Kona Community Hospital

All Charges

Charge

Type

Setting

Price

Brace Back Tlso Small [2705456]

Facility

$1,513.48

Service Code	HCPCS L0450
Hospital Charge Code	2705456
Hospital Revenue Code	274
Min. Negotiated Rate	$118.75
Max. Negotiated Rate	$1,468.08
Rate for Payer: Cash Price	$983.76
Rate for Payer: Cash Price	$983.76
Rate for Payer: Hawaii Western Management Group Commercial	$1,059.44
Rate for Payer: Health Management Network Commercial	$1,286.46
Rate for Payer: Kaiser Permanente Commercial	$953.49
Rate for Payer: Kaiser Permanente Medicaid	$771.87
Rate for Payer: MDX Hawaii PPO	$1,468.08
Rate for Payer: UnitedHealthcare Medicaid	$118.75
Rate for Payer: University Health Alliance Commercial	$847.55

Brace Back Tlso Small [2705456]

Facility

$1,513.48

Service Code	HCPCS L0450
Hospital Charge Code	2705456
Hospital Revenue Code	274
Min. Negotiated Rate	$847.55
Max. Negotiated Rate	$1,468.08
Rate for Payer: Cash Price	$983.76
Rate for Payer: Hawaii Western Management Group Commercial	$1,059.44
Rate for Payer: Health Management Network Commercial	$1,286.46
Rate for Payer: MDX Hawaii PPO	$1,468.08
Rate for Payer: University Health Alliance Commercial	$847.55

Brace Humeral Fx Extended Xsmall [2707724]

Facility

$584.08

Service Code	HCPCS L3980
Hospital Charge Code	2707724
Hospital Revenue Code	274
Min. Negotiated Rate	$232.34
Max. Negotiated Rate	$566.56
Rate for Payer: Cash Price	$379.65
Rate for Payer: Cash Price	$379.65
Rate for Payer: Hawaii Western Management Group Commercial	$408.86
Rate for Payer: Health Management Network Commercial	$496.47
Rate for Payer: Kaiser Permanente Commercial	$367.97
Rate for Payer: Kaiser Permanente Medicaid	$297.88
Rate for Payer: MDX Hawaii PPO	$566.56
Rate for Payer: UnitedHealthcare Medicaid	$232.34
Rate for Payer: University Health Alliance Commercial	$327.08

Brace Humeral Fx Extended Xsmall [2707724]

Facility

$584.08

Service Code	HCPCS L3980
Hospital Charge Code	2707724
Hospital Revenue Code	274
Min. Negotiated Rate	$327.08
Max. Negotiated Rate	$566.56
Rate for Payer: Cash Price	$379.65
Rate for Payer: Hawaii Western Management Group Commercial	$408.86
Rate for Payer: Health Management Network Commercial	$496.47
Rate for Payer: MDX Hawaii PPO	$566.56
Rate for Payer: University Health Alliance Commercial	$327.08

BRAIN CONTUSION/LACERATION & COMPLICATED SKULL FX, COMA < 1 HR OR NO COMA

Facility

$2,990.43

Service Code	APR-DRG 0561
Min. Negotiated Rate	$2,990.43
Max. Negotiated Rate	$2,990.43
Rate for Payer: AlohaCare Medicaid	$2,990.43
Rate for Payer: Hawaii Medical Service Association ABD	$2,990.43
Rate for Payer: Hawaii Medical Service Association Non-ABD	$2,990.43
Rate for Payer: Kaiser Permanente Medicaid	$2,990.43
Rate for Payer: Ohana Health Plan Medicaid	$2,990.43
Rate for Payer: UnitedHealthcare Medicaid	$2,990.43

BRAIN CONTUSION/LACERATION & COMPLICATED SKULL FX, COMA < 1 HR OR NO COMA

Facility

$4,237.92

Service Code	APR-DRG 0562
Min. Negotiated Rate	$4,237.92
Max. Negotiated Rate	$4,237.92
Rate for Payer: AlohaCare Medicaid	$4,237.92
Rate for Payer: Hawaii Medical Service Association ABD	$4,237.92
Rate for Payer: Hawaii Medical Service Association Non-ABD	$4,237.92
Rate for Payer: Kaiser Permanente Medicaid	$4,237.92
Rate for Payer: Ohana Health Plan Medicaid	$4,237.92
Rate for Payer: UnitedHealthcare Medicaid	$4,237.92

