Honoka'a Hospital and Skilled Nursing Facility

All Charges

Charge

Type

Setting

Price

NOVASURE KIT NS2007

Facility

$7,320.00

Hospital Revenue Code	272
Min. Negotiated Rate	$3,660.00
Max. Negotiated Rate	$7,100.40
Rate for Payer: AlohaCare Medicaid	$3,660.00
Rate for Payer: AlohaCare Medicare	$5,563.20
Rate for Payer: Cash Price	$4,392.00
Rate for Payer: Devoted Health Medicare	$6,148.80
Rate for Payer: Hawaii Medical Service Association Medicare	$5,563.20
Rate for Payer: Hawaii Western Management Group Commercial	$6,954.00
Rate for Payer: Health Management Network Commercial	$6,222.00
Rate for Payer: Humana Medicare	$5,563.20
Rate for Payer: Kaiser Permanente Commercial	$6,588.00
Rate for Payer: Kaiser Permanente Medicaid	$3,733.20
Rate for Payer: Kaiser Permanente Medicare	$5,563.20
Rate for Payer: MDX Hawaii PPO	$7,100.40
Rate for Payer: Ohana Health Plan Medicaid	$5,563.20
Rate for Payer: Ohana Health Plan Medicare	$5,563.20
Rate for Payer: UnitedHealthcare Medicare	$5,563.20
Rate for Payer: University Health Alliance Commercial	$5,335.55

NOVASURE KIT #NSV5KITUS-003

Facility

$2,692.00

Service Code	HCPCS C1889
Hospital Revenue Code	272
Min. Negotiated Rate	$1,346.00
Max. Negotiated Rate	$2,611.24
Rate for Payer: AlohaCare Medicaid	$1,346.00
Rate for Payer: AlohaCare Medicare	$2,045.92
Rate for Payer: Cash Price	$1,615.20
Rate for Payer: Devoted Health Medicare	$2,261.28
Rate for Payer: Hawaii Medical Service Association Medicare	$2,045.92
Rate for Payer: Hawaii Western Management Group Commercial	$2,557.40
Rate for Payer: Health Management Network Commercial	$2,288.20
Rate for Payer: Humana Medicare	$2,045.92
Rate for Payer: Kaiser Permanente Commercial	$2,422.80
Rate for Payer: Kaiser Permanente Medicaid	$1,372.92
Rate for Payer: Kaiser Permanente Medicare	$2,045.92
Rate for Payer: MDX Hawaii PPO	$2,611.24
Rate for Payer: Ohana Health Plan Medicaid	$2,045.92
Rate for Payer: Ohana Health Plan Medicare	$2,045.92
Rate for Payer: UnitedHealthcare Medicare	$2,045.92
Rate for Payer: University Health Alliance Commercial	$1,962.20

NOVASURE KIT #NSV5KITUS-003

Facility

$2,692.00

Service Code	HCPCS C1889
Hospital Revenue Code	272
Min. Negotiated Rate	$2,288.20
Max. Negotiated Rate	$2,611.24
Rate for Payer: Cash Price	$1,615.20
Rate for Payer: Health Management Network Commercial	$2,288.20
Rate for Payer: Kaiser Permanente Commercial	$2,422.80
Rate for Payer: MDX Hawaii PPO	$2,611.24

NUCLEUS TI6AI1V SIZE 3 DWG403

Facility

$14,872.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$8,328.32
Max. Negotiated Rate	$14,425.84
Rate for Payer: Cash Price	$8,923.20
Rate for Payer: Hawaii Western Management Group Commercial	$10,410.40
Rate for Payer: Health Management Network Commercial	$12,641.20
Rate for Payer: Kaiser Permanente Commercial	$13,384.80
Rate for Payer: MDX Hawaii PPO	$14,425.84
Rate for Payer: University Health Alliance Commercial	$8,328.32

