Kona Community Hospital

All Charges

Charge

Type

Setting

Price

INJECTION PRALATREXATE 1 MG

Professional

Both

$960.00

Service Code	HCPCS J9307
Min. Negotiated Rate	$392.72
Max. Negotiated Rate	$816.00
Rate for Payer: AlohaCare Medicare	$392.72
Rate for Payer: Cash Price	$624.00
Rate for Payer: Cash Price	$624.00
Rate for Payer: Devoted Health Medicare	$431.99
Rate for Payer: Hawaii Medical Service Association Medicare	$392.72
Rate for Payer: Health Management Network Commercial	$816.00
Rate for Payer: Kaiser Permanente Commercial	$471.26
Rate for Payer: Kaiser Permanente Medicaid	$471.26
Rate for Payer: Kaiser Permanente Medicare	$471.26
Rate for Payer: Ohana Health Plan Medicare	$392.72
Rate for Payer: UnitedHealthcare Medicare	$392.72

INJECTION PROCEDURE FOR CONTRAST KNEE ARTHROGRAPHY OR CONTRAST ENHANCED CT/MRI KNEE ARTHROGRAPHY

Facility

$2,837.00

Service Code	CPT 27369
Hospital Revenue Code	360
Min. Negotiated Rate	$39.93
Max. Negotiated Rate	$2,837.00
Rate for Payer: Hawaii Medical Service Association ABD	$393.00
Rate for Payer: Hawaii Medical Service Association Commercial	$2,833.00
Rate for Payer: Hawaii Medical Service Association Non-ABD	$407.95
Rate for Payer: Kaiser Permanente Medicaid	$2,837.00
Rate for Payer: UnitedHealthcare Medicaid	$39.93

INJECTION PROCEDURE FOR SHOULDER ARTHROGRAPHY OR ENHANCED CT/MRI SHOULDER ARTHROGRAPHY

Facility

$2,837.00

Service Code	CPT 23350
Hospital Revenue Code	360
Min. Negotiated Rate	$40.41
Max. Negotiated Rate	$2,837.00
Rate for Payer: Hawaii Medical Service Association ABD	$393.00
Rate for Payer: Hawaii Medical Service Association Commercial	$2,833.00
Rate for Payer: Hawaii Medical Service Association Non-ABD	$407.95
Rate for Payer: Kaiser Permanente Medicaid	$2,837.00
Rate for Payer: UnitedHealthcare Medicaid	$40.41

INJECTION PROMETHAZINE HCL UP TO 50 MG

Professional

Both

$7.00

Service Code	HCPCS J2550
Min. Negotiated Rate	$1.87
Max. Negotiated Rate	$5.95
Rate for Payer: AlohaCare Medicare	$3.34
Rate for Payer: Cash Price	$4.55
Rate for Payer: Cash Price	$4.55
Rate for Payer: Devoted Health Medicare	$3.67
Rate for Payer: Hawaii Medical Service Association Medicare	$3.34
Rate for Payer: Hawaii Western Management Group Commercial	$1.87
Rate for Payer: Health Management Network Commercial	$5.95
Rate for Payer: Kaiser Permanente Commercial	$4.01
Rate for Payer: Kaiser Permanente Medicaid	$4.01
Rate for Payer: Kaiser Permanente Medicare	$4.01
Rate for Payer: Ohana Health Plan Medicare	$3.34
Rate for Payer: UnitedHealthcare Medicare	$3.34

INJECTION RAMUCIRUMAB 5 MG

Professional

Both

$190.00

Service Code	HCPCS J9308
Min. Negotiated Rate	$59.04
Max. Negotiated Rate	$161.50
Rate for Payer: AlohaCare Medicare	$75.47
Rate for Payer: Cash Price	$123.50
Rate for Payer: Cash Price	$123.50
Rate for Payer: Devoted Health Medicare	$83.02
Rate for Payer: Hawaii Medical Service Association Medicare	$75.47
Rate for Payer: Hawaii Western Management Group Commercial	$59.04
Rate for Payer: Health Management Network Commercial	$161.50
Rate for Payer: Kaiser Permanente Commercial	$90.56
Rate for Payer: Kaiser Permanente Medicaid	$90.56
Rate for Payer: Kaiser Permanente Medicare	$90.56
Rate for Payer: Ohana Health Plan Medicare	$75.47
Rate for Payer: UnitedHealthcare Medicare	$75.47

