Honoka'a Hospital and Skilled Nursing Facility

All Charges

Charge

Type

Setting

Price

STENT 8FR URETERAL SOFT

Facility

$254.00

Service Code	HCPCS C2617
Hospital Revenue Code	278
Min. Negotiated Rate	$142.24
Max. Negotiated Rate	$246.38
Rate for Payer: Cash Price	$152.40
Rate for Payer: Hawaii Western Management Group Commercial	$177.80
Rate for Payer: Health Management Network Commercial	$215.90
Rate for Payer: Kaiser Permanente Commercial	$228.60
Rate for Payer: MDX Hawaii PPO	$246.38
Rate for Payer: University Health Alliance Commercial	$142.24

STENT 8FR URETERAL SOFT

Facility

$254.00

Service Code	HCPCS C2617
Hospital Revenue Code	278
Min. Negotiated Rate	$127.00
Max. Negotiated Rate	$246.38
Rate for Payer: AlohaCare Medicaid	$127.00
Rate for Payer: AlohaCare Medicare	$193.04
Rate for Payer: Cash Price	$152.40
Rate for Payer: Devoted Health Medicare	$213.36
Rate for Payer: Hawaii Medical Service Association Medicare	$193.04
Rate for Payer: Hawaii Western Management Group Commercial	$177.80
Rate for Payer: Health Management Network Commercial	$215.90
Rate for Payer: Humana Medicare	$193.04
Rate for Payer: Kaiser Permanente Commercial	$228.60
Rate for Payer: Kaiser Permanente Medicaid	$129.54
Rate for Payer: Kaiser Permanente Medicare	$193.04
Rate for Payer: MDX Hawaii PPO	$246.38
Rate for Payer: Ohana Health Plan Medicaid	$193.04
Rate for Payer: Ohana Health Plan Medicare	$193.04
Rate for Payer: UnitedHealthcare Medicare	$193.04
Rate for Payer: University Health Alliance Commercial	$142.24

STENT 8X20 FLEXIMA URETERAL

Facility

$581.00

Service Code	HCPCS C2625
Hospital Revenue Code	278
Min. Negotiated Rate	$325.36
Max. Negotiated Rate	$563.57
Rate for Payer: Cash Price	$348.60
Rate for Payer: Hawaii Western Management Group Commercial	$406.70
Rate for Payer: Health Management Network Commercial	$493.85
Rate for Payer: Kaiser Permanente Commercial	$522.90
Rate for Payer: MDX Hawaii PPO	$563.57
Rate for Payer: University Health Alliance Commercial	$325.36

STENT 8X20 FLEXIMA URETERAL

Facility

$581.00

Service Code	HCPCS C2625
Hospital Revenue Code	278
Min. Negotiated Rate	$290.50
Max. Negotiated Rate	$563.57
Rate for Payer: AlohaCare Medicaid	$290.50
Rate for Payer: AlohaCare Medicare	$441.56
Rate for Payer: Cash Price	$348.60
Rate for Payer: Devoted Health Medicare	$488.04
Rate for Payer: Hawaii Medical Service Association Medicare	$441.56
Rate for Payer: Hawaii Western Management Group Commercial	$406.70
Rate for Payer: Health Management Network Commercial	$493.85
Rate for Payer: Humana Medicare	$441.56
Rate for Payer: Kaiser Permanente Commercial	$522.90
Rate for Payer: Kaiser Permanente Medicaid	$296.31
Rate for Payer: Kaiser Permanente Medicare	$441.56
Rate for Payer: MDX Hawaii PPO	$563.57
Rate for Payer: Ohana Health Plan Medicaid	$441.56
Rate for Payer: Ohana Health Plan Medicare	$441.56
Rate for Payer: UnitedHealthcare Medicare	$441.56
Rate for Payer: University Health Alliance Commercial	$325.36

