Kohala Hospital

All Charges

Charge

Type

Setting

Price

IMMUNE GLOBULIN (HUMAN) (IGG) (20 GM) 10 % 200 ML INJ

Facility

$5,723.04

Service Code	HCPCS J1459
Hospital Revenue Code	250
Min. Negotiated Rate	$4,864.58
Max. Negotiated Rate	$5,551.35
Rate for Payer: Cash Price	$3,719.98
Rate for Payer: Health Management Network Commercial	$4,864.58
Rate for Payer: Kaiser Permanente Commercial	$5,150.74
Rate for Payer: MDX Hawaii PPO	$5,551.35

IMMUNE GLOBULIN (HUMAN) (IGG) (20 GM) 10 % 200 ML INJ

Facility

$5,723.04

Service Code	HCPCS J1459
Hospital Revenue Code	636
Min. Negotiated Rate	$50.43
Max. Negotiated Rate	$5,665.81
Rate for Payer: AlohaCare Medicaid	$2,861.52
Rate for Payer: AlohaCare Medicare	$5,150.74
Rate for Payer: Cash Price	$3,719.98
Rate for Payer: Cash Price	$3,719.98
Rate for Payer: Devoted Health Medicare	$5,665.81
Rate for Payer: Hawaii Medical Service Association ABD	$50.43
Rate for Payer: Hawaii Medical Service Association Commercial	$61.91
Rate for Payer: Hawaii Medical Service Association Medicare	$5,150.74
Rate for Payer: Hawaii Medical Service Association Non-ABD	$50.43
Rate for Payer: Hawaii Western Management Group Commercial	$5,436.89
Rate for Payer: Health Management Network Commercial	$4,864.58
Rate for Payer: Humana Medicare	$5,150.74
Rate for Payer: Kaiser Permanente Commercial	$5,150.74
Rate for Payer: Kaiser Permanente Medicaid	$2,918.75
Rate for Payer: Kaiser Permanente Medicare	$5,150.74
Rate for Payer: MDX Hawaii PPO	$5,551.35
Rate for Payer: Ohana Health Plan Medicaid	$5,150.74
Rate for Payer: Ohana Health Plan Medicare	$5,150.74
Rate for Payer: UnitedHealthcare Medicaid	$3,433.82
Rate for Payer: UnitedHealthcare Medicare	$5,150.74
Rate for Payer: University Health Alliance Commercial	$4,171.52

INBORN AND OTHER DISORDERS OF METABOLISM

Facility

$85,327.20

Service Code	MSDRG 642
Min. Negotiated Rate	$85,327.20
Max. Negotiated Rate	$85,327.20
Rate for Payer: Hawaii Medical Service Association Commercial	$85,327.20

INDIGOTINDISULFONATE SODIUM 8 MG/ML (0.8 %) IV SOLN

Facility

$1,236.48

Service Code	HCPCS J9220
Hospital Revenue Code	636
Min. Negotiated Rate	$11.62
Max. Negotiated Rate	$1,224.12
Rate for Payer: AlohaCare Medicaid	$618.24
Rate for Payer: AlohaCare Medicare	$1,112.83
Rate for Payer: Cash Price	$803.71
Rate for Payer: Cash Price	$803.71
Rate for Payer: Devoted Health Medicare	$1,224.12
Rate for Payer: Hawaii Medical Service Association Commercial	$11.62
Rate for Payer: Hawaii Medical Service Association Medicare	$1,112.83
Rate for Payer: Hawaii Western Management Group Commercial	$1,174.66
Rate for Payer: Health Management Network Commercial	$1,051.01
Rate for Payer: Humana Medicare	$1,112.83
Rate for Payer: Kaiser Permanente Commercial	$1,112.83
Rate for Payer: Kaiser Permanente Medicaid	$630.60
Rate for Payer: Kaiser Permanente Medicare	$1,112.83
Rate for Payer: MDX Hawaii PPO	$1,199.39
Rate for Payer: Ohana Health Plan Medicaid	$1,112.83
Rate for Payer: Ohana Health Plan Medicare	$1,112.83
Rate for Payer: UnitedHealthcare Medicaid	$741.89
Rate for Payer: UnitedHealthcare Medicare	$1,112.83
Rate for Payer: University Health Alliance Commercial	$901.27

