Kohala Hospital

All Charges

Charge

Type

Setting

Price

DISORDERS OF THE BILIARY TRACT WITH CC

Facility

$25,124.12

Service Code	MSDRG 445
Min. Negotiated Rate	$25,124.12
Max. Negotiated Rate	$25,124.12
Rate for Payer: Hawaii Medical Service Association Commercial	$25,124.12

DISORDERS OF THE BILIARY TRACT WITH MCC

Facility

$25,645.56

Service Code	MSDRG 444
Min. Negotiated Rate	$25,645.56
Max. Negotiated Rate	$25,645.56
Rate for Payer: Hawaii Medical Service Association Commercial	$25,645.56

DISORDERS OF THE BILIARY TRACT WITHOUT CC/MCC

Facility

$16,567.70

Service Code	MSDRG 446
Min. Negotiated Rate	$16,567.70
Max. Negotiated Rate	$16,567.70
Rate for Payer: Hawaii Medical Service Association Commercial	$16,567.70

DIVALPROEX 125 MG PO CDRS

Facility

$7.84

Service Code	HCPCS A9270
Hospital Revenue Code	637
Min. Negotiated Rate	$3.92
Max. Negotiated Rate	$7.76
Rate for Payer: AlohaCare Medicaid	$3.92
Rate for Payer: AlohaCare Medicare	$7.06
Rate for Payer: Cash Price	$5.10
Rate for Payer: Devoted Health Medicare	$7.76
Rate for Payer: Hawaii Medical Service Association Medicare	$7.06
Rate for Payer: Hawaii Western Management Group Commercial	$7.45
Rate for Payer: Health Management Network Commercial	$6.66
Rate for Payer: Humana Medicare	$7.06
Rate for Payer: Kaiser Permanente Commercial	$7.06
Rate for Payer: Kaiser Permanente Medicaid	$4.00
Rate for Payer: Kaiser Permanente Medicare	$7.06
Rate for Payer: MDX Hawaii PPO	$7.60
Rate for Payer: Ohana Health Plan Medicaid	$7.06
Rate for Payer: Ohana Health Plan Medicare	$7.06
Rate for Payer: UnitedHealthcare Medicare	$7.06
Rate for Payer: University Health Alliance Commercial	$5.71

DIVALPROEX 125 MG PO CDRS

Facility

$7.84

Service Code	HCPCS A9270
Hospital Revenue Code	250
Min. Negotiated Rate	$6.66
Max. Negotiated Rate	$7.60
Rate for Payer: Cash Price	$5.10
Rate for Payer: Health Management Network Commercial	$6.66
Rate for Payer: Kaiser Permanente Commercial	$7.06
Rate for Payer: MDX Hawaii PPO	$7.60

DOBUTAMINE IN D5W 250 MG/250 ML (1 MG/ML) IV SOLP TITRATION

Facility

$111.15

Service Code	HCPCS J1250
Hospital Revenue Code	636
Min. Negotiated Rate	$7.98
Max. Negotiated Rate	$110.04
Rate for Payer: AlohaCare Medicaid	$55.58
Rate for Payer: AlohaCare Medicare	$100.03
Rate for Payer: Cash Price	$72.25
Rate for Payer: Cash Price	$72.25
Rate for Payer: Devoted Health Medicare	$110.04
Rate for Payer: Hawaii Medical Service Association ABD	$7.98
Rate for Payer: Hawaii Medical Service Association Medicare	$100.03
Rate for Payer: Hawaii Medical Service Association Non-ABD	$7.98
Rate for Payer: Hawaii Western Management Group Commercial	$105.59
Rate for Payer: Health Management Network Commercial	$94.48
Rate for Payer: Humana Medicare	$100.03
Rate for Payer: Kaiser Permanente Commercial	$100.03
Rate for Payer: Kaiser Permanente Medicaid	$56.69
Rate for Payer: Kaiser Permanente Medicare	$100.03
Rate for Payer: MDX Hawaii PPO	$107.82
Rate for Payer: Ohana Health Plan Medicaid	$100.03
Rate for Payer: Ohana Health Plan Medicare	$100.03
Rate for Payer: UnitedHealthcare Medicaid	$66.69
Rate for Payer: UnitedHealthcare Medicare	$100.03
Rate for Payer: University Health Alliance Commercial	$81.02

DOBUTAMINE IN D5W 250 MG/250 ML (1 MG/ML) IV SOLP TITRATION

Facility

$111.15

Service Code	HCPCS J1250
Hospital Revenue Code	250
Min. Negotiated Rate	$94.48
Max. Negotiated Rate	$107.82
Rate for Payer: Cash Price	$72.25
Rate for Payer: Health Management Network Commercial	$94.48
Rate for Payer: Kaiser Permanente Commercial	$100.03
Rate for Payer: MDX Hawaii PPO	$107.82

