Kona Community Hospital

All Charges

Charge

Type

Setting

Price

Tube Trach Shiley 6 Cfn [2702259]

Facility

$377.08

Service Code	HCPCS A7521
Hospital Charge Code	2702259
Hospital Revenue Code	272
Min. Negotiated Rate	$47.05
Max. Negotiated Rate	$365.77
Rate for Payer: Cash Price	$245.10
Rate for Payer: Cash Price	$245.10
Rate for Payer: Hawaii Western Management Group Commercial	$358.23
Rate for Payer: Health Management Network Commercial	$320.52
Rate for Payer: Kaiser Permanente Commercial	$237.56
Rate for Payer: Kaiser Permanente Medicaid	$192.31
Rate for Payer: MDX Hawaii PPO	$365.77
Rate for Payer: UnitedHealthcare Medicaid	$47.05
Rate for Payer: University Health Alliance Commercial	$274.85

TUBE TRACH SHILEY #7 7CN80H [2702445]

Facility

$424.23

Hospital Charge Code	2702445
Hospital Revenue Code	272
Min. Negotiated Rate	$360.60
Max. Negotiated Rate	$411.50
Rate for Payer: Cash Price	$275.75
Rate for Payer: Health Management Network Commercial	$360.60
Rate for Payer: MDX Hawaii PPO	$411.50

TUBE TRACH SHILEY #7 7CN80H [2702445]

Facility

$424.23

Hospital Charge Code	2702445
Hospital Revenue Code	272
Min. Negotiated Rate	$216.36
Max. Negotiated Rate	$411.50
Rate for Payer: Cash Price	$275.75
Rate for Payer: Hawaii Western Management Group Commercial	$403.02
Rate for Payer: Health Management Network Commercial	$360.60
Rate for Payer: Kaiser Permanente Commercial	$267.26
Rate for Payer: Kaiser Permanente Medicaid	$216.36
Rate for Payer: MDX Hawaii PPO	$411.50
Rate for Payer: University Health Alliance Commercial	$309.22

TUBE TRACH SHILEY #8 8DCT [2702446]

Facility

$424.23

Hospital Charge Code	2702446
Hospital Revenue Code	272
Min. Negotiated Rate	$216.36
Max. Negotiated Rate	$411.50
Rate for Payer: Cash Price	$275.75
Rate for Payer: Hawaii Western Management Group Commercial	$403.02
Rate for Payer: Health Management Network Commercial	$360.60
Rate for Payer: Kaiser Permanente Commercial	$267.26
Rate for Payer: Kaiser Permanente Medicaid	$216.36
Rate for Payer: MDX Hawaii PPO	$411.50
Rate for Payer: University Health Alliance Commercial	$309.22

TUBE TRACH SHILEY #8 8DCT [2702446]

Facility

$424.23

Hospital Charge Code	2702446
Hospital Revenue Code	272
Min. Negotiated Rate	$360.60
Max. Negotiated Rate	$411.50
Rate for Payer: Cash Price	$275.75
Rate for Payer: Health Management Network Commercial	$360.60
Rate for Payer: MDX Hawaii PPO	$411.50

Tube Trach Shiley 8 Cfn [2702260]

Facility

$237.98

Service Code	HCPCS A7521
Hospital Charge Code	2702260
Hospital Revenue Code	272
Min. Negotiated Rate	$47.05
Max. Negotiated Rate	$230.84
Rate for Payer: Cash Price	$154.69
Rate for Payer: Cash Price	$154.69
Rate for Payer: Hawaii Western Management Group Commercial	$226.08
Rate for Payer: Health Management Network Commercial	$202.28
Rate for Payer: Kaiser Permanente Commercial	$149.93
Rate for Payer: Kaiser Permanente Medicaid	$121.37
Rate for Payer: MDX Hawaii PPO	$230.84
Rate for Payer: UnitedHealthcare Medicaid	$47.05
Rate for Payer: University Health Alliance Commercial	$173.46

