Honoka'a Hospital and Skilled Nursing Facility

All Charges

Charge

Type

Setting

Price

DICYCLOMINE 10 MG/5 ML ORAL SYRINGE [4080572]

Facility

$6.00

Service Code	NDC 00004080073
Hospital Revenue Code	637
Min. Negotiated Rate	$3.00
Max. Negotiated Rate	$5.82
Rate for Payer: AlohaCare Medicaid	$3.00
Rate for Payer: AlohaCare Medicare	$4.56
Rate for Payer: Cash Price	$3.60
Rate for Payer: Devoted Health Medicare	$5.04
Rate for Payer: Hawaii Medical Service Association Medicare	$4.56
Rate for Payer: Hawaii Western Management Group Commercial	$5.70
Rate for Payer: Health Management Network Commercial	$5.10
Rate for Payer: Humana Medicare	$4.56
Rate for Payer: Kaiser Permanente Commercial	$5.40
Rate for Payer: Kaiser Permanente Medicaid	$3.06
Rate for Payer: Kaiser Permanente Medicare	$4.56
Rate for Payer: MDX Hawaii PPO	$5.82
Rate for Payer: Ohana Health Plan Medicaid	$4.56
Rate for Payer: Ohana Health Plan Medicare	$4.56
Rate for Payer: UnitedHealthcare Medicare	$4.56
Rate for Payer: University Health Alliance Commercial	$4.37

DICYCLOMINE 10 MG CAPSULE [2418]

Facility

$3.00

Service Code	NDC 60687036911
Hospital Revenue Code	250
Min. Negotiated Rate	$2.55
Max. Negotiated Rate	$2.91
Rate for Payer: Cash Price	$1.80
Rate for Payer: Health Management Network Commercial	$2.55
Rate for Payer: Kaiser Permanente Commercial	$2.70
Rate for Payer: MDX Hawaii PPO	$2.91

DICYCLOMINE 10 MG CAPSULE [2418]

Facility

$3.00

Service Code	NDC 60687036901
Hospital Revenue Code	637
Min. Negotiated Rate	$1.50
Max. Negotiated Rate	$2.91
Rate for Payer: AlohaCare Medicaid	$1.50
Rate for Payer: AlohaCare Medicare	$2.28
Rate for Payer: Cash Price	$1.80
Rate for Payer: Devoted Health Medicare	$2.52
Rate for Payer: Hawaii Medical Service Association Medicare	$2.28
Rate for Payer: Hawaii Western Management Group Commercial	$2.85
Rate for Payer: Health Management Network Commercial	$2.55
Rate for Payer: Humana Medicare	$2.28
Rate for Payer: Kaiser Permanente Commercial	$2.70
Rate for Payer: Kaiser Permanente Medicaid	$1.53
Rate for Payer: Kaiser Permanente Medicare	$2.28
Rate for Payer: MDX Hawaii PPO	$2.91
Rate for Payer: Ohana Health Plan Medicaid	$2.28
Rate for Payer: Ohana Health Plan Medicare	$2.28
Rate for Payer: UnitedHealthcare Medicare	$2.28
Rate for Payer: University Health Alliance Commercial	$2.19

DICYCLOMINE 10 MG CAPSULE [2418]

Facility

$3.00

Service Code	NDC 60687036911
Hospital Revenue Code	637
Min. Negotiated Rate	$1.50
Max. Negotiated Rate	$2.91
Rate for Payer: AlohaCare Medicaid	$1.50
Rate for Payer: AlohaCare Medicare	$2.28
Rate for Payer: Cash Price	$1.80
Rate for Payer: Devoted Health Medicare	$2.52
Rate for Payer: Hawaii Medical Service Association Medicare	$2.28
Rate for Payer: Hawaii Western Management Group Commercial	$2.85
Rate for Payer: Health Management Network Commercial	$2.55
Rate for Payer: Humana Medicare	$2.28
Rate for Payer: Kaiser Permanente Commercial	$2.70
Rate for Payer: Kaiser Permanente Medicaid	$1.53
Rate for Payer: Kaiser Permanente Medicare	$2.28
Rate for Payer: MDX Hawaii PPO	$2.91
Rate for Payer: Ohana Health Plan Medicaid	$2.28
Rate for Payer: Ohana Health Plan Medicare	$2.28
Rate for Payer: UnitedHealthcare Medicare	$2.28
Rate for Payer: University Health Alliance Commercial	$2.19

