Kona Community Hospital

All Charges

Charge

Type

Setting

Price

Stravix Pl Umbilical Tissue 2cm x 2cm PS61022 [3644845]

Facility

$4,643.00

Service Code	HCPCS Q4133
Hospital Charge Code	3644845
Hospital Revenue Code	278
Min. Negotiated Rate	$102.14
Max. Negotiated Rate	$4,503.71
Rate for Payer: AlohaCare Medicaid	$147.01
Rate for Payer: AlohaCare Medicare	$147.01
Rate for Payer: Cash Price	$3,017.95
Rate for Payer: Cash Price	$3,017.95
Rate for Payer: Devoted Health Medicare	$161.71
Rate for Payer: Hawaii Medical Service Association ABD	$136.18
Rate for Payer: Hawaii Medical Service Association Commercial	$183.76
Rate for Payer: Hawaii Medical Service Association Medicare	$147.01
Rate for Payer: Hawaii Medical Service Association Non-ABD	$136.18
Rate for Payer: Hawaii Western Management Group Commercial	$3,250.10
Rate for Payer: Health Management Network Commercial	$3,946.55
Rate for Payer: Humana Medicare	$147.01
Rate for Payer: Kaiser Permanente Commercial	$2,925.09
Rate for Payer: Kaiser Permanente Medicaid	$2,367.93
Rate for Payer: Kaiser Permanente Medicare	$147.01
Rate for Payer: MDX Hawaii PPO	$4,503.71
Rate for Payer: Ohana Health Plan Medicaid	$161.71
Rate for Payer: Ohana Health Plan Medicare	$147.01
Rate for Payer: UnitedHealthcare Medicaid	$102.14
Rate for Payer: UnitedHealthcare Medicare	$147.01
Rate for Payer: University Health Alliance Commercial	$2,600.08

Stravix Pl Umbilical Tissue 2cm x 2cm PS61022 [3644845]

Facility

$4,643.00

Service Code	HCPCS Q4133
Hospital Charge Code	3644845
Hospital Revenue Code	278
Min. Negotiated Rate	$2,600.08
Max. Negotiated Rate	$4,503.71
Rate for Payer: Cash Price	$3,017.95
Rate for Payer: Hawaii Western Management Group Commercial	$3,250.10
Rate for Payer: Health Management Network Commercial	$3,946.55
Rate for Payer: MDX Hawaii PPO	$4,503.71
Rate for Payer: University Health Alliance Commercial	$2,600.08

Stravix Pl Umbilical Tissue 2cm x 4cm PS61024 [3644844]

Facility

$7,820.50

Service Code	HCPCS Q4133
Hospital Charge Code	3644844
Hospital Revenue Code	278
Min. Negotiated Rate	$4,379.48
Max. Negotiated Rate	$7,585.89
Rate for Payer: Cash Price	$5,083.32
Rate for Payer: Hawaii Western Management Group Commercial	$5,474.35
Rate for Payer: Health Management Network Commercial	$6,647.43
Rate for Payer: MDX Hawaii PPO	$7,585.89
Rate for Payer: University Health Alliance Commercial	$4,379.48

Stravix Pl Umbilical Tissue 2cm x 4cm PS61024 [3644844]

Facility

$7,820.50

Service Code	HCPCS Q4133
Hospital Charge Code	3644844
Hospital Revenue Code	278
Min. Negotiated Rate	$102.14
Max. Negotiated Rate	$7,585.89
Rate for Payer: AlohaCare Medicaid	$147.01
Rate for Payer: AlohaCare Medicare	$147.01
Rate for Payer: Cash Price	$5,083.32
Rate for Payer: Cash Price	$5,083.32
Rate for Payer: Devoted Health Medicare	$161.71
Rate for Payer: Hawaii Medical Service Association ABD	$136.18
Rate for Payer: Hawaii Medical Service Association Commercial	$183.76
Rate for Payer: Hawaii Medical Service Association Medicare	$147.01
Rate for Payer: Hawaii Medical Service Association Non-ABD	$136.18
Rate for Payer: Hawaii Western Management Group Commercial	$5,474.35
Rate for Payer: Health Management Network Commercial	$6,647.43
Rate for Payer: Humana Medicare	$147.01
Rate for Payer: Kaiser Permanente Commercial	$4,926.91
Rate for Payer: Kaiser Permanente Medicaid	$3,988.45
Rate for Payer: Kaiser Permanente Medicare	$147.01
Rate for Payer: MDX Hawaii PPO	$7,585.89
Rate for Payer: Ohana Health Plan Medicaid	$161.71
Rate for Payer: Ohana Health Plan Medicare	$147.01
Rate for Payer: UnitedHealthcare Medicaid	$102.14
Rate for Payer: UnitedHealthcare Medicare	$147.01
Rate for Payer: University Health Alliance Commercial	$4,379.48

