Kona Community Hospital

All Charges

Charge

Type

Setting

Price

Cannulated Screw, 6.5mm X 90mm 04.355.790 [3645539]

Facility

$2,399.90

Service Code	HCPCS C1713
Hospital Charge Code	3645539
Hospital Revenue Code	278
Min. Negotiated Rate	$1,343.94
Max. Negotiated Rate	$2,327.90
Rate for Payer: Cash Price	$1,559.94
Rate for Payer: Hawaii Western Management Group Commercial	$1,679.93
Rate for Payer: Health Management Network Commercial	$2,039.91
Rate for Payer: MDX Hawaii PPO	$2,327.90
Rate for Payer: University Health Alliance Commercial	$1,343.94

Cannula Tripledam 7mm x 7cm AR6550TD [3641108]

Facility

$349.50

Hospital Charge Code	3641108
Hospital Revenue Code	272
Min. Negotiated Rate	$297.07
Max. Negotiated Rate	$339.01
Rate for Payer: Cash Price	$227.18
Rate for Payer: Health Management Network Commercial	$297.07
Rate for Payer: MDX Hawaii PPO	$339.01

Cannula Tripledam 7mm x 7cm AR6550TD [3641108]

Facility

$349.50

Hospital Charge Code	3641108
Hospital Revenue Code	272
Min. Negotiated Rate	$178.25
Max. Negotiated Rate	$339.01
Rate for Payer: Cash Price	$227.18
Rate for Payer: Hawaii Western Management Group Commercial	$332.02
Rate for Payer: Health Management Network Commercial	$297.07
Rate for Payer: Kaiser Permanente Commercial	$220.19
Rate for Payer: Kaiser Permanente Medicaid	$178.25
Rate for Payer: MDX Hawaii PPO	$339.01
Rate for Payer: University Health Alliance Commercial	$254.75

Cannula Twist-In AR6540 [3641510]

Facility

$282.00

Hospital Charge Code	3641510
Hospital Revenue Code	272
Min. Negotiated Rate	$143.82
Max. Negotiated Rate	$273.54
Rate for Payer: Cash Price	$183.30
Rate for Payer: Hawaii Western Management Group Commercial	$267.90
Rate for Payer: Health Management Network Commercial	$239.70
Rate for Payer: Kaiser Permanente Commercial	$177.66
Rate for Payer: Kaiser Permanente Medicaid	$143.82
Rate for Payer: MDX Hawaii PPO	$273.54
Rate for Payer: University Health Alliance Commercial	$205.55

Cannula Twist-In AR6540 [3641510]

Facility

$282.00

Hospital Charge Code	3641510
Hospital Revenue Code	272
Min. Negotiated Rate	$239.70
Max. Negotiated Rate	$273.54
Rate for Payer: Cash Price	$183.30
Rate for Payer: Health Management Network Commercial	$239.70
Rate for Payer: MDX Hawaii PPO	$273.54

CAPSAICIN 0.025 % TOP CR

Facility

$38.42

Service Code	HCPCS A9270
Hospital Revenue Code	250
Min. Negotiated Rate	$32.66
Max. Negotiated Rate	$37.27
Rate for Payer: Cash Price	$24.97
Rate for Payer: Health Management Network Commercial	$32.66
Rate for Payer: MDX Hawaii PPO	$37.27

CAPSAICIN 0.025 % TOP CR

Facility

$38.42

Service Code	HCPCS A9270
Hospital Revenue Code	250
Min. Negotiated Rate	$19.59
Max. Negotiated Rate	$37.27
Rate for Payer: Cash Price	$24.97
Rate for Payer: Hawaii Western Management Group Commercial	$36.50
Rate for Payer: Health Management Network Commercial	$32.66
Rate for Payer: Kaiser Permanente Commercial	$24.20
Rate for Payer: Kaiser Permanente Medicaid	$19.59
Rate for Payer: MDX Hawaii PPO	$37.27
Rate for Payer: UnitedHealthcare Medicaid	$23.05
Rate for Payer: University Health Alliance Commercial	$28.00

