Kona Community Hospital

All Charges

Charge

Type

Setting

Price

GENTAMICIN IN NACL (ISO-OSM) 80 MG/100 ML IV IVPB

Facility

$22.08

Service Code	HCPCS J1580
Hospital Revenue Code	250
Min. Negotiated Rate	$2.62
Max. Negotiated Rate	$21.42
Rate for Payer: Cash Price	$14.35
Rate for Payer: Cash Price	$14.35
Rate for Payer: Hawaii Medical Service Association ABD	$2.62
Rate for Payer: Hawaii Medical Service Association Non-ABD	$2.62
Rate for Payer: Hawaii Western Management Group Commercial	$20.98
Rate for Payer: Health Management Network Commercial	$18.77
Rate for Payer: Kaiser Permanente Commercial	$13.91
Rate for Payer: Kaiser Permanente Medicaid	$11.26
Rate for Payer: MDX Hawaii PPO	$21.42
Rate for Payer: UnitedHealthcare Medicaid	$13.25
Rate for Payer: University Health Alliance Commercial	$16.09

GENTAMICIN SULFATE (PED) (PF) 20 MG/2 ML INJ SOLN

Facility

$39.44

Service Code	HCPCS J1580
Hospital Revenue Code	636
Min. Negotiated Rate	$2.62
Max. Negotiated Rate	$38.26
Rate for Payer: Cash Price	$25.64
Rate for Payer: Cash Price	$25.64
Rate for Payer: Hawaii Medical Service Association ABD	$2.62
Rate for Payer: Hawaii Medical Service Association Non-ABD	$2.62
Rate for Payer: Hawaii Western Management Group Commercial	$37.47
Rate for Payer: Health Management Network Commercial	$33.52
Rate for Payer: Kaiser Permanente Commercial	$24.85
Rate for Payer: Kaiser Permanente Medicaid	$20.11
Rate for Payer: MDX Hawaii PPO	$38.26
Rate for Payer: UnitedHealthcare Medicaid	$23.66
Rate for Payer: University Health Alliance Commercial	$28.75

GENTAMICIN SULFATE (PED) (PF) 20 MG/2 ML INJ SOLN

Facility

$39.44

Service Code	HCPCS J1580
Hospital Revenue Code	250
Min. Negotiated Rate	$33.52
Max. Negotiated Rate	$38.26
Rate for Payer: Cash Price	$25.64
Rate for Payer: Health Management Network Commercial	$33.52
Rate for Payer: MDX Hawaii PPO	$38.26

Gia 100-3.8 Single Use Reload Stapler GIA10038S [3643867]

Facility

$804.56

Hospital Charge Code	3643867
Hospital Revenue Code	272
Min. Negotiated Rate	$683.88
Max. Negotiated Rate	$780.42
Rate for Payer: Cash Price	$522.96
Rate for Payer: Health Management Network Commercial	$683.88
Rate for Payer: MDX Hawaii PPO	$780.42

Gia 100-3.8 Single Use Reload Stapler GIA10038S [3643867]

Facility

$804.56

Hospital Charge Code	3643867
Hospital Revenue Code	272
Min. Negotiated Rate	$410.33
Max. Negotiated Rate	$780.42
Rate for Payer: Cash Price	$522.96
Rate for Payer: Hawaii Western Management Group Commercial	$764.33
Rate for Payer: Health Management Network Commercial	$683.88
Rate for Payer: Kaiser Permanente Commercial	$506.87
Rate for Payer: Kaiser Permanente Medicaid	$410.33
Rate for Payer: MDX Hawaii PPO	$780.42
Rate for Payer: University Health Alliance Commercial	$586.44

Gia 80-3.8 Single Use Load Unit GIA8038L [3643886]

Facility

$433.43

Hospital Charge Code	3643886
Hospital Revenue Code	272
Min. Negotiated Rate	$221.05
Max. Negotiated Rate	$420.43
Rate for Payer: Cash Price	$281.73
Rate for Payer: Hawaii Western Management Group Commercial	$411.76
Rate for Payer: Health Management Network Commercial	$368.42
Rate for Payer: Kaiser Permanente Commercial	$273.06
Rate for Payer: Kaiser Permanente Medicaid	$221.05
Rate for Payer: MDX Hawaii PPO	$420.43
Rate for Payer: University Health Alliance Commercial	$315.93

Gia 80-3.8 Single Use Load Unit GIA8038L [3643886]

Facility

$433.43

Hospital Charge Code	3643886
Hospital Revenue Code	272
Min. Negotiated Rate	$368.42
Max. Negotiated Rate	$420.43
Rate for Payer: Cash Price	$281.73
Rate for Payer: Health Management Network Commercial	$368.42
Rate for Payer: MDX Hawaii PPO	$420.43

