Kona Community Hospital

All Charges

Charge

Type

Setting

Price

PHENTOLAMINE 5 MG INJ RECON.SOLN.

Facility

$1,257.17

Service Code	HCPCS J2760
Hospital Revenue Code	636
Min. Negotiated Rate	$257.45
Max. Negotiated Rate	$1,219.45
Rate for Payer: AlohaCare Medicaid	$257.45
Rate for Payer: AlohaCare Medicare	$257.45
Rate for Payer: Cash Price	$817.16
Rate for Payer: Cash Price	$817.16
Rate for Payer: Devoted Health Medicare	$283.19
Rate for Payer: Hawaii Medical Service Association ABD	$436.51
Rate for Payer: Hawaii Medical Service Association Commercial	$321.81
Rate for Payer: Hawaii Medical Service Association Medicare	$257.45
Rate for Payer: Hawaii Medical Service Association Non-ABD	$436.51
Rate for Payer: Hawaii Western Management Group Commercial	$1,194.31
Rate for Payer: Health Management Network Commercial	$1,068.59
Rate for Payer: Humana Medicare	$257.45
Rate for Payer: Kaiser Permanente Commercial	$792.02
Rate for Payer: Kaiser Permanente Medicaid	$641.16
Rate for Payer: Kaiser Permanente Medicare	$257.45
Rate for Payer: MDX Hawaii PPO	$1,219.45
Rate for Payer: Ohana Health Plan Medicaid	$283.19
Rate for Payer: Ohana Health Plan Medicare	$257.45
Rate for Payer: UnitedHealthcare Medicaid	$754.30
Rate for Payer: UnitedHealthcare Medicare	$257.45
Rate for Payer: University Health Alliance Commercial	$916.35

PHENYLEPHRINE HCL 10 MG/ML INJ SOLN

Facility

$23.70

Service Code	HCPCS J2371
Hospital Revenue Code	250
Min. Negotiated Rate	$20.14
Max. Negotiated Rate	$22.99
Rate for Payer: Cash Price	$15.40
Rate for Payer: Cash Price	$9.87
Rate for Payer: Health Management Network Commercial	$12.90
Rate for Payer: Health Management Network Commercial	$20.14
Rate for Payer: MDX Hawaii PPO	$14.72
Rate for Payer: MDX Hawaii PPO	$22.99

PHENYLEPHRINE HCL 10 MG/ML INJ SOLN

Facility

$15.18

Service Code	HCPCS J2371
Hospital Revenue Code	636
Min. Negotiated Rate	$0.01
Max. Negotiated Rate	$14.72
Rate for Payer: Cash Price	$9.87
Rate for Payer: Cash Price	$9.87
Rate for Payer: Cash Price	$15.40
Rate for Payer: Cash Price	$15.40
Rate for Payer: Hawaii Medical Service Association ABD	$0.01
Rate for Payer: Hawaii Medical Service Association ABD	$0.01
Rate for Payer: Hawaii Medical Service Association Non-ABD	$0.01
Rate for Payer: Hawaii Medical Service Association Non-ABD	$0.01
Rate for Payer: Hawaii Western Management Group Commercial	$14.42
Rate for Payer: Hawaii Western Management Group Commercial	$22.52
Rate for Payer: Health Management Network Commercial	$20.14
Rate for Payer: Health Management Network Commercial	$12.90
Rate for Payer: Kaiser Permanente Commercial	$14.93
Rate for Payer: Kaiser Permanente Commercial	$9.56
Rate for Payer: Kaiser Permanente Medicaid	$7.74
Rate for Payer: Kaiser Permanente Medicaid	$12.09
Rate for Payer: MDX Hawaii PPO	$22.99
Rate for Payer: MDX Hawaii PPO	$14.72
Rate for Payer: UnitedHealthcare Medicaid	$9.11
Rate for Payer: UnitedHealthcare Medicaid	$14.22
Rate for Payer: University Health Alliance Commercial	$17.27
Rate for Payer: University Health Alliance Commercial	$11.06

PHENYLEPHRINE HCL 2.5 % OPHT DROP

Facility

$186.21

Service Code	NDC 70756062925
Hospital Revenue Code	250
Min. Negotiated Rate	$158.28
Max. Negotiated Rate	$180.62
Rate for Payer: Cash Price	$121.04
Rate for Payer: Health Management Network Commercial	$158.28
Rate for Payer: MDX Hawaii PPO	$180.62

