Kohala Hospital

All Charges

Charge

Type

Setting

Price

ACETAMINOPHEN-CODEINE 300-30 MG PO TABLET

Facility

$7.03

Service Code	HCPCS A9270
Hospital Revenue Code	250
Min. Negotiated Rate	$5.98
Max. Negotiated Rate	$6.82
Rate for Payer: Cash Price	$4.57
Rate for Payer: Cash Price	$5.12
Rate for Payer: Health Management Network Commercial	$5.98
Rate for Payer: Health Management Network Commercial	$6.70
Rate for Payer: Kaiser Permanente Commercial	$6.33
Rate for Payer: Kaiser Permanente Commercial	$7.09
Rate for Payer: MDX Hawaii PPO	$7.64
Rate for Payer: MDX Hawaii PPO	$6.82

ACETAZOLAMIDE 250 MG PO TABLET

Facility

$15.24

Service Code	HCPCS A9270
Hospital Revenue Code	250
Min. Negotiated Rate	$12.95
Max. Negotiated Rate	$14.78
Rate for Payer: Cash Price	$9.91
Rate for Payer: Health Management Network Commercial	$12.95
Rate for Payer: Kaiser Permanente Commercial	$13.72
Rate for Payer: MDX Hawaii PPO	$14.78

ACETAZOLAMIDE 250 MG PO TABLET

Facility

$15.24

Service Code	HCPCS A9270
Hospital Revenue Code	637
Min. Negotiated Rate	$7.62
Max. Negotiated Rate	$15.09
Rate for Payer: AlohaCare Medicaid	$7.62
Rate for Payer: AlohaCare Medicare	$13.72
Rate for Payer: Cash Price	$9.91
Rate for Payer: Devoted Health Medicare	$15.09
Rate for Payer: Hawaii Medical Service Association Medicare	$13.72
Rate for Payer: Hawaii Western Management Group Commercial	$14.48
Rate for Payer: Health Management Network Commercial	$12.95
Rate for Payer: Humana Medicare	$13.72
Rate for Payer: Kaiser Permanente Commercial	$13.72
Rate for Payer: Kaiser Permanente Medicaid	$7.77
Rate for Payer: Kaiser Permanente Medicare	$13.72
Rate for Payer: MDX Hawaii PPO	$14.78
Rate for Payer: Ohana Health Plan Medicaid	$13.72
Rate for Payer: Ohana Health Plan Medicare	$13.72
Rate for Payer: UnitedHealthcare Medicare	$13.72
Rate for Payer: University Health Alliance Commercial	$11.11

ACETAZOLAMIDE SODIUM 500 MG INJ RECON.SOLN.

Facility

$216.72

Service Code	HCPCS J1120
Hospital Revenue Code	636
Min. Negotiated Rate	$17.23
Max. Negotiated Rate	$214.55
Rate for Payer: AlohaCare Medicaid	$108.36
Rate for Payer: AlohaCare Medicare	$195.05
Rate for Payer: Cash Price	$140.87
Rate for Payer: Cash Price	$140.87
Rate for Payer: Devoted Health Medicare	$214.55
Rate for Payer: Hawaii Medical Service Association ABD	$17.23
Rate for Payer: Hawaii Medical Service Association Medicare	$195.05
Rate for Payer: Hawaii Medical Service Association Non-ABD	$17.23
Rate for Payer: Hawaii Western Management Group Commercial	$205.88
Rate for Payer: Health Management Network Commercial	$184.21
Rate for Payer: Humana Medicare	$195.05
Rate for Payer: Kaiser Permanente Commercial	$195.05
Rate for Payer: Kaiser Permanente Medicaid	$110.53
Rate for Payer: Kaiser Permanente Medicare	$195.05
Rate for Payer: MDX Hawaii PPO	$210.22
Rate for Payer: Ohana Health Plan Medicaid	$195.05
Rate for Payer: Ohana Health Plan Medicare	$195.05
Rate for Payer: UnitedHealthcare Medicaid	$130.03
Rate for Payer: UnitedHealthcare Medicare	$195.05
Rate for Payer: University Health Alliance Commercial	$157.97

ACETAZOLAMIDE SODIUM 500 MG INJ RECON.SOLN.

