Kona Community Hospital

All Charges

Charge

Type

Setting

Price

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

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

Facility

$38.62

Service Code	NDC 00264752000
Hospital Revenue Code	250
Min. Negotiated Rate	$19.70
Max. Negotiated Rate	$37.46
Rate for Payer: Cash Price	$25.10
Rate for Payer: Hawaii Western Management Group Commercial	$36.69
Rate for Payer: Health Management Network Commercial	$32.83
Rate for Payer: Kaiser Permanente Commercial	$24.33
Rate for Payer: Kaiser Permanente Medicaid	$19.70
Rate for Payer: MDX Hawaii PPO	$37.46
Rate for Payer: UnitedHealthcare Medicaid	$23.17
Rate for Payer: University Health Alliance Commercial	$28.15

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

Facility

$38.62

Service Code	NDC 00338002303
Hospital Revenue Code	250
Min. Negotiated Rate	$19.70
Max. Negotiated Rate	$37.46
Rate for Payer: Cash Price	$25.10
Rate for Payer: Hawaii Western Management Group Commercial	$36.69
Rate for Payer: Health Management Network Commercial	$32.83
Rate for Payer: Kaiser Permanente Commercial	$24.33
Rate for Payer: Kaiser Permanente Medicaid	$19.70
Rate for Payer: MDX Hawaii PPO	$37.46
Rate for Payer: UnitedHealthcare Medicaid	$23.17
Rate for Payer: University Health Alliance Commercial	$28.15

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

Facility

$69.75

Service Code	NDC 00338002302
Hospital Revenue Code	250
Min. Negotiated Rate	$59.29
Max. Negotiated Rate	$67.66
Rate for Payer: Cash Price	$45.34
Rate for Payer: Health Management Network Commercial	$59.29
Rate for Payer: MDX Hawaii PPO	$67.66

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

Facility

$24.84

Service Code	NDC 00264752010
Hospital Revenue Code	250
Min. Negotiated Rate	$21.11
Max. Negotiated Rate	$24.09
Rate for Payer: Cash Price	$16.15
Rate for Payer: Health Management Network Commercial	$21.11
Rate for Payer: MDX Hawaii PPO	$24.09

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

Facility

$24.84

Service Code	NDC 00264752010
Hospital Revenue Code	250
Min. Negotiated Rate	$12.67
Max. Negotiated Rate	$24.09
Rate for Payer: Cash Price	$16.15
Rate for Payer: Hawaii Western Management Group Commercial	$23.60
Rate for Payer: Health Management Network Commercial	$21.11
Rate for Payer: Kaiser Permanente Commercial	$15.65
Rate for Payer: Kaiser Permanente Medicaid	$12.67
Rate for Payer: MDX Hawaii PPO	$24.09
Rate for Payer: UnitedHealthcare Medicaid	$14.90
Rate for Payer: University Health Alliance Commercial	$18.11

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

Facility

$50.71

Service Code	NDC 00264752020
Hospital Revenue Code	250
Min. Negotiated Rate	$43.10
Max. Negotiated Rate	$49.19
Rate for Payer: Cash Price	$32.96
Rate for Payer: Health Management Network Commercial	$43.10
Rate for Payer: MDX Hawaii PPO	$49.19

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

Facility

$69.75

Service Code	NDC 00338002302
Hospital Revenue Code	250
Min. Negotiated Rate	$35.57
Max. Negotiated Rate	$67.66
Rate for Payer: Cash Price	$45.34
Rate for Payer: Hawaii Western Management Group Commercial	$66.26
Rate for Payer: Health Management Network Commercial	$59.29
Rate for Payer: Kaiser Permanente Commercial	$43.94
Rate for Payer: Kaiser Permanente Medicaid	$35.57
Rate for Payer: MDX Hawaii PPO	$67.66
Rate for Payer: UnitedHealthcare Medicaid	$41.85
Rate for Payer: University Health Alliance Commercial	$50.84

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

Facility

$50.71

Service Code	NDC 00264752020
Hospital Revenue Code	250
Min. Negotiated Rate	$25.86
Max. Negotiated Rate	$49.19
Rate for Payer: Cash Price	$32.96
Rate for Payer: Hawaii Western Management Group Commercial	$48.17
Rate for Payer: Health Management Network Commercial	$43.10
Rate for Payer: Kaiser Permanente Commercial	$31.95
Rate for Payer: Kaiser Permanente Medicaid	$25.86
Rate for Payer: MDX Hawaii PPO	$49.19
Rate for Payer: UnitedHealthcare Medicaid	$30.43
Rate for Payer: University Health Alliance Commercial	$36.96

