Honoka'a Hospital and Skilled Nursing Facility

All Charges

Charge

Type

Setting

Price

GORE STRETCH 7X10 S0701

Facility

$668.00

Service Code	HCPCS C1768
Hospital Revenue Code	278
Min. Negotiated Rate	$374.08
Max. Negotiated Rate	$647.96
Rate for Payer: Cash Price	$400.80
Rate for Payer: Hawaii Western Management Group Commercial	$467.60
Rate for Payer: Health Management Network Commercial	$567.80
Rate for Payer: Kaiser Permanente Commercial	$601.20
Rate for Payer: MDX Hawaii PPO	$647.96
Rate for Payer: University Health Alliance Commercial	$374.08

GORE THIN 6MMX50CM HT064050A

Facility

$3,828.00

Service Code	HCPCS C1768
Hospital Revenue Code	278
Min. Negotiated Rate	$1,914.00
Max. Negotiated Rate	$3,713.16
Rate for Payer: AlohaCare Medicaid	$1,914.00
Rate for Payer: AlohaCare Medicare	$2,909.28
Rate for Payer: Cash Price	$2,296.80
Rate for Payer: Devoted Health Medicare	$3,215.52
Rate for Payer: Hawaii Medical Service Association Medicare	$2,909.28
Rate for Payer: Hawaii Western Management Group Commercial	$2,679.60
Rate for Payer: Health Management Network Commercial	$3,253.80
Rate for Payer: Humana Medicare	$2,909.28
Rate for Payer: Kaiser Permanente Commercial	$3,445.20
Rate for Payer: Kaiser Permanente Medicaid	$1,952.28
Rate for Payer: Kaiser Permanente Medicare	$2,909.28
Rate for Payer: MDX Hawaii PPO	$3,713.16
Rate for Payer: Ohana Health Plan Medicaid	$2,909.28
Rate for Payer: Ohana Health Plan Medicare	$2,909.28
Rate for Payer: UnitedHealthcare Medicare	$2,909.28
Rate for Payer: University Health Alliance Commercial	$2,143.68

GORE THIN 6MMX50CM HT064050A

Facility

$3,828.00

Service Code	HCPCS C1768
Hospital Revenue Code	278
Min. Negotiated Rate	$2,143.68
Max. Negotiated Rate	$3,713.16
Rate for Payer: Cash Price	$2,296.80
Rate for Payer: Hawaii Western Management Group Commercial	$2,679.60
Rate for Payer: Health Management Network Commercial	$3,253.80
Rate for Payer: Kaiser Permanente Commercial	$3,445.20
Rate for Payer: MDX Hawaii PPO	$3,713.16
Rate for Payer: University Health Alliance Commercial	$2,143.68

GORE THIN 6MMX80CM HT066080A

Facility

$5,884.00

Service Code	HCPCS C1768
Hospital Revenue Code	278
Min. Negotiated Rate	$3,295.04
Max. Negotiated Rate	$5,707.48
Rate for Payer: Cash Price	$3,530.40
Rate for Payer: Hawaii Western Management Group Commercial	$4,118.80
Rate for Payer: Health Management Network Commercial	$5,001.40
Rate for Payer: Kaiser Permanente Commercial	$5,295.60
Rate for Payer: MDX Hawaii PPO	$5,707.48
Rate for Payer: University Health Alliance Commercial	$3,295.04

GORE THIN 6MMX80CM HT066080A

Facility

$5,884.00

Service Code	HCPCS C1768
Hospital Revenue Code	278
Min. Negotiated Rate	$2,942.00
Max. Negotiated Rate	$5,707.48
Rate for Payer: AlohaCare Medicaid	$2,942.00
Rate for Payer: AlohaCare Medicare	$4,471.84
Rate for Payer: Cash Price	$3,530.40
Rate for Payer: Devoted Health Medicare	$4,942.56
Rate for Payer: Hawaii Medical Service Association Medicare	$4,471.84
Rate for Payer: Hawaii Western Management Group Commercial	$4,118.80
Rate for Payer: Health Management Network Commercial	$5,001.40
Rate for Payer: Humana Medicare	$4,471.84
Rate for Payer: Kaiser Permanente Commercial	$5,295.60
Rate for Payer: Kaiser Permanente Medicaid	$3,000.84
Rate for Payer: Kaiser Permanente Medicare	$4,471.84
Rate for Payer: MDX Hawaii PPO	$5,707.48
Rate for Payer: Ohana Health Plan Medicaid	$4,471.84
Rate for Payer: Ohana Health Plan Medicare	$4,471.84
Rate for Payer: UnitedHealthcare Medicare	$4,471.84
Rate for Payer: University Health Alliance Commercial	$3,295.04

