Honoka'a Hospital and Skilled Nursing Facility

All Charges

Charge

Type

Setting

Price

TEMAZEPAM 15 MG CAPSULE [7753]

Facility

$4.00

Service Code	NDC 50268077915
Hospital Revenue Code	250
Min. Negotiated Rate	$3.40
Max. Negotiated Rate	$3.88
Rate for Payer: Cash Price	$2.40
Rate for Payer: Health Management Network Commercial	$3.40
Rate for Payer: Kaiser Permanente Commercial	$3.60
Rate for Payer: MDX Hawaii PPO	$3.88

TEMNO ACT 20X15 BIOSPY

Facility

$234.00

Hospital Revenue Code	272
Min. Negotiated Rate	$198.90
Max. Negotiated Rate	$226.98
Rate for Payer: Cash Price	$140.40
Rate for Payer: Health Management Network Commercial	$198.90
Rate for Payer: Kaiser Permanente Commercial	$210.60
Rate for Payer: MDX Hawaii PPO	$226.98

TEMNO ACT 20X15 BIOSPY

Facility

$234.00

Hospital Revenue Code	272
Min. Negotiated Rate	$117.00
Max. Negotiated Rate	$226.98
Rate for Payer: AlohaCare Medicaid	$117.00
Rate for Payer: AlohaCare Medicare	$177.84
Rate for Payer: Cash Price	$140.40
Rate for Payer: Devoted Health Medicare	$196.56
Rate for Payer: Hawaii Medical Service Association Medicare	$177.84
Rate for Payer: Hawaii Western Management Group Commercial	$222.30
Rate for Payer: Health Management Network Commercial	$198.90
Rate for Payer: Humana Medicare	$177.84
Rate for Payer: Kaiser Permanente Commercial	$210.60
Rate for Payer: Kaiser Permanente Medicaid	$119.34
Rate for Payer: Kaiser Permanente Medicare	$177.84
Rate for Payer: MDX Hawaii PPO	$226.98
Rate for Payer: Ohana Health Plan Medicaid	$177.84
Rate for Payer: Ohana Health Plan Medicare	$177.84
Rate for Payer: UnitedHealthcare Medicare	$177.84
Rate for Payer: University Health Alliance Commercial	$170.56

TEMNO ACT 20X20 BIOSPY

Facility

$237.00

Hospital Revenue Code	272
Min. Negotiated Rate	$201.45
Max. Negotiated Rate	$229.89
Rate for Payer: Cash Price	$142.20
Rate for Payer: Health Management Network Commercial	$201.45
Rate for Payer: Kaiser Permanente Commercial	$213.30
Rate for Payer: MDX Hawaii PPO	$229.89

TEMNO ACT 20X20 BIOSPY

Facility

$237.00

Hospital Revenue Code	272
Min. Negotiated Rate	$118.50
Max. Negotiated Rate	$229.89
Rate for Payer: AlohaCare Medicaid	$118.50
Rate for Payer: AlohaCare Medicare	$180.12
Rate for Payer: Cash Price	$142.20
Rate for Payer: Devoted Health Medicare	$199.08
Rate for Payer: Hawaii Medical Service Association Medicare	$180.12
Rate for Payer: Hawaii Western Management Group Commercial	$225.15
Rate for Payer: Health Management Network Commercial	$201.45
Rate for Payer: Humana Medicare	$180.12
Rate for Payer: Kaiser Permanente Commercial	$213.30
Rate for Payer: Kaiser Permanente Medicaid	$120.87
Rate for Payer: Kaiser Permanente Medicare	$180.12
Rate for Payer: MDX Hawaii PPO	$229.89
Rate for Payer: Ohana Health Plan Medicaid	$180.12
Rate for Payer: Ohana Health Plan Medicare	$180.12
Rate for Payer: UnitedHealthcare Medicare	$180.12
Rate for Payer: University Health Alliance Commercial	$172.75

