Honoka'a Hospital and Skilled Nursing Facility

All Charges

Charge

Type

Setting

Price

MIDAZOLAM 2 MG/ML ORAL SYRUP [24176]

Facility

$19.00

Service Code	NDC 68094076259
Hospital Revenue Code	637
Min. Negotiated Rate	$9.50
Max. Negotiated Rate	$18.43
Rate for Payer: AlohaCare Medicaid	$9.50
Rate for Payer: AlohaCare Medicare	$14.44
Rate for Payer: Cash Price	$11.40
Rate for Payer: Devoted Health Medicare	$15.96
Rate for Payer: Hawaii Medical Service Association Medicare	$14.44
Rate for Payer: Hawaii Western Management Group Commercial	$18.05
Rate for Payer: Health Management Network Commercial	$16.15
Rate for Payer: Humana Medicare	$14.44
Rate for Payer: Kaiser Permanente Commercial	$17.10
Rate for Payer: Kaiser Permanente Medicaid	$9.69
Rate for Payer: Kaiser Permanente Medicare	$14.44
Rate for Payer: MDX Hawaii PPO	$18.43
Rate for Payer: Ohana Health Plan Medicaid	$14.44
Rate for Payer: Ohana Health Plan Medicare	$14.44
Rate for Payer: UnitedHealthcare Medicare	$14.44
Rate for Payer: University Health Alliance Commercial	$13.85

MIDAZOLAM 2 MG/ML ORAL SYRUP [24176]

Facility

$19.00

Service Code	NDC 68094076262
Hospital Revenue Code	250
Min. Negotiated Rate	$16.15
Max. Negotiated Rate	$18.43
Rate for Payer: Cash Price	$11.40
Rate for Payer: Health Management Network Commercial	$16.15
Rate for Payer: Kaiser Permanente Commercial	$17.10
Rate for Payer: MDX Hawaii PPO	$18.43

MIDAZOLAM 5 MG/ML INJECTION SOLUTION [93520]

Facility

$28.00

Service Code	HCPCS J2250
Hospital Revenue Code	636
Min. Negotiated Rate	$0.16
Max. Negotiated Rate	$27.16
Rate for Payer: AlohaCare Medicaid	$14.00
Rate for Payer: AlohaCare Medicaid	$19.50
Rate for Payer: AlohaCare Medicare	$29.64
Rate for Payer: AlohaCare Medicare	$21.28
Rate for Payer: Cash Price	$23.40
Rate for Payer: Cash Price	$16.80
Rate for Payer: Cash Price	$16.80
Rate for Payer: Cash Price	$23.40
Rate for Payer: Devoted Health Medicare	$23.52
Rate for Payer: Devoted Health Medicare	$32.76
Rate for Payer: Hawaii Medical Service Association ABD	$0.16
Rate for Payer: Hawaii Medical Service Association ABD	$0.16
Rate for Payer: Hawaii Medical Service Association Medicare	$21.28
Rate for Payer: Hawaii Medical Service Association Medicare	$29.64
Rate for Payer: Hawaii Medical Service Association Non-ABD	$0.16
Rate for Payer: Hawaii Medical Service Association Non-ABD	$0.16
Rate for Payer: Hawaii Western Management Group Commercial	$26.60
Rate for Payer: Hawaii Western Management Group Commercial	$37.05
Rate for Payer: Health Management Network Commercial	$33.15
Rate for Payer: Health Management Network Commercial	$23.80
Rate for Payer: Humana Medicare	$21.28
Rate for Payer: Humana Medicare	$29.64
Rate for Payer: Kaiser Permanente Commercial	$35.10
Rate for Payer: Kaiser Permanente Commercial	$25.20
Rate for Payer: Kaiser Permanente Medicaid	$19.89
Rate for Payer: Kaiser Permanente Medicaid	$14.28
Rate for Payer: Kaiser Permanente Medicare	$29.64
Rate for Payer: Kaiser Permanente Medicare	$21.28
Rate for Payer: MDX Hawaii PPO	$27.16
Rate for Payer: MDX Hawaii PPO	$37.83
Rate for Payer: Ohana Health Plan Medicaid	$29.64
Rate for Payer: Ohana Health Plan Medicaid	$21.28
Rate for Payer: Ohana Health Plan Medicare	$21.28
Rate for Payer: Ohana Health Plan Medicare	$29.64
Rate for Payer: UnitedHealthcare Medicaid	$16.80
Rate for Payer: UnitedHealthcare Medicaid	$23.40
Rate for Payer: UnitedHealthcare Medicare	$21.28
Rate for Payer: UnitedHealthcare Medicare	$29.64
Rate for Payer: University Health Alliance Commercial	$20.41
Rate for Payer: University Health Alliance Commercial	$28.43

