Kona Community Hospital

All Charges

Charge

Type

Setting

Price

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	$923.49
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: MDX Hawaii PPO	$1,599.62
Rate for Payer: University Health Alliance Commercial	$923.49

Bone Graft Cancellous Chips 30cc 400150 [3600527]

Facility

$2,676.14

Service Code	HCPCS C9359
Hospital Charge Code	3600527
Hospital Revenue Code	278
Min. Negotiated Rate	$1,498.64
Max. Negotiated Rate	$2,595.86
Rate for Payer: Cash Price	$1,739.49
Rate for Payer: Hawaii Western Management Group Commercial	$1,873.30
Rate for Payer: Health Management Network Commercial	$2,274.72
Rate for Payer: MDX Hawaii PPO	$2,595.86
Rate for Payer: University Health Alliance Commercial	$1,498.64

Bone Graft Cancellous Chips 30cc 400150 [3600527]

Facility

$2,676.14

Service Code	HCPCS C9359
Hospital Charge Code	3600527
Hospital Revenue Code	278
Min. Negotiated Rate	$1,364.83
Max. Negotiated Rate	$2,595.86
Rate for Payer: Cash Price	$1,739.49
Rate for Payer: Hawaii Western Management Group Commercial	$1,873.30
Rate for Payer: Health Management Network Commercial	$2,274.72
Rate for Payer: Kaiser Permanente Commercial	$1,685.97
Rate for Payer: Kaiser Permanente Medicaid	$1,364.83
Rate for Payer: MDX Hawaii PPO	$2,595.86
Rate for Payer: University Health Alliance Commercial	$1,498.64

Bone Graft Cancellous Chips 5cc 400140 [3600554]

Facility

$1,026.64

Service Code	HCPCS C9359
Hospital Charge Code	3600554
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

Bone Graft Cancellous Chips 5cc 400140 [3600554]

Facility

$1,026.64

Service Code	HCPCS C9359
Hospital Charge Code	3600554
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

Bone Graft DBX Mix 2.5cc 058025 [3600552]

Facility

$3,174.20

Service Code	HCPCS C1713
Hospital Charge Code	3600552
Hospital Revenue Code	278
Min. Negotiated Rate	$1,618.84
Max. Negotiated Rate	$3,078.97
Rate for Payer: Cash Price	$2,063.23
Rate for Payer: Hawaii Western Management Group Commercial	$2,221.94
Rate for Payer: Health Management Network Commercial	$2,698.07
Rate for Payer: Kaiser Permanente Commercial	$1,999.75
Rate for Payer: Kaiser Permanente Medicaid	$1,618.84
Rate for Payer: MDX Hawaii PPO	$3,078.97
Rate for Payer: University Health Alliance Commercial	$1,777.55

Bone Graft DBX Mix 2.5cc 058025 [3600552]

Facility

$3,174.20

Service Code	HCPCS C1713
Hospital Charge Code	3600552
Hospital Revenue Code	278
Min. Negotiated Rate	$1,777.55
Max. Negotiated Rate	$3,078.97
Rate for Payer: Cash Price	$2,063.23
Rate for Payer: Hawaii Western Management Group Commercial	$2,221.94
Rate for Payer: Health Management Network Commercial	$2,698.07
Rate for Payer: MDX Hawaii PPO	$3,078.97
Rate for Payer: University Health Alliance Commercial	$1,777.55

Bone Graft DBX Putty 0.5cc 038005 [3600553]

Facility

$803.87

Service Code	HCPCS C1713
Hospital Charge Code	3600553
Hospital Revenue Code	278
Min. Negotiated Rate	$450.17
Max. Negotiated Rate	$779.75
Rate for Payer: Cash Price	$522.52
Rate for Payer: Hawaii Western Management Group Commercial	$562.71
Rate for Payer: Health Management Network Commercial	$683.29
Rate for Payer: MDX Hawaii PPO	$779.75
Rate for Payer: University Health Alliance Commercial	$450.17

Bone Graft DBX Putty 0.5cc 038005 [3600553]

