Kona Community Hospital

All Charges

Charge

Type

Setting

Price

Lens Tecnis Symfony Optiblue Iol 24.5 [3643820]

Facility

$3,482.50

Service Code	HCPCS V2632
Hospital Charge Code	3643820
Hospital Revenue Code	276
Min. Negotiated Rate	$311.40
Max. Negotiated Rate	$3,378.03
Rate for Payer: Cash Price	$2,263.62
Rate for Payer: Cash Price	$2,263.62
Rate for Payer: Hawaii Western Management Group Commercial	$2,437.75
Rate for Payer: Health Management Network Commercial	$2,960.12
Rate for Payer: Kaiser Permanente Commercial	$2,193.97
Rate for Payer: Kaiser Permanente Medicaid	$1,776.08
Rate for Payer: MDX Hawaii PPO	$3,378.03
Rate for Payer: UnitedHealthcare Medicaid	$311.40
Rate for Payer: University Health Alliance Commercial	$1,950.20

Lens Tecnis Symfony Opticblue Toric Ii Iol 22 [3643822]

Facility

$3,482.50

Service Code	HCPCS V2632
Hospital Charge Code	3643822
Hospital Revenue Code	276
Min. Negotiated Rate	$311.40
Max. Negotiated Rate	$3,378.03
Rate for Payer: Cash Price	$2,263.62
Rate for Payer: Cash Price	$2,263.62
Rate for Payer: Hawaii Western Management Group Commercial	$2,437.75
Rate for Payer: Health Management Network Commercial	$2,960.12
Rate for Payer: Kaiser Permanente Commercial	$2,193.97
Rate for Payer: Kaiser Permanente Medicaid	$1,776.08
Rate for Payer: MDX Hawaii PPO	$3,378.03
Rate for Payer: UnitedHealthcare Medicaid	$311.40
Rate for Payer: University Health Alliance Commercial	$1,950.20

Lens Tecnis Symfony Opticblue Toric Ii Iol 22 [3643822]

Facility

$3,482.50

Service Code	HCPCS V2632
Hospital Charge Code	3643822
Hospital Revenue Code	276
Min. Negotiated Rate	$1,950.20
Max. Negotiated Rate	$3,378.03
Rate for Payer: Cash Price	$2,263.62
Rate for Payer: Hawaii Western Management Group Commercial	$2,437.75
Rate for Payer: Health Management Network Commercial	$2,960.12
Rate for Payer: MDX Hawaii PPO	$3,378.03
Rate for Payer: University Health Alliance Commercial	$1,950.20

Lens Tecnis Symfony Opticblue Toric Ii Iol 23.0 DXW150U230 [3643996]

Facility

$3,482.50

Service Code	HCPCS V2632
Hospital Charge Code	3643996
Hospital Revenue Code	276
Min. Negotiated Rate	$311.40
Max. Negotiated Rate	$3,378.03
Rate for Payer: Cash Price	$2,263.62
Rate for Payer: Cash Price	$2,263.62
Rate for Payer: Hawaii Western Management Group Commercial	$2,437.75
Rate for Payer: Health Management Network Commercial	$2,960.12
Rate for Payer: Kaiser Permanente Commercial	$2,193.97
Rate for Payer: Kaiser Permanente Medicaid	$1,776.08
Rate for Payer: MDX Hawaii PPO	$3,378.03
Rate for Payer: UnitedHealthcare Medicaid	$311.40
Rate for Payer: University Health Alliance Commercial	$1,950.20

Lens Tecnis Symfony Opticblue Toric Ii Iol 23.0 DXW150U230 [3643996]

Facility

$3,482.50

Service Code	HCPCS V2632
Hospital Charge Code	3643996
Hospital Revenue Code	276
Min. Negotiated Rate	$1,950.20
Max. Negotiated Rate	$3,378.03
Rate for Payer: Cash Price	$2,263.62
Rate for Payer: Hawaii Western Management Group Commercial	$2,437.75
Rate for Payer: Health Management Network Commercial	$2,960.12
Rate for Payer: MDX Hawaii PPO	$3,378.03
Rate for Payer: University Health Alliance Commercial	$1,950.20

