Kona Community Hospital

All Charges

Charge

Type

Setting

Price

APPLICATION OF LONG LEG SPLINT (THIGH TO ANKLE OR TOES)

Facility

$2,837.00

Service Code	CPT 29505
Hospital Revenue Code	360
Min. Negotiated Rate	$33.01
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	$33.01
Rate for Payer: UnitedHealthcare Medicare	$191.97

APPLICATION OF SHORT ARM SPLINT (FOREARM TO HAND); STATIC

Facility

$2,837.00

Service Code	CPT 29125
Hospital Revenue Code	360
Min. Negotiated Rate	$24.61
Max. Negotiated Rate	$2,837.00
Rate for Payer: AlohaCare Medicaid	$157.18
Rate for Payer: AlohaCare Medicare	$157.18
Rate for Payer: Devoted Health Medicare	$172.90
Rate for Payer: Hawaii Medical Service Association Commercial	$196.47
Rate for Payer: Hawaii Medical Service Association Medicare	$157.18
Rate for Payer: Humana Medicare	$157.18
Rate for Payer: Kaiser Permanente Medicaid	$2,837.00
Rate for Payer: Kaiser Permanente Medicare	$157.18
Rate for Payer: Ohana Health Plan Medicaid	$172.90
Rate for Payer: Ohana Health Plan Medicare	$157.18
Rate for Payer: UnitedHealthcare Medicaid	$24.61
Rate for Payer: UnitedHealthcare Medicare	$157.18

APPLICATION OF SKIN SUBSTITUTE GRAFT TO FACE, SCALP, EYELIDS, MOUTH, NECK, EARS, ORBITS, GENITALIA, HANDS, FEET, AND/OR MULTIPLE DIGITS, TOTAL WOUND SURFACE AREA UP TO 100 SQ CM; FIRST 25 SQ CM OR LESS WOUND SURFACE AREA

Facility

$9,416.00

Service Code	CPT 15275
Hospital Revenue Code	360
Min. Negotiated Rate	$456.03
Max. Negotiated Rate	$9,416.00
Rate for Payer: AlohaCare Medicaid	$873.10
Rate for Payer: AlohaCare Medicare	$873.10
Rate for Payer: Devoted Health Medicare	$960.41
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	$873.10
Rate for Payer: Hawaii Medical Service Association Non-ABD	$849.21
Rate for Payer: Humana Medicare	$873.10
Rate for Payer: Kaiser Permanente Medicaid	$2,837.00
Rate for Payer: Kaiser Permanente Medicare	$873.10
Rate for Payer: Ohana Health Plan Medicaid	$960.41
Rate for Payer: Ohana Health Plan Medicare	$873.10
Rate for Payer: UnitedHealthcare Medicaid	$456.03
Rate for Payer: UnitedHealthcare Medicare	$873.10

APPLICATION OF SKIN SUBSTITUTE GRAFT TO TRUNK, ARMS, LEGS, TOTAL WOUND SURFACE AREA UP TO 100 SQ CM; FIRST 25 SQ CM OR LESS WOUND SURFACE AREA

Facility

$2,837.00

Service Code	CPT 15271
Hospital Revenue Code	360
Min. Negotiated Rate	$393.00
Max. Negotiated Rate	$2,837.00
Rate for Payer: AlohaCare Medicaid	$873.10
Rate for Payer: AlohaCare Medicare	$873.10
Rate for Payer: Devoted Health Medicare	$960.41
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	$873.10
Rate for Payer: Hawaii Medical Service Association Non-ABD	$407.95
Rate for Payer: Humana Medicare	$873.10
Rate for Payer: Kaiser Permanente Medicaid	$2,837.00
Rate for Payer: Kaiser Permanente Medicare	$873.10
Rate for Payer: Ohana Health Plan Medicaid	$960.41
Rate for Payer: Ohana Health Plan Medicare	$873.10
Rate for Payer: UnitedHealthcare Medicaid	$456.03
Rate for Payer: UnitedHealthcare Medicare	$873.10

APPLICATION OF TOPICAL FLUORIDE VARNISH BY A PHYSICIAN OR OTHER QUALIFIED HEALTH CARE PROFESSIONAL

Facility

$2,837.00

Service Code	CPT 99188
Hospital Revenue Code	360
Min. Negotiated Rate	$9.90
Max. Negotiated Rate	$2,837.00
Rate for Payer: Kaiser Permanente Medicaid	$2,837.00
Rate for Payer: UnitedHealthcare Medicaid	$9.90

