Kona Community Hospital

All Charges

Charge

Type

Setting

Price

DEXAMETHASONE SODIUM PHOSPHATE 4 MG/ML INJ SOLN

Facility

$12.92

Service Code	HCPCS J1100
Hospital Revenue Code	636
Min. Negotiated Rate	$0.12
Max. Negotiated Rate	$12.53
Rate for Payer: Cash Price	$8.40
Rate for Payer: Cash Price	$8.40
Rate for Payer: Cash Price	$3.56
Rate for Payer: Cash Price	$3.56
Rate for Payer: Hawaii Medical Service Association ABD	$0.12
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 Medical Service Association Non-ABD	$0.12
Rate for Payer: Hawaii Western Management Group Commercial	$12.27
Rate for Payer: Hawaii Western Management Group Commercial	$5.20
Rate for Payer: Health Management Network Commercial	$10.98
Rate for Payer: Health Management Network Commercial	$4.65
Rate for Payer: Kaiser Permanente Commercial	$8.14
Rate for Payer: Kaiser Permanente Commercial	$3.45
Rate for Payer: Kaiser Permanente Medicaid	$2.79
Rate for Payer: Kaiser Permanente Medicaid	$6.59
Rate for Payer: MDX Hawaii PPO	$5.31
Rate for Payer: MDX Hawaii PPO	$12.53
Rate for Payer: UnitedHealthcare Medicaid	$7.75
Rate for Payer: UnitedHealthcare Medicaid	$3.28
Rate for Payer: University Health Alliance Commercial	$9.42
Rate for Payer: University Health Alliance Commercial	$3.99

DEXAMETHASONE SODIUM PHOSPHATE 4 MG/ML INJ SOLN

Facility

$5.47

Service Code	HCPCS J1100
Hospital Revenue Code	250
Min. Negotiated Rate	$4.65
Max. Negotiated Rate	$5.31
Rate for Payer: Cash Price	$3.56
Rate for Payer: Cash Price	$8.40
Rate for Payer: Health Management Network Commercial	$10.98
Rate for Payer: Health Management Network Commercial	$4.65
Rate for Payer: MDX Hawaii PPO	$5.31
Rate for Payer: MDX Hawaii PPO	$12.53

DEXAMETHASONE SODIUM PHOSPHATE 4 MG/ML INJ SOLN (FOR OTHER USE)

Facility

$5.47

Service Code	NDC 67457042312
Hospital Revenue Code	250
Min. Negotiated Rate	$2.79
Max. Negotiated Rate	$5.31
Rate for Payer: Cash Price	$3.56
Rate for Payer: Hawaii Western Management Group Commercial	$5.20
Rate for Payer: Health Management Network Commercial	$4.65
Rate for Payer: Kaiser Permanente Commercial	$3.45
Rate for Payer: Kaiser Permanente Medicaid	$2.79
Rate for Payer: MDX Hawaii PPO	$5.31
Rate for Payer: UnitedHealthcare Medicaid	$3.28
Rate for Payer: University Health Alliance Commercial	$3.99

DEXAMETHASONE SODIUM PHOSPHATE 4 MG/ML INJ SOLN (FOR OTHER USE)

Facility

$12.92

Service Code	NDC 67457042254
Hospital Revenue Code	250
Min. Negotiated Rate	$10.98
Max. Negotiated Rate	$12.53
Rate for Payer: Cash Price	$8.40
Rate for Payer: Health Management Network Commercial	$10.98
Rate for Payer: MDX Hawaii PPO	$12.53

DEXAMETHASONE SODIUM PHOSPHATE 4 MG/ML INJ SOLN (FOR OTHER USE)

Facility

$12.92

Service Code	NDC 67457042200
Hospital Revenue Code	250
Min. Negotiated Rate	$10.98
Max. Negotiated Rate	$12.53
Rate for Payer: Cash Price	$8.40
Rate for Payer: Health Management Network Commercial	$10.98
Rate for Payer: MDX Hawaii PPO	$12.53

DEXAMETHASONE SODIUM PHOSPHATE 4 MG/ML INJ SOLN (FOR OTHER USE)