TEMNO ACT 22X15 BIOSPY

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

TEMNO ACT 22X15 BIOSPY

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

TEMPLATE CALCANEAL KIT M224

Facility

$977.00

Hospital Revenue Code	272
Min. Negotiated Rate	$830.45
Max. Negotiated Rate	$947.69
Rate for Payer: Cash Price	$586.20
Rate for Payer: Health Management Network Commercial	$830.45
Rate for Payer: Kaiser Permanente Commercial	$879.30
Rate for Payer: MDX Hawaii PPO	$947.69

TEMPLATE CALCANEAL KIT M224

Facility

$977.00

Hospital Revenue Code	272
Min. Negotiated Rate	$488.50
Max. Negotiated Rate	$947.69
Rate for Payer: AlohaCare Medicaid	$488.50
Rate for Payer: AlohaCare Medicare	$742.52
Rate for Payer: Cash Price	$586.20
Rate for Payer: Devoted Health Medicare	$820.68
Rate for Payer: Hawaii Medical Service Association Medicare	$742.52
Rate for Payer: Hawaii Western Management Group Commercial	$928.15
Rate for Payer: Health Management Network Commercial	$830.45
Rate for Payer: Humana Medicare	$742.52
Rate for Payer: Kaiser Permanente Commercial	$879.30
Rate for Payer: Kaiser Permanente Medicaid	$498.27
Rate for Payer: Kaiser Permanente Medicare	$742.52
Rate for Payer: MDX Hawaii PPO	$947.69
Rate for Payer: Ohana Health Plan Medicaid	$742.52
Rate for Payer: Ohana Health Plan Medicare	$742.52
Rate for Payer: UnitedHealthcare Medicare	$742.52
Rate for Payer: University Health Alliance Commercial	$712.14

TEMPLATE MINIRAIL KIT M225

Facility

$591.00

Hospital Revenue Code	272
Min. Negotiated Rate	$502.35
Max. Negotiated Rate	$573.27
Rate for Payer: Cash Price	$354.60
Rate for Payer: Health Management Network Commercial	$502.35
Rate for Payer: Kaiser Permanente Commercial	$531.90
Rate for Payer: MDX Hawaii PPO	$573.27

TEMPLATE MINIRAIL KIT M225

Facility

$591.00

Hospital Revenue Code	272
Min. Negotiated Rate	$295.50
Max. Negotiated Rate	$573.27
Rate for Payer: AlohaCare Medicaid	$295.50
Rate for Payer: AlohaCare Medicare	$449.16
Rate for Payer: Cash Price	$354.60
Rate for Payer: Devoted Health Medicare	$496.44
Rate for Payer: Hawaii Medical Service Association Medicare	$449.16
Rate for Payer: Hawaii Western Management Group Commercial	$561.45
Rate for Payer: Health Management Network Commercial	$502.35
Rate for Payer: Humana Medicare	$449.16
Rate for Payer: Kaiser Permanente Commercial	$531.90
Rate for Payer: Kaiser Permanente Medicaid	$301.41
Rate for Payer: Kaiser Permanente Medicare	$449.16
Rate for Payer: MDX Hawaii PPO	$573.27
Rate for Payer: Ohana Health Plan Medicaid	$449.16
Rate for Payer: Ohana Health Plan Medicare	$449.16
Rate for Payer: UnitedHealthcare Medicare	$449.16
Rate for Payer: University Health Alliance Commercial	$430.78

TENACIO ACCESSORY KIT

Facility

$2,970.00

Service Code	HCPCS C1813
Hospital Revenue Code	278
Min. Negotiated Rate	$1,663.20
Max. Negotiated Rate	$2,880.90
Rate for Payer: Cash Price	$1,782.00
Rate for Payer: Hawaii Western Management Group Commercial	$2,079.00
Rate for Payer: Health Management Network Commercial	$2,524.50
Rate for Payer: Kaiser Permanente Commercial	$2,673.00
Rate for Payer: MDX Hawaii PPO	$2,880.90
Rate for Payer: University Health Alliance Commercial	$1,663.20

