Honoka'a Hospital and Skilled Nursing Facility

All Charges

Charge

Type

Setting

Price

FRN/GT 12X300MM LF 04.033.261S

Facility

$5,002.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$2,501.00
Max. Negotiated Rate	$4,851.94
Rate for Payer: AlohaCare Medicaid	$2,501.00
Rate for Payer: AlohaCare Medicare	$3,801.52
Rate for Payer: Cash Price	$3,001.20
Rate for Payer: Devoted Health Medicare	$4,201.68
Rate for Payer: Hawaii Medical Service Association Medicare	$3,801.52
Rate for Payer: Hawaii Western Management Group Commercial	$3,501.40
Rate for Payer: Health Management Network Commercial	$4,251.70
Rate for Payer: Humana Medicare	$3,801.52
Rate for Payer: Kaiser Permanente Commercial	$4,501.80
Rate for Payer: Kaiser Permanente Medicaid	$2,551.02
Rate for Payer: Kaiser Permanente Medicare	$3,801.52
Rate for Payer: MDX Hawaii PPO	$4,851.94
Rate for Payer: Ohana Health Plan Medicaid	$3,801.52
Rate for Payer: Ohana Health Plan Medicare	$3,801.52
Rate for Payer: UnitedHealthcare Medicare	$3,801.52
Rate for Payer: University Health Alliance Commercial	$2,801.12

FRN/GT 12X300MM RT 04.033.260S

Facility

$5,002.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$2,801.12
Max. Negotiated Rate	$4,851.94
Rate for Payer: Cash Price	$3,001.20
Rate for Payer: Hawaii Western Management Group Commercial	$3,501.40
Rate for Payer: Health Management Network Commercial	$4,251.70
Rate for Payer: Kaiser Permanente Commercial	$4,501.80
Rate for Payer: MDX Hawaii PPO	$4,851.94
Rate for Payer: University Health Alliance Commercial	$2,801.12

FRN/GT 12X300MM RT 04.033.260S

Facility

$5,002.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$2,501.00
Max. Negotiated Rate	$4,851.94
Rate for Payer: AlohaCare Medicaid	$2,501.00
Rate for Payer: AlohaCare Medicare	$3,801.52
Rate for Payer: Cash Price	$3,001.20
Rate for Payer: Devoted Health Medicare	$4,201.68
Rate for Payer: Hawaii Medical Service Association Medicare	$3,801.52
Rate for Payer: Hawaii Western Management Group Commercial	$3,501.40
Rate for Payer: Health Management Network Commercial	$4,251.70
Rate for Payer: Humana Medicare	$3,801.52
Rate for Payer: Kaiser Permanente Commercial	$4,501.80
Rate for Payer: Kaiser Permanente Medicaid	$2,551.02
Rate for Payer: Kaiser Permanente Medicare	$3,801.52
Rate for Payer: MDX Hawaii PPO	$4,851.94
Rate for Payer: Ohana Health Plan Medicaid	$3,801.52
Rate for Payer: Ohana Health Plan Medicare	$3,801.52
Rate for Payer: UnitedHealthcare Medicare	$3,801.52
Rate for Payer: University Health Alliance Commercial	$2,801.12

FRN/GT 12X320MM LF 04.033.263S

Facility

$5,002.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$2,801.12
Max. Negotiated Rate	$4,851.94
Rate for Payer: Cash Price	$3,001.20
Rate for Payer: Hawaii Western Management Group Commercial	$3,501.40
Rate for Payer: Health Management Network Commercial	$4,251.70
Rate for Payer: Kaiser Permanente Commercial	$4,501.80
Rate for Payer: MDX Hawaii PPO	$4,851.94
Rate for Payer: University Health Alliance Commercial	$2,801.12

FRN/GT 12X320MM LF 04.033.263S

Facility

$5,002.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$2,501.00
Max. Negotiated Rate	$4,851.94
Rate for Payer: AlohaCare Medicaid	$2,501.00
Rate for Payer: AlohaCare Medicare	$3,801.52
Rate for Payer: Cash Price	$3,001.20
Rate for Payer: Devoted Health Medicare	$4,201.68
Rate for Payer: Hawaii Medical Service Association Medicare	$3,801.52
Rate for Payer: Hawaii Western Management Group Commercial	$3,501.40
Rate for Payer: Health Management Network Commercial	$4,251.70
Rate for Payer: Humana Medicare	$3,801.52
Rate for Payer: Kaiser Permanente Commercial	$4,501.80
Rate for Payer: Kaiser Permanente Medicaid	$2,551.02
Rate for Payer: Kaiser Permanente Medicare	$3,801.52
Rate for Payer: MDX Hawaii PPO	$4,851.94
Rate for Payer: Ohana Health Plan Medicaid	$3,801.52
Rate for Payer: Ohana Health Plan Medicare	$3,801.52
Rate for Payer: UnitedHealthcare Medicare	$3,801.52
Rate for Payer: University Health Alliance Commercial	$2,801.12

