Kona Community Hospital

All Charges

Charge

Type

Setting

Price

LEUCOVORIN CALCIUM 500 MG INJ RECON.SOLN.

Facility

$397.48

Service Code	HCPCS J0640
Hospital Revenue Code	250
Min. Negotiated Rate	$337.86
Max. Negotiated Rate	$385.56
Rate for Payer: Cash Price	$258.36
Rate for Payer: Health Management Network Commercial	$337.86
Rate for Payer: MDX Hawaii PPO	$385.56

LEUCOVORIN CALCIUM 500 MG INJ RECON.SOLN.

Facility

$397.48

Service Code	HCPCS J0640
Hospital Revenue Code	636
Min. Negotiated Rate	$3.95
Max. Negotiated Rate	$385.56
Rate for Payer: Cash Price	$258.36
Rate for Payer: Cash Price	$258.36
Rate for Payer: Hawaii Medical Service Association ABD	$3.95
Rate for Payer: Hawaii Medical Service Association Non-ABD	$3.95
Rate for Payer: Hawaii Western Management Group Commercial	$377.61
Rate for Payer: Health Management Network Commercial	$337.86
Rate for Payer: Kaiser Permanente Commercial	$250.41
Rate for Payer: Kaiser Permanente Medicaid	$202.71
Rate for Payer: MDX Hawaii PPO	$385.56
Rate for Payer: UnitedHealthcare Medicaid	$238.49
Rate for Payer: University Health Alliance Commercial	$289.72

LEUPROLIDE 3.75 MG IM SYKT

Facility

$3,279.74

Service Code	HCPCS J1950
Hospital Revenue Code	636
Min. Negotiated Rate	$1,672.67
Max. Negotiated Rate	$3,181.35
Rate for Payer: AlohaCare Medicaid	$1,765.57
Rate for Payer: AlohaCare Medicare	$1,765.57
Rate for Payer: Cash Price	$2,131.83
Rate for Payer: Cash Price	$2,131.83
Rate for Payer: Devoted Health Medicare	$1,942.13
Rate for Payer: Hawaii Medical Service Association ABD	$1,737.10
Rate for Payer: Hawaii Medical Service Association Commercial	$2,206.96
Rate for Payer: Hawaii Medical Service Association Medicare	$1,765.57
Rate for Payer: Hawaii Medical Service Association Non-ABD	$1,737.10
Rate for Payer: Hawaii Western Management Group Commercial	$3,115.75
Rate for Payer: Health Management Network Commercial	$2,787.78
Rate for Payer: Humana Medicare	$1,765.57
Rate for Payer: Kaiser Permanente Commercial	$2,066.24
Rate for Payer: Kaiser Permanente Medicaid	$1,672.67
Rate for Payer: Kaiser Permanente Medicare	$1,765.57
Rate for Payer: MDX Hawaii PPO	$3,181.35
Rate for Payer: Ohana Health Plan Medicaid	$1,942.13
Rate for Payer: Ohana Health Plan Medicare	$1,765.57
Rate for Payer: UnitedHealthcare Medicaid	$1,967.84
Rate for Payer: UnitedHealthcare Medicare	$1,765.57
Rate for Payer: University Health Alliance Commercial	$2,390.60

LEUPROLIDE 3.75 MG IM SYKT

Facility

$3,279.74

Service Code	HCPCS J1950
Hospital Revenue Code	250
Min. Negotiated Rate	$2,787.78
Max. Negotiated Rate	$3,181.35
Rate for Payer: Cash Price	$2,131.83
Rate for Payer: Health Management Network Commercial	$2,787.78
Rate for Payer: MDX Hawaii PPO	$3,181.35

