Kona Community Hospital

All Charges

Charge

Type

Setting

Price

Hoover Neg Pres Ureteral Sheath 11fFr x 50cm IVX-NS-1150 [3645027]

Facility

$3,630.50

Service Code	HCPCS C1894
Hospital Charge Code	3645027
Hospital Revenue Code	272
Min. Negotiated Rate	$1,851.56
Max. Negotiated Rate	$3,521.59
Rate for Payer: Cash Price	$2,359.83
Rate for Payer: Hawaii Western Management Group Commercial	$3,448.97
Rate for Payer: Health Management Network Commercial	$3,085.93
Rate for Payer: Kaiser Permanente Commercial	$2,287.22
Rate for Payer: Kaiser Permanente Medicaid	$1,851.56
Rate for Payer: MDX Hawaii PPO	$3,521.59
Rate for Payer: University Health Alliance Commercial	$2,646.27

Hoover Neg Pres Ureteral Sheath 11Fr x 40cm IVX-NS-1140 [3645026]

Facility

$3,630.50

Service Code	HCPCS C1894
Hospital Charge Code	3645026
Hospital Revenue Code	272
Min. Negotiated Rate	$3,085.93
Max. Negotiated Rate	$3,521.59
Rate for Payer: Cash Price	$2,359.83
Rate for Payer: Health Management Network Commercial	$3,085.93
Rate for Payer: MDX Hawaii PPO	$3,521.59

Hoover Neg Pres Ureteral Sheath 11Fr x 40cm IVX-NS-1140 [3645026]

Facility

$3,630.50

Service Code	HCPCS C1894
Hospital Charge Code	3645026
Hospital Revenue Code	272
Min. Negotiated Rate	$1,851.56
Max. Negotiated Rate	$3,521.59
Rate for Payer: Cash Price	$2,359.83
Rate for Payer: Hawaii Western Management Group Commercial	$3,448.97
Rate for Payer: Health Management Network Commercial	$3,085.93
Rate for Payer: Kaiser Permanente Commercial	$2,287.22
Rate for Payer: Kaiser Permanente Medicaid	$1,851.56
Rate for Payer: MDX Hawaii PPO	$3,521.59
Rate for Payer: University Health Alliance Commercial	$2,646.27

Hoover Neg Pres Ureteral Sheath 12Fr x 40cm IVX-NS-1240 [3645028]

Facility

$3,630.50

Service Code	HCPCS C1894
Hospital Charge Code	3645028
Hospital Revenue Code	272
Min. Negotiated Rate	$1,851.56
Max. Negotiated Rate	$3,521.59
Rate for Payer: Cash Price	$2,359.83
Rate for Payer: Hawaii Western Management Group Commercial	$3,448.97
Rate for Payer: Health Management Network Commercial	$3,085.93
Rate for Payer: Kaiser Permanente Commercial	$2,287.22
Rate for Payer: Kaiser Permanente Medicaid	$1,851.56
Rate for Payer: MDX Hawaii PPO	$3,521.59
Rate for Payer: University Health Alliance Commercial	$2,646.27

Hoover Neg Pres Ureteral Sheath 12Fr x 40cm IVX-NS-1240 [3645028]

Facility

$3,630.50

Service Code	HCPCS C1894
Hospital Charge Code	3645028
Hospital Revenue Code	272
Min. Negotiated Rate	$3,085.93
Max. Negotiated Rate	$3,521.59
Rate for Payer: Cash Price	$2,359.83
Rate for Payer: Health Management Network Commercial	$3,085.93
Rate for Payer: MDX Hawaii PPO	$3,521.59

Hoover Neg Pres Ureteral Sheath 12Fr x 50cm IVX-NS-1250 [3645029]

Facility

$3,630.50

Service Code	HCPCS C1894
Hospital Charge Code	3645029
Hospital Revenue Code	272
Min. Negotiated Rate	$1,851.56
Max. Negotiated Rate	$3,521.59
Rate for Payer: Cash Price	$2,359.83
Rate for Payer: Hawaii Western Management Group Commercial	$3,448.97
Rate for Payer: Health Management Network Commercial	$3,085.93
Rate for Payer: Kaiser Permanente Commercial	$2,287.22
Rate for Payer: Kaiser Permanente Medicaid	$1,851.56
Rate for Payer: MDX Hawaii PPO	$3,521.59
Rate for Payer: University Health Alliance Commercial	$2,646.27

Hoover Neg Pres Ureteral Sheath 12Fr x 50cm IVX-NS-1250 [3645029]

Facility

$3,630.50

Service Code	HCPCS C1894
Hospital Charge Code	3645029
Hospital Revenue Code	272
Min. Negotiated Rate	$3,085.93
Max. Negotiated Rate	$3,521.59
Rate for Payer: Cash Price	$2,359.83
Rate for Payer: Health Management Network Commercial	$3,085.93
Rate for Payer: MDX Hawaii PPO	$3,521.59