APPL ON-BODY INJECTOR FOR TIMED SUBQ INJECTION

Professional

Both

$58.00

Service Code	HCPCS 96377
Min. Negotiated Rate	$12.00
Max. Negotiated Rate	$49.30
Rate for Payer: AlohaCare Medicaid	$12.00
Rate for Payer: AlohaCare Medicare	$20.68
Rate for Payer: Cash Price	$37.70
Rate for Payer: Cash Price	$37.70
Rate for Payer: Devoted Health Medicare	$22.75
Rate for Payer: Hawaii Medical Service Association Medicare	$20.68
Rate for Payer: Hawaii Western Management Group Commercial	$22.84
Rate for Payer: Health Management Network Commercial	$49.30
Rate for Payer: Kaiser Permanente Commercial	$24.82
Rate for Payer: Kaiser Permanente Medicaid	$24.82
Rate for Payer: Kaiser Permanente Medicare	$24.82
Rate for Payer: Ohana Health Plan Medicaid	$12.00
Rate for Payer: Ohana Health Plan Medicare	$20.68
Rate for Payer: UnitedHealthcare Medicaid	$12.00
Rate for Payer: UnitedHealthcare Medicare	$20.68

APREPITANT 40 MG PO CAP

Facility

$468.24

Service Code	HCPCS J8501
Hospital Revenue Code	250
Min. Negotiated Rate	$398.00
Max. Negotiated Rate	$454.19
Rate for Payer: Cash Price	$304.36
Rate for Payer: Health Management Network Commercial	$398.00
Rate for Payer: MDX Hawaii PPO	$454.19

APREPITANT 40 MG PO CAP

Facility

$468.24

Service Code	HCPCS J8501
Hospital Revenue Code	636
Min. Negotiated Rate	$2.72
Max. Negotiated Rate	$454.19
Rate for Payer: Cash Price	$304.36
Rate for Payer: Cash Price	$304.36
Rate for Payer: Hawaii Medical Service Association ABD	$2.72
Rate for Payer: Hawaii Medical Service Association Non-ABD	$2.72
Rate for Payer: Hawaii Western Management Group Commercial	$444.83
Rate for Payer: Health Management Network Commercial	$398.00
Rate for Payer: Kaiser Permanente Commercial	$294.99
Rate for Payer: Kaiser Permanente Medicaid	$238.80
Rate for Payer: MDX Hawaii PPO	$454.19
Rate for Payer: UnitedHealthcare Medicaid	$280.94
Rate for Payer: University Health Alliance Commercial	$341.30

AR1922PBS Punch Disp for 4.5mm P-LCK/CRKSCRW FT [3641671]

Facility

$705.34

Hospital Charge Code	3641671
Hospital Revenue Code	272
Min. Negotiated Rate	$359.72
Max. Negotiated Rate	$684.18
Rate for Payer: Cash Price	$458.47
Rate for Payer: Hawaii Western Management Group Commercial	$670.07
Rate for Payer: Health Management Network Commercial	$599.54
Rate for Payer: Kaiser Permanente Commercial	$444.36
Rate for Payer: Kaiser Permanente Medicaid	$359.72
Rate for Payer: MDX Hawaii PPO	$684.18
Rate for Payer: University Health Alliance Commercial	$514.12

AR1922PBS Punch Disp for 4.5mm P-LCK/CRKSCRW FT [3641671]

Facility

$705.34

Hospital Charge Code	3641671
Hospital Revenue Code	272
Min. Negotiated Rate	$599.54
Max. Negotiated Rate	$684.18
Rate for Payer: Cash Price	$458.47
Rate for Payer: Health Management Network Commercial	$599.54
Rate for Payer: MDX Hawaii PPO	$684.18

AR1927BCT Biocomposite Corkscrew 5.5mm FT w/SutureTape [3641198]