INJECTION RANITIDINE HYDROCHLORIDE 25 MG

Professional

Both

$18.00

Service Code	HCPCS J2780
Min. Negotiated Rate	$6.00
Max. Negotiated Rate	$15.30
Rate for Payer: Cash Price	$11.70
Rate for Payer: Cash Price	$11.70
Rate for Payer: Hawaii Western Management Group Commercial	$6.00
Rate for Payer: Health Management Network Commercial	$15.30

INJECTION RAVULIZUMAB-CWVZ 10 MG

Professional

Both

$650.00

Service Code	HCPCS J1303
Min. Negotiated Rate	$223.68
Max. Negotiated Rate	$552.50
Rate for Payer: AlohaCare Medicare	$223.68
Rate for Payer: Cash Price	$422.50
Rate for Payer: Cash Price	$422.50
Rate for Payer: Devoted Health Medicare	$246.05
Rate for Payer: Hawaii Medical Service Association Medicare	$223.68
Rate for Payer: Health Management Network Commercial	$552.50
Rate for Payer: Kaiser Permanente Commercial	$268.42
Rate for Payer: Kaiser Permanente Medicaid	$268.42
Rate for Payer: Kaiser Permanente Medicare	$268.42
Rate for Payer: Ohana Health Plan Medicare	$223.68
Rate for Payer: UnitedHealthcare Medicare	$223.68

INJECTION RITUXIMAB 10 MG

Professional

Both

$260.00

Service Code	HCPCS J9312
Min. Negotiated Rate	$74.16
Max. Negotiated Rate	$221.00
Rate for Payer: AlohaCare Medicare	$74.16
Rate for Payer: Cash Price	$169.00
Rate for Payer: Cash Price	$169.00
Rate for Payer: Devoted Health Medicare	$81.58
Rate for Payer: Hawaii Medical Service Association Medicare	$74.16
Rate for Payer: Hawaii Western Management Group Commercial	$101.47
Rate for Payer: Health Management Network Commercial	$221.00
Rate for Payer: Kaiser Permanente Commercial	$88.99
Rate for Payer: Kaiser Permanente Medicaid	$88.99
Rate for Payer: Kaiser Permanente Medicare	$88.99
Rate for Payer: Ohana Health Plan Medicare	$74.16
Rate for Payer: UnitedHealthcare Medicare	$74.16

INJECTION RITUXIMAB 10 MG AND HYALURONIDASE

Professional

Both

$115.00

Service Code	HCPCS J9311
Min. Negotiated Rate	$36.28
Max. Negotiated Rate	$97.75
Rate for Payer: AlohaCare Medicare	$36.28
Rate for Payer: Cash Price	$74.75
Rate for Payer: Cash Price	$74.75
Rate for Payer: Devoted Health Medicare	$39.91
Rate for Payer: Hawaii Medical Service Association Medicare	$36.28
Rate for Payer: Health Management Network Commercial	$97.75
Rate for Payer: Kaiser Permanente Commercial	$43.54
Rate for Payer: Kaiser Permanente Medicaid	$43.54
Rate for Payer: Kaiser Permanente Medicare	$43.54
Rate for Payer: Ohana Health Plan Medicare	$36.28
Rate for Payer: UnitedHealthcare Medicare	$36.28

INJECTION RITUXIMAB-ABBS BIOSIMILAR 10 MG

Professional

Both

$175.00

Service Code	HCPCS Q5115
Min. Negotiated Rate	$31.28
Max. Negotiated Rate	$148.75
Rate for Payer: AlohaCare Medicare	$31.28
Rate for Payer: Cash Price	$113.75
Rate for Payer: Cash Price	$113.75
Rate for Payer: Devoted Health Medicare	$34.41
Rate for Payer: Hawaii Medical Service Association Medicare	$31.28
Rate for Payer: Health Management Network Commercial	$148.75
Rate for Payer: Kaiser Permanente Commercial	$37.54
Rate for Payer: Kaiser Permanente Medicaid	$37.54
Rate for Payer: Kaiser Permanente Medicare	$37.54
Rate for Payer: Ohana Health Plan Medicare	$31.28
Rate for Payer: UnitedHealthcare Medicare	$31.28

