Kona Community Hospital

All Charges

Charge

Type

Setting

Price

ESCITALOPRAM OXALATE 10 MG PO TABLET

Facility

$23.85

Service Code	HCPCS A9270
Hospital Revenue Code	250
Min. Negotiated Rate	$20.27
Max. Negotiated Rate	$23.13
Rate for Payer: Cash Price	$15.50
Rate for Payer: Health Management Network Commercial	$20.27
Rate for Payer: MDX Hawaii PPO	$23.13

ESCITALOPRAM OXALATE 10 MG PO TABLET

Facility

$23.85

Service Code	HCPCS A9270
Hospital Revenue Code	250
Min. Negotiated Rate	$12.16
Max. Negotiated Rate	$23.13
Rate for Payer: Cash Price	$15.50
Rate for Payer: Hawaii Western Management Group Commercial	$22.66
Rate for Payer: Health Management Network Commercial	$20.27
Rate for Payer: Kaiser Permanente Commercial	$15.03
Rate for Payer: Kaiser Permanente Medicaid	$12.16
Rate for Payer: MDX Hawaii PPO	$23.13
Rate for Payer: UnitedHealthcare Medicaid	$14.31
Rate for Payer: University Health Alliance Commercial	$17.38

ESG PlasmaLoop Medium Long WA22737S [3642202]

Facility

$2,888.00

Hospital Charge Code	3642202
Hospital Revenue Code	272
Min. Negotiated Rate	$2,454.80
Max. Negotiated Rate	$2,801.36
Rate for Payer: Cash Price	$1,877.20
Rate for Payer: Health Management Network Commercial	$2,454.80
Rate for Payer: MDX Hawaii PPO	$2,801.36

ESG PlasmaLoop Medium Long WA22737S [3642202]

Facility

$2,888.00

Hospital Charge Code	3642202
Hospital Revenue Code	272
Min. Negotiated Rate	$1,472.88
Max. Negotiated Rate	$2,801.36
Rate for Payer: Cash Price	$1,877.20
Rate for Payer: Hawaii Western Management Group Commercial	$2,743.60
Rate for Payer: Health Management Network Commercial	$2,454.80
Rate for Payer: Kaiser Permanente Commercial	$1,819.44
Rate for Payer: Kaiser Permanente Medicaid	$1,472.88
Rate for Payer: MDX Hawaii PPO	$2,801.36
Rate for Payer: University Health Alliance Commercial	$2,105.06

ESG PlasmaLoop Medium WA22702S [3642134]

Facility

$2,888.00

Hospital Charge Code	3642134
Hospital Revenue Code	272
Min. Negotiated Rate	$1,472.88
Max. Negotiated Rate	$2,801.36
Rate for Payer: Cash Price	$1,877.20
Rate for Payer: Hawaii Western Management Group Commercial	$2,743.60
Rate for Payer: Health Management Network Commercial	$2,454.80
Rate for Payer: Kaiser Permanente Commercial	$1,819.44
Rate for Payer: Kaiser Permanente Medicaid	$1,472.88
Rate for Payer: MDX Hawaii PPO	$2,801.36
Rate for Payer: University Health Alliance Commercial	$2,105.06

ESG PlasmaLoop Medium WA22702S [3642134]

Facility

$2,888.00

Hospital Charge Code	3642134
Hospital Revenue Code	272
Min. Negotiated Rate	$2,454.80
Max. Negotiated Rate	$2,801.36
Rate for Payer: Cash Price	$1,877.20
Rate for Payer: Health Management Network Commercial	$2,454.80
Rate for Payer: MDX Hawaii PPO	$2,801.36

ESG Plasma Needle Right Angled WA22740S [3642302]

Facility

$2,793.28

Hospital Charge Code	3642302
Hospital Revenue Code	272
Min. Negotiated Rate	$1,424.57
Max. Negotiated Rate	$2,709.48
Rate for Payer: Cash Price	$1,815.63
Rate for Payer: Hawaii Western Management Group Commercial	$2,653.62
Rate for Payer: Health Management Network Commercial	$2,374.29
Rate for Payer: Kaiser Permanente Commercial	$1,759.77
Rate for Payer: Kaiser Permanente Medicaid	$1,424.57
Rate for Payer: MDX Hawaii PPO	$2,709.48
Rate for Payer: University Health Alliance Commercial	$2,036.02

