Kohala Hospital

All Charges

Charge

Type

Setting

Price

AZTREONAM-AVIBACTAM 2 G IV RECON.SOLN.

Facility

$918.86

Service Code	HCPCS J0458
Hospital Revenue Code	250
Min. Negotiated Rate	$781.03
Max. Negotiated Rate	$891.29
Rate for Payer: Cash Price	$597.26
Rate for Payer: Health Management Network Commercial	$781.03
Rate for Payer: Kaiser Permanente Commercial	$826.97
Rate for Payer: MDX Hawaii PPO	$891.29

AZTREONAM-AVIBACTAM 2 G IV RECON.SOLN.

Facility

$918.86

Service Code	HCPCS J0458
Hospital Revenue Code	636
Min. Negotiated Rate	$2.10
Max. Negotiated Rate	$909.67
Rate for Payer: AlohaCare Medicaid	$459.43
Rate for Payer: AlohaCare Medicare	$826.97
Rate for Payer: Cash Price	$597.26
Rate for Payer: Cash Price	$597.26
Rate for Payer: Devoted Health Medicare	$909.67
Rate for Payer: Hawaii Medical Service Association Commercial	$2.10
Rate for Payer: Hawaii Medical Service Association Medicare	$826.97
Rate for Payer: Hawaii Western Management Group Commercial	$872.92
Rate for Payer: Health Management Network Commercial	$781.03
Rate for Payer: Humana Medicare	$826.97
Rate for Payer: Kaiser Permanente Commercial	$826.97
Rate for Payer: Kaiser Permanente Medicaid	$468.62
Rate for Payer: Kaiser Permanente Medicare	$826.97
Rate for Payer: MDX Hawaii PPO	$891.29
Rate for Payer: Ohana Health Plan Medicaid	$826.97
Rate for Payer: Ohana Health Plan Medicare	$826.97
Rate for Payer: UnitedHealthcare Medicaid	$551.32
Rate for Payer: UnitedHealthcare Medicare	$826.97
Rate for Payer: University Health Alliance Commercial	$669.76

BACITRACIN ZINC-POLYMYXIN B 500-10,000 UNIT/GRAM TOP OINT

Facility

$24.15

Service Code	HCPCS A9270
Hospital Revenue Code	637
Min. Negotiated Rate	$12.07
Max. Negotiated Rate	$23.91
Rate for Payer: AlohaCare Medicaid	$12.07
Rate for Payer: AlohaCare Medicaid	$13.88
Rate for Payer: AlohaCare Medicare	$21.73
Rate for Payer: AlohaCare Medicare	$24.98
Rate for Payer: Cash Price	$15.70
Rate for Payer: Cash Price	$18.04
Rate for Payer: Devoted Health Medicare	$23.91
Rate for Payer: Devoted Health Medicare	$27.47
Rate for Payer: Hawaii Medical Service Association Medicare	$24.98
Rate for Payer: Hawaii Medical Service Association Medicare	$21.73
Rate for Payer: Hawaii Western Management Group Commercial	$26.36
Rate for Payer: Hawaii Western Management Group Commercial	$22.94
Rate for Payer: Health Management Network Commercial	$20.53
Rate for Payer: Health Management Network Commercial	$23.59
Rate for Payer: Humana Medicare	$21.73
Rate for Payer: Humana Medicare	$24.98
Rate for Payer: Kaiser Permanente Commercial	$24.98
Rate for Payer: Kaiser Permanente Commercial	$21.73
Rate for Payer: Kaiser Permanente Medicaid	$12.32
Rate for Payer: Kaiser Permanente Medicaid	$14.15
Rate for Payer: Kaiser Permanente Medicare	$21.73
Rate for Payer: Kaiser Permanente Medicare	$24.98
Rate for Payer: MDX Hawaii PPO	$23.43
Rate for Payer: MDX Hawaii PPO	$26.92
Rate for Payer: Ohana Health Plan Medicaid	$21.73
Rate for Payer: Ohana Health Plan Medicaid	$24.98
Rate for Payer: Ohana Health Plan Medicare	$24.98
Rate for Payer: Ohana Health Plan Medicare	$21.73
Rate for Payer: UnitedHealthcare Medicare	$21.73
Rate for Payer: UnitedHealthcare Medicare	$24.98
Rate for Payer: University Health Alliance Commercial	$17.60
Rate for Payer: University Health Alliance Commercial	$20.23

