Kona Community Hospital

All Charges

Charge

Type

Setting

Price

Ts Univ Rev Suture Cup 36 +2 Lt AR-9502F-36LCPC [3645471]

Facility

$11,915.50

Service Code	HCPCS C1776
Hospital Charge Code	3645471
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

Tube Blakemore Adult 20fr [2702054]

Facility

$633.98

Hospital Charge Code	2702054
Hospital Revenue Code	272
Min. Negotiated Rate	$323.33
Max. Negotiated Rate	$614.96
Rate for Payer: Cash Price	$412.09
Rate for Payer: Hawaii Western Management Group Commercial	$602.28
Rate for Payer: Health Management Network Commercial	$538.88
Rate for Payer: Kaiser Permanente Commercial	$399.41
Rate for Payer: Kaiser Permanente Medicaid	$323.33
Rate for Payer: MDX Hawaii PPO	$614.96
Rate for Payer: University Health Alliance Commercial	$462.11

Tube Blakemore Adult 20fr [2702054]

Facility

$633.98

Hospital Charge Code	2702054
Hospital Revenue Code	272
Min. Negotiated Rate	$538.88
Max. Negotiated Rate	$614.96
Rate for Payer: Cash Price	$412.09
Rate for Payer: Health Management Network Commercial	$538.88
Rate for Payer: MDX Hawaii PPO	$614.96

TUBE DOBBHOFF W/STYLET 8FR [2702083]

Facility

$94.18

Hospital Charge Code	2702083
Hospital Revenue Code	272
Min. Negotiated Rate	$80.05
Max. Negotiated Rate	$91.35
Rate for Payer: Cash Price	$61.22
Rate for Payer: Health Management Network Commercial	$80.05
Rate for Payer: MDX Hawaii PPO	$91.35

TUBE DOBBHOFF W/STYLET 8FR [2702083]

Facility

$94.18

Hospital Charge Code	2702083
Hospital Revenue Code	272
Min. Negotiated Rate	$48.03
Max. Negotiated Rate	$91.35
Rate for Payer: Cash Price	$61.22
Rate for Payer: Hawaii Western Management Group Commercial	$89.47
Rate for Payer: Health Management Network Commercial	$80.05
Rate for Payer: Kaiser Permanente Commercial	$59.33
Rate for Payer: Kaiser Permanente Medicaid	$48.03
Rate for Payer: MDX Hawaii PPO	$91.35
Rate for Payer: University Health Alliance Commercial	$68.65

Tube Endo Bronchial 37Fr Left 125037 [3703074]

Facility

$918.15

Hospital Charge Code	3703074
Hospital Revenue Code	272
Min. Negotiated Rate	$780.43
Max. Negotiated Rate	$890.61
Rate for Payer: Cash Price	$596.80
Rate for Payer: Health Management Network Commercial	$780.43
Rate for Payer: MDX Hawaii PPO	$890.61

Tube Endo Bronchial 37Fr Left 125037 [3703074]

Facility

$918.15

Hospital Charge Code	3703074
Hospital Revenue Code	272
Min. Negotiated Rate	$468.26
Max. Negotiated Rate	$890.61
Rate for Payer: Cash Price	$596.80
Rate for Payer: Hawaii Western Management Group Commercial	$872.24
Rate for Payer: Health Management Network Commercial	$780.43
Rate for Payer: Kaiser Permanente Commercial	$578.43
Rate for Payer: Kaiser Permanente Medicaid	$468.26
Rate for Payer: MDX Hawaii PPO	$890.61
Rate for Payer: University Health Alliance Commercial	$669.24

Tube Endotracheal NIM EMG sz7 8229507 [3610414]

Facility

$2,706.38

Hospital Charge Code	3610414
Hospital Revenue Code	272
Min. Negotiated Rate	$2,300.42
Max. Negotiated Rate	$2,625.19
Rate for Payer: Cash Price	$1,759.15
Rate for Payer: Health Management Network Commercial	$2,300.42
Rate for Payer: MDX Hawaii PPO	$2,625.19

Tube Endotracheal NIM EMG sz7 8229507 [3610414]

Facility

$2,706.38

Hospital Charge Code	3610414
Hospital Revenue Code	272
Min. Negotiated Rate	$1,380.25
Max. Negotiated Rate	$2,625.19
Rate for Payer: Cash Price	$1,759.15
Rate for Payer: Hawaii Western Management Group Commercial	$2,571.06
Rate for Payer: Health Management Network Commercial	$2,300.42
Rate for Payer: Kaiser Permanente Commercial	$1,705.02
Rate for Payer: Kaiser Permanente Medicaid	$1,380.25
Rate for Payer: MDX Hawaii PPO	$2,625.19
Rate for Payer: University Health Alliance Commercial	$1,972.68

Tube Gastrostomy 18fr [2702085]

