Kona Community Hospital

All Charges

Charge

Type

Setting

Price

Peg Smooth Locking 2.0mm X 22mm SPLS-20220-TS [3642652]

Facility

$673.21

Service Code	HCPCS C1713
Hospital Charge Code	3642652
Hospital Revenue Code	278
Min. Negotiated Rate	$377.00
Max. Negotiated Rate	$653.01
Rate for Payer: Cash Price	$437.59
Rate for Payer: Hawaii Western Management Group Commercial	$471.25
Rate for Payer: Health Management Network Commercial	$572.23
Rate for Payer: MDX Hawaii PPO	$653.01
Rate for Payer: University Health Alliance Commercial	$377.00

Peg Smooth Locking 2.0mm x 24mm SPLS-20240-TS [3644278]

Facility

$699.99

Service Code	HCPCS C1713
Hospital Charge Code	3644278
Hospital Revenue Code	278
Min. Negotiated Rate	$391.99
Max. Negotiated Rate	$678.99
Rate for Payer: Cash Price	$454.99
Rate for Payer: Hawaii Western Management Group Commercial	$489.99
Rate for Payer: Health Management Network Commercial	$594.99
Rate for Payer: MDX Hawaii PPO	$678.99
Rate for Payer: University Health Alliance Commercial	$391.99

Peg Smooth Locking 2.0mm x 24mm SPLS-20240-TS [3644278]

Facility

$699.99

Service Code	HCPCS C1713
Hospital Charge Code	3644278
Hospital Revenue Code	278
Min. Negotiated Rate	$356.99
Max. Negotiated Rate	$678.99
Rate for Payer: Cash Price	$454.99
Rate for Payer: Hawaii Western Management Group Commercial	$489.99
Rate for Payer: Health Management Network Commercial	$594.99
Rate for Payer: Kaiser Permanente Commercial	$440.99
Rate for Payer: Kaiser Permanente Medicaid	$356.99
Rate for Payer: MDX Hawaii PPO	$678.99
Rate for Payer: University Health Alliance Commercial	$391.99

Peg Smooth Locking 2.7mm x 10mm SPLS-27100-TS [3643282]

Facility

$809.38

Service Code	HCPCS C1713
Hospital Charge Code	3643282
Hospital Revenue Code	278
Min. Negotiated Rate	$412.78
Max. Negotiated Rate	$785.10
Rate for Payer: Cash Price	$526.10
Rate for Payer: Hawaii Western Management Group Commercial	$566.57
Rate for Payer: Health Management Network Commercial	$687.97
Rate for Payer: Kaiser Permanente Commercial	$509.91
Rate for Payer: Kaiser Permanente Medicaid	$412.78
Rate for Payer: MDX Hawaii PPO	$785.10
Rate for Payer: University Health Alliance Commercial	$453.25

Peg Smooth Locking 2.7mm x 10mm SPLS-27100-TS [3643282]

Facility

$809.38

Service Code	HCPCS C1713
Hospital Charge Code	3643282
Hospital Revenue Code	278
Min. Negotiated Rate	$453.25
Max. Negotiated Rate	$785.10
Rate for Payer: Cash Price	$526.10
Rate for Payer: Hawaii Western Management Group Commercial	$566.57
Rate for Payer: Health Management Network Commercial	$687.97
Rate for Payer: MDX Hawaii PPO	$785.10
Rate for Payer: University Health Alliance Commercial	$453.25

Peg Thrd Cort Non-Lock Ti 2.7mm x 22mm PANL-27220-TS [3644428]

Facility

$1,058.77

Service Code	HCPCS C1713
Hospital Charge Code	3644428
Hospital Revenue Code	278
Min. Negotiated Rate	$592.91
Max. Negotiated Rate	$1,027.01
Rate for Payer: Cash Price	$688.20
Rate for Payer: Hawaii Western Management Group Commercial	$741.14
Rate for Payer: Health Management Network Commercial	$899.95
Rate for Payer: MDX Hawaii PPO	$1,027.01
Rate for Payer: University Health Alliance Commercial	$592.91

Peg Thrd Cort Non-Lock Ti 2.7mm x 22mm PANL-27220-TS [3644428]

