Honoka'a Hospital and Skilled Nursing Facility

All Charges

Charge

Type

Setting

Price

IOLENS DIOP 12.0 SN6AT3 12.0

Facility

$1,733.00

Service Code	HCPCS V2787
Hospital Revenue Code	276
Min. Negotiated Rate	$970.48
Max. Negotiated Rate	$1,681.01
Rate for Payer: Cash Price	$1,039.80
Rate for Payer: Hawaii Western Management Group Commercial	$1,213.10
Rate for Payer: Health Management Network Commercial	$1,473.05
Rate for Payer: Kaiser Permanente Commercial	$1,559.70
Rate for Payer: MDX Hawaii PPO	$1,681.01
Rate for Payer: University Health Alliance Commercial	$970.48

IOLENS DIOP 12.0 SN6AT3 12.0

Facility

$1,733.00

Service Code	HCPCS V2787
Hospital Revenue Code	276
Min. Negotiated Rate	$866.50
Max. Negotiated Rate	$1,681.01
Rate for Payer: AlohaCare Medicaid	$866.50
Rate for Payer: AlohaCare Medicare	$1,317.08
Rate for Payer: Cash Price	$1,039.80
Rate for Payer: Devoted Health Medicare	$1,455.72
Rate for Payer: Hawaii Medical Service Association Medicare	$1,317.08
Rate for Payer: Hawaii Western Management Group Commercial	$1,213.10
Rate for Payer: Health Management Network Commercial	$1,473.05
Rate for Payer: Humana Medicare	$1,317.08
Rate for Payer: Kaiser Permanente Commercial	$1,559.70
Rate for Payer: Kaiser Permanente Medicaid	$883.83
Rate for Payer: Kaiser Permanente Medicare	$1,317.08
Rate for Payer: MDX Hawaii PPO	$1,681.01
Rate for Payer: Ohana Health Plan Medicaid	$1,317.08
Rate for Payer: Ohana Health Plan Medicare	$1,317.08
Rate for Payer: UnitedHealthcare Medicare	$1,317.08
Rate for Payer: University Health Alliance Commercial	$970.48

IOLENS DIOP 12.5

Facility

$1,733.00

Service Code	HCPCS V2787
Hospital Revenue Code	276
Min. Negotiated Rate	$866.50
Max. Negotiated Rate	$1,681.01
Rate for Payer: AlohaCare Medicaid	$866.50
Rate for Payer: AlohaCare Medicare	$1,317.08
Rate for Payer: Cash Price	$1,039.80
Rate for Payer: Devoted Health Medicare	$1,455.72
Rate for Payer: Hawaii Medical Service Association Medicare	$1,317.08
Rate for Payer: Hawaii Western Management Group Commercial	$1,213.10
Rate for Payer: Health Management Network Commercial	$1,473.05
Rate for Payer: Humana Medicare	$1,317.08
Rate for Payer: Kaiser Permanente Commercial	$1,559.70
Rate for Payer: Kaiser Permanente Medicaid	$883.83
Rate for Payer: Kaiser Permanente Medicare	$1,317.08
Rate for Payer: MDX Hawaii PPO	$1,681.01
Rate for Payer: Ohana Health Plan Medicaid	$1,317.08
Rate for Payer: Ohana Health Plan Medicare	$1,317.08
Rate for Payer: UnitedHealthcare Medicare	$1,317.08
Rate for Payer: University Health Alliance Commercial	$970.48

IOLENS DIOP 12.5

Facility

$1,733.00

Service Code	HCPCS V2787
Hospital Revenue Code	276
Min. Negotiated Rate	$970.48
Max. Negotiated Rate	$1,681.01
Rate for Payer: Cash Price	$1,039.80
Rate for Payer: Hawaii Western Management Group Commercial	$1,213.10
Rate for Payer: Health Management Network Commercial	$1,473.05
Rate for Payer: Kaiser Permanente Commercial	$1,559.70
Rate for Payer: MDX Hawaii PPO	$1,681.01
Rate for Payer: University Health Alliance Commercial	$970.48

