Kona Community Hospital

All Charges

Charge

Type

Setting

Price

DIMETHYL SULFOXIDE (BULK) 99.99 % MISC LIQ

Facility

$497.43

Service Code	HCPCS J1212
Hospital Revenue Code	636
Min. Negotiated Rate	$253.69
Max. Negotiated Rate	$936.23
Rate for Payer: AlohaCare Medicaid	$748.98
Rate for Payer: AlohaCare Medicare	$748.98
Rate for Payer: Cash Price	$323.33
Rate for Payer: Cash Price	$323.33
Rate for Payer: Devoted Health Medicare	$823.88
Rate for Payer: Hawaii Medical Service Association ABD	$742.90
Rate for Payer: Hawaii Medical Service Association Commercial	$936.23
Rate for Payer: Hawaii Medical Service Association Medicare	$748.98
Rate for Payer: Hawaii Medical Service Association Non-ABD	$742.90
Rate for Payer: Hawaii Western Management Group Commercial	$472.56
Rate for Payer: Health Management Network Commercial	$422.82
Rate for Payer: Humana Medicare	$748.98
Rate for Payer: Kaiser Permanente Commercial	$313.38
Rate for Payer: Kaiser Permanente Medicaid	$253.69
Rate for Payer: Kaiser Permanente Medicare	$748.98
Rate for Payer: MDX Hawaii PPO	$482.51
Rate for Payer: Ohana Health Plan Medicaid	$823.88
Rate for Payer: Ohana Health Plan Medicare	$748.98
Rate for Payer: UnitedHealthcare Medicaid	$298.46
Rate for Payer: UnitedHealthcare Medicare	$748.98
Rate for Payer: University Health Alliance Commercial	$362.58

DINOPROSTONE 10 MG VAG INSR

Facility

$1,382.18

Service Code	HCPCS A9270
Hospital Revenue Code	250
Min. Negotiated Rate	$704.91
Max. Negotiated Rate	$1,340.71
Rate for Payer: Cash Price	$898.42
Rate for Payer: Hawaii Western Management Group Commercial	$1,313.07
Rate for Payer: Health Management Network Commercial	$1,174.85
Rate for Payer: Kaiser Permanente Commercial	$870.77
Rate for Payer: Kaiser Permanente Medicaid	$704.91
Rate for Payer: MDX Hawaii PPO	$1,340.71
Rate for Payer: UnitedHealthcare Medicaid	$829.31
Rate for Payer: University Health Alliance Commercial	$1,007.47

DINOPROSTONE 10 MG VAG INSR

Facility

$1,382.18

Service Code	HCPCS A9270
Hospital Revenue Code	250
Min. Negotiated Rate	$1,174.85
Max. Negotiated Rate	$1,340.71
Rate for Payer: Cash Price	$898.42
Rate for Payer: Health Management Network Commercial	$1,174.85
Rate for Payer: MDX Hawaii PPO	$1,340.71

DIPHENHYDRAMINE HCL 12.5 MG/5 ML PO ELIX

Facility

$28.76

Service Code	HCPCS A9270
Hospital Revenue Code	250
Min. Negotiated Rate	$14.67
Max. Negotiated Rate	$27.90
Rate for Payer: Cash Price	$18.69
Rate for Payer: Hawaii Western Management Group Commercial	$27.32
Rate for Payer: Health Management Network Commercial	$24.45
Rate for Payer: Kaiser Permanente Commercial	$18.12
Rate for Payer: Kaiser Permanente Medicaid	$14.67
Rate for Payer: MDX Hawaii PPO	$27.90
Rate for Payer: UnitedHealthcare Medicaid	$17.26
Rate for Payer: University Health Alliance Commercial	$20.96

DIPHENHYDRAMINE HCL 12.5 MG/5 ML PO ELIX

Facility

$28.76

Service Code	HCPCS A9270
Hospital Revenue Code	250
Min. Negotiated Rate	$24.45
Max. Negotiated Rate	$27.90
Rate for Payer: Cash Price	$18.69
Rate for Payer: Health Management Network Commercial	$24.45
Rate for Payer: MDX Hawaii PPO	$27.90

