Honoka'a Hospital and Skilled Nursing Facility

All Charges

Charge

Type

Setting

Price

PERSONA SZ G 42-5380-007-01

Facility

$2,940.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$1,646.40
Max. Negotiated Rate	$2,851.80
Rate for Payer: Cash Price	$1,764.00
Rate for Payer: Hawaii Western Management Group Commercial	$2,058.00
Rate for Payer: Health Management Network Commercial	$2,499.00
Rate for Payer: Kaiser Permanente Commercial	$2,646.00
Rate for Payer: MDX Hawaii PPO	$2,851.80
Rate for Payer: University Health Alliance Commercial	$1,646.40

PERSONA SZ G 42-5380-007-01

Facility

$2,940.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$1,470.00
Max. Negotiated Rate	$2,851.80
Rate for Payer: AlohaCare Medicaid	$1,470.00
Rate for Payer: AlohaCare Medicare	$2,234.40
Rate for Payer: Cash Price	$1,764.00
Rate for Payer: Devoted Health Medicare	$2,469.60
Rate for Payer: Hawaii Medical Service Association Medicare	$2,234.40
Rate for Payer: Hawaii Western Management Group Commercial	$2,058.00
Rate for Payer: Health Management Network Commercial	$2,499.00
Rate for Payer: Humana Medicare	$2,234.40
Rate for Payer: Kaiser Permanente Commercial	$2,646.00
Rate for Payer: Kaiser Permanente Medicaid	$1,499.40
Rate for Payer: Kaiser Permanente Medicare	$2,234.40
Rate for Payer: MDX Hawaii PPO	$2,851.80
Rate for Payer: Ohana Health Plan Medicaid	$2,234.40
Rate for Payer: Ohana Health Plan Medicare	$2,234.40
Rate for Payer: UnitedHealthcare Medicare	$2,234.40
Rate for Payer: University Health Alliance Commercial	$1,646.40

PERSONA SZG 8 42-5182-007-08

Facility

$2,520.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$1,411.20
Max. Negotiated Rate	$2,444.40
Rate for Payer: Cash Price	$1,512.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,764.00
Rate for Payer: Health Management Network Commercial	$2,142.00
Rate for Payer: Kaiser Permanente Commercial	$2,268.00
Rate for Payer: MDX Hawaii PPO	$2,444.40
Rate for Payer: University Health Alliance Commercial	$1,411.20

PERSONA SZG 8 42-5182-007-08

Facility

$2,520.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$1,260.00
Max. Negotiated Rate	$2,444.40
Rate for Payer: AlohaCare Medicaid	$1,260.00
Rate for Payer: AlohaCare Medicare	$1,915.20
Rate for Payer: Cash Price	$1,512.00
Rate for Payer: Devoted Health Medicare	$2,116.80
Rate for Payer: Hawaii Medical Service Association Medicare	$1,915.20
Rate for Payer: Hawaii Western Management Group Commercial	$1,764.00
Rate for Payer: Health Management Network Commercial	$2,142.00
Rate for Payer: Humana Medicare	$1,915.20
Rate for Payer: Kaiser Permanente Commercial	$2,268.00
Rate for Payer: Kaiser Permanente Medicaid	$1,285.20
Rate for Payer: Kaiser Permanente Medicare	$1,915.20
Rate for Payer: MDX Hawaii PPO	$2,444.40
Rate for Payer: Ohana Health Plan Medicaid	$1,915.20
Rate for Payer: Ohana Health Plan Medicare	$1,915.20
Rate for Payer: UnitedHealthcare Medicare	$1,915.20
Rate for Payer: University Health Alliance Commercial	$1,411.20

