Kona Community Hospital

All Charges

Charge

Type

Setting

Price

GADOTERIDOL 279.3 MG/ML IV SOLN

Facility

$140.74

Service Code	HCPCS A9579
Hospital Revenue Code	255
Min. Negotiated Rate	$1.10
Max. Negotiated Rate	$136.52
Rate for Payer: Cash Price	$91.48
Rate for Payer: Cash Price	$91.48
Rate for Payer: Hawaii Western Management Group Commercial	$133.70
Rate for Payer: Health Management Network Commercial	$119.63
Rate for Payer: Kaiser Permanente Commercial	$88.67
Rate for Payer: Kaiser Permanente Medicaid	$71.78
Rate for Payer: MDX Hawaii PPO	$136.52
Rate for Payer: UnitedHealthcare Medicaid	$1.10
Rate for Payer: University Health Alliance Commercial	$102.59

GADOTERIDOL 279.3 MG/ML IV SOLN

Facility

$140.74

Service Code	HCPCS A9579
Hospital Revenue Code	255
Min. Negotiated Rate	$119.63
Max. Negotiated Rate	$136.52
Rate for Payer: Cash Price	$91.48
Rate for Payer: Health Management Network Commercial	$119.63
Rate for Payer: MDX Hawaii PPO	$136.52

GADOTERIDOL 279.3 MG/ML IV SYR

Facility

$417.98

Service Code	HCPCS A9579
Hospital Revenue Code	255
Min. Negotiated Rate	$355.28
Max. Negotiated Rate	$405.44
Rate for Payer: Cash Price	$271.69
Rate for Payer: Health Management Network Commercial	$355.28
Rate for Payer: MDX Hawaii PPO	$405.44

GADOTERIDOL 279.3 MG/ML IV SYR

Facility

$417.98

Service Code	HCPCS A9579
Hospital Revenue Code	255
Min. Negotiated Rate	$1.10
Max. Negotiated Rate	$405.44
Rate for Payer: Cash Price	$271.69
Rate for Payer: Cash Price	$271.69
Rate for Payer: Hawaii Western Management Group Commercial	$397.08
Rate for Payer: Health Management Network Commercial	$355.28
Rate for Payer: Kaiser Permanente Commercial	$263.33
Rate for Payer: Kaiser Permanente Medicaid	$213.17
Rate for Payer: MDX Hawaii PPO	$405.44
Rate for Payer: UnitedHealthcare Medicaid	$1.10
Rate for Payer: University Health Alliance Commercial	$304.67

GANCICLOVIR SODIUM 500 MG IV RECON.SOLN.

Facility

$336.00

Service Code	HCPCS J1570
Hospital Revenue Code	636
Min. Negotiated Rate	$39.62
Max. Negotiated Rate	$325.92
Rate for Payer: Cash Price	$218.40
Rate for Payer: Cash Price	$218.40
Rate for Payer: Hawaii Medical Service Association ABD	$39.62
Rate for Payer: Hawaii Medical Service Association Non-ABD	$39.62
Rate for Payer: Hawaii Western Management Group Commercial	$319.20
Rate for Payer: Health Management Network Commercial	$285.60
Rate for Payer: Kaiser Permanente Commercial	$211.68
Rate for Payer: Kaiser Permanente Medicaid	$171.36
Rate for Payer: MDX Hawaii PPO	$325.92
Rate for Payer: UnitedHealthcare Medicaid	$201.60
Rate for Payer: University Health Alliance Commercial	$244.91

GANCICLOVIR SODIUM 500 MG IV RECON.SOLN.

Facility

$336.00

Service Code	HCPCS J1570
Hospital Revenue Code	250
Min. Negotiated Rate	$285.60
Max. Negotiated Rate	$325.92
Rate for Payer: Cash Price	$218.40
Rate for Payer: Health Management Network Commercial	$285.60
Rate for Payer: MDX Hawaii PPO	$325.92

GANCICLOVIR SODIUM 50 MG/ML IV SOLN

Facility

$306.96

Service Code	HCPCS J1570
Hospital Revenue Code	250
Min. Negotiated Rate	$260.92
Max. Negotiated Rate	$297.75
Rate for Payer: Cash Price	$199.52
Rate for Payer: Health Management Network Commercial	$260.92
Rate for Payer: MDX Hawaii PPO	$297.75

