Kona Community Hospital

All Charges

Charge

Type

Setting

Price

Low Profile Screw, 2.4mm X 18mm Cortex AR-8916CX24-18 [3645529]

Facility

$1,112.32

Service Code	HCPCS C1713
Hospital Charge Code	3645529
Hospital Revenue Code	278
Min. Negotiated Rate	$567.28
Max. Negotiated Rate	$1,078.95
Rate for Payer: Cash Price	$723.01
Rate for Payer: Hawaii Western Management Group Commercial	$778.62
Rate for Payer: Health Management Network Commercial	$945.47
Rate for Payer: Kaiser Permanente Commercial	$700.76
Rate for Payer: Kaiser Permanente Medicaid	$567.28
Rate for Payer: MDX Hawaii PPO	$1,078.95
Rate for Payer: University Health Alliance Commercial	$622.90

LUNG TRANSPLANT

Facility

$223,390.95

Service Code	MSDRG 007
Min. Negotiated Rate	$10,400.00
Max. Negotiated Rate	$223,390.95
Rate for Payer: AlohaCare Medicare	$170,330.97
Rate for Payer: Devoted Health Medicare	$187,364.07
Rate for Payer: Hawaii Medical Service Association Medicare	$170,330.97
Rate for Payer: Kaiser Permanente Commercial	$223,390.95
Rate for Payer: Kaiser Permanente Medicare	$170,330.97
Rate for Payer: Ohana Health Plan Medicare	$170,330.97
Rate for Payer: UnitedHealthcare Medicare	$170,330.97
Rate for Payer: University Health Alliance Commercial	$10,400.00

LURASIDONE 40 MG PO TABLET

Facility

$174.63

Service Code	HCPCS A9270
Hospital Revenue Code	250
Min. Negotiated Rate	$89.06
Max. Negotiated Rate	$169.39
Rate for Payer: Cash Price	$113.51
Rate for Payer: Hawaii Western Management Group Commercial	$165.90
Rate for Payer: Health Management Network Commercial	$148.44
Rate for Payer: Kaiser Permanente Commercial	$110.02
Rate for Payer: Kaiser Permanente Medicaid	$89.06
Rate for Payer: MDX Hawaii PPO	$169.39
Rate for Payer: UnitedHealthcare Medicaid	$104.78
Rate for Payer: University Health Alliance Commercial	$127.29

LURASIDONE 40 MG PO TABLET

Facility

$174.63

Service Code	HCPCS A9270
Hospital Revenue Code	250
Min. Negotiated Rate	$148.44
Max. Negotiated Rate	$169.39
Rate for Payer: Cash Price	$113.51
Rate for Payer: Health Management Network Commercial	$148.44
Rate for Payer: MDX Hawaii PPO	$169.39

LYMPHATIC & OTHER MALIGNANCIES & NEOPLASMS OF UNCERTAIN BEHAVIOR

Facility

$5,727.41

Service Code	APR-DRG 6943
Min. Negotiated Rate	$5,727.41
Max. Negotiated Rate	$5,727.41
Rate for Payer: AlohaCare Medicaid	$5,727.41
Rate for Payer: Hawaii Medical Service Association ABD	$5,727.41
Rate for Payer: Hawaii Medical Service Association Non-ABD	$5,727.41
Rate for Payer: Kaiser Permanente Medicaid	$5,727.41
Rate for Payer: Ohana Health Plan Medicaid	$5,727.41
Rate for Payer: UnitedHealthcare Medicaid	$5,727.41

LYMPHATIC & OTHER MALIGNANCIES & NEOPLASMS OF UNCERTAIN BEHAVIOR

Facility

$3,893.41

Service Code	APR-DRG 6942
Min. Negotiated Rate	$3,893.41
Max. Negotiated Rate	$3,893.41
Rate for Payer: AlohaCare Medicaid	$3,893.41
Rate for Payer: Hawaii Medical Service Association ABD	$3,893.41
Rate for Payer: Hawaii Medical Service Association Non-ABD	$3,893.41
Rate for Payer: Kaiser Permanente Medicaid	$3,893.41
Rate for Payer: Ohana Health Plan Medicaid	$3,893.41
Rate for Payer: UnitedHealthcare Medicaid	$3,893.41

