Kona Community Hospital

All Charges

Charge

Type

Setting

Price

Optilume DCB 24FR OPTBDL7009B [3643200]

Facility

$14,628.00

Service Code	HCPCS C1726
Hospital Charge Code	3643200
Hospital Revenue Code	272
Min. Negotiated Rate	$12,433.80
Max. Negotiated Rate	$14,189.16
Rate for Payer: Cash Price	$9,508.20
Rate for Payer: Health Management Network Commercial	$12,433.80
Rate for Payer: MDX Hawaii PPO	$14,189.16

Optilume DCB 30 Fr OPTBDL7011B [3643154]

Facility

$14,628.00

Service Code	HCPCS C1726
Hospital Charge Code	3643154
Hospital Revenue Code	272
Min. Negotiated Rate	$7,460.28
Max. Negotiated Rate	$14,189.16
Rate for Payer: Cash Price	$9,508.20
Rate for Payer: Hawaii Western Management Group Commercial	$13,896.60
Rate for Payer: Health Management Network Commercial	$12,433.80
Rate for Payer: Kaiser Permanente Commercial	$9,215.64
Rate for Payer: Kaiser Permanente Medicaid	$7,460.28
Rate for Payer: MDX Hawaii PPO	$14,189.16
Rate for Payer: University Health Alliance Commercial	$10,662.35

Optilume DCB 30 Fr OPTBDL7011B [3643154]

Facility

$14,628.00

Service Code	HCPCS C1726
Hospital Charge Code	3643154
Hospital Revenue Code	272
Min. Negotiated Rate	$12,433.80
Max. Negotiated Rate	$14,189.16
Rate for Payer: Cash Price	$9,508.20
Rate for Payer: Health Management Network Commercial	$12,433.80
Rate for Payer: MDX Hawaii PPO	$14,189.16

Optivac Kit Double Mix 80gm 600-50-080 [3644569]

Facility

$2,450.13

Hospital Charge Code	3644569
Hospital Revenue Code	272
Min. Negotiated Rate	$1,249.57
Max. Negotiated Rate	$2,376.63
Rate for Payer: Cash Price	$1,592.58
Rate for Payer: Hawaii Western Management Group Commercial	$2,327.62
Rate for Payer: Health Management Network Commercial	$2,082.61
Rate for Payer: Kaiser Permanente Commercial	$1,543.58
Rate for Payer: Kaiser Permanente Medicaid	$1,249.57
Rate for Payer: MDX Hawaii PPO	$2,376.63
Rate for Payer: University Health Alliance Commercial	$1,785.90

Optivac Kit Double Mix 80gm 600-50-080 [3644569]

Facility

$2,450.13

Hospital Charge Code	3644569
Hospital Revenue Code	272
Min. Negotiated Rate	$2,082.61
Max. Negotiated Rate	$2,376.63
Rate for Payer: Cash Price	$1,592.58
Rate for Payer: Health Management Network Commercial	$2,082.61
Rate for Payer: MDX Hawaii PPO	$2,376.63

ORBITAL PROCEDURES WITH CC/MCC

Facility

$40,556.47

Service Code	MSDRG 113
Min. Negotiated Rate	$10,400.00
Max. Negotiated Rate	$40,556.47
Rate for Payer: AlohaCare Medicare	$30,923.46
Rate for Payer: Devoted Health Medicare	$34,015.81
Rate for Payer: Hawaii Medical Service Association Commercial	$19,430.24
Rate for Payer: Hawaii Medical Service Association Medicare	$30,923.46
Rate for Payer: Humana Medicare	$30,923.46
Rate for Payer: Kaiser Permanente Commercial	$40,556.47
Rate for Payer: Kaiser Permanente Medicare	$30,923.46
Rate for Payer: Ohana Health Plan Medicare	$30,923.46
Rate for Payer: UnitedHealthcare Medicare	$30,923.46
Rate for Payer: University Health Alliance Commercial	$10,400.00

ORBITAL PROCEDURES WITHOUT CC/MCC

Facility

$23,339.25

Service Code	MSDRG 114
Min. Negotiated Rate	$10,400.00
Max. Negotiated Rate	$23,339.25
Rate for Payer: AlohaCare Medicare	$17,795.69
Rate for Payer: Devoted Health Medicare	$19,575.26
Rate for Payer: Hawaii Medical Service Association Commercial	$19,430.24
Rate for Payer: Hawaii Medical Service Association Medicare	$17,795.69
Rate for Payer: Humana Medicare	$17,795.69
Rate for Payer: Kaiser Permanente Commercial	$23,339.25
Rate for Payer: Kaiser Permanente Medicare	$17,795.69
Rate for Payer: Ohana Health Plan Medicare	$17,795.69
Rate for Payer: UnitedHealthcare Medicare	$17,795.69
Rate for Payer: University Health Alliance Commercial	$10,400.00

