Kona Community Hospital

All Charges

Charge

Type

Setting

Price

Shunt Carotid Bypass St No Side Hole10FR X 13cm 000671 [3642207]

Facility

$256.50

Hospital Charge Code	3642207
Hospital Revenue Code	278
Min. Negotiated Rate	$143.64
Max. Negotiated Rate	$248.81
Rate for Payer: Cash Price	$166.72
Rate for Payer: Hawaii Western Management Group Commercial	$179.55
Rate for Payer: Health Management Network Commercial	$218.03
Rate for Payer: MDX Hawaii PPO	$248.81
Rate for Payer: University Health Alliance Commercial	$143.64

Shunt Carotid Bypass St No Side Hole10FR X 13cm 000671 [3642207]

Facility

$256.50

Hospital Charge Code	3642207
Hospital Revenue Code	278
Min. Negotiated Rate	$130.81
Max. Negotiated Rate	$248.81
Rate for Payer: Cash Price	$166.72
Rate for Payer: Hawaii Western Management Group Commercial	$179.55
Rate for Payer: Health Management Network Commercial	$218.03
Rate for Payer: Kaiser Permanente Commercial	$161.59
Rate for Payer: Kaiser Permanente Medicaid	$130.81
Rate for Payer: MDX Hawaii PPO	$248.81
Rate for Payer: University Health Alliance Commercial	$143.64

SICKLE CELL ANEMIA CRISIS

Facility

$11,017.33

Service Code	APR-DRG 6624
Min. Negotiated Rate	$11,017.33
Max. Negotiated Rate	$11,017.33
Rate for Payer: AlohaCare Medicaid	$11,017.33
Rate for Payer: Hawaii Medical Service Association ABD	$11,017.33
Rate for Payer: Hawaii Medical Service Association Non-ABD	$11,017.33
Rate for Payer: Kaiser Permanente Medicaid	$11,017.33
Rate for Payer: Ohana Health Plan Medicaid	$11,017.33
Rate for Payer: UnitedHealthcare Medicaid	$11,017.33

SICKLE CELL ANEMIA CRISIS

Facility

$5,330.68

Service Code	APR-DRG 6623
Min. Negotiated Rate	$5,330.68
Max. Negotiated Rate	$5,330.68
Rate for Payer: AlohaCare Medicaid	$5,330.68
Rate for Payer: Hawaii Medical Service Association ABD	$5,330.68
Rate for Payer: Hawaii Medical Service Association Non-ABD	$5,330.68
Rate for Payer: Kaiser Permanente Medicaid	$5,330.68
Rate for Payer: Ohana Health Plan Medicaid	$5,330.68
Rate for Payer: UnitedHealthcare Medicaid	$5,330.68

SICKLE CELL ANEMIA CRISIS

Facility

$2,782.19

Service Code	APR-DRG 6621
Min. Negotiated Rate	$2,782.19
Max. Negotiated Rate	$2,782.19
Rate for Payer: AlohaCare Medicaid	$2,782.19
Rate for Payer: Hawaii Medical Service Association ABD	$2,782.19
Rate for Payer: Hawaii Medical Service Association Non-ABD	$2,782.19
Rate for Payer: Kaiser Permanente Medicaid	$2,782.19
Rate for Payer: Ohana Health Plan Medicaid	$2,782.19
Rate for Payer: UnitedHealthcare Medicaid	$2,782.19

SICKLE CELL ANEMIA CRISIS

Facility

$3,734.85

Service Code	APR-DRG 6622
Min. Negotiated Rate	$3,734.85
Max. Negotiated Rate	$3,734.85
Rate for Payer: AlohaCare Medicaid	$3,734.85
Rate for Payer: Hawaii Medical Service Association ABD	$3,734.85
Rate for Payer: Hawaii Medical Service Association Non-ABD	$3,734.85
Rate for Payer: Kaiser Permanente Medicaid	$3,734.85
Rate for Payer: Ohana Health Plan Medicaid	$3,734.85
Rate for Payer: UnitedHealthcare Medicaid	$3,734.85

SIGMOIDOSCOPY, FLEXIBLE; DIAGNOSTIC, INCLUDING COLLECTION OF SPECIMEN(S) BY BRUSHING OR WASHING, WHEN PERFORMED (SEPARATE PROCEDURE)

