Kona Community Hospital

All Charges

Charge

Type

Setting

Price

INSULIN REGULAR HUMAN 100 UNIT/ML (FOR IV DRIPS) SOLN

Facility

$202.69

Service Code	HCPCS J1815
Hospital Revenue Code	250
Min. Negotiated Rate	$172.29
Max. Negotiated Rate	$196.61
Rate for Payer: Cash Price	$131.75
Rate for Payer: Health Management Network Commercial	$172.29
Rate for Payer: MDX Hawaii PPO	$196.61

INSULIN REGULAR HUMAN 100 UNIT/ML (FOR IV DRIPS) SOLN

Facility

$202.69

Service Code	HCPCS J1815
Hospital Revenue Code	637
Min. Negotiated Rate	$0.90
Max. Negotiated Rate	$196.61
Rate for Payer: Cash Price	$131.75
Rate for Payer: Cash Price	$131.75
Rate for Payer: Hawaii Medical Service Association ABD	$0.90
Rate for Payer: Hawaii Medical Service Association Non-ABD	$0.90
Rate for Payer: Hawaii Western Management Group Commercial	$192.56
Rate for Payer: Health Management Network Commercial	$172.29
Rate for Payer: Kaiser Permanente Commercial	$127.69
Rate for Payer: Kaiser Permanente Medicaid	$103.37
Rate for Payer: MDX Hawaii PPO	$196.61
Rate for Payer: University Health Alliance Commercial	$147.74

INSULIN REGULAR IN 0.9 % NACL 100 UNIT/100 ML (1 UNIT/ML) IV SOLN

Facility

$162.90

Service Code	HCPCS J3490
Hospital Revenue Code	250
Min. Negotiated Rate	$138.47
Max. Negotiated Rate	$158.01
Rate for Payer: Cash Price	$105.88
Rate for Payer: Health Management Network Commercial	$138.47
Rate for Payer: MDX Hawaii PPO	$158.01

INSULIN REGULAR IN 0.9 % NACL 100 UNIT/100 ML (1 UNIT/ML) IV SOLN

Facility

$162.90

Service Code	HCPCS J3490
Hospital Revenue Code	636
Min. Negotiated Rate	$83.08
Max. Negotiated Rate	$158.01
Rate for Payer: Cash Price	$105.88
Rate for Payer: Hawaii Western Management Group Commercial	$154.75
Rate for Payer: Health Management Network Commercial	$138.47
Rate for Payer: Kaiser Permanente Commercial	$102.63
Rate for Payer: Kaiser Permanente Medicaid	$83.08
Rate for Payer: MDX Hawaii PPO	$158.01
Rate for Payer: UnitedHealthcare Medicaid	$97.74
Rate for Payer: University Health Alliance Commercial	$118.74

INTENTIONAL SELF-HARM & ATTEMPTED SUICIDE

Facility

$4,155.78

Service Code	APR-DRG 8173
Min. Negotiated Rate	$4,155.78
Max. Negotiated Rate	$4,155.78
Rate for Payer: AlohaCare Medicaid	$4,155.78
Rate for Payer: Hawaii Medical Service Association ABD	$4,155.78
Rate for Payer: Hawaii Medical Service Association Non-ABD	$4,155.78
Rate for Payer: Kaiser Permanente Medicaid	$4,155.78
Rate for Payer: Ohana Health Plan Medicaid	$4,155.78
Rate for Payer: UnitedHealthcare Medicaid	$4,155.78

INTENTIONAL SELF-HARM & ATTEMPTED SUICIDE

Facility

$7,979.14

Service Code	APR-DRG 8174
Min. Negotiated Rate	$7,979.14
Max. Negotiated Rate	$7,979.14
Rate for Payer: AlohaCare Medicaid	$7,979.14
Rate for Payer: Hawaii Medical Service Association ABD	$7,979.14
Rate for Payer: Hawaii Medical Service Association Non-ABD	$7,979.14
Rate for Payer: Kaiser Permanente Medicaid	$7,979.14
Rate for Payer: Ohana Health Plan Medicaid	$7,979.14
Rate for Payer: UnitedHealthcare Medicaid	$7,979.14

