Kohala Hospital

All Charges

Charge

Type

Setting

Price

PEDI METHYLPREDNISOLONE 10 MG/ML INJ

Facility

$40.89

Service Code	NDC 00009003928
Hospital Revenue Code	636
Min. Negotiated Rate	$20.45
Max. Negotiated Rate	$40.48
Rate for Payer: AlohaCare Medicaid	$20.45
Rate for Payer: AlohaCare Medicare	$36.80
Rate for Payer: Cash Price	$26.58
Rate for Payer: Devoted Health Medicare	$40.48
Rate for Payer: Hawaii Medical Service Association Medicare	$36.80
Rate for Payer: Hawaii Western Management Group Commercial	$38.85
Rate for Payer: Health Management Network Commercial	$34.76
Rate for Payer: Humana Medicare	$36.80
Rate for Payer: Kaiser Permanente Commercial	$36.80
Rate for Payer: Kaiser Permanente Medicaid	$20.85
Rate for Payer: Kaiser Permanente Medicare	$36.80
Rate for Payer: MDX Hawaii PPO	$39.66
Rate for Payer: Ohana Health Plan Medicaid	$36.80
Rate for Payer: Ohana Health Plan Medicare	$36.80
Rate for Payer: UnitedHealthcare Medicaid	$24.53
Rate for Payer: UnitedHealthcare Medicare	$36.80
Rate for Payer: University Health Alliance Commercial	$29.80

PEDI METHYLPREDNISOLONE 10 MG/ML INJ

Facility

$40.89

Service Code	NDC 00009003930
Hospital Revenue Code	636
Min. Negotiated Rate	$20.45
Max. Negotiated Rate	$40.48
Rate for Payer: AlohaCare Medicaid	$20.45
Rate for Payer: AlohaCare Medicare	$36.80
Rate for Payer: Cash Price	$26.58
Rate for Payer: Devoted Health Medicare	$40.48
Rate for Payer: Hawaii Medical Service Association Medicare	$36.80
Rate for Payer: Hawaii Western Management Group Commercial	$38.85
Rate for Payer: Health Management Network Commercial	$34.76
Rate for Payer: Humana Medicare	$36.80
Rate for Payer: Kaiser Permanente Commercial	$36.80
Rate for Payer: Kaiser Permanente Medicaid	$20.85
Rate for Payer: Kaiser Permanente Medicare	$36.80
Rate for Payer: MDX Hawaii PPO	$39.66
Rate for Payer: Ohana Health Plan Medicaid	$36.80
Rate for Payer: Ohana Health Plan Medicare	$36.80
Rate for Payer: UnitedHealthcare Medicaid	$24.53
Rate for Payer: UnitedHealthcare Medicare	$36.80
Rate for Payer: University Health Alliance Commercial	$29.80

PEG 3350-ELECTROLYTES 236-22.74-6.74 -5.86 GRAM PO RECON.SOLN.

Facility

$117.36

Service Code	HCPCS A9270
Hospital Revenue Code	637
Min. Negotiated Rate	$58.68
Max. Negotiated Rate	$116.19
Rate for Payer: AlohaCare Medicaid	$58.68
Rate for Payer: AlohaCare Medicare	$105.62
Rate for Payer: Cash Price	$76.28
Rate for Payer: Devoted Health Medicare	$116.19
Rate for Payer: Hawaii Medical Service Association Medicare	$105.62
Rate for Payer: Hawaii Western Management Group Commercial	$111.49
Rate for Payer: Health Management Network Commercial	$99.76
Rate for Payer: Humana Medicare	$105.62
Rate for Payer: Kaiser Permanente Commercial	$105.62
Rate for Payer: Kaiser Permanente Medicaid	$59.85
Rate for Payer: Kaiser Permanente Medicare	$105.62
Rate for Payer: MDX Hawaii PPO	$113.84
Rate for Payer: Ohana Health Plan Medicaid	$105.62
Rate for Payer: Ohana Health Plan Medicare	$105.62
Rate for Payer: UnitedHealthcare Medicare	$105.62
Rate for Payer: University Health Alliance Commercial	$85.54

PEG 3350-ELECTROLYTES 236-22.74-6.74 -5.86 GRAM PO RECON.SOLN.

