Kona Community Hospital

All Charges

Charge

Type

Setting

Price

MEMANTINE 5 MG PO TABLET

Facility

$4.42

Service Code	HCPCS A9270
Hospital Revenue Code	250
Min. Negotiated Rate	$2.25
Max. Negotiated Rate	$4.29
Rate for Payer: Cash Price	$2.87
Rate for Payer: Hawaii Western Management Group Commercial	$4.20
Rate for Payer: Health Management Network Commercial	$3.76
Rate for Payer: Kaiser Permanente Commercial	$2.78
Rate for Payer: Kaiser Permanente Medicaid	$2.25
Rate for Payer: MDX Hawaii PPO	$4.29
Rate for Payer: UnitedHealthcare Medicaid	$2.65
Rate for Payer: University Health Alliance Commercial	$3.22

MEMANTINE 5 MG PO TABLET

Facility

$4.42

Service Code	HCPCS A9270
Hospital Revenue Code	250
Min. Negotiated Rate	$3.76
Max. Negotiated Rate	$4.29
Rate for Payer: Cash Price	$2.87
Rate for Payer: Health Management Network Commercial	$3.76
Rate for Payer: MDX Hawaii PPO	$4.29

MENING VAC A,C,Y,W135,TET (PF) 10 MCG/0.5 ML IM SOLN

Facility

$595.46

Service Code	HCPCS 90619
Hospital Revenue Code	250
Min. Negotiated Rate	$185.60
Max. Negotiated Rate	$577.60
Rate for Payer: Cash Price	$387.05
Rate for Payer: Cash Price	$387.05
Rate for Payer: Hawaii Medical Service Association ABD	$185.60
Rate for Payer: Hawaii Medical Service Association Non-ABD	$185.60
Rate for Payer: Hawaii Western Management Group Commercial	$565.69
Rate for Payer: Health Management Network Commercial	$506.14
Rate for Payer: Kaiser Permanente Commercial	$375.14
Rate for Payer: Kaiser Permanente Medicaid	$303.68
Rate for Payer: MDX Hawaii PPO	$577.60
Rate for Payer: UnitedHealthcare Medicaid	$357.28
Rate for Payer: University Health Alliance Commercial	$434.03

MENING VAC A,C,Y,W135,TET (PF) 10 MCG/0.5 ML IM SOLN

Facility

$595.46

Service Code	HCPCS 90619
Hospital Revenue Code	250
Min. Negotiated Rate	$506.14
Max. Negotiated Rate	$577.60
Rate for Payer: Cash Price	$387.05
Rate for Payer: Health Management Network Commercial	$506.14
Rate for Payer: MDX Hawaii PPO	$577.60

MENSTRUAL AND OTHER FEMALE REPRODUCTIVE SYSTEM DISORDERS WITH CC/MCC

Facility

$17,379.38

Service Code	MSDRG 760
Min. Negotiated Rate	$12,198.14
Max. Negotiated Rate	$17,379.38
Rate for Payer: AlohaCare Medicare	$13,251.40
Rate for Payer: Devoted Health Medicare	$14,576.54
Rate for Payer: Hawaii Medical Service Association Commercial	$12,198.14
Rate for Payer: Hawaii Medical Service Association Medicare	$13,251.40
Rate for Payer: Humana Medicare	$13,251.40
Rate for Payer: Kaiser Permanente Commercial	$17,379.38
Rate for Payer: Kaiser Permanente Medicare	$13,251.40
Rate for Payer: Ohana Health Plan Medicare	$13,251.40
Rate for Payer: UnitedHealthcare Medicare	$13,251.40

MENSTRUAL AND OTHER FEMALE REPRODUCTIVE SYSTEM DISORDERS WITHOUT CC/MCC

Facility

$12,198.14

Service Code	MSDRG 761
Min. Negotiated Rate	$7,503.67
Max. Negotiated Rate	$12,198.14
Rate for Payer: AlohaCare Medicare	$7,503.67
Rate for Payer: Devoted Health Medicare	$8,254.04
Rate for Payer: Hawaii Medical Service Association Commercial	$12,198.14
Rate for Payer: Hawaii Medical Service Association Medicare	$7,503.67
Rate for Payer: Humana Medicare	$7,503.67
Rate for Payer: Kaiser Permanente Commercial	$9,825.60
Rate for Payer: Kaiser Permanente Medicare	$7,503.67
Rate for Payer: Ohana Health Plan Medicare	$7,503.67
Rate for Payer: UnitedHealthcare Medicare	$7,503.67

