Honoka'a Hospital and Skilled Nursing Facility

All Charges

Charge

Type

Setting

Price

PLATE 3H/RT/75MM 02.117.203

Facility

$2,749.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,374.50
Max. Negotiated Rate	$2,666.53
Rate for Payer: AlohaCare Medicaid	$1,374.50
Rate for Payer: AlohaCare Medicare	$2,089.24
Rate for Payer: Cash Price	$1,649.40
Rate for Payer: Devoted Health Medicare	$2,309.16
Rate for Payer: Hawaii Medical Service Association Medicare	$2,089.24
Rate for Payer: Hawaii Western Management Group Commercial	$1,924.30
Rate for Payer: Health Management Network Commercial	$2,336.65
Rate for Payer: Humana Medicare	$2,089.24
Rate for Payer: Kaiser Permanente Commercial	$2,474.10
Rate for Payer: Kaiser Permanente Medicaid	$1,401.99
Rate for Payer: Kaiser Permanente Medicare	$2,089.24
Rate for Payer: MDX Hawaii PPO	$2,666.53
Rate for Payer: Ohana Health Plan Medicaid	$2,089.24
Rate for Payer: Ohana Health Plan Medicare	$2,089.24
Rate for Payer: UnitedHealthcare Medicare	$2,089.24
Rate for Payer: University Health Alliance Commercial	$1,539.44

PLATE 3H/RT/75MM 02.117.203

Facility

$2,749.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,539.44
Max. Negotiated Rate	$2,666.53
Rate for Payer: Cash Price	$1,649.40
Rate for Payer: Hawaii Western Management Group Commercial	$1,924.30
Rate for Payer: Health Management Network Commercial	$2,336.65
Rate for Payer: Kaiser Permanente Commercial	$2,474.10
Rate for Payer: MDX Hawaii PPO	$2,666.53
Rate for Payer: University Health Alliance Commercial	$1,539.44

PLATE 4.0MM COMP 162MM 12H

Facility

$2,748.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,538.88
Max. Negotiated Rate	$2,665.56
Rate for Payer: Cash Price	$1,648.80
Rate for Payer: Hawaii Western Management Group Commercial	$1,923.60
Rate for Payer: Health Management Network Commercial	$2,335.80
Rate for Payer: Kaiser Permanente Commercial	$2,473.20
Rate for Payer: MDX Hawaii PPO	$2,665.56
Rate for Payer: University Health Alliance Commercial	$1,538.88

PLATE 4.0MM COMP 162MM 12H

Facility

$2,748.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,374.00
Max. Negotiated Rate	$2,665.56
Rate for Payer: AlohaCare Medicaid	$1,374.00
Rate for Payer: AlohaCare Medicare	$2,088.48
Rate for Payer: Cash Price	$1,648.80
Rate for Payer: Devoted Health Medicare	$2,308.32
Rate for Payer: Hawaii Medical Service Association Medicare	$2,088.48
Rate for Payer: Hawaii Western Management Group Commercial	$1,923.60
Rate for Payer: Health Management Network Commercial	$2,335.80
Rate for Payer: Humana Medicare	$2,088.48
Rate for Payer: Kaiser Permanente Commercial	$2,473.20
Rate for Payer: Kaiser Permanente Medicaid	$1,401.48
Rate for Payer: Kaiser Permanente Medicare	$2,088.48
Rate for Payer: MDX Hawaii PPO	$2,665.56
Rate for Payer: Ohana Health Plan Medicaid	$2,088.48
Rate for Payer: Ohana Health Plan Medicare	$2,088.48
Rate for Payer: UnitedHealthcare Medicare	$2,088.48
Rate for Payer: University Health Alliance Commercial	$1,538.88

PLATE 4.52 VA-LCP 02.124.412

Facility

$4,419.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$2,209.50
Max. Negotiated Rate	$4,286.43
Rate for Payer: AlohaCare Medicaid	$2,209.50
Rate for Payer: AlohaCare Medicare	$3,358.44
Rate for Payer: Cash Price	$2,651.40
Rate for Payer: Devoted Health Medicare	$3,711.96
Rate for Payer: Hawaii Medical Service Association Medicare	$3,358.44
Rate for Payer: Hawaii Western Management Group Commercial	$3,093.30
Rate for Payer: Health Management Network Commercial	$3,756.15
Rate for Payer: Humana Medicare	$3,358.44
Rate for Payer: Kaiser Permanente Commercial	$3,977.10
Rate for Payer: Kaiser Permanente Medicaid	$2,253.69
Rate for Payer: Kaiser Permanente Medicare	$3,358.44
Rate for Payer: MDX Hawaii PPO	$4,286.43
Rate for Payer: Ohana Health Plan Medicaid	$3,358.44
Rate for Payer: Ohana Health Plan Medicare	$3,358.44
Rate for Payer: UnitedHealthcare Medicare	$3,358.44
Rate for Payer: University Health Alliance Commercial	$2,474.64

