Kona Community Hospital

All Charges

Charge

Type

Setting

Price

CLOSURE OF ANAL FISTULA WITH RECTAL ADVANCEMENT FLAP

Facility

$14,715.00

Service Code	CPT 46288
Hospital Revenue Code	360
Min. Negotiated Rate	$456.03
Max. Negotiated Rate	$14,715.00
Rate for Payer: AlohaCare Medicaid	$3,279.01
Rate for Payer: AlohaCare Medicare	$3,279.01
Rate for Payer: Devoted Health Medicare	$3,606.91
Rate for Payer: Hawaii Medical Service Association ABD	$1,149.00
Rate for Payer: Hawaii Medical Service Association Commercial	$14,715.00
Rate for Payer: Hawaii Medical Service Association Medicare	$3,279.01
Rate for Payer: Hawaii Medical Service Association Non-ABD	$1,154.45
Rate for Payer: Humana Medicare	$3,279.01
Rate for Payer: Kaiser Permanente Medicaid	$2,837.00
Rate for Payer: Kaiser Permanente Medicare	$3,279.01
Rate for Payer: Ohana Health Plan Medicaid	$3,606.91
Rate for Payer: Ohana Health Plan Medicare	$3,279.01
Rate for Payer: UnitedHealthcare Medicaid	$456.03
Rate for Payer: UnitedHealthcare Medicare	$3,279.01
Rate for Payer: University Health Alliance Commercial	$10,679.55

CLOSURE OF ENTEROSTOMY, LARGE OR SMALL INTESTINE; WITH RESECTION AND ANASTOMOSIS OTHER THAN COLORECTAL

Facility

$2,837.00

Service Code	CPT 44625
Hospital Revenue Code	360
Min. Negotiated Rate	$648.22
Max. Negotiated Rate	$2,837.00
Rate for Payer: Kaiser Permanente Medicaid	$2,837.00
Rate for Payer: UnitedHealthcare Medicaid	$648.22

CLOSURE OF RECTOVAGINAL FISTULA; VAGINAL OR TRANSANAL APPROACH

Facility

$14,715.00

Service Code	CPT 57300
Hospital Revenue Code	360
Min. Negotiated Rate	$456.03
Max. Negotiated Rate	$14,715.00
Rate for Payer: AlohaCare Medicaid	$3,824.16
Rate for Payer: AlohaCare Medicare	$3,824.16
Rate for Payer: Devoted Health Medicare	$4,206.58
Rate for Payer: Hawaii Medical Service Association ABD	$1,149.00
Rate for Payer: Hawaii Medical Service Association Commercial	$14,715.00
Rate for Payer: Hawaii Medical Service Association Medicare	$3,824.16
Rate for Payer: Hawaii Medical Service Association Non-ABD	$1,154.45
Rate for Payer: Humana Medicare	$3,824.16
Rate for Payer: Kaiser Permanente Medicaid	$2,837.00
Rate for Payer: Kaiser Permanente Medicare	$3,824.16
Rate for Payer: Ohana Health Plan Medicaid	$4,206.58
Rate for Payer: Ohana Health Plan Medicare	$3,824.16
Rate for Payer: UnitedHealthcare Medicaid	$456.03
Rate for Payer: UnitedHealthcare Medicare	$3,824.16
Rate for Payer: University Health Alliance Commercial	$6,743.44

CLOTRIMAZOLE 10 MG MM TROCHE

Facility

$8.88

Service Code	HCPCS A9270
Hospital Revenue Code	250
Min. Negotiated Rate	$4.53
Max. Negotiated Rate	$8.61
Rate for Payer: Cash Price	$5.77
Rate for Payer: Hawaii Western Management Group Commercial	$8.44
Rate for Payer: Health Management Network Commercial	$7.55
Rate for Payer: Kaiser Permanente Commercial	$5.59
Rate for Payer: Kaiser Permanente Medicaid	$4.53
Rate for Payer: MDX Hawaii PPO	$8.61
Rate for Payer: UnitedHealthcare Medicaid	$5.33
Rate for Payer: University Health Alliance Commercial	$6.47

CLOTRIMAZOLE 10 MG MM TROCHE

Facility

$8.88

Service Code	HCPCS A9270
Hospital Revenue Code	250
Min. Negotiated Rate	$7.55
Max. Negotiated Rate	$8.61
Rate for Payer: Cash Price	$5.77
Rate for Payer: Health Management Network Commercial	$7.55
Rate for Payer: MDX Hawaii PPO	$8.61

