Kona Community Hospital

All Charges

Charge

Type

Setting

Price

Screw Canc 4.0mm x 20mm 206.020 [3606558]

Facility

$184.64

Service Code	HCPCS C1713
Hospital Charge Code	3606558
Hospital Revenue Code	278
Min. Negotiated Rate	$103.40
Max. Negotiated Rate	$179.10
Rate for Payer: Cash Price	$120.02
Rate for Payer: Hawaii Western Management Group Commercial	$129.25
Rate for Payer: Health Management Network Commercial	$156.94
Rate for Payer: MDX Hawaii PPO	$179.10
Rate for Payer: University Health Alliance Commercial	$103.40

Screw Canc 4.0mm x 20mm 206.020 [3606558]

Facility

$184.64

Service Code	HCPCS C1713
Hospital Charge Code	3606558
Hospital Revenue Code	278
Min. Negotiated Rate	$94.17
Max. Negotiated Rate	$179.10
Rate for Payer: Cash Price	$120.02
Rate for Payer: Hawaii Western Management Group Commercial	$129.25
Rate for Payer: Health Management Network Commercial	$156.94
Rate for Payer: Kaiser Permanente Commercial	$116.32
Rate for Payer: Kaiser Permanente Medicaid	$94.17
Rate for Payer: MDX Hawaii PPO	$179.10
Rate for Payer: University Health Alliance Commercial	$103.40

Screw Canc 4.0mm x 22mm 206.022 [3606559]

Facility

$184.64

Service Code	HCPCS C1713
Hospital Charge Code	3606559
Hospital Revenue Code	278
Min. Negotiated Rate	$94.17
Max. Negotiated Rate	$179.10
Rate for Payer: Cash Price	$120.02
Rate for Payer: Hawaii Western Management Group Commercial	$129.25
Rate for Payer: Health Management Network Commercial	$156.94
Rate for Payer: Kaiser Permanente Commercial	$116.32
Rate for Payer: Kaiser Permanente Medicaid	$94.17
Rate for Payer: MDX Hawaii PPO	$179.10
Rate for Payer: University Health Alliance Commercial	$103.40

Screw Canc 4.0mm x 22mm 206.022 [3606559]

Facility

$184.64

Service Code	HCPCS C1713
Hospital Charge Code	3606559
Hospital Revenue Code	278
Min. Negotiated Rate	$103.40
Max. Negotiated Rate	$179.10
Rate for Payer: Cash Price	$120.02
Rate for Payer: Hawaii Western Management Group Commercial	$129.25
Rate for Payer: Health Management Network Commercial	$156.94
Rate for Payer: MDX Hawaii PPO	$179.10
Rate for Payer: University Health Alliance Commercial	$103.40

Screw Canc 4.0mm x 55mm 206.055 [3606568]

Facility

$211.80

Service Code	HCPCS C1713
Hospital Charge Code	3606568
Hospital Revenue Code	278
Min. Negotiated Rate	$108.02
Max. Negotiated Rate	$205.45
Rate for Payer: Cash Price	$137.67
Rate for Payer: Hawaii Western Management Group Commercial	$148.26
Rate for Payer: Health Management Network Commercial	$180.03
Rate for Payer: Kaiser Permanente Commercial	$133.43
Rate for Payer: Kaiser Permanente Medicaid	$108.02
Rate for Payer: MDX Hawaii PPO	$205.45
Rate for Payer: University Health Alliance Commercial	$118.61

Screw Canc 4.0mm x 55mm 206.055 [3606568]

Facility

$211.80

Service Code	HCPCS C1713
Hospital Charge Code	3606568
Hospital Revenue Code	278
Min. Negotiated Rate	$118.61
Max. Negotiated Rate	$205.45
Rate for Payer: Cash Price	$137.67
Rate for Payer: Hawaii Western Management Group Commercial	$148.26
Rate for Payer: Health Management Network Commercial	$180.03
Rate for Payer: MDX Hawaii PPO	$205.45
Rate for Payer: University Health Alliance Commercial	$118.61

Screw Canc 4.0mmx60mm 206.060 [3606569]