Facility

$1,058.77

Service Code	HCPCS C1713
Hospital Charge Code	3644428
Hospital Revenue Code	278
Min. Negotiated Rate	$539.97
Max. Negotiated Rate	$1,027.01
Rate for Payer: Cash Price	$688.20
Rate for Payer: Hawaii Western Management Group Commercial	$741.14
Rate for Payer: Health Management Network Commercial	$899.95
Rate for Payer: Kaiser Permanente Commercial	$667.03
Rate for Payer: Kaiser Permanente Medicaid	$539.97
Rate for Payer: MDX Hawaii PPO	$1,027.01
Rate for Payer: University Health Alliance Commercial	$592.91

Peg Threaded Lock Ti 2.3 x 21mm TPLS-23210-TS [3644530]

Facility

$732.12

Service Code	HCPCS C1713
Hospital Charge Code	3644530
Hospital Revenue Code	278
Min. Negotiated Rate	$373.38
Max. Negotiated Rate	$710.16
Rate for Payer: Cash Price	$475.88
Rate for Payer: Hawaii Western Management Group Commercial	$512.48
Rate for Payer: Health Management Network Commercial	$622.30
Rate for Payer: Kaiser Permanente Commercial	$461.24
Rate for Payer: Kaiser Permanente Medicaid	$373.38
Rate for Payer: MDX Hawaii PPO	$710.16
Rate for Payer: University Health Alliance Commercial	$409.99

Peg Threaded Lock Ti 2.3 x 21mm TPLS-23210-TS [3644530]

Facility

$732.12

Service Code	HCPCS C1713
Hospital Charge Code	3644530
Hospital Revenue Code	278
Min. Negotiated Rate	$409.99
Max. Negotiated Rate	$710.16
Rate for Payer: Cash Price	$475.88
Rate for Payer: Hawaii Western Management Group Commercial	$512.48
Rate for Payer: Health Management Network Commercial	$622.30
Rate for Payer: MDX Hawaii PPO	$710.16
Rate for Payer: University Health Alliance Commercial	$409.99

PELVIC EVISCERATION, RADICAL HYSTERECTOMY AND RADICAL VULVECTOMY WITH CC/MCC

Facility

$40,162.26

Service Code	MSDRG 734
Min. Negotiated Rate	$28,015.39
Max. Negotiated Rate	$40,162.26
Rate for Payer: AlohaCare Medicare	$28,015.39
Rate for Payer: Devoted Health Medicare	$30,816.93
Rate for Payer: Hawaii Medical Service Association Commercial	$40,162.26
Rate for Payer: Hawaii Medical Service Association Medicare	$28,015.39
Rate for Payer: Humana Medicare	$28,015.39
Rate for Payer: Kaiser Permanente Commercial	$36,742.50
Rate for Payer: Kaiser Permanente Medicare	$28,015.39
Rate for Payer: Ohana Health Plan Medicare	$28,015.39
Rate for Payer: UnitedHealthcare Medicare	$28,015.39

PELVIC EVISCERATION, RADICAL HYSTERECTOMY AND RADICAL VULVECTOMY WITHOUT CC/MCC

Facility

$40,162.26

Service Code	MSDRG 735
Min. Negotiated Rate	$17,697.05
Max. Negotiated Rate	$40,162.26
Rate for Payer: AlohaCare Medicare	$17,697.05
Rate for Payer: Devoted Health Medicare	$19,466.76
Rate for Payer: Hawaii Medical Service Association Commercial	$40,162.26
Rate for Payer: Hawaii Medical Service Association Medicare	$17,697.05
Rate for Payer: Humana Medicare	$17,697.05
Rate for Payer: Kaiser Permanente Commercial	$23,209.88
Rate for Payer: Kaiser Permanente Medicare	$17,697.05
Rate for Payer: Ohana Health Plan Medicare	$17,697.05
Rate for Payer: UnitedHealthcare Medicare	$17,697.05

PELVIC EVISCERATION, RADICAL HYSTERECTOMY & OTHER RADICAL GYN PROCS

Facility

$8,263.16

Service Code	APR-DRG 5102
Min. Negotiated Rate	$8,263.16
Max. Negotiated Rate	$8,263.16
Rate for Payer: AlohaCare Medicaid	$8,263.16
Rate for Payer: Hawaii Medical Service Association ABD	$8,263.16
Rate for Payer: Hawaii Medical Service Association Non-ABD	$8,263.16
Rate for Payer: Kaiser Permanente Medicaid	$8,263.16
Rate for Payer: Ohana Health Plan Medicaid	$8,263.16
Rate for Payer: UnitedHealthcare Medicaid	$8,263.16

