Honoka'a Hospital and Skilled Nursing Facility

All Charges

Charge

Type

Setting

Price

ROUND GIGLI SAW BLADE 12

Facility

$144.00

Hospital Revenue Code	272
Min. Negotiated Rate	$122.40
Max. Negotiated Rate	$139.68
Rate for Payer: Cash Price	$86.40
Rate for Payer: Health Management Network Commercial	$122.40
Rate for Payer: Kaiser Permanente Commercial	$129.60
Rate for Payer: MDX Hawaii PPO	$139.68

ROUND GIGLI SAW BLADE 12

Facility

$144.00

Hospital Revenue Code	272
Min. Negotiated Rate	$72.00
Max. Negotiated Rate	$139.68
Rate for Payer: AlohaCare Medicaid	$72.00
Rate for Payer: AlohaCare Medicare	$109.44
Rate for Payer: Cash Price	$86.40
Rate for Payer: Devoted Health Medicare	$120.96
Rate for Payer: Hawaii Medical Service Association Medicare	$109.44
Rate for Payer: Hawaii Western Management Group Commercial	$136.80
Rate for Payer: Health Management Network Commercial	$122.40
Rate for Payer: Humana Medicare	$109.44
Rate for Payer: Kaiser Permanente Commercial	$129.60
Rate for Payer: Kaiser Permanente Medicaid	$73.44
Rate for Payer: Kaiser Permanente Medicare	$109.44
Rate for Payer: MDX Hawaii PPO	$139.68
Rate for Payer: Ohana Health Plan Medicaid	$109.44
Rate for Payer: Ohana Health Plan Medicare	$109.44
Rate for Payer: UnitedHealthcare Medicare	$109.44
Rate for Payer: University Health Alliance Commercial	$104.96

ROUND SILICONE GS10621-620HP

Facility

$694.00

Service Code	HCPCS C1789
Hospital Revenue Code	278
Min. Negotiated Rate	$347.00
Max. Negotiated Rate	$673.18
Rate for Payer: AlohaCare Medicaid	$347.00
Rate for Payer: AlohaCare Medicare	$527.44
Rate for Payer: Cash Price	$416.40
Rate for Payer: Devoted Health Medicare	$582.96
Rate for Payer: Hawaii Medical Service Association Medicare	$527.44
Rate for Payer: Hawaii Western Management Group Commercial	$485.80
Rate for Payer: Health Management Network Commercial	$589.90
Rate for Payer: Humana Medicare	$527.44
Rate for Payer: Kaiser Permanente Commercial	$624.60
Rate for Payer: Kaiser Permanente Medicaid	$353.94
Rate for Payer: Kaiser Permanente Medicare	$527.44
Rate for Payer: MDX Hawaii PPO	$673.18
Rate for Payer: Ohana Health Plan Medicaid	$527.44
Rate for Payer: Ohana Health Plan Medicare	$527.44
Rate for Payer: UnitedHealthcare Medicare	$527.44
Rate for Payer: University Health Alliance Commercial	$388.64

ROUND SILICONE GS10621-620HP

Facility

$694.00

Service Code	HCPCS C1789
Hospital Revenue Code	278
Min. Negotiated Rate	$388.64
Max. Negotiated Rate	$673.18
Rate for Payer: Cash Price	$416.40
Rate for Payer: Hawaii Western Management Group Commercial	$485.80
Rate for Payer: Health Management Network Commercial	$589.90
Rate for Payer: Kaiser Permanente Commercial	$624.60
Rate for Payer: MDX Hawaii PPO	$673.18
Rate for Payer: University Health Alliance Commercial	$388.64