MENSTRUAL & OTHER FEMALE REPRODUCTIVE SYSTEM DISORDERS

Facility

$9,146.40

Service Code	APR-DRG 5324
Min. Negotiated Rate	$9,146.40
Max. Negotiated Rate	$9,146.40
Rate for Payer: AlohaCare Medicaid	$9,146.40
Rate for Payer: Hawaii Medical Service Association ABD	$9,146.40
Rate for Payer: Hawaii Medical Service Association Non-ABD	$9,146.40
Rate for Payer: Kaiser Permanente Medicaid	$9,146.40
Rate for Payer: Ohana Health Plan Medicaid	$9,146.40
Rate for Payer: UnitedHealthcare Medicaid	$9,146.40

MENSTRUAL & OTHER FEMALE REPRODUCTIVE SYSTEM DISORDERS

Facility

$2,351.71

Service Code	APR-DRG 5321
Min. Negotiated Rate	$2,351.71
Max. Negotiated Rate	$2,351.71
Rate for Payer: AlohaCare Medicaid	$2,351.71
Rate for Payer: Hawaii Medical Service Association ABD	$2,351.71
Rate for Payer: Hawaii Medical Service Association Non-ABD	$2,351.71
Rate for Payer: Kaiser Permanente Medicaid	$2,351.71
Rate for Payer: Ohana Health Plan Medicaid	$2,351.71
Rate for Payer: UnitedHealthcare Medicaid	$2,351.71

MENSTRUAL & OTHER FEMALE REPRODUCTIVE SYSTEM DISORDERS

Facility

$4,262.76

Service Code	APR-DRG 5323
Min. Negotiated Rate	$4,262.76
Max. Negotiated Rate	$4,262.76
Rate for Payer: AlohaCare Medicaid	$4,262.76
Rate for Payer: Hawaii Medical Service Association ABD	$4,262.76
Rate for Payer: Hawaii Medical Service Association Non-ABD	$4,262.76
Rate for Payer: Kaiser Permanente Medicaid	$4,262.76
Rate for Payer: Ohana Health Plan Medicaid	$4,262.76
Rate for Payer: UnitedHealthcare Medicaid	$4,262.76

MENSTRUAL & OTHER FEMALE REPRODUCTIVE SYSTEM DISORDERS

Facility

$2,834.41

Service Code	APR-DRG 5322
Min. Negotiated Rate	$2,834.41
Max. Negotiated Rate	$2,834.41
Rate for Payer: AlohaCare Medicaid	$2,834.41
Rate for Payer: Hawaii Medical Service Association ABD	$2,834.41
Rate for Payer: Hawaii Medical Service Association Non-ABD	$2,834.41
Rate for Payer: Kaiser Permanente Medicaid	$2,834.41
Rate for Payer: Ohana Health Plan Medicaid	$2,834.41
Rate for Payer: UnitedHealthcare Medicaid	$2,834.41

MENTAL ILLNESS DIAGNOSIS W O.R. PROCEDURE

Facility

$7,076.44

Service Code	APR-DRG 7401
Min. Negotiated Rate	$7,076.44
Max. Negotiated Rate	$7,076.44
Rate for Payer: AlohaCare Medicaid	$7,076.44
Rate for Payer: Hawaii Medical Service Association ABD	$7,076.44
Rate for Payer: Hawaii Medical Service Association Non-ABD	$7,076.44
Rate for Payer: Kaiser Permanente Medicaid	$7,076.44
Rate for Payer: Ohana Health Plan Medicaid	$7,076.44
Rate for Payer: UnitedHealthcare Medicaid	$7,076.44

MENTAL ILLNESS DIAGNOSIS W O.R. PROCEDURE

Facility

$15,222.08

Service Code	APR-DRG 7403
Min. Negotiated Rate	$15,222.08
Max. Negotiated Rate	$15,222.08
Rate for Payer: AlohaCare Medicaid	$15,222.08
Rate for Payer: Hawaii Medical Service Association ABD	$15,222.08
Rate for Payer: Hawaii Medical Service Association Non-ABD	$15,222.08
Rate for Payer: Kaiser Permanente Medicaid	$15,222.08
Rate for Payer: Ohana Health Plan Medicaid	$15,222.08
Rate for Payer: UnitedHealthcare Medicaid	$15,222.08

