Honoka'a Hospital and Skilled Nursing Facility

All Charges

Charge

Type

Setting

Price

HSC+ SMTH RND MODE 10712-410MP

Facility

$2,850.00

Service Code	HCPCS C1789
Hospital Revenue Code	278
Min. Negotiated Rate	$1,425.00
Max. Negotiated Rate	$2,764.50
Rate for Payer: AlohaCare Medicaid	$1,425.00
Rate for Payer: AlohaCare Medicare	$2,166.00
Rate for Payer: Cash Price	$1,710.00
Rate for Payer: Devoted Health Medicare	$2,394.00
Rate for Payer: Hawaii Medical Service Association Medicare	$2,166.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,995.00
Rate for Payer: Health Management Network Commercial	$2,422.50
Rate for Payer: Humana Medicare	$2,166.00
Rate for Payer: Kaiser Permanente Commercial	$2,565.00
Rate for Payer: Kaiser Permanente Medicaid	$1,453.50
Rate for Payer: Kaiser Permanente Medicare	$2,166.00
Rate for Payer: MDX Hawaii PPO	$2,764.50
Rate for Payer: Ohana Health Plan Medicaid	$2,166.00
Rate for Payer: Ohana Health Plan Medicare	$2,166.00
Rate for Payer: UnitedHealthcare Medicare	$2,166.00
Rate for Payer: University Health Alliance Commercial	$1,596.00

HSC+ SMTH RND MODE 10712-410MP

Facility

$2,850.00

Service Code	HCPCS C1789
Hospital Revenue Code	278
Min. Negotiated Rate	$1,596.00
Max. Negotiated Rate	$2,764.50
Rate for Payer: Cash Price	$1,710.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,995.00
Rate for Payer: Health Management Network Commercial	$2,422.50
Rate for Payer: Kaiser Permanente Commercial	$2,565.00
Rate for Payer: MDX Hawaii PPO	$2,764.50
Rate for Payer: University Health Alliance Commercial	$1,596.00

HSC+ SMT RND 700CC 10721-700HP

Facility

$2,850.00

Service Code	HCPCS C1789
Hospital Revenue Code	278
Min. Negotiated Rate	$1,596.00
Max. Negotiated Rate	$2,764.50
Rate for Payer: Cash Price	$1,710.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,995.00
Rate for Payer: Health Management Network Commercial	$2,422.50
Rate for Payer: Kaiser Permanente Commercial	$2,565.00
Rate for Payer: MDX Hawaii PPO	$2,764.50
Rate for Payer: University Health Alliance Commercial	$1,596.00

HSC+ SMT RND 700CC 10721-700HP

Facility

$2,850.00

Service Code	HCPCS C1789
Hospital Revenue Code	278
Min. Negotiated Rate	$1,425.00
Max. Negotiated Rate	$2,764.50
Rate for Payer: AlohaCare Medicaid	$1,425.00
Rate for Payer: AlohaCare Medicare	$2,166.00
Rate for Payer: Cash Price	$1,710.00
Rate for Payer: Devoted Health Medicare	$2,394.00
Rate for Payer: Hawaii Medical Service Association Medicare	$2,166.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,995.00
Rate for Payer: Health Management Network Commercial	$2,422.50
Rate for Payer: Humana Medicare	$2,166.00
Rate for Payer: Kaiser Permanente Commercial	$2,565.00
Rate for Payer: Kaiser Permanente Medicaid	$1,453.50
Rate for Payer: Kaiser Permanente Medicare	$2,166.00
Rate for Payer: MDX Hawaii PPO	$2,764.50
Rate for Payer: Ohana Health Plan Medicaid	$2,166.00
Rate for Payer: Ohana Health Plan Medicare	$2,166.00
Rate for Payer: UnitedHealthcare Medicare	$2,166.00
Rate for Payer: University Health Alliance Commercial	$1,596.00

HUMAN PROTHROMBIN COMPLEX,4-FACTOR 500 UNIT (400-620 UNIT) IV SOLUTION [122122]