Stryker Neptune 3 Smoke Evac Pencil w/tube 703047 [3641844]

Facility

$241.50

Hospital Charge Code	3641844
Hospital Revenue Code	272
Min. Negotiated Rate	$205.28
Max. Negotiated Rate	$234.25
Rate for Payer: Cash Price	$156.98
Rate for Payer: Health Management Network Commercial	$205.28
Rate for Payer: MDX Hawaii PPO	$234.25

Stryker Neptune 3 Smoke Evac Pencil w/tube 703047 [3641844]

Facility

$241.50

Hospital Charge Code	3641844
Hospital Revenue Code	272
Min. Negotiated Rate	$123.17
Max. Negotiated Rate	$234.25
Rate for Payer: Cash Price	$156.98
Rate for Payer: Hawaii Western Management Group Commercial	$229.43
Rate for Payer: Health Management Network Commercial	$205.28
Rate for Payer: Kaiser Permanente Commercial	$152.15
Rate for Payer: Kaiser Permanente Medicaid	$123.17
Rate for Payer: MDX Hawaii PPO	$234.25
Rate for Payer: University Health Alliance Commercial	$176.03

SUCCINYLCHOLINE CHLORIDE 200 MG/10 ML (20 MG/ML) IV SYR

Facility

$158.72

Service Code	HCPCS J0330
Hospital Revenue Code	250
Min. Negotiated Rate	$134.91
Max. Negotiated Rate	$153.96
Rate for Payer: Cash Price	$103.17
Rate for Payer: Cash Price	$96.66
Rate for Payer: Health Management Network Commercial	$126.39
Rate for Payer: Health Management Network Commercial	$134.91
Rate for Payer: MDX Hawaii PPO	$153.96
Rate for Payer: MDX Hawaii PPO	$144.24

SUCCINYLCHOLINE CHLORIDE 200 MG/10 ML (20 MG/ML) IV SYR

Facility

$148.70

Service Code	HCPCS J0330
Hospital Revenue Code	636
Min. Negotiated Rate	$0.16
Max. Negotiated Rate	$144.24
Rate for Payer: Cash Price	$96.66
Rate for Payer: Cash Price	$96.66
Rate for Payer: Cash Price	$103.17
Rate for Payer: Cash Price	$103.17
Rate for Payer: Hawaii Medical Service Association ABD	$0.16
Rate for Payer: Hawaii Medical Service Association ABD	$0.16
Rate for Payer: Hawaii Medical Service Association Non-ABD	$0.16
Rate for Payer: Hawaii Medical Service Association Non-ABD	$0.16
Rate for Payer: Hawaii Western Management Group Commercial	$141.26
Rate for Payer: Hawaii Western Management Group Commercial	$150.78
Rate for Payer: Health Management Network Commercial	$134.91
Rate for Payer: Health Management Network Commercial	$126.39
Rate for Payer: Kaiser Permanente Commercial	$99.99
Rate for Payer: Kaiser Permanente Commercial	$93.68
Rate for Payer: Kaiser Permanente Medicaid	$75.84
Rate for Payer: Kaiser Permanente Medicaid	$80.95
Rate for Payer: MDX Hawaii PPO	$153.96
Rate for Payer: MDX Hawaii PPO	$144.24
Rate for Payer: UnitedHealthcare Medicaid	$89.22
Rate for Payer: UnitedHealthcare Medicaid	$95.23
Rate for Payer: University Health Alliance Commercial	$115.69
Rate for Payer: University Health Alliance Commercial	$108.39

