Kona Community Hospital

All Charges

Charge

Type

Setting

Price

Uterine Manipulator RUMI Tip 6.7mm X 6cm UMW676 [3640531]

Facility

$445.96

Hospital Charge Code	3640531
Hospital Revenue Code	272
Min. Negotiated Rate	$379.07
Max. Negotiated Rate	$432.58
Rate for Payer: Cash Price	$289.87
Rate for Payer: Health Management Network Commercial	$379.07
Rate for Payer: MDX Hawaii PPO	$432.58

Uterine Manipulator RUMI Tip 6.7mm X 8cm UMB678 [3625438]

Facility

$445.96

Hospital Charge Code	3625438
Hospital Revenue Code	272
Min. Negotiated Rate	$379.07
Max. Negotiated Rate	$432.58
Rate for Payer: Cash Price	$289.87
Rate for Payer: Health Management Network Commercial	$379.07
Rate for Payer: MDX Hawaii PPO	$432.58

Uterine Manipulator RUMI Tip 6.7mm X 8cm UMB678 [3625438]

Facility

$445.96

Hospital Charge Code	3625438
Hospital Revenue Code	272
Min. Negotiated Rate	$227.44
Max. Negotiated Rate	$432.58
Rate for Payer: Cash Price	$289.87
Rate for Payer: Hawaii Western Management Group Commercial	$423.66
Rate for Payer: Health Management Network Commercial	$379.07
Rate for Payer: Kaiser Permanente Commercial	$280.95
Rate for Payer: Kaiser Permanente Medicaid	$227.44
Rate for Payer: MDX Hawaii PPO	$432.58
Rate for Payer: University Health Alliance Commercial	$325.06

VAGINA, CERVIX AND VULVA PROCEDURES WITH CC/MCC

Facility

$29,964.97

Service Code	MSDRG 746
Min. Negotiated Rate	$22,847.67
Max. Negotiated Rate	$29,964.97
Rate for Payer: AlohaCare Medicare	$22,847.67
Rate for Payer: Devoted Health Medicare	$25,132.44
Rate for Payer: Hawaii Medical Service Association Commercial	$26,903.41
Rate for Payer: Hawaii Medical Service Association Medicare	$22,847.67
Rate for Payer: Humana Medicare	$22,847.67
Rate for Payer: Kaiser Permanente Commercial	$29,964.97
Rate for Payer: Kaiser Permanente Medicare	$22,847.67
Rate for Payer: Ohana Health Plan Medicare	$22,847.67
Rate for Payer: UnitedHealthcare Medicare	$22,847.67

VAGINA, CERVIX AND VULVA PROCEDURES WITHOUT CC/MCC

Facility

$26,903.41

Service Code	MSDRG 747
Min. Negotiated Rate	$11,307.42
Max. Negotiated Rate	$26,903.41
Rate for Payer: AlohaCare Medicare	$11,307.42
Rate for Payer: Devoted Health Medicare	$12,438.16
Rate for Payer: Hawaii Medical Service Association Commercial	$26,903.41
Rate for Payer: Hawaii Medical Service Association Medicare	$11,307.42
Rate for Payer: Humana Medicare	$11,307.42
Rate for Payer: Kaiser Permanente Commercial	$14,481.38
Rate for Payer: Kaiser Permanente Medicare	$11,307.42
Rate for Payer: Ohana Health Plan Medicare	$11,307.42
Rate for Payer: UnitedHealthcare Medicare	$11,307.42

VAGINAL DELIVERY

Facility

$3,166.57

Service Code	APR-DRG 5602
Min. Negotiated Rate	$3,166.57
Max. Negotiated Rate	$3,166.57
Rate for Payer: AlohaCare Medicaid	$3,166.57
Rate for Payer: Hawaii Medical Service Association ABD	$3,166.57
Rate for Payer: Hawaii Medical Service Association Non-ABD	$3,166.57
Rate for Payer: Kaiser Permanente Medicaid	$3,166.57
Rate for Payer: Ohana Health Plan Medicaid	$3,166.57
Rate for Payer: UnitedHealthcare Medicaid	$3,166.57