LEUPROLIDE 7.5 MG (1 MONTH) SUBCUTANEOUS SYR

Facility

$1,177.71

Service Code	HCPCS J9217
Hospital Revenue Code	636
Min. Negotiated Rate	$155.42
Max. Negotiated Rate	$1,142.38
Rate for Payer: AlohaCare Medicaid	$176.20
Rate for Payer: AlohaCare Medicare	$176.20
Rate for Payer: Cash Price	$765.51
Rate for Payer: Cash Price	$765.51
Rate for Payer: Devoted Health Medicare	$193.82
Rate for Payer: Hawaii Medical Service Association ABD	$155.42
Rate for Payer: Hawaii Medical Service Association Commercial	$220.25
Rate for Payer: Hawaii Medical Service Association Medicare	$176.20
Rate for Payer: Hawaii Medical Service Association Non-ABD	$155.42
Rate for Payer: Hawaii Western Management Group Commercial	$1,118.82
Rate for Payer: Health Management Network Commercial	$1,001.05
Rate for Payer: Humana Medicare	$176.20
Rate for Payer: Kaiser Permanente Commercial	$741.96
Rate for Payer: Kaiser Permanente Medicaid	$600.63
Rate for Payer: Kaiser Permanente Medicare	$176.20
Rate for Payer: MDX Hawaii PPO	$1,142.38
Rate for Payer: Ohana Health Plan Medicaid	$193.82
Rate for Payer: Ohana Health Plan Medicare	$176.20
Rate for Payer: UnitedHealthcare Medicaid	$706.63
Rate for Payer: UnitedHealthcare Medicare	$176.20
Rate for Payer: University Health Alliance Commercial	$858.43

LEUPROLIDE 7.5 MG (1 MONTH) SUBCUTANEOUS SYR

Facility

$1,177.71

Service Code	HCPCS J9217
Hospital Revenue Code	250
Min. Negotiated Rate	$1,001.05
Max. Negotiated Rate	$1,142.38
Rate for Payer: Cash Price	$765.51
Rate for Payer: Health Management Network Commercial	$1,001.05
Rate for Payer: MDX Hawaii PPO	$1,142.38

LEUPROLIDE 7.5 MG IM SYKT

Facility

$3,693.98

Service Code	HCPCS J9217
Hospital Revenue Code	250
Min. Negotiated Rate	$3,139.88
Max. Negotiated Rate	$3,583.16
Rate for Payer: Cash Price	$2,401.09
Rate for Payer: Health Management Network Commercial	$3,139.88
Rate for Payer: MDX Hawaii PPO	$3,583.16

LEUPROLIDE 7.5 MG IM SYKT

Facility

$3,693.98

Service Code	HCPCS J9217
Hospital Revenue Code	636
Min. Negotiated Rate	$155.42
Max. Negotiated Rate	$3,583.16
Rate for Payer: AlohaCare Medicaid	$176.20
Rate for Payer: AlohaCare Medicare	$176.20
Rate for Payer: Cash Price	$2,401.09
Rate for Payer: Cash Price	$2,401.09
Rate for Payer: Devoted Health Medicare	$193.82
Rate for Payer: Hawaii Medical Service Association ABD	$155.42
Rate for Payer: Hawaii Medical Service Association Commercial	$220.25
Rate for Payer: Hawaii Medical Service Association Medicare	$176.20
Rate for Payer: Hawaii Medical Service Association Non-ABD	$155.42
Rate for Payer: Hawaii Western Management Group Commercial	$3,509.28
Rate for Payer: Health Management Network Commercial	$3,139.88
Rate for Payer: Humana Medicare	$176.20
Rate for Payer: Kaiser Permanente Commercial	$2,327.21
Rate for Payer: Kaiser Permanente Medicaid	$1,883.93
Rate for Payer: Kaiser Permanente Medicare	$176.20
Rate for Payer: MDX Hawaii PPO	$3,583.16
Rate for Payer: Ohana Health Plan Medicaid	$193.82
Rate for Payer: Ohana Health Plan Medicare	$176.20
Rate for Payer: UnitedHealthcare Medicaid	$2,216.39
Rate for Payer: UnitedHealthcare Medicare	$176.20
Rate for Payer: University Health Alliance Commercial	$2,692.54

