Kona Community Hospital

All Charges

Charge

Type

Setting

Price

IVERMECTIN 3 MG PO TABLET

Facility

$27.43

Service Code	HCPCS A9270
Hospital Revenue Code	250
Min. Negotiated Rate	$13.99
Max. Negotiated Rate	$26.61
Rate for Payer: Cash Price	$17.83
Rate for Payer: Hawaii Western Management Group Commercial	$26.06
Rate for Payer: Health Management Network Commercial	$23.32
Rate for Payer: Kaiser Permanente Commercial	$17.28
Rate for Payer: Kaiser Permanente Medicaid	$13.99
Rate for Payer: MDX Hawaii PPO	$26.61
Rate for Payer: UnitedHealthcare Medicaid	$16.46
Rate for Payer: University Health Alliance Commercial	$19.99

IVERMECTIN 3 MG PO TABLET

Facility

$27.43

Service Code	HCPCS A9270
Hospital Revenue Code	250
Min. Negotiated Rate	$23.32
Max. Negotiated Rate	$26.61
Rate for Payer: Cash Price	$17.83
Rate for Payer: Health Management Network Commercial	$23.32
Rate for Payer: MDX Hawaii PPO	$26.61

IV INFUSION HYDRATION EACH ADDITIONAL HOUR

Professional

Both

$40.00

Service Code	HCPCS 96361
Min. Negotiated Rate	$8.11
Max. Negotiated Rate	$34.00
Rate for Payer: AlohaCare Medicaid	$8.11
Rate for Payer: AlohaCare Medicare	$14.21
Rate for Payer: Cash Price	$26.00
Rate for Payer: Cash Price	$26.00
Rate for Payer: Devoted Health Medicare	$15.63
Rate for Payer: Hawaii Medical Service Association Medicare	$14.21
Rate for Payer: Hawaii Western Management Group Commercial	$18.68
Rate for Payer: Health Management Network Commercial	$34.00
Rate for Payer: Kaiser Permanente Commercial	$17.05
Rate for Payer: Kaiser Permanente Medicaid	$17.05
Rate for Payer: Kaiser Permanente Medicare	$17.05
Rate for Payer: Ohana Health Plan Medicaid	$8.11
Rate for Payer: Ohana Health Plan Medicare	$14.21
Rate for Payer: UnitedHealthcare Medicaid	$8.11
Rate for Payer: UnitedHealthcare Medicare	$14.21

IV INFUSION HYDRATION INITIAL 31 MIN-1 HOUR

Professional

Both

$153.00

Service Code	HCPCS 96360
Min. Negotiated Rate	$21.64
Max. Negotiated Rate	$130.05
Rate for Payer: AlohaCare Medicaid	$21.64
Rate for Payer: AlohaCare Medicare	$37.01
Rate for Payer: Cash Price	$99.45
Rate for Payer: Cash Price	$99.45
Rate for Payer: Devoted Health Medicare	$40.71
Rate for Payer: Hawaii Medical Service Association Medicare	$37.01
Rate for Payer: Hawaii Western Management Group Commercial	$59.83
Rate for Payer: Health Management Network Commercial	$130.05
Rate for Payer: Kaiser Permanente Commercial	$44.41
Rate for Payer: Kaiser Permanente Medicaid	$44.41
Rate for Payer: Kaiser Permanente Medicare	$44.41
Rate for Payer: Ohana Health Plan Medicaid	$21.64
Rate for Payer: Ohana Health Plan Medicare	$37.01
Rate for Payer: UnitedHealthcare Medicaid	$21.64
Rate for Payer: UnitedHealthcare Medicare	$37.01

IV INFUSION THERAPY/PROPHYLAXIS /DX 1ST TO 1 HR

Professional

Both

$210.00

Service Code	HCPCS 96365
Min. Negotiated Rate	$42.05
Max. Negotiated Rate	$178.50
Rate for Payer: AlohaCare Medicaid	$42.05
Rate for Payer: AlohaCare Medicare	$74.63
Rate for Payer: Cash Price	$136.50
Rate for Payer: Cash Price	$136.50
Rate for Payer: Devoted Health Medicare	$82.09
Rate for Payer: Hawaii Medical Service Association Medicare	$74.63
Rate for Payer: Hawaii Western Management Group Commercial	$73.23
Rate for Payer: Health Management Network Commercial	$178.50
Rate for Payer: Kaiser Permanente Commercial	$89.56
Rate for Payer: Kaiser Permanente Medicaid	$89.56
Rate for Payer: Kaiser Permanente Medicare	$89.56
Rate for Payer: Ohana Health Plan Medicaid	$42.05
Rate for Payer: Ohana Health Plan Medicare	$74.63
Rate for Payer: UnitedHealthcare Medicaid	$42.05
Rate for Payer: UnitedHealthcare Medicare	$74.63

