Kona Community Hospital

All Charges

Charge

Type

Setting

Price

DEBRIDEMENT, MUSCLE AND/OR FASCIA (INCLUDES EPIDERMIS, DERMIS, AND SUBCUTANEOUS TISSUE, IF PERFORMED); FIRST 20 SQ CM OR LESS

Facility

$9,416.00

Service Code	CPT 11043
Hospital Revenue Code	360
Min. Negotiated Rate	$125.89
Max. Negotiated Rate	$9,416.00
Rate for Payer: AlohaCare Medicaid	$873.10
Rate for Payer: AlohaCare Medicare	$873.10
Rate for Payer: Devoted Health Medicare	$960.41
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	$873.10
Rate for Payer: Hawaii Medical Service Association Non-ABD	$849.21
Rate for Payer: Humana Medicare	$873.10
Rate for Payer: Kaiser Permanente Medicaid	$2,837.00
Rate for Payer: Kaiser Permanente Medicare	$873.10
Rate for Payer: Ohana Health Plan Medicaid	$960.41
Rate for Payer: Ohana Health Plan Medicare	$873.10
Rate for Payer: UnitedHealthcare Medicaid	$125.89
Rate for Payer: UnitedHealthcare Medicare	$873.10
Rate for Payer: University Health Alliance Commercial	$4,035.20

DEBRIDEMENT, SUBCUTANEOUS TISSUE (INCLUDES EPIDERMIS AND DERMIS, IF PERFORMED); EACH ADDITIONAL 20 SQ CM, OR PART THEREOF (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)

Facility

$2,837.00

Service Code	CPT 11045
Hospital Revenue Code	360
Min. Negotiated Rate	$10.88
Max. Negotiated Rate	$2,837.00
Rate for Payer: Kaiser Permanente Medicaid	$2,837.00
Rate for Payer: UnitedHealthcare Medicaid	$10.88

DEBRIDEMENT, SUBCUTANEOUS TISSUE (INCLUDES EPIDERMIS AND DERMIS, IF PERFORMED); FIRST 20 SQ CM OR LESS

Facility

$5,160.40

Service Code	CPT 11042
Hospital Revenue Code	360
Min. Negotiated Rate	$44.20
Max. Negotiated Rate	$5,160.40
Rate for Payer: AlohaCare Medicaid	$480.23
Rate for Payer: AlohaCare Medicare	$480.23
Rate for Payer: Devoted Health Medicare	$528.25
Rate for Payer: Hawaii Medical Service Association Commercial	$600.29
Rate for Payer: Hawaii Medical Service Association Medicare	$480.23
Rate for Payer: Humana Medicare	$480.23
Rate for Payer: Kaiser Permanente Medicaid	$2,837.00
Rate for Payer: Kaiser Permanente Medicare	$480.23
Rate for Payer: Ohana Health Plan Medicaid	$528.25
Rate for Payer: Ohana Health Plan Medicare	$480.23
Rate for Payer: UnitedHealthcare Medicaid	$44.20
Rate for Payer: UnitedHealthcare Medicare	$480.23
Rate for Payer: University Health Alliance Commercial	$5,160.40

DECITABINE (DACOGEN) 50 MG INJ

Facility

$445.20

Service Code	HCPCS J0894
Hospital Revenue Code	636
Min. Negotiated Rate	$1.59
Max. Negotiated Rate	$431.84
Rate for Payer: Cash Price	$289.38
Rate for Payer: Cash Price	$289.38
Rate for Payer: Hawaii Medical Service Association ABD	$1.59
Rate for Payer: Hawaii Medical Service Association Non-ABD	$1.59
Rate for Payer: Hawaii Western Management Group Commercial	$422.94
Rate for Payer: Health Management Network Commercial	$378.42
Rate for Payer: Kaiser Permanente Commercial	$280.48
Rate for Payer: Kaiser Permanente Medicaid	$227.05
Rate for Payer: MDX Hawaii PPO	$431.84
Rate for Payer: UnitedHealthcare Medicaid	$267.12
Rate for Payer: University Health Alliance Commercial	$324.51

