Kona Community Hospital

All Charges

Charge

Type

Setting

Price

NYSTATIN 100000 UNIT/ML PO SUSP

Facility

$12.51

Service Code	HCPCS A9270
Hospital Revenue Code	250
Min. Negotiated Rate	$10.63
Max. Negotiated Rate	$12.13
Rate for Payer: Cash Price	$8.13
Rate for Payer: Health Management Network Commercial	$10.63
Rate for Payer: MDX Hawaii PPO	$12.13

NYSTATIN 100000 UNIT/ML PO SUSP

Facility

$12.51

Service Code	HCPCS A9270
Hospital Revenue Code	250
Min. Negotiated Rate	$6.38
Max. Negotiated Rate	$12.13
Rate for Payer: Cash Price	$8.13
Rate for Payer: Hawaii Western Management Group Commercial	$11.88
Rate for Payer: Health Management Network Commercial	$10.63
Rate for Payer: Kaiser Permanente Commercial	$7.88
Rate for Payer: Kaiser Permanente Medicaid	$6.38
Rate for Payer: MDX Hawaii PPO	$12.13
Rate for Payer: UnitedHealthcare Medicaid	$7.51
Rate for Payer: University Health Alliance Commercial	$9.12

NYSTATIN-TRIAMCINOLONE 100,000-0.1 UNIT/GRAM-% TOP OINT

Facility

$358.39

Service Code	HCPCS A9270
Hospital Revenue Code	250
Min. Negotiated Rate	$182.78
Max. Negotiated Rate	$347.64
Rate for Payer: Cash Price	$232.95
Rate for Payer: Hawaii Western Management Group Commercial	$340.47
Rate for Payer: Health Management Network Commercial	$304.63
Rate for Payer: Kaiser Permanente Commercial	$225.79
Rate for Payer: Kaiser Permanente Medicaid	$182.78
Rate for Payer: MDX Hawaii PPO	$347.64
Rate for Payer: UnitedHealthcare Medicaid	$215.03
Rate for Payer: University Health Alliance Commercial	$261.23

NYSTATIN-TRIAMCINOLONE 100,000-0.1 UNIT/GRAM-% TOP OINT

Facility

$358.39

Service Code	HCPCS A9270
Hospital Revenue Code	250
Min. Negotiated Rate	$304.63
Max. Negotiated Rate	$347.64
Rate for Payer: Cash Price	$232.95
Rate for Payer: Health Management Network Commercial	$304.63
Rate for Payer: MDX Hawaii PPO	$347.64

NYSTATIN-TRIAMCINOLONE 100,000-0.1 UNIT/G-% TOP CR

Facility

$122.08

Service Code	HCPCS A9270
Hospital Revenue Code	250
Min. Negotiated Rate	$103.77
Max. Negotiated Rate	$118.42
Rate for Payer: Cash Price	$79.35
Rate for Payer: Health Management Network Commercial	$103.77
Rate for Payer: MDX Hawaii PPO	$118.42

NYSTATIN-TRIAMCINOLONE 100,000-0.1 UNIT/G-% TOP CR

Facility

$122.08

Service Code	HCPCS A9270
Hospital Revenue Code	250
Min. Negotiated Rate	$62.26
Max. Negotiated Rate	$118.42
Rate for Payer: Cash Price	$79.35
Rate for Payer: Hawaii Western Management Group Commercial	$115.98
Rate for Payer: Health Management Network Commercial	$103.77
Rate for Payer: Kaiser Permanente Commercial	$76.91
Rate for Payer: Kaiser Permanente Medicaid	$62.26
Rate for Payer: MDX Hawaii PPO	$118.42
Rate for Payer: UnitedHealthcare Medicaid	$73.25
Rate for Payer: University Health Alliance Commercial	$88.98

OATS Kit For 16mm Allograft Plugs ABS-1981-16S [3641468]

