Kona Community Hospital

All Charges

Charge

Type

Setting

Price

02.03150.042 Screw 5.0mm Cort NCB 42mm Self Tap [3642164]

Facility

$1,492.78

Service Code	HCPCS C1713
Hospital Charge Code	3642164
Hospital Revenue Code	278
Min. Negotiated Rate	$835.96
Max. Negotiated Rate	$1,448.00
Rate for Payer: Cash Price	$970.31
Rate for Payer: Hawaii Western Management Group Commercial	$1,044.95
Rate for Payer: Health Management Network Commercial	$1,268.86
Rate for Payer: MDX Hawaii PPO	$1,448.00
Rate for Payer: University Health Alliance Commercial	$835.96

02.03150.046 Screw 5.0mm Cort NCB 46mm Self Tap [3642165]

Facility

$1,610.04

Service Code	HCPCS C1713
Hospital Charge Code	3642165
Hospital Revenue Code	278
Min. Negotiated Rate	$821.12
Max. Negotiated Rate	$1,561.74
Rate for Payer: Cash Price	$1,046.53
Rate for Payer: Hawaii Western Management Group Commercial	$1,127.03
Rate for Payer: Health Management Network Commercial	$1,368.53
Rate for Payer: Kaiser Permanente Commercial	$1,014.33
Rate for Payer: Kaiser Permanente Medicaid	$821.12
Rate for Payer: MDX Hawaii PPO	$1,561.74
Rate for Payer: University Health Alliance Commercial	$901.62

02.03150.046 Screw 5.0mm Cort NCB 46mm Self Tap [3642165]

Facility

$1,610.04

Service Code	HCPCS C1713
Hospital Charge Code	3642165
Hospital Revenue Code	278
Min. Negotiated Rate	$901.62
Max. Negotiated Rate	$1,561.74
Rate for Payer: Cash Price	$1,046.53
Rate for Payer: Hawaii Western Management Group Commercial	$1,127.03
Rate for Payer: Health Management Network Commercial	$1,368.53
Rate for Payer: MDX Hawaii PPO	$1,561.74
Rate for Payer: University Health Alliance Commercial	$901.62

02.107.302S Plate VALCP 2.7/3.5mm Olecranon 2H LT 90mm [3640039A]

Facility

$3,558.68

Service Code	HCPCS C1713
Hospital Charge Code	3640039A
Hospital Revenue Code	278
Min. Negotiated Rate	$1,992.86
Max. Negotiated Rate	$3,451.92
Rate for Payer: Cash Price	$2,313.14
Rate for Payer: Hawaii Western Management Group Commercial	$2,491.08
Rate for Payer: Health Management Network Commercial	$3,024.88
Rate for Payer: MDX Hawaii PPO	$3,451.92
Rate for Payer: University Health Alliance Commercial	$1,992.86

02.107.302S Plate VALCP 2.7/3.5mm Olecranon 2H LT 90mm [3640039A]

Facility

$3,558.68

Service Code	HCPCS C1713
Hospital Charge Code	3640039A
Hospital Revenue Code	278
Min. Negotiated Rate	$1,814.93
Max. Negotiated Rate	$3,451.92
Rate for Payer: Cash Price	$2,313.14
Rate for Payer: Hawaii Western Management Group Commercial	$2,491.08
Rate for Payer: Health Management Network Commercial	$3,024.88
Rate for Payer: Kaiser Permanente Commercial	$2,241.97
Rate for Payer: Kaiser Permanente Medicaid	$1,814.93
Rate for Payer: MDX Hawaii PPO	$3,451.92
Rate for Payer: University Health Alliance Commercial	$1,992.86

02.112.013 Plate LCP Sup Ant Clav Lat 3.5mm 5H Lt [3624255]

Facility

$5,843.00

Service Code	HCPCS C1713
Hospital Charge Code	3624255
Hospital Revenue Code	278
Min. Negotiated Rate	$3,272.08
Max. Negotiated Rate	$5,667.71
Rate for Payer: Cash Price	$3,797.95
Rate for Payer: Hawaii Western Management Group Commercial	$4,090.10
Rate for Payer: Health Management Network Commercial	$4,966.55
Rate for Payer: MDX Hawaii PPO	$5,667.71
Rate for Payer: University Health Alliance Commercial	$3,272.08