MIDAZOLAM 5 MG/ML INJECTION SOLUTION [93520]

Facility

$28.00

Service Code	HCPCS J2250
Hospital Revenue Code	250
Min. Negotiated Rate	$23.80
Max. Negotiated Rate	$27.16
Rate for Payer: Cash Price	$16.80
Rate for Payer: Cash Price	$23.40
Rate for Payer: Health Management Network Commercial	$23.80
Rate for Payer: Health Management Network Commercial	$33.15
Rate for Payer: Kaiser Permanente Commercial	$25.20
Rate for Payer: Kaiser Permanente Commercial	$35.10
Rate for Payer: MDX Hawaii PPO	$37.83
Rate for Payer: MDX Hawaii PPO	$27.16

MIDAZOLAM (PF) 1 MG/ML IN 0.9 % SODIUM CHLORIDE INTRAVENOUS SOLUTION [162718]

Facility

$114.00

Service Code	HCPCS J2251
Hospital Revenue Code	250
Min. Negotiated Rate	$96.90
Max. Negotiated Rate	$110.58
Rate for Payer: Cash Price	$68.40
Rate for Payer: Health Management Network Commercial	$96.90
Rate for Payer: Kaiser Permanente Commercial	$102.60
Rate for Payer: MDX Hawaii PPO	$110.58

MIDAZOLAM (PF) 1 MG/ML IN 0.9 % SODIUM CHLORIDE INTRAVENOUS SOLUTION [162718]

Facility

$114.00

Service Code	HCPCS J2251
Hospital Revenue Code	636
Min. Negotiated Rate	$0.17
Max. Negotiated Rate	$110.58
Rate for Payer: AlohaCare Medicaid	$57.00
Rate for Payer: AlohaCare Medicare	$86.64
Rate for Payer: Cash Price	$68.40
Rate for Payer: Cash Price	$68.40
Rate for Payer: Devoted Health Medicare	$95.76
Rate for Payer: Hawaii Medical Service Association ABD	$0.17
Rate for Payer: Hawaii Medical Service Association Medicare	$86.64
Rate for Payer: Hawaii Medical Service Association Non-ABD	$0.17
Rate for Payer: Hawaii Western Management Group Commercial	$108.30
Rate for Payer: Health Management Network Commercial	$96.90
Rate for Payer: Humana Medicare	$86.64
Rate for Payer: Kaiser Permanente Commercial	$102.60
Rate for Payer: Kaiser Permanente Medicaid	$58.14
Rate for Payer: Kaiser Permanente Medicare	$86.64
Rate for Payer: MDX Hawaii PPO	$110.58
Rate for Payer: Ohana Health Plan Medicaid	$86.64
Rate for Payer: Ohana Health Plan Medicare	$86.64
Rate for Payer: UnitedHealthcare Medicaid	$68.40
Rate for Payer: UnitedHealthcare Medicare	$86.64
Rate for Payer: University Health Alliance Commercial	$83.09

MIDAZOLAM (PF) 1 MG/ML INJECTION SOLUTION [168904]

