Kohala Hospital

All Charges

Charge

Type

Setting

Price

MIDAZOLAM 1 MG/ML NONTITRATING DRIP

Facility

$127.30

Service Code	NDC 44567061001
Hospital Revenue Code	250
Min. Negotiated Rate	$63.65
Max. Negotiated Rate	$126.03
Rate for Payer: AlohaCare Medicaid	$63.65
Rate for Payer: AlohaCare Medicare	$114.57
Rate for Payer: Cash Price	$82.74
Rate for Payer: Devoted Health Medicare	$126.03
Rate for Payer: Hawaii Medical Service Association Medicare	$114.57
Rate for Payer: Hawaii Western Management Group Commercial	$120.94
Rate for Payer: Health Management Network Commercial	$108.20
Rate for Payer: Humana Medicare	$114.57
Rate for Payer: Kaiser Permanente Commercial	$114.57
Rate for Payer: Kaiser Permanente Medicaid	$64.92
Rate for Payer: Kaiser Permanente Medicare	$114.57
Rate for Payer: MDX Hawaii PPO	$123.48
Rate for Payer: Ohana Health Plan Medicaid	$114.57
Rate for Payer: Ohana Health Plan Medicare	$114.57
Rate for Payer: UnitedHealthcare Medicaid	$76.38
Rate for Payer: UnitedHealthcare Medicare	$114.57
Rate for Payer: University Health Alliance Commercial	$92.79

MIDAZOLAM 1 MG/ML NONTITRATING DRIP

Facility

$127.30

Service Code	NDC 44567061010
Hospital Revenue Code	250
Min. Negotiated Rate	$63.65
Max. Negotiated Rate	$126.03
Rate for Payer: AlohaCare Medicaid	$63.65
Rate for Payer: AlohaCare Medicare	$114.57
Rate for Payer: Cash Price	$82.74
Rate for Payer: Devoted Health Medicare	$126.03
Rate for Payer: Hawaii Medical Service Association Medicare	$114.57
Rate for Payer: Hawaii Western Management Group Commercial	$120.94
Rate for Payer: Health Management Network Commercial	$108.20
Rate for Payer: Humana Medicare	$114.57
Rate for Payer: Kaiser Permanente Commercial	$114.57
Rate for Payer: Kaiser Permanente Medicaid	$64.92
Rate for Payer: Kaiser Permanente Medicare	$114.57
Rate for Payer: MDX Hawaii PPO	$123.48
Rate for Payer: Ohana Health Plan Medicaid	$114.57
Rate for Payer: Ohana Health Plan Medicare	$114.57
Rate for Payer: UnitedHealthcare Medicaid	$76.38
Rate for Payer: UnitedHealthcare Medicare	$114.57
Rate for Payer: University Health Alliance Commercial	$92.79

MIDAZOLAM 1 MG/ML NONTITRATING DRIP

Facility

$127.30

Service Code	NDC 44567061001
Hospital Revenue Code	250
Min. Negotiated Rate	$108.20
Max. Negotiated Rate	$123.48
Rate for Payer: Cash Price	$82.74
Rate for Payer: Health Management Network Commercial	$108.20
Rate for Payer: Kaiser Permanente Commercial	$114.57
Rate for Payer: MDX Hawaii PPO	$123.48

MIDAZOLAM 1 MG/ML NONTITRATING DRIP

Facility

$127.30

Service Code	NDC 44567061010
Hospital Revenue Code	250
Min. Negotiated Rate	$108.20
Max. Negotiated Rate	$123.48
Rate for Payer: Cash Price	$82.74
Rate for Payer: Health Management Network Commercial	$108.20
Rate for Payer: Kaiser Permanente Commercial	$114.57
Rate for Payer: MDX Hawaii PPO	$123.48

