Kona Community Hospital

All Charges

Charge

Type

Setting

Price

COLONOSCOPY THROUGH STOMA; WITH BIOPSY, SINGLE OR MULTIPLE

Facility

$6,183.00

Service Code	CPT 44389
Hospital Revenue Code	360
Min. Negotiated Rate	$456.03
Max. Negotiated Rate	$6,183.00
Rate for Payer: AlohaCare Medicaid	$1,413.65
Rate for Payer: AlohaCare Medicare	$1,413.65
Rate for Payer: Devoted Health Medicare	$1,555.02
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	$1,413.65
Rate for Payer: Hawaii Medical Service Association Non-ABD	$700.72
Rate for Payer: Humana Medicare	$1,413.65
Rate for Payer: Kaiser Permanente Medicaid	$2,837.00
Rate for Payer: Kaiser Permanente Medicare	$1,413.65
Rate for Payer: Ohana Health Plan Medicaid	$1,555.02
Rate for Payer: Ohana Health Plan Medicare	$1,413.65
Rate for Payer: UnitedHealthcare Medicaid	$456.03
Rate for Payer: UnitedHealthcare Medicare	$1,413.65

COLORECTAL CANCER SCREENING; COLONOSCOPY ON INDIVIDUAL AT HIGH RISK

Facility

$6,183.00

Service Code	CPT G0105
Hospital Revenue Code	360
Min. Negotiated Rate	$340.18
Max. Negotiated Rate	$6,183.00
Rate for Payer: AlohaCare Medicaid	$1,098.60
Rate for Payer: AlohaCare Medicare	$1,098.60
Rate for Payer: Devoted Health Medicare	$1,208.46
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	$1,098.60
Rate for Payer: Hawaii Medical Service Association Non-ABD	$700.72
Rate for Payer: Humana Medicare	$1,098.60
Rate for Payer: Kaiser Permanente Medicaid	$2,837.00
Rate for Payer: Kaiser Permanente Medicare	$1,098.60
Rate for Payer: Ohana Health Plan Medicaid	$1,208.46
Rate for Payer: Ohana Health Plan Medicare	$1,098.60
Rate for Payer: UnitedHealthcare Medicaid	$340.18
Rate for Payer: UnitedHealthcare Medicare	$1,098.60
Rate for Payer: University Health Alliance Commercial	$5,160.40

COLORECTAL CANCER SCREENING; COLONOSCOPY ON INDIVIDUAL NOT MEETING CRITERIA FOR HIGH RISK

Facility

$6,183.00

Service Code	CPT G0121
Hospital Revenue Code	360
Min. Negotiated Rate	$340.18
Max. Negotiated Rate	$6,183.00
Rate for Payer: AlohaCare Medicaid	$1,098.60
Rate for Payer: AlohaCare Medicare	$1,098.60
Rate for Payer: Devoted Health Medicare	$1,208.46
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	$1,098.60
Rate for Payer: Hawaii Medical Service Association Non-ABD	$700.72
Rate for Payer: Humana Medicare	$1,098.60
Rate for Payer: Kaiser Permanente Medicaid	$2,837.00
Rate for Payer: Kaiser Permanente Medicare	$1,098.60
Rate for Payer: Ohana Health Plan Medicaid	$1,208.46
Rate for Payer: Ohana Health Plan Medicare	$1,098.60
Rate for Payer: UnitedHealthcare Medicaid	$340.18
Rate for Payer: UnitedHealthcare Medicare	$1,098.60
Rate for Payer: University Health Alliance Commercial	$5,160.40

COLOSTOMY SKIN BARRIER TAPE, 70mm, (BLUE) 11204 [2702212]

Facility

$9.44

Service Code	HCPCS A4414
Hospital Charge Code	2702212
Hospital Revenue Code	272
Min. Negotiated Rate	$4.81
Max. Negotiated Rate	$9.16
Rate for Payer: Cash Price	$6.14
Rate for Payer: Cash Price	$6.14
Rate for Payer: Hawaii Western Management Group Commercial	$8.97
Rate for Payer: Health Management Network Commercial	$8.02
Rate for Payer: Kaiser Permanente Commercial	$5.95
Rate for Payer: Kaiser Permanente Medicaid	$4.81
Rate for Payer: MDX Hawaii PPO	$9.16
Rate for Payer: UnitedHealthcare Medicaid	$4.93
Rate for Payer: University Health Alliance Commercial	$6.88

