Honoka'a Hospital and Skilled Nursing Facility

All Charges

Charge

Type

Setting

Price

PR EVACUATION SUBUNGUAL HEMATOMA

Professional

Both

$110.44

Service Code	HCPCS 11740
Min. Negotiated Rate	$31.98
Max. Negotiated Rate	$93.87
Rate for Payer: AlohaCare Medicaid	$34.68
Rate for Payer: AlohaCare Medicare	$33.49
Rate for Payer: Cash Price	$66.26
Rate for Payer: Cash Price	$66.26
Rate for Payer: Devoted Health Medicare	$36.84
Rate for Payer: Hawaii Medical Service Association ABD	$34.68
Rate for Payer: Hawaii Medical Service Association Commercial	$51.06
Rate for Payer: Hawaii Medical Service Association Medicare	$33.49
Rate for Payer: Hawaii Medical Service Association Non-ABD	$34.68
Rate for Payer: Hawaii Western Management Group Commercial	$31.98
Rate for Payer: Health Management Network Commercial	$93.87
Rate for Payer: Kaiser Permanente Commercial	$40.19
Rate for Payer: Kaiser Permanente Medicaid	$40.19
Rate for Payer: Kaiser Permanente Medicare	$40.19
Rate for Payer: Ohana Health Plan Medicaid	$34.68
Rate for Payer: Ohana Health Plan Medicare	$33.49
Rate for Payer: UnitedHealthcare Medicaid	$34.68
Rate for Payer: UnitedHealthcare Medicare	$33.49
Rate for Payer: University Health Alliance Commercial	$38.23

PR EVAL&/FITG VOICE PROSTC DEV SUPLMNT ORAL SPEEC

Professional

Both

$131.06

Service Code	HCPCS 92597
Min. Negotiated Rate	$44.60
Max. Negotiated Rate	$111.40
Rate for Payer: AlohaCare Medicare	$74.89
Rate for Payer: Cash Price	$78.64
Rate for Payer: Cash Price	$78.64
Rate for Payer: Devoted Health Medicare	$82.38
Rate for Payer: Hawaii Medical Service Association Medicare	$74.89
Rate for Payer: Hawaii Western Management Group Commercial	$44.60
Rate for Payer: Health Management Network Commercial	$111.40
Rate for Payer: Kaiser Permanente Commercial	$89.87
Rate for Payer: Kaiser Permanente Medicaid	$89.87
Rate for Payer: Kaiser Permanente Medicare	$89.87
Rate for Payer: Ohana Health Plan Medicare	$74.89
Rate for Payer: UnitedHealthcare Medicare	$74.89

PREVALON AIRTAP SHEET XXL

Facility

$678.00

Hospital Revenue Code	272
Min. Negotiated Rate	$576.30
Max. Negotiated Rate	$657.66
Rate for Payer: Cash Price	$406.80
Rate for Payer: Health Management Network Commercial	$576.30
Rate for Payer: Kaiser Permanente Commercial	$610.20
Rate for Payer: MDX Hawaii PPO	$657.66

PREVALON AIRTAP SHEET XXL

Facility

$678.00

Hospital Revenue Code	272
Min. Negotiated Rate	$339.00
Max. Negotiated Rate	$657.66
Rate for Payer: AlohaCare Medicaid	$339.00
Rate for Payer: AlohaCare Medicare	$515.28
Rate for Payer: Cash Price	$406.80
Rate for Payer: Devoted Health Medicare	$569.52
Rate for Payer: Hawaii Medical Service Association Medicare	$515.28
Rate for Payer: Hawaii Western Management Group Commercial	$644.10
Rate for Payer: Health Management Network Commercial	$576.30
Rate for Payer: Humana Medicare	$515.28
Rate for Payer: Kaiser Permanente Commercial	$610.20
Rate for Payer: Kaiser Permanente Medicaid	$345.78
Rate for Payer: Kaiser Permanente Medicare	$515.28
Rate for Payer: MDX Hawaii PPO	$657.66
Rate for Payer: Ohana Health Plan Medicaid	$515.28
Rate for Payer: Ohana Health Plan Medicare	$515.28
Rate for Payer: UnitedHealthcare Medicare	$515.28
Rate for Payer: University Health Alliance Commercial	$494.19