CLOTRIMAZOLE 1 % TOP CR

Facility

$40.03

Service Code	HCPCS A9270
Hospital Revenue Code	250
Min. Negotiated Rate	$20.42
Max. Negotiated Rate	$38.83
Rate for Payer: Cash Price	$26.02
Rate for Payer: Cash Price	$32.98
Rate for Payer: Hawaii Western Management Group Commercial	$38.03
Rate for Payer: Hawaii Western Management Group Commercial	$48.20
Rate for Payer: Health Management Network Commercial	$34.03
Rate for Payer: Health Management Network Commercial	$43.13
Rate for Payer: Kaiser Permanente Commercial	$25.22
Rate for Payer: Kaiser Permanente Commercial	$31.97
Rate for Payer: Kaiser Permanente Medicaid	$20.42
Rate for Payer: Kaiser Permanente Medicaid	$25.88
Rate for Payer: MDX Hawaii PPO	$38.83
Rate for Payer: MDX Hawaii PPO	$49.22
Rate for Payer: UnitedHealthcare Medicaid	$30.44
Rate for Payer: UnitedHealthcare Medicaid	$24.02
Rate for Payer: University Health Alliance Commercial	$29.18
Rate for Payer: University Health Alliance Commercial	$36.98

CLOTRIMAZOLE 1 % TOP CR

Facility

$50.74

Service Code	HCPCS A9270
Hospital Revenue Code	250
Min. Negotiated Rate	$43.13
Max. Negotiated Rate	$49.22
Rate for Payer: Cash Price	$32.98
Rate for Payer: Cash Price	$26.02
Rate for Payer: Health Management Network Commercial	$34.03
Rate for Payer: Health Management Network Commercial	$43.13
Rate for Payer: MDX Hawaii PPO	$49.22
Rate for Payer: MDX Hawaii PPO	$38.83

CLOTRIMAZOLE-BETAMETHASONE 1-0.05 % TOP CR

Facility

$178.41

Service Code	HCPCS A9270
Hospital Revenue Code	250
Min. Negotiated Rate	$90.99
Max. Negotiated Rate	$173.06
Rate for Payer: Cash Price	$115.97
Rate for Payer: Cash Price	$109.43
Rate for Payer: Cash Price	$57.08
Rate for Payer: Hawaii Western Management Group Commercial	$159.93
Rate for Payer: Hawaii Western Management Group Commercial	$83.42
Rate for Payer: Hawaii Western Management Group Commercial	$169.49
Rate for Payer: Health Management Network Commercial	$74.64
Rate for Payer: Health Management Network Commercial	$143.10
Rate for Payer: Health Management Network Commercial	$151.65
Rate for Payer: Kaiser Permanente Commercial	$106.06
Rate for Payer: Kaiser Permanente Commercial	$112.40
Rate for Payer: Kaiser Permanente Commercial	$55.32
Rate for Payer: Kaiser Permanente Medicaid	$44.78
Rate for Payer: Kaiser Permanente Medicaid	$90.99
Rate for Payer: Kaiser Permanente Medicaid	$85.86
Rate for Payer: MDX Hawaii PPO	$85.18
Rate for Payer: MDX Hawaii PPO	$163.30
Rate for Payer: MDX Hawaii PPO	$173.06
Rate for Payer: UnitedHealthcare Medicaid	$107.05
Rate for Payer: UnitedHealthcare Medicaid	$101.01
Rate for Payer: UnitedHealthcare Medicaid	$52.69
Rate for Payer: University Health Alliance Commercial	$64.00
Rate for Payer: University Health Alliance Commercial	$122.71
Rate for Payer: University Health Alliance Commercial	$130.04

CLOTRIMAZOLE-BETAMETHASONE 1-0.05 % TOP CR

Facility

$178.41

Service Code	HCPCS A9270
Hospital Revenue Code	250
Min. Negotiated Rate	$151.65
Max. Negotiated Rate	$173.06
Rate for Payer: Cash Price	$115.97
Rate for Payer: Cash Price	$57.08
Rate for Payer: Cash Price	$109.43
Rate for Payer: Health Management Network Commercial	$143.10
Rate for Payer: Health Management Network Commercial	$151.65
Rate for Payer: Health Management Network Commercial	$74.64
Rate for Payer: MDX Hawaii PPO	$163.30
Rate for Payer: MDX Hawaii PPO	$85.18
Rate for Payer: MDX Hawaii PPO	$173.06

