Kona Community Hospital

All Charges

Charge

Type

Setting

Price

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 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

$45.87

Service Code	NDC 23155029041
Hospital Revenue Code	250
Min. Negotiated Rate	$38.99
Max. Negotiated Rate	$44.49
Rate for Payer: Cash Price	$29.82
Rate for Payer: Health Management Network Commercial	$38.99
Rate for Payer: MDX Hawaii PPO	$44.49

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

Facility

$47.08

Service Code	NDC 25021017302
Hospital Revenue Code	250
Min. Negotiated Rate	$24.01
Max. Negotiated Rate	$45.67
Rate for Payer: Cash Price	$30.60
Rate for Payer: Hawaii Western Management Group Commercial	$44.73
Rate for Payer: Health Management Network Commercial	$40.02
Rate for Payer: Kaiser Permanente Commercial	$29.66
Rate for Payer: Kaiser Permanente Medicaid	$24.01
Rate for Payer: MDX Hawaii PPO	$45.67
Rate for Payer: UnitedHealthcare Medicaid	$28.25
Rate for Payer: University Health Alliance Commercial	$34.32

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 INJ SOLN

Facility

$48.29

Service Code	HCPCS J0278
Hospital Revenue Code	250
Min. Negotiated Rate	$41.05
Max. Negotiated Rate	$46.84
Rate for Payer: Cash Price	$31.39
Rate for Payer: Cash Price	$29.82
Rate for Payer: Cash Price	$30.60
Rate for Payer: Health Management Network Commercial	$41.05
Rate for Payer: Health Management Network Commercial	$40.02
Rate for Payer: Health Management Network Commercial	$38.99
Rate for Payer: MDX Hawaii PPO	$44.49
Rate for Payer: MDX Hawaii PPO	$45.67
Rate for Payer: MDX Hawaii PPO	$46.84

AMIKACIN 500 MG/2 ML INJ SOLN

Facility

$45.87

Service Code	HCPCS J0278
Hospital Revenue Code	636
Min. Negotiated Rate	$0.62
Max. Negotiated Rate	$44.49
Rate for Payer: Cash Price	$29.82
Rate for Payer: Cash Price	$30.60
Rate for Payer: Cash Price	$31.39
Rate for Payer: Cash Price	$29.82
Rate for Payer: Cash Price	$31.39
Rate for Payer: Cash Price	$30.60
Rate for Payer: Hawaii Medical Service Association ABD	$0.62
Rate for Payer: Hawaii Medical Service Association ABD	$0.62
Rate for Payer: Hawaii Medical Service Association ABD	$0.62
Rate for Payer: Hawaii Medical Service Association Non-ABD	$0.62
Rate for Payer: Hawaii Medical Service Association Non-ABD	$0.62
Rate for Payer: Hawaii Medical Service Association Non-ABD	$0.62
Rate for Payer: Hawaii Western Management Group Commercial	$44.73
Rate for Payer: Hawaii Western Management Group Commercial	$43.58
Rate for Payer: Hawaii Western Management Group Commercial	$45.88
Rate for Payer: Health Management Network Commercial	$41.05
Rate for Payer: Health Management Network Commercial	$38.99
Rate for Payer: Health Management Network Commercial	$40.02
Rate for Payer: Kaiser Permanente Commercial	$30.42
Rate for Payer: Kaiser Permanente Commercial	$29.66
Rate for Payer: Kaiser Permanente Commercial	$28.90
Rate for Payer: Kaiser Permanente Medicaid	$23.39
Rate for Payer: Kaiser Permanente Medicaid	$24.63
Rate for Payer: Kaiser Permanente Medicaid	$24.01
Rate for Payer: MDX Hawaii PPO	$46.84
Rate for Payer: MDX Hawaii PPO	$45.67
Rate for Payer: MDX Hawaii PPO	$44.49
Rate for Payer: UnitedHealthcare Medicaid	$27.52
Rate for Payer: UnitedHealthcare Medicaid	$28.25
Rate for Payer: UnitedHealthcare Medicaid	$28.97
Rate for Payer: University Health Alliance Commercial	$34.32
Rate for Payer: University Health Alliance Commercial	$33.43
Rate for Payer: University Health Alliance Commercial	$35.20