DIPHENHYDRAMINE HCL 25 MG PO CAP

Facility

$1.20

Service Code	HCPCS A9270
Hospital Revenue Code	250
Min. Negotiated Rate	$0.61
Max. Negotiated Rate	$1.16
Rate for Payer: Cash Price	$0.78
Rate for Payer: Hawaii Western Management Group Commercial	$1.14
Rate for Payer: Health Management Network Commercial	$1.02
Rate for Payer: Kaiser Permanente Commercial	$0.76
Rate for Payer: Kaiser Permanente Medicaid	$0.61
Rate for Payer: MDX Hawaii PPO	$1.16
Rate for Payer: UnitedHealthcare Medicaid	$0.72
Rate for Payer: University Health Alliance Commercial	$0.87

DIPHENHYDRAMINE HCL 25 MG PO CAP

Facility

$1.20

Service Code	HCPCS A9270
Hospital Revenue Code	250
Min. Negotiated Rate	$1.02
Max. Negotiated Rate	$1.16
Rate for Payer: Cash Price	$0.78
Rate for Payer: Health Management Network Commercial	$1.02
Rate for Payer: MDX Hawaii PPO	$1.16

DIPHENHYDRAMINE HCL 50 MG/ML INJ SOLN

Facility

$6.47

Service Code	HCPCS J1200
Hospital Revenue Code	250
Min. Negotiated Rate	$5.50
Max. Negotiated Rate	$6.28
Rate for Payer: Cash Price	$4.21
Rate for Payer: Cash Price	$6.89
Rate for Payer: Health Management Network Commercial	$9.01
Rate for Payer: Health Management Network Commercial	$5.50
Rate for Payer: MDX Hawaii PPO	$10.28
Rate for Payer: MDX Hawaii PPO	$6.28

DIPHENHYDRAMINE HCL 50 MG/ML INJ SOLN

Facility

$6.47

Service Code	HCPCS J1200
Hospital Revenue Code	636
Min. Negotiated Rate	$0.90
Max. Negotiated Rate	$6.28
Rate for Payer: Cash Price	$4.21
Rate for Payer: Cash Price	$6.89
Rate for Payer: Cash Price	$4.21
Rate for Payer: Cash Price	$6.89
Rate for Payer: Hawaii Medical Service Association ABD	$0.90
Rate for Payer: Hawaii Medical Service Association ABD	$0.90
Rate for Payer: Hawaii Medical Service Association Non-ABD	$0.90
Rate for Payer: Hawaii Medical Service Association Non-ABD	$0.90
Rate for Payer: Hawaii Western Management Group Commercial	$10.07
Rate for Payer: Hawaii Western Management Group Commercial	$6.15
Rate for Payer: Health Management Network Commercial	$5.50
Rate for Payer: Health Management Network Commercial	$9.01
Rate for Payer: Kaiser Permanente Commercial	$4.08
Rate for Payer: Kaiser Permanente Commercial	$6.68
Rate for Payer: Kaiser Permanente Medicaid	$5.41
Rate for Payer: Kaiser Permanente Medicaid	$3.30
Rate for Payer: MDX Hawaii PPO	$6.28
Rate for Payer: MDX Hawaii PPO	$10.28
Rate for Payer: UnitedHealthcare Medicaid	$6.36
Rate for Payer: UnitedHealthcare Medicaid	$3.88
Rate for Payer: University Health Alliance Commercial	$4.72
Rate for Payer: University Health Alliance Commercial	$7.73

DIPHENHYDRAMINE HCL 50 MG/ML INJ SYR

Facility

$14.36

Service Code	HCPCS J1200
Hospital Revenue Code	250
Min. Negotiated Rate	$12.21
Max. Negotiated Rate	$13.93
Rate for Payer: Cash Price	$9.33
Rate for Payer: Health Management Network Commercial	$12.21
Rate for Payer: MDX Hawaii PPO	$13.93

