Honoka'a Hospital and Skilled Nursing Facility

All Charges

Charge

Type

Setting

Price

PLT VOL LT 3HOLE 7PEG NARROW

Facility

$3,020.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,691.20
Max. Negotiated Rate	$2,929.40
Rate for Payer: Cash Price	$1,812.00
Rate for Payer: Hawaii Western Management Group Commercial	$2,114.00
Rate for Payer: Health Management Network Commercial	$2,567.00
Rate for Payer: Kaiser Permanente Commercial	$2,718.00
Rate for Payer: MDX Hawaii PPO	$2,929.40
Rate for Payer: University Health Alliance Commercial	$1,691.20

PLT VOL LT 3HOLE 7PEG NARROW

Facility

$3,020.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,510.00
Max. Negotiated Rate	$2,929.40
Rate for Payer: AlohaCare Medicaid	$1,510.00
Rate for Payer: AlohaCare Medicare	$2,295.20
Rate for Payer: Cash Price	$1,812.00
Rate for Payer: Devoted Health Medicare	$2,536.80
Rate for Payer: Hawaii Medical Service Association Medicare	$2,295.20
Rate for Payer: Hawaii Western Management Group Commercial	$2,114.00
Rate for Payer: Health Management Network Commercial	$2,567.00
Rate for Payer: Humana Medicare	$2,295.20
Rate for Payer: Kaiser Permanente Commercial	$2,718.00
Rate for Payer: Kaiser Permanente Medicaid	$1,540.20
Rate for Payer: Kaiser Permanente Medicare	$2,295.20
Rate for Payer: MDX Hawaii PPO	$2,929.40
Rate for Payer: Ohana Health Plan Medicaid	$2,295.20
Rate for Payer: Ohana Health Plan Medicare	$2,295.20
Rate for Payer: UnitedHealthcare Medicare	$2,295.20
Rate for Payer: University Health Alliance Commercial	$1,691.20

PLT VOL LT 9H 7PEG VLBPL-9-7

Facility

$4,330.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$2,165.00
Max. Negotiated Rate	$4,200.10
Rate for Payer: AlohaCare Medicaid	$2,165.00
Rate for Payer: AlohaCare Medicare	$3,290.80
Rate for Payer: Cash Price	$2,598.00
Rate for Payer: Devoted Health Medicare	$3,637.20
Rate for Payer: Hawaii Medical Service Association Medicare	$3,290.80
Rate for Payer: Hawaii Western Management Group Commercial	$3,031.00
Rate for Payer: Health Management Network Commercial	$3,680.50
Rate for Payer: Humana Medicare	$3,290.80
Rate for Payer: Kaiser Permanente Commercial	$3,897.00
Rate for Payer: Kaiser Permanente Medicaid	$2,208.30
Rate for Payer: Kaiser Permanente Medicare	$3,290.80
Rate for Payer: MDX Hawaii PPO	$4,200.10
Rate for Payer: Ohana Health Plan Medicaid	$3,290.80
Rate for Payer: Ohana Health Plan Medicare	$3,290.80
Rate for Payer: UnitedHealthcare Medicare	$3,290.80
Rate for Payer: University Health Alliance Commercial	$2,424.80

PLT VOL LT 9H 7PEG VLBPL-9-7

Facility

$4,330.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$2,424.80
Max. Negotiated Rate	$4,200.10
Rate for Payer: Cash Price	$2,598.00
Rate for Payer: Hawaii Western Management Group Commercial	$3,031.00
Rate for Payer: Health Management Network Commercial	$3,680.50
Rate for Payer: Kaiser Permanente Commercial	$3,897.00
Rate for Payer: MDX Hawaii PPO	$4,200.10
Rate for Payer: University Health Alliance Commercial	$2,424.80

PLT VOL RT/11H/7PEG VLBPR-11-7

Facility

$5,310.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$2,655.00
Max. Negotiated Rate	$5,150.70
Rate for Payer: AlohaCare Medicaid	$2,655.00
Rate for Payer: AlohaCare Medicare	$4,035.60
Rate for Payer: Cash Price	$3,186.00
Rate for Payer: Devoted Health Medicare	$4,460.40
Rate for Payer: Hawaii Medical Service Association Medicare	$4,035.60
Rate for Payer: Hawaii Western Management Group Commercial	$3,717.00
Rate for Payer: Health Management Network Commercial	$4,513.50
Rate for Payer: Humana Medicare	$4,035.60
Rate for Payer: Kaiser Permanente Commercial	$4,779.00
Rate for Payer: Kaiser Permanente Medicaid	$2,708.10
Rate for Payer: Kaiser Permanente Medicare	$4,035.60
Rate for Payer: MDX Hawaii PPO	$5,150.70
Rate for Payer: Ohana Health Plan Medicaid	$4,035.60
Rate for Payer: Ohana Health Plan Medicare	$4,035.60
Rate for Payer: UnitedHealthcare Medicare	$4,035.60
Rate for Payer: University Health Alliance Commercial	$2,973.60

