Honoka'a Hospital and Skilled Nursing Facility

All Charges

Charge

Type

Setting

Price

LCP HUMERUS 2.7X3.5 02.117.704

Facility

$2,837.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,418.50
Max. Negotiated Rate	$2,751.89
Rate for Payer: AlohaCare Medicaid	$1,418.50
Rate for Payer: AlohaCare Medicare	$2,156.12
Rate for Payer: Cash Price	$1,702.20
Rate for Payer: Devoted Health Medicare	$2,383.08
Rate for Payer: Hawaii Medical Service Association Medicare	$2,156.12
Rate for Payer: Hawaii Western Management Group Commercial	$1,985.90
Rate for Payer: Health Management Network Commercial	$2,411.45
Rate for Payer: Humana Medicare	$2,156.12
Rate for Payer: Kaiser Permanente Commercial	$2,553.30
Rate for Payer: Kaiser Permanente Medicaid	$1,446.87
Rate for Payer: Kaiser Permanente Medicare	$2,156.12
Rate for Payer: MDX Hawaii PPO	$2,751.89
Rate for Payer: Ohana Health Plan Medicaid	$2,156.12
Rate for Payer: Ohana Health Plan Medicare	$2,156.12
Rate for Payer: UnitedHealthcare Medicare	$2,156.12
Rate for Payer: University Health Alliance Commercial	$1,588.72

LCP HUMERUS 2.7X3.5 02.117.704

Facility

$2,837.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,588.72
Max. Negotiated Rate	$2,751.89
Rate for Payer: Cash Price	$1,702.20
Rate for Payer: Hawaii Western Management Group Commercial	$1,985.90
Rate for Payer: Health Management Network Commercial	$2,411.45
Rate for Payer: Kaiser Permanente Commercial	$2,553.30
Rate for Payer: MDX Hawaii PPO	$2,751.89
Rate for Payer: University Health Alliance Commercial	$1,588.72

LCP PLATE 2.0, 5 HOLE/38MM

Facility

$1,180.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$660.80
Max. Negotiated Rate	$1,144.60
Rate for Payer: Cash Price	$708.00
Rate for Payer: Hawaii Western Management Group Commercial	$826.00
Rate for Payer: Health Management Network Commercial	$1,003.00
Rate for Payer: Kaiser Permanente Commercial	$1,062.00
Rate for Payer: MDX Hawaii PPO	$1,144.60
Rate for Payer: University Health Alliance Commercial	$660.80

LCP PLATE 2.0, 5 HOLE/38MM

Facility

$1,180.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$590.00
Max. Negotiated Rate	$1,144.60
Rate for Payer: AlohaCare Medicaid	$590.00
Rate for Payer: AlohaCare Medicare	$896.80
Rate for Payer: Cash Price	$708.00
Rate for Payer: Devoted Health Medicare	$991.20
Rate for Payer: Hawaii Medical Service Association Medicare	$896.80
Rate for Payer: Hawaii Western Management Group Commercial	$826.00
Rate for Payer: Health Management Network Commercial	$1,003.00
Rate for Payer: Humana Medicare	$896.80
Rate for Payer: Kaiser Permanente Commercial	$1,062.00
Rate for Payer: Kaiser Permanente Medicaid	$601.80
Rate for Payer: Kaiser Permanente Medicare	$896.80
Rate for Payer: MDX Hawaii PPO	$1,144.60
Rate for Payer: Ohana Health Plan Medicaid	$896.80
Rate for Payer: Ohana Health Plan Medicare	$896.80
Rate for Payer: UnitedHealthcare Medicare	$896.80
Rate for Payer: University Health Alliance Commercial	$660.80

LCP PLATE 3H 4.5X62MM 224.531

Facility

$1,530.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$856.80
Max. Negotiated Rate	$1,484.10
Rate for Payer: Cash Price	$918.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,071.00
Rate for Payer: Health Management Network Commercial	$1,300.50
Rate for Payer: Kaiser Permanente Commercial	$1,377.00
Rate for Payer: MDX Hawaii PPO	$1,484.10
Rate for Payer: University Health Alliance Commercial	$856.80

