Honoka'a Hospital and Skilled Nursing Facility

All Charges

Charge

Type

Setting

Price

IMPLAN STENT DRUG ELUTING MINI

Facility

$2,606.00

Service Code	HCPCS C2625
Hospital Revenue Code	278
Min. Negotiated Rate	$1,303.00
Max. Negotiated Rate	$2,527.82
Rate for Payer: AlohaCare Medicaid	$1,303.00
Rate for Payer: AlohaCare Medicare	$1,980.56
Rate for Payer: Cash Price	$1,563.60
Rate for Payer: Devoted Health Medicare	$2,189.04
Rate for Payer: Hawaii Medical Service Association Medicare	$1,980.56
Rate for Payer: Hawaii Western Management Group Commercial	$1,824.20
Rate for Payer: Health Management Network Commercial	$2,215.10
Rate for Payer: Humana Medicare	$1,980.56
Rate for Payer: Kaiser Permanente Commercial	$2,345.40
Rate for Payer: Kaiser Permanente Medicaid	$1,329.06
Rate for Payer: Kaiser Permanente Medicare	$1,980.56
Rate for Payer: MDX Hawaii PPO	$2,527.82
Rate for Payer: Ohana Health Plan Medicaid	$1,980.56
Rate for Payer: Ohana Health Plan Medicare	$1,980.56
Rate for Payer: UnitedHealthcare Medicare	$1,980.56
Rate for Payer: University Health Alliance Commercial	$1,459.36

IMPLAN STENT/INTROD 6FRX20

Facility

$2,198.00

Service Code	HCPCS C2625
Hospital Revenue Code	278
Min. Negotiated Rate	$1,230.88
Max. Negotiated Rate	$2,132.06
Rate for Payer: Cash Price	$1,318.80
Rate for Payer: Hawaii Western Management Group Commercial	$1,538.60
Rate for Payer: Health Management Network Commercial	$1,868.30
Rate for Payer: Kaiser Permanente Commercial	$1,978.20
Rate for Payer: MDX Hawaii PPO	$2,132.06
Rate for Payer: University Health Alliance Commercial	$1,230.88

IMPLAN STENT/INTROD 6FRX20

Facility

$2,198.00

Service Code	HCPCS C2625
Hospital Revenue Code	278
Min. Negotiated Rate	$1,099.00
Max. Negotiated Rate	$2,132.06
Rate for Payer: AlohaCare Medicaid	$1,099.00
Rate for Payer: AlohaCare Medicare	$1,670.48
Rate for Payer: Cash Price	$1,318.80
Rate for Payer: Devoted Health Medicare	$1,846.32
Rate for Payer: Hawaii Medical Service Association Medicare	$1,670.48
Rate for Payer: Hawaii Western Management Group Commercial	$1,538.60
Rate for Payer: Health Management Network Commercial	$1,868.30
Rate for Payer: Humana Medicare	$1,670.48
Rate for Payer: Kaiser Permanente Commercial	$1,978.20
Rate for Payer: Kaiser Permanente Medicaid	$1,120.98
Rate for Payer: Kaiser Permanente Medicare	$1,670.48
Rate for Payer: MDX Hawaii PPO	$2,132.06
Rate for Payer: Ohana Health Plan Medicaid	$1,670.48
Rate for Payer: Ohana Health Plan Medicare	$1,670.48
Rate for Payer: UnitedHealthcare Medicare	$1,670.48
Rate for Payer: University Health Alliance Commercial	$1,230.88

IMPLAN STENT/INTROD 6FRX22

Facility

$2,198.00

Service Code	HCPCS C2625
Hospital Revenue Code	278
Min. Negotiated Rate	$1,099.00
Max. Negotiated Rate	$2,132.06
Rate for Payer: AlohaCare Medicaid	$1,099.00
Rate for Payer: AlohaCare Medicare	$1,670.48
Rate for Payer: Cash Price	$1,318.80
Rate for Payer: Devoted Health Medicare	$1,846.32
Rate for Payer: Hawaii Medical Service Association Medicare	$1,670.48
Rate for Payer: Hawaii Western Management Group Commercial	$1,538.60
Rate for Payer: Health Management Network Commercial	$1,868.30
Rate for Payer: Humana Medicare	$1,670.48
Rate for Payer: Kaiser Permanente Commercial	$1,978.20
Rate for Payer: Kaiser Permanente Medicaid	$1,120.98
Rate for Payer: Kaiser Permanente Medicare	$1,670.48
Rate for Payer: MDX Hawaii PPO	$2,132.06
Rate for Payer: Ohana Health Plan Medicaid	$1,670.48
Rate for Payer: Ohana Health Plan Medicare	$1,670.48
Rate for Payer: UnitedHealthcare Medicare	$1,670.48
Rate for Payer: University Health Alliance Commercial	$1,230.88