DICYCLOMINE 10 MG CAPSULE [2418]

Facility

$3.00

Service Code	NDC 60687036901
Hospital Revenue Code	250
Min. Negotiated Rate	$2.55
Max. Negotiated Rate	$2.91
Rate for Payer: Cash Price	$1.80
Rate for Payer: Health Management Network Commercial	$2.55
Rate for Payer: Kaiser Permanente Commercial	$2.70
Rate for Payer: MDX Hawaii PPO	$2.91

DICYCLOMINE 10 MG/ML INTRAMUSCULAR SOLUTION [2417]

Facility

$122.00

Service Code	HCPCS J0500
Hospital Revenue Code	250
Min. Negotiated Rate	$103.70
Max. Negotiated Rate	$118.34
Rate for Payer: Cash Price	$73.20
Rate for Payer: Cash Price	$44.40
Rate for Payer: Health Management Network Commercial	$103.70
Rate for Payer: Health Management Network Commercial	$62.90
Rate for Payer: Kaiser Permanente Commercial	$109.80
Rate for Payer: Kaiser Permanente Commercial	$66.60
Rate for Payer: MDX Hawaii PPO	$71.78
Rate for Payer: MDX Hawaii PPO	$118.34

DICYCLOMINE 10 MG/ML INTRAMUSCULAR SOLUTION [2417]

Facility

$122.00

Service Code	HCPCS J0500
Hospital Revenue Code	636
Min. Negotiated Rate	$11.68
Max. Negotiated Rate	$118.34
Rate for Payer: AlohaCare Medicaid	$61.00
Rate for Payer: AlohaCare Medicaid	$37.00
Rate for Payer: AlohaCare Medicare	$56.24
Rate for Payer: AlohaCare Medicare	$92.72
Rate for Payer: Cash Price	$44.40
Rate for Payer: Cash Price	$73.20
Rate for Payer: Cash Price	$73.20
Rate for Payer: Cash Price	$44.40
Rate for Payer: Devoted Health Medicare	$102.48
Rate for Payer: Devoted Health Medicare	$62.16
Rate for Payer: Hawaii Medical Service Association ABD	$11.68
Rate for Payer: Hawaii Medical Service Association ABD	$11.68
Rate for Payer: Hawaii Medical Service Association Medicare	$56.24
Rate for Payer: Hawaii Medical Service Association Medicare	$92.72
Rate for Payer: Hawaii Medical Service Association Non-ABD	$11.68
Rate for Payer: Hawaii Medical Service Association Non-ABD	$11.68
Rate for Payer: Hawaii Western Management Group Commercial	$115.90
Rate for Payer: Hawaii Western Management Group Commercial	$70.30
Rate for Payer: Health Management Network Commercial	$62.90
Rate for Payer: Health Management Network Commercial	$103.70
Rate for Payer: Humana Medicare	$92.72
Rate for Payer: Humana Medicare	$56.24
Rate for Payer: Kaiser Permanente Commercial	$109.80
Rate for Payer: Kaiser Permanente Commercial	$66.60
Rate for Payer: Kaiser Permanente Medicaid	$37.74
Rate for Payer: Kaiser Permanente Medicaid	$62.22
Rate for Payer: Kaiser Permanente Medicare	$92.72
Rate for Payer: Kaiser Permanente Medicare	$56.24
Rate for Payer: MDX Hawaii PPO	$118.34
Rate for Payer: MDX Hawaii PPO	$71.78
Rate for Payer: Ohana Health Plan Medicaid	$56.24
Rate for Payer: Ohana Health Plan Medicaid	$92.72
Rate for Payer: Ohana Health Plan Medicare	$92.72
Rate for Payer: Ohana Health Plan Medicare	$56.24
Rate for Payer: UnitedHealthcare Medicaid	$44.40
Rate for Payer: UnitedHealthcare Medicaid	$73.20
Rate for Payer: UnitedHealthcare Medicare	$92.72
Rate for Payer: UnitedHealthcare Medicare	$56.24
Rate for Payer: University Health Alliance Commercial	$88.93
Rate for Payer: University Health Alliance Commercial	$53.94

