Honoka'a Hospital and Skilled Nursing Facility

All Charges

Charge

Type

Setting

Price

GRAFT COLLAGEN 6MMX39CM AG735

Facility

$3,638.00

Service Code	HCPCS C1768
Hospital Revenue Code	278
Min. Negotiated Rate	$1,819.00
Max. Negotiated Rate	$3,528.86
Rate for Payer: AlohaCare Medicaid	$1,819.00
Rate for Payer: AlohaCare Medicare	$2,764.88
Rate for Payer: Cash Price	$2,182.80
Rate for Payer: Devoted Health Medicare	$3,055.92
Rate for Payer: Hawaii Medical Service Association Medicare	$2,764.88
Rate for Payer: Hawaii Western Management Group Commercial	$2,546.60
Rate for Payer: Health Management Network Commercial	$3,092.30
Rate for Payer: Humana Medicare	$2,764.88
Rate for Payer: Kaiser Permanente Commercial	$3,274.20
Rate for Payer: Kaiser Permanente Medicaid	$1,855.38
Rate for Payer: Kaiser Permanente Medicare	$2,764.88
Rate for Payer: MDX Hawaii PPO	$3,528.86
Rate for Payer: Ohana Health Plan Medicaid	$2,764.88
Rate for Payer: Ohana Health Plan Medicare	$2,764.88
Rate for Payer: UnitedHealthcare Medicare	$2,764.88
Rate for Payer: University Health Alliance Commercial	$2,037.28

GRAFT COLLAGEN 6MMX39CM AG735

Facility

$3,638.00

Service Code	HCPCS C1768
Hospital Revenue Code	278
Min. Negotiated Rate	$2,037.28
Max. Negotiated Rate	$3,528.86
Rate for Payer: Cash Price	$2,182.80
Rate for Payer: Hawaii Western Management Group Commercial	$2,546.60
Rate for Payer: Health Management Network Commercial	$3,092.30
Rate for Payer: Kaiser Permanente Commercial	$3,274.20
Rate for Payer: MDX Hawaii PPO	$3,528.86
Rate for Payer: University Health Alliance Commercial	$2,037.28

GRAFT COLLAGEN 6MMX40CM AG740

Facility

$4,718.00

Service Code	HCPCS C1768
Hospital Revenue Code	278
Min. Negotiated Rate	$2,359.00
Max. Negotiated Rate	$4,576.46
Rate for Payer: AlohaCare Medicaid	$2,359.00
Rate for Payer: AlohaCare Medicare	$3,585.68
Rate for Payer: Cash Price	$2,830.80
Rate for Payer: Devoted Health Medicare	$3,963.12
Rate for Payer: Hawaii Medical Service Association Medicare	$3,585.68
Rate for Payer: Hawaii Western Management Group Commercial	$3,302.60
Rate for Payer: Health Management Network Commercial	$4,010.30
Rate for Payer: Humana Medicare	$3,585.68
Rate for Payer: Kaiser Permanente Commercial	$4,246.20
Rate for Payer: Kaiser Permanente Medicaid	$2,406.18
Rate for Payer: Kaiser Permanente Medicare	$3,585.68
Rate for Payer: MDX Hawaii PPO	$4,576.46
Rate for Payer: Ohana Health Plan Medicaid	$3,585.68
Rate for Payer: Ohana Health Plan Medicare	$3,585.68
Rate for Payer: UnitedHealthcare Medicare	$3,585.68
Rate for Payer: University Health Alliance Commercial	$2,642.08

GRAFT COLLAGEN 6MMX40CM AG740

Facility

$4,718.00

Service Code	HCPCS C1768
Hospital Revenue Code	278
Min. Negotiated Rate	$2,642.08
Max. Negotiated Rate	$4,576.46
Rate for Payer: Cash Price	$2,830.80
Rate for Payer: Hawaii Western Management Group Commercial	$3,302.60
Rate for Payer: Health Management Network Commercial	$4,010.30
Rate for Payer: Kaiser Permanente Commercial	$4,246.20
Rate for Payer: MDX Hawaii PPO	$4,576.46
Rate for Payer: University Health Alliance Commercial	$2,642.08