INDIGOTINDISULFONATE SODIUM 8 MG/ML (0.8 %) IV SOLN

Facility

$1,236.48

Service Code	HCPCS J9220
Hospital Revenue Code	250
Min. Negotiated Rate	$1,051.01
Max. Negotiated Rate	$1,199.39
Rate for Payer: Cash Price	$803.71
Rate for Payer: Health Management Network Commercial	$1,051.01
Rate for Payer: Kaiser Permanente Commercial	$1,112.83
Rate for Payer: MDX Hawaii PPO	$1,199.39

INDOMETHACIN 25 MG PO CAP

Facility

$2.22

Service Code	HCPCS A9270
Hospital Revenue Code	637
Min. Negotiated Rate	$1.11
Max. Negotiated Rate	$2.20
Rate for Payer: AlohaCare Medicaid	$1.11
Rate for Payer: AlohaCare Medicaid	$1.19
Rate for Payer: AlohaCare Medicare	$2.00
Rate for Payer: AlohaCare Medicare	$2.14
Rate for Payer: Cash Price	$1.44
Rate for Payer: Cash Price	$1.55
Rate for Payer: Devoted Health Medicare	$2.20
Rate for Payer: Devoted Health Medicare	$2.36
Rate for Payer: Hawaii Medical Service Association Medicare	$2.14
Rate for Payer: Hawaii Medical Service Association Medicare	$2.00
Rate for Payer: Hawaii Western Management Group Commercial	$2.26
Rate for Payer: Hawaii Western Management Group Commercial	$2.11
Rate for Payer: Health Management Network Commercial	$1.89
Rate for Payer: Health Management Network Commercial	$2.02
Rate for Payer: Humana Medicare	$2.00
Rate for Payer: Humana Medicare	$2.14
Rate for Payer: Kaiser Permanente Commercial	$2.14
Rate for Payer: Kaiser Permanente Commercial	$2.00
Rate for Payer: Kaiser Permanente Medicaid	$1.13
Rate for Payer: Kaiser Permanente Medicaid	$1.21
Rate for Payer: Kaiser Permanente Medicare	$2.00
Rate for Payer: Kaiser Permanente Medicare	$2.14
Rate for Payer: MDX Hawaii PPO	$2.15
Rate for Payer: MDX Hawaii PPO	$2.31
Rate for Payer: Ohana Health Plan Medicaid	$2.00
Rate for Payer: Ohana Health Plan Medicaid	$2.14
Rate for Payer: Ohana Health Plan Medicare	$2.14
Rate for Payer: Ohana Health Plan Medicare	$2.00
Rate for Payer: UnitedHealthcare Medicare	$2.00
Rate for Payer: UnitedHealthcare Medicare	$2.14
Rate for Payer: University Health Alliance Commercial	$1.62
Rate for Payer: University Health Alliance Commercial	$1.73

INDOMETHACIN 25 MG PO CAP

Facility

$2.22

Service Code	HCPCS A9270
Hospital Revenue Code	250
Min. Negotiated Rate	$1.89
Max. Negotiated Rate	$2.15
Rate for Payer: Cash Price	$1.44
Rate for Payer: Cash Price	$1.55
Rate for Payer: Health Management Network Commercial	$2.02
Rate for Payer: Health Management Network Commercial	$1.89
Rate for Payer: Kaiser Permanente Commercial	$2.00
Rate for Payer: Kaiser Permanente Commercial	$2.14
Rate for Payer: MDX Hawaii PPO	$2.15
Rate for Payer: MDX Hawaii PPO	$2.31

