Kona Community Hospital

All Charges

Charge

Type

Setting

Price

SURGICEL 2" X 3" 1953 [2702250]

Facility

$454.99

Hospital Charge Code	2702250
Hospital Revenue Code	272
Min. Negotiated Rate	$386.74
Max. Negotiated Rate	$441.34
Rate for Payer: Cash Price	$295.74
Rate for Payer: Health Management Network Commercial	$386.74
Rate for Payer: MDX Hawaii PPO	$441.34

SURGICEL 4" X 8" 1952 [2702251]

Facility

$740.63

Hospital Charge Code	2702251
Hospital Revenue Code	272
Min. Negotiated Rate	$629.54
Max. Negotiated Rate	$718.41
Rate for Payer: Cash Price	$481.41
Rate for Payer: Health Management Network Commercial	$629.54
Rate for Payer: MDX Hawaii PPO	$718.41

SURGICEL 4" X 8" 1952 [2702251]

Facility

$740.63

Hospital Charge Code	2702251
Hospital Revenue Code	272
Min. Negotiated Rate	$377.72
Max. Negotiated Rate	$718.41
Rate for Payer: Cash Price	$481.41
Rate for Payer: Hawaii Western Management Group Commercial	$703.60
Rate for Payer: Health Management Network Commercial	$629.54
Rate for Payer: Kaiser Permanente Commercial	$466.60
Rate for Payer: Kaiser Permanente Medicaid	$377.72
Rate for Payer: MDX Hawaii PPO	$718.41
Rate for Payer: University Health Alliance Commercial	$539.85

Surgicel Powder 3.0 Grams 3013SP [3641290]

Facility

$1,330.75

Hospital Charge Code	3641290
Hospital Revenue Code	272
Min. Negotiated Rate	$1,131.14
Max. Negotiated Rate	$1,290.83
Rate for Payer: Cash Price	$864.99
Rate for Payer: Health Management Network Commercial	$1,131.14
Rate for Payer: MDX Hawaii PPO	$1,290.83

Surgicel Powder 3.0 Grams 3013SP [3641290]

Facility

$1,330.75

Hospital Charge Code	3641290
Hospital Revenue Code	272
Min. Negotiated Rate	$678.68
Max. Negotiated Rate	$1,290.83
Rate for Payer: Cash Price	$864.99
Rate for Payer: Hawaii Western Management Group Commercial	$1,264.21
Rate for Payer: Health Management Network Commercial	$1,131.14
Rate for Payer: Kaiser Permanente Commercial	$838.37
Rate for Payer: Kaiser Permanente Medicaid	$678.68
Rate for Payer: MDX Hawaii PPO	$1,290.83
Rate for Payer: University Health Alliance Commercial	$969.98

Surgicel Powder Endoscopic Applicator 3123SPEA [3641786]

Facility

$218.01

Hospital Charge Code	3641786
Hospital Revenue Code	272
Min. Negotiated Rate	$111.19
Max. Negotiated Rate	$211.47
Rate for Payer: Cash Price	$141.71
Rate for Payer: Hawaii Western Management Group Commercial	$207.11
Rate for Payer: Health Management Network Commercial	$185.31
Rate for Payer: Kaiser Permanente Commercial	$137.35
Rate for Payer: Kaiser Permanente Medicaid	$111.19
Rate for Payer: MDX Hawaii PPO	$211.47
Rate for Payer: University Health Alliance Commercial	$158.91

Surgicel Powder Endoscopic Applicator 3123SPEA [3641786]

Facility

$218.01

Hospital Charge Code	3641786
Hospital Revenue Code	272
Min. Negotiated Rate	$185.31
Max. Negotiated Rate	$211.47
Rate for Payer: Cash Price	$141.71
Rate for Payer: Health Management Network Commercial	$185.31
Rate for Payer: MDX Hawaii PPO	$211.47

Surgiflo Endo Applicator MS1995 [3642481]

Facility

$507.49

Hospital Charge Code	3642481
Hospital Revenue Code	272
Min. Negotiated Rate	$258.82
Max. Negotiated Rate	$492.27
Rate for Payer: Cash Price	$329.87
Rate for Payer: Hawaii Western Management Group Commercial	$482.12
Rate for Payer: Health Management Network Commercial	$431.37
Rate for Payer: Kaiser Permanente Commercial	$319.72
Rate for Payer: Kaiser Permanente Medicaid	$258.82
Rate for Payer: MDX Hawaii PPO	$492.27
Rate for Payer: University Health Alliance Commercial	$369.91

Surgiflo Endo Applicator MS1995 [3642481]