LYMPHATIC & OTHER MALIGNANCIES & NEOPLASMS OF UNCERTAIN BEHAVIOR

Facility

$3,219.04

Service Code	APR-DRG 6941
Min. Negotiated Rate	$3,219.04
Max. Negotiated Rate	$3,219.04
Rate for Payer: AlohaCare Medicaid	$3,219.04
Rate for Payer: Hawaii Medical Service Association ABD	$3,219.04
Rate for Payer: Hawaii Medical Service Association Non-ABD	$3,219.04
Rate for Payer: Kaiser Permanente Medicaid	$3,219.04
Rate for Payer: Ohana Health Plan Medicaid	$3,219.04
Rate for Payer: UnitedHealthcare Medicaid	$3,219.04

LYMPHATIC & OTHER MALIGNANCIES & NEOPLASMS OF UNCERTAIN BEHAVIOR

Facility

$9,870.45

Service Code	APR-DRG 6944
Min. Negotiated Rate	$9,870.45
Max. Negotiated Rate	$9,870.45
Rate for Payer: AlohaCare Medicaid	$9,870.45
Rate for Payer: Hawaii Medical Service Association ABD	$9,870.45
Rate for Payer: Hawaii Medical Service Association Non-ABD	$9,870.45
Rate for Payer: Kaiser Permanente Medicaid	$9,870.45
Rate for Payer: Ohana Health Plan Medicaid	$9,870.45
Rate for Payer: UnitedHealthcare Medicaid	$9,870.45

LYMPHOMA AND LEUKEMIA WITH MAJOR O.R. PROCEDURES WITH CC

Facility

$77,817.40

Service Code	MSDRG 821
Min. Negotiated Rate	$29,443.78
Max. Negotiated Rate	$77,817.40
Rate for Payer: AlohaCare Medicare	$29,443.78
Rate for Payer: Devoted Health Medicare	$32,388.16
Rate for Payer: Hawaii Medical Service Association Commercial	$77,817.40
Rate for Payer: Hawaii Medical Service Association Medicare	$29,443.78
Rate for Payer: Humana Medicare	$29,443.78
Rate for Payer: Kaiser Permanente Commercial	$38,615.85
Rate for Payer: Kaiser Permanente Medicare	$29,443.78
Rate for Payer: Ohana Health Plan Medicare	$29,443.78
Rate for Payer: UnitedHealthcare Medicare	$29,443.78

LYMPHOMA AND LEUKEMIA WITH MAJOR O.R. PROCEDURES WITH MCC

Facility

$101,167.80

Service Code	MSDRG 820
Min. Negotiated Rate	$77,138.34
Max. Negotiated Rate	$101,167.80
Rate for Payer: AlohaCare Medicare	$77,138.34
Rate for Payer: Devoted Health Medicare	$84,852.17
Rate for Payer: Hawaii Medical Service Association Commercial	$77,817.40
Rate for Payer: Hawaii Medical Service Association Medicare	$77,138.34
Rate for Payer: Humana Medicare	$77,138.34
Rate for Payer: Kaiser Permanente Commercial	$101,167.80
Rate for Payer: Kaiser Permanente Medicare	$77,138.34
Rate for Payer: Ohana Health Plan Medicare	$77,138.34
Rate for Payer: UnitedHealthcare Medicare	$77,138.34

