Honoka'a Hospital and Skilled Nursing Facility

All Charges

Charge

Type

Setting

Price

MELATONIN 3 MG TABLET [16830]

Facility

$1.00

Service Code	NDC 61502000000
Hospital Revenue Code	637
Min. Negotiated Rate	$0.50
Max. Negotiated Rate	$0.97
Rate for Payer: AlohaCare Medicaid	$0.50
Rate for Payer: AlohaCare Medicare	$0.76
Rate for Payer: Cash Price	$0.60
Rate for Payer: Devoted Health Medicare	$0.84
Rate for Payer: Hawaii Medical Service Association Medicare	$0.76
Rate for Payer: Hawaii Western Management Group Commercial	$0.95
Rate for Payer: Health Management Network Commercial	$0.85
Rate for Payer: Humana Medicare	$0.76
Rate for Payer: Kaiser Permanente Commercial	$0.90
Rate for Payer: Kaiser Permanente Medicaid	$0.51
Rate for Payer: Kaiser Permanente Medicare	$0.76
Rate for Payer: MDX Hawaii PPO	$0.97
Rate for Payer: Ohana Health Plan Medicaid	$0.76
Rate for Payer: Ohana Health Plan Medicare	$0.76
Rate for Payer: UnitedHealthcare Medicare	$0.76
Rate for Payer: University Health Alliance Commercial	$0.73

MELATONIN 3 MG TABLET [16830]

Facility

$2.00

Service Code	NDC 52415000000
Hospital Revenue Code	250
Min. Negotiated Rate	$1.70
Max. Negotiated Rate	$1.94
Rate for Payer: Cash Price	$1.20
Rate for Payer: Health Management Network Commercial	$1.70
Rate for Payer: Kaiser Permanente Commercial	$1.80
Rate for Payer: MDX Hawaii PPO	$1.94

MEMANTINE 10 MG TABLET [36966]

Facility

$3.00

Service Code	NDC 60687018457
Hospital Revenue Code	637
Min. Negotiated Rate	$1.50
Max. Negotiated Rate	$2.91
Rate for Payer: AlohaCare Medicaid	$1.50
Rate for Payer: AlohaCare Medicare	$2.28
Rate for Payer: Cash Price	$1.80
Rate for Payer: Devoted Health Medicare	$2.52
Rate for Payer: Hawaii Medical Service Association Medicare	$2.28
Rate for Payer: Hawaii Western Management Group Commercial	$2.85
Rate for Payer: Health Management Network Commercial	$2.55
Rate for Payer: Humana Medicare	$2.28
Rate for Payer: Kaiser Permanente Commercial	$2.70
Rate for Payer: Kaiser Permanente Medicaid	$1.53
Rate for Payer: Kaiser Permanente Medicare	$2.28
Rate for Payer: MDX Hawaii PPO	$2.91
Rate for Payer: Ohana Health Plan Medicaid	$2.28
Rate for Payer: Ohana Health Plan Medicare	$2.28
Rate for Payer: UnitedHealthcare Medicare	$2.28
Rate for Payer: University Health Alliance Commercial	$2.19

MEMANTINE 10 MG TABLET [36966]

Facility

$3.00

Service Code	NDC 60687018457
Hospital Revenue Code	250
Min. Negotiated Rate	$2.55
Max. Negotiated Rate	$2.91
Rate for Payer: Cash Price	$1.80
Rate for Payer: Health Management Network Commercial	$2.55
Rate for Payer: Kaiser Permanente Commercial	$2.70
Rate for Payer: MDX Hawaii PPO	$2.91

MEMANTINE 10 MG TABLET [36966]

