Kona Community Hospital

All Charges

Charge

Type

Setting

Price

Dermacarrier 3:1 2195013 [3600313]

Facility

$218.21

Hospital Charge Code	3600313
Hospital Revenue Code	272
Min. Negotiated Rate	$111.29
Max. Negotiated Rate	$211.66
Rate for Payer: Cash Price	$141.84
Rate for Payer: Hawaii Western Management Group Commercial	$207.30
Rate for Payer: Health Management Network Commercial	$185.48
Rate for Payer: Kaiser Permanente Commercial	$137.47
Rate for Payer: Kaiser Permanente Medicaid	$111.29
Rate for Payer: MDX Hawaii PPO	$211.66
Rate for Payer: University Health Alliance Commercial	$159.05

Dermacarrier 3:1 2195013 [3600313]

Facility

$218.21

Hospital Charge Code	3600313
Hospital Revenue Code	272
Min. Negotiated Rate	$185.48
Max. Negotiated Rate	$211.66
Rate for Payer: Cash Price	$141.84
Rate for Payer: Health Management Network Commercial	$185.48
Rate for Payer: MDX Hawaii PPO	$211.66

DERMAL AUTOGRAFT, TRUNK, ARMS, LEGS; EACH ADDITIONAL 100 SQ CM, OR EACH ADDITIONAL 1% OF BODY AREA OF INFANTS AND CHILDREN, OR PART THEREOF (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)

Facility

$2,837.00

Service Code	CPT 15131
Hospital Revenue Code	360
Min. Negotiated Rate	$60.44
Max. Negotiated Rate	$2,837.00
Rate for Payer: Kaiser Permanente Medicaid	$2,837.00
Rate for Payer: UnitedHealthcare Medicaid	$60.44

DERMAL AUTOGRAFT, TRUNK, ARMS, LEGS; FIRST 100 SQ CM OR LESS, OR 1% OF BODY AREA OF INFANTS AND CHILDREN

Facility

$6,183.00

Service Code	CPT 15130
Hospital Revenue Code	360
Min. Negotiated Rate	$456.03
Max. Negotiated Rate	$6,183.00
Rate for Payer: AlohaCare Medicaid	$2,437.45
Rate for Payer: AlohaCare Medicare	$2,437.45
Rate for Payer: Devoted Health Medicare	$2,681.20
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	$2,437.45
Rate for Payer: Hawaii Medical Service Association Non-ABD	$700.72
Rate for Payer: Humana Medicare	$2,437.45
Rate for Payer: Kaiser Permanente Medicaid	$2,837.00
Rate for Payer: Kaiser Permanente Medicare	$2,437.45
Rate for Payer: Ohana Health Plan Medicaid	$2,681.20
Rate for Payer: Ohana Health Plan Medicare	$2,437.45
Rate for Payer: UnitedHealthcare Medicaid	$456.03
Rate for Payer: UnitedHealthcare Medicare	$2,437.45
Rate for Payer: University Health Alliance Commercial	$5,160.40

