Honoka'a Hospital and Skilled Nursing Facility

All Charges

Charge

Type

Setting

Price

NATRELLE INSPIRA 110 SCL-110

Facility

$2,190.00

Service Code	HCPCS C1789
Hospital Revenue Code	278
Min. Negotiated Rate	$1,226.40
Max. Negotiated Rate	$2,124.30
Rate for Payer: Cash Price	$1,314.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,533.00
Rate for Payer: Health Management Network Commercial	$1,861.50
Rate for Payer: Kaiser Permanente Commercial	$1,971.00
Rate for Payer: MDX Hawaii PPO	$2,124.30
Rate for Payer: University Health Alliance Commercial	$1,226.40

NATRELLE INSPIRA 110 SCL-110

Facility

$2,190.00

Service Code	HCPCS C1789
Hospital Revenue Code	278
Min. Negotiated Rate	$1,095.00
Max. Negotiated Rate	$2,124.30
Rate for Payer: AlohaCare Medicaid	$1,095.00
Rate for Payer: AlohaCare Medicare	$1,664.40
Rate for Payer: Cash Price	$1,314.00
Rate for Payer: Devoted Health Medicare	$1,839.60
Rate for Payer: Hawaii Medical Service Association Medicare	$1,664.40
Rate for Payer: Hawaii Western Management Group Commercial	$1,533.00
Rate for Payer: Health Management Network Commercial	$1,861.50
Rate for Payer: Humana Medicare	$1,664.40
Rate for Payer: Kaiser Permanente Commercial	$1,971.00
Rate for Payer: Kaiser Permanente Medicaid	$1,116.90
Rate for Payer: Kaiser Permanente Medicare	$1,664.40
Rate for Payer: MDX Hawaii PPO	$2,124.30
Rate for Payer: Ohana Health Plan Medicaid	$1,664.40
Rate for Payer: Ohana Health Plan Medicare	$1,664.40
Rate for Payer: UnitedHealthcare Medicare	$1,664.40
Rate for Payer: University Health Alliance Commercial	$1,226.40

NATRELLE SALINE-FILLED 420MM

Facility

$1,050.00

Service Code	HCPCS C1789
Hospital Revenue Code	278
Min. Negotiated Rate	$588.00
Max. Negotiated Rate	$1,018.50
Rate for Payer: Cash Price	$630.00
Rate for Payer: Hawaii Western Management Group Commercial	$735.00
Rate for Payer: Health Management Network Commercial	$892.50
Rate for Payer: Kaiser Permanente Commercial	$945.00
Rate for Payer: MDX Hawaii PPO	$1,018.50
Rate for Payer: University Health Alliance Commercial	$588.00

NATRELLE SALINE-FILLED 420MM

Facility

$1,050.00

Service Code	HCPCS C1789
Hospital Revenue Code	278
Min. Negotiated Rate	$525.00
Max. Negotiated Rate	$1,018.50
Rate for Payer: AlohaCare Medicaid	$525.00
Rate for Payer: AlohaCare Medicare	$798.00
Rate for Payer: Cash Price	$630.00
Rate for Payer: Devoted Health Medicare	$882.00
Rate for Payer: Hawaii Medical Service Association Medicare	$798.00
Rate for Payer: Hawaii Western Management Group Commercial	$735.00
Rate for Payer: Health Management Network Commercial	$892.50
Rate for Payer: Humana Medicare	$798.00
Rate for Payer: Kaiser Permanente Commercial	$945.00
Rate for Payer: Kaiser Permanente Medicaid	$535.50
Rate for Payer: Kaiser Permanente Medicare	$798.00
Rate for Payer: MDX Hawaii PPO	$1,018.50
Rate for Payer: Ohana Health Plan Medicaid	$798.00
Rate for Payer: Ohana Health Plan Medicare	$798.00
Rate for Payer: UnitedHealthcare Medicare	$798.00
Rate for Payer: University Health Alliance Commercial	$588.00

NATRELLE SALINE-FILLED 800CC

Facility

$1,050.00

Service Code	HCPCS C1789
Hospital Revenue Code	278
Min. Negotiated Rate	$588.00
Max. Negotiated Rate	$1,018.50
Rate for Payer: Cash Price	$630.00
Rate for Payer: Hawaii Western Management Group Commercial	$735.00
Rate for Payer: Health Management Network Commercial	$892.50
Rate for Payer: Kaiser Permanente Commercial	$945.00
Rate for Payer: MDX Hawaii PPO	$1,018.50
Rate for Payer: University Health Alliance Commercial	$588.00

