Kona Community Hospital

All Charges

Charge

Type

Setting

Price

ARIPIPRAZOLE 5 MG PO TABLET

Facility

$150.51

Service Code	HCPCS A9270
Hospital Revenue Code	250
Min. Negotiated Rate	$76.76
Max. Negotiated Rate	$145.99
Rate for Payer: Cash Price	$97.83
Rate for Payer: Cash Price	$92.24
Rate for Payer: Hawaii Western Management Group Commercial	$134.81
Rate for Payer: Hawaii Western Management Group Commercial	$142.98
Rate for Payer: Health Management Network Commercial	$120.61
Rate for Payer: Health Management Network Commercial	$127.93
Rate for Payer: Kaiser Permanente Commercial	$94.82
Rate for Payer: Kaiser Permanente Commercial	$89.40
Rate for Payer: Kaiser Permanente Medicaid	$76.76
Rate for Payer: Kaiser Permanente Medicaid	$72.37
Rate for Payer: MDX Hawaii PPO	$137.64
Rate for Payer: MDX Hawaii PPO	$145.99
Rate for Payer: UnitedHealthcare Medicaid	$85.14
Rate for Payer: UnitedHealthcare Medicaid	$90.31
Rate for Payer: University Health Alliance Commercial	$109.71
Rate for Payer: University Health Alliance Commercial	$103.43

ARSENIC TRIOXIDE 10 MG/10 ML IV SOLN

Facility

$613.68

Service Code	HCPCS J9017
Hospital Revenue Code	636
Min. Negotiated Rate	$5.86
Max. Negotiated Rate	$595.27
Rate for Payer: Cash Price	$398.89
Rate for Payer: Cash Price	$398.89
Rate for Payer: Hawaii Medical Service Association ABD	$5.86
Rate for Payer: Hawaii Medical Service Association Non-ABD	$5.86
Rate for Payer: Hawaii Western Management Group Commercial	$583.00
Rate for Payer: Health Management Network Commercial	$521.63
Rate for Payer: Kaiser Permanente Commercial	$386.62
Rate for Payer: Kaiser Permanente Medicaid	$312.98
Rate for Payer: MDX Hawaii PPO	$595.27
Rate for Payer: UnitedHealthcare Medicaid	$368.21
Rate for Payer: University Health Alliance Commercial	$447.31

ARSENIC TRIOXIDE 10 MG/10 ML IV SOLN

Facility

$613.68

Service Code	HCPCS J9017
Hospital Revenue Code	250
Min. Negotiated Rate	$521.63
Max. Negotiated Rate	$595.27
Rate for Payer: Cash Price	$398.89
Rate for Payer: Health Management Network Commercial	$521.63
Rate for Payer: MDX Hawaii PPO	$595.27

Artelon FlexBand 0.5X16cm 31054 [3643060]

Facility

$6,875.00

Service Code	HCPCS C1713
Hospital Charge Code	3643060
Hospital Revenue Code	278
Min. Negotiated Rate	$3,506.25
Max. Negotiated Rate	$6,668.75
Rate for Payer: Cash Price	$4,468.75
Rate for Payer: Hawaii Western Management Group Commercial	$4,812.50
Rate for Payer: Health Management Network Commercial	$5,843.75
Rate for Payer: Kaiser Permanente Commercial	$4,331.25
Rate for Payer: Kaiser Permanente Medicaid	$3,506.25
Rate for Payer: MDX Hawaii PPO	$6,668.75
Rate for Payer: University Health Alliance Commercial	$3,850.00

Artelon FlexBand 0.5X16cm 31054 [3643060]

Facility

$6,875.00

Service Code	HCPCS C1713
Hospital Charge Code	3643060
Hospital Revenue Code	278
Min. Negotiated Rate	$3,850.00
Max. Negotiated Rate	$6,668.75
Rate for Payer: Cash Price	$4,468.75
Rate for Payer: Hawaii Western Management Group Commercial	$4,812.50
Rate for Payer: Health Management Network Commercial	$5,843.75
Rate for Payer: MDX Hawaii PPO	$6,668.75
Rate for Payer: University Health Alliance Commercial	$3,850.00

Artelon Flexband 0.5x32cm 31057 [3643412]

