Kona Community Hospital

All Charges

Charge

Type

Setting

Price

Tk Triathlon Tibial Bearing Insert Sz5 13mm C [3643947]

Facility

$3,345.00

Service Code	HCPCS C1769
Hospital Charge Code	3643947
Hospital Revenue Code	272
Min. Negotiated Rate	$2,843.25
Max. Negotiated Rate	$3,244.65
Rate for Payer: Cash Price	$2,174.25
Rate for Payer: Health Management Network Commercial	$2,843.25
Rate for Payer: MDX Hawaii PPO	$3,244.65

Tk Triathlon Tibial Bearing Insert Sz5 13mm C [3643947]

Facility

$3,345.00

Service Code	HCPCS C1769
Hospital Charge Code	3643947
Hospital Revenue Code	272
Min. Negotiated Rate	$1,705.95
Max. Negotiated Rate	$3,244.65
Rate for Payer: Cash Price	$2,174.25
Rate for Payer: Hawaii Western Management Group Commercial	$3,177.75
Rate for Payer: Health Management Network Commercial	$2,843.25
Rate for Payer: Kaiser Permanente Commercial	$2,107.35
Rate for Payer: Kaiser Permanente Medicaid	$1,705.95
Rate for Payer: MDX Hawaii PPO	$3,244.65
Rate for Payer: University Health Alliance Commercial	$2,438.17

Tk Triathlon Tibial Symmetric Cone Aug Szd [3643943]

Facility

$13,016.03

Service Code	HCPCS C1769
Hospital Charge Code	3643943
Hospital Revenue Code	272
Min. Negotiated Rate	$11,063.63
Max. Negotiated Rate	$12,625.55
Rate for Payer: Cash Price	$8,460.42
Rate for Payer: Health Management Network Commercial	$11,063.63
Rate for Payer: MDX Hawaii PPO	$12,625.55

Tk Triathlon Tibial Symmetric Cone Aug Szd [3643943]

Facility

$13,016.03

Service Code	HCPCS C1769
Hospital Charge Code	3643943
Hospital Revenue Code	272
Min. Negotiated Rate	$6,638.18
Max. Negotiated Rate	$12,625.55
Rate for Payer: Cash Price	$8,460.42
Rate for Payer: Hawaii Western Management Group Commercial	$12,365.23
Rate for Payer: Health Management Network Commercial	$11,063.63
Rate for Payer: Kaiser Permanente Commercial	$8,200.10
Rate for Payer: Kaiser Permanente Medicaid	$6,638.18
Rate for Payer: MDX Hawaii PPO	$12,625.55
Rate for Payer: University Health Alliance Commercial	$9,487.38

Tk Triathlon Univ Tibial Baseplate Sz5 [3643942]

Facility

$4,138.15

Service Code	HCPCS C1769
Hospital Charge Code	3643942
Hospital Revenue Code	272
Min. Negotiated Rate	$3,517.43
Max. Negotiated Rate	$4,014.01
Rate for Payer: Cash Price	$2,689.80
Rate for Payer: Health Management Network Commercial	$3,517.43
Rate for Payer: MDX Hawaii PPO	$4,014.01

Tk Triathlon Univ Tibial Baseplate Sz5 [3643942]

Facility

$4,138.15

Service Code	HCPCS C1769
Hospital Charge Code	3643942
Hospital Revenue Code	272
Min. Negotiated Rate	$2,110.46
Max. Negotiated Rate	$4,014.01
Rate for Payer: Cash Price	$2,689.80
Rate for Payer: Hawaii Western Management Group Commercial	$3,931.24
Rate for Payer: Health Management Network Commercial	$3,517.43
Rate for Payer: Kaiser Permanente Commercial	$2,607.03
Rate for Payer: Kaiser Permanente Medicaid	$2,110.46
Rate for Payer: MDX Hawaii PPO	$4,014.01
Rate for Payer: University Health Alliance Commercial	$3,016.30

