Kohala Hospital

All Charges

Charge

Type

Setting

Price

SUMATRIPTAN SUCCINATE 6 MG/0.5 ML SUBCUTANEOUS SOLN

Facility

$72.65

Service Code	HCPCS J3030
Hospital Revenue Code	250
Min. Negotiated Rate	$61.75
Max. Negotiated Rate	$70.47
Rate for Payer: Cash Price	$47.22
Rate for Payer: Cash Price	$43.99
Rate for Payer: Health Management Network Commercial	$61.75
Rate for Payer: Health Management Network Commercial	$57.53
Rate for Payer: Kaiser Permanente Commercial	$60.91
Rate for Payer: Kaiser Permanente Commercial	$65.39
Rate for Payer: MDX Hawaii PPO	$65.65
Rate for Payer: MDX Hawaii PPO	$70.47

SURGICEL 0.5" X 2" 1955 [2702249]

Facility

$262.36

Hospital Charge Code	2702249.0
Hospital Revenue Code	272
Min. Negotiated Rate	$131.18
Max. Negotiated Rate	$259.74
Rate for Payer: AlohaCare Medicaid	$131.18
Rate for Payer: AlohaCare Medicare	$236.12
Rate for Payer: Cash Price	$170.53
Rate for Payer: Devoted Health Medicare	$259.74
Rate for Payer: Hawaii Medical Service Association Medicare	$236.12
Rate for Payer: Hawaii Western Management Group Commercial	$249.24
Rate for Payer: Health Management Network Commercial	$223.01
Rate for Payer: Humana Medicare	$236.12
Rate for Payer: Kaiser Permanente Commercial	$236.12
Rate for Payer: Kaiser Permanente Medicaid	$133.80
Rate for Payer: Kaiser Permanente Medicare	$236.12
Rate for Payer: MDX Hawaii PPO	$254.49
Rate for Payer: Ohana Health Plan Medicaid	$236.12
Rate for Payer: Ohana Health Plan Medicare	$236.12
Rate for Payer: UnitedHealthcare Medicare	$236.12
Rate for Payer: University Health Alliance Commercial	$191.23

SURGICEL 0.5" X 2" 1955 [2702249]

Facility

$262.36

Hospital Charge Code	2702249.0
Hospital Revenue Code	272
Min. Negotiated Rate	$223.01
Max. Negotiated Rate	$254.49
Rate for Payer: Cash Price	$170.53
Rate for Payer: Health Management Network Commercial	$223.01
Rate for Payer: Kaiser Permanente Commercial	$236.12
Rate for Payer: MDX Hawaii PPO	$254.49

SYNCOPE AND COLLAPSE

Facility

$14,007.88

Service Code	MSDRG 312
Min. Negotiated Rate	$14,007.88
Max. Negotiated Rate	$14,007.88
Rate for Payer: Hawaii Medical Service Association Commercial	$14,007.88

TACROLIMUS 1 MG PO CAP

Facility

$7.55

Service Code	HCPCS J7507
Hospital Revenue Code	250
Min. Negotiated Rate	$6.42
Max. Negotiated Rate	$7.32
Rate for Payer: Cash Price	$4.91
Rate for Payer: Cash Price	$16.00
Rate for Payer: Health Management Network Commercial	$6.42
Rate for Payer: Health Management Network Commercial	$20.93
Rate for Payer: Kaiser Permanente Commercial	$22.16
Rate for Payer: Kaiser Permanente Commercial	$6.79
Rate for Payer: MDX Hawaii PPO	$7.32
Rate for Payer: MDX Hawaii PPO	$23.88