DIPHENHYDRAMINE HCL 50 MG/ML INJ SYR

Facility

$14.36

Service Code	HCPCS J1200
Hospital Revenue Code	636
Min. Negotiated Rate	$0.90
Max. Negotiated Rate	$13.93
Rate for Payer: Cash Price	$9.33
Rate for Payer: Cash Price	$9.33
Rate for Payer: Hawaii Medical Service Association ABD	$0.90
Rate for Payer: Hawaii Medical Service Association Non-ABD	$0.90
Rate for Payer: Hawaii Western Management Group Commercial	$13.64
Rate for Payer: Health Management Network Commercial	$12.21
Rate for Payer: Kaiser Permanente Commercial	$9.05
Rate for Payer: Kaiser Permanente Medicaid	$7.32
Rate for Payer: MDX Hawaii PPO	$13.93
Rate for Payer: UnitedHealthcare Medicaid	$8.62
Rate for Payer: University Health Alliance Commercial	$10.47

DIPHENHYDRAMINE HCL 50 MG PO CAP

Facility

$1.20

Service Code	HCPCS A9270
Hospital Revenue Code	250
Min. Negotiated Rate	$0.61
Max. Negotiated Rate	$1.16
Rate for Payer: Cash Price	$0.78
Rate for Payer: Hawaii Western Management Group Commercial	$1.14
Rate for Payer: Health Management Network Commercial	$1.02
Rate for Payer: Kaiser Permanente Commercial	$0.76
Rate for Payer: Kaiser Permanente Medicaid	$0.61
Rate for Payer: MDX Hawaii PPO	$1.16
Rate for Payer: UnitedHealthcare Medicaid	$0.72
Rate for Payer: University Health Alliance Commercial	$0.87

DIPHENHYDRAMINE HCL 50 MG PO CAP

Facility

$1.20

Service Code	HCPCS A9270
Hospital Revenue Code	250
Min. Negotiated Rate	$1.02
Max. Negotiated Rate	$1.16
Rate for Payer: Cash Price	$0.78
Rate for Payer: Health Management Network Commercial	$1.02
Rate for Payer: MDX Hawaii PPO	$1.16

DIPHENOXYLATE-ATROPINE 2.5-0.025 MG PO TABLET

Facility

$3.87

Service Code	HCPCS A9270
Hospital Revenue Code	250
Min. Negotiated Rate	$1.97
Max. Negotiated Rate	$3.75
Rate for Payer: Cash Price	$2.52
Rate for Payer: Hawaii Western Management Group Commercial	$3.68
Rate for Payer: Health Management Network Commercial	$3.29
Rate for Payer: Kaiser Permanente Commercial	$2.44
Rate for Payer: Kaiser Permanente Medicaid	$1.97
Rate for Payer: MDX Hawaii PPO	$3.75
Rate for Payer: UnitedHealthcare Medicaid	$2.32
Rate for Payer: University Health Alliance Commercial	$2.82

DIPHENOXYLATE-ATROPINE 2.5-0.025 MG PO TABLET

Facility

$3.87

Service Code	HCPCS A9270
Hospital Revenue Code	250
Min. Negotiated Rate	$3.29
Max. Negotiated Rate	$3.75
Rate for Payer: Cash Price	$2.52
Rate for Payer: Health Management Network Commercial	$3.29
Rate for Payer: MDX Hawaii PPO	$3.75