INDOMETHACIN 50 MG PO CAP

Facility

$3.64

Service Code	HCPCS A9270
Hospital Revenue Code	637
Min. Negotiated Rate	$1.82
Max. Negotiated Rate	$3.60
Rate for Payer: AlohaCare Medicaid	$1.82
Rate for Payer: AlohaCare Medicare	$3.28
Rate for Payer: Cash Price	$2.37
Rate for Payer: Devoted Health Medicare	$3.60
Rate for Payer: Hawaii Medical Service Association Medicare	$3.28
Rate for Payer: Hawaii Western Management Group Commercial	$3.46
Rate for Payer: Health Management Network Commercial	$3.09
Rate for Payer: Humana Medicare	$3.28
Rate for Payer: Kaiser Permanente Commercial	$3.28
Rate for Payer: Kaiser Permanente Medicaid	$1.86
Rate for Payer: Kaiser Permanente Medicare	$3.28
Rate for Payer: MDX Hawaii PPO	$3.53
Rate for Payer: Ohana Health Plan Medicaid	$3.28
Rate for Payer: Ohana Health Plan Medicare	$3.28
Rate for Payer: UnitedHealthcare Medicare	$3.28
Rate for Payer: University Health Alliance Commercial	$2.65

INDOMETHACIN 50 MG PO CAP

Facility

$3.64

Service Code	HCPCS A9270
Hospital Revenue Code	250
Min. Negotiated Rate	$3.09
Max. Negotiated Rate	$3.53
Rate for Payer: Cash Price	$2.37
Rate for Payer: Health Management Network Commercial	$3.09
Rate for Payer: Kaiser Permanente Commercial	$3.28
Rate for Payer: MDX Hawaii PPO	$3.53

INFECTIONS, FEMALE REPRODUCTIVE SYSTEM WITH CC

Facility

$13,652.35

Service Code	MSDRG 758
Min. Negotiated Rate	$13,652.35
Max. Negotiated Rate	$13,652.35
Rate for Payer: Hawaii Medical Service Association Commercial	$13,652.35

INFECTIONS, FEMALE REPRODUCTIVE SYSTEM WITH MCC

Facility

$13,652.35

Service Code	MSDRG 757
Min. Negotiated Rate	$13,652.35
Max. Negotiated Rate	$13,652.35
Rate for Payer: Hawaii Medical Service Association Commercial	$13,652.35

INFECTIONS, FEMALE REPRODUCTIVE SYSTEM WITHOUT CC/MCC

Facility

$13,652.35

Service Code	MSDRG 759
Min. Negotiated Rate	$13,652.35
Max. Negotiated Rate	$13,652.35
Rate for Payer: Hawaii Medical Service Association Commercial	$13,652.35

INFECTIOUS AND PARASITIC DISEASES WITH O.R. PROCEDURES WITH CC

Facility

$154,039.30

Service Code	MSDRG 854
Min. Negotiated Rate	$154,039.30
Max. Negotiated Rate	$154,039.30
Rate for Payer: Hawaii Medical Service Association Commercial	$154,039.30

INFECTIOUS AND PARASITIC DISEASES WITH O.R. PROCEDURES WITH MCC

Facility

$154,039.30

Service Code	MSDRG 853
Min. Negotiated Rate	$154,039.30
Max. Negotiated Rate	$154,039.30
Rate for Payer: Hawaii Medical Service Association Commercial	$154,039.30

INFECTIOUS AND PARASITIC DISEASES WITH O.R. PROCEDURES WITHOUT CC/MCC

Facility

$154,039.30

Service Code	MSDRG 855
Min. Negotiated Rate	$154,039.30
Max. Negotiated Rate	$154,039.30
Rate for Payer: Hawaii Medical Service Association Commercial	$154,039.30

INFLAMMATION OF THE MALE REPRODUCTIVE SYSTEM WITH MCC

Facility

$13,178.31

Service Code	MSDRG 727
Min. Negotiated Rate	$13,178.31
Max. Negotiated Rate	$13,178.31
Rate for Payer: Hawaii Medical Service Association Commercial	$13,178.31

INFLAMMATION OF THE MALE REPRODUCTIVE SYSTEM WITHOUT MCC

Facility

$13,178.31

Service Code	MSDRG 728
Min. Negotiated Rate	$13,178.31
Max. Negotiated Rate	$13,178.31
Rate for Payer: Hawaii Medical Service Association Commercial	$13,178.31

