Kona Community Hospital

All Charges

Charge

Type

Setting

Price

INCISION AND DRAINAGE OF ABSCESS (EG, CARBUNCLE, SUPPURATIVE HIDRADENITIS, CUTANEOUS OR SUBCUTANEOUS ABSCESS, CYST, FURUNCLE, OR PARONYCHIA); SIMPLE OR SINGLE

Facility

$4,035.20

Service Code	CPT 10060
Hospital Revenue Code	360
Min. Negotiated Rate	$52.42
Max. Negotiated Rate	$4,035.20
Rate for Payer: AlohaCare Medicaid	$237.02
Rate for Payer: AlohaCare Medicare	$237.02
Rate for Payer: Devoted Health Medicare	$260.72
Rate for Payer: Hawaii Medical Service Association Commercial	$296.27
Rate for Payer: Hawaii Medical Service Association Medicare	$237.02
Rate for Payer: Humana Medicare	$237.02
Rate for Payer: Kaiser Permanente Medicaid	$2,837.00
Rate for Payer: Kaiser Permanente Medicare	$237.02
Rate for Payer: Ohana Health Plan Medicaid	$260.72
Rate for Payer: Ohana Health Plan Medicare	$237.02
Rate for Payer: UnitedHealthcare Medicaid	$52.42
Rate for Payer: UnitedHealthcare Medicare	$237.02
Rate for Payer: University Health Alliance Commercial	$4,035.20

INCISION AND DRAINAGE OF HEMATOMA, SEROMA OR FLUID COLLECTION

Facility

$5,160.40

Service Code	CPT 10140
Hospital Revenue Code	360
Min. Negotiated Rate	$456.03
Max. Negotiated Rate	$5,160.40
Rate for Payer: AlohaCare Medicaid	$1,951.11
Rate for Payer: AlohaCare Medicare	$1,951.11
Rate for Payer: Devoted Health Medicare	$2,146.22
Rate for Payer: Hawaii Medical Service Association Commercial	$2,438.89
Rate for Payer: Hawaii Medical Service Association Medicare	$1,951.11
Rate for Payer: Humana Medicare	$1,951.11
Rate for Payer: Kaiser Permanente Medicaid	$2,837.00
Rate for Payer: Kaiser Permanente Medicare	$1,951.11
Rate for Payer: Ohana Health Plan Medicaid	$2,146.22
Rate for Payer: Ohana Health Plan Medicare	$1,951.11
Rate for Payer: UnitedHealthcare Medicaid	$456.03
Rate for Payer: UnitedHealthcare Medicare	$1,951.11
Rate for Payer: University Health Alliance Commercial	$5,160.40

INCISION AND DRAINAGE OF ISCHIORECTAL AND/OR PERIRECTAL ABSCESS (SEPARATE PROCEDURE)

Facility

$6,743.44

Service Code	CPT 46040
Hospital Revenue Code	360
Min. Negotiated Rate	$456.03
Max. Negotiated Rate	$6,743.44
Rate for Payer: AlohaCare Medicaid	$1,413.65
Rate for Payer: AlohaCare Medicare	$1,413.65
Rate for Payer: Devoted Health Medicare	$1,555.02
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	$1,413.65
Rate for Payer: Hawaii Medical Service Association Non-ABD	$700.72
Rate for Payer: Humana Medicare	$1,413.65
Rate for Payer: Kaiser Permanente Medicaid	$2,837.00
Rate for Payer: Kaiser Permanente Medicare	$1,413.65
Rate for Payer: Ohana Health Plan Medicaid	$1,555.02
Rate for Payer: Ohana Health Plan Medicare	$1,413.65
Rate for Payer: UnitedHealthcare Medicaid	$456.03
Rate for Payer: UnitedHealthcare Medicare	$1,413.65
Rate for Payer: University Health Alliance Commercial	$6,743.44