PHENYLEPHRINE HCL 2.5 % OPHT DROP

Facility

$186.21

Service Code	NDC 70756062925
Hospital Revenue Code	250
Min. Negotiated Rate	$94.97
Max. Negotiated Rate	$180.62
Rate for Payer: Cash Price	$121.04
Rate for Payer: Hawaii Western Management Group Commercial	$176.90
Rate for Payer: Health Management Network Commercial	$158.28
Rate for Payer: Kaiser Permanente Commercial	$117.31
Rate for Payer: Kaiser Permanente Medicaid	$94.97
Rate for Payer: MDX Hawaii PPO	$180.62
Rate for Payer: UnitedHealthcare Medicaid	$111.73
Rate for Payer: University Health Alliance Commercial	$135.73

PHENYLEPHRINE HCL IN 0.9% NACL 40 MG/250 ML (160 MCG/ML) IV SOLN

Facility

$220.86

Service Code	HCPCS J2371
Hospital Revenue Code	636
Min. Negotiated Rate	$0.01
Max. Negotiated Rate	$214.23
Rate for Payer: Cash Price	$143.56
Rate for Payer: Cash Price	$86.38
Rate for Payer: Cash Price	$86.38
Rate for Payer: Cash Price	$143.56
Rate for Payer: Hawaii Medical Service Association ABD	$0.01
Rate for Payer: Hawaii Medical Service Association ABD	$0.01
Rate for Payer: Hawaii Medical Service Association Non-ABD	$0.01
Rate for Payer: Hawaii Medical Service Association Non-ABD	$0.01
Rate for Payer: Hawaii Western Management Group Commercial	$126.25
Rate for Payer: Hawaii Western Management Group Commercial	$209.82
Rate for Payer: Health Management Network Commercial	$187.73
Rate for Payer: Health Management Network Commercial	$112.96
Rate for Payer: Kaiser Permanente Commercial	$139.14
Rate for Payer: Kaiser Permanente Commercial	$83.72
Rate for Payer: Kaiser Permanente Medicaid	$67.77
Rate for Payer: Kaiser Permanente Medicaid	$112.64
Rate for Payer: MDX Hawaii PPO	$128.90
Rate for Payer: MDX Hawaii PPO	$214.23
Rate for Payer: UnitedHealthcare Medicaid	$79.73
Rate for Payer: UnitedHealthcare Medicaid	$132.52
Rate for Payer: University Health Alliance Commercial	$96.86
Rate for Payer: University Health Alliance Commercial	$160.98

PHENYLEPHRINE HCL IN 0.9% NACL 40 MG/250 ML (160 MCG/ML) IV SOLN

Facility

$132.89

Service Code	HCPCS J2371
Hospital Revenue Code	250
Min. Negotiated Rate	$112.96
Max. Negotiated Rate	$128.90
Rate for Payer: Cash Price	$86.38
Rate for Payer: Cash Price	$143.56
Rate for Payer: Health Management Network Commercial	$187.73
Rate for Payer: Health Management Network Commercial	$112.96
Rate for Payer: MDX Hawaii PPO	$214.23
Rate for Payer: MDX Hawaii PPO	$128.90

PHENYTOIN 100 MG/4 ML PO SUSP

Facility

$48.49

Service Code	HCPCS A9270
Hospital Revenue Code	250
Min. Negotiated Rate	$41.22
Max. Negotiated Rate	$47.04
Rate for Payer: Cash Price	$31.52
Rate for Payer: Health Management Network Commercial	$41.22
Rate for Payer: MDX Hawaii PPO	$47.04

PHENYTOIN 100 MG/4 ML PO SUSP

Facility

$48.49

Service Code	HCPCS A9270
Hospital Revenue Code	250
Min. Negotiated Rate	$24.73
Max. Negotiated Rate	$47.04
Rate for Payer: Cash Price	$31.52
Rate for Payer: Hawaii Western Management Group Commercial	$46.07
Rate for Payer: Health Management Network Commercial	$41.22
Rate for Payer: Kaiser Permanente Commercial	$30.55
Rate for Payer: Kaiser Permanente Medicaid	$24.73
Rate for Payer: MDX Hawaii PPO	$47.04
Rate for Payer: UnitedHealthcare Medicaid	$29.09
Rate for Payer: University Health Alliance Commercial	$35.34

PHENYTOIN SODIUM EXTENDED 100 MG PO CAP

Facility

$3.54

Service Code	HCPCS A9270
Hospital Revenue Code	250
Min. Negotiated Rate	$3.01
Max. Negotiated Rate	$3.43
Rate for Payer: Cash Price	$2.30
Rate for Payer: Health Management Network Commercial	$3.01
Rate for Payer: MDX Hawaii PPO	$3.43

PHENYTOIN SODIUM EXTENDED 100 MG PO CAP

Facility

$3.54

Service Code	HCPCS A9270
Hospital Revenue Code	250
Min. Negotiated Rate	$1.81
Max. Negotiated Rate	$3.43
Rate for Payer: Cash Price	$2.30
Rate for Payer: Hawaii Western Management Group Commercial	$3.36
Rate for Payer: Health Management Network Commercial	$3.01
Rate for Payer: Kaiser Permanente Commercial	$2.23
Rate for Payer: Kaiser Permanente Medicaid	$1.81
Rate for Payer: MDX Hawaii PPO	$3.43
Rate for Payer: UnitedHealthcare Medicaid	$2.12
Rate for Payer: University Health Alliance Commercial	$2.58

