Kona Community Hospital

All Charges

Charge

Type

Setting

Price

SILVER SULFADIAZINE 1 % TOP CR

Facility

$137.90

Service Code	HCPCS A9270
Hospital Revenue Code	250
Min. Negotiated Rate	$70.33
Max. Negotiated Rate	$133.76
Rate for Payer: Cash Price	$89.64
Rate for Payer: Cash Price	$67.54
Rate for Payer: Cash Price	$251.64
Rate for Payer: Hawaii Western Management Group Commercial	$98.71
Rate for Payer: Hawaii Western Management Group Commercial	$367.78
Rate for Payer: Hawaii Western Management Group Commercial	$131.00
Rate for Payer: Health Management Network Commercial	$329.07
Rate for Payer: Health Management Network Commercial	$88.32
Rate for Payer: Health Management Network Commercial	$117.22
Rate for Payer: Kaiser Permanente Commercial	$65.46
Rate for Payer: Kaiser Permanente Commercial	$86.88
Rate for Payer: Kaiser Permanente Commercial	$243.90
Rate for Payer: Kaiser Permanente Medicaid	$197.44
Rate for Payer: Kaiser Permanente Medicaid	$70.33
Rate for Payer: Kaiser Permanente Medicaid	$52.99
Rate for Payer: MDX Hawaii PPO	$375.53
Rate for Payer: MDX Hawaii PPO	$100.79
Rate for Payer: MDX Hawaii PPO	$133.76
Rate for Payer: UnitedHealthcare Medicaid	$82.74
Rate for Payer: UnitedHealthcare Medicaid	$62.35
Rate for Payer: UnitedHealthcare Medicaid	$232.28
Rate for Payer: University Health Alliance Commercial	$282.19
Rate for Payer: University Health Alliance Commercial	$75.74
Rate for Payer: University Health Alliance Commercial	$100.52

SILVER SULFADIAZINE 1 % TOP CR

Facility

$137.90

Service Code	HCPCS A9270
Hospital Revenue Code	250
Min. Negotiated Rate	$117.22
Max. Negotiated Rate	$133.76
Rate for Payer: Cash Price	$89.64
Rate for Payer: Cash Price	$251.64
Rate for Payer: Cash Price	$67.54
Rate for Payer: Health Management Network Commercial	$88.32
Rate for Payer: Health Management Network Commercial	$117.22
Rate for Payer: Health Management Network Commercial	$329.07
Rate for Payer: MDX Hawaii PPO	$100.79
Rate for Payer: MDX Hawaii PPO	$375.53
Rate for Payer: MDX Hawaii PPO	$133.76

SIMETHICONE 40 MG/0.6 ML PO DRPS

Facility

$53.13

Service Code	HCPCS A9270
Hospital Revenue Code	250
Min. Negotiated Rate	$27.10
Max. Negotiated Rate	$51.54
Rate for Payer: Cash Price	$34.53
Rate for Payer: Cash Price	$7.86
Rate for Payer: Hawaii Western Management Group Commercial	$11.49
Rate for Payer: Hawaii Western Management Group Commercial	$50.47
Rate for Payer: Health Management Network Commercial	$10.28
Rate for Payer: Health Management Network Commercial	$45.16
Rate for Payer: Kaiser Permanente Commercial	$33.47
Rate for Payer: Kaiser Permanente Commercial	$7.62
Rate for Payer: Kaiser Permanente Medicaid	$27.10
Rate for Payer: Kaiser Permanente Medicaid	$6.17
Rate for Payer: MDX Hawaii PPO	$11.73
Rate for Payer: MDX Hawaii PPO	$51.54
Rate for Payer: UnitedHealthcare Medicaid	$7.25
Rate for Payer: UnitedHealthcare Medicaid	$31.88
Rate for Payer: University Health Alliance Commercial	$38.73
Rate for Payer: University Health Alliance Commercial	$8.81

SIMETHICONE 40 MG/0.6 ML PO DRPS

Facility

$12.09

Service Code	HCPCS A9270
Hospital Revenue Code	250
Min. Negotiated Rate	$10.28
Max. Negotiated Rate	$11.73
Rate for Payer: Cash Price	$7.86
Rate for Payer: Cash Price	$34.53
Rate for Payer: Health Management Network Commercial	$10.28
Rate for Payer: Health Management Network Commercial	$45.16
Rate for Payer: MDX Hawaii PPO	$11.73
Rate for Payer: MDX Hawaii PPO	$51.54