Facility

$5.00

Service Code	HCPCS J2250
Hospital Revenue Code	636
Min. Negotiated Rate	$0.16
Max. Negotiated Rate	$4.85
Rate for Payer: AlohaCare Medicaid	$2.50
Rate for Payer: AlohaCare Medicare	$3.80
Rate for Payer: Cash Price	$3.00
Rate for Payer: Cash Price	$3.00
Rate for Payer: Devoted Health Medicare	$4.20
Rate for Payer: Hawaii Medical Service Association ABD	$0.16
Rate for Payer: Hawaii Medical Service Association Medicare	$3.80
Rate for Payer: Hawaii Medical Service Association Non-ABD	$0.16
Rate for Payer: Hawaii Western Management Group Commercial	$4.75
Rate for Payer: Health Management Network Commercial	$4.25
Rate for Payer: Humana Medicare	$3.80
Rate for Payer: Kaiser Permanente Commercial	$4.50
Rate for Payer: Kaiser Permanente Medicaid	$2.55
Rate for Payer: Kaiser Permanente Medicare	$3.80
Rate for Payer: MDX Hawaii PPO	$4.85
Rate for Payer: Ohana Health Plan Medicaid	$3.80
Rate for Payer: Ohana Health Plan Medicare	$3.80
Rate for Payer: UnitedHealthcare Medicaid	$3.00
Rate for Payer: UnitedHealthcare Medicare	$3.80
Rate for Payer: University Health Alliance Commercial	$3.64

MIDAZOLAM (PF) 1 MG/ML INJECTION SOLUTION [168904]

Facility

$5.00

Service Code	HCPCS J2250
Hospital Revenue Code	250
Min. Negotiated Rate	$4.25
Max. Negotiated Rate	$4.85
Rate for Payer: Cash Price	$3.00
Rate for Payer: Health Management Network Commercial	$4.25
Rate for Payer: Kaiser Permanente Commercial	$4.50
Rate for Payer: MDX Hawaii PPO	$4.85

MIDAZOLAM (PF) 5 MG/ML INJECTION SOLUTION [168902]

Facility

$6.00

Service Code	HCPCS J2250
Hospital Revenue Code	636
Min. Negotiated Rate	$0.16
Max. Negotiated Rate	$5.82
Rate for Payer: AlohaCare Medicaid	$3.00
Rate for Payer: AlohaCare Medicare	$4.56
Rate for Payer: Cash Price	$3.60
Rate for Payer: Cash Price	$3.60
Rate for Payer: Devoted Health Medicare	$5.04
Rate for Payer: Hawaii Medical Service Association ABD	$0.16
Rate for Payer: Hawaii Medical Service Association Medicare	$4.56
Rate for Payer: Hawaii Medical Service Association Non-ABD	$0.16
Rate for Payer: Hawaii Western Management Group Commercial	$5.70
Rate for Payer: Health Management Network Commercial	$5.10
Rate for Payer: Humana Medicare	$4.56
Rate for Payer: Kaiser Permanente Commercial	$5.40
Rate for Payer: Kaiser Permanente Medicaid	$3.06
Rate for Payer: Kaiser Permanente Medicare	$4.56
Rate for Payer: MDX Hawaii PPO	$5.82
Rate for Payer: Ohana Health Plan Medicaid	$4.56
Rate for Payer: Ohana Health Plan Medicare	$4.56
Rate for Payer: UnitedHealthcare Medicaid	$3.60
Rate for Payer: UnitedHealthcare Medicare	$4.56
Rate for Payer: University Health Alliance Commercial	$4.37

MIDAZOLAM (PF) 5 MG/ML INJECTION SOLUTION [168902]

Facility

$6.00

Service Code	HCPCS J2250
Hospital Revenue Code	250
Min. Negotiated Rate	$5.10
Max. Negotiated Rate	$5.82
Rate for Payer: Cash Price	$3.60
Rate for Payer: Health Management Network Commercial	$5.10
Rate for Payer: Kaiser Permanente Commercial	$5.40
Rate for Payer: MDX Hawaii PPO	$5.82

MIDODRINE 10 MG TABLET [33083]

Facility

$18.00

Service Code	NDC 60505132501
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

MIDODRINE 10 MG TABLET [33083]

Facility

$6.00

Service Code	NDC 60687040925
Hospital Revenue Code	250
Min. Negotiated Rate	$5.10
Max. Negotiated Rate	$5.82
Rate for Payer: Cash Price	$3.60
Rate for Payer: Health Management Network Commercial	$5.10
Rate for Payer: Kaiser Permanente Commercial	$5.40
Rate for Payer: MDX Hawaii PPO	$5.82