DICYCLOMINE 20 MG TABLET [2420]

Facility

$2.00

Service Code	NDC 60687038011
Hospital Revenue Code	637
Min. Negotiated Rate	$1.00
Max. Negotiated Rate	$1.94
Rate for Payer: AlohaCare Medicaid	$1.00
Rate for Payer: AlohaCare Medicare	$1.52
Rate for Payer: Cash Price	$1.20
Rate for Payer: Devoted Health Medicare	$1.68
Rate for Payer: Hawaii Medical Service Association Medicare	$1.52
Rate for Payer: Hawaii Western Management Group Commercial	$1.90
Rate for Payer: Health Management Network Commercial	$1.70
Rate for Payer: Humana Medicare	$1.52
Rate for Payer: Kaiser Permanente Commercial	$1.80
Rate for Payer: Kaiser Permanente Medicaid	$1.02
Rate for Payer: Kaiser Permanente Medicare	$1.52
Rate for Payer: MDX Hawaii PPO	$1.94
Rate for Payer: Ohana Health Plan Medicaid	$1.52
Rate for Payer: Ohana Health Plan Medicare	$1.52
Rate for Payer: UnitedHealthcare Medicare	$1.52
Rate for Payer: University Health Alliance Commercial	$1.46

DICYCLOMINE 20 MG TABLET [2420]

Facility

$2.00

Service Code	NDC 60687038011
Hospital Revenue Code	250
Min. Negotiated Rate	$1.70
Max. Negotiated Rate	$1.94
Rate for Payer: Cash Price	$1.20
Rate for Payer: Health Management Network Commercial	$1.70
Rate for Payer: Kaiser Permanente Commercial	$1.80
Rate for Payer: MDX Hawaii PPO	$1.94

DICYCLOMINE 20 MG TABLET [2420]

Facility

$2.00

Service Code	NDC 60687038001
Hospital Revenue Code	637
Min. Negotiated Rate	$1.00
Max. Negotiated Rate	$1.94
Rate for Payer: AlohaCare Medicaid	$1.00
Rate for Payer: AlohaCare Medicare	$1.52
Rate for Payer: Cash Price	$1.20
Rate for Payer: Devoted Health Medicare	$1.68
Rate for Payer: Hawaii Medical Service Association Medicare	$1.52
Rate for Payer: Hawaii Western Management Group Commercial	$1.90
Rate for Payer: Health Management Network Commercial	$1.70
Rate for Payer: Humana Medicare	$1.52
Rate for Payer: Kaiser Permanente Commercial	$1.80
Rate for Payer: Kaiser Permanente Medicaid	$1.02
Rate for Payer: Kaiser Permanente Medicare	$1.52
Rate for Payer: MDX Hawaii PPO	$1.94
Rate for Payer: Ohana Health Plan Medicaid	$1.52
Rate for Payer: Ohana Health Plan Medicare	$1.52
Rate for Payer: UnitedHealthcare Medicare	$1.52
Rate for Payer: University Health Alliance Commercial	$1.46

DICYCLOMINE 20 MG TABLET [2420]

