Kona Community Hospital

All Charges

Charge

Type

Setting

Price

DEXTROSE 5 %-LACTATED RINGERS IV SOLP

Facility

$30.36

Service Code	HCPCS J7121
Hospital Revenue Code	250
Min. Negotiated Rate	$0.01
Max. Negotiated Rate	$29.45
Rate for Payer: Cash Price	$19.73
Rate for Payer: Cash Price	$10.76
Rate for Payer: Cash Price	$10.76
Rate for Payer: Cash Price	$19.73
Rate for Payer: Hawaii Medical Service Association ABD	$0.01
Rate for Payer: Hawaii Medical Service Association ABD	$0.01
Rate for Payer: Hawaii Medical Service Association Non-ABD	$0.01
Rate for Payer: Hawaii Medical Service Association Non-ABD	$0.01
Rate for Payer: Hawaii Western Management Group Commercial	$15.73
Rate for Payer: Hawaii Western Management Group Commercial	$28.84
Rate for Payer: Health Management Network Commercial	$25.81
Rate for Payer: Health Management Network Commercial	$14.08
Rate for Payer: Kaiser Permanente Commercial	$19.13
Rate for Payer: Kaiser Permanente Commercial	$10.43
Rate for Payer: Kaiser Permanente Medicaid	$8.45
Rate for Payer: Kaiser Permanente Medicaid	$15.48
Rate for Payer: MDX Hawaii PPO	$29.45
Rate for Payer: MDX Hawaii PPO	$16.06
Rate for Payer: UnitedHealthcare Medicaid	$9.94
Rate for Payer: UnitedHealthcare Medicaid	$18.22
Rate for Payer: University Health Alliance Commercial	$12.07
Rate for Payer: University Health Alliance Commercial	$22.13

DIABETES

Facility

$8,420.45

Service Code	APR-DRG 4204
Min. Negotiated Rate	$8,420.45
Max. Negotiated Rate	$8,420.45
Rate for Payer: AlohaCare Medicaid	$8,420.45
Rate for Payer: Hawaii Medical Service Association ABD	$8,420.45
Rate for Payer: Hawaii Medical Service Association Non-ABD	$8,420.45
Rate for Payer: Kaiser Permanente Medicaid	$8,420.45
Rate for Payer: Ohana Health Plan Medicaid	$8,420.45
Rate for Payer: UnitedHealthcare Medicaid	$8,420.45

DIABETES

Facility

$2,975.14

Service Code	APR-DRG 4202
Min. Negotiated Rate	$2,975.14
Max. Negotiated Rate	$2,975.14
Rate for Payer: AlohaCare Medicaid	$2,975.14
Rate for Payer: Hawaii Medical Service Association ABD	$2,975.14
Rate for Payer: Hawaii Medical Service Association Non-ABD	$2,975.14
Rate for Payer: Kaiser Permanente Medicaid	$2,975.14
Rate for Payer: Ohana Health Plan Medicaid	$2,975.14
Rate for Payer: UnitedHealthcare Medicaid	$2,975.14

DIABETES

Facility

$4,198.44

Service Code	APR-DRG 4203
Min. Negotiated Rate	$4,198.44
Max. Negotiated Rate	$4,198.44
Rate for Payer: AlohaCare Medicaid	$4,198.44
Rate for Payer: Hawaii Medical Service Association ABD	$4,198.44
Rate for Payer: Hawaii Medical Service Association Non-ABD	$4,198.44
Rate for Payer: Kaiser Permanente Medicaid	$4,198.44
Rate for Payer: Ohana Health Plan Medicaid	$4,198.44
Rate for Payer: UnitedHealthcare Medicaid	$4,198.44