IMPLAN STENT/INTROD 6FRX22

Facility

$2,198.00

Service Code	HCPCS C2625
Hospital Revenue Code	278
Min. Negotiated Rate	$1,230.88
Max. Negotiated Rate	$2,132.06
Rate for Payer: Cash Price	$1,318.80
Rate for Payer: Hawaii Western Management Group Commercial	$1,538.60
Rate for Payer: Health Management Network Commercial	$1,868.30
Rate for Payer: Kaiser Permanente Commercial	$1,978.20
Rate for Payer: MDX Hawaii PPO	$2,132.06
Rate for Payer: University Health Alliance Commercial	$1,230.88

IMPLAN STENT/INTROD 6FRX24

Facility

$2,286.00

Service Code	HCPCS C2625
Hospital Revenue Code	278
Min. Negotiated Rate	$1,143.00
Max. Negotiated Rate	$2,217.42
Rate for Payer: AlohaCare Medicaid	$1,143.00
Rate for Payer: AlohaCare Medicare	$1,737.36
Rate for Payer: Cash Price	$1,371.60
Rate for Payer: Devoted Health Medicare	$1,920.24
Rate for Payer: Hawaii Medical Service Association Medicare	$1,737.36
Rate for Payer: Hawaii Western Management Group Commercial	$1,600.20
Rate for Payer: Health Management Network Commercial	$1,943.10
Rate for Payer: Humana Medicare	$1,737.36
Rate for Payer: Kaiser Permanente Commercial	$2,057.40
Rate for Payer: Kaiser Permanente Medicaid	$1,165.86
Rate for Payer: Kaiser Permanente Medicare	$1,737.36
Rate for Payer: MDX Hawaii PPO	$2,217.42
Rate for Payer: Ohana Health Plan Medicaid	$1,737.36
Rate for Payer: Ohana Health Plan Medicare	$1,737.36
Rate for Payer: UnitedHealthcare Medicare	$1,737.36
Rate for Payer: University Health Alliance Commercial	$1,280.16

IMPLAN STENT/INTROD 6FRX24

Facility

$2,286.00

Service Code	HCPCS C2625
Hospital Revenue Code	278
Min. Negotiated Rate	$1,280.16
Max. Negotiated Rate	$2,217.42
Rate for Payer: Cash Price	$1,371.60
Rate for Payer: Hawaii Western Management Group Commercial	$1,600.20
Rate for Payer: Health Management Network Commercial	$1,943.10
Rate for Payer: Kaiser Permanente Commercial	$2,057.40
Rate for Payer: MDX Hawaii PPO	$2,217.42
Rate for Payer: University Health Alliance Commercial	$1,280.16

IMPLAN STENT/INTROD 6FRX26

Facility

$2,286.00

Service Code	HCPCS C2625
Hospital Revenue Code	278
Min. Negotiated Rate	$1,143.00
Max. Negotiated Rate	$2,217.42
Rate for Payer: AlohaCare Medicaid	$1,143.00
Rate for Payer: AlohaCare Medicare	$1,737.36
Rate for Payer: Cash Price	$1,371.60
Rate for Payer: Devoted Health Medicare	$1,920.24
Rate for Payer: Hawaii Medical Service Association Medicare	$1,737.36
Rate for Payer: Hawaii Western Management Group Commercial	$1,600.20
Rate for Payer: Health Management Network Commercial	$1,943.10
Rate for Payer: Humana Medicare	$1,737.36
Rate for Payer: Kaiser Permanente Commercial	$2,057.40
Rate for Payer: Kaiser Permanente Medicaid	$1,165.86
Rate for Payer: Kaiser Permanente Medicare	$1,737.36
Rate for Payer: MDX Hawaii PPO	$2,217.42
Rate for Payer: Ohana Health Plan Medicaid	$1,737.36
Rate for Payer: Ohana Health Plan Medicare	$1,737.36
Rate for Payer: UnitedHealthcare Medicare	$1,737.36
Rate for Payer: University Health Alliance Commercial	$1,280.16