INCISION AND DRAINAGE, PERIANAL ABSCESS, SUPERFICIAL

Facility

$2,837.00

Service Code	CPT 46050
Hospital Revenue Code	360
Min. Negotiated Rate	$340.18
Max. Negotiated Rate	$2,837.00
Rate for Payer: AlohaCare Medicaid	$1,098.60
Rate for Payer: AlohaCare Medicare	$1,098.60
Rate for Payer: Devoted Health Medicare	$1,208.46
Rate for Payer: Hawaii Medical Service Association Commercial	$1,373.25
Rate for Payer: Hawaii Medical Service Association Medicare	$1,098.60
Rate for Payer: Humana Medicare	$1,098.60
Rate for Payer: Kaiser Permanente Medicaid	$2,837.00
Rate for Payer: Kaiser Permanente Medicare	$1,098.60
Rate for Payer: Ohana Health Plan Medicaid	$1,208.46
Rate for Payer: Ohana Health Plan Medicare	$1,098.60
Rate for Payer: UnitedHealthcare Medicaid	$340.18
Rate for Payer: UnitedHealthcare Medicare	$1,098.60

INCISION AND DRAINAGE, SHOULDER AREA; DEEP ABSCESS OR HEMATOMA

Facility

$4,035.20

Service Code	CPT 23030
Hospital Revenue Code	360
Min. Negotiated Rate	$393.00
Max. Negotiated Rate	$4,035.20
Rate for Payer: AlohaCare Medicaid	$3,431.47
Rate for Payer: AlohaCare Medicare	$3,431.47
Rate for Payer: Devoted Health Medicare	$3,774.62
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	$3,431.47
Rate for Payer: Hawaii Medical Service Association Non-ABD	$407.95
Rate for Payer: Humana Medicare	$3,431.47
Rate for Payer: Kaiser Permanente Medicaid	$2,837.00
Rate for Payer: Kaiser Permanente Medicare	$3,431.47
Rate for Payer: Ohana Health Plan Medicaid	$3,774.62
Rate for Payer: Ohana Health Plan Medicare	$3,431.47
Rate for Payer: UnitedHealthcare Medicaid	$456.03
Rate for Payer: UnitedHealthcare Medicare	$3,431.47
Rate for Payer: University Health Alliance Commercial	$4,035.20

INCISION AND DRAINAGE, UPPER ARM OR ELBOW AREA; DEEP ABSCESS OR HEMATOMA

Facility

$4,035.20

Service Code	CPT 23930
Hospital Revenue Code	360
Min. Negotiated Rate	$393.00
Max. Negotiated Rate	$4,035.20
Rate for Payer: AlohaCare Medicaid	$3,431.47
Rate for Payer: AlohaCare Medicare	$3,431.47
Rate for Payer: Devoted Health Medicare	$3,774.62
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	$3,431.47
Rate for Payer: Hawaii Medical Service Association Non-ABD	$407.95
Rate for Payer: Humana Medicare	$3,431.47
Rate for Payer: Kaiser Permanente Medicaid	$2,837.00
Rate for Payer: Kaiser Permanente Medicare	$3,431.47
Rate for Payer: Ohana Health Plan Medicaid	$3,774.62
Rate for Payer: Ohana Health Plan Medicare	$3,431.47
Rate for Payer: UnitedHealthcare Medicaid	$456.03
Rate for Payer: UnitedHealthcare Medicare	$3,431.47
Rate for Payer: University Health Alliance Commercial	$4,035.20

INDIGOTINDISULFONATE SODIUM 8 MG/ML (0.8 %) IV SOLN

Facility

$1,236.48

Service Code	HCPCS J9220
Hospital Revenue Code	636
Min. Negotiated Rate	$9.30
Max. Negotiated Rate	$1,199.39
Rate for Payer: AlohaCare Medicaid	$9.30
Rate for Payer: AlohaCare Medicare	$9.30
Rate for Payer: Cash Price	$803.71
Rate for Payer: Cash Price	$803.71
Rate for Payer: Devoted Health Medicare	$10.23
Rate for Payer: Hawaii Medical Service Association Commercial	$11.62
Rate for Payer: Hawaii Medical Service Association Medicare	$9.30
Rate for Payer: Hawaii Western Management Group Commercial	$1,174.66
Rate for Payer: Health Management Network Commercial	$1,051.01
Rate for Payer: Humana Medicare	$9.30
Rate for Payer: Kaiser Permanente Commercial	$778.98
Rate for Payer: Kaiser Permanente Medicaid	$630.60
Rate for Payer: Kaiser Permanente Medicare	$9.30
Rate for Payer: MDX Hawaii PPO	$1,199.39
Rate for Payer: Ohana Health Plan Medicaid	$10.23
Rate for Payer: Ohana Health Plan Medicare	$9.30
Rate for Payer: UnitedHealthcare Medicaid	$741.89
Rate for Payer: UnitedHealthcare Medicare	$9.30
Rate for Payer: University Health Alliance Commercial	$901.27

INDIGOTINDISULFONATE SODIUM 8 MG/ML (0.8 %) IV SOLN

Facility

$1,236.48

Service Code	HCPCS J9220
Hospital Revenue Code	250
Min. Negotiated Rate	$1,051.01
Max. Negotiated Rate	$1,199.39
Rate for Payer: Cash Price	$803.71
Rate for Payer: Health Management Network Commercial	$1,051.01
Rate for Payer: MDX Hawaii PPO	$1,199.39

INDOCYANINE GREEN 25 MG INJ RECON.SOLN.

