Kona Community Hospital

All Charges

Charge

Type

Setting

Price

UNLISTED PROCEDURE, DENTOALVEOLAR STRUCTURES

Facility

$2,837.00

Service Code	CPT 41899
Hospital Revenue Code	360
Min. Negotiated Rate	$35.12
Max. Negotiated Rate	$2,837.00
Rate for Payer: AlohaCare Medicaid	$279.80
Rate for Payer: AlohaCare Medicare	$279.80
Rate for Payer: Devoted Health Medicare	$307.78
Rate for Payer: Hawaii Medical Service Association Commercial	$349.75
Rate for Payer: Hawaii Medical Service Association Medicare	$279.80
Rate for Payer: Humana Medicare	$279.80
Rate for Payer: Kaiser Permanente Medicaid	$2,837.00
Rate for Payer: Kaiser Permanente Medicare	$279.80
Rate for Payer: Ohana Health Plan Medicaid	$307.78
Rate for Payer: Ohana Health Plan Medicare	$279.80
Rate for Payer: UnitedHealthcare Medicaid	$35.12
Rate for Payer: UnitedHealthcare Medicare	$279.80

UNLISTED PROCEDURE, FEMALE GENITAL SYSTEM (NONOBSTETRICAL)

Facility

$2,837.00

Service Code	CPT 58999
Hospital Revenue Code	360
Min. Negotiated Rate	$238.83
Max. Negotiated Rate	$2,837.00
Rate for Payer: AlohaCare Medicaid	$238.83
Rate for Payer: AlohaCare Medicare	$238.83
Rate for Payer: Devoted Health Medicare	$262.71
Rate for Payer: Hawaii Medical Service Association Commercial	$298.54
Rate for Payer: Hawaii Medical Service Association Medicare	$238.83
Rate for Payer: Humana Medicare	$238.83
Rate for Payer: Kaiser Permanente Medicaid	$2,837.00
Rate for Payer: Kaiser Permanente Medicare	$238.83
Rate for Payer: Ohana Health Plan Medicaid	$262.71
Rate for Payer: Ohana Health Plan Medicare	$238.83
Rate for Payer: UnitedHealthcare Medicaid	$375.03
Rate for Payer: UnitedHealthcare Medicare	$238.83

UNLISTED PROCEDURE, FEMUR OR KNEE

Facility

$2,837.00

Service Code	CPT 27599
Hospital Revenue Code	360
Min. Negotiated Rate	$179.91
Max. Negotiated Rate	$2,837.00
Rate for Payer: AlohaCare Medicaid	$291.40
Rate for Payer: AlohaCare Medicare	$291.40
Rate for Payer: Devoted Health Medicare	$320.54
Rate for Payer: Hawaii Medical Service Association Commercial	$364.25
Rate for Payer: Hawaii Medical Service Association Medicare	$291.40
Rate for Payer: Humana Medicare	$291.40
Rate for Payer: Kaiser Permanente Medicaid	$2,837.00
Rate for Payer: Kaiser Permanente Medicare	$291.40
Rate for Payer: Ohana Health Plan Medicaid	$320.54
Rate for Payer: Ohana Health Plan Medicare	$291.40
Rate for Payer: UnitedHealthcare Medicaid	$179.91
Rate for Payer: UnitedHealthcare Medicare	$291.40

UNLISTED PROCEDURE, FOREARM OR WRIST

Facility

$2,837.00

Service Code	CPT 25999
Hospital Revenue Code	360
Min. Negotiated Rate	$179.91
Max. Negotiated Rate	$2,837.00
Rate for Payer: AlohaCare Medicaid	$291.40
Rate for Payer: AlohaCare Medicare	$291.40
Rate for Payer: Devoted Health Medicare	$320.54
Rate for Payer: Hawaii Medical Service Association Commercial	$364.25
Rate for Payer: Hawaii Medical Service Association Medicare	$291.40
Rate for Payer: Humana Medicare	$291.40
Rate for Payer: Kaiser Permanente Medicaid	$2,837.00
Rate for Payer: Kaiser Permanente Medicare	$291.40
Rate for Payer: Ohana Health Plan Medicaid	$320.54
Rate for Payer: Ohana Health Plan Medicare	$291.40
Rate for Payer: UnitedHealthcare Medicaid	$179.91
Rate for Payer: UnitedHealthcare Medicare	$291.40

