Honoka'a Hospital and Skilled Nursing Facility

All Charges

Charge

Type

Setting

Price

SIMPLE PNEUMONIA AND PLEURISY WITH MCC

Facility

$24,626.38

Service Code	MSDRG 193
Min. Negotiated Rate	$24,626.38
Max. Negotiated Rate	$24,626.38
Rate for Payer: Hawaii Medical Service Association Commercial	$24,626.38

SIMPLE PNEUMONIA AND PLEURISY WITHOUT CC/MCC

Facility

$18,937.90

Service Code	MSDRG 195
Min. Negotiated Rate	$18,937.90
Max. Negotiated Rate	$18,937.90
Rate for Payer: Hawaii Medical Service Association Commercial	$18,937.90

SIMPLEX W/GENTAMICN 6195-1-010

Facility

$864.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$483.84
Max. Negotiated Rate	$838.08
Rate for Payer: Cash Price	$518.40
Rate for Payer: Hawaii Western Management Group Commercial	$604.80
Rate for Payer: Health Management Network Commercial	$734.40
Rate for Payer: Kaiser Permanente Commercial	$777.60
Rate for Payer: MDX Hawaii PPO	$838.08
Rate for Payer: University Health Alliance Commercial	$483.84

SIMPLEX W/GENTAMICN 6195-1-010

Facility

$864.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$432.00
Max. Negotiated Rate	$838.08
Rate for Payer: AlohaCare Medicaid	$432.00
Rate for Payer: AlohaCare Medicare	$656.64
Rate for Payer: Cash Price	$518.40
Rate for Payer: Devoted Health Medicare	$725.76
Rate for Payer: Hawaii Medical Service Association Medicare	$656.64
Rate for Payer: Hawaii Western Management Group Commercial	$604.80
Rate for Payer: Health Management Network Commercial	$734.40
Rate for Payer: Humana Medicare	$656.64
Rate for Payer: Kaiser Permanente Commercial	$777.60
Rate for Payer: Kaiser Permanente Medicaid	$440.64
Rate for Payer: Kaiser Permanente Medicare	$656.64
Rate for Payer: MDX Hawaii PPO	$838.08
Rate for Payer: Ohana Health Plan Medicaid	$656.64
Rate for Payer: Ohana Health Plan Medicare	$656.64
Rate for Payer: UnitedHealthcare Medicare	$656.64
Rate for Payer: University Health Alliance Commercial	$483.84

SIMPLICITI GUIDE PIN 9722908

Facility

$600.00

Hospital Revenue Code	272
Min. Negotiated Rate	$300.00
Max. Negotiated Rate	$582.00
Rate for Payer: AlohaCare Medicaid	$300.00
Rate for Payer: AlohaCare Medicare	$456.00
Rate for Payer: Cash Price	$360.00
Rate for Payer: Devoted Health Medicare	$504.00
Rate for Payer: Hawaii Medical Service Association Medicare	$456.00
Rate for Payer: Hawaii Western Management Group Commercial	$570.00
Rate for Payer: Health Management Network Commercial	$510.00
Rate for Payer: Humana Medicare	$456.00
Rate for Payer: Kaiser Permanente Commercial	$540.00
Rate for Payer: Kaiser Permanente Medicaid	$306.00
Rate for Payer: Kaiser Permanente Medicare	$456.00
Rate for Payer: MDX Hawaii PPO	$582.00
Rate for Payer: Ohana Health Plan Medicaid	$456.00
Rate for Payer: Ohana Health Plan Medicare	$456.00
Rate for Payer: UnitedHealthcare Medicare	$456.00
Rate for Payer: University Health Alliance Commercial	$437.34

SIMPLICITI GUIDE PIN 9722908

Facility

$600.00

Hospital Revenue Code	272
Min. Negotiated Rate	$510.00
Max. Negotiated Rate	$582.00
Rate for Payer: Cash Price	$360.00
Rate for Payer: Health Management Network Commercial	$510.00
Rate for Payer: Kaiser Permanente Commercial	$540.00
Rate for Payer: MDX Hawaii PPO	$582.00