PLATE 4.52 VA-LCP 02.124.412

Facility

$4,419.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$2,474.64
Max. Negotiated Rate	$4,286.43
Rate for Payer: Cash Price	$2,651.40
Rate for Payer: Hawaii Western Management Group Commercial	$3,093.30
Rate for Payer: Health Management Network Commercial	$3,756.15
Rate for Payer: Kaiser Permanente Commercial	$3,977.10
Rate for Payer: MDX Hawaii PPO	$4,286.43
Rate for Payer: University Health Alliance Commercial	$2,474.64

PLATE 4.5/6H/170MM LT 222.657

Facility

$3,479.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,948.24
Max. Negotiated Rate	$3,374.63
Rate for Payer: Cash Price	$2,087.40
Rate for Payer: Hawaii Western Management Group Commercial	$2,435.30
Rate for Payer: Health Management Network Commercial	$2,957.15
Rate for Payer: Kaiser Permanente Commercial	$3,131.10
Rate for Payer: MDX Hawaii PPO	$3,374.63
Rate for Payer: University Health Alliance Commercial	$1,948.24

PLATE 4.5/6H/170MM LT 222.657

Facility

$3,479.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,739.50
Max. Negotiated Rate	$3,374.63
Rate for Payer: AlohaCare Medicaid	$1,739.50
Rate for Payer: AlohaCare Medicare	$2,644.04
Rate for Payer: Cash Price	$2,087.40
Rate for Payer: Devoted Health Medicare	$2,922.36
Rate for Payer: Hawaii Medical Service Association Medicare	$2,644.04
Rate for Payer: Hawaii Western Management Group Commercial	$2,435.30
Rate for Payer: Health Management Network Commercial	$2,957.15
Rate for Payer: Humana Medicare	$2,644.04
Rate for Payer: Kaiser Permanente Commercial	$3,131.10
Rate for Payer: Kaiser Permanente Medicaid	$1,774.29
Rate for Payer: Kaiser Permanente Medicare	$2,644.04
Rate for Payer: MDX Hawaii PPO	$3,374.63
Rate for Payer: Ohana Health Plan Medicaid	$2,644.04
Rate for Payer: Ohana Health Plan Medicare	$2,644.04
Rate for Payer: UnitedHealthcare Medicare	$2,644.04
Rate for Payer: University Health Alliance Commercial	$1,948.24

PLATE 4.5/6H/170MM RT 222.656

Facility

$5,042.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$2,823.52
Max. Negotiated Rate	$4,890.74
Rate for Payer: Cash Price	$3,025.20
Rate for Payer: Hawaii Western Management Group Commercial	$3,529.40
Rate for Payer: Health Management Network Commercial	$4,285.70
Rate for Payer: Kaiser Permanente Commercial	$4,537.80
Rate for Payer: MDX Hawaii PPO	$4,890.74
Rate for Payer: University Health Alliance Commercial	$2,823.52

PLATE 4.5/6H/170MM RT 222.656

Facility

$5,042.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$2,521.00
Max. Negotiated Rate	$4,890.74
Rate for Payer: AlohaCare Medicaid	$2,521.00
Rate for Payer: AlohaCare Medicare	$3,831.92
Rate for Payer: Cash Price	$3,025.20
Rate for Payer: Devoted Health Medicare	$4,235.28
Rate for Payer: Hawaii Medical Service Association Medicare	$3,831.92
Rate for Payer: Hawaii Western Management Group Commercial	$3,529.40
Rate for Payer: Health Management Network Commercial	$4,285.70
Rate for Payer: Humana Medicare	$3,831.92
Rate for Payer: Kaiser Permanente Commercial	$4,537.80
Rate for Payer: Kaiser Permanente Medicaid	$2,571.42
Rate for Payer: Kaiser Permanente Medicare	$3,831.92
Rate for Payer: MDX Hawaii PPO	$4,890.74
Rate for Payer: Ohana Health Plan Medicaid	$3,831.92
Rate for Payer: Ohana Health Plan Medicare	$3,831.92
Rate for Payer: UnitedHealthcare Medicare	$3,831.92
Rate for Payer: University Health Alliance Commercial	$2,823.52