LYMPHOMA AND LEUKEMIA WITH MAJOR O.R. PROCEDURES WITHOUT CC/MCC

Facility

$31,170.35

Service Code	MSDRG 822
Min. Negotiated Rate	$15,835.92
Max. Negotiated Rate	$31,170.35
Rate for Payer: AlohaCare Medicare	$15,835.92
Rate for Payer: Devoted Health Medicare	$17,419.51
Rate for Payer: Hawaii Medical Service Association Commercial	$31,170.35
Rate for Payer: Hawaii Medical Service Association Medicare	$15,835.92
Rate for Payer: Humana Medicare	$15,835.92
Rate for Payer: Kaiser Permanente Commercial	$20,769.00
Rate for Payer: Kaiser Permanente Medicare	$15,835.92
Rate for Payer: Ohana Health Plan Medicare	$15,835.92
Rate for Payer: UnitedHealthcare Medicare	$15,835.92

LYMPHOMA AND NON-ACUTE LEUKEMIA WITH CC

Facility

$79,046.85

Service Code	MSDRG 841
Min. Negotiated Rate	$21,457.43
Max. Negotiated Rate	$79,046.85
Rate for Payer: AlohaCare Medicare	$21,457.43
Rate for Payer: Devoted Health Medicare	$23,603.17
Rate for Payer: Hawaii Medical Service Association Commercial	$79,046.85
Rate for Payer: Hawaii Medical Service Association Medicare	$21,457.43
Rate for Payer: Humana Medicare	$21,457.43
Rate for Payer: Kaiser Permanente Commercial	$28,141.65
Rate for Payer: Kaiser Permanente Medicare	$21,457.43
Rate for Payer: Ohana Health Plan Medicare	$21,457.43
Rate for Payer: UnitedHealthcare Medicare	$21,457.43

LYMPHOMA AND NON-ACUTE LEUKEMIA WITH MCC

Facility

$83,699.50

Service Code	MSDRG 840
Min. Negotiated Rate	$42,547.88
Max. Negotiated Rate	$83,699.50
Rate for Payer: AlohaCare Medicare	$42,547.88
Rate for Payer: Devoted Health Medicare	$46,802.67
Rate for Payer: Hawaii Medical Service Association Commercial	$83,699.50
Rate for Payer: Hawaii Medical Service Association Medicare	$42,547.88
Rate for Payer: Humana Medicare	$42,547.88
Rate for Payer: Kaiser Permanente Commercial	$55,802.03
Rate for Payer: Kaiser Permanente Medicare	$42,547.88
Rate for Payer: Ohana Health Plan Medicare	$42,547.88
Rate for Payer: UnitedHealthcare Medicare	$42,547.88

LYMPHOMA AND NON-ACUTE LEUKEMIA WITH OTHER PROCEDURES WITH CC

Facility

$94,113.73

Service Code	MSDRG 824
Min. Negotiated Rate	$29,798.90
Max. Negotiated Rate	$94,113.73
Rate for Payer: AlohaCare Medicare	$29,798.90
Rate for Payer: Devoted Health Medicare	$32,778.79
Rate for Payer: Hawaii Medical Service Association Commercial	$94,113.73
Rate for Payer: Hawaii Medical Service Association Medicare	$29,798.90
Rate for Payer: Humana Medicare	$29,798.90
Rate for Payer: Kaiser Permanente Commercial	$39,081.60
Rate for Payer: Kaiser Permanente Medicare	$29,798.90
Rate for Payer: Ohana Health Plan Medicare	$29,798.90
Rate for Payer: UnitedHealthcare Medicare	$29,798.90

LYMPHOMA AND NON-ACUTE LEUKEMIA WITH OTHER PROCEDURES WITH MCC

Facility

$94,113.73

Service Code	MSDRG 823
Min. Negotiated Rate	$60,302.80
Max. Negotiated Rate	$94,113.73
Rate for Payer: AlohaCare Medicare	$60,302.80
Rate for Payer: Devoted Health Medicare	$66,333.08
Rate for Payer: Hawaii Medical Service Association Commercial	$94,113.73
Rate for Payer: Hawaii Medical Service Association Medicare	$60,302.80
Rate for Payer: Humana Medicare	$60,302.80
Rate for Payer: Kaiser Permanente Commercial	$79,087.80
Rate for Payer: Kaiser Permanente Medicare	$60,302.80
Rate for Payer: Ohana Health Plan Medicare	$60,302.80
Rate for Payer: UnitedHealthcare Medicare	$60,302.80

