Kona Community Hospital

All Charges

Charge

Type

Setting

Price

SIPULEUCEL-T AUTO CD54+

Professional

Both

$90,000.00

Service Code	HCPCS Q2043
Min. Negotiated Rate	$56,269.19
Max. Negotiated Rate	$76,500.00
Rate for Payer: AlohaCare Medicare	$56,269.19
Rate for Payer: Cash Price	$58,500.00
Rate for Payer: Cash Price	$58,500.00
Rate for Payer: Devoted Health Medicare	$61,896.11
Rate for Payer: Hawaii Medical Service Association Medicare	$56,269.19
Rate for Payer: Health Management Network Commercial	$76,500.00
Rate for Payer: Kaiser Permanente Commercial	$67,523.03
Rate for Payer: Kaiser Permanente Medicaid	$67,523.03
Rate for Payer: Kaiser Permanente Medicare	$67,523.03
Rate for Payer: Ohana Health Plan Medicare	$56,269.19
Rate for Payer: UnitedHealthcare Medicare	$56,269.19

SITAGLIPTIN PHOSPHATE 50 MG PO TABLET

Facility

$63.54

Service Code	HCPCS A9270
Hospital Revenue Code	250
Min. Negotiated Rate	$32.41
Max. Negotiated Rate	$61.63
Rate for Payer: Cash Price	$41.30
Rate for Payer: Hawaii Western Management Group Commercial	$60.36
Rate for Payer: Health Management Network Commercial	$54.01
Rate for Payer: Kaiser Permanente Commercial	$40.03
Rate for Payer: Kaiser Permanente Medicaid	$32.41
Rate for Payer: MDX Hawaii PPO	$61.63
Rate for Payer: UnitedHealthcare Medicaid	$38.12
Rate for Payer: University Health Alliance Commercial	$46.31

SITAGLIPTIN PHOSPHATE 50 MG PO TABLET

Facility

$63.54

Service Code	HCPCS A9270
Hospital Revenue Code	250
Min. Negotiated Rate	$54.01
Max. Negotiated Rate	$61.63
Rate for Payer: Cash Price	$41.30
Rate for Payer: Health Management Network Commercial	$54.01
Rate for Payer: MDX Hawaii PPO	$61.63

Skin Closure Surgical Stryker Zip 16 Device PS1160 [3642507]

Facility

$452.30

Hospital Charge Code	3642507
Hospital Revenue Code	272
Min. Negotiated Rate	$384.45
Max. Negotiated Rate	$438.73
Rate for Payer: Cash Price	$294.00
Rate for Payer: Health Management Network Commercial	$384.45
Rate for Payer: MDX Hawaii PPO	$438.73

Skin Closure Surgical Stryker Zip 16 Device PS1160 [3642507]

Facility

$452.30

Hospital Charge Code	3642507
Hospital Revenue Code	272
Min. Negotiated Rate	$230.67
Max. Negotiated Rate	$438.73
Rate for Payer: Cash Price	$294.00
Rate for Payer: Hawaii Western Management Group Commercial	$429.69
Rate for Payer: Health Management Network Commercial	$384.45
Rate for Payer: Kaiser Permanente Commercial	$284.95
Rate for Payer: Kaiser Permanente Medicaid	$230.67
Rate for Payer: MDX Hawaii PPO	$438.73
Rate for Payer: University Health Alliance Commercial	$329.68

Skin Closure Surgical Stryker Zip 8i Device PS2080 [3642508]

Facility

$398.24

Hospital Charge Code	3642508
Hospital Revenue Code	272
Min. Negotiated Rate	$203.10
Max. Negotiated Rate	$386.29
Rate for Payer: Cash Price	$258.86
Rate for Payer: Hawaii Western Management Group Commercial	$378.33
Rate for Payer: Health Management Network Commercial	$338.50
Rate for Payer: Kaiser Permanente Commercial	$250.89
Rate for Payer: Kaiser Permanente Medicaid	$203.10
Rate for Payer: MDX Hawaii PPO	$386.29
Rate for Payer: University Health Alliance Commercial	$290.28

