Kohala Hospital

All Charges

Charge

Type

Setting

Price

SIGNS AND SYMPTOMS OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH MCC

Facility

$10,499.99

Service Code	MSDRG 555
Min. Negotiated Rate	$10,499.99
Max. Negotiated Rate	$10,499.99
Rate for Payer: Hawaii Medical Service Association Commercial	$10,499.99

SIGNS AND SYMPTOMS OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITHOUT MCC

Facility

$10,499.99

Service Code	MSDRG 556
Min. Negotiated Rate	$10,499.99
Max. Negotiated Rate	$10,499.99
Rate for Payer: Hawaii Medical Service Association Commercial	$10,499.99

SIGNS AND SYMPTOMS WITH MCC

Facility

$14,387.11

Service Code	MSDRG 947
Min. Negotiated Rate	$14,387.11
Max. Negotiated Rate	$14,387.11
Rate for Payer: Hawaii Medical Service Association Commercial	$14,387.11

SIGNS AND SYMPTOMS WITHOUT MCC

Facility

$13,676.05

Service Code	MSDRG 948
Min. Negotiated Rate	$13,676.05
Max. Negotiated Rate	$13,676.05
Rate for Payer: Hawaii Medical Service Association Commercial	$13,676.05

SILDENAFIL (PULM.HYPERTENSION) 20 MG PO TABLET

Facility

$4.64

Service Code	HCPCS A9270
Hospital Revenue Code	637
Min. Negotiated Rate	$2.32
Max. Negotiated Rate	$4.59
Rate for Payer: AlohaCare Medicaid	$2.32
Rate for Payer: AlohaCare Medicare	$4.18
Rate for Payer: Cash Price	$3.02
Rate for Payer: Devoted Health Medicare	$4.59
Rate for Payer: Hawaii Medical Service Association Medicare	$4.18
Rate for Payer: Hawaii Western Management Group Commercial	$4.41
Rate for Payer: Health Management Network Commercial	$3.94
Rate for Payer: Humana Medicare	$4.18
Rate for Payer: Kaiser Permanente Commercial	$4.18
Rate for Payer: Kaiser Permanente Medicaid	$2.37
Rate for Payer: Kaiser Permanente Medicare	$4.18
Rate for Payer: MDX Hawaii PPO	$4.50
Rate for Payer: Ohana Health Plan Medicaid	$4.18
Rate for Payer: Ohana Health Plan Medicare	$4.18
Rate for Payer: UnitedHealthcare Medicare	$4.18
Rate for Payer: University Health Alliance Commercial	$3.38

SILDENAFIL (PULM.HYPERTENSION) 20 MG PO TABLET

Facility

$4.64

Service Code	HCPCS A9270
Hospital Revenue Code	250
Min. Negotiated Rate	$3.94
Max. Negotiated Rate	$4.50
Rate for Payer: Cash Price	$3.02
Rate for Payer: Health Management Network Commercial	$3.94
Rate for Payer: Kaiser Permanente Commercial	$4.18
Rate for Payer: MDX Hawaii PPO	$4.50

SILVER NITRATE APPLICATORS 75-25 % TOP STICK

Facility

$4.17

Service Code	NDC 12870000101
Hospital Revenue Code	250
Min. Negotiated Rate	$2.08
Max. Negotiated Rate	$4.13
Rate for Payer: AlohaCare Medicaid	$2.08
Rate for Payer: AlohaCare Medicare	$3.75
Rate for Payer: Cash Price	$2.71
Rate for Payer: Devoted Health Medicare	$4.13
Rate for Payer: Hawaii Medical Service Association Medicare	$3.75
Rate for Payer: Hawaii Western Management Group Commercial	$3.96
Rate for Payer: Health Management Network Commercial	$3.54
Rate for Payer: Humana Medicare	$3.75
Rate for Payer: Kaiser Permanente Commercial	$3.75
Rate for Payer: Kaiser Permanente Medicaid	$2.13
Rate for Payer: Kaiser Permanente Medicare	$3.75
Rate for Payer: MDX Hawaii PPO	$4.04
Rate for Payer: Ohana Health Plan Medicaid	$3.75
Rate for Payer: Ohana Health Plan Medicare	$3.75
Rate for Payer: UnitedHealthcare Medicaid	$2.50
Rate for Payer: UnitedHealthcare Medicare	$3.75
Rate for Payer: University Health Alliance Commercial	$3.04

