Kona Community Hospital

All Charges

Charge

Type

Setting

Price

CYSTOURETHROSCOPY, WITH REMOVAL OF FOREIGN BODY, CALCULUS, OR URETERAL STENT FROM URETHRA OR BLADDER (SEPARATE PROCEDURE); COMPLICATED

Facility

$6,183.00

Service Code	CPT 52315
Hospital Revenue Code	360
Min. Negotiated Rate	$456.03
Max. Negotiated Rate	$6,183.00
Rate for Payer: AlohaCare Medicaid	$2,469.46
Rate for Payer: AlohaCare Medicare	$2,469.46
Rate for Payer: Devoted Health Medicare	$2,716.41
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	$2,469.46
Rate for Payer: Hawaii Medical Service Association Non-ABD	$700.72
Rate for Payer: Humana Medicare	$2,469.46
Rate for Payer: Kaiser Permanente Medicaid	$2,837.00
Rate for Payer: Kaiser Permanente Medicare	$2,469.46
Rate for Payer: Ohana Health Plan Medicaid	$2,716.41
Rate for Payer: Ohana Health Plan Medicare	$2,469.46
Rate for Payer: UnitedHealthcare Medicaid	$456.03
Rate for Payer: UnitedHealthcare Medicare	$2,469.46
Rate for Payer: University Health Alliance Commercial	$5,160.40

CYSTOURETHROSCOPY, WITH REMOVAL OF FOREIGN BODY, CALCULUS, OR URETERAL STENT FROM URETHRA OR BLADDER (SEPARATE PROCEDURE); SIMPLE

Facility

$11,157.19

Service Code	CPT 52310
Hospital Revenue Code	360
Min. Negotiated Rate	$456.03
Max. Negotiated Rate	$11,157.19
Rate for Payer: AlohaCare Medicaid	$2,469.46
Rate for Payer: AlohaCare Medicare	$2,469.46
Rate for Payer: Devoted Health Medicare	$2,716.41
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	$2,469.46
Rate for Payer: Hawaii Medical Service Association Non-ABD	$849.21
Rate for Payer: Humana Medicare	$2,469.46
Rate for Payer: Kaiser Permanente Medicaid	$2,837.00
Rate for Payer: Kaiser Permanente Medicare	$2,469.46
Rate for Payer: Ohana Health Plan Medicaid	$2,716.41
Rate for Payer: Ohana Health Plan Medicare	$2,469.46
Rate for Payer: UnitedHealthcare Medicaid	$456.03
Rate for Payer: UnitedHealthcare Medicare	$2,469.46
Rate for Payer: University Health Alliance Commercial	$11,157.19

CYSTOURETHROSCOPY; WITH RESECTION OR FULGURATION OF ECTOPIC URETEROCELE(S), UNILATERAL OR BILATERAL

Facility

$9,416.00

Service Code	CPT 52301
Hospital Revenue Code	360
Min. Negotiated Rate	$456.03
Max. Negotiated Rate	$9,416.00
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	$848.00
Rate for Payer: Hawaii Medical Service Association Commercial	$9,416.00
Rate for Payer: Hawaii Medical Service Association Medicare	$4,164.22
Rate for Payer: Hawaii Medical Service Association Non-ABD	$849.21
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

CYSTOURETHROSCOPY, WITH URETERAL CATHETERIZATION, WITH OR WITHOUT IRRIGATION, INSTILLATION, OR URETEROPYELOGRAPHY, EXCLUSIVE OF RADIOLOGIC SERVICE;

Facility

$5,160.40

Service Code	CPT 52005
Hospital Revenue Code	360
Min. Negotiated Rate	$393.00
Max. Negotiated Rate	$5,160.40
Rate for Payer: AlohaCare Medicaid	$2,469.46
Rate for Payer: AlohaCare Medicare	$2,469.46
Rate for Payer: Devoted Health Medicare	$2,716.41
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	$2,469.46
Rate for Payer: Hawaii Medical Service Association Non-ABD	$407.95
Rate for Payer: Humana Medicare	$2,469.46
Rate for Payer: Kaiser Permanente Medicaid	$2,837.00
Rate for Payer: Kaiser Permanente Medicare	$2,469.46
Rate for Payer: Ohana Health Plan Medicaid	$2,716.41
Rate for Payer: Ohana Health Plan Medicare	$2,469.46
Rate for Payer: UnitedHealthcare Medicaid	$456.03
Rate for Payer: UnitedHealthcare Medicare	$2,469.46
Rate for Payer: University Health Alliance Commercial	$5,160.40

