Kona Community Hospital

All Charges

Charge

Type

Setting

Price

DULOXETINE 60 MG PO CAP DR EC

Facility

$47.58

Service Code	HCPCS A9270
Hospital Revenue Code	250
Min. Negotiated Rate	$24.27
Max. Negotiated Rate	$46.15
Rate for Payer: Cash Price	$30.93
Rate for Payer: Hawaii Western Management Group Commercial	$45.20
Rate for Payer: Health Management Network Commercial	$40.44
Rate for Payer: Kaiser Permanente Commercial	$29.98
Rate for Payer: Kaiser Permanente Medicaid	$24.27
Rate for Payer: MDX Hawaii PPO	$46.15
Rate for Payer: UnitedHealthcare Medicaid	$28.55
Rate for Payer: University Health Alliance Commercial	$34.68

DULOXETINE 60 MG PO CAP DR EC

Facility

$47.58

Service Code	HCPCS A9270
Hospital Revenue Code	250
Min. Negotiated Rate	$40.44
Max. Negotiated Rate	$46.15
Rate for Payer: Cash Price	$30.93
Rate for Payer: Health Management Network Commercial	$40.44
Rate for Payer: MDX Hawaii PPO	$46.15

Duodenoscope Exalt M00542420 [3642362]

Facility

$7,325.00

Service Code	HCPCS C1748
Hospital Charge Code	3642362
Hospital Revenue Code	278
Min. Negotiated Rate	$3,735.75
Max. Negotiated Rate	$7,105.25
Rate for Payer: Cash Price	$4,761.25
Rate for Payer: Hawaii Western Management Group Commercial	$5,127.50
Rate for Payer: Health Management Network Commercial	$6,226.25
Rate for Payer: Kaiser Permanente Commercial	$4,614.75
Rate for Payer: Kaiser Permanente Medicaid	$3,735.75
Rate for Payer: MDX Hawaii PPO	$7,105.25
Rate for Payer: University Health Alliance Commercial	$4,102.00

Duodenoscope Exalt M00542420 [3642362]

Facility

$7,325.00

Service Code	HCPCS C1748
Hospital Charge Code	3642362
Hospital Revenue Code	278
Min. Negotiated Rate	$4,102.00
Max. Negotiated Rate	$7,105.25
Rate for Payer: Cash Price	$4,761.25
Rate for Payer: Hawaii Western Management Group Commercial	$5,127.50
Rate for Payer: Health Management Network Commercial	$6,226.25
Rate for Payer: MDX Hawaii PPO	$7,105.25
Rate for Payer: University Health Alliance Commercial	$4,102.00

DURVALUMAB 50 MG/ML IV SOLN

Facility

$6,272.00

Service Code	HCPCS J9173
Hospital Revenue Code	250
Min. Negotiated Rate	$5,331.20
Max. Negotiated Rate	$6,083.84
Rate for Payer: Cash Price	$4,076.80
Rate for Payer: Health Management Network Commercial	$5,331.20
Rate for Payer: MDX Hawaii PPO	$6,083.84

DURVALUMAB 50 MG/ML IV SOLN

Facility

$6,272.00

Service Code	HCPCS J9173
Hospital Revenue Code	636
Min. Negotiated Rate	$85.25
Max. Negotiated Rate	$6,083.84
Rate for Payer: AlohaCare Medicaid	$86.15
Rate for Payer: AlohaCare Medicare	$86.15
Rate for Payer: Cash Price	$4,076.80
Rate for Payer: Cash Price	$4,076.80
Rate for Payer: Devoted Health Medicare	$94.77
Rate for Payer: Hawaii Medical Service Association ABD	$85.25
Rate for Payer: Hawaii Medical Service Association Commercial	$107.69
Rate for Payer: Hawaii Medical Service Association Medicare	$86.15
Rate for Payer: Hawaii Medical Service Association Non-ABD	$85.25
Rate for Payer: Hawaii Western Management Group Commercial	$5,958.40
Rate for Payer: Health Management Network Commercial	$5,331.20
Rate for Payer: Humana Medicare	$86.15
Rate for Payer: Kaiser Permanente Commercial	$3,951.36
Rate for Payer: Kaiser Permanente Medicaid	$3,198.72
Rate for Payer: Kaiser Permanente Medicare	$86.15
Rate for Payer: MDX Hawaii PPO	$6,083.84
Rate for Payer: Ohana Health Plan Medicaid	$94.77
Rate for Payer: Ohana Health Plan Medicare	$86.15
Rate for Payer: UnitedHealthcare Medicaid	$3,763.20
Rate for Payer: UnitedHealthcare Medicare	$86.15
Rate for Payer: University Health Alliance Commercial	$4,571.66

