Honoka'a Hospital and Skilled Nursing Facility

All Charges

Charge

Type

Setting

Price

SUREFORM 60 3.5 BLUE 48360B

Facility

$906.00

Hospital Revenue Code	272
Min. Negotiated Rate	$770.10
Max. Negotiated Rate	$878.82
Rate for Payer: Cash Price	$543.60
Rate for Payer: Health Management Network Commercial	$770.10
Rate for Payer: Kaiser Permanente Commercial	$815.40
Rate for Payer: MDX Hawaii PPO	$878.82

SUREFORM 60 4.3 GREEN 48360G

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 4.3 GREEN 48360G

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

SURFACE ART TIB 42-5121-008-10

Facility

$2,850.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$1,425.00
Max. Negotiated Rate	$2,764.50
Rate for Payer: AlohaCare Medicaid	$1,425.00
Rate for Payer: AlohaCare Medicare	$2,166.00
Rate for Payer: Cash Price	$1,710.00
Rate for Payer: Devoted Health Medicare	$2,394.00
Rate for Payer: Hawaii Medical Service Association Medicare	$2,166.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,995.00
Rate for Payer: Health Management Network Commercial	$2,422.50
Rate for Payer: Humana Medicare	$2,166.00
Rate for Payer: Kaiser Permanente Commercial	$2,565.00
Rate for Payer: Kaiser Permanente Medicaid	$1,453.50
Rate for Payer: Kaiser Permanente Medicare	$2,166.00
Rate for Payer: MDX Hawaii PPO	$2,764.50
Rate for Payer: Ohana Health Plan Medicaid	$2,166.00
Rate for Payer: Ohana Health Plan Medicare	$2,166.00
Rate for Payer: UnitedHealthcare Medicare	$2,166.00
Rate for Payer: University Health Alliance Commercial	$1,596.00

SURFACE ART TIB 42-5121-008-10

Facility

$2,850.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$1,596.00
Max. Negotiated Rate	$2,764.50
Rate for Payer: Cash Price	$1,710.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,995.00
Rate for Payer: Health Management Network Commercial	$2,422.50
Rate for Payer: Kaiser Permanente Commercial	$2,565.00
Rate for Payer: MDX Hawaii PPO	$2,764.50
Rate for Payer: University Health Alliance Commercial	$1,596.00

SURFACE TIBIAL 42-5221-009-10

Facility

$2,850.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$1,596.00
Max. Negotiated Rate	$2,764.50
Rate for Payer: Cash Price	$1,710.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,995.00
Rate for Payer: Health Management Network Commercial	$2,422.50
Rate for Payer: Kaiser Permanente Commercial	$2,565.00
Rate for Payer: MDX Hawaii PPO	$2,764.50
Rate for Payer: University Health Alliance Commercial	$1,596.00

SURFACE TIBIAL 42-5221-009-10

Facility

$2,850.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$1,425.00
Max. Negotiated Rate	$2,764.50
Rate for Payer: AlohaCare Medicaid	$1,425.00
Rate for Payer: AlohaCare Medicare	$2,166.00
Rate for Payer: Cash Price	$1,710.00
Rate for Payer: Devoted Health Medicare	$2,394.00
Rate for Payer: Hawaii Medical Service Association Medicare	$2,166.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,995.00
Rate for Payer: Health Management Network Commercial	$2,422.50
Rate for Payer: Humana Medicare	$2,166.00
Rate for Payer: Kaiser Permanente Commercial	$2,565.00
Rate for Payer: Kaiser Permanente Medicaid	$1,453.50
Rate for Payer: Kaiser Permanente Medicare	$2,166.00
Rate for Payer: MDX Hawaii PPO	$2,764.50
Rate for Payer: Ohana Health Plan Medicaid	$2,166.00
Rate for Payer: Ohana Health Plan Medicare	$2,166.00
Rate for Payer: UnitedHealthcare Medicare	$2,166.00
Rate for Payer: University Health Alliance Commercial	$1,596.00

