Honoka'a Hospital and Skilled Nursing Facility

All Charges

Charge

Type

Setting

Price

RETRIEVER 3.0MM ROTH ENDO

Facility

$454.00

Service Code	HCPCS C1769
Hospital Revenue Code	272
Min. Negotiated Rate	$385.90
Max. Negotiated Rate	$440.38
Rate for Payer: Cash Price	$272.40
Rate for Payer: Health Management Network Commercial	$385.90
Rate for Payer: Kaiser Permanente Commercial	$408.60
Rate for Payer: MDX Hawaii PPO	$440.38

RETRIEVER ENDO GRASP

Facility

$147.00

Hospital Revenue Code	272
Min. Negotiated Rate	$73.50
Max. Negotiated Rate	$142.59
Rate for Payer: AlohaCare Medicaid	$73.50
Rate for Payer: AlohaCare Medicare	$111.72
Rate for Payer: Cash Price	$88.20
Rate for Payer: Devoted Health Medicare	$123.48
Rate for Payer: Hawaii Medical Service Association Medicare	$111.72
Rate for Payer: Hawaii Western Management Group Commercial	$139.65
Rate for Payer: Health Management Network Commercial	$124.95
Rate for Payer: Humana Medicare	$111.72
Rate for Payer: Kaiser Permanente Commercial	$132.30
Rate for Payer: Kaiser Permanente Medicaid	$74.97
Rate for Payer: Kaiser Permanente Medicare	$111.72
Rate for Payer: MDX Hawaii PPO	$142.59
Rate for Payer: Ohana Health Plan Medicaid	$111.72
Rate for Payer: Ohana Health Plan Medicare	$111.72
Rate for Payer: UnitedHealthcare Medicare	$111.72
Rate for Payer: University Health Alliance Commercial	$107.15

RETRIEVER ENDO GRASP

Facility

$147.00

Hospital Revenue Code	272
Min. Negotiated Rate	$124.95
Max. Negotiated Rate	$142.59
Rate for Payer: Cash Price	$88.20
Rate for Payer: Health Management Network Commercial	$124.95
Rate for Payer: Kaiser Permanente Commercial	$132.30
Rate for Payer: MDX Hawaii PPO	$142.59

RETRIEVER FOREIGN BODY

Facility

$924.00

Service Code	HCPCS C1889
Hospital Revenue Code	272
Min. Negotiated Rate	$785.40
Max. Negotiated Rate	$896.28
Rate for Payer: Cash Price	$554.40
Rate for Payer: Health Management Network Commercial	$785.40
Rate for Payer: Kaiser Permanente Commercial	$831.60
Rate for Payer: MDX Hawaii PPO	$896.28

RETRIEVER FOREIGN BODY

Facility

$924.00

Service Code	HCPCS C1889
Hospital Revenue Code	272
Min. Negotiated Rate	$462.00
Max. Negotiated Rate	$896.28
Rate for Payer: AlohaCare Medicaid	$462.00
Rate for Payer: AlohaCare Medicare	$702.24
Rate for Payer: Cash Price	$554.40
Rate for Payer: Devoted Health Medicare	$776.16
Rate for Payer: Hawaii Medical Service Association Medicare	$702.24
Rate for Payer: Hawaii Western Management Group Commercial	$877.80
Rate for Payer: Health Management Network Commercial	$785.40
Rate for Payer: Humana Medicare	$702.24
Rate for Payer: Kaiser Permanente Commercial	$831.60
Rate for Payer: Kaiser Permanente Medicaid	$471.24
Rate for Payer: Kaiser Permanente Medicare	$702.24
Rate for Payer: MDX Hawaii PPO	$896.28
Rate for Payer: Ohana Health Plan Medicaid	$702.24
Rate for Payer: Ohana Health Plan Medicare	$702.24
Rate for Payer: UnitedHealthcare Medicare	$702.24
Rate for Payer: University Health Alliance Commercial	$673.50

REUNION HUMERAL 5569-P-2017

Facility

$9,010.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$5,045.60
Max. Negotiated Rate	$8,739.70
Rate for Payer: Cash Price	$5,406.00
Rate for Payer: Hawaii Western Management Group Commercial	$6,307.00
Rate for Payer: Health Management Network Commercial	$7,658.50
Rate for Payer: Kaiser Permanente Commercial	$8,109.00
Rate for Payer: MDX Hawaii PPO	$8,739.70
Rate for Payer: University Health Alliance Commercial	$5,045.60

