Kohala Hospital

All Charges

Charge

Type

Setting

Price

ACUTE MYOCARDIAL INFARCTION, DISCHARGED ALIVE WITH CC

Facility

$28,940.14

Service Code	MSDRG 281
Min. Negotiated Rate	$28,940.14
Max. Negotiated Rate	$28,940.14
Rate for Payer: Hawaii Medical Service Association Commercial	$28,940.14

ACUTE MYOCARDIAL INFARCTION, DISCHARGED ALIVE WITH MCC

Facility

$33,467.22

Service Code	MSDRG 280
Min. Negotiated Rate	$33,467.22
Max. Negotiated Rate	$33,467.22
Rate for Payer: Hawaii Medical Service Association Commercial	$33,467.22

ACUTE MYOCARDIAL INFARCTION, DISCHARGED ALIVE WITHOUT CC/MCC

Facility

$25,337.44

Service Code	MSDRG 282
Min. Negotiated Rate	$25,337.44
Max. Negotiated Rate	$25,337.44
Rate for Payer: Hawaii Medical Service Association Commercial	$25,337.44

ACUTE MYOCARDIAL INFARCTION, EXPIRED WITH CC

Facility

$55,913.02

Service Code	MSDRG 284
Min. Negotiated Rate	$55,913.02
Max. Negotiated Rate	$55,913.02
Rate for Payer: Hawaii Medical Service Association Commercial	$55,913.02

ACUTE MYOCARDIAL INFARCTION, EXPIRED WITH MCC

Facility

$55,913.02

Service Code	MSDRG 283
Min. Negotiated Rate	$55,913.02
Max. Negotiated Rate	$55,913.02
Rate for Payer: Hawaii Medical Service Association Commercial	$55,913.02

ACUTE MYOCARDIAL INFARCTION, EXPIRED WITHOUT CC/MCC

Facility

$55,913.02

Service Code	MSDRG 285
Min. Negotiated Rate	$55,913.02
Max. Negotiated Rate	$55,913.02
Rate for Payer: Hawaii Medical Service Association Commercial	$55,913.02

ACYCLOVIR 800 MG PO TABLET

Facility

$17.27

Service Code	HCPCS A9270
Hospital Revenue Code	637
Min. Negotiated Rate	$8.63
Max. Negotiated Rate	$17.10
Rate for Payer: AlohaCare Medicaid	$8.63
Rate for Payer: AlohaCare Medicare	$15.54
Rate for Payer: Cash Price	$11.23
Rate for Payer: Devoted Health Medicare	$17.10
Rate for Payer: Hawaii Medical Service Association Medicare	$15.54
Rate for Payer: Hawaii Western Management Group Commercial	$16.41
Rate for Payer: Health Management Network Commercial	$14.68
Rate for Payer: Humana Medicare	$15.54
Rate for Payer: Kaiser Permanente Commercial	$15.54
Rate for Payer: Kaiser Permanente Medicaid	$8.81
Rate for Payer: Kaiser Permanente Medicare	$15.54
Rate for Payer: MDX Hawaii PPO	$16.75
Rate for Payer: Ohana Health Plan Medicaid	$15.54
Rate for Payer: Ohana Health Plan Medicare	$15.54
Rate for Payer: UnitedHealthcare Medicare	$15.54
Rate for Payer: University Health Alliance Commercial	$12.59

ACYCLOVIR 800 MG PO TABLET

Facility

$17.27

Service Code	HCPCS A9270
Hospital Revenue Code	250
Min. Negotiated Rate	$14.68
Max. Negotiated Rate	$16.75
Rate for Payer: Cash Price	$11.23
Rate for Payer: Health Management Network Commercial	$14.68
Rate for Payer: Kaiser Permanente Commercial	$15.54
Rate for Payer: MDX Hawaii PPO	$16.75