GORE THIN 8MMX40CM HT083040A

Facility

$3,066.00

Service Code	HCPCS C1768
Hospital Revenue Code	278
Min. Negotiated Rate	$1,533.00
Max. Negotiated Rate	$2,974.02
Rate for Payer: AlohaCare Medicaid	$1,533.00
Rate for Payer: AlohaCare Medicare	$2,330.16
Rate for Payer: Cash Price	$1,839.60
Rate for Payer: Devoted Health Medicare	$2,575.44
Rate for Payer: Hawaii Medical Service Association Medicare	$2,330.16
Rate for Payer: Hawaii Western Management Group Commercial	$2,146.20
Rate for Payer: Health Management Network Commercial	$2,606.10
Rate for Payer: Humana Medicare	$2,330.16
Rate for Payer: Kaiser Permanente Commercial	$2,759.40
Rate for Payer: Kaiser Permanente Medicaid	$1,563.66
Rate for Payer: Kaiser Permanente Medicare	$2,330.16
Rate for Payer: MDX Hawaii PPO	$2,974.02
Rate for Payer: Ohana Health Plan Medicaid	$2,330.16
Rate for Payer: Ohana Health Plan Medicare	$2,330.16
Rate for Payer: UnitedHealthcare Medicare	$2,330.16
Rate for Payer: University Health Alliance Commercial	$1,716.96

GORE THIN 8MMX40CM HT083040A

Facility

$3,066.00

Service Code	HCPCS C1768
Hospital Revenue Code	278
Min. Negotiated Rate	$1,716.96
Max. Negotiated Rate	$2,974.02
Rate for Payer: Cash Price	$1,839.60
Rate for Payer: Hawaii Western Management Group Commercial	$2,146.20
Rate for Payer: Health Management Network Commercial	$2,606.10
Rate for Payer: Kaiser Permanente Commercial	$2,759.40
Rate for Payer: MDX Hawaii PPO	$2,974.02
Rate for Payer: University Health Alliance Commercial	$1,716.96

GORE THIN 8MMX50CM HT084050A

Facility

$3,622.00

Service Code	HCPCS C1768
Hospital Revenue Code	278
Min. Negotiated Rate	$2,028.32
Max. Negotiated Rate	$3,513.34
Rate for Payer: Cash Price	$2,173.20
Rate for Payer: Hawaii Western Management Group Commercial	$2,535.40
Rate for Payer: Health Management Network Commercial	$3,078.70
Rate for Payer: Kaiser Permanente Commercial	$3,259.80
Rate for Payer: MDX Hawaii PPO	$3,513.34
Rate for Payer: University Health Alliance Commercial	$2,028.32

GORE THIN 8MMX50CM HT084050A

Facility

$3,622.00

Service Code	HCPCS C1768
Hospital Revenue Code	278
Min. Negotiated Rate	$1,811.00
Max. Negotiated Rate	$3,513.34
Rate for Payer: AlohaCare Medicaid	$1,811.00
Rate for Payer: AlohaCare Medicare	$2,752.72
Rate for Payer: Cash Price	$2,173.20
Rate for Payer: Devoted Health Medicare	$3,042.48
Rate for Payer: Hawaii Medical Service Association Medicare	$2,752.72
Rate for Payer: Hawaii Western Management Group Commercial	$2,535.40
Rate for Payer: Health Management Network Commercial	$3,078.70
Rate for Payer: Humana Medicare	$2,752.72
Rate for Payer: Kaiser Permanente Commercial	$3,259.80
Rate for Payer: Kaiser Permanente Medicaid	$1,847.22
Rate for Payer: Kaiser Permanente Medicare	$2,752.72
Rate for Payer: MDX Hawaii PPO	$3,513.34
Rate for Payer: Ohana Health Plan Medicaid	$2,752.72
Rate for Payer: Ohana Health Plan Medicare	$2,752.72
Rate for Payer: UnitedHealthcare Medicare	$2,752.72
Rate for Payer: University Health Alliance Commercial	$2,028.32

