Honoka'a Hospital and Skilled Nursing Facility

All Charges

Charge

Type

Setting

Price

AMPLATZ SHORT TAPER EX 035X260

Facility

$234.00

Service Code	HCPCS C1769
Hospital Revenue Code	272
Min. Negotiated Rate	$117.00
Max. Negotiated Rate	$226.98
Rate for Payer: AlohaCare Medicaid	$117.00
Rate for Payer: AlohaCare Medicare	$177.84
Rate for Payer: Cash Price	$140.40
Rate for Payer: Devoted Health Medicare	$196.56
Rate for Payer: Hawaii Medical Service Association Medicare	$177.84
Rate for Payer: Hawaii Western Management Group Commercial	$222.30
Rate for Payer: Health Management Network Commercial	$198.90
Rate for Payer: Humana Medicare	$177.84
Rate for Payer: Kaiser Permanente Commercial	$210.60
Rate for Payer: Kaiser Permanente Medicaid	$119.34
Rate for Payer: Kaiser Permanente Medicare	$177.84
Rate for Payer: MDX Hawaii PPO	$226.98
Rate for Payer: Ohana Health Plan Medicaid	$177.84
Rate for Payer: Ohana Health Plan Medicare	$177.84
Rate for Payer: UnitedHealthcare Medicare	$177.84
Rate for Payer: University Health Alliance Commercial	$170.56

AMPLATZ SUPER STIFF 035X260

Facility

$144.00

Service Code	HCPCS C1769
Hospital Revenue Code	272
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

AMPLATZ SUPER STIFF 035X260

Facility

$144.00

Service Code	HCPCS C1769
Hospital Revenue Code	272
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

AMPLATZ URETERAL 8.5FRX20

Facility

$441.00

Service Code	HCPCS C2625
Hospital Revenue Code	272
Min. Negotiated Rate	$220.50
Max. Negotiated Rate	$427.77
Rate for Payer: AlohaCare Medicaid	$220.50
Rate for Payer: AlohaCare Medicare	$335.16
Rate for Payer: Cash Price	$264.60
Rate for Payer: Devoted Health Medicare	$370.44
Rate for Payer: Hawaii Medical Service Association Medicare	$335.16
Rate for Payer: Hawaii Western Management Group Commercial	$418.95
Rate for Payer: Health Management Network Commercial	$374.85
Rate for Payer: Humana Medicare	$335.16
Rate for Payer: Kaiser Permanente Commercial	$396.90
Rate for Payer: Kaiser Permanente Medicaid	$224.91
Rate for Payer: Kaiser Permanente Medicare	$335.16
Rate for Payer: MDX Hawaii PPO	$427.77
Rate for Payer: Ohana Health Plan Medicaid	$335.16
Rate for Payer: Ohana Health Plan Medicare	$335.16
Rate for Payer: UnitedHealthcare Medicare	$335.16
Rate for Payer: University Health Alliance Commercial	$321.44

AMPLATZ URETERAL 8.5FRX20

Facility

$441.00

Service Code	HCPCS C2625
Hospital Revenue Code	272
Min. Negotiated Rate	$374.85
Max. Negotiated Rate	$427.77
Rate for Payer: Cash Price	$264.60
Rate for Payer: Health Management Network Commercial	$374.85
Rate for Payer: Kaiser Permanente Commercial	$396.90
Rate for Payer: MDX Hawaii PPO	$427.77

AMPLATZ URETERAL 8.5FRX22

Facility

$441.00

Service Code	HCPCS C2625
Hospital Revenue Code	272
Min. Negotiated Rate	$220.50
Max. Negotiated Rate	$427.77
Rate for Payer: AlohaCare Medicaid	$220.50
Rate for Payer: AlohaCare Medicare	$335.16
Rate for Payer: Cash Price	$264.60
Rate for Payer: Devoted Health Medicare	$370.44
Rate for Payer: Hawaii Medical Service Association Medicare	$335.16
Rate for Payer: Hawaii Western Management Group Commercial	$418.95
Rate for Payer: Health Management Network Commercial	$374.85
Rate for Payer: Humana Medicare	$335.16
Rate for Payer: Kaiser Permanente Commercial	$396.90
Rate for Payer: Kaiser Permanente Medicaid	$224.91
Rate for Payer: Kaiser Permanente Medicare	$335.16
Rate for Payer: MDX Hawaii PPO	$427.77
Rate for Payer: Ohana Health Plan Medicaid	$335.16
Rate for Payer: Ohana Health Plan Medicare	$335.16
Rate for Payer: UnitedHealthcare Medicare	$335.16
Rate for Payer: University Health Alliance Commercial	$321.44

