Kona Community Hospital

All Charges

Charge

Type

Setting

Price

Total Shoulder Univers Revers Suture Cup 36 Neutral AR-9502F-36CPC [3642758]

Facility

$11,915.50

Service Code	HCPCS C1776
Hospital Charge Code	3642758
Hospital Revenue Code	278
Min. Negotiated Rate	$6,076.90
Max. Negotiated Rate	$11,558.03
Rate for Payer: Cash Price	$7,745.08
Rate for Payer: Hawaii Western Management Group Commercial	$8,340.85
Rate for Payer: Health Management Network Commercial	$10,128.17
Rate for Payer: Kaiser Permanente Commercial	$7,506.77
Rate for Payer: Kaiser Permanente Medicaid	$6,076.90
Rate for Payer: MDX Hawaii PPO	$11,558.03
Rate for Payer: University Health Alliance Commercial	$6,672.68

Total Shoulder Univers Vaultlock Glenoid Med [3643653]

Facility

$6,562.50

Service Code	HCPCS C1776
Hospital Charge Code	3643653
Hospital Revenue Code	278
Min. Negotiated Rate	$3,346.88
Max. Negotiated Rate	$6,365.62
Rate for Payer: Cash Price	$4,265.62
Rate for Payer: Hawaii Western Management Group Commercial	$4,593.75
Rate for Payer: Health Management Network Commercial	$5,578.12
Rate for Payer: Kaiser Permanente Commercial	$4,134.38
Rate for Payer: Kaiser Permanente Medicaid	$3,346.88
Rate for Payer: MDX Hawaii PPO	$6,365.62
Rate for Payer: University Health Alliance Commercial	$3,675.00

Total Shoulder Univers Vaultlock Glenoid Med [3643653]

Facility

$6,562.50

Service Code	HCPCS C1776
Hospital Charge Code	3643653
Hospital Revenue Code	278
Min. Negotiated Rate	$3,675.00
Max. Negotiated Rate	$6,365.62
Rate for Payer: Cash Price	$4,265.62
Rate for Payer: Hawaii Western Management Group Commercial	$4,593.75
Rate for Payer: Health Management Network Commercial	$5,578.12
Rate for Payer: MDX Hawaii PPO	$6,365.62
Rate for Payer: University Health Alliance Commercial	$3,675.00

Total Shoulder Univ Rev Hum Stem Sz 12 AR-9501-12P [3644612]

Facility

$16,000.00

Service Code	HCPCS C1776
Hospital Charge Code	3644612
Hospital Revenue Code	278
Min. Negotiated Rate	$8,960.00
Max. Negotiated Rate	$15,520.00
Rate for Payer: Cash Price	$10,400.00
Rate for Payer: Hawaii Western Management Group Commercial	$11,200.00
Rate for Payer: Health Management Network Commercial	$13,600.00
Rate for Payer: MDX Hawaii PPO	$15,520.00
Rate for Payer: University Health Alliance Commercial	$8,960.00

Total Shoulder Univ Rev Hum Stem Sz 12 AR-9501-12P [3644612]

Facility

$16,000.00

Service Code	HCPCS C1776
Hospital Charge Code	3644612
Hospital Revenue Code	278
Min. Negotiated Rate	$8,160.00
Max. Negotiated Rate	$15,520.00
Rate for Payer: Cash Price	$10,400.00
Rate for Payer: Hawaii Western Management Group Commercial	$11,200.00
Rate for Payer: Health Management Network Commercial	$13,600.00
Rate for Payer: Kaiser Permanente Commercial	$10,080.00
Rate for Payer: Kaiser Permanente Medicaid	$8,160.00
Rate for Payer: MDX Hawaii PPO	$15,520.00
Rate for Payer: University Health Alliance Commercial	$8,960.00

Total Shoulder Univ Rev Suture Cup 33 +2 Lt AR-9502F-33LCPC [3645404]

Facility

$11,915.50

Service Code	HCPCS C1776
Hospital Charge Code	3645404
Hospital Revenue Code	278
Min. Negotiated Rate	$6,672.68
Max. Negotiated Rate	$11,558.03
Rate for Payer: Cash Price	$7,745.08
Rate for Payer: Hawaii Western Management Group Commercial	$8,340.85
Rate for Payer: Health Management Network Commercial	$10,128.17
Rate for Payer: MDX Hawaii PPO	$11,558.03
Rate for Payer: University Health Alliance Commercial	$6,672.68

