Kona Community Hospital

All Charges

Charge

Type

Setting

Price

EXTRACTOR OB VAC OMNICUP KIWI [2707814]

Facility

$276.26

Hospital Charge Code	2707814
Hospital Revenue Code	272
Min. Negotiated Rate	$234.82
Max. Negotiated Rate	$267.97
Rate for Payer: Cash Price	$179.57
Rate for Payer: Health Management Network Commercial	$234.82
Rate for Payer: MDX Hawaii PPO	$267.97

EXTRACTOR OB VAC OMNICUP KIWI [2707814]

Facility

$276.26

Hospital Charge Code	2707814
Hospital Revenue Code	272
Min. Negotiated Rate	$140.89
Max. Negotiated Rate	$267.97
Rate for Payer: Cash Price	$179.57
Rate for Payer: Hawaii Western Management Group Commercial	$262.45
Rate for Payer: Health Management Network Commercial	$234.82
Rate for Payer: Kaiser Permanente Commercial	$174.04
Rate for Payer: Kaiser Permanente Medicaid	$140.89
Rate for Payer: MDX Hawaii PPO	$267.97
Rate for Payer: University Health Alliance Commercial	$201.37

EXTRAOCULAR PROCEDURES EXCEPT ORBIT

Facility

$26,477.03

Service Code	MSDRG 115
Min. Negotiated Rate	$10,400.00
Max. Negotiated Rate	$26,477.03
Rate for Payer: AlohaCare Medicare	$20,188.17
Rate for Payer: Devoted Health Medicare	$22,206.99
Rate for Payer: Hawaii Medical Service Association Commercial	$18,104.36
Rate for Payer: Hawaii Medical Service Association Medicare	$20,188.17
Rate for Payer: Humana Medicare	$20,188.17
Rate for Payer: Kaiser Permanente Commercial	$26,477.03
Rate for Payer: Kaiser Permanente Medicare	$20,188.17
Rate for Payer: Ohana Health Plan Medicare	$20,188.17
Rate for Payer: UnitedHealthcare Medicare	$20,188.17
Rate for Payer: University Health Alliance Commercial	$10,400.00

EXTREME IMMATURITY OR RESPIRATORY DISTRESS SYNDROME, NEONATE

Facility

$276,627.83

Service Code	MSDRG 790
Min. Negotiated Rate	$78,173.46
Max. Negotiated Rate	$276,627.83
Rate for Payer: AlohaCare Medicare	$78,173.46
Rate for Payer: Devoted Health Medicare	$85,990.81
Rate for Payer: Hawaii Medical Service Association Commercial	$276,627.83
Rate for Payer: Hawaii Medical Service Association Medicare	$78,173.46
Rate for Payer: Humana Medicare	$78,173.46
Rate for Payer: Kaiser Permanente Commercial	$102,525.38
Rate for Payer: Kaiser Permanente Medicare	$78,173.46
Rate for Payer: Ohana Health Plan Medicare	$78,173.46
Rate for Payer: UnitedHealthcare Medicare	$78,173.46

Eye I/A Handpiece 45 degree Mill Disp 85910S [3641874]

Facility

$184.00

Hospital Charge Code	3641874
Hospital Revenue Code	272
Min. Negotiated Rate	$156.40
Max. Negotiated Rate	$178.48
Rate for Payer: Cash Price	$119.60
Rate for Payer: Health Management Network Commercial	$156.40
Rate for Payer: MDX Hawaii PPO	$178.48

Eye I/A Handpiece 45 degree Mill Disp 85910S [3641874]

Facility

$184.00

Hospital Charge Code	3641874
Hospital Revenue Code	272
Min. Negotiated Rate	$93.84
Max. Negotiated Rate	$178.48
Rate for Payer: Cash Price	$119.60
Rate for Payer: Hawaii Western Management Group Commercial	$174.80
Rate for Payer: Health Management Network Commercial	$156.40
Rate for Payer: Kaiser Permanente Commercial	$115.92
Rate for Payer: Kaiser Permanente Medicaid	$93.84
Rate for Payer: MDX Hawaii PPO	$178.48
Rate for Payer: University Health Alliance Commercial	$134.12

EYE INFECTIONS & OTHER EYE DISORDERS

Facility

$3,303.10

Service Code	APR-DRG 0822
Min. Negotiated Rate	$3,303.10
Max. Negotiated Rate	$3,303.10
Rate for Payer: AlohaCare Medicaid	$3,303.10
Rate for Payer: Hawaii Medical Service Association ABD	$3,303.10
Rate for Payer: Hawaii Medical Service Association Non-ABD	$3,303.10
Rate for Payer: Kaiser Permanente Medicaid	$3,303.10
Rate for Payer: Ohana Health Plan Medicaid	$3,303.10
Rate for Payer: UnitedHealthcare Medicaid	$3,303.10