LCP PLATE 3H 4.5X62MM 224.531

Facility

$1,530.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$765.00
Max. Negotiated Rate	$1,484.10
Rate for Payer: AlohaCare Medicaid	$765.00
Rate for Payer: AlohaCare Medicare	$1,162.80
Rate for Payer: Cash Price	$918.00
Rate for Payer: Devoted Health Medicare	$1,285.20
Rate for Payer: Hawaii Medical Service Association Medicare	$1,162.80
Rate for Payer: Hawaii Western Management Group Commercial	$1,071.00
Rate for Payer: Health Management Network Commercial	$1,300.50
Rate for Payer: Humana Medicare	$1,162.80
Rate for Payer: Kaiser Permanente Commercial	$1,377.00
Rate for Payer: Kaiser Permanente Medicaid	$780.30
Rate for Payer: Kaiser Permanente Medicare	$1,162.80
Rate for Payer: MDX Hawaii PPO	$1,484.10
Rate for Payer: Ohana Health Plan Medicaid	$1,162.80
Rate for Payer: Ohana Health Plan Medicare	$1,162.80
Rate for Payer: UnitedHealthcare Medicare	$1,162.80
Rate for Payer: University Health Alliance Commercial	$856.80

LCP PLATE 9H RT 02.110.009S

Facility

$1,039.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$519.50
Max. Negotiated Rate	$1,007.83
Rate for Payer: AlohaCare Medicaid	$519.50
Rate for Payer: AlohaCare Medicare	$789.64
Rate for Payer: Cash Price	$623.40
Rate for Payer: Devoted Health Medicare	$872.76
Rate for Payer: Hawaii Medical Service Association Medicare	$789.64
Rate for Payer: Hawaii Western Management Group Commercial	$727.30
Rate for Payer: Health Management Network Commercial	$883.15
Rate for Payer: Humana Medicare	$789.64
Rate for Payer: Kaiser Permanente Commercial	$935.10
Rate for Payer: Kaiser Permanente Medicaid	$529.89
Rate for Payer: Kaiser Permanente Medicare	$789.64
Rate for Payer: MDX Hawaii PPO	$1,007.83
Rate for Payer: Ohana Health Plan Medicaid	$789.64
Rate for Payer: Ohana Health Plan Medicare	$789.64
Rate for Payer: UnitedHealthcare Medicare	$789.64
Rate for Payer: University Health Alliance Commercial	$581.84

LCP PLATE 9H RT 02.110.009S

Facility

$1,039.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$581.84
Max. Negotiated Rate	$1,007.83
Rate for Payer: Cash Price	$623.40
Rate for Payer: Hawaii Western Management Group Commercial	$727.30
Rate for Payer: Health Management Network Commercial	$883.15
Rate for Payer: Kaiser Permanente Commercial	$935.10
Rate for Payer: MDX Hawaii PPO	$1,007.83
Rate for Payer: University Health Alliance Commercial	$581.84

LCP PROX HUM PL 241.921

Facility

$3,834.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,917.00
Max. Negotiated Rate	$3,718.98
Rate for Payer: AlohaCare Medicaid	$1,917.00
Rate for Payer: AlohaCare Medicare	$2,913.84
Rate for Payer: Cash Price	$2,300.40
Rate for Payer: Devoted Health Medicare	$3,220.56
Rate for Payer: Hawaii Medical Service Association Medicare	$2,913.84
Rate for Payer: Hawaii Western Management Group Commercial	$2,683.80
Rate for Payer: Health Management Network Commercial	$3,258.90
Rate for Payer: Humana Medicare	$2,913.84
Rate for Payer: Kaiser Permanente Commercial	$3,450.60
Rate for Payer: Kaiser Permanente Medicaid	$1,955.34
Rate for Payer: Kaiser Permanente Medicare	$2,913.84
Rate for Payer: MDX Hawaii PPO	$3,718.98
Rate for Payer: Ohana Health Plan Medicaid	$2,913.84
Rate for Payer: Ohana Health Plan Medicare	$2,913.84
Rate for Payer: UnitedHealthcare Medicare	$2,913.84
Rate for Payer: University Health Alliance Commercial	$2,147.04