Facility

$803.87

Service Code	HCPCS C1713
Hospital Charge Code	3600553
Hospital Revenue Code	278
Min. Negotiated Rate	$409.97
Max. Negotiated Rate	$779.75
Rate for Payer: Cash Price	$522.52
Rate for Payer: Hawaii Western Management Group Commercial	$562.71
Rate for Payer: Health Management Network Commercial	$683.29
Rate for Payer: Kaiser Permanente Commercial	$506.44
Rate for Payer: Kaiser Permanente Medicaid	$409.97
Rate for Payer: MDX Hawaii PPO	$779.75
Rate for Payer: University Health Alliance Commercial	$450.17

Bone Graft DBX Putty 10cc 038100 [3610398]

Facility

$6,271.40

Service Code	HCPCS C1889
Hospital Charge Code	3610398
Hospital Revenue Code	278
Min. Negotiated Rate	$3,198.41
Max. Negotiated Rate	$6,083.26
Rate for Payer: Cash Price	$4,076.41
Rate for Payer: Hawaii Western Management Group Commercial	$4,389.98
Rate for Payer: Health Management Network Commercial	$5,330.69
Rate for Payer: Kaiser Permanente Commercial	$3,950.98
Rate for Payer: Kaiser Permanente Medicaid	$3,198.41
Rate for Payer: MDX Hawaii PPO	$6,083.26
Rate for Payer: University Health Alliance Commercial	$3,511.98

Bone Graft DBX Putty 10cc 038100 [3610398]

Facility

$6,271.40

Service Code	HCPCS C1889
Hospital Charge Code	3610398
Hospital Revenue Code	278
Min. Negotiated Rate	$3,511.98
Max. Negotiated Rate	$6,083.26
Rate for Payer: Cash Price	$4,076.41
Rate for Payer: Hawaii Western Management Group Commercial	$4,389.98
Rate for Payer: Health Management Network Commercial	$5,330.69
Rate for Payer: MDX Hawaii PPO	$6,083.26
Rate for Payer: University Health Alliance Commercial	$3,511.98

Bone Putty Montage 2cc OS-MON-1604 [3644896]

Facility

$4,886.00

Hospital Charge Code	3644896
Hospital Revenue Code	272
Min. Negotiated Rate	$2,491.86
Max. Negotiated Rate	$4,739.42
Rate for Payer: Cash Price	$3,175.90
Rate for Payer: Hawaii Western Management Group Commercial	$4,641.70
Rate for Payer: Health Management Network Commercial	$4,153.10
Rate for Payer: Kaiser Permanente Commercial	$3,078.18
Rate for Payer: Kaiser Permanente Medicaid	$2,491.86
Rate for Payer: MDX Hawaii PPO	$4,739.42
Rate for Payer: University Health Alliance Commercial	$3,561.41

Bone Putty Montage 2cc OS-MON-1604 [3644896]

Facility

$4,886.00

Hospital Charge Code	3644896
Hospital Revenue Code	272
Min. Negotiated Rate	$4,153.10
Max. Negotiated Rate	$4,739.42
Rate for Payer: Cash Price	$3,175.90
Rate for Payer: Health Management Network Commercial	$4,153.10
Rate for Payer: MDX Hawaii PPO	$4,739.42

Bone Putty Montage Os-Mon-1001 [3644047]

Facility

$8,499.50

Service Code	HCPCS C1713
Hospital Charge Code	3644047
Hospital Revenue Code	278
Min. Negotiated Rate	$4,334.74
Max. Negotiated Rate	$8,244.51
Rate for Payer: Cash Price	$5,524.68
Rate for Payer: Hawaii Western Management Group Commercial	$5,949.65
Rate for Payer: Health Management Network Commercial	$7,224.57
Rate for Payer: Kaiser Permanente Commercial	$5,354.69
Rate for Payer: Kaiser Permanente Medicaid	$4,334.74
Rate for Payer: MDX Hawaii PPO	$8,244.51
Rate for Payer: University Health Alliance Commercial	$4,759.72

Bone Putty Montage Os-Mon-1001 [3644047]

