Kona Community Hospital

All Charges

Charge

Type

Setting

Price

THERAPEUTIC INJECTION IV PUSH EACH NEW DRUG

Professional

Both

$49.00

Service Code	HCPCS 96375
Min. Negotiated Rate	$10.14
Max. Negotiated Rate	$41.65
Rate for Payer: AlohaCare Medicaid	$10.14
Rate for Payer: AlohaCare Medicare	$17.21
Rate for Payer: Cash Price	$31.85
Rate for Payer: Cash Price	$31.85
Rate for Payer: Devoted Health Medicare	$18.93
Rate for Payer: Hawaii Medical Service Association Medicare	$17.21
Rate for Payer: Hawaii Western Management Group Commercial	$26.44
Rate for Payer: Health Management Network Commercial	$41.65
Rate for Payer: Kaiser Permanente Commercial	$20.65
Rate for Payer: Kaiser Permanente Medicaid	$20.65
Rate for Payer: Kaiser Permanente Medicare	$20.65
Rate for Payer: Ohana Health Plan Medicaid	$10.14
Rate for Payer: Ohana Health Plan Medicare	$17.21
Rate for Payer: UnitedHealthcare Medicaid	$10.14
Rate for Payer: UnitedHealthcare Medicare	$17.21

THERAPEUTIC PROPHYLACTIC/DX INJECTION SUBQ/IM

Professional

Both

$44.00

Service Code	HCPCS 96372
Min. Negotiated Rate	$9.24
Max. Negotiated Rate	$37.40
Rate for Payer: AlohaCare Medicaid	$9.24
Rate for Payer: AlohaCare Medicare	$16.51
Rate for Payer: Cash Price	$28.60
Rate for Payer: Cash Price	$28.60
Rate for Payer: Devoted Health Medicare	$18.16
Rate for Payer: Hawaii Medical Service Association Medicare	$16.51
Rate for Payer: Hawaii Western Management Group Commercial	$17.25
Rate for Payer: Health Management Network Commercial	$37.40
Rate for Payer: Kaiser Permanente Commercial	$19.81
Rate for Payer: Kaiser Permanente Medicaid	$19.81
Rate for Payer: Kaiser Permanente Medicare	$19.81
Rate for Payer: Ohana Health Plan Medicaid	$9.24
Rate for Payer: Ohana Health Plan Medicare	$16.51
Rate for Payer: UnitedHealthcare Medicaid	$9.24
Rate for Payer: UnitedHealthcare Medicare	$16.51

THER PROPH/DX NJX IV PUSH SINGLE/1ST SBST/DRUG

Professional

Both

$121.00

Service Code	HCPCS 96374
Min. Negotiated Rate	$24.47
Max. Negotiated Rate	$102.85
Rate for Payer: AlohaCare Medicaid	$24.47
Rate for Payer: AlohaCare Medicare	$41.72
Rate for Payer: Cash Price	$78.65
Rate for Payer: Cash Price	$78.65
Rate for Payer: Devoted Health Medicare	$45.89
Rate for Payer: Hawaii Medical Service Association Medicare	$41.72
Rate for Payer: Hawaii Western Management Group Commercial	$54.61
Rate for Payer: Health Management Network Commercial	$102.85
Rate for Payer: Kaiser Permanente Commercial	$50.06
Rate for Payer: Kaiser Permanente Medicaid	$50.06
Rate for Payer: Kaiser Permanente Medicare	$50.06
Rate for Payer: Ohana Health Plan Medicaid	$24.47
Rate for Payer: Ohana Health Plan Medicare	$41.72
Rate for Payer: UnitedHealthcare Medicaid	$24.47
Rate for Payer: UnitedHealthcare Medicare	$41.72

Th G7 Acet Liner High Wall Vit E 40mm F [3643826]

Facility

$2,500.00

Service Code	HCPCS C1776
Hospital Charge Code	3643826
Hospital Revenue Code	278
Min. Negotiated Rate	$1,275.00
Max. Negotiated Rate	$2,425.00
Rate for Payer: Cash Price	$1,625.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,750.00
Rate for Payer: Health Management Network Commercial	$2,125.00
Rate for Payer: Kaiser Permanente Commercial	$1,575.00
Rate for Payer: Kaiser Permanente Medicaid	$1,275.00
Rate for Payer: MDX Hawaii PPO	$2,425.00
Rate for Payer: University Health Alliance Commercial	$1,400.00