GRAFT CONTRLT LEG 16MMX11.5CM

Facility

$11,540.00

Service Code	HCPCS C1768
Hospital Revenue Code	278
Min. Negotiated Rate	$5,770.00
Max. Negotiated Rate	$11,193.80
Rate for Payer: AlohaCare Medicaid	$5,770.00
Rate for Payer: AlohaCare Medicare	$8,770.40
Rate for Payer: Cash Price	$6,924.00
Rate for Payer: Devoted Health Medicare	$9,693.60
Rate for Payer: Hawaii Medical Service Association Medicare	$8,770.40
Rate for Payer: Hawaii Western Management Group Commercial	$8,078.00
Rate for Payer: Health Management Network Commercial	$9,809.00
Rate for Payer: Humana Medicare	$8,770.40
Rate for Payer: Kaiser Permanente Commercial	$10,386.00
Rate for Payer: Kaiser Permanente Medicaid	$5,885.40
Rate for Payer: Kaiser Permanente Medicare	$8,770.40
Rate for Payer: MDX Hawaii PPO	$11,193.80
Rate for Payer: Ohana Health Plan Medicaid	$8,770.40
Rate for Payer: Ohana Health Plan Medicare	$8,770.40
Rate for Payer: UnitedHealthcare Medicare	$8,770.40
Rate for Payer: University Health Alliance Commercial	$6,462.40

GRAFT CONTRLT LEG 16MMX11.5CM

Facility

$11,540.00

Service Code	HCPCS C1768
Hospital Revenue Code	278
Min. Negotiated Rate	$6,462.40
Max. Negotiated Rate	$11,193.80
Rate for Payer: Cash Price	$6,924.00
Rate for Payer: Hawaii Western Management Group Commercial	$8,078.00
Rate for Payer: Health Management Network Commercial	$9,809.00
Rate for Payer: Kaiser Permanente Commercial	$10,386.00
Rate for Payer: MDX Hawaii PPO	$11,193.80
Rate for Payer: University Health Alliance Commercial	$6,462.40

GRAFT GRACILIS FGRACILIS

Facility

$2,315.00

Service Code	HCPCS C1762
Hospital Revenue Code	278
Min. Negotiated Rate	$1,296.40
Max. Negotiated Rate	$2,245.55
Rate for Payer: Cash Price	$1,389.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,620.50
Rate for Payer: Health Management Network Commercial	$1,967.75
Rate for Payer: Kaiser Permanente Commercial	$2,083.50
Rate for Payer: MDX Hawaii PPO	$2,245.55
Rate for Payer: University Health Alliance Commercial	$1,296.40

GRAFT GRACILIS FGRACILIS

Facility

$2,315.00

Service Code	HCPCS C1762
Hospital Revenue Code	278
Min. Negotiated Rate	$1,157.50
Max. Negotiated Rate	$2,245.55
Rate for Payer: AlohaCare Medicaid	$1,157.50
Rate for Payer: AlohaCare Medicare	$1,759.40
Rate for Payer: Cash Price	$1,389.00
Rate for Payer: Devoted Health Medicare	$1,944.60
Rate for Payer: Hawaii Medical Service Association Medicare	$1,759.40
Rate for Payer: Hawaii Western Management Group Commercial	$1,620.50
Rate for Payer: Health Management Network Commercial	$1,967.75
Rate for Payer: Humana Medicare	$1,759.40
Rate for Payer: Kaiser Permanente Commercial	$2,083.50
Rate for Payer: Kaiser Permanente Medicaid	$1,180.65
Rate for Payer: Kaiser Permanente Medicare	$1,759.40
Rate for Payer: MDX Hawaii PPO	$2,245.55
Rate for Payer: Ohana Health Plan Medicaid	$1,759.40
Rate for Payer: Ohana Health Plan Medicare	$1,759.40
Rate for Payer: UnitedHealthcare Medicare	$1,759.40
Rate for Payer: University Health Alliance Commercial	$1,296.40

GRAFT HEPARIN 6X40 ECH060040A

Facility

$2,712.00

Service Code	HCPCS C1768
Hospital Revenue Code	278
Min. Negotiated Rate	$1,518.72
Max. Negotiated Rate	$2,630.64
Rate for Payer: Cash Price	$1,627.20
Rate for Payer: Hawaii Western Management Group Commercial	$1,898.40
Rate for Payer: Health Management Network Commercial	$2,305.20
Rate for Payer: Kaiser Permanente Commercial	$2,440.80
Rate for Payer: MDX Hawaii PPO	$2,630.64
Rate for Payer: University Health Alliance Commercial	$1,518.72

