Honoka'a Hospital and Skilled Nursing Facility

All Charges

Charge

Type

Setting

Price

BASEPLATE TIB SZ3 5521-B-300

Facility

$3,311.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,854.16
Max. Negotiated Rate	$3,211.67
Rate for Payer: Cash Price	$1,986.60
Rate for Payer: Hawaii Western Management Group Commercial	$2,317.70
Rate for Payer: Health Management Network Commercial	$2,814.35
Rate for Payer: Kaiser Permanente Commercial	$2,979.90
Rate for Payer: MDX Hawaii PPO	$3,211.67
Rate for Payer: University Health Alliance Commercial	$1,854.16

BASEPLATE TIB UNIV 5521-B-700

Facility

$3,311.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,655.50
Max. Negotiated Rate	$3,211.67
Rate for Payer: AlohaCare Medicaid	$1,655.50
Rate for Payer: AlohaCare Medicare	$2,516.36
Rate for Payer: Cash Price	$1,986.60
Rate for Payer: Devoted Health Medicare	$2,781.24
Rate for Payer: Hawaii Medical Service Association Medicare	$2,516.36
Rate for Payer: Hawaii Western Management Group Commercial	$2,317.70
Rate for Payer: Health Management Network Commercial	$2,814.35
Rate for Payer: Humana Medicare	$2,516.36
Rate for Payer: Kaiser Permanente Commercial	$2,979.90
Rate for Payer: Kaiser Permanente Medicaid	$1,688.61
Rate for Payer: Kaiser Permanente Medicare	$2,516.36
Rate for Payer: MDX Hawaii PPO	$3,211.67
Rate for Payer: Ohana Health Plan Medicaid	$2,516.36
Rate for Payer: Ohana Health Plan Medicare	$2,516.36
Rate for Payer: UnitedHealthcare Medicare	$2,516.36
Rate for Payer: University Health Alliance Commercial	$1,854.16

BASEPLATE TIB UNIV 5521-B-700

Facility

$3,311.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,854.16
Max. Negotiated Rate	$3,211.67
Rate for Payer: Cash Price	$1,986.60
Rate for Payer: Hawaii Western Management Group Commercial	$2,317.70
Rate for Payer: Health Management Network Commercial	$2,814.35
Rate for Payer: Kaiser Permanente Commercial	$2,979.90
Rate for Payer: MDX Hawaii PPO	$3,211.67
Rate for Payer: University Health Alliance Commercial	$1,854.16

BASEPLATE TOT KNEE 5521-B-100

Facility

$3,311.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,655.50
Max. Negotiated Rate	$3,211.67
Rate for Payer: AlohaCare Medicaid	$1,655.50
Rate for Payer: AlohaCare Medicare	$2,516.36
Rate for Payer: Cash Price	$1,986.60
Rate for Payer: Devoted Health Medicare	$2,781.24
Rate for Payer: Hawaii Medical Service Association Medicare	$2,516.36
Rate for Payer: Hawaii Western Management Group Commercial	$2,317.70
Rate for Payer: Health Management Network Commercial	$2,814.35
Rate for Payer: Humana Medicare	$2,516.36
Rate for Payer: Kaiser Permanente Commercial	$2,979.90
Rate for Payer: Kaiser Permanente Medicaid	$1,688.61
Rate for Payer: Kaiser Permanente Medicare	$2,516.36
Rate for Payer: MDX Hawaii PPO	$3,211.67
Rate for Payer: Ohana Health Plan Medicaid	$2,516.36
Rate for Payer: Ohana Health Plan Medicare	$2,516.36
Rate for Payer: UnitedHealthcare Medicare	$2,516.36
Rate for Payer: University Health Alliance Commercial	$1,854.16

BASEPLATE TOT KNEE 5521-B-100

Facility

$3,311.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,854.16
Max. Negotiated Rate	$3,211.67
Rate for Payer: Cash Price	$1,986.60
Rate for Payer: Hawaii Western Management Group Commercial	$2,317.70
Rate for Payer: Health Management Network Commercial	$2,814.35
Rate for Payer: Kaiser Permanente Commercial	$2,979.90
Rate for Payer: MDX Hawaii PPO	$3,211.67
Rate for Payer: University Health Alliance Commercial	$1,854.16