BACITRACIN ZINC-POLYMYXIN B 500-10,000 UNIT/GRAM TOP OINT

Facility

$24.15

Service Code	HCPCS A9270
Hospital Revenue Code	250
Min. Negotiated Rate	$20.53
Max. Negotiated Rate	$23.43
Rate for Payer: Cash Price	$15.70
Rate for Payer: Cash Price	$18.04
Rate for Payer: Health Management Network Commercial	$23.59
Rate for Payer: Health Management Network Commercial	$20.53
Rate for Payer: Kaiser Permanente Commercial	$21.73
Rate for Payer: Kaiser Permanente Commercial	$24.98
Rate for Payer: MDX Hawaii PPO	$23.43
Rate for Payer: MDX Hawaii PPO	$26.92

BACK AND NECK PROCEDURES EXCEPT SPINAL FUSION WITH CC

Facility

$46,361.11

Service Code	MSDRG 519
Min. Negotiated Rate	$46,361.11
Max. Negotiated Rate	$46,361.11
Rate for Payer: Hawaii Medical Service Association Commercial	$46,361.11

BACK AND NECK PROCEDURES EXCEPT SPINAL FUSION WITH MCC OR DISC DEVICE OR NEUROSTIMULATOR

Facility

$46,361.11

Service Code	MSDRG 518
Min. Negotiated Rate	$46,361.11
Max. Negotiated Rate	$46,361.11
Rate for Payer: Hawaii Medical Service Association Commercial	$46,361.11

BACK AND NECK PROCEDURES EXCEPT SPINAL FUSION WITHOUT CC/MCC

Facility

$29,911.92

Service Code	MSDRG 520
Min. Negotiated Rate	$29,911.92
Max. Negotiated Rate	$29,911.92
Rate for Payer: Hawaii Medical Service Association Commercial	$29,911.92

BACLOFEN 10 MG PO TABLET

Facility

$2.56

Service Code	HCPCS A9270
Hospital Revenue Code	250
Min. Negotiated Rate	$2.18
Max. Negotiated Rate	$2.48
Rate for Payer: Cash Price	$1.66
Rate for Payer: Cash Price	$2.24
Rate for Payer: Health Management Network Commercial	$2.18
Rate for Payer: Health Management Network Commercial	$2.92
Rate for Payer: Kaiser Permanente Commercial	$3.10
Rate for Payer: Kaiser Permanente Commercial	$2.30
Rate for Payer: MDX Hawaii PPO	$3.34
Rate for Payer: MDX Hawaii PPO	$2.48

