Kohala Hospital

All Charges

Charge

Type

Setting

Price

CAFFEINE CITRATE 60 MG/3 ML (20 MG/ML) IV SOLN

Facility

$67.68

Service Code	HCPCS J0706
Hospital Revenue Code	636
Min. Negotiated Rate	$33.84
Max. Negotiated Rate	$67.00
Rate for Payer: AlohaCare Medicaid	$33.84
Rate for Payer: AlohaCare Medicare	$60.91
Rate for Payer: Cash Price	$43.99
Rate for Payer: Devoted Health Medicare	$67.00
Rate for Payer: Hawaii Medical Service Association Medicare	$60.91
Rate for Payer: Hawaii Western Management Group Commercial	$64.30
Rate for Payer: Health Management Network Commercial	$57.53
Rate for Payer: Humana Medicare	$60.91
Rate for Payer: Kaiser Permanente Commercial	$60.91
Rate for Payer: Kaiser Permanente Medicaid	$34.52
Rate for Payer: Kaiser Permanente Medicare	$60.91
Rate for Payer: MDX Hawaii PPO	$65.65
Rate for Payer: Ohana Health Plan Medicaid	$60.91
Rate for Payer: Ohana Health Plan Medicare	$60.91
Rate for Payer: UnitedHealthcare Medicaid	$40.61
Rate for Payer: UnitedHealthcare Medicare	$60.91
Rate for Payer: University Health Alliance Commercial	$49.33

CALAMINE-ZINC OXIDE 8-8 % TOP LOTN

Facility

$24.43

Service Code	HCPCS A9270
Hospital Revenue Code	637
Min. Negotiated Rate	$12.21
Max. Negotiated Rate	$24.19
Rate for Payer: AlohaCare Medicaid	$12.21
Rate for Payer: AlohaCare Medicare	$21.99
Rate for Payer: Cash Price	$15.88
Rate for Payer: Devoted Health Medicare	$24.19
Rate for Payer: Hawaii Medical Service Association Medicare	$21.99
Rate for Payer: Hawaii Western Management Group Commercial	$23.21
Rate for Payer: Health Management Network Commercial	$20.77
Rate for Payer: Humana Medicare	$21.99
Rate for Payer: Kaiser Permanente Commercial	$21.99
Rate for Payer: Kaiser Permanente Medicaid	$12.46
Rate for Payer: Kaiser Permanente Medicare	$21.99
Rate for Payer: MDX Hawaii PPO	$23.70
Rate for Payer: Ohana Health Plan Medicaid	$21.99
Rate for Payer: Ohana Health Plan Medicare	$21.99
Rate for Payer: UnitedHealthcare Medicare	$21.99
Rate for Payer: University Health Alliance Commercial	$17.81

CALAMINE-ZINC OXIDE 8-8 % TOP LOTN

Facility

$24.43

Service Code	HCPCS A9270
Hospital Revenue Code	250
Min. Negotiated Rate	$20.77
Max. Negotiated Rate	$23.70
Rate for Payer: Cash Price	$15.88
Rate for Payer: Health Management Network Commercial	$20.77
Rate for Payer: Kaiser Permanente Commercial	$21.99
Rate for Payer: MDX Hawaii PPO	$23.70

CALCITONIN (SALMON) 200 UNIT/ML INJ SOLN

Facility

$1,900.80

Service Code	HCPCS J0630
Hospital Revenue Code	250
Min. Negotiated Rate	$1,615.68
Max. Negotiated Rate	$1,843.78
Rate for Payer: Cash Price	$1,235.52
Rate for Payer: Health Management Network Commercial	$1,615.68
Rate for Payer: Kaiser Permanente Commercial	$1,710.72
Rate for Payer: MDX Hawaii PPO	$1,843.78

