Kona Community Hospital

All Charges

Charge

Type

Setting

Price

FRACTURE OF FEMUR

Facility

$3,891.50

Service Code	APR-DRG 3403
Min. Negotiated Rate	$3,891.50
Max. Negotiated Rate	$3,891.50
Rate for Payer: AlohaCare Medicaid	$3,891.50
Rate for Payer: Hawaii Medical Service Association ABD	$3,891.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$3,891.50
Rate for Payer: Kaiser Permanente Medicaid	$3,891.50
Rate for Payer: Ohana Health Plan Medicaid	$3,891.50
Rate for Payer: UnitedHealthcare Medicaid	$3,891.50

FRACTURE OF PELVIS OR DISLOCATION OF HIP

Facility

$7,781.73

Service Code	APR-DRG 3414
Min. Negotiated Rate	$7,781.73
Max. Negotiated Rate	$7,781.73
Rate for Payer: AlohaCare Medicaid	$7,781.73
Rate for Payer: Hawaii Medical Service Association ABD	$7,781.73
Rate for Payer: Hawaii Medical Service Association Non-ABD	$7,781.73
Rate for Payer: Kaiser Permanente Medicaid	$7,781.73
Rate for Payer: Ohana Health Plan Medicaid	$7,781.73
Rate for Payer: UnitedHealthcare Medicaid	$7,781.73

FRACTURE OF PELVIS OR DISLOCATION OF HIP

Facility

$3,013.99

Service Code	APR-DRG 3412
Min. Negotiated Rate	$3,013.99
Max. Negotiated Rate	$3,013.99
Rate for Payer: AlohaCare Medicaid	$3,013.99
Rate for Payer: Hawaii Medical Service Association ABD	$3,013.99
Rate for Payer: Hawaii Medical Service Association Non-ABD	$3,013.99
Rate for Payer: Kaiser Permanente Medicaid	$3,013.99
Rate for Payer: Ohana Health Plan Medicaid	$3,013.99
Rate for Payer: UnitedHealthcare Medicaid	$3,013.99

FRACTURE OF PELVIS OR DISLOCATION OF HIP

Facility

$3,836.74

Service Code	APR-DRG 3413
Min. Negotiated Rate	$3,836.74
Max. Negotiated Rate	$3,836.74
Rate for Payer: AlohaCare Medicaid	$3,836.74
Rate for Payer: Hawaii Medical Service Association ABD	$3,836.74
Rate for Payer: Hawaii Medical Service Association Non-ABD	$3,836.74
Rate for Payer: Kaiser Permanente Medicaid	$3,836.74
Rate for Payer: Ohana Health Plan Medicaid	$3,836.74
Rate for Payer: UnitedHealthcare Medicaid	$3,836.74

FRACTURE OF PELVIS OR DISLOCATION OF HIP

Facility

$2,505.82

Service Code	APR-DRG 3411
Min. Negotiated Rate	$2,505.82
Max. Negotiated Rate	$2,505.82
Rate for Payer: AlohaCare Medicaid	$2,505.82
Rate for Payer: Hawaii Medical Service Association ABD	$2,505.82
Rate for Payer: Hawaii Medical Service Association Non-ABD	$2,505.82
Rate for Payer: Kaiser Permanente Medicaid	$2,505.82
Rate for Payer: Ohana Health Plan Medicaid	$2,505.82
Rate for Payer: UnitedHealthcare Medicaid	$2,505.82

FRACTURES & DISLOCATIONS EXCEPT FEMUR, PELVIS & BACK

Facility

$3,289.09

Service Code	APR-DRG 3422
Min. Negotiated Rate	$3,289.09
Max. Negotiated Rate	$3,289.09
Rate for Payer: AlohaCare Medicaid	$3,289.09
Rate for Payer: Hawaii Medical Service Association ABD	$3,289.09
Rate for Payer: Hawaii Medical Service Association Non-ABD	$3,289.09
Rate for Payer: Kaiser Permanente Medicaid	$3,289.09
Rate for Payer: Ohana Health Plan Medicaid	$3,289.09
Rate for Payer: UnitedHealthcare Medicaid	$3,289.09

