Kona Community Hospital

All Charges

Charge

Type

Setting

Price

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

Facility

$61,396.20

Service Code	MSDRG 622
Min. Negotiated Rate	$46,813.32
Max. Negotiated Rate	$61,396.20
Rate for Payer: AlohaCare Medicare	$46,813.32
Rate for Payer: Devoted Health Medicare	$51,494.65
Rate for Payer: Hawaii Medical Service Association Commercial	$46,864.01
Rate for Payer: Hawaii Medical Service Association Medicare	$46,813.32
Rate for Payer: Humana Medicare	$46,813.32
Rate for Payer: Kaiser Permanente Commercial	$61,396.20
Rate for Payer: Kaiser Permanente Medicare	$46,813.32
Rate for Payer: Ohana Health Plan Medicare	$46,813.32
Rate for Payer: UnitedHealthcare Medicare	$46,813.32

SKIN GRAFTS AND WOUND DEBRIDEMENT FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS WITHOUT CC/MCC

Facility

$46,864.01

Service Code	MSDRG 624
Min. Negotiated Rate	$16,465.95
Max. Negotiated Rate	$46,864.01
Rate for Payer: AlohaCare Medicare	$16,465.95
Rate for Payer: Devoted Health Medicare	$18,112.54
Rate for Payer: Hawaii Medical Service Association Commercial	$46,864.01
Rate for Payer: Hawaii Medical Service Association Medicare	$16,465.95
Rate for Payer: Humana Medicare	$16,465.95
Rate for Payer: Kaiser Permanente Commercial	$21,595.28
Rate for Payer: Kaiser Permanente Medicare	$16,465.95
Rate for Payer: Ohana Health Plan Medicare	$16,465.95
Rate for Payer: UnitedHealthcare Medicare	$16,465.95

SKIN GRAFTS FOR INJURIES WITH CC/MCC

Facility

$66,173.71

Service Code	MSDRG 904
Min. Negotiated Rate	$48,311.43
Max. Negotiated Rate	$66,173.71
Rate for Payer: AlohaCare Medicare	$48,311.43
Rate for Payer: Devoted Health Medicare	$53,142.57
Rate for Payer: Hawaii Medical Service Association Commercial	$66,173.71
Rate for Payer: Hawaii Medical Service Association Medicare	$48,311.43
Rate for Payer: Humana Medicare	$48,311.43
Rate for Payer: Kaiser Permanente Commercial	$63,360.97
Rate for Payer: Kaiser Permanente Medicare	$48,311.43
Rate for Payer: Ohana Health Plan Medicare	$48,311.43
Rate for Payer: UnitedHealthcare Medicare	$48,311.43

SKIN GRAFTS FOR INJURIES WITHOUT CC/MCC

Facility

$66,173.71

Service Code	MSDRG 905
Min. Negotiated Rate	$19,510.81
Max. Negotiated Rate	$66,173.71
Rate for Payer: AlohaCare Medicare	$19,510.81
Rate for Payer: Devoted Health Medicare	$21,461.89
Rate for Payer: Hawaii Medical Service Association Commercial	$66,173.71
Rate for Payer: Hawaii Medical Service Association Medicare	$19,510.81
Rate for Payer: Humana Medicare	$19,510.81
Rate for Payer: Kaiser Permanente Commercial	$24,698.55
Rate for Payer: Kaiser Permanente Medicare	$19,510.81
Rate for Payer: Ohana Health Plan Medicare	$19,510.81
Rate for Payer: UnitedHealthcare Medicare	$19,510.81

SKIN ULCERS

Facility

$9,106.92

Service Code	APR-DRG 3804
Min. Negotiated Rate	$9,106.92
Max. Negotiated Rate	$9,106.92
Rate for Payer: AlohaCare Medicaid	$9,106.92
Rate for Payer: Hawaii Medical Service Association ABD	$9,106.92
Rate for Payer: Hawaii Medical Service Association Non-ABD	$9,106.92
Rate for Payer: Kaiser Permanente Medicaid	$9,106.92
Rate for Payer: Ohana Health Plan Medicaid	$9,106.92
Rate for Payer: UnitedHealthcare Medicaid	$9,106.92

