Honoka'a Hospital and Skilled Nursing Facility

All Charges

Charge

Type

Setting

Price

PR AEP NEURODIAGNOSTIC INTERPRETATION AND REPORT

Professional

Both

$149.71

Service Code	HCPCS 92653
Min. Negotiated Rate	$85.55
Max. Negotiated Rate	$127.25
Rate for Payer: AlohaCare Medicaid	$88.85
Rate for Payer: AlohaCare Medicare	$85.55
Rate for Payer: Cash Price	$89.83
Rate for Payer: Cash Price	$89.83
Rate for Payer: Devoted Health Medicare	$94.11
Rate for Payer: Hawaii Medical Service Association Medicare	$85.55
Rate for Payer: Health Management Network Commercial	$127.25
Rate for Payer: Kaiser Permanente Commercial	$102.66
Rate for Payer: Kaiser Permanente Medicaid	$102.66
Rate for Payer: Kaiser Permanente Medicare	$102.66
Rate for Payer: Ohana Health Plan Medicaid	$88.85
Rate for Payer: Ohana Health Plan Medicare	$85.55
Rate for Payer: UnitedHealthcare Medicaid	$88.85
Rate for Payer: UnitedHealthcare Medicare	$85.55

PR AEP SCR AUDITORY POTENTIAL W/STIMULI AUTO ALYS

Professional

Both

$49.00

Service Code	HCPCS 92650
Min. Negotiated Rate	$41.65
Max. Negotiated Rate	$41.65
Rate for Payer: Cash Price	$29.40
Rate for Payer: Health Management Network Commercial	$41.65

PR AEP THRESHOLD ESTIMATION MLT FREQUENCIES I&R

Professional

Both

$200.69

Service Code	HCPCS 92652
Min. Negotiated Rate	$114.68
Max. Negotiated Rate	$170.59
Rate for Payer: AlohaCare Medicaid	$119.51
Rate for Payer: AlohaCare Medicare	$114.68
Rate for Payer: Cash Price	$120.41
Rate for Payer: Cash Price	$120.41
Rate for Payer: Devoted Health Medicare	$126.15
Rate for Payer: Hawaii Medical Service Association Medicare	$114.68
Rate for Payer: Health Management Network Commercial	$170.59
Rate for Payer: Kaiser Permanente Commercial	$137.62
Rate for Payer: Kaiser Permanente Medicaid	$137.62
Rate for Payer: Kaiser Permanente Medicare	$137.62
Rate for Payer: Ohana Health Plan Medicaid	$119.51
Rate for Payer: Ohana Health Plan Medicare	$114.68
Rate for Payer: UnitedHealthcare Medicaid	$119.51
Rate for Payer: UnitedHealthcare Medicare	$114.68

PR AFFINITY1 SQUARE CM

Professional

Both

$461.00

Service Code	HCPCS Q4159
Min. Negotiated Rate	$144.69
Max. Negotiated Rate	$391.85
Rate for Payer: AlohaCare Medicare	$144.69
Rate for Payer: Cash Price	$276.60
Rate for Payer: Cash Price	$276.60
Rate for Payer: Devoted Health Medicare	$159.16
Rate for Payer: Hawaii Medical Service Association Medicare	$144.69
Rate for Payer: Health Management Network Commercial	$391.85
Rate for Payer: Kaiser Permanente Commercial	$173.63
Rate for Payer: Kaiser Permanente Medicaid	$173.63
Rate for Payer: Kaiser Permanente Medicare	$173.63
Rate for Payer: Ohana Health Plan Medicare	$144.69
Rate for Payer: UnitedHealthcare Medicare	$144.69

