Kona Community Hospital

All Charges

Charge

Type

Setting

Price

5% DEXTROSE/NORMAL SALINE

Professional

Both

$8.00

Service Code	HCPCS J7042
Min. Negotiated Rate	$1.29
Max. Negotiated Rate	$6.80
Rate for Payer: AlohaCare Medicare	$1.29
Rate for Payer: Cash Price	$5.20
Rate for Payer: Cash Price	$5.20
Rate for Payer: Devoted Health Medicare	$1.42
Rate for Payer: Hawaii Medical Service Association Medicare	$1.29
Rate for Payer: Hawaii Western Management Group Commercial	$3.00
Rate for Payer: Health Management Network Commercial	$6.80
Rate for Payer: Kaiser Permanente Commercial	$1.55
Rate for Payer: Kaiser Permanente Medicaid	$1.55
Rate for Payer: Kaiser Permanente Medicare	$1.55
Rate for Payer: Ohana Health Plan Medicare	$1.29
Rate for Payer: UnitedHealthcare Medicare	$1.29

5% DEXTROSE/WATER

Professional

Both

$9.00

Service Code	HCPCS J7060
Min. Negotiated Rate	$1.85
Max. Negotiated Rate	$7.65
Rate for Payer: AlohaCare Medicare	$1.87
Rate for Payer: Cash Price	$5.85
Rate for Payer: Cash Price	$5.85
Rate for Payer: Devoted Health Medicare	$2.06
Rate for Payer: Hawaii Medical Service Association Medicare	$1.87
Rate for Payer: Hawaii Western Management Group Commercial	$1.85
Rate for Payer: Health Management Network Commercial	$7.65
Rate for Payer: Kaiser Permanente Commercial	$2.24
Rate for Payer: Kaiser Permanente Medicaid	$2.24
Rate for Payer: Kaiser Permanente Medicare	$2.24
Rate for Payer: Ohana Health Plan Medicare	$1.87
Rate for Payer: UnitedHealthcare Medicare	$1.87

6.5mm X 95mm Ti Cannulated Screw 04.355.795 [3645551]

Facility

$2,399.90

Service Code	HCPCS C1713
Hospital Charge Code	3645551
Hospital Revenue Code	278
Min. Negotiated Rate	$1,343.94
Max. Negotiated Rate	$2,327.90
Rate for Payer: Cash Price	$1,559.94
Rate for Payer: Hawaii Western Management Group Commercial	$1,679.93
Rate for Payer: Health Management Network Commercial	$2,039.91
Rate for Payer: MDX Hawaii PPO	$2,327.90
Rate for Payer: University Health Alliance Commercial	$1,343.94

6.5mm X 95mm Ti Cannulated Screw 04.355.795 [3645551]

Facility

$2,399.90

Service Code	HCPCS C1713
Hospital Charge Code	3645551
Hospital Revenue Code	278
Min. Negotiated Rate	$1,223.95
Max. Negotiated Rate	$2,327.90
Rate for Payer: Cash Price	$1,559.94
Rate for Payer: Hawaii Western Management Group Commercial	$1,679.93
Rate for Payer: Health Management Network Commercial	$2,039.91
Rate for Payer: Kaiser Permanente Commercial	$1,511.94
Rate for Payer: Kaiser Permanente Medicaid	$1,223.95
Rate for Payer: MDX Hawaii PPO	$2,327.90
Rate for Payer: University Health Alliance Commercial	$1,343.94

7.5 Endotracheal Tube W/ Subglottic Suction [2709894]

Facility

$128.00

Service Code	HCPCS A7521
Hospital Charge Code	2709894
Hospital Revenue Code	272
Min. Negotiated Rate	$108.80
Max. Negotiated Rate	$124.16
Rate for Payer: Cash Price	$83.20
Rate for Payer: Health Management Network Commercial	$108.80
Rate for Payer: MDX Hawaii PPO	$124.16

