Kona Community Hospital

All Charges

Charge

Type

Setting

Price

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

ACETAZOLAMIDE 250 MG PO TABLET

Facility

$15.24

Service Code	HCPCS A9270
Hospital Revenue Code	250
Min. Negotiated Rate	$7.77
Max. Negotiated Rate	$14.78
Rate for Payer: Cash Price	$9.91
Rate for Payer: Hawaii Western Management Group Commercial	$14.48
Rate for Payer: Health Management Network Commercial	$12.95
Rate for Payer: Kaiser Permanente Commercial	$9.60
Rate for Payer: Kaiser Permanente Medicaid	$7.77
Rate for Payer: MDX Hawaii PPO	$14.78
Rate for Payer: UnitedHealthcare Medicaid	$9.14
Rate for Payer: University Health Alliance Commercial	$11.11

ACETAZOLAMIDE 250 MG PO TABLET

Facility

$15.24

Service Code	HCPCS A9270
Hospital Revenue Code	250
Min. Negotiated Rate	$12.95
Max. Negotiated Rate	$14.78
Rate for Payer: Cash Price	$9.91
Rate for Payer: Health Management Network Commercial	$12.95
Rate for Payer: MDX Hawaii PPO	$14.78

ACETAZOLAMIDE 500 MG PO CAP SR

Facility

$23.71

Service Code	HCPCS A9270
Hospital Revenue Code	250
Min. Negotiated Rate	$12.09
Max. Negotiated Rate	$23.00
Rate for Payer: Cash Price	$15.41
Rate for Payer: Hawaii Western Management Group Commercial	$22.52
Rate for Payer: Health Management Network Commercial	$20.15
Rate for Payer: Kaiser Permanente Commercial	$14.94
Rate for Payer: Kaiser Permanente Medicaid	$12.09
Rate for Payer: MDX Hawaii PPO	$23.00
Rate for Payer: UnitedHealthcare Medicaid	$14.23
Rate for Payer: University Health Alliance Commercial	$17.28

ACETAZOLAMIDE 500 MG PO CAP SR

Facility

$23.71

Service Code	HCPCS A9270
Hospital Revenue Code	250
Min. Negotiated Rate	$20.15
Max. Negotiated Rate	$23.00
Rate for Payer: Cash Price	$15.41
Rate for Payer: Health Management Network Commercial	$20.15
Rate for Payer: MDX Hawaii PPO	$23.00

ACETAZOLAMIDE SODIUM 500 MG INJ RECON.SOLN.

Facility

$216.72

Service Code	HCPCS J1120
Hospital Revenue Code	250
Min. Negotiated Rate	$184.21
Max. Negotiated Rate	$210.22
Rate for Payer: Cash Price	$140.87
Rate for Payer: Cash Price	$96.47
Rate for Payer: Cash Price	$118.53
Rate for Payer: Health Management Network Commercial	$126.15
Rate for Payer: Health Management Network Commercial	$155.01
Rate for Payer: Health Management Network Commercial	$184.21
Rate for Payer: MDX Hawaii PPO	$143.96
Rate for Payer: MDX Hawaii PPO	$210.22
Rate for Payer: MDX Hawaii PPO	$176.89

ACETAZOLAMIDE SODIUM 500 MG INJ RECON.SOLN.

Facility

$182.36

Service Code	HCPCS J1120
Hospital Revenue Code	636
Min. Negotiated Rate	$17.23
Max. Negotiated Rate	$176.89
Rate for Payer: Cash Price	$118.53
Rate for Payer: Cash Price	$96.47
Rate for Payer: Cash Price	$140.87
Rate for Payer: Cash Price	$96.47
Rate for Payer: Cash Price	$140.87
Rate for Payer: Cash Price	$118.53
Rate for Payer: Hawaii Medical Service Association ABD	$17.23
Rate for Payer: Hawaii Medical Service Association ABD	$17.23
Rate for Payer: Hawaii Medical Service Association ABD	$17.23
Rate for Payer: Hawaii Medical Service Association Non-ABD	$17.23
Rate for Payer: Hawaii Medical Service Association Non-ABD	$17.23
Rate for Payer: Hawaii Medical Service Association Non-ABD	$17.23
Rate for Payer: Hawaii Western Management Group Commercial	$173.24
Rate for Payer: Hawaii Western Management Group Commercial	$140.99
Rate for Payer: Hawaii Western Management Group Commercial	$205.88
Rate for Payer: Health Management Network Commercial	$184.21
Rate for Payer: Health Management Network Commercial	$126.15
Rate for Payer: Health Management Network Commercial	$155.01
Rate for Payer: Kaiser Permanente Commercial	$136.53
Rate for Payer: Kaiser Permanente Commercial	$93.50
Rate for Payer: Kaiser Permanente Commercial	$114.89
Rate for Payer: Kaiser Permanente Medicaid	$75.69
Rate for Payer: Kaiser Permanente Medicaid	$93.00
Rate for Payer: Kaiser Permanente Medicaid	$110.53
Rate for Payer: MDX Hawaii PPO	$210.22
Rate for Payer: MDX Hawaii PPO	$143.96
Rate for Payer: MDX Hawaii PPO	$176.89
Rate for Payer: UnitedHealthcare Medicaid	$89.05
Rate for Payer: UnitedHealthcare Medicaid	$130.03
Rate for Payer: UnitedHealthcare Medicaid	$109.42
Rate for Payer: University Health Alliance Commercial	$157.97
Rate for Payer: University Health Alliance Commercial	$132.92
Rate for Payer: University Health Alliance Commercial	$108.18