AMINOCAPROIC ACID 250 MG/ML IV SOLN

Facility

$59.32

Service Code	HCPCS J0281
Hospital Revenue Code	636
Min. Negotiated Rate	$1.50
Max. Negotiated Rate	$57.54
Rate for Payer: Cash Price	$38.56
Rate for Payer: Cash Price	$26.12
Rate for Payer: Cash Price	$26.12
Rate for Payer: Cash Price	$38.56
Rate for Payer: Hawaii Medical Service Association ABD	$1.50
Rate for Payer: Hawaii Medical Service Association ABD	$1.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$1.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$1.50
Rate for Payer: Hawaii Western Management Group Commercial	$38.18
Rate for Payer: Hawaii Western Management Group Commercial	$56.35
Rate for Payer: Health Management Network Commercial	$50.42
Rate for Payer: Health Management Network Commercial	$34.16
Rate for Payer: Kaiser Permanente Commercial	$37.37
Rate for Payer: Kaiser Permanente Commercial	$25.32
Rate for Payer: Kaiser Permanente Medicaid	$20.50
Rate for Payer: Kaiser Permanente Medicaid	$30.25
Rate for Payer: MDX Hawaii PPO	$38.98
Rate for Payer: MDX Hawaii PPO	$57.54
Rate for Payer: UnitedHealthcare Medicaid	$35.59
Rate for Payer: UnitedHealthcare Medicaid	$24.11
Rate for Payer: University Health Alliance Commercial	$43.24
Rate for Payer: University Health Alliance Commercial	$29.29

AMINOCAPROIC ACID 250 MG/ML IV SOLN

Facility

$40.19

Service Code	HCPCS J0281
Hospital Revenue Code	250
Min. Negotiated Rate	$34.16
Max. Negotiated Rate	$38.98
Rate for Payer: Cash Price	$26.12
Rate for Payer: Cash Price	$38.56
Rate for Payer: Health Management Network Commercial	$34.16
Rate for Payer: Health Management Network Commercial	$50.42
Rate for Payer: MDX Hawaii PPO	$38.98
Rate for Payer: MDX Hawaii PPO	$57.54

AMINOPHYLLINE 250 MG/10 ML IV SOLN

Facility

$100.76

Service Code	HCPCS J0280
Hospital Revenue Code	636
Min. Negotiated Rate	$8.30
Max. Negotiated Rate	$97.74
Rate for Payer: Cash Price	$65.49
Rate for Payer: Cash Price	$65.49
Rate for Payer: Hawaii Medical Service Association ABD	$8.30
Rate for Payer: Hawaii Medical Service Association Non-ABD	$8.30
Rate for Payer: Hawaii Western Management Group Commercial	$95.72
Rate for Payer: Health Management Network Commercial	$85.65
Rate for Payer: Kaiser Permanente Commercial	$63.48
Rate for Payer: Kaiser Permanente Medicaid	$51.39
Rate for Payer: MDX Hawaii PPO	$97.74
Rate for Payer: UnitedHealthcare Medicaid	$60.46
Rate for Payer: University Health Alliance Commercial	$73.44

AMINOPHYLLINE 250 MG/10 ML IV SOLN

Facility

$100.76

Service Code	HCPCS J0280
Hospital Revenue Code	250
Min. Negotiated Rate	$85.65
Max. Negotiated Rate	$97.74
Rate for Payer: Cash Price	$65.49
Rate for Payer: Health Management Network Commercial	$85.65
Rate for Payer: MDX Hawaii PPO	$97.74

AMIODARONE 200 MG PO TABLET

Facility

$3.35

Service Code	HCPCS A9270
Hospital Revenue Code	250
Min. Negotiated Rate	$1.71
Max. Negotiated Rate	$3.25
Rate for Payer: Cash Price	$2.18
Rate for Payer: Hawaii Western Management Group Commercial	$3.18
Rate for Payer: Health Management Network Commercial	$2.85
Rate for Payer: Kaiser Permanente Commercial	$2.11
Rate for Payer: Kaiser Permanente Medicaid	$1.71
Rate for Payer: MDX Hawaii PPO	$3.25
Rate for Payer: UnitedHealthcare Medicaid	$2.01
Rate for Payer: University Health Alliance Commercial	$2.44

AMIODARONE 200 MG PO TABLET

Facility

$3.35

Service Code	HCPCS A9270
Hospital Revenue Code	250
Min. Negotiated Rate	$2.85
Max. Negotiated Rate	$3.25
Rate for Payer: Cash Price	$2.18
Rate for Payer: Health Management Network Commercial	$2.85
Rate for Payer: MDX Hawaii PPO	$3.25

AMIODARONE 50 MG/ML IV SOLN

Facility

$11.05

Service Code	HCPCS J0282
Hospital Revenue Code	250
Min. Negotiated Rate	$9.39
Max. Negotiated Rate	$10.72
Rate for Payer: Cash Price	$7.18
Rate for Payer: Cash Price	$15.80
Rate for Payer: Health Management Network Commercial	$20.66
Rate for Payer: Health Management Network Commercial	$9.39
Rate for Payer: MDX Hawaii PPO	$23.57
Rate for Payer: MDX Hawaii PPO	$10.72