PR AFO ANKLE GAUNTLET PRE OTS

Professional

Both

$199.00

Service Code	HCPCS L1902
Min. Negotiated Rate	$45.66
Max. Negotiated Rate	$169.15
Rate for Payer: AlohaCare Medicaid	$45.66
Rate for Payer: AlohaCare Medicare	$116.17
Rate for Payer: Cash Price	$119.40
Rate for Payer: Cash Price	$119.40
Rate for Payer: Devoted Health Medicare	$127.79
Rate for Payer: Hawaii Medical Service Association Medicare	$116.17
Rate for Payer: Hawaii Western Management Group Commercial	$54.00
Rate for Payer: Health Management Network Commercial	$169.15
Rate for Payer: Kaiser Permanente Commercial	$139.40
Rate for Payer: Kaiser Permanente Medicaid	$139.40
Rate for Payer: Kaiser Permanente Medicare	$139.40
Rate for Payer: Ohana Health Plan Medicaid	$45.66
Rate for Payer: Ohana Health Plan Medicare	$116.17
Rate for Payer: UnitedHealthcare Medicaid	$45.66
Rate for Payer: UnitedHealthcare Medicare	$116.17

PR AGMNTJ MNDBLR BODY/ANGLE PROSTHETIC MATERIAL

Professional

Both

$5,044.10

Service Code	HCPCS 21125
Min. Negotiated Rate	$474.76
Max. Negotiated Rate	$4,287.48
Rate for Payer: AlohaCare Medicaid	$691.02
Rate for Payer: AlohaCare Medicare	$617.78
Rate for Payer: Cash Price	$3,026.46
Rate for Payer: Cash Price	$3,026.46
Rate for Payer: Devoted Health Medicare	$679.56
Rate for Payer: Hawaii Medical Service Association ABD	$691.02
Rate for Payer: Hawaii Medical Service Association Commercial	$1,066.46
Rate for Payer: Hawaii Medical Service Association Medicare	$617.78
Rate for Payer: Hawaii Medical Service Association Non-ABD	$691.02
Rate for Payer: Hawaii Western Management Group Commercial	$474.76
Rate for Payer: Health Management Network Commercial	$4,287.48
Rate for Payer: Kaiser Permanente Commercial	$741.34
Rate for Payer: Kaiser Permanente Medicaid	$741.34
Rate for Payer: Kaiser Permanente Medicare	$741.34
Rate for Payer: Ohana Health Plan Medicaid	$691.02
Rate for Payer: Ohana Health Plan Medicare	$617.78
Rate for Payer: UnitedHealthcare Medicaid	$691.02
Rate for Payer: UnitedHealthcare Medicare	$617.78
Rate for Payer: University Health Alliance Commercial	$902.93

PR ALCOHOL/SUBSTANCE SCREEN & INTERVEN 15-30 MIN

Professional

Both

$63.00

Service Code	HCPCS 99408
Min. Negotiated Rate	$31.95
Max. Negotiated Rate	$53.55
Rate for Payer: Cash Price	$37.80
Rate for Payer: Cash Price	$37.80
Rate for Payer: Hawaii Medical Service Association ABD	$31.95
Rate for Payer: Hawaii Medical Service Association Non-ABD	$31.95
Rate for Payer: Hawaii Western Management Group Commercial	$38.00
Rate for Payer: Health Management Network Commercial	$53.55

PR ALCOHOL/SUBSTANCE SCREEN & INTERVENTION >30 MIN

Professional

Both

$122.00

Service Code	HCPCS 99409
Min. Negotiated Rate	$63.89
Max. Negotiated Rate	$103.70
Rate for Payer: Cash Price	$73.20
Rate for Payer: Cash Price	$73.20
Rate for Payer: Hawaii Medical Service Association ABD	$63.89
Rate for Payer: Hawaii Medical Service Association Non-ABD	$63.89
Rate for Payer: Hawaii Western Management Group Commercial	$71.65
Rate for Payer: Health Management Network Commercial	$103.70

PRALIDOXIME 1 GRAM SOLUTION FOR INJECTION [6462]

Facility

$937.00

Service Code	NDC 60977014101
Hospital Revenue Code	250
Min. Negotiated Rate	$796.45
Max. Negotiated Rate	$908.89
Rate for Payer: Cash Price	$562.20
Rate for Payer: Health Management Network Commercial	$796.45
Rate for Payer: Kaiser Permanente Commercial	$843.30
Rate for Payer: MDX Hawaii PPO	$908.89

