Kohala Hospital

All Charges

Charge

Type

Setting

Price

RESPIRATORY SIGNS AND SYMPTOMS

Facility

$13,486.44

Service Code	MSDRG 204
Min. Negotiated Rate	$13,486.44
Max. Negotiated Rate	$13,486.44
Rate for Payer: Hawaii Medical Service Association Commercial	$13,486.44

RESPIRATORY SYSTEM DIAGNOSIS WITH VENTILATOR SUPPORT <=96 HOURS

Facility

$70,205.32

Service Code	MSDRG 208
Min. Negotiated Rate	$70,205.32
Max. Negotiated Rate	$70,205.32
Rate for Payer: Hawaii Medical Service Association Commercial	$70,205.32

RESPIRATORY SYSTEM DIAGNOSIS WITH VENTILATOR SUPPORT >96 HOURS

Facility

$185,231.13

Service Code	MSDRG 207
Min. Negotiated Rate	$185,231.13
Max. Negotiated Rate	$185,231.13
Rate for Payer: Hawaii Medical Service Association Commercial	$185,231.13

RETICULOENDOTHELIAL AND IMMUNITY DISORDERS WITH CC

Facility

$15,975.15

Service Code	MSDRG 815
Min. Negotiated Rate	$15,975.15
Max. Negotiated Rate	$15,975.15
Rate for Payer: Hawaii Medical Service Association Commercial	$15,975.15

RETICULOENDOTHELIAL AND IMMUNITY DISORDERS WITH MCC

Facility

$15,975.15

Service Code	MSDRG 814
Min. Negotiated Rate	$15,975.15
Max. Negotiated Rate	$15,975.15
Rate for Payer: Hawaii Medical Service Association Commercial	$15,975.15

RETICULOENDOTHELIAL AND IMMUNITY DISORDERS WITHOUT CC/MCC

Facility

$11,685.09

Service Code	MSDRG 816
Min. Negotiated Rate	$11,685.09
Max. Negotiated Rate	$11,685.09
Rate for Payer: Hawaii Medical Service Association Commercial	$11,685.09

REVISION OF HIP OR KNEE REPLACEMENT WITH CC

Facility

$56,576.67

Service Code	MSDRG 467
Min. Negotiated Rate	$56,576.67
Max. Negotiated Rate	$56,576.67
Rate for Payer: Hawaii Medical Service Association Commercial	$56,576.67

REVISION OF HIP OR KNEE REPLACEMENT WITH MCC

Facility

$56,576.67

Service Code	MSDRG 466
Min. Negotiated Rate	$56,576.67
Max. Negotiated Rate	$56,576.67
Rate for Payer: Hawaii Medical Service Association Commercial	$56,576.67

REVISION OF HIP OR KNEE REPLACEMENT WITHOUT CC/MCC

Facility

$56,576.67

Service Code	MSDRG 468
Min. Negotiated Rate	$56,576.67
Max. Negotiated Rate	$56,576.67
Rate for Payer: Hawaii Medical Service Association Commercial	$56,576.67

RIFAMPIN 150 MG PO CAP

Facility

$17.90

Service Code	HCPCS A9270
Hospital Revenue Code	637
Min. Negotiated Rate	$8.95
Max. Negotiated Rate	$17.72
Rate for Payer: AlohaCare Medicaid	$8.95
Rate for Payer: AlohaCare Medicare	$16.11
Rate for Payer: Cash Price	$11.64
Rate for Payer: Devoted Health Medicare	$17.72
Rate for Payer: Hawaii Medical Service Association Medicare	$16.11
Rate for Payer: Hawaii Western Management Group Commercial	$17.00
Rate for Payer: Health Management Network Commercial	$15.21
Rate for Payer: Humana Medicare	$16.11
Rate for Payer: Kaiser Permanente Commercial	$16.11
Rate for Payer: Kaiser Permanente Medicaid	$9.13
Rate for Payer: Kaiser Permanente Medicare	$16.11
Rate for Payer: MDX Hawaii PPO	$17.36
Rate for Payer: Ohana Health Plan Medicaid	$16.11
Rate for Payer: Ohana Health Plan Medicare	$16.11
Rate for Payer: UnitedHealthcare Medicare	$16.11
Rate for Payer: University Health Alliance Commercial	$13.05

