Kona Community Hospital

All Charges

Charge

Type

Setting

Price

DIGOXIN IMMUNE FAB 40 MG IV RECON.SOLN.

Facility

$7,087.20

Service Code	HCPCS J1162
Hospital Revenue Code	250
Min. Negotiated Rate	$6,024.12
Max. Negotiated Rate	$6,874.58
Rate for Payer: Cash Price	$4,606.68
Rate for Payer: Health Management Network Commercial	$6,024.12
Rate for Payer: MDX Hawaii PPO	$6,874.58

DIGOXIN IMMUNE FAB 40 MG IV RECON.SOLN.

Facility

$7,087.20

Service Code	HCPCS J1162
Hospital Revenue Code	636
Min. Negotiated Rate	$3,614.47
Max. Negotiated Rate	$6,874.58
Rate for Payer: AlohaCare Medicaid	$5,166.99
Rate for Payer: AlohaCare Medicare	$5,166.99
Rate for Payer: Cash Price	$4,606.68
Rate for Payer: Cash Price	$4,606.68
Rate for Payer: Devoted Health Medicare	$5,683.69
Rate for Payer: Hawaii Medical Service Association ABD	$4,968.58
Rate for Payer: Hawaii Medical Service Association Commercial	$6,458.74
Rate for Payer: Hawaii Medical Service Association Medicare	$5,166.99
Rate for Payer: Hawaii Medical Service Association Non-ABD	$4,968.58
Rate for Payer: Hawaii Western Management Group Commercial	$6,732.84
Rate for Payer: Health Management Network Commercial	$6,024.12
Rate for Payer: Humana Medicare	$5,166.99
Rate for Payer: Kaiser Permanente Commercial	$4,464.94
Rate for Payer: Kaiser Permanente Medicaid	$3,614.47
Rate for Payer: Kaiser Permanente Medicare	$5,166.99
Rate for Payer: MDX Hawaii PPO	$6,874.58
Rate for Payer: Ohana Health Plan Medicaid	$5,683.69
Rate for Payer: Ohana Health Plan Medicare	$5,166.99
Rate for Payer: UnitedHealthcare Medicaid	$4,252.32
Rate for Payer: UnitedHealthcare Medicare	$5,166.99
Rate for Payer: University Health Alliance Commercial	$5,165.86

DILATION AND CURETTAGE, DIAGNOSTIC AND/OR THERAPEUTIC (NONOBSTETRICAL)

Facility

$6,183.00

Service Code	CPT 58120
Hospital Revenue Code	360
Min. Negotiated Rate	$456.03
Max. Negotiated Rate	$6,183.00
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	$695.00
Rate for Payer: Hawaii Medical Service Association Commercial	$6,183.00
Rate for Payer: Hawaii Medical Service Association Medicare	$3,824.16
Rate for Payer: Hawaii Medical Service Association Non-ABD	$700.72
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	$5,160.40

Dilation Balloon Mustang 4.0mmX20mmX75cm H74939171040270 [3642108]

Facility

$1,010.58

Service Code	HCPCS C1725
Hospital Charge Code	3642108
Hospital Revenue Code	272
Min. Negotiated Rate	$858.99
Max. Negotiated Rate	$980.26
Rate for Payer: Cash Price	$656.88
Rate for Payer: Health Management Network Commercial	$858.99
Rate for Payer: MDX Hawaii PPO	$980.26

Dilation Balloon Mustang 4.0mmX20mmX75cm H74939171040270 [3642108]

Facility

$1,010.58

Service Code	HCPCS C1725
Hospital Charge Code	3642108
Hospital Revenue Code	272
Min. Negotiated Rate	$515.40
Max. Negotiated Rate	$980.26
Rate for Payer: Cash Price	$656.88
Rate for Payer: Hawaii Western Management Group Commercial	$960.05
Rate for Payer: Health Management Network Commercial	$858.99
Rate for Payer: Kaiser Permanente Commercial	$636.67
Rate for Payer: Kaiser Permanente Medicaid	$515.40
Rate for Payer: MDX Hawaii PPO	$980.26
Rate for Payer: University Health Alliance Commercial	$736.61

Dilation Balloon Mustang 4.0mmX40mmX75cm H74939171040470 [3641954]

