Kona Community Hospital

All Charges

Charge

Type

Setting

Price

TENOFOVIR DISOPROXIL FUMARATE 300 MG PO TABLET

Facility

$30.77

Service Code	HCPCS A9270
Hospital Revenue Code	250
Min. Negotiated Rate	$26.15
Max. Negotiated Rate	$29.85
Rate for Payer: Cash Price	$20.00
Rate for Payer: Health Management Network Commercial	$26.15
Rate for Payer: MDX Hawaii PPO	$29.85

TENOFOVIR DISOPROXIL FUMARATE 300 MG PO TABLET

Facility

$30.77

Service Code	HCPCS A9270
Hospital Revenue Code	250
Min. Negotiated Rate	$15.69
Max. Negotiated Rate	$29.85
Rate for Payer: Cash Price	$20.00
Rate for Payer: Hawaii Western Management Group Commercial	$29.23
Rate for Payer: Health Management Network Commercial	$26.15
Rate for Payer: Kaiser Permanente Commercial	$19.39
Rate for Payer: Kaiser Permanente Medicaid	$15.69
Rate for Payer: MDX Hawaii PPO	$29.85
Rate for Payer: UnitedHealthcare Medicaid	$18.46
Rate for Payer: University Health Alliance Commercial	$22.43

TENOLYSIS, FLEXOR OR EXTENSOR TENDON, LEG AND/OR ANKLE; SINGLE, EACH TENDON

Facility

$6,743.44

Service Code	CPT 27680
Hospital Revenue Code	360
Min. Negotiated Rate	$456.03
Max. Negotiated Rate	$6,743.44
Rate for Payer: AlohaCare Medicaid	$3,865.36
Rate for Payer: AlohaCare Medicare	$3,865.36
Rate for Payer: Devoted Health Medicare	$4,251.90
Rate for Payer: Hawaii Medical Service Association ABD	$695.00
Rate for Payer: Hawaii Medical Service Association Commercial	$6,183.00
Rate for Payer: Hawaii Medical Service Association Medicare	$3,865.36
Rate for Payer: Hawaii Medical Service Association Non-ABD	$700.72
Rate for Payer: Humana Medicare	$3,865.36
Rate for Payer: Kaiser Permanente Medicaid	$2,837.00
Rate for Payer: Kaiser Permanente Medicare	$3,865.36
Rate for Payer: Ohana Health Plan Medicaid	$4,251.90
Rate for Payer: Ohana Health Plan Medicare	$3,865.36
Rate for Payer: UnitedHealthcare Medicaid	$456.03
Rate for Payer: UnitedHealthcare Medicare	$3,865.36
Rate for Payer: University Health Alliance Commercial	$6,743.44

TERBINAFINE HCL 250 MG PO TABLET

Facility

$70.93

Service Code	HCPCS A9270
Hospital Revenue Code	250
Min. Negotiated Rate	$60.29
Max. Negotiated Rate	$68.80
Rate for Payer: Cash Price	$46.10
Rate for Payer: Health Management Network Commercial	$60.29
Rate for Payer: MDX Hawaii PPO	$68.80

TERBINAFINE HCL 250 MG PO TABLET

Facility

$70.93

Service Code	HCPCS A9270
Hospital Revenue Code	250
Min. Negotiated Rate	$36.17
Max. Negotiated Rate	$68.80
Rate for Payer: Cash Price	$46.10
Rate for Payer: Hawaii Western Management Group Commercial	$67.38
Rate for Payer: Health Management Network Commercial	$60.29
Rate for Payer: Kaiser Permanente Commercial	$44.69
Rate for Payer: Kaiser Permanente Medicaid	$36.17
Rate for Payer: MDX Hawaii PPO	$68.80
Rate for Payer: UnitedHealthcare Medicaid	$42.56
Rate for Payer: University Health Alliance Commercial	$51.70

TERBUTALINE 0.1 MG/ML INJ

Facility

$99.56

Service Code	NDC 63323066501
Hospital Revenue Code	250
Min. Negotiated Rate	$84.63
Max. Negotiated Rate	$96.57
Rate for Payer: Cash Price	$64.71
Rate for Payer: Health Management Network Commercial	$84.63
Rate for Payer: MDX Hawaii PPO	$96.57

TERBUTALINE 0.1 MG/ML INJ

Facility

$22.08

Service Code	NDC 00143974610
Hospital Revenue Code	250
Min. Negotiated Rate	$11.26
Max. Negotiated Rate	$21.42
Rate for Payer: Cash Price	$14.35
Rate for Payer: Hawaii Western Management Group Commercial	$20.98
Rate for Payer: Health Management Network Commercial	$18.77
Rate for Payer: Kaiser Permanente Commercial	$13.91
Rate for Payer: Kaiser Permanente Medicaid	$11.26
Rate for Payer: MDX Hawaii PPO	$21.42
Rate for Payer: UnitedHealthcare Medicaid	$13.25
Rate for Payer: University Health Alliance Commercial	$16.09

