Honoka'a Hospital and Skilled Nursing Facility

All Charges

Charge

Type

Setting

Price

OLMESARTAN 20 MG TABLET [32762]

Facility

$21.00

Service Code	NDC 68462043730
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

OLMESARTAN 5 MG TABLET [32761]

Facility

$20.00

Service Code	NDC 68462043630
Hospital Revenue Code	637
Min. Negotiated Rate	$10.00
Max. Negotiated Rate	$19.40
Rate for Payer: AlohaCare Medicaid	$10.00
Rate for Payer: AlohaCare Medicare	$15.20
Rate for Payer: Cash Price	$12.00
Rate for Payer: Devoted Health Medicare	$16.80
Rate for Payer: Hawaii Medical Service Association Medicare	$15.20
Rate for Payer: Hawaii Western Management Group Commercial	$19.00
Rate for Payer: Health Management Network Commercial	$17.00
Rate for Payer: Humana Medicare	$15.20
Rate for Payer: Kaiser Permanente Commercial	$18.00
Rate for Payer: Kaiser Permanente Medicaid	$10.20
Rate for Payer: Kaiser Permanente Medicare	$15.20
Rate for Payer: MDX Hawaii PPO	$19.40
Rate for Payer: Ohana Health Plan Medicaid	$15.20
Rate for Payer: Ohana Health Plan Medicare	$15.20
Rate for Payer: UnitedHealthcare Medicare	$15.20
Rate for Payer: University Health Alliance Commercial	$14.58

OLMESARTAN 5 MG TABLET [32761]

Facility

$20.00

Service Code	NDC 68462043630
Hospital Revenue Code	250
Min. Negotiated Rate	$17.00
Max. Negotiated Rate	$19.40
Rate for Payer: Cash Price	$12.00
Rate for Payer: Health Management Network Commercial	$17.00
Rate for Payer: Kaiser Permanente Commercial	$18.00
Rate for Payer: MDX Hawaii PPO	$19.40

OLMESARTAN 5 MG TABLET [32761]

Facility

$18.00

Service Code	NDC 33342017807
Hospital Revenue Code	637
Min. Negotiated Rate	$9.00
Max. Negotiated Rate	$17.46
Rate for Payer: AlohaCare Medicaid	$9.00
Rate for Payer: AlohaCare Medicare	$13.68
Rate for Payer: Cash Price	$10.80
Rate for Payer: Devoted Health Medicare	$15.12
Rate for Payer: Hawaii Medical Service Association Medicare	$13.68
Rate for Payer: Hawaii Western Management Group Commercial	$17.10
Rate for Payer: Health Management Network Commercial	$15.30
Rate for Payer: Humana Medicare	$13.68
Rate for Payer: Kaiser Permanente Commercial	$16.20
Rate for Payer: Kaiser Permanente Medicaid	$9.18
Rate for Payer: Kaiser Permanente Medicare	$13.68
Rate for Payer: MDX Hawaii PPO	$17.46
Rate for Payer: Ohana Health Plan Medicaid	$13.68
Rate for Payer: Ohana Health Plan Medicare	$13.68
Rate for Payer: UnitedHealthcare Medicare	$13.68
Rate for Payer: University Health Alliance Commercial	$13.12

OLMESARTAN 5 MG TABLET [32761]

Facility

$18.00

Service Code	NDC 33342017807
Hospital Revenue Code	250
Min. Negotiated Rate	$15.30
Max. Negotiated Rate	$17.46
Rate for Payer: Cash Price	$10.80
Rate for Payer: Health Management Network Commercial	$15.30
Rate for Payer: Kaiser Permanente Commercial	$16.20
Rate for Payer: MDX Hawaii PPO	$17.46

OLYMPUS AIR WATER VALVE MH-438

Facility

$2,660.00

Hospital Revenue Code	272
Min. Negotiated Rate	$2,261.00
Max. Negotiated Rate	$2,580.20
Rate for Payer: Cash Price	$1,596.00
Rate for Payer: Health Management Network Commercial	$2,261.00
Rate for Payer: Kaiser Permanente Commercial	$2,394.00
Rate for Payer: MDX Hawaii PPO	$2,580.20

