Kohala Hospital

All Charges

Charge

Type

Setting

Price

D&C, CONIZATION, LAPAROSCOPY AND TUBAL INTERRUPTION WITH CC/MCC

Facility

$15,643.32

Service Code	MSDRG 744
Min. Negotiated Rate	$15,643.32
Max. Negotiated Rate	$15,643.32
Rate for Payer: Hawaii Medical Service Association Commercial	$15,643.32

D&C, CONIZATION, LAPAROSCOPY AND TUBAL INTERRUPTION WITHOUT CC/MCC

Facility

$15,643.32

Service Code	MSDRG 745
Min. Negotiated Rate	$15,643.32
Max. Negotiated Rate	$15,643.32
Rate for Payer: Hawaii Medical Service Association Commercial	$15,643.32

DEGENERATIVE NERVOUS SYSTEM DISORDERS WITH MCC

Facility

$25,835.18

Service Code	MSDRG 056
Min. Negotiated Rate	$25,835.18
Max. Negotiated Rate	$25,835.18
Rate for Payer: Hawaii Medical Service Association Commercial	$25,835.18

DEGENERATIVE NERVOUS SYSTEM DISORDERS WITHOUT MCC

Facility

$25,835.18

Service Code	MSDRG 057
Min. Negotiated Rate	$25,835.18
Max. Negotiated Rate	$25,835.18
Rate for Payer: Hawaii Medical Service Association Commercial	$25,835.18

DENTAL AND ORAL DISEASES WITH CC

Facility

$19,933.38

Service Code	MSDRG 158
Min. Negotiated Rate	$19,933.38
Max. Negotiated Rate	$19,933.38
Rate for Payer: Hawaii Medical Service Association Commercial	$19,933.38

DENTAL AND ORAL DISEASES WITH MCC

Facility

$19,933.38

Service Code	MSDRG 157
Min. Negotiated Rate	$19,933.38
Max. Negotiated Rate	$19,933.38
Rate for Payer: Hawaii Medical Service Association Commercial	$19,933.38

DENTAL AND ORAL DISEASES WITHOUT CC/MCC

Facility

$19,933.38

Service Code	MSDRG 159
Min. Negotiated Rate	$19,933.38
Max. Negotiated Rate	$19,933.38
Rate for Payer: Hawaii Medical Service Association Commercial	$19,933.38

DEPRESSIVE NEUROSES

Facility

$10,002.24

Service Code	MSDRG 881
Min. Negotiated Rate	$10,002.24
Max. Negotiated Rate	$10,002.24
Rate for Payer: Hawaii Medical Service Association Commercial	$10,002.24

DERMABOND MINI DHVM12 [2707788]

Facility

$93.50

Hospital Charge Code	2707788.0
Hospital Revenue Code	272
Min. Negotiated Rate	$79.47
Max. Negotiated Rate	$90.69
Rate for Payer: Cash Price	$60.78
Rate for Payer: Health Management Network Commercial	$79.47
Rate for Payer: Kaiser Permanente Commercial	$84.15
Rate for Payer: MDX Hawaii PPO	$90.69

DERMABOND MINI DHVM12 [2707788]

Facility

$93.50

Hospital Charge Code	2707788.0
Hospital Revenue Code	272
Min. Negotiated Rate	$46.75
Max. Negotiated Rate	$92.56
Rate for Payer: AlohaCare Medicaid	$46.75
Rate for Payer: AlohaCare Medicare	$84.15
Rate for Payer: Cash Price	$60.78
Rate for Payer: Devoted Health Medicare	$92.56
Rate for Payer: Hawaii Medical Service Association Medicare	$84.15
Rate for Payer: Hawaii Western Management Group Commercial	$88.83
Rate for Payer: Health Management Network Commercial	$79.47
Rate for Payer: Humana Medicare	$84.15
Rate for Payer: Kaiser Permanente Commercial	$84.15
Rate for Payer: Kaiser Permanente Medicaid	$47.69
Rate for Payer: Kaiser Permanente Medicare	$84.15
Rate for Payer: MDX Hawaii PPO	$90.69
Rate for Payer: Ohana Health Plan Medicaid	$84.15
Rate for Payer: Ohana Health Plan Medicare	$84.15
Rate for Payer: UnitedHealthcare Medicare	$84.15
Rate for Payer: University Health Alliance Commercial	$68.15

