Honoka'a Hospital and Skilled Nursing Facility

All Charges

Charge

Type

Setting

Price

CATH BALLOON MOLD

Facility

$1,779.00

Service Code	HCPCS C2628
Hospital Revenue Code	272
Min. Negotiated Rate	$889.50
Max. Negotiated Rate	$1,725.63
Rate for Payer: AlohaCare Medicaid	$889.50
Rate for Payer: AlohaCare Medicare	$1,352.04
Rate for Payer: Cash Price	$1,067.40
Rate for Payer: Devoted Health Medicare	$1,494.36
Rate for Payer: Hawaii Medical Service Association Medicare	$1,352.04
Rate for Payer: Hawaii Western Management Group Commercial	$1,690.05
Rate for Payer: Health Management Network Commercial	$1,512.15
Rate for Payer: Humana Medicare	$1,352.04
Rate for Payer: Kaiser Permanente Commercial	$1,601.10
Rate for Payer: Kaiser Permanente Medicaid	$907.29
Rate for Payer: Kaiser Permanente Medicare	$1,352.04
Rate for Payer: MDX Hawaii PPO	$1,725.63
Rate for Payer: Ohana Health Plan Medicaid	$1,352.04
Rate for Payer: Ohana Health Plan Medicare	$1,352.04
Rate for Payer: UnitedHealthcare Medicare	$1,352.04
Rate for Payer: University Health Alliance Commercial	$1,296.71

CATH BALLOON MOLD

Facility

$1,779.00

Service Code	HCPCS C2628
Hospital Revenue Code	272
Min. Negotiated Rate	$1,512.15
Max. Negotiated Rate	$1,725.63
Rate for Payer: Cash Price	$1,067.40
Rate for Payer: Health Management Network Commercial	$1,512.15
Rate for Payer: Kaiser Permanente Commercial	$1,601.10
Rate for Payer: MDX Hawaii PPO	$1,725.63

CATH BALLOON TAMPONADE BTC-100

Facility

$400.00

Service Code	HCPCS C2628
Hospital Revenue Code	272
Min. Negotiated Rate	$340.00
Max. Negotiated Rate	$388.00
Rate for Payer: Cash Price	$240.00
Rate for Payer: Health Management Network Commercial	$340.00
Rate for Payer: Kaiser Permanente Commercial	$360.00
Rate for Payer: MDX Hawaii PPO	$388.00

CATH BALLOON TAMPONADE BTC-100

Facility

$400.00

Service Code	HCPCS C2628
Hospital Revenue Code	272
Min. Negotiated Rate	$200.00
Max. Negotiated Rate	$388.00
Rate for Payer: AlohaCare Medicaid	$200.00
Rate for Payer: AlohaCare Medicare	$304.00
Rate for Payer: Cash Price	$240.00
Rate for Payer: Devoted Health Medicare	$336.00
Rate for Payer: Hawaii Medical Service Association Medicare	$304.00
Rate for Payer: Hawaii Western Management Group Commercial	$380.00
Rate for Payer: Health Management Network Commercial	$340.00
Rate for Payer: Humana Medicare	$304.00
Rate for Payer: Kaiser Permanente Commercial	$360.00
Rate for Payer: Kaiser Permanente Medicaid	$204.00
Rate for Payer: Kaiser Permanente Medicare	$304.00
Rate for Payer: MDX Hawaii PPO	$388.00
Rate for Payer: Ohana Health Plan Medicaid	$304.00
Rate for Payer: Ohana Health Plan Medicare	$304.00
Rate for Payer: UnitedHealthcare Medicare	$304.00
Rate for Payer: University Health Alliance Commercial	$291.56

CATH BDC 10-12MM ESOPHAGEAL

Facility

$724.00

Service Code	HCPCS C1726
Hospital Revenue Code	272
Min. Negotiated Rate	$615.40
Max. Negotiated Rate	$702.28
Rate for Payer: Cash Price	$434.40
Rate for Payer: Health Management Network Commercial	$615.40
Rate for Payer: Kaiser Permanente Commercial	$651.60
Rate for Payer: MDX Hawaii PPO	$702.28

