Honoka'a Hospital and Skilled Nursing Facility

All Charges

Charge

Type

Setting

Price

GII QUICKANCHOR SZ 2 222983

Facility

$2,487.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,243.50
Max. Negotiated Rate	$2,412.39
Rate for Payer: AlohaCare Medicaid	$1,243.50
Rate for Payer: AlohaCare Medicare	$1,890.12
Rate for Payer: Cash Price	$1,492.20
Rate for Payer: Devoted Health Medicare	$2,089.08
Rate for Payer: Hawaii Medical Service Association Medicare	$1,890.12
Rate for Payer: Hawaii Western Management Group Commercial	$1,740.90
Rate for Payer: Health Management Network Commercial	$2,113.95
Rate for Payer: Humana Medicare	$1,890.12
Rate for Payer: Kaiser Permanente Commercial	$2,238.30
Rate for Payer: Kaiser Permanente Medicaid	$1,268.37
Rate for Payer: Kaiser Permanente Medicare	$1,890.12
Rate for Payer: MDX Hawaii PPO	$2,412.39
Rate for Payer: Ohana Health Plan Medicaid	$1,890.12
Rate for Payer: Ohana Health Plan Medicare	$1,890.12
Rate for Payer: UnitedHealthcare Medicare	$1,890.12
Rate for Payer: University Health Alliance Commercial	$1,392.72

GII QUICKANCHOR SZ 2 222983

Facility

$2,487.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,392.72
Max. Negotiated Rate	$2,412.39
Rate for Payer: Cash Price	$1,492.20
Rate for Payer: Hawaii Western Management Group Commercial	$1,740.90
Rate for Payer: Health Management Network Commercial	$2,113.95
Rate for Payer: Kaiser Permanente Commercial	$2,238.30
Rate for Payer: MDX Hawaii PPO	$2,412.39
Rate for Payer: University Health Alliance Commercial	$1,392.72

GLENOID 4MM MED HYBRID 113954

Facility

$3,000.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$1,500.00
Max. Negotiated Rate	$2,910.00
Rate for Payer: AlohaCare Medicaid	$1,500.00
Rate for Payer: AlohaCare Medicare	$2,280.00
Rate for Payer: Cash Price	$1,800.00
Rate for Payer: Devoted Health Medicare	$2,520.00
Rate for Payer: Hawaii Medical Service Association Medicare	$2,280.00
Rate for Payer: Hawaii Western Management Group Commercial	$2,100.00
Rate for Payer: Health Management Network Commercial	$2,550.00
Rate for Payer: Humana Medicare	$2,280.00
Rate for Payer: Kaiser Permanente Commercial	$2,700.00
Rate for Payer: Kaiser Permanente Medicaid	$1,530.00
Rate for Payer: Kaiser Permanente Medicare	$2,280.00
Rate for Payer: MDX Hawaii PPO	$2,910.00
Rate for Payer: Ohana Health Plan Medicaid	$2,280.00
Rate for Payer: Ohana Health Plan Medicare	$2,280.00
Rate for Payer: UnitedHealthcare Medicare	$2,280.00
Rate for Payer: University Health Alliance Commercial	$1,680.00

GLENOID 4MM MED HYBRID 113954

Facility

$3,000.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$1,680.00
Max. Negotiated Rate	$2,910.00
Rate for Payer: Cash Price	$1,800.00
Rate for Payer: Hawaii Western Management Group Commercial	$2,100.00
Rate for Payer: Health Management Network Commercial	$2,550.00
Rate for Payer: Kaiser Permanente Commercial	$2,700.00
Rate for Payer: MDX Hawaii PPO	$2,910.00
Rate for Payer: University Health Alliance Commercial	$1,680.00

GLENOID 52MM REUN 5542-P-0052

Facility

$4,721.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$2,643.76
Max. Negotiated Rate	$4,579.37
Rate for Payer: Cash Price	$2,832.60
Rate for Payer: Hawaii Western Management Group Commercial	$3,304.70
Rate for Payer: Health Management Network Commercial	$4,012.85
Rate for Payer: Kaiser Permanente Commercial	$4,248.90
Rate for Payer: MDX Hawaii PPO	$4,579.37
Rate for Payer: University Health Alliance Commercial	$2,643.76

