Kona Community Hospital

All Charges

Charge

Type

Setting

Price

Anti Drift Bolt Instr Kit St 1500-4850 [3644927]

Facility

$2,935.70

Hospital Charge Code	3644927
Hospital Revenue Code	272
Min. Negotiated Rate	$2,495.34
Max. Negotiated Rate	$2,847.63
Rate for Payer: Cash Price	$1,908.20
Rate for Payer: Health Management Network Commercial	$2,495.34
Rate for Payer: MDX Hawaii PPO	$2,847.63

Anti Drift Bolt Instr Kit St 1500-4850 [3644927]

Facility

$2,935.70

Hospital Charge Code	3644927
Hospital Revenue Code	272
Min. Negotiated Rate	$1,497.21
Max. Negotiated Rate	$2,847.63
Rate for Payer: Cash Price	$1,908.20
Rate for Payer: Hawaii Western Management Group Commercial	$2,788.91
Rate for Payer: Health Management Network Commercial	$2,495.34
Rate for Payer: Kaiser Permanente Commercial	$1,849.49
Rate for Payer: Kaiser Permanente Medicaid	$1,497.21
Rate for Payer: MDX Hawaii PPO	$2,847.63
Rate for Payer: University Health Alliance Commercial	$2,139.83

ANTIHEMOPHILIC FACTOR (RECOMB) 500 (+/-) UNIT IV RECON.SOLN.

Facility

$10.82

Service Code	HCPCS J7192
Hospital Revenue Code	250
Min. Negotiated Rate	$9.20
Max. Negotiated Rate	$10.50
Rate for Payer: Cash Price	$7.03
Rate for Payer: Health Management Network Commercial	$9.20
Rate for Payer: MDX Hawaii PPO	$10.50

ANTIHEMOPHILIC FACTOR (RECOMB) 500 (+/-) UNIT IV RECON.SOLN.

Facility

$10.82

Service Code	HCPCS J7192
Hospital Revenue Code	636
Min. Negotiated Rate	$1.57
Max. Negotiated Rate	$10.50
Rate for Payer: AlohaCare Medicaid	$1.57
Rate for Payer: AlohaCare Medicare	$1.57
Rate for Payer: Cash Price	$7.03
Rate for Payer: Cash Price	$7.03
Rate for Payer: Devoted Health Medicare	$1.73
Rate for Payer: Hawaii Medical Service Association Commercial	$1.96
Rate for Payer: Hawaii Medical Service Association Medicare	$1.57
Rate for Payer: Hawaii Western Management Group Commercial	$10.28
Rate for Payer: Health Management Network Commercial	$9.20
Rate for Payer: Humana Medicare	$1.57
Rate for Payer: Kaiser Permanente Commercial	$6.82
Rate for Payer: Kaiser Permanente Medicaid	$5.52
Rate for Payer: Kaiser Permanente Medicare	$1.57
Rate for Payer: MDX Hawaii PPO	$10.50
Rate for Payer: Ohana Health Plan Medicaid	$1.73
Rate for Payer: Ohana Health Plan Medicare	$1.57
Rate for Payer: UnitedHealthcare Medicaid	$6.49
Rate for Payer: UnitedHealthcare Medicare	$1.57
Rate for Payer: University Health Alliance Commercial	$7.89

AORTIC AND HEART ASSIST PROCEDURES EXCEPT PULSATION BALLOON WITH MCC

Facility

$118,643.77

Service Code	MSDRG 268
Min. Negotiated Rate	$90,463.42
Max. Negotiated Rate	$118,643.77
Rate for Payer: AlohaCare Medicare	$90,463.42
Rate for Payer: Devoted Health Medicare	$99,509.76
Rate for Payer: Hawaii Medical Service Association Commercial	$113,182.37
Rate for Payer: Hawaii Medical Service Association Medicare	$90,463.42
Rate for Payer: Humana Medicare	$90,463.42
Rate for Payer: Kaiser Permanente Commercial	$118,643.77
Rate for Payer: Kaiser Permanente Medicare	$90,463.42
Rate for Payer: Ohana Health Plan Medicare	$90,463.42
Rate for Payer: UnitedHealthcare Medicare	$90,463.42

