Kona Community Hospital

All Charges

Charge

Type

Setting

Price

BENZTROPINE 2 MG/2 ML INJ SOLN

Facility

$306.96

Service Code	HCPCS J0515
Hospital Revenue Code	636
Min. Negotiated Rate	$17.27
Max. Negotiated Rate	$297.75
Rate for Payer: Cash Price	$199.52
Rate for Payer: Cash Price	$199.52
Rate for Payer: Hawaii Medical Service Association ABD	$17.27
Rate for Payer: Hawaii Medical Service Association Non-ABD	$17.27
Rate for Payer: Hawaii Western Management Group Commercial	$291.61
Rate for Payer: Health Management Network Commercial	$260.92
Rate for Payer: Kaiser Permanente Commercial	$193.38
Rate for Payer: Kaiser Permanente Medicaid	$156.55
Rate for Payer: MDX Hawaii PPO	$297.75
Rate for Payer: UnitedHealthcare Medicaid	$184.18
Rate for Payer: University Health Alliance Commercial	$223.74

BENZTROPINE 2 MG/2 ML INJ SOLN

Facility

$306.96

Service Code	HCPCS J0515
Hospital Revenue Code	250
Min. Negotiated Rate	$260.92
Max. Negotiated Rate	$297.75
Rate for Payer: Cash Price	$199.52
Rate for Payer: Health Management Network Commercial	$260.92
Rate for Payer: MDX Hawaii PPO	$297.75

BETAMETHASONE ACET,SOD PHOS 6 MG/ML INJ SUSP

Facility

$289.79

Service Code	HCPCS J0702
Hospital Revenue Code	250
Min. Negotiated Rate	$246.32
Max. Negotiated Rate	$281.10
Rate for Payer: Cash Price	$188.36
Rate for Payer: Cash Price	$129.19
Rate for Payer: Health Management Network Commercial	$168.95
Rate for Payer: Health Management Network Commercial	$246.32
Rate for Payer: MDX Hawaii PPO	$281.10
Rate for Payer: MDX Hawaii PPO	$192.80

BETAMETHASONE ACET,SOD PHOS 6 MG/ML INJ SUSP

Facility

$198.76

Service Code	HCPCS J0702
Hospital Revenue Code	636
Min. Negotiated Rate	$6.89
Max. Negotiated Rate	$192.80
Rate for Payer: Cash Price	$129.19
Rate for Payer: Cash Price	$129.19
Rate for Payer: Cash Price	$188.36
Rate for Payer: Cash Price	$188.36
Rate for Payer: Hawaii Medical Service Association ABD	$6.89
Rate for Payer: Hawaii Medical Service Association ABD	$6.89
Rate for Payer: Hawaii Medical Service Association Non-ABD	$6.89
Rate for Payer: Hawaii Medical Service Association Non-ABD	$6.89
Rate for Payer: Hawaii Western Management Group Commercial	$188.82
Rate for Payer: Hawaii Western Management Group Commercial	$275.30
Rate for Payer: Health Management Network Commercial	$168.95
Rate for Payer: Health Management Network Commercial	$246.32
Rate for Payer: Kaiser Permanente Commercial	$125.22
Rate for Payer: Kaiser Permanente Commercial	$182.57
Rate for Payer: Kaiser Permanente Medicaid	$147.79
Rate for Payer: Kaiser Permanente Medicaid	$101.37
Rate for Payer: MDX Hawaii PPO	$281.10
Rate for Payer: MDX Hawaii PPO	$192.80
Rate for Payer: UnitedHealthcare Medicaid	$119.26
Rate for Payer: UnitedHealthcare Medicaid	$173.87
Rate for Payer: University Health Alliance Commercial	$144.88
Rate for Payer: University Health Alliance Commercial	$211.23

BETAMETHASONE VALERATE 0.1 % TOP CR

Facility

$133.82

Service Code	HCPCS A9270
Hospital Revenue Code	250
Min. Negotiated Rate	$113.75
Max. Negotiated Rate	$129.81
Rate for Payer: Cash Price	$86.98
Rate for Payer: Cash Price	$193.02
Rate for Payer: Health Management Network Commercial	$113.75
Rate for Payer: Health Management Network Commercial	$252.42
Rate for Payer: MDX Hawaii PPO	$129.81
Rate for Payer: MDX Hawaii PPO	$288.05