UNLISTED PROCEDURE, PELVIS OR HIP JOINT

Facility

$2,837.00

Service Code	CPT 27299
Hospital Revenue Code	360
Min. Negotiated Rate	$291.40
Max. Negotiated Rate	$2,837.00
Rate for Payer: AlohaCare Medicaid	$291.40
Rate for Payer: AlohaCare Medicare	$291.40
Rate for Payer: Devoted Health Medicare	$320.54
Rate for Payer: Hawaii Medical Service Association Commercial	$364.25
Rate for Payer: Hawaii Medical Service Association Medicare	$291.40
Rate for Payer: Humana Medicare	$291.40
Rate for Payer: Kaiser Permanente Medicaid	$2,837.00
Rate for Payer: Kaiser Permanente Medicare	$291.40
Rate for Payer: Ohana Health Plan Medicaid	$320.54
Rate for Payer: Ohana Health Plan Medicare	$291.40
Rate for Payer: UnitedHealthcare Medicaid	$324.74
Rate for Payer: UnitedHealthcare Medicare	$291.40

UPPER LIMB AND TOE AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS WITH CC

Facility

$37,269.42

Service Code	MSDRG 256
Min. Negotiated Rate	$22,332.08
Max. Negotiated Rate	$37,269.42
Rate for Payer: AlohaCare Medicare	$22,332.08
Rate for Payer: Devoted Health Medicare	$24,565.29
Rate for Payer: Hawaii Medical Service Association Commercial	$37,269.42
Rate for Payer: Hawaii Medical Service Association Medicare	$22,332.08
Rate for Payer: Humana Medicare	$22,332.08
Rate for Payer: Kaiser Permanente Commercial	$29,288.78
Rate for Payer: Kaiser Permanente Medicare	$22,332.08
Rate for Payer: Ohana Health Plan Medicare	$22,332.08
Rate for Payer: UnitedHealthcare Medicare	$22,332.08

UPPER LIMB AND TOE AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS WITH MCC

Facility

$46,530.15

Service Code	MSDRG 255
Min. Negotiated Rate	$35,478.27
Max. Negotiated Rate	$46,530.15
Rate for Payer: AlohaCare Medicare	$35,478.27
Rate for Payer: Devoted Health Medicare	$39,026.10
Rate for Payer: Hawaii Medical Service Association Commercial	$37,269.42
Rate for Payer: Hawaii Medical Service Association Medicare	$35,478.27
Rate for Payer: Humana Medicare	$35,478.27
Rate for Payer: Kaiser Permanente Commercial	$46,530.15
Rate for Payer: Kaiser Permanente Medicare	$35,478.27
Rate for Payer: Ohana Health Plan Medicare	$35,478.27
Rate for Payer: UnitedHealthcare Medicare	$35,478.27

UPPER LIMB AND TOE AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS WITHOUT CC/MCC

Facility

$37,269.42

Service Code	MSDRG 257
Min. Negotiated Rate	$14,365.46
Max. Negotiated Rate	$37,269.42
Rate for Payer: AlohaCare Medicare	$14,365.46
Rate for Payer: Devoted Health Medicare	$15,802.01
Rate for Payer: Hawaii Medical Service Association Commercial	$37,269.42
Rate for Payer: Hawaii Medical Service Association Medicare	$14,365.46
Rate for Payer: Humana Medicare	$14,365.46
Rate for Payer: Kaiser Permanente Commercial	$18,840.45
Rate for Payer: Kaiser Permanente Medicare	$14,365.46
Rate for Payer: Ohana Health Plan Medicare	$14,365.46
Rate for Payer: UnitedHealthcare Medicare	$14,365.46

Ureteral Access Sheath 11/13FRx28cm Navigator M0062502210 [3643018]

