Honoka'a Hospital and Skilled Nursing Facility

All Charges

Charge

Type

Setting

Price

BRACE HUMERAL OVER SHOULDER SM

Facility

$237.00

Service Code	HCPCS L3980
Hospital Revenue Code	274
Min. Negotiated Rate	$118.50
Max. Negotiated Rate	$232.34
Rate for Payer: AlohaCare Medicaid	$118.50
Rate for Payer: AlohaCare Medicare	$180.12
Rate for Payer: Cash Price	$142.20
Rate for Payer: Cash Price	$142.20
Rate for Payer: Devoted Health Medicare	$199.08
Rate for Payer: Hawaii Medical Service Association Medicare	$180.12
Rate for Payer: Hawaii Western Management Group Commercial	$165.90
Rate for Payer: Health Management Network Commercial	$201.45
Rate for Payer: Humana Medicare	$180.12
Rate for Payer: Kaiser Permanente Commercial	$213.30
Rate for Payer: Kaiser Permanente Medicaid	$120.87
Rate for Payer: Kaiser Permanente Medicare	$180.12
Rate for Payer: MDX Hawaii PPO	$229.89
Rate for Payer: Ohana Health Plan Medicaid	$180.12
Rate for Payer: Ohana Health Plan Medicare	$180.12
Rate for Payer: UnitedHealthcare Medicaid	$232.34
Rate for Payer: UnitedHealthcare Medicare	$180.12
Rate for Payer: University Health Alliance Commercial	$132.72

BRACE HUMERAL OVER SHOULDER SM

Facility

$237.00

Service Code	HCPCS L3980
Hospital Revenue Code	274
Min. Negotiated Rate	$132.72
Max. Negotiated Rate	$229.89
Rate for Payer: Cash Price	$142.20
Rate for Payer: Hawaii Western Management Group Commercial	$165.90
Rate for Payer: Health Management Network Commercial	$201.45
Rate for Payer: Kaiser Permanente Commercial	$213.30
Rate for Payer: MDX Hawaii PPO	$229.89
Rate for Payer: University Health Alliance Commercial	$132.72

BRACE HUMERAL SHOULDER MED

Facility

$243.00

Service Code	HCPCS L3980
Hospital Revenue Code	274
Min. Negotiated Rate	$136.08
Max. Negotiated Rate	$235.71
Rate for Payer: Cash Price	$145.80
Rate for Payer: Hawaii Western Management Group Commercial	$170.10
Rate for Payer: Health Management Network Commercial	$206.55
Rate for Payer: Kaiser Permanente Commercial	$218.70
Rate for Payer: MDX Hawaii PPO	$235.71
Rate for Payer: University Health Alliance Commercial	$136.08

BRACE HUMERAL SHOULDER MED

Facility

$243.00

Service Code	HCPCS L3980
Hospital Revenue Code	274
Min. Negotiated Rate	$121.50
Max. Negotiated Rate	$235.71
Rate for Payer: AlohaCare Medicaid	$121.50
Rate for Payer: AlohaCare Medicare	$184.68
Rate for Payer: Cash Price	$145.80
Rate for Payer: Cash Price	$145.80
Rate for Payer: Devoted Health Medicare	$204.12
Rate for Payer: Hawaii Medical Service Association Medicare	$184.68
Rate for Payer: Hawaii Western Management Group Commercial	$170.10
Rate for Payer: Health Management Network Commercial	$206.55
Rate for Payer: Humana Medicare	$184.68
Rate for Payer: Kaiser Permanente Commercial	$218.70
Rate for Payer: Kaiser Permanente Medicaid	$123.93
Rate for Payer: Kaiser Permanente Medicare	$184.68
Rate for Payer: MDX Hawaii PPO	$235.71
Rate for Payer: Ohana Health Plan Medicaid	$184.68
Rate for Payer: Ohana Health Plan Medicare	$184.68
Rate for Payer: UnitedHealthcare Medicaid	$232.34
Rate for Payer: UnitedHealthcare Medicare	$184.68
Rate for Payer: University Health Alliance Commercial	$136.08

