Honoka'a Hospital and Skilled Nursing Facility

All Charges

Charge

Type

Setting

Price

LATANOPROST 0.005 % EYE DROPS [18621]

Facility

$238.00

Service Code	NDC 70069042101
Hospital Revenue Code	250
Min. Negotiated Rate	$202.30
Max. Negotiated Rate	$230.86
Rate for Payer: Cash Price	$142.80
Rate for Payer: Health Management Network Commercial	$202.30
Rate for Payer: Kaiser Permanente Commercial	$214.20
Rate for Payer: MDX Hawaii PPO	$230.86

LAUNCHER BACK UP LEFT 4.5

Facility

$225.00

Service Code	HCPCS C1887
Hospital Revenue Code	272
Min. Negotiated Rate	$112.50
Max. Negotiated Rate	$218.25
Rate for Payer: AlohaCare Medicaid	$112.50
Rate for Payer: AlohaCare Medicare	$171.00
Rate for Payer: Cash Price	$135.00
Rate for Payer: Devoted Health Medicare	$189.00
Rate for Payer: Hawaii Medical Service Association Medicare	$171.00
Rate for Payer: Hawaii Western Management Group Commercial	$213.75
Rate for Payer: Health Management Network Commercial	$191.25
Rate for Payer: Humana Medicare	$171.00
Rate for Payer: Kaiser Permanente Commercial	$202.50
Rate for Payer: Kaiser Permanente Medicaid	$114.75
Rate for Payer: Kaiser Permanente Medicare	$171.00
Rate for Payer: MDX Hawaii PPO	$218.25
Rate for Payer: Ohana Health Plan Medicaid	$171.00
Rate for Payer: Ohana Health Plan Medicare	$171.00
Rate for Payer: UnitedHealthcare Medicare	$171.00
Rate for Payer: University Health Alliance Commercial	$164.00

LAUNCHER BACK UP LEFT 4.5

Facility

$225.00

Service Code	HCPCS C1887
Hospital Revenue Code	272
Min. Negotiated Rate	$191.25
Max. Negotiated Rate	$218.25
Rate for Payer: Cash Price	$135.00
Rate for Payer: Health Management Network Commercial	$191.25
Rate for Payer: Kaiser Permanente Commercial	$202.50
Rate for Payer: MDX Hawaii PPO	$218.25

LAUNCHER CORONARY 7FR EBU 3.5

Facility

$225.00

Service Code	HCPCS C1887
Hospital Revenue Code	272
Min. Negotiated Rate	$112.50
Max. Negotiated Rate	$218.25
Rate for Payer: AlohaCare Medicaid	$112.50
Rate for Payer: AlohaCare Medicare	$171.00
Rate for Payer: Cash Price	$135.00
Rate for Payer: Devoted Health Medicare	$189.00
Rate for Payer: Hawaii Medical Service Association Medicare	$171.00
Rate for Payer: Hawaii Western Management Group Commercial	$213.75
Rate for Payer: Health Management Network Commercial	$191.25
Rate for Payer: Humana Medicare	$171.00
Rate for Payer: Kaiser Permanente Commercial	$202.50
Rate for Payer: Kaiser Permanente Medicaid	$114.75
Rate for Payer: Kaiser Permanente Medicare	$171.00
Rate for Payer: MDX Hawaii PPO	$218.25
Rate for Payer: Ohana Health Plan Medicaid	$171.00
Rate for Payer: Ohana Health Plan Medicare	$171.00
Rate for Payer: UnitedHealthcare Medicare	$171.00
Rate for Payer: University Health Alliance Commercial	$164.00

LAUNCHER CORONARY 7FR EBU 3.5

Facility

$225.00

Service Code	HCPCS C1887
Hospital Revenue Code	272
Min. Negotiated Rate	$191.25
Max. Negotiated Rate	$218.25
Rate for Payer: Cash Price	$135.00
Rate for Payer: Health Management Network Commercial	$191.25
Rate for Payer: Kaiser Permanente Commercial	$202.50
Rate for Payer: MDX Hawaii PPO	$218.25

