Honoka'a Hospital and Skilled Nursing Facility

All Charges

Charge

Type

Setting

Price

STENT PANCREATIC 5FX3CM

Facility

$316.00

Service Code	HCPCS C2617
Hospital Revenue Code	278
Min. Negotiated Rate	$158.00
Max. Negotiated Rate	$306.52
Rate for Payer: AlohaCare Medicaid	$158.00
Rate for Payer: AlohaCare Medicare	$240.16
Rate for Payer: Cash Price	$189.60
Rate for Payer: Devoted Health Medicare	$265.44
Rate for Payer: Hawaii Medical Service Association Medicare	$240.16
Rate for Payer: Hawaii Western Management Group Commercial	$221.20
Rate for Payer: Health Management Network Commercial	$268.60
Rate for Payer: Humana Medicare	$240.16
Rate for Payer: Kaiser Permanente Commercial	$284.40
Rate for Payer: Kaiser Permanente Medicaid	$161.16
Rate for Payer: Kaiser Permanente Medicare	$240.16
Rate for Payer: MDX Hawaii PPO	$306.52
Rate for Payer: Ohana Health Plan Medicaid	$240.16
Rate for Payer: Ohana Health Plan Medicare	$240.16
Rate for Payer: UnitedHealthcare Medicare	$240.16
Rate for Payer: University Health Alliance Commercial	$176.96

STENT PANCREATIC 5FX3CM

Facility

$316.00

Service Code	HCPCS C2617
Hospital Revenue Code	278
Min. Negotiated Rate	$176.96
Max. Negotiated Rate	$306.52
Rate for Payer: Cash Price	$189.60
Rate for Payer: Hawaii Western Management Group Commercial	$221.20
Rate for Payer: Health Management Network Commercial	$268.60
Rate for Payer: Kaiser Permanente Commercial	$284.40
Rate for Payer: MDX Hawaii PPO	$306.52
Rate for Payer: University Health Alliance Commercial	$176.96

STENT POLARIS LOOP M0061552300

Facility

$558.00

Service Code	HCPCS C2617
Hospital Revenue Code	278
Min. Negotiated Rate	$312.48
Max. Negotiated Rate	$541.26
Rate for Payer: Cash Price	$334.80
Rate for Payer: Hawaii Western Management Group Commercial	$390.60
Rate for Payer: Health Management Network Commercial	$474.30
Rate for Payer: Kaiser Permanente Commercial	$502.20
Rate for Payer: MDX Hawaii PPO	$541.26
Rate for Payer: University Health Alliance Commercial	$312.48

STENT POLARIS LOOP M0061552300

Facility

$558.00

Service Code	HCPCS C2617
Hospital Revenue Code	278
Min. Negotiated Rate	$279.00
Max. Negotiated Rate	$541.26
Rate for Payer: AlohaCare Medicaid	$279.00
Rate for Payer: AlohaCare Medicare	$424.08
Rate for Payer: Cash Price	$334.80
Rate for Payer: Devoted Health Medicare	$468.72
Rate for Payer: Hawaii Medical Service Association Medicare	$424.08
Rate for Payer: Hawaii Western Management Group Commercial	$390.60
Rate for Payer: Health Management Network Commercial	$474.30
Rate for Payer: Humana Medicare	$424.08
Rate for Payer: Kaiser Permanente Commercial	$502.20
Rate for Payer: Kaiser Permanente Medicaid	$284.58
Rate for Payer: Kaiser Permanente Medicare	$424.08
Rate for Payer: MDX Hawaii PPO	$541.26
Rate for Payer: Ohana Health Plan Medicaid	$424.08
Rate for Payer: Ohana Health Plan Medicare	$424.08
Rate for Payer: UnitedHealthcare Medicare	$424.08
Rate for Payer: University Health Alliance Commercial	$312.48

STENT POLARIS LOOP URETERAL

Facility

$552.00

Service Code	HCPCS C2617
Hospital Revenue Code	278
Min. Negotiated Rate	$309.12
Max. Negotiated Rate	$535.44
Rate for Payer: Cash Price	$331.20
Rate for Payer: Cash Price	$341.40
Rate for Payer: Hawaii Western Management Group Commercial	$398.30
Rate for Payer: Hawaii Western Management Group Commercial	$386.40
Rate for Payer: Health Management Network Commercial	$483.65
Rate for Payer: Health Management Network Commercial	$469.20
Rate for Payer: Kaiser Permanente Commercial	$512.10
Rate for Payer: Kaiser Permanente Commercial	$496.80
Rate for Payer: MDX Hawaii PPO	$551.93
Rate for Payer: MDX Hawaii PPO	$535.44
Rate for Payer: University Health Alliance Commercial	$318.64
Rate for Payer: University Health Alliance Commercial	$309.12

