Kona Community Hospital

All Charges

Charge

Type

Setting

Price

Intro Sheath 5FR x 11cm w/Guidewire M00115711B1/ 15-711B [3642053]

Facility

$93.50

Service Code	HCPCS C1894
Hospital Charge Code	3642053
Hospital Revenue Code	272
Min. Negotiated Rate	$79.47
Max. Negotiated Rate	$90.69
Rate for Payer: Cash Price	$60.78
Rate for Payer: Health Management Network Commercial	$79.47
Rate for Payer: MDX Hawaii PPO	$90.69

Intro Sheath 5FR x 11cm w/Guidewire M00115711B1/ 15-711B [3642053]

Facility

$93.50

Service Code	HCPCS C1894
Hospital Charge Code	3642053
Hospital Revenue Code	272
Min. Negotiated Rate	$47.69
Max. Negotiated Rate	$90.69
Rate for Payer: Cash Price	$60.78
Rate for Payer: Hawaii Western Management Group Commercial	$88.83
Rate for Payer: Health Management Network Commercial	$79.47
Rate for Payer: Kaiser Permanente Commercial	$58.91
Rate for Payer: Kaiser Permanente Medicaid	$47.69
Rate for Payer: MDX Hawaii PPO	$90.69
Rate for Payer: University Health Alliance Commercial	$68.15

Intro Sheath 6FR x 11cm w/Guidewire M00115712B1/ 15-712B [3642054]

Facility

$93.50

Service Code	HCPCS C1894
Hospital Charge Code	3642054
Hospital Revenue Code	272
Min. Negotiated Rate	$79.47
Max. Negotiated Rate	$90.69
Rate for Payer: Cash Price	$60.78
Rate for Payer: Health Management Network Commercial	$79.47
Rate for Payer: MDX Hawaii PPO	$90.69

Intro Sheath 6FR x 11cm w/Guidewire M00115712B1/ 15-712B [3642054]

Facility

$93.50

Service Code	HCPCS C1894
Hospital Charge Code	3642054
Hospital Revenue Code	272
Min. Negotiated Rate	$47.69
Max. Negotiated Rate	$90.69
Rate for Payer: Cash Price	$60.78
Rate for Payer: Hawaii Western Management Group Commercial	$88.83
Rate for Payer: Health Management Network Commercial	$79.47
Rate for Payer: Kaiser Permanente Commercial	$58.91
Rate for Payer: Kaiser Permanente Medicaid	$47.69
Rate for Payer: MDX Hawaii PPO	$90.69
Rate for Payer: University Health Alliance Commercial	$68.15

Inzii 10mmx225ml Retrieval System CD001 [3644776]

Facility

$520.25

Hospital Charge Code	3644776
Hospital Revenue Code	272
Min. Negotiated Rate	$265.33
Max. Negotiated Rate	$504.64
Rate for Payer: Cash Price	$338.16
Rate for Payer: Hawaii Western Management Group Commercial	$494.24
Rate for Payer: Health Management Network Commercial	$442.21
Rate for Payer: Kaiser Permanente Commercial	$327.76
Rate for Payer: Kaiser Permanente Medicaid	$265.33
Rate for Payer: MDX Hawaii PPO	$504.64
Rate for Payer: University Health Alliance Commercial	$379.21

Inzii 10mmx225ml Retrieval System CD001 [3644776]

Facility

$520.25

Hospital Charge Code	3644776
Hospital Revenue Code	272
Min. Negotiated Rate	$442.21
Max. Negotiated Rate	$504.64
Rate for Payer: Cash Price	$338.16
Rate for Payer: Health Management Network Commercial	$442.21
Rate for Payer: MDX Hawaii PPO	$504.64

Inzii 11mm x 265ml Ripstop Redeployable Retrieval System CD005 [3644777]

Facility

$1,198.00

Hospital Charge Code	3644777
Hospital Revenue Code	272
Min. Negotiated Rate	$610.98
Max. Negotiated Rate	$1,162.06
Rate for Payer: Cash Price	$778.70
Rate for Payer: Hawaii Western Management Group Commercial	$1,138.10
Rate for Payer: Health Management Network Commercial	$1,018.30
Rate for Payer: Kaiser Permanente Commercial	$754.74
Rate for Payer: Kaiser Permanente Medicaid	$610.98
Rate for Payer: MDX Hawaii PPO	$1,162.06
Rate for Payer: University Health Alliance Commercial	$873.22

