Kona Community Hospital

All Charges

Charge

Type

Setting

Price

DIBUCAINE 1 % TOP OINT

Facility

$27.05

Service Code	HCPCS A9270
Hospital Revenue Code	250
Min. Negotiated Rate	$22.99
Max. Negotiated Rate	$26.24
Rate for Payer: Cash Price	$17.58
Rate for Payer: Health Management Network Commercial	$22.99
Rate for Payer: MDX Hawaii PPO	$26.24

DIBUCAINE 1 % TOP OINT

Facility

$27.05

Service Code	HCPCS A9270
Hospital Revenue Code	250
Min. Negotiated Rate	$13.80
Max. Negotiated Rate	$26.24
Rate for Payer: Cash Price	$17.58
Rate for Payer: Hawaii Western Management Group Commercial	$25.70
Rate for Payer: Health Management Network Commercial	$22.99
Rate for Payer: Kaiser Permanente Commercial	$17.04
Rate for Payer: Kaiser Permanente Medicaid	$13.80
Rate for Payer: MDX Hawaii PPO	$26.24
Rate for Payer: UnitedHealthcare Medicaid	$16.23
Rate for Payer: University Health Alliance Commercial	$19.72

DICLOFENAC SODIUM 1 % TOP GEL

Facility

$121.50

Service Code	HCPCS A9270
Hospital Revenue Code	250
Min. Negotiated Rate	$103.28
Max. Negotiated Rate	$117.86
Rate for Payer: Cash Price	$78.98
Rate for Payer: Cash Price	$52.88
Rate for Payer: Cash Price	$43.99
Rate for Payer: Health Management Network Commercial	$103.28
Rate for Payer: Health Management Network Commercial	$57.53
Rate for Payer: Health Management Network Commercial	$69.15
Rate for Payer: MDX Hawaii PPO	$65.65
Rate for Payer: MDX Hawaii PPO	$117.86
Rate for Payer: MDX Hawaii PPO	$78.91

DICLOFENAC SODIUM 1 % TOP GEL

Facility

$121.50

Service Code	HCPCS A9270
Hospital Revenue Code	250
Min. Negotiated Rate	$61.97
Max. Negotiated Rate	$117.86
Rate for Payer: Cash Price	$78.98
Rate for Payer: Cash Price	$52.88
Rate for Payer: Cash Price	$43.99
Rate for Payer: Hawaii Western Management Group Commercial	$77.28
Rate for Payer: Hawaii Western Management Group Commercial	$64.30
Rate for Payer: Hawaii Western Management Group Commercial	$115.42
Rate for Payer: Health Management Network Commercial	$69.15
Rate for Payer: Health Management Network Commercial	$103.28
Rate for Payer: Health Management Network Commercial	$57.53
Rate for Payer: Kaiser Permanente Commercial	$76.55
Rate for Payer: Kaiser Permanente Commercial	$42.64
Rate for Payer: Kaiser Permanente Commercial	$51.25
Rate for Payer: Kaiser Permanente Medicaid	$34.52
Rate for Payer: Kaiser Permanente Medicaid	$61.97
Rate for Payer: Kaiser Permanente Medicaid	$41.49
Rate for Payer: MDX Hawaii PPO	$65.65
Rate for Payer: MDX Hawaii PPO	$117.86
Rate for Payer: MDX Hawaii PPO	$78.91
Rate for Payer: UnitedHealthcare Medicaid	$40.61
Rate for Payer: UnitedHealthcare Medicaid	$72.90
Rate for Payer: UnitedHealthcare Medicaid	$48.81
Rate for Payer: University Health Alliance Commercial	$88.56
Rate for Payer: University Health Alliance Commercial	$49.33
Rate for Payer: University Health Alliance Commercial	$59.30

DICYCLOMINE 10 MG/ML IM SOLN

Facility

$119.85

Service Code	HCPCS J0500
Hospital Revenue Code	250
Min. Negotiated Rate	$101.87
Max. Negotiated Rate	$116.25
Rate for Payer: Cash Price	$77.90
Rate for Payer: Cash Price	$291.34
Rate for Payer: Health Management Network Commercial	$101.87
Rate for Payer: Health Management Network Commercial	$380.98
Rate for Payer: MDX Hawaii PPO	$116.25
Rate for Payer: MDX Hawaii PPO	$434.76

