Honoka'a Hospital and Skilled Nursing Facility

All Charges

Charge

Type

Setting

Price

ALUMINUM-MAG HYDROXIDE-SIMETHICONE 400 MG-400 MG-40 MG/5 ML ORAL SUSP [9014]

Facility

$17.00

Service Code	NDC 00536001583
Hospital Revenue Code	637
Min. Negotiated Rate	$8.50
Max. Negotiated Rate	$16.49
Rate for Payer: AlohaCare Medicaid	$8.50
Rate for Payer: AlohaCare Medicare	$12.92
Rate for Payer: Cash Price	$10.20
Rate for Payer: Devoted Health Medicare	$14.28
Rate for Payer: Hawaii Medical Service Association Medicare	$12.92
Rate for Payer: Hawaii Western Management Group Commercial	$16.15
Rate for Payer: Health Management Network Commercial	$14.45
Rate for Payer: Humana Medicare	$12.92
Rate for Payer: Kaiser Permanente Commercial	$15.30
Rate for Payer: Kaiser Permanente Medicaid	$8.67
Rate for Payer: Kaiser Permanente Medicare	$12.92
Rate for Payer: MDX Hawaii PPO	$16.49
Rate for Payer: Ohana Health Plan Medicaid	$12.92
Rate for Payer: Ohana Health Plan Medicare	$12.92
Rate for Payer: UnitedHealthcare Medicare	$12.92
Rate for Payer: University Health Alliance Commercial	$12.39

ALUMINUM-MAG HYDROXIDE-SIMETHICONE 400 MG-400 MG-40 MG/5 ML ORAL SUSP [9014]

Facility

$16.00

Service Code	NDC 00121176230
Hospital Revenue Code	637
Min. Negotiated Rate	$8.00
Max. Negotiated Rate	$15.52
Rate for Payer: AlohaCare Medicaid	$8.00
Rate for Payer: AlohaCare Medicare	$12.16
Rate for Payer: Cash Price	$9.60
Rate for Payer: Devoted Health Medicare	$13.44
Rate for Payer: Hawaii Medical Service Association Medicare	$12.16
Rate for Payer: Hawaii Western Management Group Commercial	$15.20
Rate for Payer: Health Management Network Commercial	$13.60
Rate for Payer: Humana Medicare	$12.16
Rate for Payer: Kaiser Permanente Commercial	$14.40
Rate for Payer: Kaiser Permanente Medicaid	$8.16
Rate for Payer: Kaiser Permanente Medicare	$12.16
Rate for Payer: MDX Hawaii PPO	$15.52
Rate for Payer: Ohana Health Plan Medicaid	$12.16
Rate for Payer: Ohana Health Plan Medicare	$12.16
Rate for Payer: UnitedHealthcare Medicare	$12.16
Rate for Payer: University Health Alliance Commercial	$11.66

ALUMINUM-MAG HYDROXIDE-SIMETHICONE 400 MG-400 MG-40 MG/5 ML ORAL SUSP [9014]

Facility

$16.00

Service Code	NDC 00121176230
Hospital Revenue Code	250
Min. Negotiated Rate	$13.60
Max. Negotiated Rate	$15.52
Rate for Payer: Cash Price	$9.60
Rate for Payer: Health Management Network Commercial	$13.60
Rate for Payer: Kaiser Permanente Commercial	$14.40
Rate for Payer: MDX Hawaii PPO	$15.52

ALUMINUM-MAG HYDROXIDE-SIMETHICONE 400 MG-400 MG-40 MG/5 ML ORAL SUSP [9014]

Facility

$17.00

Service Code	NDC 00536001583
Hospital Revenue Code	250
Min. Negotiated Rate	$14.45
Max. Negotiated Rate	$16.49
Rate for Payer: Cash Price	$10.20
Rate for Payer: Health Management Network Commercial	$14.45
Rate for Payer: Kaiser Permanente Commercial	$15.30
Rate for Payer: MDX Hawaii PPO	$16.49