Facility

$8,499.50

Service Code	HCPCS C1713
Hospital Charge Code	3644047
Hospital Revenue Code	278
Min. Negotiated Rate	$4,759.72
Max. Negotiated Rate	$8,244.51
Rate for Payer: Cash Price	$5,524.68
Rate for Payer: Hawaii Western Management Group Commercial	$5,949.65
Rate for Payer: Health Management Network Commercial	$7,224.57
Rate for Payer: MDX Hawaii PPO	$8,244.51
Rate for Payer: University Health Alliance Commercial	$4,759.72

Bone Wax W31G [3600345]

Facility

$57.29

Hospital Charge Code	3600345
Hospital Revenue Code	272
Min. Negotiated Rate	$48.70
Max. Negotiated Rate	$55.57
Rate for Payer: Cash Price	$37.24
Rate for Payer: Health Management Network Commercial	$48.70
Rate for Payer: MDX Hawaii PPO	$55.57

Bone Wax W31G [3600345]

Facility

$57.29

Hospital Charge Code	3600345
Hospital Revenue Code	272
Min. Negotiated Rate	$29.22
Max. Negotiated Rate	$55.57
Rate for Payer: Cash Price	$37.24
Rate for Payer: Hawaii Western Management Group Commercial	$54.43
Rate for Payer: Health Management Network Commercial	$48.70
Rate for Payer: Kaiser Permanente Commercial	$36.09
Rate for Payer: Kaiser Permanente Medicaid	$29.22
Rate for Payer: MDX Hawaii PPO	$55.57
Rate for Payer: University Health Alliance Commercial	$41.76

BORTEZOMIB 3.5 MG INJ RECON.SOLN. (DRY POWDER)

Facility

$162.90

Service Code	HCPCS J9041
Hospital Revenue Code	250
Min. Negotiated Rate	$138.47
Max. Negotiated Rate	$158.01
Rate for Payer: Cash Price	$105.88
Rate for Payer: Cash Price	$493.35
Rate for Payer: Health Management Network Commercial	$138.47
Rate for Payer: Health Management Network Commercial	$645.15
Rate for Payer: MDX Hawaii PPO	$158.01
Rate for Payer: MDX Hawaii PPO	$736.23

BORTEZOMIB 3.5 MG INJ RECON.SOLN. (DRY POWDER)

Facility

$759.00

Service Code	HCPCS J9041
Hospital Revenue Code	636
Min. Negotiated Rate	$1.59
Max. Negotiated Rate	$736.23
Rate for Payer: Cash Price	$493.35
Rate for Payer: Cash Price	$105.88
Rate for Payer: Cash Price	$105.88
Rate for Payer: Cash Price	$493.35
Rate for Payer: Hawaii Medical Service Association ABD	$1.59
Rate for Payer: Hawaii Medical Service Association ABD	$1.59
Rate for Payer: Hawaii Medical Service Association Non-ABD	$1.59
Rate for Payer: Hawaii Medical Service Association Non-ABD	$1.59
Rate for Payer: Hawaii Western Management Group Commercial	$154.75
Rate for Payer: Hawaii Western Management Group Commercial	$721.05
Rate for Payer: Health Management Network Commercial	$645.15
Rate for Payer: Health Management Network Commercial	$138.47
Rate for Payer: Kaiser Permanente Commercial	$478.17
Rate for Payer: Kaiser Permanente Commercial	$102.63
Rate for Payer: Kaiser Permanente Medicaid	$83.08
Rate for Payer: Kaiser Permanente Medicaid	$387.09
Rate for Payer: MDX Hawaii PPO	$736.23
Rate for Payer: MDX Hawaii PPO	$158.01
Rate for Payer: UnitedHealthcare Medicaid	$97.74
Rate for Payer: UnitedHealthcare Medicaid	$455.40
Rate for Payer: University Health Alliance Commercial	$118.74
Rate for Payer: University Health Alliance Commercial	$553.24

