Honoka'a Hospital and Skilled Nursing Facility

All Charges

Charge

Type

Setting

Price

SACUBITRIL 24 MG-VALSARTAN 26 MG TABLET [129911]

Facility

$36.00

Service Code	NDC 00078065920
Hospital Revenue Code	250
Min. Negotiated Rate	$30.60
Max. Negotiated Rate	$34.92
Rate for Payer: Cash Price	$21.60
Rate for Payer: Health Management Network Commercial	$30.60
Rate for Payer: Kaiser Permanente Commercial	$32.40
Rate for Payer: MDX Hawaii PPO	$34.92

SACUBITRIL 49 MG-VALSARTAN 51 MG TABLET [129912]

Facility

$29.00

Service Code	NDC 62332055760
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 49 MG-VALSARTAN 51 MG TABLET [129912]

Facility

$36.00

Service Code	NDC 00078077720
Hospital Revenue Code	250
Min. Negotiated Rate	$30.60
Max. Negotiated Rate	$34.92
Rate for Payer: Cash Price	$21.60
Rate for Payer: Health Management Network Commercial	$30.60
Rate for Payer: Kaiser Permanente Commercial	$32.40
Rate for Payer: MDX Hawaii PPO	$34.92

SACUBITRIL 49 MG-VALSARTAN 51 MG TABLET [129912]

Facility

$29.00

Service Code	NDC 62332055760
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 49 MG-VALSARTAN 51 MG TABLET [129912]

Facility

$36.00

Service Code	NDC 00078077720
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

SACUBITRIL 97 MG-VALSARTAN 103 MG TABLET [129913]

Facility

$36.00

Service Code	NDC 00078069620
Hospital Revenue Code	250
Min. Negotiated Rate	$30.60
Max. Negotiated Rate	$34.92
Rate for Payer: Cash Price	$21.60
Rate for Payer: Health Management Network Commercial	$30.60
Rate for Payer: Kaiser Permanente Commercial	$32.40
Rate for Payer: MDX Hawaii PPO	$34.92

SACUBITRIL 97 MG-VALSARTAN 103 MG TABLET [129913]

Facility

$36.00

Service Code	NDC 00078069620
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

SAFE SHEATH 6FX13

Facility

$200.00

Service Code	HCPCS C1892
Hospital Revenue Code	272
Min. Negotiated Rate	$170.00
Max. Negotiated Rate	$194.00
Rate for Payer: Cash Price	$120.00
Rate for Payer: Health Management Network Commercial	$170.00
Rate for Payer: Kaiser Permanente Commercial	$180.00
Rate for Payer: MDX Hawaii PPO	$194.00

SAFE SHEATH 6FX13

Facility

$200.00

Service Code	HCPCS C1892
Hospital Revenue Code	272
Min. Negotiated Rate	$100.00
Max. Negotiated Rate	$194.00
Rate for Payer: AlohaCare Medicaid	$100.00
Rate for Payer: AlohaCare Medicare	$152.00
Rate for Payer: Cash Price	$120.00
Rate for Payer: Devoted Health Medicare	$168.00
Rate for Payer: Hawaii Medical Service Association Medicare	$152.00
Rate for Payer: Hawaii Western Management Group Commercial	$190.00
Rate for Payer: Health Management Network Commercial	$170.00
Rate for Payer: Humana Medicare	$152.00
Rate for Payer: Kaiser Permanente Commercial	$180.00
Rate for Payer: Kaiser Permanente Medicaid	$102.00
Rate for Payer: Kaiser Permanente Medicare	$152.00
Rate for Payer: MDX Hawaii PPO	$194.00
Rate for Payer: Ohana Health Plan Medicaid	$152.00
Rate for Payer: Ohana Health Plan Medicare	$152.00
Rate for Payer: UnitedHealthcare Medicare	$152.00
Rate for Payer: University Health Alliance Commercial	$145.78