FRACTURES & DISLOCATIONS EXCEPT FEMUR, PELVIS & BACK

Facility

$8,082.30

Service Code	APR-DRG 3424
Min. Negotiated Rate	$8,082.30
Max. Negotiated Rate	$8,082.30
Rate for Payer: AlohaCare Medicaid	$8,082.30
Rate for Payer: Hawaii Medical Service Association ABD	$8,082.30
Rate for Payer: Hawaii Medical Service Association Non-ABD	$8,082.30
Rate for Payer: Kaiser Permanente Medicaid	$8,082.30
Rate for Payer: Ohana Health Plan Medicaid	$8,082.30
Rate for Payer: UnitedHealthcare Medicaid	$8,082.30

FRACTURES & DISLOCATIONS EXCEPT FEMUR, PELVIS & BACK

Facility

$4,543.59

Service Code	APR-DRG 3423
Min. Negotiated Rate	$4,543.59
Max. Negotiated Rate	$4,543.59
Rate for Payer: AlohaCare Medicaid	$4,543.59
Rate for Payer: Hawaii Medical Service Association ABD	$4,543.59
Rate for Payer: Hawaii Medical Service Association Non-ABD	$4,543.59
Rate for Payer: Kaiser Permanente Medicaid	$4,543.59
Rate for Payer: Ohana Health Plan Medicaid	$4,543.59
Rate for Payer: UnitedHealthcare Medicaid	$4,543.59

FRACTURES & DISLOCATIONS EXCEPT FEMUR, PELVIS & BACK

Facility

$2,561.22

Service Code	APR-DRG 3421
Min. Negotiated Rate	$2,561.22
Max. Negotiated Rate	$2,561.22
Rate for Payer: AlohaCare Medicaid	$2,561.22
Rate for Payer: Hawaii Medical Service Association ABD	$2,561.22
Rate for Payer: Hawaii Medical Service Association Non-ABD	$2,561.22
Rate for Payer: Kaiser Permanente Medicaid	$2,561.22
Rate for Payer: Ohana Health Plan Medicaid	$2,561.22
Rate for Payer: UnitedHealthcare Medicaid	$2,561.22

FRACTURES OF FEMUR WITH MCC

Facility

$27,042.83

Service Code	MSDRG 533
Min. Negotiated Rate	$12,391.00
Max. Negotiated Rate	$27,042.83
Rate for Payer: AlohaCare Medicare	$20,619.60
Rate for Payer: Devoted Health Medicare	$22,681.56
Rate for Payer: Hawaii Medical Service Association Commercial	$12,391.00
Rate for Payer: Hawaii Medical Service Association Medicare	$20,619.60
Rate for Payer: Humana Medicare	$20,619.60
Rate for Payer: Kaiser Permanente Commercial	$27,042.83
Rate for Payer: Kaiser Permanente Medicare	$20,619.60
Rate for Payer: Ohana Health Plan Medicare	$20,619.60
Rate for Payer: UnitedHealthcare Medicare	$20,619.60

FRACTURES OF FEMUR WITHOUT MCC

Facility

$13,905.23

Service Code	MSDRG 534
Min. Negotiated Rate	$10,602.44
Max. Negotiated Rate	$13,905.23
Rate for Payer: AlohaCare Medicare	$10,602.44
Rate for Payer: Devoted Health Medicare	$11,662.68
Rate for Payer: Hawaii Medical Service Association Commercial	$12,391.00
Rate for Payer: Hawaii Medical Service Association Medicare	$10,602.44
Rate for Payer: Humana Medicare	$10,602.44
Rate for Payer: Kaiser Permanente Commercial	$13,905.23
Rate for Payer: Kaiser Permanente Medicare	$10,602.44
Rate for Payer: Ohana Health Plan Medicare	$10,602.44
Rate for Payer: UnitedHealthcare Medicare	$10,602.44

