Kona Community Hospital

All Charges

Charge

Type

Setting

Price

AZITHROMYCIN 100 MG/5 ML PO SUSR

Facility

$162.39

Service Code	HCPCS A9270
Hospital Revenue Code	250
Min. Negotiated Rate	$82.82
Max. Negotiated Rate	$157.52
Rate for Payer: Cash Price	$105.55
Rate for Payer: Hawaii Western Management Group Commercial	$154.27
Rate for Payer: Health Management Network Commercial	$138.03
Rate for Payer: Kaiser Permanente Commercial	$102.31
Rate for Payer: Kaiser Permanente Medicaid	$82.82
Rate for Payer: MDX Hawaii PPO	$157.52
Rate for Payer: UnitedHealthcare Medicaid	$97.43
Rate for Payer: University Health Alliance Commercial	$118.37

AZITHROMYCIN 100 MG/5 ML PO SUSR

Facility

$162.39

Service Code	HCPCS A9270
Hospital Revenue Code	250
Min. Negotiated Rate	$138.03
Max. Negotiated Rate	$157.52
Rate for Payer: Cash Price	$105.55
Rate for Payer: Health Management Network Commercial	$138.03
Rate for Payer: MDX Hawaii PPO	$157.52

AZITHROMYCIN 200 MG/5 ML PO SUSR

Facility

$162.39

Service Code	HCPCS A9270
Hospital Revenue Code	250
Min. Negotiated Rate	$82.82
Max. Negotiated Rate	$157.52
Rate for Payer: Cash Price	$105.55
Rate for Payer: Hawaii Western Management Group Commercial	$154.27
Rate for Payer: Health Management Network Commercial	$138.03
Rate for Payer: Kaiser Permanente Commercial	$102.31
Rate for Payer: Kaiser Permanente Medicaid	$82.82
Rate for Payer: MDX Hawaii PPO	$157.52
Rate for Payer: UnitedHealthcare Medicaid	$97.43
Rate for Payer: University Health Alliance Commercial	$118.37

AZITHROMYCIN 200 MG/5 ML PO SUSR

Facility

$162.39

Service Code	HCPCS A9270
Hospital Revenue Code	250
Min. Negotiated Rate	$138.03
Max. Negotiated Rate	$157.52
Rate for Payer: Cash Price	$105.55
Rate for Payer: Health Management Network Commercial	$138.03
Rate for Payer: MDX Hawaii PPO	$157.52

AZITHROMYCIN 250 MG PO TABLET

Facility

$11.57

Service Code	HCPCS A9270
Hospital Revenue Code	250
Min. Negotiated Rate	$9.83
Max. Negotiated Rate	$11.22
Rate for Payer: Cash Price	$7.52
Rate for Payer: Cash Price	$15.13
Rate for Payer: Cash Price	$6.72
Rate for Payer: Health Management Network Commercial	$8.79
Rate for Payer: Health Management Network Commercial	$9.83
Rate for Payer: Health Management Network Commercial	$19.78
Rate for Payer: MDX Hawaii PPO	$10.03
Rate for Payer: MDX Hawaii PPO	$22.57
Rate for Payer: MDX Hawaii PPO	$11.22

