Honoka'a Hospital and Skilled Nursing Facility

All Charges

Charge

Type

Setting

Price

SHEATH URETERAL ACCESS 12FRX45

Facility

$576.00

Service Code	HCPCS C1894
Hospital Revenue Code	272
Min. Negotiated Rate	$288.00
Max. Negotiated Rate	$558.72
Rate for Payer: AlohaCare Medicaid	$288.00
Rate for Payer: AlohaCare Medicare	$437.76
Rate for Payer: Cash Price	$345.60
Rate for Payer: Devoted Health Medicare	$483.84
Rate for Payer: Hawaii Medical Service Association Medicare	$437.76
Rate for Payer: Hawaii Western Management Group Commercial	$547.20
Rate for Payer: Health Management Network Commercial	$489.60
Rate for Payer: Humana Medicare	$437.76
Rate for Payer: Kaiser Permanente Commercial	$518.40
Rate for Payer: Kaiser Permanente Medicaid	$293.76
Rate for Payer: Kaiser Permanente Medicare	$437.76
Rate for Payer: MDX Hawaii PPO	$558.72
Rate for Payer: Ohana Health Plan Medicaid	$437.76
Rate for Payer: Ohana Health Plan Medicare	$437.76
Rate for Payer: UnitedHealthcare Medicare	$437.76
Rate for Payer: University Health Alliance Commercial	$419.85

SHEATH URETERAL ACCESS 14FRX35

Facility

$576.00

Service Code	HCPCS C1894
Hospital Revenue Code	272
Min. Negotiated Rate	$288.00
Max. Negotiated Rate	$558.72
Rate for Payer: AlohaCare Medicaid	$288.00
Rate for Payer: AlohaCare Medicare	$437.76
Rate for Payer: Cash Price	$345.60
Rate for Payer: Devoted Health Medicare	$483.84
Rate for Payer: Hawaii Medical Service Association Medicare	$437.76
Rate for Payer: Hawaii Western Management Group Commercial	$547.20
Rate for Payer: Health Management Network Commercial	$489.60
Rate for Payer: Humana Medicare	$437.76
Rate for Payer: Kaiser Permanente Commercial	$518.40
Rate for Payer: Kaiser Permanente Medicaid	$293.76
Rate for Payer: Kaiser Permanente Medicare	$437.76
Rate for Payer: MDX Hawaii PPO	$558.72
Rate for Payer: Ohana Health Plan Medicaid	$437.76
Rate for Payer: Ohana Health Plan Medicare	$437.76
Rate for Payer: UnitedHealthcare Medicare	$437.76
Rate for Payer: University Health Alliance Commercial	$419.85

SHEATH URETERAL ACCESS 14FRX35

Facility

$576.00

Service Code	HCPCS C1894
Hospital Revenue Code	272
Min. Negotiated Rate	$489.60
Max. Negotiated Rate	$558.72
Rate for Payer: Cash Price	$345.60
Rate for Payer: Health Management Network Commercial	$489.60
Rate for Payer: Kaiser Permanente Commercial	$518.40
Rate for Payer: MDX Hawaii PPO	$558.72

SHEATH URETERAL ACCESS 14FRX45

Facility

$576.00

Service Code	HCPCS C1894
Hospital Revenue Code	272
Min. Negotiated Rate	$489.60
Max. Negotiated Rate	$558.72
Rate for Payer: Cash Price	$345.60
Rate for Payer: Health Management Network Commercial	$489.60
Rate for Payer: Kaiser Permanente Commercial	$518.40
Rate for Payer: MDX Hawaii PPO	$558.72

