Honoka'a Hospital and Skilled Nursing Facility

All Charges

Charge

Type

Setting

Price

PSN POLY PATLA 35M 42540000035

Facility

$1,575.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$882.00
Max. Negotiated Rate	$1,527.75
Rate for Payer: Cash Price	$945.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,102.50
Rate for Payer: Health Management Network Commercial	$1,338.75
Rate for Payer: Kaiser Permanente Commercial	$1,417.50
Rate for Payer: MDX Hawaii PPO	$1,527.75
Rate for Payer: University Health Alliance Commercial	$882.00

PSN POLY PATLA 35M 42540000035

Facility

$1,575.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$787.50
Max. Negotiated Rate	$1,527.75
Rate for Payer: AlohaCare Medicaid	$787.50
Rate for Payer: AlohaCare Medicare	$1,197.00
Rate for Payer: Cash Price	$945.00
Rate for Payer: Devoted Health Medicare	$1,323.00
Rate for Payer: Hawaii Medical Service Association Medicare	$1,197.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,102.50
Rate for Payer: Health Management Network Commercial	$1,338.75
Rate for Payer: Humana Medicare	$1,197.00
Rate for Payer: Kaiser Permanente Commercial	$1,417.50
Rate for Payer: Kaiser Permanente Medicaid	$803.25
Rate for Payer: Kaiser Permanente Medicare	$1,197.00
Rate for Payer: MDX Hawaii PPO	$1,527.75
Rate for Payer: Ohana Health Plan Medicaid	$1,197.00
Rate for Payer: Ohana Health Plan Medicare	$1,197.00
Rate for Payer: UnitedHealthcare Medicare	$1,197.00
Rate for Payer: University Health Alliance Commercial	$882.00

PSN POLY PATLA 41M 42540000041

Facility

$1,575.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$882.00
Max. Negotiated Rate	$1,527.75
Rate for Payer: Cash Price	$945.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,102.50
Rate for Payer: Health Management Network Commercial	$1,338.75
Rate for Payer: Kaiser Permanente Commercial	$1,417.50
Rate for Payer: MDX Hawaii PPO	$1,527.75
Rate for Payer: University Health Alliance Commercial	$882.00

PSN POLY PATLA 41M 42540000041

Facility

$1,575.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$787.50
Max. Negotiated Rate	$1,527.75
Rate for Payer: AlohaCare Medicaid	$787.50
Rate for Payer: AlohaCare Medicare	$1,197.00
Rate for Payer: Cash Price	$945.00
Rate for Payer: Devoted Health Medicare	$1,323.00
Rate for Payer: Hawaii Medical Service Association Medicare	$1,197.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,102.50
Rate for Payer: Health Management Network Commercial	$1,338.75
Rate for Payer: Humana Medicare	$1,197.00
Rate for Payer: Kaiser Permanente Commercial	$1,417.50
Rate for Payer: Kaiser Permanente Medicaid	$803.25
Rate for Payer: Kaiser Permanente Medicare	$1,197.00
Rate for Payer: MDX Hawaii PPO	$1,527.75
Rate for Payer: Ohana Health Plan Medicaid	$1,197.00
Rate for Payer: Ohana Health Plan Medicare	$1,197.00
Rate for Payer: UnitedHealthcare Medicare	$1,197.00
Rate for Payer: University Health Alliance Commercial	$882.00

PSN POLY PLY 42-5400-000-29

Facility

$1,500.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$840.00
Max. Negotiated Rate	$1,455.00
Rate for Payer: Cash Price	$900.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,050.00
Rate for Payer: Health Management Network Commercial	$1,275.00
Rate for Payer: Kaiser Permanente Commercial	$1,350.00
Rate for Payer: MDX Hawaii PPO	$1,455.00
Rate for Payer: University Health Alliance Commercial	$840.00

PSN POLY PLY 42-5400-000-29

Facility

$1,500.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$750.00
Max. Negotiated Rate	$1,455.00
Rate for Payer: AlohaCare Medicaid	$750.00
Rate for Payer: AlohaCare Medicare	$1,140.00
Rate for Payer: Cash Price	$900.00
Rate for Payer: Devoted Health Medicare	$1,260.00
Rate for Payer: Hawaii Medical Service Association Medicare	$1,140.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,050.00
Rate for Payer: Health Management Network Commercial	$1,275.00
Rate for Payer: Humana Medicare	$1,140.00
Rate for Payer: Kaiser Permanente Commercial	$1,350.00
Rate for Payer: Kaiser Permanente Medicaid	$765.00
Rate for Payer: Kaiser Permanente Medicare	$1,140.00
Rate for Payer: MDX Hawaii PPO	$1,455.00
Rate for Payer: Ohana Health Plan Medicaid	$1,140.00
Rate for Payer: Ohana Health Plan Medicare	$1,140.00
Rate for Payer: UnitedHealthcare Medicare	$1,140.00
Rate for Payer: University Health Alliance Commercial	$840.00

PSN TIB 5D SZ-D RT 42532006702

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

PSN TIB 5D SZ-D RT 42532006702

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

PSN TIB STEM LT 42-5320-075-01

Facility

$2,600.00

Service Code	HCPCS C1713
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

PSN TIB STEM LT 42-5320-075-01

Facility

$2,600.00

Service Code	HCPCS C1713
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

PSN TIB STEM RT 42-5320-075-02

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

PSN TIB STEM RT 42-5320-075-02

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

PSN TIB ST LEFT 42-5320-067-01

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

PSN TIB ST LEFT 42-5320-067-01

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

PSN TIB STM 5 DEG SZ C 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

PSN TIB STM 5 DEG SZ C 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

PSYCHOSES

Facility

$15,761.83

Service Code	MSDRG 885
Min. Negotiated Rate	$15,761.83
Max. Negotiated Rate	$15,761.83
Rate for Payer: Hawaii Medical Service Association Commercial	$15,761.83