BETAMETHASONE VALERATE 0.1 % TOP CR

Facility

$296.96

Service Code	HCPCS A9270
Hospital Revenue Code	250
Min. Negotiated Rate	$151.45
Max. Negotiated Rate	$288.05
Rate for Payer: Cash Price	$193.02
Rate for Payer: Cash Price	$86.98
Rate for Payer: Hawaii Western Management Group Commercial	$127.13
Rate for Payer: Hawaii Western Management Group Commercial	$282.11
Rate for Payer: Health Management Network Commercial	$113.75
Rate for Payer: Health Management Network Commercial	$252.42
Rate for Payer: Kaiser Permanente Commercial	$187.08
Rate for Payer: Kaiser Permanente Commercial	$84.31
Rate for Payer: Kaiser Permanente Medicaid	$151.45
Rate for Payer: Kaiser Permanente Medicaid	$68.25
Rate for Payer: MDX Hawaii PPO	$129.81
Rate for Payer: MDX Hawaii PPO	$288.05
Rate for Payer: UnitedHealthcare Medicaid	$80.29
Rate for Payer: UnitedHealthcare Medicaid	$178.18
Rate for Payer: University Health Alliance Commercial	$216.45
Rate for Payer: University Health Alliance Commercial	$97.54

BETHANECHOL CHLORIDE 25 MG PO TABLET

Facility

$14.74

Service Code	HCPCS A9270
Hospital Revenue Code	250
Min. Negotiated Rate	$7.52
Max. Negotiated Rate	$14.30
Rate for Payer: Cash Price	$9.58
Rate for Payer: Cash Price	$6.40
Rate for Payer: Hawaii Western Management Group Commercial	$14.00
Rate for Payer: Hawaii Western Management Group Commercial	$9.36
Rate for Payer: Health Management Network Commercial	$12.53
Rate for Payer: Health Management Network Commercial	$8.37
Rate for Payer: Kaiser Permanente Commercial	$9.29
Rate for Payer: Kaiser Permanente Commercial	$6.21
Rate for Payer: Kaiser Permanente Medicaid	$7.52
Rate for Payer: Kaiser Permanente Medicaid	$5.02
Rate for Payer: MDX Hawaii PPO	$14.30
Rate for Payer: MDX Hawaii PPO	$9.55
Rate for Payer: UnitedHealthcare Medicaid	$5.91
Rate for Payer: UnitedHealthcare Medicaid	$8.84
Rate for Payer: University Health Alliance Commercial	$10.74
Rate for Payer: University Health Alliance Commercial	$7.18

BETHANECHOL CHLORIDE 25 MG PO TABLET

Facility

$14.74

Service Code	HCPCS A9270
Hospital Revenue Code	250
Min. Negotiated Rate	$12.53
Max. Negotiated Rate	$14.30
Rate for Payer: Cash Price	$9.58
Rate for Payer: Cash Price	$6.40
Rate for Payer: Health Management Network Commercial	$8.37
Rate for Payer: Health Management Network Commercial	$12.53
Rate for Payer: MDX Hawaii PPO	$14.30
Rate for Payer: MDX Hawaii PPO	$9.55

BEVACIZUMAB 25 MG/ML IV SOLN

Facility

$4,943.72

Service Code	HCPCS J9035
Hospital Revenue Code	636
Min. Negotiated Rate	$73.05
Max. Negotiated Rate	$4,795.41
Rate for Payer: AlohaCare Medicaid	$74.36
Rate for Payer: AlohaCare Medicare	$74.36
Rate for Payer: Cash Price	$3,213.42
Rate for Payer: Cash Price	$3,213.42
Rate for Payer: Devoted Health Medicare	$81.80
Rate for Payer: Hawaii Medical Service Association ABD	$73.05
Rate for Payer: Hawaii Medical Service Association Commercial	$92.95
Rate for Payer: Hawaii Medical Service Association Medicare	$74.36
Rate for Payer: Hawaii Medical Service Association Non-ABD	$73.05
Rate for Payer: Hawaii Western Management Group Commercial	$4,696.53
Rate for Payer: Health Management Network Commercial	$4,202.16
Rate for Payer: Humana Medicare	$74.36
Rate for Payer: Kaiser Permanente Commercial	$3,114.54
Rate for Payer: Kaiser Permanente Medicaid	$2,521.30
Rate for Payer: Kaiser Permanente Medicare	$74.36
Rate for Payer: MDX Hawaii PPO	$4,795.41
Rate for Payer: Ohana Health Plan Medicaid	$81.80
Rate for Payer: Ohana Health Plan Medicare	$74.36
Rate for Payer: UnitedHealthcare Medicaid	$2,966.23
Rate for Payer: UnitedHealthcare Medicare	$74.36
Rate for Payer: University Health Alliance Commercial	$3,603.48

