Kona Community Hospital

All Charges

Charge

Type

Setting

Price

HYDROXYZINE HCL 10 MG PO TABLET

Facility

$1.53

Service Code	HCPCS A9270
Hospital Revenue Code	250
Min. Negotiated Rate	$0.78
Max. Negotiated Rate	$1.48
Rate for Payer: Cash Price	$0.99
Rate for Payer: Cash Price	$2.33
Rate for Payer: Hawaii Western Management Group Commercial	$1.45
Rate for Payer: Hawaii Western Management Group Commercial	$3.41
Rate for Payer: Health Management Network Commercial	$1.30
Rate for Payer: Health Management Network Commercial	$3.05
Rate for Payer: Kaiser Permanente Commercial	$0.96
Rate for Payer: Kaiser Permanente Commercial	$2.26
Rate for Payer: Kaiser Permanente Medicaid	$0.78
Rate for Payer: Kaiser Permanente Medicaid	$1.83
Rate for Payer: MDX Hawaii PPO	$1.48
Rate for Payer: MDX Hawaii PPO	$3.48
Rate for Payer: UnitedHealthcare Medicaid	$2.15
Rate for Payer: UnitedHealthcare Medicaid	$0.92
Rate for Payer: University Health Alliance Commercial	$1.12
Rate for Payer: University Health Alliance Commercial	$2.62

HYDROXYZINE HCL 10 MG PO TABLET

Facility

$3.59

Service Code	HCPCS A9270
Hospital Revenue Code	250
Min. Negotiated Rate	$3.05
Max. Negotiated Rate	$3.48
Rate for Payer: Cash Price	$2.33
Rate for Payer: Cash Price	$0.99
Rate for Payer: Health Management Network Commercial	$1.30
Rate for Payer: Health Management Network Commercial	$3.05
Rate for Payer: MDX Hawaii PPO	$3.48
Rate for Payer: MDX Hawaii PPO	$1.48

HYDROXYZINE HCL 25 MG PO TABLET

Facility

$2.19

Service Code	HCPCS A9270
Hospital Revenue Code	250
Min. Negotiated Rate	$1.12
Max. Negotiated Rate	$2.12
Rate for Payer: Cash Price	$1.42
Rate for Payer: Hawaii Western Management Group Commercial	$2.08
Rate for Payer: Health Management Network Commercial	$1.86
Rate for Payer: Kaiser Permanente Commercial	$1.38
Rate for Payer: Kaiser Permanente Medicaid	$1.12
Rate for Payer: MDX Hawaii PPO	$2.12
Rate for Payer: UnitedHealthcare Medicaid	$1.31
Rate for Payer: University Health Alliance Commercial	$1.60

HYDROXYZINE HCL 25 MG PO TABLET

Facility

$2.19

Service Code	HCPCS A9270
Hospital Revenue Code	250
Min. Negotiated Rate	$1.86
Max. Negotiated Rate	$2.12
Rate for Payer: Cash Price	$1.42
Rate for Payer: Health Management Network Commercial	$1.86
Rate for Payer: MDX Hawaii PPO	$2.12

HYDROXYZINE HCL 50 MG/ML IM SOLN

Facility

$157.56

Service Code	HCPCS J3410
Hospital Revenue Code	250
Min. Negotiated Rate	$133.93
Max. Negotiated Rate	$152.83
Rate for Payer: Cash Price	$102.41
Rate for Payer: Health Management Network Commercial	$133.93
Rate for Payer: MDX Hawaii PPO	$152.83

HYDROXYZINE HCL 50 MG/ML IM SOLN

Facility

$157.56

Service Code	HCPCS J3410
Hospital Revenue Code	636
Min. Negotiated Rate	$16.93
Max. Negotiated Rate	$152.83
Rate for Payer: Cash Price	$102.41
Rate for Payer: Cash Price	$102.41
Rate for Payer: Hawaii Medical Service Association ABD	$16.93
Rate for Payer: Hawaii Medical Service Association Non-ABD	$16.93
Rate for Payer: Hawaii Western Management Group Commercial	$149.68
Rate for Payer: Health Management Network Commercial	$133.93
Rate for Payer: Kaiser Permanente Commercial	$99.26
Rate for Payer: Kaiser Permanente Medicaid	$80.36
Rate for Payer: MDX Hawaii PPO	$152.83
Rate for Payer: UnitedHealthcare Medicaid	$94.54
Rate for Payer: University Health Alliance Commercial	$114.85

