Honoka'a Hospital and Skilled Nursing Facility

All Charges

Charge

Type

Setting

Price

PENICILLIN V POTASSIUM 250 MG/5 ML ORAL SOLUTION [6091]

Facility

$28.00

Service Code	NDC 00093412773
Hospital Revenue Code	250
Min. Negotiated Rate	$23.80
Max. Negotiated Rate	$27.16
Rate for Payer: Cash Price	$16.80
Rate for Payer: Health Management Network Commercial	$23.80
Rate for Payer: Kaiser Permanente Commercial	$25.20
Rate for Payer: MDX Hawaii PPO	$27.16

PENICILLIN V POTASSIUM 250 MG/5 ML ORAL SOLUTION [6091]

Facility

$28.00

Service Code	NDC 00093412773
Hospital Revenue Code	637
Min. Negotiated Rate	$14.00
Max. Negotiated Rate	$27.16
Rate for Payer: AlohaCare Medicaid	$14.00
Rate for Payer: AlohaCare Medicare	$21.28
Rate for Payer: Cash Price	$16.80
Rate for Payer: Devoted Health Medicare	$23.52
Rate for Payer: Hawaii Medical Service Association Medicare	$21.28
Rate for Payer: Hawaii Western Management Group Commercial	$26.60
Rate for Payer: Health Management Network Commercial	$23.80
Rate for Payer: Humana Medicare	$21.28
Rate for Payer: Kaiser Permanente Commercial	$25.20
Rate for Payer: Kaiser Permanente Medicaid	$14.28
Rate for Payer: Kaiser Permanente Medicare	$21.28
Rate for Payer: MDX Hawaii PPO	$27.16
Rate for Payer: Ohana Health Plan Medicaid	$21.28
Rate for Payer: Ohana Health Plan Medicare	$21.28
Rate for Payer: UnitedHealthcare Medicare	$21.28
Rate for Payer: University Health Alliance Commercial	$20.41

PENICILLIN V POTASSIUM 250 MG TABLET [6092]

Facility

$3.00

Service Code	NDC 00143983701
Hospital Revenue Code	250
Min. Negotiated Rate	$2.55
Max. Negotiated Rate	$2.91
Rate for Payer: Cash Price	$1.80
Rate for Payer: Health Management Network Commercial	$2.55
Rate for Payer: Kaiser Permanente Commercial	$2.70
Rate for Payer: MDX Hawaii PPO	$2.91

PENICILLIN V POTASSIUM 250 MG TABLET [6092]

Facility

$3.00

Service Code	NDC 00143983701
Hospital Revenue Code	637
Min. Negotiated Rate	$1.50
Max. Negotiated Rate	$2.91
Rate for Payer: AlohaCare Medicaid	$1.50
Rate for Payer: AlohaCare Medicare	$2.28
Rate for Payer: Cash Price	$1.80
Rate for Payer: Devoted Health Medicare	$2.52
Rate for Payer: Hawaii Medical Service Association Medicare	$2.28
Rate for Payer: Hawaii Western Management Group Commercial	$2.85
Rate for Payer: Health Management Network Commercial	$2.55
Rate for Payer: Humana Medicare	$2.28
Rate for Payer: Kaiser Permanente Commercial	$2.70
Rate for Payer: Kaiser Permanente Medicaid	$1.53
Rate for Payer: Kaiser Permanente Medicare	$2.28
Rate for Payer: MDX Hawaii PPO	$2.91
Rate for Payer: Ohana Health Plan Medicaid	$2.28
Rate for Payer: Ohana Health Plan Medicare	$2.28
Rate for Payer: UnitedHealthcare Medicare	$2.28
Rate for Payer: University Health Alliance Commercial	$2.19

PENICILLIN V POTASSIUM 500 MG TABLET [6093]

Facility

$3.00

Service Code	NDC 57237004101
Hospital Revenue Code	637
Min. Negotiated Rate	$1.50
Max. Negotiated Rate	$2.91
Rate for Payer: AlohaCare Medicaid	$1.50
Rate for Payer: AlohaCare Medicare	$2.28
Rate for Payer: Cash Price	$1.80
Rate for Payer: Devoted Health Medicare	$2.52
Rate for Payer: Hawaii Medical Service Association Medicare	$2.28
Rate for Payer: Hawaii Western Management Group Commercial	$2.85
Rate for Payer: Health Management Network Commercial	$2.55
Rate for Payer: Humana Medicare	$2.28
Rate for Payer: Kaiser Permanente Commercial	$2.70
Rate for Payer: Kaiser Permanente Medicaid	$1.53
Rate for Payer: Kaiser Permanente Medicare	$2.28
Rate for Payer: MDX Hawaii PPO	$2.91
Rate for Payer: Ohana Health Plan Medicaid	$2.28
Rate for Payer: Ohana Health Plan Medicare	$2.28
Rate for Payer: UnitedHealthcare Medicare	$2.28
Rate for Payer: University Health Alliance Commercial	$2.19