FRN/GT 12X320MM RT 04.033.262S

Facility

$5,002.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$2,801.12
Max. Negotiated Rate	$4,851.94
Rate for Payer: Cash Price	$3,001.20
Rate for Payer: Hawaii Western Management Group Commercial	$3,501.40
Rate for Payer: Health Management Network Commercial	$4,251.70
Rate for Payer: Kaiser Permanente Commercial	$4,501.80
Rate for Payer: MDX Hawaii PPO	$4,851.94
Rate for Payer: University Health Alliance Commercial	$2,801.12

FRN/GT 12X320MM RT 04.033.262S

Facility

$5,002.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$2,501.00
Max. Negotiated Rate	$4,851.94
Rate for Payer: AlohaCare Medicaid	$2,501.00
Rate for Payer: AlohaCare Medicare	$3,801.52
Rate for Payer: Cash Price	$3,001.20
Rate for Payer: Devoted Health Medicare	$4,201.68
Rate for Payer: Hawaii Medical Service Association Medicare	$3,801.52
Rate for Payer: Hawaii Western Management Group Commercial	$3,501.40
Rate for Payer: Health Management Network Commercial	$4,251.70
Rate for Payer: Humana Medicare	$3,801.52
Rate for Payer: Kaiser Permanente Commercial	$4,501.80
Rate for Payer: Kaiser Permanente Medicaid	$2,551.02
Rate for Payer: Kaiser Permanente Medicare	$3,801.52
Rate for Payer: MDX Hawaii PPO	$4,851.94
Rate for Payer: Ohana Health Plan Medicaid	$3,801.52
Rate for Payer: Ohana Health Plan Medicare	$3,801.52
Rate for Payer: UnitedHealthcare Medicare	$3,801.52
Rate for Payer: University Health Alliance Commercial	$2,801.12

FRN/GT 12X340MM RT 04.033.264S

Facility

$5,002.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$2,801.12
Max. Negotiated Rate	$4,851.94
Rate for Payer: Cash Price	$3,001.20
Rate for Payer: Hawaii Western Management Group Commercial	$3,501.40
Rate for Payer: Health Management Network Commercial	$4,251.70
Rate for Payer: Kaiser Permanente Commercial	$4,501.80
Rate for Payer: MDX Hawaii PPO	$4,851.94
Rate for Payer: University Health Alliance Commercial	$2,801.12

FRN/GT 12X340MM RT 04.033.264S

Facility

$5,002.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$2,501.00
Max. Negotiated Rate	$4,851.94
Rate for Payer: AlohaCare Medicaid	$2,501.00
Rate for Payer: AlohaCare Medicare	$3,801.52
Rate for Payer: Cash Price	$3,001.20
Rate for Payer: Devoted Health Medicare	$4,201.68
Rate for Payer: Hawaii Medical Service Association Medicare	$3,801.52
Rate for Payer: Hawaii Western Management Group Commercial	$3,501.40
Rate for Payer: Health Management Network Commercial	$4,251.70
Rate for Payer: Humana Medicare	$3,801.52
Rate for Payer: Kaiser Permanente Commercial	$4,501.80
Rate for Payer: Kaiser Permanente Medicaid	$2,551.02
Rate for Payer: Kaiser Permanente Medicare	$3,801.52
Rate for Payer: MDX Hawaii PPO	$4,851.94
Rate for Payer: Ohana Health Plan Medicaid	$3,801.52
Rate for Payer: Ohana Health Plan Medicare	$3,801.52
Rate for Payer: UnitedHealthcare Medicare	$3,801.52
Rate for Payer: University Health Alliance Commercial	$2,801.12

FRN/GT 12X360MM LF 04.033.267S

Facility

$5,002.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$2,501.00
Max. Negotiated Rate	$4,851.94
Rate for Payer: AlohaCare Medicaid	$2,501.00
Rate for Payer: AlohaCare Medicare	$3,801.52
Rate for Payer: Cash Price	$3,001.20
Rate for Payer: Devoted Health Medicare	$4,201.68
Rate for Payer: Hawaii Medical Service Association Medicare	$3,801.52
Rate for Payer: Hawaii Western Management Group Commercial	$3,501.40
Rate for Payer: Health Management Network Commercial	$4,251.70
Rate for Payer: Humana Medicare	$3,801.52
Rate for Payer: Kaiser Permanente Commercial	$4,501.80
Rate for Payer: Kaiser Permanente Medicaid	$2,551.02
Rate for Payer: Kaiser Permanente Medicare	$3,801.52
Rate for Payer: MDX Hawaii PPO	$4,851.94
Rate for Payer: Ohana Health Plan Medicaid	$3,801.52
Rate for Payer: Ohana Health Plan Medicare	$3,801.52
Rate for Payer: UnitedHealthcare Medicare	$3,801.52
Rate for Payer: University Health Alliance Commercial	$2,801.12

