Kona Community Hospital

All Charges

Charge

Type

Setting

Price

Midas Rex MC Dissecting Tool MC30 [3642289]

Facility

$1,630.13

Hospital Charge Code	3642289
Hospital Revenue Code	272
Min. Negotiated Rate	$1,385.61
Max. Negotiated Rate	$1,581.23
Rate for Payer: Cash Price	$1,059.58
Rate for Payer: Health Management Network Commercial	$1,385.61
Rate for Payer: MDX Hawaii PPO	$1,581.23

Midas Rex MC Dissecting Tool MC30 [3642289]

Facility

$1,630.13

Hospital Charge Code	3642289
Hospital Revenue Code	272
Min. Negotiated Rate	$831.37
Max. Negotiated Rate	$1,581.23
Rate for Payer: Cash Price	$1,059.58
Rate for Payer: Hawaii Western Management Group Commercial	$1,548.62
Rate for Payer: Health Management Network Commercial	$1,385.61
Rate for Payer: Kaiser Permanente Commercial	$1,026.98
Rate for Payer: Kaiser Permanente Medicaid	$831.37
Rate for Payer: MDX Hawaii PPO	$1,581.23
Rate for Payer: University Health Alliance Commercial	$1,188.20

MIDAZOLAM 1 MG/ML 2 ML INJ SOLN

Facility

$3.59

Service Code	HCPCS J2250
Hospital Revenue Code	636
Min. Negotiated Rate	$0.16
Max. Negotiated Rate	$3.48
Rate for Payer: Cash Price	$2.33
Rate for Payer: Cash Price	$1.98
Rate for Payer: Cash Price	$2.33
Rate for Payer: Cash Price	$1.98
Rate for Payer: Hawaii Medical Service Association ABD	$0.16
Rate for Payer: Hawaii Medical Service Association ABD	$0.16
Rate for Payer: Hawaii Medical Service Association Non-ABD	$0.16
Rate for Payer: Hawaii Medical Service Association Non-ABD	$0.16
Rate for Payer: Hawaii Western Management Group Commercial	$2.90
Rate for Payer: Hawaii Western Management Group Commercial	$3.41
Rate for Payer: Health Management Network Commercial	$3.05
Rate for Payer: Health Management Network Commercial	$2.59
Rate for Payer: Kaiser Permanente Commercial	$2.26
Rate for Payer: Kaiser Permanente Commercial	$1.92
Rate for Payer: Kaiser Permanente Medicaid	$1.56
Rate for Payer: Kaiser Permanente Medicaid	$1.83
Rate for Payer: MDX Hawaii PPO	$3.48
Rate for Payer: MDX Hawaii PPO	$2.96
Rate for Payer: UnitedHealthcare Medicaid	$1.83
Rate for Payer: UnitedHealthcare Medicaid	$2.15
Rate for Payer: University Health Alliance Commercial	$2.62
Rate for Payer: University Health Alliance Commercial	$2.22

MIDAZOLAM 1 MG/ML 2 ML INJ SOLN

Facility

$3.59

Service Code	HCPCS J2250
Hospital Revenue Code	250
Min. Negotiated Rate	$3.05
Max. Negotiated Rate	$3.48
Rate for Payer: Cash Price	$2.33
Rate for Payer: Cash Price	$1.98
Rate for Payer: Health Management Network Commercial	$2.59
Rate for Payer: Health Management Network Commercial	$3.05
Rate for Payer: MDX Hawaii PPO	$2.96
Rate for Payer: MDX Hawaii PPO	$3.48

MIDAZOLAM 1 MG/ML NONTITRATING DRIP

Facility

$95.42

Service Code	NDC 65219065050
Hospital Revenue Code	250
Min. Negotiated Rate	$48.66
Max. Negotiated Rate	$92.56
Rate for Payer: Cash Price	$62.02
Rate for Payer: Hawaii Western Management Group Commercial	$90.65
Rate for Payer: Health Management Network Commercial	$81.11
Rate for Payer: Kaiser Permanente Commercial	$60.11
Rate for Payer: Kaiser Permanente Medicaid	$48.66
Rate for Payer: MDX Hawaii PPO	$92.56
Rate for Payer: UnitedHealthcare Medicaid	$57.25
Rate for Payer: University Health Alliance Commercial	$69.55

