Kona Community Hospital

All Charges

Charge

Type

Setting

Price

Partial Knee Oxford Uni Tib Tray Cmntd SzF LM 154775 [3641174]

Facility

$7,278.00

Service Code	HCPCS C1776
Hospital Charge Code	3641174
Hospital Revenue Code	278
Min. Negotiated Rate	$3,711.78
Max. Negotiated Rate	$7,059.66
Rate for Payer: Cash Price	$4,730.70
Rate for Payer: Hawaii Western Management Group Commercial	$5,094.60
Rate for Payer: Health Management Network Commercial	$6,186.30
Rate for Payer: Kaiser Permanente Commercial	$4,585.14
Rate for Payer: Kaiser Permanente Medicaid	$3,711.78
Rate for Payer: MDX Hawaii PPO	$7,059.66
Rate for Payer: University Health Alliance Commercial	$4,075.68

Partial Knee Oxford Uni Tib Tray Cmntd SzF LM 154775 [3641174]

Facility

$7,278.00

Service Code	HCPCS C1776
Hospital Charge Code	3641174
Hospital Revenue Code	278
Min. Negotiated Rate	$4,075.68
Max. Negotiated Rate	$7,059.66
Rate for Payer: Cash Price	$4,730.70
Rate for Payer: Hawaii Western Management Group Commercial	$5,094.60
Rate for Payer: Health Management Network Commercial	$6,186.30
Rate for Payer: MDX Hawaii PPO	$7,059.66
Rate for Payer: University Health Alliance Commercial	$4,075.68

PARTIAL THICKNESS BURNS W/O SKIN GRAFT

Facility

$1,896.40

Service Code	APR-DRG 8441
Min. Negotiated Rate	$1,896.40
Max. Negotiated Rate	$1,896.40
Rate for Payer: AlohaCare Medicaid	$1,896.40
Rate for Payer: Hawaii Medical Service Association ABD	$1,896.40
Rate for Payer: Hawaii Medical Service Association Non-ABD	$1,896.40
Rate for Payer: Kaiser Permanente Medicaid	$1,896.40
Rate for Payer: Ohana Health Plan Medicaid	$1,896.40
Rate for Payer: UnitedHealthcare Medicaid	$1,896.40

PARTIAL THICKNESS BURNS W/O SKIN GRAFT

Facility

$2,949.67

Service Code	APR-DRG 8442
Min. Negotiated Rate	$2,949.67
Max. Negotiated Rate	$2,949.67
Rate for Payer: AlohaCare Medicaid	$2,949.67
Rate for Payer: Hawaii Medical Service Association ABD	$2,949.67
Rate for Payer: Hawaii Medical Service Association Non-ABD	$2,949.67
Rate for Payer: Kaiser Permanente Medicaid	$2,949.67
Rate for Payer: Ohana Health Plan Medicaid	$2,949.67
Rate for Payer: UnitedHealthcare Medicaid	$2,949.67

PARTIAL THICKNESS BURNS W/O SKIN GRAFT

Facility

$11,285.42

Service Code	APR-DRG 8444
Min. Negotiated Rate	$11,285.42
Max. Negotiated Rate	$11,285.42
Rate for Payer: AlohaCare Medicaid	$11,285.42
Rate for Payer: Hawaii Medical Service Association ABD	$11,285.42
Rate for Payer: Hawaii Medical Service Association Non-ABD	$11,285.42
Rate for Payer: Kaiser Permanente Medicaid	$11,285.42
Rate for Payer: Ohana Health Plan Medicaid	$11,285.42
Rate for Payer: UnitedHealthcare Medicaid	$11,285.42

PARTIAL THICKNESS BURNS W/O SKIN GRAFT

Facility

$4,890.01

Service Code	APR-DRG 8443
Min. Negotiated Rate	$4,890.01
Max. Negotiated Rate	$4,890.01
Rate for Payer: AlohaCare Medicaid	$4,890.01
Rate for Payer: Hawaii Medical Service Association ABD	$4,890.01
Rate for Payer: Hawaii Medical Service Association Non-ABD	$4,890.01
Rate for Payer: Kaiser Permanente Medicaid	$4,890.01
Rate for Payer: Ohana Health Plan Medicaid	$4,890.01
Rate for Payer: UnitedHealthcare Medicaid	$4,890.01

