Honoka'a Hospital and Skilled Nursing Facility

All Charges

Charge

Type

Setting

Price

GUAIFENESIN/DM 100-10 MG/10 ML SYRUP (ROBITUSSIN DM) (118 ML) (TAKE HOME) [4080394]

Facility

$15.00

Service Code	NDC 00004080182
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

GUAIFENESIN ER 600 MG TABLET, EXTENDED RELEASE 12 HR [37651]

Facility

$4.00

Service Code	NDC 68084057211
Hospital Revenue Code	250
Min. Negotiated Rate	$3.40
Max. Negotiated Rate	$3.88
Rate for Payer: Cash Price	$2.40
Rate for Payer: Health Management Network Commercial	$3.40
Rate for Payer: Kaiser Permanente Commercial	$3.60
Rate for Payer: MDX Hawaii PPO	$3.88

GUAIFENESIN ER 600 MG TABLET, EXTENDED RELEASE 12 HR [37651]

Facility

$4.00

Service Code	NDC 68084057201
Hospital Revenue Code	637
Min. Negotiated Rate	$2.00
Max. Negotiated Rate	$3.88
Rate for Payer: AlohaCare Medicaid	$2.00
Rate for Payer: AlohaCare Medicare	$3.04
Rate for Payer: Cash Price	$2.40
Rate for Payer: Devoted Health Medicare	$3.36
Rate for Payer: Hawaii Medical Service Association Medicare	$3.04
Rate for Payer: Hawaii Western Management Group Commercial	$3.80
Rate for Payer: Health Management Network Commercial	$3.40
Rate for Payer: Humana Medicare	$3.04
Rate for Payer: Kaiser Permanente Commercial	$3.60
Rate for Payer: Kaiser Permanente Medicaid	$2.04
Rate for Payer: Kaiser Permanente Medicare	$3.04
Rate for Payer: MDX Hawaii PPO	$3.88
Rate for Payer: Ohana Health Plan Medicaid	$3.04
Rate for Payer: Ohana Health Plan Medicare	$3.04
Rate for Payer: UnitedHealthcare Medicare	$3.04
Rate for Payer: University Health Alliance Commercial	$2.92

GUAIFENESIN ER 600 MG TABLET, EXTENDED RELEASE 12 HR [37651]

Facility

$4.00

Service Code	NDC 68084057201
Hospital Revenue Code	250
Min. Negotiated Rate	$3.40
Max. Negotiated Rate	$3.88
Rate for Payer: Cash Price	$2.40
Rate for Payer: Health Management Network Commercial	$3.40
Rate for Payer: Kaiser Permanente Commercial	$3.60
Rate for Payer: MDX Hawaii PPO	$3.88

GUAIFENESIN ER 600 MG TABLET, EXTENDED RELEASE 12 HR [37651]

Facility

$4.00

Service Code	NDC 68084057211
Hospital Revenue Code	637
Min. Negotiated Rate	$2.00
Max. Negotiated Rate	$3.88
Rate for Payer: AlohaCare Medicaid	$2.00
Rate for Payer: AlohaCare Medicare	$3.04
Rate for Payer: Cash Price	$2.40
Rate for Payer: Devoted Health Medicare	$3.36
Rate for Payer: Hawaii Medical Service Association Medicare	$3.04
Rate for Payer: Hawaii Western Management Group Commercial	$3.80
Rate for Payer: Health Management Network Commercial	$3.40
Rate for Payer: Humana Medicare	$3.04
Rate for Payer: Kaiser Permanente Commercial	$3.60
Rate for Payer: Kaiser Permanente Medicaid	$2.04
Rate for Payer: Kaiser Permanente Medicare	$3.04
Rate for Payer: MDX Hawaii PPO	$3.88
Rate for Payer: Ohana Health Plan Medicaid	$3.04
Rate for Payer: Ohana Health Plan Medicare	$3.04
Rate for Payer: UnitedHealthcare Medicare	$3.04
Rate for Payer: University Health Alliance Commercial	$2.92