INJECTION RITUXIMAB-ARRX BIOSIMILAR 10 MG

Professional

Both

$150.00

Service Code	HCPCS Q5123
Min. Negotiated Rate	$20.26
Max. Negotiated Rate	$127.50
Rate for Payer: AlohaCare Medicare	$20.26
Rate for Payer: Cash Price	$97.50
Rate for Payer: Cash Price	$97.50
Rate for Payer: Devoted Health Medicare	$22.29
Rate for Payer: Hawaii Medical Service Association Medicare	$20.26
Rate for Payer: Health Management Network Commercial	$127.50
Rate for Payer: Kaiser Permanente Commercial	$24.31
Rate for Payer: Kaiser Permanente Medicaid	$24.31
Rate for Payer: Kaiser Permanente Medicare	$24.31
Rate for Payer: Ohana Health Plan Medicare	$20.26
Rate for Payer: UnitedHealthcare Medicare	$20.26

INJECTION ROMIDEPSIN LYOPHILIZED 0.1 MG

Professional

Both

$100.00

Service Code	HCPCS J9319
Min. Negotiated Rate	$30.80
Max. Negotiated Rate	$85.00
Rate for Payer: AlohaCare Medicare	$30.80
Rate for Payer: Cash Price	$65.00
Rate for Payer: Cash Price	$65.00
Rate for Payer: Devoted Health Medicare	$33.88
Rate for Payer: Hawaii Medical Service Association Medicare	$30.80
Rate for Payer: Health Management Network Commercial	$85.00
Rate for Payer: Kaiser Permanente Commercial	$36.96
Rate for Payer: Kaiser Permanente Medicaid	$36.96
Rate for Payer: Kaiser Permanente Medicare	$36.96
Rate for Payer: Ohana Health Plan Medicare	$30.80
Rate for Payer: UnitedHealthcare Medicare	$30.80

INJECTION ROMIPLOSTIM 10 MCG

Professional

Both

$250.00

Service Code	HCPCS J2796
Min. Negotiated Rate	$212.50
Max. Negotiated Rate	$212.50
Rate for Payer: Cash Price	$162.50
Rate for Payer: Health Management Network Commercial	$212.50

INJECTION ROMOSOZUMAB-AQQG 1 MG

Professional

Both

$28.00

Service Code	HCPCS J3111
Min. Negotiated Rate	$12.19
Max. Negotiated Rate	$23.80
Rate for Payer: AlohaCare Medicare	$12.19
Rate for Payer: Cash Price	$18.20
Rate for Payer: Cash Price	$18.20
Rate for Payer: Devoted Health Medicare	$13.41
Rate for Payer: Hawaii Medical Service Association Medicare	$12.19
Rate for Payer: Health Management Network Commercial	$23.80
Rate for Payer: Kaiser Permanente Commercial	$14.63
Rate for Payer: Kaiser Permanente Medicaid	$14.63
Rate for Payer: Kaiser Permanente Medicare	$14.63
Rate for Payer: Ohana Health Plan Medicare	$12.19
Rate for Payer: UnitedHealthcare Medicare	$12.19

INJECTION SACITUZUMAB GOVITECAN-HZIY 2.5 MG

Professional

Both

$94.00

Service Code	HCPCS J9317
Min. Negotiated Rate	$36.80
Max. Negotiated Rate	$79.90
Rate for Payer: AlohaCare Medicare	$36.80
Rate for Payer: Cash Price	$61.10
Rate for Payer: Cash Price	$61.10
Rate for Payer: Devoted Health Medicare	$40.48
Rate for Payer: Hawaii Medical Service Association Medicare	$36.80
Rate for Payer: Health Management Network Commercial	$79.90
Rate for Payer: Kaiser Permanente Commercial	$44.16
Rate for Payer: Kaiser Permanente Medicaid	$44.16
Rate for Payer: Kaiser Permanente Medicare	$44.16
Rate for Payer: Ohana Health Plan Medicare	$36.80
Rate for Payer: UnitedHealthcare Medicare	$36.80

INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; FEMORAL NERVE, INCLUDING IMAGING GUIDANCE, WHEN PERFORMED

Facility

$4,035.20

Service Code	CPT 64447
Hospital Revenue Code	360
Min. Negotiated Rate	$340.18
Max. Negotiated Rate	$4,035.20
Rate for Payer: AlohaCare Medicaid	$833.89
Rate for Payer: AlohaCare Medicare	$833.89
Rate for Payer: Devoted Health Medicare	$917.28
Rate for Payer: Hawaii Medical Service Association ABD	$393.00
Rate for Payer: Hawaii Medical Service Association Commercial	$2,833.00
Rate for Payer: Hawaii Medical Service Association Medicare	$833.89
Rate for Payer: Hawaii Medical Service Association Non-ABD	$407.95
Rate for Payer: Humana Medicare	$833.89
Rate for Payer: Kaiser Permanente Medicaid	$2,837.00
Rate for Payer: Kaiser Permanente Medicare	$833.89
Rate for Payer: Ohana Health Plan Medicaid	$917.28
Rate for Payer: Ohana Health Plan Medicare	$833.89
Rate for Payer: UnitedHealthcare Medicaid	$340.18
Rate for Payer: UnitedHealthcare Medicare	$833.89
Rate for Payer: University Health Alliance Commercial	$4,035.20

INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; OTHER PERIPHERAL NERVE OR BRANCH

Facility

$4,035.20

Service Code	CPT 64450
Hospital Revenue Code	360
Min. Negotiated Rate	$340.18
Max. Negotiated Rate	$4,035.20
Rate for Payer: AlohaCare Medicaid	$833.89
Rate for Payer: AlohaCare Medicare	$833.89
Rate for Payer: Devoted Health Medicare	$917.28
Rate for Payer: Hawaii Medical Service Association ABD	$393.00
Rate for Payer: Hawaii Medical Service Association Commercial	$2,833.00
Rate for Payer: Hawaii Medical Service Association Medicare	$833.89
Rate for Payer: Hawaii Medical Service Association Non-ABD	$407.95
Rate for Payer: Humana Medicare	$833.89
Rate for Payer: Kaiser Permanente Medicaid	$2,837.00
Rate for Payer: Kaiser Permanente Medicare	$833.89
Rate for Payer: Ohana Health Plan Medicaid	$917.28
Rate for Payer: Ohana Health Plan Medicare	$833.89
Rate for Payer: UnitedHealthcare Medicaid	$340.18
Rate for Payer: UnitedHealthcare Medicare	$833.89
Rate for Payer: University Health Alliance Commercial	$4,035.20

INJECTION SILTUXIMAB 10 MG

Professional

Both

$375.00

Service Code	HCPCS J2860
Min. Negotiated Rate	$174.08
Max. Negotiated Rate	$318.75
Rate for Payer: AlohaCare Medicare	$174.08
Rate for Payer: Cash Price	$243.75
Rate for Payer: Cash Price	$243.75
Rate for Payer: Devoted Health Medicare	$191.49
Rate for Payer: Hawaii Medical Service Association Medicare	$174.08
Rate for Payer: Health Management Network Commercial	$318.75
Rate for Payer: Kaiser Permanente Commercial	$208.90
Rate for Payer: Kaiser Permanente Medicaid	$208.90
Rate for Payer: Kaiser Permanente Medicare	$208.90
Rate for Payer: Ohana Health Plan Medicare	$174.08
Rate for Payer: UnitedHealthcare Medicare	$174.08

INJECTION STREPTOZOCIN 1 G

Professional

Both

$1,045.00

Service Code	HCPCS J9320
Min. Negotiated Rate	$134.19
Max. Negotiated Rate	$888.25
Rate for Payer: Cash Price	$679.25
Rate for Payer: Cash Price	$679.25
Rate for Payer: Hawaii Western Management Group Commercial	$134.19
Rate for Payer: Health Management Network Commercial	$888.25

INJECTION TAFASITAMAB-CXIX 2 MG

Professional

Both

$38.00

Service Code	HCPCS J9349
Min. Negotiated Rate	$14.17
Max. Negotiated Rate	$32.30
Rate for Payer: AlohaCare Medicare	$14.17
Rate for Payer: Cash Price	$24.70
Rate for Payer: Cash Price	$24.70
Rate for Payer: Devoted Health Medicare	$15.59
Rate for Payer: Hawaii Medical Service Association Medicare	$14.17
Rate for Payer: Health Management Network Commercial	$32.30
Rate for Payer: Kaiser Permanente Commercial	$17.00
Rate for Payer: Kaiser Permanente Medicaid	$17.00
Rate for Payer: Kaiser Permanente Medicare	$17.00
Rate for Payer: Ohana Health Plan Medicare	$14.17
Rate for Payer: UnitedHealthcare Medicare	$14.17

