Kona Community Hospital

All Charges

Charge

Type

Setting

Price

Distal Clavicle Plate, Short, Left, Ss Ar-2656dl [3644561]

Facility

$6,462.50

Service Code	HCPCS C1713
Hospital Charge Code	3644561
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

DIVALPROEX 125 MG PO CDRS

Facility

$7.84

Service Code	HCPCS A9270
Hospital Revenue Code	250
Min. Negotiated Rate	$6.66
Max. Negotiated Rate	$7.60
Rate for Payer: Cash Price	$5.10
Rate for Payer: Health Management Network Commercial	$6.66
Rate for Payer: MDX Hawaii PPO	$7.60

DIVALPROEX 125 MG PO CDRS

Facility

$7.84

Service Code	HCPCS A9270
Hospital Revenue Code	250
Min. Negotiated Rate	$4.00
Max. Negotiated Rate	$7.60
Rate for Payer: Cash Price	$5.10
Rate for Payer: Hawaii Western Management Group Commercial	$7.45
Rate for Payer: Health Management Network Commercial	$6.66
Rate for Payer: Kaiser Permanente Commercial	$4.94
Rate for Payer: Kaiser Permanente Medicaid	$4.00
Rate for Payer: MDX Hawaii PPO	$7.60
Rate for Payer: UnitedHealthcare Medicaid	$4.70
Rate for Payer: University Health Alliance Commercial	$5.71

DIVERTICULECTOMY OF HYPOPHARYNX OR ESOPHAGUS, WITH OR WITHOUT MYOTOMY; CERVICAL APPROACH

Facility

$17,484.00

Service Code	CPT 43130
Hospital Revenue Code	360
Min. Negotiated Rate	$521.33
Max. Negotiated Rate	$17,484.00
Rate for Payer: AlohaCare Medicaid	$6,993.36
Rate for Payer: AlohaCare Medicare	$6,993.36
Rate for Payer: Devoted Health Medicare	$7,692.70
Rate for Payer: Hawaii Medical Service Association ABD	$1,900.00
Rate for Payer: Hawaii Medical Service Association Commercial	$17,484.00
Rate for Payer: Hawaii Medical Service Association Medicare	$6,993.36
Rate for Payer: Hawaii Medical Service Association Non-ABD	$1,902.37
Rate for Payer: Humana Medicare	$6,993.36
Rate for Payer: Kaiser Permanente Medicaid	$2,837.00
Rate for Payer: Kaiser Permanente Medicare	$6,993.36
Rate for Payer: Ohana Health Plan Medicaid	$7,692.70
Rate for Payer: Ohana Health Plan Medicare	$6,993.36
Rate for Payer: UnitedHealthcare Medicaid	$521.33
Rate for Payer: UnitedHealthcare Medicare	$6,993.36
Rate for Payer: University Health Alliance Commercial	$13,923.44

DIVERTICULITIS & DIVERTICULOSIS

Facility

$3,511.33

Service Code	APR-DRG 2442
Min. Negotiated Rate	$3,511.33
Max. Negotiated Rate	$3,511.33
Rate for Payer: AlohaCare Medicaid	$3,511.33
Rate for Payer: Hawaii Medical Service Association ABD	$3,511.33
Rate for Payer: Hawaii Medical Service Association Non-ABD	$3,511.33
Rate for Payer: Kaiser Permanente Medicaid	$3,511.33
Rate for Payer: Ohana Health Plan Medicaid	$3,511.33
Rate for Payer: UnitedHealthcare Medicaid	$3,511.33

DIVERTICULITIS & DIVERTICULOSIS

Facility

$5,312.21

Service Code	APR-DRG 2443
Min. Negotiated Rate	$5,312.21
Max. Negotiated Rate	$5,312.21
Rate for Payer: AlohaCare Medicaid	$5,312.21
Rate for Payer: Hawaii Medical Service Association ABD	$5,312.21
Rate for Payer: Hawaii Medical Service Association Non-ABD	$5,312.21
Rate for Payer: Kaiser Permanente Medicaid	$5,312.21
Rate for Payer: Ohana Health Plan Medicaid	$5,312.21
Rate for Payer: UnitedHealthcare Medicaid	$5,312.21

