Kona Community Hospital

All Charges

Charge

Type

Setting

Price

ALTERATION IN CONSCIOUSNESS

Facility

$9,301.14

Service Code	APR-DRG 0524
Min. Negotiated Rate	$9,301.14
Max. Negotiated Rate	$9,301.14
Rate for Payer: AlohaCare Medicaid	$9,301.14
Rate for Payer: Hawaii Medical Service Association ABD	$9,301.14
Rate for Payer: Hawaii Medical Service Association Non-ABD	$9,301.14
Rate for Payer: Kaiser Permanente Medicaid	$9,301.14
Rate for Payer: Ohana Health Plan Medicaid	$9,301.14
Rate for Payer: UnitedHealthcare Medicaid	$9,301.14

ALTERATION IN CONSCIOUSNESS

Facility

$4,400.95

Service Code	APR-DRG 0523
Min. Negotiated Rate	$4,400.95
Max. Negotiated Rate	$4,400.95
Rate for Payer: AlohaCare Medicaid	$4,400.95
Rate for Payer: Hawaii Medical Service Association ABD	$4,400.95
Rate for Payer: Hawaii Medical Service Association Non-ABD	$4,400.95
Rate for Payer: Kaiser Permanente Medicaid	$4,400.95
Rate for Payer: Ohana Health Plan Medicaid	$4,400.95
Rate for Payer: UnitedHealthcare Medicaid	$4,400.95

ALTERATION IN CONSCIOUSNESS

Facility

$3,393.52

Service Code	APR-DRG 0522
Min. Negotiated Rate	$3,393.52
Max. Negotiated Rate	$3,393.52
Rate for Payer: AlohaCare Medicaid	$3,393.52
Rate for Payer: Hawaii Medical Service Association ABD	$3,393.52
Rate for Payer: Hawaii Medical Service Association Non-ABD	$3,393.52
Rate for Payer: Kaiser Permanente Medicaid	$3,393.52
Rate for Payer: Ohana Health Plan Medicaid	$3,393.52
Rate for Payer: UnitedHealthcare Medicaid	$3,393.52

ALTERATION IN CONSCIOUSNESS

Facility

$2,933.75

Service Code	APR-DRG 0521
Min. Negotiated Rate	$2,933.75
Max. Negotiated Rate	$2,933.75
Rate for Payer: AlohaCare Medicaid	$2,933.75
Rate for Payer: Hawaii Medical Service Association ABD	$2,933.75
Rate for Payer: Hawaii Medical Service Association Non-ABD	$2,933.75
Rate for Payer: Kaiser Permanente Medicaid	$2,933.75
Rate for Payer: Ohana Health Plan Medicaid	$2,933.75
Rate for Payer: UnitedHealthcare Medicaid	$2,933.75

Altivate Anat Ag,Peg Glenoid Sz 50 Hw5 Rt [3643616]

Facility

$10,080.00

Service Code	HCPCS C1776
Hospital Charge Code	3643616
Hospital Revenue Code	278
Min. Negotiated Rate	$5,140.80
Max. Negotiated Rate	$9,777.60
Rate for Payer: Cash Price	$6,552.00
Rate for Payer: Hawaii Western Management Group Commercial	$7,056.00
Rate for Payer: Health Management Network Commercial	$8,568.00
Rate for Payer: Kaiser Permanente Commercial	$6,350.40
Rate for Payer: Kaiser Permanente Medicaid	$5,140.80
Rate for Payer: MDX Hawaii PPO	$9,777.60
Rate for Payer: University Health Alliance Commercial	$5,644.80

Altivate Anat Ag,Peg Glenoid Sz 50 Hw5 Rt [3643616]

Facility

$10,080.00

Service Code	HCPCS C1776
Hospital Charge Code	3643616
Hospital Revenue Code	278
Min. Negotiated Rate	$5,644.80
Max. Negotiated Rate	$9,777.60
Rate for Payer: Cash Price	$6,552.00
Rate for Payer: Hawaii Western Management Group Commercial	$7,056.00
Rate for Payer: Health Management Network Commercial	$8,568.00
Rate for Payer: MDX Hawaii PPO	$9,777.60
Rate for Payer: University Health Alliance Commercial	$5,644.80

