Kona Community Hospital

All Charges

Charge

Type

Setting

Price

LEVETIRACETAM 500 MG PO TABLET

Facility

$1.20

Service Code	HCPCS A9270
Hospital Revenue Code	250
Min. Negotiated Rate	$0.61
Max. Negotiated Rate	$1.16
Rate for Payer: Cash Price	$0.78
Rate for Payer: Cash Price	$12.61
Rate for Payer: Cash Price	$2.58
Rate for Payer: Hawaii Western Management Group Commercial	$18.43
Rate for Payer: Hawaii Western Management Group Commercial	$1.14
Rate for Payer: Hawaii Western Management Group Commercial	$3.77
Rate for Payer: Health Management Network Commercial	$1.02
Rate for Payer: Health Management Network Commercial	$3.37
Rate for Payer: Health Management Network Commercial	$16.49
Rate for Payer: Kaiser Permanente Commercial	$0.76
Rate for Payer: Kaiser Permanente Commercial	$12.22
Rate for Payer: Kaiser Permanente Commercial	$2.50
Rate for Payer: Kaiser Permanente Medicaid	$2.02
Rate for Payer: Kaiser Permanente Medicaid	$0.61
Rate for Payer: Kaiser Permanente Medicaid	$9.89
Rate for Payer: MDX Hawaii PPO	$1.16
Rate for Payer: MDX Hawaii PPO	$18.82
Rate for Payer: MDX Hawaii PPO	$3.85
Rate for Payer: UnitedHealthcare Medicaid	$0.72
Rate for Payer: UnitedHealthcare Medicaid	$11.64
Rate for Payer: UnitedHealthcare Medicaid	$2.38
Rate for Payer: University Health Alliance Commercial	$2.89
Rate for Payer: University Health Alliance Commercial	$14.14
Rate for Payer: University Health Alliance Commercial	$0.87

LEVETIRACETAM 500 MG PO TABLET

Facility

$19.40

Service Code	HCPCS A9270
Hospital Revenue Code	250
Min. Negotiated Rate	$16.49
Max. Negotiated Rate	$18.82
Rate for Payer: Cash Price	$12.61
Rate for Payer: Cash Price	$0.78
Rate for Payer: Cash Price	$2.58
Rate for Payer: Health Management Network Commercial	$1.02
Rate for Payer: Health Management Network Commercial	$16.49
Rate for Payer: Health Management Network Commercial	$3.37
Rate for Payer: MDX Hawaii PPO	$18.82
Rate for Payer: MDX Hawaii PPO	$3.85
Rate for Payer: MDX Hawaii PPO	$1.16

LEVETIRACETAM IN NACL (ISO-OS) 1000 MG/100 ML IV IVPB

Facility

$107.01

Service Code	HCPCS J1953
Hospital Revenue Code	250
Min. Negotiated Rate	$90.96
Max. Negotiated Rate	$103.80
Rate for Payer: Cash Price	$69.56
Rate for Payer: Health Management Network Commercial	$90.96
Rate for Payer: MDX Hawaii PPO	$103.80

LEVETIRACETAM IN NACL (ISO-OS) 1000 MG/100 ML IV IVPB

Facility

$107.01

Service Code	HCPCS J1953
Hospital Revenue Code	636
Min. Negotiated Rate	$0.05
Max. Negotiated Rate	$103.80
Rate for Payer: Cash Price	$69.56
Rate for Payer: Cash Price	$69.56
Rate for Payer: Hawaii Medical Service Association ABD	$0.05
Rate for Payer: Hawaii Medical Service Association Non-ABD	$0.05
Rate for Payer: Hawaii Western Management Group Commercial	$101.66
Rate for Payer: Health Management Network Commercial	$90.96
Rate for Payer: Kaiser Permanente Commercial	$67.42
Rate for Payer: Kaiser Permanente Medicaid	$54.58
Rate for Payer: MDX Hawaii PPO	$103.80
Rate for Payer: UnitedHealthcare Medicaid	$64.21
Rate for Payer: University Health Alliance Commercial	$78.00

LEVETIRACETAM IN NACL (ISO-OS) 500 MG/100 ML IV IVPB

Facility

$57.00

Service Code	HCPCS J1953
Hospital Revenue Code	250
Min. Negotiated Rate	$48.45
Max. Negotiated Rate	$55.29
Rate for Payer: Cash Price	$37.05
Rate for Payer: Cash Price	$49.37
Rate for Payer: Cash Price	$61.48
Rate for Payer: Health Management Network Commercial	$64.57
Rate for Payer: Health Management Network Commercial	$80.40
Rate for Payer: Health Management Network Commercial	$48.45
Rate for Payer: MDX Hawaii PPO	$73.68
Rate for Payer: MDX Hawaii PPO	$91.75
Rate for Payer: MDX Hawaii PPO	$55.29