Tube Trach Shiley 8 Cfn [2702260]

Facility

$237.98

Service Code	HCPCS A7521
Hospital Charge Code	2702260
Hospital Revenue Code	272
Min. Negotiated Rate	$202.28
Max. Negotiated Rate	$230.84
Rate for Payer: Cash Price	$154.69
Rate for Payer: Health Management Network Commercial	$202.28
Rate for Payer: MDX Hawaii PPO	$230.84

Tuohy-Borst Adapter W/ Side Arm G18813 [3643813]

Facility

$215.58

Hospital Charge Code	3643813
Hospital Revenue Code	272
Min. Negotiated Rate	$109.95
Max. Negotiated Rate	$209.11
Rate for Payer: Cash Price	$140.13
Rate for Payer: Hawaii Western Management Group Commercial	$204.80
Rate for Payer: Health Management Network Commercial	$183.24
Rate for Payer: Kaiser Permanente Commercial	$135.82
Rate for Payer: Kaiser Permanente Medicaid	$109.95
Rate for Payer: MDX Hawaii PPO	$209.11
Rate for Payer: University Health Alliance Commercial	$157.14

Tuohy-Borst Adapter W/ Side Arm G18813 [3643813]

Facility

$215.58

Hospital Charge Code	3643813
Hospital Revenue Code	272
Min. Negotiated Rate	$183.24
Max. Negotiated Rate	$209.11
Rate for Payer: Cash Price	$140.13
Rate for Payer: Health Management Network Commercial	$183.24
Rate for Payer: MDX Hawaii PPO	$209.11

Tuohy-Burst Adapter G18814 [3643808]

Facility

$137.60

Hospital Charge Code	3643808
Hospital Revenue Code	272
Min. Negotiated Rate	$70.18
Max. Negotiated Rate	$133.47
Rate for Payer: Cash Price	$89.44
Rate for Payer: Hawaii Western Management Group Commercial	$130.72
Rate for Payer: Health Management Network Commercial	$116.96
Rate for Payer: Kaiser Permanente Commercial	$86.69
Rate for Payer: Kaiser Permanente Medicaid	$70.18
Rate for Payer: MDX Hawaii PPO	$133.47
Rate for Payer: University Health Alliance Commercial	$100.30

Tuohy-Burst Adapter G18814 [3643808]

Facility

$137.60

Hospital Charge Code	3643808
Hospital Revenue Code	272
Min. Negotiated Rate	$116.96
Max. Negotiated Rate	$133.47
Rate for Payer: Cash Price	$89.44
Rate for Payer: Health Management Network Commercial	$116.96
Rate for Payer: MDX Hawaii PPO	$133.47

Two Hole Plate 1.5mm SS Sterile AR-8959-01S [3644254]

Facility

$6,462.50

Service Code	HCPCS C1713
Hospital Charge Code	3644254
Hospital Revenue Code	278
Min. Negotiated Rate	$3,295.88
Max. Negotiated Rate	$6,268.62
Rate for Payer: Cash Price	$4,200.62
Rate for Payer: Hawaii Western Management Group Commercial	$4,523.75
Rate for Payer: Health Management Network Commercial	$5,493.12
Rate for Payer: Kaiser Permanente Commercial	$4,071.38
Rate for Payer: Kaiser Permanente Medicaid	$3,295.88
Rate for Payer: MDX Hawaii PPO	$6,268.62
Rate for Payer: University Health Alliance Commercial	$3,619.00

Two Hole Plate 1.5mm SS Sterile AR-8959-01S [3644254]

Facility

$6,462.50

Service Code	HCPCS C1713
Hospital Charge Code	3644254
Hospital Revenue Code	278
Min. Negotiated Rate	$3,619.00
Max. Negotiated Rate	$6,268.62
Rate for Payer: Cash Price	$4,200.62
Rate for Payer: Hawaii Western Management Group Commercial	$4,523.75
Rate for Payer: Health Management Network Commercial	$5,493.12
Rate for Payer: MDX Hawaii PPO	$6,268.62
Rate for Payer: University Health Alliance Commercial	$3,619.00

