Kona Community Hospital

All Charges

Charge

Type

Setting

Price

INJECTION TRASTUZUMAB EXCLUDES BIOSIMILAR 10 MG

Professional

Both

$260.00

Service Code	HCPCS J9355
Min. Negotiated Rate	$73.43
Max. Negotiated Rate	$221.00
Rate for Payer: AlohaCare Medicare	$73.43
Rate for Payer: Cash Price	$169.00
Rate for Payer: Cash Price	$169.00
Rate for Payer: Devoted Health Medicare	$80.77
Rate for Payer: Hawaii Medical Service Association Medicare	$73.43
Rate for Payer: Hawaii Western Management Group Commercial	$93.97
Rate for Payer: Health Management Network Commercial	$221.00
Rate for Payer: Kaiser Permanente Commercial	$88.12
Rate for Payer: Kaiser Permanente Medicaid	$88.12
Rate for Payer: Kaiser Permanente Medicare	$88.12
Rate for Payer: Ohana Health Plan Medicare	$73.43
Rate for Payer: UnitedHealthcare Medicare	$73.43

INJECTION TRIPTORELIN PAMOATE 3.75 MG

Professional

Both

$1,200.00

Service Code	HCPCS J3315
Min. Negotiated Rate	$469.38
Max. Negotiated Rate	$1,020.00
Rate for Payer: AlohaCare Medicare	$469.38
Rate for Payer: Cash Price	$780.00
Rate for Payer: Cash Price	$780.00
Rate for Payer: Devoted Health Medicare	$516.32
Rate for Payer: Hawaii Medical Service Association Medicare	$469.38
Rate for Payer: Health Management Network Commercial	$1,020.00
Rate for Payer: Kaiser Permanente Commercial	$563.26
Rate for Payer: Kaiser Permanente Medicaid	$563.26
Rate for Payer: Kaiser Permanente Medicare	$563.26
Rate for Payer: Ohana Health Plan Medicare	$469.38
Rate for Payer: UnitedHealthcare Medicare	$469.38

INJECTION VINBLASTINE SULFATE 1 MG

Professional

Both

$12.00

Service Code	HCPCS J9360
Min. Negotiated Rate	$5.15
Max. Negotiated Rate	$10.20
Rate for Payer: AlohaCare Medicare	$5.15
Rate for Payer: Cash Price	$7.80
Rate for Payer: Cash Price	$7.80
Rate for Payer: Devoted Health Medicare	$5.67
Rate for Payer: Hawaii Medical Service Association Medicare	$5.15
Rate for Payer: Hawaii Western Management Group Commercial	$7.00
Rate for Payer: Health Management Network Commercial	$10.20
Rate for Payer: Kaiser Permanente Commercial	$6.18
Rate for Payer: Kaiser Permanente Medicaid	$6.18
Rate for Payer: Kaiser Permanente Medicare	$6.18
Rate for Payer: Ohana Health Plan Medicare	$5.15
Rate for Payer: UnitedHealthcare Medicare	$5.15

INJECTION VINCRISTINE SULFATE LIPOSOME 1 MG

Professional

Both

$10,265.00

Service Code	HCPCS J9371
Min. Negotiated Rate	$8,725.25
Max. Negotiated Rate	$8,725.25
Rate for Payer: Cash Price	$6,672.25
Rate for Payer: Health Management Network Commercial	$8,725.25

INJECTION VINORELBINE TARTRATE 10 MG

Professional

Both

$96.00

Service Code	HCPCS J9390
Min. Negotiated Rate	$4.97
Max. Negotiated Rate	$106.67
Rate for Payer: AlohaCare Medicare	$4.97
Rate for Payer: Cash Price	$62.40
Rate for Payer: Cash Price	$62.40
Rate for Payer: Devoted Health Medicare	$5.47
Rate for Payer: Hawaii Medical Service Association Medicare	$4.97
Rate for Payer: Hawaii Western Management Group Commercial	$106.67
Rate for Payer: Health Management Network Commercial	$81.60
Rate for Payer: Kaiser Permanente Commercial	$5.96
Rate for Payer: Kaiser Permanente Medicaid	$5.96
Rate for Payer: Kaiser Permanente Medicare	$5.96
Rate for Payer: Ohana Health Plan Medicare	$4.97
Rate for Payer: UnitedHealthcare Medicare	$4.97

