Honoka'a Hospital and Skilled Nursing Facility

All Charges

Charge

Type

Setting

Price

PEGFILGRASTIM 6 MG/0.6 ML (DELIVERABLE) WEARABLE SUBCUTANEOUS INJECTOR [129658]

Facility

$8,202.00

Service Code	HCPCS J2506
Hospital Revenue Code	250
Min. Negotiated Rate	$6,971.70
Max. Negotiated Rate	$7,955.94
Rate for Payer: Cash Price	$4,921.20
Rate for Payer: Health Management Network Commercial	$6,971.70
Rate for Payer: Kaiser Permanente Commercial	$7,381.80
Rate for Payer: MDX Hawaii PPO	$7,955.94

PEGFILGRASTIM 6 MG/0.6 ML (DELIVERABLE) WEARABLE SUBCUTANEOUS INJECTOR [129658]

Facility

$8,202.00

Service Code	HCPCS J2506
Hospital Revenue Code	636
Min. Negotiated Rate	$58.40
Max. Negotiated Rate	$7,955.94
Rate for Payer: AlohaCare Medicaid	$4,101.00
Rate for Payer: AlohaCare Medicare	$6,233.52
Rate for Payer: Cash Price	$4,921.20
Rate for Payer: Cash Price	$4,921.20
Rate for Payer: Devoted Health Medicare	$6,889.68
Rate for Payer: Hawaii Medical Service Association ABD	$58.40
Rate for Payer: Hawaii Medical Service Association Commercial	$159.22
Rate for Payer: Hawaii Medical Service Association Medicare	$6,233.52
Rate for Payer: Hawaii Medical Service Association Non-ABD	$58.40
Rate for Payer: Hawaii Western Management Group Commercial	$7,791.90
Rate for Payer: Health Management Network Commercial	$6,971.70
Rate for Payer: Humana Medicare	$6,233.52
Rate for Payer: Kaiser Permanente Commercial	$7,381.80
Rate for Payer: Kaiser Permanente Medicaid	$4,183.02
Rate for Payer: Kaiser Permanente Medicare	$6,233.52
Rate for Payer: MDX Hawaii PPO	$7,955.94
Rate for Payer: Ohana Health Plan Medicaid	$6,233.52
Rate for Payer: Ohana Health Plan Medicare	$6,233.52
Rate for Payer: UnitedHealthcare Medicaid	$4,921.20
Rate for Payer: UnitedHealthcare Medicare	$6,233.52
Rate for Payer: University Health Alliance Commercial	$5,978.44

PEGFILGRASTIM-APGF 6 MG/0.6 ML SUBCUTANEOUS SYRINGE [176068]

Facility

$5,210.00

Service Code	HCPCS Q5122
Hospital Revenue Code	250
Min. Negotiated Rate	$4,428.50
Max. Negotiated Rate	$5,053.70
Rate for Payer: Cash Price	$3,126.00
Rate for Payer: Health Management Network Commercial	$4,428.50
Rate for Payer: Kaiser Permanente Commercial	$4,689.00
Rate for Payer: MDX Hawaii PPO	$5,053.70

PEGFILGRASTIM-APGF 6 MG/0.6 ML SUBCUTANEOUS SYRINGE [176068]

