Honoka'a Hospital and Skilled Nursing Facility

All Charges

Charge

Type

Setting

Price

SHOULDER FLEX SYS DWG146

Facility

$8,306.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$4,153.00
Max. Negotiated Rate	$8,056.82
Rate for Payer: AlohaCare Medicaid	$4,153.00
Rate for Payer: AlohaCare Medicare	$6,312.56
Rate for Payer: Cash Price	$4,983.60
Rate for Payer: Devoted Health Medicare	$6,977.04
Rate for Payer: Hawaii Medical Service Association Medicare	$6,312.56
Rate for Payer: Hawaii Western Management Group Commercial	$5,814.20
Rate for Payer: Health Management Network Commercial	$7,060.10
Rate for Payer: Humana Medicare	$6,312.56
Rate for Payer: Kaiser Permanente Commercial	$7,475.40
Rate for Payer: Kaiser Permanente Medicaid	$4,236.06
Rate for Payer: Kaiser Permanente Medicare	$6,312.56
Rate for Payer: MDX Hawaii PPO	$8,056.82
Rate for Payer: Ohana Health Plan Medicaid	$6,312.56
Rate for Payer: Ohana Health Plan Medicare	$6,312.56
Rate for Payer: UnitedHealthcare Medicare	$6,312.56
Rate for Payer: University Health Alliance Commercial	$4,651.36

SHOULDER STABILIZER KIT

Facility

$332.00

Hospital Revenue Code	272
Min. Negotiated Rate	$282.20
Max. Negotiated Rate	$322.04
Rate for Payer: Cash Price	$199.20
Rate for Payer: Health Management Network Commercial	$282.20
Rate for Payer: Kaiser Permanente Commercial	$298.80
Rate for Payer: MDX Hawaii PPO	$322.04

SHOULDER STABILIZER KIT

Facility

$332.00

Hospital Revenue Code	272
Min. Negotiated Rate	$166.00
Max. Negotiated Rate	$322.04
Rate for Payer: AlohaCare Medicaid	$166.00
Rate for Payer: AlohaCare Medicare	$252.32
Rate for Payer: Cash Price	$199.20
Rate for Payer: Devoted Health Medicare	$278.88
Rate for Payer: Hawaii Medical Service Association Medicare	$252.32
Rate for Payer: Hawaii Western Management Group Commercial	$315.40
Rate for Payer: Health Management Network Commercial	$282.20
Rate for Payer: Humana Medicare	$252.32
Rate for Payer: Kaiser Permanente Commercial	$298.80
Rate for Payer: Kaiser Permanente Medicaid	$169.32
Rate for Payer: Kaiser Permanente Medicare	$252.32
Rate for Payer: MDX Hawaii PPO	$322.04
Rate for Payer: Ohana Health Plan Medicaid	$252.32
Rate for Payer: Ohana Health Plan Medicare	$252.32
Rate for Payer: UnitedHealthcare Medicare	$252.32
Rate for Payer: University Health Alliance Commercial	$241.99

SHOULDER SUSPENSION MPR-SS-KIT

Facility

$183.00

Hospital Revenue Code	272
Min. Negotiated Rate	$155.55
Max. Negotiated Rate	$177.51
Rate for Payer: Cash Price	$109.80
Rate for Payer: Health Management Network Commercial	$155.55
Rate for Payer: Kaiser Permanente Commercial	$164.70
Rate for Payer: MDX Hawaii PPO	$177.51

SHOULDER SUSPENSION MPR-SS-KIT

Facility

$183.00

Hospital Revenue Code	272
Min. Negotiated Rate	$91.50
Max. Negotiated Rate	$177.51
Rate for Payer: AlohaCare Medicaid	$91.50
Rate for Payer: AlohaCare Medicare	$139.08
Rate for Payer: Cash Price	$109.80
Rate for Payer: Devoted Health Medicare	$153.72
Rate for Payer: Hawaii Medical Service Association Medicare	$139.08
Rate for Payer: Hawaii Western Management Group Commercial	$173.85
Rate for Payer: Health Management Network Commercial	$155.55
Rate for Payer: Humana Medicare	$139.08
Rate for Payer: Kaiser Permanente Commercial	$164.70
Rate for Payer: Kaiser Permanente Medicaid	$93.33
Rate for Payer: Kaiser Permanente Medicare	$139.08
Rate for Payer: MDX Hawaii PPO	$177.51
Rate for Payer: Ohana Health Plan Medicaid	$139.08
Rate for Payer: Ohana Health Plan Medicare	$139.08
Rate for Payer: UnitedHealthcare Medicare	$139.08
Rate for Payer: University Health Alliance Commercial	$133.39

