Kona Community Hospital

All Charges

Charge

Type

Setting

Price

FUROSEMIDE 20 MG PO TABLET

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: Cash Price	$1.85
Rate for Payer: Hawaii Western Management Group Commercial	$1.14
Rate for Payer: Hawaii Western Management Group Commercial	$2.71
Rate for Payer: Health Management Network Commercial	$2.42
Rate for Payer: Health Management Network Commercial	$1.02
Rate for Payer: Kaiser Permanente Commercial	$0.76
Rate for Payer: Kaiser Permanente Commercial	$1.80
Rate for Payer: Kaiser Permanente Medicaid	$1.45
Rate for Payer: Kaiser Permanente Medicaid	$0.61
Rate for Payer: MDX Hawaii PPO	$2.76
Rate for Payer: MDX Hawaii PPO	$1.16
Rate for Payer: UnitedHealthcare Medicaid	$0.72
Rate for Payer: UnitedHealthcare Medicaid	$1.71
Rate for Payer: University Health Alliance Commercial	$2.08
Rate for Payer: University Health Alliance Commercial	$0.87

FUROSEMIDE 40 MG PO TABLET

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

FUROSEMIDE 40 MG PO TABLET

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

G6313 Alexis O C-Section Protector-Retractor [3643809]

Facility

$583.50

Hospital Charge Code	3643809
Hospital Revenue Code	272
Min. Negotiated Rate	$297.58
Max. Negotiated Rate	$566.00
Rate for Payer: Cash Price	$379.28
Rate for Payer: Hawaii Western Management Group Commercial	$554.33
Rate for Payer: Health Management Network Commercial	$495.98
Rate for Payer: Kaiser Permanente Commercial	$367.61
Rate for Payer: Kaiser Permanente Medicaid	$297.58
Rate for Payer: MDX Hawaii PPO	$566.00
Rate for Payer: University Health Alliance Commercial	$425.31

G6313 Alexis O C-Section Protector-Retractor [3643809]

Facility

$583.50

Hospital Charge Code	3643809
Hospital Revenue Code	272
Min. Negotiated Rate	$495.98
Max. Negotiated Rate	$566.00
Rate for Payer: Cash Price	$379.28
Rate for Payer: Health Management Network Commercial	$495.98
Rate for Payer: MDX Hawaii PPO	$566.00

GABAPENTIN 100 MG PO CAP

Facility

$2.97

Service Code	HCPCS A9270
Hospital Revenue Code	250
Min. Negotiated Rate	$2.52
Max. Negotiated Rate	$2.88
Rate for Payer: Cash Price	$1.93
Rate for Payer: Cash Price	$2.10
Rate for Payer: Health Management Network Commercial	$2.75
Rate for Payer: Health Management Network Commercial	$2.52
Rate for Payer: MDX Hawaii PPO	$3.13
Rate for Payer: MDX Hawaii PPO	$2.88

GABAPENTIN 100 MG PO CAP

Facility

$2.97

Service Code	HCPCS A9270
Hospital Revenue Code	250
Min. Negotiated Rate	$1.51
Max. Negotiated Rate	$2.88
Rate for Payer: Cash Price	$1.93
Rate for Payer: Cash Price	$2.10
Rate for Payer: Hawaii Western Management Group Commercial	$2.82
Rate for Payer: Hawaii Western Management Group Commercial	$3.07
Rate for Payer: Health Management Network Commercial	$2.75
Rate for Payer: Health Management Network Commercial	$2.52
Rate for Payer: Kaiser Permanente Commercial	$1.87
Rate for Payer: Kaiser Permanente Commercial	$2.03
Rate for Payer: Kaiser Permanente Medicaid	$1.65
Rate for Payer: Kaiser Permanente Medicaid	$1.51
Rate for Payer: MDX Hawaii PPO	$3.13
Rate for Payer: MDX Hawaii PPO	$2.88
Rate for Payer: UnitedHealthcare Medicaid	$1.78
Rate for Payer: UnitedHealthcare Medicaid	$1.94
Rate for Payer: University Health Alliance Commercial	$2.35
Rate for Payer: University Health Alliance Commercial	$2.16

