Honoka'a Hospital and Skilled Nursing Facility

All Charges

Charge

Type

Setting

Price

SIZER GEL RND GS10621-505MP

Facility

$844.00

Service Code	HCPCS C1789
Hospital Revenue Code	278
Min. Negotiated Rate	$472.64
Max. Negotiated Rate	$818.68
Rate for Payer: Cash Price	$506.40
Rate for Payer: Hawaii Western Management Group Commercial	$590.80
Rate for Payer: Health Management Network Commercial	$717.40
Rate for Payer: Kaiser Permanente Commercial	$759.60
Rate for Payer: MDX Hawaii PPO	$818.68
Rate for Payer: University Health Alliance Commercial	$472.64

SIZER GEL RND GS10621-505MP

Facility

$844.00

Service Code	HCPCS C1789
Hospital Revenue Code	278
Min. Negotiated Rate	$422.00
Max. Negotiated Rate	$818.68
Rate for Payer: AlohaCare Medicaid	$422.00
Rate for Payer: AlohaCare Medicare	$641.44
Rate for Payer: Cash Price	$506.40
Rate for Payer: Devoted Health Medicare	$708.96
Rate for Payer: Hawaii Medical Service Association Medicare	$641.44
Rate for Payer: Hawaii Western Management Group Commercial	$590.80
Rate for Payer: Health Management Network Commercial	$717.40
Rate for Payer: Humana Medicare	$641.44
Rate for Payer: Kaiser Permanente Commercial	$759.60
Rate for Payer: Kaiser Permanente Medicaid	$430.44
Rate for Payer: Kaiser Permanente Medicare	$641.44
Rate for Payer: MDX Hawaii PPO	$818.68
Rate for Payer: Ohana Health Plan Medicaid	$641.44
Rate for Payer: Ohana Health Plan Medicare	$641.44
Rate for Payer: UnitedHealthcare Medicare	$641.44
Rate for Payer: University Health Alliance Commercial	$472.64

SIZER HANDLE 7205-30-301

Facility

$341.00

Hospital Revenue Code	272
Min. Negotiated Rate	$170.50
Max. Negotiated Rate	$330.77
Rate for Payer: AlohaCare Medicaid	$170.50
Rate for Payer: AlohaCare Medicare	$259.16
Rate for Payer: Cash Price	$204.60
Rate for Payer: Devoted Health Medicare	$286.44
Rate for Payer: Hawaii Medical Service Association Medicare	$259.16
Rate for Payer: Hawaii Western Management Group Commercial	$323.95
Rate for Payer: Health Management Network Commercial	$289.85
Rate for Payer: Humana Medicare	$259.16
Rate for Payer: Kaiser Permanente Commercial	$306.90
Rate for Payer: Kaiser Permanente Medicaid	$173.91
Rate for Payer: Kaiser Permanente Medicare	$259.16
Rate for Payer: MDX Hawaii PPO	$330.77
Rate for Payer: Ohana Health Plan Medicaid	$259.16
Rate for Payer: Ohana Health Plan Medicare	$259.16
Rate for Payer: UnitedHealthcare Medicare	$259.16
Rate for Payer: University Health Alliance Commercial	$248.55

SIZER HANDLE 7205-30-301

Facility

$341.00

Hospital Revenue Code	272
Min. Negotiated Rate	$289.85
Max. Negotiated Rate	$330.77
Rate for Payer: Cash Price	$204.60
Rate for Payer: Health Management Network Commercial	$289.85
Rate for Payer: Kaiser Permanente Commercial	$306.90
Rate for Payer: MDX Hawaii PPO	$330.77