STENT AGILE 18MM 5.9

Facility

$5,800.00

Service Code	HCPCS C1874
Hospital Revenue Code	278
Min. Negotiated Rate	$2,900.00
Max. Negotiated Rate	$5,626.00
Rate for Payer: AlohaCare Medicaid	$2,900.00
Rate for Payer: AlohaCare Medicare	$4,408.00
Rate for Payer: Cash Price	$3,480.00
Rate for Payer: Devoted Health Medicare	$4,872.00
Rate for Payer: Hawaii Medical Service Association Medicare	$4,408.00
Rate for Payer: Hawaii Western Management Group Commercial	$4,060.00
Rate for Payer: Health Management Network Commercial	$4,930.00
Rate for Payer: Humana Medicare	$4,408.00
Rate for Payer: Kaiser Permanente Commercial	$5,220.00
Rate for Payer: Kaiser Permanente Medicaid	$2,958.00
Rate for Payer: Kaiser Permanente Medicare	$4,408.00
Rate for Payer: MDX Hawaii PPO	$5,626.00
Rate for Payer: Ohana Health Plan Medicaid	$4,408.00
Rate for Payer: Ohana Health Plan Medicare	$4,408.00
Rate for Payer: UnitedHealthcare Medicare	$4,408.00
Rate for Payer: University Health Alliance Commercial	$3,248.00

STENT AGILE 18MM 5.9

Facility

$5,800.00

Service Code	HCPCS C1874
Hospital Revenue Code	278
Min. Negotiated Rate	$3,248.00
Max. Negotiated Rate	$5,626.00
Rate for Payer: Cash Price	$3,480.00
Rate for Payer: Hawaii Western Management Group Commercial	$4,060.00
Rate for Payer: Health Management Network Commercial	$4,930.00
Rate for Payer: Kaiser Permanente Commercial	$5,220.00
Rate for Payer: MDX Hawaii PPO	$5,626.00
Rate for Payer: University Health Alliance Commercial	$3,248.00

STENT AGILE 18MM 9.7

Facility

$5,800.00

Service Code	HCPCS C1874
Hospital Revenue Code	278
Min. Negotiated Rate	$2,900.00
Max. Negotiated Rate	$5,626.00
Rate for Payer: AlohaCare Medicaid	$2,900.00
Rate for Payer: AlohaCare Medicare	$4,408.00
Rate for Payer: Cash Price	$3,480.00
Rate for Payer: Devoted Health Medicare	$4,872.00
Rate for Payer: Hawaii Medical Service Association Medicare	$4,408.00
Rate for Payer: Hawaii Western Management Group Commercial	$4,060.00
Rate for Payer: Health Management Network Commercial	$4,930.00
Rate for Payer: Humana Medicare	$4,408.00
Rate for Payer: Kaiser Permanente Commercial	$5,220.00
Rate for Payer: Kaiser Permanente Medicaid	$2,958.00
Rate for Payer: Kaiser Permanente Medicare	$4,408.00
Rate for Payer: MDX Hawaii PPO	$5,626.00
Rate for Payer: Ohana Health Plan Medicaid	$4,408.00
Rate for Payer: Ohana Health Plan Medicare	$4,408.00
Rate for Payer: UnitedHealthcare Medicare	$4,408.00
Rate for Payer: University Health Alliance Commercial	$3,248.00

STENT AGILE 18MM 9.7

Facility

$5,800.00

Service Code	HCPCS C1874
Hospital Revenue Code	278
Min. Negotiated Rate	$3,248.00
Max. Negotiated Rate	$5,626.00
Rate for Payer: Cash Price	$3,480.00
Rate for Payer: Hawaii Western Management Group Commercial	$4,060.00
Rate for Payer: Health Management Network Commercial	$4,930.00
Rate for Payer: Kaiser Permanente Commercial	$5,220.00
Rate for Payer: MDX Hawaii PPO	$5,626.00
Rate for Payer: University Health Alliance Commercial	$3,248.00