Lens Tecnis Symfony Otiblue Iol 20.0 DXR00VU200 [3644297]

Facility

$4,980.50

Service Code	HCPCS V2632
Hospital Charge Code	3644297
Hospital Revenue Code	276
Min. Negotiated Rate	$2,789.08
Max. Negotiated Rate	$4,831.09
Rate for Payer: Cash Price	$3,237.32
Rate for Payer: Hawaii Western Management Group Commercial	$3,486.35
Rate for Payer: Health Management Network Commercial	$4,233.43
Rate for Payer: MDX Hawaii PPO	$4,831.09
Rate for Payer: University Health Alliance Commercial	$2,789.08

Lens Tecnis Symfony Otiblue Iol 20.0 DXR00VU200 [3644297]

Facility

$4,980.50

Service Code	HCPCS V2632
Hospital Charge Code	3644297
Hospital Revenue Code	276
Min. Negotiated Rate	$311.40
Max. Negotiated Rate	$4,831.09
Rate for Payer: Cash Price	$3,237.32
Rate for Payer: Cash Price	$3,237.32
Rate for Payer: Hawaii Western Management Group Commercial	$3,486.35
Rate for Payer: Health Management Network Commercial	$4,233.43
Rate for Payer: Kaiser Permanente Commercial	$3,137.72
Rate for Payer: Kaiser Permanente Medicaid	$2,540.05
Rate for Payer: MDX Hawaii PPO	$4,831.09
Rate for Payer: UnitedHealthcare Medicaid	$311.40
Rate for Payer: University Health Alliance Commercial	$2,789.08

Lens Tecnis Symfony Otiblue Iol 22.5 [3643823]

Facility

$3,482.50

Service Code	HCPCS V2632
Hospital Charge Code	3643823
Hospital Revenue Code	276
Min. Negotiated Rate	$311.40
Max. Negotiated Rate	$3,378.03
Rate for Payer: Cash Price	$2,263.62
Rate for Payer: Cash Price	$2,263.62
Rate for Payer: Hawaii Western Management Group Commercial	$2,437.75
Rate for Payer: Health Management Network Commercial	$2,960.12
Rate for Payer: Kaiser Permanente Commercial	$2,193.97
Rate for Payer: Kaiser Permanente Medicaid	$1,776.08
Rate for Payer: MDX Hawaii PPO	$3,378.03
Rate for Payer: UnitedHealthcare Medicaid	$311.40
Rate for Payer: University Health Alliance Commercial	$1,950.20

Lens Tecnis Symfony Otiblue Iol 22.5 [3643823]

Facility

$3,482.50

Service Code	HCPCS V2632
Hospital Charge Code	3643823
Hospital Revenue Code	276
Min. Negotiated Rate	$1,950.20
Max. Negotiated Rate	$3,378.03
Rate for Payer: Cash Price	$2,263.62
Rate for Payer: Hawaii Western Management Group Commercial	$2,437.75
Rate for Payer: Health Management Network Commercial	$2,960.12
Rate for Payer: MDX Hawaii PPO	$3,378.03
Rate for Payer: University Health Alliance Commercial	$1,950.20

Lens Tecnis Synergy Iol 16.5 DFR00VU165 [3644299]

Facility

$4,980.50

Service Code	HCPCS V2632
Hospital Charge Code	3644299
Hospital Revenue Code	276
Min. Negotiated Rate	$311.40
Max. Negotiated Rate	$4,831.09
Rate for Payer: Cash Price	$3,237.32
Rate for Payer: Cash Price	$3,237.32
Rate for Payer: Hawaii Western Management Group Commercial	$3,486.35
Rate for Payer: Health Management Network Commercial	$4,233.43
Rate for Payer: Kaiser Permanente Commercial	$3,137.72
Rate for Payer: Kaiser Permanente Medicaid	$2,540.05
Rate for Payer: MDX Hawaii PPO	$4,831.09
Rate for Payer: UnitedHealthcare Medicaid	$311.40
Rate for Payer: University Health Alliance Commercial	$2,789.08