DECITABINE (DACOGEN) 50 MG INJ

Facility

$445.20

Service Code	HCPCS J0894
Hospital Revenue Code	250
Min. Negotiated Rate	$378.42
Max. Negotiated Rate	$431.84
Rate for Payer: Cash Price	$289.38
Rate for Payer: Health Management Network Commercial	$378.42
Rate for Payer: MDX Hawaii PPO	$431.84

DECLOT BY THROMBOLYTIC AGENT IMPLANT DEVICE/CATH

Professional

Both

$101.00

Service Code	HCPCS 36593
Min. Negotiated Rate	$35.62
Max. Negotiated Rate	$85.85
Rate for Payer: AlohaCare Medicaid	$39.39
Rate for Payer: AlohaCare Medicare	$42.92
Rate for Payer: Cash Price	$65.65
Rate for Payer: Cash Price	$65.65
Rate for Payer: Devoted Health Medicare	$47.21
Rate for Payer: Hawaii Medical Service Association Medicare	$42.92
Rate for Payer: Hawaii Western Management Group Commercial	$35.62
Rate for Payer: Health Management Network Commercial	$85.85
Rate for Payer: Kaiser Permanente Commercial	$51.50
Rate for Payer: Kaiser Permanente Medicaid	$51.50
Rate for Payer: Kaiser Permanente Medicare	$51.50
Rate for Payer: Ohana Health Plan Medicaid	$39.39
Rate for Payer: Ohana Health Plan Medicare	$42.92
Rate for Payer: UnitedHealthcare Medicaid	$39.39
Rate for Payer: UnitedHealthcare Medicare	$42.92

Defibrillator ICD Mri Cobalt Xt Dr Df4 DDPA2D4 [3644175]

Facility

$67,126.74

Service Code	HCPCS C1721
Hospital Charge Code	3644175
Hospital Revenue Code	275
Min. Negotiated Rate	$34,234.64
Max. Negotiated Rate	$65,112.94
Rate for Payer: Cash Price	$43,632.38
Rate for Payer: Hawaii Western Management Group Commercial	$46,988.72
Rate for Payer: Health Management Network Commercial	$57,057.73
Rate for Payer: Kaiser Permanente Commercial	$42,289.85
Rate for Payer: Kaiser Permanente Medicaid	$34,234.64
Rate for Payer: MDX Hawaii PPO	$65,112.94
Rate for Payer: University Health Alliance Commercial	$37,590.97

Defibrillator ICD Mri Cobalt Xt Dr Df4 DDPA2D4 [3644175]

Facility

$67,126.74

Service Code	HCPCS C1721
Hospital Charge Code	3644175
Hospital Revenue Code	275
Min. Negotiated Rate	$37,590.97
Max. Negotiated Rate	$65,112.94
Rate for Payer: Cash Price	$43,632.38
Rate for Payer: Hawaii Western Management Group Commercial	$46,988.72
Rate for Payer: Health Management Network Commercial	$57,057.73
Rate for Payer: MDX Hawaii PPO	$65,112.94
Rate for Payer: University Health Alliance Commercial	$37,590.97

DEFIBRILLATOR IMPLANTS

Facility

$25,007.25

Service Code	APR-DRG 1793
Min. Negotiated Rate	$25,007.25
Max. Negotiated Rate	$25,007.25
Rate for Payer: AlohaCare Medicaid	$25,007.25
Rate for Payer: Hawaii Medical Service Association ABD	$25,007.25
Rate for Payer: Hawaii Medical Service Association Non-ABD	$25,007.25
Rate for Payer: Kaiser Permanente Medicaid	$25,007.25
Rate for Payer: Ohana Health Plan Medicaid	$25,007.25
Rate for Payer: UnitedHealthcare Medicaid	$25,007.25