SIMPLIDERM SD.090.1020ELP

Facility

$8,247.00

Service Code	HCPCS C1763
Hospital Revenue Code	278
Min. Negotiated Rate	$4,123.50
Max. Negotiated Rate	$7,999.59
Rate for Payer: AlohaCare Medicaid	$4,123.50
Rate for Payer: AlohaCare Medicare	$6,267.72
Rate for Payer: Cash Price	$4,948.20
Rate for Payer: Devoted Health Medicare	$6,927.48
Rate for Payer: Hawaii Medical Service Association Medicare	$6,267.72
Rate for Payer: Hawaii Western Management Group Commercial	$5,772.90
Rate for Payer: Health Management Network Commercial	$7,009.95
Rate for Payer: Humana Medicare	$6,267.72
Rate for Payer: Kaiser Permanente Commercial	$7,422.30
Rate for Payer: Kaiser Permanente Medicaid	$4,205.97
Rate for Payer: Kaiser Permanente Medicare	$6,267.72
Rate for Payer: MDX Hawaii PPO	$7,999.59
Rate for Payer: Ohana Health Plan Medicaid	$6,267.72
Rate for Payer: Ohana Health Plan Medicare	$6,267.72
Rate for Payer: UnitedHealthcare Medicare	$6,267.72
Rate for Payer: University Health Alliance Commercial	$4,618.32

SIMPLIDERM SD.090.1020ELP

Facility

$8,247.00

Service Code	HCPCS C1763
Hospital Revenue Code	278
Min. Negotiated Rate	$4,618.32
Max. Negotiated Rate	$7,999.59
Rate for Payer: Cash Price	$4,948.20
Rate for Payer: Hawaii Western Management Group Commercial	$5,772.90
Rate for Payer: Health Management Network Commercial	$7,009.95
Rate for Payer: Kaiser Permanente Commercial	$7,422.30
Rate for Payer: MDX Hawaii PPO	$7,999.59
Rate for Payer: University Health Alliance Commercial	$4,618.32

SIMULTANEOUS PANCREAS AND KIDNEY TRANSPLANT

Facility

$696,862.50

Service Code	MSDRG 008
Min. Negotiated Rate	$10,400.00
Max. Negotiated Rate	$696,862.50
Rate for Payer: Hawaii Medical Service Association Commercial	$696,862.50
Rate for Payer: University Health Alliance Commercial	$10,400.00

SINCALIDE 5 MCG SOLUTION FOR INJECTION [11368]

Facility

$246.00

Service Code	HCPCS J2805
Hospital Revenue Code	250
Min. Negotiated Rate	$209.10
Max. Negotiated Rate	$238.62
Rate for Payer: Cash Price	$147.60
Rate for Payer: Health Management Network Commercial	$209.10
Rate for Payer: Kaiser Permanente Commercial	$221.40
Rate for Payer: MDX Hawaii PPO	$238.62

SINCALIDE 5 MCG SOLUTION FOR INJECTION [11368]

Facility

$246.00

Service Code	HCPCS J2805
Hospital Revenue Code	636
Min. Negotiated Rate	$123.00
Max. Negotiated Rate	$238.62
Rate for Payer: AlohaCare Medicaid	$123.00
Rate for Payer: AlohaCare Medicare	$186.96
Rate for Payer: Cash Price	$147.60
Rate for Payer: Cash Price	$147.60
Rate for Payer: Devoted Health Medicare	$206.64
Rate for Payer: Hawaii Medical Service Association ABD	$135.97
Rate for Payer: Hawaii Medical Service Association Medicare	$186.96
Rate for Payer: Hawaii Medical Service Association Non-ABD	$135.97
Rate for Payer: Hawaii Western Management Group Commercial	$233.70
Rate for Payer: Health Management Network Commercial	$209.10
Rate for Payer: Humana Medicare	$186.96
Rate for Payer: Kaiser Permanente Commercial	$221.40
Rate for Payer: Kaiser Permanente Medicaid	$125.46
Rate for Payer: Kaiser Permanente Medicare	$186.96
Rate for Payer: MDX Hawaii PPO	$238.62
Rate for Payer: Ohana Health Plan Medicaid	$186.96
Rate for Payer: Ohana Health Plan Medicare	$186.96
Rate for Payer: UnitedHealthcare Medicaid	$147.60
Rate for Payer: UnitedHealthcare Medicare	$186.96
Rate for Payer: University Health Alliance Commercial	$179.31