Facility

$216.72

Service Code	HCPCS J1120
Hospital Revenue Code	250
Min. Negotiated Rate	$184.21
Max. Negotiated Rate	$210.22
Rate for Payer: Cash Price	$140.87
Rate for Payer: Health Management Network Commercial	$184.21
Rate for Payer: Kaiser Permanente Commercial	$195.05
Rate for Payer: MDX Hawaii PPO	$210.22

ACETYLCHOLINE CHLORIDE 1 % (10 MG/ML) INTRAOC KIT

Facility

$511.07

Service Code	NDC 24208053920
Hospital Revenue Code	250
Min. Negotiated Rate	$255.53
Max. Negotiated Rate	$505.96
Rate for Payer: AlohaCare Medicaid	$255.53
Rate for Payer: AlohaCare Medicare	$459.96
Rate for Payer: Cash Price	$332.20
Rate for Payer: Devoted Health Medicare	$505.96
Rate for Payer: Hawaii Medical Service Association Medicare	$459.96
Rate for Payer: Hawaii Western Management Group Commercial	$485.52
Rate for Payer: Health Management Network Commercial	$434.41
Rate for Payer: Humana Medicare	$459.96
Rate for Payer: Kaiser Permanente Commercial	$459.96
Rate for Payer: Kaiser Permanente Medicaid	$260.65
Rate for Payer: Kaiser Permanente Medicare	$459.96
Rate for Payer: MDX Hawaii PPO	$495.74
Rate for Payer: Ohana Health Plan Medicaid	$459.96
Rate for Payer: Ohana Health Plan Medicare	$459.96
Rate for Payer: UnitedHealthcare Medicaid	$306.64
Rate for Payer: UnitedHealthcare Medicare	$459.96
Rate for Payer: University Health Alliance Commercial	$372.52

ACETYLCHOLINE CHLORIDE 1 % (10 MG/ML) INTRAOC KIT

Facility

$511.07

Service Code	NDC 24208053920
Hospital Revenue Code	250
Min. Negotiated Rate	$434.41
Max. Negotiated Rate	$495.74
Rate for Payer: Cash Price	$332.20
Rate for Payer: Health Management Network Commercial	$434.41
Rate for Payer: Kaiser Permanente Commercial	$459.96
Rate for Payer: MDX Hawaii PPO	$495.74

ACETYLCYSTEINE 20 % (200 MG/ML) IV SOLN

Facility

$225.05

Service Code	HCPCS J0132
Hospital Revenue Code	250
Min. Negotiated Rate	$191.29
Max. Negotiated Rate	$218.30
Rate for Payer: Cash Price	$146.28
Rate for Payer: Cash Price	$460.43
Rate for Payer: Health Management Network Commercial	$191.29
Rate for Payer: Health Management Network Commercial	$602.10
Rate for Payer: Kaiser Permanente Commercial	$202.54
Rate for Payer: Kaiser Permanente Commercial	$637.51
Rate for Payer: MDX Hawaii PPO	$687.10
Rate for Payer: MDX Hawaii PPO	$218.30