AORTIC AND HEART ASSIST PROCEDURES EXCEPT PULSATION BALLOON WITHOUT MCC

Facility

$97,681.56

Service Code	MSDRG 269
Min. Negotiated Rate	$55,546.77
Max. Negotiated Rate	$97,681.56
Rate for Payer: AlohaCare Medicare	$55,546.77
Rate for Payer: Devoted Health Medicare	$61,101.45
Rate for Payer: Hawaii Medical Service Association Commercial	$97,681.56
Rate for Payer: Hawaii Medical Service Association Medicare	$55,546.77
Rate for Payer: Humana Medicare	$55,546.77
Rate for Payer: Kaiser Permanente Commercial	$72,850.20
Rate for Payer: Kaiser Permanente Medicare	$55,546.77
Rate for Payer: Ohana Health Plan Medicare	$55,546.77
Rate for Payer: UnitedHealthcare Medicare	$55,546.77

APIXABAN 2.5 MG PO TABLET

Facility

$58.47

Service Code	HCPCS A9270
Hospital Revenue Code	250
Min. Negotiated Rate	$49.70
Max. Negotiated Rate	$56.72
Rate for Payer: Cash Price	$38.01
Rate for Payer: Cash Price	$38.01
Rate for Payer: Health Management Network Commercial	$49.70
Rate for Payer: Health Management Network Commercial	$49.71
Rate for Payer: MDX Hawaii PPO	$56.72
Rate for Payer: MDX Hawaii PPO	$56.73

APIXABAN 2.5 MG PO TABLET

Facility

$58.48

Service Code	HCPCS A9270
Hospital Revenue Code	250
Min. Negotiated Rate	$29.82
Max. Negotiated Rate	$56.73
Rate for Payer: Cash Price	$38.01
Rate for Payer: Cash Price	$38.01
Rate for Payer: Hawaii Western Management Group Commercial	$55.55
Rate for Payer: Hawaii Western Management Group Commercial	$55.56
Rate for Payer: Health Management Network Commercial	$49.70
Rate for Payer: Health Management Network Commercial	$49.71
Rate for Payer: Kaiser Permanente Commercial	$36.84
Rate for Payer: Kaiser Permanente Commercial	$36.84
Rate for Payer: Kaiser Permanente Medicaid	$29.82
Rate for Payer: Kaiser Permanente Medicaid	$29.82
Rate for Payer: MDX Hawaii PPO	$56.72
Rate for Payer: MDX Hawaii PPO	$56.73
Rate for Payer: UnitedHealthcare Medicaid	$35.08
Rate for Payer: UnitedHealthcare Medicaid	$35.09
Rate for Payer: University Health Alliance Commercial	$42.63
Rate for Payer: University Health Alliance Commercial	$42.62

APIXABAN 5 MG PO TABLET

Facility

$58.47

Service Code	HCPCS A9270
Hospital Revenue Code	250
Min. Negotiated Rate	$49.70
Max. Negotiated Rate	$56.72
Rate for Payer: Cash Price	$38.01
Rate for Payer: Cash Price	$38.01
Rate for Payer: Health Management Network Commercial	$49.71
Rate for Payer: Health Management Network Commercial	$49.70
Rate for Payer: MDX Hawaii PPO	$56.72
Rate for Payer: MDX Hawaii PPO	$56.73

APIXABAN 5 MG PO TABLET

Facility

$58.47

Service Code	HCPCS A9270
Hospital Revenue Code	250
Min. Negotiated Rate	$29.82
Max. Negotiated Rate	$56.72
Rate for Payer: Cash Price	$38.01
Rate for Payer: Cash Price	$38.01
Rate for Payer: Hawaii Western Management Group Commercial	$55.55
Rate for Payer: Hawaii Western Management Group Commercial	$55.56
Rate for Payer: Health Management Network Commercial	$49.70
Rate for Payer: Health Management Network Commercial	$49.71
Rate for Payer: Kaiser Permanente Commercial	$36.84
Rate for Payer: Kaiser Permanente Commercial	$36.84
Rate for Payer: Kaiser Permanente Medicaid	$29.82
Rate for Payer: Kaiser Permanente Medicaid	$29.82
Rate for Payer: MDX Hawaii PPO	$56.72
Rate for Payer: MDX Hawaii PPO	$56.73
Rate for Payer: UnitedHealthcare Medicaid	$35.09
Rate for Payer: UnitedHealthcare Medicaid	$35.08
Rate for Payer: University Health Alliance Commercial	$42.62
Rate for Payer: University Health Alliance Commercial	$42.63