ORBIT & EYE PROCEDURES

Facility

$18,360.30

Service Code	APR-DRG 0734
Min. Negotiated Rate	$18,360.30
Max. Negotiated Rate	$18,360.30
Rate for Payer: AlohaCare Medicaid	$18,360.30
Rate for Payer: Hawaii Medical Service Association ABD	$18,360.30
Rate for Payer: Hawaii Medical Service Association Non-ABD	$18,360.30
Rate for Payer: Kaiser Permanente Medicaid	$18,360.30
Rate for Payer: Ohana Health Plan Medicaid	$18,360.30
Rate for Payer: UnitedHealthcare Medicaid	$18,360.30

ORBIT & EYE PROCEDURES

Facility

$8,858.57

Service Code	APR-DRG 0733
Min. Negotiated Rate	$8,858.57
Max. Negotiated Rate	$8,858.57
Rate for Payer: AlohaCare Medicaid	$8,858.57
Rate for Payer: Hawaii Medical Service Association ABD	$8,858.57
Rate for Payer: Hawaii Medical Service Association Non-ABD	$8,858.57
Rate for Payer: Kaiser Permanente Medicaid	$8,858.57
Rate for Payer: Ohana Health Plan Medicaid	$8,858.57
Rate for Payer: UnitedHealthcare Medicaid	$8,858.57

ORBIT & EYE PROCEDURES

Facility

$5,932.46

Service Code	APR-DRG 0732
Min. Negotiated Rate	$5,932.46
Max. Negotiated Rate	$5,932.46
Rate for Payer: AlohaCare Medicaid	$5,932.46
Rate for Payer: Hawaii Medical Service Association ABD	$5,932.46
Rate for Payer: Hawaii Medical Service Association Non-ABD	$5,932.46
Rate for Payer: Kaiser Permanente Medicaid	$5,932.46
Rate for Payer: Ohana Health Plan Medicaid	$5,932.46
Rate for Payer: UnitedHealthcare Medicaid	$5,932.46

ORBIT & EYE PROCEDURES

Facility

$4,702.79

Service Code	APR-DRG 0731
Min. Negotiated Rate	$4,702.79
Max. Negotiated Rate	$4,702.79
Rate for Payer: AlohaCare Medicaid	$4,702.79
Rate for Payer: Hawaii Medical Service Association ABD	$4,702.79
Rate for Payer: Hawaii Medical Service Association Non-ABD	$4,702.79
Rate for Payer: Kaiser Permanente Medicaid	$4,702.79
Rate for Payer: Ohana Health Plan Medicaid	$4,702.79
Rate for Payer: UnitedHealthcare Medicaid	$4,702.79

ORCHIECTOMY, PARTIAL

Facility

$6,743.44

Service Code	CPT 54522
Hospital Revenue Code	360
Min. Negotiated Rate	$456.03
Max. Negotiated Rate	$6,743.44
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
Rate for Payer: University Health Alliance Commercial	$6,743.44

ORCHIECTOMY, SIMPLE (INCLUDING SUBCAPSULAR), WITH OR WITHOUT TESTICULAR PROSTHESIS, SCROTAL OR INGUINAL APPROACH

Facility

$9,416.00

Service Code	CPT 54520
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	$6,743.44

ORGANIC DISTURBANCES AND INTELLECTUAL DISABILITY

Facility

$27,753.53

Service Code	MSDRG 884
Min. Negotiated Rate	$21,161.49
Max. Negotiated Rate	$27,753.53
Rate for Payer: AlohaCare Medicare	$21,161.49
Rate for Payer: Devoted Health Medicare	$23,277.64
Rate for Payer: Hawaii Medical Service Association Commercial	$26,107.88
Rate for Payer: Hawaii Medical Service Association Medicare	$21,161.49
Rate for Payer: Humana Medicare	$21,161.49
Rate for Payer: Kaiser Permanente Commercial	$27,753.53
Rate for Payer: Kaiser Permanente Medicare	$21,161.49
Rate for Payer: Ohana Health Plan Medicare	$21,161.49
Rate for Payer: UnitedHealthcare Medicare	$21,161.49