GANCICLOVIR SODIUM 50 MG/ML IV SOLN

Facility

$306.96

Service Code	HCPCS J1570
Hospital Revenue Code	636
Min. Negotiated Rate	$39.62
Max. Negotiated Rate	$297.75
Rate for Payer: Cash Price	$199.52
Rate for Payer: Cash Price	$199.52
Rate for Payer: Hawaii Medical Service Association ABD	$39.62
Rate for Payer: Hawaii Medical Service Association Non-ABD	$39.62
Rate for Payer: Hawaii Western Management Group Commercial	$291.61
Rate for Payer: Health Management Network Commercial	$260.92
Rate for Payer: Kaiser Permanente Commercial	$193.38
Rate for Payer: Kaiser Permanente Medicaid	$156.55
Rate for Payer: MDX Hawaii PPO	$297.75
Rate for Payer: UnitedHealthcare Medicaid	$184.18
Rate for Payer: University Health Alliance Commercial	$223.74

GASTRIC FUNDOPLICATION

Facility

$5,963.66

Service Code	APR-DRG 2321
Min. Negotiated Rate	$5,963.66
Max. Negotiated Rate	$5,963.66
Rate for Payer: AlohaCare Medicaid	$5,963.66
Rate for Payer: Hawaii Medical Service Association ABD	$5,963.66
Rate for Payer: Hawaii Medical Service Association Non-ABD	$5,963.66
Rate for Payer: Kaiser Permanente Medicaid	$5,963.66
Rate for Payer: Ohana Health Plan Medicaid	$5,963.66
Rate for Payer: UnitedHealthcare Medicaid	$5,963.66

GASTRIC FUNDOPLICATION

Facility

$7,563.95

Service Code	APR-DRG 2322
Min. Negotiated Rate	$7,563.95
Max. Negotiated Rate	$7,563.95
Rate for Payer: AlohaCare Medicaid	$7,563.95
Rate for Payer: Hawaii Medical Service Association ABD	$7,563.95
Rate for Payer: Hawaii Medical Service Association Non-ABD	$7,563.95
Rate for Payer: Kaiser Permanente Medicaid	$7,563.95
Rate for Payer: Ohana Health Plan Medicaid	$7,563.95
Rate for Payer: UnitedHealthcare Medicaid	$7,563.95

GASTRIC FUNDOPLICATION

Facility

$10,085.05

Service Code	APR-DRG 2323
Min. Negotiated Rate	$10,085.05
Max. Negotiated Rate	$10,085.05
Rate for Payer: AlohaCare Medicaid	$10,085.05
Rate for Payer: Hawaii Medical Service Association ABD	$10,085.05
Rate for Payer: Hawaii Medical Service Association Non-ABD	$10,085.05
Rate for Payer: Kaiser Permanente Medicaid	$10,085.05
Rate for Payer: Ohana Health Plan Medicaid	$10,085.05
Rate for Payer: UnitedHealthcare Medicaid	$10,085.05

GASTRIC FUNDOPLICATION

Facility

$23,157.34

Service Code	APR-DRG 2324
Min. Negotiated Rate	$23,157.34
Max. Negotiated Rate	$23,157.34
Rate for Payer: AlohaCare Medicaid	$23,157.34
Rate for Payer: Hawaii Medical Service Association ABD	$23,157.34
Rate for Payer: Hawaii Medical Service Association Non-ABD	$23,157.34
Rate for Payer: Kaiser Permanente Medicaid	$23,157.34
Rate for Payer: Ohana Health Plan Medicaid	$23,157.34
Rate for Payer: UnitedHealthcare Medicaid	$23,157.34

GASTROCNEMIUS RECESSION (EG, STRAYER PROCEDURE)

Facility

$9,416.00

Service Code	CPT 27687
Hospital Revenue Code	360
Min. Negotiated Rate	$456.03
Max. Negotiated Rate	$9,416.00
Rate for Payer: AlohaCare Medicaid	$3,865.36
Rate for Payer: AlohaCare Medicare	$3,865.36
Rate for Payer: Devoted Health Medicare	$4,251.90
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	$3,865.36
Rate for Payer: Hawaii Medical Service Association Non-ABD	$849.21
Rate for Payer: Humana Medicare	$3,865.36
Rate for Payer: Kaiser Permanente Medicaid	$2,837.00
Rate for Payer: Kaiser Permanente Medicare	$3,865.36
Rate for Payer: Ohana Health Plan Medicaid	$4,251.90
Rate for Payer: Ohana Health Plan Medicare	$3,865.36
Rate for Payer: UnitedHealthcare Medicaid	$456.03
Rate for Payer: UnitedHealthcare Medicare	$3,865.36
Rate for Payer: University Health Alliance Commercial	$6,743.44

