Kona Community Hospital

All Charges

Charge

Type

Setting

Price

Lone Star Retr Sys Disp Ring 22cmX11.3cm 3302G [3643030]

Facility

$601.15

Hospital Charge Code	3643030
Hospital Revenue Code	272
Min. Negotiated Rate	$306.59
Max. Negotiated Rate	$583.12
Rate for Payer: Cash Price	$390.75
Rate for Payer: Hawaii Western Management Group Commercial	$571.09
Rate for Payer: Health Management Network Commercial	$510.98
Rate for Payer: Kaiser Permanente Commercial	$378.72
Rate for Payer: Kaiser Permanente Medicaid	$306.59
Rate for Payer: MDX Hawaii PPO	$583.12
Rate for Payer: University Health Alliance Commercial	$438.18

Lone Star Retr Sys Disp Ring 22cmX11.3cm 3302G [3643030]

Facility

$601.15

Hospital Charge Code	3643030
Hospital Revenue Code	272
Min. Negotiated Rate	$510.98
Max. Negotiated Rate	$583.12
Rate for Payer: Cash Price	$390.75
Rate for Payer: Health Management Network Commercial	$510.98
Rate for Payer: MDX Hawaii PPO	$583.12

Lone Star Retr Sys Disp Ring 32.5cmX18.3cm 3304G [3643031]

Facility

$601.15

Hospital Charge Code	3643031
Hospital Revenue Code	272
Min. Negotiated Rate	$306.59
Max. Negotiated Rate	$583.12
Rate for Payer: Cash Price	$390.75
Rate for Payer: Hawaii Western Management Group Commercial	$571.09
Rate for Payer: Health Management Network Commercial	$510.98
Rate for Payer: Kaiser Permanente Commercial	$378.72
Rate for Payer: Kaiser Permanente Medicaid	$306.59
Rate for Payer: MDX Hawaii PPO	$583.12
Rate for Payer: University Health Alliance Commercial	$438.18

Lone Star Retr Sys Disp Ring 32.5cmX18.3cm 3304G [3643031]

Facility

$601.15

Hospital Charge Code	3643031
Hospital Revenue Code	272
Min. Negotiated Rate	$510.98
Max. Negotiated Rate	$583.12
Rate for Payer: Cash Price	$390.75
Rate for Payer: Health Management Network Commercial	$510.98
Rate for Payer: MDX Hawaii PPO	$583.12

Loop Electrode 15Mmx15Mm R1515 [3602996]

Facility

$197.68

Hospital Charge Code	3602996
Hospital Revenue Code	272
Min. Negotiated Rate	$100.82
Max. Negotiated Rate	$191.75
Rate for Payer: Cash Price	$128.49
Rate for Payer: Hawaii Western Management Group Commercial	$187.80
Rate for Payer: Health Management Network Commercial	$168.03
Rate for Payer: Kaiser Permanente Commercial	$124.54
Rate for Payer: Kaiser Permanente Medicaid	$100.82
Rate for Payer: MDX Hawaii PPO	$191.75
Rate for Payer: University Health Alliance Commercial	$144.09

Loop Electrode 15Mmx15Mm R1515 [3602996]

Facility

$197.68

Hospital Charge Code	3602996
Hospital Revenue Code	272
Min. Negotiated Rate	$168.03
Max. Negotiated Rate	$191.75
Rate for Payer: Cash Price	$128.49
Rate for Payer: Health Management Network Commercial	$168.03
Rate for Payer: MDX Hawaii PPO	$191.75

Loop Electrode 15Mmx5Mm R1505 [3602998]

Facility

$147.43

Hospital Charge Code	3602998
Hospital Revenue Code	272
Min. Negotiated Rate	$125.32
Max. Negotiated Rate	$143.01
Rate for Payer: Cash Price	$95.83
Rate for Payer: Health Management Network Commercial	$125.32
Rate for Payer: MDX Hawaii PPO	$143.01

Loop Electrode 15Mmx5Mm R1505 [3602998]