PRALIDOXIME 1 GRAM SOLUTION FOR INJECTION [6462]

Facility

$937.00

Service Code	NDC 60977014127
Hospital Revenue Code	250
Min. Negotiated Rate	$796.45
Max. Negotiated Rate	$908.89
Rate for Payer: Cash Price	$562.20
Rate for Payer: Health Management Network Commercial	$796.45
Rate for Payer: Kaiser Permanente Commercial	$843.30
Rate for Payer: MDX Hawaii PPO	$908.89

PR AMBULATORY SURGICAL BOOT EAC

Professional

Both

$85.00

Service Code	HCPCS L3260
Min. Negotiated Rate	$2.28
Max. Negotiated Rate	$72.25
Rate for Payer: AlohaCare Medicaid	$2.28
Rate for Payer: Cash Price	$51.00
Rate for Payer: Cash Price	$51.00
Rate for Payer: Hawaii Western Management Group Commercial	$10.00
Rate for Payer: Health Management Network Commercial	$72.25
Rate for Payer: Ohana Health Plan Medicaid	$2.28
Rate for Payer: UnitedHealthcare Medicaid	$2.28

PRAMIPEXOLE 0.125 MG TABLET [21287]

Facility

$11.00

Service Code	NDC 13668009190
Hospital Revenue Code	637
Min. Negotiated Rate	$5.50
Max. Negotiated Rate	$10.67
Rate for Payer: AlohaCare Medicaid	$5.50
Rate for Payer: AlohaCare Medicare	$8.36
Rate for Payer: Cash Price	$6.60
Rate for Payer: Devoted Health Medicare	$9.24
Rate for Payer: Hawaii Medical Service Association Medicare	$8.36
Rate for Payer: Hawaii Western Management Group Commercial	$10.45
Rate for Payer: Health Management Network Commercial	$9.35
Rate for Payer: Humana Medicare	$8.36
Rate for Payer: Kaiser Permanente Commercial	$9.90
Rate for Payer: Kaiser Permanente Medicaid	$5.61
Rate for Payer: Kaiser Permanente Medicare	$8.36
Rate for Payer: MDX Hawaii PPO	$10.67
Rate for Payer: Ohana Health Plan Medicaid	$8.36
Rate for Payer: Ohana Health Plan Medicare	$8.36
Rate for Payer: UnitedHealthcare Medicare	$8.36
Rate for Payer: University Health Alliance Commercial	$8.02

PRAMIPEXOLE 0.125 MG TABLET [21287]

Facility

$11.00

Service Code	NDC 13668009190
Hospital Revenue Code	250
Min. Negotiated Rate	$9.35
Max. Negotiated Rate	$10.67
Rate for Payer: Cash Price	$6.60
Rate for Payer: Health Management Network Commercial	$9.35
Rate for Payer: Kaiser Permanente Commercial	$9.90
Rate for Payer: MDX Hawaii PPO	$10.67

PRAMIPEXOLE 0.5 MG TABLET [22719]

Facility

$11.00

Service Code	NDC 13668009390
Hospital Revenue Code	250
Min. Negotiated Rate	$9.35
Max. Negotiated Rate	$10.67
Rate for Payer: Cash Price	$6.60
Rate for Payer: Health Management Network Commercial	$9.35
Rate for Payer: Kaiser Permanente Commercial	$9.90
Rate for Payer: MDX Hawaii PPO	$10.67

PRAMIPEXOLE 0.5 MG TABLET [22719]

Facility

$11.00

Service Code	NDC 13668009390
Hospital Revenue Code	637
Min. Negotiated Rate	$5.50
Max. Negotiated Rate	$10.67
Rate for Payer: AlohaCare Medicaid	$5.50
Rate for Payer: AlohaCare Medicare	$8.36
Rate for Payer: Cash Price	$6.60
Rate for Payer: Devoted Health Medicare	$9.24
Rate for Payer: Hawaii Medical Service Association Medicare	$8.36
Rate for Payer: Hawaii Western Management Group Commercial	$10.45
Rate for Payer: Health Management Network Commercial	$9.35
Rate for Payer: Humana Medicare	$8.36
Rate for Payer: Kaiser Permanente Commercial	$9.90
Rate for Payer: Kaiser Permanente Medicaid	$5.61
Rate for Payer: Kaiser Permanente Medicare	$8.36
Rate for Payer: MDX Hawaii PPO	$10.67
Rate for Payer: Ohana Health Plan Medicaid	$8.36
Rate for Payer: Ohana Health Plan Medicare	$8.36
Rate for Payer: UnitedHealthcare Medicare	$8.36
Rate for Payer: University Health Alliance Commercial	$8.02

