Honoka'a Hospital and Skilled Nursing Facility

All Charges

Charge

Type

Setting

Price

CHLORHEXIDINE GLUCONATE 0.12 % MOUTHWASH [9516]

Facility

$497.00

Service Code	NDC 00116200116
Hospital Revenue Code	250
Min. Negotiated Rate	$422.45
Max. Negotiated Rate	$482.09
Rate for Payer: Cash Price	$298.20
Rate for Payer: Health Management Network Commercial	$422.45
Rate for Payer: Kaiser Permanente Commercial	$447.30
Rate for Payer: MDX Hawaii PPO	$482.09

CHLORHEXIDINE GLUCONATE 0.12 % MOUTHWASH [9516]

Facility

$8.00

Service Code	NDC 69339013817
Hospital Revenue Code	637
Min. Negotiated Rate	$4.00
Max. Negotiated Rate	$7.76
Rate for Payer: AlohaCare Medicaid	$4.00
Rate for Payer: AlohaCare Medicare	$6.08
Rate for Payer: Cash Price	$4.80
Rate for Payer: Devoted Health Medicare	$6.72
Rate for Payer: Hawaii Medical Service Association Medicare	$6.08
Rate for Payer: Hawaii Western Management Group Commercial	$7.60
Rate for Payer: Health Management Network Commercial	$6.80
Rate for Payer: Humana Medicare	$6.08
Rate for Payer: Kaiser Permanente Commercial	$7.20
Rate for Payer: Kaiser Permanente Medicaid	$4.08
Rate for Payer: Kaiser Permanente Medicare	$6.08
Rate for Payer: MDX Hawaii PPO	$7.76
Rate for Payer: Ohana Health Plan Medicaid	$6.08
Rate for Payer: Ohana Health Plan Medicare	$6.08
Rate for Payer: UnitedHealthcare Medicare	$6.08
Rate for Payer: University Health Alliance Commercial	$5.83

CHLORHEXIDINE GLUCONATE 0.12 % MOUTHWASH [9516]

Facility

$8.00

Service Code	NDC 63739005274
Hospital Revenue Code	250
Min. Negotiated Rate	$6.80
Max. Negotiated Rate	$7.76
Rate for Payer: Cash Price	$4.80
Rate for Payer: Health Management Network Commercial	$6.80
Rate for Payer: Kaiser Permanente Commercial	$7.20
Rate for Payer: MDX Hawaii PPO	$7.76

CHLORHEXIDINE GLUCONATE 0.12 % MOUTHWASH [9516]

Facility

$8.00

Service Code	NDC 69339013815
Hospital Revenue Code	637
Min. Negotiated Rate	$4.00
Max. Negotiated Rate	$7.76
Rate for Payer: AlohaCare Medicaid	$4.00
Rate for Payer: AlohaCare Medicare	$6.08
Rate for Payer: Cash Price	$4.80
Rate for Payer: Devoted Health Medicare	$6.72
Rate for Payer: Hawaii Medical Service Association Medicare	$6.08
Rate for Payer: Hawaii Western Management Group Commercial	$7.60
Rate for Payer: Health Management Network Commercial	$6.80
Rate for Payer: Humana Medicare	$6.08
Rate for Payer: Kaiser Permanente Commercial	$7.20
Rate for Payer: Kaiser Permanente Medicaid	$4.08
Rate for Payer: Kaiser Permanente Medicare	$6.08
Rate for Payer: MDX Hawaii PPO	$7.76
Rate for Payer: Ohana Health Plan Medicaid	$6.08
Rate for Payer: Ohana Health Plan Medicare	$6.08
Rate for Payer: UnitedHealthcare Medicare	$6.08
Rate for Payer: University Health Alliance Commercial	$5.83

CHLORHEXIDINE GLUCONATE 0.12 % MOUTHWASH [9516]

Facility

$8.00

Service Code	NDC 69339013817
Hospital Revenue Code	250
Min. Negotiated Rate	$6.80
Max. Negotiated Rate	$7.76
Rate for Payer: Cash Price	$4.80
Rate for Payer: Health Management Network Commercial	$6.80
Rate for Payer: Kaiser Permanente Commercial	$7.20
Rate for Payer: MDX Hawaii PPO	$7.76

CHLORHEXIDINE GLUCONATE 4 % TOPICAL LIQUID [109392]

