Honoka'a Hospital and Skilled Nursing Facility

All Charges

Charge

Type

Setting

Price

GLIPIZIDE ER 5 MG TABLET, EXTENDED RELEASE 24 HR [37649]

Facility

$3.00

Service Code	NDC 68084011101
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

GLIPIZIDE ER 5 MG TABLET, EXTENDED RELEASE 24 HR [37649]

Facility

$3.00

Service Code	NDC 68084011101
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

GLIPIZIDE ER 5 MG TABLET, EXTENDED RELEASE 24 HR [37649]

Facility

$2.00

Service Code	NDC 64980028001
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

GLUCAGON 1 MG SOLUTION FOR INJECTION [24869]

Facility

$504.00

Service Code	HCPCS J1610
Hospital Revenue Code	250
Min. Negotiated Rate	$428.40
Max. Negotiated Rate	$488.88
Rate for Payer: Cash Price	$302.40
Rate for Payer: Health Management Network Commercial	$428.40
Rate for Payer: Kaiser Permanente Commercial	$453.60
Rate for Payer: MDX Hawaii PPO	$488.88

GLUCAGON 1 MG SOLUTION FOR INJECTION [24869]

Facility

$504.00

Service Code	HCPCS J1610
Hospital Revenue Code	636
Min. Negotiated Rate	$182.91
Max. Negotiated Rate	$488.88
Rate for Payer: AlohaCare Medicaid	$252.00
Rate for Payer: AlohaCare Medicare	$383.04
Rate for Payer: Cash Price	$302.40
Rate for Payer: Cash Price	$302.40
Rate for Payer: Devoted Health Medicare	$423.36
Rate for Payer: Hawaii Medical Service Association ABD	$195.79
Rate for Payer: Hawaii Medical Service Association Commercial	$182.91
Rate for Payer: Hawaii Medical Service Association Medicare	$383.04
Rate for Payer: Hawaii Medical Service Association Non-ABD	$195.79
Rate for Payer: Hawaii Western Management Group Commercial	$478.80
Rate for Payer: Health Management Network Commercial	$428.40
Rate for Payer: Humana Medicare	$383.04
Rate for Payer: Kaiser Permanente Commercial	$453.60
Rate for Payer: Kaiser Permanente Medicaid	$257.04
Rate for Payer: Kaiser Permanente Medicare	$383.04
Rate for Payer: MDX Hawaii PPO	$488.88
Rate for Payer: Ohana Health Plan Medicaid	$383.04
Rate for Payer: Ohana Health Plan Medicare	$383.04
Rate for Payer: UnitedHealthcare Medicaid	$302.40
Rate for Payer: UnitedHealthcare Medicare	$383.04
Rate for Payer: University Health Alliance Commercial	$367.37

GLUCAGON HCL 1 MG/ML SOLUTION FOR INJECTION [129601]

Facility

$455.00

Service Code	HCPCS J1611
Hospital Revenue Code	250
Min. Negotiated Rate	$386.75
Max. Negotiated Rate	$441.35
Rate for Payer: Cash Price	$273.00
Rate for Payer: Health Management Network Commercial	$386.75
Rate for Payer: Kaiser Permanente Commercial	$409.50
Rate for Payer: MDX Hawaii PPO	$441.35

GLUCAGON HCL 1 MG/ML SOLUTION FOR INJECTION [129601]

Facility

$455.00

Service Code	HCPCS J1611
Hospital Revenue Code	636
Min. Negotiated Rate	$144.88
Max. Negotiated Rate	$441.35
Rate for Payer: AlohaCare Medicaid	$227.50
Rate for Payer: AlohaCare Medicare	$345.80
Rate for Payer: Cash Price	$273.00
Rate for Payer: Cash Price	$273.00
Rate for Payer: Devoted Health Medicare	$382.20
Rate for Payer: Hawaii Medical Service Association ABD	$144.88
Rate for Payer: Hawaii Medical Service Association Commercial	$168.75
Rate for Payer: Hawaii Medical Service Association Medicare	$345.80
Rate for Payer: Hawaii Medical Service Association Non-ABD	$144.88
Rate for Payer: Hawaii Western Management Group Commercial	$432.25
Rate for Payer: Health Management Network Commercial	$386.75
Rate for Payer: Humana Medicare	$345.80
Rate for Payer: Kaiser Permanente Commercial	$409.50
Rate for Payer: Kaiser Permanente Medicaid	$232.05
Rate for Payer: Kaiser Permanente Medicare	$345.80
Rate for Payer: MDX Hawaii PPO	$441.35
Rate for Payer: Ohana Health Plan Medicaid	$345.80
Rate for Payer: Ohana Health Plan Medicare	$345.80
Rate for Payer: UnitedHealthcare Medicaid	$273.00
Rate for Payer: UnitedHealthcare Medicare	$345.80
Rate for Payer: University Health Alliance Commercial	$331.65