TOBACCO USE CESSATION INTENSIVE >10 MINUTES

Professional

Both

$43.75

Service Code	HCPCS 99407
Min. Negotiated Rate	$22.03
Max. Negotiated Rate	$37.19
Rate for Payer: AlohaCare Medicaid	$25.04
Rate for Payer: AlohaCare Medicare	$22.03
Rate for Payer: Cash Price	$28.44
Rate for Payer: Cash Price	$28.44
Rate for Payer: Devoted Health Medicare	$24.23
Rate for Payer: Hawaii Medical Service Association ABD	$25.04
Rate for Payer: Hawaii Medical Service Association Medicare	$22.03
Rate for Payer: Hawaii Medical Service Association Non-ABD	$25.04
Rate for Payer: Hawaii Western Management Group Commercial	$27.54
Rate for Payer: Health Management Network Commercial	$37.19
Rate for Payer: Kaiser Permanente Commercial	$26.44
Rate for Payer: Kaiser Permanente Medicaid	$26.44
Rate for Payer: Kaiser Permanente Medicare	$26.44
Rate for Payer: Ohana Health Plan Medicaid	$25.04
Rate for Payer: Ohana Health Plan Medicare	$22.03
Rate for Payer: UnitedHealthcare Medicaid	$25.04
Rate for Payer: UnitedHealthcare Medicare	$22.03

TOBACCO USE CESSATION INTERMEDIATE 3-10 MINUTES

Professional

Both

$26.25

Service Code	HCPCS 99406
Min. Negotiated Rate	$10.68
Max. Negotiated Rate	$22.31
Rate for Payer: AlohaCare Medicaid	$11.80
Rate for Payer: AlohaCare Medicare	$10.68
Rate for Payer: Cash Price	$17.06
Rate for Payer: Cash Price	$17.06
Rate for Payer: Devoted Health Medicare	$11.75
Rate for Payer: Hawaii Medical Service Association ABD	$11.80
Rate for Payer: Hawaii Medical Service Association Medicare	$10.68
Rate for Payer: Hawaii Medical Service Association Non-ABD	$11.80
Rate for Payer: Hawaii Western Management Group Commercial	$14.50
Rate for Payer: Health Management Network Commercial	$22.31
Rate for Payer: Kaiser Permanente Commercial	$12.82
Rate for Payer: Kaiser Permanente Medicaid	$12.82
Rate for Payer: Kaiser Permanente Medicare	$12.82
Rate for Payer: Ohana Health Plan Medicaid	$11.80
Rate for Payer: Ohana Health Plan Medicare	$10.68
Rate for Payer: UnitedHealthcare Medicaid	$11.80
Rate for Payer: UnitedHealthcare Medicare	$10.68

TOBRAMYCIN 0.3 % OPHT DROP

Facility

$158.76

Service Code	HCPCS A9270
Hospital Revenue Code	250
Min. Negotiated Rate	$80.97
Max. Negotiated Rate	$154.00
Rate for Payer: Cash Price	$103.19
Rate for Payer: Cash Price	$25.89
Rate for Payer: Hawaii Western Management Group Commercial	$150.82
Rate for Payer: Hawaii Western Management Group Commercial	$37.84
Rate for Payer: Health Management Network Commercial	$33.86
Rate for Payer: Health Management Network Commercial	$134.95
Rate for Payer: Kaiser Permanente Commercial	$100.02
Rate for Payer: Kaiser Permanente Commercial	$25.09
Rate for Payer: Kaiser Permanente Medicaid	$20.31
Rate for Payer: Kaiser Permanente Medicaid	$80.97
Rate for Payer: MDX Hawaii PPO	$38.64
Rate for Payer: MDX Hawaii PPO	$154.00
Rate for Payer: UnitedHealthcare Medicaid	$95.26
Rate for Payer: UnitedHealthcare Medicaid	$23.90
Rate for Payer: University Health Alliance Commercial	$29.03
Rate for Payer: University Health Alliance Commercial	$115.72