GUIDE BP DRILL 47-4309-061-15

Facility

$788.00

Hospital Revenue Code	272
Min. Negotiated Rate	$394.00
Max. Negotiated Rate	$764.36
Rate for Payer: AlohaCare Medicaid	$394.00
Rate for Payer: AlohaCare Medicare	$598.88
Rate for Payer: Cash Price	$472.80
Rate for Payer: Devoted Health Medicare	$661.92
Rate for Payer: Hawaii Medical Service Association Medicare	$598.88
Rate for Payer: Hawaii Western Management Group Commercial	$748.60
Rate for Payer: Health Management Network Commercial	$669.80
Rate for Payer: Humana Medicare	$598.88
Rate for Payer: Kaiser Permanente Commercial	$709.20
Rate for Payer: Kaiser Permanente Medicaid	$401.88
Rate for Payer: Kaiser Permanente Medicare	$598.88
Rate for Payer: MDX Hawaii PPO	$764.36
Rate for Payer: Ohana Health Plan Medicaid	$598.88
Rate for Payer: Ohana Health Plan Medicare	$598.88
Rate for Payer: UnitedHealthcare Medicare	$598.88
Rate for Payer: University Health Alliance Commercial	$574.37

GUIDE BP DRILL 47-4309-061-15

Facility

$788.00

Hospital Revenue Code	272
Min. Negotiated Rate	$669.80
Max. Negotiated Rate	$764.36
Rate for Payer: Cash Price	$472.80
Rate for Payer: Health Management Network Commercial	$669.80
Rate for Payer: Kaiser Permanente Commercial	$709.20
Rate for Payer: MDX Hawaii PPO	$764.36

GUIDE MINI 1.8MM GUIDEMINI-1.8

Facility

$200.00

Service Code	HCPCS C1769
Hospital Revenue Code	272
Min. Negotiated Rate	$100.00
Max. Negotiated Rate	$194.00
Rate for Payer: AlohaCare Medicaid	$100.00
Rate for Payer: AlohaCare Medicare	$152.00
Rate for Payer: Cash Price	$120.00
Rate for Payer: Devoted Health Medicare	$168.00
Rate for Payer: Hawaii Medical Service Association Medicare	$152.00
Rate for Payer: Hawaii Western Management Group Commercial	$190.00
Rate for Payer: Health Management Network Commercial	$170.00
Rate for Payer: Humana Medicare	$152.00
Rate for Payer: Kaiser Permanente Commercial	$180.00
Rate for Payer: Kaiser Permanente Medicaid	$102.00
Rate for Payer: Kaiser Permanente Medicare	$152.00
Rate for Payer: MDX Hawaii PPO	$194.00
Rate for Payer: Ohana Health Plan Medicaid	$152.00
Rate for Payer: Ohana Health Plan Medicare	$152.00
Rate for Payer: UnitedHealthcare Medicare	$152.00
Rate for Payer: University Health Alliance Commercial	$145.78

GUIDE MINI 1.8MM GUIDEMINI-1.8

Facility

$200.00

Service Code	HCPCS C1769
Hospital Revenue Code	272
Min. Negotiated Rate	$170.00
Max. Negotiated Rate	$194.00
Rate for Payer: Cash Price	$120.00
Rate for Payer: Health Management Network Commercial	$170.00
Rate for Payer: Kaiser Permanente Commercial	$180.00
Rate for Payer: MDX Hawaii PPO	$194.00

GUIDE PEG 1.8MM GUIDEPEG-1.8

Facility

$563.00

Service Code	HCPCS C1769
Hospital Revenue Code	272
Min. Negotiated Rate	$281.50
Max. Negotiated Rate	$546.11
Rate for Payer: AlohaCare Medicaid	$281.50
Rate for Payer: AlohaCare Medicare	$427.88
Rate for Payer: Cash Price	$337.80
Rate for Payer: Devoted Health Medicare	$472.92
Rate for Payer: Hawaii Medical Service Association Medicare	$427.88
Rate for Payer: Hawaii Western Management Group Commercial	$534.85
Rate for Payer: Health Management Network Commercial	$478.55
Rate for Payer: Humana Medicare	$427.88
Rate for Payer: Kaiser Permanente Commercial	$506.70
Rate for Payer: Kaiser Permanente Medicaid	$287.13
Rate for Payer: Kaiser Permanente Medicare	$427.88
Rate for Payer: MDX Hawaii PPO	$546.11
Rate for Payer: Ohana Health Plan Medicaid	$427.88
Rate for Payer: Ohana Health Plan Medicare	$427.88
Rate for Payer: UnitedHealthcare Medicare	$427.88
Rate for Payer: University Health Alliance Commercial	$410.37

