Honoka'a Hospital and Skilled Nursing Facility

All Charges

Charge

Type

Setting

Price

SURGICLIP PREMIUM LG

Facility

$207.00

Hospital Revenue Code	272
Min. Negotiated Rate	$103.50
Max. Negotiated Rate	$200.79
Rate for Payer: AlohaCare Medicaid	$103.50
Rate for Payer: AlohaCare Medicare	$157.32
Rate for Payer: Cash Price	$124.20
Rate for Payer: Devoted Health Medicare	$173.88
Rate for Payer: Hawaii Medical Service Association Medicare	$157.32
Rate for Payer: Hawaii Western Management Group Commercial	$196.65
Rate for Payer: Health Management Network Commercial	$175.95
Rate for Payer: Humana Medicare	$157.32
Rate for Payer: Kaiser Permanente Commercial	$186.30
Rate for Payer: Kaiser Permanente Medicaid	$105.57
Rate for Payer: Kaiser Permanente Medicare	$157.32
Rate for Payer: MDX Hawaii PPO	$200.79
Rate for Payer: Ohana Health Plan Medicaid	$157.32
Rate for Payer: Ohana Health Plan Medicare	$157.32
Rate for Payer: UnitedHealthcare Medicare	$157.32
Rate for Payer: University Health Alliance Commercial	$150.88

SURGICLIP PREMIUM LG

Facility

$207.00

Hospital Revenue Code	272
Min. Negotiated Rate	$175.95
Max. Negotiated Rate	$200.79
Rate for Payer: Cash Price	$124.20
Rate for Payer: Health Management Network Commercial	$175.95
Rate for Payer: Kaiser Permanente Commercial	$186.30
Rate for Payer: MDX Hawaii PPO	$200.79

SURGICLIP PREMIUM SM

Facility

$240.00

Hospital Revenue Code	272
Min. Negotiated Rate	$204.00
Max. Negotiated Rate	$232.80
Rate for Payer: Cash Price	$144.00
Rate for Payer: Health Management Network Commercial	$204.00
Rate for Payer: Kaiser Permanente Commercial	$216.00
Rate for Payer: MDX Hawaii PPO	$232.80

SURGICLIP PREMIUM SM

Facility

$240.00

Hospital Revenue Code	272
Min. Negotiated Rate	$120.00
Max. Negotiated Rate	$232.80
Rate for Payer: AlohaCare Medicaid	$120.00
Rate for Payer: AlohaCare Medicare	$182.40
Rate for Payer: Cash Price	$144.00
Rate for Payer: Devoted Health Medicare	$201.60
Rate for Payer: Hawaii Medical Service Association Medicare	$182.40
Rate for Payer: Hawaii Western Management Group Commercial	$228.00
Rate for Payer: Health Management Network Commercial	$204.00
Rate for Payer: Humana Medicare	$182.40
Rate for Payer: Kaiser Permanente Commercial	$216.00
Rate for Payer: Kaiser Permanente Medicaid	$122.40
Rate for Payer: Kaiser Permanente Medicare	$182.40
Rate for Payer: MDX Hawaii PPO	$232.80
Rate for Payer: Ohana Health Plan Medicaid	$182.40
Rate for Payer: Ohana Health Plan Medicare	$182.40
Rate for Payer: UnitedHealthcare Medicare	$182.40
Rate for Payer: University Health Alliance Commercial	$174.94

SURGIFOAM SPONGE 8X12.5

Facility

$170.00

Hospital Revenue Code	272
Min. Negotiated Rate	$144.50
Max. Negotiated Rate	$164.90
Rate for Payer: Cash Price	$102.00
Rate for Payer: Health Management Network Commercial	$144.50
Rate for Payer: Kaiser Permanente Commercial	$153.00
Rate for Payer: MDX Hawaii PPO	$164.90