NUCLEUS TI6AI1V SIZE 3 DWG403

Facility

$14,872.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$7,436.00
Max. Negotiated Rate	$14,425.84
Rate for Payer: AlohaCare Medicaid	$7,436.00
Rate for Payer: AlohaCare Medicare	$11,302.72
Rate for Payer: Cash Price	$8,923.20
Rate for Payer: Devoted Health Medicare	$12,492.48
Rate for Payer: Hawaii Medical Service Association Medicare	$11,302.72
Rate for Payer: Hawaii Western Management Group Commercial	$10,410.40
Rate for Payer: Health Management Network Commercial	$12,641.20
Rate for Payer: Humana Medicare	$11,302.72
Rate for Payer: Kaiser Permanente Commercial	$13,384.80
Rate for Payer: Kaiser Permanente Medicaid	$7,584.72
Rate for Payer: Kaiser Permanente Medicare	$11,302.72
Rate for Payer: MDX Hawaii PPO	$14,425.84
Rate for Payer: Ohana Health Plan Medicaid	$11,302.72
Rate for Payer: Ohana Health Plan Medicare	$11,302.72
Rate for Payer: UnitedHealthcare Medicare	$11,302.72
Rate for Payer: University Health Alliance Commercial	$8,328.32

NUCLEUS TI6AI4V SIZE 1

Facility

$11,762.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$6,586.72
Max. Negotiated Rate	$11,409.14
Rate for Payer: Cash Price	$7,057.20
Rate for Payer: Hawaii Western Management Group Commercial	$8,233.40
Rate for Payer: Health Management Network Commercial	$9,997.70
Rate for Payer: Kaiser Permanente Commercial	$10,585.80
Rate for Payer: MDX Hawaii PPO	$11,409.14
Rate for Payer: University Health Alliance Commercial	$6,586.72

NUCLEUS TI6AI4V SIZE 1

Facility

$11,762.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$5,881.00
Max. Negotiated Rate	$11,409.14
Rate for Payer: AlohaCare Medicaid	$5,881.00
Rate for Payer: AlohaCare Medicare	$8,939.12
Rate for Payer: Cash Price	$7,057.20
Rate for Payer: Devoted Health Medicare	$9,880.08
Rate for Payer: Hawaii Medical Service Association Medicare	$8,939.12
Rate for Payer: Hawaii Western Management Group Commercial	$8,233.40
Rate for Payer: Health Management Network Commercial	$9,997.70
Rate for Payer: Humana Medicare	$8,939.12
Rate for Payer: Kaiser Permanente Commercial	$10,585.80
Rate for Payer: Kaiser Permanente Medicaid	$5,998.62
Rate for Payer: Kaiser Permanente Medicare	$8,939.12
Rate for Payer: MDX Hawaii PPO	$11,409.14
Rate for Payer: Ohana Health Plan Medicaid	$8,939.12
Rate for Payer: Ohana Health Plan Medicare	$8,939.12
Rate for Payer: UnitedHealthcare Medicare	$8,939.12
Rate for Payer: University Health Alliance Commercial	$6,586.72

NUCLEUS Ti6AI4V SZ 2 DWG402

Facility

$11,762.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$6,586.72
Max. Negotiated Rate	$11,409.14
Rate for Payer: Cash Price	$7,057.20
Rate for Payer: Hawaii Western Management Group Commercial	$8,233.40
Rate for Payer: Health Management Network Commercial	$9,997.70
Rate for Payer: Kaiser Permanente Commercial	$10,585.80
Rate for Payer: MDX Hawaii PPO	$11,409.14
Rate for Payer: University Health Alliance Commercial	$6,586.72