Facility

$147.43

Hospital Charge Code	3602998
Hospital Revenue Code	272
Min. Negotiated Rate	$75.19
Max. Negotiated Rate	$143.01
Rate for Payer: Cash Price	$95.83
Rate for Payer: Hawaii Western Management Group Commercial	$140.06
Rate for Payer: Health Management Network Commercial	$125.32
Rate for Payer: Kaiser Permanente Commercial	$92.88
Rate for Payer: Kaiser Permanente Medicaid	$75.19
Rate for Payer: MDX Hawaii PPO	$143.01
Rate for Payer: University Health Alliance Commercial	$107.46

Loop Electrode 15Mmx7Mm R1507 [3602985]

Facility

$197.68

Hospital Charge Code	3602985
Hospital Revenue Code	272
Min. Negotiated Rate	$100.82
Max. Negotiated Rate	$191.75
Rate for Payer: Cash Price	$128.49
Rate for Payer: Hawaii Western Management Group Commercial	$187.80
Rate for Payer: Health Management Network Commercial	$168.03
Rate for Payer: Kaiser Permanente Commercial	$124.54
Rate for Payer: Kaiser Permanente Medicaid	$100.82
Rate for Payer: MDX Hawaii PPO	$191.75
Rate for Payer: University Health Alliance Commercial	$144.09

Loop Electrode 15Mmx7Mm R1507 [3602985]

Facility

$197.68

Hospital Charge Code	3602985
Hospital Revenue Code	272
Min. Negotiated Rate	$168.03
Max. Negotiated Rate	$191.75
Rate for Payer: Cash Price	$128.49
Rate for Payer: Health Management Network Commercial	$168.03
Rate for Payer: MDX Hawaii PPO	$191.75

Loop Electrode 20Mmx10Mm 605180104 [3602986]

Facility

$160.16

Hospital Charge Code	3602986
Hospital Revenue Code	272
Min. Negotiated Rate	$136.14
Max. Negotiated Rate	$155.36
Rate for Payer: Cash Price	$104.10
Rate for Payer: Health Management Network Commercial	$136.14
Rate for Payer: MDX Hawaii PPO	$155.36

Loop Electrode 20Mmx10Mm 605180104 [3602986]

Facility

$160.16

Hospital Charge Code	3602986
Hospital Revenue Code	272
Min. Negotiated Rate	$81.68
Max. Negotiated Rate	$155.36
Rate for Payer: Cash Price	$104.10
Rate for Payer: Hawaii Western Management Group Commercial	$152.15
Rate for Payer: Health Management Network Commercial	$136.14
Rate for Payer: Kaiser Permanente Commercial	$100.90
Rate for Payer: Kaiser Permanente Medicaid	$81.68
Rate for Payer: MDX Hawaii PPO	$155.36
Rate for Payer: University Health Alliance Commercial	$116.74

Loop Electrode 20Mmx15Mm R2015 [3603109]

Facility

$207.20

Hospital Charge Code	3603109
Hospital Revenue Code	272
Min. Negotiated Rate	$105.67
Max. Negotiated Rate	$200.98
Rate for Payer: Cash Price	$134.68
Rate for Payer: Hawaii Western Management Group Commercial	$196.84
Rate for Payer: Health Management Network Commercial	$176.12
Rate for Payer: Kaiser Permanente Commercial	$130.54
Rate for Payer: Kaiser Permanente Medicaid	$105.67
Rate for Payer: MDX Hawaii PPO	$200.98
Rate for Payer: University Health Alliance Commercial	$151.03

Loop Electrode 20Mmx15Mm R2015 [3603109]

Facility

$207.20

Hospital Charge Code	3603109
Hospital Revenue Code	272
Min. Negotiated Rate	$176.12
Max. Negotiated Rate	$200.98
Rate for Payer: Cash Price	$134.68
Rate for Payer: Health Management Network Commercial	$176.12
Rate for Payer: MDX Hawaii PPO	$200.98

Loop Electrode 25Mmx10Mm R2510 [3603108]