Facility

$2,541.00

Service Code	HCPCS J7168
Hospital Revenue Code	636
Min. Negotiated Rate	$2.56
Max. Negotiated Rate	$2,464.77
Rate for Payer: AlohaCare Medicaid	$1,270.50
Rate for Payer: AlohaCare Medicare	$1,931.16
Rate for Payer: Cash Price	$1,524.60
Rate for Payer: Cash Price	$1,524.60
Rate for Payer: Devoted Health Medicare	$2,134.44
Rate for Payer: Hawaii Medical Service Association Commercial	$2.56
Rate for Payer: Hawaii Medical Service Association Medicare	$1,931.16
Rate for Payer: Hawaii Western Management Group Commercial	$2,413.95
Rate for Payer: Health Management Network Commercial	$2,159.85
Rate for Payer: Humana Medicare	$1,931.16
Rate for Payer: Kaiser Permanente Commercial	$2,286.90
Rate for Payer: Kaiser Permanente Medicaid	$1,295.91
Rate for Payer: Kaiser Permanente Medicare	$1,931.16
Rate for Payer: MDX Hawaii PPO	$2,464.77
Rate for Payer: Ohana Health Plan Medicaid	$1,931.16
Rate for Payer: Ohana Health Plan Medicare	$1,931.16
Rate for Payer: UnitedHealthcare Medicaid	$1,524.60
Rate for Payer: UnitedHealthcare Medicare	$1,931.16
Rate for Payer: University Health Alliance Commercial	$1,852.13

HUMAN PROTHROMBIN COMPLEX,4-FACTOR 500 UNIT (400-620 UNIT) IV SOLUTION [122122]

Facility

$2,541.00

Service Code	HCPCS J7168
Hospital Revenue Code	636
Min. Negotiated Rate	$2,159.85
Max. Negotiated Rate	$2,464.77
Rate for Payer: Cash Price	$1,524.60
Rate for Payer: Health Management Network Commercial	$2,159.85
Rate for Payer: Kaiser Permanente Commercial	$2,286.90
Rate for Payer: MDX Hawaii PPO	$2,464.77

HUMERAL 10.5 STEM 01.04201.102

Facility

$5,420.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$3,035.20
Max. Negotiated Rate	$5,257.40
Rate for Payer: Cash Price	$3,252.00
Rate for Payer: Hawaii Western Management Group Commercial	$3,794.00
Rate for Payer: Health Management Network Commercial	$4,607.00
Rate for Payer: Kaiser Permanente Commercial	$4,878.00
Rate for Payer: MDX Hawaii PPO	$5,257.40
Rate for Payer: University Health Alliance Commercial	$3,035.20

HUMERAL 10.5 STEM 01.04201.102

Facility

$5,420.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$2,710.00
Max. Negotiated Rate	$5,257.40
Rate for Payer: AlohaCare Medicaid	$2,710.00
Rate for Payer: AlohaCare Medicare	$4,119.20
Rate for Payer: Cash Price	$3,252.00
Rate for Payer: Devoted Health Medicare	$4,552.80
Rate for Payer: Hawaii Medical Service Association Medicare	$4,119.20
Rate for Payer: Hawaii Western Management Group Commercial	$3,794.00
Rate for Payer: Health Management Network Commercial	$4,607.00
Rate for Payer: Humana Medicare	$4,119.20
Rate for Payer: Kaiser Permanente Commercial	$4,878.00
Rate for Payer: Kaiser Permanente Medicaid	$2,764.20
Rate for Payer: Kaiser Permanente Medicare	$4,119.20
Rate for Payer: MDX Hawaii PPO	$5,257.40
Rate for Payer: Ohana Health Plan Medicaid	$4,119.20
Rate for Payer: Ohana Health Plan Medicare	$4,119.20
Rate for Payer: UnitedHealthcare Medicare	$4,119.20
Rate for Payer: University Health Alliance Commercial	$3,035.20

HUMERAL 10.5 STEM 01.04201.103

Facility

$8,000.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$4,000.00
Max. Negotiated Rate	$7,760.00
Rate for Payer: AlohaCare Medicaid	$4,000.00
Rate for Payer: AlohaCare Medicare	$6,080.00
Rate for Payer: Cash Price	$4,800.00
Rate for Payer: Devoted Health Medicare	$6,720.00
Rate for Payer: Hawaii Medical Service Association Medicare	$6,080.00
Rate for Payer: Hawaii Western Management Group Commercial	$5,600.00
Rate for Payer: Health Management Network Commercial	$6,800.00
Rate for Payer: Humana Medicare	$6,080.00
Rate for Payer: Kaiser Permanente Commercial	$7,200.00
Rate for Payer: Kaiser Permanente Medicaid	$4,080.00
Rate for Payer: Kaiser Permanente Medicare	$6,080.00
Rate for Payer: MDX Hawaii PPO	$7,760.00
Rate for Payer: Ohana Health Plan Medicaid	$6,080.00
Rate for Payer: Ohana Health Plan Medicare	$6,080.00
Rate for Payer: UnitedHealthcare Medicare	$6,080.00
Rate for Payer: University Health Alliance Commercial	$4,480.00

