Honoka'a Hospital and Skilled Nursing Facility

All Charges

Charge

Type

Setting

Price

VITAMIN E (DL, ACETATE) 180 MG (400 UNIT) CAPSULE [180774]

Facility

$1.00

Service Code	NDC 40754000000
Hospital Revenue Code	637
Min. Negotiated Rate	$0.50
Max. Negotiated Rate	$0.97
Rate for Payer: AlohaCare Medicaid	$0.50
Rate for Payer: AlohaCare Medicare	$0.76
Rate for Payer: Cash Price	$0.60
Rate for Payer: Devoted Health Medicare	$0.84
Rate for Payer: Hawaii Medical Service Association Medicare	$0.76
Rate for Payer: Hawaii Western Management Group Commercial	$0.95
Rate for Payer: Health Management Network Commercial	$0.85
Rate for Payer: Humana Medicare	$0.76
Rate for Payer: Kaiser Permanente Commercial	$0.90
Rate for Payer: Kaiser Permanente Medicaid	$0.51
Rate for Payer: Kaiser Permanente Medicare	$0.76
Rate for Payer: MDX Hawaii PPO	$0.97
Rate for Payer: Ohana Health Plan Medicaid	$0.76
Rate for Payer: Ohana Health Plan Medicare	$0.76
Rate for Payer: UnitedHealthcare Medicare	$0.76
Rate for Payer: University Health Alliance Commercial	$0.73

VITAMIN E (DL, ACETATE) 180 MG (400 UNIT) CAPSULE [180774]

Facility

$1.00

Service Code	NDC 95125000000
Hospital Revenue Code	250
Min. Negotiated Rate	$0.85
Max. Negotiated Rate	$0.97
Rate for Payer: Cash Price	$0.60
Rate for Payer: Health Management Network Commercial	$0.85
Rate for Payer: Kaiser Permanente Commercial	$0.90
Rate for Payer: MDX Hawaii PPO	$0.97

VITAMIN E (DL, ACETATE) 180 MG (400 UNIT) CAPSULE [180774]

Facility

$1.00

Service Code	NDC 95125000000
Hospital Revenue Code	637
Min. Negotiated Rate	$0.50
Max. Negotiated Rate	$0.97
Rate for Payer: AlohaCare Medicaid	$0.50
Rate for Payer: AlohaCare Medicare	$0.76
Rate for Payer: Cash Price	$0.60
Rate for Payer: Devoted Health Medicare	$0.84
Rate for Payer: Hawaii Medical Service Association Medicare	$0.76
Rate for Payer: Hawaii Western Management Group Commercial	$0.95
Rate for Payer: Health Management Network Commercial	$0.85
Rate for Payer: Humana Medicare	$0.76
Rate for Payer: Kaiser Permanente Commercial	$0.90
Rate for Payer: Kaiser Permanente Medicaid	$0.51
Rate for Payer: Kaiser Permanente Medicare	$0.76
Rate for Payer: MDX Hawaii PPO	$0.97
Rate for Payer: Ohana Health Plan Medicaid	$0.76
Rate for Payer: Ohana Health Plan Medicare	$0.76
Rate for Payer: UnitedHealthcare Medicare	$0.76
Rate for Payer: University Health Alliance Commercial	$0.73

VITAMIN E (DL, ACETATE) 180 MG (400 UNIT) CAPSULE [180774]

Facility

$1.00

Service Code	NDC 40754000000
Hospital Revenue Code	250
Min. Negotiated Rate	$0.85
Max. Negotiated Rate	$0.97
Rate for Payer: Cash Price	$0.60
Rate for Payer: Health Management Network Commercial	$0.85
Rate for Payer: Kaiser Permanente Commercial	$0.90
Rate for Payer: MDX Hawaii PPO	$0.97

VITAMINS A AND D-WHITE PETROLATUM-LANOLIN TOPICAL OINTMENT [8723]

Facility

$16.00

Service Code	NDC 71399012204
Hospital Revenue Code	637
Min. Negotiated Rate	$8.00
Max. Negotiated Rate	$15.52
Rate for Payer: AlohaCare Medicaid	$8.00
Rate for Payer: AlohaCare Medicare	$12.16
Rate for Payer: Cash Price	$9.60
Rate for Payer: Devoted Health Medicare	$13.44
Rate for Payer: Hawaii Medical Service Association Medicare	$12.16
Rate for Payer: Hawaii Western Management Group Commercial	$15.20
Rate for Payer: Health Management Network Commercial	$13.60
Rate for Payer: Humana Medicare	$12.16
Rate for Payer: Kaiser Permanente Commercial	$14.40
Rate for Payer: Kaiser Permanente Medicaid	$8.16
Rate for Payer: Kaiser Permanente Medicare	$12.16
Rate for Payer: MDX Hawaii PPO	$15.52
Rate for Payer: Ohana Health Plan Medicaid	$12.16
Rate for Payer: Ohana Health Plan Medicare	$12.16
Rate for Payer: UnitedHealthcare Medicare	$12.16
Rate for Payer: University Health Alliance Commercial	$11.66

