Kohala Hospital

All Charges

Charge

Type

Setting

Price

BENZOCAINE-MENTHOL 15-2.6 MG MM LOZG

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

BENZOCAINE-MENTHOL 15-2.6 MG MM LOZG

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

BENZOCAINE-MENTHOL 15-3.6 MG MM LOZG

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

BENZOCAINE-MENTHOL 15-3.6 MG MM LOZG

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

BENZONATATE 100 MG PO CAP

Facility

$2.73

Service Code	HCPCS A9270
Hospital Revenue Code	250
Min. Negotiated Rate	$2.32
Max. Negotiated Rate	$2.65
Rate for Payer: Cash Price	$1.77
Rate for Payer: Cash Price	$2.62
Rate for Payer: Health Management Network Commercial	$2.32
Rate for Payer: Health Management Network Commercial	$3.43
Rate for Payer: Kaiser Permanente Commercial	$2.46
Rate for Payer: Kaiser Permanente Commercial	$3.63
Rate for Payer: MDX Hawaii PPO	$3.91
Rate for Payer: MDX Hawaii PPO	$2.65

BENZONATATE 100 MG PO CAP

Facility

$4.03

Service Code	HCPCS A9270
Hospital Revenue Code	637
Min. Negotiated Rate	$2.02
Max. Negotiated Rate	$3.99
Rate for Payer: AlohaCare Medicaid	$2.02
Rate for Payer: AlohaCare Medicaid	$1.36
Rate for Payer: AlohaCare Medicare	$2.46
Rate for Payer: AlohaCare Medicare	$3.63
Rate for Payer: Cash Price	$1.77
Rate for Payer: Cash Price	$2.62
Rate for Payer: Devoted Health Medicare	$3.99
Rate for Payer: Devoted Health Medicare	$2.70
Rate for Payer: Hawaii Medical Service Association Medicare	$2.46
Rate for Payer: Hawaii Medical Service Association Medicare	$3.63
Rate for Payer: Hawaii Western Management Group Commercial	$2.59
Rate for Payer: Hawaii Western Management Group Commercial	$3.83
Rate for Payer: Health Management Network Commercial	$3.43
Rate for Payer: Health Management Network Commercial	$2.32
Rate for Payer: Humana Medicare	$3.63
Rate for Payer: Humana Medicare	$2.46
Rate for Payer: Kaiser Permanente Commercial	$2.46
Rate for Payer: Kaiser Permanente Commercial	$3.63
Rate for Payer: Kaiser Permanente Medicaid	$2.06
Rate for Payer: Kaiser Permanente Medicaid	$1.39
Rate for Payer: Kaiser Permanente Medicare	$2.46
Rate for Payer: Kaiser Permanente Medicare	$3.63
Rate for Payer: MDX Hawaii PPO	$2.65
Rate for Payer: MDX Hawaii PPO	$3.91
Rate for Payer: Ohana Health Plan Medicaid	$2.46
Rate for Payer: Ohana Health Plan Medicaid	$3.63
Rate for Payer: Ohana Health Plan Medicare	$2.46
Rate for Payer: Ohana Health Plan Medicare	$3.63
Rate for Payer: UnitedHealthcare Medicare	$3.63
Rate for Payer: UnitedHealthcare Medicare	$2.46
Rate for Payer: University Health Alliance Commercial	$2.94
Rate for Payer: University Health Alliance Commercial	$1.99

BENZTROPINE 1 MG PO TABLET

Facility

$3.25

Service Code	HCPCS A9270
Hospital Revenue Code	250
Min. Negotiated Rate	$2.76
Max. Negotiated Rate	$3.15
Rate for Payer: Cash Price	$2.11
Rate for Payer: Health Management Network Commercial	$2.76
Rate for Payer: Kaiser Permanente Commercial	$2.92
Rate for Payer: MDX Hawaii PPO	$3.15

