Honoka'a Hospital and Skilled Nursing Facility

All Charges

Charge

Type

Setting

Price

TIB STM 5 C L 42-5320-064-01

Facility

$2,600.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$1,300.00
Max. Negotiated Rate	$2,522.00
Rate for Payer: AlohaCare Medicaid	$1,300.00
Rate for Payer: AlohaCare Medicare	$1,976.00
Rate for Payer: Cash Price	$1,560.00
Rate for Payer: Devoted Health Medicare	$2,184.00
Rate for Payer: Hawaii Medical Service Association Medicare	$1,976.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,820.00
Rate for Payer: Health Management Network Commercial	$2,210.00
Rate for Payer: Humana Medicare	$1,976.00
Rate for Payer: Kaiser Permanente Commercial	$2,340.00
Rate for Payer: Kaiser Permanente Medicaid	$1,326.00
Rate for Payer: Kaiser Permanente Medicare	$1,976.00
Rate for Payer: MDX Hawaii PPO	$2,522.00
Rate for Payer: Ohana Health Plan Medicaid	$1,976.00
Rate for Payer: Ohana Health Plan Medicare	$1,976.00
Rate for Payer: UnitedHealthcare Medicare	$1,976.00
Rate for Payer: University Health Alliance Commercial	$1,456.00

TIB STM 5 C L 42-5320-064-01

Facility

$2,600.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$1,456.00
Max. Negotiated Rate	$2,522.00
Rate for Payer: Cash Price	$1,560.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,820.00
Rate for Payer: Health Management Network Commercial	$2,210.00
Rate for Payer: Kaiser Permanente Commercial	$2,340.00
Rate for Payer: MDX Hawaii PPO	$2,522.00
Rate for Payer: University Health Alliance Commercial	$1,456.00

TIB TRAY AA LEFT MEDIAL 159531

Facility

$2,400.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$2,328.00
Rate for Payer: AlohaCare Medicaid	$1,200.00
Rate for Payer: AlohaCare Medicare	$1,824.00
Rate for Payer: Cash Price	$1,440.00
Rate for Payer: Devoted Health Medicare	$2,016.00
Rate for Payer: Hawaii Medical Service Association Medicare	$1,824.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,680.00
Rate for Payer: Health Management Network Commercial	$2,040.00
Rate for Payer: Humana Medicare	$1,824.00
Rate for Payer: Kaiser Permanente Commercial	$2,160.00
Rate for Payer: Kaiser Permanente Medicaid	$1,224.00
Rate for Payer: Kaiser Permanente Medicare	$1,824.00
Rate for Payer: MDX Hawaii PPO	$2,328.00
Rate for Payer: Ohana Health Plan Medicaid	$1,824.00
Rate for Payer: Ohana Health Plan Medicare	$1,824.00
Rate for Payer: UnitedHealthcare Medicare	$1,824.00
Rate for Payer: University Health Alliance Commercial	$1,344.00

TIB TRAY AA LEFT MEDIAL 159531

Facility

$2,400.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$1,344.00
Max. Negotiated Rate	$2,328.00
Rate for Payer: Cash Price	$1,440.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,680.00
Rate for Payer: Health Management Network Commercial	$2,040.00
Rate for Payer: Kaiser Permanente Commercial	$2,160.00
Rate for Payer: MDX Hawaii PPO	$2,328.00
Rate for Payer: University Health Alliance Commercial	$1,344.00

TIB TRAY A RIGHT MEDIAL 154719

Facility

$2,400.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$1,344.00
Max. Negotiated Rate	$2,328.00
Rate for Payer: Cash Price	$1,440.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,680.00
Rate for Payer: Health Management Network Commercial	$2,040.00
Rate for Payer: Kaiser Permanente Commercial	$2,160.00
Rate for Payer: MDX Hawaii PPO	$2,328.00
Rate for Payer: University Health Alliance Commercial	$1,344.00