ACETYLCHOLINE CHLORIDE 1 % (10 MG/ML) INTRAOC KIT

Facility

$511.07

Service Code	NDC 24208053920
Hospital Revenue Code	250
Min. Negotiated Rate	$260.65
Max. Negotiated Rate	$495.74
Rate for Payer: Cash Price	$332.20
Rate for Payer: Hawaii Western Management Group Commercial	$485.52
Rate for Payer: Health Management Network Commercial	$434.41
Rate for Payer: Kaiser Permanente Commercial	$321.97
Rate for Payer: Kaiser Permanente Medicaid	$260.65
Rate for Payer: MDX Hawaii PPO	$495.74
Rate for Payer: UnitedHealthcare Medicaid	$306.64
Rate for Payer: University Health Alliance Commercial	$372.52

ACETYLCHOLINE CHLORIDE 1 % (10 MG/ML) INTRAOC KIT

Facility

$511.07

Service Code	NDC 24208053920
Hospital Revenue Code	250
Min. Negotiated Rate	$434.41
Max. Negotiated Rate	$495.74
Rate for Payer: Cash Price	$332.20
Rate for Payer: Health Management Network Commercial	$434.41
Rate for Payer: MDX Hawaii PPO	$495.74

ACETYLCYSTEINE 20 % (200 MG/ML) IV SOLN

Facility

$708.35

Service Code	HCPCS J0132
Hospital Revenue Code	636
Min. Negotiated Rate	$0.37
Max. Negotiated Rate	$687.10
Rate for Payer: Cash Price	$460.43
Rate for Payer: Cash Price	$146.28
Rate for Payer: Cash Price	$146.28
Rate for Payer: Cash Price	$460.43
Rate for Payer: Hawaii Medical Service Association ABD	$0.37
Rate for Payer: Hawaii Medical Service Association ABD	$0.37
Rate for Payer: Hawaii Medical Service Association Non-ABD	$0.37
Rate for Payer: Hawaii Medical Service Association Non-ABD	$0.37
Rate for Payer: Hawaii Western Management Group Commercial	$213.80
Rate for Payer: Hawaii Western Management Group Commercial	$672.93
Rate for Payer: Health Management Network Commercial	$602.10
Rate for Payer: Health Management Network Commercial	$191.29
Rate for Payer: Kaiser Permanente Commercial	$446.26
Rate for Payer: Kaiser Permanente Commercial	$141.78
Rate for Payer: Kaiser Permanente Medicaid	$114.78
Rate for Payer: Kaiser Permanente Medicaid	$361.26
Rate for Payer: MDX Hawaii PPO	$218.30
Rate for Payer: MDX Hawaii PPO	$687.10
Rate for Payer: UnitedHealthcare Medicaid	$135.03
Rate for Payer: UnitedHealthcare Medicaid	$425.01
Rate for Payer: University Health Alliance Commercial	$164.04
Rate for Payer: University Health Alliance Commercial	$516.32

ACETYLCYSTEINE 20 % (200 MG/ML) IV SOLN

Facility

$225.05

Service Code	HCPCS J0132
Hospital Revenue Code	250
Min. Negotiated Rate	$191.29
Max. Negotiated Rate	$218.30
Rate for Payer: Cash Price	$146.28
Rate for Payer: Cash Price	$460.43
Rate for Payer: Health Management Network Commercial	$602.10
Rate for Payer: Health Management Network Commercial	$191.29
Rate for Payer: MDX Hawaii PPO	$687.10
Rate for Payer: MDX Hawaii PPO	$218.30

