Honoka'a Hospital and Skilled Nursing Facility

All Charges

Charge

Type

Setting

Price

WIRE K #WIRE-1.1/120

Facility

$140.00

Service Code	HCPCS C1713
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

WIRE K #WIRE-1.1/120

Facility

$140.00

Service Code	HCPCS C1713
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

WIRE LOOP 2.4MM AR-1594D-24

Facility

$1,722.00

Hospital Revenue Code	272
Min. Negotiated Rate	$1,463.70
Max. Negotiated Rate	$1,670.34
Rate for Payer: Cash Price	$1,033.20
Rate for Payer: Health Management Network Commercial	$1,463.70
Rate for Payer: Kaiser Permanente Commercial	$1,549.80
Rate for Payer: MDX Hawaii PPO	$1,670.34

WIRE LOOP 2.4MM AR-1594D-24

Facility

$1,722.00

Hospital Revenue Code	272
Min. Negotiated Rate	$861.00
Max. Negotiated Rate	$1,670.34
Rate for Payer: AlohaCare Medicaid	$861.00
Rate for Payer: AlohaCare Medicare	$1,308.72
Rate for Payer: Cash Price	$1,033.20
Rate for Payer: Devoted Health Medicare	$1,446.48
Rate for Payer: Hawaii Medical Service Association Medicare	$1,308.72
Rate for Payer: Hawaii Western Management Group Commercial	$1,635.90
Rate for Payer: Health Management Network Commercial	$1,463.70
Rate for Payer: Humana Medicare	$1,308.72
Rate for Payer: Kaiser Permanente Commercial	$1,549.80
Rate for Payer: Kaiser Permanente Medicaid	$878.22
Rate for Payer: Kaiser Permanente Medicare	$1,308.72
Rate for Payer: MDX Hawaii PPO	$1,670.34
Rate for Payer: Ohana Health Plan Medicaid	$1,308.72
Rate for Payer: Ohana Health Plan Medicare	$1,308.72
Rate for Payer: UnitedHealthcare Medicare	$1,308.72
Rate for Payer: University Health Alliance Commercial	$1,255.17

WIRE OLIVE 1.3MM P99-200-1306

Facility

$478.00

Service Code	HCPCS C1713
Hospital Revenue Code	272
Min. Negotiated Rate	$406.30
Max. Negotiated Rate	$463.66
Rate for Payer: Cash Price	$286.80
Rate for Payer: Health Management Network Commercial	$406.30
Rate for Payer: Kaiser Permanente Commercial	$430.20
Rate for Payer: MDX Hawaii PPO	$463.66

WIRE OLIVE 1.3MM P99-200-1306

Facility

$478.00

Service Code	HCPCS C1713
Hospital Revenue Code	272
Min. Negotiated Rate	$239.00
Max. Negotiated Rate	$463.66
Rate for Payer: AlohaCare Medicaid	$239.00
Rate for Payer: AlohaCare Medicare	$363.28
Rate for Payer: Cash Price	$286.80
Rate for Payer: Devoted Health Medicare	$401.52
Rate for Payer: Hawaii Medical Service Association Medicare	$363.28
Rate for Payer: Hawaii Western Management Group Commercial	$454.10
Rate for Payer: Health Management Network Commercial	$406.30
Rate for Payer: Humana Medicare	$363.28
Rate for Payer: Kaiser Permanente Commercial	$430.20
Rate for Payer: Kaiser Permanente Medicaid	$243.78
Rate for Payer: Kaiser Permanente Medicare	$363.28
Rate for Payer: MDX Hawaii PPO	$463.66
Rate for Payer: Ohana Health Plan Medicaid	$363.28
Rate for Payer: Ohana Health Plan Medicare	$363.28
Rate for Payer: UnitedHealthcare Medicare	$363.28
Rate for Payer: University Health Alliance Commercial	$348.41

WIRE PILOT NITINOL 5901-6072

Facility

$150.00

Service Code	HCPCS C1769
Hospital Revenue Code	272
Min. Negotiated Rate	$75.00
Max. Negotiated Rate	$145.50
Rate for Payer: AlohaCare Medicaid	$75.00
Rate for Payer: AlohaCare Medicare	$114.00
Rate for Payer: Cash Price	$90.00
Rate for Payer: Devoted Health Medicare	$126.00
Rate for Payer: Hawaii Medical Service Association Medicare	$114.00
Rate for Payer: Hawaii Western Management Group Commercial	$142.50
Rate for Payer: Health Management Network Commercial	$127.50
Rate for Payer: Humana Medicare	$114.00
Rate for Payer: Kaiser Permanente Commercial	$135.00
Rate for Payer: Kaiser Permanente Medicaid	$76.50
Rate for Payer: Kaiser Permanente Medicare	$114.00
Rate for Payer: MDX Hawaii PPO	$145.50
Rate for Payer: Ohana Health Plan Medicaid	$114.00
Rate for Payer: Ohana Health Plan Medicare	$114.00
Rate for Payer: UnitedHealthcare Medicare	$114.00
Rate for Payer: University Health Alliance Commercial	$109.33