ORGANIC MENTAL HEALTH DISTURBANCES

Facility

$3,438.99

Service Code	APR-DRG 7572
Min. Negotiated Rate	$3,438.99
Max. Negotiated Rate	$3,438.99
Rate for Payer: AlohaCare Medicaid	$3,438.99
Rate for Payer: Hawaii Medical Service Association ABD	$3,438.99
Rate for Payer: Hawaii Medical Service Association Non-ABD	$3,438.99
Rate for Payer: Kaiser Permanente Medicaid	$3,438.99
Rate for Payer: Ohana Health Plan Medicaid	$3,438.99
Rate for Payer: UnitedHealthcare Medicaid	$3,438.99

ORGANIC MENTAL HEALTH DISTURBANCES

Facility

$2,751.34

Service Code	APR-DRG 7571
Min. Negotiated Rate	$2,751.34
Max. Negotiated Rate	$2,751.34
Rate for Payer: AlohaCare Medicaid	$2,751.34
Rate for Payer: Hawaii Medical Service Association ABD	$2,751.34
Rate for Payer: Hawaii Medical Service Association Non-ABD	$2,751.34
Rate for Payer: Kaiser Permanente Medicaid	$2,751.34
Rate for Payer: Ohana Health Plan Medicaid	$2,751.34
Rate for Payer: UnitedHealthcare Medicaid	$2,751.34

ORGANIC MENTAL HEALTH DISTURBANCES

Facility

$12,882.30

Service Code	APR-DRG 7574
Min. Negotiated Rate	$12,882.30
Max. Negotiated Rate	$12,882.30
Rate for Payer: AlohaCare Medicaid	$12,882.30
Rate for Payer: Hawaii Medical Service Association ABD	$12,882.30
Rate for Payer: Hawaii Medical Service Association Non-ABD	$12,882.30
Rate for Payer: Kaiser Permanente Medicaid	$12,882.30
Rate for Payer: Ohana Health Plan Medicaid	$12,882.30
Rate for Payer: UnitedHealthcare Medicaid	$12,882.30

ORGANIC MENTAL HEALTH DISTURBANCES

Facility

$6,046.79

Service Code	APR-DRG 7573
Min. Negotiated Rate	$6,046.79
Max. Negotiated Rate	$6,046.79
Rate for Payer: AlohaCare Medicaid	$6,046.79
Rate for Payer: Hawaii Medical Service Association ABD	$6,046.79
Rate for Payer: Hawaii Medical Service Association Non-ABD	$6,046.79
Rate for Payer: Kaiser Permanente Medicaid	$6,046.79
Rate for Payer: Ohana Health Plan Medicaid	$6,046.79
Rate for Payer: UnitedHealthcare Medicaid	$6,046.79

ORITAVANCIN 400 MG IV RECON.SOLN.

Facility

$2,511.38

Service Code	HCPCS J2407
Hospital Revenue Code	250
Min. Negotiated Rate	$2,134.67
Max. Negotiated Rate	$2,436.04
Rate for Payer: Cash Price	$1,632.40
Rate for Payer: Health Management Network Commercial	$2,134.67
Rate for Payer: MDX Hawaii PPO	$2,436.04

ORITAVANCIN 400 MG IV RECON.SOLN.

Facility

$2,511.38

Service Code	HCPCS J2407
Hospital Revenue Code	636
Min. Negotiated Rate	$28.52
Max. Negotiated Rate	$2,436.04
Rate for Payer: AlohaCare Medicaid	$28.57
Rate for Payer: AlohaCare Medicare	$28.57
Rate for Payer: Cash Price	$1,632.40
Rate for Payer: Cash Price	$1,632.40
Rate for Payer: Devoted Health Medicare	$31.43
Rate for Payer: Hawaii Medical Service Association ABD	$28.52
Rate for Payer: Hawaii Medical Service Association Commercial	$35.71
Rate for Payer: Hawaii Medical Service Association Medicare	$28.57
Rate for Payer: Hawaii Medical Service Association Non-ABD	$28.52
Rate for Payer: Hawaii Western Management Group Commercial	$2,385.81
Rate for Payer: Health Management Network Commercial	$2,134.67
Rate for Payer: Humana Medicare	$28.57
Rate for Payer: Kaiser Permanente Commercial	$1,582.17
Rate for Payer: Kaiser Permanente Medicaid	$1,280.80
Rate for Payer: Kaiser Permanente Medicare	$28.57
Rate for Payer: MDX Hawaii PPO	$2,436.04
Rate for Payer: Ohana Health Plan Medicaid	$31.43
Rate for Payer: Ohana Health Plan Medicare	$28.57
Rate for Payer: UnitedHealthcare Medicaid	$1,506.83
Rate for Payer: UnitedHealthcare Medicare	$28.57
Rate for Payer: University Health Alliance Commercial	$1,830.54

