Honoka'a Hospital and Skilled Nursing Facility

All Charges

Charge

Type

Setting

Price

HUMERAL LF 88MM 02.117.304

Facility

$2,749.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,539.44
Max. Negotiated Rate	$2,666.53
Rate for Payer: Cash Price	$1,649.40
Rate for Payer: Hawaii Western Management Group Commercial	$1,924.30
Rate for Payer: Health Management Network Commercial	$2,336.65
Rate for Payer: Kaiser Permanente Commercial	$2,474.10
Rate for Payer: MDX Hawaii PPO	$2,666.53
Rate for Payer: University Health Alliance Commercial	$1,539.44

HUMERAL PF STEM #01.04201.092

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 PF STEM #01.04201.092

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 PIN 7000-35-130

Facility

$480.00

Service Code	HCPCS C1769
Hospital Revenue Code	272
Min. Negotiated Rate	$240.00
Max. Negotiated Rate	$465.60
Rate for Payer: AlohaCare Medicaid	$240.00
Rate for Payer: AlohaCare Medicare	$364.80
Rate for Payer: Cash Price	$288.00
Rate for Payer: Devoted Health Medicare	$403.20
Rate for Payer: Hawaii Medical Service Association Medicare	$364.80
Rate for Payer: Hawaii Western Management Group Commercial	$456.00
Rate for Payer: Health Management Network Commercial	$408.00
Rate for Payer: Humana Medicare	$364.80
Rate for Payer: Kaiser Permanente Commercial	$432.00
Rate for Payer: Kaiser Permanente Medicaid	$244.80
Rate for Payer: Kaiser Permanente Medicare	$364.80
Rate for Payer: MDX Hawaii PPO	$465.60
Rate for Payer: Ohana Health Plan Medicaid	$364.80
Rate for Payer: Ohana Health Plan Medicare	$364.80
Rate for Payer: UnitedHealthcare Medicare	$364.80
Rate for Payer: University Health Alliance Commercial	$349.87

HUMERAL PIN 7000-35-130

Facility

$480.00

Service Code	HCPCS C1769
Hospital Revenue Code	272
Min. Negotiated Rate	$408.00
Max. Negotiated Rate	$465.60
Rate for Payer: Cash Price	$288.00
Rate for Payer: Health Management Network Commercial	$408.00
Rate for Payer: Kaiser Permanente Commercial	$432.00
Rate for Payer: MDX Hawaii PPO	$465.60

HUMERAL REVERSE INSERT DWP1360

Facility

$2,768.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$1,384.00
Max. Negotiated Rate	$2,684.96
Rate for Payer: AlohaCare Medicaid	$1,384.00
Rate for Payer: AlohaCare Medicare	$2,103.68
Rate for Payer: Cash Price	$1,660.80
Rate for Payer: Devoted Health Medicare	$2,325.12
Rate for Payer: Hawaii Medical Service Association Medicare	$2,103.68
Rate for Payer: Hawaii Western Management Group Commercial	$1,937.60
Rate for Payer: Health Management Network Commercial	$2,352.80
Rate for Payer: Humana Medicare	$2,103.68
Rate for Payer: Kaiser Permanente Commercial	$2,491.20
Rate for Payer: Kaiser Permanente Medicaid	$1,411.68
Rate for Payer: Kaiser Permanente Medicare	$2,103.68
Rate for Payer: MDX Hawaii PPO	$2,684.96
Rate for Payer: Ohana Health Plan Medicaid	$2,103.68
Rate for Payer: Ohana Health Plan Medicare	$2,103.68
Rate for Payer: UnitedHealthcare Medicare	$2,103.68
Rate for Payer: University Health Alliance Commercial	$1,550.08

HUMERAL REVERSE INSERT DWP1360

Facility

$2,768.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$1,550.08
Max. Negotiated Rate	$2,684.96
Rate for Payer: Cash Price	$1,660.80
Rate for Payer: Hawaii Western Management Group Commercial	$1,937.60
Rate for Payer: Health Management Network Commercial	$2,352.80
Rate for Payer: Kaiser Permanente Commercial	$2,491.20
Rate for Payer: MDX Hawaii PPO	$2,684.96
Rate for Payer: University Health Alliance Commercial	$1,550.08