AMANTADINE HCL 100 MG CAPSULE [364]

Facility

$13.00

Service Code	NDC 50268006915
Hospital Revenue Code	637
Min. Negotiated Rate	$6.50
Max. Negotiated Rate	$12.61
Rate for Payer: AlohaCare Medicaid	$6.50
Rate for Payer: AlohaCare Medicare	$9.88
Rate for Payer: Cash Price	$7.80
Rate for Payer: Devoted Health Medicare	$10.92
Rate for Payer: Hawaii Medical Service Association Medicare	$9.88
Rate for Payer: Hawaii Western Management Group Commercial	$12.35
Rate for Payer: Health Management Network Commercial	$11.05
Rate for Payer: Humana Medicare	$9.88
Rate for Payer: Kaiser Permanente Commercial	$11.70
Rate for Payer: Kaiser Permanente Medicaid	$6.63
Rate for Payer: Kaiser Permanente Medicare	$9.88
Rate for Payer: MDX Hawaii PPO	$12.61
Rate for Payer: Ohana Health Plan Medicaid	$9.88
Rate for Payer: Ohana Health Plan Medicare	$9.88
Rate for Payer: UnitedHealthcare Medicare	$9.88
Rate for Payer: University Health Alliance Commercial	$9.48

AMANTADINE HCL 100 MG CAPSULE [364]

Facility

$8.00

Service Code	NDC 60687042201
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

AMANTADINE HCL 100 MG CAPSULE [364]

Facility

$13.00

Service Code	NDC 50268006915
Hospital Revenue Code	250
Min. Negotiated Rate	$11.05
Max. Negotiated Rate	$12.61
Rate for Payer: Cash Price	$7.80
Rate for Payer: Health Management Network Commercial	$11.05
Rate for Payer: Kaiser Permanente Commercial	$11.70
Rate for Payer: MDX Hawaii PPO	$12.61

AMANTADINE HCL 100 MG CAPSULE [364]

Facility

$8.00

Service Code	NDC 60687042201
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

AMANTADINE HCL 100 MG CAPSULE [364]

Facility

$8.00

Service Code	NDC 60687042211
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

AMANTADINE HCL 100 MG CAPSULE [364]

Facility

$8.00

Service Code	NDC 60687042211
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

AMANTADINE HCL 50 MG/5 ML ORAL SOLUTION [180668]

Facility

$144.00

Service Code	NDC 00121064616
Hospital Revenue Code	637
Min. Negotiated Rate	$72.00
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: Devoted Health Medicare	$120.96
Rate for Payer: Hawaii Medical Service Association Medicare	$109.44
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 Medicare	$109.44
Rate for Payer: University Health Alliance Commercial	$104.96

AMANTADINE HCL 50 MG/5 ML ORAL SOLUTION [180668]

Facility

$144.00

Service Code	NDC 00121064616
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

AMBIENT HIPVAC 50 IFS

Facility

$1,500.00

Hospital Revenue Code	272
Min. Negotiated Rate	$750.00
Max. Negotiated Rate	$1,455.00
Rate for Payer: AlohaCare Medicaid	$750.00
Rate for Payer: AlohaCare Medicare	$1,140.00
Rate for Payer: Cash Price	$900.00
Rate for Payer: Devoted Health Medicare	$1,260.00
Rate for Payer: Hawaii Medical Service Association Medicare	$1,140.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,425.00
Rate for Payer: Health Management Network Commercial	$1,275.00
Rate for Payer: Humana Medicare	$1,140.00
Rate for Payer: Kaiser Permanente Commercial	$1,350.00
Rate for Payer: Kaiser Permanente Medicaid	$765.00
Rate for Payer: Kaiser Permanente Medicare	$1,140.00
Rate for Payer: MDX Hawaii PPO	$1,455.00
Rate for Payer: Ohana Health Plan Medicaid	$1,140.00
Rate for Payer: Ohana Health Plan Medicare	$1,140.00
Rate for Payer: UnitedHealthcare Medicare	$1,140.00
Rate for Payer: University Health Alliance Commercial	$1,093.35

