Kohala Hospital

All Charges

Charge

Type

Setting

Price

EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH MCC

Facility

$76,510.06

Service Code	MSDRG 981
Min. Negotiated Rate	$76,510.06
Max. Negotiated Rate	$76,510.06
Rate for Payer: Hawaii Medical Service Association Commercial	$76,510.06

EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITHOUT CC/MCC

Facility

$30,291.16

Service Code	MSDRG 983
Min. Negotiated Rate	$30,291.16
Max. Negotiated Rate	$30,291.16
Rate for Payer: Hawaii Medical Service Association Commercial	$30,291.16

EXTRACRANIAL PROCEDURES WITH CC

Facility

$54,135.37

Service Code	MSDRG 038
Min. Negotiated Rate	$10,400.00
Max. Negotiated Rate	$54,135.37
Rate for Payer: Hawaii Medical Service Association Commercial	$54,135.37
Rate for Payer: University Health Alliance Commercial	$10,400.00

EXTRACRANIAL PROCEDURES WITH MCC

Facility

$65,038.29

Service Code	MSDRG 037
Min. Negotiated Rate	$10,400.00
Max. Negotiated Rate	$65,038.29
Rate for Payer: Hawaii Medical Service Association Commercial	$65,038.29
Rate for Payer: University Health Alliance Commercial	$10,400.00

EXTRACRANIAL PROCEDURES WITHOUT CC/MCC

Facility

$42,142.16

Service Code	MSDRG 039
Min. Negotiated Rate	$10,400.00
Max. Negotiated Rate	$42,142.16
Rate for Payer: Hawaii Medical Service Association Commercial	$42,142.16
Rate for Payer: University Health Alliance Commercial	$10,400.00

EXTRAOCULAR PROCEDURES EXCEPT ORBIT

Facility

$17,800.20

Service Code	MSDRG 115
Min. Negotiated Rate	$10,400.00
Max. Negotiated Rate	$17,800.20
Rate for Payer: Hawaii Medical Service Association Commercial	$17,800.20
Rate for Payer: University Health Alliance Commercial	$10,400.00

EXTREME IMMATURITY OR RESPIRATORY DISTRESS SYNDROME, NEONATE

Facility

$271,980.45

Service Code	MSDRG 790
Min. Negotiated Rate	$271,980.45
Max. Negotiated Rate	$271,980.45
Rate for Payer: Hawaii Medical Service Association Commercial	$271,980.45

FAMOTIDINE 20 MG PO TABLET

Facility

$1.33

Service Code	HCPCS A9270
Hospital Revenue Code	637
Min. Negotiated Rate	$0.67
Max. Negotiated Rate	$1.32
Rate for Payer: AlohaCare Medicaid	$0.67
Rate for Payer: AlohaCare Medicare	$1.20
Rate for Payer: Cash Price	$0.86
Rate for Payer: Devoted Health Medicare	$1.32
Rate for Payer: Hawaii Medical Service Association Medicare	$1.20
Rate for Payer: Hawaii Western Management Group Commercial	$1.26
Rate for Payer: Health Management Network Commercial	$1.13
Rate for Payer: Humana Medicare	$1.20
Rate for Payer: Kaiser Permanente Commercial	$1.20
Rate for Payer: Kaiser Permanente Medicaid	$0.68
Rate for Payer: Kaiser Permanente Medicare	$1.20
Rate for Payer: MDX Hawaii PPO	$1.29
Rate for Payer: Ohana Health Plan Medicaid	$1.20
Rate for Payer: Ohana Health Plan Medicare	$1.20
Rate for Payer: UnitedHealthcare Medicare	$1.20
Rate for Payer: University Health Alliance Commercial	$0.97

FAMOTIDINE 20 MG PO TABLET

Facility

$1.33

Service Code	HCPCS A9270
Hospital Revenue Code	250
Min. Negotiated Rate	$1.13
Max. Negotiated Rate	$1.29
Rate for Payer: Cash Price	$0.86
Rate for Payer: Health Management Network Commercial	$1.13
Rate for Payer: Kaiser Permanente Commercial	$1.20
Rate for Payer: MDX Hawaii PPO	$1.29

