Kona Community Hospital

All Charges

Charge

Type

Setting

Price

SEPTICEMIA & DISSEMINATED INFECTIONS

Facility

$9,424.05

Service Code	APR-DRG 7204
Min. Negotiated Rate	$9,424.05
Max. Negotiated Rate	$9,424.05
Rate for Payer: AlohaCare Medicaid	$9,424.05
Rate for Payer: Hawaii Medical Service Association ABD	$9,424.05
Rate for Payer: Hawaii Medical Service Association Non-ABD	$9,424.05
Rate for Payer: Kaiser Permanente Medicaid	$9,424.05
Rate for Payer: Ohana Health Plan Medicaid	$9,424.05
Rate for Payer: UnitedHealthcare Medicaid	$9,424.05

SEPTICEMIA OR SEVERE SEPSIS WITH MV >96 HOURS

Facility

$185,816.76

Service Code	MSDRG 870
Min. Negotiated Rate	$90,909.28
Max. Negotiated Rate	$185,816.76
Rate for Payer: AlohaCare Medicare	$90,909.28
Rate for Payer: Devoted Health Medicare	$100,000.21
Rate for Payer: Hawaii Medical Service Association Commercial	$185,816.76
Rate for Payer: Hawaii Medical Service Association Medicare	$90,909.28
Rate for Payer: Humana Medicare	$90,909.28
Rate for Payer: Kaiser Permanente Commercial	$119,228.55
Rate for Payer: Kaiser Permanente Medicare	$90,909.28
Rate for Payer: Ohana Health Plan Medicare	$90,909.28
Rate for Payer: UnitedHealthcare Medicare	$90,909.28

SEPTICEMIA OR SEVERE SEPSIS WITHOUT MV >96 HOURS WITH MCC

Facility

$41,512.25

Service Code	MSDRG 871
Min. Negotiated Rate	$25,549.26
Max. Negotiated Rate	$41,512.25
Rate for Payer: AlohaCare Medicare	$25,549.26
Rate for Payer: Devoted Health Medicare	$28,104.19
Rate for Payer: Hawaii Medical Service Association Commercial	$41,512.25
Rate for Payer: Hawaii Medical Service Association Medicare	$25,549.26
Rate for Payer: Humana Medicare	$25,549.26
Rate for Payer: Kaiser Permanente Commercial	$33,508.12
Rate for Payer: Kaiser Permanente Medicare	$25,549.26
Rate for Payer: Ohana Health Plan Medicare	$25,549.26
Rate for Payer: UnitedHealthcare Medicare	$25,549.26

SEPTICEMIA OR SEVERE SEPSIS WITHOUT MV >96 HOURS WITHOUT MCC

Facility

$41,488.15

Service Code	MSDRG 872
Min. Negotiated Rate	$13,459.24
Max. Negotiated Rate	$41,488.15
Rate for Payer: AlohaCare Medicare	$13,459.24
Rate for Payer: Devoted Health Medicare	$14,805.16
Rate for Payer: Hawaii Medical Service Association Commercial	$41,488.15
Rate for Payer: Hawaii Medical Service Association Medicare	$13,459.24
Rate for Payer: Humana Medicare	$13,459.24
Rate for Payer: Kaiser Permanente Commercial	$17,651.92
Rate for Payer: Kaiser Permanente Medicare	$13,459.24
Rate for Payer: Ohana Health Plan Medicare	$13,459.24
Rate for Payer: UnitedHealthcare Medicare	$13,459.24

SERTRALINE 100 MG PO TABLET

Facility

$2.94

Service Code	HCPCS A9270
Hospital Revenue Code	250
Min. Negotiated Rate	$2.50
Max. Negotiated Rate	$2.85
Rate for Payer: Cash Price	$1.91
Rate for Payer: Health Management Network Commercial	$2.50
Rate for Payer: MDX Hawaii PPO	$2.85

SERTRALINE 100 MG PO TABLET

Facility

$2.94

Service Code	HCPCS A9270
Hospital Revenue Code	250
Min. Negotiated Rate	$1.50
Max. Negotiated Rate	$2.85
Rate for Payer: Cash Price	$1.91
Rate for Payer: Hawaii Western Management Group Commercial	$2.79
Rate for Payer: Health Management Network Commercial	$2.50
Rate for Payer: Kaiser Permanente Commercial	$1.85
Rate for Payer: Kaiser Permanente Medicaid	$1.50
Rate for Payer: MDX Hawaii PPO	$2.85
Rate for Payer: UnitedHealthcare Medicaid	$1.76
Rate for Payer: University Health Alliance Commercial	$2.14

SERTRALINE 25 MG PO TABLET

Facility

$2.22

Service Code	HCPCS A9270
Hospital Revenue Code	250
Min. Negotiated Rate	$1.13
Max. Negotiated Rate	$2.15
Rate for Payer: Cash Price	$1.44
Rate for Payer: Hawaii Western Management Group Commercial	$2.11
Rate for Payer: Health Management Network Commercial	$1.89
Rate for Payer: Kaiser Permanente Commercial	$1.40
Rate for Payer: Kaiser Permanente Medicaid	$1.13
Rate for Payer: MDX Hawaii PPO	$2.15
Rate for Payer: UnitedHealthcare Medicaid	$1.33
Rate for Payer: University Health Alliance Commercial	$1.62