Facility

$40.00

Service Code	NDC 16571011148
Hospital Revenue Code	637
Min. Negotiated Rate	$20.00
Max. Negotiated Rate	$38.80
Rate for Payer: AlohaCare Medicaid	$20.00
Rate for Payer: AlohaCare Medicare	$30.40
Rate for Payer: Cash Price	$24.00
Rate for Payer: Devoted Health Medicare	$33.60
Rate for Payer: Hawaii Medical Service Association Medicare	$30.40
Rate for Payer: Hawaii Western Management Group Commercial	$38.00
Rate for Payer: Health Management Network Commercial	$34.00
Rate for Payer: Humana Medicare	$30.40
Rate for Payer: Kaiser Permanente Commercial	$36.00
Rate for Payer: Kaiser Permanente Medicaid	$20.40
Rate for Payer: Kaiser Permanente Medicare	$30.40
Rate for Payer: MDX Hawaii PPO	$38.80
Rate for Payer: Ohana Health Plan Medicaid	$30.40
Rate for Payer: Ohana Health Plan Medicare	$30.40
Rate for Payer: UnitedHealthcare Medicare	$30.40
Rate for Payer: University Health Alliance Commercial	$29.16

CHLORHEXIDINE GLUCONATE 4 % TOPICAL LIQUID [109392]

Facility

$40.00

Service Code	NDC 16571011148
Hospital Revenue Code	250
Min. Negotiated Rate	$34.00
Max. Negotiated Rate	$38.80
Rate for Payer: Cash Price	$24.00
Rate for Payer: Health Management Network Commercial	$34.00
Rate for Payer: Kaiser Permanente Commercial	$36.00
Rate for Payer: MDX Hawaii PPO	$38.80

CHLORHEXIDINE GLUCONATE 4 % TOPICAL LIQUID [109392]

Facility

$73.00

Service Code	NDC 67618020030
Hospital Revenue Code	250
Min. Negotiated Rate	$62.05
Max. Negotiated Rate	$70.81
Rate for Payer: Cash Price	$43.80
Rate for Payer: Health Management Network Commercial	$62.05
Rate for Payer: Kaiser Permanente Commercial	$65.70
Rate for Payer: MDX Hawaii PPO	$70.81

CHLORHEXIDINE GLUCONATE 4 % TOPICAL LIQUID [109392]

Facility

$73.00

Service Code	NDC 67618020030
Hospital Revenue Code	637
Min. Negotiated Rate	$36.50
Max. Negotiated Rate	$70.81
Rate for Payer: AlohaCare Medicaid	$36.50
Rate for Payer: AlohaCare Medicare	$55.48
Rate for Payer: Cash Price	$43.80
Rate for Payer: Devoted Health Medicare	$61.32
Rate for Payer: Hawaii Medical Service Association Medicare	$55.48
Rate for Payer: Hawaii Western Management Group Commercial	$69.35
Rate for Payer: Health Management Network Commercial	$62.05
Rate for Payer: Humana Medicare	$55.48
Rate for Payer: Kaiser Permanente Commercial	$65.70
Rate for Payer: Kaiser Permanente Medicaid	$37.23
Rate for Payer: Kaiser Permanente Medicare	$55.48
Rate for Payer: MDX Hawaii PPO	$70.81
Rate for Payer: Ohana Health Plan Medicaid	$55.48
Rate for Payer: Ohana Health Plan Medicare	$55.48
Rate for Payer: UnitedHealthcare Medicare	$55.48
Rate for Payer: University Health Alliance Commercial	$53.21

CHLORHEXIDINE GLUCONATE 4 % TOPICAL LIQUID [109392]

Facility

$28.00

Service Code	NDC 67618020004
Hospital Revenue Code	637
Min. Negotiated Rate	$14.00
Max. Negotiated Rate	$27.16
Rate for Payer: AlohaCare Medicaid	$14.00
Rate for Payer: AlohaCare Medicare	$21.28
Rate for Payer: Cash Price	$16.80
Rate for Payer: Devoted Health Medicare	$23.52
Rate for Payer: Hawaii Medical Service Association Medicare	$21.28
Rate for Payer: Hawaii Western Management Group Commercial	$26.60
Rate for Payer: Health Management Network Commercial	$23.80
Rate for Payer: Humana Medicare	$21.28
Rate for Payer: Kaiser Permanente Commercial	$25.20
Rate for Payer: Kaiser Permanente Medicaid	$14.28
Rate for Payer: Kaiser Permanente Medicare	$21.28
Rate for Payer: MDX Hawaii PPO	$27.16
Rate for Payer: Ohana Health Plan Medicaid	$21.28
Rate for Payer: Ohana Health Plan Medicare	$21.28
Rate for Payer: UnitedHealthcare Medicare	$21.28
Rate for Payer: University Health Alliance Commercial	$20.41

