Kona Community Hospital

All Charges

Charge

Type

Setting

Price

INJECTION DEXAMETHOSONE SODIUM PHOSPHATE 1 MG

Professional

Both

$1.00

Service Code	HCPCS J1100
Min. Negotiated Rate	$0.07
Max. Negotiated Rate	$0.85
Rate for Payer: AlohaCare Medicare	$0.11
Rate for Payer: Cash Price	$0.65
Rate for Payer: Cash Price	$0.65
Rate for Payer: Devoted Health Medicare	$0.12
Rate for Payer: Hawaii Medical Service Association Medicare	$0.11
Rate for Payer: Hawaii Western Management Group Commercial	$0.07
Rate for Payer: Health Management Network Commercial	$0.85
Rate for Payer: Kaiser Permanente Commercial	$0.13
Rate for Payer: Kaiser Permanente Medicaid	$0.13
Rate for Payer: Kaiser Permanente Medicare	$0.13
Rate for Payer: Ohana Health Plan Medicare	$0.11
Rate for Payer: UnitedHealthcare Medicare	$0.11

INJECTION DEXRAZOXANE HYDROCHLORIDE PER 250 MG

Professional

Both

$375.00

Service Code	HCPCS J1190
Min. Negotiated Rate	$49.74
Max. Negotiated Rate	$318.75
Rate for Payer: AlohaCare Medicare	$49.74
Rate for Payer: Cash Price	$243.75
Rate for Payer: Cash Price	$243.75
Rate for Payer: Devoted Health Medicare	$54.71
Rate for Payer: Hawaii Medical Service Association Medicare	$49.74
Rate for Payer: Health Management Network Commercial	$318.75
Rate for Payer: Kaiser Permanente Commercial	$59.69
Rate for Payer: Kaiser Permanente Medicaid	$59.69
Rate for Payer: Kaiser Permanente Medicare	$59.69
Rate for Payer: Ohana Health Plan Medicare	$49.74
Rate for Payer: UnitedHealthcare Medicare	$49.74

INJECTION DIPHENHYDRAMINE HCL UP TO 50 MG

Professional

Both

$4.00

Service Code	HCPCS J1200
Min. Negotiated Rate	$0.69
Max. Negotiated Rate	$3.40
Rate for Payer: AlohaCare Medicare	$0.69
Rate for Payer: Cash Price	$2.60
Rate for Payer: Cash Price	$2.60
Rate for Payer: Devoted Health Medicare	$0.76
Rate for Payer: Hawaii Medical Service Association Medicare	$0.69
Rate for Payer: Hawaii Western Management Group Commercial	$1.42
Rate for Payer: Health Management Network Commercial	$3.40
Rate for Payer: Kaiser Permanente Commercial	$0.83
Rate for Payer: Kaiser Permanente Medicaid	$0.83
Rate for Payer: Kaiser Permanente Medicare	$0.83
Rate for Payer: Ohana Health Plan Medicare	$0.69
Rate for Payer: UnitedHealthcare Medicare	$0.69

INJECTION DOCETAXEL 1 MG

Professional

Both

$2.00

Service Code	HCPCS J9171
Min. Negotiated Rate	$0.56
Max. Negotiated Rate	$23.36
Rate for Payer: AlohaCare Medicare	$0.56
Rate for Payer: Cash Price	$1.30
Rate for Payer: Cash Price	$1.30
Rate for Payer: Devoted Health Medicare	$0.62
Rate for Payer: Hawaii Medical Service Association Medicare	$0.56
Rate for Payer: Hawaii Western Management Group Commercial	$23.36
Rate for Payer: Health Management Network Commercial	$1.70
Rate for Payer: Kaiser Permanente Commercial	$0.67
Rate for Payer: Kaiser Permanente Medicaid	$0.67
Rate for Payer: Kaiser Permanente Medicare	$0.67
Rate for Payer: Ohana Health Plan Medicare	$0.56
Rate for Payer: UnitedHealthcare Medicare	$0.56

INJECTION DOXORUBICIN HCL 10 MG

Professional

Both

$48.00

Service Code	HCPCS J9000
Min. Negotiated Rate	$2.73
Max. Negotiated Rate	$40.80
Rate for Payer: AlohaCare Medicare	$2.73
Rate for Payer: Cash Price	$31.20
Rate for Payer: Cash Price	$31.20
Rate for Payer: Devoted Health Medicare	$3.00
Rate for Payer: Hawaii Medical Service Association Medicare	$2.73
Rate for Payer: Hawaii Western Management Group Commercial	$7.61
Rate for Payer: Health Management Network Commercial	$40.80
Rate for Payer: Kaiser Permanente Commercial	$3.28
Rate for Payer: Kaiser Permanente Medicaid	$3.28
Rate for Payer: Kaiser Permanente Medicare	$3.28
Rate for Payer: Ohana Health Plan Medicare	$2.73
Rate for Payer: UnitedHealthcare Medicare	$2.73