AZITHROMYCIN 250 MG PO TABLET

Facility

$11.57

Service Code	HCPCS A9270
Hospital Revenue Code	250
Min. Negotiated Rate	$5.90
Max. Negotiated Rate	$11.22
Rate for Payer: Cash Price	$7.52
Rate for Payer: Cash Price	$6.72
Rate for Payer: Cash Price	$15.13
Rate for Payer: Hawaii Western Management Group Commercial	$9.82
Rate for Payer: Hawaii Western Management Group Commercial	$22.11
Rate for Payer: Hawaii Western Management Group Commercial	$10.99
Rate for Payer: Health Management Network Commercial	$19.78
Rate for Payer: Health Management Network Commercial	$8.79
Rate for Payer: Health Management Network Commercial	$9.83
Rate for Payer: Kaiser Permanente Commercial	$6.51
Rate for Payer: Kaiser Permanente Commercial	$7.29
Rate for Payer: Kaiser Permanente Commercial	$14.66
Rate for Payer: Kaiser Permanente Medicaid	$11.87
Rate for Payer: Kaiser Permanente Medicaid	$5.90
Rate for Payer: Kaiser Permanente Medicaid	$5.27
Rate for Payer: MDX Hawaii PPO	$22.57
Rate for Payer: MDX Hawaii PPO	$10.03
Rate for Payer: MDX Hawaii PPO	$11.22
Rate for Payer: UnitedHealthcare Medicaid	$6.94
Rate for Payer: UnitedHealthcare Medicaid	$6.20
Rate for Payer: UnitedHealthcare Medicaid	$13.96
Rate for Payer: University Health Alliance Commercial	$16.96
Rate for Payer: University Health Alliance Commercial	$7.54
Rate for Payer: University Health Alliance Commercial	$8.43

AZITHROMYCIN 500 MG IV RECON.SOLN.

Facility

$63.54

Service Code	HCPCS J0456
Hospital Revenue Code	636
Min. Negotiated Rate	$2.61
Max. Negotiated Rate	$61.63
Rate for Payer: Cash Price	$41.30
Rate for Payer: Cash Price	$29.60
Rate for Payer: Cash Price	$29.60
Rate for Payer: Cash Price	$41.30
Rate for Payer: Hawaii Medical Service Association ABD	$2.61
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 Medical Service Association Non-ABD	$2.61
Rate for Payer: Hawaii Western Management Group Commercial	$43.26
Rate for Payer: Hawaii Western Management Group Commercial	$60.36
Rate for Payer: Health Management Network Commercial	$54.01
Rate for Payer: Health Management Network Commercial	$38.71
Rate for Payer: Kaiser Permanente Commercial	$40.03
Rate for Payer: Kaiser Permanente Commercial	$28.69
Rate for Payer: Kaiser Permanente Medicaid	$23.23
Rate for Payer: Kaiser Permanente Medicaid	$32.41
Rate for Payer: MDX Hawaii PPO	$61.63
Rate for Payer: MDX Hawaii PPO	$44.17
Rate for Payer: UnitedHealthcare Medicaid	$27.32
Rate for Payer: UnitedHealthcare Medicaid	$38.12
Rate for Payer: University Health Alliance Commercial	$33.19
Rate for Payer: University Health Alliance Commercial	$46.31

AZITHROMYCIN 500 MG IV RECON.SOLN.

Facility

$45.54

Service Code	HCPCS J0456
Hospital Revenue Code	250
Min. Negotiated Rate	$38.71
Max. Negotiated Rate	$44.17
Rate for Payer: Cash Price	$29.60
Rate for Payer: Cash Price	$41.30
Rate for Payer: Health Management Network Commercial	$38.71
Rate for Payer: Health Management Network Commercial	$54.01
Rate for Payer: MDX Hawaii PPO	$44.17
Rate for Payer: MDX Hawaii PPO	$61.63

AZTREONAM 1 GRAM INJ RECON.SOLN.

Facility

$141.07

Service Code	HCPCS J0457
Hospital Revenue Code	250
Min. Negotiated Rate	$119.91
Max. Negotiated Rate	$136.84
Rate for Payer: Cash Price	$91.70
Rate for Payer: Cash Price	$108.80
Rate for Payer: Health Management Network Commercial	$119.91
Rate for Payer: Health Management Network Commercial	$142.27
Rate for Payer: MDX Hawaii PPO	$136.84
Rate for Payer: MDX Hawaii PPO	$162.36

AZTREONAM 1 GRAM INJ RECON.SOLN.

