Kona Community Hospital

All Charges

Charge

Type

Setting

Price

D5 % AND 0.9 % SODIUM CHLORIDE IV SOLP

Facility

$22.08

Service Code	HCPCS J7042
Hospital Revenue Code	258
Min. Negotiated Rate	$1.02
Max. Negotiated Rate	$21.42
Rate for Payer: Cash Price	$14.35
Rate for Payer: Cash Price	$14.35
Rate for Payer: Hawaii Medical Service Association ABD	$1.36
Rate for Payer: Hawaii Medical Service Association Non-ABD	$1.36
Rate for Payer: Hawaii Western Management Group Commercial	$20.98
Rate for Payer: Health Management Network Commercial	$18.77
Rate for Payer: Kaiser Permanente Commercial	$13.91
Rate for Payer: Kaiser Permanente Medicaid	$11.26
Rate for Payer: MDX Hawaii PPO	$21.42
Rate for Payer: UnitedHealthcare Medicaid	$1.02
Rate for Payer: University Health Alliance Commercial	$16.09

D5 % AND 0.9 % SODIUM CHLORIDE IV SOLP

Facility

$22.08

Service Code	HCPCS J7042
Hospital Revenue Code	258
Min. Negotiated Rate	$18.77
Max. Negotiated Rate	$21.42
Rate for Payer: Cash Price	$14.35
Rate for Payer: Health Management Network Commercial	$18.77
Rate for Payer: MDX Hawaii PPO	$21.42

D5LR 1000 ML WITH KCL 20MEQ/L IV PREMIX

Facility

$63.54

Service Code	HCPCS J3480
Hospital Revenue Code	250
Min. Negotiated Rate	$54.01
Max. Negotiated Rate	$61.63
Rate for Payer: Cash Price	$41.30
Rate for Payer: Health Management Network Commercial	$54.01
Rate for Payer: MDX Hawaii PPO	$61.63

D5LR 1000 ML WITH KCL 20MEQ/L IV PREMIX

Facility

$63.54

Service Code	HCPCS J3480
Hospital Revenue Code	636
Min. Negotiated Rate	$0.17
Max. Negotiated Rate	$61.63
Rate for Payer: Cash Price	$41.30
Rate for Payer: Cash Price	$41.30
Rate for Payer: Hawaii Medical Service Association ABD	$0.17
Rate for Payer: Hawaii Medical Service Association Non-ABD	$0.17
Rate for Payer: Hawaii Western Management Group Commercial	$60.36
Rate for Payer: Health Management Network Commercial	$54.01
Rate for Payer: Kaiser Permanente Commercial	$40.03
Rate for Payer: Kaiser Permanente Medicaid	$32.41
Rate for Payer: MDX Hawaii PPO	$61.63
Rate for Payer: UnitedHealthcare Medicaid	$38.12
Rate for Payer: University Health Alliance Commercial	$46.31

D5NS 1000 ML WITH KCL 20 MEQ/L IV PREMIX

Facility

$38.62

Service Code	HCPCS J3480
Hospital Revenue Code	636
Min. Negotiated Rate	$0.17
Max. Negotiated Rate	$37.46
Rate for Payer: Cash Price	$25.10
Rate for Payer: Cash Price	$34.53
Rate for Payer: Cash Price	$41.30
Rate for Payer: Cash Price	$34.53
Rate for Payer: Cash Price	$41.30
Rate for Payer: Cash Price	$25.10
Rate for Payer: Hawaii Medical Service Association ABD	$0.17
Rate for Payer: Hawaii Medical Service Association ABD	$0.17
Rate for Payer: Hawaii Medical Service Association ABD	$0.17
Rate for Payer: Hawaii Medical Service Association Non-ABD	$0.17
Rate for Payer: Hawaii Medical Service Association Non-ABD	$0.17
Rate for Payer: Hawaii Medical Service Association Non-ABD	$0.17
Rate for Payer: Hawaii Western Management Group Commercial	$50.47
Rate for Payer: Hawaii Western Management Group Commercial	$36.69
Rate for Payer: Hawaii Western Management Group Commercial	$60.36
Rate for Payer: Health Management Network Commercial	$54.01
Rate for Payer: Health Management Network Commercial	$32.83
Rate for Payer: Health Management Network Commercial	$45.16
Rate for Payer: Kaiser Permanente Commercial	$40.03
Rate for Payer: Kaiser Permanente Commercial	$33.47
Rate for Payer: Kaiser Permanente Commercial	$24.33
Rate for Payer: Kaiser Permanente Medicaid	$19.70
Rate for Payer: Kaiser Permanente Medicaid	$32.41
Rate for Payer: Kaiser Permanente Medicaid	$27.10
Rate for Payer: MDX Hawaii PPO	$61.63
Rate for Payer: MDX Hawaii PPO	$51.54
Rate for Payer: MDX Hawaii PPO	$37.46
Rate for Payer: UnitedHealthcare Medicaid	$23.17
Rate for Payer: UnitedHealthcare Medicaid	$31.88
Rate for Payer: UnitedHealthcare Medicaid	$38.12
Rate for Payer: University Health Alliance Commercial	$38.73
Rate for Payer: University Health Alliance Commercial	$28.15
Rate for Payer: University Health Alliance Commercial	$46.31

