Kona Community Hospital

All Charges

Charge

Type

Setting

Price

Restor Prevena 14 Day Pump Pre4010 [3643807]

Facility

$2,496.25

Hospital Charge Code	3643807
Hospital Revenue Code	272
Min. Negotiated Rate	$2,121.81
Max. Negotiated Rate	$2,421.36
Rate for Payer: Cash Price	$1,622.56
Rate for Payer: Health Management Network Commercial	$2,121.81
Rate for Payer: MDX Hawaii PPO	$2,421.36

Restrata 7.5cmx7.5cm Rwm1-3x3 [3643681]

Facility

$8,437.50

Service Code	HCPCS A2007
Hospital Charge Code	3643681
Hospital Revenue Code	278
Min. Negotiated Rate	$147.01
Max. Negotiated Rate	$8,184.38
Rate for Payer: AlohaCare Medicaid	$147.01
Rate for Payer: AlohaCare Medicare	$147.01
Rate for Payer: Cash Price	$5,484.38
Rate for Payer: Cash Price	$5,484.38
Rate for Payer: Devoted Health Medicare	$161.71
Rate for Payer: Hawaii Medical Service Association Commercial	$183.76
Rate for Payer: Hawaii Medical Service Association Medicare	$147.01
Rate for Payer: Hawaii Western Management Group Commercial	$5,906.25
Rate for Payer: Health Management Network Commercial	$7,171.88
Rate for Payer: Humana Medicare	$147.01
Rate for Payer: Kaiser Permanente Commercial	$5,315.62
Rate for Payer: Kaiser Permanente Medicaid	$4,303.12
Rate for Payer: Kaiser Permanente Medicare	$147.01
Rate for Payer: MDX Hawaii PPO	$8,184.38
Rate for Payer: Ohana Health Plan Medicaid	$161.71
Rate for Payer: Ohana Health Plan Medicare	$147.01
Rate for Payer: UnitedHealthcare Medicare	$147.01
Rate for Payer: University Health Alliance Commercial	$4,725.00

Restrata 7.5cmx7.5cm Rwm1-3x3 [3643681]

Facility

$8,437.50

Service Code	HCPCS A2007
Hospital Charge Code	3643681
Hospital Revenue Code	278
Min. Negotiated Rate	$4,725.00
Max. Negotiated Rate	$8,184.38
Rate for Payer: Cash Price	$5,484.38
Rate for Payer: Hawaii Western Management Group Commercial	$5,906.25
Rate for Payer: Health Management Network Commercial	$7,171.88
Rate for Payer: MDX Hawaii PPO	$8,184.38
Rate for Payer: University Health Alliance Commercial	$4,725.00

Restrata Meshed 3.8cm x 5.0cm RMESH-1.5x2 (Charge per sq/ cm = 18) [3644401]

Facility

$549.00

Service Code	HCPCS A2007
Hospital Charge Code	3644401
Hospital Revenue Code	278
Min. Negotiated Rate	$147.01
Max. Negotiated Rate	$532.53
Rate for Payer: AlohaCare Medicaid	$147.01
Rate for Payer: AlohaCare Medicare	$147.01
Rate for Payer: Cash Price	$356.85
Rate for Payer: Cash Price	$356.85
Rate for Payer: Devoted Health Medicare	$161.71
Rate for Payer: Hawaii Medical Service Association Commercial	$183.76
Rate for Payer: Hawaii Medical Service Association Medicare	$147.01
Rate for Payer: Hawaii Western Management Group Commercial	$384.30
Rate for Payer: Health Management Network Commercial	$466.65
Rate for Payer: Humana Medicare	$147.01
Rate for Payer: Kaiser Permanente Commercial	$345.87
Rate for Payer: Kaiser Permanente Medicaid	$279.99
Rate for Payer: Kaiser Permanente Medicare	$147.01
Rate for Payer: MDX Hawaii PPO	$532.53
Rate for Payer: Ohana Health Plan Medicaid	$161.71
Rate for Payer: Ohana Health Plan Medicare	$147.01
Rate for Payer: UnitedHealthcare Medicare	$147.01
Rate for Payer: University Health Alliance Commercial	$307.44