BRAIN CONTUSION/LACERATION & COMPLICATED SKULL FX, COMA < 1 HR OR NO COMA

Facility

$11,470.73

Service Code	APR-DRG 0564
Min. Negotiated Rate	$11,470.73
Max. Negotiated Rate	$11,470.73
Rate for Payer: AlohaCare Medicaid	$11,470.73
Rate for Payer: Hawaii Medical Service Association ABD	$11,470.73
Rate for Payer: Hawaii Medical Service Association Non-ABD	$11,470.73
Rate for Payer: Kaiser Permanente Medicaid	$11,470.73
Rate for Payer: Ohana Health Plan Medicaid	$11,470.73
Rate for Payer: UnitedHealthcare Medicaid	$11,470.73

BRAIN CONTUSION/LACERATION & COMPLICATED SKULL FX, COMA < 1 HR OR NO COMA

Facility

$6,089.75

Service Code	APR-DRG 0563
Min. Negotiated Rate	$6,089.75
Max. Negotiated Rate	$6,089.75
Rate for Payer: AlohaCare Medicaid	$6,089.75
Rate for Payer: Hawaii Medical Service Association ABD	$6,089.75
Rate for Payer: Hawaii Medical Service Association Non-ABD	$6,089.75
Rate for Payer: Kaiser Permanente Medicaid	$6,089.75
Rate for Payer: Ohana Health Plan Medicaid	$6,089.75
Rate for Payer: UnitedHealthcare Medicaid	$6,089.75

BRAIN IMAGING PET METABOLIC EVALUATION

Professional

Both

$3,869.12

Service Code	HCPCS 78608
Min. Negotiated Rate	$1,242.60
Max. Negotiated Rate	$3,288.75
Rate for Payer: AlohaCare Medicaid	$1,495.20
Rate for Payer: Cash Price	$2,514.93
Rate for Payer: Cash Price	$2,514.93
Rate for Payer: Hawaii Western Management Group Commercial	$1,242.60
Rate for Payer: Health Management Network Commercial	$3,288.75
Rate for Payer: Ohana Health Plan Medicaid	$1,495.20
Rate for Payer: UnitedHealthcare Medicaid	$1,495.20

BREAST BIOPSY, LOCAL EXCISION AND OTHER BREAST PROCEDURES WITH CC/MCC

Facility

$36,927.07

Service Code	MSDRG 584
Min. Negotiated Rate	$25,601.63
Max. Negotiated Rate	$36,927.07
Rate for Payer: AlohaCare Medicare	$28,156.12
Rate for Payer: Devoted Health Medicare	$30,971.73
Rate for Payer: Hawaii Medical Service Association Commercial	$25,601.63
Rate for Payer: Hawaii Medical Service Association Medicare	$28,156.12
Rate for Payer: Humana Medicare	$28,156.12
Rate for Payer: Kaiser Permanente Commercial	$36,927.07
Rate for Payer: Kaiser Permanente Medicare	$28,156.12
Rate for Payer: Ohana Health Plan Medicare	$28,156.12
Rate for Payer: UnitedHealthcare Medicare	$28,156.12

BREAST BIOPSY, LOCAL EXCISION AND OTHER BREAST PROCEDURES WITHOUT CC/MCC

Facility

$33,276.97

Service Code	MSDRG 585
Min. Negotiated Rate	$24,782.00
Max. Negotiated Rate	$33,276.97
Rate for Payer: AlohaCare Medicare	$25,373.00
Rate for Payer: Devoted Health Medicare	$27,910.30
Rate for Payer: Hawaii Medical Service Association Commercial	$24,782.00
Rate for Payer: Hawaii Medical Service Association Medicare	$25,373.00
Rate for Payer: Humana Medicare	$25,373.00
Rate for Payer: Kaiser Permanente Commercial	$33,276.97
Rate for Payer: Kaiser Permanente Medicare	$25,373.00
Rate for Payer: Ohana Health Plan Medicare	$25,373.00
Rate for Payer: UnitedHealthcare Medicare	$25,373.00

BREAST PROCEDURES EXCEPT MASTECTOMY

Facility

$9,038.14

Service Code	APR-DRG 3632
Min. Negotiated Rate	$9,038.14
Max. Negotiated Rate	$9,038.14
Rate for Payer: AlohaCare Medicaid	$9,038.14
Rate for Payer: Hawaii Medical Service Association ABD	$9,038.14
Rate for Payer: Hawaii Medical Service Association Non-ABD	$9,038.14
Rate for Payer: Kaiser Permanente Medicaid	$9,038.14
Rate for Payer: Ohana Health Plan Medicaid	$9,038.14
Rate for Payer: UnitedHealthcare Medicaid	$9,038.14

BREAST PROCEDURES EXCEPT MASTECTOMY

Facility

$13,161.44

Service Code	APR-DRG 3634
Min. Negotiated Rate	$13,161.44
Max. Negotiated Rate	$13,161.44
Rate for Payer: AlohaCare Medicaid	$13,161.44
Rate for Payer: Hawaii Medical Service Association ABD	$13,161.44
Rate for Payer: Hawaii Medical Service Association Non-ABD	$13,161.44
Rate for Payer: Kaiser Permanente Medicaid	$13,161.44
Rate for Payer: Ohana Health Plan Medicaid	$13,161.44
Rate for Payer: UnitedHealthcare Medicaid	$13,161.44