BEVACIZUMAB 25 MG/ML IV SOLN

Facility

$4,943.72

Service Code	HCPCS J9035
Hospital Revenue Code	250
Min. Negotiated Rate	$4,202.16
Max. Negotiated Rate	$4,795.41
Rate for Payer: Cash Price	$3,213.42
Rate for Payer: Health Management Network Commercial	$4,202.16
Rate for Payer: MDX Hawaii PPO	$4,795.41

BEVACIZUMAB-AWWB 25 MG/ML IV SOLN

Facility

$1,688.50

Service Code	HCPCS Q5107
Hospital Revenue Code	250
Min. Negotiated Rate	$1,435.22
Max. Negotiated Rate	$1,637.85
Rate for Payer: Cash Price	$1,097.53
Rate for Payer: Cash Price	$2,903.86
Rate for Payer: Health Management Network Commercial	$3,797.36
Rate for Payer: Health Management Network Commercial	$1,435.22
Rate for Payer: MDX Hawaii PPO	$1,637.85
Rate for Payer: MDX Hawaii PPO	$4,333.46

BEVACIZUMAB-AWWB 25 MG/ML IV SOLN

Facility

$4,467.48

Service Code	HCPCS Q5107
Hospital Revenue Code	250
Min. Negotiated Rate	$23.74
Max. Negotiated Rate	$4,333.46
Rate for Payer: AlohaCare Medicaid	$23.74
Rate for Payer: AlohaCare Medicaid	$23.74
Rate for Payer: AlohaCare Medicare	$23.74
Rate for Payer: AlohaCare Medicare	$23.74
Rate for Payer: Cash Price	$1,097.53
Rate for Payer: Cash Price	$1,097.53
Rate for Payer: Cash Price	$2,903.86
Rate for Payer: Cash Price	$2,903.86
Rate for Payer: Devoted Health Medicare	$26.11
Rate for Payer: Devoted Health Medicare	$26.11
Rate for Payer: Hawaii Medical Service Association ABD	$28.85
Rate for Payer: Hawaii Medical Service Association ABD	$28.85
Rate for Payer: Hawaii Medical Service Association Commercial	$29.68
Rate for Payer: Hawaii Medical Service Association Commercial	$29.68
Rate for Payer: Hawaii Medical Service Association Medicare	$23.74
Rate for Payer: Hawaii Medical Service Association Medicare	$23.74
Rate for Payer: Hawaii Medical Service Association Non-ABD	$28.85
Rate for Payer: Hawaii Medical Service Association Non-ABD	$28.85
Rate for Payer: Hawaii Western Management Group Commercial	$1,604.08
Rate for Payer: Hawaii Western Management Group Commercial	$4,244.11
Rate for Payer: Health Management Network Commercial	$1,435.22
Rate for Payer: Health Management Network Commercial	$3,797.36
Rate for Payer: Humana Medicare	$23.74
Rate for Payer: Humana Medicare	$23.74
Rate for Payer: Kaiser Permanente Commercial	$1,063.76
Rate for Payer: Kaiser Permanente Commercial	$2,814.51
Rate for Payer: Kaiser Permanente Medicaid	$2,278.41
Rate for Payer: Kaiser Permanente Medicaid	$861.13
Rate for Payer: Kaiser Permanente Medicare	$23.74
Rate for Payer: Kaiser Permanente Medicare	$23.74
Rate for Payer: MDX Hawaii PPO	$1,637.85
Rate for Payer: MDX Hawaii PPO	$4,333.46
Rate for Payer: Ohana Health Plan Medicaid	$26.11
Rate for Payer: Ohana Health Plan Medicaid	$26.11
Rate for Payer: Ohana Health Plan Medicare	$23.74
Rate for Payer: Ohana Health Plan Medicare	$23.74
Rate for Payer: UnitedHealthcare Medicaid	$2,680.49
Rate for Payer: UnitedHealthcare Medicaid	$1,013.10
Rate for Payer: UnitedHealthcare Medicare	$23.74
Rate for Payer: UnitedHealthcare Medicare	$23.74
Rate for Payer: University Health Alliance Commercial	$1,230.75
Rate for Payer: University Health Alliance Commercial	$3,256.35

BG Non-Lock Screw 2.0 x 10mm P50-153-2010 [3644487]