GLENOID 52MM REUN 5542-P-0052

Facility

$4,721.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$2,360.50
Max. Negotiated Rate	$4,579.37
Rate for Payer: AlohaCare Medicaid	$2,360.50
Rate for Payer: AlohaCare Medicare	$3,587.96
Rate for Payer: Cash Price	$2,832.60
Rate for Payer: Devoted Health Medicare	$3,965.64
Rate for Payer: Hawaii Medical Service Association Medicare	$3,587.96
Rate for Payer: Hawaii Western Management Group Commercial	$3,304.70
Rate for Payer: Health Management Network Commercial	$4,012.85
Rate for Payer: Humana Medicare	$3,587.96
Rate for Payer: Kaiser Permanente Commercial	$4,248.90
Rate for Payer: Kaiser Permanente Medicaid	$2,407.71
Rate for Payer: Kaiser Permanente Medicare	$3,587.96
Rate for Payer: MDX Hawaii PPO	$4,579.37
Rate for Payer: Ohana Health Plan Medicaid	$3,587.96
Rate for Payer: Ohana Health Plan Medicare	$3,587.96
Rate for Payer: UnitedHealthcare Medicare	$3,587.96
Rate for Payer: University Health Alliance Commercial	$2,643.76

GLENOID ARTICULAR G203-2010-W

Facility

$4,550.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$2,548.00
Max. Negotiated Rate	$4,413.50
Rate for Payer: Cash Price	$2,730.00
Rate for Payer: Hawaii Western Management Group Commercial	$3,185.00
Rate for Payer: Health Management Network Commercial	$3,867.50
Rate for Payer: Kaiser Permanente Commercial	$4,095.00
Rate for Payer: MDX Hawaii PPO	$4,413.50
Rate for Payer: University Health Alliance Commercial	$2,548.00

GLENOID ARTICULAR G203-2010-W

Facility

$4,550.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$2,275.00
Max. Negotiated Rate	$4,413.50
Rate for Payer: AlohaCare Medicaid	$2,275.00
Rate for Payer: AlohaCare Medicare	$3,458.00
Rate for Payer: Cash Price	$2,730.00
Rate for Payer: Devoted Health Medicare	$3,822.00
Rate for Payer: Hawaii Medical Service Association Medicare	$3,458.00
Rate for Payer: Hawaii Western Management Group Commercial	$3,185.00
Rate for Payer: Health Management Network Commercial	$3,867.50
Rate for Payer: Humana Medicare	$3,458.00
Rate for Payer: Kaiser Permanente Commercial	$4,095.00
Rate for Payer: Kaiser Permanente Medicaid	$2,320.50
Rate for Payer: Kaiser Permanente Medicare	$3,458.00
Rate for Payer: MDX Hawaii PPO	$4,413.50
Rate for Payer: Ohana Health Plan Medicaid	$3,458.00
Rate for Payer: Ohana Health Plan Medicare	$3,458.00
Rate for Payer: UnitedHealthcare Medicare	$3,458.00
Rate for Payer: University Health Alliance Commercial	$2,548.00

GLENOID CORTILOC PEGGED DWE401

Facility

$4,628.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$2,591.68
Max. Negotiated Rate	$4,489.16
Rate for Payer: Cash Price	$2,776.80
Rate for Payer: Hawaii Western Management Group Commercial	$3,239.60
Rate for Payer: Health Management Network Commercial	$3,933.80
Rate for Payer: Kaiser Permanente Commercial	$4,165.20
Rate for Payer: MDX Hawaii PPO	$4,489.16
Rate for Payer: University Health Alliance Commercial	$2,591.68

GLENOID CORTILOC PEGGED DWE401

Facility

$4,628.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$2,314.00
Max. Negotiated Rate	$4,489.16
Rate for Payer: AlohaCare Medicaid	$2,314.00
Rate for Payer: AlohaCare Medicare	$3,517.28
Rate for Payer: Cash Price	$2,776.80
Rate for Payer: Devoted Health Medicare	$3,887.52
Rate for Payer: Hawaii Medical Service Association Medicare	$3,517.28
Rate for Payer: Hawaii Western Management Group Commercial	$3,239.60
Rate for Payer: Health Management Network Commercial	$3,933.80
Rate for Payer: Humana Medicare	$3,517.28
Rate for Payer: Kaiser Permanente Commercial	$4,165.20
Rate for Payer: Kaiser Permanente Medicaid	$2,360.28
Rate for Payer: Kaiser Permanente Medicare	$3,517.28
Rate for Payer: MDX Hawaii PPO	$4,489.16
Rate for Payer: Ohana Health Plan Medicaid	$3,517.28
Rate for Payer: Ohana Health Plan Medicare	$3,517.28
Rate for Payer: UnitedHealthcare Medicare	$3,517.28
Rate for Payer: University Health Alliance Commercial	$2,591.68