STENT BILIARY 10F POLYMERIC

Facility

$504.00

Service Code	HCPCS C2625
Hospital Revenue Code	278
Min. Negotiated Rate	$252.00
Max. Negotiated Rate	$488.88
Rate for Payer: AlohaCare Medicaid	$252.00
Rate for Payer: AlohaCare Medicare	$383.04
Rate for Payer: Cash Price	$302.40
Rate for Payer: Devoted Health Medicare	$423.36
Rate for Payer: Hawaii Medical Service Association Medicare	$383.04
Rate for Payer: Hawaii Western Management Group Commercial	$352.80
Rate for Payer: Health Management Network Commercial	$428.40
Rate for Payer: Humana Medicare	$383.04
Rate for Payer: Kaiser Permanente Commercial	$453.60
Rate for Payer: Kaiser Permanente Medicaid	$257.04
Rate for Payer: Kaiser Permanente Medicare	$383.04
Rate for Payer: MDX Hawaii PPO	$488.88
Rate for Payer: Ohana Health Plan Medicaid	$383.04
Rate for Payer: Ohana Health Plan Medicare	$383.04
Rate for Payer: UnitedHealthcare Medicare	$383.04
Rate for Payer: University Health Alliance Commercial	$282.24

STENT BILIARY 10F POLYMERIC

Facility

$504.00

Service Code	HCPCS C2625
Hospital Revenue Code	278
Min. Negotiated Rate	$282.24
Max. Negotiated Rate	$488.88
Rate for Payer: Cash Price	$302.40
Rate for Payer: Hawaii Western Management Group Commercial	$352.80
Rate for Payer: Health Management Network Commercial	$428.40
Rate for Payer: Kaiser Permanente Commercial	$453.60
Rate for Payer: MDX Hawaii PPO	$488.88
Rate for Payer: University Health Alliance Commercial	$282.24

STENT BILIARY 10FX9

Facility

$490.00

Service Code	HCPCS C2625
Hospital Revenue Code	278
Min. Negotiated Rate	$274.40
Max. Negotiated Rate	$475.30
Rate for Payer: Cash Price	$294.00
Rate for Payer: Hawaii Western Management Group Commercial	$343.00
Rate for Payer: Health Management Network Commercial	$416.50
Rate for Payer: Kaiser Permanente Commercial	$441.00
Rate for Payer: MDX Hawaii PPO	$475.30
Rate for Payer: University Health Alliance Commercial	$274.40

STENT BILIARY 10FX9

Facility

$490.00

Service Code	HCPCS C2625
Hospital Revenue Code	278
Min. Negotiated Rate	$245.00
Max. Negotiated Rate	$475.30
Rate for Payer: AlohaCare Medicaid	$245.00
Rate for Payer: AlohaCare Medicare	$372.40
Rate for Payer: Cash Price	$294.00
Rate for Payer: Devoted Health Medicare	$411.60
Rate for Payer: Hawaii Medical Service Association Medicare	$372.40
Rate for Payer: Hawaii Western Management Group Commercial	$343.00
Rate for Payer: Health Management Network Commercial	$416.50
Rate for Payer: Humana Medicare	$372.40
Rate for Payer: Kaiser Permanente Commercial	$441.00
Rate for Payer: Kaiser Permanente Medicaid	$249.90
Rate for Payer: Kaiser Permanente Medicare	$372.40
Rate for Payer: MDX Hawaii PPO	$475.30
Rate for Payer: Ohana Health Plan Medicaid	$372.40
Rate for Payer: Ohana Health Plan Medicare	$372.40
Rate for Payer: UnitedHealthcare Medicare	$372.40
Rate for Payer: University Health Alliance Commercial	$274.40

STENT BILIARY 10MM

Facility

$4,959.00

Service Code	HCPCS C1874
Hospital Revenue Code	278
Min. Negotiated Rate	$2,777.04
Max. Negotiated Rate	$4,810.23
Rate for Payer: Cash Price	$2,975.40
Rate for Payer: Hawaii Western Management Group Commercial	$3,471.30
Rate for Payer: Health Management Network Commercial	$4,215.15
Rate for Payer: Kaiser Permanente Commercial	$4,463.10
Rate for Payer: MDX Hawaii PPO	$4,810.23
Rate for Payer: University Health Alliance Commercial	$2,777.04