FAMOTIDINE (PF) 20 MG/2 ML IV SOLN

Facility

$5.26

Service Code	HCPCS J1308
Hospital Revenue Code	250
Min. Negotiated Rate	$4.47
Max. Negotiated Rate	$5.10
Rate for Payer: Cash Price	$3.42
Rate for Payer: Health Management Network Commercial	$4.47
Rate for Payer: Kaiser Permanente Commercial	$4.73
Rate for Payer: MDX Hawaii PPO	$5.10

FAMOTIDINE (PF) 20 MG/2 ML IV SOLN

Facility

$5.26

Service Code	HCPCS J1308
Hospital Revenue Code	636
Min. Negotiated Rate	$0.01
Max. Negotiated Rate	$5.21
Rate for Payer: AlohaCare Medicaid	$2.63
Rate for Payer: AlohaCare Medicare	$4.73
Rate for Payer: Cash Price	$3.42
Rate for Payer: Cash Price	$3.42
Rate for Payer: Devoted Health Medicare	$5.21
Rate for Payer: Hawaii Medical Service Association ABD	$0.01
Rate for Payer: Hawaii Medical Service Association Medicare	$4.73
Rate for Payer: Hawaii Medical Service Association Non-ABD	$0.01
Rate for Payer: Hawaii Western Management Group Commercial	$5.00
Rate for Payer: Health Management Network Commercial	$4.47
Rate for Payer: Humana Medicare	$4.73
Rate for Payer: Kaiser Permanente Commercial	$4.73
Rate for Payer: Kaiser Permanente Medicaid	$2.68
Rate for Payer: Kaiser Permanente Medicare	$4.73
Rate for Payer: MDX Hawaii PPO	$5.10
Rate for Payer: Ohana Health Plan Medicaid	$4.73
Rate for Payer: Ohana Health Plan Medicare	$4.73
Rate for Payer: UnitedHealthcare Medicaid	$3.16
Rate for Payer: UnitedHealthcare Medicare	$4.73
Rate for Payer: University Health Alliance Commercial	$3.83

FEMALE REPRODUCTIVE SYSTEM RECONSTRUCTIVE PROCEDURES

Facility

$18,203.14

Service Code	MSDRG 748
Min. Negotiated Rate	$18,203.14
Max. Negotiated Rate	$18,203.14
Rate for Payer: Hawaii Medical Service Association Commercial	$18,203.14

FENTANYL 100 MCG/HR TRANSDERM PT72

Facility

$284.02

Service Code	HCPCS A9270
Hospital Revenue Code	250
Min. Negotiated Rate	$241.42
Max. Negotiated Rate	$275.50
Rate for Payer: Cash Price	$184.61
Rate for Payer: Health Management Network Commercial	$241.42
Rate for Payer: Kaiser Permanente Commercial	$255.62
Rate for Payer: MDX Hawaii PPO	$275.50

FENTANYL 100 MCG/HR TRANSDERM PT72

Facility

$284.02

Service Code	HCPCS A9270
Hospital Revenue Code	637
Min. Negotiated Rate	$142.01
Max. Negotiated Rate	$281.18
Rate for Payer: AlohaCare Medicaid	$142.01
Rate for Payer: AlohaCare Medicare	$255.62
Rate for Payer: Cash Price	$184.61
Rate for Payer: Devoted Health Medicare	$281.18
Rate for Payer: Hawaii Medical Service Association Medicare	$255.62
Rate for Payer: Hawaii Western Management Group Commercial	$269.82
Rate for Payer: Health Management Network Commercial	$241.42
Rate for Payer: Humana Medicare	$255.62
Rate for Payer: Kaiser Permanente Commercial	$255.62
Rate for Payer: Kaiser Permanente Medicaid	$144.85
Rate for Payer: Kaiser Permanente Medicare	$255.62
Rate for Payer: MDX Hawaii PPO	$275.50
Rate for Payer: Ohana Health Plan Medicaid	$255.62
Rate for Payer: Ohana Health Plan Medicare	$255.62
Rate for Payer: UnitedHealthcare Medicare	$255.62
Rate for Payer: University Health Alliance Commercial	$207.02

