Honoka'a Hospital and Skilled Nursing Facility

All Charges

Charge

Type

Setting

Price

SILICONE GEL SMTH RND HI 505CC

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 GEL SMTH RND HI 505CC

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

SILVER NITRATE APPLICATORS 75 %-25 % TOPICAL STICK [11359]

Facility

$4.00

Service Code	NDC 12870000101
Hospital Revenue Code	250
Min. Negotiated Rate	$3.40
Max. Negotiated Rate	$3.88
Rate for Payer: Cash Price	$2.40
Rate for Payer: Health Management Network Commercial	$3.40
Rate for Payer: Kaiser Permanente Commercial	$3.60
Rate for Payer: MDX Hawaii PPO	$3.88

SILVER NITRATE APPLICATORS 75 %-25 % TOPICAL STICK [11359]

Facility

$3.00

Service Code	NDC 12870000102
Hospital Revenue Code	637
Min. Negotiated Rate	$1.50
Max. Negotiated Rate	$2.91
Rate for Payer: AlohaCare Medicaid	$1.50
Rate for Payer: AlohaCare Medicare	$2.28
Rate for Payer: Cash Price	$1.80
Rate for Payer: Devoted Health Medicare	$2.52
Rate for Payer: Hawaii Medical Service Association Medicare	$2.28
Rate for Payer: Hawaii Western Management Group Commercial	$2.85
Rate for Payer: Health Management Network Commercial	$2.55
Rate for Payer: Humana Medicare	$2.28
Rate for Payer: Kaiser Permanente Commercial	$2.70
Rate for Payer: Kaiser Permanente Medicaid	$1.53
Rate for Payer: Kaiser Permanente Medicare	$2.28
Rate for Payer: MDX Hawaii PPO	$2.91
Rate for Payer: Ohana Health Plan Medicaid	$2.28
Rate for Payer: Ohana Health Plan Medicare	$2.28
Rate for Payer: UnitedHealthcare Medicare	$2.28
Rate for Payer: University Health Alliance Commercial	$2.19

SILVER NITRATE APPLICATORS 75 %-25 % TOPICAL STICK [11359]

Facility

$4.00

Service Code	NDC 12870000101
Hospital Revenue Code	637
Min. Negotiated Rate	$2.00
Max. Negotiated Rate	$3.88
Rate for Payer: AlohaCare Medicaid	$2.00
Rate for Payer: AlohaCare Medicare	$3.04
Rate for Payer: Cash Price	$2.40
Rate for Payer: Devoted Health Medicare	$3.36
Rate for Payer: Hawaii Medical Service Association Medicare	$3.04
Rate for Payer: Hawaii Western Management Group Commercial	$3.80
Rate for Payer: Health Management Network Commercial	$3.40
Rate for Payer: Humana Medicare	$3.04
Rate for Payer: Kaiser Permanente Commercial	$3.60
Rate for Payer: Kaiser Permanente Medicaid	$2.04
Rate for Payer: Kaiser Permanente Medicare	$3.04
Rate for Payer: MDX Hawaii PPO	$3.88
Rate for Payer: Ohana Health Plan Medicaid	$3.04
Rate for Payer: Ohana Health Plan Medicare	$3.04
Rate for Payer: UnitedHealthcare Medicare	$3.04
Rate for Payer: University Health Alliance Commercial	$2.92

SILVER NITRATE APPLICATORS 75 %-25 % TOPICAL STICK [11359]

Facility

$3.00

Service Code	NDC 12870000102
Hospital Revenue Code	250
Min. Negotiated Rate	$2.55
Max. Negotiated Rate	$2.91
Rate for Payer: Cash Price	$1.80
Rate for Payer: Health Management Network Commercial	$2.55
Rate for Payer: Kaiser Permanente Commercial	$2.70
Rate for Payer: MDX Hawaii PPO	$2.91

SILVER SULFADIAZINE 1 % TOPICAL CREAM [7224]