PELVIC EVISCERATION, RADICAL HYSTERECTOMY & OTHER RADICAL GYN PROCS

Facility

$21,385.12

Service Code	APR-DRG 5104
Min. Negotiated Rate	$21,385.12
Max. Negotiated Rate	$21,385.12
Rate for Payer: AlohaCare Medicaid	$21,385.12
Rate for Payer: Hawaii Medical Service Association ABD	$21,385.12
Rate for Payer: Hawaii Medical Service Association Non-ABD	$21,385.12
Rate for Payer: Kaiser Permanente Medicaid	$21,385.12
Rate for Payer: Ohana Health Plan Medicaid	$21,385.12
Rate for Payer: UnitedHealthcare Medicaid	$21,385.12

PELVIC EVISCERATION, RADICAL HYSTERECTOMY & OTHER RADICAL GYN PROCS

Facility

$12,951.30

Service Code	APR-DRG 5103
Min. Negotiated Rate	$12,951.30
Max. Negotiated Rate	$12,951.30
Rate for Payer: AlohaCare Medicaid	$12,951.30
Rate for Payer: Hawaii Medical Service Association ABD	$12,951.30
Rate for Payer: Hawaii Medical Service Association Non-ABD	$12,951.30
Rate for Payer: Kaiser Permanente Medicaid	$12,951.30
Rate for Payer: Ohana Health Plan Medicaid	$12,951.30
Rate for Payer: UnitedHealthcare Medicaid	$12,951.30

PELVIC EVISCERATION, RADICAL HYSTERECTOMY & OTHER RADICAL GYN PROCS

Facility

$6,514.49

Service Code	APR-DRG 5101
Min. Negotiated Rate	$6,514.49
Max. Negotiated Rate	$6,514.49
Rate for Payer: AlohaCare Medicaid	$6,514.49
Rate for Payer: Hawaii Medical Service Association ABD	$6,514.49
Rate for Payer: Hawaii Medical Service Association Non-ABD	$6,514.49
Rate for Payer: Kaiser Permanente Medicaid	$6,514.49
Rate for Payer: Ohana Health Plan Medicaid	$6,514.49
Rate for Payer: UnitedHealthcare Medicaid	$6,514.49

PEMBROLIZUMAB 25 MG/ML IV SOLN

Facility

$8,337.22

Service Code	HCPCS J9271
Hospital Revenue Code	636
Min. Negotiated Rate	$58.56
Max. Negotiated Rate	$8,087.10
Rate for Payer: AlohaCare Medicaid	$61.25
Rate for Payer: AlohaCare Medicare	$61.25
Rate for Payer: Cash Price	$5,419.19
Rate for Payer: Cash Price	$5,419.19
Rate for Payer: Devoted Health Medicare	$67.38
Rate for Payer: Hawaii Medical Service Association ABD	$58.56
Rate for Payer: Hawaii Medical Service Association Commercial	$76.56
Rate for Payer: Hawaii Medical Service Association Medicare	$61.25
Rate for Payer: Hawaii Medical Service Association Non-ABD	$58.56
Rate for Payer: Hawaii Western Management Group Commercial	$7,920.36
Rate for Payer: Health Management Network Commercial	$7,086.64
Rate for Payer: Humana Medicare	$61.25
Rate for Payer: Kaiser Permanente Commercial	$5,252.45
Rate for Payer: Kaiser Permanente Medicaid	$4,251.98
Rate for Payer: Kaiser Permanente Medicare	$61.25
Rate for Payer: MDX Hawaii PPO	$8,087.10
Rate for Payer: Ohana Health Plan Medicaid	$67.38
Rate for Payer: Ohana Health Plan Medicare	$61.25
Rate for Payer: UnitedHealthcare Medicaid	$5,002.33
Rate for Payer: UnitedHealthcare Medicare	$61.25
Rate for Payer: University Health Alliance Commercial	$6,077.00

PEMBROLIZUMAB 25 MG/ML IV SOLN

Facility

$8,337.22

Service Code	HCPCS J9271
Hospital Revenue Code	250
Min. Negotiated Rate	$7,086.64
Max. Negotiated Rate	$8,087.10
Rate for Payer: Cash Price	$5,419.19
Rate for Payer: Health Management Network Commercial	$7,086.64
Rate for Payer: MDX Hawaii PPO	$8,087.10

