Honoka'a Hospital and Skilled Nursing Facility

All Charges

Charge

Type

Setting

Price

METOPROLOL TARTRATE TABLETS (LOPRESSOR) 50 MG (TAKE HOME) [4080375]

Facility

$15.00

Service Code	NDC 00004080163
Hospital Revenue Code	253
Min. Negotiated Rate	$12.75
Max. Negotiated Rate	$14.55
Rate for Payer: Cash Price	$9.00
Rate for Payer: Health Management Network Commercial	$12.75
Rate for Payer: Kaiser Permanente Commercial	$13.50
Rate for Payer: MDX Hawaii PPO	$14.55

METOPROLOL TARTRATE TABLETS (LOPRESSOR) 50 MG (TAKE HOME) [4080375]

Facility

$15.00

Service Code	NDC 00004080163
Hospital Revenue Code	253
Min. Negotiated Rate	$7.50
Max. Negotiated Rate	$14.55
Rate for Payer: AlohaCare Medicaid	$7.50
Rate for Payer: AlohaCare Medicare	$11.40
Rate for Payer: Cash Price	$9.00
Rate for Payer: Devoted Health Medicare	$12.60
Rate for Payer: Hawaii Medical Service Association Medicare	$11.40
Rate for Payer: Hawaii Western Management Group Commercial	$14.25
Rate for Payer: Health Management Network Commercial	$12.75
Rate for Payer: Humana Medicare	$11.40
Rate for Payer: Kaiser Permanente Commercial	$13.50
Rate for Payer: Kaiser Permanente Medicaid	$7.65
Rate for Payer: Kaiser Permanente Medicare	$11.40
Rate for Payer: MDX Hawaii PPO	$14.55
Rate for Payer: Ohana Health Plan Medicaid	$11.40
Rate for Payer: Ohana Health Plan Medicare	$11.40
Rate for Payer: UnitedHealthcare Medicare	$11.40
Rate for Payer: University Health Alliance Commercial	$10.93

METRONIDAZOLE 0.75 % (37.5 MG/5 GRAM) VAGINAL GEL [10592]

Facility

$535.00

Service Code	NDC 21922003923
Hospital Revenue Code	250
Min. Negotiated Rate	$454.75
Max. Negotiated Rate	$518.95
Rate for Payer: Cash Price	$321.00
Rate for Payer: Health Management Network Commercial	$454.75
Rate for Payer: Kaiser Permanente Commercial	$481.50
Rate for Payer: MDX Hawaii PPO	$518.95

METRONIDAZOLE 0.75 % (37.5 MG/5 GRAM) VAGINAL GEL [10592]

Facility

$535.00

Service Code	NDC 21922003923
Hospital Revenue Code	637
Min. Negotiated Rate	$267.50
Max. Negotiated Rate	$518.95
Rate for Payer: AlohaCare Medicaid	$267.50
Rate for Payer: AlohaCare Medicare	$406.60
Rate for Payer: Cash Price	$321.00
Rate for Payer: Devoted Health Medicare	$449.40
Rate for Payer: Hawaii Medical Service Association Medicare	$406.60
Rate for Payer: Hawaii Western Management Group Commercial	$508.25
Rate for Payer: Health Management Network Commercial	$454.75
Rate for Payer: Humana Medicare	$406.60
Rate for Payer: Kaiser Permanente Commercial	$481.50
Rate for Payer: Kaiser Permanente Medicaid	$272.85
Rate for Payer: Kaiser Permanente Medicare	$406.60
Rate for Payer: MDX Hawaii PPO	$518.95
Rate for Payer: Ohana Health Plan Medicaid	$406.60
Rate for Payer: Ohana Health Plan Medicare	$406.60
Rate for Payer: UnitedHealthcare Medicare	$406.60
Rate for Payer: University Health Alliance Commercial	$389.96

METRONIDAZOLE 0.75 % (37.5 MG/5 GRAM) VAGINAL GEL [10592]

Facility

$535.00

Service Code	NDC 45802013970
Hospital Revenue Code	637
Min. Negotiated Rate	$267.50
Max. Negotiated Rate	$518.95
Rate for Payer: AlohaCare Medicaid	$267.50
Rate for Payer: AlohaCare Medicare	$406.60
Rate for Payer: Cash Price	$321.00
Rate for Payer: Devoted Health Medicare	$449.40
Rate for Payer: Hawaii Medical Service Association Medicare	$406.60
Rate for Payer: Hawaii Western Management Group Commercial	$508.25
Rate for Payer: Health Management Network Commercial	$454.75
Rate for Payer: Humana Medicare	$406.60
Rate for Payer: Kaiser Permanente Commercial	$481.50
Rate for Payer: Kaiser Permanente Medicaid	$272.85
Rate for Payer: Kaiser Permanente Medicare	$406.60
Rate for Payer: MDX Hawaii PPO	$518.95
Rate for Payer: Ohana Health Plan Medicaid	$406.60
Rate for Payer: Ohana Health Plan Medicare	$406.60
Rate for Payer: UnitedHealthcare Medicare	$406.60
Rate for Payer: University Health Alliance Commercial	$389.96