Inzii 11mm x 265ml Ripstop Redeployable Retrieval System CD005 [3644777]

Facility

$1,198.00

Hospital Charge Code	3644777
Hospital Revenue Code	272
Min. Negotiated Rate	$1,018.30
Max. Negotiated Rate	$1,162.06
Rate for Payer: Cash Price	$778.70
Rate for Payer: Health Management Network Commercial	$1,018.30
Rate for Payer: MDX Hawaii PPO	$1,162.06

IODINE STRONG (LUGOLS) 5 % PO SOLN

Facility

$172.12

Service Code	HCPCS A9270
Hospital Revenue Code	250
Min. Negotiated Rate	$146.30
Max. Negotiated Rate	$166.96
Rate for Payer: Cash Price	$111.88
Rate for Payer: Health Management Network Commercial	$146.30
Rate for Payer: MDX Hawaii PPO	$166.96

IODINE STRONG (LUGOLS) 5 % PO SOLN

Facility

$172.12

Service Code	HCPCS A9270
Hospital Revenue Code	250
Min. Negotiated Rate	$87.78
Max. Negotiated Rate	$166.96
Rate for Payer: Cash Price	$111.88
Rate for Payer: Hawaii Western Management Group Commercial	$163.51
Rate for Payer: Health Management Network Commercial	$146.30
Rate for Payer: Kaiser Permanente Commercial	$108.44
Rate for Payer: Kaiser Permanente Medicaid	$87.78
Rate for Payer: MDX Hawaii PPO	$166.96
Rate for Payer: UnitedHealthcare Medicaid	$103.27
Rate for Payer: University Health Alliance Commercial	$125.46

IOHEXOL 240 MG/ML IV SOLN (50 ML)

Facility

$218.17

Service Code	HCPCS Q9966
Hospital Revenue Code	255
Min. Negotiated Rate	$185.44
Max. Negotiated Rate	$211.62
Rate for Payer: Cash Price	$141.81
Rate for Payer: Health Management Network Commercial	$185.44
Rate for Payer: MDX Hawaii PPO	$211.62

IOHEXOL 240 MG/ML IV SOLN (50 ML)

Facility

$218.17

Service Code	HCPCS Q9966
Hospital Revenue Code	255
Min. Negotiated Rate	$0.45
Max. Negotiated Rate	$211.62
Rate for Payer: Cash Price	$141.81
Rate for Payer: Cash Price	$141.81
Rate for Payer: Hawaii Medical Service Association ABD	$0.45
Rate for Payer: Hawaii Medical Service Association Non-ABD	$0.45
Rate for Payer: Hawaii Western Management Group Commercial	$207.26
Rate for Payer: Health Management Network Commercial	$185.44
Rate for Payer: Kaiser Permanente Commercial	$137.45
Rate for Payer: Kaiser Permanente Medicaid	$111.27
Rate for Payer: MDX Hawaii PPO	$211.62
Rate for Payer: UnitedHealthcare Medicaid	$1.14
Rate for Payer: University Health Alliance Commercial	$159.02

IOHEXOL 350 MG/ML IV SOLN 100 ML

Facility

$498.67

Service Code	HCPCS Q9967
Hospital Revenue Code	255
Min. Negotiated Rate	$423.87
Max. Negotiated Rate	$483.71
Rate for Payer: Cash Price	$324.14
Rate for Payer: Health Management Network Commercial	$423.87
Rate for Payer: MDX Hawaii PPO	$483.71

IOHEXOL 350 MG/ML IV SOLN 100 ML

Facility

$498.67

Service Code	HCPCS Q9967
Hospital Revenue Code	255
Min. Negotiated Rate	$0.15
Max. Negotiated Rate	$483.71
Rate for Payer: Cash Price	$324.14
Rate for Payer: Cash Price	$324.14
Rate for Payer: Hawaii Medical Service Association ABD	$0.15
Rate for Payer: Hawaii Medical Service Association Non-ABD	$0.15
Rate for Payer: Hawaii Western Management Group Commercial	$473.74
Rate for Payer: Health Management Network Commercial	$423.87
Rate for Payer: Kaiser Permanente Commercial	$314.16
Rate for Payer: Kaiser Permanente Medicaid	$254.32
Rate for Payer: MDX Hawaii PPO	$483.71
Rate for Payer: UnitedHealthcare Medicaid	$0.30
Rate for Payer: University Health Alliance Commercial	$363.48