Facility

$292.00

Service Code	NDC 67877012440
Hospital Revenue Code	250
Min. Negotiated Rate	$248.20
Max. Negotiated Rate	$283.24
Rate for Payer: Cash Price	$175.20
Rate for Payer: Health Management Network Commercial	$248.20
Rate for Payer: Kaiser Permanente Commercial	$262.80
Rate for Payer: MDX Hawaii PPO	$283.24

SILVER SULFADIAZINE 1 % TOPICAL CREAM [7224]

Facility

$48.00

Service Code	NDC 67877012425
Hospital Revenue Code	250
Min. Negotiated Rate	$40.80
Max. Negotiated Rate	$46.56
Rate for Payer: Cash Price	$28.80
Rate for Payer: Health Management Network Commercial	$40.80
Rate for Payer: Kaiser Permanente Commercial	$43.20
Rate for Payer: MDX Hawaii PPO	$46.56

SILVER SULFADIAZINE 1 % TOPICAL CREAM [7224]

Facility

$88.00

Service Code	NDC 43598021085
Hospital Revenue Code	637
Min. Negotiated Rate	$44.00
Max. Negotiated Rate	$85.36
Rate for Payer: AlohaCare Medicaid	$44.00
Rate for Payer: AlohaCare Medicare	$66.88
Rate for Payer: Cash Price	$52.80
Rate for Payer: Devoted Health Medicare	$73.92
Rate for Payer: Hawaii Medical Service Association Medicare	$66.88
Rate for Payer: Hawaii Western Management Group Commercial	$83.60
Rate for Payer: Health Management Network Commercial	$74.80
Rate for Payer: Humana Medicare	$66.88
Rate for Payer: Kaiser Permanente Commercial	$79.20
Rate for Payer: Kaiser Permanente Medicaid	$44.88
Rate for Payer: Kaiser Permanente Medicare	$66.88
Rate for Payer: MDX Hawaii PPO	$85.36
Rate for Payer: Ohana Health Plan Medicaid	$66.88
Rate for Payer: Ohana Health Plan Medicare	$66.88
Rate for Payer: UnitedHealthcare Medicare	$66.88
Rate for Payer: University Health Alliance Commercial	$64.14

SILVER SULFADIAZINE 1 % TOPICAL CREAM [7224]

Facility

$227.00

Service Code	NDC 59762013104
Hospital Revenue Code	637
Min. Negotiated Rate	$113.50
Max. Negotiated Rate	$220.19
Rate for Payer: AlohaCare Medicaid	$113.50
Rate for Payer: AlohaCare Medicare	$172.52
Rate for Payer: Cash Price	$136.20
Rate for Payer: Devoted Health Medicare	$190.68
Rate for Payer: Hawaii Medical Service Association Medicare	$172.52
Rate for Payer: Hawaii Western Management Group Commercial	$215.65
Rate for Payer: Health Management Network Commercial	$192.95
Rate for Payer: Humana Medicare	$172.52
Rate for Payer: Kaiser Permanente Commercial	$204.30
Rate for Payer: Kaiser Permanente Medicaid	$115.77
Rate for Payer: Kaiser Permanente Medicare	$172.52
Rate for Payer: MDX Hawaii PPO	$220.19
Rate for Payer: Ohana Health Plan Medicaid	$172.52
Rate for Payer: Ohana Health Plan Medicare	$172.52
Rate for Payer: UnitedHealthcare Medicare	$172.52
Rate for Payer: University Health Alliance Commercial	$165.46

SILVER SULFADIAZINE 1 % TOPICAL CREAM [7224]

Facility

$292.00

Service Code	NDC 67877012440
Hospital Revenue Code	637
Min. Negotiated Rate	$146.00
Max. Negotiated Rate	$283.24
Rate for Payer: AlohaCare Medicaid	$146.00
Rate for Payer: AlohaCare Medicare	$221.92
Rate for Payer: Cash Price	$175.20
Rate for Payer: Devoted Health Medicare	$245.28
Rate for Payer: Hawaii Medical Service Association Medicare	$221.92
Rate for Payer: Hawaii Western Management Group Commercial	$277.40
Rate for Payer: Health Management Network Commercial	$248.20
Rate for Payer: Humana Medicare	$221.92
Rate for Payer: Kaiser Permanente Commercial	$262.80
Rate for Payer: Kaiser Permanente Medicaid	$148.92
Rate for Payer: Kaiser Permanente Medicare	$221.92
Rate for Payer: MDX Hawaii PPO	$283.24
Rate for Payer: Ohana Health Plan Medicaid	$221.92
Rate for Payer: Ohana Health Plan Medicare	$221.92
Rate for Payer: UnitedHealthcare Medicare	$221.92
Rate for Payer: University Health Alliance Commercial	$212.84

