Kohala Hospital

All Charges

Charge

Type

Setting

Price

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

GLYCOPYRROLATE 0.2 MG/ML INJ SOLN

Facility

$203.37

Service Code	HCPCS J1596
Hospital Revenue Code	250
Min. Negotiated Rate	$172.86
Max. Negotiated Rate	$197.27
Rate for Payer: Cash Price	$132.19
Rate for Payer: Health Management Network Commercial	$172.86
Rate for Payer: Kaiser Permanente Commercial	$183.03
Rate for Payer: MDX Hawaii PPO	$197.27

GLYCOPYRROLATE 0.2 MG/ML INJ SOLN

Facility

$203.37

Service Code	HCPCS J1596
Hospital Revenue Code	636
Min. Negotiated Rate	$0.43
Max. Negotiated Rate	$201.34
Rate for Payer: AlohaCare Medicaid	$101.69
Rate for Payer: AlohaCare Medicare	$183.03
Rate for Payer: Cash Price	$132.19
Rate for Payer: Cash Price	$132.19
Rate for Payer: Devoted Health Medicare	$201.34
Rate for Payer: Hawaii Medical Service Association ABD	$0.43
Rate for Payer: Hawaii Medical Service Association Medicare	$183.03
Rate for Payer: Hawaii Medical Service Association Non-ABD	$0.43
Rate for Payer: Hawaii Western Management Group Commercial	$193.20
Rate for Payer: Health Management Network Commercial	$172.86
Rate for Payer: Humana Medicare	$183.03
Rate for Payer: Kaiser Permanente Commercial	$183.03
Rate for Payer: Kaiser Permanente Medicaid	$103.72
Rate for Payer: Kaiser Permanente Medicare	$183.03
Rate for Payer: MDX Hawaii PPO	$197.27
Rate for Payer: Ohana Health Plan Medicaid	$183.03
Rate for Payer: Ohana Health Plan Medicare	$183.03
Rate for Payer: UnitedHealthcare Medicaid	$122.02
Rate for Payer: UnitedHealthcare Medicare	$183.03
Rate for Payer: University Health Alliance Commercial	$148.24

GLYCOPYRROLATE 1 MG PO TABLET

Facility

$5.98

Service Code	HCPCS A9270
Hospital Revenue Code	250
Min. Negotiated Rate	$5.08
Max. Negotiated Rate	$5.80
Rate for Payer: Cash Price	$3.89
Rate for Payer: Cash Price	$5.24
Rate for Payer: Health Management Network Commercial	$6.85
Rate for Payer: Health Management Network Commercial	$5.08
Rate for Payer: Kaiser Permanente Commercial	$5.38
Rate for Payer: Kaiser Permanente Commercial	$7.25
Rate for Payer: MDX Hawaii PPO	$5.80
Rate for Payer: MDX Hawaii PPO	$7.82

GLYCOPYRROLATE 1 MG PO TABLET

Facility

$5.98

Service Code	HCPCS A9270
Hospital Revenue Code	637
Min. Negotiated Rate	$2.99
Max. Negotiated Rate	$5.92
Rate for Payer: AlohaCare Medicaid	$2.99
Rate for Payer: AlohaCare Medicaid	$4.03
Rate for Payer: AlohaCare Medicare	$5.38
Rate for Payer: AlohaCare Medicare	$7.25
Rate for Payer: Cash Price	$3.89
Rate for Payer: Cash Price	$5.24
Rate for Payer: Devoted Health Medicare	$5.92
Rate for Payer: Devoted Health Medicare	$7.98
Rate for Payer: Hawaii Medical Service Association Medicare	$7.25
Rate for Payer: Hawaii Medical Service Association Medicare	$5.38
Rate for Payer: Hawaii Western Management Group Commercial	$7.66
Rate for Payer: Hawaii Western Management Group Commercial	$5.68
Rate for Payer: Health Management Network Commercial	$5.08
Rate for Payer: Health Management Network Commercial	$6.85
Rate for Payer: Humana Medicare	$5.38
Rate for Payer: Humana Medicare	$7.25
Rate for Payer: Kaiser Permanente Commercial	$7.25
Rate for Payer: Kaiser Permanente Commercial	$5.38
Rate for Payer: Kaiser Permanente Medicaid	$3.05
Rate for Payer: Kaiser Permanente Medicaid	$4.11
Rate for Payer: Kaiser Permanente Medicare	$5.38
Rate for Payer: Kaiser Permanente Medicare	$7.25
Rate for Payer: MDX Hawaii PPO	$5.80
Rate for Payer: MDX Hawaii PPO	$7.82
Rate for Payer: Ohana Health Plan Medicaid	$5.38
Rate for Payer: Ohana Health Plan Medicaid	$7.25
Rate for Payer: Ohana Health Plan Medicare	$7.25
Rate for Payer: Ohana Health Plan Medicare	$5.38
Rate for Payer: UnitedHealthcare Medicare	$5.38
Rate for Payer: UnitedHealthcare Medicare	$7.25
Rate for Payer: University Health Alliance Commercial	$4.36
Rate for Payer: University Health Alliance Commercial	$5.87