CALCITONIN (SALMON) 200 UNIT/ML INJ SOLN

Facility

$1,900.80

Service Code	HCPCS J0630
Hospital Revenue Code	636
Min. Negotiated Rate	$950.40
Max. Negotiated Rate	$1,881.79
Rate for Payer: AlohaCare Medicaid	$950.40
Rate for Payer: AlohaCare Medicare	$1,710.72
Rate for Payer: Cash Price	$1,235.52
Rate for Payer: Cash Price	$1,235.52
Rate for Payer: Devoted Health Medicare	$1,881.79
Rate for Payer: Hawaii Medical Service Association ABD	$1,142.41
Rate for Payer: Hawaii Medical Service Association Medicare	$1,710.72
Rate for Payer: Hawaii Medical Service Association Non-ABD	$1,142.41
Rate for Payer: Hawaii Western Management Group Commercial	$1,805.76
Rate for Payer: Health Management Network Commercial	$1,615.68
Rate for Payer: Humana Medicare	$1,710.72
Rate for Payer: Kaiser Permanente Commercial	$1,710.72
Rate for Payer: Kaiser Permanente Medicaid	$969.41
Rate for Payer: Kaiser Permanente Medicare	$1,710.72
Rate for Payer: MDX Hawaii PPO	$1,843.78
Rate for Payer: Ohana Health Plan Medicaid	$1,710.72
Rate for Payer: Ohana Health Plan Medicare	$1,710.72
Rate for Payer: UnitedHealthcare Medicaid	$1,140.48
Rate for Payer: UnitedHealthcare Medicare	$1,710.72
Rate for Payer: University Health Alliance Commercial	$1,385.49

CALCIUM CARBONATE 300 MG (750 MG) PO CHEW

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

CALCIUM CARBONATE 300 MG (750 MG) PO CHEW

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

CALCIUM GLUC IN NACL, ISO-OSM 1 GRAM/50 ML IV SOLN

Facility

$116.12

Service Code	HCPCS J0613
Hospital Revenue Code	636
Min. Negotiated Rate	$0.08
Max. Negotiated Rate	$114.96
Rate for Payer: AlohaCare Medicaid	$58.06
Rate for Payer: AlohaCare Medicare	$104.51
Rate for Payer: Cash Price	$75.48
Rate for Payer: Cash Price	$75.48
Rate for Payer: Devoted Health Medicare	$114.96
Rate for Payer: Hawaii Medical Service Association ABD	$0.08
Rate for Payer: Hawaii Medical Service Association Medicare	$104.51
Rate for Payer: Hawaii Medical Service Association Non-ABD	$0.08
Rate for Payer: Hawaii Western Management Group Commercial	$110.31
Rate for Payer: Health Management Network Commercial	$98.70
Rate for Payer: Humana Medicare	$104.51
Rate for Payer: Kaiser Permanente Commercial	$104.51
Rate for Payer: Kaiser Permanente Medicaid	$59.22
Rate for Payer: Kaiser Permanente Medicare	$104.51
Rate for Payer: MDX Hawaii PPO	$112.64
Rate for Payer: Ohana Health Plan Medicaid	$104.51
Rate for Payer: Ohana Health Plan Medicare	$104.51
Rate for Payer: UnitedHealthcare Medicaid	$69.67
Rate for Payer: UnitedHealthcare Medicare	$104.51
Rate for Payer: University Health Alliance Commercial	$84.64

CALCIUM GLUC IN NACL, ISO-OSM 1 GRAM/50 ML IV SOLN

Facility

$116.12

Service Code	HCPCS J0613
Hospital Revenue Code	250
Min. Negotiated Rate	$98.70
Max. Negotiated Rate	$112.64
Rate for Payer: Cash Price	$75.48
Rate for Payer: Health Management Network Commercial	$98.70
Rate for Payer: Kaiser Permanente Commercial	$104.51
Rate for Payer: MDX Hawaii PPO	$112.64

CALCIUM GLUC IN NACL, ISO-OSM 2 G/100 ML IV SOLN

Facility

$214.24

Service Code	HCPCS J0613
Hospital Revenue Code	250
Min. Negotiated Rate	$182.10
Max. Negotiated Rate	$207.81
Rate for Payer: Cash Price	$139.26
Rate for Payer: Health Management Network Commercial	$182.10
Rate for Payer: Kaiser Permanente Commercial	$192.82
Rate for Payer: MDX Hawaii PPO	$207.81