Facility

$5,210.00

Service Code	HCPCS Q5122
Hospital Revenue Code	636
Min. Negotiated Rate	$132.04
Max. Negotiated Rate	$5,053.70
Rate for Payer: AlohaCare Medicaid	$2,605.00
Rate for Payer: AlohaCare Medicare	$3,959.60
Rate for Payer: Cash Price	$3,126.00
Rate for Payer: Cash Price	$3,126.00
Rate for Payer: Devoted Health Medicare	$4,376.40
Rate for Payer: Hawaii Medical Service Association ABD	$132.04
Rate for Payer: Hawaii Medical Service Association Commercial	$166.64
Rate for Payer: Hawaii Medical Service Association Medicare	$3,959.60
Rate for Payer: Hawaii Medical Service Association Non-ABD	$132.04
Rate for Payer: Hawaii Western Management Group Commercial	$4,949.50
Rate for Payer: Health Management Network Commercial	$4,428.50
Rate for Payer: Humana Medicare	$3,959.60
Rate for Payer: Kaiser Permanente Commercial	$4,689.00
Rate for Payer: Kaiser Permanente Medicaid	$2,657.10
Rate for Payer: Kaiser Permanente Medicare	$3,959.60
Rate for Payer: MDX Hawaii PPO	$5,053.70
Rate for Payer: Ohana Health Plan Medicaid	$3,959.60
Rate for Payer: Ohana Health Plan Medicare	$3,959.60
Rate for Payer: UnitedHealthcare Medicaid	$3,126.00
Rate for Payer: UnitedHealthcare Medicare	$3,959.60
Rate for Payer: University Health Alliance Commercial	$3,797.57

PEGFILGRASTIM-CBQV 6 MG/0.6 ML (DELIVERABLE) WEARABLE SUBCUT INJECTOR [196326]

Facility

$5,510.00

Service Code	HCPCS Q5111
Hospital Revenue Code	636
Min. Negotiated Rate	$136.04
Max. Negotiated Rate	$5,344.70
Rate for Payer: AlohaCare Medicaid	$2,755.00
Rate for Payer: AlohaCare Medicare	$4,187.60
Rate for Payer: Cash Price	$3,306.00
Rate for Payer: Cash Price	$3,306.00
Rate for Payer: Devoted Health Medicare	$4,628.40
Rate for Payer: Hawaii Medical Service Association ABD	$136.04
Rate for Payer: Hawaii Medical Service Association Commercial	$169.86
Rate for Payer: Hawaii Medical Service Association Medicare	$4,187.60
Rate for Payer: Hawaii Medical Service Association Non-ABD	$136.04
Rate for Payer: Hawaii Western Management Group Commercial	$5,234.50
Rate for Payer: Health Management Network Commercial	$4,683.50
Rate for Payer: Humana Medicare	$4,187.60
Rate for Payer: Kaiser Permanente Commercial	$4,959.00
Rate for Payer: Kaiser Permanente Medicaid	$2,810.10
Rate for Payer: Kaiser Permanente Medicare	$4,187.60
Rate for Payer: MDX Hawaii PPO	$5,344.70
Rate for Payer: Ohana Health Plan Medicaid	$4,187.60
Rate for Payer: Ohana Health Plan Medicare	$4,187.60
Rate for Payer: UnitedHealthcare Medicaid	$3,306.00
Rate for Payer: UnitedHealthcare Medicare	$4,187.60
Rate for Payer: University Health Alliance Commercial	$4,016.24

PEGFILGRASTIM-CBQV 6 MG/0.6 ML (DELIVERABLE) WEARABLE SUBCUT INJECTOR [196326]

Facility

$5,510.00

Service Code	HCPCS Q5111
Hospital Revenue Code	250
Min. Negotiated Rate	$4,683.50
Max. Negotiated Rate	$5,344.70
Rate for Payer: Cash Price	$3,306.00
Rate for Payer: Health Management Network Commercial	$4,683.50
Rate for Payer: Kaiser Permanente Commercial	$4,959.00
Rate for Payer: MDX Hawaii PPO	$5,344.70

PEGFILGRASTIM-CBQV 6 MG/0.6 ML SUBCUTANEOUS SYRINGE [164810]