Facility

$117.36

Service Code	HCPCS A9270
Hospital Revenue Code	250
Min. Negotiated Rate	$99.76
Max. Negotiated Rate	$113.84
Rate for Payer: Cash Price	$76.28
Rate for Payer: Health Management Network Commercial	$99.76
Rate for Payer: Kaiser Permanente Commercial	$105.62
Rate for Payer: MDX Hawaii PPO	$113.84

PEG 400-HYPROMELLOSE-GLYCERIN 1-0.2-0.2 % OPHT DROP

Facility

$9.36

Service Code	HCPCS A9270
Hospital Revenue Code	637
Min. Negotiated Rate	$4.68
Max. Negotiated Rate	$9.27
Rate for Payer: AlohaCare Medicaid	$4.68
Rate for Payer: AlohaCare Medicare	$8.42
Rate for Payer: Cash Price	$6.08
Rate for Payer: Devoted Health Medicare	$9.27
Rate for Payer: Hawaii Medical Service Association Medicare	$8.42
Rate for Payer: Hawaii Western Management Group Commercial	$8.89
Rate for Payer: Health Management Network Commercial	$7.96
Rate for Payer: Humana Medicare	$8.42
Rate for Payer: Kaiser Permanente Commercial	$8.42
Rate for Payer: Kaiser Permanente Medicaid	$4.77
Rate for Payer: Kaiser Permanente Medicare	$8.42
Rate for Payer: MDX Hawaii PPO	$9.08
Rate for Payer: Ohana Health Plan Medicaid	$8.42
Rate for Payer: Ohana Health Plan Medicare	$8.42
Rate for Payer: UnitedHealthcare Medicare	$8.42
Rate for Payer: University Health Alliance Commercial	$6.82

PEG 400-HYPROMELLOSE-GLYCERIN 1-0.2-0.2 % OPHT DROP

Facility

$9.36

Service Code	HCPCS A9270
Hospital Revenue Code	250
Min. Negotiated Rate	$7.96
Max. Negotiated Rate	$9.08
Rate for Payer: Cash Price	$6.08
Rate for Payer: Health Management Network Commercial	$7.96
Rate for Payer: Kaiser Permanente Commercial	$8.42
Rate for Payer: MDX Hawaii PPO	$9.08

PELVIC EVISCERATION, RADICAL HYSTERECTOMY AND RADICAL VULVECTOMY WITH CC/MCC

Facility

$39,487.53

Service Code	MSDRG 734
Min. Negotiated Rate	$39,487.53
Max. Negotiated Rate	$39,487.53
Rate for Payer: Hawaii Medical Service Association Commercial	$39,487.53

PELVIC EVISCERATION, RADICAL HYSTERECTOMY AND RADICAL VULVECTOMY WITHOUT CC/MCC

Facility

$39,487.53

Service Code	MSDRG 735
Min. Negotiated Rate	$39,487.53
Max. Negotiated Rate	$39,487.53
Rate for Payer: Hawaii Medical Service Association Commercial	$39,487.53

PENICILLIN G BENZATHINE 1200000 UNIT/2 ML IM SYR

Facility

$1,006.12

Service Code	HCPCS J0561
Hospital Revenue Code	636
Min. Negotiated Rate	$29.30
Max. Negotiated Rate	$996.06
Rate for Payer: AlohaCare Medicaid	$503.06
Rate for Payer: AlohaCare Medicare	$905.51
Rate for Payer: Cash Price	$653.98
Rate for Payer: Cash Price	$653.98
Rate for Payer: Devoted Health Medicare	$996.06
Rate for Payer: Hawaii Medical Service Association ABD	$29.30
Rate for Payer: Hawaii Medical Service Association Commercial	$39.34
Rate for Payer: Hawaii Medical Service Association Medicare	$905.51
Rate for Payer: Hawaii Medical Service Association Non-ABD	$29.30
Rate for Payer: Hawaii Western Management Group Commercial	$955.81
Rate for Payer: Health Management Network Commercial	$855.20
Rate for Payer: Humana Medicare	$905.51
Rate for Payer: Kaiser Permanente Commercial	$905.51
Rate for Payer: Kaiser Permanente Medicaid	$513.12
Rate for Payer: Kaiser Permanente Medicare	$905.51
Rate for Payer: MDX Hawaii PPO	$975.94
Rate for Payer: Ohana Health Plan Medicaid	$905.51
Rate for Payer: Ohana Health Plan Medicare	$905.51
Rate for Payer: UnitedHealthcare Medicaid	$603.67
Rate for Payer: UnitedHealthcare Medicare	$905.51
Rate for Payer: University Health Alliance Commercial	$733.36