FRN/GT 12X360MM LF 04.033.267S

Facility

$5,002.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$2,801.12
Max. Negotiated Rate	$4,851.94
Rate for Payer: Cash Price	$3,001.20
Rate for Payer: Hawaii Western Management Group Commercial	$3,501.40
Rate for Payer: Health Management Network Commercial	$4,251.70
Rate for Payer: Kaiser Permanente Commercial	$4,501.80
Rate for Payer: MDX Hawaii PPO	$4,851.94
Rate for Payer: University Health Alliance Commercial	$2,801.12

FRN/GT 12X360MM RT 04.033.266S

Facility

$5,002.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$2,501.00
Max. Negotiated Rate	$4,851.94
Rate for Payer: AlohaCare Medicaid	$2,501.00
Rate for Payer: AlohaCare Medicare	$3,801.52
Rate for Payer: Cash Price	$3,001.20
Rate for Payer: Devoted Health Medicare	$4,201.68
Rate for Payer: Hawaii Medical Service Association Medicare	$3,801.52
Rate for Payer: Hawaii Western Management Group Commercial	$3,501.40
Rate for Payer: Health Management Network Commercial	$4,251.70
Rate for Payer: Humana Medicare	$3,801.52
Rate for Payer: Kaiser Permanente Commercial	$4,501.80
Rate for Payer: Kaiser Permanente Medicaid	$2,551.02
Rate for Payer: Kaiser Permanente Medicare	$3,801.52
Rate for Payer: MDX Hawaii PPO	$4,851.94
Rate for Payer: Ohana Health Plan Medicaid	$3,801.52
Rate for Payer: Ohana Health Plan Medicare	$3,801.52
Rate for Payer: UnitedHealthcare Medicare	$3,801.52
Rate for Payer: University Health Alliance Commercial	$2,801.12

FRN/GT 12X360MM RT 04.033.266S

Facility

$5,002.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$2,801.12
Max. Negotiated Rate	$4,851.94
Rate for Payer: Cash Price	$3,001.20
Rate for Payer: Hawaii Western Management Group Commercial	$3,501.40
Rate for Payer: Health Management Network Commercial	$4,251.70
Rate for Payer: Kaiser Permanente Commercial	$4,501.80
Rate for Payer: MDX Hawaii PPO	$4,851.94
Rate for Payer: University Health Alliance Commercial	$2,801.12

FRN/GT 12X380MM LF 04.033.269S

Facility

$5,002.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$2,501.00
Max. Negotiated Rate	$4,851.94
Rate for Payer: AlohaCare Medicaid	$2,501.00
Rate for Payer: AlohaCare Medicare	$3,801.52
Rate for Payer: Cash Price	$3,001.20
Rate for Payer: Devoted Health Medicare	$4,201.68
Rate for Payer: Hawaii Medical Service Association Medicare	$3,801.52
Rate for Payer: Hawaii Western Management Group Commercial	$3,501.40
Rate for Payer: Health Management Network Commercial	$4,251.70
Rate for Payer: Humana Medicare	$3,801.52
Rate for Payer: Kaiser Permanente Commercial	$4,501.80
Rate for Payer: Kaiser Permanente Medicaid	$2,551.02
Rate for Payer: Kaiser Permanente Medicare	$3,801.52
Rate for Payer: MDX Hawaii PPO	$4,851.94
Rate for Payer: Ohana Health Plan Medicaid	$3,801.52
Rate for Payer: Ohana Health Plan Medicare	$3,801.52
Rate for Payer: UnitedHealthcare Medicare	$3,801.52
Rate for Payer: University Health Alliance Commercial	$2,801.12

FRN/GT 12X380MM LF 04.033.269S

Facility

$5,002.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$2,801.12
Max. Negotiated Rate	$4,851.94
Rate for Payer: Cash Price	$3,001.20
Rate for Payer: Hawaii Western Management Group Commercial	$3,501.40
Rate for Payer: Health Management Network Commercial	$4,251.70
Rate for Payer: Kaiser Permanente Commercial	$4,501.80
Rate for Payer: MDX Hawaii PPO	$4,851.94
Rate for Payer: University Health Alliance Commercial	$2,801.12

