Kona Community Hospital

All Charges

Charge

Type

Setting

Price

TRANSFER OR TRANSPLANT OF SINGLE TENDON (WITH MUSCLE REDIRECTION OR REROUTING); EACH ADDITIONAL TENDON (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)

Facility

$2,837.00

Service Code	CPT 27692
Hospital Revenue Code	360
Min. Negotiated Rate	$102.31
Max. Negotiated Rate	$2,837.00
Rate for Payer: Kaiser Permanente Medicaid	$2,837.00
Rate for Payer: UnitedHealthcare Medicaid	$102.31

TRANSFUSION, BLOOD OR BLOOD COMPONENTS

Facility

$2,837.00

Service Code	CPT 36430
Hospital Revenue Code	360
Min. Negotiated Rate	$33.38
Max. Negotiated Rate	$2,837.00
Rate for Payer: AlohaCare Medicaid	$521.18
Rate for Payer: AlohaCare Medicare	$521.18
Rate for Payer: Devoted Health Medicare	$573.30
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	$521.18
Rate for Payer: Hawaii Medical Service Association Non-ABD	$407.95
Rate for Payer: Humana Medicare	$521.18
Rate for Payer: Kaiser Permanente Medicaid	$2,837.00
Rate for Payer: Kaiser Permanente Medicare	$521.18
Rate for Payer: Ohana Health Plan Medicaid	$573.30
Rate for Payer: Ohana Health Plan Medicare	$521.18
Rate for Payer: UnitedHealthcare Medicaid	$33.38
Rate for Payer: UnitedHealthcare Medicare	$521.18

TRANSIENT ISCHEMIA

Facility

$3,609.40

Service Code	APR-DRG 0472
Min. Negotiated Rate	$3,609.40
Max. Negotiated Rate	$3,609.40
Rate for Payer: AlohaCare Medicaid	$3,609.40
Rate for Payer: Hawaii Medical Service Association ABD	$3,609.40
Rate for Payer: Hawaii Medical Service Association Non-ABD	$3,609.40
Rate for Payer: Kaiser Permanente Medicaid	$3,609.40
Rate for Payer: Ohana Health Plan Medicaid	$3,609.40
Rate for Payer: UnitedHealthcare Medicaid	$3,609.40

TRANSIENT ISCHEMIA

Facility

$4,584.34

Service Code	APR-DRG 0473
Min. Negotiated Rate	$4,584.34
Max. Negotiated Rate	$4,584.34
Rate for Payer: AlohaCare Medicaid	$4,584.34
Rate for Payer: Hawaii Medical Service Association ABD	$4,584.34
Rate for Payer: Hawaii Medical Service Association Non-ABD	$4,584.34
Rate for Payer: Kaiser Permanente Medicaid	$4,584.34
Rate for Payer: Ohana Health Plan Medicaid	$4,584.34
Rate for Payer: UnitedHealthcare Medicaid	$4,584.34

TRANSIENT ISCHEMIA

Facility

$3,220.95

Service Code	APR-DRG 0471
Min. Negotiated Rate	$3,220.95
Max. Negotiated Rate	$3,220.95
Rate for Payer: AlohaCare Medicaid	$3,220.95
Rate for Payer: Hawaii Medical Service Association ABD	$3,220.95
Rate for Payer: Hawaii Medical Service Association Non-ABD	$3,220.95
Rate for Payer: Kaiser Permanente Medicaid	$3,220.95
Rate for Payer: Ohana Health Plan Medicaid	$3,220.95
Rate for Payer: UnitedHealthcare Medicaid	$3,220.95

TRANSIENT ISCHEMIA

Facility

$7,287.57

Service Code	APR-DRG 0474
Min. Negotiated Rate	$7,287.57
Max. Negotiated Rate	$7,287.57
Rate for Payer: AlohaCare Medicaid	$7,287.57
Rate for Payer: Hawaii Medical Service Association ABD	$7,287.57
Rate for Payer: Hawaii Medical Service Association Non-ABD	$7,287.57
Rate for Payer: Kaiser Permanente Medicaid	$7,287.57
Rate for Payer: Ohana Health Plan Medicaid	$7,287.57
Rate for Payer: UnitedHealthcare Medicaid	$7,287.57