VITAMINS A AND D-WHITE PETROLATUM-LANOLIN TOPICAL OINTMENT [8723]

Facility

$17.00

Service Code	NDC 65197040101
Hospital Revenue Code	250
Min. Negotiated Rate	$14.45
Max. Negotiated Rate	$16.49
Rate for Payer: Cash Price	$10.20
Rate for Payer: Health Management Network Commercial	$14.45
Rate for Payer: Kaiser Permanente Commercial	$15.30
Rate for Payer: MDX Hawaii PPO	$16.49

VITAMINS A AND D-WHITE PETROLATUM-LANOLIN TOPICAL OINTMENT [8723]

Facility

$16.00

Service Code	NDC 71399012204
Hospital Revenue Code	250
Min. Negotiated Rate	$13.60
Max. Negotiated Rate	$15.52
Rate for Payer: Cash Price	$9.60
Rate for Payer: Health Management Network Commercial	$13.60
Rate for Payer: Kaiser Permanente Commercial	$14.40
Rate for Payer: MDX Hawaii PPO	$15.52

VITAMINS A AND D-WHITE PETROLATUM-LANOLIN TOPICAL OINTMENT [8723]

Facility

$17.00

Service Code	NDC 65197040101
Hospital Revenue Code	637
Min. Negotiated Rate	$8.50
Max. Negotiated Rate	$16.49
Rate for Payer: AlohaCare Medicaid	$8.50
Rate for Payer: AlohaCare Medicare	$12.92
Rate for Payer: Cash Price	$10.20
Rate for Payer: Devoted Health Medicare	$14.28
Rate for Payer: Hawaii Medical Service Association Medicare	$12.92
Rate for Payer: Hawaii Western Management Group Commercial	$16.15
Rate for Payer: Health Management Network Commercial	$14.45
Rate for Payer: Humana Medicare	$12.92
Rate for Payer: Kaiser Permanente Commercial	$15.30
Rate for Payer: Kaiser Permanente Medicaid	$8.67
Rate for Payer: Kaiser Permanente Medicare	$12.92
Rate for Payer: MDX Hawaii PPO	$16.49
Rate for Payer: Ohana Health Plan Medicaid	$12.92
Rate for Payer: Ohana Health Plan Medicare	$12.92
Rate for Payer: UnitedHealthcare Medicare	$12.92
Rate for Payer: University Health Alliance Commercial	$12.39

VITOSS 2.5CC 2102-2202

Facility

$2,444.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,368.64
Max. Negotiated Rate	$2,370.68
Rate for Payer: Cash Price	$1,466.40
Rate for Payer: Hawaii Western Management Group Commercial	$1,710.80
Rate for Payer: Health Management Network Commercial	$2,077.40
Rate for Payer: Kaiser Permanente Commercial	$2,199.60
Rate for Payer: MDX Hawaii PPO	$2,370.68
Rate for Payer: University Health Alliance Commercial	$1,368.64

VITOSS 2.5CC 2102-2202

Facility

$2,444.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,222.00
Max. Negotiated Rate	$2,370.68
Rate for Payer: AlohaCare Medicaid	$1,222.00
Rate for Payer: AlohaCare Medicare	$1,857.44
Rate for Payer: Cash Price	$1,466.40
Rate for Payer: Devoted Health Medicare	$2,052.96
Rate for Payer: Hawaii Medical Service Association Medicare	$1,857.44
Rate for Payer: Hawaii Western Management Group Commercial	$1,710.80
Rate for Payer: Health Management Network Commercial	$2,077.40
Rate for Payer: Humana Medicare	$1,857.44
Rate for Payer: Kaiser Permanente Commercial	$2,199.60
Rate for Payer: Kaiser Permanente Medicaid	$1,246.44
Rate for Payer: Kaiser Permanente Medicare	$1,857.44
Rate for Payer: MDX Hawaii PPO	$2,370.68
Rate for Payer: Ohana Health Plan Medicaid	$1,857.44
Rate for Payer: Ohana Health Plan Medicare	$1,857.44
Rate for Payer: UnitedHealthcare Medicare	$1,857.44
Rate for Payer: University Health Alliance Commercial	$1,368.64