TENACIO ACCESSORY KIT

Facility

$2,970.00

Service Code	HCPCS C1813
Hospital Revenue Code	278
Min. Negotiated Rate	$1,485.00
Max. Negotiated Rate	$2,880.90
Rate for Payer: AlohaCare Medicaid	$1,485.00
Rate for Payer: AlohaCare Medicare	$2,257.20
Rate for Payer: Cash Price	$1,782.00
Rate for Payer: Devoted Health Medicare	$2,494.80
Rate for Payer: Hawaii Medical Service Association Medicare	$2,257.20
Rate for Payer: Hawaii Western Management Group Commercial	$2,079.00
Rate for Payer: Health Management Network Commercial	$2,524.50
Rate for Payer: Humana Medicare	$2,257.20
Rate for Payer: Kaiser Permanente Commercial	$2,673.00
Rate for Payer: Kaiser Permanente Medicaid	$1,514.70
Rate for Payer: Kaiser Permanente Medicare	$2,257.20
Rate for Payer: MDX Hawaii PPO	$2,880.90
Rate for Payer: Ohana Health Plan Medicaid	$2,257.20
Rate for Payer: Ohana Health Plan Medicare	$2,257.20
Rate for Payer: UnitedHealthcare Medicare	$2,257.20
Rate for Payer: University Health Alliance Commercial	$1,663.20

TENDON ANCHOR 8 2504-1

Facility

$2,700.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,350.00
Max. Negotiated Rate	$2,619.00
Rate for Payer: AlohaCare Medicaid	$1,350.00
Rate for Payer: AlohaCare Medicare	$2,052.00
Rate for Payer: Cash Price	$1,620.00
Rate for Payer: Devoted Health Medicare	$2,268.00
Rate for Payer: Hawaii Medical Service Association Medicare	$2,052.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,890.00
Rate for Payer: Health Management Network Commercial	$2,295.00
Rate for Payer: Humana Medicare	$2,052.00
Rate for Payer: Kaiser Permanente Commercial	$2,430.00
Rate for Payer: Kaiser Permanente Medicaid	$1,377.00
Rate for Payer: Kaiser Permanente Medicare	$2,052.00
Rate for Payer: MDX Hawaii PPO	$2,619.00
Rate for Payer: Ohana Health Plan Medicaid	$2,052.00
Rate for Payer: Ohana Health Plan Medicare	$2,052.00
Rate for Payer: UnitedHealthcare Medicare	$2,052.00
Rate for Payer: University Health Alliance Commercial	$1,512.00

TENDON ANCHOR 8 2504-1

Facility

$2,700.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,512.00
Max. Negotiated Rate	$2,619.00
Rate for Payer: Cash Price	$1,620.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,890.00
Rate for Payer: Health Management Network Commercial	$2,295.00
Rate for Payer: Kaiser Permanente Commercial	$2,430.00
Rate for Payer: MDX Hawaii PPO	$2,619.00
Rate for Payer: University Health Alliance Commercial	$1,512.00

TENDON GRACILIS SSG-002

Facility

$2,350.00

Service Code	HCPCS C1762
Hospital Revenue Code	278
Min. Negotiated Rate	$1,316.00
Max. Negotiated Rate	$2,279.50
Rate for Payer: Cash Price	$1,410.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,645.00
Rate for Payer: Health Management Network Commercial	$1,997.50
Rate for Payer: Kaiser Permanente Commercial	$2,115.00
Rate for Payer: MDX Hawaii PPO	$2,279.50
Rate for Payer: University Health Alliance Commercial	$1,316.00