SHEATH URETERAL ACCESS 14FRX45

Facility

$576.00

Service Code	HCPCS C1894
Hospital Revenue Code	272
Min. Negotiated Rate	$288.00
Max. Negotiated Rate	$558.72
Rate for Payer: AlohaCare Medicaid	$288.00
Rate for Payer: AlohaCare Medicare	$437.76
Rate for Payer: Cash Price	$345.60
Rate for Payer: Devoted Health Medicare	$483.84
Rate for Payer: Hawaii Medical Service Association Medicare	$437.76
Rate for Payer: Hawaii Western Management Group Commercial	$547.20
Rate for Payer: Health Management Network Commercial	$489.60
Rate for Payer: Humana Medicare	$437.76
Rate for Payer: Kaiser Permanente Commercial	$518.40
Rate for Payer: Kaiser Permanente Medicaid	$293.76
Rate for Payer: Kaiser Permanente Medicare	$437.76
Rate for Payer: MDX Hawaii PPO	$558.72
Rate for Payer: Ohana Health Plan Medicaid	$437.76
Rate for Payer: Ohana Health Plan Medicare	$437.76
Rate for Payer: UnitedHealthcare Medicare	$437.76
Rate for Payer: University Health Alliance Commercial	$419.85

SHEATH URETERAL ACCESS SET

Facility

$424.00

Service Code	HCPCS C1894
Hospital Revenue Code	272
Min. Negotiated Rate	$360.40
Max. Negotiated Rate	$411.28
Rate for Payer: Cash Price	$254.40
Rate for Payer: Health Management Network Commercial	$360.40
Rate for Payer: Kaiser Permanente Commercial	$381.60
Rate for Payer: MDX Hawaii PPO	$411.28

SHEATH URETERAL ACCESS SET

Facility

$424.00

Service Code	HCPCS C1894
Hospital Revenue Code	272
Min. Negotiated Rate	$212.00
Max. Negotiated Rate	$411.28
Rate for Payer: AlohaCare Medicaid	$212.00
Rate for Payer: AlohaCare Medicare	$322.24
Rate for Payer: Cash Price	$254.40
Rate for Payer: Devoted Health Medicare	$356.16
Rate for Payer: Hawaii Medical Service Association Medicare	$322.24
Rate for Payer: Hawaii Western Management Group Commercial	$402.80
Rate for Payer: Health Management Network Commercial	$360.40
Rate for Payer: Humana Medicare	$322.24
Rate for Payer: Kaiser Permanente Commercial	$381.60
Rate for Payer: Kaiser Permanente Medicaid	$216.24
Rate for Payer: Kaiser Permanente Medicare	$322.24
Rate for Payer: MDX Hawaii PPO	$411.28
Rate for Payer: Ohana Health Plan Medicaid	$322.24
Rate for Payer: Ohana Health Plan Medicare	$322.24
Rate for Payer: UnitedHealthcare Medicare	$322.24
Rate for Payer: University Health Alliance Commercial	$309.05

SHELL 44MM #00-5001-044-00

Facility

$1,568.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$784.00
Max. Negotiated Rate	$1,520.96
Rate for Payer: AlohaCare Medicaid	$784.00
Rate for Payer: AlohaCare Medicare	$1,191.68
Rate for Payer: Cash Price	$940.80
Rate for Payer: Devoted Health Medicare	$1,317.12
Rate for Payer: Hawaii Medical Service Association Medicare	$1,191.68
Rate for Payer: Hawaii Western Management Group Commercial	$1,097.60
Rate for Payer: Health Management Network Commercial	$1,332.80
Rate for Payer: Humana Medicare	$1,191.68
Rate for Payer: Kaiser Permanente Commercial	$1,411.20
Rate for Payer: Kaiser Permanente Medicaid	$799.68
Rate for Payer: Kaiser Permanente Medicare	$1,191.68
Rate for Payer: MDX Hawaii PPO	$1,520.96
Rate for Payer: Ohana Health Plan Medicaid	$1,191.68
Rate for Payer: Ohana Health Plan Medicare	$1,191.68
Rate for Payer: UnitedHealthcare Medicare	$1,191.68
Rate for Payer: University Health Alliance Commercial	$878.08

SHELL 44MM #00-5001-044-00

Facility

$1,568.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$878.08
Max. Negotiated Rate	$1,520.96
Rate for Payer: Cash Price	$940.80
Rate for Payer: Hawaii Western Management Group Commercial	$1,097.60
Rate for Payer: Health Management Network Commercial	$1,332.80
Rate for Payer: Kaiser Permanente Commercial	$1,411.20
Rate for Payer: MDX Hawaii PPO	$1,520.96
Rate for Payer: University Health Alliance Commercial	$878.08