PEMBROLIZUM-BERAHYALURON-PMPH 395 MG-4,800 UNIT/2.4 ML SUBCUTANEOUS SOLN

Facility

$15,556.04

Service Code	NDC 00006308399
Hospital Revenue Code	250
Min. Negotiated Rate	$7,933.58
Max. Negotiated Rate	$15,089.36
Rate for Payer: Cash Price	$10,111.43
Rate for Payer: Hawaii Western Management Group Commercial	$14,778.24
Rate for Payer: Health Management Network Commercial	$13,222.63
Rate for Payer: Kaiser Permanente Commercial	$9,800.31
Rate for Payer: Kaiser Permanente Medicaid	$7,933.58
Rate for Payer: MDX Hawaii PPO	$15,089.36
Rate for Payer: UnitedHealthcare Medicaid	$9,333.62
Rate for Payer: University Health Alliance Commercial	$11,338.80

PEMBROLIZUM-BERAHYALURON-PMPH 395 MG-4,800 UNIT/2.4 ML SUBCUTANEOUS SOLN

Facility

$15,556.04

Service Code	NDC 00006308301
Hospital Revenue Code	250
Min. Negotiated Rate	$13,222.63
Max. Negotiated Rate	$15,089.36
Rate for Payer: Cash Price	$10,111.43
Rate for Payer: Health Management Network Commercial	$13,222.63
Rate for Payer: MDX Hawaii PPO	$15,089.36

PEMBROLIZUM-BERAHYALURON-PMPH 395 MG-4,800 UNIT/2.4 ML SUBCUTANEOUS SOLN

Facility

$15,556.04

Service Code	NDC 00006308301
Hospital Revenue Code	250
Min. Negotiated Rate	$7,933.58
Max. Negotiated Rate	$15,089.36
Rate for Payer: Cash Price	$10,111.43
Rate for Payer: Hawaii Western Management Group Commercial	$14,778.24
Rate for Payer: Health Management Network Commercial	$13,222.63
Rate for Payer: Kaiser Permanente Commercial	$9,800.31
Rate for Payer: Kaiser Permanente Medicaid	$7,933.58
Rate for Payer: MDX Hawaii PPO	$15,089.36
Rate for Payer: UnitedHealthcare Medicaid	$9,333.62
Rate for Payer: University Health Alliance Commercial	$11,338.80

PEMBROLIZUM-BERAHYALURON-PMPH 395 MG-4,800 UNIT/2.4 ML SUBCUTANEOUS SOLN

Facility

$15,556.04

Service Code	NDC 00006308399
Hospital Revenue Code	250
Min. Negotiated Rate	$13,222.63
Max. Negotiated Rate	$15,089.36
Rate for Payer: Cash Price	$10,111.43
Rate for Payer: Health Management Network Commercial	$13,222.63
Rate for Payer: MDX Hawaii PPO	$15,089.36

PEMETREXED DISODIUM 100 MG IV RECON.SOLN.

Facility

$142.20

Service Code	HCPCS J9305
Hospital Revenue Code	250
Min. Negotiated Rate	$120.87
Max. Negotiated Rate	$137.93
Rate for Payer: Cash Price	$92.43
Rate for Payer: Cash Price	$1,247.13
Rate for Payer: Health Management Network Commercial	$120.87
Rate for Payer: Health Management Network Commercial	$1,630.86
Rate for Payer: MDX Hawaii PPO	$137.93
Rate for Payer: MDX Hawaii PPO	$1,861.10

PEMETREXED DISODIUM 100 MG IV RECON.SOLN.

