Honoka'a Hospital and Skilled Nursing Facility

All Charges

Charge

Type

Setting

Price

ALLOGRAFT 10.0X64 FGL10064

Facility

$7,040.00

Service Code	HCPCS C1762
Hospital Revenue Code	278
Min. Negotiated Rate	$3,520.00
Max. Negotiated Rate	$6,828.80
Rate for Payer: AlohaCare Medicaid	$3,520.00
Rate for Payer: AlohaCare Medicare	$5,350.40
Rate for Payer: Cash Price	$4,224.00
Rate for Payer: Devoted Health Medicare	$5,913.60
Rate for Payer: Hawaii Medical Service Association Medicare	$5,350.40
Rate for Payer: Hawaii Western Management Group Commercial	$4,928.00
Rate for Payer: Health Management Network Commercial	$5,984.00
Rate for Payer: Humana Medicare	$5,350.40
Rate for Payer: Kaiser Permanente Commercial	$6,336.00
Rate for Payer: Kaiser Permanente Medicaid	$3,590.40
Rate for Payer: Kaiser Permanente Medicare	$5,350.40
Rate for Payer: MDX Hawaii PPO	$6,828.80
Rate for Payer: Ohana Health Plan Medicaid	$5,350.40
Rate for Payer: Ohana Health Plan Medicare	$5,350.40
Rate for Payer: UnitedHealthcare Medicare	$5,350.40
Rate for Payer: University Health Alliance Commercial	$3,942.40

ALLOGRAFT 9X70MM FGL09070

Facility

$4,978.00

Service Code	HCPCS C1762
Hospital Revenue Code	278
Min. Negotiated Rate	$2,489.00
Max. Negotiated Rate	$4,828.66
Rate for Payer: AlohaCare Medicaid	$2,489.00
Rate for Payer: AlohaCare Medicare	$3,783.28
Rate for Payer: Cash Price	$2,986.80
Rate for Payer: Devoted Health Medicare	$4,181.52
Rate for Payer: Hawaii Medical Service Association Medicare	$3,783.28
Rate for Payer: Hawaii Western Management Group Commercial	$3,484.60
Rate for Payer: Health Management Network Commercial	$4,231.30
Rate for Payer: Humana Medicare	$3,783.28
Rate for Payer: Kaiser Permanente Commercial	$4,480.20
Rate for Payer: Kaiser Permanente Medicaid	$2,538.78
Rate for Payer: Kaiser Permanente Medicare	$3,783.28
Rate for Payer: MDX Hawaii PPO	$4,828.66
Rate for Payer: Ohana Health Plan Medicaid	$3,783.28
Rate for Payer: Ohana Health Plan Medicare	$3,783.28
Rate for Payer: UnitedHealthcare Medicare	$3,783.28
Rate for Payer: University Health Alliance Commercial	$2,787.68

ALLOGRAFT 9X70MM FGL09070

Facility

$4,978.00

Service Code	HCPCS C1762
Hospital Revenue Code	278
Min. Negotiated Rate	$2,787.68
Max. Negotiated Rate	$4,828.66
Rate for Payer: Cash Price	$2,986.80
Rate for Payer: Hawaii Western Management Group Commercial	$3,484.60
Rate for Payer: Health Management Network Commercial	$4,231.30
Rate for Payer: Kaiser Permanente Commercial	$4,480.20
Rate for Payer: MDX Hawaii PPO	$4,828.66
Rate for Payer: University Health Alliance Commercial	$2,787.68

ALLOGRAFT DERMIS DML170

Facility

$8,836.00

Service Code	HCPCS C1763
Hospital Revenue Code	278
Min. Negotiated Rate	$4,418.00
Max. Negotiated Rate	$8,570.92
Rate for Payer: AlohaCare Medicaid	$4,418.00
Rate for Payer: AlohaCare Medicare	$6,715.36
Rate for Payer: Cash Price	$5,301.60
Rate for Payer: Devoted Health Medicare	$7,422.24
Rate for Payer: Hawaii Medical Service Association Medicare	$6,715.36
Rate for Payer: Hawaii Western Management Group Commercial	$6,185.20
Rate for Payer: Health Management Network Commercial	$7,510.60
Rate for Payer: Humana Medicare	$6,715.36
Rate for Payer: Kaiser Permanente Commercial	$7,952.40
Rate for Payer: Kaiser Permanente Medicaid	$4,506.36
Rate for Payer: Kaiser Permanente Medicare	$6,715.36
Rate for Payer: MDX Hawaii PPO	$8,570.92
Rate for Payer: Ohana Health Plan Medicaid	$6,715.36
Rate for Payer: Ohana Health Plan Medicare	$6,715.36
Rate for Payer: UnitedHealthcare Medicare	$6,715.36
Rate for Payer: University Health Alliance Commercial	$4,948.16

