Kona Community Hospital

All Charges

Charge

Type

Setting

Price

SEIZURE

Facility

$2,493.08

Service Code	APR-DRG 0531
Min. Negotiated Rate	$2,493.08
Max. Negotiated Rate	$2,493.08
Rate for Payer: AlohaCare Medicaid	$2,493.08
Rate for Payer: Hawaii Medical Service Association ABD	$2,493.08
Rate for Payer: Hawaii Medical Service Association Non-ABD	$2,493.08
Rate for Payer: Kaiser Permanente Medicaid	$2,493.08
Rate for Payer: Ohana Health Plan Medicaid	$2,493.08
Rate for Payer: UnitedHealthcare Medicaid	$2,493.08

SEIZURE

Facility

$4,036.06

Service Code	APR-DRG 0533
Min. Negotiated Rate	$4,036.06
Max. Negotiated Rate	$4,036.06
Rate for Payer: AlohaCare Medicaid	$4,036.06
Rate for Payer: Hawaii Medical Service Association ABD	$4,036.06
Rate for Payer: Hawaii Medical Service Association Non-ABD	$4,036.06
Rate for Payer: Kaiser Permanente Medicaid	$4,036.06
Rate for Payer: Ohana Health Plan Medicaid	$4,036.06
Rate for Payer: UnitedHealthcare Medicaid	$4,036.06

SEIZURE

Facility

$9,794.67

Service Code	APR-DRG 0534
Min. Negotiated Rate	$9,794.67
Max. Negotiated Rate	$9,794.67
Rate for Payer: AlohaCare Medicaid	$9,794.67
Rate for Payer: Hawaii Medical Service Association ABD	$9,794.67
Rate for Payer: Hawaii Medical Service Association Non-ABD	$9,794.67
Rate for Payer: Kaiser Permanente Medicaid	$9,794.67
Rate for Payer: Ohana Health Plan Medicaid	$9,794.67
Rate for Payer: UnitedHealthcare Medicaid	$9,794.67

SEIZURES WITH MCC

Facility

$33,409.80

Service Code	MSDRG 100
Min. Negotiated Rate	$23,118.61
Max. Negotiated Rate	$33,409.80
Rate for Payer: AlohaCare Medicare	$25,474.27
Rate for Payer: Devoted Health Medicare	$28,021.70
Rate for Payer: Hawaii Medical Service Association Commercial	$23,118.61
Rate for Payer: Hawaii Medical Service Association Medicare	$25,474.27
Rate for Payer: Humana Medicare	$25,474.27
Rate for Payer: Kaiser Permanente Commercial	$33,409.80
Rate for Payer: Kaiser Permanente Medicare	$25,474.27
Rate for Payer: Ohana Health Plan Medicare	$25,474.27
Rate for Payer: UnitedHealthcare Medicare	$25,474.27

SEIZURES WITHOUT MCC

Facility

$19,960.60

Service Code	MSDRG 101
Min. Negotiated Rate	$11,871.68
Max. Negotiated Rate	$19,960.60
Rate for Payer: AlohaCare Medicare	$11,871.68
Rate for Payer: Devoted Health Medicare	$13,058.85
Rate for Payer: Hawaii Medical Service Association Commercial	$19,960.60
Rate for Payer: Hawaii Medical Service Association Medicare	$11,871.68
Rate for Payer: Humana Medicare	$11,871.68
Rate for Payer: Kaiser Permanente Commercial	$15,569.85
Rate for Payer: Kaiser Permanente Medicare	$11,871.68
Rate for Payer: Ohana Health Plan Medicare	$11,871.68
Rate for Payer: UnitedHealthcare Medicare	$11,871.68

SELENIUM SULFIDE 2.5 % TOP LOTN

Facility

$99.98

Service Code	HCPCS A9270
Hospital Revenue Code	250
Min. Negotiated Rate	$50.99
Max. Negotiated Rate	$96.98
Rate for Payer: Cash Price	$64.99
Rate for Payer: Hawaii Western Management Group Commercial	$94.98
Rate for Payer: Health Management Network Commercial	$84.98
Rate for Payer: Kaiser Permanente Commercial	$62.99
Rate for Payer: Kaiser Permanente Medicaid	$50.99
Rate for Payer: MDX Hawaii PPO	$96.98
Rate for Payer: UnitedHealthcare Medicaid	$59.99
Rate for Payer: University Health Alliance Commercial	$72.88

