Kohala Hospital

All Charges

Charge

Type

Setting

Price

MYCOPHENOLATE MOFETIL 500 MG PO TABLET

Facility

$8.63

Service Code	HCPCS J7517
Hospital Revenue Code	250
Min. Negotiated Rate	$7.34
Max. Negotiated Rate	$8.37
Rate for Payer: Cash Price	$5.61
Rate for Payer: Health Management Network Commercial	$7.34
Rate for Payer: Kaiser Permanente Commercial	$7.77
Rate for Payer: MDX Hawaii PPO	$8.37

MYCOPHENOLATE MOFETIL 500 MG PO TABLET

Facility

$8.63

Service Code	HCPCS J7517
Hospital Revenue Code	636
Min. Negotiated Rate	$0.16
Max. Negotiated Rate	$8.54
Rate for Payer: AlohaCare Medicaid	$4.32
Rate for Payer: AlohaCare Medicare	$7.77
Rate for Payer: Cash Price	$5.61
Rate for Payer: Cash Price	$5.61
Rate for Payer: Devoted Health Medicare	$8.54
Rate for Payer: Hawaii Medical Service Association ABD	$0.16
Rate for Payer: Hawaii Medical Service Association Medicare	$7.77
Rate for Payer: Hawaii Medical Service Association Non-ABD	$0.16
Rate for Payer: Hawaii Western Management Group Commercial	$8.20
Rate for Payer: Health Management Network Commercial	$7.34
Rate for Payer: Humana Medicare	$7.77
Rate for Payer: Kaiser Permanente Commercial	$7.77
Rate for Payer: Kaiser Permanente Medicaid	$4.40
Rate for Payer: Kaiser Permanente Medicare	$7.77
Rate for Payer: MDX Hawaii PPO	$8.37
Rate for Payer: Ohana Health Plan Medicaid	$7.77
Rate for Payer: Ohana Health Plan Medicare	$7.77
Rate for Payer: UnitedHealthcare Medicaid	$5.18
Rate for Payer: UnitedHealthcare Medicare	$7.77
Rate for Payer: University Health Alliance Commercial	$6.29

MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH MAJOR O.R. PROCEDURES WITH CC

Facility

$73,452.50

Service Code	MSDRG 827
Min. Negotiated Rate	$73,452.50
Max. Negotiated Rate	$73,452.50
Rate for Payer: Hawaii Medical Service Association Commercial	$73,452.50

MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH MAJOR O.R. PROCEDURES WITH MCC

Facility

$73,452.50

Service Code	MSDRG 826
Min. Negotiated Rate	$73,452.50
Max. Negotiated Rate	$73,452.50
Rate for Payer: Hawaii Medical Service Association Commercial	$73,452.50

MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH MAJOR O.R. PROCEDURES WITHOUT CC/MCC

Facility

$37,069.93

Service Code	MSDRG 828
Min. Negotiated Rate	$37,069.93
Max. Negotiated Rate	$37,069.93
Rate for Payer: Hawaii Medical Service Association Commercial	$37,069.93

MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH OTHER PROCEDURES WITH CC/MCC

Facility

$46,811.45

Service Code	MSDRG 829
Min. Negotiated Rate	$46,811.45
Max. Negotiated Rate	$46,811.45
Rate for Payer: Hawaii Medical Service Association Commercial	$46,811.45

MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH OTHER PROCEDURES WITHOUT CC/MCC

Facility

$46,811.45

Service Code	MSDRG 830
Min. Negotiated Rate	$46,811.45
Max. Negotiated Rate	$46,811.45
Rate for Payer: Hawaii Medical Service Association Commercial	$46,811.45

NAFCILLIN 2 GRAM INJ RECON.SOLN.