HOSPITAL IP/OBS DISCHARGE DAY MGMT > 30 MIN

Professional

Both

$215.00

Service Code	HCPCS 99239
Min. Negotiated Rate	$78.33
Max. Negotiated Rate	$182.75
Rate for Payer: AlohaCare Medicaid	$116.44
Rate for Payer: AlohaCare Medicare	$108.33
Rate for Payer: Cash Price	$139.75
Rate for Payer: Cash Price	$139.75
Rate for Payer: Devoted Health Medicare	$119.16
Rate for Payer: Hawaii Medical Service Association Medicare	$108.33
Rate for Payer: Hawaii Western Management Group Commercial	$78.33
Rate for Payer: Health Management Network Commercial	$182.75
Rate for Payer: Kaiser Permanente Commercial	$130.00
Rate for Payer: Kaiser Permanente Medicaid	$130.00
Rate for Payer: Kaiser Permanente Medicare	$130.00
Rate for Payer: Ohana Health Plan Medicaid	$116.44
Rate for Payer: Ohana Health Plan Medicare	$108.33
Rate for Payer: UnitedHealthcare Medicaid	$116.44
Rate for Payer: UnitedHealthcare Medicare	$108.33

HOSPITAL IP/OBS DISCHARGE DAY MGMT 30 MIN/<

Professional

Both

$145.00

Service Code	HCPCS 99238
Min. Negotiated Rate	$64.63
Max. Negotiated Rate	$123.25
Rate for Payer: AlohaCare Medicaid	$82.58
Rate for Payer: AlohaCare Medicare	$75.97
Rate for Payer: Cash Price	$94.25
Rate for Payer: Cash Price	$94.25
Rate for Payer: Devoted Health Medicare	$83.57
Rate for Payer: Hawaii Medical Service Association Medicare	$75.97
Rate for Payer: Hawaii Western Management Group Commercial	$64.63
Rate for Payer: Health Management Network Commercial	$123.25
Rate for Payer: Kaiser Permanente Commercial	$91.16
Rate for Payer: Kaiser Permanente Medicaid	$91.16
Rate for Payer: Kaiser Permanente Medicare	$91.16
Rate for Payer: Ohana Health Plan Medicaid	$82.58
Rate for Payer: Ohana Health Plan Medicare	$75.97
Rate for Payer: UnitedHealthcare Medicaid	$82.58
Rate for Payer: UnitedHealthcare Medicare	$75.97

HUMAN PROTHROMBIN COMPLEX(PCC) 1 INTERNATIONAL UNIT CHARGE

Facility

$16.45

Service Code	HCPCS J7168
Hospital Revenue Code	250
Min. Negotiated Rate	$13.98
Max. Negotiated Rate	$15.96
Rate for Payer: Cash Price	$10.69
Rate for Payer: Health Management Network Commercial	$13.98
Rate for Payer: MDX Hawaii PPO	$15.96

HUMAN PROTHROMBIN COMPLEX(PCC) 1 INTERNATIONAL UNIT CHARGE

Facility

$16.45

Service Code	HCPCS J7168
Hospital Revenue Code	636
Min. Negotiated Rate	$2.05
Max. Negotiated Rate	$15.96
Rate for Payer: AlohaCare Medicaid	$2.05
Rate for Payer: AlohaCare Medicare	$2.05
Rate for Payer: Cash Price	$10.69
Rate for Payer: Cash Price	$10.69
Rate for Payer: Devoted Health Medicare	$2.25
Rate for Payer: Hawaii Medical Service Association Commercial	$2.56
Rate for Payer: Hawaii Medical Service Association Medicare	$2.05
Rate for Payer: Hawaii Western Management Group Commercial	$15.63
Rate for Payer: Health Management Network Commercial	$13.98
Rate for Payer: Humana Medicare	$2.05
Rate for Payer: Kaiser Permanente Commercial	$10.36
Rate for Payer: Kaiser Permanente Medicaid	$8.39
Rate for Payer: Kaiser Permanente Medicare	$2.05
Rate for Payer: MDX Hawaii PPO	$15.96
Rate for Payer: Ohana Health Plan Medicaid	$2.25
Rate for Payer: Ohana Health Plan Medicare	$2.05
Rate for Payer: UnitedHealthcare Medicaid	$9.87
Rate for Payer: UnitedHealthcare Medicare	$2.05
Rate for Payer: University Health Alliance Commercial	$11.99

Humeral Insert S/36 +6 To Fit In A 36 Cup AR-9503S-06 [3645557]