AMPLATZ URETERAL 8.5FRX22

Facility

$441.00

Service Code	HCPCS C2625
Hospital Revenue Code	272
Min. Negotiated Rate	$374.85
Max. Negotiated Rate	$427.77
Rate for Payer: Cash Price	$264.60
Rate for Payer: Health Management Network Commercial	$374.85
Rate for Payer: Kaiser Permanente Commercial	$396.90
Rate for Payer: MDX Hawaii PPO	$427.77

AMPLATZ URETERAL 8.5FRX24

Facility

$441.00

Service Code	HCPCS C2625
Hospital Revenue Code	272
Min. Negotiated Rate	$220.50
Max. Negotiated Rate	$427.77
Rate for Payer: AlohaCare Medicaid	$220.50
Rate for Payer: AlohaCare Medicare	$335.16
Rate for Payer: Cash Price	$264.60
Rate for Payer: Devoted Health Medicare	$370.44
Rate for Payer: Hawaii Medical Service Association Medicare	$335.16
Rate for Payer: Hawaii Western Management Group Commercial	$418.95
Rate for Payer: Health Management Network Commercial	$374.85
Rate for Payer: Humana Medicare	$335.16
Rate for Payer: Kaiser Permanente Commercial	$396.90
Rate for Payer: Kaiser Permanente Medicaid	$224.91
Rate for Payer: Kaiser Permanente Medicare	$335.16
Rate for Payer: MDX Hawaii PPO	$427.77
Rate for Payer: Ohana Health Plan Medicaid	$335.16
Rate for Payer: Ohana Health Plan Medicare	$335.16
Rate for Payer: UnitedHealthcare Medicare	$335.16
Rate for Payer: University Health Alliance Commercial	$321.44

AMPLATZ URETERAL 8.5FRX24

Facility

$441.00

Service Code	HCPCS C2625
Hospital Revenue Code	272
Min. Negotiated Rate	$374.85
Max. Negotiated Rate	$427.77
Rate for Payer: Cash Price	$264.60
Rate for Payer: Health Management Network Commercial	$374.85
Rate for Payer: Kaiser Permanente Commercial	$396.90
Rate for Payer: MDX Hawaii PPO	$427.77

AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS EXCEPT UPPER LIMB AND TOE WITH CC

Facility

$80,800.12

Service Code	MSDRG 240
Min. Negotiated Rate	$80,800.12
Max. Negotiated Rate	$80,800.12
Rate for Payer: Hawaii Medical Service Association Commercial	$80,800.12

AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS EXCEPT UPPER LIMB AND TOE WITH MCC

Facility

$80,800.12

Service Code	MSDRG 239
Min. Negotiated Rate	$80,800.12
Max. Negotiated Rate	$80,800.12
Rate for Payer: Hawaii Medical Service Association Commercial	$80,800.12

AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS EXCEPT UPPER LIMB AND TOE WITHOUT CC/MCC

Facility

$80,800.12

Service Code	MSDRG 241
Min. Negotiated Rate	$80,800.12
Max. Negotiated Rate	$80,800.12
Rate for Payer: Hawaii Medical Service Association Commercial	$80,800.12

AMPUTATION FOR MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DISORDERS WITH CC

Facility

$40,696.33

Service Code	MSDRG 475
Min. Negotiated Rate	$40,696.33
Max. Negotiated Rate	$40,696.33
Rate for Payer: Hawaii Medical Service Association Commercial	$40,696.33

AMPUTATION FOR MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DISORDERS WITH MCC

Facility

$40,696.33

Service Code	MSDRG 474
Min. Negotiated Rate	$40,696.33
Max. Negotiated Rate	$40,696.33
Rate for Payer: Hawaii Medical Service Association Commercial	$40,696.33

AMPUTATION FOR MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DISORDERS WITHOUT CC/MCC

Facility

$40,696.33

Service Code	MSDRG 476
Min. Negotiated Rate	$40,696.33
Max. Negotiated Rate	$40,696.33
Rate for Payer: Hawaii Medical Service Association Commercial	$40,696.33

AMPUTATION OF LOWER LIMB FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS WITH CC

Facility

$71,603.74

Service Code	MSDRG 617
Min. Negotiated Rate	$71,603.74
Max. Negotiated Rate	$71,603.74
Rate for Payer: Hawaii Medical Service Association Commercial	$71,603.74

AMPUTATION OF LOWER LIMB FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS WITH MCC

Facility

$71,603.74

Service Code	MSDRG 616
Min. Negotiated Rate	$71,603.74
Max. Negotiated Rate	$71,603.74
Rate for Payer: Hawaii Medical Service Association Commercial	$71,603.74

AMPUTATION OF LOWER LIMB FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS WITHOUT CC/MCC

Facility

$71,603.74

Service Code	MSDRG 618
Min. Negotiated Rate	$71,603.74
Max. Negotiated Rate	$71,603.74
Rate for Payer: Hawaii Medical Service Association Commercial	$71,603.74

