Kona Community Hospital

All Charges

Charge

Type

Setting

Price

BLOOD COUNT COMPLETE AUTO&AUTO DIFRNTL WBC

Professional

Both

$15.00

Service Code	HCPCS 85025
Min. Negotiated Rate	$7.77
Max. Negotiated Rate	$12.75
Rate for Payer: AlohaCare Medicaid	$10.74
Rate for Payer: AlohaCare Medicare	$7.77
Rate for Payer: Cash Price	$9.75
Rate for Payer: Cash Price	$9.75
Rate for Payer: Devoted Health Medicare	$8.55
Rate for Payer: Hawaii Medical Service Association Medicare	$7.77
Rate for Payer: Hawaii Western Management Group Commercial	$10.75
Rate for Payer: Health Management Network Commercial	$12.75
Rate for Payer: Kaiser Permanente Commercial	$9.32
Rate for Payer: Kaiser Permanente Medicaid	$9.32
Rate for Payer: Kaiser Permanente Medicare	$9.32
Rate for Payer: Ohana Health Plan Medicaid	$10.74
Rate for Payer: Ohana Health Plan Medicare	$7.77
Rate for Payer: UnitedHealthcare Medicaid	$10.74
Rate for Payer: UnitedHealthcare Medicare	$7.77

BLOOD COUNT PLATELET AUTOMATED

Professional

Both

$9.00

Service Code	HCPCS 85049
Min. Negotiated Rate	$4.48
Max. Negotiated Rate	$7.65
Rate for Payer: AlohaCare Medicaid	$6.25
Rate for Payer: AlohaCare Medicare	$4.48
Rate for Payer: Cash Price	$5.85
Rate for Payer: Cash Price	$5.85
Rate for Payer: Devoted Health Medicare	$4.93
Rate for Payer: Hawaii Medical Service Association Medicare	$4.48
Rate for Payer: Hawaii Western Management Group Commercial	$6.25
Rate for Payer: Health Management Network Commercial	$7.65
Rate for Payer: Kaiser Permanente Commercial	$5.38
Rate for Payer: Kaiser Permanente Medicaid	$5.38
Rate for Payer: Kaiser Permanente Medicare	$5.38
Rate for Payer: Ohana Health Plan Medicaid	$6.25
Rate for Payer: Ohana Health Plan Medicare	$4.48
Rate for Payer: UnitedHealthcare Medicaid	$6.25
Rate for Payer: UnitedHealthcare Medicare	$4.48

BLOOD COUNT RETICULOCYTE AUTOMATED

Professional

Both

$8.00

Service Code	HCPCS 85045
Min. Negotiated Rate	$3.99
Max. Negotiated Rate	$6.80
Rate for Payer: AlohaCare Medicaid	$5.59
Rate for Payer: AlohaCare Medicare	$3.99
Rate for Payer: Cash Price	$5.20
Rate for Payer: Cash Price	$5.20
Rate for Payer: Devoted Health Medicare	$4.39
Rate for Payer: Hawaii Medical Service Association Medicare	$3.99
Rate for Payer: Hawaii Western Management Group Commercial	$5.55
Rate for Payer: Health Management Network Commercial	$6.80
Rate for Payer: Kaiser Permanente Commercial	$4.79
Rate for Payer: Kaiser Permanente Medicaid	$4.79
Rate for Payer: Kaiser Permanente Medicare	$4.79
Rate for Payer: Ohana Health Plan Medicaid	$5.59
Rate for Payer: Ohana Health Plan Medicare	$3.99
Rate for Payer: UnitedHealthcare Medicaid	$5.59
Rate for Payer: UnitedHealthcare Medicare	$3.99

