Kohala Hospital

All Charges

Charge

Type

Setting

Price

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 00169418103
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 1 MG/DOSE (4 MG/3 ML) SUBCUTANEOUS PEN INJECTOR

Facility

$2,310.98

Service Code	HCPCS A9270
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

SEMAGLUTIDE 1 MG/DOSE (4 MG/3 ML) SUBCUTANEOUS PEN INJECTOR

Facility

$2,310.98

Service Code	HCPCS A9270
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 2 MG/DOSE (8 MG/3 ML) SUBCUTANEOUS PEN INJECTOR

Facility

$2,310.98

Service Code	HCPCS A9270
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 2 MG/DOSE (8 MG/3 ML) SUBCUTANEOUS PEN INJECTOR

Facility

$2,310.98

Service Code	HCPCS A9270
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

SENNOSIDES 8.6 MG PO TABLET

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

SENNOSIDES 8.6 MG PO TABLET

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

SENNOSIDES 8.8 MG/5 ML PO SYRUP

Facility

$16.43

Service Code	HCPCS A9270
Hospital Revenue Code	250
Min. Negotiated Rate	$13.97
Max. Negotiated Rate	$15.94
Rate for Payer: Cash Price	$10.68
Rate for Payer: Health Management Network Commercial	$13.97
Rate for Payer: Kaiser Permanente Commercial	$14.79
Rate for Payer: MDX Hawaii PPO	$15.94

SENNOSIDES 8.8 MG/5 ML PO SYRUP

Facility

$16.43

Service Code	HCPCS A9270
Hospital Revenue Code	637
Min. Negotiated Rate	$8.21
Max. Negotiated Rate	$16.27
Rate for Payer: AlohaCare Medicaid	$8.21
Rate for Payer: AlohaCare Medicare	$14.79
Rate for Payer: Cash Price	$10.68
Rate for Payer: Devoted Health Medicare	$16.27
Rate for Payer: Hawaii Medical Service Association Medicare	$14.79
Rate for Payer: Hawaii Western Management Group Commercial	$15.61
Rate for Payer: Health Management Network Commercial	$13.97
Rate for Payer: Humana Medicare	$14.79
Rate for Payer: Kaiser Permanente Commercial	$14.79
Rate for Payer: Kaiser Permanente Medicaid	$8.38
Rate for Payer: Kaiser Permanente Medicare	$14.79
Rate for Payer: MDX Hawaii PPO	$15.94
Rate for Payer: Ohana Health Plan Medicaid	$14.79
Rate for Payer: Ohana Health Plan Medicare	$14.79
Rate for Payer: UnitedHealthcare Medicare	$14.79
Rate for Payer: University Health Alliance Commercial	$11.98

SEPTIC ARTHRITIS WITH CC

Facility

$24,460.46

Service Code	MSDRG 549
Min. Negotiated Rate	$24,460.46
Max. Negotiated Rate	$24,460.46
Rate for Payer: Hawaii Medical Service Association Commercial	$24,460.46

SEPTIC ARTHRITIS WITH MCC

Facility

$24,460.46

Service Code	MSDRG 548
Min. Negotiated Rate	$24,460.46
Max. Negotiated Rate	$24,460.46
Rate for Payer: Hawaii Medical Service Association Commercial	$24,460.46

SEPTIC ARTHRITIS WITHOUT CC/MCC

Facility

$24,460.46

Service Code	MSDRG 550
Min. Negotiated Rate	$24,460.46
Max. Negotiated Rate	$24,460.46
Rate for Payer: Hawaii Medical Service Association Commercial	$24,460.46

SEPTICEMIA OR SEVERE SEPSIS WITH MV >96 HOURS

Facility

$182,695.02

Service Code	MSDRG 870
Min. Negotiated Rate	$182,695.02
Max. Negotiated Rate	$182,695.02
Rate for Payer: Hawaii Medical Service Association Commercial	$182,695.02

SEPTICEMIA OR SEVERE SEPSIS WITHOUT MV >96 HOURS WITH MCC

Facility

$40,814.84

Service Code	MSDRG 871
Min. Negotiated Rate	$40,814.84
Max. Negotiated Rate	$40,814.84
Rate for Payer: Hawaii Medical Service Association Commercial	$40,814.84

SEPTICEMIA OR SEVERE SEPSIS WITHOUT MV >96 HOURS WITHOUT MCC

Facility

$40,791.14

Service Code	MSDRG 872
Min. Negotiated Rate	$40,791.14
Max. Negotiated Rate	$40,791.14
Rate for Payer: Hawaii Medical Service Association Commercial	$40,791.14

SERTRALINE 100 MG PO TABLET

Facility

$2.94

Service Code	HCPCS A9270
Hospital Revenue Code	250
Min. Negotiated Rate	$2.50
Max. Negotiated Rate	$2.85
Rate for Payer: Cash Price	$1.91
Rate for Payer: Health Management Network Commercial	$2.50
Rate for Payer: Kaiser Permanente Commercial	$2.65
Rate for Payer: MDX Hawaii PPO	$2.85

