Kona Community Hospital

All Charges

Charge

Type

Setting

Price

LITHIUM CARBONATE 300 MG PO CAP

Facility

$1.20

Service Code	HCPCS A9270
Hospital Revenue Code	250
Min. Negotiated Rate	$0.61
Max. Negotiated Rate	$1.16
Rate for Payer: Cash Price	$0.78
Rate for Payer: Cash Price	$1.32
Rate for Payer: Hawaii Western Management Group Commercial	$1.14
Rate for Payer: Hawaii Western Management Group Commercial	$1.93
Rate for Payer: Health Management Network Commercial	$1.02
Rate for Payer: Health Management Network Commercial	$1.73
Rate for Payer: Kaiser Permanente Commercial	$0.76
Rate for Payer: Kaiser Permanente Commercial	$1.28
Rate for Payer: Kaiser Permanente Medicaid	$0.61
Rate for Payer: Kaiser Permanente Medicaid	$1.04
Rate for Payer: MDX Hawaii PPO	$1.16
Rate for Payer: MDX Hawaii PPO	$1.97
Rate for Payer: UnitedHealthcare Medicaid	$1.22
Rate for Payer: UnitedHealthcare Medicaid	$0.72
Rate for Payer: University Health Alliance Commercial	$0.87
Rate for Payer: University Health Alliance Commercial	$1.48

LITHIUM CARBONATE 300 MG PO CAP

Facility

$2.03

Service Code	HCPCS A9270
Hospital Revenue Code	250
Min. Negotiated Rate	$1.73
Max. Negotiated Rate	$1.97
Rate for Payer: Cash Price	$1.32
Rate for Payer: Cash Price	$0.78
Rate for Payer: Health Management Network Commercial	$1.02
Rate for Payer: Health Management Network Commercial	$1.73
Rate for Payer: MDX Hawaii PPO	$1.97
Rate for Payer: MDX Hawaii PPO	$1.16

LITHIUM CARBONATE 300 MG PO TAB SR

Facility

$2.57

Service Code	HCPCS A9270
Hospital Revenue Code	250
Min. Negotiated Rate	$2.18
Max. Negotiated Rate	$2.49
Rate for Payer: Cash Price	$1.67
Rate for Payer: Cash Price	$1.79
Rate for Payer: Health Management Network Commercial	$2.35
Rate for Payer: Health Management Network Commercial	$2.18
Rate for Payer: MDX Hawaii PPO	$2.68
Rate for Payer: MDX Hawaii PPO	$2.49

LITHIUM CARBONATE 300 MG PO TAB SR

Facility

$2.57

Service Code	HCPCS A9270
Hospital Revenue Code	250
Min. Negotiated Rate	$1.31
Max. Negotiated Rate	$2.49
Rate for Payer: Cash Price	$1.67
Rate for Payer: Cash Price	$1.79
Rate for Payer: Hawaii Western Management Group Commercial	$2.44
Rate for Payer: Hawaii Western Management Group Commercial	$2.62
Rate for Payer: Health Management Network Commercial	$2.35
Rate for Payer: Health Management Network Commercial	$2.18
Rate for Payer: Kaiser Permanente Commercial	$1.62
Rate for Payer: Kaiser Permanente Commercial	$1.74
Rate for Payer: Kaiser Permanente Medicaid	$1.41
Rate for Payer: Kaiser Permanente Medicaid	$1.31
Rate for Payer: MDX Hawaii PPO	$2.68
Rate for Payer: MDX Hawaii PPO	$2.49
Rate for Payer: UnitedHealthcare Medicaid	$1.54
Rate for Payer: UnitedHealthcare Medicaid	$1.66
Rate for Payer: University Health Alliance Commercial	$2.01
Rate for Payer: University Health Alliance Commercial	$1.87

LITHIUM CARBONATE 450 MG PO TAB SR

Facility

$4.18

Service Code	HCPCS A9270
Hospital Revenue Code	250
Min. Negotiated Rate	$3.55
Max. Negotiated Rate	$4.05
Rate for Payer: Cash Price	$2.72
Rate for Payer: Health Management Network Commercial	$3.55
Rate for Payer: MDX Hawaii PPO	$4.05