DIABETES

Facility

$2,300.77

Service Code	APR-DRG 4201
Min. Negotiated Rate	$2,300.77
Max. Negotiated Rate	$2,300.77
Rate for Payer: AlohaCare Medicaid	$2,300.77
Rate for Payer: Hawaii Medical Service Association ABD	$2,300.77
Rate for Payer: Hawaii Medical Service Association Non-ABD	$2,300.77
Rate for Payer: Kaiser Permanente Medicaid	$2,300.77
Rate for Payer: Ohana Health Plan Medicaid	$2,300.77
Rate for Payer: UnitedHealthcare Medicaid	$2,300.77

DIABETES WITH CC

Facility

$15,459.45

Service Code	MSDRG 638
Min. Negotiated Rate	$11,787.50
Max. Negotiated Rate	$15,459.45
Rate for Payer: AlohaCare Medicare	$11,787.50
Rate for Payer: Devoted Health Medicare	$12,966.25
Rate for Payer: Hawaii Medical Service Association Commercial	$15,187.41
Rate for Payer: Hawaii Medical Service Association Medicare	$11,787.50
Rate for Payer: Humana Medicare	$11,787.50
Rate for Payer: Kaiser Permanente Commercial	$15,459.45
Rate for Payer: Kaiser Permanente Medicare	$11,787.50
Rate for Payer: Ohana Health Plan Medicare	$11,787.50
Rate for Payer: UnitedHealthcare Medicare	$11,787.50

DIABETES WITH MCC

Facility

$24,783.08

Service Code	MSDRG 637
Min. Negotiated Rate	$15,332.05
Max. Negotiated Rate	$24,783.08
Rate for Payer: AlohaCare Medicare	$18,896.57
Rate for Payer: Devoted Health Medicare	$20,786.23
Rate for Payer: Hawaii Medical Service Association Commercial	$15,332.05
Rate for Payer: Hawaii Medical Service Association Medicare	$18,896.57
Rate for Payer: Humana Medicare	$18,896.57
Rate for Payer: Kaiser Permanente Commercial	$24,783.08
Rate for Payer: Kaiser Permanente Medicare	$18,896.57
Rate for Payer: Ohana Health Plan Medicare	$18,896.57
Rate for Payer: UnitedHealthcare Medicare	$18,896.57

DIABETES WITHOUT CC/MCC

Facility

$15,066.88

Service Code	MSDRG 639
Min. Negotiated Rate	$8,170.49
Max. Negotiated Rate	$15,066.88
Rate for Payer: AlohaCare Medicare	$8,170.49
Rate for Payer: Devoted Health Medicare	$8,987.54
Rate for Payer: Hawaii Medical Service Association Commercial	$15,066.88
Rate for Payer: Hawaii Medical Service Association Medicare	$8,170.49
Rate for Payer: Humana Medicare	$8,170.49
Rate for Payer: Kaiser Permanente Commercial	$10,715.70
Rate for Payer: Kaiser Permanente Medicare	$8,170.49
Rate for Payer: Ohana Health Plan Medicare	$8,170.49
Rate for Payer: UnitedHealthcare Medicare	$8,170.49

DIAGNOSTIC BONE MARROW ASPIRATIONS

Professional

Both

$524.00

Service Code	HCPCS 38220
Min. Negotiated Rate	$56.01
Max. Negotiated Rate	$445.40
Rate for Payer: AlohaCare Medicaid	$68.20
Rate for Payer: AlohaCare Medicare	$56.01
Rate for Payer: Cash Price	$340.60
Rate for Payer: Cash Price	$340.60
Rate for Payer: Devoted Health Medicare	$61.61
Rate for Payer: Hawaii Medical Service Association ABD	$68.20
Rate for Payer: Hawaii Medical Service Association Commercial	$115.07
Rate for Payer: Hawaii Medical Service Association Medicare	$56.01
Rate for Payer: Hawaii Medical Service Association Non-ABD	$68.20
Rate for Payer: Hawaii Western Management Group Commercial	$212.16
Rate for Payer: Health Management Network Commercial	$445.40
Rate for Payer: Kaiser Permanente Commercial	$67.21
Rate for Payer: Kaiser Permanente Medicaid	$67.21
Rate for Payer: Kaiser Permanente Medicare	$67.21
Rate for Payer: Ohana Health Plan Medicaid	$68.20
Rate for Payer: Ohana Health Plan Medicare	$56.01
Rate for Payer: UnitedHealthcare Medicaid	$68.20
Rate for Payer: UnitedHealthcare Medicare	$56.01
Rate for Payer: University Health Alliance Commercial	$93.68

