Kona Community Hospital

All Charges

Charge

Type

Setting

Price

Endo Polyp Snare Hex 13mm 6245 [3640412]

Facility

$111.78

Hospital Charge Code	3640412
Hospital Revenue Code	272
Min. Negotiated Rate	$57.01
Max. Negotiated Rate	$108.43
Rate for Payer: Cash Price	$72.66
Rate for Payer: Hawaii Western Management Group Commercial	$106.19
Rate for Payer: Health Management Network Commercial	$95.01
Rate for Payer: Kaiser Permanente Commercial	$70.42
Rate for Payer: Kaiser Permanente Medicaid	$57.01
Rate for Payer: MDX Hawaii PPO	$108.43
Rate for Payer: University Health Alliance Commercial	$81.48

Endo Polyp Snare Profile Oval 13mm M00562550 [3640567]

Facility

$304.28

Hospital Charge Code	3640567
Hospital Revenue Code	272
Min. Negotiated Rate	$155.18
Max. Negotiated Rate	$295.15
Rate for Payer: Cash Price	$197.78
Rate for Payer: Hawaii Western Management Group Commercial	$289.07
Rate for Payer: Health Management Network Commercial	$258.64
Rate for Payer: Kaiser Permanente Commercial	$191.70
Rate for Payer: Kaiser Permanente Medicaid	$155.18
Rate for Payer: MDX Hawaii PPO	$295.15
Rate for Payer: University Health Alliance Commercial	$221.79

Endo Polyp Snare Profile Oval 13mm M00562550 [3640567]

Facility

$304.28

Hospital Charge Code	3640567
Hospital Revenue Code	272
Min. Negotiated Rate	$258.64
Max. Negotiated Rate	$295.15
Rate for Payer: Cash Price	$197.78
Rate for Payer: Health Management Network Commercial	$258.64
Rate for Payer: MDX Hawaii PPO	$295.15

Endo Rescue Net DGN538 [3640786]

Facility

$592.41

Hospital Charge Code	3640786
Hospital Revenue Code	272
Min. Negotiated Rate	$302.13
Max. Negotiated Rate	$574.64
Rate for Payer: Cash Price	$385.07
Rate for Payer: Hawaii Western Management Group Commercial	$562.79
Rate for Payer: Health Management Network Commercial	$503.55
Rate for Payer: Kaiser Permanente Commercial	$373.22
Rate for Payer: Kaiser Permanente Medicaid	$302.13
Rate for Payer: MDX Hawaii PPO	$574.64
Rate for Payer: University Health Alliance Commercial	$431.81

Endo Rescue Net DGN538 [3640786]

Facility

$592.41

Hospital Charge Code	3640786
Hospital Revenue Code	272
Min. Negotiated Rate	$503.55
Max. Negotiated Rate	$574.64
Rate for Payer: Cash Price	$385.07
Rate for Payer: Health Management Network Commercial	$503.55
Rate for Payer: MDX Hawaii PPO	$574.64

Endo Rescue Rat Tooth/Alligator Grasping Forcep 3835 [3642251]

Facility

$577.75

Hospital Charge Code	3642251
Hospital Revenue Code	272
Min. Negotiated Rate	$491.09
Max. Negotiated Rate	$560.42
Rate for Payer: Cash Price	$375.54
Rate for Payer: Health Management Network Commercial	$491.09
Rate for Payer: MDX Hawaii PPO	$560.42

Endo Rescue Rat Tooth/Alligator Grasping Forcep 3835 [3642251]

Facility

$577.75

Hospital Charge Code	3642251
Hospital Revenue Code	272
Min. Negotiated Rate	$294.65
Max. Negotiated Rate	$560.42
Rate for Payer: Cash Price	$375.54
Rate for Payer: Hawaii Western Management Group Commercial	$548.86
Rate for Payer: Health Management Network Commercial	$491.09
Rate for Payer: Kaiser Permanente Commercial	$363.98
Rate for Payer: Kaiser Permanente Medicaid	$294.65
Rate for Payer: MDX Hawaii PPO	$560.42
Rate for Payer: University Health Alliance Commercial	$421.12