Skin Closure Surgical Stryker Zip 8i Device PS2080 [3642508]

Facility

$398.24

Hospital Charge Code	3642508
Hospital Revenue Code	272
Min. Negotiated Rate	$338.50
Max. Negotiated Rate	$386.29
Rate for Payer: Cash Price	$258.86
Rate for Payer: Health Management Network Commercial	$338.50
Rate for Payer: MDX Hawaii PPO	$386.29

SKIN DEBRIDEMENT WITH CC

Facility

$58,941.61

Service Code	MSDRG 571
Min. Negotiated Rate	$22,221.60
Max. Negotiated Rate	$58,941.61
Rate for Payer: AlohaCare Medicare	$22,221.60
Rate for Payer: Devoted Health Medicare	$24,443.76
Rate for Payer: Hawaii Medical Service Association Commercial	$58,941.61
Rate for Payer: Hawaii Medical Service Association Medicare	$22,221.60
Rate for Payer: Humana Medicare	$22,221.60
Rate for Payer: Kaiser Permanente Commercial	$29,143.88
Rate for Payer: Kaiser Permanente Medicare	$22,221.60
Rate for Payer: Ohana Health Plan Medicare	$22,221.60
Rate for Payer: UnitedHealthcare Medicare	$22,221.60

SKIN DEBRIDEMENT WITH MCC

Facility

$61,834.46

Service Code	MSDRG 570
Min. Negotiated Rate	$38,683.61
Max. Negotiated Rate	$61,834.46
Rate for Payer: AlohaCare Medicare	$38,683.61
Rate for Payer: Devoted Health Medicare	$42,551.97
Rate for Payer: Hawaii Medical Service Association Commercial	$61,834.46
Rate for Payer: Hawaii Medical Service Association Medicare	$38,683.61
Rate for Payer: Humana Medicare	$38,683.61
Rate for Payer: Kaiser Permanente Commercial	$50,733.97
Rate for Payer: Kaiser Permanente Medicare	$38,683.61
Rate for Payer: Ohana Health Plan Medicare	$38,683.61
Rate for Payer: UnitedHealthcare Medicare	$38,683.61

SKIN DEBRIDEMENT WITHOUT CC/MCC

Facility

$30,495.35

Service Code	MSDRG 572
Min. Negotiated Rate	$15,077.02
Max. Negotiated Rate	$30,495.35
Rate for Payer: AlohaCare Medicare	$15,077.02
Rate for Payer: Devoted Health Medicare	$16,584.72
Rate for Payer: Hawaii Medical Service Association Commercial	$30,495.35
Rate for Payer: Hawaii Medical Service Association Medicare	$15,077.02
Rate for Payer: Humana Medicare	$15,077.02
Rate for Payer: Kaiser Permanente Commercial	$19,773.67
Rate for Payer: Kaiser Permanente Medicare	$15,077.02
Rate for Payer: Ohana Health Plan Medicare	$15,077.02
Rate for Payer: UnitedHealthcare Medicare	$15,077.02

SKIN GRAFT EXCEPT FOR SKIN ULCER OR CELLULITIS WITH CC

Facility

$60,918.39

Service Code	MSDRG 577
Min. Negotiated Rate	$34,864.04
Max. Negotiated Rate	$60,918.39
Rate for Payer: AlohaCare Medicare	$34,864.04
Rate for Payer: Devoted Health Medicare	$38,350.44
Rate for Payer: Hawaii Medical Service Association Commercial	$60,918.39
Rate for Payer: Hawaii Medical Service Association Medicare	$34,864.04
Rate for Payer: Humana Medicare	$34,864.04
Rate for Payer: Kaiser Permanente Commercial	$45,724.57
Rate for Payer: Kaiser Permanente Medicare	$34,864.04
Rate for Payer: Ohana Health Plan Medicare	$34,864.04
Rate for Payer: UnitedHealthcare Medicare	$34,864.04

