Honoka'a Hospital and Skilled Nursing Facility

All Charges

Charge

Type

Setting

Price

PLATE 4 HOLE 236.504

Facility

$2,163.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,081.50
Max. Negotiated Rate	$2,098.11
Rate for Payer: AlohaCare Medicaid	$1,081.50
Rate for Payer: AlohaCare Medicare	$1,643.88
Rate for Payer: Cash Price	$1,297.80
Rate for Payer: Devoted Health Medicare	$1,816.92
Rate for Payer: Hawaii Medical Service Association Medicare	$1,643.88
Rate for Payer: Hawaii Western Management Group Commercial	$1,514.10
Rate for Payer: Health Management Network Commercial	$1,838.55
Rate for Payer: Humana Medicare	$1,643.88
Rate for Payer: Kaiser Permanente Commercial	$1,946.70
Rate for Payer: Kaiser Permanente Medicaid	$1,103.13
Rate for Payer: Kaiser Permanente Medicare	$1,643.88
Rate for Payer: MDX Hawaii PPO	$2,098.11
Rate for Payer: Ohana Health Plan Medicaid	$1,643.88
Rate for Payer: Ohana Health Plan Medicare	$1,643.88
Rate for Payer: UnitedHealthcare Medicare	$1,643.88
Rate for Payer: University Health Alliance Commercial	$1,211.28

PLATE 4 HOLE 629364

Facility

$3,151.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,575.50
Max. Negotiated Rate	$3,056.47
Rate for Payer: AlohaCare Medicaid	$1,575.50
Rate for Payer: AlohaCare Medicare	$2,394.76
Rate for Payer: Cash Price	$1,890.60
Rate for Payer: Devoted Health Medicare	$2,646.84
Rate for Payer: Hawaii Medical Service Association Medicare	$2,394.76
Rate for Payer: Hawaii Western Management Group Commercial	$2,205.70
Rate for Payer: Health Management Network Commercial	$2,678.35
Rate for Payer: Humana Medicare	$2,394.76
Rate for Payer: Kaiser Permanente Commercial	$2,835.90
Rate for Payer: Kaiser Permanente Medicaid	$1,607.01
Rate for Payer: Kaiser Permanente Medicare	$2,394.76
Rate for Payer: MDX Hawaii PPO	$3,056.47
Rate for Payer: Ohana Health Plan Medicaid	$2,394.76
Rate for Payer: Ohana Health Plan Medicare	$2,394.76
Rate for Payer: UnitedHealthcare Medicare	$2,394.76
Rate for Payer: University Health Alliance Commercial	$1,764.56

PLATE 4 HOLE 629364

Facility

$3,151.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,764.56
Max. Negotiated Rate	$3,056.47
Rate for Payer: Cash Price	$1,890.60
Rate for Payer: Hawaii Western Management Group Commercial	$2,205.70
Rate for Payer: Health Management Network Commercial	$2,678.35
Rate for Payer: Kaiser Permanente Commercial	$2,835.90
Rate for Payer: MDX Hawaii PPO	$3,056.47
Rate for Payer: University Health Alliance Commercial	$1,764.56

PLATE 4 HOLES 92MM

Facility

$2,058.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,152.48
Max. Negotiated Rate	$1,996.26
Rate for Payer: Cash Price	$1,234.80
Rate for Payer: Hawaii Western Management Group Commercial	$1,440.60
Rate for Payer: Health Management Network Commercial	$1,749.30
Rate for Payer: Kaiser Permanente Commercial	$1,852.20
Rate for Payer: MDX Hawaii PPO	$1,996.26
Rate for Payer: University Health Alliance Commercial	$1,152.48