DOBUTAMINE IN D5W 250 MG/250 ML (1 MG/ML) NON-TITRATING

Facility

$109.08

Service Code	NDC 00409234631
Hospital Revenue Code	636
Min. Negotiated Rate	$54.54
Max. Negotiated Rate	$107.99
Rate for Payer: AlohaCare Medicaid	$54.54
Rate for Payer: AlohaCare Medicare	$98.17
Rate for Payer: Cash Price	$70.90
Rate for Payer: Devoted Health Medicare	$107.99
Rate for Payer: Hawaii Medical Service Association Medicare	$98.17
Rate for Payer: Hawaii Western Management Group Commercial	$103.63
Rate for Payer: Health Management Network Commercial	$92.72
Rate for Payer: Humana Medicare	$98.17
Rate for Payer: Kaiser Permanente Commercial	$98.17
Rate for Payer: Kaiser Permanente Medicaid	$55.63
Rate for Payer: Kaiser Permanente Medicare	$98.17
Rate for Payer: MDX Hawaii PPO	$105.81
Rate for Payer: Ohana Health Plan Medicaid	$98.17
Rate for Payer: Ohana Health Plan Medicare	$98.17
Rate for Payer: UnitedHealthcare Medicaid	$65.45
Rate for Payer: UnitedHealthcare Medicare	$98.17
Rate for Payer: University Health Alliance Commercial	$79.51

DOBUTAMINE IN D5W 250 MG/250 ML (1 MG/ML) NON-TITRATING

Facility

$109.08

Service Code	NDC 00409234632
Hospital Revenue Code	250
Min. Negotiated Rate	$92.72
Max. Negotiated Rate	$105.81
Rate for Payer: Cash Price	$70.90
Rate for Payer: Health Management Network Commercial	$92.72
Rate for Payer: Kaiser Permanente Commercial	$98.17
Rate for Payer: MDX Hawaii PPO	$105.81

DOBUTAMINE IN D5W 250 MG/250 ML (1 MG/ML) NON-TITRATING

Facility

$109.08

Service Code	NDC 00409234631
Hospital Revenue Code	250
Min. Negotiated Rate	$92.72
Max. Negotiated Rate	$105.81
Rate for Payer: Cash Price	$70.90
Rate for Payer: Health Management Network Commercial	$92.72
Rate for Payer: Kaiser Permanente Commercial	$98.17
Rate for Payer: MDX Hawaii PPO	$105.81

DOBUTAMINE IN D5W 250 MG/250 ML (1 MG/ML) NON-TITRATING

Facility

$109.08

Service Code	NDC 00409234632
Hospital Revenue Code	636
Min. Negotiated Rate	$54.54
Max. Negotiated Rate	$107.99
Rate for Payer: AlohaCare Medicaid	$54.54
Rate for Payer: AlohaCare Medicare	$98.17
Rate for Payer: Cash Price	$70.90
Rate for Payer: Devoted Health Medicare	$107.99
Rate for Payer: Hawaii Medical Service Association Medicare	$98.17
Rate for Payer: Hawaii Western Management Group Commercial	$103.63
Rate for Payer: Health Management Network Commercial	$92.72
Rate for Payer: Humana Medicare	$98.17
Rate for Payer: Kaiser Permanente Commercial	$98.17
Rate for Payer: Kaiser Permanente Medicaid	$55.63
Rate for Payer: Kaiser Permanente Medicare	$98.17
Rate for Payer: MDX Hawaii PPO	$105.81
Rate for Payer: Ohana Health Plan Medicaid	$98.17
Rate for Payer: Ohana Health Plan Medicare	$98.17
Rate for Payer: UnitedHealthcare Medicaid	$65.45
Rate for Payer: UnitedHealthcare Medicare	$98.17
Rate for Payer: University Health Alliance Commercial	$79.51

DOCUSATE SODIUM 100 MG PO CAP

Facility

$1.20

Service Code	HCPCS A9270
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

DOCUSATE SODIUM 100 MG PO CAP

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 Medicare	$1.08
Rate for Payer: Cash Price	$0.78
Rate for Payer: Devoted Health Medicare	$1.19
Rate for Payer: Hawaii Medical Service Association Medicare	$1.08
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 Medicare	$1.08
Rate for Payer: University Health Alliance Commercial	$0.87