BREAST PROCEDURES EXCEPT MASTECTOMY

Facility

$11,579.63

Service Code	APR-DRG 3633
Min. Negotiated Rate	$11,579.63
Max. Negotiated Rate	$11,579.63
Rate for Payer: AlohaCare Medicaid	$11,579.63
Rate for Payer: Hawaii Medical Service Association ABD	$11,579.63
Rate for Payer: Hawaii Medical Service Association Non-ABD	$11,579.63
Rate for Payer: Kaiser Permanente Medicaid	$11,579.63
Rate for Payer: Ohana Health Plan Medicaid	$11,579.63
Rate for Payer: UnitedHealthcare Medicaid	$11,579.63

BREAST PROCEDURES EXCEPT MASTECTOMY

Facility

$5,636.34

Service Code	APR-DRG 3631
Min. Negotiated Rate	$5,636.34
Max. Negotiated Rate	$5,636.34
Rate for Payer: AlohaCare Medicaid	$5,636.34
Rate for Payer: Hawaii Medical Service Association ABD	$5,636.34
Rate for Payer: Hawaii Medical Service Association Non-ABD	$5,636.34
Rate for Payer: Kaiser Permanente Medicaid	$5,636.34
Rate for Payer: Ohana Health Plan Medicaid	$5,636.34
Rate for Payer: UnitedHealthcare Medicaid	$5,636.34

BREAST REDUCTION

Facility

$17,484.00

Service Code	CPT 19318
Hospital Revenue Code	360
Min. Negotiated Rate	$521.33
Max. Negotiated Rate	$17,484.00
Rate for Payer: AlohaCare Medicaid	$7,844.33
Rate for Payer: AlohaCare Medicare	$7,844.33
Rate for Payer: Devoted Health Medicare	$8,628.76
Rate for Payer: Hawaii Medical Service Association ABD	$1,900.00
Rate for Payer: Hawaii Medical Service Association Commercial	$17,484.00
Rate for Payer: Hawaii Medical Service Association Medicare	$7,844.33
Rate for Payer: Hawaii Medical Service Association Non-ABD	$1,902.37
Rate for Payer: Humana Medicare	$7,844.33
Rate for Payer: Kaiser Permanente Medicaid	$2,837.00
Rate for Payer: Kaiser Permanente Medicare	$7,844.33
Rate for Payer: Ohana Health Plan Medicaid	$8,628.76
Rate for Payer: Ohana Health Plan Medicare	$7,844.33
Rate for Payer: UnitedHealthcare Medicaid	$521.33
Rate for Payer: UnitedHealthcare Medicare	$7,844.33
Rate for Payer: University Health Alliance Commercial	$10,679.55

Breast Tissue Expander CPX4 Low Height 350cc 3548112 [3644853]

Facility

$9,640.50

Hospital Charge Code	3644853
Hospital Revenue Code	272
Min. Negotiated Rate	$4,916.65
Max. Negotiated Rate	$9,351.28
Rate for Payer: Cash Price	$6,266.32
Rate for Payer: Hawaii Western Management Group Commercial	$9,158.48
Rate for Payer: Health Management Network Commercial	$8,194.42
Rate for Payer: Kaiser Permanente Commercial	$6,073.52
Rate for Payer: Kaiser Permanente Medicaid	$4,916.65
Rate for Payer: MDX Hawaii PPO	$9,351.28
Rate for Payer: University Health Alliance Commercial	$7,026.96

Breast Tissue Expander CPX4 Low Height 350cc 3548112 [3644853]

Facility

$9,640.50

Hospital Charge Code	3644853
Hospital Revenue Code	272
Min. Negotiated Rate	$8,194.42
Max. Negotiated Rate	$9,351.28
Rate for Payer: Cash Price	$6,266.32
Rate for Payer: Health Management Network Commercial	$8,194.42
Rate for Payer: MDX Hawaii PPO	$9,351.28

Breast Tissue Expander CPX 4 Med 450cc Mentor 354-8213 [3643197]

Facility

$9,640.50

Service Code	HCPCS C1789
Hospital Charge Code	3643197
Hospital Revenue Code	278
Min. Negotiated Rate	$5,398.68
Max. Negotiated Rate	$9,351.28
Rate for Payer: Cash Price	$6,266.32
Rate for Payer: Hawaii Western Management Group Commercial	$6,748.35
Rate for Payer: Health Management Network Commercial	$8,194.42
Rate for Payer: MDX Hawaii PPO	$9,351.28
Rate for Payer: University Health Alliance Commercial	$5,398.68

