Honoka'a Hospital and Skilled Nursing Facility

All Charges

Charge

Type

Setting

Price

SIZER RND SILICONE 470CC

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 SILICONE 510CC

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 SILICONE 510CC

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 SILI GS10610-500LP

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 SILI GS10610-500LP

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 SALINE RND 510CC SZ68510

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 SALINE RND 510CC SZ68510

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 SALINE RND SZ10621-235MP

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 SALINE RND SZ10621-235MP

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 SALINE RND SZ10621-565HP

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 SALINE RND SZ10621-565HP

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 SALINE RND SZ68650

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 SALINE RND SZ68650

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 SALINE ROUND SZHP68750

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 SALINE ROUND SZHP68750

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 SILICONE GS10621-235MP

Facility

$694.00

Service Code	HCPCS C1789
Hospital Revenue Code	278
Min. Negotiated Rate	$347.00
Max. Negotiated Rate	$673.18
Rate for Payer: AlohaCare Medicaid	$347.00
Rate for Payer: AlohaCare Medicare	$527.44
Rate for Payer: Cash Price	$416.40
Rate for Payer: Devoted Health Medicare	$582.96
Rate for Payer: Hawaii Medical Service Association Medicare	$527.44
Rate for Payer: Hawaii Western Management Group Commercial	$485.80
Rate for Payer: Health Management Network Commercial	$589.90
Rate for Payer: Humana Medicare	$527.44
Rate for Payer: Kaiser Permanente Commercial	$624.60
Rate for Payer: Kaiser Permanente Medicaid	$353.94
Rate for Payer: Kaiser Permanente Medicare	$527.44
Rate for Payer: MDX Hawaii PPO	$673.18
Rate for Payer: Ohana Health Plan Medicaid	$527.44
Rate for Payer: Ohana Health Plan Medicare	$527.44
Rate for Payer: UnitedHealthcare Medicare	$527.44
Rate for Payer: University Health Alliance Commercial	$388.64

SIZER SILICONE GS10621-235MP

Facility

$694.00

Service Code	HCPCS C1789
Hospital Revenue Code	278
Min. Negotiated Rate	$388.64
Max. Negotiated Rate	$673.18
Rate for Payer: Cash Price	$416.40
Rate for Payer: Hawaii Western Management Group Commercial	$485.80
Rate for Payer: Health Management Network Commercial	$589.90
Rate for Payer: Kaiser Permanente Commercial	$624.60
Rate for Payer: MDX Hawaii PPO	$673.18
Rate for Payer: University Health Alliance Commercial	$388.64

SIZER X-HI PRO GS10621-420XP

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 X-HI PRO GS10621-420XP

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

SKIN DEBRIDEMENT WITH CC

Facility

$57,951.39

Service Code	MSDRG 571
Min. Negotiated Rate	$57,951.39
Max. Negotiated Rate	$57,951.39
Rate for Payer: Hawaii Medical Service Association Commercial	$57,951.39

SKIN DEBRIDEMENT WITH MCC

Facility

$60,795.63

Service Code	MSDRG 570
Min. Negotiated Rate	$60,795.63
Max. Negotiated Rate	$60,795.63
Rate for Payer: Hawaii Medical Service Association Commercial	$60,795.63

SKIN DEBRIDEMENT WITHOUT CC/MCC

Facility

$29,983.03

Service Code	MSDRG 572
Min. Negotiated Rate	$29,983.03
Max. Negotiated Rate	$29,983.03
Rate for Payer: Hawaii Medical Service Association Commercial	$29,983.03

SKIN GRAFT EXCEPT FOR SKIN ULCER OR CELLULITIS WITH CC

Facility

$59,894.95

Service Code	MSDRG 577
Min. Negotiated Rate	$59,894.95
Max. Negotiated Rate	$59,894.95
Rate for Payer: Hawaii Medical Service Association Commercial	$59,894.95

SKIN GRAFT EXCEPT FOR SKIN ULCER OR CELLULITIS WITH MCC

Facility

$59,894.95

Service Code	MSDRG 576
Min. Negotiated Rate	$59,894.95
Max. Negotiated Rate	$59,894.95
Rate for Payer: Hawaii Medical Service Association Commercial	$59,894.95

SKIN GRAFT EXCEPT FOR SKIN ULCER OR CELLULITIS WITHOUT CC/MCC

Facility

$14,150.09

Service Code	MSDRG 578
Min. Negotiated Rate	$14,150.09
Max. Negotiated Rate	$14,150.09
Rate for Payer: Hawaii Medical Service Association Commercial	$14,150.09

Know your out-of-pocket cost for care.

All Charges