Kona Community Hospital

All Charges

Charge

Type

Setting

Price

ACETAMINOPHEN 1,000 MG/100 ML (10 MG/ML) IV SOLN

Facility

$56.03

Service Code	HCPCS J0134
Hospital Revenue Code	636
Min. Negotiated Rate	$0.06
Max. Negotiated Rate	$54.35
Rate for Payer: Cash Price	$36.42
Rate for Payer: Cash Price	$36.42
Rate for Payer: Hawaii Medical Service Association ABD	$0.06
Rate for Payer: Hawaii Medical Service Association Non-ABD	$0.06
Rate for Payer: Hawaii Western Management Group Commercial	$53.23
Rate for Payer: Health Management Network Commercial	$47.63
Rate for Payer: Kaiser Permanente Commercial	$35.30
Rate for Payer: Kaiser Permanente Medicaid	$28.58
Rate for Payer: MDX Hawaii PPO	$54.35
Rate for Payer: UnitedHealthcare Medicaid	$33.62
Rate for Payer: University Health Alliance Commercial	$40.84

ACETAMINOPHEN 1,000 MG/100 ML (10 MG/ML) IV SOLN

Facility

$56.03

Service Code	HCPCS J0134
Hospital Revenue Code	250
Min. Negotiated Rate	$47.63
Max. Negotiated Rate	$54.35
Rate for Payer: Cash Price	$36.42
Rate for Payer: Health Management Network Commercial	$47.63
Rate for Payer: MDX Hawaii PPO	$54.35

ACETAMINOPHEN 1,000 MG/100 ML (10 MG/ML) IV SOLN

Facility

$55.55

Service Code	HCPCS J0131
Hospital Revenue Code	250
Min. Negotiated Rate	$47.22
Max. Negotiated Rate	$53.88
Rate for Payer: Cash Price	$36.11
Rate for Payer: Health Management Network Commercial	$47.22
Rate for Payer: MDX Hawaii PPO	$53.88

ACETAMINOPHEN 1,000 MG/100 ML (10 MG/ML) IV SOLN

Facility

$55.55

Service Code	HCPCS J0131
Hospital Revenue Code	636
Min. Negotiated Rate	$0.05
Max. Negotiated Rate	$53.88
Rate for Payer: Cash Price	$36.11
Rate for Payer: Cash Price	$36.11
Rate for Payer: Hawaii Medical Service Association ABD	$0.05
Rate for Payer: Hawaii Medical Service Association Non-ABD	$0.05
Rate for Payer: Hawaii Western Management Group Commercial	$52.77
Rate for Payer: Health Management Network Commercial	$47.22
Rate for Payer: Kaiser Permanente Commercial	$35.00
Rate for Payer: Kaiser Permanente Medicaid	$28.33
Rate for Payer: MDX Hawaii PPO	$53.88
Rate for Payer: UnitedHealthcare Medicaid	$33.33
Rate for Payer: University Health Alliance Commercial	$40.49

ACETAMINOPHEN 120 MG PR SUPP

Facility

$1.71

Service Code	HCPCS A9270
Hospital Revenue Code	250
Min. Negotiated Rate	$0.87
Max. Negotiated Rate	$1.66
Rate for Payer: Cash Price	$1.11
Rate for Payer: Cash Price	$0.78
Rate for Payer: Cash Price	$3.35
Rate for Payer: Hawaii Western Management Group Commercial	$4.90
Rate for Payer: Hawaii Western Management Group Commercial	$1.62
Rate for Payer: Hawaii Western Management Group Commercial	$1.14
Rate for Payer: Health Management Network Commercial	$1.02
Rate for Payer: Health Management Network Commercial	$1.45
Rate for Payer: Health Management Network Commercial	$4.39
Rate for Payer: Kaiser Permanente Commercial	$0.76
Rate for Payer: Kaiser Permanente Commercial	$1.08
Rate for Payer: Kaiser Permanente Commercial	$3.25
Rate for Payer: Kaiser Permanente Medicaid	$0.61
Rate for Payer: Kaiser Permanente Medicaid	$0.87
Rate for Payer: Kaiser Permanente Medicaid	$2.63
Rate for Payer: MDX Hawaii PPO	$1.16
Rate for Payer: MDX Hawaii PPO	$1.66
Rate for Payer: MDX Hawaii PPO	$5.01
Rate for Payer: UnitedHealthcare Medicaid	$1.03
Rate for Payer: UnitedHealthcare Medicaid	$3.10
Rate for Payer: UnitedHealthcare Medicaid	$0.72
Rate for Payer: University Health Alliance Commercial	$3.76
Rate for Payer: University Health Alliance Commercial	$0.87
Rate for Payer: University Health Alliance Commercial	$1.25

