Kona Community Hospital

All Charges

Charge

Type

Setting

Price

Washer 7.0mm Small Cann 219.98 [3608970]

Facility

$239.27

Service Code	HCPCS C1713
Hospital Charge Code	3608970
Hospital Revenue Code	278
Min. Negotiated Rate	$133.99
Max. Negotiated Rate	$232.09
Rate for Payer: Cash Price	$155.53
Rate for Payer: Hawaii Western Management Group Commercial	$167.49
Rate for Payer: Health Management Network Commercial	$203.38
Rate for Payer: MDX Hawaii PPO	$232.09
Rate for Payer: University Health Alliance Commercial	$133.99

Washer 7.0mm Small Cann 219.98 [3608970]

Facility

$239.27

Service Code	HCPCS C1713
Hospital Charge Code	3608970
Hospital Revenue Code	278
Min. Negotiated Rate	$122.03
Max. Negotiated Rate	$232.09
Rate for Payer: Cash Price	$155.53
Rate for Payer: Hawaii Western Management Group Commercial	$167.49
Rate for Payer: Health Management Network Commercial	$203.38
Rate for Payer: Kaiser Permanente Commercial	$150.74
Rate for Payer: Kaiser Permanente Medicaid	$122.03
Rate for Payer: MDX Hawaii PPO	$232.09
Rate for Payer: University Health Alliance Commercial	$133.99

Washer 7.0mm SS AR-8870W [3644677]

Facility

$396.63

Hospital Charge Code	3644677
Hospital Revenue Code	272
Min. Negotiated Rate	$337.14
Max. Negotiated Rate	$384.73
Rate for Payer: Cash Price	$257.81
Rate for Payer: Health Management Network Commercial	$337.14
Rate for Payer: MDX Hawaii PPO	$384.73

Washer 7.0mm SS AR-8870W [3644677]

Facility

$396.63

Hospital Charge Code	3644677
Hospital Revenue Code	272
Min. Negotiated Rate	$202.28
Max. Negotiated Rate	$384.73
Rate for Payer: Cash Price	$257.81
Rate for Payer: Hawaii Western Management Group Commercial	$376.80
Rate for Payer: Health Management Network Commercial	$337.14
Rate for Payer: Kaiser Permanente Commercial	$249.88
Rate for Payer: Kaiser Permanente Medicaid	$202.28
Rate for Payer: MDX Hawaii PPO	$384.73
Rate for Payer: University Health Alliance Commercial	$289.10

Washer For Flat/Dome Screw 2.7 3.5 & 4.2mm P50-153-WS00 [3644350]

Facility

$983.80

Service Code	HCPCS C1713
Hospital Charge Code	3644350
Hospital Revenue Code	278
Min. Negotiated Rate	$501.74
Max. Negotiated Rate	$954.29
Rate for Payer: Cash Price	$639.47
Rate for Payer: Hawaii Western Management Group Commercial	$688.66
Rate for Payer: Health Management Network Commercial	$836.23
Rate for Payer: Kaiser Permanente Commercial	$619.79
Rate for Payer: Kaiser Permanente Medicaid	$501.74
Rate for Payer: MDX Hawaii PPO	$954.29
Rate for Payer: University Health Alliance Commercial	$550.93

Washer For Flat/Dome Screw 2.7 3.5 & 4.2mm P50-153-WS00 [3644350]

Facility

$983.80

Service Code	HCPCS C1713
Hospital Charge Code	3644350
Hospital Revenue Code	278
Min. Negotiated Rate	$550.93
Max. Negotiated Rate	$954.29
Rate for Payer: Cash Price	$639.47
Rate for Payer: Hawaii Western Management Group Commercial	$688.66
Rate for Payer: Health Management Network Commercial	$836.23
Rate for Payer: MDX Hawaii PPO	$954.29
Rate for Payer: University Health Alliance Commercial	$550.93

Washer Ti 13.0mm Large 419.99 [3608968]

