Honoka'a Hospital and Skilled Nursing Facility

All Charges

Charge

Type

Setting

Price

BACLOFEN 20 MG TABLET [861]

Facility

$4.00

Service Code	NDC 60687082611
Hospital Revenue Code	250
Min. Negotiated Rate	$3.40
Max. Negotiated Rate	$3.88
Rate for Payer: Cash Price	$2.40
Rate for Payer: Health Management Network Commercial	$3.40
Rate for Payer: Kaiser Permanente Commercial	$3.60
Rate for Payer: MDX Hawaii PPO	$3.88

BACLOFEN 20 MG TABLET [861]

Facility

$18.00

Service Code	NDC 70710128601
Hospital Revenue Code	637
Min. Negotiated Rate	$9.00
Max. Negotiated Rate	$17.46
Rate for Payer: AlohaCare Medicaid	$9.00
Rate for Payer: AlohaCare Medicare	$13.68
Rate for Payer: Cash Price	$10.80
Rate for Payer: Devoted Health Medicare	$15.12
Rate for Payer: Hawaii Medical Service Association Medicare	$13.68
Rate for Payer: Hawaii Western Management Group Commercial	$17.10
Rate for Payer: Health Management Network Commercial	$15.30
Rate for Payer: Humana Medicare	$13.68
Rate for Payer: Kaiser Permanente Commercial	$16.20
Rate for Payer: Kaiser Permanente Medicaid	$9.18
Rate for Payer: Kaiser Permanente Medicare	$13.68
Rate for Payer: MDX Hawaii PPO	$17.46
Rate for Payer: Ohana Health Plan Medicaid	$13.68
Rate for Payer: Ohana Health Plan Medicare	$13.68
Rate for Payer: UnitedHealthcare Medicare	$13.68
Rate for Payer: University Health Alliance Commercial	$13.12

BACLOFEN 20 MG TABLET [861]

Facility

$4.00

Service Code	NDC 60687082611
Hospital Revenue Code	637
Min. Negotiated Rate	$2.00
Max. Negotiated Rate	$3.88
Rate for Payer: AlohaCare Medicaid	$2.00
Rate for Payer: AlohaCare Medicare	$3.04
Rate for Payer: Cash Price	$2.40
Rate for Payer: Devoted Health Medicare	$3.36
Rate for Payer: Hawaii Medical Service Association Medicare	$3.04
Rate for Payer: Hawaii Western Management Group Commercial	$3.80
Rate for Payer: Health Management Network Commercial	$3.40
Rate for Payer: Humana Medicare	$3.04
Rate for Payer: Kaiser Permanente Commercial	$3.60
Rate for Payer: Kaiser Permanente Medicaid	$2.04
Rate for Payer: Kaiser Permanente Medicare	$3.04
Rate for Payer: MDX Hawaii PPO	$3.88
Rate for Payer: Ohana Health Plan Medicaid	$3.04
Rate for Payer: Ohana Health Plan Medicare	$3.04
Rate for Payer: UnitedHealthcare Medicare	$3.04
Rate for Payer: University Health Alliance Commercial	$2.92

BACLOFEN 20 MG TABLET [861]

Facility

$18.00

Service Code	NDC 70710128601
Hospital Revenue Code	250
Min. Negotiated Rate	$15.30
Max. Negotiated Rate	$17.46
Rate for Payer: Cash Price	$10.80
Rate for Payer: Health Management Network Commercial	$15.30
Rate for Payer: Kaiser Permanente Commercial	$16.20
Rate for Payer: MDX Hawaii PPO	$17.46

BACTERIAL AND TUBERCULOUS INFECTIONS OF NERVOUS SYSTEM WITH CC

Facility

$51,314.83

Service Code	MSDRG 095
Min. Negotiated Rate	$51,314.83
Max. Negotiated Rate	$51,314.83
Rate for Payer: Hawaii Medical Service Association Commercial	$51,314.83

BACTERIAL AND TUBERCULOUS INFECTIONS OF NERVOUS SYSTEM WITH MCC

Facility

$51,314.83

Service Code	MSDRG 094
Min. Negotiated Rate	$51,314.83
Max. Negotiated Rate	$51,314.83
Rate for Payer: Hawaii Medical Service Association Commercial	$51,314.83

BACTERIAL AND TUBERCULOUS INFECTIONS OF NERVOUS SYSTEM WITHOUT CC/MCC

Facility

$51,314.83

Service Code	MSDRG 096
Min. Negotiated Rate	$51,314.83
Max. Negotiated Rate	$51,314.83
Rate for Payer: Hawaii Medical Service Association Commercial	$51,314.83