NATRELLE SALINE-FILLED 800CC

Facility

$1,050.00

Service Code	HCPCS C1789
Hospital Revenue Code	278
Min. Negotiated Rate	$525.00
Max. Negotiated Rate	$1,018.50
Rate for Payer: AlohaCare Medicaid	$525.00
Rate for Payer: AlohaCare Medicare	$798.00
Rate for Payer: Cash Price	$630.00
Rate for Payer: Devoted Health Medicare	$882.00
Rate for Payer: Hawaii Medical Service Association Medicare	$798.00
Rate for Payer: Hawaii Western Management Group Commercial	$735.00
Rate for Payer: Health Management Network Commercial	$892.50
Rate for Payer: Humana Medicare	$798.00
Rate for Payer: Kaiser Permanente Commercial	$945.00
Rate for Payer: Kaiser Permanente Medicaid	$535.50
Rate for Payer: Kaiser Permanente Medicare	$798.00
Rate for Payer: MDX Hawaii PPO	$1,018.50
Rate for Payer: Ohana Health Plan Medicaid	$798.00
Rate for Payer: Ohana Health Plan Medicare	$798.00
Rate for Payer: UnitedHealthcare Medicare	$798.00
Rate for Payer: University Health Alliance Commercial	$588.00

NATRELLE SIZER 550CC

Facility

$175.00

Service Code	HCPCS C1789
Hospital Revenue Code	278
Min. Negotiated Rate	$98.00
Max. Negotiated Rate	$169.75
Rate for Payer: Cash Price	$105.00
Rate for Payer: Hawaii Western Management Group Commercial	$122.50
Rate for Payer: Health Management Network Commercial	$148.75
Rate for Payer: Kaiser Permanente Commercial	$157.50
Rate for Payer: MDX Hawaii PPO	$169.75
Rate for Payer: University Health Alliance Commercial	$98.00

NATRELLE SIZER 550CC

Facility

$175.00

Service Code	HCPCS C1789
Hospital Revenue Code	278
Min. Negotiated Rate	$87.50
Max. Negotiated Rate	$169.75
Rate for Payer: AlohaCare Medicaid	$87.50
Rate for Payer: AlohaCare Medicare	$133.00
Rate for Payer: Cash Price	$105.00
Rate for Payer: Devoted Health Medicare	$147.00
Rate for Payer: Hawaii Medical Service Association Medicare	$133.00
Rate for Payer: Hawaii Western Management Group Commercial	$122.50
Rate for Payer: Health Management Network Commercial	$148.75
Rate for Payer: Humana Medicare	$133.00
Rate for Payer: Kaiser Permanente Commercial	$157.50
Rate for Payer: Kaiser Permanente Medicaid	$89.25
Rate for Payer: Kaiser Permanente Medicare	$133.00
Rate for Payer: MDX Hawaii PPO	$169.75
Rate for Payer: Ohana Health Plan Medicaid	$133.00
Rate for Payer: Ohana Health Plan Medicare	$133.00
Rate for Payer: UnitedHealthcare Medicare	$133.00
Rate for Payer: University Health Alliance Commercial	$98.00

NATRELLE STY SALINE 68HP-700

Facility

$1,050.00

Service Code	HCPCS C1789
Hospital Revenue Code	278
Min. Negotiated Rate	$588.00
Max. Negotiated Rate	$1,018.50
Rate for Payer: Cash Price	$630.00
Rate for Payer: Hawaii Western Management Group Commercial	$735.00
Rate for Payer: Health Management Network Commercial	$892.50
Rate for Payer: Kaiser Permanente Commercial	$945.00
Rate for Payer: MDX Hawaii PPO	$1,018.50
Rate for Payer: University Health Alliance Commercial	$588.00

NATRELLE STY SALINE 68HP-700

Facility

$1,050.00

Service Code	HCPCS C1789
Hospital Revenue Code	278
Min. Negotiated Rate	$525.00
Max. Negotiated Rate	$1,018.50
Rate for Payer: AlohaCare Medicaid	$525.00
Rate for Payer: AlohaCare Medicare	$798.00
Rate for Payer: Cash Price	$630.00
Rate for Payer: Devoted Health Medicare	$882.00
Rate for Payer: Hawaii Medical Service Association Medicare	$798.00
Rate for Payer: Hawaii Western Management Group Commercial	$735.00
Rate for Payer: Health Management Network Commercial	$892.50
Rate for Payer: Humana Medicare	$798.00
Rate for Payer: Kaiser Permanente Commercial	$945.00
Rate for Payer: Kaiser Permanente Medicaid	$535.50
Rate for Payer: Kaiser Permanente Medicare	$798.00
Rate for Payer: MDX Hawaii PPO	$1,018.50
Rate for Payer: Ohana Health Plan Medicaid	$798.00
Rate for Payer: Ohana Health Plan Medicare	$798.00
Rate for Payer: UnitedHealthcare Medicare	$798.00
Rate for Payer: University Health Alliance Commercial	$588.00

