Kona Community Hospital

All Charges

Charge

Type

Setting

Price

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

Facility

$4,305.39

Service Code	HCPCS J3262
Hospital Revenue Code	250
Min. Negotiated Rate	$3,659.58
Max. Negotiated Rate	$4,176.23
Rate for Payer: Cash Price	$2,798.50
Rate for Payer: Health Management Network Commercial	$3,659.58
Rate for Payer: MDX Hawaii PPO	$4,176.23

TOLTERODINE 2 MG PO CAP SR 24HR

Facility

$72.40

Service Code	HCPCS A9270
Hospital Revenue Code	250
Min. Negotiated Rate	$36.92
Max. Negotiated Rate	$70.23
Rate for Payer: Cash Price	$47.06
Rate for Payer: Hawaii Western Management Group Commercial	$68.78
Rate for Payer: Health Management Network Commercial	$61.54
Rate for Payer: Kaiser Permanente Commercial	$45.61
Rate for Payer: Kaiser Permanente Medicaid	$36.92
Rate for Payer: MDX Hawaii PPO	$70.23
Rate for Payer: UnitedHealthcare Medicaid	$43.44
Rate for Payer: University Health Alliance Commercial	$52.77

TOLTERODINE 2 MG PO CAP SR 24HR

Facility

$72.40

Service Code	HCPCS A9270
Hospital Revenue Code	250
Min. Negotiated Rate	$61.54
Max. Negotiated Rate	$70.23
Rate for Payer: Cash Price	$47.06
Rate for Payer: Health Management Network Commercial	$61.54
Rate for Payer: MDX Hawaii PPO	$70.23

TONSIL & ADENOID PROCEDURES

Facility

$14,675.76

Service Code	APR-DRG 0974
Min. Negotiated Rate	$14,675.76
Max. Negotiated Rate	$14,675.76
Rate for Payer: AlohaCare Medicaid	$14,675.76
Rate for Payer: Hawaii Medical Service Association ABD	$14,675.76
Rate for Payer: Hawaii Medical Service Association Non-ABD	$14,675.76
Rate for Payer: Kaiser Permanente Medicaid	$14,675.76
Rate for Payer: Ohana Health Plan Medicaid	$14,675.76
Rate for Payer: UnitedHealthcare Medicaid	$14,675.76

TONSIL & ADENOID PROCEDURES

Facility

$6,281.42

Service Code	APR-DRG 0973
Min. Negotiated Rate	$6,281.42
Max. Negotiated Rate	$6,281.42
Rate for Payer: AlohaCare Medicaid	$6,281.42
Rate for Payer: Hawaii Medical Service Association ABD	$6,281.42
Rate for Payer: Hawaii Medical Service Association Non-ABD	$6,281.42
Rate for Payer: Kaiser Permanente Medicaid	$6,281.42
Rate for Payer: Ohana Health Plan Medicaid	$6,281.42
Rate for Payer: UnitedHealthcare Medicaid	$6,281.42

TONSIL & ADENOID PROCEDURES

Facility

$3,913.15

Service Code	APR-DRG 0972
Min. Negotiated Rate	$3,913.15
Max. Negotiated Rate	$3,913.15
Rate for Payer: AlohaCare Medicaid	$3,913.15
Rate for Payer: Hawaii Medical Service Association ABD	$3,913.15
Rate for Payer: Hawaii Medical Service Association Non-ABD	$3,913.15
Rate for Payer: Kaiser Permanente Medicaid	$3,913.15
Rate for Payer: Ohana Health Plan Medicaid	$3,913.15
Rate for Payer: UnitedHealthcare Medicaid	$3,913.15

TONSIL & ADENOID PROCEDURES

Facility

$2,804.48

Service Code	APR-DRG 0971
Min. Negotiated Rate	$2,804.48
Max. Negotiated Rate	$2,804.48
Rate for Payer: AlohaCare Medicaid	$2,804.48
Rate for Payer: Hawaii Medical Service Association ABD	$2,804.48
Rate for Payer: Hawaii Medical Service Association Non-ABD	$2,804.48
Rate for Payer: Kaiser Permanente Medicaid	$2,804.48
Rate for Payer: Ohana Health Plan Medicaid	$2,804.48
Rate for Payer: UnitedHealthcare Medicaid	$2,804.48