Facility

$167.38

Service Code	HCPCS J0457
Hospital Revenue Code	636
Min. Negotiated Rate	$2.67
Max. Negotiated Rate	$162.36
Rate for Payer: Cash Price	$108.80
Rate for Payer: Cash Price	$91.70
Rate for Payer: Cash Price	$108.80
Rate for Payer: Cash Price	$91.70
Rate for Payer: Hawaii Medical Service Association ABD	$2.67
Rate for Payer: Hawaii Medical Service Association ABD	$2.67
Rate for Payer: Hawaii Medical Service Association Non-ABD	$2.67
Rate for Payer: Hawaii Medical Service Association Non-ABD	$2.67
Rate for Payer: Hawaii Western Management Group Commercial	$134.02
Rate for Payer: Hawaii Western Management Group Commercial	$159.01
Rate for Payer: Health Management Network Commercial	$119.91
Rate for Payer: Health Management Network Commercial	$142.27
Rate for Payer: Kaiser Permanente Commercial	$88.87
Rate for Payer: Kaiser Permanente Commercial	$105.45
Rate for Payer: Kaiser Permanente Medicaid	$85.36
Rate for Payer: Kaiser Permanente Medicaid	$71.95
Rate for Payer: MDX Hawaii PPO	$162.36
Rate for Payer: MDX Hawaii PPO	$136.84
Rate for Payer: UnitedHealthcare Medicaid	$84.64
Rate for Payer: UnitedHealthcare Medicaid	$100.43
Rate for Payer: University Health Alliance Commercial	$102.83
Rate for Payer: University Health Alliance Commercial	$122.00

AZTREONAM 2 G INJ RECON SOLN (0.1 G/ML)

Facility

$305.06

Service Code	HCPCS J0457
Hospital Revenue Code	636
Min. Negotiated Rate	$2.67
Max. Negotiated Rate	$295.91
Rate for Payer: Cash Price	$198.29
Rate for Payer: Cash Price	$193.24
Rate for Payer: Cash Price	$198.29
Rate for Payer: Cash Price	$193.24
Rate for Payer: Hawaii Medical Service Association ABD	$2.67
Rate for Payer: Hawaii Medical Service Association ABD	$2.67
Rate for Payer: Hawaii Medical Service Association Non-ABD	$2.67
Rate for Payer: Hawaii Medical Service Association Non-ABD	$2.67
Rate for Payer: Hawaii Western Management Group Commercial	$282.43
Rate for Payer: Hawaii Western Management Group Commercial	$289.81
Rate for Payer: Health Management Network Commercial	$259.30
Rate for Payer: Health Management Network Commercial	$252.70
Rate for Payer: Kaiser Permanente Commercial	$192.19
Rate for Payer: Kaiser Permanente Commercial	$187.29
Rate for Payer: Kaiser Permanente Medicaid	$151.62
Rate for Payer: Kaiser Permanente Medicaid	$155.58
Rate for Payer: MDX Hawaii PPO	$295.91
Rate for Payer: MDX Hawaii PPO	$288.37
Rate for Payer: UnitedHealthcare Medicaid	$178.37
Rate for Payer: UnitedHealthcare Medicaid	$183.04
Rate for Payer: University Health Alliance Commercial	$222.36
Rate for Payer: University Health Alliance Commercial	$216.69

AZTREONAM 2 G INJ RECON SOLN (0.1 G/ML)

Facility

$305.06

Service Code	HCPCS J0457
Hospital Revenue Code	250
Min. Negotiated Rate	$259.30
Max. Negotiated Rate	$295.91
Rate for Payer: Cash Price	$198.29
Rate for Payer: Cash Price	$193.24
Rate for Payer: Health Management Network Commercial	$252.70
Rate for Payer: Health Management Network Commercial	$259.30
Rate for Payer: MDX Hawaii PPO	$288.37
Rate for Payer: MDX Hawaii PPO	$295.91

AZTREONAM-AVIBACTAM 2 G IV RECON.SOLN.