ACETYLCYSTEINE 20 % (200 MG/ML) IV SOLN

Facility

$225.05

Service Code	HCPCS J0132
Hospital Revenue Code	636
Min. Negotiated Rate	$0.37
Max. Negotiated Rate	$222.80
Rate for Payer: AlohaCare Medicaid	$112.53
Rate for Payer: AlohaCare Medicaid	$354.18
Rate for Payer: AlohaCare Medicare	$637.51
Rate for Payer: AlohaCare Medicare	$202.54
Rate for Payer: Cash Price	$146.28
Rate for Payer: Cash Price	$146.28
Rate for Payer: Cash Price	$460.43
Rate for Payer: Cash Price	$460.43
Rate for Payer: Devoted Health Medicare	$222.80
Rate for Payer: Devoted Health Medicare	$701.27
Rate for Payer: Hawaii Medical Service Association ABD	$0.37
Rate for Payer: Hawaii Medical Service Association ABD	$0.37
Rate for Payer: Hawaii Medical Service Association Medicare	$637.51
Rate for Payer: Hawaii Medical Service Association Medicare	$202.54
Rate for Payer: Hawaii Medical Service Association Non-ABD	$0.37
Rate for Payer: Hawaii Medical Service Association Non-ABD	$0.37
Rate for Payer: Hawaii Western Management Group Commercial	$213.80
Rate for Payer: Hawaii Western Management Group Commercial	$672.93
Rate for Payer: Health Management Network Commercial	$602.10
Rate for Payer: Health Management Network Commercial	$191.29
Rate for Payer: Humana Medicare	$637.51
Rate for Payer: Humana Medicare	$202.54
Rate for Payer: Kaiser Permanente Commercial	$202.54
Rate for Payer: Kaiser Permanente Commercial	$637.51
Rate for Payer: Kaiser Permanente Medicaid	$361.26
Rate for Payer: Kaiser Permanente Medicaid	$114.78
Rate for Payer: Kaiser Permanente Medicare	$202.54
Rate for Payer: Kaiser Permanente Medicare	$637.51
Rate for Payer: MDX Hawaii PPO	$218.30
Rate for Payer: MDX Hawaii PPO	$687.10
Rate for Payer: Ohana Health Plan Medicaid	$637.51
Rate for Payer: Ohana Health Plan Medicaid	$202.54
Rate for Payer: Ohana Health Plan Medicare	$202.54
Rate for Payer: Ohana Health Plan Medicare	$637.51
Rate for Payer: UnitedHealthcare Medicaid	$425.01
Rate for Payer: UnitedHealthcare Medicaid	$135.03
Rate for Payer: UnitedHealthcare Medicare	$202.54
Rate for Payer: UnitedHealthcare Medicare	$637.51
Rate for Payer: University Health Alliance Commercial	$164.04
Rate for Payer: University Health Alliance Commercial	$516.32

ACETYLCYSTEINE 20 % (200 MG/ML) MISC SOLN

Facility

$140.71

Service Code	HCPCS A9270
Hospital Revenue Code	637
Min. Negotiated Rate	$70.36
Max. Negotiated Rate	$139.30
Rate for Payer: AlohaCare Medicaid	$70.36
Rate for Payer: AlohaCare Medicaid	$40.22
Rate for Payer: AlohaCare Medicare	$126.64
Rate for Payer: AlohaCare Medicare	$72.40
Rate for Payer: Cash Price	$52.29
Rate for Payer: Cash Price	$91.46
Rate for Payer: Devoted Health Medicare	$139.30
Rate for Payer: Devoted Health Medicare	$79.64
Rate for Payer: Hawaii Medical Service Association Medicare	$72.40
Rate for Payer: Hawaii Medical Service Association Medicare	$126.64
Rate for Payer: Hawaii Western Management Group Commercial	$76.42
Rate for Payer: Hawaii Western Management Group Commercial	$133.67
Rate for Payer: Health Management Network Commercial	$119.60
Rate for Payer: Health Management Network Commercial	$68.37
Rate for Payer: Humana Medicare	$72.40
Rate for Payer: Humana Medicare	$126.64
Rate for Payer: Kaiser Permanente Commercial	$126.64
Rate for Payer: Kaiser Permanente Commercial	$72.40
Rate for Payer: Kaiser Permanente Medicaid	$41.02
Rate for Payer: Kaiser Permanente Medicaid	$71.76
Rate for Payer: Kaiser Permanente Medicare	$72.40
Rate for Payer: Kaiser Permanente Medicare	$126.64
Rate for Payer: MDX Hawaii PPO	$78.03
Rate for Payer: MDX Hawaii PPO	$136.49
Rate for Payer: Ohana Health Plan Medicaid	$126.64
Rate for Payer: Ohana Health Plan Medicaid	$72.40
Rate for Payer: Ohana Health Plan Medicare	$126.64
Rate for Payer: Ohana Health Plan Medicare	$72.40
Rate for Payer: UnitedHealthcare Medicare	$126.64
Rate for Payer: UnitedHealthcare Medicare	$72.40
Rate for Payer: University Health Alliance Commercial	$58.63
Rate for Payer: University Health Alliance Commercial	$102.56