LCP PROX HUM PL 241.921

Facility

$3,834.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$2,147.04
Max. Negotiated Rate	$3,718.98
Rate for Payer: Cash Price	$2,300.40
Rate for Payer: Hawaii Western Management Group Commercial	$2,683.80
Rate for Payer: Health Management Network Commercial	$3,258.90
Rate for Payer: Kaiser Permanente Commercial	$3,450.60
Rate for Payer: MDX Hawaii PPO	$3,718.98
Rate for Payer: University Health Alliance Commercial	$2,147.04

LEAD BASIC EVALUATION 306001

Facility

$240.00

Service Code	HCPCS C1897
Hospital Revenue Code	278
Min. Negotiated Rate	$134.40
Max. Negotiated Rate	$232.80
Rate for Payer: Cash Price	$144.00
Rate for Payer: Hawaii Western Management Group Commercial	$168.00
Rate for Payer: Health Management Network Commercial	$204.00
Rate for Payer: Kaiser Permanente Commercial	$216.00
Rate for Payer: MDX Hawaii PPO	$232.80
Rate for Payer: University Health Alliance Commercial	$134.40

LEAD BASIC EVALUATION 306001

Facility

$240.00

Service Code	HCPCS C1897
Hospital Revenue Code	278
Min. Negotiated Rate	$120.00
Max. Negotiated Rate	$232.80
Rate for Payer: AlohaCare Medicaid	$120.00
Rate for Payer: AlohaCare Medicare	$182.40
Rate for Payer: Cash Price	$144.00
Rate for Payer: Devoted Health Medicare	$201.60
Rate for Payer: Hawaii Medical Service Association Medicare	$182.40
Rate for Payer: Hawaii Western Management Group Commercial	$168.00
Rate for Payer: Health Management Network Commercial	$204.00
Rate for Payer: Humana Medicare	$182.40
Rate for Payer: Kaiser Permanente Commercial	$216.00
Rate for Payer: Kaiser Permanente Medicaid	$122.40
Rate for Payer: Kaiser Permanente Medicare	$182.40
Rate for Payer: MDX Hawaii PPO	$232.80
Rate for Payer: Ohana Health Plan Medicaid	$182.40
Rate for Payer: Ohana Health Plan Medicare	$182.40
Rate for Payer: UnitedHealthcare Medicare	$182.40
Rate for Payer: University Health Alliance Commercial	$134.40

LEAD CAP 109185

Facility

$200.00

Hospital Revenue Code	272
Min. Negotiated Rate	$170.00
Max. Negotiated Rate	$194.00
Rate for Payer: Cash Price	$120.00
Rate for Payer: Health Management Network Commercial	$170.00
Rate for Payer: Kaiser Permanente Commercial	$180.00
Rate for Payer: MDX Hawaii PPO	$194.00

LEAD CAP 109185

Facility

$200.00

Hospital Revenue Code	272
Min. Negotiated Rate	$100.00
Max. Negotiated Rate	$194.00
Rate for Payer: AlohaCare Medicaid	$100.00
Rate for Payer: AlohaCare Medicare	$152.00
Rate for Payer: Cash Price	$120.00
Rate for Payer: Devoted Health Medicare	$168.00
Rate for Payer: Hawaii Medical Service Association Medicare	$152.00
Rate for Payer: Hawaii Western Management Group Commercial	$190.00
Rate for Payer: Health Management Network Commercial	$170.00
Rate for Payer: Humana Medicare	$152.00
Rate for Payer: Kaiser Permanente Commercial	$180.00
Rate for Payer: Kaiser Permanente Medicaid	$102.00
Rate for Payer: Kaiser Permanente Medicare	$152.00
Rate for Payer: MDX Hawaii PPO	$194.00
Rate for Payer: Ohana Health Plan Medicaid	$152.00
Rate for Payer: Ohana Health Plan Medicare	$152.00
Rate for Payer: UnitedHealthcare Medicare	$152.00
Rate for Payer: University Health Alliance Commercial	$145.78

