Kona Community Hospital

All Charges

Charge

Type

Setting

Price

WPSM256 Retractor Wound SM Surgisleeve 2.5-6cm [3640371]

Facility

$229.76

Hospital Charge Code	3640371
Hospital Revenue Code	272
Min. Negotiated Rate	$117.18
Max. Negotiated Rate	$222.87
Rate for Payer: Cash Price	$149.34
Rate for Payer: Hawaii Western Management Group Commercial	$218.27
Rate for Payer: Health Management Network Commercial	$195.30
Rate for Payer: Kaiser Permanente Commercial	$144.75
Rate for Payer: Kaiser Permanente Medicaid	$117.18
Rate for Payer: MDX Hawaii PPO	$222.87
Rate for Payer: University Health Alliance Commercial	$167.47

WPSM256 Retractor Wound SM Surgisleeve 2.5-6cm [3640371]

Facility

$229.76

Hospital Charge Code	3640371
Hospital Revenue Code	272
Min. Negotiated Rate	$195.30
Max. Negotiated Rate	$222.87
Rate for Payer: Cash Price	$149.34
Rate for Payer: Health Management Network Commercial	$195.30
Rate for Payer: MDX Hawaii PPO	$222.87

Xtrafix 11mm x 500mm Glass Fiber Bar 00-5202-011-50 [3644143]

Facility

$2,207.20

Hospital Charge Code	3644143
Hospital Revenue Code	272
Min. Negotiated Rate	$1,125.67
Max. Negotiated Rate	$2,140.98
Rate for Payer: Cash Price	$1,434.68
Rate for Payer: Hawaii Western Management Group Commercial	$2,096.84
Rate for Payer: Health Management Network Commercial	$1,876.12
Rate for Payer: Kaiser Permanente Commercial	$1,390.54
Rate for Payer: Kaiser Permanente Medicaid	$1,125.67
Rate for Payer: MDX Hawaii PPO	$2,140.98
Rate for Payer: University Health Alliance Commercial	$1,608.83

Xtrafix 11mm x 500mm Glass Fiber Bar 00-5202-011-50 [3644143]

Facility

$2,207.20

Hospital Charge Code	3644143
Hospital Revenue Code	272
Min. Negotiated Rate	$1,876.12
Max. Negotiated Rate	$2,140.98
Rate for Payer: Cash Price	$1,434.68
Rate for Payer: Health Management Network Commercial	$1,876.12
Rate for Payer: MDX Hawaii PPO	$2,140.98

Xtrafix 30 Deg Angled Post 11mm 00-5202-090-30 [3644146]

Facility

$1,180.86

Hospital Charge Code	3644146
Hospital Revenue Code	272
Min. Negotiated Rate	$1,003.73
Max. Negotiated Rate	$1,145.43
Rate for Payer: Cash Price	$767.56
Rate for Payer: Health Management Network Commercial	$1,003.73
Rate for Payer: MDX Hawaii PPO	$1,145.43

Xtrafix 30 Deg Angled Post 11mm 00-5202-090-30 [3644146]

Facility

$1,180.86

Hospital Charge Code	3644146
Hospital Revenue Code	272
Min. Negotiated Rate	$602.24
Max. Negotiated Rate	$1,145.43
Rate for Payer: Cash Price	$767.56
Rate for Payer: Hawaii Western Management Group Commercial	$1,121.82
Rate for Payer: Health Management Network Commercial	$1,003.73
Rate for Payer: Kaiser Permanente Commercial	$743.94
Rate for Payer: Kaiser Permanente Medicaid	$602.24
Rate for Payer: MDX Hawaii PPO	$1,145.43
Rate for Payer: University Health Alliance Commercial	$860.73

Xtrafix Lrg 5 x 200 x 65mm Pin Orange 00-5204-050-65 [3644145]

Facility

$1,356.51

Service Code	HCPCS C1713
Hospital Charge Code	3644145
Hospital Revenue Code	278
Min. Negotiated Rate	$691.82
Max. Negotiated Rate	$1,315.81
Rate for Payer: Cash Price	$881.73
Rate for Payer: Hawaii Western Management Group Commercial	$949.56
Rate for Payer: Health Management Network Commercial	$1,153.03
Rate for Payer: Kaiser Permanente Commercial	$854.60
Rate for Payer: Kaiser Permanente Medicaid	$691.82
Rate for Payer: MDX Hawaii PPO	$1,315.81
Rate for Payer: University Health Alliance Commercial	$759.65