BASEPLATE TT SZ 5 5536-B-500

Facility

$3,244.00

Service Code	HCPCS C1713
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

BASEPLATE TT SZ 5 5536-B-500

Facility

$3,244.00

Service Code	HCPCS C1713
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

BASEPLTE TIBIAL SZ8 5521-B-800

Facility

$3,311.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,655.50
Max. Negotiated Rate	$3,211.67
Rate for Payer: AlohaCare Medicaid	$1,655.50
Rate for Payer: AlohaCare Medicare	$2,516.36
Rate for Payer: Cash Price	$1,986.60
Rate for Payer: Devoted Health Medicare	$2,781.24
Rate for Payer: Hawaii Medical Service Association Medicare	$2,516.36
Rate for Payer: Hawaii Western Management Group Commercial	$2,317.70
Rate for Payer: Health Management Network Commercial	$2,814.35
Rate for Payer: Humana Medicare	$2,516.36
Rate for Payer: Kaiser Permanente Commercial	$2,979.90
Rate for Payer: Kaiser Permanente Medicaid	$1,688.61
Rate for Payer: Kaiser Permanente Medicare	$2,516.36
Rate for Payer: MDX Hawaii PPO	$3,211.67
Rate for Payer: Ohana Health Plan Medicaid	$2,516.36
Rate for Payer: Ohana Health Plan Medicare	$2,516.36
Rate for Payer: UnitedHealthcare Medicare	$2,516.36
Rate for Payer: University Health Alliance Commercial	$1,854.16

BASEPLTE TIBIAL SZ8 5521-B-800

Facility

$3,311.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,854.16
Max. Negotiated Rate	$3,211.67
Rate for Payer: Cash Price	$1,986.60
Rate for Payer: Hawaii Western Management Group Commercial	$2,317.70
Rate for Payer: Health Management Network Commercial	$2,814.35
Rate for Payer: Kaiser Permanente Commercial	$2,979.90
Rate for Payer: MDX Hawaii PPO	$3,211.67
Rate for Payer: University Health Alliance Commercial	$1,854.16

BASKET AIRWAY RETRIEVAL

Facility

$952.00

Service Code	HCPCS C1889
Hospital Revenue Code	272
Min. Negotiated Rate	$809.20
Max. Negotiated Rate	$923.44
Rate for Payer: Cash Price	$571.20
Rate for Payer: Health Management Network Commercial	$809.20
Rate for Payer: Kaiser Permanente Commercial	$856.80
Rate for Payer: MDX Hawaii PPO	$923.44

BASKET AIRWAY RETRIEVAL

Facility

$952.00

Service Code	HCPCS C1889
Hospital Revenue Code	272
Min. Negotiated Rate	$476.00
Max. Negotiated Rate	$923.44
Rate for Payer: AlohaCare Medicaid	$476.00
Rate for Payer: AlohaCare Medicare	$723.52
Rate for Payer: Cash Price	$571.20
Rate for Payer: Devoted Health Medicare	$799.68
Rate for Payer: Hawaii Medical Service Association Medicare	$723.52
Rate for Payer: Hawaii Western Management Group Commercial	$904.40
Rate for Payer: Health Management Network Commercial	$809.20
Rate for Payer: Humana Medicare	$723.52
Rate for Payer: Kaiser Permanente Commercial	$856.80
Rate for Payer: Kaiser Permanente Medicaid	$485.52
Rate for Payer: Kaiser Permanente Medicare	$723.52
Rate for Payer: MDX Hawaii PPO	$923.44
Rate for Payer: Ohana Health Plan Medicaid	$723.52
Rate for Payer: Ohana Health Plan Medicare	$723.52
Rate for Payer: UnitedHealthcare Medicare	$723.52
Rate for Payer: University Health Alliance Commercial	$693.91

