Honoka'a Hospital and Skilled Nursing Facility

All Charges

Charge

Type

Setting

Price

PLATE 1/3 3-HOLE/37MM 241.33

Facility

$389.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$194.50
Max. Negotiated Rate	$377.33
Rate for Payer: AlohaCare Medicaid	$194.50
Rate for Payer: AlohaCare Medicare	$295.64
Rate for Payer: Cash Price	$233.40
Rate for Payer: Devoted Health Medicare	$326.76
Rate for Payer: Hawaii Medical Service Association Medicare	$295.64
Rate for Payer: Hawaii Western Management Group Commercial	$272.30
Rate for Payer: Health Management Network Commercial	$330.65
Rate for Payer: Humana Medicare	$295.64
Rate for Payer: Kaiser Permanente Commercial	$350.10
Rate for Payer: Kaiser Permanente Medicaid	$198.39
Rate for Payer: Kaiser Permanente Medicare	$295.64
Rate for Payer: MDX Hawaii PPO	$377.33
Rate for Payer: Ohana Health Plan Medicaid	$295.64
Rate for Payer: Ohana Health Plan Medicare	$295.64
Rate for Payer: UnitedHealthcare Medicare	$295.64
Rate for Payer: University Health Alliance Commercial	$217.84

PLATE 1/3 3-HOLE/37MM 241.33

Facility

$389.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$217.84
Max. Negotiated Rate	$377.33
Rate for Payer: Cash Price	$233.40
Rate for Payer: Hawaii Western Management Group Commercial	$272.30
Rate for Payer: Health Management Network Commercial	$330.65
Rate for Payer: Kaiser Permanente Commercial	$350.10
Rate for Payer: MDX Hawaii PPO	$377.33
Rate for Payer: University Health Alliance Commercial	$217.84

PLATE 1/3 8-HOLE/97MM 241.38

Facility

$450.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$225.00
Max. Negotiated Rate	$436.50
Rate for Payer: AlohaCare Medicaid	$225.00
Rate for Payer: AlohaCare Medicare	$342.00
Rate for Payer: Cash Price	$270.00
Rate for Payer: Devoted Health Medicare	$378.00
Rate for Payer: Hawaii Medical Service Association Medicare	$342.00
Rate for Payer: Hawaii Western Management Group Commercial	$315.00
Rate for Payer: Health Management Network Commercial	$382.50
Rate for Payer: Humana Medicare	$342.00
Rate for Payer: Kaiser Permanente Commercial	$405.00
Rate for Payer: Kaiser Permanente Medicaid	$229.50
Rate for Payer: Kaiser Permanente Medicare	$342.00
Rate for Payer: MDX Hawaii PPO	$436.50
Rate for Payer: Ohana Health Plan Medicaid	$342.00
Rate for Payer: Ohana Health Plan Medicare	$342.00
Rate for Payer: UnitedHealthcare Medicare	$342.00
Rate for Payer: University Health Alliance Commercial	$252.00

PLATE 1/3 8-HOLE/97MM 241.38

Facility

$450.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$252.00
Max. Negotiated Rate	$436.50
Rate for Payer: Cash Price	$270.00
Rate for Payer: Hawaii Western Management Group Commercial	$315.00
Rate for Payer: Health Management Network Commercial	$382.50
Rate for Payer: Kaiser Permanente Commercial	$405.00
Rate for Payer: MDX Hawaii PPO	$436.50
Rate for Payer: University Health Alliance Commercial	$252.00

PLATE 1/3 9-HOLE/109MM 241.39

Facility

$543.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$304.08
Max. Negotiated Rate	$526.71
Rate for Payer: Cash Price	$325.80
Rate for Payer: Hawaii Western Management Group Commercial	$380.10
Rate for Payer: Health Management Network Commercial	$461.55
Rate for Payer: Kaiser Permanente Commercial	$488.70
Rate for Payer: MDX Hawaii PPO	$526.71
Rate for Payer: University Health Alliance Commercial	$304.08