PERSONA TIB STM 5 DEG SZ E L

Facility

$2,600.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$1,300.00
Max. Negotiated Rate	$2,522.00
Rate for Payer: AlohaCare Medicaid	$1,300.00
Rate for Payer: AlohaCare Medicare	$1,976.00
Rate for Payer: Cash Price	$1,560.00
Rate for Payer: Devoted Health Medicare	$2,184.00
Rate for Payer: Hawaii Medical Service Association Medicare	$1,976.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,820.00
Rate for Payer: Health Management Network Commercial	$2,210.00
Rate for Payer: Humana Medicare	$1,976.00
Rate for Payer: Kaiser Permanente Commercial	$2,340.00
Rate for Payer: Kaiser Permanente Medicaid	$1,326.00
Rate for Payer: Kaiser Permanente Medicare	$1,976.00
Rate for Payer: MDX Hawaii PPO	$2,522.00
Rate for Payer: Ohana Health Plan Medicaid	$1,976.00
Rate for Payer: Ohana Health Plan Medicare	$1,976.00
Rate for Payer: UnitedHealthcare Medicare	$1,976.00
Rate for Payer: University Health Alliance Commercial	$1,456.00

PERSONA TIB STM 5 DEG SZ E L

Facility

$2,600.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$1,456.00
Max. Negotiated Rate	$2,522.00
Rate for Payer: Cash Price	$1,560.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,820.00
Rate for Payer: Health Management Network Commercial	$2,210.00
Rate for Payer: Kaiser Permanente Commercial	$2,340.00
Rate for Payer: MDX Hawaii PPO	$2,522.00
Rate for Payer: University Health Alliance Commercial	$1,456.00

PERSONA TIB STM 5 DEG SZ E R

Facility

$2,000.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$1,120.00
Max. Negotiated Rate	$1,940.00
Rate for Payer: Cash Price	$1,200.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,400.00
Rate for Payer: Health Management Network Commercial	$1,700.00
Rate for Payer: Kaiser Permanente Commercial	$1,800.00
Rate for Payer: MDX Hawaii PPO	$1,940.00
Rate for Payer: University Health Alliance Commercial	$1,120.00

PERSONA TIB STM 5 DEG SZ E R

Facility

$2,000.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$1,000.00
Max. Negotiated Rate	$1,940.00
Rate for Payer: AlohaCare Medicaid	$1,000.00
Rate for Payer: AlohaCare Medicare	$1,520.00
Rate for Payer: Cash Price	$1,200.00
Rate for Payer: Devoted Health Medicare	$1,680.00
Rate for Payer: Hawaii Medical Service Association Medicare	$1,520.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,400.00
Rate for Payer: Health Management Network Commercial	$1,700.00
Rate for Payer: Humana Medicare	$1,520.00
Rate for Payer: Kaiser Permanente Commercial	$1,800.00
Rate for Payer: Kaiser Permanente Medicaid	$1,020.00
Rate for Payer: Kaiser Permanente Medicare	$1,520.00
Rate for Payer: MDX Hawaii PPO	$1,940.00
Rate for Payer: Ohana Health Plan Medicaid	$1,520.00
Rate for Payer: Ohana Health Plan Medicare	$1,520.00
Rate for Payer: UnitedHealthcare Medicare	$1,520.00
Rate for Payer: University Health Alliance Commercial	$1,120.00

PERSONA TIB STM 5 DEG SZ H, L

Facility

$2,000.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,120.00
Max. Negotiated Rate	$1,940.00
Rate for Payer: Cash Price	$1,200.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,400.00
Rate for Payer: Health Management Network Commercial	$1,700.00
Rate for Payer: Kaiser Permanente Commercial	$1,800.00
Rate for Payer: MDX Hawaii PPO	$1,940.00
Rate for Payer: University Health Alliance Commercial	$1,120.00

PERSONA TIB STM 5 DEG SZ H, L

Facility

$2,000.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,000.00
Max. Negotiated Rate	$1,940.00
Rate for Payer: AlohaCare Medicaid	$1,000.00
Rate for Payer: AlohaCare Medicare	$1,520.00
Rate for Payer: Cash Price	$1,200.00
Rate for Payer: Devoted Health Medicare	$1,680.00
Rate for Payer: Hawaii Medical Service Association Medicare	$1,520.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,400.00
Rate for Payer: Health Management Network Commercial	$1,700.00
Rate for Payer: Humana Medicare	$1,520.00
Rate for Payer: Kaiser Permanente Commercial	$1,800.00
Rate for Payer: Kaiser Permanente Medicaid	$1,020.00
Rate for Payer: Kaiser Permanente Medicare	$1,520.00
Rate for Payer: MDX Hawaii PPO	$1,940.00
Rate for Payer: Ohana Health Plan Medicaid	$1,520.00
Rate for Payer: Ohana Health Plan Medicare	$1,520.00
Rate for Payer: UnitedHealthcare Medicare	$1,520.00
Rate for Payer: University Health Alliance Commercial	$1,120.00