GORE THIN 8MMX80CM HT087080A

Facility

$6,062.00

Service Code	HCPCS C1768
Hospital Revenue Code	278
Min. Negotiated Rate	$3,031.00
Max. Negotiated Rate	$5,880.14
Rate for Payer: AlohaCare Medicaid	$3,031.00
Rate for Payer: AlohaCare Medicare	$4,607.12
Rate for Payer: Cash Price	$3,637.20
Rate for Payer: Devoted Health Medicare	$5,092.08
Rate for Payer: Hawaii Medical Service Association Medicare	$4,607.12
Rate for Payer: Hawaii Western Management Group Commercial	$4,243.40
Rate for Payer: Health Management Network Commercial	$5,152.70
Rate for Payer: Humana Medicare	$4,607.12
Rate for Payer: Kaiser Permanente Commercial	$5,455.80
Rate for Payer: Kaiser Permanente Medicaid	$3,091.62
Rate for Payer: Kaiser Permanente Medicare	$4,607.12
Rate for Payer: MDX Hawaii PPO	$5,880.14
Rate for Payer: Ohana Health Plan Medicaid	$4,607.12
Rate for Payer: Ohana Health Plan Medicare	$4,607.12
Rate for Payer: UnitedHealthcare Medicare	$4,607.12
Rate for Payer: University Health Alliance Commercial	$3,394.72

GORE THIN 8MMX80CM HT087080A

Facility

$6,062.00

Service Code	HCPCS C1768
Hospital Revenue Code	278
Min. Negotiated Rate	$3,394.72
Max. Negotiated Rate	$5,880.14
Rate for Payer: Cash Price	$3,637.20
Rate for Payer: Hawaii Western Management Group Commercial	$4,243.40
Rate for Payer: Health Management Network Commercial	$5,152.70
Rate for Payer: Kaiser Permanente Commercial	$5,455.80
Rate for Payer: MDX Hawaii PPO	$5,880.14
Rate for Payer: University Health Alliance Commercial	$3,394.72

GORE T-IPSI 12/12CM RLT231212

Facility

$22,000.00

Service Code	HCPCS C1768
Hospital Revenue Code	278
Min. Negotiated Rate	$11,000.00
Max. Negotiated Rate	$21,340.00
Rate for Payer: AlohaCare Medicaid	$11,000.00
Rate for Payer: AlohaCare Medicare	$16,720.00
Rate for Payer: Cash Price	$13,200.00
Rate for Payer: Devoted Health Medicare	$18,480.00
Rate for Payer: Hawaii Medical Service Association Medicare	$16,720.00
Rate for Payer: Hawaii Western Management Group Commercial	$15,400.00
Rate for Payer: Health Management Network Commercial	$18,700.00
Rate for Payer: Humana Medicare	$16,720.00
Rate for Payer: Kaiser Permanente Commercial	$19,800.00
Rate for Payer: Kaiser Permanente Medicaid	$11,220.00
Rate for Payer: Kaiser Permanente Medicare	$16,720.00
Rate for Payer: MDX Hawaii PPO	$21,340.00
Rate for Payer: Ohana Health Plan Medicaid	$16,720.00
Rate for Payer: Ohana Health Plan Medicare	$16,720.00
Rate for Payer: UnitedHealthcare Medicare	$16,720.00
Rate for Payer: University Health Alliance Commercial	$12,320.00