LITHIUM CARBONATE 450 MG PO TAB SR

Facility

$4.18

Service Code	HCPCS A9270
Hospital Revenue Code	250
Min. Negotiated Rate	$2.13
Max. Negotiated Rate	$4.05
Rate for Payer: Cash Price	$2.72
Rate for Payer: Hawaii Western Management Group Commercial	$3.97
Rate for Payer: Health Management Network Commercial	$3.55
Rate for Payer: Kaiser Permanente Commercial	$2.63
Rate for Payer: Kaiser Permanente Medicaid	$2.13
Rate for Payer: MDX Hawaii PPO	$4.05
Rate for Payer: UnitedHealthcare Medicaid	$2.51
Rate for Payer: University Health Alliance Commercial	$3.05

Lithoclast Ultrasound Probe 3.8 x 403mm 68407170 [3640217]

Facility

$3,072.95

Hospital Charge Code	3640217
Hospital Revenue Code	272
Min. Negotiated Rate	$1,567.20
Max. Negotiated Rate	$2,980.76
Rate for Payer: Cash Price	$1,997.42
Rate for Payer: Hawaii Western Management Group Commercial	$2,919.30
Rate for Payer: Health Management Network Commercial	$2,612.01
Rate for Payer: Kaiser Permanente Commercial	$1,935.96
Rate for Payer: Kaiser Permanente Medicaid	$1,567.20
Rate for Payer: MDX Hawaii PPO	$2,980.76
Rate for Payer: University Health Alliance Commercial	$2,239.87

Lithoclast Ultrasound Probe 3.8 x 403mm 68407170 [3640217]

Facility

$3,072.95

Hospital Charge Code	3640217
Hospital Revenue Code	272
Min. Negotiated Rate	$2,612.01
Max. Negotiated Rate	$2,980.76
Rate for Payer: Cash Price	$1,997.42
Rate for Payer: Health Management Network Commercial	$2,612.01
Rate for Payer: MDX Hawaii PPO	$2,980.76

LITHOLAPAXY: CRUSHING OR FRAGMENTATION OF CALCULUS BY ANY MEANS IN BLADDER AND REMOVAL OF FRAGMENTS; COMPLICATED OR LARGE (OVER 2.5 CM)

Facility

$9,416.00

Service Code	CPT 52318
Hospital Revenue Code	360
Min. Negotiated Rate	$456.03
Max. Negotiated Rate	$9,416.00
Rate for Payer: AlohaCare Medicaid	$4,164.22
Rate for Payer: AlohaCare Medicare	$4,164.22
Rate for Payer: Devoted Health Medicare	$4,580.64
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	$4,164.22
Rate for Payer: Hawaii Medical Service Association Non-ABD	$849.21
Rate for Payer: Humana Medicare	$4,164.22
Rate for Payer: Kaiser Permanente Medicaid	$2,837.00
Rate for Payer: Kaiser Permanente Medicare	$4,164.22
Rate for Payer: Ohana Health Plan Medicaid	$4,580.64
Rate for Payer: Ohana Health Plan Medicare	$4,164.22
Rate for Payer: UnitedHealthcare Medicaid	$456.03
Rate for Payer: UnitedHealthcare Medicare	$4,164.22
Rate for Payer: University Health Alliance Commercial	$5,160.40

LITHOLAPAXY: CRUSHING OR FRAGMENTATION OF CALCULUS BY ANY MEANS IN BLADDER AND REMOVAL OF FRAGMENTS; SIMPLE OR SMALL (LESS THAN 2.5 CM)

Facility

$6,183.00

Service Code	CPT 52317
Hospital Revenue Code	360
Min. Negotiated Rate	$456.03
Max. Negotiated Rate	$6,183.00
Rate for Payer: AlohaCare Medicaid	$4,164.22
Rate for Payer: AlohaCare Medicare	$4,164.22
Rate for Payer: Devoted Health Medicare	$4,580.64
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	$4,164.22
Rate for Payer: Hawaii Medical Service Association Non-ABD	$700.72
Rate for Payer: Humana Medicare	$4,164.22
Rate for Payer: Kaiser Permanente Medicaid	$2,837.00
Rate for Payer: Kaiser Permanente Medicare	$4,164.22
Rate for Payer: Ohana Health Plan Medicaid	$4,580.64
Rate for Payer: Ohana Health Plan Medicare	$4,164.22
Rate for Payer: UnitedHealthcare Medicaid	$456.03
Rate for Payer: UnitedHealthcare Medicare	$4,164.22