DESMOPRESSIN 4 MCG/ML INJ SOLN

Facility

$175.32

Service Code	HCPCS J2597
Hospital Revenue Code	636
Min. Negotiated Rate	$3.89
Max. Negotiated Rate	$170.06
Rate for Payer: Cash Price	$113.96
Rate for Payer: Cash Price	$113.96
Rate for Payer: Cash Price	$78.98
Rate for Payer: Cash Price	$117.99
Rate for Payer: Cash Price	$78.98
Rate for Payer: Cash Price	$117.99
Rate for Payer: Cash Price	$52.06
Rate for Payer: Cash Price	$52.06
Rate for Payer: Hawaii Medical Service Association ABD	$3.89
Rate for Payer: Hawaii Medical Service Association ABD	$3.89
Rate for Payer: Hawaii Medical Service Association ABD	$3.89
Rate for Payer: Hawaii Medical Service Association ABD	$3.89
Rate for Payer: Hawaii Medical Service Association Non-ABD	$3.89
Rate for Payer: Hawaii Medical Service Association Non-ABD	$3.89
Rate for Payer: Hawaii Medical Service Association Non-ABD	$3.89
Rate for Payer: Hawaii Medical Service Association Non-ABD	$3.89
Rate for Payer: Hawaii Western Management Group Commercial	$166.55
Rate for Payer: Hawaii Western Management Group Commercial	$172.45
Rate for Payer: Hawaii Western Management Group Commercial	$76.09
Rate for Payer: Hawaii Western Management Group Commercial	$115.42
Rate for Payer: Health Management Network Commercial	$149.02
Rate for Payer: Health Management Network Commercial	$103.28
Rate for Payer: Health Management Network Commercial	$154.30
Rate for Payer: Health Management Network Commercial	$68.08
Rate for Payer: Kaiser Permanente Commercial	$110.45
Rate for Payer: Kaiser Permanente Commercial	$50.46
Rate for Payer: Kaiser Permanente Commercial	$114.36
Rate for Payer: Kaiser Permanente Commercial	$76.55
Rate for Payer: Kaiser Permanente Medicaid	$40.85
Rate for Payer: Kaiser Permanente Medicaid	$92.58
Rate for Payer: Kaiser Permanente Medicaid	$89.41
Rate for Payer: Kaiser Permanente Medicaid	$61.97
Rate for Payer: MDX Hawaii PPO	$117.86
Rate for Payer: MDX Hawaii PPO	$176.08
Rate for Payer: MDX Hawaii PPO	$170.06
Rate for Payer: MDX Hawaii PPO	$77.70
Rate for Payer: UnitedHealthcare Medicaid	$105.19
Rate for Payer: UnitedHealthcare Medicaid	$48.06
Rate for Payer: UnitedHealthcare Medicaid	$108.92
Rate for Payer: UnitedHealthcare Medicaid	$72.90
Rate for Payer: University Health Alliance Commercial	$58.38
Rate for Payer: University Health Alliance Commercial	$88.56
Rate for Payer: University Health Alliance Commercial	$127.79
Rate for Payer: University Health Alliance Commercial	$132.32

DESMOPRESSIN 4 MCG/ML INJ SOLN

Facility

$175.32

Service Code	HCPCS J2597
Hospital Revenue Code	250
Min. Negotiated Rate	$149.02
Max. Negotiated Rate	$170.06
Rate for Payer: Cash Price	$113.96
Rate for Payer: Cash Price	$78.98
Rate for Payer: Cash Price	$117.99
Rate for Payer: Cash Price	$52.06
Rate for Payer: Health Management Network Commercial	$103.28
Rate for Payer: Health Management Network Commercial	$68.08
Rate for Payer: Health Management Network Commercial	$154.30
Rate for Payer: Health Management Network Commercial	$149.02
Rate for Payer: MDX Hawaii PPO	$176.08
Rate for Payer: MDX Hawaii PPO	$170.06
Rate for Payer: MDX Hawaii PPO	$117.86
Rate for Payer: MDX Hawaii PPO	$77.70

DESONIDE 0.05 % TOP CR

Facility

$377.10

Service Code	HCPCS A9270
Hospital Revenue Code	250
Min. Negotiated Rate	$320.54
Max. Negotiated Rate	$365.79
Rate for Payer: Cash Price	$245.12
Rate for Payer: Health Management Network Commercial	$320.54
Rate for Payer: MDX Hawaii PPO	$365.79

DESONIDE 0.05 % TOP CR

Facility

$377.10

Service Code	HCPCS A9270
Hospital Revenue Code	250
Min. Negotiated Rate	$192.32
Max. Negotiated Rate	$365.79
Rate for Payer: Cash Price	$245.12
Rate for Payer: Hawaii Western Management Group Commercial	$358.25
Rate for Payer: Health Management Network Commercial	$320.54
Rate for Payer: Kaiser Permanente Commercial	$237.57
Rate for Payer: Kaiser Permanente Medicaid	$192.32
Rate for Payer: MDX Hawaii PPO	$365.79
Rate for Payer: UnitedHealthcare Medicaid	$226.26
Rate for Payer: University Health Alliance Commercial	$274.87