STENT BILIARY 10MM

Facility

$4,959.00

Service Code	HCPCS C1874
Hospital Revenue Code	278
Min. Negotiated Rate	$2,479.50
Max. Negotiated Rate	$4,810.23
Rate for Payer: AlohaCare Medicaid	$2,479.50
Rate for Payer: AlohaCare Medicare	$3,768.84
Rate for Payer: Cash Price	$2,975.40
Rate for Payer: Devoted Health Medicare	$4,165.56
Rate for Payer: Hawaii Medical Service Association Medicare	$3,768.84
Rate for Payer: Hawaii Western Management Group Commercial	$3,471.30
Rate for Payer: Health Management Network Commercial	$4,215.15
Rate for Payer: Humana Medicare	$3,768.84
Rate for Payer: Kaiser Permanente Commercial	$4,463.10
Rate for Payer: Kaiser Permanente Medicaid	$2,529.09
Rate for Payer: Kaiser Permanente Medicare	$3,768.84
Rate for Payer: MDX Hawaii PPO	$4,810.23
Rate for Payer: Ohana Health Plan Medicaid	$3,768.84
Rate for Payer: Ohana Health Plan Medicare	$3,768.84
Rate for Payer: UnitedHealthcare Medicare	$3,768.84
Rate for Payer: University Health Alliance Commercial	$2,777.04

STENT BILIARY 10X60

Facility

$4,984.00

Service Code	HCPCS C1874
Hospital Revenue Code	278
Min. Negotiated Rate	$2,492.00
Max. Negotiated Rate	$4,834.48
Rate for Payer: AlohaCare Medicaid	$2,492.00
Rate for Payer: AlohaCare Medicare	$3,787.84
Rate for Payer: Cash Price	$2,990.40
Rate for Payer: Devoted Health Medicare	$4,186.56
Rate for Payer: Hawaii Medical Service Association Medicare	$3,787.84
Rate for Payer: Hawaii Western Management Group Commercial	$3,488.80
Rate for Payer: Health Management Network Commercial	$4,236.40
Rate for Payer: Humana Medicare	$3,787.84
Rate for Payer: Kaiser Permanente Commercial	$4,485.60
Rate for Payer: Kaiser Permanente Medicaid	$2,541.84
Rate for Payer: Kaiser Permanente Medicare	$3,787.84
Rate for Payer: MDX Hawaii PPO	$4,834.48
Rate for Payer: Ohana Health Plan Medicaid	$3,787.84
Rate for Payer: Ohana Health Plan Medicare	$3,787.84
Rate for Payer: UnitedHealthcare Medicare	$3,787.84
Rate for Payer: University Health Alliance Commercial	$2,791.04

STENT BILIARY 10X60

Facility

$4,984.00

Service Code	HCPCS C1874
Hospital Revenue Code	278
Min. Negotiated Rate	$2,791.04
Max. Negotiated Rate	$4,834.48
Rate for Payer: Cash Price	$2,990.40
Rate for Payer: Hawaii Western Management Group Commercial	$3,488.80
Rate for Payer: Health Management Network Commercial	$4,236.40
Rate for Payer: Kaiser Permanente Commercial	$4,485.60
Rate for Payer: MDX Hawaii PPO	$4,834.48
Rate for Payer: University Health Alliance Commercial	$2,791.04

STENT BILIARY 10X80

Facility

$4,984.00

Service Code	HCPCS C1874
Hospital Revenue Code	278
Min. Negotiated Rate	$2,492.00
Max. Negotiated Rate	$4,834.48
Rate for Payer: AlohaCare Medicaid	$2,492.00
Rate for Payer: AlohaCare Medicare	$3,787.84
Rate for Payer: Cash Price	$2,990.40
Rate for Payer: Devoted Health Medicare	$4,186.56
Rate for Payer: Hawaii Medical Service Association Medicare	$3,787.84
Rate for Payer: Hawaii Western Management Group Commercial	$3,488.80
Rate for Payer: Health Management Network Commercial	$4,236.40
Rate for Payer: Humana Medicare	$3,787.84
Rate for Payer: Kaiser Permanente Commercial	$4,485.60
Rate for Payer: Kaiser Permanente Medicaid	$2,541.84
Rate for Payer: Kaiser Permanente Medicare	$3,787.84
Rate for Payer: MDX Hawaii PPO	$4,834.48
Rate for Payer: Ohana Health Plan Medicaid	$3,787.84
Rate for Payer: Ohana Health Plan Medicare	$3,787.84
Rate for Payer: UnitedHealthcare Medicare	$3,787.84
Rate for Payer: University Health Alliance Commercial	$2,791.04