LAUNCHER GUIDE JR5 6FR

Facility

$225.00

Service Code	HCPCS C1887
Hospital Revenue Code	272
Min. Negotiated Rate	$112.50
Max. Negotiated Rate	$218.25
Rate for Payer: AlohaCare Medicaid	$112.50
Rate for Payer: AlohaCare Medicare	$171.00
Rate for Payer: Cash Price	$135.00
Rate for Payer: Devoted Health Medicare	$189.00
Rate for Payer: Hawaii Medical Service Association Medicare	$171.00
Rate for Payer: Hawaii Western Management Group Commercial	$213.75
Rate for Payer: Health Management Network Commercial	$191.25
Rate for Payer: Humana Medicare	$171.00
Rate for Payer: Kaiser Permanente Commercial	$202.50
Rate for Payer: Kaiser Permanente Medicaid	$114.75
Rate for Payer: Kaiser Permanente Medicare	$171.00
Rate for Payer: MDX Hawaii PPO	$218.25
Rate for Payer: Ohana Health Plan Medicaid	$171.00
Rate for Payer: Ohana Health Plan Medicare	$171.00
Rate for Payer: UnitedHealthcare Medicare	$171.00
Rate for Payer: University Health Alliance Commercial	$164.00

LAUNCHER GUIDE JR5 6FR

Facility

$225.00

Service Code	HCPCS C1887
Hospital Revenue Code	272
Min. Negotiated Rate	$191.25
Max. Negotiated Rate	$218.25
Rate for Payer: Cash Price	$135.00
Rate for Payer: Health Management Network Commercial	$191.25
Rate for Payer: Kaiser Permanente Commercial	$202.50
Rate for Payer: MDX Hawaii PPO	$218.25

LAUNCHER JR 6F

Facility

$225.00

Service Code	HCPCS C1887
Hospital Revenue Code	272
Min. Negotiated Rate	$112.50
Max. Negotiated Rate	$218.25
Rate for Payer: AlohaCare Medicaid	$112.50
Rate for Payer: AlohaCare Medicare	$171.00
Rate for Payer: Cash Price	$135.00
Rate for Payer: Devoted Health Medicare	$189.00
Rate for Payer: Hawaii Medical Service Association Medicare	$171.00
Rate for Payer: Hawaii Western Management Group Commercial	$213.75
Rate for Payer: Health Management Network Commercial	$191.25
Rate for Payer: Humana Medicare	$171.00
Rate for Payer: Kaiser Permanente Commercial	$202.50
Rate for Payer: Kaiser Permanente Medicaid	$114.75
Rate for Payer: Kaiser Permanente Medicare	$171.00
Rate for Payer: MDX Hawaii PPO	$218.25
Rate for Payer: Ohana Health Plan Medicaid	$171.00
Rate for Payer: Ohana Health Plan Medicare	$171.00
Rate for Payer: UnitedHealthcare Medicare	$171.00
Rate for Payer: University Health Alliance Commercial	$164.00

LAUNCHER JR 6F

Facility

$225.00

Service Code	HCPCS C1887
Hospital Revenue Code	272
Min. Negotiated Rate	$191.25
Max. Negotiated Rate	$218.25
Rate for Payer: Cash Price	$135.00
Rate for Payer: Health Management Network Commercial	$191.25
Rate for Payer: Kaiser Permanente Commercial	$202.50
Rate for Payer: MDX Hawaii PPO	$218.25

LAUNCHER JR 6FX35

Facility

$225.00

Service Code	HCPCS C1887
Hospital Revenue Code	272
Min. Negotiated Rate	$112.50
Max. Negotiated Rate	$218.25
Rate for Payer: AlohaCare Medicaid	$112.50
Rate for Payer: AlohaCare Medicare	$171.00
Rate for Payer: Cash Price	$135.00
Rate for Payer: Devoted Health Medicare	$189.00
Rate for Payer: Hawaii Medical Service Association Medicare	$171.00
Rate for Payer: Hawaii Western Management Group Commercial	$213.75
Rate for Payer: Health Management Network Commercial	$191.25
Rate for Payer: Humana Medicare	$171.00
Rate for Payer: Kaiser Permanente Commercial	$202.50
Rate for Payer: Kaiser Permanente Medicaid	$114.75
Rate for Payer: Kaiser Permanente Medicare	$171.00
Rate for Payer: MDX Hawaii PPO	$218.25
Rate for Payer: Ohana Health Plan Medicaid	$171.00
Rate for Payer: Ohana Health Plan Medicare	$171.00
Rate for Payer: UnitedHealthcare Medicare	$171.00
Rate for Payer: University Health Alliance Commercial	$164.00

