Kohala Hospital

All Charges

Charge

Type

Setting

Price

VAGINA, CERVIX AND VULVA PROCEDURES WITHOUT CC/MCC

Facility

$26,451.43

Service Code	MSDRG 747
Min. Negotiated Rate	$26,451.43
Max. Negotiated Rate	$26,451.43
Rate for Payer: Hawaii Medical Service Association Commercial	$26,451.43

VAGINAL DELIVERY WITH O.R. PROCEDURES EXCEPT STERILIZATION AND/OR D&C

Facility

$12,490.95

Service Code	MSDRG 768
Min. Negotiated Rate	$7,300.00
Max. Negotiated Rate	$12,490.95
Rate for Payer: Hawaii Medical Service Association Commercial	$12,490.95
Rate for Payer: Hawaii Western Management Group Commercial	$7,300.00
Rate for Payer: University Health Alliance Commercial	$7,760.00

VAGINAL DELIVERY WITHOUT STERILIZATION OR D&C WITH CC

Facility

$10,120.75

Service Code	MSDRG 806
Min. Negotiated Rate	$7,300.00
Max. Negotiated Rate	$10,120.75
Rate for Payer: Hawaii Medical Service Association Commercial	$10,120.75
Rate for Payer: Hawaii Western Management Group Commercial	$7,300.00
Rate for Payer: University Health Alliance Commercial	$7,760.00

VAGINAL DELIVERY WITHOUT STERILIZATION OR D&C WITH MCC

Facility

$10,120.75

Service Code	MSDRG 805
Min. Negotiated Rate	$7,300.00
Max. Negotiated Rate	$10,120.75
Rate for Payer: Hawaii Medical Service Association Commercial	$10,120.75
Rate for Payer: Hawaii Western Management Group Commercial	$7,300.00
Rate for Payer: University Health Alliance Commercial	$7,760.00

VAGINAL DELIVERY WITHOUT STERILIZATION OR D&C WITHOUT CC/MCC

Facility

$9,125.27

Service Code	MSDRG 807
Min. Negotiated Rate	$7,300.00
Max. Negotiated Rate	$9,125.27
Rate for Payer: Hawaii Medical Service Association Commercial	$9,125.27
Rate for Payer: Hawaii Western Management Group Commercial	$7,300.00
Rate for Payer: University Health Alliance Commercial	$7,760.00

VAGINAL DELIVERY WITH STERILIZATION AND/OR D&C WITH CC

Facility

$14,695.24

Service Code	MSDRG 797
Min. Negotiated Rate	$7,300.00
Max. Negotiated Rate	$14,695.24
Rate for Payer: Hawaii Medical Service Association Commercial	$14,695.24
Rate for Payer: Hawaii Western Management Group Commercial	$7,300.00
Rate for Payer: University Health Alliance Commercial	$7,760.00

VAGINAL DELIVERY WITH STERILIZATION AND/OR D&C WITH MCC

Facility

$14,695.24

Service Code	MSDRG 796
Min. Negotiated Rate	$7,300.00
Max. Negotiated Rate	$14,695.24
Rate for Payer: Hawaii Medical Service Association Commercial	$14,695.24
Rate for Payer: Hawaii Western Management Group Commercial	$7,300.00
Rate for Payer: University Health Alliance Commercial	$7,760.00

VAGINAL DELIVERY WITH STERILIZATION AND/OR D&C WITHOUT CC/MCC

Facility

$14,695.24

Service Code	MSDRG 798
Min. Negotiated Rate	$7,300.00
Max. Negotiated Rate	$14,695.24
Rate for Payer: Hawaii Medical Service Association Commercial	$14,695.24
Rate for Payer: Hawaii Western Management Group Commercial	$7,300.00
Rate for Payer: University Health Alliance Commercial	$7,760.00