BAG 15MM ENDO CATCH

Facility

$397.00

Hospital Revenue Code	272
Min. Negotiated Rate	$198.50
Max. Negotiated Rate	$385.09
Rate for Payer: AlohaCare Medicaid	$198.50
Rate for Payer: AlohaCare Medicare	$301.72
Rate for Payer: Cash Price	$238.20
Rate for Payer: Devoted Health Medicare	$333.48
Rate for Payer: Hawaii Medical Service Association Medicare	$301.72
Rate for Payer: Hawaii Western Management Group Commercial	$377.15
Rate for Payer: Health Management Network Commercial	$337.45
Rate for Payer: Humana Medicare	$301.72
Rate for Payer: Kaiser Permanente Commercial	$357.30
Rate for Payer: Kaiser Permanente Medicaid	$202.47
Rate for Payer: Kaiser Permanente Medicare	$301.72
Rate for Payer: MDX Hawaii PPO	$385.09
Rate for Payer: Ohana Health Plan Medicaid	$301.72
Rate for Payer: Ohana Health Plan Medicare	$301.72
Rate for Payer: UnitedHealthcare Medicare	$301.72
Rate for Payer: University Health Alliance Commercial	$289.37

BAG 15MM ENDO CATCH

Facility

$397.00

Hospital Revenue Code	272
Min. Negotiated Rate	$337.45
Max. Negotiated Rate	$385.09
Rate for Payer: Cash Price	$238.20
Rate for Payer: Health Management Network Commercial	$337.45
Rate for Payer: Kaiser Permanente Commercial	$357.30
Rate for Payer: MDX Hawaii PPO	$385.09

BAG HYPERINFLATION 1/2L

Facility

$81.00

Hospital Revenue Code	272
Min. Negotiated Rate	$68.85
Max. Negotiated Rate	$78.57
Rate for Payer: Cash Price	$48.60
Rate for Payer: Health Management Network Commercial	$68.85
Rate for Payer: Kaiser Permanente Commercial	$72.90
Rate for Payer: MDX Hawaii PPO	$78.57

BAG HYPERINFLATION 1/2L

Facility

$81.00

Hospital Revenue Code	272
Min. Negotiated Rate	$40.50
Max. Negotiated Rate	$78.57
Rate for Payer: AlohaCare Medicaid	$40.50
Rate for Payer: AlohaCare Medicare	$61.56
Rate for Payer: Cash Price	$48.60
Rate for Payer: Devoted Health Medicare	$68.04
Rate for Payer: Hawaii Medical Service Association Medicare	$61.56
Rate for Payer: Hawaii Western Management Group Commercial	$76.95
Rate for Payer: Health Management Network Commercial	$68.85
Rate for Payer: Humana Medicare	$61.56
Rate for Payer: Kaiser Permanente Commercial	$72.90
Rate for Payer: Kaiser Permanente Medicaid	$41.31
Rate for Payer: Kaiser Permanente Medicare	$61.56
Rate for Payer: MDX Hawaii PPO	$78.57
Rate for Payer: Ohana Health Plan Medicaid	$61.56
Rate for Payer: Ohana Health Plan Medicare	$61.56
Rate for Payer: UnitedHealthcare Medicare	$61.56
Rate for Payer: University Health Alliance Commercial	$59.04

BAG RETRIEVAL ENDO

Facility

$118.00

Hospital Revenue Code	272
Min. Negotiated Rate	$59.00
Max. Negotiated Rate	$114.46
Rate for Payer: AlohaCare Medicaid	$59.00
Rate for Payer: AlohaCare Medicare	$89.68
Rate for Payer: Cash Price	$70.80
Rate for Payer: Devoted Health Medicare	$99.12
Rate for Payer: Hawaii Medical Service Association Medicare	$89.68
Rate for Payer: Hawaii Western Management Group Commercial	$112.10
Rate for Payer: Health Management Network Commercial	$100.30
Rate for Payer: Humana Medicare	$89.68
Rate for Payer: Kaiser Permanente Commercial	$106.20
Rate for Payer: Kaiser Permanente Medicaid	$60.18
Rate for Payer: Kaiser Permanente Medicare	$89.68
Rate for Payer: MDX Hawaii PPO	$114.46
Rate for Payer: Ohana Health Plan Medicaid	$89.68
Rate for Payer: Ohana Health Plan Medicare	$89.68
Rate for Payer: UnitedHealthcare Medicare	$89.68
Rate for Payer: University Health Alliance Commercial	$86.01