IOLENS DIOP 14.0 SN6AT8 14.0

Facility

$1,733.00

Service Code	HCPCS V2787
Hospital Revenue Code	276
Min. Negotiated Rate	$970.48
Max. Negotiated Rate	$1,681.01
Rate for Payer: Cash Price	$1,039.80
Rate for Payer: Hawaii Western Management Group Commercial	$1,213.10
Rate for Payer: Health Management Network Commercial	$1,473.05
Rate for Payer: Kaiser Permanente Commercial	$1,559.70
Rate for Payer: MDX Hawaii PPO	$1,681.01
Rate for Payer: University Health Alliance Commercial	$970.48

IOLENS DIOP 14.0 SN6AT8 14.0

Facility

$1,733.00

Service Code	HCPCS V2787
Hospital Revenue Code	276
Min. Negotiated Rate	$866.50
Max. Negotiated Rate	$1,681.01
Rate for Payer: AlohaCare Medicaid	$866.50
Rate for Payer: AlohaCare Medicare	$1,317.08
Rate for Payer: Cash Price	$1,039.80
Rate for Payer: Devoted Health Medicare	$1,455.72
Rate for Payer: Hawaii Medical Service Association Medicare	$1,317.08
Rate for Payer: Hawaii Western Management Group Commercial	$1,213.10
Rate for Payer: Health Management Network Commercial	$1,473.05
Rate for Payer: Humana Medicare	$1,317.08
Rate for Payer: Kaiser Permanente Commercial	$1,559.70
Rate for Payer: Kaiser Permanente Medicaid	$883.83
Rate for Payer: Kaiser Permanente Medicare	$1,317.08
Rate for Payer: MDX Hawaii PPO	$1,681.01
Rate for Payer: Ohana Health Plan Medicaid	$1,317.08
Rate for Payer: Ohana Health Plan Medicare	$1,317.08
Rate for Payer: UnitedHealthcare Medicare	$1,317.08
Rate for Payer: University Health Alliance Commercial	$970.48

IOLENS DIOP 15.5

Facility

$1,733.00

Service Code	HCPCS V2787
Hospital Revenue Code	276
Min. Negotiated Rate	$866.50
Max. Negotiated Rate	$1,681.01
Rate for Payer: AlohaCare Medicaid	$866.50
Rate for Payer: AlohaCare Medicare	$1,317.08
Rate for Payer: Cash Price	$1,039.80
Rate for Payer: Devoted Health Medicare	$1,455.72
Rate for Payer: Hawaii Medical Service Association Medicare	$1,317.08
Rate for Payer: Hawaii Western Management Group Commercial	$1,213.10
Rate for Payer: Health Management Network Commercial	$1,473.05
Rate for Payer: Humana Medicare	$1,317.08
Rate for Payer: Kaiser Permanente Commercial	$1,559.70
Rate for Payer: Kaiser Permanente Medicaid	$883.83
Rate for Payer: Kaiser Permanente Medicare	$1,317.08
Rate for Payer: MDX Hawaii PPO	$1,681.01
Rate for Payer: Ohana Health Plan Medicaid	$1,317.08
Rate for Payer: Ohana Health Plan Medicare	$1,317.08
Rate for Payer: UnitedHealthcare Medicare	$1,317.08
Rate for Payer: University Health Alliance Commercial	$970.48

IOLENS DIOP 15.5

Facility

$1,733.00

Service Code	HCPCS V2787
Hospital Revenue Code	276
Min. Negotiated Rate	$970.48
Max. Negotiated Rate	$1,681.01
Rate for Payer: Cash Price	$1,039.80
Rate for Payer: Hawaii Western Management Group Commercial	$1,213.10
Rate for Payer: Health Management Network Commercial	$1,473.05
Rate for Payer: Kaiser Permanente Commercial	$1,559.70
Rate for Payer: MDX Hawaii PPO	$1,681.01
Rate for Payer: University Health Alliance Commercial	$970.48