CALCIUM GLUC IN NACL, ISO-OSM 2 G/100 ML IV SOLN

Facility

$214.24

Service Code	HCPCS J0613
Hospital Revenue Code	636
Min. Negotiated Rate	$0.08
Max. Negotiated Rate	$212.10
Rate for Payer: AlohaCare Medicaid	$107.12
Rate for Payer: AlohaCare Medicare	$192.82
Rate for Payer: Cash Price	$139.26
Rate for Payer: Cash Price	$139.26
Rate for Payer: Devoted Health Medicare	$212.10
Rate for Payer: Hawaii Medical Service Association ABD	$0.08
Rate for Payer: Hawaii Medical Service Association Medicare	$192.82
Rate for Payer: Hawaii Medical Service Association Non-ABD	$0.08
Rate for Payer: Hawaii Western Management Group Commercial	$203.53
Rate for Payer: Health Management Network Commercial	$182.10
Rate for Payer: Humana Medicare	$192.82
Rate for Payer: Kaiser Permanente Commercial	$192.82
Rate for Payer: Kaiser Permanente Medicaid	$109.26
Rate for Payer: Kaiser Permanente Medicare	$192.82
Rate for Payer: MDX Hawaii PPO	$207.81
Rate for Payer: Ohana Health Plan Medicaid	$192.82
Rate for Payer: Ohana Health Plan Medicare	$192.82
Rate for Payer: UnitedHealthcare Medicaid	$128.54
Rate for Payer: UnitedHealthcare Medicare	$192.82
Rate for Payer: University Health Alliance Commercial	$156.16

CALCIUM GLUCONATE 100 MG/ML (10%) IV SOLN

Facility

$58.06

Service Code	HCPCS J0612
Hospital Revenue Code	250
Min. Negotiated Rate	$49.35
Max. Negotiated Rate	$56.32
Rate for Payer: Cash Price	$37.74
Rate for Payer: Health Management Network Commercial	$49.35
Rate for Payer: Kaiser Permanente Commercial	$52.25
Rate for Payer: MDX Hawaii PPO	$56.32

CALCIUM GLUCONATE 100 MG/ML (10%) IV SOLN

Facility

$58.06

Service Code	HCPCS J0612
Hospital Revenue Code	636
Min. Negotiated Rate	$0.04
Max. Negotiated Rate	$57.48
Rate for Payer: AlohaCare Medicaid	$29.03
Rate for Payer: AlohaCare Medicare	$52.25
Rate for Payer: Cash Price	$37.74
Rate for Payer: Cash Price	$37.74
Rate for Payer: Devoted Health Medicare	$57.48
Rate for Payer: Hawaii Medical Service Association ABD	$0.04
Rate for Payer: Hawaii Medical Service Association Medicare	$52.25
Rate for Payer: Hawaii Medical Service Association Non-ABD	$0.04
Rate for Payer: Hawaii Western Management Group Commercial	$55.16
Rate for Payer: Health Management Network Commercial	$49.35
Rate for Payer: Humana Medicare	$52.25
Rate for Payer: Kaiser Permanente Commercial	$52.25
Rate for Payer: Kaiser Permanente Medicaid	$29.61
Rate for Payer: Kaiser Permanente Medicare	$52.25
Rate for Payer: MDX Hawaii PPO	$56.32
Rate for Payer: Ohana Health Plan Medicaid	$52.25
Rate for Payer: Ohana Health Plan Medicare	$52.25
Rate for Payer: UnitedHealthcare Medicaid	$34.84
Rate for Payer: UnitedHealthcare Medicare	$52.25
Rate for Payer: University Health Alliance Commercial	$42.32

CAPSAICIN 0.025 % TOP CR

Facility

$38.42

Service Code	HCPCS A9270
Hospital Revenue Code	637
Min. Negotiated Rate	$19.21
Max. Negotiated Rate	$38.04
Rate for Payer: AlohaCare Medicaid	$19.21
Rate for Payer: AlohaCare Medicare	$34.58
Rate for Payer: Cash Price	$24.97
Rate for Payer: Devoted Health Medicare	$38.04
Rate for Payer: Hawaii Medical Service Association Medicare	$34.58
Rate for Payer: Hawaii Western Management Group Commercial	$36.50
Rate for Payer: Health Management Network Commercial	$32.66
Rate for Payer: Humana Medicare	$34.58
Rate for Payer: Kaiser Permanente Commercial	$34.58
Rate for Payer: Kaiser Permanente Medicaid	$19.59
Rate for Payer: Kaiser Permanente Medicare	$34.58
Rate for Payer: MDX Hawaii PPO	$37.27
Rate for Payer: Ohana Health Plan Medicaid	$34.58
Rate for Payer: Ohana Health Plan Medicare	$34.58
Rate for Payer: UnitedHealthcare Medicare	$34.58
Rate for Payer: University Health Alliance Commercial	$28.00