D5NS 1000 ML WITH KCL 20 MEQ/L IV PREMIX

Facility

$38.62

Service Code	HCPCS J3480
Hospital Revenue Code	250
Min. Negotiated Rate	$32.83
Max. Negotiated Rate	$37.46
Rate for Payer: Cash Price	$25.10
Rate for Payer: Cash Price	$34.53
Rate for Payer: Cash Price	$41.30
Rate for Payer: Health Management Network Commercial	$45.16
Rate for Payer: Health Management Network Commercial	$54.01
Rate for Payer: Health Management Network Commercial	$32.83
Rate for Payer: MDX Hawaii PPO	$51.54
Rate for Payer: MDX Hawaii PPO	$61.63
Rate for Payer: MDX Hawaii PPO	$37.46

DACARBAZINE 100 MG

Professional

Both

$20.00

Service Code	HCPCS J9130
Min. Negotiated Rate	$3.85
Max. Negotiated Rate	$22.41
Rate for Payer: AlohaCare Medicare	$3.85
Rate for Payer: Cash Price	$13.00
Rate for Payer: Cash Price	$13.00
Rate for Payer: Devoted Health Medicare	$4.24
Rate for Payer: Hawaii Medical Service Association Medicare	$3.85
Rate for Payer: Hawaii Western Management Group Commercial	$22.41
Rate for Payer: Health Management Network Commercial	$17.00
Rate for Payer: Kaiser Permanente Commercial	$4.62
Rate for Payer: Kaiser Permanente Medicaid	$4.62
Rate for Payer: Kaiser Permanente Medicare	$4.62
Rate for Payer: Ohana Health Plan Medicare	$3.85
Rate for Payer: UnitedHealthcare Medicare	$3.85

DACARBAZINE 100 MG IV RECON.SOLN.

Facility

$69.30

Service Code	HCPCS J9130
Hospital Revenue Code	636
Min. Negotiated Rate	$3.82
Max. Negotiated Rate	$67.22
Rate for Payer: Cash Price	$45.04
Rate for Payer: Cash Price	$45.04
Rate for Payer: Hawaii Medical Service Association ABD	$3.82
Rate for Payer: Hawaii Medical Service Association Non-ABD	$3.82
Rate for Payer: Hawaii Western Management Group Commercial	$65.83
Rate for Payer: Health Management Network Commercial	$58.91
Rate for Payer: Kaiser Permanente Commercial	$43.66
Rate for Payer: Kaiser Permanente Medicaid	$35.34
Rate for Payer: MDX Hawaii PPO	$67.22
Rate for Payer: UnitedHealthcare Medicaid	$41.58
Rate for Payer: University Health Alliance Commercial	$50.51

DACARBAZINE 100 MG IV RECON.SOLN.

Facility

$69.30

Service Code	HCPCS J9130
Hospital Revenue Code	250
Min. Negotiated Rate	$58.91
Max. Negotiated Rate	$67.22
Rate for Payer: Cash Price	$45.04
Rate for Payer: Health Management Network Commercial	$58.91
Rate for Payer: MDX Hawaii PPO	$67.22

DALBAVANCIN 500 MG IV SOLN

Facility

$3,253.36

Service Code	HCPCS J0875
Hospital Revenue Code	250
Min. Negotiated Rate	$2,765.36
Max. Negotiated Rate	$3,155.76
Rate for Payer: Cash Price	$2,114.68
Rate for Payer: Health Management Network Commercial	$2,765.36
Rate for Payer: MDX Hawaii PPO	$3,155.76

