Kohala Hospital

All Charges

Charge

Type

Setting

Price

GASTROINTESTINAL HEMORRHAGE WITHOUT CC/MCC

Facility

$16,378.08

Service Code	MSDRG 379
Min. Negotiated Rate	$16,378.08
Max. Negotiated Rate	$16,378.08
Rate for Payer: Hawaii Medical Service Association Commercial	$16,378.08

GASTROINTESTINAL OBSTRUCTION WITH CC

Facility

$16,662.51

Service Code	MSDRG 389
Min. Negotiated Rate	$16,662.51
Max. Negotiated Rate	$16,662.51
Rate for Payer: Hawaii Medical Service Association Commercial	$16,662.51

GASTROINTESTINAL OBSTRUCTION WITH MCC

Facility

$18,771.98

Service Code	MSDRG 388
Min. Negotiated Rate	$18,771.98
Max. Negotiated Rate	$18,771.98
Rate for Payer: Hawaii Medical Service Association Commercial	$18,771.98

GASTROINTESTINAL OBSTRUCTION WITHOUT CC/MCC

Facility

$13,273.12

Service Code	MSDRG 390
Min. Negotiated Rate	$13,273.12
Max. Negotiated Rate	$13,273.12
Rate for Payer: Hawaii Medical Service Association Commercial	$13,273.12

GENTAMICIN 40 MG/ML INJ SOLN

Facility

$25.62

Service Code	HCPCS J1580
Hospital Revenue Code	250
Min. Negotiated Rate	$21.78
Max. Negotiated Rate	$24.85
Rate for Payer: Cash Price	$16.65
Rate for Payer: Health Management Network Commercial	$21.78
Rate for Payer: Kaiser Permanente Commercial	$23.06
Rate for Payer: MDX Hawaii PPO	$24.85

GENTAMICIN 40 MG/ML INJ SOLN

Facility

$25.62

Service Code	HCPCS J1580
Hospital Revenue Code	636
Min. Negotiated Rate	$2.62
Max. Negotiated Rate	$25.36
Rate for Payer: AlohaCare Medicaid	$12.81
Rate for Payer: AlohaCare Medicare	$23.06
Rate for Payer: Cash Price	$16.65
Rate for Payer: Cash Price	$16.65
Rate for Payer: Devoted Health Medicare	$25.36
Rate for Payer: Hawaii Medical Service Association ABD	$2.62
Rate for Payer: Hawaii Medical Service Association Medicare	$23.06
Rate for Payer: Hawaii Medical Service Association Non-ABD	$2.62
Rate for Payer: Hawaii Western Management Group Commercial	$24.34
Rate for Payer: Health Management Network Commercial	$21.78
Rate for Payer: Humana Medicare	$23.06
Rate for Payer: Kaiser Permanente Commercial	$23.06
Rate for Payer: Kaiser Permanente Medicaid	$13.07
Rate for Payer: Kaiser Permanente Medicare	$23.06
Rate for Payer: MDX Hawaii PPO	$24.85
Rate for Payer: Ohana Health Plan Medicaid	$23.06
Rate for Payer: Ohana Health Plan Medicare	$23.06
Rate for Payer: UnitedHealthcare Medicaid	$15.37
Rate for Payer: UnitedHealthcare Medicare	$23.06
Rate for Payer: University Health Alliance Commercial	$18.67

GENTAMICIN SULFATE (PED) (PF) 20 MG/2 ML INJ SOLN

Facility

$39.44

Service Code	HCPCS J1580
Hospital Revenue Code	636
Min. Negotiated Rate	$2.62
Max. Negotiated Rate	$39.05
Rate for Payer: AlohaCare Medicaid	$19.72
Rate for Payer: AlohaCare Medicare	$35.50
Rate for Payer: Cash Price	$25.64
Rate for Payer: Cash Price	$25.64
Rate for Payer: Devoted Health Medicare	$39.05
Rate for Payer: Hawaii Medical Service Association ABD	$2.62
Rate for Payer: Hawaii Medical Service Association Medicare	$35.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$2.62
Rate for Payer: Hawaii Western Management Group Commercial	$37.47
Rate for Payer: Health Management Network Commercial	$33.52
Rate for Payer: Humana Medicare	$35.50
Rate for Payer: Kaiser Permanente Commercial	$35.50
Rate for Payer: Kaiser Permanente Medicaid	$20.11
Rate for Payer: Kaiser Permanente Medicare	$35.50
Rate for Payer: MDX Hawaii PPO	$38.26
Rate for Payer: Ohana Health Plan Medicaid	$35.50
Rate for Payer: Ohana Health Plan Medicare	$35.50
Rate for Payer: UnitedHealthcare Medicaid	$23.66
Rate for Payer: UnitedHealthcare Medicare	$35.50
Rate for Payer: University Health Alliance Commercial	$28.75