SURGIFOAM SPONGE 8X12.5

Facility

$170.00

Hospital Revenue Code	272
Min. Negotiated Rate	$85.00
Max. Negotiated Rate	$164.90
Rate for Payer: AlohaCare Medicaid	$85.00
Rate for Payer: AlohaCare Medicare	$129.20
Rate for Payer: Cash Price	$102.00
Rate for Payer: Devoted Health Medicare	$142.80
Rate for Payer: Hawaii Medical Service Association Medicare	$129.20
Rate for Payer: Hawaii Western Management Group Commercial	$161.50
Rate for Payer: Health Management Network Commercial	$144.50
Rate for Payer: Humana Medicare	$129.20
Rate for Payer: Kaiser Permanente Commercial	$153.00
Rate for Payer: Kaiser Permanente Medicaid	$86.70
Rate for Payer: Kaiser Permanente Medicare	$129.20
Rate for Payer: MDX Hawaii PPO	$164.90
Rate for Payer: Ohana Health Plan Medicaid	$129.20
Rate for Payer: Ohana Health Plan Medicare	$129.20
Rate for Payer: UnitedHealthcare Medicare	$129.20
Rate for Payer: University Health Alliance Commercial	$123.91

SURGIMEND PRS 8X16 606-004-108

Facility

$5,888.00

Service Code	HCPCS C9358
Hospital Revenue Code	278
Min. Negotiated Rate	$3,297.28
Max. Negotiated Rate	$5,711.36
Rate for Payer: Cash Price	$3,532.80
Rate for Payer: Hawaii Western Management Group Commercial	$4,121.60
Rate for Payer: Health Management Network Commercial	$5,004.80
Rate for Payer: Kaiser Permanente Commercial	$5,299.20
Rate for Payer: MDX Hawaii PPO	$5,711.36
Rate for Payer: University Health Alliance Commercial	$3,297.28

SURGIMEND PRS 8X16 606-004-108

Facility

$5,888.00

Service Code	HCPCS C9358
Hospital Revenue Code	278
Min. Negotiated Rate	$2,944.00
Max. Negotiated Rate	$5,711.36
Rate for Payer: AlohaCare Medicaid	$2,944.00
Rate for Payer: AlohaCare Medicare	$4,474.88
Rate for Payer: Cash Price	$3,532.80
Rate for Payer: Devoted Health Medicare	$4,945.92
Rate for Payer: Hawaii Medical Service Association Medicare	$4,474.88
Rate for Payer: Hawaii Western Management Group Commercial	$4,121.60
Rate for Payer: Health Management Network Commercial	$5,004.80
Rate for Payer: Humana Medicare	$4,474.88
Rate for Payer: Kaiser Permanente Commercial	$5,299.20
Rate for Payer: Kaiser Permanente Medicaid	$3,002.88
Rate for Payer: Kaiser Permanente Medicare	$4,474.88
Rate for Payer: MDX Hawaii PPO	$5,711.36
Rate for Payer: Ohana Health Plan Medicaid	$4,474.88
Rate for Payer: Ohana Health Plan Medicare	$4,474.88
Rate for Payer: UnitedHealthcare Medicare	$4,474.88
Rate for Payer: University Health Alliance Commercial	$3,297.28

SURGIMEND PRS THIN 606-004-104

Facility

$10,350.00

Service Code	HCPCS C9358
Hospital Revenue Code	278
Min. Negotiated Rate	$5,175.00
Max. Negotiated Rate	$10,039.50
Rate for Payer: AlohaCare Medicaid	$5,175.00
Rate for Payer: AlohaCare Medicare	$7,866.00
Rate for Payer: Cash Price	$6,210.00
Rate for Payer: Devoted Health Medicare	$8,694.00
Rate for Payer: Hawaii Medical Service Association Medicare	$7,866.00
Rate for Payer: Hawaii Western Management Group Commercial	$7,245.00
Rate for Payer: Health Management Network Commercial	$8,797.50
Rate for Payer: Humana Medicare	$7,866.00
Rate for Payer: Kaiser Permanente Commercial	$9,315.00
Rate for Payer: Kaiser Permanente Medicaid	$5,278.50
Rate for Payer: Kaiser Permanente Medicare	$7,866.00
Rate for Payer: MDX Hawaii PPO	$10,039.50
Rate for Payer: Ohana Health Plan Medicaid	$7,866.00
Rate for Payer: Ohana Health Plan Medicare	$7,866.00
Rate for Payer: UnitedHealthcare Medicare	$7,866.00
Rate for Payer: University Health Alliance Commercial	$5,796.00

