Honoka'a Hospital and Skilled Nursing Facility

All Charges

Charge

Type

Setting

Price

BALLOON BUTTON MINI M1-5-1820

Facility

$368.00

Hospital Revenue Code	272
Min. Negotiated Rate	$184.00
Max. Negotiated Rate	$356.96
Rate for Payer: AlohaCare Medicaid	$184.00
Rate for Payer: AlohaCare Medicare	$279.68
Rate for Payer: Cash Price	$220.80
Rate for Payer: Devoted Health Medicare	$309.12
Rate for Payer: Hawaii Medical Service Association Medicare	$279.68
Rate for Payer: Hawaii Western Management Group Commercial	$349.60
Rate for Payer: Health Management Network Commercial	$312.80
Rate for Payer: Humana Medicare	$279.68
Rate for Payer: Kaiser Permanente Commercial	$331.20
Rate for Payer: Kaiser Permanente Medicaid	$187.68
Rate for Payer: Kaiser Permanente Medicare	$279.68
Rate for Payer: MDX Hawaii PPO	$356.96
Rate for Payer: Ohana Health Plan Medicaid	$279.68
Rate for Payer: Ohana Health Plan Medicare	$279.68
Rate for Payer: UnitedHealthcare Medicare	$279.68
Rate for Payer: University Health Alliance Commercial	$268.24

BALLOON BUTTON MINI M1-5-1820

Facility

$368.00

Hospital Revenue Code	272
Min. Negotiated Rate	$312.80
Max. Negotiated Rate	$356.96
Rate for Payer: Cash Price	$220.80
Rate for Payer: Health Management Network Commercial	$312.80
Rate for Payer: Kaiser Permanente Commercial	$331.20
Rate for Payer: MDX Hawaii PPO	$356.96

BALLOON CATH 4.5X35 SR-4535-BC

Facility

$1,397.00

Service Code	HCPCS C1725
Hospital Revenue Code	272
Min. Negotiated Rate	$1,187.45
Max. Negotiated Rate	$1,355.09
Rate for Payer: Cash Price	$838.20
Rate for Payer: Health Management Network Commercial	$1,187.45
Rate for Payer: Kaiser Permanente Commercial	$1,257.30
Rate for Payer: MDX Hawaii PPO	$1,355.09

BALLOON CATH 4.5X35 SR-4535-BC

Facility

$1,397.00

Service Code	HCPCS C1725
Hospital Revenue Code	272
Min. Negotiated Rate	$698.50
Max. Negotiated Rate	$1,355.09
Rate for Payer: AlohaCare Medicaid	$698.50
Rate for Payer: AlohaCare Medicare	$1,061.72
Rate for Payer: Cash Price	$838.20
Rate for Payer: Devoted Health Medicare	$1,173.48
Rate for Payer: Hawaii Medical Service Association Medicare	$1,061.72
Rate for Payer: Hawaii Western Management Group Commercial	$1,327.15
Rate for Payer: Health Management Network Commercial	$1,187.45
Rate for Payer: Humana Medicare	$1,061.72
Rate for Payer: Kaiser Permanente Commercial	$1,257.30
Rate for Payer: Kaiser Permanente Medicaid	$712.47
Rate for Payer: Kaiser Permanente Medicare	$1,061.72
Rate for Payer: MDX Hawaii PPO	$1,355.09
Rate for Payer: Ohana Health Plan Medicaid	$1,061.72
Rate for Payer: Ohana Health Plan Medicare	$1,061.72
Rate for Payer: UnitedHealthcare Medicare	$1,061.72
Rate for Payer: University Health Alliance Commercial	$1,018.27

BALLOON CATH 5.0X35 SR-5035-BC

Facility

$2,565.00

Service Code	HCPCS C1725
Hospital Revenue Code	272
Min. Negotiated Rate	$2,180.25
Max. Negotiated Rate	$2,488.05
Rate for Payer: Cash Price	$1,539.00
Rate for Payer: Health Management Network Commercial	$2,180.25
Rate for Payer: Kaiser Permanente Commercial	$2,308.50
Rate for Payer: MDX Hawaii PPO	$2,488.05

