Kona Community Hospital

All Charges

Charge

Type

Setting

Price

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

Facility

$415.26

Hospital Charge Code	3640470
Hospital Revenue Code	272
Min. Negotiated Rate	$211.78
Max. Negotiated Rate	$402.80
Rate for Payer: Cash Price	$269.92
Rate for Payer: Hawaii Western Management Group Commercial	$394.50
Rate for Payer: Health Management Network Commercial	$352.97
Rate for Payer: Kaiser Permanente Commercial	$261.61
Rate for Payer: Kaiser Permanente Medicaid	$211.78
Rate for Payer: MDX Hawaii PPO	$402.80
Rate for Payer: University Health Alliance Commercial	$302.68

Reverse Shoulder Retentive Poly Liner +0 LNR-0960-00R [3644284]

Facility

$10,323.00

Service Code	HCPCS C1776
Hospital Charge Code	3644284
Hospital Revenue Code	278
Min. Negotiated Rate	$5,264.73
Max. Negotiated Rate	$10,013.31
Rate for Payer: Cash Price	$6,709.95
Rate for Payer: Hawaii Western Management Group Commercial	$7,226.10
Rate for Payer: Health Management Network Commercial	$8,774.55
Rate for Payer: Kaiser Permanente Commercial	$6,503.49
Rate for Payer: Kaiser Permanente Medicaid	$5,264.73
Rate for Payer: MDX Hawaii PPO	$10,013.31
Rate for Payer: University Health Alliance Commercial	$5,780.88

Reverse Shoulder Retentive Poly Liner +0 LNR-0960-00R [3644284]

Facility

$10,323.00

Service Code	HCPCS C1776
Hospital Charge Code	3644284
Hospital Revenue Code	278
Min. Negotiated Rate	$5,780.88
Max. Negotiated Rate	$10,013.31
Rate for Payer: Cash Price	$6,709.95
Rate for Payer: Hawaii Western Management Group Commercial	$7,226.10
Rate for Payer: Health Management Network Commercial	$8,774.55
Rate for Payer: MDX Hawaii PPO	$10,013.31
Rate for Payer: University Health Alliance Commercial	$5,780.88

Revers Shoulder 36mm CA Humeral Head Adapter AR-9502-36ARCA [3644285]

Facility

$14,047.00

Service Code	HCPCS C1776
Hospital Charge Code	3644285
Hospital Revenue Code	278
Min. Negotiated Rate	$7,163.97
Max. Negotiated Rate	$13,625.59
Rate for Payer: Cash Price	$9,130.55
Rate for Payer: Hawaii Western Management Group Commercial	$9,832.90
Rate for Payer: Health Management Network Commercial	$11,939.95
Rate for Payer: Kaiser Permanente Commercial	$8,849.61
Rate for Payer: Kaiser Permanente Medicaid	$7,163.97
Rate for Payer: MDX Hawaii PPO	$13,625.59
Rate for Payer: University Health Alliance Commercial	$7,866.32

Revers Shoulder 36mm CA Humeral Head Adapter AR-9502-36ARCA [3644285]

Facility

$14,047.00

Service Code	HCPCS C1776
Hospital Charge Code	3644285
Hospital Revenue Code	278
Min. Negotiated Rate	$7,866.32
Max. Negotiated Rate	$13,625.59
Rate for Payer: Cash Price	$9,130.55
Rate for Payer: Hawaii Western Management Group Commercial	$9,832.90
Rate for Payer: Health Management Network Commercial	$11,939.95
Rate for Payer: MDX Hawaii PPO	$13,625.59
Rate for Payer: University Health Alliance Commercial	$7,866.32

Revers Shoulder CA Humeral Head 50/19 AR-9550-19RCA [3644286]

Facility

$15,212.50

Service Code	HCPCS C1776
Hospital Charge Code	3644286
Hospital Revenue Code	278
Min. Negotiated Rate	$7,758.38
Max. Negotiated Rate	$14,756.12
Rate for Payer: Cash Price	$9,888.12
Rate for Payer: Hawaii Western Management Group Commercial	$10,648.75
Rate for Payer: Health Management Network Commercial	$12,930.62
Rate for Payer: Kaiser Permanente Commercial	$9,583.88
Rate for Payer: Kaiser Permanente Medicaid	$7,758.38
Rate for Payer: MDX Hawaii PPO	$14,756.12
Rate for Payer: University Health Alliance Commercial	$8,519.00

Revers Shoulder CA Humeral Head 50/19 AR-9550-19RCA [3644286]