Gastrointestinal Anchor Set 98701 [3644253]

Facility

$779.35

Hospital Charge Code	3644253
Hospital Revenue Code	272
Min. Negotiated Rate	$397.47
Max. Negotiated Rate	$755.97
Rate for Payer: Cash Price	$506.58
Rate for Payer: Hawaii Western Management Group Commercial	$740.38
Rate for Payer: Health Management Network Commercial	$662.45
Rate for Payer: Kaiser Permanente Commercial	$490.99
Rate for Payer: Kaiser Permanente Medicaid	$397.47
Rate for Payer: MDX Hawaii PPO	$755.97
Rate for Payer: University Health Alliance Commercial	$568.07

Gastrointestinal Anchor Set 98701 [3644253]

Facility

$779.35

Hospital Charge Code	3644253
Hospital Revenue Code	272
Min. Negotiated Rate	$662.45
Max. Negotiated Rate	$755.97
Rate for Payer: Cash Price	$506.58
Rate for Payer: Health Management Network Commercial	$662.45
Rate for Payer: MDX Hawaii PPO	$755.97

GASTROINTESTINAL HEMORRHAGE WITH CC

Facility

$21,720.41

Service Code	MSDRG 378
Min. Negotiated Rate	$12,898.92
Max. Negotiated Rate	$21,720.41
Rate for Payer: AlohaCare Medicare	$12,898.92
Rate for Payer: Devoted Health Medicare	$14,188.81
Rate for Payer: Hawaii Medical Service Association Commercial	$21,720.41
Rate for Payer: Hawaii Medical Service Association Medicare	$12,898.92
Rate for Payer: Humana Medicare	$12,898.92
Rate for Payer: Kaiser Permanente Commercial	$16,917.08
Rate for Payer: Kaiser Permanente Medicare	$12,898.92
Rate for Payer: Ohana Health Plan Medicare	$12,898.92
Rate for Payer: UnitedHealthcare Medicare	$12,898.92

GASTROINTESTINAL HEMORRHAGE WITH MCC

Facility

$31,533.00

Service Code	MSDRG 377
Min. Negotiated Rate	$21,720.41
Max. Negotiated Rate	$31,533.00
Rate for Payer: AlohaCare Medicare	$24,043.26
Rate for Payer: Devoted Health Medicare	$26,447.59
Rate for Payer: Hawaii Medical Service Association Commercial	$21,720.41
Rate for Payer: Hawaii Medical Service Association Medicare	$24,043.26
Rate for Payer: Humana Medicare	$24,043.26
Rate for Payer: Kaiser Permanente Commercial	$31,533.00
Rate for Payer: Kaiser Permanente Medicare	$24,043.26
Rate for Payer: Ohana Health Plan Medicare	$24,043.26
Rate for Payer: UnitedHealthcare Medicare	$24,043.26

GASTROINTESTINAL HEMORRHAGE WITHOUT CC/MCC

Facility

$16,657.94

Service Code	MSDRG 379
Min. Negotiated Rate	$8,291.51
Max. Negotiated Rate	$16,657.94
Rate for Payer: AlohaCare Medicare	$8,291.51
Rate for Payer: Devoted Health Medicare	$9,120.66
Rate for Payer: Hawaii Medical Service Association Commercial	$16,657.94
Rate for Payer: Hawaii Medical Service Association Medicare	$8,291.51
Rate for Payer: Humana Medicare	$8,291.51
Rate for Payer: Kaiser Permanente Commercial	$10,874.40
Rate for Payer: Kaiser Permanente Medicare	$8,291.51
Rate for Payer: Ohana Health Plan Medicare	$8,291.51
Rate for Payer: UnitedHealthcare Medicare	$8,291.51

GASTROINTESTINAL OBSTRUCTION WITH CC

Facility

$16,947.22

Service Code	MSDRG 389
Min. Negotiated Rate	$10,388.05
Max. Negotiated Rate	$16,947.22
Rate for Payer: AlohaCare Medicare	$10,388.05
Rate for Payer: Devoted Health Medicare	$11,426.85
Rate for Payer: Hawaii Medical Service Association Commercial	$16,947.22
Rate for Payer: Hawaii Medical Service Association Medicare	$10,388.05
Rate for Payer: Humana Medicare	$10,388.05
Rate for Payer: Kaiser Permanente Commercial	$13,624.05
Rate for Payer: Kaiser Permanente Medicare	$10,388.05
Rate for Payer: Ohana Health Plan Medicare	$10,388.05
Rate for Payer: UnitedHealthcare Medicare	$10,388.05