BPD & OTH CHRONIC RESPIRATORY DISEASES ARISING IN PERINATAL PERIOD

Facility

$3,159.18

Service Code	APR-DRG 1322
Min. Negotiated Rate	$3,159.18
Max. Negotiated Rate	$3,159.18
Rate for Payer: AlohaCare Medicaid	$3,159.18
Rate for Payer: Hawaii Medical Service Association ABD	$3,159.18
Rate for Payer: Hawaii Medical Service Association Non-ABD	$3,159.18
Rate for Payer: Kaiser Permanente Medicaid	$3,159.18
Rate for Payer: Ohana Health Plan Medicaid	$3,159.18
Rate for Payer: UnitedHealthcare Medicaid	$3,159.18

BPD & OTH CHRONIC RESPIRATORY DISEASES ARISING IN PERINATAL PERIOD

Facility

$5,249.80

Service Code	APR-DRG 1323
Min. Negotiated Rate	$5,249.80
Max. Negotiated Rate	$5,249.80
Rate for Payer: AlohaCare Medicaid	$5,249.80
Rate for Payer: Hawaii Medical Service Association ABD	$5,249.80
Rate for Payer: Hawaii Medical Service Association Non-ABD	$5,249.80
Rate for Payer: Kaiser Permanente Medicaid	$5,249.80
Rate for Payer: Ohana Health Plan Medicaid	$5,249.80
Rate for Payer: UnitedHealthcare Medicaid	$5,249.80

BPD & OTH CHRONIC RESPIRATORY DISEASES ARISING IN PERINATAL PERIOD

Facility

$2,354.26

Service Code	APR-DRG 1321
Min. Negotiated Rate	$2,354.26
Max. Negotiated Rate	$2,354.26
Rate for Payer: AlohaCare Medicaid	$2,354.26
Rate for Payer: Hawaii Medical Service Association ABD	$2,354.26
Rate for Payer: Hawaii Medical Service Association Non-ABD	$2,354.26
Rate for Payer: Kaiser Permanente Medicaid	$2,354.26
Rate for Payer: Ohana Health Plan Medicaid	$2,354.26
Rate for Payer: UnitedHealthcare Medicaid	$2,354.26

BPD & OTH CHRONIC RESPIRATORY DISEASES ARISING IN PERINATAL PERIOD

Facility

$8,103.95

Service Code	APR-DRG 1324
Min. Negotiated Rate	$8,103.95
Max. Negotiated Rate	$8,103.95
Rate for Payer: AlohaCare Medicaid	$8,103.95
Rate for Payer: Hawaii Medical Service Association ABD	$8,103.95
Rate for Payer: Hawaii Medical Service Association Non-ABD	$8,103.95
Rate for Payer: Kaiser Permanente Medicaid	$8,103.95
Rate for Payer: Ohana Health Plan Medicaid	$8,103.95
Rate for Payer: UnitedHealthcare Medicaid	$8,103.95

BRACE BACK TLSO LARGE [2705458]

Facility

$1,513.48

Service Code	HCPCS L0450
Hospital Charge Code	2705458
Hospital Revenue Code	274
Min. Negotiated Rate	$847.55
Max. Negotiated Rate	$1,468.08
Rate for Payer: Cash Price	$983.76
Rate for Payer: Hawaii Western Management Group Commercial	$1,059.44
Rate for Payer: Health Management Network Commercial	$1,286.46
Rate for Payer: MDX Hawaii PPO	$1,468.08
Rate for Payer: University Health Alliance Commercial	$847.55

BRACE BACK TLSO LARGE [2705458]

Facility

$1,513.48

Service Code	HCPCS L0450
Hospital Charge Code	2705458
Hospital Revenue Code	274
Min. Negotiated Rate	$118.75
Max. Negotiated Rate	$1,468.08
Rate for Payer: Cash Price	$983.76
Rate for Payer: Cash Price	$983.76
Rate for Payer: Hawaii Western Management Group Commercial	$1,059.44
Rate for Payer: Health Management Network Commercial	$1,286.46
Rate for Payer: Kaiser Permanente Commercial	$953.49
Rate for Payer: Kaiser Permanente Medicaid	$771.87
Rate for Payer: MDX Hawaii PPO	$1,468.08
Rate for Payer: UnitedHealthcare Medicaid	$118.75
Rate for Payer: University Health Alliance Commercial	$847.55

Know your out-of-pocket cost for care.

All Charges