SILVER SULFADIAZINE 1 % TOPICAL CREAM [7224]

Facility

$48.00

Service Code	NDC 67877012425
Hospital Revenue Code	637
Min. Negotiated Rate	$24.00
Max. Negotiated Rate	$46.56
Rate for Payer: AlohaCare Medicaid	$24.00
Rate for Payer: AlohaCare Medicare	$36.48
Rate for Payer: Cash Price	$28.80
Rate for Payer: Devoted Health Medicare	$40.32
Rate for Payer: Hawaii Medical Service Association Medicare	$36.48
Rate for Payer: Hawaii Western Management Group Commercial	$45.60
Rate for Payer: Health Management Network Commercial	$40.80
Rate for Payer: Humana Medicare	$36.48
Rate for Payer: Kaiser Permanente Commercial	$43.20
Rate for Payer: Kaiser Permanente Medicaid	$24.48
Rate for Payer: Kaiser Permanente Medicare	$36.48
Rate for Payer: MDX Hawaii PPO	$46.56
Rate for Payer: Ohana Health Plan Medicaid	$36.48
Rate for Payer: Ohana Health Plan Medicare	$36.48
Rate for Payer: UnitedHealthcare Medicare	$36.48
Rate for Payer: University Health Alliance Commercial	$34.99

SILVER SULFADIAZINE 1 % TOPICAL CREAM [7224]

Facility

$102.00

Service Code	NDC 61570013185
Hospital Revenue Code	637
Min. Negotiated Rate	$51.00
Max. Negotiated Rate	$98.94
Rate for Payer: AlohaCare Medicaid	$51.00
Rate for Payer: AlohaCare Medicare	$77.52
Rate for Payer: Cash Price	$61.20
Rate for Payer: Devoted Health Medicare	$85.68
Rate for Payer: Hawaii Medical Service Association Medicare	$77.52
Rate for Payer: Hawaii Western Management Group Commercial	$96.90
Rate for Payer: Health Management Network Commercial	$86.70
Rate for Payer: Humana Medicare	$77.52
Rate for Payer: Kaiser Permanente Commercial	$91.80
Rate for Payer: Kaiser Permanente Medicaid	$52.02
Rate for Payer: Kaiser Permanente Medicare	$77.52
Rate for Payer: MDX Hawaii PPO	$98.94
Rate for Payer: Ohana Health Plan Medicaid	$77.52
Rate for Payer: Ohana Health Plan Medicare	$77.52
Rate for Payer: UnitedHealthcare Medicare	$77.52
Rate for Payer: University Health Alliance Commercial	$74.35

SILVER SULFADIAZINE 1 % TOPICAL CREAM [7224]

Facility

$88.00

Service Code	NDC 43598021085
Hospital Revenue Code	250
Min. Negotiated Rate	$74.80
Max. Negotiated Rate	$85.36
Rate for Payer: Cash Price	$52.80
Rate for Payer: Health Management Network Commercial	$74.80
Rate for Payer: Kaiser Permanente Commercial	$79.20
Rate for Payer: MDX Hawaii PPO	$85.36

SILVER SULFADIAZINE 1 % TOPICAL CREAM [7224]

Facility

$227.00

Service Code	NDC 59762013104
Hospital Revenue Code	250
Min. Negotiated Rate	$192.95
Max. Negotiated Rate	$220.19
Rate for Payer: Cash Price	$136.20
Rate for Payer: Health Management Network Commercial	$192.95
Rate for Payer: Kaiser Permanente Commercial	$204.30
Rate for Payer: MDX Hawaii PPO	$220.19