Facility

$154.56

Service Code	HCPCS C1713
Hospital Charge Code	3606569
Hospital Revenue Code	278
Min. Negotiated Rate	$86.55
Max. Negotiated Rate	$149.92
Rate for Payer: Cash Price	$100.46
Rate for Payer: Hawaii Western Management Group Commercial	$108.19
Rate for Payer: Health Management Network Commercial	$131.38
Rate for Payer: MDX Hawaii PPO	$149.92
Rate for Payer: University Health Alliance Commercial	$86.55

Screw Canc 4.0mmx60mm 206.060 [3606569]

Facility

$154.56

Service Code	HCPCS C1713
Hospital Charge Code	3606569
Hospital Revenue Code	278
Min. Negotiated Rate	$78.83
Max. Negotiated Rate	$149.92
Rate for Payer: Cash Price	$100.46
Rate for Payer: Hawaii Western Management Group Commercial	$108.19
Rate for Payer: Health Management Network Commercial	$131.38
Rate for Payer: Kaiser Permanente Commercial	$97.37
Rate for Payer: Kaiser Permanente Medicaid	$78.83
Rate for Payer: MDX Hawaii PPO	$149.92
Rate for Payer: University Health Alliance Commercial	$86.55

Screw Canc 4.0x45mm 206.045 [3606566]

Facility

$184.64

Service Code	HCPCS C1713
Hospital Charge Code	3606566
Hospital Revenue Code	278
Min. Negotiated Rate	$103.40
Max. Negotiated Rate	$179.10
Rate for Payer: Cash Price	$120.02
Rate for Payer: Hawaii Western Management Group Commercial	$129.25
Rate for Payer: Health Management Network Commercial	$156.94
Rate for Payer: MDX Hawaii PPO	$179.10
Rate for Payer: University Health Alliance Commercial	$103.40

Screw Canc 4.0x45mm 206.045 [3606566]

Facility

$184.64

Service Code	HCPCS C1713
Hospital Charge Code	3606566
Hospital Revenue Code	278
Min. Negotiated Rate	$94.17
Max. Negotiated Rate	$179.10
Rate for Payer: Cash Price	$120.02
Rate for Payer: Hawaii Western Management Group Commercial	$129.25
Rate for Payer: Health Management Network Commercial	$156.94
Rate for Payer: Kaiser Permanente Commercial	$116.32
Rate for Payer: Kaiser Permanente Medicaid	$94.17
Rate for Payer: MDX Hawaii PPO	$179.10
Rate for Payer: University Health Alliance Commercial	$103.40

Screw Canc 4.0 x 45mm 207.045 [3606583]

Facility

$431.24

Service Code	HCPCS C1713
Hospital Charge Code	3606583
Hospital Revenue Code	278
Min. Negotiated Rate	$241.49
Max. Negotiated Rate	$418.30
Rate for Payer: Cash Price	$280.31
Rate for Payer: Hawaii Western Management Group Commercial	$301.87
Rate for Payer: Health Management Network Commercial	$366.55
Rate for Payer: MDX Hawaii PPO	$418.30
Rate for Payer: University Health Alliance Commercial	$241.49

Screw Canc 4.0 x 45mm 207.045 [3606583]

Facility

$431.24

Service Code	HCPCS C1713
Hospital Charge Code	3606583
Hospital Revenue Code	278
Min. Negotiated Rate	$219.93
Max. Negotiated Rate	$418.30
Rate for Payer: Cash Price	$280.31
Rate for Payer: Hawaii Western Management Group Commercial	$301.87
Rate for Payer: Health Management Network Commercial	$366.55
Rate for Payer: Kaiser Permanente Commercial	$271.68
Rate for Payer: Kaiser Permanente Medicaid	$219.93
Rate for Payer: MDX Hawaii PPO	$418.30
Rate for Payer: University Health Alliance Commercial	$241.49

Screw Cancellous 6.5x40mm Ar-13280-40 [3644007]

Facility

$1,720.13

Service Code	HCPCS C1713
Hospital Charge Code	3644007
Hospital Revenue Code	278
Min. Negotiated Rate	$963.27
Max. Negotiated Rate	$1,668.53
Rate for Payer: Cash Price	$1,118.08
Rate for Payer: Hawaii Western Management Group Commercial	$1,204.09
Rate for Payer: Health Management Network Commercial	$1,462.11
Rate for Payer: MDX Hawaii PPO	$1,668.53
Rate for Payer: University Health Alliance Commercial	$963.27