LAUNCHER JR 6FX35

Facility

$225.00

Service Code	HCPCS C1887
Hospital Revenue Code	272
Min. Negotiated Rate	$191.25
Max. Negotiated Rate	$218.25
Rate for Payer: Cash Price	$135.00
Rate for Payer: Health Management Network Commercial	$191.25
Rate for Payer: Kaiser Permanente Commercial	$202.50
Rate for Payer: MDX Hawaii PPO	$218.25

LAUNCHR BU LT 5FR EBU 3.0

Facility

$225.00

Service Code	HCPCS C1887
Hospital Revenue Code	272
Min. Negotiated Rate	$191.25
Max. Negotiated Rate	$218.25
Rate for Payer: Cash Price	$135.00
Rate for Payer: Health Management Network Commercial	$191.25
Rate for Payer: Kaiser Permanente Commercial	$202.50
Rate for Payer: MDX Hawaii PPO	$218.25

LAUNCHR BU LT 5FR EBU 3.0

Facility

$225.00

Service Code	HCPCS C1887
Hospital Revenue Code	272
Min. Negotiated Rate	$112.50
Max. Negotiated Rate	$218.25
Rate for Payer: AlohaCare Medicaid	$112.50
Rate for Payer: AlohaCare Medicare	$171.00
Rate for Payer: Cash Price	$135.00
Rate for Payer: Devoted Health Medicare	$189.00
Rate for Payer: Hawaii Medical Service Association Medicare	$171.00
Rate for Payer: Hawaii Western Management Group Commercial	$213.75
Rate for Payer: Health Management Network Commercial	$191.25
Rate for Payer: Humana Medicare	$171.00
Rate for Payer: Kaiser Permanente Commercial	$202.50
Rate for Payer: Kaiser Permanente Medicaid	$114.75
Rate for Payer: Kaiser Permanente Medicare	$171.00
Rate for Payer: MDX Hawaii PPO	$218.25
Rate for Payer: Ohana Health Plan Medicaid	$171.00
Rate for Payer: Ohana Health Plan Medicare	$171.00
Rate for Payer: UnitedHealthcare Medicare	$171.00
Rate for Payer: University Health Alliance Commercial	$164.00

LAUNCHR BU LT 5FR EBU 3.5

Facility

$225.00

Service Code	HCPCS C1887
Hospital Revenue Code	272
Min. Negotiated Rate	$112.50
Max. Negotiated Rate	$218.25
Rate for Payer: AlohaCare Medicaid	$112.50
Rate for Payer: AlohaCare Medicare	$171.00
Rate for Payer: Cash Price	$135.00
Rate for Payer: Devoted Health Medicare	$189.00
Rate for Payer: Hawaii Medical Service Association Medicare	$171.00
Rate for Payer: Hawaii Western Management Group Commercial	$213.75
Rate for Payer: Health Management Network Commercial	$191.25
Rate for Payer: Humana Medicare	$171.00
Rate for Payer: Kaiser Permanente Commercial	$202.50
Rate for Payer: Kaiser Permanente Medicaid	$114.75
Rate for Payer: Kaiser Permanente Medicare	$171.00
Rate for Payer: MDX Hawaii PPO	$218.25
Rate for Payer: Ohana Health Plan Medicaid	$171.00
Rate for Payer: Ohana Health Plan Medicare	$171.00
Rate for Payer: UnitedHealthcare Medicare	$171.00
Rate for Payer: University Health Alliance Commercial	$164.00

LAUNCHR BU LT 5FR EBU 3.5

Facility

$225.00

Service Code	HCPCS C1887
Hospital Revenue Code	272
Min. Negotiated Rate	$191.25
Max. Negotiated Rate	$218.25
Rate for Payer: Cash Price	$135.00
Rate for Payer: Health Management Network Commercial	$191.25
Rate for Payer: Kaiser Permanente Commercial	$202.50
Rate for Payer: MDX Hawaii PPO	$218.25