SINGLE LEVEL COMBINED ANTERIOR AND POSTERIOR SPINAL FUSION EXCEPT CERVICAL

Facility

$115,594.65

Service Code	MSDRG 402
Min. Negotiated Rate	$115,594.65
Max. Negotiated Rate	$115,594.65
Rate for Payer: Hawaii Medical Service Association Commercial	$115,594.65

SINGLE LOOP SNARE RETRIEV KIT

Facility

$998.00

Service Code	HCPCS C1773
Hospital Revenue Code	272
Min. Negotiated Rate	$499.00
Max. Negotiated Rate	$968.06
Rate for Payer: AlohaCare Medicaid	$499.00
Rate for Payer: AlohaCare Medicare	$758.48
Rate for Payer: Cash Price	$598.80
Rate for Payer: Devoted Health Medicare	$838.32
Rate for Payer: Hawaii Medical Service Association Medicare	$758.48
Rate for Payer: Hawaii Western Management Group Commercial	$948.10
Rate for Payer: Health Management Network Commercial	$848.30
Rate for Payer: Humana Medicare	$758.48
Rate for Payer: Kaiser Permanente Commercial	$898.20
Rate for Payer: Kaiser Permanente Medicaid	$508.98
Rate for Payer: Kaiser Permanente Medicare	$758.48
Rate for Payer: MDX Hawaii PPO	$968.06
Rate for Payer: Ohana Health Plan Medicaid	$758.48
Rate for Payer: Ohana Health Plan Medicare	$758.48
Rate for Payer: UnitedHealthcare Medicare	$758.48
Rate for Payer: University Health Alliance Commercial	$727.44

SINGLE LOOP SNARE RETRIEV KIT

Facility

$998.00

Service Code	HCPCS C1773
Hospital Revenue Code	272
Min. Negotiated Rate	$848.30
Max. Negotiated Rate	$968.06
Rate for Payer: Cash Price	$598.80
Rate for Payer: Health Management Network Commercial	$848.30
Rate for Payer: Kaiser Permanente Commercial	$898.20
Rate for Payer: MDX Hawaii PPO	$968.06

SINUS AND MASTOID PROCEDURES WITH CC/MCC

Facility

$25,882.58

Service Code	MSDRG 135
Min. Negotiated Rate	$25,882.58
Max. Negotiated Rate	$25,882.58
Rate for Payer: Hawaii Medical Service Association Commercial	$25,882.58

SINUS AND MASTOID PROCEDURES WITHOUT CC/MCC

Facility

$25,882.58

Service Code	MSDRG 136
Min. Negotiated Rate	$25,882.58
Max. Negotiated Rate	$25,882.58
Rate for Payer: Hawaii Medical Service Association Commercial	$25,882.58

SIROLIMUS 0.5 MG TABLET [104764]

Facility

$26.00

Service Code	HCPCS J7520
Hospital Revenue Code	250
Min. Negotiated Rate	$22.10
Max. Negotiated Rate	$25.22
Rate for Payer: Cash Price	$15.60
Rate for Payer: Health Management Network Commercial	$22.10
Rate for Payer: Kaiser Permanente Commercial	$23.40
Rate for Payer: MDX Hawaii PPO	$25.22

SIROLIMUS 0.5 MG TABLET [104764]

