Kona Community Hospital

All Charges

Charge

Type

Setting

Price

Dilator Ureteral Balloon 24FRx4cm Uromax 225124 [3600804]

Facility

$1,482.47

Service Code	HCPCS C1726
Hospital Charge Code	3600804
Hospital Revenue Code	272
Min. Negotiated Rate	$756.06
Max. Negotiated Rate	$1,438.00
Rate for Payer: Cash Price	$963.61
Rate for Payer: Hawaii Western Management Group Commercial	$1,408.35
Rate for Payer: Health Management Network Commercial	$1,260.10
Rate for Payer: Kaiser Permanente Commercial	$933.96
Rate for Payer: Kaiser Permanente Medicaid	$756.06
Rate for Payer: MDX Hawaii PPO	$1,438.00
Rate for Payer: University Health Alliance Commercial	$1,080.57

Dilator Ureteral Balloon 24FRx4cm Uromax 225124 [3600804]

Facility

$1,482.47

Service Code	HCPCS C1726
Hospital Charge Code	3600804
Hospital Revenue Code	272
Min. Negotiated Rate	$1,260.10
Max. Negotiated Rate	$1,438.00
Rate for Payer: Cash Price	$963.61
Rate for Payer: Health Management Network Commercial	$1,260.10
Rate for Payer: MDX Hawaii PPO	$1,438.00

Dil Ball Must 6x60mmx135cm H74939171060610 [3643350]

Facility

$1,171.23

Service Code	HCPCS C1725
Hospital Charge Code	3643350
Hospital Revenue Code	272
Min. Negotiated Rate	$995.55
Max. Negotiated Rate	$1,136.09
Rate for Payer: Cash Price	$761.30
Rate for Payer: Health Management Network Commercial	$995.55
Rate for Payer: MDX Hawaii PPO	$1,136.09

Dil Ball Must 6x60mmx135cm H74939171060610 [3643350]

Facility

$1,171.23

Service Code	HCPCS C1725
Hospital Charge Code	3643350
Hospital Revenue Code	272
Min. Negotiated Rate	$597.33
Max. Negotiated Rate	$1,136.09
Rate for Payer: Cash Price	$761.30
Rate for Payer: Hawaii Western Management Group Commercial	$1,112.67
Rate for Payer: Health Management Network Commercial	$995.55
Rate for Payer: Kaiser Permanente Commercial	$737.87
Rate for Payer: Kaiser Permanente Medicaid	$597.33
Rate for Payer: MDX Hawaii PPO	$1,136.09
Rate for Payer: University Health Alliance Commercial	$853.71

Dil Ball Ster Lp 4x20mmx135cm H74939032402010 [3643323]

Facility

$1,471.25

Service Code	HCPCS C1725
Hospital Charge Code	3643323
Hospital Revenue Code	272
Min. Negotiated Rate	$1,250.56
Max. Negotiated Rate	$1,427.11
Rate for Payer: Cash Price	$956.31
Rate for Payer: Health Management Network Commercial	$1,250.56
Rate for Payer: MDX Hawaii PPO	$1,427.11

Dil Ball Ster Lp 4x20mmx135cm H74939032402010 [3643323]

Facility

$1,471.25

Service Code	HCPCS C1725
Hospital Charge Code	3643323
Hospital Revenue Code	272
Min. Negotiated Rate	$750.34
Max. Negotiated Rate	$1,427.11
Rate for Payer: Cash Price	$956.31
Rate for Payer: Hawaii Western Management Group Commercial	$1,397.69
Rate for Payer: Health Management Network Commercial	$1,250.56
Rate for Payer: Kaiser Permanente Commercial	$926.89
Rate for Payer: Kaiser Permanente Medicaid	$750.34
Rate for Payer: MDX Hawaii PPO	$1,427.11
Rate for Payer: University Health Alliance Commercial	$1,072.39

Dil Ball Ster Lp 4x60mmx135cm H74939032406010 [3643325]