BENZTROPINE 1 MG PO TABLET

Facility

$3.25

Service Code	HCPCS A9270
Hospital Revenue Code	637
Min. Negotiated Rate	$1.62
Max. Negotiated Rate	$3.22
Rate for Payer: AlohaCare Medicaid	$1.62
Rate for Payer: AlohaCare Medicare	$2.92
Rate for Payer: Cash Price	$2.11
Rate for Payer: Devoted Health Medicare	$3.22
Rate for Payer: Hawaii Medical Service Association Medicare	$2.92
Rate for Payer: Hawaii Western Management Group Commercial	$3.09
Rate for Payer: Health Management Network Commercial	$2.76
Rate for Payer: Humana Medicare	$2.92
Rate for Payer: Kaiser Permanente Commercial	$2.92
Rate for Payer: Kaiser Permanente Medicaid	$1.66
Rate for Payer: Kaiser Permanente Medicare	$2.92
Rate for Payer: MDX Hawaii PPO	$3.15
Rate for Payer: Ohana Health Plan Medicaid	$2.92
Rate for Payer: Ohana Health Plan Medicare	$2.92
Rate for Payer: UnitedHealthcare Medicare	$2.92
Rate for Payer: University Health Alliance Commercial	$2.37

BENZTROPINE 2 MG/2 ML INJ SOLN

Facility

$306.96

Service Code	HCPCS J0515
Hospital Revenue Code	250
Min. Negotiated Rate	$260.92
Max. Negotiated Rate	$297.75
Rate for Payer: Cash Price	$199.52
Rate for Payer: Health Management Network Commercial	$260.92
Rate for Payer: Kaiser Permanente Commercial	$276.26
Rate for Payer: MDX Hawaii PPO	$297.75

BENZTROPINE 2 MG/2 ML INJ SOLN

Facility

$306.96

Service Code	HCPCS J0515
Hospital Revenue Code	636
Min. Negotiated Rate	$17.27
Max. Negotiated Rate	$303.89
Rate for Payer: AlohaCare Medicaid	$153.48
Rate for Payer: AlohaCare Medicare	$276.26
Rate for Payer: Cash Price	$199.52
Rate for Payer: Cash Price	$199.52
Rate for Payer: Devoted Health Medicare	$303.89
Rate for Payer: Hawaii Medical Service Association ABD	$17.27
Rate for Payer: Hawaii Medical Service Association Medicare	$276.26
Rate for Payer: Hawaii Medical Service Association Non-ABD	$17.27
Rate for Payer: Hawaii Western Management Group Commercial	$291.61
Rate for Payer: Health Management Network Commercial	$260.92
Rate for Payer: Humana Medicare	$276.26
Rate for Payer: Kaiser Permanente Commercial	$276.26
Rate for Payer: Kaiser Permanente Medicaid	$156.55
Rate for Payer: Kaiser Permanente Medicare	$276.26
Rate for Payer: MDX Hawaii PPO	$297.75
Rate for Payer: Ohana Health Plan Medicaid	$276.26
Rate for Payer: Ohana Health Plan Medicare	$276.26
Rate for Payer: UnitedHealthcare Medicaid	$184.18
Rate for Payer: UnitedHealthcare Medicare	$276.26
Rate for Payer: University Health Alliance Commercial	$223.74

BETAMETHASONE ACET,SOD PHOS 6 MG/ML INJ SUSP

Facility

$198.76

Service Code	HCPCS J0702
Hospital Revenue Code	250
Min. Negotiated Rate	$168.95
Max. Negotiated Rate	$192.80
Rate for Payer: Cash Price	$129.19
Rate for Payer: Cash Price	$188.36
Rate for Payer: Health Management Network Commercial	$168.95
Rate for Payer: Health Management Network Commercial	$246.32
Rate for Payer: Kaiser Permanente Commercial	$178.88
Rate for Payer: Kaiser Permanente Commercial	$260.81
Rate for Payer: MDX Hawaii PPO	$281.10
Rate for Payer: MDX Hawaii PPO	$192.80