TRANSIENT ISCHEMIA WITHOUT THROMBOLYTIC

Facility

$17,766.86

Service Code	MSDRG 069
Min. Negotiated Rate	$10,506.44
Max. Negotiated Rate	$17,766.86
Rate for Payer: AlohaCare Medicare	$10,506.44
Rate for Payer: Devoted Health Medicare	$11,557.08
Rate for Payer: Hawaii Medical Service Association Commercial	$17,766.86
Rate for Payer: Hawaii Medical Service Association Medicare	$10,506.44
Rate for Payer: Humana Medicare	$10,506.44
Rate for Payer: Kaiser Permanente Commercial	$13,779.30
Rate for Payer: Kaiser Permanente Medicare	$10,506.44
Rate for Payer: Ohana Health Plan Medicare	$10,506.44
Rate for Payer: UnitedHealthcare Medicare	$10,506.44

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

Facility

$14,715.00

Service Code	CPT 52601
Hospital Revenue Code	360
Min. Negotiated Rate	$521.33
Max. Negotiated Rate	$14,715.00
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	$1,149.00
Rate for Payer: Hawaii Medical Service Association Commercial	$14,715.00
Rate for Payer: Hawaii Medical Service Association Medicare	$6,334.13
Rate for Payer: Hawaii Medical Service Association Non-ABD	$1,154.45
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	$10,679.55

TRANSURETHRAL PROCEDURES WITH CC

Facility

$26,772.00

Service Code	MSDRG 669
Min. Negotiated Rate	$20,413.08
Max. Negotiated Rate	$26,772.00
Rate for Payer: AlohaCare Medicare	$20,413.08
Rate for Payer: Devoted Health Medicare	$22,454.39
Rate for Payer: Hawaii Medical Service Association Commercial	$21,527.55
Rate for Payer: Hawaii Medical Service Association Medicare	$20,413.08
Rate for Payer: Humana Medicare	$20,413.08
Rate for Payer: Kaiser Permanente Commercial	$26,772.00
Rate for Payer: Kaiser Permanente Medicare	$20,413.08
Rate for Payer: Ohana Health Plan Medicare	$20,413.08
Rate for Payer: UnitedHealthcare Medicare	$20,413.08

TRANSURETHRAL PROCEDURES WITH MCC

Facility

$50,370.00

Service Code	MSDRG 668
Min. Negotiated Rate	$21,527.55
Max. Negotiated Rate	$50,370.00
Rate for Payer: AlohaCare Medicare	$38,406.08
Rate for Payer: Devoted Health Medicare	$42,246.69
Rate for Payer: Hawaii Medical Service Association Commercial	$21,527.55
Rate for Payer: Hawaii Medical Service Association Medicare	$38,406.08
Rate for Payer: Humana Medicare	$38,406.08
Rate for Payer: Kaiser Permanente Commercial	$50,370.00
Rate for Payer: Kaiser Permanente Medicare	$38,406.08
Rate for Payer: Ohana Health Plan Medicare	$38,406.08
Rate for Payer: UnitedHealthcare Medicare	$38,406.08

TRANSURETHRAL PROCEDURES WITHOUT CC/MCC

Facility

$19,092.74

Service Code	MSDRG 670
Min. Negotiated Rate	$12,854.21
Max. Negotiated Rate	$19,092.74
Rate for Payer: AlohaCare Medicare	$12,854.21
Rate for Payer: Devoted Health Medicare	$14,139.63
Rate for Payer: Hawaii Medical Service Association Commercial	$19,092.74
Rate for Payer: Hawaii Medical Service Association Medicare	$12,854.21
Rate for Payer: Humana Medicare	$12,854.21
Rate for Payer: Kaiser Permanente Commercial	$16,858.42
Rate for Payer: Kaiser Permanente Medicare	$12,854.21
Rate for Payer: Ohana Health Plan Medicare	$12,854.21
Rate for Payer: UnitedHealthcare Medicare	$12,854.21