SIZER NATRELLE 110 SSZ-L110

Facility

$690.00

Service Code	HCPCS C1789
Hospital Revenue Code	278
Min. Negotiated Rate	$345.00
Max. Negotiated Rate	$669.30
Rate for Payer: AlohaCare Medicaid	$345.00
Rate for Payer: AlohaCare Medicare	$524.40
Rate for Payer: Cash Price	$414.00
Rate for Payer: Devoted Health Medicare	$579.60
Rate for Payer: Hawaii Medical Service Association Medicare	$524.40
Rate for Payer: Hawaii Western Management Group Commercial	$483.00
Rate for Payer: Health Management Network Commercial	$586.50
Rate for Payer: Humana Medicare	$524.40
Rate for Payer: Kaiser Permanente Commercial	$621.00
Rate for Payer: Kaiser Permanente Medicaid	$351.90
Rate for Payer: Kaiser Permanente Medicare	$524.40
Rate for Payer: MDX Hawaii PPO	$669.30
Rate for Payer: Ohana Health Plan Medicaid	$524.40
Rate for Payer: Ohana Health Plan Medicare	$524.40
Rate for Payer: UnitedHealthcare Medicare	$524.40
Rate for Payer: University Health Alliance Commercial	$386.40

SIZER NATRELLE 110 SSZ-L110

Facility

$690.00

Service Code	HCPCS C1789
Hospital Revenue Code	278
Min. Negotiated Rate	$386.40
Max. Negotiated Rate	$669.30
Rate for Payer: Cash Price	$414.00
Rate for Payer: Hawaii Western Management Group Commercial	$483.00
Rate for Payer: Health Management Network Commercial	$586.50
Rate for Payer: Kaiser Permanente Commercial	$621.00
Rate for Payer: MDX Hawaii PPO	$669.30
Rate for Payer: University Health Alliance Commercial	$386.40

SIZER NATRELLE 125 SSZ-LP125

Facility

$690.00

Service Code	HCPCS C1789
Hospital Revenue Code	278
Min. Negotiated Rate	$386.40
Max. Negotiated Rate	$669.30
Rate for Payer: Cash Price	$414.00
Rate for Payer: Hawaii Western Management Group Commercial	$483.00
Rate for Payer: Health Management Network Commercial	$586.50
Rate for Payer: Kaiser Permanente Commercial	$621.00
Rate for Payer: MDX Hawaii PPO	$669.30
Rate for Payer: University Health Alliance Commercial	$386.40

SIZER NATRELLE 125 SSZ-LP125

Facility

$690.00

Service Code	HCPCS C1789
Hospital Revenue Code	278
Min. Negotiated Rate	$345.00
Max. Negotiated Rate	$669.30
Rate for Payer: AlohaCare Medicaid	$345.00
Rate for Payer: AlohaCare Medicare	$524.40
Rate for Payer: Cash Price	$414.00
Rate for Payer: Devoted Health Medicare	$579.60
Rate for Payer: Hawaii Medical Service Association Medicare	$524.40
Rate for Payer: Hawaii Western Management Group Commercial	$483.00
Rate for Payer: Health Management Network Commercial	$586.50
Rate for Payer: Humana Medicare	$524.40
Rate for Payer: Kaiser Permanente Commercial	$621.00
Rate for Payer: Kaiser Permanente Medicaid	$351.90
Rate for Payer: Kaiser Permanente Medicare	$524.40
Rate for Payer: MDX Hawaii PPO	$669.30
Rate for Payer: Ohana Health Plan Medicaid	$524.40
Rate for Payer: Ohana Health Plan Medicare	$524.40
Rate for Payer: UnitedHealthcare Medicare	$524.40
Rate for Payer: University Health Alliance Commercial	$386.40