Facility

$1,155.16

Service Code	HCPCS C1713
Hospital Charge Code	3644487
Hospital Revenue Code	278
Min. Negotiated Rate	$589.13
Max. Negotiated Rate	$1,120.51
Rate for Payer: Cash Price	$750.85
Rate for Payer: Hawaii Western Management Group Commercial	$808.61
Rate for Payer: Health Management Network Commercial	$981.89
Rate for Payer: Kaiser Permanente Commercial	$727.75
Rate for Payer: Kaiser Permanente Medicaid	$589.13
Rate for Payer: MDX Hawaii PPO	$1,120.51
Rate for Payer: University Health Alliance Commercial	$646.89

BG Non-Lock Screw 2.0 x 10mm P50-153-2010 [3644487]

Facility

$1,155.16

Service Code	HCPCS C1713
Hospital Charge Code	3644487
Hospital Revenue Code	278
Min. Negotiated Rate	$646.89
Max. Negotiated Rate	$1,120.51
Rate for Payer: Cash Price	$750.85
Rate for Payer: Hawaii Western Management Group Commercial	$808.61
Rate for Payer: Health Management Network Commercial	$981.89
Rate for Payer: MDX Hawaii PPO	$1,120.51
Rate for Payer: University Health Alliance Commercial	$646.89

BG Non-Lock Screw 2.0 x 11mm P50-153-2011 [3644488]

Facility

$1,155.16

Service Code	HCPCS C1713
Hospital Charge Code	3644488
Hospital Revenue Code	278
Min. Negotiated Rate	$646.89
Max. Negotiated Rate	$1,120.51
Rate for Payer: Cash Price	$750.85
Rate for Payer: Hawaii Western Management Group Commercial	$808.61
Rate for Payer: Health Management Network Commercial	$981.89
Rate for Payer: MDX Hawaii PPO	$1,120.51
Rate for Payer: University Health Alliance Commercial	$646.89

BG Non-Lock Screw 2.0 x 11mm P50-153-2011 [3644488]

Facility

$1,155.16

Service Code	HCPCS C1713
Hospital Charge Code	3644488
Hospital Revenue Code	278
Min. Negotiated Rate	$589.13
Max. Negotiated Rate	$1,120.51
Rate for Payer: Cash Price	$750.85
Rate for Payer: Hawaii Western Management Group Commercial	$808.61
Rate for Payer: Health Management Network Commercial	$981.89
Rate for Payer: Kaiser Permanente Commercial	$727.75
Rate for Payer: Kaiser Permanente Medicaid	$589.13
Rate for Payer: MDX Hawaii PPO	$1,120.51
Rate for Payer: University Health Alliance Commercial	$646.89

BG Non-Lock Screw 2.0 x 12mm P50-153-2012 [3644489]

Facility

$1,155.16

Service Code	HCPCS C1713
Hospital Charge Code	3644489
Hospital Revenue Code	278
Min. Negotiated Rate	$646.89
Max. Negotiated Rate	$1,120.51
Rate for Payer: Cash Price	$750.85
Rate for Payer: Hawaii Western Management Group Commercial	$808.61
Rate for Payer: Health Management Network Commercial	$981.89
Rate for Payer: MDX Hawaii PPO	$1,120.51
Rate for Payer: University Health Alliance Commercial	$646.89

BG Non-Lock Screw 2.0 x 12mm P50-153-2012 [3644489]

Facility

$1,155.16

Service Code	HCPCS C1713
Hospital Charge Code	3644489
Hospital Revenue Code	278
Min. Negotiated Rate	$589.13
Max. Negotiated Rate	$1,120.51
Rate for Payer: Cash Price	$750.85
Rate for Payer: Hawaii Western Management Group Commercial	$808.61
Rate for Payer: Health Management Network Commercial	$981.89
Rate for Payer: Kaiser Permanente Commercial	$727.75
Rate for Payer: Kaiser Permanente Medicaid	$589.13
Rate for Payer: MDX Hawaii PPO	$1,120.51
Rate for Payer: University Health Alliance Commercial	$646.89

BG Non-Lock Screw 2.5 x 20mm P50-153-2520 [3644490]

Facility

$1,155.16

Service Code	HCPCS C1713
Hospital Charge Code	3644490
Hospital Revenue Code	278
Min. Negotiated Rate	$646.89
Max. Negotiated Rate	$1,120.51
Rate for Payer: Cash Price	$750.85
Rate for Payer: Hawaii Western Management Group Commercial	$808.61
Rate for Payer: Health Management Network Commercial	$981.89
Rate for Payer: MDX Hawaii PPO	$1,120.51
Rate for Payer: University Health Alliance Commercial	$646.89