CYSTOURETHROSCOPY, WITH URETEROSCOPY AND/OR PYELOSCOPY; DIAGNOSTIC

Facility

$9,416.00

Service Code	CPT 52351
Hospital Revenue Code	360
Min. Negotiated Rate	$456.03
Max. Negotiated Rate	$9,416.00
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	$848.00
Rate for Payer: Hawaii Medical Service Association Commercial	$9,416.00
Rate for Payer: Hawaii Medical Service Association Medicare	$4,164.22
Rate for Payer: Hawaii Medical Service Association Non-ABD	$849.21
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

CYSTOURETHROSCOPY, WITH URETEROSCOPY AND/OR PYELOSCOPY; WITH BIOPSY AND/OR FULGURATION OF URETERAL OR RENAL PELVIC LESION

Facility

$14,715.00

Service Code	CPT 52354
Hospital Revenue Code	360
Min. Negotiated Rate	$456.03
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	$456.03
Rate for Payer: UnitedHealthcare Medicare	$6,334.13
Rate for Payer: University Health Alliance Commercial	$10,679.55

CYSTOURETHROSCOPY, WITH URETEROSCOPY AND/OR PYELOSCOPY, WITH LITHOTRIPSY, AND URETERAL CATHETERIZATION FOR STEERABLE VACUUM ASPIRATION OF THE KIDNEY, COLLECTING SYSTEM, URETER, BLADDER, AND URETHRA IF APPLICABLE

Facility

$13,978.95

Service Code	CPT C9761
Hospital Revenue Code	360
Min. Negotiated Rate	$456.03
Max. Negotiated Rate	$13,978.95
Rate for Payer: AlohaCare Medicaid	$11,183.16
Rate for Payer: AlohaCare Medicare	$11,183.16
Rate for Payer: Devoted Health Medicare	$12,301.48
Rate for Payer: Hawaii Medical Service Association Commercial	$13,978.95
Rate for Payer: Hawaii Medical Service Association Medicare	$11,183.16
Rate for Payer: Humana Medicare	$11,183.16
Rate for Payer: Kaiser Permanente Medicaid	$2,837.00
Rate for Payer: Kaiser Permanente Medicare	$11,183.16
Rate for Payer: Ohana Health Plan Medicaid	$12,301.48
Rate for Payer: Ohana Health Plan Medicare	$11,183.16
Rate for Payer: UnitedHealthcare Medicaid	$456.03
Rate for Payer: UnitedHealthcare Medicare	$11,183.16

CYSTOURETHROSCOPY, WITH URETEROSCOPY AND/OR PYELOSCOPY; WITH LITHOTRIPSY INCLUDING INSERTION OF INDWELLING URETERAL STENT (EG, GIBBONS OR DOUBLE-J TYPE)

Facility

$14,715.00

Service Code	CPT 52356
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	$11,157.19

CYSTOURETHROSCOPY, WITH URETEROSCOPY AND/OR PYELOSCOPY; WITH LITHOTRIPSY (URETERAL CATHETERIZATION IS INCLUDED)

Facility

$10,679.55

Service Code	CPT 52353
Hospital Revenue Code	360
Min. Negotiated Rate	$521.33
Max. Negotiated Rate	$10,679.55
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	$10,679.55

CYSTOURETHROSCOPY, WITH URETEROSCOPY AND/OR PYELOSCOPY; WITH REMOVAL OR MANIPULATION OF CALCULUS (URETERAL CATHETERIZATION IS INCLUDED)

Facility

$10,679.55

Service Code	CPT 52352
Hospital Revenue Code	360
Min. Negotiated Rate	$456.03
Max. Negotiated Rate	$10,679.55
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	$848.00
Rate for Payer: Hawaii Medical Service Association Commercial	$9,416.00
Rate for Payer: Hawaii Medical Service Association Medicare	$4,164.22
Rate for Payer: Hawaii Medical Service Association Non-ABD	$849.21
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	$10,679.55

CYSTOURETHROSCOPY WITH URETEROSCOPY; WITH TREATMENT OF URETERAL STRICTURE (EG, BALLOON DILATION, LASER, ELECTROCAUTERY, AND INCISION)

Facility

$14,715.00

Service Code	CPT 52344
Hospital Revenue Code	360
Min. Negotiated Rate	$456.03
Max. Negotiated Rate	$14,715.00
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	$1,149.00
Rate for Payer: Hawaii Medical Service Association Commercial	$14,715.00
Rate for Payer: Hawaii Medical Service Association Medicare	$4,164.22
Rate for Payer: Hawaii Medical Service Association Non-ABD	$1,154.45
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