ACETYLCYSTEINE 20 % (200 MG/ML) MISC SOLN

Facility

$80.44

Service Code	HCPCS A9270
Hospital Revenue Code	250
Min. Negotiated Rate	$41.02
Max. Negotiated Rate	$78.03
Rate for Payer: Cash Price	$52.29
Rate for Payer: Cash Price	$54.68
Rate for Payer: Hawaii Western Management Group Commercial	$76.42
Rate for Payer: Hawaii Western Management Group Commercial	$79.92
Rate for Payer: Health Management Network Commercial	$71.51
Rate for Payer: Health Management Network Commercial	$68.37
Rate for Payer: Kaiser Permanente Commercial	$50.68
Rate for Payer: Kaiser Permanente Commercial	$53.00
Rate for Payer: Kaiser Permanente Medicaid	$42.91
Rate for Payer: Kaiser Permanente Medicaid	$41.02
Rate for Payer: MDX Hawaii PPO	$81.61
Rate for Payer: MDX Hawaii PPO	$78.03
Rate for Payer: UnitedHealthcare Medicaid	$48.26
Rate for Payer: UnitedHealthcare Medicaid	$50.48
Rate for Payer: University Health Alliance Commercial	$61.32
Rate for Payer: University Health Alliance Commercial	$58.63

ACETYLCYSTEINE 20 % (200 MG/ML) MISC SOLN

Facility

$80.44

Service Code	HCPCS A9270
Hospital Revenue Code	250
Min. Negotiated Rate	$68.37
Max. Negotiated Rate	$78.03
Rate for Payer: Cash Price	$52.29
Rate for Payer: Cash Price	$54.68
Rate for Payer: Health Management Network Commercial	$71.51
Rate for Payer: Health Management Network Commercial	$68.37
Rate for Payer: MDX Hawaii PPO	$81.61
Rate for Payer: MDX Hawaii PPO	$78.03

ACETYLCYSTEINE 20 % (200 MG/ML) ORAL SOLN FOR TYLENOL OVERDOSE

Facility

$140.71

Service Code	HCPCS A9270
Hospital Revenue Code	250
Min. Negotiated Rate	$71.76
Max. Negotiated Rate	$136.49
Rate for Payer: Cash Price	$91.46
Rate for Payer: Hawaii Western Management Group Commercial	$133.67
Rate for Payer: Health Management Network Commercial	$119.60
Rate for Payer: Kaiser Permanente Commercial	$88.65
Rate for Payer: Kaiser Permanente Medicaid	$71.76
Rate for Payer: MDX Hawaii PPO	$136.49
Rate for Payer: UnitedHealthcare Medicaid	$84.43
Rate for Payer: University Health Alliance Commercial	$102.56

ACETYLCYSTEINE 20 % (200 MG/ML) ORAL SOLN FOR TYLENOL OVERDOSE

Facility

$140.71

Service Code	HCPCS A9270
Hospital Revenue Code	250
Min. Negotiated Rate	$119.60
Max. Negotiated Rate	$136.49
Rate for Payer: Cash Price	$91.46
Rate for Payer: Health Management Network Commercial	$119.60
Rate for Payer: MDX Hawaii PPO	$136.49

ACL Kit Trans Tibial w/Saw Blade AR-1897S [3640101]

Facility

$2,111.88

Hospital Charge Code	3640101
Hospital Revenue Code	272
Min. Negotiated Rate	$1,077.06
Max. Negotiated Rate	$2,048.52
Rate for Payer: Cash Price	$1,372.72
Rate for Payer: Hawaii Western Management Group Commercial	$2,006.29
Rate for Payer: Health Management Network Commercial	$1,795.10
Rate for Payer: Kaiser Permanente Commercial	$1,330.48
Rate for Payer: Kaiser Permanente Medicaid	$1,077.06
Rate for Payer: MDX Hawaii PPO	$2,048.52
Rate for Payer: University Health Alliance Commercial	$1,539.35

ACL Kit Trans Tibial w/Saw Blade AR-1897S [3640101]

Facility

$2,111.88

Hospital Charge Code	3640101
Hospital Revenue Code	272
Min. Negotiated Rate	$1,795.10
Max. Negotiated Rate	$2,048.52
Rate for Payer: Cash Price	$1,372.72
Rate for Payer: Health Management Network Commercial	$1,795.10
Rate for Payer: MDX Hawaii PPO	$2,048.52

ACTIVATED CHARCOAL-SORBITOL 25 GRAM/120 ML PO SUSP

Facility

$87.06

Service Code	HCPCS A9270
Hospital Revenue Code	250
Min. Negotiated Rate	$74.00
Max. Negotiated Rate	$84.45
Rate for Payer: Cash Price	$56.59
Rate for Payer: Health Management Network Commercial	$74.00
Rate for Payer: MDX Hawaii PPO	$84.45

ACTIVATED CHARCOAL-SORBITOL 25 GRAM/120 ML PO SUSP

Facility

$87.06

Service Code	HCPCS A9270
Hospital Revenue Code	250
Min. Negotiated Rate	$44.40
Max. Negotiated Rate	$84.45
Rate for Payer: Cash Price	$56.59
Rate for Payer: Hawaii Western Management Group Commercial	$82.71
Rate for Payer: Health Management Network Commercial	$74.00
Rate for Payer: Kaiser Permanente Commercial	$54.85
Rate for Payer: Kaiser Permanente Medicaid	$44.40
Rate for Payer: MDX Hawaii PPO	$84.45
Rate for Payer: UnitedHealthcare Medicaid	$52.24
Rate for Payer: University Health Alliance Commercial	$63.46