LEVETIRACETAM IN NACL (ISO-OS) 500 MG/100 ML IV IVPB

Facility

$57.00

Service Code	HCPCS J1953
Hospital Revenue Code	636
Min. Negotiated Rate	$0.05
Max. Negotiated Rate	$55.29
Rate for Payer: Cash Price	$37.05
Rate for Payer: Cash Price	$49.37
Rate for Payer: Cash Price	$61.48
Rate for Payer: Cash Price	$49.37
Rate for Payer: Cash Price	$61.48
Rate for Payer: Cash Price	$37.05
Rate for Payer: Hawaii Medical Service Association ABD	$0.05
Rate for Payer: Hawaii Medical Service Association ABD	$0.05
Rate for Payer: Hawaii Medical Service Association ABD	$0.05
Rate for Payer: Hawaii Medical Service Association Non-ABD	$0.05
Rate for Payer: Hawaii Medical Service Association Non-ABD	$0.05
Rate for Payer: Hawaii Medical Service Association Non-ABD	$0.05
Rate for Payer: Hawaii Western Management Group Commercial	$72.16
Rate for Payer: Hawaii Western Management Group Commercial	$54.15
Rate for Payer: Hawaii Western Management Group Commercial	$89.86
Rate for Payer: Health Management Network Commercial	$80.40
Rate for Payer: Health Management Network Commercial	$48.45
Rate for Payer: Health Management Network Commercial	$64.57
Rate for Payer: Kaiser Permanente Commercial	$59.59
Rate for Payer: Kaiser Permanente Commercial	$47.85
Rate for Payer: Kaiser Permanente Commercial	$35.91
Rate for Payer: Kaiser Permanente Medicaid	$29.07
Rate for Payer: Kaiser Permanente Medicaid	$48.24
Rate for Payer: Kaiser Permanente Medicaid	$38.74
Rate for Payer: MDX Hawaii PPO	$91.75
Rate for Payer: MDX Hawaii PPO	$73.68
Rate for Payer: MDX Hawaii PPO	$55.29
Rate for Payer: UnitedHealthcare Medicaid	$34.20
Rate for Payer: UnitedHealthcare Medicaid	$45.58
Rate for Payer: UnitedHealthcare Medicaid	$56.75
Rate for Payer: University Health Alliance Commercial	$55.37
Rate for Payer: University Health Alliance Commercial	$41.55
Rate for Payer: University Health Alliance Commercial	$68.95

LEVOFLOXACIN 250 MG PO TABLET

Facility

$87.60

Service Code	HCPCS A9270
Hospital Revenue Code	250
Min. Negotiated Rate	$44.68
Max. Negotiated Rate	$84.97
Rate for Payer: Cash Price	$56.94
Rate for Payer: Hawaii Western Management Group Commercial	$83.22
Rate for Payer: Health Management Network Commercial	$74.46
Rate for Payer: Kaiser Permanente Commercial	$55.19
Rate for Payer: Kaiser Permanente Medicaid	$44.68
Rate for Payer: MDX Hawaii PPO	$84.97
Rate for Payer: UnitedHealthcare Medicaid	$52.56
Rate for Payer: University Health Alliance Commercial	$63.85

LEVOFLOXACIN 250 MG PO TABLET

Facility

$87.60

Service Code	HCPCS A9270
Hospital Revenue Code	250
Min. Negotiated Rate	$74.46
Max. Negotiated Rate	$84.97
Rate for Payer: Cash Price	$56.94
Rate for Payer: Health Management Network Commercial	$74.46
Rate for Payer: MDX Hawaii PPO	$84.97

LEVOFLOXACIN 500 MG PO TABLET

Facility

$97.77

Service Code	HCPCS A9270
Hospital Revenue Code	250
Min. Negotiated Rate	$83.10
Max. Negotiated Rate	$94.84
Rate for Payer: Cash Price	$63.55
Rate for Payer: Cash Price	$0.88
Rate for Payer: Health Management Network Commercial	$1.15
Rate for Payer: Health Management Network Commercial	$83.10
Rate for Payer: MDX Hawaii PPO	$94.84
Rate for Payer: MDX Hawaii PPO	$1.31