SUCCINYLCHOLINE CHLORIDE 20 MG/ML INJ SOLN

Facility

$61.01

Service Code	HCPCS J0330
Hospital Revenue Code	636
Min. Negotiated Rate	$0.16
Max. Negotiated Rate	$59.18
Rate for Payer: Cash Price	$39.66
Rate for Payer: Cash Price	$29.82
Rate for Payer: Cash Price	$29.82
Rate for Payer: Cash Price	$39.66
Rate for Payer: Hawaii Medical Service Association ABD	$0.16
Rate for Payer: Hawaii Medical Service Association ABD	$0.16
Rate for Payer: Hawaii Medical Service Association Non-ABD	$0.16
Rate for Payer: Hawaii Medical Service Association Non-ABD	$0.16
Rate for Payer: Hawaii Western Management Group Commercial	$43.58
Rate for Payer: Hawaii Western Management Group Commercial	$57.96
Rate for Payer: Health Management Network Commercial	$51.86
Rate for Payer: Health Management Network Commercial	$38.99
Rate for Payer: Kaiser Permanente Commercial	$38.44
Rate for Payer: Kaiser Permanente Commercial	$28.90
Rate for Payer: Kaiser Permanente Medicaid	$23.39
Rate for Payer: Kaiser Permanente Medicaid	$31.12
Rate for Payer: MDX Hawaii PPO	$44.49
Rate for Payer: MDX Hawaii PPO	$59.18
Rate for Payer: UnitedHealthcare Medicaid	$36.61
Rate for Payer: UnitedHealthcare Medicaid	$27.52
Rate for Payer: University Health Alliance Commercial	$44.47
Rate for Payer: University Health Alliance Commercial	$33.43

SUCCINYLCHOLINE CHLORIDE 20 MG/ML INJ SOLN

Facility

$45.87

Service Code	HCPCS J0330
Hospital Revenue Code	250
Min. Negotiated Rate	$38.99
Max. Negotiated Rate	$44.49
Rate for Payer: Cash Price	$29.82
Rate for Payer: Cash Price	$39.66
Rate for Payer: Health Management Network Commercial	$38.99
Rate for Payer: Health Management Network Commercial	$51.86
Rate for Payer: MDX Hawaii PPO	$44.49
Rate for Payer: MDX Hawaii PPO	$59.18

SUCCINYLCHOLINE-SOD CL,ISO(PF) 100 MG/5 ML (20 MG/ML) IV SYR

Facility

$121.50

Service Code	HCPCS J0330
Hospital Revenue Code	636
Min. Negotiated Rate	$0.16
Max. Negotiated Rate	$117.86
Rate for Payer: Cash Price	$78.98
Rate for Payer: Cash Price	$78.98
Rate for Payer: Hawaii Medical Service Association ABD	$0.16
Rate for Payer: Hawaii Medical Service Association Non-ABD	$0.16
Rate for Payer: Hawaii Western Management Group Commercial	$115.42
Rate for Payer: Health Management Network Commercial	$103.28
Rate for Payer: Kaiser Permanente Commercial	$76.55
Rate for Payer: Kaiser Permanente Medicaid	$61.97
Rate for Payer: MDX Hawaii PPO	$117.86
Rate for Payer: UnitedHealthcare Medicaid	$72.90
Rate for Payer: University Health Alliance Commercial	$88.56

SUCCINYLCHOLINE-SOD CL,ISO(PF) 100 MG/5 ML (20 MG/ML) IV SYR

Facility

$121.50

Service Code	HCPCS J0330
Hospital Revenue Code	250
Min. Negotiated Rate	$103.28
Max. Negotiated Rate	$117.86
Rate for Payer: Cash Price	$78.98
Rate for Payer: Health Management Network Commercial	$103.28
Rate for Payer: MDX Hawaii PPO	$117.86

SUCCINYLCHOLINE-SOD CL,ISO(PF) 200 MG/10 ML (20 MG/ML) IV SYR

Facility

$116.12

Service Code	HCPCS J0330
Hospital Revenue Code	636
Min. Negotiated Rate	$0.16
Max. Negotiated Rate	$112.64
Rate for Payer: Cash Price	$75.48
Rate for Payer: Cash Price	$75.48
Rate for Payer: Hawaii Medical Service Association ABD	$0.16
Rate for Payer: Hawaii Medical Service Association Non-ABD	$0.16
Rate for Payer: Hawaii Western Management Group Commercial	$110.31
Rate for Payer: Health Management Network Commercial	$98.70
Rate for Payer: Kaiser Permanente Commercial	$73.16
Rate for Payer: Kaiser Permanente Medicaid	$59.22
Rate for Payer: MDX Hawaii PPO	$112.64
Rate for Payer: UnitedHealthcare Medicaid	$69.67
Rate for Payer: University Health Alliance Commercial	$84.64

