Kohala Hospital

All Charges

Charge

Type

Setting

Price

TRAUMATIC STUPOR AND COMA >1 HOUR WITHOUT CC/MCC

Facility

$37,757.29

Service Code	MSDRG 084
Min. Negotiated Rate	$37,757.29
Max. Negotiated Rate	$37,757.29
Rate for Payer: Hawaii Medical Service Association Commercial	$37,757.29

TRAUMA TO THE SKIN, SUBCUTANEOUS TISSUE AND BREAST WITH MCC

Facility

$17,918.71

Service Code	MSDRG 604
Min. Negotiated Rate	$17,918.71
Max. Negotiated Rate	$17,918.71
Rate for Payer: Hawaii Medical Service Association Commercial	$17,918.71

TRAUMA TO THE SKIN, SUBCUTANEOUS TISSUE AND BREAST WITHOUT MCC

Facility

$14,718.94

Service Code	MSDRG 605
Min. Negotiated Rate	$14,718.94
Max. Negotiated Rate	$14,718.94
Rate for Payer: Hawaii Medical Service Association Commercial	$14,718.94

TRAY CATHETER ADD A FOLEY A304400A [2707456]

Facility

$104.89

Service Code	HCPCS A4354
Hospital Charge Code	2707456.0
Hospital Revenue Code	272
Min. Negotiated Rate	$11.50
Max. Negotiated Rate	$103.84
Rate for Payer: AlohaCare Medicaid	$52.45
Rate for Payer: AlohaCare Medicare	$94.40
Rate for Payer: Cash Price	$68.18
Rate for Payer: Cash Price	$68.18
Rate for Payer: Devoted Health Medicare	$103.84
Rate for Payer: Hawaii Medical Service Association Medicare	$94.40
Rate for Payer: Hawaii Western Management Group Commercial	$99.65
Rate for Payer: Health Management Network Commercial	$89.16
Rate for Payer: Humana Medicare	$94.40
Rate for Payer: Kaiser Permanente Commercial	$94.40
Rate for Payer: Kaiser Permanente Medicaid	$53.49
Rate for Payer: Kaiser Permanente Medicare	$94.40
Rate for Payer: MDX Hawaii PPO	$101.74
Rate for Payer: Ohana Health Plan Medicaid	$94.40
Rate for Payer: Ohana Health Plan Medicare	$94.40
Rate for Payer: UnitedHealthcare Medicaid	$11.50
Rate for Payer: UnitedHealthcare Medicare	$94.40
Rate for Payer: University Health Alliance Commercial	$76.45

TRAY CATHETER ADD A FOLEY A304400A [2707456]

Facility

$104.89

Service Code	HCPCS A4354
Hospital Charge Code	2707456.0
Hospital Revenue Code	272
Min. Negotiated Rate	$89.16
Max. Negotiated Rate	$101.74
Rate for Payer: Cash Price	$68.18
Rate for Payer: Health Management Network Commercial	$89.16
Rate for Payer: Kaiser Permanente Commercial	$94.40
Rate for Payer: MDX Hawaii PPO	$101.74

TRAY CATHETER FOLEY 2W BAG 14F A303314A [2701992]

Facility

$171.04

Hospital Charge Code	2701992.0
Hospital Revenue Code	272
Min. Negotiated Rate	$85.52
Max. Negotiated Rate	$169.33
Rate for Payer: AlohaCare Medicaid	$85.52
Rate for Payer: AlohaCare Medicare	$153.94
Rate for Payer: Cash Price	$111.18
Rate for Payer: Devoted Health Medicare	$169.33
Rate for Payer: Hawaii Medical Service Association Medicare	$153.94
Rate for Payer: Hawaii Western Management Group Commercial	$162.49
Rate for Payer: Health Management Network Commercial	$145.38
Rate for Payer: Humana Medicare	$153.94
Rate for Payer: Kaiser Permanente Commercial	$153.94
Rate for Payer: Kaiser Permanente Medicaid	$87.23
Rate for Payer: Kaiser Permanente Medicare	$153.94
Rate for Payer: MDX Hawaii PPO	$165.91
Rate for Payer: Ohana Health Plan Medicaid	$153.94
Rate for Payer: Ohana Health Plan Medicare	$153.94
Rate for Payer: UnitedHealthcare Medicare	$153.94
Rate for Payer: University Health Alliance Commercial	$124.67

TRAY CATHETER FOLEY 2W BAG 14F A303314A [2701992]