Facility

$7,425.00

Service Code	HCPCS C1776
Hospital Charge Code	3645557
Hospital Revenue Code	278
Min. Negotiated Rate	$3,786.75
Max. Negotiated Rate	$7,202.25
Rate for Payer: Cash Price	$4,826.25
Rate for Payer: Hawaii Western Management Group Commercial	$5,197.50
Rate for Payer: Health Management Network Commercial	$6,311.25
Rate for Payer: Kaiser Permanente Commercial	$4,677.75
Rate for Payer: Kaiser Permanente Medicaid	$3,786.75
Rate for Payer: MDX Hawaii PPO	$7,202.25
Rate for Payer: University Health Alliance Commercial	$4,158.00

Humeral Insert S/36 +6 To Fit In A 36 Cup AR-9503S-06 [3645557]

Facility

$7,425.00

Service Code	HCPCS C1776
Hospital Charge Code	3645557
Hospital Revenue Code	278
Min. Negotiated Rate	$4,158.00
Max. Negotiated Rate	$7,202.25
Rate for Payer: Cash Price	$4,826.25
Rate for Payer: Hawaii Western Management Group Commercial	$5,197.50
Rate for Payer: Health Management Network Commercial	$6,311.25
Rate for Payer: MDX Hawaii PPO	$7,202.25
Rate for Payer: University Health Alliance Commercial	$4,158.00

HYALURONIDASE, HUMAN RECOMB. 150 UNITS/ML INJ SOLN

Facility

$292.45

Service Code	HCPCS J3473
Hospital Revenue Code	250
Min. Negotiated Rate	$248.58
Max. Negotiated Rate	$283.68
Rate for Payer: Cash Price	$190.09
Rate for Payer: Health Management Network Commercial	$248.58
Rate for Payer: MDX Hawaii PPO	$283.68

HYALURONIDASE, HUMAN RECOMB. 150 UNITS/ML INJ SOLN

Facility

$292.45

Service Code	HCPCS J3473
Hospital Revenue Code	636
Min. Negotiated Rate	$0.36
Max. Negotiated Rate	$283.68
Rate for Payer: Cash Price	$190.09
Rate for Payer: Cash Price	$190.09
Rate for Payer: Hawaii Medical Service Association ABD	$0.36
Rate for Payer: Hawaii Medical Service Association Non-ABD	$0.36
Rate for Payer: Hawaii Western Management Group Commercial	$277.83
Rate for Payer: Health Management Network Commercial	$248.58
Rate for Payer: Kaiser Permanente Commercial	$184.24
Rate for Payer: Kaiser Permanente Medicaid	$149.15
Rate for Payer: MDX Hawaii PPO	$283.68
Rate for Payer: UnitedHealthcare Medicaid	$175.47
Rate for Payer: University Health Alliance Commercial	$213.17

HYDRALAZINE 10 MG PO TABLET

Facility

$2.27

Service Code	HCPCS A9270
Hospital Revenue Code	250
Min. Negotiated Rate	$1.93
Max. Negotiated Rate	$2.20
Rate for Payer: Cash Price	$1.48
Rate for Payer: Health Management Network Commercial	$1.93
Rate for Payer: MDX Hawaii PPO	$2.20

HYDRALAZINE 10 MG PO TABLET

Facility

$2.27

Service Code	HCPCS A9270
Hospital Revenue Code	250
Min. Negotiated Rate	$1.16
Max. Negotiated Rate	$2.20
Rate for Payer: Cash Price	$1.48
Rate for Payer: Hawaii Western Management Group Commercial	$2.16
Rate for Payer: Health Management Network Commercial	$1.93
Rate for Payer: Kaiser Permanente Commercial	$1.43
Rate for Payer: Kaiser Permanente Medicaid	$1.16
Rate for Payer: MDX Hawaii PPO	$2.20
Rate for Payer: UnitedHealthcare Medicaid	$1.36
Rate for Payer: University Health Alliance Commercial	$1.65

HYDRALAZINE 20 MG/ML INJ SOLN

Facility

$88.55

Service Code	HCPCS J0360
Hospital Revenue Code	636
Min. Negotiated Rate	$5.19
Max. Negotiated Rate	$85.89
Rate for Payer: Cash Price	$57.56
Rate for Payer: Cash Price	$57.56
Rate for Payer: Hawaii Medical Service Association ABD	$5.19
Rate for Payer: Hawaii Medical Service Association Non-ABD	$5.19
Rate for Payer: Hawaii Western Management Group Commercial	$84.12
Rate for Payer: Health Management Network Commercial	$75.27
Rate for Payer: Kaiser Permanente Commercial	$55.79
Rate for Payer: Kaiser Permanente Medicaid	$45.16
Rate for Payer: MDX Hawaii PPO	$85.89
Rate for Payer: UnitedHealthcare Medicaid	$53.13
Rate for Payer: University Health Alliance Commercial	$64.54