SURGIMEND PRS THIN 606-004-104

Facility

$10,350.00

Service Code	HCPCS C9358
Hospital Revenue Code	278
Min. Negotiated Rate	$5,796.00
Max. Negotiated Rate	$10,039.50
Rate for Payer: Cash Price	$6,210.00
Rate for Payer: Hawaii Western Management Group Commercial	$7,245.00
Rate for Payer: Health Management Network Commercial	$8,797.50
Rate for Payer: Kaiser Permanente Commercial	$9,315.00
Rate for Payer: MDX Hawaii PPO	$10,039.50
Rate for Payer: University Health Alliance Commercial	$5,796.00

SUT CHROMIC ENDO LOOP #0

Facility

$91.00

Hospital Revenue Code	272
Min. Negotiated Rate	$77.35
Max. Negotiated Rate	$88.27
Rate for Payer: Cash Price	$54.60
Rate for Payer: Health Management Network Commercial	$77.35
Rate for Payer: Kaiser Permanente Commercial	$81.90
Rate for Payer: MDX Hawaii PPO	$88.27

SUT CHROMIC ENDO LOOP #0

Facility

$91.00

Hospital Revenue Code	272
Min. Negotiated Rate	$45.50
Max. Negotiated Rate	$88.27
Rate for Payer: AlohaCare Medicaid	$45.50
Rate for Payer: AlohaCare Medicare	$69.16
Rate for Payer: Cash Price	$54.60
Rate for Payer: Devoted Health Medicare	$76.44
Rate for Payer: Hawaii Medical Service Association Medicare	$69.16
Rate for Payer: Hawaii Western Management Group Commercial	$86.45
Rate for Payer: Health Management Network Commercial	$77.35
Rate for Payer: Humana Medicare	$69.16
Rate for Payer: Kaiser Permanente Commercial	$81.90
Rate for Payer: Kaiser Permanente Medicaid	$46.41
Rate for Payer: Kaiser Permanente Medicare	$69.16
Rate for Payer: MDX Hawaii PPO	$88.27
Rate for Payer: Ohana Health Plan Medicaid	$69.16
Rate for Payer: Ohana Health Plan Medicare	$69.16
Rate for Payer: UnitedHealthcare Medicare	$69.16
Rate for Payer: University Health Alliance Commercial	$66.33

SUT CT CLOSURE SYSTEM

Facility

$590.00

Hospital Revenue Code	272
Min. Negotiated Rate	$295.00
Max. Negotiated Rate	$572.30
Rate for Payer: AlohaCare Medicaid	$295.00
Rate for Payer: AlohaCare Medicare	$448.40
Rate for Payer: Cash Price	$354.00
Rate for Payer: Devoted Health Medicare	$495.60
Rate for Payer: Hawaii Medical Service Association Medicare	$448.40
Rate for Payer: Hawaii Western Management Group Commercial	$560.50
Rate for Payer: Health Management Network Commercial	$501.50
Rate for Payer: Humana Medicare	$448.40
Rate for Payer: Kaiser Permanente Commercial	$531.00
Rate for Payer: Kaiser Permanente Medicaid	$300.90
Rate for Payer: Kaiser Permanente Medicare	$448.40
Rate for Payer: MDX Hawaii PPO	$572.30
Rate for Payer: Ohana Health Plan Medicaid	$448.40
Rate for Payer: Ohana Health Plan Medicare	$448.40
Rate for Payer: UnitedHealthcare Medicare	$448.40
Rate for Payer: University Health Alliance Commercial	$430.05

SUT CT CLOSURE SYSTEM

Facility

$590.00

Hospital Revenue Code	272
Min. Negotiated Rate	$501.50
Max. Negotiated Rate	$572.30
Rate for Payer: Cash Price	$354.00
Rate for Payer: Health Management Network Commercial	$501.50
Rate for Payer: Kaiser Permanente Commercial	$531.00
Rate for Payer: MDX Hawaii PPO	$572.30