DESMOPRESSIN 4 MCG/ML INJ SOLN

Facility

$121.50

Service Code	HCPCS J2597
Hospital Revenue Code	250
Min. Negotiated Rate	$103.28
Max. Negotiated Rate	$117.86
Rate for Payer: Cash Price	$78.98
Rate for Payer: Cash Price	$113.96
Rate for Payer: Health Management Network Commercial	$103.28
Rate for Payer: Health Management Network Commercial	$149.02
Rate for Payer: Kaiser Permanente Commercial	$109.35
Rate for Payer: Kaiser Permanente Commercial	$157.79
Rate for Payer: MDX Hawaii PPO	$170.06
Rate for Payer: MDX Hawaii PPO	$117.86

DESMOPRESSIN 4 MCG/ML INJ SOLN

Facility

$175.32

Service Code	HCPCS J2597
Hospital Revenue Code	636
Min. Negotiated Rate	$3.89
Max. Negotiated Rate	$173.57
Rate for Payer: AlohaCare Medicaid	$87.66
Rate for Payer: AlohaCare Medicaid	$60.75
Rate for Payer: AlohaCare Medicare	$109.35
Rate for Payer: AlohaCare Medicare	$157.79
Rate for Payer: Cash Price	$113.96
Rate for Payer: Cash Price	$78.98
Rate for Payer: Cash Price	$78.98
Rate for Payer: Cash Price	$113.96
Rate for Payer: Devoted Health Medicare	$120.28
Rate for Payer: Devoted Health Medicare	$173.57
Rate for Payer: Hawaii Medical Service Association ABD	$3.89
Rate for Payer: Hawaii Medical Service Association ABD	$3.89
Rate for Payer: Hawaii Medical Service Association Medicare	$109.35
Rate for Payer: Hawaii Medical Service Association Medicare	$157.79
Rate for Payer: Hawaii Medical Service Association Non-ABD	$3.89
Rate for Payer: Hawaii Medical Service Association Non-ABD	$3.89
Rate for Payer: Hawaii Western Management Group Commercial	$166.55
Rate for Payer: Hawaii Western Management Group Commercial	$115.42
Rate for Payer: Health Management Network Commercial	$103.28
Rate for Payer: Health Management Network Commercial	$149.02
Rate for Payer: Humana Medicare	$157.79
Rate for Payer: Humana Medicare	$109.35
Rate for Payer: Kaiser Permanente Commercial	$109.35
Rate for Payer: Kaiser Permanente Commercial	$157.79
Rate for Payer: Kaiser Permanente Medicaid	$89.41
Rate for Payer: Kaiser Permanente Medicaid	$61.97
Rate for Payer: Kaiser Permanente Medicare	$109.35
Rate for Payer: Kaiser Permanente Medicare	$157.79
Rate for Payer: MDX Hawaii PPO	$170.06
Rate for Payer: MDX Hawaii PPO	$117.86
Rate for Payer: Ohana Health Plan Medicaid	$109.35
Rate for Payer: Ohana Health Plan Medicaid	$157.79
Rate for Payer: Ohana Health Plan Medicare	$157.79
Rate for Payer: Ohana Health Plan Medicare	$109.35
Rate for Payer: UnitedHealthcare Medicaid	$105.19
Rate for Payer: UnitedHealthcare Medicaid	$72.90
Rate for Payer: UnitedHealthcare Medicare	$109.35
Rate for Payer: UnitedHealthcare Medicare	$157.79
Rate for Payer: University Health Alliance Commercial	$127.79
Rate for Payer: University Health Alliance Commercial	$88.56