LEUPROLIDE ACETATE (3 MONTH) 11.25 MG IM SYKT

Facility

$7,602.45

Service Code	HCPCS J1950
Hospital Revenue Code	636
Min. Negotiated Rate	$1,737.10
Max. Negotiated Rate	$7,374.38
Rate for Payer: AlohaCare Medicaid	$1,765.57
Rate for Payer: AlohaCare Medicare	$1,765.57
Rate for Payer: Cash Price	$4,941.59
Rate for Payer: Cash Price	$4,941.59
Rate for Payer: Devoted Health Medicare	$1,942.13
Rate for Payer: Hawaii Medical Service Association ABD	$1,737.10
Rate for Payer: Hawaii Medical Service Association Commercial	$2,206.96
Rate for Payer: Hawaii Medical Service Association Medicare	$1,765.57
Rate for Payer: Hawaii Medical Service Association Non-ABD	$1,737.10
Rate for Payer: Hawaii Western Management Group Commercial	$7,222.33
Rate for Payer: Health Management Network Commercial	$6,462.08
Rate for Payer: Humana Medicare	$1,765.57
Rate for Payer: Kaiser Permanente Commercial	$4,789.54
Rate for Payer: Kaiser Permanente Medicaid	$3,877.25
Rate for Payer: Kaiser Permanente Medicare	$1,765.57
Rate for Payer: MDX Hawaii PPO	$7,374.38
Rate for Payer: Ohana Health Plan Medicaid	$1,942.13
Rate for Payer: Ohana Health Plan Medicare	$1,765.57
Rate for Payer: UnitedHealthcare Medicaid	$4,561.47
Rate for Payer: UnitedHealthcare Medicare	$1,765.57
Rate for Payer: University Health Alliance Commercial	$5,541.43

LEUPROLIDE ACETATE (3 MONTH) 11.25 MG IM SYKT

Facility

$7,602.45

Service Code	HCPCS J1950
Hospital Revenue Code	250
Min. Negotiated Rate	$6,462.08
Max. Negotiated Rate	$7,374.38
Rate for Payer: Cash Price	$4,941.59
Rate for Payer: Health Management Network Commercial	$6,462.08
Rate for Payer: MDX Hawaii PPO	$7,374.38

LEUPROLIDE ACETATE (3 MONTH) 22.5 MG IM SYKT

Facility

$8,845.06

Service Code	HCPCS J9217
Hospital Revenue Code	250
Min. Negotiated Rate	$7,518.30
Max. Negotiated Rate	$8,579.71
Rate for Payer: Cash Price	$5,749.29
Rate for Payer: Health Management Network Commercial	$7,518.30
Rate for Payer: MDX Hawaii PPO	$8,579.71

LEUPROLIDE ACETATE (3 MONTH) 22.5 MG IM SYKT

Facility

$8,845.06

Service Code	HCPCS J9217
Hospital Revenue Code	636
Min. Negotiated Rate	$155.42
Max. Negotiated Rate	$8,579.71
Rate for Payer: AlohaCare Medicaid	$176.20
Rate for Payer: AlohaCare Medicare	$176.20
Rate for Payer: Cash Price	$5,749.29
Rate for Payer: Cash Price	$5,749.29
Rate for Payer: Devoted Health Medicare	$193.82
Rate for Payer: Hawaii Medical Service Association ABD	$155.42
Rate for Payer: Hawaii Medical Service Association Commercial	$220.25
Rate for Payer: Hawaii Medical Service Association Medicare	$176.20
Rate for Payer: Hawaii Medical Service Association Non-ABD	$155.42
Rate for Payer: Hawaii Western Management Group Commercial	$8,402.81
Rate for Payer: Health Management Network Commercial	$7,518.30
Rate for Payer: Humana Medicare	$176.20
Rate for Payer: Kaiser Permanente Commercial	$5,572.39
Rate for Payer: Kaiser Permanente Medicaid	$4,510.98
Rate for Payer: Kaiser Permanente Medicare	$176.20
Rate for Payer: MDX Hawaii PPO	$8,579.71
Rate for Payer: Ohana Health Plan Medicaid	$193.82
Rate for Payer: Ohana Health Plan Medicare	$176.20
Rate for Payer: UnitedHealthcare Medicaid	$5,307.04
Rate for Payer: UnitedHealthcare Medicare	$176.20
Rate for Payer: University Health Alliance Commercial	$6,447.16