TRANSURETHRAL PROSTATECTOMY

Facility

$3,764.14

Service Code	APR-DRG 4821
Min. Negotiated Rate	$3,764.14
Max. Negotiated Rate	$3,764.14
Rate for Payer: AlohaCare Medicaid	$3,764.14
Rate for Payer: Hawaii Medical Service Association ABD	$3,764.14
Rate for Payer: Hawaii Medical Service Association Non-ABD	$3,764.14
Rate for Payer: Kaiser Permanente Medicaid	$3,764.14
Rate for Payer: Ohana Health Plan Medicaid	$3,764.14
Rate for Payer: UnitedHealthcare Medicaid	$3,764.14

TRANSURETHRAL PROSTATECTOMY

Facility

$14,308.33

Service Code	APR-DRG 4824
Min. Negotiated Rate	$14,308.33
Max. Negotiated Rate	$14,308.33
Rate for Payer: AlohaCare Medicaid	$14,308.33
Rate for Payer: Hawaii Medical Service Association ABD	$14,308.33
Rate for Payer: Hawaii Medical Service Association Non-ABD	$14,308.33
Rate for Payer: Kaiser Permanente Medicaid	$14,308.33
Rate for Payer: Ohana Health Plan Medicaid	$14,308.33
Rate for Payer: UnitedHealthcare Medicaid	$14,308.33

TRANSURETHRAL PROSTATECTOMY

Facility

$8,160.63

Service Code	APR-DRG 4823
Min. Negotiated Rate	$8,160.63
Max. Negotiated Rate	$8,160.63
Rate for Payer: AlohaCare Medicaid	$8,160.63
Rate for Payer: Hawaii Medical Service Association ABD	$8,160.63
Rate for Payer: Hawaii Medical Service Association Non-ABD	$8,160.63
Rate for Payer: Kaiser Permanente Medicaid	$8,160.63
Rate for Payer: Ohana Health Plan Medicaid	$8,160.63
Rate for Payer: UnitedHealthcare Medicaid	$8,160.63

TRANSURETHRAL PROSTATECTOMY

Facility

$4,546.77

Service Code	APR-DRG 4822
Min. Negotiated Rate	$4,546.77
Max. Negotiated Rate	$4,546.77
Rate for Payer: AlohaCare Medicaid	$4,546.77
Rate for Payer: Hawaii Medical Service Association ABD	$4,546.77
Rate for Payer: Hawaii Medical Service Association Non-ABD	$4,546.77
Rate for Payer: Kaiser Permanente Medicaid	$4,546.77
Rate for Payer: Ohana Health Plan Medicaid	$4,546.77
Rate for Payer: UnitedHealthcare Medicaid	$4,546.77

TRANSURETHRAL PROSTATECTOMY WITH CC/MCC

Facility

$25,933.65

Service Code	MSDRG 713
Min. Negotiated Rate	$17,983.82
Max. Negotiated Rate	$25,933.65
Rate for Payer: AlohaCare Medicare	$19,773.87
Rate for Payer: Devoted Health Medicare	$21,751.26
Rate for Payer: Hawaii Medical Service Association Commercial	$17,983.82
Rate for Payer: Hawaii Medical Service Association Medicare	$19,773.87
Rate for Payer: Humana Medicare	$19,773.87
Rate for Payer: Kaiser Permanente Commercial	$25,933.65
Rate for Payer: Kaiser Permanente Medicare	$19,773.87
Rate for Payer: Ohana Health Plan Medicare	$19,773.87
Rate for Payer: UnitedHealthcare Medicare	$19,773.87

TRANSURETHRAL PROSTATECTOMY WITHOUT CC/MCC

Facility

$18,240.15

Service Code	MSDRG 714
Min. Negotiated Rate	$13,907.74
Max. Negotiated Rate	$18,240.15
Rate for Payer: AlohaCare Medicare	$13,907.74
Rate for Payer: Devoted Health Medicare	$15,298.51
Rate for Payer: Hawaii Medical Service Association Commercial	$14,247.24
Rate for Payer: Hawaii Medical Service Association Medicare	$13,907.74
Rate for Payer: Humana Medicare	$13,907.74
Rate for Payer: Kaiser Permanente Commercial	$18,240.15
Rate for Payer: Kaiser Permanente Medicare	$13,907.74
Rate for Payer: Ohana Health Plan Medicare	$13,907.74
Rate for Payer: UnitedHealthcare Medicare	$13,907.74

