Honoka'a Hospital and Skilled Nursing Facility

All Charges

Charge

Type

Setting

Price

DIPHTH,PERTUSSIS(ACEL),TETANUS 2.5 LF UNIT-8 MCG-5 LF/0.5ML IM SYRINGE [180683]

Facility

$88.00

Service Code	HCPCS 90715
Hospital Revenue Code	636
Min. Negotiated Rate	$38.63
Max. Negotiated Rate	$85.36
Rate for Payer: AlohaCare Medicaid	$44.00
Rate for Payer: AlohaCare Medicare	$66.88
Rate for Payer: Cash Price	$52.80
Rate for Payer: Cash Price	$52.80
Rate for Payer: Devoted Health Medicare	$73.92
Rate for Payer: Hawaii Medical Service Association ABD	$38.63
Rate for Payer: Hawaii Medical Service Association Medicare	$66.88
Rate for Payer: Hawaii Medical Service Association Non-ABD	$38.63
Rate for Payer: Hawaii Western Management Group Commercial	$83.60
Rate for Payer: Health Management Network Commercial	$74.80
Rate for Payer: Humana Medicare	$66.88
Rate for Payer: Kaiser Permanente Commercial	$79.20
Rate for Payer: Kaiser Permanente Medicaid	$44.88
Rate for Payer: Kaiser Permanente Medicare	$66.88
Rate for Payer: MDX Hawaii PPO	$85.36
Rate for Payer: Ohana Health Plan Medicaid	$66.88
Rate for Payer: Ohana Health Plan Medicare	$66.88
Rate for Payer: UnitedHealthcare Medicaid	$52.80
Rate for Payer: UnitedHealthcare Medicare	$66.88
Rate for Payer: University Health Alliance Commercial	$64.14

DIPHTH,PERTUSSIS(ACEL),TETANUS 2.5 LF UNIT-8 MCG-5 LF/0.5ML IM SYRINGE [180683]

Facility

$88.00

Service Code	HCPCS 90715
Hospital Revenue Code	250
Min. Negotiated Rate	$74.80
Max. Negotiated Rate	$85.36
Rate for Payer: Cash Price	$52.80
Rate for Payer: Health Management Network Commercial	$74.80
Rate for Payer: Kaiser Permanente Commercial	$79.20
Rate for Payer: MDX Hawaii PPO	$85.36

DIP-PERT-TET-POLIO-HIB(PF) 15 LF-20 MCG-5 LF-62 DU-10MCG/0.5 ML IM KIT [209491]

Facility

$215.00

Service Code	NDC 49281051105
Hospital Revenue Code	250
Min. Negotiated Rate	$182.75
Max. Negotiated Rate	$208.55
Rate for Payer: Cash Price	$129.00
Rate for Payer: Health Management Network Commercial	$182.75
Rate for Payer: Kaiser Permanente Commercial	$193.50
Rate for Payer: MDX Hawaii PPO	$208.55

DISORDERS OF LIVER EXCEPT MALIGNANCY, CIRRHOSIS OR ALCOHOLIC HEPATITIS WITH CC

Facility

$31,926.59

Service Code	MSDRG 442
Min. Negotiated Rate	$31,926.59
Max. Negotiated Rate	$31,926.59
Rate for Payer: Hawaii Medical Service Association Commercial	$31,926.59

DISORDERS OF LIVER EXCEPT MALIGNANCY, CIRRHOSIS OR ALCOHOLIC HEPATITIS WITH MCC

Facility

$31,926.59

Service Code	MSDRG 441
Min. Negotiated Rate	$31,926.59
Max. Negotiated Rate	$31,926.59
Rate for Payer: Hawaii Medical Service Association Commercial	$31,926.59

DISORDERS OF LIVER EXCEPT MALIGNANCY, CIRRHOSIS OR ALCOHOLIC HEPATITIS WITHOUT CC/MCC

Facility

$23,085.75

Service Code	MSDRG 443
Min. Negotiated Rate	$23,085.75
Max. Negotiated Rate	$23,085.75
Rate for Payer: Hawaii Medical Service Association Commercial	$23,085.75