INFLAMMATORY BOWEL DISEASE WITH CC

Facility

$19,435.64

Service Code	MSDRG 386
Min. Negotiated Rate	$19,435.64
Max. Negotiated Rate	$19,435.64
Rate for Payer: Hawaii Medical Service Association Commercial	$19,435.64

INFLAMMATORY BOWEL DISEASE WITH MCC

Facility

$19,435.64

Service Code	MSDRG 385
Min. Negotiated Rate	$19,435.64
Max. Negotiated Rate	$19,435.64
Rate for Payer: Hawaii Medical Service Association Commercial	$19,435.64

INFLAMMATORY BOWEL DISEASE WITHOUT CC/MCC

Facility

$19,435.64

Service Code	MSDRG 387
Min. Negotiated Rate	$19,435.64
Max. Negotiated Rate	$19,435.64
Rate for Payer: Hawaii Medical Service Association Commercial	$19,435.64

INGUINAL AND FEMORAL HERNIA PROCEDURES WITH CC

Facility

$29,888.22

Service Code	MSDRG 351
Min. Negotiated Rate	$29,888.22
Max. Negotiated Rate	$29,888.22
Rate for Payer: Hawaii Medical Service Association Commercial	$29,888.22

INGUINAL AND FEMORAL HERNIA PROCEDURES WITH MCC

Facility

$37,117.33

Service Code	MSDRG 350
Min. Negotiated Rate	$37,117.33
Max. Negotiated Rate	$37,117.33
Rate for Payer: Hawaii Medical Service Association Commercial	$37,117.33

INGUINAL AND FEMORAL HERNIA PROCEDURES WITHOUT CC/MCC

Facility

$15,453.70

Service Code	MSDRG 352
Min. Negotiated Rate	$15,453.70
Max. Negotiated Rate	$15,453.70
Rate for Payer: Hawaii Medical Service Association Commercial	$15,453.70

INSULIN DEGLUDEC 100 UNIT/ML (3 ML) SUBCUTANEOUS INSULIN PEN

Facility

$165.34

Service Code	HCPCS J1815
Hospital Revenue Code	250
Min. Negotiated Rate	$140.54
Max. Negotiated Rate	$160.38
Rate for Payer: Cash Price	$107.47
Rate for Payer: Health Management Network Commercial	$140.54
Rate for Payer: Kaiser Permanente Commercial	$148.81
Rate for Payer: MDX Hawaii PPO	$160.38

INSULIN DEGLUDEC 100 UNIT/ML (3 ML) SUBCUTANEOUS INSULIN PEN

Facility

$165.34

Service Code	HCPCS J1815
Hospital Revenue Code	637
Min. Negotiated Rate	$0.90
Max. Negotiated Rate	$163.69
Rate for Payer: AlohaCare Medicaid	$82.67
Rate for Payer: AlohaCare Medicare	$148.81
Rate for Payer: Cash Price	$107.47
Rate for Payer: Cash Price	$107.47
Rate for Payer: Devoted Health Medicare	$163.69
Rate for Payer: Hawaii Medical Service Association ABD	$0.90
Rate for Payer: Hawaii Medical Service Association Medicare	$148.81
Rate for Payer: Hawaii Medical Service Association Non-ABD	$0.90
Rate for Payer: Hawaii Western Management Group Commercial	$157.07
Rate for Payer: Health Management Network Commercial	$140.54
Rate for Payer: Humana Medicare	$148.81
Rate for Payer: Kaiser Permanente Commercial	$148.81
Rate for Payer: Kaiser Permanente Medicaid	$84.32
Rate for Payer: Kaiser Permanente Medicare	$148.81
Rate for Payer: MDX Hawaii PPO	$160.38
Rate for Payer: Ohana Health Plan Medicaid	$148.81
Rate for Payer: Ohana Health Plan Medicare	$148.81
Rate for Payer: UnitedHealthcare Medicare	$148.81
Rate for Payer: University Health Alliance Commercial	$120.52

Know your out-of-pocket cost for care.

All Charges