Honoka'a Hospital and Skilled Nursing Facility

All Charges

Charge

Type

Setting

Price

GORE T-IPSI 14.5/15 RLT311415

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 14.5/16 RLT231416

Facility

$26,882.00

Service Code	HCPCS C1768
Hospital Revenue Code	278
Min. Negotiated Rate	$15,053.92
Max. Negotiated Rate	$26,075.54
Rate for Payer: Cash Price	$16,129.20
Rate for Payer: Hawaii Western Management Group Commercial	$18,817.40
Rate for Payer: Health Management Network Commercial	$22,849.70
Rate for Payer: Kaiser Permanente Commercial	$24,193.80
Rate for Payer: MDX Hawaii PPO	$26,075.54
Rate for Payer: University Health Alliance Commercial	$15,053.92

GORE T-IPSI 14.5/16 RLT231416

Facility

$26,882.00

Service Code	HCPCS C1768
Hospital Revenue Code	278
Min. Negotiated Rate	$13,441.00
Max. Negotiated Rate	$26,075.54
Rate for Payer: AlohaCare Medicaid	$13,441.00
Rate for Payer: AlohaCare Medicare	$20,430.32
Rate for Payer: Cash Price	$16,129.20
Rate for Payer: Devoted Health Medicare	$22,580.88
Rate for Payer: Hawaii Medical Service Association Medicare	$20,430.32
Rate for Payer: Hawaii Western Management Group Commercial	$18,817.40
Rate for Payer: Health Management Network Commercial	$22,849.70
Rate for Payer: Humana Medicare	$20,430.32
Rate for Payer: Kaiser Permanente Commercial	$24,193.80
Rate for Payer: Kaiser Permanente Medicaid	$13,709.82
Rate for Payer: Kaiser Permanente Medicare	$20,430.32
Rate for Payer: MDX Hawaii PPO	$26,075.54
Rate for Payer: Ohana Health Plan Medicaid	$20,430.32
Rate for Payer: Ohana Health Plan Medicare	$20,430.32
Rate for Payer: UnitedHealthcare Medicare	$20,430.32
Rate for Payer: University Health Alliance Commercial	$15,053.92

GORE T-IPSI 14.5/16 RLT261416

Facility

$25,266.00

Service Code	HCPCS C1768
Hospital Revenue Code	278
Min. Negotiated Rate	$14,148.96
Max. Negotiated Rate	$24,508.02
Rate for Payer: Cash Price	$15,159.60
Rate for Payer: Hawaii Western Management Group Commercial	$17,686.20
Rate for Payer: Health Management Network Commercial	$21,476.10
Rate for Payer: Kaiser Permanente Commercial	$22,739.40
Rate for Payer: MDX Hawaii PPO	$24,508.02
Rate for Payer: University Health Alliance Commercial	$14,148.96

GORE T-IPSI 14.5/16 RLT261416

Facility

$25,266.00

Service Code	HCPCS C1768
Hospital Revenue Code	278
Min. Negotiated Rate	$12,633.00
Max. Negotiated Rate	$24,508.02
Rate for Payer: AlohaCare Medicaid	$12,633.00
Rate for Payer: AlohaCare Medicare	$19,202.16
Rate for Payer: Cash Price	$15,159.60
Rate for Payer: Devoted Health Medicare	$21,223.44
Rate for Payer: Hawaii Medical Service Association Medicare	$19,202.16
Rate for Payer: Hawaii Western Management Group Commercial	$17,686.20
Rate for Payer: Health Management Network Commercial	$21,476.10
Rate for Payer: Humana Medicare	$19,202.16
Rate for Payer: Kaiser Permanente Commercial	$22,739.40
Rate for Payer: Kaiser Permanente Medicaid	$12,885.66
Rate for Payer: Kaiser Permanente Medicare	$19,202.16
Rate for Payer: MDX Hawaii PPO	$24,508.02
Rate for Payer: Ohana Health Plan Medicaid	$19,202.16
Rate for Payer: Ohana Health Plan Medicare	$19,202.16
Rate for Payer: UnitedHealthcare Medicare	$19,202.16
Rate for Payer: University Health Alliance Commercial	$14,148.96

GORE T-IPSI 14.5/16 RLT281416

Facility

$24,770.00

Service Code	HCPCS C1768
Hospital Revenue Code	278
Min. Negotiated Rate	$13,871.20
Max. Negotiated Rate	$24,026.90
Rate for Payer: Cash Price	$14,862.00
Rate for Payer: Hawaii Western Management Group Commercial	$17,339.00
Rate for Payer: Health Management Network Commercial	$21,054.50
Rate for Payer: Kaiser Permanente Commercial	$22,293.00
Rate for Payer: MDX Hawaii PPO	$24,026.90
Rate for Payer: University Health Alliance Commercial	$13,871.20