PENICILLIN G BENZATHINE 1200000 UNIT/2 ML IM SYR

Facility

$1,006.12

Service Code	HCPCS J0561
Hospital Revenue Code	250
Min. Negotiated Rate	$855.20
Max. Negotiated Rate	$975.94
Rate for Payer: Cash Price	$653.98
Rate for Payer: Health Management Network Commercial	$855.20
Rate for Payer: Kaiser Permanente Commercial	$905.51
Rate for Payer: MDX Hawaii PPO	$975.94

PENICILLIN G POTASSIUM 5 MILLION UNIT INJ RECON.SOLN.

Facility

$70.67

Service Code	HCPCS J2540
Hospital Revenue Code	250
Min. Negotiated Rate	$60.07
Max. Negotiated Rate	$68.55
Rate for Payer: Cash Price	$45.94
Rate for Payer: Health Management Network Commercial	$60.07
Rate for Payer: Kaiser Permanente Commercial	$63.60
Rate for Payer: MDX Hawaii PPO	$68.55

PENICILLIN G POTASSIUM 5 MILLION UNIT INJ RECON.SOLN.

Facility

$70.67

Service Code	HCPCS J2540
Hospital Revenue Code	636
Min. Negotiated Rate	$0.88
Max. Negotiated Rate	$69.96
Rate for Payer: AlohaCare Medicaid	$35.34
Rate for Payer: AlohaCare Medicare	$63.60
Rate for Payer: Cash Price	$45.94
Rate for Payer: Cash Price	$45.94
Rate for Payer: Devoted Health Medicare	$69.96
Rate for Payer: Hawaii Medical Service Association ABD	$0.88
Rate for Payer: Hawaii Medical Service Association Medicare	$63.60
Rate for Payer: Hawaii Medical Service Association Non-ABD	$0.88
Rate for Payer: Hawaii Western Management Group Commercial	$67.14
Rate for Payer: Health Management Network Commercial	$60.07
Rate for Payer: Humana Medicare	$63.60
Rate for Payer: Kaiser Permanente Commercial	$63.60
Rate for Payer: Kaiser Permanente Medicaid	$36.04
Rate for Payer: Kaiser Permanente Medicare	$63.60
Rate for Payer: MDX Hawaii PPO	$68.55
Rate for Payer: Ohana Health Plan Medicaid	$63.60
Rate for Payer: Ohana Health Plan Medicare	$63.60
Rate for Payer: UnitedHealthcare Medicaid	$42.40
Rate for Payer: UnitedHealthcare Medicare	$63.60
Rate for Payer: University Health Alliance Commercial	$51.51

PENICILLIN V POTASSIUM 250 MG PO TABLET

Facility

$4.70

Service Code	HCPCS A9270
Hospital Revenue Code	250
Min. Negotiated Rate	$4.00
Max. Negotiated Rate	$4.56
Rate for Payer: Cash Price	$3.06
Rate for Payer: Health Management Network Commercial	$4.00
Rate for Payer: Kaiser Permanente Commercial	$4.23
Rate for Payer: MDX Hawaii PPO	$4.56