MIDAZOLAM 1 MG/ML NONTITRATING DRIP

Facility

$95.42

Service Code	NDC 65219065005
Hospital Revenue Code	250
Min. Negotiated Rate	$48.66
Max. Negotiated Rate	$92.56
Rate for Payer: Cash Price	$62.02
Rate for Payer: Hawaii Western Management Group Commercial	$90.65
Rate for Payer: Health Management Network Commercial	$81.11
Rate for Payer: Kaiser Permanente Commercial	$60.11
Rate for Payer: Kaiser Permanente Medicaid	$48.66
Rate for Payer: MDX Hawaii PPO	$92.56
Rate for Payer: UnitedHealthcare Medicaid	$57.25
Rate for Payer: University Health Alliance Commercial	$69.55

MIDAZOLAM 1 MG/ML NONTITRATING DRIP

Facility

$127.30

Service Code	NDC 44567061010
Hospital Revenue Code	250
Min. Negotiated Rate	$64.92
Max. Negotiated Rate	$123.48
Rate for Payer: Cash Price	$82.74
Rate for Payer: Hawaii Western Management Group Commercial	$120.94
Rate for Payer: Health Management Network Commercial	$108.20
Rate for Payer: Kaiser Permanente Commercial	$80.20
Rate for Payer: Kaiser Permanente Medicaid	$64.92
Rate for Payer: MDX Hawaii PPO	$123.48
Rate for Payer: UnitedHealthcare Medicaid	$76.38
Rate for Payer: University Health Alliance Commercial	$92.79

MIDAZOLAM 1 MG/ML NONTITRATING DRIP

Facility

$95.42

Service Code	NDC 65219065005
Hospital Revenue Code	250
Min. Negotiated Rate	$81.11
Max. Negotiated Rate	$92.56
Rate for Payer: Cash Price	$62.02
Rate for Payer: Health Management Network Commercial	$81.11
Rate for Payer: MDX Hawaii PPO	$92.56

MIDAZOLAM 1 MG/ML NONTITRATING DRIP

Facility

$95.42

Service Code	NDC 65219065050
Hospital Revenue Code	250
Min. Negotiated Rate	$81.11
Max. Negotiated Rate	$92.56
Rate for Payer: Cash Price	$62.02
Rate for Payer: Health Management Network Commercial	$81.11
Rate for Payer: MDX Hawaii PPO	$92.56

MIDAZOLAM 1 MG/ML NONTITRATING DRIP

Facility

$127.30

Service Code	NDC 44567061010
Hospital Revenue Code	250
Min. Negotiated Rate	$108.20
Max. Negotiated Rate	$123.48
Rate for Payer: Cash Price	$82.74
Rate for Payer: Health Management Network Commercial	$108.20
Rate for Payer: MDX Hawaii PPO	$123.48

MIDAZOLAM 1 MG/ML NONTITRATING DRIP

Facility

$127.30

Service Code	NDC 44567061001
Hospital Revenue Code	250
Min. Negotiated Rate	$64.92
Max. Negotiated Rate	$123.48
Rate for Payer: Cash Price	$82.74
Rate for Payer: Hawaii Western Management Group Commercial	$120.94
Rate for Payer: Health Management Network Commercial	$108.20
Rate for Payer: Kaiser Permanente Commercial	$80.20
Rate for Payer: Kaiser Permanente Medicaid	$64.92
Rate for Payer: MDX Hawaii PPO	$123.48
Rate for Payer: UnitedHealthcare Medicaid	$76.38
Rate for Payer: University Health Alliance Commercial	$92.79

MIDAZOLAM 1 MG/ML NONTITRATING DRIP

Facility

$127.30

Service Code	NDC 44567061001
Hospital Revenue Code	250
Min. Negotiated Rate	$108.20
Max. Negotiated Rate	$123.48
Rate for Payer: Cash Price	$82.74
Rate for Payer: Health Management Network Commercial	$108.20
Rate for Payer: MDX Hawaii PPO	$123.48