Facility

$770.83

Service Code	HCPCS C1894
Hospital Charge Code	3643018
Hospital Revenue Code	272
Min. Negotiated Rate	$393.12
Max. Negotiated Rate	$747.71
Rate for Payer: Cash Price	$501.04
Rate for Payer: Hawaii Western Management Group Commercial	$732.29
Rate for Payer: Health Management Network Commercial	$655.21
Rate for Payer: Kaiser Permanente Commercial	$485.62
Rate for Payer: Kaiser Permanente Medicaid	$393.12
Rate for Payer: MDX Hawaii PPO	$747.71
Rate for Payer: University Health Alliance Commercial	$561.86

Ureteral Access Sheath 11/13FRx28cm Navigator M0062502210 [3643018]

Facility

$770.83

Service Code	HCPCS C1894
Hospital Charge Code	3643018
Hospital Revenue Code	272
Min. Negotiated Rate	$655.21
Max. Negotiated Rate	$747.71
Rate for Payer: Cash Price	$501.04
Rate for Payer: Health Management Network Commercial	$655.21
Rate for Payer: MDX Hawaii PPO	$747.71

Ureteral Access Sheath 11/13FRx36cm Navigator M0062502220 [3601719]

Facility

$770.83

Service Code	HCPCS C2629
Hospital Charge Code	3601719
Hospital Revenue Code	272
Min. Negotiated Rate	$393.12
Max. Negotiated Rate	$747.71
Rate for Payer: Cash Price	$501.04
Rate for Payer: Hawaii Western Management Group Commercial	$732.29
Rate for Payer: Health Management Network Commercial	$655.21
Rate for Payer: Kaiser Permanente Commercial	$485.62
Rate for Payer: Kaiser Permanente Medicaid	$393.12
Rate for Payer: MDX Hawaii PPO	$747.71
Rate for Payer: University Health Alliance Commercial	$561.86

Ureteral Access Sheath 11/13FRx36cm Navigator M0062502220 [3601719]

Facility

$770.83

Service Code	HCPCS C2629
Hospital Charge Code	3601719
Hospital Revenue Code	272
Min. Negotiated Rate	$655.21
Max. Negotiated Rate	$747.71
Rate for Payer: Cash Price	$501.04
Rate for Payer: Health Management Network Commercial	$655.21
Rate for Payer: MDX Hawaii PPO	$747.71

Ureteral Access Sheath 11/13FRx46cm Navigator M0062502230 [3643017]

Facility

$770.83

Service Code	HCPCS C1894
Hospital Charge Code	3643017
Hospital Revenue Code	272
Min. Negotiated Rate	$655.21
Max. Negotiated Rate	$747.71
Rate for Payer: Cash Price	$501.04
Rate for Payer: Health Management Network Commercial	$655.21
Rate for Payer: MDX Hawaii PPO	$747.71

Ureteral Access Sheath 11/13FRx46cm Navigator M0062502230 [3643017]

Facility

$770.83

Service Code	HCPCS C1894
Hospital Charge Code	3643017
Hospital Revenue Code	272
Min. Negotiated Rate	$393.12
Max. Negotiated Rate	$747.71
Rate for Payer: Cash Price	$501.04
Rate for Payer: Hawaii Western Management Group Commercial	$732.29
Rate for Payer: Health Management Network Commercial	$655.21
Rate for Payer: Kaiser Permanente Commercial	$485.62
Rate for Payer: Kaiser Permanente Medicaid	$393.12
Rate for Payer: MDX Hawaii PPO	$747.71
Rate for Payer: University Health Alliance Commercial	$561.86

URETERAL ENDOSCOPY THROUGH URETEROTOMY, WITH OR WITHOUT IRRIGATION, INSTILLATION, OR URETEROPYELOGRAPHY, EXCLUSIVE OF RADIOLOGIC SERVICE; WITH BIOPSY

Facility

$7,917.66

Service Code	CPT 50974
Hospital Revenue Code	360
Min. Negotiated Rate	$456.03
Max. Negotiated Rate	$7,917.66
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 Commercial	$7,917.66
Rate for Payer: Hawaii Medical Service Association Medicare	$6,334.13
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	$456.03
Rate for Payer: UnitedHealthcare Medicare	$6,334.13