IV INFUSION THERAPY PROPHYLAXIS/DX EA HOUR

Professional

Both

$65.00

Service Code	HCPCS 96366
Min. Negotiated Rate	$13.35
Max. Negotiated Rate	$55.25
Rate for Payer: AlohaCare Medicaid	$13.35
Rate for Payer: AlohaCare Medicare	$23.30
Rate for Payer: Cash Price	$42.25
Rate for Payer: Cash Price	$42.25
Rate for Payer: Devoted Health Medicare	$25.63
Rate for Payer: Hawaii Medical Service Association Medicare	$23.30
Rate for Payer: Hawaii Western Management Group Commercial	$23.85
Rate for Payer: Health Management Network Commercial	$55.25
Rate for Payer: Kaiser Permanente Commercial	$27.96
Rate for Payer: Kaiser Permanente Medicaid	$27.96
Rate for Payer: Kaiser Permanente Medicare	$27.96
Rate for Payer: Ohana Health Plan Medicaid	$13.35
Rate for Payer: Ohana Health Plan Medicare	$23.30
Rate for Payer: UnitedHealthcare Medicaid	$13.35
Rate for Payer: UnitedHealthcare Medicare	$23.30

IV INFUSION THER PROPH ADDL SEQUENTIAL TO 1 HR

Professional

Both

$93.00

Service Code	HCPCS 96367
Min. Negotiated Rate	$18.82
Max. Negotiated Rate	$79.05
Rate for Payer: AlohaCare Medicaid	$18.82
Rate for Payer: AlohaCare Medicare	$32.74
Rate for Payer: Cash Price	$60.45
Rate for Payer: Cash Price	$60.45
Rate for Payer: Devoted Health Medicare	$36.01
Rate for Payer: Hawaii Medical Service Association Medicare	$32.74
Rate for Payer: Hawaii Western Management Group Commercial	$39.93
Rate for Payer: Health Management Network Commercial	$79.05
Rate for Payer: Kaiser Permanente Commercial	$39.29
Rate for Payer: Kaiser Permanente Medicaid	$39.29
Rate for Payer: Kaiser Permanente Medicare	$39.29
Rate for Payer: Ohana Health Plan Medicaid	$18.82
Rate for Payer: Ohana Health Plan Medicare	$32.74
Rate for Payer: UnitedHealthcare Medicaid	$18.82
Rate for Payer: UnitedHealthcare Medicare	$32.74

IV NFS THERAPY PROPHYLAXIS/DX CONCURRENT NFS

Professional

Both

$63.00

Service Code	HCPCS 96368
Min. Negotiated Rate	$12.92
Max. Negotiated Rate	$53.55
Rate for Payer: AlohaCare Medicaid	$12.92
Rate for Payer: AlohaCare Medicare	$22.58
Rate for Payer: Cash Price	$40.95
Rate for Payer: Cash Price	$40.95
Rate for Payer: Devoted Health Medicare	$24.84
Rate for Payer: Hawaii Medical Service Association Medicare	$22.58
Rate for Payer: Hawaii Western Management Group Commercial	$22.80
Rate for Payer: Health Management Network Commercial	$53.55
Rate for Payer: Kaiser Permanente Commercial	$27.10
Rate for Payer: Kaiser Permanente Medicaid	$27.10
Rate for Payer: Kaiser Permanente Medicare	$27.10
Rate for Payer: Ohana Health Plan Medicaid	$12.92
Rate for Payer: Ohana Health Plan Medicare	$22.58
Rate for Payer: UnitedHealthcare Medicaid	$12.92
Rate for Payer: UnitedHealthcare Medicare	$22.58

Iv Safeset Arterial Pressure Tubing [2707811]

Facility

$90.78

Hospital Charge Code	2707811
Hospital Revenue Code	272
Min. Negotiated Rate	$46.30
Max. Negotiated Rate	$88.06
Rate for Payer: Cash Price	$59.01
Rate for Payer: Hawaii Western Management Group Commercial	$86.24
Rate for Payer: Health Management Network Commercial	$77.16
Rate for Payer: Kaiser Permanente Commercial	$57.19
Rate for Payer: Kaiser Permanente Medicaid	$46.30
Rate for Payer: MDX Hawaii PPO	$88.06
Rate for Payer: University Health Alliance Commercial	$66.17