TERBUTALINE 0.1 MG/ML INJ

Facility

$99.56

Service Code	NDC 63323066501
Hospital Revenue Code	250
Min. Negotiated Rate	$50.78
Max. Negotiated Rate	$96.57
Rate for Payer: Cash Price	$64.71
Rate for Payer: Hawaii Western Management Group Commercial	$94.58
Rate for Payer: Health Management Network Commercial	$84.63
Rate for Payer: Kaiser Permanente Commercial	$62.72
Rate for Payer: Kaiser Permanente Medicaid	$50.78
Rate for Payer: MDX Hawaii PPO	$96.57
Rate for Payer: UnitedHealthcare Medicaid	$59.74
Rate for Payer: University Health Alliance Commercial	$72.57

TERBUTALINE 0.1 MG/ML INJ

Facility

$22.08

Service Code	NDC 00143974610
Hospital Revenue Code	250
Min. Negotiated Rate	$18.77
Max. Negotiated Rate	$21.42
Rate for Payer: Cash Price	$14.35
Rate for Payer: Health Management Network Commercial	$18.77
Rate for Payer: MDX Hawaii PPO	$21.42

TERBUTALINE 1 MG/ML SUBCUTANEOUS SOLN

Facility

$99.56

Service Code	HCPCS J3105
Hospital Revenue Code	636
Min. Negotiated Rate	$2.74
Max. Negotiated Rate	$96.57
Rate for Payer: Cash Price	$64.71
Rate for Payer: Cash Price	$14.35
Rate for Payer: Cash Price	$64.71
Rate for Payer: Cash Price	$14.35
Rate for Payer: Hawaii Medical Service Association ABD	$2.74
Rate for Payer: Hawaii Medical Service Association ABD	$2.74
Rate for Payer: Hawaii Medical Service Association Non-ABD	$2.74
Rate for Payer: Hawaii Medical Service Association Non-ABD	$2.74
Rate for Payer: Hawaii Western Management Group Commercial	$20.98
Rate for Payer: Hawaii Western Management Group Commercial	$94.58
Rate for Payer: Health Management Network Commercial	$84.63
Rate for Payer: Health Management Network Commercial	$18.77
Rate for Payer: Kaiser Permanente Commercial	$62.72
Rate for Payer: Kaiser Permanente Commercial	$13.91
Rate for Payer: Kaiser Permanente Medicaid	$11.26
Rate for Payer: Kaiser Permanente Medicaid	$50.78
Rate for Payer: MDX Hawaii PPO	$96.57
Rate for Payer: MDX Hawaii PPO	$21.42
Rate for Payer: UnitedHealthcare Medicaid	$13.25
Rate for Payer: UnitedHealthcare Medicaid	$59.74
Rate for Payer: University Health Alliance Commercial	$72.57
Rate for Payer: University Health Alliance Commercial	$16.09

TERBUTALINE 1 MG/ML SUBCUTANEOUS SOLN

Facility

$99.56

Service Code	HCPCS J3105
Hospital Revenue Code	250
Min. Negotiated Rate	$84.63
Max. Negotiated Rate	$96.57
Rate for Payer: Cash Price	$64.71
Rate for Payer: Cash Price	$14.35
Rate for Payer: Health Management Network Commercial	$18.77
Rate for Payer: Health Management Network Commercial	$84.63
Rate for Payer: MDX Hawaii PPO	$21.42
Rate for Payer: MDX Hawaii PPO	$96.57

Terumo Glidecath 4fr X 65cm CG415 [3644304]

Facility

$302.25

Service Code	HCPCS C1887
Hospital Charge Code	3644304
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

Terumo Glidecath 4fr X 65cm CG415 [3644304]

Facility

$302.25

Service Code	HCPCS C1887
Hospital Charge Code	3644304
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

TESTES PROCEDURES WITH CC/MCC

Facility

$52,770.22

Service Code	MSDRG 711
Min. Negotiated Rate	$27,407.74
Max. Negotiated Rate	$52,770.22
Rate for Payer: AlohaCare Medicare	$27,407.74
Rate for Payer: Devoted Health Medicare	$30,148.51
Rate for Payer: Hawaii Medical Service Association Commercial	$52,770.22
Rate for Payer: Hawaii Medical Service Association Medicare	$27,407.74
Rate for Payer: Humana Medicare	$27,407.74
Rate for Payer: Kaiser Permanente Commercial	$35,945.55
Rate for Payer: Kaiser Permanente Medicare	$27,407.74
Rate for Payer: Ohana Health Plan Medicare	$27,407.74
Rate for Payer: UnitedHealthcare Medicare	$27,407.74