HUMERAL 10.5 STEM 01.04201.103

Facility

$8,000.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$4,480.00
Max. Negotiated Rate	$7,760.00
Rate for Payer: Cash Price	$4,800.00
Rate for Payer: Hawaii Western Management Group Commercial	$5,600.00
Rate for Payer: Health Management Network Commercial	$6,800.00
Rate for Payer: Kaiser Permanente Commercial	$7,200.00
Rate for Payer: MDX Hawaii PPO	$7,760.00
Rate for Payer: University Health Alliance Commercial	$4,480.00

HUMERAL 120MM 01.04201.163

Facility

$8,000.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$4,000.00
Max. Negotiated Rate	$7,760.00
Rate for Payer: AlohaCare Medicaid	$4,000.00
Rate for Payer: AlohaCare Medicare	$6,080.00
Rate for Payer: Cash Price	$4,800.00
Rate for Payer: Devoted Health Medicare	$6,720.00
Rate for Payer: Hawaii Medical Service Association Medicare	$6,080.00
Rate for Payer: Hawaii Western Management Group Commercial	$5,600.00
Rate for Payer: Health Management Network Commercial	$6,800.00
Rate for Payer: Humana Medicare	$6,080.00
Rate for Payer: Kaiser Permanente Commercial	$7,200.00
Rate for Payer: Kaiser Permanente Medicaid	$4,080.00
Rate for Payer: Kaiser Permanente Medicare	$6,080.00
Rate for Payer: MDX Hawaii PPO	$7,760.00
Rate for Payer: Ohana Health Plan Medicaid	$6,080.00
Rate for Payer: Ohana Health Plan Medicare	$6,080.00
Rate for Payer: UnitedHealthcare Medicare	$6,080.00
Rate for Payer: University Health Alliance Commercial	$4,480.00

HUMERAL 120MM 01.04201.163

Facility

$8,000.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$4,480.00
Max. Negotiated Rate	$7,760.00
Rate for Payer: Cash Price	$4,800.00
Rate for Payer: Hawaii Western Management Group Commercial	$5,600.00
Rate for Payer: Health Management Network Commercial	$6,800.00
Rate for Payer: Kaiser Permanente Commercial	$7,200.00
Rate for Payer: MDX Hawaii PPO	$7,760.00
Rate for Payer: University Health Alliance Commercial	$4,480.00

HUMERAL 44X16MM 5552-S-4416

Facility

$4,067.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$2,033.50
Max. Negotiated Rate	$3,944.99
Rate for Payer: AlohaCare Medicaid	$2,033.50
Rate for Payer: AlohaCare Medicare	$3,090.92
Rate for Payer: Cash Price	$2,440.20
Rate for Payer: Devoted Health Medicare	$3,416.28
Rate for Payer: Hawaii Medical Service Association Medicare	$3,090.92
Rate for Payer: Hawaii Western Management Group Commercial	$2,846.90
Rate for Payer: Health Management Network Commercial	$3,456.95
Rate for Payer: Humana Medicare	$3,090.92
Rate for Payer: Kaiser Permanente Commercial	$3,660.30
Rate for Payer: Kaiser Permanente Medicaid	$2,074.17
Rate for Payer: Kaiser Permanente Medicare	$3,090.92
Rate for Payer: MDX Hawaii PPO	$3,944.99
Rate for Payer: Ohana Health Plan Medicaid	$3,090.92
Rate for Payer: Ohana Health Plan Medicare	$3,090.92
Rate for Payer: UnitedHealthcare Medicare	$3,090.92
Rate for Payer: University Health Alliance Commercial	$2,277.52

HUMERAL 44X16MM 5552-S-4416

Facility

$4,067.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$2,277.52
Max. Negotiated Rate	$3,944.99
Rate for Payer: Cash Price	$2,440.20
Rate for Payer: Hawaii Western Management Group Commercial	$2,846.90
Rate for Payer: Health Management Network Commercial	$3,456.95
Rate for Payer: Kaiser Permanente Commercial	$3,660.30
Rate for Payer: MDX Hawaii PPO	$3,944.99
Rate for Payer: University Health Alliance Commercial	$2,277.52