Restrata Meshed 3.8cm x 5.0cm RMESH-1.5x2 (Charge per sq/ cm = 18) [3644401]

Facility

$549.00

Service Code	HCPCS A2007
Hospital Charge Code	3644401
Hospital Revenue Code	278
Min. Negotiated Rate	$307.44
Max. Negotiated Rate	$532.53
Rate for Payer: Cash Price	$356.85
Rate for Payer: Hawaii Western Management Group Commercial	$384.30
Rate for Payer: Health Management Network Commercial	$466.65
Rate for Payer: MDX Hawaii PPO	$532.53
Rate for Payer: University Health Alliance Commercial	$307.44

Restrata Meshed 5.0cm x 5.0cm RMESH-2x2 (Charge by sq/ cm = 25) [3644400]

Facility

$791.02

Service Code	HCPCS A2007
Hospital Charge Code	3644400
Hospital Revenue Code	278
Min. Negotiated Rate	$147.01
Max. Negotiated Rate	$767.29
Rate for Payer: AlohaCare Medicaid	$147.01
Rate for Payer: AlohaCare Medicare	$147.01
Rate for Payer: Cash Price	$514.16
Rate for Payer: Cash Price	$514.16
Rate for Payer: Devoted Health Medicare	$161.71
Rate for Payer: Hawaii Medical Service Association Commercial	$183.76
Rate for Payer: Hawaii Medical Service Association Medicare	$147.01
Rate for Payer: Hawaii Western Management Group Commercial	$553.71
Rate for Payer: Health Management Network Commercial	$672.37
Rate for Payer: Humana Medicare	$147.01
Rate for Payer: Kaiser Permanente Commercial	$498.34
Rate for Payer: Kaiser Permanente Medicaid	$403.42
Rate for Payer: Kaiser Permanente Medicare	$147.01
Rate for Payer: MDX Hawaii PPO	$767.29
Rate for Payer: Ohana Health Plan Medicaid	$161.71
Rate for Payer: Ohana Health Plan Medicare	$147.01
Rate for Payer: UnitedHealthcare Medicare	$147.01
Rate for Payer: University Health Alliance Commercial	$442.97

Restrata Meshed 5.0cm x 5.0cm RMESH-2x2 (Charge by sq/ cm = 25) [3644400]

Facility

$791.02

Service Code	HCPCS A2007
Hospital Charge Code	3644400
Hospital Revenue Code	278
Min. Negotiated Rate	$442.97
Max. Negotiated Rate	$767.29
Rate for Payer: Cash Price	$514.16
Rate for Payer: Hawaii Western Management Group Commercial	$553.71
Rate for Payer: Health Management Network Commercial	$672.37
Rate for Payer: MDX Hawaii PPO	$767.29
Rate for Payer: University Health Alliance Commercial	$442.97

Restrata Minimatrix 500mg RMINI-500 (Charge per 5mg = 100) [3644402]

Facility

$207.20

Service Code	HCPCS A2026
Hospital Charge Code	3644402
Hospital Revenue Code	278
Min. Negotiated Rate	$105.67
Max. Negotiated Rate	$200.98
Rate for Payer: Cash Price	$134.68
Rate for Payer: Hawaii Western Management Group Commercial	$145.04
Rate for Payer: Health Management Network Commercial	$176.12
Rate for Payer: Kaiser Permanente Commercial	$130.54
Rate for Payer: Kaiser Permanente Medicaid	$105.67
Rate for Payer: MDX Hawaii PPO	$200.98
Rate for Payer: University Health Alliance Commercial	$116.03

Restrata Minimatrix 500mg RMINI-500 (Charge per 5mg = 100) [3644402]