PENICILLIN V POTASSIUM 500 MG TABLET [6093]

Facility

$3.00

Service Code	NDC 57237004101
Hospital Revenue Code	250
Min. Negotiated Rate	$2.55
Max. Negotiated Rate	$2.91
Rate for Payer: Cash Price	$1.80
Rate for Payer: Health Management Network Commercial	$2.55
Rate for Payer: Kaiser Permanente Commercial	$2.70
Rate for Payer: MDX Hawaii PPO	$2.91

PENIS PROCEDURES WITH CC/MCC

Facility

$24,958.21

Service Code	MSDRG 709
Min. Negotiated Rate	$24,958.21
Max. Negotiated Rate	$24,958.21
Rate for Payer: Hawaii Medical Service Association Commercial	$24,958.21

PENIS PROCEDURES WITHOUT CC/MCC

Facility

$24,958.21

Service Code	MSDRG 710
Min. Negotiated Rate	$24,958.21
Max. Negotiated Rate	$24,958.21
Rate for Payer: Hawaii Medical Service Association Commercial	$24,958.21

PENTAMIDINE 300 MG SOLUTION FOR INHALATION [28235]

Facility

$271.00

Service Code	HCPCS J2545
Hospital Revenue Code	250
Min. Negotiated Rate	$230.35
Max. Negotiated Rate	$262.87
Rate for Payer: Cash Price	$162.60
Rate for Payer: Cash Price	$101.40
Rate for Payer: Health Management Network Commercial	$230.35
Rate for Payer: Health Management Network Commercial	$143.65
Rate for Payer: Kaiser Permanente Commercial	$152.10
Rate for Payer: Kaiser Permanente Commercial	$243.90
Rate for Payer: MDX Hawaii PPO	$262.87
Rate for Payer: MDX Hawaii PPO	$163.93

PENTAMIDINE 300 MG SOLUTION FOR INHALATION [28235]

Facility

$169.00

Service Code	HCPCS J2545
Hospital Revenue Code	636
Min. Negotiated Rate	$82.37
Max. Negotiated Rate	$163.93
Rate for Payer: AlohaCare Medicaid	$84.50
Rate for Payer: AlohaCare Medicaid	$135.50
Rate for Payer: AlohaCare Medicare	$205.96
Rate for Payer: AlohaCare Medicare	$128.44
Rate for Payer: Cash Price	$162.60
Rate for Payer: Cash Price	$101.40
Rate for Payer: Cash Price	$101.40
Rate for Payer: Cash Price	$162.60
Rate for Payer: Devoted Health Medicare	$227.64
Rate for Payer: Devoted Health Medicare	$141.96
Rate for Payer: Hawaii Medical Service Association ABD	$82.37
Rate for Payer: Hawaii Medical Service Association ABD	$82.37
Rate for Payer: Hawaii Medical Service Association Medicare	$128.44
Rate for Payer: Hawaii Medical Service Association Medicare	$205.96
Rate for Payer: Hawaii Medical Service Association Non-ABD	$82.37
Rate for Payer: Hawaii Medical Service Association Non-ABD	$82.37
Rate for Payer: Hawaii Western Management Group Commercial	$257.45
Rate for Payer: Hawaii Western Management Group Commercial	$160.55
Rate for Payer: Health Management Network Commercial	$143.65
Rate for Payer: Health Management Network Commercial	$230.35
Rate for Payer: Humana Medicare	$205.96
Rate for Payer: Humana Medicare	$128.44
Rate for Payer: Kaiser Permanente Commercial	$152.10
Rate for Payer: Kaiser Permanente Commercial	$243.90
Rate for Payer: Kaiser Permanente Medicaid	$138.21
Rate for Payer: Kaiser Permanente Medicaid	$86.19
Rate for Payer: Kaiser Permanente Medicare	$205.96
Rate for Payer: Kaiser Permanente Medicare	$128.44
Rate for Payer: MDX Hawaii PPO	$163.93
Rate for Payer: MDX Hawaii PPO	$262.87
Rate for Payer: Ohana Health Plan Medicaid	$205.96
Rate for Payer: Ohana Health Plan Medicaid	$128.44
Rate for Payer: Ohana Health Plan Medicare	$128.44
Rate for Payer: Ohana Health Plan Medicare	$205.96
Rate for Payer: UnitedHealthcare Medicaid	$162.60
Rate for Payer: UnitedHealthcare Medicaid	$101.40
Rate for Payer: UnitedHealthcare Medicare	$128.44
Rate for Payer: UnitedHealthcare Medicare	$205.96
Rate for Payer: University Health Alliance Commercial	$123.18
Rate for Payer: University Health Alliance Commercial	$197.53

