Honoka'a Hospital and Skilled Nursing Facility

All Charges

Charge

Type

Setting

Price

LIDOCAINE (PF) 20 MG/ML (2 %) INJECTION SOLUTION [104208]

Facility

$13.00

Service Code	NDC 55150016505
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

LIDOCAINE (PF) 3.5 % EYE GEL [94220]

Facility

$71.00

Service Code	NDC 82584079201
Hospital Revenue Code	250
Min. Negotiated Rate	$60.35
Max. Negotiated Rate	$68.87
Rate for Payer: Cash Price	$42.60
Rate for Payer: Health Management Network Commercial	$60.35
Rate for Payer: Kaiser Permanente Commercial	$63.90
Rate for Payer: MDX Hawaii PPO	$68.87

LIDOCAINE (PF) 4 MG/ML (0.4 %) IN 5 % DEXTROSE INTRAVENOUS SOLUTION [14868]

Facility

$28.00

Service Code	HCPCS J2002
Hospital Revenue Code	636
Min. Negotiated Rate	$0.01
Max. Negotiated Rate	$27.16
Rate for Payer: AlohaCare Medicaid	$14.00
Rate for Payer: AlohaCare Medicare	$21.28
Rate for Payer: Cash Price	$16.80
Rate for Payer: Cash Price	$16.80
Rate for Payer: Devoted Health Medicare	$23.52
Rate for Payer: Hawaii Medical Service Association ABD	$0.01
Rate for Payer: Hawaii Medical Service Association Medicare	$21.28
Rate for Payer: Hawaii Medical Service Association Non-ABD	$0.01
Rate for Payer: Hawaii Western Management Group Commercial	$26.60
Rate for Payer: Health Management Network Commercial	$23.80
Rate for Payer: Humana Medicare	$21.28
Rate for Payer: Kaiser Permanente Commercial	$25.20
Rate for Payer: Kaiser Permanente Medicaid	$14.28
Rate for Payer: Kaiser Permanente Medicare	$21.28
Rate for Payer: MDX Hawaii PPO	$27.16
Rate for Payer: Ohana Health Plan Medicaid	$21.28
Rate for Payer: Ohana Health Plan Medicare	$21.28
Rate for Payer: UnitedHealthcare Medicaid	$16.80
Rate for Payer: UnitedHealthcare Medicare	$21.28
Rate for Payer: University Health Alliance Commercial	$20.41

LIDOCAINE (PF) 4 MG/ML (0.4 %) IN 5 % DEXTROSE INTRAVENOUS SOLUTION [14868]

Facility

$28.00

Service Code	HCPCS J2002
Hospital Revenue Code	250
Min. Negotiated Rate	$23.80
Max. Negotiated Rate	$27.16
Rate for Payer: Cash Price	$16.80
Rate for Payer: Health Management Network Commercial	$23.80
Rate for Payer: Kaiser Permanente Commercial	$25.20
Rate for Payer: MDX Hawaii PPO	$27.16

LIDOCAINE (PF) 8 MG/ML (0.8 %) IN 5 % DEXTROSE INTRAVENOUS SOLUTION [14869]

Facility

$38.00

Service Code	HCPCS J2001
Hospital Revenue Code	250
Min. Negotiated Rate	$32.30
Max. Negotiated Rate	$36.86
Rate for Payer: Cash Price	$22.80
Rate for Payer: Health Management Network Commercial	$32.30
Rate for Payer: Kaiser Permanente Commercial	$34.20
Rate for Payer: MDX Hawaii PPO	$36.86

LIDOCAINE (PF) 8 MG/ML (0.8 %) IN 5 % DEXTROSE INTRAVENOUS SOLUTION [14869]