ROUND SILICONE GS10621-625MP

Facility

$694.00

Service Code	HCPCS C1789
Hospital Revenue Code	278
Min. Negotiated Rate	$347.00
Max. Negotiated Rate	$673.18
Rate for Payer: AlohaCare Medicaid	$347.00
Rate for Payer: AlohaCare Medicare	$527.44
Rate for Payer: Cash Price	$416.40
Rate for Payer: Devoted Health Medicare	$582.96
Rate for Payer: Hawaii Medical Service Association Medicare	$527.44
Rate for Payer: Hawaii Western Management Group Commercial	$485.80
Rate for Payer: Health Management Network Commercial	$589.90
Rate for Payer: Humana Medicare	$527.44
Rate for Payer: Kaiser Permanente Commercial	$624.60
Rate for Payer: Kaiser Permanente Medicaid	$353.94
Rate for Payer: Kaiser Permanente Medicare	$527.44
Rate for Payer: MDX Hawaii PPO	$673.18
Rate for Payer: Ohana Health Plan Medicaid	$527.44
Rate for Payer: Ohana Health Plan Medicare	$527.44
Rate for Payer: UnitedHealthcare Medicare	$527.44
Rate for Payer: University Health Alliance Commercial	$388.64

ROUND SILICONE GS10621-625MP

Facility

$694.00

Service Code	HCPCS C1789
Hospital Revenue Code	278
Min. Negotiated Rate	$388.64
Max. Negotiated Rate	$673.18
Rate for Payer: Cash Price	$416.40
Rate for Payer: Hawaii Western Management Group Commercial	$485.80
Rate for Payer: Health Management Network Commercial	$589.90
Rate for Payer: Kaiser Permanente Commercial	$624.60
Rate for Payer: MDX Hawaii PPO	$673.18
Rate for Payer: University Health Alliance Commercial	$388.64

ROUTER QC 130MM #332.062

Facility

$945.00

Service Code	HCPCS C1889
Hospital Revenue Code	272
Min. Negotiated Rate	$472.50
Max. Negotiated Rate	$916.65
Rate for Payer: AlohaCare Medicaid	$472.50
Rate for Payer: AlohaCare Medicare	$718.20
Rate for Payer: Cash Price	$567.00
Rate for Payer: Devoted Health Medicare	$793.80
Rate for Payer: Hawaii Medical Service Association Medicare	$718.20
Rate for Payer: Hawaii Western Management Group Commercial	$897.75
Rate for Payer: Health Management Network Commercial	$803.25
Rate for Payer: Humana Medicare	$718.20
Rate for Payer: Kaiser Permanente Commercial	$850.50
Rate for Payer: Kaiser Permanente Medicaid	$481.95
Rate for Payer: Kaiser Permanente Medicare	$718.20
Rate for Payer: MDX Hawaii PPO	$916.65
Rate for Payer: Ohana Health Plan Medicaid	$718.20
Rate for Payer: Ohana Health Plan Medicare	$718.20
Rate for Payer: UnitedHealthcare Medicare	$718.20
Rate for Payer: University Health Alliance Commercial	$688.81

ROUTER QC 130MM #332.062

Facility

$945.00

Service Code	HCPCS C1889
Hospital Revenue Code	272
Min. Negotiated Rate	$803.25
Max. Negotiated Rate	$916.65
Rate for Payer: Cash Price	$567.00
Rate for Payer: Health Management Network Commercial	$803.25
Rate for Payer: Kaiser Permanente Commercial	$850.50
Rate for Payer: MDX Hawaii PPO	$916.65

RSA GLENOID 28MM 5572-2802

Facility

$4,400.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$2,464.00
Max. Negotiated Rate	$4,268.00
Rate for Payer: Cash Price	$2,640.00
Rate for Payer: Hawaii Western Management Group Commercial	$3,080.00
Rate for Payer: Health Management Network Commercial	$3,740.00
Rate for Payer: Kaiser Permanente Commercial	$3,960.00
Rate for Payer: MDX Hawaii PPO	$4,268.00
Rate for Payer: University Health Alliance Commercial	$2,464.00

