Honoka'a Hospital and Skilled Nursing Facility

All Charges

Charge

Type

Setting

Price

BASKET STONE RETRIEV ENDO 2.5

Facility

$923.00

Service Code	HCPCS C1889
Hospital Revenue Code	272
Min. Negotiated Rate	$461.50
Max. Negotiated Rate	$895.31
Rate for Payer: AlohaCare Medicaid	$461.50
Rate for Payer: AlohaCare Medicare	$701.48
Rate for Payer: Cash Price	$553.80
Rate for Payer: Devoted Health Medicare	$775.32
Rate for Payer: Hawaii Medical Service Association Medicare	$701.48
Rate for Payer: Hawaii Western Management Group Commercial	$876.85
Rate for Payer: Health Management Network Commercial	$784.55
Rate for Payer: Humana Medicare	$701.48
Rate for Payer: Kaiser Permanente Commercial	$830.70
Rate for Payer: Kaiser Permanente Medicaid	$470.73
Rate for Payer: Kaiser Permanente Medicare	$701.48
Rate for Payer: MDX Hawaii PPO	$895.31
Rate for Payer: Ohana Health Plan Medicaid	$701.48
Rate for Payer: Ohana Health Plan Medicare	$701.48
Rate for Payer: UnitedHealthcare Medicare	$701.48
Rate for Payer: University Health Alliance Commercial	$672.77

BASKET STONE RETRIEV ENDO 2.5

Facility

$923.00

Service Code	HCPCS C1889
Hospital Revenue Code	272
Min. Negotiated Rate	$784.55
Max. Negotiated Rate	$895.31
Rate for Payer: Cash Price	$553.80
Rate for Payer: Health Management Network Commercial	$784.55
Rate for Payer: Kaiser Permanente Commercial	$830.70
Rate for Payer: MDX Hawaii PPO	$895.31

BASKET STONE RETRIEV ENDO 3

Facility

$923.00

Service Code	HCPCS C1889
Hospital Revenue Code	272
Min. Negotiated Rate	$784.55
Max. Negotiated Rate	$895.31
Rate for Payer: Cash Price	$553.80
Rate for Payer: Health Management Network Commercial	$784.55
Rate for Payer: Kaiser Permanente Commercial	$830.70
Rate for Payer: MDX Hawaii PPO	$895.31

BASKET STONE RETRIEV ENDO 3

Facility

$923.00

Service Code	HCPCS C1889
Hospital Revenue Code	272
Min. Negotiated Rate	$461.50
Max. Negotiated Rate	$895.31
Rate for Payer: AlohaCare Medicaid	$461.50
Rate for Payer: AlohaCare Medicare	$701.48
Rate for Payer: Cash Price	$553.80
Rate for Payer: Devoted Health Medicare	$775.32
Rate for Payer: Hawaii Medical Service Association Medicare	$701.48
Rate for Payer: Hawaii Western Management Group Commercial	$876.85
Rate for Payer: Health Management Network Commercial	$784.55
Rate for Payer: Humana Medicare	$701.48
Rate for Payer: Kaiser Permanente Commercial	$830.70
Rate for Payer: Kaiser Permanente Medicaid	$470.73
Rate for Payer: Kaiser Permanente Medicare	$701.48
Rate for Payer: MDX Hawaii PPO	$895.31
Rate for Payer: Ohana Health Plan Medicaid	$701.48
Rate for Payer: Ohana Health Plan Medicare	$701.48
Rate for Payer: UnitedHealthcare Medicare	$701.48
Rate for Payer: University Health Alliance Commercial	$672.77