ALUM-MAG HYDROXIDE-SIMETH 400-400-40 MG/5 ML PO SUSP

Facility

$4.48

Service Code	HCPCS A9270
Hospital Revenue Code	250
Min. Negotiated Rate	$3.81
Max. Negotiated Rate	$4.35
Rate for Payer: Cash Price	$2.91
Rate for Payer: Cash Price	$16.26
Rate for Payer: Health Management Network Commercial	$21.26
Rate for Payer: Health Management Network Commercial	$3.81
Rate for Payer: MDX Hawaii PPO	$4.35
Rate for Payer: MDX Hawaii PPO	$24.26

ALUM-MAG HYDROXIDE-SIMETH 400-400-40 MG/5 ML PO SUSP

Facility

$25.01

Service Code	HCPCS A9270
Hospital Revenue Code	250
Min. Negotiated Rate	$12.76
Max. Negotiated Rate	$24.26
Rate for Payer: Cash Price	$16.26
Rate for Payer: Cash Price	$2.91
Rate for Payer: Hawaii Western Management Group Commercial	$23.76
Rate for Payer: Hawaii Western Management Group Commercial	$4.26
Rate for Payer: Health Management Network Commercial	$21.26
Rate for Payer: Health Management Network Commercial	$3.81
Rate for Payer: Kaiser Permanente Commercial	$15.76
Rate for Payer: Kaiser Permanente Commercial	$2.82
Rate for Payer: Kaiser Permanente Medicaid	$12.76
Rate for Payer: Kaiser Permanente Medicaid	$2.28
Rate for Payer: MDX Hawaii PPO	$24.26
Rate for Payer: MDX Hawaii PPO	$4.35
Rate for Payer: UnitedHealthcare Medicaid	$2.69
Rate for Payer: UnitedHealthcare Medicaid	$15.01
Rate for Payer: University Health Alliance Commercial	$18.23
Rate for Payer: University Health Alliance Commercial	$3.27

AM100 ActiveMatrix Placental Tissue Allograft Lrg [3643019]

Facility

$12,689.00

Service Code	HCPCS C1762
Hospital Charge Code	3643019
Hospital Revenue Code	278
Min. Negotiated Rate	$6,471.39
Max. Negotiated Rate	$12,308.33
Rate for Payer: Cash Price	$8,247.85
Rate for Payer: Hawaii Western Management Group Commercial	$8,882.30
Rate for Payer: Health Management Network Commercial	$10,785.65
Rate for Payer: Kaiser Permanente Commercial	$7,994.07
Rate for Payer: Kaiser Permanente Medicaid	$6,471.39
Rate for Payer: MDX Hawaii PPO	$12,308.33
Rate for Payer: University Health Alliance Commercial	$7,105.84

AM100 ActiveMatrix Placental Tissue Allograft Lrg [3643019]

Facility

$12,689.00

Service Code	HCPCS C1762
Hospital Charge Code	3643019
Hospital Revenue Code	278
Min. Negotiated Rate	$7,105.84
Max. Negotiated Rate	$12,308.33
Rate for Payer: Cash Price	$8,247.85
Rate for Payer: Hawaii Western Management Group Commercial	$8,882.30
Rate for Payer: Health Management Network Commercial	$10,785.65
Rate for Payer: MDX Hawaii PPO	$12,308.33
Rate for Payer: University Health Alliance Commercial	$7,105.84

AM200 ActiveMatrix Placental Tissue Allograft XXL [3642337]

Facility

$16,416.50

Service Code	HCPCS C1762
Hospital Charge Code	3642337
Hospital Revenue Code	278
Min. Negotiated Rate	$9,193.24
Max. Negotiated Rate	$15,924.00
Rate for Payer: Cash Price	$10,670.72
Rate for Payer: Hawaii Western Management Group Commercial	$11,491.55
Rate for Payer: Health Management Network Commercial	$13,954.02
Rate for Payer: MDX Hawaii PPO	$15,924.00
Rate for Payer: University Health Alliance Commercial	$9,193.24

AM200 ActiveMatrix Placental Tissue Allograft XXL [3642337]