IPILIMUMAB 200 MG/40 ML (5 MG/ML) IV SOLN

Facility

$44,581.06

Service Code	HCPCS J9228
Hospital Revenue Code	636
Min. Negotiated Rate	$183.41
Max. Negotiated Rate	$43,243.63
Rate for Payer: AlohaCare Medicaid	$187.17
Rate for Payer: AlohaCare Medicare	$187.17
Rate for Payer: Cash Price	$28,977.69
Rate for Payer: Cash Price	$28,977.69
Rate for Payer: Devoted Health Medicare	$205.89
Rate for Payer: Hawaii Medical Service Association ABD	$183.41
Rate for Payer: Hawaii Medical Service Association Commercial	$233.96
Rate for Payer: Hawaii Medical Service Association Medicare	$187.17
Rate for Payer: Hawaii Medical Service Association Non-ABD	$183.41
Rate for Payer: Hawaii Western Management Group Commercial	$42,352.01
Rate for Payer: Health Management Network Commercial	$37,893.90
Rate for Payer: Humana Medicare	$187.17
Rate for Payer: Kaiser Permanente Commercial	$28,086.07
Rate for Payer: Kaiser Permanente Medicaid	$22,736.34
Rate for Payer: Kaiser Permanente Medicare	$187.17
Rate for Payer: MDX Hawaii PPO	$43,243.63
Rate for Payer: Ohana Health Plan Medicaid	$205.89
Rate for Payer: Ohana Health Plan Medicare	$187.17
Rate for Payer: UnitedHealthcare Medicaid	$26,748.64
Rate for Payer: UnitedHealthcare Medicare	$187.17
Rate for Payer: University Health Alliance Commercial	$32,495.13

IPILIMUMAB 200 MG/40 ML (5 MG/ML) IV SOLN

Facility

$44,581.06

Service Code	HCPCS J9228
Hospital Revenue Code	250
Min. Negotiated Rate	$37,893.90
Max. Negotiated Rate	$43,243.63
Rate for Payer: Cash Price	$28,977.69
Rate for Payer: Health Management Network Commercial	$37,893.90
Rate for Payer: MDX Hawaii PPO	$43,243.63

IPILIMUMAB 50 MG/10 ML (5 MG/ML) IV SOLN

Facility

$11,984.09

Service Code	HCPCS J9228
Hospital Revenue Code	250
Min. Negotiated Rate	$10,186.48
Max. Negotiated Rate	$11,624.57
Rate for Payer: Cash Price	$7,789.66
Rate for Payer: Health Management Network Commercial	$10,186.48
Rate for Payer: MDX Hawaii PPO	$11,624.57

IPILIMUMAB 50 MG/10 ML (5 MG/ML) IV SOLN

Facility

$11,984.09

Service Code	HCPCS J9228
Hospital Revenue Code	636
Min. Negotiated Rate	$183.41
Max. Negotiated Rate	$11,624.57
Rate for Payer: AlohaCare Medicaid	$187.17
Rate for Payer: AlohaCare Medicare	$187.17
Rate for Payer: Cash Price	$7,789.66
Rate for Payer: Cash Price	$7,789.66
Rate for Payer: Devoted Health Medicare	$205.89
Rate for Payer: Hawaii Medical Service Association ABD	$183.41
Rate for Payer: Hawaii Medical Service Association Commercial	$233.96
Rate for Payer: Hawaii Medical Service Association Medicare	$187.17
Rate for Payer: Hawaii Medical Service Association Non-ABD	$183.41
Rate for Payer: Hawaii Western Management Group Commercial	$11,384.89
Rate for Payer: Health Management Network Commercial	$10,186.48
Rate for Payer: Humana Medicare	$187.17
Rate for Payer: Kaiser Permanente Commercial	$7,549.98
Rate for Payer: Kaiser Permanente Medicaid	$6,111.89
Rate for Payer: Kaiser Permanente Medicare	$187.17
Rate for Payer: MDX Hawaii PPO	$11,624.57
Rate for Payer: Ohana Health Plan Medicaid	$205.89
Rate for Payer: Ohana Health Plan Medicare	$187.17
Rate for Payer: UnitedHealthcare Medicaid	$7,190.45
Rate for Payer: UnitedHealthcare Medicare	$187.17
Rate for Payer: University Health Alliance Commercial	$8,735.20