PREVALON AIRTAP WEDGE 2XL

Facility

$415.00

Hospital Revenue Code	271
Min. Negotiated Rate	$352.75
Max. Negotiated Rate	$402.55
Rate for Payer: Cash Price	$249.00
Rate for Payer: Health Management Network Commercial	$352.75
Rate for Payer: Kaiser Permanente Commercial	$373.50
Rate for Payer: MDX Hawaii PPO	$402.55

PREVALON AIRTAP WEDGE 2XL

Facility

$415.00

Hospital Revenue Code	271
Min. Negotiated Rate	$207.50
Max. Negotiated Rate	$402.55
Rate for Payer: AlohaCare Medicaid	$207.50
Rate for Payer: AlohaCare Medicare	$315.40
Rate for Payer: Cash Price	$249.00
Rate for Payer: Devoted Health Medicare	$348.60
Rate for Payer: Hawaii Medical Service Association Medicare	$315.40
Rate for Payer: Hawaii Western Management Group Commercial	$394.25
Rate for Payer: Health Management Network Commercial	$352.75
Rate for Payer: Humana Medicare	$315.40
Rate for Payer: Kaiser Permanente Commercial	$373.50
Rate for Payer: Kaiser Permanente Medicaid	$211.65
Rate for Payer: Kaiser Permanente Medicare	$315.40
Rate for Payer: MDX Hawaii PPO	$402.55
Rate for Payer: Ohana Health Plan Medicaid	$315.40
Rate for Payer: Ohana Health Plan Medicare	$315.40
Rate for Payer: UnitedHealthcare Medicare	$315.40
Rate for Payer: University Health Alliance Commercial	$302.49

PREVALON TRANSFER SYSTEM

Facility

$382.00

Hospital Revenue Code	272
Min. Negotiated Rate	$191.00
Max. Negotiated Rate	$370.54
Rate for Payer: AlohaCare Medicaid	$191.00
Rate for Payer: AlohaCare Medicare	$290.32
Rate for Payer: Cash Price	$229.20
Rate for Payer: Devoted Health Medicare	$320.88
Rate for Payer: Hawaii Medical Service Association Medicare	$290.32
Rate for Payer: Hawaii Western Management Group Commercial	$362.90
Rate for Payer: Health Management Network Commercial	$324.70
Rate for Payer: Humana Medicare	$290.32
Rate for Payer: Kaiser Permanente Commercial	$343.80
Rate for Payer: Kaiser Permanente Medicaid	$194.82
Rate for Payer: Kaiser Permanente Medicare	$290.32
Rate for Payer: MDX Hawaii PPO	$370.54
Rate for Payer: Ohana Health Plan Medicaid	$290.32
Rate for Payer: Ohana Health Plan Medicare	$290.32
Rate for Payer: UnitedHealthcare Medicare	$290.32
Rate for Payer: University Health Alliance Commercial	$278.44

PREVALON TRANSFER SYSTEM

Facility

$382.00

Hospital Revenue Code	272
Min. Negotiated Rate	$324.70
Max. Negotiated Rate	$370.54
Rate for Payer: Cash Price	$229.20
Rate for Payer: Health Management Network Commercial	$324.70
Rate for Payer: Kaiser Permanente Commercial	$343.80
Rate for Payer: MDX Hawaii PPO	$370.54

PR EVASC PLACEMENT ILIAC ARTERY OCCLUSION DEVICE

Professional

Both

$316.00

Service Code	HCPCS 34808
Min. Negotiated Rate	$169.00
Max. Negotiated Rate	$290.15
Rate for Payer: AlohaCare Medicaid	$185.45
Rate for Payer: AlohaCare Medicare	$169.00
Rate for Payer: Cash Price	$189.60
Rate for Payer: Cash Price	$189.60
Rate for Payer: Devoted Health Medicare	$185.90
Rate for Payer: Hawaii Medical Service Association Medicare	$169.00
Rate for Payer: Health Management Network Commercial	$268.60
Rate for Payer: Kaiser Permanente Commercial	$202.80
Rate for Payer: Kaiser Permanente Medicaid	$202.80
Rate for Payer: Kaiser Permanente Medicare	$202.80
Rate for Payer: Ohana Health Plan Medicaid	$185.45
Rate for Payer: Ohana Health Plan Medicare	$169.00
Rate for Payer: UnitedHealthcare Medicaid	$185.45
Rate for Payer: UnitedHealthcare Medicare	$169.00
Rate for Payer: University Health Alliance Commercial	$290.15