MIDAZOLAM 2 MG/ML PO SYRUP

Facility

$46.32

Service Code	HCPCS A9270
Hospital Revenue Code	637
Min. Negotiated Rate	$23.16
Max. Negotiated Rate	$45.86
Rate for Payer: AlohaCare Medicaid	$23.16
Rate for Payer: AlohaCare Medicare	$41.69
Rate for Payer: Cash Price	$30.11
Rate for Payer: Devoted Health Medicare	$45.86
Rate for Payer: Hawaii Medical Service Association Medicare	$41.69
Rate for Payer: Hawaii Western Management Group Commercial	$44.00
Rate for Payer: Health Management Network Commercial	$39.37
Rate for Payer: Humana Medicare	$41.69
Rate for Payer: Kaiser Permanente Commercial	$41.69
Rate for Payer: Kaiser Permanente Medicaid	$23.62
Rate for Payer: Kaiser Permanente Medicare	$41.69
Rate for Payer: MDX Hawaii PPO	$44.93
Rate for Payer: Ohana Health Plan Medicaid	$41.69
Rate for Payer: Ohana Health Plan Medicare	$41.69
Rate for Payer: UnitedHealthcare Medicare	$41.69
Rate for Payer: University Health Alliance Commercial	$33.76

MIDAZOLAM 2 MG/ML PO SYRUP

Facility

$46.32

Service Code	HCPCS A9270
Hospital Revenue Code	250
Min. Negotiated Rate	$39.37
Max. Negotiated Rate	$44.93
Rate for Payer: Cash Price	$30.11
Rate for Payer: Health Management Network Commercial	$39.37
Rate for Payer: Kaiser Permanente Commercial	$41.69
Rate for Payer: MDX Hawaii PPO	$44.93

MIDAZOLAM 5 MG/ML INJ SOLN

Facility

$40.70

Service Code	HCPCS J2250
Hospital Revenue Code	250
Min. Negotiated Rate	$34.59
Max. Negotiated Rate	$39.48
Rate for Payer: Cash Price	$26.46
Rate for Payer: Health Management Network Commercial	$34.59
Rate for Payer: Kaiser Permanente Commercial	$36.63
Rate for Payer: MDX Hawaii PPO	$39.48

MIDAZOLAM 5 MG/ML INJ SOLN

Facility

$40.70

Service Code	HCPCS J2250
Hospital Revenue Code	636
Min. Negotiated Rate	$0.16
Max. Negotiated Rate	$40.29
Rate for Payer: AlohaCare Medicaid	$20.35
Rate for Payer: AlohaCare Medicare	$36.63
Rate for Payer: Cash Price	$26.46
Rate for Payer: Cash Price	$26.46
Rate for Payer: Devoted Health Medicare	$40.29
Rate for Payer: Hawaii Medical Service Association ABD	$0.16
Rate for Payer: Hawaii Medical Service Association Medicare	$36.63
Rate for Payer: Hawaii Medical Service Association Non-ABD	$0.16
Rate for Payer: Hawaii Western Management Group Commercial	$38.66
Rate for Payer: Health Management Network Commercial	$34.59
Rate for Payer: Humana Medicare	$36.63
Rate for Payer: Kaiser Permanente Commercial	$36.63
Rate for Payer: Kaiser Permanente Medicaid	$20.76
Rate for Payer: Kaiser Permanente Medicare	$36.63
Rate for Payer: MDX Hawaii PPO	$39.48
Rate for Payer: Ohana Health Plan Medicaid	$36.63
Rate for Payer: Ohana Health Plan Medicare	$36.63
Rate for Payer: UnitedHealthcare Medicaid	$24.42
Rate for Payer: UnitedHealthcare Medicare	$36.63
Rate for Payer: University Health Alliance Commercial	$29.67

MIDAZOLAM 5 MG/ML INTRANASAL FOR PEDIATRIC SEDATION (WHR)