Appel-Berci Cystic Duct Intro Set G08297 [3642778]

Facility

$774.96

Service Code	HCPCS C1894
Hospital Charge Code	3642778
Hospital Revenue Code	272
Min. Negotiated Rate	$395.23
Max. Negotiated Rate	$751.71
Rate for Payer: Cash Price	$503.72
Rate for Payer: Hawaii Western Management Group Commercial	$736.21
Rate for Payer: Health Management Network Commercial	$658.72
Rate for Payer: Kaiser Permanente Commercial	$488.22
Rate for Payer: Kaiser Permanente Medicaid	$395.23
Rate for Payer: MDX Hawaii PPO	$751.71
Rate for Payer: University Health Alliance Commercial	$564.87

Appel-Berci Cystic Duct Intro Set G08297 [3642778]

Facility

$774.96

Service Code	HCPCS C1894
Hospital Charge Code	3642778
Hospital Revenue Code	272
Min. Negotiated Rate	$658.72
Max. Negotiated Rate	$751.71
Rate for Payer: Cash Price	$503.72
Rate for Payer: Health Management Network Commercial	$658.72
Rate for Payer: MDX Hawaii PPO	$751.71

APPENDECTOMY WITH COMPLEX PRINCIPAL DIAGNOSIS

Facility

$5,661.18

Service Code	APR-DRG 2331
Min. Negotiated Rate	$5,661.18
Max. Negotiated Rate	$5,661.18
Rate for Payer: AlohaCare Medicaid	$5,661.18
Rate for Payer: Hawaii Medical Service Association ABD	$5,661.18
Rate for Payer: Hawaii Medical Service Association Non-ABD	$5,661.18
Rate for Payer: Kaiser Permanente Medicaid	$5,661.18
Rate for Payer: Ohana Health Plan Medicaid	$5,661.18
Rate for Payer: UnitedHealthcare Medicaid	$5,661.18

APPENDECTOMY WITH COMPLEX PRINCIPAL DIAGNOSIS

Facility

$16,878.46

Service Code	APR-DRG 2334
Min. Negotiated Rate	$16,878.46
Max. Negotiated Rate	$16,878.46
Rate for Payer: AlohaCare Medicaid	$16,878.46
Rate for Payer: Hawaii Medical Service Association ABD	$16,878.46
Rate for Payer: Hawaii Medical Service Association Non-ABD	$16,878.46
Rate for Payer: Kaiser Permanente Medicaid	$16,878.46
Rate for Payer: Ohana Health Plan Medicaid	$16,878.46
Rate for Payer: UnitedHealthcare Medicaid	$16,878.46

APPENDECTOMY WITH COMPLEX PRINCIPAL DIAGNOSIS

Facility

$10,975.30

Service Code	APR-DRG 2333
Min. Negotiated Rate	$10,975.30
Max. Negotiated Rate	$10,975.30
Rate for Payer: AlohaCare Medicaid	$10,975.30
Rate for Payer: Hawaii Medical Service Association ABD	$10,975.30
Rate for Payer: Hawaii Medical Service Association Non-ABD	$10,975.30
Rate for Payer: Kaiser Permanente Medicaid	$10,975.30
Rate for Payer: Ohana Health Plan Medicaid	$10,975.30
Rate for Payer: UnitedHealthcare Medicaid	$10,975.30