CAPSAICIN 0.025 % TOP CR

Facility

$38.42

Service Code	HCPCS A9270
Hospital Revenue Code	250
Min. Negotiated Rate	$32.66
Max. Negotiated Rate	$37.27
Rate for Payer: Cash Price	$24.97
Rate for Payer: Health Management Network Commercial	$32.66
Rate for Payer: Kaiser Permanente Commercial	$34.58
Rate for Payer: MDX Hawaii PPO	$37.27

CAPTOPRIL 12.5 MG PO TABLET

Facility

$8.61

Service Code	HCPCS A9270
Hospital Revenue Code	250
Min. Negotiated Rate	$7.32
Max. Negotiated Rate	$8.35
Rate for Payer: Cash Price	$5.60
Rate for Payer: Health Management Network Commercial	$7.32
Rate for Payer: Kaiser Permanente Commercial	$7.75
Rate for Payer: MDX Hawaii PPO	$8.35

CAPTOPRIL 12.5 MG PO TABLET

Facility

$8.61

Service Code	HCPCS A9270
Hospital Revenue Code	637
Min. Negotiated Rate	$4.30
Max. Negotiated Rate	$8.52
Rate for Payer: AlohaCare Medicaid	$4.30
Rate for Payer: AlohaCare Medicare	$7.75
Rate for Payer: Cash Price	$5.60
Rate for Payer: Devoted Health Medicare	$8.52
Rate for Payer: Hawaii Medical Service Association Medicare	$7.75
Rate for Payer: Hawaii Western Management Group Commercial	$8.18
Rate for Payer: Health Management Network Commercial	$7.32
Rate for Payer: Humana Medicare	$7.75
Rate for Payer: Kaiser Permanente Commercial	$7.75
Rate for Payer: Kaiser Permanente Medicaid	$4.39
Rate for Payer: Kaiser Permanente Medicare	$7.75
Rate for Payer: MDX Hawaii PPO	$8.35
Rate for Payer: Ohana Health Plan Medicaid	$7.75
Rate for Payer: Ohana Health Plan Medicare	$7.75
Rate for Payer: UnitedHealthcare Medicare	$7.75
Rate for Payer: University Health Alliance Commercial	$6.28

CAPTOPRIL 25 MG PO TABLET

Facility

$9.22

Service Code	HCPCS A9270
Hospital Revenue Code	250
Min. Negotiated Rate	$7.84
Max. Negotiated Rate	$8.94
Rate for Payer: Cash Price	$5.99
Rate for Payer: Health Management Network Commercial	$7.84
Rate for Payer: Kaiser Permanente Commercial	$8.30
Rate for Payer: MDX Hawaii PPO	$8.94

CAPTOPRIL 25 MG PO TABLET

Facility

$9.22

Service Code	HCPCS A9270
Hospital Revenue Code	637
Min. Negotiated Rate	$4.61
Max. Negotiated Rate	$9.13
Rate for Payer: AlohaCare Medicaid	$4.61
Rate for Payer: AlohaCare Medicare	$8.30
Rate for Payer: Cash Price	$5.99
Rate for Payer: Devoted Health Medicare	$9.13
Rate for Payer: Hawaii Medical Service Association Medicare	$8.30
Rate for Payer: Hawaii Western Management Group Commercial	$8.76
Rate for Payer: Health Management Network Commercial	$7.84
Rate for Payer: Humana Medicare	$8.30
Rate for Payer: Kaiser Permanente Commercial	$8.30
Rate for Payer: Kaiser Permanente Medicaid	$4.70
Rate for Payer: Kaiser Permanente Medicare	$8.30
Rate for Payer: MDX Hawaii PPO	$8.94
Rate for Payer: Ohana Health Plan Medicaid	$8.30
Rate for Payer: Ohana Health Plan Medicare	$8.30
Rate for Payer: UnitedHealthcare Medicare	$8.30
Rate for Payer: University Health Alliance Commercial	$6.72

CARBAMAZEPINE 100 MG PO CHEW (0.5 TAB) = 50 MG

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: Health Management Network Commercial	$1.89
Rate for Payer: Kaiser Permanente Commercial	$2.00
Rate for Payer: MDX Hawaii PPO	$2.15

