Kona Community Hospital

All Charges

Charge

Type

Setting

Price

GLYBURIDE 5 MG PO TABLET

Facility

$4.29

Service Code	HCPCS A9270
Hospital Revenue Code	250
Min. Negotiated Rate	$2.19
Max. Negotiated Rate	$4.16
Rate for Payer: Cash Price	$2.79
Rate for Payer: Hawaii Western Management Group Commercial	$4.08
Rate for Payer: Health Management Network Commercial	$3.65
Rate for Payer: Kaiser Permanente Commercial	$2.70
Rate for Payer: Kaiser Permanente Medicaid	$2.19
Rate for Payer: MDX Hawaii PPO	$4.16
Rate for Payer: UnitedHealthcare Medicaid	$2.57
Rate for Payer: University Health Alliance Commercial	$3.13

GLYBURIDE 5 MG PO TABLET

Facility

$4.29

Service Code	HCPCS A9270
Hospital Revenue Code	250
Min. Negotiated Rate	$3.65
Max. Negotiated Rate	$4.16
Rate for Payer: Cash Price	$2.79
Rate for Payer: Health Management Network Commercial	$3.65
Rate for Payer: MDX Hawaii PPO	$4.16

GLYCERIN (ADULT) PR SUPP

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

GLYCERIN (ADULT) PR SUPP

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

GLYCERIN (CHILD) 1.2 G PR SUPP

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

GLYCERIN (CHILD) 1.2 G PR SUPP

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

GLYCOPYRROLATE 0.2 MG/ML INJ SOLN

Facility

$57.96

Service Code	HCPCS J1596
Hospital Revenue Code	250
Min. Negotiated Rate	$49.27
Max. Negotiated Rate	$56.22
Rate for Payer: Cash Price	$37.67
Rate for Payer: Cash Price	$132.19
Rate for Payer: Cash Price	$14.35
Rate for Payer: Health Management Network Commercial	$49.27
Rate for Payer: Health Management Network Commercial	$18.77
Rate for Payer: Health Management Network Commercial	$172.86
Rate for Payer: MDX Hawaii PPO	$197.27
Rate for Payer: MDX Hawaii PPO	$21.42
Rate for Payer: MDX Hawaii PPO	$56.22

GLYCOPYRROLATE 0.2 MG/ML INJ SOLN

Facility

$203.37

Service Code	HCPCS J1596
Hospital Revenue Code	636
Min. Negotiated Rate	$0.43
Max. Negotiated Rate	$197.27
Rate for Payer: Cash Price	$132.19
Rate for Payer: Cash Price	$14.35
Rate for Payer: Cash Price	$37.67
Rate for Payer: Cash Price	$132.19
Rate for Payer: Cash Price	$37.67
Rate for Payer: Cash Price	$14.35
Rate for Payer: Hawaii Medical Service Association ABD	$0.43
Rate for Payer: Hawaii Medical Service Association ABD	$0.43
Rate for Payer: Hawaii Medical Service Association ABD	$0.43
Rate for Payer: Hawaii Medical Service Association Non-ABD	$0.43
Rate for Payer: Hawaii Medical Service Association Non-ABD	$0.43
Rate for Payer: Hawaii Medical Service Association Non-ABD	$0.43
Rate for Payer: Hawaii Western Management Group Commercial	$20.98
Rate for Payer: Hawaii Western Management Group Commercial	$193.20
Rate for Payer: Hawaii Western Management Group Commercial	$55.06
Rate for Payer: Health Management Network Commercial	$49.27
Rate for Payer: Health Management Network Commercial	$172.86
Rate for Payer: Health Management Network Commercial	$18.77
Rate for Payer: Kaiser Permanente Commercial	$36.51
Rate for Payer: Kaiser Permanente Commercial	$13.91
Rate for Payer: Kaiser Permanente Commercial	$128.12
Rate for Payer: Kaiser Permanente Medicaid	$103.72
Rate for Payer: Kaiser Permanente Medicaid	$29.56
Rate for Payer: Kaiser Permanente Medicaid	$11.26
Rate for Payer: MDX Hawaii PPO	$56.22
Rate for Payer: MDX Hawaii PPO	$21.42
Rate for Payer: MDX Hawaii PPO	$197.27
Rate for Payer: UnitedHealthcare Medicaid	$122.02
Rate for Payer: UnitedHealthcare Medicaid	$13.25
Rate for Payer: UnitedHealthcare Medicaid	$34.78
Rate for Payer: University Health Alliance Commercial	$16.09
Rate for Payer: University Health Alliance Commercial	$148.24
Rate for Payer: University Health Alliance Commercial	$42.25

