Kona Community Hospital

All Charges

Charge

Type

Setting

Price

CLONAZEPAM 1 MG PO TABLET

Facility

$3.91

Service Code	HCPCS A9270
Hospital Revenue Code	250
Min. Negotiated Rate	$3.32
Max. Negotiated Rate	$3.79
Rate for Payer: Cash Price	$2.54
Rate for Payer: Health Management Network Commercial	$3.32
Rate for Payer: MDX Hawaii PPO	$3.79

CLONAZEPAM 2 MG PO TABLET

Facility

$6.54

Service Code	HCPCS A9270
Hospital Revenue Code	250
Min. Negotiated Rate	$5.56
Max. Negotiated Rate	$6.34
Rate for Payer: Cash Price	$4.25
Rate for Payer: Cash Price	$4.46
Rate for Payer: Health Management Network Commercial	$5.83
Rate for Payer: Health Management Network Commercial	$5.56
Rate for Payer: MDX Hawaii PPO	$6.34
Rate for Payer: MDX Hawaii PPO	$6.65

CLONAZEPAM 2 MG PO TABLET

Facility

$6.54

Service Code	HCPCS A9270
Hospital Revenue Code	250
Min. Negotiated Rate	$3.34
Max. Negotiated Rate	$6.34
Rate for Payer: Cash Price	$4.25
Rate for Payer: Cash Price	$4.46
Rate for Payer: Hawaii Western Management Group Commercial	$6.21
Rate for Payer: Hawaii Western Management Group Commercial	$6.52
Rate for Payer: Health Management Network Commercial	$5.56
Rate for Payer: Health Management Network Commercial	$5.83
Rate for Payer: Kaiser Permanente Commercial	$4.12
Rate for Payer: Kaiser Permanente Commercial	$4.32
Rate for Payer: Kaiser Permanente Medicaid	$3.34
Rate for Payer: Kaiser Permanente Medicaid	$3.50
Rate for Payer: MDX Hawaii PPO	$6.34
Rate for Payer: MDX Hawaii PPO	$6.65
Rate for Payer: UnitedHealthcare Medicaid	$4.12
Rate for Payer: UnitedHealthcare Medicaid	$3.92
Rate for Payer: University Health Alliance Commercial	$4.77
Rate for Payer: University Health Alliance Commercial	$5.00

CLONIDINE 0.1 MG TRANSDERM PTWK

Facility

$155.13

Service Code	HCPCS A9270
Hospital Revenue Code	250
Min. Negotiated Rate	$79.12
Max. Negotiated Rate	$150.48
Rate for Payer: Cash Price	$100.83
Rate for Payer: Hawaii Western Management Group Commercial	$147.37
Rate for Payer: Health Management Network Commercial	$131.86
Rate for Payer: Kaiser Permanente Commercial	$97.73
Rate for Payer: Kaiser Permanente Medicaid	$79.12
Rate for Payer: MDX Hawaii PPO	$150.48
Rate for Payer: UnitedHealthcare Medicaid	$93.08
Rate for Payer: University Health Alliance Commercial	$113.07

CLONIDINE 0.1 MG TRANSDERM PTWK

Facility

$155.13

Service Code	HCPCS A9270
Hospital Revenue Code	250
Min. Negotiated Rate	$131.86
Max. Negotiated Rate	$150.48
Rate for Payer: Cash Price	$100.83
Rate for Payer: Health Management Network Commercial	$131.86
Rate for Payer: MDX Hawaii PPO	$150.48

CLONIDINE 0.2 MG TRANSDERM PTWK

Facility

$292.33

Service Code	HCPCS A9270
Hospital Revenue Code	250
Min. Negotiated Rate	$149.09
Max. Negotiated Rate	$283.56
Rate for Payer: Cash Price	$190.01
Rate for Payer: Hawaii Western Management Group Commercial	$277.71
Rate for Payer: Health Management Network Commercial	$248.48
Rate for Payer: Kaiser Permanente Commercial	$184.17
Rate for Payer: Kaiser Permanente Medicaid	$149.09
Rate for Payer: MDX Hawaii PPO	$283.56
Rate for Payer: UnitedHealthcare Medicaid	$175.40
Rate for Payer: University Health Alliance Commercial	$213.08