TESTES PROCEDURES WITHOUT CC/MCC

Facility

$37,341.74

Service Code	MSDRG 712
Min. Negotiated Rate	$14,464.10
Max. Negotiated Rate	$37,341.74
Rate for Payer: AlohaCare Medicare	$14,464.10
Rate for Payer: Devoted Health Medicare	$15,910.51
Rate for Payer: Hawaii Medical Service Association Commercial	$37,341.74
Rate for Payer: Hawaii Medical Service Association Medicare	$14,464.10
Rate for Payer: Humana Medicare	$14,464.10
Rate for Payer: Kaiser Permanente Commercial	$18,969.83
Rate for Payer: Kaiser Permanente Medicare	$14,464.10
Rate for Payer: Ohana Health Plan Medicare	$14,464.10
Rate for Payer: UnitedHealthcare Medicare	$14,464.10

TETANUS AND DIPHTHER. TOX (PF) 5-2 LF UNIT/0.5 ML IM SYR

Facility

$186.69

Service Code	HCPCS 90714
Hospital Revenue Code	250
Min. Negotiated Rate	$33.48
Max. Negotiated Rate	$181.09
Rate for Payer: Cash Price	$121.35
Rate for Payer: Cash Price	$121.35
Rate for Payer: Cash Price	$121.36
Rate for Payer: Cash Price	$121.36
Rate for Payer: Hawaii Medical Service Association ABD	$33.48
Rate for Payer: Hawaii Medical Service Association ABD	$33.48
Rate for Payer: Hawaii Medical Service Association Non-ABD	$33.48
Rate for Payer: Hawaii Medical Service Association Non-ABD	$33.48
Rate for Payer: Hawaii Western Management Group Commercial	$177.36
Rate for Payer: Hawaii Western Management Group Commercial	$177.37
Rate for Payer: Health Management Network Commercial	$158.70
Rate for Payer: Health Management Network Commercial	$158.69
Rate for Payer: Kaiser Permanente Commercial	$117.63
Rate for Payer: Kaiser Permanente Commercial	$117.61
Rate for Payer: Kaiser Permanente Medicaid	$95.21
Rate for Payer: Kaiser Permanente Medicaid	$95.22
Rate for Payer: MDX Hawaii PPO	$181.11
Rate for Payer: MDX Hawaii PPO	$181.09
Rate for Payer: UnitedHealthcare Medicaid	$112.01
Rate for Payer: UnitedHealthcare Medicaid	$112.03
Rate for Payer: University Health Alliance Commercial	$136.09
Rate for Payer: University Health Alliance Commercial	$136.08

TETANUS AND DIPHTHER. TOX (PF) 5-2 LF UNIT/0.5 ML IM SYR

Facility

$186.71

Service Code	HCPCS 90714
Hospital Revenue Code	250
Min. Negotiated Rate	$158.70
Max. Negotiated Rate	$181.11
Rate for Payer: Cash Price	$121.36
Rate for Payer: Cash Price	$121.35
Rate for Payer: Health Management Network Commercial	$158.69
Rate for Payer: Health Management Network Commercial	$158.70
Rate for Payer: MDX Hawaii PPO	$181.11
Rate for Payer: MDX Hawaii PPO	$181.09

TETANUS IMMUNE GLOBULIN (PF) 250 UNIT IM SYR

Facility

$1,587.68

Service Code	HCPCS J1670
Hospital Revenue Code	636
Min. Negotiated Rate	$558.12
Max. Negotiated Rate	$1,540.05
Rate for Payer: AlohaCare Medicaid	$558.12
Rate for Payer: AlohaCare Medicare	$558.12
Rate for Payer: Cash Price	$1,031.99
Rate for Payer: Cash Price	$1,031.99
Rate for Payer: Devoted Health Medicare	$613.93
Rate for Payer: Hawaii Medical Service Association ABD	$577.05
Rate for Payer: Hawaii Medical Service Association Commercial	$697.65
Rate for Payer: Hawaii Medical Service Association Medicare	$558.12
Rate for Payer: Hawaii Medical Service Association Non-ABD	$577.05
Rate for Payer: Hawaii Western Management Group Commercial	$1,508.30
Rate for Payer: Health Management Network Commercial	$1,349.53
Rate for Payer: Humana Medicare	$558.12
Rate for Payer: Kaiser Permanente Commercial	$1,000.24
Rate for Payer: Kaiser Permanente Medicaid	$809.72
Rate for Payer: Kaiser Permanente Medicare	$558.12
Rate for Payer: MDX Hawaii PPO	$1,540.05
Rate for Payer: Ohana Health Plan Medicaid	$613.93
Rate for Payer: Ohana Health Plan Medicare	$558.12
Rate for Payer: UnitedHealthcare Medicaid	$952.61
Rate for Payer: UnitedHealthcare Medicare	$558.12
Rate for Payer: University Health Alliance Commercial	$1,157.26