Facility

$15,212.50

Service Code	HCPCS C1776
Hospital Charge Code	3644286
Hospital Revenue Code	278
Min. Negotiated Rate	$8,519.00
Max. Negotiated Rate	$14,756.12
Rate for Payer: Cash Price	$9,888.12
Rate for Payer: Hawaii Western Management Group Commercial	$10,648.75
Rate for Payer: Health Management Network Commercial	$12,930.62
Rate for Payer: MDX Hawaii PPO	$14,756.12
Rate for Payer: University Health Alliance Commercial	$8,519.00

REVISION OF HIP OR KNEE REPLACEMENT WITH CC

Facility

$60,833.85

Service Code	MSDRG 467
Min. Negotiated Rate	$46,384.54
Max. Negotiated Rate	$60,833.85
Rate for Payer: AlohaCare Medicare	$46,384.54
Rate for Payer: Devoted Health Medicare	$51,022.99
Rate for Payer: Hawaii Medical Service Association Commercial	$57,543.41
Rate for Payer: Hawaii Medical Service Association Medicare	$46,384.54
Rate for Payer: Humana Medicare	$46,384.54
Rate for Payer: Kaiser Permanente Commercial	$60,833.85
Rate for Payer: Kaiser Permanente Medicare	$46,384.54
Rate for Payer: Ohana Health Plan Medicare	$46,384.54
Rate for Payer: UnitedHealthcare Medicare	$46,384.54

REVISION OF HIP OR KNEE REPLACEMENT WITH MCC

Facility

$89,793.15

Service Code	MSDRG 466
Min. Negotiated Rate	$57,543.41
Max. Negotiated Rate	$89,793.15
Rate for Payer: AlohaCare Medicare	$68,465.41
Rate for Payer: Devoted Health Medicare	$75,311.95
Rate for Payer: Hawaii Medical Service Association Commercial	$57,543.41
Rate for Payer: Hawaii Medical Service Association Medicare	$68,465.41
Rate for Payer: Humana Medicare	$68,465.41
Rate for Payer: Kaiser Permanente Commercial	$89,793.15
Rate for Payer: Kaiser Permanente Medicare	$68,465.41
Rate for Payer: Ohana Health Plan Medicare	$68,465.41
Rate for Payer: UnitedHealthcare Medicare	$68,465.41

REVISION OF HIP OR KNEE REPLACEMENT WITHOUT CC/MCC

Facility

$57,543.41

Service Code	MSDRG 468
Min. Negotiated Rate	$36,143.81
Max. Negotiated Rate	$57,543.41
Rate for Payer: AlohaCare Medicare	$36,143.81
Rate for Payer: Devoted Health Medicare	$39,758.19
Rate for Payer: Hawaii Medical Service Association Commercial	$57,543.41
Rate for Payer: Hawaii Medical Service Association Medicare	$36,143.81
Rate for Payer: Humana Medicare	$36,143.81
Rate for Payer: Kaiser Permanente Commercial	$47,403.00
Rate for Payer: Kaiser Permanente Medicare	$36,143.81
Rate for Payer: Ohana Health Plan Medicare	$36,143.81
Rate for Payer: UnitedHealthcare Medicare	$36,143.81

REVISION OF TOTAL HIP ARTHROPLASTY; BOTH COMPONENTS, WITH OR WITHOUT AUTOGRAFT OR ALLOGRAFT

Facility

$18,023.00

Service Code	CPT 27134
Hospital Revenue Code	360
Min. Negotiated Rate	$644.55
Max. Negotiated Rate	$18,023.00
Rate for Payer: AlohaCare Medicaid	$15,166.91
Rate for Payer: AlohaCare Medicare	$15,166.91
Rate for Payer: Devoted Health Medicare	$16,683.60
Rate for Payer: Hawaii Medical Service Association ABD	$2,102.00
Rate for Payer: Hawaii Medical Service Association Commercial	$18,023.00
Rate for Payer: Hawaii Medical Service Association Medicare	$15,166.91
Rate for Payer: Hawaii Medical Service Association Non-ABD	$2,102.18
Rate for Payer: Humana Medicare	$15,166.91
Rate for Payer: Kaiser Permanente Medicaid	$2,837.00
Rate for Payer: Kaiser Permanente Medicare	$15,166.91
Rate for Payer: Ohana Health Plan Medicaid	$16,683.60
Rate for Payer: Ohana Health Plan Medicare	$15,166.91
Rate for Payer: UnitedHealthcare Medicaid	$644.55
Rate for Payer: UnitedHealthcare Medicare	$15,166.91