Facility

$2.00

Service Code	NDC 60687038001
Hospital Revenue Code	250
Min. Negotiated Rate	$1.70
Max. Negotiated Rate	$1.94
Rate for Payer: Cash Price	$1.20
Rate for Payer: Health Management Network Commercial	$1.70
Rate for Payer: Kaiser Permanente Commercial	$1.80
Rate for Payer: MDX Hawaii PPO	$1.94

DICYCLOMINE TABLETS (BENTYL) 20 MG (TAKE HOME) [4080354]

Facility

$15.00

Service Code	NDC 00004080142
Hospital Revenue Code	253
Min. Negotiated Rate	$12.75
Max. Negotiated Rate	$14.55
Rate for Payer: Cash Price	$9.00
Rate for Payer: Health Management Network Commercial	$12.75
Rate for Payer: Kaiser Permanente Commercial	$13.50
Rate for Payer: MDX Hawaii PPO	$14.55

DICYCLOMINE TABLETS (BENTYL) 20 MG (TAKE HOME) [4080354]

Facility

$15.00

Service Code	NDC 00004080142
Hospital Revenue Code	253
Min. Negotiated Rate	$7.50
Max. Negotiated Rate	$14.55
Rate for Payer: AlohaCare Medicaid	$7.50
Rate for Payer: AlohaCare Medicare	$11.40
Rate for Payer: Cash Price	$9.00
Rate for Payer: Devoted Health Medicare	$12.60
Rate for Payer: Hawaii Medical Service Association Medicare	$11.40
Rate for Payer: Hawaii Western Management Group Commercial	$14.25
Rate for Payer: Health Management Network Commercial	$12.75
Rate for Payer: Humana Medicare	$11.40
Rate for Payer: Kaiser Permanente Commercial	$13.50
Rate for Payer: Kaiser Permanente Medicaid	$7.65
Rate for Payer: Kaiser Permanente Medicare	$11.40
Rate for Payer: MDX Hawaii PPO	$14.55
Rate for Payer: Ohana Health Plan Medicaid	$11.40
Rate for Payer: Ohana Health Plan Medicare	$11.40
Rate for Payer: UnitedHealthcare Medicare	$11.40
Rate for Payer: University Health Alliance Commercial	$10.93

DIGESTIVE MALIGNANCY WITH CC

Facility

$54,633.11

Service Code	MSDRG 375
Min. Negotiated Rate	$54,633.11
Max. Negotiated Rate	$54,633.11
Rate for Payer: Hawaii Medical Service Association Commercial	$54,633.11

DIGESTIVE MALIGNANCY WITH MCC

Facility

$55,936.72

Service Code	MSDRG 374
Min. Negotiated Rate	$55,936.72
Max. Negotiated Rate	$55,936.72
Rate for Payer: Hawaii Medical Service Association Commercial	$55,936.72

DIGESTIVE MALIGNANCY WITHOUT CC/MCC

Facility

$28,489.80

Service Code	MSDRG 376
Min. Negotiated Rate	$28,489.80
Max. Negotiated Rate	$28,489.80
Rate for Payer: Hawaii Medical Service Association Commercial	$28,489.80

DIGIT WIDGET EXTL FIX DWD-232

Facility

$3,300.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,650.00
Max. Negotiated Rate	$3,201.00
Rate for Payer: AlohaCare Medicaid	$1,650.00
Rate for Payer: AlohaCare Medicare	$2,508.00
Rate for Payer: Cash Price	$1,980.00
Rate for Payer: Devoted Health Medicare	$2,772.00
Rate for Payer: Hawaii Medical Service Association Medicare	$2,508.00
Rate for Payer: Hawaii Western Management Group Commercial	$2,310.00
Rate for Payer: Health Management Network Commercial	$2,805.00
Rate for Payer: Humana Medicare	$2,508.00
Rate for Payer: Kaiser Permanente Commercial	$2,970.00
Rate for Payer: Kaiser Permanente Medicaid	$1,683.00
Rate for Payer: Kaiser Permanente Medicare	$2,508.00
Rate for Payer: MDX Hawaii PPO	$3,201.00
Rate for Payer: Ohana Health Plan Medicaid	$2,508.00
Rate for Payer: Ohana Health Plan Medicare	$2,508.00
Rate for Payer: UnitedHealthcare Medicare	$2,508.00
Rate for Payer: University Health Alliance Commercial	$1,848.00

