Kona Community Hospital

All Charges

Charge

Type

Setting

Price

FERRIC CARBOXYMALTOSE 50 MG IRON/ML IV SOLN

Facility

$2,973.86

Service Code	HCPCS J1439
Hospital Revenue Code	636
Min. Negotiated Rate	$1.10
Max. Negotiated Rate	$2,884.64
Rate for Payer: AlohaCare Medicaid	$1.10
Rate for Payer: AlohaCare Medicare	$1.10
Rate for Payer: Cash Price	$1,933.01
Rate for Payer: Cash Price	$1,933.01
Rate for Payer: Devoted Health Medicare	$1.21
Rate for Payer: Hawaii Medical Service Association ABD	$1.14
Rate for Payer: Hawaii Medical Service Association Commercial	$1.38
Rate for Payer: Hawaii Medical Service Association Medicare	$1.10
Rate for Payer: Hawaii Medical Service Association Non-ABD	$1.14
Rate for Payer: Hawaii Western Management Group Commercial	$2,825.17
Rate for Payer: Health Management Network Commercial	$2,527.78
Rate for Payer: Humana Medicare	$1.10
Rate for Payer: Kaiser Permanente Commercial	$1,873.53
Rate for Payer: Kaiser Permanente Medicaid	$1,516.67
Rate for Payer: Kaiser Permanente Medicare	$1.10
Rate for Payer: MDX Hawaii PPO	$2,884.64
Rate for Payer: Ohana Health Plan Medicaid	$1.21
Rate for Payer: Ohana Health Plan Medicare	$1.10
Rate for Payer: UnitedHealthcare Medicaid	$1,784.32
Rate for Payer: UnitedHealthcare Medicare	$1.10
Rate for Payer: University Health Alliance Commercial	$2,167.65

FERRIC CARBOXYMALTOSE 50 MG IRON/ML IV SOLN

Facility

$2,973.86

Service Code	HCPCS J1439
Hospital Revenue Code	250
Min. Negotiated Rate	$2,527.78
Max. Negotiated Rate	$2,884.64
Rate for Payer: Cash Price	$1,933.01
Rate for Payer: Health Management Network Commercial	$2,527.78
Rate for Payer: MDX Hawaii PPO	$2,884.64

FERRIC SUBSULFATE 0.2 TO 0.22 GRAM/ML TOP SOLA

Facility

$101.57

Service Code	HCPCS A9270
Hospital Revenue Code	250
Min. Negotiated Rate	$51.80
Max. Negotiated Rate	$98.52
Rate for Payer: Cash Price	$66.02
Rate for Payer: Hawaii Western Management Group Commercial	$96.49
Rate for Payer: Health Management Network Commercial	$86.33
Rate for Payer: Kaiser Permanente Commercial	$63.99
Rate for Payer: Kaiser Permanente Medicaid	$51.80
Rate for Payer: MDX Hawaii PPO	$98.52
Rate for Payer: UnitedHealthcare Medicaid	$60.94
Rate for Payer: University Health Alliance Commercial	$74.03

FERRIC SUBSULFATE 0.2 TO 0.22 GRAM/ML TOP SOLA

Facility

$101.57

Service Code	HCPCS A9270
Hospital Revenue Code	250
Min. Negotiated Rate	$86.33
Max. Negotiated Rate	$98.52
Rate for Payer: Cash Price	$66.02
Rate for Payer: Health Management Network Commercial	$86.33
Rate for Payer: MDX Hawaii PPO	$98.52

FERRIC SUBSULFATE 259 MG/G TOP SOLN

Facility

$90.40

Service Code	NDC 59365606500
Hospital Revenue Code	250
Min. Negotiated Rate	$76.84
Max. Negotiated Rate	$87.69
Rate for Payer: Cash Price	$58.76
Rate for Payer: Health Management Network Commercial	$76.84
Rate for Payer: MDX Hawaii PPO	$87.69

FERRIC SUBSULFATE 259 MG/G TOP SOLN

Facility

$90.40

Service Code	NDC 59365606500
Hospital Revenue Code	250
Min. Negotiated Rate	$46.10
Max. Negotiated Rate	$87.69
Rate for Payer: Cash Price	$58.76
Rate for Payer: Hawaii Western Management Group Commercial	$85.88
Rate for Payer: Health Management Network Commercial	$76.84
Rate for Payer: Kaiser Permanente Commercial	$56.95
Rate for Payer: Kaiser Permanente Medicaid	$46.10
Rate for Payer: MDX Hawaii PPO	$87.69
Rate for Payer: UnitedHealthcare Medicaid	$54.24
Rate for Payer: University Health Alliance Commercial	$65.89