VAGINAL DELIVERY

Facility

$2,787.22

Service Code	APR-DRG 5601
Min. Negotiated Rate	$2,787.22
Max. Negotiated Rate	$2,787.22
Rate for Payer: AlohaCare Medicaid	$2,787.22
Rate for Payer: Hawaii Medical Service Association ABD	$2,787.22
Rate for Payer: Hawaii Medical Service Association Non-ABD	$2,787.22
Rate for Payer: Kaiser Permanente Medicaid	$2,787.22
Rate for Payer: Ohana Health Plan Medicaid	$2,787.22
Rate for Payer: UnitedHealthcare Medicaid	$2,787.22

VAGINAL DELIVERY

Facility

$5,121.87

Service Code	APR-DRG 5604
Min. Negotiated Rate	$5,121.87
Max. Negotiated Rate	$5,121.87
Rate for Payer: AlohaCare Medicaid	$5,121.87
Rate for Payer: Hawaii Medical Service Association ABD	$5,121.87
Rate for Payer: Hawaii Medical Service Association Non-ABD	$5,121.87
Rate for Payer: Kaiser Permanente Medicaid	$5,121.87
Rate for Payer: Ohana Health Plan Medicaid	$5,121.87
Rate for Payer: UnitedHealthcare Medicaid	$5,121.87

VAGINAL DELIVERY

Facility

$3,904.75

Service Code	APR-DRG 5603
Min. Negotiated Rate	$3,904.75
Max. Negotiated Rate	$3,904.75
Rate for Payer: AlohaCare Medicaid	$3,904.75
Rate for Payer: Hawaii Medical Service Association ABD	$3,904.75
Rate for Payer: Hawaii Medical Service Association Non-ABD	$3,904.75
Rate for Payer: Kaiser Permanente Medicaid	$3,904.75
Rate for Payer: Ohana Health Plan Medicaid	$3,904.75
Rate for Payer: UnitedHealthcare Medicaid	$3,904.75

VAGINAL DELIVERY WITH O.R. PROCEDURES EXCEPT STERILIZATION AND/OR D&C

Facility

$15,503.95

Service Code	MSDRG 768
Min. Negotiated Rate	$7,300.00
Max. Negotiated Rate	$15,503.95
Rate for Payer: AlohaCare Medicare	$14,094.50
Rate for Payer: Devoted Health Medicare	$15,503.95
Rate for Payer: Hawaii Medical Service Association Commercial	$12,704.39
Rate for Payer: Hawaii Medical Service Association Medicare	$14,094.50
Rate for Payer: Hawaii Western Management Group Commercial	$7,300.00
Rate for Payer: Humana Medicare	$14,094.50
Rate for Payer: Kaiser Permanente Commercial	$15,235.00
Rate for Payer: Kaiser Permanente Medicare	$14,094.50
Rate for Payer: Ohana Health Plan Medicare	$14,094.50
Rate for Payer: UnitedHealthcare Medicare	$14,094.50
Rate for Payer: University Health Alliance Commercial	$7,760.00

VAGINAL DELIVERY WITHOUT STERILIZATION OR D&C WITH CC

Facility

$15,235.00

Service Code	MSDRG 806
Min. Negotiated Rate	$7,300.00
Max. Negotiated Rate	$15,235.00
Rate for Payer: AlohaCare Medicare	$9,917.19
Rate for Payer: Devoted Health Medicare	$10,908.91
Rate for Payer: Hawaii Medical Service Association Commercial	$10,293.69
Rate for Payer: Hawaii Medical Service Association Medicare	$9,917.19
Rate for Payer: Hawaii Western Management Group Commercial	$7,300.00
Rate for Payer: Humana Medicare	$9,917.19
Rate for Payer: Kaiser Permanente Commercial	$15,235.00
Rate for Payer: Kaiser Permanente Medicare	$9,917.19
Rate for Payer: Ohana Health Plan Medicare	$9,917.19
Rate for Payer: UnitedHealthcare Medicare	$9,917.19
Rate for Payer: University Health Alliance Commercial	$7,760.00