DIGIT WIDGET EXTL FIX DWD-232

Facility

$3,300.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,848.00
Max. Negotiated Rate	$3,201.00
Rate for Payer: Cash Price	$1,980.00
Rate for Payer: Hawaii Western Management Group Commercial	$2,310.00
Rate for Payer: Health Management Network Commercial	$2,805.00
Rate for Payer: Kaiser Permanente Commercial	$2,970.00
Rate for Payer: MDX Hawaii PPO	$3,201.00
Rate for Payer: University Health Alliance Commercial	$1,848.00

DIGOXIN 125 MCG (0.125 MG) TABLET [2444]

Facility

$5.00

Service Code	NDC 60687054001
Hospital Revenue Code	637
Min. Negotiated Rate	$2.50
Max. Negotiated Rate	$4.85
Rate for Payer: AlohaCare Medicaid	$2.50
Rate for Payer: AlohaCare Medicare	$3.80
Rate for Payer: Cash Price	$3.00
Rate for Payer: Devoted Health Medicare	$4.20
Rate for Payer: Hawaii Medical Service Association Medicare	$3.80
Rate for Payer: Hawaii Western Management Group Commercial	$4.75
Rate for Payer: Health Management Network Commercial	$4.25
Rate for Payer: Humana Medicare	$3.80
Rate for Payer: Kaiser Permanente Commercial	$4.50
Rate for Payer: Kaiser Permanente Medicaid	$2.55
Rate for Payer: Kaiser Permanente Medicare	$3.80
Rate for Payer: MDX Hawaii PPO	$4.85
Rate for Payer: Ohana Health Plan Medicaid	$3.80
Rate for Payer: Ohana Health Plan Medicare	$3.80
Rate for Payer: UnitedHealthcare Medicare	$3.80
Rate for Payer: University Health Alliance Commercial	$3.64

DIGOXIN 125 MCG (0.125 MG) TABLET [2444]

Facility

$6.00

Service Code	NDC 60687085801
Hospital Revenue Code	637
Min. Negotiated Rate	$3.00
Max. Negotiated Rate	$5.82
Rate for Payer: AlohaCare Medicaid	$3.00
Rate for Payer: AlohaCare Medicare	$4.56
Rate for Payer: Cash Price	$3.60
Rate for Payer: Devoted Health Medicare	$5.04
Rate for Payer: Hawaii Medical Service Association Medicare	$4.56
Rate for Payer: Hawaii Western Management Group Commercial	$5.70
Rate for Payer: Health Management Network Commercial	$5.10
Rate for Payer: Humana Medicare	$4.56
Rate for Payer: Kaiser Permanente Commercial	$5.40
Rate for Payer: Kaiser Permanente Medicaid	$3.06
Rate for Payer: Kaiser Permanente Medicare	$4.56
Rate for Payer: MDX Hawaii PPO	$5.82
Rate for Payer: Ohana Health Plan Medicaid	$4.56
Rate for Payer: Ohana Health Plan Medicare	$4.56
Rate for Payer: UnitedHealthcare Medicare	$4.56
Rate for Payer: University Health Alliance Commercial	$4.37

DIGOXIN 125 MCG (0.125 MG) TABLET [2444]