TOPIRAMATE 100 MG PO TABLET

Facility

$39.59

Service Code	HCPCS A9270
Hospital Revenue Code	250
Min. Negotiated Rate	$20.19
Max. Negotiated Rate	$38.40
Rate for Payer: Cash Price	$25.73
Rate for Payer: Cash Price	$28.13
Rate for Payer: Hawaii Western Management Group Commercial	$37.61
Rate for Payer: Hawaii Western Management Group Commercial	$41.12
Rate for Payer: Health Management Network Commercial	$36.79
Rate for Payer: Health Management Network Commercial	$33.65
Rate for Payer: Kaiser Permanente Commercial	$24.94
Rate for Payer: Kaiser Permanente Commercial	$27.27
Rate for Payer: Kaiser Permanente Medicaid	$22.07
Rate for Payer: Kaiser Permanente Medicaid	$20.19
Rate for Payer: MDX Hawaii PPO	$41.98
Rate for Payer: MDX Hawaii PPO	$38.40
Rate for Payer: UnitedHealthcare Medicaid	$23.75
Rate for Payer: UnitedHealthcare Medicaid	$25.97
Rate for Payer: University Health Alliance Commercial	$31.55
Rate for Payer: University Health Alliance Commercial	$28.86

TOPIRAMATE 100 MG PO TABLET

Facility

$39.59

Service Code	HCPCS A9270
Hospital Revenue Code	250
Min. Negotiated Rate	$33.65
Max. Negotiated Rate	$38.40
Rate for Payer: Cash Price	$25.73
Rate for Payer: Cash Price	$28.13
Rate for Payer: Health Management Network Commercial	$36.79
Rate for Payer: Health Management Network Commercial	$33.65
Rate for Payer: MDX Hawaii PPO	$41.98
Rate for Payer: MDX Hawaii PPO	$38.40

TOPIRAMATE 25 MG PO TABLET

Facility

$11.60

Service Code	HCPCS A9270
Hospital Revenue Code	250
Min. Negotiated Rate	$5.92
Max. Negotiated Rate	$11.25
Rate for Payer: Cash Price	$7.54
Rate for Payer: Hawaii Western Management Group Commercial	$11.02
Rate for Payer: Health Management Network Commercial	$9.86
Rate for Payer: Kaiser Permanente Commercial	$7.31
Rate for Payer: Kaiser Permanente Medicaid	$5.92
Rate for Payer: MDX Hawaii PPO	$11.25
Rate for Payer: UnitedHealthcare Medicaid	$6.96
Rate for Payer: University Health Alliance Commercial	$8.46

TOPIRAMATE 25 MG PO TABLET

Facility

$11.60

Service Code	HCPCS A9270
Hospital Revenue Code	250
Min. Negotiated Rate	$9.86
Max. Negotiated Rate	$11.25
Rate for Payer: Cash Price	$7.54
Rate for Payer: Health Management Network Commercial	$9.86
Rate for Payer: MDX Hawaii PPO	$11.25

TOPIRAMATE 25 MG PO TABLET (0.5 TAB) = 12.5 MG

Facility

$11.60

Service Code	HCPCS A9270
Hospital Revenue Code	250
Min. Negotiated Rate	$5.92
Max. Negotiated Rate	$11.25
Rate for Payer: Cash Price	$7.54
Rate for Payer: Hawaii Western Management Group Commercial	$11.02
Rate for Payer: Health Management Network Commercial	$9.86
Rate for Payer: Kaiser Permanente Commercial	$7.31
Rate for Payer: Kaiser Permanente Medicaid	$5.92
Rate for Payer: MDX Hawaii PPO	$11.25
Rate for Payer: UnitedHealthcare Medicaid	$6.96
Rate for Payer: University Health Alliance Commercial	$8.46

TOPIRAMATE 25 MG PO TABLET (0.5 TAB) = 12.5 MG

Facility

$11.60

Service Code	HCPCS A9270
Hospital Revenue Code	250
Min. Negotiated Rate	$9.86
Max. Negotiated Rate	$11.25
Rate for Payer: Cash Price	$7.54
Rate for Payer: Health Management Network Commercial	$9.86
Rate for Payer: MDX Hawaii PPO	$11.25

Total Elbow C/m 16mm & 25mm Plug w/nozzle 32-8015-038-00 [3604030]

