Kona Community Hospital

All Charges

Charge

Type

Setting

Price

SPLENECTOMY

Facility

$21,249.48

Service Code	APR-DRG 6504
Min. Negotiated Rate	$21,249.48
Max. Negotiated Rate	$21,249.48
Rate for Payer: AlohaCare Medicaid	$21,249.48
Rate for Payer: Hawaii Medical Service Association ABD	$21,249.48
Rate for Payer: Hawaii Medical Service Association Non-ABD	$21,249.48
Rate for Payer: Kaiser Permanente Medicaid	$21,249.48
Rate for Payer: Ohana Health Plan Medicaid	$21,249.48
Rate for Payer: UnitedHealthcare Medicaid	$21,249.48

SPLENECTOMY

Facility

$14,434.41

Service Code	APR-DRG 6503
Min. Negotiated Rate	$14,434.41
Max. Negotiated Rate	$14,434.41
Rate for Payer: AlohaCare Medicaid	$14,434.41
Rate for Payer: Hawaii Medical Service Association ABD	$14,434.41
Rate for Payer: Hawaii Medical Service Association Non-ABD	$14,434.41
Rate for Payer: Kaiser Permanente Medicaid	$14,434.41
Rate for Payer: Ohana Health Plan Medicaid	$14,434.41
Rate for Payer: UnitedHealthcare Medicaid	$14,434.41

SPLENECTOMY

Facility

$9,415.13

Service Code	APR-DRG 6502
Min. Negotiated Rate	$9,415.13
Max. Negotiated Rate	$9,415.13
Rate for Payer: AlohaCare Medicaid	$9,415.13
Rate for Payer: Hawaii Medical Service Association ABD	$9,415.13
Rate for Payer: Hawaii Medical Service Association Non-ABD	$9,415.13
Rate for Payer: Kaiser Permanente Medicaid	$9,415.13
Rate for Payer: Ohana Health Plan Medicaid	$9,415.13
Rate for Payer: UnitedHealthcare Medicaid	$9,415.13

SPLENECTOMY

Facility

$6,844.36

Service Code	APR-DRG 6501
Min. Negotiated Rate	$6,844.36
Max. Negotiated Rate	$6,844.36
Rate for Payer: AlohaCare Medicaid	$6,844.36
Rate for Payer: Hawaii Medical Service Association ABD	$6,844.36
Rate for Payer: Hawaii Medical Service Association Non-ABD	$6,844.36
Rate for Payer: Kaiser Permanente Medicaid	$6,844.36
Rate for Payer: Ohana Health Plan Medicaid	$6,844.36
Rate for Payer: UnitedHealthcare Medicaid	$6,844.36

SPLENECTOMY; TOTAL (SEPARATE PROCEDURE)

Facility

$2,837.00

Service Code	CPT 38100
Hospital Revenue Code	360
Min. Negotiated Rate	$618.85
Max. Negotiated Rate	$2,837.00
Rate for Payer: Kaiser Permanente Medicaid	$2,837.00
Rate for Payer: UnitedHealthcare Medicaid	$618.85

SPLENIC PROCEDURES WITH CC

Facility

$48,462.15

Service Code	MSDRG 800
Min. Negotiated Rate	$36,951.38
Max. Negotiated Rate	$48,462.15
Rate for Payer: AlohaCare Medicare	$36,951.38
Rate for Payer: Devoted Health Medicare	$40,646.52
Rate for Payer: Hawaii Medical Service Association Commercial	$44,477.42
Rate for Payer: Hawaii Medical Service Association Medicare	$36,951.38
Rate for Payer: Humana Medicare	$36,951.38
Rate for Payer: Kaiser Permanente Commercial	$48,462.15
Rate for Payer: Kaiser Permanente Medicare	$36,951.38
Rate for Payer: Ohana Health Plan Medicare	$36,951.38
Rate for Payer: UnitedHealthcare Medicare	$36,951.38

SPLENIC PROCEDURES WITH MCC

Facility

$78,123.52

Service Code	MSDRG 799
Min. Negotiated Rate	$44,477.42
Max. Negotiated Rate	$78,123.52
Rate for Payer: AlohaCare Medicare	$59,567.56
Rate for Payer: Devoted Health Medicare	$65,524.32
Rate for Payer: Hawaii Medical Service Association Commercial	$44,477.42
Rate for Payer: Hawaii Medical Service Association Medicare	$59,567.56
Rate for Payer: Humana Medicare	$59,567.56
Rate for Payer: Kaiser Permanente Commercial	$78,123.52
Rate for Payer: Kaiser Permanente Medicare	$59,567.56
Rate for Payer: Ohana Health Plan Medicare	$59,567.56
Rate for Payer: UnitedHealthcare Medicare	$59,567.56