PENTOXIFYLLINE ER 400 MG TABLET,EXTENDED RELEASE [21300]

Facility

$4.00

Service Code	NDC 60505003306
Hospital Revenue Code	637
Min. Negotiated Rate	$2.00
Max. Negotiated Rate	$3.88
Rate for Payer: AlohaCare Medicaid	$2.00
Rate for Payer: AlohaCare Medicare	$3.04
Rate for Payer: Cash Price	$2.40
Rate for Payer: Devoted Health Medicare	$3.36
Rate for Payer: Hawaii Medical Service Association Medicare	$3.04
Rate for Payer: Hawaii Western Management Group Commercial	$3.80
Rate for Payer: Health Management Network Commercial	$3.40
Rate for Payer: Humana Medicare	$3.04
Rate for Payer: Kaiser Permanente Commercial	$3.60
Rate for Payer: Kaiser Permanente Medicaid	$2.04
Rate for Payer: Kaiser Permanente Medicare	$3.04
Rate for Payer: MDX Hawaii PPO	$3.88
Rate for Payer: Ohana Health Plan Medicaid	$3.04
Rate for Payer: Ohana Health Plan Medicare	$3.04
Rate for Payer: UnitedHealthcare Medicare	$3.04
Rate for Payer: University Health Alliance Commercial	$2.92

PENTOXIFYLLINE ER 400 MG TABLET,EXTENDED RELEASE [21300]

Facility

$2.00

Service Code	NDC 00904544861
Hospital Revenue Code	250
Min. Negotiated Rate	$1.70
Max. Negotiated Rate	$1.94
Rate for Payer: Cash Price	$1.20
Rate for Payer: Health Management Network Commercial	$1.70
Rate for Payer: Kaiser Permanente Commercial	$1.80
Rate for Payer: MDX Hawaii PPO	$1.94

PENTOXIFYLLINE ER 400 MG TABLET,EXTENDED RELEASE [21300]

Facility

$2.00

Service Code	NDC 00904544861
Hospital Revenue Code	637
Min. Negotiated Rate	$1.00
Max. Negotiated Rate	$1.94
Rate for Payer: AlohaCare Medicaid	$1.00
Rate for Payer: AlohaCare Medicare	$1.52
Rate for Payer: Cash Price	$1.20
Rate for Payer: Devoted Health Medicare	$1.68
Rate for Payer: Hawaii Medical Service Association Medicare	$1.52
Rate for Payer: Hawaii Western Management Group Commercial	$1.90
Rate for Payer: Health Management Network Commercial	$1.70
Rate for Payer: Humana Medicare	$1.52
Rate for Payer: Kaiser Permanente Commercial	$1.80
Rate for Payer: Kaiser Permanente Medicaid	$1.02
Rate for Payer: Kaiser Permanente Medicare	$1.52
Rate for Payer: MDX Hawaii PPO	$1.94
Rate for Payer: Ohana Health Plan Medicaid	$1.52
Rate for Payer: Ohana Health Plan Medicare	$1.52
Rate for Payer: UnitedHealthcare Medicare	$1.52
Rate for Payer: University Health Alliance Commercial	$1.46

PENTOXIFYLLINE ER 400 MG TABLET,EXTENDED RELEASE [21300]

Facility

$4.00

Service Code	NDC 60505003306
Hospital Revenue Code	250
Min. Negotiated Rate	$3.40
Max. Negotiated Rate	$3.88
Rate for Payer: Cash Price	$2.40
Rate for Payer: Health Management Network Commercial	$3.40
Rate for Payer: Kaiser Permanente Commercial	$3.60
Rate for Payer: MDX Hawaii PPO	$3.88