PLATE 4.5MM 6H/211MM 242.106

Facility

$4,566.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$2,283.00
Max. Negotiated Rate	$4,429.02
Rate for Payer: AlohaCare Medicaid	$2,283.00
Rate for Payer: AlohaCare Medicare	$3,470.16
Rate for Payer: Cash Price	$2,739.60
Rate for Payer: Devoted Health Medicare	$3,835.44
Rate for Payer: Hawaii Medical Service Association Medicare	$3,470.16
Rate for Payer: Hawaii Western Management Group Commercial	$3,196.20
Rate for Payer: Health Management Network Commercial	$3,881.10
Rate for Payer: Humana Medicare	$3,470.16
Rate for Payer: Kaiser Permanente Commercial	$4,109.40
Rate for Payer: Kaiser Permanente Medicaid	$2,328.66
Rate for Payer: Kaiser Permanente Medicare	$3,470.16
Rate for Payer: MDX Hawaii PPO	$4,429.02
Rate for Payer: Ohana Health Plan Medicaid	$3,470.16
Rate for Payer: Ohana Health Plan Medicare	$3,470.16
Rate for Payer: UnitedHealthcare Medicare	$3,470.16
Rate for Payer: University Health Alliance Commercial	$2,556.96

PLATE 4.5MM 6H/211MM 242.106

Facility

$4,566.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$2,556.96
Max. Negotiated Rate	$4,429.02
Rate for Payer: Cash Price	$2,739.60
Rate for Payer: Hawaii Western Management Group Commercial	$3,196.20
Rate for Payer: Health Management Network Commercial	$3,881.10
Rate for Payer: Kaiser Permanente Commercial	$4,109.40
Rate for Payer: MDX Hawaii PPO	$4,429.02
Rate for Payer: University Health Alliance Commercial	$2,556.96

PLATE 4.5MM 6H/211MM 242.806

Facility

$4,566.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$2,283.00
Max. Negotiated Rate	$4,429.02
Rate for Payer: AlohaCare Medicaid	$2,283.00
Rate for Payer: AlohaCare Medicare	$3,470.16
Rate for Payer: Cash Price	$2,739.60
Rate for Payer: Devoted Health Medicare	$3,835.44
Rate for Payer: Hawaii Medical Service Association Medicare	$3,470.16
Rate for Payer: Hawaii Western Management Group Commercial	$3,196.20
Rate for Payer: Health Management Network Commercial	$3,881.10
Rate for Payer: Humana Medicare	$3,470.16
Rate for Payer: Kaiser Permanente Commercial	$4,109.40
Rate for Payer: Kaiser Permanente Medicaid	$2,328.66
Rate for Payer: Kaiser Permanente Medicare	$3,470.16
Rate for Payer: MDX Hawaii PPO	$4,429.02
Rate for Payer: Ohana Health Plan Medicaid	$3,470.16
Rate for Payer: Ohana Health Plan Medicare	$3,470.16
Rate for Payer: UnitedHealthcare Medicare	$3,470.16
Rate for Payer: University Health Alliance Commercial	$2,556.96

PLATE 4.5MM 6H/211MM 242.806

Facility

$4,566.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$2,556.96
Max. Negotiated Rate	$4,429.02
Rate for Payer: Cash Price	$2,739.60
Rate for Payer: Hawaii Western Management Group Commercial	$3,196.20
Rate for Payer: Health Management Network Commercial	$3,881.10
Rate for Payer: Kaiser Permanente Commercial	$4,109.40
Rate for Payer: MDX Hawaii PPO	$4,429.02
Rate for Payer: University Health Alliance Commercial	$2,556.96

PLATE 4.5MM 8H/247MM 242.108

Facility

$3,536.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,768.00
Max. Negotiated Rate	$3,429.92
Rate for Payer: AlohaCare Medicaid	$1,768.00
Rate for Payer: AlohaCare Medicare	$2,687.36
Rate for Payer: Cash Price	$2,121.60
Rate for Payer: Devoted Health Medicare	$2,970.24
Rate for Payer: Hawaii Medical Service Association Medicare	$2,687.36
Rate for Payer: Hawaii Western Management Group Commercial	$2,475.20
Rate for Payer: Health Management Network Commercial	$3,005.60
Rate for Payer: Humana Medicare	$2,687.36
Rate for Payer: Kaiser Permanente Commercial	$3,182.40
Rate for Payer: Kaiser Permanente Medicaid	$1,803.36
Rate for Payer: Kaiser Permanente Medicare	$2,687.36
Rate for Payer: MDX Hawaii PPO	$3,429.92
Rate for Payer: Ohana Health Plan Medicaid	$2,687.36
Rate for Payer: Ohana Health Plan Medicare	$2,687.36
Rate for Payer: UnitedHealthcare Medicare	$2,687.36
Rate for Payer: University Health Alliance Commercial	$1,980.16