TACROLIMUS 1 MG PO CAP

Facility

$24.62

Service Code	HCPCS J7507
Hospital Revenue Code	636
Min. Negotiated Rate	$0.15
Max. Negotiated Rate	$24.37
Rate for Payer: AlohaCare Medicaid	$12.31
Rate for Payer: AlohaCare Medicaid	$3.77
Rate for Payer: AlohaCare Medicare	$6.79
Rate for Payer: AlohaCare Medicare	$22.16
Rate for Payer: Cash Price	$4.91
Rate for Payer: Cash Price	$16.00
Rate for Payer: Cash Price	$16.00
Rate for Payer: Cash Price	$4.91
Rate for Payer: Devoted Health Medicare	$7.47
Rate for Payer: Devoted Health Medicare	$24.37
Rate for Payer: Hawaii Medical Service Association ABD	$0.15
Rate for Payer: Hawaii Medical Service Association ABD	$0.15
Rate for Payer: Hawaii Medical Service Association Medicare	$22.16
Rate for Payer: Hawaii Medical Service Association Medicare	$6.79
Rate for Payer: Hawaii Medical Service Association Non-ABD	$0.15
Rate for Payer: Hawaii Medical Service Association Non-ABD	$0.15
Rate for Payer: Hawaii Western Management Group Commercial	$7.17
Rate for Payer: Hawaii Western Management Group Commercial	$23.39
Rate for Payer: Health Management Network Commercial	$20.93
Rate for Payer: Health Management Network Commercial	$6.42
Rate for Payer: Humana Medicare	$6.79
Rate for Payer: Humana Medicare	$22.16
Rate for Payer: Kaiser Permanente Commercial	$22.16
Rate for Payer: Kaiser Permanente Commercial	$6.79
Rate for Payer: Kaiser Permanente Medicaid	$3.85
Rate for Payer: Kaiser Permanente Medicaid	$12.56
Rate for Payer: Kaiser Permanente Medicare	$6.79
Rate for Payer: Kaiser Permanente Medicare	$22.16
Rate for Payer: MDX Hawaii PPO	$23.88
Rate for Payer: MDX Hawaii PPO	$7.32
Rate for Payer: Ohana Health Plan Medicaid	$6.79
Rate for Payer: Ohana Health Plan Medicaid	$22.16
Rate for Payer: Ohana Health Plan Medicare	$22.16
Rate for Payer: Ohana Health Plan Medicare	$6.79
Rate for Payer: UnitedHealthcare Medicaid	$4.53
Rate for Payer: UnitedHealthcare Medicaid	$14.77
Rate for Payer: UnitedHealthcare Medicare	$22.16
Rate for Payer: UnitedHealthcare Medicare	$6.79
Rate for Payer: University Health Alliance Commercial	$17.95
Rate for Payer: University Health Alliance Commercial	$5.50

TAMSULOSIN 0.4 MG PO CAP

Facility

$23.27

Service Code	HCPCS A9270
Hospital Revenue Code	250
Min. Negotiated Rate	$19.78
Max. Negotiated Rate	$22.57
Rate for Payer: Cash Price	$15.13
Rate for Payer: Health Management Network Commercial	$19.78
Rate for Payer: Kaiser Permanente Commercial	$20.94
Rate for Payer: MDX Hawaii PPO	$22.57

TAMSULOSIN 0.4 MG PO CAP

Facility

$23.27

Service Code	HCPCS A9270
Hospital Revenue Code	637
Min. Negotiated Rate	$11.63
Max. Negotiated Rate	$23.04
Rate for Payer: AlohaCare Medicaid	$11.63
Rate for Payer: AlohaCare Medicare	$20.94
Rate for Payer: Cash Price	$15.13
Rate for Payer: Devoted Health Medicare	$23.04
Rate for Payer: Hawaii Medical Service Association Medicare	$20.94
Rate for Payer: Hawaii Western Management Group Commercial	$22.11
Rate for Payer: Health Management Network Commercial	$19.78
Rate for Payer: Humana Medicare	$20.94
Rate for Payer: Kaiser Permanente Commercial	$20.94
Rate for Payer: Kaiser Permanente Medicaid	$11.87
Rate for Payer: Kaiser Permanente Medicare	$20.94
Rate for Payer: MDX Hawaii PPO	$22.57
Rate for Payer: Ohana Health Plan Medicaid	$20.94
Rate for Payer: Ohana Health Plan Medicare	$20.94
Rate for Payer: UnitedHealthcare Medicare	$20.94
Rate for Payer: University Health Alliance Commercial	$16.96

TENDONITIS, MYOSITIS AND BURSITIS WITH MCC

Facility

$19,767.47

Service Code	MSDRG 557
Min. Negotiated Rate	$19,767.47
Max. Negotiated Rate	$19,767.47
Rate for Payer: Hawaii Medical Service Association Commercial	$19,767.47

TENDONITIS, MYOSITIS AND BURSITIS WITHOUT MCC

Facility

$19,767.47

Service Code	MSDRG 558
Min. Negotiated Rate	$19,767.47
Max. Negotiated Rate	$19,767.47
Rate for Payer: Hawaii Medical Service Association Commercial	$19,767.47

TENECTEPLASE 50 MG IV RECON.SOLN.