IOLENS DIOP 17.5 SN6AT7 17.5

Facility

$1,733.00

Service Code	HCPCS V2787
Hospital Revenue Code	276
Min. Negotiated Rate	$970.48
Max. Negotiated Rate	$1,681.01
Rate for Payer: Cash Price	$1,039.80
Rate for Payer: Hawaii Western Management Group Commercial	$1,213.10
Rate for Payer: Health Management Network Commercial	$1,473.05
Rate for Payer: Kaiser Permanente Commercial	$1,559.70
Rate for Payer: MDX Hawaii PPO	$1,681.01
Rate for Payer: University Health Alliance Commercial	$970.48

IOLENS DIOP 17.5 SN6AT7 17.5

Facility

$1,733.00

Service Code	HCPCS V2787
Hospital Revenue Code	276
Min. Negotiated Rate	$866.50
Max. Negotiated Rate	$1,681.01
Rate for Payer: AlohaCare Medicaid	$866.50
Rate for Payer: AlohaCare Medicare	$1,317.08
Rate for Payer: Cash Price	$1,039.80
Rate for Payer: Devoted Health Medicare	$1,455.72
Rate for Payer: Hawaii Medical Service Association Medicare	$1,317.08
Rate for Payer: Hawaii Western Management Group Commercial	$1,213.10
Rate for Payer: Health Management Network Commercial	$1,473.05
Rate for Payer: Humana Medicare	$1,317.08
Rate for Payer: Kaiser Permanente Commercial	$1,559.70
Rate for Payer: Kaiser Permanente Medicaid	$883.83
Rate for Payer: Kaiser Permanente Medicare	$1,317.08
Rate for Payer: MDX Hawaii PPO	$1,681.01
Rate for Payer: Ohana Health Plan Medicaid	$1,317.08
Rate for Payer: Ohana Health Plan Medicare	$1,317.08
Rate for Payer: UnitedHealthcare Medicare	$1,317.08
Rate for Payer: University Health Alliance Commercial	$970.48

IOLENS DIOP 20.0 13.0 5.5MM

Facility

$375.00

Service Code	HCPCS V2787
Hospital Revenue Code	276
Min. Negotiated Rate	$210.00
Max. Negotiated Rate	$363.75
Rate for Payer: Cash Price	$225.00
Rate for Payer: Hawaii Western Management Group Commercial	$262.50
Rate for Payer: Health Management Network Commercial	$318.75
Rate for Payer: Kaiser Permanente Commercial	$337.50
Rate for Payer: MDX Hawaii PPO	$363.75
Rate for Payer: University Health Alliance Commercial	$210.00

IOLENS DIOP 20.0 13.0 5.5MM

Facility

$375.00

Service Code	HCPCS V2787
Hospital Revenue Code	276
Min. Negotiated Rate	$187.50
Max. Negotiated Rate	$363.75
Rate for Payer: AlohaCare Medicaid	$187.50
Rate for Payer: AlohaCare Medicare	$285.00
Rate for Payer: Cash Price	$225.00
Rate for Payer: Devoted Health Medicare	$315.00
Rate for Payer: Hawaii Medical Service Association Medicare	$285.00
Rate for Payer: Hawaii Western Management Group Commercial	$262.50
Rate for Payer: Health Management Network Commercial	$318.75
Rate for Payer: Humana Medicare	$285.00
Rate for Payer: Kaiser Permanente Commercial	$337.50
Rate for Payer: Kaiser Permanente Medicaid	$191.25
Rate for Payer: Kaiser Permanente Medicare	$285.00
Rate for Payer: MDX Hawaii PPO	$363.75
Rate for Payer: Ohana Health Plan Medicaid	$285.00
Rate for Payer: Ohana Health Plan Medicare	$285.00
Rate for Payer: UnitedHealthcare Medicare	$285.00
Rate for Payer: University Health Alliance Commercial	$210.00