LCD 2.7/3.5 2H/RT 02.117.402

Facility

$2,749.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,374.50
Max. Negotiated Rate	$2,666.53
Rate for Payer: AlohaCare Medicaid	$1,374.50
Rate for Payer: AlohaCare Medicare	$2,089.24
Rate for Payer: Cash Price	$1,649.40
Rate for Payer: Devoted Health Medicare	$2,309.16
Rate for Payer: Hawaii Medical Service Association Medicare	$2,089.24
Rate for Payer: Hawaii Western Management Group Commercial	$1,924.30
Rate for Payer: Health Management Network Commercial	$2,336.65
Rate for Payer: Humana Medicare	$2,089.24
Rate for Payer: Kaiser Permanente Commercial	$2,474.10
Rate for Payer: Kaiser Permanente Medicaid	$1,401.99
Rate for Payer: Kaiser Permanente Medicare	$2,089.24
Rate for Payer: MDX Hawaii PPO	$2,666.53
Rate for Payer: Ohana Health Plan Medicaid	$2,089.24
Rate for Payer: Ohana Health Plan Medicare	$2,089.24
Rate for Payer: UnitedHealthcare Medicare	$2,089.24
Rate for Payer: University Health Alliance Commercial	$1,539.44

LCD 2.7/3.5 2H/RT 02.117.402

Facility

$2,749.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,539.44
Max. Negotiated Rate	$2,666.53
Rate for Payer: Cash Price	$1,649.40
Rate for Payer: Hawaii Western Management Group Commercial	$1,924.30
Rate for Payer: Health Management Network Commercial	$2,336.65
Rate for Payer: Kaiser Permanente Commercial	$2,474.10
Rate for Payer: MDX Hawaii PPO	$2,666.53
Rate for Payer: University Health Alliance Commercial	$1,539.44

LCD 2.7/3.5 2H/RT 02.117.602

Facility

$2,837.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,588.72
Max. Negotiated Rate	$2,751.89
Rate for Payer: Cash Price	$1,702.20
Rate for Payer: Hawaii Western Management Group Commercial	$1,985.90
Rate for Payer: Health Management Network Commercial	$2,411.45
Rate for Payer: Kaiser Permanente Commercial	$2,553.30
Rate for Payer: MDX Hawaii PPO	$2,751.89
Rate for Payer: University Health Alliance Commercial	$1,588.72

LCD 2.7/3.5 2H/RT 02.117.602

Facility

$2,837.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,418.50
Max. Negotiated Rate	$2,751.89
Rate for Payer: Cash Price	$1,702.20
Rate for Payer: AlohaCare Medicaid	$1,418.50
Rate for Payer: AlohaCare Medicare	$2,156.12
Rate for Payer: Devoted Health Medicare	$2,383.08
Rate for Payer: Hawaii Medical Service Association Medicare	$2,156.12
Rate for Payer: Hawaii Western Management Group Commercial	$1,985.90
Rate for Payer: Health Management Network Commercial	$2,411.45
Rate for Payer: Humana Medicare	$2,156.12
Rate for Payer: Kaiser Permanente Commercial	$2,553.30
Rate for Payer: Kaiser Permanente Medicaid	$1,446.87
Rate for Payer: Kaiser Permanente Medicare	$2,156.12
Rate for Payer: MDX Hawaii PPO	$2,751.89
Rate for Payer: Ohana Health Plan Medicaid	$2,156.12
Rate for Payer: Ohana Health Plan Medicare	$2,156.12
Rate for Payer: UnitedHealthcare Medicare	$2,156.12
Rate for Payer: University Health Alliance Commercial	$1,588.72

LCP 3.5 MED PROX TIBIA 239.954

Facility

$3,291.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,842.96
Max. Negotiated Rate	$3,192.27
Rate for Payer: Cash Price	$1,974.60
Rate for Payer: Hawaii Western Management Group Commercial	$2,303.70
Rate for Payer: Health Management Network Commercial	$2,797.35
Rate for Payer: Kaiser Permanente Commercial	$2,961.90
Rate for Payer: MDX Hawaii PPO	$3,192.27
Rate for Payer: University Health Alliance Commercial	$1,842.96