Facility

$3.00

Service Code	NDC 60687018411
Hospital Revenue Code	637
Min. Negotiated Rate	$1.50
Max. Negotiated Rate	$2.91
Rate for Payer: AlohaCare Medicaid	$1.50
Rate for Payer: AlohaCare Medicare	$2.28
Rate for Payer: Cash Price	$1.80
Rate for Payer: Devoted Health Medicare	$2.52
Rate for Payer: Hawaii Medical Service Association Medicare	$2.28
Rate for Payer: Hawaii Western Management Group Commercial	$2.85
Rate for Payer: Health Management Network Commercial	$2.55
Rate for Payer: Humana Medicare	$2.28
Rate for Payer: Kaiser Permanente Commercial	$2.70
Rate for Payer: Kaiser Permanente Medicaid	$1.53
Rate for Payer: Kaiser Permanente Medicare	$2.28
Rate for Payer: MDX Hawaii PPO	$2.91
Rate for Payer: Ohana Health Plan Medicaid	$2.28
Rate for Payer: Ohana Health Plan Medicare	$2.28
Rate for Payer: UnitedHealthcare Medicare	$2.28
Rate for Payer: University Health Alliance Commercial	$2.19

MEMANTINE 10 MG TABLET [36966]

Facility

$3.00

Service Code	NDC 60687018411
Hospital Revenue Code	250
Min. Negotiated Rate	$2.55
Max. Negotiated Rate	$2.91
Rate for Payer: Cash Price	$1.80
Rate for Payer: Health Management Network Commercial	$2.55
Rate for Payer: Kaiser Permanente Commercial	$2.70
Rate for Payer: MDX Hawaii PPO	$2.91

MEMANTINE 5 MG TABLET [37170]

Facility

$3.00

Service Code	NDC 60687017357
Hospital Revenue Code	637
Min. Negotiated Rate	$1.50
Max. Negotiated Rate	$2.91
Rate for Payer: AlohaCare Medicaid	$1.50
Rate for Payer: AlohaCare Medicare	$2.28
Rate for Payer: Cash Price	$1.80
Rate for Payer: Devoted Health Medicare	$2.52
Rate for Payer: Hawaii Medical Service Association Medicare	$2.28
Rate for Payer: Hawaii Western Management Group Commercial	$2.85
Rate for Payer: Health Management Network Commercial	$2.55
Rate for Payer: Humana Medicare	$2.28
Rate for Payer: Kaiser Permanente Commercial	$2.70
Rate for Payer: Kaiser Permanente Medicaid	$1.53
Rate for Payer: Kaiser Permanente Medicare	$2.28
Rate for Payer: MDX Hawaii PPO	$2.91
Rate for Payer: Ohana Health Plan Medicaid	$2.28
Rate for Payer: Ohana Health Plan Medicare	$2.28
Rate for Payer: UnitedHealthcare Medicare	$2.28
Rate for Payer: University Health Alliance Commercial	$2.19

MEMANTINE 5 MG TABLET [37170]

Facility

$3.00

Service Code	NDC 60687017357
Hospital Revenue Code	250
Min. Negotiated Rate	$2.55
Max. Negotiated Rate	$2.91
Rate for Payer: Cash Price	$1.80
Rate for Payer: Health Management Network Commercial	$2.55
Rate for Payer: Kaiser Permanente Commercial	$2.70
Rate for Payer: MDX Hawaii PPO	$2.91

MEMANTINE 5 MG TABLET [37170]

Facility

$3.00

Service Code	NDC 60687017311
Hospital Revenue Code	637
Min. Negotiated Rate	$1.50
Max. Negotiated Rate	$2.91
Rate for Payer: AlohaCare Medicaid	$1.50
Rate for Payer: AlohaCare Medicare	$2.28
Rate for Payer: Cash Price	$1.80
Rate for Payer: Devoted Health Medicare	$2.52
Rate for Payer: Hawaii Medical Service Association Medicare	$2.28
Rate for Payer: Hawaii Western Management Group Commercial	$2.85
Rate for Payer: Health Management Network Commercial	$2.55
Rate for Payer: Humana Medicare	$2.28
Rate for Payer: Kaiser Permanente Commercial	$2.70
Rate for Payer: Kaiser Permanente Medicaid	$1.53
Rate for Payer: Kaiser Permanente Medicare	$2.28
Rate for Payer: MDX Hawaii PPO	$2.91
Rate for Payer: Ohana Health Plan Medicaid	$2.28
Rate for Payer: Ohana Health Plan Medicare	$2.28
Rate for Payer: UnitedHealthcare Medicare	$2.28
Rate for Payer: University Health Alliance Commercial	$2.19

MEMANTINE 5 MG TABLET [37170]