VALACYCLOVIR 500 MG PO TABLET

Facility

$20.48

Service Code	HCPCS A9270
Hospital Revenue Code	637
Min. Negotiated Rate	$10.24
Max. Negotiated Rate	$20.28
Rate for Payer: AlohaCare Medicaid	$10.24
Rate for Payer: AlohaCare Medicaid	$10.97
Rate for Payer: AlohaCare Medicare	$18.43
Rate for Payer: AlohaCare Medicare	$19.75
Rate for Payer: Cash Price	$13.31
Rate for Payer: Cash Price	$14.26
Rate for Payer: Devoted Health Medicare	$20.28
Rate for Payer: Devoted Health Medicare	$21.72
Rate for Payer: Hawaii Medical Service Association Medicare	$19.75
Rate for Payer: Hawaii Medical Service Association Medicare	$18.43
Rate for Payer: Hawaii Western Management Group Commercial	$20.84
Rate for Payer: Hawaii Western Management Group Commercial	$19.46
Rate for Payer: Health Management Network Commercial	$17.41
Rate for Payer: Health Management Network Commercial	$18.65
Rate for Payer: Humana Medicare	$18.43
Rate for Payer: Humana Medicare	$19.75
Rate for Payer: Kaiser Permanente Commercial	$19.75
Rate for Payer: Kaiser Permanente Commercial	$18.43
Rate for Payer: Kaiser Permanente Medicaid	$10.44
Rate for Payer: Kaiser Permanente Medicaid	$11.19
Rate for Payer: Kaiser Permanente Medicare	$18.43
Rate for Payer: Kaiser Permanente Medicare	$19.75
Rate for Payer: MDX Hawaii PPO	$19.87
Rate for Payer: MDX Hawaii PPO	$21.28
Rate for Payer: Ohana Health Plan Medicaid	$18.43
Rate for Payer: Ohana Health Plan Medicaid	$19.75
Rate for Payer: Ohana Health Plan Medicare	$19.75
Rate for Payer: Ohana Health Plan Medicare	$18.43
Rate for Payer: UnitedHealthcare Medicare	$18.43
Rate for Payer: UnitedHealthcare Medicare	$19.75
Rate for Payer: University Health Alliance Commercial	$14.93
Rate for Payer: University Health Alliance Commercial	$15.99

VALACYCLOVIR 500 MG PO TABLET

Facility

$21.94

Service Code	HCPCS A9270
Hospital Revenue Code	250
Min. Negotiated Rate	$18.65
Max. Negotiated Rate	$21.28
Rate for Payer: Cash Price	$14.26
Rate for Payer: Cash Price	$13.31
Rate for Payer: Health Management Network Commercial	$18.65
Rate for Payer: Health Management Network Commercial	$17.41
Rate for Payer: Kaiser Permanente Commercial	$18.43
Rate for Payer: Kaiser Permanente Commercial	$19.75
Rate for Payer: MDX Hawaii PPO	$21.28
Rate for Payer: MDX Hawaii PPO	$19.87

VALSARTAN 160 MG PO TABLET

Facility

$7.99

Service Code	HCPCS A9270
Hospital Revenue Code	250
Min. Negotiated Rate	$6.79
Max. Negotiated Rate	$7.75
Rate for Payer: Cash Price	$5.19
Rate for Payer: Health Management Network Commercial	$6.79
Rate for Payer: Kaiser Permanente Commercial	$7.19
Rate for Payer: MDX Hawaii PPO	$7.75

VALSARTAN 160 MG PO TABLET

Facility

$7.99

Service Code	HCPCS A9270
Hospital Revenue Code	637
Min. Negotiated Rate	$4.00
Max. Negotiated Rate	$7.91
Rate for Payer: AlohaCare Medicaid	$4.00
Rate for Payer: AlohaCare Medicare	$7.19
Rate for Payer: Cash Price	$5.19
Rate for Payer: Devoted Health Medicare	$7.91
Rate for Payer: Hawaii Medical Service Association Medicare	$7.19
Rate for Payer: Hawaii Western Management Group Commercial	$7.59
Rate for Payer: Health Management Network Commercial	$6.79
Rate for Payer: Humana Medicare	$7.19
Rate for Payer: Kaiser Permanente Commercial	$7.19
Rate for Payer: Kaiser Permanente Medicaid	$4.07
Rate for Payer: Kaiser Permanente Medicare	$7.19
Rate for Payer: MDX Hawaii PPO	$7.75
Rate for Payer: Ohana Health Plan Medicaid	$7.19
Rate for Payer: Ohana Health Plan Medicare	$7.19
Rate for Payer: UnitedHealthcare Medicare	$7.19
Rate for Payer: University Health Alliance Commercial	$5.82