SHELL BPLR 55MM 00-5001-055-00

Facility

$1,050.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$525.00
Max. Negotiated Rate	$1,018.50
Rate for Payer: AlohaCare Medicaid	$525.00
Rate for Payer: AlohaCare Medicare	$798.00
Rate for Payer: Cash Price	$630.00
Rate for Payer: Devoted Health Medicare	$882.00
Rate for Payer: Hawaii Medical Service Association Medicare	$798.00
Rate for Payer: Hawaii Western Management Group Commercial	$735.00
Rate for Payer: Health Management Network Commercial	$892.50
Rate for Payer: Humana Medicare	$798.00
Rate for Payer: Kaiser Permanente Commercial	$945.00
Rate for Payer: Kaiser Permanente Medicaid	$535.50
Rate for Payer: Kaiser Permanente Medicare	$798.00
Rate for Payer: MDX Hawaii PPO	$1,018.50
Rate for Payer: Ohana Health Plan Medicaid	$798.00
Rate for Payer: Ohana Health Plan Medicare	$798.00
Rate for Payer: UnitedHealthcare Medicare	$798.00
Rate for Payer: University Health Alliance Commercial	$588.00

SHELL BPLR 55MM 00-5001-055-00

Facility

$1,050.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$588.00
Max. Negotiated Rate	$1,018.50
Rate for Payer: Cash Price	$630.00
Rate for Payer: Hawaii Western Management Group Commercial	$735.00
Rate for Payer: Health Management Network Commercial	$892.50
Rate for Payer: Kaiser Permanente Commercial	$945.00
Rate for Payer: MDX Hawaii PPO	$1,018.50
Rate for Payer: University Health Alliance Commercial	$588.00

SHELL CLUSTER 50MM 702-1150D

Facility

$2,703.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$1,351.50
Max. Negotiated Rate	$2,621.91
Rate for Payer: AlohaCare Medicaid	$1,351.50
Rate for Payer: AlohaCare Medicare	$2,054.28
Rate for Payer: Cash Price	$1,621.80
Rate for Payer: Devoted Health Medicare	$2,270.52
Rate for Payer: Hawaii Medical Service Association Medicare	$2,054.28
Rate for Payer: Hawaii Western Management Group Commercial	$1,892.10
Rate for Payer: Health Management Network Commercial	$2,297.55
Rate for Payer: Humana Medicare	$2,054.28
Rate for Payer: Kaiser Permanente Commercial	$2,432.70
Rate for Payer: Kaiser Permanente Medicaid	$1,378.53
Rate for Payer: Kaiser Permanente Medicare	$2,054.28
Rate for Payer: MDX Hawaii PPO	$2,621.91
Rate for Payer: Ohana Health Plan Medicaid	$2,054.28
Rate for Payer: Ohana Health Plan Medicare	$2,054.28
Rate for Payer: UnitedHealthcare Medicare	$2,054.28
Rate for Payer: University Health Alliance Commercial	$1,513.68

SHELL CLUSTER 50MM 702-1150D

Facility

$2,703.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$1,513.68
Max. Negotiated Rate	$2,621.91
Rate for Payer: Cash Price	$1,621.80
Rate for Payer: Hawaii Western Management Group Commercial	$1,892.10
Rate for Payer: Health Management Network Commercial	$2,297.55
Rate for Payer: Kaiser Permanente Commercial	$2,432.70
Rate for Payer: MDX Hawaii PPO	$2,621.91
Rate for Payer: University Health Alliance Commercial	$1,513.68

SHELL CLUSTER 60MM 702-04-60G

Facility

$3,211.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$1,798.16
Max. Negotiated Rate	$3,114.67
Rate for Payer: Cash Price	$1,926.60
Rate for Payer: Hawaii Western Management Group Commercial	$2,247.70
Rate for Payer: Health Management Network Commercial	$2,729.35
Rate for Payer: Kaiser Permanente Commercial	$2,889.90
Rate for Payer: MDX Hawaii PPO	$3,114.67
Rate for Payer: University Health Alliance Commercial	$1,798.16