BRACE THUMB RIGHT LG

Facility

$96.00

Service Code	HCPCS L6624
Hospital Revenue Code	274
Min. Negotiated Rate	$48.00
Max. Negotiated Rate	$278.32
Rate for Payer: AlohaCare Medicaid	$48.00
Rate for Payer: AlohaCare Medicare	$72.96
Rate for Payer: Cash Price	$57.60
Rate for Payer: Cash Price	$57.60
Rate for Payer: Devoted Health Medicare	$80.64
Rate for Payer: Hawaii Medical Service Association Medicare	$72.96
Rate for Payer: Hawaii Western Management Group Commercial	$67.20
Rate for Payer: Health Management Network Commercial	$81.60
Rate for Payer: Humana Medicare	$72.96
Rate for Payer: Kaiser Permanente Commercial	$86.40
Rate for Payer: Kaiser Permanente Medicaid	$48.96
Rate for Payer: Kaiser Permanente Medicare	$72.96
Rate for Payer: MDX Hawaii PPO	$93.12
Rate for Payer: Ohana Health Plan Medicaid	$72.96
Rate for Payer: Ohana Health Plan Medicare	$72.96
Rate for Payer: UnitedHealthcare Medicaid	$278.32
Rate for Payer: UnitedHealthcare Medicare	$72.96
Rate for Payer: University Health Alliance Commercial	$53.76

BRACE THUMB RIGHT LG

Facility

$96.00

Service Code	HCPCS L6624
Hospital Revenue Code	274
Min. Negotiated Rate	$53.76
Max. Negotiated Rate	$93.12
Rate for Payer: Cash Price	$57.60
Rate for Payer: Hawaii Western Management Group Commercial	$67.20
Rate for Payer: Health Management Network Commercial	$81.60
Rate for Payer: Kaiser Permanente Commercial	$86.40
Rate for Payer: MDX Hawaii PPO	$93.12
Rate for Payer: University Health Alliance Commercial	$53.76

BRACE THUMB RIGHT MED

Facility

$96.00

Service Code	HCPCS L6624
Hospital Revenue Code	274
Min. Negotiated Rate	$53.76
Max. Negotiated Rate	$93.12
Rate for Payer: Cash Price	$57.60
Rate for Payer: Hawaii Western Management Group Commercial	$67.20
Rate for Payer: Health Management Network Commercial	$81.60
Rate for Payer: Kaiser Permanente Commercial	$86.40
Rate for Payer: MDX Hawaii PPO	$93.12
Rate for Payer: University Health Alliance Commercial	$53.76

BRACE THUMB RIGHT MED

Facility

$96.00

Service Code	HCPCS L6624
Hospital Revenue Code	274
Min. Negotiated Rate	$48.00
Max. Negotiated Rate	$278.32
Rate for Payer: AlohaCare Medicaid	$48.00
Rate for Payer: AlohaCare Medicare	$72.96
Rate for Payer: Cash Price	$57.60
Rate for Payer: Cash Price	$57.60
Rate for Payer: Devoted Health Medicare	$80.64
Rate for Payer: Hawaii Medical Service Association Medicare	$72.96
Rate for Payer: Hawaii Western Management Group Commercial	$67.20
Rate for Payer: Health Management Network Commercial	$81.60
Rate for Payer: Humana Medicare	$72.96
Rate for Payer: Kaiser Permanente Commercial	$86.40
Rate for Payer: Kaiser Permanente Medicaid	$48.96
Rate for Payer: Kaiser Permanente Medicare	$72.96
Rate for Payer: MDX Hawaii PPO	$93.12
Rate for Payer: Ohana Health Plan Medicaid	$72.96
Rate for Payer: Ohana Health Plan Medicare	$72.96
Rate for Payer: UnitedHealthcare Medicaid	$278.32
Rate for Payer: UnitedHealthcare Medicare	$72.96
Rate for Payer: University Health Alliance Commercial	$53.76

BRACE WALKING SKIBOOT AIR LG

Facility

$220.00

Service Code	HCPCS L4360
Hospital Revenue Code	274
Min. Negotiated Rate	$110.00
Max. Negotiated Rate	$213.40
Rate for Payer: AlohaCare Medicaid	$110.00
Rate for Payer: AlohaCare Medicare	$167.20
Rate for Payer: Cash Price	$132.00
Rate for Payer: Cash Price	$132.00
Rate for Payer: Devoted Health Medicare	$184.80
Rate for Payer: Hawaii Medical Service Association Medicare	$167.20
Rate for Payer: Hawaii Western Management Group Commercial	$154.00
Rate for Payer: Health Management Network Commercial	$187.00
Rate for Payer: Humana Medicare	$167.20
Rate for Payer: Kaiser Permanente Commercial	$198.00
Rate for Payer: Kaiser Permanente Medicaid	$112.20
Rate for Payer: Kaiser Permanente Medicare	$167.20
Rate for Payer: MDX Hawaii PPO	$213.40
Rate for Payer: Ohana Health Plan Medicaid	$167.20
Rate for Payer: Ohana Health Plan Medicare	$167.20
Rate for Payer: UnitedHealthcare Medicaid	$157.58
Rate for Payer: UnitedHealthcare Medicare	$167.20
Rate for Payer: University Health Alliance Commercial	$123.20

