Kohala Hospital

All Charges

Charge

Type

Setting

Price

NOREPINEPHRINE BITARTRATE-NACL 16 MG/250 ML (64 MCG/ML) IV SOLN

Facility

$427.06

Service Code	NDC 44567064210
Hospital Revenue Code	250
Min. Negotiated Rate	$363.00
Max. Negotiated Rate	$414.25
Rate for Payer: Cash Price	$277.59
Rate for Payer: Health Management Network Commercial	$363.00
Rate for Payer: Kaiser Permanente Commercial	$384.35
Rate for Payer: MDX Hawaii PPO	$414.25

NOREPINEPHRINE BITARTRATE-NACL 16 MG/250 ML (64 MCG/ML) IV SOLN

Facility

$427.06

Service Code	NDC 44567064210
Hospital Revenue Code	250
Min. Negotiated Rate	$213.53
Max. Negotiated Rate	$422.79
Rate for Payer: AlohaCare Medicaid	$213.53
Rate for Payer: AlohaCare Medicare	$384.35
Rate for Payer: Cash Price	$277.59
Rate for Payer: Devoted Health Medicare	$422.79
Rate for Payer: Hawaii Medical Service Association Medicare	$384.35
Rate for Payer: Hawaii Western Management Group Commercial	$405.71
Rate for Payer: Health Management Network Commercial	$363.00
Rate for Payer: Humana Medicare	$384.35
Rate for Payer: Kaiser Permanente Commercial	$384.35
Rate for Payer: Kaiser Permanente Medicaid	$217.80
Rate for Payer: Kaiser Permanente Medicare	$384.35
Rate for Payer: MDX Hawaii PPO	$414.25
Rate for Payer: Ohana Health Plan Medicaid	$384.35
Rate for Payer: Ohana Health Plan Medicare	$384.35
Rate for Payer: UnitedHealthcare Medicaid	$256.24
Rate for Payer: UnitedHealthcare Medicare	$384.35
Rate for Payer: University Health Alliance Commercial	$311.28

NORMAL NEWBORN

Facility

$2,678.33

Service Code	MSDRG 795
Min. Negotiated Rate	$2,678.33
Max. Negotiated Rate	$2,678.33
Rate for Payer: Hawaii Medical Service Association Commercial	$2,678.33

NORTRIPTYLINE 10 MG PO CAP

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

NORTRIPTYLINE 10 MG PO CAP

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

NORTRIPTYLINE 25 MG PO CAP

Facility

$1.47

Service Code	HCPCS A9270
Hospital Revenue Code	250
Min. Negotiated Rate	$1.25
Max. Negotiated Rate	$1.43
Rate for Payer: Cash Price	$0.96
Rate for Payer: Health Management Network Commercial	$1.25
Rate for Payer: Kaiser Permanente Commercial	$1.32
Rate for Payer: MDX Hawaii PPO	$1.43

NORTRIPTYLINE 25 MG PO CAP

Facility

$1.47

Service Code	HCPCS A9270
Hospital Revenue Code	637
Min. Negotiated Rate	$0.74
Max. Negotiated Rate	$1.46
Rate for Payer: AlohaCare Medicaid	$0.74
Rate for Payer: AlohaCare Medicare	$1.32
Rate for Payer: Cash Price	$0.96
Rate for Payer: Devoted Health Medicare	$1.46
Rate for Payer: Hawaii Medical Service Association Medicare	$1.32
Rate for Payer: Hawaii Western Management Group Commercial	$1.40
Rate for Payer: Health Management Network Commercial	$1.25
Rate for Payer: Humana Medicare	$1.32
Rate for Payer: Kaiser Permanente Commercial	$1.32
Rate for Payer: Kaiser Permanente Medicaid	$0.75
Rate for Payer: Kaiser Permanente Medicare	$1.32
Rate for Payer: MDX Hawaii PPO	$1.43
Rate for Payer: Ohana Health Plan Medicaid	$1.32
Rate for Payer: Ohana Health Plan Medicare	$1.32
Rate for Payer: UnitedHealthcare Medicare	$1.32
Rate for Payer: University Health Alliance Commercial	$1.07

