Kona Community Hospital

All Charges

Charge

Type

Setting

Price

SODIUM THIOSULFATE 12.5 GRAM/50 ML (250 MG/ML) IV SOLN

Facility

$489.12

Service Code	HCPCS J0209
Hospital Revenue Code	636
Min. Negotiated Rate	$0.88
Max. Negotiated Rate	$474.45
Rate for Payer: AlohaCare Medicaid	$0.88
Rate for Payer: AlohaCare Medicare	$0.88
Rate for Payer: Cash Price	$317.93
Rate for Payer: Cash Price	$317.93
Rate for Payer: Devoted Health Medicare	$0.97
Rate for Payer: Hawaii Medical Service Association Commercial	$1.10
Rate for Payer: Hawaii Medical Service Association Medicare	$0.88
Rate for Payer: Hawaii Western Management Group Commercial	$464.66
Rate for Payer: Health Management Network Commercial	$415.75
Rate for Payer: Humana Medicare	$0.88
Rate for Payer: Kaiser Permanente Commercial	$308.15
Rate for Payer: Kaiser Permanente Medicaid	$249.45
Rate for Payer: Kaiser Permanente Medicare	$0.88
Rate for Payer: MDX Hawaii PPO	$474.45
Rate for Payer: Ohana Health Plan Medicaid	$0.97
Rate for Payer: Ohana Health Plan Medicare	$0.88
Rate for Payer: UnitedHealthcare Medicaid	$293.47
Rate for Payer: UnitedHealthcare Medicare	$0.88
Rate for Payer: University Health Alliance Commercial	$356.52

SODIUM ZIRCONIUM CYCLOSILICATE 10 G PO PWPK

Facility

$136.90

Service Code	HCPCS A9270
Hospital Revenue Code	250
Min. Negotiated Rate	$116.36
Max. Negotiated Rate	$132.79
Rate for Payer: Cash Price	$88.99
Rate for Payer: Health Management Network Commercial	$116.36
Rate for Payer: MDX Hawaii PPO	$132.79

SODIUM ZIRCONIUM CYCLOSILICATE 10 G PO PWPK

Facility

$136.90

Service Code	HCPCS A9270
Hospital Revenue Code	250
Min. Negotiated Rate	$69.82
Max. Negotiated Rate	$132.79
Rate for Payer: Cash Price	$88.99
Rate for Payer: Hawaii Western Management Group Commercial	$130.06
Rate for Payer: Health Management Network Commercial	$116.36
Rate for Payer: Kaiser Permanente Commercial	$86.25
Rate for Payer: Kaiser Permanente Medicaid	$69.82
Rate for Payer: MDX Hawaii PPO	$132.79
Rate for Payer: UnitedHealthcare Medicaid	$82.14
Rate for Payer: University Health Alliance Commercial	$99.79

SOD PHOS DI, MONO-K PHOS MONO 250 MG PO TABLET

Facility

$2.81

Service Code	HCPCS A9270
Hospital Revenue Code	250
Min. Negotiated Rate	$2.39
Max. Negotiated Rate	$2.73
Rate for Payer: Cash Price	$1.83
Rate for Payer: Cash Price	$1.76
Rate for Payer: Health Management Network Commercial	$2.30
Rate for Payer: Health Management Network Commercial	$2.39
Rate for Payer: MDX Hawaii PPO	$2.73
Rate for Payer: MDX Hawaii PPO	$2.63