HUMERAL SPOOL SMALL LEFT

Facility

$6,622.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$3,311.00
Max. Negotiated Rate	$6,423.34
Rate for Payer: AlohaCare Medicaid	$3,311.00
Rate for Payer: AlohaCare Medicare	$5,032.72
Rate for Payer: Cash Price	$3,973.20
Rate for Payer: Devoted Health Medicare	$5,562.48
Rate for Payer: Hawaii Medical Service Association Medicare	$5,032.72
Rate for Payer: Hawaii Western Management Group Commercial	$4,635.40
Rate for Payer: Health Management Network Commercial	$5,628.70
Rate for Payer: Humana Medicare	$5,032.72
Rate for Payer: Kaiser Permanente Commercial	$5,959.80
Rate for Payer: Kaiser Permanente Medicaid	$3,377.22
Rate for Payer: Kaiser Permanente Medicare	$5,032.72
Rate for Payer: MDX Hawaii PPO	$6,423.34
Rate for Payer: Ohana Health Plan Medicaid	$5,032.72
Rate for Payer: Ohana Health Plan Medicare	$5,032.72
Rate for Payer: UnitedHealthcare Medicare	$5,032.72
Rate for Payer: University Health Alliance Commercial	$3,708.32

HUMERAL SPOOL SMALL LEFT

Facility

$6,622.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$3,708.32
Max. Negotiated Rate	$6,423.34
Rate for Payer: Cash Price	$3,973.20
Rate for Payer: Hawaii Western Management Group Commercial	$4,635.40
Rate for Payer: Health Management Network Commercial	$5,628.70
Rate for Payer: Kaiser Permanente Commercial	$5,959.80
Rate for Payer: MDX Hawaii PPO	$6,423.34
Rate for Payer: University Health Alliance Commercial	$3,708.32

HUMERAL STB HEAD 51MM DWG051

Facility

$8,834.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$4,417.00
Max. Negotiated Rate	$8,568.98
Rate for Payer: AlohaCare Medicaid	$4,417.00
Rate for Payer: AlohaCare Medicare	$6,713.84
Rate for Payer: Cash Price	$5,300.40
Rate for Payer: Devoted Health Medicare	$7,420.56
Rate for Payer: Hawaii Medical Service Association Medicare	$6,713.84
Rate for Payer: Hawaii Western Management Group Commercial	$6,183.80
Rate for Payer: Health Management Network Commercial	$7,508.90
Rate for Payer: Humana Medicare	$6,713.84
Rate for Payer: Kaiser Permanente Commercial	$7,950.60
Rate for Payer: Kaiser Permanente Medicaid	$4,505.34
Rate for Payer: Kaiser Permanente Medicare	$6,713.84
Rate for Payer: MDX Hawaii PPO	$8,568.98
Rate for Payer: Ohana Health Plan Medicaid	$6,713.84
Rate for Payer: Ohana Health Plan Medicare	$6,713.84
Rate for Payer: UnitedHealthcare Medicare	$6,713.84
Rate for Payer: University Health Alliance Commercial	$4,947.04

HUMERAL STB HEAD 51MM DWG051

Facility

$8,834.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$4,947.04
Max. Negotiated Rate	$8,568.98
Rate for Payer: Cash Price	$5,300.40
Rate for Payer: Hawaii Western Management Group Commercial	$6,183.80
Rate for Payer: Health Management Network Commercial	$7,508.90
Rate for Payer: Kaiser Permanente Commercial	$7,950.60
Rate for Payer: MDX Hawaii PPO	$8,568.98
Rate for Payer: University Health Alliance Commercial	$4,947.04

HUMERAL STEM 11MM AR-9100-11S

Facility

$8,350.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$4,175.00
Max. Negotiated Rate	$8,099.50
Rate for Payer: AlohaCare Medicaid	$4,175.00
Rate for Payer: AlohaCare Medicare	$6,346.00
Rate for Payer: Cash Price	$5,010.00
Rate for Payer: Devoted Health Medicare	$7,014.00
Rate for Payer: Hawaii Medical Service Association Medicare	$6,346.00
Rate for Payer: Hawaii Western Management Group Commercial	$5,845.00
Rate for Payer: Health Management Network Commercial	$7,097.50
Rate for Payer: Humana Medicare	$6,346.00
Rate for Payer: Kaiser Permanente Commercial	$7,515.00
Rate for Payer: Kaiser Permanente Medicaid	$4,258.50
Rate for Payer: Kaiser Permanente Medicare	$6,346.00
Rate for Payer: MDX Hawaii PPO	$8,099.50
Rate for Payer: Ohana Health Plan Medicaid	$6,346.00
Rate for Payer: Ohana Health Plan Medicare	$6,346.00
Rate for Payer: UnitedHealthcare Medicare	$6,346.00
Rate for Payer: University Health Alliance Commercial	$4,676.00