LithoVue Disp Digital Flex Ureterscope 791360 [3642091]

Facility

$6,753.00

Service Code	HCPCS C1747
Hospital Charge Code	3642091
Hospital Revenue Code	272
Min. Negotiated Rate	$5,740.05
Max. Negotiated Rate	$6,550.41
Rate for Payer: Cash Price	$4,389.45
Rate for Payer: Health Management Network Commercial	$5,740.05
Rate for Payer: MDX Hawaii PPO	$6,550.41

LithoVue Disp Digital Flex Ureterscope 791360 [3642091]

Facility

$6,753.00

Service Code	HCPCS C1747
Hospital Charge Code	3642091
Hospital Revenue Code	272
Min. Negotiated Rate	$3,444.03
Max. Negotiated Rate	$6,550.41
Rate for Payer: Cash Price	$4,389.45
Rate for Payer: Hawaii Western Management Group Commercial	$6,415.35
Rate for Payer: Health Management Network Commercial	$5,740.05
Rate for Payer: Kaiser Permanente Commercial	$4,254.39
Rate for Payer: Kaiser Permanente Medicaid	$3,444.03
Rate for Payer: MDX Hawaii PPO	$6,550.41
Rate for Payer: University Health Alliance Commercial	$4,922.26

LIVER TRANSPLANT &/OR INTESTINAL TRANSPLANT

Facility

$40,215.38

Service Code	APR-DRG 0012
Min. Negotiated Rate	$40,215.38
Max. Negotiated Rate	$40,215.38
Rate for Payer: AlohaCare Medicaid	$40,215.38
Rate for Payer: Hawaii Medical Service Association ABD	$40,215.38
Rate for Payer: Hawaii Medical Service Association Non-ABD	$40,215.38
Rate for Payer: Kaiser Permanente Medicaid	$40,215.38
Rate for Payer: Ohana Health Plan Medicaid	$40,215.38
Rate for Payer: UnitedHealthcare Medicaid	$40,215.38

LIVER TRANSPLANT &/OR INTESTINAL TRANSPLANT

Facility

$39,941.56

Service Code	APR-DRG 0011
Min. Negotiated Rate	$39,941.56
Max. Negotiated Rate	$39,941.56
Rate for Payer: AlohaCare Medicaid	$39,941.56
Rate for Payer: Hawaii Medical Service Association ABD	$39,941.56
Rate for Payer: Hawaii Medical Service Association Non-ABD	$39,941.56
Rate for Payer: Kaiser Permanente Medicaid	$39,941.56
Rate for Payer: Ohana Health Plan Medicaid	$39,941.56
Rate for Payer: UnitedHealthcare Medicaid	$39,941.56

LIVER TRANSPLANT &/OR INTESTINAL TRANSPLANT

Facility

$48,734.53

Service Code	APR-DRG 0013
Min. Negotiated Rate	$48,734.53
Max. Negotiated Rate	$48,734.53
Rate for Payer: AlohaCare Medicaid	$48,734.53
Rate for Payer: Hawaii Medical Service Association ABD	$48,734.53
Rate for Payer: Hawaii Medical Service Association Non-ABD	$48,734.53
Rate for Payer: Kaiser Permanente Medicaid	$48,734.53
Rate for Payer: Ohana Health Plan Medicaid	$48,734.53
Rate for Payer: UnitedHealthcare Medicaid	$48,734.53