DIVERTICULITIS & DIVERTICULOSIS

Facility

$2,753.54

Service Code	APR-DRG 2441
Min. Negotiated Rate	$2,753.54
Max. Negotiated Rate	$2,753.54
Rate for Payer: AlohaCare Medicaid	$2,753.54
Rate for Payer: Hawaii Medical Service Association ABD	$2,753.54
Rate for Payer: Hawaii Medical Service Association Non-ABD	$2,753.54
Rate for Payer: Kaiser Permanente Medicaid	$2,753.54
Rate for Payer: Ohana Health Plan Medicaid	$2,753.54
Rate for Payer: UnitedHealthcare Medicaid	$2,753.54

DIVERTICULITIS & DIVERTICULOSIS

Facility

$9,716.98

Service Code	APR-DRG 2444
Min. Negotiated Rate	$9,716.98
Max. Negotiated Rate	$9,716.98
Rate for Payer: AlohaCare Medicaid	$9,716.98
Rate for Payer: Hawaii Medical Service Association ABD	$9,716.98
Rate for Payer: Hawaii Medical Service Association Non-ABD	$9,716.98
Rate for Payer: Kaiser Permanente Medicaid	$9,716.98
Rate for Payer: Ohana Health Plan Medicaid	$9,716.98
Rate for Payer: UnitedHealthcare Medicaid	$9,716.98

DOBUTAMINE 250 MG/20 ML (12.5 MG/ML) IV SOLN

Facility

$43.17

Service Code	HCPCS J1250
Hospital Revenue Code	636
Min. Negotiated Rate	$7.98
Max. Negotiated Rate	$41.87
Rate for Payer: Cash Price	$28.06
Rate for Payer: Cash Price	$18.23
Rate for Payer: Cash Price	$18.23
Rate for Payer: Cash Price	$30.58
Rate for Payer: Cash Price	$30.58
Rate for Payer: Cash Price	$28.06
Rate for Payer: Hawaii Medical Service Association ABD	$7.98
Rate for Payer: Hawaii Medical Service Association ABD	$7.98
Rate for Payer: Hawaii Medical Service Association ABD	$7.98
Rate for Payer: Hawaii Medical Service Association Non-ABD	$7.98
Rate for Payer: Hawaii Medical Service Association Non-ABD	$7.98
Rate for Payer: Hawaii Medical Service Association Non-ABD	$7.98
Rate for Payer: Hawaii Western Management Group Commercial	$41.01
Rate for Payer: Hawaii Western Management Group Commercial	$26.65
Rate for Payer: Hawaii Western Management Group Commercial	$44.69
Rate for Payer: Health Management Network Commercial	$23.84
Rate for Payer: Health Management Network Commercial	$39.98
Rate for Payer: Health Management Network Commercial	$36.69
Rate for Payer: Kaiser Permanente Commercial	$17.67
Rate for Payer: Kaiser Permanente Commercial	$27.20
Rate for Payer: Kaiser Permanente Commercial	$29.64
Rate for Payer: Kaiser Permanente Medicaid	$23.99
Rate for Payer: Kaiser Permanente Medicaid	$22.02
Rate for Payer: Kaiser Permanente Medicaid	$14.31
Rate for Payer: MDX Hawaii PPO	$27.21
Rate for Payer: MDX Hawaii PPO	$45.63
Rate for Payer: MDX Hawaii PPO	$41.87
Rate for Payer: UnitedHealthcare Medicaid	$16.83
Rate for Payer: UnitedHealthcare Medicaid	$25.90
Rate for Payer: UnitedHealthcare Medicaid	$28.22
Rate for Payer: University Health Alliance Commercial	$31.47
Rate for Payer: University Health Alliance Commercial	$20.45
Rate for Payer: University Health Alliance Commercial	$34.29

