Honoka'a Hospital and Skilled Nursing Facility

All Charges

Charge

Type

Setting

Price

KIT FOR THE PREP OF TC-99M-TILMANOCEPT 250 MCG SOLUTION FOR INJECTION [190429]

Facility

$2,385.00

Service Code	HCPCS A9520
Hospital Revenue Code	343
Min. Negotiated Rate	$1,192.50
Max. Negotiated Rate	$2,313.45
Rate for Payer: AlohaCare Medicaid	$1,192.50
Rate for Payer: AlohaCare Medicare	$1,812.60
Rate for Payer: Cash Price	$1,431.00
Rate for Payer: Devoted Health Medicare	$2,003.40
Rate for Payer: Hawaii Medical Service Association Medicare	$1,812.60
Rate for Payer: Hawaii Western Management Group Commercial	$2,265.75
Rate for Payer: Health Management Network Commercial	$2,027.25
Rate for Payer: Humana Medicare	$1,812.60
Rate for Payer: Kaiser Permanente Commercial	$2,146.50
Rate for Payer: Kaiser Permanente Medicaid	$1,216.35
Rate for Payer: Kaiser Permanente Medicare	$1,812.60
Rate for Payer: MDX Hawaii PPO	$2,313.45
Rate for Payer: Ohana Health Plan Medicaid	$1,812.60
Rate for Payer: Ohana Health Plan Medicare	$1,812.60
Rate for Payer: UnitedHealthcare Medicare	$1,812.60
Rate for Payer: University Health Alliance Commercial	$1,738.43

KIT INFERIOR GLENOID G000-0100

Facility

$2,637.00

Hospital Revenue Code	272
Min. Negotiated Rate	$1,318.50
Max. Negotiated Rate	$2,557.89
Rate for Payer: AlohaCare Medicaid	$1,318.50
Rate for Payer: AlohaCare Medicare	$2,004.12
Rate for Payer: Cash Price	$1,582.20
Rate for Payer: Devoted Health Medicare	$2,215.08
Rate for Payer: Hawaii Medical Service Association Medicare	$2,004.12
Rate for Payer: Hawaii Western Management Group Commercial	$2,505.15
Rate for Payer: Health Management Network Commercial	$2,241.45
Rate for Payer: Humana Medicare	$2,004.12
Rate for Payer: Kaiser Permanente Commercial	$2,373.30
Rate for Payer: Kaiser Permanente Medicaid	$1,344.87
Rate for Payer: Kaiser Permanente Medicare	$2,004.12
Rate for Payer: MDX Hawaii PPO	$2,557.89
Rate for Payer: Ohana Health Plan Medicaid	$2,004.12
Rate for Payer: Ohana Health Plan Medicare	$2,004.12
Rate for Payer: UnitedHealthcare Medicare	$2,004.12
Rate for Payer: University Health Alliance Commercial	$1,922.11

KIT INFERIOR GLENOID G000-0100

Facility

$2,637.00

Hospital Revenue Code	272
Min. Negotiated Rate	$2,241.45
Max. Negotiated Rate	$2,557.89
Rate for Payer: Cash Price	$1,582.20
Rate for Payer: Health Management Network Commercial	$2,241.45
Rate for Payer: Kaiser Permanente Commercial	$2,373.30
Rate for Payer: MDX Hawaii PPO	$2,557.89

KIT IN-LINE INJECTION HOUSING

Facility

$130.00

Hospital Revenue Code	272
Min. Negotiated Rate	$65.00
Max. Negotiated Rate	$126.10
Rate for Payer: AlohaCare Medicaid	$65.00
Rate for Payer: AlohaCare Medicare	$98.80
Rate for Payer: Cash Price	$78.00
Rate for Payer: Devoted Health Medicare	$109.20
Rate for Payer: Hawaii Medical Service Association Medicare	$98.80
Rate for Payer: Hawaii Western Management Group Commercial	$123.50
Rate for Payer: Health Management Network Commercial	$110.50
Rate for Payer: Humana Medicare	$98.80
Rate for Payer: Kaiser Permanente Commercial	$117.00
Rate for Payer: Kaiser Permanente Medicaid	$66.30
Rate for Payer: Kaiser Permanente Medicare	$98.80
Rate for Payer: MDX Hawaii PPO	$126.10
Rate for Payer: Ohana Health Plan Medicaid	$98.80
Rate for Payer: Ohana Health Plan Medicare	$98.80
Rate for Payer: UnitedHealthcare Medicare	$98.80
Rate for Payer: University Health Alliance Commercial	$94.76