Lens Tecnis Synergy Iol 16.5 DFR00VU165 [3644299]

Facility

$4,980.50

Service Code	HCPCS V2632
Hospital Charge Code	3644299
Hospital Revenue Code	276
Min. Negotiated Rate	$2,789.08
Max. Negotiated Rate	$4,831.09
Rate for Payer: Cash Price	$3,237.32
Rate for Payer: Hawaii Western Management Group Commercial	$3,486.35
Rate for Payer: Health Management Network Commercial	$4,233.43
Rate for Payer: MDX Hawaii PPO	$4,831.09
Rate for Payer: University Health Alliance Commercial	$2,789.08

Lens Tecnis Synergy Iol 20.5 DFR00VU205 [3644298]

Facility

$4,980.50

Service Code	HCPCS V2632
Hospital Charge Code	3644298
Hospital Revenue Code	276
Min. Negotiated Rate	$311.40
Max. Negotiated Rate	$4,831.09
Rate for Payer: Cash Price	$3,237.32
Rate for Payer: Cash Price	$3,237.32
Rate for Payer: Hawaii Western Management Group Commercial	$3,486.35
Rate for Payer: Health Management Network Commercial	$4,233.43
Rate for Payer: Kaiser Permanente Commercial	$3,137.72
Rate for Payer: Kaiser Permanente Medicaid	$2,540.05
Rate for Payer: MDX Hawaii PPO	$4,831.09
Rate for Payer: UnitedHealthcare Medicaid	$311.40
Rate for Payer: University Health Alliance Commercial	$2,789.08

Lens Tecnis Synergy Iol 20.5 DFR00VU205 [3644298]

Facility

$4,980.50

Service Code	HCPCS V2632
Hospital Charge Code	3644298
Hospital Revenue Code	276
Min. Negotiated Rate	$2,789.08
Max. Negotiated Rate	$4,831.09
Rate for Payer: Cash Price	$3,237.32
Rate for Payer: Hawaii Western Management Group Commercial	$3,486.35
Rate for Payer: Health Management Network Commercial	$4,233.43
Rate for Payer: MDX Hawaii PPO	$4,831.09
Rate for Payer: University Health Alliance Commercial	$2,789.08

Lens Tecnis Synergy Iol 22.0 Dfr00vu220 [3643879]

Facility

$3,482.50

Service Code	HCPCS V2632
Hospital Charge Code	3643879
Hospital Revenue Code	276
Min. Negotiated Rate	$1,950.20
Max. Negotiated Rate	$3,378.03
Rate for Payer: Cash Price	$2,263.62
Rate for Payer: Hawaii Western Management Group Commercial	$2,437.75
Rate for Payer: Health Management Network Commercial	$2,960.12
Rate for Payer: MDX Hawaii PPO	$3,378.03
Rate for Payer: University Health Alliance Commercial	$1,950.20

Lens Tecnis Synergy Iol 22.0 Dfr00vu220 [3643879]

Facility

$3,482.50

Service Code	HCPCS V2632
Hospital Charge Code	3643879
Hospital Revenue Code	276
Min. Negotiated Rate	$311.40
Max. Negotiated Rate	$3,378.03
Rate for Payer: Cash Price	$2,263.62
Rate for Payer: Cash Price	$2,263.62
Rate for Payer: Hawaii Western Management Group Commercial	$2,437.75
Rate for Payer: Health Management Network Commercial	$2,960.12
Rate for Payer: Kaiser Permanente Commercial	$2,193.97
Rate for Payer: Kaiser Permanente Medicaid	$1,776.08
Rate for Payer: MDX Hawaii PPO	$3,378.03
Rate for Payer: UnitedHealthcare Medicaid	$311.40
Rate for Payer: University Health Alliance Commercial	$1,950.20

Lens Tecnis Synergy Iol 23.5 Dfr00vu235 [3643821]