Facility

$38.00

Service Code	HCPCS J2001
Hospital Revenue Code	636
Min. Negotiated Rate	$19.00
Max. Negotiated Rate	$36.86
Rate for Payer: AlohaCare Medicaid	$19.00
Rate for Payer: AlohaCare Medicare	$28.88
Rate for Payer: Cash Price	$22.80
Rate for Payer: Devoted Health Medicare	$31.92
Rate for Payer: Hawaii Medical Service Association Medicare	$28.88
Rate for Payer: Hawaii Western Management Group Commercial	$36.10
Rate for Payer: Health Management Network Commercial	$32.30
Rate for Payer: Humana Medicare	$28.88
Rate for Payer: Kaiser Permanente Commercial	$34.20
Rate for Payer: Kaiser Permanente Medicaid	$19.38
Rate for Payer: Kaiser Permanente Medicare	$28.88
Rate for Payer: MDX Hawaii PPO	$36.86
Rate for Payer: Ohana Health Plan Medicaid	$28.88
Rate for Payer: Ohana Health Plan Medicare	$28.88
Rate for Payer: UnitedHealthcare Medicaid	$22.80
Rate for Payer: UnitedHealthcare Medicare	$28.88
Rate for Payer: University Health Alliance Commercial	$27.70

LIDOCAINE-PRILOCAINE 2.5 %-2.5 % TOPICAL CREAM [10434]

Facility

$35.00

Service Code	NDC 00168035755
Hospital Revenue Code	637
Min. Negotiated Rate	$17.50
Max. Negotiated Rate	$33.95
Rate for Payer: AlohaCare Medicaid	$17.50
Rate for Payer: AlohaCare Medicare	$26.60
Rate for Payer: Cash Price	$21.00
Rate for Payer: Devoted Health Medicare	$29.40
Rate for Payer: Hawaii Medical Service Association Medicare	$26.60
Rate for Payer: Hawaii Western Management Group Commercial	$33.25
Rate for Payer: Health Management Network Commercial	$29.75
Rate for Payer: Humana Medicare	$26.60
Rate for Payer: Kaiser Permanente Commercial	$31.50
Rate for Payer: Kaiser Permanente Medicaid	$17.85
Rate for Payer: Kaiser Permanente Medicare	$26.60
Rate for Payer: MDX Hawaii PPO	$33.95
Rate for Payer: Ohana Health Plan Medicaid	$26.60
Rate for Payer: Ohana Health Plan Medicare	$26.60
Rate for Payer: UnitedHealthcare Medicare	$26.60
Rate for Payer: University Health Alliance Commercial	$25.51

LIDOCAINE-PRILOCAINE 2.5 %-2.5 % TOPICAL CREAM [10434]

Facility

$96.00

Service Code	NDC 62332058231
Hospital Revenue Code	250
Min. Negotiated Rate	$81.60
Max. Negotiated Rate	$93.12
Rate for Payer: Cash Price	$57.60
Rate for Payer: Health Management Network Commercial	$81.60
Rate for Payer: Kaiser Permanente Commercial	$86.40
Rate for Payer: MDX Hawaii PPO	$93.12

LIDOCAINE-PRILOCAINE 2.5 %-2.5 % TOPICAL CREAM [10434]

Facility

$96.00

Service Code	NDC 62332058231
Hospital Revenue Code	637
Min. Negotiated Rate	$48.00
Max. Negotiated Rate	$93.12
Rate for Payer: AlohaCare Medicaid	$48.00
Rate for Payer: AlohaCare Medicare	$72.96
Rate for Payer: Cash Price	$57.60
Rate for Payer: Devoted Health Medicare	$80.64
Rate for Payer: Hawaii Medical Service Association Medicare	$72.96
Rate for Payer: Hawaii Western Management Group Commercial	$91.20
Rate for Payer: Health Management Network Commercial	$81.60
Rate for Payer: Humana Medicare	$72.96
Rate for Payer: Kaiser Permanente Commercial	$86.40
Rate for Payer: Kaiser Permanente Medicaid	$48.96
Rate for Payer: Kaiser Permanente Medicare	$72.96
Rate for Payer: MDX Hawaii PPO	$93.12
Rate for Payer: Ohana Health Plan Medicaid	$72.96
Rate for Payer: Ohana Health Plan Medicare	$72.96
Rate for Payer: UnitedHealthcare Medicare	$72.96
Rate for Payer: University Health Alliance Commercial	$69.97