FENTANYL 12 MCG/HR TRANSDERM PT72

Facility

$102.06

Service Code	HCPCS A9270
Hospital Revenue Code	637
Min. Negotiated Rate	$51.03
Max. Negotiated Rate	$101.04
Rate for Payer: AlohaCare Medicaid	$51.03
Rate for Payer: AlohaCare Medicare	$91.85
Rate for Payer: Cash Price	$66.34
Rate for Payer: Devoted Health Medicare	$101.04
Rate for Payer: Hawaii Medical Service Association Medicare	$91.85
Rate for Payer: Hawaii Western Management Group Commercial	$96.96
Rate for Payer: Health Management Network Commercial	$86.75
Rate for Payer: Humana Medicare	$91.85
Rate for Payer: Kaiser Permanente Commercial	$91.85
Rate for Payer: Kaiser Permanente Medicaid	$52.05
Rate for Payer: Kaiser Permanente Medicare	$91.85
Rate for Payer: MDX Hawaii PPO	$99.00
Rate for Payer: Ohana Health Plan Medicaid	$91.85
Rate for Payer: Ohana Health Plan Medicare	$91.85
Rate for Payer: UnitedHealthcare Medicare	$91.85
Rate for Payer: University Health Alliance Commercial	$74.39

FENTANYL 12 MCG/HR TRANSDERM PT72

Facility

$102.06

Service Code	HCPCS A9270
Hospital Revenue Code	250
Min. Negotiated Rate	$86.75
Max. Negotiated Rate	$99.00
Rate for Payer: Cash Price	$66.34
Rate for Payer: Health Management Network Commercial	$86.75
Rate for Payer: Kaiser Permanente Commercial	$91.85
Rate for Payer: MDX Hawaii PPO	$99.00

FENTANYL 25 MCG/HR TRANSDERM PT72

Facility

$77.70

Service Code	HCPCS A9270
Hospital Revenue Code	250
Min. Negotiated Rate	$66.05
Max. Negotiated Rate	$75.37
Rate for Payer: Cash Price	$50.50
Rate for Payer: Health Management Network Commercial	$66.05
Rate for Payer: Kaiser Permanente Commercial	$69.93
Rate for Payer: MDX Hawaii PPO	$75.37

FENTANYL 25 MCG/HR TRANSDERM PT72

Facility

$77.70

Service Code	HCPCS A9270
Hospital Revenue Code	637
Min. Negotiated Rate	$38.85
Max. Negotiated Rate	$76.92
Rate for Payer: AlohaCare Medicaid	$38.85
Rate for Payer: AlohaCare Medicare	$69.93
Rate for Payer: Cash Price	$50.50
Rate for Payer: Devoted Health Medicare	$76.92
Rate for Payer: Hawaii Medical Service Association Medicare	$69.93
Rate for Payer: Hawaii Western Management Group Commercial	$73.81
Rate for Payer: Health Management Network Commercial	$66.05
Rate for Payer: Humana Medicare	$69.93
Rate for Payer: Kaiser Permanente Commercial	$69.93
Rate for Payer: Kaiser Permanente Medicaid	$39.63
Rate for Payer: Kaiser Permanente Medicare	$69.93
Rate for Payer: MDX Hawaii PPO	$75.37
Rate for Payer: Ohana Health Plan Medicaid	$69.93
Rate for Payer: Ohana Health Plan Medicare	$69.93
Rate for Payer: UnitedHealthcare Medicare	$69.93
Rate for Payer: University Health Alliance Commercial	$56.64