TIB TRAY A RIGHT MEDIAL 154719

Facility

$2,400.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$2,328.00
Rate for Payer: AlohaCare Medicaid	$1,200.00
Rate for Payer: AlohaCare Medicare	$1,824.00
Rate for Payer: Cash Price	$1,440.00
Rate for Payer: Devoted Health Medicare	$2,016.00
Rate for Payer: Hawaii Medical Service Association Medicare	$1,824.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,680.00
Rate for Payer: Health Management Network Commercial	$2,040.00
Rate for Payer: Humana Medicare	$1,824.00
Rate for Payer: Kaiser Permanente Commercial	$2,160.00
Rate for Payer: Kaiser Permanente Medicaid	$1,224.00
Rate for Payer: Kaiser Permanente Medicare	$1,824.00
Rate for Payer: MDX Hawaii PPO	$2,328.00
Rate for Payer: Ohana Health Plan Medicaid	$1,824.00
Rate for Payer: Ohana Health Plan Medicare	$1,824.00
Rate for Payer: UnitedHealthcare Medicare	$1,824.00
Rate for Payer: University Health Alliance Commercial	$1,344.00

TIB TRAY LEFT S3 02.07.1203L

Facility

$3,600.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$2,016.00
Max. Negotiated Rate	$3,492.00
Rate for Payer: Cash Price	$2,160.00
Rate for Payer: Hawaii Western Management Group Commercial	$2,520.00
Rate for Payer: Health Management Network Commercial	$3,060.00
Rate for Payer: Kaiser Permanente Commercial	$3,240.00
Rate for Payer: MDX Hawaii PPO	$3,492.00
Rate for Payer: University Health Alliance Commercial	$2,016.00

TIB TRAY LEFT S3 02.07.1203L

Facility

$3,600.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$1,800.00
Max. Negotiated Rate	$3,492.00
Rate for Payer: AlohaCare Medicaid	$1,800.00
Rate for Payer: AlohaCare Medicare	$2,736.00
Rate for Payer: Cash Price	$2,160.00
Rate for Payer: Devoted Health Medicare	$3,024.00
Rate for Payer: Hawaii Medical Service Association Medicare	$2,736.00
Rate for Payer: Hawaii Western Management Group Commercial	$2,520.00
Rate for Payer: Health Management Network Commercial	$3,060.00
Rate for Payer: Humana Medicare	$2,736.00
Rate for Payer: Kaiser Permanente Commercial	$3,240.00
Rate for Payer: Kaiser Permanente Medicaid	$1,836.00
Rate for Payer: Kaiser Permanente Medicare	$2,736.00
Rate for Payer: MDX Hawaii PPO	$3,492.00
Rate for Payer: Ohana Health Plan Medicaid	$2,736.00
Rate for Payer: Ohana Health Plan Medicare	$2,736.00
Rate for Payer: UnitedHealthcare Medicare	$2,736.00
Rate for Payer: University Health Alliance Commercial	$2,016.00

TICAGRELOR 60 MG TABLET [130191]

Facility

$28.00

Service Code	NDC 00186077660
Hospital Revenue Code	637
Min. Negotiated Rate	$14.00
Max. Negotiated Rate	$27.16
Rate for Payer: AlohaCare Medicaid	$14.00
Rate for Payer: AlohaCare Medicare	$21.28
Rate for Payer: Cash Price	$16.80
Rate for Payer: Devoted Health Medicare	$23.52
Rate for Payer: Hawaii Medical Service Association Medicare	$21.28
Rate for Payer: Hawaii Western Management Group Commercial	$26.60
Rate for Payer: Health Management Network Commercial	$23.80
Rate for Payer: Humana Medicare	$21.28
Rate for Payer: Kaiser Permanente Commercial	$25.20
Rate for Payer: Kaiser Permanente Medicaid	$14.28
Rate for Payer: Kaiser Permanente Medicare	$21.28
Rate for Payer: MDX Hawaii PPO	$27.16
Rate for Payer: Ohana Health Plan Medicaid	$21.28
Rate for Payer: Ohana Health Plan Medicare	$21.28
Rate for Payer: UnitedHealthcare Medicare	$21.28
Rate for Payer: University Health Alliance Commercial	$20.41

TICAGRELOR 60 MG TABLET [130191]