PR EVASC RPR DPLMNT AORTO-BI-ILIAC NDGFT

Professional

Both

$2,418.00

Service Code	HCPCS 34705
Min. Negotiated Rate	$1,296.59
Max. Negotiated Rate	$2,230.22
Rate for Payer: AlohaCare Medicaid	$1,418.78
Rate for Payer: AlohaCare Medicare	$1,296.59
Rate for Payer: Cash Price	$1,450.80
Rate for Payer: Cash Price	$1,450.80
Rate for Payer: Devoted Health Medicare	$1,426.25
Rate for Payer: Hawaii Medical Service Association Medicare	$1,296.59
Rate for Payer: Hawaii Western Management Group Commercial	$1,556.10
Rate for Payer: Health Management Network Commercial	$2,055.30
Rate for Payer: Kaiser Permanente Commercial	$1,555.91
Rate for Payer: Kaiser Permanente Medicaid	$1,555.91
Rate for Payer: Kaiser Permanente Medicare	$1,555.91
Rate for Payer: Ohana Health Plan Medicaid	$1,418.78
Rate for Payer: Ohana Health Plan Medicare	$1,296.59
Rate for Payer: UnitedHealthcare Medicaid	$1,418.78
Rate for Payer: UnitedHealthcare Medicare	$1,296.59
Rate for Payer: University Health Alliance Commercial	$2,230.22

PR EVASC RPR DPLMNT AORTO-BI-ILIAC NDGFT RPT

Professional

Both

$3,593.00

Service Code	HCPCS 34706
Min. Negotiated Rate	$1,924.48
Max. Negotiated Rate	$3,351.41
Rate for Payer: AlohaCare Medicaid	$2,104.59
Rate for Payer: AlohaCare Medicare	$1,924.48
Rate for Payer: Cash Price	$2,155.80
Rate for Payer: Cash Price	$2,155.80
Rate for Payer: Devoted Health Medicare	$2,116.93
Rate for Payer: Hawaii Medical Service Association Medicare	$1,924.48
Rate for Payer: Hawaii Western Management Group Commercial	$2,338.44
Rate for Payer: Health Management Network Commercial	$3,054.05
Rate for Payer: Kaiser Permanente Commercial	$2,309.38
Rate for Payer: Kaiser Permanente Medicaid	$2,309.38
Rate for Payer: Kaiser Permanente Medicare	$2,309.38
Rate for Payer: Ohana Health Plan Medicaid	$2,104.59
Rate for Payer: Ohana Health Plan Medicare	$1,924.48
Rate for Payer: UnitedHealthcare Medicaid	$2,104.59
Rate for Payer: UnitedHealthcare Medicare	$1,924.48
Rate for Payer: University Health Alliance Commercial	$3,351.41

PR EVASC RPR DPLMNT AORTO-UN-ILIAC NDGFT

Professional

Both

$2,175.00

Service Code	HCPCS 34703
Min. Negotiated Rate	$1,168.13
Max. Negotiated Rate	$1,848.75
Rate for Payer: AlohaCare Medicaid	$1,276.71
Rate for Payer: AlohaCare Medicare	$1,168.13
Rate for Payer: Cash Price	$1,305.00
Rate for Payer: Cash Price	$1,305.00
Rate for Payer: Devoted Health Medicare	$1,284.94
Rate for Payer: Hawaii Medical Service Association Medicare	$1,168.13
Rate for Payer: Hawaii Western Management Group Commercial	$1,408.16
Rate for Payer: Health Management Network Commercial	$1,848.75
Rate for Payer: Kaiser Permanente Commercial	$1,401.76
Rate for Payer: Kaiser Permanente Medicaid	$1,401.76
Rate for Payer: Kaiser Permanente Medicare	$1,401.76
Rate for Payer: Ohana Health Plan Medicaid	$1,276.71
Rate for Payer: Ohana Health Plan Medicare	$1,168.13
Rate for Payer: UnitedHealthcare Medicaid	$1,276.71
Rate for Payer: UnitedHealthcare Medicare	$1,168.13