Facility

$1,010.58

Service Code	HCPCS C1725
Hospital Charge Code	3641954
Hospital Revenue Code	272
Min. Negotiated Rate	$515.40
Max. Negotiated Rate	$980.26
Rate for Payer: Cash Price	$656.88
Rate for Payer: Hawaii Western Management Group Commercial	$960.05
Rate for Payer: Health Management Network Commercial	$858.99
Rate for Payer: Kaiser Permanente Commercial	$636.67
Rate for Payer: Kaiser Permanente Medicaid	$515.40
Rate for Payer: MDX Hawaii PPO	$980.26
Rate for Payer: University Health Alliance Commercial	$736.61

Dilation Balloon Mustang 4.0mmX40mmX75cm H74939171040470 [3641954]

Facility

$1,010.58

Service Code	HCPCS C1725
Hospital Charge Code	3641954
Hospital Revenue Code	272
Min. Negotiated Rate	$858.99
Max. Negotiated Rate	$980.26
Rate for Payer: Cash Price	$656.88
Rate for Payer: Health Management Network Commercial	$858.99
Rate for Payer: MDX Hawaii PPO	$980.26

Dilation Balloon Mustang 4.0mmX60mmX75cm H74939171040670 [3641955]

Facility

$1,010.58

Service Code	HCPCS C1725
Hospital Charge Code	3641955
Hospital Revenue Code	272
Min. Negotiated Rate	$515.40
Max. Negotiated Rate	$980.26
Rate for Payer: Cash Price	$656.88
Rate for Payer: Hawaii Western Management Group Commercial	$960.05
Rate for Payer: Health Management Network Commercial	$858.99
Rate for Payer: Kaiser Permanente Commercial	$636.67
Rate for Payer: Kaiser Permanente Medicaid	$515.40
Rate for Payer: MDX Hawaii PPO	$980.26
Rate for Payer: University Health Alliance Commercial	$736.61

Dilation Balloon Mustang 4.0mmX60mmX75cm H74939171040670 [3641955]

Facility

$1,010.58

Service Code	HCPCS C1725
Hospital Charge Code	3641955
Hospital Revenue Code	272
Min. Negotiated Rate	$858.99
Max. Negotiated Rate	$980.26
Rate for Payer: Cash Price	$656.88
Rate for Payer: Health Management Network Commercial	$858.99
Rate for Payer: MDX Hawaii PPO	$980.26

Dilation Balloon Mustang 5.0mmX20mmX75cm H74939171050270 [3642109]

Facility

$721.88

Service Code	HCPCS C1725
Hospital Charge Code	3642109
Hospital Revenue Code	272
Min. Negotiated Rate	$613.60
Max. Negotiated Rate	$700.22
Rate for Payer: Cash Price	$469.22
Rate for Payer: Health Management Network Commercial	$613.60
Rate for Payer: MDX Hawaii PPO	$700.22

Dilation Balloon Mustang 5.0mmX20mmX75cm H74939171050270 [3642109]

Facility

$721.88

Service Code	HCPCS C1725
Hospital Charge Code	3642109
Hospital Revenue Code	272
Min. Negotiated Rate	$368.16
Max. Negotiated Rate	$700.22
Rate for Payer: Cash Price	$469.22
Rate for Payer: Hawaii Western Management Group Commercial	$685.79
Rate for Payer: Health Management Network Commercial	$613.60
Rate for Payer: Kaiser Permanente Commercial	$454.78
Rate for Payer: Kaiser Permanente Medicaid	$368.16
Rate for Payer: MDX Hawaii PPO	$700.22
Rate for Payer: University Health Alliance Commercial	$526.18

Dilation Balloon Mustang 5.0mmX40mmX75cm H74939171050470 [3641956]

Facility

$1,010.58

Service Code	HCPCS C1725
Hospital Charge Code	3641956
Hospital Revenue Code	272
Min. Negotiated Rate	$515.40
Max. Negotiated Rate	$980.26
Rate for Payer: Cash Price	$656.88
Rate for Payer: Hawaii Western Management Group Commercial	$960.05
Rate for Payer: Health Management Network Commercial	$858.99
Rate for Payer: Kaiser Permanente Commercial	$636.67
Rate for Payer: Kaiser Permanente Medicaid	$515.40
Rate for Payer: MDX Hawaii PPO	$980.26
Rate for Payer: University Health Alliance Commercial	$736.61