URETHRAL PROCEDURES WITH CC/MCC

Facility

$36,112.29

Service Code	MSDRG 671
Min. Negotiated Rate	$23,609.21
Max. Negotiated Rate	$36,112.29
Rate for Payer: AlohaCare Medicare	$23,609.21
Rate for Payer: Devoted Health Medicare	$25,970.13
Rate for Payer: Hawaii Medical Service Association Commercial	$36,112.29
Rate for Payer: Hawaii Medical Service Association Medicare	$23,609.21
Rate for Payer: Humana Medicare	$23,609.21
Rate for Payer: Kaiser Permanente Commercial	$30,963.75
Rate for Payer: Kaiser Permanente Medicare	$23,609.21
Rate for Payer: Ohana Health Plan Medicare	$23,609.21
Rate for Payer: UnitedHealthcare Medicare	$23,609.21

URETHRAL PROCEDURES WITHOUT CC/MCC

Facility

$36,112.29

Service Code	MSDRG 672
Min. Negotiated Rate	$14,198.41
Max. Negotiated Rate	$36,112.29
Rate for Payer: AlohaCare Medicare	$14,198.41
Rate for Payer: Devoted Health Medicare	$15,618.25
Rate for Payer: Hawaii Medical Service Association Commercial	$36,112.29
Rate for Payer: Hawaii Medical Service Association Medicare	$14,198.41
Rate for Payer: Humana Medicare	$14,198.41
Rate for Payer: Kaiser Permanente Commercial	$18,621.38
Rate for Payer: Kaiser Permanente Medicare	$14,198.41
Rate for Payer: Ohana Health Plan Medicare	$14,198.41
Rate for Payer: UnitedHealthcare Medicare	$14,198.41

URETHRAL STRICTURE

Facility

$18,592.05

Service Code	MSDRG 697
Min. Negotiated Rate	$5,279.43
Max. Negotiated Rate	$18,592.05
Rate for Payer: AlohaCare Medicare	$14,176.05
Rate for Payer: Devoted Health Medicare	$15,593.66
Rate for Payer: Hawaii Medical Service Association Commercial	$5,279.43
Rate for Payer: Hawaii Medical Service Association Medicare	$14,176.05
Rate for Payer: Humana Medicare	$14,176.05
Rate for Payer: Kaiser Permanente Commercial	$18,592.05
Rate for Payer: Kaiser Permanente Medicare	$14,176.05
Rate for Payer: Ohana Health Plan Medicare	$14,176.05
Rate for Payer: UnitedHealthcare Medicare	$14,176.05

URETHRAL & TRANSURETHRAL PROCEDURES

Facility

$14,650.93

Service Code	APR-DRG 4464
Min. Negotiated Rate	$14,650.93
Max. Negotiated Rate	$14,650.93
Rate for Payer: AlohaCare Medicaid	$14,650.93
Rate for Payer: Hawaii Medical Service Association ABD	$14,650.93
Rate for Payer: Hawaii Medical Service Association Non-ABD	$14,650.93
Rate for Payer: Kaiser Permanente Medicaid	$14,650.93
Rate for Payer: Ohana Health Plan Medicaid	$14,650.93
Rate for Payer: UnitedHealthcare Medicaid	$14,650.93

URETHRAL & TRANSURETHRAL PROCEDURES

Facility

$8,278.44

Service Code	APR-DRG 4463
Min. Negotiated Rate	$8,278.44
Max. Negotiated Rate	$8,278.44
Rate for Payer: AlohaCare Medicaid	$8,278.44
Rate for Payer: Hawaii Medical Service Association ABD	$8,278.44
Rate for Payer: Hawaii Medical Service Association Non-ABD	$8,278.44
Rate for Payer: Kaiser Permanente Medicaid	$8,278.44
Rate for Payer: Ohana Health Plan Medicaid	$8,278.44
Rate for Payer: UnitedHealthcare Medicaid	$8,278.44