SOD PHOS DI, MONO-K PHOS MONO 250 MG PO TABLET

Facility

$2.71

Service Code	HCPCS A9270
Hospital Revenue Code	250
Min. Negotiated Rate	$1.38
Max. Negotiated Rate	$2.63
Rate for Payer: Cash Price	$1.76
Rate for Payer: Cash Price	$1.83
Rate for Payer: Hawaii Western Management Group Commercial	$2.57
Rate for Payer: Hawaii Western Management Group Commercial	$2.67
Rate for Payer: Health Management Network Commercial	$2.30
Rate for Payer: Health Management Network Commercial	$2.39
Rate for Payer: Kaiser Permanente Commercial	$1.71
Rate for Payer: Kaiser Permanente Commercial	$1.77
Rate for Payer: Kaiser Permanente Medicaid	$1.38
Rate for Payer: Kaiser Permanente Medicaid	$1.43
Rate for Payer: MDX Hawaii PPO	$2.63
Rate for Payer: MDX Hawaii PPO	$2.73
Rate for Payer: UnitedHealthcare Medicaid	$1.69
Rate for Payer: UnitedHealthcare Medicaid	$1.63
Rate for Payer: University Health Alliance Commercial	$1.98
Rate for Payer: University Health Alliance Commercial	$2.05

SOFT TISSUE PROCEDURES WITH CC

Facility

$47,201.51

Service Code	MSDRG 501
Min. Negotiated Rate	$22,992.34
Max. Negotiated Rate	$47,201.51
Rate for Payer: AlohaCare Medicare	$22,992.34
Rate for Payer: Devoted Health Medicare	$25,291.57
Rate for Payer: Hawaii Medical Service Association Commercial	$47,201.51
Rate for Payer: Hawaii Medical Service Association Medicare	$22,992.34
Rate for Payer: Humana Medicare	$22,992.34
Rate for Payer: Kaiser Permanente Commercial	$30,154.72
Rate for Payer: Kaiser Permanente Medicare	$22,992.34
Rate for Payer: Ohana Health Plan Medicare	$22,992.34
Rate for Payer: UnitedHealthcare Medicare	$22,992.34

SOFT TISSUE PROCEDURES WITH MCC

Facility

$54,592.80

Service Code	MSDRG 500
Min. Negotiated Rate	$41,625.87
Max. Negotiated Rate	$54,592.80
Rate for Payer: AlohaCare Medicare	$41,625.87
Rate for Payer: Devoted Health Medicare	$45,788.46
Rate for Payer: Hawaii Medical Service Association Commercial	$47,201.51
Rate for Payer: Hawaii Medical Service Association Medicare	$41,625.87
Rate for Payer: Humana Medicare	$41,625.87
Rate for Payer: Kaiser Permanente Commercial	$54,592.80
Rate for Payer: Kaiser Permanente Medicare	$41,625.87
Rate for Payer: Ohana Health Plan Medicare	$41,625.87
Rate for Payer: UnitedHealthcare Medicare	$41,625.87

SOFT TISSUE PROCEDURES WITHOUT CC/MCC

Facility

$23,287.36

Service Code	MSDRG 502
Min. Negotiated Rate	$17,702.30
Max. Negotiated Rate	$23,287.36
Rate for Payer: AlohaCare Medicare	$17,702.30
Rate for Payer: Devoted Health Medicare	$19,472.53
Rate for Payer: Hawaii Medical Service Association Commercial	$23,287.36
Rate for Payer: Hawaii Medical Service Association Medicare	$17,702.30
Rate for Payer: Humana Medicare	$17,702.30
Rate for Payer: Kaiser Permanente Commercial	$23,216.78
Rate for Payer: Kaiser Permanente Medicare	$17,702.30
Rate for Payer: Ohana Health Plan Medicare	$17,702.30
Rate for Payer: UnitedHealthcare Medicare	$17,702.30

SORBITOL 70 % MISC SOLN

Facility

$22.36

Service Code	HCPCS A9270
Hospital Revenue Code	250
Min. Negotiated Rate	$19.01
Max. Negotiated Rate	$21.69
Rate for Payer: Cash Price	$14.53
Rate for Payer: Health Management Network Commercial	$19.01
Rate for Payer: MDX Hawaii PPO	$21.69