Facility

$40.70

Service Code	NDC 63323041202
Hospital Revenue Code	250
Min. Negotiated Rate	$20.35
Max. Negotiated Rate	$40.29
Rate for Payer: AlohaCare Medicaid	$20.35
Rate for Payer: AlohaCare Medicare	$36.63
Rate for Payer: Cash Price	$26.46
Rate for Payer: Devoted Health Medicare	$40.29
Rate for Payer: Hawaii Medical Service Association Medicare	$36.63
Rate for Payer: Hawaii Western Management Group Commercial	$38.66
Rate for Payer: Health Management Network Commercial	$34.59
Rate for Payer: Humana Medicare	$36.63
Rate for Payer: Kaiser Permanente Commercial	$36.63
Rate for Payer: Kaiser Permanente Medicaid	$20.76
Rate for Payer: Kaiser Permanente Medicare	$36.63
Rate for Payer: MDX Hawaii PPO	$39.48
Rate for Payer: Ohana Health Plan Medicaid	$36.63
Rate for Payer: Ohana Health Plan Medicare	$36.63
Rate for Payer: UnitedHealthcare Medicaid	$24.42
Rate for Payer: UnitedHealthcare Medicare	$36.63
Rate for Payer: University Health Alliance Commercial	$29.67

MIDAZOLAM 5 MG/ML INTRANASAL FOR PEDIATRIC SEDATION (WHR)

Facility

$40.70

Service Code	NDC 63323041203
Hospital Revenue Code	250
Min. Negotiated Rate	$20.35
Max. Negotiated Rate	$40.29
Rate for Payer: AlohaCare Medicaid	$20.35
Rate for Payer: AlohaCare Medicare	$36.63
Rate for Payer: Cash Price	$26.46
Rate for Payer: Devoted Health Medicare	$40.29
Rate for Payer: Hawaii Medical Service Association Medicare	$36.63
Rate for Payer: Hawaii Western Management Group Commercial	$38.66
Rate for Payer: Health Management Network Commercial	$34.59
Rate for Payer: Humana Medicare	$36.63
Rate for Payer: Kaiser Permanente Commercial	$36.63
Rate for Payer: Kaiser Permanente Medicaid	$20.76
Rate for Payer: Kaiser Permanente Medicare	$36.63
Rate for Payer: MDX Hawaii PPO	$39.48
Rate for Payer: Ohana Health Plan Medicaid	$36.63
Rate for Payer: Ohana Health Plan Medicare	$36.63
Rate for Payer: UnitedHealthcare Medicaid	$24.42
Rate for Payer: UnitedHealthcare Medicare	$36.63
Rate for Payer: University Health Alliance Commercial	$29.67

MIDAZOLAM 5 MG/ML INTRANASAL FOR PEDIATRIC SEDATION (WHR)

Facility

$40.70

Service Code	NDC 63323041203
Hospital Revenue Code	250
Min. Negotiated Rate	$34.59
Max. Negotiated Rate	$39.48
Rate for Payer: Cash Price	$26.46
Rate for Payer: Health Management Network Commercial	$34.59
Rate for Payer: Kaiser Permanente Commercial	$36.63
Rate for Payer: MDX Hawaii PPO	$39.48

MIDAZOLAM 5 MG/ML INTRANASAL FOR PEDIATRIC SEDATION (WHR)

Facility

$40.70

Service Code	NDC 63323041202
Hospital Revenue Code	250
Min. Negotiated Rate	$34.59
Max. Negotiated Rate	$39.48
Rate for Payer: Cash Price	$26.46
Rate for Payer: Health Management Network Commercial	$34.59
Rate for Payer: Kaiser Permanente Commercial	$36.63
Rate for Payer: MDX Hawaii PPO	$39.48

MIDAZOLAM (PF) 1 MG/ML INJ SOLN 2 ML VIAL

Facility

$6.52

Service Code	HCPCS J2250
Hospital Revenue Code	250
Min. Negotiated Rate	$5.54
Max. Negotiated Rate	$6.32
Rate for Payer: Cash Price	$4.24
Rate for Payer: Health Management Network Commercial	$5.54
Rate for Payer: Kaiser Permanente Commercial	$5.87
Rate for Payer: MDX Hawaii PPO	$6.32