LIVER TRANSPLANT &/OR INTESTINAL TRANSPLANT

Facility

$80,677.85

Service Code	APR-DRG 0014
Min. Negotiated Rate	$80,677.85
Max. Negotiated Rate	$80,677.85
Rate for Payer: AlohaCare Medicaid	$80,677.85
Rate for Payer: Hawaii Medical Service Association ABD	$80,677.85
Rate for Payer: Hawaii Medical Service Association Non-ABD	$80,677.85
Rate for Payer: Kaiser Permanente Medicaid	$80,677.85
Rate for Payer: Ohana Health Plan Medicaid	$80,677.85
Rate for Payer: UnitedHealthcare Medicaid	$80,677.85

LIVER TRANSPLANT WITH MCC OR INTESTINAL TRANSPLANT

Facility

$364,738.91

Service Code	MSDRG 005
Min. Negotiated Rate	$10,400.00
Max. Negotiated Rate	$364,738.91
Rate for Payer: AlohaCare Medicare	$135,611.59
Rate for Payer: Devoted Health Medicare	$149,172.75
Rate for Payer: Hawaii Medical Service Association Commercial	$364,738.91
Rate for Payer: Hawaii Medical Service Association Medicare	$135,611.59
Rate for Payer: Kaiser Permanente Commercial	$177,856.12
Rate for Payer: Kaiser Permanente Medicare	$135,611.59
Rate for Payer: Ohana Health Plan Medicare	$135,611.59
Rate for Payer: UnitedHealthcare Medicare	$135,611.59
Rate for Payer: University Health Alliance Commercial	$10,400.00

LIVER TRANSPLANT WITHOUT MCC

Facility

$364,738.91

Service Code	MSDRG 006
Min. Negotiated Rate	$10,400.00
Max. Negotiated Rate	$364,738.91
Rate for Payer: AlohaCare Medicare	$60,989.38
Rate for Payer: Devoted Health Medicare	$67,088.32
Rate for Payer: Hawaii Medical Service Association Commercial	$364,738.91
Rate for Payer: Hawaii Medical Service Association Medicare	$60,989.38
Rate for Payer: Kaiser Permanente Commercial	$79,988.25
Rate for Payer: Kaiser Permanente Medicare	$60,989.38
Rate for Payer: Ohana Health Plan Medicare	$60,989.38
Rate for Payer: UnitedHealthcare Medicare	$60,989.38
Rate for Payer: University Health Alliance Commercial	$10,400.00

LOCAL EXCISION AND REMOVAL OF INTERNAL FIXATION DEVICES EXCEPT HIP AND FEMUR WITH CC

Facility

$36,160.50

Service Code	MSDRG 496
Min. Negotiated Rate	$23,726.27
Max. Negotiated Rate	$36,160.50
Rate for Payer: AlohaCare Medicare	$23,726.27
Rate for Payer: Devoted Health Medicare	$26,098.90
Rate for Payer: Hawaii Medical Service Association Commercial	$36,160.50
Rate for Payer: Hawaii Medical Service Association Medicare	$23,726.27
Rate for Payer: Humana Medicare	$23,726.27
Rate for Payer: Kaiser Permanente Commercial	$31,117.28
Rate for Payer: Kaiser Permanente Medicare	$23,726.27
Rate for Payer: Ohana Health Plan Medicare	$23,726.27
Rate for Payer: UnitedHealthcare Medicare	$23,726.27

LOCAL EXCISION AND REMOVAL OF INTERNAL FIXATION DEVICES EXCEPT HIP AND FEMUR WITH MCC

Facility

$62,543.32

Service Code	MSDRG 495
Min. Negotiated Rate	$38,932.81
Max. Negotiated Rate	$62,543.32
Rate for Payer: AlohaCare Medicare	$47,687.98
Rate for Payer: Devoted Health Medicare	$52,456.78
Rate for Payer: Hawaii Medical Service Association Commercial	$38,932.81
Rate for Payer: Hawaii Medical Service Association Medicare	$47,687.98
Rate for Payer: Humana Medicare	$47,687.98
Rate for Payer: Kaiser Permanente Commercial	$62,543.32
Rate for Payer: Kaiser Permanente Medicare	$47,687.98
Rate for Payer: Ohana Health Plan Medicare	$47,687.98
Rate for Payer: UnitedHealthcare Medicare	$47,687.98