02.112.013 Plate LCP Sup Ant Clav Lat 3.5mm 5H Lt [3624255]

Facility

$5,843.00

Service Code	HCPCS C1713
Hospital Charge Code	3624255
Hospital Revenue Code	278
Min. Negotiated Rate	$2,979.93
Max. Negotiated Rate	$5,667.71
Rate for Payer: Cash Price	$3,797.95
Rate for Payer: Hawaii Western Management Group Commercial	$4,090.10
Rate for Payer: Health Management Network Commercial	$4,966.55
Rate for Payer: Kaiser Permanente Commercial	$3,681.09
Rate for Payer: Kaiser Permanente Medicaid	$2,979.93
Rate for Payer: MDX Hawaii PPO	$5,667.71
Rate for Payer: University Health Alliance Commercial	$3,272.08

02.118.401 Plate VALCP Lat Dist Fib 2.7mm 3H Lt [3640825]

Facility

$4,446.35

Service Code	HCPCS C1713
Hospital Charge Code	3640825
Hospital Revenue Code	278
Min. Negotiated Rate	$2,489.96
Max. Negotiated Rate	$4,312.96
Rate for Payer: Cash Price	$2,890.13
Rate for Payer: Hawaii Western Management Group Commercial	$3,112.45
Rate for Payer: Health Management Network Commercial	$3,779.40
Rate for Payer: MDX Hawaii PPO	$4,312.96
Rate for Payer: University Health Alliance Commercial	$2,489.96

02.118.401 Plate VALCP Lat Dist Fib 2.7mm 3H Lt [3640825]

Facility

$4,446.35

Service Code	HCPCS C1713
Hospital Charge Code	3640825
Hospital Revenue Code	278
Min. Negotiated Rate	$2,267.64
Max. Negotiated Rate	$4,312.96
Rate for Payer: Cash Price	$2,890.13
Rate for Payer: Hawaii Western Management Group Commercial	$3,112.45
Rate for Payer: Health Management Network Commercial	$3,779.40
Rate for Payer: Kaiser Permanente Commercial	$2,801.20
Rate for Payer: Kaiser Permanente Medicaid	$2,267.64
Rate for Payer: MDX Hawaii PPO	$4,312.96
Rate for Payer: University Health Alliance Commercial	$2,489.96

02.130.253 Plate VA Lock Y 1.5mm 3H-HD/7H-Shaft [3642007]

Facility

$2,924.90

Service Code	HCPCS C1713
Hospital Charge Code	3642007
Hospital Revenue Code	278
Min. Negotiated Rate	$1,637.94
Max. Negotiated Rate	$2,837.15
Rate for Payer: Cash Price	$1,901.19
Rate for Payer: Hawaii Western Management Group Commercial	$2,047.43
Rate for Payer: Health Management Network Commercial	$2,486.16
Rate for Payer: MDX Hawaii PPO	$2,837.15
Rate for Payer: University Health Alliance Commercial	$1,637.94

02.130.253 Plate VA Lock Y 1.5mm 3H-HD/7H-Shaft [3642007]

Facility

$2,924.90

Service Code	HCPCS C1713
Hospital Charge Code	3642007
Hospital Revenue Code	278
Min. Negotiated Rate	$1,491.70
Max. Negotiated Rate	$2,837.15
Rate for Payer: Cash Price	$1,901.19
Rate for Payer: Hawaii Western Management Group Commercial	$2,047.43
Rate for Payer: Health Management Network Commercial	$2,486.16
Rate for Payer: Kaiser Permanente Commercial	$1,842.69
Rate for Payer: Kaiser Permanente Medicaid	$1,491.70
Rate for Payer: MDX Hawaii PPO	$2,837.15
Rate for Payer: University Health Alliance Commercial	$1,637.94

