Kona Community Hospital

All Charges

Charge

Type

Setting

Price

Graft Arthroflex 40 x 70 x 2.0mm AFLEX201 (Charge by sq/mm = 560mm) [3640959]

Facility

$98.09

Service Code	HCPCS Q4125
Hospital Charge Code	3640959
Hospital Revenue Code	278
Min. Negotiated Rate	$50.03
Max. Negotiated Rate	$183.76
Rate for Payer: AlohaCare Medicaid	$147.01
Rate for Payer: AlohaCare Medicare	$147.01
Rate for Payer: Cash Price	$63.76
Rate for Payer: Cash Price	$63.76
Rate for Payer: Devoted Health Medicare	$161.71
Rate for Payer: Hawaii Medical Service Association Commercial	$183.76
Rate for Payer: Hawaii Medical Service Association Medicare	$147.01
Rate for Payer: Hawaii Western Management Group Commercial	$68.66
Rate for Payer: Health Management Network Commercial	$83.38
Rate for Payer: Humana Medicare	$147.01
Rate for Payer: Kaiser Permanente Commercial	$61.80
Rate for Payer: Kaiser Permanente Medicaid	$50.03
Rate for Payer: Kaiser Permanente Medicare	$147.01
Rate for Payer: MDX Hawaii PPO	$95.15
Rate for Payer: Ohana Health Plan Medicaid	$161.71
Rate for Payer: Ohana Health Plan Medicare	$147.01
Rate for Payer: UnitedHealthcare Medicare	$147.01
Rate for Payer: University Health Alliance Commercial	$54.93

Graft Arthroflex 40 x 70 x 2.0mm AFLEX201 (Charge by sq/mm = 560mm) [3640959]

Facility

$98.09

Service Code	HCPCS Q4125
Hospital Charge Code	3640959
Hospital Revenue Code	278
Min. Negotiated Rate	$54.93
Max. Negotiated Rate	$95.15
Rate for Payer: Cash Price	$63.76
Rate for Payer: Hawaii Western Management Group Commercial	$68.66
Rate for Payer: Health Management Network Commercial	$83.38
Rate for Payer: MDX Hawaii PPO	$95.15
Rate for Payer: University Health Alliance Commercial	$54.93

Graft BioCleanse Gracilis Tendon 453014 [3642199]

Facility

$5,375.00

Service Code	HCPCS C1763
Hospital Charge Code	3642199
Hospital Revenue Code	278
Min. Negotiated Rate	$3,010.00
Max. Negotiated Rate	$5,213.75
Rate for Payer: Cash Price	$3,493.75
Rate for Payer: Hawaii Western Management Group Commercial	$3,762.50
Rate for Payer: Health Management Network Commercial	$4,568.75
Rate for Payer: MDX Hawaii PPO	$5,213.75
Rate for Payer: University Health Alliance Commercial	$3,010.00

Graft BioCleanse Gracilis Tendon 453014 [3642199]

Facility

$5,375.00

Service Code	HCPCS C1763
Hospital Charge Code	3642199
Hospital Revenue Code	278
Min. Negotiated Rate	$2,741.25
Max. Negotiated Rate	$5,213.75
Rate for Payer: Cash Price	$3,493.75
Rate for Payer: Hawaii Western Management Group Commercial	$3,762.50
Rate for Payer: Health Management Network Commercial	$4,568.75
Rate for Payer: Kaiser Permanente Commercial	$3,386.25
Rate for Payer: Kaiser Permanente Medicaid	$2,741.25
Rate for Payer: MDX Hawaii PPO	$5,213.75
Rate for Payer: University Health Alliance Commercial	$3,010.00

Graft Delivery Device 03.950.001s [3644023]

Facility

$754.69

Hospital Charge Code	3644023
Hospital Revenue Code	272
Min. Negotiated Rate	$641.49
Max. Negotiated Rate	$732.05
Rate for Payer: Cash Price	$490.55
Rate for Payer: Health Management Network Commercial	$641.49
Rate for Payer: MDX Hawaii PPO	$732.05

Graft Delivery Device 03.950.001s [3644023]