DIAGNOSTIC BONE MARROW BIOPSIES

Professional

Both

$500.00

Service Code	HCPCS 38221
Min. Negotiated Rate	$57.93
Max. Negotiated Rate	$425.00
Rate for Payer: AlohaCare Medicaid	$71.25
Rate for Payer: AlohaCare Medicare	$57.93
Rate for Payer: Cash Price	$325.00
Rate for Payer: Cash Price	$325.00
Rate for Payer: Devoted Health Medicare	$63.72
Rate for Payer: Hawaii Medical Service Association ABD	$71.25
Rate for Payer: Hawaii Medical Service Association Commercial	$120.19
Rate for Payer: Hawaii Medical Service Association Medicare	$57.93
Rate for Payer: Hawaii Medical Service Association Non-ABD	$71.25
Rate for Payer: Hawaii Western Management Group Commercial	$225.94
Rate for Payer: Health Management Network Commercial	$425.00
Rate for Payer: Kaiser Permanente Commercial	$69.52
Rate for Payer: Kaiser Permanente Medicaid	$69.52
Rate for Payer: Kaiser Permanente Medicare	$69.52
Rate for Payer: Ohana Health Plan Medicaid	$71.25
Rate for Payer: Ohana Health Plan Medicare	$57.93
Rate for Payer: UnitedHealthcare Medicaid	$71.25
Rate for Payer: UnitedHealthcare Medicare	$57.93
Rate for Payer: University Health Alliance Commercial	$94.65

DIAGNOSTIC BONE MARROW BIOPSIES & ASPIRATIONS

Professional

Both

$549.00

Service Code	HCPCS 38222
Min. Negotiated Rate	$62.19
Max. Negotiated Rate	$466.65
Rate for Payer: AlohaCare Medicaid	$75.42
Rate for Payer: AlohaCare Medicare	$62.19
Rate for Payer: Cash Price	$356.85
Rate for Payer: Cash Price	$356.85
Rate for Payer: Devoted Health Medicare	$68.41
Rate for Payer: Hawaii Medical Service Association ABD	$75.42
Rate for Payer: Hawaii Medical Service Association Commercial	$128.68
Rate for Payer: Hawaii Medical Service Association Medicare	$62.19
Rate for Payer: Hawaii Medical Service Association Non-ABD	$75.42
Rate for Payer: Hawaii Western Management Group Commercial	$190.32
Rate for Payer: Health Management Network Commercial	$466.65
Rate for Payer: Kaiser Permanente Commercial	$74.63
Rate for Payer: Kaiser Permanente Medicaid	$74.63
Rate for Payer: Kaiser Permanente Medicare	$74.63
Rate for Payer: Ohana Health Plan Medicaid	$75.42
Rate for Payer: Ohana Health Plan Medicare	$62.19
Rate for Payer: UnitedHealthcare Medicaid	$75.42
Rate for Payer: UnitedHealthcare Medicare	$62.19
Rate for Payer: University Health Alliance Commercial	$110.00

DIAGNOSTIC COMPUTED TOMOGRAPHY THORAX C-/C+

Professional

Both

$643.00

Service Code	HCPCS 71270
Min. Negotiated Rate	$133.95
Max. Negotiated Rate	$546.55
Rate for Payer: AlohaCare Medicaid	$133.95
Rate for Payer: AlohaCare Medicare	$215.28
Rate for Payer: Cash Price	$417.95
Rate for Payer: Cash Price	$417.95
Rate for Payer: Devoted Health Medicare	$236.81
Rate for Payer: Hawaii Medical Service Association Medicare	$215.28
Rate for Payer: Hawaii Western Management Group Commercial	$464.02
Rate for Payer: Health Management Network Commercial	$546.55
Rate for Payer: Kaiser Permanente Commercial	$258.34
Rate for Payer: Kaiser Permanente Medicaid	$258.34
Rate for Payer: Kaiser Permanente Medicare	$258.34
Rate for Payer: Ohana Health Plan Medicaid	$133.95
Rate for Payer: Ohana Health Plan Medicare	$215.28
Rate for Payer: UnitedHealthcare Medicaid	$133.95
Rate for Payer: UnitedHealthcare Medicare	$215.28