GORE T-IPSI 14.5/16 RLT281416

Facility

$24,770.00

Service Code	HCPCS C1768
Hospital Revenue Code	278
Min. Negotiated Rate	$12,385.00
Max. Negotiated Rate	$24,026.90
Rate for Payer: AlohaCare Medicaid	$12,385.00
Rate for Payer: AlohaCare Medicare	$18,825.20
Rate for Payer: Cash Price	$14,862.00
Rate for Payer: Devoted Health Medicare	$20,806.80
Rate for Payer: Hawaii Medical Service Association Medicare	$18,825.20
Rate for Payer: Hawaii Western Management Group Commercial	$17,339.00
Rate for Payer: Health Management Network Commercial	$21,054.50
Rate for Payer: Humana Medicare	$18,825.20
Rate for Payer: Kaiser Permanente Commercial	$22,293.00
Rate for Payer: Kaiser Permanente Medicaid	$12,632.70
Rate for Payer: Kaiser Permanente Medicare	$18,825.20
Rate for Payer: MDX Hawaii PPO	$24,026.90
Rate for Payer: Ohana Health Plan Medicaid	$18,825.20
Rate for Payer: Ohana Health Plan Medicare	$18,825.20
Rate for Payer: UnitedHealthcare Medicare	$18,825.20
Rate for Payer: University Health Alliance Commercial	$13,871.20

GORE T-IPSI 14.5/16 RLT351416

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 14.5/16 RLT351416

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 14.5/17 RLT311417

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 14.5/17 RLT311417

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 14.5/18 RLT231418

Facility

$27,420.00

Service Code	HCPCS C1768
Hospital Revenue Code	278
Min. Negotiated Rate	$13,710.00
Max. Negotiated Rate	$26,597.40
Rate for Payer: AlohaCare Medicaid	$13,710.00
Rate for Payer: AlohaCare Medicare	$20,839.20
Rate for Payer: Cash Price	$16,452.00
Rate for Payer: Devoted Health Medicare	$23,032.80
Rate for Payer: Hawaii Medical Service Association Medicare	$20,839.20
Rate for Payer: Hawaii Western Management Group Commercial	$19,194.00
Rate for Payer: Health Management Network Commercial	$23,307.00
Rate for Payer: Humana Medicare	$20,839.20
Rate for Payer: Kaiser Permanente Commercial	$24,678.00
Rate for Payer: Kaiser Permanente Medicaid	$13,984.20
Rate for Payer: Kaiser Permanente Medicare	$20,839.20
Rate for Payer: MDX Hawaii PPO	$26,597.40
Rate for Payer: Ohana Health Plan Medicaid	$20,839.20
Rate for Payer: Ohana Health Plan Medicare	$20,839.20
Rate for Payer: UnitedHealthcare Medicare	$20,839.20
Rate for Payer: University Health Alliance Commercial	$15,355.20

GORE T-IPSI 14.5/18 RLT231418

Facility

$27,420.00

Service Code	HCPCS C1768
Hospital Revenue Code	278
Min. Negotiated Rate	$15,355.20
Max. Negotiated Rate	$26,597.40
Rate for Payer: Cash Price	$16,452.00
Rate for Payer: Hawaii Western Management Group Commercial	$19,194.00
Rate for Payer: Health Management Network Commercial	$23,307.00
Rate for Payer: Kaiser Permanente Commercial	$24,678.00
Rate for Payer: MDX Hawaii PPO	$26,597.40
Rate for Payer: University Health Alliance Commercial	$15,355.20

GORE T-IPSI 14.5/18 RLT261418

Facility

$25,266.00

Service Code	HCPCS C1768
Hospital Revenue Code	278
Min. Negotiated Rate	$12,633.00
Max. Negotiated Rate	$24,508.02
Rate for Payer: AlohaCare Medicaid	$12,633.00
Rate for Payer: AlohaCare Medicare	$19,202.16
Rate for Payer: Cash Price	$15,159.60
Rate for Payer: Devoted Health Medicare	$21,223.44
Rate for Payer: Hawaii Medical Service Association Medicare	$19,202.16
Rate for Payer: Hawaii Western Management Group Commercial	$17,686.20
Rate for Payer: Health Management Network Commercial	$21,476.10
Rate for Payer: Humana Medicare	$19,202.16
Rate for Payer: Kaiser Permanente Commercial	$22,739.40
Rate for Payer: Kaiser Permanente Medicaid	$12,885.66
Rate for Payer: Kaiser Permanente Medicare	$19,202.16
Rate for Payer: MDX Hawaii PPO	$24,508.02
Rate for Payer: Ohana Health Plan Medicaid	$19,202.16
Rate for Payer: Ohana Health Plan Medicare	$19,202.16
Rate for Payer: UnitedHealthcare Medicare	$19,202.16
Rate for Payer: University Health Alliance Commercial	$14,148.96

