Kona Community Hospital

All Charges

Charge

Type

Setting

Price

CT PELVIS W/O CONTRAST MATERIAL

Professional

Both

$430.00

Service Code	HCPCS 72192
Min. Negotiated Rate	$89.79
Max. Negotiated Rate	$365.50
Rate for Payer: AlohaCare Medicaid	$89.79
Rate for Payer: AlohaCare Medicare	$144.61
Rate for Payer: Cash Price	$279.50
Rate for Payer: Cash Price	$279.50
Rate for Payer: Devoted Health Medicare	$159.07
Rate for Payer: Hawaii Medical Service Association Medicare	$144.61
Rate for Payer: Hawaii Western Management Group Commercial	$318.97
Rate for Payer: Health Management Network Commercial	$365.50
Rate for Payer: Kaiser Permanente Commercial	$173.53
Rate for Payer: Kaiser Permanente Medicaid	$173.53
Rate for Payer: Kaiser Permanente Medicare	$173.53
Rate for Payer: Ohana Health Plan Medicaid	$89.79
Rate for Payer: Ohana Health Plan Medicare	$144.61
Rate for Payer: UnitedHealthcare Medicaid	$89.79
Rate for Payer: UnitedHealthcare Medicare	$144.61

CT PELVIS W/O & W/CONTRAST MATERIAL

Professional

Both

$729.00

Service Code	HCPCS 72194
Min. Negotiated Rate	$173.97
Max. Negotiated Rate	$619.65
Rate for Payer: AlohaCare Medicaid	$173.97
Rate for Payer: AlohaCare Medicare	$277.70
Rate for Payer: Cash Price	$473.85
Rate for Payer: Cash Price	$473.85
Rate for Payer: Devoted Health Medicare	$305.47
Rate for Payer: Hawaii Medical Service Association Medicare	$277.70
Rate for Payer: Hawaii Western Management Group Commercial	$439.32
Rate for Payer: Health Management Network Commercial	$619.65
Rate for Payer: Kaiser Permanente Commercial	$333.24
Rate for Payer: Kaiser Permanente Medicaid	$333.24
Rate for Payer: Kaiser Permanente Medicare	$333.24
Rate for Payer: Ohana Health Plan Medicaid	$173.97
Rate for Payer: Ohana Health Plan Medicare	$277.70
Rate for Payer: UnitedHealthcare Medicaid	$173.97
Rate for Payer: UnitedHealthcare Medicare	$277.70

CT SOFT TISSUE NECK W/CONTRAST MATERIAL

Professional

Both

$600.00

Service Code	HCPCS 70491
Min. Negotiated Rate	$124.95
Max. Negotiated Rate	$510.00
Rate for Payer: AlohaCare Medicaid	$124.95
Rate for Payer: AlohaCare Medicare	$200.64
Rate for Payer: Cash Price	$390.00
Rate for Payer: Cash Price	$390.00
Rate for Payer: Devoted Health Medicare	$220.70
Rate for Payer: Hawaii Medical Service Association Medicare	$200.64
Rate for Payer: Hawaii Western Management Group Commercial	$323.80
Rate for Payer: Health Management Network Commercial	$510.00
Rate for Payer: Kaiser Permanente Commercial	$240.77
Rate for Payer: Kaiser Permanente Medicaid	$240.77
Rate for Payer: Kaiser Permanente Medicare	$240.77
Rate for Payer: Ohana Health Plan Medicaid	$124.95
Rate for Payer: Ohana Health Plan Medicare	$200.64
Rate for Payer: UnitedHealthcare Medicaid	$124.95
Rate for Payer: UnitedHealthcare Medicare	$200.64

CT SOFT TISSUE NECK W/O CONTRAST MATERIAL

Professional

Both

$487.00

Service Code	HCPCS 70490
Min. Negotiated Rate	$101.04
Max. Negotiated Rate	$413.95
Rate for Payer: AlohaCare Medicaid	$101.04
Rate for Payer: AlohaCare Medicare	$162.93
Rate for Payer: Cash Price	$316.55
Rate for Payer: Cash Price	$316.55
Rate for Payer: Devoted Health Medicare	$179.22
Rate for Payer: Hawaii Medical Service Association Medicare	$162.93
Rate for Payer: Hawaii Western Management Group Commercial	$277.62
Rate for Payer: Health Management Network Commercial	$413.95
Rate for Payer: Kaiser Permanente Commercial	$195.52
Rate for Payer: Kaiser Permanente Medicaid	$195.52
Rate for Payer: Kaiser Permanente Medicare	$195.52
Rate for Payer: Ohana Health Plan Medicaid	$101.04
Rate for Payer: Ohana Health Plan Medicare	$162.93
Rate for Payer: UnitedHealthcare Medicaid	$101.04
Rate for Payer: UnitedHealthcare Medicare	$162.93