RSA GLENOID 28MM 5572-2802

Facility

$4,400.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$2,200.00
Max. Negotiated Rate	$4,268.00
Rate for Payer: AlohaCare Medicaid	$2,200.00
Rate for Payer: AlohaCare Medicare	$3,344.00
Rate for Payer: Cash Price	$2,640.00
Rate for Payer: Devoted Health Medicare	$3,696.00
Rate for Payer: Hawaii Medical Service Association Medicare	$3,344.00
Rate for Payer: Hawaii Western Management Group Commercial	$3,080.00
Rate for Payer: Health Management Network Commercial	$3,740.00
Rate for Payer: Humana Medicare	$3,344.00
Rate for Payer: Kaiser Permanente Commercial	$3,960.00
Rate for Payer: Kaiser Permanente Medicaid	$2,244.00
Rate for Payer: Kaiser Permanente Medicare	$3,344.00
Rate for Payer: MDX Hawaii PPO	$4,268.00
Rate for Payer: Ohana Health Plan Medicaid	$3,344.00
Rate for Payer: Ohana Health Plan Medicare	$3,344.00
Rate for Payer: UnitedHealthcare Medicare	$3,344.00
Rate for Payer: University Health Alliance Commercial	$2,464.00

RSA HUMERAL CUP 5570-3602

Facility

$4,000.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$2,240.00
Max. Negotiated Rate	$3,880.00
Rate for Payer: Cash Price	$2,400.00
Rate for Payer: Hawaii Western Management Group Commercial	$2,800.00
Rate for Payer: Health Management Network Commercial	$3,400.00
Rate for Payer: Kaiser Permanente Commercial	$3,600.00
Rate for Payer: MDX Hawaii PPO	$3,880.00
Rate for Payer: University Health Alliance Commercial	$2,240.00

RSA HUMERAL CUP 5570-3602

Facility

$4,000.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$2,000.00
Max. Negotiated Rate	$3,880.00
Rate for Payer: AlohaCare Medicaid	$2,000.00
Rate for Payer: AlohaCare Medicare	$3,040.00
Rate for Payer: Cash Price	$2,400.00
Rate for Payer: Devoted Health Medicare	$3,360.00
Rate for Payer: Hawaii Medical Service Association Medicare	$3,040.00
Rate for Payer: Hawaii Western Management Group Commercial	$2,800.00
Rate for Payer: Health Management Network Commercial	$3,400.00
Rate for Payer: Humana Medicare	$3,040.00
Rate for Payer: Kaiser Permanente Commercial	$3,600.00
Rate for Payer: Kaiser Permanente Medicaid	$2,040.00
Rate for Payer: Kaiser Permanente Medicare	$3,040.00
Rate for Payer: MDX Hawaii PPO	$3,880.00
Rate for Payer: Ohana Health Plan Medicaid	$3,040.00
Rate for Payer: Ohana Health Plan Medicare	$3,040.00
Rate for Payer: UnitedHealthcare Medicare	$3,040.00
Rate for Payer: University Health Alliance Commercial	$2,240.00

RUMI INTRAUTERINE 6CM UMW676

Facility

$309.00

Hospital Revenue Code	272
Min. Negotiated Rate	$154.50
Max. Negotiated Rate	$299.73
Rate for Payer: AlohaCare Medicaid	$154.50
Rate for Payer: AlohaCare Medicare	$234.84
Rate for Payer: Cash Price	$185.40
Rate for Payer: Devoted Health Medicare	$259.56
Rate for Payer: Hawaii Medical Service Association Medicare	$234.84
Rate for Payer: Hawaii Western Management Group Commercial	$293.55
Rate for Payer: Health Management Network Commercial	$262.65
Rate for Payer: Humana Medicare	$234.84
Rate for Payer: Kaiser Permanente Commercial	$278.10
Rate for Payer: Kaiser Permanente Medicaid	$157.59
Rate for Payer: Kaiser Permanente Medicare	$234.84
Rate for Payer: MDX Hawaii PPO	$299.73
Rate for Payer: Ohana Health Plan Medicaid	$234.84
Rate for Payer: Ohana Health Plan Medicare	$234.84
Rate for Payer: UnitedHealthcare Medicare	$234.84
Rate for Payer: University Health Alliance Commercial	$225.23

