Honoka'a Hospital and Skilled Nursing Facility

All Charges

Charge

Type

Setting

Price

MARYLAND XP INLINESEAL DIVIDER

Facility

$1,782.00

Hospital Revenue Code	272
Min. Negotiated Rate	$1,514.70
Max. Negotiated Rate	$1,728.54
Rate for Payer: Cash Price	$1,069.20
Rate for Payer: Health Management Network Commercial	$1,514.70
Rate for Payer: Kaiser Permanente Commercial	$1,603.80
Rate for Payer: MDX Hawaii PPO	$1,728.54

MARYLAND XP INLINESEAL DIVIDER

Facility

$1,782.00

Hospital Revenue Code	272
Min. Negotiated Rate	$891.00
Max. Negotiated Rate	$1,728.54
Rate for Payer: AlohaCare Medicaid	$891.00
Rate for Payer: AlohaCare Medicare	$1,354.32
Rate for Payer: Cash Price	$1,069.20
Rate for Payer: Devoted Health Medicare	$1,496.88
Rate for Payer: Hawaii Medical Service Association Medicare	$1,354.32
Rate for Payer: Hawaii Western Management Group Commercial	$1,692.90
Rate for Payer: Health Management Network Commercial	$1,514.70
Rate for Payer: Humana Medicare	$1,354.32
Rate for Payer: Kaiser Permanente Commercial	$1,603.80
Rate for Payer: Kaiser Permanente Medicaid	$908.82
Rate for Payer: Kaiser Permanente Medicare	$1,354.32
Rate for Payer: MDX Hawaii PPO	$1,728.54
Rate for Payer: Ohana Health Plan Medicaid	$1,354.32
Rate for Payer: Ohana Health Plan Medicare	$1,354.32
Rate for Payer: UnitedHealthcare Medicare	$1,354.32
Rate for Payer: University Health Alliance Commercial	$1,298.90

MASK COMPRESSION

Facility

$132.00

Hospital Revenue Code	272
Min. Negotiated Rate	$66.00
Max. Negotiated Rate	$128.04
Rate for Payer: AlohaCare Medicaid	$66.00
Rate for Payer: AlohaCare Medicare	$100.32
Rate for Payer: Cash Price	$79.20
Rate for Payer: Devoted Health Medicare	$110.88
Rate for Payer: Hawaii Medical Service Association Medicare	$100.32
Rate for Payer: Hawaii Western Management Group Commercial	$125.40
Rate for Payer: Health Management Network Commercial	$112.20
Rate for Payer: Humana Medicare	$100.32
Rate for Payer: Kaiser Permanente Commercial	$118.80
Rate for Payer: Kaiser Permanente Medicaid	$67.32
Rate for Payer: Kaiser Permanente Medicare	$100.32
Rate for Payer: MDX Hawaii PPO	$128.04
Rate for Payer: Ohana Health Plan Medicaid	$100.32
Rate for Payer: Ohana Health Plan Medicare	$100.32
Rate for Payer: UnitedHealthcare Medicare	$100.32
Rate for Payer: University Health Alliance Commercial	$96.21

MASK COMPRESSION

Facility

$132.00

Hospital Revenue Code	272
Min. Negotiated Rate	$112.20
Max. Negotiated Rate	$128.04
Rate for Payer: Cash Price	$79.20
Rate for Payer: Health Management Network Commercial	$112.20
Rate for Payer: Kaiser Permanente Commercial	$118.80
Rate for Payer: MDX Hawaii PPO	$128.04

MASTECTOMY FOR MALIGNANCY WITH CC/MCC

Facility

$25,029.31

Service Code	MSDRG 582
Min. Negotiated Rate	$25,029.31
Max. Negotiated Rate	$25,029.31
Rate for Payer: Hawaii Medical Service Association Commercial	$25,029.31

MASTECTOMY FOR MALIGNANCY WITHOUT CC/MCC

Facility

$22,848.73

Service Code	MSDRG 583
Min. Negotiated Rate	$22,848.73
Max. Negotiated Rate	$22,848.73
Rate for Payer: Hawaii Medical Service Association Commercial	$22,848.73