GUIDE PEG 1.8MM GUIDEPEG-1.8

Facility

$563.00

Service Code	HCPCS C1769
Hospital Revenue Code	272
Min. Negotiated Rate	$478.55
Max. Negotiated Rate	$546.11
Rate for Payer: Cash Price	$337.80
Rate for Payer: Health Management Network Commercial	$478.55
Rate for Payer: Kaiser Permanente Commercial	$506.70
Rate for Payer: MDX Hawaii PPO	$546.11

GUIDE PIN 1.3MMX140CM 128047

Facility

$262.00

Service Code	HCPCS C1713
Hospital Revenue Code	272
Min. Negotiated Rate	$131.00
Max. Negotiated Rate	$254.14
Rate for Payer: AlohaCare Medicaid	$131.00
Rate for Payer: AlohaCare Medicare	$199.12
Rate for Payer: Cash Price	$157.20
Rate for Payer: Devoted Health Medicare	$220.08
Rate for Payer: Hawaii Medical Service Association Medicare	$199.12
Rate for Payer: Hawaii Western Management Group Commercial	$248.90
Rate for Payer: Health Management Network Commercial	$222.70
Rate for Payer: Humana Medicare	$199.12
Rate for Payer: Kaiser Permanente Commercial	$235.80
Rate for Payer: Kaiser Permanente Medicaid	$133.62
Rate for Payer: Kaiser Permanente Medicare	$199.12
Rate for Payer: MDX Hawaii PPO	$254.14
Rate for Payer: Ohana Health Plan Medicaid	$199.12
Rate for Payer: Ohana Health Plan Medicare	$199.12
Rate for Payer: UnitedHealthcare Medicare	$199.12
Rate for Payer: University Health Alliance Commercial	$190.97

GUIDE PIN 1.3MMX140CM 128047

Facility

$262.00

Service Code	HCPCS C1713
Hospital Revenue Code	272
Min. Negotiated Rate	$222.70
Max. Negotiated Rate	$254.14
Rate for Payer: Cash Price	$157.20
Rate for Payer: Health Management Network Commercial	$222.70
Rate for Payer: Kaiser Permanente Commercial	$235.80
Rate for Payer: MDX Hawaii PPO	$254.14

GUIDE PIN 1.3X140MM 1280309

Facility

$228.00

Hospital Revenue Code	272
Min. Negotiated Rate	$193.80
Max. Negotiated Rate	$221.16
Rate for Payer: Cash Price	$136.80
Rate for Payer: Health Management Network Commercial	$193.80
Rate for Payer: Kaiser Permanente Commercial	$205.20
Rate for Payer: MDX Hawaii PPO	$221.16

GUIDE PIN 1.3X140MM 1280309

Facility

$228.00

Hospital Revenue Code	272
Min. Negotiated Rate	$114.00
Max. Negotiated Rate	$221.16
Rate for Payer: AlohaCare Medicaid	$114.00
Rate for Payer: AlohaCare Medicare	$173.28
Rate for Payer: Cash Price	$136.80
Rate for Payer: Devoted Health Medicare	$191.52
Rate for Payer: Hawaii Medical Service Association Medicare	$173.28
Rate for Payer: Hawaii Western Management Group Commercial	$216.60
Rate for Payer: Health Management Network Commercial	$193.80
Rate for Payer: Humana Medicare	$173.28
Rate for Payer: Kaiser Permanente Commercial	$205.20
Rate for Payer: Kaiser Permanente Medicaid	$116.28
Rate for Payer: Kaiser Permanente Medicare	$173.28
Rate for Payer: MDX Hawaii PPO	$221.16
Rate for Payer: Ohana Health Plan Medicaid	$173.28
Rate for Payer: Ohana Health Plan Medicare	$173.28
Rate for Payer: UnitedHealthcare Medicare	$173.28
Rate for Payer: University Health Alliance Commercial	$166.19