IMPLAN STENT/INTROD 6FRX26

Facility

$2,286.00

Service Code	HCPCS C2625
Hospital Revenue Code	278
Min. Negotiated Rate	$1,280.16
Max. Negotiated Rate	$2,217.42
Rate for Payer: Cash Price	$1,371.60
Rate for Payer: Hawaii Western Management Group Commercial	$1,600.20
Rate for Payer: Health Management Network Commercial	$1,943.10
Rate for Payer: Kaiser Permanente Commercial	$2,057.40
Rate for Payer: MDX Hawaii PPO	$2,217.42
Rate for Payer: University Health Alliance Commercial	$1,280.16

IMPLAN STENT/INTROD 6FRX28

Facility

$2,199.00

Service Code	HCPCS C2625
Hospital Revenue Code	278
Min. Negotiated Rate	$1,231.44
Max. Negotiated Rate	$2,133.03
Rate for Payer: Cash Price	$1,319.40
Rate for Payer: Hawaii Western Management Group Commercial	$1,539.30
Rate for Payer: Health Management Network Commercial	$1,869.15
Rate for Payer: Kaiser Permanente Commercial	$1,979.10
Rate for Payer: MDX Hawaii PPO	$2,133.03
Rate for Payer: University Health Alliance Commercial	$1,231.44

IMPLAN STENT/INTROD 6FRX28

Facility

$2,199.00

Service Code	HCPCS C2625
Hospital Revenue Code	278
Min. Negotiated Rate	$1,099.50
Max. Negotiated Rate	$2,133.03
Rate for Payer: AlohaCare Medicaid	$1,099.50
Rate for Payer: AlohaCare Medicare	$1,671.24
Rate for Payer: Cash Price	$1,319.40
Rate for Payer: Devoted Health Medicare	$1,847.16
Rate for Payer: Hawaii Medical Service Association Medicare	$1,671.24
Rate for Payer: Hawaii Western Management Group Commercial	$1,539.30
Rate for Payer: Health Management Network Commercial	$1,869.15
Rate for Payer: Humana Medicare	$1,671.24
Rate for Payer: Kaiser Permanente Commercial	$1,979.10
Rate for Payer: Kaiser Permanente Medicaid	$1,121.49
Rate for Payer: Kaiser Permanente Medicare	$1,671.24
Rate for Payer: MDX Hawaii PPO	$2,133.03
Rate for Payer: Ohana Health Plan Medicaid	$1,671.24
Rate for Payer: Ohana Health Plan Medicare	$1,671.24
Rate for Payer: UnitedHealthcare Medicare	$1,671.24
Rate for Payer: University Health Alliance Commercial	$1,231.44

IMPLAN STENT/INTROD 6FRX30

Facility

$2,919.00

Service Code	HCPCS C2625
Hospital Revenue Code	278
Min. Negotiated Rate	$1,459.50
Max. Negotiated Rate	$2,831.43
Rate for Payer: AlohaCare Medicaid	$1,459.50
Rate for Payer: AlohaCare Medicare	$2,218.44
Rate for Payer: Cash Price	$1,751.40
Rate for Payer: Devoted Health Medicare	$2,451.96
Rate for Payer: Hawaii Medical Service Association Medicare	$2,218.44
Rate for Payer: Hawaii Western Management Group Commercial	$2,043.30
Rate for Payer: Health Management Network Commercial	$2,481.15
Rate for Payer: Humana Medicare	$2,218.44
Rate for Payer: Kaiser Permanente Commercial	$2,627.10
Rate for Payer: Kaiser Permanente Medicaid	$1,488.69
Rate for Payer: Kaiser Permanente Medicare	$2,218.44
Rate for Payer: MDX Hawaii PPO	$2,831.43
Rate for Payer: Ohana Health Plan Medicaid	$2,218.44
Rate for Payer: Ohana Health Plan Medicare	$2,218.44
Rate for Payer: UnitedHealthcare Medicare	$2,218.44
Rate for Payer: University Health Alliance Commercial	$1,634.64