Facility

$1,471.25

Service Code	HCPCS C1725
Hospital Charge Code	3643325
Hospital Revenue Code	272
Min. Negotiated Rate	$750.34
Max. Negotiated Rate	$1,427.11
Rate for Payer: Cash Price	$956.31
Rate for Payer: Hawaii Western Management Group Commercial	$1,397.69
Rate for Payer: Health Management Network Commercial	$1,250.56
Rate for Payer: Kaiser Permanente Commercial	$926.89
Rate for Payer: Kaiser Permanente Medicaid	$750.34
Rate for Payer: MDX Hawaii PPO	$1,427.11
Rate for Payer: University Health Alliance Commercial	$1,072.39

Dil Ball Ster Lp 4x60mmx135cm H74939032406010 [3643325]

Facility

$1,471.25

Service Code	HCPCS C1725
Hospital Charge Code	3643325
Hospital Revenue Code	272
Min. Negotiated Rate	$1,250.56
Max. Negotiated Rate	$1,427.11
Rate for Payer: Cash Price	$956.31
Rate for Payer: Health Management Network Commercial	$1,250.56
Rate for Payer: MDX Hawaii PPO	$1,427.11

Dil Ball Ster Lp 5x20mmx135cm H74939032502010 [3643326]

Facility

$1,031.25

Service Code	HCPCS C1725
Hospital Charge Code	3643326
Hospital Revenue Code	272
Min. Negotiated Rate	$525.94
Max. Negotiated Rate	$1,000.31
Rate for Payer: Cash Price	$670.31
Rate for Payer: Hawaii Western Management Group Commercial	$979.69
Rate for Payer: Health Management Network Commercial	$876.56
Rate for Payer: Kaiser Permanente Commercial	$649.69
Rate for Payer: Kaiser Permanente Medicaid	$525.94
Rate for Payer: MDX Hawaii PPO	$1,000.31
Rate for Payer: University Health Alliance Commercial	$751.68

Dil Ball Ster Lp 5x20mmx135cm H74939032502010 [3643326]

Facility

$1,031.25

Service Code	HCPCS C1725
Hospital Charge Code	3643326
Hospital Revenue Code	272
Min. Negotiated Rate	$876.56
Max. Negotiated Rate	$1,000.31
Rate for Payer: Cash Price	$670.31
Rate for Payer: Health Management Network Commercial	$876.56
Rate for Payer: MDX Hawaii PPO	$1,000.31

DILTIAZEM HCL 120 MG PO CAP (24 HR EXTENDED RELEASE)

Facility

$5.34

Service Code	HCPCS A9270
Hospital Revenue Code	250
Min. Negotiated Rate	$2.72
Max. Negotiated Rate	$5.18
Rate for Payer: Cash Price	$3.47
Rate for Payer: Hawaii Western Management Group Commercial	$5.07
Rate for Payer: Health Management Network Commercial	$4.54
Rate for Payer: Kaiser Permanente Commercial	$3.36
Rate for Payer: Kaiser Permanente Medicaid	$2.72
Rate for Payer: MDX Hawaii PPO	$5.18
Rate for Payer: UnitedHealthcare Medicaid	$3.20
Rate for Payer: University Health Alliance Commercial	$3.89

DILTIAZEM HCL 120 MG PO CAP (24 HR EXTENDED RELEASE)

Facility

$5.34

Service Code	HCPCS A9270
Hospital Revenue Code	250
Min. Negotiated Rate	$4.54
Max. Negotiated Rate	$5.18
Rate for Payer: Cash Price	$3.47
Rate for Payer: Health Management Network Commercial	$4.54
Rate for Payer: MDX Hawaii PPO	$5.18

DILTIAZEM HCL 180 MG PO CDCR

Facility

$7.40

Service Code	HCPCS A9270
Hospital Revenue Code	250
Min. Negotiated Rate	$6.29
Max. Negotiated Rate	$7.18
Rate for Payer: Cash Price	$4.81
Rate for Payer: Health Management Network Commercial	$6.29
Rate for Payer: MDX Hawaii PPO	$7.18

DILTIAZEM HCL 180 MG PO CDCR

Facility

$7.40

Service Code	HCPCS A9270
Hospital Revenue Code	250
Min. Negotiated Rate	$3.77
Max. Negotiated Rate	$7.18
Rate for Payer: Cash Price	$4.81
Rate for Payer: Hawaii Western Management Group Commercial	$7.03
Rate for Payer: Health Management Network Commercial	$6.29
Rate for Payer: Kaiser Permanente Commercial	$4.66
Rate for Payer: Kaiser Permanente Medicaid	$3.77
Rate for Payer: MDX Hawaii PPO	$7.18
Rate for Payer: UnitedHealthcare Medicaid	$4.44
Rate for Payer: University Health Alliance Commercial	$5.39