Facility

$5,510.00

Service Code	HCPCS Q5111
Hospital Revenue Code	636
Min. Negotiated Rate	$136.04
Max. Negotiated Rate	$5,344.70
Rate for Payer: MDX Hawaii PPO	$5,344.70
Rate for Payer: AlohaCare Medicaid	$2,755.00
Rate for Payer: AlohaCare Medicare	$4,187.60
Rate for Payer: Cash Price	$3,306.00
Rate for Payer: Cash Price	$3,306.00
Rate for Payer: Devoted Health Medicare	$4,628.40
Rate for Payer: Hawaii Medical Service Association ABD	$136.04
Rate for Payer: Hawaii Medical Service Association Commercial	$169.86
Rate for Payer: Hawaii Medical Service Association Medicare	$4,187.60
Rate for Payer: Hawaii Medical Service Association Non-ABD	$136.04
Rate for Payer: Hawaii Western Management Group Commercial	$5,234.50
Rate for Payer: Health Management Network Commercial	$4,683.50
Rate for Payer: Humana Medicare	$4,187.60
Rate for Payer: Kaiser Permanente Commercial	$4,959.00
Rate for Payer: Kaiser Permanente Medicaid	$2,810.10
Rate for Payer: Kaiser Permanente Medicare	$4,187.60
Rate for Payer: Ohana Health Plan Medicaid	$4,187.60
Rate for Payer: Ohana Health Plan Medicare	$4,187.60
Rate for Payer: UnitedHealthcare Medicaid	$3,306.00
Rate for Payer: UnitedHealthcare Medicare	$4,187.60
Rate for Payer: University Health Alliance Commercial	$4,016.24

PEGFILGRASTIM-CBQV 6 MG/0.6 ML SUBCUTANEOUS SYRINGE [164810]

Facility

$5,510.00

Service Code	HCPCS Q5111
Hospital Revenue Code	250
Min. Negotiated Rate	$4,683.50
Max. Negotiated Rate	$5,344.70
Rate for Payer: Cash Price	$3,306.00
Rate for Payer: Health Management Network Commercial	$4,683.50
Rate for Payer: Kaiser Permanente Commercial	$4,959.00
Rate for Payer: MDX Hawaii PPO	$5,344.70

PEGINTERFERON ALFA-2A 180 MCG/ML SUBCUTANEOUS SOLUTION [34034]

Facility

$1,837.00

Service Code	HCPCS S0145
Hospital Revenue Code	250
Min. Negotiated Rate	$1,561.45
Max. Negotiated Rate	$1,781.89
Rate for Payer: Cash Price	$1,102.20
Rate for Payer: Health Management Network Commercial	$1,561.45
Rate for Payer: Kaiser Permanente Commercial	$1,653.30
Rate for Payer: MDX Hawaii PPO	$1,781.89

PEGINTERFERON ALFA-2A 180 MCG/ML SUBCUTANEOUS SOLUTION [34034]

Facility

$1,837.00

Service Code	HCPCS S0145
Hospital Revenue Code	636
Min. Negotiated Rate	$918.50
Max. Negotiated Rate	$1,781.89
Rate for Payer: AlohaCare Medicaid	$918.50
Rate for Payer: AlohaCare Medicare	$1,396.12
Rate for Payer: Cash Price	$1,102.20
Rate for Payer: Devoted Health Medicare	$1,543.08
Rate for Payer: Hawaii Medical Service Association Medicare	$1,396.12
Rate for Payer: Hawaii Western Management Group Commercial	$1,745.15
Rate for Payer: Health Management Network Commercial	$1,561.45
Rate for Payer: Humana Medicare	$1,396.12
Rate for Payer: Kaiser Permanente Commercial	$1,653.30
Rate for Payer: Kaiser Permanente Medicaid	$936.87
Rate for Payer: Kaiser Permanente Medicare	$1,396.12
Rate for Payer: MDX Hawaii PPO	$1,781.89
Rate for Payer: Ohana Health Plan Medicaid	$1,396.12
Rate for Payer: Ohana Health Plan Medicare	$1,396.12
Rate for Payer: UnitedHealthcare Medicaid	$1,102.20
Rate for Payer: UnitedHealthcare Medicare	$1,396.12
Rate for Payer: University Health Alliance Commercial	$1,338.99