LCP 3.5 MED PROX TIBIA 239.954

Facility

$3,291.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,645.50
Max. Negotiated Rate	$3,192.27
Rate for Payer: AlohaCare Medicaid	$1,645.50
Rate for Payer: AlohaCare Medicare	$2,501.16
Rate for Payer: Cash Price	$1,974.60
Rate for Payer: Devoted Health Medicare	$2,764.44
Rate for Payer: Hawaii Medical Service Association Medicare	$2,501.16
Rate for Payer: Hawaii Western Management Group Commercial	$2,303.70
Rate for Payer: Health Management Network Commercial	$2,797.35
Rate for Payer: Humana Medicare	$2,501.16
Rate for Payer: Kaiser Permanente Commercial	$2,961.90
Rate for Payer: Kaiser Permanente Medicaid	$1,678.41
Rate for Payer: Kaiser Permanente Medicare	$2,501.16
Rate for Payer: MDX Hawaii PPO	$3,192.27
Rate for Payer: Ohana Health Plan Medicaid	$2,501.16
Rate for Payer: Ohana Health Plan Medicare	$2,501.16
Rate for Payer: UnitedHealthcare Medicare	$2,501.16
Rate for Payer: University Health Alliance Commercial	$1,842.96

LCP 3.5MM 3 HOLE 02.113.103

Facility

$1,926.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,078.56
Max. Negotiated Rate	$1,868.22
Rate for Payer: Cash Price	$1,155.60
Rate for Payer: Hawaii Western Management Group Commercial	$1,348.20
Rate for Payer: Health Management Network Commercial	$1,637.10
Rate for Payer: Kaiser Permanente Commercial	$1,733.40
Rate for Payer: MDX Hawaii PPO	$1,868.22
Rate for Payer: University Health Alliance Commercial	$1,078.56

LCP 3.5MM 3 HOLE 02.113.103

Facility

$1,926.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$963.00
Max. Negotiated Rate	$1,868.22
Rate for Payer: AlohaCare Medicaid	$963.00
Rate for Payer: AlohaCare Medicare	$1,463.76
Rate for Payer: Cash Price	$1,155.60
Rate for Payer: Devoted Health Medicare	$1,617.84
Rate for Payer: Hawaii Medical Service Association Medicare	$1,463.76
Rate for Payer: Hawaii Western Management Group Commercial	$1,348.20
Rate for Payer: Health Management Network Commercial	$1,637.10
Rate for Payer: Humana Medicare	$1,463.76
Rate for Payer: Kaiser Permanente Commercial	$1,733.40
Rate for Payer: Kaiser Permanente Medicaid	$982.26
Rate for Payer: Kaiser Permanente Medicare	$1,463.76
Rate for Payer: MDX Hawaii PPO	$1,868.22
Rate for Payer: Ohana Health Plan Medicaid	$1,463.76
Rate for Payer: Ohana Health Plan Medicare	$1,463.76
Rate for Payer: UnitedHealthcare Medicare	$1,463.76
Rate for Payer: University Health Alliance Commercial	$1,078.56

LCP 4.5X336MM LF 02.124.417

Facility

$4,808.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$2,692.48
Max. Negotiated Rate	$4,663.76
Rate for Payer: Cash Price	$2,884.80
Rate for Payer: Hawaii Western Management Group Commercial	$3,365.60
Rate for Payer: Health Management Network Commercial	$4,086.80
Rate for Payer: Kaiser Permanente Commercial	$4,327.20
Rate for Payer: MDX Hawaii PPO	$4,663.76
Rate for Payer: University Health Alliance Commercial	$2,692.48

LCP 4.5X336MM LF 02.124.417

Facility

$4,808.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$2,404.00
Max. Negotiated Rate	$4,663.76
Rate for Payer: AlohaCare Medicaid	$2,404.00
Rate for Payer: AlohaCare Medicare	$3,654.08
Rate for Payer: Cash Price	$2,884.80
Rate for Payer: Devoted Health Medicare	$4,038.72
Rate for Payer: Hawaii Medical Service Association Medicare	$3,654.08
Rate for Payer: Hawaii Western Management Group Commercial	$3,365.60
Rate for Payer: Health Management Network Commercial	$4,086.80
Rate for Payer: Humana Medicare	$3,654.08
Rate for Payer: Kaiser Permanente Commercial	$4,327.20
Rate for Payer: Kaiser Permanente Medicaid	$2,452.08
Rate for Payer: Kaiser Permanente Medicare	$3,654.08
Rate for Payer: MDX Hawaii PPO	$4,663.76
Rate for Payer: Ohana Health Plan Medicaid	$3,654.08
Rate for Payer: Ohana Health Plan Medicare	$3,654.08
Rate for Payer: UnitedHealthcare Medicare	$3,654.08
Rate for Payer: University Health Alliance Commercial	$2,692.48

Know your out-of-pocket cost for care.

All Charges