Facility

$3.00

Service Code	NDC 60687017311
Hospital Revenue Code	250
Min. Negotiated Rate	$2.55
Max. Negotiated Rate	$2.91
Rate for Payer: Cash Price	$1.80
Rate for Payer: Health Management Network Commercial	$2.55
Rate for Payer: Kaiser Permanente Commercial	$2.70
Rate for Payer: MDX Hawaii PPO	$2.91

MENINGOCOCCAL VAC A,C,Y,W-135,CONJ TET (PF) 10 MCG/0.5 ML IM SOLUTION [180674]

Facility

$310.00

Service Code	NDC 49281059005
Hospital Revenue Code	250
Min. Negotiated Rate	$263.50
Max. Negotiated Rate	$300.70
Rate for Payer: Cash Price	$186.00
Rate for Payer: Health Management Network Commercial	$263.50
Rate for Payer: Kaiser Permanente Commercial	$279.00
Rate for Payer: MDX Hawaii PPO	$300.70

MENINGOCOCCAL VAC A,C,Y,W-135,CONJ TET (PF) 10 MCG/0.5 ML IM SOLUTION [180674]

Facility

$310.00

Service Code	NDC 49281059010
Hospital Revenue Code	250
Min. Negotiated Rate	$263.50
Max. Negotiated Rate	$300.70
Rate for Payer: Cash Price	$186.00
Rate for Payer: Health Management Network Commercial	$263.50
Rate for Payer: Kaiser Permanente Commercial	$279.00
Rate for Payer: MDX Hawaii PPO	$300.70

MENINGOCOCCAL VAC A,C,Y,W-135,CONJ TET (PF) 10 MCG/0.5 ML IM SOLUTION [180674]

Facility

$310.00

Service Code	NDC 49281059058
Hospital Revenue Code	250
Min. Negotiated Rate	$263.50
Max. Negotiated Rate	$300.70
Rate for Payer: Cash Price	$186.00
Rate for Payer: Health Management Network Commercial	$263.50
Rate for Payer: Kaiser Permanente Commercial	$279.00
Rate for Payer: MDX Hawaii PPO	$300.70

MENINGOC VAC A,C,Y,W-135 DIP(PF) 10 MCG-5 MCG/0.5 ML IM KIT (2 VIALS) [204528]

Facility

$300.00

Service Code	NDC 58160095509
Hospital Revenue Code	250
Min. Negotiated Rate	$255.00
Max. Negotiated Rate	$291.00
Rate for Payer: Cash Price	$180.00
Rate for Payer: Health Management Network Commercial	$255.00
Rate for Payer: Kaiser Permanente Commercial	$270.00
Rate for Payer: MDX Hawaii PPO	$291.00

MENISCAL CINCH DISP #AR-4500

Facility

$1,428.00

Service Code	HCPCS C1713
Hospital Revenue Code	272
Min. Negotiated Rate	$1,213.80
Max. Negotiated Rate	$1,385.16
Rate for Payer: Cash Price	$856.80
Rate for Payer: Health Management Network Commercial	$1,213.80
Rate for Payer: Kaiser Permanente Commercial	$1,285.20
Rate for Payer: MDX Hawaii PPO	$1,385.16

MENISCAL CINCH DISP #AR-4500

Facility

$1,428.00

Service Code	HCPCS C1713
Hospital Revenue Code	272
Min. Negotiated Rate	$714.00
Max. Negotiated Rate	$1,385.16
Rate for Payer: AlohaCare Medicaid	$714.00
Rate for Payer: AlohaCare Medicare	$1,085.28
Rate for Payer: Cash Price	$856.80
Rate for Payer: Devoted Health Medicare	$1,199.52
Rate for Payer: Hawaii Medical Service Association Medicare	$1,085.28
Rate for Payer: Hawaii Western Management Group Commercial	$1,356.60
Rate for Payer: Health Management Network Commercial	$1,213.80
Rate for Payer: Humana Medicare	$1,085.28
Rate for Payer: Kaiser Permanente Commercial	$1,285.20
Rate for Payer: Kaiser Permanente Medicaid	$728.28
Rate for Payer: Kaiser Permanente Medicare	$1,085.28
Rate for Payer: MDX Hawaii PPO	$1,385.16
Rate for Payer: Ohana Health Plan Medicaid	$1,085.28
Rate for Payer: Ohana Health Plan Medicare	$1,085.28
Rate for Payer: UnitedHealthcare Medicare	$1,085.28
Rate for Payer: University Health Alliance Commercial	$1,040.87