BETAMETHASONE ACET,SOD PHOS 6 MG/ML INJ SUSP

Facility

$198.76

Service Code	HCPCS J0702
Hospital Revenue Code	636
Min. Negotiated Rate	$6.89
Max. Negotiated Rate	$196.77
Rate for Payer: AlohaCare Medicaid	$99.38
Rate for Payer: AlohaCare Medicaid	$144.90
Rate for Payer: AlohaCare Medicare	$260.81
Rate for Payer: AlohaCare Medicare	$178.88
Rate for Payer: Cash Price	$188.36
Rate for Payer: Cash Price	$129.19
Rate for Payer: Cash Price	$129.19
Rate for Payer: Cash Price	$188.36
Rate for Payer: Devoted Health Medicare	$196.77
Rate for Payer: Devoted Health Medicare	$286.89
Rate for Payer: Hawaii Medical Service Association ABD	$6.89
Rate for Payer: Hawaii Medical Service Association ABD	$6.89
Rate for Payer: Hawaii Medical Service Association Medicare	$260.81
Rate for Payer: Hawaii Medical Service Association Medicare	$178.88
Rate for Payer: Hawaii Medical Service Association Non-ABD	$6.89
Rate for Payer: Hawaii Medical Service Association Non-ABD	$6.89
Rate for Payer: Hawaii Western Management Group Commercial	$188.82
Rate for Payer: Hawaii Western Management Group Commercial	$275.30
Rate for Payer: Health Management Network Commercial	$246.32
Rate for Payer: Health Management Network Commercial	$168.95
Rate for Payer: Humana Medicare	$178.88
Rate for Payer: Humana Medicare	$260.81
Rate for Payer: Kaiser Permanente Commercial	$178.88
Rate for Payer: Kaiser Permanente Commercial	$260.81
Rate for Payer: Kaiser Permanente Medicaid	$147.79
Rate for Payer: Kaiser Permanente Medicaid	$101.37
Rate for Payer: Kaiser Permanente Medicare	$178.88
Rate for Payer: Kaiser Permanente Medicare	$260.81
Rate for Payer: MDX Hawaii PPO	$192.80
Rate for Payer: MDX Hawaii PPO	$281.10
Rate for Payer: Ohana Health Plan Medicaid	$260.81
Rate for Payer: Ohana Health Plan Medicaid	$178.88
Rate for Payer: Ohana Health Plan Medicare	$178.88
Rate for Payer: Ohana Health Plan Medicare	$260.81
Rate for Payer: UnitedHealthcare Medicaid	$173.87
Rate for Payer: UnitedHealthcare Medicaid	$119.26
Rate for Payer: UnitedHealthcare Medicare	$178.88
Rate for Payer: UnitedHealthcare Medicare	$260.81
Rate for Payer: University Health Alliance Commercial	$144.88
Rate for Payer: University Health Alliance Commercial	$211.23

BETHANECHOL CHLORIDE 25 MG PO TABLET

Facility

$9.85

Service Code	HCPCS A9270
Hospital Revenue Code	637
Min. Negotiated Rate	$4.92
Max. Negotiated Rate	$9.75
Rate for Payer: AlohaCare Medicaid	$4.92
Rate for Payer: AlohaCare Medicare	$8.87
Rate for Payer: Cash Price	$6.40
Rate for Payer: Devoted Health Medicare	$9.75
Rate for Payer: Hawaii Medical Service Association Medicare	$8.87
Rate for Payer: Hawaii Western Management Group Commercial	$9.36
Rate for Payer: Health Management Network Commercial	$8.37
Rate for Payer: Humana Medicare	$8.87
Rate for Payer: Kaiser Permanente Commercial	$8.87
Rate for Payer: Kaiser Permanente Medicaid	$5.02
Rate for Payer: Kaiser Permanente Medicare	$8.87
Rate for Payer: MDX Hawaii PPO	$9.55
Rate for Payer: Ohana Health Plan Medicaid	$8.87
Rate for Payer: Ohana Health Plan Medicare	$8.87
Rate for Payer: UnitedHealthcare Medicare	$8.87
Rate for Payer: University Health Alliance Commercial	$7.18

BETHANECHOL CHLORIDE 25 MG PO TABLET

Facility

$9.85

Service Code	HCPCS A9270
Hospital Revenue Code	250
Min. Negotiated Rate	$8.37
Max. Negotiated Rate	$9.55
Rate for Payer: Cash Price	$6.40
Rate for Payer: Health Management Network Commercial	$8.37
Rate for Payer: Kaiser Permanente Commercial	$8.87
Rate for Payer: MDX Hawaii PPO	$9.55

BILATERAL OR MULTIPLE MAJOR JOINT PROCEDURES OF LOWER EXTREMITY WITH MCC

Facility

$66,318.20

Service Code	MSDRG 461
Min. Negotiated Rate	$66,318.20
Max. Negotiated Rate	$66,318.20
Rate for Payer: Hawaii Medical Service Association Commercial	$66,318.20