ACETYLCYSTEINE 20 % (200 MG/ML) MISC SOLN

Facility

$80.44

Service Code	HCPCS A9270
Hospital Revenue Code	250
Min. Negotiated Rate	$68.37
Max. Negotiated Rate	$78.03
Rate for Payer: Cash Price	$52.29
Rate for Payer: Cash Price	$91.46
Rate for Payer: Health Management Network Commercial	$68.37
Rate for Payer: Health Management Network Commercial	$119.60
Rate for Payer: Kaiser Permanente Commercial	$72.40
Rate for Payer: Kaiser Permanente Commercial	$126.64
Rate for Payer: MDX Hawaii PPO	$136.49
Rate for Payer: MDX Hawaii PPO	$78.03

ACTIVATED CHARCOAL-SORBITOL 25 GRAM/120 ML PO SUSP

Facility

$87.06

Service Code	HCPCS A9270
Hospital Revenue Code	250
Min. Negotiated Rate	$74.00
Max. Negotiated Rate	$84.45
Rate for Payer: Cash Price	$56.59
Rate for Payer: Health Management Network Commercial	$74.00
Rate for Payer: Kaiser Permanente Commercial	$78.35
Rate for Payer: MDX Hawaii PPO	$84.45

ACTIVATED CHARCOAL-SORBITOL 25 GRAM/120 ML PO SUSP

Facility

$87.06

Service Code	HCPCS A9270
Hospital Revenue Code	637
Min. Negotiated Rate	$43.53
Max. Negotiated Rate	$86.19
Rate for Payer: AlohaCare Medicaid	$43.53
Rate for Payer: AlohaCare Medicare	$78.35
Rate for Payer: Cash Price	$56.59
Rate for Payer: Devoted Health Medicare	$86.19
Rate for Payer: Hawaii Medical Service Association Medicare	$78.35
Rate for Payer: Hawaii Western Management Group Commercial	$82.71
Rate for Payer: Health Management Network Commercial	$74.00
Rate for Payer: Humana Medicare	$78.35
Rate for Payer: Kaiser Permanente Commercial	$78.35
Rate for Payer: Kaiser Permanente Medicaid	$44.40
Rate for Payer: Kaiser Permanente Medicare	$78.35
Rate for Payer: MDX Hawaii PPO	$84.45
Rate for Payer: Ohana Health Plan Medicaid	$78.35
Rate for Payer: Ohana Health Plan Medicare	$78.35
Rate for Payer: UnitedHealthcare Medicare	$78.35
Rate for Payer: University Health Alliance Commercial	$63.46

ACTIVATED CHARCOAL-SORBITOL 50 GRAM/240 ML PO SUSP

Facility

$185.92

Service Code	HCPCS A9270
Hospital Revenue Code	250
Min. Negotiated Rate	$158.03
Max. Negotiated Rate	$180.34
Rate for Payer: Cash Price	$120.85
Rate for Payer: Health Management Network Commercial	$158.03
Rate for Payer: Kaiser Permanente Commercial	$167.33
Rate for Payer: MDX Hawaii PPO	$180.34