Iv Safeset Arterial Pressure Tubing [2707811]

Facility

$90.78

Hospital Charge Code	2707811
Hospital Revenue Code	272
Min. Negotiated Rate	$77.16
Max. Negotiated Rate	$88.06
Rate for Payer: Cash Price	$59.01
Rate for Payer: Health Management Network Commercial	$77.16
Rate for Payer: MDX Hawaii PPO	$88.06

J-Hook Cautery Probe Tip Disp 6162 [3642399]

Facility

$129.60

Hospital Charge Code	3642399
Hospital Revenue Code	272
Min. Negotiated Rate	$110.16
Max. Negotiated Rate	$125.71
Rate for Payer: Cash Price	$84.24
Rate for Payer: Health Management Network Commercial	$110.16
Rate for Payer: MDX Hawaii PPO	$125.71

J-Hook Cautery Probe Tip Disp 6162 [3642399]

Facility

$129.60

Hospital Charge Code	3642399
Hospital Revenue Code	272
Min. Negotiated Rate	$66.10
Max. Negotiated Rate	$125.71
Rate for Payer: Cash Price	$84.24
Rate for Payer: Hawaii Western Management Group Commercial	$123.12
Rate for Payer: Health Management Network Commercial	$110.16
Rate for Payer: Kaiser Permanente Commercial	$81.65
Rate for Payer: Kaiser Permanente Medicaid	$66.10
Rate for Payer: MDX Hawaii PPO	$125.71
Rate for Payer: University Health Alliance Commercial	$94.47

Juggerknot Soft Anchor 2.9mm W/Cut Needle 110005093 [3644301]

Facility

$2,091.38

Service Code	HCPCS C1713
Hospital Charge Code	3644301
Hospital Revenue Code	278
Min. Negotiated Rate	$1,171.17
Max. Negotiated Rate	$2,028.64
Rate for Payer: Cash Price	$1,359.40
Rate for Payer: Hawaii Western Management Group Commercial	$1,463.97
Rate for Payer: Health Management Network Commercial	$1,777.67
Rate for Payer: MDX Hawaii PPO	$2,028.64
Rate for Payer: University Health Alliance Commercial	$1,171.17

Juggerknot Soft Anchor 2.9mm W/Cut Needle 110005093 [3644301]

Facility

$2,091.38

Service Code	HCPCS C1713
Hospital Charge Code	3644301
Hospital Revenue Code	278
Min. Negotiated Rate	$1,066.60
Max. Negotiated Rate	$2,028.64
Rate for Payer: Cash Price	$1,359.40
Rate for Payer: Hawaii Western Management Group Commercial	$1,463.97
Rate for Payer: Health Management Network Commercial	$1,777.67
Rate for Payer: Kaiser Permanente Commercial	$1,317.57
Rate for Payer: Kaiser Permanente Medicaid	$1,066.60
Rate for Payer: MDX Hawaii PPO	$2,028.64
Rate for Payer: University Health Alliance Commercial	$1,171.17

KETAMINE 100 MG/ML INJ SOLN

Facility

$70.75

Service Code	NDC 00143950901
Hospital Revenue Code	250
Min. Negotiated Rate	$60.14
Max. Negotiated Rate	$68.63
Rate for Payer: Cash Price	$45.99
Rate for Payer: Health Management Network Commercial	$60.14
Rate for Payer: MDX Hawaii PPO	$68.63

KETAMINE 100 MG/ML INJ SOLN

Facility

$49.82

Service Code	NDC 00409205105
Hospital Revenue Code	250
Min. Negotiated Rate	$42.35
Max. Negotiated Rate	$48.33
Rate for Payer: Cash Price	$32.38
Rate for Payer: Health Management Network Commercial	$42.35
Rate for Payer: MDX Hawaii PPO	$48.33

KETAMINE 100 MG/ML INJ SOLN

Facility

$70.75

Service Code	NDC 00143950910
Hospital Revenue Code	250
Min. Negotiated Rate	$36.08
Max. Negotiated Rate	$68.63
Rate for Payer: Cash Price	$45.99
Rate for Payer: Hawaii Western Management Group Commercial	$67.21
Rate for Payer: Health Management Network Commercial	$60.14
Rate for Payer: Kaiser Permanente Commercial	$44.57
Rate for Payer: Kaiser Permanente Medicaid	$36.08
Rate for Payer: MDX Hawaii PPO	$68.63
Rate for Payer: UnitedHealthcare Medicaid	$42.45
Rate for Payer: University Health Alliance Commercial	$51.57

