Kona Community Hospital

All Charges

Charge

Type

Setting

Price

LORAZEPAM 0.5 MG PO TABLET

Facility

$3.55

Service Code	HCPCS A9270
Hospital Revenue Code	250
Min. Negotiated Rate	$1.81
Max. Negotiated Rate	$3.44
Rate for Payer: Cash Price	$2.31
Rate for Payer: Hawaii Western Management Group Commercial	$3.37
Rate for Payer: Health Management Network Commercial	$3.02
Rate for Payer: Kaiser Permanente Commercial	$2.24
Rate for Payer: Kaiser Permanente Medicaid	$1.81
Rate for Payer: MDX Hawaii PPO	$3.44
Rate for Payer: UnitedHealthcare Medicaid	$2.13
Rate for Payer: University Health Alliance Commercial	$2.59

LORAZEPAM 1 MG PO TABLET

Facility

$4.63

Service Code	HCPCS A9270
Hospital Revenue Code	250
Min. Negotiated Rate	$2.36
Max. Negotiated Rate	$4.49
Rate for Payer: Cash Price	$3.01
Rate for Payer: Cash Price	$3.16
Rate for Payer: Hawaii Western Management Group Commercial	$4.40
Rate for Payer: Hawaii Western Management Group Commercial	$4.62
Rate for Payer: Health Management Network Commercial	$3.94
Rate for Payer: Health Management Network Commercial	$4.13
Rate for Payer: Kaiser Permanente Commercial	$2.92
Rate for Payer: Kaiser Permanente Commercial	$3.06
Rate for Payer: Kaiser Permanente Medicaid	$2.36
Rate for Payer: Kaiser Permanente Medicaid	$2.48
Rate for Payer: MDX Hawaii PPO	$4.49
Rate for Payer: MDX Hawaii PPO	$4.71
Rate for Payer: UnitedHealthcare Medicaid	$2.92
Rate for Payer: UnitedHealthcare Medicaid	$2.78
Rate for Payer: University Health Alliance Commercial	$3.37
Rate for Payer: University Health Alliance Commercial	$3.54

LORAZEPAM 1 MG PO TABLET

Facility

$4.86

Service Code	HCPCS A9270
Hospital Revenue Code	250
Min. Negotiated Rate	$4.13
Max. Negotiated Rate	$4.71
Rate for Payer: Cash Price	$3.16
Rate for Payer: Cash Price	$3.01
Rate for Payer: Health Management Network Commercial	$3.94
Rate for Payer: Health Management Network Commercial	$4.13
Rate for Payer: MDX Hawaii PPO	$4.71
Rate for Payer: MDX Hawaii PPO	$4.49

LORAZEPAM 2 MG/ML INJ 1 ML SYR

Facility

$19.81

Service Code	HCPCS J2060
Hospital Revenue Code	636
Min. Negotiated Rate	$1.32
Max. Negotiated Rate	$19.22
Rate for Payer: Cash Price	$12.88
Rate for Payer: Cash Price	$12.88
Rate for Payer: Hawaii Medical Service Association ABD	$1.32
Rate for Payer: Hawaii Medical Service Association Non-ABD	$1.32
Rate for Payer: Hawaii Western Management Group Commercial	$18.82
Rate for Payer: Health Management Network Commercial	$16.84
Rate for Payer: Kaiser Permanente Commercial	$12.48
Rate for Payer: Kaiser Permanente Medicaid	$10.10
Rate for Payer: MDX Hawaii PPO	$19.22
Rate for Payer: UnitedHealthcare Medicaid	$11.89
Rate for Payer: University Health Alliance Commercial	$14.44

LORAZEPAM 2 MG/ML INJ 1 ML SYR

Facility

$19.81

Service Code	HCPCS J2060
Hospital Revenue Code	250
Min. Negotiated Rate	$16.84
Max. Negotiated Rate	$19.22
Rate for Payer: Cash Price	$12.88
Rate for Payer: Health Management Network Commercial	$16.84
Rate for Payer: MDX Hawaii PPO	$19.22

LORAZEPAM 2 MG/ML INJ SOLN

Facility

$8.63

Service Code	HCPCS J2060
Hospital Revenue Code	636
Min. Negotiated Rate	$1.32
Max. Negotiated Rate	$8.37
Rate for Payer: Cash Price	$5.61
Rate for Payer: Cash Price	$5.61
Rate for Payer: Hawaii Medical Service Association ABD	$1.32
Rate for Payer: Hawaii Medical Service Association Non-ABD	$1.32
Rate for Payer: Hawaii Western Management Group Commercial	$8.20
Rate for Payer: Health Management Network Commercial	$7.34
Rate for Payer: Kaiser Permanente Commercial	$5.44
Rate for Payer: Kaiser Permanente Medicaid	$4.40
Rate for Payer: MDX Hawaii PPO	$8.37
Rate for Payer: UnitedHealthcare Medicaid	$5.18
Rate for Payer: University Health Alliance Commercial	$6.29