PEG KIT 20FR M00568201

Facility

$240.00

Hospital Revenue Code	272
Min. Negotiated Rate	$204.00
Max. Negotiated Rate	$232.80
Rate for Payer: Cash Price	$144.00
Rate for Payer: Health Management Network Commercial	$204.00
Rate for Payer: Kaiser Permanente Commercial	$216.00
Rate for Payer: MDX Hawaii PPO	$232.80

PEG KIT 20FR M00568201

Facility

$240.00

Hospital Revenue Code	272
Min. Negotiated Rate	$120.00
Max. Negotiated Rate	$232.80
Rate for Payer: AlohaCare Medicaid	$120.00
Rate for Payer: AlohaCare Medicare	$182.40
Rate for Payer: Cash Price	$144.00
Rate for Payer: Devoted Health Medicare	$201.60
Rate for Payer: Hawaii Medical Service Association Medicare	$182.40
Rate for Payer: Hawaii Western Management Group Commercial	$228.00
Rate for Payer: Health Management Network Commercial	$204.00
Rate for Payer: Humana Medicare	$182.40
Rate for Payer: Kaiser Permanente Commercial	$216.00
Rate for Payer: Kaiser Permanente Medicaid	$122.40
Rate for Payer: Kaiser Permanente Medicare	$182.40
Rate for Payer: MDX Hawaii PPO	$232.80
Rate for Payer: Ohana Health Plan Medicaid	$182.40
Rate for Payer: Ohana Health Plan Medicare	$182.40
Rate for Payer: UnitedHealthcare Medicare	$182.40
Rate for Payer: University Health Alliance Commercial	$174.94

PEG OXFORD FEMORAL TWIN MED

Facility

$3,840.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$2,150.40
Max. Negotiated Rate	$3,724.80
Rate for Payer: Cash Price	$2,304.00
Rate for Payer: Hawaii Western Management Group Commercial	$2,688.00
Rate for Payer: Health Management Network Commercial	$3,264.00
Rate for Payer: Kaiser Permanente Commercial	$3,456.00
Rate for Payer: MDX Hawaii PPO	$3,724.80
Rate for Payer: University Health Alliance Commercial	$2,150.40

PEG OXFORD FEMORAL TWIN MED

Facility

$3,840.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$1,920.00
Max. Negotiated Rate	$3,724.80
Rate for Payer: AlohaCare Medicaid	$1,920.00
Rate for Payer: AlohaCare Medicare	$2,918.40
Rate for Payer: Cash Price	$2,304.00
Rate for Payer: Devoted Health Medicare	$3,225.60
Rate for Payer: Hawaii Medical Service Association Medicare	$2,918.40
Rate for Payer: Hawaii Western Management Group Commercial	$2,688.00
Rate for Payer: Health Management Network Commercial	$3,264.00
Rate for Payer: Humana Medicare	$2,918.40
Rate for Payer: Kaiser Permanente Commercial	$3,456.00
Rate for Payer: Kaiser Permanente Medicaid	$1,958.40
Rate for Payer: Kaiser Permanente Medicare	$2,918.40
Rate for Payer: MDX Hawaii PPO	$3,724.80
Rate for Payer: Ohana Health Plan Medicaid	$2,918.40
Rate for Payer: Ohana Health Plan Medicare	$2,918.40
Rate for Payer: UnitedHealthcare Medicare	$2,918.40
Rate for Payer: University Health Alliance Commercial	$2,150.40

PEG THREADED 2.5X20MM TP20

Facility

$600.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$336.00
Max. Negotiated Rate	$582.00
Rate for Payer: Cash Price	$360.00
Rate for Payer: Hawaii Western Management Group Commercial	$420.00
Rate for Payer: Health Management Network Commercial	$510.00
Rate for Payer: Kaiser Permanente Commercial	$540.00
Rate for Payer: MDX Hawaii PPO	$582.00
Rate for Payer: University Health Alliance Commercial	$336.00

