Honoka'a Hospital and Skilled Nursing Facility

All Charges

Charge

Type

Setting

Price

DOXYCYCLINE HYCLATE 100 MG INTRAVENOUS POWDER FOR SOLUTION [2622]

Facility

$79.00

Service Code	HCPCS J1271
Hospital Revenue Code	250
Min. Negotiated Rate	$67.15
Max. Negotiated Rate	$76.63
Rate for Payer: Cash Price	$47.40
Rate for Payer: Health Management Network Commercial	$67.15
Rate for Payer: Kaiser Permanente Commercial	$71.10
Rate for Payer: MDX Hawaii PPO	$76.63

DOXYCYCLINE HYCLATE 100 MG TABLET [2625]

Facility

$20.00

Service Code	NDC 62584069321
Hospital Revenue Code	637
Min. Negotiated Rate	$10.00
Max. Negotiated Rate	$19.40
Rate for Payer: AlohaCare Medicaid	$10.00
Rate for Payer: AlohaCare Medicare	$15.20
Rate for Payer: Cash Price	$12.00
Rate for Payer: Devoted Health Medicare	$16.80
Rate for Payer: Hawaii Medical Service Association Medicare	$15.20
Rate for Payer: Hawaii Western Management Group Commercial	$19.00
Rate for Payer: Health Management Network Commercial	$17.00
Rate for Payer: Humana Medicare	$15.20
Rate for Payer: Kaiser Permanente Commercial	$18.00
Rate for Payer: Kaiser Permanente Medicaid	$10.20
Rate for Payer: Kaiser Permanente Medicare	$15.20
Rate for Payer: MDX Hawaii PPO	$19.40
Rate for Payer: Ohana Health Plan Medicaid	$15.20
Rate for Payer: Ohana Health Plan Medicare	$15.20
Rate for Payer: UnitedHealthcare Medicare	$15.20
Rate for Payer: University Health Alliance Commercial	$14.58

DOXYCYCLINE HYCLATE 100 MG TABLET [2625]

Facility

$20.00

Service Code	NDC 62584069311
Hospital Revenue Code	637
Min. Negotiated Rate	$10.00
Max. Negotiated Rate	$19.40
Rate for Payer: AlohaCare Medicaid	$10.00
Rate for Payer: AlohaCare Medicare	$15.20
Rate for Payer: Cash Price	$12.00
Rate for Payer: Devoted Health Medicare	$16.80
Rate for Payer: Hawaii Medical Service Association Medicare	$15.20
Rate for Payer: Hawaii Western Management Group Commercial	$19.00
Rate for Payer: Health Management Network Commercial	$17.00
Rate for Payer: Humana Medicare	$15.20
Rate for Payer: Kaiser Permanente Commercial	$18.00
Rate for Payer: Kaiser Permanente Medicaid	$10.20
Rate for Payer: Kaiser Permanente Medicare	$15.20
Rate for Payer: MDX Hawaii PPO	$19.40
Rate for Payer: Ohana Health Plan Medicaid	$15.20
Rate for Payer: Ohana Health Plan Medicare	$15.20
Rate for Payer: UnitedHealthcare Medicare	$15.20
Rate for Payer: University Health Alliance Commercial	$14.58

DOXYCYCLINE HYCLATE 100 MG TABLET [2625]

Facility

$20.00

Service Code	NDC 62584069321
Hospital Revenue Code	250
Min. Negotiated Rate	$17.00
Max. Negotiated Rate	$19.40
Rate for Payer: Cash Price	$12.00
Rate for Payer: Health Management Network Commercial	$17.00
Rate for Payer: Kaiser Permanente Commercial	$18.00
Rate for Payer: MDX Hawaii PPO	$19.40

DOXYCYCLINE HYCLATE 100 MG TABLET [2625]

