Honoka'a Hospital and Skilled Nursing Facility

All Charges

Charge

Type

Setting

Price

SEPTIC ARTHRITIS WITHOUT CC/MCC

Facility

$24,460.46

Service Code	MSDRG 550
Min. Negotiated Rate	$24,460.46
Max. Negotiated Rate	$24,460.46
Rate for Payer: Hawaii Medical Service Association Commercial	$24,460.46

SEPTICEMIA OR SEVERE SEPSIS WITH MV >96 HOURS

Facility

$182,695.02

Service Code	MSDRG 870
Min. Negotiated Rate	$182,695.02
Max. Negotiated Rate	$182,695.02
Rate for Payer: Hawaii Medical Service Association Commercial	$182,695.02

SEPTICEMIA OR SEVERE SEPSIS WITHOUT MV >96 HOURS WITH MCC

Facility

$40,814.84

Service Code	MSDRG 871
Min. Negotiated Rate	$40,814.84
Max. Negotiated Rate	$40,814.84
Rate for Payer: Hawaii Medical Service Association Commercial	$40,814.84

SEPTICEMIA OR SEVERE SEPSIS WITHOUT MV >96 HOURS WITHOUT MCC

Facility

$40,791.14

Service Code	MSDRG 872
Min. Negotiated Rate	$40,791.14
Max. Negotiated Rate	$40,791.14
Rate for Payer: Hawaii Medical Service Association Commercial	$40,791.14

SERTRALINE 100 MG TABLET [11350]

Facility

$2.00

Service Code	NDC 60687025301
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

SERTRALINE 100 MG TABLET [11350]

Facility

$2.00

Service Code	NDC 60687025311
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

SERTRALINE 100 MG TABLET [11350]

Facility

$2.00

Service Code	NDC 60687025311
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

SERTRALINE 100 MG TABLET [11350]

Facility

$2.00

Service Code	NDC 60687025301
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

SERTRALINE 25 MG TABLET [19882]

Facility

$2.00

Service Code	NDC 60687023101
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

SERTRALINE 25 MG TABLET [19882]

Facility

$2.00

Service Code	NDC 60687023111
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

SERTRALINE 25 MG TABLET [19882]

Facility

$2.00

Service Code	NDC 60687023111
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

SERTRALINE 25 MG TABLET [19882]

Facility

$2.00

Service Code	NDC 60687023101
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

SERTRALINE 50 MG TABLET [11351]

Facility

$2.00

Service Code	NDC 60687024211
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

SERTRALINE 50 MG TABLET [11351]

Facility

$2.00

Service Code	NDC 60687024211
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

SERTRALINE 50 MG TABLET [11351]

Facility

$2.00

Service Code	NDC 60687024201
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

SERTRALINE 50 MG TABLET [11351]

Facility

$2.00

Service Code	NDC 60687024201
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

SET BANDER URETHERAL 6X75

Facility

$389.00

Service Code	HCPCS C2625
Hospital Revenue Code	278
Min. Negotiated Rate	$217.84
Max. Negotiated Rate	$377.33
Rate for Payer: Cash Price	$233.40
Rate for Payer: Hawaii Western Management Group Commercial	$272.30
Rate for Payer: Health Management Network Commercial	$330.65
Rate for Payer: Kaiser Permanente Commercial	$350.10
Rate for Payer: MDX Hawaii PPO	$377.33
Rate for Payer: University Health Alliance Commercial	$217.84

SET BANDER URETHERAL 6X75

Facility

$389.00

Service Code	HCPCS C2625
Hospital Revenue Code	278
Min. Negotiated Rate	$194.50
Max. Negotiated Rate	$377.33
Rate for Payer: AlohaCare Medicaid	$194.50
Rate for Payer: AlohaCare Medicare	$295.64
Rate for Payer: Cash Price	$233.40
Rate for Payer: Devoted Health Medicare	$326.76
Rate for Payer: Hawaii Medical Service Association Medicare	$295.64
Rate for Payer: Hawaii Western Management Group Commercial	$272.30
Rate for Payer: Health Management Network Commercial	$330.65
Rate for Payer: Humana Medicare	$295.64
Rate for Payer: Kaiser Permanente Commercial	$350.10
Rate for Payer: Kaiser Permanente Medicaid	$198.39
Rate for Payer: Kaiser Permanente Medicare	$295.64
Rate for Payer: MDX Hawaii PPO	$377.33
Rate for Payer: Ohana Health Plan Medicaid	$295.64
Rate for Payer: Ohana Health Plan Medicare	$295.64
Rate for Payer: UnitedHealthcare Medicare	$295.64
Rate for Payer: University Health Alliance Commercial	$217.84

SET BLADDER EVACUATOR

Facility

$116.00

Hospital Revenue Code	272
Min. Negotiated Rate	$98.60
Max. Negotiated Rate	$112.52
Rate for Payer: Cash Price	$69.60
Rate for Payer: Health Management Network Commercial	$98.60
Rate for Payer: Kaiser Permanente Commercial	$104.40
Rate for Payer: MDX Hawaii PPO	$112.52