SUCCINYLCHOLINE-SOD CL,ISO(PF) 200 MG/10 ML (20 MG/ML) IV SYR

Facility

$116.12

Service Code	HCPCS J0330
Hospital Revenue Code	250
Min. Negotiated Rate	$98.70
Max. Negotiated Rate	$112.64
Rate for Payer: Cash Price	$75.48
Rate for Payer: Health Management Network Commercial	$98.70
Rate for Payer: MDX Hawaii PPO	$112.64

SUCRALFATE 100 MG/ML PO SUSP

Facility

$62.32

Service Code	HCPCS A9270
Hospital Revenue Code	250
Min. Negotiated Rate	$52.97
Max. Negotiated Rate	$60.45
Rate for Payer: Cash Price	$40.51
Rate for Payer: Cash Price	$44.14
Rate for Payer: Health Management Network Commercial	$57.72
Rate for Payer: Health Management Network Commercial	$52.97
Rate for Payer: MDX Hawaii PPO	$65.86
Rate for Payer: MDX Hawaii PPO	$60.45

SUCRALFATE 100 MG/ML PO SUSP

Facility

$67.90

Service Code	HCPCS A9270
Hospital Revenue Code	250
Min. Negotiated Rate	$34.63
Max. Negotiated Rate	$65.86
Rate for Payer: Cash Price	$44.14
Rate for Payer: Cash Price	$40.51
Rate for Payer: Hawaii Western Management Group Commercial	$59.20
Rate for Payer: Hawaii Western Management Group Commercial	$64.50
Rate for Payer: Health Management Network Commercial	$52.97
Rate for Payer: Health Management Network Commercial	$57.72
Rate for Payer: Kaiser Permanente Commercial	$39.26
Rate for Payer: Kaiser Permanente Commercial	$42.78
Rate for Payer: Kaiser Permanente Medicaid	$34.63
Rate for Payer: Kaiser Permanente Medicaid	$31.78
Rate for Payer: MDX Hawaii PPO	$60.45
Rate for Payer: MDX Hawaii PPO	$65.86
Rate for Payer: UnitedHealthcare Medicaid	$37.39
Rate for Payer: UnitedHealthcare Medicaid	$40.74
Rate for Payer: University Health Alliance Commercial	$49.49
Rate for Payer: University Health Alliance Commercial	$45.43

SUCRALFATE 1 GRAM PO TABLET

Facility

$2.10

Service Code	HCPCS A9270
Hospital Revenue Code	250
Min. Negotiated Rate	$1.78
Max. Negotiated Rate	$2.04
Rate for Payer: Cash Price	$1.37
Rate for Payer: Cash Price	$2.55
Rate for Payer: Health Management Network Commercial	$3.33
Rate for Payer: Health Management Network Commercial	$1.78
Rate for Payer: MDX Hawaii PPO	$3.80
Rate for Payer: MDX Hawaii PPO	$2.04

SUCRALFATE 1 GRAM PO TABLET

Facility

$2.10

Service Code	HCPCS A9270
Hospital Revenue Code	250
Min. Negotiated Rate	$1.07
Max. Negotiated Rate	$2.04
Rate for Payer: Cash Price	$1.37
Rate for Payer: Cash Price	$2.55
Rate for Payer: Hawaii Western Management Group Commercial	$2.00
Rate for Payer: Hawaii Western Management Group Commercial	$3.72
Rate for Payer: Health Management Network Commercial	$3.33
Rate for Payer: Health Management Network Commercial	$1.78
Rate for Payer: Kaiser Permanente Commercial	$1.32
Rate for Payer: Kaiser Permanente Commercial	$2.47
Rate for Payer: Kaiser Permanente Medicaid	$2.00
Rate for Payer: Kaiser Permanente Medicaid	$1.07
Rate for Payer: MDX Hawaii PPO	$3.80
Rate for Payer: MDX Hawaii PPO	$2.04
Rate for Payer: UnitedHealthcare Medicaid	$1.26
Rate for Payer: UnitedHealthcare Medicaid	$2.35
Rate for Payer: University Health Alliance Commercial	$2.86
Rate for Payer: University Health Alliance Commercial	$1.53