SKIN ULCERS

Facility

$4,864.54

Service Code	APR-DRG 3803
Min. Negotiated Rate	$4,864.54
Max. Negotiated Rate	$4,864.54
Rate for Payer: AlohaCare Medicaid	$4,864.54
Rate for Payer: Hawaii Medical Service Association ABD	$4,864.54
Rate for Payer: Hawaii Medical Service Association Non-ABD	$4,864.54
Rate for Payer: Kaiser Permanente Medicaid	$4,864.54
Rate for Payer: Ohana Health Plan Medicaid	$4,864.54
Rate for Payer: UnitedHealthcare Medicaid	$4,864.54

SKIN ULCERS

Facility

$2,797.48

Service Code	APR-DRG 3801
Min. Negotiated Rate	$2,797.48
Max. Negotiated Rate	$2,797.48
Rate for Payer: AlohaCare Medicaid	$2,797.48
Rate for Payer: Hawaii Medical Service Association ABD	$2,797.48
Rate for Payer: Hawaii Medical Service Association Non-ABD	$2,797.48
Rate for Payer: Kaiser Permanente Medicaid	$2,797.48
Rate for Payer: Ohana Health Plan Medicaid	$2,797.48
Rate for Payer: UnitedHealthcare Medicaid	$2,797.48

SKIN ULCERS

Facility

$3,529.16

Service Code	APR-DRG 3802
Min. Negotiated Rate	$3,529.16
Max. Negotiated Rate	$3,529.16
Rate for Payer: AlohaCare Medicaid	$3,529.16
Rate for Payer: Hawaii Medical Service Association ABD	$3,529.16
Rate for Payer: Hawaii Medical Service Association Non-ABD	$3,529.16
Rate for Payer: Kaiser Permanente Medicaid	$3,529.16
Rate for Payer: Ohana Health Plan Medicaid	$3,529.16
Rate for Payer: UnitedHealthcare Medicaid	$3,529.16

SKIN ULCERS WITH CC

Facility

$23,432.00

Service Code	MSDRG 593
Min. Negotiated Rate	$15,603.11
Max. Negotiated Rate	$23,432.00
Rate for Payer: AlohaCare Medicare	$15,603.11
Rate for Payer: Devoted Health Medicare	$17,163.42
Rate for Payer: Hawaii Medical Service Association Commercial	$23,432.00
Rate for Payer: Hawaii Medical Service Association Medicare	$15,603.11
Rate for Payer: Humana Medicare	$15,603.11
Rate for Payer: Kaiser Permanente Commercial	$20,463.67
Rate for Payer: Kaiser Permanente Medicare	$15,603.11
Rate for Payer: Ohana Health Plan Medicare	$15,603.11
Rate for Payer: UnitedHealthcare Medicare	$15,603.11

SKIN ULCERS WITH MCC

Facility

$33,383.93

Service Code	MSDRG 592
Min. Negotiated Rate	$23,432.00
Max. Negotiated Rate	$33,383.93
Rate for Payer: AlohaCare Medicare	$25,454.55
Rate for Payer: Devoted Health Medicare	$28,000.01
Rate for Payer: Hawaii Medical Service Association Commercial	$23,432.00
Rate for Payer: Hawaii Medical Service Association Medicare	$25,454.55
Rate for Payer: Humana Medicare	$25,454.55
Rate for Payer: Kaiser Permanente Commercial	$33,383.93
Rate for Payer: Kaiser Permanente Medicare	$25,454.55
Rate for Payer: Ohana Health Plan Medicare	$25,454.55
Rate for Payer: UnitedHealthcare Medicare	$25,454.55

SKIN ULCERS WITHOUT CC/MCC

Facility

$23,432.00

Service Code	MSDRG 594
Min. Negotiated Rate	$11,400.80
Max. Negotiated Rate	$23,432.00
Rate for Payer: AlohaCare Medicare	$11,400.80
Rate for Payer: Devoted Health Medicare	$12,540.88
Rate for Payer: Hawaii Medical Service Association Commercial	$23,432.00
Rate for Payer: Hawaii Medical Service Association Medicare	$11,400.80
Rate for Payer: Humana Medicare	$11,400.80
Rate for Payer: Kaiser Permanente Commercial	$14,952.30
Rate for Payer: Kaiser Permanente Medicare	$11,400.80
Rate for Payer: Ohana Health Plan Medicare	$11,400.80
Rate for Payer: UnitedHealthcare Medicare	$11,400.80

Sling Loop Disposable Xl [2709874]

