Kona Community Hospital

All Charges

Charge

Type

Setting

Price

Motoband CP Non Lock Screw 3.5 x 22mm ST 1500-3522 [3644930]

Facility

$1,026.64

Service Code	HCPCS C1713
Hospital Charge Code	3644930
Hospital Revenue Code	278
Min. Negotiated Rate	$523.59
Max. Negotiated Rate	$995.84
Rate for Payer: Cash Price	$667.32
Rate for Payer: Hawaii Western Management Group Commercial	$718.65
Rate for Payer: Health Management Network Commercial	$872.64
Rate for Payer: Kaiser Permanente Commercial	$646.78
Rate for Payer: Kaiser Permanente Medicaid	$523.59
Rate for Payer: MDX Hawaii PPO	$995.84
Rate for Payer: University Health Alliance Commercial	$574.92

Motoband Screw Non-Lock 3.0mmx14mm 15NL-3014 [3645517]

Facility

$1,026.64

Service Code	HCPCS C1713
Hospital Charge Code	3645517
Hospital Revenue Code	278
Min. Negotiated Rate	$523.59
Max. Negotiated Rate	$995.84
Rate for Payer: Cash Price	$667.32
Rate for Payer: Hawaii Western Management Group Commercial	$718.65
Rate for Payer: Health Management Network Commercial	$872.64
Rate for Payer: Kaiser Permanente Commercial	$646.78
Rate for Payer: Kaiser Permanente Medicaid	$523.59
Rate for Payer: MDX Hawaii PPO	$995.84
Rate for Payer: University Health Alliance Commercial	$574.92

Motoband Screw Non-Lock 3.0mmx14mm 15NL-3014 [3645517]

Facility

$1,026.64

Service Code	HCPCS C1713
Hospital Charge Code	3645517
Hospital Revenue Code	278
Min. Negotiated Rate	$574.92
Max. Negotiated Rate	$995.84
Rate for Payer: Cash Price	$667.32
Rate for Payer: Hawaii Western Management Group Commercial	$718.65
Rate for Payer: Health Management Network Commercial	$872.64
Rate for Payer: MDX Hawaii PPO	$995.84
Rate for Payer: University Health Alliance Commercial	$574.92

Motoband Screw Non-Lock 3.0mmx16mm 15NL-3016 [3645518]

Facility

$1,026.64

Service Code	HCPCS C1713
Hospital Charge Code	3645518
Hospital Revenue Code	278
Min. Negotiated Rate	$574.92
Max. Negotiated Rate	$995.84
Rate for Payer: Cash Price	$667.32
Rate for Payer: Hawaii Western Management Group Commercial	$718.65
Rate for Payer: Health Management Network Commercial	$872.64
Rate for Payer: MDX Hawaii PPO	$995.84
Rate for Payer: University Health Alliance Commercial	$574.92

Motoband Screw Non-Lock 3.0mmx16mm 15NL-3016 [3645518]

Facility

$1,026.64

Service Code	HCPCS C1713
Hospital Charge Code	3645518
Hospital Revenue Code	278
Min. Negotiated Rate	$523.59
Max. Negotiated Rate	$995.84
Rate for Payer: Cash Price	$667.32
Rate for Payer: Hawaii Western Management Group Commercial	$718.65
Rate for Payer: Health Management Network Commercial	$872.64
Rate for Payer: Kaiser Permanente Commercial	$646.78
Rate for Payer: Kaiser Permanente Medicaid	$523.59
Rate for Payer: MDX Hawaii PPO	$995.84
Rate for Payer: University Health Alliance Commercial	$574.92

MOUTH PROCEDURES WITH CC/MCC

Facility

$60,797.85

Service Code	MSDRG 137
Min. Negotiated Rate	$19,639.71
Max. Negotiated Rate	$60,797.85
Rate for Payer: AlohaCare Medicare	$19,639.71
Rate for Payer: Devoted Health Medicare	$21,603.68
Rate for Payer: Hawaii Medical Service Association Commercial	$60,797.85
Rate for Payer: Hawaii Medical Service Association Medicare	$19,639.71
Rate for Payer: Humana Medicare	$19,639.71
Rate for Payer: Kaiser Permanente Commercial	$25,757.70
Rate for Payer: Kaiser Permanente Medicare	$19,639.71
Rate for Payer: Ohana Health Plan Medicare	$19,639.71
Rate for Payer: UnitedHealthcare Medicare	$19,639.71