7.5 Endotracheal Tube W/ Subglottic Suction [2709894]

Facility

$128.00

Service Code	HCPCS A7521
Hospital Charge Code	2709894
Hospital Revenue Code	272
Min. Negotiated Rate	$47.05
Max. Negotiated Rate	$124.16
Rate for Payer: Cash Price	$83.20
Rate for Payer: Cash Price	$83.20
Rate for Payer: Hawaii Western Management Group Commercial	$121.60
Rate for Payer: Health Management Network Commercial	$108.80
Rate for Payer: Kaiser Permanente Commercial	$80.64
Rate for Payer: Kaiser Permanente Medicaid	$65.28
Rate for Payer: MDX Hawaii PPO	$124.16
Rate for Payer: UnitedHealthcare Medicaid	$47.05
Rate for Payer: University Health Alliance Commercial	$93.30

7726950 Cath Groshong Dbl Lumen 9.5Fr w/Introducer [3640915]

Facility

$1,496.88

Service Code	HCPCS C1751
Hospital Charge Code	3640915
Hospital Revenue Code	278
Min. Negotiated Rate	$763.41
Max. Negotiated Rate	$1,451.97
Rate for Payer: Cash Price	$972.97
Rate for Payer: Hawaii Western Management Group Commercial	$1,047.82
Rate for Payer: Health Management Network Commercial	$1,272.35
Rate for Payer: Kaiser Permanente Commercial	$943.03
Rate for Payer: Kaiser Permanente Medicaid	$763.41
Rate for Payer: MDX Hawaii PPO	$1,451.97
Rate for Payer: University Health Alliance Commercial	$838.25

7726950 Cath Groshong Dbl Lumen 9.5Fr w/Introducer [3640915]

Facility

$1,496.88

Service Code	HCPCS C1751
Hospital Charge Code	3640915
Hospital Revenue Code	278
Min. Negotiated Rate	$838.25
Max. Negotiated Rate	$1,451.97
Rate for Payer: Cash Price	$972.97
Rate for Payer: Hawaii Western Management Group Commercial	$1,047.82
Rate for Payer: Health Management Network Commercial	$1,272.35
Rate for Payer: MDX Hawaii PPO	$1,451.97
Rate for Payer: University Health Alliance Commercial	$838.25

8.0 Endotracheal Tube W/ Subglottic Suction [2709895]

Facility

$128.00

Service Code	HCPCS A7521
Hospital Charge Code	2709895
Hospital Revenue Code	272
Min. Negotiated Rate	$108.80
Max. Negotiated Rate	$124.16
Rate for Payer: Cash Price	$83.20
Rate for Payer: Health Management Network Commercial	$108.80
Rate for Payer: MDX Hawaii PPO	$124.16

8.0 Endotracheal Tube W/ Subglottic Suction [2709895]

Facility

$128.00

Service Code	HCPCS A7521
Hospital Charge Code	2709895
Hospital Revenue Code	272
Min. Negotiated Rate	$47.05
Max. Negotiated Rate	$124.16
Rate for Payer: Cash Price	$83.20
Rate for Payer: Cash Price	$83.20
Rate for Payer: Hawaii Western Management Group Commercial	$121.60
Rate for Payer: Health Management Network Commercial	$108.80
Rate for Payer: Kaiser Permanente Commercial	$80.64
Rate for Payer: Kaiser Permanente Medicaid	$65.28
Rate for Payer: MDX Hawaii PPO	$124.16
Rate for Payer: UnitedHealthcare Medicaid	$47.05
Rate for Payer: University Health Alliance Commercial	$93.30

8/10 Dilator/Sheath Set 8fr x 70 cm M0062601200 [3643811]

Facility

$323.45

Service Code	HCPCS C1894
Hospital Charge Code	3643811
Hospital Revenue Code	272
Min. Negotiated Rate	$274.93
Max. Negotiated Rate	$313.75
Rate for Payer: Cash Price	$210.24
Rate for Payer: Health Management Network Commercial	$274.93
Rate for Payer: MDX Hawaii PPO	$313.75

8/10 Dilator/Sheath Set 8fr x 70 cm M0062601200 [3643811]

Facility

$323.45

Service Code	HCPCS C1894
Hospital Charge Code	3643811
Hospital Revenue Code	272
Min. Negotiated Rate	$164.96
Max. Negotiated Rate	$313.75
Rate for Payer: Cash Price	$210.24
Rate for Payer: Hawaii Western Management Group Commercial	$307.28
Rate for Payer: Health Management Network Commercial	$274.93
Rate for Payer: Kaiser Permanente Commercial	$203.77
Rate for Payer: Kaiser Permanente Medicaid	$164.96
Rate for Payer: MDX Hawaii PPO	$313.75
Rate for Payer: University Health Alliance Commercial	$235.76

