Kona Community Hospital

All Charges

Charge

Type

Setting

Price

STERILE TALC 4 G INTRAPL SUSR

Facility

$645.86

Service Code	NDC 62327044444
Hospital Revenue Code	250
Min. Negotiated Rate	$329.39
Max. Negotiated Rate	$626.48
Rate for Payer: Cash Price	$419.81
Rate for Payer: Hawaii Western Management Group Commercial	$613.57
Rate for Payer: Health Management Network Commercial	$548.98
Rate for Payer: Kaiser Permanente Commercial	$406.89
Rate for Payer: Kaiser Permanente Medicaid	$329.39
Rate for Payer: MDX Hawaii PPO	$626.48
Rate for Payer: UnitedHealthcare Medicaid	$387.52
Rate for Payer: University Health Alliance Commercial	$470.77

STERILE TALC 4 G INTRAPL SUSR

Facility

$645.86

Service Code	NDC 62327044444
Hospital Revenue Code	250
Min. Negotiated Rate	$548.98
Max. Negotiated Rate	$626.48
Rate for Payer: Cash Price	$419.81
Rate for Payer: Health Management Network Commercial	$548.98
Rate for Payer: MDX Hawaii PPO	$626.48

STERILE TALC 4 G INTRAPL SUSR

Facility

$645.86

Service Code	NDC 62327044404
Hospital Revenue Code	250
Min. Negotiated Rate	$329.39
Max. Negotiated Rate	$626.48
Rate for Payer: Cash Price	$419.81
Rate for Payer: Hawaii Western Management Group Commercial	$613.57
Rate for Payer: Health Management Network Commercial	$548.98
Rate for Payer: Kaiser Permanente Commercial	$406.89
Rate for Payer: Kaiser Permanente Medicaid	$329.39
Rate for Payer: MDX Hawaii PPO	$626.48
Rate for Payer: UnitedHealthcare Medicaid	$387.52
Rate for Payer: University Health Alliance Commercial	$470.77

STERILE TALC 4 G INTRAPL SUSR

Facility

$645.86

Service Code	NDC 62327044404
Hospital Revenue Code	250
Min. Negotiated Rate	$548.98
Max. Negotiated Rate	$626.48
Rate for Payer: Cash Price	$419.81
Rate for Payer: Health Management Network Commercial	$548.98
Rate for Payer: MDX Hawaii PPO	$626.48

Stimublast Dbm Putty 5cc ABS-2001-05 [3644167]

Facility

$6,172.00

Service Code	HCPCS C1713
Hospital Charge Code	3644167
Hospital Revenue Code	278
Min. Negotiated Rate	$3,147.72
Max. Negotiated Rate	$5,986.84
Rate for Payer: Cash Price	$4,011.80
Rate for Payer: Hawaii Western Management Group Commercial	$4,320.40
Rate for Payer: Health Management Network Commercial	$5,246.20
Rate for Payer: Kaiser Permanente Commercial	$3,888.36
Rate for Payer: Kaiser Permanente Medicaid	$3,147.72
Rate for Payer: MDX Hawaii PPO	$5,986.84
Rate for Payer: University Health Alliance Commercial	$3,456.32

Stimublast Dbm Putty 5cc ABS-2001-05 [3644167]

Facility

$6,172.00

Service Code	HCPCS C1713
Hospital Charge Code	3644167
Hospital Revenue Code	278
Min. Negotiated Rate	$3,456.32
Max. Negotiated Rate	$5,986.84
Rate for Payer: Cash Price	$4,011.80
Rate for Payer: Hawaii Western Management Group Commercial	$4,320.40
Rate for Payer: Health Management Network Commercial	$5,246.20
Rate for Payer: MDX Hawaii PPO	$5,986.84
Rate for Payer: University Health Alliance Commercial	$3,456.32

Stimulan Rapid Cure 10cc 620010 [3642452]