DUTASTERIDE 0.5 MG PO CAP

Facility

$38.86

Service Code	HCPCS A9270
Hospital Revenue Code	250
Min. Negotiated Rate	$33.03
Max. Negotiated Rate	$37.69
Rate for Payer: Cash Price	$25.26
Rate for Payer: Cash Price	$25.27
Rate for Payer: Health Management Network Commercial	$33.03
Rate for Payer: Health Management Network Commercial	$33.04
Rate for Payer: MDX Hawaii PPO	$37.69
Rate for Payer: MDX Hawaii PPO	$37.70

DUTASTERIDE 0.5 MG PO CAP

Facility

$38.87

Service Code	HCPCS A9270
Hospital Revenue Code	250
Min. Negotiated Rate	$19.82
Max. Negotiated Rate	$37.70
Rate for Payer: Cash Price	$25.27
Rate for Payer: Cash Price	$25.26
Rate for Payer: Hawaii Western Management Group Commercial	$36.92
Rate for Payer: Hawaii Western Management Group Commercial	$36.93
Rate for Payer: Health Management Network Commercial	$33.03
Rate for Payer: Health Management Network Commercial	$33.04
Rate for Payer: Kaiser Permanente Commercial	$24.49
Rate for Payer: Kaiser Permanente Commercial	$24.48
Rate for Payer: Kaiser Permanente Medicaid	$19.82
Rate for Payer: Kaiser Permanente Medicaid	$19.82
Rate for Payer: MDX Hawaii PPO	$37.69
Rate for Payer: MDX Hawaii PPO	$37.70
Rate for Payer: UnitedHealthcare Medicaid	$23.32
Rate for Payer: UnitedHealthcare Medicaid	$23.32
Rate for Payer: University Health Alliance Commercial	$28.33
Rate for Payer: University Health Alliance Commercial	$28.33

DXA BONE DENSITY STUDY 1/> SITES AXIAL SKEL

Professional

Both

$265.00

Service Code	HCPCS 77080
Min. Negotiated Rate	$26.02
Max. Negotiated Rate	$225.25
Rate for Payer: AlohaCare Medicaid	$26.02
Rate for Payer: AlohaCare Medicare	$43.52
Rate for Payer: Cash Price	$172.25
Rate for Payer: Cash Price	$172.25
Rate for Payer: Devoted Health Medicare	$47.87
Rate for Payer: Hawaii Medical Service Association Medicare	$43.52
Rate for Payer: Hawaii Western Management Group Commercial	$94.12
Rate for Payer: Health Management Network Commercial	$225.25
Rate for Payer: Kaiser Permanente Commercial	$52.22
Rate for Payer: Kaiser Permanente Medicaid	$52.22
Rate for Payer: Kaiser Permanente Medicare	$52.22
Rate for Payer: Ohana Health Plan Medicaid	$26.02
Rate for Payer: Ohana Health Plan Medicare	$43.52
Rate for Payer: UnitedHealthcare Medicaid	$26.02
Rate for Payer: UnitedHealthcare Medicare	$43.52

Dynabunion Short Plate LT ST 7108-DSHL [3644922]

Facility

$10,518.30

Service Code	HCPCS C1713
Hospital Charge Code	3644922
Hospital Revenue Code	278
Min. Negotiated Rate	$5,890.25
Max. Negotiated Rate	$10,202.75
Rate for Payer: Cash Price	$6,836.90
Rate for Payer: Hawaii Western Management Group Commercial	$7,362.81
Rate for Payer: Health Management Network Commercial	$8,940.56
Rate for Payer: MDX Hawaii PPO	$10,202.75
Rate for Payer: University Health Alliance Commercial	$5,890.25

Dynabunion Short Plate LT ST 7108-DSHL [3644922]

Facility

$10,518.30

Service Code	HCPCS C1713
Hospital Charge Code	3644922
Hospital Revenue Code	278
Min. Negotiated Rate	$5,364.33
Max. Negotiated Rate	$10,202.75
Rate for Payer: Cash Price	$6,836.90
Rate for Payer: Hawaii Western Management Group Commercial	$7,362.81
Rate for Payer: Health Management Network Commercial	$8,940.56
Rate for Payer: Kaiser Permanente Commercial	$6,626.53
Rate for Payer: Kaiser Permanente Medicaid	$5,364.33
Rate for Payer: MDX Hawaii PPO	$10,202.75
Rate for Payer: University Health Alliance Commercial	$5,890.25

DYSEQUILIBRIUM

Facility

$12,965.10

Service Code	MSDRG 149
Min. Negotiated Rate	$9,885.62
Max. Negotiated Rate	$12,965.10
Rate for Payer: AlohaCare Medicare	$9,885.62
Rate for Payer: Devoted Health Medicare	$10,874.18
Rate for Payer: Hawaii Medical Service Association Commercial	$12,945.46
Rate for Payer: Hawaii Medical Service Association Medicare	$9,885.62
Rate for Payer: Humana Medicare	$9,885.62
Rate for Payer: Kaiser Permanente Commercial	$12,965.10
Rate for Payer: Kaiser Permanente Medicare	$9,885.62
Rate for Payer: Ohana Health Plan Medicare	$9,885.62
Rate for Payer: UnitedHealthcare Medicare	$9,885.62