TENDON GRACILIS SSG-002

Facility

$2,350.00

Service Code	HCPCS C1762
Hospital Revenue Code	278
Min. Negotiated Rate	$1,175.00
Max. Negotiated Rate	$2,279.50
Rate for Payer: AlohaCare Medicaid	$1,175.00
Rate for Payer: AlohaCare Medicare	$1,786.00
Rate for Payer: Cash Price	$1,410.00
Rate for Payer: Devoted Health Medicare	$1,974.00
Rate for Payer: Hawaii Medical Service Association Medicare	$1,786.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,645.00
Rate for Payer: Health Management Network Commercial	$1,997.50
Rate for Payer: Humana Medicare	$1,786.00
Rate for Payer: Kaiser Permanente Commercial	$2,115.00
Rate for Payer: Kaiser Permanente Medicaid	$1,198.50
Rate for Payer: Kaiser Permanente Medicare	$1,786.00
Rate for Payer: MDX Hawaii PPO	$2,279.50
Rate for Payer: Ohana Health Plan Medicaid	$1,786.00
Rate for Payer: Ohana Health Plan Medicare	$1,786.00
Rate for Payer: UnitedHealthcare Medicare	$1,786.00
Rate for Payer: University Health Alliance Commercial	$1,316.00

TENDONITIS, MYOSITIS AND BURSITIS WITH MCC

Facility

$19,767.47

Service Code	MSDRG 557
Min. Negotiated Rate	$19,767.47
Max. Negotiated Rate	$19,767.47
Rate for Payer: Hawaii Medical Service Association Commercial	$19,767.47

TENDONITIS, MYOSITIS AND BURSITIS WITHOUT MCC

Facility

$19,767.47

Service Code	MSDRG 558
Min. Negotiated Rate	$19,767.47
Max. Negotiated Rate	$19,767.47
Rate for Payer: Hawaii Medical Service Association Commercial	$19,767.47

TENECTEPLASE 25 MG INTRAVENOUS SOLUTION [237629]

Facility

$10,457.00

Service Code	HCPCS J3101
Hospital Revenue Code	636
Min. Negotiated Rate	$171.94
Max. Negotiated Rate	$10,143.29
Rate for Payer: AlohaCare Medicaid	$5,228.50
Rate for Payer: AlohaCare Medicare	$7,947.32
Rate for Payer: Cash Price	$6,274.20
Rate for Payer: Cash Price	$6,274.20
Rate for Payer: Devoted Health Medicare	$8,783.88
Rate for Payer: Hawaii Medical Service Association ABD	$171.94
Rate for Payer: Hawaii Medical Service Association Commercial	$246.80
Rate for Payer: Hawaii Medical Service Association Medicare	$7,947.32
Rate for Payer: Hawaii Medical Service Association Non-ABD	$171.94
Rate for Payer: Hawaii Western Management Group Commercial	$9,934.15
Rate for Payer: Health Management Network Commercial	$8,888.45
Rate for Payer: Humana Medicare	$7,947.32
Rate for Payer: Kaiser Permanente Commercial	$9,411.30
Rate for Payer: Kaiser Permanente Medicaid	$5,333.07
Rate for Payer: Kaiser Permanente Medicare	$7,947.32
Rate for Payer: MDX Hawaii PPO	$10,143.29
Rate for Payer: Ohana Health Plan Medicaid	$7,947.32
Rate for Payer: Ohana Health Plan Medicare	$7,947.32
Rate for Payer: UnitedHealthcare Medicaid	$6,274.20
Rate for Payer: UnitedHealthcare Medicare	$7,947.32
Rate for Payer: University Health Alliance Commercial	$7,622.11

TENECTEPLASE 25 MG INTRAVENOUS SOLUTION [237629]

Facility

$10,457.00

Service Code	HCPCS J3101
Hospital Revenue Code	250
Min. Negotiated Rate	$8,888.45
Max. Negotiated Rate	$10,143.29
Rate for Payer: Cash Price	$6,274.20
Rate for Payer: Health Management Network Commercial	$8,888.45
Rate for Payer: Kaiser Permanente Commercial	$9,411.30
Rate for Payer: MDX Hawaii PPO	$10,143.29

TENECTEPLASE 50 MG INTRAVENOUS SOLUTION [206762]