Suction/Irrig Pulsavac Plus Fan Kit 00515047500 [3642856]

Facility

$302.25

Hospital Charge Code	3642856
Hospital Revenue Code	272
Min. Negotiated Rate	$154.15
Max. Negotiated Rate	$293.18
Rate for Payer: Cash Price	$196.46
Rate for Payer: Hawaii Western Management Group Commercial	$287.14
Rate for Payer: Health Management Network Commercial	$256.91
Rate for Payer: Kaiser Permanente Commercial	$190.42
Rate for Payer: Kaiser Permanente Medicaid	$154.15
Rate for Payer: MDX Hawaii PPO	$293.18
Rate for Payer: University Health Alliance Commercial	$220.31

Suction/Irrig Pulsavac Plus Fan Kit 00515047500 [3642856]

Facility

$302.25

Hospital Charge Code	3642856
Hospital Revenue Code	272
Min. Negotiated Rate	$256.91
Max. Negotiated Rate	$293.18
Rate for Payer: Cash Price	$196.46
Rate for Payer: Health Management Network Commercial	$256.91
Rate for Payer: MDX Hawaii PPO	$293.18

Suction/Irrig Simpulse 067700 [3607118]

Facility

$272.89

Hospital Charge Code	3607118
Hospital Revenue Code	272
Min. Negotiated Rate	$139.17
Max. Negotiated Rate	$264.70
Rate for Payer: Cash Price	$177.38
Rate for Payer: Hawaii Western Management Group Commercial	$259.25
Rate for Payer: Health Management Network Commercial	$231.96
Rate for Payer: Kaiser Permanente Commercial	$171.92
Rate for Payer: Kaiser Permanente Medicaid	$139.17
Rate for Payer: MDX Hawaii PPO	$264.70
Rate for Payer: University Health Alliance Commercial	$198.91

Suction/Irrig Simpulse 067700 [3607118]

Facility

$272.89

Hospital Charge Code	3607118
Hospital Revenue Code	272
Min. Negotiated Rate	$231.96
Max. Negotiated Rate	$264.70
Rate for Payer: Cash Price	$177.38
Rate for Payer: Health Management Network Commercial	$231.96
Rate for Payer: MDX Hawaii PPO	$264.70

Suction/Irrig Simpulse Femoral Canal Tip 0067740 [3642435]

Facility

$221.45

Hospital Charge Code	3642435
Hospital Revenue Code	272
Min. Negotiated Rate	$112.94
Max. Negotiated Rate	$214.81
Rate for Payer: Cash Price	$143.94
Rate for Payer: Hawaii Western Management Group Commercial	$210.38
Rate for Payer: Health Management Network Commercial	$188.23
Rate for Payer: Kaiser Permanente Commercial	$139.51
Rate for Payer: Kaiser Permanente Medicaid	$112.94
Rate for Payer: MDX Hawaii PPO	$214.81
Rate for Payer: University Health Alliance Commercial	$161.41

Suction/Irrig Simpulse Femoral Canal Tip 0067740 [3642435]

Facility

$221.45

Hospital Charge Code	3642435
Hospital Revenue Code	272
Min. Negotiated Rate	$188.23
Max. Negotiated Rate	$214.81
Rate for Payer: Cash Price	$143.94
Rate for Payer: Health Management Network Commercial	$188.23
Rate for Payer: MDX Hawaii PPO	$214.81

SUGAMMADEX 100 MG/ML IV SOLN

Facility

$522.63

Service Code	HCPCS J3490
Hospital Revenue Code	636
Min. Negotiated Rate	$266.54
Max. Negotiated Rate	$506.95
Rate for Payer: Cash Price	$339.71
Rate for Payer: Hawaii Western Management Group Commercial	$496.50
Rate for Payer: Health Management Network Commercial	$444.24
Rate for Payer: Kaiser Permanente Commercial	$329.26
Rate for Payer: Kaiser Permanente Medicaid	$266.54
Rate for Payer: MDX Hawaii PPO	$506.95
Rate for Payer: UnitedHealthcare Medicaid	$313.58
Rate for Payer: University Health Alliance Commercial	$380.95

Know your out-of-pocket cost for care.

All Charges