COLOSTOMY SKIN BARRIER TAPE, 70mm, (BLUE) 11204 [2702212]

Facility

$9.44

Service Code	HCPCS A4414
Hospital Charge Code	2702212
Hospital Revenue Code	272
Min. Negotiated Rate	$8.02
Max. Negotiated Rate	$9.16
Rate for Payer: Cash Price	$6.14
Rate for Payer: Health Management Network Commercial	$8.02
Rate for Payer: MDX Hawaii PPO	$9.16

COLPOSCOPY OF THE CERVIX INCLUDING UPPER/ADJACENT VAGINA; WITH LOOP ELECTRODE BIOPSY(S) OF THE CERVIX

Facility

$4,206.58

Service Code	CPT 57460
Hospital Revenue Code	360
Min. Negotiated Rate	$393.00
Max. Negotiated Rate	$4,206.58
Rate for Payer: AlohaCare Medicaid	$3,824.16
Rate for Payer: AlohaCare Medicare	$3,824.16
Rate for Payer: Devoted Health Medicare	$4,206.58
Rate for Payer: Hawaii Medical Service Association ABD	$393.00
Rate for Payer: Hawaii Medical Service Association Commercial	$2,833.00
Rate for Payer: Hawaii Medical Service Association Medicare	$3,824.16
Rate for Payer: Hawaii Medical Service Association Non-ABD	$407.95
Rate for Payer: Humana Medicare	$3,824.16
Rate for Payer: Kaiser Permanente Medicaid	$2,837.00
Rate for Payer: Kaiser Permanente Medicare	$3,824.16
Rate for Payer: Ohana Health Plan Medicaid	$4,206.58
Rate for Payer: Ohana Health Plan Medicare	$3,824.16
Rate for Payer: UnitedHealthcare Medicaid	$456.03
Rate for Payer: UnitedHealthcare Medicare	$3,824.16
Rate for Payer: University Health Alliance Commercial	$4,035.20

COMBINED ANTERIOR AND POSTERIOR CERVICAL SPINAL FUSION WITH MCC

Facility

$155,415.60

Service Code	MSDRG 429
Min. Negotiated Rate	$117,569.84
Max. Negotiated Rate	$155,415.60
Rate for Payer: AlohaCare Medicare	$118,501.16
Rate for Payer: Devoted Health Medicare	$130,351.28
Rate for Payer: Hawaii Medical Service Association Commercial	$117,569.84
Rate for Payer: Hawaii Medical Service Association Medicare	$118,501.16
Rate for Payer: Humana Medicare	$118,501.16
Rate for Payer: Kaiser Permanente Commercial	$155,415.60
Rate for Payer: Kaiser Permanente Medicare	$118,501.16
Rate for Payer: Ohana Health Plan Medicare	$118,501.16
Rate for Payer: UnitedHealthcare Medicare	$118,501.16

COMBINED ANTERIOR AND POSTERIOR CERVICAL SPINAL FUSION WITHOUT MCC

Facility

$117,569.84

Service Code	MSDRG 430
Min. Negotiated Rate	$75,853.31
Max. Negotiated Rate	$117,569.84
Rate for Payer: AlohaCare Medicare	$75,853.31
Rate for Payer: Devoted Health Medicare	$83,438.64
Rate for Payer: Hawaii Medical Service Association Commercial	$117,569.84
Rate for Payer: Hawaii Medical Service Association Medicare	$75,853.31
Rate for Payer: Humana Medicare	$75,853.31
Rate for Payer: Kaiser Permanente Commercial	$99,482.48
Rate for Payer: Kaiser Permanente Medicare	$75,853.31
Rate for Payer: Ohana Health Plan Medicare	$75,853.31
Rate for Payer: UnitedHealthcare Medicare	$75,853.31