Patch Duravess Bovine Pericardial 0.8cmX8cm DP08X8 [3642384]

Facility

$656.25

Service Code	HCPCS C1768
Hospital Charge Code	3642384
Hospital Revenue Code	278
Min. Negotiated Rate	$334.69
Max. Negotiated Rate	$636.56
Rate for Payer: Cash Price	$426.56
Rate for Payer: Hawaii Western Management Group Commercial	$459.38
Rate for Payer: Health Management Network Commercial	$557.81
Rate for Payer: Kaiser Permanente Commercial	$413.44
Rate for Payer: Kaiser Permanente Medicaid	$334.69
Rate for Payer: MDX Hawaii PPO	$636.56
Rate for Payer: University Health Alliance Commercial	$367.50

Patch Duravess Bovine Pericardial 0.8cmX8cm DP08X8 [3642384]

Facility

$656.25

Service Code	HCPCS C1768
Hospital Charge Code	3642384
Hospital Revenue Code	278
Min. Negotiated Rate	$367.50
Max. Negotiated Rate	$636.56
Rate for Payer: Cash Price	$426.56
Rate for Payer: Hawaii Western Management Group Commercial	$459.38
Rate for Payer: Health Management Network Commercial	$557.81
Rate for Payer: MDX Hawaii PPO	$636.56
Rate for Payer: University Health Alliance Commercial	$367.50

Patch Gore-Tex Soft Tissue 10cm x 15cm x 1mm 1410015010 [3645392]

Facility

$3,653.00

Service Code	HCPCS C1781
Hospital Charge Code	3645392
Hospital Revenue Code	278
Min. Negotiated Rate	$1,863.03
Max. Negotiated Rate	$3,543.41
Rate for Payer: Cash Price	$2,374.45
Rate for Payer: Hawaii Western Management Group Commercial	$2,557.10
Rate for Payer: Health Management Network Commercial	$3,105.05
Rate for Payer: Kaiser Permanente Commercial	$2,301.39
Rate for Payer: Kaiser Permanente Medicaid	$1,863.03
Rate for Payer: MDX Hawaii PPO	$3,543.41
Rate for Payer: University Health Alliance Commercial	$2,045.68

Patch Gore-Tex Soft Tissue 10cm x 15cm x 1mm 1410015010 [3645392]

Facility

$3,653.00

Service Code	HCPCS C1781
Hospital Charge Code	3645392
Hospital Revenue Code	278
Min. Negotiated Rate	$2,045.68
Max. Negotiated Rate	$3,543.41
Rate for Payer: Cash Price	$2,374.45
Rate for Payer: Hawaii Western Management Group Commercial	$2,557.10
Rate for Payer: Health Management Network Commercial	$3,105.05
Rate for Payer: MDX Hawaii PPO	$3,543.41
Rate for Payer: University Health Alliance Commercial	$2,045.68

Patella Sutureplate Ii Star Large 3mm AR-13070L-S [3644041]

Facility

$11,647.50

Service Code	HCPCS C1713
Hospital Charge Code	3644041
Hospital Revenue Code	278
Min. Negotiated Rate	$6,522.60
Max. Negotiated Rate	$11,298.08
Rate for Payer: Cash Price	$7,570.88
Rate for Payer: Hawaii Western Management Group Commercial	$8,153.25
Rate for Payer: Health Management Network Commercial	$9,900.38
Rate for Payer: MDX Hawaii PPO	$11,298.08
Rate for Payer: University Health Alliance Commercial	$6,522.60

Patella Sutureplate Ii Star Large 3mm AR-13070L-S [3644041]

Facility

$11,647.50

Service Code	HCPCS C1713
Hospital Charge Code	3644041
Hospital Revenue Code	278
Min. Negotiated Rate	$5,940.23
Max. Negotiated Rate	$11,298.08
Rate for Payer: Cash Price	$7,570.88
Rate for Payer: Hawaii Western Management Group Commercial	$8,153.25
Rate for Payer: Health Management Network Commercial	$9,900.38
Rate for Payer: Kaiser Permanente Commercial	$7,337.93
Rate for Payer: Kaiser Permanente Medicaid	$5,940.23
Rate for Payer: MDX Hawaii PPO	$11,298.08
Rate for Payer: University Health Alliance Commercial	$6,522.60