SUT ENDO 2-0 POLYSORB 48IN

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

SUT ENDO 2-0 POLYSORB 48IN

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

SUTLASSO CURVE LT AR-4068-25TL

Facility

$551.00

Hospital Revenue Code	272
Min. Negotiated Rate	$468.35
Max. Negotiated Rate	$534.47
Rate for Payer: Cash Price	$330.60
Rate for Payer: Health Management Network Commercial	$468.35
Rate for Payer: Kaiser Permanente Commercial	$495.90
Rate for Payer: MDX Hawaii PPO	$534.47

SUTLASSO CURVE LT AR-4068-25TL

Facility

$551.00

Hospital Revenue Code	272
Min. Negotiated Rate	$275.50
Max. Negotiated Rate	$534.47
Rate for Payer: AlohaCare Medicaid	$275.50
Rate for Payer: AlohaCare Medicare	$418.76
Rate for Payer: Cash Price	$330.60
Rate for Payer: Devoted Health Medicare	$462.84
Rate for Payer: Hawaii Medical Service Association Medicare	$418.76
Rate for Payer: Hawaii Western Management Group Commercial	$523.45
Rate for Payer: Health Management Network Commercial	$468.35
Rate for Payer: Humana Medicare	$418.76
Rate for Payer: Kaiser Permanente Commercial	$495.90
Rate for Payer: Kaiser Permanente Medicaid	$281.01
Rate for Payer: Kaiser Permanente Medicare	$418.76
Rate for Payer: MDX Hawaii PPO	$534.47
Rate for Payer: Ohana Health Plan Medicaid	$418.76
Rate for Payer: Ohana Health Plan Medicare	$418.76
Rate for Payer: UnitedHealthcare Medicare	$418.76
Rate for Payer: University Health Alliance Commercial	$401.62

SUT LIGASURE PDS ENDOLOOP

Facility

$600.00

Hospital Revenue Code	272
Min. Negotiated Rate	$300.00
Max. Negotiated Rate	$582.00
Rate for Payer: AlohaCare Medicaid	$300.00
Rate for Payer: AlohaCare Medicare	$456.00
Rate for Payer: Cash Price	$360.00
Rate for Payer: Devoted Health Medicare	$504.00
Rate for Payer: Hawaii Medical Service Association Medicare	$456.00
Rate for Payer: Hawaii Western Management Group Commercial	$570.00
Rate for Payer: Health Management Network Commercial	$510.00
Rate for Payer: Humana Medicare	$456.00
Rate for Payer: Kaiser Permanente Commercial	$540.00
Rate for Payer: Kaiser Permanente Medicaid	$306.00
Rate for Payer: Kaiser Permanente Medicare	$456.00
Rate for Payer: MDX Hawaii PPO	$582.00
Rate for Payer: Ohana Health Plan Medicaid	$456.00
Rate for Payer: Ohana Health Plan Medicare	$456.00
Rate for Payer: UnitedHealthcare Medicare	$456.00
Rate for Payer: University Health Alliance Commercial	$437.34

SUT LIGASURE PDS ENDOLOOP

Facility

$600.00

Hospital Revenue Code	272
Min. Negotiated Rate	$510.00
Max. Negotiated Rate	$582.00
Rate for Payer: Cash Price	$360.00
Rate for Payer: Health Management Network Commercial	$510.00
Rate for Payer: Kaiser Permanente Commercial	$540.00
Rate for Payer: MDX Hawaii PPO	$582.00