DIAGNOSTIC COMPUTED TOMOGRAPHY THORAX W/CONTRAST

Professional

Both

$540.00

Service Code	HCPCS 71260
Min. Negotiated Rate	$113.56
Max. Negotiated Rate	$459.00
Rate for Payer: AlohaCare Medicaid	$113.56
Rate for Payer: AlohaCare Medicare	$182.66
Rate for Payer: Cash Price	$351.00
Rate for Payer: Cash Price	$351.00
Rate for Payer: Devoted Health Medicare	$200.93
Rate for Payer: Hawaii Medical Service Association Medicare	$182.66
Rate for Payer: Hawaii Western Management Group Commercial	$378.67
Rate for Payer: Health Management Network Commercial	$459.00
Rate for Payer: Kaiser Permanente Commercial	$219.19
Rate for Payer: Kaiser Permanente Medicaid	$219.19
Rate for Payer: Kaiser Permanente Medicare	$219.19
Rate for Payer: Ohana Health Plan Medicaid	$113.56
Rate for Payer: Ohana Health Plan Medicare	$182.66
Rate for Payer: UnitedHealthcare Medicaid	$113.56
Rate for Payer: UnitedHealthcare Medicare	$182.66

DIAGNOSTIC COMPUTED TOMOGRAPHY THORAX W/O CNTRST

Professional

Both

$430.00

Service Code	HCPCS 71250
Min. Negotiated Rate	$89.82
Max. Negotiated Rate	$365.50
Rate for Payer: AlohaCare Medicaid	$89.82
Rate for Payer: AlohaCare Medicare	$144.66
Rate for Payer: Cash Price	$279.50
Rate for Payer: Cash Price	$279.50
Rate for Payer: Devoted Health Medicare	$159.13
Rate for Payer: Hawaii Medical Service Association Medicare	$144.66
Rate for Payer: Hawaii Western Management Group Commercial	$322.87
Rate for Payer: Health Management Network Commercial	$365.50
Rate for Payer: Kaiser Permanente Commercial	$173.59
Rate for Payer: Kaiser Permanente Medicaid	$173.59
Rate for Payer: Kaiser Permanente Medicare	$173.59
Rate for Payer: Ohana Health Plan Medicaid	$89.82
Rate for Payer: Ohana Health Plan Medicare	$144.66
Rate for Payer: UnitedHealthcare Medicaid	$89.82
Rate for Payer: UnitedHealthcare Medicare	$144.66

DIALYSIS CIRCUIT PERMANENT VASCULAR EMBOLIZATION OR OCCLUSION (INCLUDING MAIN CIRCUIT OR ANY ACCESSORY VEINS), ENDOVASCULAR, INCLUDING ALL IMAGING AND RADIOLOGICAL SUPERVISION AND INTERPRETATION NECESSARY TO COMPLETE THE INTERVENTION (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)

Facility

$2,837.00

Service Code	CPT 36909
Hospital Revenue Code	360
Min. Negotiated Rate	$190.20
Max. Negotiated Rate	$2,837.00
Rate for Payer: Kaiser Permanente Medicaid	$2,837.00
Rate for Payer: UnitedHealthcare Medicaid	$190.20