VITOSS BONE GRAFT 2102-2205

Facility

$7,048.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$3,524.00
Max. Negotiated Rate	$6,836.56
Rate for Payer: AlohaCare Medicaid	$3,524.00
Rate for Payer: AlohaCare Medicare	$5,356.48
Rate for Payer: Cash Price	$4,228.80
Rate for Payer: Devoted Health Medicare	$5,920.32
Rate for Payer: Hawaii Medical Service Association Medicare	$5,356.48
Rate for Payer: Hawaii Western Management Group Commercial	$4,933.60
Rate for Payer: Health Management Network Commercial	$5,990.80
Rate for Payer: Humana Medicare	$5,356.48
Rate for Payer: Kaiser Permanente Commercial	$6,343.20
Rate for Payer: Kaiser Permanente Medicaid	$3,594.48
Rate for Payer: Kaiser Permanente Medicare	$5,356.48
Rate for Payer: MDX Hawaii PPO	$6,836.56
Rate for Payer: Ohana Health Plan Medicaid	$5,356.48
Rate for Payer: Ohana Health Plan Medicare	$5,356.48
Rate for Payer: UnitedHealthcare Medicare	$5,356.48
Rate for Payer: University Health Alliance Commercial	$3,946.88

VITOSS BONE GRAFT 2102-2205

Facility

$7,048.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$3,946.88
Max. Negotiated Rate	$6,836.56
Rate for Payer: Cash Price	$4,228.80
Rate for Payer: Hawaii Western Management Group Commercial	$4,933.60
Rate for Payer: Health Management Network Commercial	$5,990.80
Rate for Payer: Kaiser Permanente Commercial	$6,343.20
Rate for Payer: MDX Hawaii PPO	$6,836.56
Rate for Payer: University Health Alliance Commercial	$3,946.88

VIVACIT-E 60X36MM 8851-014-36

Facility

$3,800.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$1,900.00
Max. Negotiated Rate	$3,686.00
Rate for Payer: AlohaCare Medicaid	$1,900.00
Rate for Payer: AlohaCare Medicare	$2,888.00
Rate for Payer: Cash Price	$2,280.00
Rate for Payer: Devoted Health Medicare	$3,192.00
Rate for Payer: Hawaii Medical Service Association Medicare	$2,888.00
Rate for Payer: Hawaii Western Management Group Commercial	$2,660.00
Rate for Payer: Health Management Network Commercial	$3,230.00
Rate for Payer: Humana Medicare	$2,888.00
Rate for Payer: Kaiser Permanente Commercial	$3,420.00
Rate for Payer: Kaiser Permanente Medicaid	$1,938.00
Rate for Payer: Kaiser Permanente Medicare	$2,888.00
Rate for Payer: MDX Hawaii PPO	$3,686.00
Rate for Payer: Ohana Health Plan Medicaid	$2,888.00
Rate for Payer: Ohana Health Plan Medicare	$2,888.00
Rate for Payer: UnitedHealthcare Medicare	$2,888.00
Rate for Payer: University Health Alliance Commercial	$2,128.00

VIVACIT-E 60X36MM 8851-014-36

Facility

$3,800.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$2,128.00
Max. Negotiated Rate	$3,686.00
Rate for Payer: Cash Price	$2,280.00
Rate for Payer: Hawaii Western Management Group Commercial	$2,660.00
Rate for Payer: Health Management Network Commercial	$3,230.00
Rate for Payer: Kaiser Permanente Commercial	$3,420.00
Rate for Payer: MDX Hawaii PPO	$3,686.00
Rate for Payer: University Health Alliance Commercial	$2,128.00

VLOC 3-0 CV-23 6" VLOCM0804

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

VLOC 3-0 CV-23 6" VLOCM0804

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

VOL PLATE RT/5H/5PEG VLBPR-5-5

Facility

$3,020.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,691.20
Max. Negotiated Rate	$2,929.40
Rate for Payer: Cash Price	$1,812.00
Rate for Payer: Hawaii Western Management Group Commercial	$2,114.00
Rate for Payer: Health Management Network Commercial	$2,567.00
Rate for Payer: Kaiser Permanente Commercial	$2,718.00
Rate for Payer: MDX Hawaii PPO	$2,929.40
Rate for Payer: University Health Alliance Commercial	$1,691.20