PLATE 1/3 9-HOLE/109MM 241.39

Facility

$543.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$271.50
Max. Negotiated Rate	$526.71
Rate for Payer: AlohaCare Medicaid	$271.50
Rate for Payer: AlohaCare Medicare	$412.68
Rate for Payer: Cash Price	$325.80
Rate for Payer: Devoted Health Medicare	$456.12
Rate for Payer: Hawaii Medical Service Association Medicare	$412.68
Rate for Payer: Hawaii Western Management Group Commercial	$380.10
Rate for Payer: Health Management Network Commercial	$461.55
Rate for Payer: Humana Medicare	$412.68
Rate for Payer: Kaiser Permanente Commercial	$488.70
Rate for Payer: Kaiser Permanente Medicaid	$276.93
Rate for Payer: Kaiser Permanente Medicare	$412.68
Rate for Payer: MDX Hawaii PPO	$526.71
Rate for Payer: Ohana Health Plan Medicaid	$412.68
Rate for Payer: Ohana Health Plan Medicare	$412.68
Rate for Payer: UnitedHealthcare Medicare	$412.68
Rate for Payer: University Health Alliance Commercial	$304.08

PLATE 1/3 TUBULAR 10H 626680

Facility

$1,848.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$924.00
Max. Negotiated Rate	$1,792.56
Rate for Payer: AlohaCare Medicaid	$924.00
Rate for Payer: AlohaCare Medicare	$1,404.48
Rate for Payer: Cash Price	$1,108.80
Rate for Payer: Devoted Health Medicare	$1,552.32
Rate for Payer: Hawaii Medical Service Association Medicare	$1,404.48
Rate for Payer: Hawaii Western Management Group Commercial	$1,293.60
Rate for Payer: Health Management Network Commercial	$1,570.80
Rate for Payer: Humana Medicare	$1,404.48
Rate for Payer: Kaiser Permanente Commercial	$1,663.20
Rate for Payer: Kaiser Permanente Medicaid	$942.48
Rate for Payer: Kaiser Permanente Medicare	$1,404.48
Rate for Payer: MDX Hawaii PPO	$1,792.56
Rate for Payer: Ohana Health Plan Medicaid	$1,404.48
Rate for Payer: Ohana Health Plan Medicare	$1,404.48
Rate for Payer: UnitedHealthcare Medicare	$1,404.48
Rate for Payer: University Health Alliance Commercial	$1,034.88

PLATE 1/3 TUBULAR 10H 626680

Facility

$1,848.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,034.88
Max. Negotiated Rate	$1,792.56
Rate for Payer: Cash Price	$1,108.80
Rate for Payer: Hawaii Western Management Group Commercial	$1,293.60
Rate for Payer: Health Management Network Commercial	$1,570.80
Rate for Payer: Kaiser Permanente Commercial	$1,663.20
Rate for Payer: MDX Hawaii PPO	$1,792.56
Rate for Payer: University Health Alliance Commercial	$1,034.88

PLATE 1/3 TUBULAR 83 7H 626677

Facility

$1,608.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$900.48
Max. Negotiated Rate	$1,559.76
Rate for Payer: Cash Price	$964.80
Rate for Payer: Hawaii Western Management Group Commercial	$1,125.60
Rate for Payer: Health Management Network Commercial	$1,366.80
Rate for Payer: Kaiser Permanente Commercial	$1,447.20
Rate for Payer: MDX Hawaii PPO	$1,559.76
Rate for Payer: University Health Alliance Commercial	$900.48

PLATE 1/3 TUBULAR 83 7H 626677

Facility

$1,608.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$804.00
Max. Negotiated Rate	$1,559.76
Rate for Payer: AlohaCare Medicaid	$804.00
Rate for Payer: AlohaCare Medicare	$1,222.08
Rate for Payer: Cash Price	$964.80
Rate for Payer: Devoted Health Medicare	$1,350.72
Rate for Payer: Hawaii Medical Service Association Medicare	$1,222.08
Rate for Payer: Hawaii Western Management Group Commercial	$1,125.60
Rate for Payer: Health Management Network Commercial	$1,366.80
Rate for Payer: Humana Medicare	$1,222.08
Rate for Payer: Kaiser Permanente Commercial	$1,447.20
Rate for Payer: Kaiser Permanente Medicaid	$820.08
Rate for Payer: Kaiser Permanente Medicare	$1,222.08
Rate for Payer: MDX Hawaii PPO	$1,559.76
Rate for Payer: Ohana Health Plan Medicaid	$1,222.08
Rate for Payer: Ohana Health Plan Medicare	$1,222.08
Rate for Payer: UnitedHealthcare Medicare	$1,222.08
Rate for Payer: University Health Alliance Commercial	$900.48