SIMETHICONE 80 MG PO CHEW

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: Cash Price	$0.85
Rate for Payer: Hawaii Western Management Group Commercial	$1.14
Rate for Payer: Hawaii Western Management Group Commercial	$1.24
Rate for Payer: Health Management Network Commercial	$1.02
Rate for Payer: Health Management Network Commercial	$1.10
Rate for Payer: Kaiser Permanente Commercial	$0.76
Rate for Payer: Kaiser Permanente Commercial	$0.82
Rate for Payer: Kaiser Permanente Medicaid	$0.61
Rate for Payer: Kaiser Permanente Medicaid	$0.66
Rate for Payer: MDX Hawaii PPO	$1.16
Rate for Payer: MDX Hawaii PPO	$1.26
Rate for Payer: UnitedHealthcare Medicaid	$0.78
Rate for Payer: UnitedHealthcare Medicaid	$0.72
Rate for Payer: University Health Alliance Commercial	$0.87
Rate for Payer: University Health Alliance Commercial	$0.95

SIMETHICONE 80 MG PO CHEW

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: Cash Price	$0.85
Rate for Payer: Health Management Network Commercial	$1.10
Rate for Payer: Health Management Network Commercial	$1.02
Rate for Payer: MDX Hawaii PPO	$1.16
Rate for Payer: MDX Hawaii PPO	$1.26

SIMPLE PNEUMONIA AND PLEURISY WITH CC

Facility

$24,203.43

Service Code	MSDRG 194
Min. Negotiated Rate	$10,599.83
Max. Negotiated Rate	$24,203.43
Rate for Payer: AlohaCare Medicare	$10,599.83
Rate for Payer: Devoted Health Medicare	$11,659.81
Rate for Payer: Hawaii Medical Service Association Commercial	$24,203.43
Rate for Payer: Hawaii Medical Service Association Medicare	$10,599.83
Rate for Payer: Humana Medicare	$10,599.83
Rate for Payer: Kaiser Permanente Commercial	$13,901.77
Rate for Payer: Kaiser Permanente Medicare	$10,599.83
Rate for Payer: Ohana Health Plan Medicare	$10,599.83
Rate for Payer: UnitedHealthcare Medicare	$10,599.83

SIMPLE PNEUMONIA AND PLEURISY WITH MCC

Facility

$25,047.17

Service Code	MSDRG 193
Min. Negotiated Rate	$17,287.99
Max. Negotiated Rate	$25,047.17
Rate for Payer: AlohaCare Medicare	$17,287.99
Rate for Payer: Devoted Health Medicare	$19,016.79
Rate for Payer: Hawaii Medical Service Association Commercial	$25,047.17
Rate for Payer: Hawaii Medical Service Association Medicare	$17,287.99
Rate for Payer: Humana Medicare	$17,287.99
Rate for Payer: Kaiser Permanente Commercial	$22,673.40
Rate for Payer: Kaiser Permanente Medicare	$17,287.99
Rate for Payer: Ohana Health Plan Medicare	$17,287.99
Rate for Payer: UnitedHealthcare Medicare	$17,287.99

SIMPLE PNEUMONIA AND PLEURISY WITHOUT CC/MCC

Facility

$19,261.49

Service Code	MSDRG 195
Min. Negotiated Rate	$8,266.50
Max. Negotiated Rate	$19,261.49
Rate for Payer: AlohaCare Medicare	$8,266.50
Rate for Payer: Devoted Health Medicare	$9,093.15
Rate for Payer: Hawaii Medical Service Association Commercial	$19,261.49
Rate for Payer: Hawaii Medical Service Association Medicare	$8,266.50
Rate for Payer: Humana Medicare	$8,266.50
Rate for Payer: Kaiser Permanente Commercial	$10,841.62
Rate for Payer: Kaiser Permanente Medicare	$8,266.50
Rate for Payer: Ohana Health Plan Medicare	$8,266.50
Rate for Payer: UnitedHealthcare Medicare	$8,266.50

SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR MUCOUS MEMBRANES; 20.1 CM TO 30.0 CM

Facility

$2,837.00

Service Code	CPT 12017
Hospital Revenue Code	360
Min. Negotiated Rate	$260.29
Max. Negotiated Rate	$2,837.00
Rate for Payer: AlohaCare Medicaid	$480.23
Rate for Payer: AlohaCare Medicare	$480.23
Rate for Payer: Devoted Health Medicare	$528.25
Rate for Payer: Hawaii Medical Service Association Commercial	$600.29
Rate for Payer: Hawaii Medical Service Association Medicare	$480.23
Rate for Payer: Humana Medicare	$480.23
Rate for Payer: Kaiser Permanente Medicaid	$2,837.00
Rate for Payer: Kaiser Permanente Medicare	$480.23
Rate for Payer: Ohana Health Plan Medicaid	$528.25
Rate for Payer: Ohana Health Plan Medicare	$480.23
Rate for Payer: UnitedHealthcare Medicaid	$260.29
Rate for Payer: UnitedHealthcare Medicare	$480.23

SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR MUCOUS MEMBRANES; 2.5 CM OR LESS

Facility

$2,837.00

Service Code	CPT 12011
Hospital Revenue Code	360
Min. Negotiated Rate	$75.59
Max. Negotiated Rate	$2,837.00
Rate for Payer: AlohaCare Medicaid	$237.02
Rate for Payer: AlohaCare Medicare	$237.02
Rate for Payer: Devoted Health Medicare	$260.72
Rate for Payer: Hawaii Medical Service Association Commercial	$296.27
Rate for Payer: Hawaii Medical Service Association Medicare	$237.02
Rate for Payer: Humana Medicare	$237.02
Rate for Payer: Kaiser Permanente Medicaid	$2,837.00
Rate for Payer: Kaiser Permanente Medicare	$237.02
Rate for Payer: Ohana Health Plan Medicaid	$260.72
Rate for Payer: Ohana Health Plan Medicare	$237.02
Rate for Payer: UnitedHealthcare Medicaid	$75.59
Rate for Payer: UnitedHealthcare Medicare	$237.02

SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR MUCOUS MEMBRANES; 5.1 CM TO 7.5 CM

Facility

$2,837.00

Service Code	CPT 12014
Hospital Revenue Code	360
Min. Negotiated Rate	$106.74
Max. Negotiated Rate	$2,837.00
Rate for Payer: AlohaCare Medicaid	$237.02
Rate for Payer: AlohaCare Medicare	$237.02
Rate for Payer: Devoted Health Medicare	$260.72
Rate for Payer: Hawaii Medical Service Association Commercial	$296.27
Rate for Payer: Hawaii Medical Service Association Medicare	$237.02
Rate for Payer: Humana Medicare	$237.02
Rate for Payer: Kaiser Permanente Medicaid	$2,837.00
Rate for Payer: Kaiser Permanente Medicare	$237.02
Rate for Payer: Ohana Health Plan Medicaid	$260.72
Rate for Payer: Ohana Health Plan Medicare	$237.02
Rate for Payer: UnitedHealthcare Medicaid	$106.74
Rate for Payer: UnitedHealthcare Medicare	$237.02

SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF SCALP, NECK, AXILLAE, EXTERNAL GENITALIA, TRUNK AND/OR EXTREMITIES (INCLUDING HANDS AND FEET); 2.5 CM OR LESS

Facility

$2,837.00

Service Code	CPT 12001
Hospital Revenue Code	360
Min. Negotiated Rate	$70.95
Max. Negotiated Rate	$2,837.00
Rate for Payer: AlohaCare Medicaid	$237.02
Rate for Payer: AlohaCare Medicare	$237.02
Rate for Payer: Devoted Health Medicare	$260.72
Rate for Payer: Hawaii Medical Service Association Commercial	$296.27
Rate for Payer: Hawaii Medical Service Association Medicare	$237.02
Rate for Payer: Humana Medicare	$237.02
Rate for Payer: Kaiser Permanente Medicaid	$2,837.00
Rate for Payer: Kaiser Permanente Medicare	$237.02
Rate for Payer: Ohana Health Plan Medicaid	$260.72
Rate for Payer: Ohana Health Plan Medicare	$237.02
Rate for Payer: UnitedHealthcare Medicaid	$70.95
Rate for Payer: UnitedHealthcare Medicare	$237.02

SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF SCALP, NECK, AXILLAE, EXTERNAL GENITALIA, TRUNK AND/OR EXTREMITIES (INCLUDING HANDS AND FEET); 2.6 CM TO 7.5 CM

Facility

$2,837.00

Service Code	CPT 12002
Hospital Revenue Code	360
Min. Negotiated Rate	$79.78
Max. Negotiated Rate	$2,837.00
Rate for Payer: AlohaCare Medicaid	$237.02
Rate for Payer: AlohaCare Medicare	$237.02
Rate for Payer: Devoted Health Medicare	$260.72
Rate for Payer: Hawaii Medical Service Association Commercial	$296.27
Rate for Payer: Hawaii Medical Service Association Medicare	$237.02
Rate for Payer: Humana Medicare	$237.02
Rate for Payer: Kaiser Permanente Medicaid	$2,837.00
Rate for Payer: Kaiser Permanente Medicare	$237.02
Rate for Payer: Ohana Health Plan Medicaid	$260.72
Rate for Payer: Ohana Health Plan Medicare	$237.02
Rate for Payer: UnitedHealthcare Medicaid	$79.78
Rate for Payer: UnitedHealthcare Medicare	$237.02