IOLENS DIOP 20.5

Facility

$1,733.00

Service Code	HCPCS V2787
Hospital Revenue Code	276
Min. Negotiated Rate	$866.50
Max. Negotiated Rate	$1,681.01
Rate for Payer: AlohaCare Medicaid	$866.50
Rate for Payer: AlohaCare Medicare	$1,317.08
Rate for Payer: Cash Price	$1,039.80
Rate for Payer: Devoted Health Medicare	$1,455.72
Rate for Payer: Hawaii Medical Service Association Medicare	$1,317.08
Rate for Payer: Hawaii Western Management Group Commercial	$1,213.10
Rate for Payer: Health Management Network Commercial	$1,473.05
Rate for Payer: Humana Medicare	$1,317.08
Rate for Payer: Kaiser Permanente Commercial	$1,559.70
Rate for Payer: Kaiser Permanente Medicaid	$883.83
Rate for Payer: Kaiser Permanente Medicare	$1,317.08
Rate for Payer: MDX Hawaii PPO	$1,681.01
Rate for Payer: Ohana Health Plan Medicaid	$1,317.08
Rate for Payer: Ohana Health Plan Medicare	$1,317.08
Rate for Payer: UnitedHealthcare Medicare	$1,317.08
Rate for Payer: University Health Alliance Commercial	$970.48

IOLENS DIOP 20.5

Facility

$1,733.00

Service Code	HCPCS V2787
Hospital Revenue Code	276
Min. Negotiated Rate	$970.48
Max. Negotiated Rate	$1,681.01
Rate for Payer: Cash Price	$1,039.80
Rate for Payer: Hawaii Western Management Group Commercial	$1,213.10
Rate for Payer: Health Management Network Commercial	$1,473.05
Rate for Payer: Kaiser Permanente Commercial	$1,559.70
Rate for Payer: MDX Hawaii PPO	$1,681.01
Rate for Payer: University Health Alliance Commercial	$970.48

IOLENS DIOP 23.5

Facility

$1,733.00

Service Code	HCPCS V2787
Hospital Revenue Code	276
Min. Negotiated Rate	$866.50
Max. Negotiated Rate	$1,681.01
Rate for Payer: AlohaCare Medicaid	$866.50
Rate for Payer: AlohaCare Medicare	$1,317.08
Rate for Payer: Cash Price	$1,039.80
Rate for Payer: Devoted Health Medicare	$1,455.72
Rate for Payer: Hawaii Medical Service Association Medicare	$1,317.08
Rate for Payer: Hawaii Western Management Group Commercial	$1,213.10
Rate for Payer: Health Management Network Commercial	$1,473.05
Rate for Payer: Humana Medicare	$1,317.08
Rate for Payer: Kaiser Permanente Commercial	$1,559.70
Rate for Payer: Kaiser Permanente Medicaid	$883.83
Rate for Payer: Kaiser Permanente Medicare	$1,317.08
Rate for Payer: MDX Hawaii PPO	$1,681.01
Rate for Payer: Ohana Health Plan Medicaid	$1,317.08
Rate for Payer: Ohana Health Plan Medicare	$1,317.08
Rate for Payer: UnitedHealthcare Medicare	$1,317.08
Rate for Payer: University Health Alliance Commercial	$970.48

IOLENS DIOP 23.5

Facility

$1,733.00

Service Code	HCPCS V2787
Hospital Revenue Code	276
Min. Negotiated Rate	$970.48
Max. Negotiated Rate	$1,681.01
Rate for Payer: Cash Price	$1,039.80
Rate for Payer: Hawaii Western Management Group Commercial	$1,213.10
Rate for Payer: Health Management Network Commercial	$1,473.05
Rate for Payer: Kaiser Permanente Commercial	$1,559.70
Rate for Payer: MDX Hawaii PPO	$1,681.01
Rate for Payer: University Health Alliance Commercial	$970.48