DILTIAZEM HCL 240 MG PO CAP (24 HR EXTENDED RELEASE)

Facility

$7.32

Service Code	HCPCS A9270
Hospital Revenue Code	250
Min. Negotiated Rate	$3.73
Max. Negotiated Rate	$7.10
Rate for Payer: Cash Price	$4.76
Rate for Payer: Hawaii Western Management Group Commercial	$6.95
Rate for Payer: Health Management Network Commercial	$6.22
Rate for Payer: Kaiser Permanente Commercial	$4.61
Rate for Payer: Kaiser Permanente Medicaid	$3.73
Rate for Payer: MDX Hawaii PPO	$7.10
Rate for Payer: UnitedHealthcare Medicaid	$4.39
Rate for Payer: University Health Alliance Commercial	$5.34

DILTIAZEM HCL 240 MG PO CAP (24 HR EXTENDED RELEASE)

Facility

$7.32

Service Code	HCPCS A9270
Hospital Revenue Code	250
Min. Negotiated Rate	$6.22
Max. Negotiated Rate	$7.10
Rate for Payer: Cash Price	$4.76
Rate for Payer: Health Management Network Commercial	$6.22
Rate for Payer: MDX Hawaii PPO	$7.10

DILTIAZEM HCL 30 MG PO TABLET

Facility

$2.90

Service Code	HCPCS A9270
Hospital Revenue Code	250
Min. Negotiated Rate	$1.48
Max. Negotiated Rate	$2.81
Rate for Payer: Cash Price	$1.88
Rate for Payer: Cash Price	$2.99
Rate for Payer: Hawaii Western Management Group Commercial	$2.75
Rate for Payer: Hawaii Western Management Group Commercial	$4.37
Rate for Payer: Health Management Network Commercial	$2.46
Rate for Payer: Health Management Network Commercial	$3.91
Rate for Payer: Kaiser Permanente Commercial	$1.83
Rate for Payer: Kaiser Permanente Commercial	$2.90
Rate for Payer: Kaiser Permanente Medicaid	$1.48
Rate for Payer: Kaiser Permanente Medicaid	$2.35
Rate for Payer: MDX Hawaii PPO	$2.81
Rate for Payer: MDX Hawaii PPO	$4.46
Rate for Payer: UnitedHealthcare Medicaid	$2.76
Rate for Payer: UnitedHealthcare Medicaid	$1.74
Rate for Payer: University Health Alliance Commercial	$2.11
Rate for Payer: University Health Alliance Commercial	$3.35

DILTIAZEM HCL 30 MG PO TABLET

Facility

$2.90

Service Code	HCPCS A9270
Hospital Revenue Code	250
Min. Negotiated Rate	$2.46
Max. Negotiated Rate	$2.81
Rate for Payer: Cash Price	$1.88
Rate for Payer: Cash Price	$2.99
Rate for Payer: Health Management Network Commercial	$3.91
Rate for Payer: Health Management Network Commercial	$2.46
Rate for Payer: MDX Hawaii PPO	$2.81
Rate for Payer: MDX Hawaii PPO	$4.46