03.120.026 Drill Tip Guidewire 2.5mm 300mm [3640368]

Facility

$641.00

Service Code	HCPCS C1769
Hospital Charge Code	3640368
Hospital Revenue Code	272
Min. Negotiated Rate	$326.91
Max. Negotiated Rate	$621.77
Rate for Payer: Cash Price	$416.65
Rate for Payer: Hawaii Western Management Group Commercial	$608.95
Rate for Payer: Health Management Network Commercial	$544.85
Rate for Payer: Kaiser Permanente Commercial	$403.83
Rate for Payer: Kaiser Permanente Medicaid	$326.91
Rate for Payer: MDX Hawaii PPO	$621.77
Rate for Payer: University Health Alliance Commercial	$467.22

03.120.026 Drill Tip Guidewire 2.5mm 300mm [3640368]

Facility

$641.00

Service Code	HCPCS C1769
Hospital Charge Code	3640368
Hospital Revenue Code	272
Min. Negotiated Rate	$544.85
Max. Negotiated Rate	$621.77
Rate for Payer: Cash Price	$416.65
Rate for Payer: Health Management Network Commercial	$544.85
Rate for Payer: MDX Hawaii PPO	$621.77

04.013.047 Blade Spiral Ti 75mm for Retro Fem Nail Ex [3640691]

Facility

$2,463.30

Service Code	HCPCS C1713
Hospital Charge Code	3640691
Hospital Revenue Code	278
Min. Negotiated Rate	$1,379.45
Max. Negotiated Rate	$2,389.40
Rate for Payer: Cash Price	$1,601.15
Rate for Payer: Hawaii Western Management Group Commercial	$1,724.31
Rate for Payer: Health Management Network Commercial	$2,093.80
Rate for Payer: MDX Hawaii PPO	$2,389.40
Rate for Payer: University Health Alliance Commercial	$1,379.45

04.013.047 Blade Spiral Ti 75mm for Retro Fem Nail Ex [3640691]

Facility

$2,463.30

Service Code	HCPCS C1713
Hospital Charge Code	3640691
Hospital Revenue Code	278
Min. Negotiated Rate	$1,256.28
Max. Negotiated Rate	$2,389.40
Rate for Payer: Cash Price	$1,601.15
Rate for Payer: Hawaii Western Management Group Commercial	$1,724.31
Rate for Payer: Health Management Network Commercial	$2,093.80
Rate for Payer: Kaiser Permanente Commercial	$1,551.88
Rate for Payer: Kaiser Permanente Medicaid	$1,256.28
Rate for Payer: MDX Hawaii PPO	$2,389.40
Rate for Payer: University Health Alliance Commercial	$1,379.45

1/2NS 1000 ML WITH KCL 20MEQ/L IV PREMIX

Facility

$27.60

Service Code	HCPCS J3480
Hospital Revenue Code	250
Min. Negotiated Rate	$23.46
Max. Negotiated Rate	$26.77
Rate for Payer: Cash Price	$17.94
Rate for Payer: Cash Price	$28.25
Rate for Payer: Health Management Network Commercial	$36.94
Rate for Payer: Health Management Network Commercial	$23.46
Rate for Payer: MDX Hawaii PPO	$26.77
Rate for Payer: MDX Hawaii PPO	$42.16

