Honoka'a Hospital and Skilled Nursing Facility

All Charges

Charge

Type

Setting

Price

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

BALL TIP GUIDE ROD #71631626

Facility

$1,428.00

Service Code	HCPCS C1769
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

BALL TIP GUIDE ROD #71631626

Facility

$1,428.00

Service Code	HCPCS C1769
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

BAND LIGATOR MULTIPLE

Facility

$541.00

Hospital Revenue Code	272
Min. Negotiated Rate	$459.85
Max. Negotiated Rate	$524.77
Rate for Payer: Cash Price	$324.60
Rate for Payer: Health Management Network Commercial	$459.85
Rate for Payer: Kaiser Permanente Commercial	$486.90
Rate for Payer: MDX Hawaii PPO	$524.77

BAND LIGATOR MULTIPLE

Facility

$541.00

Hospital Revenue Code	272
Min. Negotiated Rate	$270.50
Max. Negotiated Rate	$524.77
Rate for Payer: AlohaCare Medicaid	$270.50
Rate for Payer: AlohaCare Medicare	$411.16
Rate for Payer: Cash Price	$324.60
Rate for Payer: Devoted Health Medicare	$454.44
Rate for Payer: Hawaii Medical Service Association Medicare	$411.16
Rate for Payer: Hawaii Western Management Group Commercial	$513.95
Rate for Payer: Health Management Network Commercial	$459.85
Rate for Payer: Humana Medicare	$411.16
Rate for Payer: Kaiser Permanente Commercial	$486.90
Rate for Payer: Kaiser Permanente Medicaid	$275.91
Rate for Payer: Kaiser Permanente Medicare	$411.16
Rate for Payer: MDX Hawaii PPO	$524.77
Rate for Payer: Ohana Health Plan Medicaid	$411.16
Rate for Payer: Ohana Health Plan Medicare	$411.16
Rate for Payer: UnitedHealthcare Medicare	$411.16
Rate for Payer: University Health Alliance Commercial	$394.33

BAR 11MMX500

Facility

$1,383.00

Service Code	HCPCS C1713
Hospital Revenue Code	272
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	$1,313.85
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	$1,008.07

BAR 11MMX500

Facility

$1,383.00

Service Code	HCPCS C1713
Hospital Revenue Code	272
Min. Negotiated Rate	$1,175.55
Max. Negotiated Rate	$1,341.51
Rate for Payer: Cash Price	$829.80
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

BAR 11X350

Facility

$1,383.00

Hospital Revenue Code	272
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	$1,313.85
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	$1,008.07

BAR 11X350

Facility

$1,383.00

Hospital Revenue Code	272
Min. Negotiated Rate	$1,175.55
Max. Negotiated Rate	$1,341.51
Rate for Payer: Cash Price	$829.80
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

BAR 250 4922-8-250

Facility

$1,279.00

Hospital Revenue Code	272
Min. Negotiated Rate	$639.50
Max. Negotiated Rate	$1,240.63
Rate for Payer: AlohaCare Medicaid	$639.50
Rate for Payer: AlohaCare Medicare	$972.04
Rate for Payer: Cash Price	$767.40
Rate for Payer: Devoted Health Medicare	$1,074.36
Rate for Payer: Hawaii Medical Service Association Medicare	$972.04
Rate for Payer: Hawaii Western Management Group Commercial	$1,215.05
Rate for Payer: Health Management Network Commercial	$1,087.15
Rate for Payer: Humana Medicare	$972.04
Rate for Payer: Kaiser Permanente Commercial	$1,151.10
Rate for Payer: Kaiser Permanente Medicaid	$652.29
Rate for Payer: Kaiser Permanente Medicare	$972.04
Rate for Payer: MDX Hawaii PPO	$1,240.63
Rate for Payer: Ohana Health Plan Medicaid	$972.04
Rate for Payer: Ohana Health Plan Medicare	$972.04
Rate for Payer: UnitedHealthcare Medicare	$972.04
Rate for Payer: University Health Alliance Commercial	$932.26

BAR 250 4922-8-250

Facility

$1,279.00

Hospital Revenue Code	272
Min. Negotiated Rate	$1,087.15
Max. Negotiated Rate	$1,240.63
Rate for Payer: Cash Price	$767.40
Rate for Payer: Health Management Network Commercial	$1,087.15
Rate for Payer: Kaiser Permanente Commercial	$1,151.10
Rate for Payer: MDX Hawaii PPO	$1,240.63