PLATE 1/3 TUB W COLLAR 241.35

Facility

$805.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$450.80
Max. Negotiated Rate	$780.85
Rate for Payer: Cash Price	$483.00
Rate for Payer: Hawaii Western Management Group Commercial	$563.50
Rate for Payer: Health Management Network Commercial	$684.25
Rate for Payer: Kaiser Permanente Commercial	$724.50
Rate for Payer: MDX Hawaii PPO	$780.85
Rate for Payer: University Health Alliance Commercial	$450.80

PLATE 1/3 TUB W COLLAR 241.35

Facility

$805.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$402.50
Max. Negotiated Rate	$780.85
Rate for Payer: AlohaCare Medicaid	$402.50
Rate for Payer: AlohaCare Medicare	$611.80
Rate for Payer: Cash Price	$483.00
Rate for Payer: Devoted Health Medicare	$676.20
Rate for Payer: Hawaii Medical Service Association Medicare	$611.80
Rate for Payer: Hawaii Western Management Group Commercial	$563.50
Rate for Payer: Health Management Network Commercial	$684.25
Rate for Payer: Humana Medicare	$611.80
Rate for Payer: Kaiser Permanente Commercial	$724.50
Rate for Payer: Kaiser Permanente Medicaid	$410.55
Rate for Payer: Kaiser Permanente Medicare	$611.80
Rate for Payer: MDX Hawaii PPO	$780.85
Rate for Payer: Ohana Health Plan Medicaid	$611.80
Rate for Payer: Ohana Health Plan Medicare	$611.80
Rate for Payer: UnitedHealthcare Medicare	$611.80
Rate for Payer: University Health Alliance Commercial	$450.80

PLATE 1/3 TUB W COLLAR 241.37

Facility

$435.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$243.60
Max. Negotiated Rate	$421.95
Rate for Payer: Cash Price	$261.00
Rate for Payer: Hawaii Western Management Group Commercial	$304.50
Rate for Payer: Health Management Network Commercial	$369.75
Rate for Payer: Kaiser Permanente Commercial	$391.50
Rate for Payer: MDX Hawaii PPO	$421.95
Rate for Payer: University Health Alliance Commercial	$243.60

PLATE 1/3 TUB W COLLAR 241.37

Facility

$435.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$217.50
Max. Negotiated Rate	$421.95
Rate for Payer: AlohaCare Medicaid	$217.50
Rate for Payer: AlohaCare Medicare	$330.60
Rate for Payer: Cash Price	$261.00
Rate for Payer: Devoted Health Medicare	$365.40
Rate for Payer: Hawaii Medical Service Association Medicare	$330.60
Rate for Payer: Hawaii Western Management Group Commercial	$304.50
Rate for Payer: Health Management Network Commercial	$369.75
Rate for Payer: Humana Medicare	$330.60
Rate for Payer: Kaiser Permanente Commercial	$391.50
Rate for Payer: Kaiser Permanente Medicaid	$221.85
Rate for Payer: Kaiser Permanente Medicare	$330.60
Rate for Payer: MDX Hawaii PPO	$421.95
Rate for Payer: Ohana Health Plan Medicaid	$330.60
Rate for Payer: Ohana Health Plan Medicare	$330.60
Rate for Payer: UnitedHealthcare Medicare	$330.60
Rate for Payer: University Health Alliance Commercial	$243.60

PLATE 1.5 LCK T-SHP 131220152

Facility

$2,120.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,060.00
Max. Negotiated Rate	$2,056.40
Rate for Payer: AlohaCare Medicaid	$1,060.00
Rate for Payer: AlohaCare Medicare	$1,611.20
Rate for Payer: Cash Price	$1,272.00
Rate for Payer: Devoted Health Medicare	$1,780.80
Rate for Payer: Hawaii Medical Service Association Medicare	$1,611.20
Rate for Payer: Hawaii Western Management Group Commercial	$1,484.00
Rate for Payer: Health Management Network Commercial	$1,802.00
Rate for Payer: Humana Medicare	$1,611.20
Rate for Payer: Kaiser Permanente Commercial	$1,908.00
Rate for Payer: Kaiser Permanente Medicaid	$1,081.20
Rate for Payer: Kaiser Permanente Medicare	$1,611.20
Rate for Payer: MDX Hawaii PPO	$2,056.40
Rate for Payer: Ohana Health Plan Medicaid	$1,611.20
Rate for Payer: Ohana Health Plan Medicare	$1,611.20
Rate for Payer: UnitedHealthcare Medicare	$1,611.20
Rate for Payer: University Health Alliance Commercial	$1,187.20