Facility

$754.69

Hospital Charge Code	3644023
Hospital Revenue Code	272
Min. Negotiated Rate	$384.89
Max. Negotiated Rate	$732.05
Rate for Payer: Cash Price	$490.55
Rate for Payer: Hawaii Western Management Group Commercial	$716.96
Rate for Payer: Health Management Network Commercial	$641.49
Rate for Payer: Kaiser Permanente Commercial	$475.45
Rate for Payer: Kaiser Permanente Medicaid	$384.89
Rate for Payer: MDX Hawaii PPO	$732.05
Rate for Payer: University Health Alliance Commercial	$550.09

Graft Spreader AR-19007GS [3644857]

Facility

$3,315.50

Hospital Charge Code	3644857
Hospital Revenue Code	272
Min. Negotiated Rate	$1,690.90
Max. Negotiated Rate	$3,216.03
Rate for Payer: Cash Price	$2,155.08
Rate for Payer: Hawaii Western Management Group Commercial	$3,149.72
Rate for Payer: Health Management Network Commercial	$2,818.18
Rate for Payer: Kaiser Permanente Commercial	$2,088.76
Rate for Payer: Kaiser Permanente Medicaid	$1,690.90
Rate for Payer: MDX Hawaii PPO	$3,216.03
Rate for Payer: University Health Alliance Commercial	$2,416.67

Graft Spreader AR-19007GS [3644857]

Facility

$3,315.50

Hospital Charge Code	3644857
Hospital Revenue Code	272
Min. Negotiated Rate	$2,818.18
Max. Negotiated Rate	$3,216.03
Rate for Payer: Cash Price	$2,155.08
Rate for Payer: Health Management Network Commercial	$2,818.18
Rate for Payer: MDX Hawaii PPO	$3,216.03

Graft Vasc Gore Propaten Stnd Wall 6mmX60cm H060060A [3642352]

Facility

$3,965.00

Service Code	HCPCS C1768
Hospital Charge Code	3642352
Hospital Revenue Code	278
Min. Negotiated Rate	$2,022.15
Max. Negotiated Rate	$3,846.05
Rate for Payer: Cash Price	$2,577.25
Rate for Payer: Hawaii Western Management Group Commercial	$2,775.50
Rate for Payer: Health Management Network Commercial	$3,370.25
Rate for Payer: Kaiser Permanente Commercial	$2,497.95
Rate for Payer: Kaiser Permanente Medicaid	$2,022.15
Rate for Payer: MDX Hawaii PPO	$3,846.05
Rate for Payer: University Health Alliance Commercial	$2,220.40

Graft Vasc Gore Propaten Stnd Wall 6mmX60cm H060060A [3642352]

Facility

$3,965.00

Service Code	HCPCS C1768
Hospital Charge Code	3642352
Hospital Revenue Code	278
Min. Negotiated Rate	$2,220.40
Max. Negotiated Rate	$3,846.05
Rate for Payer: Cash Price	$2,577.25
Rate for Payer: Hawaii Western Management Group Commercial	$2,775.50
Rate for Payer: Health Management Network Commercial	$3,370.25
Rate for Payer: MDX Hawaii PPO	$3,846.05
Rate for Payer: University Health Alliance Commercial	$2,220.40

Graft Vasc Gore Stretch 6mmX50cm S0605 [3642037]

Facility

$2,236.50

Service Code	HCPCS C1768
Hospital Charge Code	3642037
Hospital Revenue Code	278
Min. Negotiated Rate	$1,140.62
Max. Negotiated Rate	$2,169.41
Rate for Payer: Cash Price	$1,453.72
Rate for Payer: Hawaii Western Management Group Commercial	$1,565.55
Rate for Payer: Health Management Network Commercial	$1,901.03
Rate for Payer: Kaiser Permanente Commercial	$1,408.99
Rate for Payer: Kaiser Permanente Medicaid	$1,140.62
Rate for Payer: MDX Hawaii PPO	$2,169.41
Rate for Payer: University Health Alliance Commercial	$1,252.44

Graft Vasc Gore Stretch 6mmX50cm S0605 [3642037]

Facility

$2,236.50

Service Code	HCPCS C1768
Hospital Charge Code	3642037
Hospital Revenue Code	278
Min. Negotiated Rate	$1,252.44
Max. Negotiated Rate	$2,169.41
Rate for Payer: Cash Price	$1,453.72
Rate for Payer: Hawaii Western Management Group Commercial	$1,565.55
Rate for Payer: Health Management Network Commercial	$1,901.03
Rate for Payer: MDX Hawaii PPO	$2,169.41
Rate for Payer: University Health Alliance Commercial	$1,252.44