WIRE PILOT NITINOL 5901-6072

Facility

$150.00

Service Code	HCPCS C1769
Hospital Revenue Code	272
Min. Negotiated Rate	$127.50
Max. Negotiated Rate	$145.50
Rate for Payer: Cash Price	$90.00
Rate for Payer: Health Management Network Commercial	$127.50
Rate for Payer: Kaiser Permanente Commercial	$135.00
Rate for Payer: MDX Hawaii PPO	$145.50

WIRE PRECUT 0.6X175 291.240.98

Facility

$121.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$60.50
Max. Negotiated Rate	$117.37
Rate for Payer: AlohaCare Medicaid	$60.50
Rate for Payer: AlohaCare Medicare	$91.96
Rate for Payer: Cash Price	$72.60
Rate for Payer: Devoted Health Medicare	$101.64
Rate for Payer: Hawaii Medical Service Association Medicare	$91.96
Rate for Payer: Hawaii Western Management Group Commercial	$84.70
Rate for Payer: Health Management Network Commercial	$102.85
Rate for Payer: Humana Medicare	$91.96
Rate for Payer: Kaiser Permanente Commercial	$108.90
Rate for Payer: Kaiser Permanente Medicaid	$61.71
Rate for Payer: Kaiser Permanente Medicare	$91.96
Rate for Payer: MDX Hawaii PPO	$117.37
Rate for Payer: Ohana Health Plan Medicaid	$91.96
Rate for Payer: Ohana Health Plan Medicare	$91.96
Rate for Payer: UnitedHealthcare Medicare	$91.96
Rate for Payer: University Health Alliance Commercial	$67.76

WIRE PRECUT 0.6X175 291.240.98

Facility

$121.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$67.76
Max. Negotiated Rate	$117.37
Rate for Payer: Cash Price	$72.60
Rate for Payer: Hawaii Western Management Group Commercial	$84.70
Rate for Payer: Health Management Network Commercial	$102.85
Rate for Payer: Kaiser Permanente Commercial	$108.90
Rate for Payer: MDX Hawaii PPO	$117.37
Rate for Payer: University Health Alliance Commercial	$67.76

WIRE STD STR TIP

Facility

$183.00

Service Code	HCPCS C1769
Hospital Revenue Code	272
Min. Negotiated Rate	$91.50
Max. Negotiated Rate	$177.51
Rate for Payer: AlohaCare Medicaid	$91.50
Rate for Payer: AlohaCare Medicare	$139.08
Rate for Payer: Cash Price	$109.80
Rate for Payer: Devoted Health Medicare	$153.72
Rate for Payer: Hawaii Medical Service Association Medicare	$139.08
Rate for Payer: Hawaii Western Management Group Commercial	$173.85
Rate for Payer: Health Management Network Commercial	$155.55
Rate for Payer: Humana Medicare	$139.08
Rate for Payer: Kaiser Permanente Commercial	$164.70
Rate for Payer: Kaiser Permanente Medicaid	$93.33
Rate for Payer: Kaiser Permanente Medicare	$139.08
Rate for Payer: MDX Hawaii PPO	$177.51
Rate for Payer: Ohana Health Plan Medicaid	$139.08
Rate for Payer: Ohana Health Plan Medicare	$139.08
Rate for Payer: UnitedHealthcare Medicare	$139.08
Rate for Payer: University Health Alliance Commercial	$133.39

WIRE STD STR TIP

Facility

$183.00

Service Code	HCPCS C1769
Hospital Revenue Code	272
Min. Negotiated Rate	$155.55
Max. Negotiated Rate	$177.51
Rate for Payer: Cash Price	$109.80
Rate for Payer: Health Management Network Commercial	$155.55
Rate for Payer: Kaiser Permanente Commercial	$164.70
Rate for Payer: MDX Hawaii PPO	$177.51