GLYCOPYRROLATE 1 MG PO TABLET

Facility

$7.30

Service Code	HCPCS A9270
Hospital Revenue Code	250
Min. Negotiated Rate	$6.21
Max. Negotiated Rate	$7.08
Rate for Payer: Cash Price	$4.74
Rate for Payer: Cash Price	$5.24
Rate for Payer: Cash Price	$3.89
Rate for Payer: Health Management Network Commercial	$5.08
Rate for Payer: Health Management Network Commercial	$6.21
Rate for Payer: Health Management Network Commercial	$6.85
Rate for Payer: MDX Hawaii PPO	$5.80
Rate for Payer: MDX Hawaii PPO	$7.82
Rate for Payer: MDX Hawaii PPO	$7.08

GLYCOPYRROLATE 1 MG PO TABLET

Facility

$7.30

Service Code	HCPCS A9270
Hospital Revenue Code	250
Min. Negotiated Rate	$3.72
Max. Negotiated Rate	$7.08
Rate for Payer: Cash Price	$4.74
Rate for Payer: Cash Price	$3.89
Rate for Payer: Cash Price	$5.24
Rate for Payer: Hawaii Western Management Group Commercial	$5.68
Rate for Payer: Hawaii Western Management Group Commercial	$7.66
Rate for Payer: Hawaii Western Management Group Commercial	$6.93
Rate for Payer: Health Management Network Commercial	$6.85
Rate for Payer: Health Management Network Commercial	$5.08
Rate for Payer: Health Management Network Commercial	$6.21
Rate for Payer: Kaiser Permanente Commercial	$3.77
Rate for Payer: Kaiser Permanente Commercial	$4.60
Rate for Payer: Kaiser Permanente Commercial	$5.08
Rate for Payer: Kaiser Permanente Medicaid	$4.11
Rate for Payer: Kaiser Permanente Medicaid	$3.72
Rate for Payer: Kaiser Permanente Medicaid	$3.05
Rate for Payer: MDX Hawaii PPO	$7.82
Rate for Payer: MDX Hawaii PPO	$5.80
Rate for Payer: MDX Hawaii PPO	$7.08
Rate for Payer: UnitedHealthcare Medicaid	$4.38
Rate for Payer: UnitedHealthcare Medicaid	$3.59
Rate for Payer: UnitedHealthcare Medicaid	$4.84
Rate for Payer: University Health Alliance Commercial	$5.87
Rate for Payer: University Health Alliance Commercial	$4.36
Rate for Payer: University Health Alliance Commercial	$5.32

GONADOTROPIN CHORIONIC QUALITATIVE

Professional

Both

$15.00

Service Code	HCPCS 84703
Min. Negotiated Rate	$7.52
Max. Negotiated Rate	$14.50
Rate for Payer: AlohaCare Medicaid	$10.38
Rate for Payer: AlohaCare Medicare	$7.52
Rate for Payer: Cash Price	$9.75
Rate for Payer: Cash Price	$9.75
Rate for Payer: Devoted Health Medicare	$8.27
Rate for Payer: Hawaii Medical Service Association Medicare	$7.52
Rate for Payer: Hawaii Western Management Group Commercial	$14.50
Rate for Payer: Health Management Network Commercial	$12.75
Rate for Payer: Kaiser Permanente Commercial	$9.02
Rate for Payer: Kaiser Permanente Medicaid	$9.02
Rate for Payer: Kaiser Permanente Medicare	$9.02
Rate for Payer: Ohana Health Plan Medicaid	$10.38
Rate for Payer: Ohana Health Plan Medicare	$7.52
Rate for Payer: UnitedHealthcare Medicaid	$10.38
Rate for Payer: UnitedHealthcare Medicare	$7.52