PRAMOXINE-CALAMINE 1 %-8 % LOTION [13384]

Facility

$23.00

Service Code	NDC 24385007282
Hospital Revenue Code	637
Min. Negotiated Rate	$11.50
Max. Negotiated Rate	$22.31
Rate for Payer: AlohaCare Medicaid	$11.50
Rate for Payer: AlohaCare Medicare	$17.48
Rate for Payer: Cash Price	$13.80
Rate for Payer: Devoted Health Medicare	$19.32
Rate for Payer: Hawaii Medical Service Association Medicare	$17.48
Rate for Payer: Hawaii Western Management Group Commercial	$21.85
Rate for Payer: Health Management Network Commercial	$19.55
Rate for Payer: Humana Medicare	$17.48
Rate for Payer: Kaiser Permanente Commercial	$20.70
Rate for Payer: Kaiser Permanente Medicaid	$11.73
Rate for Payer: Kaiser Permanente Medicare	$17.48
Rate for Payer: MDX Hawaii PPO	$22.31
Rate for Payer: Ohana Health Plan Medicaid	$17.48
Rate for Payer: Ohana Health Plan Medicare	$17.48
Rate for Payer: UnitedHealthcare Medicare	$17.48
Rate for Payer: University Health Alliance Commercial	$16.76

PRAMOXINE-CALAMINE 1 %-8 % LOTION [13384]

Facility

$23.00

Service Code	NDC 24385007282
Hospital Revenue Code	250
Min. Negotiated Rate	$19.55
Max. Negotiated Rate	$22.31
Rate for Payer: Cash Price	$13.80
Rate for Payer: Health Management Network Commercial	$19.55
Rate for Payer: Kaiser Permanente Commercial	$20.70
Rate for Payer: MDX Hawaii PPO	$22.31

PR AMP F/TH 1/2 JT/PHALANX W/NEURECT LOCAL FLAP

Professional

Both

$1,256.00

Service Code	HCPCS 26952
Min. Negotiated Rate	$359.32
Max. Negotiated Rate	$1,067.60
Rate for Payer: AlohaCare Medicaid	$739.33
Rate for Payer: AlohaCare Medicare	$707.31
Rate for Payer: Cash Price	$753.60
Rate for Payer: Cash Price	$753.60
Rate for Payer: Devoted Health Medicare	$778.04
Rate for Payer: Hawaii Medical Service Association Medicare	$707.31
Rate for Payer: Hawaii Western Management Group Commercial	$359.32
Rate for Payer: Health Management Network Commercial	$1,067.60
Rate for Payer: Kaiser Permanente Commercial	$848.77
Rate for Payer: Kaiser Permanente Medicaid	$848.77
Rate for Payer: Kaiser Permanente Medicare	$848.77
Rate for Payer: Ohana Health Plan Medicaid	$739.33
Rate for Payer: Ohana Health Plan Medicare	$707.31
Rate for Payer: UnitedHealthcare Medicaid	$739.33
Rate for Payer: UnitedHealthcare Medicare	$707.31