INJECTION DOXORUBICIN HCL LIPOSOMAL NOS 10 MG

Professional

Both

$400.00

Service Code	HCPCS Q2050
Min. Negotiated Rate	$71.86
Max. Negotiated Rate	$340.00
Rate for Payer: AlohaCare Medicare	$71.86
Rate for Payer: Cash Price	$260.00
Rate for Payer: Cash Price	$260.00
Rate for Payer: Devoted Health Medicare	$79.05
Rate for Payer: Hawaii Medical Service Association Medicare	$71.86
Rate for Payer: Health Management Network Commercial	$340.00
Rate for Payer: Kaiser Permanente Commercial	$86.23
Rate for Payer: Kaiser Permanente Medicaid	$86.23
Rate for Payer: Kaiser Permanente Medicare	$86.23
Rate for Payer: Ohana Health Plan Medicare	$71.86
Rate for Payer: UnitedHealthcare Medicare	$71.86

INJECTION DURVALUMAB 10 MG

Professional

Both

$230.00

Service Code	HCPCS J9173
Min. Negotiated Rate	$86.15
Max. Negotiated Rate	$195.50
Rate for Payer: AlohaCare Medicare	$86.15
Rate for Payer: Cash Price	$149.50
Rate for Payer: Cash Price	$149.50
Rate for Payer: Devoted Health Medicare	$94.77
Rate for Payer: Hawaii Medical Service Association Medicare	$86.15
Rate for Payer: Health Management Network Commercial	$195.50
Rate for Payer: Kaiser Permanente Commercial	$103.38
Rate for Payer: Kaiser Permanente Medicaid	$103.38
Rate for Payer: Kaiser Permanente Medicare	$103.38
Rate for Payer: Ohana Health Plan Medicare	$86.15
Rate for Payer: UnitedHealthcare Medicare	$86.15

INJECTION ECULIZUMAB 10 MG

Professional

Both

$690.00

Service Code	HCPCS J1300
Min. Negotiated Rate	$586.50
Max. Negotiated Rate	$586.50
Rate for Payer: Cash Price	$448.50
Rate for Payer: Health Management Network Commercial	$586.50

INJECTION ELOTUZUMAB 1 MG

Professional

Both

$20.00

Service Code	HCPCS J9176
Min. Negotiated Rate	$8.04
Max. Negotiated Rate	$17.00
Rate for Payer: AlohaCare Medicare	$8.04
Rate for Payer: Cash Price	$13.00
Rate for Payer: Cash Price	$13.00
Rate for Payer: Devoted Health Medicare	$8.84
Rate for Payer: Hawaii Medical Service Association Medicare	$8.04
Rate for Payer: Health Management Network Commercial	$17.00
Rate for Payer: Kaiser Permanente Commercial	$9.65
Rate for Payer: Kaiser Permanente Medicaid	$9.65
Rate for Payer: Kaiser Permanente Medicare	$9.65
Rate for Payer: Ohana Health Plan Medicare	$8.04
Rate for Payer: UnitedHealthcare Medicare	$8.04

INJECTION ENFORTUMAB VEDOTIN-EJFV 0.25 MG

Professional

Both

$90.00

Service Code	HCPCS J9177
Min. Negotiated Rate	$36.71
Max. Negotiated Rate	$76.50
Rate for Payer: AlohaCare Medicare	$36.71
Rate for Payer: Cash Price	$58.50
Rate for Payer: Cash Price	$58.50
Rate for Payer: Devoted Health Medicare	$40.38
Rate for Payer: Hawaii Medical Service Association Medicare	$36.71
Rate for Payer: Health Management Network Commercial	$76.50
Rate for Payer: Kaiser Permanente Commercial	$44.05
Rate for Payer: Kaiser Permanente Medicaid	$44.05
Rate for Payer: Kaiser Permanente Medicare	$44.05
Rate for Payer: Ohana Health Plan Medicare	$36.71
Rate for Payer: UnitedHealthcare Medicare	$36.71