Th G7 Acet Liner High Wall Vit E 40mm F [3643826]

Facility

$2,500.00

Service Code	HCPCS C1776
Hospital Charge Code	3643826
Hospital Revenue Code	278
Min. Negotiated Rate	$1,400.00
Max. Negotiated Rate	$2,425.00
Rate for Payer: Cash Price	$1,625.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,750.00
Rate for Payer: Health Management Network Commercial	$2,125.00
Rate for Payer: MDX Hawaii PPO	$2,425.00
Rate for Payer: University Health Alliance Commercial	$1,400.00

Th G7 Dual Mobility Acet Liner 50mm H [3643375]

Facility

$4,500.00

Service Code	HCPCS C1776
Hospital Charge Code	3643375
Hospital Revenue Code	278
Min. Negotiated Rate	$2,520.00
Max. Negotiated Rate	$4,365.00
Rate for Payer: Cash Price	$2,925.00
Rate for Payer: Hawaii Western Management Group Commercial	$3,150.00
Rate for Payer: Health Management Network Commercial	$3,825.00
Rate for Payer: MDX Hawaii PPO	$4,365.00
Rate for Payer: University Health Alliance Commercial	$2,520.00

Th G7 Dual Mobility Acet Liner 50mm H [3643375]

Facility

$4,500.00

Service Code	HCPCS C1776
Hospital Charge Code	3643375
Hospital Revenue Code	278
Min. Negotiated Rate	$2,295.00
Max. Negotiated Rate	$4,365.00
Rate for Payer: Cash Price	$2,925.00
Rate for Payer: Hawaii Western Management Group Commercial	$3,150.00
Rate for Payer: Health Management Network Commercial	$3,825.00
Rate for Payer: Kaiser Permanente Commercial	$2,835.00
Rate for Payer: Kaiser Permanente Medicaid	$2,295.00
Rate for Payer: MDX Hawaii PPO	$4,365.00
Rate for Payer: University Health Alliance Commercial	$2,520.00

Th G7 Dual Mobility Acet Liner 54mm Sz I [3643845]

Facility

$7,803.00

Service Code	HCPCS C1776
Hospital Charge Code	3643845
Hospital Revenue Code	278
Min. Negotiated Rate	$3,979.53
Max. Negotiated Rate	$7,568.91
Rate for Payer: Cash Price	$5,071.95
Rate for Payer: Hawaii Western Management Group Commercial	$5,462.10
Rate for Payer: Health Management Network Commercial	$6,632.55
Rate for Payer: Kaiser Permanente Commercial	$4,915.89
Rate for Payer: Kaiser Permanente Medicaid	$3,979.53
Rate for Payer: MDX Hawaii PPO	$7,568.91
Rate for Payer: University Health Alliance Commercial	$4,369.68

Th G7 Dual Mobility Acet Liner 54mm Sz I [3643845]

Facility

$7,803.00

Service Code	HCPCS C1776
Hospital Charge Code	3643845
Hospital Revenue Code	278
Min. Negotiated Rate	$4,369.68
Max. Negotiated Rate	$7,568.91
Rate for Payer: Cash Price	$5,071.95
Rate for Payer: Hawaii Western Management Group Commercial	$5,462.10
Rate for Payer: Health Management Network Commercial	$6,632.55
Rate for Payer: MDX Hawaii PPO	$7,568.91
Rate for Payer: University Health Alliance Commercial	$4,369.68

Th G7 Longevity Neutral Liner 40mm G 20104007 [3644039]

Facility

$2,712.50

Service Code	HCPCS C1776
Hospital Charge Code	3644039
Hospital Revenue Code	278
Min. Negotiated Rate	$1,519.00
Max. Negotiated Rate	$2,631.12
Rate for Payer: Cash Price	$1,763.12
Rate for Payer: Hawaii Western Management Group Commercial	$1,898.75
Rate for Payer: Health Management Network Commercial	$2,305.62
Rate for Payer: MDX Hawaii PPO	$2,631.12
Rate for Payer: University Health Alliance Commercial	$1,519.00