ACETAMINOPHEN 120 MG PR SUPP

Facility

$1.71

Service Code	HCPCS A9270
Hospital Revenue Code	250
Min. Negotiated Rate	$1.45
Max. Negotiated Rate	$1.66
Rate for Payer: Cash Price	$1.11
Rate for Payer: Cash Price	$0.78
Rate for Payer: Cash Price	$3.35
Rate for Payer: Health Management Network Commercial	$1.45
Rate for Payer: Health Management Network Commercial	$1.02
Rate for Payer: Health Management Network Commercial	$4.39
Rate for Payer: MDX Hawaii PPO	$1.16
Rate for Payer: MDX Hawaii PPO	$5.01
Rate for Payer: MDX Hawaii PPO	$1.66

ACETAMINOPHEN 160 MG/5 ML (5 ML) PO SUSP

Facility

$5.97

Service Code	HCPCS A9270
Hospital Revenue Code	250
Min. Negotiated Rate	$3.04
Max. Negotiated Rate	$5.79
Rate for Payer: Cash Price	$3.88
Rate for Payer: Cash Price	$4.99
Rate for Payer: Hawaii Western Management Group Commercial	$5.67
Rate for Payer: Hawaii Western Management Group Commercial	$7.30
Rate for Payer: Health Management Network Commercial	$6.53
Rate for Payer: Health Management Network Commercial	$5.07
Rate for Payer: Kaiser Permanente Commercial	$3.76
Rate for Payer: Kaiser Permanente Commercial	$4.84
Rate for Payer: Kaiser Permanente Medicaid	$3.92
Rate for Payer: Kaiser Permanente Medicaid	$3.04
Rate for Payer: MDX Hawaii PPO	$7.45
Rate for Payer: MDX Hawaii PPO	$5.79
Rate for Payer: UnitedHealthcare Medicaid	$3.58
Rate for Payer: UnitedHealthcare Medicaid	$4.61
Rate for Payer: University Health Alliance Commercial	$5.60
Rate for Payer: University Health Alliance Commercial	$4.35

ACETAMINOPHEN 160 MG/5 ML (5 ML) PO SUSP

Facility

$5.97

Service Code	HCPCS A9270
Hospital Revenue Code	250
Min. Negotiated Rate	$5.07
Max. Negotiated Rate	$5.79
Rate for Payer: Cash Price	$3.88
Rate for Payer: Cash Price	$4.99
Rate for Payer: Health Management Network Commercial	$6.53
Rate for Payer: Health Management Network Commercial	$5.07
Rate for Payer: MDX Hawaii PPO	$7.45
Rate for Payer: MDX Hawaii PPO	$5.79

ACETAMINOPHEN 160 MG/5 ML PO SUSP

Facility

$28.32

Service Code	HCPCS A9270
Hospital Revenue Code	250
Min. Negotiated Rate	$14.44
Max. Negotiated Rate	$27.47
Rate for Payer: Cash Price	$18.41
Rate for Payer: Hawaii Western Management Group Commercial	$26.90
Rate for Payer: Health Management Network Commercial	$24.07
Rate for Payer: Kaiser Permanente Commercial	$17.84
Rate for Payer: Kaiser Permanente Medicaid	$14.44
Rate for Payer: MDX Hawaii PPO	$27.47
Rate for Payer: UnitedHealthcare Medicaid	$16.99
Rate for Payer: University Health Alliance Commercial	$20.64

ACETAMINOPHEN 160 MG/5 ML PO SUSP

Facility

$28.32

Service Code	HCPCS A9270
Hospital Revenue Code	250
Min. Negotiated Rate	$24.07
Max. Negotiated Rate	$27.47
Rate for Payer: Cash Price	$18.41
Rate for Payer: Health Management Network Commercial	$24.07
Rate for Payer: MDX Hawaii PPO	$27.47

ACETAMINOPHEN 325 MG PO TABLET

Facility

$1.20

Service Code	HCPCS A9270
Hospital Revenue Code	250
Min. Negotiated Rate	$0.61
Max. Negotiated Rate	$1.16
Rate for Payer: Cash Price	$0.78
Rate for Payer: Hawaii Western Management Group Commercial	$1.14
Rate for Payer: Health Management Network Commercial	$1.02
Rate for Payer: Kaiser Permanente Commercial	$0.76
Rate for Payer: Kaiser Permanente Medicaid	$0.61
Rate for Payer: MDX Hawaii PPO	$1.16
Rate for Payer: UnitedHealthcare Medicaid	$0.72
Rate for Payer: University Health Alliance Commercial	$0.87