INJECTION EPIRUBICIN HCL 2 MG

Professional

Both

$5.00

Service Code	HCPCS J9178
Min. Negotiated Rate	$1.77
Max. Negotiated Rate	$4.25
Rate for Payer: AlohaCare Medicare	$1.77
Rate for Payer: Cash Price	$3.25
Rate for Payer: Cash Price	$3.25
Rate for Payer: Devoted Health Medicare	$1.95
Rate for Payer: Hawaii Medical Service Association Medicare	$1.77
Rate for Payer: Health Management Network Commercial	$4.25
Rate for Payer: Kaiser Permanente Commercial	$2.12
Rate for Payer: Kaiser Permanente Medicaid	$2.12
Rate for Payer: Kaiser Permanente Medicare	$2.12
Rate for Payer: Ohana Health Plan Medicare	$1.77
Rate for Payer: UnitedHealthcare Medicare	$1.77

INJECTION EPOETIN ALFA-EPBX BIOSIMILAR 1000 U

Professional

Both

$25.00

Service Code	HCPCS Q5106
Min. Negotiated Rate	$7.88
Max. Negotiated Rate	$21.25
Rate for Payer: AlohaCare Medicare	$7.88
Rate for Payer: Cash Price	$16.25
Rate for Payer: Cash Price	$16.25
Rate for Payer: Devoted Health Medicare	$8.67
Rate for Payer: Hawaii Medical Service Association Medicare	$7.88
Rate for Payer: Health Management Network Commercial	$21.25
Rate for Payer: Kaiser Permanente Commercial	$9.46
Rate for Payer: Kaiser Permanente Medicaid	$9.46
Rate for Payer: Kaiser Permanente Medicare	$9.46
Rate for Payer: Ohana Health Plan Medicare	$7.88
Rate for Payer: UnitedHealthcare Medicare	$7.88

INJECTION EPOETIN ALFA FOR NON-ESRD 1000 UNITS

Professional

Both

$25.00

Service Code	HCPCS J0885
Min. Negotiated Rate	$7.31
Max. Negotiated Rate	$21.90
Rate for Payer: AlohaCare Medicare	$7.31
Rate for Payer: Cash Price	$16.25
Rate for Payer: Cash Price	$16.25
Rate for Payer: Devoted Health Medicare	$8.04
Rate for Payer: Hawaii Medical Service Association Medicare	$7.31
Rate for Payer: Hawaii Western Management Group Commercial	$21.90
Rate for Payer: Health Management Network Commercial	$21.25
Rate for Payer: Kaiser Permanente Commercial	$8.77
Rate for Payer: Kaiser Permanente Medicaid	$8.77
Rate for Payer: Kaiser Permanente Medicare	$8.77
Rate for Payer: Ohana Health Plan Medicare	$7.31
Rate for Payer: UnitedHealthcare Medicare	$7.31

INJECTION ERIBULIN MESYLATE 0.1 MG

Professional

Both

$380.00

Service Code	HCPCS J9179
Min. Negotiated Rate	$76.76
Max. Negotiated Rate	$323.00
Rate for Payer: AlohaCare Medicare	$76.76
Rate for Payer: Cash Price	$247.00
Rate for Payer: Cash Price	$247.00
Rate for Payer: Devoted Health Medicare	$84.44
Rate for Payer: Hawaii Medical Service Association Medicare	$76.76
Rate for Payer: Health Management Network Commercial	$323.00
Rate for Payer: Kaiser Permanente Commercial	$92.11
Rate for Payer: Kaiser Permanente Medicaid	$92.11
Rate for Payer: Kaiser Permanente Medicare	$92.11
Rate for Payer: Ohana Health Plan Medicare	$76.76
Rate for Payer: UnitedHealthcare Medicare	$76.76

INJECTION ETOPOSIDE 10 MG

Professional

Both

$12.00

Service Code	HCPCS J9181
Min. Negotiated Rate	$0.90
Max. Negotiated Rate	$24.55
Rate for Payer: AlohaCare Medicare	$0.90
Rate for Payer: Cash Price	$7.80
Rate for Payer: Cash Price	$7.80
Rate for Payer: Devoted Health Medicare	$0.99
Rate for Payer: Hawaii Medical Service Association Medicare	$0.90
Rate for Payer: Hawaii Western Management Group Commercial	$24.55
Rate for Payer: Health Management Network Commercial	$10.20
Rate for Payer: Kaiser Permanente Commercial	$1.08
Rate for Payer: Kaiser Permanente Medicaid	$1.08
Rate for Payer: Kaiser Permanente Medicare	$1.08
Rate for Payer: Ohana Health Plan Medicare	$0.90
Rate for Payer: UnitedHealthcare Medicare	$0.90