LORAZEPAM 2 MG/ML INJ SOLN

Facility

$8.63

Service Code	HCPCS J2060
Hospital Revenue Code	250
Min. Negotiated Rate	$7.34
Max. Negotiated Rate	$8.37
Rate for Payer: Cash Price	$5.61
Rate for Payer: Health Management Network Commercial	$7.34
Rate for Payer: MDX Hawaii PPO	$8.37

LORAZEPAM 2 MG PO (FOR CIWA AR SCORE)

Facility

$6.74

Service Code	HCPCS A9270
Hospital Revenue Code	250
Min. Negotiated Rate	$5.73
Max. Negotiated Rate	$6.54
Rate for Payer: Cash Price	$4.38
Rate for Payer: Health Management Network Commercial	$5.73
Rate for Payer: MDX Hawaii PPO	$6.54

LORAZEPAM 2 MG PO (FOR CIWA AR SCORE)

Facility

$6.74

Service Code	HCPCS A9270
Hospital Revenue Code	250
Min. Negotiated Rate	$3.44
Max. Negotiated Rate	$6.54
Rate for Payer: Cash Price	$4.38
Rate for Payer: Hawaii Western Management Group Commercial	$6.40
Rate for Payer: Health Management Network Commercial	$5.73
Rate for Payer: Kaiser Permanente Commercial	$4.25
Rate for Payer: Kaiser Permanente Medicaid	$3.44
Rate for Payer: MDX Hawaii PPO	$6.54
Rate for Payer: UnitedHealthcare Medicaid	$4.04
Rate for Payer: University Health Alliance Commercial	$4.91

LOSARTAN 25 MG PO TABLET

Facility

$9.27

Service Code	HCPCS A9270
Hospital Revenue Code	250
Min. Negotiated Rate	$7.88
Max. Negotiated Rate	$8.99
Rate for Payer: Cash Price	$6.03
Rate for Payer: Health Management Network Commercial	$7.88
Rate for Payer: MDX Hawaii PPO	$8.99

LOSARTAN 25 MG PO TABLET

Facility

$9.27

Service Code	HCPCS A9270
Hospital Revenue Code	250
Min. Negotiated Rate	$4.73
Max. Negotiated Rate	$8.99
Rate for Payer: Cash Price	$6.03
Rate for Payer: Hawaii Western Management Group Commercial	$8.81
Rate for Payer: Health Management Network Commercial	$7.88
Rate for Payer: Kaiser Permanente Commercial	$5.84
Rate for Payer: Kaiser Permanente Medicaid	$4.73
Rate for Payer: MDX Hawaii PPO	$8.99
Rate for Payer: UnitedHealthcare Medicaid	$5.56
Rate for Payer: University Health Alliance Commercial	$6.76

LOSARTAN 50 MG PO TABLET

Facility

$3.73

Service Code	HCPCS A9270
Hospital Revenue Code	250
Min. Negotiated Rate	$3.17
Max. Negotiated Rate	$3.62
Rate for Payer: Cash Price	$2.42
Rate for Payer: Cash Price	$8.07
Rate for Payer: Health Management Network Commercial	$10.56
Rate for Payer: Health Management Network Commercial	$3.17
Rate for Payer: MDX Hawaii PPO	$3.62
Rate for Payer: MDX Hawaii PPO	$12.05

LOSARTAN 50 MG PO TABLET

Facility

$12.42

Service Code	HCPCS A9270
Hospital Revenue Code	250
Min. Negotiated Rate	$6.33
Max. Negotiated Rate	$12.05
Rate for Payer: Cash Price	$8.07
Rate for Payer: Cash Price	$2.42
Rate for Payer: Hawaii Western Management Group Commercial	$11.80
Rate for Payer: Hawaii Western Management Group Commercial	$3.54
Rate for Payer: Health Management Network Commercial	$10.56
Rate for Payer: Health Management Network Commercial	$3.17
Rate for Payer: Kaiser Permanente Commercial	$7.82
Rate for Payer: Kaiser Permanente Commercial	$2.35
Rate for Payer: Kaiser Permanente Medicaid	$6.33
Rate for Payer: Kaiser Permanente Medicaid	$1.90
Rate for Payer: MDX Hawaii PPO	$12.05
Rate for Payer: MDX Hawaii PPO	$3.62
Rate for Payer: UnitedHealthcare Medicaid	$2.24
Rate for Payer: UnitedHealthcare Medicaid	$7.45
Rate for Payer: University Health Alliance Commercial	$9.05
Rate for Payer: University Health Alliance Commercial	$2.72