TOBRAMYCIN 0.3 % OPHT DROP

Facility

$158.76

Service Code	HCPCS A9270
Hospital Revenue Code	250
Min. Negotiated Rate	$134.95
Max. Negotiated Rate	$154.00
Rate for Payer: Cash Price	$103.19
Rate for Payer: Cash Price	$25.89
Rate for Payer: Health Management Network Commercial	$33.86
Rate for Payer: Health Management Network Commercial	$134.95
Rate for Payer: MDX Hawaii PPO	$38.64
Rate for Payer: MDX Hawaii PPO	$154.00

TOBRAMYCIN 0.3 % OPHT OINT

Facility

$821.28

Service Code	HCPCS A9270
Hospital Revenue Code	250
Min. Negotiated Rate	$418.85
Max. Negotiated Rate	$796.64
Rate for Payer: Cash Price	$533.83
Rate for Payer: Hawaii Western Management Group Commercial	$780.22
Rate for Payer: Health Management Network Commercial	$698.09
Rate for Payer: Kaiser Permanente Commercial	$517.41
Rate for Payer: Kaiser Permanente Medicaid	$418.85
Rate for Payer: MDX Hawaii PPO	$796.64
Rate for Payer: UnitedHealthcare Medicaid	$492.77
Rate for Payer: University Health Alliance Commercial	$598.63

TOBRAMYCIN 0.3 % OPHT OINT

Facility

$821.28

Service Code	HCPCS A9270
Hospital Revenue Code	250
Min. Negotiated Rate	$698.09
Max. Negotiated Rate	$796.64
Rate for Payer: Cash Price	$533.83
Rate for Payer: Health Management Network Commercial	$698.09
Rate for Payer: MDX Hawaii PPO	$796.64

TOBRAMYCIN-DEXAMETHASONE 0.3-0.1 % OPHT DRPS

Facility

$511.63

Service Code	HCPCS A9270
Hospital Revenue Code	250
Min. Negotiated Rate	$434.89
Max. Negotiated Rate	$496.28
Rate for Payer: Cash Price	$332.56
Rate for Payer: Cash Price	$352.26
Rate for Payer: Health Management Network Commercial	$460.65
Rate for Payer: Health Management Network Commercial	$434.89
Rate for Payer: MDX Hawaii PPO	$525.68
Rate for Payer: MDX Hawaii PPO	$496.28

TOBRAMYCIN-DEXAMETHASONE 0.3-0.1 % OPHT DRPS

Facility

$511.63

Service Code	HCPCS A9270
Hospital Revenue Code	250
Min. Negotiated Rate	$260.93
Max. Negotiated Rate	$496.28
Rate for Payer: Cash Price	$332.56
Rate for Payer: Cash Price	$352.26
Rate for Payer: Hawaii Western Management Group Commercial	$486.05
Rate for Payer: Hawaii Western Management Group Commercial	$514.84
Rate for Payer: Health Management Network Commercial	$460.65
Rate for Payer: Health Management Network Commercial	$434.89
Rate for Payer: Kaiser Permanente Commercial	$322.33
Rate for Payer: Kaiser Permanente Commercial	$341.42
Rate for Payer: Kaiser Permanente Medicaid	$276.39
Rate for Payer: Kaiser Permanente Medicaid	$260.93
Rate for Payer: MDX Hawaii PPO	$525.68
Rate for Payer: MDX Hawaii PPO	$496.28
Rate for Payer: UnitedHealthcare Medicaid	$306.98
Rate for Payer: UnitedHealthcare Medicaid	$325.16
Rate for Payer: University Health Alliance Commercial	$395.02
Rate for Payer: University Health Alliance Commercial	$372.93

TOBRAMYCIN-DEXAMETHASONE 0.3-0.1 % OPHT OINT

Facility

$858.84

Service Code	HCPCS A9270
Hospital Revenue Code	250
Min. Negotiated Rate	$730.01
Max. Negotiated Rate	$833.07
Rate for Payer: Cash Price	$558.25
Rate for Payer: Health Management Network Commercial	$730.01
Rate for Payer: MDX Hawaii PPO	$833.07