829030070 Drill Bit Cann S-CP 2.9mmX70mm [3642198]

Facility

$1,285.35

Hospital Charge Code	3642198
Hospital Revenue Code	272
Min. Negotiated Rate	$1,092.55
Max. Negotiated Rate	$1,246.79
Rate for Payer: Cash Price	$835.48
Rate for Payer: Health Management Network Commercial	$1,092.55
Rate for Payer: MDX Hawaii PPO	$1,246.79

829030070 Drill Bit Cann S-CP 2.9mmX70mm [3642198]

Facility

$1,285.35

Hospital Charge Code	3642198
Hospital Revenue Code	272
Min. Negotiated Rate	$655.53
Max. Negotiated Rate	$1,246.79
Rate for Payer: Cash Price	$835.48
Rate for Payer: Hawaii Western Management Group Commercial	$1,221.08
Rate for Payer: Health Management Network Commercial	$1,092.55
Rate for Payer: Kaiser Permanente Commercial	$809.77
Rate for Payer: Kaiser Permanente Medicaid	$655.53
Rate for Payer: MDX Hawaii PPO	$1,246.79
Rate for Payer: University Health Alliance Commercial	$936.89

8888413823 Cath Peri Dialysis Swan Nck Coil Left Kit [3641633]

Facility

$1,705.98

Service Code	HCPCS C1750
Hospital Charge Code	3641633
Hospital Revenue Code	272
Min. Negotiated Rate	$870.05
Max. Negotiated Rate	$1,654.80
Rate for Payer: Cash Price	$1,108.89
Rate for Payer: Hawaii Western Management Group Commercial	$1,620.68
Rate for Payer: Health Management Network Commercial	$1,450.08
Rate for Payer: Kaiser Permanente Commercial	$1,074.77
Rate for Payer: Kaiser Permanente Medicaid	$870.05
Rate for Payer: MDX Hawaii PPO	$1,654.80
Rate for Payer: University Health Alliance Commercial	$1,243.49

8888413823 Cath Peri Dialysis Swan Nck Coil Left Kit [3641633]

Facility

$1,705.98

Service Code	HCPCS C1750
Hospital Charge Code	3641633
Hospital Revenue Code	272
Min. Negotiated Rate	$1,450.08
Max. Negotiated Rate	$1,654.80
Rate for Payer: Cash Price	$1,108.89
Rate for Payer: Health Management Network Commercial	$1,450.08
Rate for Payer: MDX Hawaii PPO	$1,654.80

AA 5 % NO.6-D15W-LYTES NO.23 5 % IV SOLP

Facility

$410.64

Service Code	NDC 00338703006
Hospital Revenue Code	250
Min. Negotiated Rate	$349.04
Max. Negotiated Rate	$398.32
Rate for Payer: Cash Price	$266.92
Rate for Payer: Health Management Network Commercial	$349.04
Rate for Payer: MDX Hawaii PPO	$398.32

AA 5 % NO.6-D15W-LYTES NO.23 5 % IV SOLP

Facility

$396.82

Service Code	NDC 00338703204
Hospital Revenue Code	250
Min. Negotiated Rate	$202.38
Max. Negotiated Rate	$384.92
Rate for Payer: Cash Price	$257.93
Rate for Payer: Hawaii Western Management Group Commercial	$376.98
Rate for Payer: Health Management Network Commercial	$337.30
Rate for Payer: Kaiser Permanente Commercial	$250.00
Rate for Payer: Kaiser Permanente Medicaid	$202.38
Rate for Payer: MDX Hawaii PPO	$384.92
Rate for Payer: UnitedHealthcare Medicaid	$238.09
Rate for Payer: University Health Alliance Commercial	$289.24

AA 5 % NO.6-D15W-LYTES NO.23 5 % IV SOLP

Facility

$396.82

Service Code	NDC 00338703201
Hospital Revenue Code	250
Min. Negotiated Rate	$337.30
Max. Negotiated Rate	$384.92
Rate for Payer: Cash Price	$257.93
Rate for Payer: Health Management Network Commercial	$337.30
Rate for Payer: MDX Hawaii PPO	$384.92