Facility

$171.04

Hospital Charge Code	2701992.0
Hospital Revenue Code	272
Min. Negotiated Rate	$145.38
Max. Negotiated Rate	$165.91
Rate for Payer: Cash Price	$111.18
Rate for Payer: Health Management Network Commercial	$145.38
Rate for Payer: Kaiser Permanente Commercial	$153.94
Rate for Payer: MDX Hawaii PPO	$165.91

TRAY CATHETER FOLEY 2W BAG 16F A303316A [2701993]

Facility

$171.04

Hospital Charge Code	2701993.0
Hospital Revenue Code	272
Min. Negotiated Rate	$145.38
Max. Negotiated Rate	$165.91
Rate for Payer: Cash Price	$111.18
Rate for Payer: Health Management Network Commercial	$145.38
Rate for Payer: Kaiser Permanente Commercial	$153.94
Rate for Payer: MDX Hawaii PPO	$165.91

TRAY CATHETER FOLEY 2W BAG 16F A303316A [2701993]

Facility

$171.04

Hospital Charge Code	2701993.0
Hospital Revenue Code	272
Min. Negotiated Rate	$85.52
Max. Negotiated Rate	$169.33
Rate for Payer: AlohaCare Medicaid	$85.52
Rate for Payer: AlohaCare Medicare	$153.94
Rate for Payer: Cash Price	$111.18
Rate for Payer: Devoted Health Medicare	$169.33
Rate for Payer: Hawaii Medical Service Association Medicare	$153.94
Rate for Payer: Hawaii Western Management Group Commercial	$162.49
Rate for Payer: Health Management Network Commercial	$145.38
Rate for Payer: Humana Medicare	$153.94
Rate for Payer: Kaiser Permanente Commercial	$153.94
Rate for Payer: Kaiser Permanente Medicaid	$87.23
Rate for Payer: Kaiser Permanente Medicare	$153.94
Rate for Payer: MDX Hawaii PPO	$165.91
Rate for Payer: Ohana Health Plan Medicaid	$153.94
Rate for Payer: Ohana Health Plan Medicare	$153.94
Rate for Payer: UnitedHealthcare Medicare	$153.94
Rate for Payer: University Health Alliance Commercial	$124.67

TRAY CATHETER FOLEY 2W BAG 18F A303318A [2701994]

Facility

$167.12

Hospital Charge Code	2701994.0
Hospital Revenue Code	272
Min. Negotiated Rate	$142.05
Max. Negotiated Rate	$162.11
Rate for Payer: Cash Price	$108.63
Rate for Payer: Health Management Network Commercial	$142.05
Rate for Payer: Kaiser Permanente Commercial	$150.41
Rate for Payer: MDX Hawaii PPO	$162.11

TRAY CATHETER FOLEY 2W BAG 18F A303318A [2701994]

Facility

$167.12

Hospital Charge Code	2701994.0
Hospital Revenue Code	272
Min. Negotiated Rate	$83.56
Max. Negotiated Rate	$165.45
Rate for Payer: AlohaCare Medicaid	$83.56
Rate for Payer: AlohaCare Medicare	$150.41
Rate for Payer: Cash Price	$108.63
Rate for Payer: Devoted Health Medicare	$165.45
Rate for Payer: Hawaii Medical Service Association Medicare	$150.41
Rate for Payer: Hawaii Western Management Group Commercial	$158.76
Rate for Payer: Health Management Network Commercial	$142.05
Rate for Payer: Humana Medicare	$150.41
Rate for Payer: Kaiser Permanente Commercial	$150.41
Rate for Payer: Kaiser Permanente Medicaid	$85.23
Rate for Payer: Kaiser Permanente Medicare	$150.41
Rate for Payer: MDX Hawaii PPO	$162.11
Rate for Payer: Ohana Health Plan Medicaid	$150.41
Rate for Payer: Ohana Health Plan Medicare	$150.41
Rate for Payer: UnitedHealthcare Medicare	$150.41
Rate for Payer: University Health Alliance Commercial	$121.81

TRAY LACERATION ER [2702023]

Facility

$171.84

Hospital Charge Code	2702023.0
Hospital Revenue Code	272
Min. Negotiated Rate	$146.06
Max. Negotiated Rate	$166.68
Rate for Payer: Cash Price	$111.70
Rate for Payer: Health Management Network Commercial	$146.06
Rate for Payer: Kaiser Permanente Commercial	$154.66
Rate for Payer: MDX Hawaii PPO	$166.68

