Kohala Hospital

All Charges

Charge

Type

Setting

Price

CERVICAL SPINAL FUSION WITH MCC

Facility

$61,909.62

Service Code	MSDRG 471
Min. Negotiated Rate	$61,909.62
Max. Negotiated Rate	$61,909.62
Rate for Payer: Hawaii Medical Service Association Commercial	$61,909.62

CERVICAL SPINAL FUSION WITHOUT CC/MCC

Facility

$46,005.58

Service Code	MSDRG 473
Min. Negotiated Rate	$46,005.58
Max. Negotiated Rate	$46,005.58
Rate for Payer: Hawaii Medical Service Association Commercial	$46,005.58

CESAREAN SECTION WITHOUT STERILIZATION WITH CC

Facility

$19,103.81

Service Code	MSDRG 787
Min. Negotiated Rate	$7,800.00
Max. Negotiated Rate	$19,103.81
Rate for Payer: Hawaii Medical Service Association Commercial	$19,103.81
Rate for Payer: Hawaii Western Management Group Commercial	$7,800.00
Rate for Payer: University Health Alliance Commercial	$9,950.00

CESAREAN SECTION WITHOUT STERILIZATION WITH MCC

Facility

$19,103.81

Service Code	MSDRG 786
Min. Negotiated Rate	$7,800.00
Max. Negotiated Rate	$19,103.81
Rate for Payer: Hawaii Medical Service Association Commercial	$19,103.81
Rate for Payer: Hawaii Western Management Group Commercial	$7,800.00
Rate for Payer: University Health Alliance Commercial	$9,950.00

CESAREAN SECTION WITHOUT STERILIZATION WITHOUT CC/MCC

Facility

$16,923.23

Service Code	MSDRG 788
Min. Negotiated Rate	$16,923.23
Max. Negotiated Rate	$16,923.23
Rate for Payer: Hawaii Medical Service Association Commercial	$16,923.23

CESAREAN SECTION WITH STERILIZATION WITH CC

Facility

$19,103.81

Service Code	MSDRG 784
Min. Negotiated Rate	$7,800.00
Max. Negotiated Rate	$19,103.81
Rate for Payer: Hawaii Medical Service Association Commercial	$19,103.81
Rate for Payer: Hawaii Western Management Group Commercial	$7,800.00
Rate for Payer: University Health Alliance Commercial	$9,950.00

CESAREAN SECTION WITH STERILIZATION WITH MCC

Facility

$19,103.81

Service Code	MSDRG 783
Min. Negotiated Rate	$7,800.00
Max. Negotiated Rate	$19,103.81
Rate for Payer: Hawaii Medical Service Association Commercial	$19,103.81
Rate for Payer: Hawaii Western Management Group Commercial	$7,800.00
Rate for Payer: University Health Alliance Commercial	$9,950.00

CESAREAN SECTION WITH STERILIZATION WITHOUT CC/MCC

Facility

$16,923.23

Service Code	MSDRG 785
Min. Negotiated Rate	$7,800.00
Max. Negotiated Rate	$16,923.23
Rate for Payer: Hawaii Medical Service Association Commercial	$16,923.23
Rate for Payer: Hawaii Western Management Group Commercial	$7,800.00
Rate for Payer: University Health Alliance Commercial	$9,950.00

CHEMOTHERAPY WITH ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS OR WITH HIGH DOSE CHEMOTHERAPY AGENT WITH MCC

Facility

$57,975.09

Service Code	MSDRG 837
Min. Negotiated Rate	$57,975.09
Max. Negotiated Rate	$57,975.09
Rate for Payer: Hawaii Medical Service Association Commercial	$57,975.09

CHEMOTHERAPY WITH ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS WITH CC OR HIGH DOSE CHEMOTHERAPY AGENT

Facility

$57,975.09

Service Code	MSDRG 838
Min. Negotiated Rate	$57,975.09
Max. Negotiated Rate	$57,975.09
Rate for Payer: Hawaii Medical Service Association Commercial	$57,975.09

CHEMOTHERAPY WITH ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS WITHOUT CC/MCC

Facility

$57,975.09

Service Code	MSDRG 839
Min. Negotiated Rate	$57,975.09
Max. Negotiated Rate	$57,975.09
Rate for Payer: Hawaii Medical Service Association Commercial	$57,975.09