HUMERAL STEM 11MM AR-9100-11S

Facility

$8,350.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$4,676.00
Max. Negotiated Rate	$8,099.50
Rate for Payer: Cash Price	$5,010.00
Rate for Payer: Hawaii Western Management Group Commercial	$5,845.00
Rate for Payer: Health Management Network Commercial	$7,097.50
Rate for Payer: Kaiser Permanente Commercial	$7,515.00
Rate for Payer: MDX Hawaii PPO	$8,099.50
Rate for Payer: University Health Alliance Commercial	$4,676.00

HUMERAL STEM 12-1 01.04201.123

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 STEM 12-1 01.04201.123

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 STEM 13MM AR-9100-13S

Facility

$8,350.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$4,676.00
Max. Negotiated Rate	$8,099.50
Rate for Payer: Cash Price	$5,010.00
Rate for Payer: Hawaii Western Management Group Commercial	$5,845.00
Rate for Payer: Health Management Network Commercial	$7,097.50
Rate for Payer: Kaiser Permanente Commercial	$7,515.00
Rate for Payer: MDX Hawaii PPO	$8,099.50
Rate for Payer: University Health Alliance Commercial	$4,676.00

HUMERAL STEM 13MM AR-9100-13S

Facility

$8,350.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$4,175.00
Max. Negotiated Rate	$8,099.50
Rate for Payer: AlohaCare Medicaid	$4,175.00
Rate for Payer: AlohaCare Medicare	$6,346.00
Rate for Payer: Cash Price	$5,010.00
Rate for Payer: Devoted Health Medicare	$7,014.00
Rate for Payer: Hawaii Medical Service Association Medicare	$6,346.00
Rate for Payer: Hawaii Western Management Group Commercial	$5,845.00
Rate for Payer: Health Management Network Commercial	$7,097.50
Rate for Payer: Humana Medicare	$6,346.00
Rate for Payer: Kaiser Permanente Commercial	$7,515.00
Rate for Payer: Kaiser Permanente Medicaid	$4,258.50
Rate for Payer: Kaiser Permanente Medicare	$6,346.00
Rate for Payer: MDX Hawaii PPO	$8,099.50
Rate for Payer: Ohana Health Plan Medicaid	$6,346.00
Rate for Payer: Ohana Health Plan Medicare	$6,346.00
Rate for Payer: UnitedHealthcare Medicare	$6,346.00
Rate for Payer: University Health Alliance Commercial	$4,676.00

HUMERAL STEM 8X118MM 5568-0008

Facility

$8,462.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$4,738.72
Max. Negotiated Rate	$8,208.14
Rate for Payer: Cash Price	$5,077.20
Rate for Payer: Hawaii Western Management Group Commercial	$5,923.40
Rate for Payer: Health Management Network Commercial	$7,192.70
Rate for Payer: Kaiser Permanente Commercial	$7,615.80
Rate for Payer: MDX Hawaii PPO	$8,208.14
Rate for Payer: University Health Alliance Commercial	$4,738.72

HUMERAL STEM 8X118MM 5568-0008

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

HUMERAL STEM 9X118 5569-P-2009

Facility

$9,010.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$5,045.60
Max. Negotiated Rate	$8,739.70
Rate for Payer: Cash Price	$5,406.00
Rate for Payer: Hawaii Western Management Group Commercial	$6,307.00
Rate for Payer: Health Management Network Commercial	$7,658.50
Rate for Payer: Kaiser Permanente Commercial	$8,109.00
Rate for Payer: MDX Hawaii PPO	$8,739.70
Rate for Payer: University Health Alliance Commercial	$5,045.60