OLYMPUS AIR WATER VALVE MH-438

Facility

$2,660.00

Hospital Revenue Code	272
Min. Negotiated Rate	$1,330.00
Max. Negotiated Rate	$2,580.20
Rate for Payer: AlohaCare Medicaid	$1,330.00
Rate for Payer: AlohaCare Medicare	$2,021.60
Rate for Payer: Cash Price	$1,596.00
Rate for Payer: Devoted Health Medicare	$2,234.40
Rate for Payer: Hawaii Medical Service Association Medicare	$2,021.60
Rate for Payer: Hawaii Western Management Group Commercial	$2,527.00
Rate for Payer: Health Management Network Commercial	$2,261.00
Rate for Payer: Humana Medicare	$2,021.60
Rate for Payer: Kaiser Permanente Commercial	$2,394.00
Rate for Payer: Kaiser Permanente Medicaid	$1,356.60
Rate for Payer: Kaiser Permanente Medicare	$2,021.60
Rate for Payer: MDX Hawaii PPO	$2,580.20
Rate for Payer: Ohana Health Plan Medicaid	$2,021.60
Rate for Payer: Ohana Health Plan Medicare	$2,021.60
Rate for Payer: UnitedHealthcare Medicare	$2,021.60
Rate for Payer: University Health Alliance Commercial	$1,938.87

OMNIFIT HIPCSTEM#10 #6098-1040

Facility

$10,332.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$5,166.00
Max. Negotiated Rate	$10,022.04
Rate for Payer: AlohaCare Medicaid	$5,166.00
Rate for Payer: AlohaCare Medicare	$7,852.32
Rate for Payer: Cash Price	$6,199.20
Rate for Payer: Devoted Health Medicare	$8,678.88
Rate for Payer: Hawaii Medical Service Association Medicare	$7,852.32
Rate for Payer: Hawaii Western Management Group Commercial	$7,232.40
Rate for Payer: Health Management Network Commercial	$8,782.20
Rate for Payer: Humana Medicare	$7,852.32
Rate for Payer: Kaiser Permanente Commercial	$9,298.80
Rate for Payer: Kaiser Permanente Medicaid	$5,269.32
Rate for Payer: Kaiser Permanente Medicare	$7,852.32
Rate for Payer: MDX Hawaii PPO	$10,022.04
Rate for Payer: Ohana Health Plan Medicaid	$7,852.32
Rate for Payer: Ohana Health Plan Medicare	$7,852.32
Rate for Payer: UnitedHealthcare Medicare	$7,852.32
Rate for Payer: University Health Alliance Commercial	$5,785.92

OMNIFIT HIPCSTEM#10 #6098-1040

Facility

$10,332.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$5,785.92
Max. Negotiated Rate	$10,022.04
Rate for Payer: Cash Price	$6,199.20
Rate for Payer: Hawaii Western Management Group Commercial	$7,232.40
Rate for Payer: Health Management Network Commercial	$8,782.20
Rate for Payer: Kaiser Permanente Commercial	$9,298.80
Rate for Payer: MDX Hawaii PPO	$10,022.04
Rate for Payer: University Health Alliance Commercial	$5,785.92

OMNIFIT HIPCSTEM#11 6098-1140

Facility

$10,032.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$5,016.00
Max. Negotiated Rate	$9,731.04
Rate for Payer: AlohaCare Medicaid	$5,016.00
Rate for Payer: AlohaCare Medicare	$7,624.32
Rate for Payer: Cash Price	$6,019.20
Rate for Payer: Devoted Health Medicare	$8,426.88
Rate for Payer: Hawaii Medical Service Association Medicare	$7,624.32
Rate for Payer: Hawaii Western Management Group Commercial	$7,022.40
Rate for Payer: Health Management Network Commercial	$8,527.20
Rate for Payer: Humana Medicare	$7,624.32
Rate for Payer: Kaiser Permanente Commercial	$9,028.80
Rate for Payer: Kaiser Permanente Medicaid	$5,116.32
Rate for Payer: Kaiser Permanente Medicare	$7,624.32
Rate for Payer: MDX Hawaii PPO	$9,731.04
Rate for Payer: Ohana Health Plan Medicaid	$7,624.32
Rate for Payer: Ohana Health Plan Medicare	$7,624.32
Rate for Payer: UnitedHealthcare Medicare	$7,624.32
Rate for Payer: University Health Alliance Commercial	$5,617.92