SIZER PROJECTION SZ10621-440HP

Facility

$260.00

Service Code	HCPCS C1789
Hospital Revenue Code	278
Min. Negotiated Rate	$130.00
Max. Negotiated Rate	$252.20
Rate for Payer: AlohaCare Medicaid	$130.00
Rate for Payer: AlohaCare Medicare	$197.60
Rate for Payer: Cash Price	$156.00
Rate for Payer: Devoted Health Medicare	$218.40
Rate for Payer: Hawaii Medical Service Association Medicare	$197.60
Rate for Payer: Hawaii Western Management Group Commercial	$182.00
Rate for Payer: Health Management Network Commercial	$221.00
Rate for Payer: Humana Medicare	$197.60
Rate for Payer: Kaiser Permanente Commercial	$234.00
Rate for Payer: Kaiser Permanente Medicaid	$132.60
Rate for Payer: Kaiser Permanente Medicare	$197.60
Rate for Payer: MDX Hawaii PPO	$252.20
Rate for Payer: Ohana Health Plan Medicaid	$197.60
Rate for Payer: Ohana Health Plan Medicare	$197.60
Rate for Payer: UnitedHealthcare Medicare	$197.60
Rate for Payer: University Health Alliance Commercial	$145.60

SIZER PROJECTION SZ10621-440HP

Facility

$260.00

Service Code	HCPCS C1789
Hospital Revenue Code	278
Min. Negotiated Rate	$145.60
Max. Negotiated Rate	$252.20
Rate for Payer: Cash Price	$156.00
Rate for Payer: Hawaii Western Management Group Commercial	$182.00
Rate for Payer: Health Management Network Commercial	$221.00
Rate for Payer: Kaiser Permanente Commercial	$234.00
Rate for Payer: MDX Hawaii PPO	$252.20
Rate for Payer: University Health Alliance Commercial	$145.60

SIZER PROJECTION SZ10621-455MP

Facility

$260.00

Service Code	HCPCS C1789
Hospital Revenue Code	278
Min. Negotiated Rate	$145.60
Max. Negotiated Rate	$252.20
Rate for Payer: Cash Price	$156.00
Rate for Payer: Hawaii Western Management Group Commercial	$182.00
Rate for Payer: Health Management Network Commercial	$221.00
Rate for Payer: Kaiser Permanente Commercial	$234.00
Rate for Payer: MDX Hawaii PPO	$252.20
Rate for Payer: University Health Alliance Commercial	$145.60

SIZER PROJECTION SZ10621-455MP

Facility

$260.00

Service Code	HCPCS C1789
Hospital Revenue Code	278
Min. Negotiated Rate	$130.00
Max. Negotiated Rate	$252.20
Rate for Payer: AlohaCare Medicaid	$130.00
Rate for Payer: AlohaCare Medicare	$197.60
Rate for Payer: Cash Price	$156.00
Rate for Payer: Devoted Health Medicare	$218.40
Rate for Payer: Hawaii Medical Service Association Medicare	$197.60
Rate for Payer: Hawaii Western Management Group Commercial	$182.00
Rate for Payer: Health Management Network Commercial	$221.00
Rate for Payer: Humana Medicare	$197.60
Rate for Payer: Kaiser Permanente Commercial	$234.00
Rate for Payer: Kaiser Permanente Medicaid	$132.60
Rate for Payer: Kaiser Permanente Medicare	$197.60
Rate for Payer: MDX Hawaii PPO	$252.20
Rate for Payer: Ohana Health Plan Medicaid	$197.60
Rate for Payer: Ohana Health Plan Medicare	$197.60
Rate for Payer: UnitedHealthcare Medicare	$197.60
Rate for Payer: University Health Alliance Commercial	$145.60

SIZER RND 190ML GS10512-190MP

Facility

$844.00

Service Code	HCPCS C1789
Hospital Revenue Code	278
Min. Negotiated Rate	$472.64
Max. Negotiated Rate	$818.68
Rate for Payer: Cash Price	$506.40
Rate for Payer: Hawaii Western Management Group Commercial	$590.80
Rate for Payer: Health Management Network Commercial	$717.40
Rate for Payer: Kaiser Permanente Commercial	$759.60
Rate for Payer: MDX Hawaii PPO	$818.68
Rate for Payer: University Health Alliance Commercial	$472.64

