Kona Community Hospital

All Charges

Charge

Type

Setting

Price

PEGFILGRASTIM 6 MG/0.6ML SUBCUTANEOUS SYR

Facility

$8,819.99

Service Code	HCPCS J2506
Hospital Revenue Code	250
Min. Negotiated Rate	$7,496.99
Max. Negotiated Rate	$8,555.39
Rate for Payer: Cash Price	$5,732.99
Rate for Payer: Health Management Network Commercial	$7,496.99
Rate for Payer: MDX Hawaii PPO	$8,555.39

PEGFILGRASTIM 6 MG/0.6ML SUBCUTANEOUS SYR

Facility

$8,819.99

Service Code	HCPCS J2506
Hospital Revenue Code	636
Min. Negotiated Rate	$58.40
Max. Negotiated Rate	$8,555.39
Rate for Payer: AlohaCare Medicaid	$127.38
Rate for Payer: AlohaCare Medicare	$127.38
Rate for Payer: Cash Price	$5,732.99
Rate for Payer: Cash Price	$5,732.99
Rate for Payer: Devoted Health Medicare	$140.12
Rate for Payer: Hawaii Medical Service Association ABD	$58.40
Rate for Payer: Hawaii Medical Service Association Commercial	$159.22
Rate for Payer: Hawaii Medical Service Association Medicare	$127.38
Rate for Payer: Hawaii Medical Service Association Non-ABD	$58.40
Rate for Payer: Hawaii Western Management Group Commercial	$8,378.99
Rate for Payer: Health Management Network Commercial	$7,496.99
Rate for Payer: Humana Medicare	$127.38
Rate for Payer: Kaiser Permanente Commercial	$5,556.59
Rate for Payer: Kaiser Permanente Medicaid	$4,498.19
Rate for Payer: Kaiser Permanente Medicare	$127.38
Rate for Payer: MDX Hawaii PPO	$8,555.39
Rate for Payer: Ohana Health Plan Medicaid	$140.12
Rate for Payer: Ohana Health Plan Medicare	$127.38
Rate for Payer: UnitedHealthcare Medicaid	$5,291.99
Rate for Payer: UnitedHealthcare Medicare	$127.38
Rate for Payer: University Health Alliance Commercial	$6,428.89

PEGFILGRASTIM-APGF 6 MG/0.6 ML SUBCUTANEOUS SYR

Facility

$5,828.41

Service Code	HCPCS Q5122
Hospital Revenue Code	250
Min. Negotiated Rate	$132.04
Max. Negotiated Rate	$5,653.56
Rate for Payer: AlohaCare Medicaid	$133.31
Rate for Payer: AlohaCare Medicare	$133.31
Rate for Payer: Cash Price	$3,788.47
Rate for Payer: Cash Price	$3,788.47
Rate for Payer: Devoted Health Medicare	$146.64
Rate for Payer: Hawaii Medical Service Association ABD	$132.04
Rate for Payer: Hawaii Medical Service Association Commercial	$166.64
Rate for Payer: Hawaii Medical Service Association Medicare	$133.31
Rate for Payer: Hawaii Medical Service Association Non-ABD	$132.04
Rate for Payer: Hawaii Western Management Group Commercial	$5,536.99
Rate for Payer: Health Management Network Commercial	$4,954.15
Rate for Payer: Humana Medicare	$133.31
Rate for Payer: Kaiser Permanente Commercial	$3,671.90
Rate for Payer: Kaiser Permanente Medicaid	$2,972.49
Rate for Payer: Kaiser Permanente Medicare	$133.31
Rate for Payer: MDX Hawaii PPO	$5,653.56
Rate for Payer: Ohana Health Plan Medicaid	$146.64
Rate for Payer: Ohana Health Plan Medicare	$133.31
Rate for Payer: UnitedHealthcare Medicaid	$3,497.05
Rate for Payer: UnitedHealthcare Medicare	$133.31
Rate for Payer: University Health Alliance Commercial	$4,248.33

PEGFILGRASTIM-APGF 6 MG/0.6 ML SUBCUTANEOUS SYR

Facility

$5,828.41

Service Code	HCPCS Q5122
Hospital Revenue Code	250
Min. Negotiated Rate	$4,954.15
Max. Negotiated Rate	$5,653.56
Rate for Payer: Cash Price	$3,788.47
Rate for Payer: Health Management Network Commercial	$4,954.15
Rate for Payer: MDX Hawaii PPO	$5,653.56