DIATRIZOATE MEG-DIATRIZOAT SOD 66-10 % PO SOLN

Facility

$113.51

Service Code	HCPCS Q9963
Hospital Revenue Code	255
Min. Negotiated Rate	$0.17
Max. Negotiated Rate	$110.10
Rate for Payer: Cash Price	$73.78
Rate for Payer: Cash Price	$73.78
Rate for Payer: Hawaii Medical Service Association ABD	$0.22
Rate for Payer: Hawaii Medical Service Association Non-ABD	$0.22
Rate for Payer: Hawaii Western Management Group Commercial	$107.83
Rate for Payer: Health Management Network Commercial	$96.48
Rate for Payer: Kaiser Permanente Commercial	$71.51
Rate for Payer: Kaiser Permanente Medicaid	$57.89
Rate for Payer: MDX Hawaii PPO	$110.10
Rate for Payer: UnitedHealthcare Medicaid	$0.17
Rate for Payer: University Health Alliance Commercial	$82.74

DIATRIZOATE MEG-DIATRIZOAT SOD 66-10 % PO SOLN

Facility

$113.51

Service Code	HCPCS Q9963
Hospital Revenue Code	255
Min. Negotiated Rate	$96.48
Max. Negotiated Rate	$110.10
Rate for Payer: Cash Price	$73.78
Rate for Payer: Health Management Network Commercial	$96.48
Rate for Payer: MDX Hawaii PPO	$110.10

DIATRIZOATE MEGLUMINE 30 % 300 ML URTH SOLN

Facility

$290.38

Service Code	HCPCS Q9958
Hospital Revenue Code	255
Min. Negotiated Rate	$246.82
Max. Negotiated Rate	$281.67
Rate for Payer: Cash Price	$188.75
Rate for Payer: Health Management Network Commercial	$246.82
Rate for Payer: MDX Hawaii PPO	$281.67

DIATRIZOATE MEGLUMINE 30 % 300 ML URTH SOLN

Facility

$290.38

Service Code	HCPCS Q9958
Hospital Revenue Code	255
Min. Negotiated Rate	$0.05
Max. Negotiated Rate	$281.67
Rate for Payer: Cash Price	$188.75
Rate for Payer: Cash Price	$188.75
Rate for Payer: Hawaii Medical Service Association ABD	$0.07
Rate for Payer: Hawaii Medical Service Association Non-ABD	$0.07
Rate for Payer: Hawaii Western Management Group Commercial	$275.86
Rate for Payer: Health Management Network Commercial	$246.82
Rate for Payer: Kaiser Permanente Commercial	$182.94
Rate for Payer: Kaiser Permanente Medicaid	$148.09
Rate for Payer: MDX Hawaii PPO	$281.67
Rate for Payer: UnitedHealthcare Medicaid	$0.05
Rate for Payer: University Health Alliance Commercial	$211.66

DIAZEPAM 10 MG PO TABLET

Facility

$1.73

Service Code	HCPCS A9270
Hospital Revenue Code	250
Min. Negotiated Rate	$1.47
Max. Negotiated Rate	$1.68
Rate for Payer: Cash Price	$1.12
Rate for Payer: Cash Price	$1.53
Rate for Payer: Health Management Network Commercial	$1.47
Rate for Payer: Health Management Network Commercial	$2.00
Rate for Payer: MDX Hawaii PPO	$1.68
Rate for Payer: MDX Hawaii PPO	$2.28

DIAZEPAM 10 MG PO TABLET

Facility

$2.35

Service Code	HCPCS A9270
Hospital Revenue Code	250
Min. Negotiated Rate	$1.20
Max. Negotiated Rate	$2.28
Rate for Payer: Cash Price	$1.53
Rate for Payer: Cash Price	$1.12
Rate for Payer: Hawaii Western Management Group Commercial	$2.23
Rate for Payer: Hawaii Western Management Group Commercial	$1.64
Rate for Payer: Health Management Network Commercial	$1.47
Rate for Payer: Health Management Network Commercial	$2.00
Rate for Payer: Kaiser Permanente Commercial	$1.48
Rate for Payer: Kaiser Permanente Commercial	$1.09
Rate for Payer: Kaiser Permanente Medicaid	$0.88
Rate for Payer: Kaiser Permanente Medicaid	$1.20
Rate for Payer: MDX Hawaii PPO	$1.68
Rate for Payer: MDX Hawaii PPO	$2.28
Rate for Payer: UnitedHealthcare Medicaid	$1.41
Rate for Payer: UnitedHealthcare Medicaid	$1.04
Rate for Payer: University Health Alliance Commercial	$1.26
Rate for Payer: University Health Alliance Commercial	$1.71