GUAIFENESIN 100 MG/5 ML PO LIQ

Facility

$10.66

Service Code	HCPCS A9270
Hospital Revenue Code	637
Min. Negotiated Rate	$5.33
Max. Negotiated Rate	$10.55
Rate for Payer: AlohaCare Medicaid	$5.33
Rate for Payer: AlohaCare Medicare	$9.59
Rate for Payer: Cash Price	$6.93
Rate for Payer: Devoted Health Medicare	$10.55
Rate for Payer: Hawaii Medical Service Association Medicare	$9.59
Rate for Payer: Hawaii Western Management Group Commercial	$10.13
Rate for Payer: Health Management Network Commercial	$9.06
Rate for Payer: Humana Medicare	$9.59
Rate for Payer: Kaiser Permanente Commercial	$9.59
Rate for Payer: Kaiser Permanente Medicaid	$5.44
Rate for Payer: Kaiser Permanente Medicare	$9.59
Rate for Payer: MDX Hawaii PPO	$10.34
Rate for Payer: Ohana Health Plan Medicaid	$9.59
Rate for Payer: Ohana Health Plan Medicare	$9.59
Rate for Payer: UnitedHealthcare Medicare	$9.59
Rate for Payer: University Health Alliance Commercial	$7.77

GUAIFENESIN 100 MG/5 ML PO LIQ

Facility

$10.66

Service Code	HCPCS A9270
Hospital Revenue Code	250
Min. Negotiated Rate	$9.06
Max. Negotiated Rate	$10.34
Rate for Payer: Cash Price	$6.93
Rate for Payer: Health Management Network Commercial	$9.06
Rate for Payer: Kaiser Permanente Commercial	$9.59
Rate for Payer: MDX Hawaii PPO	$10.34

GUAIFENESIN 600 MG PO TA12

Facility

$5.54

Service Code	HCPCS A9270
Hospital Revenue Code	637
Min. Negotiated Rate	$2.77
Max. Negotiated Rate	$5.48
Rate for Payer: AlohaCare Medicaid	$2.77
Rate for Payer: AlohaCare Medicare	$4.99
Rate for Payer: Cash Price	$3.60
Rate for Payer: Devoted Health Medicare	$5.48
Rate for Payer: Hawaii Medical Service Association Medicare	$4.99
Rate for Payer: Hawaii Western Management Group Commercial	$5.26
Rate for Payer: Health Management Network Commercial	$4.71
Rate for Payer: Humana Medicare	$4.99
Rate for Payer: Kaiser Permanente Commercial	$4.99
Rate for Payer: Kaiser Permanente Medicaid	$2.83
Rate for Payer: Kaiser Permanente Medicare	$4.99
Rate for Payer: MDX Hawaii PPO	$5.37
Rate for Payer: Ohana Health Plan Medicaid	$4.99
Rate for Payer: Ohana Health Plan Medicare	$4.99
Rate for Payer: UnitedHealthcare Medicare	$4.99
Rate for Payer: University Health Alliance Commercial	$4.04

GUAIFENESIN 600 MG PO TA12

Facility

$5.54

Service Code	HCPCS A9270
Hospital Revenue Code	250
Min. Negotiated Rate	$4.71
Max. Negotiated Rate	$5.37
Rate for Payer: Cash Price	$3.60
Rate for Payer: Health Management Network Commercial	$4.71
Rate for Payer: Kaiser Permanente Commercial	$4.99
Rate for Payer: MDX Hawaii PPO	$5.37