Patella Suturteplate II Star Pole Frac Large AR-13070L-P-S [3644238]

Facility

$18,975.00

Service Code	HCPCS C1713
Hospital Charge Code	3644238
Hospital Revenue Code	278
Min. Negotiated Rate	$10,626.00
Max. Negotiated Rate	$18,405.75
Rate for Payer: Cash Price	$12,333.75
Rate for Payer: Hawaii Western Management Group Commercial	$13,282.50
Rate for Payer: Health Management Network Commercial	$16,128.75
Rate for Payer: MDX Hawaii PPO	$18,405.75
Rate for Payer: University Health Alliance Commercial	$10,626.00

Patella Suturteplate II Star Pole Frac Large AR-13070L-P-S [3644238]

Facility

$18,975.00

Service Code	HCPCS C1713
Hospital Charge Code	3644238
Hospital Revenue Code	278
Min. Negotiated Rate	$9,677.25
Max. Negotiated Rate	$18,405.75
Rate for Payer: Cash Price	$12,333.75
Rate for Payer: Hawaii Western Management Group Commercial	$13,282.50
Rate for Payer: Health Management Network Commercial	$16,128.75
Rate for Payer: Kaiser Permanente Commercial	$11,954.25
Rate for Payer: Kaiser Permanente Medicaid	$9,677.25
Rate for Payer: MDX Hawaii PPO	$18,405.75
Rate for Payer: University Health Alliance Commercial	$10,626.00

Patella Template Kit Anterior 03.137.002S [3644176]

Facility

$1,423.93

Hospital Charge Code	3644176
Hospital Revenue Code	272
Min. Negotiated Rate	$726.20
Max. Negotiated Rate	$1,381.21
Rate for Payer: Cash Price	$925.55
Rate for Payer: Hawaii Western Management Group Commercial	$1,352.73
Rate for Payer: Health Management Network Commercial	$1,210.34
Rate for Payer: Kaiser Permanente Commercial	$897.08
Rate for Payer: Kaiser Permanente Medicaid	$726.20
Rate for Payer: MDX Hawaii PPO	$1,381.21
Rate for Payer: University Health Alliance Commercial	$1,037.90

Patella Template Kit Anterior 03.137.002S [3644176]

Facility

$1,423.93

Hospital Charge Code	3644176
Hospital Revenue Code	272
Min. Negotiated Rate	$1,210.34
Max. Negotiated Rate	$1,381.21
Rate for Payer: Cash Price	$925.55
Rate for Payer: Health Management Network Commercial	$1,210.34
Rate for Payer: MDX Hawaii PPO	$1,381.21

Patella Template Kit Lateral Rim ST 03.137.005S [3644972]

Facility

$1,422.91

Hospital Charge Code	3644972
Hospital Revenue Code	272
Min. Negotiated Rate	$1,209.47
Max. Negotiated Rate	$1,380.22
Rate for Payer: Cash Price	$924.89
Rate for Payer: Health Management Network Commercial	$1,209.47
Rate for Payer: MDX Hawaii PPO	$1,380.22

Patella Template Kit Lateral Rim ST 03.137.005S [3644972]

Facility

$1,422.91

Hospital Charge Code	3644972
Hospital Revenue Code	272
Min. Negotiated Rate	$725.68
Max. Negotiated Rate	$1,380.22
Rate for Payer: Cash Price	$924.89
Rate for Payer: Hawaii Western Management Group Commercial	$1,351.76
Rate for Payer: Health Management Network Commercial	$1,209.47
Rate for Payer: Kaiser Permanente Commercial	$896.43
Rate for Payer: Kaiser Permanente Medicaid	$725.68
Rate for Payer: MDX Hawaii PPO	$1,380.22
Rate for Payer: University Health Alliance Commercial	$1,037.16

PATELLECTOMY OR HEMIPATELLECTOMY

Facility

$10,679.55

Service Code	CPT 27350
Hospital Revenue Code	360
Min. Negotiated Rate	$456.03
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	$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	$10,679.55