RIFAMPIN 150 MG PO CAP

Facility

$17.90

Service Code	HCPCS A9270
Hospital Revenue Code	250
Min. Negotiated Rate	$15.21
Max. Negotiated Rate	$17.36
Rate for Payer: Cash Price	$11.64
Rate for Payer: Health Management Network Commercial	$15.21
Rate for Payer: Kaiser Permanente Commercial	$16.11
Rate for Payer: MDX Hawaii PPO	$17.36

RIFAMPIN 300 MG PO CAP

Facility

$12.33

Service Code	HCPCS A9270
Hospital Revenue Code	250
Min. Negotiated Rate	$10.48
Max. Negotiated Rate	$11.96
Rate for Payer: Cash Price	$8.01
Rate for Payer: Health Management Network Commercial	$10.48
Rate for Payer: Kaiser Permanente Commercial	$11.10
Rate for Payer: MDX Hawaii PPO	$11.96

RIFAMPIN 300 MG PO CAP

Facility

$12.33

Service Code	HCPCS A9270
Hospital Revenue Code	637
Min. Negotiated Rate	$6.17
Max. Negotiated Rate	$12.21
Rate for Payer: AlohaCare Medicaid	$6.17
Rate for Payer: AlohaCare Medicare	$11.10
Rate for Payer: Cash Price	$8.01
Rate for Payer: Devoted Health Medicare	$12.21
Rate for Payer: Hawaii Medical Service Association Medicare	$11.10
Rate for Payer: Hawaii Western Management Group Commercial	$11.71
Rate for Payer: Health Management Network Commercial	$10.48
Rate for Payer: Humana Medicare	$11.10
Rate for Payer: Kaiser Permanente Commercial	$11.10
Rate for Payer: Kaiser Permanente Medicaid	$6.29
Rate for Payer: Kaiser Permanente Medicare	$11.10
Rate for Payer: MDX Hawaii PPO	$11.96
Rate for Payer: Ohana Health Plan Medicaid	$11.10
Rate for Payer: Ohana Health Plan Medicare	$11.10
Rate for Payer: UnitedHealthcare Medicare	$11.10
Rate for Payer: University Health Alliance Commercial	$8.99

RISPERIDONE 0.5 MG PO RAPID DISSOLVING TAB

Facility

$27.14

Service Code	HCPCS A9270
Hospital Revenue Code	637
Min. Negotiated Rate	$13.57
Max. Negotiated Rate	$26.87
Rate for Payer: AlohaCare Medicaid	$13.57
Rate for Payer: AlohaCare Medicare	$24.43
Rate for Payer: Cash Price	$17.64
Rate for Payer: Devoted Health Medicare	$26.87
Rate for Payer: Hawaii Medical Service Association Medicare	$24.43
Rate for Payer: Hawaii Western Management Group Commercial	$25.78
Rate for Payer: Health Management Network Commercial	$23.07
Rate for Payer: Humana Medicare	$24.43
Rate for Payer: Kaiser Permanente Commercial	$24.43
Rate for Payer: Kaiser Permanente Medicaid	$13.84
Rate for Payer: Kaiser Permanente Medicare	$24.43
Rate for Payer: MDX Hawaii PPO	$26.33
Rate for Payer: Ohana Health Plan Medicaid	$24.43
Rate for Payer: Ohana Health Plan Medicare	$24.43
Rate for Payer: UnitedHealthcare Medicare	$24.43
Rate for Payer: University Health Alliance Commercial	$19.78

RISPERIDONE 0.5 MG PO RAPID DISSOLVING TAB

Facility

$27.14

Service Code	HCPCS A9270
Hospital Revenue Code	250
Min. Negotiated Rate	$23.07
Max. Negotiated Rate	$26.33
Rate for Payer: Cash Price	$17.64
Rate for Payer: Health Management Network Commercial	$23.07
Rate for Payer: Kaiser Permanente Commercial	$24.43
Rate for Payer: MDX Hawaii PPO	$26.33