Facility

$223.75

Hospital Charge Code	2709874
Hospital Revenue Code	272
Min. Negotiated Rate	$114.11
Max. Negotiated Rate	$217.04
Rate for Payer: Cash Price	$145.44
Rate for Payer: Hawaii Western Management Group Commercial	$212.56
Rate for Payer: Health Management Network Commercial	$190.19
Rate for Payer: Kaiser Permanente Commercial	$140.96
Rate for Payer: Kaiser Permanente Medicaid	$114.11
Rate for Payer: MDX Hawaii PPO	$217.04
Rate for Payer: University Health Alliance Commercial	$163.09

Sling Loop Disposable Xl [2709874]

Facility

$223.75

Hospital Charge Code	2709874
Hospital Revenue Code	272
Min. Negotiated Rate	$190.19
Max. Negotiated Rate	$217.04
Rate for Payer: Cash Price	$145.44
Rate for Payer: Health Management Network Commercial	$190.19
Rate for Payer: MDX Hawaii PPO	$217.04

SLING SHOULDER ABDUCTION LARGE [2701703]

Facility

$241.16

Service Code	HCPCS L3670
Hospital Charge Code	2701703
Hospital Revenue Code	274
Min. Negotiated Rate	$135.05
Max. Negotiated Rate	$233.93
Rate for Payer: Cash Price	$156.75
Rate for Payer: Hawaii Western Management Group Commercial	$168.81
Rate for Payer: Health Management Network Commercial	$204.99
Rate for Payer: MDX Hawaii PPO	$233.93
Rate for Payer: University Health Alliance Commercial	$135.05

SLING SHOULDER ABDUCTION LARGE [2701703]

Facility

$241.16

Service Code	HCPCS L3670
Hospital Charge Code	2701703
Hospital Revenue Code	274
Min. Negotiated Rate	$84.70
Max. Negotiated Rate	$233.93
Rate for Payer: Cash Price	$156.75
Rate for Payer: Cash Price	$156.75
Rate for Payer: Hawaii Western Management Group Commercial	$168.81
Rate for Payer: Health Management Network Commercial	$204.99
Rate for Payer: Kaiser Permanente Commercial	$151.93
Rate for Payer: Kaiser Permanente Medicaid	$122.99
Rate for Payer: MDX Hawaii PPO	$233.93
Rate for Payer: UnitedHealthcare Medicaid	$84.70
Rate for Payer: University Health Alliance Commercial	$135.05

SLING SHOULDER ABDUCTION MEDIUM [2701702]

Facility

$172.21

Service Code	HCPCS L3670
Hospital Charge Code	2701702
Hospital Revenue Code	274
Min. Negotiated Rate	$84.70
Max. Negotiated Rate	$167.04
Rate for Payer: Cash Price	$111.94
Rate for Payer: Cash Price	$111.94
Rate for Payer: Hawaii Western Management Group Commercial	$120.55
Rate for Payer: Health Management Network Commercial	$146.38
Rate for Payer: Kaiser Permanente Commercial	$108.49
Rate for Payer: Kaiser Permanente Medicaid	$87.83
Rate for Payer: MDX Hawaii PPO	$167.04
Rate for Payer: UnitedHealthcare Medicaid	$84.70
Rate for Payer: University Health Alliance Commercial	$96.44

SLING SHOULDER ABDUCTION MEDIUM [2701702]

Facility

$172.21

Service Code	HCPCS L3670
Hospital Charge Code	2701702
Hospital Revenue Code	274
Min. Negotiated Rate	$96.44
Max. Negotiated Rate	$167.04
Rate for Payer: Cash Price	$111.94
Rate for Payer: Hawaii Western Management Group Commercial	$120.55
Rate for Payer: Health Management Network Commercial	$146.38
Rate for Payer: MDX Hawaii PPO	$167.04
Rate for Payer: University Health Alliance Commercial	$96.44

SODIUM ACETATE 2 MEQ/ML IV SOLN

Facility

$64.37

Service Code	NDC 00409729983
Hospital Revenue Code	250
Min. Negotiated Rate	$54.71
Max. Negotiated Rate	$62.44
Rate for Payer: Cash Price	$41.84
Rate for Payer: Health Management Network Commercial	$54.71
Rate for Payer: MDX Hawaii PPO	$62.44