METRONIDAZOLE 0.75 % (37.5 MG/5 GRAM) VAGINAL GEL [10592]

Facility

$535.00

Service Code	NDC 45802013970
Hospital Revenue Code	250
Min. Negotiated Rate	$454.75
Max. Negotiated Rate	$518.95
Rate for Payer: Cash Price	$321.00
Rate for Payer: Health Management Network Commercial	$454.75
Rate for Payer: Kaiser Permanente Commercial	$481.50
Rate for Payer: MDX Hawaii PPO	$518.95

METRONIDAZOLE 250 MG TABLET [5015]

Facility

$2.00

Service Code	NDC 68001036400
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

METRONIDAZOLE 250 MG TABLET [5015]

Facility

$2.00

Service Code	NDC 00904715661
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

METRONIDAZOLE 250 MG TABLET [5015]

Facility

$2.00

Service Code	NDC 00904715661
Hospital Revenue Code	637
Min. Negotiated Rate	$1.00
Max. Negotiated Rate	$1.94
Rate for Payer: AlohaCare Medicaid	$1.00
Rate for Payer: AlohaCare Medicare	$1.52
Rate for Payer: Cash Price	$1.20
Rate for Payer: Devoted Health Medicare	$1.68
Rate for Payer: Hawaii Medical Service Association Medicare	$1.52
Rate for Payer: Hawaii Western Management Group Commercial	$1.90
Rate for Payer: Health Management Network Commercial	$1.70
Rate for Payer: Humana Medicare	$1.52
Rate for Payer: Kaiser Permanente Commercial	$1.80
Rate for Payer: Kaiser Permanente Medicaid	$1.02
Rate for Payer: Kaiser Permanente Medicare	$1.52
Rate for Payer: MDX Hawaii PPO	$1.94
Rate for Payer: Ohana Health Plan Medicaid	$1.52
Rate for Payer: Ohana Health Plan Medicare	$1.52
Rate for Payer: UnitedHealthcare Medicare	$1.52
Rate for Payer: University Health Alliance Commercial	$1.46

METRONIDAZOLE 250 MG TABLET [5015]

Facility

$2.00

Service Code	NDC 68001036400
Hospital Revenue Code	637
Min. Negotiated Rate	$1.00
Max. Negotiated Rate	$1.94
Rate for Payer: AlohaCare Medicaid	$1.00
Rate for Payer: AlohaCare Medicare	$1.52
Rate for Payer: Cash Price	$1.20
Rate for Payer: Devoted Health Medicare	$1.68
Rate for Payer: Hawaii Medical Service Association Medicare	$1.52
Rate for Payer: Hawaii Western Management Group Commercial	$1.90
Rate for Payer: Health Management Network Commercial	$1.70
Rate for Payer: Humana Medicare	$1.52
Rate for Payer: Kaiser Permanente Commercial	$1.80
Rate for Payer: Kaiser Permanente Medicaid	$1.02
Rate for Payer: Kaiser Permanente Medicare	$1.52
Rate for Payer: MDX Hawaii PPO	$1.94
Rate for Payer: Ohana Health Plan Medicaid	$1.52
Rate for Payer: Ohana Health Plan Medicare	$1.52
Rate for Payer: UnitedHealthcare Medicare	$1.52
Rate for Payer: University Health Alliance Commercial	$1.46

METRONIDAZOLE 500 MG/100 ML IN SODIUM CHLOR(ISO) INTRAVENOUS PIGGYBACK [183828]

Facility

$9.00

Service Code	HCPCS J1836
Hospital Revenue Code	250
Min. Negotiated Rate	$7.65
Max. Negotiated Rate	$8.73
Rate for Payer: Cash Price	$5.40
Rate for Payer: Health Management Network Commercial	$7.65
Rate for Payer: Kaiser Permanente Commercial	$8.10
Rate for Payer: MDX Hawaii PPO	$8.73

METRONIDAZOLE 500 MG/100 ML IN SODIUM CHLOR(ISO) INTRAVENOUS PIGGYBACK [183828]