CT THORACIC SPINE W/CONTRAST MATERIAL

Professional

Both

$552.00

Service Code	HCPCS 72129
Min. Negotiated Rate	$115.33
Max. Negotiated Rate	$469.20
Rate for Payer: AlohaCare Medicaid	$115.33
Rate for Payer: AlohaCare Medicare	$185.42
Rate for Payer: Cash Price	$358.80
Rate for Payer: Cash Price	$358.80
Rate for Payer: Devoted Health Medicare	$203.96
Rate for Payer: Hawaii Medical Service Association Medicare	$185.42
Rate for Payer: Hawaii Western Management Group Commercial	$377.25
Rate for Payer: Health Management Network Commercial	$469.20
Rate for Payer: Kaiser Permanente Commercial	$222.50
Rate for Payer: Kaiser Permanente Medicaid	$222.50
Rate for Payer: Kaiser Permanente Medicare	$222.50
Rate for Payer: Ohana Health Plan Medicaid	$115.33
Rate for Payer: Ohana Health Plan Medicare	$185.42
Rate for Payer: UnitedHealthcare Medicaid	$115.33
Rate for Payer: UnitedHealthcare Medicare	$185.42

CT THORACIC SPINE W/O CONTRAST MATERIAL

Professional

Both

$420.00

Service Code	HCPCS 72128
Min. Negotiated Rate	$87.88
Max. Negotiated Rate	$357.00
Rate for Payer: AlohaCare Medicaid	$87.88
Rate for Payer: AlohaCare Medicare	$142.32
Rate for Payer: Cash Price	$273.00
Rate for Payer: Cash Price	$273.00
Rate for Payer: Devoted Health Medicare	$156.55
Rate for Payer: Hawaii Medical Service Association Medicare	$142.32
Rate for Payer: Hawaii Western Management Group Commercial	$322.87
Rate for Payer: Health Management Network Commercial	$357.00
Rate for Payer: Kaiser Permanente Commercial	$170.78
Rate for Payer: Kaiser Permanente Medicaid	$170.78
Rate for Payer: Kaiser Permanente Medicare	$170.78
Rate for Payer: Ohana Health Plan Medicaid	$87.88
Rate for Payer: Ohana Health Plan Medicare	$142.32
Rate for Payer: UnitedHealthcare Medicaid	$87.88
Rate for Payer: UnitedHealthcare Medicare	$142.32

CT UPPER EXTREMITY W/CONTRAST MATERIAL

Professional

Both

$655.00

Service Code	HCPCS 73201
Min. Negotiated Rate	$137.43
Max. Negotiated Rate	$556.75
Rate for Payer: AlohaCare Medicaid	$137.43
Rate for Payer: AlohaCare Medicare	$219.87
Rate for Payer: Cash Price	$425.75
Rate for Payer: Cash Price	$425.75
Rate for Payer: Devoted Health Medicare	$241.86
Rate for Payer: Hawaii Medical Service Association Medicare	$219.87
Rate for Payer: Hawaii Western Management Group Commercial	$322.87
Rate for Payer: Health Management Network Commercial	$556.75
Rate for Payer: Kaiser Permanente Commercial	$263.84
Rate for Payer: Kaiser Permanente Medicaid	$263.84
Rate for Payer: Kaiser Permanente Medicare	$263.84
Rate for Payer: Ohana Health Plan Medicaid	$137.43
Rate for Payer: Ohana Health Plan Medicare	$219.87
Rate for Payer: UnitedHealthcare Medicaid	$137.43
Rate for Payer: UnitedHealthcare Medicare	$219.87

CT UPPER EXTREMITY W/O CONTRAST MATERIAL

Professional

Both

$482.00

Service Code	HCPCS 73200
Min. Negotiated Rate	$110.14
Max. Negotiated Rate	$409.70
Rate for Payer: AlohaCare Medicaid	$110.14
Rate for Payer: AlohaCare Medicare	$176.69
Rate for Payer: Cash Price	$313.30
Rate for Payer: Cash Price	$313.30
Rate for Payer: Devoted Health Medicare	$194.36
Rate for Payer: Hawaii Medical Service Association Medicare	$176.69
Rate for Payer: Hawaii Western Management Group Commercial	$277.05
Rate for Payer: Health Management Network Commercial	$409.70
Rate for Payer: Kaiser Permanente Commercial	$212.03
Rate for Payer: Kaiser Permanente Medicaid	$212.03
Rate for Payer: Kaiser Permanente Medicare	$212.03
Rate for Payer: Ohana Health Plan Medicaid	$110.14
Rate for Payer: Ohana Health Plan Medicare	$176.69
Rate for Payer: UnitedHealthcare Medicaid	$110.14
Rate for Payer: UnitedHealthcare Medicare	$176.69