GUIDE PIN 3X100 7000-30-100

Facility

$775.00

Service Code	HCPCS C1769
Hospital Revenue Code	272
Min. Negotiated Rate	$387.50
Max. Negotiated Rate	$751.75
Rate for Payer: AlohaCare Medicaid	$387.50
Rate for Payer: AlohaCare Medicare	$589.00
Rate for Payer: Cash Price	$465.00
Rate for Payer: Devoted Health Medicare	$651.00
Rate for Payer: Hawaii Medical Service Association Medicare	$589.00
Rate for Payer: Hawaii Western Management Group Commercial	$736.25
Rate for Payer: Health Management Network Commercial	$658.75
Rate for Payer: Humana Medicare	$589.00
Rate for Payer: Kaiser Permanente Commercial	$697.50
Rate for Payer: Kaiser Permanente Medicaid	$395.25
Rate for Payer: Kaiser Permanente Medicare	$589.00
Rate for Payer: MDX Hawaii PPO	$751.75
Rate for Payer: Ohana Health Plan Medicaid	$589.00
Rate for Payer: Ohana Health Plan Medicare	$589.00
Rate for Payer: UnitedHealthcare Medicare	$589.00
Rate for Payer: University Health Alliance Commercial	$564.90

GUIDE PIN 3X100 7000-30-100

Facility

$775.00

Service Code	HCPCS C1769
Hospital Revenue Code	272
Min. Negotiated Rate	$658.75
Max. Negotiated Rate	$751.75
Rate for Payer: Cash Price	$465.00
Rate for Payer: Health Management Network Commercial	$658.75
Rate for Payer: Kaiser Permanente Commercial	$697.50
Rate for Payer: MDX Hawaii PPO	$751.75

GUIDE ROD 3.0/950MM 355.041S

Facility

$784.00

Service Code	HCPCS C1769
Hospital Revenue Code	272
Min. Negotiated Rate	$392.00
Max. Negotiated Rate	$760.48
Rate for Payer: AlohaCare Medicaid	$392.00
Rate for Payer: AlohaCare Medicare	$595.84
Rate for Payer: Cash Price	$470.40
Rate for Payer: Devoted Health Medicare	$658.56
Rate for Payer: Hawaii Medical Service Association Medicare	$595.84
Rate for Payer: Hawaii Western Management Group Commercial	$744.80
Rate for Payer: Health Management Network Commercial	$666.40
Rate for Payer: Humana Medicare	$595.84
Rate for Payer: Kaiser Permanente Commercial	$705.60
Rate for Payer: Kaiser Permanente Medicaid	$399.84
Rate for Payer: Kaiser Permanente Medicare	$595.84
Rate for Payer: MDX Hawaii PPO	$760.48
Rate for Payer: Ohana Health Plan Medicaid	$595.84
Rate for Payer: Ohana Health Plan Medicare	$595.84
Rate for Payer: UnitedHealthcare Medicare	$595.84
Rate for Payer: University Health Alliance Commercial	$571.46

GUIDE ROD 3.0/950MM 355.041S

Facility

$784.00

Service Code	HCPCS C1769
Hospital Revenue Code	272
Min. Negotiated Rate	$666.40
Max. Negotiated Rate	$760.48
Rate for Payer: Cash Price	$470.40
Rate for Payer: Health Management Network Commercial	$666.40
Rate for Payer: Kaiser Permanente Commercial	$705.60
Rate for Payer: MDX Hawaii PPO	$760.48

GUIDE ROD 3.0MM, 950MM

Facility

$561.00

Service Code	HCPCS C1769
Hospital Revenue Code	272
Min. Negotiated Rate	$280.50
Max. Negotiated Rate	$544.17
Rate for Payer: AlohaCare Medicaid	$280.50
Rate for Payer: AlohaCare Medicare	$426.36
Rate for Payer: Cash Price	$336.60
Rate for Payer: Devoted Health Medicare	$471.24
Rate for Payer: Hawaii Medical Service Association Medicare	$426.36
Rate for Payer: Hawaii Western Management Group Commercial	$532.95
Rate for Payer: Health Management Network Commercial	$476.85
Rate for Payer: Humana Medicare	$426.36
Rate for Payer: Kaiser Permanente Commercial	$504.90
Rate for Payer: Kaiser Permanente Medicaid	$286.11
Rate for Payer: Kaiser Permanente Medicare	$426.36
Rate for Payer: MDX Hawaii PPO	$544.17
Rate for Payer: Ohana Health Plan Medicaid	$426.36
Rate for Payer: Ohana Health Plan Medicare	$426.36
Rate for Payer: UnitedHealthcare Medicare	$426.36
Rate for Payer: University Health Alliance Commercial	$408.91