CLONIDINE 0.2 MG TRANSDERM PTWK

Facility

$292.33

Service Code	HCPCS A9270
Hospital Revenue Code	250
Min. Negotiated Rate	$248.48
Max. Negotiated Rate	$283.56
Rate for Payer: Cash Price	$190.01
Rate for Payer: Health Management Network Commercial	$248.48
Rate for Payer: MDX Hawaii PPO	$283.56

CLONIDINE 0.3 MG/24 HR TRANSDERM PTWK

Facility

$367.27

Service Code	HCPCS A9270
Hospital Revenue Code	250
Min. Negotiated Rate	$187.31
Max. Negotiated Rate	$356.25
Rate for Payer: Cash Price	$238.73
Rate for Payer: Hawaii Western Management Group Commercial	$348.91
Rate for Payer: Health Management Network Commercial	$312.18
Rate for Payer: Kaiser Permanente Commercial	$231.38
Rate for Payer: Kaiser Permanente Medicaid	$187.31
Rate for Payer: MDX Hawaii PPO	$356.25
Rate for Payer: UnitedHealthcare Medicaid	$220.36
Rate for Payer: University Health Alliance Commercial	$267.70

CLONIDINE 0.3 MG/24 HR TRANSDERM PTWK

Facility

$367.27

Service Code	HCPCS A9270
Hospital Revenue Code	250
Min. Negotiated Rate	$312.18
Max. Negotiated Rate	$356.25
Rate for Payer: Cash Price	$238.73
Rate for Payer: Health Management Network Commercial	$312.18
Rate for Payer: MDX Hawaii PPO	$356.25

CLONIDINE HCL 0.1 MG PO TABLET

Facility

$2.02

Service Code	HCPCS A9270
Hospital Revenue Code	250
Min. Negotiated Rate	$1.72
Max. Negotiated Rate	$1.96
Rate for Payer: Cash Price	$1.31
Rate for Payer: Health Management Network Commercial	$1.72
Rate for Payer: MDX Hawaii PPO	$1.96

CLONIDINE HCL 0.1 MG PO TABLET

Facility

$2.02

Service Code	HCPCS A9270
Hospital Revenue Code	250
Min. Negotiated Rate	$1.03
Max. Negotiated Rate	$1.96
Rate for Payer: Cash Price	$1.31
Rate for Payer: Hawaii Western Management Group Commercial	$1.92
Rate for Payer: Health Management Network Commercial	$1.72
Rate for Payer: Kaiser Permanente Commercial	$1.27
Rate for Payer: Kaiser Permanente Medicaid	$1.03
Rate for Payer: MDX Hawaii PPO	$1.96
Rate for Payer: UnitedHealthcare Medicaid	$1.21
Rate for Payer: University Health Alliance Commercial	$1.47

CLOPIDOGREL 300 MG PO TABLET

Facility

$128.27

Service Code	HCPCS A9270
Hospital Revenue Code	250
Min. Negotiated Rate	$65.42
Max. Negotiated Rate	$124.42
Rate for Payer: Cash Price	$83.38
Rate for Payer: Cash Price	$86.63
Rate for Payer: Hawaii Western Management Group Commercial	$121.86
Rate for Payer: Hawaii Western Management Group Commercial	$126.62
Rate for Payer: Health Management Network Commercial	$109.03
Rate for Payer: Health Management Network Commercial	$113.29
Rate for Payer: Kaiser Permanente Commercial	$80.81
Rate for Payer: Kaiser Permanente Commercial	$83.97
Rate for Payer: Kaiser Permanente Medicaid	$65.42
Rate for Payer: Kaiser Permanente Medicaid	$67.97
Rate for Payer: MDX Hawaii PPO	$124.42
Rate for Payer: MDX Hawaii PPO	$129.28
Rate for Payer: UnitedHealthcare Medicaid	$79.97
Rate for Payer: UnitedHealthcare Medicaid	$76.96
Rate for Payer: University Health Alliance Commercial	$93.50
Rate for Payer: University Health Alliance Commercial	$97.15