DOCUSATE SODIUM 50 MG/5 ML PO LIQ

Facility

$6.30

Service Code	HCPCS A9270
Hospital Revenue Code	637
Min. Negotiated Rate	$3.15
Max. Negotiated Rate	$6.24
Rate for Payer: AlohaCare Medicaid	$3.15
Rate for Payer: AlohaCare Medicaid	$6.13
Rate for Payer: AlohaCare Medicare	$11.03
Rate for Payer: AlohaCare Medicare	$5.67
Rate for Payer: Cash Price	$7.97
Rate for Payer: Cash Price	$4.10
Rate for Payer: Devoted Health Medicare	$6.24
Rate for Payer: Devoted Health Medicare	$12.14
Rate for Payer: Hawaii Medical Service Association Medicare	$11.03
Rate for Payer: Hawaii Medical Service Association Medicare	$5.67
Rate for Payer: Hawaii Western Management Group Commercial	$11.65
Rate for Payer: Hawaii Western Management Group Commercial	$5.99
Rate for Payer: Health Management Network Commercial	$5.36
Rate for Payer: Health Management Network Commercial	$10.42
Rate for Payer: Humana Medicare	$5.67
Rate for Payer: Humana Medicare	$11.03
Rate for Payer: Kaiser Permanente Commercial	$11.03
Rate for Payer: Kaiser Permanente Commercial	$5.67
Rate for Payer: Kaiser Permanente Medicaid	$3.21
Rate for Payer: Kaiser Permanente Medicaid	$6.25
Rate for Payer: Kaiser Permanente Medicare	$11.03
Rate for Payer: Kaiser Permanente Medicare	$5.67
Rate for Payer: MDX Hawaii PPO	$11.89
Rate for Payer: MDX Hawaii PPO	$6.11
Rate for Payer: Ohana Health Plan Medicaid	$11.03
Rate for Payer: Ohana Health Plan Medicaid	$5.67
Rate for Payer: Ohana Health Plan Medicare	$11.03
Rate for Payer: Ohana Health Plan Medicare	$5.67
Rate for Payer: UnitedHealthcare Medicare	$5.67
Rate for Payer: UnitedHealthcare Medicare	$11.03
Rate for Payer: University Health Alliance Commercial	$4.59
Rate for Payer: University Health Alliance Commercial	$8.94

DOCUSATE SODIUM 50 MG/5 ML PO LIQ

Facility

$12.26

Service Code	HCPCS A9270
Hospital Revenue Code	250
Min. Negotiated Rate	$10.42
Max. Negotiated Rate	$11.89
Rate for Payer: Cash Price	$7.97
Rate for Payer: Cash Price	$4.10
Rate for Payer: Health Management Network Commercial	$10.42
Rate for Payer: Health Management Network Commercial	$5.36
Rate for Payer: Kaiser Permanente Commercial	$11.03
Rate for Payer: Kaiser Permanente Commercial	$5.67
Rate for Payer: MDX Hawaii PPO	$6.11
Rate for Payer: MDX Hawaii PPO	$11.89

DOFETILIDE 125 MCG PO CAP

Facility

$56.73

Service Code	HCPCS A9270
Hospital Revenue Code	637
Min. Negotiated Rate	$28.36
Max. Negotiated Rate	$56.16
Rate for Payer: AlohaCare Medicaid	$28.36
Rate for Payer: AlohaCare Medicare	$51.06
Rate for Payer: Cash Price	$36.87
Rate for Payer: Devoted Health Medicare	$56.16
Rate for Payer: Hawaii Medical Service Association Medicare	$51.06
Rate for Payer: Hawaii Western Management Group Commercial	$53.89
Rate for Payer: Health Management Network Commercial	$48.22
Rate for Payer: Humana Medicare	$51.06
Rate for Payer: Kaiser Permanente Commercial	$51.06
Rate for Payer: Kaiser Permanente Medicaid	$28.93
Rate for Payer: Kaiser Permanente Medicare	$51.06
Rate for Payer: MDX Hawaii PPO	$55.03
Rate for Payer: Ohana Health Plan Medicaid	$51.06
Rate for Payer: Ohana Health Plan Medicare	$51.06
Rate for Payer: UnitedHealthcare Medicare	$51.06
Rate for Payer: University Health Alliance Commercial	$41.35

DOFETILIDE 125 MCG PO CAP

Facility

$56.73

Service Code	HCPCS A9270
Hospital Revenue Code	250
Min. Negotiated Rate	$48.22
Max. Negotiated Rate	$55.03
Rate for Payer: Cash Price	$36.87
Rate for Payer: Health Management Network Commercial	$48.22
Rate for Payer: Kaiser Permanente Commercial	$51.06
Rate for Payer: MDX Hawaii PPO	$55.03