NP ACETAMINOPHEN 160 MG/5 ML PO SUSP #30 ML (WHR)

Facility

$28.32

Service Code	HCPCS A9270
Hospital Revenue Code	250
Min. Negotiated Rate	$24.07
Max. Negotiated Rate	$27.47
Rate for Payer: Cash Price	$18.41
Rate for Payer: Health Management Network Commercial	$24.07
Rate for Payer: Kaiser Permanente Commercial	$25.49
Rate for Payer: MDX Hawaii PPO	$27.47

NP ACETAMINOPHEN 160 MG/5 ML PO SUSP #30 ML (WHR)

Facility

$28.32

Service Code	HCPCS A9270
Hospital Revenue Code	637
Min. Negotiated Rate	$14.16
Max. Negotiated Rate	$28.04
Rate for Payer: AlohaCare Medicaid	$14.16
Rate for Payer: AlohaCare Medicare	$25.49
Rate for Payer: Cash Price	$18.41
Rate for Payer: Devoted Health Medicare	$28.04
Rate for Payer: Hawaii Medical Service Association Medicare	$25.49
Rate for Payer: Hawaii Western Management Group Commercial	$26.90
Rate for Payer: Health Management Network Commercial	$24.07
Rate for Payer: Humana Medicare	$25.49
Rate for Payer: Kaiser Permanente Commercial	$25.49
Rate for Payer: Kaiser Permanente Medicaid	$14.44
Rate for Payer: Kaiser Permanente Medicare	$25.49
Rate for Payer: MDX Hawaii PPO	$27.47
Rate for Payer: Ohana Health Plan Medicaid	$25.49
Rate for Payer: Ohana Health Plan Medicare	$25.49
Rate for Payer: UnitedHealthcare Medicare	$25.49
Rate for Payer: University Health Alliance Commercial	$20.64

NP ACETAMINOPHEN/CODEINE 300 - 30 MG #5 TAB (WHR)

Facility

$40.34

Service Code	HCPCS A9270
Hospital Revenue Code	250
Min. Negotiated Rate	$34.29
Max. Negotiated Rate	$39.13
Rate for Payer: Cash Price	$26.22
Rate for Payer: Health Management Network Commercial	$34.29
Rate for Payer: Kaiser Permanente Commercial	$36.31
Rate for Payer: MDX Hawaii PPO	$39.13

NP ACETAMINOPHEN/CODEINE 300 - 30 MG #5 TAB (WHR)

Facility

$40.34

Service Code	HCPCS A9270
Hospital Revenue Code	637
Min. Negotiated Rate	$20.17
Max. Negotiated Rate	$39.94
Rate for Payer: AlohaCare Medicaid	$20.17
Rate for Payer: AlohaCare Medicare	$36.31
Rate for Payer: Cash Price	$26.22
Rate for Payer: Devoted Health Medicare	$39.94
Rate for Payer: Hawaii Medical Service Association Medicare	$36.31
Rate for Payer: Hawaii Western Management Group Commercial	$38.32
Rate for Payer: Health Management Network Commercial	$34.29
Rate for Payer: Humana Medicare	$36.31
Rate for Payer: Kaiser Permanente Commercial	$36.31
Rate for Payer: Kaiser Permanente Medicaid	$20.57
Rate for Payer: Kaiser Permanente Medicare	$36.31
Rate for Payer: MDX Hawaii PPO	$39.13
Rate for Payer: Ohana Health Plan Medicaid	$36.31
Rate for Payer: Ohana Health Plan Medicare	$36.31
Rate for Payer: UnitedHealthcare Medicare	$36.31
Rate for Payer: University Health Alliance Commercial	$29.40

NP AMOXICILLIN 500 MG #3 CAP (WHR)