LEVOFLOXACIN 500 MG PO TABLET

Facility

$1.35

Service Code	HCPCS A9270
Hospital Revenue Code	250
Min. Negotiated Rate	$0.69
Max. Negotiated Rate	$1.31
Rate for Payer: Cash Price	$0.88
Rate for Payer: Cash Price	$63.55
Rate for Payer: Hawaii Western Management Group Commercial	$1.28
Rate for Payer: Hawaii Western Management Group Commercial	$92.88
Rate for Payer: Health Management Network Commercial	$1.15
Rate for Payer: Health Management Network Commercial	$83.10
Rate for Payer: Kaiser Permanente Commercial	$0.85
Rate for Payer: Kaiser Permanente Commercial	$61.60
Rate for Payer: Kaiser Permanente Medicaid	$0.69
Rate for Payer: Kaiser Permanente Medicaid	$49.86
Rate for Payer: MDX Hawaii PPO	$1.31
Rate for Payer: MDX Hawaii PPO	$94.84
Rate for Payer: UnitedHealthcare Medicaid	$58.66
Rate for Payer: UnitedHealthcare Medicaid	$0.81
Rate for Payer: University Health Alliance Commercial	$0.98
Rate for Payer: University Health Alliance Commercial	$71.26

LEVOFLOXACIN 750 MG PO TABLET

Facility

$167.35

Service Code	HCPCS A9270
Hospital Revenue Code	250
Min. Negotiated Rate	$85.35
Max. Negotiated Rate	$162.33
Rate for Payer: Cash Price	$108.78
Rate for Payer: Cash Price	$1.58
Rate for Payer: Hawaii Western Management Group Commercial	$158.98
Rate for Payer: Hawaii Western Management Group Commercial	$2.31
Rate for Payer: Health Management Network Commercial	$142.25
Rate for Payer: Health Management Network Commercial	$2.07
Rate for Payer: Kaiser Permanente Commercial	$105.43
Rate for Payer: Kaiser Permanente Commercial	$1.53
Rate for Payer: Kaiser Permanente Medicaid	$1.24
Rate for Payer: Kaiser Permanente Medicaid	$85.35
Rate for Payer: MDX Hawaii PPO	$162.33
Rate for Payer: MDX Hawaii PPO	$2.36
Rate for Payer: UnitedHealthcare Medicaid	$1.46
Rate for Payer: UnitedHealthcare Medicaid	$100.41
Rate for Payer: University Health Alliance Commercial	$121.98
Rate for Payer: University Health Alliance Commercial	$1.77

LEVOFLOXACIN 750 MG PO TABLET

Facility

$167.35

Service Code	HCPCS A9270
Hospital Revenue Code	250
Min. Negotiated Rate	$142.25
Max. Negotiated Rate	$162.33
Rate for Payer: Cash Price	$108.78
Rate for Payer: Cash Price	$1.58
Rate for Payer: Health Management Network Commercial	$2.07
Rate for Payer: Health Management Network Commercial	$142.25
Rate for Payer: MDX Hawaii PPO	$162.33
Rate for Payer: MDX Hawaii PPO	$2.36

LEVOFLOXACIN IN D5W 250 MG/50 ML IVPB

Facility

$23.19

Service Code	HCPCS J1956
Hospital Revenue Code	250
Min. Negotiated Rate	$19.71
Max. Negotiated Rate	$22.49
Rate for Payer: Cash Price	$15.07
Rate for Payer: Health Management Network Commercial	$19.71
Rate for Payer: MDX Hawaii PPO	$22.49

LEVOFLOXACIN IN D5W 250 MG/50 ML IVPB

Facility

$23.19

Service Code	HCPCS J1956
Hospital Revenue Code	636
Min. Negotiated Rate	$1.96
Max. Negotiated Rate	$22.49
Rate for Payer: Cash Price	$15.07
Rate for Payer: Cash Price	$15.07
Rate for Payer: Hawaii Medical Service Association ABD	$1.96
Rate for Payer: Hawaii Medical Service Association Non-ABD	$1.96
Rate for Payer: Hawaii Western Management Group Commercial	$22.03
Rate for Payer: Health Management Network Commercial	$19.71
Rate for Payer: Kaiser Permanente Commercial	$14.61
Rate for Payer: Kaiser Permanente Medicaid	$11.83
Rate for Payer: MDX Hawaii PPO	$22.49
Rate for Payer: UnitedHealthcare Medicaid	$13.91
Rate for Payer: University Health Alliance Commercial	$16.90

