Kona Community Hospital

All Charges

Charge

Type

Setting

Price

Mis Headed Screw 33mm 00-5983-040-33 [3645549]

Facility

$658.25

Service Code	HCPCS C1776
Hospital Charge Code	3645549
Hospital Revenue Code	278
Min. Negotiated Rate	$368.62
Max. Negotiated Rate	$638.50
Rate for Payer: Cash Price	$427.86
Rate for Payer: Hawaii Western Management Group Commercial	$460.77
Rate for Payer: Health Management Network Commercial	$559.51
Rate for Payer: MDX Hawaii PPO	$638.50
Rate for Payer: University Health Alliance Commercial	$368.62

Mis Headed Screw 33mm 00-5983-040-33 [3645549]

Facility

$658.25

Service Code	HCPCS C1776
Hospital Charge Code	3645549
Hospital Revenue Code	278
Min. Negotiated Rate	$335.71
Max. Negotiated Rate	$638.50
Rate for Payer: Cash Price	$427.86
Rate for Payer: Hawaii Western Management Group Commercial	$460.77
Rate for Payer: Health Management Network Commercial	$559.51
Rate for Payer: Kaiser Permanente Commercial	$414.70
Rate for Payer: Kaiser Permanente Medicaid	$335.71
Rate for Payer: MDX Hawaii PPO	$638.50
Rate for Payer: University Health Alliance Commercial	$368.62

MISOPROSTOL 1000 MCG DOSE

Facility

$74.43

Service Code	HCPCS A9270
Hospital Revenue Code	250
Min. Negotiated Rate	$37.96
Max. Negotiated Rate	$72.20
Rate for Payer: Cash Price	$48.38
Rate for Payer: Hawaii Western Management Group Commercial	$70.71
Rate for Payer: Health Management Network Commercial	$63.27
Rate for Payer: Kaiser Permanente Commercial	$46.89
Rate for Payer: Kaiser Permanente Medicaid	$37.96
Rate for Payer: MDX Hawaii PPO	$72.20
Rate for Payer: UnitedHealthcare Medicaid	$44.66
Rate for Payer: University Health Alliance Commercial	$54.25

MISOPROSTOL 1000 MCG DOSE

Facility

$74.43

Service Code	HCPCS A9270
Hospital Revenue Code	250
Min. Negotiated Rate	$63.27
Max. Negotiated Rate	$72.20
Rate for Payer: Cash Price	$48.38
Rate for Payer: Health Management Network Commercial	$63.27
Rate for Payer: MDX Hawaii PPO	$72.20

MISOPROSTOL 100 MCG PO TAB (0.25 TAB) = 25 MCG

Facility

$5.41

Service Code	NDC RPKWH000185
Hospital Revenue Code	250
Min. Negotiated Rate	$2.76
Max. Negotiated Rate	$5.25
Rate for Payer: Cash Price	$3.52
Rate for Payer: Hawaii Western Management Group Commercial	$5.14
Rate for Payer: Health Management Network Commercial	$4.60
Rate for Payer: Kaiser Permanente Commercial	$3.41
Rate for Payer: Kaiser Permanente Medicaid	$2.76
Rate for Payer: MDX Hawaii PPO	$5.25
Rate for Payer: UnitedHealthcare Medicaid	$3.25
Rate for Payer: University Health Alliance Commercial	$3.94

MISOPROSTOL 100 MCG PO TAB (0.25 TAB) = 25 MCG

Facility

$5.41

Service Code	NDC RPKWH000185
Hospital Revenue Code	250
Min. Negotiated Rate	$4.60
Max. Negotiated Rate	$5.25
Rate for Payer: Cash Price	$3.52
Rate for Payer: Health Management Network Commercial	$4.60
Rate for Payer: MDX Hawaii PPO	$5.25