MENTAL ILLNESS DIAGNOSIS W O.R. PROCEDURE

Facility

$32,717.28

Service Code	APR-DRG 7404
Min. Negotiated Rate	$32,717.28
Max. Negotiated Rate	$32,717.28
Rate for Payer: AlohaCare Medicaid	$32,717.28
Rate for Payer: Hawaii Medical Service Association ABD	$32,717.28
Rate for Payer: Hawaii Medical Service Association Non-ABD	$32,717.28
Rate for Payer: Kaiser Permanente Medicaid	$32,717.28
Rate for Payer: Ohana Health Plan Medicaid	$32,717.28
Rate for Payer: UnitedHealthcare Medicaid	$32,717.28

MENTAL ILLNESS DIAGNOSIS W O.R. PROCEDURE

Facility

$7,444.80

Service Code	APR-DRG 7402
Min. Negotiated Rate	$7,444.80
Max. Negotiated Rate	$7,444.80
Rate for Payer: AlohaCare Medicaid	$7,444.80
Rate for Payer: Hawaii Medical Service Association ABD	$7,444.80
Rate for Payer: Hawaii Medical Service Association Non-ABD	$7,444.80
Rate for Payer: Kaiser Permanente Medicaid	$7,444.80
Rate for Payer: Ohana Health Plan Medicaid	$7,444.80
Rate for Payer: UnitedHealthcare Medicaid	$7,444.80

MEPERIDINE (PF) 25 MG/ML INJ SOLN

Facility

$14.00

Service Code	HCPCS J2175
Hospital Revenue Code	250
Min. Negotiated Rate	$11.90
Max. Negotiated Rate	$13.58
Rate for Payer: Cash Price	$9.10
Rate for Payer: Health Management Network Commercial	$11.90
Rate for Payer: MDX Hawaii PPO	$13.58

MEPERIDINE (PF) 25 MG/ML INJ SOLN

Facility

$14.00

Service Code	HCPCS J2175
Hospital Revenue Code	636
Min. Negotiated Rate	$7.14
Max. Negotiated Rate	$15.69
Rate for Payer: Cash Price	$9.10
Rate for Payer: Cash Price	$9.10
Rate for Payer: Hawaii Medical Service Association ABD	$15.69
Rate for Payer: Hawaii Medical Service Association Non-ABD	$15.69
Rate for Payer: Hawaii Western Management Group Commercial	$13.30
Rate for Payer: Health Management Network Commercial	$11.90
Rate for Payer: Kaiser Permanente Commercial	$8.82
Rate for Payer: Kaiser Permanente Medicaid	$7.14
Rate for Payer: MDX Hawaii PPO	$13.58
Rate for Payer: UnitedHealthcare Medicaid	$8.40
Rate for Payer: University Health Alliance Commercial	$10.20

MEPERIDINE (PF) 50 MG/ML INJ SYR

Facility

$46.14

Service Code	HCPCS J2175
Hospital Revenue Code	250
Min. Negotiated Rate	$39.22
Max. Negotiated Rate	$44.76
Rate for Payer: Cash Price	$29.99
Rate for Payer: Health Management Network Commercial	$39.22
Rate for Payer: MDX Hawaii PPO	$44.76

MEPERIDINE (PF) 50 MG/ML INJ SYR

Facility

$46.14

Service Code	HCPCS J2175
Hospital Revenue Code	636
Min. Negotiated Rate	$15.69
Max. Negotiated Rate	$44.76
Rate for Payer: Cash Price	$29.99
Rate for Payer: Cash Price	$29.99
Rate for Payer: Hawaii Medical Service Association ABD	$15.69
Rate for Payer: Hawaii Medical Service Association Non-ABD	$15.69
Rate for Payer: Hawaii Western Management Group Commercial	$43.83
Rate for Payer: Health Management Network Commercial	$39.22
Rate for Payer: Kaiser Permanente Commercial	$29.07
Rate for Payer: Kaiser Permanente Medicaid	$23.53
Rate for Payer: MDX Hawaii PPO	$44.76
Rate for Payer: UnitedHealthcare Medicaid	$27.68
Rate for Payer: University Health Alliance Commercial	$33.63