Gia 80-3.8 Single Use Reload Stapler GIA8038S [3643885]

Facility

$742.18

Hospital Charge Code	3643885
Hospital Revenue Code	272
Min. Negotiated Rate	$630.85
Max. Negotiated Rate	$719.91
Rate for Payer: Cash Price	$482.42
Rate for Payer: Health Management Network Commercial	$630.85
Rate for Payer: MDX Hawaii PPO	$719.91

Gia 80-3.8 Single Use Reload Stapler GIA8038S [3643885]

Facility

$742.18

Hospital Charge Code	3643885
Hospital Revenue Code	272
Min. Negotiated Rate	$378.51
Max. Negotiated Rate	$719.91
Rate for Payer: Cash Price	$482.42
Rate for Payer: Hawaii Western Management Group Commercial	$705.07
Rate for Payer: Health Management Network Commercial	$630.85
Rate for Payer: Kaiser Permanente Commercial	$467.57
Rate for Payer: Kaiser Permanente Medicaid	$378.51
Rate for Payer: MDX Hawaii PPO	$719.91
Rate for Payer: University Health Alliance Commercial	$540.98

Gia 80 Black Stapler Tri-Tech GIA80XTS [3644116]

Facility

$936.09

Hospital Charge Code	3644116
Hospital Revenue Code	272
Min. Negotiated Rate	$477.41
Max. Negotiated Rate	$908.01
Rate for Payer: Cash Price	$608.46
Rate for Payer: Hawaii Western Management Group Commercial	$889.29
Rate for Payer: Health Management Network Commercial	$795.68
Rate for Payer: Kaiser Permanente Commercial	$589.74
Rate for Payer: Kaiser Permanente Medicaid	$477.41
Rate for Payer: MDX Hawaii PPO	$908.01
Rate for Payer: University Health Alliance Commercial	$682.32

Gia 80 Black Stapler Tri-Tech GIA80XTS [3644116]

Facility

$936.09

Hospital Charge Code	3644116
Hospital Revenue Code	272
Min. Negotiated Rate	$795.68
Max. Negotiated Rate	$908.01
Rate for Payer: Cash Price	$608.46
Rate for Payer: Health Management Network Commercial	$795.68
Rate for Payer: MDX Hawaii PPO	$908.01

GLIMEPIRIDE 2 MG PO TABLET

Facility

$3.60

Service Code	HCPCS A9270
Hospital Revenue Code	250
Min. Negotiated Rate	$3.06
Max. Negotiated Rate	$3.49
Rate for Payer: Cash Price	$2.34
Rate for Payer: Health Management Network Commercial	$3.06
Rate for Payer: MDX Hawaii PPO	$3.49

GLIMEPIRIDE 2 MG PO TABLET

Facility

$3.60

Service Code	HCPCS A9270
Hospital Revenue Code	250
Min. Negotiated Rate	$1.84
Max. Negotiated Rate	$3.49
Rate for Payer: Cash Price	$2.34
Rate for Payer: Hawaii Western Management Group Commercial	$3.42
Rate for Payer: Health Management Network Commercial	$3.06
Rate for Payer: Kaiser Permanente Commercial	$2.27
Rate for Payer: Kaiser Permanente Medicaid	$1.84
Rate for Payer: MDX Hawaii PPO	$3.49
Rate for Payer: UnitedHealthcare Medicaid	$2.16
Rate for Payer: University Health Alliance Commercial	$2.62

GLIPIZIDE 10 MG PO TABLET

Facility

$3.70

Service Code	HCPCS A9270
Hospital Revenue Code	250
Min. Negotiated Rate	$1.89
Max. Negotiated Rate	$3.59
Rate for Payer: MDX Hawaii PPO	$3.43
Rate for Payer: Cash Price	$2.41
Rate for Payer: Cash Price	$2.30
Rate for Payer: Hawaii Western Management Group Commercial	$3.36
Rate for Payer: Hawaii Western Management Group Commercial	$3.52
Rate for Payer: Health Management Network Commercial	$3.01
Rate for Payer: Health Management Network Commercial	$3.15
Rate for Payer: Kaiser Permanente Commercial	$2.23
Rate for Payer: Kaiser Permanente Commercial	$2.33
Rate for Payer: Kaiser Permanente Medicaid	$1.81
Rate for Payer: Kaiser Permanente Medicaid	$1.89
Rate for Payer: MDX Hawaii PPO	$3.59
Rate for Payer: UnitedHealthcare Medicaid	$2.12
Rate for Payer: UnitedHealthcare Medicaid	$2.22
Rate for Payer: University Health Alliance Commercial	$2.70
Rate for Payer: University Health Alliance Commercial	$2.58