AMBIENT HIPVAC 50 IFS

Facility

$1,500.00

Hospital Revenue Code	272
Min. Negotiated Rate	$1,275.00
Max. Negotiated Rate	$1,455.00
Rate for Payer: Cash Price	$900.00
Rate for Payer: Health Management Network Commercial	$1,275.00
Rate for Payer: Kaiser Permanente Commercial	$1,350.00
Rate for Payer: MDX Hawaii PPO	$1,455.00

AMIKACIN 500 MG/2 ML INJECTION SOLUTION [108131]

Facility

$32.00

Service Code	HCPCS J0278
Hospital Revenue Code	250
Min. Negotiated Rate	$27.20
Max. Negotiated Rate	$31.04
Rate for Payer: Cash Price	$19.20
Rate for Payer: Cash Price	$8.40
Rate for Payer: Cash Price	$24.60
Rate for Payer: Health Management Network Commercial	$34.85
Rate for Payer: Health Management Network Commercial	$11.90
Rate for Payer: Health Management Network Commercial	$27.20
Rate for Payer: Kaiser Permanente Commercial	$36.90
Rate for Payer: Kaiser Permanente Commercial	$12.60
Rate for Payer: Kaiser Permanente Commercial	$28.80
Rate for Payer: MDX Hawaii PPO	$31.04
Rate for Payer: MDX Hawaii PPO	$13.58
Rate for Payer: MDX Hawaii PPO	$39.77

AMIKACIN 500 MG/2 ML INJECTION SOLUTION [108131]

Facility

$32.00

Service Code	HCPCS J0278
Hospital Revenue Code	636
Min. Negotiated Rate	$0.62
Max. Negotiated Rate	$31.04
Rate for Payer: AlohaCare Medicaid	$16.00
Rate for Payer: AlohaCare Medicaid	$20.50
Rate for Payer: AlohaCare Medicaid	$7.00
Rate for Payer: AlohaCare Medicare	$31.16
Rate for Payer: AlohaCare Medicare	$10.64
Rate for Payer: AlohaCare Medicare	$24.32
Rate for Payer: Cash Price	$8.40
Rate for Payer: Cash Price	$24.60
Rate for Payer: Cash Price	$8.40
Rate for Payer: Cash Price	$24.60
Rate for Payer: Cash Price	$19.20
Rate for Payer: Cash Price	$19.20
Rate for Payer: Devoted Health Medicare	$34.44
Rate for Payer: Devoted Health Medicare	$26.88
Rate for Payer: Devoted Health Medicare	$11.76
Rate for Payer: Hawaii Medical Service Association ABD	$0.62
Rate for Payer: Hawaii Medical Service Association ABD	$0.62
Rate for Payer: Hawaii Medical Service Association ABD	$0.62
Rate for Payer: Hawaii Medical Service Association Medicare	$24.32
Rate for Payer: Hawaii Medical Service Association Medicare	$31.16
Rate for Payer: Hawaii Medical Service Association Medicare	$10.64
Rate for Payer: Hawaii Medical Service Association Non-ABD	$0.62
Rate for Payer: Hawaii Medical Service Association Non-ABD	$0.62
Rate for Payer: Hawaii Medical Service Association Non-ABD	$0.62
Rate for Payer: Hawaii Western Management Group Commercial	$38.95
Rate for Payer: Hawaii Western Management Group Commercial	$13.30
Rate for Payer: Hawaii Western Management Group Commercial	$30.40
Rate for Payer: Health Management Network Commercial	$11.90
Rate for Payer: Health Management Network Commercial	$27.20
Rate for Payer: Health Management Network Commercial	$34.85
Rate for Payer: Humana Medicare	$24.32
Rate for Payer: Humana Medicare	$10.64
Rate for Payer: Humana Medicare	$31.16
Rate for Payer: Kaiser Permanente Commercial	$28.80
Rate for Payer: Kaiser Permanente Commercial	$36.90
Rate for Payer: Kaiser Permanente Commercial	$12.60
Rate for Payer: Kaiser Permanente Medicaid	$16.32
Rate for Payer: Kaiser Permanente Medicaid	$20.91
Rate for Payer: Kaiser Permanente Medicaid	$7.14
Rate for Payer: Kaiser Permanente Medicare	$24.32
Rate for Payer: Kaiser Permanente Medicare	$10.64
Rate for Payer: Kaiser Permanente Medicare	$31.16
Rate for Payer: MDX Hawaii PPO	$39.77
Rate for Payer: MDX Hawaii PPO	$13.58
Rate for Payer: MDX Hawaii PPO	$31.04
Rate for Payer: Ohana Health Plan Medicaid	$24.32
Rate for Payer: Ohana Health Plan Medicaid	$31.16
Rate for Payer: Ohana Health Plan Medicaid	$10.64
Rate for Payer: Ohana Health Plan Medicare	$31.16
Rate for Payer: Ohana Health Plan Medicare	$10.64
Rate for Payer: Ohana Health Plan Medicare	$24.32
Rate for Payer: UnitedHealthcare Medicaid	$8.40
Rate for Payer: UnitedHealthcare Medicaid	$19.20
Rate for Payer: UnitedHealthcare Medicaid	$24.60
Rate for Payer: UnitedHealthcare Medicare	$10.64
Rate for Payer: UnitedHealthcare Medicare	$31.16
Rate for Payer: UnitedHealthcare Medicare	$24.32
Rate for Payer: University Health Alliance Commercial	$29.88
Rate for Payer: University Health Alliance Commercial	$23.32
Rate for Payer: University Health Alliance Commercial	$10.20