NUCLEUS Ti6AI4V SZ 2 DWG402

Facility

$11,762.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$5,881.00
Max. Negotiated Rate	$11,409.14
Rate for Payer: AlohaCare Medicaid	$5,881.00
Rate for Payer: AlohaCare Medicare	$8,939.12
Rate for Payer: Cash Price	$7,057.20
Rate for Payer: Devoted Health Medicare	$9,880.08
Rate for Payer: Hawaii Medical Service Association Medicare	$8,939.12
Rate for Payer: Hawaii Western Management Group Commercial	$8,233.40
Rate for Payer: Health Management Network Commercial	$9,997.70
Rate for Payer: Humana Medicare	$8,939.12
Rate for Payer: Kaiser Permanente Commercial	$10,585.80
Rate for Payer: Kaiser Permanente Medicaid	$5,998.62
Rate for Payer: Kaiser Permanente Medicare	$8,939.12
Rate for Payer: MDX Hawaii PPO	$11,409.14
Rate for Payer: Ohana Health Plan Medicaid	$8,939.12
Rate for Payer: Ohana Health Plan Medicare	$8,939.12
Rate for Payer: UnitedHealthcare Medicare	$8,939.12
Rate for Payer: University Health Alliance Commercial	$6,586.72

NURSE VISIT ONLY - FACILITY ONLY

Facility

$513.00

Service Code	HCPCS G0463
Hospital Charge Code	761G046302
Hospital Revenue Code	761
Min. Negotiated Rate	$436.05
Max. Negotiated Rate	$497.61
Rate for Payer: Cash Price	$307.80
Rate for Payer: Health Management Network Commercial	$436.05
Rate for Payer: Kaiser Permanente Commercial	$461.70
Rate for Payer: MDX Hawaii PPO	$497.61

NURSE VISIT ONLY - FACILITY ONLY

Facility

$513.00

Service Code	HCPCS G0463
Hospital Charge Code	761G046302
Hospital Revenue Code	761
Min. Negotiated Rate	$96.65
Max. Negotiated Rate	$497.61
Rate for Payer: AlohaCare Medicaid	$256.50
Rate for Payer: AlohaCare Medicare	$389.88
Rate for Payer: Cash Price	$307.80
Rate for Payer: Cash Price	$307.80
Rate for Payer: Devoted Health Medicare	$430.92
Rate for Payer: Hawaii Medical Service Association Commercial	$170.03
Rate for Payer: Hawaii Medical Service Association Medicare	$389.88
Rate for Payer: Hawaii Western Management Group Commercial	$487.35
Rate for Payer: Health Management Network Commercial	$436.05
Rate for Payer: Humana Medicare	$389.88
Rate for Payer: Kaiser Permanente Commercial	$461.70
Rate for Payer: Kaiser Permanente Medicaid	$261.63
Rate for Payer: Kaiser Permanente Medicare	$389.88
Rate for Payer: MDX Hawaii PPO	$497.61
Rate for Payer: Ohana Health Plan Medicaid	$389.88
Rate for Payer: Ohana Health Plan Medicare	$389.88
Rate for Payer: UnitedHealthcare Medicaid	$96.65
Rate for Payer: UnitedHealthcare Medicare	$389.88
Rate for Payer: University Health Alliance Commercial	$373.93

NUSHIELD NO-1440

Facility

$2,850.00

Service Code	HCPCS Q4160
Hospital Revenue Code	636
Min. Negotiated Rate	$2,422.50
Max. Negotiated Rate	$2,764.50
Rate for Payer: Cash Price	$1,710.00
Rate for Payer: Health Management Network Commercial	$2,422.50
Rate for Payer: Kaiser Permanente Commercial	$2,565.00
Rate for Payer: MDX Hawaii PPO	$2,764.50