LOTEPREDNOL ETABONATE 0.5 % OPHT DRPS

Facility

$603.89

Service Code	HCPCS A9270
Hospital Revenue Code	250
Min. Negotiated Rate	$513.31
Max. Negotiated Rate	$585.77
Rate for Payer: Cash Price	$392.53
Rate for Payer: Health Management Network Commercial	$513.31
Rate for Payer: MDX Hawaii PPO	$585.77

LOTEPREDNOL ETABONATE 0.5 % OPHT DRPS

Facility

$603.89

Service Code	HCPCS A9270
Hospital Revenue Code	250
Min. Negotiated Rate	$307.98
Max. Negotiated Rate	$585.77
Rate for Payer: Cash Price	$392.53
Rate for Payer: Hawaii Western Management Group Commercial	$573.70
Rate for Payer: Health Management Network Commercial	$513.31
Rate for Payer: Kaiser Permanente Commercial	$380.45
Rate for Payer: Kaiser Permanente Medicaid	$307.98
Rate for Payer: MDX Hawaii PPO	$585.77
Rate for Payer: UnitedHealthcare Medicaid	$362.33
Rate for Payer: University Health Alliance Commercial	$440.18

LOWER EXTREMITY AND HUMERUS PROCEDURES EXCEPT HIP, FOOT AND FEMUR WITH CC

Facility

$55,687.17

Service Code	MSDRG 493
Min. Negotiated Rate	$33,356.72
Max. Negotiated Rate	$55,687.17
Rate for Payer: AlohaCare Medicare	$33,356.72
Rate for Payer: Devoted Health Medicare	$36,692.39
Rate for Payer: Hawaii Medical Service Association Commercial	$55,687.17
Rate for Payer: Hawaii Medical Service Association Medicare	$33,356.72
Rate for Payer: Humana Medicare	$33,356.72
Rate for Payer: Kaiser Permanente Commercial	$43,747.72
Rate for Payer: Kaiser Permanente Medicare	$33,356.72
Rate for Payer: Ohana Health Plan Medicare	$33,356.72
Rate for Payer: UnitedHealthcare Medicare	$33,356.72

LOWER EXTREMITY AND HUMERUS PROCEDURES EXCEPT HIP, FOOT AND FEMUR WITH MCC

Facility

$63,335.10

Service Code	MSDRG 492
Min. Negotiated Rate	$48,291.70
Max. Negotiated Rate	$63,335.10
Rate for Payer: AlohaCare Medicare	$48,291.70
Rate for Payer: Devoted Health Medicare	$53,120.87
Rate for Payer: Hawaii Medical Service Association Commercial	$55,687.17
Rate for Payer: Hawaii Medical Service Association Medicare	$48,291.70
Rate for Payer: Humana Medicare	$48,291.70
Rate for Payer: Kaiser Permanente Commercial	$63,335.10
Rate for Payer: Kaiser Permanente Medicare	$48,291.70
Rate for Payer: Ohana Health Plan Medicare	$48,291.70
Rate for Payer: UnitedHealthcare Medicare	$48,291.70

LOWER EXTREMITY AND HUMERUS PROCEDURES EXCEPT HIP, FOOT AND FEMUR WITHOUT CC/MCC

Facility

$34,612.12

Service Code	MSDRG 494
Min. Negotiated Rate	$26,391.02
Max. Negotiated Rate	$34,612.12
Rate for Payer: AlohaCare Medicare	$26,391.02
Rate for Payer: Devoted Health Medicare	$29,030.12
Rate for Payer: Hawaii Medical Service Association Commercial	$32,881.95
Rate for Payer: Hawaii Medical Service Association Medicare	$26,391.02
Rate for Payer: Humana Medicare	$26,391.02
Rate for Payer: Kaiser Permanente Commercial	$34,612.12
Rate for Payer: Kaiser Permanente Medicare	$26,391.02
Rate for Payer: Ohana Health Plan Medicare	$26,391.02
Rate for Payer: UnitedHealthcare Medicare	$26,391.02