Facility

$7,278.00

Service Code	HCPCS C1713
Hospital Charge Code	3642452
Hospital Revenue Code	278
Min. Negotiated Rate	$3,711.78
Max. Negotiated Rate	$7,059.66
Rate for Payer: Cash Price	$4,730.70
Rate for Payer: Hawaii Western Management Group Commercial	$5,094.60
Rate for Payer: Health Management Network Commercial	$6,186.30
Rate for Payer: Kaiser Permanente Commercial	$4,585.14
Rate for Payer: Kaiser Permanente Medicaid	$3,711.78
Rate for Payer: MDX Hawaii PPO	$7,059.66
Rate for Payer: University Health Alliance Commercial	$4,075.68

Stimulan Rapid Cure 10cc 620010 [3642452]

Facility

$7,278.00

Service Code	HCPCS C1713
Hospital Charge Code	3642452
Hospital Revenue Code	278
Min. Negotiated Rate	$4,075.68
Max. Negotiated Rate	$7,059.66
Rate for Payer: Cash Price	$4,730.70
Rate for Payer: Hawaii Western Management Group Commercial	$5,094.60
Rate for Payer: Health Management Network Commercial	$6,186.30
Rate for Payer: MDX Hawaii PPO	$7,059.66
Rate for Payer: University Health Alliance Commercial	$4,075.68

Stimulan Rapid Cure 20cc 620020 [3642745]

Facility

$11,828.00

Service Code	HCPCS C1713
Hospital Charge Code	3642745
Hospital Revenue Code	278
Min. Negotiated Rate	$6,032.28
Max. Negotiated Rate	$11,473.16
Rate for Payer: Cash Price	$7,688.20
Rate for Payer: Hawaii Western Management Group Commercial	$8,279.60
Rate for Payer: Health Management Network Commercial	$10,053.80
Rate for Payer: Kaiser Permanente Commercial	$7,451.64
Rate for Payer: Kaiser Permanente Medicaid	$6,032.28
Rate for Payer: MDX Hawaii PPO	$11,473.16
Rate for Payer: University Health Alliance Commercial	$6,623.68

Stimulan Rapid Cure 20cc 620020 [3642745]

Facility

$11,828.00

Service Code	HCPCS C1713
Hospital Charge Code	3642745
Hospital Revenue Code	278
Min. Negotiated Rate	$6,623.68
Max. Negotiated Rate	$11,473.16
Rate for Payer: Cash Price	$7,688.20
Rate for Payer: Hawaii Western Management Group Commercial	$8,279.60
Rate for Payer: Health Management Network Commercial	$10,053.80
Rate for Payer: MDX Hawaii PPO	$11,473.16
Rate for Payer: University Health Alliance Commercial	$6,623.68

STOMACH, ESOPHAGEAL AND DUODENAL PROCEDURES WITH CC

Facility

$91,172.67

Service Code	MSDRG 327
Min. Negotiated Rate	$32,147.98
Max. Negotiated Rate	$91,172.67
Rate for Payer: AlohaCare Medicare	$32,147.98
Rate for Payer: Devoted Health Medicare	$35,362.78
Rate for Payer: Hawaii Medical Service Association Commercial	$91,172.67
Rate for Payer: Hawaii Medical Service Association Medicare	$32,147.98
Rate for Payer: Humana Medicare	$32,147.98
Rate for Payer: Kaiser Permanente Commercial	$42,162.45
Rate for Payer: Kaiser Permanente Medicare	$32,147.98
Rate for Payer: Ohana Health Plan Medicare	$32,147.98
Rate for Payer: UnitedHealthcare Medicare	$32,147.98

STOMACH, ESOPHAGEAL AND DUODENAL PROCEDURES WITH MCC

Facility

$128,803.70

Service Code	MSDRG 326
Min. Negotiated Rate	$65,598.10
Max. Negotiated Rate	$128,803.70
Rate for Payer: AlohaCare Medicare	$65,598.10
Rate for Payer: Devoted Health Medicare	$72,157.91
Rate for Payer: Hawaii Medical Service Association Commercial	$128,803.70
Rate for Payer: Hawaii Medical Service Association Medicare	$65,598.10
Rate for Payer: Humana Medicare	$65,598.10
Rate for Payer: Kaiser Permanente Commercial	$86,032.65
Rate for Payer: Kaiser Permanente Medicare	$65,598.10
Rate for Payer: Ohana Health Plan Medicare	$65,598.10
Rate for Payer: UnitedHealthcare Medicare	$65,598.10