URETHRAL & TRANSURETHRAL PROCEDURES

Facility

$5,319.22

Service Code	APR-DRG 4462
Min. Negotiated Rate	$5,319.22
Max. Negotiated Rate	$5,319.22
Rate for Payer: AlohaCare Medicaid	$5,319.22
Rate for Payer: Hawaii Medical Service Association ABD	$5,319.22
Rate for Payer: Hawaii Medical Service Association Non-ABD	$5,319.22
Rate for Payer: Kaiser Permanente Medicaid	$5,319.22
Rate for Payer: Ohana Health Plan Medicaid	$5,319.22
Rate for Payer: UnitedHealthcare Medicaid	$5,319.22

URETHRAL & TRANSURETHRAL PROCEDURES

Facility

$4,233.47

Service Code	APR-DRG 4461
Min. Negotiated Rate	$4,233.47
Max. Negotiated Rate	$4,233.47
Rate for Payer: AlohaCare Medicaid	$4,233.47
Rate for Payer: Hawaii Medical Service Association ABD	$4,233.47
Rate for Payer: Hawaii Medical Service Association Non-ABD	$4,233.47
Rate for Payer: Kaiser Permanente Medicaid	$4,233.47
Rate for Payer: Ohana Health Plan Medicaid	$4,233.47
Rate for Payer: UnitedHealthcare Medicaid	$4,233.47

URETHRORRHAPHY, SUTURE OF URETHRAL WOUND OR INJURY; PENILE

Facility

$6,967.54

Service Code	CPT 53505
Hospital Revenue Code	360
Min. Negotiated Rate	$393.00
Max. Negotiated Rate	$6,967.54
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	$393.00
Rate for Payer: Hawaii Medical Service Association Commercial	$2,833.00
Rate for Payer: Hawaii Medical Service Association Medicare	$6,334.13
Rate for Payer: Hawaii Medical Service Association Non-ABD	$407.95
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	$456.03
Rate for Payer: UnitedHealthcare Medicare	$6,334.13
Rate for Payer: University Health Alliance Commercial	$5,160.40

URINALYSIS MICROSCOPIC ONLY

Professional

Both

$7.88

Service Code	HCPCS 81015
Min. Negotiated Rate	$3.05
Max. Negotiated Rate	$6.70
Rate for Payer: AlohaCare Medicaid	$4.20
Rate for Payer: AlohaCare Medicare	$3.05
Rate for Payer: Cash Price	$5.12
Rate for Payer: Cash Price	$5.12
Rate for Payer: Devoted Health Medicare	$3.35
Rate for Payer: Hawaii Medical Service Association Medicare	$3.05
Rate for Payer: Hawaii Western Management Group Commercial	$4.20
Rate for Payer: Health Management Network Commercial	$6.70
Rate for Payer: Kaiser Permanente Commercial	$3.66
Rate for Payer: Kaiser Permanente Medicaid	$3.66
Rate for Payer: Kaiser Permanente Medicare	$3.66
Rate for Payer: Ohana Health Plan Medicaid	$4.20
Rate for Payer: Ohana Health Plan Medicare	$3.05
Rate for Payer: UnitedHealthcare Medicaid	$4.20
Rate for Payer: UnitedHealthcare Medicare	$3.05

URINARY STONES & ACQUIRED UPPER URINARY TRACT OBSTRUCTION

Facility

$9,437.42

Service Code	APR-DRG 4654
Min. Negotiated Rate	$9,437.42
Max. Negotiated Rate	$9,437.42
Rate for Payer: AlohaCare Medicaid	$9,437.42
Rate for Payer: Hawaii Medical Service Association ABD	$9,437.42
Rate for Payer: Hawaii Medical Service Association Non-ABD	$9,437.42
Rate for Payer: Kaiser Permanente Medicaid	$9,437.42
Rate for Payer: Ohana Health Plan Medicaid	$9,437.42
Rate for Payer: UnitedHealthcare Medicaid	$9,437.42

Know your out-of-pocket cost for care.

All Charges