Facility

$7.19

Service Code	HCPCS A9270
Hospital Revenue Code	637
Min. Negotiated Rate	$3.60
Max. Negotiated Rate	$7.12
Rate for Payer: AlohaCare Medicaid	$3.60
Rate for Payer: AlohaCare Medicare	$6.47
Rate for Payer: Cash Price	$4.67
Rate for Payer: Devoted Health Medicare	$7.12
Rate for Payer: Hawaii Medical Service Association Medicare	$6.47
Rate for Payer: Hawaii Western Management Group Commercial	$6.83
Rate for Payer: Health Management Network Commercial	$6.11
Rate for Payer: Humana Medicare	$6.47
Rate for Payer: Kaiser Permanente Commercial	$6.47
Rate for Payer: Kaiser Permanente Medicaid	$3.67
Rate for Payer: Kaiser Permanente Medicare	$6.47
Rate for Payer: MDX Hawaii PPO	$6.97
Rate for Payer: Ohana Health Plan Medicaid	$6.47
Rate for Payer: Ohana Health Plan Medicare	$6.47
Rate for Payer: UnitedHealthcare Medicare	$6.47
Rate for Payer: University Health Alliance Commercial	$5.24

NP AMOXICILLIN 500 MG #3 CAP (WHR)

Facility

$7.19

Service Code	HCPCS A9270
Hospital Revenue Code	250
Min. Negotiated Rate	$6.11
Max. Negotiated Rate	$6.97
Rate for Payer: Cash Price	$4.67
Rate for Payer: Health Management Network Commercial	$6.11
Rate for Payer: Kaiser Permanente Commercial	$6.47
Rate for Payer: MDX Hawaii PPO	$6.97

NP AMOXICILLIN-POT CLAVULANATE 500-125 MG #3 CAP (WHR)

Facility

$65.01

Service Code	HCPCS A9270
Hospital Revenue Code	250
Min. Negotiated Rate	$55.26
Max. Negotiated Rate	$63.06
Rate for Payer: Cash Price	$42.26
Rate for Payer: Health Management Network Commercial	$55.26
Rate for Payer: Kaiser Permanente Commercial	$58.51
Rate for Payer: MDX Hawaii PPO	$63.06

NP AMOXICILLIN-POT CLAVULANATE 500-125 MG #3 CAP (WHR)

Facility

$65.01

Service Code	HCPCS A9270
Hospital Revenue Code	637
Min. Negotiated Rate	$32.51
Max. Negotiated Rate	$64.36
Rate for Payer: AlohaCare Medicaid	$32.51
Rate for Payer: AlohaCare Medicare	$58.51
Rate for Payer: Cash Price	$42.26
Rate for Payer: Devoted Health Medicare	$64.36
Rate for Payer: Hawaii Medical Service Association Medicare	$58.51
Rate for Payer: Hawaii Western Management Group Commercial	$61.76
Rate for Payer: Health Management Network Commercial	$55.26
Rate for Payer: Humana Medicare	$58.51
Rate for Payer: Kaiser Permanente Commercial	$58.51
Rate for Payer: Kaiser Permanente Medicaid	$33.16
Rate for Payer: Kaiser Permanente Medicare	$58.51
Rate for Payer: MDX Hawaii PPO	$63.06
Rate for Payer: Ohana Health Plan Medicaid	$58.51
Rate for Payer: Ohana Health Plan Medicare	$58.51
Rate for Payer: UnitedHealthcare Medicare	$58.51
Rate for Payer: University Health Alliance Commercial	$47.39

NP AMOXICILLIN-POT CLAVULANATE 875-125 MG #2 TAB (WHR)

Facility

$32.39

Service Code	HCPCS A9270
Hospital Revenue Code	637
Min. Negotiated Rate	$16.20
Max. Negotiated Rate	$32.07
Rate for Payer: AlohaCare Medicaid	$16.20
Rate for Payer: AlohaCare Medicare	$29.15
Rate for Payer: Cash Price	$21.05
Rate for Payer: Devoted Health Medicare	$32.07
Rate for Payer: Hawaii Medical Service Association Medicare	$29.15
Rate for Payer: Hawaii Western Management Group Commercial	$30.77
Rate for Payer: Health Management Network Commercial	$27.53
Rate for Payer: Humana Medicare	$29.15
Rate for Payer: Kaiser Permanente Commercial	$29.15
Rate for Payer: Kaiser Permanente Medicaid	$16.52
Rate for Payer: Kaiser Permanente Medicare	$29.15
Rate for Payer: MDX Hawaii PPO	$31.42
Rate for Payer: Ohana Health Plan Medicaid	$29.15
Rate for Payer: Ohana Health Plan Medicare	$29.15
Rate for Payer: UnitedHealthcare Medicare	$29.15
Rate for Payer: University Health Alliance Commercial	$23.61