CATH BDC 10-12MM ESOPHAGEAL

Facility

$724.00

Service Code	HCPCS C1726
Hospital Revenue Code	272
Min. Negotiated Rate	$362.00
Max. Negotiated Rate	$702.28
Rate for Payer: AlohaCare Medicaid	$362.00
Rate for Payer: AlohaCare Medicare	$550.24
Rate for Payer: Cash Price	$434.40
Rate for Payer: Devoted Health Medicare	$608.16
Rate for Payer: Hawaii Medical Service Association Medicare	$550.24
Rate for Payer: Hawaii Western Management Group Commercial	$687.80
Rate for Payer: Health Management Network Commercial	$615.40
Rate for Payer: Humana Medicare	$550.24
Rate for Payer: Kaiser Permanente Commercial	$651.60
Rate for Payer: Kaiser Permanente Medicaid	$369.24
Rate for Payer: Kaiser Permanente Medicare	$550.24
Rate for Payer: MDX Hawaii PPO	$702.28
Rate for Payer: Ohana Health Plan Medicaid	$550.24
Rate for Payer: Ohana Health Plan Medicare	$550.24
Rate for Payer: UnitedHealthcare Medicare	$550.24
Rate for Payer: University Health Alliance Commercial	$527.72

CATH BDC 12-15MM ESOPHAGEAL

Facility

$724.00

Service Code	HCPCS C1726
Hospital Revenue Code	272
Min. Negotiated Rate	$362.00
Max. Negotiated Rate	$702.28
Rate for Payer: AlohaCare Medicaid	$362.00
Rate for Payer: AlohaCare Medicare	$550.24
Rate for Payer: Cash Price	$434.40
Rate for Payer: Devoted Health Medicare	$608.16
Rate for Payer: Hawaii Medical Service Association Medicare	$550.24
Rate for Payer: Hawaii Western Management Group Commercial	$687.80
Rate for Payer: Health Management Network Commercial	$615.40
Rate for Payer: Humana Medicare	$550.24
Rate for Payer: Kaiser Permanente Commercial	$651.60
Rate for Payer: Kaiser Permanente Medicaid	$369.24
Rate for Payer: Kaiser Permanente Medicare	$550.24
Rate for Payer: MDX Hawaii PPO	$702.28
Rate for Payer: Ohana Health Plan Medicaid	$550.24
Rate for Payer: Ohana Health Plan Medicare	$550.24
Rate for Payer: UnitedHealthcare Medicare	$550.24
Rate for Payer: University Health Alliance Commercial	$527.72

CATH BDC 12-15MM ESOPHAGEAL

Facility

$724.00

Service Code	HCPCS C1726
Hospital Revenue Code	272
Min. Negotiated Rate	$615.40
Max. Negotiated Rate	$702.28
Rate for Payer: Cash Price	$434.40
Rate for Payer: Health Management Network Commercial	$615.40
Rate for Payer: Kaiser Permanente Commercial	$651.60
Rate for Payer: MDX Hawaii PPO	$702.28

CATH BDC 15-18MM ESOPHAGEAL

Facility

$724.00

Service Code	HCPCS C1726
Hospital Revenue Code	272
Min. Negotiated Rate	$615.40
Max. Negotiated Rate	$702.28
Rate for Payer: Cash Price	$434.40
Rate for Payer: Health Management Network Commercial	$615.40
Rate for Payer: Kaiser Permanente Commercial	$651.60
Rate for Payer: MDX Hawaii PPO	$702.28

CATH BDC 15-18MM ESOPHAGEAL

Facility

$724.00

Service Code	HCPCS C1726
Hospital Revenue Code	272
Min. Negotiated Rate	$362.00
Max. Negotiated Rate	$702.28
Rate for Payer: AlohaCare Medicaid	$362.00
Rate for Payer: AlohaCare Medicare	$550.24
Rate for Payer: Cash Price	$434.40
Rate for Payer: Devoted Health Medicare	$608.16
Rate for Payer: Hawaii Medical Service Association Medicare	$550.24
Rate for Payer: Hawaii Western Management Group Commercial	$687.80
Rate for Payer: Health Management Network Commercial	$615.40
Rate for Payer: Humana Medicare	$550.24
Rate for Payer: Kaiser Permanente Commercial	$651.60
Rate for Payer: Kaiser Permanente Medicaid	$369.24
Rate for Payer: Kaiser Permanente Medicare	$550.24
Rate for Payer: MDX Hawaii PPO	$702.28
Rate for Payer: Ohana Health Plan Medicaid	$550.24
Rate for Payer: Ohana Health Plan Medicare	$550.24
Rate for Payer: UnitedHealthcare Medicare	$550.24
Rate for Payer: University Health Alliance Commercial	$527.72