GRAFT HEPARIN 6X40 ECH060040A

Facility

$2,712.00

Service Code	HCPCS C1768
Hospital Revenue Code	278
Min. Negotiated Rate	$1,356.00
Max. Negotiated Rate	$2,630.64
Rate for Payer: AlohaCare Medicaid	$1,356.00
Rate for Payer: AlohaCare Medicare	$2,061.12
Rate for Payer: Cash Price	$1,627.20
Rate for Payer: Devoted Health Medicare	$2,278.08
Rate for Payer: Hawaii Medical Service Association Medicare	$2,061.12
Rate for Payer: Hawaii Western Management Group Commercial	$1,898.40
Rate for Payer: Health Management Network Commercial	$2,305.20
Rate for Payer: Humana Medicare	$2,061.12
Rate for Payer: Kaiser Permanente Commercial	$2,440.80
Rate for Payer: Kaiser Permanente Medicaid	$1,383.12
Rate for Payer: Kaiser Permanente Medicare	$2,061.12
Rate for Payer: MDX Hawaii PPO	$2,630.64
Rate for Payer: Ohana Health Plan Medicaid	$2,061.12
Rate for Payer: Ohana Health Plan Medicare	$2,061.12
Rate for Payer: UnitedHealthcare Medicare	$2,061.12
Rate for Payer: University Health Alliance Commercial	$1,518.72

GRAFT HERO 1000 SUPERHERO

Facility

$8,800.00

Service Code	HCPCS C1750
Hospital Revenue Code	278
Min. Negotiated Rate	$4,928.00
Max. Negotiated Rate	$8,536.00
Rate for Payer: Cash Price	$5,280.00
Rate for Payer: Hawaii Western Management Group Commercial	$6,160.00
Rate for Payer: Health Management Network Commercial	$7,480.00
Rate for Payer: Kaiser Permanente Commercial	$7,920.00
Rate for Payer: MDX Hawaii PPO	$8,536.00
Rate for Payer: University Health Alliance Commercial	$4,928.00

GRAFT HERO 1000 SUPERHERO

Facility

$8,800.00

Service Code	HCPCS C1750
Hospital Revenue Code	278
Min. Negotiated Rate	$4,400.00
Max. Negotiated Rate	$8,536.00
Rate for Payer: AlohaCare Medicaid	$4,400.00
Rate for Payer: AlohaCare Medicare	$6,688.00
Rate for Payer: Cash Price	$5,280.00
Rate for Payer: Devoted Health Medicare	$7,392.00
Rate for Payer: Hawaii Medical Service Association Medicare	$6,688.00
Rate for Payer: Hawaii Western Management Group Commercial	$6,160.00
Rate for Payer: Health Management Network Commercial	$7,480.00
Rate for Payer: Humana Medicare	$6,688.00
Rate for Payer: Kaiser Permanente Commercial	$7,920.00
Rate for Payer: Kaiser Permanente Medicaid	$4,488.00
Rate for Payer: Kaiser Permanente Medicare	$6,688.00
Rate for Payer: MDX Hawaii PPO	$8,536.00
Rate for Payer: Ohana Health Plan Medicaid	$6,688.00
Rate for Payer: Ohana Health Plan Medicare	$6,688.00
Rate for Payer: UnitedHealthcare Medicare	$6,688.00
Rate for Payer: University Health Alliance Commercial	$4,928.00

GRAFT ILIAC CREST WEDGE BONE

Facility

$2,070.00

Service Code	HCPCS C1762
Hospital Revenue Code	278
Min. Negotiated Rate	$1,159.20
Max. Negotiated Rate	$2,007.90
Rate for Payer: Cash Price	$1,242.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,449.00
Rate for Payer: Health Management Network Commercial	$1,759.50
Rate for Payer: Kaiser Permanente Commercial	$1,863.00
Rate for Payer: MDX Hawaii PPO	$2,007.90
Rate for Payer: University Health Alliance Commercial	$1,159.20