VOL PLATE RT/5H/5PEG VLBPR-5-5

Facility

$3,020.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,510.00
Max. Negotiated Rate	$2,929.40
Rate for Payer: AlohaCare Medicaid	$1,510.00
Rate for Payer: AlohaCare Medicare	$2,295.20
Rate for Payer: Cash Price	$1,812.00
Rate for Payer: Devoted Health Medicare	$2,536.80
Rate for Payer: Hawaii Medical Service Association Medicare	$2,295.20
Rate for Payer: Hawaii Western Management Group Commercial	$2,114.00
Rate for Payer: Health Management Network Commercial	$2,567.00
Rate for Payer: Humana Medicare	$2,295.20
Rate for Payer: Kaiser Permanente Commercial	$2,718.00
Rate for Payer: Kaiser Permanente Medicaid	$1,540.20
Rate for Payer: Kaiser Permanente Medicare	$2,295.20
Rate for Payer: MDX Hawaii PPO	$2,929.40
Rate for Payer: Ohana Health Plan Medicaid	$2,295.20
Rate for Payer: Ohana Health Plan Medicare	$2,295.20
Rate for Payer: UnitedHealthcare Medicare	$2,295.20
Rate for Payer: University Health Alliance Commercial	$1,691.20

VORICONAZOLE 200 MG/20ML IV (WET SOLR VIAL) [43033010]

Facility

$125.00

Service Code	HCPCS J3465
Hospital Revenue Code	250
Min. Negotiated Rate	$106.25
Max. Negotiated Rate	$121.25
Rate for Payer: Cash Price	$75.00
Rate for Payer: Cash Price	$87.00
Rate for Payer: Health Management Network Commercial	$123.25
Rate for Payer: Health Management Network Commercial	$106.25
Rate for Payer: Kaiser Permanente Commercial	$112.50
Rate for Payer: Kaiser Permanente Commercial	$130.50
Rate for Payer: MDX Hawaii PPO	$140.65
Rate for Payer: MDX Hawaii PPO	$121.25

VORICONAZOLE 200 MG/20ML IV (WET SOLR VIAL) [43033010]

Facility

$125.00

Service Code	HCPCS J3465
Hospital Revenue Code	636
Min. Negotiated Rate	$0.78
Max. Negotiated Rate	$121.25
Rate for Payer: AlohaCare Medicaid	$62.50
Rate for Payer: AlohaCare Medicaid	$72.50
Rate for Payer: AlohaCare Medicare	$110.20
Rate for Payer: AlohaCare Medicare	$95.00
Rate for Payer: Cash Price	$87.00
Rate for Payer: Cash Price	$75.00
Rate for Payer: Cash Price	$75.00
Rate for Payer: Cash Price	$87.00
Rate for Payer: Devoted Health Medicare	$105.00
Rate for Payer: Devoted Health Medicare	$121.80
Rate for Payer: Hawaii Medical Service Association ABD	$0.78
Rate for Payer: Hawaii Medical Service Association ABD	$0.78
Rate for Payer: Hawaii Medical Service Association Medicare	$110.20
Rate for Payer: Hawaii Medical Service Association Medicare	$95.00
Rate for Payer: Hawaii Medical Service Association Non-ABD	$0.78
Rate for Payer: Hawaii Medical Service Association Non-ABD	$0.78
Rate for Payer: Hawaii Western Management Group Commercial	$137.75
Rate for Payer: Hawaii Western Management Group Commercial	$118.75
Rate for Payer: Health Management Network Commercial	$106.25
Rate for Payer: Health Management Network Commercial	$123.25
Rate for Payer: Humana Medicare	$110.20
Rate for Payer: Humana Medicare	$95.00
Rate for Payer: Kaiser Permanente Commercial	$130.50
Rate for Payer: Kaiser Permanente Commercial	$112.50
Rate for Payer: Kaiser Permanente Medicaid	$73.95
Rate for Payer: Kaiser Permanente Medicaid	$63.75
Rate for Payer: Kaiser Permanente Medicare	$110.20
Rate for Payer: Kaiser Permanente Medicare	$95.00
Rate for Payer: MDX Hawaii PPO	$121.25
Rate for Payer: MDX Hawaii PPO	$140.65
Rate for Payer: Ohana Health Plan Medicaid	$95.00
Rate for Payer: Ohana Health Plan Medicaid	$110.20
Rate for Payer: Ohana Health Plan Medicare	$95.00
Rate for Payer: Ohana Health Plan Medicare	$110.20
Rate for Payer: UnitedHealthcare Medicaid	$75.00
Rate for Payer: UnitedHealthcare Medicaid	$87.00
Rate for Payer: UnitedHealthcare Medicare	$110.20
Rate for Payer: UnitedHealthcare Medicare	$95.00
Rate for Payer: University Health Alliance Commercial	$91.11
Rate for Payer: University Health Alliance Commercial	$105.69