Facility

$844.38

Service Code	HCPCS C1713
Hospital Charge Code	3604030
Hospital Revenue Code	278
Min. Negotiated Rate	$430.63
Max. Negotiated Rate	$819.05
Rate for Payer: Cash Price	$548.85
Rate for Payer: Hawaii Western Management Group Commercial	$591.07
Rate for Payer: Health Management Network Commercial	$717.72
Rate for Payer: Kaiser Permanente Commercial	$531.96
Rate for Payer: Kaiser Permanente Medicaid	$430.63
Rate for Payer: MDX Hawaii PPO	$819.05
Rate for Payer: University Health Alliance Commercial	$472.85

Total Elbow C/m 16mm & 25mm Plug w/nozzle 32-8015-038-00 [3604030]

Facility

$844.38

Service Code	HCPCS C1713
Hospital Charge Code	3604030
Hospital Revenue Code	278
Min. Negotiated Rate	$472.85
Max. Negotiated Rate	$819.05
Rate for Payer: Cash Price	$548.85
Rate for Payer: Hawaii Western Management Group Commercial	$591.07
Rate for Payer: Health Management Network Commercial	$717.72
Rate for Payer: MDX Hawaii PPO	$819.05
Rate for Payer: University Health Alliance Commercial	$472.85

Total Elbow C/m Humeral Assembly 4" Xsm 32-8105-027-04 [3644029]

Facility

$13,500.00

Service Code	HCPCS C1776
Hospital Charge Code	3644029
Hospital Revenue Code	278
Min. Negotiated Rate	$7,560.00
Max. Negotiated Rate	$13,095.00
Rate for Payer: Cash Price	$8,775.00
Rate for Payer: Hawaii Western Management Group Commercial	$9,450.00
Rate for Payer: Health Management Network Commercial	$11,475.00
Rate for Payer: MDX Hawaii PPO	$13,095.00
Rate for Payer: University Health Alliance Commercial	$7,560.00

Total Elbow C/m Humeral Assembly 4" Xsm 32-8105-027-04 [3644029]

Facility

$13,500.00

Service Code	HCPCS C1776
Hospital Charge Code	3644029
Hospital Revenue Code	278
Min. Negotiated Rate	$6,885.00
Max. Negotiated Rate	$13,095.00
Rate for Payer: Cash Price	$8,775.00
Rate for Payer: Hawaii Western Management Group Commercial	$9,450.00
Rate for Payer: Health Management Network Commercial	$11,475.00
Rate for Payer: Kaiser Permanente Commercial	$8,505.00
Rate for Payer: Kaiser Permanente Medicaid	$6,885.00
Rate for Payer: MDX Hawaii PPO	$13,095.00
Rate for Payer: University Health Alliance Commercial	$7,560.00

Total Elbow C/m Ulna Assembly 3" Xsm Lt 32-8105-043-01 [3644028]

Facility

$12,250.00

Service Code	HCPCS C1776
Hospital Charge Code	3644028
Hospital Revenue Code	278
Min. Negotiated Rate	$6,247.50
Max. Negotiated Rate	$11,882.50
Rate for Payer: Cash Price	$7,962.50
Rate for Payer: Hawaii Western Management Group Commercial	$8,575.00
Rate for Payer: Health Management Network Commercial	$10,412.50
Rate for Payer: Kaiser Permanente Commercial	$7,717.50
Rate for Payer: Kaiser Permanente Medicaid	$6,247.50
Rate for Payer: MDX Hawaii PPO	$11,882.50
Rate for Payer: University Health Alliance Commercial	$6,860.00

Total Elbow C/m Ulna Assembly 3" Xsm Lt 32-8105-043-01 [3644028]

Facility

$12,250.00

Service Code	HCPCS C1776
Hospital Charge Code	3644028
Hospital Revenue Code	278
Min. Negotiated Rate	$6,860.00
Max. Negotiated Rate	$11,882.50
Rate for Payer: Cash Price	$7,962.50
Rate for Payer: Hawaii Western Management Group Commercial	$8,575.00
Rate for Payer: Health Management Network Commercial	$10,412.50
Rate for Payer: MDX Hawaii PPO	$11,882.50
Rate for Payer: University Health Alliance Commercial	$6,860.00

Total Hip Biolox Delta Fem Hd 12/14 40mm +5 1365-40-720 [3644407]