VALSARTAN 80 MG PO TABLET

Facility

$10.71

Service Code	HCPCS A9270
Hospital Revenue Code	250
Min. Negotiated Rate	$9.10
Max. Negotiated Rate	$10.39
Rate for Payer: Cash Price	$6.96
Rate for Payer: Health Management Network Commercial	$9.10
Rate for Payer: Kaiser Permanente Commercial	$9.64
Rate for Payer: MDX Hawaii PPO	$10.39

VALSARTAN 80 MG PO TABLET

Facility

$10.71

Service Code	HCPCS A9270
Hospital Revenue Code	637
Min. Negotiated Rate	$5.36
Max. Negotiated Rate	$10.60
Rate for Payer: AlohaCare Medicaid	$5.36
Rate for Payer: AlohaCare Medicare	$9.64
Rate for Payer: Cash Price	$6.96
Rate for Payer: Devoted Health Medicare	$10.60
Rate for Payer: Hawaii Medical Service Association Medicare	$9.64
Rate for Payer: Hawaii Western Management Group Commercial	$10.17
Rate for Payer: Health Management Network Commercial	$9.10
Rate for Payer: Humana Medicare	$9.64
Rate for Payer: Kaiser Permanente Commercial	$9.64
Rate for Payer: Kaiser Permanente Medicaid	$5.46
Rate for Payer: Kaiser Permanente Medicare	$9.64
Rate for Payer: MDX Hawaii PPO	$10.39
Rate for Payer: Ohana Health Plan Medicaid	$9.64
Rate for Payer: Ohana Health Plan Medicare	$9.64
Rate for Payer: UnitedHealthcare Medicare	$9.64
Rate for Payer: University Health Alliance Commercial	$7.81

VANCOMYCIN 1000 MG IV RECON.SOLN.

Facility

$85.41

Service Code	HCPCS J3373
Hospital Revenue Code	250
Min. Negotiated Rate	$72.60
Max. Negotiated Rate	$82.85
Rate for Payer: Cash Price	$55.52
Rate for Payer: Cash Price	$63.50
Rate for Payer: Health Management Network Commercial	$72.60
Rate for Payer: Health Management Network Commercial	$83.04
Rate for Payer: Kaiser Permanente Commercial	$76.87
Rate for Payer: Kaiser Permanente Commercial	$87.92
Rate for Payer: MDX Hawaii PPO	$94.76
Rate for Payer: MDX Hawaii PPO	$82.85

VANCOMYCIN 1000 MG IV RECON.SOLN.