Facility

$3,482.50

Service Code	HCPCS V2632
Hospital Charge Code	3643821
Hospital Revenue Code	276
Min. Negotiated Rate	$1,950.20
Max. Negotiated Rate	$3,378.03
Rate for Payer: Cash Price	$2,263.62
Rate for Payer: Hawaii Western Management Group Commercial	$2,437.75
Rate for Payer: Health Management Network Commercial	$2,960.12
Rate for Payer: MDX Hawaii PPO	$3,378.03
Rate for Payer: University Health Alliance Commercial	$1,950.20

Lens Tecnis Synergy Iol 23.5 Dfr00vu235 [3643821]

Facility

$3,482.50

Service Code	HCPCS V2632
Hospital Charge Code	3643821
Hospital Revenue Code	276
Min. Negotiated Rate	$311.40
Max. Negotiated Rate	$3,378.03
Rate for Payer: Cash Price	$2,263.62
Rate for Payer: Cash Price	$2,263.62
Rate for Payer: Hawaii Western Management Group Commercial	$2,437.75
Rate for Payer: Health Management Network Commercial	$2,960.12
Rate for Payer: Kaiser Permanente Commercial	$2,193.97
Rate for Payer: Kaiser Permanente Medicaid	$1,776.08
Rate for Payer: MDX Hawaii PPO	$3,378.03
Rate for Payer: UnitedHealthcare Medicaid	$311.40
Rate for Payer: University Health Alliance Commercial	$1,950.20

LEUCOVORIN CALCIUM 100 MG INJ RECON.SOLN.

Facility

$84.24

Service Code	HCPCS J0640
Hospital Revenue Code	250
Min. Negotiated Rate	$71.60
Max. Negotiated Rate	$81.71
Rate for Payer: Cash Price	$54.76
Rate for Payer: Cash Price	$65.52
Rate for Payer: Cash Price	$76.28
Rate for Payer: Health Management Network Commercial	$71.60
Rate for Payer: Health Management Network Commercial	$99.76
Rate for Payer: Health Management Network Commercial	$85.68
Rate for Payer: MDX Hawaii PPO	$97.78
Rate for Payer: MDX Hawaii PPO	$113.84
Rate for Payer: MDX Hawaii PPO	$81.71

LEUCOVORIN CALCIUM 100 MG INJ RECON.SOLN.

Facility

$100.80

Service Code	HCPCS J0640
Hospital Revenue Code	636
Min. Negotiated Rate	$3.95
Max. Negotiated Rate	$97.78
Rate for Payer: Cash Price	$65.52
Rate for Payer: Cash Price	$76.28
Rate for Payer: Cash Price	$54.76
Rate for Payer: Cash Price	$65.52
Rate for Payer: Cash Price	$54.76
Rate for Payer: Cash Price	$76.28
Rate for Payer: Hawaii Medical Service Association ABD	$3.95
Rate for Payer: Hawaii Medical Service Association ABD	$3.95
Rate for Payer: Hawaii Medical Service Association ABD	$3.95
Rate for Payer: Hawaii Medical Service Association Non-ABD	$3.95
Rate for Payer: Hawaii Medical Service Association Non-ABD	$3.95
Rate for Payer: Hawaii Medical Service Association Non-ABD	$3.95
Rate for Payer: Hawaii Western Management Group Commercial	$111.49
Rate for Payer: Hawaii Western Management Group Commercial	$95.76
Rate for Payer: Hawaii Western Management Group Commercial	$80.03
Rate for Payer: Health Management Network Commercial	$71.60
Rate for Payer: Health Management Network Commercial	$85.68
Rate for Payer: Health Management Network Commercial	$99.76
Rate for Payer: Kaiser Permanente Commercial	$53.07
Rate for Payer: Kaiser Permanente Commercial	$73.94
Rate for Payer: Kaiser Permanente Commercial	$63.50
Rate for Payer: Kaiser Permanente Medicaid	$51.41
Rate for Payer: Kaiser Permanente Medicaid	$42.96
Rate for Payer: Kaiser Permanente Medicaid	$59.85
Rate for Payer: MDX Hawaii PPO	$81.71
Rate for Payer: MDX Hawaii PPO	$113.84
Rate for Payer: MDX Hawaii PPO	$97.78
Rate for Payer: UnitedHealthcare Medicaid	$60.48
Rate for Payer: UnitedHealthcare Medicaid	$70.42
Rate for Payer: UnitedHealthcare Medicaid	$50.54
Rate for Payer: University Health Alliance Commercial	$85.54
Rate for Payer: University Health Alliance Commercial	$73.47
Rate for Payer: University Health Alliance Commercial	$61.40