PLT VOL RT/11H/7PEG VLBPR-11-7

Facility

$5,310.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$2,973.60
Max. Negotiated Rate	$5,150.70
Rate for Payer: Cash Price	$3,186.00
Rate for Payer: Hawaii Western Management Group Commercial	$3,717.00
Rate for Payer: Health Management Network Commercial	$4,513.50
Rate for Payer: Kaiser Permanente Commercial	$4,779.00
Rate for Payer: MDX Hawaii PPO	$5,150.70
Rate for Payer: University Health Alliance Commercial	$2,973.60

PLUG

Facility

$392.00

Service Code	HCPCS C1781
Hospital Revenue Code	278
Min. Negotiated Rate	$219.52
Max. Negotiated Rate	$380.24
Rate for Payer: Cash Price	$235.20
Rate for Payer: Hawaii Western Management Group Commercial	$274.40
Rate for Payer: Health Management Network Commercial	$333.20
Rate for Payer: Kaiser Permanente Commercial	$352.80
Rate for Payer: MDX Hawaii PPO	$380.24
Rate for Payer: University Health Alliance Commercial	$219.52

PLUG

Facility

$392.00

Service Code	HCPCS C1781
Hospital Revenue Code	278
Min. Negotiated Rate	$196.00
Max. Negotiated Rate	$380.24
Rate for Payer: AlohaCare Medicaid	$196.00
Rate for Payer: AlohaCare Medicare	$297.92
Rate for Payer: Cash Price	$235.20
Rate for Payer: Devoted Health Medicare	$329.28
Rate for Payer: Hawaii Medical Service Association Medicare	$297.92
Rate for Payer: Hawaii Western Management Group Commercial	$274.40
Rate for Payer: Health Management Network Commercial	$333.20
Rate for Payer: Humana Medicare	$297.92
Rate for Payer: Kaiser Permanente Commercial	$352.80
Rate for Payer: Kaiser Permanente Medicaid	$199.92
Rate for Payer: Kaiser Permanente Medicare	$297.92
Rate for Payer: MDX Hawaii PPO	$380.24
Rate for Payer: Ohana Health Plan Medicaid	$297.92
Rate for Payer: Ohana Health Plan Medicare	$297.92
Rate for Payer: UnitedHealthcare Medicare	$297.92
Rate for Payer: University Health Alliance Commercial	$219.52

PLUG 16MM/25MM 32-8105-038-00

Facility

$727.00

Hospital Revenue Code	272
Min. Negotiated Rate	$363.50
Max. Negotiated Rate	$705.19
Rate for Payer: AlohaCare Medicaid	$363.50
Rate for Payer: AlohaCare Medicare	$552.52
Rate for Payer: Cash Price	$436.20
Rate for Payer: Devoted Health Medicare	$610.68
Rate for Payer: Hawaii Medical Service Association Medicare	$552.52
Rate for Payer: Hawaii Western Management Group Commercial	$690.65
Rate for Payer: Health Management Network Commercial	$617.95
Rate for Payer: Humana Medicare	$552.52
Rate for Payer: Kaiser Permanente Commercial	$654.30
Rate for Payer: Kaiser Permanente Medicaid	$370.77
Rate for Payer: Kaiser Permanente Medicare	$552.52
Rate for Payer: MDX Hawaii PPO	$705.19
Rate for Payer: Ohana Health Plan Medicaid	$552.52
Rate for Payer: Ohana Health Plan Medicare	$552.52
Rate for Payer: UnitedHealthcare Medicare	$552.52
Rate for Payer: University Health Alliance Commercial	$529.91

PLUG 16MM/25MM 32-8105-038-00

Facility

$727.00

Hospital Revenue Code	272
Min. Negotiated Rate	$617.95
Max. Negotiated Rate	$705.19
Rate for Payer: Cash Price	$436.20
Rate for Payer: Health Management Network Commercial	$617.95
Rate for Payer: Kaiser Permanente Commercial	$654.30
Rate for Payer: MDX Hawaii PPO	$705.19

