Honoka'a Hospital and Skilled Nursing Facility

All Charges

Charge

Type

Setting

Price

INSERT HUM S36/+3 AR-9503S-03

Facility

$2,030.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$1,136.80
Max. Negotiated Rate	$1,969.10
Rate for Payer: Cash Price	$1,218.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,421.00
Rate for Payer: Health Management Network Commercial	$1,725.50
Rate for Payer: Kaiser Permanente Commercial	$1,827.00
Rate for Payer: MDX Hawaii PPO	$1,969.10
Rate for Payer: University Health Alliance Commercial	$1,136.80

INSERTION KIT AR-3610PK-3

Facility

$886.00

Service Code	HCPCS C1713
Hospital Revenue Code	272
Min. Negotiated Rate	$753.10
Max. Negotiated Rate	$859.42
Rate for Payer: Cash Price	$531.60
Rate for Payer: Health Management Network Commercial	$753.10
Rate for Payer: Kaiser Permanente Commercial	$797.40
Rate for Payer: MDX Hawaii PPO	$859.42

INSERTION KIT AR-3610PK-3

Facility

$886.00

Service Code	HCPCS C1713
Hospital Revenue Code	272
Min. Negotiated Rate	$443.00
Max. Negotiated Rate	$859.42
Rate for Payer: AlohaCare Medicaid	$443.00
Rate for Payer: AlohaCare Medicare	$673.36
Rate for Payer: Cash Price	$531.60
Rate for Payer: Devoted Health Medicare	$744.24
Rate for Payer: Hawaii Medical Service Association Medicare	$673.36
Rate for Payer: Hawaii Western Management Group Commercial	$841.70
Rate for Payer: Health Management Network Commercial	$753.10
Rate for Payer: Humana Medicare	$673.36
Rate for Payer: Kaiser Permanente Commercial	$797.40
Rate for Payer: Kaiser Permanente Medicaid	$451.86
Rate for Payer: Kaiser Permanente Medicare	$673.36
Rate for Payer: MDX Hawaii PPO	$859.42
Rate for Payer: Ohana Health Plan Medicaid	$673.36
Rate for Payer: Ohana Health Plan Medicare	$673.36
Rate for Payer: UnitedHealthcare Medicare	$673.36
Rate for Payer: University Health Alliance Commercial	$645.81

INSERT JOURNEY II BSC XLPE

Facility

$4,038.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$2,019.00
Max. Negotiated Rate	$3,916.86
Rate for Payer: AlohaCare Medicaid	$2,019.00
Rate for Payer: AlohaCare Medicare	$3,068.88
Rate for Payer: Cash Price	$2,422.80
Rate for Payer: Devoted Health Medicare	$3,391.92
Rate for Payer: Hawaii Medical Service Association Medicare	$3,068.88
Rate for Payer: Hawaii Western Management Group Commercial	$2,826.60
Rate for Payer: Health Management Network Commercial	$3,432.30
Rate for Payer: Humana Medicare	$3,068.88
Rate for Payer: Kaiser Permanente Commercial	$3,634.20
Rate for Payer: Kaiser Permanente Medicaid	$2,059.38
Rate for Payer: Kaiser Permanente Medicare	$3,068.88
Rate for Payer: MDX Hawaii PPO	$3,916.86
Rate for Payer: Ohana Health Plan Medicaid	$3,068.88
Rate for Payer: Ohana Health Plan Medicare	$3,068.88
Rate for Payer: UnitedHealthcare Medicare	$3,068.88
Rate for Payer: University Health Alliance Commercial	$2,261.28

INSERT JOURNEY II BSC XLPE

Facility

$4,038.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$2,261.28
Max. Negotiated Rate	$3,916.86
Rate for Payer: Cash Price	$2,422.80
Rate for Payer: Hawaii Western Management Group Commercial	$2,826.60
Rate for Payer: Health Management Network Commercial	$3,432.30
Rate for Payer: Kaiser Permanente Commercial	$3,634.20
Rate for Payer: MDX Hawaii PPO	$3,916.86
Rate for Payer: University Health Alliance Commercial	$2,261.28