COMBINED ANTEROPOSTERIOR COLPORRHAPHY, INCLUDING CYSTOURETHROSCOPY, WHEN PERFORMED; WITH ENTEROCELE REPAIR

Facility

$16,700.00

Service Code	CPT 57265
Hospital Revenue Code	360
Min. Negotiated Rate	$521.33
Max. Negotiated Rate	$16,700.00
Rate for Payer: AlohaCare Medicaid	$5,909.62
Rate for Payer: AlohaCare Medicare	$5,909.62
Rate for Payer: Devoted Health Medicare	$6,500.58
Rate for Payer: Hawaii Medical Service Association ABD	$848.00
Rate for Payer: Hawaii Medical Service Association Commercial	$9,416.00
Rate for Payer: Hawaii Medical Service Association Medicare	$5,909.62
Rate for Payer: Hawaii Medical Service Association Non-ABD	$849.21
Rate for Payer: Humana Medicare	$5,909.62
Rate for Payer: Kaiser Permanente Medicaid	$2,837.00
Rate for Payer: Kaiser Permanente Medicare	$5,909.62
Rate for Payer: Ohana Health Plan Medicaid	$6,500.58
Rate for Payer: Ohana Health Plan Medicare	$5,909.62
Rate for Payer: UnitedHealthcare Medicaid	$521.33
Rate for Payer: UnitedHealthcare Medicare	$5,909.62
Rate for Payer: University Health Alliance Commercial	$16,700.00

COMPLEX AORTIC ARCH PROCEDURES

Facility

$196,664.91

Service Code	MSDRG 209
Min. Negotiated Rate	$148,873.53
Max. Negotiated Rate	$196,664.91
Rate for Payer: AlohaCare Medicare	$148,873.53
Rate for Payer: Devoted Health Medicare	$163,760.88
Rate for Payer: Hawaii Medical Service Association Commercial	$196,664.91
Rate for Payer: Hawaii Medical Service Association Medicare	$148,873.53
Rate for Payer: Humana Medicare	$148,873.53
Rate for Payer: Kaiser Permanente Commercial	$195,249.30
Rate for Payer: Kaiser Permanente Medicare	$148,873.53
Rate for Payer: Ohana Health Plan Medicare	$148,873.53
Rate for Payer: UnitedHealthcare Medicare	$148,873.53

COMPLICATED PEPTIC ULCER WITH CC

Facility

$24,203.43

Service Code	MSDRG 381
Min. Negotiated Rate	$14,251.02
Max. Negotiated Rate	$24,203.43
Rate for Payer: AlohaCare Medicare	$14,251.02
Rate for Payer: Devoted Health Medicare	$15,676.12
Rate for Payer: Hawaii Medical Service Association Commercial	$24,203.43
Rate for Payer: Hawaii Medical Service Association Medicare	$14,251.02
Rate for Payer: Humana Medicare	$14,251.02
Rate for Payer: Kaiser Permanente Commercial	$18,690.38
Rate for Payer: Kaiser Permanente Medicare	$14,251.02
Rate for Payer: Ohana Health Plan Medicare	$14,251.02
Rate for Payer: UnitedHealthcare Medicare	$14,251.02

COMPLICATED PEPTIC ULCER WITH MCC

Facility

$33,847.95

Service Code	MSDRG 380
Min. Negotiated Rate	$24,203.43
Max. Negotiated Rate	$33,847.95
Rate for Payer: AlohaCare Medicare	$25,808.35
Rate for Payer: Devoted Health Medicare	$28,389.19
Rate for Payer: Hawaii Medical Service Association Commercial	$24,203.43
Rate for Payer: Hawaii Medical Service Association Medicare	$25,808.35
Rate for Payer: Humana Medicare	$25,808.35
Rate for Payer: Kaiser Permanente Commercial	$33,847.95
Rate for Payer: Kaiser Permanente Medicare	$25,808.35
Rate for Payer: Ohana Health Plan Medicare	$25,808.35
Rate for Payer: UnitedHealthcare Medicare	$25,808.35

COMPLICATED PEPTIC ULCER WITHOUT CC/MCC

Facility

$24,203.43

Service Code	MSDRG 382
Min. Negotiated Rate	$10,530.11
Max. Negotiated Rate	$24,203.43
Rate for Payer: AlohaCare Medicare	$10,530.11
Rate for Payer: Devoted Health Medicare	$11,583.12
Rate for Payer: Hawaii Medical Service Association Commercial	$24,203.43
Rate for Payer: Hawaii Medical Service Association Medicare	$10,530.11
Rate for Payer: Humana Medicare	$10,530.11
Rate for Payer: Kaiser Permanente Commercial	$13,810.35
Rate for Payer: Kaiser Permanente Medicare	$10,530.11
Rate for Payer: Ohana Health Plan Medicare	$10,530.11
Rate for Payer: UnitedHealthcare Medicare	$10,530.11