DEXAMETHASONE 0.5 MG PO TABLET

Facility

$1.20

Service Code	HCPCS J8540
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

DEXAMETHASONE 0.5 MG PO TABLET

Facility

$1.20

Service Code	HCPCS J8540
Hospital Revenue Code	636
Min. Negotiated Rate	$0.02
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: Cash Price	$0.78
Rate for Payer: Devoted Health Medicare	$1.19
Rate for Payer: Hawaii Medical Service Association ABD	$0.02
Rate for Payer: Hawaii Medical Service Association Medicare	$1.08
Rate for Payer: Hawaii Medical Service Association Non-ABD	$0.02
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 Medicaid	$0.72
Rate for Payer: UnitedHealthcare Medicare	$1.08
Rate for Payer: University Health Alliance Commercial	$0.87

DEXAMETHASONE 2 MG PO TABLET

Facility

$3.29

Service Code	HCPCS J8540
Hospital Revenue Code	250
Min. Negotiated Rate	$2.80
Max. Negotiated Rate	$3.19
Rate for Payer: Cash Price	$2.14
Rate for Payer: Health Management Network Commercial	$2.80
Rate for Payer: Kaiser Permanente Commercial	$2.96
Rate for Payer: MDX Hawaii PPO	$3.19

DEXAMETHASONE 2 MG PO TABLET

Facility

$3.29

Service Code	HCPCS J8540
Hospital Revenue Code	636
Min. Negotiated Rate	$0.02
Max. Negotiated Rate	$3.26
Rate for Payer: AlohaCare Medicaid	$1.65
Rate for Payer: AlohaCare Medicare	$2.96
Rate for Payer: Cash Price	$2.14
Rate for Payer: Cash Price	$2.14
Rate for Payer: Devoted Health Medicare	$3.26
Rate for Payer: Hawaii Medical Service Association ABD	$0.02
Rate for Payer: Hawaii Medical Service Association Medicare	$2.96
Rate for Payer: Hawaii Medical Service Association Non-ABD	$0.02
Rate for Payer: Hawaii Western Management Group Commercial	$3.13
Rate for Payer: Health Management Network Commercial	$2.80
Rate for Payer: Humana Medicare	$2.96
Rate for Payer: Kaiser Permanente Commercial	$2.96
Rate for Payer: Kaiser Permanente Medicaid	$1.68
Rate for Payer: Kaiser Permanente Medicare	$2.96
Rate for Payer: MDX Hawaii PPO	$3.19
Rate for Payer: Ohana Health Plan Medicaid	$2.96
Rate for Payer: Ohana Health Plan Medicare	$2.96
Rate for Payer: UnitedHealthcare Medicaid	$1.97
Rate for Payer: UnitedHealthcare Medicare	$2.96
Rate for Payer: University Health Alliance Commercial	$2.40

DEXAMETHASONE 4 MG PO TABLET

Facility

$6.66

Service Code	HCPCS J8540
Hospital Revenue Code	250
Min. Negotiated Rate	$5.66
Max. Negotiated Rate	$6.46
Rate for Payer: Cash Price	$4.33
Rate for Payer: Health Management Network Commercial	$5.66
Rate for Payer: Kaiser Permanente Commercial	$5.99
Rate for Payer: MDX Hawaii PPO	$6.46

DEXAMETHASONE 4 MG PO TABLET

Facility

$6.66

Service Code	HCPCS J8540
Hospital Revenue Code	636
Min. Negotiated Rate	$0.02
Max. Negotiated Rate	$6.59
Rate for Payer: AlohaCare Medicaid	$3.33
Rate for Payer: AlohaCare Medicare	$5.99
Rate for Payer: Cash Price	$4.33
Rate for Payer: Cash Price	$4.33
Rate for Payer: Devoted Health Medicare	$6.59
Rate for Payer: Hawaii Medical Service Association ABD	$0.02
Rate for Payer: Hawaii Medical Service Association Medicare	$5.99
Rate for Payer: Hawaii Medical Service Association Non-ABD	$0.02
Rate for Payer: Hawaii Western Management Group Commercial	$6.33
Rate for Payer: Health Management Network Commercial	$5.66
Rate for Payer: Humana Medicare	$5.99
Rate for Payer: Kaiser Permanente Commercial	$5.99
Rate for Payer: Kaiser Permanente Medicaid	$3.40
Rate for Payer: Kaiser Permanente Medicare	$5.99
Rate for Payer: MDX Hawaii PPO	$6.46
Rate for Payer: Ohana Health Plan Medicaid	$5.99
Rate for Payer: Ohana Health Plan Medicare	$5.99
Rate for Payer: UnitedHealthcare Medicaid	$4.00
Rate for Payer: UnitedHealthcare Medicare	$5.99
Rate for Payer: University Health Alliance Commercial	$4.85