Total Shoulder Univ Rev Suture Cup 33 +2 Lt AR-9502F-33LCPC [3645404]

Facility

$11,915.50

Service Code	HCPCS C1776
Hospital Charge Code	3645404
Hospital Revenue Code	278
Min. Negotiated Rate	$6,076.90
Max. Negotiated Rate	$11,558.03
Rate for Payer: Cash Price	$7,745.08
Rate for Payer: Hawaii Western Management Group Commercial	$8,340.85
Rate for Payer: Health Management Network Commercial	$10,128.17
Rate for Payer: Kaiser Permanente Commercial	$7,506.77
Rate for Payer: Kaiser Permanente Medicaid	$6,076.90
Rate for Payer: MDX Hawaii PPO	$11,558.03
Rate for Payer: University Health Alliance Commercial	$6,672.68

Total Shoulder Univ Rev Suture Cup 39 +2 Lt AR-9502F-39LCPC [3644613]

Facility

$11,915.50

Service Code	HCPCS C1776
Hospital Charge Code	3644613
Hospital Revenue Code	278
Min. Negotiated Rate	$6,076.90
Max. Negotiated Rate	$11,558.03
Rate for Payer: Cash Price	$7,745.08
Rate for Payer: Hawaii Western Management Group Commercial	$8,340.85
Rate for Payer: Health Management Network Commercial	$10,128.17
Rate for Payer: Kaiser Permanente Commercial	$7,506.77
Rate for Payer: Kaiser Permanente Medicaid	$6,076.90
Rate for Payer: MDX Hawaii PPO	$11,558.03
Rate for Payer: University Health Alliance Commercial	$6,672.68

Total Shoulder Univ Rev Suture Cup 39 +2 Lt AR-9502F-39LCPC [3644613]

Facility

$11,915.50

Service Code	HCPCS C1776
Hospital Charge Code	3644613
Hospital Revenue Code	278
Min. Negotiated Rate	$6,672.68
Max. Negotiated Rate	$11,558.03
Rate for Payer: Cash Price	$7,745.08
Rate for Payer: Hawaii Western Management Group Commercial	$8,340.85
Rate for Payer: Health Management Network Commercial	$10,128.17
Rate for Payer: MDX Hawaii PPO	$11,558.03
Rate for Payer: University Health Alliance Commercial	$6,672.68

Total Shoulder Usp Ii Humeral Head 44/17 [3643654]

Facility

$7,292.50

Service Code	HCPCS C1776
Hospital Charge Code	3643654
Hospital Revenue Code	278
Min. Negotiated Rate	$4,083.80
Max. Negotiated Rate	$7,073.73
Rate for Payer: Cash Price	$4,740.12
Rate for Payer: Hawaii Western Management Group Commercial	$5,104.75
Rate for Payer: Health Management Network Commercial	$6,198.62
Rate for Payer: MDX Hawaii PPO	$7,073.73
Rate for Payer: University Health Alliance Commercial	$4,083.80

Total Shoulder Usp Ii Humeral Head 44/17 [3643654]

Facility

$7,292.50

Service Code	HCPCS C1776
Hospital Charge Code	3643654
Hospital Revenue Code	278
Min. Negotiated Rate	$3,719.18
Max. Negotiated Rate	$7,073.73
Rate for Payer: Cash Price	$4,740.12
Rate for Payer: Hawaii Western Management Group Commercial	$5,104.75
Rate for Payer: Health Management Network Commercial	$6,198.62
Rate for Payer: Kaiser Permanente Commercial	$4,594.27
Rate for Payer: Kaiser Permanente Medicaid	$3,719.18
Rate for Payer: MDX Hawaii PPO	$7,073.73
Rate for Payer: University Health Alliance Commercial	$4,083.80

Total Shoulder Versa-Dial 42x18x46 Hum Head 113032 [3644447]