MOUTH PROCEDURES WITHOUT CC/MCC

Facility

$32,303.38

Service Code	MSDRG 138
Min. Negotiated Rate	$11,655.98
Max. Negotiated Rate	$32,303.38
Rate for Payer: AlohaCare Medicare	$11,655.98
Rate for Payer: Devoted Health Medicare	$12,821.58
Rate for Payer: Hawaii Medical Service Association Commercial	$32,303.38
Rate for Payer: Hawaii Medical Service Association Medicare	$11,655.98
Rate for Payer: Humana Medicare	$11,655.98
Rate for Payer: Kaiser Permanente Commercial	$15,286.95
Rate for Payer: Kaiser Permanente Medicare	$11,655.98
Rate for Payer: Ohana Health Plan Medicare	$11,655.98
Rate for Payer: UnitedHealthcare Medicare	$11,655.98

MOXIFLOXACIN 0.5 % OPHT DROP

Facility

$587.42

Service Code	NDC 68180042201
Hospital Revenue Code	250
Min. Negotiated Rate	$299.58
Max. Negotiated Rate	$569.80
Rate for Payer: Cash Price	$381.82
Rate for Payer: Hawaii Western Management Group Commercial	$558.05
Rate for Payer: Health Management Network Commercial	$499.31
Rate for Payer: Kaiser Permanente Commercial	$370.07
Rate for Payer: Kaiser Permanente Medicaid	$299.58
Rate for Payer: MDX Hawaii PPO	$569.80
Rate for Payer: UnitedHealthcare Medicaid	$352.45
Rate for Payer: University Health Alliance Commercial	$428.17

MOXIFLOXACIN 0.5 % OPHT DROP

Facility

$441.75

Service Code	NDC 82667070003
Hospital Revenue Code	250
Min. Negotiated Rate	$375.49
Max. Negotiated Rate	$428.50
Rate for Payer: Cash Price	$287.14
Rate for Payer: Health Management Network Commercial	$375.49
Rate for Payer: MDX Hawaii PPO	$428.50

MOXIFLOXACIN 0.5 % OPHT DROP

Facility

$441.75

Service Code	NDC 82667070003
Hospital Revenue Code	250
Min. Negotiated Rate	$225.29
Max. Negotiated Rate	$428.50
Rate for Payer: Cash Price	$287.14
Rate for Payer: Hawaii Western Management Group Commercial	$419.66
Rate for Payer: Health Management Network Commercial	$375.49
Rate for Payer: Kaiser Permanente Commercial	$278.30
Rate for Payer: Kaiser Permanente Medicaid	$225.29
Rate for Payer: MDX Hawaii PPO	$428.50
Rate for Payer: UnitedHealthcare Medicaid	$265.05
Rate for Payer: University Health Alliance Commercial	$321.99

MOXIFLOXACIN 0.5 % OPHT DROP

Facility

$587.42

Service Code	NDC 60505058204
Hospital Revenue Code	250
Min. Negotiated Rate	$499.31
Max. Negotiated Rate	$569.80
Rate for Payer: Cash Price	$381.82
Rate for Payer: Health Management Network Commercial	$499.31
Rate for Payer: MDX Hawaii PPO	$569.80

MOXIFLOXACIN 0.5 % OPHT DROP

Facility

$587.42

Service Code	NDC 60505058204
Hospital Revenue Code	250
Min. Negotiated Rate	$299.58
Max. Negotiated Rate	$569.80
Rate for Payer: Cash Price	$381.82
Rate for Payer: Hawaii Western Management Group Commercial	$558.05
Rate for Payer: Health Management Network Commercial	$499.31
Rate for Payer: Kaiser Permanente Commercial	$370.07
Rate for Payer: Kaiser Permanente Medicaid	$299.58
Rate for Payer: MDX Hawaii PPO	$569.80
Rate for Payer: UnitedHealthcare Medicaid	$352.45
Rate for Payer: University Health Alliance Commercial	$428.17

MOXIFLOXACIN 0.5 % OPHT DROP

Facility

$587.36

Service Code	NDC 62332050503
Hospital Revenue Code	250
Min. Negotiated Rate	$499.26
Max. Negotiated Rate	$569.74
Rate for Payer: Cash Price	$381.78
Rate for Payer: Health Management Network Commercial	$499.26
Rate for Payer: MDX Hawaii PPO	$569.74

MOXIFLOXACIN 0.5 % OPHT DROP

Facility

$587.42

Service Code	NDC 68180042201
Hospital Revenue Code	250
Min. Negotiated Rate	$499.31
Max. Negotiated Rate	$569.80
Rate for Payer: Cash Price	$381.82
Rate for Payer: Health Management Network Commercial	$499.31
Rate for Payer: MDX Hawaii PPO	$569.80

