Kohala Hospital

All Charges

Charge

Type

Setting

Price

MORPHINE CONCENTRATE 20 (20 MG/ML) PO SOLN

Facility

$2.07

Service Code	HCPCS A9270
Hospital Revenue Code	250
Min. Negotiated Rate	$1.76
Max. Negotiated Rate	$2.01
Rate for Payer: Cash Price	$1.35
Rate for Payer: Health Management Network Commercial	$1.76
Rate for Payer: Kaiser Permanente Commercial	$1.86
Rate for Payer: MDX Hawaii PPO	$2.01

MORPHINE (PF) IN 0.9 % SOD CHL 50 MG/50 ML (1 MG/ML) IV PCA SYR

Facility

$57.48

Service Code	HCPCS J7999
Hospital Revenue Code	636
Min. Negotiated Rate	$28.74
Max. Negotiated Rate	$56.91
Rate for Payer: AlohaCare Medicaid	$28.74
Rate for Payer: AlohaCare Medicare	$51.73
Rate for Payer: Cash Price	$37.36
Rate for Payer: Devoted Health Medicare	$56.91
Rate for Payer: Hawaii Medical Service Association Medicare	$51.73
Rate for Payer: Hawaii Western Management Group Commercial	$54.61
Rate for Payer: Health Management Network Commercial	$48.86
Rate for Payer: Humana Medicare	$51.73
Rate for Payer: Kaiser Permanente Commercial	$51.73
Rate for Payer: Kaiser Permanente Medicaid	$29.31
Rate for Payer: Kaiser Permanente Medicare	$51.73
Rate for Payer: MDX Hawaii PPO	$55.76
Rate for Payer: Ohana Health Plan Medicaid	$51.73
Rate for Payer: Ohana Health Plan Medicare	$51.73
Rate for Payer: UnitedHealthcare Medicaid	$34.49
Rate for Payer: UnitedHealthcare Medicare	$51.73
Rate for Payer: University Health Alliance Commercial	$41.90

MORPHINE (PF) IN 0.9 % SOD CHL 50 MG/50 ML (1 MG/ML) IV PCA SYR

Facility

$57.48

Service Code	HCPCS J7999
Hospital Revenue Code	250
Min. Negotiated Rate	$48.86
Max. Negotiated Rate	$55.76
Rate for Payer: Cash Price	$37.36
Rate for Payer: Health Management Network Commercial	$48.86
Rate for Payer: Kaiser Permanente Commercial	$51.73
Rate for Payer: MDX Hawaii PPO	$55.76

MOUTH PROCEDURES WITH CC/MCC

Facility

$59,776.44

Service Code	MSDRG 137
Min. Negotiated Rate	$59,776.44
Max. Negotiated Rate	$59,776.44
Rate for Payer: Hawaii Medical Service Association Commercial	$59,776.44

MOUTH PROCEDURES WITHOUT CC/MCC

Facility

$31,760.68

Service Code	MSDRG 138
Min. Negotiated Rate	$31,760.68
Max. Negotiated Rate	$31,760.68
Rate for Payer: Hawaii Medical Service Association Commercial	$31,760.68

MOXIFLOXACIN 0.5 % OPHT DROP

Facility

$587.36

Service Code	NDC 62332050503
Hospital Revenue Code	250
Min. Negotiated Rate	$499.26
Max. Negotiated Rate	$569.74
Rate for Payer: Cash Price	$381.78
Rate for Payer: Health Management Network Commercial	$499.26
Rate for Payer: Kaiser Permanente Commercial	$528.62
Rate for Payer: MDX Hawaii PPO	$569.74

MOXIFLOXACIN 0.5 % OPHT DROP

Facility

$587.42

Service Code	NDC 60505058204
Hospital Revenue Code	250
Min. Negotiated Rate	$499.31
Max. Negotiated Rate	$569.80
Rate for Payer: Cash Price	$381.82
Rate for Payer: Health Management Network Commercial	$499.31
Rate for Payer: Kaiser Permanente Commercial	$528.68
Rate for Payer: MDX Hawaii PPO	$569.80