SET BLADDER EVACUATOR

Facility

$116.00

Hospital Revenue Code	272
Min. Negotiated Rate	$58.00
Max. Negotiated Rate	$112.52
Rate for Payer: AlohaCare Medicaid	$58.00
Rate for Payer: AlohaCare Medicare	$88.16
Rate for Payer: Cash Price	$69.60
Rate for Payer: Devoted Health Medicare	$97.44
Rate for Payer: Hawaii Medical Service Association Medicare	$88.16
Rate for Payer: Hawaii Western Management Group Commercial	$110.20
Rate for Payer: Health Management Network Commercial	$98.60
Rate for Payer: Humana Medicare	$88.16
Rate for Payer: Kaiser Permanente Commercial	$104.40
Rate for Payer: Kaiser Permanente Medicaid	$59.16
Rate for Payer: Kaiser Permanente Medicare	$88.16
Rate for Payer: MDX Hawaii PPO	$112.52
Rate for Payer: Ohana Health Plan Medicaid	$88.16
Rate for Payer: Ohana Health Plan Medicare	$88.16
Rate for Payer: UnitedHealthcare Medicare	$88.16
Rate for Payer: University Health Alliance Commercial	$84.55

SET COMMON DUCT EXPLORATION

Facility

$2,020.00

Service Code	HCPCS C1726
Hospital Revenue Code	272
Min. Negotiated Rate	$1,717.00
Max. Negotiated Rate	$1,959.40
Rate for Payer: Cash Price	$1,212.00
Rate for Payer: Health Management Network Commercial	$1,717.00
Rate for Payer: Kaiser Permanente Commercial	$1,818.00
Rate for Payer: MDX Hawaii PPO	$1,959.40

SET COMMON DUCT EXPLORATION

Facility

$2,020.00

Service Code	HCPCS C1726
Hospital Revenue Code	272
Min. Negotiated Rate	$1,010.00
Max. Negotiated Rate	$1,959.40
Rate for Payer: AlohaCare Medicaid	$1,010.00
Rate for Payer: AlohaCare Medicare	$1,535.20
Rate for Payer: Cash Price	$1,212.00
Rate for Payer: Devoted Health Medicare	$1,696.80
Rate for Payer: Hawaii Medical Service Association Medicare	$1,535.20
Rate for Payer: Hawaii Western Management Group Commercial	$1,919.00
Rate for Payer: Health Management Network Commercial	$1,717.00
Rate for Payer: Humana Medicare	$1,535.20
Rate for Payer: Kaiser Permanente Commercial	$1,818.00
Rate for Payer: Kaiser Permanente Medicaid	$1,030.20
Rate for Payer: Kaiser Permanente Medicare	$1,535.20
Rate for Payer: MDX Hawaii PPO	$1,959.40
Rate for Payer: Ohana Health Plan Medicaid	$1,535.20
Rate for Payer: Ohana Health Plan Medicare	$1,535.20
Rate for Payer: UnitedHealthcare Medicare	$1,535.20
Rate for Payer: University Health Alliance Commercial	$1,472.38

SET CRYOTHERAPY

Facility

$4,343.00

Service Code	HCPCS C2618
Hospital Revenue Code	272
Min. Negotiated Rate	$2,171.50
Max. Negotiated Rate	$4,212.71
Rate for Payer: AlohaCare Medicaid	$2,171.50
Rate for Payer: AlohaCare Medicare	$3,300.68
Rate for Payer: Cash Price	$2,605.80
Rate for Payer: Devoted Health Medicare	$3,648.12
Rate for Payer: Hawaii Medical Service Association Medicare	$3,300.68
Rate for Payer: Hawaii Western Management Group Commercial	$4,125.85
Rate for Payer: Health Management Network Commercial	$3,691.55
Rate for Payer: Humana Medicare	$3,300.68
Rate for Payer: Kaiser Permanente Commercial	$3,908.70
Rate for Payer: Kaiser Permanente Medicaid	$2,214.93
Rate for Payer: Kaiser Permanente Medicare	$3,300.68
Rate for Payer: MDX Hawaii PPO	$4,212.71
Rate for Payer: Ohana Health Plan Medicaid	$3,300.68
Rate for Payer: Ohana Health Plan Medicare	$3,300.68
Rate for Payer: UnitedHealthcare Medicare	$3,300.68
Rate for Payer: University Health Alliance Commercial	$3,165.61

SET CRYOTHERAPY

Facility

$4,343.00

Service Code	HCPCS C2618
Hospital Revenue Code	272
Min. Negotiated Rate	$3,691.55
Max. Negotiated Rate	$4,212.71
Rate for Payer: Cash Price	$2,605.80
Rate for Payer: Health Management Network Commercial	$3,691.55
Rate for Payer: Kaiser Permanente Commercial	$3,908.70
Rate for Payer: MDX Hawaii PPO	$4,212.71

SET IRRIG SIMPULSE SYSTEM

Facility

$210.00

Hospital Revenue Code	272
Min. Negotiated Rate	$105.00
Max. Negotiated Rate	$203.70
Rate for Payer: AlohaCare Medicaid	$105.00
Rate for Payer: AlohaCare Medicare	$159.60
Rate for Payer: Cash Price	$126.00
Rate for Payer: Devoted Health Medicare	$176.40
Rate for Payer: Hawaii Medical Service Association Medicare	$159.60
Rate for Payer: Hawaii Western Management Group Commercial	$199.50
Rate for Payer: Health Management Network Commercial	$178.50
Rate for Payer: Humana Medicare	$159.60
Rate for Payer: Kaiser Permanente Commercial	$189.00
Rate for Payer: Kaiser Permanente Medicaid	$107.10
Rate for Payer: Kaiser Permanente Medicare	$159.60
Rate for Payer: MDX Hawaii PPO	$203.70
Rate for Payer: Ohana Health Plan Medicaid	$159.60
Rate for Payer: Ohana Health Plan Medicare	$159.60
Rate for Payer: UnitedHealthcare Medicare	$159.60
Rate for Payer: University Health Alliance Commercial	$153.07

Know your out-of-pocket cost for care.

All Charges