LIDOCAINE-PRILOCAINE 2.5 %-2.5 % TOPICAL CREAM [10434]

Facility

$35.00

Service Code	NDC 00168035755
Hospital Revenue Code	250
Min. Negotiated Rate	$29.75
Max. Negotiated Rate	$33.95
Rate for Payer: Cash Price	$21.00
Rate for Payer: Health Management Network Commercial	$29.75
Rate for Payer: Kaiser Permanente Commercial	$31.50
Rate for Payer: MDX Hawaii PPO	$33.95

LIDOCAINE-PRILOCAINE 2.5 %-2.5 % TOPICAL CREAM [10434]

Facility

$35.00

Service Code	NDC 00168035705
Hospital Revenue Code	637
Min. Negotiated Rate	$17.50
Max. Negotiated Rate	$33.95
Rate for Payer: AlohaCare Medicaid	$17.50
Rate for Payer: AlohaCare Medicare	$26.60
Rate for Payer: Cash Price	$21.00
Rate for Payer: Devoted Health Medicare	$29.40
Rate for Payer: Hawaii Medical Service Association Medicare	$26.60
Rate for Payer: Hawaii Western Management Group Commercial	$33.25
Rate for Payer: Health Management Network Commercial	$29.75
Rate for Payer: Humana Medicare	$26.60
Rate for Payer: Kaiser Permanente Commercial	$31.50
Rate for Payer: Kaiser Permanente Medicaid	$17.85
Rate for Payer: Kaiser Permanente Medicare	$26.60
Rate for Payer: MDX Hawaii PPO	$33.95
Rate for Payer: Ohana Health Plan Medicaid	$26.60
Rate for Payer: Ohana Health Plan Medicare	$26.60
Rate for Payer: UnitedHealthcare Medicare	$26.60
Rate for Payer: University Health Alliance Commercial	$25.51

LIDOCAINE-PRILOCAINE 2.5 %-2.5 % TOPICAL CREAM [10434]

Facility

$35.00

Service Code	NDC 00168035705
Hospital Revenue Code	250
Min. Negotiated Rate	$29.75
Max. Negotiated Rate	$33.95
Rate for Payer: Cash Price	$21.00
Rate for Payer: Health Management Network Commercial	$29.75
Rate for Payer: Kaiser Permanente Commercial	$31.50
Rate for Payer: MDX Hawaii PPO	$33.95

LIDOCAINE-TRANSPARENT DRESSING 4 % TOPICAL KIT [30183]

Facility

$60.00

Service Code	NDC 24357070107
Hospital Revenue Code	250
Min. Negotiated Rate	$51.00
Max. Negotiated Rate	$58.20
Rate for Payer: Cash Price	$36.00
Rate for Payer: Health Management Network Commercial	$51.00
Rate for Payer: Kaiser Permanente Commercial	$54.00
Rate for Payer: MDX Hawaii PPO	$58.20

LIGASURE ADVANCE SPD#LF5544

Facility

$2,200.00

Hospital Revenue Code	272
Min. Negotiated Rate	$1,870.00
Max. Negotiated Rate	$2,134.00
Rate for Payer: Cash Price	$1,320.00
Rate for Payer: Health Management Network Commercial	$1,870.00
Rate for Payer: Kaiser Permanente Commercial	$1,980.00
Rate for Payer: MDX Hawaii PPO	$2,134.00

LIGASURE ADVANCE SPD#LF5544

Facility

$2,200.00

Hospital Revenue Code	272
Min. Negotiated Rate	$1,100.00
Max. Negotiated Rate	$2,134.00
Rate for Payer: AlohaCare Medicaid	$1,100.00
Rate for Payer: AlohaCare Medicare	$1,672.00
Rate for Payer: Cash Price	$1,320.00
Rate for Payer: Devoted Health Medicare	$1,848.00
Rate for Payer: Hawaii Medical Service Association Medicare	$1,672.00
Rate for Payer: Hawaii Western Management Group Commercial	$2,090.00
Rate for Payer: Health Management Network Commercial	$1,870.00
Rate for Payer: Humana Medicare	$1,672.00
Rate for Payer: Kaiser Permanente Commercial	$1,980.00
Rate for Payer: Kaiser Permanente Medicaid	$1,122.00
Rate for Payer: Kaiser Permanente Medicare	$1,672.00
Rate for Payer: MDX Hawaii PPO	$2,134.00
Rate for Payer: Ohana Health Plan Medicaid	$1,672.00
Rate for Payer: Ohana Health Plan Medicare	$1,672.00
Rate for Payer: UnitedHealthcare Medicare	$1,672.00
Rate for Payer: University Health Alliance Commercial	$1,603.58