BRACE WALKING SKIBOOT AIR LG

Facility

$220.00

Service Code	HCPCS L4360
Hospital Revenue Code	274
Min. Negotiated Rate	$123.20
Max. Negotiated Rate	$213.40
Rate for Payer: Cash Price	$132.00
Rate for Payer: Hawaii Western Management Group Commercial	$154.00
Rate for Payer: Health Management Network Commercial	$187.00
Rate for Payer: Kaiser Permanente Commercial	$198.00
Rate for Payer: MDX Hawaii PPO	$213.40
Rate for Payer: University Health Alliance Commercial	$123.20

BRACE WALKING SKIBOOT AIR MED

Facility

$220.00

Service Code	HCPCS L4360
Hospital Revenue Code	274
Min. Negotiated Rate	$110.00
Max. Negotiated Rate	$213.40
Rate for Payer: AlohaCare Medicaid	$110.00
Rate for Payer: AlohaCare Medicare	$167.20
Rate for Payer: Cash Price	$132.00
Rate for Payer: Cash Price	$132.00
Rate for Payer: Devoted Health Medicare	$184.80
Rate for Payer: Hawaii Medical Service Association Medicare	$167.20
Rate for Payer: Hawaii Western Management Group Commercial	$154.00
Rate for Payer: Health Management Network Commercial	$187.00
Rate for Payer: Humana Medicare	$167.20
Rate for Payer: Kaiser Permanente Commercial	$198.00
Rate for Payer: Kaiser Permanente Medicaid	$112.20
Rate for Payer: Kaiser Permanente Medicare	$167.20
Rate for Payer: MDX Hawaii PPO	$213.40
Rate for Payer: Ohana Health Plan Medicaid	$167.20
Rate for Payer: Ohana Health Plan Medicare	$167.20
Rate for Payer: UnitedHealthcare Medicaid	$157.58
Rate for Payer: UnitedHealthcare Medicare	$167.20
Rate for Payer: University Health Alliance Commercial	$123.20

BRACE WALKING SKIBOOT AIR MED

Facility

$220.00

Service Code	HCPCS L4360
Hospital Revenue Code	274
Min. Negotiated Rate	$123.20
Max. Negotiated Rate	$213.40
Rate for Payer: Cash Price	$132.00
Rate for Payer: Hawaii Western Management Group Commercial	$154.00
Rate for Payer: Health Management Network Commercial	$187.00
Rate for Payer: Kaiser Permanente Commercial	$198.00
Rate for Payer: MDX Hawaii PPO	$213.40
Rate for Payer: University Health Alliance Commercial	$123.20

BRACE WRIST ABDUCT THUMB L XLG

Facility

$90.00

Service Code	HCPCS L3908
Hospital Revenue Code	274
Min. Negotiated Rate	$50.40
Max. Negotiated Rate	$87.30
Rate for Payer: Cash Price	$54.00
Rate for Payer: Hawaii Western Management Group Commercial	$63.00
Rate for Payer: Health Management Network Commercial	$76.50
Rate for Payer: Kaiser Permanente Commercial	$81.00
Rate for Payer: MDX Hawaii PPO	$87.30
Rate for Payer: University Health Alliance Commercial	$50.40

BRACE WRIST ABDUCT THUMB L XLG

Facility

$90.00

Service Code	HCPCS L3908
Hospital Revenue Code	274
Min. Negotiated Rate	$45.00
Max. Negotiated Rate	$87.30
Rate for Payer: AlohaCare Medicaid	$45.00
Rate for Payer: AlohaCare Medicare	$68.40
Rate for Payer: Cash Price	$54.00
Rate for Payer: Cash Price	$54.00
Rate for Payer: Devoted Health Medicare	$75.60
Rate for Payer: Hawaii Medical Service Association Medicare	$68.40
Rate for Payer: Hawaii Western Management Group Commercial	$63.00
Rate for Payer: Health Management Network Commercial	$76.50
Rate for Payer: Humana Medicare	$68.40
Rate for Payer: Kaiser Permanente Commercial	$81.00
Rate for Payer: Kaiser Permanente Medicaid	$45.90
Rate for Payer: Kaiser Permanente Medicare	$68.40
Rate for Payer: MDX Hawaii PPO	$87.30
Rate for Payer: Ohana Health Plan Medicaid	$68.40
Rate for Payer: Ohana Health Plan Medicare	$68.40
Rate for Payer: UnitedHealthcare Medicaid	$49.46
Rate for Payer: UnitedHealthcare Medicare	$68.40
Rate for Payer: University Health Alliance Commercial	$50.40