BACLOFEN 10 MG PO TABLET

Facility

$3.44

Service Code	HCPCS A9270
Hospital Revenue Code	637
Min. Negotiated Rate	$1.72
Max. Negotiated Rate	$3.41
Rate for Payer: AlohaCare Medicaid	$1.72
Rate for Payer: AlohaCare Medicaid	$1.28
Rate for Payer: AlohaCare Medicare	$3.10
Rate for Payer: AlohaCare Medicare	$2.30
Rate for Payer: Cash Price	$1.66
Rate for Payer: Cash Price	$2.24
Rate for Payer: Devoted Health Medicare	$2.53
Rate for Payer: Devoted Health Medicare	$3.41
Rate for Payer: Hawaii Medical Service Association Medicare	$2.30
Rate for Payer: Hawaii Medical Service Association Medicare	$3.10
Rate for Payer: Hawaii Western Management Group Commercial	$2.43
Rate for Payer: Hawaii Western Management Group Commercial	$3.27
Rate for Payer: Health Management Network Commercial	$2.92
Rate for Payer: Health Management Network Commercial	$2.18
Rate for Payer: Humana Medicare	$3.10
Rate for Payer: Humana Medicare	$2.30
Rate for Payer: Kaiser Permanente Commercial	$2.30
Rate for Payer: Kaiser Permanente Commercial	$3.10
Rate for Payer: Kaiser Permanente Medicaid	$1.31
Rate for Payer: Kaiser Permanente Medicaid	$1.75
Rate for Payer: Kaiser Permanente Medicare	$3.10
Rate for Payer: Kaiser Permanente Medicare	$2.30
Rate for Payer: MDX Hawaii PPO	$2.48
Rate for Payer: MDX Hawaii PPO	$3.34
Rate for Payer: Ohana Health Plan Medicaid	$3.10
Rate for Payer: Ohana Health Plan Medicaid	$2.30
Rate for Payer: Ohana Health Plan Medicare	$3.10
Rate for Payer: Ohana Health Plan Medicare	$2.30
Rate for Payer: UnitedHealthcare Medicare	$2.30
Rate for Payer: UnitedHealthcare Medicare	$3.10
Rate for Payer: University Health Alliance Commercial	$2.51
Rate for Payer: University Health Alliance Commercial	$1.87

BACLOFEN 20 MG PO TABLET

Facility

$3.68

Service Code	HCPCS A9270
Hospital Revenue Code	250
Min. Negotiated Rate	$3.13
Max. Negotiated Rate	$3.57
Rate for Payer: Cash Price	$2.39
Rate for Payer: Health Management Network Commercial	$3.13
Rate for Payer: Kaiser Permanente Commercial	$3.31
Rate for Payer: MDX Hawaii PPO	$3.57

BACLOFEN 20 MG PO TABLET

Facility

$3.68

Service Code	HCPCS A9270
Hospital Revenue Code	637
Min. Negotiated Rate	$1.84
Max. Negotiated Rate	$3.64
Rate for Payer: AlohaCare Medicaid	$1.84
Rate for Payer: AlohaCare Medicare	$3.31
Rate for Payer: Cash Price	$2.39
Rate for Payer: Devoted Health Medicare	$3.64
Rate for Payer: Hawaii Medical Service Association Medicare	$3.31
Rate for Payer: Hawaii Western Management Group Commercial	$3.50
Rate for Payer: Health Management Network Commercial	$3.13
Rate for Payer: Humana Medicare	$3.31
Rate for Payer: Kaiser Permanente Commercial	$3.31
Rate for Payer: Kaiser Permanente Medicaid	$1.88
Rate for Payer: Kaiser Permanente Medicare	$3.31
Rate for Payer: MDX Hawaii PPO	$3.57
Rate for Payer: Ohana Health Plan Medicaid	$3.31
Rate for Payer: Ohana Health Plan Medicare	$3.31
Rate for Payer: UnitedHealthcare Medicare	$3.31
Rate for Payer: University Health Alliance Commercial	$2.68

BACTERIAL AND TUBERCULOUS INFECTIONS OF NERVOUS SYSTEM WITH CC

Facility

$51,314.83

Service Code	MSDRG 095
Min. Negotiated Rate	$51,314.83
Max. Negotiated Rate	$51,314.83
Rate for Payer: Hawaii Medical Service Association Commercial	$51,314.83

BACTERIAL AND TUBERCULOUS INFECTIONS OF NERVOUS SYSTEM WITH MCC

Facility

$51,314.83

Service Code	MSDRG 094
Min. Negotiated Rate	$51,314.83
Max. Negotiated Rate	$51,314.83
Rate for Payer: Hawaii Medical Service Association Commercial	$51,314.83

BACTERIAL AND TUBERCULOUS INFECTIONS OF NERVOUS SYSTEM WITHOUT CC/MCC

Facility

$51,314.83

Service Code	MSDRG 096
Min. Negotiated Rate	$51,314.83
Max. Negotiated Rate	$51,314.83
Rate for Payer: Hawaii Medical Service Association Commercial	$51,314.83

