Kohala Hospital

All Charges

Charge

Type

Setting

Price

WARFARIN 2 MG PO TAB

Facility

$3.40

Service Code	HCPCS A9270
Hospital Revenue Code	250
Min. Negotiated Rate	$2.89
Max. Negotiated Rate	$3.30
Rate for Payer: Cash Price	$2.21
Rate for Payer: Health Management Network Commercial	$2.89
Rate for Payer: Kaiser Permanente Commercial	$3.06
Rate for Payer: MDX Hawaii PPO	$3.30

WHITE PETROLATUM-MINERAL OIL 56.8-42.5 % OPHT OINT

Facility

$56.85

Service Code	HCPCS A9270
Hospital Revenue Code	637
Min. Negotiated Rate	$28.43
Max. Negotiated Rate	$56.28
Rate for Payer: AlohaCare Medicaid	$28.43
Rate for Payer: AlohaCare Medicare	$51.16
Rate for Payer: Cash Price	$36.95
Rate for Payer: Devoted Health Medicare	$56.28
Rate for Payer: Hawaii Medical Service Association Medicare	$51.16
Rate for Payer: Hawaii Western Management Group Commercial	$54.01
Rate for Payer: Health Management Network Commercial	$48.32
Rate for Payer: Humana Medicare	$51.16
Rate for Payer: Kaiser Permanente Commercial	$51.16
Rate for Payer: Kaiser Permanente Medicaid	$28.99
Rate for Payer: Kaiser Permanente Medicare	$51.16
Rate for Payer: MDX Hawaii PPO	$55.14
Rate for Payer: Ohana Health Plan Medicaid	$51.16
Rate for Payer: Ohana Health Plan Medicare	$51.16
Rate for Payer: UnitedHealthcare Medicare	$51.16
Rate for Payer: University Health Alliance Commercial	$41.44

WHITE PETROLATUM-MINERAL OIL 56.8-42.5 % OPHT OINT

Facility

$56.85

Service Code	HCPCS A9270
Hospital Revenue Code	250
Min. Negotiated Rate	$48.32
Max. Negotiated Rate	$55.14
Rate for Payer: Cash Price	$36.95
Rate for Payer: Health Management Network Commercial	$48.32
Rate for Payer: Kaiser Permanente Commercial	$51.16
Rate for Payer: MDX Hawaii PPO	$55.14

WHITE PETROLATUM TOP GEL

Facility

$4.14

Service Code	HCPCS A9270
Hospital Revenue Code	637
Min. Negotiated Rate	$2.07
Max. Negotiated Rate	$4.10
Rate for Payer: AlohaCare Medicaid	$2.07
Rate for Payer: AlohaCare Medicare	$3.73
Rate for Payer: Cash Price	$2.69
Rate for Payer: Devoted Health Medicare	$4.10
Rate for Payer: Hawaii Medical Service Association Medicare	$3.73
Rate for Payer: Hawaii Western Management Group Commercial	$3.93
Rate for Payer: Health Management Network Commercial	$3.52
Rate for Payer: Humana Medicare	$3.73
Rate for Payer: Kaiser Permanente Commercial	$3.73
Rate for Payer: Kaiser Permanente Medicaid	$2.11
Rate for Payer: Kaiser Permanente Medicare	$3.73
Rate for Payer: MDX Hawaii PPO	$4.02
Rate for Payer: Ohana Health Plan Medicaid	$3.73
Rate for Payer: Ohana Health Plan Medicare	$3.73
Rate for Payer: UnitedHealthcare Medicare	$3.73
Rate for Payer: University Health Alliance Commercial	$3.02

WHITE PETROLATUM TOP GEL

Facility

$4.14

Service Code	HCPCS A9270
Hospital Revenue Code	250
Min. Negotiated Rate	$3.52
Max. Negotiated Rate	$4.02
Rate for Payer: Cash Price	$2.69
Rate for Payer: Health Management Network Commercial	$3.52
Rate for Payer: Kaiser Permanente Commercial	$3.73
Rate for Payer: MDX Hawaii PPO	$4.02