SIMULTANEOUS PANCREAS AND KIDNEY TRANSPLANT

Facility

$708,769.91

Service Code	MSDRG 008
Min. Negotiated Rate	$10,400.00
Max. Negotiated Rate	$708,769.91
Rate for Payer: AlohaCare Medicare	$73,715.99
Rate for Payer: Devoted Health Medicare	$81,087.59
Rate for Payer: Hawaii Medical Service Association Commercial	$708,769.91
Rate for Payer: Hawaii Medical Service Association Medicare	$73,715.99
Rate for Payer: Kaiser Permanente Commercial	$96,679.35
Rate for Payer: Kaiser Permanente Medicare	$73,715.99
Rate for Payer: Ohana Health Plan Medicare	$73,715.99
Rate for Payer: UnitedHealthcare Medicare	$73,715.99
Rate for Payer: University Health Alliance Commercial	$10,400.00

SIMULTANEOUS PANCREAS AND KIDNEY TRANSPLANT WITH HEMODIALYSIS

Facility

$114,319.20

Service Code	MSDRG 019
Min. Negotiated Rate	$93,839.72
Max. Negotiated Rate	$114,319.20
Rate for Payer: AlohaCare Medicare	$93,839.72
Rate for Payer: Devoted Health Medicare	$103,223.69
Rate for Payer: Hawaii Medical Service Association Medicare	$93,839.72
Rate for Payer: Humana Medicare	$93,839.72
Rate for Payer: Kaiser Permanente Commercial	$114,319.20
Rate for Payer: Kaiser Permanente Medicare	$93,839.72
Rate for Payer: Ohana Health Plan Medicare	$93,839.72
Rate for Payer: UnitedHealthcare Medicare	$93,839.72

SINCALIDE 5 MCG INJ RECON.SOLN.

Facility

$523.65

Service Code	HCPCS J2805
Hospital Revenue Code	250
Min. Negotiated Rate	$445.10
Max. Negotiated Rate	$507.94
Rate for Payer: Cash Price	$340.37
Rate for Payer: Health Management Network Commercial	$445.10
Rate for Payer: MDX Hawaii PPO	$507.94

SINCALIDE 5 MCG INJ RECON.SOLN.

Facility

$523.65

Service Code	HCPCS J2805
Hospital Revenue Code	636
Min. Negotiated Rate	$135.97
Max. Negotiated Rate	$507.94
Rate for Payer: Cash Price	$340.37
Rate for Payer: Cash Price	$340.37
Rate for Payer: Hawaii Medical Service Association ABD	$135.97
Rate for Payer: Hawaii Medical Service Association Non-ABD	$135.97
Rate for Payer: Hawaii Western Management Group Commercial	$497.47
Rate for Payer: Health Management Network Commercial	$445.10
Rate for Payer: Kaiser Permanente Commercial	$329.90
Rate for Payer: Kaiser Permanente Medicaid	$267.06
Rate for Payer: MDX Hawaii PPO	$507.94
Rate for Payer: UnitedHealthcare Medicaid	$314.19
Rate for Payer: University Health Alliance Commercial	$381.69

Single Action Pumping System M0067201001 [3642089]

Facility

$339.71

Hospital Charge Code	3642089
Hospital Revenue Code	272
Min. Negotiated Rate	$288.75
Max. Negotiated Rate	$329.52
Rate for Payer: Cash Price	$220.81
Rate for Payer: Health Management Network Commercial	$288.75
Rate for Payer: MDX Hawaii PPO	$329.52

Single Action Pumping System M0067201001 [3642089]

Facility

$339.71

Hospital Charge Code	3642089
Hospital Revenue Code	272
Min. Negotiated Rate	$173.25
Max. Negotiated Rate	$329.52
Rate for Payer: Cash Price	$220.81
Rate for Payer: Hawaii Western Management Group Commercial	$322.72
Rate for Payer: Health Management Network Commercial	$288.75
Rate for Payer: Kaiser Permanente Commercial	$214.02
Rate for Payer: Kaiser Permanente Medicaid	$173.25
Rate for Payer: MDX Hawaii PPO	$329.52
Rate for Payer: University Health Alliance Commercial	$247.61