STENT POLARIS LOOP URETERAL

Facility

$569.00

Service Code	HCPCS C2617
Hospital Revenue Code	278
Min. Negotiated Rate	$284.50
Max. Negotiated Rate	$551.93
Rate for Payer: AlohaCare Medicaid	$284.50
Rate for Payer: AlohaCare Medicaid	$276.00
Rate for Payer: AlohaCare Medicare	$432.44
Rate for Payer: AlohaCare Medicare	$419.52
Rate for Payer: Cash Price	$331.20
Rate for Payer: Cash Price	$341.40
Rate for Payer: Devoted Health Medicare	$463.68
Rate for Payer: Devoted Health Medicare	$477.96
Rate for Payer: Hawaii Medical Service Association Medicare	$419.52
Rate for Payer: Hawaii Medical Service Association Medicare	$432.44
Rate for Payer: Hawaii Western Management Group Commercial	$386.40
Rate for Payer: Hawaii Western Management Group Commercial	$398.30
Rate for Payer: Health Management Network Commercial	$483.65
Rate for Payer: Health Management Network Commercial	$469.20
Rate for Payer: Humana Medicare	$432.44
Rate for Payer: Humana Medicare	$419.52
Rate for Payer: Kaiser Permanente Commercial	$496.80
Rate for Payer: Kaiser Permanente Commercial	$512.10
Rate for Payer: Kaiser Permanente Medicaid	$281.52
Rate for Payer: Kaiser Permanente Medicaid	$290.19
Rate for Payer: Kaiser Permanente Medicare	$432.44
Rate for Payer: Kaiser Permanente Medicare	$419.52
Rate for Payer: MDX Hawaii PPO	$535.44
Rate for Payer: MDX Hawaii PPO	$551.93
Rate for Payer: Ohana Health Plan Medicaid	$432.44
Rate for Payer: Ohana Health Plan Medicaid	$419.52
Rate for Payer: Ohana Health Plan Medicare	$432.44
Rate for Payer: Ohana Health Plan Medicare	$419.52
Rate for Payer: UnitedHealthcare Medicare	$419.52
Rate for Payer: UnitedHealthcare Medicare	$432.44
Rate for Payer: University Health Alliance Commercial	$318.64
Rate for Payer: University Health Alliance Commercial	$309.12

STENT PUSHER 4/5FR

Facility

$201.00

Service Code	HCPCS C1889
Hospital Revenue Code	278
Min. Negotiated Rate	$112.56
Max. Negotiated Rate	$194.97
Rate for Payer: Cash Price	$120.60
Rate for Payer: Hawaii Western Management Group Commercial	$140.70
Rate for Payer: Health Management Network Commercial	$170.85
Rate for Payer: Kaiser Permanente Commercial	$180.90
Rate for Payer: MDX Hawaii PPO	$194.97
Rate for Payer: University Health Alliance Commercial	$112.56

STENT PUSHER 4/5FR

Facility

$201.00

Service Code	HCPCS C1889
Hospital Revenue Code	278
Min. Negotiated Rate	$100.50
Max. Negotiated Rate	$194.97
Rate for Payer: AlohaCare Medicaid	$100.50
Rate for Payer: AlohaCare Medicare	$152.76
Rate for Payer: Cash Price	$120.60
Rate for Payer: Devoted Health Medicare	$168.84
Rate for Payer: Hawaii Medical Service Association Medicare	$152.76
Rate for Payer: Hawaii Western Management Group Commercial	$140.70
Rate for Payer: Health Management Network Commercial	$170.85
Rate for Payer: Humana Medicare	$152.76
Rate for Payer: Kaiser Permanente Commercial	$180.90
Rate for Payer: Kaiser Permanente Medicaid	$102.51
Rate for Payer: Kaiser Permanente Medicare	$152.76
Rate for Payer: MDX Hawaii PPO	$194.97
Rate for Payer: Ohana Health Plan Medicaid	$152.76
Rate for Payer: Ohana Health Plan Medicare	$152.76
Rate for Payer: UnitedHealthcare Medicare	$152.76
Rate for Payer: University Health Alliance Commercial	$112.56