Dilation Balloon Mustang 5.0mmX40mmX75cm H74939171050470 [3641956]

Facility

$1,010.58

Service Code	HCPCS C1725
Hospital Charge Code	3641956
Hospital Revenue Code	272
Min. Negotiated Rate	$858.99
Max. Negotiated Rate	$980.26
Rate for Payer: Cash Price	$656.88
Rate for Payer: Health Management Network Commercial	$858.99
Rate for Payer: MDX Hawaii PPO	$980.26

Dilation Balloon Mustang 6.0mmX20mmX75cm H74939171060270 [3642110]

Facility

$1,010.58

Service Code	HCPCS C1725
Hospital Charge Code	3642110
Hospital Revenue Code	272
Min. Negotiated Rate	$515.40
Max. Negotiated Rate	$980.26
Rate for Payer: Cash Price	$656.88
Rate for Payer: Hawaii Western Management Group Commercial	$960.05
Rate for Payer: Health Management Network Commercial	$858.99
Rate for Payer: Kaiser Permanente Commercial	$636.67
Rate for Payer: Kaiser Permanente Medicaid	$515.40
Rate for Payer: MDX Hawaii PPO	$980.26
Rate for Payer: University Health Alliance Commercial	$736.61

Dilation Balloon Mustang 6.0mmX20mmX75cm H74939171060270 [3642110]

Facility

$1,010.58

Service Code	HCPCS C1725
Hospital Charge Code	3642110
Hospital Revenue Code	272
Min. Negotiated Rate	$858.99
Max. Negotiated Rate	$980.26
Rate for Payer: Cash Price	$656.88
Rate for Payer: Health Management Network Commercial	$858.99
Rate for Payer: MDX Hawaii PPO	$980.26

Dilation Balloon Mustang 6.0mmX40mmX75cm H74939171060470 [3641958]

Facility

$1,010.58

Service Code	HCPCS C1725
Hospital Charge Code	3641958
Hospital Revenue Code	272
Min. Negotiated Rate	$515.40
Max. Negotiated Rate	$980.26
Rate for Payer: Cash Price	$656.88
Rate for Payer: Hawaii Western Management Group Commercial	$960.05
Rate for Payer: Health Management Network Commercial	$858.99
Rate for Payer: Kaiser Permanente Commercial	$636.67
Rate for Payer: Kaiser Permanente Medicaid	$515.40
Rate for Payer: MDX Hawaii PPO	$980.26
Rate for Payer: University Health Alliance Commercial	$736.61

Dilation Balloon Mustang 6.0mmX40mmX75cm H74939171060470 [3641958]

Facility

$1,010.58

Service Code	HCPCS C1725
Hospital Charge Code	3641958
Hospital Revenue Code	272
Min. Negotiated Rate	$858.99
Max. Negotiated Rate	$980.26
Rate for Payer: Cash Price	$656.88
Rate for Payer: Health Management Network Commercial	$858.99
Rate for Payer: MDX Hawaii PPO	$980.26

Dilation Balloon Mustang 6.0mmX60mmX75cm H74939171060670 [3641959]

Facility

$721.88

Service Code	HCPCS C1725
Hospital Charge Code	3641959
Hospital Revenue Code	272
Min. Negotiated Rate	$613.60
Max. Negotiated Rate	$700.22
Rate for Payer: Cash Price	$469.22
Rate for Payer: Health Management Network Commercial	$613.60
Rate for Payer: MDX Hawaii PPO	$700.22

Dilation Balloon Mustang 6.0mmX60mmX75cm H74939171060670 [3641959]

Facility

$721.88

Service Code	HCPCS C1725
Hospital Charge Code	3641959
Hospital Revenue Code	272
Min. Negotiated Rate	$368.16
Max. Negotiated Rate	$700.22
Rate for Payer: Cash Price	$469.22
Rate for Payer: Hawaii Western Management Group Commercial	$685.79
Rate for Payer: Health Management Network Commercial	$613.60
Rate for Payer: Kaiser Permanente Commercial	$454.78
Rate for Payer: Kaiser Permanente Medicaid	$368.16
Rate for Payer: MDX Hawaii PPO	$700.22
Rate for Payer: University Health Alliance Commercial	$526.18