NP AMOXICILLIN-POT CLAVULANATE 875-125 MG #2 TAB (WHR)

Facility

$32.39

Service Code	HCPCS A9270
Hospital Revenue Code	250
Min. Negotiated Rate	$27.53
Max. Negotiated Rate	$31.42
Rate for Payer: Cash Price	$21.05
Rate for Payer: Health Management Network Commercial	$27.53
Rate for Payer: Kaiser Permanente Commercial	$29.15
Rate for Payer: MDX Hawaii PPO	$31.42

NP BENZONATATE 100 MG #6 CAP (WHR)

Facility

$80.18

Service Code	HCPCS A9270
Hospital Revenue Code	250
Min. Negotiated Rate	$68.15
Max. Negotiated Rate	$77.77
Rate for Payer: Cash Price	$52.12
Rate for Payer: Health Management Network Commercial	$68.15
Rate for Payer: Kaiser Permanente Commercial	$72.16
Rate for Payer: MDX Hawaii PPO	$77.77

NP BENZONATATE 100 MG #6 CAP (WHR)

Facility

$80.18

Service Code	HCPCS A9270
Hospital Revenue Code	637
Min. Negotiated Rate	$40.09
Max. Negotiated Rate	$79.38
Rate for Payer: AlohaCare Medicaid	$40.09
Rate for Payer: AlohaCare Medicare	$72.16
Rate for Payer: Cash Price	$52.12
Rate for Payer: Devoted Health Medicare	$79.38
Rate for Payer: Hawaii Medical Service Association Medicare	$72.16
Rate for Payer: Hawaii Western Management Group Commercial	$76.17
Rate for Payer: Health Management Network Commercial	$68.15
Rate for Payer: Humana Medicare	$72.16
Rate for Payer: Kaiser Permanente Commercial	$72.16
Rate for Payer: Kaiser Permanente Medicaid	$40.89
Rate for Payer: Kaiser Permanente Medicare	$72.16
Rate for Payer: MDX Hawaii PPO	$77.77
Rate for Payer: Ohana Health Plan Medicaid	$72.16
Rate for Payer: Ohana Health Plan Medicare	$72.16
Rate for Payer: UnitedHealthcare Medicare	$72.16
Rate for Payer: University Health Alliance Commercial	$58.44

NP BUPRENORPHINE SL 2 MG #3 TAB (WHR)

Facility

$45.15

Service Code	HCPCS J0571
Hospital Revenue Code	250
Min. Negotiated Rate	$38.38
Max. Negotiated Rate	$43.80
Rate for Payer: Cash Price	$29.35
Rate for Payer: Health Management Network Commercial	$38.38
Rate for Payer: Kaiser Permanente Commercial	$40.63
Rate for Payer: MDX Hawaii PPO	$43.80

NP BUPRENORPHINE SL 2 MG #3 TAB (WHR)

Facility

$45.15

Service Code	HCPCS J0571
Hospital Revenue Code	637
Min. Negotiated Rate	$22.57
Max. Negotiated Rate	$44.70
Rate for Payer: AlohaCare Medicaid	$22.57
Rate for Payer: AlohaCare Medicare	$40.63
Rate for Payer: Cash Price	$29.35
Rate for Payer: Devoted Health Medicare	$44.70
Rate for Payer: Hawaii Medical Service Association Medicare	$40.63
Rate for Payer: Hawaii Western Management Group Commercial	$42.89
Rate for Payer: Health Management Network Commercial	$38.38
Rate for Payer: Humana Medicare	$40.63
Rate for Payer: Kaiser Permanente Commercial	$40.63
Rate for Payer: Kaiser Permanente Medicaid	$23.03
Rate for Payer: Kaiser Permanente Medicare	$40.63
Rate for Payer: MDX Hawaii PPO	$43.80
Rate for Payer: Ohana Health Plan Medicaid	$40.63
Rate for Payer: Ohana Health Plan Medicare	$40.63
Rate for Payer: UnitedHealthcare Medicare	$40.63
Rate for Payer: University Health Alliance Commercial	$32.91