HALOPERIDOL 0.5 MG PO TABLET

Facility

$1.92

Service Code	HCPCS A9270
Hospital Revenue Code	637
Min. Negotiated Rate	$0.96
Max. Negotiated Rate	$1.90
Rate for Payer: AlohaCare Medicaid	$0.96
Rate for Payer: AlohaCare Medicare	$1.73
Rate for Payer: Cash Price	$1.25
Rate for Payer: Devoted Health Medicare	$1.90
Rate for Payer: Hawaii Medical Service Association Medicare	$1.73
Rate for Payer: Hawaii Western Management Group Commercial	$1.82
Rate for Payer: Health Management Network Commercial	$1.63
Rate for Payer: Humana Medicare	$1.73
Rate for Payer: Kaiser Permanente Commercial	$1.73
Rate for Payer: Kaiser Permanente Medicaid	$0.98
Rate for Payer: Kaiser Permanente Medicare	$1.73
Rate for Payer: MDX Hawaii PPO	$1.86
Rate for Payer: Ohana Health Plan Medicaid	$1.73
Rate for Payer: Ohana Health Plan Medicare	$1.73
Rate for Payer: UnitedHealthcare Medicare	$1.73
Rate for Payer: University Health Alliance Commercial	$1.40

HALOPERIDOL 0.5 MG PO TABLET

Facility

$1.92

Service Code	HCPCS A9270
Hospital Revenue Code	250
Min. Negotiated Rate	$1.63
Max. Negotiated Rate	$1.86
Rate for Payer: Cash Price	$1.25
Rate for Payer: Health Management Network Commercial	$1.63
Rate for Payer: Kaiser Permanente Commercial	$1.73
Rate for Payer: MDX Hawaii PPO	$1.86

HALOPERIDOL DECANOATE 100 MG/ML IM SOLN

Facility

$167.04

Service Code	HCPCS J1631
Hospital Revenue Code	250
Min. Negotiated Rate	$141.98
Max. Negotiated Rate	$162.03
Rate for Payer: Cash Price	$108.58
Rate for Payer: Cash Price	$98.89
Rate for Payer: Health Management Network Commercial	$141.98
Rate for Payer: Health Management Network Commercial	$129.32
Rate for Payer: Kaiser Permanente Commercial	$136.93
Rate for Payer: Kaiser Permanente Commercial	$150.34
Rate for Payer: MDX Hawaii PPO	$147.58
Rate for Payer: MDX Hawaii PPO	$162.03

HALOPERIDOL DECANOATE 100 MG/ML IM SOLN

Facility

$167.04

Service Code	HCPCS J1631
Hospital Revenue Code	636
Min. Negotiated Rate	$4.68
Max. Negotiated Rate	$165.37
Rate for Payer: AlohaCare Medicaid	$83.52
Rate for Payer: AlohaCare Medicaid	$76.07
Rate for Payer: AlohaCare Medicare	$136.93
Rate for Payer: AlohaCare Medicare	$150.34
Rate for Payer: Cash Price	$108.58
Rate for Payer: Cash Price	$98.89
Rate for Payer: Cash Price	$108.58
Rate for Payer: Cash Price	$98.89
Rate for Payer: Devoted Health Medicare	$150.62
Rate for Payer: Devoted Health Medicare	$165.37
Rate for Payer: Hawaii Medical Service Association ABD	$4.68
Rate for Payer: Hawaii Medical Service Association ABD	$4.68
Rate for Payer: Hawaii Medical Service Association Medicare	$150.34
Rate for Payer: Hawaii Medical Service Association Medicare	$136.93
Rate for Payer: Hawaii Medical Service Association Non-ABD	$4.68
Rate for Payer: Hawaii Medical Service Association Non-ABD	$4.68
Rate for Payer: Hawaii Western Management Group Commercial	$144.53
Rate for Payer: Hawaii Western Management Group Commercial	$158.69
Rate for Payer: Health Management Network Commercial	$141.98
Rate for Payer: Health Management Network Commercial	$129.32
Rate for Payer: Humana Medicare	$150.34
Rate for Payer: Humana Medicare	$136.93
Rate for Payer: Kaiser Permanente Commercial	$136.93
Rate for Payer: Kaiser Permanente Commercial	$150.34
Rate for Payer: Kaiser Permanente Medicaid	$77.59
Rate for Payer: Kaiser Permanente Medicaid	$85.19
Rate for Payer: Kaiser Permanente Medicare	$136.93
Rate for Payer: Kaiser Permanente Medicare	$150.34
Rate for Payer: MDX Hawaii PPO	$162.03
Rate for Payer: MDX Hawaii PPO	$147.58
Rate for Payer: Ohana Health Plan Medicaid	$136.93
Rate for Payer: Ohana Health Plan Medicaid	$150.34
Rate for Payer: Ohana Health Plan Medicare	$150.34
Rate for Payer: Ohana Health Plan Medicare	$136.93
Rate for Payer: UnitedHealthcare Medicaid	$91.28
Rate for Payer: UnitedHealthcare Medicaid	$100.22
Rate for Payer: UnitedHealthcare Medicare	$150.34
Rate for Payer: UnitedHealthcare Medicare	$136.93
Rate for Payer: University Health Alliance Commercial	$121.76
Rate for Payer: University Health Alliance Commercial	$110.89