Facility

$7,875.00

Service Code	HCPCS C1713
Hospital Charge Code	3643412
Hospital Revenue Code	278
Min. Negotiated Rate	$4,016.25
Max. Negotiated Rate	$7,638.75
Rate for Payer: Cash Price	$5,118.75
Rate for Payer: Hawaii Western Management Group Commercial	$5,512.50
Rate for Payer: Health Management Network Commercial	$6,693.75
Rate for Payer: Kaiser Permanente Commercial	$4,961.25
Rate for Payer: Kaiser Permanente Medicaid	$4,016.25
Rate for Payer: MDX Hawaii PPO	$7,638.75
Rate for Payer: University Health Alliance Commercial	$4,410.00

Artelon Flexband 0.5x32cm 31057 [3643412]

Facility

$7,875.00

Service Code	HCPCS C1713
Hospital Charge Code	3643412
Hospital Revenue Code	278
Min. Negotiated Rate	$4,410.00
Max. Negotiated Rate	$7,638.75
Rate for Payer: Cash Price	$5,118.75
Rate for Payer: Hawaii Western Management Group Commercial	$5,512.50
Rate for Payer: Health Management Network Commercial	$6,693.75
Rate for Payer: MDX Hawaii PPO	$7,638.75
Rate for Payer: University Health Alliance Commercial	$4,410.00

Artelon Flexband 0.7x32cm 31058 [3643907]

Facility

$13,928.00

Service Code	HCPCS C1713
Hospital Charge Code	3643907
Hospital Revenue Code	278
Min. Negotiated Rate	$7,799.68
Max. Negotiated Rate	$13,510.16
Rate for Payer: Cash Price	$9,053.20
Rate for Payer: Hawaii Western Management Group Commercial	$9,749.60
Rate for Payer: Health Management Network Commercial	$11,838.80
Rate for Payer: MDX Hawaii PPO	$13,510.16
Rate for Payer: University Health Alliance Commercial	$7,799.68

Artelon Flexband 0.7x32cm 31058 [3643907]

Facility

$13,928.00

Service Code	HCPCS C1713
Hospital Charge Code	3643907
Hospital Revenue Code	278
Min. Negotiated Rate	$7,103.28
Max. Negotiated Rate	$13,510.16
Rate for Payer: Cash Price	$9,053.20
Rate for Payer: Hawaii Western Management Group Commercial	$9,749.60
Rate for Payer: Health Management Network Commercial	$11,838.80
Rate for Payer: Kaiser Permanente Commercial	$8,774.64
Rate for Payer: Kaiser Permanente Medicaid	$7,103.28
Rate for Payer: MDX Hawaii PPO	$13,510.16
Rate for Payer: University Health Alliance Commercial	$7,799.68

Artelon Flexband Multi Kit 71016 [3644015]

Facility

$11,750.00

Service Code	HCPCS C1713
Hospital Charge Code	3644015
Hospital Revenue Code	278
Min. Negotiated Rate	$6,580.00
Max. Negotiated Rate	$11,397.50
Rate for Payer: Cash Price	$7,637.50
Rate for Payer: Hawaii Western Management Group Commercial	$8,225.00
Rate for Payer: Health Management Network Commercial	$9,987.50
Rate for Payer: MDX Hawaii PPO	$11,397.50
Rate for Payer: University Health Alliance Commercial	$6,580.00

Artelon Flexband Multi Kit 71016 [3644015]

Facility

$11,750.00

Service Code	HCPCS C1713
Hospital Charge Code	3644015
Hospital Revenue Code	278
Min. Negotiated Rate	$5,992.50
Max. Negotiated Rate	$11,397.50
Rate for Payer: Cash Price	$7,637.50
Rate for Payer: Hawaii Western Management Group Commercial	$8,225.00
Rate for Payer: Health Management Network Commercial	$9,987.50
Rate for Payer: Kaiser Permanente Commercial	$7,402.50
Rate for Payer: Kaiser Permanente Medicaid	$5,992.50
Rate for Payer: MDX Hawaii PPO	$11,397.50
Rate for Payer: University Health Alliance Commercial	$6,580.00

Artelon Flexband Twist Anchor 3.85x17 Ta385 [3644016]

Facility

$2,205.00

Service Code	HCPCS C1713
Hospital Charge Code	3644016
Hospital Revenue Code	278
Min. Negotiated Rate	$1,234.80
Max. Negotiated Rate	$2,138.85
Rate for Payer: Cash Price	$1,433.25
Rate for Payer: Hawaii Western Management Group Commercial	$1,543.50
Rate for Payer: Health Management Network Commercial	$1,874.25
Rate for Payer: MDX Hawaii PPO	$2,138.85
Rate for Payer: University Health Alliance Commercial	$1,234.80

Artelon Flexband Twist Anchor 3.85x17 Ta385 [3644016]