LEUPROLIDE ACETATE (3 MONTH) 22.5 MG SUBCUTANEOUS SYR

Facility

$2,744.49

Service Code	HCPCS J9217
Hospital Revenue Code	250
Min. Negotiated Rate	$2,332.82
Max. Negotiated Rate	$2,662.16
Rate for Payer: Cash Price	$1,783.92
Rate for Payer: Health Management Network Commercial	$2,332.82
Rate for Payer: MDX Hawaii PPO	$2,662.16

LEUPROLIDE ACETATE (3 MONTH) 22.5 MG SUBCUTANEOUS SYR

Facility

$2,744.49

Service Code	HCPCS J9217
Hospital Revenue Code	636
Min. Negotiated Rate	$155.42
Max. Negotiated Rate	$2,662.16
Rate for Payer: AlohaCare Medicaid	$176.20
Rate for Payer: AlohaCare Medicare	$176.20
Rate for Payer: Cash Price	$1,783.92
Rate for Payer: Cash Price	$1,783.92
Rate for Payer: Devoted Health Medicare	$193.82
Rate for Payer: Hawaii Medical Service Association ABD	$155.42
Rate for Payer: Hawaii Medical Service Association Commercial	$220.25
Rate for Payer: Hawaii Medical Service Association Medicare	$176.20
Rate for Payer: Hawaii Medical Service Association Non-ABD	$155.42
Rate for Payer: Hawaii Western Management Group Commercial	$2,607.27
Rate for Payer: Health Management Network Commercial	$2,332.82
Rate for Payer: Humana Medicare	$176.20
Rate for Payer: Kaiser Permanente Commercial	$1,729.03
Rate for Payer: Kaiser Permanente Medicaid	$1,399.69
Rate for Payer: Kaiser Permanente Medicare	$176.20
Rate for Payer: MDX Hawaii PPO	$2,662.16
Rate for Payer: Ohana Health Plan Medicaid	$193.82
Rate for Payer: Ohana Health Plan Medicare	$176.20
Rate for Payer: UnitedHealthcare Medicaid	$1,646.69
Rate for Payer: UnitedHealthcare Medicare	$176.20
Rate for Payer: University Health Alliance Commercial	$2,000.46

LEUPROLIDE ACETATE (6 MONTH) 45 MG IM SYKT

Facility

$16,571.99

Service Code	HCPCS J9217
Hospital Revenue Code	250
Min. Negotiated Rate	$14,086.19
Max. Negotiated Rate	$16,074.83
Rate for Payer: Cash Price	$10,771.79
Rate for Payer: Health Management Network Commercial	$14,086.19
Rate for Payer: MDX Hawaii PPO	$16,074.83

LEUPROLIDE ACETATE (6 MONTH) 45 MG IM SYKT

Facility

$16,571.99

Service Code	HCPCS J9217
Hospital Revenue Code	636
Min. Negotiated Rate	$155.42
Max. Negotiated Rate	$16,074.83
Rate for Payer: AlohaCare Medicaid	$176.20
Rate for Payer: AlohaCare Medicare	$176.20
Rate for Payer: Cash Price	$10,771.79
Rate for Payer: Cash Price	$10,771.79
Rate for Payer: Devoted Health Medicare	$193.82
Rate for Payer: Hawaii Medical Service Association ABD	$155.42
Rate for Payer: Hawaii Medical Service Association Commercial	$220.25
Rate for Payer: Hawaii Medical Service Association Medicare	$176.20
Rate for Payer: Hawaii Medical Service Association Non-ABD	$155.42
Rate for Payer: Hawaii Western Management Group Commercial	$15,743.39
Rate for Payer: Health Management Network Commercial	$14,086.19
Rate for Payer: Humana Medicare	$176.20
Rate for Payer: Kaiser Permanente Commercial	$10,440.35
Rate for Payer: Kaiser Permanente Medicaid	$8,451.71
Rate for Payer: Kaiser Permanente Medicare	$176.20
Rate for Payer: MDX Hawaii PPO	$16,074.83
Rate for Payer: Ohana Health Plan Medicaid	$193.82
Rate for Payer: Ohana Health Plan Medicare	$176.20
Rate for Payer: UnitedHealthcare Medicaid	$9,943.19
Rate for Payer: UnitedHealthcare Medicare	$176.20
Rate for Payer: University Health Alliance Commercial	$12,079.32