CHLORHEXIDINE GLUCONATE 4 % TOPICAL LIQUID [109392]

Facility

$28.00

Service Code	NDC 67618020004
Hospital Revenue Code	250
Min. Negotiated Rate	$23.80
Max. Negotiated Rate	$27.16
Rate for Payer: Cash Price	$16.80
Rate for Payer: Health Management Network Commercial	$23.80
Rate for Payer: Kaiser Permanente Commercial	$25.20
Rate for Payer: MDX Hawaii PPO	$27.16

CHLOROPROCAINE (PF) 30 MG/ML (3 %) INJECTION SOLUTION [134068]

Facility

$95.00

Service Code	HCPCS J2401
Hospital Revenue Code	250
Min. Negotiated Rate	$80.75
Max. Negotiated Rate	$92.15
Rate for Payer: Cash Price	$57.00
Rate for Payer: Health Management Network Commercial	$80.75
Rate for Payer: Kaiser Permanente Commercial	$85.50
Rate for Payer: MDX Hawaii PPO	$92.15

CHLOROPROCAINE (PF) 30 MG/ML (3 %) INJECTION SOLUTION [134068]

Facility

$95.00

Service Code	HCPCS J2401
Hospital Revenue Code	636
Min. Negotiated Rate	$0.04
Max. Negotiated Rate	$92.15
Rate for Payer: AlohaCare Medicaid	$47.50
Rate for Payer: AlohaCare Medicare	$72.20
Rate for Payer: Cash Price	$57.00
Rate for Payer: Cash Price	$57.00
Rate for Payer: Devoted Health Medicare	$79.80
Rate for Payer: Hawaii Medical Service Association ABD	$0.04
Rate for Payer: Hawaii Medical Service Association Medicare	$72.20
Rate for Payer: Hawaii Medical Service Association Non-ABD	$0.04
Rate for Payer: Hawaii Western Management Group Commercial	$90.25
Rate for Payer: Health Management Network Commercial	$80.75
Rate for Payer: Humana Medicare	$72.20
Rate for Payer: Kaiser Permanente Commercial	$85.50
Rate for Payer: Kaiser Permanente Medicaid	$48.45
Rate for Payer: Kaiser Permanente Medicare	$72.20
Rate for Payer: MDX Hawaii PPO	$92.15
Rate for Payer: Ohana Health Plan Medicaid	$72.20
Rate for Payer: Ohana Health Plan Medicare	$72.20
Rate for Payer: UnitedHealthcare Medicaid	$57.00
Rate for Payer: UnitedHealthcare Medicare	$72.20
Rate for Payer: University Health Alliance Commercial	$69.25

CHLOROTHIAZIDE SODIUM 500 MG INTRAVENOUS SOLUTION [9526]

Facility

$144.00

Service Code	HCPCS J1205
Hospital Revenue Code	636
Min. Negotiated Rate	$40.38
Max. Negotiated Rate	$139.68
Rate for Payer: AlohaCare Medicaid	$72.00
Rate for Payer: AlohaCare Medicare	$109.44
Rate for Payer: Cash Price	$86.40
Rate for Payer: Cash Price	$86.40
Rate for Payer: Devoted Health Medicare	$120.96
Rate for Payer: Hawaii Medical Service Association ABD	$40.38
Rate for Payer: Hawaii Medical Service Association Medicare	$109.44
Rate for Payer: Hawaii Medical Service Association Non-ABD	$40.38
Rate for Payer: Hawaii Western Management Group Commercial	$136.80
Rate for Payer: Health Management Network Commercial	$122.40
Rate for Payer: Humana Medicare	$109.44
Rate for Payer: Kaiser Permanente Commercial	$129.60
Rate for Payer: Kaiser Permanente Medicaid	$73.44
Rate for Payer: Kaiser Permanente Medicare	$109.44
Rate for Payer: MDX Hawaii PPO	$139.68
Rate for Payer: Ohana Health Plan Medicaid	$109.44
Rate for Payer: Ohana Health Plan Medicare	$109.44
Rate for Payer: UnitedHealthcare Medicaid	$86.40
Rate for Payer: UnitedHealthcare Medicare	$109.44
Rate for Payer: University Health Alliance Commercial	$104.96