SIZER RND 190ML GS10512-190MP

Facility

$844.00

Service Code	HCPCS C1789
Hospital Revenue Code	278
Min. Negotiated Rate	$422.00
Max. Negotiated Rate	$818.68
Rate for Payer: AlohaCare Medicaid	$422.00
Rate for Payer: AlohaCare Medicare	$641.44
Rate for Payer: Cash Price	$506.40
Rate for Payer: Devoted Health Medicare	$708.96
Rate for Payer: Hawaii Medical Service Association Medicare	$641.44
Rate for Payer: Hawaii Western Management Group Commercial	$590.80
Rate for Payer: Health Management Network Commercial	$717.40
Rate for Payer: Humana Medicare	$641.44
Rate for Payer: Kaiser Permanente Commercial	$759.60
Rate for Payer: Kaiser Permanente Medicaid	$430.44
Rate for Payer: Kaiser Permanente Medicare	$641.44
Rate for Payer: MDX Hawaii PPO	$818.68
Rate for Payer: Ohana Health Plan Medicaid	$641.44
Rate for Payer: Ohana Health Plan Medicare	$641.44
Rate for Payer: UnitedHealthcare Medicare	$641.44
Rate for Payer: University Health Alliance Commercial	$472.64

SIZER RND 255CC SZ10621-255MP

Facility

$175.00

Service Code	HCPCS C1789
Hospital Revenue Code	278
Min. Negotiated Rate	$87.50
Max. Negotiated Rate	$169.75
Rate for Payer: AlohaCare Medicaid	$87.50
Rate for Payer: AlohaCare Medicare	$133.00
Rate for Payer: Cash Price	$105.00
Rate for Payer: Devoted Health Medicare	$147.00
Rate for Payer: Hawaii Medical Service Association Medicare	$133.00
Rate for Payer: Hawaii Western Management Group Commercial	$122.50
Rate for Payer: Health Management Network Commercial	$148.75
Rate for Payer: Humana Medicare	$133.00
Rate for Payer: Kaiser Permanente Commercial	$157.50
Rate for Payer: Kaiser Permanente Medicaid	$89.25
Rate for Payer: Kaiser Permanente Medicare	$133.00
Rate for Payer: MDX Hawaii PPO	$169.75
Rate for Payer: Ohana Health Plan Medicaid	$133.00
Rate for Payer: Ohana Health Plan Medicare	$133.00
Rate for Payer: UnitedHealthcare Medicare	$133.00
Rate for Payer: University Health Alliance Commercial	$98.00

SIZER RND 255CC SZ10621-255MP

Facility

$175.00

Service Code	HCPCS C1789
Hospital Revenue Code	278
Min. Negotiated Rate	$98.00
Max. Negotiated Rate	$169.75
Rate for Payer: Cash Price	$105.00
Rate for Payer: Hawaii Western Management Group Commercial	$122.50
Rate for Payer: Health Management Network Commercial	$148.75
Rate for Payer: Kaiser Permanente Commercial	$157.50
Rate for Payer: MDX Hawaii PPO	$169.75
Rate for Payer: University Health Alliance Commercial	$98.00

SIZER RND 355CC SZ10621-355MP

Facility

$260.00

Service Code	HCPCS C1789
Hospital Revenue Code	278
Min. Negotiated Rate	$145.60
Max. Negotiated Rate	$252.20
Rate for Payer: Cash Price	$156.00
Rate for Payer: Hawaii Western Management Group Commercial	$182.00
Rate for Payer: Health Management Network Commercial	$221.00
Rate for Payer: Kaiser Permanente Commercial	$234.00
Rate for Payer: MDX Hawaii PPO	$252.20
Rate for Payer: University Health Alliance Commercial	$145.60

