Honoka'a Hospital and Skilled Nursing Facility

All Charges

Charge

Type

Setting

Price

BARIUM SULFATE 40 % (W/V), 30 % (W/W) ORAL SUSPENSION [39786]

Facility

$48.00

Service Code	NDC 32909011600
Hospital Revenue Code	637
Min. Negotiated Rate	$24.00
Max. Negotiated Rate	$46.56
Rate for Payer: AlohaCare Medicaid	$24.00
Rate for Payer: AlohaCare Medicare	$36.48
Rate for Payer: Cash Price	$28.80
Rate for Payer: Devoted Health Medicare	$40.32
Rate for Payer: Hawaii Medical Service Association Medicare	$36.48
Rate for Payer: Hawaii Western Management Group Commercial	$45.60
Rate for Payer: Health Management Network Commercial	$40.80
Rate for Payer: Humana Medicare	$36.48
Rate for Payer: Kaiser Permanente Commercial	$43.20
Rate for Payer: Kaiser Permanente Medicaid	$24.48
Rate for Payer: Kaiser Permanente Medicare	$36.48
Rate for Payer: MDX Hawaii PPO	$46.56
Rate for Payer: Ohana Health Plan Medicaid	$36.48
Rate for Payer: Ohana Health Plan Medicare	$36.48
Rate for Payer: UnitedHealthcare Medicare	$36.48
Rate for Payer: University Health Alliance Commercial	$34.99

BARIUM SULFATE 40 % (W/V), 30 % (W/W) ORAL SUSPENSION [39786]

Facility

$48.00

Service Code	NDC 32909011600
Hospital Revenue Code	250
Min. Negotiated Rate	$40.80
Max. Negotiated Rate	$46.56
Rate for Payer: Cash Price	$28.80
Rate for Payer: Health Management Network Commercial	$40.80
Rate for Payer: Kaiser Permanente Commercial	$43.20
Rate for Payer: MDX Hawaii PPO	$46.56

BARIUM SULFATE 700 MG TABLET [100992]

Facility

$12.00

Service Code	NDC 10361077831
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

BARIUM SULFATE 700 MG TABLET [100992]

Facility

$12.00

Service Code	NDC 10361077831
Hospital Revenue Code	637
Min. Negotiated Rate	$6.00
Max. Negotiated Rate	$11.64
Rate for Payer: AlohaCare Medicaid	$6.00
Rate for Payer: AlohaCare Medicare	$9.12
Rate for Payer: Cash Price	$7.20
Rate for Payer: Devoted Health Medicare	$10.08
Rate for Payer: Hawaii Medical Service Association Medicare	$9.12
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 Medicare	$9.12
Rate for Payer: University Health Alliance Commercial	$8.75

BARIUM SULFATE 96 % (W/W) ORAL POWDER FOR SUSPENSION [13031]

Facility

$21.00

Service Code	NDC 32909075003
Hospital Revenue Code	250
Min. Negotiated Rate	$17.85
Max. Negotiated Rate	$20.37
Rate for Payer: Cash Price	$12.60
Rate for Payer: Health Management Network Commercial	$17.85
Rate for Payer: Kaiser Permanente Commercial	$18.90
Rate for Payer: MDX Hawaii PPO	$20.37

BARIUM SULFATE 96 % (W/W) ORAL POWDER FOR SUSPENSION [13031]

Facility

$21.00

Service Code	NDC 32909075003
Hospital Revenue Code	637
Min. Negotiated Rate	$10.50
Max. Negotiated Rate	$20.37
Rate for Payer: AlohaCare Medicaid	$10.50
Rate for Payer: AlohaCare Medicare	$15.96
Rate for Payer: Cash Price	$12.60
Rate for Payer: Devoted Health Medicare	$17.64
Rate for Payer: Hawaii Medical Service Association Medicare	$15.96
Rate for Payer: Hawaii Western Management Group Commercial	$19.95
Rate for Payer: Health Management Network Commercial	$17.85
Rate for Payer: Humana Medicare	$15.96
Rate for Payer: Kaiser Permanente Commercial	$18.90
Rate for Payer: Kaiser Permanente Medicaid	$10.71
Rate for Payer: Kaiser Permanente Medicare	$15.96
Rate for Payer: MDX Hawaii PPO	$20.37
Rate for Payer: Ohana Health Plan Medicaid	$15.96
Rate for Payer: Ohana Health Plan Medicare	$15.96
Rate for Payer: UnitedHealthcare Medicare	$15.96
Rate for Payer: University Health Alliance Commercial	$15.31