Facility

$20.00

Service Code	NDC 62584069311
Hospital Revenue Code	250
Min. Negotiated Rate	$17.00
Max. Negotiated Rate	$19.40
Rate for Payer: Cash Price	$12.00
Rate for Payer: Health Management Network Commercial	$17.00
Rate for Payer: Kaiser Permanente Commercial	$18.00
Rate for Payer: MDX Hawaii PPO	$19.40

DOXYCYCLINE HYCLATE TABLETS (VIBRAMYCIN) 100 MG (TAKE HOME) [4080357]

Facility

$15.00

Service Code	NDC 00004080145
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

DOXYCYCLINE HYCLATE TABLETS (VIBRAMYCIN) 100 MG (TAKE HOME) [4080357]

Facility

$15.00

Service Code	NDC 00004080145
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

DRAIN BLAKE FLAT 10MM

Facility

$111.00

Hospital Revenue Code	272
Min. Negotiated Rate	$94.35
Max. Negotiated Rate	$107.67
Rate for Payer: Cash Price	$66.60
Rate for Payer: Health Management Network Commercial	$94.35
Rate for Payer: Kaiser Permanente Commercial	$99.90
Rate for Payer: MDX Hawaii PPO	$107.67

DRAIN BLAKE FLAT 10MM

Facility

$111.00

Hospital Revenue Code	272
Min. Negotiated Rate	$55.50
Max. Negotiated Rate	$107.67
Rate for Payer: AlohaCare Medicaid	$55.50
Rate for Payer: AlohaCare Medicare	$84.36
Rate for Payer: Cash Price	$66.60
Rate for Payer: Devoted Health Medicare	$93.24
Rate for Payer: Hawaii Medical Service Association Medicare	$84.36
Rate for Payer: Hawaii Western Management Group Commercial	$105.45
Rate for Payer: Health Management Network Commercial	$94.35
Rate for Payer: Humana Medicare	$84.36
Rate for Payer: Kaiser Permanente Commercial	$99.90
Rate for Payer: Kaiser Permanente Medicaid	$56.61
Rate for Payer: Kaiser Permanente Medicare	$84.36
Rate for Payer: MDX Hawaii PPO	$107.67
Rate for Payer: Ohana Health Plan Medicaid	$84.36
Rate for Payer: Ohana Health Plan Medicare	$84.36
Rate for Payer: UnitedHealthcare Medicare	$84.36
Rate for Payer: University Health Alliance Commercial	$80.91

DRAIN BLAKE RND 10FR

Facility

$117.00

Hospital Revenue Code	272
Min. Negotiated Rate	$99.45
Max. Negotiated Rate	$113.49
Rate for Payer: Cash Price	$70.20
Rate for Payer: Health Management Network Commercial	$99.45
Rate for Payer: Kaiser Permanente Commercial	$105.30
Rate for Payer: MDX Hawaii PPO	$113.49

DRAIN BLAKE RND 10FR

Facility

$117.00

Hospital Revenue Code	272
Min. Negotiated Rate	$58.50
Max. Negotiated Rate	$113.49
Rate for Payer: AlohaCare Medicaid	$58.50
Rate for Payer: AlohaCare Medicare	$88.92
Rate for Payer: Cash Price	$70.20
Rate for Payer: Devoted Health Medicare	$98.28
Rate for Payer: Hawaii Medical Service Association Medicare	$88.92
Rate for Payer: Hawaii Western Management Group Commercial	$111.15
Rate for Payer: Health Management Network Commercial	$99.45
Rate for Payer: Humana Medicare	$88.92
Rate for Payer: Kaiser Permanente Commercial	$105.30
Rate for Payer: Kaiser Permanente Medicaid	$59.67
Rate for Payer: Kaiser Permanente Medicare	$88.92
Rate for Payer: MDX Hawaii PPO	$113.49
Rate for Payer: Ohana Health Plan Medicaid	$88.92
Rate for Payer: Ohana Health Plan Medicare	$88.92
Rate for Payer: UnitedHealthcare Medicare	$88.92
Rate for Payer: University Health Alliance Commercial	$85.28