IMPLAN STENT/INTROD 6FRX30

Facility

$2,919.00

Service Code	HCPCS C2625
Hospital Revenue Code	278
Min. Negotiated Rate	$1,634.64
Max. Negotiated Rate	$2,831.43
Rate for Payer: Cash Price	$1,751.40
Rate for Payer: Hawaii Western Management Group Commercial	$2,043.30
Rate for Payer: Health Management Network Commercial	$2,481.15
Rate for Payer: Kaiser Permanente Commercial	$2,627.10
Rate for Payer: MDX Hawaii PPO	$2,831.43
Rate for Payer: University Health Alliance Commercial	$1,634.64

IMPLAN STENT PANCREATIC 4FX3

Facility

$316.00

Service Code	HCPCS C2617
Hospital Revenue Code	278
Min. Negotiated Rate	$176.96
Max. Negotiated Rate	$306.52
Rate for Payer: Cash Price	$189.60
Rate for Payer: Hawaii Western Management Group Commercial	$221.20
Rate for Payer: Health Management Network Commercial	$268.60
Rate for Payer: Kaiser Permanente Commercial	$284.40
Rate for Payer: MDX Hawaii PPO	$306.52
Rate for Payer: University Health Alliance Commercial	$176.96

IMPLAN STENT PANCREATIC 4FX3

Facility

$316.00

Service Code	HCPCS C2617
Hospital Revenue Code	278
Min. Negotiated Rate	$158.00
Max. Negotiated Rate	$306.52
Rate for Payer: AlohaCare Medicaid	$158.00
Rate for Payer: AlohaCare Medicare	$240.16
Rate for Payer: Cash Price	$189.60
Rate for Payer: Devoted Health Medicare	$265.44
Rate for Payer: Hawaii Medical Service Association Medicare	$240.16
Rate for Payer: Hawaii Western Management Group Commercial	$221.20
Rate for Payer: Health Management Network Commercial	$268.60
Rate for Payer: Humana Medicare	$240.16
Rate for Payer: Kaiser Permanente Commercial	$284.40
Rate for Payer: Kaiser Permanente Medicaid	$161.16
Rate for Payer: Kaiser Permanente Medicare	$240.16
Rate for Payer: MDX Hawaii PPO	$306.52
Rate for Payer: Ohana Health Plan Medicaid	$240.16
Rate for Payer: Ohana Health Plan Medicare	$240.16
Rate for Payer: UnitedHealthcare Medicare	$240.16
Rate for Payer: University Health Alliance Commercial	$176.96

IMPLAN STENT PANCREATIC DUCT

Facility

$294.00

Service Code	HCPCS C2617
Hospital Revenue Code	278
Min. Negotiated Rate	$164.64
Max. Negotiated Rate	$285.18
Rate for Payer: Cash Price	$176.40
Rate for Payer: Hawaii Western Management Group Commercial	$205.80
Rate for Payer: Health Management Network Commercial	$249.90
Rate for Payer: Kaiser Permanente Commercial	$264.60
Rate for Payer: MDX Hawaii PPO	$285.18
Rate for Payer: University Health Alliance Commercial	$164.64

IMPLAN STENT PANCREATIC DUCT

Facility

$294.00

Service Code	HCPCS C2617
Hospital Revenue Code	278
Min. Negotiated Rate	$147.00
Max. Negotiated Rate	$285.18
Rate for Payer: AlohaCare Medicaid	$147.00
Rate for Payer: AlohaCare Medicare	$223.44
Rate for Payer: Cash Price	$176.40
Rate for Payer: Devoted Health Medicare	$246.96
Rate for Payer: Hawaii Medical Service Association Medicare	$223.44
Rate for Payer: Hawaii Western Management Group Commercial	$205.80
Rate for Payer: Health Management Network Commercial	$249.90
Rate for Payer: Humana Medicare	$223.44
Rate for Payer: Kaiser Permanente Commercial	$264.60
Rate for Payer: Kaiser Permanente Medicaid	$149.94
Rate for Payer: Kaiser Permanente Medicare	$223.44
Rate for Payer: MDX Hawaii PPO	$285.18
Rate for Payer: Ohana Health Plan Medicaid	$223.44
Rate for Payer: Ohana Health Plan Medicare	$223.44
Rate for Payer: UnitedHealthcare Medicare	$223.44
Rate for Payer: University Health Alliance Commercial	$164.64