CAPSULORRHAPHY, ANTERIOR, ANY TYPE; WITH CORACOID PROCESS TRANSFER

Facility

$16,700.00

Service Code	CPT 23462
Hospital Revenue Code	360
Min. Negotiated Rate	$521.33
Max. Negotiated Rate	$16,700.00
Rate for Payer: AlohaCare Medicaid	$8,572.09
Rate for Payer: AlohaCare Medicare	$8,572.09
Rate for Payer: Devoted Health Medicare	$9,429.30
Rate for Payer: Hawaii Medical Service Association ABD	$848.00
Rate for Payer: Hawaii Medical Service Association Commercial	$9,416.00
Rate for Payer: Hawaii Medical Service Association Medicare	$8,572.09
Rate for Payer: Hawaii Medical Service Association Non-ABD	$849.21
Rate for Payer: Humana Medicare	$8,572.09
Rate for Payer: Kaiser Permanente Medicaid	$2,837.00
Rate for Payer: Kaiser Permanente Medicare	$8,572.09
Rate for Payer: Ohana Health Plan Medicaid	$9,429.30
Rate for Payer: Ohana Health Plan Medicare	$8,572.09
Rate for Payer: UnitedHealthcare Medicaid	$521.33
Rate for Payer: UnitedHealthcare Medicare	$8,572.09
Rate for Payer: University Health Alliance Commercial	$16,700.00

CAPTOPRIL 12.5 MG PO TABLET

Facility

$8.61

Service Code	HCPCS A9270
Hospital Revenue Code	250
Min. Negotiated Rate	$4.39
Max. Negotiated Rate	$8.35
Rate for Payer: Cash Price	$5.60
Rate for Payer: Hawaii Western Management Group Commercial	$8.18
Rate for Payer: Health Management Network Commercial	$7.32
Rate for Payer: Kaiser Permanente Commercial	$5.42
Rate for Payer: Kaiser Permanente Medicaid	$4.39
Rate for Payer: MDX Hawaii PPO	$8.35
Rate for Payer: UnitedHealthcare Medicaid	$5.17
Rate for Payer: University Health Alliance Commercial	$6.28

CAPTOPRIL 12.5 MG PO TABLET

Facility

$8.61

Service Code	HCPCS A9270
Hospital Revenue Code	250
Min. Negotiated Rate	$7.32
Max. Negotiated Rate	$8.35
Rate for Payer: Cash Price	$5.60
Rate for Payer: Health Management Network Commercial	$7.32
Rate for Payer: MDX Hawaii PPO	$8.35

CAPTOPRIL 25 MG PO TABLET

Facility

$9.22

Service Code	HCPCS A9270
Hospital Revenue Code	250
Min. Negotiated Rate	$7.84
Max. Negotiated Rate	$8.94
Rate for Payer: Cash Price	$5.99
Rate for Payer: Health Management Network Commercial	$7.84
Rate for Payer: MDX Hawaii PPO	$8.94

CAPTOPRIL 25 MG PO TABLET

Facility

$9.22

Service Code	HCPCS A9270
Hospital Revenue Code	250
Min. Negotiated Rate	$4.70
Max. Negotiated Rate	$8.94
Rate for Payer: Cash Price	$5.99
Rate for Payer: Hawaii Western Management Group Commercial	$8.76
Rate for Payer: Health Management Network Commercial	$7.84
Rate for Payer: Kaiser Permanente Commercial	$5.81
Rate for Payer: Kaiser Permanente Medicaid	$4.70
Rate for Payer: MDX Hawaii PPO	$8.94
Rate for Payer: UnitedHealthcare Medicaid	$5.53
Rate for Payer: University Health Alliance Commercial	$6.72