Cuff/cryo Knee Gravity Cooler 18"-23" Med 11a [3643332]

Facility

$307.42

Hospital Charge Code	3643332
Hospital Revenue Code	272
Min. Negotiated Rate	$156.78
Max. Negotiated Rate	$298.20
Rate for Payer: Cash Price	$199.82
Rate for Payer: Hawaii Western Management Group Commercial	$292.05
Rate for Payer: Health Management Network Commercial	$261.31
Rate for Payer: Kaiser Permanente Commercial	$193.67
Rate for Payer: Kaiser Permanente Medicaid	$156.78
Rate for Payer: MDX Hawaii PPO	$298.20
Rate for Payer: University Health Alliance Commercial	$224.08

Cuff/cryo Knee Gravity Cooler 18"-23" Med 11a [3643332]

Facility

$307.42

Hospital Charge Code	3643332
Hospital Revenue Code	272
Min. Negotiated Rate	$261.31
Max. Negotiated Rate	$298.20
Rate for Payer: Cash Price	$199.82
Rate for Payer: Health Management Network Commercial	$261.31
Rate for Payer: MDX Hawaii PPO	$298.20

CVA & PRECEREBRAL OCCLUSION W INFARCT

Facility

$10,169.74

Service Code	APR-DRG 0454
Min. Negotiated Rate	$10,169.74
Max. Negotiated Rate	$10,169.74
Rate for Payer: AlohaCare Medicaid	$10,169.74
Rate for Payer: Hawaii Medical Service Association ABD	$10,169.74
Rate for Payer: Hawaii Medical Service Association Non-ABD	$10,169.74
Rate for Payer: Kaiser Permanente Medicaid	$10,169.74
Rate for Payer: Ohana Health Plan Medicaid	$10,169.74
Rate for Payer: UnitedHealthcare Medicaid	$10,169.74

CVA & PRECEREBRAL OCCLUSION W INFARCT

Facility

$6,350.20

Service Code	APR-DRG 0453
Min. Negotiated Rate	$6,350.20
Max. Negotiated Rate	$6,350.20
Rate for Payer: AlohaCare Medicaid	$6,350.20
Rate for Payer: Hawaii Medical Service Association ABD	$6,350.20
Rate for Payer: Hawaii Medical Service Association Non-ABD	$6,350.20
Rate for Payer: Kaiser Permanente Medicaid	$6,350.20
Rate for Payer: Ohana Health Plan Medicaid	$6,350.20
Rate for Payer: UnitedHealthcare Medicaid	$6,350.20

CVA & PRECEREBRAL OCCLUSION W INFARCT

Facility

$4,627.65

Service Code	APR-DRG 0452
Min. Negotiated Rate	$4,627.65
Max. Negotiated Rate	$4,627.65
Rate for Payer: AlohaCare Medicaid	$4,627.65
Rate for Payer: Hawaii Medical Service Association ABD	$4,627.65
Rate for Payer: Hawaii Medical Service Association Non-ABD	$4,627.65
Rate for Payer: Kaiser Permanente Medicaid	$4,627.65
Rate for Payer: Ohana Health Plan Medicaid	$4,627.65
Rate for Payer: UnitedHealthcare Medicaid	$4,627.65

CVA & PRECEREBRAL OCCLUSION W INFARCT

Facility

$3,839.92

Service Code	APR-DRG 0451
Min. Negotiated Rate	$3,839.92
Max. Negotiated Rate	$3,839.92
Rate for Payer: AlohaCare Medicaid	$3,839.92
Rate for Payer: Hawaii Medical Service Association ABD	$3,839.92
Rate for Payer: Hawaii Medical Service Association Non-ABD	$3,839.92
Rate for Payer: Kaiser Permanente Medicaid	$3,839.92
Rate for Payer: Ohana Health Plan Medicaid	$3,839.92
Rate for Payer: UnitedHealthcare Medicaid	$3,839.92