MIDODRINE 10 MG TABLET [33083]

Facility

$6.00

Service Code	NDC 60687040925
Hospital Revenue Code	637
Min. Negotiated Rate	$3.00
Max. Negotiated Rate	$5.82
Rate for Payer: AlohaCare Medicaid	$3.00
Rate for Payer: AlohaCare Medicare	$4.56
Rate for Payer: Cash Price	$3.60
Rate for Payer: Devoted Health Medicare	$5.04
Rate for Payer: Hawaii Medical Service Association Medicare	$4.56
Rate for Payer: Hawaii Western Management Group Commercial	$5.70
Rate for Payer: Health Management Network Commercial	$5.10
Rate for Payer: Humana Medicare	$4.56
Rate for Payer: Kaiser Permanente Commercial	$5.40
Rate for Payer: Kaiser Permanente Medicaid	$3.06
Rate for Payer: Kaiser Permanente Medicare	$4.56
Rate for Payer: MDX Hawaii PPO	$5.82
Rate for Payer: Ohana Health Plan Medicaid	$4.56
Rate for Payer: Ohana Health Plan Medicare	$4.56
Rate for Payer: UnitedHealthcare Medicare	$4.56
Rate for Payer: University Health Alliance Commercial	$4.37

MIDODRINE 10 MG TABLET [33083]

Facility

$18.00

Service Code	NDC 60505132501
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

MIDODRINE 5 MG TABLET [10610]

Facility

$4.00

Service Code	NDC 60687039801
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

MIDODRINE 5 MG TABLET [10610]

Facility

$4.00

Service Code	NDC 60687039801
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

MIDODRINE 5 MG TABLET [10610]

Facility

$4.00

Service Code	NDC 60687039811
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

MIDODRINE 5 MG TABLET [10610]

Facility

$4.00

Service Code	NDC 60687039811
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

MIFEPRISTONE 200 MG TABLET [28975]

Facility

$108.00

Service Code	NDC 64875000101
Hospital Revenue Code	637
Min. Negotiated Rate	$54.00
Max. Negotiated Rate	$104.76
Rate for Payer: AlohaCare Medicaid	$54.00
Rate for Payer: AlohaCare Medicare	$82.08
Rate for Payer: Cash Price	$64.80
Rate for Payer: Devoted Health Medicare	$90.72
Rate for Payer: Hawaii Medical Service Association Medicare	$82.08
Rate for Payer: Hawaii Western Management Group Commercial	$102.60
Rate for Payer: Health Management Network Commercial	$91.80
Rate for Payer: Humana Medicare	$82.08
Rate for Payer: Kaiser Permanente Commercial	$97.20
Rate for Payer: Kaiser Permanente Medicaid	$55.08
Rate for Payer: Kaiser Permanente Medicare	$82.08
Rate for Payer: MDX Hawaii PPO	$104.76
Rate for Payer: Ohana Health Plan Medicaid	$82.08
Rate for Payer: Ohana Health Plan Medicare	$82.08
Rate for Payer: UnitedHealthcare Medicare	$82.08
Rate for Payer: University Health Alliance Commercial	$78.72

MIFEPRISTONE 200 MG TABLET [28975]

Facility

$108.00

Service Code	NDC 64875000101
Hospital Revenue Code	250
Min. Negotiated Rate	$91.80
Max. Negotiated Rate	$104.76
Rate for Payer: Cash Price	$64.80
Rate for Payer: Health Management Network Commercial	$91.80
Rate for Payer: Kaiser Permanente Commercial	$97.20
Rate for Payer: MDX Hawaii PPO	$104.76

MILRINONE 20 MG/100 ML(200 MCG/ML) IN 5 % DEXTROSE INTRAVENOUS PIGGYBK [137869]