PENICILLIN V POTASSIUM 250 MG PO TABLET

Facility

$4.70

Service Code	HCPCS A9270
Hospital Revenue Code	637
Min. Negotiated Rate	$2.35
Max. Negotiated Rate	$4.65
Rate for Payer: AlohaCare Medicaid	$2.35
Rate for Payer: AlohaCare Medicare	$4.23
Rate for Payer: Cash Price	$3.06
Rate for Payer: Devoted Health Medicare	$4.65
Rate for Payer: Hawaii Medical Service Association Medicare	$4.23
Rate for Payer: Hawaii Western Management Group Commercial	$4.46
Rate for Payer: Health Management Network Commercial	$4.00
Rate for Payer: Humana Medicare	$4.23
Rate for Payer: Kaiser Permanente Commercial	$4.23
Rate for Payer: Kaiser Permanente Medicaid	$2.40
Rate for Payer: Kaiser Permanente Medicare	$4.23
Rate for Payer: MDX Hawaii PPO	$4.56
Rate for Payer: Ohana Health Plan Medicaid	$4.23
Rate for Payer: Ohana Health Plan Medicare	$4.23
Rate for Payer: UnitedHealthcare Medicare	$4.23
Rate for Payer: University Health Alliance Commercial	$3.43

PENICILLIN V POTASSIUM 500 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

PENICILLIN V POTASSIUM 500 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

PENIS PROCEDURES WITH CC/MCC

Facility

$24,958.21

Service Code	MSDRG 709
Min. Negotiated Rate	$24,958.21
Max. Negotiated Rate	$24,958.21
Rate for Payer: Hawaii Medical Service Association Commercial	$24,958.21

PENIS PROCEDURES WITHOUT CC/MCC

Facility

$24,958.21

Service Code	MSDRG 710
Min. Negotiated Rate	$24,958.21
Max. Negotiated Rate	$24,958.21
Rate for Payer: Hawaii Medical Service Association Commercial	$24,958.21

PERCUTANEOUS AND OTHER INTRACARDIAC PROCEDURES WITH MCC

Facility

$53,400.61

Service Code	MSDRG 273
Min. Negotiated Rate	$53,400.61
Max. Negotiated Rate	$53,400.61
Rate for Payer: Hawaii Medical Service Association Commercial	$53,400.61

PERCUTANEOUS AND OTHER INTRACARDIAC PROCEDURES WITHOUT MCC

Facility

$37,591.37

Service Code	MSDRG 274
Min. Negotiated Rate	$37,591.37
Max. Negotiated Rate	$37,591.37
Rate for Payer: Hawaii Medical Service Association Commercial	$37,591.37

PERCUTANEOUS CARDIOVASCULAR PROCEDURES WITH INTRALUMINAL DEVICE WITH MCC OR 4+ ARTERIES/INTRALUMINAL DEVICES

Facility

$57,050.71

Service Code	MSDRG 321
Min. Negotiated Rate	$57,050.71
Max. Negotiated Rate	$57,050.71
Rate for Payer: Hawaii Medical Service Association Commercial	$57,050.71

PERCUTANEOUS CARDIOVASCULAR PROCEDURES WITH INTRALUMINAL DEVICE WITHOUT MCC

Facility

$40,483.02

Service Code	MSDRG 322
Min. Negotiated Rate	$40,483.02
Max. Negotiated Rate	$40,483.02
Rate for Payer: Hawaii Medical Service Association Commercial	$40,483.02

PERCUTANEOUS CARDIOVASCULAR PROCEDURES WITHOUT INTRALUMINAL DEVICE WITH MCC

Facility

$47,996.55

Service Code	MSDRG 250
Min. Negotiated Rate	$47,996.55
Max. Negotiated Rate	$47,996.55
Rate for Payer: Hawaii Medical Service Association Commercial	$47,996.55

PERCUTANEOUS CARDIOVASCULAR PROCEDURES WITHOUT INTRALUMINAL DEVICE WITHOUT MCC

Facility

$35,742.62

Service Code	MSDRG 251
Min. Negotiated Rate	$35,742.62
Max. Negotiated Rate	$35,742.62
Rate for Payer: Hawaii Medical Service Association Commercial	$35,742.62

PERCUTANEOUS CORONARY ATHERECTOMY WITH INTRALUMINAL DEVICE WITH MCC

Facility

$57,050.71

Service Code	MSDRG 359
Min. Negotiated Rate	$57,050.71
Max. Negotiated Rate	$57,050.71
Rate for Payer: Hawaii Medical Service Association Commercial	$57,050.71

Know your out-of-pocket cost for care.

All Charges