HYDROXYZINE HCL 50 MG PO TABLET

Facility

$6.16

Service Code	HCPCS A9270
Hospital Revenue Code	250
Min. Negotiated Rate	$5.24
Max. Negotiated Rate	$5.98
Rate for Payer: Cash Price	$4.00
Rate for Payer: Health Management Network Commercial	$5.24
Rate for Payer: MDX Hawaii PPO	$5.98

HYDROXYZINE HCL 50 MG PO TABLET

Facility

$6.16

Service Code	HCPCS A9270
Hospital Revenue Code	250
Min. Negotiated Rate	$3.14
Max. Negotiated Rate	$5.98
Rate for Payer: Cash Price	$4.00
Rate for Payer: Hawaii Western Management Group Commercial	$5.85
Rate for Payer: Health Management Network Commercial	$5.24
Rate for Payer: Kaiser Permanente Commercial	$3.88
Rate for Payer: Kaiser Permanente Medicaid	$3.14
Rate for Payer: MDX Hawaii PPO	$5.98
Rate for Payer: UnitedHealthcare Medicaid	$3.70
Rate for Payer: University Health Alliance Commercial	$4.49

HYOSCYAMINE SULFATE 0.125 MG/5 ML PO ELIX

Facility

$6.16

Service Code	HCPCS A9270
Hospital Revenue Code	250
Min. Negotiated Rate	$5.24
Max. Negotiated Rate	$5.98
Rate for Payer: Cash Price	$4.00
Rate for Payer: Health Management Network Commercial	$5.24
Rate for Payer: MDX Hawaii PPO	$5.98

HYOSCYAMINE SULFATE 0.125 MG/5 ML PO ELIX

Facility

$6.16

Service Code	HCPCS A9270
Hospital Revenue Code	250
Min. Negotiated Rate	$3.14
Max. Negotiated Rate	$5.98
Rate for Payer: Cash Price	$4.00
Rate for Payer: Hawaii Western Management Group Commercial	$5.85
Rate for Payer: Health Management Network Commercial	$5.24
Rate for Payer: Kaiser Permanente Commercial	$3.88
Rate for Payer: Kaiser Permanente Medicaid	$3.14
Rate for Payer: MDX Hawaii PPO	$5.98
Rate for Payer: UnitedHealthcare Medicaid	$3.70
Rate for Payer: University Health Alliance Commercial	$4.49

HYPERTENSION

Facility

$3,078.94

Service Code	APR-DRG 1992
Min. Negotiated Rate	$3,078.94
Max. Negotiated Rate	$3,078.94
Rate for Payer: AlohaCare Medicaid	$3,078.94
Rate for Payer: Hawaii Medical Service Association ABD	$3,078.94
Rate for Payer: Hawaii Medical Service Association Non-ABD	$3,078.94
Rate for Payer: Kaiser Permanente Medicaid	$3,078.94
Rate for Payer: Ohana Health Plan Medicaid	$3,078.94
Rate for Payer: UnitedHealthcare Medicaid	$3,078.94

HYPERTENSION

Facility

$2,542.75

Service Code	APR-DRG 1991
Min. Negotiated Rate	$2,542.75
Max. Negotiated Rate	$2,542.75
Rate for Payer: AlohaCare Medicaid	$2,542.75
Rate for Payer: Hawaii Medical Service Association ABD	$2,542.75
Rate for Payer: Hawaii Medical Service Association Non-ABD	$2,542.75
Rate for Payer: Kaiser Permanente Medicaid	$2,542.75
Rate for Payer: Ohana Health Plan Medicaid	$2,542.75
Rate for Payer: UnitedHealthcare Medicaid	$2,542.75