SHUNT PRUITT-INA 2013-10

Facility

$2,098.00

Service Code	HCPCS C1889
Hospital Revenue Code	278
Min. Negotiated Rate	$1,174.88
Max. Negotiated Rate	$2,035.06
Rate for Payer: Cash Price	$1,258.80
Rate for Payer: Hawaii Western Management Group Commercial	$1,468.60
Rate for Payer: Health Management Network Commercial	$1,783.30
Rate for Payer: Kaiser Permanente Commercial	$1,888.20
Rate for Payer: MDX Hawaii PPO	$2,035.06
Rate for Payer: University Health Alliance Commercial	$1,174.88

SHUNT PRUITT-INA 2013-10

Facility

$2,098.00

Service Code	HCPCS C1889
Hospital Revenue Code	278
Min. Negotiated Rate	$1,049.00
Max. Negotiated Rate	$2,035.06
Rate for Payer: AlohaCare Medicaid	$1,049.00
Rate for Payer: AlohaCare Medicare	$1,594.48
Rate for Payer: Cash Price	$1,258.80
Rate for Payer: Devoted Health Medicare	$1,762.32
Rate for Payer: Hawaii Medical Service Association Medicare	$1,594.48
Rate for Payer: Hawaii Western Management Group Commercial	$1,468.60
Rate for Payer: Health Management Network Commercial	$1,783.30
Rate for Payer: Humana Medicare	$1,594.48
Rate for Payer: Kaiser Permanente Commercial	$1,888.20
Rate for Payer: Kaiser Permanente Medicaid	$1,069.98
Rate for Payer: Kaiser Permanente Medicare	$1,594.48
Rate for Payer: MDX Hawaii PPO	$2,035.06
Rate for Payer: Ohana Health Plan Medicaid	$1,594.48
Rate for Payer: Ohana Health Plan Medicare	$1,594.48
Rate for Payer: UnitedHealthcare Medicare	$1,594.48
Rate for Payer: University Health Alliance Commercial	$1,174.88

SIGNS AND SYMPTOMS OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH MCC

Facility

$10,499.99

Service Code	MSDRG 555
Min. Negotiated Rate	$10,499.99
Max. Negotiated Rate	$10,499.99
Rate for Payer: Hawaii Medical Service Association Commercial	$10,499.99

SIGNS AND SYMPTOMS OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITHOUT MCC

Facility

$10,499.99

Service Code	MSDRG 556
Min. Negotiated Rate	$10,499.99
Max. Negotiated Rate	$10,499.99
Rate for Payer: Hawaii Medical Service Association Commercial	$10,499.99

SIGNS AND SYMPTOMS WITH MCC

Facility

$14,387.11

Service Code	MSDRG 947
Min. Negotiated Rate	$14,387.11
Max. Negotiated Rate	$14,387.11
Rate for Payer: Hawaii Medical Service Association Commercial	$14,387.11

SIGNS AND SYMPTOMS WITHOUT MCC

Facility

$13,676.05

Service Code	MSDRG 948
Min. Negotiated Rate	$13,676.05
Max. Negotiated Rate	$13,676.05
Rate for Payer: Hawaii Medical Service Association Commercial	$13,676.05

SILDENAFIL (PULMONARY HYPERTENSION) 20 MG TABLET [41832]

