Honoka'a Hospital and Skilled Nursing Facility

All Charges

Charge

Type

Setting

Price

ONDANSETRON HCL (PF) 4 MG/2 ML INJECTION SOLUTION [106348]

Facility

$4.00

Service Code	HCPCS J2405
Hospital Revenue Code	636
Min. Negotiated Rate	$0.09
Max. Negotiated Rate	$3.88
Rate for Payer: Kaiser Permanente Medicaid	$1.53
Rate for Payer: AlohaCare Medicaid	$2.00
Rate for Payer: AlohaCare Medicaid	$3.00
Rate for Payer: AlohaCare Medicaid	$1.50
Rate for Payer: AlohaCare Medicaid	$3.50
Rate for Payer: AlohaCare Medicare	$5.32
Rate for Payer: AlohaCare Medicare	$2.28
Rate for Payer: AlohaCare Medicare	$3.04
Rate for Payer: AlohaCare Medicare	$4.56
Rate for Payer: Cash Price	$4.20
Rate for Payer: Cash Price	$2.40
Rate for Payer: Cash Price	$1.80
Rate for Payer: Cash Price	$4.20
Rate for Payer: Cash Price	$1.80
Rate for Payer: Cash Price	$3.60
Rate for Payer: Cash Price	$2.40
Rate for Payer: Cash Price	$3.60
Rate for Payer: Devoted Health Medicare	$5.04
Rate for Payer: Devoted Health Medicare	$3.36
Rate for Payer: Devoted Health Medicare	$5.88
Rate for Payer: Devoted Health Medicare	$2.52
Rate for Payer: Hawaii Medical Service Association ABD	$0.09
Rate for Payer: Hawaii Medical Service Association ABD	$0.09
Rate for Payer: Hawaii Medical Service Association ABD	$0.09
Rate for Payer: Hawaii Medical Service Association ABD	$0.09
Rate for Payer: Hawaii Medical Service Association Medicare	$2.28
Rate for Payer: Hawaii Medical Service Association Medicare	$5.32
Rate for Payer: Hawaii Medical Service Association Medicare	$4.56
Rate for Payer: Hawaii Medical Service Association Medicare	$3.04
Rate for Payer: Hawaii Medical Service Association Non-ABD	$0.09
Rate for Payer: Hawaii Medical Service Association Non-ABD	$0.09
Rate for Payer: Hawaii Medical Service Association Non-ABD	$0.09
Rate for Payer: Hawaii Medical Service Association Non-ABD	$0.09
Rate for Payer: Hawaii Western Management Group Commercial	$6.65
Rate for Payer: Hawaii Western Management Group Commercial	$5.70
Rate for Payer: Hawaii Western Management Group Commercial	$2.85
Rate for Payer: Hawaii Western Management Group Commercial	$3.80
Rate for Payer: Health Management Network Commercial	$5.10
Rate for Payer: Health Management Network Commercial	$2.55
Rate for Payer: Health Management Network Commercial	$3.40
Rate for Payer: Health Management Network Commercial	$5.95
Rate for Payer: Humana Medicare	$2.28
Rate for Payer: Humana Medicare	$4.56
Rate for Payer: Humana Medicare	$3.04
Rate for Payer: Humana Medicare	$5.32
Rate for Payer: Kaiser Permanente Commercial	$5.40
Rate for Payer: Kaiser Permanente Commercial	$3.60
Rate for Payer: Kaiser Permanente Commercial	$2.70
Rate for Payer: Kaiser Permanente Commercial	$6.30
Rate for Payer: Kaiser Permanente Medicaid	$2.04
Rate for Payer: Kaiser Permanente Medicaid	$3.06
Rate for Payer: Kaiser Permanente Medicaid	$3.57
Rate for Payer: Kaiser Permanente Medicare	$4.56
Rate for Payer: Kaiser Permanente Medicare	$2.28
Rate for Payer: Kaiser Permanente Medicare	$5.32
Rate for Payer: Kaiser Permanente Medicare	$3.04
Rate for Payer: MDX Hawaii PPO	$5.82
Rate for Payer: MDX Hawaii PPO	$2.91
Rate for Payer: MDX Hawaii PPO	$6.79
Rate for Payer: MDX Hawaii PPO	$3.88
Rate for Payer: Ohana Health Plan Medicaid	$3.04
Rate for Payer: Ohana Health Plan Medicaid	$4.56
Rate for Payer: Ohana Health Plan Medicaid	$2.28
Rate for Payer: Ohana Health Plan Medicaid	$5.32
Rate for Payer: Ohana Health Plan Medicare	$5.32
Rate for Payer: Ohana Health Plan Medicare	$4.56
Rate for Payer: Ohana Health Plan Medicare	$3.04
Rate for Payer: Ohana Health Plan Medicare	$2.28
Rate for Payer: UnitedHealthcare Medicaid	$2.40
Rate for Payer: UnitedHealthcare Medicaid	$3.60
Rate for Payer: UnitedHealthcare Medicaid	$1.80
Rate for Payer: UnitedHealthcare Medicaid	$4.20
Rate for Payer: UnitedHealthcare Medicare	$2.28
Rate for Payer: UnitedHealthcare Medicare	$4.56
Rate for Payer: UnitedHealthcare Medicare	$5.32
Rate for Payer: UnitedHealthcare Medicare	$3.04
Rate for Payer: University Health Alliance Commercial	$2.19
Rate for Payer: University Health Alliance Commercial	$2.92
Rate for Payer: University Health Alliance Commercial	$4.37
Rate for Payer: University Health Alliance Commercial	$5.10