Mepilex Post-Op Dressing 2.5"x3" 498100 [3644250]

Facility

$59.16

Service Code	HCPCS A6213
Hospital Charge Code	3644250
Hospital Revenue Code	272
Min. Negotiated Rate	$10.39
Max. Negotiated Rate	$57.39
Rate for Payer: Cash Price	$38.45
Rate for Payer: Cash Price	$38.45
Rate for Payer: Hawaii Western Management Group Commercial	$56.20
Rate for Payer: Health Management Network Commercial	$50.29
Rate for Payer: Kaiser Permanente Commercial	$37.27
Rate for Payer: Kaiser Permanente Medicaid	$30.17
Rate for Payer: MDX Hawaii PPO	$57.39
Rate for Payer: UnitedHealthcare Medicaid	$10.39
Rate for Payer: University Health Alliance Commercial	$43.12

Mepilex Post-Op Dressing 2.5"x3" 498100 [3644250]

Facility

$59.16

Service Code	HCPCS A6213
Hospital Charge Code	3644250
Hospital Revenue Code	272
Min. Negotiated Rate	$50.29
Max. Negotiated Rate	$57.39
Rate for Payer: Cash Price	$38.45
Rate for Payer: Health Management Network Commercial	$50.29
Rate for Payer: MDX Hawaii PPO	$57.39

Mepilex Post-Op Dressing 4x10 498450 [3643642]

Facility

$209.98

Hospital Charge Code	3643642
Hospital Revenue Code	272
Min. Negotiated Rate	$107.09
Max. Negotiated Rate	$203.68
Rate for Payer: Cash Price	$136.49
Rate for Payer: Hawaii Western Management Group Commercial	$199.48
Rate for Payer: Health Management Network Commercial	$178.48
Rate for Payer: Kaiser Permanente Commercial	$132.29
Rate for Payer: Kaiser Permanente Medicaid	$107.09
Rate for Payer: MDX Hawaii PPO	$203.68
Rate for Payer: University Health Alliance Commercial	$153.05

Mepilex Post-Op Dressing 4x10 498450 [3643642]

Facility

$209.98

Hospital Charge Code	3643642
Hospital Revenue Code	272
Min. Negotiated Rate	$178.48
Max. Negotiated Rate	$203.68
Rate for Payer: Cash Price	$136.49
Rate for Payer: Health Management Network Commercial	$178.48
Rate for Payer: MDX Hawaii PPO	$203.68

Mepilex Post-Op Dressing 4x12 498600 [3643648]

Facility

$901.98

Hospital Charge Code	3643648
Hospital Revenue Code	272
Min. Negotiated Rate	$460.01
Max. Negotiated Rate	$874.92
Rate for Payer: Cash Price	$586.29
Rate for Payer: Hawaii Western Management Group Commercial	$856.88
Rate for Payer: Health Management Network Commercial	$766.68
Rate for Payer: Kaiser Permanente Commercial	$568.25
Rate for Payer: Kaiser Permanente Medicaid	$460.01
Rate for Payer: MDX Hawaii PPO	$874.92
Rate for Payer: University Health Alliance Commercial	$657.45

Mepilex Post-Op Dressing 4x12 498600 [3643648]

Facility

$901.98

Hospital Charge Code	3643648
Hospital Revenue Code	272
Min. Negotiated Rate	$766.68
Max. Negotiated Rate	$874.92
Rate for Payer: Cash Price	$586.29
Rate for Payer: Health Management Network Commercial	$766.68
Rate for Payer: MDX Hawaii PPO	$874.92

Mepilex Post-Op Dressing 4x14 498650 [3643643]

Facility

$265.13

Hospital Charge Code	3643643
Hospital Revenue Code	272
Min. Negotiated Rate	$225.36
Max. Negotiated Rate	$257.18
Rate for Payer: Cash Price	$172.33
Rate for Payer: Health Management Network Commercial	$225.36
Rate for Payer: MDX Hawaii PPO	$257.18

Know your out-of-pocket cost for care.

All Charges