DOBUTAMINE 250 MG/20 ML (12.5 MG/ML) IV SOLN

Facility

$47.04

Service Code	HCPCS J1250
Hospital Revenue Code	250
Min. Negotiated Rate	$39.98
Max. Negotiated Rate	$45.63
Rate for Payer: Cash Price	$30.58
Rate for Payer: Cash Price	$18.23
Rate for Payer: Cash Price	$28.06
Rate for Payer: Health Management Network Commercial	$23.84
Rate for Payer: Health Management Network Commercial	$36.69
Rate for Payer: Health Management Network Commercial	$39.98
Rate for Payer: MDX Hawaii PPO	$27.21
Rate for Payer: MDX Hawaii PPO	$45.63
Rate for Payer: MDX Hawaii PPO	$41.87

DOBUTAMINE IN D5W 250 MG/250 ML (1 MG/ML) IV SOLP TITRATION

Facility

$109.08

Service Code	HCPCS J1250
Hospital Revenue Code	250
Min. Negotiated Rate	$92.72
Max. Negotiated Rate	$105.81
Rate for Payer: Cash Price	$70.90
Rate for Payer: Cash Price	$72.25
Rate for Payer: Health Management Network Commercial	$92.72
Rate for Payer: Health Management Network Commercial	$94.48
Rate for Payer: MDX Hawaii PPO	$105.81
Rate for Payer: MDX Hawaii PPO	$107.82

DOBUTAMINE IN D5W 250 MG/250 ML (1 MG/ML) IV SOLP TITRATION

Facility

$109.08

Service Code	HCPCS J1250
Hospital Revenue Code	636
Min. Negotiated Rate	$7.98
Max. Negotiated Rate	$105.81
Rate for Payer: Cash Price	$70.90
Rate for Payer: Cash Price	$72.25
Rate for Payer: Cash Price	$70.90
Rate for Payer: Cash Price	$72.25
Rate for Payer: Hawaii Medical Service Association ABD	$7.98
Rate for Payer: Hawaii Medical Service Association ABD	$7.98
Rate for Payer: Hawaii Medical Service Association Non-ABD	$7.98
Rate for Payer: Hawaii Medical Service Association Non-ABD	$7.98
Rate for Payer: Hawaii Western Management Group Commercial	$105.59
Rate for Payer: Hawaii Western Management Group Commercial	$103.63
Rate for Payer: Health Management Network Commercial	$94.48
Rate for Payer: Health Management Network Commercial	$92.72
Rate for Payer: Kaiser Permanente Commercial	$70.02
Rate for Payer: Kaiser Permanente Commercial	$68.72
Rate for Payer: Kaiser Permanente Medicaid	$55.63
Rate for Payer: Kaiser Permanente Medicaid	$56.69
Rate for Payer: MDX Hawaii PPO	$105.81
Rate for Payer: MDX Hawaii PPO	$107.82
Rate for Payer: UnitedHealthcare Medicaid	$66.69
Rate for Payer: UnitedHealthcare Medicaid	$65.45
Rate for Payer: University Health Alliance Commercial	$79.51
Rate for Payer: University Health Alliance Commercial	$81.02

DOBUTAMINE IN D5W 250 MG/250 ML (1 MG/ML) NON-TITRATING

Facility

$109.08

Service Code	NDC 00409234632
Hospital Revenue Code	250
Min. Negotiated Rate	$92.72
Max. Negotiated Rate	$105.81
Rate for Payer: Cash Price	$70.90
Rate for Payer: Health Management Network Commercial	$92.72
Rate for Payer: MDX Hawaii PPO	$105.81

