Kohala Hospital

All Charges

Charge

Type

Setting

Price

RIVAROXABAN 20 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 20 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

RIVASTIGMINE TARTRATE 1.5 MG PO CAP

Facility

$25.74

Service Code	HCPCS A9270
Hospital Revenue Code	250
Min. Negotiated Rate	$21.88
Max. Negotiated Rate	$24.97
Rate for Payer: Cash Price	$16.73
Rate for Payer: Health Management Network Commercial	$21.88
Rate for Payer: Kaiser Permanente Commercial	$23.17
Rate for Payer: MDX Hawaii PPO	$24.97

RIVASTIGMINE TARTRATE 1.5 MG PO CAP

Facility

$25.74

Service Code	HCPCS A9270
Hospital Revenue Code	637
Min. Negotiated Rate	$12.87
Max. Negotiated Rate	$25.48
Rate for Payer: AlohaCare Medicaid	$12.87
Rate for Payer: AlohaCare Medicare	$23.17
Rate for Payer: Cash Price	$16.73
Rate for Payer: Devoted Health Medicare	$25.48
Rate for Payer: Hawaii Medical Service Association Medicare	$23.17
Rate for Payer: Hawaii Western Management Group Commercial	$24.45
Rate for Payer: Health Management Network Commercial	$21.88
Rate for Payer: Humana Medicare	$23.17
Rate for Payer: Kaiser Permanente Commercial	$23.17
Rate for Payer: Kaiser Permanente Medicaid	$13.13
Rate for Payer: Kaiser Permanente Medicare	$23.17
Rate for Payer: MDX Hawaii PPO	$24.97
Rate for Payer: Ohana Health Plan Medicaid	$23.17
Rate for Payer: Ohana Health Plan Medicare	$23.17
Rate for Payer: UnitedHealthcare Medicare	$23.17
Rate for Payer: University Health Alliance Commercial	$18.76

RIVASTIGMINE TARTRATE 3 MG PO CAP

Facility

$22.26

Service Code	HCPCS A9270
Hospital Revenue Code	637
Min. Negotiated Rate	$11.13
Max. Negotiated Rate	$22.04
Rate for Payer: AlohaCare Medicaid	$11.13
Rate for Payer: AlohaCare Medicare	$20.03
Rate for Payer: Cash Price	$14.47
Rate for Payer: Devoted Health Medicare	$22.04
Rate for Payer: Hawaii Medical Service Association Medicare	$20.03
Rate for Payer: Hawaii Western Management Group Commercial	$21.15
Rate for Payer: Health Management Network Commercial	$18.92
Rate for Payer: Humana Medicare	$20.03
Rate for Payer: Kaiser Permanente Commercial	$20.03
Rate for Payer: Kaiser Permanente Medicaid	$11.35
Rate for Payer: Kaiser Permanente Medicare	$20.03
Rate for Payer: MDX Hawaii PPO	$21.59
Rate for Payer: Ohana Health Plan Medicaid	$20.03
Rate for Payer: Ohana Health Plan Medicare	$20.03
Rate for Payer: UnitedHealthcare Medicare	$20.03
Rate for Payer: University Health Alliance Commercial	$16.23

RIVASTIGMINE TARTRATE 3 MG PO CAP

Facility

$22.26

Service Code	HCPCS A9270
Hospital Revenue Code	250
Min. Negotiated Rate	$18.92
Max. Negotiated Rate	$21.59
Rate for Payer: Cash Price	$14.47
Rate for Payer: Health Management Network Commercial	$18.92
Rate for Payer: Kaiser Permanente Commercial	$20.03
Rate for Payer: MDX Hawaii PPO	$21.59

ROCURONIUM 10 MG/ML IV SOLN

Facility

$20.51

Service Code	NDC 00409318910
Hospital Revenue Code	250
Min. Negotiated Rate	$10.26
Max. Negotiated Rate	$20.30
Rate for Payer: AlohaCare Medicaid	$10.26
Rate for Payer: AlohaCare Medicare	$18.46
Rate for Payer: Cash Price	$13.33
Rate for Payer: Devoted Health Medicare	$20.30
Rate for Payer: Hawaii Medical Service Association Medicare	$18.46
Rate for Payer: Hawaii Western Management Group Commercial	$19.48
Rate for Payer: Health Management Network Commercial	$17.43
Rate for Payer: Humana Medicare	$18.46
Rate for Payer: Kaiser Permanente Commercial	$18.46
Rate for Payer: Kaiser Permanente Medicaid	$10.46
Rate for Payer: Kaiser Permanente Medicare	$18.46
Rate for Payer: MDX Hawaii PPO	$19.89
Rate for Payer: Ohana Health Plan Medicaid	$18.46
Rate for Payer: Ohana Health Plan Medicare	$18.46
Rate for Payer: UnitedHealthcare Medicaid	$12.31
Rate for Payer: UnitedHealthcare Medicare	$18.46
Rate for Payer: University Health Alliance Commercial	$14.95

