Honoka'a Hospital and Skilled Nursing Facility

All Charges

Charge

Type

Setting

Price

PARIETEX PLUG

Facility

$398.00

Service Code	HCPCS C1781
Hospital Revenue Code	278
Min. Negotiated Rate	$199.00
Max. Negotiated Rate	$386.06
Rate for Payer: AlohaCare Medicaid	$199.00
Rate for Payer: AlohaCare Medicare	$302.48
Rate for Payer: Cash Price	$238.80
Rate for Payer: Devoted Health Medicare	$334.32
Rate for Payer: Hawaii Medical Service Association Medicare	$302.48
Rate for Payer: Hawaii Western Management Group Commercial	$278.60
Rate for Payer: Health Management Network Commercial	$338.30
Rate for Payer: Humana Medicare	$302.48
Rate for Payer: Kaiser Permanente Commercial	$358.20
Rate for Payer: Kaiser Permanente Medicaid	$202.98
Rate for Payer: Kaiser Permanente Medicare	$302.48
Rate for Payer: MDX Hawaii PPO	$386.06
Rate for Payer: Ohana Health Plan Medicaid	$302.48
Rate for Payer: Ohana Health Plan Medicare	$302.48
Rate for Payer: UnitedHealthcare Medicare	$302.48
Rate for Payer: University Health Alliance Commercial	$222.88

PAROXETINE 10 MG TABLET [16632]

Facility

$10.00

Service Code	NDC 68382009706
Hospital Revenue Code	637
Min. Negotiated Rate	$5.00
Max. Negotiated Rate	$9.70
Rate for Payer: AlohaCare Medicaid	$5.00
Rate for Payer: AlohaCare Medicare	$7.60
Rate for Payer: Cash Price	$6.00
Rate for Payer: Devoted Health Medicare	$8.40
Rate for Payer: Hawaii Medical Service Association Medicare	$7.60
Rate for Payer: Hawaii Western Management Group Commercial	$9.50
Rate for Payer: Health Management Network Commercial	$8.50
Rate for Payer: Humana Medicare	$7.60
Rate for Payer: Kaiser Permanente Commercial	$9.00
Rate for Payer: Kaiser Permanente Medicaid	$5.10
Rate for Payer: Kaiser Permanente Medicare	$7.60
Rate for Payer: MDX Hawaii PPO	$9.70
Rate for Payer: Ohana Health Plan Medicaid	$7.60
Rate for Payer: Ohana Health Plan Medicare	$7.60
Rate for Payer: UnitedHealthcare Medicare	$7.60
Rate for Payer: University Health Alliance Commercial	$7.29

PAROXETINE 10 MG TABLET [16632]

Facility

$10.00

Service Code	NDC 68382009706
Hospital Revenue Code	250
Min. Negotiated Rate	$8.50
Max. Negotiated Rate	$9.70
Rate for Payer: Cash Price	$6.00
Rate for Payer: Health Management Network Commercial	$8.50
Rate for Payer: Kaiser Permanente Commercial	$9.00
Rate for Payer: MDX Hawaii PPO	$9.70

PAROXETINE 20 MG TABLET [10855]

Facility

$10.00

Service Code	NDC 68382009806
Hospital Revenue Code	637
Min. Negotiated Rate	$5.00
Max. Negotiated Rate	$9.70
Rate for Payer: AlohaCare Medicaid	$5.00
Rate for Payer: AlohaCare Medicare	$7.60
Rate for Payer: Cash Price	$6.00
Rate for Payer: Devoted Health Medicare	$8.40
Rate for Payer: Hawaii Medical Service Association Medicare	$7.60
Rate for Payer: Hawaii Western Management Group Commercial	$9.50
Rate for Payer: Health Management Network Commercial	$8.50
Rate for Payer: Humana Medicare	$7.60
Rate for Payer: Kaiser Permanente Commercial	$9.00
Rate for Payer: Kaiser Permanente Medicaid	$5.10
Rate for Payer: Kaiser Permanente Medicare	$7.60
Rate for Payer: MDX Hawaii PPO	$9.70
Rate for Payer: Ohana Health Plan Medicaid	$7.60
Rate for Payer: Ohana Health Plan Medicare	$7.60
Rate for Payer: UnitedHealthcare Medicare	$7.60
Rate for Payer: University Health Alliance Commercial	$7.29

PAROXETINE 20 MG TABLET [10855]

