Honoka'a Hospital and Skilled Nursing Facility

All Charges

Charge

Type

Setting

Price

SUMATRIPTAN 6 MG/0.5 ML SUBCUTANEOUS SOLUTION [97343]

Facility

$33.00

Service Code	NDC 55150017301
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

SUMATRIPTAN 6 MG/0.5 ML SUBCUTANEOUS SOLUTION [97343]

Facility

$36.00

Service Code	NDC 00143963805
Hospital Revenue Code	250
Min. Negotiated Rate	$30.60
Max. Negotiated Rate	$34.92
Rate for Payer: Cash Price	$21.60
Rate for Payer: Health Management Network Commercial	$30.60
Rate for Payer: Kaiser Permanente Commercial	$32.40
Rate for Payer: MDX Hawaii PPO	$34.92

SUNDT CAR SHNT 3.5MM/NL8505079

Facility

$2,470.00

Service Code	HCPCS C1889
Hospital Revenue Code	272
Min. Negotiated Rate	$2,099.50
Max. Negotiated Rate	$2,395.90
Rate for Payer: Cash Price	$1,482.00
Rate for Payer: Health Management Network Commercial	$2,099.50
Rate for Payer: Kaiser Permanente Commercial	$2,223.00
Rate for Payer: MDX Hawaii PPO	$2,395.90

SUNDT CAR SHNT 3.5MM/NL8505079

Facility

$2,470.00

Service Code	HCPCS C1889
Hospital Revenue Code	272
Min. Negotiated Rate	$1,235.00
Max. Negotiated Rate	$2,395.90
Rate for Payer: AlohaCare Medicaid	$1,235.00
Rate for Payer: AlohaCare Medicare	$1,877.20
Rate for Payer: Cash Price	$1,482.00
Rate for Payer: Devoted Health Medicare	$2,074.80
Rate for Payer: Hawaii Medical Service Association Medicare	$1,877.20
Rate for Payer: Hawaii Western Management Group Commercial	$2,346.50
Rate for Payer: Health Management Network Commercial	$2,099.50
Rate for Payer: Humana Medicare	$1,877.20
Rate for Payer: Kaiser Permanente Commercial	$2,223.00
Rate for Payer: Kaiser Permanente Medicaid	$1,259.70
Rate for Payer: Kaiser Permanente Medicare	$1,877.20
Rate for Payer: MDX Hawaii PPO	$2,395.90
Rate for Payer: Ohana Health Plan Medicaid	$1,877.20
Rate for Payer: Ohana Health Plan Medicare	$1,877.20
Rate for Payer: UnitedHealthcare Medicare	$1,877.20
Rate for Payer: University Health Alliance Commercial	$1,800.38

SUNDT CAR SHNT 3MM/NL8505070

Facility

$2,000.00

Service Code	HCPCS C1889
Hospital Revenue Code	272
Min. Negotiated Rate	$1,700.00
Max. Negotiated Rate	$1,940.00
Rate for Payer: Cash Price	$1,200.00
Rate for Payer: Health Management Network Commercial	$1,700.00
Rate for Payer: Kaiser Permanente Commercial	$1,800.00
Rate for Payer: MDX Hawaii PPO	$1,940.00

SUNDT CAR SHNT 3MM/NL8505070

Facility

$2,000.00

Service Code	HCPCS C1889
Hospital Revenue Code	272
Min. Negotiated Rate	$1,000.00
Max. Negotiated Rate	$1,940.00
Rate for Payer: AlohaCare Medicaid	$1,000.00
Rate for Payer: AlohaCare Medicare	$1,520.00
Rate for Payer: Cash Price	$1,200.00
Rate for Payer: Devoted Health Medicare	$1,680.00
Rate for Payer: Hawaii Medical Service Association Medicare	$1,520.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,900.00
Rate for Payer: Health Management Network Commercial	$1,700.00
Rate for Payer: Humana Medicare	$1,520.00
Rate for Payer: Kaiser Permanente Commercial	$1,800.00
Rate for Payer: Kaiser Permanente Medicaid	$1,020.00
Rate for Payer: Kaiser Permanente Medicare	$1,520.00
Rate for Payer: MDX Hawaii PPO	$1,940.00
Rate for Payer: Ohana Health Plan Medicaid	$1,520.00
Rate for Payer: Ohana Health Plan Medicare	$1,520.00
Rate for Payer: UnitedHealthcare Medicare	$1,520.00
Rate for Payer: University Health Alliance Commercial	$1,457.80