SAFESHEATH 8X23

Facility

$563.00

Service Code	HCPCS C1892
Hospital Revenue Code	272
Min. Negotiated Rate	$281.50
Max. Negotiated Rate	$546.11
Rate for Payer: AlohaCare Medicaid	$281.50
Rate for Payer: AlohaCare Medicare	$427.88
Rate for Payer: Cash Price	$337.80
Rate for Payer: Devoted Health Medicare	$472.92
Rate for Payer: Hawaii Medical Service Association Medicare	$427.88
Rate for Payer: Hawaii Western Management Group Commercial	$534.85
Rate for Payer: Health Management Network Commercial	$478.55
Rate for Payer: Humana Medicare	$427.88
Rate for Payer: Kaiser Permanente Commercial	$506.70
Rate for Payer: Kaiser Permanente Medicaid	$287.13
Rate for Payer: Kaiser Permanente Medicare	$427.88
Rate for Payer: MDX Hawaii PPO	$546.11
Rate for Payer: Ohana Health Plan Medicaid	$427.88
Rate for Payer: Ohana Health Plan Medicare	$427.88
Rate for Payer: UnitedHealthcare Medicare	$427.88
Rate for Payer: University Health Alliance Commercial	$410.37

SAFESHEATH 8X23

Facility

$563.00

Service Code	HCPCS C1892
Hospital Revenue Code	272
Min. Negotiated Rate	$478.55
Max. Negotiated Rate	$546.11
Rate for Payer: Cash Price	$337.80
Rate for Payer: Health Management Network Commercial	$478.55
Rate for Payer: Kaiser Permanente Commercial	$506.70
Rate for Payer: MDX Hawaii PPO	$546.11

SAFESHEATH II SS6 398339

Facility

$236.00

Service Code	HCPCS C1892
Hospital Revenue Code	272
Min. Negotiated Rate	$118.00
Max. Negotiated Rate	$228.92
Rate for Payer: AlohaCare Medicaid	$118.00
Rate for Payer: AlohaCare Medicare	$179.36
Rate for Payer: Cash Price	$141.60
Rate for Payer: Devoted Health Medicare	$198.24
Rate for Payer: Hawaii Medical Service Association Medicare	$179.36
Rate for Payer: Hawaii Western Management Group Commercial	$224.20
Rate for Payer: Health Management Network Commercial	$200.60
Rate for Payer: Humana Medicare	$179.36
Rate for Payer: Kaiser Permanente Commercial	$212.40
Rate for Payer: Kaiser Permanente Medicaid	$120.36
Rate for Payer: Kaiser Permanente Medicare	$179.36
Rate for Payer: MDX Hawaii PPO	$228.92
Rate for Payer: Ohana Health Plan Medicaid	$179.36
Rate for Payer: Ohana Health Plan Medicare	$179.36
Rate for Payer: UnitedHealthcare Medicare	$179.36
Rate for Payer: University Health Alliance Commercial	$172.02

SAFESHEATH II SS6 398339

Facility

$236.00

Service Code	HCPCS C1892
Hospital Revenue Code	272
Min. Negotiated Rate	$200.60
Max. Negotiated Rate	$228.92
Rate for Payer: Cash Price	$141.60
Rate for Payer: Health Management Network Commercial	$200.60
Rate for Payer: Kaiser Permanente Commercial	$212.40
Rate for Payer: MDX Hawaii PPO	$228.92

SAFESHEATH II SS8 398343

Facility

$236.00

Service Code	HCPCS C1892
Hospital Revenue Code	272
Min. Negotiated Rate	$118.00
Max. Negotiated Rate	$228.92
Rate for Payer: AlohaCare Medicaid	$118.00
Rate for Payer: AlohaCare Medicare	$179.36
Rate for Payer: Cash Price	$141.60
Rate for Payer: Devoted Health Medicare	$198.24
Rate for Payer: Hawaii Medical Service Association Medicare	$179.36
Rate for Payer: Hawaii Western Management Group Commercial	$224.20
Rate for Payer: Health Management Network Commercial	$200.60
Rate for Payer: Humana Medicare	$179.36
Rate for Payer: Kaiser Permanente Commercial	$212.40
Rate for Payer: Kaiser Permanente Medicaid	$120.36
Rate for Payer: Kaiser Permanente Medicare	$179.36
Rate for Payer: MDX Hawaii PPO	$228.92
Rate for Payer: Ohana Health Plan Medicaid	$179.36
Rate for Payer: Ohana Health Plan Medicare	$179.36
Rate for Payer: UnitedHealthcare Medicare	$179.36
Rate for Payer: University Health Alliance Commercial	$172.02

SAFESHEATH II SS8 398343

Facility

$236.00

Service Code	HCPCS C1892
Hospital Revenue Code	272
Min. Negotiated Rate	$200.60
Max. Negotiated Rate	$228.92
Rate for Payer: Cash Price	$141.60
Rate for Payer: Health Management Network Commercial	$200.60
Rate for Payer: Kaiser Permanente Commercial	$212.40
Rate for Payer: MDX Hawaii PPO	$228.92