LEUCOVORIN CALCIUM 10 MG/ML INJ SOLN

Facility

$485.49

Service Code	HCPCS J0640
Hospital Revenue Code	636
Min. Negotiated Rate	$3.95
Max. Negotiated Rate	$470.93
Rate for Payer: Cash Price	$315.57
Rate for Payer: Cash Price	$315.57
Rate for Payer: Hawaii Medical Service Association ABD	$3.95
Rate for Payer: Hawaii Medical Service Association Non-ABD	$3.95
Rate for Payer: Hawaii Western Management Group Commercial	$461.22
Rate for Payer: Health Management Network Commercial	$412.67
Rate for Payer: Kaiser Permanente Commercial	$305.86
Rate for Payer: Kaiser Permanente Medicaid	$247.60
Rate for Payer: MDX Hawaii PPO	$470.93
Rate for Payer: UnitedHealthcare Medicaid	$291.29
Rate for Payer: University Health Alliance Commercial	$353.87

LEUCOVORIN CALCIUM 10 MG/ML INJ SOLN

Facility

$485.49

Service Code	HCPCS J0640
Hospital Revenue Code	250
Min. Negotiated Rate	$412.67
Max. Negotiated Rate	$470.93
Rate for Payer: Cash Price	$315.57
Rate for Payer: Health Management Network Commercial	$412.67
Rate for Payer: MDX Hawaii PPO	$470.93

LEUCOVORIN CALCIUM 200 MG INJ RECON.SOLN.

Facility

$100.80

Service Code	HCPCS J0640
Hospital Revenue Code	636
Min. Negotiated Rate	$3.95
Max. Negotiated Rate	$97.78
Rate for Payer: Cash Price	$65.52
Rate for Payer: Cash Price	$76.28
Rate for Payer: Cash Price	$239.85
Rate for Payer: Cash Price	$76.28
Rate for Payer: Cash Price	$239.85
Rate for Payer: Cash Price	$65.52
Rate for Payer: Hawaii Medical Service Association ABD	$3.95
Rate for Payer: Hawaii Medical Service Association ABD	$3.95
Rate for Payer: Hawaii Medical Service Association ABD	$3.95
Rate for Payer: Hawaii Medical Service Association Non-ABD	$3.95
Rate for Payer: Hawaii Medical Service Association Non-ABD	$3.95
Rate for Payer: Hawaii Medical Service Association Non-ABD	$3.95
Rate for Payer: Hawaii Western Management Group Commercial	$111.49
Rate for Payer: Hawaii Western Management Group Commercial	$95.76
Rate for Payer: Hawaii Western Management Group Commercial	$350.55
Rate for Payer: Health Management Network Commercial	$313.65
Rate for Payer: Health Management Network Commercial	$85.68
Rate for Payer: Health Management Network Commercial	$99.76
Rate for Payer: Kaiser Permanente Commercial	$232.47
Rate for Payer: Kaiser Permanente Commercial	$73.94
Rate for Payer: Kaiser Permanente Commercial	$63.50
Rate for Payer: Kaiser Permanente Medicaid	$51.41
Rate for Payer: Kaiser Permanente Medicaid	$188.19
Rate for Payer: Kaiser Permanente Medicaid	$59.85
Rate for Payer: MDX Hawaii PPO	$357.93
Rate for Payer: MDX Hawaii PPO	$113.84
Rate for Payer: MDX Hawaii PPO	$97.78
Rate for Payer: UnitedHealthcare Medicaid	$60.48
Rate for Payer: UnitedHealthcare Medicaid	$70.42
Rate for Payer: UnitedHealthcare Medicaid	$221.40
Rate for Payer: University Health Alliance Commercial	$85.54
Rate for Payer: University Health Alliance Commercial	$73.47
Rate for Payer: University Health Alliance Commercial	$268.96

LEUCOVORIN CALCIUM 200 MG INJ RECON.SOLN.