PR AMP F/TH 1/2 JT/PHALANX W/NEURECT W/DIR CLSR

Professional

Both

$1,306.34

Service Code	HCPCS 26951
Min. Negotiated Rate	$357.50
Max. Negotiated Rate	$1,110.39
Rate for Payer: AlohaCare Medicaid	$765.05
Rate for Payer: AlohaCare Medicare	$746.48
Rate for Payer: Cash Price	$783.80
Rate for Payer: Cash Price	$783.80
Rate for Payer: Devoted Health Medicare	$821.13
Rate for Payer: Hawaii Medical Service Association Medicare	$746.48
Rate for Payer: Hawaii Western Management Group Commercial	$357.50
Rate for Payer: Health Management Network Commercial	$1,110.39
Rate for Payer: Kaiser Permanente Commercial	$895.78
Rate for Payer: Kaiser Permanente Medicaid	$895.78
Rate for Payer: Kaiser Permanente Medicare	$895.78
Rate for Payer: Ohana Health Plan Medicaid	$765.05
Rate for Payer: Ohana Health Plan Medicare	$746.48
Rate for Payer: UnitedHealthcare Medicaid	$765.05
Rate for Payer: UnitedHealthcare Medicare	$746.48

PR AMP LEG THRU TIBIA&FIBULA RE-AMPUTATION

Professional

Both

$1,110.00

Service Code	HCPCS 27886
Min. Negotiated Rate	$506.22
Max. Negotiated Rate	$943.50
Rate for Payer: AlohaCare Medicaid	$649.37
Rate for Payer: AlohaCare Medicare	$595.65
Rate for Payer: Cash Price	$666.00
Rate for Payer: Cash Price	$666.00
Rate for Payer: Devoted Health Medicare	$655.22
Rate for Payer: Hawaii Medical Service Association Medicare	$595.65
Rate for Payer: Hawaii Western Management Group Commercial	$506.22
Rate for Payer: Health Management Network Commercial	$943.50
Rate for Payer: Kaiser Permanente Commercial	$714.78
Rate for Payer: Kaiser Permanente Medicaid	$714.78
Rate for Payer: Kaiser Permanente Medicare	$714.78
Rate for Payer: Ohana Health Plan Medicaid	$649.37
Rate for Payer: Ohana Health Plan Medicare	$595.65
Rate for Payer: UnitedHealthcare Medicaid	$649.37
Rate for Payer: UnitedHealthcare Medicare	$595.65

PR AMP LEG THRU TIBIA&FIBULA SEC CLOSURE/SCAR REV

Professional

Both

$996.00

Service Code	HCPCS 27884
Min. Negotiated Rate	$364.00
Max. Negotiated Rate	$846.60
Rate for Payer: AlohaCare Medicaid	$581.74
Rate for Payer: AlohaCare Medicare	$545.53
Rate for Payer: Cash Price	$597.60
Rate for Payer: Cash Price	$597.60
Rate for Payer: Devoted Health Medicare	$600.08
Rate for Payer: Hawaii Medical Service Association Medicare	$545.53
Rate for Payer: Hawaii Western Management Group Commercial	$364.00
Rate for Payer: Health Management Network Commercial	$846.60
Rate for Payer: Kaiser Permanente Commercial	$654.64
Rate for Payer: Kaiser Permanente Medicaid	$654.64
Rate for Payer: Kaiser Permanente Medicare	$654.64
Rate for Payer: Ohana Health Plan Medicaid	$581.74
Rate for Payer: Ohana Health Plan Medicare	$545.53
Rate for Payer: UnitedHealthcare Medicaid	$581.74
Rate for Payer: UnitedHealthcare Medicare	$545.53

PR AMP MTCRPL W/FINGER/THUMB W/WO INTEROSS TRANSFER

Professional

Both

$1,390.00

Service Code	HCPCS 26910
Min. Negotiated Rate	$423.54
Max. Negotiated Rate	$1,181.50
Rate for Payer: AlohaCare Medicaid	$817.04
Rate for Payer: AlohaCare Medicare	$779.40
Rate for Payer: Cash Price	$834.00
Rate for Payer: Cash Price	$834.00
Rate for Payer: Devoted Health Medicare	$857.34
Rate for Payer: Hawaii Medical Service Association Medicare	$779.40
Rate for Payer: Hawaii Western Management Group Commercial	$423.54
Rate for Payer: Health Management Network Commercial	$1,181.50
Rate for Payer: Kaiser Permanente Commercial	$935.28
Rate for Payer: Kaiser Permanente Medicaid	$935.28
Rate for Payer: Kaiser Permanente Medicare	$935.28
Rate for Payer: Ohana Health Plan Medicaid	$817.04
Rate for Payer: Ohana Health Plan Medicare	$779.40
Rate for Payer: UnitedHealthcare Medicaid	$817.04
Rate for Payer: UnitedHealthcare Medicare	$779.40