PLATE 4 HOLES 92MM

Facility

$2,058.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,029.00
Max. Negotiated Rate	$1,996.26
Rate for Payer: AlohaCare Medicaid	$1,029.00
Rate for Payer: AlohaCare Medicare	$1,564.08
Rate for Payer: Cash Price	$1,234.80
Rate for Payer: Devoted Health Medicare	$1,728.72
Rate for Payer: Hawaii Medical Service Association Medicare	$1,564.08
Rate for Payer: Hawaii Western Management Group Commercial	$1,440.60
Rate for Payer: Health Management Network Commercial	$1,749.30
Rate for Payer: Humana Medicare	$1,564.08
Rate for Payer: Kaiser Permanente Commercial	$1,852.20
Rate for Payer: Kaiser Permanente Medicaid	$1,049.58
Rate for Payer: Kaiser Permanente Medicare	$1,564.08
Rate for Payer: MDX Hawaii PPO	$1,996.26
Rate for Payer: Ohana Health Plan Medicaid	$1,564.08
Rate for Payer: Ohana Health Plan Medicare	$1,564.08
Rate for Payer: UnitedHealthcare Medicare	$1,564.08
Rate for Payer: University Health Alliance Commercial	$1,152.48

PLATE 4 HOLES 96MM

Facility

$2,058.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,029.00
Max. Negotiated Rate	$1,996.26
Rate for Payer: AlohaCare Medicaid	$1,029.00
Rate for Payer: AlohaCare Medicare	$1,564.08
Rate for Payer: Cash Price	$1,234.80
Rate for Payer: Devoted Health Medicare	$1,728.72
Rate for Payer: Hawaii Medical Service Association Medicare	$1,564.08
Rate for Payer: Hawaii Western Management Group Commercial	$1,440.60
Rate for Payer: Health Management Network Commercial	$1,749.30
Rate for Payer: Humana Medicare	$1,564.08
Rate for Payer: Kaiser Permanente Commercial	$1,852.20
Rate for Payer: Kaiser Permanente Medicaid	$1,049.58
Rate for Payer: Kaiser Permanente Medicare	$1,564.08
Rate for Payer: MDX Hawaii PPO	$1,996.26
Rate for Payer: Ohana Health Plan Medicaid	$1,564.08
Rate for Payer: Ohana Health Plan Medicare	$1,564.08
Rate for Payer: UnitedHealthcare Medicare	$1,564.08
Rate for Payer: University Health Alliance Commercial	$1,152.48

PLATE 4 HOLES 96MM

Facility

$2,058.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,152.48
Max. Negotiated Rate	$1,996.26
Rate for Payer: Cash Price	$1,234.80
Rate for Payer: Hawaii Western Management Group Commercial	$1,440.60
Rate for Payer: Health Management Network Commercial	$1,749.30
Rate for Payer: Kaiser Permanente Commercial	$1,852.20
Rate for Payer: MDX Hawaii PPO	$1,996.26
Rate for Payer: University Health Alliance Commercial	$1,152.48

PLATE 4H/RT/111MM 02.117.604

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

PLATE 4H/RT/111MM 02.117.604

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

PLATE 626675

Facility

$1,234.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$691.04
Max. Negotiated Rate	$1,196.98
Rate for Payer: Cash Price	$740.40
Rate for Payer: Hawaii Western Management Group Commercial	$863.80
Rate for Payer: Health Management Network Commercial	$1,048.90
Rate for Payer: Kaiser Permanente Commercial	$1,110.60
Rate for Payer: MDX Hawaii PPO	$1,196.98
Rate for Payer: University Health Alliance Commercial	$691.04