Facility

$5.00

Service Code	NDC 60687078821
Hospital Revenue Code	250
Min. Negotiated Rate	$4.25
Max. Negotiated Rate	$4.85
Rate for Payer: Cash Price	$3.00
Rate for Payer: Health Management Network Commercial	$4.25
Rate for Payer: Kaiser Permanente Commercial	$4.50
Rate for Payer: MDX Hawaii PPO	$4.85

SILDENAFIL (PULMONARY HYPERTENSION) 20 MG TABLET [41832]

Facility

$5.00

Service Code	NDC 60687078811
Hospital Revenue Code	637
Min. Negotiated Rate	$2.50
Max. Negotiated Rate	$4.85
Rate for Payer: AlohaCare Medicaid	$2.50
Rate for Payer: AlohaCare Medicare	$3.80
Rate for Payer: Cash Price	$3.00
Rate for Payer: Devoted Health Medicare	$4.20
Rate for Payer: Hawaii Medical Service Association Medicare	$3.80
Rate for Payer: Hawaii Western Management Group Commercial	$4.75
Rate for Payer: Health Management Network Commercial	$4.25
Rate for Payer: Humana Medicare	$3.80
Rate for Payer: Kaiser Permanente Commercial	$4.50
Rate for Payer: Kaiser Permanente Medicaid	$2.55
Rate for Payer: Kaiser Permanente Medicare	$3.80
Rate for Payer: MDX Hawaii PPO	$4.85
Rate for Payer: Ohana Health Plan Medicaid	$3.80
Rate for Payer: Ohana Health Plan Medicare	$3.80
Rate for Payer: UnitedHealthcare Medicare	$3.80
Rate for Payer: University Health Alliance Commercial	$3.64

SILDENAFIL (PULMONARY HYPERTENSION) 20 MG TABLET [41832]

Facility

$5.00

Service Code	NDC 60687078811
Hospital Revenue Code	250
Min. Negotiated Rate	$4.25
Max. Negotiated Rate	$4.85
Rate for Payer: Cash Price	$3.00
Rate for Payer: Health Management Network Commercial	$4.25
Rate for Payer: Kaiser Permanente Commercial	$4.50
Rate for Payer: MDX Hawaii PPO	$4.85

SILDENAFIL (PULMONARY HYPERTENSION) 20 MG TABLET [41832]

Facility

$5.00

Service Code	NDC 60687078821
Hospital Revenue Code	637
Min. Negotiated Rate	$2.50
Max. Negotiated Rate	$4.85
Rate for Payer: AlohaCare Medicaid	$2.50
Rate for Payer: AlohaCare Medicare	$3.80
Rate for Payer: Cash Price	$3.00
Rate for Payer: Devoted Health Medicare	$4.20
Rate for Payer: Hawaii Medical Service Association Medicare	$3.80
Rate for Payer: Hawaii Western Management Group Commercial	$4.75
Rate for Payer: Health Management Network Commercial	$4.25
Rate for Payer: Humana Medicare	$3.80
Rate for Payer: Kaiser Permanente Commercial	$4.50
Rate for Payer: Kaiser Permanente Medicaid	$2.55
Rate for Payer: Kaiser Permanente Medicare	$3.80
Rate for Payer: MDX Hawaii PPO	$4.85
Rate for Payer: Ohana Health Plan Medicaid	$3.80
Rate for Payer: Ohana Health Plan Medicare	$3.80
Rate for Payer: UnitedHealthcare Medicare	$3.80
Rate for Payer: University Health Alliance Commercial	$3.64

SILICON BR IMPL 10721-420XP

Facility

$2,850.00

Service Code	HCPCS C1789
Hospital Revenue Code	278
Min. Negotiated Rate	$1,425.00
Max. Negotiated Rate	$2,764.50
Rate for Payer: AlohaCare Medicaid	$1,425.00
Rate for Payer: AlohaCare Medicare	$2,166.00
Rate for Payer: Cash Price	$1,710.00
Rate for Payer: Devoted Health Medicare	$2,394.00
Rate for Payer: Hawaii Medical Service Association Medicare	$2,166.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,995.00
Rate for Payer: Health Management Network Commercial	$2,422.50
Rate for Payer: Humana Medicare	$2,166.00
Rate for Payer: Kaiser Permanente Commercial	$2,565.00
Rate for Payer: Kaiser Permanente Medicaid	$1,453.50
Rate for Payer: Kaiser Permanente Medicare	$2,166.00
Rate for Payer: MDX Hawaii PPO	$2,764.50
Rate for Payer: Ohana Health Plan Medicaid	$2,166.00
Rate for Payer: Ohana Health Plan Medicare	$2,166.00
Rate for Payer: UnitedHealthcare Medicare	$2,166.00
Rate for Payer: University Health Alliance Commercial	$1,596.00