Facility

$5.47

Service Code	NDC 67457042300
Hospital Revenue Code	250
Min. Negotiated Rate	$4.65
Max. Negotiated Rate	$5.31
Rate for Payer: Cash Price	$3.56
Rate for Payer: Health Management Network Commercial	$4.65
Rate for Payer: MDX Hawaii PPO	$5.31

DEXAMETHASONE SODIUM PHOSPHATE 4 MG/ML INJ SOLN (FOR OTHER USE)

Facility

$12.92

Service Code	NDC 67457042200
Hospital Revenue Code	250
Min. Negotiated Rate	$6.59
Max. Negotiated Rate	$12.53
Rate for Payer: Cash Price	$8.40
Rate for Payer: Hawaii Western Management Group Commercial	$12.27
Rate for Payer: Health Management Network Commercial	$10.98
Rate for Payer: Kaiser Permanente Commercial	$8.14
Rate for Payer: Kaiser Permanente Medicaid	$6.59
Rate for Payer: MDX Hawaii PPO	$12.53
Rate for Payer: UnitedHealthcare Medicaid	$7.75
Rate for Payer: University Health Alliance Commercial	$9.42

DEXAMETHASONE SODIUM PHOSPHATE 4 MG/ML INJ SOLN (FOR OTHER USE)

Facility

$5.47

Service Code	NDC 67457042300
Hospital Revenue Code	250
Min. Negotiated Rate	$2.79
Max. Negotiated Rate	$5.31
Rate for Payer: Cash Price	$3.56
Rate for Payer: Hawaii Western Management Group Commercial	$5.20
Rate for Payer: Health Management Network Commercial	$4.65
Rate for Payer: Kaiser Permanente Commercial	$3.45
Rate for Payer: Kaiser Permanente Medicaid	$2.79
Rate for Payer: MDX Hawaii PPO	$5.31
Rate for Payer: UnitedHealthcare Medicaid	$3.28
Rate for Payer: University Health Alliance Commercial	$3.99

DEXAMETHASONE SODIUM PHOSPHATE 4 MG/ML INJ SOLN (FOR OTHER USE)

Facility

$12.92

Service Code	NDC 67457042254
Hospital Revenue Code	250
Min. Negotiated Rate	$6.59
Max. Negotiated Rate	$12.53
Rate for Payer: Cash Price	$8.40
Rate for Payer: Hawaii Western Management Group Commercial	$12.27
Rate for Payer: Health Management Network Commercial	$10.98
Rate for Payer: Kaiser Permanente Commercial	$8.14
Rate for Payer: Kaiser Permanente Medicaid	$6.59
Rate for Payer: MDX Hawaii PPO	$12.53
Rate for Payer: UnitedHealthcare Medicaid	$7.75
Rate for Payer: University Health Alliance Commercial	$9.42

DEXAMETHASONE SODIUM PHOSPHATE 4 MG/ML INJ SOLN (FOR OTHER USE)

Facility

$5.47

Service Code	NDC 67457042312
Hospital Revenue Code	250
Min. Negotiated Rate	$4.65
Max. Negotiated Rate	$5.31
Rate for Payer: Cash Price	$3.56
Rate for Payer: Health Management Network Commercial	$4.65
Rate for Payer: MDX Hawaii PPO	$5.31

DEXMEDETOMIDINE 200 MCG/2 ML IV SOLN

Facility

$28.98

Service Code	NDC 66794023002
Hospital Revenue Code	250
Min. Negotiated Rate	$24.63
Max. Negotiated Rate	$28.11
Rate for Payer: Cash Price	$18.84
Rate for Payer: Health Management Network Commercial	$24.63
Rate for Payer: MDX Hawaii PPO	$28.11

DEXMEDETOMIDINE 200 MCG/2 ML IV SOLN

Facility

$28.98

Service Code	NDC 66794023002
Hospital Revenue Code	250
Min. Negotiated Rate	$14.78
Max. Negotiated Rate	$28.11
Rate for Payer: Cash Price	$18.84
Rate for Payer: Hawaii Western Management Group Commercial	$27.53
Rate for Payer: Health Management Network Commercial	$24.63
Rate for Payer: Kaiser Permanente Commercial	$18.26
Rate for Payer: Kaiser Permanente Medicaid	$14.78
Rate for Payer: MDX Hawaii PPO	$28.11
Rate for Payer: UnitedHealthcare Medicaid	$17.39
Rate for Payer: University Health Alliance Commercial	$21.12