D10 %-0.45 % SODIUM CHLORIDE IV BASE SOLP 1000 ML

Facility

$53.13

Service Code	NDC 00264762200
Hospital Revenue Code	250
Min. Negotiated Rate	$45.16
Max. Negotiated Rate	$51.54
Rate for Payer: Cash Price	$34.53
Rate for Payer: Health Management Network Commercial	$45.16
Rate for Payer: MDX Hawaii PPO	$51.54

D10 %-0.45 % SODIUM CHLORIDE IV BASE SOLP 1000 ML

Facility

$53.13

Service Code	NDC 00264762200
Hospital Revenue Code	250
Min. Negotiated Rate	$27.10
Max. Negotiated Rate	$51.54
Rate for Payer: Cash Price	$34.53
Rate for Payer: Hawaii Western Management Group Commercial	$50.47
Rate for Payer: Health Management Network Commercial	$45.16
Rate for Payer: Kaiser Permanente Commercial	$33.47
Rate for Payer: Kaiser Permanente Medicaid	$27.10
Rate for Payer: MDX Hawaii PPO	$51.54
Rate for Payer: UnitedHealthcare Medicaid	$31.88
Rate for Payer: University Health Alliance Commercial	$38.73

D20W 500 ML (ML/KG/HR)

Facility

$78.03

Service Code	HCPCS J3490
Hospital Revenue Code	250
Min. Negotiated Rate	$66.33
Max. Negotiated Rate	$75.69
Rate for Payer: Cash Price	$50.72
Rate for Payer: Health Management Network Commercial	$66.33
Rate for Payer: MDX Hawaii PPO	$75.69

D20W 500 ML (ML/KG/HR)

Facility

$78.03

Service Code	HCPCS J3490
Hospital Revenue Code	636
Min. Negotiated Rate	$39.80
Max. Negotiated Rate	$75.69
Rate for Payer: Cash Price	$50.72
Rate for Payer: Hawaii Western Management Group Commercial	$74.13
Rate for Payer: Health Management Network Commercial	$66.33
Rate for Payer: Kaiser Permanente Commercial	$49.16
Rate for Payer: Kaiser Permanente Medicaid	$39.80
Rate for Payer: MDX Hawaii PPO	$75.69
Rate for Payer: UnitedHealthcare Medicaid	$46.82
Rate for Payer: University Health Alliance Commercial	$56.88

D5 %-0.45 % SODIUM CHLORIDE IV SOLP

Facility

$27.60

Service Code	NDC 00990792609
Hospital Revenue Code	250
Min. Negotiated Rate	$14.08
Max. Negotiated Rate	$26.77
Rate for Payer: Cash Price	$17.94
Rate for Payer: Hawaii Western Management Group Commercial	$26.22
Rate for Payer: Health Management Network Commercial	$23.46
Rate for Payer: Kaiser Permanente Commercial	$17.39
Rate for Payer: Kaiser Permanente Medicaid	$14.08
Rate for Payer: MDX Hawaii PPO	$26.77
Rate for Payer: UnitedHealthcare Medicaid	$16.56
Rate for Payer: University Health Alliance Commercial	$20.12

D5 %-0.45 % SODIUM CHLORIDE IV SOLP

Facility

$16.56

Service Code	NDC 00264761200
Hospital Revenue Code	250
Min. Negotiated Rate	$8.45
Max. Negotiated Rate	$16.06
Rate for Payer: Cash Price	$10.76
Rate for Payer: Hawaii Western Management Group Commercial	$15.73
Rate for Payer: Health Management Network Commercial	$14.08
Rate for Payer: Kaiser Permanente Commercial	$10.43
Rate for Payer: Kaiser Permanente Medicaid	$8.45
Rate for Payer: MDX Hawaii PPO	$16.06
Rate for Payer: UnitedHealthcare Medicaid	$9.94
Rate for Payer: University Health Alliance Commercial	$12.07

D5 %-0.45 % SODIUM CHLORIDE IV SOLP

Facility

$22.08

Service Code	NDC 00264761210
Hospital Revenue Code	250
Min. Negotiated Rate	$18.77
Max. Negotiated Rate	$21.42
Rate for Payer: Cash Price	$14.35
Rate for Payer: Health Management Network Commercial	$18.77
Rate for Payer: MDX Hawaii PPO	$21.42