GASTROINTESTINAL OBSTRUCTION WITH MCC

Facility

$25,474.80

Service Code	MSDRG 388
Min. Negotiated Rate	$19,092.74
Max. Negotiated Rate	$25,474.80
Rate for Payer: Humana Medicare	$19,424.01
Rate for Payer: AlohaCare Medicare	$19,424.01
Rate for Payer: Devoted Health Medicare	$21,366.41
Rate for Payer: Hawaii Medical Service Association Commercial	$19,092.74
Rate for Payer: Hawaii Medical Service Association Medicare	$19,424.01
Rate for Payer: Kaiser Permanente Commercial	$25,474.80
Rate for Payer: Kaiser Permanente Medicare	$19,424.01
Rate for Payer: Ohana Health Plan Medicare	$19,424.01
Rate for Payer: UnitedHealthcare Medicare	$19,424.01

GASTROINTESTINAL OBSTRUCTION WITHOUT CC/MCC

Facility

$13,499.92

Service Code	MSDRG 390
Min. Negotiated Rate	$7,155.11
Max. Negotiated Rate	$13,499.92
Rate for Payer: AlohaCare Medicare	$7,155.11
Rate for Payer: Devoted Health Medicare	$7,870.62
Rate for Payer: Hawaii Medical Service Association Commercial	$13,499.92
Rate for Payer: Hawaii Medical Service Association Medicare	$7,155.11
Rate for Payer: Humana Medicare	$7,155.11
Rate for Payer: Kaiser Permanente Commercial	$9,384.00
Rate for Payer: Kaiser Permanente Medicare	$7,155.11
Rate for Payer: Ohana Health Plan Medicare	$7,155.11
Rate for Payer: UnitedHealthcare Medicare	$7,155.11

GASTROINTESTINAL VASCULAR INSUFFICIENCY

Facility

$3,184.65

Service Code	APR-DRG 2461
Min. Negotiated Rate	$3,184.65
Max. Negotiated Rate	$3,184.65
Rate for Payer: AlohaCare Medicaid	$3,184.65
Rate for Payer: Hawaii Medical Service Association ABD	$3,184.65
Rate for Payer: Hawaii Medical Service Association Non-ABD	$3,184.65
Rate for Payer: Kaiser Permanente Medicaid	$3,184.65
Rate for Payer: Ohana Health Plan Medicaid	$3,184.65
Rate for Payer: UnitedHealthcare Medicaid	$3,184.65

GASTROINTESTINAL VASCULAR INSUFFICIENCY

Facility

$3,887.05

Service Code	APR-DRG 2462
Min. Negotiated Rate	$3,887.05
Max. Negotiated Rate	$3,887.05
Rate for Payer: AlohaCare Medicaid	$3,887.05
Rate for Payer: Hawaii Medical Service Association ABD	$3,887.05
Rate for Payer: Hawaii Medical Service Association Non-ABD	$3,887.05
Rate for Payer: Kaiser Permanente Medicaid	$3,887.05
Rate for Payer: Ohana Health Plan Medicaid	$3,887.05
Rate for Payer: UnitedHealthcare Medicaid	$3,887.05

GASTROINTESTINAL VASCULAR INSUFFICIENCY

Facility

$5,592.40

Service Code	APR-DRG 2463
Min. Negotiated Rate	$5,592.40
Max. Negotiated Rate	$5,592.40
Rate for Payer: AlohaCare Medicaid	$5,592.40
Rate for Payer: Hawaii Medical Service Association ABD	$5,592.40
Rate for Payer: Hawaii Medical Service Association Non-ABD	$5,592.40
Rate for Payer: Kaiser Permanente Medicaid	$5,592.40
Rate for Payer: Ohana Health Plan Medicaid	$5,592.40
Rate for Payer: UnitedHealthcare Medicaid	$5,592.40

GASTROINTESTINAL VASCULAR INSUFFICIENCY

Facility

$8,838.83

Service Code	APR-DRG 2464
Min. Negotiated Rate	$8,838.83
Max. Negotiated Rate	$8,838.83
Rate for Payer: AlohaCare Medicaid	$8,838.83
Rate for Payer: Hawaii Medical Service Association ABD	$8,838.83
Rate for Payer: Hawaii Medical Service Association Non-ABD	$8,838.83
Rate for Payer: Kaiser Permanente Medicaid	$8,838.83
Rate for Payer: Ohana Health Plan Medicaid	$8,838.83
Rate for Payer: UnitedHealthcare Medicaid	$8,838.83

Know your out-of-pocket cost for care.

All Charges