LIGASURE EXACT DISSECT LF2019

Facility

$1,521.00

Hospital Revenue Code	272
Min. Negotiated Rate	$760.50
Max. Negotiated Rate	$1,475.37
Rate for Payer: AlohaCare Medicaid	$760.50
Rate for Payer: AlohaCare Medicare	$1,155.96
Rate for Payer: Cash Price	$912.60
Rate for Payer: Devoted Health Medicare	$1,277.64
Rate for Payer: Hawaii Medical Service Association Medicare	$1,155.96
Rate for Payer: Hawaii Western Management Group Commercial	$1,444.95
Rate for Payer: Health Management Network Commercial	$1,292.85
Rate for Payer: Humana Medicare	$1,155.96
Rate for Payer: Kaiser Permanente Commercial	$1,368.90
Rate for Payer: Kaiser Permanente Medicaid	$775.71
Rate for Payer: Kaiser Permanente Medicare	$1,155.96
Rate for Payer: MDX Hawaii PPO	$1,475.37
Rate for Payer: Ohana Health Plan Medicaid	$1,155.96
Rate for Payer: Ohana Health Plan Medicare	$1,155.96
Rate for Payer: UnitedHealthcare Medicare	$1,155.96
Rate for Payer: University Health Alliance Commercial	$1,108.66

LIGASURE EXACT DISSECT LF2019

Facility

$1,521.00

Hospital Revenue Code	272
Min. Negotiated Rate	$1,292.85
Max. Negotiated Rate	$1,475.37
Rate for Payer: Cash Price	$912.60
Rate for Payer: Health Management Network Commercial	$1,292.85
Rate for Payer: Kaiser Permanente Commercial	$1,368.90
Rate for Payer: MDX Hawaii PPO	$1,475.37

LIGASURE L-HOOK 5X44 LF5644

Facility

$1,814.00

Hospital Revenue Code	272
Min. Negotiated Rate	$907.00
Max. Negotiated Rate	$1,759.58
Rate for Payer: AlohaCare Medicaid	$907.00
Rate for Payer: AlohaCare Medicare	$1,378.64
Rate for Payer: Cash Price	$1,088.40
Rate for Payer: Devoted Health Medicare	$1,523.76
Rate for Payer: Hawaii Medical Service Association Medicare	$1,378.64
Rate for Payer: Hawaii Western Management Group Commercial	$1,723.30
Rate for Payer: Health Management Network Commercial	$1,541.90
Rate for Payer: Humana Medicare	$1,378.64
Rate for Payer: Kaiser Permanente Commercial	$1,632.60
Rate for Payer: Kaiser Permanente Medicaid	$925.14
Rate for Payer: Kaiser Permanente Medicare	$1,378.64
Rate for Payer: MDX Hawaii PPO	$1,759.58
Rate for Payer: Ohana Health Plan Medicaid	$1,378.64
Rate for Payer: Ohana Health Plan Medicare	$1,378.64
Rate for Payer: UnitedHealthcare Medicare	$1,378.64
Rate for Payer: University Health Alliance Commercial	$1,322.22

LIGASURE L-HOOK 5X44 LF5644

Facility

$1,814.00

Hospital Revenue Code	272
Min. Negotiated Rate	$1,541.90
Max. Negotiated Rate	$1,759.58
Rate for Payer: Cash Price	$1,088.40
Rate for Payer: Health Management Network Commercial	$1,541.90
Rate for Payer: Kaiser Permanente Commercial	$1,632.60
Rate for Payer: MDX Hawaii PPO	$1,759.58