PEGFILGRASTIM-CBQV 6 MG/0.6 ML SUBCUTANEOUS ATIN

Facility

$6,128.40

Service Code	HCPCS Q5111
Hospital Revenue Code	250
Min. Negotiated Rate	$135.89
Max. Negotiated Rate	$5,944.55
Rate for Payer: AlohaCare Medicaid	$135.89
Rate for Payer: AlohaCare Medicare	$135.89
Rate for Payer: Cash Price	$3,983.46
Rate for Payer: Cash Price	$3,983.46
Rate for Payer: Devoted Health Medicare	$149.48
Rate for Payer: Hawaii Medical Service Association ABD	$136.04
Rate for Payer: Hawaii Medical Service Association Commercial	$169.86
Rate for Payer: Hawaii Medical Service Association Medicare	$135.89
Rate for Payer: Hawaii Medical Service Association Non-ABD	$136.04
Rate for Payer: Hawaii Western Management Group Commercial	$5,821.98
Rate for Payer: Health Management Network Commercial	$5,209.14
Rate for Payer: Humana Medicare	$135.89
Rate for Payer: Kaiser Permanente Commercial	$3,860.89
Rate for Payer: Kaiser Permanente Medicaid	$3,125.48
Rate for Payer: Kaiser Permanente Medicare	$135.89
Rate for Payer: MDX Hawaii PPO	$5,944.55
Rate for Payer: Ohana Health Plan Medicaid	$149.48
Rate for Payer: Ohana Health Plan Medicare	$135.89
Rate for Payer: UnitedHealthcare Medicaid	$3,677.04
Rate for Payer: UnitedHealthcare Medicare	$135.89
Rate for Payer: University Health Alliance Commercial	$4,466.99

PEGFILGRASTIM-CBQV 6 MG/0.6 ML SUBCUTANEOUS ATIN

Facility

$6,128.40

Service Code	HCPCS Q5111
Hospital Revenue Code	250
Min. Negotiated Rate	$5,209.14
Max. Negotiated Rate	$5,944.55
Rate for Payer: Cash Price	$3,983.46
Rate for Payer: Health Management Network Commercial	$5,209.14
Rate for Payer: MDX Hawaii PPO	$5,944.55

PEGFILGRASTIM-CBQV 6 MG/0.6 ML SUBCUTANEOUS SYR

Facility

$6,128.40

Service Code	HCPCS Q5111
Hospital Revenue Code	250
Min. Negotiated Rate	$135.89
Max. Negotiated Rate	$5,944.55
Rate for Payer: AlohaCare Medicaid	$135.89
Rate for Payer: AlohaCare Medicare	$135.89
Rate for Payer: Cash Price	$3,983.46
Rate for Payer: Cash Price	$3,983.46
Rate for Payer: Devoted Health Medicare	$149.48
Rate for Payer: Hawaii Medical Service Association ABD	$136.04
Rate for Payer: Hawaii Medical Service Association Commercial	$169.86
Rate for Payer: Hawaii Medical Service Association Medicare	$135.89
Rate for Payer: Hawaii Medical Service Association Non-ABD	$136.04
Rate for Payer: Hawaii Western Management Group Commercial	$5,821.98
Rate for Payer: Health Management Network Commercial	$5,209.14
Rate for Payer: Humana Medicare	$135.89
Rate for Payer: Kaiser Permanente Commercial	$3,860.89
Rate for Payer: Kaiser Permanente Medicaid	$3,125.48
Rate for Payer: Kaiser Permanente Medicare	$135.89
Rate for Payer: MDX Hawaii PPO	$5,944.55
Rate for Payer: Ohana Health Plan Medicaid	$149.48
Rate for Payer: Ohana Health Plan Medicare	$135.89
Rate for Payer: UnitedHealthcare Medicaid	$3,677.04
Rate for Payer: UnitedHealthcare Medicare	$135.89
Rate for Payer: University Health Alliance Commercial	$4,466.99

