Kona Community Hospital

All Charges

Charge

Type

Setting

Price

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

DOCUSATE SODIUM 50 MG/5 ML PO LIQ

Facility

$12.26

Service Code	HCPCS A9270
Hospital Revenue Code	250
Min. Negotiated Rate	$10.42
Max. Negotiated Rate	$11.89
Rate for Payer: Cash Price	$7.97
Rate for Payer: Cash Price	$4.10
Rate for Payer: Health Management Network Commercial	$5.36
Rate for Payer: Health Management Network Commercial	$10.42
Rate for Payer: MDX Hawaii PPO	$6.11
Rate for Payer: MDX Hawaii PPO	$11.89

DOCUSATE SODIUM 50 MG/5 ML PO LIQ

Facility

$12.26

Service Code	HCPCS A9270
Hospital Revenue Code	250
Min. Negotiated Rate	$6.25
Max. Negotiated Rate	$11.89
Rate for Payer: Cash Price	$7.97
Rate for Payer: Cash Price	$4.10
Rate for Payer: Hawaii Western Management Group Commercial	$11.65
Rate for Payer: Hawaii Western Management Group Commercial	$5.99
Rate for Payer: Health Management Network Commercial	$5.36
Rate for Payer: Health Management Network Commercial	$10.42
Rate for Payer: Kaiser Permanente Commercial	$7.72
Rate for Payer: Kaiser Permanente Commercial	$3.97
Rate for Payer: Kaiser Permanente Medicaid	$3.21
Rate for Payer: Kaiser Permanente Medicaid	$6.25
Rate for Payer: MDX Hawaii PPO	$6.11
Rate for Payer: MDX Hawaii PPO	$11.89
Rate for Payer: UnitedHealthcare Medicaid	$7.36
Rate for Payer: UnitedHealthcare Medicaid	$3.78
Rate for Payer: University Health Alliance Commercial	$4.59
Rate for Payer: University Health Alliance Commercial	$8.94

DOFETILIDE 125 MCG PO CAP

Facility

$56.73

Service Code	HCPCS A9270
Hospital Revenue Code	250
Min. Negotiated Rate	$28.93
Max. Negotiated Rate	$55.03
Rate for Payer: Cash Price	$36.87
Rate for Payer: Hawaii Western Management Group Commercial	$53.89
Rate for Payer: Health Management Network Commercial	$48.22
Rate for Payer: Kaiser Permanente Commercial	$35.74
Rate for Payer: Kaiser Permanente Medicaid	$28.93
Rate for Payer: MDX Hawaii PPO	$55.03
Rate for Payer: UnitedHealthcare Medicaid	$34.04
Rate for Payer: University Health Alliance Commercial	$41.35

DOFETILIDE 125 MCG PO CAP

Facility

$56.73

Service Code	HCPCS A9270
Hospital Revenue Code	250
Min. Negotiated Rate	$48.22
Max. Negotiated Rate	$55.03
Rate for Payer: Cash Price	$36.87
Rate for Payer: Health Management Network Commercial	$48.22
Rate for Payer: MDX Hawaii PPO	$55.03

DONEPEZIL 10 MG PO TABLET

Facility

$4.29

Service Code	HCPCS A9270
Hospital Revenue Code	250
Min. Negotiated Rate	$3.65
Max. Negotiated Rate	$4.16
Rate for Payer: Cash Price	$2.79
Rate for Payer: Health Management Network Commercial	$3.65
Rate for Payer: MDX Hawaii PPO	$4.16

DONEPEZIL 10 MG PO TABLET

Facility

$4.29

Service Code	HCPCS A9270
Hospital Revenue Code	250
Min. Negotiated Rate	$2.19
Max. Negotiated Rate	$4.16
Rate for Payer: Cash Price	$2.79
Rate for Payer: Hawaii Western Management Group Commercial	$4.08
Rate for Payer: Health Management Network Commercial	$3.65
Rate for Payer: Kaiser Permanente Commercial	$2.70
Rate for Payer: Kaiser Permanente Medicaid	$2.19
Rate for Payer: MDX Hawaii PPO	$4.16
Rate for Payer: UnitedHealthcare Medicaid	$2.57
Rate for Payer: University Health Alliance Commercial	$3.13

DONEPEZIL 5 MG PO TABLET

Facility

$4.29

Service Code	HCPCS A9270
Hospital Revenue Code	250
Min. Negotiated Rate	$3.65
Max. Negotiated Rate	$4.16
Rate for Payer: Cash Price	$2.79
Rate for Payer: Health Management Network Commercial	$3.65
Rate for Payer: MDX Hawaii PPO	$4.16