Facility

$26.00

Service Code	HCPCS J7520
Hospital Revenue Code	636
Min. Negotiated Rate	$0.96
Max. Negotiated Rate	$25.22
Rate for Payer: AlohaCare Medicaid	$13.00
Rate for Payer: AlohaCare Medicare	$19.76
Rate for Payer: Cash Price	$15.60
Rate for Payer: Cash Price	$15.60
Rate for Payer: Devoted Health Medicare	$21.84
Rate for Payer: Hawaii Medical Service Association ABD	$0.96
Rate for Payer: Hawaii Medical Service Association Medicare	$19.76
Rate for Payer: Hawaii Medical Service Association Non-ABD	$0.96
Rate for Payer: Hawaii Western Management Group Commercial	$24.70
Rate for Payer: Health Management Network Commercial	$22.10
Rate for Payer: Humana Medicare	$19.76
Rate for Payer: Kaiser Permanente Commercial	$23.40
Rate for Payer: Kaiser Permanente Medicaid	$13.26
Rate for Payer: Kaiser Permanente Medicare	$19.76
Rate for Payer: MDX Hawaii PPO	$25.22
Rate for Payer: Ohana Health Plan Medicaid	$19.76
Rate for Payer: Ohana Health Plan Medicare	$19.76
Rate for Payer: UnitedHealthcare Medicaid	$15.60
Rate for Payer: UnitedHealthcare Medicare	$19.76
Rate for Payer: University Health Alliance Commercial	$18.95

SITAGLIPTIN PHOSPHATE 100 MG TABLET [77617]

Facility

$33.00

Service Code	NDC 00006027701
Hospital Revenue Code	637
Min. Negotiated Rate	$16.50
Max. Negotiated Rate	$32.01
Rate for Payer: AlohaCare Medicaid	$16.50
Rate for Payer: AlohaCare Medicare	$25.08
Rate for Payer: Cash Price	$19.80
Rate for Payer: Devoted Health Medicare	$27.72
Rate for Payer: Hawaii Medical Service Association Medicare	$25.08
Rate for Payer: Hawaii Western Management Group Commercial	$31.35
Rate for Payer: Health Management Network Commercial	$28.05
Rate for Payer: Humana Medicare	$25.08
Rate for Payer: Kaiser Permanente Commercial	$29.70
Rate for Payer: Kaiser Permanente Medicaid	$16.83
Rate for Payer: Kaiser Permanente Medicare	$25.08
Rate for Payer: MDX Hawaii PPO	$32.01
Rate for Payer: Ohana Health Plan Medicaid	$25.08
Rate for Payer: Ohana Health Plan Medicare	$25.08
Rate for Payer: UnitedHealthcare Medicare	$25.08
Rate for Payer: University Health Alliance Commercial	$24.05

SITAGLIPTIN PHOSPHATE 100 MG TABLET [77617]

Facility

$33.00

Service Code	NDC 00006027728
Hospital Revenue Code	637
Min. Negotiated Rate	$16.50
Max. Negotiated Rate	$32.01
Rate for Payer: AlohaCare Medicaid	$16.50
Rate for Payer: AlohaCare Medicare	$25.08
Rate for Payer: Cash Price	$19.80
Rate for Payer: Devoted Health Medicare	$27.72
Rate for Payer: Hawaii Medical Service Association Medicare	$25.08
Rate for Payer: Hawaii Western Management Group Commercial	$31.35
Rate for Payer: Health Management Network Commercial	$28.05
Rate for Payer: Humana Medicare	$25.08
Rate for Payer: Kaiser Permanente Commercial	$29.70
Rate for Payer: Kaiser Permanente Medicaid	$16.83
Rate for Payer: Kaiser Permanente Medicare	$25.08
Rate for Payer: MDX Hawaii PPO	$32.01
Rate for Payer: Ohana Health Plan Medicaid	$25.08
Rate for Payer: Ohana Health Plan Medicare	$25.08
Rate for Payer: UnitedHealthcare Medicare	$25.08
Rate for Payer: University Health Alliance Commercial	$24.05

SITAGLIPTIN PHOSPHATE 100 MG TABLET [77617]