Facility

$6,025.00

Hospital Charge Code	3641468
Hospital Revenue Code	272
Min. Negotiated Rate	$3,072.75
Max. Negotiated Rate	$5,844.25
Rate for Payer: Cash Price	$3,916.25
Rate for Payer: Hawaii Western Management Group Commercial	$5,723.75
Rate for Payer: Health Management Network Commercial	$5,121.25
Rate for Payer: Kaiser Permanente Commercial	$3,795.75
Rate for Payer: Kaiser Permanente Medicaid	$3,072.75
Rate for Payer: MDX Hawaii PPO	$5,844.25
Rate for Payer: University Health Alliance Commercial	$4,391.62

OATS Kit For 16mm Allograft Plugs ABS-1981-16S [3641468]

Facility

$6,025.00

Hospital Charge Code	3641468
Hospital Revenue Code	272
Min. Negotiated Rate	$5,121.25
Max. Negotiated Rate	$5,844.25
Rate for Payer: Cash Price	$3,916.25
Rate for Payer: Health Management Network Commercial	$5,121.25
Rate for Payer: MDX Hawaii PPO	$5,844.25

OB/GYN

Facility

$3,000.00

Hospital Charge Code	H0000003
Hospital Revenue Code	112
Min. Negotiated Rate	$2,550.00
Max. Negotiated Rate	$7,250.00
Rate for Payer: Cash Price	$1,950.00
Rate for Payer: Cash Price	$1,950.00
Rate for Payer: Hawaii Western Management Group Commercial	$7,250.00
Rate for Payer: Health Management Network Commercial	$2,550.00
Rate for Payer: MDX Hawaii PPO	$2,910.00
Rate for Payer: University Health Alliance Commercial	$5,923.00

OBINUTUZUMAB 1000 MG/40 ML IV SOLN

Facility

$11,918.74

Service Code	HCPCS J9301
Hospital Revenue Code	636
Min. Negotiated Rate	$78.46
Max. Negotiated Rate	$11,561.18
Rate for Payer: AlohaCare Medicaid	$81.81
Rate for Payer: AlohaCare Medicare	$81.81
Rate for Payer: Cash Price	$7,747.18
Rate for Payer: Cash Price	$7,747.18
Rate for Payer: Devoted Health Medicare	$89.99
Rate for Payer: Hawaii Medical Service Association ABD	$78.46
Rate for Payer: Hawaii Medical Service Association Commercial	$102.26
Rate for Payer: Hawaii Medical Service Association Medicare	$81.81
Rate for Payer: Hawaii Medical Service Association Non-ABD	$78.46
Rate for Payer: Hawaii Western Management Group Commercial	$11,322.80
Rate for Payer: Health Management Network Commercial	$10,130.93
Rate for Payer: Humana Medicare	$81.81
Rate for Payer: Kaiser Permanente Commercial	$7,508.81
Rate for Payer: Kaiser Permanente Medicaid	$6,078.56
Rate for Payer: Kaiser Permanente Medicare	$81.81
Rate for Payer: MDX Hawaii PPO	$11,561.18
Rate for Payer: Ohana Health Plan Medicaid	$89.99
Rate for Payer: Ohana Health Plan Medicare	$81.81
Rate for Payer: UnitedHealthcare Medicaid	$7,151.24
Rate for Payer: UnitedHealthcare Medicare	$81.81
Rate for Payer: University Health Alliance Commercial	$8,687.57

OBINUTUZUMAB 1000 MG/40 ML IV SOLN

Facility

$11,918.74

Service Code	HCPCS J9301
Hospital Revenue Code	250
Min. Negotiated Rate	$10,130.93
Max. Negotiated Rate	$11,561.18
Rate for Payer: Cash Price	$7,747.18
Rate for Payer: Health Management Network Commercial	$10,130.93
Rate for Payer: MDX Hawaii PPO	$11,561.18