Facility

$9.00

Service Code	HCPCS J1836
Hospital Revenue Code	636
Min. Negotiated Rate	$0.03
Max. Negotiated Rate	$8.73
Rate for Payer: AlohaCare Medicaid	$4.50
Rate for Payer: AlohaCare Medicare	$6.84
Rate for Payer: Cash Price	$5.40
Rate for Payer: Cash Price	$5.40
Rate for Payer: Devoted Health Medicare	$7.56
Rate for Payer: Hawaii Medical Service Association ABD	$0.03
Rate for Payer: Hawaii Medical Service Association Medicare	$6.84
Rate for Payer: Hawaii Medical Service Association Non-ABD	$0.03
Rate for Payer: Hawaii Western Management Group Commercial	$8.55
Rate for Payer: Health Management Network Commercial	$7.65
Rate for Payer: Humana Medicare	$6.84
Rate for Payer: Kaiser Permanente Commercial	$8.10
Rate for Payer: Kaiser Permanente Medicaid	$4.59
Rate for Payer: Kaiser Permanente Medicare	$6.84
Rate for Payer: MDX Hawaii PPO	$8.73
Rate for Payer: Ohana Health Plan Medicaid	$6.84
Rate for Payer: Ohana Health Plan Medicare	$6.84
Rate for Payer: UnitedHealthcare Medicaid	$5.40
Rate for Payer: UnitedHealthcare Medicare	$6.84
Rate for Payer: University Health Alliance Commercial	$6.56

METRONIDAZOLE 500 MG TABLET [5016]

Facility

$4.00

Service Code	NDC 60687055001
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

METRONIDAZOLE 500 MG TABLET [5016]

Facility

$4.00

Service Code	NDC 60687055001
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

METRONIDAZOLE 500 MG TABLET [5016]

Facility

$4.00

Service Code	NDC 60687055011
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

METRONIDAZOLE 500 MG TABLET [5016]

Facility

$4.00

Service Code	NDC 60687055011
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

METRONIDAZOLE TABLETS (FLAGYL) 500 MG (TAKE HOME) [4080376]

Facility

$15.00

Service Code	NDC 00004080164
Hospital Revenue Code	253
Min. Negotiated Rate	$7.50
Max. Negotiated Rate	$14.55
Rate for Payer: AlohaCare Medicaid	$7.50
Rate for Payer: AlohaCare Medicare	$11.40
Rate for Payer: Cash Price	$9.00
Rate for Payer: Devoted Health Medicare	$12.60
Rate for Payer: Hawaii Medical Service Association Medicare	$11.40
Rate for Payer: Hawaii Western Management Group Commercial	$14.25
Rate for Payer: Health Management Network Commercial	$12.75
Rate for Payer: Humana Medicare	$11.40
Rate for Payer: Kaiser Permanente Commercial	$13.50
Rate for Payer: Kaiser Permanente Medicaid	$7.65
Rate for Payer: Kaiser Permanente Medicare	$11.40
Rate for Payer: MDX Hawaii PPO	$14.55
Rate for Payer: Ohana Health Plan Medicaid	$11.40
Rate for Payer: Ohana Health Plan Medicare	$11.40
Rate for Payer: UnitedHealthcare Medicare	$11.40
Rate for Payer: University Health Alliance Commercial	$10.93

METRONIDAZOLE TABLETS (FLAGYL) 500 MG (TAKE HOME) [4080376]

Facility

$15.00

Service Code	NDC 00004080164
Hospital Revenue Code	253
Min. Negotiated Rate	$12.75
Max. Negotiated Rate	$14.55
Rate for Payer: Cash Price	$9.00
Rate for Payer: Health Management Network Commercial	$12.75
Rate for Payer: Kaiser Permanente Commercial	$13.50
Rate for Payer: MDX Hawaii PPO	$14.55

MEXILETINE 150 MG CAPSULE [10595]

Facility

$9.00

Service Code	NDC 00093873901
Hospital Revenue Code	637
Min. Negotiated Rate	$4.50
Max. Negotiated Rate	$8.73
Rate for Payer: AlohaCare Medicaid	$4.50
Rate for Payer: AlohaCare Medicare	$6.84
Rate for Payer: Cash Price	$5.40
Rate for Payer: Devoted Health Medicare	$7.56
Rate for Payer: Hawaii Medical Service Association Medicare	$6.84
Rate for Payer: Hawaii Western Management Group Commercial	$8.55
Rate for Payer: Health Management Network Commercial	$7.65
Rate for Payer: Humana Medicare	$6.84
Rate for Payer: Kaiser Permanente Commercial	$8.10
Rate for Payer: Kaiser Permanente Medicaid	$4.59
Rate for Payer: Kaiser Permanente Medicare	$6.84
Rate for Payer: MDX Hawaii PPO	$8.73
Rate for Payer: Ohana Health Plan Medicaid	$6.84
Rate for Payer: Ohana Health Plan Medicare	$6.84
Rate for Payer: UnitedHealthcare Medicare	$6.84
Rate for Payer: University Health Alliance Commercial	$6.56