BLOOD OCCULT PEROXIDASE ACTV QUAL FECES 1-3 SPEC

Professional

Both

$8.40

Service Code	HCPCS 82272
Min. Negotiated Rate	$4.23
Max. Negotiated Rate	$7.14
Rate for Payer: AlohaCare Medicaid	$4.54
Rate for Payer: AlohaCare Medicare	$4.23
Rate for Payer: Cash Price	$5.46
Rate for Payer: Cash Price	$5.46
Rate for Payer: Devoted Health Medicare	$4.65
Rate for Payer: Hawaii Medical Service Association Medicare	$4.23
Rate for Payer: Hawaii Western Management Group Commercial	$4.53
Rate for Payer: Health Management Network Commercial	$7.14
Rate for Payer: Kaiser Permanente Commercial	$5.08
Rate for Payer: Kaiser Permanente Medicaid	$5.08
Rate for Payer: Kaiser Permanente Medicare	$5.08
Rate for Payer: Ohana Health Plan Medicaid	$4.54
Rate for Payer: Ohana Health Plan Medicare	$4.23
Rate for Payer: UnitedHealthcare Medicaid	$4.54
Rate for Payer: UnitedHealthcare Medicare	$4.23

BLOOD OCCULT PEROXIDASE ACTV QUAL FECES 1 DETER

Professional

Both

$8.40

Service Code	HCPCS 82270
Min. Negotiated Rate	$3.50
Max. Negotiated Rate	$7.14
Rate for Payer: AlohaCare Medicaid	$4.49
Rate for Payer: AlohaCare Medicare	$4.38
Rate for Payer: Cash Price	$5.46
Rate for Payer: Cash Price	$5.46
Rate for Payer: Devoted Health Medicare	$4.82
Rate for Payer: Hawaii Medical Service Association Medicare	$4.38
Rate for Payer: Hawaii Western Management Group Commercial	$3.50
Rate for Payer: Health Management Network Commercial	$7.14
Rate for Payer: Kaiser Permanente Commercial	$5.26
Rate for Payer: Kaiser Permanente Medicaid	$5.26
Rate for Payer: Kaiser Permanente Medicare	$5.26
Rate for Payer: Ohana Health Plan Medicaid	$4.49
Rate for Payer: Ohana Health Plan Medicare	$4.38
Rate for Payer: UnitedHealthcare Medicaid	$4.49
Rate for Payer: UnitedHealthcare Medicare	$4.38

Bolt For Fem Neck Sys 100mm 04.168.300S [3642035]

Facility

$2,523.93

Service Code	HCPCS C1713
Hospital Charge Code	3642035
Hospital Revenue Code	278
Min. Negotiated Rate	$1,413.40
Max. Negotiated Rate	$2,448.21
Rate for Payer: Cash Price	$1,640.55
Rate for Payer: Hawaii Western Management Group Commercial	$1,766.75
Rate for Payer: Health Management Network Commercial	$2,145.34
Rate for Payer: MDX Hawaii PPO	$2,448.21
Rate for Payer: University Health Alliance Commercial	$1,413.40

Bolt For Fem Neck Sys 100mm 04.168.300S [3642035]

Facility

$2,523.93

Service Code	HCPCS C1713
Hospital Charge Code	3642035
Hospital Revenue Code	278
Min. Negotiated Rate	$1,287.20
Max. Negotiated Rate	$2,448.21
Rate for Payer: Cash Price	$1,640.55
Rate for Payer: Hawaii Western Management Group Commercial	$1,766.75
Rate for Payer: Health Management Network Commercial	$2,145.34
Rate for Payer: Kaiser Permanente Commercial	$1,590.08
Rate for Payer: Kaiser Permanente Medicaid	$1,287.20
Rate for Payer: MDX Hawaii PPO	$2,448.21
Rate for Payer: University Health Alliance Commercial	$1,413.40

Bolt For Fem Neck Sys 105mm 04.168.305S [3642276]

Facility

$2,524.44

Service Code	HCPCS C1713
Hospital Charge Code	3642276
Hospital Revenue Code	278
Min. Negotiated Rate	$1,413.69
Max. Negotiated Rate	$2,448.71
Rate for Payer: Cash Price	$1,640.89
Rate for Payer: Hawaii Western Management Group Commercial	$1,767.11
Rate for Payer: Health Management Network Commercial	$2,145.77
Rate for Payer: MDX Hawaii PPO	$2,448.71
Rate for Payer: University Health Alliance Commercial	$1,413.69

Bolt For Fem Neck Sys 105mm 04.168.305S [3642276]