Facility

$80.10

Service Code	HCPCS J2290
Hospital Revenue Code	636
Min. Negotiated Rate	$0.06
Max. Negotiated Rate	$79.30
Rate for Payer: AlohaCare Medicaid	$40.05
Rate for Payer: AlohaCare Medicaid	$68.81
Rate for Payer: AlohaCare Medicare	$123.85
Rate for Payer: AlohaCare Medicare	$72.09
Rate for Payer: Cash Price	$89.45
Rate for Payer: Cash Price	$52.06
Rate for Payer: Cash Price	$89.45
Rate for Payer: Cash Price	$52.06
Rate for Payer: Devoted Health Medicare	$136.23
Rate for Payer: Devoted Health Medicare	$79.30
Rate for Payer: Hawaii Medical Service Association ABD	$0.06
Rate for Payer: Hawaii Medical Service Association ABD	$0.06
Rate for Payer: Hawaii Medical Service Association Medicare	$123.85
Rate for Payer: Hawaii Medical Service Association Medicare	$72.09
Rate for Payer: Hawaii Medical Service Association Non-ABD	$0.06
Rate for Payer: Hawaii Medical Service Association Non-ABD	$0.06
Rate for Payer: Hawaii Western Management Group Commercial	$130.73
Rate for Payer: Hawaii Western Management Group Commercial	$76.09
Rate for Payer: Health Management Network Commercial	$68.08
Rate for Payer: Health Management Network Commercial	$116.97
Rate for Payer: Humana Medicare	$123.85
Rate for Payer: Humana Medicare	$72.09
Rate for Payer: Kaiser Permanente Commercial	$72.09
Rate for Payer: Kaiser Permanente Commercial	$123.85
Rate for Payer: Kaiser Permanente Medicaid	$40.85
Rate for Payer: Kaiser Permanente Medicaid	$70.18
Rate for Payer: Kaiser Permanente Medicare	$72.09
Rate for Payer: Kaiser Permanente Medicare	$123.85
Rate for Payer: MDX Hawaii PPO	$77.70
Rate for Payer: MDX Hawaii PPO	$133.48
Rate for Payer: Ohana Health Plan Medicaid	$72.09
Rate for Payer: Ohana Health Plan Medicaid	$123.85
Rate for Payer: Ohana Health Plan Medicare	$72.09
Rate for Payer: Ohana Health Plan Medicare	$123.85
Rate for Payer: UnitedHealthcare Medicaid	$48.06
Rate for Payer: UnitedHealthcare Medicaid	$82.57
Rate for Payer: UnitedHealthcare Medicare	$123.85
Rate for Payer: UnitedHealthcare Medicare	$72.09
Rate for Payer: University Health Alliance Commercial	$58.38
Rate for Payer: University Health Alliance Commercial	$100.30

NAFCILLIN 2 GRAM INJ RECON.SOLN.

Facility

$137.61

Service Code	HCPCS J2290
Hospital Revenue Code	250
Min. Negotiated Rate	$116.97
Max. Negotiated Rate	$133.48
Rate for Payer: Cash Price	$89.45
Rate for Payer: Cash Price	$52.06
Rate for Payer: Health Management Network Commercial	$68.08
Rate for Payer: Health Management Network Commercial	$116.97
Rate for Payer: Kaiser Permanente Commercial	$123.85
Rate for Payer: Kaiser Permanente Commercial	$72.09
Rate for Payer: MDX Hawaii PPO	$133.48
Rate for Payer: MDX Hawaii PPO	$77.70

NALOXONE 0.4 MG/ML INJ SOLN 1 ML VIAL

Facility

$38.62

Service Code	HCPCS J2312
Hospital Revenue Code	250
Min. Negotiated Rate	$32.83
Max. Negotiated Rate	$37.46
Rate for Payer: Cash Price	$25.10
Rate for Payer: Health Management Network Commercial	$32.83
Rate for Payer: Kaiser Permanente Commercial	$34.76
Rate for Payer: MDX Hawaii PPO	$37.46

NALOXONE 0.4 MG/ML INJ SOLN 1 ML VIAL

Facility

$38.62

Service Code	HCPCS J2312
Hospital Revenue Code	636
Min. Negotiated Rate	$0.07
Max. Negotiated Rate	$38.23
Rate for Payer: AlohaCare Medicaid	$19.31
Rate for Payer: AlohaCare Medicare	$34.76
Rate for Payer: Cash Price	$25.10
Rate for Payer: Cash Price	$25.10
Rate for Payer: Devoted Health Medicare	$38.23
Rate for Payer: Hawaii Medical Service Association ABD	$0.07
Rate for Payer: Hawaii Medical Service Association Medicare	$34.76
Rate for Payer: Hawaii Medical Service Association Non-ABD	$0.07
Rate for Payer: Hawaii Western Management Group Commercial	$36.69
Rate for Payer: Health Management Network Commercial	$32.83
Rate for Payer: Humana Medicare	$34.76
Rate for Payer: Kaiser Permanente Commercial	$34.76
Rate for Payer: Kaiser Permanente Medicaid	$19.70
Rate for Payer: Kaiser Permanente Medicare	$34.76
Rate for Payer: MDX Hawaii PPO	$37.46
Rate for Payer: Ohana Health Plan Medicaid	$34.76
Rate for Payer: Ohana Health Plan Medicare	$34.76
Rate for Payer: UnitedHealthcare Medicaid	$23.17
Rate for Payer: UnitedHealthcare Medicare	$34.76
Rate for Payer: University Health Alliance Commercial	$28.15