PR AMPUTATION ARM THRU HUMERUS W/PRIMARY CLOSURE

Professional

Both

$1,369.00

Service Code	HCPCS 24900
Min. Negotiated Rate	$530.40
Max. Negotiated Rate	$1,163.65
Rate for Payer: AlohaCare Medicaid	$767.04
Rate for Payer: AlohaCare Medicare	$734.02
Rate for Payer: Cash Price	$821.40
Rate for Payer: Cash Price	$821.40
Rate for Payer: Devoted Health Medicare	$807.42
Rate for Payer: Hawaii Medical Service Association Medicare	$734.02
Rate for Payer: Hawaii Western Management Group Commercial	$530.40
Rate for Payer: Health Management Network Commercial	$1,163.65
Rate for Payer: Kaiser Permanente Commercial	$880.82
Rate for Payer: Kaiser Permanente Medicaid	$880.82
Rate for Payer: Kaiser Permanente Medicare	$880.82
Rate for Payer: Ohana Health Plan Medicaid	$767.04
Rate for Payer: Ohana Health Plan Medicare	$734.02
Rate for Payer: UnitedHealthcare Medicaid	$767.04
Rate for Payer: UnitedHealthcare Medicare	$734.02

PR AMPUTATION FOOT TRANSMETARSAL

Professional

Both

$1,226.00

Service Code	HCPCS 28805
Min. Negotiated Rate	$446.94
Max. Negotiated Rate	$1,042.10
Rate for Payer: AlohaCare Medicaid	$715.54
Rate for Payer: AlohaCare Medicare	$652.50
Rate for Payer: Cash Price	$735.60
Rate for Payer: Cash Price	$735.60
Rate for Payer: Devoted Health Medicare	$717.75
Rate for Payer: Hawaii Medical Service Association Medicare	$652.50
Rate for Payer: Hawaii Western Management Group Commercial	$446.94
Rate for Payer: Health Management Network Commercial	$1,042.10
Rate for Payer: Kaiser Permanente Commercial	$783.00
Rate for Payer: Kaiser Permanente Medicaid	$783.00
Rate for Payer: Kaiser Permanente Medicare	$783.00
Rate for Payer: Ohana Health Plan Medicaid	$715.54
Rate for Payer: Ohana Health Plan Medicare	$652.50
Rate for Payer: UnitedHealthcare Medicaid	$715.54
Rate for Payer: UnitedHealthcare Medicare	$652.50

PR AMPUTATION LEG THROUGH TIBIA&FIBULA

Professional

Both

$1,499.00

Service Code	HCPCS 27880
Min. Negotiated Rate	$611.00
Max. Negotiated Rate	$1,274.15
Rate for Payer: AlohaCare Medicaid	$878.69
Rate for Payer: AlohaCare Medicare	$798.38
Rate for Payer: Cash Price	$899.40
Rate for Payer: Cash Price	$899.40
Rate for Payer: Devoted Health Medicare	$878.22
Rate for Payer: Hawaii Medical Service Association Medicare	$798.38
Rate for Payer: Hawaii Western Management Group Commercial	$611.00
Rate for Payer: Health Management Network Commercial	$1,274.15
Rate for Payer: Kaiser Permanente Commercial	$958.06
Rate for Payer: Kaiser Permanente Medicaid	$958.06
Rate for Payer: Kaiser Permanente Medicare	$958.06
Rate for Payer: Ohana Health Plan Medicaid	$878.69
Rate for Payer: Ohana Health Plan Medicare	$798.38
Rate for Payer: UnitedHealthcare Medicaid	$878.69
Rate for Payer: UnitedHealthcare Medicare	$798.38

Know your out-of-pocket cost for care.

All Charges