MOXIFLOXACIN 0.5 % OPHT DROP

Facility

$587.36

Service Code	NDC 62332050503
Hospital Revenue Code	250
Min. Negotiated Rate	$299.55
Max. Negotiated Rate	$569.74
Rate for Payer: Cash Price	$381.78
Rate for Payer: Hawaii Western Management Group Commercial	$557.99
Rate for Payer: Health Management Network Commercial	$499.26
Rate for Payer: Kaiser Permanente Commercial	$370.04
Rate for Payer: Kaiser Permanente Medicaid	$299.55
Rate for Payer: MDX Hawaii PPO	$569.74
Rate for Payer: UnitedHealthcare Medicaid	$352.42
Rate for Payer: University Health Alliance Commercial	$428.13

MULTIPLE LEVEL COMBINED ANTERIOR AND POSTERIOR SPINAL FUSION EXCEPT CERVICAL WITH CC

Facility

$124,520.85

Service Code	MSDRG 427
Min. Negotiated Rate	$94,944.55
Max. Negotiated Rate	$124,520.85
Rate for Payer: AlohaCare Medicare	$94,944.55
Rate for Payer: Devoted Health Medicare	$104,439.01
Rate for Payer: Hawaii Medical Service Association Commercial	$117,569.84
Rate for Payer: Hawaii Medical Service Association Medicare	$94,944.55
Rate for Payer: Humana Medicare	$94,944.55
Rate for Payer: Kaiser Permanente Commercial	$124,520.85
Rate for Payer: Kaiser Permanente Medicare	$94,944.55
Rate for Payer: Ohana Health Plan Medicare	$94,944.55
Rate for Payer: UnitedHealthcare Medicare	$94,944.55

MULTIPLE LEVEL COMBINED ANTERIOR AND POSTERIOR SPINAL FUSION EXCEPT CERVICAL WITH MCC OR CUSTOM-MADE ANATOMICALLY DESIGNED INTERBODY FUSION DEVICE

Facility

$190,115.70

Service Code	MSDRG 426
Min. Negotiated Rate	$117,569.84
Max. Negotiated Rate	$190,115.70
Rate for Payer: AlohaCare Medicare	$144,959.27
Rate for Payer: Devoted Health Medicare	$159,455.20
Rate for Payer: Hawaii Medical Service Association Commercial	$117,569.84
Rate for Payer: Hawaii Medical Service Association Medicare	$144,959.27
Rate for Payer: Humana Medicare	$144,959.27
Rate for Payer: Kaiser Permanente Commercial	$190,115.70
Rate for Payer: Kaiser Permanente Medicare	$144,959.27
Rate for Payer: Ohana Health Plan Medicare	$144,959.27
Rate for Payer: UnitedHealthcare Medicare	$144,959.27

MULTIPLE LEVEL COMBINED ANTERIOR AND POSTERIOR SPINAL FUSION EXCEPT CERVICAL WITHOUT CC/MCC

Facility

$117,569.84

Service Code	MSDRG 428
Min. Negotiated Rate	$73,944.84
Max. Negotiated Rate	$117,569.84
Rate for Payer: AlohaCare Medicare	$73,944.84
Rate for Payer: Devoted Health Medicare	$81,339.32
Rate for Payer: Hawaii Medical Service Association Commercial	$117,569.84
Rate for Payer: Hawaii Medical Service Association Medicare	$73,944.84
Rate for Payer: Humana Medicare	$73,944.84
Rate for Payer: Kaiser Permanente Commercial	$96,979.50
Rate for Payer: Kaiser Permanente Medicare	$73,944.84
Rate for Payer: Ohana Health Plan Medicare	$73,944.84
Rate for Payer: UnitedHealthcare Medicare	$73,944.84

MULTIPLE LEVEL SPINAL FUSION EXCEPT CERVICAL WITH MCC OR CUSTOM-MADE ANATOMICALLY DESIGNED INTERBODY FUSION DEVICE

Facility

$115,257.60

Service Code	MSDRG 447
Min. Negotiated Rate	$85,700.38
Max. Negotiated Rate	$115,257.60
Rate for Payer: AlohaCare Medicare	$87,881.52
Rate for Payer: Devoted Health Medicare	$96,669.67
Rate for Payer: Hawaii Medical Service Association Commercial	$85,700.38
Rate for Payer: Hawaii Medical Service Association Medicare	$87,881.52
Rate for Payer: Humana Medicare	$87,881.52
Rate for Payer: Kaiser Permanente Commercial	$115,257.60
Rate for Payer: Kaiser Permanente Medicare	$87,881.52
Rate for Payer: Ohana Health Plan Medicare	$87,881.52
Rate for Payer: UnitedHealthcare Medicare	$87,881.52