HALOPERIDOL LACTATE 5 MG/ML INJ SOLN

Facility

$7.95

Service Code	HCPCS J1630
Hospital Revenue Code	250
Min. Negotiated Rate	$6.76
Max. Negotiated Rate	$7.71
Rate for Payer: Cash Price	$5.17
Rate for Payer: Health Management Network Commercial	$6.76
Rate for Payer: Kaiser Permanente Commercial	$7.16
Rate for Payer: MDX Hawaii PPO	$7.71

HALOPERIDOL LACTATE 5 MG/ML INJ SOLN

Facility

$7.95

Service Code	HCPCS J1630
Hospital Revenue Code	636
Min. Negotiated Rate	$0.84
Max. Negotiated Rate	$7.87
Rate for Payer: AlohaCare Medicaid	$3.98
Rate for Payer: AlohaCare Medicare	$7.16
Rate for Payer: Cash Price	$5.17
Rate for Payer: Cash Price	$5.17
Rate for Payer: Devoted Health Medicare	$7.87
Rate for Payer: Hawaii Medical Service Association ABD	$0.84
Rate for Payer: Hawaii Medical Service Association Medicare	$7.16
Rate for Payer: Hawaii Medical Service Association Non-ABD	$0.84
Rate for Payer: Hawaii Western Management Group Commercial	$7.55
Rate for Payer: Health Management Network Commercial	$6.76
Rate for Payer: Humana Medicare	$7.16
Rate for Payer: Kaiser Permanente Commercial	$7.16
Rate for Payer: Kaiser Permanente Medicaid	$4.05
Rate for Payer: Kaiser Permanente Medicare	$7.16
Rate for Payer: MDX Hawaii PPO	$7.71
Rate for Payer: Ohana Health Plan Medicaid	$7.16
Rate for Payer: Ohana Health Plan Medicare	$7.16
Rate for Payer: UnitedHealthcare Medicaid	$4.77
Rate for Payer: UnitedHealthcare Medicare	$7.16
Rate for Payer: University Health Alliance Commercial	$5.79

HAND OR WRIST PROCEDURES, EXCEPT MAJOR THUMB OR JOINT PROCEDURES WITH CC/MCC

Facility

$26,641.05

Service Code	MSDRG 513
Min. Negotiated Rate	$26,641.05
Max. Negotiated Rate	$26,641.05
Rate for Payer: Hawaii Medical Service Association Commercial	$26,641.05

HAND OR WRIST PROCEDURES, EXCEPT MAJOR THUMB OR JOINT PROCEDURES WITHOUT CC/MCC

Facility

$18,416.45

Service Code	MSDRG 514
Min. Negotiated Rate	$18,416.45
Max. Negotiated Rate	$18,416.45
Rate for Payer: Hawaii Medical Service Association Commercial	$18,416.45