INJECTION VIT B-12 CYANOCOBALAMIN TO 1000 MCG

Professional

Both

$6.00

Service Code	HCPCS J3420
Min. Negotiated Rate	$0.67
Max. Negotiated Rate	$5.10
Rate for Payer: AlohaCare Medicare	$0.67
Rate for Payer: Cash Price	$3.90
Rate for Payer: Cash Price	$3.90
Rate for Payer: Devoted Health Medicare	$0.74
Rate for Payer: Hawaii Medical Service Association Medicare	$0.67
Rate for Payer: Hawaii Western Management Group Commercial	$1.13
Rate for Payer: Health Management Network Commercial	$5.10
Rate for Payer: Kaiser Permanente Commercial	$0.80
Rate for Payer: Kaiser Permanente Medicaid	$0.80
Rate for Payer: Kaiser Permanente Medicare	$0.80
Rate for Payer: Ohana Health Plan Medicare	$0.67
Rate for Payer: UnitedHealthcare Medicare	$0.67

INJECTION ZIV-AFLIBERCEPT 1 MG

Professional

Both

$23.00

Service Code	HCPCS J9400
Min. Negotiated Rate	$8.61
Max. Negotiated Rate	$19.55
Rate for Payer: AlohaCare Medicare	$8.61
Rate for Payer: Cash Price	$14.95
Rate for Payer: Cash Price	$14.95
Rate for Payer: Devoted Health Medicare	$9.47
Rate for Payer: Hawaii Medical Service Association Medicare	$8.61
Rate for Payer: Health Management Network Commercial	$19.55
Rate for Payer: Kaiser Permanente Commercial	$10.33
Rate for Payer: Kaiser Permanente Medicaid	$10.33
Rate for Payer: Kaiser Permanente Medicare	$10.33
Rate for Payer: Ohana Health Plan Medicare	$8.61
Rate for Payer: UnitedHealthcare Medicare	$8.61

INJECTION ZOLEDRONIC ACID 1 MG

Professional

Both

$26.00

Service Code	HCPCS J3489
Min. Negotiated Rate	$22.10
Max. Negotiated Rate	$94.50
Rate for Payer: AlohaCare Medicare	$30.88
Rate for Payer: Cash Price	$16.90
Rate for Payer: Cash Price	$16.90
Rate for Payer: Devoted Health Medicare	$33.97
Rate for Payer: Hawaii Medical Service Association Medicare	$30.88
Rate for Payer: Hawaii Western Management Group Commercial	$94.50
Rate for Payer: Health Management Network Commercial	$22.10
Rate for Payer: Kaiser Permanente Commercial	$37.06
Rate for Payer: Kaiser Permanente Medicaid	$37.06
Rate for Payer: Kaiser Permanente Medicare	$37.06
Rate for Payer: Ohana Health Plan Medicare	$30.88
Rate for Payer: UnitedHealthcare Medicare	$30.88

INJECT PEGFILGRASTIM EXCLUDES BIOSIMILAR 0.5 MG

Professional

Both

$500.00

Service Code	HCPCS J2506
Min. Negotiated Rate	$127.38
Max. Negotiated Rate	$425.00
Rate for Payer: AlohaCare Medicare	$127.38
Rate for Payer: Cash Price	$325.00
Rate for Payer: Cash Price	$325.00
Rate for Payer: Devoted Health Medicare	$140.12
Rate for Payer: Hawaii Medical Service Association Medicare	$127.38
Rate for Payer: Health Management Network Commercial	$425.00
Rate for Payer: Kaiser Permanente Commercial	$152.86
Rate for Payer: Kaiser Permanente Medicaid	$152.86
Rate for Payer: Kaiser Permanente Medicare	$152.86
Rate for Payer: Ohana Health Plan Medicare	$127.38
Rate for Payer: UnitedHealthcare Medicare	$127.38

INJ FERUMOXYTOL TX IRON DEF ANEMIA 1 MG NON-ESRD

Professional

Both

$4.00

Service Code	HCPCS Q0138
Min. Negotiated Rate	$0.23
Max. Negotiated Rate	$3.40
Rate for Payer: AlohaCare Medicare	$0.23
Rate for Payer: Cash Price	$2.60
Rate for Payer: Cash Price	$2.60
Rate for Payer: Devoted Health Medicare	$0.25
Rate for Payer: Hawaii Medical Service Association Medicare	$0.23
Rate for Payer: Health Management Network Commercial	$3.40
Rate for Payer: Kaiser Permanente Commercial	$0.28
Rate for Payer: Kaiser Permanente Medicaid	$0.28
Rate for Payer: Kaiser Permanente Medicare	$0.28
Rate for Payer: Ohana Health Plan Medicare	$0.23
Rate for Payer: UnitedHealthcare Medicare	$0.23