ACTIVATED CHARCOAL-SORBITOL 50 GRAM/240 ML PO SUSP

Facility

$185.92

Service Code	HCPCS A9270
Hospital Revenue Code	250
Min. Negotiated Rate	$158.03
Max. Negotiated Rate	$180.34
Rate for Payer: Cash Price	$120.85
Rate for Payer: Cash Price	$75.64
Rate for Payer: Health Management Network Commercial	$98.91
Rate for Payer: Health Management Network Commercial	$158.03
Rate for Payer: MDX Hawaii PPO	$180.34
Rate for Payer: MDX Hawaii PPO	$112.88

ACTIVATED CHARCOAL-SORBITOL 50 GRAM/240 ML PO SUSP

Facility

$116.37

Service Code	HCPCS A9270
Hospital Revenue Code	250
Min. Negotiated Rate	$59.35
Max. Negotiated Rate	$112.88
Rate for Payer: Cash Price	$75.64
Rate for Payer: Cash Price	$120.85
Rate for Payer: Hawaii Western Management Group Commercial	$110.55
Rate for Payer: Hawaii Western Management Group Commercial	$176.62
Rate for Payer: Health Management Network Commercial	$98.91
Rate for Payer: Health Management Network Commercial	$158.03
Rate for Payer: Kaiser Permanente Commercial	$73.31
Rate for Payer: Kaiser Permanente Commercial	$117.13
Rate for Payer: Kaiser Permanente Medicaid	$59.35
Rate for Payer: Kaiser Permanente Medicaid	$94.82
Rate for Payer: MDX Hawaii PPO	$112.88
Rate for Payer: MDX Hawaii PPO	$180.34
Rate for Payer: UnitedHealthcare Medicaid	$111.55
Rate for Payer: UnitedHealthcare Medicaid	$69.82
Rate for Payer: University Health Alliance Commercial	$84.82
Rate for Payer: University Health Alliance Commercial	$135.52

Activation Tool S0457-000 [3644658]

Facility

$1,246.20

Hospital Charge Code	3644658
Hospital Revenue Code	272
Min. Negotiated Rate	$635.56
Max. Negotiated Rate	$1,208.81
Rate for Payer: Cash Price	$810.03
Rate for Payer: Hawaii Western Management Group Commercial	$1,183.89
Rate for Payer: Health Management Network Commercial	$1,059.27
Rate for Payer: Kaiser Permanente Commercial	$785.11
Rate for Payer: Kaiser Permanente Medicaid	$635.56
Rate for Payer: MDX Hawaii PPO	$1,208.81
Rate for Payer: University Health Alliance Commercial	$908.36

Activation Tool S0457-000 [3644658]

Facility

$1,246.20

Hospital Charge Code	3644658
Hospital Revenue Code	272
Min. Negotiated Rate	$1,059.27
Max. Negotiated Rate	$1,208.81
Rate for Payer: Cash Price	$810.03
Rate for Payer: Health Management Network Commercial	$1,059.27
Rate for Payer: MDX Hawaii PPO	$1,208.81

ActiveMatrix Placental Tissue Allograft XL AM150 [3642524]

Facility

$9,390.00

Service Code	HCPCS C1762
Hospital Charge Code	3642524
Hospital Revenue Code	278
Min. Negotiated Rate	$4,788.90
Max. Negotiated Rate	$9,108.30
Rate for Payer: Cash Price	$6,103.50
Rate for Payer: Hawaii Western Management Group Commercial	$6,573.00
Rate for Payer: Health Management Network Commercial	$7,981.50
Rate for Payer: Kaiser Permanente Commercial	$5,915.70
Rate for Payer: Kaiser Permanente Medicaid	$4,788.90
Rate for Payer: MDX Hawaii PPO	$9,108.30
Rate for Payer: University Health Alliance Commercial	$5,258.40

ActiveMatrix Placental Tissue Allograft XL AM150 [3642524]

Facility

$9,390.00

Service Code	HCPCS C1762
Hospital Charge Code	3642524
Hospital Revenue Code	278
Min. Negotiated Rate	$5,258.40
Max. Negotiated Rate	$9,108.30
Rate for Payer: Cash Price	$6,103.50
Rate for Payer: Hawaii Western Management Group Commercial	$6,573.00
Rate for Payer: Health Management Network Commercial	$7,981.50
Rate for Payer: MDX Hawaii PPO	$9,108.30
Rate for Payer: University Health Alliance Commercial	$5,258.40

Know your out-of-pocket cost for care.

All Charges