Facility

$142.20

Service Code	HCPCS J9305
Hospital Revenue Code	636
Min. Negotiated Rate	$3.73
Max. Negotiated Rate	$137.93
Rate for Payer: AlohaCare Medicaid	$4.04
Rate for Payer: AlohaCare Medicaid	$4.04
Rate for Payer: AlohaCare Medicare	$4.04
Rate for Payer: AlohaCare Medicare	$4.04
Rate for Payer: Cash Price	$92.43
Rate for Payer: Cash Price	$1,247.13
Rate for Payer: Cash Price	$92.43
Rate for Payer: Cash Price	$1,247.13
Rate for Payer: Devoted Health Medicare	$4.44
Rate for Payer: Devoted Health Medicare	$4.44
Rate for Payer: Hawaii Medical Service Association ABD	$3.73
Rate for Payer: Hawaii Medical Service Association ABD	$3.73
Rate for Payer: Hawaii Medical Service Association Commercial	$5.05
Rate for Payer: Hawaii Medical Service Association Commercial	$5.05
Rate for Payer: Hawaii Medical Service Association Medicare	$4.04
Rate for Payer: Hawaii Medical Service Association Medicare	$4.04
Rate for Payer: Hawaii Medical Service Association Non-ABD	$3.73
Rate for Payer: Hawaii Medical Service Association Non-ABD	$3.73
Rate for Payer: Hawaii Western Management Group Commercial	$135.09
Rate for Payer: Hawaii Western Management Group Commercial	$1,822.73
Rate for Payer: Health Management Network Commercial	$1,630.86
Rate for Payer: Health Management Network Commercial	$120.87
Rate for Payer: Humana Medicare	$4.04
Rate for Payer: Humana Medicare	$4.04
Rate for Payer: Kaiser Permanente Commercial	$89.59
Rate for Payer: Kaiser Permanente Commercial	$1,208.76
Rate for Payer: Kaiser Permanente Medicaid	$72.52
Rate for Payer: Kaiser Permanente Medicaid	$978.52
Rate for Payer: Kaiser Permanente Medicare	$4.04
Rate for Payer: Kaiser Permanente Medicare	$4.04
Rate for Payer: MDX Hawaii PPO	$137.93
Rate for Payer: MDX Hawaii PPO	$1,861.10
Rate for Payer: Ohana Health Plan Medicaid	$4.44
Rate for Payer: Ohana Health Plan Medicaid	$4.44
Rate for Payer: Ohana Health Plan Medicare	$4.04
Rate for Payer: Ohana Health Plan Medicare	$4.04
Rate for Payer: UnitedHealthcare Medicaid	$85.32
Rate for Payer: UnitedHealthcare Medicaid	$1,151.20
Rate for Payer: UnitedHealthcare Medicare	$4.04
Rate for Payer: UnitedHealthcare Medicare	$4.04
Rate for Payer: University Health Alliance Commercial	$103.65
Rate for Payer: University Health Alliance Commercial	$1,398.51

PEMETREXED DISODIUM 500 MG IV RECON.SOLN.

Facility

$551.40

Service Code	HCPCS J9305
Hospital Revenue Code	636
Min. Negotiated Rate	$3.73
Max. Negotiated Rate	$534.86
Rate for Payer: AlohaCare Medicaid	$4.04
Rate for Payer: AlohaCare Medicare	$4.04
Rate for Payer: Cash Price	$358.41
Rate for Payer: Cash Price	$358.41
Rate for Payer: Devoted Health Medicare	$4.44
Rate for Payer: Hawaii Medical Service Association ABD	$3.73
Rate for Payer: Hawaii Medical Service Association Commercial	$5.05
Rate for Payer: Hawaii Medical Service Association Medicare	$4.04
Rate for Payer: Hawaii Medical Service Association Non-ABD	$3.73
Rate for Payer: Hawaii Western Management Group Commercial	$523.83
Rate for Payer: Health Management Network Commercial	$468.69
Rate for Payer: Humana Medicare	$4.04
Rate for Payer: Kaiser Permanente Commercial	$347.38
Rate for Payer: Kaiser Permanente Medicaid	$281.21
Rate for Payer: Kaiser Permanente Medicare	$4.04
Rate for Payer: MDX Hawaii PPO	$534.86
Rate for Payer: Ohana Health Plan Medicaid	$4.44
Rate for Payer: Ohana Health Plan Medicare	$4.04
Rate for Payer: UnitedHealthcare Medicaid	$330.84
Rate for Payer: UnitedHealthcare Medicare	$4.04
Rate for Payer: University Health Alliance Commercial	$401.92

PEMETREXED DISODIUM 500 MG IV RECON.SOLN.

Facility

$551.40

Service Code	HCPCS J9305
Hospital Revenue Code	250
Min. Negotiated Rate	$468.69
Max. Negotiated Rate	$534.86
Rate for Payer: Cash Price	$358.41
Rate for Payer: Health Management Network Commercial	$468.69
Rate for Payer: MDX Hawaii PPO	$534.86

Know your out-of-pocket cost for care.

All Charges