AMIODARONE 50 MG/ML IV SOLN

Facility

$24.30

Service Code	HCPCS J0282
Hospital Revenue Code	636
Min. Negotiated Rate	$0.51
Max. Negotiated Rate	$23.57
Rate for Payer: Cash Price	$15.80
Rate for Payer: Cash Price	$7.18
Rate for Payer: Cash Price	$7.18
Rate for Payer: Cash Price	$15.80
Rate for Payer: Hawaii Medical Service Association ABD	$0.51
Rate for Payer: Hawaii Medical Service Association ABD	$0.51
Rate for Payer: Hawaii Medical Service Association Non-ABD	$0.51
Rate for Payer: Hawaii Medical Service Association Non-ABD	$0.51
Rate for Payer: Hawaii Western Management Group Commercial	$10.50
Rate for Payer: Hawaii Western Management Group Commercial	$23.09
Rate for Payer: Health Management Network Commercial	$20.66
Rate for Payer: Health Management Network Commercial	$9.39
Rate for Payer: Kaiser Permanente Commercial	$15.31
Rate for Payer: Kaiser Permanente Commercial	$6.96
Rate for Payer: Kaiser Permanente Medicaid	$5.64
Rate for Payer: Kaiser Permanente Medicaid	$12.39
Rate for Payer: MDX Hawaii PPO	$10.72
Rate for Payer: MDX Hawaii PPO	$23.57
Rate for Payer: UnitedHealthcare Medicaid	$6.63
Rate for Payer: UnitedHealthcare Medicaid	$14.58
Rate for Payer: University Health Alliance Commercial	$8.05
Rate for Payer: University Health Alliance Commercial	$17.71

AMIODARONE IN DEXTROSE,ISO-OSM 150 MG/100 ML (1.5 MG/ML) IV SOLN

Facility

$161.66

Service Code	HCPCS J0283
Hospital Revenue Code	250
Min. Negotiated Rate	$137.41
Max. Negotiated Rate	$156.81
Rate for Payer: Cash Price	$105.08
Rate for Payer: Health Management Network Commercial	$137.41
Rate for Payer: MDX Hawaii PPO	$156.81

AMIODARONE IN DEXTROSE,ISO-OSM 150 MG/100 ML (1.5 MG/ML) IV SOLN

Facility

$161.66

Service Code	HCPCS J0283
Hospital Revenue Code	636
Min. Negotiated Rate	$2.61
Max. Negotiated Rate	$156.81
Rate for Payer: Cash Price	$105.08
Rate for Payer: Cash Price	$105.08
Rate for Payer: Hawaii Medical Service Association ABD	$2.61
Rate for Payer: Hawaii Medical Service Association Non-ABD	$2.61
Rate for Payer: Hawaii Western Management Group Commercial	$153.58
Rate for Payer: Health Management Network Commercial	$137.41
Rate for Payer: Kaiser Permanente Commercial	$101.85
Rate for Payer: Kaiser Permanente Medicaid	$82.45
Rate for Payer: MDX Hawaii PPO	$156.81
Rate for Payer: UnitedHealthcare Medicaid	$97.00
Rate for Payer: University Health Alliance Commercial	$117.83

AMIODARONE IN DEXTROSE,ISO-OSM 360 MG/200 ML (1.8 MG/ML) IV SOLN

Facility

$209.27

Service Code	HCPCS J0283
Hospital Revenue Code	636
Min. Negotiated Rate	$2.61
Max. Negotiated Rate	$202.99
Rate for Payer: Cash Price	$136.03
Rate for Payer: Cash Price	$136.03
Rate for Payer: Hawaii Medical Service Association ABD	$2.61
Rate for Payer: Hawaii Medical Service Association Non-ABD	$2.61
Rate for Payer: Hawaii Western Management Group Commercial	$198.81
Rate for Payer: Health Management Network Commercial	$177.88
Rate for Payer: Kaiser Permanente Commercial	$131.84
Rate for Payer: Kaiser Permanente Medicaid	$106.73
Rate for Payer: MDX Hawaii PPO	$202.99
Rate for Payer: UnitedHealthcare Medicaid	$125.56
Rate for Payer: University Health Alliance Commercial	$152.54