PLATE 626675

Facility

$1,234.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$617.00
Max. Negotiated Rate	$1,196.98
Rate for Payer: AlohaCare Medicaid	$617.00
Rate for Payer: AlohaCare Medicare	$937.84
Rate for Payer: Cash Price	$740.40
Rate for Payer: Devoted Health Medicare	$1,036.56
Rate for Payer: Hawaii Medical Service Association Medicare	$937.84
Rate for Payer: Hawaii Western Management Group Commercial	$863.80
Rate for Payer: Health Management Network Commercial	$1,048.90
Rate for Payer: Humana Medicare	$937.84
Rate for Payer: Kaiser Permanente Commercial	$1,110.60
Rate for Payer: Kaiser Permanente Medicaid	$629.34
Rate for Payer: Kaiser Permanente Medicare	$937.84
Rate for Payer: MDX Hawaii PPO	$1,196.98
Rate for Payer: Ohana Health Plan Medicaid	$937.84
Rate for Payer: Ohana Health Plan Medicare	$937.84
Rate for Payer: UnitedHealthcare Medicare	$937.84
Rate for Payer: University Health Alliance Commercial	$691.04

PLATE 626993

Facility

$3,016.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,688.96
Max. Negotiated Rate	$2,925.52
Rate for Payer: Cash Price	$1,809.60
Rate for Payer: Hawaii Western Management Group Commercial	$2,111.20
Rate for Payer: Health Management Network Commercial	$2,563.60
Rate for Payer: Kaiser Permanente Commercial	$2,714.40
Rate for Payer: MDX Hawaii PPO	$2,925.52
Rate for Payer: University Health Alliance Commercial	$1,688.96

PLATE 626993

Facility

$3,016.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,508.00
Max. Negotiated Rate	$2,925.52
Rate for Payer: AlohaCare Medicaid	$1,508.00
Rate for Payer: AlohaCare Medicare	$2,292.16
Rate for Payer: Cash Price	$1,809.60
Rate for Payer: Devoted Health Medicare	$2,533.44
Rate for Payer: Hawaii Medical Service Association Medicare	$2,292.16
Rate for Payer: Hawaii Western Management Group Commercial	$2,111.20
Rate for Payer: Health Management Network Commercial	$2,563.60
Rate for Payer: Humana Medicare	$2,292.16
Rate for Payer: Kaiser Permanente Commercial	$2,714.40
Rate for Payer: Kaiser Permanente Medicaid	$1,538.16
Rate for Payer: Kaiser Permanente Medicare	$2,292.16
Rate for Payer: MDX Hawaii PPO	$2,925.52
Rate for Payer: Ohana Health Plan Medicaid	$2,292.16
Rate for Payer: Ohana Health Plan Medicare	$2,292.16
Rate for Payer: UnitedHealthcare Medicare	$2,292.16
Rate for Payer: University Health Alliance Commercial	$1,688.96

PLATE 6 HOLE 627306

Facility

$5,101.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$2,856.56
Max. Negotiated Rate	$4,947.97
Rate for Payer: Cash Price	$3,060.60
Rate for Payer: Hawaii Western Management Group Commercial	$3,570.70
Rate for Payer: Health Management Network Commercial	$4,335.85
Rate for Payer: Kaiser Permanente Commercial	$4,590.90
Rate for Payer: MDX Hawaii PPO	$4,947.97
Rate for Payer: University Health Alliance Commercial	$2,856.56

PLATE 6 HOLE 627306

Facility

$5,101.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$2,550.50
Max. Negotiated Rate	$4,947.97
Rate for Payer: AlohaCare Medicaid	$2,550.50
Rate for Payer: AlohaCare Medicare	$3,876.76
Rate for Payer: Cash Price	$3,060.60
Rate for Payer: Devoted Health Medicare	$4,284.84
Rate for Payer: Hawaii Medical Service Association Medicare	$3,876.76
Rate for Payer: Hawaii Western Management Group Commercial	$3,570.70
Rate for Payer: Health Management Network Commercial	$4,335.85
Rate for Payer: Humana Medicare	$3,876.76
Rate for Payer: Kaiser Permanente Commercial	$4,590.90
Rate for Payer: Kaiser Permanente Medicaid	$2,601.51
Rate for Payer: Kaiser Permanente Medicare	$3,876.76
Rate for Payer: MDX Hawaii PPO	$4,947.97
Rate for Payer: Ohana Health Plan Medicaid	$3,876.76
Rate for Payer: Ohana Health Plan Medicare	$3,876.76
Rate for Payer: UnitedHealthcare Medicare	$3,876.76
Rate for Payer: University Health Alliance Commercial	$2,856.56