Endo SerosaFuse (Esophyx Z) Cartridge Refill 7.5 R2175 [3601741]

Facility

$2,753.00

Hospital Charge Code	3601741
Hospital Revenue Code	272
Min. Negotiated Rate	$2,340.05
Max. Negotiated Rate	$2,670.41
Rate for Payer: Cash Price	$1,789.45
Rate for Payer: Health Management Network Commercial	$2,340.05
Rate for Payer: MDX Hawaii PPO	$2,670.41

Endo SerosaFuse (Esophyx Z) Cartridge Refill 7.5 R2175 [3601741]

Facility

$2,753.00

Hospital Charge Code	3601741
Hospital Revenue Code	272
Min. Negotiated Rate	$1,404.03
Max. Negotiated Rate	$2,670.41
Rate for Payer: Cash Price	$1,789.45
Rate for Payer: Hawaii Western Management Group Commercial	$2,615.35
Rate for Payer: Health Management Network Commercial	$2,340.05
Rate for Payer: Kaiser Permanente Commercial	$1,734.39
Rate for Payer: Kaiser Permanente Medicaid	$1,404.03
Rate for Payer: MDX Hawaii PPO	$2,670.41
Rate for Payer: University Health Alliance Commercial	$2,006.66

Endo SerosaFuse Implantable Fastener Kit (Esophyx Z Plus)7.5mm R2275 [3641462]

Facility

$19,808.00

Service Code	HCPCS C1889
Hospital Charge Code	3641462
Hospital Revenue Code	278
Min. Negotiated Rate	$10,102.08
Max. Negotiated Rate	$19,213.76
Rate for Payer: Cash Price	$12,875.20
Rate for Payer: Hawaii Western Management Group Commercial	$13,865.60
Rate for Payer: Health Management Network Commercial	$16,836.80
Rate for Payer: Kaiser Permanente Commercial	$12,479.04
Rate for Payer: Kaiser Permanente Medicaid	$10,102.08
Rate for Payer: MDX Hawaii PPO	$19,213.76
Rate for Payer: University Health Alliance Commercial	$11,092.48

Endo SerosaFuse Implantable Fastener Kit (Esophyx Z Plus)7.5mm R2275 [3641462]

Facility

$19,808.00

Service Code	HCPCS C1889
Hospital Charge Code	3641462
Hospital Revenue Code	278
Min. Negotiated Rate	$11,092.48
Max. Negotiated Rate	$19,213.76
Rate for Payer: Cash Price	$12,875.20
Rate for Payer: Hawaii Western Management Group Commercial	$13,865.60
Rate for Payer: Health Management Network Commercial	$16,836.80
Rate for Payer: MDX Hawaii PPO	$19,213.76
Rate for Payer: University Health Alliance Commercial	$11,092.48

ENDOVASCULAR ABDOMINAL AORTA WITH ILIAC BRANCH PROCEDURES

Facility

$98,444.02

Service Code	MSDRG 213
Min. Negotiated Rate	$75,061.53
Max. Negotiated Rate	$98,444.02
Rate for Payer: AlohaCare Medicare	$75,061.53
Rate for Payer: Devoted Health Medicare	$82,567.68
Rate for Payer: Hawaii Medical Service Association Commercial	$97,681.56
Rate for Payer: Hawaii Medical Service Association Medicare	$75,061.53
Rate for Payer: Humana Medicare	$75,061.53
Rate for Payer: Kaiser Permanente Commercial	$98,444.02
Rate for Payer: Kaiser Permanente Medicare	$75,061.53
Rate for Payer: Ohana Health Plan Medicare	$75,061.53
Rate for Payer: UnitedHealthcare Medicare	$75,061.53