SILVER NITRATE APPLICATORS 75-25 % TOP STICK

Facility

$4.17

Service Code	NDC 12870000101
Hospital Revenue Code	250
Min. Negotiated Rate	$3.54
Max. Negotiated Rate	$4.04
Rate for Payer: Cash Price	$2.71
Rate for Payer: Health Management Network Commercial	$3.54
Rate for Payer: Kaiser Permanente Commercial	$3.75
Rate for Payer: MDX Hawaii PPO	$4.04

SILVER SULFADIAZINE 1 % TOP CR

Facility

$53.61

Service Code	HCPCS A9270
Hospital Revenue Code	250
Min. Negotiated Rate	$45.57
Max. Negotiated Rate	$52.00
Rate for Payer: Cash Price	$34.85
Rate for Payer: Cash Price	$89.64
Rate for Payer: Health Management Network Commercial	$117.22
Rate for Payer: Health Management Network Commercial	$45.57
Rate for Payer: Kaiser Permanente Commercial	$124.11
Rate for Payer: Kaiser Permanente Commercial	$48.25
Rate for Payer: MDX Hawaii PPO	$52.00
Rate for Payer: MDX Hawaii PPO	$133.76

SILVER SULFADIAZINE 1 % TOP CR

Facility

$53.61

Service Code	HCPCS A9270
Hospital Revenue Code	637
Min. Negotiated Rate	$26.80
Max. Negotiated Rate	$53.07
Rate for Payer: AlohaCare Medicaid	$26.80
Rate for Payer: AlohaCare Medicaid	$68.95
Rate for Payer: AlohaCare Medicare	$124.11
Rate for Payer: AlohaCare Medicare	$48.25
Rate for Payer: Cash Price	$89.64
Rate for Payer: Cash Price	$34.85
Rate for Payer: Devoted Health Medicare	$136.52
Rate for Payer: Devoted Health Medicare	$53.07
Rate for Payer: Hawaii Medical Service Association Medicare	$48.25
Rate for Payer: Hawaii Medical Service Association Medicare	$124.11
Rate for Payer: Hawaii Western Management Group Commercial	$50.93
Rate for Payer: Hawaii Western Management Group Commercial	$131.00
Rate for Payer: Health Management Network Commercial	$117.22
Rate for Payer: Health Management Network Commercial	$45.57
Rate for Payer: Humana Medicare	$124.11
Rate for Payer: Humana Medicare	$48.25
Rate for Payer: Kaiser Permanente Commercial	$124.11
Rate for Payer: Kaiser Permanente Commercial	$48.25
Rate for Payer: Kaiser Permanente Medicaid	$70.33
Rate for Payer: Kaiser Permanente Medicaid	$27.34
Rate for Payer: Kaiser Permanente Medicare	$48.25
Rate for Payer: Kaiser Permanente Medicare	$124.11
Rate for Payer: MDX Hawaii PPO	$52.00
Rate for Payer: MDX Hawaii PPO	$133.76
Rate for Payer: Ohana Health Plan Medicaid	$124.11
Rate for Payer: Ohana Health Plan Medicaid	$48.25
Rate for Payer: Ohana Health Plan Medicare	$124.11
Rate for Payer: Ohana Health Plan Medicare	$48.25
Rate for Payer: UnitedHealthcare Medicare	$124.11
Rate for Payer: UnitedHealthcare Medicare	$48.25
Rate for Payer: University Health Alliance Commercial	$100.52
Rate for Payer: University Health Alliance Commercial	$39.08