EYE INFECTIONS & OTHER EYE DISORDERS

Facility

$4,720.62

Service Code	APR-DRG 0823
Min. Negotiated Rate	$4,720.62
Max. Negotiated Rate	$4,720.62
Rate for Payer: AlohaCare Medicaid	$4,720.62
Rate for Payer: Hawaii Medical Service Association ABD	$4,720.62
Rate for Payer: Hawaii Medical Service Association Non-ABD	$4,720.62
Rate for Payer: Kaiser Permanente Medicaid	$4,720.62
Rate for Payer: Ohana Health Plan Medicaid	$4,720.62
Rate for Payer: UnitedHealthcare Medicaid	$4,720.62

EYE INFECTIONS & OTHER EYE DISORDERS

Facility

$9,215.81

Service Code	APR-DRG 0824
Min. Negotiated Rate	$9,215.81
Max. Negotiated Rate	$9,215.81
Rate for Payer: AlohaCare Medicaid	$9,215.81
Rate for Payer: Hawaii Medical Service Association ABD	$9,215.81
Rate for Payer: Hawaii Medical Service Association Non-ABD	$9,215.81
Rate for Payer: Kaiser Permanente Medicaid	$9,215.81
Rate for Payer: Ohana Health Plan Medicaid	$9,215.81
Rate for Payer: UnitedHealthcare Medicaid	$9,215.81

EYE INFECTIONS & OTHER EYE DISORDERS

Facility

$2,602.61

Service Code	APR-DRG 0821
Min. Negotiated Rate	$2,602.61
Max. Negotiated Rate	$2,602.61
Rate for Payer: AlohaCare Medicaid	$2,602.61
Rate for Payer: Hawaii Medical Service Association ABD	$2,602.61
Rate for Payer: Hawaii Medical Service Association Non-ABD	$2,602.61
Rate for Payer: Kaiser Permanente Medicaid	$2,602.61
Rate for Payer: Ohana Health Plan Medicaid	$2,602.61
Rate for Payer: UnitedHealthcare Medicaid	$2,602.61

Eye Retractor Malyugin Ring 7.0Mm MAL0002/MAL1002 [3601049]

Facility

$840.13

Hospital Charge Code	3601049
Hospital Revenue Code	272
Min. Negotiated Rate	$714.11
Max. Negotiated Rate	$814.93
Rate for Payer: Cash Price	$546.08
Rate for Payer: Health Management Network Commercial	$714.11
Rate for Payer: MDX Hawaii PPO	$814.93

Eye Retractor Malyugin Ring 7.0Mm MAL0002/MAL1002 [3601049]

Facility

$840.13

Hospital Charge Code	3601049
Hospital Revenue Code	272
Min. Negotiated Rate	$428.47
Max. Negotiated Rate	$814.93
Rate for Payer: Cash Price	$546.08
Rate for Payer: Hawaii Western Management Group Commercial	$798.12
Rate for Payer: Health Management Network Commercial	$714.11
Rate for Payer: Kaiser Permanente Commercial	$529.28
Rate for Payer: Kaiser Permanente Medicaid	$428.47
Rate for Payer: MDX Hawaii PPO	$814.93
Rate for Payer: University Health Alliance Commercial	$612.37

FACIAL BONE PROCEDURES EXCEPT MAJOR CRANIAL/FACIAL BONE PROCEDURES

Facility

$29,196.78

Service Code	APR-DRG 0924
Min. Negotiated Rate	$29,196.78
Max. Negotiated Rate	$29,196.78
Rate for Payer: AlohaCare Medicaid	$29,196.78
Rate for Payer: Hawaii Medical Service Association ABD	$29,196.78
Rate for Payer: Hawaii Medical Service Association Non-ABD	$29,196.78
Rate for Payer: Kaiser Permanente Medicaid	$29,196.78
Rate for Payer: Ohana Health Plan Medicaid	$29,196.78
Rate for Payer: UnitedHealthcare Medicaid	$29,196.78

FACIAL BONE PROCEDURES EXCEPT MAJOR CRANIAL/FACIAL BONE PROCEDURES

Facility

$6,368.03

Service Code	APR-DRG 0921
Min. Negotiated Rate	$6,368.03
Max. Negotiated Rate	$6,368.03
Rate for Payer: AlohaCare Medicaid	$6,368.03
Rate for Payer: Hawaii Medical Service Association ABD	$6,368.03
Rate for Payer: Hawaii Medical Service Association Non-ABD	$6,368.03
Rate for Payer: Kaiser Permanente Medicaid	$6,368.03
Rate for Payer: Ohana Health Plan Medicaid	$6,368.03
Rate for Payer: UnitedHealthcare Medicaid	$6,368.03