RUMI INTRAUTERINE 6CM UMW676

Facility

$309.00

Hospital Revenue Code	272
Min. Negotiated Rate	$262.65
Max. Negotiated Rate	$299.73
Rate for Payer: Cash Price	$185.40
Rate for Payer: Health Management Network Commercial	$262.65
Rate for Payer: Kaiser Permanente Commercial	$278.10
Rate for Payer: MDX Hawaii PPO	$299.73

RUMI KOH EFFCIENT 3.0 KCRUMI30

Facility

$553.00

Hospital Revenue Code	272
Min. Negotiated Rate	$470.05
Max. Negotiated Rate	$536.41
Rate for Payer: Cash Price	$331.80
Rate for Payer: Health Management Network Commercial	$470.05
Rate for Payer: Kaiser Permanente Commercial	$497.70
Rate for Payer: MDX Hawaii PPO	$536.41

RUMI KOH EFFCIENT 3.0 KCRUMI30

Facility

$553.00

Hospital Revenue Code	272
Min. Negotiated Rate	$276.50
Max. Negotiated Rate	$536.41
Rate for Payer: AlohaCare Medicaid	$276.50
Rate for Payer: AlohaCare Medicare	$420.28
Rate for Payer: Cash Price	$331.80
Rate for Payer: Devoted Health Medicare	$464.52
Rate for Payer: Hawaii Medical Service Association Medicare	$420.28
Rate for Payer: Hawaii Western Management Group Commercial	$525.35
Rate for Payer: Health Management Network Commercial	$470.05
Rate for Payer: Humana Medicare	$420.28
Rate for Payer: Kaiser Permanente Commercial	$497.70
Rate for Payer: Kaiser Permanente Medicaid	$282.03
Rate for Payer: Kaiser Permanente Medicare	$420.28
Rate for Payer: MDX Hawaii PPO	$536.41
Rate for Payer: Ohana Health Plan Medicaid	$420.28
Rate for Payer: Ohana Health Plan Medicare	$420.28
Rate for Payer: UnitedHealthcare Medicare	$420.28
Rate for Payer: University Health Alliance Commercial	$403.08

RUMI KOH EFFICIENT3.5 KCRUMI35

Facility

$594.00

Hospital Revenue Code	272
Min. Negotiated Rate	$297.00
Max. Negotiated Rate	$576.18
Rate for Payer: AlohaCare Medicaid	$297.00
Rate for Payer: AlohaCare Medicare	$451.44
Rate for Payer: Cash Price	$356.40
Rate for Payer: Devoted Health Medicare	$498.96
Rate for Payer: Hawaii Medical Service Association Medicare	$451.44
Rate for Payer: Hawaii Western Management Group Commercial	$564.30
Rate for Payer: Health Management Network Commercial	$504.90
Rate for Payer: Humana Medicare	$451.44
Rate for Payer: Kaiser Permanente Commercial	$534.60
Rate for Payer: Kaiser Permanente Medicaid	$302.94
Rate for Payer: Kaiser Permanente Medicare	$451.44
Rate for Payer: MDX Hawaii PPO	$576.18
Rate for Payer: Ohana Health Plan Medicaid	$451.44
Rate for Payer: Ohana Health Plan Medicare	$451.44
Rate for Payer: UnitedHealthcare Medicare	$451.44
Rate for Payer: University Health Alliance Commercial	$432.97

RUMI KOH EFFICIENT3.5 KCRUMI35

Facility

$594.00

Hospital Revenue Code	272
Min. Negotiated Rate	$504.90
Max. Negotiated Rate	$576.18
Rate for Payer: Cash Price	$356.40
Rate for Payer: Health Management Network Commercial	$504.90
Rate for Payer: Kaiser Permanente Commercial	$534.60
Rate for Payer: MDX Hawaii PPO	$576.18