NP CEPHALEXIN 500 MG #4 CAP (WHR)

Facility

$26.99

Service Code	HCPCS A9270
Hospital Revenue Code	637
Min. Negotiated Rate	$13.49
Max. Negotiated Rate	$26.72
Rate for Payer: AlohaCare Medicaid	$13.49
Rate for Payer: AlohaCare Medicare	$24.29
Rate for Payer: Cash Price	$17.54
Rate for Payer: Devoted Health Medicare	$26.72
Rate for Payer: Hawaii Medical Service Association Medicare	$24.29
Rate for Payer: Hawaii Western Management Group Commercial	$25.64
Rate for Payer: Health Management Network Commercial	$22.94
Rate for Payer: Humana Medicare	$24.29
Rate for Payer: Kaiser Permanente Commercial	$24.29
Rate for Payer: Kaiser Permanente Medicaid	$13.76
Rate for Payer: Kaiser Permanente Medicare	$24.29
Rate for Payer: MDX Hawaii PPO	$26.18
Rate for Payer: Ohana Health Plan Medicaid	$24.29
Rate for Payer: Ohana Health Plan Medicare	$24.29
Rate for Payer: UnitedHealthcare Medicare	$24.29
Rate for Payer: University Health Alliance Commercial	$19.67

NP CEPHALEXIN 500 MG #4 CAP (WHR)

Facility

$26.99

Service Code	HCPCS A9270
Hospital Revenue Code	250
Min. Negotiated Rate	$22.94
Max. Negotiated Rate	$26.18
Rate for Payer: Cash Price	$17.54
Rate for Payer: Health Management Network Commercial	$22.94
Rate for Payer: Kaiser Permanente Commercial	$24.29
Rate for Payer: MDX Hawaii PPO	$26.18

NP CIPROFLOXACIN 500 MG #2 TAB (WHR)

Facility

$3.41

Service Code	HCPCS A9270
Hospital Revenue Code	637
Min. Negotiated Rate	$1.71
Max. Negotiated Rate	$3.38
Rate for Payer: AlohaCare Medicaid	$1.71
Rate for Payer: AlohaCare Medicare	$3.07
Rate for Payer: Cash Price	$2.22
Rate for Payer: Devoted Health Medicare	$3.38
Rate for Payer: Hawaii Medical Service Association Medicare	$3.07
Rate for Payer: Hawaii Western Management Group Commercial	$3.24
Rate for Payer: Health Management Network Commercial	$2.90
Rate for Payer: Humana Medicare	$3.07
Rate for Payer: Kaiser Permanente Commercial	$3.07
Rate for Payer: Kaiser Permanente Medicaid	$1.74
Rate for Payer: Kaiser Permanente Medicare	$3.07
Rate for Payer: MDX Hawaii PPO	$3.31
Rate for Payer: Ohana Health Plan Medicaid	$3.07
Rate for Payer: Ohana Health Plan Medicare	$3.07
Rate for Payer: UnitedHealthcare Medicare	$3.07
Rate for Payer: University Health Alliance Commercial	$2.49

NP CIPROFLOXACIN 500 MG #2 TAB (WHR)

Facility

$3.41

Service Code	HCPCS A9270
Hospital Revenue Code	250
Min. Negotiated Rate	$2.90
Max. Negotiated Rate	$3.31
Rate for Payer: Cash Price	$2.22
Rate for Payer: Health Management Network Commercial	$2.90
Rate for Payer: Kaiser Permanente Commercial	$3.07
Rate for Payer: MDX Hawaii PPO	$3.31

Know your out-of-pocket cost for care.

All Charges