Facility

$768.74

Service Code	NDC 70100042402
Hospital Revenue Code	250
Min. Negotiated Rate	$392.06
Max. Negotiated Rate	$745.68
Rate for Payer: Cash Price	$499.68
Rate for Payer: Hawaii Western Management Group Commercial	$730.30
Rate for Payer: Health Management Network Commercial	$653.43
Rate for Payer: Kaiser Permanente Commercial	$484.31
Rate for Payer: Kaiser Permanente Medicaid	$392.06
Rate for Payer: MDX Hawaii PPO	$745.68
Rate for Payer: UnitedHealthcare Medicaid	$461.24
Rate for Payer: University Health Alliance Commercial	$560.33

INDOCYANINE GREEN 25 MG INJ RECON.SOLN.

Facility

$768.74

Service Code	NDC 70100042401
Hospital Revenue Code	250
Min. Negotiated Rate	$653.43
Max. Negotiated Rate	$745.68
Rate for Payer: Cash Price	$499.68
Rate for Payer: Health Management Network Commercial	$653.43
Rate for Payer: MDX Hawaii PPO	$745.68

INDOCYANINE GREEN 25 MG INJ RECON.SOLN.

Facility

$768.74

Service Code	NDC 70100042401
Hospital Revenue Code	250
Min. Negotiated Rate	$392.06
Max. Negotiated Rate	$745.68
Rate for Payer: Cash Price	$499.68
Rate for Payer: Hawaii Western Management Group Commercial	$730.30
Rate for Payer: Health Management Network Commercial	$653.43
Rate for Payer: Kaiser Permanente Commercial	$484.31
Rate for Payer: Kaiser Permanente Medicaid	$392.06
Rate for Payer: MDX Hawaii PPO	$745.68
Rate for Payer: UnitedHealthcare Medicaid	$461.24
Rate for Payer: University Health Alliance Commercial	$560.33

INDOCYANINE GREEN 25 MG INJ RECON.SOLN.

Facility

$768.74

Service Code	NDC 70100042402
Hospital Revenue Code	250
Min. Negotiated Rate	$653.43
Max. Negotiated Rate	$745.68
Rate for Payer: Cash Price	$499.68
Rate for Payer: Health Management Network Commercial	$653.43
Rate for Payer: MDX Hawaii PPO	$745.68

INDOMETHACIN 25 MG PO CAP

Facility

$2.38

Service Code	HCPCS A9270
Hospital Revenue Code	250
Min. Negotiated Rate	$2.02
Max. Negotiated Rate	$2.31
Rate for Payer: Cash Price	$1.55
Rate for Payer: Cash Price	$1.44
Rate for Payer: Health Management Network Commercial	$1.89
Rate for Payer: Health Management Network Commercial	$2.02
Rate for Payer: MDX Hawaii PPO	$2.31
Rate for Payer: MDX Hawaii PPO	$2.15

INDOMETHACIN 25 MG PO CAP

Facility

$2.22

Service Code	HCPCS A9270
Hospital Revenue Code	250
Min. Negotiated Rate	$1.13
Max. Negotiated Rate	$2.15
Rate for Payer: Cash Price	$1.44
Rate for Payer: Cash Price	$1.55
Rate for Payer: Hawaii Western Management Group Commercial	$2.11
Rate for Payer: Hawaii Western Management Group Commercial	$2.26
Rate for Payer: Health Management Network Commercial	$1.89
Rate for Payer: Health Management Network Commercial	$2.02
Rate for Payer: Kaiser Permanente Commercial	$1.40
Rate for Payer: Kaiser Permanente Commercial	$1.50
Rate for Payer: Kaiser Permanente Medicaid	$1.13
Rate for Payer: Kaiser Permanente Medicaid	$1.21
Rate for Payer: MDX Hawaii PPO	$2.15
Rate for Payer: MDX Hawaii PPO	$2.31
Rate for Payer: UnitedHealthcare Medicaid	$1.43
Rate for Payer: UnitedHealthcare Medicaid	$1.33
Rate for Payer: University Health Alliance Commercial	$1.62
Rate for Payer: University Health Alliance Commercial	$1.73