GORE T-IPSI 14.5/18 RLT261418

Facility

$25,266.00

Service Code	HCPCS C1768
Hospital Revenue Code	278
Min. Negotiated Rate	$14,148.96
Max. Negotiated Rate	$24,508.02
Rate for Payer: Cash Price	$15,159.60
Rate for Payer: Hawaii Western Management Group Commercial	$17,686.20
Rate for Payer: Health Management Network Commercial	$21,476.10
Rate for Payer: Kaiser Permanente Commercial	$22,739.40
Rate for Payer: MDX Hawaii PPO	$24,508.02
Rate for Payer: University Health Alliance Commercial	$14,148.96

GORE T-IPSI 14.5/18 RLT281418

Facility

$23,692.00

Service Code	HCPCS C1768
Hospital Revenue Code	278
Min. Negotiated Rate	$13,267.52
Max. Negotiated Rate	$22,981.24
Rate for Payer: Cash Price	$14,215.20
Rate for Payer: Hawaii Western Management Group Commercial	$16,584.40
Rate for Payer: Health Management Network Commercial	$20,138.20
Rate for Payer: Kaiser Permanente Commercial	$21,322.80
Rate for Payer: MDX Hawaii PPO	$22,981.24
Rate for Payer: University Health Alliance Commercial	$13,267.52

GORE T-IPSI 14.5/18 RLT281418

Facility

$23,692.00

Service Code	HCPCS C1768
Hospital Revenue Code	278
Min. Negotiated Rate	$11,846.00
Max. Negotiated Rate	$22,981.24
Rate for Payer: AlohaCare Medicaid	$11,846.00
Rate for Payer: AlohaCare Medicare	$18,005.92
Rate for Payer: Cash Price	$14,215.20
Rate for Payer: Devoted Health Medicare	$19,901.28
Rate for Payer: Hawaii Medical Service Association Medicare	$18,005.92
Rate for Payer: Hawaii Western Management Group Commercial	$16,584.40
Rate for Payer: Health Management Network Commercial	$20,138.20
Rate for Payer: Humana Medicare	$18,005.92
Rate for Payer: Kaiser Permanente Commercial	$21,322.80
Rate for Payer: Kaiser Permanente Medicaid	$12,082.92
Rate for Payer: Kaiser Permanente Medicare	$18,005.92
Rate for Payer: MDX Hawaii PPO	$22,981.24
Rate for Payer: Ohana Health Plan Medicaid	$18,005.92
Rate for Payer: Ohana Health Plan Medicare	$18,005.92
Rate for Payer: UnitedHealthcare Medicare	$18,005.92
Rate for Payer: University Health Alliance Commercial	$13,267.52

GORE T-IPSI 14.5/18 RLT351418

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 14.5/18 RLT351418

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

GOSERELIN 10.8 MG SUBCUTANEOUS IMPLANT [16254]

Facility

$4,211.00

Service Code	HCPCS J9202
Hospital Revenue Code	250
Min. Negotiated Rate	$3,579.35
Max. Negotiated Rate	$4,084.67
Rate for Payer: Cash Price	$2,526.60
Rate for Payer: Health Management Network Commercial	$3,579.35
Rate for Payer: Kaiser Permanente Commercial	$3,789.90
Rate for Payer: MDX Hawaii PPO	$4,084.67

GOSERELIN 10.8 MG SUBCUTANEOUS IMPLANT [16254]

Facility

$4,211.00

Service Code	HCPCS J9202
Hospital Revenue Code	637
Min. Negotiated Rate	$550.61
Max. Negotiated Rate	$4,084.67
Rate for Payer: AlohaCare Medicaid	$2,105.50
Rate for Payer: AlohaCare Medicare	$3,200.36
Rate for Payer: Cash Price	$2,526.60
Rate for Payer: Cash Price	$2,526.60
Rate for Payer: Devoted Health Medicare	$3,537.24
Rate for Payer: Hawaii Medical Service Association ABD	$734.15
Rate for Payer: Hawaii Medical Service Association Medicare	$3,200.36
Rate for Payer: Hawaii Medical Service Association Non-ABD	$734.15
Rate for Payer: Hawaii Western Management Group Commercial	$4,000.45
Rate for Payer: Health Management Network Commercial	$3,579.35
Rate for Payer: Humana Medicare	$3,200.36
Rate for Payer: Kaiser Permanente Commercial	$3,789.90
Rate for Payer: Kaiser Permanente Medicaid	$2,147.61
Rate for Payer: Kaiser Permanente Medicare	$3,200.36
Rate for Payer: MDX Hawaii PPO	$4,084.67
Rate for Payer: Ohana Health Plan Medicaid	$3,200.36
Rate for Payer: Ohana Health Plan Medicare	$3,200.36
Rate for Payer: UnitedHealthcare Medicaid	$550.61
Rate for Payer: UnitedHealthcare Medicare	$3,200.36
Rate for Payer: University Health Alliance Commercial	$3,069.40