GLUCAGON HCL 1 MG SOLUTION FOR INJECTION [170521]

Facility

$504.00

Service Code	HCPCS J1611
Hospital Revenue Code	636
Min. Negotiated Rate	$144.88
Max. Negotiated Rate	$488.88
Rate for Payer: AlohaCare Medicaid	$252.00
Rate for Payer: AlohaCare Medicare	$383.04
Rate for Payer: Cash Price	$302.40
Rate for Payer: Cash Price	$302.40
Rate for Payer: Devoted Health Medicare	$423.36
Rate for Payer: Hawaii Medical Service Association ABD	$144.88
Rate for Payer: Hawaii Medical Service Association Commercial	$168.75
Rate for Payer: Hawaii Medical Service Association Medicare	$383.04
Rate for Payer: Hawaii Medical Service Association Non-ABD	$144.88
Rate for Payer: Hawaii Western Management Group Commercial	$478.80
Rate for Payer: Health Management Network Commercial	$428.40
Rate for Payer: Humana Medicare	$383.04
Rate for Payer: Kaiser Permanente Commercial	$453.60
Rate for Payer: Kaiser Permanente Medicaid	$257.04
Rate for Payer: Kaiser Permanente Medicare	$383.04
Rate for Payer: MDX Hawaii PPO	$488.88
Rate for Payer: Ohana Health Plan Medicaid	$383.04
Rate for Payer: Ohana Health Plan Medicare	$383.04
Rate for Payer: UnitedHealthcare Medicaid	$302.40
Rate for Payer: UnitedHealthcare Medicare	$383.04
Rate for Payer: University Health Alliance Commercial	$367.37

GLUCAGON HCL 1 MG SOLUTION FOR INJECTION [170521]

Facility

$504.00

Service Code	HCPCS J1611
Hospital Revenue Code	250
Min. Negotiated Rate	$428.40
Max. Negotiated Rate	$488.88
Rate for Payer: Cash Price	$302.40
Rate for Payer: Health Management Network Commercial	$428.40
Rate for Payer: Kaiser Permanente Commercial	$453.60
Rate for Payer: MDX Hawaii PPO	$488.88

GLYBURIDE 2.5 MG TABLET [10126]

Facility

$2.00

Service Code	NDC 72241003905
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

GLYBURIDE 2.5 MG TABLET [10126]

Facility

$2.00

Service Code	NDC 72241003905
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

GLYBURIDE 5 MG TABLET [3489]

Facility

$3.00

Service Code	NDC 00093936401
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

GLYBURIDE 5 MG TABLET [3489]

Facility

$3.00

Service Code	NDC 72241004005
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

GLYBURIDE 5 MG TABLET [3489]

Facility

$3.00

Service Code	NDC 00093936401
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

GLYBURIDE 5 MG TABLET [3489]

Facility

$3.00

Service Code	NDC 72241004005
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

GLYCERIN (ADULT) RECTAL SUPPOSITORY [41003]

Facility

$1.00

Service Code	NDC 46122022171
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

GLYCERIN (ADULT) RECTAL SUPPOSITORY [41003]

Facility

$1.00

Service Code	NDC 42510000000
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

GLYCERIN (ADULT) RECTAL SUPPOSITORY [41003]

Facility

$1.00

Service Code	NDC 42511000000
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

GLYCERIN (ADULT) RECTAL SUPPOSITORY [41003]

Facility

$1.00

Service Code	NDC 46122022171
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

GLYCERIN (ADULT) RECTAL SUPPOSITORY [41003]

Facility

$1.00

Service Code	NDC 42511000000
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

GLYCERIN (ADULT) RECTAL SUPPOSITORY [41003]

Facility

$1.00

Service Code	NDC 42510000000
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

GLYCERIN (CHILD) RECTAL SUPPOSITORY [76974]

Facility

$1.00

Service Code	NDC 42512000000
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

GLYCERIN (CHILD) RECTAL SUPPOSITORY [76974]

Facility

$1.00

Service Code	NDC 42512000000
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

GLYCERIN (CHILD) RECTAL SUPPOSITORY [76974]

Facility

$1.00

Service Code	NDC 46122022263
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

GLYCERIN (CHILD) RECTAL SUPPOSITORY [76974]

Facility

$1.00

Service Code	NDC 46122022263
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

Know your out-of-pocket cost for care.

All Charges