PR EVASC RPR DPLMNT AORTO-UN-ILIAC NDGFT RPT

Professional

Both

$3,603.00

Service Code	HCPCS 34704
Min. Negotiated Rate	$1,885.61
Max. Negotiated Rate	$3,062.55
Rate for Payer: AlohaCare Medicaid	$2,120.87
Rate for Payer: AlohaCare Medicare	$1,885.61
Rate for Payer: Cash Price	$2,161.80
Rate for Payer: Cash Price	$2,161.80
Rate for Payer: Devoted Health Medicare	$2,074.17
Rate for Payer: Hawaii Medical Service Association Medicare	$1,885.61
Rate for Payer: Hawaii Western Management Group Commercial	$2,341.04
Rate for Payer: Health Management Network Commercial	$3,062.55
Rate for Payer: Kaiser Permanente Commercial	$2,262.73
Rate for Payer: Kaiser Permanente Medicaid	$2,262.73
Rate for Payer: Kaiser Permanente Medicare	$2,262.73
Rate for Payer: Ohana Health Plan Medicaid	$2,120.87
Rate for Payer: Ohana Health Plan Medicare	$1,885.61
Rate for Payer: UnitedHealthcare Medicaid	$2,120.87
Rate for Payer: UnitedHealthcare Medicare	$1,885.61

PR EVASC RPR DTA COVERAGE ART ORIGIN 1ST ENDOPROSTH

Professional

Both

$2,833.00

Service Code	HCPCS 33880
Min. Negotiated Rate	$1,220.51
Max. Negotiated Rate	$2,408.05
Rate for Payer: AlohaCare Medicaid	$1,664.06
Rate for Payer: AlohaCare Medicare	$1,220.51
Rate for Payer: Cash Price	$1,699.80
Rate for Payer: Cash Price	$1,699.80
Rate for Payer: Devoted Health Medicare	$1,342.56
Rate for Payer: Hawaii Medical Service Association Medicare	$1,220.51
Rate for Payer: Hawaii Western Management Group Commercial	$1,807.52
Rate for Payer: Health Management Network Commercial	$2,408.05
Rate for Payer: Kaiser Permanente Commercial	$1,464.61
Rate for Payer: Kaiser Permanente Medicaid	$1,464.61
Rate for Payer: Kaiser Permanente Medicare	$1,464.61
Rate for Payer: Ohana Health Plan Medicaid	$1,664.06
Rate for Payer: Ohana Health Plan Medicare	$1,220.51
Rate for Payer: UnitedHealthcare Medicaid	$1,664.06
Rate for Payer: UnitedHealthcare Medicare	$1,220.51

PR EVASC RPR ILIAC ART TM OF A-ILIAC ART NDGFT UNI

Professional

Both

$691.00

Service Code	HCPCS 34717
Min. Negotiated Rate	$369.80
Max. Negotiated Rate	$647.67
Rate for Payer: AlohaCare Medicaid	$406.07
Rate for Payer: AlohaCare Medicare	$369.80
Rate for Payer: Cash Price	$414.60
Rate for Payer: Cash Price	$414.60
Rate for Payer: Devoted Health Medicare	$406.78
Rate for Payer: Hawaii Medical Service Association Medicare	$369.80
Rate for Payer: Hawaii Western Management Group Commercial	$451.88
Rate for Payer: Health Management Network Commercial	$587.35
Rate for Payer: Kaiser Permanente Commercial	$443.76
Rate for Payer: Kaiser Permanente Medicaid	$443.76
Rate for Payer: Kaiser Permanente Medicare	$443.76
Rate for Payer: Ohana Health Plan Medicaid	$406.07
Rate for Payer: Ohana Health Plan Medicare	$369.80
Rate for Payer: UnitedHealthcare Medicaid	$406.07
Rate for Payer: UnitedHealthcare Medicare	$369.80
Rate for Payer: University Health Alliance Commercial	$647.67