SIZER RND 355CC SZ10621-355MP

Facility

$260.00

Service Code	HCPCS C1789
Hospital Revenue Code	278
Min. Negotiated Rate	$130.00
Max. Negotiated Rate	$252.20
Rate for Payer: AlohaCare Medicaid	$130.00
Rate for Payer: AlohaCare Medicare	$197.60
Rate for Payer: Cash Price	$156.00
Rate for Payer: Devoted Health Medicare	$218.40
Rate for Payer: Hawaii Medical Service Association Medicare	$197.60
Rate for Payer: Hawaii Western Management Group Commercial	$182.00
Rate for Payer: Health Management Network Commercial	$221.00
Rate for Payer: Humana Medicare	$197.60
Rate for Payer: Kaiser Permanente Commercial	$234.00
Rate for Payer: Kaiser Permanente Medicaid	$132.60
Rate for Payer: Kaiser Permanente Medicare	$197.60
Rate for Payer: MDX Hawaii PPO	$252.20
Rate for Payer: Ohana Health Plan Medicaid	$197.60
Rate for Payer: Ohana Health Plan Medicare	$197.60
Rate for Payer: UnitedHealthcare Medicare	$197.60
Rate for Payer: University Health Alliance Commercial	$145.60

SIZER RND BREAST SZ10621-215MP

Facility

$260.00

Service Code	HCPCS C1789
Hospital Revenue Code	278
Min. Negotiated Rate	$130.00
Max. Negotiated Rate	$252.20
Rate for Payer: AlohaCare Medicaid	$130.00
Rate for Payer: AlohaCare Medicare	$197.60
Rate for Payer: Cash Price	$156.00
Rate for Payer: Devoted Health Medicare	$218.40
Rate for Payer: Hawaii Medical Service Association Medicare	$197.60
Rate for Payer: Hawaii Western Management Group Commercial	$182.00
Rate for Payer: Health Management Network Commercial	$221.00
Rate for Payer: Humana Medicare	$197.60
Rate for Payer: Kaiser Permanente Commercial	$234.00
Rate for Payer: Kaiser Permanente Medicaid	$132.60
Rate for Payer: Kaiser Permanente Medicare	$197.60
Rate for Payer: MDX Hawaii PPO	$252.20
Rate for Payer: Ohana Health Plan Medicaid	$197.60
Rate for Payer: Ohana Health Plan Medicare	$197.60
Rate for Payer: UnitedHealthcare Medicare	$197.60
Rate for Payer: University Health Alliance Commercial	$145.60

SIZER RND BREAST SZ10621-215MP

Facility

$260.00

Service Code	HCPCS C1789
Hospital Revenue Code	278
Min. Negotiated Rate	$145.60
Max. Negotiated Rate	$252.20
Rate for Payer: Cash Price	$156.00
Rate for Payer: Hawaii Western Management Group Commercial	$182.00
Rate for Payer: Health Management Network Commercial	$221.00
Rate for Payer: Kaiser Permanente Commercial	$234.00
Rate for Payer: MDX Hawaii PPO	$252.20
Rate for Payer: University Health Alliance Commercial	$145.60

SIZER RND GS10621-285MP

Facility

$844.00

Service Code	HCPCS C1789
Hospital Revenue Code	278
Min. Negotiated Rate	$422.00
Max. Negotiated Rate	$818.68
Rate for Payer: AlohaCare Medicaid	$422.00
Rate for Payer: AlohaCare Medicare	$641.44
Rate for Payer: Cash Price	$506.40
Rate for Payer: Devoted Health Medicare	$708.96
Rate for Payer: Hawaii Medical Service Association Medicare	$641.44
Rate for Payer: Hawaii Western Management Group Commercial	$590.80
Rate for Payer: Health Management Network Commercial	$717.40
Rate for Payer: Humana Medicare	$641.44
Rate for Payer: Kaiser Permanente Commercial	$759.60
Rate for Payer: Kaiser Permanente Medicaid	$430.44
Rate for Payer: Kaiser Permanente Medicare	$641.44
Rate for Payer: MDX Hawaii PPO	$818.68
Rate for Payer: Ohana Health Plan Medicaid	$641.44
Rate for Payer: Ohana Health Plan Medicare	$641.44
Rate for Payer: UnitedHealthcare Medicare	$641.44
Rate for Payer: University Health Alliance Commercial	$472.64