Facility

$28.00

Service Code	NDC 00186077660
Hospital Revenue Code	250
Min. Negotiated Rate	$23.80
Max. Negotiated Rate	$27.16
Rate for Payer: Cash Price	$16.80
Rate for Payer: Health Management Network Commercial	$23.80
Rate for Payer: Kaiser Permanente Commercial	$25.20
Rate for Payer: MDX Hawaii PPO	$27.16

TICAGRELOR 90 MG TABLET [110427]

Facility

$28.00

Service Code	NDC 00186077739
Hospital Revenue Code	637
Min. Negotiated Rate	$14.00
Max. Negotiated Rate	$27.16
Rate for Payer: AlohaCare Medicaid	$14.00
Rate for Payer: AlohaCare Medicare	$21.28
Rate for Payer: Cash Price	$16.80
Rate for Payer: Devoted Health Medicare	$23.52
Rate for Payer: Hawaii Medical Service Association Medicare	$21.28
Rate for Payer: Hawaii Western Management Group Commercial	$26.60
Rate for Payer: Health Management Network Commercial	$23.80
Rate for Payer: Humana Medicare	$21.28
Rate for Payer: Kaiser Permanente Commercial	$25.20
Rate for Payer: Kaiser Permanente Medicaid	$14.28
Rate for Payer: Kaiser Permanente Medicare	$21.28
Rate for Payer: MDX Hawaii PPO	$27.16
Rate for Payer: Ohana Health Plan Medicaid	$21.28
Rate for Payer: Ohana Health Plan Medicare	$21.28
Rate for Payer: UnitedHealthcare Medicare	$21.28
Rate for Payer: University Health Alliance Commercial	$20.41

TICAGRELOR 90 MG TABLET [110427]

Facility

$28.00

Service Code	NDC 00186077739
Hospital Revenue Code	250
Min. Negotiated Rate	$23.80
Max. Negotiated Rate	$27.16
Rate for Payer: Cash Price	$16.80
Rate for Payer: Health Management Network Commercial	$23.80
Rate for Payer: Kaiser Permanente Commercial	$25.20
Rate for Payer: MDX Hawaii PPO	$27.16

TI END CAP 0MM STRDRV T25

Facility

$900.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$504.00
Max. Negotiated Rate	$873.00
Rate for Payer: Cash Price	$540.00
Rate for Payer: Hawaii Western Management Group Commercial	$630.00
Rate for Payer: Health Management Network Commercial	$765.00
Rate for Payer: Kaiser Permanente Commercial	$810.00
Rate for Payer: MDX Hawaii PPO	$873.00
Rate for Payer: University Health Alliance Commercial	$504.00

TI END CAP 0MM STRDRV T25

Facility

$900.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$450.00
Max. Negotiated Rate	$873.00
Rate for Payer: AlohaCare Medicaid	$450.00
Rate for Payer: AlohaCare Medicare	$684.00
Rate for Payer: Cash Price	$540.00
Rate for Payer: Devoted Health Medicare	$756.00
Rate for Payer: Hawaii Medical Service Association Medicare	$684.00
Rate for Payer: Hawaii Western Management Group Commercial	$630.00
Rate for Payer: Health Management Network Commercial	$765.00
Rate for Payer: Humana Medicare	$684.00
Rate for Payer: Kaiser Permanente Commercial	$810.00
Rate for Payer: Kaiser Permanente Medicaid	$459.00
Rate for Payer: Kaiser Permanente Medicare	$684.00
Rate for Payer: MDX Hawaii PPO	$873.00
Rate for Payer: Ohana Health Plan Medicaid	$684.00
Rate for Payer: Ohana Health Plan Medicare	$684.00
Rate for Payer: UnitedHealthcare Medicare	$684.00
Rate for Payer: University Health Alliance Commercial	$504.00

TI END CAP 10MM STRDRV T25

Facility

$900.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$504.00
Max. Negotiated Rate	$873.00
Rate for Payer: Cash Price	$540.00
Rate for Payer: Hawaii Western Management Group Commercial	$630.00
Rate for Payer: Health Management Network Commercial	$765.00
Rate for Payer: Kaiser Permanente Commercial	$810.00
Rate for Payer: MDX Hawaii PPO	$873.00
Rate for Payer: University Health Alliance Commercial	$504.00