MIDAZOLAM 2 MG/ML PO SYRUP

Facility

$46.32

Service Code	HCPCS A9270
Hospital Revenue Code	250
Min. Negotiated Rate	$39.37
Max. Negotiated Rate	$44.93
Rate for Payer: Cash Price	$30.11
Rate for Payer: Health Management Network Commercial	$39.37
Rate for Payer: MDX Hawaii PPO	$44.93

MIDAZOLAM 2 MG/ML PO SYRUP

Facility

$46.32

Service Code	HCPCS A9270
Hospital Revenue Code	250
Min. Negotiated Rate	$23.62
Max. Negotiated Rate	$44.93
Rate for Payer: Cash Price	$30.11
Rate for Payer: Hawaii Western Management Group Commercial	$44.00
Rate for Payer: Health Management Network Commercial	$39.37
Rate for Payer: Kaiser Permanente Commercial	$29.18
Rate for Payer: Kaiser Permanente Medicaid	$23.62
Rate for Payer: MDX Hawaii PPO	$44.93
Rate for Payer: UnitedHealthcare Medicaid	$27.79
Rate for Payer: University Health Alliance Commercial	$33.76

MIDAZOLAM 5 MG/ML INJ SOLN

Facility

$40.70

Service Code	HCPCS J2250
Hospital Revenue Code	250
Min. Negotiated Rate	$34.59
Max. Negotiated Rate	$39.48
Rate for Payer: Cash Price	$26.46
Rate for Payer: Health Management Network Commercial	$34.59
Rate for Payer: MDX Hawaii PPO	$39.48

MIDAZOLAM 5 MG/ML INJ SOLN

Facility

$40.70

Service Code	HCPCS J2250
Hospital Revenue Code	636
Min. Negotiated Rate	$0.16
Max. Negotiated Rate	$39.48
Rate for Payer: Cash Price	$26.46
Rate for Payer: Cash Price	$26.46
Rate for Payer: Hawaii Medical Service Association ABD	$0.16
Rate for Payer: Hawaii Medical Service Association Non-ABD	$0.16
Rate for Payer: Hawaii Western Management Group Commercial	$38.66
Rate for Payer: Health Management Network Commercial	$34.59
Rate for Payer: Kaiser Permanente Commercial	$25.64
Rate for Payer: Kaiser Permanente Medicaid	$20.76
Rate for Payer: MDX Hawaii PPO	$39.48
Rate for Payer: UnitedHealthcare Medicaid	$24.42
Rate for Payer: University Health Alliance Commercial	$29.67

MIDAZOLAM 5 MG/ML INTRANASAL

Facility

$40.70

Service Code	NDC 63323041202
Hospital Revenue Code	250
Min. Negotiated Rate	$34.59
Max. Negotiated Rate	$39.48
Rate for Payer: Cash Price	$26.46
Rate for Payer: Health Management Network Commercial	$34.59
Rate for Payer: MDX Hawaii PPO	$39.48

MIDAZOLAM 5 MG/ML INTRANASAL

Facility

$40.70

Service Code	NDC 63323041202
Hospital Revenue Code	250
Min. Negotiated Rate	$20.76
Max. Negotiated Rate	$39.48
Rate for Payer: Cash Price	$26.46
Rate for Payer: Hawaii Western Management Group Commercial	$38.66
Rate for Payer: Health Management Network Commercial	$34.59
Rate for Payer: Kaiser Permanente Commercial	$25.64
Rate for Payer: Kaiser Permanente Medicaid	$20.76
Rate for Payer: MDX Hawaii PPO	$39.48
Rate for Payer: UnitedHealthcare Medicaid	$24.42
Rate for Payer: University Health Alliance Commercial	$29.67

MIDAZOLAM 5 MG/ML INTRANASAL

Facility

$40.70

Service Code	NDC 63323041203
Hospital Revenue Code	250
Min. Negotiated Rate	$34.59
Max. Negotiated Rate	$39.48
Rate for Payer: Cash Price	$26.46
Rate for Payer: Health Management Network Commercial	$34.59
Rate for Payer: MDX Hawaii PPO	$39.48