GLIPIZIDE 10 MG PO TABLET

Facility

$3.54

Service Code	HCPCS A9270
Hospital Revenue Code	250
Min. Negotiated Rate	$3.01
Max. Negotiated Rate	$3.43
Rate for Payer: Cash Price	$2.30
Rate for Payer: Cash Price	$2.41
Rate for Payer: Health Management Network Commercial	$3.15
Rate for Payer: Health Management Network Commercial	$3.01
Rate for Payer: MDX Hawaii PPO	$3.43
Rate for Payer: MDX Hawaii PPO	$3.59

GLIPIZIDE 5 MG PO TABLET

Facility

$2.09

Service Code	HCPCS A9270
Hospital Revenue Code	250
Min. Negotiated Rate	$1.78
Max. Negotiated Rate	$2.03
Rate for Payer: Cash Price	$1.36
Rate for Payer: Health Management Network Commercial	$1.78
Rate for Payer: MDX Hawaii PPO	$2.03

GLIPIZIDE 5 MG PO TABLET

Facility

$2.09

Service Code	HCPCS A9270
Hospital Revenue Code	250
Min. Negotiated Rate	$1.07
Max. Negotiated Rate	$2.03
Rate for Payer: Cash Price	$1.36
Rate for Payer: Hawaii Western Management Group Commercial	$1.99
Rate for Payer: Health Management Network Commercial	$1.78
Rate for Payer: Kaiser Permanente Commercial	$1.32
Rate for Payer: Kaiser Permanente Medicaid	$1.07
Rate for Payer: MDX Hawaii PPO	$2.03
Rate for Payer: UnitedHealthcare Medicaid	$1.25
Rate for Payer: University Health Alliance Commercial	$1.52

GLIPIZIDE XL 5 MG PO TAB

Facility

$2.25

Service Code	HCPCS A9270
Hospital Revenue Code	250
Min. Negotiated Rate	$1.91
Max. Negotiated Rate	$2.18
Rate for Payer: Cash Price	$1.46
Rate for Payer: Health Management Network Commercial	$1.91
Rate for Payer: MDX Hawaii PPO	$2.18

GLIPIZIDE XL 5 MG PO TAB

Facility

$2.25

Service Code	HCPCS A9270
Hospital Revenue Code	250
Min. Negotiated Rate	$1.15
Max. Negotiated Rate	$2.18
Rate for Payer: Cash Price	$1.46
Rate for Payer: Hawaii Western Management Group Commercial	$2.14
Rate for Payer: Health Management Network Commercial	$1.91
Rate for Payer: Kaiser Permanente Commercial	$1.42
Rate for Payer: Kaiser Permanente Medicaid	$1.15
Rate for Payer: MDX Hawaii PPO	$2.18
Rate for Payer: UnitedHealthcare Medicaid	$1.35
Rate for Payer: University Health Alliance Commercial	$1.64

GLUCAGON 1 MG INJ RECON.SOLN.

Facility

$821.28

Service Code	HCPCS J1610
Hospital Revenue Code	636
Min. Negotiated Rate	$146.33
Max. Negotiated Rate	$796.64
Rate for Payer: AlohaCare Medicaid	$146.33
Rate for Payer: AlohaCare Medicare	$146.33
Rate for Payer: Cash Price	$533.83
Rate for Payer: Cash Price	$533.83
Rate for Payer: Devoted Health Medicare	$160.96
Rate for Payer: Hawaii Medical Service Association ABD	$195.79
Rate for Payer: Hawaii Medical Service Association Commercial	$182.91
Rate for Payer: Hawaii Medical Service Association Medicare	$146.33
Rate for Payer: Hawaii Medical Service Association Non-ABD	$195.79
Rate for Payer: Hawaii Western Management Group Commercial	$780.22
Rate for Payer: Health Management Network Commercial	$698.09
Rate for Payer: Humana Medicare	$146.33
Rate for Payer: Kaiser Permanente Commercial	$517.41
Rate for Payer: Kaiser Permanente Medicaid	$418.85
Rate for Payer: Kaiser Permanente Medicare	$146.33
Rate for Payer: MDX Hawaii PPO	$796.64
Rate for Payer: Ohana Health Plan Medicaid	$160.96
Rate for Payer: Ohana Health Plan Medicare	$146.33
Rate for Payer: UnitedHealthcare Medicaid	$492.77
Rate for Payer: UnitedHealthcare Medicare	$146.33
Rate for Payer: University Health Alliance Commercial	$598.63

GLUCAGON 1 MG INJ RECON.SOLN.