BAR 300 4922-8-300

Facility

$1,312.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$734.72
Max. Negotiated Rate	$1,272.64
Rate for Payer: Cash Price	$787.20
Rate for Payer: Hawaii Western Management Group Commercial	$918.40
Rate for Payer: Health Management Network Commercial	$1,115.20
Rate for Payer: Kaiser Permanente Commercial	$1,180.80
Rate for Payer: MDX Hawaii PPO	$1,272.64
Rate for Payer: University Health Alliance Commercial	$734.72

BAR 300 4922-8-300

Facility

$1,312.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$656.00
Max. Negotiated Rate	$1,272.64
Rate for Payer: AlohaCare Medicaid	$656.00
Rate for Payer: AlohaCare Medicare	$997.12
Rate for Payer: Cash Price	$787.20
Rate for Payer: Devoted Health Medicare	$1,102.08
Rate for Payer: Hawaii Medical Service Association Medicare	$997.12
Rate for Payer: Hawaii Western Management Group Commercial	$918.40
Rate for Payer: Health Management Network Commercial	$1,115.20
Rate for Payer: Humana Medicare	$997.12
Rate for Payer: Kaiser Permanente Commercial	$1,180.80
Rate for Payer: Kaiser Permanente Medicaid	$669.12
Rate for Payer: Kaiser Permanente Medicare	$997.12
Rate for Payer: MDX Hawaii PPO	$1,272.64
Rate for Payer: Ohana Health Plan Medicaid	$997.12
Rate for Payer: Ohana Health Plan Medicare	$997.12
Rate for Payer: UnitedHealthcare Medicare	$997.12
Rate for Payer: University Health Alliance Commercial	$734.72

BAR 400 4922-8-400

Facility

$1,788.00

Hospital Revenue Code	272
Min. Negotiated Rate	$1,519.80
Max. Negotiated Rate	$1,734.36
Rate for Payer: Cash Price	$1,072.80
Rate for Payer: Health Management Network Commercial	$1,519.80
Rate for Payer: Kaiser Permanente Commercial	$1,609.20
Rate for Payer: MDX Hawaii PPO	$1,734.36

BAR 400 4922-8-400

Facility

$1,788.00

Hospital Revenue Code	272
Min. Negotiated Rate	$894.00
Max. Negotiated Rate	$1,734.36
Rate for Payer: AlohaCare Medicaid	$894.00
Rate for Payer: AlohaCare Medicare	$1,358.88
Rate for Payer: Cash Price	$1,072.80
Rate for Payer: Devoted Health Medicare	$1,501.92
Rate for Payer: Hawaii Medical Service Association Medicare	$1,358.88
Rate for Payer: Hawaii Western Management Group Commercial	$1,698.60
Rate for Payer: Health Management Network Commercial	$1,519.80
Rate for Payer: Humana Medicare	$1,358.88
Rate for Payer: Kaiser Permanente Commercial	$1,609.20
Rate for Payer: Kaiser Permanente Medicaid	$911.88
Rate for Payer: Kaiser Permanente Medicare	$1,358.88
Rate for Payer: MDX Hawaii PPO	$1,734.36
Rate for Payer: Ohana Health Plan Medicaid	$1,358.88
Rate for Payer: Ohana Health Plan Medicare	$1,358.88
Rate for Payer: UnitedHealthcare Medicare	$1,358.88
Rate for Payer: University Health Alliance Commercial	$1,303.27

BARICITINIB 2 MG TABLET [160676]

Facility

$167.00

Service Code	NDC 00002418230
Hospital Revenue Code	637
Min. Negotiated Rate	$83.50
Max. Negotiated Rate	$161.99
Rate for Payer: AlohaCare Medicaid	$83.50
Rate for Payer: AlohaCare Medicare	$126.92
Rate for Payer: Cash Price	$100.20
Rate for Payer: Devoted Health Medicare	$140.28
Rate for Payer: Hawaii Medical Service Association Medicare	$126.92
Rate for Payer: Hawaii Western Management Group Commercial	$158.65
Rate for Payer: Health Management Network Commercial	$141.95
Rate for Payer: Humana Medicare	$126.92
Rate for Payer: Kaiser Permanente Commercial	$150.30
Rate for Payer: Kaiser Permanente Medicaid	$85.17
Rate for Payer: Kaiser Permanente Medicare	$126.92
Rate for Payer: MDX Hawaii PPO	$161.99
Rate for Payer: Ohana Health Plan Medicaid	$126.92
Rate for Payer: Ohana Health Plan Medicare	$126.92
Rate for Payer: UnitedHealthcare Medicare	$126.92
Rate for Payer: University Health Alliance Commercial	$121.73