TI END CAP 10MM STRDRV T25

Facility

$900.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$450.00
Max. Negotiated Rate	$873.00
Rate for Payer: AlohaCare Medicaid	$450.00
Rate for Payer: AlohaCare Medicare	$684.00
Rate for Payer: Cash Price	$540.00
Rate for Payer: Devoted Health Medicare	$756.00
Rate for Payer: Hawaii Medical Service Association Medicare	$684.00
Rate for Payer: Hawaii Western Management Group Commercial	$630.00
Rate for Payer: Health Management Network Commercial	$765.00
Rate for Payer: Humana Medicare	$684.00
Rate for Payer: Kaiser Permanente Commercial	$810.00
Rate for Payer: Kaiser Permanente Medicaid	$459.00
Rate for Payer: Kaiser Permanente Medicare	$684.00
Rate for Payer: MDX Hawaii PPO	$873.00
Rate for Payer: Ohana Health Plan Medicaid	$684.00
Rate for Payer: Ohana Health Plan Medicare	$684.00
Rate for Payer: UnitedHealthcare Medicare	$684.00
Rate for Payer: University Health Alliance Commercial	$504.00

TI END CAP 15MM STRDRV T25

Facility

$900.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$450.00
Max. Negotiated Rate	$873.00
Rate for Payer: AlohaCare Medicaid	$450.00
Rate for Payer: AlohaCare Medicare	$684.00
Rate for Payer: Cash Price	$540.00
Rate for Payer: Devoted Health Medicare	$756.00
Rate for Payer: Hawaii Medical Service Association Medicare	$684.00
Rate for Payer: Hawaii Western Management Group Commercial	$630.00
Rate for Payer: Health Management Network Commercial	$765.00
Rate for Payer: Humana Medicare	$684.00
Rate for Payer: Kaiser Permanente Commercial	$810.00
Rate for Payer: Kaiser Permanente Medicaid	$459.00
Rate for Payer: Kaiser Permanente Medicare	$684.00
Rate for Payer: MDX Hawaii PPO	$873.00
Rate for Payer: Ohana Health Plan Medicaid	$684.00
Rate for Payer: Ohana Health Plan Medicare	$684.00
Rate for Payer: UnitedHealthcare Medicare	$684.00
Rate for Payer: University Health Alliance Commercial	$504.00

TI END CAP 15MM STRDRV T25

Facility

$900.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$504.00
Max. Negotiated Rate	$873.00
Rate for Payer: Cash Price	$540.00
Rate for Payer: Hawaii Western Management Group Commercial	$630.00
Rate for Payer: Health Management Network Commercial	$765.00
Rate for Payer: Kaiser Permanente Commercial	$810.00
Rate for Payer: MDX Hawaii PPO	$873.00
Rate for Payer: University Health Alliance Commercial	$504.00

TI END CAP 5MM STRDRV T25

Facility

$900.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$450.00
Max. Negotiated Rate	$873.00
Rate for Payer: AlohaCare Medicaid	$450.00
Rate for Payer: AlohaCare Medicare	$684.00
Rate for Payer: Cash Price	$540.00
Rate for Payer: Devoted Health Medicare	$756.00
Rate for Payer: Hawaii Medical Service Association Medicare	$684.00
Rate for Payer: Hawaii Western Management Group Commercial	$630.00
Rate for Payer: Health Management Network Commercial	$765.00
Rate for Payer: Humana Medicare	$684.00
Rate for Payer: Kaiser Permanente Commercial	$810.00
Rate for Payer: Kaiser Permanente Medicaid	$459.00
Rate for Payer: Kaiser Permanente Medicare	$684.00
Rate for Payer: MDX Hawaii PPO	$873.00
Rate for Payer: Ohana Health Plan Medicaid	$684.00
Rate for Payer: Ohana Health Plan Medicare	$684.00
Rate for Payer: UnitedHealthcare Medicare	$684.00
Rate for Payer: University Health Alliance Commercial	$504.00