MATCHSTICK 3.0MM 5220-107-530

Facility

$434.00

Hospital Revenue Code	272
Min. Negotiated Rate	$217.00
Max. Negotiated Rate	$420.98
Rate for Payer: AlohaCare Medicaid	$217.00
Rate for Payer: AlohaCare Medicare	$329.84
Rate for Payer: Cash Price	$260.40
Rate for Payer: Devoted Health Medicare	$364.56
Rate for Payer: Hawaii Medical Service Association Medicare	$329.84
Rate for Payer: Hawaii Western Management Group Commercial	$412.30
Rate for Payer: Health Management Network Commercial	$368.90
Rate for Payer: Humana Medicare	$329.84
Rate for Payer: Kaiser Permanente Commercial	$390.60
Rate for Payer: Kaiser Permanente Medicaid	$221.34
Rate for Payer: Kaiser Permanente Medicare	$329.84
Rate for Payer: MDX Hawaii PPO	$420.98
Rate for Payer: Ohana Health Plan Medicaid	$329.84
Rate for Payer: Ohana Health Plan Medicare	$329.84
Rate for Payer: UnitedHealthcare Medicare	$329.84
Rate for Payer: University Health Alliance Commercial	$316.34

MATCHSTICK 3.0MM 5220-107-530

Facility

$434.00

Hospital Revenue Code	272
Min. Negotiated Rate	$368.90
Max. Negotiated Rate	$420.98
Rate for Payer: Cash Price	$260.40
Rate for Payer: Health Management Network Commercial	$368.90
Rate for Payer: Kaiser Permanente Commercial	$390.60
Rate for Payer: MDX Hawaii PPO	$420.98

MATRIXMAND 1.5 DB 03.503.408

Facility

$1,131.00

Hospital Revenue Code	272
Min. Negotiated Rate	$565.50
Max. Negotiated Rate	$1,097.07
Rate for Payer: AlohaCare Medicaid	$565.50
Rate for Payer: AlohaCare Medicare	$859.56
Rate for Payer: Cash Price	$678.60
Rate for Payer: Devoted Health Medicare	$950.04
Rate for Payer: Hawaii Medical Service Association Medicare	$859.56
Rate for Payer: Hawaii Western Management Group Commercial	$1,074.45
Rate for Payer: Health Management Network Commercial	$961.35
Rate for Payer: Humana Medicare	$859.56
Rate for Payer: Kaiser Permanente Commercial	$1,017.90
Rate for Payer: Kaiser Permanente Medicaid	$576.81
Rate for Payer: Kaiser Permanente Medicare	$859.56
Rate for Payer: MDX Hawaii PPO	$1,097.07
Rate for Payer: Ohana Health Plan Medicaid	$859.56
Rate for Payer: Ohana Health Plan Medicare	$859.56
Rate for Payer: UnitedHealthcare Medicare	$859.56
Rate for Payer: University Health Alliance Commercial	$824.39

MATRIXMAND 1.5 DB 03.503.408

Facility

$1,131.00

Hospital Revenue Code	272
Min. Negotiated Rate	$961.35
Max. Negotiated Rate	$1,097.07
Rate for Payer: Cash Price	$678.60
Rate for Payer: Health Management Network Commercial	$961.35
Rate for Payer: Kaiser Permanente Commercial	$1,017.90
Rate for Payer: MDX Hawaii PPO	$1,097.07

MATRIXMIDFACE 4M 04.503.204.01

Facility

$806.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$451.36
Max. Negotiated Rate	$781.82
Rate for Payer: Cash Price	$483.60
Rate for Payer: Hawaii Western Management Group Commercial	$564.20
Rate for Payer: Health Management Network Commercial	$685.10
Rate for Payer: Kaiser Permanente Commercial	$725.40
Rate for Payer: MDX Hawaii PPO	$781.82
Rate for Payer: University Health Alliance Commercial	$451.36