SURGICAL MESH/TISSUE WSM1015

Facility

$3,690.00

Service Code	HCPCS Q4166
Hospital Revenue Code	636
Min. Negotiated Rate	$20.85
Max. Negotiated Rate	$3,579.30
Rate for Payer: AlohaCare Medicaid	$1,845.00
Rate for Payer: AlohaCare Medicare	$2,804.40
Rate for Payer: Cash Price	$2,214.00
Rate for Payer: Cash Price	$2,214.00
Rate for Payer: Devoted Health Medicare	$3,099.60
Rate for Payer: Hawaii Medical Service Association ABD	$20.85
Rate for Payer: Hawaii Medical Service Association Commercial	$158.93
Rate for Payer: Hawaii Medical Service Association Medicare	$2,804.40
Rate for Payer: Hawaii Medical Service Association Non-ABD	$20.85
Rate for Payer: Hawaii Western Management Group Commercial	$3,505.50
Rate for Payer: Health Management Network Commercial	$3,136.50
Rate for Payer: Humana Medicare	$2,804.40
Rate for Payer: Kaiser Permanente Commercial	$3,321.00
Rate for Payer: Kaiser Permanente Medicaid	$1,881.90
Rate for Payer: Kaiser Permanente Medicare	$2,804.40
Rate for Payer: MDX Hawaii PPO	$3,579.30
Rate for Payer: Ohana Health Plan Medicaid	$2,804.40
Rate for Payer: Ohana Health Plan Medicare	$2,804.40
Rate for Payer: UnitedHealthcare Medicaid	$2,214.00
Rate for Payer: UnitedHealthcare Medicare	$2,804.40
Rate for Payer: University Health Alliance Commercial	$2,689.64

SURGICAL MESH/TISSUE WSM1015

Facility

$3,690.00

Service Code	HCPCS Q4166
Hospital Revenue Code	636
Min. Negotiated Rate	$3,136.50
Max. Negotiated Rate	$3,579.30
Rate for Payer: Cash Price	$2,214.00
Rate for Payer: Health Management Network Commercial	$3,136.50
Rate for Payer: Kaiser Permanente Commercial	$3,321.00
Rate for Payer: MDX Hawaii PPO	$3,579.30

SURGICAL MESH WSM0710

Facility

$2,050.00

Service Code	HCPCS Q4166
Hospital Revenue Code	636
Min. Negotiated Rate	$20.85
Max. Negotiated Rate	$1,988.50
Rate for Payer: AlohaCare Medicaid	$1,025.00
Rate for Payer: AlohaCare Medicare	$1,558.00
Rate for Payer: Cash Price	$1,230.00
Rate for Payer: Cash Price	$1,230.00
Rate for Payer: Devoted Health Medicare	$1,722.00
Rate for Payer: Hawaii Medical Service Association ABD	$20.85
Rate for Payer: Hawaii Medical Service Association Commercial	$158.93
Rate for Payer: Hawaii Medical Service Association Medicare	$1,558.00
Rate for Payer: Hawaii Medical Service Association Non-ABD	$20.85
Rate for Payer: Hawaii Western Management Group Commercial	$1,947.50
Rate for Payer: Health Management Network Commercial	$1,742.50
Rate for Payer: Humana Medicare	$1,558.00
Rate for Payer: Kaiser Permanente Commercial	$1,845.00
Rate for Payer: Kaiser Permanente Medicaid	$1,045.50
Rate for Payer: Kaiser Permanente Medicare	$1,558.00
Rate for Payer: MDX Hawaii PPO	$1,988.50
Rate for Payer: Ohana Health Plan Medicaid	$1,558.00
Rate for Payer: Ohana Health Plan Medicare	$1,558.00
Rate for Payer: UnitedHealthcare Medicaid	$1,230.00
Rate for Payer: UnitedHealthcare Medicare	$1,558.00
Rate for Payer: University Health Alliance Commercial	$1,494.24