KIT IN-LINE INJECTION HOUSING

Facility

$130.00

Hospital Revenue Code	272
Min. Negotiated Rate	$110.50
Max. Negotiated Rate	$126.10
Rate for Payer: Cash Price	$78.00
Rate for Payer: Health Management Network Commercial	$110.50
Rate for Payer: Kaiser Permanente Commercial	$117.00
Rate for Payer: MDX Hawaii PPO	$126.10

KIT INTERSTIM REVISION 3560031

Facility

$1,452.00

Hospital Revenue Code	272
Min. Negotiated Rate	$726.00
Max. Negotiated Rate	$1,408.44
Rate for Payer: AlohaCare Medicaid	$726.00
Rate for Payer: AlohaCare Medicare	$1,103.52
Rate for Payer: Cash Price	$871.20
Rate for Payer: Devoted Health Medicare	$1,219.68
Rate for Payer: Hawaii Medical Service Association Medicare	$1,103.52
Rate for Payer: Hawaii Western Management Group Commercial	$1,379.40
Rate for Payer: Health Management Network Commercial	$1,234.20
Rate for Payer: Humana Medicare	$1,103.52
Rate for Payer: Kaiser Permanente Commercial	$1,306.80
Rate for Payer: Kaiser Permanente Medicaid	$740.52
Rate for Payer: Kaiser Permanente Medicare	$1,103.52
Rate for Payer: MDX Hawaii PPO	$1,408.44
Rate for Payer: Ohana Health Plan Medicaid	$1,103.52
Rate for Payer: Ohana Health Plan Medicare	$1,103.52
Rate for Payer: UnitedHealthcare Medicare	$1,103.52
Rate for Payer: University Health Alliance Commercial	$1,058.36

KIT INTERSTIM REVISION 3560031

Facility

$1,452.00

Hospital Revenue Code	272
Min. Negotiated Rate	$1,234.20
Max. Negotiated Rate	$1,408.44
Rate for Payer: Cash Price	$871.20
Rate for Payer: Health Management Network Commercial	$1,234.20
Rate for Payer: Kaiser Permanente Commercial	$1,306.80
Rate for Payer: MDX Hawaii PPO	$1,408.44

KIT IV CATH 2 LUMEN

Facility

$170.00

Service Code	HCPCS C1751
Hospital Revenue Code	272
Min. Negotiated Rate	$85.00
Max. Negotiated Rate	$164.90
Rate for Payer: AlohaCare Medicaid	$85.00
Rate for Payer: AlohaCare Medicare	$129.20
Rate for Payer: Cash Price	$102.00
Rate for Payer: Devoted Health Medicare	$142.80
Rate for Payer: Hawaii Medical Service Association Medicare	$129.20
Rate for Payer: Hawaii Western Management Group Commercial	$161.50
Rate for Payer: Health Management Network Commercial	$144.50
Rate for Payer: Humana Medicare	$129.20
Rate for Payer: Kaiser Permanente Commercial	$153.00
Rate for Payer: Kaiser Permanente Medicaid	$86.70
Rate for Payer: Kaiser Permanente Medicare	$129.20
Rate for Payer: MDX Hawaii PPO	$164.90
Rate for Payer: Ohana Health Plan Medicaid	$129.20
Rate for Payer: Ohana Health Plan Medicare	$129.20
Rate for Payer: UnitedHealthcare Medicare	$129.20
Rate for Payer: University Health Alliance Commercial	$123.91

KIT IV CATH 2 LUMEN

Facility

$170.00

Service Code	HCPCS C1751
Hospital Revenue Code	272
Min. Negotiated Rate	$144.50
Max. Negotiated Rate	$164.90
Rate for Payer: Cash Price	$102.00
Rate for Payer: Health Management Network Commercial	$144.50
Rate for Payer: Kaiser Permanente Commercial	$153.00
Rate for Payer: MDX Hawaii PPO	$164.90