FRACTURES OF HIP AND PELVIS WITH MCC

Facility

$22,114.50

Service Code	MSDRG 535
Min. Negotiated Rate	$16,861.86
Max. Negotiated Rate	$22,114.50
Rate for Payer: AlohaCare Medicare	$16,861.86
Rate for Payer: Devoted Health Medicare	$18,548.05
Rate for Payer: Hawaii Medical Service Association Commercial	$17,742.75
Rate for Payer: Hawaii Medical Service Association Medicare	$16,861.86
Rate for Payer: Humana Medicare	$16,861.86
Rate for Payer: Kaiser Permanente Commercial	$22,114.50
Rate for Payer: Kaiser Permanente Medicare	$16,861.86
Rate for Payer: Ohana Health Plan Medicare	$16,861.86
Rate for Payer: UnitedHealthcare Medicare	$16,861.86

FRACTURES OF HIP AND PELVIS WITHOUT MCC

Facility

$17,742.75

Service Code	MSDRG 536
Min. Negotiated Rate	$10,622.18
Max. Negotiated Rate	$17,742.75
Rate for Payer: AlohaCare Medicare	$10,622.18
Rate for Payer: Devoted Health Medicare	$11,684.40
Rate for Payer: Hawaii Medical Service Association Commercial	$17,742.75
Rate for Payer: Hawaii Medical Service Association Medicare	$10,622.18
Rate for Payer: Humana Medicare	$10,622.18
Rate for Payer: Kaiser Permanente Commercial	$13,931.10
Rate for Payer: Kaiser Permanente Medicare	$10,622.18
Rate for Payer: Ohana Health Plan Medicare	$10,622.18
Rate for Payer: UnitedHealthcare Medicare	$10,622.18

FRACTURE, SPRAIN, STRAIN AND DISLOCATION EXCEPT FEMUR, HIP, PELVIS AND THIGH WITH MCC

Facility

$24,577.80

Service Code	MSDRG 562
Min. Negotiated Rate	$13,379.39
Max. Negotiated Rate	$24,577.80
Rate for Payer: AlohaCare Medicare	$18,740.07
Rate for Payer: Devoted Health Medicare	$20,614.08
Rate for Payer: Hawaii Medical Service Association Commercial	$13,379.39
Rate for Payer: Hawaii Medical Service Association Medicare	$18,740.07
Rate for Payer: Humana Medicare	$18,740.07
Rate for Payer: Kaiser Permanente Commercial	$24,577.80
Rate for Payer: Kaiser Permanente Medicare	$18,740.07
Rate for Payer: Ohana Health Plan Medicare	$18,740.07
Rate for Payer: UnitedHealthcare Medicare	$18,740.07

FRACTURE, SPRAIN, STRAIN AND DISLOCATION EXCEPT FEMUR, HIP, PELVIS AND THIGH WITHOUT MCC

Facility

$15,447.38

Service Code	MSDRG 563
Min. Negotiated Rate	$11,778.31
Max. Negotiated Rate	$15,447.38
Rate for Payer: AlohaCare Medicare	$11,778.31
Rate for Payer: Devoted Health Medicare	$12,956.14
Rate for Payer: Hawaii Medical Service Association Commercial	$13,379.39
Rate for Payer: Hawaii Medical Service Association Medicare	$11,778.31
Rate for Payer: Humana Medicare	$11,778.31
Rate for Payer: Kaiser Permanente Commercial	$15,447.38
Rate for Payer: Kaiser Permanente Medicare	$11,778.31
Rate for Payer: Ohana Health Plan Medicare	$11,778.31
Rate for Payer: UnitedHealthcare Medicare	$11,778.31