SURGICAL MESH WSM0710

Facility

$2,050.00

Service Code	HCPCS Q4166
Hospital Revenue Code	636
Min. Negotiated Rate	$1,742.50
Max. Negotiated Rate	$1,988.50
Rate for Payer: Cash Price	$1,230.00
Rate for Payer: Health Management Network Commercial	$1,742.50
Rate for Payer: Kaiser Permanente Commercial	$1,845.00
Rate for Payer: MDX Hawaii PPO	$1,988.50

SURGICAL POST BRA LG M5001-L

Facility

$106.00

Hospital Revenue Code	272
Min. Negotiated Rate	$90.10
Max. Negotiated Rate	$102.82
Rate for Payer: Cash Price	$63.60
Rate for Payer: Health Management Network Commercial	$90.10
Rate for Payer: Kaiser Permanente Commercial	$95.40
Rate for Payer: MDX Hawaii PPO	$102.82

SURGICAL POST BRA LG M5001-L

Facility

$106.00

Hospital Revenue Code	272
Min. Negotiated Rate	$53.00
Max. Negotiated Rate	$102.82
Rate for Payer: AlohaCare Medicaid	$53.00
Rate for Payer: AlohaCare Medicare	$80.56
Rate for Payer: Cash Price	$63.60
Rate for Payer: Devoted Health Medicare	$89.04
Rate for Payer: Hawaii Medical Service Association Medicare	$80.56
Rate for Payer: Hawaii Western Management Group Commercial	$100.70
Rate for Payer: Health Management Network Commercial	$90.10
Rate for Payer: Humana Medicare	$80.56
Rate for Payer: Kaiser Permanente Commercial	$95.40
Rate for Payer: Kaiser Permanente Medicaid	$54.06
Rate for Payer: Kaiser Permanente Medicare	$80.56
Rate for Payer: MDX Hawaii PPO	$102.82
Rate for Payer: Ohana Health Plan Medicaid	$80.56
Rate for Payer: Ohana Health Plan Medicare	$80.56
Rate for Payer: UnitedHealthcare Medicare	$80.56
Rate for Payer: University Health Alliance Commercial	$77.26

SURGICAL POST BRA MED M5001-M

Facility

$106.00

Hospital Revenue Code	272
Min. Negotiated Rate	$53.00
Max. Negotiated Rate	$102.82
Rate for Payer: AlohaCare Medicaid	$53.00
Rate for Payer: AlohaCare Medicare	$80.56
Rate for Payer: Cash Price	$63.60
Rate for Payer: Devoted Health Medicare	$89.04
Rate for Payer: Hawaii Medical Service Association Medicare	$80.56
Rate for Payer: Hawaii Western Management Group Commercial	$100.70
Rate for Payer: Health Management Network Commercial	$90.10
Rate for Payer: Humana Medicare	$80.56
Rate for Payer: Kaiser Permanente Commercial	$95.40
Rate for Payer: Kaiser Permanente Medicaid	$54.06
Rate for Payer: Kaiser Permanente Medicare	$80.56
Rate for Payer: MDX Hawaii PPO	$102.82
Rate for Payer: Ohana Health Plan Medicaid	$80.56
Rate for Payer: Ohana Health Plan Medicare	$80.56
Rate for Payer: UnitedHealthcare Medicare	$80.56
Rate for Payer: University Health Alliance Commercial	$77.26

SURGICAL POST BRA MED M5001-M

Facility

$106.00

Hospital Revenue Code	272
Min. Negotiated Rate	$90.10
Max. Negotiated Rate	$102.82
Rate for Payer: Cash Price	$63.60
Rate for Payer: Health Management Network Commercial	$90.10
Rate for Payer: Kaiser Permanente Commercial	$95.40
Rate for Payer: MDX Hawaii PPO	$102.82

SURGICAL POST BRA XLG M5001-XL

Facility

$106.00

Hospital Revenue Code	272
Min. Negotiated Rate	$90.10
Max. Negotiated Rate	$102.82
Rate for Payer: Cash Price	$63.60
Rate for Payer: Health Management Network Commercial	$90.10
Rate for Payer: Kaiser Permanente Commercial	$95.40
Rate for Payer: MDX Hawaii PPO	$102.82

