Honoka'a Hospital and Skilled Nursing Facility

All Charges

Charge

Type

Setting

Price

IBUPROFEN 600 MG TABLET [3844]

Facility

$2.00

Service Code	NDC 00904585461
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

IBUPROFEN 600 MG TABLET [3844]

Facility

$2.00

Service Code	NDC 00904585461
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

IBUPROFEN 600 MG TABLET [3844]

Facility

$2.00

Service Code	NDC 60687045711
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

IBUPROFEN 600 MG TABLET [3844]

Facility

$2.00

Service Code	NDC 60687045701
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

IBUPROFEN 600 MG TABLET [3844]

Facility

$2.00

Service Code	NDC 60687045711
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

IBUPROFEN 800 MG TABLET [3845]

Facility

$2.00

Service Code	NDC 00904585561
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

IBUPROFEN 800 MG TABLET [3845]

Facility

$2.00

Service Code	NDC 00904585561
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

IBUPROFEN SUSPENSION (MOTRIN) 100 MG/5 ML (120 ML) (TAKE HOME) [4080367]

Facility

$15.00

Service Code	NDC 00004080155
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

IBUPROFEN SUSPENSION (MOTRIN) 100 MG/5 ML (120 ML) (TAKE HOME) [4080367]

Facility

$15.00

Service Code	NDC 00004080155
Hospital Revenue Code	253
Min. Negotiated Rate	$7.50
Max. Negotiated Rate	$14.55
Rate for Payer: AlohaCare Medicaid	$7.50
Rate for Payer: AlohaCare Medicare	$11.40
Rate for Payer: Cash Price	$9.00
Rate for Payer: Devoted Health Medicare	$12.60
Rate for Payer: Hawaii Medical Service Association Medicare	$11.40
Rate for Payer: Hawaii Western Management Group Commercial	$14.25
Rate for Payer: Health Management Network Commercial	$12.75
Rate for Payer: Humana Medicare	$11.40
Rate for Payer: Kaiser Permanente Commercial	$13.50
Rate for Payer: Kaiser Permanente Medicaid	$7.65
Rate for Payer: Kaiser Permanente Medicare	$11.40
Rate for Payer: MDX Hawaii PPO	$14.55
Rate for Payer: Ohana Health Plan Medicaid	$11.40
Rate for Payer: Ohana Health Plan Medicare	$11.40
Rate for Payer: UnitedHealthcare Medicare	$11.40
Rate for Payer: University Health Alliance Commercial	$10.93

IBUPROFEN TABLETS (MOTRIN) 400 MG (TAKE HOME) [4080368]

Facility

$15.00

Service Code	NDC 00004080156
Hospital Revenue Code	253
Min. Negotiated Rate	$7.50
Max. Negotiated Rate	$14.55
Rate for Payer: AlohaCare Medicaid	$7.50
Rate for Payer: AlohaCare Medicare	$11.40
Rate for Payer: Cash Price	$9.00
Rate for Payer: Devoted Health Medicare	$12.60
Rate for Payer: Hawaii Medical Service Association Medicare	$11.40
Rate for Payer: Hawaii Western Management Group Commercial	$14.25
Rate for Payer: Health Management Network Commercial	$12.75
Rate for Payer: Humana Medicare	$11.40
Rate for Payer: Kaiser Permanente Commercial	$13.50
Rate for Payer: Kaiser Permanente Medicaid	$7.65
Rate for Payer: Kaiser Permanente Medicare	$11.40
Rate for Payer: MDX Hawaii PPO	$14.55
Rate for Payer: Ohana Health Plan Medicaid	$11.40
Rate for Payer: Ohana Health Plan Medicare	$11.40
Rate for Payer: UnitedHealthcare Medicare	$11.40
Rate for Payer: University Health Alliance Commercial	$10.93

IBUPROFEN TABLETS (MOTRIN) 400 MG (TAKE HOME) [4080368]

Facility

$15.00

Service Code	NDC 00004080156
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

ICATIBANT 30 MG/3 ML SUBCUTANEOUS SYRINGE [191015]

Facility

$13,209.00

Service Code	HCPCS J1744
Hospital Revenue Code	250
Min. Negotiated Rate	$11,227.65
Max. Negotiated Rate	$12,812.73
Rate for Payer: Cash Price	$7,925.40
Rate for Payer: Health Management Network Commercial	$11,227.65
Rate for Payer: Kaiser Permanente Commercial	$11,888.10
Rate for Payer: MDX Hawaii PPO	$12,812.73