SUNDT EXT ENDART SHUNT 3MM X

Facility

$1,393.00

Service Code	HCPCS C1889
Hospital Revenue Code	272
Min. Negotiated Rate	$1,184.05
Max. Negotiated Rate	$1,351.21
Rate for Payer: Cash Price	$835.80
Rate for Payer: Health Management Network Commercial	$1,184.05
Rate for Payer: Kaiser Permanente Commercial	$1,253.70
Rate for Payer: MDX Hawaii PPO	$1,351.21

SUNDT EXT ENDART SHUNT 3MM X

Facility

$1,393.00

Service Code	HCPCS C1889
Hospital Revenue Code	272
Min. Negotiated Rate	$696.50
Max. Negotiated Rate	$1,351.21
Rate for Payer: AlohaCare Medicaid	$696.50
Rate for Payer: AlohaCare Medicare	$1,058.68
Rate for Payer: Cash Price	$835.80
Rate for Payer: Devoted Health Medicare	$1,170.12
Rate for Payer: Hawaii Medical Service Association Medicare	$1,058.68
Rate for Payer: Hawaii Western Management Group Commercial	$1,323.35
Rate for Payer: Health Management Network Commercial	$1,184.05
Rate for Payer: Humana Medicare	$1,058.68
Rate for Payer: Kaiser Permanente Commercial	$1,253.70
Rate for Payer: Kaiser Permanente Medicaid	$710.43
Rate for Payer: Kaiser Permanente Medicare	$1,058.68
Rate for Payer: MDX Hawaii PPO	$1,351.21
Rate for Payer: Ohana Health Plan Medicaid	$1,058.68
Rate for Payer: Ohana Health Plan Medicare	$1,058.68
Rate for Payer: UnitedHealthcare Medicare	$1,058.68
Rate for Payer: University Health Alliance Commercial	$1,015.36

SUPERIOR CLAVICLE 8H RT 628028

Facility

$3,450.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,932.00
Max. Negotiated Rate	$3,346.50
Rate for Payer: Cash Price	$2,070.00
Rate for Payer: Hawaii Western Management Group Commercial	$2,415.00
Rate for Payer: Health Management Network Commercial	$2,932.50
Rate for Payer: Kaiser Permanente Commercial	$3,105.00
Rate for Payer: MDX Hawaii PPO	$3,346.50
Rate for Payer: University Health Alliance Commercial	$1,932.00

SUPERIOR CLAVICLE 8H RT 628028

Facility

$3,450.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,725.00
Max. Negotiated Rate	$3,346.50
Rate for Payer: AlohaCare Medicaid	$1,725.00
Rate for Payer: AlohaCare Medicare	$2,622.00
Rate for Payer: Cash Price	$2,070.00
Rate for Payer: Devoted Health Medicare	$2,898.00
Rate for Payer: Hawaii Medical Service Association Medicare	$2,622.00
Rate for Payer: Hawaii Western Management Group Commercial	$2,415.00
Rate for Payer: Health Management Network Commercial	$2,932.50
Rate for Payer: Humana Medicare	$2,622.00
Rate for Payer: Kaiser Permanente Commercial	$3,105.00
Rate for Payer: Kaiser Permanente Medicaid	$1,759.50
Rate for Payer: Kaiser Permanente Medicare	$2,622.00
Rate for Payer: MDX Hawaii PPO	$3,346.50
Rate for Payer: Ohana Health Plan Medicaid	$2,622.00
Rate for Payer: Ohana Health Plan Medicare	$2,622.00
Rate for Payer: UnitedHealthcare Medicare	$2,622.00
Rate for Payer: University Health Alliance Commercial	$1,932.00