GLENOID HEAD AS 01.04223.236

Facility

$3,444.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$1,722.00
Max. Negotiated Rate	$3,340.68
Rate for Payer: AlohaCare Medicaid	$1,722.00
Rate for Payer: AlohaCare Medicare	$2,617.44
Rate for Payer: Cash Price	$2,066.40
Rate for Payer: Devoted Health Medicare	$2,892.96
Rate for Payer: Hawaii Medical Service Association Medicare	$2,617.44
Rate for Payer: Hawaii Western Management Group Commercial	$2,410.80
Rate for Payer: Health Management Network Commercial	$2,927.40
Rate for Payer: Humana Medicare	$2,617.44
Rate for Payer: Kaiser Permanente Commercial	$3,099.60
Rate for Payer: Kaiser Permanente Medicaid	$1,756.44
Rate for Payer: Kaiser Permanente Medicare	$2,617.44
Rate for Payer: MDX Hawaii PPO	$3,340.68
Rate for Payer: Ohana Health Plan Medicaid	$2,617.44
Rate for Payer: Ohana Health Plan Medicare	$2,617.44
Rate for Payer: UnitedHealthcare Medicare	$2,617.44
Rate for Payer: University Health Alliance Commercial	$1,928.64

GLENOID HEAD AS 01.04223.236

Facility

$3,444.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$1,928.64
Max. Negotiated Rate	$3,340.68
Rate for Payer: Cash Price	$2,066.40
Rate for Payer: Hawaii Western Management Group Commercial	$2,410.80
Rate for Payer: Health Management Network Commercial	$2,927.40
Rate for Payer: Kaiser Permanente Commercial	$3,099.60
Rate for Payer: MDX Hawaii PPO	$3,340.68
Rate for Payer: University Health Alliance Commercial	$1,928.64

GLENOID LATERALIZED BASEPLATE

Facility

$3,000.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$1,500.00
Max. Negotiated Rate	$2,910.00
Rate for Payer: AlohaCare Medicaid	$1,500.00
Rate for Payer: AlohaCare Medicare	$2,280.00
Rate for Payer: Cash Price	$1,800.00
Rate for Payer: Devoted Health Medicare	$2,520.00
Rate for Payer: Hawaii Medical Service Association Medicare	$2,280.00
Rate for Payer: Hawaii Western Management Group Commercial	$2,100.00
Rate for Payer: Health Management Network Commercial	$2,550.00
Rate for Payer: Humana Medicare	$2,280.00
Rate for Payer: Kaiser Permanente Commercial	$2,700.00
Rate for Payer: Kaiser Permanente Medicaid	$1,530.00
Rate for Payer: Kaiser Permanente Medicare	$2,280.00
Rate for Payer: MDX Hawaii PPO	$2,910.00
Rate for Payer: Ohana Health Plan Medicaid	$2,280.00
Rate for Payer: Ohana Health Plan Medicare	$2,280.00
Rate for Payer: UnitedHealthcare Medicare	$2,280.00
Rate for Payer: University Health Alliance Commercial	$1,680.00

GLENOID LATERALIZED BASEPLATE

Facility

$3,000.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$1,680.00
Max. Negotiated Rate	$2,910.00
Rate for Payer: Cash Price	$1,800.00
Rate for Payer: Hawaii Western Management Group Commercial	$2,100.00
Rate for Payer: Health Management Network Commercial	$2,550.00
Rate for Payer: Kaiser Permanente Commercial	$2,700.00
Rate for Payer: MDX Hawaii PPO	$2,910.00
Rate for Payer: University Health Alliance Commercial	$1,680.00