NUSHIELD NO-1440

Facility

$2,850.00

Service Code	HCPCS Q4160
Hospital Revenue Code	636
Min. Negotiated Rate	$158.93
Max. Negotiated Rate	$2,764.50
Rate for Payer: AlohaCare Medicaid	$1,425.00
Rate for Payer: AlohaCare Medicare	$2,166.00
Rate for Payer: Cash Price	$1,710.00
Rate for Payer: Cash Price	$1,710.00
Rate for Payer: Devoted Health Medicare	$2,394.00
Rate for Payer: Hawaii Medical Service Association ABD	$530.00
Rate for Payer: Hawaii Medical Service Association Commercial	$158.93
Rate for Payer: Hawaii Medical Service Association Medicare	$2,166.00
Rate for Payer: Hawaii Medical Service Association Non-ABD	$530.00
Rate for Payer: Hawaii Western Management Group Commercial	$2,707.50
Rate for Payer: Health Management Network Commercial	$2,422.50
Rate for Payer: Humana Medicare	$2,166.00
Rate for Payer: Kaiser Permanente Commercial	$2,565.00
Rate for Payer: Kaiser Permanente Medicaid	$1,453.50
Rate for Payer: Kaiser Permanente Medicare	$2,166.00
Rate for Payer: MDX Hawaii PPO	$2,764.50
Rate for Payer: Ohana Health Plan Medicaid	$2,166.00
Rate for Payer: Ohana Health Plan Medicare	$2,166.00
Rate for Payer: UnitedHealthcare Medicaid	$1,710.00
Rate for Payer: UnitedHealthcare Medicare	$2,166.00
Rate for Payer: University Health Alliance Commercial	$2,077.36

NXGN GH 14MM 00-5964-050-14

Facility

$2,803.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$1,569.68
Max. Negotiated Rate	$2,718.91
Rate for Payer: Cash Price	$1,681.80
Rate for Payer: Hawaii Western Management Group Commercial	$1,962.10
Rate for Payer: Health Management Network Commercial	$2,382.55
Rate for Payer: Kaiser Permanente Commercial	$2,522.70
Rate for Payer: MDX Hawaii PPO	$2,718.91
Rate for Payer: University Health Alliance Commercial	$1,569.68

NXGN GH 14MM 00-5964-050-14

Facility

$2,803.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$1,401.50
Max. Negotiated Rate	$2,718.91
Rate for Payer: AlohaCare Medicaid	$1,401.50
Rate for Payer: AlohaCare Medicare	$2,130.28
Rate for Payer: Cash Price	$1,681.80
Rate for Payer: Devoted Health Medicare	$2,354.52
Rate for Payer: Hawaii Medical Service Association Medicare	$2,130.28
Rate for Payer: Hawaii Western Management Group Commercial	$1,962.10
Rate for Payer: Health Management Network Commercial	$2,382.55
Rate for Payer: Humana Medicare	$2,130.28
Rate for Payer: Kaiser Permanente Commercial	$2,522.70
Rate for Payer: Kaiser Permanente Medicaid	$1,429.53
Rate for Payer: Kaiser Permanente Medicare	$2,130.28
Rate for Payer: MDX Hawaii PPO	$2,718.91
Rate for Payer: Ohana Health Plan Medicaid	$2,130.28
Rate for Payer: Ohana Health Plan Medicare	$2,130.28
Rate for Payer: UnitedHealthcare Medicare	$2,130.28
Rate for Payer: University Health Alliance Commercial	$1,569.68

NXGN PATEL 32MM 00-5972-066-32

Facility

$3,288.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$1,841.28
Max. Negotiated Rate	$3,189.36
Rate for Payer: Cash Price	$1,972.80
Rate for Payer: Hawaii Western Management Group Commercial	$2,301.60
Rate for Payer: Health Management Network Commercial	$2,794.80
Rate for Payer: Kaiser Permanente Commercial	$2,959.20
Rate for Payer: MDX Hawaii PPO	$3,189.36
Rate for Payer: University Health Alliance Commercial	$1,841.28