Facility

$10.00

Service Code	NDC 68382009806
Hospital Revenue Code	250
Min. Negotiated Rate	$8.50
Max. Negotiated Rate	$9.70
Rate for Payer: Cash Price	$6.00
Rate for Payer: Health Management Network Commercial	$8.50
Rate for Payer: Kaiser Permanente Commercial	$9.00
Rate for Payer: MDX Hawaii PPO	$9.70

PAROXETINE 20 MG TABLET [10855]

Facility

$10.00

Service Code	NDC 68084004501
Hospital Revenue Code	637
Min. Negotiated Rate	$5.00
Max. Negotiated Rate	$9.70
Rate for Payer: AlohaCare Medicaid	$5.00
Rate for Payer: AlohaCare Medicare	$7.60
Rate for Payer: Cash Price	$6.00
Rate for Payer: Devoted Health Medicare	$8.40
Rate for Payer: Hawaii Medical Service Association Medicare	$7.60
Rate for Payer: Hawaii Western Management Group Commercial	$9.50
Rate for Payer: Health Management Network Commercial	$8.50
Rate for Payer: Humana Medicare	$7.60
Rate for Payer: Kaiser Permanente Commercial	$9.00
Rate for Payer: Kaiser Permanente Medicaid	$5.10
Rate for Payer: Kaiser Permanente Medicare	$7.60
Rate for Payer: MDX Hawaii PPO	$9.70
Rate for Payer: Ohana Health Plan Medicaid	$7.60
Rate for Payer: Ohana Health Plan Medicare	$7.60
Rate for Payer: UnitedHealthcare Medicare	$7.60
Rate for Payer: University Health Alliance Commercial	$7.29

PAROXETINE 20 MG TABLET [10855]

Facility

$10.00

Service Code	NDC 68084004501
Hospital Revenue Code	250
Min. Negotiated Rate	$8.50
Max. Negotiated Rate	$9.70
Rate for Payer: Cash Price	$6.00
Rate for Payer: Health Management Network Commercial	$8.50
Rate for Payer: Kaiser Permanente Commercial	$9.00
Rate for Payer: MDX Hawaii PPO	$9.70

PATCH WITTMANN EWP 2040

Facility

$16,200.00

Hospital Revenue Code	272
Min. Negotiated Rate	$8,100.00
Max. Negotiated Rate	$15,714.00
Rate for Payer: AlohaCare Medicaid	$8,100.00
Rate for Payer: AlohaCare Medicare	$12,312.00
Rate for Payer: Cash Price	$9,720.00
Rate for Payer: Devoted Health Medicare	$13,608.00
Rate for Payer: Hawaii Medical Service Association Medicare	$12,312.00
Rate for Payer: Hawaii Western Management Group Commercial	$15,390.00
Rate for Payer: Health Management Network Commercial	$13,770.00
Rate for Payer: Humana Medicare	$12,312.00
Rate for Payer: Kaiser Permanente Commercial	$14,580.00
Rate for Payer: Kaiser Permanente Medicaid	$8,262.00
Rate for Payer: Kaiser Permanente Medicare	$12,312.00
Rate for Payer: MDX Hawaii PPO	$15,714.00
Rate for Payer: Ohana Health Plan Medicaid	$12,312.00
Rate for Payer: Ohana Health Plan Medicare	$12,312.00
Rate for Payer: UnitedHealthcare Medicare	$12,312.00
Rate for Payer: University Health Alliance Commercial	$11,808.18

PATCH WITTMANN EWP 2040

Facility

$16,200.00

Hospital Revenue Code	272
Min. Negotiated Rate	$13,770.00
Max. Negotiated Rate	$15,714.00
Rate for Payer: Cash Price	$9,720.00
Rate for Payer: Health Management Network Commercial	$13,770.00
Rate for Payer: Kaiser Permanente Commercial	$14,580.00
Rate for Payer: MDX Hawaii PPO	$15,714.00