Th G7 Longevity Neutral Liner 40mm G 20104007 [3644039]

Facility

$2,712.50

Service Code	HCPCS C1776
Hospital Charge Code	3644039
Hospital Revenue Code	278
Min. Negotiated Rate	$1,383.38
Max. Negotiated Rate	$2,631.12
Rate for Payer: Cash Price	$1,763.12
Rate for Payer: Hawaii Western Management Group Commercial	$1,898.75
Rate for Payer: Health Management Network Commercial	$2,305.62
Rate for Payer: Kaiser Permanente Commercial	$1,708.88
Rate for Payer: Kaiser Permanente Medicaid	$1,383.38
Rate for Payer: MDX Hawaii PPO	$2,631.12
Rate for Payer: University Health Alliance Commercial	$1,519.00

Th G7 Osseo Ti Acet Shell Mlt Hl 62mm Sz H [3643815]

Facility

$8,312.50

Service Code	HCPCS C1776
Hospital Charge Code	3643815
Hospital Revenue Code	278
Min. Negotiated Rate	$4,239.38
Max. Negotiated Rate	$8,063.12
Rate for Payer: Cash Price	$5,403.12
Rate for Payer: Hawaii Western Management Group Commercial	$5,818.75
Rate for Payer: Health Management Network Commercial	$7,065.62
Rate for Payer: Kaiser Permanente Commercial	$5,236.88
Rate for Payer: Kaiser Permanente Medicaid	$4,239.38
Rate for Payer: MDX Hawaii PPO	$8,063.12
Rate for Payer: University Health Alliance Commercial	$4,655.00

Th G7 Osseo Ti Acet Shell Mlt Hl 62mm Sz H [3643815]

Facility

$8,312.50

Service Code	HCPCS C1776
Hospital Charge Code	3643815
Hospital Revenue Code	278
Min. Negotiated Rate	$4,655.00
Max. Negotiated Rate	$8,063.12
Rate for Payer: Cash Price	$5,403.12
Rate for Payer: Hawaii Western Management Group Commercial	$5,818.75
Rate for Payer: Health Management Network Commercial	$7,065.62
Rate for Payer: MDX Hawaii PPO	$8,063.12
Rate for Payer: University Health Alliance Commercial	$4,655.00

Th G7 Osseo Ti Acet Shell Multi Hole 60mm SzG 110010268 [3643848]

Facility

$13,053.00

Service Code	HCPCS C1776
Hospital Charge Code	3643848
Hospital Revenue Code	278
Min. Negotiated Rate	$6,657.03
Max. Negotiated Rate	$12,661.41
Rate for Payer: Cash Price	$8,484.45
Rate for Payer: Hawaii Western Management Group Commercial	$9,137.10
Rate for Payer: Health Management Network Commercial	$11,095.05
Rate for Payer: Kaiser Permanente Commercial	$8,223.39
Rate for Payer: Kaiser Permanente Medicaid	$6,657.03
Rate for Payer: MDX Hawaii PPO	$12,661.41
Rate for Payer: University Health Alliance Commercial	$7,309.68

Th G7 Osseo Ti Acet Shell Multi Hole 60mm SzG 110010268 [3643848]

Facility

$13,053.00

Service Code	HCPCS C1776
Hospital Charge Code	3643848
Hospital Revenue Code	278
Min. Negotiated Rate	$7,309.68
Max. Negotiated Rate	$12,661.41
Rate for Payer: Cash Price	$8,484.45
Rate for Payer: Hawaii Western Management Group Commercial	$9,137.10
Rate for Payer: Health Management Network Commercial	$11,095.05
Rate for Payer: MDX Hawaii PPO	$12,661.41
Rate for Payer: University Health Alliance Commercial	$7,309.68

Th G7 Osseo Ti Acet Shell Multi Hole 66mm Szi [3643844]