EAR, NOSE, MOUTH AND THROAT MALIGNANCY WITH CC

Facility

$35,967.64

Service Code	MSDRG 147
Min. Negotiated Rate	$16,723.74
Max. Negotiated Rate	$35,967.64
Rate for Payer: AlohaCare Medicare	$16,723.74
Rate for Payer: Devoted Health Medicare	$18,396.11
Rate for Payer: Hawaii Medical Service Association Commercial	$35,967.64
Rate for Payer: Hawaii Medical Service Association Medicare	$16,723.74
Rate for Payer: Humana Medicare	$16,723.74
Rate for Payer: Kaiser Permanente Commercial	$21,933.38
Rate for Payer: Kaiser Permanente Medicare	$16,723.74
Rate for Payer: Ohana Health Plan Medicare	$16,723.74
Rate for Payer: UnitedHealthcare Medicare	$16,723.74

EAR, NOSE, MOUTH AND THROAT MALIGNANCY WITH MCC

Facility

$36,525.15

Service Code	MSDRG 146
Min. Negotiated Rate	$27,849.67
Max. Negotiated Rate	$36,525.15
Rate for Payer: AlohaCare Medicare	$27,849.67
Rate for Payer: Devoted Health Medicare	$30,634.64
Rate for Payer: Hawaii Medical Service Association Commercial	$35,967.64
Rate for Payer: Hawaii Medical Service Association Medicare	$27,849.67
Rate for Payer: Humana Medicare	$27,849.67
Rate for Payer: Kaiser Permanente Commercial	$36,525.15
Rate for Payer: Kaiser Permanente Medicare	$27,849.67
Rate for Payer: Ohana Health Plan Medicare	$27,849.67
Rate for Payer: UnitedHealthcare Medicare	$27,849.67

EAR, NOSE, MOUTH AND THROAT MALIGNANCY WITHOUT CC/MCC

Facility

$35,967.64

Service Code	MSDRG 148
Min. Negotiated Rate	$10,484.08
Max. Negotiated Rate	$35,967.64
Rate for Payer: AlohaCare Medicare	$10,484.08
Rate for Payer: Devoted Health Medicare	$11,532.49
Rate for Payer: Hawaii Medical Service Association Commercial	$35,967.64
Rate for Payer: Hawaii Medical Service Association Medicare	$10,484.08
Rate for Payer: Humana Medicare	$10,484.08
Rate for Payer: Kaiser Permanente Commercial	$13,749.98
Rate for Payer: Kaiser Permanente Medicare	$10,484.08
Rate for Payer: Ohana Health Plan Medicare	$10,484.08
Rate for Payer: UnitedHealthcare Medicare	$10,484.08

EAR, NOSE, MOUTH, THROAT, CRANIAL/FACIAL MALIGNANCIES

Facility

$4,160.23

Service Code	APR-DRG 1102
Min. Negotiated Rate	$4,160.23
Max. Negotiated Rate	$4,160.23
Rate for Payer: AlohaCare Medicaid	$4,160.23
Rate for Payer: Hawaii Medical Service Association ABD	$4,160.23
Rate for Payer: Hawaii Medical Service Association Non-ABD	$4,160.23
Rate for Payer: Kaiser Permanente Medicaid	$4,160.23
Rate for Payer: Ohana Health Plan Medicaid	$4,160.23
Rate for Payer: UnitedHealthcare Medicaid	$4,160.23

EAR, NOSE, MOUTH, THROAT, CRANIAL/FACIAL MALIGNANCIES

Facility

$5,759.88

Service Code	APR-DRG 1103
Min. Negotiated Rate	$5,759.88
Max. Negotiated Rate	$5,759.88
Rate for Payer: AlohaCare Medicaid	$5,759.88
Rate for Payer: Hawaii Medical Service Association ABD	$5,759.88
Rate for Payer: Hawaii Medical Service Association Non-ABD	$5,759.88
Rate for Payer: Kaiser Permanente Medicaid	$5,759.88
Rate for Payer: Ohana Health Plan Medicaid	$5,759.88
Rate for Payer: UnitedHealthcare Medicaid	$5,759.88