BARIUM SULFATE 98 % ORAL POWDER FOR SUSPENSION [19436]

Facility

$24.00

Service Code	NDC 32909076401
Hospital Revenue Code	637
Min. Negotiated Rate	$12.00
Max. Negotiated Rate	$23.28
Rate for Payer: AlohaCare Medicaid	$12.00
Rate for Payer: AlohaCare Medicare	$18.24
Rate for Payer: Cash Price	$14.40
Rate for Payer: Devoted Health Medicare	$20.16
Rate for Payer: Hawaii Medical Service Association Medicare	$18.24
Rate for Payer: Hawaii Western Management Group Commercial	$22.80
Rate for Payer: Health Management Network Commercial	$20.40
Rate for Payer: Humana Medicare	$18.24
Rate for Payer: Kaiser Permanente Commercial	$21.60
Rate for Payer: Kaiser Permanente Medicaid	$12.24
Rate for Payer: Kaiser Permanente Medicare	$18.24
Rate for Payer: MDX Hawaii PPO	$23.28
Rate for Payer: Ohana Health Plan Medicaid	$18.24
Rate for Payer: Ohana Health Plan Medicare	$18.24
Rate for Payer: UnitedHealthcare Medicare	$18.24
Rate for Payer: University Health Alliance Commercial	$17.49

BARIUM SULFATE 98 % ORAL POWDER FOR SUSPENSION [19436]

Facility

$24.00

Service Code	NDC 32909076401
Hospital Revenue Code	250
Min. Negotiated Rate	$20.40
Max. Negotiated Rate	$23.28
Rate for Payer: Cash Price	$14.40
Rate for Payer: Health Management Network Commercial	$20.40
Rate for Payer: Kaiser Permanente Commercial	$21.60
Rate for Payer: MDX Hawaii PPO	$23.28

BARTHOLIN GLAND CATH 5640-00

Facility

$132.00

Service Code	HCPCS C1729
Hospital Revenue Code	272
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

BARTHOLIN GLAND CATH 5640-00

Facility

$132.00

Service Code	HCPCS C1729
Hospital Revenue Code	272
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

BASE PLATE 15MM 00-4349-015-00

Facility

$4,300.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$2,150.00
Max. Negotiated Rate	$4,171.00
Rate for Payer: AlohaCare Medicaid	$2,150.00
Rate for Payer: AlohaCare Medicare	$3,268.00
Rate for Payer: Cash Price	$2,580.00
Rate for Payer: Devoted Health Medicare	$3,612.00
Rate for Payer: Hawaii Medical Service Association Medicare	$3,268.00
Rate for Payer: Hawaii Western Management Group Commercial	$3,010.00
Rate for Payer: Health Management Network Commercial	$3,655.00
Rate for Payer: Humana Medicare	$3,268.00
Rate for Payer: Kaiser Permanente Commercial	$3,870.00
Rate for Payer: Kaiser Permanente Medicaid	$2,193.00
Rate for Payer: Kaiser Permanente Medicare	$3,268.00
Rate for Payer: MDX Hawaii PPO	$4,171.00
Rate for Payer: Ohana Health Plan Medicaid	$3,268.00
Rate for Payer: Ohana Health Plan Medicare	$3,268.00
Rate for Payer: UnitedHealthcare Medicare	$3,268.00
Rate for Payer: University Health Alliance Commercial	$2,408.00

BASE PLATE 15MM 00-4349-015-00

Facility

$4,300.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$2,408.00
Max. Negotiated Rate	$4,171.00
Rate for Payer: Cash Price	$2,580.00
Rate for Payer: Hawaii Western Management Group Commercial	$3,010.00
Rate for Payer: Health Management Network Commercial	$3,655.00
Rate for Payer: Kaiser Permanente Commercial	$3,870.00
Rate for Payer: MDX Hawaii PPO	$4,171.00
Rate for Payer: University Health Alliance Commercial	$2,408.00