Facility

$1,778.00

Service Code	HCPCS C1713
Hospital Charge Code	3641198
Hospital Revenue Code	278
Min. Negotiated Rate	$906.78
Max. Negotiated Rate	$1,724.66
Rate for Payer: Cash Price	$1,155.70
Rate for Payer: Hawaii Western Management Group Commercial	$1,244.60
Rate for Payer: Health Management Network Commercial	$1,511.30
Rate for Payer: Kaiser Permanente Commercial	$1,120.14
Rate for Payer: Kaiser Permanente Medicaid	$906.78
Rate for Payer: MDX Hawaii PPO	$1,724.66
Rate for Payer: University Health Alliance Commercial	$995.68

AR1927BCT Biocomposite Corkscrew 5.5mm FT w/SutureTape [3641198]

Facility

$1,778.00

Service Code	HCPCS C1713
Hospital Charge Code	3641198
Hospital Revenue Code	278
Min. Negotiated Rate	$995.68
Max. Negotiated Rate	$1,724.66
Rate for Payer: Cash Price	$1,155.70
Rate for Payer: Hawaii Western Management Group Commercial	$1,244.60
Rate for Payer: Health Management Network Commercial	$1,511.30
Rate for Payer: MDX Hawaii PPO	$1,724.66
Rate for Payer: University Health Alliance Commercial	$995.68

AR-7234 Fiberloop 2 [3602008]

Facility

$376.50

Hospital Charge Code	3602008
Hospital Revenue Code	272
Min. Negotiated Rate	$320.02
Max. Negotiated Rate	$365.20
Rate for Payer: Cash Price	$244.72
Rate for Payer: Health Management Network Commercial	$320.02
Rate for Payer: MDX Hawaii PPO	$365.20

AR-7234 Fiberloop 2 [3602008]

Facility

$376.50

Hospital Charge Code	3602008
Hospital Revenue Code	272
Min. Negotiated Rate	$192.01
Max. Negotiated Rate	$365.20
Rate for Payer: Cash Price	$244.72
Rate for Payer: Hawaii Western Management Group Commercial	$357.68
Rate for Payer: Health Management Network Commercial	$320.02
Rate for Payer: Kaiser Permanente Commercial	$237.19
Rate for Payer: Kaiser Permanente Medicaid	$192.01
Rate for Payer: MDX Hawaii PPO	$365.20
Rate for Payer: University Health Alliance Commercial	$274.43

ARGATROBAN 100 MG/ML IV SOLN

Facility

$1,298.76

Service Code	HCPCS J0883
Hospital Revenue Code	636
Min. Negotiated Rate	$0.74
Max. Negotiated Rate	$1,259.80
Rate for Payer: AlohaCare Medicaid	$1.01
Rate for Payer: AlohaCare Medicare	$1.01
Rate for Payer: Cash Price	$844.19
Rate for Payer: Cash Price	$844.19
Rate for Payer: Devoted Health Medicare	$1.11
Rate for Payer: Hawaii Medical Service Association ABD	$0.74
Rate for Payer: Hawaii Medical Service Association Commercial	$1.26
Rate for Payer: Hawaii Medical Service Association Medicare	$1.01
Rate for Payer: Hawaii Medical Service Association Non-ABD	$0.74
Rate for Payer: Hawaii Western Management Group Commercial	$1,233.82
Rate for Payer: Health Management Network Commercial	$1,103.95
Rate for Payer: Humana Medicare	$1.01
Rate for Payer: Kaiser Permanente Commercial	$818.22
Rate for Payer: Kaiser Permanente Medicaid	$662.37
Rate for Payer: Kaiser Permanente Medicare	$1.01
Rate for Payer: MDX Hawaii PPO	$1,259.80
Rate for Payer: Ohana Health Plan Medicaid	$1.11
Rate for Payer: Ohana Health Plan Medicare	$1.01
Rate for Payer: UnitedHealthcare Medicaid	$779.26
Rate for Payer: UnitedHealthcare Medicare	$1.01
Rate for Payer: University Health Alliance Commercial	$946.67

ARGATROBAN 100 MG/ML IV SOLN

Facility

$1,298.76

Service Code	HCPCS J0883
Hospital Revenue Code	250
Min. Negotiated Rate	$1,103.95
Max. Negotiated Rate	$1,259.80
Rate for Payer: Cash Price	$844.19
Rate for Payer: Health Management Network Commercial	$1,103.95
Rate for Payer: MDX Hawaii PPO	$1,259.80