ESG Plasma Needle Right Angled WA22740S [3642302]

Facility

$2,793.28

Hospital Charge Code	3642302
Hospital Revenue Code	272
Min. Negotiated Rate	$2,374.29
Max. Negotiated Rate	$2,709.48
Rate for Payer: Cash Price	$1,815.63
Rate for Payer: Health Management Network Commercial	$2,374.29
Rate for Payer: MDX Hawaii PPO	$2,709.48

ESG Plasma OvalButton Long WA22741S [3642203]

Facility

$3,248.00

Hospital Charge Code	3642203
Hospital Revenue Code	272
Min. Negotiated Rate	$1,656.48
Max. Negotiated Rate	$3,150.56
Rate for Payer: Cash Price	$2,111.20
Rate for Payer: Hawaii Western Management Group Commercial	$3,085.60
Rate for Payer: Health Management Network Commercial	$2,760.80
Rate for Payer: Kaiser Permanente Commercial	$2,046.24
Rate for Payer: Kaiser Permanente Medicaid	$1,656.48
Rate for Payer: MDX Hawaii PPO	$3,150.56
Rate for Payer: University Health Alliance Commercial	$2,367.47

ESG Plasma OvalButton Long WA22741S [3642203]

Facility

$3,248.00

Hospital Charge Code	3642203
Hospital Revenue Code	272
Min. Negotiated Rate	$2,760.80
Max. Negotiated Rate	$3,150.56
Rate for Payer: Cash Price	$2,111.20
Rate for Payer: Health Management Network Commercial	$2,760.80
Rate for Payer: MDX Hawaii PPO	$3,150.56

ESG Plasma OvalButton WA22766S [3642135]

Facility

$3,248.00

Hospital Charge Code	3642135
Hospital Revenue Code	272
Min. Negotiated Rate	$1,656.48
Max. Negotiated Rate	$3,150.56
Rate for Payer: Cash Price	$2,111.20
Rate for Payer: Hawaii Western Management Group Commercial	$3,085.60
Rate for Payer: Health Management Network Commercial	$2,760.80
Rate for Payer: Kaiser Permanente Commercial	$2,046.24
Rate for Payer: Kaiser Permanente Medicaid	$1,656.48
Rate for Payer: MDX Hawaii PPO	$3,150.56
Rate for Payer: University Health Alliance Commercial	$2,367.47

ESG Plasma OvalButton WA22766S [3642135]

Facility

$3,248.00

Hospital Charge Code	3642135
Hospital Revenue Code	272
Min. Negotiated Rate	$2,760.80
Max. Negotiated Rate	$3,150.56
Rate for Payer: Cash Price	$2,111.20
Rate for Payer: Health Management Network Commercial	$2,760.80
Rate for Payer: MDX Hawaii PPO	$3,150.56

ESMOLOL 100 MG/10 ML (10 MG/ML) IV SOLN

Facility

$52.16

Service Code	HCPCS J1805
Hospital Revenue Code	250
Min. Negotiated Rate	$44.34
Max. Negotiated Rate	$50.60
Rate for Payer: Cash Price	$33.90
Rate for Payer: Health Management Network Commercial	$44.34
Rate for Payer: MDX Hawaii PPO	$50.60

ESMOLOL 100 MG/10 ML (10 MG/ML) IV SOLN

Facility

$52.16

Service Code	HCPCS J1805
Hospital Revenue Code	636
Min. Negotiated Rate	$0.28
Max. Negotiated Rate	$50.60
Rate for Payer: Cash Price	$33.90
Rate for Payer: Cash Price	$33.90
Rate for Payer: Hawaii Medical Service Association ABD	$0.28
Rate for Payer: Hawaii Medical Service Association Non-ABD	$0.28
Rate for Payer: Hawaii Western Management Group Commercial	$49.55
Rate for Payer: Health Management Network Commercial	$44.34
Rate for Payer: Kaiser Permanente Commercial	$32.86
Rate for Payer: Kaiser Permanente Medicaid	$26.60
Rate for Payer: MDX Hawaii PPO	$50.60
Rate for Payer: UnitedHealthcare Medicaid	$31.30
Rate for Payer: University Health Alliance Commercial	$38.02