SACITUZUMAB GOVITECAN-HZIY 180 MG/18ML IV (WET SOLR VIAL) [430173279]

Facility

$3,577.00

Service Code	HCPCS J9317
Hospital Revenue Code	636
Min. Negotiated Rate	$36.26
Max. Negotiated Rate	$3,469.69
Rate for Payer: AlohaCare Medicaid	$1,788.50
Rate for Payer: AlohaCare Medicare	$2,718.52
Rate for Payer: Cash Price	$2,146.20
Rate for Payer: Cash Price	$2,146.20
Rate for Payer: Devoted Health Medicare	$3,004.68
Rate for Payer: Hawaii Medical Service Association ABD	$36.26
Rate for Payer: Hawaii Medical Service Association Commercial	$46.00
Rate for Payer: Hawaii Medical Service Association Medicare	$2,718.52
Rate for Payer: Hawaii Medical Service Association Non-ABD	$36.26
Rate for Payer: Hawaii Western Management Group Commercial	$3,398.15
Rate for Payer: Health Management Network Commercial	$3,040.45
Rate for Payer: Humana Medicare	$2,718.52
Rate for Payer: Kaiser Permanente Commercial	$3,219.30
Rate for Payer: Kaiser Permanente Medicaid	$1,824.27
Rate for Payer: Kaiser Permanente Medicare	$2,718.52
Rate for Payer: MDX Hawaii PPO	$3,469.69
Rate for Payer: Ohana Health Plan Medicaid	$2,718.52
Rate for Payer: Ohana Health Plan Medicare	$2,718.52
Rate for Payer: UnitedHealthcare Medicaid	$2,146.20
Rate for Payer: UnitedHealthcare Medicare	$2,718.52
Rate for Payer: University Health Alliance Commercial	$2,607.28

SACITUZUMAB GOVITECAN-HZIY 180 MG/18ML IV (WET SOLR VIAL) [430173279]

Facility

$3,577.00

Service Code	HCPCS J9317
Hospital Revenue Code	250
Min. Negotiated Rate	$3,040.45
Max. Negotiated Rate	$3,469.69
Rate for Payer: Cash Price	$2,146.20
Rate for Payer: Health Management Network Commercial	$3,040.45
Rate for Payer: Kaiser Permanente Commercial	$3,219.30
Rate for Payer: MDX Hawaii PPO	$3,469.69

SACITUZUMAB GOVITECAN-HZIY 180 MG INTRAVENOUS SOLUTION [173279]

Facility

$3,577.00

Service Code	HCPCS J9317
Hospital Revenue Code	636
Min. Negotiated Rate	$36.26
Max. Negotiated Rate	$3,469.69
Rate for Payer: AlohaCare Medicaid	$1,788.50
Rate for Payer: AlohaCare Medicare	$2,718.52
Rate for Payer: Cash Price	$2,146.20
Rate for Payer: Cash Price	$2,146.20
Rate for Payer: Devoted Health Medicare	$3,004.68
Rate for Payer: Hawaii Medical Service Association ABD	$36.26
Rate for Payer: Hawaii Medical Service Association Commercial	$46.00
Rate for Payer: Hawaii Medical Service Association Medicare	$2,718.52
Rate for Payer: Hawaii Medical Service Association Non-ABD	$36.26
Rate for Payer: Hawaii Western Management Group Commercial	$3,398.15
Rate for Payer: Health Management Network Commercial	$3,040.45
Rate for Payer: Humana Medicare	$2,718.52
Rate for Payer: Kaiser Permanente Commercial	$3,219.30
Rate for Payer: Kaiser Permanente Medicaid	$1,824.27
Rate for Payer: Kaiser Permanente Medicare	$2,718.52
Rate for Payer: MDX Hawaii PPO	$3,469.69
Rate for Payer: Ohana Health Plan Medicaid	$2,718.52
Rate for Payer: Ohana Health Plan Medicare	$2,718.52
Rate for Payer: UnitedHealthcare Medicaid	$2,146.20
Rate for Payer: UnitedHealthcare Medicare	$2,718.52
Rate for Payer: University Health Alliance Commercial	$2,607.28