Xtrafix Lrg 5 x 200 x 65mm Pin Orange 00-5204-050-65 [3644145]

Facility

$1,356.51

Service Code	HCPCS C1713
Hospital Charge Code	3644145
Hospital Revenue Code	278
Min. Negotiated Rate	$759.65
Max. Negotiated Rate	$1,315.81
Rate for Payer: Cash Price	$881.73
Rate for Payer: Hawaii Western Management Group Commercial	$949.56
Rate for Payer: Health Management Network Commercial	$1,153.03
Rate for Payer: MDX Hawaii PPO	$1,315.81
Rate for Payer: University Health Alliance Commercial	$759.65

Xtrafix Lrg 5 x 250 x 85mm Pin Orange 00-5204-050-85 [3644144]

Facility

$1,356.51

Service Code	HCPCS C1713
Hospital Charge Code	3644144
Hospital Revenue Code	278
Min. Negotiated Rate	$691.82
Max. Negotiated Rate	$1,315.81
Rate for Payer: Cash Price	$881.73
Rate for Payer: Hawaii Western Management Group Commercial	$949.56
Rate for Payer: Health Management Network Commercial	$1,153.03
Rate for Payer: Kaiser Permanente Commercial	$854.60
Rate for Payer: Kaiser Permanente Medicaid	$691.82
Rate for Payer: MDX Hawaii PPO	$1,315.81
Rate for Payer: University Health Alliance Commercial	$759.65

Xtrafix Lrg 5 x 250 x 85mm Pin Orange 00-5204-050-85 [3644144]

Facility

$1,356.51

Service Code	HCPCS C1713
Hospital Charge Code	3644144
Hospital Revenue Code	278
Min. Negotiated Rate	$759.65
Max. Negotiated Rate	$1,315.81
Rate for Payer: Cash Price	$881.73
Rate for Payer: Hawaii Western Management Group Commercial	$949.56
Rate for Payer: Health Management Network Commercial	$1,153.03
Rate for Payer: MDX Hawaii PPO	$1,315.81
Rate for Payer: University Health Alliance Commercial	$759.65

Xtrafix Lrg Blue 105mm Pin Clamp 00-5200-040-08 [3644141]

Facility

$4,894.10

Hospital Charge Code	3644141
Hospital Revenue Code	272
Min. Negotiated Rate	$2,495.99
Max. Negotiated Rate	$4,747.28
Rate for Payer: Cash Price	$3,181.17
Rate for Payer: Hawaii Western Management Group Commercial	$4,649.40
Rate for Payer: Health Management Network Commercial	$4,159.98
Rate for Payer: Kaiser Permanente Commercial	$3,083.28
Rate for Payer: Kaiser Permanente Medicaid	$2,495.99
Rate for Payer: MDX Hawaii PPO	$4,747.28
Rate for Payer: University Health Alliance Commercial	$3,567.31

Xtrafix Lrg Blue 105mm Pin Clamp 00-5200-040-08 [3644141]

Facility

$4,894.10

Hospital Charge Code	3644141
Hospital Revenue Code	272
Min. Negotiated Rate	$4,159.98
Max. Negotiated Rate	$4,747.28
Rate for Payer: Cash Price	$3,181.17
Rate for Payer: Health Management Network Commercial	$4,159.98
Rate for Payer: MDX Hawaii PPO	$4,747.28

Xtrafix Lrg Blue Bar To Bar Clamp 3-D 00-5200-010-01 [3644142]

Facility

$4,193.00

Hospital Charge Code	3644142
Hospital Revenue Code	272
Min. Negotiated Rate	$3,564.05
Max. Negotiated Rate	$4,067.21
Rate for Payer: Cash Price	$2,725.45
Rate for Payer: Health Management Network Commercial	$3,564.05
Rate for Payer: MDX Hawaii PPO	$4,067.21

Xtrafix Lrg Blue Bar To Bar Clamp 3-D 00-5200-010-01 [3644142]