APPENDECTOMY WITH COMPLEX PRINCIPAL DIAGNOSIS

Facility

$7,296.49

Service Code	APR-DRG 2332
Min. Negotiated Rate	$7,296.49
Max. Negotiated Rate	$7,296.49
Rate for Payer: AlohaCare Medicaid	$7,296.49
Rate for Payer: Hawaii Medical Service Association ABD	$7,296.49
Rate for Payer: Hawaii Medical Service Association Non-ABD	$7,296.49
Rate for Payer: Kaiser Permanente Medicaid	$7,296.49
Rate for Payer: Ohana Health Plan Medicaid	$7,296.49
Rate for Payer: UnitedHealthcare Medicaid	$7,296.49

APPENDECTOMY WITHOUT COMPLEX PRINCIPAL DIAGNOSIS

Facility

$13,754.31

Service Code	APR-DRG 2344
Min. Negotiated Rate	$13,754.31
Max. Negotiated Rate	$13,754.31
Rate for Payer: AlohaCare Medicaid	$13,754.31
Rate for Payer: Hawaii Medical Service Association ABD	$13,754.31
Rate for Payer: Hawaii Medical Service Association Non-ABD	$13,754.31
Rate for Payer: Kaiser Permanente Medicaid	$13,754.31
Rate for Payer: Ohana Health Plan Medicaid	$13,754.31
Rate for Payer: UnitedHealthcare Medicaid	$13,754.31

APPENDECTOMY WITHOUT COMPLEX PRINCIPAL DIAGNOSIS

Facility

$8,219.85

Service Code	APR-DRG 2343
Min. Negotiated Rate	$8,219.85
Max. Negotiated Rate	$8,219.85
Rate for Payer: AlohaCare Medicaid	$8,219.85
Rate for Payer: Hawaii Medical Service Association ABD	$8,219.85
Rate for Payer: Hawaii Medical Service Association Non-ABD	$8,219.85
Rate for Payer: Kaiser Permanente Medicaid	$8,219.85
Rate for Payer: Ohana Health Plan Medicaid	$8,219.85
Rate for Payer: UnitedHealthcare Medicaid	$8,219.85

APPENDECTOMY WITHOUT COMPLEX PRINCIPAL DIAGNOSIS

Facility

$4,114.38

Service Code	APR-DRG 2341
Min. Negotiated Rate	$4,114.38
Max. Negotiated Rate	$4,114.38
Rate for Payer: AlohaCare Medicaid	$4,114.38
Rate for Payer: Hawaii Medical Service Association ABD	$4,114.38
Rate for Payer: Hawaii Medical Service Association Non-ABD	$4,114.38
Rate for Payer: Kaiser Permanente Medicaid	$4,114.38
Rate for Payer: Ohana Health Plan Medicaid	$4,114.38
Rate for Payer: UnitedHealthcare Medicaid	$4,114.38

APPENDECTOMY WITHOUT COMPLEX PRINCIPAL DIAGNOSIS

Facility

$5,597.50

Service Code	APR-DRG 2342
Min. Negotiated Rate	$5,597.50
Max. Negotiated Rate	$5,597.50
Rate for Payer: AlohaCare Medicaid	$5,597.50
Rate for Payer: Hawaii Medical Service Association ABD	$5,597.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$5,597.50
Rate for Payer: Kaiser Permanente Medicaid	$5,597.50
Rate for Payer: Ohana Health Plan Medicaid	$5,597.50
Rate for Payer: UnitedHealthcare Medicaid	$5,597.50

APPENDIX PROCEDURES WITH CC

Facility

$32,231.06

Service Code	MSDRG 398
Min. Negotiated Rate	$19,908.03
Max. Negotiated Rate	$32,231.06
Rate for Payer: AlohaCare Medicare	$19,908.03
Rate for Payer: Devoted Health Medicare	$21,898.83
Rate for Payer: Hawaii Medical Service Association Commercial	$32,231.06
Rate for Payer: Hawaii Medical Service Association Medicare	$19,908.03
Rate for Payer: Humana Medicare	$19,908.03
Rate for Payer: Kaiser Permanente Commercial	$26,109.60
Rate for Payer: Kaiser Permanente Medicare	$19,908.03
Rate for Payer: Ohana Health Plan Medicare	$19,908.03
Rate for Payer: UnitedHealthcare Medicare	$19,908.03