Facility

$2,837.00

Service Code	CPT 45330
Hospital Revenue Code	360
Min. Negotiated Rate	$340.18
Max. Negotiated Rate	$2,837.00
Rate for Payer: AlohaCare Medicaid	$1,098.60
Rate for Payer: AlohaCare Medicare	$1,098.60
Rate for Payer: Devoted Health Medicare	$1,208.46
Rate for Payer: Hawaii Medical Service Association ABD	$393.00
Rate for Payer: Hawaii Medical Service Association Commercial	$2,833.00
Rate for Payer: Hawaii Medical Service Association Medicare	$1,098.60
Rate for Payer: Hawaii Medical Service Association Non-ABD	$407.95
Rate for Payer: Humana Medicare	$1,098.60
Rate for Payer: Kaiser Permanente Medicaid	$2,837.00
Rate for Payer: Kaiser Permanente Medicare	$1,098.60
Rate for Payer: Ohana Health Plan Medicaid	$1,208.46
Rate for Payer: Ohana Health Plan Medicare	$1,098.60
Rate for Payer: UnitedHealthcare Medicaid	$340.18
Rate for Payer: UnitedHealthcare Medicare	$1,098.60

SIGMOIDOSCOPY, FLEXIBLE; WITH BIOPSY, SINGLE OR MULTIPLE

Facility

$2,837.00

Service Code	CPT 45331
Hospital Revenue Code	360
Min. Negotiated Rate	$340.18
Max. Negotiated Rate	$2,837.00
Rate for Payer: AlohaCare Medicaid	$1,098.60
Rate for Payer: AlohaCare Medicare	$1,098.60
Rate for Payer: Devoted Health Medicare	$1,208.46
Rate for Payer: Hawaii Medical Service Association ABD	$393.00
Rate for Payer: Hawaii Medical Service Association Commercial	$2,833.00
Rate for Payer: Hawaii Medical Service Association Medicare	$1,098.60
Rate for Payer: Hawaii Medical Service Association Non-ABD	$407.95
Rate for Payer: Humana Medicare	$1,098.60
Rate for Payer: Kaiser Permanente Medicaid	$2,837.00
Rate for Payer: Kaiser Permanente Medicare	$1,098.60
Rate for Payer: Ohana Health Plan Medicaid	$1,208.46
Rate for Payer: Ohana Health Plan Medicare	$1,098.60
Rate for Payer: UnitedHealthcare Medicaid	$340.18
Rate for Payer: UnitedHealthcare Medicare	$1,098.60

SIGMOIDOSCOPY, FLEXIBLE; WITH DIRECTED SUBMUCOSAL INJECTION(S), ANY SUBSTANCE

Facility

$6,183.00

Service Code	CPT 45335
Hospital Revenue Code	360
Min. Negotiated Rate	$340.18
Max. Negotiated Rate	$6,183.00
Rate for Payer: AlohaCare Medicaid	$1,098.60
Rate for Payer: AlohaCare Medicare	$1,098.60
Rate for Payer: Devoted Health Medicare	$1,208.46
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	$1,098.60
Rate for Payer: Hawaii Medical Service Association Non-ABD	$700.72
Rate for Payer: Humana Medicare	$1,098.60
Rate for Payer: Kaiser Permanente Medicaid	$2,837.00
Rate for Payer: Kaiser Permanente Medicare	$1,098.60
Rate for Payer: Ohana Health Plan Medicaid	$1,208.46
Rate for Payer: Ohana Health Plan Medicare	$1,098.60
Rate for Payer: UnitedHealthcare Medicaid	$340.18
Rate for Payer: UnitedHealthcare Medicare	$1,098.60

SIGNS AND SYMPTOMS OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH MCC

Facility

$22,801.05

Service Code	MSDRG 555
Min. Negotiated Rate	$10,679.40
Max. Negotiated Rate	$22,801.05
Rate for Payer: AlohaCare Medicare	$17,385.32
Rate for Payer: Devoted Health Medicare	$19,123.85
Rate for Payer: Hawaii Medical Service Association Commercial	$10,679.40
Rate for Payer: Hawaii Medical Service Association Medicare	$17,385.32
Rate for Payer: Humana Medicare	$17,385.32
Rate for Payer: Kaiser Permanente Commercial	$22,801.05
Rate for Payer: Kaiser Permanente Medicare	$17,385.32
Rate for Payer: Ohana Health Plan Medicare	$17,385.32
Rate for Payer: UnitedHealthcare Medicare	$17,385.32

SIGNS AND SYMPTOMS OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITHOUT MCC

Facility

$14,327.85

Service Code	MSDRG 556
Min. Negotiated Rate	$10,679.40
Max. Negotiated Rate	$14,327.85
Rate for Payer: AlohaCare Medicare	$10,924.70
Rate for Payer: Devoted Health Medicare	$12,017.17
Rate for Payer: Hawaii Medical Service Association Commercial	$10,679.40
Rate for Payer: Hawaii Medical Service Association Medicare	$10,924.70
Rate for Payer: Humana Medicare	$10,924.70
Rate for Payer: Kaiser Permanente Commercial	$14,327.85
Rate for Payer: Kaiser Permanente Medicare	$10,924.70
Rate for Payer: Ohana Health Plan Medicare	$10,924.70
Rate for Payer: UnitedHealthcare Medicare	$10,924.70