ACYCLOVIR SODIUM 50 MG/ML IV SOLN

Facility

$142.20

Service Code	HCPCS J0133
Hospital Revenue Code	250
Min. Negotiated Rate	$120.87
Max. Negotiated Rate	$137.93
Rate for Payer: Cash Price	$92.43
Rate for Payer: Cash Price	$54.76
Rate for Payer: Health Management Network Commercial	$120.87
Rate for Payer: Health Management Network Commercial	$71.60
Rate for Payer: Kaiser Permanente Commercial	$127.98
Rate for Payer: Kaiser Permanente Commercial	$75.82
Rate for Payer: MDX Hawaii PPO	$81.71
Rate for Payer: MDX Hawaii PPO	$137.93

ACYCLOVIR SODIUM 50 MG/ML IV SOLN

Facility

$142.20

Service Code	HCPCS J0133
Hospital Revenue Code	636
Min. Negotiated Rate	$0.03
Max. Negotiated Rate	$140.78
Rate for Payer: AlohaCare Medicaid	$71.10
Rate for Payer: AlohaCare Medicaid	$42.12
Rate for Payer: AlohaCare Medicare	$75.82
Rate for Payer: AlohaCare Medicare	$127.98
Rate for Payer: Cash Price	$54.76
Rate for Payer: Cash Price	$92.43
Rate for Payer: Cash Price	$92.43
Rate for Payer: Cash Price	$54.76
Rate for Payer: Devoted Health Medicare	$140.78
Rate for Payer: Devoted Health Medicare	$83.40
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	$75.82
Rate for Payer: Hawaii Medical Service Association Medicare	$127.98
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	$135.09
Rate for Payer: Hawaii Western Management Group Commercial	$80.03
Rate for Payer: Health Management Network Commercial	$71.60
Rate for Payer: Health Management Network Commercial	$120.87
Rate for Payer: Humana Medicare	$127.98
Rate for Payer: Humana Medicare	$75.82
Rate for Payer: Kaiser Permanente Commercial	$127.98
Rate for Payer: Kaiser Permanente Commercial	$75.82
Rate for Payer: Kaiser Permanente Medicaid	$42.96
Rate for Payer: Kaiser Permanente Medicaid	$72.52
Rate for Payer: Kaiser Permanente Medicare	$127.98
Rate for Payer: Kaiser Permanente Medicare	$75.82
Rate for Payer: MDX Hawaii PPO	$137.93
Rate for Payer: MDX Hawaii PPO	$81.71
Rate for Payer: Ohana Health Plan Medicaid	$75.82
Rate for Payer: Ohana Health Plan Medicaid	$127.98
Rate for Payer: Ohana Health Plan Medicare	$127.98
Rate for Payer: Ohana Health Plan Medicare	$75.82
Rate for Payer: UnitedHealthcare Medicaid	$50.54
Rate for Payer: UnitedHealthcare Medicaid	$85.32
Rate for Payer: UnitedHealthcare Medicare	$127.98
Rate for Payer: UnitedHealthcare Medicare	$75.82
Rate for Payer: University Health Alliance Commercial	$103.65
Rate for Payer: University Health Alliance Commercial	$61.40

ADENOSINE 3 MG/ML IV SOLN

Facility

$45.87

Service Code	HCPCS J0153
Hospital Revenue Code	250
Min. Negotiated Rate	$38.99
Max. Negotiated Rate	$44.49
Rate for Payer: Cash Price	$29.82
Rate for Payer: Health Management Network Commercial	$38.99
Rate for Payer: Kaiser Permanente Commercial	$41.28
Rate for Payer: MDX Hawaii PPO	$44.49