PLATE 4.5MM 8H/247MM 242.108

Facility

$3,536.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,980.16
Max. Negotiated Rate	$3,429.92
Rate for Payer: Cash Price	$2,121.60
Rate for Payer: Hawaii Western Management Group Commercial	$2,475.20
Rate for Payer: Health Management Network Commercial	$3,005.60
Rate for Payer: Kaiser Permanente Commercial	$3,182.40
Rate for Payer: MDX Hawaii PPO	$3,429.92
Rate for Payer: University Health Alliance Commercial	$1,980.16

PLATE 4.5MM 8H/247MM 242.808

Facility

$4,788.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$2,681.28
Max. Negotiated Rate	$4,644.36
Rate for Payer: Cash Price	$2,872.80
Rate for Payer: Hawaii Western Management Group Commercial	$3,351.60
Rate for Payer: Health Management Network Commercial	$4,069.80
Rate for Payer: Kaiser Permanente Commercial	$4,309.20
Rate for Payer: MDX Hawaii PPO	$4,644.36
Rate for Payer: University Health Alliance Commercial	$2,681.28

PLATE 4.5MM 8H/247MM 242.808

Facility

$4,788.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$2,394.00
Max. Negotiated Rate	$4,644.36
Rate for Payer: AlohaCare Medicaid	$2,394.00
Rate for Payer: AlohaCare Medicare	$3,638.88
Rate for Payer: Cash Price	$2,872.80
Rate for Payer: Devoted Health Medicare	$4,021.92
Rate for Payer: Hawaii Medical Service Association Medicare	$3,638.88
Rate for Payer: Hawaii Western Management Group Commercial	$3,351.60
Rate for Payer: Health Management Network Commercial	$4,069.80
Rate for Payer: Humana Medicare	$3,638.88
Rate for Payer: Kaiser Permanente Commercial	$4,309.20
Rate for Payer: Kaiser Permanente Medicaid	$2,441.88
Rate for Payer: Kaiser Permanente Medicare	$3,638.88
Rate for Payer: MDX Hawaii PPO	$4,644.36
Rate for Payer: Ohana Health Plan Medicaid	$3,638.88
Rate for Payer: Ohana Health Plan Medicare	$3,638.88
Rate for Payer: UnitedHealthcare Medicare	$3,638.88
Rate for Payer: University Health Alliance Commercial	$2,681.28

PLATE 4.5MM LCP 6H 02.124.407

Facility

$4,056.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$2,271.36
Max. Negotiated Rate	$3,934.32
Rate for Payer: Cash Price	$2,433.60
Rate for Payer: Hawaii Western Management Group Commercial	$2,839.20
Rate for Payer: Health Management Network Commercial	$3,447.60
Rate for Payer: Kaiser Permanente Commercial	$3,650.40
Rate for Payer: MDX Hawaii PPO	$3,934.32
Rate for Payer: University Health Alliance Commercial	$2,271.36

PLATE 4.5MM LCP 6H 02.124.407

Facility

$4,056.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$2,028.00
Max. Negotiated Rate	$3,934.32
Rate for Payer: AlohaCare Medicaid	$2,028.00
Rate for Payer: AlohaCare Medicare	$3,082.56
Rate for Payer: Cash Price	$2,433.60
Rate for Payer: Devoted Health Medicare	$3,407.04
Rate for Payer: Hawaii Medical Service Association Medicare	$3,082.56
Rate for Payer: Hawaii Western Management Group Commercial	$2,839.20
Rate for Payer: Health Management Network Commercial	$3,447.60
Rate for Payer: Humana Medicare	$3,082.56
Rate for Payer: Kaiser Permanente Commercial	$3,650.40
Rate for Payer: Kaiser Permanente Medicaid	$2,068.56
Rate for Payer: Kaiser Permanente Medicare	$3,082.56
Rate for Payer: MDX Hawaii PPO	$3,934.32
Rate for Payer: Ohana Health Plan Medicaid	$3,082.56
Rate for Payer: Ohana Health Plan Medicare	$3,082.56
Rate for Payer: UnitedHealthcare Medicare	$3,082.56
Rate for Payer: University Health Alliance Commercial	$2,271.36