ROCURONIUM 10 MG/ML IV SOLN

Facility

$60.38

Service Code	NDC 55150022505
Hospital Revenue Code	250
Min. Negotiated Rate	$51.32
Max. Negotiated Rate	$58.57
Rate for Payer: Cash Price	$39.25
Rate for Payer: Health Management Network Commercial	$51.32
Rate for Payer: Kaiser Permanente Commercial	$54.34
Rate for Payer: MDX Hawaii PPO	$58.57

ROCURONIUM 10 MG/ML IV SOLN

Facility

$60.38

Service Code	NDC 55150022505
Hospital Revenue Code	250
Min. Negotiated Rate	$30.19
Max. Negotiated Rate	$59.78
Rate for Payer: AlohaCare Medicaid	$30.19
Rate for Payer: AlohaCare Medicare	$54.34
Rate for Payer: Cash Price	$39.25
Rate for Payer: Devoted Health Medicare	$59.78
Rate for Payer: Hawaii Medical Service Association Medicare	$54.34
Rate for Payer: Hawaii Western Management Group Commercial	$57.36
Rate for Payer: Health Management Network Commercial	$51.32
Rate for Payer: Humana Medicare	$54.34
Rate for Payer: Kaiser Permanente Commercial	$54.34
Rate for Payer: Kaiser Permanente Medicaid	$30.79
Rate for Payer: Kaiser Permanente Medicare	$54.34
Rate for Payer: MDX Hawaii PPO	$58.57
Rate for Payer: Ohana Health Plan Medicaid	$54.34
Rate for Payer: Ohana Health Plan Medicare	$54.34
Rate for Payer: UnitedHealthcare Medicaid	$36.23
Rate for Payer: UnitedHealthcare Medicare	$54.34
Rate for Payer: University Health Alliance Commercial	$44.01

ROCURONIUM 10 MG/ML IV SOLN

Facility

$16.56

Service Code	NDC 00143925001
Hospital Revenue Code	250
Min. Negotiated Rate	$14.08
Max. Negotiated Rate	$16.06
Rate for Payer: Cash Price	$10.76
Rate for Payer: Health Management Network Commercial	$14.08
Rate for Payer: Kaiser Permanente Commercial	$14.90
Rate for Payer: MDX Hawaii PPO	$16.06

ROCURONIUM 10 MG/ML IV SOLN

Facility

$16.56

Service Code	NDC 00143925001
Hospital Revenue Code	250
Min. Negotiated Rate	$8.28
Max. Negotiated Rate	$16.39
Rate for Payer: AlohaCare Medicaid	$8.28
Rate for Payer: AlohaCare Medicare	$14.90
Rate for Payer: Cash Price	$10.76
Rate for Payer: Devoted Health Medicare	$16.39
Rate for Payer: Hawaii Medical Service Association Medicare	$14.90
Rate for Payer: Hawaii Western Management Group Commercial	$15.73
Rate for Payer: Health Management Network Commercial	$14.08
Rate for Payer: Humana Medicare	$14.90
Rate for Payer: Kaiser Permanente Commercial	$14.90
Rate for Payer: Kaiser Permanente Medicaid	$8.45
Rate for Payer: Kaiser Permanente Medicare	$14.90
Rate for Payer: MDX Hawaii PPO	$16.06
Rate for Payer: Ohana Health Plan Medicaid	$14.90
Rate for Payer: Ohana Health Plan Medicare	$14.90
Rate for Payer: UnitedHealthcare Medicaid	$9.94
Rate for Payer: UnitedHealthcare Medicare	$14.90
Rate for Payer: University Health Alliance Commercial	$12.07