LOCAL EXCISION AND REMOVAL OF INTERNAL FIXATION DEVICES EXCEPT HIP AND FEMUR WITHOUT CC/MCC

Facility

$25,095.39

Service Code	MSDRG 497
Min. Negotiated Rate	$15,892.50
Max. Negotiated Rate	$25,095.39
Rate for Payer: AlohaCare Medicare	$15,892.50
Rate for Payer: Devoted Health Medicare	$17,481.75
Rate for Payer: Hawaii Medical Service Association Commercial	$25,095.39
Rate for Payer: Hawaii Medical Service Association Medicare	$15,892.50
Rate for Payer: Humana Medicare	$15,892.50
Rate for Payer: Kaiser Permanente Commercial	$19,866.83
Rate for Payer: Kaiser Permanente Medicare	$15,892.50
Rate for Payer: Ohana Health Plan Medicare	$15,892.50
Rate for Payer: UnitedHealthcare Medicare	$15,892.50

LOCAL EXCISION AND REMOVAL OF INTERNAL FIXATION DEVICES OF HIP AND FEMUR WITH CC/MCC

Facility

$52,039.80

Service Code	MSDRG 498
Min. Negotiated Rate	$39,679.26
Max. Negotiated Rate	$52,039.80
Rate for Payer: AlohaCare Medicare	$39,679.26
Rate for Payer: Devoted Health Medicare	$43,647.19
Rate for Payer: Hawaii Medical Service Association Commercial	$43,705.99
Rate for Payer: Hawaii Medical Service Association Medicare	$39,679.26
Rate for Payer: Humana Medicare	$39,679.26
Rate for Payer: Kaiser Permanente Commercial	$52,039.80
Rate for Payer: Kaiser Permanente Medicare	$39,679.26
Rate for Payer: Ohana Health Plan Medicare	$39,679.26
Rate for Payer: UnitedHealthcare Medicare	$39,679.26

LOCAL EXCISION AND REMOVAL OF INTERNAL FIXATION DEVICES OF HIP AND FEMUR WITHOUT CC/MCC

Facility

$43,705.99

Service Code	MSDRG 499
Min. Negotiated Rate	$26,500.20
Max. Negotiated Rate	$43,705.99
Rate for Payer: AlohaCare Medicare	$26,500.20
Rate for Payer: Devoted Health Medicare	$29,150.22
Rate for Payer: Hawaii Medical Service Association Commercial	$43,705.99
Rate for Payer: Hawaii Medical Service Association Medicare	$26,500.20
Rate for Payer: Humana Medicare	$26,500.20
Rate for Payer: Kaiser Permanente Commercial	$34,755.30
Rate for Payer: Kaiser Permanente Medicare	$26,500.20
Rate for Payer: Ohana Health Plan Medicare	$26,500.20
Rate for Payer: UnitedHealthcare Medicare	$26,500.20

LOCKED PRIVATE

Facility

$2,750.00

Hospital Charge Code	H0000005
Hospital Revenue Code	114
Min. Negotiated Rate	$2,337.50
Max. Negotiated Rate	$3,200.00
Rate for Payer: Cash Price	$1,787.50
Rate for Payer: Cash Price	$1,787.50
Rate for Payer: Cash Price	$1,787.50
Rate for Payer: Hawaii Western Management Group Commercial	$3,200.00
Rate for Payer: Health Management Network Commercial	$2,337.50
Rate for Payer: MDX Hawaii PPO	$2,667.50
Rate for Payer: University Health Alliance Commercial	$3,150.00

LOCKED SEMI PRIVATE

Facility

$2,750.00

Hospital Charge Code	H0000011
Hospital Revenue Code	124
Min. Negotiated Rate	$2,337.50
Max. Negotiated Rate	$3,200.00
Rate for Payer: Cash Price	$1,787.50
Rate for Payer: Cash Price	$1,787.50
Rate for Payer: Cash Price	$1,787.50
Rate for Payer: Hawaii Western Management Group Commercial	$3,200.00
Rate for Payer: Health Management Network Commercial	$2,337.50
Rate for Payer: MDX Hawaii PPO	$2,667.50
Rate for Payer: University Health Alliance Commercial	$3,150.00

Know your out-of-pocket cost for care.

All Charges