Screw Cancellous 6.5x40mm Ar-13280-40 [3644007]

Facility

$1,720.13

Service Code	HCPCS C1713
Hospital Charge Code	3644007
Hospital Revenue Code	278
Min. Negotiated Rate	$877.27
Max. Negotiated Rate	$1,668.53
Rate for Payer: Cash Price	$1,118.08
Rate for Payer: Hawaii Western Management Group Commercial	$1,204.09
Rate for Payer: Health Management Network Commercial	$1,462.11
Rate for Payer: Kaiser Permanente Commercial	$1,083.68
Rate for Payer: Kaiser Permanente Medicaid	$877.27
Rate for Payer: MDX Hawaii PPO	$1,668.53
Rate for Payer: University Health Alliance Commercial	$963.27

Screw Canc FT 5.0mm x 40mm 8022-040 [3644654]

Facility

$2,414.25

Service Code	HCPCS C1713
Hospital Charge Code	3644654
Hospital Revenue Code	278
Min. Negotiated Rate	$1,231.27
Max. Negotiated Rate	$2,341.82
Rate for Payer: Cash Price	$1,569.26
Rate for Payer: Hawaii Western Management Group Commercial	$1,689.97
Rate for Payer: Health Management Network Commercial	$2,052.11
Rate for Payer: Kaiser Permanente Commercial	$1,520.98
Rate for Payer: Kaiser Permanente Medicaid	$1,231.27
Rate for Payer: MDX Hawaii PPO	$2,341.82
Rate for Payer: University Health Alliance Commercial	$1,351.98

Screw Canc FT 5.0mm x 40mm 8022-040 [3644654]

Facility

$2,414.25

Service Code	HCPCS C1713
Hospital Charge Code	3644654
Hospital Revenue Code	278
Min. Negotiated Rate	$1,351.98
Max. Negotiated Rate	$2,341.82
Rate for Payer: Cash Price	$1,569.26
Rate for Payer: Hawaii Western Management Group Commercial	$1,689.97
Rate for Payer: Health Management Network Commercial	$2,052.11
Rate for Payer: MDX Hawaii PPO	$2,341.82
Rate for Payer: University Health Alliance Commercial	$1,351.98

Screw Canc FT 5.0mm x 50mm 8022-050 [3644655]

Facility

$2,414.25

Service Code	HCPCS C1713
Hospital Charge Code	3644655
Hospital Revenue Code	278
Min. Negotiated Rate	$1,351.98
Max. Negotiated Rate	$2,341.82
Rate for Payer: Cash Price	$1,569.26
Rate for Payer: Hawaii Western Management Group Commercial	$1,689.97
Rate for Payer: Health Management Network Commercial	$2,052.11
Rate for Payer: MDX Hawaii PPO	$2,341.82
Rate for Payer: University Health Alliance Commercial	$1,351.98

Screw Canc FT 5.0mm x 50mm 8022-050 [3644655]

Facility

$2,414.25

Service Code	HCPCS C1713
Hospital Charge Code	3644655
Hospital Revenue Code	278
Min. Negotiated Rate	$1,231.27
Max. Negotiated Rate	$2,341.82
Rate for Payer: Cash Price	$1,569.26
Rate for Payer: Hawaii Western Management Group Commercial	$1,689.97
Rate for Payer: Health Management Network Commercial	$2,052.11
Rate for Payer: Kaiser Permanente Commercial	$1,520.98
Rate for Payer: Kaiser Permanente Medicaid	$1,231.27
Rate for Payer: MDX Hawaii PPO	$2,341.82
Rate for Payer: University Health Alliance Commercial	$1,351.98

Screw Canc Lock 4.0mm X 30mm 816140030 [3642579]

Facility

$1,268.69

Service Code	HCPCS C1713
Hospital Charge Code	3642579
Hospital Revenue Code	278
Min. Negotiated Rate	$647.03
Max. Negotiated Rate	$1,230.63
Rate for Payer: Cash Price	$824.65
Rate for Payer: Hawaii Western Management Group Commercial	$888.08
Rate for Payer: Health Management Network Commercial	$1,078.39
Rate for Payer: Kaiser Permanente Commercial	$799.27
Rate for Payer: Kaiser Permanente Medicaid	$647.03
Rate for Payer: MDX Hawaii PPO	$1,230.63
Rate for Payer: University Health Alliance Commercial	$710.47