ROCURONIUM 10 MG/ML IV SOLN

Facility

$16.56

Service Code	NDC 00143925010
Hospital Revenue Code	250
Min. Negotiated Rate	$14.08
Max. Negotiated Rate	$16.06
Rate for Payer: Cash Price	$10.76
Rate for Payer: Health Management Network Commercial	$14.08
Rate for Payer: Kaiser Permanente Commercial	$14.90
Rate for Payer: MDX Hawaii PPO	$16.06

ROCURONIUM 10 MG/ML IV SOLN

Facility

$16.56

Service Code	NDC 00143925010
Hospital Revenue Code	250
Min. Negotiated Rate	$8.28
Max. Negotiated Rate	$16.39
Rate for Payer: AlohaCare Medicaid	$8.28
Rate for Payer: AlohaCare Medicare	$14.90
Rate for Payer: Cash Price	$10.76
Rate for Payer: Devoted Health Medicare	$16.39
Rate for Payer: Hawaii Medical Service Association Medicare	$14.90
Rate for Payer: Hawaii Western Management Group Commercial	$15.73
Rate for Payer: Health Management Network Commercial	$14.08
Rate for Payer: Humana Medicare	$14.90
Rate for Payer: Kaiser Permanente Commercial	$14.90
Rate for Payer: Kaiser Permanente Medicaid	$8.45
Rate for Payer: Kaiser Permanente Medicare	$14.90
Rate for Payer: MDX Hawaii PPO	$16.06
Rate for Payer: Ohana Health Plan Medicaid	$14.90
Rate for Payer: Ohana Health Plan Medicare	$14.90
Rate for Payer: UnitedHealthcare Medicaid	$9.94
Rate for Payer: UnitedHealthcare Medicare	$14.90
Rate for Payer: University Health Alliance Commercial	$12.07

ROCURONIUM 10 MG/ML IV SOLN

Facility

$20.51

Service Code	NDC 00409318905
Hospital Revenue Code	250
Min. Negotiated Rate	$17.43
Max. Negotiated Rate	$19.89
Rate for Payer: Cash Price	$13.33
Rate for Payer: Health Management Network Commercial	$17.43
Rate for Payer: Kaiser Permanente Commercial	$18.46
Rate for Payer: MDX Hawaii PPO	$19.89

ROCURONIUM 10 MG/ML IV SOLN

Facility

$20.51

Service Code	NDC 00409318910
Hospital Revenue Code	250
Min. Negotiated Rate	$17.43
Max. Negotiated Rate	$19.89
Rate for Payer: Cash Price	$13.33
Rate for Payer: Health Management Network Commercial	$17.43
Rate for Payer: Kaiser Permanente Commercial	$18.46
Rate for Payer: MDX Hawaii PPO	$19.89

ROCURONIUM 10 MG/ML IV SOLN

Facility

$20.51

Service Code	NDC 00409318905
Hospital Revenue Code	250
Min. Negotiated Rate	$10.26
Max. Negotiated Rate	$20.30
Rate for Payer: AlohaCare Medicaid	$10.26
Rate for Payer: AlohaCare Medicare	$18.46
Rate for Payer: Cash Price	$13.33
Rate for Payer: Devoted Health Medicare	$20.30
Rate for Payer: Hawaii Medical Service Association Medicare	$18.46
Rate for Payer: Hawaii Western Management Group Commercial	$19.48
Rate for Payer: Health Management Network Commercial	$17.43
Rate for Payer: Humana Medicare	$18.46
Rate for Payer: Kaiser Permanente Commercial	$18.46
Rate for Payer: Kaiser Permanente Medicaid	$10.46
Rate for Payer: Kaiser Permanente Medicare	$18.46
Rate for Payer: MDX Hawaii PPO	$19.89
Rate for Payer: Ohana Health Plan Medicaid	$18.46
Rate for Payer: Ohana Health Plan Medicare	$18.46
Rate for Payer: UnitedHealthcare Medicaid	$12.31
Rate for Payer: UnitedHealthcare Medicare	$18.46
Rate for Payer: University Health Alliance Commercial	$14.95