NATRELLE STY SALINE 68HP-800

Facility

$1,050.00

Service Code	HCPCS C1789
Hospital Revenue Code	278
Min. Negotiated Rate	$525.00
Max. Negotiated Rate	$1,018.50
Rate for Payer: AlohaCare Medicaid	$525.00
Rate for Payer: AlohaCare Medicare	$798.00
Rate for Payer: Cash Price	$630.00
Rate for Payer: Devoted Health Medicare	$882.00
Rate for Payer: Hawaii Medical Service Association Medicare	$798.00
Rate for Payer: Hawaii Western Management Group Commercial	$735.00
Rate for Payer: Health Management Network Commercial	$892.50
Rate for Payer: Humana Medicare	$798.00
Rate for Payer: Kaiser Permanente Commercial	$945.00
Rate for Payer: Kaiser Permanente Medicaid	$535.50
Rate for Payer: Kaiser Permanente Medicare	$798.00
Rate for Payer: MDX Hawaii PPO	$1,018.50
Rate for Payer: Ohana Health Plan Medicaid	$798.00
Rate for Payer: Ohana Health Plan Medicare	$798.00
Rate for Payer: UnitedHealthcare Medicare	$798.00
Rate for Payer: University Health Alliance Commercial	$588.00

NATRELLE STY SALINE 68HP-800

Facility

$1,050.00

Service Code	HCPCS C1789
Hospital Revenue Code	278
Min. Negotiated Rate	$588.00
Max. Negotiated Rate	$1,018.50
Rate for Payer: Cash Price	$630.00
Rate for Payer: Hawaii Western Management Group Commercial	$735.00
Rate for Payer: Health Management Network Commercial	$892.50
Rate for Payer: Kaiser Permanente Commercial	$945.00
Rate for Payer: MDX Hawaii PPO	$1,018.50
Rate for Payer: University Health Alliance Commercial	$588.00

NATURELLE STY SALINE 684HP-500

Facility

$1,050.00

Service Code	HCPCS C1789
Hospital Revenue Code	278
Min. Negotiated Rate	$525.00
Max. Negotiated Rate	$1,018.50
Rate for Payer: AlohaCare Medicaid	$525.00
Rate for Payer: AlohaCare Medicare	$798.00
Rate for Payer: Cash Price	$630.00
Rate for Payer: Devoted Health Medicare	$882.00
Rate for Payer: Hawaii Medical Service Association Medicare	$798.00
Rate for Payer: Hawaii Western Management Group Commercial	$735.00
Rate for Payer: Health Management Network Commercial	$892.50
Rate for Payer: Humana Medicare	$798.00
Rate for Payer: Kaiser Permanente Commercial	$945.00
Rate for Payer: Kaiser Permanente Medicaid	$535.50
Rate for Payer: Kaiser Permanente Medicare	$798.00
Rate for Payer: MDX Hawaii PPO	$1,018.50
Rate for Payer: Ohana Health Plan Medicaid	$798.00
Rate for Payer: Ohana Health Plan Medicare	$798.00
Rate for Payer: UnitedHealthcare Medicare	$798.00
Rate for Payer: University Health Alliance Commercial	$588.00

NATURELLE STY SALINE 684HP-500

Facility

$1,050.00

Service Code	HCPCS C1789
Hospital Revenue Code	278
Min. Negotiated Rate	$588.00
Max. Negotiated Rate	$1,018.50
Rate for Payer: Cash Price	$630.00
Rate for Payer: Hawaii Western Management Group Commercial	$735.00
Rate for Payer: Health Management Network Commercial	$892.50
Rate for Payer: Kaiser Permanente Commercial	$945.00
Rate for Payer: MDX Hawaii PPO	$1,018.50
Rate for Payer: University Health Alliance Commercial	$588.00

NEBIVOLOL 5 MG TABLET [89284]