MATRIXMIDFACE 4M 04.503.204.01

Facility

$806.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$403.00
Max. Negotiated Rate	$781.82
Rate for Payer: AlohaCare Medicaid	$403.00
Rate for Payer: AlohaCare Medicare	$612.56
Rate for Payer: Cash Price	$483.60
Rate for Payer: Devoted Health Medicare	$677.04
Rate for Payer: Hawaii Medical Service Association Medicare	$612.56
Rate for Payer: Hawaii Western Management Group Commercial	$564.20
Rate for Payer: Health Management Network Commercial	$685.10
Rate for Payer: Humana Medicare	$612.56
Rate for Payer: Kaiser Permanente Commercial	$725.40
Rate for Payer: Kaiser Permanente Medicaid	$411.06
Rate for Payer: Kaiser Permanente Medicare	$612.56
Rate for Payer: MDX Hawaii PPO	$781.82
Rate for Payer: Ohana Health Plan Medicaid	$612.56
Rate for Payer: Ohana Health Plan Medicare	$612.56
Rate for Payer: UnitedHealthcare Medicare	$612.56
Rate for Payer: University Health Alliance Commercial	$451.36

MATRIXMIDFACE OBL 04.503.355

Facility

$2,148.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,202.88
Max. Negotiated Rate	$2,083.56
Rate for Payer: Cash Price	$1,288.80
Rate for Payer: Hawaii Western Management Group Commercial	$1,503.60
Rate for Payer: Health Management Network Commercial	$1,825.80
Rate for Payer: Kaiser Permanente Commercial	$1,933.20
Rate for Payer: MDX Hawaii PPO	$2,083.56
Rate for Payer: University Health Alliance Commercial	$1,202.88

MATRIXMIDFACE OBL 04.503.355

Facility

$2,148.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,074.00
Max. Negotiated Rate	$2,083.56
Rate for Payer: AlohaCare Medicaid	$1,074.00
Rate for Payer: AlohaCare Medicare	$1,632.48
Rate for Payer: Cash Price	$1,288.80
Rate for Payer: Devoted Health Medicare	$1,804.32
Rate for Payer: Hawaii Medical Service Association Medicare	$1,632.48
Rate for Payer: Hawaii Western Management Group Commercial	$1,503.60
Rate for Payer: Health Management Network Commercial	$1,825.80
Rate for Payer: Humana Medicare	$1,632.48
Rate for Payer: Kaiser Permanente Commercial	$1,933.20
Rate for Payer: Kaiser Permanente Medicaid	$1,095.48
Rate for Payer: Kaiser Permanente Medicare	$1,632.48
Rate for Payer: MDX Hawaii PPO	$2,083.56
Rate for Payer: Ohana Health Plan Medicaid	$1,632.48
Rate for Payer: Ohana Health Plan Medicare	$1,632.48
Rate for Payer: UnitedHealthcare Medicare	$1,632.48
Rate for Payer: University Health Alliance Commercial	$1,202.88

MATRIXMIDFACE OBL LT 3X4 HOLES

Facility

$2,301.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,288.56
Max. Negotiated Rate	$2,231.97
Rate for Payer: Cash Price	$1,380.60
Rate for Payer: Hawaii Western Management Group Commercial	$1,610.70
Rate for Payer: Health Management Network Commercial	$1,955.85
Rate for Payer: Kaiser Permanente Commercial	$2,070.90
Rate for Payer: MDX Hawaii PPO	$2,231.97
Rate for Payer: University Health Alliance Commercial	$1,288.56

MATRIXMIDFACE OBL LT 3X4 HOLES

Facility

$2,301.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,150.50
Max. Negotiated Rate	$2,231.97
Rate for Payer: AlohaCare Medicaid	$1,150.50
Rate for Payer: AlohaCare Medicare	$1,748.76
Rate for Payer: Cash Price	$1,380.60
Rate for Payer: Devoted Health Medicare	$1,932.84
Rate for Payer: Hawaii Medical Service Association Medicare	$1,748.76
Rate for Payer: Hawaii Western Management Group Commercial	$1,610.70
Rate for Payer: Health Management Network Commercial	$1,955.85
Rate for Payer: Humana Medicare	$1,748.76
Rate for Payer: Kaiser Permanente Commercial	$2,070.90
Rate for Payer: Kaiser Permanente Medicaid	$1,173.51
Rate for Payer: Kaiser Permanente Medicare	$1,748.76
Rate for Payer: MDX Hawaii PPO	$2,231.97
Rate for Payer: Ohana Health Plan Medicaid	$1,748.76
Rate for Payer: Ohana Health Plan Medicare	$1,748.76
Rate for Payer: UnitedHealthcare Medicare	$1,748.76
Rate for Payer: University Health Alliance Commercial	$1,288.56