COMPLICATIONS OF TREATMENT WITH CC

Facility

$28,301.62

Service Code	MSDRG 920
Min. Negotiated Rate	$13,183.01
Max. Negotiated Rate	$28,301.62
Rate for Payer: AlohaCare Medicare	$13,183.01
Rate for Payer: Devoted Health Medicare	$14,501.31
Rate for Payer: Hawaii Medical Service Association Commercial	$28,301.62
Rate for Payer: Hawaii Medical Service Association Medicare	$13,183.01
Rate for Payer: Humana Medicare	$13,183.01
Rate for Payer: Kaiser Permanente Commercial	$17,289.67
Rate for Payer: Kaiser Permanente Medicare	$13,183.01
Rate for Payer: Ohana Health Plan Medicare	$13,183.01
Rate for Payer: UnitedHealthcare Medicare	$13,183.01

COMPLICATIONS OF TREATMENT WITH MCC

Facility

$31,581.30

Service Code	MSDRG 919
Min. Negotiated Rate	$24,080.09
Max. Negotiated Rate	$31,581.30
Rate for Payer: AlohaCare Medicare	$24,080.09
Rate for Payer: Devoted Health Medicare	$26,488.10
Rate for Payer: Hawaii Medical Service Association Commercial	$28,301.62
Rate for Payer: Hawaii Medical Service Association Medicare	$24,080.09
Rate for Payer: Humana Medicare	$24,080.09
Rate for Payer: Kaiser Permanente Commercial	$31,581.30
Rate for Payer: Kaiser Permanente Medicare	$24,080.09
Rate for Payer: Ohana Health Plan Medicare	$24,080.09
Rate for Payer: UnitedHealthcare Medicare	$24,080.09

COMPLICATIONS OF TREATMENT WITHOUT CC/MCC

Facility

$16,031.16

Service Code	MSDRG 921
Min. Negotiated Rate	$9,054.35
Max. Negotiated Rate	$16,031.16
Rate for Payer: AlohaCare Medicare	$9,054.35
Rate for Payer: Devoted Health Medicare	$9,959.78
Rate for Payer: Hawaii Medical Service Association Commercial	$16,031.16
Rate for Payer: Hawaii Medical Service Association Medicare	$9,054.35
Rate for Payer: Humana Medicare	$9,054.35
Rate for Payer: Kaiser Permanente Commercial	$11,874.90
Rate for Payer: Kaiser Permanente Medicare	$9,054.35
Rate for Payer: Ohana Health Plan Medicare	$9,054.35
Rate for Payer: UnitedHealthcare Medicare	$9,054.35

COMPOUNDING VEHICLE SF NO.9 PO LIQ

Facility

$111.40

Service Code	NDC 00574030216
Hospital Revenue Code	250
Min. Negotiated Rate	$94.69
Max. Negotiated Rate	$108.06
Rate for Payer: Cash Price	$72.41
Rate for Payer: Health Management Network Commercial	$94.69
Rate for Payer: MDX Hawaii PPO	$108.06

COMPOUNDING VEHICLE SF NO.9 PO LIQ

Facility

$111.40

Service Code	NDC 00574030216
Hospital Revenue Code	250
Min. Negotiated Rate	$56.81
Max. Negotiated Rate	$108.06
Rate for Payer: Cash Price	$72.41
Rate for Payer: Hawaii Western Management Group Commercial	$105.83
Rate for Payer: Health Management Network Commercial	$94.69
Rate for Payer: Kaiser Permanente Commercial	$70.18
Rate for Payer: Kaiser Permanente Medicaid	$56.81
Rate for Payer: MDX Hawaii PPO	$108.06
Rate for Payer: UnitedHealthcare Medicaid	$66.84
Rate for Payer: University Health Alliance Commercial	$81.20

COMPREHENSIVE METABOLIC PANEL

Professional

Both

$21.00

Service Code	HCPCS 80053
Min. Negotiated Rate	$10.56
Max. Negotiated Rate	$22.20
Rate for Payer: AlohaCare Medicaid	$14.61
Rate for Payer: AlohaCare Medicare	$10.56
Rate for Payer: Cash Price	$13.65
Rate for Payer: Cash Price	$13.65
Rate for Payer: Devoted Health Medicare	$11.62
Rate for Payer: Hawaii Medical Service Association Medicare	$10.56
Rate for Payer: Hawaii Western Management Group Commercial	$22.20
Rate for Payer: Health Management Network Commercial	$17.85
Rate for Payer: Kaiser Permanente Commercial	$12.67
Rate for Payer: Kaiser Permanente Medicaid	$12.67
Rate for Payer: Kaiser Permanente Medicare	$12.67
Rate for Payer: Ohana Health Plan Medicaid	$14.61
Rate for Payer: Ohana Health Plan Medicare	$10.56
Rate for Payer: UnitedHealthcare Medicaid	$14.61
Rate for Payer: UnitedHealthcare Medicare	$10.56