1/2NS 1000 ML WITH KCL 20MEQ/L IV PREMIX

Facility

$43.46

Service Code	HCPCS J3480
Hospital Revenue Code	636
Min. Negotiated Rate	$0.17
Max. Negotiated Rate	$42.16
Rate for Payer: Cash Price	$28.25
Rate for Payer: Cash Price	$17.94
Rate for Payer: Cash Price	$28.25
Rate for Payer: Cash Price	$17.94
Rate for Payer: Hawaii Medical Service Association ABD	$0.17
Rate for Payer: Hawaii Medical Service Association ABD	$0.17
Rate for Payer: Hawaii Medical Service Association Non-ABD	$0.17
Rate for Payer: Hawaii Medical Service Association Non-ABD	$0.17
Rate for Payer: Hawaii Western Management Group Commercial	$26.22
Rate for Payer: Hawaii Western Management Group Commercial	$41.29
Rate for Payer: Health Management Network Commercial	$36.94
Rate for Payer: Health Management Network Commercial	$23.46
Rate for Payer: Kaiser Permanente Commercial	$27.38
Rate for Payer: Kaiser Permanente Commercial	$17.39
Rate for Payer: Kaiser Permanente Medicaid	$22.16
Rate for Payer: Kaiser Permanente Medicaid	$14.08
Rate for Payer: MDX Hawaii PPO	$26.77
Rate for Payer: MDX Hawaii PPO	$42.16
Rate for Payer: UnitedHealthcare Medicaid	$16.56
Rate for Payer: UnitedHealthcare Medicaid	$26.08
Rate for Payer: University Health Alliance Commercial	$31.68
Rate for Payer: University Health Alliance Commercial	$20.12

1ST HOSPITAL IP/OBS CARE HIGH MDM 75 MINUTES

Professional

Both

$405.00

Service Code	HCPCS 99223
Min. Negotiated Rate	$149.55
Max. Negotiated Rate	$344.25
Rate for Payer: AlohaCare Medicaid	$174.14
Rate for Payer: AlohaCare Medicare	$156.50
Rate for Payer: Cash Price	$263.25
Rate for Payer: Cash Price	$263.25
Rate for Payer: Devoted Health Medicare	$172.15
Rate for Payer: Hawaii Medical Service Association Medicare	$156.50
Rate for Payer: Hawaii Western Management Group Commercial	$149.55
Rate for Payer: Health Management Network Commercial	$344.25
Rate for Payer: Kaiser Permanente Commercial	$187.80
Rate for Payer: Kaiser Permanente Medicaid	$187.80
Rate for Payer: Kaiser Permanente Medicare	$187.80
Rate for Payer: Ohana Health Plan Medicaid	$174.14
Rate for Payer: Ohana Health Plan Medicare	$156.50
Rate for Payer: UnitedHealthcare Medicaid	$174.14
Rate for Payer: UnitedHealthcare Medicare	$156.50

1ST HOSPITAL IP/OBS CARE MODERATE MDM 55 MINUTES

Professional

Both

$275.00

Service Code	HCPCS 99222
Min. Negotiated Rate	$113.39
Max. Negotiated Rate	$233.75
Rate for Payer: AlohaCare Medicaid	$131.00
Rate for Payer: AlohaCare Medicare	$116.73
Rate for Payer: Cash Price	$178.75
Rate for Payer: Cash Price	$178.75
Rate for Payer: Devoted Health Medicare	$128.40
Rate for Payer: Hawaii Medical Service Association Medicare	$116.73
Rate for Payer: Hawaii Western Management Group Commercial	$113.39
Rate for Payer: Health Management Network Commercial	$233.75
Rate for Payer: Kaiser Permanente Commercial	$140.08
Rate for Payer: Kaiser Permanente Medicaid	$140.08
Rate for Payer: Kaiser Permanente Medicare	$140.08
Rate for Payer: Ohana Health Plan Medicaid	$131.00
Rate for Payer: Ohana Health Plan Medicare	$116.73
Rate for Payer: UnitedHealthcare Medicaid	$131.00
Rate for Payer: UnitedHealthcare Medicare	$116.73