SORBITOL 70 % MISC SOLN

Facility

$22.36

Service Code	HCPCS A9270
Hospital Revenue Code	250
Min. Negotiated Rate	$11.40
Max. Negotiated Rate	$21.69
Rate for Payer: Cash Price	$14.53
Rate for Payer: Hawaii Western Management Group Commercial	$21.24
Rate for Payer: Health Management Network Commercial	$19.01
Rate for Payer: Kaiser Permanente Commercial	$14.09
Rate for Payer: Kaiser Permanente Medicaid	$11.40
Rate for Payer: MDX Hawaii PPO	$21.69
Rate for Payer: UnitedHealthcare Medicaid	$13.42
Rate for Payer: University Health Alliance Commercial	$16.30

SORBITOL-MANNITOL-XANTHAN GUM PO LIQ

Facility

$48.29

Service Code	NDC 15137002127
Hospital Revenue Code	255
Min. Negotiated Rate	$24.63
Max. Negotiated Rate	$46.84
Rate for Payer: Cash Price	$31.39
Rate for Payer: Hawaii Western Management Group Commercial	$45.88
Rate for Payer: Health Management Network Commercial	$41.05
Rate for Payer: Kaiser Permanente Commercial	$30.42
Rate for Payer: Kaiser Permanente Medicaid	$24.63
Rate for Payer: MDX Hawaii PPO	$46.84
Rate for Payer: University Health Alliance Commercial	$35.20

SORBITOL-MANNITOL-XANTHAN GUM PO LIQ

Facility

$48.29

Service Code	NDC 15137002127
Hospital Revenue Code	255
Min. Negotiated Rate	$41.05
Max. Negotiated Rate	$46.84
Rate for Payer: Cash Price	$31.39
Rate for Payer: Health Management Network Commercial	$41.05
Rate for Payer: MDX Hawaii PPO	$46.84

SOTALOL 80 MG PO TABLET

Facility

$12.81

Service Code	HCPCS A9270
Hospital Revenue Code	250
Min. Negotiated Rate	$10.89
Max. Negotiated Rate	$12.43
Rate for Payer: Cash Price	$8.33
Rate for Payer: Cash Price	$9.20
Rate for Payer: Health Management Network Commercial	$12.03
Rate for Payer: Health Management Network Commercial	$10.89
Rate for Payer: MDX Hawaii PPO	$12.43
Rate for Payer: MDX Hawaii PPO	$13.73

SOTALOL 80 MG PO TABLET

Facility

$12.81

Service Code	HCPCS A9270
Hospital Revenue Code	250
Min. Negotiated Rate	$6.53
Max. Negotiated Rate	$12.43
Rate for Payer: Cash Price	$8.33
Rate for Payer: Cash Price	$9.20
Rate for Payer: Hawaii Western Management Group Commercial	$12.17
Rate for Payer: Hawaii Western Management Group Commercial	$13.44
Rate for Payer: Health Management Network Commercial	$10.89
Rate for Payer: Health Management Network Commercial	$12.03
Rate for Payer: Kaiser Permanente Commercial	$8.07
Rate for Payer: Kaiser Permanente Commercial	$8.91
Rate for Payer: Kaiser Permanente Medicaid	$6.53
Rate for Payer: Kaiser Permanente Medicaid	$7.22
Rate for Payer: MDX Hawaii PPO	$12.43
Rate for Payer: MDX Hawaii PPO	$13.73
Rate for Payer: UnitedHealthcare Medicaid	$8.49
Rate for Payer: UnitedHealthcare Medicaid	$7.69
Rate for Payer: University Health Alliance Commercial	$9.34
Rate for Payer: University Health Alliance Commercial	$10.31

SP 2.6 FiberTak RC, Dbload Tape BL/W,Blk/W AR-3632SP [3643050]

