Honoka'a Hospital and Skilled Nursing Facility

All Charges

Charge

Type

Setting

Price

INSERT TIBIAL 5537-G-416-E

Facility

$4,903.00

Service Code	HCPCS C1713
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 TIBIAL 5537-G-611-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 TIBIAL 5537-G-611-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 TIBIAL BEARING PS

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 TIBIAL BEARING PS

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

INSERT TIBIAL SZ 2 5532-G-209

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 TIBIAL SZ 2 5532-G-209

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 TIBIAL SZ7 5532-G-712-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 TIBIAL SZ7 5532-G-712-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

INSERT TIBIAL SZ8 5532-G-810-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 TIBIAL SZ8 5532-G-810-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

INSERT TIBIAL TOTAL STABILIZER

Facility

$5,148.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$2,574.00
Max. Negotiated Rate	$4,993.56
Rate for Payer: AlohaCare Medicaid	$2,574.00
Rate for Payer: AlohaCare Medicare	$3,912.48
Rate for Payer: Cash Price	$3,088.80
Rate for Payer: Devoted Health Medicare	$4,324.32
Rate for Payer: Hawaii Medical Service Association Medicare	$3,912.48
Rate for Payer: Hawaii Western Management Group Commercial	$3,603.60
Rate for Payer: Health Management Network Commercial	$4,375.80
Rate for Payer: Humana Medicare	$3,912.48
Rate for Payer: Kaiser Permanente Commercial	$4,633.20
Rate for Payer: Kaiser Permanente Medicaid	$2,625.48
Rate for Payer: Kaiser Permanente Medicare	$3,912.48
Rate for Payer: MDX Hawaii PPO	$4,993.56
Rate for Payer: Ohana Health Plan Medicaid	$3,912.48
Rate for Payer: Ohana Health Plan Medicare	$3,912.48
Rate for Payer: UnitedHealthcare Medicare	$3,912.48
Rate for Payer: University Health Alliance Commercial	$2,882.88

INSERT TIBIAL TOTAL STABILIZER

Facility

$5,148.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$2,882.88
Max. Negotiated Rate	$4,993.56
Rate for Payer: Cash Price	$3,088.80
Rate for Payer: Hawaii Western Management Group Commercial	$3,603.60
Rate for Payer: Health Management Network Commercial	$4,375.80
Rate for Payer: Kaiser Permanente Commercial	$4,633.20
Rate for Payer: MDX Hawaii PPO	$4,993.56
Rate for Payer: University Health Alliance Commercial	$2,882.88

INSERT TIBIAL TRI 5537-G-516-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 TIBIAL TRI 5537-G-516-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 TIBIAL TRIATHLON X3

Facility

$5,148.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$2,574.00
Max. Negotiated Rate	$4,993.56
Rate for Payer: AlohaCare Medicaid	$2,574.00
Rate for Payer: AlohaCare Medicare	$3,912.48
Rate for Payer: Cash Price	$3,088.80
Rate for Payer: Devoted Health Medicare	$4,324.32
Rate for Payer: Hawaii Medical Service Association Medicare	$3,912.48
Rate for Payer: Hawaii Western Management Group Commercial	$3,603.60
Rate for Payer: Health Management Network Commercial	$4,375.80
Rate for Payer: Humana Medicare	$3,912.48
Rate for Payer: Kaiser Permanente Commercial	$4,633.20
Rate for Payer: Kaiser Permanente Medicaid	$2,625.48
Rate for Payer: Kaiser Permanente Medicare	$3,912.48
Rate for Payer: MDX Hawaii PPO	$4,993.56
Rate for Payer: Ohana Health Plan Medicaid	$3,912.48
Rate for Payer: Ohana Health Plan Medicare	$3,912.48
Rate for Payer: UnitedHealthcare Medicare	$3,912.48
Rate for Payer: University Health Alliance Commercial	$2,882.88

INSERT TIBIAL TRIATHLON X3

Facility

$5,148.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$2,882.88
Max. Negotiated Rate	$4,993.56
Rate for Payer: Cash Price	$3,088.80
Rate for Payer: Hawaii Western Management Group Commercial	$3,603.60
Rate for Payer: Health Management Network Commercial	$4,375.80
Rate for Payer: Kaiser Permanente Commercial	$4,633.20
Rate for Payer: MDX Hawaii PPO	$4,993.56
Rate for Payer: University Health Alliance Commercial	$2,882.88

INSERT TIBIAL X3 5531-G-413-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

INSERT TIBIAL X3 5531-G-413-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 TIB THRIA 5537-G-409-E

Facility

$5,148.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$2,574.00
Max. Negotiated Rate	$4,993.56
Rate for Payer: AlohaCare Medicaid	$2,574.00
Rate for Payer: AlohaCare Medicare	$3,912.48
Rate for Payer: Cash Price	$3,088.80
Rate for Payer: Devoted Health Medicare	$4,324.32
Rate for Payer: Hawaii Medical Service Association Medicare	$3,912.48
Rate for Payer: Hawaii Western Management Group Commercial	$3,603.60
Rate for Payer: Health Management Network Commercial	$4,375.80
Rate for Payer: Humana Medicare	$3,912.48
Rate for Payer: Kaiser Permanente Commercial	$4,633.20
Rate for Payer: Kaiser Permanente Medicaid	$2,625.48
Rate for Payer: Kaiser Permanente Medicare	$3,912.48
Rate for Payer: MDX Hawaii PPO	$4,993.56
Rate for Payer: Ohana Health Plan Medicaid	$3,912.48
Rate for Payer: Ohana Health Plan Medicare	$3,912.48
Rate for Payer: UnitedHealthcare Medicare	$3,912.48
Rate for Payer: University Health Alliance Commercial	$2,882.88

INSERT TIB THRIA 5537-G-409-E

Facility

$5,148.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$2,882.88
Max. Negotiated Rate	$4,993.56
Rate for Payer: Cash Price	$3,088.80
Rate for Payer: Hawaii Western Management Group Commercial	$3,603.60
Rate for Payer: Health Management Network Commercial	$4,375.80
Rate for Payer: Kaiser Permanente Commercial	$4,633.20
Rate for Payer: MDX Hawaii PPO	$4,993.56
Rate for Payer: University Health Alliance Commercial	$2,882.88

INSERT TRIALTHON 5531-G-512-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 TRIALTHON 5531-G-512-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

INSERT TRIATHLON 5531-G-310-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

INSERT TRIATHLON 5531-G-310-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

Know your out-of-pocket cost for care.

All Charges