Facility

$100.80

Service Code	HCPCS J0640
Hospital Revenue Code	250
Min. Negotiated Rate	$85.68
Max. Negotiated Rate	$97.78
Rate for Payer: Cash Price	$65.52
Rate for Payer: Cash Price	$76.28
Rate for Payer: Cash Price	$239.85
Rate for Payer: Health Management Network Commercial	$99.76
Rate for Payer: Health Management Network Commercial	$313.65
Rate for Payer: Health Management Network Commercial	$85.68
Rate for Payer: MDX Hawaii PPO	$113.84
Rate for Payer: MDX Hawaii PPO	$357.93
Rate for Payer: MDX Hawaii PPO	$97.78

LEUCOVORIN CALCIUM 350 MG INJ RECON.SOLN.

Facility

$147.17

Service Code	HCPCS J0640
Hospital Revenue Code	636
Min. Negotiated Rate	$3.95
Max. Negotiated Rate	$142.75
Rate for Payer: Cash Price	$95.66
Rate for Payer: Cash Price	$221.99
Rate for Payer: Cash Price	$81.67
Rate for Payer: Cash Price	$81.67
Rate for Payer: Cash Price	$221.99
Rate for Payer: Cash Price	$95.66
Rate for Payer: Hawaii Medical Service Association ABD	$3.95
Rate for Payer: Hawaii Medical Service Association ABD	$3.95
Rate for Payer: Hawaii Medical Service Association ABD	$3.95
Rate for Payer: Hawaii Medical Service Association Non-ABD	$3.95
Rate for Payer: Hawaii Medical Service Association Non-ABD	$3.95
Rate for Payer: Hawaii Medical Service Association Non-ABD	$3.95
Rate for Payer: Hawaii Western Management Group Commercial	$119.36
Rate for Payer: Hawaii Western Management Group Commercial	$139.81
Rate for Payer: Hawaii Western Management Group Commercial	$324.44
Rate for Payer: Health Management Network Commercial	$290.29
Rate for Payer: Health Management Network Commercial	$106.79
Rate for Payer: Health Management Network Commercial	$125.09
Rate for Payer: Kaiser Permanente Commercial	$215.16
Rate for Payer: Kaiser Permanente Commercial	$92.72
Rate for Payer: Kaiser Permanente Commercial	$79.15
Rate for Payer: Kaiser Permanente Medicaid	$64.08
Rate for Payer: Kaiser Permanente Medicaid	$75.06
Rate for Payer: Kaiser Permanente Medicaid	$174.18
Rate for Payer: MDX Hawaii PPO	$121.87
Rate for Payer: MDX Hawaii PPO	$142.75
Rate for Payer: MDX Hawaii PPO	$331.27
Rate for Payer: UnitedHealthcare Medicaid	$88.30
Rate for Payer: UnitedHealthcare Medicaid	$204.91
Rate for Payer: UnitedHealthcare Medicaid	$75.38
Rate for Payer: University Health Alliance Commercial	$91.58
Rate for Payer: University Health Alliance Commercial	$107.27
Rate for Payer: University Health Alliance Commercial	$248.93

LEUCOVORIN CALCIUM 350 MG INJ RECON.SOLN.

Facility

$341.52

Service Code	HCPCS J0640
Hospital Revenue Code	250
Min. Negotiated Rate	$290.29
Max. Negotiated Rate	$331.27
Rate for Payer: Cash Price	$221.99
Rate for Payer: Cash Price	$95.66
Rate for Payer: Cash Price	$81.67
Rate for Payer: Health Management Network Commercial	$290.29
Rate for Payer: Health Management Network Commercial	$106.79
Rate for Payer: Health Management Network Commercial	$125.09
Rate for Payer: MDX Hawaii PPO	$331.27
Rate for Payer: MDX Hawaii PPO	$142.75
Rate for Payer: MDX Hawaii PPO	$121.87

Know your out-of-pocket cost for care.

All Charges