LIGASURE MARYLA LF1937/ LF1737

Facility

$1,650.00

Hospital Revenue Code	272
Min. Negotiated Rate	$825.00
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: Devoted Health Medicare	$1,386.00
Rate for Payer: Hawaii Medical Service Association Medicare	$1,254.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,567.50
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	$1,202.68

LIGASURE MARYLA LF1937/ LF1737

Facility

$1,650.00

Hospital Revenue Code	272
Min. Negotiated Rate	$1,402.50
Max. Negotiated Rate	$1,600.50
Rate for Payer: Cash Price	$990.00
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

LIGASURE MARYLAND XP LXMJ37L

Facility

$1,626.00

Hospital Revenue Code	272
Min. Negotiated Rate	$813.00
Max. Negotiated Rate	$1,577.22
Rate for Payer: AlohaCare Medicaid	$813.00
Rate for Payer: AlohaCare Medicare	$1,235.76
Rate for Payer: Cash Price	$975.60
Rate for Payer: Devoted Health Medicare	$1,365.84
Rate for Payer: Hawaii Medical Service Association Medicare	$1,235.76
Rate for Payer: Hawaii Western Management Group Commercial	$1,544.70
Rate for Payer: Health Management Network Commercial	$1,382.10
Rate for Payer: Humana Medicare	$1,235.76
Rate for Payer: Kaiser Permanente Commercial	$1,463.40
Rate for Payer: Kaiser Permanente Medicaid	$829.26
Rate for Payer: Kaiser Permanente Medicare	$1,235.76
Rate for Payer: MDX Hawaii PPO	$1,577.22
Rate for Payer: Ohana Health Plan Medicaid	$1,235.76
Rate for Payer: Ohana Health Plan Medicare	$1,235.76
Rate for Payer: UnitedHealthcare Medicare	$1,235.76
Rate for Payer: University Health Alliance Commercial	$1,185.19

LIGASURE MARYLAND XP LXMJ37L

Facility

$1,626.00

Hospital Revenue Code	272
Min. Negotiated Rate	$1,382.10
Max. Negotiated Rate	$1,577.22
Rate for Payer: Cash Price	$975.60
Rate for Payer: Health Management Network Commercial	$1,382.10
Rate for Payer: Kaiser Permanente Commercial	$1,463.40
Rate for Payer: MDX Hawaii PPO	$1,577.22

LIMB REATTACHMENT, HIP AND FEMUR PROCEDURES FOR MULTIPLE SIGNIFICANT TRAUMA

Facility

$214,242.38

Service Code	MSDRG 956
Min. Negotiated Rate	$214,242.38
Max. Negotiated Rate	$214,242.38
Rate for Payer: Hawaii Medical Service Association Commercial	$214,242.38

LINER 42MM CMNTLESS 626-00-42E

Facility

$3,331.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$1,665.50
Max. Negotiated Rate	$3,231.07
Rate for Payer: AlohaCare Medicaid	$1,665.50
Rate for Payer: AlohaCare Medicare	$2,531.56
Rate for Payer: Cash Price	$1,998.60
Rate for Payer: Devoted Health Medicare	$2,798.04
Rate for Payer: Hawaii Medical Service Association Medicare	$2,531.56
Rate for Payer: Hawaii Western Management Group Commercial	$2,331.70
Rate for Payer: Health Management Network Commercial	$2,831.35
Rate for Payer: Humana Medicare	$2,531.56
Rate for Payer: Kaiser Permanente Commercial	$2,997.90
Rate for Payer: Kaiser Permanente Medicaid	$1,698.81
Rate for Payer: Kaiser Permanente Medicare	$2,531.56
Rate for Payer: MDX Hawaii PPO	$3,231.07
Rate for Payer: Ohana Health Plan Medicaid	$2,531.56
Rate for Payer: Ohana Health Plan Medicare	$2,531.56
Rate for Payer: UnitedHealthcare Medicare	$2,531.56
Rate for Payer: University Health Alliance Commercial	$1,865.36

Know your out-of-pocket cost for care.

All Charges