Kohala Hospital

All Charges

Charge

Type

Setting

Price

DEXAMETHASONE SODIUM PHOSPHATE 4 MG/ML INJ SOLN

Facility

$5.47

Service Code	HCPCS J1100
Hospital Revenue Code	250
Min. Negotiated Rate	$4.65
Max. Negotiated Rate	$5.31
Rate for Payer: Cash Price	$3.56
Rate for Payer: Health Management Network Commercial	$4.65
Rate for Payer: Kaiser Permanente Commercial	$4.92
Rate for Payer: MDX Hawaii PPO	$5.31

DEXAMETHASONE SODIUM PHOSPHATE 4 MG/ML INJ SOLN (FOR OTHER USE)

Facility

$5.47

Service Code	NDC 67457042300
Hospital Revenue Code	250
Min. Negotiated Rate	$2.73
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: Devoted Health Medicare	$5.42
Rate for Payer: Hawaii Medical Service Association Medicare	$4.92
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

DEXAMETHASONE SODIUM PHOSPHATE 4 MG/ML INJ SOLN (FOR OTHER USE)

Facility

$5.47

Service Code	NDC 67457042300
Hospital Revenue Code	250
Min. Negotiated Rate	$4.65
Max. Negotiated Rate	$5.31
Rate for Payer: Cash Price	$3.56
Rate for Payer: Health Management Network Commercial	$4.65
Rate for Payer: Kaiser Permanente Commercial	$4.92
Rate for Payer: MDX Hawaii PPO	$5.31

DEXAMETHASONE SODIUM PHOSPHATE 4 MG/ML INJ SOLN (FOR OTHER USE)

Facility

$5.47

Service Code	NDC 67457042312
Hospital Revenue Code	250
Min. Negotiated Rate	$4.65
Max. Negotiated Rate	$5.31
Rate for Payer: Cash Price	$3.56
Rate for Payer: Health Management Network Commercial	$4.65
Rate for Payer: Kaiser Permanente Commercial	$4.92
Rate for Payer: MDX Hawaii PPO	$5.31

DEXAMETHASONE SODIUM PHOSPHATE 4 MG/ML INJ SOLN (FOR OTHER USE)

Facility

$5.47

Service Code	NDC 67457042312
Hospital Revenue Code	250
Min. Negotiated Rate	$2.73
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: Devoted Health Medicare	$5.42
Rate for Payer: Hawaii Medical Service Association Medicare	$4.92
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

DEXTROMETHORPHAN-GUAIFENESIN 10-100 MG/5 ML PO SYRUP

Facility

$15.30

Service Code	HCPCS A9270
Hospital Revenue Code	637
Min. Negotiated Rate	$7.65
Max. Negotiated Rate	$15.15
Rate for Payer: AlohaCare Medicaid	$7.65
Rate for Payer: AlohaCare Medicare	$13.77
Rate for Payer: Cash Price	$9.94
Rate for Payer: Devoted Health Medicare	$15.15
Rate for Payer: Hawaii Medical Service Association Medicare	$13.77
Rate for Payer: Hawaii Western Management Group Commercial	$14.54
Rate for Payer: Health Management Network Commercial	$13.01
Rate for Payer: Humana Medicare	$13.77
Rate for Payer: Kaiser Permanente Commercial	$13.77
Rate for Payer: Kaiser Permanente Medicaid	$7.80
Rate for Payer: Kaiser Permanente Medicare	$13.77
Rate for Payer: MDX Hawaii PPO	$14.84
Rate for Payer: Ohana Health Plan Medicaid	$13.77
Rate for Payer: Ohana Health Plan Medicare	$13.77
Rate for Payer: UnitedHealthcare Medicare	$13.77
Rate for Payer: University Health Alliance Commercial	$11.15

DEXTROMETHORPHAN-GUAIFENESIN 10-100 MG/5 ML PO SYRUP

Facility

$15.30

Service Code	HCPCS A9270
Hospital Revenue Code	250
Min. Negotiated Rate	$13.01
Max. Negotiated Rate	$14.84
Rate for Payer: Cash Price	$9.94
Rate for Payer: Health Management Network Commercial	$13.01
Rate for Payer: Kaiser Permanente Commercial	$13.77
Rate for Payer: MDX Hawaii PPO	$14.84