Facility

$16,416.50

Service Code	HCPCS C1762
Hospital Charge Code	3642337
Hospital Revenue Code	278
Min. Negotiated Rate	$8,372.42
Max. Negotiated Rate	$15,924.00
Rate for Payer: Cash Price	$10,670.72
Rate for Payer: Hawaii Western Management Group Commercial	$11,491.55
Rate for Payer: Health Management Network Commercial	$13,954.02
Rate for Payer: Kaiser Permanente Commercial	$10,342.40
Rate for Payer: Kaiser Permanente Medicaid	$8,372.42
Rate for Payer: MDX Hawaii PPO	$15,924.00
Rate for Payer: University Health Alliance Commercial	$9,193.24

AMANTADINE HCL 100 MG PO CAP

Facility

$19.23

Service Code	HCPCS A9270
Hospital Revenue Code	250
Min. Negotiated Rate	$16.35
Max. Negotiated Rate	$18.65
Rate for Payer: Cash Price	$12.50
Rate for Payer: Health Management Network Commercial	$16.35
Rate for Payer: MDX Hawaii PPO	$18.65

AMANTADINE HCL 100 MG PO CAP

Facility

$19.23

Service Code	HCPCS A9270
Hospital Revenue Code	250
Min. Negotiated Rate	$9.81
Max. Negotiated Rate	$18.65
Rate for Payer: Cash Price	$12.50
Rate for Payer: Hawaii Western Management Group Commercial	$18.27
Rate for Payer: Health Management Network Commercial	$16.35
Rate for Payer: Kaiser Permanente Commercial	$12.11
Rate for Payer: Kaiser Permanente Medicaid	$9.81
Rate for Payer: MDX Hawaii PPO	$18.65
Rate for Payer: UnitedHealthcare Medicaid	$11.54
Rate for Payer: University Health Alliance Commercial	$14.02

AMANTADINE HCL 50 MG/5 ML PO SOLN

Facility

$27.27

Service Code	HCPCS A9270
Hospital Revenue Code	250
Min. Negotiated Rate	$13.91
Max. Negotiated Rate	$26.45
Rate for Payer: Cash Price	$17.73
Rate for Payer: Hawaii Western Management Group Commercial	$25.91
Rate for Payer: Health Management Network Commercial	$23.18
Rate for Payer: Kaiser Permanente Commercial	$17.18
Rate for Payer: Kaiser Permanente Medicaid	$13.91
Rate for Payer: MDX Hawaii PPO	$26.45
Rate for Payer: UnitedHealthcare Medicaid	$16.36
Rate for Payer: University Health Alliance Commercial	$19.88

AMANTADINE HCL 50 MG/5 ML PO SOLN

Facility

$27.27

Service Code	HCPCS A9270
Hospital Revenue Code	250
Min. Negotiated Rate	$23.18
Max. Negotiated Rate	$26.45
Rate for Payer: Cash Price	$17.73
Rate for Payer: Health Management Network Commercial	$23.18
Rate for Payer: MDX Hawaii PPO	$26.45

Ambu Bag Child [2709897]

Facility

$164.56

Hospital Charge Code	2709897
Hospital Revenue Code	272
Min. Negotiated Rate	$139.88
Max. Negotiated Rate	$159.62
Rate for Payer: Cash Price	$106.96
Rate for Payer: Health Management Network Commercial	$139.88
Rate for Payer: MDX Hawaii PPO	$159.62

Ambu Bag Child [2709897]

Facility

$164.56

Hospital Charge Code	2709897
Hospital Revenue Code	272
Min. Negotiated Rate	$83.93
Max. Negotiated Rate	$159.62
Rate for Payer: Cash Price	$106.96
Rate for Payer: Hawaii Western Management Group Commercial	$156.33
Rate for Payer: Health Management Network Commercial	$139.88
Rate for Payer: Kaiser Permanente Commercial	$103.67
Rate for Payer: Kaiser Permanente Medicaid	$83.93
Rate for Payer: MDX Hawaii PPO	$159.62
Rate for Payer: University Health Alliance Commercial	$119.95

AMBUL BAG ADULT [2700090]

Facility

$59.84

Hospital Charge Code	2700090
Hospital Revenue Code	272
Min. Negotiated Rate	$50.86
Max. Negotiated Rate	$58.04
Rate for Payer: Cash Price	$38.90
Rate for Payer: Health Management Network Commercial	$50.86
Rate for Payer: MDX Hawaii PPO	$58.04