CLOPIDOGREL 300 MG PO TABLET

Facility

$133.28

Service Code	HCPCS A9270
Hospital Revenue Code	250
Min. Negotiated Rate	$113.29
Max. Negotiated Rate	$129.28
Rate for Payer: Cash Price	$86.63
Rate for Payer: Cash Price	$83.38
Rate for Payer: Health Management Network Commercial	$109.03
Rate for Payer: Health Management Network Commercial	$113.29
Rate for Payer: MDX Hawaii PPO	$129.28
Rate for Payer: MDX Hawaii PPO	$124.42

CLOPIDOGREL 75 MG PO TABLET

Facility

$42.55

Service Code	HCPCS A9270
Hospital Revenue Code	250
Min. Negotiated Rate	$36.17
Max. Negotiated Rate	$41.27
Rate for Payer: Cash Price	$27.66
Rate for Payer: Cash Price	$28.09
Rate for Payer: Health Management Network Commercial	$36.74
Rate for Payer: Health Management Network Commercial	$36.17
Rate for Payer: MDX Hawaii PPO	$41.27
Rate for Payer: MDX Hawaii PPO	$41.92

CLOPIDOGREL 75 MG PO TABLET

Facility

$42.55

Service Code	HCPCS A9270
Hospital Revenue Code	250
Min. Negotiated Rate	$21.70
Max. Negotiated Rate	$41.27
Rate for Payer: Cash Price	$27.66
Rate for Payer: Cash Price	$28.09
Rate for Payer: Hawaii Western Management Group Commercial	$40.42
Rate for Payer: Hawaii Western Management Group Commercial	$41.06
Rate for Payer: Health Management Network Commercial	$36.17
Rate for Payer: Health Management Network Commercial	$36.74
Rate for Payer: Kaiser Permanente Commercial	$26.81
Rate for Payer: Kaiser Permanente Commercial	$27.23
Rate for Payer: Kaiser Permanente Medicaid	$22.04
Rate for Payer: Kaiser Permanente Medicaid	$21.70
Rate for Payer: MDX Hawaii PPO	$41.27
Rate for Payer: MDX Hawaii PPO	$41.92
Rate for Payer: UnitedHealthcare Medicaid	$25.53
Rate for Payer: UnitedHealthcare Medicaid	$25.93
Rate for Payer: University Health Alliance Commercial	$31.01
Rate for Payer: University Health Alliance Commercial	$31.50

CLOSED TREATMENT OF DISTAL FIBULAR FRACTURE (LATERAL MALLEOLUS); WITHOUT MANIPULATION

Facility

$2,837.00

Service Code	CPT 27786
Hospital Revenue Code	360
Min. Negotiated Rate	$157.64
Max. Negotiated Rate	$2,837.00
Rate for Payer: AlohaCare Medicaid	$291.40
Rate for Payer: AlohaCare Medicare	$291.40
Rate for Payer: Devoted Health Medicare	$320.54
Rate for Payer: Hawaii Medical Service Association ABD	$393.00
Rate for Payer: Hawaii Medical Service Association Commercial	$2,833.00
Rate for Payer: Hawaii Medical Service Association Medicare	$291.40
Rate for Payer: Hawaii Medical Service Association Non-ABD	$407.95
Rate for Payer: Humana Medicare	$291.40
Rate for Payer: Kaiser Permanente Medicaid	$2,837.00
Rate for Payer: Kaiser Permanente Medicare	$291.40
Rate for Payer: Ohana Health Plan Medicaid	$320.54
Rate for Payer: Ohana Health Plan Medicare	$291.40
Rate for Payer: UnitedHealthcare Medicaid	$157.64
Rate for Payer: UnitedHealthcare Medicare	$291.40