KIT LEAD SURESCAN MRUI 978B128

Facility

$9,563.00

Service Code	HCPCS C1788
Hospital Revenue Code	278
Min. Negotiated Rate	$4,781.50
Max. Negotiated Rate	$9,276.11
Rate for Payer: AlohaCare Medicaid	$4,781.50
Rate for Payer: AlohaCare Medicare	$7,267.88
Rate for Payer: Cash Price	$5,737.80
Rate for Payer: Devoted Health Medicare	$8,032.92
Rate for Payer: Hawaii Medical Service Association Medicare	$7,267.88
Rate for Payer: Hawaii Western Management Group Commercial	$6,694.10
Rate for Payer: Health Management Network Commercial	$8,128.55
Rate for Payer: Humana Medicare	$7,267.88
Rate for Payer: Kaiser Permanente Commercial	$8,606.70
Rate for Payer: Kaiser Permanente Medicaid	$4,877.13
Rate for Payer: Kaiser Permanente Medicare	$7,267.88
Rate for Payer: MDX Hawaii PPO	$9,276.11
Rate for Payer: Ohana Health Plan Medicaid	$7,267.88
Rate for Payer: Ohana Health Plan Medicare	$7,267.88
Rate for Payer: UnitedHealthcare Medicare	$7,267.88
Rate for Payer: University Health Alliance Commercial	$5,355.28

KIT LEAD SURESCAN MRUI 978B128

Facility

$9,563.00

Service Code	HCPCS C1788
Hospital Revenue Code	278
Min. Negotiated Rate	$5,355.28
Max. Negotiated Rate	$9,276.11
Rate for Payer: Cash Price	$5,737.80
Rate for Payer: Hawaii Western Management Group Commercial	$6,694.10
Rate for Payer: Health Management Network Commercial	$8,128.55
Rate for Payer: Kaiser Permanente Commercial	$8,606.70
Rate for Payer: MDX Hawaii PPO	$9,276.11
Rate for Payer: University Health Alliance Commercial	$5,355.28

KIT LEEP REDIKIT

Facility

$202.00

Hospital Revenue Code	272
Min. Negotiated Rate	$101.00
Max. Negotiated Rate	$195.94
Rate for Payer: AlohaCare Medicaid	$101.00
Rate for Payer: AlohaCare Medicare	$153.52
Rate for Payer: Cash Price	$121.20
Rate for Payer: Devoted Health Medicare	$169.68
Rate for Payer: Hawaii Medical Service Association Medicare	$153.52
Rate for Payer: Hawaii Western Management Group Commercial	$191.90
Rate for Payer: Health Management Network Commercial	$171.70
Rate for Payer: Humana Medicare	$153.52
Rate for Payer: Kaiser Permanente Commercial	$181.80
Rate for Payer: Kaiser Permanente Medicaid	$103.02
Rate for Payer: Kaiser Permanente Medicare	$153.52
Rate for Payer: MDX Hawaii PPO	$195.94
Rate for Payer: Ohana Health Plan Medicaid	$153.52
Rate for Payer: Ohana Health Plan Medicare	$153.52
Rate for Payer: UnitedHealthcare Medicare	$153.52
Rate for Payer: University Health Alliance Commercial	$147.24

KIT LEEP REDIKIT

Facility

$202.00

Hospital Revenue Code	272
Min. Negotiated Rate	$171.70
Max. Negotiated Rate	$195.94
Rate for Payer: Cash Price	$121.20
Rate for Payer: Health Management Network Commercial	$171.70
Rate for Payer: Kaiser Permanente Commercial	$181.80
Rate for Payer: MDX Hawaii PPO	$195.94

KIT MISCARRIAGE MANAGE #UEK

Facility

$392.00

Hospital Revenue Code	272
Min. Negotiated Rate	$333.20
Max. Negotiated Rate	$380.24
Rate for Payer: Cash Price	$235.20
Rate for Payer: Health Management Network Commercial	$333.20
Rate for Payer: Kaiser Permanente Commercial	$352.80
Rate for Payer: MDX Hawaii PPO	$380.24

KIT MISCARRIAGE MANAGE #UEK

Facility

$392.00

Hospital Revenue Code	272
Min. Negotiated Rate	$196.00
Max. Negotiated Rate	$380.24
Rate for Payer: AlohaCare Medicaid	$196.00
Rate for Payer: AlohaCare Medicare	$297.92
Rate for Payer: Cash Price	$235.20
Rate for Payer: Devoted Health Medicare	$329.28
Rate for Payer: Hawaii Medical Service Association Medicare	$297.92
Rate for Payer: Hawaii Western Management Group Commercial	$372.40
Rate for Payer: Health Management Network Commercial	$333.20
Rate for Payer: Humana Medicare	$297.92
Rate for Payer: Kaiser Permanente Commercial	$352.80
Rate for Payer: Kaiser Permanente Medicaid	$199.92
Rate for Payer: Kaiser Permanente Medicare	$297.92
Rate for Payer: MDX Hawaii PPO	$380.24
Rate for Payer: Ohana Health Plan Medicaid	$297.92
Rate for Payer: Ohana Health Plan Medicare	$297.92
Rate for Payer: UnitedHealthcare Medicare	$297.92
Rate for Payer: University Health Alliance Commercial	$285.73