GORE T-IPSI 12/12CM RLT231212

Facility

$22,000.00

Service Code	HCPCS C1768
Hospital Revenue Code	278
Min. Negotiated Rate	$12,320.00
Max. Negotiated Rate	$21,340.00
Rate for Payer: Cash Price	$13,200.00
Rate for Payer: Hawaii Western Management Group Commercial	$15,400.00
Rate for Payer: Health Management Network Commercial	$18,700.00
Rate for Payer: Kaiser Permanente Commercial	$19,800.00
Rate for Payer: MDX Hawaii PPO	$21,340.00
Rate for Payer: University Health Alliance Commercial	$12,320.00

GORE T-IPSI 12/12CM RLT261212

Facility

$22,000.00

Service Code	HCPCS C1768
Hospital Revenue Code	278
Min. Negotiated Rate	$11,000.00
Max. Negotiated Rate	$21,340.00
Rate for Payer: AlohaCare Medicaid	$11,000.00
Rate for Payer: AlohaCare Medicare	$16,720.00
Rate for Payer: Cash Price	$13,200.00
Rate for Payer: Devoted Health Medicare	$18,480.00
Rate for Payer: Hawaii Medical Service Association Medicare	$16,720.00
Rate for Payer: Hawaii Western Management Group Commercial	$15,400.00
Rate for Payer: Health Management Network Commercial	$18,700.00
Rate for Payer: Humana Medicare	$16,720.00
Rate for Payer: Kaiser Permanente Commercial	$19,800.00
Rate for Payer: Kaiser Permanente Medicaid	$11,220.00
Rate for Payer: Kaiser Permanente Medicare	$16,720.00
Rate for Payer: MDX Hawaii PPO	$21,340.00
Rate for Payer: Ohana Health Plan Medicaid	$16,720.00
Rate for Payer: Ohana Health Plan Medicare	$16,720.00
Rate for Payer: UnitedHealthcare Medicare	$16,720.00
Rate for Payer: University Health Alliance Commercial	$12,320.00

GORE T-IPSI 12/12CM RLT261212

Facility

$22,000.00

Service Code	HCPCS C1768
Hospital Revenue Code	278
Min. Negotiated Rate	$12,320.00
Max. Negotiated Rate	$21,340.00
Rate for Payer: Cash Price	$13,200.00
Rate for Payer: Hawaii Western Management Group Commercial	$15,400.00
Rate for Payer: Health Management Network Commercial	$18,700.00
Rate for Payer: Kaiser Permanente Commercial	$19,800.00
Rate for Payer: MDX Hawaii PPO	$21,340.00
Rate for Payer: University Health Alliance Commercial	$12,320.00

GORE T-IPSI 12/12CM RLT281212

Facility

$22,000.00

Service Code	HCPCS C1768
Hospital Revenue Code	278
Min. Negotiated Rate	$12,320.00
Max. Negotiated Rate	$21,340.00
Rate for Payer: Cash Price	$13,200.00
Rate for Payer: Hawaii Western Management Group Commercial	$15,400.00
Rate for Payer: Health Management Network Commercial	$18,700.00
Rate for Payer: Kaiser Permanente Commercial	$19,800.00
Rate for Payer: MDX Hawaii PPO	$21,340.00
Rate for Payer: University Health Alliance Commercial	$12,320.00

GORE T-IPSI 12/12CM RLT281212

Facility

$22,000.00

Service Code	HCPCS C1768
Hospital Revenue Code	278
Min. Negotiated Rate	$11,000.00
Max. Negotiated Rate	$21,340.00
Rate for Payer: AlohaCare Medicaid	$11,000.00
Rate for Payer: AlohaCare Medicare	$16,720.00
Rate for Payer: Cash Price	$13,200.00
Rate for Payer: Devoted Health Medicare	$18,480.00
Rate for Payer: Hawaii Medical Service Association Medicare	$16,720.00
Rate for Payer: Hawaii Western Management Group Commercial	$15,400.00
Rate for Payer: Health Management Network Commercial	$18,700.00
Rate for Payer: Humana Medicare	$16,720.00
Rate for Payer: Kaiser Permanente Commercial	$19,800.00
Rate for Payer: Kaiser Permanente Medicaid	$11,220.00
Rate for Payer: Kaiser Permanente Medicare	$16,720.00
Rate for Payer: MDX Hawaii PPO	$21,340.00
Rate for Payer: Ohana Health Plan Medicaid	$16,720.00
Rate for Payer: Ohana Health Plan Medicare	$16,720.00
Rate for Payer: UnitedHealthcare Medicare	$16,720.00
Rate for Payer: University Health Alliance Commercial	$12,320.00