REUNION HUMERAL 5569-P-2017

Facility

$9,010.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$4,505.00
Max. Negotiated Rate	$8,739.70
Rate for Payer: AlohaCare Medicaid	$4,505.00
Rate for Payer: AlohaCare Medicare	$6,847.60
Rate for Payer: Cash Price	$5,406.00
Rate for Payer: Devoted Health Medicare	$7,568.40
Rate for Payer: Hawaii Medical Service Association Medicare	$6,847.60
Rate for Payer: Hawaii Western Management Group Commercial	$6,307.00
Rate for Payer: Health Management Network Commercial	$7,658.50
Rate for Payer: Humana Medicare	$6,847.60
Rate for Payer: Kaiser Permanente Commercial	$8,109.00
Rate for Payer: Kaiser Permanente Medicaid	$4,595.10
Rate for Payer: Kaiser Permanente Medicare	$6,847.60
Rate for Payer: MDX Hawaii PPO	$8,739.70
Rate for Payer: Ohana Health Plan Medicaid	$6,847.60
Rate for Payer: Ohana Health Plan Medicare	$6,847.60
Rate for Payer: UnitedHealthcare Medicare	$6,847.60
Rate for Payer: University Health Alliance Commercial	$5,045.60

REUNION INSERT 5571-S-3606

Facility

$3,200.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$1,792.00
Max. Negotiated Rate	$3,104.00
Rate for Payer: Cash Price	$1,920.00
Rate for Payer: Hawaii Western Management Group Commercial	$2,240.00
Rate for Payer: Health Management Network Commercial	$2,720.00
Rate for Payer: Kaiser Permanente Commercial	$2,880.00
Rate for Payer: MDX Hawaii PPO	$3,104.00
Rate for Payer: University Health Alliance Commercial	$1,792.00

REUNION INSERT 5571-S-3606

Facility

$3,200.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$1,600.00
Max. Negotiated Rate	$3,104.00
Rate for Payer: AlohaCare Medicaid	$1,600.00
Rate for Payer: AlohaCare Medicare	$2,432.00
Rate for Payer: Cash Price	$1,920.00
Rate for Payer: Devoted Health Medicare	$2,688.00
Rate for Payer: Hawaii Medical Service Association Medicare	$2,432.00
Rate for Payer: Hawaii Western Management Group Commercial	$2,240.00
Rate for Payer: Health Management Network Commercial	$2,720.00
Rate for Payer: Humana Medicare	$2,432.00
Rate for Payer: Kaiser Permanente Commercial	$2,880.00
Rate for Payer: Kaiser Permanente Medicaid	$1,632.00
Rate for Payer: Kaiser Permanente Medicare	$2,432.00
Rate for Payer: MDX Hawaii PPO	$3,104.00
Rate for Payer: Ohana Health Plan Medicaid	$2,432.00
Rate for Payer: Ohana Health Plan Medicare	$2,432.00
Rate for Payer: UnitedHealthcare Medicare	$2,432.00
Rate for Payer: University Health Alliance Commercial	$1,792.00

REUNION RSA SYS 5571-S-3604-E

Facility

$3,200.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$1,792.00
Max. Negotiated Rate	$3,104.00
Rate for Payer: Cash Price	$1,920.00
Rate for Payer: Hawaii Western Management Group Commercial	$2,240.00
Rate for Payer: Health Management Network Commercial	$2,720.00
Rate for Payer: Kaiser Permanente Commercial	$2,880.00
Rate for Payer: MDX Hawaii PPO	$3,104.00
Rate for Payer: University Health Alliance Commercial	$1,792.00

REUNION RSA SYS 5571-S-3604-E

Facility

$3,200.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$1,600.00
Max. Negotiated Rate	$3,104.00
Rate for Payer: AlohaCare Medicaid	$1,600.00
Rate for Payer: AlohaCare Medicare	$2,432.00
Rate for Payer: Cash Price	$1,920.00
Rate for Payer: Devoted Health Medicare	$2,688.00
Rate for Payer: Hawaii Medical Service Association Medicare	$2,432.00
Rate for Payer: Hawaii Western Management Group Commercial	$2,240.00
Rate for Payer: Health Management Network Commercial	$2,720.00
Rate for Payer: Humana Medicare	$2,432.00
Rate for Payer: Kaiser Permanente Commercial	$2,880.00
Rate for Payer: Kaiser Permanente Medicaid	$1,632.00
Rate for Payer: Kaiser Permanente Medicare	$2,432.00
Rate for Payer: MDX Hawaii PPO	$3,104.00
Rate for Payer: Ohana Health Plan Medicaid	$2,432.00
Rate for Payer: Ohana Health Plan Medicare	$2,432.00
Rate for Payer: UnitedHealthcare Medicare	$2,432.00
Rate for Payer: University Health Alliance Commercial	$1,792.00