SERTRALINE 25 MG PO TABLET

Facility

$2.22

Service Code	HCPCS A9270
Hospital Revenue Code	250
Min. Negotiated Rate	$1.89
Max. Negotiated Rate	$2.15
Rate for Payer: Cash Price	$1.44
Rate for Payer: Health Management Network Commercial	$1.89
Rate for Payer: MDX Hawaii PPO	$2.15

SERTRALINE 50 MG PO TABLET

Facility

$2.22

Service Code	HCPCS A9270
Hospital Revenue Code	250
Min. Negotiated Rate	$1.89
Max. Negotiated Rate	$2.15
Rate for Payer: Cash Price	$1.44
Rate for Payer: Health Management Network Commercial	$1.89
Rate for Payer: MDX Hawaii PPO	$2.15

SERTRALINE 50 MG PO TABLET

Facility

$2.22

Service Code	HCPCS A9270
Hospital Revenue Code	250
Min. Negotiated Rate	$1.13
Max. Negotiated Rate	$2.15
Rate for Payer: Cash Price	$1.44
Rate for Payer: Hawaii Western Management Group Commercial	$2.11
Rate for Payer: Health Management Network Commercial	$1.89
Rate for Payer: Kaiser Permanente Commercial	$1.40
Rate for Payer: Kaiser Permanente Medicaid	$1.13
Rate for Payer: MDX Hawaii PPO	$2.15
Rate for Payer: UnitedHealthcare Medicaid	$1.33
Rate for Payer: University Health Alliance Commercial	$1.62

SET TUR/BLADDER IRRIGATION BAG Y TYPE 2C4041 [2701646]

Facility

$130.48

Hospital Charge Code	2701646
Hospital Revenue Code	272
Min. Negotiated Rate	$66.54
Max. Negotiated Rate	$126.57
Rate for Payer: Cash Price	$84.81
Rate for Payer: Hawaii Western Management Group Commercial	$123.96
Rate for Payer: Health Management Network Commercial	$110.91
Rate for Payer: Kaiser Permanente Commercial	$82.20
Rate for Payer: Kaiser Permanente Medicaid	$66.54
Rate for Payer: MDX Hawaii PPO	$126.57
Rate for Payer: University Health Alliance Commercial	$95.11

SET TUR/BLADDER IRRIGATION BAG Y TYPE 2C4041 [2701646]

Facility

$130.48

Hospital Charge Code	2701646
Hospital Revenue Code	272
Min. Negotiated Rate	$110.91
Max. Negotiated Rate	$126.57
Rate for Payer: Cash Price	$84.81
Rate for Payer: Health Management Network Commercial	$110.91
Rate for Payer: MDX Hawaii PPO	$126.57

SET WARMER FLUID ADULT [2701666]

Facility

$91.29

Hospital Charge Code	2701666
Hospital Revenue Code	272
Min. Negotiated Rate	$77.60
Max. Negotiated Rate	$88.55
Rate for Payer: Cash Price	$59.34
Rate for Payer: Health Management Network Commercial	$77.60
Rate for Payer: MDX Hawaii PPO	$88.55

SET WARMER FLUID ADULT [2701666]

Facility

$91.29

Hospital Charge Code	2701666
Hospital Revenue Code	272
Min. Negotiated Rate	$46.56
Max. Negotiated Rate	$88.55
Rate for Payer: Cash Price	$59.34
Rate for Payer: Hawaii Western Management Group Commercial	$86.73
Rate for Payer: Health Management Network Commercial	$77.60
Rate for Payer: Kaiser Permanente Commercial	$57.51
Rate for Payer: Kaiser Permanente Medicaid	$46.56
Rate for Payer: MDX Hawaii PPO	$88.55
Rate for Payer: University Health Alliance Commercial	$66.54

SEVOFLURANE 99.97 % INHAL LIQ

Facility

$536.35

Service Code	NDC 66794001525
Hospital Revenue Code	250
Min. Negotiated Rate	$273.54
Max. Negotiated Rate	$520.26
Rate for Payer: Cash Price	$348.63
Rate for Payer: Hawaii Western Management Group Commercial	$509.53
Rate for Payer: Health Management Network Commercial	$455.90
Rate for Payer: Kaiser Permanente Commercial	$337.90
Rate for Payer: Kaiser Permanente Medicaid	$273.54
Rate for Payer: MDX Hawaii PPO	$520.26
Rate for Payer: UnitedHealthcare Medicaid	$321.81
Rate for Payer: University Health Alliance Commercial	$390.95

SEVOFLURANE 99.97 % INHAL LIQ

Facility

$536.35

Service Code	NDC 66794001525
Hospital Revenue Code	250
Min. Negotiated Rate	$455.90
Max. Negotiated Rate	$520.26
Rate for Payer: Cash Price	$348.63
Rate for Payer: Health Management Network Commercial	$455.90
Rate for Payer: MDX Hawaii PPO	$520.26