SURGICAL POST BRA XLG M5001-XL

Facility

$106.00

Hospital Revenue Code	272
Min. Negotiated Rate	$53.00
Max. Negotiated Rate	$102.82
Rate for Payer: AlohaCare Medicaid	$53.00
Rate for Payer: AlohaCare Medicare	$80.56
Rate for Payer: Cash Price	$63.60
Rate for Payer: Devoted Health Medicare	$89.04
Rate for Payer: Hawaii Medical Service Association Medicare	$80.56
Rate for Payer: Hawaii Western Management Group Commercial	$100.70
Rate for Payer: Health Management Network Commercial	$90.10
Rate for Payer: Humana Medicare	$80.56
Rate for Payer: Kaiser Permanente Commercial	$95.40
Rate for Payer: Kaiser Permanente Medicaid	$54.06
Rate for Payer: Kaiser Permanente Medicare	$80.56
Rate for Payer: MDX Hawaii PPO	$102.82
Rate for Payer: Ohana Health Plan Medicaid	$80.56
Rate for Payer: Ohana Health Plan Medicare	$80.56
Rate for Payer: UnitedHealthcare Medicare	$80.56
Rate for Payer: University Health Alliance Commercial	$77.26

SURGICEL APPLICATOR 3123SPEA

Facility

$133.00

Hospital Revenue Code	272
Min. Negotiated Rate	$66.50
Max. Negotiated Rate	$129.01
Rate for Payer: AlohaCare Medicaid	$66.50
Rate for Payer: AlohaCare Medicare	$101.08
Rate for Payer: Cash Price	$79.80
Rate for Payer: Devoted Health Medicare	$111.72
Rate for Payer: Hawaii Medical Service Association Medicare	$101.08
Rate for Payer: Hawaii Western Management Group Commercial	$126.35
Rate for Payer: Health Management Network Commercial	$113.05
Rate for Payer: Humana Medicare	$101.08
Rate for Payer: Kaiser Permanente Commercial	$119.70
Rate for Payer: Kaiser Permanente Medicaid	$67.83
Rate for Payer: Kaiser Permanente Medicare	$101.08
Rate for Payer: MDX Hawaii PPO	$129.01
Rate for Payer: Ohana Health Plan Medicaid	$101.08
Rate for Payer: Ohana Health Plan Medicare	$101.08
Rate for Payer: UnitedHealthcare Medicare	$101.08
Rate for Payer: University Health Alliance Commercial	$96.94

SURGICEL APPLICATOR 3123SPEA

Facility

$133.00

Hospital Revenue Code	272
Min. Negotiated Rate	$113.05
Max. Negotiated Rate	$129.01
Rate for Payer: Cash Price	$79.80
Rate for Payer: Health Management Network Commercial	$113.05
Rate for Payer: Kaiser Permanente Commercial	$119.70
Rate for Payer: MDX Hawaii PPO	$129.01

SURGICEL POWDER 3.0GM 3013SP

Facility

$2,248.00

Hospital Revenue Code	272
Min. Negotiated Rate	$1,910.80
Max. Negotiated Rate	$2,180.56
Rate for Payer: Cash Price	$1,348.80
Rate for Payer: Health Management Network Commercial	$1,910.80
Rate for Payer: Kaiser Permanente Commercial	$2,023.20
Rate for Payer: MDX Hawaii PPO	$2,180.56