DRAIN BLAKE RND 15FR

Facility

$116.00

Hospital Revenue Code	272
Min. Negotiated Rate	$58.00
Max. Negotiated Rate	$112.52
Rate for Payer: AlohaCare Medicaid	$58.00
Rate for Payer: AlohaCare Medicare	$88.16
Rate for Payer: Cash Price	$69.60
Rate for Payer: Devoted Health Medicare	$97.44
Rate for Payer: Hawaii Medical Service Association Medicare	$88.16
Rate for Payer: Hawaii Western Management Group Commercial	$110.20
Rate for Payer: Health Management Network Commercial	$98.60
Rate for Payer: Humana Medicare	$88.16
Rate for Payer: Kaiser Permanente Commercial	$104.40
Rate for Payer: Kaiser Permanente Medicaid	$59.16
Rate for Payer: Kaiser Permanente Medicare	$88.16
Rate for Payer: MDX Hawaii PPO	$112.52
Rate for Payer: Ohana Health Plan Medicaid	$88.16
Rate for Payer: Ohana Health Plan Medicare	$88.16
Rate for Payer: UnitedHealthcare Medicare	$88.16
Rate for Payer: University Health Alliance Commercial	$84.55

DRAIN BLAKE RND 15FR

Facility

$116.00

Hospital Revenue Code	272
Min. Negotiated Rate	$98.60
Max. Negotiated Rate	$112.52
Rate for Payer: Cash Price	$69.60
Rate for Payer: Health Management Network Commercial	$98.60
Rate for Payer: Kaiser Permanente Commercial	$104.40
Rate for Payer: MDX Hawaii PPO	$112.52

DRAIN FLUTED ROUND 19FR

Facility

$106.00

Hospital Revenue Code	272
Min. Negotiated Rate	$53.00
Max. Negotiated Rate	$102.82
Rate for Payer: AlohaCare Medicaid	$53.00
Rate for Payer: AlohaCare Medicare	$80.56
Rate for Payer: Cash Price	$63.60
Rate for Payer: Devoted Health Medicare	$89.04
Rate for Payer: Hawaii Medical Service Association Medicare	$80.56
Rate for Payer: Hawaii Western Management Group Commercial	$100.70
Rate for Payer: Health Management Network Commercial	$90.10
Rate for Payer: Humana Medicare	$80.56
Rate for Payer: Kaiser Permanente Commercial	$95.40
Rate for Payer: Kaiser Permanente Medicaid	$54.06
Rate for Payer: Kaiser Permanente Medicare	$80.56
Rate for Payer: MDX Hawaii PPO	$102.82
Rate for Payer: Ohana Health Plan Medicaid	$80.56
Rate for Payer: Ohana Health Plan Medicare	$80.56
Rate for Payer: UnitedHealthcare Medicare	$80.56
Rate for Payer: University Health Alliance Commercial	$77.26

DRAIN FLUTED ROUND 19FR

Facility

$106.00

Hospital Revenue Code	272
Min. Negotiated Rate	$90.10
Max. Negotiated Rate	$102.82
Rate for Payer: Cash Price	$63.60
Rate for Payer: Health Management Network Commercial	$90.10
Rate for Payer: Kaiser Permanente Commercial	$95.40
Rate for Payer: MDX Hawaii PPO	$102.82

DRAIN RND HUBLESS 28FR

Facility

$146.00

Hospital Revenue Code	272
Min. Negotiated Rate	$73.00
Max. Negotiated Rate	$141.62
Rate for Payer: AlohaCare Medicaid	$73.00
Rate for Payer: AlohaCare Medicare	$110.96
Rate for Payer: Cash Price	$87.60
Rate for Payer: Devoted Health Medicare	$122.64
Rate for Payer: Hawaii Medical Service Association Medicare	$110.96
Rate for Payer: Hawaii Western Management Group Commercial	$138.70
Rate for Payer: Health Management Network Commercial	$124.10
Rate for Payer: Humana Medicare	$110.96
Rate for Payer: Kaiser Permanente Commercial	$131.40
Rate for Payer: Kaiser Permanente Medicaid	$74.46
Rate for Payer: Kaiser Permanente Medicare	$110.96
Rate for Payer: MDX Hawaii PPO	$141.62
Rate for Payer: Ohana Health Plan Medicaid	$110.96
Rate for Payer: Ohana Health Plan Medicare	$110.96
Rate for Payer: UnitedHealthcare Medicare	$110.96
Rate for Payer: University Health Alliance Commercial	$106.42