ONDANSETRON ODT (ZOFRAN) 4 MG (TAKE HOME) [4080383]

Facility

$15.00

Service Code	HCPCS Q0162
Hospital Revenue Code	253
Min. Negotiated Rate	$0.01
Max. Negotiated Rate	$14.55
Rate for Payer: AlohaCare Medicaid	$7.50
Rate for Payer: AlohaCare Medicare	$11.40
Rate for Payer: Cash Price	$9.00
Rate for Payer: Cash Price	$9.00
Rate for Payer: Devoted Health Medicare	$12.60
Rate for Payer: Hawaii Medical Service Association ABD	$0.01
Rate for Payer: Hawaii Medical Service Association Medicare	$11.40
Rate for Payer: Hawaii Medical Service Association Non-ABD	$0.01
Rate for Payer: Hawaii Western Management Group Commercial	$14.25
Rate for Payer: Health Management Network Commercial	$12.75
Rate for Payer: Humana Medicare	$11.40
Rate for Payer: Kaiser Permanente Commercial	$13.50
Rate for Payer: Kaiser Permanente Medicaid	$7.65
Rate for Payer: Kaiser Permanente Medicare	$11.40
Rate for Payer: MDX Hawaii PPO	$14.55
Rate for Payer: Ohana Health Plan Medicaid	$11.40
Rate for Payer: Ohana Health Plan Medicare	$11.40
Rate for Payer: UnitedHealthcare Medicaid	$0.01
Rate for Payer: UnitedHealthcare Medicare	$11.40
Rate for Payer: University Health Alliance Commercial	$10.93

ONDANSETRON ODT (ZOFRAN) 4 MG (TAKE HOME) [4080383]

Facility

$15.00

Service Code	HCPCS Q0162
Hospital Revenue Code	253
Min. Negotiated Rate	$12.75
Max. Negotiated Rate	$14.55
Rate for Payer: Cash Price	$9.00
Rate for Payer: Health Management Network Commercial	$12.75
Rate for Payer: Kaiser Permanente Commercial	$13.50
Rate for Payer: MDX Hawaii PPO	$14.55

OPTISEAL VALVED INTROD 6X13

Facility

$910.00

Service Code	HCPCS C1892
Hospital Revenue Code	272
Min. Negotiated Rate	$455.00
Max. Negotiated Rate	$882.70
Rate for Payer: AlohaCare Medicaid	$455.00
Rate for Payer: AlohaCare Medicare	$691.60
Rate for Payer: Cash Price	$546.00
Rate for Payer: Devoted Health Medicare	$764.40
Rate for Payer: Hawaii Medical Service Association Medicare	$691.60
Rate for Payer: Hawaii Western Management Group Commercial	$864.50
Rate for Payer: Health Management Network Commercial	$773.50
Rate for Payer: Humana Medicare	$691.60
Rate for Payer: Kaiser Permanente Commercial	$819.00
Rate for Payer: Kaiser Permanente Medicaid	$464.10
Rate for Payer: Kaiser Permanente Medicare	$691.60
Rate for Payer: MDX Hawaii PPO	$882.70
Rate for Payer: Ohana Health Plan Medicaid	$691.60
Rate for Payer: Ohana Health Plan Medicare	$691.60
Rate for Payer: UnitedHealthcare Medicare	$691.60
Rate for Payer: University Health Alliance Commercial	$663.30