TETANUS IMMUNE GLOBULIN (PF) 250 UNIT IM SYR

Facility

$1,587.68

Service Code	HCPCS J1670
Hospital Revenue Code	250
Min. Negotiated Rate	$1,349.53
Max. Negotiated Rate	$1,540.05
Rate for Payer: Cash Price	$1,031.99
Rate for Payer: Health Management Network Commercial	$1,349.53
Rate for Payer: MDX Hawaii PPO	$1,540.05

TETRACAINE HCL (PF) 0.5 % OPHT DROP

Facility

$75.47

Service Code	HCPCS A9270
Hospital Revenue Code	250
Min. Negotiated Rate	$38.49
Max. Negotiated Rate	$73.21
Rate for Payer: Cash Price	$49.06
Rate for Payer: Hawaii Western Management Group Commercial	$71.70
Rate for Payer: Health Management Network Commercial	$64.15
Rate for Payer: Kaiser Permanente Commercial	$47.55
Rate for Payer: Kaiser Permanente Medicaid	$38.49
Rate for Payer: MDX Hawaii PPO	$73.21
Rate for Payer: UnitedHealthcare Medicaid	$45.28
Rate for Payer: University Health Alliance Commercial	$55.01

TETRACAINE HCL (PF) 0.5 % OPHT DROP

Facility

$75.47

Service Code	HCPCS A9270
Hospital Revenue Code	250
Min. Negotiated Rate	$64.15
Max. Negotiated Rate	$73.21
Rate for Payer: Cash Price	$49.06
Rate for Payer: Health Management Network Commercial	$64.15
Rate for Payer: MDX Hawaii PPO	$73.21

Th Echo Bi-Metric Mp Fp Ho Fem Stem Sz 18 [3643671]

Facility

$13,750.00

Service Code	HCPCS C1776
Hospital Charge Code	3643671
Hospital Revenue Code	278
Min. Negotiated Rate	$7,012.50
Max. Negotiated Rate	$13,337.50
Rate for Payer: Cash Price	$8,937.50
Rate for Payer: Hawaii Western Management Group Commercial	$9,625.00
Rate for Payer: Health Management Network Commercial	$11,687.50
Rate for Payer: Kaiser Permanente Commercial	$8,662.50
Rate for Payer: Kaiser Permanente Medicaid	$7,012.50
Rate for Payer: MDX Hawaii PPO	$13,337.50
Rate for Payer: University Health Alliance Commercial	$7,700.00

Th Echo Bi-Metric Mp Fp Ho Fem Stem Sz 18 [3643671]

Facility

$13,750.00

Service Code	HCPCS C1776
Hospital Charge Code	3643671
Hospital Revenue Code	278
Min. Negotiated Rate	$7,700.00
Max. Negotiated Rate	$13,337.50
Rate for Payer: Cash Price	$8,937.50
Rate for Payer: Hawaii Western Management Group Commercial	$9,625.00
Rate for Payer: Health Management Network Commercial	$11,687.50
Rate for Payer: MDX Hawaii PPO	$13,337.50
Rate for Payer: University Health Alliance Commercial	$7,700.00

Th Echo Bi-Metric Mp Fp So Fem Stem Sz 8 [3643814]

Facility

$13,750.00

Service Code	HCPCS C1776
Hospital Charge Code	3643814
Hospital Revenue Code	278
Min. Negotiated Rate	$7,012.50
Max. Negotiated Rate	$13,337.50
Rate for Payer: Cash Price	$8,937.50
Rate for Payer: Hawaii Western Management Group Commercial	$9,625.00
Rate for Payer: Health Management Network Commercial	$11,687.50
Rate for Payer: Kaiser Permanente Commercial	$8,662.50
Rate for Payer: Kaiser Permanente Medicaid	$7,012.50
Rate for Payer: MDX Hawaii PPO	$13,337.50
Rate for Payer: University Health Alliance Commercial	$7,700.00

Th Echo Bi-Metric Mp Fp So Fem Stem Sz 8 [3643814]

Facility

$13,750.00

Service Code	HCPCS C1776
Hospital Charge Code	3643814
Hospital Revenue Code	278
Min. Negotiated Rate	$7,700.00
Max. Negotiated Rate	$13,337.50
Rate for Payer: Cash Price	$8,937.50
Rate for Payer: Hawaii Western Management Group Commercial	$9,625.00
Rate for Payer: Health Management Network Commercial	$11,687.50
Rate for Payer: MDX Hawaii PPO	$13,337.50
Rate for Payer: University Health Alliance Commercial	$7,700.00

Know your out-of-pocket cost for care.

All Charges