DICYCLOMINE 10 MG/ML IM SOLN

Facility

$448.21

Service Code	HCPCS J0500
Hospital Revenue Code	636
Min. Negotiated Rate	$11.68
Max. Negotiated Rate	$434.76
Rate for Payer: Cash Price	$291.34
Rate for Payer: Cash Price	$77.90
Rate for Payer: Cash Price	$77.90
Rate for Payer: Cash Price	$291.34
Rate for Payer: Hawaii Medical Service Association ABD	$11.68
Rate for Payer: Hawaii Medical Service Association ABD	$11.68
Rate for Payer: Hawaii Medical Service Association Non-ABD	$11.68
Rate for Payer: Hawaii Medical Service Association Non-ABD	$11.68
Rate for Payer: Hawaii Western Management Group Commercial	$113.86
Rate for Payer: Hawaii Western Management Group Commercial	$425.80
Rate for Payer: Health Management Network Commercial	$380.98
Rate for Payer: Health Management Network Commercial	$101.87
Rate for Payer: Kaiser Permanente Commercial	$282.37
Rate for Payer: Kaiser Permanente Commercial	$75.51
Rate for Payer: Kaiser Permanente Medicaid	$61.12
Rate for Payer: Kaiser Permanente Medicaid	$228.59
Rate for Payer: MDX Hawaii PPO	$434.76
Rate for Payer: MDX Hawaii PPO	$116.25
Rate for Payer: UnitedHealthcare Medicaid	$71.91
Rate for Payer: UnitedHealthcare Medicaid	$268.93
Rate for Payer: University Health Alliance Commercial	$87.36
Rate for Payer: University Health Alliance Commercial	$326.70

DICYCLOMINE 10 MG PO CAP

Facility

$2.48

Service Code	HCPCS A9270
Hospital Revenue Code	250
Min. Negotiated Rate	$2.11
Max. Negotiated Rate	$2.41
Rate for Payer: Cash Price	$1.61
Rate for Payer: Cash Price	$2.37
Rate for Payer: Health Management Network Commercial	$2.11
Rate for Payer: Health Management Network Commercial	$3.09
Rate for Payer: MDX Hawaii PPO	$2.41
Rate for Payer: MDX Hawaii PPO	$3.53

DICYCLOMINE 10 MG PO CAP

Facility

$3.64

Service Code	HCPCS A9270
Hospital Revenue Code	250
Min. Negotiated Rate	$1.86
Max. Negotiated Rate	$3.53
Rate for Payer: Cash Price	$2.37
Rate for Payer: Cash Price	$1.61
Rate for Payer: Hawaii Western Management Group Commercial	$2.36
Rate for Payer: Hawaii Western Management Group Commercial	$3.46
Rate for Payer: Health Management Network Commercial	$2.11
Rate for Payer: Health Management Network Commercial	$3.09
Rate for Payer: Kaiser Permanente Commercial	$1.56
Rate for Payer: Kaiser Permanente Commercial	$2.29
Rate for Payer: Kaiser Permanente Medicaid	$1.86
Rate for Payer: Kaiser Permanente Medicaid	$1.26
Rate for Payer: MDX Hawaii PPO	$3.53
Rate for Payer: MDX Hawaii PPO	$2.41
Rate for Payer: UnitedHealthcare Medicaid	$1.49
Rate for Payer: UnitedHealthcare Medicaid	$2.18
Rate for Payer: University Health Alliance Commercial	$1.81
Rate for Payer: University Health Alliance Commercial	$2.65