OBSERVATION

Facility

$174.00

Service Code	HCPCS 99221
Hospital Charge Code	H0000044
Hospital Revenue Code	762
Min. Negotiated Rate	$53.33
Max. Negotiated Rate	$1,200.00
Rate for Payer: Cash Price	$113.10
Rate for Payer: Cash Price	$113.10
Rate for Payer: Cash Price	$113.10
Rate for Payer: Hawaii Medical Service Association Commercial	$1,200.00
Rate for Payer: Hawaii Western Management Group Commercial	$165.30
Rate for Payer: Health Management Network Commercial	$147.90
Rate for Payer: Kaiser Permanente Commercial	$109.62
Rate for Payer: Kaiser Permanente Medicaid	$88.74
Rate for Payer: MDX Hawaii PPO	$168.78
Rate for Payer: UnitedHealthcare Medicaid	$53.33
Rate for Payer: University Health Alliance Commercial	$126.83

OBSERVATION

Facility

$174.00

Service Code	HCPCS 99221
Hospital Charge Code	H0000044
Hospital Revenue Code	762
Min. Negotiated Rate	$147.90
Max. Negotiated Rate	$168.78
Rate for Payer: Cash Price	$113.10
Rate for Payer: Health Management Network Commercial	$147.90
Rate for Payer: MDX Hawaii PPO	$168.78

OBSERVATION

Facility

$174.00

Service Code	HCPCS 99221
Hospital Charge Code	H0000043
Hospital Revenue Code	762
Min. Negotiated Rate	$53.33
Max. Negotiated Rate	$1,200.00
Rate for Payer: Cash Price	$113.10
Rate for Payer: Cash Price	$113.10
Rate for Payer: Cash Price	$113.10
Rate for Payer: Hawaii Medical Service Association Commercial	$1,200.00
Rate for Payer: Hawaii Western Management Group Commercial	$165.30
Rate for Payer: Health Management Network Commercial	$147.90
Rate for Payer: Kaiser Permanente Commercial	$109.62
Rate for Payer: Kaiser Permanente Medicaid	$88.74
Rate for Payer: MDX Hawaii PPO	$168.78
Rate for Payer: UnitedHealthcare Medicaid	$53.33
Rate for Payer: University Health Alliance Commercial	$126.83

OBSERVATION

Facility

$174.00

Service Code	HCPCS 99221
Hospital Charge Code	H0000043
Hospital Revenue Code	762
Min. Negotiated Rate	$147.90
Max. Negotiated Rate	$168.78
Rate for Payer: Cash Price	$113.10
Rate for Payer: Health Management Network Commercial	$147.90
Rate for Payer: MDX Hawaii PPO	$168.78

OBSERVATION CARVE OUT

Facility

$174.00

Service Code	HCPCS 99221
Hospital Charge Code	K0000101
Hospital Revenue Code	762
Min. Negotiated Rate	$53.33
Max. Negotiated Rate	$1,200.00
Rate for Payer: Cash Price	$113.10
Rate for Payer: Cash Price	$113.10
Rate for Payer: Cash Price	$113.10
Rate for Payer: Hawaii Medical Service Association Commercial	$1,200.00
Rate for Payer: Hawaii Western Management Group Commercial	$165.30
Rate for Payer: Health Management Network Commercial	$147.90
Rate for Payer: Kaiser Permanente Commercial	$109.62
Rate for Payer: Kaiser Permanente Medicaid	$88.74
Rate for Payer: MDX Hawaii PPO	$168.78
Rate for Payer: UnitedHealthcare Medicaid	$53.33
Rate for Payer: University Health Alliance Commercial	$126.83

OBSERVATION CARVE OUT

Facility

$174.00

Service Code	HCPCS 99221
Hospital Charge Code	K0000101
Hospital Revenue Code	762
Min. Negotiated Rate	$147.90
Max. Negotiated Rate	$168.78
Rate for Payer: Cash Price	$113.10
Rate for Payer: Health Management Network Commercial	$147.90
Rate for Payer: MDX Hawaii PPO	$168.78