OMNIFIT HIPCSTEM#11 6098-1140

Facility

$10,032.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$5,617.92
Max. Negotiated Rate	$9,731.04
Rate for Payer: Cash Price	$6,019.20
Rate for Payer: Hawaii Western Management Group Commercial	$7,022.40
Rate for Payer: Health Management Network Commercial	$8,527.20
Rate for Payer: Kaiser Permanente Commercial	$9,028.80
Rate for Payer: MDX Hawaii PPO	$9,731.04
Rate for Payer: University Health Alliance Commercial	$5,617.92

OMNIFIT HIPCSTEM#4 6098-0425

Facility

$3,096.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$1,733.76
Max. Negotiated Rate	$3,003.12
Rate for Payer: Cash Price	$1,857.60
Rate for Payer: Hawaii Western Management Group Commercial	$2,167.20
Rate for Payer: Health Management Network Commercial	$2,631.60
Rate for Payer: Kaiser Permanente Commercial	$2,786.40
Rate for Payer: MDX Hawaii PPO	$3,003.12
Rate for Payer: University Health Alliance Commercial	$1,733.76

OMNIFIT HIPCSTEM#4 6098-0425

Facility

$3,096.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$1,548.00
Max. Negotiated Rate	$3,003.12
Rate for Payer: AlohaCare Medicaid	$1,548.00
Rate for Payer: AlohaCare Medicare	$2,352.96
Rate for Payer: Cash Price	$1,857.60
Rate for Payer: Devoted Health Medicare	$2,600.64
Rate for Payer: Hawaii Medical Service Association Medicare	$2,352.96
Rate for Payer: Hawaii Western Management Group Commercial	$2,167.20
Rate for Payer: Health Management Network Commercial	$2,631.60
Rate for Payer: Humana Medicare	$2,352.96
Rate for Payer: Kaiser Permanente Commercial	$2,786.40
Rate for Payer: Kaiser Permanente Medicaid	$1,578.96
Rate for Payer: Kaiser Permanente Medicare	$2,352.96
Rate for Payer: MDX Hawaii PPO	$3,003.12
Rate for Payer: Ohana Health Plan Medicaid	$2,352.96
Rate for Payer: Ohana Health Plan Medicare	$2,352.96
Rate for Payer: UnitedHealthcare Medicare	$2,352.96
Rate for Payer: University Health Alliance Commercial	$1,733.76

OMNIFIT HIPCSTEM#5 6098-0530

Facility

$3,096.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$1,548.00
Max. Negotiated Rate	$3,003.12
Rate for Payer: AlohaCare Medicaid	$1,548.00
Rate for Payer: AlohaCare Medicare	$2,352.96
Rate for Payer: Cash Price	$1,857.60
Rate for Payer: Devoted Health Medicare	$2,600.64
Rate for Payer: Hawaii Medical Service Association Medicare	$2,352.96
Rate for Payer: Hawaii Western Management Group Commercial	$2,167.20
Rate for Payer: Health Management Network Commercial	$2,631.60
Rate for Payer: Humana Medicare	$2,352.96
Rate for Payer: Kaiser Permanente Commercial	$2,786.40
Rate for Payer: Kaiser Permanente Medicaid	$1,578.96
Rate for Payer: Kaiser Permanente Medicare	$2,352.96
Rate for Payer: MDX Hawaii PPO	$3,003.12
Rate for Payer: Ohana Health Plan Medicaid	$2,352.96
Rate for Payer: Ohana Health Plan Medicare	$2,352.96
Rate for Payer: UnitedHealthcare Medicare	$2,352.96
Rate for Payer: University Health Alliance Commercial	$1,733.76

OMNIFIT HIPCSTEM#5 6098-0530

Facility

$3,096.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$1,733.76
Max. Negotiated Rate	$3,003.12
Rate for Payer: Cash Price	$1,857.60
Rate for Payer: Hawaii Western Management Group Commercial	$2,167.20
Rate for Payer: Health Management Network Commercial	$2,631.60
Rate for Payer: Kaiser Permanente Commercial	$2,786.40
Rate for Payer: MDX Hawaii PPO	$3,003.12
Rate for Payer: University Health Alliance Commercial	$1,733.76

OMNIFIT HIPCSTEM#7 #6098-0735

Facility

$3,096.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$1,733.76
Max. Negotiated Rate	$3,003.12
Rate for Payer: Cash Price	$1,857.60
Rate for Payer: Hawaii Western Management Group Commercial	$2,167.20
Rate for Payer: Health Management Network Commercial	$2,631.60
Rate for Payer: Kaiser Permanente Commercial	$2,786.40
Rate for Payer: MDX Hawaii PPO	$3,003.12
Rate for Payer: University Health Alliance Commercial	$1,733.76