CARBACHOL 0.01 % INTRAOC SOLN

Facility

$210.39

Service Code	NDC 00065002315
Hospital Revenue Code	250
Min. Negotiated Rate	$178.83
Max. Negotiated Rate	$204.08
Rate for Payer: Cash Price	$136.75
Rate for Payer: Health Management Network Commercial	$178.83
Rate for Payer: MDX Hawaii PPO	$204.08

CARBACHOL 0.01 % INTRAOC SOLN

Facility

$210.39

Service Code	NDC 00065002315
Hospital Revenue Code	250
Min. Negotiated Rate	$107.30
Max. Negotiated Rate	$204.08
Rate for Payer: Cash Price	$136.75
Rate for Payer: Hawaii Western Management Group Commercial	$199.87
Rate for Payer: Health Management Network Commercial	$178.83
Rate for Payer: Kaiser Permanente Commercial	$132.55
Rate for Payer: Kaiser Permanente Medicaid	$107.30
Rate for Payer: MDX Hawaii PPO	$204.08
Rate for Payer: UnitedHealthcare Medicaid	$126.23
Rate for Payer: University Health Alliance Commercial	$153.35

CARBAMAZEPINE 100 MG PO CHEW

Facility

$3.64

Service Code	HCPCS A9270
Hospital Revenue Code	250
Min. Negotiated Rate	$3.09
Max. Negotiated Rate	$3.53
Rate for Payer: Cash Price	$2.37
Rate for Payer: Health Management Network Commercial	$3.09
Rate for Payer: MDX Hawaii PPO	$3.53

CARBAMAZEPINE 100 MG PO CHEW

Facility

$3.64

Service Code	HCPCS A9270
Hospital Revenue Code	250
Min. Negotiated Rate	$1.86
Max. Negotiated Rate	$3.53
Rate for Payer: Cash Price	$2.37
Rate for Payer: Hawaii Western Management Group Commercial	$3.46
Rate for Payer: Health Management Network Commercial	$3.09
Rate for Payer: Kaiser Permanente Commercial	$2.29
Rate for Payer: Kaiser Permanente Medicaid	$1.86
Rate for Payer: MDX Hawaii PPO	$3.53
Rate for Payer: UnitedHealthcare Medicaid	$2.18
Rate for Payer: University Health Alliance Commercial	$2.65

CARBAMAZEPINE 100 MG PO CHEW (0.5 TAB) = 50 MG

Facility

$2.22

Service Code	HCPCS A9270
Hospital Revenue Code	250
Min. Negotiated Rate	$1.13
Max. Negotiated Rate	$2.15
Rate for Payer: Cash Price	$1.44
Rate for Payer: Hawaii Western Management Group Commercial	$2.11
Rate for Payer: Health Management Network Commercial	$1.89
Rate for Payer: Kaiser Permanente Commercial	$1.40
Rate for Payer: Kaiser Permanente Medicaid	$1.13
Rate for Payer: MDX Hawaii PPO	$2.15
Rate for Payer: UnitedHealthcare Medicaid	$1.33
Rate for Payer: University Health Alliance Commercial	$1.62

CARBAMAZEPINE 100 MG PO CHEW (0.5 TAB) = 50 MG

Facility

$2.22

Service Code	HCPCS A9270
Hospital Revenue Code	250
Min. Negotiated Rate	$1.89
Max. Negotiated Rate	$2.15
Rate for Payer: Cash Price	$1.44
Rate for Payer: Health Management Network Commercial	$1.89
Rate for Payer: MDX Hawaii PPO	$2.15

CARBAMAZEPINE 200 MG PO TABLET

Facility

$8.83

Service Code	HCPCS A9270
Hospital Revenue Code	250
Min. Negotiated Rate	$4.50
Max. Negotiated Rate	$8.57
Rate for Payer: Cash Price	$5.74
Rate for Payer: Hawaii Western Management Group Commercial	$8.39
Rate for Payer: Health Management Network Commercial	$7.51
Rate for Payer: Kaiser Permanente Commercial	$5.56
Rate for Payer: Kaiser Permanente Medicaid	$4.50
Rate for Payer: MDX Hawaii PPO	$8.57
Rate for Payer: UnitedHealthcare Medicaid	$5.30
Rate for Payer: University Health Alliance Commercial	$6.44