SINGLE LEVEL COMBINED ANTERIOR AND POSTERIOR SPINAL FUSION EXCEPT CERVICAL

Facility

$117,569.84

Service Code	MSDRG 402
Min. Negotiated Rate	$52,880.69
Max. Negotiated Rate	$117,569.84
Rate for Payer: AlohaCare Medicare	$52,880.69
Rate for Payer: Devoted Health Medicare	$58,168.76
Rate for Payer: Hawaii Medical Service Association Commercial	$117,569.84
Rate for Payer: Hawaii Medical Service Association Medicare	$52,880.69
Rate for Payer: Humana Medicare	$52,880.69
Rate for Payer: Kaiser Permanente Commercial	$69,353.62
Rate for Payer: Kaiser Permanente Medicare	$52,880.69
Rate for Payer: Ohana Health Plan Medicare	$52,880.69
Rate for Payer: UnitedHealthcare Medicare	$52,880.69

SINGLE LEVEL SPINAL FUSION EXCEPT CERVICAL WITH MCC OR CUSTOM-MADE ANATOMICALLY DESIGNED INTERBODY FUSION DEVICE

Facility

$91,935.60

Service Code	MSDRG 450
Min. Negotiated Rate	$70,098.98
Max. Negotiated Rate	$91,935.60
Rate for Payer: AlohaCare Medicare	$70,098.98
Rate for Payer: Devoted Health Medicare	$77,108.88
Rate for Payer: Hawaii Medical Service Association Medicare	$70,098.98
Rate for Payer: Humana Medicare	$70,098.98
Rate for Payer: Kaiser Permanente Commercial	$91,935.60
Rate for Payer: Kaiser Permanente Medicare	$70,098.98
Rate for Payer: Ohana Health Plan Medicare	$70,098.98
Rate for Payer: UnitedHealthcare Medicare	$70,098.98

SINGLE LEVEL SPINAL FUSION EXCEPT CERVICAL WITHOUT MCC

Facility

$55,724.40

Service Code	MSDRG 451
Min. Negotiated Rate	$42,488.70
Max. Negotiated Rate	$55,724.40
Rate for Payer: AlohaCare Medicare	$42,488.70
Rate for Payer: Devoted Health Medicare	$46,737.57
Rate for Payer: Hawaii Medical Service Association Medicare	$42,488.70
Rate for Payer: Humana Medicare	$42,488.70
Rate for Payer: Kaiser Permanente Commercial	$55,724.40
Rate for Payer: Kaiser Permanente Medicare	$42,488.70
Rate for Payer: Ohana Health Plan Medicare	$42,488.70
Rate for Payer: UnitedHealthcare Medicare	$42,488.70

SINUS AND MASTOID PROCEDURES WITH CC/MCC

Facility

$36,487.20

Service Code	MSDRG 135
Min. Negotiated Rate	$26,324.84
Max. Negotiated Rate	$36,487.20
Rate for Payer: AlohaCare Medicare	$28,541.50
Rate for Payer: Devoted Health Medicare	$31,395.65
Rate for Payer: Hawaii Medical Service Association Commercial	$26,324.84
Rate for Payer: Hawaii Medical Service Association Medicare	$28,541.50
Rate for Payer: Humana Medicare	$28,541.50
Rate for Payer: Kaiser Permanente Commercial	$36,487.20
Rate for Payer: Kaiser Permanente Medicare	$28,541.50
Rate for Payer: Ohana Health Plan Medicare	$28,541.50
Rate for Payer: UnitedHealthcare Medicare	$28,541.50

SINUS AND MASTOID PROCEDURES WITHOUT CC/MCC

Facility

$26,324.84

Service Code	MSDRG 136
Min. Negotiated Rate	$13,354.01
Max. Negotiated Rate	$26,324.84
Rate for Payer: AlohaCare Medicare	$13,354.01
Rate for Payer: Devoted Health Medicare	$14,689.41
Rate for Payer: Hawaii Medical Service Association Commercial	$26,324.84
Rate for Payer: Hawaii Medical Service Association Medicare	$13,354.01
Rate for Payer: Humana Medicare	$13,354.01
Rate for Payer: Kaiser Permanente Commercial	$17,513.92
Rate for Payer: Kaiser Permanente Medicare	$13,354.01
Rate for Payer: Ohana Health Plan Medicare	$13,354.01
Rate for Payer: UnitedHealthcare Medicare	$13,354.01

Know your out-of-pocket cost for care.

All Charges