OPTISEAL VALVED INTROD 6X13

Facility

$910.00

Service Code	HCPCS C1892
Hospital Revenue Code	272
Min. Negotiated Rate	$773.50
Max. Negotiated Rate	$882.70
Rate for Payer: Cash Price	$546.00
Rate for Payer: Health Management Network Commercial	$773.50
Rate for Payer: Kaiser Permanente Commercial	$819.00
Rate for Payer: MDX Hawaii PPO	$882.70

OPTISEAL VALVED INTROD 6X25

Facility

$910.00

Service Code	HCPCS C1892
Hospital Revenue Code	272
Min. Negotiated Rate	$773.50
Max. Negotiated Rate	$882.70
Rate for Payer: Cash Price	$546.00
Rate for Payer: Health Management Network Commercial	$773.50
Rate for Payer: Kaiser Permanente Commercial	$819.00
Rate for Payer: MDX Hawaii PPO	$882.70

OPTISEAL VALVED INTROD 6X25

Facility

$910.00

Service Code	HCPCS C1892
Hospital Revenue Code	272
Min. Negotiated Rate	$455.00
Max. Negotiated Rate	$882.70
Rate for Payer: AlohaCare Medicaid	$455.00
Rate for Payer: AlohaCare Medicare	$691.60
Rate for Payer: Cash Price	$546.00
Rate for Payer: Devoted Health Medicare	$764.40
Rate for Payer: Hawaii Medical Service Association Medicare	$691.60
Rate for Payer: Hawaii Western Management Group Commercial	$864.50
Rate for Payer: Health Management Network Commercial	$773.50
Rate for Payer: Humana Medicare	$691.60
Rate for Payer: Kaiser Permanente Commercial	$819.00
Rate for Payer: Kaiser Permanente Medicaid	$464.10
Rate for Payer: Kaiser Permanente Medicare	$691.60
Rate for Payer: MDX Hawaii PPO	$882.70
Rate for Payer: Ohana Health Plan Medicaid	$691.60
Rate for Payer: Ohana Health Plan Medicare	$691.60
Rate for Payer: UnitedHealthcare Medicare	$691.60
Rate for Payer: University Health Alliance Commercial	$663.30

OPTISEAL VALVED INTROD 8X13

Facility

$910.00

Service Code	HCPCS C1892
Hospital Revenue Code	272
Min. Negotiated Rate	$773.50
Max. Negotiated Rate	$882.70
Rate for Payer: Cash Price	$546.00
Rate for Payer: Health Management Network Commercial	$773.50
Rate for Payer: Kaiser Permanente Commercial	$819.00
Rate for Payer: MDX Hawaii PPO	$882.70

OPTISEAL VALVED INTROD 8X13

Facility

$910.00

Service Code	HCPCS C1892
Hospital Revenue Code	272
Min. Negotiated Rate	$455.00
Max. Negotiated Rate	$882.70
Rate for Payer: AlohaCare Medicaid	$455.00
Rate for Payer: AlohaCare Medicare	$691.60
Rate for Payer: Cash Price	$546.00
Rate for Payer: Devoted Health Medicare	$764.40
Rate for Payer: Hawaii Medical Service Association Medicare	$691.60
Rate for Payer: Hawaii Western Management Group Commercial	$864.50
Rate for Payer: Health Management Network Commercial	$773.50
Rate for Payer: Humana Medicare	$691.60
Rate for Payer: Kaiser Permanente Commercial	$819.00
Rate for Payer: Kaiser Permanente Medicaid	$464.10
Rate for Payer: Kaiser Permanente Medicare	$691.60
Rate for Payer: MDX Hawaii PPO	$882.70
Rate for Payer: Ohana Health Plan Medicaid	$691.60
Rate for Payer: Ohana Health Plan Medicare	$691.60
Rate for Payer: UnitedHealthcare Medicare	$691.60
Rate for Payer: University Health Alliance Commercial	$663.30