ACETAMINOPHEN 325 MG PO TABLET

Facility

$1.20

Service Code	HCPCS A9270
Hospital Revenue Code	250
Min. Negotiated Rate	$1.02
Max. Negotiated Rate	$1.16
Rate for Payer: Cash Price	$0.78
Rate for Payer: Health Management Network Commercial	$1.02
Rate for Payer: MDX Hawaii PPO	$1.16

ACETAMINOPHEN 325 MG PR SUPP

Facility

$5.62

Service Code	HCPCS A9270
Hospital Revenue Code	250
Min. Negotiated Rate	$2.87
Max. Negotiated Rate	$5.45
Rate for Payer: Cash Price	$3.65
Rate for Payer: Hawaii Western Management Group Commercial	$5.34
Rate for Payer: Health Management Network Commercial	$4.78
Rate for Payer: Kaiser Permanente Commercial	$3.54
Rate for Payer: Kaiser Permanente Medicaid	$2.87
Rate for Payer: MDX Hawaii PPO	$5.45
Rate for Payer: UnitedHealthcare Medicaid	$3.37
Rate for Payer: University Health Alliance Commercial	$4.10

ACETAMINOPHEN 325 MG PR SUPP

Facility

$5.62

Service Code	HCPCS A9270
Hospital Revenue Code	250
Min. Negotiated Rate	$4.78
Max. Negotiated Rate	$5.45
Rate for Payer: Cash Price	$3.65
Rate for Payer: Health Management Network Commercial	$4.78
Rate for Payer: MDX Hawaii PPO	$5.45

ACETAMINOPHEN 500 MG PO TABLET

Facility

$1.20

Service Code	HCPCS A9270
Hospital Revenue Code	250
Min. Negotiated Rate	$1.02
Max. Negotiated Rate	$1.16
Rate for Payer: Cash Price	$0.78
Rate for Payer: Health Management Network Commercial	$1.02
Rate for Payer: MDX Hawaii PPO	$1.16

ACETAMINOPHEN 500 MG PO TABLET

Facility

$1.20

Service Code	HCPCS A9270
Hospital Revenue Code	250
Min. Negotiated Rate	$0.61
Max. Negotiated Rate	$1.16
Rate for Payer: Cash Price	$0.78
Rate for Payer: Hawaii Western Management Group Commercial	$1.14
Rate for Payer: Health Management Network Commercial	$1.02
Rate for Payer: Kaiser Permanente Commercial	$0.76
Rate for Payer: Kaiser Permanente Medicaid	$0.61
Rate for Payer: MDX Hawaii PPO	$1.16
Rate for Payer: UnitedHealthcare Medicaid	$0.72
Rate for Payer: University Health Alliance Commercial	$0.87

ACETAMINOPHEN 650 MG PR SUPP

Facility

$3.68

Service Code	HCPCS A9270
Hospital Revenue Code	250
Min. Negotiated Rate	$3.13
Max. Negotiated Rate	$3.57
Rate for Payer: Cash Price	$2.39
Rate for Payer: Health Management Network Commercial	$3.13
Rate for Payer: MDX Hawaii PPO	$3.57

ACETAMINOPHEN 650 MG PR SUPP

Facility

$3.68

Service Code	HCPCS A9270
Hospital Revenue Code	250
Min. Negotiated Rate	$1.88
Max. Negotiated Rate	$3.57
Rate for Payer: Cash Price	$2.39
Rate for Payer: Hawaii Western Management Group Commercial	$3.50
Rate for Payer: Health Management Network Commercial	$3.13
Rate for Payer: Kaiser Permanente Commercial	$2.32
Rate for Payer: Kaiser Permanente Medicaid	$1.88
Rate for Payer: MDX Hawaii PPO	$3.57
Rate for Payer: UnitedHealthcare Medicaid	$2.21
Rate for Payer: University Health Alliance Commercial	$2.68

ACETAMINOPHEN-CAFFEINE 500-65 MG PO TABLET

Facility

$1.75

Service Code	HCPCS A9270
Hospital Revenue Code	250
Min. Negotiated Rate	$1.49
Max. Negotiated Rate	$1.70
Rate for Payer: Cash Price	$1.14
Rate for Payer: Health Management Network Commercial	$1.49
Rate for Payer: MDX Hawaii PPO	$1.70