NXGN PATEL 32MM 00-5972-066-32

Facility

$3,288.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$1,644.00
Max. Negotiated Rate	$3,189.36
Rate for Payer: AlohaCare Medicaid	$1,644.00
Rate for Payer: AlohaCare Medicare	$2,498.88
Rate for Payer: Cash Price	$1,972.80
Rate for Payer: Devoted Health Medicare	$2,761.92
Rate for Payer: Hawaii Medical Service Association Medicare	$2,498.88
Rate for Payer: Hawaii Western Management Group Commercial	$2,301.60
Rate for Payer: Health Management Network Commercial	$2,794.80
Rate for Payer: Humana Medicare	$2,498.88
Rate for Payer: Kaiser Permanente Commercial	$2,959.20
Rate for Payer: Kaiser Permanente Medicaid	$1,676.88
Rate for Payer: Kaiser Permanente Medicare	$2,498.88
Rate for Payer: MDX Hawaii PPO	$3,189.36
Rate for Payer: Ohana Health Plan Medicaid	$2,498.88
Rate for Payer: Ohana Health Plan Medicare	$2,498.88
Rate for Payer: UnitedHealthcare Medicare	$2,498.88
Rate for Payer: University Health Alliance Commercial	$1,841.28

NXGN PATEL 35MM 00-5972-066-35

Facility

$3,288.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$1,841.28
Max. Negotiated Rate	$3,189.36
Rate for Payer: Cash Price	$1,972.80
Rate for Payer: Hawaii Western Management Group Commercial	$2,301.60
Rate for Payer: Health Management Network Commercial	$2,794.80
Rate for Payer: Kaiser Permanente Commercial	$2,959.20
Rate for Payer: MDX Hawaii PPO	$3,189.36
Rate for Payer: University Health Alliance Commercial	$1,841.28

NXGN PATEL 35MM 00-5972-066-35

Facility

$3,288.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$1,644.00
Max. Negotiated Rate	$3,189.36
Rate for Payer: AlohaCare Medicaid	$1,644.00
Rate for Payer: AlohaCare Medicare	$2,498.88
Rate for Payer: Cash Price	$1,972.80
Rate for Payer: Devoted Health Medicare	$2,761.92
Rate for Payer: Hawaii Medical Service Association Medicare	$2,498.88
Rate for Payer: Hawaii Western Management Group Commercial	$2,301.60
Rate for Payer: Health Management Network Commercial	$2,794.80
Rate for Payer: Humana Medicare	$2,498.88
Rate for Payer: Kaiser Permanente Commercial	$2,959.20
Rate for Payer: Kaiser Permanente Medicaid	$1,676.88
Rate for Payer: Kaiser Permanente Medicare	$2,498.88
Rate for Payer: MDX Hawaii PPO	$3,189.36
Rate for Payer: Ohana Health Plan Medicaid	$2,498.88
Rate for Payer: Ohana Health Plan Medicare	$2,498.88
Rate for Payer: UnitedHealthcare Medicare	$2,498.88
Rate for Payer: University Health Alliance Commercial	$1,841.28

NYSTATIN 100,000 UNIT/GRAM TOPICAL CREAM [5749]

Facility

$62.00

Service Code	NDC 00713067815
Hospital Revenue Code	250
Min. Negotiated Rate	$52.70
Max. Negotiated Rate	$60.14
Rate for Payer: Cash Price	$37.20
Rate for Payer: Health Management Network Commercial	$52.70
Rate for Payer: Kaiser Permanente Commercial	$55.80
Rate for Payer: MDX Hawaii PPO	$60.14

NYSTATIN 100,000 UNIT/GRAM TOPICAL CREAM [5749]

Facility

$62.00

Service Code	NDC 00713067815
Hospital Revenue Code	637
Min. Negotiated Rate	$31.00
Max. Negotiated Rate	$60.14
Rate for Payer: AlohaCare Medicaid	$31.00
Rate for Payer: AlohaCare Medicare	$47.12
Rate for Payer: Cash Price	$37.20
Rate for Payer: Devoted Health Medicare	$52.08
Rate for Payer: Hawaii Medical Service Association Medicare	$47.12
Rate for Payer: Hawaii Western Management Group Commercial	$58.90
Rate for Payer: Health Management Network Commercial	$52.70
Rate for Payer: Humana Medicare	$47.12
Rate for Payer: Kaiser Permanente Commercial	$55.80
Rate for Payer: Kaiser Permanente Medicaid	$31.62
Rate for Payer: Kaiser Permanente Medicare	$47.12
Rate for Payer: MDX Hawaii PPO	$60.14
Rate for Payer: Ohana Health Plan Medicaid	$47.12
Rate for Payer: Ohana Health Plan Medicare	$47.12
Rate for Payer: UnitedHealthcare Medicare	$47.12
Rate for Payer: University Health Alliance Commercial	$45.19