Facility

$14,475.05

Service Code	HCPCS C1776
Hospital Charge Code	3644407
Hospital Revenue Code	278
Min. Negotiated Rate	$7,382.28
Max. Negotiated Rate	$14,040.80
Rate for Payer: Cash Price	$9,408.78
Rate for Payer: Hawaii Western Management Group Commercial	$10,132.53
Rate for Payer: Health Management Network Commercial	$12,303.79
Rate for Payer: Kaiser Permanente Commercial	$9,119.28
Rate for Payer: Kaiser Permanente Medicaid	$7,382.28
Rate for Payer: MDX Hawaii PPO	$14,040.80
Rate for Payer: University Health Alliance Commercial	$8,106.03

Total Hip Biolox Delta Fem Hd 12/14 40mm +5 1365-40-720 [3644407]

Facility

$14,475.05

Service Code	HCPCS C1776
Hospital Charge Code	3644407
Hospital Revenue Code	278
Min. Negotiated Rate	$8,106.03
Max. Negotiated Rate	$14,040.80
Rate for Payer: Cash Price	$9,408.78
Rate for Payer: Hawaii Western Management Group Commercial	$10,132.53
Rate for Payer: Health Management Network Commercial	$12,303.79
Rate for Payer: MDX Hawaii PPO	$14,040.80
Rate for Payer: University Health Alliance Commercial	$8,106.03

Total Hip BIOLOX Delta Fem HD 28mm +3.5mm 00-8775-028-03 [3640895]

Facility

$3,990.50

Service Code	HCPCS C1776
Hospital Charge Code	3640895
Hospital Revenue Code	278
Min. Negotiated Rate	$2,234.68
Max. Negotiated Rate	$3,870.78
Rate for Payer: Cash Price	$2,593.83
Rate for Payer: Hawaii Western Management Group Commercial	$2,793.35
Rate for Payer: Health Management Network Commercial	$3,391.93
Rate for Payer: MDX Hawaii PPO	$3,870.78
Rate for Payer: University Health Alliance Commercial	$2,234.68

Total Hip BIOLOX Delta Fem HD 28mm +3.5mm 00-8775-028-03 [3640895]

Facility

$3,990.50

Service Code	HCPCS C1776
Hospital Charge Code	3640895
Hospital Revenue Code	278
Min. Negotiated Rate	$2,035.15
Max. Negotiated Rate	$3,870.78
Rate for Payer: Cash Price	$2,593.83
Rate for Payer: Hawaii Western Management Group Commercial	$2,793.35
Rate for Payer: Health Management Network Commercial	$3,391.93
Rate for Payer: Kaiser Permanente Commercial	$2,514.01
Rate for Payer: Kaiser Permanente Medicaid	$2,035.15
Rate for Payer: MDX Hawaii PPO	$3,870.78
Rate for Payer: University Health Alliance Commercial	$2,234.68

Total Hip BIOLOX Delta Fem HD 36mm +0mm 00-8775-036-02 [3641619]

Facility

$3,990.50

Service Code	HCPCS C1776
Hospital Charge Code	3641619
Hospital Revenue Code	278
Min. Negotiated Rate	$2,035.15
Max. Negotiated Rate	$3,870.78
Rate for Payer: Cash Price	$2,593.83
Rate for Payer: Hawaii Western Management Group Commercial	$2,793.35
Rate for Payer: Health Management Network Commercial	$3,391.93
Rate for Payer: Kaiser Permanente Commercial	$2,514.01
Rate for Payer: Kaiser Permanente Medicaid	$2,035.15
Rate for Payer: MDX Hawaii PPO	$3,870.78
Rate for Payer: University Health Alliance Commercial	$2,234.68

Total Hip BIOLOX Delta Fem HD 36mm +0mm 00-8775-036-02 [3641619]

Facility

$3,990.50

Service Code	HCPCS C1776
Hospital Charge Code	3641619
Hospital Revenue Code	278
Min. Negotiated Rate	$2,234.68
Max. Negotiated Rate	$3,870.78
Rate for Payer: Cash Price	$2,593.83
Rate for Payer: Hawaii Western Management Group Commercial	$2,793.35
Rate for Payer: Health Management Network Commercial	$3,391.93
Rate for Payer: MDX Hawaii PPO	$3,870.78
Rate for Payer: University Health Alliance Commercial	$2,234.68

Know your out-of-pocket cost for care.

All Charges