DISORDERS OF PANCREAS EXCEPT MALIGNANCY WITH CC

Facility

$24,958.21

Service Code	MSDRG 439
Min. Negotiated Rate	$24,958.21
Max. Negotiated Rate	$24,958.21
Rate for Payer: Hawaii Medical Service Association Commercial	$24,958.21

DISORDERS OF PANCREAS EXCEPT MALIGNANCY WITH MCC

Facility

$24,958.21

Service Code	MSDRG 438
Min. Negotiated Rate	$24,958.21
Max. Negotiated Rate	$24,958.21
Rate for Payer: Hawaii Medical Service Association Commercial	$24,958.21

DISORDERS OF PANCREAS EXCEPT MALIGNANCY WITHOUT CC/MCC

Facility

$24,958.21

Service Code	MSDRG 440
Min. Negotiated Rate	$24,958.21
Max. Negotiated Rate	$24,958.21
Rate for Payer: Hawaii Medical Service Association Commercial	$24,958.21

DISORDERS OF PERSONALITY AND IMPULSE CONTROL

Facility

$21,118.48

Service Code	MSDRG 883
Min. Negotiated Rate	$21,118.48
Max. Negotiated Rate	$21,118.48
Rate for Payer: Hawaii Medical Service Association Commercial	$21,118.48

DISORDERS OF THE BILIARY TRACT WITH CC

Facility

$25,124.12

Service Code	MSDRG 445
Min. Negotiated Rate	$25,124.12
Max. Negotiated Rate	$25,124.12
Rate for Payer: Hawaii Medical Service Association Commercial	$25,124.12

DISORDERS OF THE BILIARY TRACT WITH MCC

Facility

$25,645.56

Service Code	MSDRG 444
Min. Negotiated Rate	$25,645.56
Max. Negotiated Rate	$25,645.56
Rate for Payer: Hawaii Medical Service Association Commercial	$25,645.56

DISORDERS OF THE BILIARY TRACT WITHOUT CC/MCC

Facility

$16,567.70

Service Code	MSDRG 446
Min. Negotiated Rate	$16,567.70
Max. Negotiated Rate	$16,567.70
Rate for Payer: Hawaii Medical Service Association Commercial	$16,567.70

DISP INSTR KIT MINI AR-1322DSC

Facility

$689.00

Hospital Revenue Code	272
Min. Negotiated Rate	$585.65
Max. Negotiated Rate	$668.33
Rate for Payer: Cash Price	$413.40
Rate for Payer: Health Management Network Commercial	$585.65
Rate for Payer: Kaiser Permanente Commercial	$620.10
Rate for Payer: MDX Hawaii PPO	$668.33

DISP INSTR KIT MINI AR-1322DSC

Facility

$689.00

Hospital Revenue Code	272
Min. Negotiated Rate	$344.50
Max. Negotiated Rate	$668.33
Rate for Payer: AlohaCare Medicaid	$344.50
Rate for Payer: AlohaCare Medicare	$523.64
Rate for Payer: Cash Price	$413.40
Rate for Payer: Devoted Health Medicare	$578.76
Rate for Payer: Hawaii Medical Service Association Medicare	$523.64
Rate for Payer: Hawaii Western Management Group Commercial	$654.55
Rate for Payer: Health Management Network Commercial	$585.65
Rate for Payer: Humana Medicare	$523.64
Rate for Payer: Kaiser Permanente Commercial	$620.10
Rate for Payer: Kaiser Permanente Medicaid	$351.39
Rate for Payer: Kaiser Permanente Medicare	$523.64
Rate for Payer: MDX Hawaii PPO	$668.33
Rate for Payer: Ohana Health Plan Medicaid	$523.64
Rate for Payer: Ohana Health Plan Medicare	$523.64
Rate for Payer: UnitedHealthcare Medicare	$523.64
Rate for Payer: University Health Alliance Commercial	$502.21