SHELL CLUSTER 60MM 702-04-60G

Facility

$3,211.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$1,605.50
Max. Negotiated Rate	$3,114.67
Rate for Payer: Kaiser Permanente Medicare	$2,440.36
Rate for Payer: AlohaCare Medicaid	$1,605.50
Rate for Payer: AlohaCare Medicare	$2,440.36
Rate for Payer: Cash Price	$1,926.60
Rate for Payer: Devoted Health Medicare	$2,697.24
Rate for Payer: Hawaii Medical Service Association Medicare	$2,440.36
Rate for Payer: Hawaii Western Management Group Commercial	$2,247.70
Rate for Payer: Health Management Network Commercial	$2,729.35
Rate for Payer: Humana Medicare	$2,440.36
Rate for Payer: Kaiser Permanente Commercial	$2,889.90
Rate for Payer: Kaiser Permanente Medicaid	$1,637.61
Rate for Payer: MDX Hawaii PPO	$3,114.67
Rate for Payer: Ohana Health Plan Medicaid	$2,440.36
Rate for Payer: Ohana Health Plan Medicare	$2,440.36
Rate for Payer: UnitedHealthcare Medicare	$2,440.36
Rate for Payer: University Health Alliance Commercial	$1,798.16

SHELL CUP 45MM 00-5001-45-00

Facility

$1,568.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$784.00
Max. Negotiated Rate	$1,520.96
Rate for Payer: AlohaCare Medicaid	$784.00
Rate for Payer: AlohaCare Medicare	$1,191.68
Rate for Payer: Cash Price	$940.80
Rate for Payer: Devoted Health Medicare	$1,317.12
Rate for Payer: Hawaii Medical Service Association Medicare	$1,191.68
Rate for Payer: Hawaii Western Management Group Commercial	$1,097.60
Rate for Payer: Health Management Network Commercial	$1,332.80
Rate for Payer: Humana Medicare	$1,191.68
Rate for Payer: Kaiser Permanente Commercial	$1,411.20
Rate for Payer: Kaiser Permanente Medicaid	$799.68
Rate for Payer: Kaiser Permanente Medicare	$1,191.68
Rate for Payer: MDX Hawaii PPO	$1,520.96
Rate for Payer: Ohana Health Plan Medicaid	$1,191.68
Rate for Payer: Ohana Health Plan Medicare	$1,191.68
Rate for Payer: UnitedHealthcare Medicare	$1,191.68
Rate for Payer: University Health Alliance Commercial	$878.08

SHELL CUP 45MM 00-5001-45-00

Facility

$1,568.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$878.08
Max. Negotiated Rate	$1,520.96
Rate for Payer: Cash Price	$940.80
Rate for Payer: Hawaii Western Management Group Commercial	$1,097.60
Rate for Payer: Health Management Network Commercial	$1,332.80
Rate for Payer: Kaiser Permanente Commercial	$1,411.20
Rate for Payer: MDX Hawaii PPO	$1,520.96
Rate for Payer: University Health Alliance Commercial	$878.08

SHELL HEMI 64MM 509-02-64G

Facility

$11,560.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$6,473.60
Max. Negotiated Rate	$11,213.20
Rate for Payer: Cash Price	$6,936.00
Rate for Payer: Hawaii Western Management Group Commercial	$8,092.00
Rate for Payer: Health Management Network Commercial	$9,826.00
Rate for Payer: Kaiser Permanente Commercial	$10,404.00
Rate for Payer: MDX Hawaii PPO	$11,213.20
Rate for Payer: University Health Alliance Commercial	$6,473.60