RISPERIDONE 1 MG PO RAPID DISSOLVING TAB

Facility

$30.38

Service Code	HCPCS A9270
Hospital Revenue Code	637
Min. Negotiated Rate	$15.19
Max. Negotiated Rate	$30.08
Rate for Payer: AlohaCare Medicaid	$15.19
Rate for Payer: AlohaCare Medicare	$27.34
Rate for Payer: Cash Price	$19.75
Rate for Payer: Devoted Health Medicare	$30.08
Rate for Payer: Hawaii Medical Service Association Medicare	$27.34
Rate for Payer: Hawaii Western Management Group Commercial	$28.86
Rate for Payer: Health Management Network Commercial	$25.82
Rate for Payer: Humana Medicare	$27.34
Rate for Payer: Kaiser Permanente Commercial	$27.34
Rate for Payer: Kaiser Permanente Medicaid	$15.49
Rate for Payer: Kaiser Permanente Medicare	$27.34
Rate for Payer: MDX Hawaii PPO	$29.47
Rate for Payer: Ohana Health Plan Medicaid	$27.34
Rate for Payer: Ohana Health Plan Medicare	$27.34
Rate for Payer: UnitedHealthcare Medicare	$27.34
Rate for Payer: University Health Alliance Commercial	$22.14

RISPERIDONE 1 MG PO RAPID DISSOLVING TAB

Facility

$30.38

Service Code	HCPCS A9270
Hospital Revenue Code	250
Min. Negotiated Rate	$25.82
Max. Negotiated Rate	$29.47
Rate for Payer: Cash Price	$19.75
Rate for Payer: Health Management Network Commercial	$25.82
Rate for Payer: Kaiser Permanente Commercial	$27.34
Rate for Payer: MDX Hawaii PPO	$29.47

RISPERIDONE 4 MG PO TABLET

Facility

$67.57

Service Code	HCPCS A9270
Hospital Revenue Code	250
Min. Negotiated Rate	$57.43
Max. Negotiated Rate	$65.54
Rate for Payer: Cash Price	$43.92
Rate for Payer: Health Management Network Commercial	$57.43
Rate for Payer: Kaiser Permanente Commercial	$60.81
Rate for Payer: MDX Hawaii PPO	$65.54

RISPERIDONE 4 MG PO TABLET

Facility

$67.57

Service Code	HCPCS A9270
Hospital Revenue Code	637
Min. Negotiated Rate	$33.78
Max. Negotiated Rate	$66.89
Rate for Payer: AlohaCare Medicaid	$33.78
Rate for Payer: AlohaCare Medicare	$60.81
Rate for Payer: Cash Price	$43.92
Rate for Payer: Devoted Health Medicare	$66.89
Rate for Payer: Hawaii Medical Service Association Medicare	$60.81
Rate for Payer: Hawaii Western Management Group Commercial	$64.19
Rate for Payer: Health Management Network Commercial	$57.43
Rate for Payer: Humana Medicare	$60.81
Rate for Payer: Kaiser Permanente Commercial	$60.81
Rate for Payer: Kaiser Permanente Medicaid	$34.46
Rate for Payer: Kaiser Permanente Medicare	$60.81
Rate for Payer: MDX Hawaii PPO	$65.54
Rate for Payer: Ohana Health Plan Medicaid	$60.81
Rate for Payer: Ohana Health Plan Medicare	$60.81
Rate for Payer: UnitedHealthcare Medicare	$60.81
Rate for Payer: University Health Alliance Commercial	$49.25

RITONAVIR 100 MG PO TABLET

Facility

$64.58

Service Code	HCPCS A9270
Hospital Revenue Code	637
Min. Negotiated Rate	$32.29
Max. Negotiated Rate	$63.93
Rate for Payer: AlohaCare Medicaid	$32.29
Rate for Payer: AlohaCare Medicare	$58.12
Rate for Payer: Cash Price	$41.98
Rate for Payer: Devoted Health Medicare	$63.93
Rate for Payer: Hawaii Medical Service Association Medicare	$58.12
Rate for Payer: Hawaii Western Management Group Commercial	$61.35
Rate for Payer: Health Management Network Commercial	$54.89
Rate for Payer: Humana Medicare	$58.12
Rate for Payer: Kaiser Permanente Commercial	$58.12
Rate for Payer: Kaiser Permanente Medicaid	$32.94
Rate for Payer: Kaiser Permanente Medicare	$58.12
Rate for Payer: MDX Hawaii PPO	$62.64
Rate for Payer: Ohana Health Plan Medicaid	$58.12
Rate for Payer: Ohana Health Plan Medicare	$58.12
Rate for Payer: UnitedHealthcare Medicare	$58.12
Rate for Payer: University Health Alliance Commercial	$47.07