GABAPENTIN 300 MG PO CAP

Facility

$7.61

Service Code	HCPCS A9270
Hospital Revenue Code	250
Min. Negotiated Rate	$3.88
Max. Negotiated Rate	$7.38
Rate for Payer: Cash Price	$4.95
Rate for Payer: Hawaii Western Management Group Commercial	$7.23
Rate for Payer: Health Management Network Commercial	$6.47
Rate for Payer: Kaiser Permanente Commercial	$4.79
Rate for Payer: Kaiser Permanente Medicaid	$3.88
Rate for Payer: MDX Hawaii PPO	$7.38
Rate for Payer: UnitedHealthcare Medicaid	$4.57
Rate for Payer: University Health Alliance Commercial	$5.55

GABAPENTIN 300 MG PO CAP

Facility

$7.61

Service Code	HCPCS A9270
Hospital Revenue Code	250
Min. Negotiated Rate	$6.47
Max. Negotiated Rate	$7.38
Rate for Payer: Cash Price	$4.95
Rate for Payer: Health Management Network Commercial	$6.47
Rate for Payer: MDX Hawaii PPO	$7.38

GABAPENTIN 600 MG PO TABLET

Facility

$13.37

Service Code	HCPCS A9270
Hospital Revenue Code	250
Min. Negotiated Rate	$11.36
Max. Negotiated Rate	$12.97
Rate for Payer: Cash Price	$8.69
Rate for Payer: Cash Price	$1.26
Rate for Payer: Health Management Network Commercial	$11.36
Rate for Payer: Health Management Network Commercial	$1.65
Rate for Payer: MDX Hawaii PPO	$12.97
Rate for Payer: MDX Hawaii PPO	$1.88

GABAPENTIN 600 MG PO TABLET

Facility

$1.94

Service Code	HCPCS A9270
Hospital Revenue Code	250
Min. Negotiated Rate	$0.99
Max. Negotiated Rate	$1.88
Rate for Payer: Cash Price	$1.26
Rate for Payer: Cash Price	$8.69
Rate for Payer: Hawaii Western Management Group Commercial	$12.70
Rate for Payer: Hawaii Western Management Group Commercial	$1.84
Rate for Payer: Health Management Network Commercial	$11.36
Rate for Payer: Health Management Network Commercial	$1.65
Rate for Payer: Kaiser Permanente Commercial	$1.22
Rate for Payer: Kaiser Permanente Commercial	$8.42
Rate for Payer: Kaiser Permanente Medicaid	$0.99
Rate for Payer: Kaiser Permanente Medicaid	$6.82
Rate for Payer: MDX Hawaii PPO	$12.97
Rate for Payer: MDX Hawaii PPO	$1.88
Rate for Payer: UnitedHealthcare Medicaid	$8.02
Rate for Payer: UnitedHealthcare Medicaid	$1.16
Rate for Payer: University Health Alliance Commercial	$1.41
Rate for Payer: University Health Alliance Commercial	$9.75

GABAPENTIN 800 MG PO TABLET

Facility

$16.05

Service Code	HCPCS A9270
Hospital Revenue Code	250
Min. Negotiated Rate	$13.64
Max. Negotiated Rate	$15.57
Rate for Payer: Cash Price	$10.43
Rate for Payer: Cash Price	$10.88
Rate for Payer: Health Management Network Commercial	$14.23
Rate for Payer: Health Management Network Commercial	$13.64
Rate for Payer: MDX Hawaii PPO	$15.57
Rate for Payer: MDX Hawaii PPO	$16.24