NALOXONE 1 MG/ML INJ SYR

Facility

$154.62

Service Code	HCPCS J2312
Hospital Revenue Code	250
Min. Negotiated Rate	$131.43
Max. Negotiated Rate	$149.98
Rate for Payer: Cash Price	$100.50
Rate for Payer: Health Management Network Commercial	$131.43
Rate for Payer: Kaiser Permanente Commercial	$139.16
Rate for Payer: MDX Hawaii PPO	$149.98

NALOXONE 1 MG/ML INJ SYR

Facility

$154.62

Service Code	HCPCS J2312
Hospital Revenue Code	636
Min. Negotiated Rate	$0.07
Max. Negotiated Rate	$153.07
Rate for Payer: AlohaCare Medicaid	$77.31
Rate for Payer: AlohaCare Medicare	$139.16
Rate for Payer: Cash Price	$100.50
Rate for Payer: Cash Price	$100.50
Rate for Payer: Devoted Health Medicare	$153.07
Rate for Payer: Hawaii Medical Service Association ABD	$0.07
Rate for Payer: Hawaii Medical Service Association Medicare	$139.16
Rate for Payer: Hawaii Medical Service Association Non-ABD	$0.07
Rate for Payer: Hawaii Western Management Group Commercial	$146.89
Rate for Payer: Health Management Network Commercial	$131.43
Rate for Payer: Humana Medicare	$139.16
Rate for Payer: Kaiser Permanente Commercial	$139.16
Rate for Payer: Kaiser Permanente Medicaid	$78.86
Rate for Payer: Kaiser Permanente Medicare	$139.16
Rate for Payer: MDX Hawaii PPO	$149.98
Rate for Payer: Ohana Health Plan Medicaid	$139.16
Rate for Payer: Ohana Health Plan Medicare	$139.16
Rate for Payer: UnitedHealthcare Medicaid	$92.77
Rate for Payer: UnitedHealthcare Medicare	$139.16
Rate for Payer: University Health Alliance Commercial	$112.70

NALTREXONE 50 MG PO TABLET

Facility

$23.81

Service Code	HCPCS A9270
Hospital Revenue Code	637
Min. Negotiated Rate	$11.90
Max. Negotiated Rate	$23.57
Rate for Payer: AlohaCare Medicaid	$11.90
Rate for Payer: AlohaCare Medicare	$21.43
Rate for Payer: Cash Price	$15.48
Rate for Payer: Devoted Health Medicare	$23.57
Rate for Payer: Hawaii Medical Service Association Medicare	$21.43
Rate for Payer: Hawaii Western Management Group Commercial	$22.62
Rate for Payer: Health Management Network Commercial	$20.24
Rate for Payer: Humana Medicare	$21.43
Rate for Payer: Kaiser Permanente Commercial	$21.43
Rate for Payer: Kaiser Permanente Medicaid	$12.14
Rate for Payer: Kaiser Permanente Medicare	$21.43
Rate for Payer: MDX Hawaii PPO	$23.10
Rate for Payer: Ohana Health Plan Medicaid	$21.43
Rate for Payer: Ohana Health Plan Medicare	$21.43
Rate for Payer: UnitedHealthcare Medicare	$21.43
Rate for Payer: University Health Alliance Commercial	$17.36

NALTREXONE 50 MG PO TABLET

Facility

$23.81

Service Code	HCPCS A9270
Hospital Revenue Code	250
Min. Negotiated Rate	$20.24
Max. Negotiated Rate	$23.10
Rate for Payer: Cash Price	$15.48
Rate for Payer: Health Management Network Commercial	$20.24
Rate for Payer: Kaiser Permanente Commercial	$21.43
Rate for Payer: MDX Hawaii PPO	$23.10