DICYCLOMINE 20 MG PO TABLET

Facility

$3.21

Service Code	HCPCS A9270
Hospital Revenue Code	250
Min. Negotiated Rate	$1.64
Max. Negotiated Rate	$3.11
Rate for Payer: Cash Price	$2.09
Rate for Payer: Cash Price	$2.01
Rate for Payer: Hawaii Western Management Group Commercial	$3.05
Rate for Payer: Hawaii Western Management Group Commercial	$2.94
Rate for Payer: Health Management Network Commercial	$2.73
Rate for Payer: Health Management Network Commercial	$2.63
Rate for Payer: Kaiser Permanente Commercial	$2.02
Rate for Payer: Kaiser Permanente Commercial	$1.95
Rate for Payer: Kaiser Permanente Medicaid	$1.58
Rate for Payer: Kaiser Permanente Medicaid	$1.64
Rate for Payer: MDX Hawaii PPO	$3.11
Rate for Payer: MDX Hawaii PPO	$3.00
Rate for Payer: UnitedHealthcare Medicaid	$1.85
Rate for Payer: UnitedHealthcare Medicaid	$1.93
Rate for Payer: University Health Alliance Commercial	$2.34
Rate for Payer: University Health Alliance Commercial	$2.25

DICYCLOMINE 20 MG PO TABLET

Facility

$3.21

Service Code	HCPCS A9270
Hospital Revenue Code	250
Min. Negotiated Rate	$2.73
Max. Negotiated Rate	$3.11
Rate for Payer: Cash Price	$2.09
Rate for Payer: Cash Price	$2.01
Rate for Payer: Health Management Network Commercial	$2.63
Rate for Payer: Health Management Network Commercial	$2.73
Rate for Payer: MDX Hawaii PPO	$3.00
Rate for Payer: MDX Hawaii PPO	$3.11

DIFLUPREDNATE 0.05 % OPHT DROP

Facility

$705.44

Service Code	HCPCS A9270
Hospital Revenue Code	250
Min. Negotiated Rate	$359.77
Max. Negotiated Rate	$684.28
Rate for Payer: Cash Price	$458.54
Rate for Payer: Hawaii Western Management Group Commercial	$670.17
Rate for Payer: Health Management Network Commercial	$599.62
Rate for Payer: Kaiser Permanente Commercial	$444.43
Rate for Payer: Kaiser Permanente Medicaid	$359.77
Rate for Payer: MDX Hawaii PPO	$684.28
Rate for Payer: UnitedHealthcare Medicaid	$423.26
Rate for Payer: University Health Alliance Commercial	$514.20

DIFLUPREDNATE 0.05 % OPHT DROP

Facility

$705.44

Service Code	HCPCS A9270
Hospital Revenue Code	250
Min. Negotiated Rate	$599.62
Max. Negotiated Rate	$684.28
Rate for Payer: Cash Price	$458.54
Rate for Payer: Health Management Network Commercial	$599.62
Rate for Payer: MDX Hawaii PPO	$684.28

DIGESTIVE MALIGNANCY

Facility

$4,245.57

Service Code	APR-DRG 2402
Min. Negotiated Rate	$4,245.57
Max. Negotiated Rate	$4,245.57
Rate for Payer: AlohaCare Medicaid	$4,245.57
Rate for Payer: Hawaii Medical Service Association ABD	$4,245.57
Rate for Payer: Hawaii Medical Service Association Non-ABD	$4,245.57
Rate for Payer: Kaiser Permanente Medicaid	$4,245.57
Rate for Payer: Ohana Health Plan Medicaid	$4,245.57
Rate for Payer: UnitedHealthcare Medicaid	$4,245.57

DIGESTIVE MALIGNANCY

Facility

$5,830.57

Service Code	APR-DRG 2403
Min. Negotiated Rate	$5,830.57
Max. Negotiated Rate	$5,830.57
Rate for Payer: AlohaCare Medicaid	$5,830.57
Rate for Payer: Hawaii Medical Service Association ABD	$5,830.57
Rate for Payer: Hawaii Medical Service Association Non-ABD	$5,830.57
Rate for Payer: Kaiser Permanente Medicaid	$5,830.57
Rate for Payer: Ohana Health Plan Medicaid	$5,830.57
Rate for Payer: UnitedHealthcare Medicaid	$5,830.57