ADENOSINE 3 MG/ML IV SOLN

Facility

$45.87

Service Code	HCPCS J0153
Hospital Revenue Code	636
Min. Negotiated Rate	$0.46
Max. Negotiated Rate	$45.41
Rate for Payer: AlohaCare Medicaid	$22.93
Rate for Payer: AlohaCare Medicare	$41.28
Rate for Payer: Cash Price	$29.82
Rate for Payer: Cash Price	$29.82
Rate for Payer: Devoted Health Medicare	$45.41
Rate for Payer: Hawaii Medical Service Association ABD	$0.46
Rate for Payer: Hawaii Medical Service Association Medicare	$41.28
Rate for Payer: Hawaii Medical Service Association Non-ABD	$0.46
Rate for Payer: Hawaii Western Management Group Commercial	$43.58
Rate for Payer: Health Management Network Commercial	$38.99
Rate for Payer: Humana Medicare	$41.28
Rate for Payer: Kaiser Permanente Commercial	$41.28
Rate for Payer: Kaiser Permanente Medicaid	$23.39
Rate for Payer: Kaiser Permanente Medicare	$41.28
Rate for Payer: MDX Hawaii PPO	$44.49
Rate for Payer: Ohana Health Plan Medicaid	$41.28
Rate for Payer: Ohana Health Plan Medicare	$41.28
Rate for Payer: UnitedHealthcare Medicaid	$27.52
Rate for Payer: UnitedHealthcare Medicare	$41.28
Rate for Payer: University Health Alliance Commercial	$33.43

ADENOSINE 3 MG/ML IV SYR

Facility

$84.24

Service Code	HCPCS J0153
Hospital Revenue Code	636
Min. Negotiated Rate	$0.46
Max. Negotiated Rate	$83.40
Rate for Payer: AlohaCare Medicaid	$42.12
Rate for Payer: AlohaCare Medicare	$75.82
Rate for Payer: Cash Price	$54.76
Rate for Payer: Cash Price	$54.76
Rate for Payer: Devoted Health Medicare	$83.40
Rate for Payer: Hawaii Medical Service Association ABD	$0.46
Rate for Payer: Hawaii Medical Service Association Medicare	$75.82
Rate for Payer: Hawaii Medical Service Association Non-ABD	$0.46
Rate for Payer: Hawaii Western Management Group Commercial	$80.03
Rate for Payer: Health Management Network Commercial	$71.60
Rate for Payer: Humana Medicare	$75.82
Rate for Payer: Kaiser Permanente Commercial	$75.82
Rate for Payer: Kaiser Permanente Medicaid	$42.96
Rate for Payer: Kaiser Permanente Medicare	$75.82
Rate for Payer: MDX Hawaii PPO	$81.71
Rate for Payer: Ohana Health Plan Medicaid	$75.82
Rate for Payer: Ohana Health Plan Medicare	$75.82
Rate for Payer: UnitedHealthcare Medicaid	$50.54
Rate for Payer: UnitedHealthcare Medicare	$75.82
Rate for Payer: University Health Alliance Commercial	$61.40

ADENOSINE 3 MG/ML IV SYR

Facility

$84.24

Service Code	HCPCS J0153
Hospital Revenue Code	250
Min. Negotiated Rate	$71.60
Max. Negotiated Rate	$81.71
Rate for Payer: Cash Price	$54.76
Rate for Payer: Health Management Network Commercial	$71.60
Rate for Payer: Kaiser Permanente Commercial	$75.82
Rate for Payer: MDX Hawaii PPO	$81.71

ADRENAL AND PITUITARY PROCEDURES WITH CC/MCC

Facility

$57,050.71

Service Code	MSDRG 614
Min. Negotiated Rate	$57,050.71
Max. Negotiated Rate	$57,050.71
Rate for Payer: Hawaii Medical Service Association Commercial	$57,050.71

ADRENAL AND PITUITARY PROCEDURES WITHOUT CC/MCC

Facility

$57,050.71

Service Code	MSDRG 615
Min. Negotiated Rate	$57,050.71
Max. Negotiated Rate	$57,050.71
Rate for Payer: Hawaii Medical Service Association Commercial	$57,050.71

AFTERCARE, MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH CC

Facility

$16,567.70

Service Code	MSDRG 560
Min. Negotiated Rate	$16,567.70
Max. Negotiated Rate	$16,567.70
Rate for Payer: Hawaii Medical Service Association Commercial	$16,567.70