SIMETHICONE 40 MG/0.6 ML PO DRPS

Facility

$53.13

Service Code	HCPCS A9270
Hospital Revenue Code	250
Min. Negotiated Rate	$45.16
Max. Negotiated Rate	$51.54
Rate for Payer: Cash Price	$34.53
Rate for Payer: Cash Price	$7.86
Rate for Payer: Health Management Network Commercial	$45.16
Rate for Payer: Health Management Network Commercial	$10.28
Rate for Payer: Kaiser Permanente Commercial	$47.82
Rate for Payer: Kaiser Permanente Commercial	$10.88
Rate for Payer: MDX Hawaii PPO	$11.73
Rate for Payer: MDX Hawaii PPO	$51.54

SIMETHICONE 40 MG/0.6 ML PO DRPS

Facility

$12.09

Service Code	HCPCS A9270
Hospital Revenue Code	637
Min. Negotiated Rate	$6.04
Max. Negotiated Rate	$11.97
Rate for Payer: AlohaCare Medicaid	$6.04
Rate for Payer: AlohaCare Medicaid	$26.57
Rate for Payer: AlohaCare Medicare	$10.88
Rate for Payer: AlohaCare Medicare	$47.82
Rate for Payer: Cash Price	$34.53
Rate for Payer: Cash Price	$7.86
Rate for Payer: Devoted Health Medicare	$11.97
Rate for Payer: Devoted Health Medicare	$52.60
Rate for Payer: Hawaii Medical Service Association Medicare	$47.82
Rate for Payer: Hawaii Medical Service Association Medicare	$10.88
Rate for Payer: Hawaii Western Management Group Commercial	$50.47
Rate for Payer: Hawaii Western Management Group Commercial	$11.49
Rate for Payer: Health Management Network Commercial	$10.28
Rate for Payer: Health Management Network Commercial	$45.16
Rate for Payer: Humana Medicare	$47.82
Rate for Payer: Humana Medicare	$10.88
Rate for Payer: Kaiser Permanente Commercial	$10.88
Rate for Payer: Kaiser Permanente Commercial	$47.82
Rate for Payer: Kaiser Permanente Medicaid	$27.10
Rate for Payer: Kaiser Permanente Medicaid	$6.17
Rate for Payer: Kaiser Permanente Medicare	$47.82
Rate for Payer: Kaiser Permanente Medicare	$10.88
Rate for Payer: MDX Hawaii PPO	$51.54
Rate for Payer: MDX Hawaii PPO	$11.73
Rate for Payer: Ohana Health Plan Medicaid	$10.88
Rate for Payer: Ohana Health Plan Medicaid	$47.82
Rate for Payer: Ohana Health Plan Medicare	$10.88
Rate for Payer: Ohana Health Plan Medicare	$47.82
Rate for Payer: UnitedHealthcare Medicare	$10.88
Rate for Payer: UnitedHealthcare Medicare	$47.82
Rate for Payer: University Health Alliance Commercial	$38.73
Rate for Payer: University Health Alliance Commercial	$8.81

SIMETHICONE 80 MG PO CHEW

Facility

$1.30

Service Code	HCPCS A9270
Hospital Revenue Code	250
Min. Negotiated Rate	$1.10
Max. Negotiated Rate	$1.26
Rate for Payer: Cash Price	$0.85
Rate for Payer: Cash Price	$0.78
Rate for Payer: Health Management Network Commercial	$1.10
Rate for Payer: Health Management Network Commercial	$1.02
Rate for Payer: Kaiser Permanente Commercial	$1.17
Rate for Payer: Kaiser Permanente Commercial	$1.08
Rate for Payer: MDX Hawaii PPO	$1.16
Rate for Payer: MDX Hawaii PPO	$1.26