OCCULT BLOOD,STOOL

Facility

$206.00

Service Code	HCPCS 82274
Hospital Charge Code	H3011429
Hospital Revenue Code	301
Min. Negotiated Rate	$175.10
Max. Negotiated Rate	$199.82
Rate for Payer: Cash Price	$133.90
Rate for Payer: Health Management Network Commercial	$175.10
Rate for Payer: MDX Hawaii PPO	$199.82

OCCULT BLOOD,STOOL

Facility

$206.00

Service Code	HCPCS 82274
Hospital Charge Code	H3011429
Hospital Revenue Code	301
Min. Negotiated Rate	$13.33
Max. Negotiated Rate	$199.82
Rate for Payer: AlohaCare Medicaid	$15.92
Rate for Payer: AlohaCare Medicare	$15.92
Rate for Payer: Cash Price	$133.90
Rate for Payer: Cash Price	$133.90
Rate for Payer: Devoted Health Medicare	$17.51
Rate for Payer: Hawaii Medical Service Association ABD	$13.33
Rate for Payer: Hawaii Medical Service Association Commercial	$19.90
Rate for Payer: Hawaii Medical Service Association Medicare	$15.92
Rate for Payer: Hawaii Medical Service Association Non-ABD	$21.31
Rate for Payer: Hawaii Western Management Group Commercial	$15.92
Rate for Payer: Health Management Network Commercial	$175.10
Rate for Payer: Humana Medicare	$15.92
Rate for Payer: Kaiser Permanente Commercial	$129.78
Rate for Payer: Kaiser Permanente Medicaid	$105.06
Rate for Payer: Kaiser Permanente Medicare	$15.92
Rate for Payer: MDX Hawaii PPO	$199.82
Rate for Payer: Ohana Health Plan Medicaid	$17.51
Rate for Payer: Ohana Health Plan Medicare	$15.92
Rate for Payer: UnitedHealthcare Medicaid	$13.33
Rate for Payer: UnitedHealthcare Medicare	$15.92
Rate for Payer: University Health Alliance Commercial	$41.11

OCTREOTIDE ACETATE 1000 MCG/ML INJ SOLN

Facility

$1,271.53

Service Code	HCPCS J2354
Hospital Revenue Code	637
Min. Negotiated Rate	$0.46
Max. Negotiated Rate	$1,233.38
Rate for Payer: Cash Price	$826.49
Rate for Payer: Cash Price	$826.49
Rate for Payer: Hawaii Medical Service Association ABD	$0.61
Rate for Payer: Hawaii Medical Service Association Non-ABD	$0.61
Rate for Payer: Hawaii Western Management Group Commercial	$1,207.95
Rate for Payer: Health Management Network Commercial	$1,080.80
Rate for Payer: Kaiser Permanente Commercial	$801.06
Rate for Payer: Kaiser Permanente Medicaid	$648.48
Rate for Payer: MDX Hawaii PPO	$1,233.38
Rate for Payer: UnitedHealthcare Medicaid	$0.46
Rate for Payer: University Health Alliance Commercial	$926.82

OCTREOTIDE ACETATE 1000 MCG/ML INJ SOLN

Facility

$1,271.53

Service Code	HCPCS J2354
Hospital Revenue Code	250
Min. Negotiated Rate	$1,080.80
Max. Negotiated Rate	$1,233.38
Rate for Payer: Cash Price	$826.49
Rate for Payer: Health Management Network Commercial	$1,080.80
Rate for Payer: MDX Hawaii PPO	$1,233.38