ACTIVATED CHARCOAL-SORBITOL 50 GRAM/240 ML PO SUSP

Facility

$185.92

Service Code	HCPCS A9270
Hospital Revenue Code	637
Min. Negotiated Rate	$92.96
Max. Negotiated Rate	$184.06
Rate for Payer: AlohaCare Medicaid	$92.96
Rate for Payer: AlohaCare Medicare	$167.33
Rate for Payer: Cash Price	$120.85
Rate for Payer: Devoted Health Medicare	$184.06
Rate for Payer: Hawaii Medical Service Association Medicare	$167.33
Rate for Payer: Hawaii Western Management Group Commercial	$176.62
Rate for Payer: Health Management Network Commercial	$158.03
Rate for Payer: Humana Medicare	$167.33
Rate for Payer: Kaiser Permanente Commercial	$167.33
Rate for Payer: Kaiser Permanente Medicaid	$94.82
Rate for Payer: Kaiser Permanente Medicare	$167.33
Rate for Payer: MDX Hawaii PPO	$180.34
Rate for Payer: Ohana Health Plan Medicaid	$167.33
Rate for Payer: Ohana Health Plan Medicare	$167.33
Rate for Payer: UnitedHealthcare Medicare	$167.33
Rate for Payer: University Health Alliance Commercial	$135.52

ACUTE ADJUSTMENT REACTION AND PSYCHOSOCIAL DYSFUNCTION

Facility

$11,661.38

Service Code	MSDRG 880
Min. Negotiated Rate	$11,661.38
Max. Negotiated Rate	$11,661.38
Rate for Payer: Hawaii Medical Service Association Commercial	$11,661.38

ACUTE AND SUBACUTE ENDOCARDITIS WITH CC

Facility

$47,996.55

Service Code	MSDRG 289
Min. Negotiated Rate	$47,996.55
Max. Negotiated Rate	$47,996.55
Rate for Payer: Hawaii Medical Service Association Commercial	$47,996.55

ACUTE AND SUBACUTE ENDOCARDITIS WITH MCC

Facility

$47,996.55

Service Code	MSDRG 288
Min. Negotiated Rate	$47,996.55
Max. Negotiated Rate	$47,996.55
Rate for Payer: Hawaii Medical Service Association Commercial	$47,996.55

ACUTE AND SUBACUTE ENDOCARDITIS WITHOUT CC/MCC

Facility

$47,996.55

Service Code	MSDRG 290
Min. Negotiated Rate	$47,996.55
Max. Negotiated Rate	$47,996.55
Rate for Payer: Hawaii Medical Service Association Commercial	$47,996.55

ACUTE LEUKEMIA WITH CC

Facility

$139,699.59

Service Code	MSDRG 835
Min. Negotiated Rate	$139,699.59
Max. Negotiated Rate	$139,699.59
Rate for Payer: Hawaii Medical Service Association Commercial	$139,699.59

ACUTE LEUKEMIA WITH MCC

Facility

$139,699.59

Service Code	MSDRG 834
Min. Negotiated Rate	$139,699.59
Max. Negotiated Rate	$139,699.59
Rate for Payer: Hawaii Medical Service Association Commercial	$139,699.59

ACUTE LEUKEMIA WITH OTHER PROCEDURES

Facility

$139,699.59

Service Code	MSDRG 850
Min. Negotiated Rate	$139,699.59
Max. Negotiated Rate	$139,699.59
Rate for Payer: Hawaii Medical Service Association Commercial	$139,699.59

ACUTE LEUKEMIA WITHOUT CC/MCC

Facility

$139,699.59

Service Code	MSDRG 836
Min. Negotiated Rate	$139,699.59
Max. Negotiated Rate	$139,699.59
Rate for Payer: Hawaii Medical Service Association Commercial	$139,699.59

ACUTE MAJOR EYE INFECTIONS WITH CC/MCC

Facility

$9,125.27

Service Code	MSDRG 121
Min. Negotiated Rate	$9,125.27
Max. Negotiated Rate	$9,125.27
Rate for Payer: Hawaii Medical Service Association Commercial	$9,125.27

ACUTE MAJOR EYE INFECTIONS WITHOUT CC/MCC

Facility

$9,125.27

Service Code	MSDRG 122
Min. Negotiated Rate	$9,125.27
Max. Negotiated Rate	$9,125.27
Rate for Payer: Hawaii Medical Service Association Commercial	$9,125.27

Know your out-of-pocket cost for care.

All Charges