TRANSURETHRAL RESECTION OF BLADDER NECK (SEPARATE PROCEDURE)

Facility

$6,743.44

Service Code	CPT 52500
Hospital Revenue Code	360
Min. Negotiated Rate	$456.03
Max. Negotiated Rate	$6,743.44
Rate for Payer: AlohaCare Medicaid	$4,164.22
Rate for Payer: AlohaCare Medicare	$4,164.22
Rate for Payer: Devoted Health Medicare	$4,580.64
Rate for Payer: Hawaii Medical Service Association ABD	$695.00
Rate for Payer: Hawaii Medical Service Association Commercial	$6,183.00
Rate for Payer: Hawaii Medical Service Association Medicare	$4,164.22
Rate for Payer: Hawaii Medical Service Association Non-ABD	$700.72
Rate for Payer: Humana Medicare	$4,164.22
Rate for Payer: Kaiser Permanente Medicaid	$2,837.00
Rate for Payer: Kaiser Permanente Medicare	$4,164.22
Rate for Payer: Ohana Health Plan Medicaid	$4,580.64
Rate for Payer: Ohana Health Plan Medicare	$4,164.22
Rate for Payer: UnitedHealthcare Medicaid	$456.03
Rate for Payer: UnitedHealthcare Medicare	$4,164.22
Rate for Payer: University Health Alliance Commercial	$6,743.44

TRANSURETHRAL RESECTION; RESIDUAL OR REGROWTH OF OBSTRUCTIVE PROSTATE TISSUE INCLUDING CONTROL OF POSTOPERATIVE BLEEDING, COMPLETE (VASECTOMY, MEATOTOMY, CYSTOURETHROSCOPY, URETHRAL CALIBRATION AND/OR DILATION, AND INTERNAL URETHROTOMY ARE INCLUDED)

Facility

$14,715.00

Service Code	CPT 52630
Hospital Revenue Code	360
Min. Negotiated Rate	$521.33
Max. Negotiated Rate	$14,715.00
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	$1,149.00
Rate for Payer: Hawaii Medical Service Association Commercial	$14,715.00
Rate for Payer: Hawaii Medical Service Association Medicare	$6,334.13
Rate for Payer: Hawaii Medical Service Association Non-ABD	$1,154.45
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	$5,160.40

TRANSVERSUS ABDOMINIS PLANE (TAP) BLOCK (ABDOMINAL PLANE BLOCK, RECTUS SHEATH BLOCK) BILATERAL; BY INJECTIONS (INCLUDES IMAGING GUIDANCE, WHEN PERFORMED)

Facility

$2,837.00

Service Code	CPT 64488
Hospital Revenue Code	360
Min. Negotiated Rate	$67.16
Max. Negotiated Rate	$2,837.00
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 Non-ABD	$407.95
Rate for Payer: Kaiser Permanente Medicaid	$2,837.00
Rate for Payer: UnitedHealthcare Medicaid	$67.16

TRANSVERSUS ABDOMINIS PLANE (TAP) BLOCK (ABDOMINAL PLANE BLOCK, RECTUS SHEATH BLOCK) UNILATERAL; BY INJECTION(S) (INCLUDES IMAGING GUIDANCE, WHEN PERFORMED)

Facility

$2,837.00

Service Code	CPT 64486
Hospital Revenue Code	360
Min. Negotiated Rate	$53.89
Max. Negotiated Rate	$2,837.00
Rate for Payer: Kaiser Permanente Medicaid	$2,837.00
Rate for Payer: UnitedHealthcare Medicaid	$53.89

TRASTUZUMAB 150 MG IV RECON.SOLN.