DRAIN RND HUBLESS 28FR

Facility

$146.00

Hospital Revenue Code	272
Min. Negotiated Rate	$124.10
Max. Negotiated Rate	$141.62
Rate for Payer: Cash Price	$87.60
Rate for Payer: Health Management Network Commercial	$124.10
Rate for Payer: Kaiser Permanente Commercial	$131.40
Rate for Payer: MDX Hawaii PPO	$141.62

DRAIN T-TUBE 12FR SU130-1238

Facility

$938.00

Service Code	HCPCS C1729
Hospital Revenue Code	272
Min. Negotiated Rate	$469.00
Max. Negotiated Rate	$909.86
Rate for Payer: AlohaCare Medicaid	$469.00
Rate for Payer: AlohaCare Medicare	$712.88
Rate for Payer: Cash Price	$562.80
Rate for Payer: Devoted Health Medicare	$787.92
Rate for Payer: Hawaii Medical Service Association Medicare	$712.88
Rate for Payer: Hawaii Western Management Group Commercial	$891.10
Rate for Payer: Health Management Network Commercial	$797.30
Rate for Payer: Humana Medicare	$712.88
Rate for Payer: Kaiser Permanente Commercial	$844.20
Rate for Payer: Kaiser Permanente Medicaid	$478.38
Rate for Payer: Kaiser Permanente Medicare	$712.88
Rate for Payer: MDX Hawaii PPO	$909.86
Rate for Payer: Ohana Health Plan Medicaid	$712.88
Rate for Payer: Ohana Health Plan Medicare	$712.88
Rate for Payer: UnitedHealthcare Medicare	$712.88
Rate for Payer: University Health Alliance Commercial	$683.71

DRAIN T-TUBE 12FR SU130-1238

Facility

$938.00

Service Code	HCPCS C1729
Hospital Revenue Code	272
Min. Negotiated Rate	$797.30
Max. Negotiated Rate	$909.86
Rate for Payer: Cash Price	$562.80
Rate for Payer: Health Management Network Commercial	$797.30
Rate for Payer: Kaiser Permanente Commercial	$844.20
Rate for Payer: MDX Hawaii PPO	$909.86

DRAIN T-TUBE 14FR

Facility

$938.00

Service Code	HCPCS A4649
Hospital Revenue Code	272
Min. Negotiated Rate	$469.00
Max. Negotiated Rate	$909.86
Rate for Payer: AlohaCare Medicaid	$469.00
Rate for Payer: AlohaCare Medicare	$712.88
Rate for Payer: Cash Price	$562.80
Rate for Payer: Devoted Health Medicare	$787.92
Rate for Payer: Hawaii Medical Service Association Medicare	$712.88
Rate for Payer: Hawaii Western Management Group Commercial	$891.10
Rate for Payer: Health Management Network Commercial	$797.30
Rate for Payer: Humana Medicare	$712.88
Rate for Payer: Kaiser Permanente Commercial	$844.20
Rate for Payer: Kaiser Permanente Medicaid	$478.38
Rate for Payer: Kaiser Permanente Medicare	$712.88
Rate for Payer: MDX Hawaii PPO	$909.86
Rate for Payer: Ohana Health Plan Medicaid	$712.88
Rate for Payer: Ohana Health Plan Medicare	$712.88
Rate for Payer: UnitedHealthcare Medicare	$712.88
Rate for Payer: University Health Alliance Commercial	$683.71