INTENTIONAL SELF-HARM & ATTEMPTED SUICIDE

Facility

$2,047.32

Service Code	APR-DRG 8171
Min. Negotiated Rate	$2,047.32
Max. Negotiated Rate	$2,047.32
Rate for Payer: AlohaCare Medicaid	$2,047.32
Rate for Payer: Hawaii Medical Service Association ABD	$2,047.32
Rate for Payer: Hawaii Medical Service Association Non-ABD	$2,047.32
Rate for Payer: Kaiser Permanente Medicaid	$2,047.32
Rate for Payer: Ohana Health Plan Medicaid	$2,047.32
Rate for Payer: UnitedHealthcare Medicaid	$2,047.32

INTENTIONAL SELF-HARM & ATTEMPTED SUICIDE

Facility

$2,586.69

Service Code	APR-DRG 8172
Min. Negotiated Rate	$2,586.69
Max. Negotiated Rate	$2,586.69
Rate for Payer: AlohaCare Medicaid	$2,586.69
Rate for Payer: Hawaii Medical Service Association ABD	$2,586.69
Rate for Payer: Hawaii Medical Service Association Non-ABD	$2,586.69
Rate for Payer: Kaiser Permanente Medicaid	$2,586.69
Rate for Payer: Ohana Health Plan Medicaid	$2,586.69
Rate for Payer: UnitedHealthcare Medicaid	$2,586.69

Interceed 3X4 4350 [3602155]

Facility

$1,529.18

Service Code	HCPCS C1765
Hospital Charge Code	3602155
Hospital Revenue Code	278
Min. Negotiated Rate	$856.34
Max. Negotiated Rate	$1,483.30
Rate for Payer: Cash Price	$993.97
Rate for Payer: Hawaii Western Management Group Commercial	$1,070.43
Rate for Payer: Health Management Network Commercial	$1,299.80
Rate for Payer: MDX Hawaii PPO	$1,483.30
Rate for Payer: University Health Alliance Commercial	$856.34

Interceed 3X4 4350 [3602155]

Facility

$1,529.18

Service Code	HCPCS C1765
Hospital Charge Code	3602155
Hospital Revenue Code	278
Min. Negotiated Rate	$779.88
Max. Negotiated Rate	$1,483.30
Rate for Payer: Cash Price	$993.97
Rate for Payer: Hawaii Western Management Group Commercial	$1,070.43
Rate for Payer: Health Management Network Commercial	$1,299.80
Rate for Payer: Kaiser Permanente Commercial	$963.38
Rate for Payer: Kaiser Permanente Medicaid	$779.88
Rate for Payer: MDX Hawaii PPO	$1,483.30
Rate for Payer: University Health Alliance Commercial	$856.34

INTERSTITIAL & ALVEOLAR LUNG DISEASES

Facility

$3,226.68

Service Code	APR-DRG 1421
Min. Negotiated Rate	$3,226.68
Max. Negotiated Rate	$3,226.68
Rate for Payer: AlohaCare Medicaid	$3,226.68
Rate for Payer: Hawaii Medical Service Association ABD	$3,226.68
Rate for Payer: Hawaii Medical Service Association Non-ABD	$3,226.68
Rate for Payer: Kaiser Permanente Medicaid	$3,226.68
Rate for Payer: Ohana Health Plan Medicaid	$3,226.68
Rate for Payer: UnitedHealthcare Medicaid	$3,226.68

INTERSTITIAL & ALVEOLAR LUNG DISEASES

Facility

$3,760.32

Service Code	APR-DRG 1422
Min. Negotiated Rate	$3,760.32
Max. Negotiated Rate	$3,760.32
Rate for Payer: AlohaCare Medicaid	$3,760.32
Rate for Payer: Hawaii Medical Service Association ABD	$3,760.32
Rate for Payer: Hawaii Medical Service Association Non-ABD	$3,760.32
Rate for Payer: Kaiser Permanente Medicaid	$3,760.32
Rate for Payer: Ohana Health Plan Medicaid	$3,760.32
Rate for Payer: UnitedHealthcare Medicaid	$3,760.32

INTERSTITIAL & ALVEOLAR LUNG DISEASES

Facility

$5,076.59

Service Code	APR-DRG 1423
Min. Negotiated Rate	$5,076.59
Max. Negotiated Rate	$5,076.59
Rate for Payer: AlohaCare Medicaid	$5,076.59
Rate for Payer: Hawaii Medical Service Association ABD	$5,076.59
Rate for Payer: Hawaii Medical Service Association Non-ABD	$5,076.59
Rate for Payer: Kaiser Permanente Medicaid	$5,076.59
Rate for Payer: Ohana Health Plan Medicaid	$5,076.59
Rate for Payer: UnitedHealthcare Medicaid	$5,076.59