HYDRALAZINE 20 MG/ML INJ SOLN

Facility

$88.55

Service Code	HCPCS J0360
Hospital Revenue Code	250
Min. Negotiated Rate	$75.27
Max. Negotiated Rate	$85.89
Rate for Payer: Cash Price	$57.56
Rate for Payer: Health Management Network Commercial	$75.27
Rate for Payer: MDX Hawaii PPO	$85.89

HYDRALAZINE 25 MG PO TABLET

Facility

$1.41

Service Code	HCPCS A9270
Hospital Revenue Code	250
Min. Negotiated Rate	$0.72
Max. Negotiated Rate	$1.37
Rate for Payer: Cash Price	$0.92
Rate for Payer: Hawaii Western Management Group Commercial	$1.34
Rate for Payer: Health Management Network Commercial	$1.20
Rate for Payer: Kaiser Permanente Commercial	$0.89
Rate for Payer: Kaiser Permanente Medicaid	$0.72
Rate for Payer: MDX Hawaii PPO	$1.37
Rate for Payer: UnitedHealthcare Medicaid	$0.85
Rate for Payer: University Health Alliance Commercial	$1.03

HYDRALAZINE 25 MG PO TABLET

Facility

$1.41

Service Code	HCPCS A9270
Hospital Revenue Code	250
Min. Negotiated Rate	$1.20
Max. Negotiated Rate	$1.37
Rate for Payer: Cash Price	$0.92
Rate for Payer: Health Management Network Commercial	$1.20
Rate for Payer: MDX Hawaii PPO	$1.37

HYDROCHLOROTHIAZIDE 12.5 MG PO CAP

Facility

$1.56

Service Code	HCPCS A9270
Hospital Revenue Code	250
Min. Negotiated Rate	$0.80
Max. Negotiated Rate	$1.51
Rate for Payer: Cash Price	$1.01
Rate for Payer: Cash Price	$1.53
Rate for Payer: Hawaii Western Management Group Commercial	$1.48
Rate for Payer: Hawaii Western Management Group Commercial	$2.23
Rate for Payer: Health Management Network Commercial	$1.33
Rate for Payer: Health Management Network Commercial	$2.00
Rate for Payer: Kaiser Permanente Commercial	$0.98
Rate for Payer: Kaiser Permanente Commercial	$1.48
Rate for Payer: Kaiser Permanente Medicaid	$0.80
Rate for Payer: Kaiser Permanente Medicaid	$1.20
Rate for Payer: MDX Hawaii PPO	$1.51
Rate for Payer: MDX Hawaii PPO	$2.28
Rate for Payer: UnitedHealthcare Medicaid	$1.41
Rate for Payer: UnitedHealthcare Medicaid	$0.94
Rate for Payer: University Health Alliance Commercial	$1.14
Rate for Payer: University Health Alliance Commercial	$1.71

HYDROCHLOROTHIAZIDE 12.5 MG PO CAP

Facility

$2.35

Service Code	HCPCS A9270
Hospital Revenue Code	250
Min. Negotiated Rate	$2.00
Max. Negotiated Rate	$2.28
Rate for Payer: Cash Price	$1.53
Rate for Payer: Cash Price	$1.01
Rate for Payer: Health Management Network Commercial	$1.33
Rate for Payer: Health Management Network Commercial	$2.00
Rate for Payer: MDX Hawaii PPO	$2.28
Rate for Payer: MDX Hawaii PPO	$1.51

HYDROCHLOROTHIAZIDE 25 MG PO TABLET

Facility

$1.40

Service Code	HCPCS A9270
Hospital Revenue Code	250
Min. Negotiated Rate	$0.71
Max. Negotiated Rate	$1.36
Rate for Payer: Cash Price	$0.91
Rate for Payer: Hawaii Western Management Group Commercial	$1.33
Rate for Payer: Health Management Network Commercial	$1.19
Rate for Payer: Kaiser Permanente Commercial	$0.88
Rate for Payer: Kaiser Permanente Medicaid	$0.71
Rate for Payer: MDX Hawaii PPO	$1.36
Rate for Payer: UnitedHealthcare Medicaid	$0.84
Rate for Payer: University Health Alliance Commercial	$1.02

HYDROCHLOROTHIAZIDE 25 MG PO TABLET

Facility

$1.40

Service Code	HCPCS A9270
Hospital Revenue Code	250
Min. Negotiated Rate	$1.19
Max. Negotiated Rate	$1.36
Rate for Payer: Cash Price	$0.91
Rate for Payer: Health Management Network Commercial	$1.19
Rate for Payer: MDX Hawaii PPO	$1.36

Know your out-of-pocket cost for care.

All Charges