AA 5 % NO.6-D15W-LYTES NO.23 5 % IV SOLP

Facility

$410.64

Service Code	NDC 00338703006
Hospital Revenue Code	250
Min. Negotiated Rate	$209.43
Max. Negotiated Rate	$398.32
Rate for Payer: Cash Price	$266.92
Rate for Payer: Hawaii Western Management Group Commercial	$390.11
Rate for Payer: Health Management Network Commercial	$349.04
Rate for Payer: Kaiser Permanente Commercial	$258.70
Rate for Payer: Kaiser Permanente Medicaid	$209.43
Rate for Payer: MDX Hawaii PPO	$398.32
Rate for Payer: UnitedHealthcare Medicaid	$246.38
Rate for Payer: University Health Alliance Commercial	$299.32

AA 5 % NO.6-D15W-LYTES NO.23 5 % IV SOLP

Facility

$410.64

Service Code	NDC 00338703001
Hospital Revenue Code	250
Min. Negotiated Rate	$349.04
Max. Negotiated Rate	$398.32
Rate for Payer: Cash Price	$266.92
Rate for Payer: Health Management Network Commercial	$349.04
Rate for Payer: MDX Hawaii PPO	$398.32

AA 5 % NO.6-D15W-LYTES NO.23 5 % IV SOLP

Facility

$396.82

Service Code	NDC 00338703201
Hospital Revenue Code	250
Min. Negotiated Rate	$202.38
Max. Negotiated Rate	$384.92
Rate for Payer: Cash Price	$257.93
Rate for Payer: Hawaii Western Management Group Commercial	$376.98
Rate for Payer: Health Management Network Commercial	$337.30
Rate for Payer: Kaiser Permanente Commercial	$250.00
Rate for Payer: Kaiser Permanente Medicaid	$202.38
Rate for Payer: MDX Hawaii PPO	$384.92
Rate for Payer: UnitedHealthcare Medicaid	$238.09
Rate for Payer: University Health Alliance Commercial	$289.24

AA 5 % NO.6-D15W-LYTES NO.23 5 % IV SOLP

Facility

$410.64

Service Code	NDC 00338703001
Hospital Revenue Code	250
Min. Negotiated Rate	$209.43
Max. Negotiated Rate	$398.32
Rate for Payer: Cash Price	$266.92
Rate for Payer: Hawaii Western Management Group Commercial	$390.11
Rate for Payer: Health Management Network Commercial	$349.04
Rate for Payer: Kaiser Permanente Commercial	$258.70
Rate for Payer: Kaiser Permanente Medicaid	$209.43
Rate for Payer: MDX Hawaii PPO	$398.32
Rate for Payer: UnitedHealthcare Medicaid	$246.38
Rate for Payer: University Health Alliance Commercial	$299.32

AA 5 % NO.6-D15W-LYTES NO.23 5 % IV SOLP

Facility

$396.82

Service Code	NDC 00338703204
Hospital Revenue Code	250
Min. Negotiated Rate	$337.30
Max. Negotiated Rate	$384.92
Rate for Payer: Cash Price	$257.93
Rate for Payer: Health Management Network Commercial	$337.30
Rate for Payer: MDX Hawaii PPO	$384.92

AA 5 % NO.6-D20W-LYTES NO.23 5 % IV SOLP

Facility

$204.30

Service Code	NDC 00338114803
Hospital Revenue Code	250
Min. Negotiated Rate	$104.19
Max. Negotiated Rate	$198.17
Rate for Payer: Cash Price	$132.80
Rate for Payer: Hawaii Western Management Group Commercial	$194.09
Rate for Payer: Health Management Network Commercial	$173.66
Rate for Payer: Kaiser Permanente Commercial	$128.71
Rate for Payer: Kaiser Permanente Medicaid	$104.19
Rate for Payer: MDX Hawaii PPO	$198.17
Rate for Payer: UnitedHealthcare Medicaid	$122.58
Rate for Payer: University Health Alliance Commercial	$148.91

Know your out-of-pocket cost for care.

All Charges