Facility

$207.20

Hospital Charge Code	3603108
Hospital Revenue Code	272
Min. Negotiated Rate	$105.67
Max. Negotiated Rate	$200.98
Rate for Payer: Cash Price	$134.68
Rate for Payer: Hawaii Western Management Group Commercial	$196.84
Rate for Payer: Health Management Network Commercial	$176.12
Rate for Payer: Kaiser Permanente Commercial	$130.54
Rate for Payer: Kaiser Permanente Medicaid	$105.67
Rate for Payer: MDX Hawaii PPO	$200.98
Rate for Payer: University Health Alliance Commercial	$151.03

Loop Electrode 25Mmx10Mm R2510 [3603108]

Facility

$207.20

Hospital Charge Code	3603108
Hospital Revenue Code	272
Min. Negotiated Rate	$176.12
Max. Negotiated Rate	$200.98
Rate for Payer: Cash Price	$134.68
Rate for Payer: Health Management Network Commercial	$176.12
Rate for Payer: MDX Hawaii PPO	$200.98

Loop Electrode 5Mm Ball Tip 605181103 [3603002]

Facility

$160.16

Hospital Charge Code	3603002
Hospital Revenue Code	272
Min. Negotiated Rate	$136.14
Max. Negotiated Rate	$155.36
Rate for Payer: Cash Price	$104.10
Rate for Payer: Health Management Network Commercial	$136.14
Rate for Payer: MDX Hawaii PPO	$155.36

Loop Electrode 5Mm Ball Tip 605181103 [3603002]

Facility

$160.16

Hospital Charge Code	3603002
Hospital Revenue Code	272
Min. Negotiated Rate	$81.68
Max. Negotiated Rate	$155.36
Rate for Payer: Cash Price	$104.10
Rate for Payer: Hawaii Western Management Group Commercial	$152.15
Rate for Payer: Health Management Network Commercial	$136.14
Rate for Payer: Kaiser Permanente Commercial	$100.90
Rate for Payer: Kaiser Permanente Medicaid	$81.68
Rate for Payer: MDX Hawaii PPO	$155.36
Rate for Payer: University Health Alliance Commercial	$116.74

LOPERAMIDE 1 MG/7.5 ML PO LIQ

Facility

$17.48

Service Code	HCPCS A9270
Hospital Revenue Code	250
Min. Negotiated Rate	$14.86
Max. Negotiated Rate	$16.96
Rate for Payer: Cash Price	$11.36
Rate for Payer: Cash Price	$13.57
Rate for Payer: Cash Price	$1.62
Rate for Payer: Health Management Network Commercial	$2.12
Rate for Payer: Health Management Network Commercial	$17.74
Rate for Payer: Health Management Network Commercial	$14.86
Rate for Payer: MDX Hawaii PPO	$20.24
Rate for Payer: MDX Hawaii PPO	$2.42
Rate for Payer: MDX Hawaii PPO	$16.96

LOPERAMIDE 1 MG/7.5 ML PO LIQ

Facility

$20.87

Service Code	HCPCS A9270
Hospital Revenue Code	250
Min. Negotiated Rate	$10.64
Max. Negotiated Rate	$20.24
Rate for Payer: Cash Price	$13.57
Rate for Payer: Cash Price	$11.36
Rate for Payer: Cash Price	$1.62
Rate for Payer: Hawaii Western Management Group Commercial	$19.83
Rate for Payer: Hawaii Western Management Group Commercial	$2.37
Rate for Payer: Hawaii Western Management Group Commercial	$16.61
Rate for Payer: Health Management Network Commercial	$14.86
Rate for Payer: Health Management Network Commercial	$2.12
Rate for Payer: Health Management Network Commercial	$17.74
Rate for Payer: Kaiser Permanente Commercial	$11.01
Rate for Payer: Kaiser Permanente Commercial	$13.15
Rate for Payer: Kaiser Permanente Commercial	$1.57
Rate for Payer: Kaiser Permanente Medicaid	$8.91
Rate for Payer: Kaiser Permanente Medicaid	$10.64
Rate for Payer: Kaiser Permanente Medicaid	$1.27
Rate for Payer: MDX Hawaii PPO	$16.96
Rate for Payer: MDX Hawaii PPO	$20.24
Rate for Payer: MDX Hawaii PPO	$2.42
Rate for Payer: UnitedHealthcare Medicaid	$12.52
Rate for Payer: UnitedHealthcare Medicaid	$1.49
Rate for Payer: UnitedHealthcare Medicaid	$10.49
Rate for Payer: University Health Alliance Commercial	$1.81
Rate for Payer: University Health Alliance Commercial	$15.21
Rate for Payer: University Health Alliance Commercial	$12.74