Facility

$918.86

Service Code	HCPCS J0458
Hospital Revenue Code	250
Min. Negotiated Rate	$781.03
Max. Negotiated Rate	$891.29
Rate for Payer: Cash Price	$597.26
Rate for Payer: Health Management Network Commercial	$781.03
Rate for Payer: MDX Hawaii PPO	$891.29

AZTREONAM-AVIBACTAM 2 G IV RECON.SOLN.

Facility

$918.86

Service Code	HCPCS J0458
Hospital Revenue Code	636
Min. Negotiated Rate	$1.68
Max. Negotiated Rate	$891.29
Rate for Payer: AlohaCare Medicaid	$1.68
Rate for Payer: AlohaCare Medicare	$1.68
Rate for Payer: Cash Price	$597.26
Rate for Payer: Cash Price	$597.26
Rate for Payer: Devoted Health Medicare	$1.85
Rate for Payer: Hawaii Medical Service Association Commercial	$2.10
Rate for Payer: Hawaii Medical Service Association Medicare	$1.68
Rate for Payer: Hawaii Western Management Group Commercial	$872.92
Rate for Payer: Health Management Network Commercial	$781.03
Rate for Payer: Humana Medicare	$1.68
Rate for Payer: Kaiser Permanente Commercial	$578.88
Rate for Payer: Kaiser Permanente Medicaid	$468.62
Rate for Payer: Kaiser Permanente Medicare	$1.68
Rate for Payer: MDX Hawaii PPO	$891.29
Rate for Payer: Ohana Health Plan Medicaid	$1.85
Rate for Payer: Ohana Health Plan Medicare	$1.68
Rate for Payer: UnitedHealthcare Medicaid	$551.32
Rate for Payer: UnitedHealthcare Medicare	$1.68
Rate for Payer: University Health Alliance Commercial	$669.76

BACITRACIN ZINC-POLYMYXIN B 500-10,000 UNIT/GRAM TOP OINT

Facility

$24.15

Service Code	HCPCS A9270
Hospital Revenue Code	250
Min. Negotiated Rate	$12.32
Max. Negotiated Rate	$23.43
Rate for Payer: Cash Price	$15.70
Rate for Payer: Cash Price	$18.04
Rate for Payer: Hawaii Western Management Group Commercial	$22.94
Rate for Payer: Hawaii Western Management Group Commercial	$26.36
Rate for Payer: Health Management Network Commercial	$20.53
Rate for Payer: Health Management Network Commercial	$23.59
Rate for Payer: Kaiser Permanente Commercial	$15.21
Rate for Payer: Kaiser Permanente Commercial	$17.48
Rate for Payer: Kaiser Permanente Medicaid	$12.32
Rate for Payer: Kaiser Permanente Medicaid	$14.15
Rate for Payer: MDX Hawaii PPO	$23.43
Rate for Payer: MDX Hawaii PPO	$26.92
Rate for Payer: UnitedHealthcare Medicaid	$16.65
Rate for Payer: UnitedHealthcare Medicaid	$14.49
Rate for Payer: University Health Alliance Commercial	$17.60
Rate for Payer: University Health Alliance Commercial	$20.23

BACITRACIN ZINC-POLYMYXIN B 500-10,000 UNIT/GRAM TOP OINT

Facility

$24.15

Service Code	HCPCS A9270
Hospital Revenue Code	250
Min. Negotiated Rate	$20.53
Max. Negotiated Rate	$23.43
Rate for Payer: Cash Price	$15.70
Rate for Payer: Cash Price	$18.04
Rate for Payer: Health Management Network Commercial	$23.59
Rate for Payer: Health Management Network Commercial	$20.53
Rate for Payer: MDX Hawaii PPO	$23.43
Rate for Payer: MDX Hawaii PPO	$26.92