DILATION & CURETTAGE FOR NON-OBSTETRIC DIAGNOSES

Facility

$3,766.05

Service Code	APR-DRG 5171
Min. Negotiated Rate	$3,766.05
Max. Negotiated Rate	$3,766.05
Rate for Payer: AlohaCare Medicaid	$3,766.05
Rate for Payer: Hawaii Medical Service Association ABD	$3,766.05
Rate for Payer: Hawaii Medical Service Association Non-ABD	$3,766.05
Rate for Payer: Kaiser Permanente Medicaid	$3,766.05
Rate for Payer: Ohana Health Plan Medicaid	$3,766.05
Rate for Payer: UnitedHealthcare Medicaid	$3,766.05

DILATION & CURETTAGE FOR NON-OBSTETRIC DIAGNOSES

Facility

$7,314.96

Service Code	APR-DRG 5173
Min. Negotiated Rate	$7,314.96
Max. Negotiated Rate	$7,314.96
Rate for Payer: AlohaCare Medicaid	$7,314.96
Rate for Payer: Hawaii Medical Service Association ABD	$7,314.96
Rate for Payer: Hawaii Medical Service Association Non-ABD	$7,314.96
Rate for Payer: Kaiser Permanente Medicaid	$7,314.96
Rate for Payer: Ohana Health Plan Medicaid	$7,314.96
Rate for Payer: UnitedHealthcare Medicaid	$7,314.96

DILATION & CURETTAGE FOR NON-OBSTETRIC DIAGNOSES

Facility

$15,601.04

Service Code	APR-DRG 5174
Min. Negotiated Rate	$15,601.04
Max. Negotiated Rate	$15,601.04
Rate for Payer: AlohaCare Medicaid	$15,601.04
Rate for Payer: Hawaii Medical Service Association ABD	$15,601.04
Rate for Payer: Hawaii Medical Service Association Non-ABD	$15,601.04
Rate for Payer: Kaiser Permanente Medicaid	$15,601.04
Rate for Payer: Ohana Health Plan Medicaid	$15,601.04
Rate for Payer: UnitedHealthcare Medicaid	$15,601.04

DILATION & CURETTAGE FOR NON-OBSTETRIC DIAGNOSES

Facility

$4,802.77

Service Code	APR-DRG 5172
Min. Negotiated Rate	$4,802.77
Max. Negotiated Rate	$4,802.77
Rate for Payer: AlohaCare Medicaid	$4,802.77
Rate for Payer: Hawaii Medical Service Association ABD	$4,802.77
Rate for Payer: Hawaii Medical Service Association Non-ABD	$4,802.77
Rate for Payer: Kaiser Permanente Medicaid	$4,802.77
Rate for Payer: Ohana Health Plan Medicaid	$4,802.77
Rate for Payer: UnitedHealthcare Medicaid	$4,802.77

Dilator Ureteral Balloon 18FRx4cm Uromax M006225122 [3600801]

Facility

$1,105.91

Service Code	HCPCS C1726
Hospital Charge Code	3600801
Hospital Revenue Code	272
Min. Negotiated Rate	$940.02
Max. Negotiated Rate	$1,072.73
Rate for Payer: Cash Price	$718.84
Rate for Payer: Health Management Network Commercial	$940.02
Rate for Payer: MDX Hawaii PPO	$1,072.73

Dilator Ureteral Balloon 18FRx4cm Uromax M006225122 [3600801]

Facility

$1,105.91

Service Code	HCPCS C1726
Hospital Charge Code	3600801
Hospital Revenue Code	272
Min. Negotiated Rate	$564.01
Max. Negotiated Rate	$1,072.73
Rate for Payer: Cash Price	$718.84
Rate for Payer: Hawaii Western Management Group Commercial	$1,050.61
Rate for Payer: Health Management Network Commercial	$940.02
Rate for Payer: Kaiser Permanente Commercial	$696.72
Rate for Payer: Kaiser Permanente Medicaid	$564.01
Rate for Payer: MDX Hawaii PPO	$1,072.73
Rate for Payer: University Health Alliance Commercial	$806.10

Know your out-of-pocket cost for care.

All Charges