DIPH,PERTUS(ACEL),TET PED (PF) 15-10-5 LF-MCG-LF/0.5ML IM SUSP

Facility

$134.52

Service Code	HCPCS 90700
Hospital Revenue Code	250
Min. Negotiated Rate	$32.42
Max. Negotiated Rate	$130.48
Rate for Payer: Cash Price	$87.44
Rate for Payer: Cash Price	$87.42
Rate for Payer: Cash Price	$87.42
Rate for Payer: Cash Price	$87.44
Rate for Payer: Hawaii Medical Service Association ABD	$32.42
Rate for Payer: Hawaii Medical Service Association ABD	$32.42
Rate for Payer: Hawaii Medical Service Association Non-ABD	$32.42
Rate for Payer: Hawaii Medical Service Association Non-ABD	$32.42
Rate for Payer: Hawaii Western Management Group Commercial	$127.78
Rate for Payer: Hawaii Western Management Group Commercial	$127.79
Rate for Payer: Health Management Network Commercial	$114.34
Rate for Payer: Health Management Network Commercial	$114.33
Rate for Payer: Kaiser Permanente Commercial	$84.75
Rate for Payer: Kaiser Permanente Commercial	$84.73
Rate for Payer: Kaiser Permanente Medicaid	$68.59
Rate for Payer: Kaiser Permanente Medicaid	$68.61
Rate for Payer: MDX Hawaii PPO	$130.47
Rate for Payer: MDX Hawaii PPO	$130.48
Rate for Payer: UnitedHealthcare Medicaid	$80.71
Rate for Payer: UnitedHealthcare Medicaid	$80.70
Rate for Payer: University Health Alliance Commercial	$98.05
Rate for Payer: University Health Alliance Commercial	$98.04

DIPH,PERTUS(ACEL),TET PED (PF) 15-10-5 LF-MCG-LF/0.5ML IM SUSP

Facility

$134.50

Service Code	HCPCS 90700
Hospital Revenue Code	250
Min. Negotiated Rate	$114.33
Max. Negotiated Rate	$130.47
Rate for Payer: Cash Price	$87.42
Rate for Payer: Cash Price	$87.44
Rate for Payer: Health Management Network Commercial	$114.33
Rate for Payer: Health Management Network Commercial	$114.34
Rate for Payer: MDX Hawaii PPO	$130.47
Rate for Payer: MDX Hawaii PPO	$130.48

DIPH,PERTUSS(ACEL),TET VAC(PF) 2 LF-(2.5-5-3-5 MCG)-5LF/0.5 ML IM SYR

Facility

$212.38

Service Code	HCPCS 90715
Hospital Revenue Code	250
Min. Negotiated Rate	$38.63
Max. Negotiated Rate	$206.01
Rate for Payer: Cash Price	$138.05
Rate for Payer: Cash Price	$138.05
Rate for Payer: Hawaii Medical Service Association ABD	$38.63
Rate for Payer: Hawaii Medical Service Association Non-ABD	$38.63
Rate for Payer: Hawaii Western Management Group Commercial	$201.76
Rate for Payer: Health Management Network Commercial	$180.52
Rate for Payer: Kaiser Permanente Commercial	$133.80
Rate for Payer: Kaiser Permanente Medicaid	$108.31
Rate for Payer: MDX Hawaii PPO	$206.01
Rate for Payer: UnitedHealthcare Medicaid	$127.43
Rate for Payer: University Health Alliance Commercial	$154.80

DIPH,PERTUSS(ACEL),TET VAC(PF) 2 LF-(2.5-5-3-5 MCG)-5LF/0.5 ML IM SYR

Facility

$212.38

Service Code	HCPCS 90715
Hospital Revenue Code	250
Min. Negotiated Rate	$180.52
Max. Negotiated Rate	$206.01
Rate for Payer: Cash Price	$138.05
Rate for Payer: Health Management Network Commercial	$180.52
Rate for Payer: MDX Hawaii PPO	$206.01

DISORDERS OF GALLBLADDER & BILIARY TRACT

Facility

$10,288.83

Service Code	APR-DRG 2844
Min. Negotiated Rate	$10,288.83
Max. Negotiated Rate	$10,288.83
Rate for Payer: AlohaCare Medicaid	$10,288.83
Rate for Payer: Hawaii Medical Service Association ABD	$10,288.83
Rate for Payer: Hawaii Medical Service Association Non-ABD	$10,288.83
Rate for Payer: Kaiser Permanente Medicaid	$10,288.83
Rate for Payer: Ohana Health Plan Medicaid	$10,288.83
Rate for Payer: UnitedHealthcare Medicaid	$10,288.83