LEUPROLIDE ACETATE (6 MONTH) 45 MG SUBCUTANEOUS SYR

Facility

$4,370.56

Service Code	HCPCS J9217
Hospital Revenue Code	636
Min. Negotiated Rate	$155.42
Max. Negotiated Rate	$4,239.44
Rate for Payer: AlohaCare Medicaid	$176.20
Rate for Payer: AlohaCare Medicare	$176.20
Rate for Payer: Cash Price	$2,840.86
Rate for Payer: Cash Price	$2,840.86
Rate for Payer: Devoted Health Medicare	$193.82
Rate for Payer: Hawaii Medical Service Association ABD	$155.42
Rate for Payer: Hawaii Medical Service Association Commercial	$220.25
Rate for Payer: Hawaii Medical Service Association Medicare	$176.20
Rate for Payer: Hawaii Medical Service Association Non-ABD	$155.42
Rate for Payer: Hawaii Western Management Group Commercial	$4,152.03
Rate for Payer: Health Management Network Commercial	$3,714.98
Rate for Payer: Humana Medicare	$176.20
Rate for Payer: Kaiser Permanente Commercial	$2,753.45
Rate for Payer: Kaiser Permanente Medicaid	$2,228.99
Rate for Payer: Kaiser Permanente Medicare	$176.20
Rate for Payer: MDX Hawaii PPO	$4,239.44
Rate for Payer: Ohana Health Plan Medicaid	$193.82
Rate for Payer: Ohana Health Plan Medicare	$176.20
Rate for Payer: UnitedHealthcare Medicaid	$2,622.34
Rate for Payer: UnitedHealthcare Medicare	$176.20
Rate for Payer: University Health Alliance Commercial	$3,185.70

LEUPROLIDE ACETATE (6 MONTH) 45 MG SUBCUTANEOUS SYR

Facility

$4,370.56

Service Code	HCPCS J9217
Hospital Revenue Code	250
Min. Negotiated Rate	$3,714.98
Max. Negotiated Rate	$4,239.44
Rate for Payer: Cash Price	$2,840.86
Rate for Payer: Health Management Network Commercial	$3,714.98
Rate for Payer: MDX Hawaii PPO	$4,239.44

LEUPROLIDE ACETATE 7.5 MG

Professional

Both

$625.00

Service Code	HCPCS J9217
Min. Negotiated Rate	$176.20
Max. Negotiated Rate	$909.81
Rate for Payer: AlohaCare Medicare	$176.20
Rate for Payer: Cash Price	$406.25
Rate for Payer: Cash Price	$406.25
Rate for Payer: Devoted Health Medicare	$193.82
Rate for Payer: Hawaii Medical Service Association Medicare	$176.20
Rate for Payer: Hawaii Western Management Group Commercial	$909.81
Rate for Payer: Health Management Network Commercial	$531.25
Rate for Payer: Kaiser Permanente Commercial	$211.44
Rate for Payer: Kaiser Permanente Medicaid	$211.44
Rate for Payer: Kaiser Permanente Medicare	$211.44
Rate for Payer: Ohana Health Plan Medicare	$176.20
Rate for Payer: UnitedHealthcare Medicare	$176.20

Level One Thoracic Rib Template Sterile 24-015-61-71 [3644313]

Facility

$1,064.13

Hospital Charge Code	3644313
Hospital Revenue Code	272
Min. Negotiated Rate	$904.51
Max. Negotiated Rate	$1,032.21
Rate for Payer: Cash Price	$691.68
Rate for Payer: Health Management Network Commercial	$904.51
Rate for Payer: MDX Hawaii PPO	$1,032.21

Level One Thoracic Rib Template Sterile 24-015-61-71 [3644313]

Facility

$1,064.13

Hospital Charge Code	3644313
Hospital Revenue Code	272
Min. Negotiated Rate	$542.71
Max. Negotiated Rate	$1,032.21
Rate for Payer: Cash Price	$691.68
Rate for Payer: Hawaii Western Management Group Commercial	$1,010.92
Rate for Payer: Health Management Network Commercial	$904.51
Rate for Payer: Kaiser Permanente Commercial	$670.40
Rate for Payer: Kaiser Permanente Medicaid	$542.71
Rate for Payer: MDX Hawaii PPO	$1,032.21
Rate for Payer: University Health Alliance Commercial	$775.64