MATRIXMIDFACE RIM 04.503.373

Facility

$2,556.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,278.00
Max. Negotiated Rate	$2,479.32
Rate for Payer: AlohaCare Medicaid	$1,278.00
Rate for Payer: AlohaCare Medicare	$1,942.56
Rate for Payer: Cash Price	$1,533.60
Rate for Payer: Devoted Health Medicare	$2,147.04
Rate for Payer: Hawaii Medical Service Association Medicare	$1,942.56
Rate for Payer: Hawaii Western Management Group Commercial	$1,789.20
Rate for Payer: Health Management Network Commercial	$2,172.60
Rate for Payer: Humana Medicare	$1,942.56
Rate for Payer: Kaiser Permanente Commercial	$2,300.40
Rate for Payer: Kaiser Permanente Medicaid	$1,303.56
Rate for Payer: Kaiser Permanente Medicare	$1,942.56
Rate for Payer: MDX Hawaii PPO	$2,479.32
Rate for Payer: Ohana Health Plan Medicaid	$1,942.56
Rate for Payer: Ohana Health Plan Medicare	$1,942.56
Rate for Payer: UnitedHealthcare Medicare	$1,942.56
Rate for Payer: University Health Alliance Commercial	$1,431.36

MATRIXMIDFACE RIM 04.503.373

Facility

$2,556.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,431.36
Max. Negotiated Rate	$2,479.32
Rate for Payer: Cash Price	$1,533.60
Rate for Payer: Hawaii Western Management Group Commercial	$1,789.20
Rate for Payer: Health Management Network Commercial	$2,172.60
Rate for Payer: Kaiser Permanente Commercial	$2,300.40
Rate for Payer: MDX Hawaii PPO	$2,479.32
Rate for Payer: University Health Alliance Commercial	$1,431.36

MATRIX WOUND THIN 4X10 54101T

Facility

$17,483.00

Service Code	HCPCS Q4108
Hospital Revenue Code	636
Min. Negotiated Rate	$49.12
Max. Negotiated Rate	$16,958.51
Rate for Payer: AlohaCare Medicaid	$8,741.50
Rate for Payer: AlohaCare Medicare	$13,287.08
Rate for Payer: Cash Price	$10,489.80
Rate for Payer: Cash Price	$10,489.80
Rate for Payer: Devoted Health Medicare	$14,685.72
Rate for Payer: Hawaii Medical Service Association ABD	$49.12
Rate for Payer: Hawaii Medical Service Association Commercial	$158.93
Rate for Payer: Hawaii Medical Service Association Medicare	$13,287.08
Rate for Payer: Hawaii Medical Service Association Non-ABD	$49.12
Rate for Payer: Hawaii Western Management Group Commercial	$16,608.85
Rate for Payer: Health Management Network Commercial	$14,860.55
Rate for Payer: Humana Medicare	$13,287.08
Rate for Payer: Kaiser Permanente Commercial	$15,734.70
Rate for Payer: Kaiser Permanente Medicaid	$8,916.33
Rate for Payer: Kaiser Permanente Medicare	$13,287.08
Rate for Payer: MDX Hawaii PPO	$16,958.51
Rate for Payer: Ohana Health Plan Medicaid	$13,287.08
Rate for Payer: Ohana Health Plan Medicare	$13,287.08
Rate for Payer: UnitedHealthcare Medicaid	$10,489.80
Rate for Payer: UnitedHealthcare Medicare	$13,287.08
Rate for Payer: University Health Alliance Commercial	$12,743.36

MATRIX WOUND THIN 4X10 54101T

Facility

$17,483.00

Service Code	HCPCS Q4108
Hospital Revenue Code	636
Min. Negotiated Rate	$14,860.55
Max. Negotiated Rate	$16,958.51
Rate for Payer: Cash Price	$10,489.80
Rate for Payer: Health Management Network Commercial	$14,860.55
Rate for Payer: Kaiser Permanente Commercial	$15,734.70
Rate for Payer: MDX Hawaii PPO	$16,958.51