Compression Plates Atcs Single Use AR-19083 [3644859]

Facility

$2,942.00

Hospital Charge Code	3644859
Hospital Revenue Code	272
Min. Negotiated Rate	$2,500.70
Max. Negotiated Rate	$2,853.74
Rate for Payer: Cash Price	$1,912.30
Rate for Payer: Health Management Network Commercial	$2,500.70
Rate for Payer: MDX Hawaii PPO	$2,853.74

Compression Plates Atcs Single Use AR-19083 [3644859]

Facility

$2,942.00

Hospital Charge Code	3644859
Hospital Revenue Code	272
Min. Negotiated Rate	$1,500.42
Max. Negotiated Rate	$2,853.74
Rate for Payer: Cash Price	$1,912.30
Rate for Payer: Hawaii Western Management Group Commercial	$2,794.90
Rate for Payer: Health Management Network Commercial	$2,500.70
Rate for Payer: Kaiser Permanente Commercial	$1,853.46
Rate for Payer: Kaiser Permanente Medicaid	$1,500.42
Rate for Payer: MDX Hawaii PPO	$2,853.74
Rate for Payer: University Health Alliance Commercial	$2,144.42

COMPUTER-ASSISTED MUSCULOSKELETAL SURGICAL NAVIGATIONAL ORTHOPEDIC PROCEDURE, WITH IMAGE-GUIDANCE BASED ON FLUOROSCOPIC IMAGES (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)

Facility

$2,837.00

Service Code	CPT 0054T
Hospital Revenue Code	360
Min. Negotiated Rate	$2,837.00
Max. Negotiated Rate	$2,837.00
Rate for Payer: Kaiser Permanente Medicaid	$2,837.00

COMPUTER-ASSISTED SURGICAL NAVIGATIONAL PROCEDURE FOR MUSCULOSKELETAL PROCEDURES, IMAGE-LESS (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)

Facility

$2,837.00

Service Code	CPT 20985
Hospital Revenue Code	360
Min. Negotiated Rate	$75.09
Max. Negotiated Rate	$2,837.00
Rate for Payer: Kaiser Permanente Medicaid	$2,837.00
Rate for Payer: UnitedHealthcare Medicaid	$75.09

CONCOMITANT AORTIC AND MITRAL VALVE PROCEDURES

Facility

$187,578.23

Service Code	MSDRG 212
Min. Negotiated Rate	$129,719.77
Max. Negotiated Rate	$187,578.23
Rate for Payer: AlohaCare Medicare	$143,024.49
Rate for Payer: Devoted Health Medicare	$157,326.94
Rate for Payer: Hawaii Medical Service Association Commercial	$129,719.77
Rate for Payer: Hawaii Medical Service Association Medicare	$143,024.49
Rate for Payer: Humana Medicare	$143,024.49
Rate for Payer: Kaiser Permanente Commercial	$187,578.23
Rate for Payer: Kaiser Permanente Medicare	$143,024.49
Rate for Payer: Ohana Health Plan Medicare	$143,024.49
Rate for Payer: UnitedHealthcare Medicare	$143,024.49

CONCOMITANT LEFT ATRIAL APPENDAGE CLOSURE AND CARDIAC ABLATION

Facility

$115,342.12

Service Code	MSDRG 317
Min. Negotiated Rate	$87,945.98
Max. Negotiated Rate	$115,342.12
Rate for Payer: AlohaCare Medicare	$87,945.98
Rate for Payer: Devoted Health Medicare	$96,740.58
Rate for Payer: Hawaii Medical Service Association Medicare	$87,945.98
Rate for Payer: Humana Medicare	$87,945.98
Rate for Payer: Kaiser Permanente Commercial	$115,342.12
Rate for Payer: Kaiser Permanente Medicare	$87,945.98
Rate for Payer: Ohana Health Plan Medicare	$87,945.98
Rate for Payer: UnitedHealthcare Medicare	$87,945.98

Know your out-of-pocket cost for care.

All Charges