MIDAZOLAM (PF) 1 MG/ML INJ SOLN 2 ML VIAL

Facility

$6.52

Service Code	HCPCS J2250
Hospital Revenue Code	636
Min. Negotiated Rate	$0.16
Max. Negotiated Rate	$6.45
Rate for Payer: AlohaCare Medicaid	$3.26
Rate for Payer: AlohaCare Medicare	$5.87
Rate for Payer: Cash Price	$4.24
Rate for Payer: Cash Price	$4.24
Rate for Payer: Devoted Health Medicare	$6.45
Rate for Payer: Hawaii Medical Service Association ABD	$0.16
Rate for Payer: Hawaii Medical Service Association Medicare	$5.87
Rate for Payer: Hawaii Medical Service Association Non-ABD	$0.16
Rate for Payer: Hawaii Western Management Group Commercial	$6.19
Rate for Payer: Health Management Network Commercial	$5.54
Rate for Payer: Humana Medicare	$5.87
Rate for Payer: Kaiser Permanente Commercial	$5.87
Rate for Payer: Kaiser Permanente Medicaid	$3.33
Rate for Payer: Kaiser Permanente Medicare	$5.87
Rate for Payer: MDX Hawaii PPO	$6.32
Rate for Payer: Ohana Health Plan Medicaid	$5.87
Rate for Payer: Ohana Health Plan Medicare	$5.87
Rate for Payer: UnitedHealthcare Medicaid	$3.91
Rate for Payer: UnitedHealthcare Medicare	$5.87
Rate for Payer: University Health Alliance Commercial	$4.75

MIDAZOLAM (PF) 5 MG/ML INJ SOLN

Facility

$7.49

Service Code	HCPCS J2250
Hospital Revenue Code	250
Min. Negotiated Rate	$6.37
Max. Negotiated Rate	$7.27
Rate for Payer: Cash Price	$4.87
Rate for Payer: Health Management Network Commercial	$6.37
Rate for Payer: Kaiser Permanente Commercial	$6.74
Rate for Payer: MDX Hawaii PPO	$7.27

MIDAZOLAM (PF) 5 MG/ML INJ SOLN

Facility

$7.49

Service Code	HCPCS J2250
Hospital Revenue Code	636
Min. Negotiated Rate	$0.16
Max. Negotiated Rate	$7.42
Rate for Payer: AlohaCare Medicaid	$3.75
Rate for Payer: AlohaCare Medicare	$6.74
Rate for Payer: Cash Price	$4.87
Rate for Payer: Cash Price	$4.87
Rate for Payer: Devoted Health Medicare	$7.42
Rate for Payer: Hawaii Medical Service Association ABD	$0.16
Rate for Payer: Hawaii Medical Service Association Medicare	$6.74
Rate for Payer: Hawaii Medical Service Association Non-ABD	$0.16
Rate for Payer: Hawaii Western Management Group Commercial	$7.12
Rate for Payer: Health Management Network Commercial	$6.37
Rate for Payer: Humana Medicare	$6.74
Rate for Payer: Kaiser Permanente Commercial	$6.74
Rate for Payer: Kaiser Permanente Medicaid	$3.82
Rate for Payer: Kaiser Permanente Medicare	$6.74
Rate for Payer: MDX Hawaii PPO	$7.27
Rate for Payer: Ohana Health Plan Medicaid	$6.74
Rate for Payer: Ohana Health Plan Medicare	$6.74
Rate for Payer: UnitedHealthcare Medicaid	$4.49
Rate for Payer: UnitedHealthcare Medicare	$6.74
Rate for Payer: University Health Alliance Commercial	$5.46

MIDAZOLAM (PF) 5 MG/ML INTRANASAL FOR PEDIATRIC SEDATION (WHR)

Facility

$7.49

Service Code	NDC 00409230822
Hospital Revenue Code	250
Min. Negotiated Rate	$3.75
Max. Negotiated Rate	$7.42
Rate for Payer: AlohaCare Medicaid	$3.75
Rate for Payer: AlohaCare Medicare	$6.74
Rate for Payer: Cash Price	$4.87
Rate for Payer: Devoted Health Medicare	$7.42
Rate for Payer: Hawaii Medical Service Association Medicare	$6.74
Rate for Payer: Hawaii Western Management Group Commercial	$7.12
Rate for Payer: Health Management Network Commercial	$6.37
Rate for Payer: Humana Medicare	$6.74
Rate for Payer: Kaiser Permanente Commercial	$6.74
Rate for Payer: Kaiser Permanente Medicaid	$3.82
Rate for Payer: Kaiser Permanente Medicare	$6.74
Rate for Payer: MDX Hawaii PPO	$7.27
Rate for Payer: Ohana Health Plan Medicaid	$6.74
Rate for Payer: Ohana Health Plan Medicare	$6.74
Rate for Payer: UnitedHealthcare Medicaid	$4.49
Rate for Payer: UnitedHealthcare Medicare	$6.74
Rate for Payer: University Health Alliance Commercial	$5.46