BALANCED SALT SOLN NO.2 IRRIG. INTRAOC SOLN

Facility

$70.36

Service Code	NDC 00065079515
Hospital Revenue Code	250
Min. Negotiated Rate	$59.81
Max. Negotiated Rate	$68.25
Rate for Payer: Cash Price	$45.73
Rate for Payer: Health Management Network Commercial	$59.81
Rate for Payer: Kaiser Permanente Commercial	$63.32
Rate for Payer: MDX Hawaii PPO	$68.25

BALANCED SALT SOLN NO.2 IRRIG. INTRAOC SOLN

Facility

$70.36

Service Code	NDC 00065079515
Hospital Revenue Code	250
Min. Negotiated Rate	$35.18
Max. Negotiated Rate	$69.66
Rate for Payer: AlohaCare Medicaid	$35.18
Rate for Payer: AlohaCare Medicare	$63.32
Rate for Payer: Cash Price	$45.73
Rate for Payer: Devoted Health Medicare	$69.66
Rate for Payer: Hawaii Medical Service Association Medicare	$63.32
Rate for Payer: Hawaii Western Management Group Commercial	$66.84
Rate for Payer: Health Management Network Commercial	$59.81
Rate for Payer: Humana Medicare	$63.32
Rate for Payer: Kaiser Permanente Commercial	$63.32
Rate for Payer: Kaiser Permanente Medicaid	$35.88
Rate for Payer: Kaiser Permanente Medicare	$63.32
Rate for Payer: MDX Hawaii PPO	$68.25
Rate for Payer: Ohana Health Plan Medicaid	$63.32
Rate for Payer: Ohana Health Plan Medicare	$63.32
Rate for Payer: UnitedHealthcare Medicaid	$42.22
Rate for Payer: UnitedHealthcare Medicare	$63.32
Rate for Payer: University Health Alliance Commercial	$51.29

B-COMPLEX WITH VITAMIN C PO TABLET

Facility

$1.20

Service Code	HCPCS A9270
Hospital Revenue Code	637
Min. Negotiated Rate	$0.60
Max. Negotiated Rate	$1.19
Rate for Payer: AlohaCare Medicaid	$0.60
Rate for Payer: AlohaCare Medicare	$1.08
Rate for Payer: Cash Price	$0.78
Rate for Payer: Devoted Health Medicare	$1.19
Rate for Payer: Hawaii Medical Service Association Medicare	$1.08
Rate for Payer: Hawaii Western Management Group Commercial	$1.14
Rate for Payer: Health Management Network Commercial	$1.02
Rate for Payer: Humana Medicare	$1.08
Rate for Payer: Kaiser Permanente Commercial	$1.08
Rate for Payer: Kaiser Permanente Medicaid	$0.61
Rate for Payer: Kaiser Permanente Medicare	$1.08
Rate for Payer: MDX Hawaii PPO	$1.16
Rate for Payer: Ohana Health Plan Medicaid	$1.08
Rate for Payer: Ohana Health Plan Medicare	$1.08
Rate for Payer: UnitedHealthcare Medicare	$1.08
Rate for Payer: University Health Alliance Commercial	$0.87

B-COMPLEX WITH VITAMIN C PO TABLET

Facility

$1.20

Service Code	HCPCS A9270
Hospital Revenue Code	250
Min. Negotiated Rate	$1.02
Max. Negotiated Rate	$1.16
Rate for Payer: Cash Price	$0.78
Rate for Payer: Health Management Network Commercial	$1.02
Rate for Payer: Kaiser Permanente Commercial	$1.08
Rate for Payer: MDX Hawaii PPO	$1.16

BEHAVIORAL AND DEVELOPMENTAL DISORDERS

Facility

$14,126.39

Service Code	MSDRG 886
Min. Negotiated Rate	$14,126.39
Max. Negotiated Rate	$14,126.39
Rate for Payer: Hawaii Medical Service Association Commercial	$14,126.39