DILTIAZEM HCL 5 MG/ML IV SOLN

Facility

$39.73

Service Code	HCPCS J1163
Hospital Revenue Code	636
Min. Negotiated Rate	$0.04
Max. Negotiated Rate	$38.54
Rate for Payer: Cash Price	$25.82
Rate for Payer: Cash Price	$10.09
Rate for Payer: Cash Price	$12.27
Rate for Payer: Cash Price	$10.09
Rate for Payer: Cash Price	$34.85
Rate for Payer: Cash Price	$10.48
Rate for Payer: Cash Price	$10.48
Rate for Payer: Cash Price	$34.85
Rate for Payer: Cash Price	$25.82
Rate for Payer: Cash Price	$12.27
Rate for Payer: Hawaii Medical Service Association ABD	$0.04
Rate for Payer: Hawaii Medical Service Association ABD	$0.04
Rate for Payer: Hawaii Medical Service Association ABD	$0.04
Rate for Payer: Hawaii Medical Service Association ABD	$0.04
Rate for Payer: Hawaii Medical Service Association ABD	$0.04
Rate for Payer: Hawaii Medical Service Association Non-ABD	$0.04
Rate for Payer: Hawaii Medical Service Association Non-ABD	$0.04
Rate for Payer: Hawaii Medical Service Association Non-ABD	$0.04
Rate for Payer: Hawaii Medical Service Association Non-ABD	$0.04
Rate for Payer: Hawaii Medical Service Association Non-ABD	$0.04
Rate for Payer: Hawaii Western Management Group Commercial	$15.31
Rate for Payer: Hawaii Western Management Group Commercial	$37.74
Rate for Payer: Hawaii Western Management Group Commercial	$50.93
Rate for Payer: Hawaii Western Management Group Commercial	$17.94
Rate for Payer: Hawaii Western Management Group Commercial	$14.74
Rate for Payer: Health Management Network Commercial	$13.70
Rate for Payer: Health Management Network Commercial	$45.57
Rate for Payer: Health Management Network Commercial	$13.19
Rate for Payer: Health Management Network Commercial	$16.05
Rate for Payer: Health Management Network Commercial	$33.77
Rate for Payer: Kaiser Permanente Commercial	$11.89
Rate for Payer: Kaiser Permanente Commercial	$33.77
Rate for Payer: Kaiser Permanente Commercial	$9.78
Rate for Payer: Kaiser Permanente Commercial	$10.16
Rate for Payer: Kaiser Permanente Commercial	$25.03
Rate for Payer: Kaiser Permanente Medicaid	$8.22
Rate for Payer: Kaiser Permanente Medicaid	$20.26
Rate for Payer: Kaiser Permanente Medicaid	$7.92
Rate for Payer: Kaiser Permanente Medicaid	$27.34
Rate for Payer: Kaiser Permanente Medicaid	$9.63
Rate for Payer: MDX Hawaii PPO	$18.31
Rate for Payer: MDX Hawaii PPO	$52.00
Rate for Payer: MDX Hawaii PPO	$38.54
Rate for Payer: MDX Hawaii PPO	$15.05
Rate for Payer: MDX Hawaii PPO	$15.64
Rate for Payer: UnitedHealthcare Medicaid	$11.33
Rate for Payer: UnitedHealthcare Medicaid	$23.84
Rate for Payer: UnitedHealthcare Medicaid	$9.31
Rate for Payer: UnitedHealthcare Medicaid	$9.67
Rate for Payer: UnitedHealthcare Medicaid	$32.17
Rate for Payer: University Health Alliance Commercial	$11.75
Rate for Payer: University Health Alliance Commercial	$13.76
Rate for Payer: University Health Alliance Commercial	$28.96
Rate for Payer: University Health Alliance Commercial	$39.08
Rate for Payer: University Health Alliance Commercial	$11.31

DILTIAZEM HCL 5 MG/ML IV SOLN

Facility

$39.73

Service Code	HCPCS J1163
Hospital Revenue Code	250
Min. Negotiated Rate	$33.77
Max. Negotiated Rate	$38.54
Rate for Payer: Cash Price	$25.82
Rate for Payer: Cash Price	$12.27
Rate for Payer: Cash Price	$10.48
Rate for Payer: Cash Price	$34.85
Rate for Payer: Cash Price	$10.09
Rate for Payer: Health Management Network Commercial	$16.05
Rate for Payer: Health Management Network Commercial	$13.19
Rate for Payer: Health Management Network Commercial	$13.70
Rate for Payer: Health Management Network Commercial	$33.77
Rate for Payer: Health Management Network Commercial	$45.57
Rate for Payer: MDX Hawaii PPO	$52.00
Rate for Payer: MDX Hawaii PPO	$38.54
Rate for Payer: MDX Hawaii PPO	$15.05
Rate for Payer: MDX Hawaii PPO	$18.31
Rate for Payer: MDX Hawaii PPO	$15.64