CHLOROTHIAZIDE SODIUM 500 MG INTRAVENOUS SOLUTION [9526]

Facility

$144.00

Service Code	HCPCS J1205
Hospital Revenue Code	250
Min. Negotiated Rate	$122.40
Max. Negotiated Rate	$139.68
Rate for Payer: Cash Price	$86.40
Rate for Payer: Health Management Network Commercial	$122.40
Rate for Payer: Kaiser Permanente Commercial	$129.60
Rate for Payer: MDX Hawaii PPO	$139.68

CHLORPROMAZINE 25 MG/ML INJECTION SOLUTION [1649]

Facility

$100.00

Service Code	HCPCS J3230
Hospital Revenue Code	250
Min. Negotiated Rate	$85.00
Max. Negotiated Rate	$97.00
Rate for Payer: Cash Price	$60.00
Rate for Payer: Health Management Network Commercial	$85.00
Rate for Payer: Kaiser Permanente Commercial	$90.00
Rate for Payer: MDX Hawaii PPO	$97.00

CHLORPROMAZINE 25 MG/ML INJECTION SOLUTION [1649]

Facility

$100.00

Service Code	HCPCS J3230
Hospital Revenue Code	636
Min. Negotiated Rate	$27.07
Max. Negotiated Rate	$97.00
Rate for Payer: AlohaCare Medicaid	$50.00
Rate for Payer: AlohaCare Medicare	$76.00
Rate for Payer: Cash Price	$60.00
Rate for Payer: Cash Price	$60.00
Rate for Payer: Devoted Health Medicare	$84.00
Rate for Payer: Hawaii Medical Service Association ABD	$27.07
Rate for Payer: Hawaii Medical Service Association Medicare	$76.00
Rate for Payer: Hawaii Medical Service Association Non-ABD	$27.07
Rate for Payer: Hawaii Western Management Group Commercial	$95.00
Rate for Payer: Health Management Network Commercial	$85.00
Rate for Payer: Humana Medicare	$76.00
Rate for Payer: Kaiser Permanente Commercial	$90.00
Rate for Payer: Kaiser Permanente Medicaid	$51.00
Rate for Payer: Kaiser Permanente Medicare	$76.00
Rate for Payer: MDX Hawaii PPO	$97.00
Rate for Payer: Ohana Health Plan Medicaid	$76.00
Rate for Payer: Ohana Health Plan Medicare	$76.00
Rate for Payer: UnitedHealthcare Medicaid	$60.00
Rate for Payer: UnitedHealthcare Medicare	$76.00
Rate for Payer: University Health Alliance Commercial	$72.89

CHLORPROMAZINE 25 MG TABLET [1656]

Facility

$23.00

Service Code	NDC 69238105601
Hospital Revenue Code	637
Min. Negotiated Rate	$11.50
Max. Negotiated Rate	$22.31
Rate for Payer: AlohaCare Medicaid	$11.50
Rate for Payer: AlohaCare Medicare	$17.48
Rate for Payer: Cash Price	$13.80
Rate for Payer: Devoted Health Medicare	$19.32
Rate for Payer: Hawaii Medical Service Association Medicare	$17.48
Rate for Payer: Hawaii Western Management Group Commercial	$21.85
Rate for Payer: Health Management Network Commercial	$19.55
Rate for Payer: Humana Medicare	$17.48
Rate for Payer: Kaiser Permanente Commercial	$20.70
Rate for Payer: Kaiser Permanente Medicaid	$11.73
Rate for Payer: Kaiser Permanente Medicare	$17.48
Rate for Payer: MDX Hawaii PPO	$22.31
Rate for Payer: Ohana Health Plan Medicaid	$17.48
Rate for Payer: Ohana Health Plan Medicare	$17.48
Rate for Payer: UnitedHealthcare Medicare	$17.48
Rate for Payer: University Health Alliance Commercial	$16.76

CHLORPROMAZINE 25 MG TABLET [1656]

Facility

$23.00

Service Code	NDC 68462086201
Hospital Revenue Code	250
Min. Negotiated Rate	$19.55
Max. Negotiated Rate	$22.31
Rate for Payer: Cash Price	$13.80
Rate for Payer: Health Management Network Commercial	$19.55
Rate for Payer: Kaiser Permanente Commercial	$20.70
Rate for Payer: MDX Hawaii PPO	$22.31

CHLORPROMAZINE 25 MG TABLET [1656]