BASEPLATE GLENOID LATER DWJ502

Facility

$7,944.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$4,448.64
Max. Negotiated Rate	$7,705.68
Rate for Payer: Cash Price	$4,766.40
Rate for Payer: Hawaii Western Management Group Commercial	$5,560.80
Rate for Payer: Health Management Network Commercial	$6,752.40
Rate for Payer: Kaiser Permanente Commercial	$7,149.60
Rate for Payer: MDX Hawaii PPO	$7,705.68
Rate for Payer: University Health Alliance Commercial	$4,448.64

BASEPLATE GLENOID LATER DWJ502

Facility

$7,944.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$3,972.00
Max. Negotiated Rate	$7,705.68
Rate for Payer: AlohaCare Medicaid	$3,972.00
Rate for Payer: AlohaCare Medicare	$6,037.44
Rate for Payer: Cash Price	$4,766.40
Rate for Payer: Devoted Health Medicare	$6,672.96
Rate for Payer: Hawaii Medical Service Association Medicare	$6,037.44
Rate for Payer: Hawaii Western Management Group Commercial	$5,560.80
Rate for Payer: Health Management Network Commercial	$6,752.40
Rate for Payer: Humana Medicare	$6,037.44
Rate for Payer: Kaiser Permanente Commercial	$7,149.60
Rate for Payer: Kaiser Permanente Medicaid	$4,051.44
Rate for Payer: Kaiser Permanente Medicare	$6,037.44
Rate for Payer: MDX Hawaii PPO	$7,705.68
Rate for Payer: Ohana Health Plan Medicaid	$6,037.44
Rate for Payer: Ohana Health Plan Medicare	$6,037.44
Rate for Payer: UnitedHealthcare Medicare	$6,037.44
Rate for Payer: University Health Alliance Commercial	$4,448.64

BASEPLATE MINI TAPR ADPTR

Facility

$2,864.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$1,432.00
Max. Negotiated Rate	$2,778.08
Rate for Payer: AlohaCare Medicaid	$1,432.00
Rate for Payer: AlohaCare Medicare	$2,176.64
Rate for Payer: Cash Price	$1,718.40
Rate for Payer: Devoted Health Medicare	$2,405.76
Rate for Payer: Hawaii Medical Service Association Medicare	$2,176.64
Rate for Payer: Hawaii Western Management Group Commercial	$2,004.80
Rate for Payer: Health Management Network Commercial	$2,434.40
Rate for Payer: Humana Medicare	$2,176.64
Rate for Payer: Kaiser Permanente Commercial	$2,577.60
Rate for Payer: Kaiser Permanente Medicaid	$1,460.64
Rate for Payer: Kaiser Permanente Medicare	$2,176.64
Rate for Payer: MDX Hawaii PPO	$2,778.08
Rate for Payer: Ohana Health Plan Medicaid	$2,176.64
Rate for Payer: Ohana Health Plan Medicare	$2,176.64
Rate for Payer: UnitedHealthcare Medicare	$2,176.64
Rate for Payer: University Health Alliance Commercial	$1,603.84

BASEPLATE MINI TAPR ADPTR

Facility

$2,864.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$1,603.84
Max. Negotiated Rate	$2,778.08
Rate for Payer: Cash Price	$1,718.40
Rate for Payer: Hawaii Western Management Group Commercial	$2,004.80
Rate for Payer: Health Management Network Commercial	$2,434.40
Rate for Payer: Kaiser Permanente Commercial	$2,577.60
Rate for Payer: MDX Hawaii PPO	$2,778.08
Rate for Payer: University Health Alliance Commercial	$1,603.84

BASEPLATE REV TIBIA 5612-B-500

Facility

$10,353.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$5,797.68
Max. Negotiated Rate	$10,042.41
Rate for Payer: Cash Price	$6,211.80
Rate for Payer: Hawaii Western Management Group Commercial	$7,247.10
Rate for Payer: Health Management Network Commercial	$8,800.05
Rate for Payer: Kaiser Permanente Commercial	$9,317.70
Rate for Payer: MDX Hawaii PPO	$10,042.41
Rate for Payer: University Health Alliance Commercial	$5,797.68