LEVOFLOXACIN IN D5W 500 MG/100 ML IV IVPB

Facility

$32.02

Service Code	HCPCS J1956
Hospital Revenue Code	250
Min. Negotiated Rate	$27.22
Max. Negotiated Rate	$31.06
Rate for Payer: Cash Price	$20.81
Rate for Payer: Cash Price	$25.42
Rate for Payer: Health Management Network Commercial	$27.22
Rate for Payer: Health Management Network Commercial	$33.23
Rate for Payer: MDX Hawaii PPO	$31.06
Rate for Payer: MDX Hawaii PPO	$37.93

LEVOFLOXACIN IN D5W 500 MG/100 ML IV IVPB

Facility

$39.10

Service Code	HCPCS J1956
Hospital Revenue Code	636
Min. Negotiated Rate	$1.96
Max. Negotiated Rate	$37.93
Rate for Payer: Cash Price	$25.42
Rate for Payer: Cash Price	$20.81
Rate for Payer: Cash Price	$20.81
Rate for Payer: Cash Price	$25.42
Rate for Payer: Hawaii Medical Service Association ABD	$1.96
Rate for Payer: Hawaii Medical Service Association ABD	$1.96
Rate for Payer: Hawaii Medical Service Association Non-ABD	$1.96
Rate for Payer: Hawaii Medical Service Association Non-ABD	$1.96
Rate for Payer: Hawaii Western Management Group Commercial	$30.42
Rate for Payer: Hawaii Western Management Group Commercial	$37.15
Rate for Payer: Health Management Network Commercial	$33.23
Rate for Payer: Health Management Network Commercial	$27.22
Rate for Payer: Kaiser Permanente Commercial	$24.63
Rate for Payer: Kaiser Permanente Commercial	$20.17
Rate for Payer: Kaiser Permanente Medicaid	$16.33
Rate for Payer: Kaiser Permanente Medicaid	$19.94
Rate for Payer: MDX Hawaii PPO	$37.93
Rate for Payer: MDX Hawaii PPO	$31.06
Rate for Payer: UnitedHealthcare Medicaid	$19.21
Rate for Payer: UnitedHealthcare Medicaid	$23.46
Rate for Payer: University Health Alliance Commercial	$23.34
Rate for Payer: University Health Alliance Commercial	$28.50

LEVOFLOXACIN IN D5W 750 MG/150 ML IV IVPB

Facility

$40.07

Service Code	HCPCS J1956
Hospital Revenue Code	250
Min. Negotiated Rate	$34.06
Max. Negotiated Rate	$38.87
Rate for Payer: Cash Price	$26.05
Rate for Payer: Cash Price	$37.84
Rate for Payer: Health Management Network Commercial	$34.06
Rate for Payer: Health Management Network Commercial	$49.48
Rate for Payer: MDX Hawaii PPO	$38.87
Rate for Payer: MDX Hawaii PPO	$56.46

LEVOFLOXACIN IN D5W 750 MG/150 ML IV IVPB

Facility

$40.07

Service Code	HCPCS J1956
Hospital Revenue Code	636
Min. Negotiated Rate	$1.96
Max. Negotiated Rate	$38.87
Rate for Payer: Cash Price	$26.05
Rate for Payer: Cash Price	$37.84
Rate for Payer: Cash Price	$37.84
Rate for Payer: Cash Price	$26.05
Rate for Payer: Hawaii Medical Service Association ABD	$1.96
Rate for Payer: Hawaii Medical Service Association ABD	$1.96
Rate for Payer: Hawaii Medical Service Association Non-ABD	$1.96
Rate for Payer: Hawaii Medical Service Association Non-ABD	$1.96
Rate for Payer: Hawaii Western Management Group Commercial	$38.07
Rate for Payer: Hawaii Western Management Group Commercial	$55.30
Rate for Payer: Health Management Network Commercial	$49.48
Rate for Payer: Health Management Network Commercial	$34.06
Rate for Payer: Kaiser Permanente Commercial	$25.24
Rate for Payer: Kaiser Permanente Commercial	$36.67
Rate for Payer: Kaiser Permanente Medicaid	$29.69
Rate for Payer: Kaiser Permanente Medicaid	$20.44
Rate for Payer: MDX Hawaii PPO	$56.46
Rate for Payer: MDX Hawaii PPO	$38.87
Rate for Payer: UnitedHealthcare Medicaid	$24.04
Rate for Payer: UnitedHealthcare Medicaid	$34.93
Rate for Payer: University Health Alliance Commercial	$42.43
Rate for Payer: University Health Alliance Commercial	$29.21

LEVONORGESTREL 1.5 MG PO TABLET

Facility

$152.55

Service Code	HCPCS A9270
Hospital Revenue Code	250
Min. Negotiated Rate	$129.67
Max. Negotiated Rate	$147.97
Rate for Payer: Cash Price	$99.16
Rate for Payer: Health Management Network Commercial	$129.67
Rate for Payer: MDX Hawaii PPO	$147.97