SERTRALINE 100 MG PO TABLET

Facility

$2.94

Service Code	HCPCS A9270
Hospital Revenue Code	637
Min. Negotiated Rate	$1.47
Max. Negotiated Rate	$2.91
Rate for Payer: AlohaCare Medicaid	$1.47
Rate for Payer: AlohaCare Medicare	$2.65
Rate for Payer: Cash Price	$1.91
Rate for Payer: Devoted Health Medicare	$2.91
Rate for Payer: Hawaii Medical Service Association Medicare	$2.65
Rate for Payer: Hawaii Western Management Group Commercial	$2.79
Rate for Payer: Health Management Network Commercial	$2.50
Rate for Payer: Humana Medicare	$2.65
Rate for Payer: Kaiser Permanente Commercial	$2.65
Rate for Payer: Kaiser Permanente Medicaid	$1.50
Rate for Payer: Kaiser Permanente Medicare	$2.65
Rate for Payer: MDX Hawaii PPO	$2.85
Rate for Payer: Ohana Health Plan Medicaid	$2.65
Rate for Payer: Ohana Health Plan Medicare	$2.65
Rate for Payer: UnitedHealthcare Medicare	$2.65
Rate for Payer: University Health Alliance Commercial	$2.14

SERTRALINE 25 MG PO TABLET

Facility

$2.22

Service Code	HCPCS A9270
Hospital Revenue Code	250
Min. Negotiated Rate	$1.89
Max. Negotiated Rate	$2.15
Rate for Payer: Cash Price	$1.44
Rate for Payer: Health Management Network Commercial	$1.89
Rate for Payer: Kaiser Permanente Commercial	$2.00
Rate for Payer: MDX Hawaii PPO	$2.15

SERTRALINE 25 MG PO TABLET

Facility

$2.22

Service Code	HCPCS A9270
Hospital Revenue Code	637
Min. Negotiated Rate	$1.11
Max. Negotiated Rate	$2.20
Rate for Payer: AlohaCare Medicaid	$1.11
Rate for Payer: AlohaCare Medicare	$2.00
Rate for Payer: Cash Price	$1.44
Rate for Payer: Devoted Health Medicare	$2.20
Rate for Payer: Hawaii Medical Service Association Medicare	$2.00
Rate for Payer: Hawaii Western Management Group Commercial	$2.11
Rate for Payer: Health Management Network Commercial	$1.89
Rate for Payer: Humana Medicare	$2.00
Rate for Payer: Kaiser Permanente Commercial	$2.00
Rate for Payer: Kaiser Permanente Medicaid	$1.13
Rate for Payer: Kaiser Permanente Medicare	$2.00
Rate for Payer: MDX Hawaii PPO	$2.15
Rate for Payer: Ohana Health Plan Medicaid	$2.00
Rate for Payer: Ohana Health Plan Medicare	$2.00
Rate for Payer: UnitedHealthcare Medicare	$2.00
Rate for Payer: University Health Alliance Commercial	$1.62

SERTRALINE 50 MG PO TABLET

Facility

$2.22

Service Code	HCPCS A9270
Hospital Revenue Code	637
Min. Negotiated Rate	$1.11
Max. Negotiated Rate	$2.20
Rate for Payer: AlohaCare Medicaid	$1.11
Rate for Payer: AlohaCare Medicare	$2.00
Rate for Payer: Cash Price	$1.44
Rate for Payer: Devoted Health Medicare	$2.20
Rate for Payer: Hawaii Medical Service Association Medicare	$2.00
Rate for Payer: Hawaii Western Management Group Commercial	$2.11
Rate for Payer: Health Management Network Commercial	$1.89
Rate for Payer: Humana Medicare	$2.00
Rate for Payer: Kaiser Permanente Commercial	$2.00
Rate for Payer: Kaiser Permanente Medicaid	$1.13
Rate for Payer: Kaiser Permanente Medicare	$2.00
Rate for Payer: MDX Hawaii PPO	$2.15
Rate for Payer: Ohana Health Plan Medicaid	$2.00
Rate for Payer: Ohana Health Plan Medicare	$2.00
Rate for Payer: UnitedHealthcare Medicare	$2.00
Rate for Payer: University Health Alliance Commercial	$1.62

SERTRALINE 50 MG PO TABLET

Facility

$2.22

Service Code	HCPCS A9270
Hospital Revenue Code	250
Min. Negotiated Rate	$1.89
Max. Negotiated Rate	$2.15
Rate for Payer: Cash Price	$1.44
Rate for Payer: Health Management Network Commercial	$1.89
Rate for Payer: Kaiser Permanente Commercial	$2.00
Rate for Payer: MDX Hawaii PPO	$2.15

SHOULDER, ELBOW OR FOREARM PROCEDURES, EXCEPT MAJOR JOINT PROCEDURES WITH CC

Facility

$23,180.56

Service Code	MSDRG 511
Min. Negotiated Rate	$23,180.56
Max. Negotiated Rate	$23,180.56
Rate for Payer: Hawaii Medical Service Association Commercial	$23,180.56

SHOULDER, ELBOW OR FOREARM PROCEDURES, EXCEPT MAJOR JOINT PROCEDURES WITH MCC

Facility

$23,180.56

Service Code	MSDRG 510
Min. Negotiated Rate	$23,180.56
Max. Negotiated Rate	$23,180.56
Rate for Payer: Hawaii Medical Service Association Commercial	$23,180.56

SHOULDER, ELBOW OR FOREARM PROCEDURES, EXCEPT MAJOR JOINT PROCEDURES WITHOUT CC/MCC

Facility

$21,782.14

Service Code	MSDRG 512
Min. Negotiated Rate	$21,782.14
Max. Negotiated Rate	$21,782.14
Rate for Payer: Hawaii Medical Service Association Commercial	$21,782.14

Know your out-of-pocket cost for care.

All Charges