TOBRAMYCIN-DEXAMETHASONE 0.3-0.1 % OPHT OINT

Facility

$858.84

Service Code	HCPCS A9270
Hospital Revenue Code	250
Min. Negotiated Rate	$438.01
Max. Negotiated Rate	$833.07
Rate for Payer: Cash Price	$558.25
Rate for Payer: Hawaii Western Management Group Commercial	$815.90
Rate for Payer: Health Management Network Commercial	$730.01
Rate for Payer: Kaiser Permanente Commercial	$541.07
Rate for Payer: Kaiser Permanente Medicaid	$438.01
Rate for Payer: MDX Hawaii PPO	$833.07
Rate for Payer: UnitedHealthcare Medicaid	$515.30
Rate for Payer: University Health Alliance Commercial	$626.01

TOBRAMYCIN IN 0.225 % NACL 300 MG/5 ML INHAL NEBU

Facility

$533.47

Service Code	NDC 65162091446
Hospital Revenue Code	250
Min. Negotiated Rate	$272.07
Max. Negotiated Rate	$517.47
Rate for Payer: Cash Price	$346.76
Rate for Payer: Hawaii Western Management Group Commercial	$506.80
Rate for Payer: Health Management Network Commercial	$453.45
Rate for Payer: Kaiser Permanente Commercial	$336.09
Rate for Payer: Kaiser Permanente Medicaid	$272.07
Rate for Payer: MDX Hawaii PPO	$517.47
Rate for Payer: UnitedHealthcare Medicaid	$320.08
Rate for Payer: University Health Alliance Commercial	$388.85

TOBRAMYCIN IN 0.225 % NACL 300 MG/5 ML INHAL NEBU

Facility

$533.47

Service Code	NDC 65162091446
Hospital Revenue Code	250
Min. Negotiated Rate	$453.45
Max. Negotiated Rate	$517.47
Rate for Payer: Cash Price	$346.76
Rate for Payer: Health Management Network Commercial	$453.45
Rate for Payer: MDX Hawaii PPO	$517.47

TOBRAMYCIN SULFATE 1.2 G INJ RECON.SOLN.

Facility

$358.80

Service Code	HCPCS J3260
Hospital Revenue Code	636
Min. Negotiated Rate	$2.46
Max. Negotiated Rate	$348.04
Rate for Payer: Cash Price	$233.22
Rate for Payer: Cash Price	$233.22
Rate for Payer: Hawaii Medical Service Association ABD	$2.46
Rate for Payer: Hawaii Medical Service Association Non-ABD	$2.46
Rate for Payer: Hawaii Western Management Group Commercial	$340.86
Rate for Payer: Health Management Network Commercial	$304.98
Rate for Payer: Kaiser Permanente Commercial	$226.04
Rate for Payer: Kaiser Permanente Medicaid	$182.99
Rate for Payer: MDX Hawaii PPO	$348.04
Rate for Payer: UnitedHealthcare Medicaid	$215.28
Rate for Payer: University Health Alliance Commercial	$261.53

TOBRAMYCIN SULFATE 1.2 G INJ RECON.SOLN.

Facility

$358.80

Service Code	HCPCS J3260
Hospital Revenue Code	250
Min. Negotiated Rate	$304.98
Max. Negotiated Rate	$348.04
Rate for Payer: Cash Price	$233.22
Rate for Payer: Health Management Network Commercial	$304.98
Rate for Payer: MDX Hawaii PPO	$348.04