OMNIFIT HIPCSTEM#7 #6098-0735

Facility

$3,096.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$1,548.00
Max. Negotiated Rate	$3,003.12
Rate for Payer: AlohaCare Medicaid	$1,548.00
Rate for Payer: AlohaCare Medicare	$2,352.96
Rate for Payer: Cash Price	$1,857.60
Rate for Payer: Devoted Health Medicare	$2,600.64
Rate for Payer: Hawaii Medical Service Association Medicare	$2,352.96
Rate for Payer: Hawaii Western Management Group Commercial	$2,167.20
Rate for Payer: Health Management Network Commercial	$2,631.60
Rate for Payer: Humana Medicare	$2,352.96
Rate for Payer: Kaiser Permanente Commercial	$2,786.40
Rate for Payer: Kaiser Permanente Medicaid	$1,578.96
Rate for Payer: Kaiser Permanente Medicare	$2,352.96
Rate for Payer: MDX Hawaii PPO	$3,003.12
Rate for Payer: Ohana Health Plan Medicaid	$2,352.96
Rate for Payer: Ohana Health Plan Medicare	$2,352.96
Rate for Payer: UnitedHealthcare Medicare	$2,352.96
Rate for Payer: University Health Alliance Commercial	$1,733.76

OMNIFIT HIPCSTEM#8 #6098-0835

Facility

$3,096.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$1,548.00
Max. Negotiated Rate	$3,003.12
Rate for Payer: AlohaCare Medicaid	$1,548.00
Rate for Payer: AlohaCare Medicare	$2,352.96
Rate for Payer: Cash Price	$1,857.60
Rate for Payer: Devoted Health Medicare	$2,600.64
Rate for Payer: Hawaii Medical Service Association Medicare	$2,352.96
Rate for Payer: Hawaii Western Management Group Commercial	$2,167.20
Rate for Payer: Health Management Network Commercial	$2,631.60
Rate for Payer: Humana Medicare	$2,352.96
Rate for Payer: Kaiser Permanente Commercial	$2,786.40
Rate for Payer: Kaiser Permanente Medicaid	$1,578.96
Rate for Payer: Kaiser Permanente Medicare	$2,352.96
Rate for Payer: MDX Hawaii PPO	$3,003.12
Rate for Payer: Ohana Health Plan Medicaid	$2,352.96
Rate for Payer: Ohana Health Plan Medicare	$2,352.96
Rate for Payer: UnitedHealthcare Medicare	$2,352.96
Rate for Payer: University Health Alliance Commercial	$1,733.76

OMNIFIT HIPCSTEM#8 #6098-0835

Facility

$3,096.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$1,733.76
Max. Negotiated Rate	$3,003.12
Rate for Payer: Cash Price	$1,857.60
Rate for Payer: Hawaii Western Management Group Commercial	$2,167.20
Rate for Payer: Health Management Network Commercial	$2,631.60
Rate for Payer: Kaiser Permanente Commercial	$2,786.40
Rate for Payer: MDX Hawaii PPO	$3,003.12
Rate for Payer: University Health Alliance Commercial	$1,733.76

OMNIFIT HIPCSTEM#9 #6098-0940

Facility

$3,096.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$1,733.76
Max. Negotiated Rate	$3,003.12
Rate for Payer: Cash Price	$1,857.60
Rate for Payer: Hawaii Western Management Group Commercial	$2,167.20
Rate for Payer: Health Management Network Commercial	$2,631.60
Rate for Payer: Kaiser Permanente Commercial	$2,786.40
Rate for Payer: MDX Hawaii PPO	$3,003.12
Rate for Payer: University Health Alliance Commercial	$1,733.76