GONADOTROPIN CHORIONIC QUANTITATIVE

Professional

Both

$30.00

Service Code	HCPCS 84702
Min. Negotiated Rate	$15.05
Max. Negotiated Rate	$25.50
Rate for Payer: AlohaCare Medicaid	$20.80
Rate for Payer: AlohaCare Medicare	$15.05
Rate for Payer: Cash Price	$19.50
Rate for Payer: Cash Price	$19.50
Rate for Payer: Devoted Health Medicare	$16.55
Rate for Payer: Hawaii Medical Service Association Medicare	$15.05
Rate for Payer: Hawaii Western Management Group Commercial	$20.80
Rate for Payer: Health Management Network Commercial	$25.50
Rate for Payer: Kaiser Permanente Commercial	$18.06
Rate for Payer: Kaiser Permanente Medicaid	$18.06
Rate for Payer: Kaiser Permanente Medicare	$18.06
Rate for Payer: Ohana Health Plan Medicaid	$20.80
Rate for Payer: Ohana Health Plan Medicare	$15.05
Rate for Payer: UnitedHealthcare Medicaid	$20.80
Rate for Payer: UnitedHealthcare Medicare	$15.05

GONADOTROPIN FOLLICLE STIMULATING HORMONE

Professional

Both

$37.00

Service Code	HCPCS 83001
Min. Negotiated Rate	$18.58
Max. Negotiated Rate	$31.45
Rate for Payer: AlohaCare Medicaid	$25.69
Rate for Payer: AlohaCare Medicare	$18.58
Rate for Payer: Cash Price	$24.05
Rate for Payer: Cash Price	$24.05
Rate for Payer: Devoted Health Medicare	$20.44
Rate for Payer: Hawaii Medical Service Association Medicare	$18.58
Rate for Payer: Hawaii Western Management Group Commercial	$25.70
Rate for Payer: Health Management Network Commercial	$31.45
Rate for Payer: Kaiser Permanente Commercial	$22.30
Rate for Payer: Kaiser Permanente Medicaid	$22.30
Rate for Payer: Kaiser Permanente Medicare	$22.30
Rate for Payer: Ohana Health Plan Medicaid	$25.69
Rate for Payer: Ohana Health Plan Medicare	$18.58
Rate for Payer: UnitedHealthcare Medicaid	$25.69
Rate for Payer: UnitedHealthcare Medicare	$18.58

GONADOTROPIN LUTEINIZING HORMONE

Professional

Both

$37.00

Service Code	HCPCS 83002
Min. Negotiated Rate	$18.52
Max. Negotiated Rate	$31.45
Rate for Payer: AlohaCare Medicaid	$25.60
Rate for Payer: AlohaCare Medicare	$18.52
Rate for Payer: Cash Price	$24.05
Rate for Payer: Cash Price	$24.05
Rate for Payer: Devoted Health Medicare	$20.37
Rate for Payer: Hawaii Medical Service Association Medicare	$18.52
Rate for Payer: Hawaii Western Management Group Commercial	$25.60
Rate for Payer: Health Management Network Commercial	$31.45
Rate for Payer: Kaiser Permanente Commercial	$22.22
Rate for Payer: Kaiser Permanente Medicaid	$22.22
Rate for Payer: Kaiser Permanente Medicare	$22.22
Rate for Payer: Ohana Health Plan Medicaid	$25.60
Rate for Payer: Ohana Health Plan Medicare	$18.52
Rate for Payer: UnitedHealthcare Medicaid	$25.60
Rate for Payer: UnitedHealthcare Medicare	$18.52

GOSERELIN 10.8 MG SUBCUTANEOUS IMPLANT

Facility

$4,829.16

Service Code	HCPCS J9202
Hospital Revenue Code	250
Min. Negotiated Rate	$4,104.79
Max. Negotiated Rate	$4,684.29
Rate for Payer: Cash Price	$3,138.95
Rate for Payer: Health Management Network Commercial	$4,104.79
Rate for Payer: MDX Hawaii PPO	$4,684.29