SILVER SULFADIAZINE 1 % TOPICAL CREAM [7224]

Facility

$102.00

Service Code	NDC 61570013185
Hospital Revenue Code	250
Min. Negotiated Rate	$86.70
Max. Negotiated Rate	$98.94
Rate for Payer: Cash Price	$61.20
Rate for Payer: Health Management Network Commercial	$86.70
Rate for Payer: Kaiser Permanente Commercial	$91.80
Rate for Payer: MDX Hawaii PPO	$98.94

SIMETHICONE 40 MG/0.6 ML ORAL DROPS,SUSPENSION [7228]

Facility

$10.00

Service Code	NDC 71399004101
Hospital Revenue Code	250
Min. Negotiated Rate	$8.50
Max. Negotiated Rate	$9.70
Rate for Payer: Cash Price	$6.00
Rate for Payer: Health Management Network Commercial	$8.50
Rate for Payer: Kaiser Permanente Commercial	$9.00
Rate for Payer: MDX Hawaii PPO	$9.70

SIMETHICONE 40 MG/0.6 ML ORAL DROPS,SUSPENSION [7228]

Facility

$10.00

Service Code	NDC 00536130375
Hospital Revenue Code	250
Min. Negotiated Rate	$8.50
Max. Negotiated Rate	$9.70
Rate for Payer: Cash Price	$6.00
Rate for Payer: Health Management Network Commercial	$8.50
Rate for Payer: Kaiser Permanente Commercial	$9.00
Rate for Payer: MDX Hawaii PPO	$9.70

SIMETHICONE 40 MG/0.6 ML ORAL DROPS,SUSPENSION [7228]

Facility

$10.00

Service Code	NDC 71399004101
Hospital Revenue Code	637
Min. Negotiated Rate	$5.00
Max. Negotiated Rate	$9.70
Rate for Payer: AlohaCare Medicaid	$5.00
Rate for Payer: AlohaCare Medicare	$7.60
Rate for Payer: Cash Price	$6.00
Rate for Payer: Devoted Health Medicare	$8.40
Rate for Payer: Hawaii Medical Service Association Medicare	$7.60
Rate for Payer: Hawaii Western Management Group Commercial	$9.50
Rate for Payer: Health Management Network Commercial	$8.50
Rate for Payer: Humana Medicare	$7.60
Rate for Payer: Kaiser Permanente Commercial	$9.00
Rate for Payer: Kaiser Permanente Medicaid	$5.10
Rate for Payer: Kaiser Permanente Medicare	$7.60
Rate for Payer: MDX Hawaii PPO	$9.70
Rate for Payer: Ohana Health Plan Medicaid	$7.60
Rate for Payer: Ohana Health Plan Medicare	$7.60
Rate for Payer: UnitedHealthcare Medicare	$7.60
Rate for Payer: University Health Alliance Commercial	$7.29

SIMETHICONE 40 MG/0.6 ML ORAL DROPS,SUSPENSION [7228]

Facility

$10.00

Service Code	NDC 00536130375
Hospital Revenue Code	637
Min. Negotiated Rate	$5.00
Max. Negotiated Rate	$9.70
Rate for Payer: AlohaCare Medicaid	$5.00
Rate for Payer: AlohaCare Medicare	$7.60
Rate for Payer: Cash Price	$6.00
Rate for Payer: Devoted Health Medicare	$8.40
Rate for Payer: Hawaii Medical Service Association Medicare	$7.60
Rate for Payer: Hawaii Western Management Group Commercial	$9.50
Rate for Payer: Health Management Network Commercial	$8.50
Rate for Payer: Humana Medicare	$7.60
Rate for Payer: Kaiser Permanente Commercial	$9.00
Rate for Payer: Kaiser Permanente Medicaid	$5.10
Rate for Payer: Kaiser Permanente Medicare	$7.60
Rate for Payer: MDX Hawaii PPO	$9.70
Rate for Payer: Ohana Health Plan Medicaid	$7.60
Rate for Payer: Ohana Health Plan Medicare	$7.60
Rate for Payer: UnitedHealthcare Medicare	$7.60
Rate for Payer: University Health Alliance Commercial	$7.29