ARGATROBAN IN 0.9 % SOD CHLOR 1 MG/ML IV SOLN

Facility

$651.05

Service Code	HCPCS J0883
Hospital Revenue Code	250
Min. Negotiated Rate	$553.39
Max. Negotiated Rate	$631.52
Rate for Payer: Cash Price	$423.18
Rate for Payer: Health Management Network Commercial	$553.39
Rate for Payer: MDX Hawaii PPO	$631.52

ARGATROBAN IN 0.9 % SOD CHLOR 1 MG/ML IV SOLN

Facility

$651.05

Service Code	HCPCS J0883
Hospital Revenue Code	636
Min. Negotiated Rate	$0.74
Max. Negotiated Rate	$631.52
Rate for Payer: AlohaCare Medicaid	$1.01
Rate for Payer: AlohaCare Medicare	$1.01
Rate for Payer: Cash Price	$423.18
Rate for Payer: Cash Price	$423.18
Rate for Payer: Devoted Health Medicare	$1.11
Rate for Payer: Hawaii Medical Service Association ABD	$0.74
Rate for Payer: Hawaii Medical Service Association Commercial	$1.26
Rate for Payer: Hawaii Medical Service Association Medicare	$1.01
Rate for Payer: Hawaii Medical Service Association Non-ABD	$0.74
Rate for Payer: Hawaii Western Management Group Commercial	$618.50
Rate for Payer: Health Management Network Commercial	$553.39
Rate for Payer: Humana Medicare	$1.01
Rate for Payer: Kaiser Permanente Commercial	$410.16
Rate for Payer: Kaiser Permanente Medicaid	$332.04
Rate for Payer: Kaiser Permanente Medicare	$1.01
Rate for Payer: MDX Hawaii PPO	$631.52
Rate for Payer: Ohana Health Plan Medicaid	$1.11
Rate for Payer: Ohana Health Plan Medicare	$1.01
Rate for Payer: UnitedHealthcare Medicaid	$390.63
Rate for Payer: UnitedHealthcare Medicare	$1.01
Rate for Payer: University Health Alliance Commercial	$474.55

ARIPIPRAZOLE 10 MG PO TABLET

Facility

$141.90

Service Code	HCPCS A9270
Hospital Revenue Code	250
Min. Negotiated Rate	$120.61
Max. Negotiated Rate	$137.64
Rate for Payer: Cash Price	$92.24
Rate for Payer: Cash Price	$97.81
Rate for Payer: Health Management Network Commercial	$120.61
Rate for Payer: Health Management Network Commercial	$127.91
Rate for Payer: MDX Hawaii PPO	$137.64
Rate for Payer: MDX Hawaii PPO	$145.97

ARIPIPRAZOLE 10 MG PO TABLET

Facility

$150.48

Service Code	HCPCS A9270
Hospital Revenue Code	250
Min. Negotiated Rate	$76.74
Max. Negotiated Rate	$145.97
Rate for Payer: Cash Price	$97.81
Rate for Payer: Cash Price	$92.24
Rate for Payer: Hawaii Western Management Group Commercial	$134.81
Rate for Payer: Hawaii Western Management Group Commercial	$142.96
Rate for Payer: Health Management Network Commercial	$120.61
Rate for Payer: Health Management Network Commercial	$127.91
Rate for Payer: Kaiser Permanente Commercial	$94.80
Rate for Payer: Kaiser Permanente Commercial	$89.40
Rate for Payer: Kaiser Permanente Medicaid	$76.74
Rate for Payer: Kaiser Permanente Medicaid	$72.37
Rate for Payer: MDX Hawaii PPO	$137.64
Rate for Payer: MDX Hawaii PPO	$145.97
Rate for Payer: UnitedHealthcare Medicaid	$85.14
Rate for Payer: UnitedHealthcare Medicaid	$90.29
Rate for Payer: University Health Alliance Commercial	$109.68
Rate for Payer: University Health Alliance Commercial	$103.43