HYPERTENSION

Facility

$4,239.83

Service Code	APR-DRG 1993
Min. Negotiated Rate	$4,239.83
Max. Negotiated Rate	$4,239.83
Rate for Payer: AlohaCare Medicaid	$4,239.83
Rate for Payer: Hawaii Medical Service Association ABD	$4,239.83
Rate for Payer: Hawaii Medical Service Association Non-ABD	$4,239.83
Rate for Payer: Kaiser Permanente Medicaid	$4,239.83
Rate for Payer: Ohana Health Plan Medicaid	$4,239.83
Rate for Payer: UnitedHealthcare Medicaid	$4,239.83

HYPERTENSION

Facility

$6,930.96

Service Code	APR-DRG 1994
Min. Negotiated Rate	$6,930.96
Max. Negotiated Rate	$6,930.96
Rate for Payer: AlohaCare Medicaid	$6,930.96
Rate for Payer: Hawaii Medical Service Association ABD	$6,930.96
Rate for Payer: Hawaii Medical Service Association Non-ABD	$6,930.96
Rate for Payer: Kaiser Permanente Medicaid	$6,930.96
Rate for Payer: Ohana Health Plan Medicaid	$6,930.96
Rate for Payer: UnitedHealthcare Medicaid	$6,930.96

HYPERTENSION WITH MCC

Facility

$20,527.50

Service Code	MSDRG 304
Min. Negotiated Rate	$13,933.85
Max. Negotiated Rate	$20,527.50
Rate for Payer: AlohaCare Medicare	$15,651.79
Rate for Payer: Devoted Health Medicare	$17,216.97
Rate for Payer: Hawaii Medical Service Association Commercial	$13,933.85
Rate for Payer: Hawaii Medical Service Association Medicare	$15,651.79
Rate for Payer: Humana Medicare	$15,651.79
Rate for Payer: Kaiser Permanente Commercial	$20,527.50
Rate for Payer: Kaiser Permanente Medicare	$15,651.79
Rate for Payer: Ohana Health Plan Medicare	$15,651.79
Rate for Payer: UnitedHealthcare Medicare	$15,651.79

HYPERTENSION WITHOUT MCC

Facility

$13,933.85

Service Code	MSDRG 305
Min. Negotiated Rate	$9,931.66
Max. Negotiated Rate	$13,933.85
Rate for Payer: AlohaCare Medicare	$9,931.66
Rate for Payer: Devoted Health Medicare	$10,924.83
Rate for Payer: Hawaii Medical Service Association Commercial	$13,933.85
Rate for Payer: Hawaii Medical Service Association Medicare	$9,931.66
Rate for Payer: Humana Medicare	$9,931.66
Rate for Payer: Kaiser Permanente Commercial	$13,025.48
Rate for Payer: Kaiser Permanente Medicare	$9,931.66
Rate for Payer: Ohana Health Plan Medicare	$9,931.66
Rate for Payer: UnitedHealthcare Medicare	$9,931.66

HYPOVOLEMIA & RELATED ELECTROLYTE DISORDERS

Facility

$3,793.44

Service Code	APR-DRG 4223
Min. Negotiated Rate	$3,793.44
Max. Negotiated Rate	$3,793.44
Rate for Payer: AlohaCare Medicaid	$3,793.44
Rate for Payer: Hawaii Medical Service Association ABD	$3,793.44
Rate for Payer: Hawaii Medical Service Association Non-ABD	$3,793.44
Rate for Payer: Kaiser Permanente Medicaid	$3,793.44
Rate for Payer: Ohana Health Plan Medicaid	$3,793.44
Rate for Payer: UnitedHealthcare Medicaid	$3,793.44

HYPOVOLEMIA & RELATED ELECTROLYTE DISORDERS

Facility

$1,979.18

Service Code	APR-DRG 4221
Min. Negotiated Rate	$1,979.18
Max. Negotiated Rate	$1,979.18
Rate for Payer: AlohaCare Medicaid	$1,979.18
Rate for Payer: Hawaii Medical Service Association ABD	$1,979.18
Rate for Payer: Hawaii Medical Service Association Non-ABD	$1,979.18
Rate for Payer: Kaiser Permanente Medicaid	$1,979.18
Rate for Payer: Ohana Health Plan Medicaid	$1,979.18
Rate for Payer: UnitedHealthcare Medicaid	$1,979.18