SIMETHICONE 80 MG PO CHEW

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 Medicaid	$0.65
Rate for Payer: AlohaCare Medicare	$1.08
Rate for Payer: AlohaCare Medicare	$1.17
Rate for Payer: Cash Price	$0.85
Rate for Payer: Cash Price	$0.78
Rate for Payer: Devoted Health Medicare	$1.19
Rate for Payer: Devoted Health Medicare	$1.29
Rate for Payer: Hawaii Medical Service Association Medicare	$1.17
Rate for Payer: Hawaii Medical Service Association Medicare	$1.08
Rate for Payer: Hawaii Western Management Group Commercial	$1.24
Rate for Payer: Hawaii Western Management Group Commercial	$1.14
Rate for Payer: Health Management Network Commercial	$1.02
Rate for Payer: Health Management Network Commercial	$1.10
Rate for Payer: Humana Medicare	$1.17
Rate for Payer: Humana Medicare	$1.08
Rate for Payer: Kaiser Permanente Commercial	$1.08
Rate for Payer: Kaiser Permanente Commercial	$1.17
Rate for Payer: Kaiser Permanente Medicaid	$0.66
Rate for Payer: Kaiser Permanente Medicaid	$0.61
Rate for Payer: Kaiser Permanente Medicare	$1.17
Rate for Payer: Kaiser Permanente Medicare	$1.08
Rate for Payer: MDX Hawaii PPO	$1.26
Rate for Payer: MDX Hawaii PPO	$1.16
Rate for Payer: Ohana Health Plan Medicaid	$1.08
Rate for Payer: Ohana Health Plan Medicaid	$1.17
Rate for Payer: Ohana Health Plan Medicare	$1.08
Rate for Payer: Ohana Health Plan Medicare	$1.17
Rate for Payer: UnitedHealthcare Medicare	$1.08
Rate for Payer: UnitedHealthcare Medicare	$1.17
Rate for Payer: University Health Alliance Commercial	$0.95
Rate for Payer: University Health Alliance Commercial	$0.87

SIMPLE PNEUMONIA AND PLEURISY WITH CC

Facility

$23,796.81

Service Code	MSDRG 194
Min. Negotiated Rate	$23,796.81
Max. Negotiated Rate	$23,796.81
Rate for Payer: Hawaii Medical Service Association Commercial	$23,796.81

SIMPLE PNEUMONIA AND PLEURISY WITH MCC

Facility

$24,626.38

Service Code	MSDRG 193
Min. Negotiated Rate	$24,626.38
Max. Negotiated Rate	$24,626.38
Rate for Payer: Hawaii Medical Service Association Commercial	$24,626.38

SIMPLE PNEUMONIA AND PLEURISY WITHOUT CC/MCC

Facility

$18,937.90

Service Code	MSDRG 195
Min. Negotiated Rate	$18,937.90
Max. Negotiated Rate	$18,937.90
Rate for Payer: Hawaii Medical Service Association Commercial	$18,937.90

SIMULTANEOUS PANCREAS AND KIDNEY TRANSPLANT

Facility

$696,862.50

Service Code	MSDRG 008
Min. Negotiated Rate	$10,400.00
Max. Negotiated Rate	$696,862.50
Rate for Payer: Hawaii Medical Service Association Commercial	$696,862.50
Rate for Payer: University Health Alliance Commercial	$10,400.00

SINCALIDE 5 MCG INJ RECON.SOLN.

Facility

$523.65

Service Code	HCPCS J2805
Hospital Revenue Code	250
Min. Negotiated Rate	$445.10
Max. Negotiated Rate	$507.94
Rate for Payer: Cash Price	$340.37
Rate for Payer: Health Management Network Commercial	$445.10
Rate for Payer: Kaiser Permanente Commercial	$471.29
Rate for Payer: MDX Hawaii PPO	$507.94

SINCALIDE 5 MCG INJ RECON.SOLN.