Facility

$85.41

Service Code	HCPCS J3373
Hospital Revenue Code	636
Min. Negotiated Rate	$0.03
Max. Negotiated Rate	$84.56
Rate for Payer: AlohaCare Medicaid	$42.70
Rate for Payer: AlohaCare Medicaid	$48.84
Rate for Payer: AlohaCare Medicare	$87.92
Rate for Payer: AlohaCare Medicare	$76.87
Rate for Payer: Cash Price	$63.50
Rate for Payer: Cash Price	$55.52
Rate for Payer: Cash Price	$55.52
Rate for Payer: Cash Price	$63.50
Rate for Payer: Devoted Health Medicare	$84.56
Rate for Payer: Devoted Health Medicare	$96.71
Rate for Payer: Hawaii Medical Service Association ABD	$0.03
Rate for Payer: Hawaii Medical Service Association ABD	$0.03
Rate for Payer: Hawaii Medical Service Association Medicare	$87.92
Rate for Payer: Hawaii Medical Service Association Medicare	$76.87
Rate for Payer: Hawaii Medical Service Association Non-ABD	$0.03
Rate for Payer: Hawaii Medical Service Association Non-ABD	$0.03
Rate for Payer: Hawaii Western Management Group Commercial	$81.14
Rate for Payer: Hawaii Western Management Group Commercial	$92.81
Rate for Payer: Health Management Network Commercial	$83.04
Rate for Payer: Health Management Network Commercial	$72.60
Rate for Payer: Humana Medicare	$76.87
Rate for Payer: Humana Medicare	$87.92
Rate for Payer: Kaiser Permanente Commercial	$76.87
Rate for Payer: Kaiser Permanente Commercial	$87.92
Rate for Payer: Kaiser Permanente Medicaid	$49.82
Rate for Payer: Kaiser Permanente Medicaid	$43.56
Rate for Payer: Kaiser Permanente Medicare	$76.87
Rate for Payer: Kaiser Permanente Medicare	$87.92
Rate for Payer: MDX Hawaii PPO	$82.85
Rate for Payer: MDX Hawaii PPO	$94.76
Rate for Payer: Ohana Health Plan Medicaid	$87.92
Rate for Payer: Ohana Health Plan Medicaid	$76.87
Rate for Payer: Ohana Health Plan Medicare	$76.87
Rate for Payer: Ohana Health Plan Medicare	$87.92
Rate for Payer: UnitedHealthcare Medicaid	$58.61
Rate for Payer: UnitedHealthcare Medicaid	$51.25
Rate for Payer: UnitedHealthcare Medicare	$76.87
Rate for Payer: UnitedHealthcare Medicare	$87.92
Rate for Payer: University Health Alliance Commercial	$62.26
Rate for Payer: University Health Alliance Commercial	$71.21

VANCOMYCIN 125 MG PO CAP

Facility

$147.61

Service Code	HCPCS A9270
Hospital Revenue Code	637
Min. Negotiated Rate	$73.81
Max. Negotiated Rate	$146.13
Rate for Payer: AlohaCare Medicaid	$73.81
Rate for Payer: AlohaCare Medicare	$132.85
Rate for Payer: Cash Price	$95.95
Rate for Payer: Devoted Health Medicare	$146.13
Rate for Payer: Hawaii Medical Service Association Medicare	$132.85
Rate for Payer: Hawaii Western Management Group Commercial	$140.23
Rate for Payer: Health Management Network Commercial	$125.47
Rate for Payer: Humana Medicare	$132.85
Rate for Payer: Kaiser Permanente Commercial	$132.85
Rate for Payer: Kaiser Permanente Medicaid	$75.28
Rate for Payer: Kaiser Permanente Medicare	$132.85
Rate for Payer: MDX Hawaii PPO	$143.18
Rate for Payer: Ohana Health Plan Medicaid	$132.85
Rate for Payer: Ohana Health Plan Medicare	$132.85
Rate for Payer: UnitedHealthcare Medicare	$132.85
Rate for Payer: University Health Alliance Commercial	$107.59

VANCOMYCIN 125 MG PO CAP

Facility

$147.61

Service Code	HCPCS A9270
Hospital Revenue Code	250
Min. Negotiated Rate	$125.47
Max. Negotiated Rate	$143.18
Rate for Payer: Cash Price	$95.95
Rate for Payer: Health Management Network Commercial	$125.47
Rate for Payer: Kaiser Permanente Commercial	$132.85
Rate for Payer: MDX Hawaii PPO	$143.18

VANCOMYCIN 500 MG IV RECON.SOLN.

Facility

$49.07

Service Code	HCPCS J3373
Hospital Revenue Code	250
Min. Negotiated Rate	$41.71
Max. Negotiated Rate	$47.60
Rate for Payer: Cash Price	$31.90
Rate for Payer: Health Management Network Commercial	$41.71
Rate for Payer: Kaiser Permanente Commercial	$44.16
Rate for Payer: MDX Hawaii PPO	$47.60

VANCOMYCIN 500 MG IV RECON.SOLN.