ALLOGRAFT DERMIS DML170

Facility

$8,836.00

Service Code	HCPCS C1763
Hospital Revenue Code	278
Min. Negotiated Rate	$4,948.16
Max. Negotiated Rate	$8,570.92
Rate for Payer: Cash Price	$5,301.60
Rate for Payer: Hawaii Western Management Group Commercial	$6,185.20
Rate for Payer: Health Management Network Commercial	$7,510.60
Rate for Payer: Kaiser Permanente Commercial	$7,952.40
Rate for Payer: MDX Hawaii PPO	$8,570.92
Rate for Payer: University Health Alliance Commercial	$4,948.16

ALLOGRAFT FGL10074

Facility

$7,040.00

Service Code	HCPCS C1762
Hospital Revenue Code	278
Min. Negotiated Rate	$3,520.00
Max. Negotiated Rate	$6,828.80
Rate for Payer: AlohaCare Medicaid	$3,520.00
Rate for Payer: AlohaCare Medicare	$5,350.40
Rate for Payer: Cash Price	$4,224.00
Rate for Payer: Devoted Health Medicare	$5,913.60
Rate for Payer: Hawaii Medical Service Association Medicare	$5,350.40
Rate for Payer: Hawaii Western Management Group Commercial	$4,928.00
Rate for Payer: Health Management Network Commercial	$5,984.00
Rate for Payer: Humana Medicare	$5,350.40
Rate for Payer: Kaiser Permanente Commercial	$6,336.00
Rate for Payer: Kaiser Permanente Medicaid	$3,590.40
Rate for Payer: Kaiser Permanente Medicare	$5,350.40
Rate for Payer: MDX Hawaii PPO	$6,828.80
Rate for Payer: Ohana Health Plan Medicaid	$5,350.40
Rate for Payer: Ohana Health Plan Medicare	$5,350.40
Rate for Payer: UnitedHealthcare Medicare	$5,350.40
Rate for Payer: University Health Alliance Commercial	$3,942.40

ALLOGRAFT FGL10074

Facility

$7,040.00

Service Code	HCPCS C1762
Hospital Revenue Code	278
Min. Negotiated Rate	$3,942.40
Max. Negotiated Rate	$6,828.80
Rate for Payer: Cash Price	$4,224.00
Rate for Payer: Hawaii Western Management Group Commercial	$4,928.00
Rate for Payer: Health Management Network Commercial	$5,984.00
Rate for Payer: Kaiser Permanente Commercial	$6,336.00
Rate for Payer: MDX Hawaii PPO	$6,828.80
Rate for Payer: University Health Alliance Commercial	$3,942.40

ALLOGRAFT GRAFTLINK FGL09065

Facility

$8,298.00

Service Code	HCPCS C1762
Hospital Revenue Code	278
Min. Negotiated Rate	$4,646.88
Max. Negotiated Rate	$8,049.06
Rate for Payer: Cash Price	$4,978.80
Rate for Payer: Hawaii Western Management Group Commercial	$5,808.60
Rate for Payer: Health Management Network Commercial	$7,053.30
Rate for Payer: Kaiser Permanente Commercial	$7,468.20
Rate for Payer: MDX Hawaii PPO	$8,049.06
Rate for Payer: University Health Alliance Commercial	$4,646.88

ALLOGRAFT GRAFTLINK FGL09065

Facility

$8,298.00

Service Code	HCPCS C1762
Hospital Revenue Code	278
Min. Negotiated Rate	$4,149.00
Max. Negotiated Rate	$8,049.06
Rate for Payer: AlohaCare Medicaid	$4,149.00
Rate for Payer: AlohaCare Medicare	$6,306.48
Rate for Payer: Cash Price	$4,978.80
Rate for Payer: Devoted Health Medicare	$6,970.32
Rate for Payer: Hawaii Medical Service Association Medicare	$6,306.48
Rate for Payer: Hawaii Western Management Group Commercial	$5,808.60
Rate for Payer: Health Management Network Commercial	$7,053.30
Rate for Payer: Humana Medicare	$6,306.48
Rate for Payer: Kaiser Permanente Commercial	$7,468.20
Rate for Payer: Kaiser Permanente Medicaid	$4,231.98
Rate for Payer: Kaiser Permanente Medicare	$6,306.48
Rate for Payer: MDX Hawaii PPO	$8,049.06
Rate for Payer: Ohana Health Plan Medicaid	$6,306.48
Rate for Payer: Ohana Health Plan Medicare	$6,306.48
Rate for Payer: UnitedHealthcare Medicare	$6,306.48
Rate for Payer: University Health Alliance Commercial	$4,646.88