PEGFILGRASTIM-CBQV 6 MG/0.6 ML SUBCUTANEOUS SYR

Facility

$6,128.40

Service Code	HCPCS Q5111
Hospital Revenue Code	250
Min. Negotiated Rate	$5,209.14
Max. Negotiated Rate	$5,944.55
Rate for Payer: Cash Price	$3,983.46
Rate for Payer: Health Management Network Commercial	$5,209.14
Rate for Payer: MDX Hawaii PPO	$5,944.55

PEGFILGRASTIM-JMDB 6 MG/0.6 ML SUBCUTANEOUS SYR

Facility

$3,623.41

Service Code	HCPCS Q5108
Hospital Revenue Code	250
Min. Negotiated Rate	$3,079.90
Max. Negotiated Rate	$3,514.71
Rate for Payer: Cash Price	$2,355.22
Rate for Payer: Health Management Network Commercial	$3,079.90
Rate for Payer: MDX Hawaii PPO	$3,514.71

PEGFILGRASTIM-JMDB 6 MG/0.6 ML SUBCUTANEOUS SYR

Facility

$3,623.41

Service Code	HCPCS Q5108
Hospital Revenue Code	250
Min. Negotiated Rate	$79.50
Max. Negotiated Rate	$3,514.71
Rate for Payer: AlohaCare Medicaid	$79.50
Rate for Payer: AlohaCare Medicare	$79.50
Rate for Payer: Cash Price	$2,355.22
Rate for Payer: Cash Price	$2,355.22
Rate for Payer: Devoted Health Medicare	$87.45
Rate for Payer: Hawaii Medical Service Association ABD	$103.71
Rate for Payer: Hawaii Medical Service Association Commercial	$99.38
Rate for Payer: Hawaii Medical Service Association Medicare	$79.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$103.71
Rate for Payer: Hawaii Western Management Group Commercial	$3,442.24
Rate for Payer: Health Management Network Commercial	$3,079.90
Rate for Payer: Humana Medicare	$79.50
Rate for Payer: Kaiser Permanente Commercial	$2,282.75
Rate for Payer: Kaiser Permanente Medicaid	$1,847.94
Rate for Payer: Kaiser Permanente Medicare	$79.50
Rate for Payer: MDX Hawaii PPO	$3,514.71
Rate for Payer: Ohana Health Plan Medicaid	$87.45
Rate for Payer: Ohana Health Plan Medicare	$79.50
Rate for Payer: UnitedHealthcare Medicaid	$2,174.05
Rate for Payer: UnitedHealthcare Medicare	$79.50
Rate for Payer: University Health Alliance Commercial	$2,641.10

Peg High Comp Locking Ti 2.7 x 28mm HCLP-27280-TS [3644425]

Facility

$737.47

Service Code	HCPCS C1713
Hospital Charge Code	3644425
Hospital Revenue Code	278
Min. Negotiated Rate	$376.11
Max. Negotiated Rate	$715.35
Rate for Payer: Cash Price	$479.36
Rate for Payer: Hawaii Western Management Group Commercial	$516.23
Rate for Payer: Health Management Network Commercial	$626.85
Rate for Payer: Kaiser Permanente Commercial	$464.61
Rate for Payer: Kaiser Permanente Medicaid	$376.11
Rate for Payer: MDX Hawaii PPO	$715.35
Rate for Payer: University Health Alliance Commercial	$412.98

Peg High Comp Locking Ti 2.7 x 28mm HCLP-27280-TS [3644425]

Facility

$737.47

Service Code	HCPCS C1713
Hospital Charge Code	3644425
Hospital Revenue Code	278
Min. Negotiated Rate	$412.98
Max. Negotiated Rate	$715.35
Rate for Payer: Cash Price	$479.36
Rate for Payer: Hawaii Western Management Group Commercial	$516.23
Rate for Payer: Health Management Network Commercial	$626.85
Rate for Payer: MDX Hawaii PPO	$715.35
Rate for Payer: University Health Alliance Commercial	$412.98

Peg Smooth Lock 2.0x26mm SPLS-20260-TS [3643903]

