Honoka'a Hospital and Skilled Nursing Facility

All Charges

Charge

Type

Setting

Price

HUMERAL STEM CEMENTED DWF702B

Facility

$10,750.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$6,020.00
Max. Negotiated Rate	$10,427.50
Rate for Payer: Cash Price	$6,450.00
Rate for Payer: Hawaii Western Management Group Commercial	$7,525.00
Rate for Payer: Health Management Network Commercial	$9,137.50
Rate for Payer: Kaiser Permanente Commercial	$9,675.00
Rate for Payer: MDX Hawaii PPO	$10,427.50
Rate for Payer: University Health Alliance Commercial	$6,020.00

HUMERAL STEM CEMENTED DWF702B

Facility

$10,750.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$5,375.00
Max. Negotiated Rate	$10,427.50
Rate for Payer: AlohaCare Medicaid	$5,375.00
Rate for Payer: AlohaCare Medicare	$8,170.00
Rate for Payer: Cash Price	$6,450.00
Rate for Payer: Devoted Health Medicare	$9,030.00
Rate for Payer: Hawaii Medical Service Association Medicare	$8,170.00
Rate for Payer: Hawaii Western Management Group Commercial	$7,525.00
Rate for Payer: Health Management Network Commercial	$9,137.50
Rate for Payer: Humana Medicare	$8,170.00
Rate for Payer: Kaiser Permanente Commercial	$9,675.00
Rate for Payer: Kaiser Permanente Medicaid	$5,482.50
Rate for Payer: Kaiser Permanente Medicare	$8,170.00
Rate for Payer: MDX Hawaii PPO	$10,427.50
Rate for Payer: Ohana Health Plan Medicaid	$8,170.00
Rate for Payer: Ohana Health Plan Medicare	$8,170.00
Rate for Payer: UnitedHealthcare Medicare	$8,170.00
Rate for Payer: University Health Alliance Commercial	$6,020.00

HUMERAL STEM CEMENTED X10.5-10

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 CEMENTED X10.5-10

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 CEMENTED X5-70

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 CEMENTED X5-70

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 CEMENTED X6-70

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 CEMENTED X6-70

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 CEMENTED X7-90

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 CEMENTED X7-90

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 CEMENTED X9-100

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 CEMENTED X9-100

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 LNG PTC DWF613B

Facility

$11,368.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$6,366.08
Max. Negotiated Rate	$11,026.96
Rate for Payer: Cash Price	$6,820.80
Rate for Payer: Hawaii Western Management Group Commercial	$7,957.60
Rate for Payer: Health Management Network Commercial	$9,662.80
Rate for Payer: Kaiser Permanente Commercial	$10,231.20
Rate for Payer: MDX Hawaii PPO	$11,026.96
Rate for Payer: University Health Alliance Commercial	$6,366.08

HUMERAL STEM LNG PTC DWF613B

Facility

$11,368.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$5,684.00
Max. Negotiated Rate	$11,026.96
Rate for Payer: AlohaCare Medicaid	$5,684.00
Rate for Payer: AlohaCare Medicare	$8,639.68
Rate for Payer: Cash Price	$6,820.80
Rate for Payer: Devoted Health Medicare	$9,549.12
Rate for Payer: Hawaii Medical Service Association Medicare	$8,639.68
Rate for Payer: Hawaii Western Management Group Commercial	$7,957.60
Rate for Payer: Health Management Network Commercial	$9,662.80
Rate for Payer: Humana Medicare	$8,639.68
Rate for Payer: Kaiser Permanente Commercial	$10,231.20
Rate for Payer: Kaiser Permanente Medicaid	$5,797.68
Rate for Payer: Kaiser Permanente Medicare	$8,639.68
Rate for Payer: MDX Hawaii PPO	$11,026.96
Rate for Payer: Ohana Health Plan Medicaid	$8,639.68
Rate for Payer: Ohana Health Plan Medicare	$8,639.68
Rate for Payer: UnitedHealthcare Medicare	$8,639.68
Rate for Payer: University Health Alliance Commercial	$6,366.08

HUMERAL STEM MICRO 11MM 113611

Facility

$8,800.00

Service Code	HCPCS C1776
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

HUMERAL STEM MICRO 11MM 113611

Facility

$8,800.00

Service Code	HCPCS C1776
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

HUMERAL STEM MINI 10MM 113630

Facility

$13,880.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$6,940.00
Max. Negotiated Rate	$13,463.60
Rate for Payer: AlohaCare Medicaid	$6,940.00
Rate for Payer: AlohaCare Medicare	$10,548.80
Rate for Payer: Cash Price	$8,328.00
Rate for Payer: Devoted Health Medicare	$11,659.20
Rate for Payer: Hawaii Medical Service Association Medicare	$10,548.80
Rate for Payer: Hawaii Western Management Group Commercial	$9,716.00
Rate for Payer: Health Management Network Commercial	$11,798.00
Rate for Payer: Humana Medicare	$10,548.80
Rate for Payer: Kaiser Permanente Commercial	$12,492.00
Rate for Payer: Kaiser Permanente Medicaid	$7,078.80
Rate for Payer: Kaiser Permanente Medicare	$10,548.80
Rate for Payer: MDX Hawaii PPO	$13,463.60
Rate for Payer: Ohana Health Plan Medicaid	$10,548.80
Rate for Payer: Ohana Health Plan Medicare	$10,548.80
Rate for Payer: UnitedHealthcare Medicare	$10,548.80
Rate for Payer: University Health Alliance Commercial	$7,772.80