DONEPEZIL 5 MG PO TABLET

Facility

$4.29

Service Code	HCPCS A9270
Hospital Revenue Code	250
Min. Negotiated Rate	$2.19
Max. Negotiated Rate	$4.16
Rate for Payer: Cash Price	$2.79
Rate for Payer: Hawaii Western Management Group Commercial	$4.08
Rate for Payer: Health Management Network Commercial	$3.65
Rate for Payer: Kaiser Permanente Commercial	$2.70
Rate for Payer: Kaiser Permanente Medicaid	$2.19
Rate for Payer: MDX Hawaii PPO	$4.16
Rate for Payer: UnitedHealthcare Medicaid	$2.57
Rate for Payer: University Health Alliance Commercial	$3.13

DOPAMINE 200 MG/5 ML (40 MG/ML) IV SOLN

Facility

$22.11

Service Code	HCPCS J1265
Hospital Revenue Code	250
Min. Negotiated Rate	$18.79
Max. Negotiated Rate	$21.45
Rate for Payer: Cash Price	$14.37
Rate for Payer: Health Management Network Commercial	$18.79
Rate for Payer: MDX Hawaii PPO	$21.45

DOPAMINE 200 MG/5 ML (40 MG/ML) IV SOLN

Facility

$22.11

Service Code	HCPCS J1265
Hospital Revenue Code	636
Min. Negotiated Rate	$0.66
Max. Negotiated Rate	$21.45
Rate for Payer: Cash Price	$14.37
Rate for Payer: Cash Price	$14.37
Rate for Payer: Hawaii Medical Service Association ABD	$0.66
Rate for Payer: Hawaii Medical Service Association Non-ABD	$0.66
Rate for Payer: Hawaii Western Management Group Commercial	$21.00
Rate for Payer: Health Management Network Commercial	$18.79
Rate for Payer: Kaiser Permanente Commercial	$13.93
Rate for Payer: Kaiser Permanente Medicaid	$11.28
Rate for Payer: MDX Hawaii PPO	$21.45
Rate for Payer: UnitedHealthcare Medicaid	$13.27
Rate for Payer: University Health Alliance Commercial	$16.12

DOPAMINE IN 5 % DEXTROSE 400 MG/250 ML (1,600 MCG/ML) IV SOLN

Facility

$83.21

Service Code	HCPCS J1265
Hospital Revenue Code	636
Min. Negotiated Rate	$0.66
Max. Negotiated Rate	$80.71
Rate for Payer: Cash Price	$54.09
Rate for Payer: Cash Price	$56.51
Rate for Payer: Cash Price	$50.05
Rate for Payer: Cash Price	$50.05
Rate for Payer: Cash Price	$56.51
Rate for Payer: Cash Price	$54.09
Rate for Payer: Hawaii Medical Service Association ABD	$0.66
Rate for Payer: Hawaii Medical Service Association ABD	$0.66
Rate for Payer: Hawaii Medical Service Association ABD	$0.66
Rate for Payer: Hawaii Medical Service Association Non-ABD	$0.66
Rate for Payer: Hawaii Medical Service Association Non-ABD	$0.66
Rate for Payer: Hawaii Medical Service Association Non-ABD	$0.66
Rate for Payer: Hawaii Western Management Group Commercial	$73.15
Rate for Payer: Hawaii Western Management Group Commercial	$79.05
Rate for Payer: Hawaii Western Management Group Commercial	$82.59
Rate for Payer: Health Management Network Commercial	$73.90
Rate for Payer: Health Management Network Commercial	$65.45
Rate for Payer: Health Management Network Commercial	$70.73
Rate for Payer: Kaiser Permanente Commercial	$54.77
Rate for Payer: Kaiser Permanente Commercial	$52.42
Rate for Payer: Kaiser Permanente Commercial	$48.51
Rate for Payer: Kaiser Permanente Medicaid	$39.27
Rate for Payer: Kaiser Permanente Medicaid	$42.44
Rate for Payer: Kaiser Permanente Medicaid	$44.34
Rate for Payer: MDX Hawaii PPO	$74.69
Rate for Payer: MDX Hawaii PPO	$80.71
Rate for Payer: MDX Hawaii PPO	$84.33
Rate for Payer: UnitedHealthcare Medicaid	$49.93
Rate for Payer: UnitedHealthcare Medicaid	$52.16
Rate for Payer: UnitedHealthcare Medicaid	$46.20
Rate for Payer: University Health Alliance Commercial	$56.13
Rate for Payer: University Health Alliance Commercial	$60.65
Rate for Payer: University Health Alliance Commercial	$63.37