DEFIBRILLATOR IMPLANTS

Facility

$34,889.16

Service Code	APR-DRG 1794
Min. Negotiated Rate	$34,889.16
Max. Negotiated Rate	$34,889.16
Rate for Payer: AlohaCare Medicaid	$34,889.16
Rate for Payer: Hawaii Medical Service Association ABD	$34,889.16
Rate for Payer: Hawaii Medical Service Association Non-ABD	$34,889.16
Rate for Payer: Kaiser Permanente Medicaid	$34,889.16
Rate for Payer: Ohana Health Plan Medicaid	$34,889.16
Rate for Payer: UnitedHealthcare Medicaid	$34,889.16

DEFIBRILLATOR IMPLANTS

Facility

$21,229.10

Service Code	APR-DRG 1792
Min. Negotiated Rate	$21,229.10
Max. Negotiated Rate	$21,229.10
Rate for Payer: AlohaCare Medicaid	$21,229.10
Rate for Payer: Hawaii Medical Service Association ABD	$21,229.10
Rate for Payer: Hawaii Medical Service Association Non-ABD	$21,229.10
Rate for Payer: Kaiser Permanente Medicaid	$21,229.10
Rate for Payer: Ohana Health Plan Medicaid	$21,229.10
Rate for Payer: UnitedHealthcare Medicaid	$21,229.10

DEFIBRILLATOR IMPLANTS

Facility

$19,408.48

Service Code	APR-DRG 1791
Min. Negotiated Rate	$19,408.48
Max. Negotiated Rate	$19,408.48
Rate for Payer: AlohaCare Medicaid	$19,408.48
Rate for Payer: Hawaii Medical Service Association ABD	$19,408.48
Rate for Payer: Hawaii Medical Service Association Non-ABD	$19,408.48
Rate for Payer: Kaiser Permanente Medicaid	$19,408.48
Rate for Payer: Ohana Health Plan Medicaid	$19,408.48
Rate for Payer: UnitedHealthcare Medicaid	$19,408.48

Defibrillator Momentum El Icd Dr D121 [3643876]

Facility

$67,953.50

Service Code	HCPCS C1721
Hospital Charge Code	3643876
Hospital Revenue Code	275
Min. Negotiated Rate	$34,656.29
Max. Negotiated Rate	$65,914.90
Rate for Payer: Cash Price	$44,169.78
Rate for Payer: Hawaii Western Management Group Commercial	$47,567.45
Rate for Payer: Health Management Network Commercial	$57,760.47
Rate for Payer: Kaiser Permanente Commercial	$42,810.71
Rate for Payer: Kaiser Permanente Medicaid	$34,656.29
Rate for Payer: MDX Hawaii PPO	$65,914.90
Rate for Payer: University Health Alliance Commercial	$38,053.96

Defibrillator Momentum El Icd Dr D121 [3643876]

Facility

$67,953.50

Service Code	HCPCS C1721
Hospital Charge Code	3643876
Hospital Revenue Code	275
Min. Negotiated Rate	$38,053.96
Max. Negotiated Rate	$65,914.90
Rate for Payer: Cash Price	$44,169.78
Rate for Payer: Hawaii Western Management Group Commercial	$47,567.45
Rate for Payer: Health Management Network Commercial	$57,760.47
Rate for Payer: MDX Hawaii PPO	$65,914.90
Rate for Payer: University Health Alliance Commercial	$38,053.96

Defibrillator Perciva Icd Df4 Dr D413 [3643875]

Facility

$62,277.25

Service Code	HCPCS C1721
Hospital Charge Code	3643875
Hospital Revenue Code	275
Min. Negotiated Rate	$34,875.26
Max. Negotiated Rate	$60,408.93
Rate for Payer: Cash Price	$40,480.21
Rate for Payer: Hawaii Western Management Group Commercial	$43,594.07
Rate for Payer: Health Management Network Commercial	$52,935.66
Rate for Payer: MDX Hawaii PPO	$60,408.93
Rate for Payer: University Health Alliance Commercial	$34,875.26

Defibrillator Perciva Icd Df4 Dr D413 [3643875]