SURGICEL POWDER 3.0GM 3013SP

Facility

$2,248.00

Hospital Revenue Code	272
Min. Negotiated Rate	$1,124.00
Max. Negotiated Rate	$2,180.56
Rate for Payer: AlohaCare Medicaid	$1,124.00
Rate for Payer: AlohaCare Medicare	$1,708.48
Rate for Payer: Cash Price	$1,348.80
Rate for Payer: Devoted Health Medicare	$1,888.32
Rate for Payer: Hawaii Medical Service Association Medicare	$1,708.48
Rate for Payer: Hawaii Western Management Group Commercial	$2,135.60
Rate for Payer: Health Management Network Commercial	$1,910.80
Rate for Payer: Humana Medicare	$1,708.48
Rate for Payer: Kaiser Permanente Commercial	$2,023.20
Rate for Payer: Kaiser Permanente Medicaid	$1,146.48
Rate for Payer: Kaiser Permanente Medicare	$1,708.48
Rate for Payer: MDX Hawaii PPO	$2,180.56
Rate for Payer: Ohana Health Plan Medicaid	$1,708.48
Rate for Payer: Ohana Health Plan Medicare	$1,708.48
Rate for Payer: UnitedHealthcare Medicare	$1,708.48
Rate for Payer: University Health Alliance Commercial	$1,638.57

SURGICEL SNOW 2X4IN 2082

Facility

$596.00

Hospital Revenue Code	272
Min. Negotiated Rate	$506.60
Max. Negotiated Rate	$578.12
Rate for Payer: Cash Price	$357.60
Rate for Payer: Health Management Network Commercial	$506.60
Rate for Payer: Kaiser Permanente Commercial	$536.40
Rate for Payer: MDX Hawaii PPO	$578.12

SURGICEL SNOW 2X4IN 2082

Facility

$596.00

Hospital Revenue Code	272
Min. Negotiated Rate	$298.00
Max. Negotiated Rate	$578.12
Rate for Payer: AlohaCare Medicaid	$298.00
Rate for Payer: AlohaCare Medicare	$452.96
Rate for Payer: Cash Price	$357.60
Rate for Payer: Devoted Health Medicare	$500.64
Rate for Payer: Hawaii Medical Service Association Medicare	$452.96
Rate for Payer: Hawaii Western Management Group Commercial	$566.20
Rate for Payer: Health Management Network Commercial	$506.60
Rate for Payer: Humana Medicare	$452.96
Rate for Payer: Kaiser Permanente Commercial	$536.40
Rate for Payer: Kaiser Permanente Medicaid	$303.96
Rate for Payer: Kaiser Permanente Medicare	$452.96
Rate for Payer: MDX Hawaii PPO	$578.12
Rate for Payer: Ohana Health Plan Medicaid	$452.96
Rate for Payer: Ohana Health Plan Medicare	$452.96
Rate for Payer: UnitedHealthcare Medicare	$452.96
Rate for Payer: University Health Alliance Commercial	$434.42

SURGICLIP PREMIUM

Facility

$215.00

Hospital Revenue Code	272
Min. Negotiated Rate	$107.50
Max. Negotiated Rate	$208.55
Rate for Payer: AlohaCare Medicaid	$107.50
Rate for Payer: AlohaCare Medicare	$163.40
Rate for Payer: Cash Price	$129.00
Rate for Payer: Devoted Health Medicare	$180.60
Rate for Payer: Hawaii Medical Service Association Medicare	$163.40
Rate for Payer: Hawaii Western Management Group Commercial	$204.25
Rate for Payer: Health Management Network Commercial	$182.75
Rate for Payer: Humana Medicare	$163.40
Rate for Payer: Kaiser Permanente Commercial	$193.50
Rate for Payer: Kaiser Permanente Medicaid	$109.65
Rate for Payer: Kaiser Permanente Medicare	$163.40
Rate for Payer: MDX Hawaii PPO	$208.55
Rate for Payer: Ohana Health Plan Medicaid	$163.40
Rate for Payer: Ohana Health Plan Medicare	$163.40
Rate for Payer: UnitedHealthcare Medicare	$163.40
Rate for Payer: University Health Alliance Commercial	$156.71

SURGICLIP PREMIUM

Facility

$215.00

Hospital Revenue Code	272
Min. Negotiated Rate	$182.75
Max. Negotiated Rate	$208.55
Rate for Payer: Cash Price	$129.00
Rate for Payer: Health Management Network Commercial	$182.75
Rate for Payer: Kaiser Permanente Commercial	$193.50
Rate for Payer: MDX Hawaii PPO	$208.55

Know your out-of-pocket cost for care.

All Charges