Kona Community Hospital

All Charges

Charge

Type

Setting

Price

Staple Ta45 3.5Mm Reload TA4535L [3606728]

Facility

$259.07

Hospital Charge Code	3606728
Hospital Revenue Code	272
Min. Negotiated Rate	$132.13
Max. Negotiated Rate	$251.30
Rate for Payer: Cash Price	$168.40
Rate for Payer: Hawaii Western Management Group Commercial	$246.12
Rate for Payer: Health Management Network Commercial	$220.21
Rate for Payer: Kaiser Permanente Commercial	$163.21
Rate for Payer: Kaiser Permanente Medicaid	$132.13
Rate for Payer: MDX Hawaii PPO	$251.30
Rate for Payer: University Health Alliance Commercial	$188.84

Staple Ta45 3.5Mm Reload TA4535L [3606728]

Facility

$259.07

Hospital Charge Code	3606728
Hospital Revenue Code	272
Min. Negotiated Rate	$220.21
Max. Negotiated Rate	$251.30
Rate for Payer: Cash Price	$168.40
Rate for Payer: Health Management Network Commercial	$220.21
Rate for Payer: MDX Hawaii PPO	$251.30

Staple TA 60mmX3.5Mm Reload TA6035L [3641724]

Facility

$318.32

Hospital Charge Code	3641724
Hospital Revenue Code	272
Min. Negotiated Rate	$270.57
Max. Negotiated Rate	$308.77
Rate for Payer: Cash Price	$206.91
Rate for Payer: Health Management Network Commercial	$270.57
Rate for Payer: MDX Hawaii PPO	$308.77

Staple TA 60mmX3.5Mm Reload TA6035L [3641724]

Facility

$318.32

Hospital Charge Code	3641724
Hospital Revenue Code	272
Min. Negotiated Rate	$162.34
Max. Negotiated Rate	$308.77
Rate for Payer: Cash Price	$206.91
Rate for Payer: Hawaii Western Management Group Commercial	$302.40
Rate for Payer: Health Management Network Commercial	$270.57
Rate for Payer: Kaiser Permanente Commercial	$200.54
Rate for Payer: Kaiser Permanente Medicaid	$162.34
Rate for Payer: MDX Hawaii PPO	$308.77
Rate for Payer: University Health Alliance Commercial	$232.02

Staple TA 60mmX4.8Mm Reload TA6048L [3641985]

Facility

$232.13

Hospital Charge Code	3641985
Hospital Revenue Code	272
Min. Negotiated Rate	$118.39
Max. Negotiated Rate	$225.17
Rate for Payer: Cash Price	$150.88
Rate for Payer: Hawaii Western Management Group Commercial	$220.52
Rate for Payer: Health Management Network Commercial	$197.31
Rate for Payer: Kaiser Permanente Commercial	$146.24
Rate for Payer: Kaiser Permanente Medicaid	$118.39
Rate for Payer: MDX Hawaii PPO	$225.17
Rate for Payer: University Health Alliance Commercial	$169.20

Staple TA 60mmX4.8Mm Reload TA6048L [3641985]

Facility

$232.13

Hospital Charge Code	3641985
Hospital Revenue Code	272
Min. Negotiated Rate	$197.31
Max. Negotiated Rate	$225.17
Rate for Payer: Cash Price	$150.88
Rate for Payer: Health Management Network Commercial	$197.31
Rate for Payer: MDX Hawaii PPO	$225.17

Steinman Pin 1.6mm x 6Inch Bay Tip 144256 [3641313]

Facility

$466.20

Hospital Charge Code	3641313
Hospital Revenue Code	272
Min. Negotiated Rate	$237.76
Max. Negotiated Rate	$452.21
Rate for Payer: Cash Price	$303.03
Rate for Payer: Hawaii Western Management Group Commercial	$442.89
Rate for Payer: Health Management Network Commercial	$396.27
Rate for Payer: Kaiser Permanente Commercial	$293.71
Rate for Payer: Kaiser Permanente Medicaid	$237.76
Rate for Payer: MDX Hawaii PPO	$452.21
Rate for Payer: University Health Alliance Commercial	$339.81