Facility

$62,277.25

Service Code	HCPCS C1721
Hospital Charge Code	3643875
Hospital Revenue Code	275
Min. Negotiated Rate	$31,761.40
Max. Negotiated Rate	$60,408.93
Rate for Payer: Cash Price	$40,480.21
Rate for Payer: Hawaii Western Management Group Commercial	$43,594.07
Rate for Payer: Health Management Network Commercial	$52,935.66
Rate for Payer: Kaiser Permanente Commercial	$39,234.67
Rate for Payer: Kaiser Permanente Medicaid	$31,761.40
Rate for Payer: MDX Hawaii PPO	$60,408.93
Rate for Payer: University Health Alliance Commercial	$34,875.26

DEGENERATIVE NERVOUS SYSTEM DISORDERS EXC MULT SCLEROSIS

Facility

$2,984.06

Service Code	APR-DRG 0421
Min. Negotiated Rate	$2,984.06
Max. Negotiated Rate	$2,984.06
Rate for Payer: AlohaCare Medicaid	$2,984.06
Rate for Payer: Hawaii Medical Service Association ABD	$2,984.06
Rate for Payer: Hawaii Medical Service Association Non-ABD	$2,984.06
Rate for Payer: Kaiser Permanente Medicaid	$2,984.06
Rate for Payer: Ohana Health Plan Medicaid	$2,984.06
Rate for Payer: UnitedHealthcare Medicaid	$2,984.06

DEGENERATIVE NERVOUS SYSTEM DISORDERS EXC MULT SCLEROSIS

Facility

$3,689.64

Service Code	APR-DRG 0422
Min. Negotiated Rate	$3,689.64
Max. Negotiated Rate	$3,689.64
Rate for Payer: AlohaCare Medicaid	$3,689.64
Rate for Payer: Hawaii Medical Service Association ABD	$3,689.64
Rate for Payer: Hawaii Medical Service Association Non-ABD	$3,689.64
Rate for Payer: Kaiser Permanente Medicaid	$3,689.64
Rate for Payer: Ohana Health Plan Medicaid	$3,689.64
Rate for Payer: UnitedHealthcare Medicaid	$3,689.64

DEGENERATIVE NERVOUS SYSTEM DISORDERS EXC MULT SCLEROSIS

Facility

$5,273.37

Service Code	APR-DRG 0423
Min. Negotiated Rate	$5,273.37
Max. Negotiated Rate	$5,273.37
Rate for Payer: AlohaCare Medicaid	$5,273.37
Rate for Payer: Hawaii Medical Service Association ABD	$5,273.37
Rate for Payer: Hawaii Medical Service Association Non-ABD	$5,273.37
Rate for Payer: Kaiser Permanente Medicaid	$5,273.37
Rate for Payer: Ohana Health Plan Medicaid	$5,273.37
Rate for Payer: UnitedHealthcare Medicaid	$5,273.37

DEGENERATIVE NERVOUS SYSTEM DISORDERS EXC MULT SCLEROSIS

Facility

$11,366.93

Service Code	APR-DRG 0424
Min. Negotiated Rate	$11,366.93
Max. Negotiated Rate	$11,366.93
Rate for Payer: AlohaCare Medicaid	$11,366.93
Rate for Payer: Hawaii Medical Service Association ABD	$11,366.93
Rate for Payer: Hawaii Medical Service Association Non-ABD	$11,366.93
Rate for Payer: Kaiser Permanente Medicaid	$11,366.93
Rate for Payer: Ohana Health Plan Medicaid	$11,366.93
Rate for Payer: UnitedHealthcare Medicaid	$11,366.93

DEGENERATIVE NERVOUS SYSTEM DISORDERS WITH MCC

Facility

$40,073.47

Service Code	MSDRG 056
Min. Negotiated Rate	$26,276.63
Max. Negotiated Rate	$40,073.47
Rate for Payer: AlohaCare Medicare	$30,555.19
Rate for Payer: Devoted Health Medicare	$33,610.71
Rate for Payer: Hawaii Medical Service Association Commercial	$26,276.63
Rate for Payer: Hawaii Medical Service Association Medicare	$30,555.19
Rate for Payer: Humana Medicare	$30,555.19
Rate for Payer: Kaiser Permanente Commercial	$40,073.47
Rate for Payer: Kaiser Permanente Medicare	$30,555.19
Rate for Payer: Ohana Health Plan Medicare	$30,555.19
Rate for Payer: UnitedHealthcare Medicare	$30,555.19