DEXMEDETOMIDINE 200 MCG/2 ML IV SOLN

Facility

$28.98

Service Code	NDC 66794023042
Hospital Revenue Code	250
Min. Negotiated Rate	$24.63
Max. Negotiated Rate	$28.11
Rate for Payer: Cash Price	$18.84
Rate for Payer: Health Management Network Commercial	$24.63
Rate for Payer: MDX Hawaii PPO	$28.11

DEXMEDETOMIDINE 200 MCG/2 ML IV SOLN

Facility

$112.84

Service Code	NDC 16729023930
Hospital Revenue Code	250
Min. Negotiated Rate	$57.55
Max. Negotiated Rate	$109.45
Rate for Payer: Cash Price	$73.35
Rate for Payer: Hawaii Western Management Group Commercial	$107.20
Rate for Payer: Health Management Network Commercial	$95.91
Rate for Payer: Kaiser Permanente Commercial	$71.09
Rate for Payer: Kaiser Permanente Medicaid	$57.55
Rate for Payer: MDX Hawaii PPO	$109.45
Rate for Payer: UnitedHealthcare Medicaid	$67.70
Rate for Payer: University Health Alliance Commercial	$82.25

DEXMEDETOMIDINE 200 MCG/2 ML IV SOLN

Facility

$112.84

Service Code	NDC 16729023993
Hospital Revenue Code	250
Min. Negotiated Rate	$95.91
Max. Negotiated Rate	$109.45
Rate for Payer: Cash Price	$73.35
Rate for Payer: Health Management Network Commercial	$95.91
Rate for Payer: MDX Hawaii PPO	$109.45

DEXMEDETOMIDINE 200 MCG/2 ML IV SOLN

Facility

$112.84

Service Code	NDC 16729023930
Hospital Revenue Code	250
Min. Negotiated Rate	$95.91
Max. Negotiated Rate	$109.45
Rate for Payer: Cash Price	$73.35
Rate for Payer: Health Management Network Commercial	$95.91
Rate for Payer: MDX Hawaii PPO	$109.45

DEXMEDETOMIDINE 200 MCG/2 ML IV SOLN

Facility

$28.98

Service Code	NDC 66794023042
Hospital Revenue Code	250
Min. Negotiated Rate	$14.78
Max. Negotiated Rate	$28.11
Rate for Payer: Cash Price	$18.84
Rate for Payer: Hawaii Western Management Group Commercial	$27.53
Rate for Payer: Health Management Network Commercial	$24.63
Rate for Payer: Kaiser Permanente Commercial	$18.26
Rate for Payer: Kaiser Permanente Medicaid	$14.78
Rate for Payer: MDX Hawaii PPO	$28.11
Rate for Payer: UnitedHealthcare Medicaid	$17.39
Rate for Payer: University Health Alliance Commercial	$21.12

DEXMEDETOMIDINE 200 MCG/2 ML IV SOLN

Facility

$112.84

Service Code	NDC 16729023993
Hospital Revenue Code	250
Min. Negotiated Rate	$57.55
Max. Negotiated Rate	$109.45
Rate for Payer: Cash Price	$73.35
Rate for Payer: Hawaii Western Management Group Commercial	$107.20
Rate for Payer: Health Management Network Commercial	$95.91
Rate for Payer: Kaiser Permanente Commercial	$71.09
Rate for Payer: Kaiser Permanente Medicaid	$57.55
Rate for Payer: MDX Hawaii PPO	$109.45
Rate for Payer: UnitedHealthcare Medicaid	$67.70
Rate for Payer: University Health Alliance Commercial	$82.25