BELLADONNA ALKALOIDS-OPIUM 16.2-30 MG PR SUPP

Facility

$131.93

Service Code	HCPCS A9270
Hospital Revenue Code	637
Min. Negotiated Rate	$65.97
Max. Negotiated Rate	$130.61
Rate for Payer: AlohaCare Medicaid	$65.97
Rate for Payer: AlohaCare Medicare	$118.74
Rate for Payer: Cash Price	$85.75
Rate for Payer: Devoted Health Medicare	$130.61
Rate for Payer: Hawaii Medical Service Association Medicare	$118.74
Rate for Payer: Hawaii Western Management Group Commercial	$125.33
Rate for Payer: Health Management Network Commercial	$112.14
Rate for Payer: Humana Medicare	$118.74
Rate for Payer: Kaiser Permanente Commercial	$118.74
Rate for Payer: Kaiser Permanente Medicaid	$67.28
Rate for Payer: Kaiser Permanente Medicare	$118.74
Rate for Payer: MDX Hawaii PPO	$127.97
Rate for Payer: Ohana Health Plan Medicaid	$118.74
Rate for Payer: Ohana Health Plan Medicare	$118.74
Rate for Payer: UnitedHealthcare Medicare	$118.74
Rate for Payer: University Health Alliance Commercial	$96.16

BELLADONNA ALKALOIDS-OPIUM 16.2-30 MG PR SUPP

Facility

$131.93

Service Code	HCPCS A9270
Hospital Revenue Code	250
Min. Negotiated Rate	$112.14
Max. Negotiated Rate	$127.97
Rate for Payer: Cash Price	$85.75
Rate for Payer: Health Management Network Commercial	$112.14
Rate for Payer: Kaiser Permanente Commercial	$118.74
Rate for Payer: MDX Hawaii PPO	$127.97

BENIGN PROSTATIC HYPERTROPHY WITH MCC

Facility

$25,005.61

Service Code	MSDRG 725
Min. Negotiated Rate	$25,005.61
Max. Negotiated Rate	$25,005.61
Rate for Payer: Hawaii Medical Service Association Commercial	$25,005.61

BENIGN PROSTATIC HYPERTROPHY WITHOUT MCC

Facility

$25,005.61

Service Code	MSDRG 726
Min. Negotiated Rate	$25,005.61
Max. Negotiated Rate	$25,005.61
Rate for Payer: Hawaii Medical Service Association Commercial	$25,005.61

BENZOCAINE 20 % MM NON-AER.SPRY

Facility

$75.25

Service Code	HCPCS A9270
Hospital Revenue Code	250
Min. Negotiated Rate	$63.96
Max. Negotiated Rate	$72.99
Rate for Payer: Cash Price	$48.91
Rate for Payer: Health Management Network Commercial	$63.96
Rate for Payer: Kaiser Permanente Commercial	$67.72
Rate for Payer: MDX Hawaii PPO	$72.99

BENZOCAINE 20 % MM NON-AER.SPRY

Facility

$75.25

Service Code	HCPCS A9270
Hospital Revenue Code	637
Min. Negotiated Rate	$37.62
Max. Negotiated Rate	$74.50
Rate for Payer: AlohaCare Medicaid	$37.62
Rate for Payer: AlohaCare Medicare	$67.72
Rate for Payer: Cash Price	$48.91
Rate for Payer: Devoted Health Medicare	$74.50
Rate for Payer: Hawaii Medical Service Association Medicare	$67.72
Rate for Payer: Hawaii Western Management Group Commercial	$71.49
Rate for Payer: Health Management Network Commercial	$63.96
Rate for Payer: Humana Medicare	$67.72
Rate for Payer: Kaiser Permanente Commercial	$67.72
Rate for Payer: Kaiser Permanente Medicaid	$38.38
Rate for Payer: Kaiser Permanente Medicare	$67.72
Rate for Payer: MDX Hawaii PPO	$72.99
Rate for Payer: Ohana Health Plan Medicaid	$67.72
Rate for Payer: Ohana Health Plan Medicare	$67.72
Rate for Payer: UnitedHealthcare Medicare	$67.72
Rate for Payer: University Health Alliance Commercial	$54.85

Know your out-of-pocket cost for care.

All Charges