BASKET ESCAPE URINARY STONE

Facility

$913.00

Service Code	HCPCS C1889
Hospital Revenue Code	272
Min. Negotiated Rate	$776.05
Max. Negotiated Rate	$885.61
Rate for Payer: Cash Price	$547.80
Rate for Payer: Health Management Network Commercial	$776.05
Rate for Payer: Kaiser Permanente Commercial	$821.70
Rate for Payer: MDX Hawaii PPO	$885.61

BASKET ESCAPE URINARY STONE

Facility

$913.00

Service Code	HCPCS C1889
Hospital Revenue Code	272
Min. Negotiated Rate	$456.50
Max. Negotiated Rate	$885.61
Rate for Payer: AlohaCare Medicaid	$456.50
Rate for Payer: AlohaCare Medicare	$693.88
Rate for Payer: Cash Price	$547.80
Rate for Payer: Devoted Health Medicare	$766.92
Rate for Payer: Hawaii Medical Service Association Medicare	$693.88
Rate for Payer: Hawaii Western Management Group Commercial	$867.35
Rate for Payer: Health Management Network Commercial	$776.05
Rate for Payer: Humana Medicare	$693.88
Rate for Payer: Kaiser Permanente Commercial	$821.70
Rate for Payer: Kaiser Permanente Medicaid	$465.63
Rate for Payer: Kaiser Permanente Medicare	$693.88
Rate for Payer: MDX Hawaii PPO	$885.61
Rate for Payer: Ohana Health Plan Medicaid	$693.88
Rate for Payer: Ohana Health Plan Medicare	$693.88
Rate for Payer: UnitedHealthcare Medicare	$693.88
Rate for Payer: University Health Alliance Commercial	$665.49

BASKET FORCEP MINI 3PRONG

Facility

$898.00

Hospital Revenue Code	272
Min. Negotiated Rate	$449.00
Max. Negotiated Rate	$871.06
Rate for Payer: AlohaCare Medicaid	$449.00
Rate for Payer: AlohaCare Medicare	$682.48
Rate for Payer: Cash Price	$538.80
Rate for Payer: Devoted Health Medicare	$754.32
Rate for Payer: Hawaii Medical Service Association Medicare	$682.48
Rate for Payer: Hawaii Western Management Group Commercial	$853.10
Rate for Payer: Health Management Network Commercial	$763.30
Rate for Payer: Humana Medicare	$682.48
Rate for Payer: Kaiser Permanente Commercial	$808.20
Rate for Payer: Kaiser Permanente Medicaid	$457.98
Rate for Payer: Kaiser Permanente Medicare	$682.48
Rate for Payer: MDX Hawaii PPO	$871.06
Rate for Payer: Ohana Health Plan Medicaid	$682.48
Rate for Payer: Ohana Health Plan Medicare	$682.48
Rate for Payer: UnitedHealthcare Medicare	$682.48
Rate for Payer: University Health Alliance Commercial	$654.55

BASKET FORCEP MINI 3PRONG

Facility

$898.00

Hospital Revenue Code	272
Min. Negotiated Rate	$763.30
Max. Negotiated Rate	$871.06
Rate for Payer: Cash Price	$538.80
Rate for Payer: Health Management Network Commercial	$763.30
Rate for Payer: Kaiser Permanente Commercial	$808.20
Rate for Payer: MDX Hawaii PPO	$871.06

BASKET MINI GRASPING

Facility

$817.00

Hospital Revenue Code	272
Min. Negotiated Rate	$694.45
Max. Negotiated Rate	$792.49
Rate for Payer: Cash Price	$490.20
Rate for Payer: Health Management Network Commercial	$694.45
Rate for Payer: Kaiser Permanente Commercial	$735.30
Rate for Payer: MDX Hawaii PPO	$792.49