SUPPORT FOREARM RIGHT

Facility

$119.00

Service Code	HCPCS L3908
Hospital Revenue Code	274
Min. Negotiated Rate	$49.46
Max. Negotiated Rate	$115.43
Rate for Payer: AlohaCare Medicaid	$59.50
Rate for Payer: AlohaCare Medicare	$90.44
Rate for Payer: Cash Price	$71.40
Rate for Payer: Cash Price	$71.40
Rate for Payer: Devoted Health Medicare	$99.96
Rate for Payer: Hawaii Medical Service Association Medicare	$90.44
Rate for Payer: Hawaii Western Management Group Commercial	$83.30
Rate for Payer: Health Management Network Commercial	$101.15
Rate for Payer: Humana Medicare	$90.44
Rate for Payer: Kaiser Permanente Commercial	$107.10
Rate for Payer: Kaiser Permanente Medicaid	$60.69
Rate for Payer: Kaiser Permanente Medicare	$90.44
Rate for Payer: MDX Hawaii PPO	$115.43
Rate for Payer: Ohana Health Plan Medicaid	$90.44
Rate for Payer: Ohana Health Plan Medicare	$90.44
Rate for Payer: UnitedHealthcare Medicaid	$49.46
Rate for Payer: UnitedHealthcare Medicare	$90.44
Rate for Payer: University Health Alliance Commercial	$66.64

SUPPORT FOREARM RIGHT

Facility

$119.00

Service Code	HCPCS L3908
Hospital Revenue Code	274
Min. Negotiated Rate	$66.64
Max. Negotiated Rate	$115.43
Rate for Payer: Cash Price	$71.40
Rate for Payer: Hawaii Western Management Group Commercial	$83.30
Rate for Payer: Health Management Network Commercial	$101.15
Rate for Payer: Kaiser Permanente Commercial	$107.10
Rate for Payer: MDX Hawaii PPO	$115.43
Rate for Payer: University Health Alliance Commercial	$66.64

SUREFORM 45 2.0 GRAY 48345M

Facility

$750.00

Hospital Revenue Code	272
Min. Negotiated Rate	$375.00
Max. Negotiated Rate	$727.50
Rate for Payer: AlohaCare Medicaid	$375.00
Rate for Payer: AlohaCare Medicare	$570.00
Rate for Payer: Cash Price	$450.00
Rate for Payer: Devoted Health Medicare	$630.00
Rate for Payer: Hawaii Medical Service Association Medicare	$570.00
Rate for Payer: Hawaii Western Management Group Commercial	$712.50
Rate for Payer: Health Management Network Commercial	$637.50
Rate for Payer: Humana Medicare	$570.00
Rate for Payer: Kaiser Permanente Commercial	$675.00
Rate for Payer: Kaiser Permanente Medicaid	$382.50
Rate for Payer: Kaiser Permanente Medicare	$570.00
Rate for Payer: MDX Hawaii PPO	$727.50
Rate for Payer: Ohana Health Plan Medicaid	$570.00
Rate for Payer: Ohana Health Plan Medicare	$570.00
Rate for Payer: UnitedHealthcare Medicare	$570.00
Rate for Payer: University Health Alliance Commercial	$546.67

SUREFORM 45 2.0 GRAY 48345M

Facility

$750.00

Hospital Revenue Code	272
Min. Negotiated Rate	$637.50
Max. Negotiated Rate	$727.50
Rate for Payer: Cash Price	$450.00
Rate for Payer: Health Management Network Commercial	$637.50
Rate for Payer: Kaiser Permanente Commercial	$675.00
Rate for Payer: MDX Hawaii PPO	$727.50

SUREFORM 45 2.5 WHITE 48345W

Facility

$788.00

Hospital Revenue Code	272
Min. Negotiated Rate	$669.80
Max. Negotiated Rate	$764.36
Rate for Payer: Cash Price	$472.80
Rate for Payer: Health Management Network Commercial	$669.80
Rate for Payer: Kaiser Permanente Commercial	$709.20
Rate for Payer: MDX Hawaii PPO	$764.36

SUREFORM 45 2.5 WHITE 48345W

Facility

$788.00

Hospital Revenue Code	272
Min. Negotiated Rate	$394.00
Max. Negotiated Rate	$764.36
Rate for Payer: AlohaCare Medicaid	$394.00
Rate for Payer: AlohaCare Medicare	$598.88
Rate for Payer: Cash Price	$472.80
Rate for Payer: Devoted Health Medicare	$661.92
Rate for Payer: Hawaii Medical Service Association Medicare	$598.88
Rate for Payer: Hawaii Western Management Group Commercial	$748.60
Rate for Payer: Health Management Network Commercial	$669.80
Rate for Payer: Humana Medicare	$598.88
Rate for Payer: Kaiser Permanente Commercial	$709.20
Rate for Payer: Kaiser Permanente Medicaid	$401.88
Rate for Payer: Kaiser Permanente Medicare	$598.88
Rate for Payer: MDX Hawaii PPO	$764.36
Rate for Payer: Ohana Health Plan Medicaid	$598.88
Rate for Payer: Ohana Health Plan Medicare	$598.88
Rate for Payer: UnitedHealthcare Medicare	$598.88
Rate for Payer: University Health Alliance Commercial	$574.37