O.R. PROCEDURES FOR OBESITY WITH CC

Facility

$52,601.47

Service Code	MSDRG 620
Min. Negotiated Rate	$21,048.37
Max. Negotiated Rate	$52,601.47
Rate for Payer: AlohaCare Medicare	$21,048.37
Rate for Payer: Devoted Health Medicare	$23,153.21
Rate for Payer: Hawaii Medical Service Association Commercial	$52,601.47
Rate for Payer: Hawaii Medical Service Association Medicare	$21,048.37
Rate for Payer: Humana Medicare	$21,048.37
Rate for Payer: Kaiser Permanente Commercial	$27,605.17
Rate for Payer: Kaiser Permanente Medicare	$21,048.37
Rate for Payer: Ohana Health Plan Medicare	$21,048.37
Rate for Payer: UnitedHealthcare Medicare	$21,048.37

O.R. PROCEDURES FOR OBESITY WITH MCC

Facility

$52,601.47

Service Code	MSDRG 619
Min. Negotiated Rate	$37,977.30
Max. Negotiated Rate	$52,601.47
Rate for Payer: AlohaCare Medicare	$37,977.30
Rate for Payer: Devoted Health Medicare	$41,775.03
Rate for Payer: Hawaii Medical Service Association Commercial	$52,601.47
Rate for Payer: Hawaii Medical Service Association Medicare	$37,977.30
Rate for Payer: Humana Medicare	$37,977.30
Rate for Payer: Kaiser Permanente Commercial	$49,807.65
Rate for Payer: Kaiser Permanente Medicare	$37,977.30
Rate for Payer: Ohana Health Plan Medicare	$37,977.30
Rate for Payer: UnitedHealthcare Medicare	$37,977.30

O.R. PROCEDURES FOR OBESITY WITHOUT CC/MCC

Facility

$52,384.51

Service Code	MSDRG 621
Min. Negotiated Rate	$19,839.63
Max. Negotiated Rate	$52,384.51
Rate for Payer: AlohaCare Medicare	$19,839.63
Rate for Payer: Devoted Health Medicare	$21,823.59
Rate for Payer: Hawaii Medical Service Association Commercial	$52,384.51
Rate for Payer: Hawaii Medical Service Association Medicare	$19,839.63
Rate for Payer: Humana Medicare	$19,839.63
Rate for Payer: Kaiser Permanente Commercial	$26,019.90
Rate for Payer: Kaiser Permanente Medicare	$19,839.63
Rate for Payer: Ohana Health Plan Medicare	$19,839.63
Rate for Payer: UnitedHealthcare Medicare	$19,839.63

O.R. PROCEDURES WITH DIAGNOSES OF OTHER CONTACT WITH HEALTH SERVICES WITH CC

Facility

$40,311.53

Service Code	MSDRG 940
Min. Negotiated Rate	$30,736.71
Max. Negotiated Rate	$40,311.53
Rate for Payer: AlohaCare Medicare	$30,736.71
Rate for Payer: Devoted Health Medicare	$33,810.38
Rate for Payer: Hawaii Medical Service Association Commercial	$39,246.20
Rate for Payer: Hawaii Medical Service Association Medicare	$30,736.71
Rate for Payer: Humana Medicare	$30,736.71
Rate for Payer: Kaiser Permanente Commercial	$40,311.53
Rate for Payer: Kaiser Permanente Medicare	$30,736.71
Rate for Payer: Ohana Health Plan Medicare	$30,736.71
Rate for Payer: UnitedHealthcare Medicare	$30,736.71

O.R. PROCEDURES WITH DIAGNOSES OF OTHER CONTACT WITH HEALTH SERVICES WITH MCC

Facility

$62,591.62

Service Code	MSDRG 939
Min. Negotiated Rate	$39,246.20
Max. Negotiated Rate	$62,591.62
Rate for Payer: AlohaCare Medicare	$47,724.82
Rate for Payer: Devoted Health Medicare	$52,497.30
Rate for Payer: Hawaii Medical Service Association Commercial	$39,246.20
Rate for Payer: Hawaii Medical Service Association Medicare	$47,724.82
Rate for Payer: Humana Medicare	$47,724.82
Rate for Payer: Kaiser Permanente Commercial	$62,591.62
Rate for Payer: Kaiser Permanente Medicare	$47,724.82
Rate for Payer: Ohana Health Plan Medicare	$47,724.82
Rate for Payer: UnitedHealthcare Medicare	$47,724.82

Know your out-of-pocket cost for care.

All Charges