DIGESTIVE MALIGNANCY

Facility

$3,829.73

Service Code	APR-DRG 2401
Min. Negotiated Rate	$3,829.73
Max. Negotiated Rate	$3,829.73
Rate for Payer: AlohaCare Medicaid	$3,829.73
Rate for Payer: Hawaii Medical Service Association ABD	$3,829.73
Rate for Payer: Hawaii Medical Service Association Non-ABD	$3,829.73
Rate for Payer: Kaiser Permanente Medicaid	$3,829.73
Rate for Payer: Ohana Health Plan Medicaid	$3,829.73
Rate for Payer: UnitedHealthcare Medicaid	$3,829.73

DIGESTIVE MALIGNANCY

Facility

$9,450.16

Service Code	APR-DRG 2404
Min. Negotiated Rate	$9,450.16
Max. Negotiated Rate	$9,450.16
Rate for Payer: AlohaCare Medicaid	$9,450.16
Rate for Payer: Hawaii Medical Service Association ABD	$9,450.16
Rate for Payer: Hawaii Medical Service Association Non-ABD	$9,450.16
Rate for Payer: Kaiser Permanente Medicaid	$9,450.16
Rate for Payer: Ohana Health Plan Medicaid	$9,450.16
Rate for Payer: UnitedHealthcare Medicaid	$9,450.16

DIGESTIVE MALIGNANCY WITH CC

Facility

$55,566.64

Service Code	MSDRG 375
Min. Negotiated Rate	$15,909.60
Max. Negotiated Rate	$55,566.64
Rate for Payer: AlohaCare Medicare	$15,909.60
Rate for Payer: Devoted Health Medicare	$17,500.56
Rate for Payer: Hawaii Medical Service Association Commercial	$55,566.64
Rate for Payer: Hawaii Medical Service Association Medicare	$15,909.60
Rate for Payer: Humana Medicare	$15,909.60
Rate for Payer: Kaiser Permanente Commercial	$20,865.60
Rate for Payer: Kaiser Permanente Medicare	$15,909.60
Rate for Payer: Ohana Health Plan Medicare	$15,909.60
Rate for Payer: UnitedHealthcare Medicare	$15,909.60

DIGESTIVE MALIGNANCY WITH MCC

Facility

$56,892.52

Service Code	MSDRG 374
Min. Negotiated Rate	$28,129.82
Max. Negotiated Rate	$56,892.52
Rate for Payer: AlohaCare Medicare	$28,129.82
Rate for Payer: Devoted Health Medicare	$30,942.80
Rate for Payer: Hawaii Medical Service Association Commercial	$56,892.52
Rate for Payer: Hawaii Medical Service Association Medicare	$28,129.82
Rate for Payer: Humana Medicare	$28,129.82
Rate for Payer: Kaiser Permanente Commercial	$36,892.57
Rate for Payer: Kaiser Permanente Medicare	$28,129.82
Rate for Payer: Ohana Health Plan Medicare	$28,129.82
Rate for Payer: UnitedHealthcare Medicare	$28,129.82

DIGESTIVE MALIGNANCY WITHOUT CC/MCC

Facility

$28,976.61

Service Code	MSDRG 376
Min. Negotiated Rate	$12,157.11
Max. Negotiated Rate	$28,976.61
Rate for Payer: AlohaCare Medicare	$12,157.11
Rate for Payer: Devoted Health Medicare	$13,372.82
Rate for Payer: Hawaii Medical Service Association Commercial	$28,976.61
Rate for Payer: Hawaii Medical Service Association Medicare	$12,157.11
Rate for Payer: Humana Medicare	$12,157.11
Rate for Payer: Kaiser Permanente Commercial	$15,944.17
Rate for Payer: Kaiser Permanente Medicare	$12,157.11
Rate for Payer: Ohana Health Plan Medicare	$12,157.11
Rate for Payer: UnitedHealthcare Medicare	$12,157.11

DIGOXIN 125 MCG (0.125 MG) PO TABLET

Facility

$8.05

Service Code	HCPCS A9270
Hospital Revenue Code	250
Min. Negotiated Rate	$6.84
Max. Negotiated Rate	$7.81
Rate for Payer: Cash Price	$5.23
Rate for Payer: Health Management Network Commercial	$6.84
Rate for Payer: MDX Hawaii PPO	$7.81