ALLOGRAFT GRAFTLINK FGL09573

Facility

$4,590.00

Service Code	HCPCS C1762
Hospital Revenue Code	278
Min. Negotiated Rate	$2,570.40
Max. Negotiated Rate	$4,452.30
Rate for Payer: Cash Price	$2,754.00
Rate for Payer: Hawaii Western Management Group Commercial	$3,213.00
Rate for Payer: Health Management Network Commercial	$3,901.50
Rate for Payer: Kaiser Permanente Commercial	$4,131.00
Rate for Payer: MDX Hawaii PPO	$4,452.30
Rate for Payer: University Health Alliance Commercial	$2,570.40

ALLOGRAFT GRAFTLINK FGL09573

Facility

$4,590.00

Service Code	HCPCS C1762
Hospital Revenue Code	278
Min. Negotiated Rate	$2,295.00
Max. Negotiated Rate	$4,452.30
Rate for Payer: AlohaCare Medicaid	$2,295.00
Rate for Payer: AlohaCare Medicare	$3,488.40
Rate for Payer: Cash Price	$2,754.00
Rate for Payer: Devoted Health Medicare	$3,855.60
Rate for Payer: Hawaii Medical Service Association Medicare	$3,488.40
Rate for Payer: Hawaii Western Management Group Commercial	$3,213.00
Rate for Payer: Health Management Network Commercial	$3,901.50
Rate for Payer: Humana Medicare	$3,488.40
Rate for Payer: Kaiser Permanente Commercial	$4,131.00
Rate for Payer: Kaiser Permanente Medicaid	$2,340.90
Rate for Payer: Kaiser Permanente Medicare	$3,488.40
Rate for Payer: MDX Hawaii PPO	$4,452.30
Rate for Payer: Ohana Health Plan Medicaid	$3,488.40
Rate for Payer: Ohana Health Plan Medicare	$3,488.40
Rate for Payer: UnitedHealthcare Medicare	$3,488.40
Rate for Payer: University Health Alliance Commercial	$2,570.40

ALLOMAX GRAFT 7X10 #1180060

Facility

$4,542.00

Service Code	HCPCS C1781
Hospital Revenue Code	278
Min. Negotiated Rate	$2,543.52
Max. Negotiated Rate	$4,405.74
Rate for Payer: Cash Price	$2,725.20
Rate for Payer: Hawaii Western Management Group Commercial	$3,179.40
Rate for Payer: Health Management Network Commercial	$3,860.70
Rate for Payer: Kaiser Permanente Commercial	$4,087.80
Rate for Payer: MDX Hawaii PPO	$4,405.74
Rate for Payer: University Health Alliance Commercial	$2,543.52

ALLOMAX GRAFT 7X10 #1180060

Facility

$4,542.00

Service Code	HCPCS C1781
Hospital Revenue Code	278
Min. Negotiated Rate	$2,271.00
Max. Negotiated Rate	$4,405.74
Rate for Payer: AlohaCare Medicaid	$2,271.00
Rate for Payer: AlohaCare Medicare	$3,451.92
Rate for Payer: Cash Price	$2,725.20
Rate for Payer: Devoted Health Medicare	$3,815.28
Rate for Payer: Hawaii Medical Service Association Medicare	$3,451.92
Rate for Payer: Hawaii Western Management Group Commercial	$3,179.40
Rate for Payer: Health Management Network Commercial	$3,860.70
Rate for Payer: Humana Medicare	$3,451.92
Rate for Payer: Kaiser Permanente Commercial	$4,087.80
Rate for Payer: Kaiser Permanente Medicaid	$2,316.42
Rate for Payer: Kaiser Permanente Medicare	$3,451.92
Rate for Payer: MDX Hawaii PPO	$4,405.74
Rate for Payer: Ohana Health Plan Medicaid	$3,451.92
Rate for Payer: Ohana Health Plan Medicare	$3,451.92
Rate for Payer: UnitedHealthcare Medicare	$3,451.92
Rate for Payer: University Health Alliance Commercial	$2,543.52