BAG RETRIEVAL ENDO

Facility

$118.00

Hospital Revenue Code	272
Min. Negotiated Rate	$100.30
Max. Negotiated Rate	$114.46
Rate for Payer: Cash Price	$70.80
Rate for Payer: Health Management Network Commercial	$100.30
Rate for Payer: Kaiser Permanente Commercial	$106.20
Rate for Payer: MDX Hawaii PPO	$114.46

BAG UROLOGY DRAIN

Facility

$101.00

Service Code	HCPCS A4649
Hospital Revenue Code	272
Min. Negotiated Rate	$50.50
Max. Negotiated Rate	$97.97
Rate for Payer: AlohaCare Medicaid	$50.50
Rate for Payer: AlohaCare Medicare	$76.76
Rate for Payer: Cash Price	$60.60
Rate for Payer: Devoted Health Medicare	$84.84
Rate for Payer: Hawaii Medical Service Association Medicare	$76.76
Rate for Payer: Hawaii Western Management Group Commercial	$95.95
Rate for Payer: Health Management Network Commercial	$85.85
Rate for Payer: Humana Medicare	$76.76
Rate for Payer: Kaiser Permanente Commercial	$90.90
Rate for Payer: Kaiser Permanente Medicaid	$51.51
Rate for Payer: Kaiser Permanente Medicare	$76.76
Rate for Payer: MDX Hawaii PPO	$97.97
Rate for Payer: Ohana Health Plan Medicaid	$76.76
Rate for Payer: Ohana Health Plan Medicare	$76.76
Rate for Payer: UnitedHealthcare Medicare	$76.76
Rate for Payer: University Health Alliance Commercial	$73.62

BAG UROLOGY DRAIN

Facility

$101.00

Service Code	HCPCS A4649
Hospital Revenue Code	272
Min. Negotiated Rate	$85.85
Max. Negotiated Rate	$97.97
Rate for Payer: Cash Price	$60.60
Rate for Payer: Health Management Network Commercial	$85.85
Rate for Payer: Kaiser Permanente Commercial	$90.90
Rate for Payer: MDX Hawaii PPO	$97.97

BALANCED SALT SOLUTION COMBINATION NO.1 INTRAOCULAR IRRIGATION [834]

Facility

$186.00

Service Code	NDC 00065080050
Hospital Revenue Code	250
Min. Negotiated Rate	$158.10
Max. Negotiated Rate	$180.42
Rate for Payer: Cash Price	$111.60
Rate for Payer: Health Management Network Commercial	$158.10
Rate for Payer: Kaiser Permanente Commercial	$167.40
Rate for Payer: MDX Hawaii PPO	$180.42

BALANCED SALT SOLUTION COMBINATION NO.2 INTRAOCULAR IRRIGATION [37578]

Facility

$38.00

Service Code	NDC 00065079515
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

BALANCED SALT SOLUTION COMBINATION NO.2 INTRAOCULAR IRRIGATION [37578]

Facility

$38.00

Service Code	NDC 00065079515
Hospital Revenue Code	637
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 Medicare	$28.88
Rate for Payer: University Health Alliance Commercial	$27.70

BALANCED SALT SOLUTION NON-SURGICAL NO.3 EYE WASH [2999]

Facility

$84.00

Service Code	NDC 00065053001
Hospital Revenue Code	637
Min. Negotiated Rate	$42.00
Max. Negotiated Rate	$81.48
Rate for Payer: AlohaCare Medicaid	$42.00
Rate for Payer: AlohaCare Medicare	$63.84
Rate for Payer: Cash Price	$50.40
Rate for Payer: Devoted Health Medicare	$70.56
Rate for Payer: Hawaii Medical Service Association Medicare	$63.84
Rate for Payer: Hawaii Western Management Group Commercial	$79.80
Rate for Payer: Health Management Network Commercial	$71.40
Rate for Payer: Humana Medicare	$63.84
Rate for Payer: Kaiser Permanente Commercial	$75.60
Rate for Payer: Kaiser Permanente Medicaid	$42.84
Rate for Payer: Kaiser Permanente Medicare	$63.84
Rate for Payer: MDX Hawaii PPO	$81.48
Rate for Payer: Ohana Health Plan Medicaid	$63.84
Rate for Payer: Ohana Health Plan Medicare	$63.84
Rate for Payer: UnitedHealthcare Medicare	$63.84
Rate for Payer: University Health Alliance Commercial	$61.23

BALANCED SALT SOLUTION NON-SURGICAL NO.3 EYE WASH [2999]