ENDOVASCULAR CARDIAC VALVE REPLACEMENT AND SUPPLEMENT PROCEDURES WITH MCC

Facility

$105,714.90

Service Code	MSDRG 266
Min. Negotiated Rate	$80,605.41
Max. Negotiated Rate	$105,714.90
Rate for Payer: AlohaCare Medicare	$80,605.41
Rate for Payer: Devoted Health Medicare	$88,665.95
Rate for Payer: Hawaii Medical Service Association Commercial	$93,944.98
Rate for Payer: Hawaii Medical Service Association Medicare	$80,605.41
Rate for Payer: Humana Medicare	$80,605.41
Rate for Payer: Kaiser Permanente Commercial	$105,714.90
Rate for Payer: Kaiser Permanente Medicare	$80,605.41
Rate for Payer: Ohana Health Plan Medicare	$80,605.41
Rate for Payer: UnitedHealthcare Medicare	$80,605.41

ENDOVASCULAR CARDIAC VALVE REPLACEMENT AND SUPPLEMENT PROCEDURES WITHOUT MCC

Facility

$82,123.80

Service Code	MSDRG 267
Min. Negotiated Rate	$62,617.70
Max. Negotiated Rate	$82,123.80
Rate for Payer: AlohaCare Medicare	$62,617.70
Rate for Payer: Devoted Health Medicare	$68,879.47
Rate for Payer: Hawaii Medical Service Association Commercial	$81,819.16
Rate for Payer: Hawaii Medical Service Association Medicare	$62,617.70
Rate for Payer: Humana Medicare	$62,617.70
Rate for Payer: Kaiser Permanente Commercial	$82,123.80
Rate for Payer: Kaiser Permanente Medicare	$62,617.70
Rate for Payer: Ohana Health Plan Medicare	$62,617.70
Rate for Payer: UnitedHealthcare Medicare	$62,617.70

EndoVive Peg Kit 20FR 0900/0904 [3601082]

Facility

$434.00

Hospital Charge Code	3601082
Hospital Revenue Code	272
Min. Negotiated Rate	$368.90
Max. Negotiated Rate	$420.98
Rate for Payer: Cash Price	$282.10
Rate for Payer: Health Management Network Commercial	$368.90
Rate for Payer: MDX Hawaii PPO	$420.98

EndoVive Peg Kit 20FR 0900/0904 [3601082]

Facility

$434.00

Hospital Charge Code	3601082
Hospital Revenue Code	272
Min. Negotiated Rate	$221.34
Max. Negotiated Rate	$420.98
Rate for Payer: Cash Price	$282.10
Rate for Payer: Hawaii Western Management Group Commercial	$412.30
Rate for Payer: Health Management Network Commercial	$368.90
Rate for Payer: Kaiser Permanente Commercial	$273.42
Rate for Payer: Kaiser Permanente Medicaid	$221.34
Rate for Payer: MDX Hawaii PPO	$420.98
Rate for Payer: University Health Alliance Commercial	$316.34

ENFORTUMAB VEDOTIN-EJFV 30 MG IV RECON.SOLN.

Facility

$6,174.60

Service Code	HCPCS J9177
Hospital Revenue Code	250
Min. Negotiated Rate	$5,248.41
Max. Negotiated Rate	$5,989.36
Rate for Payer: Cash Price	$4,013.49
Rate for Payer: Health Management Network Commercial	$5,248.41
Rate for Payer: MDX Hawaii PPO	$5,989.36

ENFORTUMAB VEDOTIN-EJFV 30 MG IV RECON.SOLN.

Facility

$6,174.60

Service Code	HCPCS J9177
Hospital Revenue Code	636
Min. Negotiated Rate	$36.66
Max. Negotiated Rate	$5,989.36
Rate for Payer: AlohaCare Medicaid	$36.71
Rate for Payer: AlohaCare Medicare	$36.71
Rate for Payer: Cash Price	$4,013.49
Rate for Payer: Cash Price	$4,013.49
Rate for Payer: Devoted Health Medicare	$40.38
Rate for Payer: Hawaii Medical Service Association ABD	$36.66
Rate for Payer: Hawaii Medical Service Association Commercial	$45.89
Rate for Payer: Hawaii Medical Service Association Medicare	$36.71
Rate for Payer: Hawaii Medical Service Association Non-ABD	$36.66
Rate for Payer: Hawaii Western Management Group Commercial	$5,865.87
Rate for Payer: Health Management Network Commercial	$5,248.41
Rate for Payer: Humana Medicare	$36.71
Rate for Payer: Kaiser Permanente Commercial	$3,890.00
Rate for Payer: Kaiser Permanente Medicaid	$3,149.05
Rate for Payer: Kaiser Permanente Medicare	$36.71
Rate for Payer: MDX Hawaii PPO	$5,989.36
Rate for Payer: Ohana Health Plan Medicaid	$40.38
Rate for Payer: Ohana Health Plan Medicare	$36.71
Rate for Payer: UnitedHealthcare Medicaid	$3,704.76
Rate for Payer: UnitedHealthcare Medicare	$36.71
Rate for Payer: University Health Alliance Commercial	$4,500.67