MISOPROSTOL 100 MCG PO TABLET

Facility

$6.82

Service Code	HCPCS A9270
Hospital Revenue Code	250
Min. Negotiated Rate	$3.48
Max. Negotiated Rate	$6.62
Rate for Payer: Cash Price	$4.43
Rate for Payer: Cash Price	$8.90
Rate for Payer: Hawaii Western Management Group Commercial	$6.48
Rate for Payer: Hawaii Western Management Group Commercial	$13.01
Rate for Payer: Health Management Network Commercial	$11.64
Rate for Payer: Health Management Network Commercial	$5.80
Rate for Payer: Kaiser Permanente Commercial	$4.30
Rate for Payer: Kaiser Permanente Commercial	$8.62
Rate for Payer: Kaiser Permanente Medicaid	$6.98
Rate for Payer: Kaiser Permanente Medicaid	$3.48
Rate for Payer: MDX Hawaii PPO	$13.28
Rate for Payer: MDX Hawaii PPO	$6.62
Rate for Payer: UnitedHealthcare Medicaid	$4.09
Rate for Payer: UnitedHealthcare Medicaid	$8.21
Rate for Payer: University Health Alliance Commercial	$9.98
Rate for Payer: University Health Alliance Commercial	$4.97

MISOPROSTOL 100 MCG PO TABLET

Facility

$13.69

Service Code	HCPCS A9270
Hospital Revenue Code	250
Min. Negotiated Rate	$11.64
Max. Negotiated Rate	$13.28
Rate for Payer: Cash Price	$8.90
Rate for Payer: Cash Price	$4.43
Rate for Payer: Health Management Network Commercial	$5.80
Rate for Payer: Health Management Network Commercial	$11.64
Rate for Payer: MDX Hawaii PPO	$6.62
Rate for Payer: MDX Hawaii PPO	$13.28

MISOPROSTOL 200 MCG PO TABLET

Facility

$15.05

Service Code	HCPCS A9270
Hospital Revenue Code	250
Min. Negotiated Rate	$7.68
Max. Negotiated Rate	$14.60
Rate for Payer: Cash Price	$9.78
Rate for Payer: Cash Price	$4.31
Rate for Payer: Cash Price	$4.30
Rate for Payer: Hawaii Western Management Group Commercial	$6.30
Rate for Payer: Hawaii Western Management Group Commercial	$6.29
Rate for Payer: Hawaii Western Management Group Commercial	$14.30
Rate for Payer: Health Management Network Commercial	$5.64
Rate for Payer: Health Management Network Commercial	$12.79
Rate for Payer: Health Management Network Commercial	$5.63
Rate for Payer: Kaiser Permanente Commercial	$9.48
Rate for Payer: Kaiser Permanente Commercial	$4.17
Rate for Payer: Kaiser Permanente Commercial	$4.18
Rate for Payer: Kaiser Permanente Medicaid	$3.38
Rate for Payer: Kaiser Permanente Medicaid	$7.68
Rate for Payer: Kaiser Permanente Medicaid	$3.38
Rate for Payer: MDX Hawaii PPO	$6.42
Rate for Payer: MDX Hawaii PPO	$14.60
Rate for Payer: MDX Hawaii PPO	$6.43
Rate for Payer: UnitedHealthcare Medicaid	$3.97
Rate for Payer: UnitedHealthcare Medicaid	$9.03
Rate for Payer: UnitedHealthcare Medicaid	$3.98
Rate for Payer: University Health Alliance Commercial	$10.97
Rate for Payer: University Health Alliance Commercial	$4.83
Rate for Payer: University Health Alliance Commercial	$4.83

MISOPROSTOL 200 MCG PO TABLET

Facility

$15.05

Service Code	HCPCS A9270
Hospital Revenue Code	250
Min. Negotiated Rate	$12.79
Max. Negotiated Rate	$14.60
Rate for Payer: Cash Price	$9.78
Rate for Payer: Cash Price	$4.31
Rate for Payer: Cash Price	$4.30
Rate for Payer: Health Management Network Commercial	$12.79
Rate for Payer: Health Management Network Commercial	$5.63
Rate for Payer: Health Management Network Commercial	$5.64
Rate for Payer: MDX Hawaii PPO	$14.60
Rate for Payer: MDX Hawaii PPO	$6.42
Rate for Payer: MDX Hawaii PPO	$6.43

MITOMYCIN 20 MG IV RECON.SOLN.