Facility

$195.36

Service Code	HCPCS B4087
Hospital Charge Code	2702085
Hospital Revenue Code	272
Min. Negotiated Rate	$166.06
Max. Negotiated Rate	$189.50
Rate for Payer: Cash Price	$126.98
Rate for Payer: Health Management Network Commercial	$166.06
Rate for Payer: MDX Hawaii PPO	$189.50

Tube Gastrostomy 18fr [2702085]

Facility

$195.36

Service Code	HCPCS B4087
Hospital Charge Code	2702085
Hospital Revenue Code	272
Min. Negotiated Rate	$38.22
Max. Negotiated Rate	$189.50
Rate for Payer: Cash Price	$126.98
Rate for Payer: Cash Price	$126.98
Rate for Payer: Hawaii Western Management Group Commercial	$185.59
Rate for Payer: Health Management Network Commercial	$166.06
Rate for Payer: Kaiser Permanente Commercial	$123.08
Rate for Payer: Kaiser Permanente Medicaid	$99.63
Rate for Payer: MDX Hawaii PPO	$189.50
Rate for Payer: UnitedHealthcare Medicaid	$38.22
Rate for Payer: University Health Alliance Commercial	$142.40

TUBE GASTROSTOMY 20FR 8884720205E [2702086]

Facility

$195.36

Service Code	HCPCS B4087
Hospital Charge Code	2702086
Hospital Revenue Code	272
Min. Negotiated Rate	$38.22
Max. Negotiated Rate	$189.50
Rate for Payer: Cash Price	$126.98
Rate for Payer: Cash Price	$126.98
Rate for Payer: Hawaii Western Management Group Commercial	$185.59
Rate for Payer: Health Management Network Commercial	$166.06
Rate for Payer: Kaiser Permanente Commercial	$123.08
Rate for Payer: Kaiser Permanente Medicaid	$99.63
Rate for Payer: MDX Hawaii PPO	$189.50
Rate for Payer: UnitedHealthcare Medicaid	$38.22
Rate for Payer: University Health Alliance Commercial	$142.40

TUBE GASTROSTOMY 20FR 8884720205E [2702086]

Facility

$195.36

Service Code	HCPCS B4087
Hospital Charge Code	2702086
Hospital Revenue Code	272
Min. Negotiated Rate	$166.06
Max. Negotiated Rate	$189.50
Rate for Payer: Cash Price	$126.98
Rate for Payer: Health Management Network Commercial	$166.06
Rate for Payer: MDX Hawaii PPO	$189.50

TUBE GASTROSTOMY 24FR [2702088]

Facility

$195.36

Service Code	HCPCS B4087
Hospital Charge Code	2702088
Hospital Revenue Code	272
Min. Negotiated Rate	$38.22
Max. Negotiated Rate	$189.50
Rate for Payer: Cash Price	$126.98
Rate for Payer: Cash Price	$126.98
Rate for Payer: Hawaii Western Management Group Commercial	$185.59
Rate for Payer: Health Management Network Commercial	$166.06
Rate for Payer: Kaiser Permanente Commercial	$123.08
Rate for Payer: Kaiser Permanente Medicaid	$99.63
Rate for Payer: MDX Hawaii PPO	$189.50
Rate for Payer: UnitedHealthcare Medicaid	$38.22
Rate for Payer: University Health Alliance Commercial	$142.40

TUBE GASTROSTOMY 24FR [2702088]

Facility

$195.36

Service Code	HCPCS B4087
Hospital Charge Code	2702088
Hospital Revenue Code	272
Min. Negotiated Rate	$166.06
Max. Negotiated Rate	$189.50
Rate for Payer: Cash Price	$126.98
Rate for Payer: Health Management Network Commercial	$166.06
Rate for Payer: MDX Hawaii PPO	$189.50

Tube Gastrostomy Capsule Dome 20fr 9C2020I [3642522]

Facility

$606.50

Hospital Charge Code	3642522
Hospital Revenue Code	272
Min. Negotiated Rate	$309.31
Max. Negotiated Rate	$588.30
Rate for Payer: Cash Price	$394.22
Rate for Payer: Hawaii Western Management Group Commercial	$576.17
Rate for Payer: Health Management Network Commercial	$515.52
Rate for Payer: Kaiser Permanente Commercial	$382.10
Rate for Payer: Kaiser Permanente Medicaid	$309.31
Rate for Payer: MDX Hawaii PPO	$588.30
Rate for Payer: University Health Alliance Commercial	$442.08

Tube Gastrostomy Capsule Dome 20fr 9C2020I [3642522]

Facility

$606.50

Hospital Charge Code	3642522
Hospital Revenue Code	272
Min. Negotiated Rate	$515.52
Max. Negotiated Rate	$588.30
Rate for Payer: Cash Price	$394.22
Rate for Payer: Health Management Network Commercial	$515.52
Rate for Payer: MDX Hawaii PPO	$588.30

Tube Gastrostomy Jejunal 18FrX22cm MIC 82501822 [3641998]