Facility

$23.00

Service Code	NDC 68462086201
Hospital Revenue Code	637
Min. Negotiated Rate	$11.50
Max. Negotiated Rate	$22.31
Rate for Payer: AlohaCare Medicaid	$11.50
Rate for Payer: AlohaCare Medicare	$17.48
Rate for Payer: Cash Price	$13.80
Rate for Payer: Devoted Health Medicare	$19.32
Rate for Payer: Hawaii Medical Service Association Medicare	$17.48
Rate for Payer: Hawaii Western Management Group Commercial	$21.85
Rate for Payer: Health Management Network Commercial	$19.55
Rate for Payer: Humana Medicare	$17.48
Rate for Payer: Kaiser Permanente Commercial	$20.70
Rate for Payer: Kaiser Permanente Medicaid	$11.73
Rate for Payer: Kaiser Permanente Medicare	$17.48
Rate for Payer: MDX Hawaii PPO	$22.31
Rate for Payer: Ohana Health Plan Medicaid	$17.48
Rate for Payer: Ohana Health Plan Medicare	$17.48
Rate for Payer: UnitedHealthcare Medicare	$17.48
Rate for Payer: University Health Alliance Commercial	$16.76

CHLORPROMAZINE 25 MG TABLET [1656]

Facility

$23.00

Service Code	NDC 69238105601
Hospital Revenue Code	250
Min. Negotiated Rate	$19.55
Max. Negotiated Rate	$22.31
Rate for Payer: Cash Price	$13.80
Rate for Payer: Health Management Network Commercial	$19.55
Rate for Payer: Kaiser Permanente Commercial	$20.70
Rate for Payer: MDX Hawaii PPO	$22.31

CHLORTHALIDONE 25 MG TABLET [1661]

Facility

$9.00

Service Code	NDC 60687031725
Hospital Revenue Code	250
Min. Negotiated Rate	$7.65
Max. Negotiated Rate	$8.73
Rate for Payer: Cash Price	$5.40
Rate for Payer: Health Management Network Commercial	$7.65
Rate for Payer: Kaiser Permanente Commercial	$8.10
Rate for Payer: MDX Hawaii PPO	$8.73

CHLORTHALIDONE 25 MG TABLET [1661]

Facility

$9.00

Service Code	NDC 60687031795
Hospital Revenue Code	250
Min. Negotiated Rate	$7.65
Max. Negotiated Rate	$8.73
Rate for Payer: Cash Price	$5.40
Rate for Payer: Health Management Network Commercial	$7.65
Rate for Payer: Kaiser Permanente Commercial	$8.10
Rate for Payer: MDX Hawaii PPO	$8.73

CHLORTHALIDONE 25 MG TABLET [1661]

Facility

$9.00

Service Code	NDC 51079005820
Hospital Revenue Code	637
Min. Negotiated Rate	$4.50
Max. Negotiated Rate	$8.73
Rate for Payer: AlohaCare Medicaid	$4.50
Rate for Payer: AlohaCare Medicare	$6.84
Rate for Payer: Cash Price	$5.40
Rate for Payer: Devoted Health Medicare	$7.56
Rate for Payer: Hawaii Medical Service Association Medicare	$6.84
Rate for Payer: Hawaii Western Management Group Commercial	$8.55
Rate for Payer: Health Management Network Commercial	$7.65
Rate for Payer: Humana Medicare	$6.84
Rate for Payer: Kaiser Permanente Commercial	$8.10
Rate for Payer: Kaiser Permanente Medicaid	$4.59
Rate for Payer: Kaiser Permanente Medicare	$6.84
Rate for Payer: MDX Hawaii PPO	$8.73
Rate for Payer: Ohana Health Plan Medicaid	$6.84
Rate for Payer: Ohana Health Plan Medicare	$6.84
Rate for Payer: UnitedHealthcare Medicare	$6.84
Rate for Payer: University Health Alliance Commercial	$6.56

CHLORTHALIDONE 25 MG TABLET [1661]

Facility

$9.00

Service Code	NDC 51079005820
Hospital Revenue Code	250
Min. Negotiated Rate	$7.65
Max. Negotiated Rate	$8.73
Rate for Payer: Cash Price	$5.40
Rate for Payer: Health Management Network Commercial	$7.65
Rate for Payer: Kaiser Permanente Commercial	$8.10
Rate for Payer: MDX Hawaii PPO	$8.73

Know your out-of-pocket cost for care.

All Charges