GRAFT ILIAC CREST WEDGE BONE

Facility

$2,070.00

Service Code	HCPCS C1762
Hospital Revenue Code	278
Min. Negotiated Rate	$1,035.00
Max. Negotiated Rate	$2,007.90
Rate for Payer: AlohaCare Medicaid	$1,035.00
Rate for Payer: AlohaCare Medicare	$1,573.20
Rate for Payer: Cash Price	$1,242.00
Rate for Payer: Devoted Health Medicare	$1,738.80
Rate for Payer: Hawaii Medical Service Association Medicare	$1,573.20
Rate for Payer: Hawaii Western Management Group Commercial	$1,449.00
Rate for Payer: Health Management Network Commercial	$1,759.50
Rate for Payer: Humana Medicare	$1,573.20
Rate for Payer: Kaiser Permanente Commercial	$1,863.00
Rate for Payer: Kaiser Permanente Medicaid	$1,055.70
Rate for Payer: Kaiser Permanente Medicare	$1,573.20
Rate for Payer: MDX Hawaii PPO	$2,007.90
Rate for Payer: Ohana Health Plan Medicaid	$1,573.20
Rate for Payer: Ohana Health Plan Medicare	$1,573.20
Rate for Payer: UnitedHealthcare Medicare	$1,573.20
Rate for Payer: University Health Alliance Commercial	$1,159.20

GRAFT LEG 12MMX10CM PXC121000

Facility

$4,510.00

Service Code	HCPCS C1768
Hospital Revenue Code	278
Min. Negotiated Rate	$2,525.60
Max. Negotiated Rate	$4,374.70
Rate for Payer: Cash Price	$2,706.00
Rate for Payer: Hawaii Western Management Group Commercial	$3,157.00
Rate for Payer: Health Management Network Commercial	$3,833.50
Rate for Payer: Kaiser Permanente Commercial	$4,059.00
Rate for Payer: MDX Hawaii PPO	$4,374.70
Rate for Payer: University Health Alliance Commercial	$2,525.60

GRAFT LEG 12MMX10CM PXC121000

Facility

$4,510.00

Service Code	HCPCS C1768
Hospital Revenue Code	278
Min. Negotiated Rate	$2,255.00
Max. Negotiated Rate	$4,374.70
Rate for Payer: AlohaCare Medicaid	$2,255.00
Rate for Payer: AlohaCare Medicare	$3,427.60
Rate for Payer: Cash Price	$2,706.00
Rate for Payer: Devoted Health Medicare	$3,788.40
Rate for Payer: Hawaii Medical Service Association Medicare	$3,427.60
Rate for Payer: Hawaii Western Management Group Commercial	$3,157.00
Rate for Payer: Health Management Network Commercial	$3,833.50
Rate for Payer: Humana Medicare	$3,427.60
Rate for Payer: Kaiser Permanente Commercial	$4,059.00
Rate for Payer: Kaiser Permanente Medicaid	$2,300.10
Rate for Payer: Kaiser Permanente Medicare	$3,427.60
Rate for Payer: MDX Hawaii PPO	$4,374.70
Rate for Payer: Ohana Health Plan Medicaid	$3,427.60
Rate for Payer: Ohana Health Plan Medicare	$3,427.60
Rate for Payer: UnitedHealthcare Medicare	$3,427.60
Rate for Payer: University Health Alliance Commercial	$2,525.60

GRAFT LEG 12MMX12CM PXC121200

Facility

$9,020.00

Service Code	HCPCS C1768
Hospital Revenue Code	278
Min. Negotiated Rate	$4,510.00
Max. Negotiated Rate	$8,749.40
Rate for Payer: AlohaCare Medicaid	$4,510.00
Rate for Payer: AlohaCare Medicare	$6,855.20
Rate for Payer: Cash Price	$5,412.00
Rate for Payer: Devoted Health Medicare	$7,576.80
Rate for Payer: Hawaii Medical Service Association Medicare	$6,855.20
Rate for Payer: Hawaii Western Management Group Commercial	$6,314.00
Rate for Payer: Health Management Network Commercial	$7,667.00
Rate for Payer: Humana Medicare	$6,855.20
Rate for Payer: Kaiser Permanente Commercial	$8,118.00
Rate for Payer: Kaiser Permanente Medicaid	$4,600.20
Rate for Payer: Kaiser Permanente Medicare	$6,855.20
Rate for Payer: MDX Hawaii PPO	$8,749.40
Rate for Payer: Ohana Health Plan Medicaid	$6,855.20
Rate for Payer: Ohana Health Plan Medicare	$6,855.20
Rate for Payer: UnitedHealthcare Medicare	$6,855.20
Rate for Payer: University Health Alliance Commercial	$5,051.20