TX PLAN CARE COORD MGMT CA EST PT CHG REGIMEN

Professional

Both

$350.00

Service Code	HCPCS S0354
Min. Negotiated Rate	$297.50
Max. Negotiated Rate	$297.50
Rate for Payer: Cash Price	$227.50
Rate for Payer: Health Management Network Commercial	$297.50

TX PLANNING CARE COORDINATION MGMT CANCR INIT TX

Professional

Both

$350.00

Service Code	HCPCS S0353
Min. Negotiated Rate	$297.50
Max. Negotiated Rate	$297.50
Rate for Payer: Cash Price	$227.50
Rate for Payer: Health Management Network Commercial	$297.50

Ultragrab Hs Fiber Blue #2 UHMWPE Suture 66cm 72205440 [3644380]

Facility

$1,018.45

Service Code	HCPCS C1713
Hospital Charge Code	3644380
Hospital Revenue Code	278
Min. Negotiated Rate	$519.41
Max. Negotiated Rate	$987.90
Rate for Payer: Cash Price	$661.99
Rate for Payer: Hawaii Western Management Group Commercial	$712.91
Rate for Payer: Health Management Network Commercial	$865.68
Rate for Payer: Kaiser Permanente Commercial	$641.62
Rate for Payer: Kaiser Permanente Medicaid	$519.41
Rate for Payer: MDX Hawaii PPO	$987.90
Rate for Payer: University Health Alliance Commercial	$570.33

Ultragrab Hs Fiber Blue #2 UHMWPE Suture 66cm 72205440 [3644380]

Facility

$1,018.45

Service Code	HCPCS C1713
Hospital Charge Code	3644380
Hospital Revenue Code	278
Min. Negotiated Rate	$570.33
Max. Negotiated Rate	$987.90
Rate for Payer: Cash Price	$661.99
Rate for Payer: Hawaii Western Management Group Commercial	$712.91
Rate for Payer: Health Management Network Commercial	$865.68
Rate for Payer: MDX Hawaii PPO	$987.90
Rate for Payer: University Health Alliance Commercial	$570.33

Ultragrab Suture Manager #2 Cobraid Blue 48" 72205439 [3644237]

Facility

$769.60

Hospital Charge Code	3644237
Hospital Revenue Code	272
Min. Negotiated Rate	$392.50
Max. Negotiated Rate	$746.51
Rate for Payer: Cash Price	$500.24
Rate for Payer: Hawaii Western Management Group Commercial	$731.12
Rate for Payer: Health Management Network Commercial	$654.16
Rate for Payer: Kaiser Permanente Commercial	$484.85
Rate for Payer: Kaiser Permanente Medicaid	$392.50
Rate for Payer: MDX Hawaii PPO	$746.51
Rate for Payer: University Health Alliance Commercial	$560.96

Ultragrab Suture Manager #2 Cobraid Blue 48" 72205439 [3644237]

Facility

$769.60

Hospital Charge Code	3644237
Hospital Revenue Code	272
Min. Negotiated Rate	$654.16
Max. Negotiated Rate	$746.51
Rate for Payer: Cash Price	$500.24
Rate for Payer: Health Management Network Commercial	$654.16
Rate for Payer: MDX Hawaii PPO	$746.51