KIT NEPHROSTOMY BALLOON

Facility

$913.00

Service Code	HCPCS C1726
Hospital Revenue Code	272
Min. Negotiated Rate	$776.05
Max. Negotiated Rate	$885.61
Rate for Payer: Cash Price	$547.80
Rate for Payer: Health Management Network Commercial	$776.05
Rate for Payer: Kaiser Permanente Commercial	$821.70
Rate for Payer: MDX Hawaii PPO	$885.61

KIT NEPHROSTOMY BALLOON

Facility

$913.00

Service Code	HCPCS C1726
Hospital Revenue Code	272
Min. Negotiated Rate	$456.50
Max. Negotiated Rate	$885.61
Rate for Payer: AlohaCare Medicaid	$456.50
Rate for Payer: AlohaCare Medicare	$693.88
Rate for Payer: Cash Price	$547.80
Rate for Payer: Devoted Health Medicare	$766.92
Rate for Payer: Hawaii Medical Service Association Medicare	$693.88
Rate for Payer: Hawaii Western Management Group Commercial	$867.35
Rate for Payer: Health Management Network Commercial	$776.05
Rate for Payer: Humana Medicare	$693.88
Rate for Payer: Kaiser Permanente Commercial	$821.70
Rate for Payer: Kaiser Permanente Medicaid	$465.63
Rate for Payer: Kaiser Permanente Medicare	$693.88
Rate for Payer: MDX Hawaii PPO	$885.61
Rate for Payer: Ohana Health Plan Medicaid	$693.88
Rate for Payer: Ohana Health Plan Medicare	$693.88
Rate for Payer: UnitedHealthcare Medicare	$693.88
Rate for Payer: University Health Alliance Commercial	$665.49

KIT PERC ACCESS

Facility

$507.00

Service Code	HCPCS C1769
Hospital Revenue Code	272
Min. Negotiated Rate	$253.50
Max. Negotiated Rate	$491.79
Rate for Payer: AlohaCare Medicaid	$253.50
Rate for Payer: AlohaCare Medicare	$385.32
Rate for Payer: Cash Price	$304.20
Rate for Payer: Devoted Health Medicare	$425.88
Rate for Payer: Hawaii Medical Service Association Medicare	$385.32
Rate for Payer: Hawaii Western Management Group Commercial	$481.65
Rate for Payer: Health Management Network Commercial	$430.95
Rate for Payer: Humana Medicare	$385.32
Rate for Payer: Kaiser Permanente Commercial	$456.30
Rate for Payer: Kaiser Permanente Medicaid	$258.57
Rate for Payer: Kaiser Permanente Medicare	$385.32
Rate for Payer: MDX Hawaii PPO	$491.79
Rate for Payer: Ohana Health Plan Medicaid	$385.32
Rate for Payer: Ohana Health Plan Medicare	$385.32
Rate for Payer: UnitedHealthcare Medicare	$385.32
Rate for Payer: University Health Alliance Commercial	$369.55

KIT PERC ACCESS

Facility

$507.00

Service Code	HCPCS C1769
Hospital Revenue Code	272
Min. Negotiated Rate	$430.95
Max. Negotiated Rate	$491.79
Rate for Payer: Cash Price	$304.20
Rate for Payer: Health Management Network Commercial	$430.95
Rate for Payer: Kaiser Permanente Commercial	$456.30
Rate for Payer: MDX Hawaii PPO	$491.79

KIT PERCUTANEOUS INTRO SET

Facility

$249.00

Service Code	HCPCS C1892
Hospital Revenue Code	272
Min. Negotiated Rate	$124.50
Max. Negotiated Rate	$241.53
Rate for Payer: AlohaCare Medicaid	$124.50
Rate for Payer: AlohaCare Medicare	$189.24
Rate for Payer: Cash Price	$149.40
Rate for Payer: Devoted Health Medicare	$209.16
Rate for Payer: Hawaii Medical Service Association Medicare	$189.24
Rate for Payer: Hawaii Western Management Group Commercial	$236.55
Rate for Payer: Health Management Network Commercial	$211.65
Rate for Payer: Humana Medicare	$189.24
Rate for Payer: Kaiser Permanente Commercial	$224.10
Rate for Payer: Kaiser Permanente Medicaid	$126.99
Rate for Payer: Kaiser Permanente Medicare	$189.24
Rate for Payer: MDX Hawaii PPO	$241.53
Rate for Payer: Ohana Health Plan Medicaid	$189.24
Rate for Payer: Ohana Health Plan Medicare	$189.24
Rate for Payer: UnitedHealthcare Medicare	$189.24
Rate for Payer: University Health Alliance Commercial	$181.50