BASKET MINI GRASPING

Facility

$817.00

Hospital Revenue Code	272
Min. Negotiated Rate	$408.50
Max. Negotiated Rate	$792.49
Rate for Payer: AlohaCare Medicaid	$408.50
Rate for Payer: AlohaCare Medicare	$620.92
Rate for Payer: Cash Price	$490.20
Rate for Payer: Devoted Health Medicare	$686.28
Rate for Payer: Hawaii Medical Service Association Medicare	$620.92
Rate for Payer: Hawaii Western Management Group Commercial	$776.15
Rate for Payer: Health Management Network Commercial	$694.45
Rate for Payer: Humana Medicare	$620.92
Rate for Payer: Kaiser Permanente Commercial	$735.30
Rate for Payer: Kaiser Permanente Medicaid	$416.67
Rate for Payer: Kaiser Permanente Medicare	$620.92
Rate for Payer: MDX Hawaii PPO	$792.49
Rate for Payer: Ohana Health Plan Medicaid	$620.92
Rate for Payer: Ohana Health Plan Medicare	$620.92
Rate for Payer: UnitedHealthcare Medicare	$620.92
Rate for Payer: University Health Alliance Commercial	$595.51

BASKET NITINOL 1.9 ZERO TIP

Facility

$746.00

Service Code	HCPCS C1889
Hospital Revenue Code	272
Min. Negotiated Rate	$634.10
Max. Negotiated Rate	$723.62
Rate for Payer: Cash Price	$447.60
Rate for Payer: Health Management Network Commercial	$634.10
Rate for Payer: Kaiser Permanente Commercial	$671.40
Rate for Payer: MDX Hawaii PPO	$723.62

BASKET NITINOL 1.9 ZERO TIP

Facility

$746.00

Service Code	HCPCS C1889
Hospital Revenue Code	272
Min. Negotiated Rate	$373.00
Max. Negotiated Rate	$723.62
Rate for Payer: AlohaCare Medicaid	$373.00
Rate for Payer: AlohaCare Medicare	$566.96
Rate for Payer: Cash Price	$447.60
Rate for Payer: Devoted Health Medicare	$626.64
Rate for Payer: Hawaii Medical Service Association Medicare	$566.96
Rate for Payer: Hawaii Western Management Group Commercial	$708.70
Rate for Payer: Health Management Network Commercial	$634.10
Rate for Payer: Humana Medicare	$566.96
Rate for Payer: Kaiser Permanente Commercial	$671.40
Rate for Payer: Kaiser Permanente Medicaid	$380.46
Rate for Payer: Kaiser Permanente Medicare	$566.96
Rate for Payer: MDX Hawaii PPO	$723.62
Rate for Payer: Ohana Health Plan Medicaid	$566.96
Rate for Payer: Ohana Health Plan Medicare	$566.96
Rate for Payer: UnitedHealthcare Medicare	$566.96
Rate for Payer: University Health Alliance Commercial	$543.76

BASKET RETRIEVAL 15MM

Facility

$1,568.00

Service Code	HCPCS C1889
Hospital Revenue Code	272
Min. Negotiated Rate	$784.00
Max. Negotiated Rate	$1,520.96
Rate for Payer: AlohaCare Medicaid	$784.00
Rate for Payer: AlohaCare Medicare	$1,191.68
Rate for Payer: Cash Price	$940.80
Rate for Payer: Devoted Health Medicare	$1,317.12
Rate for Payer: Hawaii Medical Service Association Medicare	$1,191.68
Rate for Payer: Hawaii Western Management Group Commercial	$1,489.60
Rate for Payer: Health Management Network Commercial	$1,332.80
Rate for Payer: Humana Medicare	$1,191.68
Rate for Payer: Kaiser Permanente Commercial	$1,411.20
Rate for Payer: Kaiser Permanente Medicaid	$799.68
Rate for Payer: Kaiser Permanente Medicare	$1,191.68
Rate for Payer: MDX Hawaii PPO	$1,520.96
Rate for Payer: Ohana Health Plan Medicaid	$1,191.68
Rate for Payer: Ohana Health Plan Medicare	$1,191.68
Rate for Payer: UnitedHealthcare Medicare	$1,191.68
Rate for Payer: University Health Alliance Commercial	$1,142.92