Facility

$10,457.00

Service Code	HCPCS J3101
Hospital Revenue Code	636
Min. Negotiated Rate	$171.94
Max. Negotiated Rate	$10,143.29
Rate for Payer: AlohaCare Medicaid	$5,228.50
Rate for Payer: AlohaCare Medicare	$7,947.32
Rate for Payer: Cash Price	$6,274.20
Rate for Payer: Cash Price	$6,274.20
Rate for Payer: Devoted Health Medicare	$8,783.88
Rate for Payer: Hawaii Medical Service Association ABD	$171.94
Rate for Payer: Hawaii Medical Service Association Commercial	$246.80
Rate for Payer: Hawaii Medical Service Association Medicare	$7,947.32
Rate for Payer: Hawaii Medical Service Association Non-ABD	$171.94
Rate for Payer: Hawaii Western Management Group Commercial	$9,934.15
Rate for Payer: Health Management Network Commercial	$8,888.45
Rate for Payer: Humana Medicare	$7,947.32
Rate for Payer: Kaiser Permanente Commercial	$9,411.30
Rate for Payer: Kaiser Permanente Medicaid	$5,333.07
Rate for Payer: Kaiser Permanente Medicare	$7,947.32
Rate for Payer: MDX Hawaii PPO	$10,143.29
Rate for Payer: Ohana Health Plan Medicaid	$7,947.32
Rate for Payer: Ohana Health Plan Medicare	$7,947.32
Rate for Payer: UnitedHealthcare Medicaid	$6,274.20
Rate for Payer: UnitedHealthcare Medicare	$7,947.32
Rate for Payer: University Health Alliance Commercial	$7,622.11

TENECTEPLASE 50 MG INTRAVENOUS SOLUTION [206762]

Facility

$10,457.00

Service Code	HCPCS J3101
Hospital Revenue Code	250
Min. Negotiated Rate	$8,888.45
Max. Negotiated Rate	$10,143.29
Rate for Payer: Cash Price	$6,274.20
Rate for Payer: Health Management Network Commercial	$8,888.45
Rate for Payer: Kaiser Permanente Commercial	$9,411.30
Rate for Payer: MDX Hawaii PPO	$10,143.29

TENMO ACT 20X11 BIOPSY

Facility

$234.00

Hospital Revenue Code	272
Min. Negotiated Rate	$117.00
Max. Negotiated Rate	$226.98
Rate for Payer: AlohaCare Medicaid	$117.00
Rate for Payer: AlohaCare Medicare	$177.84
Rate for Payer: Cash Price	$140.40
Rate for Payer: Devoted Health Medicare	$196.56
Rate for Payer: Hawaii Medical Service Association Medicare	$177.84
Rate for Payer: Hawaii Western Management Group Commercial	$222.30
Rate for Payer: Health Management Network Commercial	$198.90
Rate for Payer: Humana Medicare	$177.84
Rate for Payer: Kaiser Permanente Commercial	$210.60
Rate for Payer: Kaiser Permanente Medicaid	$119.34
Rate for Payer: Kaiser Permanente Medicare	$177.84
Rate for Payer: MDX Hawaii PPO	$226.98
Rate for Payer: Ohana Health Plan Medicaid	$177.84
Rate for Payer: Ohana Health Plan Medicare	$177.84
Rate for Payer: UnitedHealthcare Medicare	$177.84
Rate for Payer: University Health Alliance Commercial	$170.56

TENMO ACT 20X11 BIOPSY

Facility

$234.00

Hospital Revenue Code	272
Min. Negotiated Rate	$198.90
Max. Negotiated Rate	$226.98
Rate for Payer: Cash Price	$140.40
Rate for Payer: Health Management Network Commercial	$198.90
Rate for Payer: Kaiser Permanente Commercial	$210.60
Rate for Payer: MDX Hawaii PPO	$226.98

Know your out-of-pocket cost for care.

All Charges