SACUBITRIL-VALSARTAN 24-26 MG PO TABLET

Facility

$66.67

Service Code	HCPCS A9270
Hospital Revenue Code	637
Min. Negotiated Rate	$33.34
Max. Negotiated Rate	$66.00
Rate for Payer: Kaiser Permanente Medicaid	$34.00
Rate for Payer: AlohaCare Medicaid	$33.34
Rate for Payer: AlohaCare Medicaid	$32.74
Rate for Payer: AlohaCare Medicare	$58.93
Rate for Payer: AlohaCare Medicare	$60.00
Rate for Payer: Cash Price	$42.56
Rate for Payer: Cash Price	$43.34
Rate for Payer: Devoted Health Medicare	$64.83
Rate for Payer: Devoted Health Medicare	$66.00
Rate for Payer: Hawaii Medical Service Association Medicare	$60.00
Rate for Payer: Hawaii Medical Service Association Medicare	$58.93
Rate for Payer: Hawaii Western Management Group Commercial	$63.34
Rate for Payer: Hawaii Western Management Group Commercial	$62.21
Rate for Payer: Health Management Network Commercial	$55.66
Rate for Payer: Health Management Network Commercial	$56.67
Rate for Payer: Humana Medicare	$58.93
Rate for Payer: Humana Medicare	$60.00
Rate for Payer: Kaiser Permanente Commercial	$58.93
Rate for Payer: Kaiser Permanente Commercial	$60.00
Rate for Payer: Kaiser Permanente Medicaid	$33.39
Rate for Payer: Kaiser Permanente Medicare	$60.00
Rate for Payer: Kaiser Permanente Medicare	$58.93
Rate for Payer: MDX Hawaii PPO	$64.67
Rate for Payer: MDX Hawaii PPO	$63.52
Rate for Payer: Ohana Health Plan Medicaid	$58.93
Rate for Payer: Ohana Health Plan Medicaid	$60.00
Rate for Payer: Ohana Health Plan Medicare	$58.93
Rate for Payer: Ohana Health Plan Medicare	$60.00
Rate for Payer: UnitedHealthcare Medicare	$58.93
Rate for Payer: UnitedHealthcare Medicare	$60.00
Rate for Payer: University Health Alliance Commercial	$47.73
Rate for Payer: University Health Alliance Commercial	$48.60

SACUBITRIL-VALSARTAN 24-26 MG PO TABLET

Facility

$66.67

Service Code	HCPCS A9270
Hospital Revenue Code	250
Min. Negotiated Rate	$56.67
Max. Negotiated Rate	$64.67
Rate for Payer: Cash Price	$43.34
Rate for Payer: Cash Price	$42.56
Rate for Payer: Health Management Network Commercial	$55.66
Rate for Payer: Health Management Network Commercial	$56.67
Rate for Payer: Kaiser Permanente Commercial	$58.93
Rate for Payer: Kaiser Permanente Commercial	$60.00
Rate for Payer: MDX Hawaii PPO	$64.67
Rate for Payer: MDX Hawaii PPO	$63.52

SALIVARY GLAND PROCEDURES

Facility

$21,758.44

Service Code	MSDRG 139
Min. Negotiated Rate	$21,758.44
Max. Negotiated Rate	$21,758.44
Rate for Payer: Hawaii Medical Service Association Commercial	$21,758.44

SCOPOLAMINE BASE 1 MG OVER 3 DAYS TRANSDERM PT3D

Facility

$101.63

Service Code	HCPCS A9270
Hospital Revenue Code	637
Min. Negotiated Rate	$50.81
Max. Negotiated Rate	$100.61
Rate for Payer: AlohaCare Medicaid	$50.81
Rate for Payer: AlohaCare Medicaid	$56.56
Rate for Payer: AlohaCare Medicare	$101.81
Rate for Payer: AlohaCare Medicare	$91.47
Rate for Payer: Cash Price	$66.06
Rate for Payer: Cash Price	$73.53
Rate for Payer: Devoted Health Medicare	$111.99
Rate for Payer: Devoted Health Medicare	$100.61
Rate for Payer: Hawaii Medical Service Association Medicare	$101.81
Rate for Payer: Hawaii Medical Service Association Medicare	$91.47
Rate for Payer: Hawaii Western Management Group Commercial	$107.46
Rate for Payer: Hawaii Western Management Group Commercial	$96.55
Rate for Payer: Health Management Network Commercial	$86.39
Rate for Payer: Health Management Network Commercial	$96.15
Rate for Payer: Humana Medicare	$101.81
Rate for Payer: Humana Medicare	$91.47
Rate for Payer: Kaiser Permanente Commercial	$91.47
Rate for Payer: Kaiser Permanente Commercial	$101.81
Rate for Payer: Kaiser Permanente Medicaid	$57.69
Rate for Payer: Kaiser Permanente Medicaid	$51.83
Rate for Payer: Kaiser Permanente Medicare	$91.47
Rate for Payer: Kaiser Permanente Medicare	$101.81
Rate for Payer: MDX Hawaii PPO	$98.58
Rate for Payer: MDX Hawaii PPO	$109.73
Rate for Payer: Ohana Health Plan Medicaid	$91.47
Rate for Payer: Ohana Health Plan Medicaid	$101.81
Rate for Payer: Ohana Health Plan Medicare	$91.47
Rate for Payer: Ohana Health Plan Medicare	$101.81
Rate for Payer: UnitedHealthcare Medicare	$91.47
Rate for Payer: UnitedHealthcare Medicare	$101.81
Rate for Payer: University Health Alliance Commercial	$74.08
Rate for Payer: University Health Alliance Commercial	$82.45