FENTANYL 50 MCG/HR TRANSDERM PT72

Facility

$127.14

Service Code	HCPCS A9270
Hospital Revenue Code	637
Min. Negotiated Rate	$63.57
Max. Negotiated Rate	$125.87
Rate for Payer: AlohaCare Medicaid	$63.57
Rate for Payer: AlohaCare Medicare	$114.43
Rate for Payer: Cash Price	$82.64
Rate for Payer: Devoted Health Medicare	$125.87
Rate for Payer: Hawaii Medical Service Association Medicare	$114.43
Rate for Payer: Hawaii Western Management Group Commercial	$120.78
Rate for Payer: Health Management Network Commercial	$108.07
Rate for Payer: Humana Medicare	$114.43
Rate for Payer: Kaiser Permanente Commercial	$114.43
Rate for Payer: Kaiser Permanente Medicaid	$64.84
Rate for Payer: Kaiser Permanente Medicare	$114.43
Rate for Payer: MDX Hawaii PPO	$123.33
Rate for Payer: Ohana Health Plan Medicaid	$114.43
Rate for Payer: Ohana Health Plan Medicare	$114.43
Rate for Payer: UnitedHealthcare Medicare	$114.43
Rate for Payer: University Health Alliance Commercial	$92.67

FENTANYL 50 MCG/HR TRANSDERM PT72

Facility

$127.14

Service Code	HCPCS A9270
Hospital Revenue Code	250
Min. Negotiated Rate	$108.07
Max. Negotiated Rate	$123.33
Rate for Payer: Cash Price	$82.64
Rate for Payer: Health Management Network Commercial	$108.07
Rate for Payer: Kaiser Permanente Commercial	$114.43
Rate for Payer: MDX Hawaii PPO	$123.33

FENTANYL CITRATE (PF) 50 MCG/ML INJ SOLN VIAL

Facility

$15.51

Service Code	HCPCS J3010
Hospital Revenue Code	636
Min. Negotiated Rate	$0.96
Max. Negotiated Rate	$15.35
Rate for Payer: AlohaCare Medicaid	$7.75
Rate for Payer: AlohaCare Medicaid	$5.87
Rate for Payer: AlohaCare Medicare	$10.56
Rate for Payer: AlohaCare Medicare	$13.96
Rate for Payer: Cash Price	$10.08
Rate for Payer: Cash Price	$7.62
Rate for Payer: Cash Price	$10.08
Rate for Payer: Cash Price	$7.62
Rate for Payer: Devoted Health Medicare	$11.61
Rate for Payer: Devoted Health Medicare	$15.35
Rate for Payer: Hawaii Medical Service Association ABD	$0.96
Rate for Payer: Hawaii Medical Service Association ABD	$0.96
Rate for Payer: Hawaii Medical Service Association Medicare	$13.96
Rate for Payer: Hawaii Medical Service Association Medicare	$10.56
Rate for Payer: Hawaii Medical Service Association Non-ABD	$0.96
Rate for Payer: Hawaii Medical Service Association Non-ABD	$0.96
Rate for Payer: Hawaii Western Management Group Commercial	$11.14
Rate for Payer: Hawaii Western Management Group Commercial	$14.73
Rate for Payer: Health Management Network Commercial	$13.18
Rate for Payer: Health Management Network Commercial	$9.97
Rate for Payer: Humana Medicare	$13.96
Rate for Payer: Humana Medicare	$10.56
Rate for Payer: Kaiser Permanente Commercial	$10.56
Rate for Payer: Kaiser Permanente Commercial	$13.96
Rate for Payer: Kaiser Permanente Medicaid	$5.98
Rate for Payer: Kaiser Permanente Medicaid	$7.91
Rate for Payer: Kaiser Permanente Medicare	$10.56
Rate for Payer: Kaiser Permanente Medicare	$13.96
Rate for Payer: MDX Hawaii PPO	$15.04
Rate for Payer: MDX Hawaii PPO	$11.38
Rate for Payer: Ohana Health Plan Medicaid	$10.56
Rate for Payer: Ohana Health Plan Medicaid	$13.96
Rate for Payer: Ohana Health Plan Medicare	$13.96
Rate for Payer: Ohana Health Plan Medicare	$10.56
Rate for Payer: UnitedHealthcare Medicaid	$7.04
Rate for Payer: UnitedHealthcare Medicaid	$9.31
Rate for Payer: UnitedHealthcare Medicare	$13.96
Rate for Payer: UnitedHealthcare Medicare	$10.56
Rate for Payer: University Health Alliance Commercial	$11.31
Rate for Payer: University Health Alliance Commercial	$8.55