Facility

$507.49

Hospital Charge Code	3642481
Hospital Revenue Code	272
Min. Negotiated Rate	$431.37
Max. Negotiated Rate	$492.27
Rate for Payer: Cash Price	$329.87
Rate for Payer: Health Management Network Commercial	$431.37
Rate for Payer: MDX Hawaii PPO	$492.27

Surgiflo W/Thrombin 8ml 2994 [3642471]

Facility

$1,529.73

Hospital Charge Code	3642471
Hospital Revenue Code	272
Min. Negotiated Rate	$1,300.27
Max. Negotiated Rate	$1,483.84
Rate for Payer: Cash Price	$994.32
Rate for Payer: Health Management Network Commercial	$1,300.27
Rate for Payer: MDX Hawaii PPO	$1,483.84

Surgiflo W/Thrombin 8ml 2994 [3642471]

Facility

$1,529.73

Hospital Charge Code	3642471
Hospital Revenue Code	272
Min. Negotiated Rate	$780.16
Max. Negotiated Rate	$1,483.84
Rate for Payer: Cash Price	$994.32
Rate for Payer: Hawaii Western Management Group Commercial	$1,453.24
Rate for Payer: Health Management Network Commercial	$1,300.27
Rate for Payer: Kaiser Permanente Commercial	$963.73
Rate for Payer: Kaiser Permanente Medicaid	$780.16
Rate for Payer: MDX Hawaii PPO	$1,483.84
Rate for Payer: University Health Alliance Commercial	$1,115.02

Suture 0 PDSII VIO CT LP D6361 [3642590]

Facility

$264.99

Hospital Charge Code	3642590
Hospital Revenue Code	272
Min. Negotiated Rate	$135.14
Max. Negotiated Rate	$257.04
Rate for Payer: Cash Price	$172.24
Rate for Payer: Hawaii Western Management Group Commercial	$251.74
Rate for Payer: Health Management Network Commercial	$225.24
Rate for Payer: Kaiser Permanente Commercial	$166.94
Rate for Payer: Kaiser Permanente Medicaid	$135.14
Rate for Payer: MDX Hawaii PPO	$257.04
Rate for Payer: University Health Alliance Commercial	$193.15

Suture 0 PDSII VIO CT LP D6361 [3642590]

Facility

$264.99

Hospital Charge Code	3642590
Hospital Revenue Code	272
Min. Negotiated Rate	$225.24
Max. Negotiated Rate	$257.04
Rate for Payer: Cash Price	$172.24
Rate for Payer: Health Management Network Commercial	$225.24
Rate for Payer: MDX Hawaii PPO	$257.04

Suture Anchor Swivelock Tenodesis Peek AR-7324PSL [3644102]

Facility

$3,765.50

Service Code	HCPCS C1713
Hospital Charge Code	3644102
Hospital Revenue Code	278
Min. Negotiated Rate	$1,920.40
Max. Negotiated Rate	$3,652.53
Rate for Payer: Cash Price	$2,447.58
Rate for Payer: Hawaii Western Management Group Commercial	$2,635.85
Rate for Payer: Health Management Network Commercial	$3,200.68
Rate for Payer: Kaiser Permanente Commercial	$2,372.26
Rate for Payer: Kaiser Permanente Medicaid	$1,920.40
Rate for Payer: MDX Hawaii PPO	$3,652.53
Rate for Payer: University Health Alliance Commercial	$2,108.68

Suture Anchor Swivelock Tenodesis Peek AR-7324PSL [3644102]

Facility

$3,765.50

Service Code	HCPCS C1713
Hospital Charge Code	3644102
Hospital Revenue Code	278
Min. Negotiated Rate	$2,108.68
Max. Negotiated Rate	$3,652.53
Rate for Payer: Cash Price	$2,447.58
Rate for Payer: Hawaii Western Management Group Commercial	$2,635.85
Rate for Payer: Health Management Network Commercial	$3,200.68
Rate for Payer: MDX Hawaii PPO	$3,652.53
Rate for Payer: University Health Alliance Commercial	$2,108.68

Suture Ethibond 0 MO-7 CR CX41D [3642550]

Facility

$152.16

Hospital Charge Code	3642550
Hospital Revenue Code	272
Min. Negotiated Rate	$129.34
Max. Negotiated Rate	$147.60
Rate for Payer: Cash Price	$98.90
Rate for Payer: Health Management Network Commercial	$129.34
Rate for Payer: MDX Hawaii PPO	$147.60

Suture Ethibond 0 MO-7 CR CX41D [3642550]

Facility

$152.16

Hospital Charge Code	3642550
Hospital Revenue Code	272
Min. Negotiated Rate	$77.60
Max. Negotiated Rate	$147.60
Rate for Payer: Cash Price	$98.90
Rate for Payer: Hawaii Western Management Group Commercial	$144.55
Rate for Payer: Health Management Network Commercial	$129.34
Rate for Payer: Kaiser Permanente Commercial	$95.86
Rate for Payer: Kaiser Permanente Medicaid	$77.60
Rate for Payer: MDX Hawaii PPO	$147.60
Rate for Payer: University Health Alliance Commercial	$110.91