KIT PERCUTANEOUS INTRO SET

Facility

$249.00

Service Code	HCPCS C1892
Hospital Revenue Code	272
Min. Negotiated Rate	$211.65
Max. Negotiated Rate	$241.53
Rate for Payer: Cash Price	$149.40
Rate for Payer: Health Management Network Commercial	$211.65
Rate for Payer: Kaiser Permanente Commercial	$224.10
Rate for Payer: MDX Hawaii PPO	$241.53

KIT PERICARDIOCENTESIS

Facility

$530.00

Service Code	HCPCS C1729
Hospital Revenue Code	272
Min. Negotiated Rate	$265.00
Max. Negotiated Rate	$514.10
Rate for Payer: AlohaCare Medicaid	$265.00
Rate for Payer: AlohaCare Medicare	$402.80
Rate for Payer: Cash Price	$318.00
Rate for Payer: Devoted Health Medicare	$445.20
Rate for Payer: Hawaii Medical Service Association Medicare	$402.80
Rate for Payer: Hawaii Western Management Group Commercial	$503.50
Rate for Payer: Health Management Network Commercial	$450.50
Rate for Payer: Humana Medicare	$402.80
Rate for Payer: Kaiser Permanente Commercial	$477.00
Rate for Payer: Kaiser Permanente Medicaid	$270.30
Rate for Payer: Kaiser Permanente Medicare	$402.80
Rate for Payer: MDX Hawaii PPO	$514.10
Rate for Payer: Ohana Health Plan Medicaid	$402.80
Rate for Payer: Ohana Health Plan Medicare	$402.80
Rate for Payer: UnitedHealthcare Medicare	$402.80
Rate for Payer: University Health Alliance Commercial	$386.32

KIT PERICARDIOCENTESIS

Facility

$530.00

Service Code	HCPCS C1729
Hospital Revenue Code	272
Min. Negotiated Rate	$450.50
Max. Negotiated Rate	$514.10
Rate for Payer: Cash Price	$318.00
Rate for Payer: Health Management Network Commercial	$450.50
Rate for Payer: Kaiser Permanente Commercial	$477.00
Rate for Payer: MDX Hawaii PPO	$514.10

KIT PREPARATION OF TC 99M-SESTAMIBI COMBO NO.1 IV SOLUTION [134046]

Facility

$463.00

Service Code	HCPCS A9500
Hospital Revenue Code	343
Min. Negotiated Rate	$393.55
Max. Negotiated Rate	$449.11
Rate for Payer: Cash Price	$277.80
Rate for Payer: Health Management Network Commercial	$393.55
Rate for Payer: Kaiser Permanente Commercial	$416.70
Rate for Payer: MDX Hawaii PPO	$449.11

KIT PREPARATION OF TC 99M-SESTAMIBI COMBO NO.1 IV SOLUTION [134046]

Facility

$463.00

Service Code	HCPCS A9500
Hospital Revenue Code	343
Min. Negotiated Rate	$83.20
Max. Negotiated Rate	$449.11
Rate for Payer: Kaiser Permanente Commercial	$416.70
Rate for Payer: AlohaCare Medicaid	$231.50
Rate for Payer: AlohaCare Medicare	$351.88
Rate for Payer: Cash Price	$277.80
Rate for Payer: Cash Price	$277.80
Rate for Payer: Devoted Health Medicare	$388.92
Rate for Payer: Hawaii Medical Service Association Medicare	$351.88
Rate for Payer: Hawaii Western Management Group Commercial	$439.85
Rate for Payer: Health Management Network Commercial	$393.55
Rate for Payer: Humana Medicare	$351.88
Rate for Payer: Kaiser Permanente Medicaid	$236.13
Rate for Payer: Kaiser Permanente Medicare	$351.88
Rate for Payer: MDX Hawaii PPO	$449.11
Rate for Payer: Ohana Health Plan Medicaid	$351.88
Rate for Payer: Ohana Health Plan Medicare	$351.88
Rate for Payer: UnitedHealthcare Medicaid	$83.20
Rate for Payer: UnitedHealthcare Medicare	$351.88
Rate for Payer: University Health Alliance Commercial	$337.48

Know your out-of-pocket cost for care.

All Charges