Facility

$207.20

Service Code	HCPCS A2026
Hospital Charge Code	3644402
Hospital Revenue Code	278
Min. Negotiated Rate	$116.03
Max. Negotiated Rate	$200.98
Rate for Payer: Cash Price	$134.68
Rate for Payer: Hawaii Western Management Group Commercial	$145.04
Rate for Payer: Health Management Network Commercial	$176.12
Rate for Payer: MDX Hawaii PPO	$200.98
Rate for Payer: University Health Alliance Commercial	$116.03

Restrata Wound Matrix 2.5cm x 2.5cm RWM1-1x1 (Charge by sq/ cm = 6.25) [3644399]

Facility

$962.38

Service Code	HCPCS A2007
Hospital Charge Code	3644399
Hospital Revenue Code	278
Min. Negotiated Rate	$538.93
Max. Negotiated Rate	$933.51
Rate for Payer: Cash Price	$625.55
Rate for Payer: Hawaii Western Management Group Commercial	$673.67
Rate for Payer: Health Management Network Commercial	$818.02
Rate for Payer: MDX Hawaii PPO	$933.51
Rate for Payer: University Health Alliance Commercial	$538.93

Restrata Wound Matrix 2.5cm x 2.5cm RWM1-1x1 (Charge by sq/ cm = 6.25) [3644399]

Facility

$962.38

Service Code	HCPCS A2007
Hospital Charge Code	3644399
Hospital Revenue Code	278
Min. Negotiated Rate	$147.01
Max. Negotiated Rate	$933.51
Rate for Payer: AlohaCare Medicaid	$147.01
Rate for Payer: AlohaCare Medicare	$147.01
Rate for Payer: Cash Price	$625.55
Rate for Payer: Cash Price	$625.55
Rate for Payer: Devoted Health Medicare	$161.71
Rate for Payer: Hawaii Medical Service Association Commercial	$183.76
Rate for Payer: Hawaii Medical Service Association Medicare	$147.01
Rate for Payer: Hawaii Western Management Group Commercial	$673.67
Rate for Payer: Health Management Network Commercial	$818.02
Rate for Payer: Humana Medicare	$147.01
Rate for Payer: Kaiser Permanente Commercial	$606.30
Rate for Payer: Kaiser Permanente Medicaid	$490.81
Rate for Payer: Kaiser Permanente Medicare	$147.01
Rate for Payer: MDX Hawaii PPO	$933.51
Rate for Payer: Ohana Health Plan Medicaid	$161.71
Rate for Payer: Ohana Health Plan Medicare	$147.01
Rate for Payer: UnitedHealthcare Medicare	$147.01
Rate for Payer: University Health Alliance Commercial	$538.93

Restroation Insert 48g Liner 7236-2-854 [3645565]

Facility

$7,122.60

Service Code	HCPCS C1776
Hospital Charge Code	3645565
Hospital Revenue Code	278
Min. Negotiated Rate	$3,632.53
Max. Negotiated Rate	$6,908.92
Rate for Payer: Cash Price	$4,629.69
Rate for Payer: Hawaii Western Management Group Commercial	$4,985.82
Rate for Payer: Health Management Network Commercial	$6,054.21
Rate for Payer: Kaiser Permanente Commercial	$4,487.24
Rate for Payer: Kaiser Permanente Medicaid	$3,632.53
Rate for Payer: MDX Hawaii PPO	$6,908.92
Rate for Payer: University Health Alliance Commercial	$3,988.66

Restroation Insert 48g Liner 7236-2-854 [3645565]

Facility

$7,122.60

Service Code	HCPCS C1776
Hospital Charge Code	3645565
Hospital Revenue Code	278
Min. Negotiated Rate	$3,988.66
Max. Negotiated Rate	$6,908.92
Rate for Payer: Cash Price	$4,629.69
Rate for Payer: Hawaii Western Management Group Commercial	$4,985.82
Rate for Payer: Health Management Network Commercial	$6,054.21
Rate for Payer: MDX Hawaii PPO	$6,908.92
Rate for Payer: University Health Alliance Commercial	$3,988.66