Facility

$2,524.44

Service Code	HCPCS C1713
Hospital Charge Code	3642276
Hospital Revenue Code	278
Min. Negotiated Rate	$1,287.46
Max. Negotiated Rate	$2,448.71
Rate for Payer: Cash Price	$1,640.89
Rate for Payer: Hawaii Western Management Group Commercial	$1,767.11
Rate for Payer: Health Management Network Commercial	$2,145.77
Rate for Payer: Kaiser Permanente Commercial	$1,590.40
Rate for Payer: Kaiser Permanente Medicaid	$1,287.46
Rate for Payer: MDX Hawaii PPO	$2,448.71
Rate for Payer: University Health Alliance Commercial	$1,413.69

Bolt For Fem Neck Sys 75mm 04.168.275S [3641728]

Facility

$2,523.93

Service Code	HCPCS C1713
Hospital Charge Code	3641728
Hospital Revenue Code	278
Min. Negotiated Rate	$1,287.20
Max. Negotiated Rate	$2,448.21
Rate for Payer: Cash Price	$1,640.55
Rate for Payer: Hawaii Western Management Group Commercial	$1,766.75
Rate for Payer: Health Management Network Commercial	$2,145.34
Rate for Payer: Kaiser Permanente Commercial	$1,590.08
Rate for Payer: Kaiser Permanente Medicaid	$1,287.20
Rate for Payer: MDX Hawaii PPO	$2,448.21
Rate for Payer: University Health Alliance Commercial	$1,413.40

Bolt For Fem Neck Sys 75mm 04.168.275S [3641728]

Facility

$2,523.93

Service Code	HCPCS C1713
Hospital Charge Code	3641728
Hospital Revenue Code	278
Min. Negotiated Rate	$1,413.40
Max. Negotiated Rate	$2,448.21
Rate for Payer: Cash Price	$1,640.55
Rate for Payer: Hawaii Western Management Group Commercial	$1,766.75
Rate for Payer: Health Management Network Commercial	$2,145.34
Rate for Payer: MDX Hawaii PPO	$2,448.21
Rate for Payer: University Health Alliance Commercial	$1,413.40

Bolt For Fem Neck Sys 80mm 04.168.280S [3642039]

Facility

$2,523.93

Service Code	HCPCS C1713
Hospital Charge Code	3642039
Hospital Revenue Code	278
Min. Negotiated Rate	$1,287.20
Max. Negotiated Rate	$2,448.21
Rate for Payer: Cash Price	$1,640.55
Rate for Payer: Hawaii Western Management Group Commercial	$1,766.75
Rate for Payer: Health Management Network Commercial	$2,145.34
Rate for Payer: Kaiser Permanente Commercial	$1,590.08
Rate for Payer: Kaiser Permanente Medicaid	$1,287.20
Rate for Payer: MDX Hawaii PPO	$2,448.21
Rate for Payer: University Health Alliance Commercial	$1,413.40

Bolt For Fem Neck Sys 80mm 04.168.280S [3642039]

Facility

$2,523.93

Service Code	HCPCS C1713
Hospital Charge Code	3642039
Hospital Revenue Code	278
Min. Negotiated Rate	$1,413.40
Max. Negotiated Rate	$2,448.21
Rate for Payer: Cash Price	$1,640.55
Rate for Payer: Hawaii Western Management Group Commercial	$1,766.75
Rate for Payer: Health Management Network Commercial	$2,145.34
Rate for Payer: MDX Hawaii PPO	$2,448.21
Rate for Payer: University Health Alliance Commercial	$1,413.40

Bolt For Fem Neck Sys 85mm 04.168.285S [3641742]

Facility

$2,523.93

Service Code	HCPCS C1713
Hospital Charge Code	3641742
Hospital Revenue Code	278
Min. Negotiated Rate	$1,413.40
Max. Negotiated Rate	$2,448.21
Rate for Payer: Cash Price	$1,640.55
Rate for Payer: Hawaii Western Management Group Commercial	$1,766.75
Rate for Payer: Health Management Network Commercial	$2,145.34
Rate for Payer: MDX Hawaii PPO	$2,448.21
Rate for Payer: University Health Alliance Commercial	$1,413.40