Facility

$1,393.99

Hospital Charge Code	3641998
Hospital Revenue Code	272
Min. Negotiated Rate	$710.93
Max. Negotiated Rate	$1,352.17
Rate for Payer: Cash Price	$906.09
Rate for Payer: Hawaii Western Management Group Commercial	$1,324.29
Rate for Payer: Health Management Network Commercial	$1,184.89
Rate for Payer: Kaiser Permanente Commercial	$878.21
Rate for Payer: Kaiser Permanente Medicaid	$710.93
Rate for Payer: MDX Hawaii PPO	$1,352.17
Rate for Payer: University Health Alliance Commercial	$1,016.08

Tube Gastrostomy Jejunal 18FrX22cm MIC 82501822 [3641998]

Facility

$1,393.99

Hospital Charge Code	3641998
Hospital Revenue Code	272
Min. Negotiated Rate	$1,184.89
Max. Negotiated Rate	$1,352.17
Rate for Payer: Cash Price	$906.09
Rate for Payer: Health Management Network Commercial	$1,184.89
Rate for Payer: MDX Hawaii PPO	$1,352.17

Tube Gastrostomy Jejunal 18FrX30cm MIC 82501830 [3641999]

Facility

$1,372.84

Hospital Charge Code	3641999
Hospital Revenue Code	272
Min. Negotiated Rate	$1,166.91
Max. Negotiated Rate	$1,331.65
Rate for Payer: Cash Price	$892.35
Rate for Payer: Health Management Network Commercial	$1,166.91
Rate for Payer: MDX Hawaii PPO	$1,331.65

Tube Gastrostomy Jejunal 18FrX30cm MIC 82501830 [3641999]

Facility

$1,372.84

Hospital Charge Code	3641999
Hospital Revenue Code	272
Min. Negotiated Rate	$700.15
Max. Negotiated Rate	$1,331.65
Rate for Payer: Cash Price	$892.35
Rate for Payer: Hawaii Western Management Group Commercial	$1,304.20
Rate for Payer: Health Management Network Commercial	$1,166.91
Rate for Payer: Kaiser Permanente Commercial	$864.89
Rate for Payer: Kaiser Permanente Medicaid	$700.15
Rate for Payer: MDX Hawaii PPO	$1,331.65
Rate for Payer: University Health Alliance Commercial	$1,000.66

Tube Gastrostomy Jejunal 18FrX45cm MIC 825018 [3642000]

Facility

$1,409.09

Hospital Charge Code	3642000
Hospital Revenue Code	272
Min. Negotiated Rate	$1,197.73
Max. Negotiated Rate	$1,366.82
Rate for Payer: Cash Price	$915.91
Rate for Payer: Health Management Network Commercial	$1,197.73
Rate for Payer: MDX Hawaii PPO	$1,366.82

Tube Gastrostomy Jejunal 18FrX45cm MIC 825018 [3642000]

Facility

$1,409.09

Hospital Charge Code	3642000
Hospital Revenue Code	272
Min. Negotiated Rate	$718.64
Max. Negotiated Rate	$1,366.82
Rate for Payer: Cash Price	$915.91
Rate for Payer: Hawaii Western Management Group Commercial	$1,338.64
Rate for Payer: Health Management Network Commercial	$1,197.73
Rate for Payer: Kaiser Permanente Commercial	$887.73
Rate for Payer: Kaiser Permanente Medicaid	$718.64
Rate for Payer: MDX Hawaii PPO	$1,366.82
Rate for Payer: University Health Alliance Commercial	$1,027.09

Tube Jejunal Feeding 12frx51cm 0200-12lv [3644443]

Facility

$892.98

Service Code	HCPCS B4087
Hospital Charge Code	3644443
Hospital Revenue Code	272
Min. Negotiated Rate	$759.03
Max. Negotiated Rate	$866.19
Rate for Payer: Cash Price	$580.44
Rate for Payer: Health Management Network Commercial	$759.03
Rate for Payer: MDX Hawaii PPO	$866.19

Tube Jejunal Feeding 12frx51cm 0200-12lv [3644443]

Facility

$892.98

Service Code	HCPCS B4087
Hospital Charge Code	3644443
Hospital Revenue Code	272
Min. Negotiated Rate	$38.22
Max. Negotiated Rate	$866.19
Rate for Payer: Cash Price	$580.44
Rate for Payer: Cash Price	$580.44
Rate for Payer: Hawaii Western Management Group Commercial	$848.33
Rate for Payer: Health Management Network Commercial	$759.03
Rate for Payer: Kaiser Permanente Commercial	$562.58
Rate for Payer: Kaiser Permanente Medicaid	$455.42
Rate for Payer: MDX Hawaii PPO	$866.19
Rate for Payer: UnitedHealthcare Medicaid	$38.22
Rate for Payer: University Health Alliance Commercial	$650.89

Know your out-of-pocket cost for care.

All Charges