Honoka'a Hospital and Skilled Nursing Facility

All Charges

Charge

Type

Setting

Price

EXTENSION PERCUTANEOUS 3560022

Facility

$929.00

Service Code	HCPCS C1883
Hospital Revenue Code	278
Min. Negotiated Rate	$464.50
Max. Negotiated Rate	$901.13
Rate for Payer: AlohaCare Medicaid	$464.50
Rate for Payer: AlohaCare Medicare	$706.04
Rate for Payer: Cash Price	$557.40
Rate for Payer: Devoted Health Medicare	$780.36
Rate for Payer: Hawaii Medical Service Association Medicare	$706.04
Rate for Payer: Hawaii Western Management Group Commercial	$650.30
Rate for Payer: Health Management Network Commercial	$789.65
Rate for Payer: Humana Medicare	$706.04
Rate for Payer: Kaiser Permanente Commercial	$836.10
Rate for Payer: Kaiser Permanente Medicaid	$473.79
Rate for Payer: Kaiser Permanente Medicare	$706.04
Rate for Payer: MDX Hawaii PPO	$901.13
Rate for Payer: Ohana Health Plan Medicaid	$706.04
Rate for Payer: Ohana Health Plan Medicare	$706.04
Rate for Payer: UnitedHealthcare Medicare	$706.04
Rate for Payer: University Health Alliance Commercial	$520.24

EXTENSIVE BURNS OR FULL THICKNESS BURNS WITH MV >96 HOURS WITHOUT SKIN GRAFT

Facility

$61,625.20

Service Code	MSDRG 933
Min. Negotiated Rate	$61,625.20
Max. Negotiated Rate	$61,625.20
Rate for Payer: Hawaii Medical Service Association Commercial	$61,625.20

EXTENSIVE BURNS OR FULL THICKNESS BURNS WITH MV >96 HOURS WITH SKIN GRAFT

Facility

$382,502.88

Service Code	MSDRG 927
Min. Negotiated Rate	$382,502.88
Max. Negotiated Rate	$382,502.88
Rate for Payer: Hawaii Medical Service Association Commercial	$382,502.88

EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH CC

Facility

$45,650.05

Service Code	MSDRG 982
Min. Negotiated Rate	$45,650.05
Max. Negotiated Rate	$45,650.05
Rate for Payer: Hawaii Medical Service Association Commercial	$45,650.05

EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH MCC

Facility

$76,510.06

Service Code	MSDRG 981
Min. Negotiated Rate	$76,510.06
Max. Negotiated Rate	$76,510.06
Rate for Payer: Hawaii Medical Service Association Commercial	$76,510.06

EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITHOUT CC/MCC

Facility

$30,291.16

Service Code	MSDRG 983
Min. Negotiated Rate	$30,291.16
Max. Negotiated Rate	$30,291.16
Rate for Payer: Hawaii Medical Service Association Commercial	$30,291.16

EXTERNAL FIXATOR 03.305.006

Facility

$2,574.00

Hospital Revenue Code	278
Min. Negotiated Rate	$1,287.00
Max. Negotiated Rate	$2,496.78
Rate for Payer: AlohaCare Medicaid	$1,287.00
Rate for Payer: AlohaCare Medicare	$1,956.24
Rate for Payer: Cash Price	$1,544.40
Rate for Payer: Devoted Health Medicare	$2,162.16
Rate for Payer: Hawaii Medical Service Association Medicare	$1,956.24
Rate for Payer: Hawaii Western Management Group Commercial	$1,801.80
Rate for Payer: Health Management Network Commercial	$2,187.90
Rate for Payer: Humana Medicare	$1,956.24
Rate for Payer: Kaiser Permanente Commercial	$2,316.60
Rate for Payer: Kaiser Permanente Medicaid	$1,312.74
Rate for Payer: Kaiser Permanente Medicare	$1,956.24
Rate for Payer: MDX Hawaii PPO	$2,496.78
Rate for Payer: Ohana Health Plan Medicaid	$1,956.24
Rate for Payer: Ohana Health Plan Medicare	$1,956.24
Rate for Payer: UnitedHealthcare Medicare	$1,956.24
Rate for Payer: University Health Alliance Commercial	$1,441.44

EXTERNAL FIXATOR 03.305.006

Facility

$2,574.00

Hospital Revenue Code	278
Min. Negotiated Rate	$1,441.44
Max. Negotiated Rate	$2,496.78
Rate for Payer: Cash Price	$1,544.40
Rate for Payer: Hawaii Western Management Group Commercial	$1,801.80
Rate for Payer: Health Management Network Commercial	$2,187.90
Rate for Payer: Kaiser Permanente Commercial	$2,316.60
Rate for Payer: MDX Hawaii PPO	$2,496.78
Rate for Payer: University Health Alliance Commercial	$1,441.44