FULL TERM NEONATE WITH MAJOR PROBLEMS

Facility

$71,925.60

Service Code	MSDRG 793
Min. Negotiated Rate	$19,309.71
Max. Negotiated Rate	$71,925.60
Rate for Payer: AlohaCare Medicare	$54,841.78
Rate for Payer: Devoted Health Medicare	$60,325.96
Rate for Payer: Hawaii Medical Service Association Commercial	$19,309.71
Rate for Payer: Hawaii Medical Service Association Medicare	$54,841.78
Rate for Payer: Humana Medicare	$54,841.78
Rate for Payer: Kaiser Permanente Commercial	$71,925.60
Rate for Payer: Kaiser Permanente Medicare	$54,841.78
Rate for Payer: Ohana Health Plan Medicare	$54,841.78
Rate for Payer: UnitedHealthcare Medicare	$54,841.78

FULL THICKNESS BURN WITHOUT SKIN GRAFT OR INHALATION INJURY

Facility

$38,132.85

Service Code	MSDRG 934
Min. Negotiated Rate	$29,075.52
Max. Negotiated Rate	$38,132.85
Rate for Payer: AlohaCare Medicare	$29,075.52
Rate for Payer: Devoted Health Medicare	$31,983.07
Rate for Payer: Hawaii Medical Service Association Medicare	$29,075.52
Rate for Payer: Humana Medicare	$29,075.52
Rate for Payer: Kaiser Permanente Commercial	$38,132.85
Rate for Payer: Kaiser Permanente Medicare	$29,075.52
Rate for Payer: Ohana Health Plan Medicare	$29,075.52
Rate for Payer: UnitedHealthcare Medicare	$29,075.52

FULL THICKNESS BURN WITH SKIN GRAFT OR INHALATION INJURY WITH CC/MCC

Facility

$123,729.07

Service Code	MSDRG 928
Min. Negotiated Rate	$94,340.86
Max. Negotiated Rate	$123,729.07
Rate for Payer: AlohaCare Medicare	$94,340.86
Rate for Payer: Devoted Health Medicare	$103,774.95
Rate for Payer: Hawaii Medical Service Association Medicare	$94,340.86
Rate for Payer: Humana Medicare	$94,340.86
Rate for Payer: Kaiser Permanente Commercial	$123,729.07
Rate for Payer: Kaiser Permanente Medicare	$94,340.86
Rate for Payer: Ohana Health Plan Medicare	$94,340.86
Rate for Payer: UnitedHealthcare Medicare	$94,340.86

FULL THICKNESS BURN WITH SKIN GRAFT OR INHALATION INJURY WITHOUT CC/MCC

Facility

$55,558.80

Service Code	MSDRG 929
Min. Negotiated Rate	$42,362.44
Max. Negotiated Rate	$55,558.80
Rate for Payer: AlohaCare Medicare	$42,362.44
Rate for Payer: Devoted Health Medicare	$46,598.68
Rate for Payer: Hawaii Medical Service Association Medicare	$42,362.44
Rate for Payer: Humana Medicare	$42,362.44
Rate for Payer: Kaiser Permanente Commercial	$55,558.80
Rate for Payer: Kaiser Permanente Medicare	$42,362.44
Rate for Payer: Ohana Health Plan Medicare	$42,362.44
Rate for Payer: UnitedHealthcare Medicare	$42,362.44

FULL THICKNESS GRAFT, FREE, INCLUDING DIRECT CLOSURE OF DONOR SITE, SCALP, ARMS, AND/OR LEGS; 20 SQ CM OR LESS

Facility

$9,416.00

Service Code	CPT 15220
Hospital Revenue Code	360
Min. Negotiated Rate	$456.03
Max. Negotiated Rate	$9,416.00
Rate for Payer: AlohaCare Medicaid	$2,437.45
Rate for Payer: AlohaCare Medicare	$2,437.45
Rate for Payer: Devoted Health Medicare	$2,681.20
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	$2,437.45
Rate for Payer: Hawaii Medical Service Association Non-ABD	$849.21
Rate for Payer: Humana Medicare	$2,437.45
Rate for Payer: Kaiser Permanente Medicaid	$2,837.00
Rate for Payer: Kaiser Permanente Medicare	$2,437.45
Rate for Payer: Ohana Health Plan Medicaid	$2,681.20
Rate for Payer: Ohana Health Plan Medicare	$2,437.45
Rate for Payer: UnitedHealthcare Medicaid	$456.03
Rate for Payer: UnitedHealthcare Medicare	$2,437.45
Rate for Payer: University Health Alliance Commercial	$5,160.40