SUT POLYSORB ENDO LOOP #0

Facility

$136.00

Hospital Revenue Code	272
Min. Negotiated Rate	$68.00
Max. Negotiated Rate	$131.92
Rate for Payer: AlohaCare Medicaid	$68.00
Rate for Payer: AlohaCare Medicare	$103.36
Rate for Payer: Cash Price	$81.60
Rate for Payer: Devoted Health Medicare	$114.24
Rate for Payer: Hawaii Medical Service Association Medicare	$103.36
Rate for Payer: Hawaii Western Management Group Commercial	$129.20
Rate for Payer: Health Management Network Commercial	$115.60
Rate for Payer: Humana Medicare	$103.36
Rate for Payer: Kaiser Permanente Commercial	$122.40
Rate for Payer: Kaiser Permanente Medicaid	$69.36
Rate for Payer: Kaiser Permanente Medicare	$103.36
Rate for Payer: MDX Hawaii PPO	$131.92
Rate for Payer: Ohana Health Plan Medicaid	$103.36
Rate for Payer: Ohana Health Plan Medicare	$103.36
Rate for Payer: UnitedHealthcare Medicare	$103.36
Rate for Payer: University Health Alliance Commercial	$99.13

SUT POLYSORB ENDO LOOP #0

Facility

$136.00

Hospital Revenue Code	272
Min. Negotiated Rate	$115.60
Max. Negotiated Rate	$131.92
Rate for Payer: Cash Price	$81.60
Rate for Payer: Health Management Network Commercial	$115.60
Rate for Payer: Kaiser Permanente Commercial	$122.40
Rate for Payer: MDX Hawaii PPO	$131.92

SUTURE ANCHOR 2.4X8.5MM

Facility

$1,562.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$874.72
Max. Negotiated Rate	$1,515.14
Rate for Payer: Cash Price	$937.20
Rate for Payer: Hawaii Western Management Group Commercial	$1,093.40
Rate for Payer: Health Management Network Commercial	$1,327.70
Rate for Payer: Kaiser Permanente Commercial	$1,405.80
Rate for Payer: MDX Hawaii PPO	$1,515.14
Rate for Payer: University Health Alliance Commercial	$874.72

SUTURE ANCHOR 2.4X8.5MM

Facility

$1,562.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$781.00
Max. Negotiated Rate	$1,515.14
Rate for Payer: AlohaCare Medicaid	$781.00
Rate for Payer: AlohaCare Medicare	$1,187.12
Rate for Payer: Cash Price	$937.20
Rate for Payer: Devoted Health Medicare	$1,312.08
Rate for Payer: Hawaii Medical Service Association Medicare	$1,187.12
Rate for Payer: Hawaii Western Management Group Commercial	$1,093.40
Rate for Payer: Health Management Network Commercial	$1,327.70
Rate for Payer: Humana Medicare	$1,187.12
Rate for Payer: Kaiser Permanente Commercial	$1,405.80
Rate for Payer: Kaiser Permanente Medicaid	$796.62
Rate for Payer: Kaiser Permanente Medicare	$1,187.12
Rate for Payer: MDX Hawaii PPO	$1,515.14
Rate for Payer: Ohana Health Plan Medicaid	$1,187.12
Rate for Payer: Ohana Health Plan Medicare	$1,187.12
Rate for Payer: UnitedHealthcare Medicare	$1,187.12
Rate for Payer: University Health Alliance Commercial	$874.72

SUTURE ANCHOR 4.75 72203704

Facility

$1,663.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$831.50
Max. Negotiated Rate	$1,613.11
Rate for Payer: AlohaCare Medicaid	$831.50
Rate for Payer: AlohaCare Medicare	$1,263.88
Rate for Payer: Cash Price	$997.80
Rate for Payer: Devoted Health Medicare	$1,396.92
Rate for Payer: Hawaii Medical Service Association Medicare	$1,263.88
Rate for Payer: Hawaii Western Management Group Commercial	$1,164.10
Rate for Payer: Health Management Network Commercial	$1,413.55
Rate for Payer: Humana Medicare	$1,263.88
Rate for Payer: Kaiser Permanente Commercial	$1,496.70
Rate for Payer: Kaiser Permanente Medicaid	$848.13
Rate for Payer: Kaiser Permanente Medicare	$1,263.88
Rate for Payer: MDX Hawaii PPO	$1,613.11
Rate for Payer: Ohana Health Plan Medicaid	$1,263.88
Rate for Payer: Ohana Health Plan Medicare	$1,263.88
Rate for Payer: UnitedHealthcare Medicare	$1,263.88
Rate for Payer: University Health Alliance Commercial	$931.28

Know your out-of-pocket cost for care.

All Charges