Bolt For Fem Neck Sys 85mm 04.168.285S [3641742]

Facility

$2,523.93

Service Code	HCPCS C1713
Hospital Charge Code	3641742
Hospital Revenue Code	278
Min. Negotiated Rate	$1,287.20
Max. Negotiated Rate	$2,448.21
Rate for Payer: Cash Price	$1,640.55
Rate for Payer: Hawaii Western Management Group Commercial	$1,766.75
Rate for Payer: Health Management Network Commercial	$2,145.34
Rate for Payer: Kaiser Permanente Commercial	$1,590.08
Rate for Payer: Kaiser Permanente Medicaid	$1,287.20
Rate for Payer: MDX Hawaii PPO	$2,448.21
Rate for Payer: University Health Alliance Commercial	$1,413.40

Bolt For Fem Neck Sys 90mm 04.168.290S [3641982]

Facility

$2,523.93

Service Code	HCPCS C1713
Hospital Charge Code	3641982
Hospital Revenue Code	278
Min. Negotiated Rate	$1,413.40
Max. Negotiated Rate	$2,448.21
Rate for Payer: Cash Price	$1,640.55
Rate for Payer: Hawaii Western Management Group Commercial	$1,766.75
Rate for Payer: Health Management Network Commercial	$2,145.34
Rate for Payer: MDX Hawaii PPO	$2,448.21
Rate for Payer: University Health Alliance Commercial	$1,413.40

Bolt For Fem Neck Sys 90mm 04.168.290S [3641982]

Facility

$2,523.93

Service Code	HCPCS C1713
Hospital Charge Code	3641982
Hospital Revenue Code	278
Min. Negotiated Rate	$1,287.20
Max. Negotiated Rate	$2,448.21
Rate for Payer: Cash Price	$1,640.55
Rate for Payer: Hawaii Western Management Group Commercial	$1,766.75
Rate for Payer: Health Management Network Commercial	$2,145.34
Rate for Payer: Kaiser Permanente Commercial	$1,590.08
Rate for Payer: Kaiser Permanente Medicaid	$1,287.20
Rate for Payer: MDX Hawaii PPO	$2,448.21
Rate for Payer: University Health Alliance Commercial	$1,413.40

Bolt For Fem Neck Sys 95mm 04.168.295S [3641726]

Facility

$2,523.93

Service Code	HCPCS C1713
Hospital Charge Code	3641726
Hospital Revenue Code	278
Min. Negotiated Rate	$1,287.20
Max. Negotiated Rate	$2,448.21
Rate for Payer: Cash Price	$1,640.55
Rate for Payer: Hawaii Western Management Group Commercial	$1,766.75
Rate for Payer: Health Management Network Commercial	$2,145.34
Rate for Payer: Kaiser Permanente Commercial	$1,590.08
Rate for Payer: Kaiser Permanente Medicaid	$1,287.20
Rate for Payer: MDX Hawaii PPO	$2,448.21
Rate for Payer: University Health Alliance Commercial	$1,413.40

Bolt For Fem Neck Sys 95mm 04.168.295S [3641726]

Facility

$2,523.93

Service Code	HCPCS C1713
Hospital Charge Code	3641726
Hospital Revenue Code	278
Min. Negotiated Rate	$1,413.40
Max. Negotiated Rate	$2,448.21
Rate for Payer: Cash Price	$1,640.55
Rate for Payer: Hawaii Western Management Group Commercial	$1,766.75
Rate for Payer: Health Management Network Commercial	$2,145.34
Rate for Payer: MDX Hawaii PPO	$2,448.21
Rate for Payer: University Health Alliance Commercial	$1,413.40

Bone Cement Bravo Hv 40g 611-01-040 [3645427]

Facility

$1,727.50

Hospital Charge Code	3645427
Hospital Revenue Code	272
Min. Negotiated Rate	$1,468.38
Max. Negotiated Rate	$1,675.67
Rate for Payer: Cash Price	$1,122.88
Rate for Payer: Health Management Network Commercial	$1,468.38
Rate for Payer: MDX Hawaii PPO	$1,675.67