Facility

$11,075.12

Service Code	HCPCS J3101
Hospital Revenue Code	250
Min. Negotiated Rate	$9,413.85
Max. Negotiated Rate	$10,742.87
Rate for Payer: Cash Price	$7,198.83
Rate for Payer: Health Management Network Commercial	$9,413.85
Rate for Payer: Kaiser Permanente Commercial	$9,967.61
Rate for Payer: MDX Hawaii PPO	$10,742.87

TENECTEPLASE 50 MG IV RECON.SOLN.

Facility

$11,075.12

Service Code	HCPCS J3101
Hospital Revenue Code	636
Min. Negotiated Rate	$171.94
Max. Negotiated Rate	$10,964.37
Rate for Payer: AlohaCare Medicaid	$5,537.56
Rate for Payer: AlohaCare Medicare	$9,967.61
Rate for Payer: Cash Price	$7,198.83
Rate for Payer: Cash Price	$7,198.83
Rate for Payer: Devoted Health Medicare	$10,964.37
Rate for Payer: Hawaii Medical Service Association ABD	$171.94
Rate for Payer: Hawaii Medical Service Association Commercial	$246.80
Rate for Payer: Hawaii Medical Service Association Medicare	$9,967.61
Rate for Payer: Hawaii Medical Service Association Non-ABD	$171.94
Rate for Payer: Hawaii Western Management Group Commercial	$10,521.36
Rate for Payer: Health Management Network Commercial	$9,413.85
Rate for Payer: Humana Medicare	$9,967.61
Rate for Payer: Kaiser Permanente Commercial	$9,967.61
Rate for Payer: Kaiser Permanente Medicaid	$5,648.31
Rate for Payer: Kaiser Permanente Medicare	$9,967.61
Rate for Payer: MDX Hawaii PPO	$10,742.87
Rate for Payer: Ohana Health Plan Medicaid	$9,967.61
Rate for Payer: Ohana Health Plan Medicare	$9,967.61
Rate for Payer: UnitedHealthcare Medicaid	$6,645.07
Rate for Payer: UnitedHealthcare Medicare	$9,967.61
Rate for Payer: University Health Alliance Commercial	$8,072.65

TENOFOVIR DISOPROXIL FUMARATE 300 MG PO TABLET

Facility

$30.77

Service Code	HCPCS A9270
Hospital Revenue Code	250
Min. Negotiated Rate	$26.15
Max. Negotiated Rate	$29.85
Rate for Payer: Cash Price	$20.00
Rate for Payer: Health Management Network Commercial	$26.15
Rate for Payer: Kaiser Permanente Commercial	$27.69
Rate for Payer: MDX Hawaii PPO	$29.85

TENOFOVIR DISOPROXIL FUMARATE 300 MG PO TABLET

Facility

$30.77

Service Code	HCPCS A9270
Hospital Revenue Code	637
Min. Negotiated Rate	$15.38
Max. Negotiated Rate	$30.46
Rate for Payer: AlohaCare Medicaid	$15.38
Rate for Payer: AlohaCare Medicare	$27.69
Rate for Payer: Cash Price	$20.00
Rate for Payer: Devoted Health Medicare	$30.46
Rate for Payer: Hawaii Medical Service Association Medicare	$27.69
Rate for Payer: Hawaii Western Management Group Commercial	$29.23
Rate for Payer: Health Management Network Commercial	$26.15
Rate for Payer: Humana Medicare	$27.69
Rate for Payer: Kaiser Permanente Commercial	$27.69
Rate for Payer: Kaiser Permanente Medicaid	$15.69
Rate for Payer: Kaiser Permanente Medicare	$27.69
Rate for Payer: MDX Hawaii PPO	$29.85
Rate for Payer: Ohana Health Plan Medicaid	$27.69
Rate for Payer: Ohana Health Plan Medicare	$27.69
Rate for Payer: UnitedHealthcare Medicare	$27.69
Rate for Payer: University Health Alliance Commercial	$22.43