DOBUTAMINE IN D5W 250 MG/250 ML (1 MG/ML) NON-TITRATING

Facility

$109.08

Service Code	NDC 00409234631
Hospital Revenue Code	250
Min. Negotiated Rate	$55.63
Max. Negotiated Rate	$105.81
Rate for Payer: Cash Price	$70.90
Rate for Payer: Hawaii Western Management Group Commercial	$103.63
Rate for Payer: Health Management Network Commercial	$92.72
Rate for Payer: Kaiser Permanente Commercial	$68.72
Rate for Payer: Kaiser Permanente Medicaid	$55.63
Rate for Payer: MDX Hawaii PPO	$105.81
Rate for Payer: UnitedHealthcare Medicaid	$65.45
Rate for Payer: University Health Alliance Commercial	$79.51

DOBUTAMINE IN D5W 250 MG/250 ML (1 MG/ML) NON-TITRATING

Facility

$109.08

Service Code	NDC 00409234632
Hospital Revenue Code	250
Min. Negotiated Rate	$55.63
Max. Negotiated Rate	$105.81
Rate for Payer: Cash Price	$70.90
Rate for Payer: Hawaii Western Management Group Commercial	$103.63
Rate for Payer: Health Management Network Commercial	$92.72
Rate for Payer: Kaiser Permanente Commercial	$68.72
Rate for Payer: Kaiser Permanente Medicaid	$55.63
Rate for Payer: MDX Hawaii PPO	$105.81
Rate for Payer: UnitedHealthcare Medicaid	$65.45
Rate for Payer: University Health Alliance Commercial	$79.51

DOBUTAMINE IN D5W 250 MG/250 ML (1 MG/ML) NON-TITRATING

Facility

$109.08

Service Code	NDC 00409234631
Hospital Revenue Code	250
Min. Negotiated Rate	$92.72
Max. Negotiated Rate	$105.81
Rate for Payer: Cash Price	$70.90
Rate for Payer: Health Management Network Commercial	$92.72
Rate for Payer: MDX Hawaii PPO	$105.81

DOCETAXEL 160 MG/16 ML (10 MG/ML) IV SOLN

Facility

$904.32

Service Code	HCPCS J9171
Hospital Revenue Code	250
Min. Negotiated Rate	$768.67
Max. Negotiated Rate	$877.19
Rate for Payer: Cash Price	$587.81
Rate for Payer: Health Management Network Commercial	$768.67
Rate for Payer: MDX Hawaii PPO	$877.19

DOCETAXEL 160 MG/16 ML (10 MG/ML) IV SOLN

Facility

$904.32

Service Code	HCPCS J9171
Hospital Revenue Code	636
Min. Negotiated Rate	$0.38
Max. Negotiated Rate	$877.19
Rate for Payer: Cash Price	$587.81
Rate for Payer: Cash Price	$587.81
Rate for Payer: Hawaii Medical Service Association ABD	$0.38
Rate for Payer: Hawaii Medical Service Association Non-ABD	$0.38
Rate for Payer: Hawaii Western Management Group Commercial	$859.10
Rate for Payer: Health Management Network Commercial	$768.67
Rate for Payer: Kaiser Permanente Commercial	$569.72
Rate for Payer: Kaiser Permanente Medicaid	$461.20
Rate for Payer: MDX Hawaii PPO	$877.19
Rate for Payer: UnitedHealthcare Medicaid	$542.59
Rate for Payer: University Health Alliance Commercial	$659.16