SIGNS AND SYMPTOMS WITH MCC

Facility

$21,897.15

Service Code	MSDRG 947
Min. Negotiated Rate	$14,632.95
Max. Negotiated Rate	$21,897.15
Rate for Payer: AlohaCare Medicare	$16,696.11
Rate for Payer: Devoted Health Medicare	$18,365.72
Rate for Payer: Hawaii Medical Service Association Commercial	$14,632.95
Rate for Payer: Hawaii Medical Service Association Medicare	$16,696.11
Rate for Payer: Humana Medicare	$16,696.11
Rate for Payer: Kaiser Permanente Commercial	$21,897.15
Rate for Payer: Kaiser Permanente Medicare	$16,696.11
Rate for Payer: Ohana Health Plan Medicare	$16,696.11
Rate for Payer: UnitedHealthcare Medicare	$16,696.11

SIGNS AND SYMPTOMS WITHOUT MCC

Facility

$13,909.74

Service Code	MSDRG 948
Min. Negotiated Rate	$10,528.78
Max. Negotiated Rate	$13,909.74
Rate for Payer: AlohaCare Medicare	$10,528.78
Rate for Payer: Devoted Health Medicare	$11,581.66
Rate for Payer: Hawaii Medical Service Association Commercial	$13,909.74
Rate for Payer: Hawaii Medical Service Association Medicare	$10,528.78
Rate for Payer: Humana Medicare	$10,528.78
Rate for Payer: Kaiser Permanente Commercial	$13,808.62
Rate for Payer: Kaiser Permanente Medicare	$10,528.78
Rate for Payer: Ohana Health Plan Medicare	$10,528.78
Rate for Payer: UnitedHealthcare Medicare	$10,528.78

SIGNS, SYMPTOMS & OTHER FACTORS INFLUENCING HEALTH STATUS

Facility

$2,405.84

Service Code	APR-DRG 8611
Min. Negotiated Rate	$2,405.84
Max. Negotiated Rate	$2,405.84
Rate for Payer: AlohaCare Medicaid	$2,405.84
Rate for Payer: Hawaii Medical Service Association ABD	$2,405.84
Rate for Payer: Hawaii Medical Service Association Non-ABD	$2,405.84
Rate for Payer: Kaiser Permanente Medicaid	$2,405.84
Rate for Payer: Ohana Health Plan Medicaid	$2,405.84
Rate for Payer: UnitedHealthcare Medicaid	$2,405.84

SIGNS, SYMPTOMS & OTHER FACTORS INFLUENCING HEALTH STATUS

Facility

$4,137.95

Service Code	APR-DRG 8613
Min. Negotiated Rate	$4,137.95
Max. Negotiated Rate	$4,137.95
Rate for Payer: AlohaCare Medicaid	$4,137.95
Rate for Payer: Hawaii Medical Service Association ABD	$4,137.95
Rate for Payer: Hawaii Medical Service Association Non-ABD	$4,137.95
Rate for Payer: Kaiser Permanente Medicaid	$4,137.95
Rate for Payer: Ohana Health Plan Medicaid	$4,137.95
Rate for Payer: UnitedHealthcare Medicaid	$4,137.95

SIGNS, SYMPTOMS & OTHER FACTORS INFLUENCING HEALTH STATUS

Facility

$7,482.44

Service Code	APR-DRG 8614
Min. Negotiated Rate	$7,482.44
Max. Negotiated Rate	$7,482.44
Rate for Payer: AlohaCare Medicaid	$7,482.44
Rate for Payer: Hawaii Medical Service Association ABD	$7,482.44
Rate for Payer: Hawaii Medical Service Association Non-ABD	$7,482.44
Rate for Payer: Kaiser Permanente Medicaid	$7,482.44
Rate for Payer: Ohana Health Plan Medicaid	$7,482.44
Rate for Payer: UnitedHealthcare Medicaid	$7,482.44

SIGNS, SYMPTOMS & OTHER FACTORS INFLUENCING HEALTH STATUS

Facility

$3,029.27

Service Code	APR-DRG 8612
Min. Negotiated Rate	$3,029.27
Max. Negotiated Rate	$3,029.27
Rate for Payer: AlohaCare Medicaid	$3,029.27
Rate for Payer: Hawaii Medical Service Association ABD	$3,029.27
Rate for Payer: Hawaii Medical Service Association Non-ABD	$3,029.27
Rate for Payer: Kaiser Permanente Medicaid	$3,029.27
Rate for Payer: Ohana Health Plan Medicaid	$3,029.27
Rate for Payer: UnitedHealthcare Medicaid	$3,029.27