SPLENIC PROCEDURES WITHOUT CC/MCC

Facility

$44,477.42

Service Code	MSDRG 801
Min. Negotiated Rate	$25,107.31
Max. Negotiated Rate	$44,477.42
Rate for Payer: AlohaCare Medicare	$25,107.31
Rate for Payer: Devoted Health Medicare	$27,618.04
Rate for Payer: Hawaii Medical Service Association Commercial	$44,477.42
Rate for Payer: Hawaii Medical Service Association Medicare	$25,107.31
Rate for Payer: Humana Medicare	$25,107.31
Rate for Payer: Kaiser Permanente Commercial	$32,928.53
Rate for Payer: Kaiser Permanente Medicare	$25,107.31
Rate for Payer: Ohana Health Plan Medicare	$25,107.31
Rate for Payer: UnitedHealthcare Medicare	$25,107.31

SPLIT-THICKNESS AUTOGRAFT, TRUNK, ARMS, LEGS; EACH ADDITIONAL 100 SQ CM, OR EACH ADDITIONAL 1% OF BODY AREA OF INFANTS AND CHILDREN, OR PART THEREOF (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)

Facility

$2,837.00

Service Code	CPT 15101
Hospital Revenue Code	360
Min. Negotiated Rate	$88.76
Max. Negotiated Rate	$2,837.00
Rate for Payer: Kaiser Permanente Medicaid	$2,837.00
Rate for Payer: UnitedHealthcare Medicaid	$88.76

SPLIT-THICKNESS AUTOGRAFT, TRUNK, ARMS, LEGS; FIRST 100 SQ CM OR LESS, OR 1% OF BODY AREA OF INFANTS AND CHILDREN (EXCEPT 15050)

Facility

$6,183.00

Service Code	CPT 15100
Hospital Revenue Code	360
Min. Negotiated Rate	$456.03
Max. Negotiated Rate	$6,183.00
Rate for Payer: AlohaCare Medicaid	$2,437.45
Rate for Payer: AlohaCare Medicare	$2,437.45
Rate for Payer: Devoted Health Medicare	$2,681.20
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	$2,437.45
Rate for Payer: Hawaii Medical Service Association Non-ABD	$700.72
Rate for Payer: Humana Medicare	$2,437.45
Rate for Payer: Kaiser Permanente Medicaid	$2,837.00
Rate for Payer: Kaiser Permanente Medicare	$2,437.45
Rate for Payer: Ohana Health Plan Medicaid	$2,681.20
Rate for Payer: Ohana Health Plan Medicare	$2,437.45
Rate for Payer: UnitedHealthcare Medicaid	$456.03
Rate for Payer: UnitedHealthcare Medicare	$2,437.45
Rate for Payer: University Health Alliance Commercial	$5,160.40

SPRAINS, STRAINS, AND DISLOCATIONS OF HIP, PELVIS AND THIGH WITH CC/MCC

Facility

$25,336.46

Service Code	MSDRG 537
Min. Negotiated Rate	$12,551.69
Max. Negotiated Rate	$25,336.46
Rate for Payer: AlohaCare Medicare	$12,551.69
Rate for Payer: Devoted Health Medicare	$13,806.86
Rate for Payer: Hawaii Medical Service Association Commercial	$25,336.46
Rate for Payer: Hawaii Medical Service Association Medicare	$12,551.69
Rate for Payer: Humana Medicare	$12,551.69
Rate for Payer: Kaiser Permanente Commercial	$16,461.67
Rate for Payer: Kaiser Permanente Medicare	$12,551.69
Rate for Payer: Ohana Health Plan Medicare	$12,551.69
Rate for Payer: UnitedHealthcare Medicare	$12,551.69

SPRAINS, STRAINS, AND DISLOCATIONS OF HIP, PELVIS AND THIGH WITHOUT CC/MCC

Facility

$25,336.46

Service Code	MSDRG 538
Min. Negotiated Rate	$9,473.94
Max. Negotiated Rate	$25,336.46
Rate for Payer: AlohaCare Medicare	$9,473.94
Rate for Payer: Devoted Health Medicare	$10,421.33
Rate for Payer: Hawaii Medical Service Association Commercial	$25,336.46
Rate for Payer: Hawaii Medical Service Association Medicare	$9,473.94
Rate for Payer: Humana Medicare	$9,473.94
Rate for Payer: Kaiser Permanente Commercial	$12,425.17
Rate for Payer: Kaiser Permanente Medicare	$9,473.94
Rate for Payer: Ohana Health Plan Medicare	$9,473.94
Rate for Payer: UnitedHealthcare Medicare	$9,473.94