Facility

$64.00

Service Code	HCPCS J2260
Hospital Revenue Code	636
Min. Negotiated Rate	$1.40
Max. Negotiated Rate	$62.08
Rate for Payer: AlohaCare Medicaid	$32.00
Rate for Payer: AlohaCare Medicare	$48.64
Rate for Payer: Cash Price	$38.40
Rate for Payer: Cash Price	$38.40
Rate for Payer: Devoted Health Medicare	$53.76
Rate for Payer: Hawaii Medical Service Association ABD	$1.40
Rate for Payer: Hawaii Medical Service Association Medicare	$48.64
Rate for Payer: Hawaii Medical Service Association Non-ABD	$1.40
Rate for Payer: Hawaii Western Management Group Commercial	$60.80
Rate for Payer: Health Management Network Commercial	$54.40
Rate for Payer: Humana Medicare	$48.64
Rate for Payer: Kaiser Permanente Commercial	$57.60
Rate for Payer: Kaiser Permanente Medicaid	$32.64
Rate for Payer: Kaiser Permanente Medicare	$48.64
Rate for Payer: MDX Hawaii PPO	$62.08
Rate for Payer: Ohana Health Plan Medicaid	$48.64
Rate for Payer: Ohana Health Plan Medicare	$48.64
Rate for Payer: UnitedHealthcare Medicaid	$38.40
Rate for Payer: UnitedHealthcare Medicare	$48.64
Rate for Payer: University Health Alliance Commercial	$46.65

MILRINONE 20 MG/100 ML(200 MCG/ML) IN 5 % DEXTROSE INTRAVENOUS PIGGYBK [137869]

Facility

$64.00

Service Code	HCPCS J2260
Hospital Revenue Code	250
Min. Negotiated Rate	$54.40
Max. Negotiated Rate	$62.08
Rate for Payer: Cash Price	$38.40
Rate for Payer: Health Management Network Commercial	$54.40
Rate for Payer: Kaiser Permanente Commercial	$57.60
Rate for Payer: MDX Hawaii PPO	$62.08

MINERAL OIL ENEMA [5087]

Facility

$13.00

Service Code	NDC 00132030140
Hospital Revenue Code	250
Min. Negotiated Rate	$11.05
Max. Negotiated Rate	$12.61
Rate for Payer: Cash Price	$7.80
Rate for Payer: Health Management Network Commercial	$11.05
Rate for Payer: Kaiser Permanente Commercial	$11.70
Rate for Payer: MDX Hawaii PPO	$12.61

MINERAL OIL ENEMA [5087]

Facility

$13.00

Service Code	NDC 00132030140
Hospital Revenue Code	637
Min. Negotiated Rate	$6.50
Max. Negotiated Rate	$12.61
Rate for Payer: AlohaCare Medicaid	$6.50
Rate for Payer: AlohaCare Medicare	$9.88
Rate for Payer: Cash Price	$7.80
Rate for Payer: Devoted Health Medicare	$10.92
Rate for Payer: Hawaii Medical Service Association Medicare	$9.88
Rate for Payer: Hawaii Western Management Group Commercial	$12.35
Rate for Payer: Health Management Network Commercial	$11.05
Rate for Payer: Humana Medicare	$9.88
Rate for Payer: Kaiser Permanente Commercial	$11.70
Rate for Payer: Kaiser Permanente Medicaid	$6.63
Rate for Payer: Kaiser Permanente Medicare	$9.88
Rate for Payer: MDX Hawaii PPO	$12.61
Rate for Payer: Ohana Health Plan Medicaid	$9.88
Rate for Payer: Ohana Health Plan Medicare	$9.88
Rate for Payer: UnitedHealthcare Medicare	$9.88
Rate for Payer: University Health Alliance Commercial	$9.48

MINERAL OIL, LIGHT STERILE [209376]

Facility

$69.00

Service Code	NDC 25410000000
Hospital Revenue Code	250
Min. Negotiated Rate	$58.65
Max. Negotiated Rate	$66.93
Rate for Payer: Cash Price	$41.40
Rate for Payer: Health Management Network Commercial	$58.65
Rate for Payer: Kaiser Permanente Commercial	$62.10
Rate for Payer: MDX Hawaii PPO	$66.93

Know your out-of-pocket cost for care.

All Charges