SHELL HEMI 64MM 509-02-64G

Facility

$11,560.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$5,780.00
Max. Negotiated Rate	$11,213.20
Rate for Payer: AlohaCare Medicaid	$5,780.00
Rate for Payer: AlohaCare Medicare	$8,785.60
Rate for Payer: Cash Price	$6,936.00
Rate for Payer: Devoted Health Medicare	$9,710.40
Rate for Payer: Hawaii Medical Service Association Medicare	$8,785.60
Rate for Payer: Hawaii Western Management Group Commercial	$8,092.00
Rate for Payer: Health Management Network Commercial	$9,826.00
Rate for Payer: Humana Medicare	$8,785.60
Rate for Payer: Kaiser Permanente Commercial	$10,404.00
Rate for Payer: Kaiser Permanente Medicaid	$5,895.60
Rate for Payer: Kaiser Permanente Medicare	$8,785.60
Rate for Payer: MDX Hawaii PPO	$11,213.20
Rate for Payer: Ohana Health Plan Medicaid	$8,785.60
Rate for Payer: Ohana Health Plan Medicare	$8,785.60
Rate for Payer: UnitedHealthcare Medicare	$8,785.60
Rate for Payer: University Health Alliance Commercial	$6,473.60

SHOULDER CRYO/CUFF 12A01

Facility

$205.00

Hospital Revenue Code	272
Min. Negotiated Rate	$102.50
Max. Negotiated Rate	$198.85
Rate for Payer: AlohaCare Medicaid	$102.50
Rate for Payer: AlohaCare Medicare	$155.80
Rate for Payer: Cash Price	$123.00
Rate for Payer: Devoted Health Medicare	$172.20
Rate for Payer: Hawaii Medical Service Association Medicare	$155.80
Rate for Payer: Hawaii Western Management Group Commercial	$194.75
Rate for Payer: Health Management Network Commercial	$174.25
Rate for Payer: Humana Medicare	$155.80
Rate for Payer: Kaiser Permanente Commercial	$184.50
Rate for Payer: Kaiser Permanente Medicaid	$104.55
Rate for Payer: Kaiser Permanente Medicare	$155.80
Rate for Payer: MDX Hawaii PPO	$198.85
Rate for Payer: Ohana Health Plan Medicaid	$155.80
Rate for Payer: Ohana Health Plan Medicare	$155.80
Rate for Payer: UnitedHealthcare Medicare	$155.80
Rate for Payer: University Health Alliance Commercial	$149.42

SHOULDER CRYO/CUFF 12A01

Facility

$205.00

Hospital Revenue Code	272
Min. Negotiated Rate	$174.25
Max. Negotiated Rate	$198.85
Rate for Payer: Cash Price	$123.00
Rate for Payer: Health Management Network Commercial	$174.25
Rate for Payer: Kaiser Permanente Commercial	$184.50
Rate for Payer: MDX Hawaii PPO	$198.85

SHOULDER, ELBOW OR FOREARM PROCEDURES, EXCEPT MAJOR JOINT PROCEDURES WITH CC

Facility

$23,180.56

Service Code	MSDRG 511
Min. Negotiated Rate	$23,180.56
Max. Negotiated Rate	$23,180.56
Rate for Payer: Hawaii Medical Service Association Commercial	$23,180.56

SHOULDER, ELBOW OR FOREARM PROCEDURES, EXCEPT MAJOR JOINT PROCEDURES WITH MCC

Facility

$23,180.56

Service Code	MSDRG 510
Min. Negotiated Rate	$23,180.56
Max. Negotiated Rate	$23,180.56
Rate for Payer: Hawaii Medical Service Association Commercial	$23,180.56

SHOULDER, ELBOW OR FOREARM PROCEDURES, EXCEPT MAJOR JOINT PROCEDURES WITHOUT CC/MCC

Facility

$21,782.14

Service Code	MSDRG 512
Min. Negotiated Rate	$21,782.14
Max. Negotiated Rate	$21,782.14
Rate for Payer: Hawaii Medical Service Association Commercial	$21,782.14

SHOULDER FLEX SYS DWG146

Facility

$8,306.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$4,651.36
Max. Negotiated Rate	$8,056.82
Rate for Payer: Cash Price	$4,983.60
Rate for Payer: Hawaii Western Management Group Commercial	$5,814.20
Rate for Payer: Health Management Network Commercial	$7,060.10
Rate for Payer: Kaiser Permanente Commercial	$7,475.40
Rate for Payer: MDX Hawaii PPO	$8,056.82
Rate for Payer: University Health Alliance Commercial	$4,651.36

Know your out-of-pocket cost for care.

All Charges