DOCETAXEL 160 MG/8 ML (20 MG/ML) IV SOLN

Facility

$1,143.06

Service Code	HCPCS J9171
Hospital Revenue Code	636
Min. Negotiated Rate	$0.38
Max. Negotiated Rate	$1,108.77
Rate for Payer: Cash Price	$742.99
Rate for Payer: Cash Price	$742.99
Rate for Payer: Hawaii Medical Service Association ABD	$0.38
Rate for Payer: Hawaii Medical Service Association Non-ABD	$0.38
Rate for Payer: Hawaii Western Management Group Commercial	$1,085.91
Rate for Payer: Health Management Network Commercial	$971.60
Rate for Payer: Kaiser Permanente Commercial	$720.13
Rate for Payer: Kaiser Permanente Medicaid	$582.96
Rate for Payer: MDX Hawaii PPO	$1,108.77
Rate for Payer: UnitedHealthcare Medicaid	$685.84
Rate for Payer: University Health Alliance Commercial	$833.18

DOCETAXEL 160 MG/8 ML (20 MG/ML) IV SOLN

Facility

$1,143.06

Service Code	HCPCS J9171
Hospital Revenue Code	250
Min. Negotiated Rate	$971.60
Max. Negotiated Rate	$1,108.77
Rate for Payer: Cash Price	$742.99
Rate for Payer: Health Management Network Commercial	$971.60
Rate for Payer: MDX Hawaii PPO	$1,108.77

DOCETAXEL 20 MG/ML (1 ML) IV SOLN

Facility

$121.50

Service Code	HCPCS J9171
Hospital Revenue Code	250
Min. Negotiated Rate	$103.28
Max. Negotiated Rate	$117.86
Rate for Payer: Cash Price	$78.98
Rate for Payer: Health Management Network Commercial	$103.28
Rate for Payer: MDX Hawaii PPO	$117.86

DOCETAXEL 20 MG/ML (1 ML) IV SOLN

Facility

$121.50

Service Code	HCPCS J9171
Hospital Revenue Code	636
Min. Negotiated Rate	$0.38
Max. Negotiated Rate	$117.86
Rate for Payer: Cash Price	$78.98
Rate for Payer: Cash Price	$78.98
Rate for Payer: Hawaii Medical Service Association ABD	$0.38
Rate for Payer: Hawaii Medical Service Association Non-ABD	$0.38
Rate for Payer: Hawaii Western Management Group Commercial	$115.42
Rate for Payer: Health Management Network Commercial	$103.28
Rate for Payer: Kaiser Permanente Commercial	$76.55
Rate for Payer: Kaiser Permanente Medicaid	$61.97
Rate for Payer: MDX Hawaii PPO	$117.86
Rate for Payer: UnitedHealthcare Medicaid	$72.90
Rate for Payer: University Health Alliance Commercial	$88.56

DOCETAXEL 80 MG/4 ML (20 MG/ML) IV SOLN

Facility

$1,143.06

Service Code	HCPCS J9171
Hospital Revenue Code	250
Min. Negotiated Rate	$971.60
Max. Negotiated Rate	$1,108.77
Rate for Payer: Cash Price	$742.99
Rate for Payer: Health Management Network Commercial	$971.60
Rate for Payer: MDX Hawaii PPO	$1,108.77

DOCETAXEL 80 MG/4 ML (20 MG/ML) IV SOLN

Facility

$1,143.06

Service Code	HCPCS J9171
Hospital Revenue Code	636
Min. Negotiated Rate	$0.38
Max. Negotiated Rate	$1,108.77
Rate for Payer: Cash Price	$742.99
Rate for Payer: Cash Price	$742.99
Rate for Payer: Hawaii Medical Service Association ABD	$0.38
Rate for Payer: Hawaii Medical Service Association Non-ABD	$0.38
Rate for Payer: Hawaii Western Management Group Commercial	$1,085.91
Rate for Payer: Health Management Network Commercial	$971.60
Rate for Payer: Kaiser Permanente Commercial	$720.13
Rate for Payer: Kaiser Permanente Medicaid	$582.96
Rate for Payer: MDX Hawaii PPO	$1,108.77
Rate for Payer: UnitedHealthcare Medicaid	$685.84
Rate for Payer: University Health Alliance Commercial	$833.18

DOCUSATE SODIUM 100 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

Know your out-of-pocket cost for care.

All Charges