Kona Community Hospital

All Charges

Charge

Type

Setting

Price

NORFLURANE-PENTAFLUOROPROPANE TOP AERO.SPRAY

Facility

$162.08

Service Code	NDC 00386000803
Hospital Revenue Code	250
Min. Negotiated Rate	$82.66
Max. Negotiated Rate	$157.22
Rate for Payer: Cash Price	$105.35
Rate for Payer: Hawaii Western Management Group Commercial	$153.98
Rate for Payer: Health Management Network Commercial	$137.77
Rate for Payer: Kaiser Permanente Commercial	$102.11
Rate for Payer: Kaiser Permanente Medicaid	$82.66
Rate for Payer: MDX Hawaii PPO	$157.22
Rate for Payer: UnitedHealthcare Medicaid	$97.25
Rate for Payer: University Health Alliance Commercial	$118.14

Norian Drillable Fs Putty 3cc 07.704.103s [3644022]

Facility

$3,434.13

Service Code	HCPCS C1713
Hospital Charge Code	3644022
Hospital Revenue Code	278
Min. Negotiated Rate	$1,923.11
Max. Negotiated Rate	$3,331.11
Rate for Payer: Cash Price	$2,232.18
Rate for Payer: Hawaii Western Management Group Commercial	$2,403.89
Rate for Payer: Health Management Network Commercial	$2,919.01
Rate for Payer: MDX Hawaii PPO	$3,331.11
Rate for Payer: University Health Alliance Commercial	$1,923.11

Norian Drillable Fs Putty 3cc 07.704.103s [3644022]

Facility

$3,434.13

Service Code	HCPCS C1713
Hospital Charge Code	3644022
Hospital Revenue Code	278
Min. Negotiated Rate	$1,751.41
Max. Negotiated Rate	$3,331.11
Rate for Payer: Cash Price	$2,232.18
Rate for Payer: Hawaii Western Management Group Commercial	$2,403.89
Rate for Payer: Health Management Network Commercial	$2,919.01
Rate for Payer: Kaiser Permanente Commercial	$2,163.50
Rate for Payer: Kaiser Permanente Medicaid	$1,751.41
Rate for Payer: MDX Hawaii PPO	$3,331.11
Rate for Payer: University Health Alliance Commercial	$1,923.11

NORMAL NEWBORN

Facility

$3,446.55

Service Code	MSDRG 795
Min. Negotiated Rate	$2,724.09
Max. Negotiated Rate	$3,446.55
Rate for Payer: AlohaCare Medicare	$2,864.27
Rate for Payer: Devoted Health Medicare	$3,150.70
Rate for Payer: Hawaii Medical Service Association Commercial	$2,724.09
Rate for Payer: Hawaii Medical Service Association Medicare	$2,864.27
Rate for Payer: Humana Medicare	$2,864.27
Rate for Payer: Kaiser Permanente Commercial	$3,446.55
Rate for Payer: Kaiser Permanente Medicare	$2,864.27
Rate for Payer: Ohana Health Plan Medicare	$2,864.27
Rate for Payer: UnitedHealthcare Medicare	$2,864.27

NORTRIPTYLINE 10 MG PO CAP

Facility

$1.20

Service Code	HCPCS A9270
Hospital Revenue Code	250
Min. Negotiated Rate	$1.02
Max. Negotiated Rate	$1.16
Rate for Payer: Cash Price	$0.78
Rate for Payer: Health Management Network Commercial	$1.02
Rate for Payer: MDX Hawaii PPO	$1.16

NORTRIPTYLINE 10 MG PO CAP

Facility

$1.20

Service Code	HCPCS A9270
Hospital Revenue Code	250
Min. Negotiated Rate	$0.61
Max. Negotiated Rate	$1.16
Rate for Payer: Cash Price	$0.78
Rate for Payer: Hawaii Western Management Group Commercial	$1.14
Rate for Payer: Health Management Network Commercial	$1.02
Rate for Payer: Kaiser Permanente Commercial	$0.76
Rate for Payer: Kaiser Permanente Medicaid	$0.61
Rate for Payer: MDX Hawaii PPO	$1.16
Rate for Payer: UnitedHealthcare Medicaid	$0.72
Rate for Payer: University Health Alliance Commercial	$0.87

NORTRIPTYLINE 25 MG PO CAP

Facility

$1.47

Service Code	HCPCS A9270
Hospital Revenue Code	250
Min. Negotiated Rate	$0.75
Max. Negotiated Rate	$1.43
Rate for Payer: Cash Price	$0.96
Rate for Payer: Hawaii Western Management Group Commercial	$1.40
Rate for Payer: Health Management Network Commercial	$1.25
Rate for Payer: Kaiser Permanente Commercial	$0.93
Rate for Payer: Kaiser Permanente Medicaid	$0.75
Rate for Payer: MDX Hawaii PPO	$1.43
Rate for Payer: UnitedHealthcare Medicaid	$0.88
Rate for Payer: University Health Alliance Commercial	$1.07