LOWER EXTREMITY ARTERIAL PROCEDURES

Facility

$7,871.52

Service Code	APR-DRG 1811
Min. Negotiated Rate	$7,871.52
Max. Negotiated Rate	$7,871.52
Rate for Payer: AlohaCare Medicaid	$7,871.52
Rate for Payer: Hawaii Medical Service Association ABD	$7,871.52
Rate for Payer: Hawaii Medical Service Association Non-ABD	$7,871.52
Rate for Payer: Kaiser Permanente Medicaid	$7,871.52
Rate for Payer: Ohana Health Plan Medicaid	$7,871.52
Rate for Payer: UnitedHealthcare Medicaid	$7,871.52

LOWER EXTREMITY ARTERIAL PROCEDURES

Facility

$16,322.53

Service Code	APR-DRG 1813
Min. Negotiated Rate	$16,322.53
Max. Negotiated Rate	$16,322.53
Rate for Payer: AlohaCare Medicaid	$16,322.53
Rate for Payer: Hawaii Medical Service Association ABD	$16,322.53
Rate for Payer: Hawaii Medical Service Association Non-ABD	$16,322.53
Rate for Payer: Kaiser Permanente Medicaid	$16,322.53
Rate for Payer: Ohana Health Plan Medicaid	$16,322.53
Rate for Payer: UnitedHealthcare Medicaid	$16,322.53

LOWER EXTREMITY ARTERIAL PROCEDURES

Facility

$25,701.37

Service Code	APR-DRG 1814
Min. Negotiated Rate	$25,701.37
Max. Negotiated Rate	$25,701.37
Rate for Payer: AlohaCare Medicaid	$25,701.37
Rate for Payer: Hawaii Medical Service Association ABD	$25,701.37
Rate for Payer: Hawaii Medical Service Association Non-ABD	$25,701.37
Rate for Payer: Kaiser Permanente Medicaid	$25,701.37
Rate for Payer: Ohana Health Plan Medicaid	$25,701.37
Rate for Payer: UnitedHealthcare Medicaid	$25,701.37

LOWER EXTREMITY ARTERIAL PROCEDURES

Facility

$10,662.63

Service Code	APR-DRG 1812
Min. Negotiated Rate	$10,662.63
Max. Negotiated Rate	$10,662.63
Rate for Payer: AlohaCare Medicaid	$10,662.63
Rate for Payer: Hawaii Medical Service Association ABD	$10,662.63
Rate for Payer: Hawaii Medical Service Association Non-ABD	$10,662.63
Rate for Payer: Kaiser Permanente Medicaid	$10,662.63
Rate for Payer: Ohana Health Plan Medicaid	$10,662.63
Rate for Payer: UnitedHealthcare Medicaid	$10,662.63

Low-Profile AC Repair System AR2371 [3642595]

Facility

$6,112.50

Hospital Charge Code	3642595
Hospital Revenue Code	272
Min. Negotiated Rate	$5,195.62
Max. Negotiated Rate	$5,929.12
Rate for Payer: Cash Price	$3,973.12
Rate for Payer: Health Management Network Commercial	$5,195.62
Rate for Payer: MDX Hawaii PPO	$5,929.12

Low-Profile AC Repair System AR2371 [3642595]

Facility

$6,112.50

Hospital Charge Code	3642595
Hospital Revenue Code	272
Min. Negotiated Rate	$3,117.38
Max. Negotiated Rate	$5,929.12
Rate for Payer: Cash Price	$3,973.12
Rate for Payer: Hawaii Western Management Group Commercial	$5,806.88
Rate for Payer: Health Management Network Commercial	$5,195.62
Rate for Payer: Kaiser Permanente Commercial	$3,850.88
Rate for Payer: Kaiser Permanente Medicaid	$3,117.38
Rate for Payer: MDX Hawaii PPO	$5,929.12
Rate for Payer: University Health Alliance Commercial	$4,455.40

Low Profile Screw, 2.4mm X 18mm Cortex AR-8916CX24-18 [3645529]

Facility

$1,112.32

Service Code	HCPCS C1713
Hospital Charge Code	3645529
Hospital Revenue Code	278
Min. Negotiated Rate	$622.90
Max. Negotiated Rate	$1,078.95
Rate for Payer: Cash Price	$723.01
Rate for Payer: Hawaii Western Management Group Commercial	$778.62
Rate for Payer: Health Management Network Commercial	$945.47
Rate for Payer: MDX Hawaii PPO	$1,078.95
Rate for Payer: University Health Alliance Commercial	$622.90

Know your out-of-pocket cost for care.

All Charges