TOBRAMYCIN SULFATE 40 MG/ML INJ SOLN

Facility

$16.48

Service Code	HCPCS J3260
Hospital Revenue Code	636
Min. Negotiated Rate	$2.46
Max. Negotiated Rate	$15.99
Rate for Payer: Cash Price	$10.71
Rate for Payer: Cash Price	$10.71
Rate for Payer: Hawaii Medical Service Association ABD	$2.46
Rate for Payer: Hawaii Medical Service Association Non-ABD	$2.46
Rate for Payer: Hawaii Western Management Group Commercial	$15.66
Rate for Payer: Health Management Network Commercial	$14.01
Rate for Payer: Kaiser Permanente Commercial	$10.38
Rate for Payer: Kaiser Permanente Medicaid	$8.40
Rate for Payer: MDX Hawaii PPO	$15.99
Rate for Payer: UnitedHealthcare Medicaid	$9.89
Rate for Payer: University Health Alliance Commercial	$12.01

TOBRAMYCIN SULFATE 40 MG/ML INJ SOLN

Facility

$16.48

Service Code	HCPCS J3260
Hospital Revenue Code	250
Min. Negotiated Rate	$14.01
Max. Negotiated Rate	$15.99
Rate for Payer: Cash Price	$10.71
Rate for Payer: Health Management Network Commercial	$14.01
Rate for Payer: MDX Hawaii PPO	$15.99

TOBRAMYCIN SULFATE (BULK) 634 MCG/MG (NOT LESS THAN, USP) MISC POWD

Facility

$792.43

Service Code	NDC 38779031906
Hospital Revenue Code	250
Min. Negotiated Rate	$404.14
Max. Negotiated Rate	$768.66
Rate for Payer: Cash Price	$515.08
Rate for Payer: Hawaii Western Management Group Commercial	$752.81
Rate for Payer: Health Management Network Commercial	$673.57
Rate for Payer: Kaiser Permanente Commercial	$499.23
Rate for Payer: Kaiser Permanente Medicaid	$404.14
Rate for Payer: MDX Hawaii PPO	$768.66
Rate for Payer: UnitedHealthcare Medicaid	$475.46
Rate for Payer: University Health Alliance Commercial	$577.60

TOBRAMYCIN SULFATE (BULK) 634 MCG/MG (NOT LESS THAN, USP) MISC POWD

Facility

$792.43

Service Code	NDC 38779031906
Hospital Revenue Code	250
Min. Negotiated Rate	$673.57
Max. Negotiated Rate	$768.66
Rate for Payer: Cash Price	$515.08
Rate for Payer: Health Management Network Commercial	$673.57
Rate for Payer: MDX Hawaii PPO	$768.66

TOCILIZUMAB 400 MG/20 ML (20 MG/ML) IV SOLN

Facility

$4,305.39

Service Code	HCPCS J3262
Hospital Revenue Code	636
Min. Negotiated Rate	$5.53
Max. Negotiated Rate	$4,176.23
Rate for Payer: AlohaCare Medicaid	$5.53
Rate for Payer: AlohaCare Medicare	$5.53
Rate for Payer: Cash Price	$2,798.50
Rate for Payer: Cash Price	$2,798.50
Rate for Payer: Devoted Health Medicare	$6.08
Rate for Payer: Hawaii Medical Service Association ABD	$5.79
Rate for Payer: Hawaii Medical Service Association Commercial	$6.91
Rate for Payer: Hawaii Medical Service Association Medicare	$5.53
Rate for Payer: Hawaii Medical Service Association Non-ABD	$5.79
Rate for Payer: Hawaii Western Management Group Commercial	$4,090.12
Rate for Payer: Health Management Network Commercial	$3,659.58
Rate for Payer: Humana Medicare	$5.53
Rate for Payer: Kaiser Permanente Commercial	$2,712.40
Rate for Payer: Kaiser Permanente Medicaid	$2,195.75
Rate for Payer: Kaiser Permanente Medicare	$5.53
Rate for Payer: MDX Hawaii PPO	$4,176.23
Rate for Payer: Ohana Health Plan Medicaid	$6.08
Rate for Payer: Ohana Health Plan Medicare	$5.53
Rate for Payer: UnitedHealthcare Medicaid	$2,583.23
Rate for Payer: UnitedHealthcare Medicare	$5.53
Rate for Payer: University Health Alliance Commercial	$3,138.20

Know your out-of-pocket cost for care.

All Charges