NYSTATIN 100,000 UNIT/GRAM TOPICAL OINTMENT [5750]

Facility

$59.00

Service Code	NDC 72578008901
Hospital Revenue Code	637
Min. Negotiated Rate	$29.50
Max. Negotiated Rate	$57.23
Rate for Payer: AlohaCare Medicaid	$29.50
Rate for Payer: AlohaCare Medicare	$44.84
Rate for Payer: Cash Price	$35.40
Rate for Payer: Devoted Health Medicare	$49.56
Rate for Payer: Hawaii Medical Service Association Medicare	$44.84
Rate for Payer: Hawaii Western Management Group Commercial	$56.05
Rate for Payer: Health Management Network Commercial	$50.15
Rate for Payer: Humana Medicare	$44.84
Rate for Payer: Kaiser Permanente Commercial	$53.10
Rate for Payer: Kaiser Permanente Medicaid	$30.09
Rate for Payer: Kaiser Permanente Medicare	$44.84
Rate for Payer: MDX Hawaii PPO	$57.23
Rate for Payer: Ohana Health Plan Medicaid	$44.84
Rate for Payer: Ohana Health Plan Medicare	$44.84
Rate for Payer: UnitedHealthcare Medicare	$44.84
Rate for Payer: University Health Alliance Commercial	$43.01

NYSTATIN 100,000 UNIT/GRAM TOPICAL OINTMENT [5750]

Facility

$59.00

Service Code	NDC 72578008901
Hospital Revenue Code	250
Min. Negotiated Rate	$50.15
Max. Negotiated Rate	$57.23
Rate for Payer: Cash Price	$35.40
Rate for Payer: Health Management Network Commercial	$50.15
Rate for Payer: Kaiser Permanente Commercial	$53.10
Rate for Payer: MDX Hawaii PPO	$57.23

NYSTATIN 100,000 UNIT/GRAM TOPICAL OINTMENT [5750]

Facility

$62.00

Service Code	NDC 45802004835
Hospital Revenue Code	250
Min. Negotiated Rate	$52.70
Max. Negotiated Rate	$60.14
Rate for Payer: Cash Price	$37.20
Rate for Payer: Health Management Network Commercial	$52.70
Rate for Payer: Kaiser Permanente Commercial	$55.80
Rate for Payer: MDX Hawaii PPO	$60.14

NYSTATIN 100,000 UNIT/GRAM TOPICAL OINTMENT [5750]

Facility

$62.00

Service Code	NDC 45802004835
Hospital Revenue Code	637
Min. Negotiated Rate	$31.00
Max. Negotiated Rate	$60.14
Rate for Payer: AlohaCare Medicaid	$31.00
Rate for Payer: AlohaCare Medicare	$47.12
Rate for Payer: Cash Price	$37.20
Rate for Payer: Devoted Health Medicare	$52.08
Rate for Payer: Hawaii Medical Service Association Medicare	$47.12
Rate for Payer: Hawaii Western Management Group Commercial	$58.90
Rate for Payer: Health Management Network Commercial	$52.70
Rate for Payer: Humana Medicare	$47.12
Rate for Payer: Kaiser Permanente Commercial	$55.80
Rate for Payer: Kaiser Permanente Medicaid	$31.62
Rate for Payer: Kaiser Permanente Medicare	$47.12
Rate for Payer: MDX Hawaii PPO	$60.14
Rate for Payer: Ohana Health Plan Medicaid	$47.12
Rate for Payer: Ohana Health Plan Medicare	$47.12
Rate for Payer: UnitedHealthcare Medicare	$47.12
Rate for Payer: University Health Alliance Commercial	$45.19

Know your out-of-pocket cost for care.

All Charges