DEXAMETHASONE SODIUM PHOSPHATE 10 MG/ML INJ SOLN

Facility

$7.89

Service Code	HCPCS J1100
Hospital Revenue Code	250
Min. Negotiated Rate	$6.71
Max. Negotiated Rate	$7.65
Rate for Payer: Cash Price	$5.13
Rate for Payer: Health Management Network Commercial	$6.71
Rate for Payer: Kaiser Permanente Commercial	$7.10
Rate for Payer: MDX Hawaii PPO	$7.65

DEXAMETHASONE SODIUM PHOSPHATE 10 MG/ML INJ SOLN

Facility

$7.89

Service Code	HCPCS J1100
Hospital Revenue Code	636
Min. Negotiated Rate	$0.12
Max. Negotiated Rate	$7.81
Rate for Payer: AlohaCare Medicaid	$3.94
Rate for Payer: AlohaCare Medicare	$7.10
Rate for Payer: Cash Price	$5.13
Rate for Payer: Cash Price	$5.13
Rate for Payer: Devoted Health Medicare	$7.81
Rate for Payer: Hawaii Medical Service Association ABD	$0.12
Rate for Payer: Hawaii Medical Service Association Medicare	$7.10
Rate for Payer: Hawaii Medical Service Association Non-ABD	$0.12
Rate for Payer: Hawaii Western Management Group Commercial	$7.50
Rate for Payer: Health Management Network Commercial	$6.71
Rate for Payer: Humana Medicare	$7.10
Rate for Payer: Kaiser Permanente Commercial	$7.10
Rate for Payer: Kaiser Permanente Medicaid	$4.02
Rate for Payer: Kaiser Permanente Medicare	$7.10
Rate for Payer: MDX Hawaii PPO	$7.65
Rate for Payer: Ohana Health Plan Medicaid	$7.10
Rate for Payer: Ohana Health Plan Medicare	$7.10
Rate for Payer: UnitedHealthcare Medicaid	$4.73
Rate for Payer: UnitedHealthcare Medicare	$7.10
Rate for Payer: University Health Alliance Commercial	$5.75

DEXAMETHASONE SODIUM PHOSPHATE 10 MG/ML INJ SOLN (FOR OTHER USE)

Facility

$7.89

Service Code	NDC 00641036725
Hospital Revenue Code	250
Min. Negotiated Rate	$6.71
Max. Negotiated Rate	$7.65
Rate for Payer: Cash Price	$5.13
Rate for Payer: Health Management Network Commercial	$6.71
Rate for Payer: Kaiser Permanente Commercial	$7.10
Rate for Payer: MDX Hawaii PPO	$7.65

DEXAMETHASONE SODIUM PHOSPHATE 10 MG/ML INJ SOLN (FOR OTHER USE)

Facility

$7.89

Service Code	NDC 00641036725
Hospital Revenue Code	250
Min. Negotiated Rate	$3.94
Max. Negotiated Rate	$7.81
Rate for Payer: AlohaCare Medicaid	$3.94
Rate for Payer: AlohaCare Medicare	$7.10
Rate for Payer: Cash Price	$5.13
Rate for Payer: Devoted Health Medicare	$7.81
Rate for Payer: Hawaii Medical Service Association Medicare	$7.10
Rate for Payer: Hawaii Western Management Group Commercial	$7.50
Rate for Payer: Health Management Network Commercial	$6.71
Rate for Payer: Humana Medicare	$7.10
Rate for Payer: Kaiser Permanente Commercial	$7.10
Rate for Payer: Kaiser Permanente Medicaid	$4.02
Rate for Payer: Kaiser Permanente Medicare	$7.10
Rate for Payer: MDX Hawaii PPO	$7.65
Rate for Payer: Ohana Health Plan Medicaid	$7.10
Rate for Payer: Ohana Health Plan Medicare	$7.10
Rate for Payer: UnitedHealthcare Medicaid	$4.73
Rate for Payer: UnitedHealthcare Medicare	$7.10
Rate for Payer: University Health Alliance Commercial	$5.75