Facility

$4,193.00

Hospital Charge Code	3644142
Hospital Revenue Code	272
Min. Negotiated Rate	$2,138.43
Max. Negotiated Rate	$4,067.21
Rate for Payer: Cash Price	$2,725.45
Rate for Payer: Hawaii Western Management Group Commercial	$3,983.35
Rate for Payer: Health Management Network Commercial	$3,564.05
Rate for Payer: Kaiser Permanente Commercial	$2,641.59
Rate for Payer: Kaiser Permanente Medicaid	$2,138.43
Rate for Payer: MDX Hawaii PPO	$4,067.21
Rate for Payer: University Health Alliance Commercial	$3,056.28

Xtrafix Lrg Blue Bar To Pin Clamp 3-D 00-5200-010-02 [3644140]

Facility

$4,193.00

Hospital Charge Code	3644140
Hospital Revenue Code	272
Min. Negotiated Rate	$3,564.05
Max. Negotiated Rate	$4,067.21
Rate for Payer: Cash Price	$2,725.45
Rate for Payer: Health Management Network Commercial	$3,564.05
Rate for Payer: MDX Hawaii PPO	$4,067.21

Xtrafix Lrg Blue Bar To Pin Clamp 3-D 00-5200-010-02 [3644140]

Facility

$4,193.00

Hospital Charge Code	3644140
Hospital Revenue Code	272
Min. Negotiated Rate	$2,138.43
Max. Negotiated Rate	$4,067.21
Rate for Payer: Cash Price	$2,725.45
Rate for Payer: Hawaii Western Management Group Commercial	$3,983.35
Rate for Payer: Health Management Network Commercial	$3,564.05
Rate for Payer: Kaiser Permanente Commercial	$2,641.59
Rate for Payer: Kaiser Permanente Medicaid	$2,138.43
Rate for Payer: MDX Hawaii PPO	$4,067.21
Rate for Payer: University Health Alliance Commercial	$3,056.28

ZIDOVUDINE 10 MG/ML IV SOLN

Facility

$138.89

Service Code	HCPCS J3485
Hospital Revenue Code	250
Min. Negotiated Rate	$118.06
Max. Negotiated Rate	$134.72
Rate for Payer: Cash Price	$90.28
Rate for Payer: Health Management Network Commercial	$118.06
Rate for Payer: MDX Hawaii PPO	$134.72

ZIDOVUDINE 10 MG/ML IV SOLN

Facility

$138.89

Service Code	HCPCS J3485
Hospital Revenue Code	636
Min. Negotiated Rate	$1.51
Max. Negotiated Rate	$134.72
Rate for Payer: AlohaCare Medicaid	$1.51
Rate for Payer: AlohaCare Medicare	$1.51
Rate for Payer: Cash Price	$90.28
Rate for Payer: Cash Price	$90.28
Rate for Payer: Devoted Health Medicare	$1.66
Rate for Payer: Hawaii Medical Service Association ABD	$1.51
Rate for Payer: Hawaii Medical Service Association Commercial	$1.89
Rate for Payer: Hawaii Medical Service Association Medicare	$1.51
Rate for Payer: Hawaii Medical Service Association Non-ABD	$1.51
Rate for Payer: Hawaii Western Management Group Commercial	$131.95
Rate for Payer: Health Management Network Commercial	$118.06
Rate for Payer: Humana Medicare	$1.51
Rate for Payer: Kaiser Permanente Commercial	$87.50
Rate for Payer: Kaiser Permanente Medicaid	$70.83
Rate for Payer: Kaiser Permanente Medicare	$1.51
Rate for Payer: MDX Hawaii PPO	$134.72
Rate for Payer: Ohana Health Plan Medicaid	$1.66
Rate for Payer: Ohana Health Plan Medicare	$1.51
Rate for Payer: UnitedHealthcare Medicaid	$83.33
Rate for Payer: UnitedHealthcare Medicare	$1.51
Rate for Payer: University Health Alliance Commercial	$101.24

ZIDOVUDINE 10 MG/ML PO SYRUP

Facility

$294.52

Service Code	HCPCS A9270
Hospital Revenue Code	250
Min. Negotiated Rate	$150.21
Max. Negotiated Rate	$285.68
Rate for Payer: Cash Price	$191.44
Rate for Payer: Hawaii Western Management Group Commercial	$279.79
Rate for Payer: Health Management Network Commercial	$250.34
Rate for Payer: Kaiser Permanente Commercial	$185.55
Rate for Payer: Kaiser Permanente Medicaid	$150.21
Rate for Payer: MDX Hawaii PPO	$285.68
Rate for Payer: UnitedHealthcare Medicaid	$176.71
Rate for Payer: University Health Alliance Commercial	$214.68