DEXTROSE 10 % IN WATER (D10W) 10 % IV SOLP

Facility

$69.75

Service Code	NDC 00338002302
Hospital Revenue Code	250
Min. Negotiated Rate	$34.88
Max. Negotiated Rate	$69.05
Rate for Payer: AlohaCare Medicaid	$34.88
Rate for Payer: AlohaCare Medicare	$62.77
Rate for Payer: Cash Price	$45.34
Rate for Payer: Devoted Health Medicare	$69.05
Rate for Payer: Hawaii Medical Service Association Medicare	$62.77
Rate for Payer: Hawaii Western Management Group Commercial	$66.26
Rate for Payer: Health Management Network Commercial	$59.29
Rate for Payer: Humana Medicare	$62.77
Rate for Payer: Kaiser Permanente Commercial	$62.77
Rate for Payer: Kaiser Permanente Medicaid	$35.57
Rate for Payer: Kaiser Permanente Medicare	$62.77
Rate for Payer: MDX Hawaii PPO	$67.66
Rate for Payer: Ohana Health Plan Medicaid	$62.77
Rate for Payer: Ohana Health Plan Medicare	$62.77
Rate for Payer: UnitedHealthcare Medicaid	$41.85
Rate for Payer: UnitedHealthcare Medicare	$62.77
Rate for Payer: University Health Alliance Commercial	$50.84

DEXTROSE 10 % IN WATER (D10W) 10 % IV SOLP

Facility

$69.75

Service Code	NDC 00338002302
Hospital Revenue Code	250
Min. Negotiated Rate	$59.29
Max. Negotiated Rate	$67.66
Rate for Payer: Cash Price	$45.34
Rate for Payer: Health Management Network Commercial	$59.29
Rate for Payer: Kaiser Permanente Commercial	$62.77
Rate for Payer: MDX Hawaii PPO	$67.66

DEXTROSE 10 % IN WATER (D10W) 10 % IV SOLP

Facility

$38.62

Service Code	NDC 00264752000
Hospital Revenue Code	250
Min. Negotiated Rate	$19.31
Max. Negotiated Rate	$38.23
Rate for Payer: AlohaCare Medicaid	$19.31
Rate for Payer: AlohaCare Medicare	$34.76
Rate for Payer: Cash Price	$25.10
Rate for Payer: Devoted Health Medicare	$38.23
Rate for Payer: Hawaii Medical Service Association Medicare	$34.76
Rate for Payer: Hawaii Western Management Group Commercial	$36.69
Rate for Payer: Health Management Network Commercial	$32.83
Rate for Payer: Humana Medicare	$34.76
Rate for Payer: Kaiser Permanente Commercial	$34.76
Rate for Payer: Kaiser Permanente Medicaid	$19.70
Rate for Payer: Kaiser Permanente Medicare	$34.76
Rate for Payer: MDX Hawaii PPO	$37.46
Rate for Payer: Ohana Health Plan Medicaid	$34.76
Rate for Payer: Ohana Health Plan Medicare	$34.76
Rate for Payer: UnitedHealthcare Medicaid	$23.17
Rate for Payer: UnitedHealthcare Medicare	$34.76
Rate for Payer: University Health Alliance Commercial	$28.15

DEXTROSE 10 % IN WATER (D10W) 10 % IV SOLP

Facility

$38.62

Service Code	NDC 00264752000
Hospital Revenue Code	250
Min. Negotiated Rate	$32.83
Max. Negotiated Rate	$37.46
Rate for Payer: Cash Price	$25.10
Rate for Payer: Health Management Network Commercial	$32.83
Rate for Payer: Kaiser Permanente Commercial	$34.76
Rate for Payer: MDX Hawaii PPO	$37.46