Facility

$3,045.50

Service Code	HCPCS C1713
Hospital Charge Code	3643050
Hospital Revenue Code	278
Min. Negotiated Rate	$1,553.20
Max. Negotiated Rate	$2,954.14
Rate for Payer: Cash Price	$1,979.58
Rate for Payer: Hawaii Western Management Group Commercial	$2,131.85
Rate for Payer: Health Management Network Commercial	$2,588.68
Rate for Payer: Kaiser Permanente Commercial	$1,918.66
Rate for Payer: Kaiser Permanente Medicaid	$1,553.20
Rate for Payer: MDX Hawaii PPO	$2,954.14
Rate for Payer: University Health Alliance Commercial	$1,705.48

SP 2.6 FiberTak RC, Dbload Tape BL/W,Blk/W AR-3632SP [3643050]

Facility

$3,045.50

Service Code	HCPCS C1713
Hospital Charge Code	3643050
Hospital Revenue Code	278
Min. Negotiated Rate	$1,705.48
Max. Negotiated Rate	$2,954.14
Rate for Payer: Cash Price	$1,979.58
Rate for Payer: Hawaii Western Management Group Commercial	$2,131.85
Rate for Payer: Health Management Network Commercial	$2,588.68
Rate for Payer: MDX Hawaii PPO	$2,954.14
Rate for Payer: University Health Alliance Commercial	$1,705.48

Spectrum Gv Bone Cement SPECTRUM40 [3644081]

Facility

$3,428.00

Service Code	HCPCS C1713
Hospital Charge Code	3644081
Hospital Revenue Code	278
Min. Negotiated Rate	$1,919.68
Max. Negotiated Rate	$3,325.16
Rate for Payer: Cash Price	$2,228.20
Rate for Payer: Hawaii Western Management Group Commercial	$2,399.60
Rate for Payer: Health Management Network Commercial	$2,913.80
Rate for Payer: MDX Hawaii PPO	$3,325.16
Rate for Payer: University Health Alliance Commercial	$1,919.68

Spectrum Gv Bone Cement SPECTRUM40 [3644081]

Facility

$3,428.00

Service Code	HCPCS C1713
Hospital Charge Code	3644081
Hospital Revenue Code	278
Min. Negotiated Rate	$1,748.28
Max. Negotiated Rate	$3,325.16
Rate for Payer: Cash Price	$2,228.20
Rate for Payer: Hawaii Western Management Group Commercial	$2,399.60
Rate for Payer: Health Management Network Commercial	$2,913.80
Rate for Payer: Kaiser Permanente Commercial	$2,159.64
Rate for Payer: Kaiser Permanente Medicaid	$1,748.28
Rate for Payer: MDX Hawaii PPO	$3,325.16
Rate for Payer: University Health Alliance Commercial	$1,919.68

Speedbrg BC Achilles w/KL DX CC 3.9mm AR-9928BCK-DX [3644528]

Facility

$18,390.50

Service Code	HCPCS C1713
Hospital Charge Code	3644528
Hospital Revenue Code	278
Min. Negotiated Rate	$9,379.16
Max. Negotiated Rate	$17,838.78
Rate for Payer: Cash Price	$11,953.82
Rate for Payer: Hawaii Western Management Group Commercial	$12,873.35
Rate for Payer: Health Management Network Commercial	$15,631.92
Rate for Payer: Kaiser Permanente Commercial	$11,586.01
Rate for Payer: Kaiser Permanente Medicaid	$9,379.16
Rate for Payer: MDX Hawaii PPO	$17,838.78
Rate for Payer: University Health Alliance Commercial	$10,298.68

Speedbrg BC Achilles w/KL DX CC 3.9mm AR-9928BCK-DX [3644528]

Facility

$18,390.50

Service Code	HCPCS C1713
Hospital Charge Code	3644528
Hospital Revenue Code	278
Min. Negotiated Rate	$10,298.68
Max. Negotiated Rate	$17,838.78
Rate for Payer: Cash Price	$11,953.82
Rate for Payer: Hawaii Western Management Group Commercial	$12,873.35
Rate for Payer: Health Management Network Commercial	$15,631.92
Rate for Payer: MDX Hawaii PPO	$17,838.78
Rate for Payer: University Health Alliance Commercial	$10,298.68