SKIN GRAFT EXCEPT FOR SKIN ULCER OR CELLULITIS WITH MCC

Facility

$84,545.70

Service Code	MSDRG 576
Min. Negotiated Rate	$60,918.39
Max. Negotiated Rate	$84,545.70
Rate for Payer: AlohaCare Medicare	$64,464.34
Rate for Payer: Devoted Health Medicare	$70,910.77
Rate for Payer: Hawaii Medical Service Association Commercial	$60,918.39
Rate for Payer: Hawaii Medical Service Association Medicare	$64,464.34
Rate for Payer: Humana Medicare	$64,464.34
Rate for Payer: Kaiser Permanente Commercial	$84,545.70
Rate for Payer: Kaiser Permanente Medicare	$64,464.34
Rate for Payer: Ohana Health Plan Medicare	$64,464.34
Rate for Payer: UnitedHealthcare Medicare	$64,464.34

SKIN GRAFT EXCEPT FOR SKIN ULCER OR CELLULITIS WITHOUT CC/MCC

Facility

$27,710.40

Service Code	MSDRG 578
Min. Negotiated Rate	$14,391.88
Max. Negotiated Rate	$27,710.40
Rate for Payer: AlohaCare Medicare	$21,128.61
Rate for Payer: Devoted Health Medicare	$23,241.47
Rate for Payer: Hawaii Medical Service Association Commercial	$14,391.88
Rate for Payer: Hawaii Medical Service Association Medicare	$21,128.61
Rate for Payer: Humana Medicare	$21,128.61
Rate for Payer: Kaiser Permanente Commercial	$27,710.40
Rate for Payer: Kaiser Permanente Medicare	$21,128.61
Rate for Payer: Ohana Health Plan Medicare	$21,128.61
Rate for Payer: UnitedHealthcare Medicare	$21,128.61

SKIN GRAFT, EXCEPT HAND, FOR MUSCULOSKELETAL & CONNECTIVE TISSUE DIAGNOSES

Facility

$26,185.98

Service Code	APR-DRG 3124
Min. Negotiated Rate	$26,185.98
Max. Negotiated Rate	$26,185.98
Rate for Payer: AlohaCare Medicaid	$26,185.98
Rate for Payer: Hawaii Medical Service Association ABD	$26,185.98
Rate for Payer: Hawaii Medical Service Association Non-ABD	$26,185.98
Rate for Payer: Kaiser Permanente Medicaid	$26,185.98
Rate for Payer: Ohana Health Plan Medicaid	$26,185.98
Rate for Payer: UnitedHealthcare Medicaid	$26,185.98

SKIN GRAFT, EXCEPT HAND, FOR MUSCULOSKELETAL & CONNECTIVE TISSUE DIAGNOSES

Facility

$5,881.51

Service Code	APR-DRG 3121
Min. Negotiated Rate	$5,881.51
Max. Negotiated Rate	$5,881.51
Rate for Payer: AlohaCare Medicaid	$5,881.51
Rate for Payer: Hawaii Medical Service Association ABD	$5,881.51
Rate for Payer: Hawaii Medical Service Association Non-ABD	$5,881.51
Rate for Payer: Kaiser Permanente Medicaid	$5,881.51
Rate for Payer: Ohana Health Plan Medicaid	$5,881.51
Rate for Payer: UnitedHealthcare Medicaid	$5,881.51