BACK AND NECK PROCEDURES EXCEPT SPINAL FUSION WITH CC

Facility

$47,153.29

Service Code	MSDRG 519
Min. Negotiated Rate	$26,308.16
Max. Negotiated Rate	$47,153.29
Rate for Payer: UnitedHealthcare Medicare	$26,308.16
Rate for Payer: AlohaCare Medicare	$26,308.16
Rate for Payer: Devoted Health Medicare	$28,938.98
Rate for Payer: Hawaii Medical Service Association Commercial	$47,153.29
Rate for Payer: Hawaii Medical Service Association Medicare	$26,308.16
Rate for Payer: Humana Medicare	$26,308.16
Rate for Payer: Kaiser Permanente Commercial	$34,503.45
Rate for Payer: Kaiser Permanente Medicare	$26,308.16
Rate for Payer: Ohana Health Plan Medicare	$26,308.16

BACK AND NECK PROCEDURES EXCEPT SPINAL FUSION WITH MCC OR DISC DEVICE OR NEUROSTIMULATOR

Facility

$64,468.43

Service Code	MSDRG 518
Min. Negotiated Rate	$47,153.29
Max. Negotiated Rate	$64,468.43
Rate for Payer: AlohaCare Medicare	$49,155.84
Rate for Payer: Devoted Health Medicare	$54,071.42
Rate for Payer: Hawaii Medical Service Association Commercial	$47,153.29
Rate for Payer: Hawaii Medical Service Association Medicare	$49,155.84
Rate for Payer: Humana Medicare	$49,155.84
Rate for Payer: Kaiser Permanente Commercial	$64,468.43
Rate for Payer: Kaiser Permanente Medicare	$49,155.84
Rate for Payer: Ohana Health Plan Medicare	$49,155.84
Rate for Payer: UnitedHealthcare Medicare	$49,155.84

BACK AND NECK PROCEDURES EXCEPT SPINAL FUSION WITHOUT CC/MCC

Facility

$30,423.03

Service Code	MSDRG 520
Min. Negotiated Rate	$19,648.91
Max. Negotiated Rate	$30,423.03
Rate for Payer: AlohaCare Medicare	$19,648.91
Rate for Payer: Devoted Health Medicare	$21,613.80
Rate for Payer: Hawaii Medical Service Association Commercial	$30,423.03
Rate for Payer: Hawaii Medical Service Association Medicare	$19,648.91
Rate for Payer: Humana Medicare	$19,648.91
Rate for Payer: Kaiser Permanente Commercial	$25,769.78
Rate for Payer: Kaiser Permanente Medicare	$19,648.91
Rate for Payer: Ohana Health Plan Medicare	$19,648.91
Rate for Payer: UnitedHealthcare Medicare	$19,648.91

BACLOFEN 10 MG PO TABLET

Facility

$3.44

Service Code	HCPCS A9270
Hospital Revenue Code	250
Min. Negotiated Rate	$1.75
Max. Negotiated Rate	$3.34
Rate for Payer: Cash Price	$2.24
Rate for Payer: Cash Price	$1.66
Rate for Payer: Hawaii Western Management Group Commercial	$2.43
Rate for Payer: Hawaii Western Management Group Commercial	$3.27
Rate for Payer: Health Management Network Commercial	$2.18
Rate for Payer: Health Management Network Commercial	$2.92
Rate for Payer: Kaiser Permanente Commercial	$1.61
Rate for Payer: Kaiser Permanente Commercial	$2.17
Rate for Payer: Kaiser Permanente Medicaid	$1.75
Rate for Payer: Kaiser Permanente Medicaid	$1.31
Rate for Payer: MDX Hawaii PPO	$3.34
Rate for Payer: MDX Hawaii PPO	$2.48
Rate for Payer: UnitedHealthcare Medicaid	$1.54
Rate for Payer: UnitedHealthcare Medicaid	$2.06
Rate for Payer: University Health Alliance Commercial	$1.87
Rate for Payer: University Health Alliance Commercial	$2.51

BACLOFEN 10 MG PO TABLET

Facility

$2.56

Service Code	HCPCS A9270
Hospital Revenue Code	250
Min. Negotiated Rate	$2.18
Max. Negotiated Rate	$2.48
Rate for Payer: Cash Price	$1.66
Rate for Payer: Cash Price	$2.24
Rate for Payer: Health Management Network Commercial	$2.92
Rate for Payer: Health Management Network Commercial	$2.18
Rate for Payer: MDX Hawaii PPO	$2.48
Rate for Payer: MDX Hawaii PPO	$3.34