INDOMETHACIN 50 MG PO CAP

Facility

$3.64

Service Code	HCPCS A9270
Hospital Revenue Code	250
Min. Negotiated Rate	$3.09
Max. Negotiated Rate	$3.53
Rate for Payer: Cash Price	$2.37
Rate for Payer: Health Management Network Commercial	$3.09
Rate for Payer: MDX Hawaii PPO	$3.53

INDOMETHACIN 50 MG PO CAP

Facility

$3.64

Service Code	HCPCS A9270
Hospital Revenue Code	250
Min. Negotiated Rate	$1.86
Max. Negotiated Rate	$3.53
Rate for Payer: Cash Price	$2.37
Rate for Payer: Hawaii Western Management Group Commercial	$3.46
Rate for Payer: Health Management Network Commercial	$3.09
Rate for Payer: Kaiser Permanente Commercial	$2.29
Rate for Payer: Kaiser Permanente Medicaid	$1.86
Rate for Payer: MDX Hawaii PPO	$3.53
Rate for Payer: UnitedHealthcare Medicaid	$2.18
Rate for Payer: University Health Alliance Commercial	$2.65

INFECTIONS, FEMALE REPRODUCTIVE SYSTEM WITH CC

Facility

$16,887.75

Service Code	MSDRG 758
Min. Negotiated Rate	$12,876.56
Max. Negotiated Rate	$16,887.75
Rate for Payer: AlohaCare Medicare	$12,876.56
Rate for Payer: Devoted Health Medicare	$14,164.22
Rate for Payer: Hawaii Medical Service Association Commercial	$13,885.63
Rate for Payer: Hawaii Medical Service Association Medicare	$12,876.56
Rate for Payer: Humana Medicare	$12,876.56
Rate for Payer: Kaiser Permanente Commercial	$16,887.75
Rate for Payer: Kaiser Permanente Medicare	$12,876.56
Rate for Payer: Ohana Health Plan Medicare	$12,876.56
Rate for Payer: UnitedHealthcare Medicare	$12,876.56

INFECTIONS, FEMALE REPRODUCTIVE SYSTEM WITH MCC

Facility

$24,700.28

Service Code	MSDRG 757
Min. Negotiated Rate	$13,885.63
Max. Negotiated Rate	$24,700.28
Rate for Payer: AlohaCare Medicare	$18,833.45
Rate for Payer: Devoted Health Medicare	$20,716.79
Rate for Payer: Hawaii Medical Service Association Commercial	$13,885.63
Rate for Payer: Hawaii Medical Service Association Medicare	$18,833.45
Rate for Payer: Humana Medicare	$18,833.45
Rate for Payer: Kaiser Permanente Commercial	$24,700.28
Rate for Payer: Kaiser Permanente Medicare	$18,833.45
Rate for Payer: Ohana Health Plan Medicare	$18,833.45
Rate for Payer: UnitedHealthcare Medicare	$18,833.45

INFECTIONS, FEMALE REPRODUCTIVE SYSTEM WITHOUT CC/MCC

Facility

$13,885.63

Service Code	MSDRG 759
Min. Negotiated Rate	$8,728.18
Max. Negotiated Rate	$13,885.63
Rate for Payer: AlohaCare Medicare	$8,728.18
Rate for Payer: Devoted Health Medicare	$9,601.00
Rate for Payer: Hawaii Medical Service Association Commercial	$13,885.63
Rate for Payer: Hawaii Medical Service Association Medicare	$8,728.18
Rate for Payer: Humana Medicare	$8,728.18
Rate for Payer: Kaiser Permanente Commercial	$11,447.10
Rate for Payer: Kaiser Permanente Medicare	$8,728.18
Rate for Payer: Ohana Health Plan Medicare	$8,728.18
Rate for Payer: UnitedHealthcare Medicare	$8,728.18