FRN/GT 12X380 RT 04.033.268S

Facility

$5,002.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$2,801.12
Max. Negotiated Rate	$4,851.94
Rate for Payer: Cash Price	$3,001.20
Rate for Payer: Hawaii Western Management Group Commercial	$3,501.40
Rate for Payer: Health Management Network Commercial	$4,251.70
Rate for Payer: Kaiser Permanente Commercial	$4,501.80
Rate for Payer: MDX Hawaii PPO	$4,851.94
Rate for Payer: University Health Alliance Commercial	$2,801.12

FRN/GT 12X380 RT 04.033.268S

Facility

$5,002.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$2,501.00
Max. Negotiated Rate	$4,851.94
Rate for Payer: AlohaCare Medicaid	$2,501.00
Rate for Payer: AlohaCare Medicare	$3,801.52
Rate for Payer: Cash Price	$3,001.20
Rate for Payer: Devoted Health Medicare	$4,201.68
Rate for Payer: Hawaii Medical Service Association Medicare	$3,801.52
Rate for Payer: Hawaii Western Management Group Commercial	$3,501.40
Rate for Payer: Health Management Network Commercial	$4,251.70
Rate for Payer: Humana Medicare	$3,801.52
Rate for Payer: Kaiser Permanente Commercial	$4,501.80
Rate for Payer: Kaiser Permanente Medicaid	$2,551.02
Rate for Payer: Kaiser Permanente Medicare	$3,801.52
Rate for Payer: MDX Hawaii PPO	$4,851.94
Rate for Payer: Ohana Health Plan Medicaid	$3,801.52
Rate for Payer: Ohana Health Plan Medicare	$3,801.52
Rate for Payer: UnitedHealthcare Medicare	$3,801.52
Rate for Payer: University Health Alliance Commercial	$2,801.12

FRN/GT 12X400MM LF 04.033.271S

Facility

$5,002.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$2,501.00
Max. Negotiated Rate	$4,851.94
Rate for Payer: AlohaCare Medicaid	$2,501.00
Rate for Payer: AlohaCare Medicare	$3,801.52
Rate for Payer: Cash Price	$3,001.20
Rate for Payer: Devoted Health Medicare	$4,201.68
Rate for Payer: Hawaii Medical Service Association Medicare	$3,801.52
Rate for Payer: Hawaii Western Management Group Commercial	$3,501.40
Rate for Payer: Health Management Network Commercial	$4,251.70
Rate for Payer: Humana Medicare	$3,801.52
Rate for Payer: Kaiser Permanente Commercial	$4,501.80
Rate for Payer: Kaiser Permanente Medicaid	$2,551.02
Rate for Payer: Kaiser Permanente Medicare	$3,801.52
Rate for Payer: MDX Hawaii PPO	$4,851.94
Rate for Payer: Ohana Health Plan Medicaid	$3,801.52
Rate for Payer: Ohana Health Plan Medicare	$3,801.52
Rate for Payer: UnitedHealthcare Medicare	$3,801.52
Rate for Payer: University Health Alliance Commercial	$2,801.12

FRN/GT 12X400MM LF 04.033.271S

Facility

$5,002.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$2,801.12
Max. Negotiated Rate	$4,851.94
Rate for Payer: Cash Price	$3,001.20
Rate for Payer: Hawaii Western Management Group Commercial	$3,501.40
Rate for Payer: Health Management Network Commercial	$4,251.70
Rate for Payer: Kaiser Permanente Commercial	$4,501.80
Rate for Payer: MDX Hawaii PPO	$4,851.94
Rate for Payer: University Health Alliance Commercial	$2,801.12

FRN/GT 12X400MM RT 04.033.270S

Facility

$5,002.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$2,501.00
Max. Negotiated Rate	$4,851.94
Rate for Payer: AlohaCare Medicaid	$2,501.00
Rate for Payer: AlohaCare Medicare	$3,801.52
Rate for Payer: Cash Price	$3,001.20
Rate for Payer: Devoted Health Medicare	$4,201.68
Rate for Payer: Hawaii Medical Service Association Medicare	$3,801.52
Rate for Payer: Hawaii Western Management Group Commercial	$3,501.40
Rate for Payer: Health Management Network Commercial	$4,251.70
Rate for Payer: Humana Medicare	$3,801.52
Rate for Payer: Kaiser Permanente Commercial	$4,501.80
Rate for Payer: Kaiser Permanente Medicaid	$2,551.02
Rate for Payer: Kaiser Permanente Medicare	$3,801.52
Rate for Payer: MDX Hawaii PPO	$4,851.94
Rate for Payer: Ohana Health Plan Medicaid	$3,801.52
Rate for Payer: Ohana Health Plan Medicare	$3,801.52
Rate for Payer: UnitedHealthcare Medicare	$3,801.52
Rate for Payer: University Health Alliance Commercial	$2,801.12