LEVETIRACETAM 500 MG/5 ML (5 ML) PO SOLN

Facility

$18.17

Service Code	HCPCS A9270
Hospital Revenue Code	250
Min. Negotiated Rate	$15.44
Max. Negotiated Rate	$17.62
Rate for Payer: Cash Price	$11.81
Rate for Payer: Cash Price	$28.12
Rate for Payer: Cash Price	$11.77
Rate for Payer: Health Management Network Commercial	$15.39
Rate for Payer: Health Management Network Commercial	$15.44
Rate for Payer: Health Management Network Commercial	$36.77
Rate for Payer: MDX Hawaii PPO	$17.57
Rate for Payer: MDX Hawaii PPO	$41.96
Rate for Payer: MDX Hawaii PPO	$17.62

LEVETIRACETAM 500 MG/5 ML (5 ML) PO SOLN

Facility

$18.17

Service Code	HCPCS A9270
Hospital Revenue Code	250
Min. Negotiated Rate	$9.27
Max. Negotiated Rate	$17.62
Rate for Payer: Cash Price	$11.81
Rate for Payer: Cash Price	$11.77
Rate for Payer: Cash Price	$28.12
Rate for Payer: Hawaii Western Management Group Commercial	$17.20
Rate for Payer: Hawaii Western Management Group Commercial	$41.10
Rate for Payer: Hawaii Western Management Group Commercial	$17.26
Rate for Payer: Health Management Network Commercial	$36.77
Rate for Payer: Health Management Network Commercial	$15.39
Rate for Payer: Health Management Network Commercial	$15.44
Rate for Payer: Kaiser Permanente Commercial	$11.41
Rate for Payer: Kaiser Permanente Commercial	$11.45
Rate for Payer: Kaiser Permanente Commercial	$27.25
Rate for Payer: Kaiser Permanente Medicaid	$22.06
Rate for Payer: Kaiser Permanente Medicaid	$9.27
Rate for Payer: Kaiser Permanente Medicaid	$9.24
Rate for Payer: MDX Hawaii PPO	$41.96
Rate for Payer: MDX Hawaii PPO	$17.57
Rate for Payer: MDX Hawaii PPO	$17.62
Rate for Payer: UnitedHealthcare Medicaid	$10.90
Rate for Payer: UnitedHealthcare Medicaid	$10.87
Rate for Payer: UnitedHealthcare Medicaid	$25.96
Rate for Payer: University Health Alliance Commercial	$31.53
Rate for Payer: University Health Alliance Commercial	$13.20
Rate for Payer: University Health Alliance Commercial	$13.24

LEVETIRACETAM 500 MG/5 ML IV SOLN

Facility

$21.48

Service Code	HCPCS J1953
Hospital Revenue Code	250
Min. Negotiated Rate	$18.26
Max. Negotiated Rate	$20.84
Rate for Payer: Cash Price	$13.96
Rate for Payer: Health Management Network Commercial	$18.26
Rate for Payer: MDX Hawaii PPO	$20.84

LEVETIRACETAM 500 MG/5 ML IV SOLN

Facility

$21.48

Service Code	HCPCS J1953
Hospital Revenue Code	636
Min. Negotiated Rate	$0.05
Max. Negotiated Rate	$20.84
Rate for Payer: Cash Price	$13.96
Rate for Payer: Cash Price	$13.96
Rate for Payer: Hawaii Medical Service Association ABD	$0.05
Rate for Payer: Hawaii Medical Service Association Non-ABD	$0.05
Rate for Payer: Hawaii Western Management Group Commercial	$20.41
Rate for Payer: Health Management Network Commercial	$18.26
Rate for Payer: Kaiser Permanente Commercial	$13.53
Rate for Payer: Kaiser Permanente Medicaid	$10.95
Rate for Payer: MDX Hawaii PPO	$20.84
Rate for Payer: UnitedHealthcare Medicaid	$12.89
Rate for Payer: University Health Alliance Commercial	$15.66

Know your out-of-pocket cost for care.

All Charges