PHLEBOTOMY THERAPEUTIC SEPARATE PROCEDURE

Professional

Both

$315.00

Service Code	HCPCS 99195
Min. Negotiated Rate	$18.61
Max. Negotiated Rate	$267.75
Rate for Payer: AlohaCare Medicaid	$108.60
Rate for Payer: AlohaCare Medicare	$110.72
Rate for Payer: Cash Price	$204.75
Rate for Payer: Cash Price	$204.75
Rate for Payer: Devoted Health Medicare	$121.79
Rate for Payer: Hawaii Medical Service Association Medicare	$110.72
Rate for Payer: Hawaii Western Management Group Commercial	$18.61
Rate for Payer: Health Management Network Commercial	$267.75
Rate for Payer: Kaiser Permanente Commercial	$132.86
Rate for Payer: Kaiser Permanente Medicaid	$132.86
Rate for Payer: Kaiser Permanente Medicare	$132.86
Rate for Payer: Ohana Health Plan Medicaid	$108.60
Rate for Payer: Ohana Health Plan Medicare	$110.72
Rate for Payer: UnitedHealthcare Medicaid	$108.60
Rate for Payer: UnitedHealthcare Medicare	$110.72

PHYS/QHP TELEPHONE EVALUATION 5-10 MIN

Professional

Both

$89.00

Service Code	HCPCS 99441
Min. Negotiated Rate	$19.90
Max. Negotiated Rate	$75.65
Rate for Payer: Cash Price	$57.85
Rate for Payer: Cash Price	$57.85
Rate for Payer: Hawaii Western Management Group Commercial	$19.90
Rate for Payer: Health Management Network Commercial	$75.65

PHYTONADIONE 10 MG/ML INJ ORAL SOLN

Facility

$195.07

Service Code	NDC 69097070896
Hospital Revenue Code	250
Min. Negotiated Rate	$165.81
Max. Negotiated Rate	$189.22
Rate for Payer: Cash Price	$126.80
Rate for Payer: Health Management Network Commercial	$165.81
Rate for Payer: MDX Hawaii PPO	$189.22

PHYTONADIONE 10 MG/ML INJ ORAL SOLN

Facility

$195.07

Service Code	NDC 69097070831
Hospital Revenue Code	250
Min. Negotiated Rate	$99.49
Max. Negotiated Rate	$189.22
Rate for Payer: Cash Price	$126.80
Rate for Payer: Hawaii Western Management Group Commercial	$185.32
Rate for Payer: Health Management Network Commercial	$165.81
Rate for Payer: Kaiser Permanente Commercial	$122.89
Rate for Payer: Kaiser Permanente Medicaid	$99.49
Rate for Payer: MDX Hawaii PPO	$189.22
Rate for Payer: UnitedHealthcare Medicaid	$117.04
Rate for Payer: University Health Alliance Commercial	$142.19

PHYTONADIONE 10 MG/ML INJ ORAL SOLN

Facility

$195.07

Service Code	NDC 69097070896
Hospital Revenue Code	250
Min. Negotiated Rate	$99.49
Max. Negotiated Rate	$189.22
Rate for Payer: Cash Price	$126.80
Rate for Payer: Hawaii Western Management Group Commercial	$185.32
Rate for Payer: Health Management Network Commercial	$165.81
Rate for Payer: Kaiser Permanente Commercial	$122.89
Rate for Payer: Kaiser Permanente Medicaid	$99.49
Rate for Payer: MDX Hawaii PPO	$189.22
Rate for Payer: UnitedHealthcare Medicaid	$117.04
Rate for Payer: University Health Alliance Commercial	$142.19

PHYTONADIONE 10 MG/ML INJ ORAL SOLN

Facility

$195.07

Service Code	NDC 69097070831
Hospital Revenue Code	250
Min. Negotiated Rate	$165.81
Max. Negotiated Rate	$189.22
Rate for Payer: Cash Price	$126.80
Rate for Payer: Health Management Network Commercial	$165.81
Rate for Payer: MDX Hawaii PPO	$189.22

PHYTONADIONE 10 MG/ML INJ SOLN (SQ)

