaii PPO	$316.89
Rate for Payer: University Health Alliance Commercial	$238.12

Lap Versastep 5Mm Long W/Exp Slv VS101505 [3603145]

Facility

$326.69

Hospital Charge Code	3603145
Hospital Revenue Code	272
Min. Negotiated Rate	$277.69
Max. Negotiated Rate	$316.89
Rate for Payer: Cash Price	$212.35
Rate for Payer: Health Management Network Commercial	$277.69
Rate for Payer: MDX Hawaii PPO	$316.89

LASER ENUCLEATION OF THE PROSTATE WITH MORCELLATION, INCLUDING CONTROL OF POSTOPERATIVE BLEEDING, COMPLETE (VASECTOMY, MEATOTOMY, CYSTOURETHROSCOPY, URETHRAL CALIBRATION AND/OR DILATION, INTERNAL URETHROTOMY AND TRANSURETHRAL RESECTION OF PROSTATE ARE INCLUDED IF PERFORMED)

Facility

$18,023.00

Service Code	CPT 52649
Hospital Revenue Code	360
Min. Negotiated Rate	$521.33
Max. Negotiated Rate	$18,023.00
Rate for Payer: AlohaCare Medicaid	$6,334.13
Rate for Payer: AlohaCare Medicare	$6,334.13
Rate for Payer: Devoted Health Medicare	$6,967.54
Rate for Payer: Hawaii Medical Service Association ABD	$2,102.00
Rate for Payer: Hawaii Medical Service Association Commercial	$18,023.00
Rate for Payer: Hawaii Medical Service Association Medicare	$6,334.13
Rate for Payer: Hawaii Medical Service Association Non-ABD	$2,102.18
Rate for Payer: Humana Medicare	$6,334.13
Rate for Payer: Kaiser Permanente Medicaid	$2,837.00
Rate for Payer: Kaiser Permanente Medicare	$6,334.13
Rate for Payer: Ohana Health Plan Medicaid	$6,967.54
Rate for Payer: Ohana Health Plan Medicare	$6,334.13
Rate for Payer: UnitedHealthcare Medicaid	$521.33
Rate for Payer: UnitedHealthcare Medicare	$6,334.13

Laser Fiber Cyber 1000um OAF009903 [3642769]

Facility

$9,028.00

Hospital Charge Code	3642769
Hospital Revenue Code	272
Min. Negotiated Rate	$7,673.80
Max. Negotiated Rate	$8,757.16
Rate for Payer: Cash Price	$5,868.20
Rate for Payer: Health Management Network Commercial	$7,673.80
Rate for Payer: MDX Hawaii PPO	$8,757.16

Laser Fiber Cyber 1000um OAF009903 [3642769]

Facility

$9,028.00

Hospital Charge Code	3642769
Hospital Revenue Code	272
Min. Negotiated Rate	$4,604.28
Max. Negotiated Rate	$8,757.16
Rate for Payer: Cash Price	$5,868.20
Rate for Payer: Hawaii Western Management Group Commercial	$8,576.60
Rate for Payer: Health Management Network Commercial	$7,673.80
Rate for Payer: Kaiser Permanente Commercial	$5,687.64
Rate for Payer: Kaiser Permanente Medicaid	$4,604.28
Rate for Payer: MDX Hawaii PPO	$8,757.16
Rate for Payer: University Health Alliance Commercial	$6,580.51

Laser Fiber Cyber 200um Single Use OAF002001 [3642768]

Facility

$5,003.00

Hospital Charge Code	3642768
Hospital Revenue Code	272
Min. Negotiated Rate	$2,551.53
Max. Negotiated Rate	$4,852.91
Rate for Payer: Cash Price	$3,251.95
Rate for Payer: Hawaii Western Management Group Commercial	$4,752.85
Rate for Payer: Health Management Network Commercial	$4,252.55
Rate for Payer: Kaiser Permanente Commercial	$3,151.89
Rate for Payer: Kaiser Permanente Medicaid	$2,551.53
Rate for Payer: MDX Hawaii PPO	$4,852.91
Rate for Payer: University Health Alliance Commercial	$3,646.69

Laser Fiber Cyber 200um Single Use OAF002001 [3642768]

Facility

$5,003.00

Hospital Charge Code	3642768
Hospital Revenue Code	272
Min. Negotiated Rate	$4,252.55
Max. Negotiated Rate	$4,852.91
Rate for Payer: Cash Price	$3,251.95
Rate for Payer: Health Management Network Commercial	$4,252.55
Rate for Payer: MDX Hawaii PPO	$4,852.91

Laser Fiber Moses 200 AC10030100 [3642152]

Facility

$2,701.51

Hospital Charge Code	3642152
Hospital Revenue Code	272
Min. Negotiated Rate	$2,296.28
Max. Negotiated Rate	$2,620.46
Rate for Payer: Cash Price	$1,755.98
Rate for Payer: Health Management Network Commercial	$2,296.28
Rate for Payer: MDX Hawaii PPO	$2,620.46

Laser Fiber Moses 200 AC10030100 [3642152]

Facility

$2,701.51

Hospital Charge Code	3642152
Hospital Revenue Code	272
Min. Negotiated Rate	$1,377.77
Max. Negotiated Rate	$2,620.46
Rate for Payer: Cash Price	$1,755.98
Rate for Payer: Hawaii Western Management Group Commercial	$2,566.43
Rate for Payer: Health Management Network Commercial	$2,296.28
Rate for Payer: Kaiser Permanente Commercial	$1,701.95
Rate for Payer: Kaiser Permanente Medicaid	$1,377.77
Rate for Payer: MDX Hawaii PPO	$2,620.46
Rate for Payer: University Health Alliance Commercial	$1,969.13