NAPROXEN 250 MG PO TABLET

Facility

$4.30

Service Code	HCPCS A9270
Hospital Revenue Code	637
Min. Negotiated Rate	$2.15
Max. Negotiated Rate	$4.26
Rate for Payer: AlohaCare Medicaid	$2.15
Rate for Payer: AlohaCare Medicare	$3.87
Rate for Payer: Cash Price	$2.80
Rate for Payer: Devoted Health Medicare	$4.26
Rate for Payer: Hawaii Medical Service Association Medicare	$3.87
Rate for Payer: Hawaii Western Management Group Commercial	$4.08
Rate for Payer: Health Management Network Commercial	$3.65
Rate for Payer: Humana Medicare	$3.87
Rate for Payer: Kaiser Permanente Commercial	$3.87
Rate for Payer: Kaiser Permanente Medicaid	$2.19
Rate for Payer: Kaiser Permanente Medicare	$3.87
Rate for Payer: MDX Hawaii PPO	$4.17
Rate for Payer: Ohana Health Plan Medicaid	$3.87
Rate for Payer: Ohana Health Plan Medicare	$3.87
Rate for Payer: UnitedHealthcare Medicare	$3.87
Rate for Payer: University Health Alliance Commercial	$3.13

NAPROXEN 250 MG PO TABLET

Facility

$4.30

Service Code	HCPCS A9270
Hospital Revenue Code	250
Min. Negotiated Rate	$3.65
Max. Negotiated Rate	$4.17
Rate for Payer: Cash Price	$2.80
Rate for Payer: Health Management Network Commercial	$3.65
Rate for Payer: Kaiser Permanente Commercial	$3.87
Rate for Payer: MDX Hawaii PPO	$4.17

NEOMYCIN-BACITRACNZN-POLYMYXNB 3.5-400-5,000 MG-UNIT-UNIT TOP OIPK

Facility

$1.54

Service Code	HCPCS A9270
Hospital Revenue Code	637
Min. Negotiated Rate	$0.77
Max. Negotiated Rate	$1.52
Rate for Payer: AlohaCare Medicaid	$0.77
Rate for Payer: AlohaCare Medicare	$1.39
Rate for Payer: Cash Price	$1.00
Rate for Payer: Devoted Health Medicare	$1.52
Rate for Payer: Hawaii Medical Service Association Medicare	$1.39
Rate for Payer: Hawaii Western Management Group Commercial	$1.46
Rate for Payer: Health Management Network Commercial	$1.31
Rate for Payer: Humana Medicare	$1.39
Rate for Payer: Kaiser Permanente Commercial	$1.39
Rate for Payer: Kaiser Permanente Medicaid	$0.79
Rate for Payer: Kaiser Permanente Medicare	$1.39
Rate for Payer: MDX Hawaii PPO	$1.49
Rate for Payer: Ohana Health Plan Medicaid	$1.39
Rate for Payer: Ohana Health Plan Medicare	$1.39
Rate for Payer: UnitedHealthcare Medicare	$1.39
Rate for Payer: University Health Alliance Commercial	$1.12

NEOMYCIN-BACITRACNZN-POLYMYXNB 3.5-400-5,000 MG-UNIT-UNIT TOP OIPK

Facility

$1.54

Service Code	HCPCS A9270
Hospital Revenue Code	250
Min. Negotiated Rate	$1.31
Max. Negotiated Rate	$1.49
Rate for Payer: Cash Price	$1.00
Rate for Payer: Health Management Network Commercial	$1.31
Rate for Payer: Kaiser Permanente Commercial	$1.39
Rate for Payer: MDX Hawaii PPO	$1.49

NEOMYCIN-BACITRACNZN-POLYMYXNB 3.5MG-400 UNIT- 5,000 UNIT/GRAM TOP OINT

Facility

$29.79

Service Code	HCPCS A9270
Hospital Revenue Code	637
Min. Negotiated Rate	$14.89
Max. Negotiated Rate	$29.49
Rate for Payer: AlohaCare Medicaid	$14.89
Rate for Payer: AlohaCare Medicare	$26.81
Rate for Payer: Cash Price	$19.36
Rate for Payer: Devoted Health Medicare	$29.49
Rate for Payer: Hawaii Medical Service Association Medicare	$26.81
Rate for Payer: Hawaii Western Management Group Commercial	$28.30
Rate for Payer: Health Management Network Commercial	$25.32
Rate for Payer: Humana Medicare	$26.81
Rate for Payer: Kaiser Permanente Commercial	$26.81
Rate for Payer: Kaiser Permanente Medicaid	$15.19
Rate for Payer: Kaiser Permanente Medicare	$26.81
Rate for Payer: MDX Hawaii PPO	$28.90
Rate for Payer: Ohana Health Plan Medicaid	$26.81
Rate for Payer: Ohana Health Plan Medicare	$26.81
Rate for Payer: UnitedHealthcare Medicare	$26.81
Rate for Payer: University Health Alliance Commercial	$21.71