SKIN GRAFT, EXCEPT HAND, FOR MUSCULOSKELETAL & CONNECTIVE TISSUE DIAGNOSES

Facility

$12,413.84

Service Code	APR-DRG 3123
Min. Negotiated Rate	$12,413.84
Max. Negotiated Rate	$12,413.84
Rate for Payer: AlohaCare Medicaid	$12,413.84
Rate for Payer: Hawaii Medical Service Association ABD	$12,413.84
Rate for Payer: Hawaii Medical Service Association Non-ABD	$12,413.84
Rate for Payer: Kaiser Permanente Medicaid	$12,413.84
Rate for Payer: Ohana Health Plan Medicaid	$12,413.84
Rate for Payer: UnitedHealthcare Medicaid	$12,413.84

SKIN GRAFT, EXCEPT HAND, FOR MUSCULOSKELETAL & CONNECTIVE TISSUE DIAGNOSES

Facility

$7,546.75

Service Code	APR-DRG 3122
Min. Negotiated Rate	$7,546.75
Max. Negotiated Rate	$7,546.75
Rate for Payer: AlohaCare Medicaid	$7,546.75
Rate for Payer: Hawaii Medical Service Association ABD	$7,546.75
Rate for Payer: Hawaii Medical Service Association Non-ABD	$7,546.75
Rate for Payer: Kaiser Permanente Medicaid	$7,546.75
Rate for Payer: Ohana Health Plan Medicaid	$7,546.75
Rate for Payer: UnitedHealthcare Medicaid	$7,546.75

SKIN GRAFT FOR SKIN & SUBCUTANEOUS TISSUE DIAGNOSES

Facility

$6,336.19

Service Code	APR-DRG 3612
Min. Negotiated Rate	$6,336.19
Max. Negotiated Rate	$6,336.19
Rate for Payer: AlohaCare Medicaid	$6,336.19
Rate for Payer: Hawaii Medical Service Association ABD	$6,336.19
Rate for Payer: Hawaii Medical Service Association Non-ABD	$6,336.19
Rate for Payer: Kaiser Permanente Medicaid	$6,336.19
Rate for Payer: Ohana Health Plan Medicaid	$6,336.19
Rate for Payer: UnitedHealthcare Medicaid	$6,336.19

SKIN GRAFT FOR SKIN & SUBCUTANEOUS TISSUE DIAGNOSES

Facility

$5,475.87

Service Code	APR-DRG 3611
Min. Negotiated Rate	$5,475.87
Max. Negotiated Rate	$5,475.87
Rate for Payer: AlohaCare Medicaid	$5,475.87
Rate for Payer: Hawaii Medical Service Association ABD	$5,475.87
Rate for Payer: Hawaii Medical Service Association Non-ABD	$5,475.87
Rate for Payer: Kaiser Permanente Medicaid	$5,475.87
Rate for Payer: Ohana Health Plan Medicaid	$5,475.87
Rate for Payer: UnitedHealthcare Medicaid	$5,475.87

SKIN GRAFT FOR SKIN & SUBCUTANEOUS TISSUE DIAGNOSES

Facility

$20,696.73

Service Code	APR-DRG 3614
Min. Negotiated Rate	$20,696.73
Max. Negotiated Rate	$20,696.73
Rate for Payer: AlohaCare Medicaid	$20,696.73
Rate for Payer: Hawaii Medical Service Association ABD	$20,696.73
Rate for Payer: Hawaii Medical Service Association Non-ABD	$20,696.73
Rate for Payer: Kaiser Permanente Medicaid	$20,696.73
Rate for Payer: Ohana Health Plan Medicaid	$20,696.73
Rate for Payer: UnitedHealthcare Medicaid	$20,696.73

SKIN GRAFT FOR SKIN & SUBCUTANEOUS TISSUE DIAGNOSES

Facility

$9,461.62

Service Code	APR-DRG 3613
Min. Negotiated Rate	$9,461.62
Max. Negotiated Rate	$9,461.62
Rate for Payer: AlohaCare Medicaid	$9,461.62
Rate for Payer: Hawaii Medical Service Association ABD	$9,461.62
Rate for Payer: Hawaii Medical Service Association Non-ABD	$9,461.62
Rate for Payer: Kaiser Permanente Medicaid	$9,461.62
Rate for Payer: Ohana Health Plan Medicaid	$9,461.62
Rate for Payer: UnitedHealthcare Medicaid	$9,461.62