BG Non-Lock Screw 2.5 x 20mm P50-153-2520 [3644490]

Facility

$1,155.16

Service Code	HCPCS C1713
Hospital Charge Code	3644490
Hospital Revenue Code	278
Min. Negotiated Rate	$589.13
Max. Negotiated Rate	$1,120.51
Rate for Payer: Cash Price	$750.85
Rate for Payer: Hawaii Western Management Group Commercial	$808.61
Rate for Payer: Health Management Network Commercial	$981.89
Rate for Payer: Kaiser Permanente Commercial	$727.75
Rate for Payer: Kaiser Permanente Medicaid	$589.13
Rate for Payer: MDX Hawaii PPO	$1,120.51
Rate for Payer: University Health Alliance Commercial	$646.89

BG Non-Lock Screw 2.5 x 24mm P50-153-2524 [3644491]

Facility

$1,155.16

Service Code	HCPCS C1713
Hospital Charge Code	3644491
Hospital Revenue Code	278
Min. Negotiated Rate	$589.13
Max. Negotiated Rate	$1,120.51
Rate for Payer: Cash Price	$750.85
Rate for Payer: Hawaii Western Management Group Commercial	$808.61
Rate for Payer: Health Management Network Commercial	$981.89
Rate for Payer: Kaiser Permanente Commercial	$727.75
Rate for Payer: Kaiser Permanente Medicaid	$589.13
Rate for Payer: MDX Hawaii PPO	$1,120.51
Rate for Payer: University Health Alliance Commercial	$646.89

BG Non-Lock Screw 2.5 x 24mm P50-153-2524 [3644491]

Facility

$1,155.16

Service Code	HCPCS C1713
Hospital Charge Code	3644491
Hospital Revenue Code	278
Min. Negotiated Rate	$646.89
Max. Negotiated Rate	$1,120.51
Rate for Payer: Cash Price	$750.85
Rate for Payer: Hawaii Western Management Group Commercial	$808.61
Rate for Payer: Health Management Network Commercial	$981.89
Rate for Payer: MDX Hawaii PPO	$1,120.51
Rate for Payer: University Health Alliance Commercial	$646.89

BG Non-Lock Screw 2.5 x 26mm P50-153-2526 [3644492]

Facility

$1,155.16

Service Code	HCPCS C1713
Hospital Charge Code	3644492
Hospital Revenue Code	278
Min. Negotiated Rate	$589.13
Max. Negotiated Rate	$1,120.51
Rate for Payer: Cash Price	$750.85
Rate for Payer: Hawaii Western Management Group Commercial	$808.61
Rate for Payer: Health Management Network Commercial	$981.89
Rate for Payer: Kaiser Permanente Commercial	$727.75
Rate for Payer: Kaiser Permanente Medicaid	$589.13
Rate for Payer: MDX Hawaii PPO	$1,120.51
Rate for Payer: University Health Alliance Commercial	$646.89

BG Non-Lock Screw 2.5 x 26mm P50-153-2526 [3644492]

Facility

$1,155.16

Service Code	HCPCS C1713
Hospital Charge Code	3644492
Hospital Revenue Code	278
Min. Negotiated Rate	$646.89
Max. Negotiated Rate	$1,120.51
Rate for Payer: Cash Price	$750.85
Rate for Payer: Hawaii Western Management Group Commercial	$808.61
Rate for Payer: Health Management Network Commercial	$981.89
Rate for Payer: MDX Hawaii PPO	$1,120.51
Rate for Payer: University Health Alliance Commercial	$646.89

BILATERAL OR MULTIPLE MAJOR JOINT PROCEDURES OF LOWER EXTREMITY WITH MCC

Facility

$92,470.35

Service Code	MSDRG 461
Min. Negotiated Rate	$67,451.39
Max. Negotiated Rate	$92,470.35
Rate for Payer: AlohaCare Medicare	$72,642.73
Rate for Payer: Devoted Health Medicare	$79,907.00
Rate for Payer: Hawaii Medical Service Association Commercial	$67,451.39
Rate for Payer: Hawaii Medical Service Association Medicare	$72,642.73
Rate for Payer: Humana Medicare	$72,642.73
Rate for Payer: Kaiser Permanente Commercial	$92,470.35
Rate for Payer: Kaiser Permanente Medicare	$72,642.73
Rate for Payer: Ohana Health Plan Medicare	$72,642.73
Rate for Payer: UnitedHealthcare Medicare	$72,642.73

Know your out-of-pocket cost for care.

All Charges