SUREFORM 45 3.5 BLUE 48345B

Facility

$750.00

Hospital Revenue Code	272
Min. Negotiated Rate	$375.00
Max. Negotiated Rate	$727.50
Rate for Payer: AlohaCare Medicaid	$375.00
Rate for Payer: AlohaCare Medicare	$570.00
Rate for Payer: Cash Price	$450.00
Rate for Payer: Devoted Health Medicare	$630.00
Rate for Payer: Hawaii Medical Service Association Medicare	$570.00
Rate for Payer: Hawaii Western Management Group Commercial	$712.50
Rate for Payer: Health Management Network Commercial	$637.50
Rate for Payer: Humana Medicare	$570.00
Rate for Payer: Kaiser Permanente Commercial	$675.00
Rate for Payer: Kaiser Permanente Medicaid	$382.50
Rate for Payer: Kaiser Permanente Medicare	$570.00
Rate for Payer: MDX Hawaii PPO	$727.50
Rate for Payer: Ohana Health Plan Medicaid	$570.00
Rate for Payer: Ohana Health Plan Medicare	$570.00
Rate for Payer: UnitedHealthcare Medicare	$570.00
Rate for Payer: University Health Alliance Commercial	$546.67

SUREFORM 45 3.5 BLUE 48345B

Facility

$750.00

Hospital Revenue Code	272
Min. Negotiated Rate	$637.50
Max. Negotiated Rate	$727.50
Rate for Payer: Cash Price	$450.00
Rate for Payer: Health Management Network Commercial	$637.50
Rate for Payer: Kaiser Permanente Commercial	$675.00
Rate for Payer: MDX Hawaii PPO	$727.50

SUREFORM 45 4.3 GREEN 48345G

Facility

$750.00

Hospital Revenue Code	272
Min. Negotiated Rate	$637.50
Max. Negotiated Rate	$727.50
Rate for Payer: Cash Price	$450.00
Rate for Payer: Health Management Network Commercial	$637.50
Rate for Payer: Kaiser Permanente Commercial	$675.00
Rate for Payer: MDX Hawaii PPO	$727.50

SUREFORM 45 4.3 GREEN 48345G

Facility

$750.00

Hospital Revenue Code	272
Min. Negotiated Rate	$375.00
Max. Negotiated Rate	$727.50
Rate for Payer: AlohaCare Medicaid	$375.00
Rate for Payer: AlohaCare Medicare	$570.00
Rate for Payer: Cash Price	$450.00
Rate for Payer: Devoted Health Medicare	$630.00
Rate for Payer: Hawaii Medical Service Association Medicare	$570.00
Rate for Payer: Hawaii Western Management Group Commercial	$712.50
Rate for Payer: Health Management Network Commercial	$637.50
Rate for Payer: Humana Medicare	$570.00
Rate for Payer: Kaiser Permanente Commercial	$675.00
Rate for Payer: Kaiser Permanente Medicaid	$382.50
Rate for Payer: Kaiser Permanente Medicare	$570.00
Rate for Payer: MDX Hawaii PPO	$727.50
Rate for Payer: Ohana Health Plan Medicaid	$570.00
Rate for Payer: Ohana Health Plan Medicare	$570.00
Rate for Payer: UnitedHealthcare Medicare	$570.00
Rate for Payer: University Health Alliance Commercial	$546.67

SUREFORM 45 4.6 BLACK 48345T

Facility

$750.00

Hospital Revenue Code	272
Min. Negotiated Rate	$637.50
Max. Negotiated Rate	$727.50
Rate for Payer: Cash Price	$450.00
Rate for Payer: Health Management Network Commercial	$637.50
Rate for Payer: Kaiser Permanente Commercial	$675.00
Rate for Payer: MDX Hawaii PPO	$727.50