PATELLA 36X10MM X3 5550-G-360

Facility

$3,628.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$1,814.00
Max. Negotiated Rate	$3,519.16
Rate for Payer: AlohaCare Medicaid	$1,814.00
Rate for Payer: AlohaCare Medicare	$2,757.28
Rate for Payer: Cash Price	$2,176.80
Rate for Payer: Devoted Health Medicare	$3,047.52
Rate for Payer: Hawaii Medical Service Association Medicare	$2,757.28
Rate for Payer: Hawaii Western Management Group Commercial	$2,539.60
Rate for Payer: Health Management Network Commercial	$3,083.80
Rate for Payer: Humana Medicare	$2,757.28
Rate for Payer: Kaiser Permanente Commercial	$3,265.20
Rate for Payer: Kaiser Permanente Medicaid	$1,850.28
Rate for Payer: Kaiser Permanente Medicare	$2,757.28
Rate for Payer: MDX Hawaii PPO	$3,519.16
Rate for Payer: Ohana Health Plan Medicaid	$2,757.28
Rate for Payer: Ohana Health Plan Medicare	$2,757.28
Rate for Payer: UnitedHealthcare Medicare	$2,757.28
Rate for Payer: University Health Alliance Commercial	$2,031.68

PATELLA 36X10MM X3 5550-G-360

Facility

$3,628.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$2,031.68
Max. Negotiated Rate	$3,519.16
Rate for Payer: Cash Price	$2,176.80
Rate for Payer: Hawaii Western Management Group Commercial	$2,539.60
Rate for Payer: Health Management Network Commercial	$3,083.80
Rate for Payer: Kaiser Permanente Commercial	$3,265.20
Rate for Payer: MDX Hawaii PPO	$3,519.16
Rate for Payer: University Health Alliance Commercial	$2,031.68

PATELLA 38X42X11MM 5551-T-381

Facility

$956.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$478.00
Max. Negotiated Rate	$927.32
Rate for Payer: AlohaCare Medicaid	$478.00
Rate for Payer: AlohaCare Medicare	$726.56
Rate for Payer: Cash Price	$573.60
Rate for Payer: Devoted Health Medicare	$803.04
Rate for Payer: Hawaii Medical Service Association Medicare	$726.56
Rate for Payer: Hawaii Western Management Group Commercial	$669.20
Rate for Payer: Health Management Network Commercial	$812.60
Rate for Payer: Humana Medicare	$726.56
Rate for Payer: Kaiser Permanente Commercial	$860.40
Rate for Payer: Kaiser Permanente Medicaid	$487.56
Rate for Payer: Kaiser Permanente Medicare	$726.56
Rate for Payer: MDX Hawaii PPO	$927.32
Rate for Payer: Ohana Health Plan Medicaid	$726.56
Rate for Payer: Ohana Health Plan Medicare	$726.56
Rate for Payer: UnitedHealthcare Medicare	$726.56
Rate for Payer: University Health Alliance Commercial	$535.36

PATELLA 38X42X11MM 5551-T-381

Facility

$956.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$535.36
Max. Negotiated Rate	$927.32
Rate for Payer: Cash Price	$573.60
Rate for Payer: Hawaii Western Management Group Commercial	$669.20
Rate for Payer: Health Management Network Commercial	$812.60
Rate for Payer: Kaiser Permanente Commercial	$860.40
Rate for Payer: MDX Hawaii PPO	$927.32
Rate for Payer: University Health Alliance Commercial	$535.36

PATELLA A32X10MM 5552-L-320

Facility

$2,317.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$1,297.52
Max. Negotiated Rate	$2,247.49
Rate for Payer: Cash Price	$1,390.20
Rate for Payer: Hawaii Western Management Group Commercial	$1,621.90
Rate for Payer: Health Management Network Commercial	$1,969.45
Rate for Payer: Kaiser Permanente Commercial	$2,085.30
Rate for Payer: MDX Hawaii PPO	$2,247.49
Rate for Payer: University Health Alliance Commercial	$1,297.52

PATELLA A32X10MM 5552-L-320

Facility

$2,317.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$1,158.50
Max. Negotiated Rate	$2,247.49
Rate for Payer: AlohaCare Medicaid	$1,158.50
Rate for Payer: AlohaCare Medicare	$1,760.92
Rate for Payer: Cash Price	$1,390.20
Rate for Payer: Devoted Health Medicare	$1,946.28
Rate for Payer: Hawaii Medical Service Association Medicare	$1,760.92
Rate for Payer: Hawaii Western Management Group Commercial	$1,621.90
Rate for Payer: Health Management Network Commercial	$1,969.45
Rate for Payer: Humana Medicare	$1,760.92
Rate for Payer: Kaiser Permanente Commercial	$2,085.30
Rate for Payer: Kaiser Permanente Medicaid	$1,181.67
Rate for Payer: Kaiser Permanente Medicare	$1,760.92
Rate for Payer: MDX Hawaii PPO	$2,247.49
Rate for Payer: Ohana Health Plan Medicaid	$1,760.92
Rate for Payer: Ohana Health Plan Medicare	$1,760.92
Rate for Payer: UnitedHealthcare Medicare	$1,760.92
Rate for Payer: University Health Alliance Commercial	$1,297.52