CYANOCOBALAMIN VITAMIN B-12

Professional

Both

$30.00

Service Code	HCPCS 82607
Min. Negotiated Rate	$15.08
Max. Negotiated Rate	$25.50
Rate for Payer: AlohaCare Medicaid	$20.83
Rate for Payer: AlohaCare Medicare	$15.08
Rate for Payer: Cash Price	$19.50
Rate for Payer: Cash Price	$19.50
Rate for Payer: Devoted Health Medicare	$16.59
Rate for Payer: Hawaii Medical Service Association Medicare	$15.08
Rate for Payer: Hawaii Western Management Group Commercial	$20.83
Rate for Payer: Health Management Network Commercial	$25.50
Rate for Payer: Kaiser Permanente Commercial	$18.10
Rate for Payer: Kaiser Permanente Medicaid	$18.10
Rate for Payer: Kaiser Permanente Medicare	$18.10
Rate for Payer: Ohana Health Plan Medicaid	$20.83
Rate for Payer: Ohana Health Plan Medicare	$15.08
Rate for Payer: UnitedHealthcare Medicaid	$20.83
Rate for Payer: UnitedHealthcare Medicare	$15.08

CYANOCOBALAMIN (VITAMIN B-12) 1000 MCG/ML INJ SOLN

Facility

$18.77

Service Code	HCPCS J3420
Hospital Revenue Code	636
Min. Negotiated Rate	$0.95
Max. Negotiated Rate	$18.21
Rate for Payer: Cash Price	$12.20
Rate for Payer: Cash Price	$12.20
Rate for Payer: Hawaii Medical Service Association ABD	$0.95
Rate for Payer: Hawaii Medical Service Association Non-ABD	$0.95
Rate for Payer: Hawaii Western Management Group Commercial	$17.83
Rate for Payer: Health Management Network Commercial	$15.95
Rate for Payer: Kaiser Permanente Commercial	$11.83
Rate for Payer: Kaiser Permanente Medicaid	$9.57
Rate for Payer: MDX Hawaii PPO	$18.21
Rate for Payer: UnitedHealthcare Medicaid	$11.26
Rate for Payer: University Health Alliance Commercial	$13.68

CYANOCOBALAMIN (VITAMIN B-12) 1000 MCG/ML INJ SOLN

Facility

$18.77

Service Code	HCPCS J3420
Hospital Revenue Code	250
Min. Negotiated Rate	$15.95
Max. Negotiated Rate	$18.21
Rate for Payer: Cash Price	$12.20
Rate for Payer: Health Management Network Commercial	$15.95
Rate for Payer: MDX Hawaii PPO	$18.21

CYANOCOBALAMIN (VITAMIN B-12) 1000 MCG PO TABLET

Facility

$1.20

Service Code	HCPCS A9270
Hospital Revenue Code	250
Min. Negotiated Rate	$1.02
Max. Negotiated Rate	$1.16
Rate for Payer: Cash Price	$0.78
Rate for Payer: Cash Price	$1.27
Rate for Payer: Health Management Network Commercial	$1.67
Rate for Payer: Health Management Network Commercial	$1.02
Rate for Payer: MDX Hawaii PPO	$1.90
Rate for Payer: MDX Hawaii PPO	$1.16

CYANOCOBALAMIN (VITAMIN B-12) 1000 MCG PO TABLET

Facility

$1.96

Service Code	HCPCS A9270
Hospital Revenue Code	250
Min. Negotiated Rate	$1.00
Max. Negotiated Rate	$1.90
Rate for Payer: Cash Price	$1.27
Rate for Payer: Cash Price	$0.78
Rate for Payer: Hawaii Western Management Group Commercial	$1.14
Rate for Payer: Hawaii Western Management Group Commercial	$1.86
Rate for Payer: Health Management Network Commercial	$1.02
Rate for Payer: Health Management Network Commercial	$1.67
Rate for Payer: Kaiser Permanente Commercial	$0.76
Rate for Payer: Kaiser Permanente Commercial	$1.23
Rate for Payer: Kaiser Permanente Medicaid	$1.00
Rate for Payer: Kaiser Permanente Medicaid	$0.61
Rate for Payer: MDX Hawaii PPO	$1.16
Rate for Payer: MDX Hawaii PPO	$1.90
Rate for Payer: UnitedHealthcare Medicaid	$0.72
Rate for Payer: UnitedHealthcare Medicaid	$1.18
Rate for Payer: University Health Alliance Commercial	$1.43
Rate for Payer: University Health Alliance Commercial	$0.87