DESTRUCTION OF LESION(S), ANUS (EG, CONDYLOMA, PAPILLOMA, MOLLUSCUM CONTAGIOSUM, HERPETIC VESICLE), SIMPLE; SURGICAL EXCISION

Facility

$6,183.00

Service Code	CPT 46922
Hospital Revenue Code	360
Min. Negotiated Rate	$456.03
Max. Negotiated Rate	$6,183.00
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	$695.00
Rate for Payer: Hawaii Medical Service Association Commercial	$6,183.00
Rate for Payer: Hawaii Medical Service Association Medicare	$3,279.01
Rate for Payer: Hawaii Medical Service Association Non-ABD	$700.72
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

DESVENLAFAXINE SUCCINATE 50 MG PO TAB SR 24H

Facility

$67.48

Service Code	HCPCS A9270
Hospital Revenue Code	250
Min. Negotiated Rate	$34.41
Max. Negotiated Rate	$65.46
Rate for Payer: Cash Price	$43.86
Rate for Payer: Hawaii Western Management Group Commercial	$64.11
Rate for Payer: Health Management Network Commercial	$57.36
Rate for Payer: Kaiser Permanente Commercial	$42.51
Rate for Payer: Kaiser Permanente Medicaid	$34.41
Rate for Payer: MDX Hawaii PPO	$65.46
Rate for Payer: UnitedHealthcare Medicaid	$40.49
Rate for Payer: University Health Alliance Commercial	$49.19

DESVENLAFAXINE SUCCINATE 50 MG PO TAB SR 24H

Facility

$67.48

Service Code	HCPCS A9270
Hospital Revenue Code	250
Min. Negotiated Rate	$57.36
Max. Negotiated Rate	$65.46
Rate for Payer: Cash Price	$43.86
Rate for Payer: Health Management Network Commercial	$57.36
Rate for Payer: MDX Hawaii PPO	$65.46

DEXAMETHASONE 0.5 MG PO TABLET

Facility

$1.20

Service Code	HCPCS J8540
Hospital Revenue Code	636
Min. Negotiated Rate	$0.02
Max. Negotiated Rate	$1.16
Rate for Payer: Cash Price	$0.78
Rate for Payer: Cash Price	$0.78
Rate for Payer: Hawaii Medical Service Association ABD	$0.02
Rate for Payer: Hawaii Medical Service Association Non-ABD	$0.02
Rate for Payer: Hawaii Western Management Group Commercial	$1.14
Rate for Payer: Health Management Network Commercial	$1.02
Rate for Payer: Kaiser Permanente Commercial	$0.76
Rate for Payer: Kaiser Permanente Medicaid	$0.61
Rate for Payer: MDX Hawaii PPO	$1.16
Rate for Payer: UnitedHealthcare Medicaid	$0.72
Rate for Payer: University Health Alliance Commercial	$0.87

DEXAMETHASONE 0.5 MG PO TABLET

Facility

$1.20

Service Code	HCPCS J8540
Hospital Revenue Code	250
Min. Negotiated Rate	$1.02
Max. Negotiated Rate	$1.16
Rate for Payer: Cash Price	$0.78
Rate for Payer: Health Management Network Commercial	$1.02
Rate for Payer: MDX Hawaii PPO	$1.16

DEXAMETHASONE 2 MG PO TABLET

Facility

$3.29

Service Code	HCPCS J8540
Hospital Revenue Code	250
Min. Negotiated Rate	$2.80
Max. Negotiated Rate	$3.19
Rate for Payer: Cash Price	$2.14
Rate for Payer: Health Management Network Commercial	$2.80
Rate for Payer: MDX Hawaii PPO	$3.19

