Honoka'a Hospital and Skilled Nursing Facility

All Charges

Charge

Type

Setting

Price

TOTAL STABILIZER FEM 5512-F-40

Facility

$12,283.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$6,878.48
Max. Negotiated Rate	$11,914.51
Rate for Payer: Cash Price	$7,369.80
Rate for Payer: Hawaii Western Management Group Commercial	$8,598.10
Rate for Payer: Health Management Network Commercial	$10,440.55
Rate for Payer: Kaiser Permanente Commercial	$11,054.70
Rate for Payer: MDX Hawaii PPO	$11,914.51
Rate for Payer: University Health Alliance Commercial	$6,878.48

TOTAL STABILIZER FEM 5512-F-40

Facility

$12,283.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$6,141.50
Max. Negotiated Rate	$11,914.51
Rate for Payer: AlohaCare Medicaid	$6,141.50
Rate for Payer: AlohaCare Medicare	$9,335.08
Rate for Payer: Cash Price	$7,369.80
Rate for Payer: Devoted Health Medicare	$10,317.72
Rate for Payer: Hawaii Medical Service Association Medicare	$9,335.08
Rate for Payer: Hawaii Western Management Group Commercial	$8,598.10
Rate for Payer: Health Management Network Commercial	$10,440.55
Rate for Payer: Humana Medicare	$9,335.08
Rate for Payer: Kaiser Permanente Commercial	$11,054.70
Rate for Payer: Kaiser Permanente Medicaid	$6,264.33
Rate for Payer: Kaiser Permanente Medicare	$9,335.08
Rate for Payer: MDX Hawaii PPO	$11,914.51
Rate for Payer: Ohana Health Plan Medicaid	$9,335.08
Rate for Payer: Ohana Health Plan Medicare	$9,335.08
Rate for Payer: UnitedHealthcare Medicare	$9,335.08
Rate for Payer: University Health Alliance Commercial	$6,878.48

TOURN CUFF STERILE 12X3 15-110

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

TOURN CUFF STERILE 12X3 15-110

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

TOURN CUFF STERILE 18X4 15-130

Facility

$187.00

Hospital Revenue Code	272
Min. Negotiated Rate	$93.50
Max. Negotiated Rate	$181.39
Rate for Payer: AlohaCare Medicaid	$93.50
Rate for Payer: AlohaCare Medicare	$142.12
Rate for Payer: Cash Price	$112.20
Rate for Payer: Devoted Health Medicare	$157.08
Rate for Payer: Hawaii Medical Service Association Medicare	$142.12
Rate for Payer: Hawaii Western Management Group Commercial	$177.65
Rate for Payer: Health Management Network Commercial	$158.95
Rate for Payer: Humana Medicare	$142.12
Rate for Payer: Kaiser Permanente Commercial	$168.30
Rate for Payer: Kaiser Permanente Medicaid	$95.37
Rate for Payer: Kaiser Permanente Medicare	$142.12
Rate for Payer: MDX Hawaii PPO	$181.39
Rate for Payer: Ohana Health Plan Medicaid	$142.12
Rate for Payer: Ohana Health Plan Medicare	$142.12
Rate for Payer: UnitedHealthcare Medicare	$142.12
Rate for Payer: University Health Alliance Commercial	$136.30

TOURN CUFF STERILE 18X4 15-130

Facility

$187.00

Hospital Revenue Code	272
Min. Negotiated Rate	$158.95
Max. Negotiated Rate	$181.39
Rate for Payer: Cash Price	$112.20
Rate for Payer: Health Management Network Commercial	$158.95
Rate for Payer: Kaiser Permanente Commercial	$168.30
Rate for Payer: MDX Hawaii PPO	$181.39