CLOSED TREATMENT OF DISTAL RADIAL FRACTURE (EG, COLLES OR SMITH TYPE) OR EPIPHYSEAL SEPARATION, INCLUDES CLOSED TREATMENT OF FRACTURE OF ULNAR STYLOID, WHEN PERFORMED; WITH MANIPULATION

Facility

$6,183.00

Service Code	CPT 25605
Hospital Revenue Code	360
Min. Negotiated Rate	$340.18
Max. Negotiated Rate	$6,183.00
Rate for Payer: AlohaCare Medicaid	$1,899.59
Rate for Payer: AlohaCare Medicare	$1,899.59
Rate for Payer: Devoted Health Medicare	$2,089.55
Rate for Payer: Hawaii Medical Service Association ABD	$695.00
Rate for Payer: Hawaii Medical Service Association Commercial	$6,183.00
Rate for Payer: Hawaii Medical Service Association Medicare	$1,899.59
Rate for Payer: Hawaii Medical Service Association Non-ABD	$700.72
Rate for Payer: Humana Medicare	$1,899.59
Rate for Payer: Kaiser Permanente Medicaid	$2,837.00
Rate for Payer: Kaiser Permanente Medicare	$1,899.59
Rate for Payer: Ohana Health Plan Medicaid	$2,089.55
Rate for Payer: Ohana Health Plan Medicare	$1,899.59
Rate for Payer: UnitedHealthcare Medicaid	$340.18
Rate for Payer: UnitedHealthcare Medicare	$1,899.59
Rate for Payer: University Health Alliance Commercial	$5,160.40

CLOSED TREATMENT OF DISTAL RADIAL FRACTURE (EG, COLLES OR SMITH TYPE) OR EPIPHYSEAL SEPARATION, INCLUDES CLOSED TREATMENT OF FRACTURE OF ULNAR STYLOID, WHEN PERFORMED; WITHOUT MANIPULATION

Facility

$20,300.00

Service Code	CPT 25600
Hospital Revenue Code	360
Min. Negotiated Rate	$143.02
Max. Negotiated Rate	$20,300.00
Rate for Payer: AlohaCare Medicaid	$291.40
Rate for Payer: AlohaCare Medicare	$291.40
Rate for Payer: Devoted Health Medicare	$320.54
Rate for Payer: Hawaii Medical Service Association Commercial	$364.25
Rate for Payer: Hawaii Medical Service Association Medicare	$291.40
Rate for Payer: Humana Medicare	$291.40
Rate for Payer: Kaiser Permanente Medicaid	$2,837.00
Rate for Payer: Kaiser Permanente Medicare	$291.40
Rate for Payer: Ohana Health Plan Medicaid	$320.54
Rate for Payer: Ohana Health Plan Medicare	$291.40
Rate for Payer: UnitedHealthcare Medicaid	$143.02
Rate for Payer: UnitedHealthcare Medicare	$291.40
Rate for Payer: University Health Alliance Commercial	$20,300.00

CLOSED TREATMENT OF FRACTURE, PHALANX OR PHALANGES, OTHER THAN GREAT TOE; WITH MANIPULATION, EACH

Facility

$2,837.00

Service Code	CPT 28515
Hospital Revenue Code	360
Min. Negotiated Rate	$84.64
Max. Negotiated Rate	$2,837.00
Rate for Payer: AlohaCare Medicaid	$291.40
Rate for Payer: AlohaCare Medicare	$291.40
Rate for Payer: Devoted Health Medicare	$320.54
Rate for Payer: Hawaii Medical Service Association Commercial	$364.25
Rate for Payer: Hawaii Medical Service Association Medicare	$291.40
Rate for Payer: Humana Medicare	$291.40
Rate for Payer: Kaiser Permanente Medicaid	$2,837.00
Rate for Payer: Kaiser Permanente Medicare	$291.40
Rate for Payer: Ohana Health Plan Medicaid	$320.54
Rate for Payer: Ohana Health Plan Medicare	$291.40
Rate for Payer: UnitedHealthcare Medicaid	$84.64
Rate for Payer: UnitedHealthcare Medicare	$291.40