DIAZEPAM 5 MG/ML INJ SYR

Facility

$119.89

Service Code	HCPCS J3360
Hospital Revenue Code	250
Min. Negotiated Rate	$101.91
Max. Negotiated Rate	$116.29
Rate for Payer: Cash Price	$77.93
Rate for Payer: Cash Price	$102.29
Rate for Payer: Health Management Network Commercial	$101.91
Rate for Payer: Health Management Network Commercial	$133.76
Rate for Payer: MDX Hawaii PPO	$116.29
Rate for Payer: MDX Hawaii PPO	$152.65

DIAZEPAM 5 MG/ML INJ SYR

Facility

$119.89

Service Code	HCPCS J3360
Hospital Revenue Code	636
Min. Negotiated Rate	$6.17
Max. Negotiated Rate	$116.29
Rate for Payer: Cash Price	$77.93
Rate for Payer: Cash Price	$77.93
Rate for Payer: Cash Price	$102.29
Rate for Payer: Cash Price	$102.29
Rate for Payer: Hawaii Medical Service Association ABD	$6.17
Rate for Payer: Hawaii Medical Service Association ABD	$6.17
Rate for Payer: Hawaii Medical Service Association Non-ABD	$6.17
Rate for Payer: Hawaii Medical Service Association Non-ABD	$6.17
Rate for Payer: Hawaii Western Management Group Commercial	$113.90
Rate for Payer: Hawaii Western Management Group Commercial	$149.50
Rate for Payer: Health Management Network Commercial	$133.76
Rate for Payer: Health Management Network Commercial	$101.91
Rate for Payer: Kaiser Permanente Commercial	$99.14
Rate for Payer: Kaiser Permanente Commercial	$75.53
Rate for Payer: Kaiser Permanente Medicaid	$61.14
Rate for Payer: Kaiser Permanente Medicaid	$80.26
Rate for Payer: MDX Hawaii PPO	$152.65
Rate for Payer: MDX Hawaii PPO	$116.29
Rate for Payer: UnitedHealthcare Medicaid	$71.93
Rate for Payer: UnitedHealthcare Medicaid	$94.42
Rate for Payer: University Health Alliance Commercial	$114.71
Rate for Payer: University Health Alliance Commercial	$87.39

DIAZEPAM 5 MG PO TABLET

Facility

$1.78

Service Code	HCPCS A9270
Hospital Revenue Code	250
Min. Negotiated Rate	$1.51
Max. Negotiated Rate	$1.73
Rate for Payer: Cash Price	$1.16
Rate for Payer: Health Management Network Commercial	$1.51
Rate for Payer: MDX Hawaii PPO	$1.73

DIAZEPAM 5 MG PO TABLET

Facility

$1.78

Service Code	HCPCS A9270
Hospital Revenue Code	250
Min. Negotiated Rate	$0.91
Max. Negotiated Rate	$1.73
Rate for Payer: Cash Price	$1.16
Rate for Payer: Hawaii Western Management Group Commercial	$1.69
Rate for Payer: Health Management Network Commercial	$1.51
Rate for Payer: Kaiser Permanente Commercial	$1.12
Rate for Payer: Kaiser Permanente Medicaid	$0.91
Rate for Payer: MDX Hawaii PPO	$1.73
Rate for Payer: UnitedHealthcare Medicaid	$1.07
Rate for Payer: University Health Alliance Commercial	$1.30

Know your out-of-pocket cost for care.

All Charges