STENT SET FILIFORM DBL PIG

Facility

$473.00

Service Code	HCPCS C2617
Hospital Revenue Code	278
Min. Negotiated Rate	$236.50
Max. Negotiated Rate	$458.81
Rate for Payer: Devoted Health Medicare	$397.32
Rate for Payer: AlohaCare Medicaid	$236.50
Rate for Payer: AlohaCare Medicaid	$266.00
Rate for Payer: AlohaCare Medicare	$359.48
Rate for Payer: AlohaCare Medicare	$404.32
Rate for Payer: Cash Price	$283.80
Rate for Payer: Cash Price	$319.20
Rate for Payer: Devoted Health Medicare	$446.88
Rate for Payer: Hawaii Medical Service Association Medicare	$404.32
Rate for Payer: Hawaii Medical Service Association Medicare	$359.48
Rate for Payer: Hawaii Western Management Group Commercial	$372.40
Rate for Payer: Hawaii Western Management Group Commercial	$331.10
Rate for Payer: Health Management Network Commercial	$402.05
Rate for Payer: Health Management Network Commercial	$452.20
Rate for Payer: Humana Medicare	$359.48
Rate for Payer: Humana Medicare	$404.32
Rate for Payer: Kaiser Permanente Commercial	$478.80
Rate for Payer: Kaiser Permanente Commercial	$425.70
Rate for Payer: Kaiser Permanente Medicaid	$241.23
Rate for Payer: Kaiser Permanente Medicaid	$271.32
Rate for Payer: Kaiser Permanente Medicare	$359.48
Rate for Payer: Kaiser Permanente Medicare	$404.32
Rate for Payer: MDX Hawaii PPO	$458.81
Rate for Payer: MDX Hawaii PPO	$516.04
Rate for Payer: Ohana Health Plan Medicaid	$359.48
Rate for Payer: Ohana Health Plan Medicaid	$404.32
Rate for Payer: Ohana Health Plan Medicare	$404.32
Rate for Payer: Ohana Health Plan Medicare	$359.48
Rate for Payer: UnitedHealthcare Medicare	$359.48
Rate for Payer: UnitedHealthcare Medicare	$404.32
Rate for Payer: University Health Alliance Commercial	$264.88
Rate for Payer: University Health Alliance Commercial	$297.92

STENT SET FILIFORM DBL PIG

Facility

$473.00

Service Code	HCPCS C2617
Hospital Revenue Code	278
Min. Negotiated Rate	$264.88
Max. Negotiated Rate	$458.81
Rate for Payer: Cash Price	$283.80
Rate for Payer: Cash Price	$319.20
Rate for Payer: Hawaii Western Management Group Commercial	$331.10
Rate for Payer: Hawaii Western Management Group Commercial	$372.40
Rate for Payer: Health Management Network Commercial	$402.05
Rate for Payer: Health Management Network Commercial	$452.20
Rate for Payer: Kaiser Permanente Commercial	$478.80
Rate for Payer: Kaiser Permanente Commercial	$425.70
Rate for Payer: MDX Hawaii PPO	$458.81
Rate for Payer: MDX Hawaii PPO	$516.04
Rate for Payer: University Health Alliance Commercial	$297.92
Rate for Payer: University Health Alliance Commercial	$264.88

STENT SYSTEM 7X40 SR-0740-CS

Facility

$5,400.00

Service Code	HCPCS C1876
Hospital Revenue Code	278
Min. Negotiated Rate	$3,024.00
Max. Negotiated Rate	$5,238.00
Rate for Payer: Cash Price	$3,240.00
Rate for Payer: Hawaii Western Management Group Commercial	$3,780.00
Rate for Payer: Health Management Network Commercial	$4,590.00
Rate for Payer: Kaiser Permanente Commercial	$4,860.00
Rate for Payer: MDX Hawaii PPO	$5,238.00
Rate for Payer: University Health Alliance Commercial	$3,024.00

STENT SYSTEM 7X40 SR-0740-CS

Facility

$5,400.00

Service Code	HCPCS C1876
Hospital Revenue Code	278
Min. Negotiated Rate	$2,700.00
Max. Negotiated Rate	$5,238.00
Rate for Payer: AlohaCare Medicaid	$2,700.00
Rate for Payer: AlohaCare Medicare	$4,104.00
Rate for Payer: Cash Price	$3,240.00
Rate for Payer: Devoted Health Medicare	$4,536.00
Rate for Payer: Hawaii Medical Service Association Medicare	$4,104.00
Rate for Payer: Hawaii Western Management Group Commercial	$3,780.00
Rate for Payer: Health Management Network Commercial	$4,590.00
Rate for Payer: Humana Medicare	$4,104.00
Rate for Payer: Kaiser Permanente Commercial	$4,860.00
Rate for Payer: Kaiser Permanente Medicaid	$2,754.00
Rate for Payer: Kaiser Permanente Medicare	$4,104.00
Rate for Payer: MDX Hawaii PPO	$5,238.00
Rate for Payer: Ohana Health Plan Medicaid	$4,104.00
Rate for Payer: Ohana Health Plan Medicare	$4,104.00
Rate for Payer: UnitedHealthcare Medicare	$4,104.00
Rate for Payer: University Health Alliance Commercial	$3,024.00

