Honoka'a Hospital and Skilled Nursing Facility

All Charges

Charge

Type

Setting

Price

TROPICAMIDE 0.5 % EYE DROPS [8249]

Facility

$94.00

Service Code	NDC 61314035401
Hospital Revenue Code	637
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

TROPICAMIDE 0.5 % EYE DROPS [8249]

Facility

$94.00

Service Code	NDC 61314035401
Hospital Revenue Code	250
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

TROPICAMIDE 1 % EYE DROPS [8250]

Facility

$125.00

Service Code	NDC 70069012101
Hospital Revenue Code	637
Min. Negotiated Rate	$62.50
Max. Negotiated Rate	$121.25
Rate for Payer: AlohaCare Medicaid	$62.50
Rate for Payer: AlohaCare Medicare	$95.00
Rate for Payer: Cash Price	$75.00
Rate for Payer: Devoted Health Medicare	$105.00
Rate for Payer: Hawaii Medical Service Association Medicare	$95.00
Rate for Payer: Hawaii Western Management Group Commercial	$118.75
Rate for Payer: Health Management Network Commercial	$106.25
Rate for Payer: Humana Medicare	$95.00
Rate for Payer: Kaiser Permanente Commercial	$112.50
Rate for Payer: Kaiser Permanente Medicaid	$63.75
Rate for Payer: Kaiser Permanente Medicare	$95.00
Rate for Payer: MDX Hawaii PPO	$121.25
Rate for Payer: Ohana Health Plan Medicaid	$95.00
Rate for Payer: Ohana Health Plan Medicare	$95.00
Rate for Payer: UnitedHealthcare Medicare	$95.00
Rate for Payer: University Health Alliance Commercial	$91.11

TROPICAMIDE 1 % EYE DROPS [8250]

Facility

$125.00

Service Code	NDC 70069012101
Hospital Revenue Code	250
Min. Negotiated Rate	$106.25
Max. Negotiated Rate	$121.25
Rate for Payer: Cash Price	$75.00
Rate for Payer: Health Management Network Commercial	$106.25
Rate for Payer: Kaiser Permanente Commercial	$112.50
Rate for Payer: MDX Hawaii PPO	$121.25

TRUSELECT STRAIGHT 021X130

Facility

$2,025.00

Service Code	HCPCS C1887
Hospital Revenue Code	272
Min. Negotiated Rate	$1,012.50
Max. Negotiated Rate	$1,964.25
Rate for Payer: AlohaCare Medicaid	$1,012.50
Rate for Payer: AlohaCare Medicare	$1,539.00
Rate for Payer: Cash Price	$1,215.00
Rate for Payer: Devoted Health Medicare	$1,701.00
Rate for Payer: Hawaii Medical Service Association Medicare	$1,539.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,923.75
Rate for Payer: Health Management Network Commercial	$1,721.25
Rate for Payer: Humana Medicare	$1,539.00
Rate for Payer: Kaiser Permanente Commercial	$1,822.50
Rate for Payer: Kaiser Permanente Medicaid	$1,032.75
Rate for Payer: Kaiser Permanente Medicare	$1,539.00
Rate for Payer: MDX Hawaii PPO	$1,964.25
Rate for Payer: Ohana Health Plan Medicaid	$1,539.00
Rate for Payer: Ohana Health Plan Medicare	$1,539.00
Rate for Payer: UnitedHealthcare Medicare	$1,539.00
Rate for Payer: University Health Alliance Commercial	$1,476.02

TRUSELECT STRAIGHT 021X130

Facility

$2,025.00

Service Code	HCPCS C1887
Hospital Revenue Code	272
Min. Negotiated Rate	$1,721.25
Max. Negotiated Rate	$1,964.25
Rate for Payer: Cash Price	$1,215.00
Rate for Payer: Health Management Network Commercial	$1,721.25
Rate for Payer: Kaiser Permanente Commercial	$1,822.50
Rate for Payer: MDX Hawaii PPO	$1,964.25