CYCLOBENZAPRINE 10 MG PO TABLET

Facility

$6.40

Service Code	HCPCS A9270
Hospital Revenue Code	250
Min. Negotiated Rate	$3.26
Max. Negotiated Rate	$6.21
Rate for Payer: Cash Price	$4.16
Rate for Payer: Cash Price	$0.78
Rate for Payer: Hawaii Western Management Group Commercial	$1.14
Rate for Payer: Hawaii Western Management Group Commercial	$6.08
Rate for Payer: Health Management Network Commercial	$1.02
Rate for Payer: Health Management Network Commercial	$5.44
Rate for Payer: Kaiser Permanente Commercial	$4.03
Rate for Payer: Kaiser Permanente Commercial	$0.76
Rate for Payer: Kaiser Permanente Medicaid	$3.26
Rate for Payer: Kaiser Permanente Medicaid	$0.61
Rate for Payer: MDX Hawaii PPO	$1.16
Rate for Payer: MDX Hawaii PPO	$6.21
Rate for Payer: UnitedHealthcare Medicaid	$0.72
Rate for Payer: UnitedHealthcare Medicaid	$3.84
Rate for Payer: University Health Alliance Commercial	$4.66
Rate for Payer: University Health Alliance Commercial	$0.87

CYCLOBENZAPRINE 10 MG PO TABLET

Facility

$1.20

Service Code	HCPCS A9270
Hospital Revenue Code	250
Min. Negotiated Rate	$1.02
Max. Negotiated Rate	$1.16
Rate for Payer: Cash Price	$0.78
Rate for Payer: Cash Price	$4.16
Rate for Payer: Health Management Network Commercial	$1.02
Rate for Payer: Health Management Network Commercial	$5.44
Rate for Payer: MDX Hawaii PPO	$1.16
Rate for Payer: MDX Hawaii PPO	$6.21

CYCLOBENZAPRINE 5 MG PO TABLET

Facility

$6.90

Service Code	HCPCS A9270
Hospital Revenue Code	250
Min. Negotiated Rate	$5.87
Max. Negotiated Rate	$6.69
Rate for Payer: Cash Price	$4.49
Rate for Payer: Cash Price	$5.89
Rate for Payer: Health Management Network Commercial	$7.70
Rate for Payer: Health Management Network Commercial	$5.87
Rate for Payer: MDX Hawaii PPO	$6.69
Rate for Payer: MDX Hawaii PPO	$8.79

CYCLOBENZAPRINE 5 MG PO TABLET

Facility

$6.90

Service Code	HCPCS A9270
Hospital Revenue Code	250
Min. Negotiated Rate	$3.52
Max. Negotiated Rate	$6.69
Rate for Payer: Cash Price	$4.49
Rate for Payer: Cash Price	$5.89
Rate for Payer: Hawaii Western Management Group Commercial	$6.55
Rate for Payer: Hawaii Western Management Group Commercial	$8.61
Rate for Payer: Health Management Network Commercial	$5.87
Rate for Payer: Health Management Network Commercial	$7.70
Rate for Payer: Kaiser Permanente Commercial	$4.35
Rate for Payer: Kaiser Permanente Commercial	$5.71
Rate for Payer: Kaiser Permanente Medicaid	$3.52
Rate for Payer: Kaiser Permanente Medicaid	$4.62
Rate for Payer: MDX Hawaii PPO	$6.69
Rate for Payer: MDX Hawaii PPO	$8.79
Rate for Payer: UnitedHealthcare Medicaid	$5.44
Rate for Payer: UnitedHealthcare Medicaid	$4.14
Rate for Payer: University Health Alliance Commercial	$5.03
Rate for Payer: University Health Alliance Commercial	$6.60

CYCLOPENTOLATE 1 % OPHT DROP

Facility

$87.56

Service Code	NDC 61314039601
Hospital Revenue Code	250
Min. Negotiated Rate	$44.66
Max. Negotiated Rate	$84.93
Rate for Payer: Cash Price	$56.91
Rate for Payer: Hawaii Western Management Group Commercial	$83.18
Rate for Payer: Health Management Network Commercial	$74.43
Rate for Payer: Kaiser Permanente Commercial	$55.16
Rate for Payer: Kaiser Permanente Medicaid	$44.66
Rate for Payer: MDX Hawaii PPO	$84.93
Rate for Payer: UnitedHealthcare Medicaid	$52.54
Rate for Payer: University Health Alliance Commercial	$63.82

CYCLOPENTOLATE 1 % OPHT DROP

Facility

$164.69

Service Code	NDC 00065039602
Hospital Revenue Code	250
Min. Negotiated Rate	$139.99
Max. Negotiated Rate	$159.75
Rate for Payer: Cash Price	$107.05
Rate for Payer: Health Management Network Commercial	$139.99
Rate for Payer: MDX Hawaii PPO	$159.75

Know your out-of-pocket cost for care.

All Charges