Facility

$1,298.76

Service Code	HCPCS J9280
Hospital Revenue Code	636
Min. Negotiated Rate	$28.27
Max. Negotiated Rate	$1,259.80
Rate for Payer: AlohaCare Medicaid	$28.46
Rate for Payer: AlohaCare Medicare	$28.46
Rate for Payer: Cash Price	$844.19
Rate for Payer: Cash Price	$844.19
Rate for Payer: Devoted Health Medicare	$31.31
Rate for Payer: Hawaii Medical Service Association ABD	$28.27
Rate for Payer: Hawaii Medical Service Association Commercial	$35.58
Rate for Payer: Hawaii Medical Service Association Medicare	$28.46
Rate for Payer: Hawaii Medical Service Association Non-ABD	$28.27
Rate for Payer: Hawaii Western Management Group Commercial	$1,233.82
Rate for Payer: Health Management Network Commercial	$1,103.95
Rate for Payer: Humana Medicare	$28.46
Rate for Payer: Kaiser Permanente Commercial	$818.22
Rate for Payer: Kaiser Permanente Medicaid	$662.37
Rate for Payer: Kaiser Permanente Medicare	$28.46
Rate for Payer: MDX Hawaii PPO	$1,259.80
Rate for Payer: Ohana Health Plan Medicaid	$31.31
Rate for Payer: Ohana Health Plan Medicare	$28.46
Rate for Payer: UnitedHealthcare Medicaid	$779.26
Rate for Payer: UnitedHealthcare Medicare	$28.46
Rate for Payer: University Health Alliance Commercial	$946.67

MITOMYCIN 20 MG IV RECON.SOLN.

Facility

$1,298.76

Service Code	HCPCS J9280
Hospital Revenue Code	250
Min. Negotiated Rate	$1,103.95
Max. Negotiated Rate	$1,259.80
Rate for Payer: Cash Price	$844.19
Rate for Payer: Health Management Network Commercial	$1,103.95
Rate for Payer: MDX Hawaii PPO	$1,259.80

MITOMYCIN 40 MG X 2 INPY KIT

Facility

$31,052.40

Service Code	HCPCS J9281
Hospital Revenue Code	250
Min. Negotiated Rate	$26,394.54
Max. Negotiated Rate	$30,120.83
Rate for Payer: Cash Price	$20,184.06
Rate for Payer: Health Management Network Commercial	$26,394.54
Rate for Payer: MDX Hawaii PPO	$30,120.83

MITOMYCIN 40 MG X 2 INPY KIT

Facility

$31,052.40

Service Code	HCPCS J9281
Hospital Revenue Code	636
Min. Negotiated Rate	$317.42
Max. Negotiated Rate	$30,120.83
Rate for Payer: AlohaCare Medicaid	$323.17
Rate for Payer: AlohaCare Medicare	$323.17
Rate for Payer: Cash Price	$20,184.06
Rate for Payer: Cash Price	$20,184.06
Rate for Payer: Devoted Health Medicare	$355.49
Rate for Payer: Hawaii Medical Service Association ABD	$317.42
Rate for Payer: Hawaii Medical Service Association Commercial	$403.96
Rate for Payer: Hawaii Medical Service Association Medicare	$323.17
Rate for Payer: Hawaii Medical Service Association Non-ABD	$317.42
Rate for Payer: Hawaii Western Management Group Commercial	$29,499.78
Rate for Payer: Health Management Network Commercial	$26,394.54
Rate for Payer: Humana Medicare	$323.17
Rate for Payer: Kaiser Permanente Commercial	$19,563.01
Rate for Payer: Kaiser Permanente Medicaid	$15,836.72
Rate for Payer: Kaiser Permanente Medicare	$323.17
Rate for Payer: MDX Hawaii PPO	$30,120.83
Rate for Payer: Ohana Health Plan Medicaid	$355.49
Rate for Payer: Ohana Health Plan Medicare	$323.17
Rate for Payer: UnitedHealthcare Medicaid	$18,631.44
Rate for Payer: UnitedHealthcare Medicare	$323.17
Rate for Payer: University Health Alliance Commercial	$22,634.09