INTERSTITIAL & ALVEOLAR LUNG DISEASES

Facility

$7,504.09

Service Code	APR-DRG 1424
Min. Negotiated Rate	$7,504.09
Max. Negotiated Rate	$7,504.09
Rate for Payer: AlohaCare Medicaid	$7,504.09
Rate for Payer: Hawaii Medical Service Association ABD	$7,504.09
Rate for Payer: Hawaii Medical Service Association Non-ABD	$7,504.09
Rate for Payer: Kaiser Permanente Medicaid	$7,504.09
Rate for Payer: Ohana Health Plan Medicaid	$7,504.09
Rate for Payer: UnitedHealthcare Medicaid	$7,504.09

INTERSTITIAL LUNG DISEASE WITH CC

Facility

$34,979.26

Service Code	MSDRG 197
Min. Negotiated Rate	$12,483.30
Max. Negotiated Rate	$34,979.26
Rate for Payer: AlohaCare Medicare	$12,483.30
Rate for Payer: Devoted Health Medicare	$13,731.63
Rate for Payer: Hawaii Medical Service Association Commercial	$34,979.26
Rate for Payer: Hawaii Medical Service Association Medicare	$12,483.30
Rate for Payer: Humana Medicare	$12,483.30
Rate for Payer: Kaiser Permanente Commercial	$16,371.98
Rate for Payer: Kaiser Permanente Medicare	$12,483.30
Rate for Payer: Ohana Health Plan Medicare	$12,483.30
Rate for Payer: UnitedHealthcare Medicare	$12,483.30

INTERSTITIAL LUNG DISEASE WITH MCC

Facility

$34,979.26

Service Code	MSDRG 196
Min. Negotiated Rate	$24,821.90
Max. Negotiated Rate	$34,979.26
Rate for Payer: AlohaCare Medicare	$24,821.90
Rate for Payer: Devoted Health Medicare	$27,304.09
Rate for Payer: Hawaii Medical Service Association Commercial	$34,979.26
Rate for Payer: Hawaii Medical Service Association Medicare	$24,821.90
Rate for Payer: Humana Medicare	$24,821.90
Rate for Payer: Kaiser Permanente Commercial	$32,554.20
Rate for Payer: Kaiser Permanente Medicare	$24,821.90
Rate for Payer: Ohana Health Plan Medicare	$24,821.90
Rate for Payer: UnitedHealthcare Medicare	$24,821.90

INTERSTITIAL LUNG DISEASE WITHOUT CC/MCC

Facility

$34,979.26

Service Code	MSDRG 198
Min. Negotiated Rate	$9,420.00
Max. Negotiated Rate	$34,979.26
Rate for Payer: AlohaCare Medicare	$9,420.00
Rate for Payer: Devoted Health Medicare	$10,362.00
Rate for Payer: Hawaii Medical Service Association Commercial	$34,979.26
Rate for Payer: Hawaii Medical Service Association Medicare	$9,420.00
Rate for Payer: Humana Medicare	$9,420.00
Rate for Payer: Kaiser Permanente Commercial	$12,354.45
Rate for Payer: Kaiser Permanente Medicare	$9,420.00
Rate for Payer: Ohana Health Plan Medicare	$9,420.00
Rate for Payer: UnitedHealthcare Medicare	$9,420.00

INTERVERTEBRAL DISC EXCISION & DECOMPRESSION

Facility

$9,240.01

Service Code	APR-DRG 3103
Min. Negotiated Rate	$9,240.01
Max. Negotiated Rate	$9,240.01
Rate for Payer: AlohaCare Medicaid	$9,240.01
Rate for Payer: Hawaii Medical Service Association ABD	$9,240.01
Rate for Payer: Hawaii Medical Service Association Non-ABD	$9,240.01
Rate for Payer: Kaiser Permanente Medicaid	$9,240.01
Rate for Payer: Ohana Health Plan Medicaid	$9,240.01
Rate for Payer: UnitedHealthcare Medicaid	$9,240.01

INTERVERTEBRAL DISC EXCISION & DECOMPRESSION

Facility

$6,892.12

Service Code	APR-DRG 3102
Min. Negotiated Rate	$6,892.12
Max. Negotiated Rate	$6,892.12
Rate for Payer: AlohaCare Medicaid	$6,892.12
Rate for Payer: Hawaii Medical Service Association ABD	$6,892.12
Rate for Payer: Hawaii Medical Service Association Non-ABD	$6,892.12
Rate for Payer: Kaiser Permanente Medicaid	$6,892.12
Rate for Payer: Ohana Health Plan Medicaid	$6,892.12
Rate for Payer: UnitedHealthcare Medicaid	$6,892.12