STOMACH, ESOPHAGEAL AND DUODENAL PROCEDURES WITHOUT CC/MCC

Facility

$39,029.23

Service Code	MSDRG 328
Min. Negotiated Rate	$21,074.67
Max. Negotiated Rate	$39,029.23
Rate for Payer: AlohaCare Medicare	$21,074.67
Rate for Payer: Devoted Health Medicare	$23,182.14
Rate for Payer: Hawaii Medical Service Association Commercial	$39,029.23
Rate for Payer: Hawaii Medical Service Association Medicare	$21,074.67
Rate for Payer: Humana Medicare	$21,074.67
Rate for Payer: Kaiser Permanente Commercial	$27,639.67
Rate for Payer: Kaiser Permanente Medicare	$21,074.67
Rate for Payer: Ohana Health Plan Medicare	$21,074.67
Rate for Payer: UnitedHealthcare Medicare	$21,074.67

Stone Basket 1.9FR Zero Tip M0063901050 [3601721]

Facility

$1,192.06

Hospital Charge Code	3601721
Hospital Revenue Code	272
Min. Negotiated Rate	$607.95
Max. Negotiated Rate	$1,156.30
Rate for Payer: Cash Price	$774.84
Rate for Payer: Hawaii Western Management Group Commercial	$1,132.46
Rate for Payer: Health Management Network Commercial	$1,013.25
Rate for Payer: Kaiser Permanente Commercial	$751.00
Rate for Payer: Kaiser Permanente Medicaid	$607.95
Rate for Payer: MDX Hawaii PPO	$1,156.30
Rate for Payer: University Health Alliance Commercial	$868.89

Stone Basket 1.9FR Zero Tip M0063901050 [3601721]

Facility

$1,192.06

Hospital Charge Code	3601721
Hospital Revenue Code	272
Min. Negotiated Rate	$1,013.25
Max. Negotiated Rate	$1,156.30
Rate for Payer: Cash Price	$774.84
Rate for Payer: Health Management Network Commercial	$1,013.25
Rate for Payer: MDX Hawaii PPO	$1,156.30

Stone Basket 8mm Dakota M006390500 [3642090]

Facility

$1,218.03

Hospital Charge Code	3642090
Hospital Revenue Code	272
Min. Negotiated Rate	$621.20
Max. Negotiated Rate	$1,181.49
Rate for Payer: Cash Price	$791.72
Rate for Payer: Hawaii Western Management Group Commercial	$1,157.13
Rate for Payer: Health Management Network Commercial	$1,035.33
Rate for Payer: Kaiser Permanente Commercial	$767.36
Rate for Payer: Kaiser Permanente Medicaid	$621.20
Rate for Payer: MDX Hawaii PPO	$1,181.49
Rate for Payer: University Health Alliance Commercial	$887.82

Stone Basket 8mm Dakota M006390500 [3642090]

Facility

$1,218.03

Hospital Charge Code	3642090
Hospital Revenue Code	272
Min. Negotiated Rate	$1,035.33
Max. Negotiated Rate	$1,181.49
Rate for Payer: Cash Price	$791.72
Rate for Payer: Health Management Network Commercial	$1,035.33
Rate for Payer: MDX Hawaii PPO	$1,181.49

Straight Plate, 2.7mm, 10-Hole AR-18827P-07 [3645525]

Facility

$8,475.00

Service Code	HCPCS C1713
Hospital Charge Code	3645525
Hospital Revenue Code	278
Min. Negotiated Rate	$4,322.25
Max. Negotiated Rate	$8,220.75
Rate for Payer: Cash Price	$5,508.75
Rate for Payer: Hawaii Western Management Group Commercial	$5,932.50
Rate for Payer: Health Management Network Commercial	$7,203.75
Rate for Payer: Kaiser Permanente Commercial	$5,339.25
Rate for Payer: Kaiser Permanente Medicaid	$4,322.25
Rate for Payer: MDX Hawaii PPO	$8,220.75
Rate for Payer: University Health Alliance Commercial	$4,746.00