PENUMBRA ENGINE

Facility

$4,500.00

Service Code	HCPCS C1887
Hospital Revenue Code	272
Min. Negotiated Rate	$2,250.00
Max. Negotiated Rate	$4,365.00
Rate for Payer: AlohaCare Medicaid	$2,250.00
Rate for Payer: AlohaCare Medicare	$3,420.00
Rate for Payer: Cash Price	$2,700.00
Rate for Payer: Devoted Health Medicare	$3,780.00
Rate for Payer: Hawaii Medical Service Association Medicare	$3,420.00
Rate for Payer: Hawaii Western Management Group Commercial	$4,275.00
Rate for Payer: Health Management Network Commercial	$3,825.00
Rate for Payer: Humana Medicare	$3,420.00
Rate for Payer: Kaiser Permanente Commercial	$4,050.00
Rate for Payer: Kaiser Permanente Medicaid	$2,295.00
Rate for Payer: Kaiser Permanente Medicare	$3,420.00
Rate for Payer: MDX Hawaii PPO	$4,365.00
Rate for Payer: Ohana Health Plan Medicaid	$3,420.00
Rate for Payer: Ohana Health Plan Medicare	$3,420.00
Rate for Payer: UnitedHealthcare Medicare	$3,420.00
Rate for Payer: University Health Alliance Commercial	$3,280.05

PENUMBRA ENGINE

Facility

$4,500.00

Service Code	HCPCS C1887
Hospital Revenue Code	272
Min. Negotiated Rate	$3,825.00
Max. Negotiated Rate	$4,365.00
Rate for Payer: Cash Price	$2,700.00
Rate for Payer: Health Management Network Commercial	$3,825.00
Rate for Payer: Kaiser Permanente Commercial	$4,050.00
Rate for Payer: MDX Hawaii PPO	$4,365.00

PENUMBRA ENGINE CANISTER

Facility

$1,260.00

Service Code	HCPCS C1887
Hospital Revenue Code	272
Min. Negotiated Rate	$630.00
Max. Negotiated Rate	$1,222.20
Rate for Payer: AlohaCare Medicaid	$630.00
Rate for Payer: AlohaCare Medicare	$957.60
Rate for Payer: Cash Price	$756.00
Rate for Payer: Devoted Health Medicare	$1,058.40
Rate for Payer: Hawaii Medical Service Association Medicare	$957.60
Rate for Payer: Hawaii Western Management Group Commercial	$1,197.00
Rate for Payer: Health Management Network Commercial	$1,071.00
Rate for Payer: Humana Medicare	$957.60
Rate for Payer: Kaiser Permanente Commercial	$1,134.00
Rate for Payer: Kaiser Permanente Medicaid	$642.60
Rate for Payer: Kaiser Permanente Medicare	$957.60
Rate for Payer: MDX Hawaii PPO	$1,222.20
Rate for Payer: Ohana Health Plan Medicaid	$957.60
Rate for Payer: Ohana Health Plan Medicare	$957.60
Rate for Payer: UnitedHealthcare Medicare	$957.60
Rate for Payer: University Health Alliance Commercial	$918.41

PENUMBRA ENGINE CANISTER

Facility

$1,260.00

Service Code	HCPCS C1887
Hospital Revenue Code	272
Min. Negotiated Rate	$1,071.00
Max. Negotiated Rate	$1,222.20
Rate for Payer: Cash Price	$756.00
Rate for Payer: Health Management Network Commercial	$1,071.00
Rate for Payer: Kaiser Permanente Commercial	$1,134.00
Rate for Payer: MDX Hawaii PPO	$1,222.20

PERC 2.4 INSERT KIT #AR-1934PI

Facility

$977.00

Hospital Revenue Code	272
Min. Negotiated Rate	$488.50
Max. Negotiated Rate	$947.69
Rate for Payer: AlohaCare Medicaid	$488.50
Rate for Payer: AlohaCare Medicare	$742.52
Rate for Payer: Cash Price	$586.20
Rate for Payer: Devoted Health Medicare	$820.68
Rate for Payer: Hawaii Medical Service Association Medicare	$742.52
Rate for Payer: Hawaii Western Management Group Commercial	$928.15
Rate for Payer: Health Management Network Commercial	$830.45
Rate for Payer: Humana Medicare	$742.52
Rate for Payer: Kaiser Permanente Commercial	$879.30
Rate for Payer: Kaiser Permanente Medicaid	$498.27
Rate for Payer: Kaiser Permanente Medicare	$742.52
Rate for Payer: MDX Hawaii PPO	$947.69
Rate for Payer: Ohana Health Plan Medicaid	$742.52
Rate for Payer: Ohana Health Plan Medicare	$742.52
Rate for Payer: UnitedHealthcare Medicare	$742.52
Rate for Payer: University Health Alliance Commercial	$712.14