ENOXAPARIN 100 MG/ML SUBCUTANEOUS SYR

Facility

$92.52

Service Code	HCPCS J1650
Hospital Revenue Code	636
Min. Negotiated Rate	$1.24
Max. Negotiated Rate	$89.74
Rate for Payer: MDX Hawaii PPO	$89.74
Rate for Payer: Cash Price	$60.14
Rate for Payer: Cash Price	$35.54
Rate for Payer: Cash Price	$35.54
Rate for Payer: Cash Price	$60.14
Rate for Payer: Hawaii Medical Service Association ABD	$1.24
Rate for Payer: Hawaii Medical Service Association ABD	$1.24
Rate for Payer: Hawaii Medical Service Association Non-ABD	$1.24
Rate for Payer: Hawaii Medical Service Association Non-ABD	$1.24
Rate for Payer: Hawaii Western Management Group Commercial	$51.95
Rate for Payer: Hawaii Western Management Group Commercial	$87.89
Rate for Payer: Health Management Network Commercial	$78.64
Rate for Payer: Health Management Network Commercial	$46.48
Rate for Payer: Kaiser Permanente Commercial	$58.29
Rate for Payer: Kaiser Permanente Commercial	$34.45
Rate for Payer: Kaiser Permanente Medicaid	$27.89
Rate for Payer: Kaiser Permanente Medicaid	$47.19
Rate for Payer: MDX Hawaii PPO	$53.04
Rate for Payer: UnitedHealthcare Medicaid	$55.51
Rate for Payer: UnitedHealthcare Medicaid	$32.81
Rate for Payer: University Health Alliance Commercial	$67.44
Rate for Payer: University Health Alliance Commercial	$39.86

ENOXAPARIN 100 MG/ML SUBCUTANEOUS SYR

Facility

$54.68

Service Code	HCPCS J1650
Hospital Revenue Code	250
Min. Negotiated Rate	$46.48
Max. Negotiated Rate	$53.04
Rate for Payer: Cash Price	$35.54
Rate for Payer: Cash Price	$60.14
Rate for Payer: Health Management Network Commercial	$46.48
Rate for Payer: Health Management Network Commercial	$78.64
Rate for Payer: MDX Hawaii PPO	$53.04
Rate for Payer: MDX Hawaii PPO	$89.74

ENOXAPARIN 120 MG/0.8 ML SUBCUTANEOUS SYR

Facility

$111.15

Service Code	HCPCS J1650
Hospital Revenue Code	636
Min. Negotiated Rate	$1.24
Max. Negotiated Rate	$107.82
Rate for Payer: Cash Price	$72.25
Rate for Payer: Cash Price	$72.25
Rate for Payer: Hawaii Medical Service Association ABD	$1.24
Rate for Payer: Hawaii Medical Service Association Non-ABD	$1.24
Rate for Payer: Hawaii Western Management Group Commercial	$105.59
Rate for Payer: Health Management Network Commercial	$94.48
Rate for Payer: Kaiser Permanente Commercial	$70.02
Rate for Payer: Kaiser Permanente Medicaid	$56.69
Rate for Payer: MDX Hawaii PPO	$107.82
Rate for Payer: UnitedHealthcare Medicaid	$66.69
Rate for Payer: University Health Alliance Commercial	$81.02