Speedbrg IMP SYS W/BIO-COMP SWVLK AR2600SBS4 [3641287]

Facility

$10,204.00

Service Code	HCPCS C1713
Hospital Charge Code	3641287
Hospital Revenue Code	278
Min. Negotiated Rate	$5,204.04
Max. Negotiated Rate	$9,897.88
Rate for Payer: Cash Price	$6,632.60
Rate for Payer: Hawaii Western Management Group Commercial	$7,142.80
Rate for Payer: Health Management Network Commercial	$8,673.40
Rate for Payer: Kaiser Permanente Commercial	$6,428.52
Rate for Payer: Kaiser Permanente Medicaid	$5,204.04
Rate for Payer: MDX Hawaii PPO	$9,897.88
Rate for Payer: University Health Alliance Commercial	$5,714.24

Speedbrg IMP SYS W/BIO-COMP SWVLK AR2600SBS4 [3641287]

Facility

$10,204.00

Service Code	HCPCS C1713
Hospital Charge Code	3641287
Hospital Revenue Code	278
Min. Negotiated Rate	$5,714.24
Max. Negotiated Rate	$9,897.88
Rate for Payer: Cash Price	$6,632.60
Rate for Payer: Hawaii Western Management Group Commercial	$7,142.80
Rate for Payer: Health Management Network Commercial	$8,673.40
Rate for Payer: MDX Hawaii PPO	$9,897.88
Rate for Payer: University Health Alliance Commercial	$5,714.24

Speedbrg Imp Sys w/Jump Peek Achilles AR-8928PJ-CP [3642814]

Facility

$13,140.50

Service Code	HCPCS C1713
Hospital Charge Code	3642814
Hospital Revenue Code	278
Min. Negotiated Rate	$7,358.68
Max. Negotiated Rate	$12,746.28
Rate for Payer: Cash Price	$8,541.33
Rate for Payer: Hawaii Western Management Group Commercial	$9,198.35
Rate for Payer: Health Management Network Commercial	$11,169.42
Rate for Payer: MDX Hawaii PPO	$12,746.28
Rate for Payer: University Health Alliance Commercial	$7,358.68

Speedbrg Imp Sys w/Jump Peek Achilles AR-8928PJ-CP [3642814]

Facility

$13,140.50

Service Code	HCPCS C1713
Hospital Charge Code	3642814
Hospital Revenue Code	278
Min. Negotiated Rate	$6,701.65
Max. Negotiated Rate	$12,746.28
Rate for Payer: Cash Price	$8,541.33
Rate for Payer: Hawaii Western Management Group Commercial	$9,198.35
Rate for Payer: Health Management Network Commercial	$11,169.42
Rate for Payer: Kaiser Permanente Commercial	$8,278.51
Rate for Payer: Kaiser Permanente Medicaid	$6,701.65
Rate for Payer: MDX Hawaii PPO	$12,746.28
Rate for Payer: University Health Alliance Commercial	$7,358.68

Speed Drill Kit w/2.65mm Drill Bit DK265C [3641017]

Facility

$1,651.40

Hospital Charge Code	3641017
Hospital Revenue Code	272
Min. Negotiated Rate	$842.21
Max. Negotiated Rate	$1,601.86
Rate for Payer: Cash Price	$1,073.41
Rate for Payer: Hawaii Western Management Group Commercial	$1,568.83
Rate for Payer: Health Management Network Commercial	$1,403.69
Rate for Payer: Kaiser Permanente Commercial	$1,040.38
Rate for Payer: Kaiser Permanente Medicaid	$842.21
Rate for Payer: MDX Hawaii PPO	$1,601.86
Rate for Payer: University Health Alliance Commercial	$1,203.71

Know your out-of-pocket cost for care.

All Charges