WHITE PETROLATUM TOP OIPK

Facility

$1.47

Service Code	HCPCS A9270
Hospital Revenue Code	637
Min. Negotiated Rate	$0.74
Max. Negotiated Rate	$1.46
Rate for Payer: AlohaCare Medicaid	$0.74
Rate for Payer: AlohaCare Medicare	$1.32
Rate for Payer: Cash Price	$0.96
Rate for Payer: Devoted Health Medicare	$1.46
Rate for Payer: Hawaii Medical Service Association Medicare	$1.32
Rate for Payer: Hawaii Western Management Group Commercial	$1.40
Rate for Payer: Health Management Network Commercial	$1.25
Rate for Payer: Humana Medicare	$1.32
Rate for Payer: Kaiser Permanente Commercial	$1.32
Rate for Payer: Kaiser Permanente Medicaid	$0.75
Rate for Payer: Kaiser Permanente Medicare	$1.32
Rate for Payer: MDX Hawaii PPO	$1.43
Rate for Payer: Ohana Health Plan Medicaid	$1.32
Rate for Payer: Ohana Health Plan Medicare	$1.32
Rate for Payer: UnitedHealthcare Medicare	$1.32
Rate for Payer: University Health Alliance Commercial	$1.07

WHITE PETROLATUM TOP OIPK

Facility

$1.47

Service Code	HCPCS A9270
Hospital Revenue Code	250
Min. Negotiated Rate	$1.25
Max. Negotiated Rate	$1.43
Rate for Payer: Cash Price	$0.96
Rate for Payer: Health Management Network Commercial	$1.25
Rate for Payer: Kaiser Permanente Commercial	$1.32
Rate for Payer: MDX Hawaii PPO	$1.43

WOUND DEBRIDEMENT AND SKIN GRAFT EXCEPT HAND FOR MUSCULOSKELETAL AND CONNECTIVE TISSUE DISORDERS WITH CC

Facility

$101,136.43

Service Code	MSDRG 464
Min. Negotiated Rate	$101,136.43
Max. Negotiated Rate	$101,136.43
Rate for Payer: Hawaii Medical Service Association Commercial	$101,136.43

WOUND DEBRIDEMENT AND SKIN GRAFT EXCEPT HAND FOR MUSCULOSKELETAL AND CONNECTIVE TISSUE DISORDERS WITH MCC

Facility

$101,136.43

Service Code	MSDRG 463
Min. Negotiated Rate	$101,136.43
Max. Negotiated Rate	$101,136.43
Rate for Payer: Hawaii Medical Service Association Commercial	$101,136.43

WOUND DEBRIDEMENT AND SKIN GRAFT EXCEPT HAND FOR MUSCULOSKELETAL AND CONNECTIVE TISSUE DISORDERS WITHOUT CC/MCC

Facility

$101,136.43

Service Code	MSDRG 465
Min. Negotiated Rate	$101,136.43
Max. Negotiated Rate	$101,136.43
Rate for Payer: Hawaii Medical Service Association Commercial	$101,136.43

WOUND DEBRIDEMENTS FOR INJURIES WITH CC

Facility

$28,086.87

Service Code	MSDRG 902
Min. Negotiated Rate	$28,086.87
Max. Negotiated Rate	$28,086.87
Rate for Payer: Hawaii Medical Service Association Commercial	$28,086.87

WOUND DEBRIDEMENTS FOR INJURIES WITH MCC

Facility

$28,086.87

Service Code	MSDRG 901
Min. Negotiated Rate	$28,086.87
Max. Negotiated Rate	$28,086.87
Rate for Payer: Hawaii Medical Service Association Commercial	$28,086.87

WOUND DEBRIDEMENTS FOR INJURIES WITHOUT CC/MCC

Facility

$28,086.87

Service Code	MSDRG 903
Min. Negotiated Rate	$28,086.87
Max. Negotiated Rate	$28,086.87
Rate for Payer: Hawaii Medical Service Association Commercial	$28,086.87

ZINC OXIDE-COD LIVER OIL 40 % TOP PASTE

Facility

$40.21

Service Code	HCPCS A9270
Hospital Revenue Code	637
Min. Negotiated Rate	$20.11
Max. Negotiated Rate	$39.81
Rate for Payer: AlohaCare Medicaid	$20.11
Rate for Payer: AlohaCare Medicare	$36.19
Rate for Payer: Cash Price	$26.14
Rate for Payer: Devoted Health Medicare	$39.81
Rate for Payer: Hawaii Medical Service Association Medicare	$36.19
Rate for Payer: Hawaii Western Management Group Commercial	$38.20
Rate for Payer: Health Management Network Commercial	$34.18
Rate for Payer: Humana Medicare	$36.19
Rate for Payer: Kaiser Permanente Commercial	$36.19
Rate for Payer: Kaiser Permanente Medicaid	$20.51
Rate for Payer: Kaiser Permanente Medicare	$36.19
Rate for Payer: MDX Hawaii PPO	$39.00
Rate for Payer: Ohana Health Plan Medicaid	$36.19
Rate for Payer: Ohana Health Plan Medicare	$36.19
Rate for Payer: UnitedHealthcare Medicare	$36.19
Rate for Payer: University Health Alliance Commercial	$29.31