INSERT MDM X3 1236-2-244

Facility

$3,244.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$1,816.64
Max. Negotiated Rate	$3,146.68
Rate for Payer: Cash Price	$1,946.40
Rate for Payer: Hawaii Western Management Group Commercial	$2,270.80
Rate for Payer: Health Management Network Commercial	$2,757.40
Rate for Payer: Kaiser Permanente Commercial	$2,919.60
Rate for Payer: MDX Hawaii PPO	$3,146.68
Rate for Payer: University Health Alliance Commercial	$1,816.64

INSERT MDM X3 1236-2-244

Facility

$3,244.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$1,622.00
Max. Negotiated Rate	$3,146.68
Rate for Payer: AlohaCare Medicaid	$1,622.00
Rate for Payer: AlohaCare Medicare	$2,465.44
Rate for Payer: Cash Price	$1,946.40
Rate for Payer: Devoted Health Medicare	$2,724.96
Rate for Payer: Hawaii Medical Service Association Medicare	$2,465.44
Rate for Payer: Hawaii Western Management Group Commercial	$2,270.80
Rate for Payer: Health Management Network Commercial	$2,757.40
Rate for Payer: Humana Medicare	$2,465.44
Rate for Payer: Kaiser Permanente Commercial	$2,919.60
Rate for Payer: Kaiser Permanente Medicaid	$1,654.44
Rate for Payer: Kaiser Permanente Medicare	$2,465.44
Rate for Payer: MDX Hawaii PPO	$3,146.68
Rate for Payer: Ohana Health Plan Medicaid	$2,465.44
Rate for Payer: Ohana Health Plan Medicare	$2,465.44
Rate for Payer: UnitedHealthcare Medicare	$2,465.44
Rate for Payer: University Health Alliance Commercial	$1,816.64

INSERT POLYEHTYLENE 723-00-36E

Facility

$2,703.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$1,513.68
Max. Negotiated Rate	$2,621.91
Rate for Payer: Cash Price	$1,621.80
Rate for Payer: Hawaii Western Management Group Commercial	$1,892.10
Rate for Payer: Health Management Network Commercial	$2,297.55
Rate for Payer: Kaiser Permanente Commercial	$2,432.70
Rate for Payer: MDX Hawaii PPO	$2,621.91
Rate for Payer: University Health Alliance Commercial	$1,513.68

INSERT POLYEHTYLENE 723-00-36E

Facility

$2,703.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$1,351.50
Max. Negotiated Rate	$2,621.91
Rate for Payer: AlohaCare Medicaid	$1,351.50
Rate for Payer: AlohaCare Medicare	$2,054.28
Rate for Payer: Cash Price	$1,621.80
Rate for Payer: Devoted Health Medicare	$2,270.52
Rate for Payer: Hawaii Medical Service Association Medicare	$2,054.28
Rate for Payer: Hawaii Western Management Group Commercial	$1,892.10
Rate for Payer: Health Management Network Commercial	$2,297.55
Rate for Payer: Humana Medicare	$2,054.28
Rate for Payer: Kaiser Permanente Commercial	$2,432.70
Rate for Payer: Kaiser Permanente Medicaid	$1,378.53
Rate for Payer: Kaiser Permanente Medicare	$2,054.28
Rate for Payer: MDX Hawaii PPO	$2,621.91
Rate for Payer: Ohana Health Plan Medicaid	$2,054.28
Rate for Payer: Ohana Health Plan Medicare	$2,054.28
Rate for Payer: UnitedHealthcare Medicare	$2,054.28
Rate for Payer: University Health Alliance Commercial	$1,513.68

INSERT POLYETHYLENE 723-00-36F

Facility

$2,703.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$1,513.68
Max. Negotiated Rate	$2,621.91
Rate for Payer: Cash Price	$1,621.80
Rate for Payer: Hawaii Western Management Group Commercial	$1,892.10
Rate for Payer: Health Management Network Commercial	$2,297.55
Rate for Payer: Kaiser Permanente Commercial	$2,432.70
Rate for Payer: MDX Hawaii PPO	$2,621.91
Rate for Payer: University Health Alliance Commercial	$1,513.68