MIDAZOLAM (PF) 5 MG/ML INTRANASAL FOR PEDIATRIC SEDATION (WHR)

Facility

$7.49

Service Code	NDC 00409230802
Hospital Revenue Code	250
Min. Negotiated Rate	$3.75
Max. Negotiated Rate	$7.42
Rate for Payer: AlohaCare Medicaid	$3.75
Rate for Payer: AlohaCare Medicare	$6.74
Rate for Payer: Cash Price	$4.87
Rate for Payer: Devoted Health Medicare	$7.42
Rate for Payer: Hawaii Medical Service Association Medicare	$6.74
Rate for Payer: Hawaii Western Management Group Commercial	$7.12
Rate for Payer: Health Management Network Commercial	$6.37
Rate for Payer: Humana Medicare	$6.74
Rate for Payer: Kaiser Permanente Commercial	$6.74
Rate for Payer: Kaiser Permanente Medicaid	$3.82
Rate for Payer: Kaiser Permanente Medicare	$6.74
Rate for Payer: MDX Hawaii PPO	$7.27
Rate for Payer: Ohana Health Plan Medicaid	$6.74
Rate for Payer: Ohana Health Plan Medicare	$6.74
Rate for Payer: UnitedHealthcare Medicaid	$4.49
Rate for Payer: UnitedHealthcare Medicare	$6.74
Rate for Payer: University Health Alliance Commercial	$5.46

MIDAZOLAM (PF) 5 MG/ML INTRANASAL FOR PEDIATRIC SEDATION (WHR)

Facility

$7.49

Service Code	NDC 00409230802
Hospital Revenue Code	250
Min. Negotiated Rate	$6.37
Max. Negotiated Rate	$7.27
Rate for Payer: Cash Price	$4.87
Rate for Payer: Health Management Network Commercial	$6.37
Rate for Payer: Kaiser Permanente Commercial	$6.74
Rate for Payer: MDX Hawaii PPO	$7.27

MIDAZOLAM (PF) 5 MG/ML INTRANASAL FOR PEDIATRIC SEDATION (WHR)

Facility

$7.49

Service Code	NDC 00409230822
Hospital Revenue Code	250
Min. Negotiated Rate	$6.37
Max. Negotiated Rate	$7.27
Rate for Payer: Cash Price	$4.87
Rate for Payer: Health Management Network Commercial	$6.37
Rate for Payer: Kaiser Permanente Commercial	$6.74
Rate for Payer: MDX Hawaii PPO	$7.27

MIDAZOLAM (PF) IN 0.9 % NACL 1 MG/ML IV SOLN

Facility

$127.30

Service Code	HCPCS J2251
Hospital Revenue Code	250
Min. Negotiated Rate	$108.20
Max. Negotiated Rate	$123.48
Rate for Payer: Cash Price	$82.74
Rate for Payer: Health Management Network Commercial	$108.20
Rate for Payer: Kaiser Permanente Commercial	$114.57
Rate for Payer: MDX Hawaii PPO	$123.48