D5 %-0.45 % SODIUM CHLORIDE IV SOLP

Facility

$16.56

Service Code	NDC 00264761200
Hospital Revenue Code	250
Min. Negotiated Rate	$14.08
Max. Negotiated Rate	$16.06
Rate for Payer: Cash Price	$10.76
Rate for Payer: Health Management Network Commercial	$14.08
Rate for Payer: MDX Hawaii PPO	$16.06

D5 %-0.45 % SODIUM CHLORIDE IV SOLP

Facility

$22.08

Service Code	NDC 00264761210
Hospital Revenue Code	250
Min. Negotiated Rate	$11.26
Max. Negotiated Rate	$21.42
Rate for Payer: Cash Price	$14.35
Rate for Payer: Hawaii Western Management Group Commercial	$20.98
Rate for Payer: Health Management Network Commercial	$18.77
Rate for Payer: Kaiser Permanente Commercial	$13.91
Rate for Payer: Kaiser Permanente Medicaid	$11.26
Rate for Payer: MDX Hawaii PPO	$21.42
Rate for Payer: UnitedHealthcare Medicaid	$13.25
Rate for Payer: University Health Alliance Commercial	$16.09

D5 %-0.45 % SODIUM CHLORIDE IV SOLP

Facility

$27.60

Service Code	NDC 00990792609
Hospital Revenue Code	250
Min. Negotiated Rate	$23.46
Max. Negotiated Rate	$26.77
Rate for Payer: Cash Price	$17.94
Rate for Payer: Health Management Network Commercial	$23.46
Rate for Payer: MDX Hawaii PPO	$26.77

D5-1/2NS 1000 ML WITH KCL 10 MEQ/L IV PREMIX

Facility

$57.96

Service Code	HCPCS J3480
Hospital Revenue Code	250
Min. Negotiated Rate	$49.27
Max. Negotiated Rate	$56.22
Rate for Payer: Cash Price	$37.67
Rate for Payer: Health Management Network Commercial	$49.27
Rate for Payer: MDX Hawaii PPO	$56.22

D5-1/2NS 1000 ML WITH KCL 10 MEQ/L IV PREMIX

Facility

$57.96

Service Code	HCPCS J3480
Hospital Revenue Code	636
Min. Negotiated Rate	$0.17
Max. Negotiated Rate	$56.22
Rate for Payer: Cash Price	$37.67
Rate for Payer: Cash Price	$37.67
Rate for Payer: Hawaii Medical Service Association ABD	$0.17
Rate for Payer: Hawaii Medical Service Association Non-ABD	$0.17
Rate for Payer: Hawaii Western Management Group Commercial	$55.06
Rate for Payer: Health Management Network Commercial	$49.27
Rate for Payer: Kaiser Permanente Commercial	$36.51
Rate for Payer: Kaiser Permanente Medicaid	$29.56
Rate for Payer: MDX Hawaii PPO	$56.22
Rate for Payer: UnitedHealthcare Medicaid	$34.78
Rate for Payer: University Health Alliance Commercial	$42.25

D5-1/2NS 1000 ML WITH KCL 20 MEQ/L IV PREMIX

Facility

$38.62

Service Code	HCPCS J3480
Hospital Revenue Code	250
Min. Negotiated Rate	$32.83
Max. Negotiated Rate	$37.46
Rate for Payer: Cash Price	$25.10
Rate for Payer: Health Management Network Commercial	$32.83
Rate for Payer: MDX Hawaii PPO	$37.46

D5-1/2NS 1000 ML WITH KCL 20 MEQ/L IV PREMIX

Facility

$38.62

Service Code	HCPCS J3480
Hospital Revenue Code	636
Min. Negotiated Rate	$0.17
Max. Negotiated Rate	$37.46
Rate for Payer: Cash Price	$25.10
Rate for Payer: Cash Price	$25.10
Rate for Payer: Hawaii Medical Service Association ABD	$0.17
Rate for Payer: Hawaii Medical Service Association Non-ABD	$0.17
Rate for Payer: Hawaii Western Management Group Commercial	$36.69
Rate for Payer: Health Management Network Commercial	$32.83
Rate for Payer: Kaiser Permanente Commercial	$24.33
Rate for Payer: Kaiser Permanente Medicaid	$19.70
Rate for Payer: MDX Hawaii PPO	$37.46
Rate for Payer: UnitedHealthcare Medicaid	$23.17
Rate for Payer: University Health Alliance Commercial	$28.15

Know your out-of-pocket cost for care.

All Charges