MENISCAL CINCH II AR-4501

Facility

$1,383.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$774.48
Max. Negotiated Rate	$1,341.51
Rate for Payer: Cash Price	$829.80
Rate for Payer: Hawaii Western Management Group Commercial	$968.10
Rate for Payer: Health Management Network Commercial	$1,175.55
Rate for Payer: Kaiser Permanente Commercial	$1,244.70
Rate for Payer: MDX Hawaii PPO	$1,341.51
Rate for Payer: University Health Alliance Commercial	$774.48

MENISCAL CINCH II AR-4501

Facility

$1,383.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$691.50
Max. Negotiated Rate	$1,341.51
Rate for Payer: AlohaCare Medicaid	$691.50
Rate for Payer: AlohaCare Medicare	$1,051.08
Rate for Payer: Cash Price	$829.80
Rate for Payer: Devoted Health Medicare	$1,161.72
Rate for Payer: Hawaii Medical Service Association Medicare	$1,051.08
Rate for Payer: Hawaii Western Management Group Commercial	$968.10
Rate for Payer: Health Management Network Commercial	$1,175.55
Rate for Payer: Humana Medicare	$1,051.08
Rate for Payer: Kaiser Permanente Commercial	$1,244.70
Rate for Payer: Kaiser Permanente Medicaid	$705.33
Rate for Payer: Kaiser Permanente Medicare	$1,051.08
Rate for Payer: MDX Hawaii PPO	$1,341.51
Rate for Payer: Ohana Health Plan Medicaid	$1,051.08
Rate for Payer: Ohana Health Plan Medicare	$1,051.08
Rate for Payer: UnitedHealthcare Medicare	$1,051.08
Rate for Payer: University Health Alliance Commercial	$774.48

MENSTRUAL AND OTHER FEMALE REPRODUCTIVE SYSTEM DISORDERS WITH CC/MCC

Facility

$11,993.21

Service Code	MSDRG 760
Min. Negotiated Rate	$11,993.21
Max. Negotiated Rate	$11,993.21
Rate for Payer: Hawaii Medical Service Association Commercial	$11,993.21

MENSTRUAL AND OTHER FEMALE REPRODUCTIVE SYSTEM DISORDERS WITHOUT CC/MCC

Facility

$11,993.21

Service Code	MSDRG 761
Min. Negotiated Rate	$11,993.21
Max. Negotiated Rate	$11,993.21
Rate for Payer: Hawaii Medical Service Association Commercial	$11,993.21

MEPERIDINE (PF) 25 MG/ML INJECTION SOLUTION [4903]

Facility

$11.00

Service Code	HCPCS J2175
Hospital Revenue Code	636
Min. Negotiated Rate	$5.50
Max. Negotiated Rate	$15.69
Rate for Payer: AlohaCare Medicaid	$5.50
Rate for Payer: AlohaCare Medicare	$8.36
Rate for Payer: Cash Price	$6.60
Rate for Payer: Cash Price	$6.60
Rate for Payer: Devoted Health Medicare	$9.24
Rate for Payer: Hawaii Medical Service Association ABD	$15.69
Rate for Payer: Hawaii Medical Service Association Medicare	$8.36
Rate for Payer: Hawaii Medical Service Association Non-ABD	$15.69
Rate for Payer: Hawaii Western Management Group Commercial	$10.45
Rate for Payer: Health Management Network Commercial	$9.35
Rate for Payer: Humana Medicare	$8.36
Rate for Payer: Kaiser Permanente Commercial	$9.90
Rate for Payer: Kaiser Permanente Medicaid	$5.61
Rate for Payer: Kaiser Permanente Medicare	$8.36
Rate for Payer: MDX Hawaii PPO	$10.67
Rate for Payer: Ohana Health Plan Medicaid	$8.36
Rate for Payer: Ohana Health Plan Medicare	$8.36
Rate for Payer: UnitedHealthcare Medicaid	$6.60
Rate for Payer: UnitedHealthcare Medicare	$8.36
Rate for Payer: University Health Alliance Commercial	$8.02