Square Electrode 10mm x 8mm Es16 [3644251]

Facility

$147.36

Hospital Charge Code	3644251
Hospital Revenue Code	272
Min. Negotiated Rate	$125.26
Max. Negotiated Rate	$142.94
Rate for Payer: Cash Price	$95.78
Rate for Payer: Health Management Network Commercial	$125.26
Rate for Payer: MDX Hawaii PPO	$142.94

Square Electrode 10mm x 8mm Es16 [3644251]

Facility

$147.36

Hospital Charge Code	3644251
Hospital Revenue Code	272
Min. Negotiated Rate	$75.15
Max. Negotiated Rate	$142.94
Rate for Payer: Cash Price	$95.78
Rate for Payer: Hawaii Western Management Group Commercial	$139.99
Rate for Payer: Health Management Network Commercial	$125.26
Rate for Payer: Kaiser Permanente Commercial	$92.84
Rate for Payer: Kaiser Permanente Medicaid	$75.15
Rate for Payer: MDX Hawaii PPO	$142.94
Rate for Payer: University Health Alliance Commercial	$107.41

Staple 75mm Reloads Ethicon SR75 [3642960]

Facility

$2,060.63

Hospital Charge Code	3642960
Hospital Revenue Code	272
Min. Negotiated Rate	$1,050.92
Max. Negotiated Rate	$1,998.81
Rate for Payer: Cash Price	$1,339.41
Rate for Payer: Hawaii Western Management Group Commercial	$1,957.60
Rate for Payer: Health Management Network Commercial	$1,751.54
Rate for Payer: Kaiser Permanente Commercial	$1,298.20
Rate for Payer: Kaiser Permanente Medicaid	$1,050.92
Rate for Payer: MDX Hawaii PPO	$1,998.81
Rate for Payer: University Health Alliance Commercial	$1,501.99

Staple 75mm Reloads Ethicon SR75 [3642960]

Facility

$2,060.63

Hospital Charge Code	3642960
Hospital Revenue Code	272
Min. Negotiated Rate	$1,751.54
Max. Negotiated Rate	$1,998.81
Rate for Payer: Cash Price	$1,339.41
Rate for Payer: Health Management Network Commercial	$1,751.54
Rate for Payer: MDX Hawaii PPO	$1,998.81

Staple Contour Green Reload GCR40G [3622552]

Facility

$1,980.21

Hospital Charge Code	3622552
Hospital Revenue Code	272
Min. Negotiated Rate	$1,009.91
Max. Negotiated Rate	$1,920.80
Rate for Payer: Cash Price	$1,287.14
Rate for Payer: Hawaii Western Management Group Commercial	$1,881.20
Rate for Payer: Health Management Network Commercial	$1,683.18
Rate for Payer: Kaiser Permanente Commercial	$1,247.53
Rate for Payer: Kaiser Permanente Medicaid	$1,009.91
Rate for Payer: MDX Hawaii PPO	$1,920.80
Rate for Payer: University Health Alliance Commercial	$1,443.38

Staple Contour Green Reload GCR40G [3622552]

Facility

$1,980.21

Hospital Charge Code	3622552
Hospital Revenue Code	272
Min. Negotiated Rate	$1,683.18
Max. Negotiated Rate	$1,920.80
Rate for Payer: Cash Price	$1,287.14
Rate for Payer: Health Management Network Commercial	$1,683.18
Rate for Payer: MDX Hawaii PPO	$1,920.80

Staple Dynanite Niti w/Instr 13w x 15\12L AR-8718DS-131512 [3644646]

Facility

$12,559.50

Service Code	HCPCS C1713
Hospital Charge Code	3644646
Hospital Revenue Code	278
Min. Negotiated Rate	$6,405.35
Max. Negotiated Rate	$12,182.72
Rate for Payer: Cash Price	$8,163.68
Rate for Payer: Hawaii Western Management Group Commercial	$8,791.65
Rate for Payer: Health Management Network Commercial	$10,675.58
Rate for Payer: Kaiser Permanente Commercial	$7,912.48
Rate for Payer: Kaiser Permanente Medicaid	$6,405.35
Rate for Payer: MDX Hawaii PPO	$12,182.72
Rate for Payer: University Health Alliance Commercial	$7,033.32