NORTRIPTYLINE 25 MG PO CAP

Facility

$1.47

Service Code	HCPCS A9270
Hospital Revenue Code	250
Min. Negotiated Rate	$1.25
Max. Negotiated Rate	$1.43
Rate for Payer: Cash Price	$0.96
Rate for Payer: Health Management Network Commercial	$1.25
Rate for Payer: MDX Hawaii PPO	$1.43

NOT OTHERWISE CLASSIFIED ANTINEOPLASTIC DRUG

Professional

Both

$0.01

Service Code	HCPCS J9999
Min. Negotiated Rate	$0.01
Max. Negotiated Rate	$0.01
Rate for Payer: Cash Price	$0.01
Rate for Payer: Health Management Network Commercial	$0.01

NovaSure Advanced Endometrial Ablation Device NS2013US [3601201]

Facility

$5,486.00

Hospital Charge Code	3601201
Hospital Revenue Code	272
Min. Negotiated Rate	$4,663.10
Max. Negotiated Rate	$5,321.42
Rate for Payer: Cash Price	$3,565.90
Rate for Payer: Health Management Network Commercial	$4,663.10
Rate for Payer: MDX Hawaii PPO	$5,321.42

NovaSure Advanced Endometrial Ablation Device NS2013US [3601201]

Facility

$5,486.00

Hospital Charge Code	3601201
Hospital Revenue Code	272
Min. Negotiated Rate	$2,797.86
Max. Negotiated Rate	$5,321.42
Rate for Payer: Cash Price	$3,565.90
Rate for Payer: Hawaii Western Management Group Commercial	$5,211.70
Rate for Payer: Health Management Network Commercial	$4,663.10
Rate for Payer: Kaiser Permanente Commercial	$3,456.18
Rate for Payer: Kaiser Permanente Medicaid	$2,797.86
Rate for Payer: MDX Hawaii PPO	$5,321.42
Rate for Payer: University Health Alliance Commercial	$3,998.75

NP ACETAMINOPHEN 160 MG/5 ML PO SUSP #30 ML (WHR)

Facility

$28.32

Service Code	HCPCS A9270
Hospital Revenue Code	250
Min. Negotiated Rate	$24.07
Max. Negotiated Rate	$27.47
Rate for Payer: Cash Price	$18.41
Rate for Payer: Health Management Network Commercial	$24.07
Rate for Payer: MDX Hawaii PPO	$27.47

NP ACETAMINOPHEN 160 MG/5 ML PO SUSP #30 ML (WHR)

Facility

$28.32

Service Code	HCPCS A9270
Hospital Revenue Code	250
Min. Negotiated Rate	$14.44
Max. Negotiated Rate	$27.47
Rate for Payer: Cash Price	$18.41
Rate for Payer: Hawaii Western Management Group Commercial	$26.90
Rate for Payer: Health Management Network Commercial	$24.07
Rate for Payer: Kaiser Permanente Commercial	$17.84
Rate for Payer: Kaiser Permanente Medicaid	$14.44
Rate for Payer: MDX Hawaii PPO	$27.47
Rate for Payer: UnitedHealthcare Medicaid	$16.99
Rate for Payer: University Health Alliance Commercial	$20.64

NP ACETAMINOPHEN/CODEINE 300 - 30 MG #5 TAB (WHR)

Facility

$40.34

Service Code	HCPCS A9270
Hospital Revenue Code	250
Min. Negotiated Rate	$34.29
Max. Negotiated Rate	$39.13
Rate for Payer: Cash Price	$26.22
Rate for Payer: Health Management Network Commercial	$34.29
Rate for Payer: MDX Hawaii PPO	$39.13

NP ACETAMINOPHEN/CODEINE 300 - 30 MG #5 TAB (WHR)

Facility

$40.34

Service Code	HCPCS A9270
Hospital Revenue Code	250
Min. Negotiated Rate	$20.57
Max. Negotiated Rate	$39.13
Rate for Payer: Cash Price	$26.22
Rate for Payer: Hawaii Western Management Group Commercial	$38.32
Rate for Payer: Health Management Network Commercial	$34.29
Rate for Payer: Kaiser Permanente Commercial	$25.41
Rate for Payer: Kaiser Permanente Medicaid	$20.57
Rate for Payer: MDX Hawaii PPO	$39.13
Rate for Payer: UnitedHealthcare Medicaid	$24.20
Rate for Payer: University Health Alliance Commercial	$29.40

NP AMOXICILLIN 500 MG #3 CAP (WHR)

Facility

$7.19

Service Code	HCPCS A9270
Hospital Revenue Code	250
Min. Negotiated Rate	$6.11
Max. Negotiated Rate	$6.97
Rate for Payer: Cash Price	$4.67
Rate for Payer: Health Management Network Commercial	$6.11
Rate for Payer: MDX Hawaii PPO	$6.97

NP AMOXICILLIN 500 MG #3 CAP (WHR)

Facility

$7.19

Service Code	HCPCS A9270
Hospital Revenue Code	250
Min. Negotiated Rate	$3.67
Max. Negotiated Rate	$6.97
Rate for Payer: Cash Price	$4.67
Rate for Payer: Hawaii Western Management Group Commercial	$6.83
Rate for Payer: Health Management Network Commercial	$6.11
Rate for Payer: Kaiser Permanente Commercial	$4.53
Rate for Payer: Kaiser Permanente Medicaid	$3.67
Rate for Payer: MDX Hawaii PPO	$6.97
Rate for Payer: UnitedHealthcare Medicaid	$4.31
Rate for Payer: University Health Alliance Commercial	$5.24