Facility

$468.13

Service Code	HCPCS C1713
Hospital Charge Code	3643903
Hospital Revenue Code	278
Min. Negotiated Rate	$238.75
Max. Negotiated Rate	$454.09
Rate for Payer: Cash Price	$304.28
Rate for Payer: Hawaii Western Management Group Commercial	$327.69
Rate for Payer: Health Management Network Commercial	$397.91
Rate for Payer: Kaiser Permanente Commercial	$294.92
Rate for Payer: Kaiser Permanente Medicaid	$238.75
Rate for Payer: MDX Hawaii PPO	$454.09
Rate for Payer: University Health Alliance Commercial	$262.15

Peg Smooth Lock 2.0x26mm SPLS-20260-TS [3643903]

Facility

$468.13

Service Code	HCPCS C1713
Hospital Charge Code	3643903
Hospital Revenue Code	278
Min. Negotiated Rate	$262.15
Max. Negotiated Rate	$454.09
Rate for Payer: Cash Price	$304.28
Rate for Payer: Hawaii Western Management Group Commercial	$327.69
Rate for Payer: Health Management Network Commercial	$397.91
Rate for Payer: MDX Hawaii PPO	$454.09
Rate for Payer: University Health Alliance Commercial	$262.15

Peg Smooth Locking 2.0mm x 14mm SPLS-20140-TS [3643304]

Facility

$468.13

Service Code	HCPCS C1713
Hospital Charge Code	3643304
Hospital Revenue Code	278
Min. Negotiated Rate	$238.75
Max. Negotiated Rate	$454.09
Rate for Payer: Cash Price	$304.28
Rate for Payer: Hawaii Western Management Group Commercial	$327.69
Rate for Payer: Health Management Network Commercial	$397.91
Rate for Payer: Kaiser Permanente Commercial	$294.92
Rate for Payer: Kaiser Permanente Medicaid	$238.75
Rate for Payer: MDX Hawaii PPO	$454.09
Rate for Payer: University Health Alliance Commercial	$262.15

Peg Smooth Locking 2.0mm x 14mm SPLS-20140-TS [3643304]

Facility

$468.13

Service Code	HCPCS C1713
Hospital Charge Code	3643304
Hospital Revenue Code	278
Min. Negotiated Rate	$262.15
Max. Negotiated Rate	$454.09
Rate for Payer: Cash Price	$304.28
Rate for Payer: Hawaii Western Management Group Commercial	$327.69
Rate for Payer: Health Management Network Commercial	$397.91
Rate for Payer: MDX Hawaii PPO	$454.09
Rate for Payer: University Health Alliance Commercial	$262.15

Peg Smooth Locking 2.0mm x 16mm SPLS-20160-TS [3643902]

Facility

$699.99

Service Code	HCPCS C1713
Hospital Charge Code	3643902
Hospital Revenue Code	278
Min. Negotiated Rate	$356.99
Max. Negotiated Rate	$678.99
Rate for Payer: Cash Price	$454.99
Rate for Payer: Hawaii Western Management Group Commercial	$489.99
Rate for Payer: Health Management Network Commercial	$594.99
Rate for Payer: Kaiser Permanente Commercial	$440.99
Rate for Payer: Kaiser Permanente Medicaid	$356.99
Rate for Payer: MDX Hawaii PPO	$678.99
Rate for Payer: University Health Alliance Commercial	$391.99

Peg Smooth Locking 2.0mm x 16mm SPLS-20160-TS [3643902]

Facility

$699.99

Service Code	HCPCS C1713
Hospital Charge Code	3643902
Hospital Revenue Code	278
Min. Negotiated Rate	$391.99
Max. Negotiated Rate	$678.99
Rate for Payer: Cash Price	$454.99
Rate for Payer: Hawaii Western Management Group Commercial	$489.99
Rate for Payer: Health Management Network Commercial	$594.99
Rate for Payer: MDX Hawaii PPO	$678.99
Rate for Payer: University Health Alliance Commercial	$391.99

Peg Smooth Locking 2.0mm x 18mm SPLS-20180-TS [3643305]

Facility

$699.99

Service Code	HCPCS C1713
Hospital Charge Code	3643305
Hospital Revenue Code	278
Min. Negotiated Rate	$356.99
Max. Negotiated Rate	$678.99
Rate for Payer: Cash Price	$454.99
Rate for Payer: Hawaii Western Management Group Commercial	$489.99
Rate for Payer: Health Management Network Commercial	$594.99
Rate for Payer: Kaiser Permanente Commercial	$440.99
Rate for Payer: Kaiser Permanente Medicaid	$356.99
Rate for Payer: MDX Hawaii PPO	$678.99
Rate for Payer: University Health Alliance Commercial	$391.99