HYPOVOLEMIA & RELATED ELECTROLYTE DISORDERS

Facility

$2,636.36

Service Code	APR-DRG 4222
Min. Negotiated Rate	$2,636.36
Max. Negotiated Rate	$2,636.36
Rate for Payer: AlohaCare Medicaid	$2,636.36
Rate for Payer: Hawaii Medical Service Association ABD	$2,636.36
Rate for Payer: Hawaii Medical Service Association Non-ABD	$2,636.36
Rate for Payer: Kaiser Permanente Medicaid	$2,636.36
Rate for Payer: Ohana Health Plan Medicaid	$2,636.36
Rate for Payer: UnitedHealthcare Medicaid	$2,636.36

HYPOVOLEMIA & RELATED ELECTROLYTE DISORDERS

Facility

$6,803.60

Service Code	APR-DRG 4224
Min. Negotiated Rate	$6,803.60
Max. Negotiated Rate	$6,803.60
Rate for Payer: AlohaCare Medicaid	$6,803.60
Rate for Payer: Hawaii Medical Service Association ABD	$6,803.60
Rate for Payer: Hawaii Medical Service Association Non-ABD	$6,803.60
Rate for Payer: Kaiser Permanente Medicaid	$6,803.60
Rate for Payer: Ohana Health Plan Medicaid	$6,803.60
Rate for Payer: UnitedHealthcare Medicaid	$6,803.60

HYSTEROSCOPY, SURGICAL; WITH DIVISION OR RESECTION OF INTRAUTERINE SEPTUM (ANY METHOD)

Facility

$14,715.00

Service Code	CPT 58560
Hospital Revenue Code	360
Min. Negotiated Rate	$456.03
Max. Negotiated Rate	$14,715.00
Rate for Payer: AlohaCare Medicaid	$5,909.62
Rate for Payer: AlohaCare Medicare	$5,909.62
Rate for Payer: Devoted Health Medicare	$6,500.58
Rate for Payer: Hawaii Medical Service Association ABD	$1,149.00
Rate for Payer: Hawaii Medical Service Association Commercial	$14,715.00
Rate for Payer: Hawaii Medical Service Association Medicare	$5,909.62
Rate for Payer: Hawaii Medical Service Association Non-ABD	$1,154.45
Rate for Payer: Humana Medicare	$5,909.62
Rate for Payer: Kaiser Permanente Medicaid	$2,837.00
Rate for Payer: Kaiser Permanente Medicare	$5,909.62
Rate for Payer: Ohana Health Plan Medicaid	$6,500.58
Rate for Payer: Ohana Health Plan Medicare	$5,909.62
Rate for Payer: UnitedHealthcare Medicaid	$456.03
Rate for Payer: UnitedHealthcare Medicare	$5,909.62
Rate for Payer: University Health Alliance Commercial	$6,743.44

HYSTEROSCOPY, SURGICAL; WITH ENDOMETRIAL ABLATION (EG, ENDOMETRIAL RESECTION, ELECTROSURGICAL ABLATION, THERMOABLATION)

Facility

$24,500.00

Service Code	CPT 58563
Hospital Revenue Code	360
Min. Negotiated Rate	$456.03
Max. Negotiated Rate	$24,500.00
Rate for Payer: AlohaCare Medicaid	$5,909.62
Rate for Payer: AlohaCare Medicare	$5,909.62
Rate for Payer: Devoted Health Medicare	$6,500.58
Rate for Payer: Hawaii Medical Service Association ABD	$695.00
Rate for Payer: Hawaii Medical Service Association Commercial	$6,183.00
Rate for Payer: Hawaii Medical Service Association Medicare	$5,909.62
Rate for Payer: Hawaii Medical Service Association Non-ABD	$700.72
Rate for Payer: Humana Medicare	$5,909.62
Rate for Payer: Kaiser Permanente Medicaid	$2,837.00
Rate for Payer: Kaiser Permanente Medicare	$5,909.62
Rate for Payer: Ohana Health Plan Medicaid	$6,500.58
Rate for Payer: Ohana Health Plan Medicare	$5,909.62
Rate for Payer: UnitedHealthcare Medicaid	$456.03
Rate for Payer: UnitedHealthcare Medicare	$5,909.62
Rate for Payer: University Health Alliance Commercial	$24,500.00