INJECTION FAMOTIDINE 20 MG

Professional

Both

$5.00

Service Code	HCPCS S0028
Min. Negotiated Rate	$3.69
Max. Negotiated Rate	$4.25
Rate for Payer: Cash Price	$3.25
Rate for Payer: Cash Price	$3.25
Rate for Payer: Hawaii Western Management Group Commercial	$3.69
Rate for Payer: Health Management Network Commercial	$4.25

INJECTION FAM-TRASTUZUMAB DERUXTECAN-NXKI 1 MG

Professional

Both

$74.00

Service Code	HCPCS J9358
Min. Negotiated Rate	$31.26
Max. Negotiated Rate	$62.90
Rate for Payer: AlohaCare Medicare	$31.26
Rate for Payer: Cash Price	$48.10
Rate for Payer: Cash Price	$48.10
Rate for Payer: Devoted Health Medicare	$34.39
Rate for Payer: Hawaii Medical Service Association Medicare	$31.26
Rate for Payer: Health Management Network Commercial	$62.90
Rate for Payer: Kaiser Permanente Commercial	$37.51
Rate for Payer: Kaiser Permanente Medicaid	$37.51
Rate for Payer: Kaiser Permanente Medicare	$37.51
Rate for Payer: Ohana Health Plan Medicare	$31.26
Rate for Payer: UnitedHealthcare Medicare	$31.26

INJECTION FERRIC CARBOXYMALTOSE 1 MG

Professional

Both

$3.00

Service Code	HCPCS J1439
Min. Negotiated Rate	$1.10
Max. Negotiated Rate	$2.55
Rate for Payer: AlohaCare Medicare	$1.10
Rate for Payer: Cash Price	$1.95
Rate for Payer: Cash Price	$1.95
Rate for Payer: Devoted Health Medicare	$1.21
Rate for Payer: Hawaii Medical Service Association Medicare	$1.10
Rate for Payer: Hawaii Western Management Group Commercial	$1.47
Rate for Payer: Health Management Network Commercial	$2.55
Rate for Payer: Kaiser Permanente Commercial	$1.32
Rate for Payer: Kaiser Permanente Medicaid	$1.32
Rate for Payer: Kaiser Permanente Medicare	$1.32
Rate for Payer: Ohana Health Plan Medicare	$1.10
Rate for Payer: UnitedHealthcare Medicare	$1.10

INJECTION FERRIC DERISOMALTOSE 10 MG

Professional

Both

$75.00

Service Code	HCPCS J1437
Min. Negotiated Rate	$21.93
Max. Negotiated Rate	$63.75
Rate for Payer: AlohaCare Medicare	$21.93
Rate for Payer: Cash Price	$48.75
Rate for Payer: Cash Price	$48.75
Rate for Payer: Devoted Health Medicare	$24.12
Rate for Payer: Hawaii Medical Service Association Medicare	$21.93
Rate for Payer: Health Management Network Commercial	$63.75
Rate for Payer: Kaiser Permanente Commercial	$26.32
Rate for Payer: Kaiser Permanente Medicaid	$26.32
Rate for Payer: Kaiser Permanente Medicare	$26.32
Rate for Payer: Ohana Health Plan Medicare	$21.93
Rate for Payer: UnitedHealthcare Medicare	$21.93

INJECTION FILGRASTIM-AAFI BIOSIMILAR 1 MCG

Professional

Both

$1.00

Service Code	HCPCS Q5110
Min. Negotiated Rate	$0.28
Max. Negotiated Rate	$0.85
Rate for Payer: AlohaCare Medicare	$0.28
Rate for Payer: Cash Price	$0.65
Rate for Payer: Cash Price	$0.65
Rate for Payer: Devoted Health Medicare	$0.31
Rate for Payer: Hawaii Medical Service Association Medicare	$0.28
Rate for Payer: Health Management Network Commercial	$0.85
Rate for Payer: Kaiser Permanente Commercial	$0.34
Rate for Payer: Kaiser Permanente Medicaid	$0.34
Rate for Payer: Kaiser Permanente Medicare	$0.34
Rate for Payer: Ohana Health Plan Medicare	$0.28
Rate for Payer: UnitedHealthcare Medicare	$0.28