Graft Vasc Gore Stretch Standard Wall 4-7mmX45cm S47045 [3642519]

Facility

$3,351.50

Service Code	HCPCS C1768
Hospital Charge Code	3642519
Hospital Revenue Code	278
Min. Negotiated Rate	$1,709.27
Max. Negotiated Rate	$3,250.95
Rate for Payer: Cash Price	$2,178.48
Rate for Payer: Hawaii Western Management Group Commercial	$2,346.05
Rate for Payer: Health Management Network Commercial	$2,848.78
Rate for Payer: Kaiser Permanente Commercial	$2,111.45
Rate for Payer: Kaiser Permanente Medicaid	$1,709.27
Rate for Payer: MDX Hawaii PPO	$3,250.95
Rate for Payer: University Health Alliance Commercial	$1,876.84

Graft Vasc Gore Stretch Standard Wall 4-7mmX45cm S47045 [3642519]

Facility

$3,351.50

Service Code	HCPCS C1768
Hospital Charge Code	3642519
Hospital Revenue Code	278
Min. Negotiated Rate	$1,876.84
Max. Negotiated Rate	$3,250.95
Rate for Payer: Cash Price	$2,178.48
Rate for Payer: Hawaii Western Management Group Commercial	$2,346.05
Rate for Payer: Health Management Network Commercial	$2,848.78
Rate for Payer: MDX Hawaii PPO	$3,250.95
Rate for Payer: University Health Alliance Commercial	$1,876.84

GUAIFENESIN 100 MG/5 ML PO LIQ

Facility

$10.66

Service Code	HCPCS A9270
Hospital Revenue Code	250
Min. Negotiated Rate	$9.06
Max. Negotiated Rate	$10.34
Rate for Payer: Cash Price	$6.93
Rate for Payer: Health Management Network Commercial	$9.06
Rate for Payer: MDX Hawaii PPO	$10.34

GUAIFENESIN 100 MG/5 ML PO LIQ

Facility

$10.66

Service Code	HCPCS A9270
Hospital Revenue Code	250
Min. Negotiated Rate	$5.44
Max. Negotiated Rate	$10.34
Rate for Payer: Cash Price	$6.93
Rate for Payer: Hawaii Western Management Group Commercial	$10.13
Rate for Payer: Health Management Network Commercial	$9.06
Rate for Payer: Kaiser Permanente Commercial	$6.72
Rate for Payer: Kaiser Permanente Medicaid	$5.44
Rate for Payer: MDX Hawaii PPO	$10.34
Rate for Payer: UnitedHealthcare Medicaid	$6.40
Rate for Payer: University Health Alliance Commercial	$7.77

GUAIFENESIN 600 MG PO TA12

Facility

$5.54

Service Code	HCPCS A9270
Hospital Revenue Code	250
Min. Negotiated Rate	$2.83
Max. Negotiated Rate	$5.37
Rate for Payer: Cash Price	$3.60
Rate for Payer: Hawaii Western Management Group Commercial	$5.26
Rate for Payer: Health Management Network Commercial	$4.71
Rate for Payer: Kaiser Permanente Commercial	$3.49
Rate for Payer: Kaiser Permanente Medicaid	$2.83
Rate for Payer: MDX Hawaii PPO	$5.37
Rate for Payer: UnitedHealthcare Medicaid	$3.32
Rate for Payer: University Health Alliance Commercial	$4.04

GUAIFENESIN 600 MG PO TA12

Facility

$5.54

Service Code	HCPCS A9270
Hospital Revenue Code	250
Min. Negotiated Rate	$4.71
Max. Negotiated Rate	$5.37
Rate for Payer: Cash Price	$3.60
Rate for Payer: Health Management Network Commercial	$4.71
Rate for Payer: MDX Hawaii PPO	$5.37

Guide Pin 3.2mm x 330mm S0100-000 [3644624]