TTKNIFE ELECTROSURGCAL KD-640L

Facility

$2,110.00

Hospital Revenue Code	272
Min. Negotiated Rate	$1,793.50
Max. Negotiated Rate	$2,046.70
Rate for Payer: Cash Price	$1,266.00
Rate for Payer: Health Management Network Commercial	$1,793.50
Rate for Payer: Kaiser Permanente Commercial	$1,899.00
Rate for Payer: MDX Hawaii PPO	$2,046.70

TTKNIFE ELECTROSURGCAL KD-640L

Facility

$2,110.00

Hospital Revenue Code	272
Min. Negotiated Rate	$1,055.00
Max. Negotiated Rate	$2,046.70
Rate for Payer: AlohaCare Medicaid	$1,055.00
Rate for Payer: AlohaCare Medicare	$1,603.60
Rate for Payer: Cash Price	$1,266.00
Rate for Payer: Devoted Health Medicare	$1,772.40
Rate for Payer: Hawaii Medical Service Association Medicare	$1,603.60
Rate for Payer: Hawaii Western Management Group Commercial	$2,004.50
Rate for Payer: Health Management Network Commercial	$1,793.50
Rate for Payer: Humana Medicare	$1,603.60
Rate for Payer: Kaiser Permanente Commercial	$1,899.00
Rate for Payer: Kaiser Permanente Medicaid	$1,076.10
Rate for Payer: Kaiser Permanente Medicare	$1,603.60
Rate for Payer: MDX Hawaii PPO	$2,046.70
Rate for Payer: Ohana Health Plan Medicaid	$1,603.60
Rate for Payer: Ohana Health Plan Medicare	$1,603.60
Rate for Payer: UnitedHealthcare Medicare	$1,603.60
Rate for Payer: University Health Alliance Commercial	$1,537.98

TUBE 16F ENFIT GASTRO

Facility

$140.00

Hospital Revenue Code	272
Min. Negotiated Rate	$119.00
Max. Negotiated Rate	$135.80
Rate for Payer: Cash Price	$84.00
Rate for Payer: Health Management Network Commercial	$119.00
Rate for Payer: Kaiser Permanente Commercial	$126.00
Rate for Payer: MDX Hawaii PPO	$135.80

TUBE 16F ENFIT GASTRO

Facility

$140.00

Hospital Revenue Code	272
Min. Negotiated Rate	$70.00
Max. Negotiated Rate	$135.80
Rate for Payer: AlohaCare Medicaid	$70.00
Rate for Payer: AlohaCare Medicare	$106.40
Rate for Payer: Cash Price	$84.00
Rate for Payer: Devoted Health Medicare	$117.60
Rate for Payer: Hawaii Medical Service Association Medicare	$106.40
Rate for Payer: Hawaii Western Management Group Commercial	$133.00
Rate for Payer: Health Management Network Commercial	$119.00
Rate for Payer: Humana Medicare	$106.40
Rate for Payer: Kaiser Permanente Commercial	$126.00
Rate for Payer: Kaiser Permanente Medicaid	$71.40
Rate for Payer: Kaiser Permanente Medicare	$106.40
Rate for Payer: MDX Hawaii PPO	$135.80
Rate for Payer: Ohana Health Plan Medicaid	$106.40
Rate for Payer: Ohana Health Plan Medicare	$106.40
Rate for Payer: UnitedHealthcare Medicare	$106.40
Rate for Payer: University Health Alliance Commercial	$102.05

TUBE 18FR ENFIT GASTRO

Facility

$140.00

Hospital Revenue Code	272
Min. Negotiated Rate	$119.00
Max. Negotiated Rate	$135.80
Rate for Payer: Cash Price	$84.00
Rate for Payer: Health Management Network Commercial	$119.00
Rate for Payer: Kaiser Permanente Commercial	$126.00
Rate for Payer: MDX Hawaii PPO	$135.80