Facility

$84.00

Service Code	NDC 00065053001
Hospital Revenue Code	250
Min. Negotiated Rate	$71.40
Max. Negotiated Rate	$81.48
Rate for Payer: Cash Price	$50.40
Rate for Payer: Health Management Network Commercial	$71.40
Rate for Payer: Kaiser Permanente Commercial	$75.60
Rate for Payer: MDX Hawaii PPO	$81.48

BALLOON 2.5X20 AGENT DCB

Facility

$12,350.00

Service Code	HCPCS C9610
Hospital Revenue Code	272
Min. Negotiated Rate	$6,175.00
Max. Negotiated Rate	$11,979.50
Rate for Payer: AlohaCare Medicaid	$6,175.00
Rate for Payer: AlohaCare Medicare	$9,386.00
Rate for Payer: Cash Price	$7,410.00
Rate for Payer: Devoted Health Medicare	$10,374.00
Rate for Payer: Hawaii Medical Service Association Medicare	$9,386.00
Rate for Payer: Hawaii Western Management Group Commercial	$11,732.50
Rate for Payer: Health Management Network Commercial	$10,497.50
Rate for Payer: Humana Medicare	$9,386.00
Rate for Payer: Kaiser Permanente Commercial	$11,115.00
Rate for Payer: Kaiser Permanente Medicaid	$6,298.50
Rate for Payer: Kaiser Permanente Medicare	$9,386.00
Rate for Payer: MDX Hawaii PPO	$11,979.50
Rate for Payer: Ohana Health Plan Medicaid	$9,386.00
Rate for Payer: Ohana Health Plan Medicare	$9,386.00
Rate for Payer: UnitedHealthcare Medicare	$9,386.00
Rate for Payer: University Health Alliance Commercial	$9,001.92

BALLOON 2.5X20 AGENT DCB

Facility

$12,350.00

Service Code	HCPCS C9610
Hospital Revenue Code	272
Min. Negotiated Rate	$10,497.50
Max. Negotiated Rate	$11,979.50
Rate for Payer: Cash Price	$7,410.00
Rate for Payer: Health Management Network Commercial	$10,497.50
Rate for Payer: Kaiser Permanente Commercial	$11,115.00
Rate for Payer: MDX Hawaii PPO	$11,979.50

BALLOON 2.5X30 AGENT DCB

Facility

$12,350.00

Service Code	HCPCS C9610
Hospital Revenue Code	272
Min. Negotiated Rate	$6,175.00
Max. Negotiated Rate	$11,979.50
Rate for Payer: AlohaCare Medicaid	$6,175.00
Rate for Payer: AlohaCare Medicare	$9,386.00
Rate for Payer: Cash Price	$7,410.00
Rate for Payer: Devoted Health Medicare	$10,374.00
Rate for Payer: Hawaii Medical Service Association Medicare	$9,386.00
Rate for Payer: Hawaii Western Management Group Commercial	$11,732.50
Rate for Payer: Health Management Network Commercial	$10,497.50
Rate for Payer: Humana Medicare	$9,386.00
Rate for Payer: Kaiser Permanente Commercial	$11,115.00
Rate for Payer: Kaiser Permanente Medicaid	$6,298.50
Rate for Payer: Kaiser Permanente Medicare	$9,386.00
Rate for Payer: MDX Hawaii PPO	$11,979.50
Rate for Payer: Ohana Health Plan Medicaid	$9,386.00
Rate for Payer: Ohana Health Plan Medicare	$9,386.00
Rate for Payer: UnitedHealthcare Medicare	$9,386.00
Rate for Payer: University Health Alliance Commercial	$9,001.92

BALLOON 2.5X30 AGENT DCB

Facility

$12,350.00

Service Code	HCPCS C9610
Hospital Revenue Code	272
Min. Negotiated Rate	$10,497.50
Max. Negotiated Rate	$11,979.50
Rate for Payer: Cash Price	$7,410.00
Rate for Payer: Health Management Network Commercial	$10,497.50
Rate for Payer: Kaiser Permanente Commercial	$11,115.00
Rate for Payer: MDX Hawaii PPO	$11,979.50

BALLOON 2X12 AGENT DCB

Facility

$12,350.00

Service Code	HCPCS C9610
Hospital Revenue Code	272
Min. Negotiated Rate	$10,497.50
Max. Negotiated Rate	$11,979.50
Rate for Payer: Cash Price	$7,410.00
Rate for Payer: Health Management Network Commercial	$10,497.50
Rate for Payer: Kaiser Permanente Commercial	$11,115.00
Rate for Payer: MDX Hawaii PPO	$11,979.50

Know your out-of-pocket cost for care.

All Charges