PLATE 6 HOLES 629506

Facility

$1,514.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$847.84
Max. Negotiated Rate	$1,468.58
Rate for Payer: MDX Hawaii PPO	$1,468.58
Rate for Payer: Cash Price	$908.40
Rate for Payer: Hawaii Western Management Group Commercial	$1,059.80
Rate for Payer: Health Management Network Commercial	$1,286.90
Rate for Payer: Kaiser Permanente Commercial	$1,362.60
Rate for Payer: University Health Alliance Commercial	$847.84

PLATE 6 HOLES 629506

Facility

$1,514.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$757.00
Max. Negotiated Rate	$1,468.58
Rate for Payer: AlohaCare Medicaid	$757.00
Rate for Payer: AlohaCare Medicare	$1,150.64
Rate for Payer: Cash Price	$908.40
Rate for Payer: Devoted Health Medicare	$1,271.76
Rate for Payer: Hawaii Medical Service Association Medicare	$1,150.64
Rate for Payer: Hawaii Western Management Group Commercial	$1,059.80
Rate for Payer: Health Management Network Commercial	$1,286.90
Rate for Payer: Humana Medicare	$1,150.64
Rate for Payer: Kaiser Permanente Commercial	$1,362.60
Rate for Payer: Kaiser Permanente Medicaid	$772.14
Rate for Payer: Kaiser Permanente Medicare	$1,150.64
Rate for Payer: MDX Hawaii PPO	$1,468.58
Rate for Payer: Ohana Health Plan Medicaid	$1,150.64
Rate for Payer: Ohana Health Plan Medicare	$1,150.64
Rate for Payer: UnitedHealthcare Medicare	$1,150.64
Rate for Payer: University Health Alliance Commercial	$847.84

PLATE 77MM 3 HOLES

Facility

$2,156.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,078.00
Max. Negotiated Rate	$2,091.32
Rate for Payer: AlohaCare Medicaid	$1,078.00
Rate for Payer: AlohaCare Medicare	$1,638.56
Rate for Payer: Cash Price	$1,293.60
Rate for Payer: Devoted Health Medicare	$1,811.04
Rate for Payer: Hawaii Medical Service Association Medicare	$1,638.56
Rate for Payer: Hawaii Western Management Group Commercial	$1,509.20
Rate for Payer: Health Management Network Commercial	$1,832.60
Rate for Payer: Humana Medicare	$1,638.56
Rate for Payer: Kaiser Permanente Commercial	$1,940.40
Rate for Payer: Kaiser Permanente Medicaid	$1,099.56
Rate for Payer: Kaiser Permanente Medicare	$1,638.56
Rate for Payer: MDX Hawaii PPO	$2,091.32
Rate for Payer: Ohana Health Plan Medicaid	$1,638.56
Rate for Payer: Ohana Health Plan Medicare	$1,638.56
Rate for Payer: UnitedHealthcare Medicare	$1,638.56
Rate for Payer: University Health Alliance Commercial	$1,207.36

PLATE 77MM 3 HOLES

Facility

$2,156.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,207.36
Max. Negotiated Rate	$2,091.32
Rate for Payer: Cash Price	$1,293.60
Rate for Payer: Hawaii Western Management Group Commercial	$1,509.20
Rate for Payer: Health Management Network Commercial	$1,832.60
Rate for Payer: Kaiser Permanente Commercial	$1,940.40
Rate for Payer: MDX Hawaii PPO	$2,091.32
Rate for Payer: University Health Alliance Commercial	$1,207.36