STENT BILIARY 10X80

Facility

$4,984.00

Service Code	HCPCS C1874
Hospital Revenue Code	278
Min. Negotiated Rate	$2,791.04
Max. Negotiated Rate	$4,834.48
Rate for Payer: Cash Price	$2,990.40
Rate for Payer: Hawaii Western Management Group Commercial	$3,488.80
Rate for Payer: Health Management Network Commercial	$4,236.40
Rate for Payer: Kaiser Permanente Commercial	$4,485.60
Rate for Payer: MDX Hawaii PPO	$4,834.48
Rate for Payer: University Health Alliance Commercial	$2,791.04

STENT BILIARY 7FX9

Facility

$2,123.00

Service Code	HCPCS C2625
Hospital Revenue Code	278
Min. Negotiated Rate	$1,188.88
Max. Negotiated Rate	$2,059.31
Rate for Payer: Cash Price	$1,273.80
Rate for Payer: Hawaii Western Management Group Commercial	$1,486.10
Rate for Payer: Health Management Network Commercial	$1,804.55
Rate for Payer: Kaiser Permanente Commercial	$1,910.70
Rate for Payer: MDX Hawaii PPO	$2,059.31
Rate for Payer: University Health Alliance Commercial	$1,188.88

STENT BILIARY 7FX9

Facility

$2,123.00

Service Code	HCPCS C2625
Hospital Revenue Code	278
Min. Negotiated Rate	$1,061.50
Max. Negotiated Rate	$2,059.31
Rate for Payer: AlohaCare Medicaid	$1,061.50
Rate for Payer: AlohaCare Medicare	$1,613.48
Rate for Payer: Cash Price	$1,273.80
Rate for Payer: Devoted Health Medicare	$1,783.32
Rate for Payer: Hawaii Medical Service Association Medicare	$1,613.48
Rate for Payer: Hawaii Western Management Group Commercial	$1,486.10
Rate for Payer: Health Management Network Commercial	$1,804.55
Rate for Payer: Humana Medicare	$1,613.48
Rate for Payer: Kaiser Permanente Commercial	$1,910.70
Rate for Payer: Kaiser Permanente Medicaid	$1,082.73
Rate for Payer: Kaiser Permanente Medicare	$1,613.48
Rate for Payer: MDX Hawaii PPO	$2,059.31
Rate for Payer: Ohana Health Plan Medicaid	$1,613.48
Rate for Payer: Ohana Health Plan Medicare	$1,613.48
Rate for Payer: UnitedHealthcare Medicare	$1,613.48
Rate for Payer: University Health Alliance Commercial	$1,188.88

STENT COLON WALLFLEX 25X90

Facility

$5,075.00

Service Code	HCPCS C1876
Hospital Revenue Code	278
Min. Negotiated Rate	$2,842.00
Max. Negotiated Rate	$4,922.75
Rate for Payer: Cash Price	$3,045.00
Rate for Payer: Hawaii Western Management Group Commercial	$3,552.50
Rate for Payer: Health Management Network Commercial	$4,313.75
Rate for Payer: Kaiser Permanente Commercial	$4,567.50
Rate for Payer: MDX Hawaii PPO	$4,922.75
Rate for Payer: University Health Alliance Commercial	$2,842.00