REVISION OF TOTAL KNEE ARTHROPLASTY, WITH OR WITHOUT ALLOGRAFT; FEMORAL AND ENTIRE TIBIAL COMPONENT

Facility

$24,500.00

Service Code	CPT 27487
Hospital Revenue Code	360
Min. Negotiated Rate	$644.55
Max. Negotiated Rate	$24,500.00
Rate for Payer: AlohaCare Medicaid	$20,713.48
Rate for Payer: AlohaCare Medicare	$20,713.48
Rate for Payer: Devoted Health Medicare	$22,784.83
Rate for Payer: Hawaii Medical Service Association ABD	$1,900.00
Rate for Payer: Hawaii Medical Service Association Commercial	$17,484.00
Rate for Payer: Hawaii Medical Service Association Medicare	$20,713.48
Rate for Payer: Hawaii Medical Service Association Non-ABD	$1,902.37
Rate for Payer: Humana Medicare	$20,713.48
Rate for Payer: Kaiser Permanente Medicaid	$2,837.00
Rate for Payer: Kaiser Permanente Medicare	$20,713.48
Rate for Payer: Ohana Health Plan Medicaid	$22,784.83
Rate for Payer: Ohana Health Plan Medicare	$20,713.48
Rate for Payer: UnitedHealthcare Medicaid	$644.55
Rate for Payer: UnitedHealthcare Medicare	$20,713.48
Rate for Payer: University Health Alliance Commercial	$24,500.00

REVISION OF TOTAL SHOULDER ARTHROPLASTY, INCLUDING ALLOGRAFT WHEN PERFORMED; HUMERAL AND GLENOID COMPONENT

Facility

$18,023.00

Service Code	CPT 23474
Hospital Revenue Code	360
Min. Negotiated Rate	$521.33
Max. Negotiated Rate	$18,023.00
Rate for Payer: AlohaCare Medicaid	$15,166.91
Rate for Payer: AlohaCare Medicare	$15,166.91
Rate for Payer: Devoted Health Medicare	$16,683.60
Rate for Payer: Hawaii Medical Service Association ABD	$2,102.00
Rate for Payer: Hawaii Medical Service Association Commercial	$18,023.00
Rate for Payer: Hawaii Medical Service Association Medicare	$15,166.91
Rate for Payer: Hawaii Medical Service Association Non-ABD	$2,102.18
Rate for Payer: Humana Medicare	$15,166.91
Rate for Payer: Kaiser Permanente Medicaid	$2,837.00
Rate for Payer: Kaiser Permanente Medicare	$15,166.91
Rate for Payer: Ohana Health Plan Medicaid	$16,683.60
Rate for Payer: Ohana Health Plan Medicare	$15,166.91
Rate for Payer: UnitedHealthcare Medicaid	$521.33
Rate for Payer: UnitedHealthcare Medicare	$15,166.91

REVISION OF TOTAL SHOULDER ARTHROPLASTY, INCLUDING ALLOGRAFT WHEN PERFORMED; HUMERAL AND GLENOID COMPONENT

Facility

$18,023.00

Service Code	CPT 23474
Hospital Revenue Code	361
Min. Negotiated Rate	$521.33
Max. Negotiated Rate	$18,023.00
Rate for Payer: AlohaCare Medicaid	$15,166.91
Rate for Payer: AlohaCare Medicare	$15,166.91
Rate for Payer: Devoted Health Medicare	$16,683.60
Rate for Payer: Hawaii Medical Service Association ABD	$2,102.00
Rate for Payer: Hawaii Medical Service Association Commercial	$18,023.00
Rate for Payer: Hawaii Medical Service Association Medicare	$15,166.91
Rate for Payer: Hawaii Medical Service Association Non-ABD	$2,102.18
Rate for Payer: Humana Medicare	$15,166.91
Rate for Payer: Kaiser Permanente Medicaid	$2,837.00
Rate for Payer: Kaiser Permanente Medicare	$15,166.91
Rate for Payer: Ohana Health Plan Medicaid	$16,683.60
Rate for Payer: Ohana Health Plan Medicare	$15,166.91
Rate for Payer: UnitedHealthcare Medicaid	$521.33
Rate for Payer: UnitedHealthcare Medicare	$15,166.91

REVISION, OPEN, ARTERIOVENOUS FISTULA; WITHOUT THROMBECTOMY, AUTOGENOUS OR NONAUTOGENOUS DIALYSIS GRAFT (SEPARATE PROCEDURE)