Facility

$49.07

Service Code	HCPCS J3373
Hospital Revenue Code	636
Min. Negotiated Rate	$0.03
Max. Negotiated Rate	$48.58
Rate for Payer: AlohaCare Medicaid	$24.54
Rate for Payer: AlohaCare Medicare	$44.16
Rate for Payer: Cash Price	$31.90
Rate for Payer: Cash Price	$31.90
Rate for Payer: Devoted Health Medicare	$48.58
Rate for Payer: Hawaii Medical Service Association ABD	$0.03
Rate for Payer: Hawaii Medical Service Association Medicare	$44.16
Rate for Payer: Hawaii Medical Service Association Non-ABD	$0.03
Rate for Payer: Hawaii Western Management Group Commercial	$46.62
Rate for Payer: Health Management Network Commercial	$41.71
Rate for Payer: Humana Medicare	$44.16
Rate for Payer: Kaiser Permanente Commercial	$44.16
Rate for Payer: Kaiser Permanente Medicaid	$25.03
Rate for Payer: Kaiser Permanente Medicare	$44.16
Rate for Payer: MDX Hawaii PPO	$47.60
Rate for Payer: Ohana Health Plan Medicaid	$44.16
Rate for Payer: Ohana Health Plan Medicare	$44.16
Rate for Payer: UnitedHealthcare Medicaid	$29.44
Rate for Payer: UnitedHealthcare Medicare	$44.16
Rate for Payer: University Health Alliance Commercial	$35.77

VANCOMYCIN 750 MG IV RECON.SOLN.

Facility

$55.55

Service Code	HCPCS J3373
Hospital Revenue Code	636
Min. Negotiated Rate	$0.03
Max. Negotiated Rate	$54.99
Rate for Payer: AlohaCare Medicaid	$27.77
Rate for Payer: AlohaCare Medicaid	$28.59
Rate for Payer: AlohaCare Medicare	$51.45
Rate for Payer: AlohaCare Medicare	$49.99
Rate for Payer: Cash Price	$37.16
Rate for Payer: Cash Price	$36.11
Rate for Payer: Cash Price	$36.11
Rate for Payer: Cash Price	$37.16
Rate for Payer: Devoted Health Medicare	$54.99
Rate for Payer: Devoted Health Medicare	$56.60
Rate for Payer: Hawaii Medical Service Association ABD	$0.03
Rate for Payer: Hawaii Medical Service Association ABD	$0.03
Rate for Payer: Hawaii Medical Service Association Medicare	$51.45
Rate for Payer: Hawaii Medical Service Association Medicare	$49.99
Rate for Payer: Hawaii Medical Service Association Non-ABD	$0.03
Rate for Payer: Hawaii Medical Service Association Non-ABD	$0.03
Rate for Payer: Hawaii Western Management Group Commercial	$52.77
Rate for Payer: Hawaii Western Management Group Commercial	$54.31
Rate for Payer: Health Management Network Commercial	$48.59
Rate for Payer: Health Management Network Commercial	$47.22
Rate for Payer: Humana Medicare	$49.99
Rate for Payer: Humana Medicare	$51.45
Rate for Payer: Kaiser Permanente Commercial	$49.99
Rate for Payer: Kaiser Permanente Commercial	$51.45
Rate for Payer: Kaiser Permanente Medicaid	$29.16
Rate for Payer: Kaiser Permanente Medicaid	$28.33
Rate for Payer: Kaiser Permanente Medicare	$49.99
Rate for Payer: Kaiser Permanente Medicare	$51.45
Rate for Payer: MDX Hawaii PPO	$53.88
Rate for Payer: MDX Hawaii PPO	$55.45
Rate for Payer: Ohana Health Plan Medicaid	$51.45
Rate for Payer: Ohana Health Plan Medicaid	$49.99
Rate for Payer: Ohana Health Plan Medicare	$49.99
Rate for Payer: Ohana Health Plan Medicare	$51.45
Rate for Payer: UnitedHealthcare Medicaid	$34.30
Rate for Payer: UnitedHealthcare Medicaid	$33.33
Rate for Payer: UnitedHealthcare Medicare	$49.99
Rate for Payer: UnitedHealthcare Medicare	$51.45
Rate for Payer: University Health Alliance Commercial	$40.49
Rate for Payer: University Health Alliance Commercial	$41.67