Facility

$262.56

Service Code	HCPCS C1713
Hospital Charge Code	3608968
Hospital Revenue Code	278
Min. Negotiated Rate	$147.03
Max. Negotiated Rate	$254.68
Rate for Payer: Cash Price	$170.66
Rate for Payer: Hawaii Western Management Group Commercial	$183.79
Rate for Payer: Health Management Network Commercial	$223.18
Rate for Payer: MDX Hawaii PPO	$254.68
Rate for Payer: University Health Alliance Commercial	$147.03

Washer Ti 13.0mm Large 419.99 [3608968]

Facility

$262.56

Service Code	HCPCS C1713
Hospital Charge Code	3608968
Hospital Revenue Code	278
Min. Negotiated Rate	$133.91
Max. Negotiated Rate	$254.68
Rate for Payer: Cash Price	$170.66
Rate for Payer: Hawaii Western Management Group Commercial	$183.79
Rate for Payer: Health Management Network Commercial	$223.18
Rate for Payer: Kaiser Permanente Commercial	$165.41
Rate for Payer: Kaiser Permanente Medicaid	$133.91
Rate for Payer: MDX Hawaii PPO	$254.68
Rate for Payer: University Health Alliance Commercial	$147.03

Washer Ti 6.5mm Ar-8730W [3644888]

Facility

$425.38

Hospital Charge Code	3644888
Hospital Revenue Code	272
Min. Negotiated Rate	$361.57
Max. Negotiated Rate	$412.62
Rate for Payer: Cash Price	$276.50
Rate for Payer: Health Management Network Commercial	$361.57
Rate for Payer: MDX Hawaii PPO	$412.62

Washer Ti 6.5mm Ar-8730W [3644888]

Facility

$425.38

Hospital Charge Code	3644888
Hospital Revenue Code	272
Min. Negotiated Rate	$216.94
Max. Negotiated Rate	$412.62
Rate for Payer: Cash Price	$276.50
Rate for Payer: Hawaii Western Management Group Commercial	$404.11
Rate for Payer: Health Management Network Commercial	$361.57
Rate for Payer: Kaiser Permanente Commercial	$267.99
Rate for Payer: Kaiser Permanente Medicaid	$216.94
Rate for Payer: MDX Hawaii PPO	$412.62
Rate for Payer: University Health Alliance Commercial	$310.06

WHITE PETROLATUM-MINERAL OIL 56.8-42.5 % OPHT OINT

Facility

$56.85

Service Code	HCPCS A9270
Hospital Revenue Code	250
Min. Negotiated Rate	$28.99
Max. Negotiated Rate	$55.14
Rate for Payer: Cash Price	$36.95
Rate for Payer: Hawaii Western Management Group Commercial	$54.01
Rate for Payer: Health Management Network Commercial	$48.32
Rate for Payer: Kaiser Permanente Commercial	$35.82
Rate for Payer: Kaiser Permanente Medicaid	$28.99
Rate for Payer: MDX Hawaii PPO	$55.14
Rate for Payer: UnitedHealthcare Medicaid	$34.11
Rate for Payer: University Health Alliance Commercial	$41.44

WHITE PETROLATUM-MINERAL OIL 56.8-42.5 % OPHT OINT

Facility

$56.85

Service Code	HCPCS A9270
Hospital Revenue Code	250
Min. Negotiated Rate	$48.32
Max. Negotiated Rate	$55.14
Rate for Payer: Cash Price	$36.95
Rate for Payer: Health Management Network Commercial	$48.32
Rate for Payer: MDX Hawaii PPO	$55.14

WHITE PETROLATUM TOP GEL

Facility

$4.14

Service Code	HCPCS A9270
Hospital Revenue Code	250
Min. Negotiated Rate	$3.52
Max. Negotiated Rate	$4.02
Rate for Payer: Cash Price	$2.69
Rate for Payer: Health Management Network Commercial	$3.52
Rate for Payer: MDX Hawaii PPO	$4.02