M/L-10 Clip Cartridge 19 Clips 1112 [3642400]

Facility

$402.38

Hospital Charge Code	3642400
Hospital Revenue Code	272
Min. Negotiated Rate	$205.21
Max. Negotiated Rate	$390.31
Rate for Payer: Cash Price	$261.55
Rate for Payer: Hawaii Western Management Group Commercial	$382.26
Rate for Payer: Health Management Network Commercial	$342.02
Rate for Payer: Kaiser Permanente Commercial	$253.50
Rate for Payer: Kaiser Permanente Medicaid	$205.21
Rate for Payer: MDX Hawaii PPO	$390.31
Rate for Payer: University Health Alliance Commercial	$293.29

M/L-10 Clip Cartridge 19 Clips 1112 [3642400]

Facility

$402.38

Hospital Charge Code	3642400
Hospital Revenue Code	272
Min. Negotiated Rate	$342.02
Max. Negotiated Rate	$390.31
Rate for Payer: Cash Price	$261.55
Rate for Payer: Health Management Network Commercial	$342.02
Rate for Payer: MDX Hawaii PPO	$390.31

MODERATELY EXTENSIVE OR PROCEDURES FOR OTHER COMPLICATIONS OF TREATMENT

Facility

$18,932.79

Service Code	APR-DRG 7934
Min. Negotiated Rate	$18,932.79
Max. Negotiated Rate	$18,932.79
Rate for Payer: AlohaCare Medicaid	$18,932.79
Rate for Payer: Hawaii Medical Service Association ABD	$18,932.79
Rate for Payer: Hawaii Medical Service Association Non-ABD	$18,932.79
Rate for Payer: Kaiser Permanente Medicaid	$18,932.79
Rate for Payer: Ohana Health Plan Medicaid	$18,932.79
Rate for Payer: UnitedHealthcare Medicaid	$18,932.79

MODERATELY EXTENSIVE OR PROCEDURES FOR OTHER COMPLICATIONS OF TREATMENT

Facility

$4,618.10

Service Code	APR-DRG 7931
Min. Negotiated Rate	$4,618.10
Max. Negotiated Rate	$4,618.10
Rate for Payer: AlohaCare Medicaid	$4,618.10
Rate for Payer: Hawaii Medical Service Association ABD	$4,618.10
Rate for Payer: Hawaii Medical Service Association Non-ABD	$4,618.10
Rate for Payer: Kaiser Permanente Medicaid	$4,618.10
Rate for Payer: Ohana Health Plan Medicaid	$4,618.10
Rate for Payer: UnitedHealthcare Medicaid	$4,618.10

MODERATELY EXTENSIVE OR PROCEDURES FOR OTHER COMPLICATIONS OF TREATMENT

Facility

$6,397.96

Service Code	APR-DRG 7932
Min. Negotiated Rate	$6,397.96
Max. Negotiated Rate	$6,397.96
Rate for Payer: AlohaCare Medicaid	$6,397.96
Rate for Payer: Hawaii Medical Service Association ABD	$6,397.96
Rate for Payer: Hawaii Medical Service Association Non-ABD	$6,397.96
Rate for Payer: Kaiser Permanente Medicaid	$6,397.96
Rate for Payer: Ohana Health Plan Medicaid	$6,397.96
Rate for Payer: UnitedHealthcare Medicaid	$6,397.96