DISP INTR KIT SM AR-8934DSC

Facility

$780.00

Hospital Revenue Code	272
Min. Negotiated Rate	$390.00
Max. Negotiated Rate	$756.60
Rate for Payer: AlohaCare Medicaid	$390.00
Rate for Payer: AlohaCare Medicare	$592.80
Rate for Payer: Cash Price	$468.00
Rate for Payer: Devoted Health Medicare	$655.20
Rate for Payer: Hawaii Medical Service Association Medicare	$592.80
Rate for Payer: Hawaii Western Management Group Commercial	$741.00
Rate for Payer: Health Management Network Commercial	$663.00
Rate for Payer: Humana Medicare	$592.80
Rate for Payer: Kaiser Permanente Commercial	$702.00
Rate for Payer: Kaiser Permanente Medicaid	$397.80
Rate for Payer: Kaiser Permanente Medicare	$592.80
Rate for Payer: MDX Hawaii PPO	$756.60
Rate for Payer: Ohana Health Plan Medicaid	$592.80
Rate for Payer: Ohana Health Plan Medicare	$592.80
Rate for Payer: UnitedHealthcare Medicare	$592.80
Rate for Payer: University Health Alliance Commercial	$568.54

DISP INTR KIT SM AR-8934DSC

Facility

$780.00

Hospital Revenue Code	272
Min. Negotiated Rate	$663.00
Max. Negotiated Rate	$756.60
Rate for Payer: Cash Price	$468.00
Rate for Payer: Health Management Network Commercial	$663.00
Rate for Payer: Kaiser Permanente Commercial	$702.00
Rate for Payer: MDX Hawaii PPO	$756.60

DISPOSABLE FACK MASK 7210559

Facility

$149.00

Hospital Revenue Code	272
Min. Negotiated Rate	$126.65
Max. Negotiated Rate	$144.53
Rate for Payer: Cash Price	$89.40
Rate for Payer: Health Management Network Commercial	$126.65
Rate for Payer: Kaiser Permanente Commercial	$134.10
Rate for Payer: MDX Hawaii PPO	$144.53

DISPOSABLE FACK MASK 7210559

Facility

$149.00

Hospital Revenue Code	272
Min. Negotiated Rate	$74.50
Max. Negotiated Rate	$144.53
Rate for Payer: AlohaCare Medicaid	$74.50
Rate for Payer: AlohaCare Medicare	$113.24
Rate for Payer: Cash Price	$89.40
Rate for Payer: Devoted Health Medicare	$125.16
Rate for Payer: Hawaii Medical Service Association Medicare	$113.24
Rate for Payer: Hawaii Western Management Group Commercial	$141.55
Rate for Payer: Health Management Network Commercial	$126.65
Rate for Payer: Humana Medicare	$113.24
Rate for Payer: Kaiser Permanente Commercial	$134.10
Rate for Payer: Kaiser Permanente Medicaid	$75.99
Rate for Payer: Kaiser Permanente Medicare	$113.24
Rate for Payer: MDX Hawaii PPO	$144.53
Rate for Payer: Ohana Health Plan Medicaid	$113.24
Rate for Payer: Ohana Health Plan Medicare	$113.24
Rate for Payer: UnitedHealthcare Medicare	$113.24
Rate for Payer: University Health Alliance Commercial	$108.61

DISPSABLE KIT, HIP 1.8MM DRILL

Facility

$1,050.00

Hospital Revenue Code	272
Min. Negotiated Rate	$525.00
Max. Negotiated Rate	$1,018.50
Rate for Payer: AlohaCare Medicaid	$525.00
Rate for Payer: AlohaCare Medicare	$798.00
Rate for Payer: Cash Price	$630.00
Rate for Payer: Devoted Health Medicare	$882.00
Rate for Payer: Hawaii Medical Service Association Medicare	$798.00
Rate for Payer: Hawaii Western Management Group Commercial	$997.50
Rate for Payer: Health Management Network Commercial	$892.50
Rate for Payer: Humana Medicare	$798.00
Rate for Payer: Kaiser Permanente Commercial	$945.00
Rate for Payer: Kaiser Permanente Medicaid	$535.50
Rate for Payer: Kaiser Permanente Medicare	$798.00
Rate for Payer: MDX Hawaii PPO	$1,018.50
Rate for Payer: Ohana Health Plan Medicaid	$798.00
Rate for Payer: Ohana Health Plan Medicare	$798.00
Rate for Payer: UnitedHealthcare Medicare	$798.00
Rate for Payer: University Health Alliance Commercial	$765.35