IP/OBS CONSLTJ NEW/EST PT HIGH MDM 80 MINUTES

Professional

Both

$450.00

Service Code	HCPCS 99255
Min. Negotiated Rate	$190.80
Max. Negotiated Rate	$382.50
Rate for Payer: Cash Price	$292.50
Rate for Payer: Cash Price	$292.50
Rate for Payer: Hawaii Western Management Group Commercial	$190.80
Rate for Payer: Health Management Network Commercial	$382.50

IP/OBS CONSLTJ NEW/EST PT LOW MDM 45 MINUTES

Professional

Both

$230.00

Service Code	HCPCS 99253
Min. Negotiated Rate	$102.55
Max. Negotiated Rate	$195.50
Rate for Payer: Cash Price	$149.50
Rate for Payer: Cash Price	$149.50
Rate for Payer: Hawaii Western Management Group Commercial	$102.55
Rate for Payer: Health Management Network Commercial	$195.50

IP/OBS CONSLTJ NEW/EST PT MOD MDM 60 MINUTES

Professional

Both

$350.00

Service Code	HCPCS 99254
Min. Negotiated Rate	$141.07
Max. Negotiated Rate	$297.50
Rate for Payer: Cash Price	$227.50
Rate for Payer: Cash Price	$227.50
Rate for Payer: Hawaii Western Management Group Commercial	$141.07
Rate for Payer: Health Management Network Commercial	$297.50

IP/OBS CONSLTJ NEW/EST PT SF MDM 35 MINUTES

Professional

Both

$180.00

Service Code	HCPCS 99252
Min. Negotiated Rate	$77.22
Max. Negotiated Rate	$153.00
Rate for Payer: Cash Price	$117.00
Rate for Payer: Cash Price	$117.00
Rate for Payer: Hawaii Western Management Group Commercial	$77.22
Rate for Payer: Health Management Network Commercial	$153.00

IPRATROPIUM-ALBUTEROL 0.5 MG-3 MG(2.5 MG BASE)/3 ML INHAL NEBU

Facility

$12.19

Service Code	NDC 00487020101
Hospital Revenue Code	250
Min. Negotiated Rate	$10.36
Max. Negotiated Rate	$11.82
Rate for Payer: Cash Price	$7.92
Rate for Payer: Health Management Network Commercial	$10.36
Rate for Payer: MDX Hawaii PPO	$11.82

IPRATROPIUM-ALBUTEROL 0.5 MG-3 MG(2.5 MG BASE)/3 ML INHAL NEBU

Facility

$4.31

Service Code	NDC 60687040583
Hospital Revenue Code	250
Min. Negotiated Rate	$3.66
Max. Negotiated Rate	$4.18
Rate for Payer: Cash Price	$2.80
Rate for Payer: Health Management Network Commercial	$3.66
Rate for Payer: MDX Hawaii PPO	$4.18

IPRATROPIUM-ALBUTEROL 0.5 MG-3 MG(2.5 MG BASE)/3 ML INHAL NEBU

Facility

$4.31

Service Code	NDC 60687040583
Hospital Revenue Code	250
Min. Negotiated Rate	$2.20
Max. Negotiated Rate	$4.18
Rate for Payer: Cash Price	$2.80
Rate for Payer: Hawaii Western Management Group Commercial	$4.09
Rate for Payer: Health Management Network Commercial	$3.66
Rate for Payer: Kaiser Permanente Commercial	$2.72
Rate for Payer: Kaiser Permanente Medicaid	$2.20
Rate for Payer: MDX Hawaii PPO	$4.18
Rate for Payer: UnitedHealthcare Medicaid	$2.59
Rate for Payer: University Health Alliance Commercial	$3.14

Know your out-of-pocket cost for care.

All Charges