Peg Smooth Locking 2.0mm x 18mm SPLS-20180-TS [3643305]

Facility

$699.99

Service Code	HCPCS C1713
Hospital Charge Code	3643305
Hospital Revenue Code	278
Min. Negotiated Rate	$391.99
Max. Negotiated Rate	$678.99
Rate for Payer: Cash Price	$454.99
Rate for Payer: Hawaii Western Management Group Commercial	$489.99
Rate for Payer: Health Management Network Commercial	$594.99
Rate for Payer: MDX Hawaii PPO	$678.99
Rate for Payer: University Health Alliance Commercial	$391.99

Peg Smooth Locking 2.0mmx19mm [3643306]

Facility

$468.13

Service Code	HCPCS C1713
Hospital Charge Code	3643306
Hospital Revenue Code	278
Min. Negotiated Rate	$238.75
Max. Negotiated Rate	$454.09
Rate for Payer: Cash Price	$304.28
Rate for Payer: Hawaii Western Management Group Commercial	$327.69
Rate for Payer: Health Management Network Commercial	$397.91
Rate for Payer: Kaiser Permanente Commercial	$294.92
Rate for Payer: Kaiser Permanente Medicaid	$238.75
Rate for Payer: MDX Hawaii PPO	$454.09
Rate for Payer: University Health Alliance Commercial	$262.15

Peg Smooth Locking 2.0mmx19mm [3643306]

Facility

$468.13

Service Code	HCPCS C1713
Hospital Charge Code	3643306
Hospital Revenue Code	278
Min. Negotiated Rate	$262.15
Max. Negotiated Rate	$454.09
Rate for Payer: Cash Price	$304.28
Rate for Payer: Hawaii Western Management Group Commercial	$327.69
Rate for Payer: Health Management Network Commercial	$397.91
Rate for Payer: MDX Hawaii PPO	$454.09
Rate for Payer: University Health Alliance Commercial	$262.15

Peg Smooth Locking 2.0mm x 21mm SPLS-20210-TS [3643418]

Facility

$699.99

Service Code	HCPCS C1713
Hospital Charge Code	3643418
Hospital Revenue Code	278
Min. Negotiated Rate	$391.99
Max. Negotiated Rate	$678.99
Rate for Payer: Cash Price	$454.99
Rate for Payer: Hawaii Western Management Group Commercial	$489.99
Rate for Payer: Health Management Network Commercial	$594.99
Rate for Payer: MDX Hawaii PPO	$678.99
Rate for Payer: University Health Alliance Commercial	$391.99

Peg Smooth Locking 2.0mm x 21mm SPLS-20210-TS [3643418]

Facility

$699.99

Service Code	HCPCS C1713
Hospital Charge Code	3643418
Hospital Revenue Code	278
Min. Negotiated Rate	$356.99
Max. Negotiated Rate	$678.99
Rate for Payer: Cash Price	$454.99
Rate for Payer: Hawaii Western Management Group Commercial	$489.99
Rate for Payer: Health Management Network Commercial	$594.99
Rate for Payer: Kaiser Permanente Commercial	$440.99
Rate for Payer: Kaiser Permanente Medicaid	$356.99
Rate for Payer: MDX Hawaii PPO	$678.99
Rate for Payer: University Health Alliance Commercial	$391.99

Peg Smooth Locking 2.0mm X 22mm SPLS-20220-TS [3642652]

Facility

$673.21

Service Code	HCPCS C1713
Hospital Charge Code	3642652
Hospital Revenue Code	278
Min. Negotiated Rate	$343.34
Max. Negotiated Rate	$653.01
Rate for Payer: Cash Price	$437.59
Rate for Payer: Hawaii Western Management Group Commercial	$471.25
Rate for Payer: Health Management Network Commercial	$572.23
Rate for Payer: Kaiser Permanente Commercial	$424.12
Rate for Payer: Kaiser Permanente Medicaid	$343.34
Rate for Payer: MDX Hawaii PPO	$653.01
Rate for Payer: University Health Alliance Commercial	$377.00

Know your out-of-pocket cost for care.

All Charges