EXTRACRANIAL PROCEDURES WITH CC

Facility

$54,135.37

Service Code	MSDRG 038
Min. Negotiated Rate	$10,400.00
Max. Negotiated Rate	$54,135.37
Rate for Payer: Hawaii Medical Service Association Commercial	$54,135.37
Rate for Payer: University Health Alliance Commercial	$10,400.00

EXTRACRANIAL PROCEDURES WITH MCC

Facility

$65,038.29

Service Code	MSDRG 037
Min. Negotiated Rate	$10,400.00
Max. Negotiated Rate	$65,038.29
Rate for Payer: Hawaii Medical Service Association Commercial	$65,038.29
Rate for Payer: University Health Alliance Commercial	$10,400.00

EXTRACRANIAL PROCEDURES WITHOUT CC/MCC

Facility

$42,142.16

Service Code	MSDRG 039
Min. Negotiated Rate	$10,400.00
Max. Negotiated Rate	$42,142.16
Rate for Payer: Hawaii Medical Service Association Commercial	$42,142.16
Rate for Payer: University Health Alliance Commercial	$10,400.00

EXTRAOCULAR PROCEDURES EXCEPT ORBIT

Facility

$17,800.20

Service Code	MSDRG 115
Min. Negotiated Rate	$10,400.00
Max. Negotiated Rate	$17,800.20
Rate for Payer: Hawaii Medical Service Association Commercial	$17,800.20
Rate for Payer: University Health Alliance Commercial	$10,400.00

EXTREME IMMATURITY OR RESPIRATORY DISTRESS SYNDROME, NEONATE

Facility

$271,980.45

Service Code	MSDRG 790
Min. Negotiated Rate	$271,980.45
Max. Negotiated Rate	$271,980.45
Rate for Payer: Hawaii Medical Service Association Commercial	$271,980.45

EZETIMIBE 10 MG TABLET [34153]

Facility

$31.00

Service Code	NDC 60687037321
Hospital Revenue Code	637
Min. Negotiated Rate	$15.50
Max. Negotiated Rate	$30.07
Rate for Payer: AlohaCare Medicaid	$15.50
Rate for Payer: AlohaCare Medicare	$23.56
Rate for Payer: Cash Price	$18.60
Rate for Payer: Devoted Health Medicare	$26.04
Rate for Payer: Hawaii Medical Service Association Medicare	$23.56
Rate for Payer: Hawaii Western Management Group Commercial	$29.45
Rate for Payer: Health Management Network Commercial	$26.35
Rate for Payer: Humana Medicare	$23.56
Rate for Payer: Kaiser Permanente Commercial	$27.90
Rate for Payer: Kaiser Permanente Medicaid	$15.81
Rate for Payer: Kaiser Permanente Medicare	$23.56
Rate for Payer: MDX Hawaii PPO	$30.07
Rate for Payer: Ohana Health Plan Medicaid	$23.56
Rate for Payer: Ohana Health Plan Medicare	$23.56
Rate for Payer: UnitedHealthcare Medicare	$23.56
Rate for Payer: University Health Alliance Commercial	$22.60

EZETIMIBE 10 MG TABLET [34153]

Facility

$31.00

Service Code	NDC 60687037311
Hospital Revenue Code	637
Min. Negotiated Rate	$15.50
Max. Negotiated Rate	$30.07
Rate for Payer: AlohaCare Medicaid	$15.50
Rate for Payer: AlohaCare Medicare	$23.56
Rate for Payer: Cash Price	$18.60
Rate for Payer: Devoted Health Medicare	$26.04
Rate for Payer: Hawaii Medical Service Association Medicare	$23.56
Rate for Payer: Hawaii Western Management Group Commercial	$29.45
Rate for Payer: Health Management Network Commercial	$26.35
Rate for Payer: Humana Medicare	$23.56
Rate for Payer: Kaiser Permanente Commercial	$27.90
Rate for Payer: Kaiser Permanente Medicaid	$15.81
Rate for Payer: Kaiser Permanente Medicare	$23.56
Rate for Payer: MDX Hawaii PPO	$30.07
Rate for Payer: Ohana Health Plan Medicaid	$23.56
Rate for Payer: Ohana Health Plan Medicare	$23.56
Rate for Payer: UnitedHealthcare Medicare	$23.56
Rate for Payer: University Health Alliance Commercial	$22.60

EZETIMIBE 10 MG TABLET [34153]