INTERVERTEBRAL DISC EXCISION & DECOMPRESSION

Facility

$17,578.95

Service Code	APR-DRG 3104
Min. Negotiated Rate	$17,578.95
Max. Negotiated Rate	$17,578.95
Rate for Payer: AlohaCare Medicaid	$17,578.95
Rate for Payer: Hawaii Medical Service Association ABD	$17,578.95
Rate for Payer: Hawaii Medical Service Association Non-ABD	$17,578.95
Rate for Payer: Kaiser Permanente Medicaid	$17,578.95
Rate for Payer: Ohana Health Plan Medicaid	$17,578.95
Rate for Payer: UnitedHealthcare Medicaid	$17,578.95

INTERVERTEBRAL DISC EXCISION & DECOMPRESSION

Facility

$5,540.19

Service Code	APR-DRG 3101
Min. Negotiated Rate	$5,540.19
Max. Negotiated Rate	$5,540.19
Rate for Payer: AlohaCare Medicaid	$5,540.19
Rate for Payer: Hawaii Medical Service Association ABD	$5,540.19
Rate for Payer: Hawaii Medical Service Association Non-ABD	$5,540.19
Rate for Payer: Kaiser Permanente Medicaid	$5,540.19
Rate for Payer: Ohana Health Plan Medicaid	$5,540.19
Rate for Payer: UnitedHealthcare Medicaid	$5,540.19

INTESTINAL OBSTRUCTION

Facility

$3,278.26

Service Code	APR-DRG 2472
Min. Negotiated Rate	$3,278.26
Max. Negotiated Rate	$3,278.26
Rate for Payer: AlohaCare Medicaid	$3,278.26
Rate for Payer: Hawaii Medical Service Association ABD	$3,278.26
Rate for Payer: Hawaii Medical Service Association Non-ABD	$3,278.26
Rate for Payer: Kaiser Permanente Medicaid	$3,278.26
Rate for Payer: Ohana Health Plan Medicaid	$3,278.26
Rate for Payer: UnitedHealthcare Medicaid	$3,278.26

INTESTINAL OBSTRUCTION

Facility

$4,962.61

Service Code	APR-DRG 2473
Min. Negotiated Rate	$4,962.61
Max. Negotiated Rate	$4,962.61
Rate for Payer: AlohaCare Medicaid	$4,962.61
Rate for Payer: Hawaii Medical Service Association ABD	$4,962.61
Rate for Payer: Hawaii Medical Service Association Non-ABD	$4,962.61
Rate for Payer: Kaiser Permanente Medicaid	$4,962.61
Rate for Payer: Ohana Health Plan Medicaid	$4,962.61
Rate for Payer: UnitedHealthcare Medicaid	$4,962.61

INTESTINAL OBSTRUCTION

Facility

$2,530.66

Service Code	APR-DRG 2471
Min. Negotiated Rate	$2,530.66
Max. Negotiated Rate	$2,530.66
Rate for Payer: AlohaCare Medicaid	$2,530.66
Rate for Payer: Hawaii Medical Service Association ABD	$2,530.66
Rate for Payer: Hawaii Medical Service Association Non-ABD	$2,530.66
Rate for Payer: Kaiser Permanente Medicaid	$2,530.66
Rate for Payer: Ohana Health Plan Medicaid	$2,530.66
Rate for Payer: UnitedHealthcare Medicaid	$2,530.66

INTESTINAL OBSTRUCTION

Facility

$8,749.04

Service Code	APR-DRG 2474
Min. Negotiated Rate	$8,749.04
Max. Negotiated Rate	$8,749.04
Rate for Payer: AlohaCare Medicaid	$8,749.04
Rate for Payer: Hawaii Medical Service Association ABD	$8,749.04
Rate for Payer: Hawaii Medical Service Association Non-ABD	$8,749.04
Rate for Payer: Kaiser Permanente Medicaid	$8,749.04
Rate for Payer: Ohana Health Plan Medicaid	$8,749.04
Rate for Payer: UnitedHealthcare Medicaid	$8,749.04

Know your out-of-pocket cost for care.

All Charges