INJ FOSNETUPITANT 235 MG & PALONOSETRON 0.25 MG

Professional

Both

$1,300.00

Service Code	HCPCS J1454
Min. Negotiated Rate	$524.18
Max. Negotiated Rate	$1,105.00
Rate for Payer: AlohaCare Medicare	$524.18
Rate for Payer: Cash Price	$845.00
Rate for Payer: Cash Price	$845.00
Rate for Payer: Devoted Health Medicare	$576.60
Rate for Payer: Hawaii Medical Service Association Medicare	$524.18
Rate for Payer: Health Management Network Commercial	$1,105.00
Rate for Payer: Kaiser Permanente Commercial	$629.02
Rate for Payer: Kaiser Permanente Medicaid	$629.02
Rate for Payer: Kaiser Permanente Medicare	$629.02
Rate for Payer: Ohana Health Plan Medicare	$524.18
Rate for Payer: UnitedHealthcare Medicare	$524.18

INJ HYDROCORTISONE SODIUM SUCCINATE TO 100 MG

Professional

Both

$42.00

Service Code	HCPCS J1720
Min. Negotiated Rate	$12.00
Max. Negotiated Rate	$35.70
Rate for Payer: AlohaCare Medicare	$22.14
Rate for Payer: Cash Price	$27.30
Rate for Payer: Cash Price	$27.30
Rate for Payer: Devoted Health Medicare	$24.35
Rate for Payer: Hawaii Medical Service Association Medicare	$22.14
Rate for Payer: Hawaii Western Management Group Commercial	$12.00
Rate for Payer: Health Management Network Commercial	$35.70
Rate for Payer: Kaiser Permanente Commercial	$26.57
Rate for Payer: Kaiser Permanente Medicaid	$26.57
Rate for Payer: Kaiser Permanente Medicare	$26.57
Rate for Payer: Ohana Health Plan Medicare	$22.14
Rate for Payer: UnitedHealthcare Medicare	$22.14

INJ IG GAMMAGARD LIQ IV NONLYOPHILIZED 500 MG

Professional

Both

$138.00

Service Code	HCPCS J1569
Min. Negotiated Rate	$49.08
Max. Negotiated Rate	$117.30
Rate for Payer: AlohaCare Medicare	$49.08
Rate for Payer: Cash Price	$89.70
Rate for Payer: Cash Price	$89.70
Rate for Payer: Devoted Health Medicare	$53.99
Rate for Payer: Hawaii Medical Service Association Medicare	$49.08
Rate for Payer: Health Management Network Commercial	$117.30
Rate for Payer: Kaiser Permanente Commercial	$58.90
Rate for Payer: Kaiser Permanente Medicaid	$58.90
Rate for Payer: Kaiser Permanente Medicare	$58.90
Rate for Payer: Ohana Health Plan Medicare	$49.08
Rate for Payer: UnitedHealthcare Medicare	$49.08

INJ IG IV LYPHILIZED NOT OTHERWISE SPEC 500 MG

Professional

Both

$200.00

Service Code	HCPCS J1566
Min. Negotiated Rate	$49.68
Max. Negotiated Rate	$170.00
Rate for Payer: AlohaCare Medicare	$80.40
Rate for Payer: Cash Price	$130.00
Rate for Payer: Cash Price	$130.00
Rate for Payer: Devoted Health Medicare	$88.44
Rate for Payer: Hawaii Medical Service Association Medicare	$80.40
Rate for Payer: Hawaii Western Management Group Commercial	$49.68
Rate for Payer: Health Management Network Commercial	$170.00
Rate for Payer: Kaiser Permanente Commercial	$96.48
Rate for Payer: Kaiser Permanente Medicaid	$96.48
Rate for Payer: Kaiser Permanente Medicare	$96.48
Rate for Payer: Ohana Health Plan Medicare	$80.40
Rate for Payer: UnitedHealthcare Medicare	$80.40

INJ IG OCTOGAM IV NONLYOPHILIZED 500 MG

Professional

Both

$125.00

Service Code	HCPCS J1568
Min. Negotiated Rate	$47.04
Max. Negotiated Rate	$106.25
Rate for Payer: AlohaCare Medicare	$47.04
Rate for Payer: Cash Price	$81.25
Rate for Payer: Cash Price	$81.25
Rate for Payer: Devoted Health Medicare	$51.74
Rate for Payer: Hawaii Medical Service Association Medicare	$47.04
Rate for Payer: Health Management Network Commercial	$106.25
Rate for Payer: Kaiser Permanente Commercial	$56.45
Rate for Payer: Kaiser Permanente Medicaid	$56.45
Rate for Payer: Kaiser Permanente Medicare	$56.45
Rate for Payer: Ohana Health Plan Medicare	$47.04
Rate for Payer: UnitedHealthcare Medicare	$47.04