OCTREOTIDE ACETATE 100 MCG/ML INJ SOLN

Facility

$21.53

Service Code	HCPCS J2354
Hospital Revenue Code	637
Min. Negotiated Rate	$0.46
Max. Negotiated Rate	$20.88
Rate for Payer: Cash Price	$13.99
Rate for Payer: Cash Price	$26.68
Rate for Payer: Cash Price	$26.68
Rate for Payer: Cash Price	$37.49
Rate for Payer: Cash Price	$37.49
Rate for Payer: Cash Price	$13.99
Rate for Payer: Hawaii Medical Service Association ABD	$0.61
Rate for Payer: Hawaii Medical Service Association ABD	$0.61
Rate for Payer: Hawaii Medical Service Association ABD	$0.61
Rate for Payer: Hawaii Medical Service Association Non-ABD	$0.61
Rate for Payer: Hawaii Medical Service Association Non-ABD	$0.61
Rate for Payer: Hawaii Medical Service Association Non-ABD	$0.61
Rate for Payer: Hawaii Western Management Group Commercial	$54.79
Rate for Payer: Hawaii Western Management Group Commercial	$20.45
Rate for Payer: Hawaii Western Management Group Commercial	$38.99
Rate for Payer: Health Management Network Commercial	$34.88
Rate for Payer: Health Management Network Commercial	$49.02
Rate for Payer: Health Management Network Commercial	$18.30
Rate for Payer: Kaiser Permanente Commercial	$25.86
Rate for Payer: Kaiser Permanente Commercial	$13.56
Rate for Payer: Kaiser Permanente Commercial	$36.33
Rate for Payer: Kaiser Permanente Medicaid	$29.41
Rate for Payer: Kaiser Permanente Medicaid	$10.98
Rate for Payer: Kaiser Permanente Medicaid	$20.93
Rate for Payer: MDX Hawaii PPO	$20.88
Rate for Payer: MDX Hawaii PPO	$55.94
Rate for Payer: MDX Hawaii PPO	$39.81
Rate for Payer: UnitedHealthcare Medicaid	$0.46
Rate for Payer: UnitedHealthcare Medicaid	$0.46
Rate for Payer: UnitedHealthcare Medicaid	$0.46
Rate for Payer: University Health Alliance Commercial	$29.91
Rate for Payer: University Health Alliance Commercial	$42.04
Rate for Payer: University Health Alliance Commercial	$15.69

OCTREOTIDE ACETATE 100 MCG/ML INJ SOLN

Facility

$41.04

Service Code	HCPCS J2354
Hospital Revenue Code	250
Min. Negotiated Rate	$34.88
Max. Negotiated Rate	$39.81
Rate for Payer: Cash Price	$26.68
Rate for Payer: Cash Price	$13.99
Rate for Payer: Cash Price	$37.49
Rate for Payer: Health Management Network Commercial	$18.30
Rate for Payer: Health Management Network Commercial	$34.88
Rate for Payer: Health Management Network Commercial	$49.02
Rate for Payer: MDX Hawaii PPO	$20.88
Rate for Payer: MDX Hawaii PPO	$55.94
Rate for Payer: MDX Hawaii PPO	$39.81

OCTREOTIDE ACETATE 50 MCG/ML INJ SOLN

Facility

$24.84

Service Code	HCPCS J2354
Hospital Revenue Code	250
Min. Negotiated Rate	$21.11
Max. Negotiated Rate	$24.09
Rate for Payer: Cash Price	$16.15
Rate for Payer: Health Management Network Commercial	$21.11
Rate for Payer: MDX Hawaii PPO	$24.09

OCTREOTIDE ACETATE 50 MCG/ML INJ SOLN

Facility

$24.84

Service Code	HCPCS J2354
Hospital Revenue Code	637
Min. Negotiated Rate	$0.46
Max. Negotiated Rate	$24.09
Rate for Payer: Cash Price	$16.15
Rate for Payer: Cash Price	$16.15
Rate for Payer: Hawaii Medical Service Association ABD	$0.61
Rate for Payer: Hawaii Medical Service Association Non-ABD	$0.61
Rate for Payer: Hawaii Western Management Group Commercial	$23.60
Rate for Payer: Health Management Network Commercial	$21.11
Rate for Payer: Kaiser Permanente Commercial	$15.65
Rate for Payer: Kaiser Permanente Medicaid	$12.67
Rate for Payer: MDX Hawaii PPO	$24.09
Rate for Payer: UnitedHealthcare Medicaid	$0.46
Rate for Payer: University Health Alliance Commercial	$18.11

Know your out-of-pocket cost for care.

All Charges