WHITE PETROLATUM TOP GEL

Facility

$4.14

Service Code	HCPCS A9270
Hospital Revenue Code	250
Min. Negotiated Rate	$2.11
Max. Negotiated Rate	$4.02
Rate for Payer: Cash Price	$2.69
Rate for Payer: Hawaii Western Management Group Commercial	$3.93
Rate for Payer: Health Management Network Commercial	$3.52
Rate for Payer: Kaiser Permanente Commercial	$2.61
Rate for Payer: Kaiser Permanente Medicaid	$2.11
Rate for Payer: MDX Hawaii PPO	$4.02
Rate for Payer: UnitedHealthcare Medicaid	$2.48
Rate for Payer: University Health Alliance Commercial	$3.02

WHITE PETROLATUM TOP OIPK

Facility

$1.47

Service Code	HCPCS A9270
Hospital Revenue Code	250
Min. Negotiated Rate	$1.25
Max. Negotiated Rate	$1.43
Rate for Payer: Cash Price	$0.96
Rate for Payer: Health Management Network Commercial	$1.25
Rate for Payer: MDX Hawaii PPO	$1.43

WHITE PETROLATUM TOP OIPK

Facility

$1.47

Service Code	HCPCS A9270
Hospital Revenue Code	250
Min. Negotiated Rate	$0.75
Max. Negotiated Rate	$1.43
Rate for Payer: Cash Price	$0.96
Rate for Payer: Hawaii Western Management Group Commercial	$1.40
Rate for Payer: Health Management Network Commercial	$1.25
Rate for Payer: Kaiser Permanente Commercial	$0.93
Rate for Payer: Kaiser Permanente Medicaid	$0.75
Rate for Payer: MDX Hawaii PPO	$1.43
Rate for Payer: UnitedHealthcare Medicaid	$0.88
Rate for Payer: University Health Alliance Commercial	$1.07

Wire C .028 Trocar Tip 00505004600 [3609000]

Facility

$73.70

Service Code	HCPCS C1713
Hospital Charge Code	3609000
Hospital Revenue Code	278
Min. Negotiated Rate	$41.27
Max. Negotiated Rate	$71.49
Rate for Payer: Cash Price	$47.90
Rate for Payer: Hawaii Western Management Group Commercial	$51.59
Rate for Payer: Health Management Network Commercial	$62.65
Rate for Payer: MDX Hawaii PPO	$71.49
Rate for Payer: University Health Alliance Commercial	$41.27

Wire C .028 Trocar Tip 00505004600 [3609000]

Facility

$73.70

Service Code	HCPCS C1713
Hospital Charge Code	3609000
Hospital Revenue Code	278
Min. Negotiated Rate	$37.59
Max. Negotiated Rate	$71.49
Rate for Payer: Cash Price	$47.90
Rate for Payer: Hawaii Western Management Group Commercial	$51.59
Rate for Payer: Health Management Network Commercial	$62.65
Rate for Payer: Kaiser Permanente Commercial	$46.43
Rate for Payer: Kaiser Permanente Medicaid	$37.59
Rate for Payer: MDX Hawaii PPO	$71.49
Rate for Payer: University Health Alliance Commercial	$41.27

Wire C .035 Trocar Tip 00505004700 [3609001]

Facility

$72.68

Service Code	HCPCS C1713
Hospital Charge Code	3609001
Hospital Revenue Code	278
Min. Negotiated Rate	$37.07
Max. Negotiated Rate	$70.50
Rate for Payer: Cash Price	$47.24
Rate for Payer: Hawaii Western Management Group Commercial	$50.88
Rate for Payer: Health Management Network Commercial	$61.78
Rate for Payer: Kaiser Permanente Commercial	$45.79
Rate for Payer: Kaiser Permanente Medicaid	$37.07
Rate for Payer: MDX Hawaii PPO	$70.50
Rate for Payer: University Health Alliance Commercial	$40.70