CHEMOTHERAPY WITHOUT ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS WITH CC

Facility

$18,511.26

Service Code	MSDRG 847
Min. Negotiated Rate	$18,511.26
Max. Negotiated Rate	$18,511.26
Rate for Payer: Hawaii Medical Service Association Commercial	$18,511.26

CHEMOTHERAPY WITHOUT ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS WITH MCC

Facility

$18,511.26

Service Code	MSDRG 846
Min. Negotiated Rate	$18,511.26
Max. Negotiated Rate	$18,511.26
Rate for Payer: Hawaii Medical Service Association Commercial	$18,511.26

CHEMOTHERAPY WITHOUT ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS WITHOUT CC/MCC

Facility

$18,511.26

Service Code	MSDRG 848
Min. Negotiated Rate	$18,511.26
Max. Negotiated Rate	$18,511.26
Rate for Payer: Hawaii Medical Service Association Commercial	$18,511.26

CHEST PAIN

Facility

$11,448.07

Service Code	MSDRG 313
Min. Negotiated Rate	$11,448.07
Max. Negotiated Rate	$11,448.07
Rate for Payer: Hawaii Medical Service Association Commercial	$11,448.07

CHLORDIAZEPOXIDE HCL 10 MG PO CAP

Facility

$3.43

Service Code	HCPCS A9270
Hospital Revenue Code	637
Min. Negotiated Rate	$1.72
Max. Negotiated Rate	$3.40
Rate for Payer: AlohaCare Medicaid	$1.72
Rate for Payer: AlohaCare Medicare	$3.09
Rate for Payer: Cash Price	$2.23
Rate for Payer: Devoted Health Medicare	$3.40
Rate for Payer: Hawaii Medical Service Association Medicare	$3.09
Rate for Payer: Hawaii Western Management Group Commercial	$3.26
Rate for Payer: Health Management Network Commercial	$2.92
Rate for Payer: Humana Medicare	$3.09
Rate for Payer: Kaiser Permanente Commercial	$3.09
Rate for Payer: Kaiser Permanente Medicaid	$1.75
Rate for Payer: Kaiser Permanente Medicare	$3.09
Rate for Payer: MDX Hawaii PPO	$3.33
Rate for Payer: Ohana Health Plan Medicaid	$3.09
Rate for Payer: Ohana Health Plan Medicare	$3.09
Rate for Payer: UnitedHealthcare Medicare	$3.09
Rate for Payer: University Health Alliance Commercial	$2.50

CHLORDIAZEPOXIDE HCL 10 MG PO CAP

Facility

$3.43

Service Code	HCPCS A9270
Hospital Revenue Code	250
Min. Negotiated Rate	$2.92
Max. Negotiated Rate	$3.33
Rate for Payer: Cash Price	$2.23
Rate for Payer: Health Management Network Commercial	$2.92
Rate for Payer: Kaiser Permanente Commercial	$3.09
Rate for Payer: MDX Hawaii PPO	$3.33

CHLORDIAZEPOXIDE HCL 25 MG PO CAP

Facility

$3.70

Service Code	HCPCS A9270
Hospital Revenue Code	250
Min. Negotiated Rate	$3.15
Max. Negotiated Rate	$3.59
Rate for Payer: Cash Price	$2.41
Rate for Payer: Health Management Network Commercial	$3.15
Rate for Payer: Kaiser Permanente Commercial	$3.33
Rate for Payer: MDX Hawaii PPO	$3.59

CHLORDIAZEPOXIDE HCL 25 MG PO CAP

Facility

$3.70

Service Code	HCPCS A9270
Hospital Revenue Code	637
Min. Negotiated Rate	$1.85
Max. Negotiated Rate	$3.66
Rate for Payer: AlohaCare Medicaid	$1.85
Rate for Payer: AlohaCare Medicare	$3.33
Rate for Payer: Cash Price	$2.41
Rate for Payer: Devoted Health Medicare	$3.66
Rate for Payer: Hawaii Medical Service Association Medicare	$3.33
Rate for Payer: Hawaii Western Management Group Commercial	$3.52
Rate for Payer: Health Management Network Commercial	$3.15
Rate for Payer: Humana Medicare	$3.33
Rate for Payer: Kaiser Permanente Commercial	$3.33
Rate for Payer: Kaiser Permanente Medicaid	$1.89
Rate for Payer: Kaiser Permanente Medicare	$3.33
Rate for Payer: MDX Hawaii PPO	$3.59
Rate for Payer: Ohana Health Plan Medicaid	$3.33
Rate for Payer: Ohana Health Plan Medicare	$3.33
Rate for Payer: UnitedHealthcare Medicare	$3.33
Rate for Payer: University Health Alliance Commercial	$2.70