Straight Plate, 2.7mm, 10-Hole AR-18827P-07 [3645525]

Facility

$8,475.00

Service Code	HCPCS C1713
Hospital Charge Code	3645525
Hospital Revenue Code	278
Min. Negotiated Rate	$4,746.00
Max. Negotiated Rate	$8,220.75
Rate for Payer: Cash Price	$5,508.75
Rate for Payer: Hawaii Western Management Group Commercial	$5,932.50
Rate for Payer: Health Management Network Commercial	$7,203.75
Rate for Payer: MDX Hawaii PPO	$8,220.75
Rate for Payer: University Health Alliance Commercial	$4,746.00

Stravix Cryopreserved Umbilical Tissue 2cm x 4cm PS60005 [3644255]

Facility

$7,488.00

Service Code	HCPCS Q4133
Hospital Charge Code	3644255
Hospital Revenue Code	278
Min. Negotiated Rate	$102.14
Max. Negotiated Rate	$7,263.36
Rate for Payer: AlohaCare Medicaid	$147.01
Rate for Payer: AlohaCare Medicare	$147.01
Rate for Payer: Cash Price	$4,867.20
Rate for Payer: Cash Price	$4,867.20
Rate for Payer: Devoted Health Medicare	$161.71
Rate for Payer: Hawaii Medical Service Association ABD	$136.18
Rate for Payer: Hawaii Medical Service Association Commercial	$183.76
Rate for Payer: Hawaii Medical Service Association Medicare	$147.01
Rate for Payer: Hawaii Medical Service Association Non-ABD	$136.18
Rate for Payer: Hawaii Western Management Group Commercial	$5,241.60
Rate for Payer: Health Management Network Commercial	$6,364.80
Rate for Payer: Humana Medicare	$147.01
Rate for Payer: Kaiser Permanente Commercial	$4,717.44
Rate for Payer: Kaiser Permanente Medicaid	$3,818.88
Rate for Payer: Kaiser Permanente Medicare	$147.01
Rate for Payer: MDX Hawaii PPO	$7,263.36
Rate for Payer: Ohana Health Plan Medicaid	$161.71
Rate for Payer: Ohana Health Plan Medicare	$147.01
Rate for Payer: UnitedHealthcare Medicaid	$102.14
Rate for Payer: UnitedHealthcare Medicare	$147.01
Rate for Payer: University Health Alliance Commercial	$4,193.28

Stravix Cryopreserved Umbilical Tissue 2cm x 4cm PS60005 [3644255]

Facility

$7,488.00

Service Code	HCPCS Q4133
Hospital Charge Code	3644255
Hospital Revenue Code	278
Min. Negotiated Rate	$4,193.28
Max. Negotiated Rate	$7,263.36
Rate for Payer: Cash Price	$4,867.20
Rate for Payer: Hawaii Western Management Group Commercial	$5,241.60
Rate for Payer: Health Management Network Commercial	$6,364.80
Rate for Payer: MDX Hawaii PPO	$7,263.36
Rate for Payer: University Health Alliance Commercial	$4,193.28

Stravix Meshed Umbilical Tissue 3cm x 6cm PS60036 [3643980]