HUMERAL STEM MINI 10MM 113630

Facility

$13,880.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$7,772.80
Max. Negotiated Rate	$13,463.60
Rate for Payer: Cash Price	$8,328.00
Rate for Payer: Hawaii Western Management Group Commercial	$9,716.00
Rate for Payer: Health Management Network Commercial	$11,798.00
Rate for Payer: Kaiser Permanente Commercial	$12,492.00
Rate for Payer: MDX Hawaii PPO	$13,463.60
Rate for Payer: University Health Alliance Commercial	$7,772.80

HUMERAL STEM STD PTC

Facility

$8,762.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$4,381.00
Max. Negotiated Rate	$8,499.14
Rate for Payer: AlohaCare Medicaid	$4,381.00
Rate for Payer: AlohaCare Medicare	$6,659.12
Rate for Payer: Cash Price	$5,257.20
Rate for Payer: Devoted Health Medicare	$7,360.08
Rate for Payer: Hawaii Medical Service Association Medicare	$6,659.12
Rate for Payer: Hawaii Western Management Group Commercial	$6,133.40
Rate for Payer: Health Management Network Commercial	$7,447.70
Rate for Payer: Humana Medicare	$6,659.12
Rate for Payer: Kaiser Permanente Commercial	$7,885.80
Rate for Payer: Kaiser Permanente Medicaid	$4,468.62
Rate for Payer: Kaiser Permanente Medicare	$6,659.12
Rate for Payer: MDX Hawaii PPO	$8,499.14
Rate for Payer: Ohana Health Plan Medicaid	$6,659.12
Rate for Payer: Ohana Health Plan Medicare	$6,659.12
Rate for Payer: UnitedHealthcare Medicare	$6,659.12
Rate for Payer: University Health Alliance Commercial	$4,906.72

HUMERAL STEM STD PTC

Facility

$8,762.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$4,906.72
Max. Negotiated Rate	$8,499.14
Rate for Payer: Cash Price	$5,257.20
Rate for Payer: Hawaii Western Management Group Commercial	$6,133.40
Rate for Payer: Health Management Network Commercial	$7,447.70
Rate for Payer: Kaiser Permanente Commercial	$7,885.80
Rate for Payer: MDX Hawaii PPO	$8,499.14
Rate for Payer: University Health Alliance Commercial	$4,906.72

HUMERAL STEM STND PTC DWF604A

Facility

$11,368.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$5,684.00
Max. Negotiated Rate	$11,026.96
Rate for Payer: AlohaCare Medicaid	$5,684.00
Rate for Payer: AlohaCare Medicare	$8,639.68
Rate for Payer: Cash Price	$6,820.80
Rate for Payer: Devoted Health Medicare	$9,549.12
Rate for Payer: Hawaii Medical Service Association Medicare	$8,639.68
Rate for Payer: Hawaii Western Management Group Commercial	$7,957.60
Rate for Payer: Health Management Network Commercial	$9,662.80
Rate for Payer: Humana Medicare	$8,639.68
Rate for Payer: Kaiser Permanente Commercial	$10,231.20
Rate for Payer: Kaiser Permanente Medicaid	$5,797.68
Rate for Payer: Kaiser Permanente Medicare	$8,639.68
Rate for Payer: MDX Hawaii PPO	$11,026.96
Rate for Payer: Ohana Health Plan Medicaid	$8,639.68
Rate for Payer: Ohana Health Plan Medicare	$8,639.68
Rate for Payer: UnitedHealthcare Medicare	$8,639.68
Rate for Payer: University Health Alliance Commercial	$6,366.08

HUMERAL STEM STND PTC DWF604A

Facility

$11,368.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$6,366.08
Max. Negotiated Rate	$11,026.96
Rate for Payer: Cash Price	$6,820.80
Rate for Payer: Hawaii Western Management Group Commercial	$7,957.60
Rate for Payer: Health Management Network Commercial	$9,662.80
Rate for Payer: Kaiser Permanente Commercial	$10,231.20
Rate for Payer: MDX Hawaii PPO	$11,026.96
Rate for Payer: University Health Alliance Commercial	$6,366.08

HUMERAL STEM SZ 2+ DWX2PS

Facility

$10,762.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$6,026.72
Max. Negotiated Rate	$10,439.14
Rate for Payer: Cash Price	$6,457.20
Rate for Payer: Hawaii Western Management Group Commercial	$7,533.40
Rate for Payer: Health Management Network Commercial	$9,147.70
Rate for Payer: Kaiser Permanente Commercial	$9,685.80
Rate for Payer: MDX Hawaii PPO	$10,439.14
Rate for Payer: University Health Alliance Commercial	$6,026.72

HUMERAL STEM SZ 2+ DWX2PS

Facility

$10,762.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$5,381.00
Max. Negotiated Rate	$10,439.14
Rate for Payer: AlohaCare Medicaid	$5,381.00
Rate for Payer: AlohaCare Medicare	$8,179.12
Rate for Payer: Cash Price	$6,457.20
Rate for Payer: Devoted Health Medicare	$9,040.08
Rate for Payer: Hawaii Medical Service Association Medicare	$8,179.12
Rate for Payer: Hawaii Western Management Group Commercial	$7,533.40
Rate for Payer: Health Management Network Commercial	$9,147.70
Rate for Payer: Humana Medicare	$8,179.12
Rate for Payer: Kaiser Permanente Commercial	$9,685.80
Rate for Payer: Kaiser Permanente Medicaid	$5,488.62
Rate for Payer: Kaiser Permanente Medicare	$8,179.12
Rate for Payer: MDX Hawaii PPO	$10,439.14
Rate for Payer: Ohana Health Plan Medicaid	$8,179.12
Rate for Payer: Ohana Health Plan Medicare	$8,179.12
Rate for Payer: UnitedHealthcare Medicare	$8,179.12
Rate for Payer: University Health Alliance Commercial	$6,026.72

HUMERAL STEM UC12 01.04201.122

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

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