Sig Power Control Shell REF# SIGSHELL [3643865]

Facility

$796.38

Hospital Charge Code	3643865
Hospital Revenue Code	272
Min. Negotiated Rate	$406.15
Max. Negotiated Rate	$772.49
Rate for Payer: Cash Price	$517.65
Rate for Payer: Hawaii Western Management Group Commercial	$756.56
Rate for Payer: Health Management Network Commercial	$676.92
Rate for Payer: Kaiser Permanente Commercial	$501.72
Rate for Payer: Kaiser Permanente Medicaid	$406.15
Rate for Payer: MDX Hawaii PPO	$772.49
Rate for Payer: University Health Alliance Commercial	$580.48

Sig Power Control Shell REF# SIGSHELL [3643865]

Facility

$796.38

Hospital Charge Code	3643865
Hospital Revenue Code	272
Min. Negotiated Rate	$676.92
Max. Negotiated Rate	$772.49
Rate for Payer: Cash Price	$517.65
Rate for Payer: Health Management Network Commercial	$676.92
Rate for Payer: MDX Hawaii PPO	$772.49

SILDENAFIL (PULM.HYPERTENSION) 20 MG PO TABLET

Facility

$4.64

Service Code	HCPCS A9270
Hospital Revenue Code	250
Min. Negotiated Rate	$2.37
Max. Negotiated Rate	$4.50
Rate for Payer: Cash Price	$3.02
Rate for Payer: Hawaii Western Management Group Commercial	$4.41
Rate for Payer: Health Management Network Commercial	$3.94
Rate for Payer: Kaiser Permanente Commercial	$2.92
Rate for Payer: Kaiser Permanente Medicaid	$2.37
Rate for Payer: MDX Hawaii PPO	$4.50
Rate for Payer: UnitedHealthcare Medicaid	$2.78
Rate for Payer: University Health Alliance Commercial	$3.38

SILDENAFIL (PULM.HYPERTENSION) 20 MG PO TABLET

Facility

$4.64

Service Code	HCPCS A9270
Hospital Revenue Code	250
Min. Negotiated Rate	$3.94
Max. Negotiated Rate	$4.50
Rate for Payer: Cash Price	$3.02
Rate for Payer: Health Management Network Commercial	$3.94
Rate for Payer: MDX Hawaii PPO	$4.50

SILVER NITRATE APPLICATORS 75-25 % TOP STICK

Facility

$3.89

Service Code	NDC 12870000102
Hospital Revenue Code	250
Min. Negotiated Rate	$1.98
Max. Negotiated Rate	$3.77
Rate for Payer: Cash Price	$2.53
Rate for Payer: Hawaii Western Management Group Commercial	$3.70
Rate for Payer: Health Management Network Commercial	$3.31
Rate for Payer: Kaiser Permanente Commercial	$2.45
Rate for Payer: Kaiser Permanente Medicaid	$1.98
Rate for Payer: MDX Hawaii PPO	$3.77
Rate for Payer: UnitedHealthcare Medicaid	$2.33
Rate for Payer: University Health Alliance Commercial	$2.84

SILVER NITRATE APPLICATORS 75-25 % TOP STICK

Facility

$4.17

Service Code	NDC 12870000101
Hospital Revenue Code	250
Min. Negotiated Rate	$3.54
Max. Negotiated Rate	$4.04
Rate for Payer: Cash Price	$2.71
Rate for Payer: Health Management Network Commercial	$3.54
Rate for Payer: MDX Hawaii PPO	$4.04

SILVER NITRATE APPLICATORS 75-25 % TOP STICK

Facility

$4.17

Service Code	NDC 12870000101
Hospital Revenue Code	250
Min. Negotiated Rate	$2.13
Max. Negotiated Rate	$4.04
Rate for Payer: Cash Price	$2.71
Rate for Payer: Hawaii Western Management Group Commercial	$3.96
Rate for Payer: Health Management Network Commercial	$3.54
Rate for Payer: Kaiser Permanente Commercial	$2.63
Rate for Payer: Kaiser Permanente Medicaid	$2.13
Rate for Payer: MDX Hawaii PPO	$4.04
Rate for Payer: UnitedHealthcare Medicaid	$2.50
Rate for Payer: University Health Alliance Commercial	$3.04

SILVER NITRATE APPLICATORS 75-25 % TOP STICK

Facility

$3.89

Service Code	NDC 12870000102
Hospital Revenue Code	250
Min. Negotiated Rate	$3.31
Max. Negotiated Rate	$3.77
Rate for Payer: Cash Price	$2.53
Rate for Payer: Health Management Network Commercial	$3.31
Rate for Payer: MDX Hawaii PPO	$3.77

Know your out-of-pocket cost for care.

All Charges