DEXTROSE 25 % IN WATER (D25W) IV SYR

Facility

$103.25

Service Code	NDC 00409177540
Hospital Revenue Code	250
Min. Negotiated Rate	$87.76
Max. Negotiated Rate	$100.15
Rate for Payer: Cash Price	$67.11
Rate for Payer: Health Management Network Commercial	$87.76
Rate for Payer: MDX Hawaii PPO	$100.15

DEXTROSE 25 % IN WATER (D25W) IV SYR

Facility

$103.25

Service Code	NDC 00409177510
Hospital Revenue Code	250
Min. Negotiated Rate	$52.66
Max. Negotiated Rate	$100.15
Rate for Payer: Cash Price	$67.11
Rate for Payer: Hawaii Western Management Group Commercial	$98.09
Rate for Payer: Health Management Network Commercial	$87.76
Rate for Payer: Kaiser Permanente Commercial	$65.05
Rate for Payer: Kaiser Permanente Medicaid	$52.66
Rate for Payer: MDX Hawaii PPO	$100.15
Rate for Payer: UnitedHealthcare Medicaid	$61.95
Rate for Payer: University Health Alliance Commercial	$75.26

DEXTROSE 25 % IN WATER (D25W) IV SYR

Facility

$103.25

Service Code	NDC 00409177510
Hospital Revenue Code	250
Min. Negotiated Rate	$87.76
Max. Negotiated Rate	$100.15
Rate for Payer: Cash Price	$67.11
Rate for Payer: Health Management Network Commercial	$87.76
Rate for Payer: MDX Hawaii PPO	$100.15

DEXTROSE 25 % IN WATER (D25W) IV SYR

Facility

$103.25

Service Code	NDC 00409177540
Hospital Revenue Code	250
Min. Negotiated Rate	$52.66
Max. Negotiated Rate	$100.15
Rate for Payer: Cash Price	$67.11
Rate for Payer: Hawaii Western Management Group Commercial	$98.09
Rate for Payer: Health Management Network Commercial	$87.76
Rate for Payer: Kaiser Permanente Commercial	$65.05
Rate for Payer: Kaiser Permanente Medicaid	$52.66
Rate for Payer: MDX Hawaii PPO	$100.15
Rate for Payer: UnitedHealthcare Medicaid	$61.95
Rate for Payer: University Health Alliance Commercial	$75.26

DEXTROSE 40 % PO GEL

Facility

$22.03

Service Code	HCPCS A9270
Hospital Revenue Code	250
Min. Negotiated Rate	$18.73
Max. Negotiated Rate	$21.37
Rate for Payer: Cash Price	$14.32
Rate for Payer: Health Management Network Commercial	$18.73
Rate for Payer: MDX Hawaii PPO	$21.37

DEXTROSE 40 % PO GEL

Facility

$22.03

Service Code	HCPCS A9270
Hospital Revenue Code	250
Min. Negotiated Rate	$11.24
Max. Negotiated Rate	$21.37
Rate for Payer: Cash Price	$14.32
Rate for Payer: Hawaii Western Management Group Commercial	$20.93
Rate for Payer: Health Management Network Commercial	$18.73
Rate for Payer: Kaiser Permanente Commercial	$13.88
Rate for Payer: Kaiser Permanente Medicaid	$11.24
Rate for Payer: MDX Hawaii PPO	$21.37
Rate for Payer: UnitedHealthcare Medicaid	$13.22
Rate for Payer: University Health Alliance Commercial	$16.06

DEXTROSE 5%-0.2 % SOD CHLORIDE IV SOLP

Facility

$27.60

Service Code	NDC 00264761600
Hospital Revenue Code	250
Min. Negotiated Rate	$14.08
Max. Negotiated Rate	$26.77
Rate for Payer: Cash Price	$17.94
Rate for Payer: Hawaii Western Management Group Commercial	$26.22
Rate for Payer: Health Management Network Commercial	$23.46
Rate for Payer: Kaiser Permanente Commercial	$17.39
Rate for Payer: Kaiser Permanente Medicaid	$14.08
Rate for Payer: MDX Hawaii PPO	$26.77
Rate for Payer: UnitedHealthcare Medicaid	$16.56
Rate for Payer: University Health Alliance Commercial	$20.12

DEXTROSE 5%-0.2 % SOD CHLORIDE IV SOLP

Facility

$71.82

Service Code	NDC 00990792403
Hospital Revenue Code	250
Min. Negotiated Rate	$61.05
Max. Negotiated Rate	$69.67
Rate for Payer: Cash Price	$46.68
Rate for Payer: Health Management Network Commercial	$61.05
Rate for Payer: MDX Hawaii PPO	$69.67