VAGINAL DELIVERY WITHOUT STERILIZATION OR D&C WITH MCC

Facility

$15,613.90

Service Code	MSDRG 805
Min. Negotiated Rate	$7,300.00
Max. Negotiated Rate	$15,613.90
Rate for Payer: AlohaCare Medicare	$14,194.45
Rate for Payer: Devoted Health Medicare	$15,613.90
Rate for Payer: Hawaii Medical Service Association Commercial	$10,293.69
Rate for Payer: Hawaii Medical Service Association Medicare	$14,194.45
Rate for Payer: Hawaii Western Management Group Commercial	$7,300.00
Rate for Payer: Humana Medicare	$14,194.45
Rate for Payer: Kaiser Permanente Commercial	$15,235.00
Rate for Payer: Kaiser Permanente Medicare	$14,194.45
Rate for Payer: Ohana Health Plan Medicare	$14,194.45
Rate for Payer: UnitedHealthcare Medicare	$14,194.45
Rate for Payer: University Health Alliance Commercial	$7,760.00

VAGINAL DELIVERY WITHOUT STERILIZATION OR D&C WITHOUT CC/MCC

Facility

$15,235.00

Service Code	MSDRG 807
Min. Negotiated Rate	$7,300.00
Max. Negotiated Rate	$15,235.00
Rate for Payer: AlohaCare Medicare	$8,867.59
Rate for Payer: Devoted Health Medicare	$9,754.35
Rate for Payer: Hawaii Medical Service Association Commercial	$9,281.19
Rate for Payer: Hawaii Medical Service Association Medicare	$8,867.59
Rate for Payer: Hawaii Western Management Group Commercial	$7,300.00
Rate for Payer: Humana Medicare	$8,867.59
Rate for Payer: Kaiser Permanente Commercial	$15,235.00
Rate for Payer: Kaiser Permanente Medicare	$8,867.59
Rate for Payer: Ohana Health Plan Medicare	$8,867.59
Rate for Payer: UnitedHealthcare Medicare	$8,867.59
Rate for Payer: University Health Alliance Commercial	$7,760.00

VAGINAL DELIVERY WITH STERILIZATION AND/OR D&C WITH CC

Facility

$15,235.00

Service Code	MSDRG 797
Min. Negotiated Rate	$7,300.00
Max. Negotiated Rate	$15,235.00
Rate for Payer: AlohaCare Medicare	$13,158.02
Rate for Payer: Devoted Health Medicare	$14,473.82
Rate for Payer: Hawaii Medical Service Association Commercial	$14,946.34
Rate for Payer: Hawaii Medical Service Association Medicare	$13,158.02
Rate for Payer: Hawaii Western Management Group Commercial	$7,300.00
Rate for Payer: Humana Medicare	$13,158.02
Rate for Payer: Kaiser Permanente Commercial	$15,235.00
Rate for Payer: Kaiser Permanente Medicare	$13,158.02
Rate for Payer: Ohana Health Plan Medicare	$13,158.02
Rate for Payer: UnitedHealthcare Medicare	$13,158.02
Rate for Payer: University Health Alliance Commercial	$7,760.00

VAGINAL DELIVERY WITH STERILIZATION AND/OR D&C WITH MCC

Facility

$16,884.22

Service Code	MSDRG 796
Min. Negotiated Rate	$7,300.00
Max. Negotiated Rate	$16,884.22
Rate for Payer: AlohaCare Medicare	$15,349.29
Rate for Payer: Devoted Health Medicare	$16,884.22
Rate for Payer: Hawaii Medical Service Association Commercial	$14,946.34
Rate for Payer: Hawaii Medical Service Association Medicare	$15,349.29
Rate for Payer: Hawaii Western Management Group Commercial	$7,300.00
Rate for Payer: Humana Medicare	$15,349.29
Rate for Payer: Kaiser Permanente Commercial	$15,235.00
Rate for Payer: Kaiser Permanente Medicare	$15,349.29
Rate for Payer: Ohana Health Plan Medicare	$15,349.29
Rate for Payer: UnitedHealthcare Medicare	$15,349.29
Rate for Payer: University Health Alliance Commercial	$7,760.00