GOSERELIN 3.6 MG SUBCUTANEOUS IMPLANT [10137]

Facility

$1,849.00

Service Code	HCPCS J9202
Hospital Revenue Code	637
Min. Negotiated Rate	$550.61
Max. Negotiated Rate	$1,793.53
Rate for Payer: AlohaCare Medicaid	$924.50
Rate for Payer: AlohaCare Medicare	$1,405.24
Rate for Payer: Cash Price	$1,109.40
Rate for Payer: Cash Price	$1,109.40
Rate for Payer: Devoted Health Medicare	$1,553.16
Rate for Payer: Hawaii Medical Service Association ABD	$734.15
Rate for Payer: Hawaii Medical Service Association Medicare	$1,405.24
Rate for Payer: Hawaii Medical Service Association Non-ABD	$734.15
Rate for Payer: Hawaii Western Management Group Commercial	$1,756.55
Rate for Payer: Health Management Network Commercial	$1,571.65
Rate for Payer: Humana Medicare	$1,405.24
Rate for Payer: Kaiser Permanente Commercial	$1,664.10
Rate for Payer: Kaiser Permanente Medicaid	$942.99
Rate for Payer: Kaiser Permanente Medicare	$1,405.24
Rate for Payer: MDX Hawaii PPO	$1,793.53
Rate for Payer: Ohana Health Plan Medicaid	$1,405.24
Rate for Payer: Ohana Health Plan Medicare	$1,405.24
Rate for Payer: UnitedHealthcare Medicaid	$550.61
Rate for Payer: UnitedHealthcare Medicare	$1,405.24
Rate for Payer: University Health Alliance Commercial	$1,347.74

GOSERELIN 3.6 MG SUBCUTANEOUS IMPLANT [10137]

Facility

$1,849.00

Service Code	HCPCS J9202
Hospital Revenue Code	250
Min. Negotiated Rate	$1,571.65
Max. Negotiated Rate	$1,793.53
Rate for Payer: Cash Price	$1,109.40
Rate for Payer: Health Management Network Commercial	$1,571.65
Rate for Payer: Kaiser Permanente Commercial	$1,664.10
Rate for Payer: MDX Hawaii PPO	$1,793.53

GRAFT AMNIC MEMBRANE 1.5X2

Facility

$1,725.00

Service Code	HCPCS V2787
Hospital Revenue Code	276
Min. Negotiated Rate	$966.00
Max. Negotiated Rate	$1,673.25
Rate for Payer: Cash Price	$1,035.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,207.50
Rate for Payer: Health Management Network Commercial	$1,466.25
Rate for Payer: Kaiser Permanente Commercial	$1,552.50
Rate for Payer: MDX Hawaii PPO	$1,673.25
Rate for Payer: University Health Alliance Commercial	$966.00

GRAFT AMNIC MEMBRANE 1.5X2

Facility

$1,725.00

Service Code	HCPCS V2787
Hospital Revenue Code	276
Min. Negotiated Rate	$862.50
Max. Negotiated Rate	$1,673.25
Rate for Payer: AlohaCare Medicaid	$862.50
Rate for Payer: AlohaCare Medicare	$1,311.00
Rate for Payer: Cash Price	$1,035.00
Rate for Payer: Devoted Health Medicare	$1,449.00
Rate for Payer: Hawaii Medical Service Association Medicare	$1,311.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,207.50
Rate for Payer: Health Management Network Commercial	$1,466.25
Rate for Payer: Humana Medicare	$1,311.00
Rate for Payer: Kaiser Permanente Commercial	$1,552.50
Rate for Payer: Kaiser Permanente Medicaid	$879.75
Rate for Payer: Kaiser Permanente Medicare	$1,311.00
Rate for Payer: MDX Hawaii PPO	$1,673.25
Rate for Payer: Ohana Health Plan Medicaid	$1,311.00
Rate for Payer: Ohana Health Plan Medicare	$1,311.00
Rate for Payer: UnitedHealthcare Medicare	$1,311.00
Rate for Payer: University Health Alliance Commercial	$966.00

Know your out-of-pocket cost for care.

All Charges