DEGENERATIVE NERVOUS SYSTEM DISORDERS WITHOUT MCC

Facility

$26,276.63

Service Code	MSDRG 057
Min. Negotiated Rate	$17,040.72
Max. Negotiated Rate	$26,276.63
Rate for Payer: AlohaCare Medicare	$17,040.72
Rate for Payer: Devoted Health Medicare	$18,744.79
Rate for Payer: Hawaii Medical Service Association Commercial	$26,276.63
Rate for Payer: Hawaii Medical Service Association Medicare	$17,040.72
Rate for Payer: Humana Medicare	$17,040.72
Rate for Payer: Kaiser Permanente Commercial	$22,349.10
Rate for Payer: Kaiser Permanente Medicare	$17,040.72
Rate for Payer: Ohana Health Plan Medicare	$17,040.72
Rate for Payer: UnitedHealthcare Medicare	$17,040.72

DENOSUMAB 120 MG/1.7 ML (70 MG/ML) SUBCUTANEOUS SOLN

Facility

$5,258.09

Service Code	HCPCS J0897
Hospital Revenue Code	250
Min. Negotiated Rate	$4,469.38
Max. Negotiated Rate	$5,100.35
Rate for Payer: Cash Price	$3,417.76
Rate for Payer: Health Management Network Commercial	$4,469.38
Rate for Payer: MDX Hawaii PPO	$5,100.35

DENOSUMAB 120 MG/1.7 ML (70 MG/ML) SUBCUTANEOUS SOLN

Facility

$5,258.09

Service Code	HCPCS J0897
Hospital Revenue Code	636
Min. Negotiated Rate	$29.24
Max. Negotiated Rate	$5,100.35
Rate for Payer: AlohaCare Medicaid	$29.51
Rate for Payer: AlohaCare Medicare	$29.51
Rate for Payer: Cash Price	$3,417.76
Rate for Payer: Cash Price	$3,417.76
Rate for Payer: Devoted Health Medicare	$32.46
Rate for Payer: Hawaii Medical Service Association ABD	$29.24
Rate for Payer: Hawaii Medical Service Association Commercial	$36.89
Rate for Payer: Hawaii Medical Service Association Medicare	$29.51
Rate for Payer: Hawaii Medical Service Association Non-ABD	$29.24
Rate for Payer: Hawaii Western Management Group Commercial	$4,995.19
Rate for Payer: Health Management Network Commercial	$4,469.38
Rate for Payer: Humana Medicare	$29.51
Rate for Payer: Kaiser Permanente Commercial	$3,312.60
Rate for Payer: Kaiser Permanente Medicaid	$2,681.63
Rate for Payer: Kaiser Permanente Medicare	$29.51
Rate for Payer: MDX Hawaii PPO	$5,100.35
Rate for Payer: Ohana Health Plan Medicaid	$32.46
Rate for Payer: Ohana Health Plan Medicare	$29.51
Rate for Payer: UnitedHealthcare Medicaid	$3,154.85
Rate for Payer: UnitedHealthcare Medicare	$29.51
Rate for Payer: University Health Alliance Commercial	$3,832.62

DENOSUMAB 60 MG/ML SUBCUTANEOUS SYR

Facility

$3,368.92

Service Code	HCPCS J0897
Hospital Revenue Code	250
Min. Negotiated Rate	$2,863.58
Max. Negotiated Rate	$3,267.85
Rate for Payer: Cash Price	$2,189.80
Rate for Payer: Health Management Network Commercial	$2,863.58
Rate for Payer: MDX Hawaii PPO	$3,267.85

Know your out-of-pocket cost for care.

All Charges