STENT URETERAL 6FRX22-30CM

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

STENT URETERAL 6FRX22-30CM

Facility

$415.00

Service Code	HCPCS C2617
Hospital Revenue Code	278
Min. Negotiated Rate	$232.40
Max. Negotiated Rate	$402.55
Rate for Payer: Cash Price	$249.00
Rate for Payer: Hawaii Western Management Group Commercial	$290.50
Rate for Payer: Health Management Network Commercial	$352.75
Rate for Payer: Kaiser Permanente Commercial	$373.50
Rate for Payer: MDX Hawaii PPO	$402.55
Rate for Payer: University Health Alliance Commercial	$232.40

STERLING MONORAIL 4.5X20X135

Facility

$875.00

Service Code	HCPCS C1725
Hospital Revenue Code	272
Min. Negotiated Rate	$437.50
Max. Negotiated Rate	$848.75
Rate for Payer: AlohaCare Medicaid	$437.50
Rate for Payer: AlohaCare Medicare	$665.00
Rate for Payer: Cash Price	$525.00
Rate for Payer: Devoted Health Medicare	$735.00
Rate for Payer: Hawaii Medical Service Association Medicare	$665.00
Rate for Payer: Hawaii Western Management Group Commercial	$831.25
Rate for Payer: Health Management Network Commercial	$743.75
Rate for Payer: Humana Medicare	$665.00
Rate for Payer: Kaiser Permanente Commercial	$787.50
Rate for Payer: Kaiser Permanente Medicaid	$446.25
Rate for Payer: Kaiser Permanente Medicare	$665.00
Rate for Payer: MDX Hawaii PPO	$848.75
Rate for Payer: Ohana Health Plan Medicaid	$665.00
Rate for Payer: Ohana Health Plan Medicare	$665.00
Rate for Payer: UnitedHealthcare Medicare	$665.00
Rate for Payer: University Health Alliance Commercial	$637.79

STERLING MONORAIL 4.5X20X135

Facility

$875.00

Service Code	HCPCS C1725
Hospital Revenue Code	272
Min. Negotiated Rate	$743.75
Max. Negotiated Rate	$848.75
Rate for Payer: Cash Price	$525.00
Rate for Payer: Health Management Network Commercial	$743.75
Rate for Payer: Kaiser Permanente Commercial	$787.50
Rate for Payer: MDX Hawaii PPO	$848.75

STOMACH, ESOPHAGEAL AND DUODENAL PROCEDURES WITH CC

Facility

$89,640.96

Service Code	MSDRG 327
Min. Negotiated Rate	$89,640.96
Max. Negotiated Rate	$89,640.96
Rate for Payer: Hawaii Medical Service Association Commercial	$89,640.96

STOMACH, ESOPHAGEAL AND DUODENAL PROCEDURES WITH MCC

Facility

$126,639.79

Service Code	MSDRG 326
Min. Negotiated Rate	$126,639.79
Max. Negotiated Rate	$126,639.79
Rate for Payer: Hawaii Medical Service Association Commercial	$126,639.79

STOMACH, ESOPHAGEAL AND DUODENAL PROCEDURES WITHOUT CC/MCC

Facility

$38,373.54

Service Code	MSDRG 328
Min. Negotiated Rate	$38,373.54
Max. Negotiated Rate	$38,373.54
Rate for Payer: Hawaii Medical Service Association Commercial	$38,373.54

STRATAFIX 2-0 CT-2 9 SXPP1B432

Facility

$124.00

Hospital Revenue Code	272
Min. Negotiated Rate	$62.00
Max. Negotiated Rate	$120.28
Rate for Payer: AlohaCare Medicaid	$62.00
Rate for Payer: AlohaCare Medicare	$94.24
Rate for Payer: Cash Price	$74.40
Rate for Payer: Devoted Health Medicare	$104.16
Rate for Payer: Hawaii Medical Service Association Medicare	$94.24
Rate for Payer: Hawaii Western Management Group Commercial	$117.80
Rate for Payer: Health Management Network Commercial	$105.40
Rate for Payer: Humana Medicare	$94.24
Rate for Payer: Kaiser Permanente Commercial	$111.60
Rate for Payer: Kaiser Permanente Medicaid	$63.24
Rate for Payer: Kaiser Permanente Medicare	$94.24
Rate for Payer: MDX Hawaii PPO	$120.28
Rate for Payer: Ohana Health Plan Medicaid	$94.24
Rate for Payer: Ohana Health Plan Medicare	$94.24
Rate for Payer: UnitedHealthcare Medicare	$94.24
Rate for Payer: University Health Alliance Commercial	$90.38