AMBUL BAG ADULT [2700090]

Facility

$59.84

Hospital Charge Code	2700090
Hospital Revenue Code	272
Min. Negotiated Rate	$30.52
Max. Negotiated Rate	$58.04
Rate for Payer: Cash Price	$38.90
Rate for Payer: Hawaii Western Management Group Commercial	$56.85
Rate for Payer: Health Management Network Commercial	$50.86
Rate for Payer: Kaiser Permanente Commercial	$37.70
Rate for Payer: Kaiser Permanente Medicaid	$30.52
Rate for Payer: MDX Hawaii PPO	$58.04
Rate for Payer: University Health Alliance Commercial	$43.62

AMIKACIN 500 MG/2 ML (250 MG/ML) INJ SOLN FOR OTHER USE

Facility

$45.87

Service Code	NDC 23155029031
Hospital Revenue Code	250
Min. Negotiated Rate	$23.39
Max. Negotiated Rate	$44.49
Rate for Payer: Cash Price	$29.82
Rate for Payer: Hawaii Western Management Group Commercial	$43.58
Rate for Payer: Health Management Network Commercial	$38.99
Rate for Payer: Kaiser Permanente Commercial	$28.90
Rate for Payer: Kaiser Permanente Medicaid	$23.39
Rate for Payer: MDX Hawaii PPO	$44.49
Rate for Payer: UnitedHealthcare Medicaid	$27.52
Rate for Payer: University Health Alliance Commercial	$33.43

AMIKACIN 500 MG/2 ML (250 MG/ML) INJ SOLN FOR OTHER USE

Facility

$48.29

Service Code	NDC 00641616701
Hospital Revenue Code	250
Min. Negotiated Rate	$41.05
Max. Negotiated Rate	$46.84
Rate for Payer: Cash Price	$31.39
Rate for Payer: Health Management Network Commercial	$41.05
Rate for Payer: MDX Hawaii PPO	$46.84

AMIKACIN 500 MG/2 ML (250 MG/ML) INJ SOLN FOR OTHER USE

Facility

$48.29

Service Code	NDC 00641616710
Hospital Revenue Code	250
Min. Negotiated Rate	$41.05
Max. Negotiated Rate	$46.84
Rate for Payer: Cash Price	$31.39
Rate for Payer: Health Management Network Commercial	$41.05
Rate for Payer: MDX Hawaii PPO	$46.84

AMIKACIN 500 MG/2 ML (250 MG/ML) INJ SOLN FOR OTHER USE

Facility

$48.29

Service Code	NDC 00641616701
Hospital Revenue Code	250
Min. Negotiated Rate	$24.63
Max. Negotiated Rate	$46.84
Rate for Payer: Cash Price	$31.39
Rate for Payer: Hawaii Western Management Group Commercial	$45.88
Rate for Payer: Health Management Network Commercial	$41.05
Rate for Payer: Kaiser Permanente Commercial	$30.42
Rate for Payer: Kaiser Permanente Medicaid	$24.63
Rate for Payer: MDX Hawaii PPO	$46.84
Rate for Payer: UnitedHealthcare Medicaid	$28.97
Rate for Payer: University Health Alliance Commercial	$35.20

AMIKACIN 500 MG/2 ML (250 MG/ML) INJ SOLN FOR OTHER USE

Facility

$48.29

Service Code	NDC 00641616710
Hospital Revenue Code	250
Min. Negotiated Rate	$24.63
Max. Negotiated Rate	$46.84
Rate for Payer: Cash Price	$31.39
Rate for Payer: Hawaii Western Management Group Commercial	$45.88
Rate for Payer: Health Management Network Commercial	$41.05
Rate for Payer: Kaiser Permanente Commercial	$30.42
Rate for Payer: Kaiser Permanente Medicaid	$24.63
Rate for Payer: MDX Hawaii PPO	$46.84
Rate for Payer: UnitedHealthcare Medicaid	$28.97
Rate for Payer: University Health Alliance Commercial	$35.20

Know your out-of-pocket cost for care.

All Charges