Facility

$2,205.00

Service Code	HCPCS C1713
Hospital Charge Code	3644016
Hospital Revenue Code	278
Min. Negotiated Rate	$1,124.55
Max. Negotiated Rate	$2,138.85
Rate for Payer: Cash Price	$1,433.25
Rate for Payer: Hawaii Western Management Group Commercial	$1,543.50
Rate for Payer: Health Management Network Commercial	$1,874.25
Rate for Payer: Kaiser Permanente Commercial	$1,389.15
Rate for Payer: Kaiser Permanente Medicaid	$1,124.55
Rate for Payer: MDX Hawaii PPO	$2,138.85
Rate for Payer: University Health Alliance Commercial	$1,234.80

ARTERIOVENOUS ANASTOMOSIS, OPEN; BY UPPER ARM BASILIC VEIN TRANSPOSITION

Facility

$9,416.00

Service Code	CPT 36819
Hospital Revenue Code	360
Min. Negotiated Rate	$521.33
Max. Negotiated Rate	$9,416.00
Rate for Payer: AlohaCare Medicaid	$6,573.58
Rate for Payer: AlohaCare Medicare	$6,573.58
Rate for Payer: Devoted Health Medicare	$7,230.94
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	$6,573.58
Rate for Payer: Hawaii Medical Service Association Non-ABD	$849.21
Rate for Payer: Humana Medicare	$6,573.58
Rate for Payer: Kaiser Permanente Medicaid	$2,837.00
Rate for Payer: Kaiser Permanente Medicare	$6,573.58
Rate for Payer: Ohana Health Plan Medicaid	$7,230.94
Rate for Payer: Ohana Health Plan Medicare	$6,573.58
Rate for Payer: UnitedHealthcare Medicaid	$521.33
Rate for Payer: UnitedHealthcare Medicare	$6,573.58
Rate for Payer: University Health Alliance Commercial	$6,743.44

ARTERIOVENOUS ANASTOMOSIS, OPEN; BY UPPER ARM CEPHALIC VEIN TRANSPOSITION

Facility

$9,416.00

Service Code	CPT 36818
Hospital Revenue Code	360
Min. Negotiated Rate	$521.33
Max. Negotiated Rate	$9,416.00
Rate for Payer: AlohaCare Medicaid	$6,573.58
Rate for Payer: AlohaCare Medicare	$6,573.58
Rate for Payer: Devoted Health Medicare	$7,230.94
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	$6,573.58
Rate for Payer: Hawaii Medical Service Association Non-ABD	$849.21
Rate for Payer: Humana Medicare	$6,573.58
Rate for Payer: Kaiser Permanente Medicaid	$2,837.00
Rate for Payer: Kaiser Permanente Medicare	$6,573.58
Rate for Payer: Ohana Health Plan Medicaid	$7,230.94
Rate for Payer: Ohana Health Plan Medicare	$6,573.58
Rate for Payer: UnitedHealthcare Medicaid	$521.33
Rate for Payer: UnitedHealthcare Medicare	$6,573.58
Rate for Payer: University Health Alliance Commercial	$6,743.44

ARTERIOVENOUS ANASTOMOSIS, OPEN; DIRECT, ANY SITE (EG, CIMINO TYPE) (SEPARATE PROCEDURE)

Facility

$9,416.00

Service Code	CPT 36821
Hospital Revenue Code	360
Min. Negotiated Rate	$456.03
Max. Negotiated Rate	$9,416.00
Rate for Payer: AlohaCare Medicaid	$3,730.07
Rate for Payer: AlohaCare Medicare	$3,730.07
Rate for Payer: Devoted Health Medicare	$4,103.08
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	$3,730.07
Rate for Payer: Hawaii Medical Service Association Non-ABD	$849.21
Rate for Payer: Humana Medicare	$3,730.07
Rate for Payer: Kaiser Permanente Medicaid	$2,837.00
Rate for Payer: Kaiser Permanente Medicare	$3,730.07
Rate for Payer: Ohana Health Plan Medicaid	$4,103.08
Rate for Payer: Ohana Health Plan Medicare	$3,730.07
Rate for Payer: UnitedHealthcare Medicaid	$456.03
Rate for Payer: UnitedHealthcare Medicare	$3,730.07
Rate for Payer: University Health Alliance Commercial	$6,743.44

Arthrex Btb Ib Tightrope W/flipcutter Iii Dri AR-1288BTBIB-FC3 [3643408]