GOSERELIN 10.8 MG SUBCUTANEOUS IMPLANT

Facility

$4,829.16

Service Code	HCPCS J9202
Hospital Revenue Code	636
Min. Negotiated Rate	$734.15
Max. Negotiated Rate	$4,684.29
Rate for Payer: Cash Price	$3,138.95
Rate for Payer: Cash Price	$3,138.95
Rate for Payer: Hawaii Medical Service Association ABD	$734.15
Rate for Payer: Hawaii Medical Service Association Non-ABD	$734.15
Rate for Payer: Hawaii Western Management Group Commercial	$4,587.70
Rate for Payer: Health Management Network Commercial	$4,104.79
Rate for Payer: Kaiser Permanente Commercial	$3,042.37
Rate for Payer: Kaiser Permanente Medicaid	$2,462.87
Rate for Payer: MDX Hawaii PPO	$4,684.29
Rate for Payer: UnitedHealthcare Medicaid	$2,897.50
Rate for Payer: University Health Alliance Commercial	$3,519.97

GOSERELIN 3.6 MG SUBCUTANEOUS IMPLANT

Facility

$2,467.14

Service Code	HCPCS J9202
Hospital Revenue Code	636
Min. Negotiated Rate	$734.15
Max. Negotiated Rate	$2,393.13
Rate for Payer: Cash Price	$1,603.64
Rate for Payer: Cash Price	$1,603.64
Rate for Payer: Hawaii Medical Service Association ABD	$734.15
Rate for Payer: Hawaii Medical Service Association Non-ABD	$734.15
Rate for Payer: Hawaii Western Management Group Commercial	$2,343.78
Rate for Payer: Health Management Network Commercial	$2,097.07
Rate for Payer: Kaiser Permanente Commercial	$1,554.30
Rate for Payer: Kaiser Permanente Medicaid	$1,258.24
Rate for Payer: MDX Hawaii PPO	$2,393.13
Rate for Payer: UnitedHealthcare Medicaid	$1,480.28
Rate for Payer: University Health Alliance Commercial	$1,798.30

GOSERELIN 3.6 MG SUBCUTANEOUS IMPLANT

Facility

$2,467.14

Service Code	HCPCS J9202
Hospital Revenue Code	250
Min. Negotiated Rate	$2,097.07
Max. Negotiated Rate	$2,393.13
Rate for Payer: Cash Price	$1,603.64
Rate for Payer: Health Management Network Commercial	$2,097.07
Rate for Payer: MDX Hawaii PPO	$2,393.13

GOSERELIN ACETATE IMPLANT PER 3.6 MG

Professional

Both

$1,630.00

Service Code	HCPCS J9202
Min. Negotiated Rate	$443.00
Max. Negotiated Rate	$1,385.50
Rate for Payer: Cash Price	$1,059.50
Rate for Payer: Cash Price	$1,059.50
Rate for Payer: Hawaii Western Management Group Commercial	$443.00
Rate for Payer: Health Management Network Commercial	$1,385.50

GPS Cannula 100mm 75000100 [3644265]

Facility

$2,598.75

Hospital Charge Code	3644265
Hospital Revenue Code	272
Min. Negotiated Rate	$2,208.94
Max. Negotiated Rate	$2,520.79
Rate for Payer: Cash Price	$1,689.19
Rate for Payer: Health Management Network Commercial	$2,208.94
Rate for Payer: MDX Hawaii PPO	$2,520.79

GPS Cannula 100mm 75000100 [3644265]

Facility

$2,598.75

Hospital Charge Code	3644265
Hospital Revenue Code	272
Min. Negotiated Rate	$1,325.36
Max. Negotiated Rate	$2,520.79
Rate for Payer: Cash Price	$1,689.19
Rate for Payer: Hawaii Western Management Group Commercial	$2,468.81
Rate for Payer: Health Management Network Commercial	$2,208.94
Rate for Payer: Kaiser Permanente Commercial	$1,637.21
Rate for Payer: Kaiser Permanente Medicaid	$1,325.36
Rate for Payer: MDX Hawaii PPO	$2,520.79
Rate for Payer: University Health Alliance Commercial	$1,894.23