BASKET URINARY STONE NITINOL

Facility

$880.00

Service Code	HCPCS C1889
Hospital Revenue Code	272
Min. Negotiated Rate	$440.00
Max. Negotiated Rate	$853.60
Rate for Payer: AlohaCare Medicaid	$440.00
Rate for Payer: AlohaCare Medicare	$668.80
Rate for Payer: Cash Price	$528.00
Rate for Payer: Devoted Health Medicare	$739.20
Rate for Payer: Hawaii Medical Service Association Medicare	$668.80
Rate for Payer: Hawaii Western Management Group Commercial	$836.00
Rate for Payer: Health Management Network Commercial	$748.00
Rate for Payer: Humana Medicare	$668.80
Rate for Payer: Kaiser Permanente Commercial	$792.00
Rate for Payer: Kaiser Permanente Medicaid	$448.80
Rate for Payer: Kaiser Permanente Medicare	$668.80
Rate for Payer: MDX Hawaii PPO	$853.60
Rate for Payer: Ohana Health Plan Medicaid	$668.80
Rate for Payer: Ohana Health Plan Medicare	$668.80
Rate for Payer: UnitedHealthcare Medicare	$668.80
Rate for Payer: University Health Alliance Commercial	$641.43

BASKET URINARY STONE NITINOL

Facility

$880.00

Service Code	HCPCS C1889
Hospital Revenue Code	272
Min. Negotiated Rate	$748.00
Max. Negotiated Rate	$853.60
Rate for Payer: Cash Price	$528.00
Rate for Payer: Health Management Network Commercial	$748.00
Rate for Payer: Kaiser Permanente Commercial	$792.00
Rate for Payer: MDX Hawaii PPO	$853.60

BATTERY INTERSTIM II IPG 97800

Facility

$24,528.00

Service Code	HCPCS C1767
Hospital Revenue Code	278
Min. Negotiated Rate	$12,264.00
Max. Negotiated Rate	$23,792.16
Rate for Payer: AlohaCare Medicaid	$12,264.00
Rate for Payer: AlohaCare Medicare	$18,641.28
Rate for Payer: Cash Price	$14,716.80
Rate for Payer: Devoted Health Medicare	$20,603.52
Rate for Payer: Hawaii Medical Service Association Medicare	$18,641.28
Rate for Payer: Hawaii Western Management Group Commercial	$17,169.60
Rate for Payer: Health Management Network Commercial	$20,848.80
Rate for Payer: Humana Medicare	$18,641.28
Rate for Payer: Kaiser Permanente Commercial	$22,075.20
Rate for Payer: Kaiser Permanente Medicaid	$12,509.28
Rate for Payer: Kaiser Permanente Medicare	$18,641.28
Rate for Payer: MDX Hawaii PPO	$23,792.16
Rate for Payer: Ohana Health Plan Medicaid	$18,641.28
Rate for Payer: Ohana Health Plan Medicare	$18,641.28
Rate for Payer: UnitedHealthcare Medicare	$18,641.28
Rate for Payer: University Health Alliance Commercial	$13,735.68

BATTERY INTERSTIM II IPG 97800

Facility

$24,528.00

Service Code	HCPCS C1767
Hospital Revenue Code	278
Min. Negotiated Rate	$13,735.68
Max. Negotiated Rate	$23,792.16
Rate for Payer: Cash Price	$14,716.80
Rate for Payer: Hawaii Western Management Group Commercial	$17,169.60
Rate for Payer: Health Management Network Commercial	$20,848.80
Rate for Payer: Kaiser Permanente Commercial	$22,075.20
Rate for Payer: MDX Hawaii PPO	$23,792.16
Rate for Payer: University Health Alliance Commercial	$13,735.68