MEPERIDINE (PF) 25 MG/ML INJECTION SOLUTION [4903]

Facility

$11.00

Service Code	HCPCS J2175
Hospital Revenue Code	250
Min. Negotiated Rate	$9.35
Max. Negotiated Rate	$10.67
Rate for Payer: Cash Price	$6.60
Rate for Payer: Health Management Network Commercial	$9.35
Rate for Payer: Kaiser Permanente Commercial	$9.90
Rate for Payer: MDX Hawaii PPO	$10.67

MEPERIDINE (PF) 50 MG/ML INJECTION SOLUTION [4904]

Facility

$12.00

Service Code	HCPCS J2175
Hospital Revenue Code	250
Min. Negotiated Rate	$10.20
Max. Negotiated Rate	$11.64
Rate for Payer: Cash Price	$7.20
Rate for Payer: Health Management Network Commercial	$10.20
Rate for Payer: Kaiser Permanente Commercial	$10.80
Rate for Payer: MDX Hawaii PPO	$11.64

MEPERIDINE (PF) 50 MG/ML INJECTION SOLUTION [4904]

Facility

$12.00

Service Code	HCPCS J2175
Hospital Revenue Code	636
Min. Negotiated Rate	$6.00
Max. Negotiated Rate	$15.69
Rate for Payer: AlohaCare Medicaid	$6.00
Rate for Payer: AlohaCare Medicare	$9.12
Rate for Payer: Cash Price	$7.20
Rate for Payer: Cash Price	$7.20
Rate for Payer: Devoted Health Medicare	$10.08
Rate for Payer: Hawaii Medical Service Association ABD	$15.69
Rate for Payer: Hawaii Medical Service Association Medicare	$9.12
Rate for Payer: Hawaii Medical Service Association Non-ABD	$15.69
Rate for Payer: Hawaii Western Management Group Commercial	$11.40
Rate for Payer: Health Management Network Commercial	$10.20
Rate for Payer: Humana Medicare	$9.12
Rate for Payer: Kaiser Permanente Commercial	$10.80
Rate for Payer: Kaiser Permanente Medicaid	$6.12
Rate for Payer: Kaiser Permanente Medicare	$9.12
Rate for Payer: MDX Hawaii PPO	$11.64
Rate for Payer: Ohana Health Plan Medicaid	$9.12
Rate for Payer: Ohana Health Plan Medicare	$9.12
Rate for Payer: UnitedHealthcare Medicaid	$7.20
Rate for Payer: UnitedHealthcare Medicare	$9.12
Rate for Payer: University Health Alliance Commercial	$8.75

MEPILEX BORDER 3.6X4 498200

Facility

$75.00

Service Code	HCPCS A6212
Hospital Revenue Code	272
Min. Negotiated Rate	$10.11
Max. Negotiated Rate	$72.75
Rate for Payer: AlohaCare Medicaid	$37.50
Rate for Payer: AlohaCare Medicare	$57.00
Rate for Payer: Cash Price	$45.00
Rate for Payer: Cash Price	$45.00
Rate for Payer: Devoted Health Medicare	$63.00
Rate for Payer: Hawaii Medical Service Association Medicare	$57.00
Rate for Payer: Hawaii Western Management Group Commercial	$71.25
Rate for Payer: Health Management Network Commercial	$63.75
Rate for Payer: Humana Medicare	$57.00
Rate for Payer: Kaiser Permanente Commercial	$67.50
Rate for Payer: Kaiser Permanente Medicaid	$38.25
Rate for Payer: Kaiser Permanente Medicare	$57.00
Rate for Payer: MDX Hawaii PPO	$72.75
Rate for Payer: Ohana Health Plan Medicaid	$57.00
Rate for Payer: Ohana Health Plan Medicare	$57.00
Rate for Payer: UnitedHealthcare Medicaid	$10.11
Rate for Payer: UnitedHealthcare Medicare	$57.00
Rate for Payer: University Health Alliance Commercial	$54.67

Know your out-of-pocket cost for care.

All Charges