BASEPLATE REV TIBIA 5612-B-500

Facility

$10,353.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$5,176.50
Max. Negotiated Rate	$10,042.41
Rate for Payer: AlohaCare Medicaid	$5,176.50
Rate for Payer: AlohaCare Medicare	$7,868.28
Rate for Payer: Cash Price	$6,211.80
Rate for Payer: Devoted Health Medicare	$8,696.52
Rate for Payer: Hawaii Medical Service Association Medicare	$7,868.28
Rate for Payer: Hawaii Western Management Group Commercial	$7,247.10
Rate for Payer: Health Management Network Commercial	$8,800.05
Rate for Payer: Humana Medicare	$7,868.28
Rate for Payer: Kaiser Permanente Commercial	$9,317.70
Rate for Payer: Kaiser Permanente Medicaid	$5,280.03
Rate for Payer: Kaiser Permanente Medicare	$7,868.28
Rate for Payer: MDX Hawaii PPO	$10,042.41
Rate for Payer: Ohana Health Plan Medicaid	$7,868.28
Rate for Payer: Ohana Health Plan Medicare	$7,868.28
Rate for Payer: UnitedHealthcare Medicare	$7,868.28
Rate for Payer: University Health Alliance Commercial	$5,797.68

BASEPLATE RSA 28MM 5572-2800

Facility

$4,400.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$2,200.00
Max. Negotiated Rate	$4,268.00
Rate for Payer: AlohaCare Medicaid	$2,200.00
Rate for Payer: AlohaCare Medicare	$3,344.00
Rate for Payer: Cash Price	$2,640.00
Rate for Payer: Devoted Health Medicare	$3,696.00
Rate for Payer: Hawaii Medical Service Association Medicare	$3,344.00
Rate for Payer: Hawaii Western Management Group Commercial	$3,080.00
Rate for Payer: Health Management Network Commercial	$3,740.00
Rate for Payer: Humana Medicare	$3,344.00
Rate for Payer: Kaiser Permanente Commercial	$3,960.00
Rate for Payer: Kaiser Permanente Medicaid	$2,244.00
Rate for Payer: Kaiser Permanente Medicare	$3,344.00
Rate for Payer: MDX Hawaii PPO	$4,268.00
Rate for Payer: Ohana Health Plan Medicaid	$3,344.00
Rate for Payer: Ohana Health Plan Medicare	$3,344.00
Rate for Payer: UnitedHealthcare Medicare	$3,344.00
Rate for Payer: University Health Alliance Commercial	$2,464.00

BASEPLATE RSA 28MM 5572-2800

Facility

$4,400.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$2,464.00
Max. Negotiated Rate	$4,268.00
Rate for Payer: Cash Price	$2,640.00
Rate for Payer: Hawaii Western Management Group Commercial	$3,080.00
Rate for Payer: Health Management Network Commercial	$3,740.00
Rate for Payer: Kaiser Permanente Commercial	$3,960.00
Rate for Payer: MDX Hawaii PPO	$4,268.00
Rate for Payer: University Health Alliance Commercial	$2,464.00

BASEPLATE S GLENOID AR-9120-01

Facility

$3,430.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,715.00
Max. Negotiated Rate	$3,327.10
Rate for Payer: AlohaCare Medicaid	$1,715.00
Rate for Payer: AlohaCare Medicare	$2,606.80
Rate for Payer: Cash Price	$2,058.00
Rate for Payer: Devoted Health Medicare	$2,881.20
Rate for Payer: Hawaii Medical Service Association Medicare	$2,606.80
Rate for Payer: Hawaii Western Management Group Commercial	$2,401.00
Rate for Payer: Health Management Network Commercial	$2,915.50
Rate for Payer: Humana Medicare	$2,606.80
Rate for Payer: Kaiser Permanente Commercial	$3,087.00
Rate for Payer: Kaiser Permanente Medicaid	$1,749.30
Rate for Payer: Kaiser Permanente Medicare	$2,606.80
Rate for Payer: MDX Hawaii PPO	$3,327.10
Rate for Payer: Ohana Health Plan Medicaid	$2,606.80
Rate for Payer: Ohana Health Plan Medicare	$2,606.80
Rate for Payer: UnitedHealthcare Medicare	$2,606.80
Rate for Payer: University Health Alliance Commercial	$1,920.80