Facility

$5,528.00

Service Code	HCPCS C1776
Hospital Charge Code	3644447
Hospital Revenue Code	278
Min. Negotiated Rate	$2,819.28
Max. Negotiated Rate	$5,362.16
Rate for Payer: Cash Price	$3,593.20
Rate for Payer: Hawaii Western Management Group Commercial	$3,869.60
Rate for Payer: Health Management Network Commercial	$4,698.80
Rate for Payer: Kaiser Permanente Commercial	$3,482.64
Rate for Payer: Kaiser Permanente Medicaid	$2,819.28
Rate for Payer: MDX Hawaii PPO	$5,362.16
Rate for Payer: University Health Alliance Commercial	$3,095.68

Total Shoulder Versa-Dial 42x18x46 Hum Head 113032 [3644447]

Facility

$5,528.00

Service Code	HCPCS C1776
Hospital Charge Code	3644447
Hospital Revenue Code	278
Min. Negotiated Rate	$3,095.68
Max. Negotiated Rate	$5,362.16
Rate for Payer: Cash Price	$3,593.20
Rate for Payer: Hawaii Western Management Group Commercial	$3,869.60
Rate for Payer: Health Management Network Commercial	$4,698.80
Rate for Payer: MDX Hawaii PPO	$5,362.16
Rate for Payer: University Health Alliance Commercial	$3,095.68

TOTAL THYROID LOBECTOMY, UNILATERAL; WITH CONTRALATERAL SUBTOTAL LOBECTOMY, INCLUDING ISTHMUSECTOMY

Facility

$17,484.00

Service Code	CPT 60225
Hospital Revenue Code	360
Min. Negotiated Rate	$521.33
Max. Negotiated Rate	$17,484.00
Rate for Payer: AlohaCare Medicaid	$7,141.85
Rate for Payer: AlohaCare Medicare	$7,141.85
Rate for Payer: Devoted Health Medicare	$7,856.03
Rate for Payer: Hawaii Medical Service Association ABD	$1,900.00
Rate for Payer: Hawaii Medical Service Association Commercial	$17,484.00
Rate for Payer: Hawaii Medical Service Association Medicare	$7,141.85
Rate for Payer: Hawaii Medical Service Association Non-ABD	$1,902.37
Rate for Payer: Humana Medicare	$7,141.85
Rate for Payer: Kaiser Permanente Medicaid	$2,837.00
Rate for Payer: Kaiser Permanente Medicare	$7,141.85
Rate for Payer: Ohana Health Plan Medicaid	$7,856.03
Rate for Payer: Ohana Health Plan Medicare	$7,141.85
Rate for Payer: UnitedHealthcare Medicaid	$521.33
Rate for Payer: UnitedHealthcare Medicare	$7,141.85

TOTAL THYROID LOBECTOMY, UNILATERAL; WITH OR WITHOUT ISTHMUSECTOMY

Facility

$20,300.00

Service Code	CPT 60220
Hospital Revenue Code	360
Min. Negotiated Rate	$521.33
Max. Negotiated Rate	$20,300.00
Rate for Payer: AlohaCare Medicaid	$7,141.85
Rate for Payer: AlohaCare Medicare	$7,141.85
Rate for Payer: Devoted Health Medicare	$7,856.03
Rate for Payer: Hawaii Medical Service Association ABD	$1,900.00
Rate for Payer: Hawaii Medical Service Association Commercial	$17,484.00
Rate for Payer: Hawaii Medical Service Association Medicare	$7,141.85
Rate for Payer: Hawaii Medical Service Association Non-ABD	$1,902.37
Rate for Payer: Humana Medicare	$7,141.85
Rate for Payer: Kaiser Permanente Medicaid	$2,837.00
Rate for Payer: Kaiser Permanente Medicare	$7,141.85
Rate for Payer: Ohana Health Plan Medicaid	$7,856.03
Rate for Payer: Ohana Health Plan Medicare	$7,141.85
Rate for Payer: UnitedHealthcare Medicaid	$521.33
Rate for Payer: UnitedHealthcare Medicare	$7,141.85
Rate for Payer: University Health Alliance Commercial	$20,300.00