DEXAMETHASONE SODIUM PHOSPHATE 10 MG/ML INJ SOLN (FOR OTHER USE)

Facility

$7.89

Service Code	NDC 00641036721
Hospital Revenue Code	250
Min. Negotiated Rate	$3.94
Max. Negotiated Rate	$7.81
Rate for Payer: AlohaCare Medicaid	$3.94
Rate for Payer: AlohaCare Medicare	$7.10
Rate for Payer: Cash Price	$5.13
Rate for Payer: Devoted Health Medicare	$7.81
Rate for Payer: Hawaii Medical Service Association Medicare	$7.10
Rate for Payer: Hawaii Western Management Group Commercial	$7.50
Rate for Payer: Health Management Network Commercial	$6.71
Rate for Payer: Humana Medicare	$7.10
Rate for Payer: Kaiser Permanente Commercial	$7.10
Rate for Payer: Kaiser Permanente Medicaid	$4.02
Rate for Payer: Kaiser Permanente Medicare	$7.10
Rate for Payer: MDX Hawaii PPO	$7.65
Rate for Payer: Ohana Health Plan Medicaid	$7.10
Rate for Payer: Ohana Health Plan Medicare	$7.10
Rate for Payer: UnitedHealthcare Medicaid	$4.73
Rate for Payer: UnitedHealthcare Medicare	$7.10
Rate for Payer: University Health Alliance Commercial	$5.75

DEXAMETHASONE SODIUM PHOSPHATE 10 MG/ML INJ SOLN (FOR OTHER USE)

Facility

$7.89

Service Code	NDC 00641036721
Hospital Revenue Code	250
Min. Negotiated Rate	$6.71
Max. Negotiated Rate	$7.65
Rate for Payer: Cash Price	$5.13
Rate for Payer: Health Management Network Commercial	$6.71
Rate for Payer: Kaiser Permanente Commercial	$7.10
Rate for Payer: MDX Hawaii PPO	$7.65

DEXAMETHASONE SODIUM PHOSPHATE 4 MG/ML INJ SOLN

Facility

$5.47

Service Code	HCPCS J1100
Hospital Revenue Code	636
Min. Negotiated Rate	$0.12
Max. Negotiated Rate	$5.42
Rate for Payer: AlohaCare Medicaid	$2.73
Rate for Payer: AlohaCare Medicare	$4.92
Rate for Payer: Cash Price	$3.56
Rate for Payer: Cash Price	$3.56
Rate for Payer: Devoted Health Medicare	$5.42
Rate for Payer: Hawaii Medical Service Association ABD	$0.12
Rate for Payer: Hawaii Medical Service Association Medicare	$4.92
Rate for Payer: Hawaii Medical Service Association Non-ABD	$0.12
Rate for Payer: Hawaii Western Management Group Commercial	$5.20
Rate for Payer: Health Management Network Commercial	$4.65
Rate for Payer: Humana Medicare	$4.92
Rate for Payer: Kaiser Permanente Commercial	$4.92
Rate for Payer: Kaiser Permanente Medicaid	$2.79
Rate for Payer: Kaiser Permanente Medicare	$4.92
Rate for Payer: MDX Hawaii PPO	$5.31
Rate for Payer: Ohana Health Plan Medicaid	$4.92
Rate for Payer: Ohana Health Plan Medicare	$4.92
Rate for Payer: UnitedHealthcare Medicaid	$3.28
Rate for Payer: UnitedHealthcare Medicare	$4.92
Rate for Payer: University Health Alliance Commercial	$3.99

Know your out-of-pocket cost for care.

All Charges