FULVESTRANT 250 MG/5 ML IM SYR

Facility

$445.20

Service Code	HCPCS J9395
Hospital Revenue Code	250
Min. Negotiated Rate	$378.42
Max. Negotiated Rate	$431.84
Rate for Payer: Cash Price	$289.38
Rate for Payer: Cash Price	$272.53
Rate for Payer: Cash Price	$398.89
Rate for Payer: Health Management Network Commercial	$356.39
Rate for Payer: Health Management Network Commercial	$378.42
Rate for Payer: Health Management Network Commercial	$521.63
Rate for Payer: MDX Hawaii PPO	$431.84
Rate for Payer: MDX Hawaii PPO	$595.27
Rate for Payer: MDX Hawaii PPO	$406.70

FULVESTRANT 250 MG/5 ML IM SYR

Facility

$445.20

Service Code	HCPCS J9395
Hospital Revenue Code	636
Min. Negotiated Rate	$6.98
Max. Negotiated Rate	$431.84
Rate for Payer: Cash Price	$289.38
Rate for Payer: Cash Price	$272.53
Rate for Payer: Cash Price	$272.53
Rate for Payer: Cash Price	$398.89
Rate for Payer: Cash Price	$398.89
Rate for Payer: Cash Price	$289.38
Rate for Payer: Hawaii Medical Service Association ABD	$6.98
Rate for Payer: Hawaii Medical Service Association ABD	$6.98
Rate for Payer: Hawaii Medical Service Association ABD	$6.98
Rate for Payer: Hawaii Medical Service Association Non-ABD	$6.98
Rate for Payer: Hawaii Medical Service Association Non-ABD	$6.98
Rate for Payer: Hawaii Medical Service Association Non-ABD	$6.98
Rate for Payer: Hawaii Western Management Group Commercial	$422.94
Rate for Payer: Hawaii Western Management Group Commercial	$398.32
Rate for Payer: Hawaii Western Management Group Commercial	$583.00
Rate for Payer: Health Management Network Commercial	$378.42
Rate for Payer: Health Management Network Commercial	$356.39
Rate for Payer: Health Management Network Commercial	$521.63
Rate for Payer: Kaiser Permanente Commercial	$264.15
Rate for Payer: Kaiser Permanente Commercial	$280.48
Rate for Payer: Kaiser Permanente Commercial	$386.62
Rate for Payer: Kaiser Permanente Medicaid	$213.83
Rate for Payer: Kaiser Permanente Medicaid	$227.05
Rate for Payer: Kaiser Permanente Medicaid	$312.98
Rate for Payer: MDX Hawaii PPO	$595.27
Rate for Payer: MDX Hawaii PPO	$406.70
Rate for Payer: MDX Hawaii PPO	$431.84
Rate for Payer: UnitedHealthcare Medicaid	$251.57
Rate for Payer: UnitedHealthcare Medicaid	$368.21
Rate for Payer: UnitedHealthcare Medicaid	$267.12
Rate for Payer: University Health Alliance Commercial	$447.31
Rate for Payer: University Health Alliance Commercial	$305.61
Rate for Payer: University Health Alliance Commercial	$324.51