SILICON BR IMPL 10721-420XP

Facility

$2,850.00

Service Code	HCPCS C1789
Hospital Revenue Code	278
Min. Negotiated Rate	$1,596.00
Max. Negotiated Rate	$2,764.50
Rate for Payer: Cash Price	$1,710.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,995.00
Rate for Payer: Health Management Network Commercial	$2,422.50
Rate for Payer: Kaiser Permanente Commercial	$2,565.00
Rate for Payer: MDX Hawaii PPO	$2,764.50
Rate for Payer: University Health Alliance Commercial	$1,596.00

SILICONE BREAST 10610-190LP

Facility

$2,250.00

Service Code	HCPCS C1789
Hospital Revenue Code	278
Min. Negotiated Rate	$1,260.00
Max. Negotiated Rate	$2,182.50
Rate for Payer: Cash Price	$1,350.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,575.00
Rate for Payer: Health Management Network Commercial	$1,912.50
Rate for Payer: Kaiser Permanente Commercial	$2,025.00
Rate for Payer: MDX Hawaii PPO	$2,182.50
Rate for Payer: University Health Alliance Commercial	$1,260.00

SILICONE BREAST 10610-190LP

Facility

$2,250.00

Service Code	HCPCS C1789
Hospital Revenue Code	278
Min. Negotiated Rate	$1,125.00
Max. Negotiated Rate	$2,182.50
Rate for Payer: AlohaCare Medicaid	$1,125.00
Rate for Payer: AlohaCare Medicare	$1,710.00
Rate for Payer: Cash Price	$1,350.00
Rate for Payer: Devoted Health Medicare	$1,890.00
Rate for Payer: Hawaii Medical Service Association Medicare	$1,710.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,575.00
Rate for Payer: Health Management Network Commercial	$1,912.50
Rate for Payer: Humana Medicare	$1,710.00
Rate for Payer: Kaiser Permanente Commercial	$2,025.00
Rate for Payer: Kaiser Permanente Medicaid	$1,147.50
Rate for Payer: Kaiser Permanente Medicare	$1,710.00
Rate for Payer: MDX Hawaii PPO	$2,182.50
Rate for Payer: Ohana Health Plan Medicaid	$1,710.00
Rate for Payer: Ohana Health Plan Medicare	$1,710.00
Rate for Payer: UnitedHealthcare Medicare	$1,710.00
Rate for Payer: University Health Alliance Commercial	$1,260.00

SILICONE FINGER SZ 0 OSTF-00

Facility

$2,400.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$1,344.00
Max. Negotiated Rate	$2,328.00
Rate for Payer: Cash Price	$1,440.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,680.00
Rate for Payer: Health Management Network Commercial	$2,040.00
Rate for Payer: Kaiser Permanente Commercial	$2,160.00
Rate for Payer: MDX Hawaii PPO	$2,328.00
Rate for Payer: University Health Alliance Commercial	$1,344.00

SILICONE FINGER SZ 0 OSTF-00

Facility

$2,400.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$2,328.00
Rate for Payer: AlohaCare Medicaid	$1,200.00
Rate for Payer: AlohaCare Medicare	$1,824.00
Rate for Payer: Cash Price	$1,440.00
Rate for Payer: Devoted Health Medicare	$2,016.00
Rate for Payer: Hawaii Medical Service Association Medicare	$1,824.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,680.00
Rate for Payer: Health Management Network Commercial	$2,040.00
Rate for Payer: Humana Medicare	$1,824.00
Rate for Payer: Kaiser Permanente Commercial	$2,160.00
Rate for Payer: Kaiser Permanente Medicaid	$1,224.00
Rate for Payer: Kaiser Permanente Medicare	$1,824.00
Rate for Payer: MDX Hawaii PPO	$2,328.00
Rate for Payer: Ohana Health Plan Medicaid	$1,824.00
Rate for Payer: Ohana Health Plan Medicare	$1,824.00
Rate for Payer: UnitedHealthcare Medicare	$1,824.00
Rate for Payer: University Health Alliance Commercial	$1,344.00