BILATERAL OR MULTIPLE MAJOR JOINT PROCEDURES OF LOWER EXTREMITY WITHOUT MCC

Facility

$66,318.20

Service Code	MSDRG 462
Min. Negotiated Rate	$66,318.20
Max. Negotiated Rate	$66,318.20
Rate for Payer: Hawaii Medical Service Association Commercial	$66,318.20

BILIARY TRACT PROCEDURES EXCEPT ONLY CHOLECYSTECTOMY WITH OR WITHOUT C.D.E. WITH CC

Facility

$46,242.60

Service Code	MSDRG 409
Min. Negotiated Rate	$46,242.60
Max. Negotiated Rate	$46,242.60
Rate for Payer: Hawaii Medical Service Association Commercial	$46,242.60

BILIARY TRACT PROCEDURES EXCEPT ONLY CHOLECYSTECTOMY WITH OR WITHOUT C.D.E. WITH MCC

Facility

$46,242.60

Service Code	MSDRG 408
Min. Negotiated Rate	$46,242.60
Max. Negotiated Rate	$46,242.60
Rate for Payer: Hawaii Medical Service Association Commercial	$46,242.60

BILIARY TRACT PROCEDURES EXCEPT ONLY CHOLECYSTECTOMY WITH OR WITHOUT C.D.E. WITHOUT CC/MCC

Facility

$45,247.12

Service Code	MSDRG 410
Min. Negotiated Rate	$45,247.12
Max. Negotiated Rate	$45,247.12
Rate for Payer: Hawaii Medical Service Association Commercial	$45,247.12

BIOPSIES OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH CC

Facility

$47,830.64

Service Code	MSDRG 478
Min. Negotiated Rate	$47,830.64
Max. Negotiated Rate	$47,830.64
Rate for Payer: Hawaii Medical Service Association Commercial	$47,830.64

BIOPSIES OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH MCC

Facility

$47,830.64

Service Code	MSDRG 477
Min. Negotiated Rate	$47,830.64
Max. Negotiated Rate	$47,830.64
Rate for Payer: Hawaii Medical Service Association Commercial	$47,830.64

BIOPSIES OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITHOUT CC/MCC

Facility

$47,830.64

Service Code	MSDRG 479
Min. Negotiated Rate	$47,830.64
Max. Negotiated Rate	$47,830.64
Rate for Payer: Hawaii Medical Service Association Commercial	$47,830.64

BISACODYL 10 MG PR SUPP

Facility

$1.74

Service Code	HCPCS A9270
Hospital Revenue Code	637
Min. Negotiated Rate	$0.87
Max. Negotiated Rate	$1.72
Rate for Payer: AlohaCare Medicaid	$0.87
Rate for Payer: AlohaCare Medicare	$1.57
Rate for Payer: Cash Price	$1.13
Rate for Payer: Devoted Health Medicare	$1.72
Rate for Payer: Hawaii Medical Service Association Medicare	$1.57
Rate for Payer: Hawaii Western Management Group Commercial	$1.65
Rate for Payer: Health Management Network Commercial	$1.48
Rate for Payer: Humana Medicare	$1.57
Rate for Payer: Kaiser Permanente Commercial	$1.57
Rate for Payer: Kaiser Permanente Medicaid	$0.89
Rate for Payer: Kaiser Permanente Medicare	$1.57
Rate for Payer: MDX Hawaii PPO	$1.69
Rate for Payer: Ohana Health Plan Medicaid	$1.57
Rate for Payer: Ohana Health Plan Medicare	$1.57
Rate for Payer: UnitedHealthcare Medicare	$1.57
Rate for Payer: University Health Alliance Commercial	$1.27

BISACODYL 10 MG PR SUPP

Facility

$1.74

Service Code	HCPCS A9270
Hospital Revenue Code	250
Min. Negotiated Rate	$1.48
Max. Negotiated Rate	$1.69
Rate for Payer: Cash Price	$1.13
Rate for Payer: Health Management Network Commercial	$1.48
Rate for Payer: Kaiser Permanente Commercial	$1.57
Rate for Payer: MDX Hawaii PPO	$1.69

BISACODYL 5 MG PO TAB DR EC

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

Know your out-of-pocket cost for care.

All Charges