BAYONET FORCEP 6.25IN BIPOLAR

Facility

$229.00

Hospital Revenue Code	272
Min. Negotiated Rate	$114.50
Max. Negotiated Rate	$222.13
Rate for Payer: AlohaCare Medicaid	$114.50
Rate for Payer: AlohaCare Medicare	$174.04
Rate for Payer: Cash Price	$137.40
Rate for Payer: Devoted Health Medicare	$192.36
Rate for Payer: Hawaii Medical Service Association Medicare	$174.04
Rate for Payer: Hawaii Western Management Group Commercial	$217.55
Rate for Payer: Health Management Network Commercial	$194.65
Rate for Payer: Humana Medicare	$174.04
Rate for Payer: Kaiser Permanente Commercial	$206.10
Rate for Payer: Kaiser Permanente Medicaid	$116.79
Rate for Payer: Kaiser Permanente Medicare	$174.04
Rate for Payer: MDX Hawaii PPO	$222.13
Rate for Payer: Ohana Health Plan Medicaid	$174.04
Rate for Payer: Ohana Health Plan Medicare	$174.04
Rate for Payer: UnitedHealthcare Medicare	$174.04
Rate for Payer: University Health Alliance Commercial	$166.92

BAYONET FORCEP 6.25IN BIPOLAR

Facility

$229.00

Hospital Revenue Code	272
Min. Negotiated Rate	$194.65
Max. Negotiated Rate	$222.13
Rate for Payer: Cash Price	$137.40
Rate for Payer: Health Management Network Commercial	$194.65
Rate for Payer: Kaiser Permanente Commercial	$206.10
Rate for Payer: MDX Hawaii PPO	$222.13

BCG LIVE 50 MG INTRAVESICAL SUSPENSION [21570]

Facility

$328.00

Service Code	HCPCS J9030
Hospital Revenue Code	636
Min. Negotiated Rate	$3.12
Max. Negotiated Rate	$318.16
Rate for Payer: AlohaCare Medicaid	$164.00
Rate for Payer: AlohaCare Medicare	$249.28
Rate for Payer: Cash Price	$196.80
Rate for Payer: Cash Price	$196.80
Rate for Payer: Devoted Health Medicare	$275.52
Rate for Payer: Hawaii Medical Service Association ABD	$3.12
Rate for Payer: Hawaii Medical Service Association Commercial	$4.24
Rate for Payer: Hawaii Medical Service Association Medicare	$249.28
Rate for Payer: Hawaii Medical Service Association Non-ABD	$3.12
Rate for Payer: Hawaii Western Management Group Commercial	$311.60
Rate for Payer: Health Management Network Commercial	$278.80
Rate for Payer: Humana Medicare	$249.28
Rate for Payer: Kaiser Permanente Commercial	$295.20
Rate for Payer: Kaiser Permanente Medicaid	$167.28
Rate for Payer: Kaiser Permanente Medicare	$249.28
Rate for Payer: MDX Hawaii PPO	$318.16
Rate for Payer: Ohana Health Plan Medicaid	$249.28
Rate for Payer: Ohana Health Plan Medicare	$249.28
Rate for Payer: UnitedHealthcare Medicaid	$196.80
Rate for Payer: UnitedHealthcare Medicare	$249.28
Rate for Payer: University Health Alliance Commercial	$239.08

BCG LIVE 50 MG INTRAVESICAL SUSPENSION [21570]

Facility

$328.00

Service Code	HCPCS J9030
Hospital Revenue Code	250
Min. Negotiated Rate	$278.80
Max. Negotiated Rate	$318.16
Rate for Payer: Cash Price	$196.80
Rate for Payer: Health Management Network Commercial	$278.80
Rate for Payer: Kaiser Permanente Commercial	$295.20
Rate for Payer: MDX Hawaii PPO	$318.16

BCG LIVE 50 MG/ML (WET IS SUSR VIAL) [43021570]