Facility

$8,312.50

Service Code	HCPCS C1776
Hospital Charge Code	3643844
Hospital Revenue Code	278
Min. Negotiated Rate	$4,239.38
Max. Negotiated Rate	$8,063.12
Rate for Payer: Cash Price	$5,403.12
Rate for Payer: Hawaii Western Management Group Commercial	$5,818.75
Rate for Payer: Health Management Network Commercial	$7,065.62
Rate for Payer: Kaiser Permanente Commercial	$5,236.88
Rate for Payer: Kaiser Permanente Medicaid	$4,239.38
Rate for Payer: MDX Hawaii PPO	$8,063.12
Rate for Payer: University Health Alliance Commercial	$4,655.00

Th G7 Osseo Ti Acet Shell Multi Hole 66mm Szi [3643844]

Facility

$8,312.50

Service Code	HCPCS C1776
Hospital Charge Code	3643844
Hospital Revenue Code	278
Min. Negotiated Rate	$4,655.00
Max. Negotiated Rate	$8,063.12
Rate for Payer: Cash Price	$5,403.12
Rate for Payer: Hawaii Western Management Group Commercial	$5,818.75
Rate for Payer: Health Management Network Commercial	$7,065.62
Rate for Payer: MDX Hawaii PPO	$8,063.12
Rate for Payer: University Health Alliance Commercial	$4,655.00

Th G7 Screw 6.5mmx45mm [3643264]

Facility

$308.75

Service Code	HCPCS C1713
Hospital Charge Code	3643264
Hospital Revenue Code	278
Min. Negotiated Rate	$172.90
Max. Negotiated Rate	$299.49
Rate for Payer: Cash Price	$200.69
Rate for Payer: Hawaii Western Management Group Commercial	$216.12
Rate for Payer: Health Management Network Commercial	$262.44
Rate for Payer: MDX Hawaii PPO	$299.49
Rate for Payer: University Health Alliance Commercial	$172.90

Th G7 Screw 6.5mmx45mm [3643264]

Facility

$308.75

Service Code	HCPCS C1713
Hospital Charge Code	3643264
Hospital Revenue Code	278
Min. Negotiated Rate	$157.46
Max. Negotiated Rate	$299.49
Rate for Payer: Cash Price	$200.69
Rate for Payer: Hawaii Western Management Group Commercial	$216.12
Rate for Payer: Health Management Network Commercial	$262.44
Rate for Payer: Kaiser Permanente Commercial	$194.51
Rate for Payer: Kaiser Permanente Medicaid	$157.46
Rate for Payer: MDX Hawaii PPO	$299.49
Rate for Payer: University Health Alliance Commercial	$172.90

THIAMINE HCL (VITAMIN B1) 100 MG/ML INJ SOLN

Facility

$61.20

Service Code	HCPCS J3411
Hospital Revenue Code	250
Min. Negotiated Rate	$52.02
Max. Negotiated Rate	$59.36
Rate for Payer: Cash Price	$39.78
Rate for Payer: Cash Price	$37.52
Rate for Payer: Cash Price	$28.87
Rate for Payer: Health Management Network Commercial	$52.02
Rate for Payer: Health Management Network Commercial	$37.76
Rate for Payer: Health Management Network Commercial	$49.06
Rate for Payer: MDX Hawaii PPO	$59.36
Rate for Payer: MDX Hawaii PPO	$55.99
Rate for Payer: MDX Hawaii PPO	$43.09