LOPERAMIDE 2 MG PO CAP

Facility

$5.64

Service Code	HCPCS A9270
Hospital Revenue Code	250
Min. Negotiated Rate	$4.79
Max. Negotiated Rate	$5.47
Rate for Payer: Cash Price	$3.67
Rate for Payer: Health Management Network Commercial	$4.79
Rate for Payer: MDX Hawaii PPO	$5.47

LOPERAMIDE 2 MG PO CAP

Facility

$5.64

Service Code	HCPCS A9270
Hospital Revenue Code	250
Min. Negotiated Rate	$2.88
Max. Negotiated Rate	$5.47
Rate for Payer: Cash Price	$3.67
Rate for Payer: Hawaii Western Management Group Commercial	$5.36
Rate for Payer: Health Management Network Commercial	$4.79
Rate for Payer: Kaiser Permanente Commercial	$3.55
Rate for Payer: Kaiser Permanente Medicaid	$2.88
Rate for Payer: MDX Hawaii PPO	$5.47
Rate for Payer: UnitedHealthcare Medicaid	$3.38
Rate for Payer: University Health Alliance Commercial	$4.11

LORATADINE 10 MG PO TABLET

Facility

$4.72

Service Code	HCPCS A9270
Hospital Revenue Code	250
Min. Negotiated Rate	$4.01
Max. Negotiated Rate	$4.58
Rate for Payer: Cash Price	$3.07
Rate for Payer: Cash Price	$2.52
Rate for Payer: Health Management Network Commercial	$3.30
Rate for Payer: Health Management Network Commercial	$4.01
Rate for Payer: MDX Hawaii PPO	$4.58
Rate for Payer: MDX Hawaii PPO	$3.76

LORATADINE 10 MG PO TABLET

Facility

$3.88

Service Code	HCPCS A9270
Hospital Revenue Code	250
Min. Negotiated Rate	$1.98
Max. Negotiated Rate	$3.76
Rate for Payer: MDX Hawaii PPO	$3.76
Rate for Payer: Cash Price	$2.52
Rate for Payer: Cash Price	$3.07
Rate for Payer: Hawaii Western Management Group Commercial	$3.69
Rate for Payer: Hawaii Western Management Group Commercial	$4.48
Rate for Payer: Health Management Network Commercial	$3.30
Rate for Payer: Health Management Network Commercial	$4.01
Rate for Payer: Kaiser Permanente Commercial	$2.44
Rate for Payer: Kaiser Permanente Commercial	$2.97
Rate for Payer: Kaiser Permanente Medicaid	$1.98
Rate for Payer: Kaiser Permanente Medicaid	$2.41
Rate for Payer: MDX Hawaii PPO	$4.58
Rate for Payer: UnitedHealthcare Medicaid	$2.83
Rate for Payer: UnitedHealthcare Medicaid	$2.33
Rate for Payer: University Health Alliance Commercial	$2.83
Rate for Payer: University Health Alliance Commercial	$3.44

LORAZEPAM 0.5 MG PO TABLET

Facility

$3.55

Service Code	HCPCS A9270
Hospital Revenue Code	250
Min. Negotiated Rate	$3.02
Max. Negotiated Rate	$3.44
Rate for Payer: Cash Price	$2.31
Rate for Payer: Health Management Network Commercial	$3.02
Rate for Payer: MDX Hawaii PPO	$3.44

Know your out-of-pocket cost for care.

All Charges