Breast Tissue Expander CPX 4 Med 450cc Mentor 354-8213 [3643197]

Facility

$9,640.50

Service Code	HCPCS C1789
Hospital Charge Code	3643197
Hospital Revenue Code	278
Min. Negotiated Rate	$4,916.65
Max. Negotiated Rate	$9,351.28
Rate for Payer: Cash Price	$6,266.32
Rate for Payer: Hawaii Western Management Group Commercial	$6,748.35
Rate for Payer: Health Management Network Commercial	$8,194.42
Rate for Payer: Kaiser Permanente Commercial	$6,073.52
Rate for Payer: Kaiser Permanente Medicaid	$4,916.65
Rate for Payer: MDX Hawaii PPO	$9,351.28
Rate for Payer: University Health Alliance Commercial	$5,398.68

Breast Tissue Expander CPX 4 Med Mentor 3548212 [3642673]

Facility

$4,687.50

Service Code	HCPCS C1789
Hospital Charge Code	3642673
Hospital Revenue Code	278
Min. Negotiated Rate	$2,625.00
Max. Negotiated Rate	$4,546.88
Rate for Payer: Cash Price	$3,046.88
Rate for Payer: Hawaii Western Management Group Commercial	$3,281.25
Rate for Payer: Health Management Network Commercial	$3,984.38
Rate for Payer: MDX Hawaii PPO	$4,546.88
Rate for Payer: University Health Alliance Commercial	$2,625.00

Breast Tissue Expander CPX 4 Med Mentor 3548212 [3642673]

Facility

$4,687.50

Service Code	HCPCS C1789
Hospital Charge Code	3642673
Hospital Revenue Code	278
Min. Negotiated Rate	$2,390.62
Max. Negotiated Rate	$4,546.88
Rate for Payer: Cash Price	$3,046.88
Rate for Payer: Hawaii Western Management Group Commercial	$3,281.25
Rate for Payer: Health Management Network Commercial	$3,984.38
Rate for Payer: Kaiser Permanente Commercial	$2,953.12
Rate for Payer: Kaiser Permanente Medicaid	$2,390.62
Rate for Payer: MDX Hawaii PPO	$4,546.88
Rate for Payer: University Health Alliance Commercial	$2,625.00

BRIEF COMMUNICATION TECH-BSD SVC EST PT 5-10 MIN

Professional

Both

$31.59

Service Code	HCPCS 98016
Min. Negotiated Rate	$0.01
Max. Negotiated Rate	$26.85
Rate for Payer: AlohaCare Medicaid	$0.01
Rate for Payer: AlohaCare Medicare	$13.07
Rate for Payer: Cash Price	$20.53
Rate for Payer: Cash Price	$20.53
Rate for Payer: Devoted Health Medicare	$14.38
Rate for Payer: Hawaii Medical Service Association Medicare	$13.07
Rate for Payer: Health Management Network Commercial	$26.85
Rate for Payer: Kaiser Permanente Commercial	$15.68
Rate for Payer: Kaiser Permanente Medicaid	$15.68
Rate for Payer: Kaiser Permanente Medicare	$15.68
Rate for Payer: Ohana Health Plan Medicaid	$0.01
Rate for Payer: Ohana Health Plan Medicare	$13.07
Rate for Payer: UnitedHealthcare Medicaid	$0.01
Rate for Payer: UnitedHealthcare Medicare	$13.07

BRIMONIDINE 0.15 % OPHT DROP

Facility

$637.93

Service Code	NDC 61314014405
Hospital Revenue Code	250
Min. Negotiated Rate	$542.24
Max. Negotiated Rate	$618.79
Rate for Payer: Cash Price	$414.65
Rate for Payer: Health Management Network Commercial	$542.24
Rate for Payer: MDX Hawaii PPO	$618.79

BRIMONIDINE 0.15 % OPHT DROP

Facility

$637.93

Service Code	NDC 61314014405
Hospital Revenue Code	250
Min. Negotiated Rate	$325.34
Max. Negotiated Rate	$618.79
Rate for Payer: Cash Price	$414.65
Rate for Payer: Hawaii Western Management Group Commercial	$606.03
Rate for Payer: Health Management Network Commercial	$542.24
Rate for Payer: Kaiser Permanente Commercial	$401.90
Rate for Payer: Kaiser Permanente Medicaid	$325.34
Rate for Payer: MDX Hawaii PPO	$618.79
Rate for Payer: UnitedHealthcare Medicaid	$382.76
Rate for Payer: University Health Alliance Commercial	$464.99

Know your out-of-pocket cost for care.

All Charges