DEXTROSE 5%-0.2 % SOD CHLORIDE IV SOLP

Facility

$121.50

Service Code	NDC 00990792402
Hospital Revenue Code	250
Min. Negotiated Rate	$103.28
Max. Negotiated Rate	$117.86
Rate for Payer: Cash Price	$78.98
Rate for Payer: Health Management Network Commercial	$103.28
Rate for Payer: MDX Hawaii PPO	$117.86

DEXTROSE 5%-0.2 % SOD CHLORIDE IV SOLP

Facility

$71.82

Service Code	NDC 00990792403
Hospital Revenue Code	250
Min. Negotiated Rate	$36.63
Max. Negotiated Rate	$69.67
Rate for Payer: Cash Price	$46.68
Rate for Payer: Hawaii Western Management Group Commercial	$68.23
Rate for Payer: Health Management Network Commercial	$61.05
Rate for Payer: Kaiser Permanente Commercial	$45.25
Rate for Payer: Kaiser Permanente Medicaid	$36.63
Rate for Payer: MDX Hawaii PPO	$69.67
Rate for Payer: UnitedHealthcare Medicaid	$43.09
Rate for Payer: University Health Alliance Commercial	$52.35

DEXTROSE 5%-0.2 % SOD CHLORIDE IV SOLP

Facility

$27.60

Service Code	NDC 00264761600
Hospital Revenue Code	250
Min. Negotiated Rate	$23.46
Max. Negotiated Rate	$26.77
Rate for Payer: Cash Price	$17.94
Rate for Payer: Health Management Network Commercial	$23.46
Rate for Payer: MDX Hawaii PPO	$26.77

DEXTROSE 5%-0.2 % SOD CHLORIDE IV SOLP

Facility

$53.13

Service Code	NDC 00264761610
Hospital Revenue Code	250
Min. Negotiated Rate	$27.10
Max. Negotiated Rate	$51.54
Rate for Payer: Cash Price	$34.53
Rate for Payer: Hawaii Western Management Group Commercial	$50.47
Rate for Payer: Health Management Network Commercial	$45.16
Rate for Payer: Kaiser Permanente Commercial	$33.47
Rate for Payer: Kaiser Permanente Medicaid	$27.10
Rate for Payer: MDX Hawaii PPO	$51.54
Rate for Payer: UnitedHealthcare Medicaid	$31.88
Rate for Payer: University Health Alliance Commercial	$38.73

DEXTROSE 5%-0.2 % SOD CHLORIDE IV SOLP

Facility

$53.13

Service Code	NDC 00264761610
Hospital Revenue Code	250
Min. Negotiated Rate	$45.16
Max. Negotiated Rate	$51.54
Rate for Payer: Cash Price	$34.53
Rate for Payer: Health Management Network Commercial	$45.16
Rate for Payer: MDX Hawaii PPO	$51.54

DEXTROSE 5%-0.2 % SOD CHLORIDE IV SOLP

Facility

$121.50

Service Code	NDC 00990792402
Hospital Revenue Code	250
Min. Negotiated Rate	$61.97
Max. Negotiated Rate	$117.86
Rate for Payer: Cash Price	$78.98
Rate for Payer: Hawaii Western Management Group Commercial	$115.42
Rate for Payer: Health Management Network Commercial	$103.28
Rate for Payer: Kaiser Permanente Commercial	$76.55
Rate for Payer: Kaiser Permanente Medicaid	$61.97
Rate for Payer: MDX Hawaii PPO	$117.86
Rate for Payer: UnitedHealthcare Medicaid	$72.90
Rate for Payer: University Health Alliance Commercial	$88.56

DEXTROSE 50 % IN WATER (D50W) IV SOLP

Facility

$28.71

Service Code	NDC 00409664816
Hospital Revenue Code	250
Min. Negotiated Rate	$14.64
Max. Negotiated Rate	$27.85
Rate for Payer: Cash Price	$18.66
Rate for Payer: Hawaii Western Management Group Commercial	$27.27
Rate for Payer: Health Management Network Commercial	$24.40
Rate for Payer: Kaiser Permanente Commercial	$18.09
Rate for Payer: Kaiser Permanente Medicaid	$14.64
Rate for Payer: MDX Hawaii PPO	$27.85
Rate for Payer: UnitedHealthcare Medicaid	$17.23
Rate for Payer: University Health Alliance Commercial	$20.93

DEXTROSE 50 % IN WATER (D50W) IV SOLP

Facility

$28.71

Service Code	NDC 00409664802
Hospital Revenue Code	250
Min. Negotiated Rate	$24.40
Max. Negotiated Rate	$27.85
Rate for Payer: Cash Price	$18.66
Rate for Payer: Health Management Network Commercial	$24.40
Rate for Payer: MDX Hawaii PPO	$27.85

Know your out-of-pocket cost for care.

All Charges