DEXAMETHASONE 2 MG PO TABLET

Facility

$3.29

Service Code	HCPCS J8540
Hospital Revenue Code	636
Min. Negotiated Rate	$0.02
Max. Negotiated Rate	$3.19
Rate for Payer: Cash Price	$2.14
Rate for Payer: Cash Price	$2.14
Rate for Payer: Hawaii Medical Service Association ABD	$0.02
Rate for Payer: Hawaii Medical Service Association Non-ABD	$0.02
Rate for Payer: Hawaii Western Management Group Commercial	$3.13
Rate for Payer: Health Management Network Commercial	$2.80
Rate for Payer: Kaiser Permanente Commercial	$2.07
Rate for Payer: Kaiser Permanente Medicaid	$1.68
Rate for Payer: MDX Hawaii PPO	$3.19
Rate for Payer: UnitedHealthcare Medicaid	$1.97
Rate for Payer: University Health Alliance Commercial	$2.40

DEXAMETHASONE 4 MG PO TABLET

Facility

$6.66

Service Code	HCPCS J8540
Hospital Revenue Code	250
Min. Negotiated Rate	$5.66
Max. Negotiated Rate	$6.46
Rate for Payer: Cash Price	$4.33
Rate for Payer: Health Management Network Commercial	$5.66
Rate for Payer: MDX Hawaii PPO	$6.46

DEXAMETHASONE 4 MG PO TABLET

Facility

$6.66

Service Code	HCPCS J8540
Hospital Revenue Code	636
Min. Negotiated Rate	$0.02
Max. Negotiated Rate	$6.46
Rate for Payer: Cash Price	$4.33
Rate for Payer: Cash Price	$4.33
Rate for Payer: Hawaii Medical Service Association ABD	$0.02
Rate for Payer: Hawaii Medical Service Association Non-ABD	$0.02
Rate for Payer: Hawaii Western Management Group Commercial	$6.33
Rate for Payer: Health Management Network Commercial	$5.66
Rate for Payer: Kaiser Permanente Commercial	$4.20
Rate for Payer: Kaiser Permanente Medicaid	$3.40
Rate for Payer: MDX Hawaii PPO	$6.46
Rate for Payer: UnitedHealthcare Medicaid	$4.00
Rate for Payer: University Health Alliance Commercial	$4.85

DEXAMETHASONE SODIUM PHOSPHATE 10 MG/ML INJ SOLN

Facility

$7.89

Service Code	HCPCS J1100
Hospital Revenue Code	250
Min. Negotiated Rate	$6.71
Max. Negotiated Rate	$7.65
Rate for Payer: Cash Price	$5.13
Rate for Payer: Health Management Network Commercial	$6.71
Rate for Payer: MDX Hawaii PPO	$7.65

DEXAMETHASONE SODIUM PHOSPHATE 10 MG/ML INJ SOLN

Facility

$7.89

Service Code	HCPCS J1100
Hospital Revenue Code	636
Min. Negotiated Rate	$0.12
Max. Negotiated Rate	$7.65
Rate for Payer: Cash Price	$5.13
Rate for Payer: Cash Price	$5.13
Rate for Payer: Hawaii Medical Service Association ABD	$0.12
Rate for Payer: Hawaii Medical Service Association Non-ABD	$0.12
Rate for Payer: Hawaii Western Management Group Commercial	$7.50
Rate for Payer: Health Management Network Commercial	$6.71
Rate for Payer: Kaiser Permanente Commercial	$4.97
Rate for Payer: Kaiser Permanente Medicaid	$4.02
Rate for Payer: MDX Hawaii PPO	$7.65
Rate for Payer: UnitedHealthcare Medicaid	$4.73
Rate for Payer: University Health Alliance Commercial	$5.75

DEXAMETHASONE SODIUM PHOSPHATE 10 MG/ML INJ SOLN (FOR OTHER USE)