GENTAMICIN SULFATE (PED) (PF) 20 MG/2 ML INJ SOLN

Facility

$39.44

Service Code	HCPCS J1580
Hospital Revenue Code	250
Min. Negotiated Rate	$33.52
Max. Negotiated Rate	$38.26
Rate for Payer: Cash Price	$25.64
Rate for Payer: Health Management Network Commercial	$33.52
Rate for Payer: Kaiser Permanente Commercial	$35.50
Rate for Payer: MDX Hawaii PPO	$38.26

GLIMEPIRIDE 2 MG PO TABLET

Facility

$3.60

Service Code	HCPCS A9270
Hospital Revenue Code	250
Min. Negotiated Rate	$3.06
Max. Negotiated Rate	$3.49
Rate for Payer: Cash Price	$2.34
Rate for Payer: Health Management Network Commercial	$3.06
Rate for Payer: Kaiser Permanente Commercial	$3.24
Rate for Payer: MDX Hawaii PPO	$3.49

GLIMEPIRIDE 2 MG PO TABLET

Facility

$3.60

Service Code	HCPCS A9270
Hospital Revenue Code	637
Min. Negotiated Rate	$1.80
Max. Negotiated Rate	$3.56
Rate for Payer: AlohaCare Medicaid	$1.80
Rate for Payer: AlohaCare Medicare	$3.24
Rate for Payer: Cash Price	$2.34
Rate for Payer: Devoted Health Medicare	$3.56
Rate for Payer: Hawaii Medical Service Association Medicare	$3.24
Rate for Payer: Hawaii Western Management Group Commercial	$3.42
Rate for Payer: Health Management Network Commercial	$3.06
Rate for Payer: Humana Medicare	$3.24
Rate for Payer: Kaiser Permanente Commercial	$3.24
Rate for Payer: Kaiser Permanente Medicaid	$1.84
Rate for Payer: Kaiser Permanente Medicare	$3.24
Rate for Payer: MDX Hawaii PPO	$3.49
Rate for Payer: Ohana Health Plan Medicaid	$3.24
Rate for Payer: Ohana Health Plan Medicare	$3.24
Rate for Payer: UnitedHealthcare Medicare	$3.24
Rate for Payer: University Health Alliance Commercial	$2.62

GLIPIZIDE 10 MG PO TABLET

Facility

$3.54

Service Code	HCPCS A9270
Hospital Revenue Code	637
Min. Negotiated Rate	$1.77
Max. Negotiated Rate	$3.50
Rate for Payer: AlohaCare Medicaid	$1.77
Rate for Payer: AlohaCare Medicare	$3.19
Rate for Payer: Cash Price	$2.30
Rate for Payer: Devoted Health Medicare	$3.50
Rate for Payer: Hawaii Medical Service Association Medicare	$3.19
Rate for Payer: Hawaii Western Management Group Commercial	$3.36
Rate for Payer: Health Management Network Commercial	$3.01
Rate for Payer: Humana Medicare	$3.19
Rate for Payer: Kaiser Permanente Commercial	$3.19
Rate for Payer: Kaiser Permanente Medicaid	$1.81
Rate for Payer: Kaiser Permanente Medicare	$3.19
Rate for Payer: MDX Hawaii PPO	$3.43
Rate for Payer: Ohana Health Plan Medicaid	$3.19
Rate for Payer: Ohana Health Plan Medicare	$3.19
Rate for Payer: UnitedHealthcare Medicare	$3.19
Rate for Payer: University Health Alliance Commercial	$2.58