OPTISEAL VALVED INTROD 9X13

Facility

$910.00

Service Code	HCPCS C1894
Hospital Revenue Code	272
Min. Negotiated Rate	$773.50
Max. Negotiated Rate	$882.70
Rate for Payer: Cash Price	$546.00
Rate for Payer: Health Management Network Commercial	$773.50
Rate for Payer: Kaiser Permanente Commercial	$819.00
Rate for Payer: MDX Hawaii PPO	$882.70

OPTISEAL VALVED INTROD 9X13

Facility

$910.00

Service Code	HCPCS C1894
Hospital Revenue Code	272
Min. Negotiated Rate	$455.00
Max. Negotiated Rate	$882.70
Rate for Payer: AlohaCare Medicaid	$455.00
Rate for Payer: AlohaCare Medicare	$691.60
Rate for Payer: Cash Price	$546.00
Rate for Payer: Devoted Health Medicare	$764.40
Rate for Payer: Hawaii Medical Service Association Medicare	$691.60
Rate for Payer: Hawaii Western Management Group Commercial	$864.50
Rate for Payer: Health Management Network Commercial	$773.50
Rate for Payer: Humana Medicare	$691.60
Rate for Payer: Kaiser Permanente Commercial	$819.00
Rate for Payer: Kaiser Permanente Medicaid	$464.10
Rate for Payer: Kaiser Permanente Medicare	$691.60
Rate for Payer: MDX Hawaii PPO	$882.70
Rate for Payer: Ohana Health Plan Medicaid	$691.60
Rate for Payer: Ohana Health Plan Medicare	$691.60
Rate for Payer: UnitedHealthcare Medicare	$691.60
Rate for Payer: University Health Alliance Commercial	$663.30

OPTITORQUE TIGER 6F 4X100

Facility

$225.00

Service Code	HCPCS C1887
Hospital Revenue Code	272
Min. Negotiated Rate	$112.50
Max. Negotiated Rate	$218.25
Rate for Payer: AlohaCare Medicaid	$112.50
Rate for Payer: AlohaCare Medicare	$171.00
Rate for Payer: Cash Price	$135.00
Rate for Payer: Devoted Health Medicare	$189.00
Rate for Payer: Hawaii Medical Service Association Medicare	$171.00
Rate for Payer: Hawaii Western Management Group Commercial	$213.75
Rate for Payer: Health Management Network Commercial	$191.25
Rate for Payer: Humana Medicare	$171.00
Rate for Payer: Kaiser Permanente Commercial	$202.50
Rate for Payer: Kaiser Permanente Medicaid	$114.75
Rate for Payer: Kaiser Permanente Medicare	$171.00
Rate for Payer: MDX Hawaii PPO	$218.25
Rate for Payer: Ohana Health Plan Medicaid	$171.00
Rate for Payer: Ohana Health Plan Medicare	$171.00
Rate for Payer: UnitedHealthcare Medicare	$171.00
Rate for Payer: University Health Alliance Commercial	$164.00

OPTITORQUE TIGER 6F 4X100

Facility

$225.00

Service Code	HCPCS C1887
Hospital Revenue Code	272
Min. Negotiated Rate	$191.25
Max. Negotiated Rate	$218.25
Rate for Payer: Cash Price	$135.00
Rate for Payer: Health Management Network Commercial	$191.25
Rate for Payer: Kaiser Permanente Commercial	$202.50
Rate for Payer: MDX Hawaii PPO	$218.25

ORBITAL PROCEDURES WITH CC/MCC

Facility

$19,103.81

Service Code	MSDRG 113
Min. Negotiated Rate	$10,400.00
Max. Negotiated Rate	$19,103.81
Rate for Payer: Hawaii Medical Service Association Commercial	$19,103.81
Rate for Payer: University Health Alliance Commercial	$10,400.00

ORBITAL PROCEDURES WITHOUT CC/MCC

Facility

$19,103.81

Service Code	MSDRG 114
Min. Negotiated Rate	$10,400.00
Max. Negotiated Rate	$19,103.81
Rate for Payer: Hawaii Medical Service Association Commercial	$19,103.81
Rate for Payer: University Health Alliance Commercial	$10,400.00

ORGANIC DISTURBANCES AND INTELLECTUAL DISABILITY

Facility

$25,669.27

Service Code	MSDRG 884
Min. Negotiated Rate	$25,669.27
Max. Negotiated Rate	$25,669.27
Rate for Payer: Hawaii Medical Service Association Commercial	$25,669.27