RETICULOENDOTHELIAL AND IMMUNITY DISORDERS WITH CC

Facility

$17,491.50

Service Code	MSDRG 815
Min. Negotiated Rate	$13,336.89
Max. Negotiated Rate	$17,491.50
Rate for Payer: AlohaCare Medicare	$13,336.89
Rate for Payer: Devoted Health Medicare	$14,670.58
Rate for Payer: Hawaii Medical Service Association Commercial	$16,248.12
Rate for Payer: Hawaii Medical Service Association Medicare	$13,336.89
Rate for Payer: Humana Medicare	$13,336.89
Rate for Payer: Kaiser Permanente Commercial	$17,491.50
Rate for Payer: Kaiser Permanente Medicare	$13,336.89
Rate for Payer: Ohana Health Plan Medicare	$13,336.89
Rate for Payer: UnitedHealthcare Medicare	$13,336.89

RETICULOENDOTHELIAL AND IMMUNITY DISORDERS WITH MCC

Facility

$36,685.57

Service Code	MSDRG 814
Min. Negotiated Rate	$16,248.12
Max. Negotiated Rate	$36,685.57
Rate for Payer: AlohaCare Medicare	$27,971.99
Rate for Payer: Devoted Health Medicare	$30,769.19
Rate for Payer: Hawaii Medical Service Association Commercial	$16,248.12
Rate for Payer: Hawaii Medical Service Association Medicare	$27,971.99
Rate for Payer: Humana Medicare	$27,971.99
Rate for Payer: Kaiser Permanente Commercial	$36,685.57
Rate for Payer: Kaiser Permanente Medicare	$27,971.99
Rate for Payer: Ohana Health Plan Medicare	$27,971.99
Rate for Payer: UnitedHealthcare Medicare	$27,971.99

RETICULOENDOTHELIAL AND IMMUNITY DISORDERS WITHOUT CC/MCC

Facility

$11,884.75

Service Code	MSDRG 816
Min. Negotiated Rate	$8,312.55
Max. Negotiated Rate	$11,884.75
Rate for Payer: AlohaCare Medicare	$8,312.55
Rate for Payer: Devoted Health Medicare	$9,143.81
Rate for Payer: Hawaii Medical Service Association Commercial	$11,884.75
Rate for Payer: Hawaii Medical Service Association Medicare	$8,312.55
Rate for Payer: Humana Medicare	$8,312.55
Rate for Payer: Kaiser Permanente Commercial	$10,902.00
Rate for Payer: Kaiser Permanente Medicare	$8,312.55
Rate for Payer: Ohana Health Plan Medicare	$8,312.55
Rate for Payer: UnitedHealthcare Medicare	$8,312.55

Retractor Alexis O Ring Wound 9-14cm G6303 [3603181]

Facility

$520.25

Hospital Charge Code	3603181
Hospital Revenue Code	272
Min. Negotiated Rate	$442.21
Max. Negotiated Rate	$504.64
Rate for Payer: Cash Price	$338.16
Rate for Payer: Health Management Network Commercial	$442.21
Rate for Payer: MDX Hawaii PPO	$504.64

Retractor Alexis O Ring Wound 9-14cm G6303 [3603181]

Facility

$520.25

Hospital Charge Code	3603181
Hospital Revenue Code	272
Min. Negotiated Rate	$265.33
Max. Negotiated Rate	$504.64
Rate for Payer: Cash Price	$338.16
Rate for Payer: Hawaii Western Management Group Commercial	$494.24
Rate for Payer: Health Management Network Commercial	$442.21
Rate for Payer: Kaiser Permanente Commercial	$327.76
Rate for Payer: Kaiser Permanente Medicaid	$265.33
Rate for Payer: MDX Hawaii PPO	$504.64
Rate for Payer: University Health Alliance Commercial	$379.21