Facility

$195.07

Service Code	HCPCS J3430
Hospital Revenue Code	636
Min. Negotiated Rate	$2.84
Max. Negotiated Rate	$189.22
Rate for Payer: Cash Price	$126.80
Rate for Payer: Cash Price	$126.80
Rate for Payer: Hawaii Medical Service Association ABD	$2.84
Rate for Payer: Hawaii Medical Service Association Non-ABD	$2.84
Rate for Payer: Hawaii Western Management Group Commercial	$185.32
Rate for Payer: Health Management Network Commercial	$165.81
Rate for Payer: Kaiser Permanente Commercial	$122.89
Rate for Payer: Kaiser Permanente Medicaid	$99.49
Rate for Payer: MDX Hawaii PPO	$189.22
Rate for Payer: UnitedHealthcare Medicaid	$117.04
Rate for Payer: University Health Alliance Commercial	$142.19

PHYTONADIONE 10 MG/ML INJ SOLN (SQ)

Facility

$195.07

Service Code	HCPCS J3430
Hospital Revenue Code	250
Min. Negotiated Rate	$165.81
Max. Negotiated Rate	$189.22
Rate for Payer: Cash Price	$126.80
Rate for Payer: Health Management Network Commercial	$165.81
Rate for Payer: MDX Hawaii PPO	$189.22

PHYTONADIONE (VITAMIN K1) 1 MG/0.5 ML INJ SYR

Facility

$120.39

Service Code	HCPCS J3430
Hospital Revenue Code	250
Min. Negotiated Rate	$102.33
Max. Negotiated Rate	$116.78
Rate for Payer: Cash Price	$78.25
Rate for Payer: Health Management Network Commercial	$102.33
Rate for Payer: MDX Hawaii PPO	$116.78

PHYTONADIONE (VITAMIN K1) 1 MG/0.5 ML INJ SYR

Facility

$120.39

Service Code	HCPCS J3430
Hospital Revenue Code	636
Min. Negotiated Rate	$2.84
Max. Negotiated Rate	$116.78
Rate for Payer: Cash Price	$78.25
Rate for Payer: Cash Price	$78.25
Rate for Payer: Hawaii Medical Service Association ABD	$2.84
Rate for Payer: Hawaii Medical Service Association Non-ABD	$2.84
Rate for Payer: Hawaii Western Management Group Commercial	$114.37
Rate for Payer: Health Management Network Commercial	$102.33
Rate for Payer: Kaiser Permanente Commercial	$75.85
Rate for Payer: Kaiser Permanente Medicaid	$61.40
Rate for Payer: MDX Hawaii PPO	$116.78
Rate for Payer: UnitedHealthcare Medicaid	$72.23
Rate for Payer: University Health Alliance Commercial	$87.75

PICC DOUBLE LUMEN 4FR [2702979]

Facility

$1,835.13

Service Code	HCPCS C1751
Hospital Charge Code	2702979
Hospital Revenue Code	272
Min. Negotiated Rate	$935.92
Max. Negotiated Rate	$1,780.08
Rate for Payer: Cash Price	$1,192.83
Rate for Payer: Hawaii Western Management Group Commercial	$1,743.37
Rate for Payer: Health Management Network Commercial	$1,559.86
Rate for Payer: Kaiser Permanente Commercial	$1,156.13
Rate for Payer: Kaiser Permanente Medicaid	$935.92
Rate for Payer: MDX Hawaii PPO	$1,780.08
Rate for Payer: University Health Alliance Commercial	$1,337.63

PICC DOUBLE LUMEN 4FR [2702979]

Facility

$1,835.13

Service Code	HCPCS C1751
Hospital Charge Code	2702979
Hospital Revenue Code	272
Min. Negotiated Rate	$1,559.86
Max. Negotiated Rate	$1,780.08
Rate for Payer: Cash Price	$1,192.83
Rate for Payer: Health Management Network Commercial	$1,559.86
Rate for Payer: MDX Hawaii PPO	$1,780.08

PICC MICROINTRODUCER 5FR [2702965]

Facility

$261.75

Hospital Charge Code	2702965
Hospital Revenue Code	272
Min. Negotiated Rate	$133.49
Max. Negotiated Rate	$253.90
Rate for Payer: Cash Price	$170.14
Rate for Payer: Hawaii Western Management Group Commercial	$248.66
Rate for Payer: Health Management Network Commercial	$222.49
Rate for Payer: Kaiser Permanente Commercial	$164.90
Rate for Payer: Kaiser Permanente Medicaid	$133.49
Rate for Payer: MDX Hawaii PPO	$253.90
Rate for Payer: University Health Alliance Commercial	$190.79

PICC MICROINTRODUCER 5FR [2702965]

Facility

$261.75

Hospital Charge Code	2702965
Hospital Revenue Code	272
Min. Negotiated Rate	$222.49
Max. Negotiated Rate	$253.90
Rate for Payer: Cash Price	$170.14
Rate for Payer: Health Management Network Commercial	$222.49
Rate for Payer: MDX Hawaii PPO	$253.90

Know your out-of-pocket cost for care.

All Charges