VAGINAL DELIVERY WITH STERILIZATION AND/OR D&C WITHOUT CC/MCC

Facility

$15,235.00

Service Code	MSDRG 798
Min. Negotiated Rate	$7,300.00
Max. Negotiated Rate	$15,235.00
Rate for Payer: AlohaCare Medicare	$12,588.51
Rate for Payer: Devoted Health Medicare	$13,847.36
Rate for Payer: Hawaii Medical Service Association Commercial	$14,946.34
Rate for Payer: Hawaii Medical Service Association Medicare	$12,588.51
Rate for Payer: Hawaii Western Management Group Commercial	$7,300.00
Rate for Payer: Humana Medicare	$12,588.51
Rate for Payer: Kaiser Permanente Commercial	$15,235.00
Rate for Payer: Kaiser Permanente Medicare	$12,588.51
Rate for Payer: Ohana Health Plan Medicare	$12,588.51
Rate for Payer: UnitedHealthcare Medicare	$12,588.51
Rate for Payer: University Health Alliance Commercial	$7,760.00

VAGINAL DELIVERY W O.R. PROCEDURE EXCEPT STERILIZATION &/OR D&C

Facility

$2,933.69

Service Code	APR-DRG 5421
Min. Negotiated Rate	$2,933.69
Max. Negotiated Rate	$2,933.69
Rate for Payer: AlohaCare Medicaid	$2,933.69
Rate for Payer: Hawaii Medical Service Association ABD	$2,933.69
Rate for Payer: Hawaii Medical Service Association Non-ABD	$2,933.69
Rate for Payer: Kaiser Permanente Medicaid	$2,933.69
Rate for Payer: Ohana Health Plan Medicaid	$2,933.69
Rate for Payer: UnitedHealthcare Medicaid	$2,933.69

VAGINAL DELIVERY W O.R. PROCEDURE EXCEPT STERILIZATION &/OR D&C

Facility

$3,440.46

Service Code	APR-DRG 5422
Min. Negotiated Rate	$3,440.46
Max. Negotiated Rate	$3,440.46
Rate for Payer: AlohaCare Medicaid	$3,440.46
Rate for Payer: Hawaii Medical Service Association ABD	$3,440.46
Rate for Payer: Hawaii Medical Service Association Non-ABD	$3,440.46
Rate for Payer: Kaiser Permanente Medicaid	$3,440.46
Rate for Payer: Ohana Health Plan Medicaid	$3,440.46
Rate for Payer: UnitedHealthcare Medicaid	$3,440.46

VAGINAL DELIVERY W O.R. PROCEDURE EXCEPT STERILIZATION &/OR D&C

Facility

$10,923.34

Service Code	APR-DRG 5424
Min. Negotiated Rate	$10,923.34
Max. Negotiated Rate	$10,923.34
Rate for Payer: AlohaCare Medicaid	$10,923.34
Rate for Payer: Hawaii Medical Service Association ABD	$10,923.34
Rate for Payer: Hawaii Medical Service Association Non-ABD	$10,923.34
Rate for Payer: Kaiser Permanente Medicaid	$10,923.34
Rate for Payer: Ohana Health Plan Medicaid	$10,923.34
Rate for Payer: UnitedHealthcare Medicaid	$10,923.34

VAGINAL DELIVERY W O.R. PROCEDURE EXCEPT STERILIZATION &/OR D&C

Facility

$4,685.41

Service Code	APR-DRG 5423
Min. Negotiated Rate	$4,685.41
Max. Negotiated Rate	$4,685.41
Rate for Payer: AlohaCare Medicaid	$4,685.41
Rate for Payer: Hawaii Medical Service Association ABD	$4,685.41
Rate for Payer: Hawaii Medical Service Association Non-ABD	$4,685.41
Rate for Payer: Kaiser Permanente Medicaid	$4,685.41
Rate for Payer: Ohana Health Plan Medicaid	$4,685.41
Rate for Payer: UnitedHealthcare Medicaid	$4,685.41