HUMERAL CUP 32X2 5570-3202

Facility

$4,000.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$2,240.00
Max. Negotiated Rate	$3,880.00
Rate for Payer: Cash Price	$2,400.00
Rate for Payer: Hawaii Western Management Group Commercial	$2,800.00
Rate for Payer: Health Management Network Commercial	$3,400.00
Rate for Payer: Kaiser Permanente Commercial	$3,600.00
Rate for Payer: MDX Hawaii PPO	$3,880.00
Rate for Payer: University Health Alliance Commercial	$2,240.00

HUMERAL CUP 32X2 5570-3202

Facility

$4,000.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$2,000.00
Max. Negotiated Rate	$3,880.00
Rate for Payer: AlohaCare Medicaid	$2,000.00
Rate for Payer: AlohaCare Medicare	$3,040.00
Rate for Payer: Cash Price	$2,400.00
Rate for Payer: Devoted Health Medicare	$3,360.00
Rate for Payer: Hawaii Medical Service Association Medicare	$3,040.00
Rate for Payer: Hawaii Western Management Group Commercial	$2,800.00
Rate for Payer: Health Management Network Commercial	$3,400.00
Rate for Payer: Humana Medicare	$3,040.00
Rate for Payer: Kaiser Permanente Commercial	$3,600.00
Rate for Payer: Kaiser Permanente Medicaid	$2,040.00
Rate for Payer: Kaiser Permanente Medicare	$3,040.00
Rate for Payer: MDX Hawaii PPO	$3,880.00
Rate for Payer: Ohana Health Plan Medicaid	$3,040.00
Rate for Payer: Ohana Health Plan Medicare	$3,040.00
Rate for Payer: UnitedHealthcare Medicare	$3,040.00
Rate for Payer: University Health Alliance Commercial	$2,240.00

HUMERAL CUP 36X4MM 5570-3604

Facility

$4,000.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$2,000.00
Max. Negotiated Rate	$3,880.00
Rate for Payer: AlohaCare Medicaid	$2,000.00
Rate for Payer: AlohaCare Medicare	$3,040.00
Rate for Payer: Cash Price	$2,400.00
Rate for Payer: Devoted Health Medicare	$3,360.00
Rate for Payer: Hawaii Medical Service Association Medicare	$3,040.00
Rate for Payer: Hawaii Western Management Group Commercial	$2,800.00
Rate for Payer: Health Management Network Commercial	$3,400.00
Rate for Payer: Humana Medicare	$3,040.00
Rate for Payer: Kaiser Permanente Commercial	$3,600.00
Rate for Payer: Kaiser Permanente Medicaid	$2,040.00
Rate for Payer: Kaiser Permanente Medicare	$3,040.00
Rate for Payer: MDX Hawaii PPO	$3,880.00
Rate for Payer: Ohana Health Plan Medicaid	$3,040.00
Rate for Payer: Ohana Health Plan Medicare	$3,040.00
Rate for Payer: UnitedHealthcare Medicare	$3,040.00
Rate for Payer: University Health Alliance Commercial	$2,240.00

HUMERAL CUP 36X4MM 5570-3604

Facility

$4,000.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$2,240.00
Max. Negotiated Rate	$3,880.00
Rate for Payer: Cash Price	$2,400.00
Rate for Payer: Hawaii Western Management Group Commercial	$2,800.00
Rate for Payer: Health Management Network Commercial	$3,400.00
Rate for Payer: Kaiser Permanente Commercial	$3,600.00
Rate for Payer: MDX Hawaii PPO	$3,880.00
Rate for Payer: University Health Alliance Commercial	$2,240.00