Wire C .035 Trocar Tip 00505004700 [3609001]

Facility

$72.68

Service Code	HCPCS C1713
Hospital Charge Code	3609001
Hospital Revenue Code	278
Min. Negotiated Rate	$40.70
Max. Negotiated Rate	$70.50
Rate for Payer: Cash Price	$47.24
Rate for Payer: Hawaii Western Management Group Commercial	$50.88
Rate for Payer: Health Management Network Commercial	$61.78
Rate for Payer: MDX Hawaii PPO	$70.50
Rate for Payer: University Health Alliance Commercial	$40.70

Wire C .045 Trocar Tip 00505004800 [3608991]

Facility

$72.68

Service Code	HCPCS C1713
Hospital Charge Code	3608991
Hospital Revenue Code	278
Min. Negotiated Rate	$37.07
Max. Negotiated Rate	$70.50
Rate for Payer: Cash Price	$47.24
Rate for Payer: Hawaii Western Management Group Commercial	$50.88
Rate for Payer: Health Management Network Commercial	$61.78
Rate for Payer: Kaiser Permanente Commercial	$45.79
Rate for Payer: Kaiser Permanente Medicaid	$37.07
Rate for Payer: MDX Hawaii PPO	$70.50
Rate for Payer: University Health Alliance Commercial	$40.70

Wire C .045 Trocar Tip 00505004800 [3608991]

Facility

$72.68

Service Code	HCPCS C1713
Hospital Charge Code	3608991
Hospital Revenue Code	278
Min. Negotiated Rate	$40.70
Max. Negotiated Rate	$70.50
Rate for Payer: Cash Price	$47.24
Rate for Payer: Hawaii Western Management Group Commercial	$50.88
Rate for Payer: Health Management Network Commercial	$61.78
Rate for Payer: MDX Hawaii PPO	$70.50
Rate for Payer: University Health Alliance Commercial	$40.70

Wire C .062 Trocar Tip 00505004900 [3609004]

Facility

$60.69

Service Code	HCPCS C1713
Hospital Charge Code	3609004
Hospital Revenue Code	278
Min. Negotiated Rate	$33.99
Max. Negotiated Rate	$58.87
Rate for Payer: Cash Price	$39.45
Rate for Payer: Hawaii Western Management Group Commercial	$42.48
Rate for Payer: Health Management Network Commercial	$51.59
Rate for Payer: MDX Hawaii PPO	$58.87
Rate for Payer: University Health Alliance Commercial	$33.99

Wire C .062 Trocar Tip 00505004900 [3609004]

Facility

$60.69

Service Code	HCPCS C1713
Hospital Charge Code	3609004
Hospital Revenue Code	278
Min. Negotiated Rate	$30.95
Max. Negotiated Rate	$58.87
Rate for Payer: Cash Price	$39.45
Rate for Payer: Hawaii Western Management Group Commercial	$42.48
Rate for Payer: Health Management Network Commercial	$51.59
Rate for Payer: Kaiser Permanente Commercial	$38.23
Rate for Payer: Kaiser Permanente Medicaid	$30.95
Rate for Payer: MDX Hawaii PPO	$58.87
Rate for Payer: University Health Alliance Commercial	$33.99

Wire Compression Threaded 1.6 x 15 x 150mm 03.211.415 [3644378]

Facility

$422.96

Hospital Charge Code	3644378
Hospital Revenue Code	272
Min. Negotiated Rate	$215.71
Max. Negotiated Rate	$410.27
Rate for Payer: Cash Price	$274.92
Rate for Payer: Hawaii Western Management Group Commercial	$401.81
Rate for Payer: Health Management Network Commercial	$359.52
Rate for Payer: Kaiser Permanente Commercial	$266.46
Rate for Payer: Kaiser Permanente Medicaid	$215.71
Rate for Payer: MDX Hawaii PPO	$410.27
Rate for Payer: University Health Alliance Commercial	$308.30

Know your out-of-pocket cost for care.

All Charges