PATELLA ASYMETRIC 5551-G-299-E

Facility

$2,317.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$1,158.50
Max. Negotiated Rate	$2,247.49
Rate for Payer: AlohaCare Medicaid	$1,158.50
Rate for Payer: AlohaCare Medicare	$1,760.92
Rate for Payer: Cash Price	$1,390.20
Rate for Payer: Devoted Health Medicare	$1,946.28
Rate for Payer: Hawaii Medical Service Association Medicare	$1,760.92
Rate for Payer: Hawaii Western Management Group Commercial	$1,621.90
Rate for Payer: Health Management Network Commercial	$1,969.45
Rate for Payer: Humana Medicare	$1,760.92
Rate for Payer: Kaiser Permanente Commercial	$2,085.30
Rate for Payer: Kaiser Permanente Medicaid	$1,181.67
Rate for Payer: Kaiser Permanente Medicare	$1,760.92
Rate for Payer: MDX Hawaii PPO	$2,247.49
Rate for Payer: Ohana Health Plan Medicaid	$1,760.92
Rate for Payer: Ohana Health Plan Medicare	$1,760.92
Rate for Payer: UnitedHealthcare Medicare	$1,760.92
Rate for Payer: University Health Alliance Commercial	$1,297.52

PATELLA ASYMETRIC 5551-G-299-E

Facility

$2,317.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$1,297.52
Max. Negotiated Rate	$2,247.49
Rate for Payer: Cash Price	$1,390.20
Rate for Payer: Hawaii Western Management Group Commercial	$1,621.90
Rate for Payer: Health Management Network Commercial	$1,969.45
Rate for Payer: Kaiser Permanente Commercial	$2,085.30
Rate for Payer: MDX Hawaii PPO	$2,247.49
Rate for Payer: University Health Alliance Commercial	$1,297.52

PATELLA DOME 35MM 1518-20-035

Facility

$1,650.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$825.00
Max. Negotiated Rate	$1,600.50
Rate for Payer: AlohaCare Medicaid	$825.00
Rate for Payer: AlohaCare Medicare	$1,254.00
Rate for Payer: Cash Price	$990.00
Rate for Payer: Devoted Health Medicare	$1,386.00
Rate for Payer: Hawaii Medical Service Association Medicare	$1,254.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,155.00
Rate for Payer: Health Management Network Commercial	$1,402.50
Rate for Payer: Humana Medicare	$1,254.00
Rate for Payer: Kaiser Permanente Commercial	$1,485.00
Rate for Payer: Kaiser Permanente Medicaid	$841.50
Rate for Payer: Kaiser Permanente Medicare	$1,254.00
Rate for Payer: MDX Hawaii PPO	$1,600.50
Rate for Payer: Ohana Health Plan Medicaid	$1,254.00
Rate for Payer: Ohana Health Plan Medicare	$1,254.00
Rate for Payer: UnitedHealthcare Medicare	$1,254.00
Rate for Payer: University Health Alliance Commercial	$924.00

PATELLA DOME 35MM 1518-20-035

Facility

$1,650.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$924.00
Max. Negotiated Rate	$1,600.50
Rate for Payer: Cash Price	$990.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,155.00
Rate for Payer: Health Management Network Commercial	$1,402.50
Rate for Payer: Kaiser Permanente Commercial	$1,485.00
Rate for Payer: MDX Hawaii PPO	$1,600.50
Rate for Payer: University Health Alliance Commercial	$924.00

PATELLA DOME 41MM 1518-20-041

Facility

$1,650.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$924.00
Max. Negotiated Rate	$1,600.50
Rate for Payer: Cash Price	$990.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,155.00
Rate for Payer: Health Management Network Commercial	$1,402.50
Rate for Payer: Kaiser Permanente Commercial	$1,485.00
Rate for Payer: MDX Hawaii PPO	$1,600.50
Rate for Payer: University Health Alliance Commercial	$924.00