RITONAVIR 100 MG PO TABLET

Facility

$64.58

Service Code	HCPCS A9270
Hospital Revenue Code	250
Min. Negotiated Rate	$54.89
Max. Negotiated Rate	$62.64
Rate for Payer: Cash Price	$41.98
Rate for Payer: Health Management Network Commercial	$54.89
Rate for Payer: Kaiser Permanente Commercial	$58.12
Rate for Payer: MDX Hawaii PPO	$62.64

RIVAROXABAN 10 MG PO TABLET

Facility

$100.54

Service Code	HCPCS A9270
Hospital Revenue Code	250
Min. Negotiated Rate	$85.46
Max. Negotiated Rate	$97.52
Rate for Payer: Cash Price	$65.35
Rate for Payer: Health Management Network Commercial	$85.46
Rate for Payer: Kaiser Permanente Commercial	$90.49
Rate for Payer: MDX Hawaii PPO	$97.52

RIVAROXABAN 10 MG PO TABLET

Facility

$100.54

Service Code	HCPCS A9270
Hospital Revenue Code	637
Min. Negotiated Rate	$50.27
Max. Negotiated Rate	$99.53
Rate for Payer: AlohaCare Medicaid	$50.27
Rate for Payer: AlohaCare Medicare	$90.49
Rate for Payer: Cash Price	$65.35
Rate for Payer: Devoted Health Medicare	$99.53
Rate for Payer: Hawaii Medical Service Association Medicare	$90.49
Rate for Payer: Hawaii Western Management Group Commercial	$95.51
Rate for Payer: Health Management Network Commercial	$85.46
Rate for Payer: Humana Medicare	$90.49
Rate for Payer: Kaiser Permanente Commercial	$90.49
Rate for Payer: Kaiser Permanente Medicaid	$51.28
Rate for Payer: Kaiser Permanente Medicare	$90.49
Rate for Payer: MDX Hawaii PPO	$97.52
Rate for Payer: Ohana Health Plan Medicaid	$90.49
Rate for Payer: Ohana Health Plan Medicare	$90.49
Rate for Payer: UnitedHealthcare Medicare	$90.49
Rate for Payer: University Health Alliance Commercial	$73.28

RIVAROXABAN 15 MG PO TABLET

Facility

$100.54

Service Code	HCPCS A9270
Hospital Revenue Code	637
Min. Negotiated Rate	$50.27
Max. Negotiated Rate	$99.53
Rate for Payer: AlohaCare Medicaid	$50.27
Rate for Payer: AlohaCare Medicare	$90.49
Rate for Payer: Cash Price	$65.35
Rate for Payer: Devoted Health Medicare	$99.53
Rate for Payer: Hawaii Medical Service Association Medicare	$90.49
Rate for Payer: Hawaii Western Management Group Commercial	$95.51
Rate for Payer: Health Management Network Commercial	$85.46
Rate for Payer: Humana Medicare	$90.49
Rate for Payer: Kaiser Permanente Commercial	$90.49
Rate for Payer: Kaiser Permanente Medicaid	$51.28
Rate for Payer: Kaiser Permanente Medicare	$90.49
Rate for Payer: MDX Hawaii PPO	$97.52
Rate for Payer: Ohana Health Plan Medicaid	$90.49
Rate for Payer: Ohana Health Plan Medicare	$90.49
Rate for Payer: UnitedHealthcare Medicare	$90.49
Rate for Payer: University Health Alliance Commercial	$73.28

RIVAROXABAN 15 MG PO TABLET

Facility

$100.54

Service Code	HCPCS A9270
Hospital Revenue Code	250
Min. Negotiated Rate	$85.46
Max. Negotiated Rate	$97.52
Rate for Payer: Cash Price	$65.35
Rate for Payer: Health Management Network Commercial	$85.46
Rate for Payer: Kaiser Permanente Commercial	$90.49
Rate for Payer: MDX Hawaii PPO	$97.52

Know your out-of-pocket cost for care.

All Charges