INSERT POLYETHYLENE 723-00-36F

Facility

$2,703.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$1,351.50
Max. Negotiated Rate	$2,621.91
Rate for Payer: AlohaCare Medicaid	$1,351.50
Rate for Payer: AlohaCare Medicare	$2,054.28
Rate for Payer: Cash Price	$1,621.80
Rate for Payer: Devoted Health Medicare	$2,270.52
Rate for Payer: Hawaii Medical Service Association Medicare	$2,054.28
Rate for Payer: Hawaii Western Management Group Commercial	$1,892.10
Rate for Payer: Health Management Network Commercial	$2,297.55
Rate for Payer: Humana Medicare	$2,054.28
Rate for Payer: Kaiser Permanente Commercial	$2,432.70
Rate for Payer: Kaiser Permanente Medicaid	$1,378.53
Rate for Payer: Kaiser Permanente Medicare	$2,054.28
Rate for Payer: MDX Hawaii PPO	$2,621.91
Rate for Payer: Ohana Health Plan Medicaid	$2,054.28
Rate for Payer: Ohana Health Plan Medicare	$2,054.28
Rate for Payer: UnitedHealthcare Medicare	$2,054.28
Rate for Payer: University Health Alliance Commercial	$1,513.68

INSERT RETENTIVE REV DWF364B

Facility

$5,976.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$3,346.56
Max. Negotiated Rate	$5,796.72
Rate for Payer: Cash Price	$3,585.60
Rate for Payer: Hawaii Western Management Group Commercial	$4,183.20
Rate for Payer: Health Management Network Commercial	$5,079.60
Rate for Payer: Kaiser Permanente Commercial	$5,378.40
Rate for Payer: MDX Hawaii PPO	$5,796.72
Rate for Payer: University Health Alliance Commercial	$3,346.56

INSERT RETENTIVE REV DWF364B

Facility

$5,976.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$2,988.00
Max. Negotiated Rate	$5,796.72
Rate for Payer: AlohaCare Medicaid	$2,988.00
Rate for Payer: AlohaCare Medicare	$4,541.76
Rate for Payer: Cash Price	$3,585.60
Rate for Payer: Devoted Health Medicare	$5,019.84
Rate for Payer: Hawaii Medical Service Association Medicare	$4,541.76
Rate for Payer: Hawaii Western Management Group Commercial	$4,183.20
Rate for Payer: Health Management Network Commercial	$5,079.60
Rate for Payer: Humana Medicare	$4,541.76
Rate for Payer: Kaiser Permanente Commercial	$5,378.40
Rate for Payer: Kaiser Permanente Medicaid	$3,047.76
Rate for Payer: Kaiser Permanente Medicare	$4,541.76
Rate for Payer: MDX Hawaii PPO	$5,796.72
Rate for Payer: Ohana Health Plan Medicaid	$4,541.76
Rate for Payer: Ohana Health Plan Medicare	$4,541.76
Rate for Payer: UnitedHealthcare Medicare	$4,541.76
Rate for Payer: University Health Alliance Commercial	$3,346.56

INSERT REVERSED +3MM

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

INSERT REVERSED +3MM

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

INSERT REVERSED THICKNESS +9MM

Facility

$3,530.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$1,765.00
Max. Negotiated Rate	$3,424.10
Rate for Payer: AlohaCare Medicaid	$1,765.00
Rate for Payer: AlohaCare Medicare	$2,682.80
Rate for Payer: Cash Price	$2,118.00
Rate for Payer: Devoted Health Medicare	$2,965.20
Rate for Payer: Hawaii Medical Service Association Medicare	$2,682.80
Rate for Payer: Hawaii Western Management Group Commercial	$2,471.00
Rate for Payer: Health Management Network Commercial	$3,000.50
Rate for Payer: Humana Medicare	$2,682.80
Rate for Payer: Kaiser Permanente Commercial	$3,177.00
Rate for Payer: Kaiser Permanente Medicaid	$1,800.30
Rate for Payer: Kaiser Permanente Medicare	$2,682.80
Rate for Payer: MDX Hawaii PPO	$3,424.10
Rate for Payer: Ohana Health Plan Medicaid	$2,682.80
Rate for Payer: Ohana Health Plan Medicare	$2,682.80
Rate for Payer: UnitedHealthcare Medicare	$2,682.80
Rate for Payer: University Health Alliance Commercial	$1,976.80