TI END CAP 5MM STRDRV T25

Facility

$900.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$504.00
Max. Negotiated Rate	$873.00
Rate for Payer: Cash Price	$540.00
Rate for Payer: Hawaii Western Management Group Commercial	$630.00
Rate for Payer: Health Management Network Commercial	$765.00
Rate for Payer: Kaiser Permanente Commercial	$810.00
Rate for Payer: MDX Hawaii PPO	$873.00
Rate for Payer: University Health Alliance Commercial	$504.00

TI END CAP T40X0MM 04.003.000

Facility

$791.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$442.96
Max. Negotiated Rate	$767.27
Rate for Payer: Cash Price	$474.60
Rate for Payer: Hawaii Western Management Group Commercial	$553.70
Rate for Payer: Health Management Network Commercial	$672.35
Rate for Payer: Kaiser Permanente Commercial	$711.90
Rate for Payer: MDX Hawaii PPO	$767.27
Rate for Payer: University Health Alliance Commercial	$442.96

TI END CAP T40X0MM 04.003.000

Facility

$791.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$395.50
Max. Negotiated Rate	$767.27
Rate for Payer: AlohaCare Medicaid	$395.50
Rate for Payer: AlohaCare Medicare	$601.16
Rate for Payer: Cash Price	$474.60
Rate for Payer: Devoted Health Medicare	$664.44
Rate for Payer: Hawaii Medical Service Association Medicare	$601.16
Rate for Payer: Hawaii Western Management Group Commercial	$553.70
Rate for Payer: Health Management Network Commercial	$672.35
Rate for Payer: Humana Medicare	$601.16
Rate for Payer: Kaiser Permanente Commercial	$711.90
Rate for Payer: Kaiser Permanente Medicaid	$403.41
Rate for Payer: Kaiser Permanente Medicare	$601.16
Rate for Payer: MDX Hawaii PPO	$767.27
Rate for Payer: Ohana Health Plan Medicaid	$601.16
Rate for Payer: Ohana Health Plan Medicare	$601.16
Rate for Payer: UnitedHealthcare Medicare	$601.16
Rate for Payer: University Health Alliance Commercial	$442.96

TI END CAP T40X10MM 04.003.002

Facility

$791.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$442.96
Max. Negotiated Rate	$767.27
Rate for Payer: Cash Price	$474.60
Rate for Payer: Hawaii Western Management Group Commercial	$553.70
Rate for Payer: Health Management Network Commercial	$672.35
Rate for Payer: Kaiser Permanente Commercial	$711.90
Rate for Payer: MDX Hawaii PPO	$767.27
Rate for Payer: University Health Alliance Commercial	$442.96

TI END CAP T40X10MM 04.003.002

Facility

$791.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$395.50
Max. Negotiated Rate	$767.27
Rate for Payer: AlohaCare Medicaid	$395.50
Rate for Payer: AlohaCare Medicare	$601.16
Rate for Payer: Cash Price	$474.60
Rate for Payer: Devoted Health Medicare	$664.44
Rate for Payer: Hawaii Medical Service Association Medicare	$601.16
Rate for Payer: Hawaii Western Management Group Commercial	$553.70
Rate for Payer: Health Management Network Commercial	$672.35
Rate for Payer: Humana Medicare	$601.16
Rate for Payer: Kaiser Permanente Commercial	$711.90
Rate for Payer: Kaiser Permanente Medicaid	$403.41
Rate for Payer: Kaiser Permanente Medicare	$601.16
Rate for Payer: MDX Hawaii PPO	$767.27
Rate for Payer: Ohana Health Plan Medicaid	$601.16
Rate for Payer: Ohana Health Plan Medicare	$601.16
Rate for Payer: UnitedHealthcare Medicare	$601.16
Rate for Payer: University Health Alliance Commercial	$442.96

TI END CAP T40X15MM 04.003.003

Facility

$791.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$442.96
Max. Negotiated Rate	$767.27
Rate for Payer: Cash Price	$474.60
Rate for Payer: Hawaii Western Management Group Commercial	$553.70
Rate for Payer: Health Management Network Commercial	$672.35
Rate for Payer: Kaiser Permanente Commercial	$711.90
Rate for Payer: MDX Hawaii PPO	$767.27
Rate for Payer: University Health Alliance Commercial	$442.96

Know your out-of-pocket cost for care.

All Charges