SUREFORM 45 4.6 BLACK 48345T

Facility

$750.00

Hospital Revenue Code	272
Min. Negotiated Rate	$375.00
Max. Negotiated Rate	$727.50
Rate for Payer: AlohaCare Medicaid	$375.00
Rate for Payer: AlohaCare Medicare	$570.00
Rate for Payer: Cash Price	$450.00
Rate for Payer: Devoted Health Medicare	$630.00
Rate for Payer: Hawaii Medical Service Association Medicare	$570.00
Rate for Payer: Hawaii Western Management Group Commercial	$712.50
Rate for Payer: Health Management Network Commercial	$637.50
Rate for Payer: Humana Medicare	$570.00
Rate for Payer: Kaiser Permanente Commercial	$675.00
Rate for Payer: Kaiser Permanente Medicaid	$382.50
Rate for Payer: Kaiser Permanente Medicare	$570.00
Rate for Payer: MDX Hawaii PPO	$727.50
Rate for Payer: Ohana Health Plan Medicaid	$570.00
Rate for Payer: Ohana Health Plan Medicare	$570.00
Rate for Payer: UnitedHealthcare Medicare	$570.00
Rate for Payer: University Health Alliance Commercial	$546.67

SUREFORM 60 2.5 WHITE 48360W

Facility

$863.00

Hospital Revenue Code	272
Min. Negotiated Rate	$733.55
Max. Negotiated Rate	$837.11
Rate for Payer: Cash Price	$517.80
Rate for Payer: Health Management Network Commercial	$733.55
Rate for Payer: Kaiser Permanente Commercial	$776.70
Rate for Payer: MDX Hawaii PPO	$837.11

SUREFORM 60 2.5 WHITE 48360W

Facility

$863.00

Hospital Revenue Code	272
Min. Negotiated Rate	$431.50
Max. Negotiated Rate	$837.11
Rate for Payer: AlohaCare Medicaid	$431.50
Rate for Payer: AlohaCare Medicare	$655.88
Rate for Payer: Cash Price	$517.80
Rate for Payer: Devoted Health Medicare	$724.92
Rate for Payer: Hawaii Medical Service Association Medicare	$655.88
Rate for Payer: Hawaii Western Management Group Commercial	$819.85
Rate for Payer: Health Management Network Commercial	$733.55
Rate for Payer: Humana Medicare	$655.88
Rate for Payer: Kaiser Permanente Commercial	$776.70
Rate for Payer: Kaiser Permanente Medicaid	$440.13
Rate for Payer: Kaiser Permanente Medicare	$655.88
Rate for Payer: MDX Hawaii PPO	$837.11
Rate for Payer: Ohana Health Plan Medicaid	$655.88
Rate for Payer: Ohana Health Plan Medicare	$655.88
Rate for Payer: UnitedHealthcare Medicare	$655.88
Rate for Payer: University Health Alliance Commercial	$629.04

SUREFORM 60 3.5 BLUE 48360B

Facility

$906.00

Hospital Revenue Code	272
Min. Negotiated Rate	$453.00
Max. Negotiated Rate	$878.82
Rate for Payer: AlohaCare Medicaid	$453.00
Rate for Payer: AlohaCare Medicare	$688.56
Rate for Payer: Cash Price	$543.60
Rate for Payer: Devoted Health Medicare	$761.04
Rate for Payer: Hawaii Medical Service Association Medicare	$688.56
Rate for Payer: Hawaii Western Management Group Commercial	$860.70
Rate for Payer: Health Management Network Commercial	$770.10
Rate for Payer: Humana Medicare	$688.56
Rate for Payer: Kaiser Permanente Commercial	$815.40
Rate for Payer: Kaiser Permanente Medicaid	$462.06
Rate for Payer: Kaiser Permanente Medicare	$688.56
Rate for Payer: MDX Hawaii PPO	$878.82
Rate for Payer: Ohana Health Plan Medicaid	$688.56
Rate for Payer: Ohana Health Plan Medicare	$688.56
Rate for Payer: UnitedHealthcare Medicare	$688.56
Rate for Payer: University Health Alliance Commercial	$660.38

Know your out-of-pocket cost for care.

All Charges