ULTRASOUND ACCELERATED AND OTHER THROMBOLYSIS OF PERIPHERAL VASCULAR STRUCTURES WITH MCC

Facility

$96,016.95

Service Code	MSDRG 278
Min. Negotiated Rate	$73,140.64
Max. Negotiated Rate	$96,016.95
Rate for Payer: AlohaCare Medicare	$73,210.92
Rate for Payer: Devoted Health Medicare	$80,532.01
Rate for Payer: Hawaii Medical Service Association Commercial	$73,140.64
Rate for Payer: Hawaii Medical Service Association Medicare	$73,210.92
Rate for Payer: Humana Medicare	$73,210.92
Rate for Payer: Kaiser Permanente Commercial	$96,016.95
Rate for Payer: Kaiser Permanente Medicare	$73,210.92
Rate for Payer: Ohana Health Plan Medicare	$73,210.92
Rate for Payer: UnitedHealthcare Medicare	$73,210.92

ULTRASOUND ACCELERATED AND OTHER THROMBOLYSIS OF PERIPHERAL VASCULAR STRUCTURES WITHOUT MCC

Facility

$73,140.64

Service Code	MSDRG 279
Min. Negotiated Rate	$47,434.13
Max. Negotiated Rate	$73,140.64
Rate for Payer: AlohaCare Medicare	$47,434.13
Rate for Payer: Devoted Health Medicare	$52,177.54
Rate for Payer: Hawaii Medical Service Association Commercial	$73,140.64
Rate for Payer: Hawaii Medical Service Association Medicare	$47,434.13
Rate for Payer: Humana Medicare	$47,434.13
Rate for Payer: Kaiser Permanente Commercial	$62,210.40
Rate for Payer: Kaiser Permanente Medicare	$47,434.13
Rate for Payer: Ohana Health Plan Medicare	$47,434.13
Rate for Payer: UnitedHealthcare Medicare	$47,434.13

ULTRASOUND ACCELERATED AND OTHER THROMBOLYSIS WITH PRINCIPAL DIAGNOSIS PULMONARY EMBOLISM

Facility

$51,342.90

Service Code	MSDRG 173
Min. Negotiated Rate	$39,147.89
Max. Negotiated Rate	$51,342.90
Rate for Payer: AlohaCare Medicare	$39,147.89
Rate for Payer: Devoted Health Medicare	$43,062.68
Rate for Payer: Hawaii Medical Service Association Medicare	$39,147.89
Rate for Payer: Humana Medicare	$39,147.89
Rate for Payer: Kaiser Permanente Commercial	$51,342.90
Rate for Payer: Kaiser Permanente Medicare	$39,147.89
Rate for Payer: Ohana Health Plan Medicare	$39,147.89
Rate for Payer: UnitedHealthcare Medicare	$39,147.89

UNCLASSIFIED BIOLOGICS

Professional

Both

$0.01

Service Code	HCPCS J3590
Min. Negotiated Rate	$0.01
Max. Negotiated Rate	$0.01
Rate for Payer: Cash Price	$0.01
Rate for Payer: Health Management Network Commercial	$0.01

UNCLASSIFIED DRUGS

Professional

Both

$5.00

Service Code	HCPCS J3490
Min. Negotiated Rate	$4.25
Max. Negotiated Rate	$4.25
Rate for Payer: Cash Price	$3.25
Rate for Payer: Health Management Network Commercial	$4.25

UNCOMPLICATED PEPTIC ULCER WITH MCC

Facility

$23,817.08

Service Code	MSDRG 383
Min. Negotiated Rate	$18,160.03
Max. Negotiated Rate	$23,817.08
Rate for Payer: AlohaCare Medicare	$18,160.03
Rate for Payer: Devoted Health Medicare	$19,976.03
Rate for Payer: Hawaii Medical Service Association Commercial	$19,960.60
Rate for Payer: Hawaii Medical Service Association Medicare	$18,160.03
Rate for Payer: Humana Medicare	$18,160.03
Rate for Payer: Kaiser Permanente Commercial	$23,817.08
Rate for Payer: Kaiser Permanente Medicare	$18,160.03
Rate for Payer: Ohana Health Plan Medicare	$18,160.03
Rate for Payer: UnitedHealthcare Medicare	$18,160.03

Know your out-of-pocket cost for care.

All Charges