TOURN CUFF STERILE 24X4 15-140

Facility

$195.00

Hospital Revenue Code	272
Min. Negotiated Rate	$97.50
Max. Negotiated Rate	$189.15
Rate for Payer: AlohaCare Medicaid	$97.50
Rate for Payer: AlohaCare Medicare	$148.20
Rate for Payer: Cash Price	$117.00
Rate for Payer: Devoted Health Medicare	$163.80
Rate for Payer: Hawaii Medical Service Association Medicare	$148.20
Rate for Payer: Hawaii Western Management Group Commercial	$185.25
Rate for Payer: Health Management Network Commercial	$165.75
Rate for Payer: Humana Medicare	$148.20
Rate for Payer: Kaiser Permanente Commercial	$175.50
Rate for Payer: Kaiser Permanente Medicaid	$99.45
Rate for Payer: Kaiser Permanente Medicare	$148.20
Rate for Payer: MDX Hawaii PPO	$189.15
Rate for Payer: Ohana Health Plan Medicaid	$148.20
Rate for Payer: Ohana Health Plan Medicare	$148.20
Rate for Payer: UnitedHealthcare Medicare	$148.20
Rate for Payer: University Health Alliance Commercial	$142.14

TOURN CUFF STERILE 24X4 15-140

Facility

$195.00

Hospital Revenue Code	272
Min. Negotiated Rate	$165.75
Max. Negotiated Rate	$189.15
Rate for Payer: Cash Price	$117.00
Rate for Payer: Health Management Network Commercial	$165.75
Rate for Payer: Kaiser Permanente Commercial	$175.50
Rate for Payer: MDX Hawaii PPO	$189.15

TOURN CUFF STERILE 30X5 15-150

Facility

$225.00

Hospital Revenue Code	272
Min. Negotiated Rate	$112.50
Max. Negotiated Rate	$218.25
Rate for Payer: AlohaCare Medicaid	$112.50
Rate for Payer: AlohaCare Medicare	$171.00
Rate for Payer: Cash Price	$135.00
Rate for Payer: Devoted Health Medicare	$189.00
Rate for Payer: Hawaii Medical Service Association Medicare	$171.00
Rate for Payer: Hawaii Western Management Group Commercial	$213.75
Rate for Payer: Health Management Network Commercial	$191.25
Rate for Payer: Humana Medicare	$171.00
Rate for Payer: Kaiser Permanente Commercial	$202.50
Rate for Payer: Kaiser Permanente Medicaid	$114.75
Rate for Payer: Kaiser Permanente Medicare	$171.00
Rate for Payer: MDX Hawaii PPO	$218.25
Rate for Payer: Ohana Health Plan Medicaid	$171.00
Rate for Payer: Ohana Health Plan Medicare	$171.00
Rate for Payer: UnitedHealthcare Medicare	$171.00
Rate for Payer: University Health Alliance Commercial	$164.00

TOURN CUFF STERILE 30X5 15-150

Facility

$225.00

Hospital Revenue Code	272
Min. Negotiated Rate	$191.25
Max. Negotiated Rate	$218.25
Rate for Payer: Cash Price	$135.00
Rate for Payer: Health Management Network Commercial	$191.25
Rate for Payer: Kaiser Permanente Commercial	$202.50
Rate for Payer: MDX Hawaii PPO	$218.25

TOURN CUFF STERILE 34X5 15-160

Facility

$238.00

Hospital Revenue Code	272
Min. Negotiated Rate	$119.00
Max. Negotiated Rate	$230.86
Rate for Payer: AlohaCare Medicaid	$119.00
Rate for Payer: AlohaCare Medicare	$180.88
Rate for Payer: Cash Price	$142.80
Rate for Payer: Devoted Health Medicare	$199.92
Rate for Payer: Hawaii Medical Service Association Medicare	$180.88
Rate for Payer: Hawaii Western Management Group Commercial	$226.10
Rate for Payer: Health Management Network Commercial	$202.30
Rate for Payer: Humana Medicare	$180.88
Rate for Payer: Kaiser Permanente Commercial	$214.20
Rate for Payer: Kaiser Permanente Medicaid	$121.38
Rate for Payer: Kaiser Permanente Medicare	$180.88
Rate for Payer: MDX Hawaii PPO	$230.86
Rate for Payer: Ohana Health Plan Medicaid	$180.88
Rate for Payer: Ohana Health Plan Medicare	$180.88
Rate for Payer: UnitedHealthcare Medicare	$180.88
Rate for Payer: University Health Alliance Commercial	$173.48