CLOZAPINE 100 MG PO TABLET

Facility

$9.11

Service Code	HCPCS A9270
Hospital Revenue Code	250
Min. Negotiated Rate	$4.65
Max. Negotiated Rate	$8.84
Rate for Payer: Cash Price	$5.92
Rate for Payer: Cash Price	$12.41
Rate for Payer: Hawaii Western Management Group Commercial	$18.14
Rate for Payer: Hawaii Western Management Group Commercial	$8.65
Rate for Payer: Health Management Network Commercial	$16.23
Rate for Payer: Health Management Network Commercial	$7.74
Rate for Payer: Kaiser Permanente Commercial	$5.74
Rate for Payer: Kaiser Permanente Commercial	$12.03
Rate for Payer: Kaiser Permanente Medicaid	$4.65
Rate for Payer: Kaiser Permanente Medicaid	$9.74
Rate for Payer: MDX Hawaii PPO	$18.52
Rate for Payer: MDX Hawaii PPO	$8.84
Rate for Payer: UnitedHealthcare Medicaid	$11.45
Rate for Payer: UnitedHealthcare Medicaid	$5.47
Rate for Payer: University Health Alliance Commercial	$6.64
Rate for Payer: University Health Alliance Commercial	$13.91

CLOZAPINE 100 MG PO TABLET

Facility

$19.09

Service Code	HCPCS A9270
Hospital Revenue Code	250
Min. Negotiated Rate	$16.23
Max. Negotiated Rate	$18.52
Rate for Payer: Cash Price	$12.41
Rate for Payer: Cash Price	$5.92
Rate for Payer: Health Management Network Commercial	$16.23
Rate for Payer: Health Management Network Commercial	$7.74
Rate for Payer: MDX Hawaii PPO	$18.52
Rate for Payer: MDX Hawaii PPO	$8.84

CLOZAPINE 25 MG PO TABLET

Facility

$3.59

Service Code	HCPCS A9270
Hospital Revenue Code	250
Min. Negotiated Rate	$1.83
Max. Negotiated Rate	$3.48
Rate for Payer: Cash Price	$2.33
Rate for Payer: Cash Price	$4.78
Rate for Payer: Hawaii Western Management Group Commercial	$3.41
Rate for Payer: Hawaii Western Management Group Commercial	$6.98
Rate for Payer: Health Management Network Commercial	$3.05
Rate for Payer: Health Management Network Commercial	$6.25
Rate for Payer: Kaiser Permanente Commercial	$2.26
Rate for Payer: Kaiser Permanente Commercial	$4.63
Rate for Payer: Kaiser Permanente Medicaid	$1.83
Rate for Payer: Kaiser Permanente Medicaid	$3.75
Rate for Payer: MDX Hawaii PPO	$3.48
Rate for Payer: MDX Hawaii PPO	$7.13
Rate for Payer: UnitedHealthcare Medicaid	$4.41
Rate for Payer: UnitedHealthcare Medicaid	$2.15
Rate for Payer: University Health Alliance Commercial	$2.62
Rate for Payer: University Health Alliance Commercial	$5.36

CLOZAPINE 25 MG PO TABLET

Facility

$3.59

Service Code	HCPCS A9270
Hospital Revenue Code	250
Min. Negotiated Rate	$3.05
Max. Negotiated Rate	$3.48
Rate for Payer: Cash Price	$2.33
Rate for Payer: Cash Price	$4.78
Rate for Payer: Health Management Network Commercial	$6.25
Rate for Payer: Health Management Network Commercial	$3.05
Rate for Payer: MDX Hawaii PPO	$3.48
Rate for Payer: MDX Hawaii PPO	$7.13

COAGULATION DISORDERS

Facility

$32,809.63

Service Code	MSDRG 813
Min. Negotiated Rate	$20,061.90
Max. Negotiated Rate	$32,809.63
Rate for Payer: AlohaCare Medicare	$20,061.90
Rate for Payer: Devoted Health Medicare	$22,068.09
Rate for Payer: Hawaii Medical Service Association Commercial	$32,809.63
Rate for Payer: Hawaii Medical Service Association Medicare	$20,061.90
Rate for Payer: Humana Medicare	$20,061.90
Rate for Payer: Kaiser Permanente Commercial	$26,311.42
Rate for Payer: Kaiser Permanente Medicare	$20,061.90
Rate for Payer: Ohana Health Plan Medicare	$20,061.90
Rate for Payer: UnitedHealthcare Medicare	$20,061.90

COAGULATION FACTOR VIIA RECOMB 1 MG (1,000 MCG) IV RECON.SOLN.