FACIAL BONE PROCEDURES EXCEPT MAJOR CRANIAL/FACIAL BONE PROCEDURES

Facility

$8,550.99

Service Code	APR-DRG 0922
Min. Negotiated Rate	$8,550.99
Max. Negotiated Rate	$8,550.99
Rate for Payer: AlohaCare Medicaid	$8,550.99
Rate for Payer: Hawaii Medical Service Association ABD	$8,550.99
Rate for Payer: Hawaii Medical Service Association Non-ABD	$8,550.99
Rate for Payer: Kaiser Permanente Medicaid	$8,550.99
Rate for Payer: Ohana Health Plan Medicaid	$8,550.99
Rate for Payer: UnitedHealthcare Medicaid	$8,550.99

FACIAL BONE PROCEDURES EXCEPT MAJOR CRANIAL/FACIAL BONE PROCEDURES

Facility

$13,427.63

Service Code	APR-DRG 0923
Min. Negotiated Rate	$13,427.63
Max. Negotiated Rate	$13,427.63
Rate for Payer: AlohaCare Medicaid	$13,427.63
Rate for Payer: Hawaii Medical Service Association ABD	$13,427.63
Rate for Payer: Hawaii Medical Service Association Non-ABD	$13,427.63
Rate for Payer: Kaiser Permanente Medicaid	$13,427.63
Rate for Payer: Ohana Health Plan Medicaid	$13,427.63
Rate for Payer: UnitedHealthcare Medicaid	$13,427.63

FAMOTIDINE 20 MG PO TABLET

Facility

$1.33

Service Code	HCPCS A9270
Hospital Revenue Code	250
Min. Negotiated Rate	$0.68
Max. Negotiated Rate	$1.29
Rate for Payer: Cash Price	$0.86
Rate for Payer: Hawaii Western Management Group Commercial	$1.26
Rate for Payer: Health Management Network Commercial	$1.13
Rate for Payer: Kaiser Permanente Commercial	$0.84
Rate for Payer: Kaiser Permanente Medicaid	$0.68
Rate for Payer: MDX Hawaii PPO	$1.29
Rate for Payer: UnitedHealthcare Medicaid	$0.80
Rate for Payer: University Health Alliance Commercial	$0.97

FAMOTIDINE 20 MG PO TABLET

Facility

$1.33

Service Code	HCPCS A9270
Hospital Revenue Code	250
Min. Negotiated Rate	$1.13
Max. Negotiated Rate	$1.29
Rate for Payer: Cash Price	$0.86
Rate for Payer: Health Management Network Commercial	$1.13
Rate for Payer: MDX Hawaii PPO	$1.29

FAMOTIDINE (PF) 20 MG/2 ML IV SOLN

Facility

$4.97

Service Code	HCPCS J1308
Hospital Revenue Code	250
Min. Negotiated Rate	$4.22
Max. Negotiated Rate	$4.82
Rate for Payer: Cash Price	$3.23
Rate for Payer: Cash Price	$3.42
Rate for Payer: Cash Price	$3.84
Rate for Payer: Health Management Network Commercial	$5.01
Rate for Payer: Health Management Network Commercial	$4.47
Rate for Payer: Health Management Network Commercial	$4.22
Rate for Payer: MDX Hawaii PPO	$5.10
Rate for Payer: MDX Hawaii PPO	$5.72
Rate for Payer: MDX Hawaii PPO	$4.82

FAMOTIDINE (PF) 20 MG/2 ML IV SOLN

Facility

$5.26

Service Code	HCPCS J1308
Hospital Revenue Code	636
Min. Negotiated Rate	$0.01
Max. Negotiated Rate	$5.10
Rate for Payer: Cash Price	$3.42
Rate for Payer: Cash Price	$3.23
Rate for Payer: Cash Price	$3.84
Rate for Payer: Cash Price	$3.84
Rate for Payer: Cash Price	$3.42
Rate for Payer: Cash Price	$3.23
Rate for Payer: Hawaii Medical Service Association ABD	$0.01
Rate for Payer: Hawaii Medical Service Association ABD	$0.01
Rate for Payer: Hawaii Medical Service Association ABD	$0.01
Rate for Payer: Hawaii Medical Service Association Non-ABD	$0.01
Rate for Payer: Hawaii Medical Service Association Non-ABD	$0.01
Rate for Payer: Hawaii Medical Service Association Non-ABD	$0.01
Rate for Payer: Hawaii Western Management Group Commercial	$5.00
Rate for Payer: Hawaii Western Management Group Commercial	$4.72
Rate for Payer: Hawaii Western Management Group Commercial	$5.61
Rate for Payer: Health Management Network Commercial	$4.22
Rate for Payer: Health Management Network Commercial	$4.47
Rate for Payer: Health Management Network Commercial	$5.01
Rate for Payer: Kaiser Permanente Commercial	$3.72
Rate for Payer: Kaiser Permanente Commercial	$3.13
Rate for Payer: Kaiser Permanente Commercial	$3.31
Rate for Payer: Kaiser Permanente Medicaid	$2.68
Rate for Payer: Kaiser Permanente Medicaid	$3.01
Rate for Payer: Kaiser Permanente Medicaid	$2.53
Rate for Payer: MDX Hawaii PPO	$4.82
Rate for Payer: MDX Hawaii PPO	$5.10
Rate for Payer: MDX Hawaii PPO	$5.72
Rate for Payer: UnitedHealthcare Medicaid	$3.16
Rate for Payer: UnitedHealthcare Medicaid	$3.54
Rate for Payer: UnitedHealthcare Medicaid	$2.98
Rate for Payer: University Health Alliance Commercial	$3.83
Rate for Payer: University Health Alliance Commercial	$3.62
Rate for Payer: University Health Alliance Commercial	$4.30