CHLORDIAZEPOXIDE HCL 5 MG PO CAP

Facility

$1.95

Service Code	HCPCS A9270
Hospital Revenue Code	250
Min. Negotiated Rate	$1.66
Max. Negotiated Rate	$1.89
Rate for Payer: Cash Price	$1.27
Rate for Payer: Health Management Network Commercial	$1.66
Rate for Payer: Kaiser Permanente Commercial	$1.75
Rate for Payer: MDX Hawaii PPO	$1.89

CHLORDIAZEPOXIDE HCL 5 MG PO CAP

Facility

$1.95

Service Code	HCPCS A9270
Hospital Revenue Code	637
Min. Negotiated Rate	$0.98
Max. Negotiated Rate	$1.93
Rate for Payer: AlohaCare Medicaid	$0.98
Rate for Payer: AlohaCare Medicare	$1.75
Rate for Payer: Cash Price	$1.27
Rate for Payer: Devoted Health Medicare	$1.93
Rate for Payer: Hawaii Medical Service Association Medicare	$1.75
Rate for Payer: Hawaii Western Management Group Commercial	$1.85
Rate for Payer: Health Management Network Commercial	$1.66
Rate for Payer: Humana Medicare	$1.75
Rate for Payer: Kaiser Permanente Commercial	$1.75
Rate for Payer: Kaiser Permanente Medicaid	$0.99
Rate for Payer: Kaiser Permanente Medicare	$1.75
Rate for Payer: MDX Hawaii PPO	$1.89
Rate for Payer: Ohana Health Plan Medicaid	$1.75
Rate for Payer: Ohana Health Plan Medicare	$1.75
Rate for Payer: UnitedHealthcare Medicare	$1.75
Rate for Payer: University Health Alliance Commercial	$1.42

CHLORHEXIDINE GLUCONATE 0.12 % MM MOUTHWASH

Facility

$12.92

Service Code	HCPCS A9270
Hospital Revenue Code	637
Min. Negotiated Rate	$6.46
Max. Negotiated Rate	$12.79
Rate for Payer: AlohaCare Medicaid	$6.46
Rate for Payer: AlohaCare Medicaid	$5.96
Rate for Payer: AlohaCare Medicaid	$6.29
Rate for Payer: AlohaCare Medicare	$10.74
Rate for Payer: AlohaCare Medicare	$11.63
Rate for Payer: AlohaCare Medicare	$11.33
Rate for Payer: Cash Price	$8.18
Rate for Payer: Cash Price	$7.75
Rate for Payer: Cash Price	$8.40
Rate for Payer: Devoted Health Medicare	$12.46
Rate for Payer: Devoted Health Medicare	$11.81
Rate for Payer: Devoted Health Medicare	$12.79
Rate for Payer: Hawaii Medical Service Association Medicare	$10.74
Rate for Payer: Hawaii Medical Service Association Medicare	$11.33
Rate for Payer: Hawaii Medical Service Association Medicare	$11.63
Rate for Payer: Hawaii Western Management Group Commercial	$11.96
Rate for Payer: Hawaii Western Management Group Commercial	$12.27
Rate for Payer: Hawaii Western Management Group Commercial	$11.33
Rate for Payer: Health Management Network Commercial	$10.14
Rate for Payer: Health Management Network Commercial	$10.98
Rate for Payer: Health Management Network Commercial	$10.70
Rate for Payer: Humana Medicare	$10.74
Rate for Payer: Humana Medicare	$11.33
Rate for Payer: Humana Medicare	$11.63
Rate for Payer: Kaiser Permanente Commercial	$11.63
Rate for Payer: Kaiser Permanente Commercial	$10.74
Rate for Payer: Kaiser Permanente Commercial	$11.33
Rate for Payer: Kaiser Permanente Medicaid	$6.08
Rate for Payer: Kaiser Permanente Medicaid	$6.59
Rate for Payer: Kaiser Permanente Medicaid	$6.42
Rate for Payer: Kaiser Permanente Medicare	$10.74
Rate for Payer: Kaiser Permanente Medicare	$11.63
Rate for Payer: Kaiser Permanente Medicare	$11.33
Rate for Payer: MDX Hawaii PPO	$12.53
Rate for Payer: MDX Hawaii PPO	$12.21
Rate for Payer: MDX Hawaii PPO	$11.57
Rate for Payer: Ohana Health Plan Medicaid	$10.74
Rate for Payer: Ohana Health Plan Medicaid	$11.33
Rate for Payer: Ohana Health Plan Medicaid	$11.63
Rate for Payer: Ohana Health Plan Medicare	$10.74
Rate for Payer: Ohana Health Plan Medicare	$11.33
Rate for Payer: Ohana Health Plan Medicare	$11.63
Rate for Payer: UnitedHealthcare Medicare	$11.33
Rate for Payer: UnitedHealthcare Medicare	$11.63
Rate for Payer: UnitedHealthcare Medicare	$10.74
Rate for Payer: University Health Alliance Commercial	$9.42
Rate for Payer: University Health Alliance Commercial	$8.70
Rate for Payer: University Health Alliance Commercial	$9.18