BALLOON CATH 5.0X35 SR-5035-BC

Facility

$2,565.00

Service Code	HCPCS C1725
Hospital Revenue Code	272
Min. Negotiated Rate	$1,282.50
Max. Negotiated Rate	$2,488.05
Rate for Payer: AlohaCare Medicaid	$1,282.50
Rate for Payer: AlohaCare Medicare	$1,949.40
Rate for Payer: Cash Price	$1,539.00
Rate for Payer: Devoted Health Medicare	$2,154.60
Rate for Payer: Hawaii Medical Service Association Medicare	$1,949.40
Rate for Payer: Hawaii Western Management Group Commercial	$2,436.75
Rate for Payer: Health Management Network Commercial	$2,180.25
Rate for Payer: Humana Medicare	$1,949.40
Rate for Payer: Kaiser Permanente Commercial	$2,308.50
Rate for Payer: Kaiser Permanente Medicaid	$1,308.15
Rate for Payer: Kaiser Permanente Medicare	$1,949.40
Rate for Payer: MDX Hawaii PPO	$2,488.05
Rate for Payer: Ohana Health Plan Medicaid	$1,949.40
Rate for Payer: Ohana Health Plan Medicare	$1,949.40
Rate for Payer: UnitedHealthcare Medicare	$1,949.40
Rate for Payer: University Health Alliance Commercial	$1,869.63

BALLOON CATH 5.5X35 SR-5535-BC

Facility

$1,397.00

Service Code	HCPCS C1725
Hospital Revenue Code	272
Min. Negotiated Rate	$1,187.45
Max. Negotiated Rate	$1,355.09
Rate for Payer: Cash Price	$838.20
Rate for Payer: Health Management Network Commercial	$1,187.45
Rate for Payer: Kaiser Permanente Commercial	$1,257.30
Rate for Payer: MDX Hawaii PPO	$1,355.09

BALLOON CATH 5.5X35 SR-5535-BC

Facility

$1,397.00

Service Code	HCPCS C1725
Hospital Revenue Code	272
Min. Negotiated Rate	$698.50
Max. Negotiated Rate	$1,355.09
Rate for Payer: AlohaCare Medicaid	$698.50
Rate for Payer: AlohaCare Medicare	$1,061.72
Rate for Payer: Cash Price	$838.20
Rate for Payer: Devoted Health Medicare	$1,173.48
Rate for Payer: Hawaii Medical Service Association Medicare	$1,061.72
Rate for Payer: Hawaii Western Management Group Commercial	$1,327.15
Rate for Payer: Health Management Network Commercial	$1,187.45
Rate for Payer: Humana Medicare	$1,061.72
Rate for Payer: Kaiser Permanente Commercial	$1,257.30
Rate for Payer: Kaiser Permanente Medicaid	$712.47
Rate for Payer: Kaiser Permanente Medicare	$1,061.72
Rate for Payer: MDX Hawaii PPO	$1,355.09
Rate for Payer: Ohana Health Plan Medicaid	$1,061.72
Rate for Payer: Ohana Health Plan Medicare	$1,061.72
Rate for Payer: UnitedHealthcare Medicare	$1,061.72
Rate for Payer: University Health Alliance Commercial	$1,018.27

BALLOON DILATION CATH 4.0X35

Facility

$2,565.00

Service Code	HCPCS C1725
Hospital Revenue Code	272
Min. Negotiated Rate	$1,282.50
Max. Negotiated Rate	$2,488.05
Rate for Payer: AlohaCare Medicaid	$1,282.50
Rate for Payer: AlohaCare Medicare	$1,949.40
Rate for Payer: Cash Price	$1,539.00
Rate for Payer: Devoted Health Medicare	$2,154.60
Rate for Payer: Hawaii Medical Service Association Medicare	$1,949.40
Rate for Payer: Hawaii Western Management Group Commercial	$2,436.75
Rate for Payer: Health Management Network Commercial	$2,180.25
Rate for Payer: Humana Medicare	$1,949.40
Rate for Payer: Kaiser Permanente Commercial	$2,308.50
Rate for Payer: Kaiser Permanente Medicaid	$1,308.15
Rate for Payer: Kaiser Permanente Medicare	$1,949.40
Rate for Payer: MDX Hawaii PPO	$2,488.05
Rate for Payer: Ohana Health Plan Medicaid	$1,949.40
Rate for Payer: Ohana Health Plan Medicare	$1,949.40
Rate for Payer: UnitedHealthcare Medicare	$1,949.40
Rate for Payer: University Health Alliance Commercial	$1,869.63

BALLOON DILATION CATH 4.0X35

Facility

$2,565.00

Service Code	HCPCS C1725
Hospital Revenue Code	272
Min. Negotiated Rate	$2,180.25
Max. Negotiated Rate	$2,488.05
Rate for Payer: Cash Price	$1,539.00
Rate for Payer: Health Management Network Commercial	$2,180.25
Rate for Payer: Kaiser Permanente Commercial	$2,308.50
Rate for Payer: MDX Hawaii PPO	$2,488.05