Facility

$1,380.07

Hospital Charge Code	3644624
Hospital Revenue Code	272
Min. Negotiated Rate	$1,173.06
Max. Negotiated Rate	$1,338.67
Rate for Payer: Cash Price	$897.05
Rate for Payer: Health Management Network Commercial	$1,173.06
Rate for Payer: MDX Hawaii PPO	$1,338.67

Guide Pin 3.2mm x 330mm S0100-000 [3644624]

Facility

$1,380.07

Hospital Charge Code	3644624
Hospital Revenue Code	272
Min. Negotiated Rate	$703.84
Max. Negotiated Rate	$1,338.67
Rate for Payer: Cash Price	$897.05
Rate for Payer: Hawaii Western Management Group Commercial	$1,311.07
Rate for Payer: Health Management Network Commercial	$1,173.06
Rate for Payer: Kaiser Permanente Commercial	$869.44
Rate for Payer: Kaiser Permanente Medicaid	$703.84
Rate for Payer: MDX Hawaii PPO	$1,338.67
Rate for Payer: University Health Alliance Commercial	$1,005.93

Guide Pin 3.2mm x 381mm S0100-381 [3644625]

Facility

$1,599.38

Hospital Charge Code	3644625
Hospital Revenue Code	272
Min. Negotiated Rate	$1,359.47
Max. Negotiated Rate	$1,551.40
Rate for Payer: Cash Price	$1,039.60
Rate for Payer: Health Management Network Commercial	$1,359.47
Rate for Payer: MDX Hawaii PPO	$1,551.40

Guide Pin 3.2mm x 381mm S0100-381 [3644625]

Facility

$1,599.38

Hospital Charge Code	3644625
Hospital Revenue Code	272
Min. Negotiated Rate	$815.68
Max. Negotiated Rate	$1,551.40
Rate for Payer: Cash Price	$1,039.60
Rate for Payer: Hawaii Western Management Group Commercial	$1,519.41
Rate for Payer: Health Management Network Commercial	$1,359.47
Rate for Payer: Kaiser Permanente Commercial	$1,007.61
Rate for Payer: Kaiser Permanente Medicaid	$815.68
Rate for Payer: MDX Hawaii PPO	$1,551.40
Rate for Payer: University Health Alliance Commercial	$1,165.79

Guide Pin Threaded 3.2mm 903003004 [3643665]

Facility

$932.75

Service Code	HCPCS C1713
Hospital Charge Code	3643665
Hospital Revenue Code	278
Min. Negotiated Rate	$475.70
Max. Negotiated Rate	$904.77
Rate for Payer: Cash Price	$606.29
Rate for Payer: Hawaii Western Management Group Commercial	$652.92
Rate for Payer: Health Management Network Commercial	$792.84
Rate for Payer: Kaiser Permanente Commercial	$587.63
Rate for Payer: Kaiser Permanente Medicaid	$475.70
Rate for Payer: MDX Hawaii PPO	$904.77
Rate for Payer: University Health Alliance Commercial	$522.34

Guide Pin Threaded 3.2mm 903003004 [3643665]

Facility

$932.75

Service Code	HCPCS C1713
Hospital Charge Code	3643665
Hospital Revenue Code	278
Min. Negotiated Rate	$522.34
Max. Negotiated Rate	$904.77
Rate for Payer: Cash Price	$606.29
Rate for Payer: Hawaii Western Management Group Commercial	$652.92
Rate for Payer: Health Management Network Commercial	$792.84
Rate for Payer: MDX Hawaii PPO	$904.77
Rate for Payer: University Health Alliance Commercial	$522.34

Guide Pin Threaded 3.2 X 444mm 281001175 [3627534]

Facility

$1,586.56

Hospital Charge Code	3627534
Hospital Revenue Code	272
Min. Negotiated Rate	$809.15
Max. Negotiated Rate	$1,538.96
Rate for Payer: Cash Price	$1,031.26
Rate for Payer: Hawaii Western Management Group Commercial	$1,507.23
Rate for Payer: Health Management Network Commercial	$1,348.58
Rate for Payer: Kaiser Permanente Commercial	$999.53
Rate for Payer: Kaiser Permanente Medicaid	$809.15
Rate for Payer: MDX Hawaii PPO	$1,538.96
Rate for Payer: University Health Alliance Commercial	$1,156.44

Know your out-of-pocket cost for care.

All Charges