PREVENA DRSG 13CM PRE1155US

Facility

$1,033.00

Hospital Revenue Code	272
Min. Negotiated Rate	$516.50
Max. Negotiated Rate	$1,002.01
Rate for Payer: AlohaCare Medicaid	$516.50
Rate for Payer: AlohaCare Medicare	$785.08
Rate for Payer: Cash Price	$619.80
Rate for Payer: Devoted Health Medicare	$867.72
Rate for Payer: Hawaii Medical Service Association Medicare	$785.08
Rate for Payer: Hawaii Western Management Group Commercial	$981.35
Rate for Payer: Health Management Network Commercial	$878.05
Rate for Payer: Humana Medicare	$785.08
Rate for Payer: Kaiser Permanente Commercial	$929.70
Rate for Payer: Kaiser Permanente Medicaid	$526.83
Rate for Payer: Kaiser Permanente Medicare	$785.08
Rate for Payer: MDX Hawaii PPO	$1,002.01
Rate for Payer: Ohana Health Plan Medicaid	$785.08
Rate for Payer: Ohana Health Plan Medicare	$785.08
Rate for Payer: UnitedHealthcare Medicare	$785.08
Rate for Payer: University Health Alliance Commercial	$752.95

PREVENA DRSG 13CM PRE1155US

Facility

$1,033.00

Hospital Revenue Code	272
Min. Negotiated Rate	$878.05
Max. Negotiated Rate	$1,002.01
Rate for Payer: Cash Price	$619.80
Rate for Payer: Health Management Network Commercial	$878.05
Rate for Payer: Kaiser Permanente Commercial	$929.70
Rate for Payer: MDX Hawaii PPO	$1,002.01

PREVENA DRSG 20CM PRE1055US

Facility

$1,057.00

Hospital Revenue Code	272
Min. Negotiated Rate	$528.50
Max. Negotiated Rate	$1,025.29
Rate for Payer: AlohaCare Medicaid	$528.50
Rate for Payer: AlohaCare Medicare	$803.32
Rate for Payer: Cash Price	$634.20
Rate for Payer: Devoted Health Medicare	$887.88
Rate for Payer: Hawaii Medical Service Association Medicare	$803.32
Rate for Payer: Hawaii Western Management Group Commercial	$1,004.15
Rate for Payer: Health Management Network Commercial	$898.45
Rate for Payer: Humana Medicare	$803.32
Rate for Payer: Kaiser Permanente Commercial	$951.30
Rate for Payer: Kaiser Permanente Medicaid	$539.07
Rate for Payer: Kaiser Permanente Medicare	$803.32
Rate for Payer: MDX Hawaii PPO	$1,025.29
Rate for Payer: Ohana Health Plan Medicaid	$803.32
Rate for Payer: Ohana Health Plan Medicare	$803.32
Rate for Payer: UnitedHealthcare Medicare	$803.32
Rate for Payer: University Health Alliance Commercial	$770.45

PREVENA DRSG 20CM PRE1055US

Facility

$1,057.00

Hospital Revenue Code	272
Min. Negotiated Rate	$898.45
Max. Negotiated Rate	$1,025.29
Rate for Payer: Cash Price	$634.20
Rate for Payer: Health Management Network Commercial	$898.45
Rate for Payer: Kaiser Permanente Commercial	$951.30
Rate for Payer: MDX Hawaii PPO	$1,025.29

PREVENA PLUS 125 PRE4000US

Facility

$1,950.00

Service Code	HCPCS 97608
Hospital Revenue Code	360
Min. Negotiated Rate	$1,657.50
Max. Negotiated Rate	$1,891.50
Rate for Payer: Cash Price	$1,170.00
Rate for Payer: Health Management Network Commercial	$1,657.50
Rate for Payer: Kaiser Permanente Commercial	$1,755.00
Rate for Payer: MDX Hawaii PPO	$1,891.50