Facility

$328.00

Service Code	HCPCS J9030
Hospital Revenue Code	636
Min. Negotiated Rate	$3.12
Max. Negotiated Rate	$318.16
Rate for Payer: AlohaCare Medicaid	$164.00
Rate for Payer: AlohaCare Medicare	$249.28
Rate for Payer: Cash Price	$196.80
Rate for Payer: Cash Price	$196.80
Rate for Payer: Devoted Health Medicare	$275.52
Rate for Payer: Hawaii Medical Service Association ABD	$3.12
Rate for Payer: Hawaii Medical Service Association Commercial	$4.24
Rate for Payer: Hawaii Medical Service Association Medicare	$249.28
Rate for Payer: Hawaii Medical Service Association Non-ABD	$3.12
Rate for Payer: Hawaii Western Management Group Commercial	$311.60
Rate for Payer: Health Management Network Commercial	$278.80
Rate for Payer: Humana Medicare	$249.28
Rate for Payer: Kaiser Permanente Commercial	$295.20
Rate for Payer: Kaiser Permanente Medicaid	$167.28
Rate for Payer: Kaiser Permanente Medicare	$249.28
Rate for Payer: MDX Hawaii PPO	$318.16
Rate for Payer: Ohana Health Plan Medicaid	$249.28
Rate for Payer: Ohana Health Plan Medicare	$249.28
Rate for Payer: UnitedHealthcare Medicaid	$196.80
Rate for Payer: UnitedHealthcare Medicare	$249.28
Rate for Payer: University Health Alliance Commercial	$239.08

BCG LIVE 50 MG/ML (WET IS SUSR VIAL) [43021570]

Facility

$328.00

Service Code	HCPCS J9030
Hospital Revenue Code	250
Min. Negotiated Rate	$278.80
Max. Negotiated Rate	$318.16
Rate for Payer: Cash Price	$196.80
Rate for Payer: Health Management Network Commercial	$278.80
Rate for Payer: Kaiser Permanente Commercial	$295.20
Rate for Payer: MDX Hawaii PPO	$318.16

BEARING INSERT PS 5532-G-609-E

Facility

$2,676.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$1,338.00
Max. Negotiated Rate	$2,595.72
Rate for Payer: AlohaCare Medicaid	$1,338.00
Rate for Payer: AlohaCare Medicare	$2,033.76
Rate for Payer: Cash Price	$1,605.60
Rate for Payer: Devoted Health Medicare	$2,247.84
Rate for Payer: Hawaii Medical Service Association Medicare	$2,033.76
Rate for Payer: Hawaii Western Management Group Commercial	$1,873.20
Rate for Payer: Health Management Network Commercial	$2,274.60
Rate for Payer: Humana Medicare	$2,033.76
Rate for Payer: Kaiser Permanente Commercial	$2,408.40
Rate for Payer: Kaiser Permanente Medicaid	$1,364.76
Rate for Payer: Kaiser Permanente Medicare	$2,033.76
Rate for Payer: MDX Hawaii PPO	$2,595.72
Rate for Payer: Ohana Health Plan Medicaid	$2,033.76
Rate for Payer: Ohana Health Plan Medicare	$2,033.76
Rate for Payer: UnitedHealthcare Medicare	$2,033.76
Rate for Payer: University Health Alliance Commercial	$1,498.56

BEARING INSERT PS 5532-G-609-E

Facility

$2,676.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$1,498.56
Max. Negotiated Rate	$2,595.72
Rate for Payer: Cash Price	$1,605.60
Rate for Payer: Hawaii Western Management Group Commercial	$1,873.20
Rate for Payer: Health Management Network Commercial	$2,274.60
Rate for Payer: Kaiser Permanente Commercial	$2,408.40
Rate for Payer: MDX Hawaii PPO	$2,595.72
Rate for Payer: University Health Alliance Commercial	$1,498.56