GRAFT LEG 12MMX12CM PXC121200

Facility

$9,020.00

Service Code	HCPCS C1768
Hospital Revenue Code	278
Min. Negotiated Rate	$5,051.20
Max. Negotiated Rate	$8,749.40
Rate for Payer: Cash Price	$5,412.00
Rate for Payer: Hawaii Western Management Group Commercial	$6,314.00
Rate for Payer: Health Management Network Commercial	$7,667.00
Rate for Payer: Kaiser Permanente Commercial	$8,118.00
Rate for Payer: MDX Hawaii PPO	$8,749.40
Rate for Payer: University Health Alliance Commercial	$5,051.20

GRAFT LEG 12MMX14CM PXC121400

Facility

$9,246.00

Service Code	HCPCS C1768
Hospital Revenue Code	278
Min. Negotiated Rate	$4,623.00
Max. Negotiated Rate	$8,968.62
Rate for Payer: AlohaCare Medicaid	$4,623.00
Rate for Payer: AlohaCare Medicare	$7,026.96
Rate for Payer: Cash Price	$5,547.60
Rate for Payer: Devoted Health Medicare	$7,766.64
Rate for Payer: Hawaii Medical Service Association Medicare	$7,026.96
Rate for Payer: Hawaii Western Management Group Commercial	$6,472.20
Rate for Payer: Health Management Network Commercial	$7,859.10
Rate for Payer: Humana Medicare	$7,026.96
Rate for Payer: Kaiser Permanente Commercial	$8,321.40
Rate for Payer: Kaiser Permanente Medicaid	$4,715.46
Rate for Payer: Kaiser Permanente Medicare	$7,026.96
Rate for Payer: MDX Hawaii PPO	$8,968.62
Rate for Payer: Ohana Health Plan Medicaid	$7,026.96
Rate for Payer: Ohana Health Plan Medicare	$7,026.96
Rate for Payer: UnitedHealthcare Medicare	$7,026.96
Rate for Payer: University Health Alliance Commercial	$5,177.76

GRAFT LEG 12MMX14CM PXC121400

Facility

$9,246.00

Service Code	HCPCS C1768
Hospital Revenue Code	278
Min. Negotiated Rate	$5,177.76
Max. Negotiated Rate	$8,968.62
Rate for Payer: Cash Price	$5,547.60
Rate for Payer: Hawaii Western Management Group Commercial	$6,472.20
Rate for Payer: Health Management Network Commercial	$7,859.10
Rate for Payer: Kaiser Permanente Commercial	$8,321.40
Rate for Payer: MDX Hawaii PPO	$8,968.62
Rate for Payer: University Health Alliance Commercial	$5,177.76

GRAFT LEG 16X13.5CM PLC161400

Facility

$11,540.00

Service Code	HCPCS C1768
Hospital Revenue Code	278
Min. Negotiated Rate	$5,770.00
Max. Negotiated Rate	$11,193.80
Rate for Payer: AlohaCare Medicaid	$5,770.00
Rate for Payer: AlohaCare Medicare	$8,770.40
Rate for Payer: Cash Price	$6,924.00
Rate for Payer: Devoted Health Medicare	$9,693.60
Rate for Payer: Hawaii Medical Service Association Medicare	$8,770.40
Rate for Payer: Hawaii Western Management Group Commercial	$8,078.00
Rate for Payer: Health Management Network Commercial	$9,809.00
Rate for Payer: Humana Medicare	$8,770.40
Rate for Payer: Kaiser Permanente Commercial	$10,386.00
Rate for Payer: Kaiser Permanente Medicaid	$5,885.40
Rate for Payer: Kaiser Permanente Medicare	$8,770.40
Rate for Payer: MDX Hawaii PPO	$11,193.80
Rate for Payer: Ohana Health Plan Medicaid	$8,770.40
Rate for Payer: Ohana Health Plan Medicare	$8,770.40
Rate for Payer: UnitedHealthcare Medicare	$8,770.40
Rate for Payer: University Health Alliance Commercial	$6,462.40