FERROUS SULFATE 300 MG (60 MG IRON)/5 ML PO LIQ

Facility

$22.47

Service Code	HCPCS A9270
Hospital Revenue Code	250
Min. Negotiated Rate	$19.10
Max. Negotiated Rate	$21.80
Rate for Payer: Cash Price	$14.61
Rate for Payer: Health Management Network Commercial	$19.10
Rate for Payer: MDX Hawaii PPO	$21.80

FERROUS SULFATE 300 MG (60 MG IRON)/5 ML PO LIQ

Facility

$22.47

Service Code	HCPCS A9270
Hospital Revenue Code	250
Min. Negotiated Rate	$11.46
Max. Negotiated Rate	$21.80
Rate for Payer: Cash Price	$14.61
Rate for Payer: Hawaii Western Management Group Commercial	$21.35
Rate for Payer: Health Management Network Commercial	$19.10
Rate for Payer: Kaiser Permanente Commercial	$14.16
Rate for Payer: Kaiser Permanente Medicaid	$11.46
Rate for Payer: MDX Hawaii PPO	$21.80
Rate for Payer: UnitedHealthcare Medicaid	$13.48
Rate for Payer: University Health Alliance Commercial	$16.38

FERROUS SULFATE 324 MG (65 MG IRON) PO TAB DR EC

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

FERROUS SULFATE 324 MG (65 MG IRON) PO TAB DR EC

Facility

$1.20

Service Code	HCPCS A9270
Hospital Revenue Code	250
Min. Negotiated Rate	$0.61
Max. Negotiated Rate	$1.16
Rate for Payer: Cash Price	$0.78
Rate for Payer: Hawaii Western Management Group Commercial	$1.14
Rate for Payer: Health Management Network Commercial	$1.02
Rate for Payer: Kaiser Permanente Commercial	$0.76
Rate for Payer: Kaiser Permanente Medicaid	$0.61
Rate for Payer: MDX Hawaii PPO	$1.16
Rate for Payer: UnitedHealthcare Medicaid	$0.72
Rate for Payer: University Health Alliance Commercial	$0.87

FERUMOXYTOL 510 MG/17 ML (30 MG/ML) IV SOLN

Facility

$2,550.75

Service Code	HCPCS Q0139
Hospital Revenue Code	250
Min. Negotiated Rate	$2,168.14
Max. Negotiated Rate	$2,474.23
Rate for Payer: Cash Price	$1,657.99
Rate for Payer: Health Management Network Commercial	$2,168.14
Rate for Payer: MDX Hawaii PPO	$2,474.23

FERUMOXYTOL 510 MG/17 ML (30 MG/ML) IV SOLN

Facility

$2,550.75

Service Code	HCPCS Q0139
Hospital Revenue Code	250
Min. Negotiated Rate	$0.23
Max. Negotiated Rate	$2,474.23
Rate for Payer: AlohaCare Medicaid	$0.23
Rate for Payer: AlohaCare Medicare	$0.23
Rate for Payer: Cash Price	$1,657.99
Rate for Payer: Cash Price	$1,657.99
Rate for Payer: Devoted Health Medicare	$0.25
Rate for Payer: Hawaii Medical Service Association Commercial	$0.29
Rate for Payer: Hawaii Medical Service Association Medicare	$0.23
Rate for Payer: Hawaii Western Management Group Commercial	$2,423.21
Rate for Payer: Health Management Network Commercial	$2,168.14
Rate for Payer: Humana Medicare	$0.23
Rate for Payer: Kaiser Permanente Commercial	$1,606.97
Rate for Payer: Kaiser Permanente Medicaid	$1,300.88
Rate for Payer: Kaiser Permanente Medicare	$0.23
Rate for Payer: MDX Hawaii PPO	$2,474.23
Rate for Payer: Ohana Health Plan Medicaid	$0.25
Rate for Payer: Ohana Health Plan Medicare	$0.23
Rate for Payer: UnitedHealthcare Medicaid	$1,530.45
Rate for Payer: UnitedHealthcare Medicare	$0.23
Rate for Payer: University Health Alliance Commercial	$1,859.24

FERUMOXYTOL 510 MG/17 ML (30 MG/ML) IV SOLN (NON-ESRD)