BASKET RETRIEVAL 15MM

Facility

$1,568.00

Service Code	HCPCS C1889
Hospital Revenue Code	272
Min. Negotiated Rate	$1,332.80
Max. Negotiated Rate	$1,520.96
Rate for Payer: Cash Price	$940.80
Rate for Payer: Health Management Network Commercial	$1,332.80
Rate for Payer: Kaiser Permanente Commercial	$1,411.20
Rate for Payer: MDX Hawaii PPO	$1,520.96

BASKET STONE EXTRACTOR

Facility

$926.00

Service Code	HCPCS A4649
Hospital Revenue Code	272
Min. Negotiated Rate	$463.00
Max. Negotiated Rate	$898.22
Rate for Payer: AlohaCare Medicaid	$463.00
Rate for Payer: AlohaCare Medicare	$703.76
Rate for Payer: Cash Price	$555.60
Rate for Payer: Devoted Health Medicare	$777.84
Rate for Payer: Hawaii Medical Service Association Medicare	$703.76
Rate for Payer: Hawaii Western Management Group Commercial	$879.70
Rate for Payer: Health Management Network Commercial	$787.10
Rate for Payer: Humana Medicare	$703.76
Rate for Payer: Kaiser Permanente Commercial	$833.40
Rate for Payer: Kaiser Permanente Medicaid	$472.26
Rate for Payer: Kaiser Permanente Medicare	$703.76
Rate for Payer: MDX Hawaii PPO	$898.22
Rate for Payer: Ohana Health Plan Medicaid	$703.76
Rate for Payer: Ohana Health Plan Medicare	$703.76
Rate for Payer: UnitedHealthcare Medicare	$703.76
Rate for Payer: University Health Alliance Commercial	$674.96

BASKET STONE EXTRACTOR

Facility

$926.00

Service Code	HCPCS A4649
Hospital Revenue Code	272
Min. Negotiated Rate	$787.10
Max. Negotiated Rate	$898.22
Rate for Payer: Cash Price	$555.60
Rate for Payer: Health Management Network Commercial	$787.10
Rate for Payer: Kaiser Permanente Commercial	$833.40
Rate for Payer: MDX Hawaii PPO	$898.22

BASKET STONE RETRIEV ENDO 2

Facility

$923.00

Service Code	HCPCS C1889
Hospital Revenue Code	272
Min. Negotiated Rate	$461.50
Max. Negotiated Rate	$895.31
Rate for Payer: AlohaCare Medicaid	$461.50
Rate for Payer: AlohaCare Medicare	$701.48
Rate for Payer: Cash Price	$553.80
Rate for Payer: Devoted Health Medicare	$775.32
Rate for Payer: Hawaii Medical Service Association Medicare	$701.48
Rate for Payer: Hawaii Western Management Group Commercial	$876.85
Rate for Payer: Health Management Network Commercial	$784.55
Rate for Payer: Humana Medicare	$701.48
Rate for Payer: Kaiser Permanente Commercial	$830.70
Rate for Payer: Kaiser Permanente Medicaid	$470.73
Rate for Payer: Kaiser Permanente Medicare	$701.48
Rate for Payer: MDX Hawaii PPO	$895.31
Rate for Payer: Ohana Health Plan Medicaid	$701.48
Rate for Payer: Ohana Health Plan Medicare	$701.48
Rate for Payer: UnitedHealthcare Medicare	$701.48
Rate for Payer: University Health Alliance Commercial	$672.77

BASKET STONE RETRIEV ENDO 2

Facility

$923.00

Service Code	HCPCS C1889
Hospital Revenue Code	272
Min. Negotiated Rate	$784.55
Max. Negotiated Rate	$895.31
Rate for Payer: Cash Price	$553.80
Rate for Payer: Health Management Network Commercial	$784.55
Rate for Payer: Kaiser Permanente Commercial	$830.70
Rate for Payer: MDX Hawaii PPO	$895.31

Know your out-of-pocket cost for care.

All Charges