DRAIN T-TUBE 14FR

Facility

$938.00

Service Code	HCPCS A4649
Hospital Revenue Code	272
Min. Negotiated Rate	$797.30
Max. Negotiated Rate	$909.86
Rate for Payer: Cash Price	$562.80
Rate for Payer: Health Management Network Commercial	$797.30
Rate for Payer: Kaiser Permanente Commercial	$844.20
Rate for Payer: MDX Hawaii PPO	$909.86

DRAIN T-TUBE 16FR

Facility

$938.00

Service Code	HCPCS C1729
Hospital Revenue Code	272
Min. Negotiated Rate	$469.00
Max. Negotiated Rate	$909.86
Rate for Payer: AlohaCare Medicaid	$469.00
Rate for Payer: AlohaCare Medicare	$712.88
Rate for Payer: Cash Price	$562.80
Rate for Payer: Devoted Health Medicare	$787.92
Rate for Payer: Hawaii Medical Service Association Medicare	$712.88
Rate for Payer: Hawaii Western Management Group Commercial	$891.10
Rate for Payer: Health Management Network Commercial	$797.30
Rate for Payer: Humana Medicare	$712.88
Rate for Payer: Kaiser Permanente Commercial	$844.20
Rate for Payer: Kaiser Permanente Medicaid	$478.38
Rate for Payer: Kaiser Permanente Medicare	$712.88
Rate for Payer: MDX Hawaii PPO	$909.86
Rate for Payer: Ohana Health Plan Medicaid	$712.88
Rate for Payer: Ohana Health Plan Medicare	$712.88
Rate for Payer: UnitedHealthcare Medicare	$712.88
Rate for Payer: University Health Alliance Commercial	$683.71

DRAIN T-TUBE 16FR

Facility

$938.00

Service Code	HCPCS C1729
Hospital Revenue Code	272
Min. Negotiated Rate	$797.30
Max. Negotiated Rate	$909.86
Rate for Payer: Cash Price	$562.80
Rate for Payer: Health Management Network Commercial	$797.30
Rate for Payer: Kaiser Permanente Commercial	$844.20
Rate for Payer: MDX Hawaii PPO	$909.86

DRAIN VALVE HEIMLICK CHEST

Facility

$195.00

Hospital Revenue Code	272
Min. Negotiated Rate	$97.50
Max. Negotiated Rate	$189.15
Rate for Payer: AlohaCare Medicaid	$97.50
Rate for Payer: AlohaCare Medicare	$148.20
Rate for Payer: Cash Price	$117.00
Rate for Payer: Devoted Health Medicare	$163.80
Rate for Payer: Hawaii Medical Service Association Medicare	$148.20
Rate for Payer: Hawaii Western Management Group Commercial	$185.25
Rate for Payer: Health Management Network Commercial	$165.75
Rate for Payer: Humana Medicare	$148.20
Rate for Payer: Kaiser Permanente Commercial	$175.50
Rate for Payer: Kaiser Permanente Medicaid	$99.45
Rate for Payer: Kaiser Permanente Medicare	$148.20
Rate for Payer: MDX Hawaii PPO	$189.15
Rate for Payer: Ohana Health Plan Medicaid	$148.20
Rate for Payer: Ohana Health Plan Medicare	$148.20
Rate for Payer: UnitedHealthcare Medicare	$148.20
Rate for Payer: University Health Alliance Commercial	$142.14

DRAIN VALVE HEIMLICK CHEST

Facility

$195.00

Hospital Revenue Code	272
Min. Negotiated Rate	$165.75
Max. Negotiated Rate	$189.15
Rate for Payer: Cash Price	$117.00
Rate for Payer: Health Management Network Commercial	$165.75
Rate for Payer: Kaiser Permanente Commercial	$175.50
Rate for Payer: MDX Hawaii PPO	$189.15

Know your out-of-pocket cost for care.

All Charges