THIAMINE HCL (VITAMIN B1) 100 MG/ML INJ SOLN

Facility

$57.72

Service Code	HCPCS J3411
Hospital Revenue Code	636
Min. Negotiated Rate	$1.79
Max. Negotiated Rate	$55.99
Rate for Payer: Cash Price	$37.52
Rate for Payer: Cash Price	$39.78
Rate for Payer: Cash Price	$28.87
Rate for Payer: Cash Price	$28.87
Rate for Payer: Cash Price	$39.78
Rate for Payer: Cash Price	$37.52
Rate for Payer: Hawaii Medical Service Association ABD	$1.79
Rate for Payer: Hawaii Medical Service Association ABD	$1.79
Rate for Payer: Hawaii Medical Service Association ABD	$1.79
Rate for Payer: Hawaii Medical Service Association Non-ABD	$1.79
Rate for Payer: Hawaii Medical Service Association Non-ABD	$1.79
Rate for Payer: Hawaii Medical Service Association Non-ABD	$1.79
Rate for Payer: Hawaii Western Management Group Commercial	$42.20
Rate for Payer: Hawaii Western Management Group Commercial	$54.83
Rate for Payer: Hawaii Western Management Group Commercial	$58.14
Rate for Payer: Health Management Network Commercial	$52.02
Rate for Payer: Health Management Network Commercial	$37.76
Rate for Payer: Health Management Network Commercial	$49.06
Rate for Payer: Kaiser Permanente Commercial	$38.56
Rate for Payer: Kaiser Permanente Commercial	$36.36
Rate for Payer: Kaiser Permanente Commercial	$27.98
Rate for Payer: Kaiser Permanente Medicaid	$22.65
Rate for Payer: Kaiser Permanente Medicaid	$29.44
Rate for Payer: Kaiser Permanente Medicaid	$31.21
Rate for Payer: MDX Hawaii PPO	$43.09
Rate for Payer: MDX Hawaii PPO	$55.99
Rate for Payer: MDX Hawaii PPO	$59.36
Rate for Payer: UnitedHealthcare Medicaid	$34.63
Rate for Payer: UnitedHealthcare Medicaid	$36.72
Rate for Payer: UnitedHealthcare Medicaid	$26.65
Rate for Payer: University Health Alliance Commercial	$32.38
Rate for Payer: University Health Alliance Commercial	$42.07
Rate for Payer: University Health Alliance Commercial	$44.61

THIAMINE MONONITRATE (VIT B1) 100 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: Cash Price	$1.13
Rate for Payer: Hawaii Western Management Group Commercial	$1.14
Rate for Payer: Hawaii Western Management Group Commercial	$1.65
Rate for Payer: Health Management Network Commercial	$1.48
Rate for Payer: Health Management Network Commercial	$1.02
Rate for Payer: Kaiser Permanente Commercial	$0.76
Rate for Payer: Kaiser Permanente Commercial	$1.10
Rate for Payer: Kaiser Permanente Medicaid	$0.89
Rate for Payer: Kaiser Permanente Medicaid	$0.61
Rate for Payer: MDX Hawaii PPO	$1.69
Rate for Payer: MDX Hawaii PPO	$1.16
Rate for Payer: UnitedHealthcare Medicaid	$0.72
Rate for Payer: UnitedHealthcare Medicaid	$1.04
Rate for Payer: University Health Alliance Commercial	$1.27
Rate for Payer: University Health Alliance Commercial	$0.87

THIAMINE MONONITRATE (VIT B1) 100 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: Cash Price	$1.13
Rate for Payer: Health Management Network Commercial	$1.48
Rate for Payer: Health Management Network Commercial	$1.02
Rate for Payer: MDX Hawaii PPO	$1.69
Rate for Payer: MDX Hawaii PPO	$1.16

Thoracic Catheter Sharp Tip 24Fr 8888561050 [3641361]

Facility

$124.95

Service Code	HCPCS C1729
Hospital Charge Code	3641361
Hospital Revenue Code	272
Min. Negotiated Rate	$106.21
Max. Negotiated Rate	$121.20
Rate for Payer: Cash Price	$81.22
Rate for Payer: Health Management Network Commercial	$106.21
Rate for Payer: MDX Hawaii PPO	$121.20

Thoracic Catheter Sharp Tip 24Fr 8888561050 [3641361]

Facility

$124.95

Service Code	HCPCS C1729
Hospital Charge Code	3641361
Hospital Revenue Code	272
Min. Negotiated Rate	$63.72
Max. Negotiated Rate	$121.20
Rate for Payer: Cash Price	$81.22
Rate for Payer: Hawaii Western Management Group Commercial	$118.70
Rate for Payer: Health Management Network Commercial	$106.21
Rate for Payer: Kaiser Permanente Commercial	$78.72
Rate for Payer: Kaiser Permanente Medicaid	$63.72
Rate for Payer: MDX Hawaii PPO	$121.20
Rate for Payer: University Health Alliance Commercial	$91.08

Know your out-of-pocket cost for care.

All Charges