GORE T-IPSI 12/14CM RLT231214

Facility

$22,000.00

Service Code	HCPCS C1768
Hospital Revenue Code	278
Min. Negotiated Rate	$11,000.00
Max. Negotiated Rate	$21,340.00
Rate for Payer: AlohaCare Medicaid	$11,000.00
Rate for Payer: AlohaCare Medicare	$16,720.00
Rate for Payer: Cash Price	$13,200.00
Rate for Payer: Devoted Health Medicare	$18,480.00
Rate for Payer: Hawaii Medical Service Association Medicare	$16,720.00
Rate for Payer: Hawaii Western Management Group Commercial	$15,400.00
Rate for Payer: Health Management Network Commercial	$18,700.00
Rate for Payer: Humana Medicare	$16,720.00
Rate for Payer: Kaiser Permanente Commercial	$19,800.00
Rate for Payer: Kaiser Permanente Medicaid	$11,220.00
Rate for Payer: Kaiser Permanente Medicare	$16,720.00
Rate for Payer: MDX Hawaii PPO	$21,340.00
Rate for Payer: Ohana Health Plan Medicaid	$16,720.00
Rate for Payer: Ohana Health Plan Medicare	$16,720.00
Rate for Payer: UnitedHealthcare Medicare	$16,720.00
Rate for Payer: University Health Alliance Commercial	$12,320.00

GORE T-IPSI 12/14CM RLT231214

Facility

$22,000.00

Service Code	HCPCS C1768
Hospital Revenue Code	278
Min. Negotiated Rate	$12,320.00
Max. Negotiated Rate	$21,340.00
Rate for Payer: Cash Price	$13,200.00
Rate for Payer: Hawaii Western Management Group Commercial	$15,400.00
Rate for Payer: Health Management Network Commercial	$18,700.00
Rate for Payer: Kaiser Permanente Commercial	$19,800.00
Rate for Payer: MDX Hawaii PPO	$21,340.00
Rate for Payer: University Health Alliance Commercial	$12,320.00

GORE T-IPSI 12/14CM RLT261214

Facility

$22,550.00

Service Code	HCPCS C1768
Hospital Revenue Code	278
Min. Negotiated Rate	$12,628.00
Max. Negotiated Rate	$21,873.50
Rate for Payer: Cash Price	$13,530.00
Rate for Payer: Hawaii Western Management Group Commercial	$15,785.00
Rate for Payer: Health Management Network Commercial	$19,167.50
Rate for Payer: Kaiser Permanente Commercial	$20,295.00
Rate for Payer: MDX Hawaii PPO	$21,873.50
Rate for Payer: University Health Alliance Commercial	$12,628.00

GORE T-IPSI 12/14CM RLT261214

Facility

$22,550.00

Service Code	HCPCS C1768
Hospital Revenue Code	278
Min. Negotiated Rate	$11,275.00
Max. Negotiated Rate	$21,873.50
Rate for Payer: AlohaCare Medicaid	$11,275.00
Rate for Payer: AlohaCare Medicare	$17,138.00
Rate for Payer: Cash Price	$13,530.00
Rate for Payer: Devoted Health Medicare	$18,942.00
Rate for Payer: Hawaii Medical Service Association Medicare	$17,138.00
Rate for Payer: Hawaii Western Management Group Commercial	$15,785.00
Rate for Payer: Health Management Network Commercial	$19,167.50
Rate for Payer: Humana Medicare	$17,138.00
Rate for Payer: Kaiser Permanente Commercial	$20,295.00
Rate for Payer: Kaiser Permanente Medicaid	$11,500.50
Rate for Payer: Kaiser Permanente Medicare	$17,138.00
Rate for Payer: MDX Hawaii PPO	$21,873.50
Rate for Payer: Ohana Health Plan Medicaid	$17,138.00
Rate for Payer: Ohana Health Plan Medicare	$17,138.00
Rate for Payer: UnitedHealthcare Medicare	$17,138.00
Rate for Payer: University Health Alliance Commercial	$12,628.00