KETAMINE 100 MG/ML INJ SOLN

Facility

$49.82

Service Code	NDC 00409205105
Hospital Revenue Code	250
Min. Negotiated Rate	$25.41
Max. Negotiated Rate	$48.33
Rate for Payer: Cash Price	$32.38
Rate for Payer: Hawaii Western Management Group Commercial	$47.33
Rate for Payer: Health Management Network Commercial	$42.35
Rate for Payer: Kaiser Permanente Commercial	$31.39
Rate for Payer: Kaiser Permanente Medicaid	$25.41
Rate for Payer: MDX Hawaii PPO	$48.33
Rate for Payer: UnitedHealthcare Medicaid	$29.89
Rate for Payer: University Health Alliance Commercial	$36.31

KETAMINE 100 MG/ML INJ SOLN

Facility

$49.82

Service Code	NDC 00409004005
Hospital Revenue Code	250
Min. Negotiated Rate	$42.35
Max. Negotiated Rate	$48.33
Rate for Payer: Cash Price	$32.38
Rate for Payer: Health Management Network Commercial	$42.35
Rate for Payer: MDX Hawaii PPO	$48.33

KETAMINE 100 MG/ML INJ SOLN

Facility

$49.82

Service Code	NDC 00409004005
Hospital Revenue Code	250
Min. Negotiated Rate	$25.41
Max. Negotiated Rate	$48.33
Rate for Payer: Cash Price	$32.38
Rate for Payer: Hawaii Western Management Group Commercial	$47.33
Rate for Payer: Health Management Network Commercial	$42.35
Rate for Payer: Kaiser Permanente Commercial	$31.39
Rate for Payer: Kaiser Permanente Medicaid	$25.41
Rate for Payer: MDX Hawaii PPO	$48.33
Rate for Payer: UnitedHealthcare Medicaid	$29.89
Rate for Payer: University Health Alliance Commercial	$36.31

KETAMINE 100 MG/ML INJ SOLN

Facility

$70.75

Service Code	NDC 00143950910
Hospital Revenue Code	250
Min. Negotiated Rate	$60.14
Max. Negotiated Rate	$68.63
Rate for Payer: Cash Price	$45.99
Rate for Payer: Health Management Network Commercial	$60.14
Rate for Payer: MDX Hawaii PPO	$68.63

KETAMINE 100 MG/ML INJ SOLN

Facility

$49.82

Service Code	NDC 00409004010
Hospital Revenue Code	250
Min. Negotiated Rate	$25.41
Max. Negotiated Rate	$48.33
Rate for Payer: Cash Price	$32.38
Rate for Payer: Hawaii Western Management Group Commercial	$47.33
Rate for Payer: Health Management Network Commercial	$42.35
Rate for Payer: Kaiser Permanente Commercial	$31.39
Rate for Payer: Kaiser Permanente Medicaid	$25.41
Rate for Payer: MDX Hawaii PPO	$48.33
Rate for Payer: UnitedHealthcare Medicaid	$29.89
Rate for Payer: University Health Alliance Commercial	$36.31

KETAMINE 100 MG/ML INJ SOLN

Facility

$70.75

Service Code	NDC 00143950901
Hospital Revenue Code	250
Min. Negotiated Rate	$36.08
Max. Negotiated Rate	$68.63
Rate for Payer: Cash Price	$45.99
Rate for Payer: Hawaii Western Management Group Commercial	$67.21
Rate for Payer: Health Management Network Commercial	$60.14
Rate for Payer: Kaiser Permanente Commercial	$44.57
Rate for Payer: Kaiser Permanente Medicaid	$36.08
Rate for Payer: MDX Hawaii PPO	$68.63
Rate for Payer: UnitedHealthcare Medicaid	$42.45
Rate for Payer: University Health Alliance Commercial	$51.57

KETAMINE 100 MG/ML INJ SOLN

Facility

$49.82

Service Code	NDC 00409004010
Hospital Revenue Code	250
Min. Negotiated Rate	$42.35
Max. Negotiated Rate	$48.33
Rate for Payer: Cash Price	$32.38
Rate for Payer: Health Management Network Commercial	$42.35
Rate for Payer: MDX Hawaii PPO	$48.33

KETAMINE 100 MG/ML INJ SOLN

Facility

$49.82

Service Code	NDC 00409205115
Hospital Revenue Code	250
Min. Negotiated Rate	$42.35
Max. Negotiated Rate	$48.33
Rate for Payer: Cash Price	$32.38
Rate for Payer: Health Management Network Commercial	$42.35
Rate for Payer: MDX Hawaii PPO	$48.33

Know your out-of-pocket cost for care.

All Charges