SCOPOLAMINE BASE 1 MG OVER 3 DAYS TRANSDERM PT3D

Facility

$101.63

Service Code	HCPCS A9270
Hospital Revenue Code	250
Min. Negotiated Rate	$86.39
Max. Negotiated Rate	$98.58
Rate for Payer: Cash Price	$66.06
Rate for Payer: Cash Price	$73.53
Rate for Payer: Health Management Network Commercial	$96.15
Rate for Payer: Health Management Network Commercial	$86.39
Rate for Payer: Kaiser Permanente Commercial	$101.81
Rate for Payer: Kaiser Permanente Commercial	$91.47
Rate for Payer: MDX Hawaii PPO	$98.58
Rate for Payer: MDX Hawaii PPO	$109.73

SEIZURES WITH MCC

Facility

$22,730.22

Service Code	MSDRG 100
Min. Negotiated Rate	$22,730.22
Max. Negotiated Rate	$22,730.22
Rate for Payer: Hawaii Medical Service Association Commercial	$22,730.22

SEIZURES WITHOUT MCC

Facility

$19,625.26

Service Code	MSDRG 101
Min. Negotiated Rate	$19,625.26
Max. Negotiated Rate	$19,625.26
Rate for Payer: Hawaii Medical Service Association Commercial	$19,625.26

SEMAGLUTIDE 0.25 MG OR 0.5 MG (2 MG/3 ML) SUBCUTANEOUS PEN INJECTOR

Facility

$2,310.98

Service Code	NDC 00169418113
Hospital Revenue Code	637
Min. Negotiated Rate	$1,155.49
Max. Negotiated Rate	$2,287.87
Rate for Payer: AlohaCare Medicaid	$1,155.49
Rate for Payer: AlohaCare Medicare	$2,079.88
Rate for Payer: Cash Price	$1,502.14
Rate for Payer: Devoted Health Medicare	$2,287.87
Rate for Payer: Hawaii Medical Service Association Medicare	$2,079.88
Rate for Payer: Hawaii Western Management Group Commercial	$2,195.43
Rate for Payer: Health Management Network Commercial	$1,964.33
Rate for Payer: Humana Medicare	$2,079.88
Rate for Payer: Kaiser Permanente Commercial	$2,079.88
Rate for Payer: Kaiser Permanente Medicaid	$1,178.60
Rate for Payer: Kaiser Permanente Medicare	$2,079.88
Rate for Payer: MDX Hawaii PPO	$2,241.65
Rate for Payer: Ohana Health Plan Medicaid	$2,079.88
Rate for Payer: Ohana Health Plan Medicare	$2,079.88
Rate for Payer: UnitedHealthcare Medicare	$2,079.88
Rate for Payer: University Health Alliance Commercial	$1,684.47

SEMAGLUTIDE 0.25 MG OR 0.5 MG (2 MG/3 ML) SUBCUTANEOUS PEN INJECTOR

Facility

$2,310.98

Service Code	NDC 00169418113
Hospital Revenue Code	250
Min. Negotiated Rate	$1,964.33
Max. Negotiated Rate	$2,241.65
Rate for Payer: Cash Price	$1,502.14
Rate for Payer: Health Management Network Commercial	$1,964.33
Rate for Payer: Kaiser Permanente Commercial	$2,079.88
Rate for Payer: MDX Hawaii PPO	$2,241.65

Know your out-of-pocket cost for care.

All Charges