WIRE STRAIGHT 300 V14 CONTROL

Facility

$599.00

Service Code	HCPCS C1769
Hospital Revenue Code	272
Min. Negotiated Rate	$299.50
Max. Negotiated Rate	$581.03
Rate for Payer: AlohaCare Medicaid	$299.50
Rate for Payer: AlohaCare Medicare	$455.24
Rate for Payer: Cash Price	$359.40
Rate for Payer: Devoted Health Medicare	$503.16
Rate for Payer: Hawaii Medical Service Association Medicare	$455.24
Rate for Payer: Hawaii Western Management Group Commercial	$569.05
Rate for Payer: Health Management Network Commercial	$509.15
Rate for Payer: Humana Medicare	$455.24
Rate for Payer: Kaiser Permanente Commercial	$539.10
Rate for Payer: Kaiser Permanente Medicaid	$305.49
Rate for Payer: Kaiser Permanente Medicare	$455.24
Rate for Payer: MDX Hawaii PPO	$581.03
Rate for Payer: Ohana Health Plan Medicaid	$455.24
Rate for Payer: Ohana Health Plan Medicare	$455.24
Rate for Payer: UnitedHealthcare Medicare	$455.24
Rate for Payer: University Health Alliance Commercial	$436.61

WIRE STRAIGHT 300 V14 CONTROL

Facility

$599.00

Service Code	HCPCS C1769
Hospital Revenue Code	272
Min. Negotiated Rate	$509.15
Max. Negotiated Rate	$581.03
Rate for Payer: Cash Price	$359.40
Rate for Payer: Health Management Network Commercial	$509.15
Rate for Payer: Kaiser Permanente Commercial	$539.10
Rate for Payer: MDX Hawaii PPO	$581.03

WIRE THREADED 70/15 1.6MM M420

Facility

$641.00

Service Code	HCPCS C1769
Hospital Revenue Code	272
Min. Negotiated Rate	$320.50
Max. Negotiated Rate	$621.77
Rate for Payer: AlohaCare Medicaid	$320.50
Rate for Payer: AlohaCare Medicare	$487.16
Rate for Payer: Cash Price	$384.60
Rate for Payer: Devoted Health Medicare	$538.44
Rate for Payer: Hawaii Medical Service Association Medicare	$487.16
Rate for Payer: Hawaii Western Management Group Commercial	$608.95
Rate for Payer: Health Management Network Commercial	$544.85
Rate for Payer: Humana Medicare	$487.16
Rate for Payer: Kaiser Permanente Commercial	$576.90
Rate for Payer: Kaiser Permanente Medicaid	$326.91
Rate for Payer: Kaiser Permanente Medicare	$487.16
Rate for Payer: MDX Hawaii PPO	$621.77
Rate for Payer: Ohana Health Plan Medicaid	$487.16
Rate for Payer: Ohana Health Plan Medicare	$487.16
Rate for Payer: UnitedHealthcare Medicare	$487.16
Rate for Payer: University Health Alliance Commercial	$467.22

WIRE THREADED 70/15 1.6MM M420

Facility

$641.00

Service Code	HCPCS C1769
Hospital Revenue Code	272
Min. Negotiated Rate	$544.85
Max. Negotiated Rate	$621.77
Rate for Payer: Cash Price	$384.60
Rate for Payer: Health Management Network Commercial	$544.85
Rate for Payer: Kaiser Permanente Commercial	$576.90
Rate for Payer: MDX Hawaii PPO	$621.77

WOLVERINE CB 2.25X10

Facility

$2,805.00

Service Code	HCPCS C1725
Hospital Revenue Code	272
Min. Negotiated Rate	$2,384.25
Max. Negotiated Rate	$2,720.85
Rate for Payer: Cash Price	$1,683.00
Rate for Payer: Health Management Network Commercial	$2,384.25
Rate for Payer: Kaiser Permanente Commercial	$2,524.50
Rate for Payer: MDX Hawaii PPO	$2,720.85

WOLVERINE CB 2.25X10

Facility

$2,805.00

Service Code	HCPCS C1725
Hospital Revenue Code	272
Min. Negotiated Rate	$1,402.50
Max. Negotiated Rate	$2,720.85
Rate for Payer: AlohaCare Medicaid	$1,402.50
Rate for Payer: AlohaCare Medicare	$2,131.80
Rate for Payer: Cash Price	$1,683.00
Rate for Payer: Devoted Health Medicare	$2,356.20
Rate for Payer: Hawaii Medical Service Association Medicare	$2,131.80
Rate for Payer: Hawaii Western Management Group Commercial	$2,664.75
Rate for Payer: Health Management Network Commercial	$2,384.25
Rate for Payer: Humana Medicare	$2,131.80
Rate for Payer: Kaiser Permanente Commercial	$2,524.50
Rate for Payer: Kaiser Permanente Medicaid	$1,430.55
Rate for Payer: Kaiser Permanente Medicare	$2,131.80
Rate for Payer: MDX Hawaii PPO	$2,720.85
Rate for Payer: Ohana Health Plan Medicaid	$2,131.80
Rate for Payer: Ohana Health Plan Medicare	$2,131.80
Rate for Payer: UnitedHealthcare Medicare	$2,131.80
Rate for Payer: University Health Alliance Commercial	$2,044.56