BRACKET TL ASSM STUD 51-10462

Facility

$365.00

Hospital Revenue Code	272
Min. Negotiated Rate	$182.50
Max. Negotiated Rate	$354.05
Rate for Payer: AlohaCare Medicaid	$182.50
Rate for Payer: AlohaCare Medicare	$277.40
Rate for Payer: Cash Price	$219.00
Rate for Payer: Devoted Health Medicare	$306.60
Rate for Payer: Hawaii Medical Service Association Medicare	$277.40
Rate for Payer: Hawaii Western Management Group Commercial	$346.75
Rate for Payer: Health Management Network Commercial	$310.25
Rate for Payer: Humana Medicare	$277.40
Rate for Payer: Kaiser Permanente Commercial	$328.50
Rate for Payer: Kaiser Permanente Medicaid	$186.15
Rate for Payer: Kaiser Permanente Medicare	$277.40
Rate for Payer: MDX Hawaii PPO	$354.05
Rate for Payer: Ohana Health Plan Medicaid	$277.40
Rate for Payer: Ohana Health Plan Medicare	$277.40
Rate for Payer: UnitedHealthcare Medicare	$277.40
Rate for Payer: University Health Alliance Commercial	$266.05

BRACKET TL ASSM STUD 51-10462

Facility

$365.00

Hospital Revenue Code	272
Min. Negotiated Rate	$310.25
Max. Negotiated Rate	$354.05
Rate for Payer: Cash Price	$219.00
Rate for Payer: Health Management Network Commercial	$310.25
Rate for Payer: Kaiser Permanente Commercial	$328.50
Rate for Payer: MDX Hawaii PPO	$354.05

BRA POST SURGI 3X M5001-XXXL

Facility

$135.00

Hospital Revenue Code	272
Min. Negotiated Rate	$67.50
Max. Negotiated Rate	$130.95
Rate for Payer: AlohaCare Medicaid	$67.50
Rate for Payer: AlohaCare Medicare	$102.60
Rate for Payer: Cash Price	$81.00
Rate for Payer: Devoted Health Medicare	$113.40
Rate for Payer: Hawaii Medical Service Association Medicare	$102.60
Rate for Payer: Hawaii Western Management Group Commercial	$128.25
Rate for Payer: Health Management Network Commercial	$114.75
Rate for Payer: Humana Medicare	$102.60
Rate for Payer: Kaiser Permanente Commercial	$121.50
Rate for Payer: Kaiser Permanente Medicaid	$68.85
Rate for Payer: Kaiser Permanente Medicare	$102.60
Rate for Payer: MDX Hawaii PPO	$130.95
Rate for Payer: Ohana Health Plan Medicaid	$102.60
Rate for Payer: Ohana Health Plan Medicare	$102.60
Rate for Payer: UnitedHealthcare Medicare	$102.60
Rate for Payer: University Health Alliance Commercial	$98.40

BRA POST SURGI 3X M5001-XXXL

Facility

$135.00

Hospital Revenue Code	272
Min. Negotiated Rate	$114.75
Max. Negotiated Rate	$130.95
Rate for Payer: Cash Price	$81.00
Rate for Payer: Health Management Network Commercial	$114.75
Rate for Payer: Kaiser Permanente Commercial	$121.50
Rate for Payer: MDX Hawaii PPO	$130.95

BRA POST SURGICAL 2X M5001-XXL

Facility

$135.00

Hospital Revenue Code	272
Min. Negotiated Rate	$114.75
Max. Negotiated Rate	$130.95
Rate for Payer: Cash Price	$81.00
Rate for Payer: Health Management Network Commercial	$114.75
Rate for Payer: Kaiser Permanente Commercial	$121.50
Rate for Payer: MDX Hawaii PPO	$130.95