PATELLA DOME 41MM 1518-20-041

Facility

$1,650.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$825.00
Max. Negotiated Rate	$1,600.50
Rate for Payer: AlohaCare Medicaid	$825.00
Rate for Payer: AlohaCare Medicare	$1,254.00
Rate for Payer: Cash Price	$990.00
Rate for Payer: Devoted Health Medicare	$1,386.00
Rate for Payer: Hawaii Medical Service Association Medicare	$1,254.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,155.00
Rate for Payer: Health Management Network Commercial	$1,402.50
Rate for Payer: Humana Medicare	$1,254.00
Rate for Payer: Kaiser Permanente Commercial	$1,485.00
Rate for Payer: Kaiser Permanente Medicaid	$841.50
Rate for Payer: Kaiser Permanente Medicare	$1,254.00
Rate for Payer: MDX Hawaii PPO	$1,600.50
Rate for Payer: Ohana Health Plan Medicaid	$1,254.00
Rate for Payer: Ohana Health Plan Medicare	$1,254.00
Rate for Payer: UnitedHealthcare Medicare	$1,254.00
Rate for Payer: University Health Alliance Commercial	$924.00

PATELLA RESURFACE 02.07.0035RP

Facility

$1,575.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$787.50
Max. Negotiated Rate	$1,527.75
Rate for Payer: AlohaCare Medicaid	$787.50
Rate for Payer: AlohaCare Medicare	$1,197.00
Rate for Payer: Cash Price	$945.00
Rate for Payer: Devoted Health Medicare	$1,323.00
Rate for Payer: Hawaii Medical Service Association Medicare	$1,197.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,102.50
Rate for Payer: Health Management Network Commercial	$1,338.75
Rate for Payer: Humana Medicare	$1,197.00
Rate for Payer: Kaiser Permanente Commercial	$1,417.50
Rate for Payer: Kaiser Permanente Medicaid	$803.25
Rate for Payer: Kaiser Permanente Medicare	$1,197.00
Rate for Payer: MDX Hawaii PPO	$1,527.75
Rate for Payer: Ohana Health Plan Medicaid	$1,197.00
Rate for Payer: Ohana Health Plan Medicare	$1,197.00
Rate for Payer: UnitedHealthcare Medicare	$1,197.00
Rate for Payer: University Health Alliance Commercial	$882.00

PATELLA RESURFACE 02.07.0035RP

Facility

$1,575.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$882.00
Max. Negotiated Rate	$1,527.75
Rate for Payer: Cash Price	$945.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,102.50
Rate for Payer: Health Management Network Commercial	$1,338.75
Rate for Payer: Kaiser Permanente Commercial	$1,417.50
Rate for Payer: MDX Hawaii PPO	$1,527.75
Rate for Payer: University Health Alliance Commercial	$882.00

PATELLA RESURF S2 02.07.0034RP

Facility

$1,575.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$787.50
Max. Negotiated Rate	$1,527.75
Rate for Payer: AlohaCare Medicaid	$787.50
Rate for Payer: AlohaCare Medicare	$1,197.00
Rate for Payer: Cash Price	$945.00
Rate for Payer: Devoted Health Medicare	$1,323.00
Rate for Payer: Hawaii Medical Service Association Medicare	$1,197.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,102.50
Rate for Payer: Health Management Network Commercial	$1,338.75
Rate for Payer: Humana Medicare	$1,197.00
Rate for Payer: Kaiser Permanente Commercial	$1,417.50
Rate for Payer: Kaiser Permanente Medicaid	$803.25
Rate for Payer: Kaiser Permanente Medicare	$1,197.00
Rate for Payer: MDX Hawaii PPO	$1,527.75
Rate for Payer: Ohana Health Plan Medicaid	$1,197.00
Rate for Payer: Ohana Health Plan Medicare	$1,197.00
Rate for Payer: UnitedHealthcare Medicare	$1,197.00
Rate for Payer: University Health Alliance Commercial	$882.00

PATELLA RESURF S2 02.07.0034RP

Facility

$1,575.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$882.00
Max. Negotiated Rate	$1,527.75
Rate for Payer: Cash Price	$945.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,102.50
Rate for Payer: Health Management Network Commercial	$1,338.75
Rate for Payer: Kaiser Permanente Commercial	$1,417.50
Rate for Payer: MDX Hawaii PPO	$1,527.75
Rate for Payer: University Health Alliance Commercial	$882.00

Know your out-of-pocket cost for care.

All Charges