INJECTION TBO-FILGRASTIM 1 MICROGRAM

Professional

Both

$2.00

Service Code	HCPCS J1447
Min. Negotiated Rate	$0.25
Max. Negotiated Rate	$1.70
Rate for Payer: AlohaCare Medicare	$0.25
Rate for Payer: Cash Price	$1.30
Rate for Payer: Cash Price	$1.30
Rate for Payer: Devoted Health Medicare	$0.28
Rate for Payer: Hawaii Medical Service Association Medicare	$0.25
Rate for Payer: Hawaii Western Management Group Commercial	$0.90
Rate for Payer: Health Management Network Commercial	$1.70
Rate for Payer: Kaiser Permanente Commercial	$0.30
Rate for Payer: Kaiser Permanente Medicaid	$0.30
Rate for Payer: Kaiser Permanente Medicare	$0.30
Rate for Payer: Ohana Health Plan Medicare	$0.25
Rate for Payer: UnitedHealthcare Medicare	$0.25

INJECTION TEMSIROLIMUS 1 MG

Professional

Both

$105.00

Service Code	HCPCS J9330
Min. Negotiated Rate	$30.08
Max. Negotiated Rate	$89.25
Rate for Payer: AlohaCare Medicare	$30.08
Rate for Payer: Cash Price	$68.25
Rate for Payer: Cash Price	$68.25
Rate for Payer: Devoted Health Medicare	$33.09
Rate for Payer: Hawaii Medical Service Association Medicare	$30.08
Rate for Payer: Health Management Network Commercial	$89.25
Rate for Payer: Kaiser Permanente Commercial	$36.10
Rate for Payer: Kaiser Permanente Medicaid	$36.10
Rate for Payer: Kaiser Permanente Medicare	$36.10
Rate for Payer: Ohana Health Plan Medicare	$30.08
Rate for Payer: UnitedHealthcare Medicare	$30.08

INJECTION TOPOTECAN 0.1 MG

Professional

Both

$4.00

Service Code	HCPCS J9351
Min. Negotiated Rate	$2.11
Max. Negotiated Rate	$3.40
Rate for Payer: AlohaCare Medicare	$2.11
Rate for Payer: Cash Price	$2.60
Rate for Payer: Cash Price	$2.60
Rate for Payer: Devoted Health Medicare	$2.32
Rate for Payer: Hawaii Medical Service Association Medicare	$2.11
Rate for Payer: Health Management Network Commercial	$3.40
Rate for Payer: Kaiser Permanente Commercial	$2.53
Rate for Payer: Kaiser Permanente Medicaid	$2.53
Rate for Payer: Kaiser Permanente Medicare	$2.53
Rate for Payer: Ohana Health Plan Medicare	$2.11
Rate for Payer: UnitedHealthcare Medicare	$2.11

INJECTION TRABECTEDIN 0.1 MG

Professional

Both

$975.00

Service Code	HCPCS J9352
Min. Negotiated Rate	$391.07
Max. Negotiated Rate	$828.75
Rate for Payer: AlohaCare Medicare	$391.07
Rate for Payer: Cash Price	$633.75
Rate for Payer: Cash Price	$633.75
Rate for Payer: Devoted Health Medicare	$430.18
Rate for Payer: Hawaii Medical Service Association Medicare	$391.07
Rate for Payer: Health Management Network Commercial	$828.75
Rate for Payer: Kaiser Permanente Commercial	$469.28
Rate for Payer: Kaiser Permanente Medicaid	$469.28
Rate for Payer: Kaiser Permanente Medicare	$469.28
Rate for Payer: Ohana Health Plan Medicare	$391.07
Rate for Payer: UnitedHealthcare Medicare	$391.07

INJECTION TRASTUZUMAB-ANNS BIOSIMILAR 10 MG

Professional

Both

$100.00

Service Code	HCPCS Q5117
Min. Negotiated Rate	$56.38
Max. Negotiated Rate	$85.00
Rate for Payer: AlohaCare Medicare	$56.38
Rate for Payer: Cash Price	$65.00
Rate for Payer: Cash Price	$65.00
Rate for Payer: Devoted Health Medicare	$62.02
Rate for Payer: Hawaii Medical Service Association Medicare	$56.38
Rate for Payer: Health Management Network Commercial	$85.00
Rate for Payer: Kaiser Permanente Commercial	$67.66
Rate for Payer: Kaiser Permanente Medicaid	$67.66
Rate for Payer: Kaiser Permanente Medicare	$67.66
Rate for Payer: Ohana Health Plan Medicare	$56.38
Rate for Payer: UnitedHealthcare Medicare	$56.38

Know your out-of-pocket cost for care.

All Charges