NP AMOXICILLIN-POT CLAVULANATE 500-125 MG #3 CAP (WHR)

Facility

$65.01

Service Code	HCPCS A9270
Hospital Revenue Code	250
Min. Negotiated Rate	$33.16
Max. Negotiated Rate	$63.06
Rate for Payer: Cash Price	$42.26
Rate for Payer: Hawaii Western Management Group Commercial	$61.76
Rate for Payer: Health Management Network Commercial	$55.26
Rate for Payer: Kaiser Permanente Commercial	$40.96
Rate for Payer: Kaiser Permanente Medicaid	$33.16
Rate for Payer: MDX Hawaii PPO	$63.06
Rate for Payer: UnitedHealthcare Medicaid	$39.01
Rate for Payer: University Health Alliance Commercial	$47.39

NP AMOXICILLIN-POT CLAVULANATE 500-125 MG #3 CAP (WHR)

Facility

$65.01

Service Code	HCPCS A9270
Hospital Revenue Code	250
Min. Negotiated Rate	$55.26
Max. Negotiated Rate	$63.06
Rate for Payer: Cash Price	$42.26
Rate for Payer: Health Management Network Commercial	$55.26
Rate for Payer: MDX Hawaii PPO	$63.06

NP AMOXICILLIN-POT CLAVULANATE 875-125 MG #2 TAB (WHR)

Facility

$32.39

Service Code	HCPCS A9270
Hospital Revenue Code	250
Min. Negotiated Rate	$27.53
Max. Negotiated Rate	$31.42
Rate for Payer: Cash Price	$21.05
Rate for Payer: Health Management Network Commercial	$27.53
Rate for Payer: MDX Hawaii PPO	$31.42

NP AMOXICILLIN-POT CLAVULANATE 875-125 MG #2 TAB (WHR)

Facility

$32.39

Service Code	HCPCS A9270
Hospital Revenue Code	250
Min. Negotiated Rate	$16.52
Max. Negotiated Rate	$31.42
Rate for Payer: Cash Price	$21.05
Rate for Payer: Hawaii Western Management Group Commercial	$30.77
Rate for Payer: Health Management Network Commercial	$27.53
Rate for Payer: Kaiser Permanente Commercial	$20.41
Rate for Payer: Kaiser Permanente Medicaid	$16.52
Rate for Payer: MDX Hawaii PPO	$31.42
Rate for Payer: UnitedHealthcare Medicaid	$19.43
Rate for Payer: University Health Alliance Commercial	$23.61

NP BENZONATATE 100 MG #6 CAP (WHR)

Facility

$80.18

Service Code	HCPCS A9270
Hospital Revenue Code	250
Min. Negotiated Rate	$68.15
Max. Negotiated Rate	$77.77
Rate for Payer: Cash Price	$52.12
Rate for Payer: Health Management Network Commercial	$68.15
Rate for Payer: MDX Hawaii PPO	$77.77

NP BENZONATATE 100 MG #6 CAP (WHR)

Facility

$80.18

Service Code	HCPCS A9270
Hospital Revenue Code	250
Min. Negotiated Rate	$40.89
Max. Negotiated Rate	$77.77
Rate for Payer: Cash Price	$52.12
Rate for Payer: Hawaii Western Management Group Commercial	$76.17
Rate for Payer: Health Management Network Commercial	$68.15
Rate for Payer: Kaiser Permanente Commercial	$50.51
Rate for Payer: Kaiser Permanente Medicaid	$40.89
Rate for Payer: MDX Hawaii PPO	$77.77
Rate for Payer: UnitedHealthcare Medicaid	$48.11
Rate for Payer: University Health Alliance Commercial	$58.44

NP BUPRENORPHINE SL 2 MG #3 TAB (WHR)

Facility

$45.15

Service Code	HCPCS J0571
Hospital Revenue Code	637
Min. Negotiated Rate	$23.03
Max. Negotiated Rate	$43.80
Rate for Payer: Cash Price	$29.35
Rate for Payer: Hawaii Western Management Group Commercial	$42.89
Rate for Payer: Health Management Network Commercial	$38.38
Rate for Payer: Kaiser Permanente Commercial	$28.44
Rate for Payer: Kaiser Permanente Medicaid	$23.03
Rate for Payer: MDX Hawaii PPO	$43.80
Rate for Payer: University Health Alliance Commercial	$32.91

NP BUPRENORPHINE SL 2 MG #3 TAB (WHR)

Facility

$45.15

Service Code	HCPCS J0571
Hospital Revenue Code	250
Min. Negotiated Rate	$38.38
Max. Negotiated Rate	$43.80
Rate for Payer: Cash Price	$29.35
Rate for Payer: Health Management Network Commercial	$38.38
Rate for Payer: MDX Hawaii PPO	$43.80

Know your out-of-pocket cost for care.

All Charges