ICD EVERA MRI XT DDMB1D1

Facility

$43,890.00

Service Code	HCPCS C1721
Hospital Revenue Code	275
Min. Negotiated Rate	$24,578.40
Max. Negotiated Rate	$42,573.30
Rate for Payer: Cash Price	$26,334.00
Rate for Payer: Hawaii Western Management Group Commercial	$30,723.00
Rate for Payer: Health Management Network Commercial	$37,306.50
Rate for Payer: Kaiser Permanente Commercial	$39,501.00
Rate for Payer: MDX Hawaii PPO	$42,573.30
Rate for Payer: University Health Alliance Commercial	$24,578.40

ICD EVERA MRI XT DDMB1D1

Facility

$43,890.00

Service Code	HCPCS C1721
Hospital Revenue Code	275
Min. Negotiated Rate	$21,945.00
Max. Negotiated Rate	$42,573.30
Rate for Payer: AlohaCare Medicaid	$21,945.00
Rate for Payer: AlohaCare Medicare	$33,356.40
Rate for Payer: Cash Price	$26,334.00
Rate for Payer: Devoted Health Medicare	$36,867.60
Rate for Payer: Hawaii Medical Service Association Medicare	$33,356.40
Rate for Payer: Hawaii Western Management Group Commercial	$30,723.00
Rate for Payer: Health Management Network Commercial	$37,306.50
Rate for Payer: Humana Medicare	$33,356.40
Rate for Payer: Kaiser Permanente Commercial	$39,501.00
Rate for Payer: Kaiser Permanente Medicaid	$22,383.90
Rate for Payer: Kaiser Permanente Medicare	$33,356.40
Rate for Payer: MDX Hawaii PPO	$42,573.30
Rate for Payer: Ohana Health Plan Medicaid	$33,356.40
Rate for Payer: Ohana Health Plan Medicare	$33,356.40
Rate for Payer: UnitedHealthcare Medicare	$33,356.40
Rate for Payer: University Health Alliance Commercial	$24,578.40

ICEFORCE CRYO NEEDLE

Facility

$3,790.00

Service Code	HCPCS C2618
Hospital Revenue Code	272
Min. Negotiated Rate	$3,221.50
Max. Negotiated Rate	$3,676.30
Rate for Payer: Cash Price	$2,274.00
Rate for Payer: Health Management Network Commercial	$3,221.50
Rate for Payer: Kaiser Permanente Commercial	$3,411.00
Rate for Payer: MDX Hawaii PPO	$3,676.30

ICEFORCE CRYO NEEDLE

Facility

$3,790.00

Service Code	HCPCS C2618
Hospital Revenue Code	272
Min. Negotiated Rate	$1,895.00
Max. Negotiated Rate	$3,676.30
Rate for Payer: AlohaCare Medicaid	$1,895.00
Rate for Payer: AlohaCare Medicare	$2,880.40
Rate for Payer: Cash Price	$2,274.00
Rate for Payer: Devoted Health Medicare	$3,183.60
Rate for Payer: Hawaii Medical Service Association Medicare	$2,880.40
Rate for Payer: Hawaii Western Management Group Commercial	$3,600.50
Rate for Payer: Health Management Network Commercial	$3,221.50
Rate for Payer: Humana Medicare	$2,880.40
Rate for Payer: Kaiser Permanente Commercial	$3,411.00
Rate for Payer: Kaiser Permanente Medicaid	$1,932.90
Rate for Payer: Kaiser Permanente Medicare	$2,880.40
Rate for Payer: MDX Hawaii PPO	$3,676.30
Rate for Payer: Ohana Health Plan Medicaid	$2,880.40
Rate for Payer: Ohana Health Plan Medicare	$2,880.40
Rate for Payer: UnitedHealthcare Medicare	$2,880.40
Rate for Payer: University Health Alliance Commercial	$2,762.53

ICEPEARL CRYO NEEDLE

Facility

$3,790.00

Service Code	HCPCS C2618
Hospital Revenue Code	272
Min. Negotiated Rate	$1,895.00
Max. Negotiated Rate	$3,676.30
Rate for Payer: AlohaCare Medicaid	$1,895.00
Rate for Payer: AlohaCare Medicare	$2,880.40
Rate for Payer: Cash Price	$2,274.00
Rate for Payer: Devoted Health Medicare	$3,183.60
Rate for Payer: Hawaii Medical Service Association Medicare	$2,880.40
Rate for Payer: Hawaii Western Management Group Commercial	$3,600.50
Rate for Payer: Health Management Network Commercial	$3,221.50
Rate for Payer: Humana Medicare	$2,880.40
Rate for Payer: Kaiser Permanente Commercial	$3,411.00
Rate for Payer: Kaiser Permanente Medicaid	$1,932.90
Rate for Payer: Kaiser Permanente Medicare	$2,880.40
Rate for Payer: MDX Hawaii PPO	$3,676.30
Rate for Payer: Ohana Health Plan Medicaid	$2,880.40
Rate for Payer: Ohana Health Plan Medicare	$2,880.40
Rate for Payer: UnitedHealthcare Medicare	$2,880.40
Rate for Payer: University Health Alliance Commercial	$2,762.53