Staple Dynanite Niti w/Instr 13w x 15\12L AR-8718DS-131512 [3644646]

Facility

$12,559.50

Service Code	HCPCS C1713
Hospital Charge Code	3644646
Hospital Revenue Code	278
Min. Negotiated Rate	$7,033.32
Max. Negotiated Rate	$12,182.72
Rate for Payer: Cash Price	$8,163.68
Rate for Payer: Hawaii Western Management Group Commercial	$8,791.65
Rate for Payer: Health Management Network Commercial	$10,675.58
Rate for Payer: MDX Hawaii PPO	$12,182.72
Rate for Payer: University Health Alliance Commercial	$7,033.32

Staple Dynanite Niti w/Instr 15w x 15L AR-8718DS-1515 [3644647]

Facility

$14,890.50

Service Code	HCPCS C1713
Hospital Charge Code	3644647
Hospital Revenue Code	278
Min. Negotiated Rate	$8,338.68
Max. Negotiated Rate	$14,443.78
Rate for Payer: Cash Price	$9,678.83
Rate for Payer: Hawaii Western Management Group Commercial	$10,423.35
Rate for Payer: Health Management Network Commercial	$12,656.92
Rate for Payer: MDX Hawaii PPO	$14,443.78
Rate for Payer: University Health Alliance Commercial	$8,338.68

Staple Dynanite Niti w/Instr 15w x 15L AR-8718DS-1515 [3644647]

Facility

$14,890.50

Service Code	HCPCS C1713
Hospital Charge Code	3644647
Hospital Revenue Code	278
Min. Negotiated Rate	$7,594.15
Max. Negotiated Rate	$14,443.78
Rate for Payer: Cash Price	$9,678.83
Rate for Payer: Hawaii Western Management Group Commercial	$10,423.35
Rate for Payer: Health Management Network Commercial	$12,656.92
Rate for Payer: Kaiser Permanente Commercial	$9,381.01
Rate for Payer: Kaiser Permanente Medicaid	$7,594.15
Rate for Payer: MDX Hawaii PPO	$14,443.78
Rate for Payer: University Health Alliance Commercial	$8,338.68

Staple Dynanite Niti w/Instr 18w x 15L AR-8719DS-1815 [3644648]

Facility

$14,890.50

Service Code	HCPCS C1713
Hospital Charge Code	3644648
Hospital Revenue Code	278
Min. Negotiated Rate	$7,594.15
Max. Negotiated Rate	$14,443.78
Rate for Payer: Cash Price	$9,678.83
Rate for Payer: Hawaii Western Management Group Commercial	$10,423.35
Rate for Payer: Health Management Network Commercial	$12,656.92
Rate for Payer: Kaiser Permanente Commercial	$9,381.01
Rate for Payer: Kaiser Permanente Medicaid	$7,594.15
Rate for Payer: MDX Hawaii PPO	$14,443.78
Rate for Payer: University Health Alliance Commercial	$8,338.68

Staple Dynanite Niti w/Instr 18w x 15L AR-8719DS-1815 [3644648]

Facility

$14,890.50

Service Code	HCPCS C1713
Hospital Charge Code	3644648
Hospital Revenue Code	278
Min. Negotiated Rate	$8,338.68
Max. Negotiated Rate	$14,443.78
Rate for Payer: Cash Price	$9,678.83
Rate for Payer: Hawaii Western Management Group Commercial	$10,423.35
Rate for Payer: Health Management Network Commercial	$12,656.92
Rate for Payer: MDX Hawaii PPO	$14,443.78
Rate for Payer: University Health Alliance Commercial	$8,338.68

Staple Endo Gia Ii 45 2.5 Dlu 030425 [3607633]

Facility

$610.47

Hospital Charge Code	3607633
Hospital Revenue Code	272
Min. Negotiated Rate	$311.34
Max. Negotiated Rate	$592.16
Rate for Payer: Cash Price	$396.81
Rate for Payer: Hawaii Western Management Group Commercial	$579.95
Rate for Payer: Health Management Network Commercial	$518.90
Rate for Payer: Kaiser Permanente Commercial	$384.60
Rate for Payer: Kaiser Permanente Medicaid	$311.34
Rate for Payer: MDX Hawaii PPO	$592.16
Rate for Payer: University Health Alliance Commercial	$444.97

Know your out-of-pocket cost for care.

All Charges