PERC 2.4 INSERT KIT #AR-1934PI

Facility

$977.00

Hospital Revenue Code	272
Min. Negotiated Rate	$830.45
Max. Negotiated Rate	$947.69
Rate for Payer: Cash Price	$586.20
Rate for Payer: Health Management Network Commercial	$830.45
Rate for Payer: Kaiser Permanente Commercial	$879.30
Rate for Payer: MDX Hawaii PPO	$947.69

PERCEPTA CRTP MRI US

Facility

$34,000.00

Service Code	HCPCS C2621
Hospital Revenue Code	275
Min. Negotiated Rate	$19,040.00
Max. Negotiated Rate	$32,980.00
Rate for Payer: Cash Price	$20,400.00
Rate for Payer: Hawaii Western Management Group Commercial	$23,800.00
Rate for Payer: Health Management Network Commercial	$28,900.00
Rate for Payer: Kaiser Permanente Commercial	$30,600.00
Rate for Payer: MDX Hawaii PPO	$32,980.00
Rate for Payer: University Health Alliance Commercial	$19,040.00

PERCEPTA CRTP MRI US

Facility

$34,000.00

Service Code	HCPCS C2621
Hospital Revenue Code	275
Min. Negotiated Rate	$17,000.00
Max. Negotiated Rate	$32,980.00
Rate for Payer: AlohaCare Medicaid	$17,000.00
Rate for Payer: AlohaCare Medicare	$25,840.00
Rate for Payer: Cash Price	$20,400.00
Rate for Payer: Devoted Health Medicare	$28,560.00
Rate for Payer: Hawaii Medical Service Association Medicare	$25,840.00
Rate for Payer: Hawaii Western Management Group Commercial	$23,800.00
Rate for Payer: Health Management Network Commercial	$28,900.00
Rate for Payer: Humana Medicare	$25,840.00
Rate for Payer: Kaiser Permanente Commercial	$30,600.00
Rate for Payer: Kaiser Permanente Medicaid	$17,340.00
Rate for Payer: Kaiser Permanente Medicare	$25,840.00
Rate for Payer: MDX Hawaii PPO	$32,980.00
Rate for Payer: Ohana Health Plan Medicaid	$25,840.00
Rate for Payer: Ohana Health Plan Medicare	$25,840.00
Rate for Payer: UnitedHealthcare Medicare	$25,840.00
Rate for Payer: University Health Alliance Commercial	$19,040.00

PERCIVA ICD DF4

Facility

$28,368.00

Service Code	HCPCS C1721
Hospital Revenue Code	275
Min. Negotiated Rate	$14,184.00
Max. Negotiated Rate	$27,516.96
Rate for Payer: AlohaCare Medicaid	$14,184.00
Rate for Payer: AlohaCare Medicare	$21,559.68
Rate for Payer: Cash Price	$17,020.80
Rate for Payer: Devoted Health Medicare	$23,829.12
Rate for Payer: Hawaii Medical Service Association Medicare	$21,559.68
Rate for Payer: Hawaii Western Management Group Commercial	$19,857.60
Rate for Payer: Health Management Network Commercial	$24,112.80
Rate for Payer: Humana Medicare	$21,559.68
Rate for Payer: Kaiser Permanente Commercial	$25,531.20
Rate for Payer: Kaiser Permanente Medicaid	$14,467.68
Rate for Payer: Kaiser Permanente Medicare	$21,559.68
Rate for Payer: MDX Hawaii PPO	$27,516.96
Rate for Payer: Ohana Health Plan Medicaid	$21,559.68
Rate for Payer: Ohana Health Plan Medicare	$21,559.68
Rate for Payer: UnitedHealthcare Medicare	$21,559.68
Rate for Payer: University Health Alliance Commercial	$15,886.08

PERCIVA ICD DF4

Facility

$28,368.00

Service Code	HCPCS C1721
Hospital Revenue Code	275
Min. Negotiated Rate	$15,886.08
Max. Negotiated Rate	$27,516.96
Rate for Payer: Cash Price	$17,020.80
Rate for Payer: Hawaii Western Management Group Commercial	$19,857.60
Rate for Payer: Health Management Network Commercial	$24,112.80
Rate for Payer: Kaiser Permanente Commercial	$25,531.20
Rate for Payer: MDX Hawaii PPO	$27,516.96
Rate for Payer: University Health Alliance Commercial	$15,886.08

PERCUTANEOUS AND OTHER INTRACARDIAC PROCEDURES WITH MCC

Facility

$53,400.61

Service Code	MSDRG 273
Min. Negotiated Rate	$53,400.61
Max. Negotiated Rate	$53,400.61
Rate for Payer: Hawaii Medical Service Association Commercial	$53,400.61

Know your out-of-pocket cost for care.

All Charges