ALLOPURINOL 100 MG TABLET [310]

Facility

$2.00

Service Code	NDC 60687067701
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

ALLOPURINOL 100 MG TABLET [310]

Facility

$2.00

Service Code	NDC 00904704161
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

ALLOPURINOL 100 MG TABLET [310]

Facility

$2.00

Service Code	NDC 60687067711
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

ALLOPURINOL 100 MG TABLET [310]

Facility

$2.00

Service Code	NDC 60687067711
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

ALLOPURINOL 100 MG TABLET [310]

Facility

$2.00

Service Code	NDC 00904704161
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

ALLOPURINOL 100 MG TABLET [310]

Facility

$2.00

Service Code	NDC 60687067701
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

ALLOPURINOL 300 MG TABLET [311]

Facility

$4.00

Service Code	NDC 60687068801
Hospital Revenue Code	637
Min. Negotiated Rate	$2.00
Max. Negotiated Rate	$3.88
Rate for Payer: AlohaCare Medicaid	$2.00
Rate for Payer: AlohaCare Medicare	$3.04
Rate for Payer: Cash Price	$2.40
Rate for Payer: Devoted Health Medicare	$3.36
Rate for Payer: Hawaii Medical Service Association Medicare	$3.04
Rate for Payer: Hawaii Western Management Group Commercial	$3.80
Rate for Payer: Health Management Network Commercial	$3.40
Rate for Payer: Humana Medicare	$3.04
Rate for Payer: Kaiser Permanente Commercial	$3.60
Rate for Payer: Kaiser Permanente Medicaid	$2.04
Rate for Payer: Kaiser Permanente Medicare	$3.04
Rate for Payer: MDX Hawaii PPO	$3.88
Rate for Payer: Ohana Health Plan Medicaid	$3.04
Rate for Payer: Ohana Health Plan Medicare	$3.04
Rate for Payer: UnitedHealthcare Medicare	$3.04
Rate for Payer: University Health Alliance Commercial	$2.92

ALLOPURINOL 300 MG TABLET [311]

Facility

$3.00

Service Code	NDC 00904657261
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

ALLOPURINOL 300 MG TABLET [311]

Facility

$3.00

Service Code	NDC 00904657261
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

ALLOPURINOL 300 MG TABLET [311]

Facility

$4.00

Service Code	NDC 60687068801
Hospital Revenue Code	250
Min. Negotiated Rate	$3.40
Max. Negotiated Rate	$3.88
Rate for Payer: Cash Price	$2.40
Rate for Payer: Health Management Network Commercial	$3.40
Rate for Payer: Kaiser Permanente Commercial	$3.60
Rate for Payer: MDX Hawaii PPO	$3.88

ALLOPURINOL 300 MG TABLET [311]

Facility

$4.00

Service Code	NDC 60687068811
Hospital Revenue Code	637
Min. Negotiated Rate	$2.00
Max. Negotiated Rate	$3.88
Rate for Payer: AlohaCare Medicaid	$2.00
Rate for Payer: AlohaCare Medicare	$3.04
Rate for Payer: Cash Price	$2.40
Rate for Payer: Devoted Health Medicare	$3.36
Rate for Payer: Hawaii Medical Service Association Medicare	$3.04
Rate for Payer: Hawaii Western Management Group Commercial	$3.80
Rate for Payer: Health Management Network Commercial	$3.40
Rate for Payer: Humana Medicare	$3.04
Rate for Payer: Kaiser Permanente Commercial	$3.60
Rate for Payer: Kaiser Permanente Medicaid	$2.04
Rate for Payer: Kaiser Permanente Medicare	$3.04
Rate for Payer: MDX Hawaii PPO	$3.88
Rate for Payer: Ohana Health Plan Medicaid	$3.04
Rate for Payer: Ohana Health Plan Medicare	$3.04
Rate for Payer: UnitedHealthcare Medicare	$3.04
Rate for Payer: University Health Alliance Commercial	$2.92

ALLOPURINOL 300 MG TABLET [311]

Facility

$4.00

Service Code	NDC 60687068811
Hospital Revenue Code	250
Min. Negotiated Rate	$3.40
Max. Negotiated Rate	$3.88
Rate for Payer: Cash Price	$2.40
Rate for Payer: Health Management Network Commercial	$3.40
Rate for Payer: Kaiser Permanente Commercial	$3.60
Rate for Payer: MDX Hawaii PPO	$3.88

Know your out-of-pocket cost for care.

All Charges