HAND PROCEDURES FOR INJURIES

Facility

$22,161.37

Service Code	MSDRG 906
Min. Negotiated Rate	$22,161.37
Max. Negotiated Rate	$22,161.37
Rate for Payer: Hawaii Medical Service Association Commercial	$22,161.37

HCHG 5-HIAA 24 HR URINE

Facility

$99.00

Service Code	HCPCS 83497
Hospital Charge Code	H3010112
Hospital Revenue Code	301
Min. Negotiated Rate	$84.15
Max. Negotiated Rate	$96.03
Rate for Payer: Cash Price	$64.35
Rate for Payer: Health Management Network Commercial	$84.15
Rate for Payer: Kaiser Permanente Commercial	$89.10
Rate for Payer: MDX Hawaii PPO	$96.03

HCHG 5-HIAA 24 HR URINE

Facility

$99.00

Service Code	HCPCS 83497
Hospital Charge Code	H3010112
Hospital Revenue Code	301
Min. Negotiated Rate	$12.90
Max. Negotiated Rate	$98.01
Rate for Payer: AlohaCare Medicaid	$49.50
Rate for Payer: AlohaCare Medicare	$89.10
Rate for Payer: Cash Price	$64.35
Rate for Payer: Cash Price	$64.35
Rate for Payer: Devoted Health Medicare	$98.01
Rate for Payer: Hawaii Medical Service Association ABD	$17.82
Rate for Payer: Hawaii Medical Service Association Commercial	$16.12
Rate for Payer: Hawaii Medical Service Association Medicare	$89.10
Rate for Payer: Hawaii Medical Service Association Non-ABD	$18.71
Rate for Payer: Hawaii Western Management Group Commercial	$12.90
Rate for Payer: Health Management Network Commercial	$84.15
Rate for Payer: Humana Medicare	$89.10
Rate for Payer: Kaiser Permanente Commercial	$89.10
Rate for Payer: Kaiser Permanente Medicaid	$50.49
Rate for Payer: Kaiser Permanente Medicare	$89.10
Rate for Payer: MDX Hawaii PPO	$96.03
Rate for Payer: Ohana Health Plan Medicaid	$89.10
Rate for Payer: Ohana Health Plan Medicare	$89.10
Rate for Payer: UnitedHealthcare Medicaid	$17.82
Rate for Payer: UnitedHealthcare Medicare	$89.10
Rate for Payer: University Health Alliance Commercial	$33.32

HCHG AB COXIELLA BRUNETII EA

Facility

$92.00

Service Code	HCPCS 86638
Hospital Charge Code	H3020106
Hospital Revenue Code	302
Min. Negotiated Rate	$10.16
Max. Negotiated Rate	$91.08
Rate for Payer: AlohaCare Medicaid	$46.00
Rate for Payer: AlohaCare Medicare	$82.80
Rate for Payer: Cash Price	$59.80
Rate for Payer: Cash Price	$59.80
Rate for Payer: Devoted Health Medicare	$91.08
Rate for Payer: Hawaii Medical Service Association ABD	$10.16
Rate for Payer: Hawaii Medical Service Association Commercial	$15.15
Rate for Payer: Hawaii Medical Service Association Medicare	$82.80
Rate for Payer: Hawaii Medical Service Association Non-ABD	$16.74
Rate for Payer: Hawaii Western Management Group Commercial	$12.12
Rate for Payer: Health Management Network Commercial	$78.20
Rate for Payer: Humana Medicare	$82.80
Rate for Payer: Kaiser Permanente Commercial	$82.80
Rate for Payer: Kaiser Permanente Medicaid	$46.92
Rate for Payer: Kaiser Permanente Medicare	$82.80
Rate for Payer: MDX Hawaii PPO	$89.24
Rate for Payer: Ohana Health Plan Medicaid	$82.80
Rate for Payer: Ohana Health Plan Medicare	$82.80
Rate for Payer: UnitedHealthcare Medicaid	$10.16
Rate for Payer: UnitedHealthcare Medicare	$82.80
Rate for Payer: University Health Alliance Commercial	$31.34