DALBAVANCIN 500 MG IV SOLN

Facility

$3,253.36

Service Code	HCPCS J0875
Hospital Revenue Code	636
Min. Negotiated Rate	$15.00
Max. Negotiated Rate	$3,155.76
Rate for Payer: AlohaCare Medicaid	$15.00
Rate for Payer: AlohaCare Medicare	$15.00
Rate for Payer: Cash Price	$2,114.68
Rate for Payer: Cash Price	$2,114.68
Rate for Payer: Devoted Health Medicare	$16.50
Rate for Payer: Hawaii Medical Service Association ABD	$15.55
Rate for Payer: Hawaii Medical Service Association Commercial	$18.75
Rate for Payer: Hawaii Medical Service Association Medicare	$15.00
Rate for Payer: Hawaii Medical Service Association Non-ABD	$15.55
Rate for Payer: Hawaii Western Management Group Commercial	$3,090.69
Rate for Payer: Health Management Network Commercial	$2,765.36
Rate for Payer: Humana Medicare	$15.00
Rate for Payer: Kaiser Permanente Commercial	$2,049.62
Rate for Payer: Kaiser Permanente Medicaid	$1,659.21
Rate for Payer: Kaiser Permanente Medicare	$15.00
Rate for Payer: MDX Hawaii PPO	$3,155.76
Rate for Payer: Ohana Health Plan Medicaid	$16.50
Rate for Payer: Ohana Health Plan Medicare	$15.00
Rate for Payer: UnitedHealthcare Medicaid	$1,952.02
Rate for Payer: UnitedHealthcare Medicare	$15.00
Rate for Payer: University Health Alliance Commercial	$2,371.37

DANTROLENE 250 MG IV SUSR

Facility

$5,095.64

Service Code	HCPCS J3490
Hospital Revenue Code	250
Min. Negotiated Rate	$4,331.29
Max. Negotiated Rate	$4,942.77
Rate for Payer: Cash Price	$3,312.17
Rate for Payer: Health Management Network Commercial	$4,331.29
Rate for Payer: MDX Hawaii PPO	$4,942.77

DANTROLENE 250 MG IV SUSR

Facility

$5,095.64

Service Code	HCPCS J3490
Hospital Revenue Code	636
Min. Negotiated Rate	$2,598.78
Max. Negotiated Rate	$4,942.77
Rate for Payer: Cash Price	$3,312.17
Rate for Payer: Hawaii Western Management Group Commercial	$4,840.86
Rate for Payer: Health Management Network Commercial	$4,331.29
Rate for Payer: Kaiser Permanente Commercial	$3,210.25
Rate for Payer: Kaiser Permanente Medicaid	$2,598.78
Rate for Payer: MDX Hawaii PPO	$4,942.77
Rate for Payer: UnitedHealthcare Medicaid	$3,057.38
Rate for Payer: University Health Alliance Commercial	$3,714.21

DANTROLENE 25 MG PO CAP

Facility

$5.32

Service Code	HCPCS A9270
Hospital Revenue Code	250
Min. Negotiated Rate	$2.71
Max. Negotiated Rate	$5.16
Rate for Payer: Cash Price	$3.46
Rate for Payer: Hawaii Western Management Group Commercial	$5.05
Rate for Payer: Health Management Network Commercial	$4.52
Rate for Payer: Kaiser Permanente Commercial	$3.35
Rate for Payer: Kaiser Permanente Medicaid	$2.71
Rate for Payer: MDX Hawaii PPO	$5.16
Rate for Payer: UnitedHealthcare Medicaid	$3.19
Rate for Payer: University Health Alliance Commercial	$3.88

DANTROLENE 25 MG PO CAP

Facility

$5.32

Service Code	HCPCS A9270
Hospital Revenue Code	250
Min. Negotiated Rate	$4.52
Max. Negotiated Rate	$5.16
Rate for Payer: Cash Price	$3.46
Rate for Payer: Health Management Network Commercial	$4.52
Rate for Payer: MDX Hawaii PPO	$5.16

DAPSONE 25 MG PO TABLET

Facility

$13.61

Service Code	HCPCS A9270
Hospital Revenue Code	250
Min. Negotiated Rate	$6.94
Max. Negotiated Rate	$13.20
Rate for Payer: Cash Price	$8.85
Rate for Payer: Hawaii Western Management Group Commercial	$12.93
Rate for Payer: Health Management Network Commercial	$11.57
Rate for Payer: Kaiser Permanente Commercial	$8.57
Rate for Payer: Kaiser Permanente Medicaid	$6.94
Rate for Payer: MDX Hawaii PPO	$13.20
Rate for Payer: UnitedHealthcare Medicaid	$8.17
Rate for Payer: University Health Alliance Commercial	$9.92

DAPSONE 25 MG PO TABLET

Facility

$13.61

Service Code	HCPCS A9270
Hospital Revenue Code	250
Min. Negotiated Rate	$11.57
Max. Negotiated Rate	$13.20
Rate for Payer: Cash Price	$8.85
Rate for Payer: Health Management Network Commercial	$11.57
Rate for Payer: MDX Hawaii PPO	$13.20