MIDAZOLAM 5 MG/ML INTRANASAL

Facility

$40.70

Service Code	NDC 63323041203
Hospital Revenue Code	250
Min. Negotiated Rate	$20.76
Max. Negotiated Rate	$39.48
Rate for Payer: Cash Price	$26.46
Rate for Payer: Hawaii Western Management Group Commercial	$38.66
Rate for Payer: Health Management Network Commercial	$34.59
Rate for Payer: Kaiser Permanente Commercial	$25.64
Rate for Payer: Kaiser Permanente Medicaid	$20.76
Rate for Payer: MDX Hawaii PPO	$39.48
Rate for Payer: UnitedHealthcare Medicaid	$24.42
Rate for Payer: University Health Alliance Commercial	$29.67

MIDAZOLAM (PF) 1 MG/ML INJ SOLN 2 ML VIAL

Facility

$6.52

Service Code	HCPCS J2250
Hospital Revenue Code	250
Min. Negotiated Rate	$5.54
Max. Negotiated Rate	$6.32
Rate for Payer: Cash Price	$4.24
Rate for Payer: Health Management Network Commercial	$5.54
Rate for Payer: MDX Hawaii PPO	$6.32

MIDAZOLAM (PF) 1 MG/ML INJ SOLN 2 ML VIAL

Facility

$6.52

Service Code	HCPCS J2250
Hospital Revenue Code	636
Min. Negotiated Rate	$0.16
Max. Negotiated Rate	$6.32
Rate for Payer: Cash Price	$4.24
Rate for Payer: Cash Price	$4.24
Rate for Payer: Hawaii Medical Service Association ABD	$0.16
Rate for Payer: Hawaii Medical Service Association Non-ABD	$0.16
Rate for Payer: Hawaii Western Management Group Commercial	$6.19
Rate for Payer: Health Management Network Commercial	$5.54
Rate for Payer: Kaiser Permanente Commercial	$4.11
Rate for Payer: Kaiser Permanente Medicaid	$3.33
Rate for Payer: MDX Hawaii PPO	$6.32
Rate for Payer: UnitedHealthcare Medicaid	$3.91
Rate for Payer: University Health Alliance Commercial	$4.75

MIDAZOLAM (PF) 5 MG/ML INJ SOLN

Facility

$7.49

Service Code	HCPCS J2250
Hospital Revenue Code	250
Min. Negotiated Rate	$6.37
Max. Negotiated Rate	$7.27
Rate for Payer: Cash Price	$4.87
Rate for Payer: Health Management Network Commercial	$6.37
Rate for Payer: MDX Hawaii PPO	$7.27

MIDAZOLAM (PF) 5 MG/ML INJ SOLN

Facility

$7.49

Service Code	HCPCS J2250
Hospital Revenue Code	636
Min. Negotiated Rate	$0.16
Max. Negotiated Rate	$7.27
Rate for Payer: Cash Price	$4.87
Rate for Payer: Cash Price	$4.87
Rate for Payer: Hawaii Medical Service Association ABD	$0.16
Rate for Payer: Hawaii Medical Service Association Non-ABD	$0.16
Rate for Payer: Hawaii Western Management Group Commercial	$7.12
Rate for Payer: Health Management Network Commercial	$6.37
Rate for Payer: Kaiser Permanente Commercial	$4.72
Rate for Payer: Kaiser Permanente Medicaid	$3.82
Rate for Payer: MDX Hawaii PPO	$7.27
Rate for Payer: UnitedHealthcare Medicaid	$4.49
Rate for Payer: University Health Alliance Commercial	$5.46

MIDAZOLAM (PF) 5 MG/ML INTRANASAL FOR PEDIATRIC SEDATION (WHR)

Facility

$7.49

Service Code	NDC 00409230802
Hospital Revenue Code	250
Min. Negotiated Rate	$6.37
Max. Negotiated Rate	$7.27
Rate for Payer: Cash Price	$4.87
Rate for Payer: Health Management Network Commercial	$6.37
Rate for Payer: MDX Hawaii PPO	$7.27

Know your out-of-pocket cost for care.

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