Facility

$33.00

Service Code	NDC 00006027728
Hospital Revenue Code	250
Min. Negotiated Rate	$28.05
Max. Negotiated Rate	$32.01
Rate for Payer: Cash Price	$19.80
Rate for Payer: Health Management Network Commercial	$28.05
Rate for Payer: Kaiser Permanente Commercial	$29.70
Rate for Payer: MDX Hawaii PPO	$32.01

SITAGLIPTIN PHOSPHATE 100 MG TABLET [77617]

Facility

$33.00

Service Code	NDC 00006027701
Hospital Revenue Code	250
Min. Negotiated Rate	$28.05
Max. Negotiated Rate	$32.01
Rate for Payer: Cash Price	$19.80
Rate for Payer: Health Management Network Commercial	$28.05
Rate for Payer: Kaiser Permanente Commercial	$29.70
Rate for Payer: MDX Hawaii PPO	$32.01

SITAGLIPTIN PHOSPHATE 25 MG TABLET [77615]

Facility

$33.00

Service Code	NDC 00006022128
Hospital Revenue Code	637
Min. Negotiated Rate	$16.50
Max. Negotiated Rate	$32.01
Rate for Payer: AlohaCare Medicaid	$16.50
Rate for Payer: AlohaCare Medicare	$25.08
Rate for Payer: Cash Price	$19.80
Rate for Payer: Devoted Health Medicare	$27.72
Rate for Payer: Hawaii Medical Service Association Medicare	$25.08
Rate for Payer: Hawaii Western Management Group Commercial	$31.35
Rate for Payer: Health Management Network Commercial	$28.05
Rate for Payer: Humana Medicare	$25.08
Rate for Payer: Kaiser Permanente Commercial	$29.70
Rate for Payer: Kaiser Permanente Medicaid	$16.83
Rate for Payer: Kaiser Permanente Medicare	$25.08
Rate for Payer: MDX Hawaii PPO	$32.01
Rate for Payer: Ohana Health Plan Medicaid	$25.08
Rate for Payer: Ohana Health Plan Medicare	$25.08
Rate for Payer: UnitedHealthcare Medicare	$25.08
Rate for Payer: University Health Alliance Commercial	$24.05

SITAGLIPTIN PHOSPHATE 25 MG TABLET [77615]

Facility

$33.00

Service Code	NDC 00006022101
Hospital Revenue Code	637
Min. Negotiated Rate	$16.50
Max. Negotiated Rate	$32.01
Rate for Payer: AlohaCare Medicaid	$16.50
Rate for Payer: AlohaCare Medicare	$25.08
Rate for Payer: Cash Price	$19.80
Rate for Payer: Devoted Health Medicare	$27.72
Rate for Payer: Hawaii Medical Service Association Medicare	$25.08
Rate for Payer: Hawaii Western Management Group Commercial	$31.35
Rate for Payer: Health Management Network Commercial	$28.05
Rate for Payer: Humana Medicare	$25.08
Rate for Payer: Kaiser Permanente Commercial	$29.70
Rate for Payer: Kaiser Permanente Medicaid	$16.83
Rate for Payer: Kaiser Permanente Medicare	$25.08
Rate for Payer: MDX Hawaii PPO	$32.01
Rate for Payer: Ohana Health Plan Medicaid	$25.08
Rate for Payer: Ohana Health Plan Medicare	$25.08
Rate for Payer: UnitedHealthcare Medicare	$25.08
Rate for Payer: University Health Alliance Commercial	$24.05

SITAGLIPTIN PHOSPHATE 25 MG TABLET [77615]

Facility

$33.00

Service Code	NDC 00006022131
Hospital Revenue Code	250
Min. Negotiated Rate	$28.05
Max. Negotiated Rate	$32.01
Rate for Payer: Cash Price	$19.80
Rate for Payer: Health Management Network Commercial	$28.05
Rate for Payer: Kaiser Permanente Commercial	$29.70
Rate for Payer: MDX Hawaii PPO	$32.01

Know your out-of-pocket cost for care.

All Charges