SELENIUM SULFIDE 2.5 % TOP LOTN

Facility

$99.98

Service Code	HCPCS A9270
Hospital Revenue Code	250
Min. Negotiated Rate	$84.98
Max. Negotiated Rate	$96.98
Rate for Payer: Cash Price	$64.99
Rate for Payer: Health Management Network Commercial	$84.98
Rate for Payer: MDX Hawaii PPO	$96.98

SEMAGLUTIDE 0.25 MG OR 0.5 MG (2 MG/3 ML) SUBCUTANEOUS PEN INJECTOR

Facility

$2,310.98

Service Code	NDC 00169418103
Hospital Revenue Code	250
Min. Negotiated Rate	$1,178.60
Max. Negotiated Rate	$2,241.65
Rate for Payer: Cash Price	$1,502.14
Rate for Payer: Hawaii Western Management Group Commercial	$2,195.43
Rate for Payer: Health Management Network Commercial	$1,964.33
Rate for Payer: Kaiser Permanente Commercial	$1,455.92
Rate for Payer: Kaiser Permanente Medicaid	$1,178.60
Rate for Payer: MDX Hawaii PPO	$2,241.65
Rate for Payer: UnitedHealthcare Medicaid	$1,386.59
Rate for Payer: University Health Alliance Commercial	$1,684.47

SEMAGLUTIDE 0.25 MG OR 0.5 MG (2 MG/3 ML) SUBCUTANEOUS PEN INJECTOR

Facility

$2,310.98

Service Code	NDC 00169418113
Hospital Revenue Code	250
Min. Negotiated Rate	$1,964.33
Max. Negotiated Rate	$2,241.65
Rate for Payer: Cash Price	$1,502.14
Rate for Payer: Health Management Network Commercial	$1,964.33
Rate for Payer: MDX Hawaii PPO	$2,241.65

SEMAGLUTIDE 0.25 MG OR 0.5 MG (2 MG/3 ML) SUBCUTANEOUS PEN INJECTOR

Facility

$2,310.98

Service Code	NDC 00169418113
Hospital Revenue Code	250
Min. Negotiated Rate	$1,178.60
Max. Negotiated Rate	$2,241.65
Rate for Payer: Cash Price	$1,502.14
Rate for Payer: Hawaii Western Management Group Commercial	$2,195.43
Rate for Payer: Health Management Network Commercial	$1,964.33
Rate for Payer: Kaiser Permanente Commercial	$1,455.92
Rate for Payer: Kaiser Permanente Medicaid	$1,178.60
Rate for Payer: MDX Hawaii PPO	$2,241.65
Rate for Payer: UnitedHealthcare Medicaid	$1,386.59
Rate for Payer: University Health Alliance Commercial	$1,684.47

SEMAGLUTIDE 0.25 MG OR 0.5 MG (2 MG/3 ML) SUBCUTANEOUS PEN INJECTOR

Facility

$2,310.98

Service Code	NDC 00169418103
Hospital Revenue Code	250
Min. Negotiated Rate	$1,964.33
Max. Negotiated Rate	$2,241.65
Rate for Payer: Cash Price	$1,502.14
Rate for Payer: Health Management Network Commercial	$1,964.33
Rate for Payer: MDX Hawaii PPO	$2,241.65

SEMAGLUTIDE 1 MG/DOSE (4 MG/3 ML) SUBCUTANEOUS PEN INJECTOR

Facility

$2,310.98

Service Code	HCPCS A9270
Hospital Revenue Code	250
Min. Negotiated Rate	$1,964.33
Max. Negotiated Rate	$2,241.65
Rate for Payer: Cash Price	$1,502.14
Rate for Payer: Health Management Network Commercial	$1,964.33
Rate for Payer: MDX Hawaii PPO	$2,241.65