FUROSEMIDE 10 MG/ML INJ SOLN

Facility

$23.09

Service Code	HCPCS J1938
Hospital Revenue Code	250
Min. Negotiated Rate	$19.63
Max. Negotiated Rate	$22.40
Rate for Payer: Cash Price	$15.01
Rate for Payer: Cash Price	$10.52
Rate for Payer: Cash Price	$20.96
Rate for Payer: Cash Price	$3.59
Rate for Payer: Health Management Network Commercial	$13.76
Rate for Payer: Health Management Network Commercial	$4.69
Rate for Payer: Health Management Network Commercial	$27.40
Rate for Payer: Health Management Network Commercial	$19.63
Rate for Payer: MDX Hawaii PPO	$31.27
Rate for Payer: MDX Hawaii PPO	$22.40
Rate for Payer: MDX Hawaii PPO	$15.70
Rate for Payer: MDX Hawaii PPO	$5.35

FUROSEMIDE 10 MG/ML INJ SOLN

Facility

$23.09

Service Code	HCPCS J1938
Hospital Revenue Code	636
Min. Negotiated Rate	$0.02
Max. Negotiated Rate	$22.40
Rate for Payer: Cash Price	$15.01
Rate for Payer: Cash Price	$15.01
Rate for Payer: Cash Price	$10.52
Rate for Payer: Cash Price	$20.96
Rate for Payer: Cash Price	$10.52
Rate for Payer: Cash Price	$20.96
Rate for Payer: Cash Price	$3.59
Rate for Payer: Cash Price	$3.59
Rate for Payer: Hawaii Medical Service Association ABD	$0.02
Rate for Payer: Hawaii Medical Service Association ABD	$0.02
Rate for Payer: Hawaii Medical Service Association ABD	$0.02
Rate for Payer: Hawaii Medical Service Association ABD	$0.02
Rate for Payer: Hawaii Medical Service Association Non-ABD	$0.02
Rate for Payer: Hawaii Medical Service Association Non-ABD	$0.02
Rate for Payer: Hawaii Medical Service Association Non-ABD	$0.02
Rate for Payer: Hawaii Medical Service Association Non-ABD	$0.02
Rate for Payer: Hawaii Western Management Group Commercial	$21.94
Rate for Payer: Hawaii Western Management Group Commercial	$30.63
Rate for Payer: Hawaii Western Management Group Commercial	$5.24
Rate for Payer: Hawaii Western Management Group Commercial	$15.38
Rate for Payer: Health Management Network Commercial	$19.63
Rate for Payer: Health Management Network Commercial	$13.76
Rate for Payer: Health Management Network Commercial	$27.40
Rate for Payer: Health Management Network Commercial	$4.69
Rate for Payer: Kaiser Permanente Commercial	$14.55
Rate for Payer: Kaiser Permanente Commercial	$3.48
Rate for Payer: Kaiser Permanente Commercial	$20.31
Rate for Payer: Kaiser Permanente Commercial	$10.20
Rate for Payer: Kaiser Permanente Medicaid	$2.82
Rate for Payer: Kaiser Permanente Medicaid	$16.44
Rate for Payer: Kaiser Permanente Medicaid	$11.78
Rate for Payer: Kaiser Permanente Medicaid	$8.26
Rate for Payer: MDX Hawaii PPO	$15.70
Rate for Payer: MDX Hawaii PPO	$31.27
Rate for Payer: MDX Hawaii PPO	$22.40
Rate for Payer: MDX Hawaii PPO	$5.35
Rate for Payer: UnitedHealthcare Medicaid	$13.85
Rate for Payer: UnitedHealthcare Medicaid	$3.31
Rate for Payer: UnitedHealthcare Medicaid	$19.34
Rate for Payer: UnitedHealthcare Medicaid	$9.71
Rate for Payer: University Health Alliance Commercial	$4.02
Rate for Payer: University Health Alliance Commercial	$11.80
Rate for Payer: University Health Alliance Commercial	$16.83
Rate for Payer: University Health Alliance Commercial	$23.50

FUROSEMIDE 20 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	$1.85
Rate for Payer: Health Management Network Commercial	$2.42
Rate for Payer: Health Management Network Commercial	$1.02
Rate for Payer: MDX Hawaii PPO	$2.76
Rate for Payer: MDX Hawaii PPO	$1.16

Know your out-of-pocket cost for care.

All Charges