SAFETY PEG KIT 20FR

Facility

$586.00

Hospital Revenue Code	272
Min. Negotiated Rate	$293.00
Max. Negotiated Rate	$568.42
Rate for Payer: AlohaCare Medicaid	$293.00
Rate for Payer: AlohaCare Medicare	$445.36
Rate for Payer: Cash Price	$351.60
Rate for Payer: Devoted Health Medicare	$492.24
Rate for Payer: Hawaii Medical Service Association Medicare	$445.36
Rate for Payer: Hawaii Western Management Group Commercial	$556.70
Rate for Payer: Health Management Network Commercial	$498.10
Rate for Payer: Humana Medicare	$445.36
Rate for Payer: Kaiser Permanente Commercial	$527.40
Rate for Payer: Kaiser Permanente Medicaid	$298.86
Rate for Payer: Kaiser Permanente Medicare	$445.36
Rate for Payer: MDX Hawaii PPO	$568.42
Rate for Payer: Ohana Health Plan Medicaid	$445.36
Rate for Payer: Ohana Health Plan Medicare	$445.36
Rate for Payer: UnitedHealthcare Medicare	$445.36
Rate for Payer: University Health Alliance Commercial	$427.14

SAFETY PEG KIT 20FR

Facility

$586.00

Hospital Revenue Code	272
Min. Negotiated Rate	$498.10
Max. Negotiated Rate	$568.42
Rate for Payer: Cash Price	$351.60
Rate for Payer: Health Management Network Commercial	$498.10
Rate for Payer: Kaiser Permanente Commercial	$527.40
Rate for Payer: MDX Hawaii PPO	$568.42

SALINE BREAST SIZER SZHP68500

Facility

$175.00

Service Code	HCPCS C1789
Hospital Revenue Code	278
Min. Negotiated Rate	$87.50
Max. Negotiated Rate	$169.75
Rate for Payer: AlohaCare Medicaid	$87.50
Rate for Payer: AlohaCare Medicare	$133.00
Rate for Payer: Cash Price	$105.00
Rate for Payer: Devoted Health Medicare	$147.00
Rate for Payer: Hawaii Medical Service Association Medicare	$133.00
Rate for Payer: Hawaii Western Management Group Commercial	$122.50
Rate for Payer: Health Management Network Commercial	$148.75
Rate for Payer: Humana Medicare	$133.00
Rate for Payer: Kaiser Permanente Commercial	$157.50
Rate for Payer: Kaiser Permanente Medicaid	$89.25
Rate for Payer: Kaiser Permanente Medicare	$133.00
Rate for Payer: MDX Hawaii PPO	$169.75
Rate for Payer: Ohana Health Plan Medicaid	$133.00
Rate for Payer: Ohana Health Plan Medicare	$133.00
Rate for Payer: UnitedHealthcare Medicare	$133.00
Rate for Payer: University Health Alliance Commercial	$98.00

SALINE BREAST SIZER SZHP68500

Facility

$175.00

Service Code	HCPCS C1789
Hospital Revenue Code	278
Min. Negotiated Rate	$98.00
Max. Negotiated Rate	$169.75
Rate for Payer: Cash Price	$105.00
Rate for Payer: Hawaii Western Management Group Commercial	$122.50
Rate for Payer: Health Management Network Commercial	$148.75
Rate for Payer: Kaiser Permanente Commercial	$157.50
Rate for Payer: MDX Hawaii PPO	$169.75
Rate for Payer: University Health Alliance Commercial	$98.00

SALINE SIZER SZ10621-470HP

Facility

$175.00

Service Code	HCPCS C1789
Hospital Revenue Code	278
Min. Negotiated Rate	$98.00
Max. Negotiated Rate	$169.75
Rate for Payer: Cash Price	$105.00
Rate for Payer: Hawaii Western Management Group Commercial	$122.50
Rate for Payer: Health Management Network Commercial	$148.75
Rate for Payer: Kaiser Permanente Commercial	$157.50
Rate for Payer: MDX Hawaii PPO	$169.75
Rate for Payer: University Health Alliance Commercial	$98.00