PLATE 1.5 LCK T-SHP 131220152

Facility

$2,120.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,187.20
Max. Negotiated Rate	$2,056.40
Rate for Payer: Cash Price	$1,272.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,484.00
Rate for Payer: Health Management Network Commercial	$1,802.00
Rate for Payer: Kaiser Permanente Commercial	$1,908.00
Rate for Payer: MDX Hawaii PPO	$2,056.40
Rate for Payer: University Health Alliance Commercial	$1,187.20

PLATE 16 HOLE 627616

Facility

$6,753.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$3,376.50
Max. Negotiated Rate	$6,550.41
Rate for Payer: AlohaCare Medicaid	$3,376.50
Rate for Payer: AlohaCare Medicare	$5,132.28
Rate for Payer: Cash Price	$4,051.80
Rate for Payer: Devoted Health Medicare	$5,672.52
Rate for Payer: Hawaii Medical Service Association Medicare	$5,132.28
Rate for Payer: Hawaii Western Management Group Commercial	$4,727.10
Rate for Payer: Health Management Network Commercial	$5,740.05
Rate for Payer: Humana Medicare	$5,132.28
Rate for Payer: Kaiser Permanente Commercial	$6,077.70
Rate for Payer: Kaiser Permanente Medicaid	$3,444.03
Rate for Payer: Kaiser Permanente Medicare	$5,132.28
Rate for Payer: MDX Hawaii PPO	$6,550.41
Rate for Payer: Ohana Health Plan Medicaid	$5,132.28
Rate for Payer: Ohana Health Plan Medicare	$5,132.28
Rate for Payer: UnitedHealthcare Medicare	$5,132.28
Rate for Payer: University Health Alliance Commercial	$3,781.68

PLATE 16 HOLE 627616

Facility

$6,753.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$3,781.68
Max. Negotiated Rate	$6,550.41
Rate for Payer: Cash Price	$4,051.80
Rate for Payer: Hawaii Western Management Group Commercial	$4,727.10
Rate for Payer: Health Management Network Commercial	$5,740.05
Rate for Payer: Kaiser Permanente Commercial	$6,077.70
Rate for Payer: MDX Hawaii PPO	$6,550.41
Rate for Payer: University Health Alliance Commercial	$3,781.68

PLATE 1.7MM S LCKIN Z, NARR 9H

Facility

$1,900.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,064.00
Max. Negotiated Rate	$1,843.00
Rate for Payer: Cash Price	$1,140.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,330.00
Rate for Payer: Health Management Network Commercial	$1,615.00
Rate for Payer: Kaiser Permanente Commercial	$1,710.00
Rate for Payer: MDX Hawaii PPO	$1,843.00
Rate for Payer: University Health Alliance Commercial	$1,064.00

PLATE 1.7MM S LCKIN Z, NARR 9H

Facility

$1,900.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$950.00
Max. Negotiated Rate	$1,843.00
Rate for Payer: AlohaCare Medicaid	$950.00
Rate for Payer: AlohaCare Medicare	$1,444.00
Rate for Payer: Cash Price	$1,140.00
Rate for Payer: Devoted Health Medicare	$1,596.00
Rate for Payer: Hawaii Medical Service Association Medicare	$1,444.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,330.00
Rate for Payer: Health Management Network Commercial	$1,615.00
Rate for Payer: Humana Medicare	$1,444.00
Rate for Payer: Kaiser Permanente Commercial	$1,710.00
Rate for Payer: Kaiser Permanente Medicaid	$969.00
Rate for Payer: Kaiser Permanente Medicare	$1,444.00
Rate for Payer: MDX Hawaii PPO	$1,843.00
Rate for Payer: Ohana Health Plan Medicaid	$1,444.00
Rate for Payer: Ohana Health Plan Medicare	$1,444.00
Rate for Payer: UnitedHealthcare Medicare	$1,444.00
Rate for Payer: University Health Alliance Commercial	$1,064.00

PLATE 1.7 STR 16H 57-08216

Facility

$1,548.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$866.88
Max. Negotiated Rate	$1,501.56
Rate for Payer: Cash Price	$928.80
Rate for Payer: Hawaii Western Management Group Commercial	$1,083.60
Rate for Payer: Health Management Network Commercial	$1,315.80
Rate for Payer: Kaiser Permanente Commercial	$1,393.20
Rate for Payer: MDX Hawaii PPO	$1,501.56
Rate for Payer: University Health Alliance Commercial	$866.88