DEXTROSE 25 % IN WATER (D25W) IV SYR

Facility

$103.25

Service Code	NDC 00409177510
Hospital Revenue Code	250
Min. Negotiated Rate	$51.62
Max. Negotiated Rate	$102.22
Rate for Payer: AlohaCare Medicaid	$51.62
Rate for Payer: AlohaCare Medicare	$92.92
Rate for Payer: Cash Price	$67.11
Rate for Payer: Devoted Health Medicare	$102.22
Rate for Payer: Hawaii Medical Service Association Medicare	$92.92
Rate for Payer: Hawaii Western Management Group Commercial	$98.09
Rate for Payer: Health Management Network Commercial	$87.76
Rate for Payer: Humana Medicare	$92.92
Rate for Payer: Kaiser Permanente Commercial	$92.92
Rate for Payer: Kaiser Permanente Medicaid	$52.66
Rate for Payer: Kaiser Permanente Medicare	$92.92
Rate for Payer: MDX Hawaii PPO	$100.15
Rate for Payer: Ohana Health Plan Medicaid	$92.92
Rate for Payer: Ohana Health Plan Medicare	$92.92
Rate for Payer: UnitedHealthcare Medicaid	$61.95
Rate for Payer: UnitedHealthcare Medicare	$92.92
Rate for Payer: University Health Alliance Commercial	$75.26

DEXTROSE 25 % IN WATER (D25W) IV SYR

Facility

$103.25

Service Code	NDC 00409177510
Hospital Revenue Code	250
Min. Negotiated Rate	$87.76
Max. Negotiated Rate	$100.15
Rate for Payer: Cash Price	$67.11
Rate for Payer: Health Management Network Commercial	$87.76
Rate for Payer: Kaiser Permanente Commercial	$92.92
Rate for Payer: MDX Hawaii PPO	$100.15

DEXTROSE 40 % PO GEL

Facility

$22.03

Service Code	HCPCS A9270
Hospital Revenue Code	637
Min. Negotiated Rate	$11.02
Max. Negotiated Rate	$21.81
Rate for Payer: AlohaCare Medicaid	$11.02
Rate for Payer: AlohaCare Medicare	$19.83
Rate for Payer: Cash Price	$14.32
Rate for Payer: Devoted Health Medicare	$21.81
Rate for Payer: Hawaii Medical Service Association Medicare	$19.83
Rate for Payer: Hawaii Western Management Group Commercial	$20.93
Rate for Payer: Health Management Network Commercial	$18.73
Rate for Payer: Humana Medicare	$19.83
Rate for Payer: Kaiser Permanente Commercial	$19.83
Rate for Payer: Kaiser Permanente Medicaid	$11.24
Rate for Payer: Kaiser Permanente Medicare	$19.83
Rate for Payer: MDX Hawaii PPO	$21.37
Rate for Payer: Ohana Health Plan Medicaid	$19.83
Rate for Payer: Ohana Health Plan Medicare	$19.83
Rate for Payer: UnitedHealthcare Medicare	$19.83
Rate for Payer: University Health Alliance Commercial	$16.06

DEXTROSE 40 % PO GEL

Facility

$22.03

Service Code	HCPCS A9270
Hospital Revenue Code	250
Min. Negotiated Rate	$18.73
Max. Negotiated Rate	$21.37
Rate for Payer: Cash Price	$14.32
Rate for Payer: Health Management Network Commercial	$18.73
Rate for Payer: Kaiser Permanente Commercial	$19.83
Rate for Payer: MDX Hawaii PPO	$21.37

DEXTROSE 5%-0.2 % SOD CHLORIDE IV SOLP

Facility

$27.60

Service Code	NDC 00264761600
Hospital Revenue Code	250
Min. Negotiated Rate	$23.46
Max. Negotiated Rate	$26.77
Rate for Payer: Cash Price	$17.94
Rate for Payer: Health Management Network Commercial	$23.46
Rate for Payer: Kaiser Permanente Commercial	$24.84
Rate for Payer: MDX Hawaii PPO	$26.77