HUMERAL CUP 40 STD 110031427

Facility

$2,600.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$1,300.00
Max. Negotiated Rate	$2,522.00
Rate for Payer: AlohaCare Medicaid	$1,300.00
Rate for Payer: AlohaCare Medicare	$1,976.00
Rate for Payer: Cash Price	$1,560.00
Rate for Payer: Devoted Health Medicare	$2,184.00
Rate for Payer: Hawaii Medical Service Association Medicare	$1,976.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,820.00
Rate for Payer: Health Management Network Commercial	$2,210.00
Rate for Payer: Humana Medicare	$1,976.00
Rate for Payer: Kaiser Permanente Commercial	$2,340.00
Rate for Payer: Kaiser Permanente Medicaid	$1,326.00
Rate for Payer: Kaiser Permanente Medicare	$1,976.00
Rate for Payer: MDX Hawaii PPO	$2,522.00
Rate for Payer: Ohana Health Plan Medicaid	$1,976.00
Rate for Payer: Ohana Health Plan Medicare	$1,976.00
Rate for Payer: UnitedHealthcare Medicare	$1,976.00
Rate for Payer: University Health Alliance Commercial	$1,456.00

HUMERAL CUP 40 STD 110031427

Facility

$2,600.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$1,456.00
Max. Negotiated Rate	$2,522.00
Rate for Payer: Cash Price	$1,560.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,820.00
Rate for Payer: Health Management Network Commercial	$2,210.00
Rate for Payer: Kaiser Permanente Commercial	$2,340.00
Rate for Payer: MDX Hawaii PPO	$2,522.00
Rate for Payer: University Health Alliance Commercial	$1,456.00

HUMERAL CUP AS 01.04223.100

Facility

$2,302.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$1,151.00
Max. Negotiated Rate	$2,232.94
Rate for Payer: AlohaCare Medicaid	$1,151.00
Rate for Payer: AlohaCare Medicare	$1,749.52
Rate for Payer: Cash Price	$1,381.20
Rate for Payer: Devoted Health Medicare	$1,933.68
Rate for Payer: Hawaii Medical Service Association Medicare	$1,749.52
Rate for Payer: Hawaii Western Management Group Commercial	$1,611.40
Rate for Payer: Health Management Network Commercial	$1,956.70
Rate for Payer: Humana Medicare	$1,749.52
Rate for Payer: Kaiser Permanente Commercial	$2,071.80
Rate for Payer: Kaiser Permanente Medicaid	$1,174.02
Rate for Payer: Kaiser Permanente Medicare	$1,749.52
Rate for Payer: MDX Hawaii PPO	$2,232.94
Rate for Payer: Ohana Health Plan Medicaid	$1,749.52
Rate for Payer: Ohana Health Plan Medicare	$1,749.52
Rate for Payer: UnitedHealthcare Medicare	$1,749.52
Rate for Payer: University Health Alliance Commercial	$1,289.12

HUMERAL CUP AS 01.04223.100

Facility

$2,302.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$1,289.12
Max. Negotiated Rate	$2,232.94
Rate for Payer: Cash Price	$1,381.20
Rate for Payer: Hawaii Western Management Group Commercial	$1,611.40
Rate for Payer: Health Management Network Commercial	$1,956.70
Rate for Payer: Kaiser Permanente Commercial	$2,071.80
Rate for Payer: MDX Hawaii PPO	$2,232.94
Rate for Payer: University Health Alliance Commercial	$1,289.12

HUMERAL CUP AS 01.04223.106

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

HUMERAL CUP AS 01.04223.106

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

HUMERAL FRACT STEM 5568-0006

Facility

$8,462.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$4,231.00
Max. Negotiated Rate	$8,208.14
Rate for Payer: AlohaCare Medicaid	$4,231.00
Rate for Payer: AlohaCare Medicare	$6,431.12
Rate for Payer: Cash Price	$5,077.20
Rate for Payer: Devoted Health Medicare	$7,108.08
Rate for Payer: Hawaii Medical Service Association Medicare	$6,431.12
Rate for Payer: Hawaii Western Management Group Commercial	$5,923.40
Rate for Payer: Health Management Network Commercial	$7,192.70
Rate for Payer: Humana Medicare	$6,431.12
Rate for Payer: Kaiser Permanente Commercial	$7,615.80
Rate for Payer: Kaiser Permanente Medicaid	$4,315.62
Rate for Payer: Kaiser Permanente Medicare	$6,431.12
Rate for Payer: MDX Hawaii PPO	$8,208.14
Rate for Payer: Ohana Health Plan Medicaid	$6,431.12
Rate for Payer: Ohana Health Plan Medicare	$6,431.12
Rate for Payer: UnitedHealthcare Medicare	$6,431.12
Rate for Payer: University Health Alliance Commercial	$4,738.72

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