ESMOLOL IN NACL (ISO-OSM) 2500 MG/250 ML IV SOLP

Facility

$471.48

Service Code	HCPCS J1805
Hospital Revenue Code	250
Min. Negotiated Rate	$400.76
Max. Negotiated Rate	$457.34
Rate for Payer: Cash Price	$306.46
Rate for Payer: Health Management Network Commercial	$400.76
Rate for Payer: MDX Hawaii PPO	$457.34

ESMOLOL IN NACL (ISO-OSM) 2500 MG/250 ML IV SOLP

Facility

$471.48

Service Code	HCPCS J1805
Hospital Revenue Code	636
Min. Negotiated Rate	$0.28
Max. Negotiated Rate	$457.34
Rate for Payer: Cash Price	$306.46
Rate for Payer: Cash Price	$306.46
Rate for Payer: Hawaii Medical Service Association ABD	$0.28
Rate for Payer: Hawaii Medical Service Association Non-ABD	$0.28
Rate for Payer: Hawaii Western Management Group Commercial	$447.91
Rate for Payer: Health Management Network Commercial	$400.76
Rate for Payer: Kaiser Permanente Commercial	$297.03
Rate for Payer: Kaiser Permanente Medicaid	$240.45
Rate for Payer: MDX Hawaii PPO	$457.34
Rate for Payer: UnitedHealthcare Medicaid	$282.89
Rate for Payer: University Health Alliance Commercial	$343.66

ESOPHAGITIS, GASTROENTERITIS AND MISCELLANEOUS DIGESTIVE DISORDERS WITH MCC

Facility

$21,878.17

Service Code	MSDRG 391
Min. Negotiated Rate	$16,681.65
Max. Negotiated Rate	$21,878.17
Rate for Payer: AlohaCare Medicare	$16,681.65
Rate for Payer: Devoted Health Medicare	$18,349.81
Rate for Payer: Hawaii Medical Service Association Commercial	$17,212.40
Rate for Payer: Hawaii Medical Service Association Medicare	$16,681.65
Rate for Payer: Humana Medicare	$16,681.65
Rate for Payer: Kaiser Permanente Commercial	$21,878.17
Rate for Payer: Kaiser Permanente Medicare	$16,681.65
Rate for Payer: Ohana Health Plan Medicare	$16,681.65
Rate for Payer: UnitedHealthcare Medicare	$16,681.65

ESOPHAGITIS, GASTROENTERITIS AND MISCELLANEOUS DIGESTIVE DISORDERS WITHOUT MCC

Facility

$14,801.70

Service Code	MSDRG 392
Min. Negotiated Rate	$10,253.91
Max. Negotiated Rate	$14,801.70
Rate for Payer: AlohaCare Medicare	$10,253.91
Rate for Payer: Devoted Health Medicare	$11,279.30
Rate for Payer: Hawaii Medical Service Association Commercial	$14,801.70
Rate for Payer: Hawaii Medical Service Association Medicare	$10,253.91
Rate for Payer: Humana Medicare	$10,253.91
Rate for Payer: Kaiser Permanente Commercial	$13,448.10
Rate for Payer: Kaiser Permanente Medicare	$10,253.91
Rate for Payer: Ohana Health Plan Medicare	$10,253.91
Rate for Payer: UnitedHealthcare Medicare	$10,253.91

ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; DIAGNOSTIC, INCLUDING COLLECTION OF SPECIMEN(S) BY BRUSHING OR WASHING, WHEN PERFORMED (SEPARATE PROCEDURE)

Facility

$2,837.00

Service Code	CPT 43235
Hospital Revenue Code	360
Min. Negotiated Rate	$393.00
Max. Negotiated Rate	$2,837.00
Rate for Payer: AlohaCare Medicaid	$1,071.46
Rate for Payer: AlohaCare Medicare	$1,071.46
Rate for Payer: Devoted Health Medicare	$1,178.61
Rate for Payer: Hawaii Medical Service Association ABD	$393.00
Rate for Payer: Hawaii Medical Service Association Commercial	$2,833.00
Rate for Payer: Hawaii Medical Service Association Medicare	$1,071.46
Rate for Payer: Hawaii Medical Service Association Non-ABD	$407.95
Rate for Payer: Humana Medicare	$1,071.46
Rate for Payer: Kaiser Permanente Medicaid	$2,837.00
Rate for Payer: Kaiser Permanente Medicare	$1,071.46
Rate for Payer: Ohana Health Plan Medicaid	$1,178.61
Rate for Payer: Ohana Health Plan Medicare	$1,071.46
Rate for Payer: UnitedHealthcare Medicaid	$456.03
Rate for Payer: UnitedHealthcare Medicare	$1,071.46

ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; WITH ABLATION OF TUMOR(S), POLYP(S), OR OTHER LESION(S) (INCLUDES PRE- AND POST-DILATION AND GUIDE WIRE PASSAGE, WHEN PERFORMED)

Facility

$6,183.00

Service Code	CPT 43270
Hospital Revenue Code	360
Min. Negotiated Rate	$456.03
Max. Negotiated Rate	$6,183.00
Rate for Payer: AlohaCare Medicaid	$2,266.89
Rate for Payer: AlohaCare Medicare	$2,266.89
Rate for Payer: Devoted Health Medicare	$2,493.58
Rate for Payer: Hawaii Medical Service Association ABD	$695.00
Rate for Payer: Hawaii Medical Service Association Commercial	$6,183.00
Rate for Payer: Hawaii Medical Service Association Medicare	$2,266.89
Rate for Payer: Hawaii Medical Service Association Non-ABD	$700.72
Rate for Payer: Humana Medicare	$2,266.89
Rate for Payer: Kaiser Permanente Medicaid	$2,837.00
Rate for Payer: Kaiser Permanente Medicare	$2,266.89
Rate for Payer: Ohana Health Plan Medicaid	$2,493.58
Rate for Payer: Ohana Health Plan Medicare	$2,266.89
Rate for Payer: UnitedHealthcare Medicaid	$456.03
Rate for Payer: UnitedHealthcare Medicare	$2,266.89

ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; WITH BAND LIGATION OF ESOPHAGEAL/GASTRIC VARICES

Facility

$6,183.00

Service Code	CPT 43244
Hospital Revenue Code	360
Min. Negotiated Rate	$456.03
Max. Negotiated Rate	$6,183.00
Rate for Payer: AlohaCare Medicaid	$2,266.89
Rate for Payer: AlohaCare Medicare	$2,266.89
Rate for Payer: Devoted Health Medicare	$2,493.58
Rate for Payer: Hawaii Medical Service Association ABD	$695.00
Rate for Payer: Hawaii Medical Service Association Commercial	$6,183.00
Rate for Payer: Hawaii Medical Service Association Medicare	$2,266.89
Rate for Payer: Hawaii Medical Service Association Non-ABD	$700.72
Rate for Payer: Humana Medicare	$2,266.89
Rate for Payer: Kaiser Permanente Medicaid	$2,837.00
Rate for Payer: Kaiser Permanente Medicare	$2,266.89
Rate for Payer: Ohana Health Plan Medicaid	$2,493.58
Rate for Payer: Ohana Health Plan Medicare	$2,266.89
Rate for Payer: UnitedHealthcare Medicaid	$456.03
Rate for Payer: UnitedHealthcare Medicare	$2,266.89
Rate for Payer: University Health Alliance Commercial	$5,160.40

ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; WITH BIOPSY, SINGLE OR MULTIPLE

Facility

$6,183.00

Service Code	CPT 43239
Hospital Revenue Code	360
Min. Negotiated Rate	$456.03
Max. Negotiated Rate	$6,183.00
Rate for Payer: AlohaCare Medicaid	$1,071.46
Rate for Payer: AlohaCare Medicare	$1,071.46
Rate for Payer: Devoted Health Medicare	$1,178.61
Rate for Payer: Hawaii Medical Service Association ABD	$695.00
Rate for Payer: Hawaii Medical Service Association Commercial	$6,183.00
Rate for Payer: Hawaii Medical Service Association Medicare	$1,071.46
Rate for Payer: Hawaii Medical Service Association Non-ABD	$700.72
Rate for Payer: Humana Medicare	$1,071.46
Rate for Payer: Kaiser Permanente Medicaid	$2,837.00
Rate for Payer: Kaiser Permanente Medicare	$1,071.46
Rate for Payer: Ohana Health Plan Medicaid	$1,178.61
Rate for Payer: Ohana Health Plan Medicare	$1,071.46
Rate for Payer: UnitedHealthcare Medicaid	$456.03
Rate for Payer: UnitedHealthcare Medicare	$1,071.46
Rate for Payer: University Health Alliance Commercial	$5,160.40

ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; WITH CONTROL OF BLEEDING, ANY METHOD

Facility

$6,183.00

Service Code	CPT 43255
Hospital Revenue Code	360
Min. Negotiated Rate	$456.03
Max. Negotiated Rate	$6,183.00
Rate for Payer: AlohaCare Medicaid	$2,266.89
Rate for Payer: AlohaCare Medicare	$2,266.89
Rate for Payer: Devoted Health Medicare	$2,493.58
Rate for Payer: Hawaii Medical Service Association ABD	$695.00
Rate for Payer: Hawaii Medical Service Association Commercial	$6,183.00
Rate for Payer: Hawaii Medical Service Association Medicare	$2,266.89
Rate for Payer: Hawaii Medical Service Association Non-ABD	$700.72
Rate for Payer: Humana Medicare	$2,266.89
Rate for Payer: Kaiser Permanente Medicaid	$2,837.00
Rate for Payer: Kaiser Permanente Medicare	$2,266.89
Rate for Payer: Ohana Health Plan Medicaid	$2,493.58
Rate for Payer: Ohana Health Plan Medicare	$2,266.89
Rate for Payer: UnitedHealthcare Medicaid	$456.03
Rate for Payer: UnitedHealthcare Medicare	$2,266.89
Rate for Payer: University Health Alliance Commercial	$5,160.40

ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; WITH DILATION OF GASTRIC/DUODENAL STRICTURE(S) (EG, BALLOON, BOUGIE)

Facility

$6,183.00

Service Code	CPT 43245
Hospital Revenue Code	360
Min. Negotiated Rate	$456.03
Max. Negotiated Rate	$6,183.00
Rate for Payer: AlohaCare Medicaid	$2,266.89
Rate for Payer: AlohaCare Medicare	$2,266.89
Rate for Payer: Devoted Health Medicare	$2,493.58
Rate for Payer: Hawaii Medical Service Association ABD	$695.00
Rate for Payer: Hawaii Medical Service Association Commercial	$6,183.00
Rate for Payer: Hawaii Medical Service Association Medicare	$2,266.89
Rate for Payer: Hawaii Medical Service Association Non-ABD	$700.72
Rate for Payer: Humana Medicare	$2,266.89
Rate for Payer: Kaiser Permanente Medicaid	$2,837.00
Rate for Payer: Kaiser Permanente Medicare	$2,266.89
Rate for Payer: Ohana Health Plan Medicaid	$2,493.58
Rate for Payer: Ohana Health Plan Medicare	$2,266.89
Rate for Payer: UnitedHealthcare Medicaid	$456.03
Rate for Payer: UnitedHealthcare Medicare	$2,266.89
Rate for Payer: University Health Alliance Commercial	$5,160.40

ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; WITH DIRECTED PLACEMENT OF PERCUTANEOUS GASTROSTOMY TUBE

Facility

$6,183.00

Service Code	CPT 43246
Hospital Revenue Code	360
Min. Negotiated Rate	$456.03
Max. Negotiated Rate	$6,183.00
Rate for Payer: AlohaCare Medicaid	$2,266.89
Rate for Payer: AlohaCare Medicare	$2,266.89
Rate for Payer: Devoted Health Medicare	$2,493.58
Rate for Payer: Hawaii Medical Service Association ABD	$695.00
Rate for Payer: Hawaii Medical Service Association Commercial	$6,183.00
Rate for Payer: Hawaii Medical Service Association Medicare	$2,266.89
Rate for Payer: Hawaii Medical Service Association Non-ABD	$700.72
Rate for Payer: Humana Medicare	$2,266.89
Rate for Payer: Kaiser Permanente Medicaid	$2,837.00
Rate for Payer: Kaiser Permanente Medicare	$2,266.89
Rate for Payer: Ohana Health Plan Medicaid	$2,493.58
Rate for Payer: Ohana Health Plan Medicare	$2,266.89
Rate for Payer: UnitedHealthcare Medicaid	$456.03
Rate for Payer: UnitedHealthcare Medicare	$2,266.89
Rate for Payer: University Health Alliance Commercial	$5,160.40

Know your out-of-pocket cost for care.

All Charges