SKIN GRAFT FOR SKIN ULCER OR CELLULITIS WITH CC

Facility

$59,881.65

Service Code	MSDRG 574
Min. Negotiated Rate	$45,658.51
Max. Negotiated Rate	$59,881.65
Rate for Payer: AlohaCare Medicare	$45,658.51
Rate for Payer: Devoted Health Medicare	$50,224.36
Rate for Payer: Hawaii Medical Service Association Commercial	$58,724.65
Rate for Payer: Hawaii Medical Service Association Medicare	$45,658.51
Rate for Payer: Humana Medicare	$45,658.51
Rate for Payer: Kaiser Permanente Commercial	$59,881.65
Rate for Payer: Kaiser Permanente Medicare	$45,658.51
Rate for Payer: Ohana Health Plan Medicare	$45,658.51
Rate for Payer: UnitedHealthcare Medicare	$45,658.51

SKIN GRAFT FOR SKIN ULCER OR CELLULITIS WITH MCC

Facility

$113,011.65

Service Code	MSDRG 573
Min. Negotiated Rate	$61,930.88
Max. Negotiated Rate	$113,011.65
Rate for Payer: AlohaCare Medicare	$86,169.04
Rate for Payer: Devoted Health Medicare	$94,785.94
Rate for Payer: Hawaii Medical Service Association Commercial	$61,930.88
Rate for Payer: Hawaii Medical Service Association Medicare	$86,169.04
Rate for Payer: Humana Medicare	$86,169.04
Rate for Payer: Kaiser Permanente Commercial	$113,011.65
Rate for Payer: Kaiser Permanente Medicare	$86,169.04
Rate for Payer: Ohana Health Plan Medicare	$86,169.04
Rate for Payer: UnitedHealthcare Medicare	$86,169.04

SKIN GRAFT FOR SKIN ULCER OR CELLULITIS WITHOUT CC/MCC

Facility

$35,581.93

Service Code	MSDRG 575
Min. Negotiated Rate	$23,635.51
Max. Negotiated Rate	$35,581.93
Rate for Payer: AlohaCare Medicare	$23,635.51
Rate for Payer: Devoted Health Medicare	$25,999.06
Rate for Payer: Hawaii Medical Service Association Commercial	$35,581.93
Rate for Payer: Hawaii Medical Service Association Medicare	$23,635.51
Rate for Payer: Humana Medicare	$23,635.51
Rate for Payer: Kaiser Permanente Commercial	$28,179.60
Rate for Payer: Kaiser Permanente Medicare	$23,635.51
Rate for Payer: Ohana Health Plan Medicare	$23,635.51
Rate for Payer: UnitedHealthcare Medicare	$23,635.51

SKIN GRAFTS AND WOUND DEBRIDEMENT FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS WITH CC

Facility

$46,864.01

Service Code	MSDRG 623
Min. Negotiated Rate	$23,594.75
Max. Negotiated Rate	$46,864.01
Rate for Payer: AlohaCare Medicare	$23,594.75
Rate for Payer: Devoted Health Medicare	$25,954.22
Rate for Payer: Hawaii Medical Service Association Commercial	$46,864.01
Rate for Payer: Hawaii Medical Service Association Medicare	$23,594.75
Rate for Payer: Humana Medicare	$23,594.75
Rate for Payer: Kaiser Permanente Commercial	$30,944.78
Rate for Payer: Kaiser Permanente Medicare	$23,594.75
Rate for Payer: Ohana Health Plan Medicare	$23,594.75
Rate for Payer: UnitedHealthcare Medicare	$23,594.75

Know your out-of-pocket cost for care.

All Charges