DISPSABLE KIT, HIP 1.8MM DRILL

Facility

$1,050.00

Hospital Revenue Code	272
Min. Negotiated Rate	$892.50
Max. Negotiated Rate	$1,018.50
Rate for Payer: Cash Price	$630.00
Rate for Payer: Health Management Network Commercial	$892.50
Rate for Payer: Kaiser Permanente Commercial	$945.00
Rate for Payer: MDX Hawaii PPO	$1,018.50

DISSECTOR 3.0MMX7CM AR-7300DS

Facility

$264.00

Hospital Revenue Code	272
Min. Negotiated Rate	$132.00
Max. Negotiated Rate	$256.08
Rate for Payer: AlohaCare Medicaid	$132.00
Rate for Payer: AlohaCare Medicare	$200.64
Rate for Payer: Cash Price	$158.40
Rate for Payer: Devoted Health Medicare	$221.76
Rate for Payer: Hawaii Medical Service Association Medicare	$200.64
Rate for Payer: Hawaii Western Management Group Commercial	$250.80
Rate for Payer: Health Management Network Commercial	$224.40
Rate for Payer: Humana Medicare	$200.64
Rate for Payer: Kaiser Permanente Commercial	$237.60
Rate for Payer: Kaiser Permanente Medicaid	$134.64
Rate for Payer: Kaiser Permanente Medicare	$200.64
Rate for Payer: MDX Hawaii PPO	$256.08
Rate for Payer: Ohana Health Plan Medicaid	$200.64
Rate for Payer: Ohana Health Plan Medicare	$200.64
Rate for Payer: UnitedHealthcare Medicare	$200.64
Rate for Payer: University Health Alliance Commercial	$192.43

DISSECTOR 3.0MMX7CM AR-7300DS

Facility

$264.00

Hospital Revenue Code	272
Min. Negotiated Rate	$224.40
Max. Negotiated Rate	$256.08
Rate for Payer: Cash Price	$158.40
Rate for Payer: Health Management Network Commercial	$224.40
Rate for Payer: Kaiser Permanente Commercial	$237.60
Rate for Payer: MDX Hawaii PPO	$256.08

DISSECTOR 3.5MMX13C AR-8350DS

Facility

$208.00

Hospital Revenue Code	272
Min. Negotiated Rate	$104.00
Max. Negotiated Rate	$201.76
Rate for Payer: AlohaCare Medicaid	$104.00
Rate for Payer: AlohaCare Medicare	$158.08
Rate for Payer: Cash Price	$124.80
Rate for Payer: Devoted Health Medicare	$174.72
Rate for Payer: Hawaii Medical Service Association Medicare	$158.08
Rate for Payer: Hawaii Western Management Group Commercial	$197.60
Rate for Payer: Health Management Network Commercial	$176.80
Rate for Payer: Humana Medicare	$158.08
Rate for Payer: Kaiser Permanente Commercial	$187.20
Rate for Payer: Kaiser Permanente Medicaid	$106.08
Rate for Payer: Kaiser Permanente Medicare	$158.08
Rate for Payer: MDX Hawaii PPO	$201.76
Rate for Payer: Ohana Health Plan Medicaid	$158.08
Rate for Payer: Ohana Health Plan Medicare	$158.08
Rate for Payer: UnitedHealthcare Medicare	$158.08
Rate for Payer: University Health Alliance Commercial	$151.61

DISSECTOR 3.5MMX13C AR-8350DS

Facility

$208.00

Hospital Revenue Code	272
Min. Negotiated Rate	$176.80
Max. Negotiated Rate	$201.76
Rate for Payer: Cash Price	$124.80
Rate for Payer: Health Management Network Commercial	$176.80
Rate for Payer: Kaiser Permanente Commercial	$187.20
Rate for Payer: MDX Hawaii PPO	$201.76

Know your out-of-pocket cost for care.

All Charges