TERBINAFINE HCL 250 MG PO TABLET

Facility

$70.93

Service Code	HCPCS A9270
Hospital Revenue Code	250
Min. Negotiated Rate	$60.29
Max. Negotiated Rate	$68.80
Rate for Payer: Cash Price	$46.10
Rate for Payer: Health Management Network Commercial	$60.29
Rate for Payer: Kaiser Permanente Commercial	$63.84
Rate for Payer: MDX Hawaii PPO	$68.80

TERBINAFINE HCL 250 MG PO TABLET

Facility

$70.93

Service Code	HCPCS A9270
Hospital Revenue Code	637
Min. Negotiated Rate	$35.47
Max. Negotiated Rate	$70.22
Rate for Payer: AlohaCare Medicaid	$35.47
Rate for Payer: AlohaCare Medicare	$63.84
Rate for Payer: Cash Price	$46.10
Rate for Payer: Devoted Health Medicare	$70.22
Rate for Payer: Hawaii Medical Service Association Medicare	$63.84
Rate for Payer: Hawaii Western Management Group Commercial	$67.38
Rate for Payer: Health Management Network Commercial	$60.29
Rate for Payer: Humana Medicare	$63.84
Rate for Payer: Kaiser Permanente Commercial	$63.84
Rate for Payer: Kaiser Permanente Medicaid	$36.17
Rate for Payer: Kaiser Permanente Medicare	$63.84
Rate for Payer: MDX Hawaii PPO	$68.80
Rate for Payer: Ohana Health Plan Medicaid	$63.84
Rate for Payer: Ohana Health Plan Medicare	$63.84
Rate for Payer: UnitedHealthcare Medicare	$63.84
Rate for Payer: University Health Alliance Commercial	$51.70

TERBUTALINE 0.1 MG/ML INJ

Facility

$22.08

Service Code	NDC 00143974610
Hospital Revenue Code	250
Min. Negotiated Rate	$18.77
Max. Negotiated Rate	$21.42
Rate for Payer: Cash Price	$14.35
Rate for Payer: Health Management Network Commercial	$18.77
Rate for Payer: Kaiser Permanente Commercial	$19.87
Rate for Payer: MDX Hawaii PPO	$21.42

TERBUTALINE 0.1 MG/ML INJ

Facility

$22.08

Service Code	NDC 00143974601
Hospital Revenue Code	250
Min. Negotiated Rate	$18.77
Max. Negotiated Rate	$21.42
Rate for Payer: Cash Price	$14.35
Rate for Payer: Health Management Network Commercial	$18.77
Rate for Payer: Kaiser Permanente Commercial	$19.87
Rate for Payer: MDX Hawaii PPO	$21.42

TERBUTALINE 0.1 MG/ML INJ

Facility

$22.08

Service Code	NDC 00143974610
Hospital Revenue Code	636
Min. Negotiated Rate	$11.04
Max. Negotiated Rate	$21.86
Rate for Payer: AlohaCare Medicaid	$11.04
Rate for Payer: AlohaCare Medicare	$19.87
Rate for Payer: Cash Price	$14.35
Rate for Payer: Devoted Health Medicare	$21.86
Rate for Payer: Hawaii Medical Service Association Medicare	$19.87
Rate for Payer: Hawaii Western Management Group Commercial	$20.98
Rate for Payer: Health Management Network Commercial	$18.77
Rate for Payer: Humana Medicare	$19.87
Rate for Payer: Kaiser Permanente Commercial	$19.87
Rate for Payer: Kaiser Permanente Medicaid	$11.26
Rate for Payer: Kaiser Permanente Medicare	$19.87
Rate for Payer: MDX Hawaii PPO	$21.42
Rate for Payer: Ohana Health Plan Medicaid	$19.87
Rate for Payer: Ohana Health Plan Medicare	$19.87
Rate for Payer: UnitedHealthcare Medicaid	$13.25
Rate for Payer: UnitedHealthcare Medicare	$19.87
Rate for Payer: University Health Alliance Commercial	$16.09