Facility

$523.65

Service Code	HCPCS J2805
Hospital Revenue Code	636
Min. Negotiated Rate	$135.97
Max. Negotiated Rate	$518.41
Rate for Payer: AlohaCare Medicaid	$261.82
Rate for Payer: AlohaCare Medicare	$471.29
Rate for Payer: Cash Price	$340.37
Rate for Payer: Cash Price	$340.37
Rate for Payer: Devoted Health Medicare	$518.41
Rate for Payer: Hawaii Medical Service Association ABD	$135.97
Rate for Payer: Hawaii Medical Service Association Medicare	$471.29
Rate for Payer: Hawaii Medical Service Association Non-ABD	$135.97
Rate for Payer: Hawaii Western Management Group Commercial	$497.47
Rate for Payer: Health Management Network Commercial	$445.10
Rate for Payer: Humana Medicare	$471.29
Rate for Payer: Kaiser Permanente Commercial	$471.29
Rate for Payer: Kaiser Permanente Medicaid	$267.06
Rate for Payer: Kaiser Permanente Medicare	$471.29
Rate for Payer: MDX Hawaii PPO	$507.94
Rate for Payer: Ohana Health Plan Medicaid	$471.29
Rate for Payer: Ohana Health Plan Medicare	$471.29
Rate for Payer: UnitedHealthcare Medicaid	$314.19
Rate for Payer: UnitedHealthcare Medicare	$471.29
Rate for Payer: University Health Alliance Commercial	$381.69

SINGLE LEVEL COMBINED ANTERIOR AND POSTERIOR SPINAL FUSION EXCEPT CERVICAL

Facility

$115,594.65

Service Code	MSDRG 402
Min. Negotiated Rate	$115,594.65
Max. Negotiated Rate	$115,594.65
Rate for Payer: Hawaii Medical Service Association Commercial	$115,594.65

SINUS AND MASTOID PROCEDURES WITH CC/MCC

Facility

$25,882.58

Service Code	MSDRG 135
Min. Negotiated Rate	$25,882.58
Max. Negotiated Rate	$25,882.58
Rate for Payer: Hawaii Medical Service Association Commercial	$25,882.58

SINUS AND MASTOID PROCEDURES WITHOUT CC/MCC

Facility

$25,882.58

Service Code	MSDRG 136
Min. Negotiated Rate	$25,882.58
Max. Negotiated Rate	$25,882.58
Rate for Payer: Hawaii Medical Service Association Commercial	$25,882.58

SITAGLIPTIN PHOSPHATE 50 MG PO TABLET

Facility

$63.54

Service Code	HCPCS A9270
Hospital Revenue Code	637
Min. Negotiated Rate	$31.77
Max. Negotiated Rate	$62.90
Rate for Payer: AlohaCare Medicaid	$31.77
Rate for Payer: AlohaCare Medicare	$57.19
Rate for Payer: Cash Price	$41.30
Rate for Payer: Devoted Health Medicare	$62.90
Rate for Payer: Hawaii Medical Service Association Medicare	$57.19
Rate for Payer: Hawaii Western Management Group Commercial	$60.36
Rate for Payer: Health Management Network Commercial	$54.01
Rate for Payer: Humana Medicare	$57.19
Rate for Payer: Kaiser Permanente Commercial	$57.19
Rate for Payer: Kaiser Permanente Medicaid	$32.41
Rate for Payer: Kaiser Permanente Medicare	$57.19
Rate for Payer: MDX Hawaii PPO	$61.63
Rate for Payer: Ohana Health Plan Medicaid	$57.19
Rate for Payer: Ohana Health Plan Medicare	$57.19
Rate for Payer: UnitedHealthcare Medicare	$57.19
Rate for Payer: University Health Alliance Commercial	$46.31

SITAGLIPTIN PHOSPHATE 50 MG PO TABLET

Facility

$63.54

Service Code	HCPCS A9270
Hospital Revenue Code	250
Min. Negotiated Rate	$54.01
Max. Negotiated Rate	$61.63
Rate for Payer: Cash Price	$41.30
Rate for Payer: Health Management Network Commercial	$54.01
Rate for Payer: Kaiser Permanente Commercial	$57.19
Rate for Payer: MDX Hawaii PPO	$61.63

Know your out-of-pocket cost for care.

All Charges