SODIUM ACETATE 2 MEQ/ML IV SOLN

Facility

$64.37

Service Code	NDC 00409729973
Hospital Revenue Code	250
Min. Negotiated Rate	$32.83
Max. Negotiated Rate	$62.44
Rate for Payer: Cash Price	$41.84
Rate for Payer: Hawaii Western Management Group Commercial	$61.15
Rate for Payer: Health Management Network Commercial	$54.71
Rate for Payer: Kaiser Permanente Commercial	$40.55
Rate for Payer: Kaiser Permanente Medicaid	$32.83
Rate for Payer: MDX Hawaii PPO	$62.44
Rate for Payer: UnitedHealthcare Medicaid	$38.62
Rate for Payer: University Health Alliance Commercial	$46.92

SODIUM ACETATE 2 MEQ/ML IV SOLN

Facility

$64.37

Service Code	NDC 00409729983
Hospital Revenue Code	250
Min. Negotiated Rate	$32.83
Max. Negotiated Rate	$62.44
Rate for Payer: Cash Price	$41.84
Rate for Payer: Hawaii Western Management Group Commercial	$61.15
Rate for Payer: Health Management Network Commercial	$54.71
Rate for Payer: Kaiser Permanente Commercial	$40.55
Rate for Payer: Kaiser Permanente Medicaid	$32.83
Rate for Payer: MDX Hawaii PPO	$62.44
Rate for Payer: UnitedHealthcare Medicaid	$38.62
Rate for Payer: University Health Alliance Commercial	$46.92

SODIUM ACETATE 2 MEQ/ML IV SOLN

Facility

$64.37

Service Code	NDC 00409729973
Hospital Revenue Code	250
Min. Negotiated Rate	$54.71
Max. Negotiated Rate	$62.44
Rate for Payer: Cash Price	$41.84
Rate for Payer: Health Management Network Commercial	$54.71
Rate for Payer: MDX Hawaii PPO	$62.44

SODIUM BICARBONATE 4.2 % IV SOLN

Facility

$115.42

Service Code	NDC 63323008305
Hospital Revenue Code	250
Min. Negotiated Rate	$58.86
Max. Negotiated Rate	$111.96
Rate for Payer: Cash Price	$75.02
Rate for Payer: Hawaii Western Management Group Commercial	$109.65
Rate for Payer: Health Management Network Commercial	$98.11
Rate for Payer: Kaiser Permanente Commercial	$72.71
Rate for Payer: Kaiser Permanente Medicaid	$58.86
Rate for Payer: MDX Hawaii PPO	$111.96
Rate for Payer: UnitedHealthcare Medicaid	$69.25
Rate for Payer: University Health Alliance Commercial	$84.13

SODIUM BICARBONATE 4.2 % IV SOLN

Facility

$47.06

Service Code	NDC 00409555512
Hospital Revenue Code	250
Min. Negotiated Rate	$24.00
Max. Negotiated Rate	$45.65
Rate for Payer: Cash Price	$30.59
Rate for Payer: Hawaii Western Management Group Commercial	$44.71
Rate for Payer: Health Management Network Commercial	$40.00
Rate for Payer: Kaiser Permanente Commercial	$29.65
Rate for Payer: Kaiser Permanente Medicaid	$24.00
Rate for Payer: MDX Hawaii PPO	$45.65
Rate for Payer: UnitedHealthcare Medicaid	$28.24
Rate for Payer: University Health Alliance Commercial	$34.30

SODIUM BICARBONATE 4.2 % IV SOLN

Facility

$47.06

Service Code	NDC 00409555502
Hospital Revenue Code	250
Min. Negotiated Rate	$40.00
Max. Negotiated Rate	$45.65
Rate for Payer: Cash Price	$30.59
Rate for Payer: Health Management Network Commercial	$40.00
Rate for Payer: MDX Hawaii PPO	$45.65

SODIUM BICARBONATE 4.2 % IV SOLN

Facility

$47.06

Service Code	NDC 00409555502
Hospital Revenue Code	250
Min. Negotiated Rate	$24.00
Max. Negotiated Rate	$45.65
Rate for Payer: Cash Price	$30.59
Rate for Payer: Hawaii Western Management Group Commercial	$44.71
Rate for Payer: Health Management Network Commercial	$40.00
Rate for Payer: Kaiser Permanente Commercial	$29.65
Rate for Payer: Kaiser Permanente Medicaid	$24.00
Rate for Payer: MDX Hawaii PPO	$45.65
Rate for Payer: UnitedHealthcare Medicaid	$28.24
Rate for Payer: University Health Alliance Commercial	$34.30

Know your out-of-pocket cost for care.

All Charges