TOXIC EFFECTS OF NON-MEDICINAL SUBSTANCES

Facility

$2,866.89

Service Code	APR-DRG 8162
Min. Negotiated Rate	$2,866.89
Max. Negotiated Rate	$2,866.89
Rate for Payer: AlohaCare Medicaid	$2,866.89
Rate for Payer: Hawaii Medical Service Association ABD	$2,866.89
Rate for Payer: Hawaii Medical Service Association Non-ABD	$2,866.89
Rate for Payer: Kaiser Permanente Medicaid	$2,866.89
Rate for Payer: Ohana Health Plan Medicaid	$2,866.89
Rate for Payer: UnitedHealthcare Medicaid	$2,866.89

TOXIC EFFECTS OF NON-MEDICINAL SUBSTANCES

Facility

$7,459.51

Service Code	APR-DRG 8164
Min. Negotiated Rate	$7,459.51
Max. Negotiated Rate	$7,459.51
Rate for Payer: AlohaCare Medicaid	$7,459.51
Rate for Payer: Hawaii Medical Service Association ABD	$7,459.51
Rate for Payer: Hawaii Medical Service Association Non-ABD	$7,459.51
Rate for Payer: Kaiser Permanente Medicaid	$7,459.51
Rate for Payer: Ohana Health Plan Medicaid	$7,459.51
Rate for Payer: UnitedHealthcare Medicaid	$7,459.51

TOXIC EFFECTS OF NON-MEDICINAL SUBSTANCES

Facility

$3,825.91

Service Code	APR-DRG 8163
Min. Negotiated Rate	$3,825.91
Max. Negotiated Rate	$3,825.91
Rate for Payer: AlohaCare Medicaid	$3,825.91
Rate for Payer: Hawaii Medical Service Association ABD	$3,825.91
Rate for Payer: Hawaii Medical Service Association Non-ABD	$3,825.91
Rate for Payer: Kaiser Permanente Medicaid	$3,825.91
Rate for Payer: Ohana Health Plan Medicaid	$3,825.91
Rate for Payer: UnitedHealthcare Medicaid	$3,825.91

TOXIC EFFECTS OF NON-MEDICINAL SUBSTANCES

Facility

$2,421.13

Service Code	APR-DRG 8161
Min. Negotiated Rate	$2,421.13
Max. Negotiated Rate	$2,421.13
Rate for Payer: AlohaCare Medicaid	$2,421.13
Rate for Payer: Hawaii Medical Service Association ABD	$2,421.13
Rate for Payer: Hawaii Medical Service Association Non-ABD	$2,421.13
Rate for Payer: Kaiser Permanente Medicaid	$2,421.13
Rate for Payer: Ohana Health Plan Medicaid	$2,421.13
Rate for Payer: UnitedHealthcare Medicaid	$2,421.13

TRACHEOSTOMY FOR FACE, MOUTH AND NECK DIAGNOSES OR LARYNGECTOMY WITH CC

Facility

$84,543.25

Service Code	MSDRG 012
Min. Negotiated Rate	$10,400.00
Max. Negotiated Rate	$84,543.25
Rate for Payer: AlohaCare Medicare	$55,452.06
Rate for Payer: Devoted Health Medicare	$60,997.27
Rate for Payer: Hawaii Medical Service Association Commercial	$84,543.25
Rate for Payer: Hawaii Medical Service Association Medicare	$55,452.06
Rate for Payer: Humana Medicare	$55,452.06
Rate for Payer: Kaiser Permanente Commercial	$72,726.00
Rate for Payer: Kaiser Permanente Medicare	$55,452.06
Rate for Payer: Ohana Health Plan Medicare	$55,452.06
Rate for Payer: UnitedHealthcare Medicare	$55,452.06
Rate for Payer: University Health Alliance Commercial	$10,400.00