DOPAMINE IN 5 % DEXTROSE 400 MG/250 ML (1,600 MCG/ML) IV SOLN

Facility

$86.94

Service Code	HCPCS J1265
Hospital Revenue Code	250
Min. Negotiated Rate	$73.90
Max. Negotiated Rate	$84.33
Rate for Payer: Cash Price	$56.51
Rate for Payer: Cash Price	$54.09
Rate for Payer: Cash Price	$50.05
Rate for Payer: Health Management Network Commercial	$73.90
Rate for Payer: Health Management Network Commercial	$65.45
Rate for Payer: Health Management Network Commercial	$70.73
Rate for Payer: MDX Hawaii PPO	$84.33
Rate for Payer: MDX Hawaii PPO	$80.71
Rate for Payer: MDX Hawaii PPO	$74.69

DORSAL & LUMBAR FUSION PROC EXCEPT FOR CURVATURE OF BACK

Facility

$24,305.50

Service Code	APR-DRG 3043
Min. Negotiated Rate	$24,305.50
Max. Negotiated Rate	$24,305.50
Rate for Payer: AlohaCare Medicaid	$24,305.50
Rate for Payer: Hawaii Medical Service Association ABD	$24,305.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$24,305.50
Rate for Payer: Kaiser Permanente Medicaid	$24,305.50
Rate for Payer: Ohana Health Plan Medicaid	$24,305.50
Rate for Payer: UnitedHealthcare Medicaid	$24,305.50

DORSAL & LUMBAR FUSION PROC EXCEPT FOR CURVATURE OF BACK

Facility

$35,171.27

Service Code	APR-DRG 3044
Min. Negotiated Rate	$35,171.27
Max. Negotiated Rate	$35,171.27
Rate for Payer: AlohaCare Medicaid	$35,171.27
Rate for Payer: Hawaii Medical Service Association ABD	$35,171.27
Rate for Payer: Hawaii Medical Service Association Non-ABD	$35,171.27
Rate for Payer: Kaiser Permanente Medicaid	$35,171.27
Rate for Payer: Ohana Health Plan Medicaid	$35,171.27
Rate for Payer: UnitedHealthcare Medicaid	$35,171.27

DORSAL & LUMBAR FUSION PROC EXCEPT FOR CURVATURE OF BACK

Facility

$16,996.27

Service Code	APR-DRG 3042
Min. Negotiated Rate	$16,996.27
Max. Negotiated Rate	$16,996.27
Rate for Payer: AlohaCare Medicaid	$16,996.27
Rate for Payer: Hawaii Medical Service Association ABD	$16,996.27
Rate for Payer: Hawaii Medical Service Association Non-ABD	$16,996.27
Rate for Payer: Kaiser Permanente Medicaid	$16,996.27
Rate for Payer: Ohana Health Plan Medicaid	$16,996.27
Rate for Payer: UnitedHealthcare Medicaid	$16,996.27

DORSAL & LUMBAR FUSION PROC EXCEPT FOR CURVATURE OF BACK

Facility

$14,468.80

Service Code	APR-DRG 3041
Min. Negotiated Rate	$14,468.80
Max. Negotiated Rate	$14,468.80
Rate for Payer: AlohaCare Medicaid	$14,468.80
Rate for Payer: Hawaii Medical Service Association ABD	$14,468.80
Rate for Payer: Hawaii Medical Service Association Non-ABD	$14,468.80
Rate for Payer: Kaiser Permanente Medicaid	$14,468.80
Rate for Payer: Ohana Health Plan Medicaid	$14,468.80
Rate for Payer: UnitedHealthcare Medicaid	$14,468.80

DORSAL & LUMBAR FUSION PROC FOR CURVATURE OF BACK

Facility

$37,567.56

Service Code	APR-DRG 3033
Min. Negotiated Rate	$37,567.56
Max. Negotiated Rate	$37,567.56
Rate for Payer: AlohaCare Medicaid	$37,567.56
Rate for Payer: Hawaii Medical Service Association ABD	$37,567.56
Rate for Payer: Hawaii Medical Service Association Non-ABD	$37,567.56
Rate for Payer: Kaiser Permanente Medicaid	$37,567.56
Rate for Payer: Ohana Health Plan Medicaid	$37,567.56
Rate for Payer: UnitedHealthcare Medicaid	$37,567.56