DONEPEZIL 10 MG PO TABLET

Facility

$4.29

Service Code	HCPCS A9270
Hospital Revenue Code	250
Min. Negotiated Rate	$3.65
Max. Negotiated Rate	$4.16
Rate for Payer: Cash Price	$2.79
Rate for Payer: Health Management Network Commercial	$3.65
Rate for Payer: Kaiser Permanente Commercial	$3.86
Rate for Payer: MDX Hawaii PPO	$4.16

DONEPEZIL 10 MG PO TABLET

Facility

$4.29

Service Code	HCPCS A9270
Hospital Revenue Code	637
Min. Negotiated Rate	$2.15
Max. Negotiated Rate	$4.25
Rate for Payer: AlohaCare Medicaid	$2.15
Rate for Payer: AlohaCare Medicare	$3.86
Rate for Payer: Cash Price	$2.79
Rate for Payer: Devoted Health Medicare	$4.25
Rate for Payer: Hawaii Medical Service Association Medicare	$3.86
Rate for Payer: Hawaii Western Management Group Commercial	$4.08
Rate for Payer: Health Management Network Commercial	$3.65
Rate for Payer: Humana Medicare	$3.86
Rate for Payer: Kaiser Permanente Commercial	$3.86
Rate for Payer: Kaiser Permanente Medicaid	$2.19
Rate for Payer: Kaiser Permanente Medicare	$3.86
Rate for Payer: MDX Hawaii PPO	$4.16
Rate for Payer: Ohana Health Plan Medicaid	$3.86
Rate for Payer: Ohana Health Plan Medicare	$3.86
Rate for Payer: UnitedHealthcare Medicare	$3.86
Rate for Payer: University Health Alliance Commercial	$3.13

DONEPEZIL 5 MG PO TABLET

Facility

$4.29

Service Code	HCPCS A9270
Hospital Revenue Code	637
Min. Negotiated Rate	$2.15
Max. Negotiated Rate	$4.25
Rate for Payer: AlohaCare Medicaid	$2.15
Rate for Payer: AlohaCare Medicare	$3.86
Rate for Payer: Cash Price	$2.79
Rate for Payer: Devoted Health Medicare	$4.25
Rate for Payer: Hawaii Medical Service Association Medicare	$3.86
Rate for Payer: Hawaii Western Management Group Commercial	$4.08
Rate for Payer: Health Management Network Commercial	$3.65
Rate for Payer: Humana Medicare	$3.86
Rate for Payer: Kaiser Permanente Commercial	$3.86
Rate for Payer: Kaiser Permanente Medicaid	$2.19
Rate for Payer: Kaiser Permanente Medicare	$3.86
Rate for Payer: MDX Hawaii PPO	$4.16
Rate for Payer: Ohana Health Plan Medicaid	$3.86
Rate for Payer: Ohana Health Plan Medicare	$3.86
Rate for Payer: UnitedHealthcare Medicare	$3.86
Rate for Payer: University Health Alliance Commercial	$3.13

DONEPEZIL 5 MG PO TABLET

Facility

$4.29

Service Code	HCPCS A9270
Hospital Revenue Code	250
Min. Negotiated Rate	$3.65
Max. Negotiated Rate	$4.16
Rate for Payer: Cash Price	$2.79
Rate for Payer: Health Management Network Commercial	$3.65
Rate for Payer: Kaiser Permanente Commercial	$3.86
Rate for Payer: MDX Hawaii PPO	$4.16

DOPAMINE IN 5 % DEXTROSE 400 MG/250 ML (1,600 MCG/ML) IV SOLN

Facility

$86.94

Service Code	HCPCS J1265
Hospital Revenue Code	250
Min. Negotiated Rate	$73.90
Max. Negotiated Rate	$84.33
Rate for Payer: Cash Price	$56.51
Rate for Payer: Cash Price	$54.09
Rate for Payer: Health Management Network Commercial	$73.90
Rate for Payer: Health Management Network Commercial	$70.73
Rate for Payer: Kaiser Permanente Commercial	$74.89
Rate for Payer: Kaiser Permanente Commercial	$78.25
Rate for Payer: MDX Hawaii PPO	$80.71
Rate for Payer: MDX Hawaii PPO	$84.33