PERSON TIB STM 5 DEG SZ H, R

Facility

$2,600.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$1,300.00
Max. Negotiated Rate	$2,522.00
Rate for Payer: AlohaCare Medicaid	$1,300.00
Rate for Payer: AlohaCare Medicare	$1,976.00
Rate for Payer: Cash Price	$1,560.00
Rate for Payer: Devoted Health Medicare	$2,184.00
Rate for Payer: Hawaii Medical Service Association Medicare	$1,976.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,820.00
Rate for Payer: Health Management Network Commercial	$2,210.00
Rate for Payer: Humana Medicare	$1,976.00
Rate for Payer: Kaiser Permanente Commercial	$2,340.00
Rate for Payer: Kaiser Permanente Medicaid	$1,326.00
Rate for Payer: Kaiser Permanente Medicare	$1,976.00
Rate for Payer: MDX Hawaii PPO	$2,522.00
Rate for Payer: Ohana Health Plan Medicaid	$1,976.00
Rate for Payer: Ohana Health Plan Medicare	$1,976.00
Rate for Payer: UnitedHealthcare Medicare	$1,976.00
Rate for Payer: University Health Alliance Commercial	$1,456.00

PERSON TIB STM 5 DEG SZ H, R

Facility

$2,600.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$1,456.00
Max. Negotiated Rate	$2,522.00
Rate for Payer: Cash Price	$1,560.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,820.00
Rate for Payer: Health Management Network Commercial	$2,210.00
Rate for Payer: Kaiser Permanente Commercial	$2,340.00
Rate for Payer: MDX Hawaii PPO	$2,522.00
Rate for Payer: University Health Alliance Commercial	$1,456.00

PERTUZUMAB 1,200 MG-TRASTUZUMAB 600 MG-HYALURON-ZZXF/15 ML SUBCUT SOLN [174456]

Facility

$17,200.00

Service Code	HCPCS J9316
Hospital Revenue Code	250
Min. Negotiated Rate	$14,620.00
Max. Negotiated Rate	$16,684.00
Rate for Payer: Cash Price	$10,320.00
Rate for Payer: Health Management Network Commercial	$14,620.00
Rate for Payer: Kaiser Permanente Commercial	$15,480.00
Rate for Payer: MDX Hawaii PPO	$16,684.00

PERTUZUMAB 1,200 MG-TRASTUZUMAB 600 MG-HYALURON-ZZXF/15 ML SUBCUT SOLN [174456]

Facility

$17,200.00

Service Code	HCPCS J9316
Hospital Revenue Code	636
Min. Negotiated Rate	$63.39
Max. Negotiated Rate	$16,684.00
Rate for Payer: AlohaCare Medicaid	$8,600.00
Rate for Payer: AlohaCare Medicare	$13,072.00
Rate for Payer: Cash Price	$10,320.00
Rate for Payer: Cash Price	$10,320.00
Rate for Payer: Devoted Health Medicare	$14,448.00
Rate for Payer: Hawaii Medical Service Association ABD	$63.39
Rate for Payer: Hawaii Medical Service Association Commercial	$75.29
Rate for Payer: Hawaii Medical Service Association Medicare	$13,072.00
Rate for Payer: Hawaii Medical Service Association Non-ABD	$63.39
Rate for Payer: Hawaii Western Management Group Commercial	$16,340.00
Rate for Payer: Health Management Network Commercial	$14,620.00
Rate for Payer: Humana Medicare	$13,072.00
Rate for Payer: Kaiser Permanente Commercial	$15,480.00
Rate for Payer: Kaiser Permanente Medicaid	$8,772.00
Rate for Payer: Kaiser Permanente Medicare	$13,072.00
Rate for Payer: MDX Hawaii PPO	$16,684.00
Rate for Payer: Ohana Health Plan Medicaid	$13,072.00
Rate for Payer: Ohana Health Plan Medicare	$13,072.00
Rate for Payer: UnitedHealthcare Medicaid	$10,320.00
Rate for Payer: UnitedHealthcare Medicare	$13,072.00
Rate for Payer: University Health Alliance Commercial	$12,537.08