REVERSED GLENOID DWJ013

Facility

$6,028.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$3,375.68
Max. Negotiated Rate	$5,847.16
Rate for Payer: Cash Price	$3,616.80
Rate for Payer: Hawaii Western Management Group Commercial	$4,219.60
Rate for Payer: Health Management Network Commercial	$5,123.80
Rate for Payer: Kaiser Permanente Commercial	$5,425.20
Rate for Payer: MDX Hawaii PPO	$5,847.16
Rate for Payer: University Health Alliance Commercial	$3,375.68

REVERSED GLENOID DWJ013

Facility

$6,028.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$3,014.00
Max. Negotiated Rate	$5,847.16
Rate for Payer: AlohaCare Medicaid	$3,014.00
Rate for Payer: AlohaCare Medicare	$4,581.28
Rate for Payer: Cash Price	$3,616.80
Rate for Payer: Devoted Health Medicare	$5,063.52
Rate for Payer: Hawaii Medical Service Association Medicare	$4,581.28
Rate for Payer: Hawaii Western Management Group Commercial	$4,219.60
Rate for Payer: Health Management Network Commercial	$5,123.80
Rate for Payer: Humana Medicare	$4,581.28
Rate for Payer: Kaiser Permanente Commercial	$5,425.20
Rate for Payer: Kaiser Permanente Medicaid	$3,074.28
Rate for Payer: Kaiser Permanente Medicare	$4,581.28
Rate for Payer: MDX Hawaii PPO	$5,847.16
Rate for Payer: Ohana Health Plan Medicaid	$4,581.28
Rate for Payer: Ohana Health Plan Medicare	$4,581.28
Rate for Payer: UnitedHealthcare Medicare	$4,581.28
Rate for Payer: University Health Alliance Commercial	$3,375.68

REVERSED INSERT DWF421B

Facility

$2,768.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$1,550.08
Max. Negotiated Rate	$2,684.96
Rate for Payer: Cash Price	$1,660.80
Rate for Payer: Hawaii Western Management Group Commercial	$1,937.60
Rate for Payer: Health Management Network Commercial	$2,352.80
Rate for Payer: Kaiser Permanente Commercial	$2,491.20
Rate for Payer: MDX Hawaii PPO	$2,684.96
Rate for Payer: University Health Alliance Commercial	$1,550.08

REVERSED INSERT DWF421B

Facility

$2,768.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$1,384.00
Max. Negotiated Rate	$2,684.96
Rate for Payer: AlohaCare Medicaid	$1,384.00
Rate for Payer: AlohaCare Medicare	$2,103.68
Rate for Payer: Cash Price	$1,660.80
Rate for Payer: Devoted Health Medicare	$2,325.12
Rate for Payer: Hawaii Medical Service Association Medicare	$2,103.68
Rate for Payer: Hawaii Western Management Group Commercial	$1,937.60
Rate for Payer: Health Management Network Commercial	$2,352.80
Rate for Payer: Humana Medicare	$2,103.68
Rate for Payer: Kaiser Permanente Commercial	$2,491.20
Rate for Payer: Kaiser Permanente Medicaid	$1,411.68
Rate for Payer: Kaiser Permanente Medicare	$2,103.68
Rate for Payer: MDX Hawaii PPO	$2,684.96
Rate for Payer: Ohana Health Plan Medicaid	$2,103.68
Rate for Payer: Ohana Health Plan Medicare	$2,103.68
Rate for Payer: UnitedHealthcare Medicare	$2,103.68
Rate for Payer: University Health Alliance Commercial	$1,550.08

REVISION OF HIP OR KNEE REPLACEMENT WITH CC

Facility

$56,576.67

Service Code	MSDRG 467
Min. Negotiated Rate	$56,576.67
Max. Negotiated Rate	$56,576.67
Rate for Payer: Hawaii Medical Service Association Commercial	$56,576.67