ARIPIPRAZOLE 15 MG PO TABLET

Facility

$12.26

Service Code	HCPCS A9270
Hospital Revenue Code	250
Min. Negotiated Rate	$6.25
Max. Negotiated Rate	$11.89
Rate for Payer: Cash Price	$7.97
Rate for Payer: Cash Price	$97.81
Rate for Payer: Hawaii Western Management Group Commercial	$11.65
Rate for Payer: Hawaii Western Management Group Commercial	$142.96
Rate for Payer: Health Management Network Commercial	$10.42
Rate for Payer: Health Management Network Commercial	$127.91
Rate for Payer: Kaiser Permanente Commercial	$7.72
Rate for Payer: Kaiser Permanente Commercial	$94.80
Rate for Payer: Kaiser Permanente Medicaid	$6.25
Rate for Payer: Kaiser Permanente Medicaid	$76.74
Rate for Payer: MDX Hawaii PPO	$11.89
Rate for Payer: MDX Hawaii PPO	$145.97
Rate for Payer: UnitedHealthcare Medicaid	$90.29
Rate for Payer: UnitedHealthcare Medicaid	$7.36
Rate for Payer: University Health Alliance Commercial	$8.94
Rate for Payer: University Health Alliance Commercial	$109.68

ARIPIPRAZOLE 15 MG PO TABLET

Facility

$12.26

Service Code	HCPCS A9270
Hospital Revenue Code	250
Min. Negotiated Rate	$10.42
Max. Negotiated Rate	$11.89
Rate for Payer: Cash Price	$7.97
Rate for Payer: Cash Price	$97.81
Rate for Payer: Health Management Network Commercial	$127.91
Rate for Payer: Health Management Network Commercial	$10.42
Rate for Payer: MDX Hawaii PPO	$11.89
Rate for Payer: MDX Hawaii PPO	$145.97

ARIPIPRAZOLE 400 MG IM SERS

Facility

$4,603.73

Service Code	HCPCS J0401
Hospital Revenue Code	636
Min. Negotiated Rate	$7.24
Max. Negotiated Rate	$4,465.62
Rate for Payer: AlohaCare Medicare	$7.27
Rate for Payer: AlohaCare Medicaid	$7.27
Rate for Payer: Cash Price	$2,992.42
Rate for Payer: Cash Price	$2,992.42
Rate for Payer: Devoted Health Medicare	$8.00
Rate for Payer: Hawaii Medical Service Association ABD	$7.24
Rate for Payer: Hawaii Medical Service Association Commercial	$9.09
Rate for Payer: Hawaii Medical Service Association Medicare	$7.27
Rate for Payer: Hawaii Medical Service Association Non-ABD	$7.24
Rate for Payer: Hawaii Western Management Group Commercial	$4,373.54
Rate for Payer: Health Management Network Commercial	$3,913.17
Rate for Payer: Humana Medicare	$7.27
Rate for Payer: Kaiser Permanente Commercial	$2,900.35
Rate for Payer: Kaiser Permanente Medicaid	$2,347.90
Rate for Payer: Kaiser Permanente Medicare	$7.27
Rate for Payer: MDX Hawaii PPO	$4,465.62
Rate for Payer: Ohana Health Plan Medicaid	$8.00
Rate for Payer: Ohana Health Plan Medicare	$7.27
Rate for Payer: UnitedHealthcare Medicaid	$2,762.24
Rate for Payer: UnitedHealthcare Medicare	$7.27
Rate for Payer: University Health Alliance Commercial	$3,355.66

ARIPIPRAZOLE 400 MG IM SERS

Facility

$4,603.73

Service Code	HCPCS J0401
Hospital Revenue Code	250
Min. Negotiated Rate	$3,913.17
Max. Negotiated Rate	$4,465.62
Rate for Payer: Cash Price	$2,992.42
Rate for Payer: Health Management Network Commercial	$3,913.17
Rate for Payer: MDX Hawaii PPO	$4,465.62

ARIPIPRAZOLE 5 MG PO TABLET

Facility

$141.90

Service Code	HCPCS A9270
Hospital Revenue Code	250
Min. Negotiated Rate	$120.61
Max. Negotiated Rate	$137.64
Rate for Payer: Cash Price	$92.24
Rate for Payer: Cash Price	$97.83
Rate for Payer: Health Management Network Commercial	$120.61
Rate for Payer: Health Management Network Commercial	$127.93
Rate for Payer: MDX Hawaii PPO	$137.64
Rate for Payer: MDX Hawaii PPO	$145.99

Know your out-of-pocket cost for care.

All Charges