EAR, NOSE, MOUTH, THROAT, CRANIAL/FACIAL MALIGNANCIES

Facility

$10,006.72

Service Code	APR-DRG 1104
Min. Negotiated Rate	$10,006.72
Max. Negotiated Rate	$10,006.72
Rate for Payer: AlohaCare Medicaid	$10,006.72
Rate for Payer: Hawaii Medical Service Association ABD	$10,006.72
Rate for Payer: Hawaii Medical Service Association Non-ABD	$10,006.72
Rate for Payer: Kaiser Permanente Medicaid	$10,006.72
Rate for Payer: Ohana Health Plan Medicaid	$10,006.72
Rate for Payer: UnitedHealthcare Medicaid	$10,006.72

EAR, NOSE, MOUTH, THROAT, CRANIAL/FACIAL MALIGNANCIES

Facility

$3,698.55

Service Code	APR-DRG 1101
Min. Negotiated Rate	$3,698.55
Max. Negotiated Rate	$3,698.55
Rate for Payer: AlohaCare Medicaid	$3,698.55
Rate for Payer: Hawaii Medical Service Association ABD	$3,698.55
Rate for Payer: Hawaii Medical Service Association Non-ABD	$3,698.55
Rate for Payer: Kaiser Permanente Medicaid	$3,698.55
Rate for Payer: Ohana Health Plan Medicaid	$3,698.55
Rate for Payer: UnitedHealthcare Medicaid	$3,698.55

EATING DISORDERS

Facility

$4,325.83

Service Code	APR-DRG 7591
Min. Negotiated Rate	$4,325.83
Max. Negotiated Rate	$4,325.83
Rate for Payer: AlohaCare Medicaid	$4,325.83
Rate for Payer: Hawaii Medical Service Association ABD	$4,325.83
Rate for Payer: Hawaii Medical Service Association Non-ABD	$4,325.83
Rate for Payer: Kaiser Permanente Medicaid	$4,325.83
Rate for Payer: Ohana Health Plan Medicaid	$4,325.83
Rate for Payer: UnitedHealthcare Medicaid	$4,325.83

EATING DISORDERS

Facility

$8,194.70

Service Code	APR-DRG 7593
Min. Negotiated Rate	$8,194.70
Max. Negotiated Rate	$8,194.70
Rate for Payer: AlohaCare Medicaid	$8,194.70
Rate for Payer: Hawaii Medical Service Association ABD	$8,194.70
Rate for Payer: Hawaii Medical Service Association Non-ABD	$8,194.70
Rate for Payer: Kaiser Permanente Medicaid	$8,194.70
Rate for Payer: Ohana Health Plan Medicaid	$8,194.70
Rate for Payer: UnitedHealthcare Medicaid	$8,194.70

EATING DISORDERS

Facility

$5,667.45

Service Code	APR-DRG 7592
Min. Negotiated Rate	$5,667.45
Max. Negotiated Rate	$5,667.45
Rate for Payer: AlohaCare Medicaid	$5,667.45
Rate for Payer: Hawaii Medical Service Association ABD	$5,667.45
Rate for Payer: Hawaii Medical Service Association Non-ABD	$5,667.45
Rate for Payer: Kaiser Permanente Medicaid	$5,667.45
Rate for Payer: Ohana Health Plan Medicaid	$5,667.45
Rate for Payer: UnitedHealthcare Medicaid	$5,667.45

EATING DISORDERS

Facility

$13,801.37

Service Code	APR-DRG 7594
Min. Negotiated Rate	$13,801.37
Max. Negotiated Rate	$13,801.37
Rate for Payer: AlohaCare Medicaid	$13,801.37
Rate for Payer: Hawaii Medical Service Association ABD	$13,801.37
Rate for Payer: Hawaii Medical Service Association Non-ABD	$13,801.37
Rate for Payer: Kaiser Permanente Medicaid	$13,801.37
Rate for Payer: Ohana Health Plan Medicaid	$13,801.37
Rate for Payer: UnitedHealthcare Medicaid	$13,801.37

Echelon 60 Cutter Blue Reload GST60B [3640191]

Facility

$503.13

Hospital Charge Code	3640191
Hospital Revenue Code	272
Min. Negotiated Rate	$256.60
Max. Negotiated Rate	$488.04
Rate for Payer: Cash Price	$327.03
Rate for Payer: Hawaii Western Management Group Commercial	$477.97
Rate for Payer: Health Management Network Commercial	$427.66
Rate for Payer: Kaiser Permanente Commercial	$316.97
Rate for Payer: Kaiser Permanente Medicaid	$256.60
Rate for Payer: MDX Hawaii PPO	$488.04
Rate for Payer: University Health Alliance Commercial	$366.73

Echelon 60 Cutter Blue Reload GST60B [3640191]

Facility

$503.13

Hospital Charge Code	3640191
Hospital Revenue Code	272
Min. Negotiated Rate	$427.66
Max. Negotiated Rate	$488.04
Rate for Payer: Cash Price	$327.03
Rate for Payer: Health Management Network Commercial	$427.66
Rate for Payer: MDX Hawaii PPO	$488.04

Know your out-of-pocket cost for care.

All Charges