PLUG CABLE 5MM 661002S

Facility

$891.00

Hospital Revenue Code	272
Min. Negotiated Rate	$445.50
Max. Negotiated Rate	$864.27
Rate for Payer: AlohaCare Medicaid	$445.50
Rate for Payer: AlohaCare Medicare	$677.16
Rate for Payer: Cash Price	$534.60
Rate for Payer: Devoted Health Medicare	$748.44
Rate for Payer: Hawaii Medical Service Association Medicare	$677.16
Rate for Payer: Hawaii Western Management Group Commercial	$846.45
Rate for Payer: Health Management Network Commercial	$757.35
Rate for Payer: Humana Medicare	$677.16
Rate for Payer: Kaiser Permanente Commercial	$801.90
Rate for Payer: Kaiser Permanente Medicaid	$454.41
Rate for Payer: Kaiser Permanente Medicare	$677.16
Rate for Payer: MDX Hawaii PPO	$864.27
Rate for Payer: Ohana Health Plan Medicaid	$677.16
Rate for Payer: Ohana Health Plan Medicare	$677.16
Rate for Payer: UnitedHealthcare Medicare	$677.16
Rate for Payer: University Health Alliance Commercial	$649.45

PLUG CABLE 5MM 661002S

Facility

$891.00

Hospital Revenue Code	272
Min. Negotiated Rate	$757.35
Max. Negotiated Rate	$864.27
Rate for Payer: Cash Price	$534.60
Rate for Payer: Health Management Network Commercial	$757.35
Rate for Payer: Kaiser Permanente Commercial	$801.90
Rate for Payer: MDX Hawaii PPO	$864.27

PLUG LEAD BLIND 119602

Facility

$180.00

Hospital Revenue Code	272
Min. Negotiated Rate	$90.00
Max. Negotiated Rate	$174.60
Rate for Payer: AlohaCare Medicaid	$90.00
Rate for Payer: AlohaCare Medicare	$136.80
Rate for Payer: Cash Price	$108.00
Rate for Payer: Devoted Health Medicare	$151.20
Rate for Payer: Hawaii Medical Service Association Medicare	$136.80
Rate for Payer: Hawaii Western Management Group Commercial	$171.00
Rate for Payer: Health Management Network Commercial	$153.00
Rate for Payer: Humana Medicare	$136.80
Rate for Payer: Kaiser Permanente Commercial	$162.00
Rate for Payer: Kaiser Permanente Medicaid	$91.80
Rate for Payer: Kaiser Permanente Medicare	$136.80
Rate for Payer: MDX Hawaii PPO	$174.60
Rate for Payer: Ohana Health Plan Medicaid	$136.80
Rate for Payer: Ohana Health Plan Medicare	$136.80
Rate for Payer: UnitedHealthcare Medicare	$136.80
Rate for Payer: University Health Alliance Commercial	$131.20

PLUG LEAD BLIND 119602

Facility

$180.00

Hospital Revenue Code	272
Min. Negotiated Rate	$153.00
Max. Negotiated Rate	$174.60
Rate for Payer: Cash Price	$108.00
Rate for Payer: Health Management Network Commercial	$153.00
Rate for Payer: Kaiser Permanente Commercial	$162.00
Rate for Payer: MDX Hawaii PPO	$174.60

PLUS STENT GRAFT BLN CATH

Facility

$1,698.00

Service Code	HCPCS C1726
Hospital Revenue Code	272
Min. Negotiated Rate	$849.00
Max. Negotiated Rate	$1,647.06
Rate for Payer: AlohaCare Medicaid	$849.00
Rate for Payer: AlohaCare Medicare	$1,290.48
Rate for Payer: Cash Price	$1,018.80
Rate for Payer: Devoted Health Medicare	$1,426.32
Rate for Payer: Hawaii Medical Service Association Medicare	$1,290.48
Rate for Payer: Hawaii Western Management Group Commercial	$1,613.10
Rate for Payer: Health Management Network Commercial	$1,443.30
Rate for Payer: Humana Medicare	$1,290.48
Rate for Payer: Kaiser Permanente Commercial	$1,528.20
Rate for Payer: Kaiser Permanente Medicaid	$865.98
Rate for Payer: Kaiser Permanente Medicare	$1,290.48
Rate for Payer: MDX Hawaii PPO	$1,647.06
Rate for Payer: Ohana Health Plan Medicaid	$1,290.48
Rate for Payer: Ohana Health Plan Medicare	$1,290.48
Rate for Payer: UnitedHealthcare Medicare	$1,290.48
Rate for Payer: University Health Alliance Commercial	$1,237.67

PLUS STENT GRAFT BLN CATH

Facility

$1,698.00

Service Code	HCPCS C1726
Hospital Revenue Code	272
Min. Negotiated Rate	$1,443.30
Max. Negotiated Rate	$1,647.06
Rate for Payer: Cash Price	$1,018.80
Rate for Payer: Health Management Network Commercial	$1,443.30
Rate for Payer: Kaiser Permanente Commercial	$1,528.20
Rate for Payer: MDX Hawaii PPO	$1,647.06