Steinman Pin 1.6mm x 6Inch Bay Tip 144256 [3641313]

Facility

$466.20

Hospital Charge Code	3641313
Hospital Revenue Code	272
Min. Negotiated Rate	$396.27
Max. Negotiated Rate	$452.21
Rate for Payer: Cash Price	$303.03
Rate for Payer: Health Management Network Commercial	$396.27
Rate for Payer: MDX Hawaii PPO	$452.21

Steinman Pin 2.0mm x 229mm Smooth 5/64 187-01-59 [3604860]

Facility

$168.00

Service Code	HCPCS C1713
Hospital Charge Code	3604860
Hospital Revenue Code	278
Min. Negotiated Rate	$85.68
Max. Negotiated Rate	$162.96
Rate for Payer: Cash Price	$109.20
Rate for Payer: Hawaii Western Management Group Commercial	$117.60
Rate for Payer: Health Management Network Commercial	$142.80
Rate for Payer: Kaiser Permanente Commercial	$105.84
Rate for Payer: Kaiser Permanente Medicaid	$85.68
Rate for Payer: MDX Hawaii PPO	$162.96
Rate for Payer: University Health Alliance Commercial	$94.08

Steinman Pin 2.0mm x 229mm Smooth 5/64 187-01-59 [3604860]

Facility

$168.00

Service Code	HCPCS C1713
Hospital Charge Code	3604860
Hospital Revenue Code	278
Min. Negotiated Rate	$94.08
Max. Negotiated Rate	$162.96
Rate for Payer: Cash Price	$109.20
Rate for Payer: Hawaii Western Management Group Commercial	$117.60
Rate for Payer: Health Management Network Commercial	$142.80
Rate for Payer: MDX Hawaii PPO	$162.96
Rate for Payer: University Health Alliance Commercial	$94.08

Steinman Pin 2.4mm Smooth 3/32 1870259 [3604861]

Facility

$525.00

Service Code	HCPCS C1713
Hospital Charge Code	3604861
Hospital Revenue Code	278
Min. Negotiated Rate	$294.00
Max. Negotiated Rate	$509.25
Rate for Payer: Cash Price	$341.25
Rate for Payer: Hawaii Western Management Group Commercial	$367.50
Rate for Payer: Health Management Network Commercial	$446.25
Rate for Payer: MDX Hawaii PPO	$509.25
Rate for Payer: University Health Alliance Commercial	$294.00

Steinman Pin 2.4mm Smooth 3/32 1870259 [3604861]

Facility

$525.00

Service Code	HCPCS C1713
Hospital Charge Code	3604861
Hospital Revenue Code	278
Min. Negotiated Rate	$267.75
Max. Negotiated Rate	$509.25
Rate for Payer: Cash Price	$341.25
Rate for Payer: Hawaii Western Management Group Commercial	$367.50
Rate for Payer: Health Management Network Commercial	$446.25
Rate for Payer: Kaiser Permanente Commercial	$330.75
Rate for Payer: Kaiser Permanente Medicaid	$267.75
Rate for Payer: MDX Hawaii PPO	$509.25
Rate for Payer: University Health Alliance Commercial	$294.00

Steinman Pin 2.8mm x 229mm Smooth 7/64 187-03-59 [3604862]

Facility

$154.64

Service Code	HCPCS C1713
Hospital Charge Code	3604862
Hospital Revenue Code	278
Min. Negotiated Rate	$78.87
Max. Negotiated Rate	$150.00
Rate for Payer: Cash Price	$100.52
Rate for Payer: Hawaii Western Management Group Commercial	$108.25
Rate for Payer: Health Management Network Commercial	$131.44
Rate for Payer: Kaiser Permanente Commercial	$97.42
Rate for Payer: Kaiser Permanente Medicaid	$78.87
Rate for Payer: MDX Hawaii PPO	$150.00
Rate for Payer: University Health Alliance Commercial	$86.60

Steinman Pin 2.8mm x 229mm Smooth 7/64 187-03-59 [3604862]