PSYLLIUM HUSK (WITH SUGAR) 3.4 GRAM ORAL POWDER PACKET [95957]

Facility

$2.00

Service Code	NDC 37000002310
Hospital Revenue Code	637
Min. Negotiated Rate	$1.00
Max. Negotiated Rate	$1.94
Rate for Payer: AlohaCare Medicaid	$1.00
Rate for Payer: AlohaCare Medicare	$1.52
Rate for Payer: Cash Price	$1.20
Rate for Payer: Devoted Health Medicare	$1.68
Rate for Payer: Hawaii Medical Service Association Medicare	$1.52
Rate for Payer: Hawaii Western Management Group Commercial	$1.90
Rate for Payer: Health Management Network Commercial	$1.70
Rate for Payer: Humana Medicare	$1.52
Rate for Payer: Kaiser Permanente Commercial	$1.80
Rate for Payer: Kaiser Permanente Medicaid	$1.02
Rate for Payer: Kaiser Permanente Medicare	$1.52
Rate for Payer: MDX Hawaii PPO	$1.94
Rate for Payer: Ohana Health Plan Medicaid	$1.52
Rate for Payer: Ohana Health Plan Medicare	$1.52
Rate for Payer: UnitedHealthcare Medicare	$1.52
Rate for Payer: University Health Alliance Commercial	$1.46

PSYLLIUM HUSK (WITH SUGAR) 3.4 GRAM ORAL POWDER PACKET [95957]

Facility

$2.00

Service Code	NDC 37000002310
Hospital Revenue Code	250
Min. Negotiated Rate	$1.70
Max. Negotiated Rate	$1.94
Rate for Payer: Cash Price	$1.20
Rate for Payer: Health Management Network Commercial	$1.70
Rate for Payer: Kaiser Permanente Commercial	$1.80
Rate for Payer: MDX Hawaii PPO	$1.94

PULMONARY EDEMA AND RESPIRATORY FAILURE

Facility

$45,602.65

Service Code	MSDRG 189
Min. Negotiated Rate	$45,602.65
Max. Negotiated Rate	$45,602.65
Rate for Payer: Hawaii Medical Service Association Commercial	$45,602.65

PULMONARY EMBOLISM WITH MCC OR ACUTE COR PULMONALE

Facility

$30,954.81

Service Code	MSDRG 175
Min. Negotiated Rate	$30,954.81
Max. Negotiated Rate	$30,954.81
Rate for Payer: Hawaii Medical Service Association Commercial	$30,954.81

PULMONARY EMBOLISM WITHOUT MCC

Facility

$30,954.81

Service Code	MSDRG 176
Min. Negotiated Rate	$30,954.81
Max. Negotiated Rate	$30,954.81
Rate for Payer: Hawaii Medical Service Association Commercial	$30,954.81

PULSE GENERATOR V 3150

Facility

$43,200.00

Service Code	HCPCS C1767
Hospital Revenue Code	278
Min. Negotiated Rate	$21,600.00
Max. Negotiated Rate	$41,904.00
Rate for Payer: AlohaCare Medicaid	$21,600.00
Rate for Payer: AlohaCare Medicare	$32,832.00
Rate for Payer: Cash Price	$25,920.00
Rate for Payer: Devoted Health Medicare	$36,288.00
Rate for Payer: Hawaii Medical Service Association Medicare	$32,832.00
Rate for Payer: Hawaii Western Management Group Commercial	$30,240.00
Rate for Payer: Health Management Network Commercial	$36,720.00
Rate for Payer: Humana Medicare	$32,832.00
Rate for Payer: Kaiser Permanente Commercial	$38,880.00
Rate for Payer: Kaiser Permanente Medicaid	$22,032.00
Rate for Payer: Kaiser Permanente Medicare	$32,832.00
Rate for Payer: MDX Hawaii PPO	$41,904.00
Rate for Payer: Ohana Health Plan Medicaid	$32,832.00
Rate for Payer: Ohana Health Plan Medicare	$32,832.00
Rate for Payer: UnitedHealthcare Medicare	$32,832.00
Rate for Payer: University Health Alliance Commercial	$24,192.00

PULSE GENERATOR V 3150

Facility

$43,200.00

Service Code	HCPCS C1767
Hospital Revenue Code	278
Min. Negotiated Rate	$24,192.00
Max. Negotiated Rate	$41,904.00
Rate for Payer: Cash Price	$25,920.00
Rate for Payer: Hawaii Western Management Group Commercial	$30,240.00
Rate for Payer: Health Management Network Commercial	$36,720.00
Rate for Payer: Kaiser Permanente Commercial	$38,880.00
Rate for Payer: MDX Hawaii PPO	$41,904.00
Rate for Payer: University Health Alliance Commercial	$24,192.00

PUMP AMS 700 LGX 18CM

Facility

$25,458.00

Service Code	HCPCS C1813
Hospital Revenue Code	278
Min. Negotiated Rate	$14,256.48
Max. Negotiated Rate	$24,694.26
Rate for Payer: Cash Price	$15,274.80
Rate for Payer: Hawaii Western Management Group Commercial	$17,820.60
Rate for Payer: Health Management Network Commercial	$21,639.30
Rate for Payer: Kaiser Permanente Commercial	$22,912.20
Rate for Payer: MDX Hawaii PPO	$24,694.26
Rate for Payer: University Health Alliance Commercial	$14,256.48

Know your out-of-pocket cost for care.

All Charges