TERBUTALINE 0.1 MG/ML INJ

Facility

$22.08

Service Code	NDC 00143974601
Hospital Revenue Code	636
Min. Negotiated Rate	$11.04
Max. Negotiated Rate	$21.86
Rate for Payer: AlohaCare Medicaid	$11.04
Rate for Payer: AlohaCare Medicare	$19.87
Rate for Payer: Cash Price	$14.35
Rate for Payer: Devoted Health Medicare	$21.86
Rate for Payer: Hawaii Medical Service Association Medicare	$19.87
Rate for Payer: Hawaii Western Management Group Commercial	$20.98
Rate for Payer: Health Management Network Commercial	$18.77
Rate for Payer: Humana Medicare	$19.87
Rate for Payer: Kaiser Permanente Commercial	$19.87
Rate for Payer: Kaiser Permanente Medicaid	$11.26
Rate for Payer: Kaiser Permanente Medicare	$19.87
Rate for Payer: MDX Hawaii PPO	$21.42
Rate for Payer: Ohana Health Plan Medicaid	$19.87
Rate for Payer: Ohana Health Plan Medicare	$19.87
Rate for Payer: UnitedHealthcare Medicaid	$13.25
Rate for Payer: UnitedHealthcare Medicare	$19.87
Rate for Payer: University Health Alliance Commercial	$16.09

TERBUTALINE 1 MG/ML SUBCUTANEOUS SOLN

Facility

$22.08

Service Code	HCPCS J3105
Hospital Revenue Code	636
Min. Negotiated Rate	$2.74
Max. Negotiated Rate	$21.86
Rate for Payer: AlohaCare Medicaid	$11.04
Rate for Payer: AlohaCare Medicaid	$49.78
Rate for Payer: AlohaCare Medicare	$89.60
Rate for Payer: AlohaCare Medicare	$19.87
Rate for Payer: Cash Price	$64.71
Rate for Payer: Cash Price	$14.35
Rate for Payer: Cash Price	$14.35
Rate for Payer: Cash Price	$64.71
Rate for Payer: Devoted Health Medicare	$21.86
Rate for Payer: Devoted Health Medicare	$98.56
Rate for Payer: Hawaii Medical Service Association ABD	$2.74
Rate for Payer: Hawaii Medical Service Association ABD	$2.74
Rate for Payer: Hawaii Medical Service Association Medicare	$89.60
Rate for Payer: Hawaii Medical Service Association Medicare	$19.87
Rate for Payer: Hawaii Medical Service Association Non-ABD	$2.74
Rate for Payer: Hawaii Medical Service Association Non-ABD	$2.74
Rate for Payer: Hawaii Western Management Group Commercial	$20.98
Rate for Payer: Hawaii Western Management Group Commercial	$94.58
Rate for Payer: Health Management Network Commercial	$84.63
Rate for Payer: Health Management Network Commercial	$18.77
Rate for Payer: Humana Medicare	$19.87
Rate for Payer: Humana Medicare	$89.60
Rate for Payer: Kaiser Permanente Commercial	$19.87
Rate for Payer: Kaiser Permanente Commercial	$89.60
Rate for Payer: Kaiser Permanente Medicaid	$50.78
Rate for Payer: Kaiser Permanente Medicaid	$11.26
Rate for Payer: Kaiser Permanente Medicare	$19.87
Rate for Payer: Kaiser Permanente Medicare	$89.60
Rate for Payer: MDX Hawaii PPO	$21.42
Rate for Payer: MDX Hawaii PPO	$96.57
Rate for Payer: Ohana Health Plan Medicaid	$89.60
Rate for Payer: Ohana Health Plan Medicaid	$19.87
Rate for Payer: Ohana Health Plan Medicare	$19.87
Rate for Payer: Ohana Health Plan Medicare	$89.60
Rate for Payer: UnitedHealthcare Medicaid	$59.74
Rate for Payer: UnitedHealthcare Medicaid	$13.25
Rate for Payer: UnitedHealthcare Medicare	$19.87
Rate for Payer: UnitedHealthcare Medicare	$89.60
Rate for Payer: University Health Alliance Commercial	$16.09
Rate for Payer: University Health Alliance Commercial	$72.57