Facility

$154.64

Service Code	HCPCS C1713
Hospital Charge Code	3604862
Hospital Revenue Code	278
Min. Negotiated Rate	$86.60
Max. Negotiated Rate	$150.00
Rate for Payer: Cash Price	$100.52
Rate for Payer: Hawaii Western Management Group Commercial	$108.25
Rate for Payer: Health Management Network Commercial	$131.44
Rate for Payer: MDX Hawaii PPO	$150.00
Rate for Payer: University Health Alliance Commercial	$86.60

Steinman Pin 3.6mm x 229mm Threaded 9/64 262-03-04 [3604874]

Facility

$263.98

Service Code	HCPCS C1713
Hospital Charge Code	3604874
Hospital Revenue Code	278
Min. Negotiated Rate	$134.63
Max. Negotiated Rate	$256.06
Rate for Payer: Cash Price	$171.59
Rate for Payer: Hawaii Western Management Group Commercial	$184.79
Rate for Payer: Health Management Network Commercial	$224.38
Rate for Payer: Kaiser Permanente Commercial	$166.31
Rate for Payer: Kaiser Permanente Medicaid	$134.63
Rate for Payer: MDX Hawaii PPO	$256.06
Rate for Payer: University Health Alliance Commercial	$147.83

Steinman Pin 3.6mm x 229mm Threaded 9/64 262-03-04 [3604874]

Facility

$263.98

Service Code	HCPCS C1713
Hospital Charge Code	3604874
Hospital Revenue Code	278
Min. Negotiated Rate	$147.83
Max. Negotiated Rate	$256.06
Rate for Payer: Cash Price	$171.59
Rate for Payer: Hawaii Western Management Group Commercial	$184.79
Rate for Payer: Health Management Network Commercial	$224.38
Rate for Payer: MDX Hawaii PPO	$256.06
Rate for Payer: University Health Alliance Commercial	$147.83

Stent Self Expanding Innova 6mmX20mmX75cm H74939293060270 [3641961]

Facility

$3,437.50

Service Code	HCPCS C1876
Hospital Charge Code	3641961
Hospital Revenue Code	278
Min. Negotiated Rate	$1,925.00
Max. Negotiated Rate	$3,334.38
Rate for Payer: Cash Price	$2,234.38
Rate for Payer: Hawaii Western Management Group Commercial	$2,406.25
Rate for Payer: Health Management Network Commercial	$2,921.88
Rate for Payer: MDX Hawaii PPO	$3,334.38
Rate for Payer: University Health Alliance Commercial	$1,925.00

Stent Self Expanding Innova 6mmX20mmX75cm H74939293060270 [3641961]

Facility

$3,437.50

Service Code	HCPCS C1876
Hospital Charge Code	3641961
Hospital Revenue Code	278
Min. Negotiated Rate	$1,753.12
Max. Negotiated Rate	$3,334.38
Rate for Payer: Cash Price	$2,234.38
Rate for Payer: Hawaii Western Management Group Commercial	$2,406.25
Rate for Payer: Health Management Network Commercial	$2,921.88
Rate for Payer: Kaiser Permanente Commercial	$2,165.62
Rate for Payer: Kaiser Permanente Medicaid	$1,753.12
Rate for Payer: MDX Hawaii PPO	$3,334.38
Rate for Payer: University Health Alliance Commercial	$1,925.00

Stent Ureteral Inlay Optima 4.7FR 20cm 788420 [3642073]

Facility

$758.19

Service Code	HCPCS C2617
Hospital Charge Code	3642073
Hospital Revenue Code	278
Min. Negotiated Rate	$424.59
Max. Negotiated Rate	$735.44
Rate for Payer: Cash Price	$492.82
Rate for Payer: Hawaii Western Management Group Commercial	$530.73
Rate for Payer: Health Management Network Commercial	$644.46
Rate for Payer: MDX Hawaii PPO	$735.44
Rate for Payer: University Health Alliance Commercial	$424.59

Stent Ureteral Inlay Optima 4.7FR 20cm 788420 [3642073]