BALLOON ENFLATE SR-6025-BC

Facility

$1,397.00

Service Code	HCPCS C1725
Hospital Revenue Code	272
Min. Negotiated Rate	$698.50
Max. Negotiated Rate	$1,355.09
Rate for Payer: AlohaCare Medicaid	$698.50
Rate for Payer: AlohaCare Medicare	$1,061.72
Rate for Payer: Cash Price	$838.20
Rate for Payer: Devoted Health Medicare	$1,173.48
Rate for Payer: Hawaii Medical Service Association Medicare	$1,061.72
Rate for Payer: Hawaii Western Management Group Commercial	$1,327.15
Rate for Payer: Health Management Network Commercial	$1,187.45
Rate for Payer: Humana Medicare	$1,061.72
Rate for Payer: Kaiser Permanente Commercial	$1,257.30
Rate for Payer: Kaiser Permanente Medicaid	$712.47
Rate for Payer: Kaiser Permanente Medicare	$1,061.72
Rate for Payer: MDX Hawaii PPO	$1,355.09
Rate for Payer: Ohana Health Plan Medicaid	$1,061.72
Rate for Payer: Ohana Health Plan Medicare	$1,061.72
Rate for Payer: UnitedHealthcare Medicare	$1,061.72
Rate for Payer: University Health Alliance Commercial	$1,018.27

BALLOON ENFLATE SR-6025-BC

Facility

$1,397.00

Service Code	HCPCS C1725
Hospital Revenue Code	272
Min. Negotiated Rate	$1,187.45
Max. Negotiated Rate	$1,355.09
Rate for Payer: Cash Price	$838.20
Rate for Payer: Health Management Network Commercial	$1,187.45
Rate for Payer: Kaiser Permanente Commercial	$1,257.30
Rate for Payer: MDX Hawaii PPO	$1,355.09

BALLOON ESOPHA/COLON 10-12

Facility

$825.00

Service Code	HCPCS C1726
Hospital Revenue Code	272
Min. Negotiated Rate	$412.50
Max. Negotiated Rate	$800.25
Rate for Payer: AlohaCare Medicaid	$412.50
Rate for Payer: AlohaCare Medicare	$627.00
Rate for Payer: Cash Price	$495.00
Rate for Payer: Devoted Health Medicare	$693.00
Rate for Payer: Hawaii Medical Service Association Medicare	$627.00
Rate for Payer: Hawaii Western Management Group Commercial	$783.75
Rate for Payer: Health Management Network Commercial	$701.25
Rate for Payer: Humana Medicare	$627.00
Rate for Payer: Kaiser Permanente Commercial	$742.50
Rate for Payer: Kaiser Permanente Medicaid	$420.75
Rate for Payer: Kaiser Permanente Medicare	$627.00
Rate for Payer: MDX Hawaii PPO	$800.25
Rate for Payer: Ohana Health Plan Medicaid	$627.00
Rate for Payer: Ohana Health Plan Medicare	$627.00
Rate for Payer: UnitedHealthcare Medicare	$627.00
Rate for Payer: University Health Alliance Commercial	$601.34

BALLOON ESOPHA/COLON 10-12

Facility

$825.00

Service Code	HCPCS C1726
Hospital Revenue Code	272
Min. Negotiated Rate	$701.25
Max. Negotiated Rate	$800.25
Rate for Payer: Cash Price	$495.00
Rate for Payer: Health Management Network Commercial	$701.25
Rate for Payer: Kaiser Permanente Commercial	$742.50
Rate for Payer: MDX Hawaii PPO	$800.25

BALLOON ESOPHA/COLON 15-18

Facility

$825.00

Service Code	HCPCS C1726
Hospital Revenue Code	272
Min. Negotiated Rate	$701.25
Max. Negotiated Rate	$800.25
Rate for Payer: Cash Price	$495.00
Rate for Payer: Health Management Network Commercial	$701.25
Rate for Payer: Kaiser Permanente Commercial	$742.50
Rate for Payer: MDX Hawaii PPO	$800.25