IOLENS DIOP 8.5

Facility

$1,733.00

Service Code	HCPCS V2787
Hospital Revenue Code	276
Min. Negotiated Rate	$866.50
Max. Negotiated Rate	$1,681.01
Rate for Payer: AlohaCare Medicaid	$866.50
Rate for Payer: AlohaCare Medicare	$1,317.08
Rate for Payer: Cash Price	$1,039.80
Rate for Payer: Devoted Health Medicare	$1,455.72
Rate for Payer: Hawaii Medical Service Association Medicare	$1,317.08
Rate for Payer: Hawaii Western Management Group Commercial	$1,213.10
Rate for Payer: Health Management Network Commercial	$1,473.05
Rate for Payer: Humana Medicare	$1,317.08
Rate for Payer: Kaiser Permanente Commercial	$1,559.70
Rate for Payer: Kaiser Permanente Medicaid	$883.83
Rate for Payer: Kaiser Permanente Medicare	$1,317.08
Rate for Payer: MDX Hawaii PPO	$1,681.01
Rate for Payer: Ohana Health Plan Medicaid	$1,317.08
Rate for Payer: Ohana Health Plan Medicare	$1,317.08
Rate for Payer: UnitedHealthcare Medicare	$1,317.08
Rate for Payer: University Health Alliance Commercial	$970.48

IOLENS DIOP 8.5

Facility

$1,733.00

Service Code	HCPCS V2787
Hospital Revenue Code	276
Min. Negotiated Rate	$970.48
Max. Negotiated Rate	$1,681.01
Rate for Payer: Cash Price	$1,039.80
Rate for Payer: Hawaii Western Management Group Commercial	$1,213.10
Rate for Payer: Health Management Network Commercial	$1,473.05
Rate for Payer: Kaiser Permanente Commercial	$1,559.70
Rate for Payer: MDX Hawaii PPO	$1,681.01
Rate for Payer: University Health Alliance Commercial	$970.48

IOLENS DIOP 9.5 SN6AT5 9.5

Facility

$1,733.00

Service Code	HCPCS V2787
Hospital Revenue Code	276
Min. Negotiated Rate	$970.48
Max. Negotiated Rate	$1,681.01
Rate for Payer: Cash Price	$1,039.80
Rate for Payer: Hawaii Western Management Group Commercial	$1,213.10
Rate for Payer: Health Management Network Commercial	$1,473.05
Rate for Payer: Kaiser Permanente Commercial	$1,559.70
Rate for Payer: MDX Hawaii PPO	$1,681.01
Rate for Payer: University Health Alliance Commercial	$970.48

IOLENS DIOP 9.5 SN6AT5 9.5

Facility

$1,733.00

Service Code	HCPCS V2787
Hospital Revenue Code	276
Min. Negotiated Rate	$866.50
Max. Negotiated Rate	$1,681.01
Rate for Payer: AlohaCare Medicaid	$866.50
Rate for Payer: AlohaCare Medicare	$1,317.08
Rate for Payer: Cash Price	$1,039.80
Rate for Payer: Devoted Health Medicare	$1,455.72
Rate for Payer: Hawaii Medical Service Association Medicare	$1,317.08
Rate for Payer: Hawaii Western Management Group Commercial	$1,213.10
Rate for Payer: Health Management Network Commercial	$1,473.05
Rate for Payer: Humana Medicare	$1,317.08
Rate for Payer: Kaiser Permanente Commercial	$1,559.70
Rate for Payer: Kaiser Permanente Medicaid	$883.83
Rate for Payer: Kaiser Permanente Medicare	$1,317.08
Rate for Payer: MDX Hawaii PPO	$1,681.01
Rate for Payer: Ohana Health Plan Medicaid	$1,317.08
Rate for Payer: Ohana Health Plan Medicare	$1,317.08
Rate for Payer: UnitedHealthcare Medicare	$1,317.08
Rate for Payer: University Health Alliance Commercial	$970.48

IOLENS TORICE 27.5

Facility

$1,733.00

Service Code	HCPCS V2787
Hospital Revenue Code	276
Min. Negotiated Rate	$970.48
Max. Negotiated Rate	$1,681.01
Rate for Payer: Cash Price	$1,039.80
Rate for Payer: Hawaii Western Management Group Commercial	$1,213.10
Rate for Payer: Health Management Network Commercial	$1,473.05
Rate for Payer: Kaiser Permanente Commercial	$1,559.70
Rate for Payer: MDX Hawaii PPO	$1,681.01
Rate for Payer: University Health Alliance Commercial	$970.48