Bone Cement Bravo Hv 40g 611-01-040 [3645427]

Facility

$1,727.50

Hospital Charge Code	3645427
Hospital Revenue Code	272
Min. Negotiated Rate	$881.02
Max. Negotiated Rate	$1,675.67
Rate for Payer: Cash Price	$1,122.88
Rate for Payer: Hawaii Western Management Group Commercial	$1,641.12
Rate for Payer: Health Management Network Commercial	$1,468.38
Rate for Payer: Kaiser Permanente Commercial	$1,088.33
Rate for Payer: Kaiser Permanente Medicaid	$881.02
Rate for Payer: MDX Hawaii PPO	$1,675.67
Rate for Payer: University Health Alliance Commercial	$1,259.17

BONE DISEASES AND ARTHROPATHIES WITH MCC

Facility

$22,361.17

Service Code	MSDRG 553
Min. Negotiated Rate	$12,704.39
Max. Negotiated Rate	$22,361.17
Rate for Payer: AlohaCare Medicare	$17,049.93
Rate for Payer: Devoted Health Medicare	$18,754.92
Rate for Payer: Hawaii Medical Service Association Commercial	$12,704.39
Rate for Payer: Hawaii Medical Service Association Medicare	$17,049.93
Rate for Payer: Humana Medicare	$17,049.93
Rate for Payer: Kaiser Permanente Commercial	$22,361.17
Rate for Payer: Kaiser Permanente Medicare	$17,049.93
Rate for Payer: Ohana Health Plan Medicare	$17,049.93
Rate for Payer: UnitedHealthcare Medicare	$17,049.93

BONE DISEASES AND ARTHROPATHIES WITHOUT MCC

Facility

$14,319.23

Service Code	MSDRG 554
Min. Negotiated Rate	$10,918.12
Max. Negotiated Rate	$14,319.23
Rate for Payer: AlohaCare Medicare	$10,918.12
Rate for Payer: Devoted Health Medicare	$12,009.93
Rate for Payer: Hawaii Medical Service Association Commercial	$12,607.96
Rate for Payer: Hawaii Medical Service Association Medicare	$10,918.12
Rate for Payer: Humana Medicare	$10,918.12
Rate for Payer: Kaiser Permanente Commercial	$14,319.23
Rate for Payer: Kaiser Permanente Medicare	$10,918.12
Rate for Payer: Ohana Health Plan Medicare	$10,918.12
Rate for Payer: UnitedHealthcare Medicare	$10,918.12

BONE GRAFT, ANY DONOR AREA; MINOR OR SMALL (EG, DOWEL OR BUTTON)

Facility

$9,429.30

Service Code	CPT 20900
Hospital Revenue Code	360
Min. Negotiated Rate	$456.03
Max. Negotiated Rate	$9,429.30
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	$695.00
Rate for Payer: Hawaii Medical Service Association Commercial	$6,183.00
Rate for Payer: Hawaii Medical Service Association Medicare	$8,572.09
Rate for Payer: Hawaii Medical Service Association Non-ABD	$700.72
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	$456.03
Rate for Payer: UnitedHealthcare Medicare	$8,572.09
Rate for Payer: University Health Alliance Commercial	$6,743.44

Bone Graft Cancellous Chips 15cc 400145 [3640503]

Facility

$1,649.09

Service Code	HCPCS C1713
Hospital Charge Code	3640503
Hospital Revenue Code	278
Min. Negotiated Rate	$841.04
Max. Negotiated Rate	$1,599.62
Rate for Payer: Cash Price	$1,071.91
Rate for Payer: Hawaii Western Management Group Commercial	$1,154.36
Rate for Payer: Health Management Network Commercial	$1,401.73
Rate for Payer: Kaiser Permanente Commercial	$1,038.93
Rate for Payer: Kaiser Permanente Medicaid	$841.04
Rate for Payer: MDX Hawaii PPO	$1,599.62
Rate for Payer: University Health Alliance Commercial	$923.49

Know your out-of-pocket cost for care.

All Charges