GORE T-IPSI 12/14CM RLT281214

Facility

$22,000.00

Service Code	HCPCS C1768
Hospital Revenue Code	278
Min. Negotiated Rate	$11,000.00
Max. Negotiated Rate	$21,340.00
Rate for Payer: AlohaCare Medicaid	$11,000.00
Rate for Payer: AlohaCare Medicare	$16,720.00
Rate for Payer: Cash Price	$13,200.00
Rate for Payer: Devoted Health Medicare	$18,480.00
Rate for Payer: Hawaii Medical Service Association Medicare	$16,720.00
Rate for Payer: Hawaii Western Management Group Commercial	$15,400.00
Rate for Payer: Health Management Network Commercial	$18,700.00
Rate for Payer: Humana Medicare	$16,720.00
Rate for Payer: Kaiser Permanente Commercial	$19,800.00
Rate for Payer: Kaiser Permanente Medicaid	$11,220.00
Rate for Payer: Kaiser Permanente Medicare	$16,720.00
Rate for Payer: MDX Hawaii PPO	$21,340.00
Rate for Payer: Ohana Health Plan Medicaid	$16,720.00
Rate for Payer: Ohana Health Plan Medicare	$16,720.00
Rate for Payer: UnitedHealthcare Medicare	$16,720.00
Rate for Payer: University Health Alliance Commercial	$12,320.00

GORE T-IPSI 12/14CM RLT281214

Facility

$22,000.00

Service Code	HCPCS C1768
Hospital Revenue Code	278
Min. Negotiated Rate	$12,320.00
Max. Negotiated Rate	$21,340.00
Rate for Payer: Cash Price	$13,200.00
Rate for Payer: Hawaii Western Management Group Commercial	$15,400.00
Rate for Payer: Health Management Network Commercial	$18,700.00
Rate for Payer: Kaiser Permanente Commercial	$19,800.00
Rate for Payer: MDX Hawaii PPO	$21,340.00
Rate for Payer: University Health Alliance Commercial	$12,320.00

GORE T-IPSI 12/16CM RLT231216

Facility

$22,000.00

Service Code	HCPCS C1768
Hospital Revenue Code	278
Min. Negotiated Rate	$12,320.00
Max. Negotiated Rate	$21,340.00
Rate for Payer: Cash Price	$13,200.00
Rate for Payer: Hawaii Western Management Group Commercial	$15,400.00
Rate for Payer: Health Management Network Commercial	$18,700.00
Rate for Payer: Kaiser Permanente Commercial	$19,800.00
Rate for Payer: MDX Hawaii PPO	$21,340.00
Rate for Payer: University Health Alliance Commercial	$12,320.00

GORE T-IPSI 12/16CM RLT231216

Facility

$22,000.00

Service Code	HCPCS C1768
Hospital Revenue Code	278
Min. Negotiated Rate	$11,000.00
Max. Negotiated Rate	$21,340.00
Rate for Payer: AlohaCare Medicaid	$11,000.00
Rate for Payer: AlohaCare Medicare	$16,720.00
Rate for Payer: Cash Price	$13,200.00
Rate for Payer: Devoted Health Medicare	$18,480.00
Rate for Payer: Hawaii Medical Service Association Medicare	$16,720.00
Rate for Payer: Hawaii Western Management Group Commercial	$15,400.00
Rate for Payer: Health Management Network Commercial	$18,700.00
Rate for Payer: Humana Medicare	$16,720.00
Rate for Payer: Kaiser Permanente Commercial	$19,800.00
Rate for Payer: Kaiser Permanente Medicaid	$11,220.00
Rate for Payer: Kaiser Permanente Medicare	$16,720.00
Rate for Payer: MDX Hawaii PPO	$21,340.00
Rate for Payer: Ohana Health Plan Medicaid	$16,720.00
Rate for Payer: Ohana Health Plan Medicare	$16,720.00
Rate for Payer: UnitedHealthcare Medicare	$16,720.00
Rate for Payer: University Health Alliance Commercial	$12,320.00

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