Facility

$11,898.00

Service Code	HCPCS Q4133
Hospital Charge Code	3643980
Hospital Revenue Code	278
Min. Negotiated Rate	$102.14
Max. Negotiated Rate	$11,541.06
Rate for Payer: AlohaCare Medicaid	$147.01
Rate for Payer: AlohaCare Medicare	$147.01
Rate for Payer: Cash Price	$7,733.70
Rate for Payer: Cash Price	$7,733.70
Rate for Payer: Devoted Health Medicare	$161.71
Rate for Payer: Hawaii Medical Service Association ABD	$136.18
Rate for Payer: Hawaii Medical Service Association Commercial	$183.76
Rate for Payer: Hawaii Medical Service Association Medicare	$147.01
Rate for Payer: Hawaii Medical Service Association Non-ABD	$136.18
Rate for Payer: Hawaii Western Management Group Commercial	$8,328.60
Rate for Payer: Health Management Network Commercial	$10,113.30
Rate for Payer: Humana Medicare	$147.01
Rate for Payer: Kaiser Permanente Commercial	$7,495.74
Rate for Payer: Kaiser Permanente Medicaid	$6,067.98
Rate for Payer: Kaiser Permanente Medicare	$147.01
Rate for Payer: MDX Hawaii PPO	$11,541.06
Rate for Payer: Ohana Health Plan Medicaid	$161.71
Rate for Payer: Ohana Health Plan Medicare	$147.01
Rate for Payer: UnitedHealthcare Medicaid	$102.14
Rate for Payer: UnitedHealthcare Medicare	$147.01
Rate for Payer: University Health Alliance Commercial	$6,662.88

Stravix Meshed Umbilical Tissue 3cm x 6cm PS60036 [3643980]

Facility

$11,898.00

Service Code	HCPCS Q4133
Hospital Charge Code	3643980
Hospital Revenue Code	278
Min. Negotiated Rate	$6,662.88
Max. Negotiated Rate	$11,541.06
Rate for Payer: Cash Price	$7,733.70
Rate for Payer: Hawaii Western Management Group Commercial	$8,328.60
Rate for Payer: Health Management Network Commercial	$10,113.30
Rate for Payer: MDX Hawaii PPO	$11,541.06
Rate for Payer: University Health Alliance Commercial	$6,662.88

Stravix PL Placental Tissue Graft 3cm x 6cm PS61036 [3642811]

Facility

$12,641.75

Service Code	HCPCS Q4133
Hospital Charge Code	3642811
Hospital Revenue Code	278
Min. Negotiated Rate	$102.14
Max. Negotiated Rate	$12,262.50
Rate for Payer: AlohaCare Medicaid	$147.01
Rate for Payer: AlohaCare Medicare	$147.01
Rate for Payer: Cash Price	$8,217.14
Rate for Payer: Cash Price	$8,217.14
Rate for Payer: Devoted Health Medicare	$161.71
Rate for Payer: Hawaii Medical Service Association ABD	$136.18
Rate for Payer: Hawaii Medical Service Association Commercial	$183.76
Rate for Payer: Hawaii Medical Service Association Medicare	$147.01
Rate for Payer: Hawaii Medical Service Association Non-ABD	$136.18
Rate for Payer: Hawaii Western Management Group Commercial	$8,849.23
Rate for Payer: Health Management Network Commercial	$10,745.49
Rate for Payer: Humana Medicare	$147.01
Rate for Payer: Kaiser Permanente Commercial	$7,964.30
Rate for Payer: Kaiser Permanente Medicaid	$6,447.29
Rate for Payer: Kaiser Permanente Medicare	$147.01
Rate for Payer: MDX Hawaii PPO	$12,262.50
Rate for Payer: Ohana Health Plan Medicaid	$161.71
Rate for Payer: Ohana Health Plan Medicare	$147.01
Rate for Payer: UnitedHealthcare Medicaid	$102.14
Rate for Payer: UnitedHealthcare Medicare	$147.01
Rate for Payer: University Health Alliance Commercial	$7,079.38

Stravix PL Placental Tissue Graft 3cm x 6cm PS61036 [3642811]

Facility

$12,641.75

Service Code	HCPCS Q4133
Hospital Charge Code	3642811
Hospital Revenue Code	278
Min. Negotiated Rate	$7,079.38
Max. Negotiated Rate	$12,262.50
Rate for Payer: Cash Price	$8,217.14
Rate for Payer: Hawaii Western Management Group Commercial	$8,849.23
Rate for Payer: Health Management Network Commercial	$10,745.49
Rate for Payer: MDX Hawaii PPO	$12,262.50
Rate for Payer: University Health Alliance Commercial	$7,079.38

Know your out-of-pocket cost for care.

All Charges