FENTANYL CITRATE (PF) 50 MCG/ML INJ SOLN VIAL

Facility

$15.51

Service Code	HCPCS J3010
Hospital Revenue Code	250
Min. Negotiated Rate	$13.18
Max. Negotiated Rate	$15.04
Rate for Payer: Cash Price	$10.08
Rate for Payer: Cash Price	$7.62
Rate for Payer: Health Management Network Commercial	$13.18
Rate for Payer: Health Management Network Commercial	$9.97
Rate for Payer: Kaiser Permanente Commercial	$10.56
Rate for Payer: Kaiser Permanente Commercial	$13.96
Rate for Payer: MDX Hawaii PPO	$11.38
Rate for Payer: MDX Hawaii PPO	$15.04

FENTANYL CITRATE (PF) 50 MCG/ML INTRANASAL 2 ML

Facility

$15.51

Service Code	NDC 00409909412
Hospital Revenue Code	250
Min. Negotiated Rate	$13.18
Max. Negotiated Rate	$15.04
Rate for Payer: Cash Price	$10.08
Rate for Payer: Health Management Network Commercial	$13.18
Rate for Payer: Kaiser Permanente Commercial	$13.96
Rate for Payer: MDX Hawaii PPO	$15.04

FENTANYL CITRATE (PF) 50 MCG/ML INTRANASAL 2 ML

Facility

$15.51

Service Code	NDC 00409909422
Hospital Revenue Code	250
Min. Negotiated Rate	$7.75
Max. Negotiated Rate	$15.35
Rate for Payer: AlohaCare Medicaid	$7.75
Rate for Payer: AlohaCare Medicare	$13.96
Rate for Payer: Cash Price	$10.08
Rate for Payer: Devoted Health Medicare	$15.35
Rate for Payer: Hawaii Medical Service Association Medicare	$13.96
Rate for Payer: Hawaii Western Management Group Commercial	$14.73
Rate for Payer: Health Management Network Commercial	$13.18
Rate for Payer: Humana Medicare	$13.96
Rate for Payer: Kaiser Permanente Commercial	$13.96
Rate for Payer: Kaiser Permanente Medicaid	$7.91
Rate for Payer: Kaiser Permanente Medicare	$13.96
Rate for Payer: MDX Hawaii PPO	$15.04
Rate for Payer: Ohana Health Plan Medicaid	$13.96
Rate for Payer: Ohana Health Plan Medicare	$13.96
Rate for Payer: UnitedHealthcare Medicaid	$9.31
Rate for Payer: UnitedHealthcare Medicare	$13.96
Rate for Payer: University Health Alliance Commercial	$11.31

FENTANYL CITRATE (PF) 50 MCG/ML INTRANASAL 2 ML

Facility

$11.73

Service Code	NDC 00641602725
Hospital Revenue Code	250
Min. Negotiated Rate	$9.97
Max. Negotiated Rate	$11.38
Rate for Payer: Cash Price	$7.62
Rate for Payer: Health Management Network Commercial	$9.97
Rate for Payer: Kaiser Permanente Commercial	$10.56
Rate for Payer: MDX Hawaii PPO	$11.38

Know your out-of-pocket cost for care.

All Charges