LYMPHOMA AND NON-ACUTE LEUKEMIA WITH OTHER PROCEDURES WITHOUT CC/MCC

Facility

$25,481.10

Service Code	MSDRG 825
Min. Negotiated Rate	$17,748.34
Max. Negotiated Rate	$25,481.10
Rate for Payer: AlohaCare Medicare	$17,748.34
Rate for Payer: Devoted Health Medicare	$19,523.17
Rate for Payer: Hawaii Medical Service Association Commercial	$25,481.10
Rate for Payer: Hawaii Medical Service Association Medicare	$17,748.34
Rate for Payer: Humana Medicare	$17,748.34
Rate for Payer: Kaiser Permanente Commercial	$23,277.15
Rate for Payer: Kaiser Permanente Medicare	$17,748.34
Rate for Payer: Ohana Health Plan Medicare	$17,748.34
Rate for Payer: UnitedHealthcare Medicare	$17,748.34

LYMPHOMA AND NON-ACUTE LEUKEMIA WITHOUT CC/MCC

Facility

$51,902.37

Service Code	MSDRG 842
Min. Negotiated Rate	$13,289.56
Max. Negotiated Rate	$51,902.37
Rate for Payer: AlohaCare Medicare	$13,289.56
Rate for Payer: Devoted Health Medicare	$14,618.52
Rate for Payer: Hawaii Medical Service Association Commercial	$51,902.37
Rate for Payer: Hawaii Medical Service Association Medicare	$13,289.56
Rate for Payer: Humana Medicare	$13,289.56
Rate for Payer: Kaiser Permanente Commercial	$17,429.40
Rate for Payer: Kaiser Permanente Medicare	$13,289.56
Rate for Payer: Ohana Health Plan Medicare	$13,289.56
Rate for Payer: UnitedHealthcare Medicare	$13,289.56

LYMPHOMA, MYELOMA & NON-ACUTE LEUKEMIA

Facility

$4,743.55

Service Code	APR-DRG 6911
Min. Negotiated Rate	$4,743.55
Max. Negotiated Rate	$4,743.55
Rate for Payer: AlohaCare Medicaid	$4,743.55
Rate for Payer: Hawaii Medical Service Association ABD	$4,743.55
Rate for Payer: Hawaii Medical Service Association Non-ABD	$4,743.55
Rate for Payer: Kaiser Permanente Medicaid	$4,743.55
Rate for Payer: Ohana Health Plan Medicaid	$4,743.55
Rate for Payer: UnitedHealthcare Medicaid	$4,743.55

LYMPHOMA, MYELOMA & NON-ACUTE LEUKEMIA

Facility

$8,500.05

Service Code	APR-DRG 6913
Min. Negotiated Rate	$8,500.05
Max. Negotiated Rate	$8,500.05
Rate for Payer: AlohaCare Medicaid	$8,500.05
Rate for Payer: Hawaii Medical Service Association ABD	$8,500.05
Rate for Payer: Hawaii Medical Service Association Non-ABD	$8,500.05
Rate for Payer: Kaiser Permanente Medicaid	$8,500.05
Rate for Payer: Ohana Health Plan Medicaid	$8,500.05
Rate for Payer: UnitedHealthcare Medicaid	$8,500.05