Facility

$758.19

Service Code	HCPCS C2617
Hospital Charge Code	3642073
Hospital Revenue Code	278
Min. Negotiated Rate	$386.68
Max. Negotiated Rate	$735.44
Rate for Payer: Cash Price	$492.82
Rate for Payer: Hawaii Western Management Group Commercial	$530.73
Rate for Payer: Health Management Network Commercial	$644.46
Rate for Payer: Kaiser Permanente Commercial	$477.66
Rate for Payer: Kaiser Permanente Medicaid	$386.68
Rate for Payer: MDX Hawaii PPO	$735.44
Rate for Payer: University Health Alliance Commercial	$424.59

Stent Ureteral Inlay Optima 4.7FR 22cm 788422 [3642074]

Facility

$1,170.26

Service Code	HCPCS C2617
Hospital Charge Code	3642074
Hospital Revenue Code	278
Min. Negotiated Rate	$596.83
Max. Negotiated Rate	$1,135.15
Rate for Payer: Cash Price	$760.67
Rate for Payer: Hawaii Western Management Group Commercial	$819.18
Rate for Payer: Health Management Network Commercial	$994.72
Rate for Payer: Kaiser Permanente Commercial	$737.26
Rate for Payer: Kaiser Permanente Medicaid	$596.83
Rate for Payer: MDX Hawaii PPO	$1,135.15
Rate for Payer: University Health Alliance Commercial	$655.35

Stent Ureteral Inlay Optima 4.7FR 22cm 788422 [3642074]

Facility

$1,170.26

Service Code	HCPCS C2617
Hospital Charge Code	3642074
Hospital Revenue Code	278
Min. Negotiated Rate	$655.35
Max. Negotiated Rate	$1,135.15
Rate for Payer: Cash Price	$760.67
Rate for Payer: Hawaii Western Management Group Commercial	$819.18
Rate for Payer: Health Management Network Commercial	$994.72
Rate for Payer: MDX Hawaii PPO	$1,135.15
Rate for Payer: University Health Alliance Commercial	$655.35

Stent Ureteral Inlay Optima 4.7FR 24cm 788424 [3642075]

Facility

$1,170.26

Service Code	HCPCS C2617
Hospital Charge Code	3642075
Hospital Revenue Code	278
Min. Negotiated Rate	$596.83
Max. Negotiated Rate	$1,135.15
Rate for Payer: Cash Price	$760.67
Rate for Payer: Hawaii Western Management Group Commercial	$819.18
Rate for Payer: Health Management Network Commercial	$994.72
Rate for Payer: Kaiser Permanente Commercial	$737.26
Rate for Payer: Kaiser Permanente Medicaid	$596.83
Rate for Payer: MDX Hawaii PPO	$1,135.15
Rate for Payer: University Health Alliance Commercial	$655.35

Stent Ureteral Inlay Optima 4.7FR 24cm 788424 [3642075]

Facility

$1,170.26

Service Code	HCPCS C2617
Hospital Charge Code	3642075
Hospital Revenue Code	278
Min. Negotiated Rate	$655.35
Max. Negotiated Rate	$1,135.15
Rate for Payer: Cash Price	$760.67
Rate for Payer: Hawaii Western Management Group Commercial	$819.18
Rate for Payer: Health Management Network Commercial	$994.72
Rate for Payer: MDX Hawaii PPO	$1,135.15
Rate for Payer: University Health Alliance Commercial	$655.35

Stent Ureteral Inlay Optima 4.7FR 26cm 788426 [3642076]

Facility

$1,170.26

Service Code	HCPCS C2617
Hospital Charge Code	3642076
Hospital Revenue Code	278
Min. Negotiated Rate	$655.35
Max. Negotiated Rate	$1,135.15
Rate for Payer: Cash Price	$760.67
Rate for Payer: Hawaii Western Management Group Commercial	$819.18
Rate for Payer: Health Management Network Commercial	$994.72
Rate for Payer: MDX Hawaii PPO	$1,135.15
Rate for Payer: University Health Alliance Commercial	$655.35

Know your out-of-pocket cost for care.

All Charges