INJ METHYLPRDNISOLONE SODIUM SUCCNAT TO 125 MG

Professional

Both

$18.00

Service Code	HCPCS J2930
Min. Negotiated Rate	$9.56
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	$9.56
Rate for Payer: Health Management Network Commercial	$15.30

INJ METHYLPRDNISOLONE SODIUM SUCCNAT TO 40 MG

Professional

Both

$13.00

Service Code	HCPCS J2920
Min. Negotiated Rate	$3.60
Max. Negotiated Rate	$11.05
Rate for Payer: Cash Price	$8.45
Rate for Payer: Cash Price	$8.45
Rate for Payer: Hawaii Western Management Group Commercial	$3.60
Rate for Payer: Health Management Network Commercial	$11.05

INJ OCTREOTIDE DEPOT FORM IM INJ 1 MG

Professional

Both

$615.00

Service Code	HCPCS J2353
Min. Negotiated Rate	$97.56
Max. Negotiated Rate	$522.75
Rate for Payer: AlohaCare Medicare	$188.35
Rate for Payer: Cash Price	$399.75
Rate for Payer: Cash Price	$399.75
Rate for Payer: Devoted Health Medicare	$207.19
Rate for Payer: Hawaii Medical Service Association Medicare	$188.35
Rate for Payer: Hawaii Western Management Group Commercial	$97.56
Rate for Payer: Health Management Network Commercial	$522.75
Rate for Payer: Kaiser Permanente Commercial	$226.02
Rate for Payer: Kaiser Permanente Medicaid	$226.02
Rate for Payer: Kaiser Permanente Medicare	$226.02
Rate for Payer: Ohana Health Plan Medicare	$188.35
Rate for Payer: UnitedHealthcare Medicare	$188.35

INJ RITUXIMAB-PVVR BIOSIMILAR RUXIENCE 10 MG

Professional

Both

$120.00

Service Code	HCPCS Q5119
Min. Negotiated Rate	$13.69
Max. Negotiated Rate	$102.00
Rate for Payer: AlohaCare Medicare	$13.69
Rate for Payer: Cash Price	$78.00
Rate for Payer: Cash Price	$78.00
Rate for Payer: Devoted Health Medicare	$15.06
Rate for Payer: Hawaii Medical Service Association Medicare	$13.69
Rate for Payer: Health Management Network Commercial	$102.00
Rate for Payer: Kaiser Permanente Commercial	$16.43
Rate for Payer: Kaiser Permanente Medicaid	$16.43
Rate for Payer: Kaiser Permanente Medicare	$16.43
Rate for Payer: Ohana Health Plan Medicare	$13.69
Rate for Payer: UnitedHealthcare Medicare	$13.69

INJ SODIM FERRIC GLUCONATE CMPLX SUCROSE 12.5 MG

Professional

Both

$6.00

Service Code	HCPCS J2916
Min. Negotiated Rate	$2.39
Max. Negotiated Rate	$6.87
Rate for Payer: AlohaCare Medicare	$2.39
Rate for Payer: Cash Price	$3.90
Rate for Payer: Cash Price	$3.90
Rate for Payer: Devoted Health Medicare	$2.63
Rate for Payer: Hawaii Medical Service Association Medicare	$2.39
Rate for Payer: Hawaii Western Management Group Commercial	$6.87
Rate for Payer: Health Management Network Commercial	$5.10
Rate for Payer: Kaiser Permanente Commercial	$2.87
Rate for Payer: Kaiser Permanente Medicaid	$2.87
Rate for Payer: Kaiser Permanente Medicare	$2.87
Rate for Payer: Ohana Health Plan Medicare	$2.39
Rate for Payer: UnitedHealthcare Medicare	$2.39

INJ TALIMOGENE LAHERPAREPVEC PER 1 M PLAQUE F U

Professional

Both

$172.00

Service Code	HCPCS J9325
Min. Negotiated Rate	$73.94
Max. Negotiated Rate	$146.20
Rate for Payer: AlohaCare Medicare	$73.94
Rate for Payer: Cash Price	$111.80
Rate for Payer: Cash Price	$111.80
Rate for Payer: Devoted Health Medicare	$81.33
Rate for Payer: Hawaii Medical Service Association Medicare	$73.94
Rate for Payer: Health Management Network Commercial	$146.20
Rate for Payer: Kaiser Permanente Commercial	$88.73
Rate for Payer: Kaiser Permanente Medicaid	$88.73
Rate for Payer: Kaiser Permanente Medicare	$88.73
Rate for Payer: Ohana Health Plan Medicare	$73.94
Rate for Payer: UnitedHealthcare Medicare	$73.94