ACETAMINOPHEN-CAFFEINE 500-65 MG PO TABLET

Facility

$1.75

Service Code	HCPCS A9270
Hospital Revenue Code	250
Min. Negotiated Rate	$0.89
Max. Negotiated Rate	$1.70
Rate for Payer: Cash Price	$1.14
Rate for Payer: Hawaii Western Management Group Commercial	$1.66
Rate for Payer: Health Management Network Commercial	$1.49
Rate for Payer: Kaiser Permanente Commercial	$1.10
Rate for Payer: Kaiser Permanente Medicaid	$0.89
Rate for Payer: MDX Hawaii PPO	$1.70
Rate for Payer: UnitedHealthcare Medicaid	$1.05
Rate for Payer: University Health Alliance Commercial	$1.28

ACETAMINOPHEN-CODEINE 120-12 MG/5 ML PO SOLN

Facility

$2.21

Service Code	HCPCS A9270
Hospital Revenue Code	250
Min. Negotiated Rate	$1.88
Max. Negotiated Rate	$2.14
Rate for Payer: Cash Price	$1.44
Rate for Payer: Health Management Network Commercial	$1.88
Rate for Payer: MDX Hawaii PPO	$2.14

ACETAMINOPHEN-CODEINE 120-12 MG/5 ML PO SOLN

Facility

$2.21

Service Code	HCPCS A9270
Hospital Revenue Code	250
Min. Negotiated Rate	$1.13
Max. Negotiated Rate	$2.14
Rate for Payer: Cash Price	$1.44
Rate for Payer: Hawaii Western Management Group Commercial	$2.10
Rate for Payer: Health Management Network Commercial	$1.88
Rate for Payer: Kaiser Permanente Commercial	$1.39
Rate for Payer: Kaiser Permanente Medicaid	$1.13
Rate for Payer: MDX Hawaii PPO	$2.14
Rate for Payer: UnitedHealthcare Medicaid	$1.33
Rate for Payer: University Health Alliance Commercial	$1.61

ACETAMINOPHEN-CODEINE 120 MG-12 MG /5 ML (5 ML) PO SOLN

Facility

$56.68

Service Code	HCPCS A9270
Hospital Revenue Code	250
Min. Negotiated Rate	$48.18
Max. Negotiated Rate	$54.98
Rate for Payer: Cash Price	$36.84
Rate for Payer: Health Management Network Commercial	$48.18
Rate for Payer: MDX Hawaii PPO	$54.98

ACETAMINOPHEN-CODEINE 120 MG-12 MG /5 ML (5 ML) PO SOLN

Facility

$56.68

Service Code	HCPCS A9270
Hospital Revenue Code	250
Min. Negotiated Rate	$28.91
Max. Negotiated Rate	$54.98
Rate for Payer: Cash Price	$36.84
Rate for Payer: Hawaii Western Management Group Commercial	$53.85
Rate for Payer: Health Management Network Commercial	$48.18
Rate for Payer: Kaiser Permanente Commercial	$35.71
Rate for Payer: Kaiser Permanente Medicaid	$28.91
Rate for Payer: MDX Hawaii PPO	$54.98
Rate for Payer: UnitedHealthcare Medicaid	$34.01
Rate for Payer: University Health Alliance Commercial	$41.31

ACETAMINOPHEN-CODEINE 300-30 MG PO TABLET

Facility

$7.03

Service Code	HCPCS A9270
Hospital Revenue Code	250
Min. Negotiated Rate	$3.59
Max. Negotiated Rate	$6.82
Rate for Payer: Cash Price	$4.57
Rate for Payer: Cash Price	$5.12
Rate for Payer: Hawaii Western Management Group Commercial	$6.68
Rate for Payer: Hawaii Western Management Group Commercial	$7.49
Rate for Payer: Health Management Network Commercial	$5.98
Rate for Payer: Health Management Network Commercial	$6.70
Rate for Payer: Kaiser Permanente Commercial	$4.43
Rate for Payer: Kaiser Permanente Commercial	$4.96
Rate for Payer: Kaiser Permanente Medicaid	$3.59
Rate for Payer: Kaiser Permanente Medicaid	$4.02
Rate for Payer: MDX Hawaii PPO	$6.82
Rate for Payer: MDX Hawaii PPO	$7.64
Rate for Payer: UnitedHealthcare Medicaid	$4.73
Rate for Payer: UnitedHealthcare Medicaid	$4.22
Rate for Payer: University Health Alliance Commercial	$5.12
Rate for Payer: University Health Alliance Commercial	$5.74

Know your out-of-pocket cost for care.

All Charges