STENT COLON WALLFLEX 25X90

Facility

$5,075.00

Service Code	HCPCS C1876
Hospital Revenue Code	278
Min. Negotiated Rate	$2,537.50
Max. Negotiated Rate	$4,922.75
Rate for Payer: AlohaCare Medicaid	$2,537.50
Rate for Payer: AlohaCare Medicare	$3,857.00
Rate for Payer: Cash Price	$3,045.00
Rate for Payer: Devoted Health Medicare	$4,263.00
Rate for Payer: Hawaii Medical Service Association Medicare	$3,857.00
Rate for Payer: Hawaii Western Management Group Commercial	$3,552.50
Rate for Payer: Health Management Network Commercial	$4,313.75
Rate for Payer: Humana Medicare	$3,857.00
Rate for Payer: Kaiser Permanente Commercial	$4,567.50
Rate for Payer: Kaiser Permanente Medicaid	$2,588.25
Rate for Payer: Kaiser Permanente Medicare	$3,857.00
Rate for Payer: MDX Hawaii PPO	$4,922.75
Rate for Payer: Ohana Health Plan Medicaid	$3,857.00
Rate for Payer: Ohana Health Plan Medicare	$3,857.00
Rate for Payer: UnitedHealthcare Medicare	$3,857.00
Rate for Payer: University Health Alliance Commercial	$2,842.00

STENT CONTOUR 4.8FX22-30CM

Facility

$419.00

Service Code	HCPCS C2617
Hospital Revenue Code	278
Min. Negotiated Rate	$209.50
Max. Negotiated Rate	$406.43
Rate for Payer: AlohaCare Medicaid	$209.50
Rate for Payer: AlohaCare Medicare	$318.44
Rate for Payer: Cash Price	$251.40
Rate for Payer: Devoted Health Medicare	$351.96
Rate for Payer: Hawaii Medical Service Association Medicare	$318.44
Rate for Payer: Hawaii Western Management Group Commercial	$293.30
Rate for Payer: Health Management Network Commercial	$356.15
Rate for Payer: Humana Medicare	$318.44
Rate for Payer: Kaiser Permanente Commercial	$377.10
Rate for Payer: Kaiser Permanente Medicaid	$213.69
Rate for Payer: Kaiser Permanente Medicare	$318.44
Rate for Payer: MDX Hawaii PPO	$406.43
Rate for Payer: Ohana Health Plan Medicaid	$318.44
Rate for Payer: Ohana Health Plan Medicare	$318.44
Rate for Payer: UnitedHealthcare Medicare	$318.44
Rate for Payer: University Health Alliance Commercial	$234.64

STENT CONTOUR 4.8FX22-30CM

Facility

$419.00

Service Code	HCPCS C2617
Hospital Revenue Code	278
Min. Negotiated Rate	$234.64
Max. Negotiated Rate	$406.43
Rate for Payer: Cash Price	$251.40
Rate for Payer: Hawaii Western Management Group Commercial	$293.30
Rate for Payer: Health Management Network Commercial	$356.15
Rate for Payer: Kaiser Permanente Commercial	$377.10
Rate for Payer: MDX Hawaii PPO	$406.43
Rate for Payer: University Health Alliance Commercial	$234.64

STENT CONTOUR VL URETERAL

Facility

$415.00

Service Code	HCPCS C2617
Hospital Revenue Code	278
Min. Negotiated Rate	$207.50
Max. Negotiated Rate	$402.55
Rate for Payer: AlohaCare Medicaid	$207.50
Rate for Payer: AlohaCare Medicare	$315.40
Rate for Payer: Cash Price	$249.00
Rate for Payer: Devoted Health Medicare	$348.60
Rate for Payer: Hawaii Medical Service Association Medicare	$315.40
Rate for Payer: Hawaii Western Management Group Commercial	$290.50
Rate for Payer: Health Management Network Commercial	$352.75
Rate for Payer: Humana Medicare	$315.40
Rate for Payer: Kaiser Permanente Commercial	$373.50
Rate for Payer: Kaiser Permanente Medicaid	$211.65
Rate for Payer: Kaiser Permanente Medicare	$315.40
Rate for Payer: MDX Hawaii PPO	$402.55
Rate for Payer: Ohana Health Plan Medicaid	$315.40
Rate for Payer: Ohana Health Plan Medicare	$315.40
Rate for Payer: UnitedHealthcare Medicare	$315.40
Rate for Payer: University Health Alliance Commercial	$232.40

Know your out-of-pocket cost for care.

All Charges