TRAY LACERATION ER [2702023]

Facility

$171.84

Hospital Charge Code	2702023.0
Hospital Revenue Code	272
Min. Negotiated Rate	$85.92
Max. Negotiated Rate	$170.12
Rate for Payer: AlohaCare Medicaid	$85.92
Rate for Payer: AlohaCare Medicare	$154.66
Rate for Payer: Cash Price	$111.70
Rate for Payer: Devoted Health Medicare	$170.12
Rate for Payer: Hawaii Medical Service Association Medicare	$154.66
Rate for Payer: Hawaii Western Management Group Commercial	$163.25
Rate for Payer: Health Management Network Commercial	$146.06
Rate for Payer: Humana Medicare	$154.66
Rate for Payer: Kaiser Permanente Commercial	$154.66
Rate for Payer: Kaiser Permanente Medicaid	$87.64
Rate for Payer: Kaiser Permanente Medicare	$154.66
Rate for Payer: MDX Hawaii PPO	$166.68
Rate for Payer: Ohana Health Plan Medicaid	$154.66
Rate for Payer: Ohana Health Plan Medicare	$154.66
Rate for Payer: UnitedHealthcare Medicare	$154.66
Rate for Payer: University Health Alliance Commercial	$125.25

TRAZODONE 100 MG PO TABLET

Facility

$1.23

Service Code	HCPCS A9270
Hospital Revenue Code	637
Min. Negotiated Rate	$0.62
Max. Negotiated Rate	$1.22
Rate for Payer: AlohaCare Medicaid	$0.62
Rate for Payer: AlohaCare Medicare	$1.11
Rate for Payer: Cash Price	$0.80
Rate for Payer: Devoted Health Medicare	$1.22
Rate for Payer: Hawaii Medical Service Association Medicare	$1.11
Rate for Payer: Hawaii Western Management Group Commercial	$1.17
Rate for Payer: Health Management Network Commercial	$1.05
Rate for Payer: Humana Medicare	$1.11
Rate for Payer: Kaiser Permanente Commercial	$1.11
Rate for Payer: Kaiser Permanente Medicaid	$0.63
Rate for Payer: Kaiser Permanente Medicare	$1.11
Rate for Payer: MDX Hawaii PPO	$1.19
Rate for Payer: Ohana Health Plan Medicaid	$1.11
Rate for Payer: Ohana Health Plan Medicare	$1.11
Rate for Payer: UnitedHealthcare Medicare	$1.11
Rate for Payer: University Health Alliance Commercial	$0.90

TRAZODONE 100 MG PO TABLET

Facility

$1.23

Service Code	HCPCS A9270
Hospital Revenue Code	250
Min. Negotiated Rate	$1.05
Max. Negotiated Rate	$1.19
Rate for Payer: Cash Price	$0.80
Rate for Payer: Health Management Network Commercial	$1.05
Rate for Payer: Kaiser Permanente Commercial	$1.11
Rate for Payer: MDX Hawaii PPO	$1.19

TRAZODONE 50 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

TRAZODONE 50 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

TRIAMCINOLONE ACETONIDE 0.1 % TOP CR

Facility

$21.45

Service Code	HCPCS A9270
Hospital Revenue Code	637
Min. Negotiated Rate	$10.72
Max. Negotiated Rate	$21.24
Rate for Payer: AlohaCare Medicaid	$10.72
Rate for Payer: AlohaCare Medicare	$19.30
Rate for Payer: Cash Price	$13.94
Rate for Payer: Devoted Health Medicare	$21.24
Rate for Payer: Hawaii Medical Service Association Medicare	$19.30
Rate for Payer: Hawaii Western Management Group Commercial	$20.38
Rate for Payer: Health Management Network Commercial	$18.23
Rate for Payer: Humana Medicare	$19.30
Rate for Payer: Kaiser Permanente Commercial	$19.30
Rate for Payer: Kaiser Permanente Medicaid	$10.94
Rate for Payer: Kaiser Permanente Medicare	$19.30
Rate for Payer: MDX Hawaii PPO	$20.81
Rate for Payer: Ohana Health Plan Medicaid	$19.30
Rate for Payer: Ohana Health Plan Medicare	$19.30
Rate for Payer: UnitedHealthcare Medicare	$19.30
Rate for Payer: University Health Alliance Commercial	$15.63