GLIPIZIDE 10 MG PO TABLET

Facility

$3.54

Service Code	HCPCS A9270
Hospital Revenue Code	250
Min. Negotiated Rate	$3.01
Max. Negotiated Rate	$3.43
Rate for Payer: Cash Price	$2.30
Rate for Payer: Health Management Network Commercial	$3.01
Rate for Payer: Kaiser Permanente Commercial	$3.19
Rate for Payer: MDX Hawaii PPO	$3.43

GLIPIZIDE 5 MG PO TABLET

Facility

$2.09

Service Code	HCPCS A9270
Hospital Revenue Code	637
Min. Negotiated Rate	$1.04
Max. Negotiated Rate	$2.07
Rate for Payer: AlohaCare Medicaid	$1.04
Rate for Payer: AlohaCare Medicare	$1.88
Rate for Payer: Cash Price	$1.36
Rate for Payer: Devoted Health Medicare	$2.07
Rate for Payer: Hawaii Medical Service Association Medicare	$1.88
Rate for Payer: Hawaii Western Management Group Commercial	$1.99
Rate for Payer: Health Management Network Commercial	$1.78
Rate for Payer: Humana Medicare	$1.88
Rate for Payer: Kaiser Permanente Commercial	$1.88
Rate for Payer: Kaiser Permanente Medicaid	$1.07
Rate for Payer: Kaiser Permanente Medicare	$1.88
Rate for Payer: MDX Hawaii PPO	$2.03
Rate for Payer: Ohana Health Plan Medicaid	$1.88
Rate for Payer: Ohana Health Plan Medicare	$1.88
Rate for Payer: UnitedHealthcare Medicare	$1.88
Rate for Payer: University Health Alliance Commercial	$1.52

GLIPIZIDE 5 MG PO TABLET

Facility

$2.09

Service Code	HCPCS A9270
Hospital Revenue Code	250
Min. Negotiated Rate	$1.78
Max. Negotiated Rate	$2.03
Rate for Payer: Cash Price	$1.36
Rate for Payer: Health Management Network Commercial	$1.78
Rate for Payer: Kaiser Permanente Commercial	$1.88
Rate for Payer: MDX Hawaii PPO	$2.03

GLIPIZIDE XL 5 MG PO TAB

Facility

$2.25

Service Code	HCPCS A9270
Hospital Revenue Code	637
Min. Negotiated Rate	$1.12
Max. Negotiated Rate	$2.23
Rate for Payer: AlohaCare Medicaid	$1.12
Rate for Payer: AlohaCare Medicare	$2.02
Rate for Payer: Cash Price	$1.46
Rate for Payer: Devoted Health Medicare	$2.23
Rate for Payer: Hawaii Medical Service Association Medicare	$2.02
Rate for Payer: Hawaii Western Management Group Commercial	$2.14
Rate for Payer: Health Management Network Commercial	$1.91
Rate for Payer: Humana Medicare	$2.02
Rate for Payer: Kaiser Permanente Commercial	$2.02
Rate for Payer: Kaiser Permanente Medicaid	$1.15
Rate for Payer: Kaiser Permanente Medicare	$2.02
Rate for Payer: MDX Hawaii PPO	$2.18
Rate for Payer: Ohana Health Plan Medicaid	$2.02
Rate for Payer: Ohana Health Plan Medicare	$2.02
Rate for Payer: UnitedHealthcare Medicare	$2.02
Rate for Payer: University Health Alliance Commercial	$1.64

GLIPIZIDE XL 5 MG PO TAB

Facility

$2.25

Service Code	HCPCS A9270
Hospital Revenue Code	250
Min. Negotiated Rate	$1.91
Max. Negotiated Rate	$2.18
Rate for Payer: Cash Price	$1.46
Rate for Payer: Health Management Network Commercial	$1.91
Rate for Payer: Kaiser Permanente Commercial	$2.02
Rate for Payer: MDX Hawaii PPO	$2.18

GLUCAGON 1 MG INJ RECON.SOLN.

Facility

$821.28

Service Code	HCPCS J1610
Hospital Revenue Code	250
Min. Negotiated Rate	$698.09
Max. Negotiated Rate	$796.64
Rate for Payer: Cash Price	$533.83
Rate for Payer: Health Management Network Commercial	$698.09
Rate for Payer: Kaiser Permanente Commercial	$739.15
Rate for Payer: MDX Hawaii PPO	$796.64

GLUCAGON 1 MG INJ RECON.SOLN.