BRA POST SURGICAL 2X M5001-XXL

Facility

$135.00

Hospital Revenue Code	272
Min. Negotiated Rate	$67.50
Max. Negotiated Rate	$130.95
Rate for Payer: AlohaCare Medicaid	$67.50
Rate for Payer: AlohaCare Medicare	$102.60
Rate for Payer: Cash Price	$81.00
Rate for Payer: Devoted Health Medicare	$113.40
Rate for Payer: Hawaii Medical Service Association Medicare	$102.60
Rate for Payer: Hawaii Western Management Group Commercial	$128.25
Rate for Payer: Health Management Network Commercial	$114.75
Rate for Payer: Humana Medicare	$102.60
Rate for Payer: Kaiser Permanente Commercial	$121.50
Rate for Payer: Kaiser Permanente Medicaid	$68.85
Rate for Payer: Kaiser Permanente Medicare	$102.60
Rate for Payer: MDX Hawaii PPO	$130.95
Rate for Payer: Ohana Health Plan Medicaid	$102.60
Rate for Payer: Ohana Health Plan Medicare	$102.60
Rate for Payer: UnitedHealthcare Medicare	$102.60
Rate for Payer: University Health Alliance Commercial	$98.40

BREAST BIOPSY, LOCAL EXCISION AND OTHER BREAST PROCEDURES WITH CC/MCC

Facility

$25,171.52

Service Code	MSDRG 584
Min. Negotiated Rate	$25,171.52
Max. Negotiated Rate	$25,171.52
Rate for Payer: Hawaii Medical Service Association Commercial	$25,171.52

BREAST BIOPSY, LOCAL EXCISION AND OTHER BREAST PROCEDURES WITHOUT CC/MCC

Facility

$24,365.66

Service Code	MSDRG 585
Min. Negotiated Rate	$24,365.66
Max. Negotiated Rate	$24,365.66
Rate for Payer: Hawaii Medical Service Association Commercial	$24,365.66

BREAST HSC+ 10721-195MP

Facility

$2,850.00

Service Code	HCPCS C1789
Hospital Revenue Code	278
Min. Negotiated Rate	$1,425.00
Max. Negotiated Rate	$2,764.50
Rate for Payer: AlohaCare Medicaid	$1,425.00
Rate for Payer: AlohaCare Medicare	$2,166.00
Rate for Payer: Cash Price	$1,710.00
Rate for Payer: Devoted Health Medicare	$2,394.00
Rate for Payer: Hawaii Medical Service Association Medicare	$2,166.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,995.00
Rate for Payer: Health Management Network Commercial	$2,422.50
Rate for Payer: Humana Medicare	$2,166.00
Rate for Payer: Kaiser Permanente Commercial	$2,565.00
Rate for Payer: Kaiser Permanente Medicaid	$1,453.50
Rate for Payer: Kaiser Permanente Medicare	$2,166.00
Rate for Payer: MDX Hawaii PPO	$2,764.50
Rate for Payer: Ohana Health Plan Medicaid	$2,166.00
Rate for Payer: Ohana Health Plan Medicare	$2,166.00
Rate for Payer: UnitedHealthcare Medicare	$2,166.00
Rate for Payer: University Health Alliance Commercial	$1,596.00

BREAST HSC+ 10721-195MP

Facility

$2,850.00

Service Code	HCPCS C1789
Hospital Revenue Code	278
Min. Negotiated Rate	$1,596.00
Max. Negotiated Rate	$2,764.50
Rate for Payer: Cash Price	$1,710.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,995.00
Rate for Payer: Health Management Network Commercial	$2,422.50
Rate for Payer: Kaiser Permanente Commercial	$2,565.00
Rate for Payer: MDX Hawaii PPO	$2,764.50
Rate for Payer: University Health Alliance Commercial	$1,596.00

BREAST HSC+ 10721-215MP

Facility

$2,850.00

Service Code	HCPCS C1789
Hospital Revenue Code	278
Min. Negotiated Rate	$1,425.00
Max. Negotiated Rate	$2,764.50
Rate for Payer: AlohaCare Medicaid	$1,425.00
Rate for Payer: AlohaCare Medicare	$2,166.00
Rate for Payer: Cash Price	$1,710.00
Rate for Payer: Devoted Health Medicare	$2,394.00
Rate for Payer: Hawaii Medical Service Association Medicare	$2,166.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,995.00
Rate for Payer: Health Management Network Commercial	$2,422.50
Rate for Payer: Humana Medicare	$2,166.00
Rate for Payer: Kaiser Permanente Commercial	$2,565.00
Rate for Payer: Kaiser Permanente Medicaid	$1,453.50
Rate for Payer: Kaiser Permanente Medicare	$2,166.00
Rate for Payer: MDX Hawaii PPO	$2,764.50
Rate for Payer: Ohana Health Plan Medicaid	$2,166.00
Rate for Payer: Ohana Health Plan Medicare	$2,166.00
Rate for Payer: UnitedHealthcare Medicare	$2,166.00
Rate for Payer: University Health Alliance Commercial	$1,596.00

Know your out-of-pocket cost for care.

All Charges