DEXTROSE 5%-0.2 % SOD CHLORIDE IV SOLP

Facility

$27.60

Service Code	NDC 00264761600
Hospital Revenue Code	250
Min. Negotiated Rate	$13.80
Max. Negotiated Rate	$27.32
Rate for Payer: AlohaCare Medicaid	$13.80
Rate for Payer: AlohaCare Medicare	$24.84
Rate for Payer: Cash Price	$17.94
Rate for Payer: Devoted Health Medicare	$27.32
Rate for Payer: Hawaii Medical Service Association Medicare	$24.84
Rate for Payer: Hawaii Western Management Group Commercial	$26.22
Rate for Payer: Health Management Network Commercial	$23.46
Rate for Payer: Humana Medicare	$24.84
Rate for Payer: Kaiser Permanente Commercial	$24.84
Rate for Payer: Kaiser Permanente Medicaid	$14.08
Rate for Payer: Kaiser Permanente Medicare	$24.84
Rate for Payer: MDX Hawaii PPO	$26.77
Rate for Payer: Ohana Health Plan Medicaid	$24.84
Rate for Payer: Ohana Health Plan Medicare	$24.84
Rate for Payer: UnitedHealthcare Medicaid	$16.56
Rate for Payer: UnitedHealthcare Medicare	$24.84
Rate for Payer: University Health Alliance Commercial	$20.12

DEXTROSE 50 % IN WATER (D50W) IV SOLP

Facility

$28.71

Service Code	NDC 00409664816
Hospital Revenue Code	250
Min. Negotiated Rate	$14.36
Max. Negotiated Rate	$28.42
Rate for Payer: AlohaCare Medicaid	$14.36
Rate for Payer: AlohaCare Medicare	$25.84
Rate for Payer: Cash Price	$18.66
Rate for Payer: Devoted Health Medicare	$28.42
Rate for Payer: Hawaii Medical Service Association Medicare	$25.84
Rate for Payer: Hawaii Western Management Group Commercial	$27.27
Rate for Payer: Health Management Network Commercial	$24.40
Rate for Payer: Humana Medicare	$25.84
Rate for Payer: Kaiser Permanente Commercial	$25.84
Rate for Payer: Kaiser Permanente Medicaid	$14.64
Rate for Payer: Kaiser Permanente Medicare	$25.84
Rate for Payer: MDX Hawaii PPO	$27.85
Rate for Payer: Ohana Health Plan Medicaid	$25.84
Rate for Payer: Ohana Health Plan Medicare	$25.84
Rate for Payer: UnitedHealthcare Medicaid	$17.23
Rate for Payer: UnitedHealthcare Medicare	$25.84
Rate for Payer: University Health Alliance Commercial	$20.93

DEXTROSE 50 % IN WATER (D50W) IV SOLP

Facility

$28.71

Service Code	NDC 00409664816
Hospital Revenue Code	250
Min. Negotiated Rate	$24.40
Max. Negotiated Rate	$27.85
Rate for Payer: Cash Price	$18.66
Rate for Payer: Health Management Network Commercial	$24.40
Rate for Payer: Kaiser Permanente Commercial	$25.84
Rate for Payer: MDX Hawaii PPO	$27.85

DEXTROSE 50 % IN WATER (D50W) IV SOLP

Facility

$28.71

Service Code	NDC 00409664802
Hospital Revenue Code	250
Min. Negotiated Rate	$14.36
Max. Negotiated Rate	$28.42
Rate for Payer: AlohaCare Medicaid	$14.36
Rate for Payer: AlohaCare Medicare	$25.84
Rate for Payer: Cash Price	$18.66
Rate for Payer: Devoted Health Medicare	$28.42
Rate for Payer: Hawaii Medical Service Association Medicare	$25.84
Rate for Payer: Hawaii Western Management Group Commercial	$27.27
Rate for Payer: Health Management Network Commercial	$24.40
Rate for Payer: Humana Medicare	$25.84
Rate for Payer: Kaiser Permanente Commercial	$25.84
Rate for Payer: Kaiser Permanente Medicaid	$14.64
Rate for Payer: Kaiser Permanente Medicare	$25.84
Rate for Payer: MDX Hawaii PPO	$27.85
Rate for Payer: Ohana Health Plan Medicaid	$25.84
Rate for Payer: Ohana Health Plan Medicare	$25.84
Rate for Payer: UnitedHealthcare Medicaid	$17.23
Rate for Payer: UnitedHealthcare Medicare	$25.84
Rate for Payer: University Health Alliance Commercial	$20.93