VAGINAL DELIVERY W STERILIZATION &/OR D&C

Facility

$4,078.31

Service Code	APR-DRG 5411
Min. Negotiated Rate	$4,078.31
Max. Negotiated Rate	$4,078.31
Rate for Payer: AlohaCare Medicaid	$4,078.31
Rate for Payer: Hawaii Medical Service Association ABD	$4,078.31
Rate for Payer: Hawaii Medical Service Association Non-ABD	$4,078.31
Rate for Payer: Kaiser Permanente Medicaid	$4,078.31
Rate for Payer: Ohana Health Plan Medicaid	$4,078.31
Rate for Payer: UnitedHealthcare Medicaid	$4,078.31

VAGINAL DELIVERY W STERILIZATION &/OR D&C

Facility

$8,836.21

Service Code	APR-DRG 5414
Min. Negotiated Rate	$8,836.21
Max. Negotiated Rate	$8,836.21
Rate for Payer: AlohaCare Medicaid	$8,836.21
Rate for Payer: Hawaii Medical Service Association ABD	$8,836.21
Rate for Payer: Hawaii Medical Service Association Non-ABD	$8,836.21
Rate for Payer: Kaiser Permanente Medicaid	$8,836.21
Rate for Payer: Ohana Health Plan Medicaid	$8,836.21
Rate for Payer: UnitedHealthcare Medicaid	$8,836.21

VAGINAL DELIVERY W STERILIZATION &/OR D&C

Facility

$5,090.38

Service Code	APR-DRG 5413
Min. Negotiated Rate	$5,090.38
Max. Negotiated Rate	$5,090.38
Rate for Payer: AlohaCare Medicaid	$5,090.38
Rate for Payer: Hawaii Medical Service Association ABD	$5,090.38
Rate for Payer: Hawaii Medical Service Association Non-ABD	$5,090.38
Rate for Payer: Kaiser Permanente Medicaid	$5,090.38
Rate for Payer: Ohana Health Plan Medicaid	$5,090.38
Rate for Payer: UnitedHealthcare Medicaid	$5,090.38

VAGINAL DELIVERY W STERILIZATION &/OR D&C

Facility

$4,162.53

Service Code	APR-DRG 5412
Min. Negotiated Rate	$4,162.53
Max. Negotiated Rate	$4,162.53
Rate for Payer: AlohaCare Medicaid	$4,162.53
Rate for Payer: Hawaii Medical Service Association ABD	$4,162.53
Rate for Payer: Hawaii Medical Service Association Non-ABD	$4,162.53
Rate for Payer: Kaiser Permanente Medicaid	$4,162.53
Rate for Payer: Ohana Health Plan Medicaid	$4,162.53
Rate for Payer: UnitedHealthcare Medicaid	$4,162.53

VALACYCLOVIR 500 MG PO TABLET

Facility

$21.94

Service Code	HCPCS A9270
Hospital Revenue Code	250
Min. Negotiated Rate	$11.19
Max. Negotiated Rate	$21.28
Rate for Payer: Cash Price	$14.26
Rate for Payer: Cash Price	$13.31
Rate for Payer: Hawaii Western Management Group Commercial	$19.46
Rate for Payer: Hawaii Western Management Group Commercial	$20.84
Rate for Payer: Health Management Network Commercial	$17.41
Rate for Payer: Health Management Network Commercial	$18.65
Rate for Payer: Kaiser Permanente Commercial	$13.82
Rate for Payer: Kaiser Permanente Commercial	$12.90
Rate for Payer: Kaiser Permanente Medicaid	$11.19
Rate for Payer: Kaiser Permanente Medicaid	$10.44
Rate for Payer: MDX Hawaii PPO	$19.87
Rate for Payer: MDX Hawaii PPO	$21.28
Rate for Payer: UnitedHealthcare Medicaid	$12.29
Rate for Payer: UnitedHealthcare Medicaid	$13.16
Rate for Payer: University Health Alliance Commercial	$15.99
Rate for Payer: University Health Alliance Commercial	$14.93

Know your out-of-pocket cost for care.

All Charges