MIDAZOLAM (PF) IN 0.9 % NACL 1 MG/ML IV SOLN

Facility

$127.30

Service Code	HCPCS J2251
Hospital Revenue Code	636
Min. Negotiated Rate	$0.17
Max. Negotiated Rate	$126.03
Rate for Payer: AlohaCare Medicaid	$63.65
Rate for Payer: AlohaCare Medicare	$114.57
Rate for Payer: Cash Price	$82.74
Rate for Payer: Cash Price	$82.74
Rate for Payer: Devoted Health Medicare	$126.03
Rate for Payer: Hawaii Medical Service Association ABD	$0.17
Rate for Payer: Hawaii Medical Service Association Medicare	$114.57
Rate for Payer: Hawaii Medical Service Association Non-ABD	$0.17
Rate for Payer: Hawaii Western Management Group Commercial	$120.94
Rate for Payer: Health Management Network Commercial	$108.20
Rate for Payer: Humana Medicare	$114.57
Rate for Payer: Kaiser Permanente Commercial	$114.57
Rate for Payer: Kaiser Permanente Medicaid	$64.92
Rate for Payer: Kaiser Permanente Medicare	$114.57
Rate for Payer: MDX Hawaii PPO	$123.48
Rate for Payer: Ohana Health Plan Medicaid	$114.57
Rate for Payer: Ohana Health Plan Medicare	$114.57
Rate for Payer: UnitedHealthcare Medicaid	$76.38
Rate for Payer: UnitedHealthcare Medicare	$114.57
Rate for Payer: University Health Alliance Commercial	$92.79

MIDODRINE 5 MG PO TABLET

Facility

$4.97

Service Code	HCPCS A9270
Hospital Revenue Code	250
Min. Negotiated Rate	$4.22
Max. Negotiated Rate	$4.82
Rate for Payer: Cash Price	$3.23
Rate for Payer: Health Management Network Commercial	$4.22
Rate for Payer: Kaiser Permanente Commercial	$4.47
Rate for Payer: MDX Hawaii PPO	$4.82

MIDODRINE 5 MG PO TABLET

Facility

$4.97

Service Code	HCPCS A9270
Hospital Revenue Code	637
Min. Negotiated Rate	$2.48
Max. Negotiated Rate	$4.92
Rate for Payer: AlohaCare Medicaid	$2.48
Rate for Payer: AlohaCare Medicare	$4.47
Rate for Payer: Cash Price	$3.23
Rate for Payer: Devoted Health Medicare	$4.92
Rate for Payer: Hawaii Medical Service Association Medicare	$4.47
Rate for Payer: Hawaii Western Management Group Commercial	$4.72
Rate for Payer: Health Management Network Commercial	$4.22
Rate for Payer: Humana Medicare	$4.47
Rate for Payer: Kaiser Permanente Commercial	$4.47
Rate for Payer: Kaiser Permanente Medicaid	$2.53
Rate for Payer: Kaiser Permanente Medicare	$4.47
Rate for Payer: MDX Hawaii PPO	$4.82
Rate for Payer: Ohana Health Plan Medicaid	$4.47
Rate for Payer: Ohana Health Plan Medicare	$4.47
Rate for Payer: UnitedHealthcare Medicare	$4.47
Rate for Payer: University Health Alliance Commercial	$3.62

MINERAL OIL, LIGHT STERILE MISC OIL

Facility

$112.31

Service Code	HCPCS A9270
Hospital Revenue Code	637
Min. Negotiated Rate	$56.16
Max. Negotiated Rate	$111.19
Rate for Payer: AlohaCare Medicaid	$56.16
Rate for Payer: AlohaCare Medicare	$101.08
Rate for Payer: Cash Price	$73.00
Rate for Payer: Devoted Health Medicare	$111.19
Rate for Payer: Hawaii Medical Service Association Medicare	$101.08
Rate for Payer: Hawaii Western Management Group Commercial	$106.69
Rate for Payer: Health Management Network Commercial	$95.46
Rate for Payer: Humana Medicare	$101.08
Rate for Payer: Kaiser Permanente Commercial	$101.08
Rate for Payer: Kaiser Permanente Medicaid	$57.28
Rate for Payer: Kaiser Permanente Medicare	$101.08
Rate for Payer: MDX Hawaii PPO	$108.94
Rate for Payer: Ohana Health Plan Medicaid	$101.08
Rate for Payer: Ohana Health Plan Medicare	$101.08
Rate for Payer: UnitedHealthcare Medicare	$101.08
Rate for Payer: University Health Alliance Commercial	$81.86

Know your out-of-pocket cost for care.

All Charges