AMIODARONE IN DEXTROSE,ISO-OSM 360 MG/200 ML (1.8 MG/ML) IV SOLN

Facility

$209.27

Service Code	HCPCS J0283
Hospital Revenue Code	250
Min. Negotiated Rate	$177.88
Max. Negotiated Rate	$202.99
Rate for Payer: Cash Price	$136.03
Rate for Payer: Health Management Network Commercial	$177.88
Rate for Payer: MDX Hawaii PPO	$202.99

AMITRIPTYLINE 10 MG PO TABLET

Facility

$1.76

Service Code	HCPCS A9270
Hospital Revenue Code	250
Min. Negotiated Rate	$1.50
Max. Negotiated Rate	$1.71
Rate for Payer: Cash Price	$1.14
Rate for Payer: Health Management Network Commercial	$1.50
Rate for Payer: MDX Hawaii PPO	$1.71

AMITRIPTYLINE 10 MG PO TABLET

Facility

$1.76

Service Code	HCPCS A9270
Hospital Revenue Code	250
Min. Negotiated Rate	$0.90
Max. Negotiated Rate	$1.71
Rate for Payer: Cash Price	$1.14
Rate for Payer: Hawaii Western Management Group Commercial	$1.67
Rate for Payer: Health Management Network Commercial	$1.50
Rate for Payer: Kaiser Permanente Commercial	$1.11
Rate for Payer: Kaiser Permanente Medicaid	$0.90
Rate for Payer: MDX Hawaii PPO	$1.71
Rate for Payer: UnitedHealthcare Medicaid	$1.06
Rate for Payer: University Health Alliance Commercial	$1.28

AMITRIPTYLINE 25 MG PO TABLET

Facility

$2.85

Service Code	HCPCS A9270
Hospital Revenue Code	250
Min. Negotiated Rate	$2.42
Max. Negotiated Rate	$2.76
Rate for Payer: Cash Price	$1.85
Rate for Payer: Cash Price	$2.29
Rate for Payer: Health Management Network Commercial	$2.99
Rate for Payer: Health Management Network Commercial	$2.42
Rate for Payer: MDX Hawaii PPO	$3.41
Rate for Payer: MDX Hawaii PPO	$2.76

AMITRIPTYLINE 25 MG PO TABLET

Facility

$2.85

Service Code	HCPCS A9270
Hospital Revenue Code	250
Min. Negotiated Rate	$1.45
Max. Negotiated Rate	$2.76
Rate for Payer: Cash Price	$1.85
Rate for Payer: Cash Price	$2.29
Rate for Payer: Hawaii Western Management Group Commercial	$2.71
Rate for Payer: Hawaii Western Management Group Commercial	$3.34
Rate for Payer: Health Management Network Commercial	$2.99
Rate for Payer: Health Management Network Commercial	$2.42
Rate for Payer: Kaiser Permanente Commercial	$1.80
Rate for Payer: Kaiser Permanente Commercial	$2.22
Rate for Payer: Kaiser Permanente Medicaid	$1.80
Rate for Payer: Kaiser Permanente Medicaid	$1.45
Rate for Payer: MDX Hawaii PPO	$3.41
Rate for Payer: MDX Hawaii PPO	$2.76
Rate for Payer: UnitedHealthcare Medicaid	$1.71
Rate for Payer: UnitedHealthcare Medicaid	$2.11
Rate for Payer: University Health Alliance Commercial	$2.57
Rate for Payer: University Health Alliance Commercial	$2.08

AMITRIPTYLINE 50 MG PO TABLET

Facility

$3.85

Service Code	HCPCS A9270
Hospital Revenue Code	250
Min. Negotiated Rate	$1.96
Max. Negotiated Rate	$3.73
Rate for Payer: Cash Price	$2.50
Rate for Payer: Hawaii Western Management Group Commercial	$3.66
Rate for Payer: Health Management Network Commercial	$3.27
Rate for Payer: Kaiser Permanente Commercial	$2.43
Rate for Payer: Kaiser Permanente Medicaid	$1.96
Rate for Payer: MDX Hawaii PPO	$3.73
Rate for Payer: UnitedHealthcare Medicaid	$2.31
Rate for Payer: University Health Alliance Commercial	$2.81

AMITRIPTYLINE 50 MG PO TABLET

Facility

$3.85

Service Code	HCPCS A9270
Hospital Revenue Code	250
Min. Negotiated Rate	$3.27
Max. Negotiated Rate	$3.73
Rate for Payer: Cash Price	$2.50
Rate for Payer: Health Management Network Commercial	$3.27
Rate for Payer: MDX Hawaii PPO	$3.73

Know your out-of-pocket cost for care.

All Charges