BEARING INSERTR 42-5299-003-01

Facility

$328.00

Hospital Revenue Code	272
Min. Negotiated Rate	$164.00
Max. Negotiated Rate	$318.16
Rate for Payer: AlohaCare Medicaid	$164.00
Rate for Payer: AlohaCare Medicare	$249.28
Rate for Payer: Cash Price	$196.80
Rate for Payer: Devoted Health Medicare	$275.52
Rate for Payer: Hawaii Medical Service Association Medicare	$249.28
Rate for Payer: Hawaii Western Management Group Commercial	$311.60
Rate for Payer: Health Management Network Commercial	$278.80
Rate for Payer: Humana Medicare	$249.28
Rate for Payer: Kaiser Permanente Commercial	$295.20
Rate for Payer: Kaiser Permanente Medicaid	$167.28
Rate for Payer: Kaiser Permanente Medicare	$249.28
Rate for Payer: MDX Hawaii PPO	$318.16
Rate for Payer: Ohana Health Plan Medicaid	$249.28
Rate for Payer: Ohana Health Plan Medicare	$249.28
Rate for Payer: UnitedHealthcare Medicare	$249.28
Rate for Payer: University Health Alliance Commercial	$239.08

BEARING INSERTR 42-5299-003-01

Facility

$328.00

Hospital Revenue Code	272
Min. Negotiated Rate	$278.80
Max. Negotiated Rate	$318.16
Rate for Payer: Cash Price	$196.80
Rate for Payer: Health Management Network Commercial	$278.80
Rate for Payer: Kaiser Permanente Commercial	$295.20
Rate for Payer: MDX Hawaii PPO	$318.16

BEARING INSERT SZ.3 5532-G-309

Facility

$2,703.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$1,351.50
Max. Negotiated Rate	$2,621.91
Rate for Payer: AlohaCare Medicaid	$1,351.50
Rate for Payer: AlohaCare Medicare	$2,054.28
Rate for Payer: Cash Price	$1,621.80
Rate for Payer: Devoted Health Medicare	$2,270.52
Rate for Payer: Hawaii Medical Service Association Medicare	$2,054.28
Rate for Payer: Hawaii Western Management Group Commercial	$1,892.10
Rate for Payer: Health Management Network Commercial	$2,297.55
Rate for Payer: Humana Medicare	$2,054.28
Rate for Payer: Kaiser Permanente Commercial	$2,432.70
Rate for Payer: Kaiser Permanente Medicaid	$1,378.53
Rate for Payer: Kaiser Permanente Medicare	$2,054.28
Rate for Payer: MDX Hawaii PPO	$2,621.91
Rate for Payer: Ohana Health Plan Medicaid	$2,054.28
Rate for Payer: Ohana Health Plan Medicare	$2,054.28
Rate for Payer: UnitedHealthcare Medicare	$2,054.28
Rate for Payer: University Health Alliance Commercial	$1,513.68

BEARING INSERT SZ.3 5532-G-309

Facility

$2,703.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$1,513.68
Max. Negotiated Rate	$2,621.91
Rate for Payer: Cash Price	$1,621.80
Rate for Payer: Hawaii Western Management Group Commercial	$1,892.10
Rate for Payer: Health Management Network Commercial	$2,297.55
Rate for Payer: Kaiser Permanente Commercial	$2,432.70
Rate for Payer: MDX Hawaii PPO	$2,621.91
Rate for Payer: University Health Alliance Commercial	$1,513.68

BEARING INSERT SZ.5 5531-G-511

Facility

$7,716.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$3,858.00
Max. Negotiated Rate	$7,484.52
Rate for Payer: AlohaCare Medicaid	$3,858.00
Rate for Payer: AlohaCare Medicare	$5,864.16
Rate for Payer: Cash Price	$4,629.60
Rate for Payer: Devoted Health Medicare	$6,481.44
Rate for Payer: Hawaii Medical Service Association Medicare	$5,864.16
Rate for Payer: Hawaii Western Management Group Commercial	$5,401.20
Rate for Payer: Health Management Network Commercial	$6,558.60
Rate for Payer: Humana Medicare	$5,864.16
Rate for Payer: Kaiser Permanente Commercial	$6,944.40
Rate for Payer: Kaiser Permanente Medicaid	$3,935.16
Rate for Payer: Kaiser Permanente Medicare	$5,864.16
Rate for Payer: MDX Hawaii PPO	$7,484.52
Rate for Payer: Ohana Health Plan Medicaid	$5,864.16
Rate for Payer: Ohana Health Plan Medicare	$5,864.16
Rate for Payer: UnitedHealthcare Medicare	$5,864.16
Rate for Payer: University Health Alliance Commercial	$4,320.96