FRN/GT 12X400MM RT 04.033.270S

Facility

$5,002.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$2,801.12
Max. Negotiated Rate	$4,851.94
Rate for Payer: Cash Price	$3,001.20
Rate for Payer: Hawaii Western Management Group Commercial	$3,501.40
Rate for Payer: Health Management Network Commercial	$4,251.70
Rate for Payer: Kaiser Permanente Commercial	$4,501.80
Rate for Payer: MDX Hawaii PPO	$4,851.94
Rate for Payer: University Health Alliance Commercial	$2,801.12

FRN/GT 12X420MM LF 04.033.273S

Facility

$5,002.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$2,801.12
Max. Negotiated Rate	$4,851.94
Rate for Payer: Cash Price	$3,001.20
Rate for Payer: Hawaii Western Management Group Commercial	$3,501.40
Rate for Payer: Health Management Network Commercial	$4,251.70
Rate for Payer: Kaiser Permanente Commercial	$4,501.80
Rate for Payer: MDX Hawaii PPO	$4,851.94
Rate for Payer: University Health Alliance Commercial	$2,801.12

FRN/GT 12X420MM LF 04.033.273S

Facility

$5,002.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$2,501.00
Max. Negotiated Rate	$4,851.94
Rate for Payer: AlohaCare Medicaid	$2,501.00
Rate for Payer: AlohaCare Medicare	$3,801.52
Rate for Payer: Cash Price	$3,001.20
Rate for Payer: Devoted Health Medicare	$4,201.68
Rate for Payer: Hawaii Medical Service Association Medicare	$3,801.52
Rate for Payer: Hawaii Western Management Group Commercial	$3,501.40
Rate for Payer: Health Management Network Commercial	$4,251.70
Rate for Payer: Humana Medicare	$3,801.52
Rate for Payer: Kaiser Permanente Commercial	$4,501.80
Rate for Payer: Kaiser Permanente Medicaid	$2,551.02
Rate for Payer: Kaiser Permanente Medicare	$3,801.52
Rate for Payer: MDX Hawaii PPO	$4,851.94
Rate for Payer: Ohana Health Plan Medicaid	$3,801.52
Rate for Payer: Ohana Health Plan Medicare	$3,801.52
Rate for Payer: UnitedHealthcare Medicare	$3,801.52
Rate for Payer: University Health Alliance Commercial	$2,801.12

FRN/GT 12X420MM RT 04.033.272S

Facility

$5,002.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$2,501.00
Max. Negotiated Rate	$4,851.94
Rate for Payer: AlohaCare Medicaid	$2,501.00
Rate for Payer: AlohaCare Medicare	$3,801.52
Rate for Payer: Cash Price	$3,001.20
Rate for Payer: Devoted Health Medicare	$4,201.68
Rate for Payer: Hawaii Medical Service Association Medicare	$3,801.52
Rate for Payer: Hawaii Western Management Group Commercial	$3,501.40
Rate for Payer: Health Management Network Commercial	$4,251.70
Rate for Payer: Humana Medicare	$3,801.52
Rate for Payer: Kaiser Permanente Commercial	$4,501.80
Rate for Payer: Kaiser Permanente Medicaid	$2,551.02
Rate for Payer: Kaiser Permanente Medicare	$3,801.52
Rate for Payer: MDX Hawaii PPO	$4,851.94
Rate for Payer: Ohana Health Plan Medicaid	$3,801.52
Rate for Payer: Ohana Health Plan Medicare	$3,801.52
Rate for Payer: UnitedHealthcare Medicare	$3,801.52
Rate for Payer: University Health Alliance Commercial	$2,801.12

FRN/GT 12X420MM RT 04.033.272S

Facility

$5,002.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$2,801.12
Max. Negotiated Rate	$4,851.94
Rate for Payer: Cash Price	$3,001.20
Rate for Payer: Hawaii Western Management Group Commercial	$3,501.40
Rate for Payer: Health Management Network Commercial	$4,251.70
Rate for Payer: Kaiser Permanente Commercial	$4,501.80
Rate for Payer: MDX Hawaii PPO	$4,851.94
Rate for Payer: University Health Alliance Commercial	$2,801.12

Know your out-of-pocket cost for care.

All Charges