SIMETHICONE 80 MG CHEWABLE TABLET [7227]

Facility

$1.00

Service Code	NDC 77333081225
Hospital Revenue Code	250
Min. Negotiated Rate	$0.85
Max. Negotiated Rate	$0.97
Rate for Payer: Cash Price	$0.60
Rate for Payer: Health Management Network Commercial	$0.85
Rate for Payer: Kaiser Permanente Commercial	$0.90
Rate for Payer: MDX Hawaii PPO	$0.97

SIMETHICONE 80 MG CHEWABLE TABLET [7227]

Facility

$1.00

Service Code	NDC 77333081210
Hospital Revenue Code	637
Min. Negotiated Rate	$0.50
Max. Negotiated Rate	$0.97
Rate for Payer: AlohaCare Medicaid	$0.50
Rate for Payer: AlohaCare Medicare	$0.76
Rate for Payer: Cash Price	$0.60
Rate for Payer: Devoted Health Medicare	$0.84
Rate for Payer: Hawaii Medical Service Association Medicare	$0.76
Rate for Payer: Hawaii Western Management Group Commercial	$0.95
Rate for Payer: Health Management Network Commercial	$0.85
Rate for Payer: Humana Medicare	$0.76
Rate for Payer: Kaiser Permanente Commercial	$0.90
Rate for Payer: Kaiser Permanente Medicaid	$0.51
Rate for Payer: Kaiser Permanente Medicare	$0.76
Rate for Payer: MDX Hawaii PPO	$0.97
Rate for Payer: Ohana Health Plan Medicaid	$0.76
Rate for Payer: Ohana Health Plan Medicare	$0.76
Rate for Payer: UnitedHealthcare Medicare	$0.76
Rate for Payer: University Health Alliance Commercial	$0.73

SIMETHICONE 80 MG CHEWABLE TABLET [7227]

Facility

$1.00

Service Code	NDC 77333081225
Hospital Revenue Code	637
Min. Negotiated Rate	$0.50
Max. Negotiated Rate	$0.97
Rate for Payer: AlohaCare Medicaid	$0.50
Rate for Payer: AlohaCare Medicare	$0.76
Rate for Payer: Cash Price	$0.60
Rate for Payer: Devoted Health Medicare	$0.84
Rate for Payer: Hawaii Medical Service Association Medicare	$0.76
Rate for Payer: Hawaii Western Management Group Commercial	$0.95
Rate for Payer: Health Management Network Commercial	$0.85
Rate for Payer: Humana Medicare	$0.76
Rate for Payer: Kaiser Permanente Commercial	$0.90
Rate for Payer: Kaiser Permanente Medicaid	$0.51
Rate for Payer: Kaiser Permanente Medicare	$0.76
Rate for Payer: MDX Hawaii PPO	$0.97
Rate for Payer: Ohana Health Plan Medicaid	$0.76
Rate for Payer: Ohana Health Plan Medicare	$0.76
Rate for Payer: UnitedHealthcare Medicare	$0.76
Rate for Payer: University Health Alliance Commercial	$0.73

SIMETHICONE 80 MG CHEWABLE TABLET [7227]

Facility

$1.00

Service Code	NDC 77333081210
Hospital Revenue Code	250
Min. Negotiated Rate	$0.85
Max. Negotiated Rate	$0.97
Rate for Payer: Cash Price	$0.60
Rate for Payer: Health Management Network Commercial	$0.85
Rate for Payer: Kaiser Permanente Commercial	$0.90
Rate for Payer: MDX Hawaii PPO	$0.97

SIMPLE PNEUMONIA AND PLEURISY WITH CC

Facility

$23,796.81

Service Code	MSDRG 194
Min. Negotiated Rate	$23,796.81
Max. Negotiated Rate	$23,796.81
Rate for Payer: Hawaii Medical Service Association Commercial	$23,796.81

Know your out-of-pocket cost for care.

All Charges