Kona Community Hospital

All Charges

Charge

Type

Setting

Price

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	$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 28cm 788428 [3642077]

Facility

$1,170.26

Service Code	HCPCS C2617
Hospital Charge Code	3642077
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 28cm 788428 [3642077]

Facility

$1,170.26

Service Code	HCPCS C2617
Hospital Charge Code	3642077
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 30cm 788430 [3642078]

Facility

$1,170.26

Service Code	HCPCS C2617
Hospital Charge Code	3642078
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 30cm 788430 [3642078]

Facility

$1,170.26

Service Code	HCPCS C2617
Hospital Charge Code	3642078
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 6FR 20cm 788620 [3642079]

Facility

$758.19

Service Code	HCPCS C2617
Hospital Charge Code	3642079
Hospital Revenue Code	278
Min. Negotiated Rate	$386.68
Max. Negotiated Rate	$735.44
Rate for Payer: MDX Hawaii PPO	$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: University Health Alliance Commercial	$424.59

Stent Ureteral Inlay Optima 6FR 20cm 788620 [3642079]

Facility

$758.19

Service Code	HCPCS C2617
Hospital Charge Code	3642079
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 6FR 22cm 788622 [3642080]

Facility

$1,165.87

Service Code	HCPCS C2617
Hospital Charge Code	3642080
Hospital Revenue Code	278
Min. Negotiated Rate	$652.89
Max. Negotiated Rate	$1,130.89
Rate for Payer: Cash Price	$757.82
Rate for Payer: Hawaii Western Management Group Commercial	$816.11
Rate for Payer: Health Management Network Commercial	$990.99
Rate for Payer: MDX Hawaii PPO	$1,130.89
Rate for Payer: University Health Alliance Commercial	$652.89

Stent Ureteral Inlay Optima 6FR 22cm 788622 [3642080]

Facility

$1,165.87

Service Code	HCPCS C2617
Hospital Charge Code	3642080
Hospital Revenue Code	278
Min. Negotiated Rate	$594.59
Max. Negotiated Rate	$1,130.89
Rate for Payer: Cash Price	$757.82
Rate for Payer: Hawaii Western Management Group Commercial	$816.11
Rate for Payer: Health Management Network Commercial	$990.99
Rate for Payer: Kaiser Permanente Commercial	$734.50
Rate for Payer: Kaiser Permanente Medicaid	$594.59
Rate for Payer: MDX Hawaii PPO	$1,130.89
Rate for Payer: University Health Alliance Commercial	$652.89

Stent Ureteral Inlay Optima 6FR 24cm 788624 [3642081]

Facility

$1,170.26

Service Code	HCPCS C2617
Hospital Charge Code	3642081
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 6FR 24cm 788624 [3642081]

Facility

$1,170.26

Service Code	HCPCS C2617
Hospital Charge Code	3642081
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 6FR 26cm 788626 [3642082]

Facility

$1,170.26

Service Code	HCPCS C2617
Hospital Charge Code	3642082
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 6FR 26cm 788626 [3642082]

Facility

$1,170.26

Service Code	HCPCS C2617
Hospital Charge Code	3642082
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 6FR 28cm 788628 [3642083]

Facility

$1,170.26

Service Code	HCPCS C2617
Hospital Charge Code	3642083
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 6FR 28cm 788628 [3642083]

Facility

$1,170.26

Service Code	HCPCS C2617
Hospital Charge Code	3642083
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 6FR 30cm 788630 [3642084]

Facility

$1,170.26

Service Code	HCPCS C2617
Hospital Charge Code	3642084
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 6FR 30cm 788630 [3642084]

Facility

$1,170.26

Service Code	HCPCS C2617
Hospital Charge Code	3642084
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 8FR 22cm 788822 [3643118]