GRAFT LEG 16X13.5CM PLC161400

Facility

$11,540.00

Service Code	HCPCS C1768
Hospital Revenue Code	278
Min. Negotiated Rate	$6,462.40
Max. Negotiated Rate	$11,193.80
Rate for Payer: Cash Price	$6,924.00
Rate for Payer: Hawaii Western Management Group Commercial	$8,078.00
Rate for Payer: Health Management Network Commercial	$9,809.00
Rate for Payer: Kaiser Permanente Commercial	$10,386.00
Rate for Payer: MDX Hawaii PPO	$11,193.80
Rate for Payer: University Health Alliance Commercial	$6,462.40

GRAFT LEG 18X11.5CM PLC181200

Facility

$10,670.00

Hospital Revenue Code	278
Min. Negotiated Rate	$5,975.20
Max. Negotiated Rate	$10,349.90
Rate for Payer: Cash Price	$6,402.00
Rate for Payer: Hawaii Western Management Group Commercial	$7,469.00
Rate for Payer: Health Management Network Commercial	$9,069.50
Rate for Payer: Kaiser Permanente Commercial	$9,603.00
Rate for Payer: MDX Hawaii PPO	$10,349.90
Rate for Payer: University Health Alliance Commercial	$5,975.20

GRAFT LEG 18X11.5CM PLC181200

Facility

$10,670.00

Hospital Revenue Code	278
Min. Negotiated Rate	$5,335.00
Max. Negotiated Rate	$10,349.90
Rate for Payer: AlohaCare Medicaid	$5,335.00
Rate for Payer: AlohaCare Medicare	$8,109.20
Rate for Payer: Cash Price	$6,402.00
Rate for Payer: Devoted Health Medicare	$8,962.80
Rate for Payer: Hawaii Medical Service Association Medicare	$8,109.20
Rate for Payer: Hawaii Western Management Group Commercial	$7,469.00
Rate for Payer: Health Management Network Commercial	$9,069.50
Rate for Payer: Humana Medicare	$8,109.20
Rate for Payer: Kaiser Permanente Commercial	$9,603.00
Rate for Payer: Kaiser Permanente Medicaid	$5,441.70
Rate for Payer: Kaiser Permanente Medicare	$8,109.20
Rate for Payer: MDX Hawaii PPO	$10,349.90
Rate for Payer: Ohana Health Plan Medicaid	$8,109.20
Rate for Payer: Ohana Health Plan Medicare	$8,109.20
Rate for Payer: UnitedHealthcare Medicare	$8,109.20
Rate for Payer: University Health Alliance Commercial	$5,975.20

GRAFT LEG 18X13.5CM PLC181400

Facility

$10,156.00

Service Code	HCPCS C1768
Hospital Revenue Code	278
Min. Negotiated Rate	$5,078.00
Max. Negotiated Rate	$9,851.32
Rate for Payer: AlohaCare Medicaid	$5,078.00
Rate for Payer: AlohaCare Medicare	$7,718.56
Rate for Payer: Cash Price	$6,093.60
Rate for Payer: Devoted Health Medicare	$8,531.04
Rate for Payer: Hawaii Medical Service Association Medicare	$7,718.56
Rate for Payer: Hawaii Western Management Group Commercial	$7,109.20
Rate for Payer: Health Management Network Commercial	$8,632.60
Rate for Payer: Humana Medicare	$7,718.56
Rate for Payer: Kaiser Permanente Commercial	$9,140.40
Rate for Payer: Kaiser Permanente Medicaid	$5,179.56
Rate for Payer: Kaiser Permanente Medicare	$7,718.56
Rate for Payer: MDX Hawaii PPO	$9,851.32
Rate for Payer: Ohana Health Plan Medicaid	$7,718.56
Rate for Payer: Ohana Health Plan Medicare	$7,718.56
Rate for Payer: UnitedHealthcare Medicare	$7,718.56
Rate for Payer: University Health Alliance Commercial	$5,687.36

Know your out-of-pocket cost for care.

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