GABAPENTIN 800 MG PO TABLET

Facility

$16.05

Service Code	HCPCS A9270
Hospital Revenue Code	250
Min. Negotiated Rate	$8.19
Max. Negotiated Rate	$15.57
Rate for Payer: Cash Price	$10.43
Rate for Payer: Cash Price	$10.88
Rate for Payer: Hawaii Western Management Group Commercial	$15.25
Rate for Payer: Hawaii Western Management Group Commercial	$15.90
Rate for Payer: Health Management Network Commercial	$13.64
Rate for Payer: Health Management Network Commercial	$14.23
Rate for Payer: Kaiser Permanente Commercial	$10.11
Rate for Payer: Kaiser Permanente Commercial	$10.55
Rate for Payer: Kaiser Permanente Medicaid	$8.19
Rate for Payer: Kaiser Permanente Medicaid	$8.54
Rate for Payer: MDX Hawaii PPO	$15.57
Rate for Payer: MDX Hawaii PPO	$16.24
Rate for Payer: UnitedHealthcare Medicaid	$10.04
Rate for Payer: UnitedHealthcare Medicaid	$9.63
Rate for Payer: University Health Alliance Commercial	$11.70
Rate for Payer: University Health Alliance Commercial	$12.20

GADOPICLENOL 0.5 MMOL/ML IV SOLN (10 ML)

Facility

$471.75

Service Code	HCPCS A9573
Hospital Revenue Code	255
Min. Negotiated Rate	$2.56
Max. Negotiated Rate	$457.60
Rate for Payer: Cash Price	$306.64
Rate for Payer: Cash Price	$306.64
Rate for Payer: Hawaii Western Management Group Commercial	$448.16
Rate for Payer: Health Management Network Commercial	$400.99
Rate for Payer: Kaiser Permanente Commercial	$297.20
Rate for Payer: Kaiser Permanente Medicaid	$240.59
Rate for Payer: MDX Hawaii PPO	$457.60
Rate for Payer: UnitedHealthcare Medicaid	$2.56
Rate for Payer: University Health Alliance Commercial	$343.86

GADOPICLENOL 0.5 MMOL/ML IV SOLN (10 ML)

Facility

$471.75

Service Code	HCPCS A9573
Hospital Revenue Code	255
Min. Negotiated Rate	$400.99
Max. Negotiated Rate	$457.60
Rate for Payer: Cash Price	$306.64
Rate for Payer: Health Management Network Commercial	$400.99
Rate for Payer: MDX Hawaii PPO	$457.60

GADOPICLENOL 0.5 MMOL/ML IV SOLN (3 ML)

Facility

$158.34

Service Code	HCPCS A9573
Hospital Revenue Code	255
Min. Negotiated Rate	$134.59
Max. Negotiated Rate	$153.59
Rate for Payer: Cash Price	$102.92
Rate for Payer: Health Management Network Commercial	$134.59
Rate for Payer: MDX Hawaii PPO	$153.59

GADOPICLENOL 0.5 MMOL/ML IV SOLN (3 ML)

Facility

$158.34

Service Code	HCPCS A9573
Hospital Revenue Code	255
Min. Negotiated Rate	$2.56
Max. Negotiated Rate	$153.59
Rate for Payer: Cash Price	$102.92
Rate for Payer: Cash Price	$102.92
Rate for Payer: Hawaii Western Management Group Commercial	$150.42
Rate for Payer: Health Management Network Commercial	$134.59
Rate for Payer: Kaiser Permanente Commercial	$99.75
Rate for Payer: Kaiser Permanente Medicaid	$80.75
Rate for Payer: MDX Hawaii PPO	$153.59
Rate for Payer: UnitedHealthcare Medicaid	$2.56
Rate for Payer: University Health Alliance Commercial	$115.41

GADOPICLENOL 0.5 MMOL/ML IV SOLN (7.5 ML)

Facility

$390.27

Service Code	HCPCS A9573
Hospital Revenue Code	255
Min. Negotiated Rate	$331.73
Max. Negotiated Rate	$378.56
Rate for Payer: Cash Price	$253.68
Rate for Payer: Health Management Network Commercial	$331.73
Rate for Payer: MDX Hawaii PPO	$378.56

GADOPICLENOL 0.5 MMOL/ML IV SOLN (7.5 ML)