IOLENS TORICE 27.5

Facility

$1,733.00

Service Code	HCPCS V2787
Hospital Revenue Code	276
Min. Negotiated Rate	$866.50
Max. Negotiated Rate	$1,681.01
Rate for Payer: AlohaCare Medicaid	$866.50
Rate for Payer: AlohaCare Medicare	$1,317.08
Rate for Payer: Cash Price	$1,039.80
Rate for Payer: Devoted Health Medicare	$1,455.72
Rate for Payer: Hawaii Medical Service Association Medicare	$1,317.08
Rate for Payer: Hawaii Western Management Group Commercial	$1,213.10
Rate for Payer: Health Management Network Commercial	$1,473.05
Rate for Payer: Humana Medicare	$1,317.08
Rate for Payer: Kaiser Permanente Commercial	$1,559.70
Rate for Payer: Kaiser Permanente Medicaid	$883.83
Rate for Payer: Kaiser Permanente Medicare	$1,317.08
Rate for Payer: MDX Hawaii PPO	$1,681.01
Rate for Payer: Ohana Health Plan Medicaid	$1,317.08
Rate for Payer: Ohana Health Plan Medicare	$1,317.08
Rate for Payer: UnitedHealthcare Medicare	$1,317.08
Rate for Payer: University Health Alliance Commercial	$970.48

IPERIA PROMRI 7DR-T 392409

Facility

$41,580.00

Service Code	HCPCS C1721
Hospital Revenue Code	275
Min. Negotiated Rate	$20,790.00
Max. Negotiated Rate	$40,332.60
Rate for Payer: AlohaCare Medicaid	$20,790.00
Rate for Payer: AlohaCare Medicare	$31,600.80
Rate for Payer: Cash Price	$24,948.00
Rate for Payer: Devoted Health Medicare	$34,927.20
Rate for Payer: Hawaii Medical Service Association Medicare	$31,600.80
Rate for Payer: Hawaii Western Management Group Commercial	$29,106.00
Rate for Payer: Health Management Network Commercial	$35,343.00
Rate for Payer: Humana Medicare	$31,600.80
Rate for Payer: Kaiser Permanente Commercial	$37,422.00
Rate for Payer: Kaiser Permanente Medicaid	$21,205.80
Rate for Payer: Kaiser Permanente Medicare	$31,600.80
Rate for Payer: MDX Hawaii PPO	$40,332.60
Rate for Payer: Ohana Health Plan Medicaid	$31,600.80
Rate for Payer: Ohana Health Plan Medicare	$31,600.80
Rate for Payer: UnitedHealthcare Medicare	$31,600.80
Rate for Payer: University Health Alliance Commercial	$23,284.80

IPERIA PROMRI 7DR-T 392409

Facility

$41,580.00

Service Code	HCPCS C1721
Hospital Revenue Code	275
Min. Negotiated Rate	$23,284.80
Max. Negotiated Rate	$40,332.60
Rate for Payer: Cash Price	$24,948.00
Rate for Payer: Hawaii Western Management Group Commercial	$29,106.00
Rate for Payer: Health Management Network Commercial	$35,343.00
Rate for Payer: Kaiser Permanente Commercial	$37,422.00
Rate for Payer: MDX Hawaii PPO	$40,332.60
Rate for Payer: University Health Alliance Commercial	$23,284.80

IPILIMUMAB 200 MG/40 ML (5 MG/ML) INTRAVENOUS SOLUTION [108956]

Facility

$43,963.00

Service Code	HCPCS J9228
Hospital Revenue Code	250
Min. Negotiated Rate	$37,368.55
Max. Negotiated Rate	$42,644.11
Rate for Payer: Cash Price	$26,377.80
Rate for Payer: Cash Price	$17,120.40
Rate for Payer: Health Management Network Commercial	$24,253.90
Rate for Payer: Health Management Network Commercial	$37,368.55
Rate for Payer: Kaiser Permanente Commercial	$25,680.60
Rate for Payer: Kaiser Permanente Commercial	$39,566.70
Rate for Payer: MDX Hawaii PPO	$42,644.11
Rate for Payer: MDX Hawaii PPO	$27,677.98

Know your out-of-pocket cost for care.

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