LEAD KIT INTRODUCER 3550-18

Facility

$980.00

Service Code	HCPCS C1894
Hospital Revenue Code	272
Min. Negotiated Rate	$490.00
Max. Negotiated Rate	$950.60
Rate for Payer: AlohaCare Medicaid	$490.00
Rate for Payer: AlohaCare Medicare	$744.80
Rate for Payer: Cash Price	$588.00
Rate for Payer: Devoted Health Medicare	$823.20
Rate for Payer: Hawaii Medical Service Association Medicare	$744.80
Rate for Payer: Hawaii Western Management Group Commercial	$931.00
Rate for Payer: Health Management Network Commercial	$833.00
Rate for Payer: Humana Medicare	$744.80
Rate for Payer: Kaiser Permanente Commercial	$882.00
Rate for Payer: Kaiser Permanente Medicaid	$499.80
Rate for Payer: Kaiser Permanente Medicare	$744.80
Rate for Payer: MDX Hawaii PPO	$950.60
Rate for Payer: Ohana Health Plan Medicaid	$744.80
Rate for Payer: Ohana Health Plan Medicare	$744.80
Rate for Payer: UnitedHealthcare Medicare	$744.80
Rate for Payer: University Health Alliance Commercial	$714.32

LEAD KIT INTRODUCER 3550-18

Facility

$980.00

Service Code	HCPCS C1894
Hospital Revenue Code	272
Min. Negotiated Rate	$833.00
Max. Negotiated Rate	$950.60
Rate for Payer: Cash Price	$588.00
Rate for Payer: Health Management Network Commercial	$833.00
Rate for Payer: Kaiser Permanente Commercial	$882.00
Rate for Payer: MDX Hawaii PPO	$950.60

LEAD KIT QUADRIPOLAR 3889-28

Facility

$7,110.00

Service Code	HCPCS C1778
Hospital Revenue Code	278
Min. Negotiated Rate	$3,981.60
Max. Negotiated Rate	$6,896.70
Rate for Payer: Cash Price	$4,266.00
Rate for Payer: Hawaii Western Management Group Commercial	$4,977.00
Rate for Payer: Health Management Network Commercial	$6,043.50
Rate for Payer: Kaiser Permanente Commercial	$6,399.00
Rate for Payer: MDX Hawaii PPO	$6,896.70
Rate for Payer: University Health Alliance Commercial	$3,981.60

LEAD KIT QUADRIPOLAR 3889-28

Facility

$7,110.00

Service Code	HCPCS C1778
Hospital Revenue Code	278
Min. Negotiated Rate	$3,555.00
Max. Negotiated Rate	$6,896.70
Rate for Payer: AlohaCare Medicaid	$3,555.00
Rate for Payer: AlohaCare Medicare	$5,403.60
Rate for Payer: Cash Price	$4,266.00
Rate for Payer: Devoted Health Medicare	$5,972.40
Rate for Payer: Hawaii Medical Service Association Medicare	$5,403.60
Rate for Payer: Hawaii Western Management Group Commercial	$4,977.00
Rate for Payer: Health Management Network Commercial	$6,043.50
Rate for Payer: Humana Medicare	$5,403.60
Rate for Payer: Kaiser Permanente Commercial	$6,399.00
Rate for Payer: Kaiser Permanente Medicaid	$3,626.10
Rate for Payer: Kaiser Permanente Medicare	$5,403.60
Rate for Payer: MDX Hawaii PPO	$6,896.70
Rate for Payer: Ohana Health Plan Medicaid	$5,403.60
Rate for Payer: Ohana Health Plan Medicare	$5,403.60
Rate for Payer: UnitedHealthcare Medicare	$5,403.60
Rate for Payer: University Health Alliance Commercial	$3,981.60

LEAD PLEXA PROMRI 413997

Facility

$8,000.00

Service Code	HCPCS C1777
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

LEAD PLEXA PROMRI 413997

Facility

$8,000.00

Service Code	HCPCS C1777
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

LEAD RESPIRATORY SENSING

Facility

$6,750.00

Service Code	HCPCS C1778
Hospital Revenue Code	278
Min. Negotiated Rate	$3,780.00
Max. Negotiated Rate	$6,547.50
Rate for Payer: Cash Price	$4,050.00
Rate for Payer: Hawaii Western Management Group Commercial	$4,725.00
Rate for Payer: Health Management Network Commercial	$5,737.50
Rate for Payer: Kaiser Permanente Commercial	$6,075.00
Rate for Payer: MDX Hawaii PPO	$6,547.50
Rate for Payer: University Health Alliance Commercial	$3,780.00