DAPTOMYCIN 500 MG IV RECON.SOLN. (MG/KG)

Facility

$1,349.71

Service Code	HCPCS J0878
Hospital Revenue Code	250
Min. Negotiated Rate	$1,147.25
Max. Negotiated Rate	$1,309.22
Rate for Payer: Cash Price	$877.31
Rate for Payer: Cash Price	$92.43
Rate for Payer: Health Management Network Commercial	$1,147.25
Rate for Payer: Health Management Network Commercial	$120.87
Rate for Payer: MDX Hawaii PPO	$1,309.22
Rate for Payer: MDX Hawaii PPO	$137.93

DAPTOMYCIN 500 MG IV RECON.SOLN. (MG/KG)

Facility

$142.20

Service Code	HCPCS J0878
Hospital Revenue Code	636
Min. Negotiated Rate	$0.91
Max. Negotiated Rate	$137.93
Rate for Payer: Kaiser Permanente Commercial	$850.32
Rate for Payer: Cash Price	$92.43
Rate for Payer: Cash Price	$877.31
Rate for Payer: Cash Price	$877.31
Rate for Payer: Cash Price	$92.43
Rate for Payer: Hawaii Medical Service Association ABD	$0.91
Rate for Payer: Hawaii Medical Service Association ABD	$0.91
Rate for Payer: Hawaii Medical Service Association Non-ABD	$0.91
Rate for Payer: Hawaii Medical Service Association Non-ABD	$0.91
Rate for Payer: Hawaii Western Management Group Commercial	$1,282.22
Rate for Payer: Hawaii Western Management Group Commercial	$135.09
Rate for Payer: Health Management Network Commercial	$120.87
Rate for Payer: Health Management Network Commercial	$1,147.25
Rate for Payer: Kaiser Permanente Commercial	$89.59
Rate for Payer: Kaiser Permanente Medicaid	$688.35
Rate for Payer: Kaiser Permanente Medicaid	$72.52
Rate for Payer: MDX Hawaii PPO	$1,309.22
Rate for Payer: MDX Hawaii PPO	$137.93
Rate for Payer: UnitedHealthcare Medicaid	$85.32
Rate for Payer: UnitedHealthcare Medicaid	$809.83
Rate for Payer: University Health Alliance Commercial	$983.80
Rate for Payer: University Health Alliance Commercial	$103.65

DARATUMUMAB-HYALURONIDASE-FIHJ 1,800 MG-30,000 UNIT/15 ML SUBCUTANEOUS SOLN

Facility

$13,804.64

Service Code	HCPCS J9144
Hospital Revenue Code	250
Min. Negotiated Rate	$11,733.94
Max. Negotiated Rate	$13,390.50
Rate for Payer: Cash Price	$8,973.02
Rate for Payer: Health Management Network Commercial	$11,733.94
Rate for Payer: MDX Hawaii PPO	$13,390.50

DARATUMUMAB-HYALURONIDASE-FIHJ 1,800 MG-30,000 UNIT/15 ML SUBCUTANEOUS SOLN

Facility

$13,804.64

Service Code	HCPCS J9144
Hospital Revenue Code	636
Min. Negotiated Rate	$54.67
Max. Negotiated Rate	$13,390.50
Rate for Payer: AlohaCare Medicaid	$55.03
Rate for Payer: AlohaCare Medicare	$55.03
Rate for Payer: Cash Price	$8,973.02
Rate for Payer: Cash Price	$8,973.02
Rate for Payer: Devoted Health Medicare	$60.53
Rate for Payer: Hawaii Medical Service Association ABD	$54.67
Rate for Payer: Hawaii Medical Service Association Commercial	$68.79
Rate for Payer: Hawaii Medical Service Association Medicare	$55.03
Rate for Payer: Hawaii Medical Service Association Non-ABD	$54.67
Rate for Payer: Hawaii Western Management Group Commercial	$13,114.41
Rate for Payer: Health Management Network Commercial	$11,733.94
Rate for Payer: Humana Medicare	$55.03
Rate for Payer: Kaiser Permanente Commercial	$8,696.92
Rate for Payer: Kaiser Permanente Medicaid	$7,040.37
Rate for Payer: Kaiser Permanente Medicare	$55.03
Rate for Payer: MDX Hawaii PPO	$13,390.50
Rate for Payer: Ohana Health Plan Medicaid	$60.53
Rate for Payer: Ohana Health Plan Medicare	$55.03
Rate for Payer: UnitedHealthcare Medicaid	$8,282.78
Rate for Payer: UnitedHealthcare Medicare	$55.03
Rate for Payer: University Health Alliance Commercial	$10,062.20