TRIAMCINOLONE ACETONIDE 0.1 % TOP CR

Facility

$21.45

Service Code	HCPCS A9270
Hospital Revenue Code	250
Min. Negotiated Rate	$18.23
Max. Negotiated Rate	$20.81
Rate for Payer: Cash Price	$13.94
Rate for Payer: Health Management Network Commercial	$18.23
Rate for Payer: Kaiser Permanente Commercial	$19.30
Rate for Payer: MDX Hawaii PPO	$20.81

TRIAMCINOLONE ACETONIDE 40 MG/ML INJ SUSP

Facility

$58.93

Service Code	HCPCS J3301
Hospital Revenue Code	250
Min. Negotiated Rate	$50.09
Max. Negotiated Rate	$57.16
Rate for Payer: Cash Price	$38.30
Rate for Payer: Health Management Network Commercial	$50.09
Rate for Payer: Kaiser Permanente Commercial	$53.04
Rate for Payer: MDX Hawaii PPO	$57.16

TRIAMCINOLONE ACETONIDE 40 MG/ML INJ SUSP

Facility

$58.93

Service Code	HCPCS J3301
Hospital Revenue Code	636
Min. Negotiated Rate	$0.86
Max. Negotiated Rate	$58.34
Rate for Payer: AlohaCare Medicaid	$29.46
Rate for Payer: AlohaCare Medicare	$53.04
Rate for Payer: Cash Price	$38.30
Rate for Payer: Cash Price	$38.30
Rate for Payer: Devoted Health Medicare	$58.34
Rate for Payer: Hawaii Medical Service Association ABD	$0.86
Rate for Payer: Hawaii Medical Service Association Medicare	$53.04
Rate for Payer: Hawaii Medical Service Association Non-ABD	$0.86
Rate for Payer: Hawaii Western Management Group Commercial	$55.98
Rate for Payer: Health Management Network Commercial	$50.09
Rate for Payer: Humana Medicare	$53.04
Rate for Payer: Kaiser Permanente Commercial	$53.04
Rate for Payer: Kaiser Permanente Medicaid	$30.05
Rate for Payer: Kaiser Permanente Medicare	$53.04
Rate for Payer: MDX Hawaii PPO	$57.16
Rate for Payer: Ohana Health Plan Medicaid	$53.04
Rate for Payer: Ohana Health Plan Medicare	$53.04
Rate for Payer: UnitedHealthcare Medicaid	$35.36
Rate for Payer: UnitedHealthcare Medicare	$53.04
Rate for Payer: University Health Alliance Commercial	$42.95

TRIAMTERENE-HYDROCHLOROTHIAZID 37.5-25 MG PO CAP

Facility

$2.06

Service Code	HCPCS A9270
Hospital Revenue Code	250
Min. Negotiated Rate	$1.75
Max. Negotiated Rate	$2.00
Rate for Payer: Cash Price	$1.34
Rate for Payer: Health Management Network Commercial	$1.75
Rate for Payer: Kaiser Permanente Commercial	$1.85
Rate for Payer: MDX Hawaii PPO	$2.00

TRIAMTERENE-HYDROCHLOROTHIAZID 37.5-25 MG PO CAP

Facility

$2.06

Service Code	HCPCS A9270
Hospital Revenue Code	637
Min. Negotiated Rate	$1.03
Max. Negotiated Rate	$2.04
Rate for Payer: AlohaCare Medicaid	$1.03
Rate for Payer: AlohaCare Medicare	$1.85
Rate for Payer: Cash Price	$1.34
Rate for Payer: Devoted Health Medicare	$2.04
Rate for Payer: Hawaii Medical Service Association Medicare	$1.85
Rate for Payer: Hawaii Western Management Group Commercial	$1.96
Rate for Payer: Health Management Network Commercial	$1.75
Rate for Payer: Humana Medicare	$1.85
Rate for Payer: Kaiser Permanente Commercial	$1.85
Rate for Payer: Kaiser Permanente Medicaid	$1.05
Rate for Payer: Kaiser Permanente Medicare	$1.85
Rate for Payer: MDX Hawaii PPO	$2.00
Rate for Payer: Ohana Health Plan Medicaid	$1.85
Rate for Payer: Ohana Health Plan Medicare	$1.85
Rate for Payer: UnitedHealthcare Medicare	$1.85
Rate for Payer: University Health Alliance Commercial	$1.50

TRIHEXYPHENIDYL 2 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

TRIHEXYPHENIDYL 2 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

Know your out-of-pocket cost for care.

All Charges