ZINC OXIDE-COD LIVER OIL 40 % TOP PASTE

Facility

$40.21

Service Code	HCPCS A9270
Hospital Revenue Code	250
Min. Negotiated Rate	$34.18
Max. Negotiated Rate	$39.00
Rate for Payer: Cash Price	$26.14
Rate for Payer: Health Management Network Commercial	$34.18
Rate for Payer: Kaiser Permanente Commercial	$36.19
Rate for Payer: MDX Hawaii PPO	$39.00

ZIPRASIDONE HCL 20 MG PO CAP

Facility

$52.47

Service Code	HCPCS A9270
Hospital Revenue Code	637
Min. Negotiated Rate	$26.23
Max. Negotiated Rate	$51.95
Rate for Payer: AlohaCare Medicaid	$26.23
Rate for Payer: AlohaCare Medicare	$47.22
Rate for Payer: Cash Price	$34.11
Rate for Payer: Devoted Health Medicare	$51.95
Rate for Payer: Hawaii Medical Service Association Medicare	$47.22
Rate for Payer: Hawaii Western Management Group Commercial	$49.85
Rate for Payer: Health Management Network Commercial	$44.60
Rate for Payer: Humana Medicare	$47.22
Rate for Payer: Kaiser Permanente Commercial	$47.22
Rate for Payer: Kaiser Permanente Medicaid	$26.76
Rate for Payer: Kaiser Permanente Medicare	$47.22
Rate for Payer: MDX Hawaii PPO	$50.90
Rate for Payer: Ohana Health Plan Medicaid	$47.22
Rate for Payer: Ohana Health Plan Medicare	$47.22
Rate for Payer: UnitedHealthcare Medicare	$47.22
Rate for Payer: University Health Alliance Commercial	$38.25

ZIPRASIDONE HCL 20 MG PO CAP

Facility

$52.47

Service Code	HCPCS A9270
Hospital Revenue Code	250
Min. Negotiated Rate	$44.60
Max. Negotiated Rate	$50.90
Rate for Payer: Cash Price	$34.11
Rate for Payer: Health Management Network Commercial	$44.60
Rate for Payer: Kaiser Permanente Commercial	$47.22
Rate for Payer: MDX Hawaii PPO	$50.90

ZIPRASIDONE MESYLATE 20 MG IM RECON.SOLN. (FOR SWFI INJ FILE)

Facility

$153.76

Service Code	HCPCS J3486
Hospital Revenue Code	250
Min. Negotiated Rate	$130.70
Max. Negotiated Rate	$149.15
Rate for Payer: Cash Price	$99.94
Rate for Payer: Cash Price	$138.18
Rate for Payer: Health Management Network Commercial	$130.70
Rate for Payer: Health Management Network Commercial	$180.69
Rate for Payer: Kaiser Permanente Commercial	$138.38
Rate for Payer: Kaiser Permanente Commercial	$191.32
Rate for Payer: MDX Hawaii PPO	$206.20
Rate for Payer: MDX Hawaii PPO	$149.15

ZIPRASIDONE MESYLATE 20 MG IM RECON.SOLN. (FOR SWFI INJ FILE)