GUIDE ROD 3.0MM, 950MM

Facility

$561.00

Service Code	HCPCS C1769
Hospital Revenue Code	272
Min. Negotiated Rate	$476.85
Max. Negotiated Rate	$544.17
Rate for Payer: Cash Price	$336.60
Rate for Payer: Health Management Network Commercial	$476.85
Rate for Payer: Kaiser Permanente Commercial	$504.90
Rate for Payer: MDX Hawaii PPO	$544.17

GUIDE RS 2.5DRL 47-4309-046-01

Facility

$788.00

Hospital Revenue Code	272
Min. Negotiated Rate	$669.80
Max. Negotiated Rate	$764.36
Rate for Payer: Cash Price	$472.80
Rate for Payer: Health Management Network Commercial	$669.80
Rate for Payer: Kaiser Permanente Commercial	$709.20
Rate for Payer: MDX Hawaii PPO	$764.36

GUIDE RS 2.5DRL 47-4309-046-01

Facility

$788.00

Hospital Revenue Code	272
Min. Negotiated Rate	$394.00
Max. Negotiated Rate	$764.36
Rate for Payer: AlohaCare Medicaid	$394.00
Rate for Payer: AlohaCare Medicare	$598.88
Rate for Payer: Cash Price	$472.80
Rate for Payer: Devoted Health Medicare	$661.92
Rate for Payer: Hawaii Medical Service Association Medicare	$598.88
Rate for Payer: Hawaii Western Management Group Commercial	$748.60
Rate for Payer: Health Management Network Commercial	$669.80
Rate for Payer: Humana Medicare	$598.88
Rate for Payer: Kaiser Permanente Commercial	$709.20
Rate for Payer: Kaiser Permanente Medicaid	$401.88
Rate for Payer: Kaiser Permanente Medicare	$598.88
Rate for Payer: MDX Hawaii PPO	$764.36
Rate for Payer: Ohana Health Plan Medicaid	$598.88
Rate for Payer: Ohana Health Plan Medicare	$598.88
Rate for Payer: UnitedHealthcare Medicare	$598.88
Rate for Payer: University Health Alliance Commercial	$574.37

GUIDE RS 2.5PIN 47-4309-025-01

Facility

$599.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$299.50
Max. Negotiated Rate	$581.03
Rate for Payer: AlohaCare Medicaid	$299.50
Rate for Payer: AlohaCare Medicare	$455.24
Rate for Payer: Cash Price	$359.40
Rate for Payer: Devoted Health Medicare	$503.16
Rate for Payer: Hawaii Medical Service Association Medicare	$455.24
Rate for Payer: Hawaii Western Management Group Commercial	$419.30
Rate for Payer: Health Management Network Commercial	$509.15
Rate for Payer: Humana Medicare	$455.24
Rate for Payer: Kaiser Permanente Commercial	$539.10
Rate for Payer: Kaiser Permanente Medicaid	$305.49
Rate for Payer: Kaiser Permanente Medicare	$455.24
Rate for Payer: MDX Hawaii PPO	$581.03
Rate for Payer: Ohana Health Plan Medicaid	$455.24
Rate for Payer: Ohana Health Plan Medicare	$455.24
Rate for Payer: UnitedHealthcare Medicare	$455.24
Rate for Payer: University Health Alliance Commercial	$335.44

GUIDE RS 2.5PIN 47-4309-025-01

Facility

$599.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$335.44
Max. Negotiated Rate	$581.03
Rate for Payer: Cash Price	$359.40
Rate for Payer: Hawaii Western Management Group Commercial	$419.30
Rate for Payer: Health Management Network Commercial	$509.15
Rate for Payer: Kaiser Permanente Commercial	$539.10
Rate for Payer: MDX Hawaii PPO	$581.03
Rate for Payer: University Health Alliance Commercial	$335.44

Know your out-of-pocket cost for care.

All Charges