Facility

$821.28

Service Code	HCPCS J1610
Hospital Revenue Code	636
Min. Negotiated Rate	$182.91
Max. Negotiated Rate	$813.07
Rate for Payer: AlohaCare Medicaid	$410.64
Rate for Payer: AlohaCare Medicare	$739.15
Rate for Payer: Cash Price	$533.83
Rate for Payer: Cash Price	$533.83
Rate for Payer: Devoted Health Medicare	$813.07
Rate for Payer: Hawaii Medical Service Association ABD	$195.79
Rate for Payer: Hawaii Medical Service Association Commercial	$182.91
Rate for Payer: Hawaii Medical Service Association Medicare	$739.15
Rate for Payer: Hawaii Medical Service Association Non-ABD	$195.79
Rate for Payer: Hawaii Western Management Group Commercial	$780.22
Rate for Payer: Health Management Network Commercial	$698.09
Rate for Payer: Humana Medicare	$739.15
Rate for Payer: Kaiser Permanente Commercial	$739.15
Rate for Payer: Kaiser Permanente Medicaid	$418.85
Rate for Payer: Kaiser Permanente Medicare	$739.15
Rate for Payer: MDX Hawaii PPO	$796.64
Rate for Payer: Ohana Health Plan Medicaid	$739.15
Rate for Payer: Ohana Health Plan Medicare	$739.15
Rate for Payer: UnitedHealthcare Medicaid	$492.77
Rate for Payer: UnitedHealthcare Medicare	$739.15
Rate for Payer: University Health Alliance Commercial	$598.63

GLUCAGON HCL 1 MG/ML INJ RECON.SOLN.

Facility

$764.57

Service Code	HCPCS J1611
Hospital Revenue Code	636
Min. Negotiated Rate	$144.88
Max. Negotiated Rate	$756.92
Rate for Payer: AlohaCare Medicaid	$382.29
Rate for Payer: AlohaCare Medicare	$688.11
Rate for Payer: Cash Price	$496.97
Rate for Payer: Cash Price	$496.97
Rate for Payer: Devoted Health Medicare	$756.92
Rate for Payer: Hawaii Medical Service Association ABD	$144.88
Rate for Payer: Hawaii Medical Service Association Commercial	$168.75
Rate for Payer: Hawaii Medical Service Association Medicare	$688.11
Rate for Payer: Hawaii Medical Service Association Non-ABD	$144.88
Rate for Payer: Hawaii Western Management Group Commercial	$726.34
Rate for Payer: Health Management Network Commercial	$649.88
Rate for Payer: Humana Medicare	$688.11
Rate for Payer: Kaiser Permanente Commercial	$688.11
Rate for Payer: Kaiser Permanente Medicaid	$389.93
Rate for Payer: Kaiser Permanente Medicare	$688.11
Rate for Payer: MDX Hawaii PPO	$741.63
Rate for Payer: Ohana Health Plan Medicaid	$688.11
Rate for Payer: Ohana Health Plan Medicare	$688.11
Rate for Payer: UnitedHealthcare Medicaid	$458.74
Rate for Payer: UnitedHealthcare Medicare	$688.11
Rate for Payer: University Health Alliance Commercial	$557.30

GLUCAGON HCL 1 MG/ML INJ RECON.SOLN.

Facility

$764.57

Service Code	HCPCS J1611
Hospital Revenue Code	250
Min. Negotiated Rate	$649.88
Max. Negotiated Rate	$741.63
Rate for Payer: Cash Price	$496.97
Rate for Payer: Health Management Network Commercial	$649.88
Rate for Payer: Kaiser Permanente Commercial	$688.11
Rate for Payer: MDX Hawaii PPO	$741.63

GLYBURIDE 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

GLYBURIDE 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

GLYCERIN (ADULT) PR SUPP

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

GLYCERIN (ADULT) PR SUPP

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

GLYCERIN (CHILD) 1.2 G PR SUPP

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

Know your out-of-pocket cost for care.

All Charges