MULTIPLE LEVEL SPINAL FUSION EXCEPT CERVICAL WITHOUT MCC

Facility

$80,637.91

Service Code	MSDRG 448
Min. Negotiated Rate	$55,778.24
Max. Negotiated Rate	$80,637.91
Rate for Payer: AlohaCare Medicare	$55,778.24
Rate for Payer: Devoted Health Medicare	$61,356.06
Rate for Payer: Hawaii Medical Service Association Commercial	$80,637.91
Rate for Payer: Hawaii Medical Service Association Medicare	$55,778.24
Rate for Payer: Humana Medicare	$55,778.24
Rate for Payer: Kaiser Permanente Commercial	$73,153.80
Rate for Payer: Kaiser Permanente Medicare	$55,778.24
Rate for Payer: Ohana Health Plan Medicare	$55,778.24
Rate for Payer: UnitedHealthcare Medicare	$55,778.24

MULTIPLE SCLEROSIS AND CEREBELLAR ATAXIA WITH CC

Facility

$21,405.53

Service Code	MSDRG 059
Min. Negotiated Rate	$16,321.26
Max. Negotiated Rate	$21,405.53
Rate for Payer: AlohaCare Medicare	$16,321.26
Rate for Payer: Devoted Health Medicare	$17,953.39
Rate for Payer: Hawaii Medical Service Association Commercial	$20,515.06
Rate for Payer: Hawaii Medical Service Association Medicare	$16,321.26
Rate for Payer: Humana Medicare	$16,321.26
Rate for Payer: Kaiser Permanente Commercial	$21,405.53
Rate for Payer: Kaiser Permanente Medicare	$16,321.26
Rate for Payer: Ohana Health Plan Medicare	$16,321.26
Rate for Payer: UnitedHealthcare Medicare	$16,321.26

MULTIPLE SCLEROSIS AND CEREBELLAR ATAXIA WITH MCC

Facility

$29,488.88

Service Code	MSDRG 058
Min. Negotiated Rate	$20,515.06
Max. Negotiated Rate	$29,488.88
Rate for Payer: AlohaCare Medicare	$22,484.65
Rate for Payer: Devoted Health Medicare	$24,733.12
Rate for Payer: Hawaii Medical Service Association Commercial	$20,515.06
Rate for Payer: Hawaii Medical Service Association Medicare	$22,484.65
Rate for Payer: Humana Medicare	$22,484.65
Rate for Payer: Kaiser Permanente Commercial	$29,488.88
Rate for Payer: Kaiser Permanente Medicare	$22,484.65
Rate for Payer: Ohana Health Plan Medicare	$22,484.65
Rate for Payer: UnitedHealthcare Medicare	$22,484.65

MULTIPLE SCLEROSIS AND CEREBELLAR ATAXIA WITHOUT CC/MCC

Facility

$20,515.06

Service Code	MSDRG 060
Min. Negotiated Rate	$12,097.92
Max. Negotiated Rate	$20,515.06
Rate for Payer: AlohaCare Medicare	$12,097.92
Rate for Payer: Devoted Health Medicare	$13,307.71
Rate for Payer: Hawaii Medical Service Association Commercial	$20,515.06
Rate for Payer: Hawaii Medical Service Association Medicare	$12,097.92
Rate for Payer: Humana Medicare	$12,097.92
Rate for Payer: Kaiser Permanente Commercial	$15,866.55
Rate for Payer: Kaiser Permanente Medicare	$12,097.92
Rate for Payer: Ohana Health Plan Medicare	$12,097.92
Rate for Payer: UnitedHealthcare Medicare	$12,097.92

MULTIPLE SCLEROSIS & OTHER DEMYELINATING DISEASES

Facility

$3,799.17

Service Code	APR-DRG 0431
Min. Negotiated Rate	$3,799.17
Max. Negotiated Rate	$3,799.17
Rate for Payer: AlohaCare Medicaid	$3,799.17
Rate for Payer: Hawaii Medical Service Association ABD	$3,799.17
Rate for Payer: Hawaii Medical Service Association Non-ABD	$3,799.17
Rate for Payer: Kaiser Permanente Medicaid	$3,799.17
Rate for Payer: Ohana Health Plan Medicaid	$3,799.17
Rate for Payer: UnitedHealthcare Medicaid	$3,799.17

MULTIPLE SCLEROSIS & OTHER DEMYELINATING DISEASES

Facility

$4,822.51

Service Code	APR-DRG 0432
Min. Negotiated Rate	$4,822.51
Max. Negotiated Rate	$4,822.51
Rate for Payer: AlohaCare Medicaid	$4,822.51
Rate for Payer: Hawaii Medical Service Association ABD	$4,822.51
Rate for Payer: Hawaii Medical Service Association Non-ABD	$4,822.51
Rate for Payer: Kaiser Permanente Medicaid	$4,822.51
Rate for Payer: Ohana Health Plan Medicaid	$4,822.51
Rate for Payer: UnitedHealthcare Medicaid	$4,822.51

Know your out-of-pocket cost for care.

All Charges