O.R. PROCEDURES FOR OBESITY WITH CC

Facility

$51,717.76

Service Code	MSDRG 620
Min. Negotiated Rate	$51,717.76
Max. Negotiated Rate	$51,717.76
Rate for Payer: Hawaii Medical Service Association Commercial	$51,717.76

O.R. PROCEDURES FOR OBESITY WITH MCC

Facility

$51,717.76

Service Code	MSDRG 619
Min. Negotiated Rate	$51,717.76
Max. Negotiated Rate	$51,717.76
Rate for Payer: Hawaii Medical Service Association Commercial	$51,717.76

O.R. PROCEDURES FOR OBESITY WITHOUT CC/MCC

Facility

$51,504.45

Service Code	MSDRG 621
Min. Negotiated Rate	$51,504.45
Max. Negotiated Rate	$51,504.45
Rate for Payer: Hawaii Medical Service Association Commercial	$51,504.45

O.R. PROCEDURES WITH DIAGNOSES OF OTHER CONTACT WITH HEALTH SERVICES WITH CC

Facility

$38,586.86

Service Code	MSDRG 940
Min. Negotiated Rate	$38,586.86
Max. Negotiated Rate	$38,586.86
Rate for Payer: Hawaii Medical Service Association Commercial	$38,586.86

O.R. PROCEDURES WITH DIAGNOSES OF OTHER CONTACT WITH HEALTH SERVICES WITH MCC

Facility

$38,586.86

Service Code	MSDRG 939
Min. Negotiated Rate	$38,586.86
Max. Negotiated Rate	$38,586.86
Rate for Payer: Hawaii Medical Service Association Commercial	$38,586.86

O.R. PROCEDURES WITH DIAGNOSES OF OTHER CONTACT WITH HEALTH SERVICES WITHOUT CC/MCC

Facility

$38,586.86

Service Code	MSDRG 941
Min. Negotiated Rate	$38,586.86
Max. Negotiated Rate	$38,586.86
Rate for Payer: Hawaii Medical Service Association Commercial	$38,586.86

O.R. PROCEDURES WITH PRINCIPAL DIAGNOSIS OF MENTAL ILLNESS

Facility

$85,990.86

Service Code	MSDRG 876
Min. Negotiated Rate	$85,990.86
Max. Negotiated Rate	$85,990.86
Rate for Payer: Hawaii Medical Service Association Commercial	$85,990.86

ORTHALIGN PLUS 403001

Facility

$2,250.00

Hospital Revenue Code	272
Min. Negotiated Rate	$1,912.50
Max. Negotiated Rate	$2,182.50
Rate for Payer: Cash Price	$1,350.00
Rate for Payer: Health Management Network Commercial	$1,912.50
Rate for Payer: Kaiser Permanente Commercial	$2,025.00
Rate for Payer: MDX Hawaii PPO	$2,182.50

ORTHALIGN PLUS 403001

Facility

$2,250.00

Hospital Revenue Code	272
Min. Negotiated Rate	$1,125.00
Max. Negotiated Rate	$2,182.50
Rate for Payer: AlohaCare Medicaid	$1,125.00
Rate for Payer: AlohaCare Medicare	$1,710.00
Rate for Payer: Cash Price	$1,350.00
Rate for Payer: Devoted Health Medicare	$1,890.00
Rate for Payer: Hawaii Medical Service Association Medicare	$1,710.00
Rate for Payer: Hawaii Western Management Group Commercial	$2,137.50
Rate for Payer: Health Management Network Commercial	$1,912.50
Rate for Payer: Humana Medicare	$1,710.00
Rate for Payer: Kaiser Permanente Commercial	$2,025.00
Rate for Payer: Kaiser Permanente Medicaid	$1,147.50
Rate for Payer: Kaiser Permanente Medicare	$1,710.00
Rate for Payer: MDX Hawaii PPO	$2,182.50
Rate for Payer: Ohana Health Plan Medicaid	$1,710.00
Rate for Payer: Ohana Health Plan Medicare	$1,710.00
Rate for Payer: UnitedHealthcare Medicare	$1,710.00
Rate for Payer: University Health Alliance Commercial	$1,640.03

Know your out-of-pocket cost for care.

All Charges