LEVONORGESTREL 1.5 MG PO TABLET

Facility

$152.55

Service Code	HCPCS A9270
Hospital Revenue Code	250
Min. Negotiated Rate	$77.80
Max. Negotiated Rate	$147.97
Rate for Payer: Cash Price	$99.16
Rate for Payer: Hawaii Western Management Group Commercial	$144.92
Rate for Payer: Health Management Network Commercial	$129.67
Rate for Payer: Kaiser Permanente Commercial	$96.11
Rate for Payer: Kaiser Permanente Medicaid	$77.80
Rate for Payer: MDX Hawaii PPO	$147.97
Rate for Payer: UnitedHealthcare Medicaid	$91.53
Rate for Payer: University Health Alliance Commercial	$111.19

LEVOTHYROXINE 100 MCG IV RECON.SOLN.

Facility

$489.87

Service Code	HCPCS J0651
Hospital Revenue Code	250
Min. Negotiated Rate	$416.39
Max. Negotiated Rate	$475.17
Rate for Payer: Cash Price	$318.42
Rate for Payer: Health Management Network Commercial	$416.39
Rate for Payer: MDX Hawaii PPO	$475.17

LEVOTHYROXINE 100 MCG IV RECON.SOLN.

Facility

$489.87

Service Code	HCPCS J0651
Hospital Revenue Code	636
Min. Negotiated Rate	$6.96
Max. Negotiated Rate	$475.17
Rate for Payer: AlohaCare Medicaid	$6.96
Rate for Payer: AlohaCare Medicare	$6.96
Rate for Payer: Cash Price	$318.42
Rate for Payer: Cash Price	$318.42
Rate for Payer: Devoted Health Medicare	$7.66
Rate for Payer: Hawaii Medical Service Association ABD	$7.10
Rate for Payer: Hawaii Medical Service Association Commercial	$8.70
Rate for Payer: Hawaii Medical Service Association Medicare	$6.96
Rate for Payer: Hawaii Medical Service Association Non-ABD	$7.10
Rate for Payer: Hawaii Western Management Group Commercial	$465.38
Rate for Payer: Health Management Network Commercial	$416.39
Rate for Payer: Humana Medicare	$6.96
Rate for Payer: Kaiser Permanente Commercial	$308.62
Rate for Payer: Kaiser Permanente Medicaid	$249.83
Rate for Payer: Kaiser Permanente Medicare	$6.96
Rate for Payer: MDX Hawaii PPO	$475.17
Rate for Payer: Ohana Health Plan Medicaid	$7.66
Rate for Payer: Ohana Health Plan Medicare	$6.96
Rate for Payer: UnitedHealthcare Medicaid	$293.92
Rate for Payer: UnitedHealthcare Medicare	$6.96
Rate for Payer: University Health Alliance Commercial	$357.07

LEVOTHYROXINE 100 MCG PO TABLET

Facility

$4.00

Service Code	HCPCS A9270
Hospital Revenue Code	250
Min. Negotiated Rate	$2.04
Max. Negotiated Rate	$3.88
Rate for Payer: Cash Price	$2.60
Rate for Payer: Hawaii Western Management Group Commercial	$3.80
Rate for Payer: Health Management Network Commercial	$3.40
Rate for Payer: Kaiser Permanente Commercial	$2.52
Rate for Payer: Kaiser Permanente Medicaid	$2.04
Rate for Payer: MDX Hawaii PPO	$3.88
Rate for Payer: UnitedHealthcare Medicaid	$2.40
Rate for Payer: University Health Alliance Commercial	$2.92

LEVOTHYROXINE 100 MCG PO TABLET

Facility

$4.00

Service Code	HCPCS A9270
Hospital Revenue Code	250
Min. Negotiated Rate	$3.40
Max. Negotiated Rate	$3.88
Rate for Payer: Cash Price	$2.60
Rate for Payer: Health Management Network Commercial	$3.40
Rate for Payer: MDX Hawaii PPO	$3.88

LEVOTHYROXINE 25 MCG PO TABLET

Facility

$3.09

Service Code	HCPCS A9270
Hospital Revenue Code	250
Min. Negotiated Rate	$2.63
Max. Negotiated Rate	$3.00
Rate for Payer: Cash Price	$2.01
Rate for Payer: Health Management Network Commercial	$2.63
Rate for Payer: MDX Hawaii PPO	$3.00

Know your out-of-pocket cost for care.

All Charges