MEXILETINE 150 MG CAPSULE [10595]

Facility

$9.00

Service Code	NDC 00093873901
Hospital Revenue Code	250
Min. Negotiated Rate	$7.65
Max. Negotiated Rate	$8.73
Rate for Payer: Cash Price	$5.40
Rate for Payer: Health Management Network Commercial	$7.65
Rate for Payer: Kaiser Permanente Commercial	$8.10
Rate for Payer: MDX Hawaii PPO	$8.73

MEXILETINE 150 MG CAPSULE [10595]

Facility

$9.00

Service Code	NDC 50742023901
Hospital Revenue Code	637
Min. Negotiated Rate	$4.50
Max. Negotiated Rate	$8.73
Rate for Payer: AlohaCare Medicaid	$4.50
Rate for Payer: AlohaCare Medicare	$6.84
Rate for Payer: Cash Price	$5.40
Rate for Payer: Devoted Health Medicare	$7.56
Rate for Payer: Hawaii Medical Service Association Medicare	$6.84
Rate for Payer: Hawaii Western Management Group Commercial	$8.55
Rate for Payer: Health Management Network Commercial	$7.65
Rate for Payer: Humana Medicare	$6.84
Rate for Payer: Kaiser Permanente Commercial	$8.10
Rate for Payer: Kaiser Permanente Medicaid	$4.59
Rate for Payer: Kaiser Permanente Medicare	$6.84
Rate for Payer: MDX Hawaii PPO	$8.73
Rate for Payer: Ohana Health Plan Medicaid	$6.84
Rate for Payer: Ohana Health Plan Medicare	$6.84
Rate for Payer: UnitedHealthcare Medicare	$6.84
Rate for Payer: University Health Alliance Commercial	$6.56

MEXILETINE 150 MG CAPSULE [10595]

Facility

$9.00

Service Code	NDC 50742023901
Hospital Revenue Code	250
Min. Negotiated Rate	$7.65
Max. Negotiated Rate	$8.73
Rate for Payer: Cash Price	$5.40
Rate for Payer: Health Management Network Commercial	$7.65
Rate for Payer: Kaiser Permanente Commercial	$8.10
Rate for Payer: MDX Hawaii PPO	$8.73

MIC G-12 LAP INTRODUCER KIT

Facility

$877.00

Service Code	HCPCS C1769
Hospital Revenue Code	272
Min. Negotiated Rate	$438.50
Max. Negotiated Rate	$850.69
Rate for Payer: AlohaCare Medicaid	$438.50
Rate for Payer: AlohaCare Medicare	$666.52
Rate for Payer: Cash Price	$526.20
Rate for Payer: Devoted Health Medicare	$736.68
Rate for Payer: Hawaii Medical Service Association Medicare	$666.52
Rate for Payer: Hawaii Western Management Group Commercial	$833.15
Rate for Payer: Health Management Network Commercial	$745.45
Rate for Payer: Humana Medicare	$666.52
Rate for Payer: Kaiser Permanente Commercial	$789.30
Rate for Payer: Kaiser Permanente Medicaid	$447.27
Rate for Payer: Kaiser Permanente Medicare	$666.52
Rate for Payer: MDX Hawaii PPO	$850.69
Rate for Payer: Ohana Health Plan Medicaid	$666.52
Rate for Payer: Ohana Health Plan Medicare	$666.52
Rate for Payer: UnitedHealthcare Medicare	$666.52
Rate for Payer: University Health Alliance Commercial	$639.25

MIC G-12 LAP INTRODUCER KIT

Facility

$877.00

Service Code	HCPCS C1769
Hospital Revenue Code	272
Min. Negotiated Rate	$745.45
Max. Negotiated Rate	$850.69
Rate for Payer: Cash Price	$526.20
Rate for Payer: Health Management Network Commercial	$745.45
Rate for Payer: Kaiser Permanente Commercial	$789.30
Rate for Payer: MDX Hawaii PPO	$850.69

MIC G-24 LAP INTRODUCER KIT

Facility

$930.00

Service Code	HCPCS C1894
Hospital Revenue Code	272
Min. Negotiated Rate	$790.50
Max. Negotiated Rate	$902.10
Rate for Payer: Cash Price	$558.00
Rate for Payer: Health Management Network Commercial	$790.50
Rate for Payer: Kaiser Permanente Commercial	$837.00
Rate for Payer: MDX Hawaii PPO	$902.10

Know your out-of-pocket cost for care.

All Charges