AFTERCARE, MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH MCC

Facility

$16,567.70

Service Code	MSDRG 559
Min. Negotiated Rate	$16,567.70
Max. Negotiated Rate	$16,567.70
Rate for Payer: Hawaii Medical Service Association Commercial	$16,567.70

AFTERCARE, MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITHOUT CC/MCC

Facility

$16,567.70

Service Code	MSDRG 561
Min. Negotiated Rate	$16,567.70
Max. Negotiated Rate	$16,567.70
Rate for Payer: Hawaii Medical Service Association Commercial	$16,567.70

AFTERCARE WITH CC/MCC

Facility

$17,610.59

Service Code	MSDRG 949
Min. Negotiated Rate	$17,610.59
Max. Negotiated Rate	$17,610.59
Rate for Payer: Hawaii Medical Service Association Commercial	$17,610.59

AFTERCARE WITHOUT CC/MCC

Facility

$5,214.44

Service Code	MSDRG 950
Min. Negotiated Rate	$5,214.44
Max. Negotiated Rate	$5,214.44
Rate for Payer: Hawaii Medical Service Association Commercial	$5,214.44

AICD GENERATOR PROCEDURES

Facility

$77,315.92

Service Code	MSDRG 245
Min. Negotiated Rate	$77,315.92
Max. Negotiated Rate	$77,315.92
Rate for Payer: Hawaii Medical Service Association Commercial	$77,315.92

AICD LEAD PROCEDURES

Facility

$77,315.92

Service Code	MSDRG 265
Min. Negotiated Rate	$77,315.92
Max. Negotiated Rate	$77,315.92
Rate for Payer: Hawaii Medical Service Association Commercial	$77,315.92

ALBUMIN 25 % 50 ML (FOR ALBUMIN SHORTAGE)

Facility

$299.53

Service Code	HCPCS P9047
Hospital Revenue Code	636
Min. Negotiated Rate	$53.08
Max. Negotiated Rate	$296.53
Rate for Payer: AlohaCare Medicaid	$149.76
Rate for Payer: AlohaCare Medicare	$269.58
Rate for Payer: Cash Price	$194.69
Rate for Payer: Cash Price	$194.69
Rate for Payer: Devoted Health Medicare	$296.53
Rate for Payer: Hawaii Medical Service Association ABD	$53.08
Rate for Payer: Hawaii Medical Service Association Commercial	$66.35
Rate for Payer: Hawaii Medical Service Association Medicare	$269.58
Rate for Payer: Hawaii Medical Service Association Non-ABD	$53.08
Rate for Payer: Hawaii Western Management Group Commercial	$284.55
Rate for Payer: Health Management Network Commercial	$254.60
Rate for Payer: Humana Medicare	$269.58
Rate for Payer: Kaiser Permanente Commercial	$269.58
Rate for Payer: Kaiser Permanente Medicaid	$152.76
Rate for Payer: Kaiser Permanente Medicare	$269.58
Rate for Payer: MDX Hawaii PPO	$290.54
Rate for Payer: Ohana Health Plan Medicaid	$269.58
Rate for Payer: Ohana Health Plan Medicare	$269.58
Rate for Payer: UnitedHealthcare Medicaid	$179.72
Rate for Payer: UnitedHealthcare Medicare	$269.58
Rate for Payer: University Health Alliance Commercial	$218.33

ALBUMIN 25 % 50 ML (FOR ALBUMIN SHORTAGE)

Facility

$299.53

Service Code	HCPCS P9047
Hospital Revenue Code	250
Min. Negotiated Rate	$254.60
Max. Negotiated Rate	$290.54
Rate for Payer: Cash Price	$194.69
Rate for Payer: Health Management Network Commercial	$254.60
Rate for Payer: Kaiser Permanente Commercial	$269.58
Rate for Payer: MDX Hawaii PPO	$290.54

Know your out-of-pocket cost for care.

All Charges