INSERT REVERSED THICKNESS +9MM

Facility

$3,530.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$1,976.80
Max. Negotiated Rate	$3,424.10
Rate for Payer: Cash Price	$2,118.00
Rate for Payer: Hawaii Western Management Group Commercial	$2,471.00
Rate for Payer: Health Management Network Commercial	$3,000.50
Rate for Payer: Kaiser Permanente Commercial	$3,177.00
Rate for Payer: MDX Hawaii PPO	$3,424.10
Rate for Payer: University Health Alliance Commercial	$1,976.80

INSERT REVERSE THCK +6 DWF391B

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

INSERT REVERSE THCK +6 DWF391B

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

INSERT REV THICK +3MM DWP1363

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

INSERT REV THICK +3MM DWP1363

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

INSERT STABILIZER 5537-G-316-E

Facility

$4,903.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$2,451.50
Max. Negotiated Rate	$4,755.91
Rate for Payer: AlohaCare Medicaid	$2,451.50
Rate for Payer: AlohaCare Medicare	$3,726.28
Rate for Payer: Cash Price	$2,941.80
Rate for Payer: Devoted Health Medicare	$4,118.52
Rate for Payer: Hawaii Medical Service Association Medicare	$3,726.28
Rate for Payer: Hawaii Western Management Group Commercial	$3,432.10
Rate for Payer: Health Management Network Commercial	$4,167.55
Rate for Payer: Humana Medicare	$3,726.28
Rate for Payer: Kaiser Permanente Commercial	$4,412.70
Rate for Payer: Kaiser Permanente Medicaid	$2,500.53
Rate for Payer: Kaiser Permanente Medicare	$3,726.28
Rate for Payer: MDX Hawaii PPO	$4,755.91
Rate for Payer: Ohana Health Plan Medicaid	$3,726.28
Rate for Payer: Ohana Health Plan Medicare	$3,726.28
Rate for Payer: UnitedHealthcare Medicare	$3,726.28
Rate for Payer: University Health Alliance Commercial	$2,745.68

INSERT STABILIZER 5537-G-316-E

Facility

$4,903.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$2,745.68
Max. Negotiated Rate	$4,755.91
Rate for Payer: Cash Price	$2,941.80
Rate for Payer: Hawaii Western Management Group Commercial	$3,432.10
Rate for Payer: Health Management Network Commercial	$4,167.55
Rate for Payer: Kaiser Permanente Commercial	$4,412.70
Rate for Payer: MDX Hawaii PPO	$4,755.91
Rate for Payer: University Health Alliance Commercial	$2,745.68

INSERT TB 5531-G-613-E

Facility

$2,676.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$1,338.00
Max. Negotiated Rate	$2,595.72
Rate for Payer: AlohaCare Medicaid	$1,338.00
Rate for Payer: AlohaCare Medicare	$2,033.76
Rate for Payer: Cash Price	$1,605.60
Rate for Payer: Devoted Health Medicare	$2,247.84
Rate for Payer: Hawaii Medical Service Association Medicare	$2,033.76
Rate for Payer: Hawaii Western Management Group Commercial	$1,873.20
Rate for Payer: Health Management Network Commercial	$2,274.60
Rate for Payer: Humana Medicare	$2,033.76
Rate for Payer: Kaiser Permanente Commercial	$2,408.40
Rate for Payer: Kaiser Permanente Medicaid	$1,364.76
Rate for Payer: Kaiser Permanente Medicare	$2,033.76
Rate for Payer: MDX Hawaii PPO	$2,595.72
Rate for Payer: Ohana Health Plan Medicaid	$2,033.76
Rate for Payer: Ohana Health Plan Medicare	$2,033.76
Rate for Payer: UnitedHealthcare Medicare	$2,033.76
Rate for Payer: University Health Alliance Commercial	$1,498.56

INSERT TB 5531-G-613-E

Facility

$2,676.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$1,498.56
Max. Negotiated Rate	$2,595.72
Rate for Payer: Cash Price	$1,605.60
Rate for Payer: Hawaii Western Management Group Commercial	$1,873.20
Rate for Payer: Health Management Network Commercial	$2,274.60
Rate for Payer: Kaiser Permanente Commercial	$2,408.40
Rate for Payer: MDX Hawaii PPO	$2,595.72
Rate for Payer: University Health Alliance Commercial	$1,498.56

Know your out-of-pocket cost for care.

All Charges