INFECTIONS OF UPPER RESPIRATORY TRACT

Facility

$1,742.93

Service Code	APR-DRG 1131
Min. Negotiated Rate	$1,742.93
Max. Negotiated Rate	$1,742.93
Rate for Payer: AlohaCare Medicaid	$1,742.93
Rate for Payer: Hawaii Medical Service Association ABD	$1,742.93
Rate for Payer: Hawaii Medical Service Association Non-ABD	$1,742.93
Rate for Payer: Kaiser Permanente Medicaid	$1,742.93
Rate for Payer: Ohana Health Plan Medicaid	$1,742.93
Rate for Payer: UnitedHealthcare Medicaid	$1,742.93

INFECTIONS OF UPPER RESPIRATORY TRACT

Facility

$6,838.63

Service Code	APR-DRG 1134
Min. Negotiated Rate	$6,838.63
Max. Negotiated Rate	$6,838.63
Rate for Payer: AlohaCare Medicaid	$6,838.63
Rate for Payer: Hawaii Medical Service Association ABD	$6,838.63
Rate for Payer: Hawaii Medical Service Association Non-ABD	$6,838.63
Rate for Payer: Kaiser Permanente Medicaid	$6,838.63
Rate for Payer: Ohana Health Plan Medicaid	$6,838.63
Rate for Payer: UnitedHealthcare Medicaid	$6,838.63

INFECTIONS OF UPPER RESPIRATORY TRACT

Facility

$3,707.47

Service Code	APR-DRG 1133
Min. Negotiated Rate	$3,707.47
Max. Negotiated Rate	$3,707.47
Rate for Payer: AlohaCare Medicaid	$3,707.47
Rate for Payer: Hawaii Medical Service Association ABD	$3,707.47
Rate for Payer: Hawaii Medical Service Association Non-ABD	$3,707.47
Rate for Payer: Kaiser Permanente Medicaid	$3,707.47
Rate for Payer: Ohana Health Plan Medicaid	$3,707.47
Rate for Payer: UnitedHealthcare Medicaid	$3,707.47

INFECTIONS OF UPPER RESPIRATORY TRACT

Facility

$2,483.53

Service Code	APR-DRG 1132
Min. Negotiated Rate	$2,483.53
Max. Negotiated Rate	$2,483.53
Rate for Payer: AlohaCare Medicaid	$2,483.53
Rate for Payer: Hawaii Medical Service Association ABD	$2,483.53
Rate for Payer: Hawaii Medical Service Association Non-ABD	$2,483.53
Rate for Payer: Kaiser Permanente Medicaid	$2,483.53
Rate for Payer: Ohana Health Plan Medicaid	$2,483.53
Rate for Payer: UnitedHealthcare Medicaid	$2,483.53

INFECTIOUS AND PARASITIC DISEASES WITH O.R. PROCEDURES WITH CC

Facility

$156,671.39

Service Code	MSDRG 854
Min. Negotiated Rate	$26,280.54
Max. Negotiated Rate	$156,671.39
Rate for Payer: AlohaCare Medicare	$26,280.54
Rate for Payer: Devoted Health Medicare	$28,908.59
Rate for Payer: Hawaii Medical Service Association Commercial	$156,671.39
Rate for Payer: Hawaii Medical Service Association Medicare	$26,280.54
Rate for Payer: Humana Medicare	$26,280.54
Rate for Payer: Kaiser Permanente Commercial	$34,467.22
Rate for Payer: Kaiser Permanente Medicare	$26,280.54
Rate for Payer: Ohana Health Plan Medicare	$26,280.54
Rate for Payer: UnitedHealthcare Medicare	$26,280.54

INFECTIOUS AND PARASITIC DISEASES WITH O.R. PROCEDURES WITH MCC

Facility

$156,671.39

Service Code	MSDRG 853
Min. Negotiated Rate	$64,956.26
Max. Negotiated Rate	$156,671.39
Rate for Payer: AlohaCare Medicare	$64,956.26
Rate for Payer: Devoted Health Medicare	$71,451.89
Rate for Payer: Hawaii Medical Service Association Commercial	$156,671.39
Rate for Payer: Hawaii Medical Service Association Medicare	$64,956.26
Rate for Payer: Humana Medicare	$64,956.26
Rate for Payer: Kaiser Permanente Commercial	$85,190.85
Rate for Payer: Kaiser Permanente Medicare	$64,956.26
Rate for Payer: Ohana Health Plan Medicare	$64,956.26
Rate for Payer: UnitedHealthcare Medicare	$64,956.26

Know your out-of-pocket cost for care.

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