DEXMEDETOMIDINE IN 0.9 % NACL 400 MCG/100 ML (4 MCG/ML) IV SOLN

Facility

$99.98

Service Code	NDC 00338955712
Hospital Revenue Code	250
Min. Negotiated Rate	$50.99
Max. Negotiated Rate	$96.98
Rate for Payer: Cash Price	$64.99
Rate for Payer: Hawaii Western Management Group Commercial	$94.98
Rate for Payer: Health Management Network Commercial	$84.98
Rate for Payer: Kaiser Permanente Commercial	$62.99
Rate for Payer: Kaiser Permanente Medicaid	$50.99
Rate for Payer: MDX Hawaii PPO	$96.98
Rate for Payer: UnitedHealthcare Medicaid	$59.99
Rate for Payer: University Health Alliance Commercial	$72.88

DEXMEDETOMIDINE IN 0.9 % NACL 400 MCG/100 ML (4 MCG/ML) IV SOLN

Facility

$99.98

Service Code	NDC 00338955712
Hospital Revenue Code	250
Min. Negotiated Rate	$84.98
Max. Negotiated Rate	$96.98
Rate for Payer: Cash Price	$64.99
Rate for Payer: Health Management Network Commercial	$84.98
Rate for Payer: MDX Hawaii PPO	$96.98

DEXTROAMPHETAMINE-AMPHETAMINE 30 MG PO CAP SR 24HR

Facility

$39.26

Service Code	HCPCS A9270
Hospital Revenue Code	250
Min. Negotiated Rate	$20.02
Max. Negotiated Rate	$38.08
Rate for Payer: Cash Price	$25.52
Rate for Payer: Hawaii Western Management Group Commercial	$37.30
Rate for Payer: Health Management Network Commercial	$33.37
Rate for Payer: Kaiser Permanente Commercial	$24.73
Rate for Payer: Kaiser Permanente Medicaid	$20.02
Rate for Payer: MDX Hawaii PPO	$38.08
Rate for Payer: UnitedHealthcare Medicaid	$23.56
Rate for Payer: University Health Alliance Commercial	$28.62

DEXTROAMPHETAMINE-AMPHETAMINE 30 MG PO CAP SR 24HR

Facility

$39.26

Service Code	HCPCS A9270
Hospital Revenue Code	250
Min. Negotiated Rate	$33.37
Max. Negotiated Rate	$38.08
Rate for Payer: Cash Price	$25.52
Rate for Payer: Health Management Network Commercial	$33.37
Rate for Payer: MDX Hawaii PPO	$38.08

DEXTROMETHORPHAN-GUAIFENESIN 10-100 MG/5 ML PO SYRUP

Facility

$15.30

Service Code	HCPCS A9270
Hospital Revenue Code	250
Min. Negotiated Rate	$7.80
Max. Negotiated Rate	$14.84
Rate for Payer: Cash Price	$9.94
Rate for Payer: Hawaii Western Management Group Commercial	$14.54
Rate for Payer: Health Management Network Commercial	$13.01
Rate for Payer: Kaiser Permanente Commercial	$9.64
Rate for Payer: Kaiser Permanente Medicaid	$7.80
Rate for Payer: MDX Hawaii PPO	$14.84
Rate for Payer: UnitedHealthcare Medicaid	$9.18
Rate for Payer: University Health Alliance Commercial	$11.15

DEXTROMETHORPHAN-GUAIFENESIN 10-100 MG/5 ML PO SYRUP

Facility

$15.30

Service Code	HCPCS A9270
Hospital Revenue Code	250
Min. Negotiated Rate	$13.01
Max. Negotiated Rate	$14.84
Rate for Payer: Cash Price	$9.94
Rate for Payer: Health Management Network Commercial	$13.01
Rate for Payer: MDX Hawaii PPO	$14.84

DEXTROSE 10 % IN WATER (D10W) 10 % IV SOLP

Facility

$38.62

Service Code	NDC 00264752000
Hospital Revenue Code	250
Min. Negotiated Rate	$32.83
Max. Negotiated Rate	$37.46
Rate for Payer: Cash Price	$25.10
Rate for Payer: Health Management Network Commercial	$32.83
Rate for Payer: MDX Hawaii PPO	$37.46

Know your out-of-pocket cost for care.

All Charges