MOXIFLOXACIN 0.5 % OPHT DROP

Facility

$587.42

Service Code	NDC 60505058204
Hospital Revenue Code	250
Min. Negotiated Rate	$293.71
Max. Negotiated Rate	$581.55
Rate for Payer: AlohaCare Medicaid	$293.71
Rate for Payer: AlohaCare Medicare	$528.68
Rate for Payer: Cash Price	$381.82
Rate for Payer: Devoted Health Medicare	$581.55
Rate for Payer: Hawaii Medical Service Association Medicare	$528.68
Rate for Payer: Hawaii Western Management Group Commercial	$558.05
Rate for Payer: Health Management Network Commercial	$499.31
Rate for Payer: Humana Medicare	$528.68
Rate for Payer: Kaiser Permanente Commercial	$528.68
Rate for Payer: Kaiser Permanente Medicaid	$299.58
Rate for Payer: Kaiser Permanente Medicare	$528.68
Rate for Payer: MDX Hawaii PPO	$569.80
Rate for Payer: Ohana Health Plan Medicaid	$528.68
Rate for Payer: Ohana Health Plan Medicare	$528.68
Rate for Payer: UnitedHealthcare Medicaid	$352.45
Rate for Payer: UnitedHealthcare Medicare	$528.68
Rate for Payer: University Health Alliance Commercial	$428.17

MOXIFLOXACIN 0.5 % OPHT DROP

Facility

$587.36

Service Code	NDC 62332050503
Hospital Revenue Code	250
Min. Negotiated Rate	$293.68
Max. Negotiated Rate	$581.49
Rate for Payer: AlohaCare Medicaid	$293.68
Rate for Payer: AlohaCare Medicare	$528.62
Rate for Payer: Cash Price	$381.78
Rate for Payer: Devoted Health Medicare	$581.49
Rate for Payer: Hawaii Medical Service Association Medicare	$528.62
Rate for Payer: Hawaii Western Management Group Commercial	$557.99
Rate for Payer: Health Management Network Commercial	$499.26
Rate for Payer: Humana Medicare	$528.62
Rate for Payer: Kaiser Permanente Commercial	$528.62
Rate for Payer: Kaiser Permanente Medicaid	$299.55
Rate for Payer: Kaiser Permanente Medicare	$528.62
Rate for Payer: MDX Hawaii PPO	$569.74
Rate for Payer: Ohana Health Plan Medicaid	$528.62
Rate for Payer: Ohana Health Plan Medicare	$528.62
Rate for Payer: UnitedHealthcare Medicaid	$352.42
Rate for Payer: UnitedHealthcare Medicare	$528.62
Rate for Payer: University Health Alliance Commercial	$428.13

MULTIPLE LEVEL COMBINED ANTERIOR AND POSTERIOR SPINAL FUSION EXCEPT CERVICAL WITH CC

Facility

$115,594.65

Service Code	MSDRG 427
Min. Negotiated Rate	$115,594.65
Max. Negotiated Rate	$115,594.65
Rate for Payer: Hawaii Medical Service Association Commercial	$115,594.65

MULTIPLE LEVEL COMBINED ANTERIOR AND POSTERIOR SPINAL FUSION EXCEPT CERVICAL WITH MCC OR CUSTOM-MADE ANATOMICALLY DESIGNED INTERBODY FUSION DEVICE

Facility

$115,594.65

Service Code	MSDRG 426
Min. Negotiated Rate	$115,594.65
Max. Negotiated Rate	$115,594.65
Rate for Payer: Hawaii Medical Service Association Commercial	$115,594.65

MULTIPLE LEVEL COMBINED ANTERIOR AND POSTERIOR SPINAL FUSION EXCEPT CERVICAL WITHOUT CC/MCC

Facility

$115,594.65

Service Code	MSDRG 428
Min. Negotiated Rate	$115,594.65
Max. Negotiated Rate	$115,594.65
Rate for Payer: Hawaii Medical Service Association Commercial	$115,594.65

MULTIPLE LEVEL SPINAL FUSION EXCEPT CERVICAL WITH MCC OR CUSTOM-MADE ANATOMICALLY DESIGNED INTERBODY FUSION DEVICE

Facility

$84,260.61

Service Code	MSDRG 447
Min. Negotiated Rate	$84,260.61
Max. Negotiated Rate	$84,260.61
Rate for Payer: Hawaii Medical Service Association Commercial	$84,260.61