BARICITINIB 2 MG TABLET [160676]

Facility

$167.00

Service Code	NDC 00002418230
Hospital Revenue Code	250
Min. Negotiated Rate	$141.95
Max. Negotiated Rate	$161.99
Rate for Payer: Cash Price	$100.20
Rate for Payer: Health Management Network Commercial	$141.95
Rate for Payer: Kaiser Permanente Commercial	$150.30
Rate for Payer: MDX Hawaii PPO	$161.99

BARIUM SULFATE 105 % (W/V), 58 % (W/W) ORAL SUSPENSION [97296]

Facility

$1.00

Service Code	NDC 32909016755
Hospital Revenue Code	250
Min. Negotiated Rate	$0.85
Max. Negotiated Rate	$0.97
Rate for Payer: Cash Price	$0.60
Rate for Payer: Health Management Network Commercial	$0.85
Rate for Payer: Kaiser Permanente Commercial	$0.90
Rate for Payer: MDX Hawaii PPO	$0.97

BARIUM SULFATE 105 % (W/V), 58 % (W/W) ORAL SUSPENSION [97296]

Facility

$1.00

Service Code	NDC 32909016755
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

BARIUM SULFATE 2 % (W/V) ORAL SUSPENSION [18299]

Facility

$19.00

Service Code	NDC 32909074603
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

BARIUM SULFATE 2 % (W/V) ORAL SUSPENSION [18299]

Facility

$19.00

Service Code	NDC 32909074603
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

BARIUM SULFATE 40 % (W/V), 29 % (W/W) (1,500 CPS) ORAL SUSPENSION [209049]

Facility

$151.00

Service Code	NDC 32909012107
Hospital Revenue Code	250
Min. Negotiated Rate	$128.35
Max. Negotiated Rate	$146.47
Rate for Payer: Cash Price	$90.60
Rate for Payer: Health Management Network Commercial	$128.35
Rate for Payer: Kaiser Permanente Commercial	$135.90
Rate for Payer: MDX Hawaii PPO	$146.47

BARIUM SULFATE 40 % (W/V), 29 % (W/W) (1,500 CPS) ORAL SUSPENSION [209049]

Facility

$151.00

Service Code	NDC 32909012107
Hospital Revenue Code	637
Min. Negotiated Rate	$75.50
Max. Negotiated Rate	$146.47
Rate for Payer: Kaiser Permanente Commercial	$135.90
Rate for Payer: AlohaCare Medicaid	$75.50
Rate for Payer: AlohaCare Medicare	$114.76
Rate for Payer: Cash Price	$90.60
Rate for Payer: Devoted Health Medicare	$126.84
Rate for Payer: Hawaii Medical Service Association Medicare	$114.76
Rate for Payer: Hawaii Western Management Group Commercial	$143.45
Rate for Payer: Health Management Network Commercial	$128.35
Rate for Payer: Humana Medicare	$114.76
Rate for Payer: Kaiser Permanente Medicaid	$77.01
Rate for Payer: Kaiser Permanente Medicare	$114.76
Rate for Payer: MDX Hawaii PPO	$146.47
Rate for Payer: Ohana Health Plan Medicaid	$114.76
Rate for Payer: Ohana Health Plan Medicare	$114.76
Rate for Payer: UnitedHealthcare Medicare	$114.76
Rate for Payer: University Health Alliance Commercial	$110.06

BARIUM SULFATE 40 % (W/V), 30% (W/W) ORAL PASTE [104159]

Facility

$132.00

Service Code	NDC 32909012522
Hospital Revenue Code	637
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

BARIUM SULFATE 40 % (W/V), 30% (W/W) ORAL PASTE [104159]

Facility

$132.00

Service Code	NDC 32909012522
Hospital Revenue Code	250
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

Know your out-of-pocket cost for care.

All Charges