Retractor Alexis Wound 2-4cm C8312 [3625290]

Facility

$399.50

Hospital Charge Code	3625290
Hospital Revenue Code	272
Min. Negotiated Rate	$339.57
Max. Negotiated Rate	$387.51
Rate for Payer: Cash Price	$259.68
Rate for Payer: Health Management Network Commercial	$339.57
Rate for Payer: MDX Hawaii PPO	$387.51

Retractor Alexis Wound 2-4cm C8312 [3625290]

Facility

$399.50

Hospital Charge Code	3625290
Hospital Revenue Code	272
Min. Negotiated Rate	$203.75
Max. Negotiated Rate	$387.51
Rate for Payer: Cash Price	$259.68
Rate for Payer: Hawaii Western Management Group Commercial	$379.52
Rate for Payer: Health Management Network Commercial	$339.57
Rate for Payer: Kaiser Permanente Commercial	$251.69
Rate for Payer: Kaiser Permanente Medicaid	$203.75
Rate for Payer: MDX Hawaii PPO	$387.51
Rate for Payer: University Health Alliance Commercial	$291.20

Retractor Alexis Wound 5-9cm C8302/C8402 [3640111]

Facility

$388.00

Hospital Charge Code	3640111
Hospital Revenue Code	272
Min. Negotiated Rate	$197.88
Max. Negotiated Rate	$376.36
Rate for Payer: Cash Price	$252.20
Rate for Payer: Hawaii Western Management Group Commercial	$368.60
Rate for Payer: Health Management Network Commercial	$329.80
Rate for Payer: Kaiser Permanente Commercial	$244.44
Rate for Payer: Kaiser Permanente Medicaid	$197.88
Rate for Payer: MDX Hawaii PPO	$376.36
Rate for Payer: University Health Alliance Commercial	$282.81

Retractor Alexis Wound 5-9cm C8302/C8402 [3640111]

Facility

$388.00

Hospital Charge Code	3640111
Hospital Revenue Code	272
Min. Negotiated Rate	$329.80
Max. Negotiated Rate	$376.36
Rate for Payer: Cash Price	$252.20
Rate for Payer: Health Management Network Commercial	$329.80
Rate for Payer: MDX Hawaii PPO	$376.36

Retractor Wound Med Surgisleeve 5-9cm WPMD509 [3640601]

Facility

$229.76

Hospital Charge Code	3640601
Hospital Revenue Code	272
Min. Negotiated Rate	$117.18
Max. Negotiated Rate	$222.87
Rate for Payer: Cash Price	$149.34
Rate for Payer: Hawaii Western Management Group Commercial	$218.27
Rate for Payer: Health Management Network Commercial	$195.30
Rate for Payer: Kaiser Permanente Commercial	$144.75
Rate for Payer: Kaiser Permanente Medicaid	$117.18
Rate for Payer: MDX Hawaii PPO	$222.87
Rate for Payer: University Health Alliance Commercial	$167.47

Retractor Wound Med Surgisleeve 5-9cm WPMD509 [3640601]

Facility

$229.76

Hospital Charge Code	3640601
Hospital Revenue Code	272
Min. Negotiated Rate	$195.30
Max. Negotiated Rate	$222.87
Rate for Payer: Cash Price	$149.34
Rate for Payer: Health Management Network Commercial	$195.30
Rate for Payer: MDX Hawaii PPO	$222.87

Retractor Wound XSM Surgisleeve 2-4cm WPXSM24 [3640470]

Facility

$415.26

Hospital Charge Code	3640470
Hospital Revenue Code	272
Min. Negotiated Rate	$352.97
Max. Negotiated Rate	$402.80
Rate for Payer: Cash Price	$269.92
Rate for Payer: Health Management Network Commercial	$352.97
Rate for Payer: MDX Hawaii PPO	$402.80

Know your out-of-pocket cost for care.

All Charges