DIGOXIN 125 MCG (0.125 MG) PO TABLET

Facility

$8.05

Service Code	HCPCS A9270
Hospital Revenue Code	250
Min. Negotiated Rate	$4.11
Max. Negotiated Rate	$7.81
Rate for Payer: Cash Price	$5.23
Rate for Payer: Hawaii Western Management Group Commercial	$7.65
Rate for Payer: Health Management Network Commercial	$6.84
Rate for Payer: Kaiser Permanente Commercial	$5.07
Rate for Payer: Kaiser Permanente Medicaid	$4.11
Rate for Payer: MDX Hawaii PPO	$7.81
Rate for Payer: UnitedHealthcare Medicaid	$4.83
Rate for Payer: University Health Alliance Commercial	$5.87

DIGOXIN 250 MCG (0.25 MG) PO TABLET

Facility

$12.70

Service Code	HCPCS A9270
Hospital Revenue Code	250
Min. Negotiated Rate	$10.79
Max. Negotiated Rate	$12.32
Rate for Payer: Cash Price	$8.25
Rate for Payer: Cash Price	$4.84
Rate for Payer: Health Management Network Commercial	$6.33
Rate for Payer: Health Management Network Commercial	$10.79
Rate for Payer: MDX Hawaii PPO	$12.32
Rate for Payer: MDX Hawaii PPO	$7.23

DIGOXIN 250 MCG (0.25 MG) PO TABLET

Facility

$12.70

Service Code	HCPCS A9270
Hospital Revenue Code	250
Min. Negotiated Rate	$6.48
Max. Negotiated Rate	$12.32
Rate for Payer: Cash Price	$8.25
Rate for Payer: Cash Price	$4.84
Rate for Payer: Hawaii Western Management Group Commercial	$12.06
Rate for Payer: Hawaii Western Management Group Commercial	$7.08
Rate for Payer: Health Management Network Commercial	$10.79
Rate for Payer: Health Management Network Commercial	$6.33
Rate for Payer: Kaiser Permanente Commercial	$8.00
Rate for Payer: Kaiser Permanente Commercial	$4.69
Rate for Payer: Kaiser Permanente Medicaid	$3.80
Rate for Payer: Kaiser Permanente Medicaid	$6.48
Rate for Payer: MDX Hawaii PPO	$12.32
Rate for Payer: MDX Hawaii PPO	$7.23
Rate for Payer: UnitedHealthcare Medicaid	$4.47
Rate for Payer: UnitedHealthcare Medicaid	$7.62
Rate for Payer: University Health Alliance Commercial	$9.26
Rate for Payer: University Health Alliance Commercial	$5.43

DIGOXIN 250 MCG/ML (0.25 MG/ML) INJ SOLN

Facility

$30.36

Service Code	HCPCS J1160
Hospital Revenue Code	250
Min. Negotiated Rate	$25.81
Max. Negotiated Rate	$29.45
Rate for Payer: Cash Price	$19.73
Rate for Payer: Health Management Network Commercial	$25.81
Rate for Payer: MDX Hawaii PPO	$29.45

DIGOXIN 250 MCG/ML (0.25 MG/ML) INJ SOLN

Facility

$30.36

Service Code	HCPCS J1160
Hospital Revenue Code	636
Min. Negotiated Rate	$4.00
Max. Negotiated Rate	$29.45
Rate for Payer: Cash Price	$19.73
Rate for Payer: Cash Price	$19.73
Rate for Payer: Hawaii Medical Service Association ABD	$4.00
Rate for Payer: Hawaii Medical Service Association Non-ABD	$4.00
Rate for Payer: Hawaii Western Management Group Commercial	$28.84
Rate for Payer: Health Management Network Commercial	$25.81
Rate for Payer: Kaiser Permanente Commercial	$19.13
Rate for Payer: Kaiser Permanente Medicaid	$15.48
Rate for Payer: MDX Hawaii PPO	$29.45
Rate for Payer: UnitedHealthcare Medicaid	$18.22
Rate for Payer: University Health Alliance Commercial	$22.13

Know your out-of-pocket cost for care.

All Charges