SEMAGLUTIDE 1 MG/DOSE (4 MG/3 ML) SUBCUTANEOUS PEN INJECTOR

Facility

$2,310.98

Service Code	HCPCS A9270
Hospital Revenue Code	250
Min. Negotiated Rate	$1,178.60
Max. Negotiated Rate	$2,241.65
Rate for Payer: Cash Price	$1,502.14
Rate for Payer: Hawaii Western Management Group Commercial	$2,195.43
Rate for Payer: Health Management Network Commercial	$1,964.33
Rate for Payer: Kaiser Permanente Commercial	$1,455.92
Rate for Payer: Kaiser Permanente Medicaid	$1,178.60
Rate for Payer: MDX Hawaii PPO	$2,241.65
Rate for Payer: UnitedHealthcare Medicaid	$1,386.59
Rate for Payer: University Health Alliance Commercial	$1,684.47

SENNOSIDES 8.6 MG PO TABLET

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: Hawaii Western Management Group Commercial	$1.14
Rate for Payer: Health Management Network Commercial	$1.02
Rate for Payer: Kaiser Permanente Commercial	$0.76
Rate for Payer: Kaiser Permanente Medicaid	$0.61
Rate for Payer: MDX Hawaii PPO	$1.16
Rate for Payer: UnitedHealthcare Medicaid	$0.72
Rate for Payer: University Health Alliance Commercial	$0.87

SENNOSIDES 8.6 MG PO TABLET

Facility

$1.20

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

SENNOSIDES 8.8 MG/5 ML PO SYRUP

Facility

$16.43

Service Code	HCPCS A9270
Hospital Revenue Code	250
Min. Negotiated Rate	$13.97
Max. Negotiated Rate	$15.94
Rate for Payer: Cash Price	$10.68
Rate for Payer: Health Management Network Commercial	$13.97
Rate for Payer: MDX Hawaii PPO	$15.94

SENNOSIDES 8.8 MG/5 ML PO SYRUP

Facility

$16.43

Service Code	HCPCS A9270
Hospital Revenue Code	250
Min. Negotiated Rate	$8.38
Max. Negotiated Rate	$15.94
Rate for Payer: Cash Price	$10.68
Rate for Payer: Hawaii Western Management Group Commercial	$15.61
Rate for Payer: Health Management Network Commercial	$13.97
Rate for Payer: Kaiser Permanente Commercial	$10.35
Rate for Payer: Kaiser Permanente Medicaid	$8.38
Rate for Payer: MDX Hawaii PPO	$15.94
Rate for Payer: UnitedHealthcare Medicaid	$9.86
Rate for Payer: University Health Alliance Commercial	$11.98

Seprafilm Adhesion Barrier 4301-02 [3642479]

Facility

$1,874.43

Hospital Charge Code	3642479
Hospital Revenue Code	272
Min. Negotiated Rate	$955.96
Max. Negotiated Rate	$1,818.20
Rate for Payer: Cash Price	$1,218.38
Rate for Payer: Hawaii Western Management Group Commercial	$1,780.71
Rate for Payer: Health Management Network Commercial	$1,593.27
Rate for Payer: Kaiser Permanente Commercial	$1,180.89
Rate for Payer: Kaiser Permanente Medicaid	$955.96
Rate for Payer: MDX Hawaii PPO	$1,818.20
Rate for Payer: University Health Alliance Commercial	$1,366.27

Seprafilm Adhesion Barrier 4301-02 [3642479]

Facility

$1,874.43

Hospital Charge Code	3642479
Hospital Revenue Code	272
Min. Negotiated Rate	$1,593.27
Max. Negotiated Rate	$1,818.20
Rate for Payer: Cash Price	$1,218.38
Rate for Payer: Health Management Network Commercial	$1,593.27
Rate for Payer: MDX Hawaii PPO	$1,818.20

SEPTIC ARTHRITIS WITH CC

Facility

$24,878.42

Service Code	MSDRG 549
Min. Negotiated Rate	$15,878.02
Max. Negotiated Rate	$24,878.42
Rate for Payer: AlohaCare Medicare	$15,878.02
Rate for Payer: Devoted Health Medicare	$17,465.82
Rate for Payer: Hawaii Medical Service Association Commercial	$24,878.42
Rate for Payer: Hawaii Medical Service Association Medicare	$15,878.02
Rate for Payer: Humana Medicare	$15,878.02
Rate for Payer: Kaiser Permanente Commercial	$20,824.20
Rate for Payer: Kaiser Permanente Medicare	$15,878.02
Rate for Payer: Ohana Health Plan Medicare	$15,878.02
Rate for Payer: UnitedHealthcare Medicare	$15,878.02