Facility

$6.00

Service Code	NDC 60687085811
Hospital Revenue Code	637
Min. Negotiated Rate	$3.00
Max. Negotiated Rate	$5.82
Rate for Payer: AlohaCare Medicaid	$3.00
Rate for Payer: AlohaCare Medicare	$4.56
Rate for Payer: Cash Price	$3.60
Rate for Payer: Devoted Health Medicare	$5.04
Rate for Payer: Hawaii Medical Service Association Medicare	$4.56
Rate for Payer: Hawaii Western Management Group Commercial	$5.70
Rate for Payer: Health Management Network Commercial	$5.10
Rate for Payer: Humana Medicare	$4.56
Rate for Payer: Kaiser Permanente Commercial	$5.40
Rate for Payer: Kaiser Permanente Medicaid	$3.06
Rate for Payer: Kaiser Permanente Medicare	$4.56
Rate for Payer: MDX Hawaii PPO	$5.82
Rate for Payer: Ohana Health Plan Medicaid	$4.56
Rate for Payer: Ohana Health Plan Medicare	$4.56
Rate for Payer: UnitedHealthcare Medicare	$4.56
Rate for Payer: University Health Alliance Commercial	$4.37

DIGOXIN 125 MCG (0.125 MG) TABLET [2444]

Facility

$5.00

Service Code	NDC 60687054011
Hospital Revenue Code	637
Min. Negotiated Rate	$2.50
Max. Negotiated Rate	$4.85
Rate for Payer: AlohaCare Medicaid	$2.50
Rate for Payer: AlohaCare Medicare	$3.80
Rate for Payer: Cash Price	$3.00
Rate for Payer: Devoted Health Medicare	$4.20
Rate for Payer: Hawaii Medical Service Association Medicare	$3.80
Rate for Payer: Hawaii Western Management Group Commercial	$4.75
Rate for Payer: Health Management Network Commercial	$4.25
Rate for Payer: Humana Medicare	$3.80
Rate for Payer: Kaiser Permanente Commercial	$4.50
Rate for Payer: Kaiser Permanente Medicaid	$2.55
Rate for Payer: Kaiser Permanente Medicare	$3.80
Rate for Payer: MDX Hawaii PPO	$4.85
Rate for Payer: Ohana Health Plan Medicaid	$3.80
Rate for Payer: Ohana Health Plan Medicare	$3.80
Rate for Payer: UnitedHealthcare Medicare	$3.80
Rate for Payer: University Health Alliance Commercial	$3.64

DIGOXIN 125 MCG (0.125 MG) TABLET [2444]

Facility

$6.00

Service Code	NDC 60687085801
Hospital Revenue Code	250
Min. Negotiated Rate	$5.10
Max. Negotiated Rate	$5.82
Rate for Payer: Cash Price	$3.60
Rate for Payer: Health Management Network Commercial	$5.10
Rate for Payer: Kaiser Permanente Commercial	$5.40
Rate for Payer: MDX Hawaii PPO	$5.82

DIGOXIN 125 MCG (0.125 MG) TABLET [2444]

Facility

$5.00

Service Code	NDC 60687054011
Hospital Revenue Code	250
Min. Negotiated Rate	$4.25
Max. Negotiated Rate	$4.85
Rate for Payer: Cash Price	$3.00
Rate for Payer: Health Management Network Commercial	$4.25
Rate for Payer: Kaiser Permanente Commercial	$4.50
Rate for Payer: MDX Hawaii PPO	$4.85

DIGOXIN 125 MCG (0.125 MG) TABLET [2444]

Facility

$5.00

Service Code	NDC 60687054001
Hospital Revenue Code	250
Min. Negotiated Rate	$4.25
Max. Negotiated Rate	$4.85
Rate for Payer: Cash Price	$3.00
Rate for Payer: Health Management Network Commercial	$4.25
Rate for Payer: Kaiser Permanente Commercial	$4.50
Rate for Payer: MDX Hawaii PPO	$4.85

Know your out-of-pocket cost for care.

All Charges