OMNIFIT HIPCSTEM#9 #6098-0940

Facility

$3,096.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$1,548.00
Max. Negotiated Rate	$3,003.12
Rate for Payer: AlohaCare Medicaid	$1,548.00
Rate for Payer: AlohaCare Medicare	$2,352.96
Rate for Payer: Cash Price	$1,857.60
Rate for Payer: Devoted Health Medicare	$2,600.64
Rate for Payer: Hawaii Medical Service Association Medicare	$2,352.96
Rate for Payer: Hawaii Western Management Group Commercial	$2,167.20
Rate for Payer: Health Management Network Commercial	$2,631.60
Rate for Payer: Humana Medicare	$2,352.96
Rate for Payer: Kaiser Permanente Commercial	$2,786.40
Rate for Payer: Kaiser Permanente Medicaid	$1,578.96
Rate for Payer: Kaiser Permanente Medicare	$2,352.96
Rate for Payer: MDX Hawaii PPO	$3,003.12
Rate for Payer: Ohana Health Plan Medicaid	$2,352.96
Rate for Payer: Ohana Health Plan Medicare	$2,352.96
Rate for Payer: UnitedHealthcare Medicare	$2,352.96
Rate for Payer: University Health Alliance Commercial	$1,733.76

OMNIFIT HIP STEM#10 #6097-1040

Facility

$10,332.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$5,785.92
Max. Negotiated Rate	$10,022.04
Rate for Payer: Cash Price	$6,199.20
Rate for Payer: Hawaii Western Management Group Commercial	$7,232.40
Rate for Payer: Health Management Network Commercial	$8,782.20
Rate for Payer: Kaiser Permanente Commercial	$9,298.80
Rate for Payer: MDX Hawaii PPO	$10,022.04
Rate for Payer: University Health Alliance Commercial	$5,785.92

OMNIFIT HIP STEM#10 #6097-1040

Facility

$10,332.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$5,166.00
Max. Negotiated Rate	$10,022.04
Rate for Payer: AlohaCare Medicaid	$5,166.00
Rate for Payer: AlohaCare Medicare	$7,852.32
Rate for Payer: Cash Price	$6,199.20
Rate for Payer: Devoted Health Medicare	$8,678.88
Rate for Payer: Hawaii Medical Service Association Medicare	$7,852.32
Rate for Payer: Hawaii Western Management Group Commercial	$7,232.40
Rate for Payer: Health Management Network Commercial	$8,782.20
Rate for Payer: Humana Medicare	$7,852.32
Rate for Payer: Kaiser Permanente Commercial	$9,298.80
Rate for Payer: Kaiser Permanente Medicaid	$5,269.32
Rate for Payer: Kaiser Permanente Medicare	$7,852.32
Rate for Payer: MDX Hawaii PPO	$10,022.04
Rate for Payer: Ohana Health Plan Medicaid	$7,852.32
Rate for Payer: Ohana Health Plan Medicare	$7,852.32
Rate for Payer: UnitedHealthcare Medicare	$7,852.32
Rate for Payer: University Health Alliance Commercial	$5,785.92

OMNIFIT HIP STEM#11 #6097-1140

Facility

$10,032.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$5,617.92
Max. Negotiated Rate	$9,731.04
Rate for Payer: Cash Price	$6,019.20
Rate for Payer: Hawaii Western Management Group Commercial	$7,022.40
Rate for Payer: Health Management Network Commercial	$8,527.20
Rate for Payer: Kaiser Permanente Commercial	$9,028.80
Rate for Payer: MDX Hawaii PPO	$9,731.04
Rate for Payer: University Health Alliance Commercial	$5,617.92

OMNIFIT HIP STEM#11 #6097-1140

Facility

$10,032.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$5,016.00
Max. Negotiated Rate	$9,731.04
Rate for Payer: AlohaCare Medicaid	$5,016.00
Rate for Payer: AlohaCare Medicare	$7,624.32
Rate for Payer: Cash Price	$6,019.20
Rate for Payer: Devoted Health Medicare	$8,426.88
Rate for Payer: Hawaii Medical Service Association Medicare	$7,624.32
Rate for Payer: Hawaii Western Management Group Commercial	$7,022.40
Rate for Payer: Health Management Network Commercial	$8,527.20
Rate for Payer: Humana Medicare	$7,624.32
Rate for Payer: Kaiser Permanente Commercial	$9,028.80
Rate for Payer: Kaiser Permanente Medicaid	$5,116.32
Rate for Payer: Kaiser Permanente Medicare	$7,624.32
Rate for Payer: MDX Hawaii PPO	$9,731.04
Rate for Payer: Ohana Health Plan Medicaid	$7,624.32
Rate for Payer: Ohana Health Plan Medicare	$7,624.32
Rate for Payer: UnitedHealthcare Medicare	$7,624.32
Rate for Payer: University Health Alliance Commercial	$5,617.92

Know your out-of-pocket cost for care.

All Charges