CLOSED TREATMENT OF HIP DISLOCATION, TRAUMATIC; REQUIRING ANESTHESIA

Facility

$5,160.40

Service Code	CPT 27252
Hospital Revenue Code	360
Min. Negotiated Rate	$340.18
Max. Negotiated Rate	$5,160.40
Rate for Payer: AlohaCare Medicaid	$1,899.59
Rate for Payer: AlohaCare Medicare	$1,899.59
Rate for Payer: Devoted Health Medicare	$2,089.55
Rate for Payer: Hawaii Medical Service Association ABD	$393.00
Rate for Payer: Hawaii Medical Service Association Commercial	$2,833.00
Rate for Payer: Hawaii Medical Service Association Medicare	$1,899.59
Rate for Payer: Hawaii Medical Service Association Non-ABD	$407.95
Rate for Payer: Humana Medicare	$1,899.59
Rate for Payer: Kaiser Permanente Medicaid	$2,837.00
Rate for Payer: Kaiser Permanente Medicare	$1,899.59
Rate for Payer: Ohana Health Plan Medicaid	$2,089.55
Rate for Payer: Ohana Health Plan Medicare	$1,899.59
Rate for Payer: UnitedHealthcare Medicaid	$340.18
Rate for Payer: UnitedHealthcare Medicare	$1,899.59
Rate for Payer: University Health Alliance Commercial	$5,160.40

CLOSED TREATMENT OF HUMERAL EPICONDYLAR FRACTURE, MEDIAL OR LATERAL; WITHOUT MANIPULATION

Facility

$2,837.00

Service Code	CPT 24560
Hospital Revenue Code	360
Min. Negotiated Rate	$160.55
Max. Negotiated Rate	$2,837.00
Rate for Payer: AlohaCare Medicaid	$291.40
Rate for Payer: AlohaCare Medicare	$291.40
Rate for Payer: Devoted Health Medicare	$320.54
Rate for Payer: Hawaii Medical Service Association Commercial	$364.25
Rate for Payer: Hawaii Medical Service Association Medicare	$291.40
Rate for Payer: Humana Medicare	$291.40
Rate for Payer: Kaiser Permanente Medicaid	$2,837.00
Rate for Payer: Kaiser Permanente Medicare	$291.40
Rate for Payer: Ohana Health Plan Medicaid	$320.54
Rate for Payer: Ohana Health Plan Medicare	$291.40
Rate for Payer: UnitedHealthcare Medicaid	$160.55
Rate for Payer: UnitedHealthcare Medicare	$291.40

CLOSED TREATMENT OF RADIAL AND ULNAR SHAFT FRACTURES; WITH MANIPULATION

Facility

$10,679.55

Service Code	CPT 25565
Hospital Revenue Code	360
Min. Negotiated Rate	$322.44
Max. Negotiated Rate	$10,679.55
Rate for Payer: AlohaCare Medicaid	$1,899.59
Rate for Payer: AlohaCare Medicare	$1,899.59
Rate for Payer: Devoted Health Medicare	$2,089.55
Rate for Payer: Hawaii Medical Service Association ABD	$393.00
Rate for Payer: Hawaii Medical Service Association Commercial	$2,833.00
Rate for Payer: Hawaii Medical Service Association Medicare	$1,899.59
Rate for Payer: Hawaii Medical Service Association Non-ABD	$407.95
Rate for Payer: Humana Medicare	$1,899.59
Rate for Payer: Kaiser Permanente Medicaid	$2,837.00
Rate for Payer: Kaiser Permanente Medicare	$1,899.59
Rate for Payer: Ohana Health Plan Medicaid	$2,089.55
Rate for Payer: Ohana Health Plan Medicare	$1,899.59
Rate for Payer: UnitedHealthcare Medicaid	$322.44
Rate for Payer: UnitedHealthcare Medicare	$1,899.59
Rate for Payer: University Health Alliance Commercial	$10,679.55