IMPLAN STIMULATION LEAD

Facility

$3,900.00

Service Code	HCPCS C1778
Hospital Revenue Code	278
Min. Negotiated Rate	$2,184.00
Max. Negotiated Rate	$3,783.00
Rate for Payer: Cash Price	$2,340.00
Rate for Payer: Hawaii Western Management Group Commercial	$2,730.00
Rate for Payer: Health Management Network Commercial	$3,315.00
Rate for Payer: Kaiser Permanente Commercial	$3,510.00
Rate for Payer: MDX Hawaii PPO	$3,783.00
Rate for Payer: University Health Alliance Commercial	$2,184.00

IMPLAN STIMULATION LEAD

Facility

$3,900.00

Service Code	HCPCS C1778
Hospital Revenue Code	278
Min. Negotiated Rate	$1,950.00
Max. Negotiated Rate	$3,783.00
Rate for Payer: AlohaCare Medicaid	$1,950.00
Rate for Payer: AlohaCare Medicare	$2,964.00
Rate for Payer: Cash Price	$2,340.00
Rate for Payer: Devoted Health Medicare	$3,276.00
Rate for Payer: Hawaii Medical Service Association Medicare	$2,964.00
Rate for Payer: Hawaii Western Management Group Commercial	$2,730.00
Rate for Payer: Health Management Network Commercial	$3,315.00
Rate for Payer: Humana Medicare	$2,964.00
Rate for Payer: Kaiser Permanente Commercial	$3,510.00
Rate for Payer: Kaiser Permanente Medicaid	$1,989.00
Rate for Payer: Kaiser Permanente Medicare	$2,964.00
Rate for Payer: MDX Hawaii PPO	$3,783.00
Rate for Payer: Ohana Health Plan Medicaid	$2,964.00
Rate for Payer: Ohana Health Plan Medicare	$2,964.00
Rate for Payer: UnitedHealthcare Medicare	$2,964.00
Rate for Payer: University Health Alliance Commercial	$2,184.00

IMPLANT ALLODERM 2X4CM

Facility

$1,650.00

Service Code	HCPCS Q4116
Hospital Revenue Code	278
Min. Negotiated Rate	$924.00
Max. Negotiated Rate	$1,600.50
Rate for Payer: Cash Price	$990.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,155.00
Rate for Payer: Health Management Network Commercial	$1,402.50
Rate for Payer: Kaiser Permanente Commercial	$1,485.00
Rate for Payer: MDX Hawaii PPO	$1,600.50
Rate for Payer: University Health Alliance Commercial	$924.00

IMPLANT ALLODERM 2X4CM

Facility

$1,650.00

Service Code	HCPCS Q4116
Hospital Revenue Code	278
Min. Negotiated Rate	$158.93
Max. Negotiated Rate	$1,600.50
Rate for Payer: AlohaCare Medicaid	$825.00
Rate for Payer: AlohaCare Medicare	$1,254.00
Rate for Payer: Cash Price	$990.00
Rate for Payer: Cash Price	$990.00
Rate for Payer: Devoted Health Medicare	$1,386.00
Rate for Payer: Hawaii Medical Service Association Commercial	$158.93
Rate for Payer: Hawaii Medical Service Association Medicare	$1,254.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,155.00
Rate for Payer: Health Management Network Commercial	$1,402.50
Rate for Payer: Humana Medicare	$1,254.00
Rate for Payer: Kaiser Permanente Commercial	$1,485.00
Rate for Payer: Kaiser Permanente Medicaid	$841.50
Rate for Payer: Kaiser Permanente Medicare	$1,254.00
Rate for Payer: MDX Hawaii PPO	$1,600.50
Rate for Payer: Ohana Health Plan Medicaid	$1,254.00
Rate for Payer: Ohana Health Plan Medicare	$1,254.00
Rate for Payer: UnitedHealthcare Medicare	$1,254.00
Rate for Payer: University Health Alliance Commercial	$924.00