NEOMYCIN-BACITRACNZN-POLYMYXNB 3.5MG-400 UNIT- 5,000 UNIT/GRAM TOP OINT

Facility

$29.79

Service Code	HCPCS A9270
Hospital Revenue Code	250
Min. Negotiated Rate	$25.32
Max. Negotiated Rate	$28.90
Rate for Payer: Cash Price	$19.36
Rate for Payer: Health Management Network Commercial	$25.32
Rate for Payer: Kaiser Permanente Commercial	$26.81
Rate for Payer: MDX Hawaii PPO	$28.90

NEOMYCIN-POLYMYXIN-GRAMICIDIN 1.75 MG-10,000 UNIT-0.025MG/ML OPHT DROP

Facility

$313.67

Service Code	NDC 24208079062
Hospital Revenue Code	250
Min. Negotiated Rate	$266.62
Max. Negotiated Rate	$304.26
Rate for Payer: Cash Price	$203.89
Rate for Payer: Health Management Network Commercial	$266.62
Rate for Payer: Kaiser Permanente Commercial	$282.30
Rate for Payer: MDX Hawaii PPO	$304.26

NEOMYCIN-POLYMYXIN-GRAMICIDIN 1.75 MG-10,000 UNIT-0.025MG/ML OPHT DROP

Facility

$313.67

Service Code	NDC 24208079062
Hospital Revenue Code	250
Min. Negotiated Rate	$156.84
Max. Negotiated Rate	$310.53
Rate for Payer: AlohaCare Medicaid	$156.84
Rate for Payer: AlohaCare Medicare	$282.30
Rate for Payer: Cash Price	$203.89
Rate for Payer: Devoted Health Medicare	$310.53
Rate for Payer: Hawaii Medical Service Association Medicare	$282.30
Rate for Payer: Hawaii Western Management Group Commercial	$297.99
Rate for Payer: Health Management Network Commercial	$266.62
Rate for Payer: Humana Medicare	$282.30
Rate for Payer: Kaiser Permanente Commercial	$282.30
Rate for Payer: Kaiser Permanente Medicaid	$159.97
Rate for Payer: Kaiser Permanente Medicare	$282.30
Rate for Payer: MDX Hawaii PPO	$304.26
Rate for Payer: Ohana Health Plan Medicaid	$282.30
Rate for Payer: Ohana Health Plan Medicare	$282.30
Rate for Payer: UnitedHealthcare Medicaid	$188.20
Rate for Payer: UnitedHealthcare Medicare	$282.30
Rate for Payer: University Health Alliance Commercial	$228.63

NEOMYCIN-POLYMYXIN-HC 3.5-10,000-1 MG-UNIT/ML-% OTIC SUSP

Facility

$389.56

Service Code	HCPCS A9270
Hospital Revenue Code	250
Min. Negotiated Rate	$331.13
Max. Negotiated Rate	$377.87
Rate for Payer: Cash Price	$253.21
Rate for Payer: Health Management Network Commercial	$331.13
Rate for Payer: Kaiser Permanente Commercial	$350.60
Rate for Payer: MDX Hawaii PPO	$377.87

NEOMYCIN-POLYMYXIN-HC 3.5-10,000-1 MG-UNIT/ML-% OTIC SUSP

Facility

$389.56

Service Code	HCPCS A9270
Hospital Revenue Code	637
Min. Negotiated Rate	$194.78
Max. Negotiated Rate	$385.66
Rate for Payer: AlohaCare Medicaid	$194.78
Rate for Payer: AlohaCare Medicare	$350.60
Rate for Payer: Cash Price	$253.21
Rate for Payer: Devoted Health Medicare	$385.66
Rate for Payer: Hawaii Medical Service Association Medicare	$350.60
Rate for Payer: Hawaii Western Management Group Commercial	$370.08
Rate for Payer: Health Management Network Commercial	$331.13
Rate for Payer: Humana Medicare	$350.60
Rate for Payer: Kaiser Permanente Commercial	$350.60
Rate for Payer: Kaiser Permanente Medicaid	$198.68
Rate for Payer: Kaiser Permanente Medicare	$350.60
Rate for Payer: MDX Hawaii PPO	$377.87
Rate for Payer: Ohana Health Plan Medicaid	$350.60
Rate for Payer: Ohana Health Plan Medicare	$350.60
Rate for Payer: UnitedHealthcare Medicare	$350.60
Rate for Payer: University Health Alliance Commercial	$283.95

Know your out-of-pocket cost for care.

All Charges