TRACHEOSTOMY FOR FACE, MOUTH AND NECK DIAGNOSES OR LARYNGECTOMY WITH MCC

Facility

$94,083.23

Service Code	MSDRG 011
Min. Negotiated Rate	$10,400.00
Max. Negotiated Rate	$94,083.23
Rate for Payer: AlohaCare Medicare	$71,736.50
Rate for Payer: Devoted Health Medicare	$78,910.15
Rate for Payer: Hawaii Medical Service Association Commercial	$84,543.25
Rate for Payer: Hawaii Medical Service Association Medicare	$71,736.50
Rate for Payer: Humana Medicare	$71,736.50
Rate for Payer: Kaiser Permanente Commercial	$94,083.23
Rate for Payer: Kaiser Permanente Medicare	$71,736.50
Rate for Payer: Ohana Health Plan Medicare	$71,736.50
Rate for Payer: UnitedHealthcare Medicare	$71,736.50
Rate for Payer: University Health Alliance Commercial	$10,400.00

TRACHEOSTOMY FOR FACE, MOUTH AND NECK DIAGNOSES OR LARYNGECTOMY WITHOUT CC/MCC

Facility

$84,543.25

Service Code	MSDRG 013
Min. Negotiated Rate	$10,400.00
Max. Negotiated Rate	$84,543.25
Rate for Payer: AlohaCare Medicare	$37,903.64
Rate for Payer: Devoted Health Medicare	$41,694.00
Rate for Payer: Hawaii Medical Service Association Commercial	$84,543.25
Rate for Payer: Hawaii Medical Service Association Medicare	$37,903.64
Rate for Payer: Humana Medicare	$37,903.64
Rate for Payer: Kaiser Permanente Commercial	$49,711.05
Rate for Payer: Kaiser Permanente Medicare	$37,903.64
Rate for Payer: Ohana Health Plan Medicare	$37,903.64
Rate for Payer: UnitedHealthcare Medicare	$37,903.64
Rate for Payer: University Health Alliance Commercial	$10,400.00

TRACHEOSTOMY WITH MV >96 HOURS OR PRINCIPAL DIAGNOSIS EXCEPT FACE, MOUTH AND NECK WITHOUT MAJOR O.R. PROCEDURES

Facility

$411,506.49

Service Code	MSDRG 004
Min. Negotiated Rate	$10,400.00
Max. Negotiated Rate	$411,506.49
Rate for Payer: AlohaCare Medicare	$182,184.23
Rate for Payer: Devoted Health Medicare	$200,402.65
Rate for Payer: Hawaii Medical Service Association Commercial	$411,506.49
Rate for Payer: Hawaii Medical Service Association Medicare	$182,184.23
Rate for Payer: Humana Medicare	$182,184.23
Rate for Payer: Kaiser Permanente Commercial	$238,936.65
Rate for Payer: Kaiser Permanente Medicare	$182,184.23
Rate for Payer: Ohana Health Plan Medicare	$182,184.23
Rate for Payer: UnitedHealthcare Medicare	$182,184.23
Rate for Payer: University Health Alliance Commercial	$10,400.00

TRACHEOSTOMY W MV 96+ HOURS W EXTENSIVE PROCEDURE

Facility

$49,287.28

Service Code	APR-DRG 0043
Min. Negotiated Rate	$49,287.28
Max. Negotiated Rate	$49,287.28
Rate for Payer: AlohaCare Medicaid	$49,287.28
Rate for Payer: Hawaii Medical Service Association ABD	$49,287.28
Rate for Payer: Hawaii Medical Service Association Non-ABD	$49,287.28
Rate for Payer: Kaiser Permanente Medicaid	$49,287.28
Rate for Payer: Ohana Health Plan Medicaid	$49,287.28
Rate for Payer: UnitedHealthcare Medicaid	$49,287.28

TRACHEOSTOMY W MV 96+ HOURS W EXTENSIVE PROCEDURE

Facility

$70,456.52

Service Code	APR-DRG 0044
Min. Negotiated Rate	$70,456.52
Max. Negotiated Rate	$70,456.52
Rate for Payer: AlohaCare Medicaid	$70,456.52
Rate for Payer: Hawaii Medical Service Association ABD	$70,456.52
Rate for Payer: Hawaii Medical Service Association Non-ABD	$70,456.52
Rate for Payer: Kaiser Permanente Medicaid	$70,456.52
Rate for Payer: Ohana Health Plan Medicaid	$70,456.52
Rate for Payer: UnitedHealthcare Medicaid	$70,456.52

Know your out-of-pocket cost for care.

All Charges