SIZER RND GS10621-285MP

Facility

$844.00

Service Code	HCPCS C1789
Hospital Revenue Code	278
Min. Negotiated Rate	$472.64
Max. Negotiated Rate	$818.68
Rate for Payer: Cash Price	$506.40
Rate for Payer: Hawaii Western Management Group Commercial	$590.80
Rate for Payer: Health Management Network Commercial	$717.40
Rate for Payer: Kaiser Permanente Commercial	$759.60
Rate for Payer: MDX Hawaii PPO	$818.68
Rate for Payer: University Health Alliance Commercial	$472.64

SIZER RND GS10621-700HP

Facility

$844.00

Service Code	HCPCS C1789
Hospital Revenue Code	278
Min. Negotiated Rate	$472.64
Max. Negotiated Rate	$818.68
Rate for Payer: Cash Price	$506.40
Rate for Payer: Hawaii Western Management Group Commercial	$590.80
Rate for Payer: Health Management Network Commercial	$717.40
Rate for Payer: Kaiser Permanente Commercial	$759.60
Rate for Payer: MDX Hawaii PPO	$818.68
Rate for Payer: University Health Alliance Commercial	$472.64

SIZER RND GS10621-700HP

Facility

$844.00

Service Code	HCPCS C1789
Hospital Revenue Code	278
Min. Negotiated Rate	$422.00
Max. Negotiated Rate	$818.68
Rate for Payer: AlohaCare Medicaid	$422.00
Rate for Payer: AlohaCare Medicare	$641.44
Rate for Payer: Cash Price	$506.40
Rate for Payer: Devoted Health Medicare	$708.96
Rate for Payer: Hawaii Medical Service Association Medicare	$641.44
Rate for Payer: Hawaii Western Management Group Commercial	$590.80
Rate for Payer: Health Management Network Commercial	$717.40
Rate for Payer: Humana Medicare	$641.44
Rate for Payer: Kaiser Permanente Commercial	$759.60
Rate for Payer: Kaiser Permanente Medicaid	$430.44
Rate for Payer: Kaiser Permanente Medicare	$641.44
Rate for Payer: MDX Hawaii PPO	$818.68
Rate for Payer: Ohana Health Plan Medicaid	$641.44
Rate for Payer: Ohana Health Plan Medicare	$641.44
Rate for Payer: UnitedHealthcare Medicare	$641.44
Rate for Payer: University Health Alliance Commercial	$472.64

SIZER RND SILICONE 470CC

Facility

$844.00

Service Code	HCPCS C1789
Hospital Revenue Code	278
Min. Negotiated Rate	$422.00
Max. Negotiated Rate	$818.68
Rate for Payer: AlohaCare Medicaid	$422.00
Rate for Payer: AlohaCare Medicare	$641.44
Rate for Payer: Cash Price	$506.40
Rate for Payer: Devoted Health Medicare	$708.96
Rate for Payer: Hawaii Medical Service Association Medicare	$641.44
Rate for Payer: Hawaii Western Management Group Commercial	$590.80
Rate for Payer: Health Management Network Commercial	$717.40
Rate for Payer: Humana Medicare	$641.44
Rate for Payer: Kaiser Permanente Commercial	$759.60
Rate for Payer: Kaiser Permanente Medicaid	$430.44
Rate for Payer: Kaiser Permanente Medicare	$641.44
Rate for Payer: MDX Hawaii PPO	$818.68
Rate for Payer: Ohana Health Plan Medicaid	$641.44
Rate for Payer: Ohana Health Plan Medicare	$641.44
Rate for Payer: UnitedHealthcare Medicare	$641.44
Rate for Payer: University Health Alliance Commercial	$472.64

Know your out-of-pocket cost for care.

All Charges