Facility

$390.27

Service Code	HCPCS A9573
Hospital Revenue Code	255
Min. Negotiated Rate	$2.56
Max. Negotiated Rate	$378.56
Rate for Payer: Cash Price	$253.68
Rate for Payer: Cash Price	$253.68
Rate for Payer: Hawaii Western Management Group Commercial	$370.76
Rate for Payer: Health Management Network Commercial	$331.73
Rate for Payer: Kaiser Permanente Commercial	$245.87
Rate for Payer: Kaiser Permanente Medicaid	$199.04
Rate for Payer: MDX Hawaii PPO	$378.56
Rate for Payer: UnitedHealthcare Medicaid	$2.56
Rate for Payer: University Health Alliance Commercial	$284.47

GADOTERIDOL 279.3 MG/ML IV (10 ML)

Facility

$300.61

Service Code	HCPCS A9579
Hospital Revenue Code	255
Min. Negotiated Rate	$255.52
Max. Negotiated Rate	$291.59
Rate for Payer: Cash Price	$195.40
Rate for Payer: Health Management Network Commercial	$255.52
Rate for Payer: MDX Hawaii PPO	$291.59

GADOTERIDOL 279.3 MG/ML IV (10 ML)

Facility

$300.61

Service Code	HCPCS A9579
Hospital Revenue Code	255
Min. Negotiated Rate	$1.10
Max. Negotiated Rate	$291.59
Rate for Payer: Cash Price	$195.40
Rate for Payer: Cash Price	$195.40
Rate for Payer: Hawaii Western Management Group Commercial	$285.58
Rate for Payer: Health Management Network Commercial	$255.52
Rate for Payer: Kaiser Permanente Commercial	$189.38
Rate for Payer: Kaiser Permanente Medicaid	$153.31
Rate for Payer: MDX Hawaii PPO	$291.59
Rate for Payer: UnitedHealthcare Medicaid	$1.10
Rate for Payer: University Health Alliance Commercial	$219.11

GADOTERIDOL 279.3 MG/ML IV (15 ML)

Facility

$393.75

Service Code	HCPCS A9579
Hospital Revenue Code	255
Min. Negotiated Rate	$1.10
Max. Negotiated Rate	$381.94
Rate for Payer: Cash Price	$255.94
Rate for Payer: Cash Price	$255.94
Rate for Payer: Hawaii Western Management Group Commercial	$374.06
Rate for Payer: Health Management Network Commercial	$334.69
Rate for Payer: Kaiser Permanente Commercial	$248.06
Rate for Payer: Kaiser Permanente Medicaid	$200.81
Rate for Payer: MDX Hawaii PPO	$381.94
Rate for Payer: UnitedHealthcare Medicaid	$1.10
Rate for Payer: University Health Alliance Commercial	$287.00

GADOTERIDOL 279.3 MG/ML IV (15 ML)

Facility

$393.75

Service Code	HCPCS A9579
Hospital Revenue Code	255
Min. Negotiated Rate	$334.69
Max. Negotiated Rate	$381.94
Rate for Payer: Cash Price	$255.94
Rate for Payer: Health Management Network Commercial	$334.69
Rate for Payer: MDX Hawaii PPO	$381.94

GADOTERIDOL 279.3 MG/ML IV (20 ML)

Facility

$458.19

Service Code	HCPCS A9579
Hospital Revenue Code	255
Min. Negotiated Rate	$389.46
Max. Negotiated Rate	$444.44
Rate for Payer: Cash Price	$297.82
Rate for Payer: Health Management Network Commercial	$389.46
Rate for Payer: MDX Hawaii PPO	$444.44

GADOTERIDOL 279.3 MG/ML IV (20 ML)

Facility

$458.19

Service Code	HCPCS A9579
Hospital Revenue Code	255
Min. Negotiated Rate	$1.10
Max. Negotiated Rate	$444.44
Rate for Payer: Cash Price	$297.82
Rate for Payer: Cash Price	$297.82
Rate for Payer: Hawaii Western Management Group Commercial	$435.28
Rate for Payer: Health Management Network Commercial	$389.46
Rate for Payer: Kaiser Permanente Commercial	$288.66
Rate for Payer: Kaiser Permanente Medicaid	$233.68
Rate for Payer: MDX Hawaii PPO	$444.44
Rate for Payer: UnitedHealthcare Medicaid	$1.10
Rate for Payer: University Health Alliance Commercial	$333.97

Know your out-of-pocket cost for care.

All Charges