IMPLANT BIOINDUCTIVE LG 4566

Facility

$4,000.00

Service Code	HCPCS C1763
Hospital Revenue Code	278
Min. Negotiated Rate	$2,000.00
Max. Negotiated Rate	$3,880.00
Rate for Payer: AlohaCare Medicaid	$2,000.00
Rate for Payer: AlohaCare Medicare	$3,040.00
Rate for Payer: Cash Price	$2,400.00
Rate for Payer: Devoted Health Medicare	$3,360.00
Rate for Payer: Hawaii Medical Service Association Medicare	$3,040.00
Rate for Payer: Hawaii Western Management Group Commercial	$2,800.00
Rate for Payer: Health Management Network Commercial	$3,400.00
Rate for Payer: Humana Medicare	$3,040.00
Rate for Payer: Kaiser Permanente Commercial	$3,600.00
Rate for Payer: Kaiser Permanente Medicaid	$2,040.00
Rate for Payer: Kaiser Permanente Medicare	$3,040.00
Rate for Payer: MDX Hawaii PPO	$3,880.00
Rate for Payer: Ohana Health Plan Medicaid	$3,040.00
Rate for Payer: Ohana Health Plan Medicare	$3,040.00
Rate for Payer: UnitedHealthcare Medicare	$3,040.00
Rate for Payer: University Health Alliance Commercial	$2,240.00

IMPLANT BIOINDUCTIVE LG 4566

Facility

$4,000.00

Service Code	HCPCS C1763
Hospital Revenue Code	278
Min. Negotiated Rate	$2,240.00
Max. Negotiated Rate	$3,880.00
Rate for Payer: Cash Price	$2,400.00
Rate for Payer: Hawaii Western Management Group Commercial	$2,800.00
Rate for Payer: Health Management Network Commercial	$3,400.00
Rate for Payer: Kaiser Permanente Commercial	$3,600.00
Rate for Payer: MDX Hawaii PPO	$3,880.00
Rate for Payer: University Health Alliance Commercial	$2,240.00

IMPLANT PENILE PROSTHSEIS

Facility

$25,110.00

Service Code	HCPCS C2622
Hospital Revenue Code	278
Min. Negotiated Rate	$14,061.60
Max. Negotiated Rate	$24,356.70
Rate for Payer: Cash Price	$15,066.00
Rate for Payer: Hawaii Western Management Group Commercial	$17,577.00
Rate for Payer: Health Management Network Commercial	$21,343.50
Rate for Payer: Kaiser Permanente Commercial	$22,599.00
Rate for Payer: MDX Hawaii PPO	$24,356.70
Rate for Payer: University Health Alliance Commercial	$14,061.60

IMPLANT PENILE PROSTHSEIS

Facility

$25,110.00

Service Code	HCPCS C2622
Hospital Revenue Code	278
Min. Negotiated Rate	$12,555.00
Max. Negotiated Rate	$24,356.70
Rate for Payer: AlohaCare Medicaid	$12,555.00
Rate for Payer: AlohaCare Medicare	$19,083.60
Rate for Payer: Cash Price	$15,066.00
Rate for Payer: Devoted Health Medicare	$21,092.40
Rate for Payer: Hawaii Medical Service Association Medicare	$19,083.60
Rate for Payer: Hawaii Western Management Group Commercial	$17,577.00
Rate for Payer: Health Management Network Commercial	$21,343.50
Rate for Payer: Humana Medicare	$19,083.60
Rate for Payer: Kaiser Permanente Commercial	$22,599.00
Rate for Payer: Kaiser Permanente Medicaid	$12,806.10
Rate for Payer: Kaiser Permanente Medicare	$19,083.60
Rate for Payer: MDX Hawaii PPO	$24,356.70
Rate for Payer: Ohana Health Plan Medicaid	$19,083.60
Rate for Payer: Ohana Health Plan Medicare	$19,083.60
Rate for Payer: UnitedHealthcare Medicare	$19,083.60
Rate for Payer: University Health Alliance Commercial	$14,061.60

Know your out-of-pocket cost for care.

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