BEARING INSERT SZ.5 5531-G-511

Facility

$7,716.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$4,320.96
Max. Negotiated Rate	$7,484.52
Rate for Payer: Cash Price	$4,629.60
Rate for Payer: Hawaii Western Management Group Commercial	$5,401.20
Rate for Payer: Health Management Network Commercial	$6,558.60
Rate for Payer: Kaiser Permanente Commercial	$6,944.40
Rate for Payer: MDX Hawaii PPO	$7,484.52
Rate for Payer: University Health Alliance Commercial	$4,320.96

BEARING INSERT X3 5530-G-711

Facility

$7,316.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$4,096.96
Max. Negotiated Rate	$7,096.52
Rate for Payer: Cash Price	$4,389.60
Rate for Payer: Hawaii Western Management Group Commercial	$5,121.20
Rate for Payer: Health Management Network Commercial	$6,218.60
Rate for Payer: Kaiser Permanente Commercial	$6,584.40
Rate for Payer: MDX Hawaii PPO	$7,096.52
Rate for Payer: University Health Alliance Commercial	$4,096.96

BEARING INSERT X3 5530-G-711

Facility

$7,316.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$3,658.00
Max. Negotiated Rate	$7,096.52
Rate for Payer: AlohaCare Medicaid	$3,658.00
Rate for Payer: AlohaCare Medicare	$5,560.16
Rate for Payer: Cash Price	$4,389.60
Rate for Payer: Devoted Health Medicare	$6,145.44
Rate for Payer: Hawaii Medical Service Association Medicare	$5,560.16
Rate for Payer: Hawaii Western Management Group Commercial	$5,121.20
Rate for Payer: Health Management Network Commercial	$6,218.60
Rate for Payer: Humana Medicare	$5,560.16
Rate for Payer: Kaiser Permanente Commercial	$6,584.40
Rate for Payer: Kaiser Permanente Medicaid	$3,731.16
Rate for Payer: Kaiser Permanente Medicare	$5,560.16
Rate for Payer: MDX Hawaii PPO	$7,096.52
Rate for Payer: Ohana Health Plan Medicaid	$5,560.16
Rate for Payer: Ohana Health Plan Medicare	$5,560.16
Rate for Payer: UnitedHealthcare Medicare	$5,560.16
Rate for Payer: University Health Alliance Commercial	$4,096.96

BEARING INSERT X3 5532-G-414-E

Facility

$2,676.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$1,338.00
Max. Negotiated Rate	$2,595.72
Rate for Payer: AlohaCare Medicaid	$1,338.00
Rate for Payer: AlohaCare Medicare	$2,033.76
Rate for Payer: Cash Price	$1,605.60
Rate for Payer: Devoted Health Medicare	$2,247.84
Rate for Payer: Hawaii Medical Service Association Medicare	$2,033.76
Rate for Payer: Hawaii Western Management Group Commercial	$1,873.20
Rate for Payer: Health Management Network Commercial	$2,274.60
Rate for Payer: Humana Medicare	$2,033.76
Rate for Payer: Kaiser Permanente Commercial	$2,408.40
Rate for Payer: Kaiser Permanente Medicaid	$1,364.76
Rate for Payer: Kaiser Permanente Medicare	$2,033.76
Rate for Payer: MDX Hawaii PPO	$2,595.72
Rate for Payer: Ohana Health Plan Medicaid	$2,033.76
Rate for Payer: Ohana Health Plan Medicare	$2,033.76
Rate for Payer: UnitedHealthcare Medicare	$2,033.76
Rate for Payer: University Health Alliance Commercial	$1,498.56

Know your out-of-pocket cost for care.

All Charges