Facility

$852.34

Service Code	HCPCS C2617
Hospital Charge Code	3643118
Hospital Revenue Code	278
Min. Negotiated Rate	$434.69
Max. Negotiated Rate	$826.77
Rate for Payer: Cash Price	$554.02
Rate for Payer: Hawaii Western Management Group Commercial	$596.64
Rate for Payer: Health Management Network Commercial	$724.49
Rate for Payer: Kaiser Permanente Commercial	$536.97
Rate for Payer: Kaiser Permanente Medicaid	$434.69
Rate for Payer: MDX Hawaii PPO	$826.77
Rate for Payer: University Health Alliance Commercial	$477.31

Stent Ureteral Inlay Optima 8FR 22cm 788822 [3643118]

Facility

$852.34

Service Code	HCPCS C2617
Hospital Charge Code	3643118
Hospital Revenue Code	278
Min. Negotiated Rate	$477.31
Max. Negotiated Rate	$826.77
Rate for Payer: Cash Price	$554.02
Rate for Payer: Hawaii Western Management Group Commercial	$596.64
Rate for Payer: Health Management Network Commercial	$724.49
Rate for Payer: MDX Hawaii PPO	$826.77
Rate for Payer: University Health Alliance Commercial	$477.31

Stent Ureteral Inlay Optima 8FR 24cm 788824 [3643258]

Facility

$852.34

Service Code	HCPCS C2625
Hospital Charge Code	3643258
Hospital Revenue Code	278
Min. Negotiated Rate	$477.31
Max. Negotiated Rate	$826.77
Rate for Payer: Cash Price	$554.02
Rate for Payer: Hawaii Western Management Group Commercial	$596.64
Rate for Payer: Health Management Network Commercial	$724.49
Rate for Payer: MDX Hawaii PPO	$826.77
Rate for Payer: University Health Alliance Commercial	$477.31

Stent Ureteral Inlay Optima 8FR 24cm 788824 [3643258]

Facility

$852.34

Service Code	HCPCS C2625
Hospital Charge Code	3643258
Hospital Revenue Code	278
Min. Negotiated Rate	$434.69
Max. Negotiated Rate	$826.77
Rate for Payer: Cash Price	$554.02
Rate for Payer: Hawaii Western Management Group Commercial	$596.64
Rate for Payer: Health Management Network Commercial	$724.49
Rate for Payer: Kaiser Permanente Commercial	$536.97
Rate for Payer: Kaiser Permanente Medicaid	$434.69
Rate for Payer: MDX Hawaii PPO	$826.77
Rate for Payer: University Health Alliance Commercial	$477.31

Stent Ureteral Inlay Optima 8FR 26cm 788826 [3642767]

Facility

$1,170.26

Service Code	HCPCS C2617
Hospital Charge Code	3642767
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 8FR 26cm 788826 [3642767]

Facility

$1,170.26

Service Code	HCPCS C2617
Hospital Charge Code	3642767
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 8FR 28cm 788828 [3642974]

Facility

$375.25

Service Code	HCPCS C2617
Hospital Charge Code	3642974
Hospital Revenue Code	278
Min. Negotiated Rate	$191.38
Max. Negotiated Rate	$363.99
Rate for Payer: Cash Price	$243.91
Rate for Payer: Hawaii Western Management Group Commercial	$262.68
Rate for Payer: Health Management Network Commercial	$318.96
Rate for Payer: Kaiser Permanente Commercial	$236.41
Rate for Payer: Kaiser Permanente Medicaid	$191.38
Rate for Payer: MDX Hawaii PPO	$363.99
Rate for Payer: University Health Alliance Commercial	$210.14

Stent Ureteral Inlay Optima 8FR 28cm 788828 [3642974]

Facility

$375.25

Service Code	HCPCS C2617
Hospital Charge Code	3642974
Hospital Revenue Code	278
Min. Negotiated Rate	$210.14
Max. Negotiated Rate	$363.99
Rate for Payer: Cash Price	$243.91
Rate for Payer: Hawaii Western Management Group Commercial	$262.68
Rate for Payer: Health Management Network Commercial	$318.96
Rate for Payer: MDX Hawaii PPO	$363.99
Rate for Payer: University Health Alliance Commercial	$210.14

Know your out-of-pocket cost for care.

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