SEPTIC ARTHRITIS WITH MCC

Facility

$33,308.03

Service Code	MSDRG 548
Min. Negotiated Rate	$24,878.42
Max. Negotiated Rate	$33,308.03
Rate for Payer: AlohaCare Medicare	$25,396.68
Rate for Payer: Devoted Health Medicare	$27,936.35
Rate for Payer: Hawaii Medical Service Association Commercial	$24,878.42
Rate for Payer: Hawaii Medical Service Association Medicare	$25,396.68
Rate for Payer: Humana Medicare	$25,396.68
Rate for Payer: Kaiser Permanente Commercial	$33,308.03
Rate for Payer: Kaiser Permanente Medicare	$25,396.68
Rate for Payer: Ohana Health Plan Medicare	$25,396.68
Rate for Payer: UnitedHealthcare Medicare	$25,396.68

SEPTIC ARTHRITIS WITHOUT CC/MCC

Facility

$24,878.42

Service Code	MSDRG 550
Min. Negotiated Rate	$11,496.83
Max. Negotiated Rate	$24,878.42
Rate for Payer: AlohaCare Medicare	$11,496.83
Rate for Payer: Devoted Health Medicare	$12,646.51
Rate for Payer: Hawaii Medical Service Association Commercial	$24,878.42
Rate for Payer: Hawaii Medical Service Association Medicare	$11,496.83
Rate for Payer: Humana Medicare	$11,496.83
Rate for Payer: Kaiser Permanente Commercial	$15,078.23
Rate for Payer: Kaiser Permanente Medicare	$11,496.83
Rate for Payer: Ohana Health Plan Medicare	$11,496.83
Rate for Payer: UnitedHealthcare Medicare	$11,496.83

SEPTICEMIA & DISSEMINATED INFECTIONS

Facility

$2,997.43

Service Code	APR-DRG 7201
Min. Negotiated Rate	$2,997.43
Max. Negotiated Rate	$2,997.43
Rate for Payer: AlohaCare Medicaid	$2,997.43
Rate for Payer: Hawaii Medical Service Association ABD	$2,997.43
Rate for Payer: Hawaii Medical Service Association Non-ABD	$2,997.43
Rate for Payer: Kaiser Permanente Medicaid	$2,997.43
Rate for Payer: Ohana Health Plan Medicaid	$2,997.43
Rate for Payer: UnitedHealthcare Medicaid	$2,997.43

SEPTICEMIA & DISSEMINATED INFECTIONS

Facility

$5,627.43

Service Code	APR-DRG 7203
Min. Negotiated Rate	$5,627.43
Max. Negotiated Rate	$5,627.43
Rate for Payer: AlohaCare Medicaid	$5,627.43
Rate for Payer: Hawaii Medical Service Association ABD	$5,627.43
Rate for Payer: Hawaii Medical Service Association Non-ABD	$5,627.43
Rate for Payer: Kaiser Permanente Medicaid	$5,627.43
Rate for Payer: Ohana Health Plan Medicaid	$5,627.43
Rate for Payer: UnitedHealthcare Medicaid	$5,627.43

SEPTICEMIA & DISSEMINATED INFECTIONS

Facility

$3,846.93

Service Code	APR-DRG 7202
Min. Negotiated Rate	$3,846.93
Max. Negotiated Rate	$3,846.93
Rate for Payer: AlohaCare Medicaid	$3,846.93
Rate for Payer: Hawaii Medical Service Association ABD	$3,846.93
Rate for Payer: Hawaii Medical Service Association Non-ABD	$3,846.93
Rate for Payer: Kaiser Permanente Medicaid	$3,846.93
Rate for Payer: Ohana Health Plan Medicaid	$3,846.93
Rate for Payer: UnitedHealthcare Medicaid	$3,846.93

Know your out-of-pocket cost for care.

All Charges