MULTIPLE LEVEL SPINAL FUSION EXCEPT CERVICAL WITHOUT MCC

Facility

$79,283.19

Service Code	MSDRG 448
Min. Negotiated Rate	$79,283.19
Max. Negotiated Rate	$79,283.19
Rate for Payer: Hawaii Medical Service Association Commercial	$79,283.19

MULTIPLE SCLEROSIS AND CEREBELLAR ATAXIA WITH CC

Facility

$20,170.40

Service Code	MSDRG 059
Min. Negotiated Rate	$20,170.40
Max. Negotiated Rate	$20,170.40
Rate for Payer: Hawaii Medical Service Association Commercial	$20,170.40

MULTIPLE SCLEROSIS AND CEREBELLAR ATAXIA WITH MCC

Facility

$20,170.40

Service Code	MSDRG 058
Min. Negotiated Rate	$20,170.40
Max. Negotiated Rate	$20,170.40
Rate for Payer: Hawaii Medical Service Association Commercial	$20,170.40

MULTIPLE SCLEROSIS AND CEREBELLAR ATAXIA WITHOUT CC/MCC

Facility

$20,170.40

Service Code	MSDRG 060
Min. Negotiated Rate	$20,170.40
Max. Negotiated Rate	$20,170.40
Rate for Payer: Hawaii Medical Service Association Commercial	$20,170.40

MULTIVITAMIN WITH FOLIC ACID 400 MCG 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

MULTIVITAMIN WITH FOLIC ACID 400 MCG 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

MULTIVIT-IRON-FA-CALCIUM-MINS 9 MG IRON-400 MCG PO TABLET

Facility

$1.43

Service Code	HCPCS A9270
Hospital Revenue Code	637
Min. Negotiated Rate	$0.72
Max. Negotiated Rate	$1.42
Rate for Payer: AlohaCare Medicaid	$0.72
Rate for Payer: AlohaCare Medicare	$1.29
Rate for Payer: Cash Price	$0.93
Rate for Payer: Devoted Health Medicare	$1.42
Rate for Payer: Hawaii Medical Service Association Medicare	$1.29
Rate for Payer: Hawaii Western Management Group Commercial	$1.36
Rate for Payer: Health Management Network Commercial	$1.22
Rate for Payer: Humana Medicare	$1.29
Rate for Payer: Kaiser Permanente Commercial	$1.29
Rate for Payer: Kaiser Permanente Medicaid	$0.73
Rate for Payer: Kaiser Permanente Medicare	$1.29
Rate for Payer: MDX Hawaii PPO	$1.39
Rate for Payer: Ohana Health Plan Medicaid	$1.29
Rate for Payer: Ohana Health Plan Medicare	$1.29
Rate for Payer: UnitedHealthcare Medicare	$1.29
Rate for Payer: University Health Alliance Commercial	$1.04

MULTIVIT-IRON-FA-CALCIUM-MINS 9 MG IRON-400 MCG PO TABLET

Facility

$1.43

Service Code	HCPCS A9270
Hospital Revenue Code	250
Min. Negotiated Rate	$1.22
Max. Negotiated Rate	$1.39
Rate for Payer: Cash Price	$0.93
Rate for Payer: Health Management Network Commercial	$1.22
Rate for Payer: Kaiser Permanente Commercial	$1.29
Rate for Payer: MDX Hawaii PPO	$1.39

MUPIROCIN 2 % TOP OINT

Facility

$194.97

Service Code	HCPCS A9270
Hospital Revenue Code	250
Min. Negotiated Rate	$165.72
Max. Negotiated Rate	$189.12
Rate for Payer: Cash Price	$126.73
Rate for Payer: Cash Price	$41.96
Rate for Payer: Health Management Network Commercial	$165.72
Rate for Payer: Health Management Network Commercial	$54.87
Rate for Payer: Kaiser Permanente Commercial	$175.47
Rate for Payer: Kaiser Permanente Commercial	$58.09
Rate for Payer: MDX Hawaii PPO	$62.61
Rate for Payer: MDX Hawaii PPO	$189.12