TUBE 18FR ENFIT GASTRO

Facility

$140.00

Hospital Revenue Code	272
Min. Negotiated Rate	$70.00
Max. Negotiated Rate	$135.80
Rate for Payer: AlohaCare Medicaid	$70.00
Rate for Payer: AlohaCare Medicare	$106.40
Rate for Payer: Cash Price	$84.00
Rate for Payer: Devoted Health Medicare	$117.60
Rate for Payer: Hawaii Medical Service Association Medicare	$106.40
Rate for Payer: Hawaii Western Management Group Commercial	$133.00
Rate for Payer: Health Management Network Commercial	$119.00
Rate for Payer: Humana Medicare	$106.40
Rate for Payer: Kaiser Permanente Commercial	$126.00
Rate for Payer: Kaiser Permanente Medicaid	$71.40
Rate for Payer: Kaiser Permanente Medicare	$106.40
Rate for Payer: MDX Hawaii PPO	$135.80
Rate for Payer: Ohana Health Plan Medicaid	$106.40
Rate for Payer: Ohana Health Plan Medicare	$106.40
Rate for Payer: UnitedHealthcare Medicare	$106.40
Rate for Payer: University Health Alliance Commercial	$102.05

TUBE 20FR ENFIT GASTRO

Facility

$140.00

Hospital Revenue Code	272
Min. Negotiated Rate	$70.00
Max. Negotiated Rate	$135.80
Rate for Payer: AlohaCare Medicaid	$70.00
Rate for Payer: AlohaCare Medicare	$106.40
Rate for Payer: Cash Price	$84.00
Rate for Payer: Devoted Health Medicare	$117.60
Rate for Payer: Hawaii Medical Service Association Medicare	$106.40
Rate for Payer: Hawaii Western Management Group Commercial	$133.00
Rate for Payer: Health Management Network Commercial	$119.00
Rate for Payer: Humana Medicare	$106.40
Rate for Payer: Kaiser Permanente Commercial	$126.00
Rate for Payer: Kaiser Permanente Medicaid	$71.40
Rate for Payer: Kaiser Permanente Medicare	$106.40
Rate for Payer: MDX Hawaii PPO	$135.80
Rate for Payer: Ohana Health Plan Medicaid	$106.40
Rate for Payer: Ohana Health Plan Medicare	$106.40
Rate for Payer: UnitedHealthcare Medicare	$106.40
Rate for Payer: University Health Alliance Commercial	$102.05

TUBE 20FR ENFIT GASTRO

Facility

$140.00

Hospital Revenue Code	272
Min. Negotiated Rate	$119.00
Max. Negotiated Rate	$135.80
Rate for Payer: Cash Price	$84.00
Rate for Payer: Health Management Network Commercial	$119.00
Rate for Payer: Kaiser Permanente Commercial	$126.00
Rate for Payer: MDX Hawaii PPO	$135.80

TUBE CHEST THALQUIK 10F

Facility

$732.00

Service Code	HCPCS C1729
Hospital Revenue Code	272
Min. Negotiated Rate	$622.20
Max. Negotiated Rate	$710.04
Rate for Payer: Cash Price	$439.20
Rate for Payer: Health Management Network Commercial	$622.20
Rate for Payer: Kaiser Permanente Commercial	$658.80
Rate for Payer: MDX Hawaii PPO	$710.04

TUBE CHEST THALQUIK 10F

Facility

$732.00

Service Code	HCPCS C1729
Hospital Revenue Code	272
Min. Negotiated Rate	$366.00
Max. Negotiated Rate	$710.04
Rate for Payer: AlohaCare Medicaid	$366.00
Rate for Payer: AlohaCare Medicare	$556.32
Rate for Payer: Cash Price	$439.20
Rate for Payer: Devoted Health Medicare	$614.88
Rate for Payer: Hawaii Medical Service Association Medicare	$556.32
Rate for Payer: Hawaii Western Management Group Commercial	$695.40
Rate for Payer: Health Management Network Commercial	$622.20
Rate for Payer: Humana Medicare	$556.32
Rate for Payer: Kaiser Permanente Commercial	$658.80
Rate for Payer: Kaiser Permanente Medicaid	$373.32
Rate for Payer: Kaiser Permanente Medicare	$556.32
Rate for Payer: MDX Hawaii PPO	$710.04
Rate for Payer: Ohana Health Plan Medicaid	$556.32
Rate for Payer: Ohana Health Plan Medicare	$556.32
Rate for Payer: UnitedHealthcare Medicare	$556.32
Rate for Payer: University Health Alliance Commercial	$533.55