DISORDERS OF GALLBLADDER & BILIARY TRACT

Facility

$5,880.88

Service Code	APR-DRG 2843
Min. Negotiated Rate	$5,880.88
Max. Negotiated Rate	$5,880.88
Rate for Payer: AlohaCare Medicaid	$5,880.88
Rate for Payer: Hawaii Medical Service Association ABD	$5,880.88
Rate for Payer: Hawaii Medical Service Association Non-ABD	$5,880.88
Rate for Payer: Kaiser Permanente Medicaid	$5,880.88
Rate for Payer: Ohana Health Plan Medicaid	$5,880.88
Rate for Payer: UnitedHealthcare Medicaid	$5,880.88

DISORDERS OF GALLBLADDER & BILIARY TRACT

Facility

$4,291.42

Service Code	APR-DRG 2842
Min. Negotiated Rate	$4,291.42
Max. Negotiated Rate	$4,291.42
Rate for Payer: AlohaCare Medicaid	$4,291.42
Rate for Payer: Hawaii Medical Service Association ABD	$4,291.42
Rate for Payer: Hawaii Medical Service Association Non-ABD	$4,291.42
Rate for Payer: Kaiser Permanente Medicaid	$4,291.42
Rate for Payer: Ohana Health Plan Medicaid	$4,291.42
Rate for Payer: UnitedHealthcare Medicaid	$4,291.42

DISORDERS OF GALLBLADDER & BILIARY TRACT

Facility

$3,432.37

Service Code	APR-DRG 2841
Min. Negotiated Rate	$3,432.37
Max. Negotiated Rate	$3,432.37
Rate for Payer: AlohaCare Medicaid	$3,432.37
Rate for Payer: Hawaii Medical Service Association ABD	$3,432.37
Rate for Payer: Hawaii Medical Service Association Non-ABD	$3,432.37
Rate for Payer: Kaiser Permanente Medicaid	$3,432.37
Rate for Payer: Ohana Health Plan Medicaid	$3,432.37
Rate for Payer: UnitedHealthcare Medicaid	$3,432.37

DISORDERS OF LIVER EXCEPT MALIGNANCY, CIRRHOSIS OR ALCOHOLIC HEPATITIS WITH CC

Facility

$32,472.13

Service Code	MSDRG 442
Min. Negotiated Rate	$12,696.36
Max. Negotiated Rate	$32,472.13
Rate for Payer: AlohaCare Medicare	$12,696.36
Rate for Payer: Devoted Health Medicare	$13,966.00
Rate for Payer: Hawaii Medical Service Association Commercial	$32,472.13
Rate for Payer: Hawaii Medical Service Association Medicare	$12,696.36
Rate for Payer: Humana Medicare	$12,696.36
Rate for Payer: Kaiser Permanente Commercial	$16,651.42
Rate for Payer: Kaiser Permanente Medicare	$12,696.36
Rate for Payer: Ohana Health Plan Medicare	$12,696.36
Rate for Payer: UnitedHealthcare Medicare	$12,696.36

DISORDERS OF LIVER EXCEPT MALIGNANCY, CIRRHOSIS OR ALCOHOLIC HEPATITIS WITH MCC

Facility

$32,472.13

Service Code	MSDRG 441
Min. Negotiated Rate	$23,605.26
Max. Negotiated Rate	$32,472.13
Rate for Payer: AlohaCare Medicare	$23,605.26
Rate for Payer: Devoted Health Medicare	$25,965.79
Rate for Payer: Hawaii Medical Service Association Commercial	$32,472.13
Rate for Payer: Hawaii Medical Service Association Medicare	$23,605.26
Rate for Payer: Humana Medicare	$23,605.26
Rate for Payer: Kaiser Permanente Commercial	$30,958.58
Rate for Payer: Kaiser Permanente Medicare	$23,605.26
Rate for Payer: Ohana Health Plan Medicare	$23,605.26
Rate for Payer: UnitedHealthcare Medicare	$23,605.26

Know your out-of-pocket cost for care.

All Charges