TOURN CUFF STERILE 34X5 15-160

Facility

$238.00

Hospital Revenue Code	272
Min. Negotiated Rate	$202.30
Max. Negotiated Rate	$230.86
Rate for Payer: Cash Price	$142.80
Rate for Payer: Health Management Network Commercial	$202.30
Rate for Payer: Kaiser Permanente Commercial	$214.20
Rate for Payer: MDX Hawaii PPO	$230.86

TOURNIQUET 12IN

Facility

$94.00

Hospital Revenue Code	272
Min. Negotiated Rate	$79.90
Max. Negotiated Rate	$91.18
Rate for Payer: Cash Price	$56.40
Rate for Payer: Health Management Network Commercial	$79.90
Rate for Payer: Kaiser Permanente Commercial	$84.60
Rate for Payer: MDX Hawaii PPO	$91.18

TOURNIQUET 12IN

Facility

$94.00

Hospital Revenue Code	272
Min. Negotiated Rate	$47.00
Max. Negotiated Rate	$91.18
Rate for Payer: AlohaCare Medicaid	$47.00
Rate for Payer: AlohaCare Medicare	$71.44
Rate for Payer: Cash Price	$56.40
Rate for Payer: Devoted Health Medicare	$78.96
Rate for Payer: Hawaii Medical Service Association Medicare	$71.44
Rate for Payer: Hawaii Western Management Group Commercial	$89.30
Rate for Payer: Health Management Network Commercial	$79.90
Rate for Payer: Humana Medicare	$71.44
Rate for Payer: Kaiser Permanente Commercial	$84.60
Rate for Payer: Kaiser Permanente Medicaid	$47.94
Rate for Payer: Kaiser Permanente Medicare	$71.44
Rate for Payer: MDX Hawaii PPO	$91.18
Rate for Payer: Ohana Health Plan Medicaid	$71.44
Rate for Payer: Ohana Health Plan Medicare	$71.44
Rate for Payer: UnitedHealthcare Medicare	$71.44
Rate for Payer: University Health Alliance Commercial	$68.52

TOURNIQUET 18" 5921-218-135

Facility

$107.00

Hospital Revenue Code	272
Min. Negotiated Rate	$90.95
Max. Negotiated Rate	$103.79
Rate for Payer: Cash Price	$64.20
Rate for Payer: Health Management Network Commercial	$90.95
Rate for Payer: Kaiser Permanente Commercial	$96.30
Rate for Payer: MDX Hawaii PPO	$103.79

TOURNIQUET 18" 5921-218-135

Facility

$107.00

Hospital Revenue Code	272
Min. Negotiated Rate	$53.50
Max. Negotiated Rate	$103.79
Rate for Payer: AlohaCare Medicaid	$53.50
Rate for Payer: AlohaCare Medicare	$81.32
Rate for Payer: Cash Price	$64.20
Rate for Payer: Devoted Health Medicare	$89.88
Rate for Payer: Hawaii Medical Service Association Medicare	$81.32
Rate for Payer: Hawaii Western Management Group Commercial	$101.65
Rate for Payer: Health Management Network Commercial	$90.95
Rate for Payer: Humana Medicare	$81.32
Rate for Payer: Kaiser Permanente Commercial	$96.30
Rate for Payer: Kaiser Permanente Medicaid	$54.57
Rate for Payer: Kaiser Permanente Medicare	$81.32
Rate for Payer: MDX Hawaii PPO	$103.79
Rate for Payer: Ohana Health Plan Medicaid	$81.32
Rate for Payer: Ohana Health Plan Medicare	$81.32
Rate for Payer: UnitedHealthcare Medicare	$81.32
Rate for Payer: University Health Alliance Commercial	$77.99