TUBE CHEST THALQUIK 8F

Facility

$678.00

Service Code	HCPCS C1729
Hospital Revenue Code	272
Min. Negotiated Rate	$339.00
Max. Negotiated Rate	$657.66
Rate for Payer: AlohaCare Medicaid	$339.00
Rate for Payer: AlohaCare Medicare	$515.28
Rate for Payer: Cash Price	$406.80
Rate for Payer: Devoted Health Medicare	$569.52
Rate for Payer: Hawaii Medical Service Association Medicare	$515.28
Rate for Payer: Hawaii Western Management Group Commercial	$644.10
Rate for Payer: Health Management Network Commercial	$576.30
Rate for Payer: Humana Medicare	$515.28
Rate for Payer: Kaiser Permanente Commercial	$610.20
Rate for Payer: Kaiser Permanente Medicaid	$345.78
Rate for Payer: Kaiser Permanente Medicare	$515.28
Rate for Payer: MDX Hawaii PPO	$657.66
Rate for Payer: Ohana Health Plan Medicaid	$515.28
Rate for Payer: Ohana Health Plan Medicare	$515.28
Rate for Payer: UnitedHealthcare Medicare	$515.28
Rate for Payer: University Health Alliance Commercial	$494.19

TUBE CHEST THALQUIK 8F

Facility

$678.00

Service Code	HCPCS C1729
Hospital Revenue Code	272
Min. Negotiated Rate	$576.30
Max. Negotiated Rate	$657.66
Rate for Payer: Cash Price	$406.80
Rate for Payer: Health Management Network Commercial	$576.30
Rate for Payer: Kaiser Permanente Commercial	$610.20
Rate for Payer: MDX Hawaii PPO	$657.66

TUBE DISTAL ATTACHMENT

Facility

$634.00

Hospital Revenue Code	272
Min. Negotiated Rate	$317.00
Max. Negotiated Rate	$614.98
Rate for Payer: AlohaCare Medicaid	$317.00
Rate for Payer: AlohaCare Medicare	$481.84
Rate for Payer: Cash Price	$380.40
Rate for Payer: Devoted Health Medicare	$532.56
Rate for Payer: Hawaii Medical Service Association Medicare	$481.84
Rate for Payer: Hawaii Western Management Group Commercial	$602.30
Rate for Payer: Health Management Network Commercial	$538.90
Rate for Payer: Humana Medicare	$481.84
Rate for Payer: Kaiser Permanente Commercial	$570.60
Rate for Payer: Kaiser Permanente Medicaid	$323.34
Rate for Payer: Kaiser Permanente Medicare	$481.84
Rate for Payer: MDX Hawaii PPO	$614.98
Rate for Payer: Ohana Health Plan Medicaid	$481.84
Rate for Payer: Ohana Health Plan Medicare	$481.84
Rate for Payer: UnitedHealthcare Medicare	$481.84
Rate for Payer: University Health Alliance Commercial	$462.12

TUBE DISTAL ATTACHMENT

Facility

$634.00

Hospital Revenue Code	272
Min. Negotiated Rate	$538.90
Max. Negotiated Rate	$614.98
Rate for Payer: Cash Price	$380.40
Rate for Payer: Health Management Network Commercial	$538.90
Rate for Payer: Kaiser Permanente Commercial	$570.60
Rate for Payer: MDX Hawaii PPO	$614.98

TUBE EMG

Facility

$1,068.00

Hospital Revenue Code	272
Min. Negotiated Rate	$907.80
Max. Negotiated Rate	$1,035.96
Rate for Payer: Cash Price	$640.80
Rate for Payer: Health Management Network Commercial	$907.80
Rate for Payer: Kaiser Permanente Commercial	$961.20
Rate for Payer: MDX Hawaii PPO	$1,035.96