PEG THREADED 2.5X20MM TP20

Facility

$600.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$300.00
Max. Negotiated Rate	$582.00
Rate for Payer: AlohaCare Medicaid	$300.00
Rate for Payer: AlohaCare Medicare	$456.00
Rate for Payer: Cash Price	$360.00
Rate for Payer: Devoted Health Medicare	$504.00
Rate for Payer: Hawaii Medical Service Association Medicare	$456.00
Rate for Payer: Hawaii Western Management Group Commercial	$420.00
Rate for Payer: Health Management Network Commercial	$510.00
Rate for Payer: Humana Medicare	$456.00
Rate for Payer: Kaiser Permanente Commercial	$540.00
Rate for Payer: Kaiser Permanente Medicaid	$306.00
Rate for Payer: Kaiser Permanente Medicare	$456.00
Rate for Payer: MDX Hawaii PPO	$582.00
Rate for Payer: Ohana Health Plan Medicaid	$456.00
Rate for Payer: Ohana Health Plan Medicare	$456.00
Rate for Payer: UnitedHealthcare Medicare	$456.00
Rate for Payer: University Health Alliance Commercial	$336.00

PEG THREADED 2.5X24MM TP24

Facility

$600.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$300.00
Max. Negotiated Rate	$582.00
Rate for Payer: AlohaCare Medicaid	$300.00
Rate for Payer: AlohaCare Medicare	$456.00
Rate for Payer: Cash Price	$360.00
Rate for Payer: Devoted Health Medicare	$504.00
Rate for Payer: Hawaii Medical Service Association Medicare	$456.00
Rate for Payer: Hawaii Western Management Group Commercial	$420.00
Rate for Payer: Health Management Network Commercial	$510.00
Rate for Payer: Humana Medicare	$456.00
Rate for Payer: Kaiser Permanente Commercial	$540.00
Rate for Payer: Kaiser Permanente Medicaid	$306.00
Rate for Payer: Kaiser Permanente Medicare	$456.00
Rate for Payer: MDX Hawaii PPO	$582.00
Rate for Payer: Ohana Health Plan Medicaid	$456.00
Rate for Payer: Ohana Health Plan Medicare	$456.00
Rate for Payer: UnitedHealthcare Medicare	$456.00
Rate for Payer: University Health Alliance Commercial	$336.00

PEG THREADED 2.5X24MM TP24

Facility

$600.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$336.00
Max. Negotiated Rate	$582.00
Rate for Payer: Cash Price	$360.00
Rate for Payer: Hawaii Western Management Group Commercial	$420.00
Rate for Payer: Health Management Network Commercial	$510.00
Rate for Payer: Kaiser Permanente Commercial	$540.00
Rate for Payer: MDX Hawaii PPO	$582.00
Rate for Payer: University Health Alliance Commercial	$336.00

PEG THREADED 2.5X30MM TP30000

Facility

$417.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$233.52
Max. Negotiated Rate	$404.49
Rate for Payer: Cash Price	$250.20
Rate for Payer: Hawaii Western Management Group Commercial	$291.90
Rate for Payer: Health Management Network Commercial	$354.45
Rate for Payer: Kaiser Permanente Commercial	$375.30
Rate for Payer: MDX Hawaii PPO	$404.49
Rate for Payer: University Health Alliance Commercial	$233.52

PEG THREADED 2.5X30MM TP30000

Facility

$417.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$208.50
Max. Negotiated Rate	$404.49
Rate for Payer: AlohaCare Medicaid	$208.50
Rate for Payer: AlohaCare Medicare	$316.92
Rate for Payer: Cash Price	$250.20
Rate for Payer: Devoted Health Medicare	$350.28
Rate for Payer: Hawaii Medical Service Association Medicare	$316.92
Rate for Payer: Hawaii Western Management Group Commercial	$291.90
Rate for Payer: Health Management Network Commercial	$354.45
Rate for Payer: Humana Medicare	$316.92
Rate for Payer: Kaiser Permanente Commercial	$375.30
Rate for Payer: Kaiser Permanente Medicaid	$212.67
Rate for Payer: Kaiser Permanente Medicare	$316.92
Rate for Payer: MDX Hawaii PPO	$404.49
Rate for Payer: Ohana Health Plan Medicaid	$316.92
Rate for Payer: Ohana Health Plan Medicare	$316.92
Rate for Payer: UnitedHealthcare Medicare	$316.92
Rate for Payer: University Health Alliance Commercial	$233.52