LYMPHOMA, MYELOMA & NON-ACUTE LEUKEMIA

Facility

$16,002.86

Service Code	APR-DRG 6914
Min. Negotiated Rate	$16,002.86
Max. Negotiated Rate	$16,002.86
Rate for Payer: AlohaCare Medicaid	$16,002.86
Rate for Payer: Hawaii Medical Service Association ABD	$16,002.86
Rate for Payer: Hawaii Medical Service Association Non-ABD	$16,002.86
Rate for Payer: Kaiser Permanente Medicaid	$16,002.86
Rate for Payer: Ohana Health Plan Medicaid	$16,002.86
Rate for Payer: UnitedHealthcare Medicaid	$16,002.86

LYMPHOMA, MYELOMA & NON-ACUTE LEUKEMIA

Facility

$5,446.58

Service Code	APR-DRG 6912
Min. Negotiated Rate	$5,446.58
Max. Negotiated Rate	$5,446.58
Rate for Payer: AlohaCare Medicaid	$5,446.58
Rate for Payer: Hawaii Medical Service Association ABD	$5,446.58
Rate for Payer: Hawaii Medical Service Association Non-ABD	$5,446.58
Rate for Payer: Kaiser Permanente Medicaid	$5,446.58
Rate for Payer: Ohana Health Plan Medicaid	$5,446.58
Rate for Payer: UnitedHealthcare Medicaid	$5,446.58

M001PCB5020500 Balloon Peripheral Cutting 5.0mmX2.0cmX50cm [3641978]

Facility

$3,878.00

Service Code	HCPCS C1725
Hospital Charge Code	3641978
Hospital Revenue Code	272
Min. Negotiated Rate	$1,977.78
Max. Negotiated Rate	$3,761.66
Rate for Payer: Cash Price	$2,520.70
Rate for Payer: Hawaii Western Management Group Commercial	$3,684.10
Rate for Payer: Health Management Network Commercial	$3,296.30
Rate for Payer: Kaiser Permanente Commercial	$2,443.14
Rate for Payer: Kaiser Permanente Medicaid	$1,977.78
Rate for Payer: MDX Hawaii PPO	$3,761.66
Rate for Payer: University Health Alliance Commercial	$2,826.67

M001PCB5020500 Balloon Peripheral Cutting 5.0mmX2.0cmX50cm [3641978]

Facility

$3,878.00

Service Code	HCPCS C1725
Hospital Charge Code	3641978
Hospital Revenue Code	272
Min. Negotiated Rate	$3,296.30
Max. Negotiated Rate	$3,761.66
Rate for Payer: Cash Price	$2,520.70
Rate for Payer: Health Management Network Commercial	$3,296.30
Rate for Payer: MDX Hawaii PPO	$3,761.66

M001PCB6020500 Balloon Peripheral Cutting 6.0mmX2.0cmX50cm [3641979]

Facility

$3,878.00

Service Code	HCPCS C1725
Hospital Charge Code	3641979
Hospital Revenue Code	272
Min. Negotiated Rate	$1,977.78
Max. Negotiated Rate	$3,761.66
Rate for Payer: Cash Price	$2,520.70
Rate for Payer: Hawaii Western Management Group Commercial	$3,684.10
Rate for Payer: Health Management Network Commercial	$3,296.30
Rate for Payer: Kaiser Permanente Commercial	$2,443.14
Rate for Payer: Kaiser Permanente Medicaid	$1,977.78
Rate for Payer: MDX Hawaii PPO	$3,761.66
Rate for Payer: University Health Alliance Commercial	$2,826.67

M001PCB6020500 Balloon Peripheral Cutting 6.0mmX2.0cmX50cm [3641979]

Facility

$3,878.00

Service Code	HCPCS C1725
Hospital Charge Code	3641979
Hospital Revenue Code	272
Min. Negotiated Rate	$3,296.30
Max. Negotiated Rate	$3,761.66
Rate for Payer: Cash Price	$2,520.70
Rate for Payer: Health Management Network Commercial	$3,296.30
Rate for Payer: MDX Hawaii PPO	$3,761.66

Know your out-of-pocket cost for care.

All Charges