BASEPLATE S GLENOID AR-9120-01

Facility

$3,430.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,920.80
Max. Negotiated Rate	$3,327.10
Rate for Payer: Cash Price	$2,058.00
Rate for Payer: Hawaii Western Management Group Commercial	$2,401.00
Rate for Payer: Health Management Network Commercial	$2,915.50
Rate for Payer: Kaiser Permanente Commercial	$3,087.00
Rate for Payer: MDX Hawaii PPO	$3,327.10
Rate for Payer: University Health Alliance Commercial	$1,920.80

BASEPLATE TIB 42-5420-075-01

Facility

$4,980.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$2,490.00
Max. Negotiated Rate	$4,830.60
Rate for Payer: AlohaCare Medicaid	$2,490.00
Rate for Payer: AlohaCare Medicare	$3,784.80
Rate for Payer: Cash Price	$2,988.00
Rate for Payer: Devoted Health Medicare	$4,183.20
Rate for Payer: Hawaii Medical Service Association Medicare	$3,784.80
Rate for Payer: Hawaii Western Management Group Commercial	$3,486.00
Rate for Payer: Health Management Network Commercial	$4,233.00
Rate for Payer: Humana Medicare	$3,784.80
Rate for Payer: Kaiser Permanente Commercial	$4,482.00
Rate for Payer: Kaiser Permanente Medicaid	$2,539.80
Rate for Payer: Kaiser Permanente Medicare	$3,784.80
Rate for Payer: MDX Hawaii PPO	$4,830.60
Rate for Payer: Ohana Health Plan Medicaid	$3,784.80
Rate for Payer: Ohana Health Plan Medicare	$3,784.80
Rate for Payer: UnitedHealthcare Medicare	$3,784.80
Rate for Payer: University Health Alliance Commercial	$2,788.80

BASEPLATE TIB 42-5420-075-01

Facility

$4,980.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$2,788.80
Max. Negotiated Rate	$4,830.60
Rate for Payer: Cash Price	$2,988.00
Rate for Payer: Hawaii Western Management Group Commercial	$3,486.00
Rate for Payer: Health Management Network Commercial	$4,233.00
Rate for Payer: Kaiser Permanente Commercial	$4,482.00
Rate for Payer: MDX Hawaii PPO	$4,830.60
Rate for Payer: University Health Alliance Commercial	$2,788.80

BASEPLATE TIB SZ3 5521-B-300

Facility

$3,311.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,655.50
Max. Negotiated Rate	$3,211.67
Rate for Payer: AlohaCare Medicaid	$1,655.50
Rate for Payer: AlohaCare Medicare	$2,516.36
Rate for Payer: Cash Price	$1,986.60
Rate for Payer: Devoted Health Medicare	$2,781.24
Rate for Payer: Hawaii Medical Service Association Medicare	$2,516.36
Rate for Payer: Hawaii Western Management Group Commercial	$2,317.70
Rate for Payer: Health Management Network Commercial	$2,814.35
Rate for Payer: Humana Medicare	$2,516.36
Rate for Payer: Kaiser Permanente Commercial	$2,979.90
Rate for Payer: Kaiser Permanente Medicaid	$1,688.61
Rate for Payer: Kaiser Permanente Medicare	$2,516.36
Rate for Payer: MDX Hawaii PPO	$3,211.67
Rate for Payer: Ohana Health Plan Medicaid	$2,516.36
Rate for Payer: Ohana Health Plan Medicare	$2,516.36
Rate for Payer: UnitedHealthcare Medicare	$2,516.36
Rate for Payer: University Health Alliance Commercial	$1,854.16

Know your out-of-pocket cost for care.

All Charges