BACLOFEN 20 MG PO TABLET

Facility

$3.68

Service Code	HCPCS A9270
Hospital Revenue Code	250
Min. Negotiated Rate	$1.88
Max. Negotiated Rate	$3.57
Rate for Payer: Cash Price	$2.39
Rate for Payer: Cash Price	$18.41
Rate for Payer: Hawaii Western Management Group Commercial	$3.50
Rate for Payer: Hawaii Western Management Group Commercial	$26.90
Rate for Payer: Health Management Network Commercial	$3.13
Rate for Payer: Health Management Network Commercial	$24.07
Rate for Payer: Kaiser Permanente Commercial	$2.32
Rate for Payer: Kaiser Permanente Commercial	$17.84
Rate for Payer: Kaiser Permanente Medicaid	$14.44
Rate for Payer: Kaiser Permanente Medicaid	$1.88
Rate for Payer: MDX Hawaii PPO	$3.57
Rate for Payer: MDX Hawaii PPO	$27.47
Rate for Payer: UnitedHealthcare Medicaid	$16.99
Rate for Payer: UnitedHealthcare Medicaid	$2.21
Rate for Payer: University Health Alliance Commercial	$2.68
Rate for Payer: University Health Alliance Commercial	$20.64

BACLOFEN 20 MG PO TABLET

Facility

$3.68

Service Code	HCPCS A9270
Hospital Revenue Code	250
Min. Negotiated Rate	$3.13
Max. Negotiated Rate	$3.57
Rate for Payer: Cash Price	$2.39
Rate for Payer: Cash Price	$18.41
Rate for Payer: Health Management Network Commercial	$24.07
Rate for Payer: Health Management Network Commercial	$3.13
Rate for Payer: MDX Hawaii PPO	$27.47
Rate for Payer: MDX Hawaii PPO	$3.57

BACTERIAL AND TUBERCULOUS INFECTIONS OF NERVOUS SYSTEM WITH CC

Facility

$52,191.65

Service Code	MSDRG 095
Min. Negotiated Rate	$33,923.61
Max. Negotiated Rate	$52,191.65
Rate for Payer: AlohaCare Medicare	$33,923.61
Rate for Payer: Devoted Health Medicare	$37,315.97
Rate for Payer: Hawaii Medical Service Association Commercial	$52,191.65
Rate for Payer: Hawaii Medical Service Association Medicare	$33,923.61
Rate for Payer: Humana Medicare	$33,923.61
Rate for Payer: Kaiser Permanente Commercial	$44,491.20
Rate for Payer: Kaiser Permanente Medicare	$33,923.61
Rate for Payer: Ohana Health Plan Medicare	$33,923.61
Rate for Payer: UnitedHealthcare Medicare	$33,923.61

BACTERIAL AND TUBERCULOUS INFECTIONS OF NERVOUS SYSTEM WITH MCC

Facility

$60,709.65

Service Code	MSDRG 094
Min. Negotiated Rate	$46,289.86
Max. Negotiated Rate	$60,709.65
Rate for Payer: AlohaCare Medicare	$46,289.86
Rate for Payer: Devoted Health Medicare	$50,918.85
Rate for Payer: Hawaii Medical Service Association Commercial	$52,191.65
Rate for Payer: Hawaii Medical Service Association Medicare	$46,289.86
Rate for Payer: Humana Medicare	$46,289.86
Rate for Payer: Kaiser Permanente Commercial	$60,709.65
Rate for Payer: Kaiser Permanente Medicare	$46,289.86
Rate for Payer: Ohana Health Plan Medicare	$46,289.86
Rate for Payer: UnitedHealthcare Medicare	$46,289.86

Know your out-of-pocket cost for care.

All Charges