AMS 700 ACCESSORY KIT 72401850

Facility

$2,970.00

Hospital Revenue Code	272
Min. Negotiated Rate	$1,485.00
Max. Negotiated Rate	$2,880.90
Rate for Payer: AlohaCare Medicaid	$1,485.00
Rate for Payer: AlohaCare Medicare	$2,257.20
Rate for Payer: Cash Price	$1,782.00
Rate for Payer: Devoted Health Medicare	$2,494.80
Rate for Payer: Hawaii Medical Service Association Medicare	$2,257.20
Rate for Payer: Hawaii Western Management Group Commercial	$2,821.50
Rate for Payer: Health Management Network Commercial	$2,524.50
Rate for Payer: Humana Medicare	$2,257.20
Rate for Payer: Kaiser Permanente Commercial	$2,673.00
Rate for Payer: Kaiser Permanente Medicaid	$1,514.70
Rate for Payer: Kaiser Permanente Medicare	$2,257.20
Rate for Payer: MDX Hawaii PPO	$2,880.90
Rate for Payer: Ohana Health Plan Medicaid	$2,257.20
Rate for Payer: Ohana Health Plan Medicare	$2,257.20
Rate for Payer: UnitedHealthcare Medicare	$2,257.20
Rate for Payer: University Health Alliance Commercial	$2,164.83

AMS 700 ACCESSORY KIT 72401850

Facility

$2,970.00

Hospital Revenue Code	272
Min. Negotiated Rate	$2,524.50
Max. Negotiated Rate	$2,880.90
Rate for Payer: Cash Price	$1,782.00
Rate for Payer: Health Management Network Commercial	$2,524.50
Rate for Payer: Kaiser Permanente Commercial	$2,673.00
Rate for Payer: MDX Hawaii PPO	$2,880.90

AMS CONCEAL RESERVR 720185-01

Facility

$6,345.00

Service Code	HCPCS C1813
Hospital Revenue Code	278
Min. Negotiated Rate	$3,553.20
Max. Negotiated Rate	$6,154.65
Rate for Payer: Cash Price	$3,807.00
Rate for Payer: Hawaii Western Management Group Commercial	$4,441.50
Rate for Payer: Health Management Network Commercial	$5,393.25
Rate for Payer: Kaiser Permanente Commercial	$5,710.50
Rate for Payer: MDX Hawaii PPO	$6,154.65
Rate for Payer: University Health Alliance Commercial	$3,553.20

AMS CONCEAL RESERVR 720185-01

Facility

$6,345.00

Service Code	HCPCS C1813
Hospital Revenue Code	278
Min. Negotiated Rate	$3,172.50
Max. Negotiated Rate	$6,154.65
Rate for Payer: AlohaCare Medicaid	$3,172.50
Rate for Payer: AlohaCare Medicare	$4,822.20
Rate for Payer: Cash Price	$3,807.00
Rate for Payer: Devoted Health Medicare	$5,329.80
Rate for Payer: Hawaii Medical Service Association Medicare	$4,822.20
Rate for Payer: Hawaii Western Management Group Commercial	$4,441.50
Rate for Payer: Health Management Network Commercial	$5,393.25
Rate for Payer: Humana Medicare	$4,822.20
Rate for Payer: Kaiser Permanente Commercial	$5,710.50
Rate for Payer: Kaiser Permanente Medicaid	$3,235.95
Rate for Payer: Kaiser Permanente Medicare	$4,822.20
Rate for Payer: MDX Hawaii PPO	$6,154.65
Rate for Payer: Ohana Health Plan Medicaid	$4,822.20
Rate for Payer: Ohana Health Plan Medicare	$4,822.20
Rate for Payer: UnitedHealthcare Medicare	$4,822.20
Rate for Payer: University Health Alliance Commercial	$3,553.20

ANAL AND STOMAL PROCEDURES WITH CC

Facility

$22,872.43

Service Code	MSDRG 348
Min. Negotiated Rate	$22,872.43
Max. Negotiated Rate	$22,872.43
Rate for Payer: Hawaii Medical Service Association Commercial	$22,872.43

ANAL AND STOMAL PROCEDURES WITH MCC

Facility

$28,513.51

Service Code	MSDRG 347
Min. Negotiated Rate	$28,513.51
Max. Negotiated Rate	$28,513.51
Rate for Payer: Hawaii Medical Service Association Commercial	$28,513.51

ANAL AND STOMAL PROCEDURES WITHOUT CC/MCC

Facility

$14,197.50

Service Code	MSDRG 349
Min. Negotiated Rate	$14,197.50
Max. Negotiated Rate	$14,197.50
Rate for Payer: Hawaii Medical Service Association Commercial	$14,197.50

Know your out-of-pocket cost for care.

All Charges