PNEUMOCOCCAL 20-VALENT CONJ VACCINE-DIP CRM (PF) 0.5 ML IM SYRINGE [180721]

Facility

$510.00

Service Code	NDC 00005200002
Hospital Revenue Code	250
Min. Negotiated Rate	$433.50
Max. Negotiated Rate	$494.70
Rate for Payer: Cash Price	$306.00
Rate for Payer: Health Management Network Commercial	$433.50
Rate for Payer: Kaiser Permanente Commercial	$459.00
Rate for Payer: MDX Hawaii PPO	$494.70

PNEUMOCOCCAL 20-VALENT CONJ VACCINE-DIP CRM (PF) 0.5 ML IM SYRINGE [180721]

Facility

$495.00

Service Code	NDC 00005200010
Hospital Revenue Code	250
Min. Negotiated Rate	$420.75
Max. Negotiated Rate	$480.15
Rate for Payer: Cash Price	$297.00
Rate for Payer: Health Management Network Commercial	$420.75
Rate for Payer: Kaiser Permanente Commercial	$445.50
Rate for Payer: MDX Hawaii PPO	$480.15

PNEUMOCOCCAL 20-VALENT CONJ VACCINE-DIP CRM (PF) 0.5 ML IM SYRINGE [180721]

Facility

$510.00

Service Code	NDC 00005200001
Hospital Revenue Code	250
Min. Negotiated Rate	$433.50
Max. Negotiated Rate	$494.70
Rate for Payer: Cash Price	$306.00
Rate for Payer: Health Management Network Commercial	$433.50
Rate for Payer: Kaiser Permanente Commercial	$459.00
Rate for Payer: MDX Hawaii PPO	$494.70

PNEUMOPERITONEUNM NDL PN120

Facility

$232.00

Hospital Revenue Code	272
Min. Negotiated Rate	$197.20
Max. Negotiated Rate	$225.04
Rate for Payer: Cash Price	$139.20
Rate for Payer: Health Management Network Commercial	$197.20
Rate for Payer: Kaiser Permanente Commercial	$208.80
Rate for Payer: MDX Hawaii PPO	$225.04

PNEUMOPERITONEUNM NDL PN120

Facility

$232.00

Hospital Revenue Code	272
Min. Negotiated Rate	$116.00
Max. Negotiated Rate	$225.04
Rate for Payer: AlohaCare Medicaid	$116.00
Rate for Payer: AlohaCare Medicare	$176.32
Rate for Payer: Cash Price	$139.20
Rate for Payer: Devoted Health Medicare	$194.88
Rate for Payer: Hawaii Medical Service Association Medicare	$176.32
Rate for Payer: Hawaii Western Management Group Commercial	$220.40
Rate for Payer: Health Management Network Commercial	$197.20
Rate for Payer: Humana Medicare	$176.32
Rate for Payer: Kaiser Permanente Commercial	$208.80
Rate for Payer: Kaiser Permanente Medicaid	$118.32
Rate for Payer: Kaiser Permanente Medicare	$176.32
Rate for Payer: MDX Hawaii PPO	$225.04
Rate for Payer: Ohana Health Plan Medicaid	$176.32
Rate for Payer: Ohana Health Plan Medicare	$176.32
Rate for Payer: UnitedHealthcare Medicare	$176.32
Rate for Payer: University Health Alliance Commercial	$169.10

PNEUMOTHORAX WITH CC

Facility

$17,373.57

Service Code	MSDRG 200
Min. Negotiated Rate	$17,373.57
Max. Negotiated Rate	$17,373.57
Rate for Payer: Hawaii Medical Service Association Commercial	$17,373.57

PNEUMOTHORAX WITH MCC

Facility

$18,321.65

Service Code	MSDRG 199
Min. Negotiated Rate	$18,321.65
Max. Negotiated Rate	$18,321.65
Rate for Payer: Hawaii Medical Service Association Commercial	$18,321.65

PNEUMOTHORAX WITHOUT CC/MCC

Facility

$13,770.86

Service Code	MSDRG 201
Min. Negotiated Rate	$13,770.86
Max. Negotiated Rate	$13,770.86
Rate for Payer: Hawaii Medical Service Association Commercial	$13,770.86

POISONING AND TOXIC EFFECTS OF DRUGS WITH MCC

Facility

$20,597.04

Service Code	MSDRG 917
Min. Negotiated Rate	$20,597.04
Max. Negotiated Rate	$20,597.04
Rate for Payer: Hawaii Medical Service Association Commercial	$20,597.04

Know your out-of-pocket cost for care.

All Charges