Laser Fiber Moses 365 AC10030110 [3642153]

Facility

$2,194.13

Hospital Charge Code	3642153
Hospital Revenue Code	272
Min. Negotiated Rate	$1,119.01
Max. Negotiated Rate	$2,128.31
Rate for Payer: Cash Price	$1,426.18
Rate for Payer: Hawaii Western Management Group Commercial	$2,084.42
Rate for Payer: Health Management Network Commercial	$1,865.01
Rate for Payer: Kaiser Permanente Commercial	$1,382.30
Rate for Payer: Kaiser Permanente Medicaid	$1,119.01
Rate for Payer: MDX Hawaii PPO	$2,128.31
Rate for Payer: University Health Alliance Commercial	$1,599.30

Laser Fiber Moses 365 AC10030110 [3642153]

Facility

$2,194.13

Hospital Charge Code	3642153
Hospital Revenue Code	272
Min. Negotiated Rate	$1,865.01
Max. Negotiated Rate	$2,128.31
Rate for Payer: Cash Price	$1,426.18
Rate for Payer: Health Management Network Commercial	$1,865.01
Rate for Payer: MDX Hawaii PPO	$2,128.31

Laser Fiber Moses 550 AC10030120 [3642154]

Facility

$2,886.43

Hospital Charge Code	3642154
Hospital Revenue Code	272
Min. Negotiated Rate	$1,472.08
Max. Negotiated Rate	$2,799.84
Rate for Payer: Cash Price	$1,876.18
Rate for Payer: Hawaii Western Management Group Commercial	$2,742.11
Rate for Payer: Health Management Network Commercial	$2,453.47
Rate for Payer: Kaiser Permanente Commercial	$1,818.45
Rate for Payer: Kaiser Permanente Medicaid	$1,472.08
Rate for Payer: MDX Hawaii PPO	$2,799.84
Rate for Payer: University Health Alliance Commercial	$2,103.92

Laser Fiber Moses 550 AC10030120 [3642154]

Facility

$2,886.43

Hospital Charge Code	3642154
Hospital Revenue Code	272
Min. Negotiated Rate	$2,453.47
Max. Negotiated Rate	$2,799.84
Rate for Payer: Cash Price	$1,876.18
Rate for Payer: Health Management Network Commercial	$2,453.47
Rate for Payer: MDX Hawaii PPO	$2,799.84

LASER VAPORIZATION OF PROSTATE, INCLUDING CONTROL OF POSTOPERATIVE BLEEDING, COMPLETE (VASECTOMY, MEATOTOMY, CYSTOURETHROSCOPY, URETHRAL CALIBRATION AND/OR DILATION, INTERNAL URETHROTOMY AND TRANSURETHRAL RESECTION OF PROSTATE ARE INCLUDED IF PERFORMED)

Facility

$24,500.00

Service Code	CPT 52648
Hospital Revenue Code	360
Min. Negotiated Rate	$521.33
Max. Negotiated Rate	$24,500.00
Rate for Payer: AlohaCare Medicaid	$6,334.13
Rate for Payer: AlohaCare Medicare	$6,334.13
Rate for Payer: Devoted Health Medicare	$6,967.54
Rate for Payer: Hawaii Medical Service Association ABD	$848.00
Rate for Payer: Hawaii Medical Service Association Commercial	$9,416.00
Rate for Payer: Hawaii Medical Service Association Medicare	$6,334.13
Rate for Payer: Hawaii Medical Service Association Non-ABD	$849.21
Rate for Payer: Humana Medicare	$6,334.13
Rate for Payer: Kaiser Permanente Medicaid	$2,837.00
Rate for Payer: Kaiser Permanente Medicare	$6,334.13
Rate for Payer: Ohana Health Plan Medicaid	$6,967.54
Rate for Payer: Ohana Health Plan Medicare	$6,334.13
Rate for Payer: UnitedHealthcare Medicaid	$521.33
Rate for Payer: UnitedHealthcare Medicare	$6,334.13
Rate for Payer: University Health Alliance Commercial	$24,500.00

LATANOPROST 0.005 % OPHT DROP

Facility

$428.86

Service Code	HCPCS A9270
Hospital Revenue Code	250
Min. Negotiated Rate	$218.72
Max. Negotiated Rate	$415.99
Rate for Payer: Cash Price	$278.76
Rate for Payer: Cash Price	$278.15
Rate for Payer: Hawaii Western Management Group Commercial	$407.42
Rate for Payer: Hawaii Western Management Group Commercial	$406.52
Rate for Payer: Health Management Network Commercial	$364.53
Rate for Payer: Health Management Network Commercial	$363.73
Rate for Payer: Kaiser Permanente Commercial	$270.18
Rate for Payer: Kaiser Permanente Commercial	$269.59
Rate for Payer: Kaiser Permanente Medicaid	$218.24
Rate for Payer: Kaiser Permanente Medicaid	$218.72
Rate for Payer: MDX Hawaii PPO	$415.99
Rate for Payer: MDX Hawaii PPO	$415.08
Rate for Payer: UnitedHealthcare Medicaid	$256.75
Rate for Payer: UnitedHealthcare Medicaid	$257.32
Rate for Payer: University Health Alliance Commercial	$312.60
Rate for Payer: University Health Alliance Commercial	$311.91

Know your out-of-pocket cost for care.

All Charges