BALLOON ESOPHA/COLON 15-18

Facility

$825.00

Service Code	HCPCS C1726
Hospital Revenue Code	272
Min. Negotiated Rate	$412.50
Max. Negotiated Rate	$800.25
Rate for Payer: AlohaCare Medicaid	$412.50
Rate for Payer: AlohaCare Medicare	$627.00
Rate for Payer: Cash Price	$495.00
Rate for Payer: Devoted Health Medicare	$693.00
Rate for Payer: Hawaii Medical Service Association Medicare	$627.00
Rate for Payer: Hawaii Western Management Group Commercial	$783.75
Rate for Payer: Health Management Network Commercial	$701.25
Rate for Payer: Humana Medicare	$627.00
Rate for Payer: Kaiser Permanente Commercial	$742.50
Rate for Payer: Kaiser Permanente Medicaid	$420.75
Rate for Payer: Kaiser Permanente Medicare	$627.00
Rate for Payer: MDX Hawaii PPO	$800.25
Rate for Payer: Ohana Health Plan Medicaid	$627.00
Rate for Payer: Ohana Health Plan Medicare	$627.00
Rate for Payer: UnitedHealthcare Medicare	$627.00
Rate for Payer: University Health Alliance Commercial	$601.34

BALLOON ESOPHA/COLON 18-20

Facility

$825.00

Service Code	HCPCS C1726
Hospital Revenue Code	272
Min. Negotiated Rate	$701.25
Max. Negotiated Rate	$800.25
Rate for Payer: Cash Price	$495.00
Rate for Payer: Health Management Network Commercial	$701.25
Rate for Payer: Kaiser Permanente Commercial	$742.50
Rate for Payer: MDX Hawaii PPO	$800.25

BALLOON ESOPHA/COLON 18-20

Facility

$825.00

Service Code	HCPCS C1726
Hospital Revenue Code	272
Min. Negotiated Rate	$412.50
Max. Negotiated Rate	$800.25
Rate for Payer: AlohaCare Medicaid	$412.50
Rate for Payer: AlohaCare Medicare	$627.00
Rate for Payer: Cash Price	$495.00
Rate for Payer: Devoted Health Medicare	$693.00
Rate for Payer: Hawaii Medical Service Association Medicare	$627.00
Rate for Payer: Hawaii Western Management Group Commercial	$783.75
Rate for Payer: Health Management Network Commercial	$701.25
Rate for Payer: Humana Medicare	$627.00
Rate for Payer: Kaiser Permanente Commercial	$742.50
Rate for Payer: Kaiser Permanente Medicaid	$420.75
Rate for Payer: Kaiser Permanente Medicare	$627.00
Rate for Payer: MDX Hawaii PPO	$800.25
Rate for Payer: Ohana Health Plan Medicaid	$627.00
Rate for Payer: Ohana Health Plan Medicare	$627.00
Rate for Payer: UnitedHealthcare Medicare	$627.00
Rate for Payer: University Health Alliance Commercial	$601.34

BALLOON ESOPHA/COLON 6-8

Facility

$825.00

Service Code	HCPCS C1726
Hospital Revenue Code	272
Min. Negotiated Rate	$412.50
Max. Negotiated Rate	$800.25
Rate for Payer: AlohaCare Medicaid	$412.50
Rate for Payer: AlohaCare Medicare	$627.00
Rate for Payer: Cash Price	$495.00
Rate for Payer: Devoted Health Medicare	$693.00
Rate for Payer: Hawaii Medical Service Association Medicare	$627.00
Rate for Payer: Hawaii Western Management Group Commercial	$783.75
Rate for Payer: Health Management Network Commercial	$701.25
Rate for Payer: Humana Medicare	$627.00
Rate for Payer: Kaiser Permanente Commercial	$742.50
Rate for Payer: Kaiser Permanente Medicaid	$420.75
Rate for Payer: Kaiser Permanente Medicare	$627.00
Rate for Payer: MDX Hawaii PPO	$800.25
Rate for Payer: Ohana Health Plan Medicaid	$627.00
Rate for Payer: Ohana Health Plan Medicare	$627.00
Rate for Payer: UnitedHealthcare Medicare	$627.00
Rate for Payer: University Health Alliance Commercial	$601.34

BALLOON ESOPHA/COLON 6-8

Facility

$825.00

Service Code	HCPCS C1726
Hospital Revenue Code	272
Min. Negotiated Rate	$701.25
Max. Negotiated Rate	$800.25
Rate for Payer: Cash Price	$495.00
Rate for Payer: Health Management Network Commercial	$701.25
Rate for Payer: Kaiser Permanente Commercial	$742.50
Rate for Payer: MDX Hawaii PPO	$800.25