Facility

$2,550.75

Service Code	HCPCS Q0138
Hospital Revenue Code	250
Min. Negotiated Rate	$2,168.14
Max. Negotiated Rate	$2,474.23
Rate for Payer: Cash Price	$1,657.99
Rate for Payer: Health Management Network Commercial	$2,168.14
Rate for Payer: MDX Hawaii PPO	$2,474.23

FERUMOXYTOL 510 MG/17 ML (30 MG/ML) IV SOLN (NON-ESRD)

Facility

$2,550.75

Service Code	HCPCS Q0138
Hospital Revenue Code	250
Min. Negotiated Rate	$0.23
Max. Negotiated Rate	$2,474.23
Rate for Payer: AlohaCare Medicaid	$0.23
Rate for Payer: AlohaCare Medicare	$0.23
Rate for Payer: Cash Price	$1,657.99
Rate for Payer: Cash Price	$1,657.99
Rate for Payer: Devoted Health Medicare	$0.25
Rate for Payer: Hawaii Medical Service Association Commercial	$0.29
Rate for Payer: Hawaii Medical Service Association Medicare	$0.23
Rate for Payer: Hawaii Western Management Group Commercial	$2,423.21
Rate for Payer: Health Management Network Commercial	$2,168.14
Rate for Payer: Humana Medicare	$0.23
Rate for Payer: Kaiser Permanente Commercial	$1,606.97
Rate for Payer: Kaiser Permanente Medicaid	$1,300.88
Rate for Payer: Kaiser Permanente Medicare	$0.23
Rate for Payer: MDX Hawaii PPO	$2,474.23
Rate for Payer: Ohana Health Plan Medicaid	$0.25
Rate for Payer: Ohana Health Plan Medicare	$0.23
Rate for Payer: UnitedHealthcare Medicaid	$1,530.45
Rate for Payer: UnitedHealthcare Medicare	$0.23
Rate for Payer: University Health Alliance Commercial	$1,859.24

FEVER AND INFLAMMATORY CONDITIONS

Facility

$22,949.86

Service Code	MSDRG 864
Min. Negotiated Rate	$11,675.72
Max. Negotiated Rate	$22,949.86
Rate for Payer: AlohaCare Medicare	$11,675.72
Rate for Payer: Devoted Health Medicare	$12,843.29
Rate for Payer: Hawaii Medical Service Association Commercial	$22,949.86
Rate for Payer: Hawaii Medical Service Association Medicare	$11,675.72
Rate for Payer: Humana Medicare	$11,675.72
Rate for Payer: Kaiser Permanente Commercial	$15,312.83
Rate for Payer: Kaiser Permanente Medicare	$11,675.72
Rate for Payer: Ohana Health Plan Medicare	$11,675.72
Rate for Payer: UnitedHealthcare Medicare	$11,675.72

FEVER & INFLAMMATORY CONDITIONS

Facility

$2,937.57

Service Code	APR-DRG 7222
Min. Negotiated Rate	$2,937.57
Max. Negotiated Rate	$2,937.57
Rate for Payer: AlohaCare Medicaid	$2,937.57
Rate for Payer: Hawaii Medical Service Association ABD	$2,937.57
Rate for Payer: Hawaii Medical Service Association Non-ABD	$2,937.57
Rate for Payer: Kaiser Permanente Medicaid	$2,937.57
Rate for Payer: Ohana Health Plan Medicaid	$2,937.57
Rate for Payer: UnitedHealthcare Medicaid	$2,937.57

FEVER & INFLAMMATORY CONDITIONS

Facility

$6,170.62

Service Code	APR-DRG 7224
Min. Negotiated Rate	$6,170.62
Max. Negotiated Rate	$6,170.62
Rate for Payer: AlohaCare Medicaid	$6,170.62
Rate for Payer: Hawaii Medical Service Association ABD	$6,170.62
Rate for Payer: Hawaii Medical Service Association Non-ABD	$6,170.62
Rate for Payer: Kaiser Permanente Medicaid	$6,170.62
Rate for Payer: Ohana Health Plan Medicaid	$6,170.62
Rate for Payer: UnitedHealthcare Medicaid	$6,170.62

FEVER & INFLAMMATORY CONDITIONS

Facility

$3,986.39

Service Code	APR-DRG 7223
Min. Negotiated Rate	$3,986.39
Max. Negotiated Rate	$3,986.39
Rate for Payer: AlohaCare Medicaid	$3,986.39
Rate for Payer: Hawaii Medical Service Association ABD	$3,986.39
Rate for Payer: Hawaii Medical Service Association Non-ABD	$3,986.39
Rate for Payer: Kaiser Permanente Medicaid	$3,986.39
Rate for Payer: Ohana Health Plan Medicaid	$3,986.39
Rate for Payer: UnitedHealthcare Medicaid	$3,986.39