CARBAMAZEPINE 100 MG PO CHEW (0.5 TAB) = 50 MG

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 Medicare	$2.00
Rate for Payer: Cash Price	$1.44
Rate for Payer: Devoted Health Medicare	$2.20
Rate for Payer: Hawaii Medical Service Association Medicare	$2.00
Rate for Payer: Hawaii Western Management Group Commercial	$2.11
Rate for Payer: Health Management Network Commercial	$1.89
Rate for Payer: Humana Medicare	$2.00
Rate for Payer: Kaiser Permanente Commercial	$2.00
Rate for Payer: Kaiser Permanente Medicaid	$1.13
Rate for Payer: Kaiser Permanente Medicare	$2.00
Rate for Payer: MDX Hawaii PPO	$2.15
Rate for Payer: Ohana Health Plan Medicaid	$2.00
Rate for Payer: Ohana Health Plan Medicare	$2.00
Rate for Payer: UnitedHealthcare Medicare	$2.00
Rate for Payer: University Health Alliance Commercial	$1.62

CARBAMAZEPINE 200 MG PO TABLET

Facility

$8.83

Service Code	HCPCS A9270
Hospital Revenue Code	250
Min. Negotiated Rate	$7.51
Max. Negotiated Rate	$8.57
Rate for Payer: Cash Price	$5.74
Rate for Payer: Health Management Network Commercial	$7.51
Rate for Payer: Kaiser Permanente Commercial	$7.95
Rate for Payer: MDX Hawaii PPO	$8.57

CARBAMAZEPINE 200 MG PO TABLET

Facility

$8.83

Service Code	HCPCS A9270
Hospital Revenue Code	637
Min. Negotiated Rate	$4.42
Max. Negotiated Rate	$8.74
Rate for Payer: AlohaCare Medicaid	$4.42
Rate for Payer: AlohaCare Medicare	$7.95
Rate for Payer: Cash Price	$5.74
Rate for Payer: Devoted Health Medicare	$8.74
Rate for Payer: Hawaii Medical Service Association Medicare	$7.95
Rate for Payer: Hawaii Western Management Group Commercial	$8.39
Rate for Payer: Health Management Network Commercial	$7.51
Rate for Payer: Humana Medicare	$7.95
Rate for Payer: Kaiser Permanente Commercial	$7.95
Rate for Payer: Kaiser Permanente Medicaid	$4.50
Rate for Payer: Kaiser Permanente Medicare	$7.95
Rate for Payer: MDX Hawaii PPO	$8.57
Rate for Payer: Ohana Health Plan Medicaid	$7.95
Rate for Payer: Ohana Health Plan Medicare	$7.95
Rate for Payer: UnitedHealthcare Medicare	$7.95
Rate for Payer: University Health Alliance Commercial	$6.44

CARBAMIDE PEROXIDE 6.5 % OTIC DROP

Facility

$46.31

Service Code	HCPCS A9270
Hospital Revenue Code	250
Min. Negotiated Rate	$39.36
Max. Negotiated Rate	$44.92
Rate for Payer: Cash Price	$30.10
Rate for Payer: Health Management Network Commercial	$39.36
Rate for Payer: Kaiser Permanente Commercial	$41.68
Rate for Payer: MDX Hawaii PPO	$44.92

CARBAMIDE PEROXIDE 6.5 % OTIC DROP

Facility

$46.31

Service Code	HCPCS A9270
Hospital Revenue Code	637
Min. Negotiated Rate	$23.16
Max. Negotiated Rate	$45.85
Rate for Payer: AlohaCare Medicaid	$23.16
Rate for Payer: AlohaCare Medicare	$41.68
Rate for Payer: Cash Price	$30.10
Rate for Payer: Devoted Health Medicare	$45.85
Rate for Payer: Hawaii Medical Service Association Medicare	$41.68
Rate for Payer: Hawaii Western Management Group Commercial	$43.99
Rate for Payer: Health Management Network Commercial	$39.36
Rate for Payer: Humana Medicare	$41.68
Rate for Payer: Kaiser Permanente Commercial	$41.68
Rate for Payer: Kaiser Permanente Medicaid	$23.62
Rate for Payer: Kaiser Permanente Medicare	$41.68
Rate for Payer: MDX Hawaii PPO	$44.92
Rate for Payer: Ohana Health Plan Medicaid	$41.68
Rate for Payer: Ohana Health Plan Medicare	$41.68
Rate for Payer: UnitedHealthcare Medicare	$41.68
Rate for Payer: University Health Alliance Commercial	$33.76

Know your out-of-pocket cost for care.

All Charges