HUMERAL STEM 9X118 5569-P-2009

Facility

$9,010.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$4,505.00
Max. Negotiated Rate	$8,739.70
Rate for Payer: AlohaCare Medicaid	$4,505.00
Rate for Payer: AlohaCare Medicare	$6,847.60
Rate for Payer: Cash Price	$5,406.00
Rate for Payer: Devoted Health Medicare	$7,568.40
Rate for Payer: Hawaii Medical Service Association Medicare	$6,847.60
Rate for Payer: Hawaii Western Management Group Commercial	$6,307.00
Rate for Payer: Health Management Network Commercial	$7,658.50
Rate for Payer: Humana Medicare	$6,847.60
Rate for Payer: Kaiser Permanente Commercial	$8,109.00
Rate for Payer: Kaiser Permanente Medicaid	$4,595.10
Rate for Payer: Kaiser Permanente Medicare	$6,847.60
Rate for Payer: MDX Hawaii PPO	$8,739.70
Rate for Payer: Ohana Health Plan Medicaid	$6,847.60
Rate for Payer: Ohana Health Plan Medicare	$6,847.60
Rate for Payer: UnitedHealthcare Medicare	$6,847.60
Rate for Payer: University Health Alliance Commercial	$5,045.60

HUMERAL STEM AS PRESS-FIT

Facility

$10,976.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$5,488.00
Max. Negotiated Rate	$10,646.72
Rate for Payer: AlohaCare Medicaid	$5,488.00
Rate for Payer: AlohaCare Medicare	$8,341.76
Rate for Payer: Cash Price	$6,585.60
Rate for Payer: Devoted Health Medicare	$9,219.84
Rate for Payer: Hawaii Medical Service Association Medicare	$8,341.76
Rate for Payer: Hawaii Western Management Group Commercial	$7,683.20
Rate for Payer: Health Management Network Commercial	$9,329.60
Rate for Payer: Humana Medicare	$8,341.76
Rate for Payer: Kaiser Permanente Commercial	$9,878.40
Rate for Payer: Kaiser Permanente Medicaid	$5,597.76
Rate for Payer: Kaiser Permanente Medicare	$8,341.76
Rate for Payer: MDX Hawaii PPO	$10,646.72
Rate for Payer: Ohana Health Plan Medicaid	$8,341.76
Rate for Payer: Ohana Health Plan Medicare	$8,341.76
Rate for Payer: UnitedHealthcare Medicare	$8,341.76
Rate for Payer: University Health Alliance Commercial	$6,146.56

HUMERAL STEM AS PRESS-FIT

Facility

$10,976.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$6,146.56
Max. Negotiated Rate	$10,646.72
Rate for Payer: Cash Price	$6,585.60
Rate for Payer: Hawaii Western Management Group Commercial	$7,683.20
Rate for Payer: Health Management Network Commercial	$9,329.60
Rate for Payer: Kaiser Permanente Commercial	$9,878.40
Rate for Payer: MDX Hawaii PPO	$10,646.72
Rate for Payer: University Health Alliance Commercial	$6,146.56

HUMERAL STEM C9#01.04211.092

Facility

$6,608.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$3,304.00
Max. Negotiated Rate	$6,409.76
Rate for Payer: AlohaCare Medicaid	$3,304.00
Rate for Payer: AlohaCare Medicare	$5,022.08
Rate for Payer: Cash Price	$3,964.80
Rate for Payer: Devoted Health Medicare	$5,550.72
Rate for Payer: Hawaii Medical Service Association Medicare	$5,022.08
Rate for Payer: Hawaii Western Management Group Commercial	$4,625.60
Rate for Payer: Health Management Network Commercial	$5,616.80
Rate for Payer: Humana Medicare	$5,022.08
Rate for Payer: Kaiser Permanente Commercial	$5,947.20
Rate for Payer: Kaiser Permanente Medicaid	$3,370.08
Rate for Payer: Kaiser Permanente Medicare	$5,022.08
Rate for Payer: MDX Hawaii PPO	$6,409.76
Rate for Payer: Ohana Health Plan Medicaid	$5,022.08
Rate for Payer: Ohana Health Plan Medicare	$5,022.08
Rate for Payer: UnitedHealthcare Medicare	$5,022.08
Rate for Payer: University Health Alliance Commercial	$3,700.48

HUMERAL STEM C9#01.04211.092

Facility

$6,608.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$3,700.48
Max. Negotiated Rate	$6,409.76
Rate for Payer: Cash Price	$3,964.80
Rate for Payer: Hawaii Western Management Group Commercial	$4,625.60
Rate for Payer: Health Management Network Commercial	$5,616.80
Rate for Payer: Kaiser Permanente Commercial	$5,947.20
Rate for Payer: MDX Hawaii PPO	$6,409.76
Rate for Payer: University Health Alliance Commercial	$3,700.48

Know your out-of-pocket cost for care.

All Charges