CLOSED TREATMENT OF RADIAL SHAFT FRACTURE AND CLOSED TREATMENT OF DISLOCATION OF DISTAL RADIOULNAR JOINT (GALEAZZI FRACTURE/DISLOCATION)

Facility

$2,837.00

Service Code	CPT 25520
Hospital Revenue Code	360
Min. Negotiated Rate	$366.03
Max. Negotiated Rate	$2,837.00
Rate for Payer: AlohaCare Medicaid	$1,899.59
Rate for Payer: AlohaCare Medicare	$1,899.59
Rate for Payer: Devoted Health Medicare	$2,089.55
Rate for Payer: Hawaii Medical Service Association ABD	$393.00
Rate for Payer: Hawaii Medical Service Association Commercial	$2,833.00
Rate for Payer: Hawaii Medical Service Association Medicare	$1,899.59
Rate for Payer: Hawaii Medical Service Association Non-ABD	$407.95
Rate for Payer: Humana Medicare	$1,899.59
Rate for Payer: Kaiser Permanente Medicaid	$2,837.00
Rate for Payer: Kaiser Permanente Medicare	$1,899.59
Rate for Payer: Ohana Health Plan Medicaid	$2,089.55
Rate for Payer: Ohana Health Plan Medicare	$1,899.59
Rate for Payer: UnitedHealthcare Medicaid	$366.03
Rate for Payer: UnitedHealthcare Medicare	$1,899.59

CLOSED TREATMENT OF RADIAL SHAFT FRACTURE; WITH MANIPULATION

Facility

$2,837.00

Service Code	CPT 25505
Hospital Revenue Code	360
Min. Negotiated Rate	$340.18
Max. Negotiated Rate	$2,837.00
Rate for Payer: AlohaCare Medicaid	$1,899.59
Rate for Payer: AlohaCare Medicare	$1,899.59
Rate for Payer: Devoted Health Medicare	$2,089.55
Rate for Payer: Hawaii Medical Service Association Commercial	$2,374.49
Rate for Payer: Hawaii Medical Service Association Medicare	$1,899.59
Rate for Payer: Humana Medicare	$1,899.59
Rate for Payer: Kaiser Permanente Medicaid	$2,837.00
Rate for Payer: Kaiser Permanente Medicare	$1,899.59
Rate for Payer: Ohana Health Plan Medicaid	$2,089.55
Rate for Payer: Ohana Health Plan Medicare	$1,899.59
Rate for Payer: UnitedHealthcare Medicaid	$340.18
Rate for Payer: UnitedHealthcare Medicare	$1,899.59

CLOSED TREATMENT OF TIBIAL SHAFT FRACTURE (WITH OR WITHOUT FIBULAR FRACTURE); WITH MANIPULATION, WITH OR WITHOUT SKELETAL TRACTION

Facility

$4,035.20

Service Code	CPT 27752
Hospital Revenue Code	360
Min. Negotiated Rate	$393.00
Max. Negotiated Rate	$4,035.20
Rate for Payer: AlohaCare Medicaid	$1,899.59
Rate for Payer: AlohaCare Medicare	$1,899.59
Rate for Payer: Devoted Health Medicare	$2,089.55
Rate for Payer: Hawaii Medical Service Association ABD	$393.00
Rate for Payer: Hawaii Medical Service Association Commercial	$2,833.00
Rate for Payer: Hawaii Medical Service Association Medicare	$1,899.59
Rate for Payer: Hawaii Medical Service Association Non-ABD	$407.95
Rate for Payer: Humana Medicare	$1,899.59
Rate for Payer: Kaiser Permanente Medicaid	$2,837.00
Rate for Payer: Kaiser Permanente Medicare	$1,899.59
Rate for Payer: Ohana Health Plan Medicaid	$2,089.55
Rate for Payer: Ohana Health Plan Medicare	$1,899.59
Rate for Payer: UnitedHealthcare Medicaid	$456.03
Rate for Payer: UnitedHealthcare Medicare	$1,899.59
Rate for Payer: University Health Alliance Commercial	$4,035.20

Know your out-of-pocket cost for care.

All Charges