Facility

$7.89

Service Code	NDC 00641036721
Hospital Revenue Code	250
Min. Negotiated Rate	$6.71
Max. Negotiated Rate	$7.65
Rate for Payer: Cash Price	$5.13
Rate for Payer: Health Management Network Commercial	$6.71
Rate for Payer: MDX Hawaii PPO	$7.65

DEXAMETHASONE SODIUM PHOSPHATE 10 MG/ML INJ SOLN (FOR OTHER USE)

Facility

$7.89

Service Code	NDC 00641036725
Hospital Revenue Code	250
Min. Negotiated Rate	$6.71
Max. Negotiated Rate	$7.65
Rate for Payer: Cash Price	$5.13
Rate for Payer: Health Management Network Commercial	$6.71
Rate for Payer: MDX Hawaii PPO	$7.65

DEXAMETHASONE SODIUM PHOSPHATE 10 MG/ML INJ SOLN (FOR OTHER USE)

Facility

$7.89

Service Code	NDC 00641036725
Hospital Revenue Code	250
Min. Negotiated Rate	$4.02
Max. Negotiated Rate	$7.65
Rate for Payer: Cash Price	$5.13
Rate for Payer: Hawaii Western Management Group Commercial	$7.50
Rate for Payer: Health Management Network Commercial	$6.71
Rate for Payer: Kaiser Permanente Commercial	$4.97
Rate for Payer: Kaiser Permanente Medicaid	$4.02
Rate for Payer: MDX Hawaii PPO	$7.65
Rate for Payer: UnitedHealthcare Medicaid	$4.73
Rate for Payer: University Health Alliance Commercial	$5.75

DEXAMETHASONE SODIUM PHOSPHATE 10 MG/ML INJ SOLN (FOR OTHER USE)

Facility

$7.89

Service Code	NDC 00641036721
Hospital Revenue Code	250
Min. Negotiated Rate	$4.02
Max. Negotiated Rate	$7.65
Rate for Payer: Cash Price	$5.13
Rate for Payer: Hawaii Western Management Group Commercial	$7.50
Rate for Payer: Health Management Network Commercial	$6.71
Rate for Payer: Kaiser Permanente Commercial	$4.97
Rate for Payer: Kaiser Permanente Medicaid	$4.02
Rate for Payer: MDX Hawaii PPO	$7.65
Rate for Payer: UnitedHealthcare Medicaid	$4.73
Rate for Payer: University Health Alliance Commercial	$5.75

DEXAMETHASONE SODIUM PHOSPHATE 20 MG/5ML INJ SOLN

Facility

$43.02

Service Code	HCPCS J1100
Hospital Revenue Code	636
Min. Negotiated Rate	$0.12
Max. Negotiated Rate	$41.73
Rate for Payer: Cash Price	$27.96
Rate for Payer: Cash Price	$27.96
Rate for Payer: Hawaii Medical Service Association ABD	$0.12
Rate for Payer: Hawaii Medical Service Association Non-ABD	$0.12
Rate for Payer: Hawaii Western Management Group Commercial	$40.87
Rate for Payer: Health Management Network Commercial	$36.57
Rate for Payer: Kaiser Permanente Commercial	$27.10
Rate for Payer: Kaiser Permanente Medicaid	$21.94
Rate for Payer: MDX Hawaii PPO	$41.73
Rate for Payer: UnitedHealthcare Medicaid	$25.81
Rate for Payer: University Health Alliance Commercial	$31.36

DEXAMETHASONE SODIUM PHOSPHATE 20 MG/5ML INJ SOLN

Facility

$43.02

Service Code	HCPCS J1100
Hospital Revenue Code	250
Min. Negotiated Rate	$36.57
Max. Negotiated Rate	$41.73
Rate for Payer: Cash Price	$27.96
Rate for Payer: Health Management Network Commercial	$36.57
Rate for Payer: MDX Hawaii PPO	$41.73

Know your out-of-pocket cost for care.

All Charges