GLENOID LATERALIZED DWJ022

Facility

$9,566.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$4,783.00
Max. Negotiated Rate	$9,279.02
Rate for Payer: AlohaCare Medicaid	$4,783.00
Rate for Payer: AlohaCare Medicare	$7,270.16
Rate for Payer: Cash Price	$5,739.60
Rate for Payer: Devoted Health Medicare	$8,035.44
Rate for Payer: Hawaii Medical Service Association Medicare	$7,270.16
Rate for Payer: Hawaii Western Management Group Commercial	$6,696.20
Rate for Payer: Health Management Network Commercial	$8,131.10
Rate for Payer: Humana Medicare	$7,270.16
Rate for Payer: Kaiser Permanente Commercial	$8,609.40
Rate for Payer: Kaiser Permanente Medicaid	$4,878.66
Rate for Payer: Kaiser Permanente Medicare	$7,270.16
Rate for Payer: MDX Hawaii PPO	$9,279.02
Rate for Payer: Ohana Health Plan Medicaid	$7,270.16
Rate for Payer: Ohana Health Plan Medicare	$7,270.16
Rate for Payer: UnitedHealthcare Medicare	$7,270.16
Rate for Payer: University Health Alliance Commercial	$5,356.96

GLENOID LATERALIZED DWJ022

Facility

$9,566.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$5,356.96
Max. Negotiated Rate	$9,279.02
Rate for Payer: Cash Price	$5,739.60
Rate for Payer: Hawaii Western Management Group Commercial	$6,696.20
Rate for Payer: Health Management Network Commercial	$8,131.10
Rate for Payer: Kaiser Permanente Commercial	$8,609.40
Rate for Payer: MDX Hawaii PPO	$9,279.02
Rate for Payer: University Health Alliance Commercial	$5,356.96

GLENOID MED PE PEG AR-9105-02

Facility

$3,150.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$1,575.00
Max. Negotiated Rate	$3,055.50
Rate for Payer: AlohaCare Medicaid	$1,575.00
Rate for Payer: AlohaCare Medicare	$2,394.00
Rate for Payer: Cash Price	$1,890.00
Rate for Payer: Devoted Health Medicare	$2,646.00
Rate for Payer: Hawaii Medical Service Association Medicare	$2,394.00
Rate for Payer: Hawaii Western Management Group Commercial	$2,205.00
Rate for Payer: Health Management Network Commercial	$2,677.50
Rate for Payer: Humana Medicare	$2,394.00
Rate for Payer: Kaiser Permanente Commercial	$2,835.00
Rate for Payer: Kaiser Permanente Medicaid	$1,606.50
Rate for Payer: Kaiser Permanente Medicare	$2,394.00
Rate for Payer: MDX Hawaii PPO	$3,055.50
Rate for Payer: Ohana Health Plan Medicaid	$2,394.00
Rate for Payer: Ohana Health Plan Medicare	$2,394.00
Rate for Payer: UnitedHealthcare Medicare	$2,394.00
Rate for Payer: University Health Alliance Commercial	$1,764.00

GLENOID MED PE PEG AR-9105-02

Facility

$3,150.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$1,764.00
Max. Negotiated Rate	$3,055.50
Rate for Payer: Cash Price	$1,890.00
Rate for Payer: Hawaii Western Management Group Commercial	$2,205.00
Rate for Payer: Health Management Network Commercial	$2,677.50
Rate for Payer: Kaiser Permanente Commercial	$2,835.00
Rate for Payer: MDX Hawaii PPO	$3,055.50
Rate for Payer: University Health Alliance Commercial	$1,764.00

GLENOID POLY PEG SM AR-9105-01

Facility

$4,500.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$2,250.00
Max. Negotiated Rate	$4,365.00
Rate for Payer: AlohaCare Medicaid	$2,250.00
Rate for Payer: AlohaCare Medicare	$3,420.00
Rate for Payer: Cash Price	$2,700.00
Rate for Payer: Devoted Health Medicare	$3,780.00
Rate for Payer: Hawaii Medical Service Association Medicare	$3,420.00
Rate for Payer: Hawaii Western Management Group Commercial	$3,150.00
Rate for Payer: Health Management Network Commercial	$3,825.00
Rate for Payer: Humana Medicare	$3,420.00
Rate for Payer: Kaiser Permanente Commercial	$4,050.00
Rate for Payer: Kaiser Permanente Medicaid	$2,295.00
Rate for Payer: Kaiser Permanente Medicare	$3,420.00
Rate for Payer: MDX Hawaii PPO	$4,365.00
Rate for Payer: Ohana Health Plan Medicaid	$3,420.00
Rate for Payer: Ohana Health Plan Medicare	$3,420.00
Rate for Payer: UnitedHealthcare Medicare	$3,420.00
Rate for Payer: University Health Alliance Commercial	$2,520.00