VORICONAZOLE 200 MG INTRAVENOUS SOLUTION [33010]

Facility

$145.00

Service Code	HCPCS J3465
Hospital Revenue Code	636
Min. Negotiated Rate	$0.78
Max. Negotiated Rate	$140.65
Rate for Payer: AlohaCare Medicaid	$72.50
Rate for Payer: AlohaCare Medicare	$110.20
Rate for Payer: Cash Price	$87.00
Rate for Payer: Cash Price	$87.00
Rate for Payer: Devoted Health Medicare	$121.80
Rate for Payer: Hawaii Medical Service Association ABD	$0.78
Rate for Payer: Hawaii Medical Service Association Medicare	$110.20
Rate for Payer: Hawaii Medical Service Association Non-ABD	$0.78
Rate for Payer: Hawaii Western Management Group Commercial	$137.75
Rate for Payer: Health Management Network Commercial	$123.25
Rate for Payer: Humana Medicare	$110.20
Rate for Payer: Kaiser Permanente Commercial	$130.50
Rate for Payer: Kaiser Permanente Medicaid	$73.95
Rate for Payer: Kaiser Permanente Medicare	$110.20
Rate for Payer: MDX Hawaii PPO	$140.65
Rate for Payer: Ohana Health Plan Medicaid	$110.20
Rate for Payer: Ohana Health Plan Medicare	$110.20
Rate for Payer: UnitedHealthcare Medicaid	$87.00
Rate for Payer: UnitedHealthcare Medicare	$110.20
Rate for Payer: University Health Alliance Commercial	$105.69

VORICONAZOLE 200 MG INTRAVENOUS SOLUTION [33010]

Facility

$145.00

Service Code	HCPCS J3465
Hospital Revenue Code	250
Min. Negotiated Rate	$123.25
Max. Negotiated Rate	$140.65
Rate for Payer: Cash Price	$87.00
Rate for Payer: Health Management Network Commercial	$123.25
Rate for Payer: Kaiser Permanente Commercial	$130.50
Rate for Payer: MDX Hawaii PPO	$140.65

VORICONAZOLE 200 MG TABLET [33009]

Facility

$67.00

Service Code	NDC 00904702404
Hospital Revenue Code	637
Min. Negotiated Rate	$33.50
Max. Negotiated Rate	$64.99
Rate for Payer: AlohaCare Medicaid	$33.50
Rate for Payer: AlohaCare Medicare	$50.92
Rate for Payer: Cash Price	$40.20
Rate for Payer: Devoted Health Medicare	$56.28
Rate for Payer: Hawaii Medical Service Association Medicare	$50.92
Rate for Payer: Hawaii Western Management Group Commercial	$63.65
Rate for Payer: Health Management Network Commercial	$56.95
Rate for Payer: Humana Medicare	$50.92
Rate for Payer: Kaiser Permanente Commercial	$60.30
Rate for Payer: Kaiser Permanente Medicaid	$34.17
Rate for Payer: Kaiser Permanente Medicare	$50.92
Rate for Payer: MDX Hawaii PPO	$64.99
Rate for Payer: Ohana Health Plan Medicaid	$50.92
Rate for Payer: Ohana Health Plan Medicare	$50.92
Rate for Payer: UnitedHealthcare Medicare	$50.92
Rate for Payer: University Health Alliance Commercial	$48.84

VORICONAZOLE 200 MG TABLET [33009]

Facility

$160.00

Service Code	NDC 68462057330
Hospital Revenue Code	250
Min. Negotiated Rate	$136.00
Max. Negotiated Rate	$155.20
Rate for Payer: Cash Price	$96.00
Rate for Payer: Health Management Network Commercial	$136.00
Rate for Payer: Kaiser Permanente Commercial	$144.00
Rate for Payer: MDX Hawaii PPO	$155.20

VORICONAZOLE 200 MG TABLET [33009]

Facility

$118.00

Service Code	NDC 60687027321
Hospital Revenue Code	250
Min. Negotiated Rate	$100.30
Max. Negotiated Rate	$114.46
Rate for Payer: Cash Price	$70.80
Rate for Payer: Health Management Network Commercial	$100.30
Rate for Payer: Kaiser Permanente Commercial	$106.20
Rate for Payer: MDX Hawaii PPO	$114.46

Know your out-of-pocket cost for care.

All Charges