Facility

$8,125.00

Service Code	HCPCS C1713
Hospital Charge Code	3643408
Hospital Revenue Code	278
Min. Negotiated Rate	$4,143.75
Max. Negotiated Rate	$7,881.25
Rate for Payer: Cash Price	$5,281.25
Rate for Payer: Hawaii Western Management Group Commercial	$5,687.50
Rate for Payer: Health Management Network Commercial	$6,906.25
Rate for Payer: Kaiser Permanente Commercial	$5,118.75
Rate for Payer: Kaiser Permanente Medicaid	$4,143.75
Rate for Payer: MDX Hawaii PPO	$7,881.25
Rate for Payer: University Health Alliance Commercial	$4,550.00

Arthrex Btb Ib Tightrope W/flipcutter Iii Dri AR-1288BTBIB-FC3 [3643408]

Facility

$8,125.00

Service Code	HCPCS C1713
Hospital Charge Code	3643408
Hospital Revenue Code	278
Min. Negotiated Rate	$4,550.00
Max. Negotiated Rate	$7,881.25
Rate for Payer: Cash Price	$5,281.25
Rate for Payer: Hawaii Western Management Group Commercial	$5,687.50
Rate for Payer: Health Management Network Commercial	$6,906.25
Rate for Payer: MDX Hawaii PPO	$7,881.25
Rate for Payer: University Health Alliance Commercial	$4,550.00

Arthrex Flip Cutter III Drill AR-1204FF [3642219]

Facility

$3,617.00

Hospital Charge Code	3642219
Hospital Revenue Code	272
Min. Negotiated Rate	$3,074.45
Max. Negotiated Rate	$3,508.49
Rate for Payer: Cash Price	$2,351.05
Rate for Payer: Health Management Network Commercial	$3,074.45
Rate for Payer: MDX Hawaii PPO	$3,508.49

Arthrex Flip Cutter III Drill AR-1204FF [3642219]

Facility

$3,617.00

Hospital Charge Code	3642219
Hospital Revenue Code	272
Min. Negotiated Rate	$1,844.67
Max. Negotiated Rate	$3,508.49
Rate for Payer: Cash Price	$2,351.05
Rate for Payer: Hawaii Western Management Group Commercial	$3,436.15
Rate for Payer: Health Management Network Commercial	$3,074.45
Rate for Payer: Kaiser Permanente Commercial	$2,278.71
Rate for Payer: Kaiser Permanente Medicaid	$1,844.67
Rate for Payer: MDX Hawaii PPO	$3,508.49
Rate for Payer: University Health Alliance Commercial	$2,636.43

ARTHROCENTESIS, ASPIRATION AND/OR INJECTION, MAJOR JOINT OR BURSA (EG, SHOULDER, HIP, KNEE, SUBACROMIAL BURSA); WITHOUT ULTRASOUND GUIDANCE

Facility

$4,035.20

Service Code	CPT 20610
Hospital Revenue Code	360
Min. Negotiated Rate	$48.79
Max. Negotiated Rate	$4,035.20
Rate for Payer: AlohaCare Medicaid	$362.62
Rate for Payer: AlohaCare Medicare	$362.62
Rate for Payer: Devoted Health Medicare	$398.88
Rate for Payer: Hawaii Medical Service Association ABD	$393.00
Rate for Payer: Hawaii Medical Service Association Commercial	$2,833.00
Rate for Payer: Hawaii Medical Service Association Medicare	$362.62
Rate for Payer: Hawaii Medical Service Association Non-ABD	$407.95
Rate for Payer: Humana Medicare	$362.62
Rate for Payer: Kaiser Permanente Medicaid	$2,837.00
Rate for Payer: Kaiser Permanente Medicare	$362.62
Rate for Payer: Ohana Health Plan Medicaid	$398.88
Rate for Payer: Ohana Health Plan Medicare	$362.62
Rate for Payer: UnitedHealthcare Medicaid	$48.79
Rate for Payer: UnitedHealthcare Medicare	$362.62
Rate for Payer: University Health Alliance Commercial	$4,035.20

ARTHROCENTESIS, ASPIRATION AND/OR INJECTION, MAJOR JOINT OR BURSA (EG, SHOULDER, HIP, KNEE, SUBACROMIAL BURSA); WITH ULTRASOUND GUIDANCE, WITH PERMANENT RECORDING AND REPORTING