FEVER & INFLAMMATORY CONDITIONS

Facility

$2,111.00

Service Code	APR-DRG 7221
Min. Negotiated Rate	$2,111.00
Max. Negotiated Rate	$2,111.00
Rate for Payer: AlohaCare Medicaid	$2,111.00
Rate for Payer: Hawaii Medical Service Association ABD	$2,111.00
Rate for Payer: Hawaii Medical Service Association Non-ABD	$2,111.00
Rate for Payer: Kaiser Permanente Medicaid	$2,111.00
Rate for Payer: Ohana Health Plan Medicaid	$2,111.00
Rate for Payer: UnitedHealthcare Medicaid	$2,111.00

Fibergraft Bg Putty 2cc 78000020 [3644264]

Facility

$6,438.00

Service Code	HCPCS C1713
Hospital Charge Code	3644264
Hospital Revenue Code	278
Min. Negotiated Rate	$3,605.28
Max. Negotiated Rate	$6,244.86
Rate for Payer: Cash Price	$4,184.70
Rate for Payer: Hawaii Western Management Group Commercial	$4,506.60
Rate for Payer: Health Management Network Commercial	$5,472.30
Rate for Payer: MDX Hawaii PPO	$6,244.86
Rate for Payer: University Health Alliance Commercial	$3,605.28

Fibergraft Bg Putty 2cc 78000020 [3644264]

Facility

$6,438.00

Service Code	HCPCS C1713
Hospital Charge Code	3644264
Hospital Revenue Code	278
Min. Negotiated Rate	$3,283.38
Max. Negotiated Rate	$6,244.86
Rate for Payer: Cash Price	$4,184.70
Rate for Payer: Hawaii Western Management Group Commercial	$4,506.60
Rate for Payer: Health Management Network Commercial	$5,472.30
Rate for Payer: Kaiser Permanente Commercial	$4,055.94
Rate for Payer: Kaiser Permanente Medicaid	$3,283.38
Rate for Payer: MDX Hawaii PPO	$6,244.86
Rate for Payer: University Health Alliance Commercial	$3,605.28

Fiberloop 4 AR-7229-12 [3641024]

Facility

$376.50

Hospital Charge Code	3641024
Hospital Revenue Code	272
Min. Negotiated Rate	$192.01
Max. Negotiated Rate	$365.20
Rate for Payer: Cash Price	$244.72
Rate for Payer: Hawaii Western Management Group Commercial	$357.68
Rate for Payer: Health Management Network Commercial	$320.02
Rate for Payer: Kaiser Permanente Commercial	$237.19
Rate for Payer: Kaiser Permanente Medicaid	$192.01
Rate for Payer: MDX Hawaii PPO	$365.20
Rate for Payer: University Health Alliance Commercial	$274.43

Fiberloop 4 AR-7229-12 [3641024]

Facility

$376.50

Hospital Charge Code	3641024
Hospital Revenue Code	272
Min. Negotiated Rate	$320.02
Max. Negotiated Rate	$365.20
Rate for Payer: Cash Price	$244.72
Rate for Payer: Health Management Network Commercial	$320.02
Rate for Payer: MDX Hawaii PPO	$365.20

Fibersnare #2 Fiberwire #2 26" Blk/wh AR-7209SNT [3643959]

Facility

$765.63

Hospital Charge Code	3643959
Hospital Revenue Code	272
Min. Negotiated Rate	$650.79
Max. Negotiated Rate	$742.66
Rate for Payer: Cash Price	$497.66
Rate for Payer: Health Management Network Commercial	$650.79
Rate for Payer: MDX Hawaii PPO	$742.66

Fibersnare #2 Fiberwire #2 26" Blk/wh AR-7209SNT [3643959]

Facility

$765.63

Hospital Charge Code	3643959
Hospital Revenue Code	272
Min. Negotiated Rate	$390.47
Max. Negotiated Rate	$742.66
Rate for Payer: Cash Price	$497.66
Rate for Payer: Hawaii Western Management Group Commercial	$727.35
Rate for Payer: Health Management Network Commercial	$650.79
Rate for Payer: Kaiser Permanente Commercial	$482.35
Rate for Payer: Kaiser Permanente Medicaid	$390.47
Rate for Payer: MDX Hawaii PPO	$742.66
Rate for Payer: University Health Alliance Commercial	$558.07

Know your out-of-pocket cost for care.

All Charges