Grafix PL Prime Placental Membrane 5 x 5cm PS13055 [3644307]

Facility

$10,953.00

Service Code	HCPCS Q4133
Hospital Charge Code	3644307
Hospital Revenue Code	278
Min. Negotiated Rate	$102.14
Max. Negotiated Rate	$10,624.41
Rate for Payer: AlohaCare Medicaid	$147.01
Rate for Payer: AlohaCare Medicare	$147.01
Rate for Payer: Cash Price	$7,119.45
Rate for Payer: Cash Price	$7,119.45
Rate for Payer: Devoted Health Medicare	$161.71
Rate for Payer: Hawaii Medical Service Association ABD	$136.18
Rate for Payer: Hawaii Medical Service Association Commercial	$183.76
Rate for Payer: Hawaii Medical Service Association Medicare	$147.01
Rate for Payer: Hawaii Medical Service Association Non-ABD	$136.18
Rate for Payer: Hawaii Western Management Group Commercial	$7,667.10
Rate for Payer: Health Management Network Commercial	$9,310.05
Rate for Payer: Humana Medicare	$147.01
Rate for Payer: Kaiser Permanente Commercial	$6,900.39
Rate for Payer: Kaiser Permanente Medicaid	$5,586.03
Rate for Payer: Kaiser Permanente Medicare	$147.01
Rate for Payer: MDX Hawaii PPO	$10,624.41
Rate for Payer: Ohana Health Plan Medicaid	$161.71
Rate for Payer: Ohana Health Plan Medicare	$147.01
Rate for Payer: UnitedHealthcare Medicaid	$102.14
Rate for Payer: UnitedHealthcare Medicare	$147.01
Rate for Payer: University Health Alliance Commercial	$6,133.68

Grafix PL Prime Placental Membrane 5 x 5cm PS13055 [3644307]

Facility

$10,953.00

Service Code	HCPCS Q4133
Hospital Charge Code	3644307
Hospital Revenue Code	278
Min. Negotiated Rate	$6,133.68
Max. Negotiated Rate	$10,624.41
Rate for Payer: Cash Price	$7,119.45
Rate for Payer: Hawaii Western Management Group Commercial	$7,667.10
Rate for Payer: Health Management Network Commercial	$9,310.05
Rate for Payer: MDX Hawaii PPO	$10,624.41
Rate for Payer: University Health Alliance Commercial	$6,133.68

Graft Allomax 7 X 10cm 1180710M [3600556]

Facility

$10,249.50

Service Code	HCPCS C1781
Hospital Charge Code	3600556
Hospital Revenue Code	278
Min. Negotiated Rate	$5,739.72
Max. Negotiated Rate	$9,942.01
Rate for Payer: Cash Price	$6,662.18
Rate for Payer: Hawaii Western Management Group Commercial	$7,174.65
Rate for Payer: Health Management Network Commercial	$8,712.08
Rate for Payer: MDX Hawaii PPO	$9,942.01
Rate for Payer: University Health Alliance Commercial	$5,739.72

Graft Allomax 7 X 10cm 1180710M [3600556]

Facility

$10,249.50

Service Code	HCPCS C1781
Hospital Charge Code	3600556
Hospital Revenue Code	278
Min. Negotiated Rate	$5,227.24
Max. Negotiated Rate	$9,942.01
Rate for Payer: Cash Price	$6,662.18
Rate for Payer: Hawaii Western Management Group Commercial	$7,174.65
Rate for Payer: Health Management Network Commercial	$8,712.08
Rate for Payer: Kaiser Permanente Commercial	$6,457.19
Rate for Payer: Kaiser Permanente Medicaid	$5,227.24
Rate for Payer: MDX Hawaii PPO	$9,942.01
Rate for Payer: University Health Alliance Commercial	$5,739.72

Know your out-of-pocket cost for care.

All Charges