Facility

$2,988.51

Service Code	HCPCS J9355
Hospital Revenue Code	636
Min. Negotiated Rate	$73.43
Max. Negotiated Rate	$2,898.85
Rate for Payer: AlohaCare Medicaid	$73.43
Rate for Payer: AlohaCare Medicare	$73.43
Rate for Payer: Cash Price	$1,942.53
Rate for Payer: Cash Price	$1,942.53
Rate for Payer: Devoted Health Medicare	$80.77
Rate for Payer: Hawaii Medical Service Association ABD	$76.18
Rate for Payer: Hawaii Medical Service Association Commercial	$91.79
Rate for Payer: Hawaii Medical Service Association Medicare	$73.43
Rate for Payer: Hawaii Medical Service Association Non-ABD	$76.18
Rate for Payer: Hawaii Western Management Group Commercial	$2,839.08
Rate for Payer: Health Management Network Commercial	$2,540.23
Rate for Payer: Humana Medicare	$73.43
Rate for Payer: Kaiser Permanente Commercial	$1,882.76
Rate for Payer: Kaiser Permanente Medicaid	$1,524.14
Rate for Payer: Kaiser Permanente Medicare	$73.43
Rate for Payer: MDX Hawaii PPO	$2,898.85
Rate for Payer: Ohana Health Plan Medicaid	$80.77
Rate for Payer: Ohana Health Plan Medicare	$73.43
Rate for Payer: UnitedHealthcare Medicaid	$1,793.11
Rate for Payer: UnitedHealthcare Medicare	$73.43
Rate for Payer: University Health Alliance Commercial	$2,178.32

TRASTUZUMAB 150 MG IV RECON.SOLN.

Facility

$2,988.51

Service Code	HCPCS J9355
Hospital Revenue Code	250
Min. Negotiated Rate	$2,540.23
Max. Negotiated Rate	$2,898.85
Rate for Payer: Cash Price	$1,942.53
Rate for Payer: Health Management Network Commercial	$2,540.23
Rate for Payer: MDX Hawaii PPO	$2,898.85

TRASTUZUMAB-ANNS 150 MG IV RECON.SOLN.

Facility

$2,750.49

Service Code	HCPCS Q5117
Hospital Revenue Code	250
Min. Negotiated Rate	$2,337.92
Max. Negotiated Rate	$2,667.98
Rate for Payer: Cash Price	$1,787.82
Rate for Payer: Health Management Network Commercial	$2,337.92
Rate for Payer: MDX Hawaii PPO	$2,667.98

TRASTUZUMAB-ANNS 150 MG IV RECON.SOLN.

Facility

$2,750.49

Service Code	HCPCS Q5117
Hospital Revenue Code	250
Min. Negotiated Rate	$43.28
Max. Negotiated Rate	$2,667.98
Rate for Payer: AlohaCare Medicaid	$56.38
Rate for Payer: AlohaCare Medicare	$56.38
Rate for Payer: Cash Price	$1,787.82
Rate for Payer: Cash Price	$1,787.82
Rate for Payer: Devoted Health Medicare	$62.02
Rate for Payer: Hawaii Medical Service Association ABD	$43.28
Rate for Payer: Hawaii Medical Service Association Commercial	$70.47
Rate for Payer: Hawaii Medical Service Association Medicare	$56.38
Rate for Payer: Hawaii Medical Service Association Non-ABD	$43.28
Rate for Payer: Hawaii Western Management Group Commercial	$2,612.97
Rate for Payer: Health Management Network Commercial	$2,337.92
Rate for Payer: Humana Medicare	$56.38
Rate for Payer: Kaiser Permanente Commercial	$1,732.81
Rate for Payer: Kaiser Permanente Medicaid	$1,402.75
Rate for Payer: Kaiser Permanente Medicare	$56.38
Rate for Payer: MDX Hawaii PPO	$2,667.98
Rate for Payer: Ohana Health Plan Medicaid	$62.02
Rate for Payer: Ohana Health Plan Medicare	$56.38
Rate for Payer: UnitedHealthcare Medicaid	$1,650.29
Rate for Payer: UnitedHealthcare Medicare	$56.38
Rate for Payer: University Health Alliance Commercial	$2,004.83

Know your out-of-pocket cost for care.

All Charges