Facility

$14,715.00

Service Code	CPT 36832
Hospital Revenue Code	360
Min. Negotiated Rate	$521.33
Max. Negotiated Rate	$14,715.00
Rate for Payer: AlohaCare Medicaid	$6,573.58
Rate for Payer: AlohaCare Medicare	$6,573.58
Rate for Payer: Devoted Health Medicare	$7,230.94
Rate for Payer: Hawaii Medical Service Association ABD	$1,149.00
Rate for Payer: Hawaii Medical Service Association Commercial	$14,715.00
Rate for Payer: Hawaii Medical Service Association Medicare	$6,573.58
Rate for Payer: Hawaii Medical Service Association Non-ABD	$1,154.45
Rate for Payer: Humana Medicare	$6,573.58
Rate for Payer: Kaiser Permanente Medicaid	$2,837.00
Rate for Payer: Kaiser Permanente Medicare	$6,573.58
Rate for Payer: Ohana Health Plan Medicaid	$7,230.94
Rate for Payer: Ohana Health Plan Medicare	$6,573.58
Rate for Payer: UnitedHealthcare Medicaid	$521.33
Rate for Payer: UnitedHealthcare Medicare	$6,573.58
Rate for Payer: University Health Alliance Commercial	$10,679.55

REVISION, OPEN, ARTERIOVENOUS FISTULA; WITH THROMBECTOMY, AUTOGENOUS OR NONAUTOGENOUS DIALYSIS GRAFT (SEPARATE PROCEDURE)

Facility

$10,679.55

Service Code	CPT 36833
Hospital Revenue Code	360
Min. Negotiated Rate	$521.33
Max. Negotiated Rate	$10,679.55
Rate for Payer: AlohaCare Medicaid	$6,573.58
Rate for Payer: AlohaCare Medicare	$6,573.58
Rate for Payer: Devoted Health Medicare	$7,230.94
Rate for Payer: Hawaii Medical Service Association ABD	$848.00
Rate for Payer: Hawaii Medical Service Association Commercial	$9,416.00
Rate for Payer: Hawaii Medical Service Association Medicare	$6,573.58
Rate for Payer: Hawaii Medical Service Association Non-ABD	$849.21
Rate for Payer: Humana Medicare	$6,573.58
Rate for Payer: Kaiser Permanente Medicaid	$2,837.00
Rate for Payer: Kaiser Permanente Medicare	$6,573.58
Rate for Payer: Ohana Health Plan Medicaid	$7,230.94
Rate for Payer: Ohana Health Plan Medicare	$6,573.58
Rate for Payer: UnitedHealthcare Medicaid	$521.33
Rate for Payer: UnitedHealthcare Medicare	$6,573.58
Rate for Payer: University Health Alliance Commercial	$10,679.55

RIFAMPIN 150 MG PO CAP

Facility

$17.90

Service Code	HCPCS A9270
Hospital Revenue Code	250
Min. Negotiated Rate	$15.21
Max. Negotiated Rate	$17.36
Rate for Payer: Cash Price	$11.64
Rate for Payer: Cash Price	$13.72
Rate for Payer: Health Management Network Commercial	$17.93
Rate for Payer: Health Management Network Commercial	$15.21
Rate for Payer: MDX Hawaii PPO	$17.36
Rate for Payer: MDX Hawaii PPO	$20.47

RIFAMPIN 150 MG PO CAP

Facility

$21.10

Service Code	HCPCS A9270
Hospital Revenue Code	250
Min. Negotiated Rate	$10.76
Max. Negotiated Rate	$20.47
Rate for Payer: Cash Price	$13.72
Rate for Payer: Cash Price	$11.64
Rate for Payer: Hawaii Western Management Group Commercial	$20.05
Rate for Payer: Hawaii Western Management Group Commercial	$17.00
Rate for Payer: Health Management Network Commercial	$17.93
Rate for Payer: Health Management Network Commercial	$15.21
Rate for Payer: Kaiser Permanente Commercial	$11.28
Rate for Payer: Kaiser Permanente Commercial	$13.29
Rate for Payer: Kaiser Permanente Medicaid	$10.76
Rate for Payer: Kaiser Permanente Medicaid	$9.13
Rate for Payer: MDX Hawaii PPO	$20.47
Rate for Payer: MDX Hawaii PPO	$17.36
Rate for Payer: UnitedHealthcare Medicaid	$10.74
Rate for Payer: UnitedHealthcare Medicaid	$12.66
Rate for Payer: University Health Alliance Commercial	$15.38
Rate for Payer: University Health Alliance Commercial	$13.05