TUBE EMG

Facility

$1,068.00

Hospital Revenue Code	272
Min. Negotiated Rate	$534.00
Max. Negotiated Rate	$1,035.96
Rate for Payer: AlohaCare Medicaid	$534.00
Rate for Payer: AlohaCare Medicare	$811.68
Rate for Payer: Cash Price	$640.80
Rate for Payer: Devoted Health Medicare	$897.12
Rate for Payer: Hawaii Medical Service Association Medicare	$811.68
Rate for Payer: Hawaii Western Management Group Commercial	$1,014.60
Rate for Payer: Health Management Network Commercial	$907.80
Rate for Payer: Humana Medicare	$811.68
Rate for Payer: Kaiser Permanente Commercial	$961.20
Rate for Payer: Kaiser Permanente Medicaid	$544.68
Rate for Payer: Kaiser Permanente Medicare	$811.68
Rate for Payer: MDX Hawaii PPO	$1,035.96
Rate for Payer: Ohana Health Plan Medicaid	$811.68
Rate for Payer: Ohana Health Plan Medicare	$811.68
Rate for Payer: UnitedHealthcare Medicare	$811.68
Rate for Payer: University Health Alliance Commercial	$778.47

TUBE EMG ENDOTRACH SZ6

Facility

$1,495.00

Hospital Revenue Code	270
Min. Negotiated Rate	$1,270.75
Max. Negotiated Rate	$1,450.15
Rate for Payer: Cash Price	$897.00
Rate for Payer: Health Management Network Commercial	$1,270.75
Rate for Payer: Kaiser Permanente Commercial	$1,345.50
Rate for Payer: MDX Hawaii PPO	$1,450.15

TUBE EMG ENDOTRACH SZ6

Facility

$1,495.00

Hospital Revenue Code	270
Min. Negotiated Rate	$747.50
Max. Negotiated Rate	$1,450.15
Rate for Payer: AlohaCare Medicaid	$747.50
Rate for Payer: AlohaCare Medicare	$1,136.20
Rate for Payer: Cash Price	$897.00
Rate for Payer: Devoted Health Medicare	$1,255.80
Rate for Payer: Hawaii Medical Service Association Medicare	$1,136.20
Rate for Payer: Hawaii Western Management Group Commercial	$1,420.25
Rate for Payer: Health Management Network Commercial	$1,270.75
Rate for Payer: Humana Medicare	$1,136.20
Rate for Payer: Kaiser Permanente Commercial	$1,345.50
Rate for Payer: Kaiser Permanente Medicaid	$762.45
Rate for Payer: Kaiser Permanente Medicare	$1,136.20
Rate for Payer: MDX Hawaii PPO	$1,450.15
Rate for Payer: Ohana Health Plan Medicaid	$1,136.20
Rate for Payer: Ohana Health Plan Medicare	$1,136.20
Rate for Payer: UnitedHealthcare Medicare	$1,136.20
Rate for Payer: University Health Alliance Commercial	$1,089.71

TUBE EMG ENDOTRACH SZ7

Facility

$1,540.00

Hospital Revenue Code	270
Min. Negotiated Rate	$770.00
Max. Negotiated Rate	$1,493.80
Rate for Payer: AlohaCare Medicaid	$770.00
Rate for Payer: AlohaCare Medicare	$1,170.40
Rate for Payer: Cash Price	$924.00
Rate for Payer: Devoted Health Medicare	$1,293.60
Rate for Payer: Hawaii Medical Service Association Medicare	$1,170.40
Rate for Payer: Hawaii Western Management Group Commercial	$1,463.00
Rate for Payer: Health Management Network Commercial	$1,309.00
Rate for Payer: Humana Medicare	$1,170.40
Rate for Payer: Kaiser Permanente Commercial	$1,386.00
Rate for Payer: Kaiser Permanente Medicaid	$785.40
Rate for Payer: Kaiser Permanente Medicare	$1,170.40
Rate for Payer: MDX Hawaii PPO	$1,493.80
Rate for Payer: Ohana Health Plan Medicaid	$1,170.40
Rate for Payer: Ohana Health Plan Medicare	$1,170.40
Rate for Payer: UnitedHealthcare Medicare	$1,170.40
Rate for Payer: University Health Alliance Commercial	$1,122.51

Know your out-of-pocket cost for care.

All Charges