CARBAMAZEPINE 200 MG PO TABLET

Facility

$8.83

Service Code	HCPCS A9270
Hospital Revenue Code	250
Min. Negotiated Rate	$7.51
Max. Negotiated Rate	$8.57
Rate for Payer: Cash Price	$5.74
Rate for Payer: Health Management Network Commercial	$7.51
Rate for Payer: MDX Hawaii PPO	$8.57

CARBAMIDE PEROXIDE 6.5 % OTIC DROP

Facility

$46.31

Service Code	HCPCS A9270
Hospital Revenue Code	250
Min. Negotiated Rate	$23.62
Max. Negotiated Rate	$44.92
Rate for Payer: Cash Price	$30.10
Rate for Payer: Hawaii Western Management Group Commercial	$43.99
Rate for Payer: Health Management Network Commercial	$39.36
Rate for Payer: Kaiser Permanente Commercial	$29.18
Rate for Payer: Kaiser Permanente Medicaid	$23.62
Rate for Payer: MDX Hawaii PPO	$44.92
Rate for Payer: UnitedHealthcare Medicaid	$27.79
Rate for Payer: University Health Alliance Commercial	$33.76

CARBAMIDE PEROXIDE 6.5 % OTIC DROP

Facility

$46.31

Service Code	HCPCS A9270
Hospital Revenue Code	250
Min. Negotiated Rate	$39.36
Max. Negotiated Rate	$44.92
Rate for Payer: Cash Price	$30.10
Rate for Payer: Health Management Network Commercial	$39.36
Rate for Payer: MDX Hawaii PPO	$44.92

CARBIDOPA-LEVODOPA 10-100 MG PO TABLET

Facility

$4.27

Service Code	HCPCS A9270
Hospital Revenue Code	250
Min. Negotiated Rate	$3.63
Max. Negotiated Rate	$4.14
Rate for Payer: Cash Price	$2.78
Rate for Payer: Health Management Network Commercial	$3.63
Rate for Payer: MDX Hawaii PPO	$4.14

CARBIDOPA-LEVODOPA 10-100 MG PO TABLET

Facility

$4.27

Service Code	HCPCS A9270
Hospital Revenue Code	250
Min. Negotiated Rate	$2.18
Max. Negotiated Rate	$4.14
Rate for Payer: Cash Price	$2.78
Rate for Payer: Hawaii Western Management Group Commercial	$4.06
Rate for Payer: Health Management Network Commercial	$3.63
Rate for Payer: Kaiser Permanente Commercial	$2.69
Rate for Payer: Kaiser Permanente Medicaid	$2.18
Rate for Payer: MDX Hawaii PPO	$4.14
Rate for Payer: UnitedHealthcare Medicaid	$2.56
Rate for Payer: University Health Alliance Commercial	$3.11

CARBIDOPA-LEVODOPA 25-100 MG PO TABLET

Facility

$4.53

Service Code	HCPCS A9270
Hospital Revenue Code	250
Min. Negotiated Rate	$2.31
Max. Negotiated Rate	$4.39
Rate for Payer: Cash Price	$2.94
Rate for Payer: Hawaii Western Management Group Commercial	$4.30
Rate for Payer: Health Management Network Commercial	$3.85
Rate for Payer: Kaiser Permanente Commercial	$2.85
Rate for Payer: Kaiser Permanente Medicaid	$2.31
Rate for Payer: MDX Hawaii PPO	$4.39
Rate for Payer: UnitedHealthcare Medicaid	$2.72
Rate for Payer: University Health Alliance Commercial	$3.30

Know your out-of-pocket cost for care.

All Charges