MUPIROCIN 2 % TOP OINT

Facility

$64.55

Service Code	HCPCS A9270
Hospital Revenue Code	637
Min. Negotiated Rate	$32.27
Max. Negotiated Rate	$63.90
Rate for Payer: AlohaCare Medicaid	$32.27
Rate for Payer: AlohaCare Medicaid	$97.48
Rate for Payer: AlohaCare Medicare	$175.47
Rate for Payer: AlohaCare Medicare	$58.09
Rate for Payer: Cash Price	$126.73
Rate for Payer: Cash Price	$41.96
Rate for Payer: Devoted Health Medicare	$193.02
Rate for Payer: Devoted Health Medicare	$63.90
Rate for Payer: Hawaii Medical Service Association Medicare	$175.47
Rate for Payer: Hawaii Medical Service Association Medicare	$58.09
Rate for Payer: Hawaii Western Management Group Commercial	$61.32
Rate for Payer: Hawaii Western Management Group Commercial	$185.22
Rate for Payer: Health Management Network Commercial	$165.72
Rate for Payer: Health Management Network Commercial	$54.87
Rate for Payer: Humana Medicare	$58.09
Rate for Payer: Humana Medicare	$175.47
Rate for Payer: Kaiser Permanente Commercial	$58.09
Rate for Payer: Kaiser Permanente Commercial	$175.47
Rate for Payer: Kaiser Permanente Medicaid	$99.43
Rate for Payer: Kaiser Permanente Medicaid	$32.92
Rate for Payer: Kaiser Permanente Medicare	$58.09
Rate for Payer: Kaiser Permanente Medicare	$175.47
Rate for Payer: MDX Hawaii PPO	$62.61
Rate for Payer: MDX Hawaii PPO	$189.12
Rate for Payer: Ohana Health Plan Medicaid	$58.09
Rate for Payer: Ohana Health Plan Medicaid	$175.47
Rate for Payer: Ohana Health Plan Medicare	$58.09
Rate for Payer: Ohana Health Plan Medicare	$175.47
Rate for Payer: UnitedHealthcare Medicare	$175.47
Rate for Payer: UnitedHealthcare Medicare	$58.09
Rate for Payer: University Health Alliance Commercial	$142.11
Rate for Payer: University Health Alliance Commercial	$47.05

MVI, ADULT NO.4 WITH VIT K 3,300 UNIT- 150 MCG/10 ML IV SOLN

Facility

$81.68

Service Code	NDC 54643564901
Hospital Revenue Code	250
Min. Negotiated Rate	$40.84
Max. Negotiated Rate	$80.86
Rate for Payer: AlohaCare Medicaid	$40.84
Rate for Payer: AlohaCare Medicare	$73.51
Rate for Payer: Cash Price	$53.09
Rate for Payer: Devoted Health Medicare	$80.86
Rate for Payer: Hawaii Medical Service Association Medicare	$73.51
Rate for Payer: Hawaii Western Management Group Commercial	$77.60
Rate for Payer: Health Management Network Commercial	$69.43
Rate for Payer: Humana Medicare	$73.51
Rate for Payer: Kaiser Permanente Commercial	$73.51
Rate for Payer: Kaiser Permanente Medicaid	$41.66
Rate for Payer: Kaiser Permanente Medicare	$73.51
Rate for Payer: MDX Hawaii PPO	$79.23
Rate for Payer: Ohana Health Plan Medicaid	$73.51
Rate for Payer: Ohana Health Plan Medicare	$73.51
Rate for Payer: UnitedHealthcare Medicaid	$49.01
Rate for Payer: UnitedHealthcare Medicare	$73.51
Rate for Payer: University Health Alliance Commercial	$59.54

MVI, ADULT NO.4 WITH VIT K 3,300 UNIT- 150 MCG/10 ML IV SOLN

Facility

$81.68

Service Code	NDC 54643564901
Hospital Revenue Code	250
Min. Negotiated Rate	$69.43
Max. Negotiated Rate	$79.23
Rate for Payer: Cash Price	$53.09
Rate for Payer: Health Management Network Commercial	$69.43
Rate for Payer: Kaiser Permanente Commercial	$73.51
Rate for Payer: MDX Hawaii PPO	$79.23

Know your out-of-pocket cost for care.

All Charges