DOPAMINE IN 5 % DEXTROSE 400 MG/250 ML (1,600 MCG/ML) IV SOLN

Facility

$86.94

Service Code	HCPCS J1265
Hospital Revenue Code	636
Min. Negotiated Rate	$0.66
Max. Negotiated Rate	$86.07
Rate for Payer: AlohaCare Medicaid	$43.47
Rate for Payer: AlohaCare Medicaid	$41.60
Rate for Payer: AlohaCare Medicare	$74.89
Rate for Payer: AlohaCare Medicare	$78.25
Rate for Payer: Cash Price	$56.51
Rate for Payer: Cash Price	$54.09
Rate for Payer: Cash Price	$56.51
Rate for Payer: Cash Price	$54.09
Rate for Payer: Devoted Health Medicare	$82.38
Rate for Payer: Devoted Health Medicare	$86.07
Rate for Payer: Hawaii Medical Service Association ABD	$0.66
Rate for Payer: Hawaii Medical Service Association ABD	$0.66
Rate for Payer: Hawaii Medical Service Association Medicare	$78.25
Rate for Payer: Hawaii Medical Service Association Medicare	$74.89
Rate for Payer: Hawaii Medical Service Association Non-ABD	$0.66
Rate for Payer: Hawaii Medical Service Association Non-ABD	$0.66
Rate for Payer: Hawaii Western Management Group Commercial	$79.05
Rate for Payer: Hawaii Western Management Group Commercial	$82.59
Rate for Payer: Health Management Network Commercial	$73.90
Rate for Payer: Health Management Network Commercial	$70.73
Rate for Payer: Humana Medicare	$78.25
Rate for Payer: Humana Medicare	$74.89
Rate for Payer: Kaiser Permanente Commercial	$74.89
Rate for Payer: Kaiser Permanente Commercial	$78.25
Rate for Payer: Kaiser Permanente Medicaid	$42.44
Rate for Payer: Kaiser Permanente Medicaid	$44.34
Rate for Payer: Kaiser Permanente Medicare	$74.89
Rate for Payer: Kaiser Permanente Medicare	$78.25
Rate for Payer: MDX Hawaii PPO	$84.33
Rate for Payer: MDX Hawaii PPO	$80.71
Rate for Payer: Ohana Health Plan Medicaid	$74.89
Rate for Payer: Ohana Health Plan Medicaid	$78.25
Rate for Payer: Ohana Health Plan Medicare	$78.25
Rate for Payer: Ohana Health Plan Medicare	$74.89
Rate for Payer: UnitedHealthcare Medicaid	$49.93
Rate for Payer: UnitedHealthcare Medicaid	$52.16
Rate for Payer: UnitedHealthcare Medicare	$78.25
Rate for Payer: UnitedHealthcare Medicare	$74.89
Rate for Payer: University Health Alliance Commercial	$63.37
Rate for Payer: University Health Alliance Commercial	$60.65

DORZOLAMIDE-TIMOLOL (PF) 2-0.5 % OPHT DROPPERETTE

Facility

$15.46

Service Code	HCPCS A9270
Hospital Revenue Code	250
Min. Negotiated Rate	$13.14
Max. Negotiated Rate	$15.00
Rate for Payer: Cash Price	$10.05
Rate for Payer: Health Management Network Commercial	$13.14
Rate for Payer: Kaiser Permanente Commercial	$13.91
Rate for Payer: MDX Hawaii PPO	$15.00

DORZOLAMIDE-TIMOLOL (PF) 2-0.5 % OPHT DROPPERETTE

Facility

$15.46

Service Code	HCPCS A9270
Hospital Revenue Code	637
Min. Negotiated Rate	$7.73
Max. Negotiated Rate	$15.31
Rate for Payer: AlohaCare Medicaid	$7.73
Rate for Payer: AlohaCare Medicare	$13.91
Rate for Payer: Cash Price	$10.05
Rate for Payer: Devoted Health Medicare	$15.31
Rate for Payer: Hawaii Medical Service Association Medicare	$13.91
Rate for Payer: Hawaii Western Management Group Commercial	$14.69
Rate for Payer: Health Management Network Commercial	$13.14
Rate for Payer: Humana Medicare	$13.91
Rate for Payer: Kaiser Permanente Commercial	$13.91
Rate for Payer: Kaiser Permanente Medicaid	$7.88
Rate for Payer: Kaiser Permanente Medicare	$13.91
Rate for Payer: MDX Hawaii PPO	$15.00
Rate for Payer: Ohana Health Plan Medicaid	$13.91
Rate for Payer: Ohana Health Plan Medicare	$13.91
Rate for Payer: UnitedHealthcare Medicare	$13.91
Rate for Payer: University Health Alliance Commercial	$11.27

Know your out-of-pocket cost for care.

All Charges