HYSTEROSCOPY, SURGICAL; WITH REMOVAL OF IMPACTED FOREIGN BODY

Facility

$6,743.44

Service Code	CPT 58562
Hospital Revenue Code	360
Min. Negotiated Rate	$456.03
Max. Negotiated Rate	$6,743.44
Rate for Payer: AlohaCare Medicaid	$3,824.16
Rate for Payer: AlohaCare Medicare	$3,824.16
Rate for Payer: Devoted Health Medicare	$4,206.58
Rate for Payer: Hawaii Medical Service Association ABD	$695.00
Rate for Payer: Hawaii Medical Service Association Commercial	$6,183.00
Rate for Payer: Hawaii Medical Service Association Medicare	$3,824.16
Rate for Payer: Hawaii Medical Service Association Non-ABD	$700.72
Rate for Payer: Humana Medicare	$3,824.16
Rate for Payer: Kaiser Permanente Medicaid	$2,837.00
Rate for Payer: Kaiser Permanente Medicare	$3,824.16
Rate for Payer: Ohana Health Plan Medicaid	$4,206.58
Rate for Payer: Ohana Health Plan Medicare	$3,824.16
Rate for Payer: UnitedHealthcare Medicaid	$456.03
Rate for Payer: UnitedHealthcare Medicare	$3,824.16
Rate for Payer: University Health Alliance Commercial	$6,743.44

HYSTEROSCOPY, SURGICAL; WITH REMOVAL OF LEIOMYOMATA

Facility

$14,715.00

Service Code	CPT 58561
Hospital Revenue Code	360
Min. Negotiated Rate	$456.03
Max. Negotiated Rate	$14,715.00
Rate for Payer: AlohaCare Medicaid	$5,909.62
Rate for Payer: AlohaCare Medicare	$5,909.62
Rate for Payer: Devoted Health Medicare	$6,500.58
Rate for Payer: Hawaii Medical Service Association ABD	$1,149.00
Rate for Payer: Hawaii Medical Service Association Commercial	$14,715.00
Rate for Payer: Hawaii Medical Service Association Medicare	$5,909.62
Rate for Payer: Hawaii Medical Service Association Non-ABD	$1,154.45
Rate for Payer: Humana Medicare	$5,909.62
Rate for Payer: Kaiser Permanente Medicaid	$2,837.00
Rate for Payer: Kaiser Permanente Medicare	$5,909.62
Rate for Payer: Ohana Health Plan Medicaid	$6,500.58
Rate for Payer: Ohana Health Plan Medicare	$5,909.62
Rate for Payer: UnitedHealthcare Medicaid	$456.03
Rate for Payer: UnitedHealthcare Medicare	$5,909.62
Rate for Payer: University Health Alliance Commercial	$6,743.44

HYSTEROSCOPY, SURGICAL; WITH SAMPLING (BIOPSY) OF ENDOMETRIUM AND/OR POLYPECTOMY, WITH OR WITHOUT D & C

Facility

$9,416.00

Service Code	CPT 58558
Hospital Revenue Code	360
Min. Negotiated Rate	$456.03
Max. Negotiated Rate	$9,416.00
Rate for Payer: AlohaCare Medicaid	$3,824.16
Rate for Payer: AlohaCare Medicare	$3,824.16
Rate for Payer: Devoted Health Medicare	$4,206.58
Rate for Payer: Hawaii Medical Service Association ABD	$848.00
Rate for Payer: Hawaii Medical Service Association Commercial	$9,416.00
Rate for Payer: Hawaii Medical Service Association Medicare	$3,824.16
Rate for Payer: Hawaii Medical Service Association Non-ABD	$849.21
Rate for Payer: Humana Medicare	$3,824.16
Rate for Payer: Kaiser Permanente Medicaid	$2,837.00
Rate for Payer: Kaiser Permanente Medicare	$3,824.16
Rate for Payer: Ohana Health Plan Medicaid	$4,206.58
Rate for Payer: Ohana Health Plan Medicare	$3,824.16
Rate for Payer: UnitedHealthcare Medicaid	$456.03
Rate for Payer: UnitedHealthcare Medicare	$3,824.16
Rate for Payer: University Health Alliance Commercial	$6,743.44

Know your out-of-pocket cost for care.

All Charges