Facility

$15.52

Service Code	HCPCS J7189
Hospital Revenue Code	636
Min. Negotiated Rate	$2.64
Max. Negotiated Rate	$15.05
Rate for Payer: AlohaCare Medicaid	$2.64
Rate for Payer: AlohaCare Medicare	$2.64
Rate for Payer: Cash Price	$10.09
Rate for Payer: Cash Price	$10.09
Rate for Payer: Devoted Health Medicare	$2.90
Rate for Payer: Hawaii Medical Service Association Commercial	$3.30
Rate for Payer: Hawaii Medical Service Association Medicare	$2.64
Rate for Payer: Hawaii Western Management Group Commercial	$14.74
Rate for Payer: Health Management Network Commercial	$13.19
Rate for Payer: Humana Medicare	$2.64
Rate for Payer: Kaiser Permanente Commercial	$9.78
Rate for Payer: Kaiser Permanente Medicaid	$7.92
Rate for Payer: Kaiser Permanente Medicare	$2.64
Rate for Payer: MDX Hawaii PPO	$15.05
Rate for Payer: Ohana Health Plan Medicaid	$2.90
Rate for Payer: Ohana Health Plan Medicare	$2.64
Rate for Payer: UnitedHealthcare Medicaid	$9.31
Rate for Payer: UnitedHealthcare Medicare	$2.64
Rate for Payer: University Health Alliance Commercial	$11.31

COAGULATION FACTOR VIIA RECOMB 1 MG (1,000 MCG) IV RECON.SOLN.

Facility

$15.52

Service Code	HCPCS J7189
Hospital Revenue Code	250
Min. Negotiated Rate	$13.19
Max. Negotiated Rate	$15.05
Rate for Payer: Cash Price	$10.09
Rate for Payer: Health Management Network Commercial	$13.19
Rate for Payer: MDX Hawaii PPO	$15.05

COAGULATION FACTOR VIIA RECOMB 2 MG (2,000 MCG) IV RECON.SOLN.

Facility

$15.52

Service Code	HCPCS J7189
Hospital Revenue Code	250
Min. Negotiated Rate	$13.19
Max. Negotiated Rate	$15.05
Rate for Payer: Cash Price	$10.09
Rate for Payer: Health Management Network Commercial	$13.19
Rate for Payer: MDX Hawaii PPO	$15.05

COAGULATION FACTOR VIIA RECOMB 2 MG (2,000 MCG) IV RECON.SOLN.

Facility

$15.52

Service Code	HCPCS J7189
Hospital Revenue Code	636
Min. Negotiated Rate	$2.64
Max. Negotiated Rate	$15.05
Rate for Payer: AlohaCare Medicaid	$2.64
Rate for Payer: AlohaCare Medicare	$2.64
Rate for Payer: Cash Price	$10.09
Rate for Payer: Cash Price	$10.09
Rate for Payer: Devoted Health Medicare	$2.90
Rate for Payer: Hawaii Medical Service Association Commercial	$3.30
Rate for Payer: Hawaii Medical Service Association Medicare	$2.64
Rate for Payer: Hawaii Western Management Group Commercial	$14.74
Rate for Payer: Health Management Network Commercial	$13.19
Rate for Payer: Humana Medicare	$2.64
Rate for Payer: Kaiser Permanente Commercial	$9.78
Rate for Payer: Kaiser Permanente Medicaid	$7.92
Rate for Payer: Kaiser Permanente Medicare	$2.64
Rate for Payer: MDX Hawaii PPO	$15.05
Rate for Payer: Ohana Health Plan Medicaid	$2.90
Rate for Payer: Ohana Health Plan Medicare	$2.64
Rate for Payer: UnitedHealthcare Medicaid	$9.31
Rate for Payer: UnitedHealthcare Medicare	$2.64
Rate for Payer: University Health Alliance Commercial	$11.31