TOURNIQUET 30" 5921-030-135

Facility

$55.00

Hospital Revenue Code	272
Min. Negotiated Rate	$27.50
Max. Negotiated Rate	$53.35
Rate for Payer: AlohaCare Medicaid	$27.50
Rate for Payer: AlohaCare Medicare	$41.80
Rate for Payer: Cash Price	$33.00
Rate for Payer: Devoted Health Medicare	$46.20
Rate for Payer: Hawaii Medical Service Association Medicare	$41.80
Rate for Payer: Hawaii Western Management Group Commercial	$52.25
Rate for Payer: Health Management Network Commercial	$46.75
Rate for Payer: Humana Medicare	$41.80
Rate for Payer: Kaiser Permanente Commercial	$49.50
Rate for Payer: Kaiser Permanente Medicaid	$28.05
Rate for Payer: Kaiser Permanente Medicare	$41.80
Rate for Payer: MDX Hawaii PPO	$53.35
Rate for Payer: Ohana Health Plan Medicaid	$41.80
Rate for Payer: Ohana Health Plan Medicare	$41.80
Rate for Payer: UnitedHealthcare Medicare	$41.80
Rate for Payer: University Health Alliance Commercial	$40.09

TOURNIQUET 30" 5921-030-135

Facility

$55.00

Hospital Revenue Code	272
Min. Negotiated Rate	$46.75
Max. Negotiated Rate	$53.35
Rate for Payer: Cash Price	$33.00
Rate for Payer: Health Management Network Commercial	$46.75
Rate for Payer: Kaiser Permanente Commercial	$49.50
Rate for Payer: MDX Hawaii PPO	$53.35

TOURNIQUET 34" 5921-034-135

Facility

$139.00

Hospital Revenue Code	272
Min. Negotiated Rate	$118.15
Max. Negotiated Rate	$134.83
Rate for Payer: Cash Price	$83.40
Rate for Payer: Health Management Network Commercial	$118.15
Rate for Payer: Kaiser Permanente Commercial	$125.10
Rate for Payer: MDX Hawaii PPO	$134.83

TOURNIQUET 34" 5921-034-135

Facility

$139.00

Hospital Revenue Code	272
Min. Negotiated Rate	$69.50
Max. Negotiated Rate	$134.83
Rate for Payer: AlohaCare Medicaid	$69.50
Rate for Payer: AlohaCare Medicare	$105.64
Rate for Payer: Cash Price	$83.40
Rate for Payer: Devoted Health Medicare	$116.76
Rate for Payer: Hawaii Medical Service Association Medicare	$105.64
Rate for Payer: Hawaii Western Management Group Commercial	$132.05
Rate for Payer: Health Management Network Commercial	$118.15
Rate for Payer: Humana Medicare	$105.64
Rate for Payer: Kaiser Permanente Commercial	$125.10
Rate for Payer: Kaiser Permanente Medicaid	$70.89
Rate for Payer: Kaiser Permanente Medicare	$105.64
Rate for Payer: MDX Hawaii PPO	$134.83
Rate for Payer: Ohana Health Plan Medicaid	$105.64
Rate for Payer: Ohana Health Plan Medicare	$105.64
Rate for Payer: UnitedHealthcare Medicare	$105.64
Rate for Payer: University Health Alliance Commercial	$101.32

TOURNIQUET 44IN

Facility

$127.00

Hospital Revenue Code	272
Min. Negotiated Rate	$107.95
Max. Negotiated Rate	$123.19
Rate for Payer: Cash Price	$76.20
Rate for Payer: Health Management Network Commercial	$107.95
Rate for Payer: Kaiser Permanente Commercial	$114.30
Rate for Payer: MDX Hawaii PPO	$123.19