REVISION OF HIP OR KNEE REPLACEMENT WITH MCC

Facility

$56,576.67

Service Code	MSDRG 466
Min. Negotiated Rate	$56,576.67
Max. Negotiated Rate	$56,576.67
Rate for Payer: Hawaii Medical Service Association Commercial	$56,576.67

REVISION OF HIP OR KNEE REPLACEMENT WITHOUT CC/MCC

Facility

$56,576.67

Service Code	MSDRG 468
Min. Negotiated Rate	$56,576.67
Max. Negotiated Rate	$56,576.67
Rate for Payer: Hawaii Medical Service Association Commercial	$56,576.67

RFX HUMERAL 10X123MM 5568-0010

Facility

$8,462.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$4,738.72
Max. Negotiated Rate	$8,208.14
Rate for Payer: Cash Price	$5,077.20
Rate for Payer: Hawaii Western Management Group Commercial	$5,923.40
Rate for Payer: Health Management Network Commercial	$7,192.70
Rate for Payer: Kaiser Permanente Commercial	$7,615.80
Rate for Payer: MDX Hawaii PPO	$8,208.14
Rate for Payer: University Health Alliance Commercial	$4,738.72

RFX HUMERAL 10X123MM 5568-0010

Facility

$8,462.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$4,231.00
Max. Negotiated Rate	$8,208.14
Rate for Payer: AlohaCare Medicaid	$4,231.00
Rate for Payer: AlohaCare Medicare	$6,431.12
Rate for Payer: Cash Price	$5,077.20
Rate for Payer: Devoted Health Medicare	$7,108.08
Rate for Payer: Hawaii Medical Service Association Medicare	$6,431.12
Rate for Payer: Hawaii Western Management Group Commercial	$5,923.40
Rate for Payer: Health Management Network Commercial	$7,192.70
Rate for Payer: Humana Medicare	$6,431.12
Rate for Payer: Kaiser Permanente Commercial	$7,615.80
Rate for Payer: Kaiser Permanente Medicaid	$4,315.62
Rate for Payer: Kaiser Permanente Medicare	$6,431.12
Rate for Payer: MDX Hawaii PPO	$8,208.14
Rate for Payer: Ohana Health Plan Medicaid	$6,431.12
Rate for Payer: Ohana Health Plan Medicare	$6,431.12
Rate for Payer: UnitedHealthcare Medicare	$6,431.12
Rate for Payer: University Health Alliance Commercial	$4,738.72

RHO(D) IMMUNE GLOBULIN 1,500 UNIT (300 MCG)/2 ML INJECTION SYRINGE [127772]

Facility

$307.00

Service Code	HCPCS J2791
Hospital Revenue Code	250
Min. Negotiated Rate	$260.95
Max. Negotiated Rate	$297.79
Rate for Payer: Cash Price	$184.20
Rate for Payer: Cash Price	$223.20
Rate for Payer: Health Management Network Commercial	$260.95
Rate for Payer: Health Management Network Commercial	$316.20
Rate for Payer: Kaiser Permanente Commercial	$276.30
Rate for Payer: Kaiser Permanente Commercial	$334.80
Rate for Payer: MDX Hawaii PPO	$360.84
Rate for Payer: MDX Hawaii PPO	$297.79

RHO(D) IMMUNE GLOBULIN 1,500 UNIT (300 MCG)/2 ML INJECTION SYRINGE [127772]