COAGULATION & PLATELET DISORDERS

Facility

$7,181.86

Service Code	APR-DRG 6613
Min. Negotiated Rate	$7,181.86
Max. Negotiated Rate	$7,181.86
Rate for Payer: AlohaCare Medicaid	$7,181.86
Rate for Payer: Hawaii Medical Service Association ABD	$7,181.86
Rate for Payer: Hawaii Medical Service Association Non-ABD	$7,181.86
Rate for Payer: Kaiser Permanente Medicaid	$7,181.86
Rate for Payer: Ohana Health Plan Medicaid	$7,181.86
Rate for Payer: UnitedHealthcare Medicaid	$7,181.86

COAGULATION & PLATELET DISORDERS

Facility

$3,408.17

Service Code	APR-DRG 6611
Min. Negotiated Rate	$3,408.17
Max. Negotiated Rate	$3,408.17
Rate for Payer: AlohaCare Medicaid	$3,408.17
Rate for Payer: Hawaii Medical Service Association ABD	$3,408.17
Rate for Payer: Hawaii Medical Service Association Non-ABD	$3,408.17
Rate for Payer: Kaiser Permanente Medicaid	$3,408.17
Rate for Payer: Ohana Health Plan Medicaid	$3,408.17
Rate for Payer: UnitedHealthcare Medicaid	$3,408.17

COAGULATION & PLATELET DISORDERS

Facility

$12,837.31

Service Code	APR-DRG 6614
Min. Negotiated Rate	$12,837.31
Max. Negotiated Rate	$12,837.31
Rate for Payer: AlohaCare Medicaid	$12,837.31
Rate for Payer: Hawaii Medical Service Association ABD	$12,837.31
Rate for Payer: Hawaii Medical Service Association Non-ABD	$12,837.31
Rate for Payer: Kaiser Permanente Medicaid	$12,837.31
Rate for Payer: Ohana Health Plan Medicaid	$12,837.31
Rate for Payer: UnitedHealthcare Medicaid	$12,837.31

COAGULATION & PLATELET DISORDERS

Facility

$4,702.15

Service Code	APR-DRG 6612
Min. Negotiated Rate	$4,702.15
Max. Negotiated Rate	$4,702.15
Rate for Payer: AlohaCare Medicaid	$4,702.15
Rate for Payer: Hawaii Medical Service Association ABD	$4,702.15
Rate for Payer: Hawaii Medical Service Association Non-ABD	$4,702.15
Rate for Payer: Kaiser Permanente Medicaid	$4,702.15
Rate for Payer: Ohana Health Plan Medicaid	$4,702.15
Rate for Payer: UnitedHealthcare Medicaid	$4,702.15

Cobra Suture Passer Capture SP 3910-900-097 [3644272]

Facility

$1,331.88

Hospital Charge Code	3644272
Hospital Revenue Code	272
Min. Negotiated Rate	$1,132.10
Max. Negotiated Rate	$1,291.92
Rate for Payer: Cash Price	$865.72
Rate for Payer: Health Management Network Commercial	$1,132.10
Rate for Payer: MDX Hawaii PPO	$1,291.92

Cobra Suture Passer Capture SP 3910-900-097 [3644272]

Facility

$1,331.88

Hospital Charge Code	3644272
Hospital Revenue Code	272
Min. Negotiated Rate	$679.26
Max. Negotiated Rate	$1,291.92
Rate for Payer: Cash Price	$865.72
Rate for Payer: Hawaii Western Management Group Commercial	$1,265.29
Rate for Payer: Health Management Network Commercial	$1,132.10
Rate for Payer: Kaiser Permanente Commercial	$839.08
Rate for Payer: Kaiser Permanente Medicaid	$679.26
Rate for Payer: MDX Hawaii PPO	$1,291.92
Rate for Payer: University Health Alliance Commercial	$970.81

COCAINE 4 % NASAL SOLN

Facility

$1,134.35

Service Code	HCPCS C9046
Hospital Revenue Code	250
Min. Negotiated Rate	$578.52
Max. Negotiated Rate	$1,100.32
Rate for Payer: Cash Price	$737.33
Rate for Payer: Hawaii Western Management Group Commercial	$1,077.63
Rate for Payer: Health Management Network Commercial	$964.20
Rate for Payer: Kaiser Permanente Commercial	$714.64
Rate for Payer: Kaiser Permanente Medicaid	$578.52
Rate for Payer: MDX Hawaii PPO	$1,100.32
Rate for Payer: UnitedHealthcare Medicaid	$680.61
Rate for Payer: University Health Alliance Commercial	$826.83

Know your out-of-pocket cost for care.

All Charges