TOURNIQUET 44IN

Facility

$127.00

Hospital Revenue Code	272
Min. Negotiated Rate	$63.50
Max. Negotiated Rate	$123.19
Rate for Payer: AlohaCare Medicaid	$63.50
Rate for Payer: AlohaCare Medicare	$96.52
Rate for Payer: Cash Price	$76.20
Rate for Payer: Devoted Health Medicare	$106.68
Rate for Payer: Hawaii Medical Service Association Medicare	$96.52
Rate for Payer: Hawaii Western Management Group Commercial	$120.65
Rate for Payer: Health Management Network Commercial	$107.95
Rate for Payer: Humana Medicare	$96.52
Rate for Payer: Kaiser Permanente Commercial	$114.30
Rate for Payer: Kaiser Permanente Medicaid	$64.77
Rate for Payer: Kaiser Permanente Medicare	$96.52
Rate for Payer: MDX Hawaii PPO	$123.19
Rate for Payer: Ohana Health Plan Medicaid	$96.52
Rate for Payer: Ohana Health Plan Medicare	$96.52
Rate for Payer: UnitedHealthcare Medicare	$96.52
Rate for Payer: University Health Alliance Commercial	$92.57

TOURNIQUET CUFF

Facility

$94.00

Hospital Revenue Code	272
Min. Negotiated Rate	$47.00
Max. Negotiated Rate	$91.18
Rate for Payer: AlohaCare Medicaid	$47.00
Rate for Payer: AlohaCare Medicare	$71.44
Rate for Payer: Cash Price	$56.40
Rate for Payer: Devoted Health Medicare	$78.96
Rate for Payer: Hawaii Medical Service Association Medicare	$71.44
Rate for Payer: Hawaii Western Management Group Commercial	$89.30
Rate for Payer: Health Management Network Commercial	$79.90
Rate for Payer: Humana Medicare	$71.44
Rate for Payer: Kaiser Permanente Commercial	$84.60
Rate for Payer: Kaiser Permanente Medicaid	$47.94
Rate for Payer: Kaiser Permanente Medicare	$71.44
Rate for Payer: MDX Hawaii PPO	$91.18
Rate for Payer: Ohana Health Plan Medicaid	$71.44
Rate for Payer: Ohana Health Plan Medicare	$71.44
Rate for Payer: UnitedHealthcare Medicare	$71.44
Rate for Payer: University Health Alliance Commercial	$68.52

TOURNIQUET CUFF

Facility

$94.00

Hospital Revenue Code	272
Min. Negotiated Rate	$79.90
Max. Negotiated Rate	$91.18
Rate for Payer: Cash Price	$56.40
Rate for Payer: Health Management Network Commercial	$79.90
Rate for Payer: Kaiser Permanente Commercial	$84.60
Rate for Payer: MDX Hawaii PPO	$91.18

TOURNQ NS 18X4 5921-218-135NS

Facility

$107.00

Hospital Revenue Code	272
Min. Negotiated Rate	$53.50
Max. Negotiated Rate	$103.79
Rate for Payer: AlohaCare Medicaid	$53.50
Rate for Payer: AlohaCare Medicare	$81.32
Rate for Payer: Cash Price	$64.20
Rate for Payer: Devoted Health Medicare	$89.88
Rate for Payer: Hawaii Medical Service Association Medicare	$81.32
Rate for Payer: Hawaii Western Management Group Commercial	$101.65
Rate for Payer: Health Management Network Commercial	$90.95
Rate for Payer: Humana Medicare	$81.32
Rate for Payer: Kaiser Permanente Commercial	$96.30
Rate for Payer: Kaiser Permanente Medicaid	$54.57
Rate for Payer: Kaiser Permanente Medicare	$81.32
Rate for Payer: MDX Hawaii PPO	$103.79
Rate for Payer: Ohana Health Plan Medicaid	$81.32
Rate for Payer: Ohana Health Plan Medicare	$81.32
Rate for Payer: UnitedHealthcare Medicare	$81.32
Rate for Payer: University Health Alliance Commercial	$77.99

Know your out-of-pocket cost for care.

All Charges