SACITUZUMAB GOVITECAN-HZIY 180 MG INTRAVENOUS SOLUTION [173279]

Facility

$3,577.00

Service Code	HCPCS J9317
Hospital Revenue Code	250
Min. Negotiated Rate	$3,040.45
Max. Negotiated Rate	$3,469.69
Rate for Payer: Cash Price	$2,146.20
Rate for Payer: Health Management Network Commercial	$3,040.45
Rate for Payer: Kaiser Permanente Commercial	$3,219.30
Rate for Payer: MDX Hawaii PPO	$3,469.69

SACUBITRIL 24 MG-VALSARTAN 26 MG TABLET [129911]

Facility

$29.00

Service Code	NDC 62332055660
Hospital Revenue Code	637
Min. Negotiated Rate	$14.50
Max. Negotiated Rate	$28.13
Rate for Payer: AlohaCare Medicaid	$14.50
Rate for Payer: AlohaCare Medicare	$22.04
Rate for Payer: Cash Price	$17.40
Rate for Payer: Devoted Health Medicare	$24.36
Rate for Payer: Hawaii Medical Service Association Medicare	$22.04
Rate for Payer: Hawaii Western Management Group Commercial	$27.55
Rate for Payer: Health Management Network Commercial	$24.65
Rate for Payer: Humana Medicare	$22.04
Rate for Payer: Kaiser Permanente Commercial	$26.10
Rate for Payer: Kaiser Permanente Medicaid	$14.79
Rate for Payer: Kaiser Permanente Medicare	$22.04
Rate for Payer: MDX Hawaii PPO	$28.13
Rate for Payer: Ohana Health Plan Medicaid	$22.04
Rate for Payer: Ohana Health Plan Medicare	$22.04
Rate for Payer: UnitedHealthcare Medicare	$22.04
Rate for Payer: University Health Alliance Commercial	$21.14

SACUBITRIL 24 MG-VALSARTAN 26 MG TABLET [129911]

Facility

$29.00

Service Code	NDC 62332055660
Hospital Revenue Code	250
Min. Negotiated Rate	$24.65
Max. Negotiated Rate	$28.13
Rate for Payer: Cash Price	$17.40
Rate for Payer: Health Management Network Commercial	$24.65
Rate for Payer: Kaiser Permanente Commercial	$26.10
Rate for Payer: MDX Hawaii PPO	$28.13

SACUBITRIL 24 MG-VALSARTAN 26 MG TABLET [129911]

Facility

$36.00

Service Code	NDC 00078065920
Hospital Revenue Code	637
Min. Negotiated Rate	$18.00
Max. Negotiated Rate	$34.92
Rate for Payer: AlohaCare Medicaid	$18.00
Rate for Payer: AlohaCare Medicare	$27.36
Rate for Payer: Cash Price	$21.60
Rate for Payer: Devoted Health Medicare	$30.24
Rate for Payer: Hawaii Medical Service Association Medicare	$27.36
Rate for Payer: Hawaii Western Management Group Commercial	$34.20
Rate for Payer: Health Management Network Commercial	$30.60
Rate for Payer: Humana Medicare	$27.36
Rate for Payer: Kaiser Permanente Commercial	$32.40
Rate for Payer: Kaiser Permanente Medicaid	$18.36
Rate for Payer: Kaiser Permanente Medicare	$27.36
Rate for Payer: MDX Hawaii PPO	$34.92
Rate for Payer: Ohana Health Plan Medicaid	$27.36
Rate for Payer: Ohana Health Plan Medicare	$27.36
Rate for Payer: UnitedHealthcare Medicare	$27.36
Rate for Payer: University Health Alliance Commercial	$26.24

Know your out-of-pocket cost for care.

All Charges