STRATAFIX 2-0 CT-2 9 SXPP1B432

Facility

$124.00

Hospital Revenue Code	272
Min. Negotiated Rate	$105.40
Max. Negotiated Rate	$120.28
Rate for Payer: Cash Price	$74.40
Rate for Payer: Health Management Network Commercial	$105.40
Rate for Payer: Kaiser Permanente Commercial	$111.60
Rate for Payer: MDX Hawaii PPO	$120.28

STRATAFIX SPIRAL SXPP1B450

Facility

$124.00

Hospital Revenue Code	272
Min. Negotiated Rate	$105.40
Max. Negotiated Rate	$120.28
Rate for Payer: Cash Price	$74.40
Rate for Payer: Health Management Network Commercial	$105.40
Rate for Payer: Kaiser Permanente Commercial	$111.60
Rate for Payer: MDX Hawaii PPO	$120.28

STRATAFIX SPIRAL SXPP1B450

Facility

$124.00

Hospital Revenue Code	272
Min. Negotiated Rate	$62.00
Max. Negotiated Rate	$120.28
Rate for Payer: AlohaCare Medicaid	$62.00
Rate for Payer: AlohaCare Medicare	$94.24
Rate for Payer: Cash Price	$74.40
Rate for Payer: Devoted Health Medicare	$104.16
Rate for Payer: Hawaii Medical Service Association Medicare	$94.24
Rate for Payer: Hawaii Western Management Group Commercial	$117.80
Rate for Payer: Health Management Network Commercial	$105.40
Rate for Payer: Humana Medicare	$94.24
Rate for Payer: Kaiser Permanente Commercial	$111.60
Rate for Payer: Kaiser Permanente Medicaid	$63.24
Rate for Payer: Kaiser Permanente Medicare	$94.24
Rate for Payer: MDX Hawaii PPO	$120.28
Rate for Payer: Ohana Health Plan Medicaid	$94.24
Rate for Payer: Ohana Health Plan Medicare	$94.24
Rate for Payer: UnitedHealthcare Medicare	$94.24
Rate for Payer: University Health Alliance Commercial	$90.38

STREPTOMYCIN 1 GRAM INTRAMUSCULAR SOLUTION [7508]

Facility

$188.00

Service Code	HCPCS J3000
Hospital Revenue Code	250
Min. Negotiated Rate	$159.80
Max. Negotiated Rate	$182.36
Rate for Payer: Cash Price	$112.80
Rate for Payer: Health Management Network Commercial	$159.80
Rate for Payer: Kaiser Permanente Commercial	$169.20
Rate for Payer: MDX Hawaii PPO	$182.36

STREPTOMYCIN 1 GRAM INTRAMUSCULAR SOLUTION [7508]

Facility

$188.00

Service Code	HCPCS J3000
Hospital Revenue Code	636
Min. Negotiated Rate	$31.35
Max. Negotiated Rate	$182.36
Rate for Payer: AlohaCare Medicaid	$94.00
Rate for Payer: AlohaCare Medicare	$142.88
Rate for Payer: Cash Price	$112.80
Rate for Payer: Cash Price	$112.80
Rate for Payer: Devoted Health Medicare	$157.92
Rate for Payer: Hawaii Medical Service Association ABD	$31.35
Rate for Payer: Hawaii Medical Service Association Medicare	$142.88
Rate for Payer: Hawaii Medical Service Association Non-ABD	$31.35
Rate for Payer: Hawaii Western Management Group Commercial	$178.60
Rate for Payer: Health Management Network Commercial	$159.80
Rate for Payer: Humana Medicare	$142.88
Rate for Payer: Kaiser Permanente Commercial	$169.20
Rate for Payer: Kaiser Permanente Medicaid	$95.88
Rate for Payer: Kaiser Permanente Medicare	$142.88
Rate for Payer: MDX Hawaii PPO	$182.36
Rate for Payer: Ohana Health Plan Medicaid	$142.88
Rate for Payer: Ohana Health Plan Medicare	$142.88
Rate for Payer: UnitedHealthcare Medicaid	$112.80
Rate for Payer: UnitedHealthcare Medicare	$142.88
Rate for Payer: University Health Alliance Commercial	$137.03

Know your out-of-pocket cost for care.

All Charges