Facility

$153.76

Service Code	HCPCS J3486
Hospital Revenue Code	636
Min. Negotiated Rate	$3.14
Max. Negotiated Rate	$152.22
Rate for Payer: Devoted Health Medicare	$210.45
Rate for Payer: AlohaCare Medicaid	$76.88
Rate for Payer: AlohaCare Medicaid	$106.29
Rate for Payer: AlohaCare Medicare	$191.32
Rate for Payer: AlohaCare Medicare	$138.38
Rate for Payer: Cash Price	$138.18
Rate for Payer: Cash Price	$99.94
Rate for Payer: Cash Price	$99.94
Rate for Payer: Cash Price	$138.18
Rate for Payer: Devoted Health Medicare	$152.22
Rate for Payer: Hawaii Medical Service Association ABD	$3.14
Rate for Payer: Hawaii Medical Service Association ABD	$3.14
Rate for Payer: Hawaii Medical Service Association Medicare	$191.32
Rate for Payer: Hawaii Medical Service Association Medicare	$138.38
Rate for Payer: Hawaii Medical Service Association Non-ABD	$3.14
Rate for Payer: Hawaii Medical Service Association Non-ABD	$3.14
Rate for Payer: Hawaii Western Management Group Commercial	$146.07
Rate for Payer: Hawaii Western Management Group Commercial	$201.95
Rate for Payer: Health Management Network Commercial	$180.69
Rate for Payer: Health Management Network Commercial	$130.70
Rate for Payer: Humana Medicare	$138.38
Rate for Payer: Humana Medicare	$191.32
Rate for Payer: Kaiser Permanente Commercial	$138.38
Rate for Payer: Kaiser Permanente Commercial	$191.32
Rate for Payer: Kaiser Permanente Medicaid	$108.42
Rate for Payer: Kaiser Permanente Medicaid	$78.42
Rate for Payer: Kaiser Permanente Medicare	$138.38
Rate for Payer: Kaiser Permanente Medicare	$191.32
Rate for Payer: MDX Hawaii PPO	$149.15
Rate for Payer: MDX Hawaii PPO	$206.20
Rate for Payer: Ohana Health Plan Medicaid	$191.32
Rate for Payer: Ohana Health Plan Medicaid	$138.38
Rate for Payer: Ohana Health Plan Medicare	$138.38
Rate for Payer: Ohana Health Plan Medicare	$191.32
Rate for Payer: UnitedHealthcare Medicaid	$127.55
Rate for Payer: UnitedHealthcare Medicaid	$92.26
Rate for Payer: UnitedHealthcare Medicare	$138.38
Rate for Payer: UnitedHealthcare Medicare	$191.32
Rate for Payer: University Health Alliance Commercial	$112.08
Rate for Payer: University Health Alliance Commercial	$154.95

ZOLPIDEM 5 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 Medicaid	$14.19
Rate for Payer: AlohaCare Medicare	$1.08
Rate for Payer: AlohaCare Medicare	$25.53
Rate for Payer: Cash Price	$18.44
Rate for Payer: Cash Price	$0.78
Rate for Payer: Devoted Health Medicare	$1.19
Rate for Payer: Devoted Health Medicare	$28.09
Rate for Payer: Hawaii Medical Service Association Medicare	$25.53
Rate for Payer: Hawaii Medical Service Association Medicare	$1.08
Rate for Payer: Hawaii Western Management Group Commercial	$26.95
Rate for Payer: Hawaii Western Management Group Commercial	$1.14
Rate for Payer: Health Management Network Commercial	$1.02
Rate for Payer: Health Management Network Commercial	$24.11
Rate for Payer: Humana Medicare	$25.53
Rate for Payer: Humana Medicare	$1.08
Rate for Payer: Kaiser Permanente Commercial	$1.08
Rate for Payer: Kaiser Permanente Commercial	$25.53
Rate for Payer: Kaiser Permanente Medicaid	$14.47
Rate for Payer: Kaiser Permanente Medicaid	$0.61
Rate for Payer: Kaiser Permanente Medicare	$25.53
Rate for Payer: Kaiser Permanente Medicare	$1.08
Rate for Payer: MDX Hawaii PPO	$27.52
Rate for Payer: MDX Hawaii PPO	$1.16
Rate for Payer: Ohana Health Plan Medicaid	$1.08
Rate for Payer: Ohana Health Plan Medicaid	$25.53
Rate for Payer: Ohana Health Plan Medicare	$1.08
Rate for Payer: Ohana Health Plan Medicare	$25.53
Rate for Payer: UnitedHealthcare Medicare	$1.08
Rate for Payer: UnitedHealthcare Medicare	$25.53
Rate for Payer: University Health Alliance Commercial	$20.68
Rate for Payer: University Health Alliance Commercial	$0.87

ZOLPIDEM 5 MG PO TABLET

Facility

$28.37

Service Code	HCPCS A9270
Hospital Revenue Code	250
Min. Negotiated Rate	$24.11
Max. Negotiated Rate	$27.52
Rate for Payer: Cash Price	$18.44
Rate for Payer: Cash Price	$0.78
Rate for Payer: Health Management Network Commercial	$24.11
Rate for Payer: Health Management Network Commercial	$1.02
Rate for Payer: Kaiser Permanente Commercial	$25.53
Rate for Payer: Kaiser Permanente Commercial	$1.08
Rate for Payer: MDX Hawaii PPO	$1.16
Rate for Payer: MDX Hawaii PPO	$27.52

Know your out-of-pocket cost for care.

All Charges