INSERTION OF INTRAUTERINE DEVICE (IUD)

Facility

$4,035.20

Service Code	CPT 58300
Hospital Revenue Code	360
Min. Negotiated Rate	$51.59
Max. Negotiated Rate	$4,035.20
Rate for Payer: Kaiser Permanente Medicaid	$2,837.00
Rate for Payer: UnitedHealthcare Medicaid	$51.59
Rate for Payer: University Health Alliance Commercial	$4,035.20

INSERTION OF NON-TUNNELED CENTRALLY INSERTED CENTRAL VENOUS CATHETER; AGE 5 YEARS OR OLDER

Facility

$4,103.08

Service Code	CPT 36556
Hospital Revenue Code	360
Min. Negotiated Rate	$340.18
Max. Negotiated Rate	$4,103.08
Rate for Payer: AlohaCare Medicaid	$3,730.07
Rate for Payer: AlohaCare Medicare	$3,730.07
Rate for Payer: Devoted Health Medicare	$4,103.08
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	$3,730.07
Rate for Payer: Hawaii Medical Service Association Non-ABD	$407.95
Rate for Payer: Humana Medicare	$3,730.07
Rate for Payer: Kaiser Permanente Medicaid	$2,837.00
Rate for Payer: Kaiser Permanente Medicare	$3,730.07
Rate for Payer: Ohana Health Plan Medicaid	$4,103.08
Rate for Payer: Ohana Health Plan Medicare	$3,730.07
Rate for Payer: UnitedHealthcare Medicaid	$340.18
Rate for Payer: UnitedHealthcare Medicare	$3,730.07

INSERTION OF PERIPHERALLY INSERTED CENTRAL VENOUS ACCESS DEVICE, WITH SUBCUTANEOUS PORT; AGE 5 YEARS OR OLDER

Facility

$9,416.00

Service Code	CPT 36571
Hospital Revenue Code	360
Min. Negotiated Rate	$456.03
Max. Negotiated Rate	$9,416.00
Rate for Payer: AlohaCare Medicaid	$3,730.07
Rate for Payer: AlohaCare Medicare	$3,730.07
Rate for Payer: Devoted Health Medicare	$4,103.08
Rate for Payer: Hawaii Medical Service Association ABD	$848.00
Rate for Payer: Hawaii Medical Service Association Commercial	$9,416.00
Rate for Payer: Hawaii Medical Service Association Medicare	$3,730.07
Rate for Payer: Hawaii Medical Service Association Non-ABD	$849.21
Rate for Payer: Humana Medicare	$3,730.07
Rate for Payer: Kaiser Permanente Medicaid	$2,837.00
Rate for Payer: Kaiser Permanente Medicare	$3,730.07
Rate for Payer: Ohana Health Plan Medicaid	$4,103.08
Rate for Payer: Ohana Health Plan Medicare	$3,730.07
Rate for Payer: UnitedHealthcare Medicaid	$456.03
Rate for Payer: UnitedHealthcare Medicare	$3,730.07
Rate for Payer: University Health Alliance Commercial	$6,743.44

INSERTION OF TEMPORARY INDWELLING BLADDER CATHETER; COMPLICATED (EG, ALTERED ANATOMY, FRACTURED CATHETER/BALLOON)

Facility

$2,837.00

Service Code	CPT 51703
Hospital Revenue Code	360
Min. Negotiated Rate	$58.37
Max. Negotiated Rate	$2,837.00
Rate for Payer: AlohaCare Medicaid	$152.01
Rate for Payer: AlohaCare Medicare	$152.01
Rate for Payer: Devoted Health Medicare	$167.21
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	$152.01
Rate for Payer: Hawaii Medical Service Association Non-ABD	$407.95
Rate for Payer: Humana Medicare	$152.01
Rate for Payer: Kaiser Permanente Medicaid	$2,837.00
Rate for Payer: Kaiser Permanente Medicare	$152.01
Rate for Payer: Ohana Health Plan Medicaid	$167.21
Rate for Payer: Ohana Health Plan Medicare	$152.01
Rate for Payer: UnitedHealthcare Medicaid	$58.37
Rate for Payer: UnitedHealthcare Medicare	$152.01

Know your out-of-pocket cost for care.

All Charges