PEG TWIG FEMUR SMALL

Facility

$3,840.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$2,150.40
Max. Negotiated Rate	$3,724.80
Rate for Payer: Cash Price	$2,304.00
Rate for Payer: Hawaii Western Management Group Commercial	$2,688.00
Rate for Payer: Health Management Network Commercial	$3,264.00
Rate for Payer: Kaiser Permanente Commercial	$3,456.00
Rate for Payer: MDX Hawaii PPO	$3,724.80
Rate for Payer: University Health Alliance Commercial	$2,150.40

PEG TWIG FEMUR SMALL

Facility

$3,840.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$1,920.00
Max. Negotiated Rate	$3,724.80
Rate for Payer: AlohaCare Medicaid	$1,920.00
Rate for Payer: AlohaCare Medicare	$2,918.40
Rate for Payer: Cash Price	$2,304.00
Rate for Payer: Devoted Health Medicare	$3,225.60
Rate for Payer: Hawaii Medical Service Association Medicare	$2,918.40
Rate for Payer: Hawaii Western Management Group Commercial	$2,688.00
Rate for Payer: Health Management Network Commercial	$3,264.00
Rate for Payer: Humana Medicare	$2,918.40
Rate for Payer: Kaiser Permanente Commercial	$3,456.00
Rate for Payer: Kaiser Permanente Medicaid	$1,958.40
Rate for Payer: Kaiser Permanente Medicare	$2,918.40
Rate for Payer: MDX Hawaii PPO	$3,724.80
Rate for Payer: Ohana Health Plan Medicaid	$2,918.40
Rate for Payer: Ohana Health Plan Medicare	$2,918.40
Rate for Payer: UnitedHealthcare Medicare	$2,918.40
Rate for Payer: University Health Alliance Commercial	$2,150.40

PELVIC EVISCERATION, RADICAL HYSTERECTOMY AND RADICAL VULVECTOMY WITH CC/MCC

Facility

$39,487.53

Service Code	MSDRG 734
Min. Negotiated Rate	$39,487.53
Max. Negotiated Rate	$39,487.53
Rate for Payer: Hawaii Medical Service Association Commercial	$39,487.53

PELVIC EVISCERATION, RADICAL HYSTERECTOMY AND RADICAL VULVECTOMY WITHOUT CC/MCC

Facility

$39,487.53

Service Code	MSDRG 735
Min. Negotiated Rate	$39,487.53
Max. Negotiated Rate	$39,487.53
Rate for Payer: Hawaii Medical Service Association Commercial	$39,487.53

PEMBROLIZUMAB 25 MG/ML INTRAVENOUS SOLUTION [127964]

Facility

$14,938.00

Service Code	HCPCS J9271
Hospital Revenue Code	250
Min. Negotiated Rate	$12,697.30
Max. Negotiated Rate	$14,489.86
Rate for Payer: Cash Price	$8,962.80
Rate for Payer: Cash Price	$4,631.40
Rate for Payer: Health Management Network Commercial	$6,561.15
Rate for Payer: Health Management Network Commercial	$12,697.30
Rate for Payer: Kaiser Permanente Commercial	$13,444.20
Rate for Payer: Kaiser Permanente Commercial	$6,947.10
Rate for Payer: MDX Hawaii PPO	$14,489.86
Rate for Payer: MDX Hawaii PPO	$7,487.43

Know your out-of-pocket cost for care.

All Charges