PATHOLOGICAL FRACTURES AND MUSCULOSKELETAL AND CONNECTIVE TISSUE MALIGNANCY WITH CC

Facility

$33,436.41

Service Code	MSDRG 543
Min. Negotiated Rate	$13,521.03
Max. Negotiated Rate	$33,436.41
Rate for Payer: AlohaCare Medicare	$13,521.03
Rate for Payer: Devoted Health Medicare	$14,873.13
Rate for Payer: Hawaii Medical Service Association Commercial	$33,436.41
Rate for Payer: Hawaii Medical Service Association Medicare	$13,521.03
Rate for Payer: Humana Medicare	$13,521.03
Rate for Payer: Kaiser Permanente Commercial	$17,733.00
Rate for Payer: Kaiser Permanente Medicare	$13,521.03
Rate for Payer: Ohana Health Plan Medicare	$13,521.03
Rate for Payer: UnitedHealthcare Medicare	$13,521.03

PATHOLOGICAL FRACTURES AND MUSCULOSKELETAL AND CONNECTIVE TISSUE MALIGNANCY WITH MCC

Facility

$33,436.41

Service Code	MSDRG 542
Min. Negotiated Rate	$23,234.36
Max. Negotiated Rate	$33,436.41
Rate for Payer: AlohaCare Medicare	$23,234.36
Rate for Payer: Devoted Health Medicare	$25,557.80
Rate for Payer: Hawaii Medical Service Association Commercial	$33,436.41
Rate for Payer: Hawaii Medical Service Association Medicare	$23,234.36
Rate for Payer: Humana Medicare	$23,234.36
Rate for Payer: Kaiser Permanente Commercial	$30,472.12
Rate for Payer: Kaiser Permanente Medicare	$23,234.36
Rate for Payer: Ohana Health Plan Medicare	$23,234.36
Rate for Payer: UnitedHealthcare Medicare	$23,234.36

PATHOLOGICAL FRACTURES AND MUSCULOSKELETAL AND CONNECTIVE TISSUE MALIGNANCY WITHOUT CC/MCC

Facility

$33,436.41

Service Code	MSDRG 544
Min. Negotiated Rate	$9,925.09
Max. Negotiated Rate	$33,436.41
Rate for Payer: AlohaCare Medicare	$9,925.09
Rate for Payer: Devoted Health Medicare	$10,917.60
Rate for Payer: Hawaii Medical Service Association Commercial	$33,436.41
Rate for Payer: Hawaii Medical Service Association Medicare	$9,925.09
Rate for Payer: Humana Medicare	$9,925.09
Rate for Payer: Kaiser Permanente Commercial	$13,016.85
Rate for Payer: Kaiser Permanente Medicare	$9,925.09
Rate for Payer: Ohana Health Plan Medicare	$9,925.09
Rate for Payer: UnitedHealthcare Medicare	$9,925.09

PEDI CEFEPIME SYRINGE (WHR)

Facility

$141.58

Service Code	HCPCS J0692
Hospital Revenue Code	250
Min. Negotiated Rate	$120.34
Max. Negotiated Rate	$137.33
Rate for Payer: Cash Price	$92.03
Rate for Payer: Health Management Network Commercial	$120.34
Rate for Payer: MDX Hawaii PPO	$137.33

PEDI CEFEPIME SYRINGE (WHR)

Facility

$141.58

Service Code	HCPCS J0692
Hospital Revenue Code	636
Min. Negotiated Rate	$6.19
Max. Negotiated Rate	$137.33
Rate for Payer: Cash Price	$92.03
Rate for Payer: Cash Price	$92.03
Rate for Payer: Hawaii Medical Service Association ABD	$6.19
Rate for Payer: Hawaii Medical Service Association Non-ABD	$6.19
Rate for Payer: Hawaii Western Management Group Commercial	$134.50
Rate for Payer: Health Management Network Commercial	$120.34
Rate for Payer: Kaiser Permanente Commercial	$89.20
Rate for Payer: Kaiser Permanente Medicaid	$72.21
Rate for Payer: MDX Hawaii PPO	$137.33
Rate for Payer: UnitedHealthcare Medicaid	$84.95
Rate for Payer: University Health Alliance Commercial	$103.20

PEDI FAT EMULSION 20% IV

Facility

$129.78

Service Code	NDC 00264446030
Hospital Revenue Code	250
Min. Negotiated Rate	$110.31
Max. Negotiated Rate	$125.89
Rate for Payer: Cash Price	$84.36
Rate for Payer: Health Management Network Commercial	$110.31
Rate for Payer: MDX Hawaii PPO	$125.89

Know your out-of-pocket cost for care.

All Charges