Facility

$13.00

Service Code	NDC 60687064121
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

NEBIVOLOL 5 MG TABLET [89284]

Facility

$13.00

Service Code	NDC 60687064111
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

NEBIVOLOL 5 MG TABLET [89284]

Facility

$13.00

Service Code	NDC 60687064111
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

NEBIVOLOL 5 MG TABLET [89284]

Facility

$13.00

Service Code	NDC 60687064121
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

NEEDLE 10X3.25 DECOMPRESSION

Facility

$108.00

Hospital Revenue Code	272
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

NEEDLE 10X3.25 DECOMPRESSION

Facility

$108.00

Hospital Revenue Code	272
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

NEEDLE 14G BIOPSY SOFT TISSUE

Facility

$96.00

Hospital Revenue Code	272
Min. Negotiated Rate	$48.00
Max. Negotiated Rate	$93.12
Rate for Payer: AlohaCare Medicaid	$48.00
Rate for Payer: AlohaCare Medicare	$72.96
Rate for Payer: Cash Price	$57.60
Rate for Payer: Devoted Health Medicare	$80.64
Rate for Payer: Hawaii Medical Service Association Medicare	$72.96
Rate for Payer: Hawaii Western Management Group Commercial	$91.20
Rate for Payer: Health Management Network Commercial	$81.60
Rate for Payer: Humana Medicare	$72.96
Rate for Payer: Kaiser Permanente Commercial	$86.40
Rate for Payer: Kaiser Permanente Medicaid	$48.96
Rate for Payer: Kaiser Permanente Medicare	$72.96
Rate for Payer: MDX Hawaii PPO	$93.12
Rate for Payer: Ohana Health Plan Medicaid	$72.96
Rate for Payer: Ohana Health Plan Medicare	$72.96
Rate for Payer: UnitedHealthcare Medicare	$72.96
Rate for Payer: University Health Alliance Commercial	$69.97

NEEDLE 14G BIOPSY SOFT TISSUE

Facility

$96.00

Hospital Revenue Code	272
Min. Negotiated Rate	$81.60
Max. Negotiated Rate	$93.12
Rate for Payer: Cash Price	$57.60
Rate for Payer: Health Management Network Commercial	$81.60
Rate for Payer: Kaiser Permanente Commercial	$86.40
Rate for Payer: MDX Hawaii PPO	$93.12

NEEDLE 14GX4.5 BIOPSY

Facility

$96.00

Hospital Revenue Code	272
Min. Negotiated Rate	$81.60
Max. Negotiated Rate	$93.12
Rate for Payer: Cash Price	$57.60
Rate for Payer: Health Management Network Commercial	$81.60
Rate for Payer: Kaiser Permanente Commercial	$86.40
Rate for Payer: MDX Hawaii PPO	$93.12

NEEDLE 14GX4.5 BIOPSY

Facility

$96.00

Hospital Revenue Code	272
Min. Negotiated Rate	$48.00
Max. Negotiated Rate	$93.12
Rate for Payer: AlohaCare Medicaid	$48.00
Rate for Payer: AlohaCare Medicare	$72.96
Rate for Payer: Cash Price	$57.60
Rate for Payer: Devoted Health Medicare	$80.64
Rate for Payer: Hawaii Medical Service Association Medicare	$72.96
Rate for Payer: Hawaii Western Management Group Commercial	$91.20
Rate for Payer: Health Management Network Commercial	$81.60
Rate for Payer: Humana Medicare	$72.96
Rate for Payer: Kaiser Permanente Commercial	$86.40
Rate for Payer: Kaiser Permanente Medicaid	$48.96
Rate for Payer: Kaiser Permanente Medicare	$72.96
Rate for Payer: MDX Hawaii PPO	$93.12
Rate for Payer: Ohana Health Plan Medicaid	$72.96
Rate for Payer: Ohana Health Plan Medicare	$72.96
Rate for Payer: UnitedHealthcare Medicare	$72.96
Rate for Payer: University Health Alliance Commercial	$69.97

NEEDLE 150MM INSUFFLATION

Facility

$89.00

Hospital Revenue Code	272
Min. Negotiated Rate	$75.65
Max. Negotiated Rate	$86.33
Rate for Payer: Cash Price	$53.40
Rate for Payer: Health Management Network Commercial	$75.65
Rate for Payer: Kaiser Permanente Commercial	$80.10
Rate for Payer: MDX Hawaii PPO	$86.33

Know your out-of-pocket cost for care.

All Charges