SILICONE FINGER SZ1 OSTF-1

Facility

$2,400.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$2,328.00
Rate for Payer: AlohaCare Medicaid	$1,200.00
Rate for Payer: AlohaCare Medicare	$1,824.00
Rate for Payer: Cash Price	$1,440.00
Rate for Payer: Devoted Health Medicare	$2,016.00
Rate for Payer: Hawaii Medical Service Association Medicare	$1,824.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,680.00
Rate for Payer: Health Management Network Commercial	$2,040.00
Rate for Payer: Humana Medicare	$1,824.00
Rate for Payer: Kaiser Permanente Commercial	$2,160.00
Rate for Payer: Kaiser Permanente Medicaid	$1,224.00
Rate for Payer: Kaiser Permanente Medicare	$1,824.00
Rate for Payer: MDX Hawaii PPO	$2,328.00
Rate for Payer: Ohana Health Plan Medicaid	$1,824.00
Rate for Payer: Ohana Health Plan Medicare	$1,824.00
Rate for Payer: UnitedHealthcare Medicare	$1,824.00
Rate for Payer: University Health Alliance Commercial	$1,344.00

SILICONE FINGER SZ1 OSTF-1

Facility

$2,400.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$1,344.00
Max. Negotiated Rate	$2,328.00
Rate for Payer: Cash Price	$1,440.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,680.00
Rate for Payer: Health Management Network Commercial	$2,040.00
Rate for Payer: Kaiser Permanente Commercial	$2,160.00
Rate for Payer: MDX Hawaii PPO	$2,328.00
Rate for Payer: University Health Alliance Commercial	$1,344.00

SILICONE GEL 10621-590MP

Facility

$2,250.00

Service Code	HCPCS C1789
Hospital Revenue Code	278
Min. Negotiated Rate	$1,260.00
Max. Negotiated Rate	$2,182.50
Rate for Payer: Cash Price	$1,350.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,575.00
Rate for Payer: Health Management Network Commercial	$1,912.50
Rate for Payer: Kaiser Permanente Commercial	$2,025.00
Rate for Payer: MDX Hawaii PPO	$2,182.50
Rate for Payer: University Health Alliance Commercial	$1,260.00

SILICONE GEL 10621-590MP

Facility

$2,250.00

Service Code	HCPCS C1789
Hospital Revenue Code	278
Min. Negotiated Rate	$1,125.00
Max. Negotiated Rate	$2,182.50
Rate for Payer: AlohaCare Medicaid	$1,125.00
Rate for Payer: AlohaCare Medicare	$1,710.00
Rate for Payer: Cash Price	$1,350.00
Rate for Payer: Devoted Health Medicare	$1,890.00
Rate for Payer: Hawaii Medical Service Association Medicare	$1,710.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,575.00
Rate for Payer: Health Management Network Commercial	$1,912.50
Rate for Payer: Humana Medicare	$1,710.00
Rate for Payer: Kaiser Permanente Commercial	$2,025.00
Rate for Payer: Kaiser Permanente Medicaid	$1,147.50
Rate for Payer: Kaiser Permanente Medicare	$1,710.00
Rate for Payer: MDX Hawaii PPO	$2,182.50
Rate for Payer: Ohana Health Plan Medicaid	$1,710.00
Rate for Payer: Ohana Health Plan Medicare	$1,710.00
Rate for Payer: UnitedHealthcare Medicare	$1,710.00
Rate for Payer: University Health Alliance Commercial	$1,260.00

Know your out-of-pocket cost for care.

All Charges