AMILORIDE 5 MG TABLET [391]

Facility

$1.00

Service Code	NDC 00574029201
Hospital Revenue Code	637
Min. Negotiated Rate	$0.50
Max. Negotiated Rate	$0.97
Rate for Payer: AlohaCare Medicaid	$0.50
Rate for Payer: AlohaCare Medicare	$0.76
Rate for Payer: Cash Price	$0.60
Rate for Payer: Devoted Health Medicare	$0.84
Rate for Payer: Hawaii Medical Service Association Medicare	$0.76
Rate for Payer: Hawaii Western Management Group Commercial	$0.95
Rate for Payer: Health Management Network Commercial	$0.85
Rate for Payer: Humana Medicare	$0.76
Rate for Payer: Kaiser Permanente Commercial	$0.90
Rate for Payer: Kaiser Permanente Medicaid	$0.51
Rate for Payer: Kaiser Permanente Medicare	$0.76
Rate for Payer: MDX Hawaii PPO	$0.97
Rate for Payer: Ohana Health Plan Medicaid	$0.76
Rate for Payer: Ohana Health Plan Medicare	$0.76
Rate for Payer: UnitedHealthcare Medicare	$0.76
Rate for Payer: University Health Alliance Commercial	$0.73

AMILORIDE 5 MG TABLET [391]

Facility

$1.00

Service Code	NDC 00574029201
Hospital Revenue Code	250
Min. Negotiated Rate	$0.85
Max. Negotiated Rate	$0.97
Rate for Payer: Cash Price	$0.60
Rate for Payer: Health Management Network Commercial	$0.85
Rate for Payer: Kaiser Permanente Commercial	$0.90
Rate for Payer: MDX Hawaii PPO	$0.97

AMINO ACID 4.25 % NO.1-DEXTROSE 5 %-ELECTROLYTES NO.39 IV SOLUTION [23162]

Facility

$182.00

Service Code	NDC 00338702206
Hospital Revenue Code	250
Min. Negotiated Rate	$154.70
Max. Negotiated Rate	$176.54
Rate for Payer: Cash Price	$109.20
Rate for Payer: Health Management Network Commercial	$154.70
Rate for Payer: Kaiser Permanente Commercial	$163.80
Rate for Payer: MDX Hawaii PPO	$176.54