DARBEPOETIN ALFA IN POLYSORBAT 100 MCG/0.5 ML INJ SYR

Facility

$1,846.83

Service Code	HCPCS J0881
Hospital Revenue Code	636
Min. Negotiated Rate	$3.00
Max. Negotiated Rate	$1,791.43
Rate for Payer: AlohaCare Medicaid	$3.07
Rate for Payer: AlohaCare Medicare	$3.07
Rate for Payer: Cash Price	$1,200.44
Rate for Payer: Cash Price	$1,200.44
Rate for Payer: Devoted Health Medicare	$3.38
Rate for Payer: Hawaii Medical Service Association ABD	$3.00
Rate for Payer: Hawaii Medical Service Association Commercial	$3.84
Rate for Payer: Hawaii Medical Service Association Medicare	$3.07
Rate for Payer: Hawaii Medical Service Association Non-ABD	$3.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,754.49
Rate for Payer: Health Management Network Commercial	$1,569.81
Rate for Payer: Humana Medicare	$3.07
Rate for Payer: Kaiser Permanente Commercial	$1,163.50
Rate for Payer: Kaiser Permanente Medicaid	$941.88
Rate for Payer: Kaiser Permanente Medicare	$3.07
Rate for Payer: MDX Hawaii PPO	$1,791.43
Rate for Payer: Ohana Health Plan Medicaid	$3.38
Rate for Payer: Ohana Health Plan Medicare	$3.07
Rate for Payer: UnitedHealthcare Medicaid	$1,108.10
Rate for Payer: UnitedHealthcare Medicare	$3.07
Rate for Payer: University Health Alliance Commercial	$1,346.15

DARBEPOETIN ALFA IN POLYSORBAT 100 MCG/0.5 ML INJ SYR

Facility

$1,846.83

Service Code	HCPCS J0881
Hospital Revenue Code	250
Min. Negotiated Rate	$1,569.81
Max. Negotiated Rate	$1,791.43
Rate for Payer: Cash Price	$1,200.44
Rate for Payer: Health Management Network Commercial	$1,569.81
Rate for Payer: MDX Hawaii PPO	$1,791.43

DARBEPOETIN ALFA IN POLYSORBAT 100 MCG/0.5 ML INJ SYR FOR ESRD

Facility

$1,846.83

Service Code	HCPCS J0882
Hospital Revenue Code	250
Min. Negotiated Rate	$1,569.81
Max. Negotiated Rate	$1,791.43
Rate for Payer: Cash Price	$1,200.44
Rate for Payer: Health Management Network Commercial	$1,569.81
Rate for Payer: MDX Hawaii PPO	$1,791.43

DARBEPOETIN ALFA IN POLYSORBAT 100 MCG/0.5 ML INJ SYR FOR ESRD

Facility

$1,846.83

Service Code	HCPCS J0882
Hospital Revenue Code	636
Min. Negotiated Rate	$3.00
Max. Negotiated Rate	$1,791.43
Rate for Payer: AlohaCare Medicaid	$3.07
Rate for Payer: AlohaCare Medicare	$3.07
Rate for Payer: Cash Price	$1,200.44
Rate for Payer: Cash Price	$1,200.44
Rate for Payer: Devoted Health Medicare	$3.38
Rate for Payer: Hawaii Medical Service Association ABD	$3.00
Rate for Payer: Hawaii Medical Service Association Commercial	$3.84
Rate for Payer: Hawaii Medical Service Association Medicare	$3.07
Rate for Payer: Hawaii Medical Service Association Non-ABD	$3.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,754.49
Rate for Payer: Health Management Network Commercial	$1,569.81
Rate for Payer: Humana Medicare	$3.07
Rate for Payer: Kaiser Permanente Commercial	$1,163.50
Rate for Payer: Kaiser Permanente Medicaid	$941.88
Rate for Payer: Kaiser Permanente Medicare	$3.07
Rate for Payer: MDX Hawaii PPO	$1,791.43
Rate for Payer: Ohana Health Plan Medicaid	$3.38
Rate for Payer: Ohana Health Plan Medicare	$3.07
Rate for Payer: UnitedHealthcare Medicaid	$1,108.10
Rate for Payer: UnitedHealthcare Medicare	$3.07
Rate for Payer: University Health Alliance Commercial	$1,346.15

Know your out-of-pocket cost for care.

All Charges