DILTIAZEM HCL 60 MG PO TABLET

Facility

$8.65

Service Code	HCPCS A9270
Hospital Revenue Code	250
Min. Negotiated Rate	$4.41
Max. Negotiated Rate	$8.39
Rate for Payer: Cash Price	$5.62
Rate for Payer: Cash Price	$4.69
Rate for Payer: Hawaii Western Management Group Commercial	$6.85
Rate for Payer: Hawaii Western Management Group Commercial	$8.22
Rate for Payer: Health Management Network Commercial	$6.13
Rate for Payer: Health Management Network Commercial	$7.35
Rate for Payer: Kaiser Permanente Commercial	$5.45
Rate for Payer: Kaiser Permanente Commercial	$4.54
Rate for Payer: Kaiser Permanente Medicaid	$4.41
Rate for Payer: Kaiser Permanente Medicaid	$3.68
Rate for Payer: MDX Hawaii PPO	$6.99
Rate for Payer: MDX Hawaii PPO	$8.39
Rate for Payer: UnitedHealthcare Medicaid	$4.33
Rate for Payer: UnitedHealthcare Medicaid	$5.19
Rate for Payer: University Health Alliance Commercial	$6.30
Rate for Payer: University Health Alliance Commercial	$5.26

DILTIAZEM HCL 60 MG PO TABLET

Facility

$7.21

Service Code	HCPCS A9270
Hospital Revenue Code	250
Min. Negotiated Rate	$6.13
Max. Negotiated Rate	$6.99
Rate for Payer: Cash Price	$4.69
Rate for Payer: Cash Price	$5.62
Rate for Payer: Health Management Network Commercial	$6.13
Rate for Payer: Health Management Network Commercial	$7.35
Rate for Payer: MDX Hawaii PPO	$6.99
Rate for Payer: MDX Hawaii PPO	$8.39

DIMETHYL SULFOXIDE 50 % INTRAVES SOLN

Facility

$1,754.97

Service Code	HCPCS J1212
Hospital Revenue Code	636
Min. Negotiated Rate	$742.90
Max. Negotiated Rate	$1,702.32
Rate for Payer: Ohana Health Plan Medicaid	$823.88
Rate for Payer: AlohaCare Medicaid	$748.98
Rate for Payer: AlohaCare Medicare	$748.98
Rate for Payer: Cash Price	$1,140.73
Rate for Payer: Cash Price	$1,140.73
Rate for Payer: Devoted Health Medicare	$823.88
Rate for Payer: Hawaii Medical Service Association ABD	$742.90
Rate for Payer: Hawaii Medical Service Association Commercial	$936.23
Rate for Payer: Hawaii Medical Service Association Medicare	$748.98
Rate for Payer: Hawaii Medical Service Association Non-ABD	$742.90
Rate for Payer: Hawaii Western Management Group Commercial	$1,667.22
Rate for Payer: Health Management Network Commercial	$1,491.72
Rate for Payer: Humana Medicare	$748.98
Rate for Payer: Kaiser Permanente Commercial	$1,105.63
Rate for Payer: Kaiser Permanente Medicaid	$895.03
Rate for Payer: Kaiser Permanente Medicare	$748.98
Rate for Payer: MDX Hawaii PPO	$1,702.32
Rate for Payer: Ohana Health Plan Medicare	$748.98
Rate for Payer: UnitedHealthcare Medicaid	$1,052.98
Rate for Payer: UnitedHealthcare Medicare	$748.98
Rate for Payer: University Health Alliance Commercial	$1,279.20

DIMETHYL SULFOXIDE 50 % INTRAVES SOLN

Facility

$1,754.97

Service Code	HCPCS J1212
Hospital Revenue Code	250
Min. Negotiated Rate	$1,491.72
Max. Negotiated Rate	$1,702.32
Rate for Payer: Cash Price	$1,140.73
Rate for Payer: Health Management Network Commercial	$1,491.72
Rate for Payer: MDX Hawaii PPO	$1,702.32

DIMETHYL SULFOXIDE (BULK) 99.99 % MISC LIQ

Facility

$497.43

Service Code	HCPCS J1212
Hospital Revenue Code	250
Min. Negotiated Rate	$422.82
Max. Negotiated Rate	$482.51
Rate for Payer: Cash Price	$323.33
Rate for Payer: Health Management Network Commercial	$422.82
Rate for Payer: MDX Hawaii PPO	$482.51

Know your out-of-pocket cost for care.

All Charges