VANCOMYCIN 750 MG IV RECON.SOLN.

Facility

$55.55

Service Code	HCPCS J3373
Hospital Revenue Code	250
Min. Negotiated Rate	$47.22
Max. Negotiated Rate	$53.88
Rate for Payer: Cash Price	$36.11
Rate for Payer: Cash Price	$37.16
Rate for Payer: Health Management Network Commercial	$47.22
Rate for Payer: Health Management Network Commercial	$48.59
Rate for Payer: Kaiser Permanente Commercial	$49.99
Rate for Payer: Kaiser Permanente Commercial	$51.45
Rate for Payer: MDX Hawaii PPO	$55.45
Rate for Payer: MDX Hawaii PPO	$53.88

VANCOMYCIN-DILUENT COMBO NO.1 1.25 GRAM/250 ML IV IVPB

Facility

$96.66

Service Code	HCPCS J3375
Hospital Revenue Code	636
Min. Negotiated Rate	$0.13
Max. Negotiated Rate	$95.69
Rate for Payer: AlohaCare Medicaid	$48.33
Rate for Payer: AlohaCare Medicare	$86.99
Rate for Payer: Cash Price	$62.83
Rate for Payer: Cash Price	$62.83
Rate for Payer: Devoted Health Medicare	$95.69
Rate for Payer: Hawaii Medical Service Association ABD	$0.13
Rate for Payer: Hawaii Medical Service Association Medicare	$86.99
Rate for Payer: Hawaii Medical Service Association Non-ABD	$0.13
Rate for Payer: Hawaii Western Management Group Commercial	$91.83
Rate for Payer: Health Management Network Commercial	$82.16
Rate for Payer: Humana Medicare	$86.99
Rate for Payer: Kaiser Permanente Commercial	$86.99
Rate for Payer: Kaiser Permanente Medicaid	$49.30
Rate for Payer: Kaiser Permanente Medicare	$86.99
Rate for Payer: MDX Hawaii PPO	$93.76
Rate for Payer: Ohana Health Plan Medicaid	$86.99
Rate for Payer: Ohana Health Plan Medicare	$86.99
Rate for Payer: UnitedHealthcare Medicaid	$58.00
Rate for Payer: UnitedHealthcare Medicare	$86.99
Rate for Payer: University Health Alliance Commercial	$70.46

VANCOMYCIN-DILUENT COMBO NO.1 1.25 GRAM/250 ML IV IVPB

Facility

$96.66

Service Code	HCPCS J3375
Hospital Revenue Code	250
Min. Negotiated Rate	$82.16
Max. Negotiated Rate	$93.76
Rate for Payer: Cash Price	$62.83
Rate for Payer: Health Management Network Commercial	$82.16
Rate for Payer: Kaiser Permanente Commercial	$86.99
Rate for Payer: MDX Hawaii PPO	$93.76

VANCOMYCIN-DILUENT COMBO NO.1 1.5 GRAM/300 ML IV IVPB

Facility

$113.64

Service Code	HCPCS J3375
Hospital Revenue Code	250
Min. Negotiated Rate	$96.59
Max. Negotiated Rate	$110.23
Rate for Payer: Cash Price	$73.87
Rate for Payer: Health Management Network Commercial	$96.59
Rate for Payer: Kaiser Permanente Commercial	$102.28
Rate for Payer: MDX Hawaii PPO	$110.23

Know your out-of-pocket cost for care.

All Charges