ICEPEARL CRYO NEEDLE

Facility

$3,790.00

Service Code	HCPCS C2618
Hospital Revenue Code	272
Min. Negotiated Rate	$3,221.50
Max. Negotiated Rate	$3,676.30
Rate for Payer: Cash Price	$2,274.00
Rate for Payer: Health Management Network Commercial	$3,221.50
Rate for Payer: Kaiser Permanente Commercial	$3,411.00
Rate for Payer: MDX Hawaii PPO	$3,676.30

ICEROD CRYO NEEDLE

Facility

$3,790.00

Service Code	HCPCS C2618
Hospital Revenue Code	272
Min. Negotiated Rate	$3,221.50
Max. Negotiated Rate	$3,676.30
Rate for Payer: Cash Price	$2,274.00
Rate for Payer: Health Management Network Commercial	$3,221.50
Rate for Payer: Kaiser Permanente Commercial	$3,411.00
Rate for Payer: MDX Hawaii PPO	$3,676.30

ICEROD CRYO NEEDLE

Facility

$3,790.00

Service Code	HCPCS C2618
Hospital Revenue Code	272
Min. Negotiated Rate	$1,895.00
Max. Negotiated Rate	$3,676.30
Rate for Payer: AlohaCare Medicaid	$1,895.00
Rate for Payer: AlohaCare Medicare	$2,880.40
Rate for Payer: Cash Price	$2,274.00
Rate for Payer: Devoted Health Medicare	$3,183.60
Rate for Payer: Hawaii Medical Service Association Medicare	$2,880.40
Rate for Payer: Hawaii Western Management Group Commercial	$3,600.50
Rate for Payer: Health Management Network Commercial	$3,221.50
Rate for Payer: Humana Medicare	$2,880.40
Rate for Payer: Kaiser Permanente Commercial	$3,411.00
Rate for Payer: Kaiser Permanente Medicaid	$1,932.90
Rate for Payer: Kaiser Permanente Medicare	$2,880.40
Rate for Payer: MDX Hawaii PPO	$3,676.30
Rate for Payer: Ohana Health Plan Medicaid	$2,880.40
Rate for Payer: Ohana Health Plan Medicare	$2,880.40
Rate for Payer: UnitedHealthcare Medicare	$2,880.40
Rate for Payer: University Health Alliance Commercial	$2,762.53

ICOSAPENT ETHYL 1 GRAM CAPSULE [119049]

Facility

$16.00

Service Code	NDC 60687076411
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

ICOSAPENT ETHYL 1 GRAM CAPSULE [119049]

Facility

$13.00

Service Code	NDC 52937000120
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

ICOSAPENT ETHYL 1 GRAM CAPSULE [119049]

Facility

$12.00

Service Code	NDC 00054050823
Hospital Revenue Code	637
Min. Negotiated Rate	$6.00
Max. Negotiated Rate	$11.64
Rate for Payer: AlohaCare Medicaid	$6.00
Rate for Payer: AlohaCare Medicare	$9.12
Rate for Payer: Cash Price	$7.20
Rate for Payer: Devoted Health Medicare	$10.08
Rate for Payer: Hawaii Medical Service Association Medicare	$9.12
Rate for Payer: Hawaii Western Management Group Commercial	$11.40
Rate for Payer: Health Management Network Commercial	$10.20
Rate for Payer: Humana Medicare	$9.12
Rate for Payer: Kaiser Permanente Commercial	$10.80
Rate for Payer: Kaiser Permanente Medicaid	$6.12
Rate for Payer: Kaiser Permanente Medicare	$9.12
Rate for Payer: MDX Hawaii PPO	$11.64
Rate for Payer: Ohana Health Plan Medicaid	$9.12
Rate for Payer: Ohana Health Plan Medicare	$9.12
Rate for Payer: UnitedHealthcare Medicare	$9.12
Rate for Payer: University Health Alliance Commercial	$8.75

ICOSAPENT ETHYL 1 GRAM CAPSULE [119049]

Facility

$16.00

Service Code	NDC 60687076411
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

ICOSAPENT ETHYL 1 GRAM CAPSULE [119049]

Facility

$13.00

Service Code	NDC 52937000120
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

Know your out-of-pocket cost for care.

All Charges