RIFAMPIN 300 MG PO CAP

Facility

$12.33

Service Code	HCPCS A9270
Hospital Revenue Code	250
Min. Negotiated Rate	$10.48
Max. Negotiated Rate	$11.96
Rate for Payer: Cash Price	$8.01
Rate for Payer: Health Management Network Commercial	$10.48
Rate for Payer: MDX Hawaii PPO	$11.96

RIFAMPIN 300 MG PO CAP

Facility

$12.33

Service Code	HCPCS A9270
Hospital Revenue Code	250
Min. Negotiated Rate	$6.29
Max. Negotiated Rate	$11.96
Rate for Payer: Cash Price	$8.01
Rate for Payer: Hawaii Western Management Group Commercial	$11.71
Rate for Payer: Health Management Network Commercial	$10.48
Rate for Payer: Kaiser Permanente Commercial	$7.77
Rate for Payer: Kaiser Permanente Medicaid	$6.29
Rate for Payer: MDX Hawaii PPO	$11.96
Rate for Payer: UnitedHealthcare Medicaid	$7.40
Rate for Payer: University Health Alliance Commercial	$8.99

RIFAMPIN 600 MG IV RECON.SOLN.

Facility

$610.70

Service Code	HCPCS J2804
Hospital Revenue Code	636
Min. Negotiated Rate	$0.16
Max. Negotiated Rate	$592.38
Rate for Payer: Cash Price	$396.96
Rate for Payer: Cash Price	$396.96
Rate for Payer: Hawaii Medical Service Association ABD	$0.16
Rate for Payer: Hawaii Medical Service Association Non-ABD	$0.16
Rate for Payer: Hawaii Western Management Group Commercial	$580.16
Rate for Payer: Health Management Network Commercial	$519.10
Rate for Payer: Kaiser Permanente Commercial	$384.74
Rate for Payer: Kaiser Permanente Medicaid	$311.46
Rate for Payer: MDX Hawaii PPO	$592.38
Rate for Payer: UnitedHealthcare Medicaid	$366.42
Rate for Payer: University Health Alliance Commercial	$445.14

RIFAMPIN 600 MG IV RECON.SOLN.

Facility

$610.70

Service Code	HCPCS J2804
Hospital Revenue Code	250
Min. Negotiated Rate	$519.10
Max. Negotiated Rate	$592.38
Rate for Payer: Cash Price	$396.96
Rate for Payer: Health Management Network Commercial	$519.10
Rate for Payer: MDX Hawaii PPO	$592.38

RISPERIDONE 0.25 MG PO TABLET

Facility

$21.54

Service Code	HCPCS A9270
Hospital Revenue Code	250
Min. Negotiated Rate	$10.99
Max. Negotiated Rate	$20.89
Rate for Payer: Cash Price	$14.00
Rate for Payer: Hawaii Western Management Group Commercial	$20.46
Rate for Payer: Health Management Network Commercial	$18.31
Rate for Payer: Kaiser Permanente Commercial	$13.57
Rate for Payer: Kaiser Permanente Medicaid	$10.99
Rate for Payer: MDX Hawaii PPO	$20.89
Rate for Payer: UnitedHealthcare Medicaid	$12.92
Rate for Payer: University Health Alliance Commercial	$15.70

RISPERIDONE 0.25 MG PO TABLET

Facility

$21.54

Service Code	HCPCS A9270
Hospital Revenue Code	250
Min. Negotiated Rate	$18.31
Max. Negotiated Rate	$20.89
Rate for Payer: Cash Price	$14.00
Rate for Payer: Health Management Network Commercial	$18.31
Rate for Payer: MDX Hawaii PPO	$20.89

RISPERIDONE 0.5 MG PO RAPID DISSOLVING TAB

Facility

$27.14

Service Code	HCPCS A9270
Hospital Revenue Code	250
Min. Negotiated Rate	$13.84
Max. Negotiated Rate	$26.33
Rate for Payer: Cash Price	$17.64
Rate for Payer: Hawaii Western Management Group Commercial	$25.78
Rate for Payer: Health Management Network Commercial	$23.07
Rate for Payer: Kaiser Permanente Commercial	$17.10
Rate for Payer: Kaiser Permanente Medicaid	$13.84
Rate for Payer: MDX Hawaii PPO	$26.33
Rate for Payer: UnitedHealthcare Medicaid	$16.28
Rate for Payer: University Health Alliance Commercial	$19.78

Know your out-of-pocket cost for care.

All Charges