Facility

$4,035.20

Service Code	CPT 20611
Hospital Revenue Code	360
Min. Negotiated Rate	$58.92
Max. Negotiated Rate	$4,035.20
Rate for Payer: AlohaCare Medicaid	$362.62
Rate for Payer: AlohaCare Medicare	$362.62
Rate for Payer: Devoted Health Medicare	$398.88
Rate for Payer: Hawaii Medical Service Association ABD	$393.00
Rate for Payer: Hawaii Medical Service Association Commercial	$2,833.00
Rate for Payer: Hawaii Medical Service Association Medicare	$362.62
Rate for Payer: Hawaii Medical Service Association Non-ABD	$407.95
Rate for Payer: Humana Medicare	$362.62
Rate for Payer: Kaiser Permanente Medicaid	$2,837.00
Rate for Payer: Kaiser Permanente Medicare	$362.62
Rate for Payer: Ohana Health Plan Medicaid	$398.88
Rate for Payer: Ohana Health Plan Medicare	$362.62
Rate for Payer: UnitedHealthcare Medicaid	$58.92
Rate for Payer: UnitedHealthcare Medicare	$362.62
Rate for Payer: University Health Alliance Commercial	$4,035.20

ARTHRODESIS, GREAT TOE; METATARSOPHALANGEAL JOINT

Facility

$10,679.55

Service Code	CPT 28750
Hospital Revenue Code	360
Min. Negotiated Rate	$521.33
Max. Negotiated Rate	$10,679.55
Rate for Payer: AlohaCare Medicaid	$8,572.09
Rate for Payer: AlohaCare Medicare	$8,572.09
Rate for Payer: Devoted Health Medicare	$9,429.30
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	$8,572.09
Rate for Payer: Hawaii Medical Service Association Non-ABD	$849.21
Rate for Payer: Humana Medicare	$8,572.09
Rate for Payer: Kaiser Permanente Medicaid	$2,837.00
Rate for Payer: Kaiser Permanente Medicare	$8,572.09
Rate for Payer: Ohana Health Plan Medicaid	$9,429.30
Rate for Payer: Ohana Health Plan Medicare	$8,572.09
Rate for Payer: UnitedHealthcare Medicaid	$521.33
Rate for Payer: UnitedHealthcare Medicare	$8,572.09
Rate for Payer: University Health Alliance Commercial	$10,679.55

ARTHRODESIS, MIDTARSAL OR TARSOMETATARSAL, MULTIPLE OR TRANSVERSE;

Facility

$16,683.60

Service Code	CPT 28730
Hospital Revenue Code	360
Min. Negotiated Rate	$521.33
Max. Negotiated Rate	$16,683.60
Rate for Payer: AlohaCare Medicaid	$15,166.91
Rate for Payer: AlohaCare Medicare	$15,166.91
Rate for Payer: Devoted Health Medicare	$16,683.60
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	$15,166.91
Rate for Payer: Hawaii Medical Service Association Non-ABD	$849.21
Rate for Payer: Humana Medicare	$15,166.91
Rate for Payer: Kaiser Permanente Medicaid	$2,837.00
Rate for Payer: Kaiser Permanente Medicare	$15,166.91
Rate for Payer: Ohana Health Plan Medicaid	$16,683.60
Rate for Payer: Ohana Health Plan Medicare	$15,166.91
Rate for Payer: UnitedHealthcare Medicaid	$521.33
Rate for Payer: UnitedHealthcare Medicare	$15,166.91
Rate for Payer: University Health Alliance Commercial	$10,679.55

ARTHRODESIS, MIDTARSAL OR TARSOMETATARSAL, SINGLE JOINT

Facility

$10,679.55

Service Code	CPT 28740
Hospital Revenue Code	360
Min. Negotiated Rate	$521.33
Max. Negotiated Rate	$10,679.55
Rate for Payer: AlohaCare Medicaid	$8,572.09
Rate for Payer: AlohaCare Medicare	$8,572.09
Rate for Payer: Devoted Health Medicare	$9,429.30
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	$8,572.09
Rate for Payer: Hawaii Medical Service Association Non-ABD	$849.21
Rate for Payer: Humana Medicare	$8,572.09
Rate for Payer: Kaiser Permanente Medicaid	$2,837.00
Rate for Payer: Kaiser Permanente Medicare	$8,572.09
Rate for Payer: Ohana Health Plan Medicaid	$9,429.30
Rate for Payer: Ohana Health Plan Medicare	$8,572.09
Rate for Payer: UnitedHealthcare Medicaid	$521.33
Rate for Payer: UnitedHealthcare Medicare	$8,572.09
Rate for Payer: University Health Alliance Commercial	$10,679.55

Know your out-of-pocket cost for care.

All Charges