PREVENA PLUS 125 PRE4000US

Facility

$1,950.00

Service Code	HCPCS 97608
Hospital Revenue Code	360
Min. Negotiated Rate	$24.26
Max. Negotiated Rate	$2,837.00
Rate for Payer: AlohaCare Medicaid	$975.00
Rate for Payer: AlohaCare Medicare	$1,482.00
Rate for Payer: Cash Price	$1,170.00
Rate for Payer: Cash Price	$1,170.00
Rate for Payer: Cash Price	$1,170.00
Rate for Payer: Devoted Health Medicare	$1,638.00
Rate for Payer: Hawaii Medical Service Association Commercial	$519.15
Rate for Payer: Hawaii Medical Service Association Medicare	$1,482.00
Rate for Payer: Health Management Network Commercial	$1,657.50
Rate for Payer: Humana Medicare	$1,482.00
Rate for Payer: Kaiser Permanente Commercial	$1,755.00
Rate for Payer: Kaiser Permanente Medicaid	$2,837.00
Rate for Payer: Kaiser Permanente Medicare	$1,482.00
Rate for Payer: MDX Hawaii PPO	$1,891.50
Rate for Payer: Ohana Health Plan Medicaid	$1,482.00
Rate for Payer: Ohana Health Plan Medicare	$1,482.00
Rate for Payer: UnitedHealthcare Medicaid	$24.26
Rate for Payer: UnitedHealthcare Medicare	$1,482.00
Rate for Payer: University Health Alliance Commercial	$1,421.36

PREVENA PLUS 150ML PRE4095

Facility

$208.00

Hospital Revenue Code	272
Min. Negotiated Rate	$104.00
Max. Negotiated Rate	$201.76
Rate for Payer: AlohaCare Medicaid	$104.00
Rate for Payer: AlohaCare Medicare	$158.08
Rate for Payer: Cash Price	$124.80
Rate for Payer: Devoted Health Medicare	$174.72
Rate for Payer: Hawaii Medical Service Association Medicare	$158.08
Rate for Payer: Hawaii Western Management Group Commercial	$197.60
Rate for Payer: Health Management Network Commercial	$176.80
Rate for Payer: Humana Medicare	$158.08
Rate for Payer: Kaiser Permanente Commercial	$187.20
Rate for Payer: Kaiser Permanente Medicaid	$106.08
Rate for Payer: Kaiser Permanente Medicare	$158.08
Rate for Payer: MDX Hawaii PPO	$201.76
Rate for Payer: Ohana Health Plan Medicaid	$158.08
Rate for Payer: Ohana Health Plan Medicare	$158.08
Rate for Payer: UnitedHealthcare Medicare	$158.08
Rate for Payer: University Health Alliance Commercial	$151.61

PREVENA PLUS 150ML PRE4095

Facility

$208.00

Hospital Revenue Code	272
Min. Negotiated Rate	$176.80
Max. Negotiated Rate	$201.76
Rate for Payer: Cash Price	$124.80
Rate for Payer: Health Management Network Commercial	$176.80
Rate for Payer: Kaiser Permanente Commercial	$187.20
Rate for Payer: MDX Hawaii PPO	$201.76

PREVENA PLUS DRSG PRE4055US

Facility

$1,327.00

Hospital Revenue Code	272
Min. Negotiated Rate	$1,127.95
Max. Negotiated Rate	$1,287.19
Rate for Payer: Cash Price	$796.20
Rate for Payer: Health Management Network Commercial	$1,127.95
Rate for Payer: Kaiser Permanente Commercial	$1,194.30
Rate for Payer: MDX Hawaii PPO	$1,287.19

PREVENA PLUS DRSG PRE4055US

Facility

$1,327.00

Hospital Revenue Code	272
Min. Negotiated Rate	$663.50
Max. Negotiated Rate	$1,287.19
Rate for Payer: AlohaCare Medicaid	$663.50
Rate for Payer: AlohaCare Medicare	$1,008.52
Rate for Payer: Cash Price	$796.20
Rate for Payer: Devoted Health Medicare	$1,114.68
Rate for Payer: Hawaii Medical Service Association Medicare	$1,008.52
Rate for Payer: Hawaii Western Management Group Commercial	$1,260.65
Rate for Payer: Health Management Network Commercial	$1,127.95
Rate for Payer: Humana Medicare	$1,008.52
Rate for Payer: Kaiser Permanente Commercial	$1,194.30
Rate for Payer: Kaiser Permanente Medicaid	$676.77
Rate for Payer: Kaiser Permanente Medicare	$1,008.52
Rate for Payer: MDX Hawaii PPO	$1,287.19
Rate for Payer: Ohana Health Plan Medicaid	$1,008.52
Rate for Payer: Ohana Health Plan Medicare	$1,008.52
Rate for Payer: UnitedHealthcare Medicare	$1,008.52
Rate for Payer: University Health Alliance Commercial	$967.25

Know your out-of-pocket cost for care.

All Charges