MODERATELY EXTENSIVE OR PROCEDURES FOR OTHER COMPLICATIONS OF TREATMENT

Facility

$9,681.95

Service Code	APR-DRG 7933
Min. Negotiated Rate	$9,681.95
Max. Negotiated Rate	$9,681.95
Rate for Payer: AlohaCare Medicaid	$9,681.95
Rate for Payer: Hawaii Medical Service Association ABD	$9,681.95
Rate for Payer: Hawaii Medical Service Association Non-ABD	$9,681.95
Rate for Payer: Kaiser Permanente Medicaid	$9,681.95
Rate for Payer: Ohana Health Plan Medicaid	$9,681.95
Rate for Payer: UnitedHealthcare Medicaid	$9,681.95

MODERATELY EXTENSIVE PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS

Facility

$5,468.86

Service Code	APR-DRG 9511
Min. Negotiated Rate	$5,468.86
Max. Negotiated Rate	$5,468.86
Rate for Payer: AlohaCare Medicaid	$5,468.86
Rate for Payer: Hawaii Medical Service Association ABD	$5,468.86
Rate for Payer: Hawaii Medical Service Association Non-ABD	$5,468.86
Rate for Payer: Kaiser Permanente Medicaid	$5,468.86
Rate for Payer: Ohana Health Plan Medicaid	$5,468.86
Rate for Payer: UnitedHealthcare Medicaid	$5,468.86

MODERATELY EXTENSIVE PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS

Facility

$11,138.32

Service Code	APR-DRG 9513
Min. Negotiated Rate	$11,138.32
Max. Negotiated Rate	$11,138.32
Rate for Payer: AlohaCare Medicaid	$11,138.32
Rate for Payer: Hawaii Medical Service Association ABD	$11,138.32
Rate for Payer: Hawaii Medical Service Association Non-ABD	$11,138.32
Rate for Payer: Kaiser Permanente Medicaid	$11,138.32
Rate for Payer: Ohana Health Plan Medicaid	$11,138.32
Rate for Payer: UnitedHealthcare Medicaid	$11,138.32

MODERATELY EXTENSIVE PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS

Facility

$20,814.54

Service Code	APR-DRG 9514
Min. Negotiated Rate	$20,814.54
Max. Negotiated Rate	$20,814.54
Rate for Payer: AlohaCare Medicaid	$20,814.54
Rate for Payer: Hawaii Medical Service Association ABD	$20,814.54
Rate for Payer: Hawaii Medical Service Association Non-ABD	$20,814.54
Rate for Payer: Kaiser Permanente Medicaid	$20,814.54
Rate for Payer: Ohana Health Plan Medicaid	$20,814.54
Rate for Payer: UnitedHealthcare Medicaid	$20,814.54

MODERATELY EXTENSIVE PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS

Facility

$7,591.33

Service Code	APR-DRG 9512
Min. Negotiated Rate	$7,591.33
Max. Negotiated Rate	$7,591.33
Rate for Payer: AlohaCare Medicaid	$7,591.33
Rate for Payer: Hawaii Medical Service Association ABD	$7,591.33
Rate for Payer: Hawaii Medical Service Association Non-ABD	$7,591.33
Rate for Payer: Kaiser Permanente Medicaid	$7,591.33
Rate for Payer: Ohana Health Plan Medicaid	$7,591.33
Rate for Payer: UnitedHealthcare Medicaid	$7,591.33

Modified Maryland Dissector Tip Disp 3322 [3642397]

Facility

$413.88

Hospital Charge Code	3642397
Hospital Revenue Code	272
Min. Negotiated Rate	$351.80
Max. Negotiated Rate	$401.46
Rate for Payer: Cash Price	$269.02
Rate for Payer: Health Management Network Commercial	$351.80
Rate for Payer: MDX Hawaii PPO	$401.46

Know your out-of-pocket cost for care.

All Charges