CHLORHEXIDINE GLUCONATE 0.12 % MM MOUTHWASH

Facility

$12.92

Service Code	HCPCS A9270
Hospital Revenue Code	250
Min. Negotiated Rate	$10.98
Max. Negotiated Rate	$12.53
Rate for Payer: Cash Price	$8.40
Rate for Payer: Cash Price	$8.18
Rate for Payer: Cash Price	$7.75
Rate for Payer: Health Management Network Commercial	$10.98
Rate for Payer: Health Management Network Commercial	$10.14
Rate for Payer: Health Management Network Commercial	$10.70
Rate for Payer: Kaiser Permanente Commercial	$11.33
Rate for Payer: Kaiser Permanente Commercial	$10.74
Rate for Payer: Kaiser Permanente Commercial	$11.63
Rate for Payer: MDX Hawaii PPO	$12.21
Rate for Payer: MDX Hawaii PPO	$11.57
Rate for Payer: MDX Hawaii PPO	$12.53

CHLORPROMAZINE 100 MG PO TABLET

Facility

$79.64

Service Code	HCPCS A9270
Hospital Revenue Code	637
Min. Negotiated Rate	$39.82
Max. Negotiated Rate	$78.84
Rate for Payer: AlohaCare Medicaid	$39.82
Rate for Payer: AlohaCare Medicare	$71.68
Rate for Payer: Cash Price	$51.77
Rate for Payer: Devoted Health Medicare	$78.84
Rate for Payer: Hawaii Medical Service Association Medicare	$71.68
Rate for Payer: Hawaii Western Management Group Commercial	$75.66
Rate for Payer: Health Management Network Commercial	$67.69
Rate for Payer: Humana Medicare	$71.68
Rate for Payer: Kaiser Permanente Commercial	$71.68
Rate for Payer: Kaiser Permanente Medicaid	$40.62
Rate for Payer: Kaiser Permanente Medicare	$71.68
Rate for Payer: MDX Hawaii PPO	$77.25
Rate for Payer: Ohana Health Plan Medicaid	$71.68
Rate for Payer: Ohana Health Plan Medicare	$71.68
Rate for Payer: UnitedHealthcare Medicare	$71.68
Rate for Payer: University Health Alliance Commercial	$58.05

CHLORPROMAZINE 100 MG PO TABLET

Facility

$79.64

Service Code	HCPCS A9270
Hospital Revenue Code	250
Min. Negotiated Rate	$67.69
Max. Negotiated Rate	$77.25
Rate for Payer: Cash Price	$51.77
Rate for Payer: Health Management Network Commercial	$67.69
Rate for Payer: Kaiser Permanente Commercial	$71.68
Rate for Payer: MDX Hawaii PPO	$77.25

Know your out-of-pocket cost for care.

All Charges