APPENDIX PROCEDURES WITH MCC

Facility

$41,312.03

Service Code	MSDRG 397
Min. Negotiated Rate	$31,499.56
Max. Negotiated Rate	$41,312.03
Rate for Payer: AlohaCare Medicare	$31,499.56
Rate for Payer: Devoted Health Medicare	$34,649.52
Rate for Payer: Hawaii Medical Service Association Commercial	$34,906.94
Rate for Payer: Hawaii Medical Service Association Medicare	$31,499.56
Rate for Payer: Humana Medicare	$31,499.56
Rate for Payer: Kaiser Permanente Commercial	$41,312.03
Rate for Payer: Kaiser Permanente Medicare	$31,499.56
Rate for Payer: Ohana Health Plan Medicare	$31,499.56
Rate for Payer: UnitedHealthcare Medicare	$31,499.56

APPENDIX PROCEDURES WITHOUT CC/MCC

Facility

$24,058.79

Service Code	MSDRG 399
Min. Negotiated Rate	$15,055.97
Max. Negotiated Rate	$24,058.79
Rate for Payer: AlohaCare Medicare	$15,055.97
Rate for Payer: Devoted Health Medicare	$16,561.57
Rate for Payer: Hawaii Medical Service Association Commercial	$24,058.79
Rate for Payer: Hawaii Medical Service Association Medicare	$15,055.97
Rate for Payer: Humana Medicare	$15,055.97
Rate for Payer: Kaiser Permanente Commercial	$19,746.08
Rate for Payer: Kaiser Permanente Medicare	$15,055.97
Rate for Payer: Ohana Health Plan Medicare	$15,055.97
Rate for Payer: UnitedHealthcare Medicare	$15,055.97

APPLICATION OF LONG ARM SPLINT (SHOULDER TO HAND)

Facility

$2,837.00

Service Code	CPT 29105
Hospital Revenue Code	360
Min. Negotiated Rate	$34.95
Max. Negotiated Rate	$2,837.00
Rate for Payer: AlohaCare Medicaid	$191.97
Rate for Payer: AlohaCare Medicare	$191.97
Rate for Payer: Devoted Health Medicare	$211.17
Rate for Payer: Hawaii Medical Service Association Commercial	$239.96
Rate for Payer: Hawaii Medical Service Association Medicare	$191.97
Rate for Payer: Humana Medicare	$191.97
Rate for Payer: Kaiser Permanente Medicaid	$2,837.00
Rate for Payer: Kaiser Permanente Medicare	$191.97
Rate for Payer: Ohana Health Plan Medicaid	$211.17
Rate for Payer: Ohana Health Plan Medicare	$191.97
Rate for Payer: UnitedHealthcare Medicaid	$34.95
Rate for Payer: UnitedHealthcare Medicare	$191.97

APPLICATION OF LONG LEG CAST (THIGH TO TOES); WALKER OR AMBULATORY TYPE

Facility

$2,837.00

Service Code	CPT 29355
Hospital Revenue Code	360
Min. Negotiated Rate	$67.99
Max. Negotiated Rate	$2,837.00
Rate for Payer: AlohaCare Medicaid	$330.41
Rate for Payer: AlohaCare Medicare	$330.41
Rate for Payer: Devoted Health Medicare	$363.45
Rate for Payer: Hawaii Medical Service Association Commercial	$413.01
Rate for Payer: Hawaii Medical Service Association Medicare	$330.41
Rate for Payer: Humana Medicare	$330.41
Rate for Payer: Kaiser Permanente Medicaid	$2,837.00
Rate for Payer: Kaiser Permanente Medicare	$330.41
Rate for Payer: Ohana Health Plan Medicaid	$363.45
Rate for Payer: Ohana Health Plan Medicare	$330.41
Rate for Payer: UnitedHealthcare Medicaid	$67.99
Rate for Payer: UnitedHealthcare Medicare	$330.41

Know your out-of-pocket cost for care.

All Charges