DEXTROSE 50 % IN WATER (D50W) IV SOLP

Facility

$28.71

Service Code	NDC 00409664802
Hospital Revenue Code	250
Min. Negotiated Rate	$24.40
Max. Negotiated Rate	$27.85
Rate for Payer: Cash Price	$18.66
Rate for Payer: Health Management Network Commercial	$24.40
Rate for Payer: Kaiser Permanente Commercial	$25.84
Rate for Payer: MDX Hawaii PPO	$27.85

DEXTROSE 50 % IN WATER (D50W) IV SYR

Facility

$99.56

Service Code	NDC 00409751716
Hospital Revenue Code	250
Min. Negotiated Rate	$49.78
Max. Negotiated Rate	$98.56
Rate for Payer: AlohaCare Medicaid	$49.78
Rate for Payer: AlohaCare Medicare	$89.60
Rate for Payer: Cash Price	$64.71
Rate for Payer: Devoted Health Medicare	$98.56
Rate for Payer: Hawaii Medical Service Association Medicare	$89.60
Rate for Payer: Hawaii Western Management Group Commercial	$94.58
Rate for Payer: Health Management Network Commercial	$84.63
Rate for Payer: Humana Medicare	$89.60
Rate for Payer: Kaiser Permanente Commercial	$89.60
Rate for Payer: Kaiser Permanente Medicaid	$50.78
Rate for Payer: Kaiser Permanente Medicare	$89.60
Rate for Payer: MDX Hawaii PPO	$96.57
Rate for Payer: Ohana Health Plan Medicaid	$89.60
Rate for Payer: Ohana Health Plan Medicare	$89.60
Rate for Payer: UnitedHealthcare Medicaid	$59.74
Rate for Payer: UnitedHealthcare Medicare	$89.60
Rate for Payer: University Health Alliance Commercial	$72.57

DEXTROSE 50 % IN WATER (D50W) IV SYR

Facility

$99.56

Service Code	NDC 00409751766
Hospital Revenue Code	250
Min. Negotiated Rate	$84.63
Max. Negotiated Rate	$96.57
Rate for Payer: Cash Price	$64.71
Rate for Payer: Health Management Network Commercial	$84.63
Rate for Payer: Kaiser Permanente Commercial	$89.60
Rate for Payer: MDX Hawaii PPO	$96.57

DEXTROSE 50 % IN WATER (D50W) IV SYR

Facility

$99.56

Service Code	NDC 00409751716
Hospital Revenue Code	250
Min. Negotiated Rate	$84.63
Max. Negotiated Rate	$96.57
Rate for Payer: Cash Price	$64.71
Rate for Payer: Health Management Network Commercial	$84.63
Rate for Payer: Kaiser Permanente Commercial	$89.60
Rate for Payer: MDX Hawaii PPO	$96.57

DEXTROSE 50 % IN WATER (D50W) IV SYR

Facility

$101.84

Service Code	NDC 76329330201
Hospital Revenue Code	250
Min. Negotiated Rate	$50.92
Max. Negotiated Rate	$100.82
Rate for Payer: AlohaCare Medicaid	$50.92
Rate for Payer: AlohaCare Medicare	$91.66
Rate for Payer: Cash Price	$66.20
Rate for Payer: Devoted Health Medicare	$100.82
Rate for Payer: Hawaii Medical Service Association Medicare	$91.66
Rate for Payer: Hawaii Western Management Group Commercial	$96.75
Rate for Payer: Health Management Network Commercial	$86.56
Rate for Payer: Humana Medicare	$91.66
Rate for Payer: Kaiser Permanente Commercial	$91.66
Rate for Payer: Kaiser Permanente Medicaid	$51.94
Rate for Payer: Kaiser Permanente Medicare	$91.66
Rate for Payer: MDX Hawaii PPO	$98.78
Rate for Payer: Ohana Health Plan Medicaid	$91.66
Rate for Payer: Ohana Health Plan Medicare	$91.66
Rate for Payer: UnitedHealthcare Medicaid	$61.10
Rate for Payer: UnitedHealthcare Medicare	$91.66
Rate for Payer: University Health Alliance Commercial	$74.23

Know your out-of-pocket cost for care.

All Charges