Facility

$307.00

Service Code	HCPCS J2791
Hospital Revenue Code	636
Min. Negotiated Rate	$4.97
Max. Negotiated Rate	$297.79
Rate for Payer: AlohaCare Medicaid	$153.50
Rate for Payer: AlohaCare Medicaid	$186.00
Rate for Payer: AlohaCare Medicare	$282.72
Rate for Payer: AlohaCare Medicare	$233.32
Rate for Payer: Cash Price	$223.20
Rate for Payer: Cash Price	$184.20
Rate for Payer: Cash Price	$184.20
Rate for Payer: Cash Price	$223.20
Rate for Payer: Devoted Health Medicare	$257.88
Rate for Payer: Devoted Health Medicare	$312.48
Rate for Payer: Hawaii Medical Service Association ABD	$4.97
Rate for Payer: Hawaii Medical Service Association ABD	$4.97
Rate for Payer: Hawaii Medical Service Association Medicare	$282.72
Rate for Payer: Hawaii Medical Service Association Medicare	$233.32
Rate for Payer: Hawaii Medical Service Association Non-ABD	$4.97
Rate for Payer: Hawaii Medical Service Association Non-ABD	$4.97
Rate for Payer: Hawaii Western Management Group Commercial	$291.65
Rate for Payer: Hawaii Western Management Group Commercial	$353.40
Rate for Payer: Health Management Network Commercial	$316.20
Rate for Payer: Health Management Network Commercial	$260.95
Rate for Payer: Humana Medicare	$233.32
Rate for Payer: Humana Medicare	$282.72
Rate for Payer: Kaiser Permanente Commercial	$276.30
Rate for Payer: Kaiser Permanente Commercial	$334.80
Rate for Payer: Kaiser Permanente Medicaid	$189.72
Rate for Payer: Kaiser Permanente Medicaid	$156.57
Rate for Payer: Kaiser Permanente Medicare	$233.32
Rate for Payer: Kaiser Permanente Medicare	$282.72
Rate for Payer: MDX Hawaii PPO	$297.79
Rate for Payer: MDX Hawaii PPO	$360.84
Rate for Payer: Ohana Health Plan Medicaid	$282.72
Rate for Payer: Ohana Health Plan Medicaid	$233.32
Rate for Payer: Ohana Health Plan Medicare	$233.32
Rate for Payer: Ohana Health Plan Medicare	$282.72
Rate for Payer: UnitedHealthcare Medicaid	$223.20
Rate for Payer: UnitedHealthcare Medicaid	$184.20
Rate for Payer: UnitedHealthcare Medicare	$233.32
Rate for Payer: UnitedHealthcare Medicare	$282.72
Rate for Payer: University Health Alliance Commercial	$223.77
Rate for Payer: University Health Alliance Commercial	$271.15

RHO(D) IMMUNE GLOBULIN 1,500 UNIT (300 MCG) INTRAMUSCULAR SYRINGE [127771]

Facility

$222.00

Service Code	HCPCS J2790
Hospital Revenue Code	250
Min. Negotiated Rate	$188.70
Max. Negotiated Rate	$215.34
Rate for Payer: Cash Price	$133.20
Rate for Payer: Health Management Network Commercial	$188.70
Rate for Payer: Kaiser Permanente Commercial	$199.80
Rate for Payer: MDX Hawaii PPO	$215.34

RHO(D) IMMUNE GLOBULIN 1,500 UNIT (300 MCG) INTRAMUSCULAR SYRINGE [127771]

Facility

$222.00

Service Code	HCPCS J2790
Hospital Revenue Code	636
Min. Negotiated Rate	$82.42
Max. Negotiated Rate	$215.34
Rate for Payer: AlohaCare Medicaid	$111.00
Rate for Payer: AlohaCare Medicare	$168.72
Rate for Payer: Cash Price	$133.20
Rate for Payer: Cash Price	$133.20
Rate for Payer: Devoted Health Medicare	$186.48
Rate for Payer: Hawaii Medical Service Association ABD	$82.42
Rate for Payer: Hawaii Medical Service Association Medicare	$168.72
Rate for Payer: Hawaii Medical Service Association Non-ABD	$82.42
Rate for Payer: Hawaii Western Management Group Commercial	$210.90
Rate for Payer: Health Management Network Commercial	$188.70
Rate for Payer: Humana Medicare	$168.72
Rate for Payer: Kaiser Permanente Commercial	$199.80
Rate for Payer: Kaiser Permanente Medicaid	$113.22
Rate for Payer: Kaiser Permanente Medicare	$168.72
Rate for Payer: MDX Hawaii PPO	$215.34
Rate for Payer: Ohana Health Plan Medicaid	$168.72
Rate for Payer: Ohana Health Plan Medicare	$168.72
Rate for Payer: UnitedHealthcare Medicaid	$133.20
Rate for Payer: UnitedHealthcare Medicare	$168.72
Rate for Payer: University Health Alliance Commercial	$161.82

RIFAMPIN 300 MG CAPSULE [11293]

Facility

$8.00

Service Code	NDC 60687058601
Hospital Revenue Code	250
Min. Negotiated Rate	$6.80
Max. Negotiated Rate	$7.76
Rate for Payer: Cash Price	$4.80
Rate for Payer: Health Management Network Commercial	$6.80
Rate for Payer: Kaiser Permanente Commercial	$7.20
Rate for Payer: MDX Hawaii PPO	$7.76

Know your out-of-pocket cost for care.

All Charges