PERTUZUMAB 420 MG/14 ML (30 MG/ML) INTRAVENOUS SOLUTION [116596]

Facility

$11,459.00

Service Code	HCPCS J9306
Hospital Revenue Code	636
Min. Negotiated Rate	$16.89
Max. Negotiated Rate	$11,115.23
Rate for Payer: AlohaCare Medicaid	$5,729.50
Rate for Payer: AlohaCare Medicare	$8,708.84
Rate for Payer: Cash Price	$6,875.40
Rate for Payer: Cash Price	$6,875.40
Rate for Payer: Devoted Health Medicare	$9,625.56
Rate for Payer: Hawaii Medical Service Association ABD	$16.89
Rate for Payer: Hawaii Medical Service Association Commercial	$21.27
Rate for Payer: Hawaii Medical Service Association Medicare	$8,708.84
Rate for Payer: Hawaii Medical Service Association Non-ABD	$16.89
Rate for Payer: Hawaii Western Management Group Commercial	$10,886.05
Rate for Payer: Health Management Network Commercial	$9,740.15
Rate for Payer: Humana Medicare	$8,708.84
Rate for Payer: Kaiser Permanente Commercial	$10,313.10
Rate for Payer: Kaiser Permanente Medicaid	$5,844.09
Rate for Payer: Kaiser Permanente Medicare	$8,708.84
Rate for Payer: MDX Hawaii PPO	$11,115.23
Rate for Payer: Ohana Health Plan Medicaid	$8,708.84
Rate for Payer: Ohana Health Plan Medicare	$8,708.84
Rate for Payer: UnitedHealthcare Medicaid	$6,875.40
Rate for Payer: UnitedHealthcare Medicare	$8,708.84
Rate for Payer: University Health Alliance Commercial	$8,352.47

PERTUZUMAB 420 MG/14 ML (30 MG/ML) INTRAVENOUS SOLUTION [116596]

Facility

$11,459.00

Service Code	HCPCS J9306
Hospital Revenue Code	250
Min. Negotiated Rate	$9,740.15
Max. Negotiated Rate	$11,115.23
Rate for Payer: Cash Price	$6,875.40
Rate for Payer: Health Management Network Commercial	$9,740.15
Rate for Payer: Kaiser Permanente Commercial	$10,313.10
Rate for Payer: MDX Hawaii PPO	$11,115.23

PERTUZUMAB 600 MG-TRASTUZUMAB 600 MG-HYALURONID-ZZXF/10 ML SUBCUT SOLN [174455]

Facility

$11,633.00

Service Code	HCPCS J9316
Hospital Revenue Code	636
Min. Negotiated Rate	$63.39
Max. Negotiated Rate	$11,284.01
Rate for Payer: AlohaCare Medicaid	$5,816.50
Rate for Payer: AlohaCare Medicare	$8,841.08
Rate for Payer: Cash Price	$6,979.80
Rate for Payer: Cash Price	$6,979.80
Rate for Payer: Devoted Health Medicare	$9,771.72
Rate for Payer: Hawaii Medical Service Association ABD	$63.39
Rate for Payer: Hawaii Medical Service Association Commercial	$75.29
Rate for Payer: Hawaii Medical Service Association Medicare	$8,841.08
Rate for Payer: Hawaii Medical Service Association Non-ABD	$63.39
Rate for Payer: Hawaii Western Management Group Commercial	$11,051.35
Rate for Payer: Health Management Network Commercial	$9,888.05
Rate for Payer: Humana Medicare	$8,841.08
Rate for Payer: Kaiser Permanente Commercial	$10,469.70
Rate for Payer: Kaiser Permanente Medicaid	$5,932.83
Rate for Payer: Kaiser Permanente Medicare	$8,841.08
Rate for Payer: MDX Hawaii PPO	$11,284.01
Rate for Payer: Ohana Health Plan Medicaid	$8,841.08
Rate for Payer: Ohana Health Plan Medicare	$8,841.08
Rate for Payer: UnitedHealthcare Medicaid	$6,979.80
Rate for Payer: UnitedHealthcare Medicare	$8,841.08
Rate for Payer: University Health Alliance Commercial	$8,479.29