GLENOID POLY PEG SM AR-9105-01

Facility

$4,500.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$2,520.00
Max. Negotiated Rate	$4,365.00
Rate for Payer: Cash Price	$2,700.00
Rate for Payer: Hawaii Western Management Group Commercial	$3,150.00
Rate for Payer: Health Management Network Commercial	$3,825.00
Rate for Payer: Kaiser Permanente Commercial	$4,050.00
Rate for Payer: MDX Hawaii PPO	$4,365.00
Rate for Payer: University Health Alliance Commercial	$2,520.00

GLENOID PRESS-FIT SHORT POST

Facility

$1,605.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$802.50
Max. Negotiated Rate	$1,556.85
Rate for Payer: AlohaCare Medicaid	$802.50
Rate for Payer: AlohaCare Medicare	$1,219.80
Rate for Payer: Cash Price	$963.00
Rate for Payer: Devoted Health Medicare	$1,348.20
Rate for Payer: Hawaii Medical Service Association Medicare	$1,219.80
Rate for Payer: Hawaii Western Management Group Commercial	$1,123.50
Rate for Payer: Health Management Network Commercial	$1,364.25
Rate for Payer: Humana Medicare	$1,219.80
Rate for Payer: Kaiser Permanente Commercial	$1,444.50
Rate for Payer: Kaiser Permanente Medicaid	$818.55
Rate for Payer: Kaiser Permanente Medicare	$1,219.80
Rate for Payer: MDX Hawaii PPO	$1,556.85
Rate for Payer: Ohana Health Plan Medicaid	$1,219.80
Rate for Payer: Ohana Health Plan Medicare	$1,219.80
Rate for Payer: UnitedHealthcare Medicare	$1,219.80
Rate for Payer: University Health Alliance Commercial	$898.80

GLENOID PRESS-FIT SHORT POST

Facility

$1,605.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$898.80
Max. Negotiated Rate	$1,556.85
Rate for Payer: Cash Price	$963.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,123.50
Rate for Payer: Health Management Network Commercial	$1,364.25
Rate for Payer: Kaiser Permanente Commercial	$1,444.50
Rate for Payer: MDX Hawaii PPO	$1,556.85
Rate for Payer: University Health Alliance Commercial	$898.80

GLENOID PT HYBRID PT-113950

Facility

$1,050.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$525.00
Max. Negotiated Rate	$1,018.50
Rate for Payer: AlohaCare Medicaid	$525.00
Rate for Payer: AlohaCare Medicare	$798.00
Rate for Payer: Cash Price	$630.00
Rate for Payer: Devoted Health Medicare	$882.00
Rate for Payer: Hawaii Medical Service Association Medicare	$798.00
Rate for Payer: Hawaii Western Management Group Commercial	$735.00
Rate for Payer: Health Management Network Commercial	$892.50
Rate for Payer: Humana Medicare	$798.00
Rate for Payer: Kaiser Permanente Commercial	$945.00
Rate for Payer: Kaiser Permanente Medicaid	$535.50
Rate for Payer: Kaiser Permanente Medicare	$798.00
Rate for Payer: MDX Hawaii PPO	$1,018.50
Rate for Payer: Ohana Health Plan Medicaid	$798.00
Rate for Payer: Ohana Health Plan Medicare	$798.00
Rate for Payer: UnitedHealthcare Medicare	$798.00
Rate for Payer: University Health Alliance Commercial	$588.00

GLENOID PT HYBRID PT-113950

Facility

$1,050.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$588.00
Max. Negotiated Rate	$1,018.50
Rate for Payer: Cash Price	$630.00
Rate for Payer: Hawaii Western Management Group Commercial	$735.00
Rate for Payer: Health Management Network Commercial	$892.50
Rate for Payer: Kaiser Permanente Commercial	$945.00
Rate for Payer: MDX Hawaii PPO	$1,018.50
Rate for Payer: University Health Alliance Commercial	$588.00

GLENOID REVERSE AUGMENT DWJ505

Facility

$3,000.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$1,680.00
Max. Negotiated Rate	$2,910.00
Rate for Payer: Cash Price	$1,800.00
Rate for Payer: Hawaii Western Management Group Commercial	$2,100.00
Rate for Payer: Health Management Network Commercial	$2,550.00
Rate for Payer: Kaiser Permanente Commercial	$2,700.00
Rate for Payer: MDX Hawaii PPO	$2,910.00
Rate for Payer: University Health Alliance Commercial	$1,680.00

Know your out-of-pocket cost for care.

All Charges