AMINO ACID 4.25 % NO.1-DEXTROSE 5 %-ELECTROLYTES NO.39 IV SOLUTION [23162]

Facility

$182.00

Service Code	NDC 00338702201
Hospital Revenue Code	250
Min. Negotiated Rate	$154.70
Max. Negotiated Rate	$176.54
Rate for Payer: Cash Price	$109.20
Rate for Payer: Health Management Network Commercial	$154.70
Rate for Payer: Kaiser Permanente Commercial	$163.80
Rate for Payer: MDX Hawaii PPO	$176.54

AMINO ACID 4.25 % NO.1-DEXTROSE 5 %-ELECTROLYTES NO.39 IV SOLUTION [23162]

Facility

$364.00

Service Code	NDC 00338114403
Hospital Revenue Code	250
Min. Negotiated Rate	$309.40
Max. Negotiated Rate	$353.08
Rate for Payer: Cash Price	$218.40
Rate for Payer: Cash Price	$109.20
Rate for Payer: Health Management Network Commercial	$154.70
Rate for Payer: Health Management Network Commercial	$309.40
Rate for Payer: Kaiser Permanente Commercial	$327.60
Rate for Payer: Kaiser Permanente Commercial	$163.80
Rate for Payer: MDX Hawaii PPO	$353.08
Rate for Payer: MDX Hawaii PPO	$176.54

AMINO ACID 4.25 % NO.1 IN DEXTROSE 5 % INTRAVENOUS SOLUTION [25749]

Facility

$161.00

Service Code	NDC 00338113303
Hospital Revenue Code	250
Min. Negotiated Rate	$136.85
Max. Negotiated Rate	$156.17
Rate for Payer: Cash Price	$96.60
Rate for Payer: Health Management Network Commercial	$136.85
Rate for Payer: Kaiser Permanente Commercial	$144.90
Rate for Payer: MDX Hawaii PPO	$156.17

AMINO ACID 5 % NO.6-DEXTROSE 20 %-ELECTROLYTES NO.23 IV SOLUTION [23214]

Facility

$364.00

Service Code	NDC 00338112504
Hospital Revenue Code	250
Min. Negotiated Rate	$309.40
Max. Negotiated Rate	$353.08
Rate for Payer: Cash Price	$218.40
Rate for Payer: Health Management Network Commercial	$309.40
Rate for Payer: Kaiser Permanente Commercial	$327.60
Rate for Payer: MDX Hawaii PPO	$353.08

AMINO ACID 5 % NO.6-DEXTROSE 20 %-ELECTROLYTES NO.23 IV SOLUTION [23214]

Facility

$378.00

Service Code	NDC 00338114803
Hospital Revenue Code	250
Min. Negotiated Rate	$321.30
Max. Negotiated Rate	$366.66
Rate for Payer: Cash Price	$226.80
Rate for Payer: Cash Price	$113.40
Rate for Payer: Health Management Network Commercial	$160.65
Rate for Payer: Health Management Network Commercial	$321.30
Rate for Payer: Kaiser Permanente Commercial	$170.10
Rate for Payer: Kaiser Permanente Commercial	$340.20
Rate for Payer: MDX Hawaii PPO	$366.66
Rate for Payer: MDX Hawaii PPO	$183.33

AMINO ACID 5 % NO.6-DEXTROSE 20 %-ELECTROLYTES NO.23 IV SOLUTION [23214]

Facility

$364.00

Service Code	NDC 00338703604
Hospital Revenue Code	250
Min. Negotiated Rate	$309.40
Max. Negotiated Rate	$353.08
Rate for Payer: Cash Price	$218.40
Rate for Payer: Health Management Network Commercial	$309.40
Rate for Payer: Kaiser Permanente Commercial	$327.60
Rate for Payer: MDX Hawaii PPO	$353.08

Know your out-of-pocket cost for care.

All Charges