WOLVERINE CB 4X15

Facility

$2,550.00

Service Code	HCPCS C1725
Hospital Revenue Code	272
Min. Negotiated Rate	$2,167.50
Max. Negotiated Rate	$2,473.50
Rate for Payer: Cash Price	$1,530.00
Rate for Payer: Health Management Network Commercial	$2,167.50
Rate for Payer: Kaiser Permanente Commercial	$2,295.00
Rate for Payer: MDX Hawaii PPO	$2,473.50

WOLVERINE CB 4X15

Facility

$2,550.00

Service Code	HCPCS C1725
Hospital Revenue Code	272
Min. Negotiated Rate	$1,275.00
Max. Negotiated Rate	$2,473.50
Rate for Payer: AlohaCare Medicaid	$1,275.00
Rate for Payer: AlohaCare Medicare	$1,938.00
Rate for Payer: Cash Price	$1,530.00
Rate for Payer: Devoted Health Medicare	$2,142.00
Rate for Payer: Hawaii Medical Service Association Medicare	$1,938.00
Rate for Payer: Hawaii Western Management Group Commercial	$2,422.50
Rate for Payer: Health Management Network Commercial	$2,167.50
Rate for Payer: Humana Medicare	$1,938.00
Rate for Payer: Kaiser Permanente Commercial	$2,295.00
Rate for Payer: Kaiser Permanente Medicaid	$1,300.50
Rate for Payer: Kaiser Permanente Medicare	$1,938.00
Rate for Payer: MDX Hawaii PPO	$2,473.50
Rate for Payer: Ohana Health Plan Medicaid	$1,938.00
Rate for Payer: Ohana Health Plan Medicare	$1,938.00
Rate for Payer: UnitedHealthcare Medicare	$1,938.00
Rate for Payer: University Health Alliance Commercial	$1,858.69

WOUND CLOSURE SYL-WC-32-050

Facility

$260.00

Hospital Revenue Code	272
Min. Negotiated Rate	$221.00
Max. Negotiated Rate	$252.20
Rate for Payer: Cash Price	$156.00
Rate for Payer: Health Management Network Commercial	$221.00
Rate for Payer: Kaiser Permanente Commercial	$234.00
Rate for Payer: MDX Hawaii PPO	$252.20

WOUND CLOSURE SYL-WC-32-050

Facility

$260.00

Hospital Revenue Code	272
Min. Negotiated Rate	$130.00
Max. Negotiated Rate	$252.20
Rate for Payer: AlohaCare Medicaid	$130.00
Rate for Payer: AlohaCare Medicare	$197.60
Rate for Payer: Cash Price	$156.00
Rate for Payer: Devoted Health Medicare	$218.40
Rate for Payer: Hawaii Medical Service Association Medicare	$197.60
Rate for Payer: Hawaii Western Management Group Commercial	$247.00
Rate for Payer: Health Management Network Commercial	$221.00
Rate for Payer: Humana Medicare	$197.60
Rate for Payer: Kaiser Permanente Commercial	$234.00
Rate for Payer: Kaiser Permanente Medicaid	$132.60
Rate for Payer: Kaiser Permanente Medicare	$197.60
Rate for Payer: MDX Hawaii PPO	$252.20
Rate for Payer: Ohana Health Plan Medicaid	$197.60
Rate for Payer: Ohana Health Plan Medicare	$197.60
Rate for Payer: UnitedHealthcare Medicare	$197.60
Rate for Payer: University Health Alliance Commercial	$189.51

WOUND DEBRIDEMENT AND SKIN GRAFT EXCEPT HAND FOR MUSCULOSKELETAL AND CONNECTIVE TISSUE DISORDERS WITH CC

Facility

$101,136.43

Service Code	MSDRG 464
Min. Negotiated Rate	$101,136.43
Max. Negotiated Rate	$101,136.43
Rate for Payer: Hawaii Medical Service Association Commercial	$101,136.43

WOUND DEBRIDEMENT AND SKIN GRAFT EXCEPT HAND FOR MUSCULOSKELETAL AND CONNECTIVE TISSUE DISORDERS WITH MCC

Facility

$101,136.43

Service Code	MSDRG 463
Min. Negotiated Rate	$101,136.43
Max. Negotiated Rate	$101,136.43
Rate for Payer: Hawaii Medical Service Association Commercial	$101,136.43

WOUND DEBRIDEMENT AND SKIN GRAFT EXCEPT HAND FOR MUSCULOSKELETAL AND CONNECTIVE TISSUE DISORDERS WITHOUT CC/MCC

Facility

$101,136.43

Service Code	MSDRG 465
Min. Negotiated Rate	$101,136.43
Max. Negotiated Rate	$101,136.43
Rate for Payer: Hawaii Medical Service Association Commercial	$101,136.43

Know your out-of-pocket cost for care.

All Charges