PERTUZUMAB 600 MG-TRASTUZUMAB 600 MG-HYALURONID-ZZXF/10 ML SUBCUT SOLN [174455]

Facility

$11,633.00

Service Code	HCPCS J9316
Hospital Revenue Code	250
Min. Negotiated Rate	$9,888.05
Max. Negotiated Rate	$11,284.01
Rate for Payer: Cash Price	$6,979.80
Rate for Payer: Health Management Network Commercial	$9,888.05
Rate for Payer: Kaiser Permanente Commercial	$10,469.70
Rate for Payer: MDX Hawaii PPO	$11,284.01

PHENAZOPYRIDINE 100 MG TABLET [6193]

Facility

$10.00

Service Code	NDC 65162068110
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

PHENAZOPYRIDINE 100 MG TABLET [6193]

Facility

$10.00

Service Code	NDC 65162068110
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

PHENAZOPYRIDINE 200 MG TABLET [6194]

Facility

$14.00

Service Code	NDC 65162068210
Hospital Revenue Code	637
Min. Negotiated Rate	$7.00
Max. Negotiated Rate	$13.58
Rate for Payer: AlohaCare Medicaid	$7.00
Rate for Payer: AlohaCare Medicare	$10.64
Rate for Payer: Cash Price	$8.40
Rate for Payer: Devoted Health Medicare	$11.76
Rate for Payer: Hawaii Medical Service Association Medicare	$10.64
Rate for Payer: Hawaii Western Management Group Commercial	$13.30
Rate for Payer: Health Management Network Commercial	$11.90
Rate for Payer: Humana Medicare	$10.64
Rate for Payer: Kaiser Permanente Commercial	$12.60
Rate for Payer: Kaiser Permanente Medicaid	$7.14
Rate for Payer: Kaiser Permanente Medicare	$10.64
Rate for Payer: MDX Hawaii PPO	$13.58
Rate for Payer: Ohana Health Plan Medicaid	$10.64
Rate for Payer: Ohana Health Plan Medicare	$10.64
Rate for Payer: UnitedHealthcare Medicare	$10.64
Rate for Payer: University Health Alliance Commercial	$10.20

PHENAZOPYRIDINE 200 MG TABLET [6194]

Facility

$14.00

Service Code	NDC 65162068210
Hospital Revenue Code	250
Min. Negotiated Rate	$11.90
Max. Negotiated Rate	$13.58
Rate for Payer: Cash Price	$8.40
Rate for Payer: Health Management Network Commercial	$11.90
Rate for Payer: Kaiser Permanente Commercial	$12.60
Rate for Payer: MDX Hawaii PPO	$13.58

PHENAZOPYRIDINE TABLETS (PYRIDIUM) 200 MG (TAKE HOME) [4080389]

Facility

$15.00

Service Code	NDC 00004080177
Hospital Revenue Code	253
Min. Negotiated Rate	$7.50
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: Devoted Health Medicare	$12.60
Rate for Payer: Hawaii Medical Service Association Medicare	$11.40
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 Medicare	$11.40
Rate for Payer: University Health Alliance Commercial	$10.93

PHENAZOPYRIDINE TABLETS (PYRIDIUM) 200 MG (TAKE HOME) [4080389]

Facility

$15.00

Service Code	NDC 00004080177
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

PHENOBARBITAL 32.4 MG TABLET [6217]

Facility

$3.00

Service Code	NDC 63739029410
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

Know your out-of-pocket cost for care.

All Charges