TERBUTALINE 1 MG/ML SUBCUTANEOUS SOLN

Facility

$22.08

Service Code	HCPCS J3105
Hospital Revenue Code	250
Min. Negotiated Rate	$18.77
Max. Negotiated Rate	$21.42
Rate for Payer: Cash Price	$14.35
Rate for Payer: Cash Price	$64.71
Rate for Payer: Health Management Network Commercial	$18.77
Rate for Payer: Health Management Network Commercial	$84.63
Rate for Payer: Kaiser Permanente Commercial	$19.87
Rate for Payer: Kaiser Permanente Commercial	$89.60
Rate for Payer: MDX Hawaii PPO	$96.57
Rate for Payer: MDX Hawaii PPO	$21.42

TESTES PROCEDURES WITH CC/MCC

Facility

$51,883.68

Service Code	MSDRG 711
Min. Negotiated Rate	$51,883.68
Max. Negotiated Rate	$51,883.68
Rate for Payer: Hawaii Medical Service Association Commercial	$51,883.68

TESTES PROCEDURES WITHOUT CC/MCC

Facility

$36,714.40

Service Code	MSDRG 712
Min. Negotiated Rate	$36,714.40
Max. Negotiated Rate	$36,714.40
Rate for Payer: Hawaii Medical Service Association Commercial	$36,714.40

TETANUS AND DIPHTHER. TOX (PF) 5-2 LF UNIT/0.5 ML IM SYR

Facility

$186.69

Service Code	HCPCS 90714
Hospital Revenue Code	636
Min. Negotiated Rate	$33.48
Max. Negotiated Rate	$184.82
Rate for Payer: AlohaCare Medicaid	$93.34
Rate for Payer: AlohaCare Medicaid	$93.36
Rate for Payer: AlohaCare Medicare	$168.04
Rate for Payer: AlohaCare Medicare	$168.02
Rate for Payer: Cash Price	$121.36
Rate for Payer: Cash Price	$121.35
Rate for Payer: Cash Price	$121.35
Rate for Payer: Cash Price	$121.36
Rate for Payer: Devoted Health Medicare	$184.84
Rate for Payer: Devoted Health Medicare	$184.82
Rate for Payer: Hawaii Medical Service Association ABD	$33.48
Rate for Payer: Hawaii Medical Service Association ABD	$33.48
Rate for Payer: Hawaii Medical Service Association Medicare	$168.02
Rate for Payer: Hawaii Medical Service Association Medicare	$168.04
Rate for Payer: Hawaii Medical Service Association Non-ABD	$33.48
Rate for Payer: Hawaii Medical Service Association Non-ABD	$33.48
Rate for Payer: Hawaii Western Management Group Commercial	$177.37
Rate for Payer: Hawaii Western Management Group Commercial	$177.36
Rate for Payer: Health Management Network Commercial	$158.69
Rate for Payer: Health Management Network Commercial	$158.70
Rate for Payer: Humana Medicare	$168.04
Rate for Payer: Humana Medicare	$168.02
Rate for Payer: Kaiser Permanente Commercial	$168.02
Rate for Payer: Kaiser Permanente Commercial	$168.04
Rate for Payer: Kaiser Permanente Medicaid	$95.22
Rate for Payer: Kaiser Permanente Medicaid	$95.21
Rate for Payer: Kaiser Permanente Medicare	$168.04
Rate for Payer: Kaiser Permanente Medicare	$168.02
Rate for Payer: MDX Hawaii PPO	$181.09
Rate for Payer: MDX Hawaii PPO	$181.11
Rate for Payer: Ohana Health Plan Medicaid	$168.04
Rate for Payer: Ohana Health Plan Medicaid	$168.02
Rate for Payer: Ohana Health Plan Medicare	$168.02
Rate for Payer: Ohana Health Plan Medicare	$168.04
Rate for Payer: UnitedHealthcare Medicaid	$112.03
Rate for Payer: UnitedHealthcare Medicaid	$112.01
Rate for Payer: UnitedHealthcare Medicare	$168.02
Rate for Payer: UnitedHealthcare Medicare	$168.04
Rate for Payer: University Health Alliance Commercial	$136.08
Rate for Payer: University Health Alliance Commercial	$136.09

Know your out-of-pocket cost for care.

All Charges