SALINE SIZER SZ10621-470HP

Facility

$175.00

Service Code	HCPCS C1789
Hospital Revenue Code	278
Min. Negotiated Rate	$87.50
Max. Negotiated Rate	$169.75
Rate for Payer: AlohaCare Medicaid	$87.50
Rate for Payer: AlohaCare Medicare	$133.00
Rate for Payer: Cash Price	$105.00
Rate for Payer: Devoted Health Medicare	$147.00
Rate for Payer: Hawaii Medical Service Association Medicare	$133.00
Rate for Payer: Hawaii Western Management Group Commercial	$122.50
Rate for Payer: Health Management Network Commercial	$148.75
Rate for Payer: Humana Medicare	$133.00
Rate for Payer: Kaiser Permanente Commercial	$157.50
Rate for Payer: Kaiser Permanente Medicaid	$89.25
Rate for Payer: Kaiser Permanente Medicare	$133.00
Rate for Payer: MDX Hawaii PPO	$169.75
Rate for Payer: Ohana Health Plan Medicaid	$133.00
Rate for Payer: Ohana Health Plan Medicare	$133.00
Rate for Payer: UnitedHealthcare Medicare	$133.00
Rate for Payer: University Health Alliance Commercial	$98.00

SALIVARY GLAND PROCEDURES

Facility

$21,758.44

Service Code	MSDRG 139
Min. Negotiated Rate	$21,758.44
Max. Negotiated Rate	$21,758.44
Rate for Payer: Hawaii Medical Service Association Commercial	$21,758.44

SAW BLADE 13MM 6113-127-100

Facility

$253.00

Hospital Revenue Code	272
Min. Negotiated Rate	$215.05
Max. Negotiated Rate	$245.41
Rate for Payer: Cash Price	$151.80
Rate for Payer: Health Management Network Commercial	$215.05
Rate for Payer: Kaiser Permanente Commercial	$227.70
Rate for Payer: MDX Hawaii PPO	$245.41

SAW BLADE 13MM 6113-127-100

Facility

$253.00

Hospital Revenue Code	272
Min. Negotiated Rate	$126.50
Max. Negotiated Rate	$245.41
Rate for Payer: AlohaCare Medicaid	$126.50
Rate for Payer: AlohaCare Medicare	$192.28
Rate for Payer: Cash Price	$151.80
Rate for Payer: Devoted Health Medicare	$212.52
Rate for Payer: Hawaii Medical Service Association Medicare	$192.28
Rate for Payer: Hawaii Western Management Group Commercial	$240.35
Rate for Payer: Health Management Network Commercial	$215.05
Rate for Payer: Humana Medicare	$192.28
Rate for Payer: Kaiser Permanente Commercial	$227.70
Rate for Payer: Kaiser Permanente Medicaid	$129.03
Rate for Payer: Kaiser Permanente Medicare	$192.28
Rate for Payer: MDX Hawaii PPO	$245.41
Rate for Payer: Ohana Health Plan Medicaid	$192.28
Rate for Payer: Ohana Health Plan Medicare	$192.28
Rate for Payer: UnitedHealthcare Medicare	$192.28
Rate for Payer: University Health Alliance Commercial	$184.41

SAWBLADE OXFORD #506269

Facility

$2,550.00

Hospital Revenue Code	272
Min. Negotiated Rate	$1,275.00
Max. Negotiated Rate	$2,473.50
Rate for Payer: AlohaCare Medicaid	$1,275.00
Rate for Payer: AlohaCare Medicare	$1,938.00
Rate for Payer: Cash Price	$1,530.00
Rate for Payer: Devoted Health Medicare	$2,142.00
Rate for Payer: Hawaii Medical Service Association Medicare	$1,938.00
Rate for Payer: Hawaii Western Management Group Commercial	$2,422.50
Rate for Payer: Health Management Network Commercial	$2,167.50
Rate for Payer: Humana Medicare	$1,938.00
Rate for Payer: Kaiser Permanente Commercial	$2,295.00
Rate for Payer: Kaiser Permanente Medicaid	$1,300.50
Rate for Payer: Kaiser Permanente Medicare	$1,938.00
Rate for Payer: MDX Hawaii PPO	$2,473.50
Rate for Payer: Ohana Health Plan Medicaid	$1,938.00
Rate for Payer: Ohana Health Plan Medicare	$1,938.00
Rate for Payer: UnitedHealthcare Medicare	$1,938.00
Rate for Payer: University Health Alliance Commercial	$1,858.69

Know your out-of-pocket cost for care.

All Charges