Facility

$821.28

Service Code	HCPCS J1610
Hospital Revenue Code	250
Min. Negotiated Rate	$698.09
Max. Negotiated Rate	$796.64
Rate for Payer: Cash Price	$533.83
Rate for Payer: Health Management Network Commercial	$698.09
Rate for Payer: MDX Hawaii PPO	$796.64

GLUCAGON HCL 1 MG/ML INJ RECON.SOLN.

Facility

$764.57

Service Code	HCPCS J1611
Hospital Revenue Code	250
Min. Negotiated Rate	$649.88
Max. Negotiated Rate	$741.63
Rate for Payer: Cash Price	$496.97
Rate for Payer: Health Management Network Commercial	$649.88
Rate for Payer: MDX Hawaii PPO	$741.63

GLUCAGON HCL 1 MG/ML INJ RECON.SOLN.

Facility

$764.57

Service Code	HCPCS J1611
Hospital Revenue Code	636
Min. Negotiated Rate	$135.00
Max. Negotiated Rate	$741.63
Rate for Payer: AlohaCare Medicaid	$135.00
Rate for Payer: AlohaCare Medicare	$135.00
Rate for Payer: Cash Price	$496.97
Rate for Payer: Cash Price	$496.97
Rate for Payer: Devoted Health Medicare	$148.50
Rate for Payer: Hawaii Medical Service Association ABD	$144.88
Rate for Payer: Hawaii Medical Service Association Commercial	$168.75
Rate for Payer: Hawaii Medical Service Association Medicare	$135.00
Rate for Payer: Hawaii Medical Service Association Non-ABD	$144.88
Rate for Payer: Hawaii Western Management Group Commercial	$726.34
Rate for Payer: Health Management Network Commercial	$649.88
Rate for Payer: Humana Medicare	$135.00
Rate for Payer: Kaiser Permanente Commercial	$481.68
Rate for Payer: Kaiser Permanente Medicaid	$389.93
Rate for Payer: Kaiser Permanente Medicare	$135.00
Rate for Payer: MDX Hawaii PPO	$741.63
Rate for Payer: Ohana Health Plan Medicaid	$148.50
Rate for Payer: Ohana Health Plan Medicare	$135.00
Rate for Payer: UnitedHealthcare Medicaid	$458.74
Rate for Payer: UnitedHealthcare Medicare	$135.00
Rate for Payer: University Health Alliance Commercial	$557.30

GLUC BLD GLUC MNTR DEV CLEARED FDA SPEC HOME USE

Professional

Both

$7.00

Service Code	HCPCS 82962
Min. Negotiated Rate	$2.50
Max. Negotiated Rate	$5.95
Rate for Payer: AlohaCare Medicaid	$2.50
Rate for Payer: AlohaCare Medicare	$3.28
Rate for Payer: Cash Price	$4.55
Rate for Payer: Cash Price	$4.55
Rate for Payer: Devoted Health Medicare	$3.61
Rate for Payer: Hawaii Medical Service Association Medicare	$3.28
Rate for Payer: Hawaii Western Management Group Commercial	$4.38
Rate for Payer: Health Management Network Commercial	$5.95
Rate for Payer: Kaiser Permanente Commercial	$3.94
Rate for Payer: Kaiser Permanente Medicaid	$3.94
Rate for Payer: Kaiser Permanente Medicare	$3.94
Rate for Payer: Ohana Health Plan Medicaid	$2.50
Rate for Payer: Ohana Health Plan Medicare	$3.28
Rate for Payer: UnitedHealthcare Medicaid	$2.50
Rate for Payer: UnitedHealthcare Medicare	$3.28

GLUCOSE QUANTITATIVE BLOOD XCPT REAGENT STRIP

Professional

Both

$8.00

Service Code	HCPCS 82947
Min. Negotiated Rate	$3.93
Max. Negotiated Rate	$6.80
Rate for Payer: AlohaCare Medicaid	$5.42
Rate for Payer: AlohaCare Medicare	$3.93
Rate for Payer: Cash Price	$5.20
Rate for Payer: Cash Price	$5.20
Rate for Payer: Devoted Health Medicare	$4.32
Rate for Payer: Hawaii Medical Service Association Medicare	$3.93
Rate for Payer: Hawaii Western Management Group Commercial	$5.43
Rate for Payer: Health Management Network Commercial	$6.80
Rate for Payer: Kaiser Permanente Commercial	$4.72
Rate for Payer: Kaiser Permanente Medicaid	$4.72
Rate for Payer: Kaiser Permanente Medicare	$4.72
Rate for Payer: Ohana Health Plan Medicaid	$5.42
Rate for Payer: Ohana Health Plan Medicare	$3.93
Rate for Payer: UnitedHealthcare Medicaid	$5.42
Rate for Payer: UnitedHealthcare Medicare	$3.93

Know your out-of-pocket cost for care.

All Charges