CATH BDC 8-10MM ESOPHAGEAL

Facility

$724.00

Service Code	HCPCS C1726
Hospital Revenue Code	272
Min. Negotiated Rate	$362.00
Max. Negotiated Rate	$702.28
Rate for Payer: AlohaCare Medicaid	$362.00
Rate for Payer: AlohaCare Medicare	$550.24
Rate for Payer: Cash Price	$434.40
Rate for Payer: Devoted Health Medicare	$608.16
Rate for Payer: Hawaii Medical Service Association Medicare	$550.24
Rate for Payer: Hawaii Western Management Group Commercial	$687.80
Rate for Payer: Health Management Network Commercial	$615.40
Rate for Payer: Humana Medicare	$550.24
Rate for Payer: Kaiser Permanente Commercial	$651.60
Rate for Payer: Kaiser Permanente Medicaid	$369.24
Rate for Payer: Kaiser Permanente Medicare	$550.24
Rate for Payer: MDX Hawaii PPO	$702.28
Rate for Payer: Ohana Health Plan Medicaid	$550.24
Rate for Payer: Ohana Health Plan Medicare	$550.24
Rate for Payer: UnitedHealthcare Medicare	$550.24
Rate for Payer: University Health Alliance Commercial	$527.72

CATH BDC 8-10MM ESOPHAGEAL

Facility

$724.00

Service Code	HCPCS C1726
Hospital Revenue Code	272
Min. Negotiated Rate	$615.40
Max. Negotiated Rate	$702.28
Rate for Payer: Cash Price	$434.40
Rate for Payer: Health Management Network Commercial	$615.40
Rate for Payer: Kaiser Permanente Commercial	$651.60
Rate for Payer: MDX Hawaii PPO	$702.28

CATH CHOLANGIOGRAM

Facility

$175.00

Hospital Revenue Code	272
Min. Negotiated Rate	$87.50
Max. Negotiated Rate	$169.75
Rate for Payer: AlohaCare Medicaid	$87.50
Rate for Payer: AlohaCare Medicare	$133.00
Rate for Payer: Cash Price	$105.00
Rate for Payer: Devoted Health Medicare	$147.00
Rate for Payer: Hawaii Medical Service Association Medicare	$133.00
Rate for Payer: Hawaii Western Management Group Commercial	$166.25
Rate for Payer: Health Management Network Commercial	$148.75
Rate for Payer: Humana Medicare	$133.00
Rate for Payer: Kaiser Permanente Commercial	$157.50
Rate for Payer: Kaiser Permanente Medicaid	$89.25
Rate for Payer: Kaiser Permanente Medicare	$133.00
Rate for Payer: MDX Hawaii PPO	$169.75
Rate for Payer: Ohana Health Plan Medicaid	$133.00
Rate for Payer: Ohana Health Plan Medicare	$133.00
Rate for Payer: UnitedHealthcare Medicare	$133.00
Rate for Payer: University Health Alliance Commercial	$127.56

CATH CHOLANGIOGRAM

Facility

$175.00

Hospital Revenue Code	272
Min. Negotiated Rate	$148.75
Max. Negotiated Rate	$169.75
Rate for Payer: Cash Price	$105.00
Rate for Payer: Health Management Network Commercial	$148.75
Rate for Payer: Kaiser Permanente Commercial	$157.50
Rate for Payer: MDX Hawaii PPO	$169.75

CATH CHOLANGIOGRAM INTRO

Facility

$223.00

Hospital Revenue Code	272
Min. Negotiated Rate	$189.55
Max. Negotiated Rate	$216.31
Rate for Payer: Cash Price	$133.80
Rate for Payer: Health Management Network Commercial	$189.55
Rate for Payer: Kaiser Permanente Commercial	$200.70
Rate for Payer: MDX Hawaii PPO	$216.31

CATH CHOLANGIOGRAM INTRO

Facility

$223.00

Hospital Revenue Code	272
Min. Negotiated Rate	$111.50
Max. Negotiated Rate	$216.31
Rate for Payer: AlohaCare Medicaid	$111.50
Rate for Payer: AlohaCare Medicare	$169.48
Rate for Payer: Cash Price	$133.80
Rate for Payer: Devoted Health Medicare	$187.32
Rate for Payer: Hawaii Medical Service Association Medicare	$169.48
Rate for Payer: Hawaii Western Management Group Commercial	$211.85
Rate for Payer: Health Management Network Commercial	$189.55
Rate for Payer: Humana Medicare	$169.48
Rate for Payer: Kaiser Permanente Commercial	$200.70
Rate for Payer: Kaiser Permanente Medicaid	$113.73
Rate for Payer: Kaiser Permanente Medicare	$169.48
Rate for Payer: MDX Hawaii PPO	$216.31
Rate for Payer: Ohana Health Plan Medicaid	$169.48
Rate for Payer: Ohana Health Plan Medicare	$169.48
Rate for Payer: UnitedHealthcare Medicare	$169.48
Rate for Payer: University Health Alliance Commercial	$162.54