PLATE 4.5X195 8H LF 02.124.409

Facility

$4,136.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$2,068.00
Max. Negotiated Rate	$4,011.92
Rate for Payer: AlohaCare Medicaid	$2,068.00
Rate for Payer: AlohaCare Medicare	$3,143.36
Rate for Payer: Cash Price	$2,481.60
Rate for Payer: Devoted Health Medicare	$3,474.24
Rate for Payer: Hawaii Medical Service Association Medicare	$3,143.36
Rate for Payer: Hawaii Western Management Group Commercial	$2,895.20
Rate for Payer: Health Management Network Commercial	$3,515.60
Rate for Payer: Humana Medicare	$3,143.36
Rate for Payer: Kaiser Permanente Commercial	$3,722.40
Rate for Payer: Kaiser Permanente Medicaid	$2,109.36
Rate for Payer: Kaiser Permanente Medicare	$3,143.36
Rate for Payer: MDX Hawaii PPO	$4,011.92
Rate for Payer: Ohana Health Plan Medicaid	$3,143.36
Rate for Payer: Ohana Health Plan Medicare	$3,143.36
Rate for Payer: UnitedHealthcare Medicare	$3,143.36
Rate for Payer: University Health Alliance Commercial	$2,316.16

PLATE 4.5X195 8H LF 02.124.409

Facility

$4,136.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$2,316.16
Max. Negotiated Rate	$4,011.92
Rate for Payer: Cash Price	$2,481.60
Rate for Payer: Hawaii Western Management Group Commercial	$2,895.20
Rate for Payer: Health Management Network Commercial	$3,515.60
Rate for Payer: Kaiser Permanente Commercial	$3,722.40
Rate for Payer: MDX Hawaii PPO	$4,011.92
Rate for Payer: University Health Alliance Commercial	$2,316.16

PLATE 45X195 RT 8H 02.124.408

Facility

$4,136.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$2,068.00
Max. Negotiated Rate	$4,011.92
Rate for Payer: AlohaCare Medicaid	$2,068.00
Rate for Payer: AlohaCare Medicare	$3,143.36
Rate for Payer: Cash Price	$2,481.60
Rate for Payer: Devoted Health Medicare	$3,474.24
Rate for Payer: Hawaii Medical Service Association Medicare	$3,143.36
Rate for Payer: Hawaii Western Management Group Commercial	$2,895.20
Rate for Payer: Health Management Network Commercial	$3,515.60
Rate for Payer: Humana Medicare	$3,143.36
Rate for Payer: Kaiser Permanente Commercial	$3,722.40
Rate for Payer: Kaiser Permanente Medicaid	$2,109.36
Rate for Payer: Kaiser Permanente Medicare	$3,143.36
Rate for Payer: MDX Hawaii PPO	$4,011.92
Rate for Payer: Ohana Health Plan Medicaid	$3,143.36
Rate for Payer: Ohana Health Plan Medicare	$3,143.36
Rate for Payer: UnitedHealthcare Medicare	$3,143.36
Rate for Payer: University Health Alliance Commercial	$2,316.16

PLATE 45X195 RT 8H 02.124.408

Facility

$4,136.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$2,316.16
Max. Negotiated Rate	$4,011.92
Rate for Payer: Cash Price	$2,481.60
Rate for Payer: Hawaii Western Management Group Commercial	$2,895.20
Rate for Payer: Health Management Network Commercial	$3,515.60
Rate for Payer: Kaiser Permanente Commercial	$3,722.40
Rate for Payer: MDX Hawaii PPO	$4,011.92
Rate for Payer: University Health Alliance Commercial	$2,316.16

PLATE 4 HOLE 236.504

Facility

$2,163.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,211.28
Max. Negotiated Rate	$2,098.11
Rate for Payer: Cash Price	$1,297.80
Rate for Payer: Hawaii Western Management Group Commercial	$1,514.10
Rate for Payer: Health Management Network Commercial	$1,838.55
Rate for Payer: Kaiser Permanente Commercial	$1,946.70
Rate for Payer: MDX Hawaii PPO	$2,098.11
Rate for Payer: University Health Alliance Commercial	$1,211.28

Know your out-of-pocket cost for care.

All Charges