MDM LINER 46MM 626-00-46F

Facility

$3,344.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$1,872.64
Max. Negotiated Rate	$3,243.68
Rate for Payer: Cash Price	$2,006.40
Rate for Payer: Hawaii Western Management Group Commercial	$2,340.80
Rate for Payer: Health Management Network Commercial	$2,842.40
Rate for Payer: Kaiser Permanente Commercial	$3,009.60
Rate for Payer: MDX Hawaii PPO	$3,243.68
Rate for Payer: University Health Alliance Commercial	$1,872.64

MDM LINER 46MM 626-00-46F

Facility

$3,344.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$1,672.00
Max. Negotiated Rate	$3,243.68
Rate for Payer: AlohaCare Medicaid	$1,672.00
Rate for Payer: AlohaCare Medicare	$2,541.44
Rate for Payer: Cash Price	$2,006.40
Rate for Payer: Devoted Health Medicare	$2,808.96
Rate for Payer: Hawaii Medical Service Association Medicare	$2,541.44
Rate for Payer: Hawaii Western Management Group Commercial	$2,340.80
Rate for Payer: Health Management Network Commercial	$2,842.40
Rate for Payer: Humana Medicare	$2,541.44
Rate for Payer: Kaiser Permanente Commercial	$3,009.60
Rate for Payer: Kaiser Permanente Medicaid	$1,705.44
Rate for Payer: Kaiser Permanente Medicare	$2,541.44
Rate for Payer: MDX Hawaii PPO	$3,243.68
Rate for Payer: Ohana Health Plan Medicaid	$2,541.44
Rate for Payer: Ohana Health Plan Medicare	$2,541.44
Rate for Payer: UnitedHealthcare Medicare	$2,541.44
Rate for Payer: University Health Alliance Commercial	$1,872.64

MDM LINER CEMENTIES 626-00-48G

Facility

$4,271.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$2,135.50
Max. Negotiated Rate	$4,142.87
Rate for Payer: AlohaCare Medicaid	$2,135.50
Rate for Payer: AlohaCare Medicare	$3,245.96
Rate for Payer: Cash Price	$2,562.60
Rate for Payer: Devoted Health Medicare	$3,587.64
Rate for Payer: Hawaii Medical Service Association Medicare	$3,245.96
Rate for Payer: Hawaii Western Management Group Commercial	$2,989.70
Rate for Payer: Health Management Network Commercial	$3,630.35
Rate for Payer: Humana Medicare	$3,245.96
Rate for Payer: Kaiser Permanente Commercial	$3,843.90
Rate for Payer: Kaiser Permanente Medicaid	$2,178.21
Rate for Payer: Kaiser Permanente Medicare	$3,245.96
Rate for Payer: MDX Hawaii PPO	$4,142.87
Rate for Payer: Ohana Health Plan Medicaid	$3,245.96
Rate for Payer: Ohana Health Plan Medicare	$3,245.96
Rate for Payer: UnitedHealthcare Medicare	$3,245.96
Rate for Payer: University Health Alliance Commercial	$2,391.76

MDM LINER CEMENTIES 626-00-48G

Facility

$4,271.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$2,391.76
Max. Negotiated Rate	$4,142.87
Rate for Payer: Cash Price	$2,562.60
Rate for Payer: Hawaii Western Management Group Commercial	$2,989.70
Rate for Payer: Health Management Network Commercial	$3,630.35
Rate for Payer: Kaiser Permanente Commercial	$3,843.90
Rate for Payer: MDX Hawaii PPO	$4,142.87
Rate for Payer: University Health Alliance Commercial	$2,391.76

MEASLES,MUMPS,RUBELLA VACCINE LIVE(PF)1,000-12,500TCID50/0.5 ML SUBCUT [168883]

Facility

$176.00

Service Code	HCPCS 90710
Hospital Revenue Code	250
Min. Negotiated Rate	$149.60
Max. Negotiated Rate	$170.72
Rate for Payer: Cash Price	$105.60
Rate for Payer: Health Management Network Commercial	$149.60
Rate for Payer: Kaiser Permanente Commercial	$158.40
Rate for Payer: MDX Hawaii PPO	$170.72

Know your out-of-pocket cost for care.

All Charges