FAM-TRASTUZUMAB DERUXTECN-NXKI 100 MG IV RECON.SOLN.

Facility

$4,822.17

Service Code	HCPCS J9358
Hospital Revenue Code	636
Min. Negotiated Rate	$30.00
Max. Negotiated Rate	$4,677.50
Rate for Payer: AlohaCare Medicaid	$31.26
Rate for Payer: AlohaCare Medicare	$31.26
Rate for Payer: Cash Price	$3,134.41
Rate for Payer: Cash Price	$3,134.41
Rate for Payer: Devoted Health Medicare	$34.39
Rate for Payer: Hawaii Medical Service Association ABD	$30.00
Rate for Payer: Hawaii Medical Service Association Commercial	$39.08
Rate for Payer: Hawaii Medical Service Association Medicare	$31.26
Rate for Payer: Hawaii Medical Service Association Non-ABD	$30.00
Rate for Payer: Hawaii Western Management Group Commercial	$4,581.06
Rate for Payer: Health Management Network Commercial	$4,098.84
Rate for Payer: Humana Medicare	$31.26
Rate for Payer: Kaiser Permanente Commercial	$3,037.97
Rate for Payer: Kaiser Permanente Medicaid	$2,459.31
Rate for Payer: Kaiser Permanente Medicare	$31.26
Rate for Payer: MDX Hawaii PPO	$4,677.50
Rate for Payer: Ohana Health Plan Medicaid	$34.39
Rate for Payer: Ohana Health Plan Medicare	$31.26
Rate for Payer: UnitedHealthcare Medicaid	$2,893.30
Rate for Payer: UnitedHealthcare Medicare	$31.26
Rate for Payer: University Health Alliance Commercial	$3,514.88

FAM-TRASTUZUMAB DERUXTECN-NXKI 100 MG IV RECON.SOLN.

Facility

$4,822.17

Service Code	HCPCS J9358
Hospital Revenue Code	250
Min. Negotiated Rate	$4,098.84
Max. Negotiated Rate	$4,677.50
Rate for Payer: Cash Price	$3,134.41
Rate for Payer: Health Management Network Commercial	$4,098.84
Rate for Payer: MDX Hawaii PPO	$4,677.50

Fast Fix 360 Cvd Del Sys 72202468 [3640169]

Facility

$2,576.00

Hospital Charge Code	3640169
Hospital Revenue Code	272
Min. Negotiated Rate	$1,313.76
Max. Negotiated Rate	$2,498.72
Rate for Payer: Cash Price	$1,674.40
Rate for Payer: Hawaii Western Management Group Commercial	$2,447.20
Rate for Payer: Health Management Network Commercial	$2,189.60
Rate for Payer: Kaiser Permanente Commercial	$1,622.88
Rate for Payer: Kaiser Permanente Medicaid	$1,313.76
Rate for Payer: MDX Hawaii PPO	$2,498.72
Rate for Payer: University Health Alliance Commercial	$1,877.65

Fast Fix 360 Cvd Del Sys 72202468 [3640169]

Facility

$2,576.00

Hospital Charge Code	3640169
Hospital Revenue Code	272
Min. Negotiated Rate	$2,189.60
Max. Negotiated Rate	$2,498.72
Rate for Payer: Cash Price	$1,674.40
Rate for Payer: Health Management Network Commercial	$2,189.60
Rate for Payer: MDX Hawaii PPO	$2,498.72

Fast Fix 360 Knot Pusher/Cutter Slot Cann 72202674 [3640458]

Facility

$888.16

Hospital Charge Code	3640458
Hospital Revenue Code	272
Min. Negotiated Rate	$754.94
Max. Negotiated Rate	$861.52
Rate for Payer: Cash Price	$577.30
Rate for Payer: Health Management Network Commercial	$754.94
Rate for Payer: MDX Hawaii PPO	$861.52

Know your out-of-pocket cost for care.

All Charges