HCHG AB COXIELLA BRUNETII EA

Facility

$92.00

Service Code	HCPCS 86638
Hospital Charge Code	H3020104
Hospital Revenue Code	302
Min. Negotiated Rate	$10.16
Max. Negotiated Rate	$91.08
Rate for Payer: AlohaCare Medicaid	$46.00
Rate for Payer: AlohaCare Medicare	$82.80
Rate for Payer: Cash Price	$59.80
Rate for Payer: Cash Price	$59.80
Rate for Payer: Devoted Health Medicare	$91.08
Rate for Payer: Hawaii Medical Service Association ABD	$10.16
Rate for Payer: Hawaii Medical Service Association Commercial	$15.15
Rate for Payer: Hawaii Medical Service Association Medicare	$82.80
Rate for Payer: Hawaii Medical Service Association Non-ABD	$16.74
Rate for Payer: Hawaii Western Management Group Commercial	$12.12
Rate for Payer: Health Management Network Commercial	$78.20
Rate for Payer: Humana Medicare	$82.80
Rate for Payer: Kaiser Permanente Commercial	$82.80
Rate for Payer: Kaiser Permanente Medicaid	$46.92
Rate for Payer: Kaiser Permanente Medicare	$82.80
Rate for Payer: MDX Hawaii PPO	$89.24
Rate for Payer: Ohana Health Plan Medicaid	$82.80
Rate for Payer: Ohana Health Plan Medicare	$82.80
Rate for Payer: UnitedHealthcare Medicaid	$10.16
Rate for Payer: UnitedHealthcare Medicare	$82.80
Rate for Payer: University Health Alliance Commercial	$31.34

HCHG AB COXIELLA BRUNETII EA

Facility

$92.00

Service Code	HCPCS 86638
Hospital Charge Code	H3020102
Hospital Revenue Code	302
Min. Negotiated Rate	$10.16
Max. Negotiated Rate	$91.08
Rate for Payer: AlohaCare Medicaid	$46.00
Rate for Payer: AlohaCare Medicare	$82.80
Rate for Payer: Cash Price	$59.80
Rate for Payer: Cash Price	$59.80
Rate for Payer: Devoted Health Medicare	$91.08
Rate for Payer: Hawaii Medical Service Association ABD	$10.16
Rate for Payer: Hawaii Medical Service Association Commercial	$15.15
Rate for Payer: Hawaii Medical Service Association Medicare	$82.80
Rate for Payer: Hawaii Medical Service Association Non-ABD	$16.74
Rate for Payer: Hawaii Western Management Group Commercial	$12.12
Rate for Payer: Health Management Network Commercial	$78.20
Rate for Payer: Humana Medicare	$82.80
Rate for Payer: Kaiser Permanente Commercial	$82.80
Rate for Payer: Kaiser Permanente Medicaid	$46.92
Rate for Payer: Kaiser Permanente Medicare	$82.80
Rate for Payer: MDX Hawaii PPO	$89.24
Rate for Payer: Ohana Health Plan Medicaid	$82.80
Rate for Payer: Ohana Health Plan Medicare	$82.80
Rate for Payer: UnitedHealthcare Medicaid	$10.16
Rate for Payer: UnitedHealthcare Medicare	$82.80
Rate for Payer: University Health Alliance Commercial	$31.34

HCHG AB COXIELLA BRUNETII EA

Facility

$92.00

Service Code	HCPCS 86638
Hospital Charge Code	H3020104
Hospital Revenue Code	302
Min. Negotiated Rate	$78.20
Max. Negotiated Rate	$89.24
Rate for Payer: Cash Price	$59.80
Rate for Payer: Health Management Network Commercial	$78.20
Rate for Payer: Kaiser Permanente Commercial	$82.80
Rate for Payer: MDX Hawaii PPO	$89.24

HCHG AB COXIELLA BRUNETII EA

Facility

$92.00

Service Code	HCPCS 86638
Hospital Charge Code	H3020102
Hospital Revenue Code	302
Min. Negotiated Rate	$78.20
Max. Negotiated Rate	$89.24
Rate for Payer: Cash Price	$59.80
Rate for Payer: Health Management Network Commercial	$78.20
Rate for Payer: Kaiser Permanente Commercial	$82.80
Rate for Payer: MDX Hawaii PPO	$89.24

Know your out-of-pocket cost for care.

All Charges