DORSAL & LUMBAR FUSION PROC FOR CURVATURE OF BACK

Facility

$23,739.38

Service Code	APR-DRG 3031
Min. Negotiated Rate	$23,739.38
Max. Negotiated Rate	$23,739.38
Rate for Payer: AlohaCare Medicaid	$23,739.38
Rate for Payer: Hawaii Medical Service Association ABD	$23,739.38
Rate for Payer: Hawaii Medical Service Association Non-ABD	$23,739.38
Rate for Payer: Kaiser Permanente Medicaid	$23,739.38
Rate for Payer: Ohana Health Plan Medicaid	$23,739.38
Rate for Payer: UnitedHealthcare Medicaid	$23,739.38

DORSAL & LUMBAR FUSION PROC FOR CURVATURE OF BACK

Facility

$27,803.46

Service Code	APR-DRG 3032
Min. Negotiated Rate	$27,803.46
Max. Negotiated Rate	$27,803.46
Rate for Payer: AlohaCare Medicaid	$27,803.46
Rate for Payer: Hawaii Medical Service Association ABD	$27,803.46
Rate for Payer: Hawaii Medical Service Association Non-ABD	$27,803.46
Rate for Payer: Kaiser Permanente Medicaid	$27,803.46
Rate for Payer: Ohana Health Plan Medicaid	$27,803.46
Rate for Payer: UnitedHealthcare Medicaid	$27,803.46

DORSAL & LUMBAR FUSION PROC FOR CURVATURE OF BACK

Facility

$49,059.30

Service Code	APR-DRG 3034
Min. Negotiated Rate	$49,059.30
Max. Negotiated Rate	$49,059.30
Rate for Payer: AlohaCare Medicaid	$49,059.30
Rate for Payer: Hawaii Medical Service Association ABD	$49,059.30
Rate for Payer: Hawaii Medical Service Association Non-ABD	$49,059.30
Rate for Payer: Kaiser Permanente Medicaid	$49,059.30
Rate for Payer: Ohana Health Plan Medicaid	$49,059.30
Rate for Payer: UnitedHealthcare Medicaid	$49,059.30

DORZOLAMIDE-TIMOLOL (PF) 2-0.5 % OPHT DROPPERETTE

Facility

$15.46

Service Code	HCPCS A9270
Hospital Revenue Code	250
Min. Negotiated Rate	$13.14
Max. Negotiated Rate	$15.00
Rate for Payer: Cash Price	$10.05
Rate for Payer: Health Management Network Commercial	$13.14
Rate for Payer: MDX Hawaii PPO	$15.00

DORZOLAMIDE-TIMOLOL (PF) 2-0.5 % OPHT DROPPERETTE

Facility

$15.46

Service Code	HCPCS A9270
Hospital Revenue Code	250
Min. Negotiated Rate	$7.88
Max. Negotiated Rate	$15.00
Rate for Payer: Cash Price	$10.05
Rate for Payer: Hawaii Western Management Group Commercial	$14.69
Rate for Payer: Health Management Network Commercial	$13.14
Rate for Payer: Kaiser Permanente Commercial	$9.74
Rate for Payer: Kaiser Permanente Medicaid	$7.88
Rate for Payer: MDX Hawaii PPO	$15.00
Rate for Payer: UnitedHealthcare Medicaid	$9.28
Rate for Payer: University Health Alliance Commercial	$11.27

Double Strand Anterior Tibialis Tendon 0.90 x 25cm DAT-001 [3644459]

Facility

$8,538.00

Service Code	HCPCS C1889
Hospital Charge Code	3644459
Hospital Revenue Code	278
Min. Negotiated Rate	$4,781.28
Max. Negotiated Rate	$8,281.86
Rate for Payer: Cash Price	$5,549.70
Rate for Payer: Hawaii Western Management Group Commercial	$5,976.60
Rate for Payer: Health Management Network Commercial	$7,257.30
Rate for Payer: MDX Hawaii PPO	$8,281.86
Rate for Payer: University Health Alliance Commercial	$4,781.28

Double Strand Anterior Tibialis Tendon 0.90 x 25cm DAT-001 [3644459]

Facility

$8,538.00

Service Code	HCPCS C1889
Hospital Charge Code	3644459
Hospital Revenue Code	278
Min. Negotiated Rate	$4,354.38
Max. Negotiated Rate	$8,281.86
Rate for Payer: Cash Price	$5,549.70
Rate for Payer: Hawaii Western Management Group Commercial	$5,976.60
Rate for Payer: Health Management Network Commercial	$7,257.30
Rate for Payer: Kaiser Permanente Commercial	$5,378.94
Rate for Payer: Kaiser Permanente Medicaid	$4,354.38
Rate for Payer: MDX Hawaii PPO	$8,281.86
Rate for Payer: University Health Alliance Commercial	$4,781.28

Know your out-of-pocket cost for care.

All Charges