ENOXAPARIN 120 MG/0.8 ML SUBCUTANEOUS SYR

Facility

$111.15

Service Code	HCPCS J1650
Hospital Revenue Code	250
Min. Negotiated Rate	$94.48
Max. Negotiated Rate	$107.82
Rate for Payer: Cash Price	$72.25
Rate for Payer: Health Management Network Commercial	$94.48
Rate for Payer: MDX Hawaii PPO	$107.82

ENOXAPARIN 30 MG/0.3 ML SUBCUTANEOUS SYR

Facility

$24.84

Service Code	HCPCS J1650
Hospital Revenue Code	250
Min. Negotiated Rate	$21.11
Max. Negotiated Rate	$24.09
Rate for Payer: Cash Price	$16.15
Rate for Payer: Cash Price	$14.95
Rate for Payer: Cash Price	$9.94
Rate for Payer: Health Management Network Commercial	$21.11
Rate for Payer: Health Management Network Commercial	$13.00
Rate for Payer: Health Management Network Commercial	$19.55
Rate for Payer: MDX Hawaii PPO	$24.09
Rate for Payer: MDX Hawaii PPO	$22.31
Rate for Payer: MDX Hawaii PPO	$14.83

ENOXAPARIN 30 MG/0.3 ML SUBCUTANEOUS SYR

Facility

$23.00

Service Code	HCPCS J1650
Hospital Revenue Code	636
Min. Negotiated Rate	$1.24
Max. Negotiated Rate	$22.31
Rate for Payer: Cash Price	$14.95
Rate for Payer: Cash Price	$16.15
Rate for Payer: Cash Price	$9.94
Rate for Payer: Cash Price	$9.94
Rate for Payer: Cash Price	$16.15
Rate for Payer: Cash Price	$14.95
Rate for Payer: Hawaii Medical Service Association ABD	$1.24
Rate for Payer: Hawaii Medical Service Association ABD	$1.24
Rate for Payer: Hawaii Medical Service Association ABD	$1.24
Rate for Payer: Hawaii Medical Service Association Non-ABD	$1.24
Rate for Payer: Hawaii Medical Service Association Non-ABD	$1.24
Rate for Payer: Hawaii Medical Service Association Non-ABD	$1.24
Rate for Payer: Hawaii Western Management Group Commercial	$14.53
Rate for Payer: Hawaii Western Management Group Commercial	$21.85
Rate for Payer: Hawaii Western Management Group Commercial	$23.60
Rate for Payer: Health Management Network Commercial	$21.11
Rate for Payer: Health Management Network Commercial	$13.00
Rate for Payer: Health Management Network Commercial	$19.55
Rate for Payer: Kaiser Permanente Commercial	$15.65
Rate for Payer: Kaiser Permanente Commercial	$14.49
Rate for Payer: Kaiser Permanente Commercial	$9.63
Rate for Payer: Kaiser Permanente Medicaid	$7.80
Rate for Payer: Kaiser Permanente Medicaid	$11.73
Rate for Payer: Kaiser Permanente Medicaid	$12.67
Rate for Payer: MDX Hawaii PPO	$14.83
Rate for Payer: MDX Hawaii PPO	$22.31
Rate for Payer: MDX Hawaii PPO	$24.09
Rate for Payer: UnitedHealthcare Medicaid	$13.80
Rate for Payer: UnitedHealthcare Medicaid	$14.90
Rate for Payer: UnitedHealthcare Medicaid	$9.17
Rate for Payer: University Health Alliance Commercial	$11.14
Rate for Payer: University Health Alliance Commercial	$16.76
Rate for Payer: University Health Alliance Commercial	$18.11

ENOXAPARIN 40 MG/0.4 ML SUBCUTANEOUS SYR

Facility

$20.32

Service Code	HCPCS J1650
Hospital Revenue Code	250
Min. Negotiated Rate	$17.27
Max. Negotiated Rate	$19.71
Rate for Payer: Cash Price	$13.21
Rate for Payer: Cash Price	$33.08
Rate for Payer: Health Management Network Commercial	$43.27
Rate for Payer: Health Management Network Commercial	$17.27
Rate for Payer: MDX Hawaii PPO	$49.37
Rate for Payer: MDX Hawaii PPO	$19.71

Know your out-of-pocket cost for care.

All Charges