INJECTION FILGRASTIM BIOSIMILAR 1 MCG

Professional

Both

$1.00

Service Code	HCPCS Q5101
Min. Negotiated Rate	$0.35
Max. Negotiated Rate	$0.99
Rate for Payer: AlohaCare Medicare	$0.35
Rate for Payer: Cash Price	$0.65
Rate for Payer: Cash Price	$0.65
Rate for Payer: Devoted Health Medicare	$0.39
Rate for Payer: Hawaii Medical Service Association Medicare	$0.35
Rate for Payer: Hawaii Western Management Group Commercial	$0.99
Rate for Payer: Health Management Network Commercial	$0.85
Rate for Payer: Kaiser Permanente Commercial	$0.42
Rate for Payer: Kaiser Permanente Medicaid	$0.42
Rate for Payer: Kaiser Permanente Medicare	$0.42
Rate for Payer: Ohana Health Plan Medicare	$0.35
Rate for Payer: UnitedHealthcare Medicare	$0.35

INJECTION FILGRASTIM EXCLUDES BIOSIMILARS 1 MIC

Professional

Both

$3.00

Service Code	HCPCS J1442
Min. Negotiated Rate	$1.02
Max. Negotiated Rate	$2.55
Rate for Payer: AlohaCare Medicare	$1.02
Rate for Payer: Cash Price	$1.95
Rate for Payer: Cash Price	$1.95
Rate for Payer: Devoted Health Medicare	$1.12
Rate for Payer: Hawaii Medical Service Association Medicare	$1.02
Rate for Payer: Hawaii Western Management Group Commercial	$1.15
Rate for Payer: Health Management Network Commercial	$2.55
Rate for Payer: Kaiser Permanente Commercial	$1.22
Rate for Payer: Kaiser Permanente Medicaid	$1.22
Rate for Payer: Kaiser Permanente Medicare	$1.22
Rate for Payer: Ohana Health Plan Medicare	$1.02
Rate for Payer: UnitedHealthcare Medicare	$1.02

INJECTION FLUDARABINE PHOSPHATE 50 MG

Professional

Both

$287.00

Service Code	HCPCS J9185
Min. Negotiated Rate	$217.73
Max. Negotiated Rate	$339.48
Rate for Payer: AlohaCare Medicare	$217.73
Rate for Payer: Cash Price	$186.55
Rate for Payer: Cash Price	$186.55
Rate for Payer: Devoted Health Medicare	$239.50
Rate for Payer: Hawaii Medical Service Association Medicare	$217.73
Rate for Payer: Hawaii Western Management Group Commercial	$339.48
Rate for Payer: Health Management Network Commercial	$243.95
Rate for Payer: Kaiser Permanente Commercial	$261.28
Rate for Payer: Kaiser Permanente Medicaid	$261.28
Rate for Payer: Kaiser Permanente Medicare	$261.28
Rate for Payer: Ohana Health Plan Medicare	$217.73
Rate for Payer: UnitedHealthcare Medicare	$217.73

INJECTION FLUOROURACIL 500 MG

Professional

Both

$6.00

Service Code	HCPCS J9190
Min. Negotiated Rate	$2.06
Max. Negotiated Rate	$5.10
Rate for Payer: AlohaCare Medicare	$2.06
Rate for Payer: Cash Price	$3.90
Rate for Payer: Cash Price	$3.90
Rate for Payer: Devoted Health Medicare	$2.27
Rate for Payer: Hawaii Medical Service Association Medicare	$2.06
Rate for Payer: Hawaii Western Management Group Commercial	$4.30
Rate for Payer: Health Management Network Commercial	$5.10
Rate for Payer: Kaiser Permanente Commercial	$2.47
Rate for Payer: Kaiser Permanente Medicaid	$2.47
Rate for Payer: Kaiser Permanente Medicare	$2.47
Rate for Payer: Ohana Health Plan Medicare	$2.06
Rate for Payer: UnitedHealthcare Medicare	$2.06

INJECTION FOSAPREPITANT 1 MG

Professional

Both

$1.00

Service Code	HCPCS J1453
Min. Negotiated Rate	$0.11
Max. Negotiated Rate	$1.85
Rate for Payer: AlohaCare Medicare	$0.11
Rate for Payer: Cash Price	$0.65
Rate for Payer: Cash Price	$0.65
Rate for Payer: Devoted Health Medicare	$0.12
Rate for Payer: Hawaii Medical Service Association Medicare	$0.11
Rate for Payer: Hawaii Western Management Group Commercial	$1.85
Rate for Payer: Health Management Network Commercial	$0.85
Rate for Payer: Kaiser Permanente Commercial	$0.13
Rate for Payer: Kaiser Permanente Medicaid	$0.13
Rate for Payer: Kaiser Permanente Medicare	$0.13
Rate for Payer: Ohana Health Plan Medicare	$0.11
Rate for Payer: UnitedHealthcare Medicare	$0.11

Know your out-of-pocket cost for care.

All Charges