ZIDOVUDINE 10 MG/ML PO SYRUP

Facility

$294.52

Service Code	HCPCS A9270
Hospital Revenue Code	250
Min. Negotiated Rate	$250.34
Max. Negotiated Rate	$285.68
Rate for Payer: Cash Price	$191.44
Rate for Payer: Health Management Network Commercial	$250.34
Rate for Payer: MDX Hawaii PPO	$285.68

ZINC OXIDE-COD LIVER OIL 40 % TOP PASTE

Facility

$40.21

Service Code	HCPCS A9270
Hospital Revenue Code	250
Min. Negotiated Rate	$34.18
Max. Negotiated Rate	$39.00
Rate for Payer: Cash Price	$26.14
Rate for Payer: Health Management Network Commercial	$34.18
Rate for Payer: MDX Hawaii PPO	$39.00

ZINC OXIDE-COD LIVER OIL 40 % TOP PASTE

Facility

$40.21

Service Code	HCPCS A9270
Hospital Revenue Code	250
Min. Negotiated Rate	$20.51
Max. Negotiated Rate	$39.00
Rate for Payer: Cash Price	$26.14
Rate for Payer: Hawaii Western Management Group Commercial	$38.20
Rate for Payer: Health Management Network Commercial	$34.18
Rate for Payer: Kaiser Permanente Commercial	$25.33
Rate for Payer: Kaiser Permanente Medicaid	$20.51
Rate for Payer: MDX Hawaii PPO	$39.00
Rate for Payer: UnitedHealthcare Medicaid	$24.13
Rate for Payer: University Health Alliance Commercial	$29.31

ZIPRASIDONE HCL 20 MG PO CAP

Facility

$52.47

Service Code	HCPCS A9270
Hospital Revenue Code	250
Min. Negotiated Rate	$44.60
Max. Negotiated Rate	$50.90
Rate for Payer: Cash Price	$34.11
Rate for Payer: Cash Price	$34.42
Rate for Payer: Health Management Network Commercial	$45.01
Rate for Payer: Health Management Network Commercial	$44.60
Rate for Payer: MDX Hawaii PPO	$50.90
Rate for Payer: MDX Hawaii PPO	$51.36

ZIPRASIDONE HCL 20 MG PO CAP

Facility

$52.47

Service Code	HCPCS A9270
Hospital Revenue Code	250
Min. Negotiated Rate	$26.76
Max. Negotiated Rate	$50.90
Rate for Payer: Cash Price	$34.11
Rate for Payer: Cash Price	$34.42
Rate for Payer: Hawaii Western Management Group Commercial	$49.85
Rate for Payer: Hawaii Western Management Group Commercial	$50.30
Rate for Payer: Health Management Network Commercial	$44.60
Rate for Payer: Health Management Network Commercial	$45.01
Rate for Payer: Kaiser Permanente Commercial	$33.06
Rate for Payer: Kaiser Permanente Commercial	$33.36
Rate for Payer: Kaiser Permanente Medicaid	$26.76
Rate for Payer: Kaiser Permanente Medicaid	$27.00
Rate for Payer: MDX Hawaii PPO	$50.90
Rate for Payer: MDX Hawaii PPO	$51.36
Rate for Payer: UnitedHealthcare Medicaid	$31.77
Rate for Payer: UnitedHealthcare Medicaid	$31.48
Rate for Payer: University Health Alliance Commercial	$38.25
Rate for Payer: University Health Alliance Commercial	$38.60

ZIPRASIDONE HCL 40 MG PO CAP

Facility

$52.47

Service Code	HCPCS A9270
Hospital Revenue Code	250
Min. Negotiated Rate	$44.60
Max. Negotiated Rate	$50.90
Rate for Payer: Cash Price	$34.11
Rate for Payer: Health Management Network Commercial	$44.60
Rate for Payer: MDX Hawaii PPO	$50.90

Know your out-of-pocket cost for care.

All Charges