Sharpshooter Handle 4700 [3640757]

Facility

$2,261.94

Hospital Charge Code	3640757
Hospital Revenue Code	272
Min. Negotiated Rate	$1,922.65
Max. Negotiated Rate	$2,194.08
Rate for Payer: Cash Price	$1,470.26
Rate for Payer: Health Management Network Commercial	$1,922.65
Rate for Payer: MDX Hawaii PPO	$2,194.08

Sharpshooter Handle 4700 [3640757]

Facility

$2,261.94

Hospital Charge Code	3640757
Hospital Revenue Code	272
Min. Negotiated Rate	$1,153.59
Max. Negotiated Rate	$2,194.08
Rate for Payer: Cash Price	$1,470.26
Rate for Payer: Hawaii Western Management Group Commercial	$2,148.84
Rate for Payer: Health Management Network Commercial	$1,922.65
Rate for Payer: Kaiser Permanente Commercial	$1,425.02
Rate for Payer: Kaiser Permanente Medicaid	$1,153.59
Rate for Payer: MDX Hawaii PPO	$2,194.08
Rate for Payer: University Health Alliance Commercial	$1,648.73

SharpShooter Suture Tape 1.0mm Blue HS4703 [3643180]

Facility

$1,050.74

Hospital Charge Code	3643180
Hospital Revenue Code	272
Min. Negotiated Rate	$535.88
Max. Negotiated Rate	$1,019.22
Rate for Payer: Cash Price	$682.98
Rate for Payer: Hawaii Western Management Group Commercial	$998.20
Rate for Payer: Health Management Network Commercial	$893.13
Rate for Payer: Kaiser Permanente Commercial	$661.97
Rate for Payer: Kaiser Permanente Medicaid	$535.88
Rate for Payer: MDX Hawaii PPO	$1,019.22
Rate for Payer: University Health Alliance Commercial	$765.88

SharpShooter Suture Tape 1.0mm Blue HS4703 [3643180]

Facility

$1,050.74

Hospital Charge Code	3643180
Hospital Revenue Code	272
Min. Negotiated Rate	$893.13
Max. Negotiated Rate	$1,019.22
Rate for Payer: Cash Price	$682.98
Rate for Payer: Health Management Network Commercial	$893.13
Rate for Payer: MDX Hawaii PPO	$1,019.22

Shaver Burr Round HL 8 Flute 4.0mmX19cm AR6400RBE [3642417]

Facility

$716.05

Hospital Charge Code	3642417
Hospital Revenue Code	272
Min. Negotiated Rate	$608.64
Max. Negotiated Rate	$694.57
Rate for Payer: Cash Price	$465.43
Rate for Payer: Health Management Network Commercial	$608.64
Rate for Payer: MDX Hawaii PPO	$694.57

Shaver Burr Round HL 8 Flute 4.0mmX19cm AR6400RBE [3642417]

Facility

$716.05

Hospital Charge Code	3642417
Hospital Revenue Code	272
Min. Negotiated Rate	$365.19
Max. Negotiated Rate	$694.57
Rate for Payer: Cash Price	$465.43
Rate for Payer: Hawaii Western Management Group Commercial	$680.25
Rate for Payer: Health Management Network Commercial	$608.64
Rate for Payer: Kaiser Permanente Commercial	$451.11
Rate for Payer: Kaiser Permanente Medicaid	$365.19
Rate for Payer: MDX Hawaii PPO	$694.57
Rate for Payer: University Health Alliance Commercial	$521.93

Shoulder ALT Rev Glen Baseplate Periph Drill 804-06-331 [3644772]

Facility

$2,820.50

Hospital Charge Code	3644772
Hospital Revenue Code	272
Min. Negotiated Rate	$1,438.45
Max. Negotiated Rate	$2,735.89
Rate for Payer: Cash Price	$1,833.32
Rate for Payer: Hawaii Western Management Group Commercial	$2,679.47
Rate for Payer: Health Management Network Commercial	$2,397.43
Rate for Payer: Kaiser Permanente Commercial	$1,776.91
Rate for Payer: Kaiser Permanente Medicaid	$1,438.45
Rate for Payer: MDX Hawaii PPO	$2,735.89
Rate for Payer: University Health Alliance Commercial	$2,055.86

Shoulder ALT Rev Glen Baseplate Periph Drill 804-06-331 [3644772]

Facility

$2,820.50

Hospital Charge Code	3644772
Hospital Revenue Code	272
Min. Negotiated Rate	$2,397.43
Max. Negotiated Rate	$2,735.89
Rate for Payer: Cash Price	$1,833.32
Rate for Payer: Health Management Network Commercial	$2,397.43
Rate for Payer: MDX Hawaii PPO	$2,735.89

Shoulder ALT Rev Glenoid Cann Tap 6.5mm 804-06-318 [3644755]

Facility

$3,878.00

Hospital Charge Code	3644755
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