Screw Canc Lock 4.0mm X 30mm 816140030 [3642579]

Facility

$1,268.69

Service Code	HCPCS C1713
Hospital Charge Code	3642579
Hospital Revenue Code	278
Min. Negotiated Rate	$710.47
Max. Negotiated Rate	$1,230.63
Rate for Payer: Cash Price	$824.65
Rate for Payer: Hawaii Western Management Group Commercial	$888.08
Rate for Payer: Health Management Network Commercial	$1,078.39
Rate for Payer: MDX Hawaii PPO	$1,230.63
Rate for Payer: University Health Alliance Commercial	$710.47

Screw Canc Lock 4.0mm X 36mm 816140036 [3642147]

Facility

$1,268.69

Service Code	HCPCS C1713
Hospital Charge Code	3642147
Hospital Revenue Code	278
Min. Negotiated Rate	$710.47
Max. Negotiated Rate	$1,230.63
Rate for Payer: Cash Price	$824.65
Rate for Payer: Hawaii Western Management Group Commercial	$888.08
Rate for Payer: Health Management Network Commercial	$1,078.39
Rate for Payer: MDX Hawaii PPO	$1,230.63
Rate for Payer: University Health Alliance Commercial	$710.47

Screw Canc Lock 4.0mm X 36mm 816140036 [3642147]

Facility

$1,268.69

Service Code	HCPCS C1713
Hospital Charge Code	3642147
Hospital Revenue Code	278
Min. Negotiated Rate	$647.03
Max. Negotiated Rate	$1,230.63
Rate for Payer: Cash Price	$824.65
Rate for Payer: Hawaii Western Management Group Commercial	$888.08
Rate for Payer: Health Management Network Commercial	$1,078.39
Rate for Payer: Kaiser Permanente Commercial	$799.27
Rate for Payer: Kaiser Permanente Medicaid	$647.03
Rate for Payer: MDX Hawaii PPO	$1,230.63
Rate for Payer: University Health Alliance Commercial	$710.47

Screw Canc Lock 4.0mm X 38mm 816140038 [3641530]

Facility

$1,331.88

Service Code	HCPCS C1713
Hospital Charge Code	3641530
Hospital Revenue Code	278
Min. Negotiated Rate	$745.85
Max. Negotiated Rate	$1,291.92
Rate for Payer: Cash Price	$865.72
Rate for Payer: Hawaii Western Management Group Commercial	$932.32
Rate for Payer: Health Management Network Commercial	$1,132.10
Rate for Payer: MDX Hawaii PPO	$1,291.92
Rate for Payer: University Health Alliance Commercial	$745.85

Screw Canc Lock 4.0mm X 38mm 816140038 [3641530]

Facility

$1,331.88

Service Code	HCPCS C1713
Hospital Charge Code	3641530
Hospital Revenue Code	278
Min. Negotiated Rate	$679.26
Max. Negotiated Rate	$1,291.92
Rate for Payer: Cash Price	$865.72
Rate for Payer: Hawaii Western Management Group Commercial	$932.32
Rate for Payer: Health Management Network Commercial	$1,132.10
Rate for Payer: Kaiser Permanente Commercial	$839.08
Rate for Payer: Kaiser Permanente Medicaid	$679.26
Rate for Payer: MDX Hawaii PPO	$1,291.92
Rate for Payer: University Health Alliance Commercial	$745.85

Screw Canc Lock 4.0mm X 44mm 816140044 [3642122]

Facility

$1,268.69

Service Code	HCPCS C1713
Hospital Charge Code	3642122
Hospital Revenue Code	278
Min. Negotiated Rate	$647.03
Max. Negotiated Rate	$1,230.63
Rate for Payer: Cash Price	$824.65
Rate for Payer: Hawaii Western Management Group Commercial	$888.08
Rate for Payer: Health Management Network Commercial	$1,078.39
Rate for Payer: Kaiser Permanente Commercial	$799.27
Rate for Payer: Kaiser Permanente Medicaid	$647.03
Rate for Payer: MDX Hawaii PPO	$1,230.63
Rate for Payer: University Health Alliance Commercial	$710.47

Know your out-of-pocket cost for care.

All Charges