1ST HOSPITAL IP/OBS CARE SF/LOW MDM 40 MINUTES

Professional

Both

$205.00

Service Code	HCPCS 99221
Min. Negotiated Rate	$68.50
Max. Negotiated Rate	$174.25
Rate for Payer: AlohaCare Medicaid	$82.48
Rate for Payer: AlohaCare Medicare	$73.69
Rate for Payer: Cash Price	$133.25
Rate for Payer: Cash Price	$133.25
Rate for Payer: Devoted Health Medicare	$81.06
Rate for Payer: Hawaii Medical Service Association Medicare	$73.69
Rate for Payer: Hawaii Western Management Group Commercial	$68.50
Rate for Payer: Health Management Network Commercial	$174.25
Rate for Payer: Kaiser Permanente Commercial	$88.43
Rate for Payer: Kaiser Permanente Medicaid	$88.43
Rate for Payer: Kaiser Permanente Medicare	$88.43
Rate for Payer: Ohana Health Plan Medicaid	$82.48
Rate for Payer: Ohana Health Plan Medicare	$73.69
Rate for Payer: UnitedHealthcare Medicaid	$82.48
Rate for Payer: UnitedHealthcare Medicare	$73.69

2.0mm Cann Countersink Driver Qc 03.333.200 [3644872]

Facility

$3,396.28

Hospital Charge Code	3644872
Hospital Revenue Code	272
Min. Negotiated Rate	$2,886.84
Max. Negotiated Rate	$3,294.39
Rate for Payer: Cash Price	$2,207.58
Rate for Payer: Health Management Network Commercial	$2,886.84
Rate for Payer: MDX Hawaii PPO	$3,294.39

2.0mm Cann Countersink Driver Qc 03.333.200 [3644872]

Facility

$3,396.28

Hospital Charge Code	3644872
Hospital Revenue Code	272
Min. Negotiated Rate	$1,732.10
Max. Negotiated Rate	$3,294.39
Rate for Payer: Cash Price	$2,207.58
Rate for Payer: Hawaii Western Management Group Commercial	$3,226.47
Rate for Payer: Health Management Network Commercial	$2,886.84
Rate for Payer: Kaiser Permanente Commercial	$2,139.66
Rate for Payer: Kaiser Permanente Medicaid	$1,732.10
Rate for Payer: MDX Hawaii PPO	$3,294.39
Rate for Payer: University Health Alliance Commercial	$2,475.55

2296003111 Blade Saw Oscil Sagittal 25.0x9.0mm [3600321]

Facility

$275.79

Hospital Charge Code	3600321
Hospital Revenue Code	272
Min. Negotiated Rate	$140.65
Max. Negotiated Rate	$267.52
Rate for Payer: Cash Price	$179.26
Rate for Payer: Hawaii Western Management Group Commercial	$262.00
Rate for Payer: Health Management Network Commercial	$234.42
Rate for Payer: Kaiser Permanente Commercial	$173.75
Rate for Payer: Kaiser Permanente Medicaid	$140.65
Rate for Payer: MDX Hawaii PPO	$267.52
Rate for Payer: University Health Alliance Commercial	$201.02

2296003111 Blade Saw Oscil Sagittal 25.0x9.0mm [3600321]

Facility

$275.79

Hospital Charge Code	3600321
Hospital Revenue Code	272
Min. Negotiated Rate	$234.42
Max. Negotiated Rate	$267.52
Rate for Payer: Cash Price	$179.26
Rate for Payer: Health Management Network Commercial	$234.42
Rate for Payer: MDX Hawaii PPO	$267.52

2.5/3.0mm Cann Countersink Driver QC 03.333.201 [3644875]

Facility

$3,049.78

Hospital Charge Code	3644875
Hospital Revenue Code	272
Min. Negotiated Rate	$1,555.39
Max. Negotiated Rate	$2,958.29
Rate for Payer: Cash Price	$1,982.36
Rate for Payer: Hawaii Western Management Group Commercial	$2,897.29
Rate for Payer: Health Management Network Commercial	$2,592.31
Rate for Payer: Kaiser Permanente Commercial	$1,921.36
Rate for Payer: Kaiser Permanente Medicaid	$1,555.39
Rate for Payer: MDX Hawaii PPO	$2,958.29
Rate for Payer: University Health Alliance Commercial	$2,222.98

Know your out-of-pocket cost for care.

All Charges