BALLOON RETRIEVAL 12X15

Facility

$560.00

Service Code	HCPCS C1889
Hospital Revenue Code	272
Min. Negotiated Rate	$476.00
Max. Negotiated Rate	$543.20
Rate for Payer: Cash Price	$336.00
Rate for Payer: Health Management Network Commercial	$476.00
Rate for Payer: Kaiser Permanente Commercial	$504.00
Rate for Payer: MDX Hawaii PPO	$543.20

BALLOON RETRIEVAL 12X15

Facility

$560.00

Service Code	HCPCS C1889
Hospital Revenue Code	272
Min. Negotiated Rate	$280.00
Max. Negotiated Rate	$543.20
Rate for Payer: AlohaCare Medicaid	$280.00
Rate for Payer: AlohaCare Medicare	$425.60
Rate for Payer: Cash Price	$336.00
Rate for Payer: Devoted Health Medicare	$470.40
Rate for Payer: Hawaii Medical Service Association Medicare	$425.60
Rate for Payer: Hawaii Western Management Group Commercial	$532.00
Rate for Payer: Health Management Network Commercial	$476.00
Rate for Payer: Humana Medicare	$425.60
Rate for Payer: Kaiser Permanente Commercial	$504.00
Rate for Payer: Kaiser Permanente Medicaid	$285.60
Rate for Payer: Kaiser Permanente Medicare	$425.60
Rate for Payer: MDX Hawaii PPO	$543.20
Rate for Payer: Ohana Health Plan Medicaid	$425.60
Rate for Payer: Ohana Health Plan Medicare	$425.60
Rate for Payer: UnitedHealthcare Medicare	$425.60
Rate for Payer: University Health Alliance Commercial	$408.18

BALLOON RETRIEVAL 12X9

Facility

$560.00

Service Code	HCPCS C1889
Hospital Revenue Code	272
Min. Negotiated Rate	$280.00
Max. Negotiated Rate	$543.20
Rate for Payer: AlohaCare Medicaid	$280.00
Rate for Payer: AlohaCare Medicare	$425.60
Rate for Payer: Cash Price	$336.00
Rate for Payer: Devoted Health Medicare	$470.40
Rate for Payer: Hawaii Medical Service Association Medicare	$425.60
Rate for Payer: Hawaii Western Management Group Commercial	$532.00
Rate for Payer: Health Management Network Commercial	$476.00
Rate for Payer: Humana Medicare	$425.60
Rate for Payer: Kaiser Permanente Commercial	$504.00
Rate for Payer: Kaiser Permanente Medicaid	$285.60
Rate for Payer: Kaiser Permanente Medicare	$425.60
Rate for Payer: MDX Hawaii PPO	$543.20
Rate for Payer: Ohana Health Plan Medicaid	$425.60
Rate for Payer: Ohana Health Plan Medicare	$425.60
Rate for Payer: UnitedHealthcare Medicare	$425.60
Rate for Payer: University Health Alliance Commercial	$408.18

BALLOON RETRIEVAL 12X9

Facility

$560.00

Service Code	HCPCS C1889
Hospital Revenue Code	272
Min. Negotiated Rate	$476.00
Max. Negotiated Rate	$543.20
Rate for Payer: Cash Price	$336.00
Rate for Payer: Health Management Network Commercial	$476.00
Rate for Payer: Kaiser Permanente Commercial	$504.00
Rate for Payer: MDX Hawaii PPO	$543.20

BALLOON RETRIEVAL 15X18

Facility

$560.00

Service Code	HCPCS C1889
Hospital Revenue Code	278
Min. Negotiated Rate	$280.00
Max. Negotiated Rate	$543.20
Rate for Payer: AlohaCare Medicaid	$280.00
Rate for Payer: AlohaCare Medicare	$425.60
Rate for Payer: Cash Price	$336.00
Rate for Payer: Devoted Health Medicare	$470.40
Rate for Payer: Hawaii Medical Service Association Medicare	$425.60
Rate for Payer: Hawaii Western Management Group Commercial	$392.00
Rate for Payer: Health Management Network Commercial	$476.00
Rate for Payer: Humana Medicare	$425.60
Rate for Payer: Kaiser Permanente Commercial	$504.00
Rate for Payer: Kaiser Permanente Medicaid	$285.60
Rate for Payer: Kaiser Permanente Medicare	$425.60
Rate for Payer: MDX Hawaii PPO	$543.20
Rate for Payer: Ohana Health Plan Medicaid	$425.60
Rate for Payer: Ohana Health Plan Medicare	$425.60
Rate for Payer: UnitedHealthcare Medicare	$425.60
Rate for Payer: University Health Alliance Commercial	$313.60

Know your out-of-pocket cost for care.

All Charges