LEAD RESPIRATORY SENSING

Facility

$6,750.00

Service Code	HCPCS C1778
Hospital Revenue Code	278
Min. Negotiated Rate	$3,375.00
Max. Negotiated Rate	$6,547.50
Rate for Payer: AlohaCare Medicaid	$3,375.00
Rate for Payer: AlohaCare Medicare	$5,130.00
Rate for Payer: Cash Price	$4,050.00
Rate for Payer: Devoted Health Medicare	$5,670.00
Rate for Payer: Hawaii Medical Service Association Medicare	$5,130.00
Rate for Payer: Hawaii Western Management Group Commercial	$4,725.00
Rate for Payer: Health Management Network Commercial	$5,737.50
Rate for Payer: Humana Medicare	$5,130.00
Rate for Payer: Kaiser Permanente Commercial	$6,075.00
Rate for Payer: Kaiser Permanente Medicaid	$3,442.50
Rate for Payer: Kaiser Permanente Medicare	$5,130.00
Rate for Payer: MDX Hawaii PPO	$6,547.50
Rate for Payer: Ohana Health Plan Medicaid	$5,130.00
Rate for Payer: Ohana Health Plan Medicare	$5,130.00
Rate for Payer: UnitedHealthcare Medicare	$5,130.00
Rate for Payer: University Health Alliance Commercial	$3,780.00

LEAD TEMP PACING 5FR

Facility

$394.00

Service Code	HCPCS C1883
Hospital Revenue Code	275
Min. Negotiated Rate	$197.00
Max. Negotiated Rate	$382.18
Rate for Payer: AlohaCare Medicaid	$197.00
Rate for Payer: AlohaCare Medicare	$299.44
Rate for Payer: Cash Price	$236.40
Rate for Payer: Devoted Health Medicare	$330.96
Rate for Payer: Hawaii Medical Service Association Medicare	$299.44
Rate for Payer: Hawaii Western Management Group Commercial	$275.80
Rate for Payer: Health Management Network Commercial	$334.90
Rate for Payer: Humana Medicare	$299.44
Rate for Payer: Kaiser Permanente Commercial	$354.60
Rate for Payer: Kaiser Permanente Medicaid	$200.94
Rate for Payer: Kaiser Permanente Medicare	$299.44
Rate for Payer: MDX Hawaii PPO	$382.18
Rate for Payer: Ohana Health Plan Medicaid	$299.44
Rate for Payer: Ohana Health Plan Medicare	$299.44
Rate for Payer: UnitedHealthcare Medicare	$299.44
Rate for Payer: University Health Alliance Commercial	$220.64

LEAD TEMP PACING 5FR

Facility

$394.00

Service Code	HCPCS C1883
Hospital Revenue Code	275
Min. Negotiated Rate	$220.64
Max. Negotiated Rate	$382.18
Rate for Payer: Cash Price	$236.40
Rate for Payer: Hawaii Western Management Group Commercial	$275.80
Rate for Payer: Health Management Network Commercial	$334.90
Rate for Payer: Kaiser Permanente Commercial	$354.60
Rate for Payer: MDX Hawaii PPO	$382.18
Rate for Payer: University Health Alliance Commercial	$220.64

LEAD TEMP PACING 6FR

Facility

$394.00

Service Code	HCPCS C1883
Hospital Revenue Code	275
Min. Negotiated Rate	$197.00
Max. Negotiated Rate	$382.18
Rate for Payer: AlohaCare Medicaid	$197.00
Rate for Payer: AlohaCare Medicare	$299.44
Rate for Payer: Cash Price	$236.40
Rate for Payer: Devoted Health Medicare	$330.96
Rate for Payer: Hawaii Medical Service Association Medicare	$299.44
Rate for Payer: Hawaii Western Management Group Commercial	$275.80
Rate for Payer: Health Management Network Commercial	$334.90
Rate for Payer: Humana Medicare	$299.44
Rate for Payer: Kaiser Permanente Commercial	$354.60
Rate for Payer: Kaiser Permanente Medicaid	$200.94
Rate for Payer: Kaiser Permanente Medicare	$299.44
Rate for Payer: MDX Hawaii PPO	$382.18
Rate for Payer: Ohana Health Plan Medicaid	$299.44
Rate for Payer: Ohana Health Plan Medicare	$299.44
Rate for Payer: UnitedHealthcare Medicare	$299.44
Rate for Payer: University Health Alliance Commercial	$220.64

Know your out-of-pocket cost for care.

All Charges