Facility

$31.00

Service Code	NDC 60687037321
Hospital Revenue Code	250
Min. Negotiated Rate	$26.35
Max. Negotiated Rate	$30.07
Rate for Payer: Cash Price	$18.60
Rate for Payer: Health Management Network Commercial	$26.35
Rate for Payer: Kaiser Permanente Commercial	$27.90
Rate for Payer: MDX Hawaii PPO	$30.07

EZETIMIBE 10 MG TABLET [34153]

Facility

$31.00

Service Code	NDC 60687037311
Hospital Revenue Code	250
Min. Negotiated Rate	$26.35
Max. Negotiated Rate	$30.07
Rate for Payer: Cash Price	$18.60
Rate for Payer: Health Management Network Commercial	$26.35
Rate for Payer: Kaiser Permanente Commercial	$27.90
Rate for Payer: MDX Hawaii PPO	$30.07

FAMCICLOVIR 125 MG TABLET [16082]

Facility

$21.00

Service Code	NDC 33342002407
Hospital Revenue Code	637
Min. Negotiated Rate	$10.50
Max. Negotiated Rate	$20.37
Rate for Payer: AlohaCare Medicaid	$10.50
Rate for Payer: AlohaCare Medicare	$15.96
Rate for Payer: Cash Price	$12.60
Rate for Payer: Devoted Health Medicare	$17.64
Rate for Payer: Hawaii Medical Service Association Medicare	$15.96
Rate for Payer: Hawaii Western Management Group Commercial	$19.95
Rate for Payer: Health Management Network Commercial	$17.85
Rate for Payer: Humana Medicare	$15.96
Rate for Payer: Kaiser Permanente Commercial	$18.90
Rate for Payer: Kaiser Permanente Medicaid	$10.71
Rate for Payer: Kaiser Permanente Medicare	$15.96
Rate for Payer: MDX Hawaii PPO	$20.37
Rate for Payer: Ohana Health Plan Medicaid	$15.96
Rate for Payer: Ohana Health Plan Medicare	$15.96
Rate for Payer: UnitedHealthcare Medicare	$15.96
Rate for Payer: University Health Alliance Commercial	$15.31

FAMCICLOVIR 125 MG TABLET [16082]

Facility

$21.00

Service Code	NDC 33342002407
Hospital Revenue Code	250
Min. Negotiated Rate	$17.85
Max. Negotiated Rate	$20.37
Rate for Payer: Cash Price	$12.60
Rate for Payer: Health Management Network Commercial	$17.85
Rate for Payer: Kaiser Permanente Commercial	$18.90
Rate for Payer: MDX Hawaii PPO	$20.37

FAMCICLOVIR 500 MG TABLET [13358]

Facility

$32.00

Service Code	NDC 33342002607
Hospital Revenue Code	637
Min. Negotiated Rate	$16.00
Max. Negotiated Rate	$31.04
Rate for Payer: AlohaCare Medicaid	$16.00
Rate for Payer: AlohaCare Medicare	$24.32
Rate for Payer: Cash Price	$19.20
Rate for Payer: Devoted Health Medicare	$26.88
Rate for Payer: Hawaii Medical Service Association Medicare	$24.32
Rate for Payer: Hawaii Western Management Group Commercial	$30.40
Rate for Payer: Health Management Network Commercial	$27.20
Rate for Payer: Humana Medicare	$24.32
Rate for Payer: Kaiser Permanente Commercial	$28.80
Rate for Payer: Kaiser Permanente Medicaid	$16.32
Rate for Payer: Kaiser Permanente Medicare	$24.32
Rate for Payer: MDX Hawaii PPO	$31.04
Rate for Payer: Ohana Health Plan Medicaid	$24.32
Rate for Payer: Ohana Health Plan Medicare	$24.32
Rate for Payer: UnitedHealthcare Medicare	$24.32
Rate for Payer: University Health Alliance Commercial	$23.32

FAMCICLOVIR 500 MG TABLET [13358]

Facility

$32.00

Service Code	NDC 33342002607
Hospital Revenue Code	250
Min. Negotiated Rate	$27.20
Max. Negotiated Rate	$31.04
Rate for Payer: Cash Price	$19.20
Rate for Payer: Health Management Network Commercial	$27.20
Rate for Payer: Kaiser Permanente Commercial	$28.80
Rate for Payer: MDX Hawaii PPO	$31.04

FAMOTIDINE 20 MG TABLET [10011]

Facility

$1.00

Service Code	NDC 00904719306
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

FAMOTIDINE 20 MG TABLET [10011]

Facility

$1.00

Service Code	NDC 00904719306
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

FAMOTIDINE 20 MG TABLET [10011]

Facility

$6.00

Service Code	NDC 50268030315
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

FAMOTIDINE 20 MG TABLET [10011]

Facility

$1.00

Service Code	NDC 00904719361
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

Know your out-of-pocket cost for care.

All Charges