Suture Ethibond 0 SH D8495 [3643038]

Facility

$228.20

Hospital Charge Code	3643038
Hospital Revenue Code	272
Min. Negotiated Rate	$193.97
Max. Negotiated Rate	$221.35
Rate for Payer: Cash Price	$148.33
Rate for Payer: Health Management Network Commercial	$193.97
Rate for Payer: MDX Hawaii PPO	$221.35

Suture Ethibond 0 SH D8495 [3643038]

Facility

$228.20

Hospital Charge Code	3643038
Hospital Revenue Code	272
Min. Negotiated Rate	$116.38
Max. Negotiated Rate	$221.35
Rate for Payer: Cash Price	$148.33
Rate for Payer: Hawaii Western Management Group Commercial	$216.79
Rate for Payer: Health Management Network Commercial	$193.97
Rate for Payer: Kaiser Permanente Commercial	$143.77
Rate for Payer: Kaiser Permanente Medicaid	$116.38
Rate for Payer: MDX Hawaii PPO	$221.35
Rate for Payer: University Health Alliance Commercial	$166.33

Suture Ethibond 1 CTX CR CX30D [3642549]

Facility

$128.96

Hospital Charge Code	3642549
Hospital Revenue Code	272
Min. Negotiated Rate	$65.77
Max. Negotiated Rate	$125.09
Rate for Payer: Cash Price	$83.82
Rate for Payer: Hawaii Western Management Group Commercial	$122.51
Rate for Payer: Health Management Network Commercial	$109.62
Rate for Payer: Kaiser Permanente Commercial	$81.24
Rate for Payer: Kaiser Permanente Medicaid	$65.77
Rate for Payer: MDX Hawaii PPO	$125.09
Rate for Payer: University Health Alliance Commercial	$94.00

Suture Ethibond 1 CTX CR CX30D [3642549]

Facility

$128.96

Hospital Charge Code	3642549
Hospital Revenue Code	272
Min. Negotiated Rate	$109.62
Max. Negotiated Rate	$125.09
Rate for Payer: Cash Price	$83.82
Rate for Payer: Health Management Network Commercial	$109.62
Rate for Payer: MDX Hawaii PPO	$125.09

Suture Ethibond 2 OS-6 DC493 [3642547]

Facility

$247.17

Hospital Charge Code	3642547
Hospital Revenue Code	272
Min. Negotiated Rate	$210.09
Max. Negotiated Rate	$239.75
Rate for Payer: Cash Price	$160.66
Rate for Payer: Health Management Network Commercial	$210.09
Rate for Payer: MDX Hawaii PPO	$239.75

Suture Ethibond 2 OS-6 DC493 [3642547]

Facility

$247.17

Hospital Charge Code	3642547
Hospital Revenue Code	272
Min. Negotiated Rate	$126.06
Max. Negotiated Rate	$239.75
Rate for Payer: Cash Price	$160.66
Rate for Payer: Hawaii Western Management Group Commercial	$234.81
Rate for Payer: Health Management Network Commercial	$210.09
Rate for Payer: Kaiser Permanente Commercial	$155.72
Rate for Payer: Kaiser Permanente Medicaid	$126.06
Rate for Payer: MDX Hawaii PPO	$239.75
Rate for Payer: University Health Alliance Commercial	$180.16

Suture Ethibond 2 V-37 MX69G [3642482]

Facility

$174.48

Hospital Charge Code	3642482
Hospital Revenue Code	272
Min. Negotiated Rate	$88.98
Max. Negotiated Rate	$169.25
Rate for Payer: Cash Price	$113.41
Rate for Payer: Hawaii Western Management Group Commercial	$165.76
Rate for Payer: Health Management Network Commercial	$148.31
Rate for Payer: Kaiser Permanente Commercial	$109.92
Rate for Payer: Kaiser Permanente Medicaid	$88.98
Rate for Payer: MDX Hawaii PPO	$169.25
Rate for Payer: University Health Alliance Commercial	$127.18

Suture Ethibond 2 V-37 MX69G [3642482]

Facility

$174.48

Hospital Charge Code	3642482
Hospital Revenue Code	272
Min. Negotiated Rate	$148.31
Max. Negotiated Rate	$169.25
Rate for Payer: Cash Price	$113.41
Rate for Payer: Health Management Network Commercial	$148.31
Rate for Payer: MDX Hawaii PPO	$169.25

Know your out-of-pocket cost for care.

All Charges