PLATE 1.7 STR 16H 57-08216

Facility

$1,548.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$774.00
Max. Negotiated Rate	$1,501.56
Rate for Payer: AlohaCare Medicaid	$774.00
Rate for Payer: AlohaCare Medicare	$1,176.48
Rate for Payer: Cash Price	$928.80
Rate for Payer: Devoted Health Medicare	$1,300.32
Rate for Payer: Hawaii Medical Service Association Medicare	$1,176.48
Rate for Payer: Hawaii Western Management Group Commercial	$1,083.60
Rate for Payer: Health Management Network Commercial	$1,315.80
Rate for Payer: Humana Medicare	$1,176.48
Rate for Payer: Kaiser Permanente Commercial	$1,393.20
Rate for Payer: Kaiser Permanente Medicaid	$789.48
Rate for Payer: Kaiser Permanente Medicare	$1,176.48
Rate for Payer: MDX Hawaii PPO	$1,501.56
Rate for Payer: Ohana Health Plan Medicaid	$1,176.48
Rate for Payer: Ohana Health Plan Medicare	$1,176.48
Rate for Payer: UnitedHealthcare Medicare	$1,176.48
Rate for Payer: University Health Alliance Commercial	$866.88

PLATE 2.0 LCP 10H/73 247.360

Facility

$1,033.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$516.50
Max. Negotiated Rate	$1,002.01
Rate for Payer: AlohaCare Medicaid	$516.50
Rate for Payer: AlohaCare Medicare	$785.08
Rate for Payer: Cash Price	$619.80
Rate for Payer: Devoted Health Medicare	$867.72
Rate for Payer: Hawaii Medical Service Association Medicare	$785.08
Rate for Payer: Hawaii Western Management Group Commercial	$723.10
Rate for Payer: Health Management Network Commercial	$878.05
Rate for Payer: Humana Medicare	$785.08
Rate for Payer: Kaiser Permanente Commercial	$929.70
Rate for Payer: Kaiser Permanente Medicaid	$526.83
Rate for Payer: Kaiser Permanente Medicare	$785.08
Rate for Payer: MDX Hawaii PPO	$1,002.01
Rate for Payer: Ohana Health Plan Medicaid	$785.08
Rate for Payer: Ohana Health Plan Medicare	$785.08
Rate for Payer: UnitedHealthcare Medicare	$785.08
Rate for Payer: University Health Alliance Commercial	$578.48

PLATE 2.0 LCP 10H/73 247.360

Facility

$1,033.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$578.48
Max. Negotiated Rate	$1,002.01
Rate for Payer: Cash Price	$619.80
Rate for Payer: Hawaii Western Management Group Commercial	$723.10
Rate for Payer: Health Management Network Commercial	$878.05
Rate for Payer: Kaiser Permanente Commercial	$929.70
Rate for Payer: MDX Hawaii PPO	$1,002.01
Rate for Payer: University Health Alliance Commercial	$578.48

PLATE 2.0 LCP 3H/7H 247.615

Facility

$1,566.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$783.00
Max. Negotiated Rate	$1,519.02
Rate for Payer: AlohaCare Medicaid	$783.00
Rate for Payer: AlohaCare Medicare	$1,190.16
Rate for Payer: Cash Price	$939.60
Rate for Payer: Devoted Health Medicare	$1,315.44
Rate for Payer: Hawaii Medical Service Association Medicare	$1,190.16
Rate for Payer: Hawaii Western Management Group Commercial	$1,096.20
Rate for Payer: Health Management Network Commercial	$1,331.10
Rate for Payer: Humana Medicare	$1,190.16
Rate for Payer: Kaiser Permanente Commercial	$1,409.40
Rate for Payer: Kaiser Permanente Medicaid	$798.66
Rate for Payer: Kaiser Permanente Medicare	$1,190.16
Rate for Payer: MDX Hawaii PPO	$1,519.02
Rate for Payer: Ohana Health Plan Medicaid	$1,190.16
Rate for Payer: Ohana Health Plan Medicare	$1,190.16
Rate for Payer: UnitedHealthcare Medicare	$1,190.16
Rate for Payer: University Health Alliance Commercial	$876.96

Know your out-of-pocket cost for care.

All Charges