CATH COUNCIL 20F FOLEY

Facility

$114.00

Hospital Revenue Code	272
Min. Negotiated Rate	$96.90
Max. Negotiated Rate	$110.58
Rate for Payer: Cash Price	$68.40
Rate for Payer: Health Management Network Commercial	$96.90
Rate for Payer: Kaiser Permanente Commercial	$102.60
Rate for Payer: MDX Hawaii PPO	$110.58

CATH COUNCIL 20F FOLEY

Facility

$114.00

Hospital Revenue Code	272
Min. Negotiated Rate	$57.00
Max. Negotiated Rate	$110.58
Rate for Payer: AlohaCare Medicaid	$57.00
Rate for Payer: AlohaCare Medicare	$86.64
Rate for Payer: Cash Price	$68.40
Rate for Payer: Devoted Health Medicare	$95.76
Rate for Payer: Hawaii Medical Service Association Medicare	$86.64
Rate for Payer: Hawaii Western Management Group Commercial	$108.30
Rate for Payer: Health Management Network Commercial	$96.90
Rate for Payer: Humana Medicare	$86.64
Rate for Payer: Kaiser Permanente Commercial	$102.60
Rate for Payer: Kaiser Permanente Medicaid	$58.14
Rate for Payer: Kaiser Permanente Medicare	$86.64
Rate for Payer: MDX Hawaii PPO	$110.58
Rate for Payer: Ohana Health Plan Medicaid	$86.64
Rate for Payer: Ohana Health Plan Medicare	$86.64
Rate for Payer: UnitedHealthcare Medicare	$86.64
Rate for Payer: University Health Alliance Commercial	$83.09

CATH DRAIN 5FX15 CENTESIS

Facility

$107.00

Service Code	HCPCS C1729
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

CATH DRAIN 5FX15 CENTESIS

Facility

$107.00

Service Code	HCPCS C1729
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

CATH DRAIN 5FX9 CENTESIS

Facility

$107.00

Service Code	HCPCS C1729
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

CATH DRAIN 5FX9 CENTESIS

Facility

$107.00

Service Code	HCPCS C1729
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

CATH DUAL LUMEN URETERAL

Facility

$273.00

Service Code	HCPCS C1758
Hospital Revenue Code	272
Min. Negotiated Rate	$136.50
Max. Negotiated Rate	$264.81
Rate for Payer: AlohaCare Medicaid	$136.50
Rate for Payer: AlohaCare Medicare	$207.48
Rate for Payer: Cash Price	$163.80
Rate for Payer: Devoted Health Medicare	$229.32
Rate for Payer: Hawaii Medical Service Association Medicare	$207.48
Rate for Payer: Hawaii Western Management Group Commercial	$259.35
Rate for Payer: Health Management Network Commercial	$232.05
Rate for Payer: Humana Medicare	$207.48
Rate for Payer: Kaiser Permanente Commercial	$245.70
Rate for Payer: Kaiser Permanente Medicaid	$139.23
Rate for Payer: Kaiser Permanente Medicare	$207.48
Rate for Payer: MDX Hawaii PPO	$264.81
Rate for Payer: Ohana Health Plan Medicaid	$207.48
Rate for Payer: Ohana Health Plan Medicare	$207.48
Rate for Payer: UnitedHealthcare Medicare	$207.48
Rate for Payer: University Health Alliance Commercial	$198.99

CATH DUAL LUMEN URETERAL

Facility

$273.00

Service Code	HCPCS C1758
Hospital Revenue Code	272
Min. Negotiated Rate	$232.05
Max. Negotiated Rate	$264.81
Rate for Payer: Cash Price	$163.80
Rate for Payer: Health Management Network Commercial	$232.05
Rate for Payer: Kaiser Permanente Commercial	$245.70
Rate for Payer: MDX Hawaii PPO	$264.81

CATH ENT DILATION 7X20

Facility

$3,300.00

Service Code	HCPCS C1726
Hospital Revenue Code	272
Min. Negotiated Rate	$2,805.00
Max. Negotiated Rate	$3,201.00
Rate for Payer: Cash Price	$1,980.00
Rate for Payer: Health Management Network Commercial	$2,805.00
Rate for Payer: Kaiser Permanente Commercial	$2,970.00
Rate for Payer: MDX Hawaii PPO	$3,201.00

Know your out-of-pocket cost for care.

All Charges