PLATE 8H 1MM CRV 04.503.709

Facility

$2,614.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,463.84
Max. Negotiated Rate	$2,535.58
Rate for Payer: Cash Price	$1,568.40
Rate for Payer: Hawaii Western Management Group Commercial	$1,829.80
Rate for Payer: Health Management Network Commercial	$2,221.90
Rate for Payer: Kaiser Permanente Commercial	$2,352.60
Rate for Payer: MDX Hawaii PPO	$2,535.58
Rate for Payer: University Health Alliance Commercial	$1,463.84

PLATE 8H 1MM CRV 04.503.709

Facility

$2,614.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,307.00
Max. Negotiated Rate	$2,535.58
Rate for Payer: AlohaCare Medicaid	$1,307.00
Rate for Payer: AlohaCare Medicare	$1,986.64
Rate for Payer: Cash Price	$1,568.40
Rate for Payer: Devoted Health Medicare	$2,195.76
Rate for Payer: Hawaii Medical Service Association Medicare	$1,986.64
Rate for Payer: Hawaii Western Management Group Commercial	$1,829.80
Rate for Payer: Health Management Network Commercial	$2,221.90
Rate for Payer: Humana Medicare	$1,986.64
Rate for Payer: Kaiser Permanente Commercial	$2,352.60
Rate for Payer: Kaiser Permanente Medicaid	$1,333.14
Rate for Payer: Kaiser Permanente Medicare	$1,986.64
Rate for Payer: MDX Hawaii PPO	$2,535.58
Rate for Payer: Ohana Health Plan Medicaid	$1,986.64
Rate for Payer: Ohana Health Plan Medicare	$1,986.64
Rate for Payer: UnitedHealthcare Medicare	$1,986.64
Rate for Payer: University Health Alliance Commercial	$1,463.84

PLATE 8 HOLE 629508

Facility

$2,225.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,112.50
Max. Negotiated Rate	$2,158.25
Rate for Payer: AlohaCare Medicaid	$1,112.50
Rate for Payer: AlohaCare Medicare	$1,691.00
Rate for Payer: Cash Price	$1,335.00
Rate for Payer: Devoted Health Medicare	$1,869.00
Rate for Payer: Hawaii Medical Service Association Medicare	$1,691.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,557.50
Rate for Payer: Health Management Network Commercial	$1,891.25
Rate for Payer: Humana Medicare	$1,691.00
Rate for Payer: Kaiser Permanente Commercial	$2,002.50
Rate for Payer: Kaiser Permanente Medicaid	$1,134.75
Rate for Payer: Kaiser Permanente Medicare	$1,691.00
Rate for Payer: MDX Hawaii PPO	$2,158.25
Rate for Payer: Ohana Health Plan Medicaid	$1,691.00
Rate for Payer: Ohana Health Plan Medicare	$1,691.00
Rate for Payer: UnitedHealthcare Medicare	$1,691.00
Rate for Payer: University Health Alliance Commercial	$1,246.00

PLATE 8 HOLE 629508

Facility

$2,225.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,246.00
Max. Negotiated Rate	$2,158.25
Rate for Payer: Cash Price	$1,335.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,557.50
Rate for Payer: Health Management Network Commercial	$1,891.25
Rate for Payer: Kaiser Permanente Commercial	$2,002.50
Rate for Payer: MDX Hawaii PPO	$2,158.25
Rate for Payer: University Health Alliance Commercial	$1,246.00

PLATE 9H CRVD 5MMX188MM

Facility

$6,054.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$3,390.24
Max. Negotiated Rate	$5,872.38
Rate for Payer: Cash Price	$3,632.40
Rate for Payer: Hawaii Western Management Group Commercial	$4,237.80
Rate for Payer: Health Management Network Commercial	$5,145.90
Rate for Payer: Kaiser Permanente Commercial	$5,448.60
Rate for Payer: MDX Hawaii PPO	$5,872.38
Rate for Payer: University Health Alliance Commercial	$3,390.24

PLATE 9H CRVD 5MMX188MM

Facility

$6,054.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$3,027.00
Max. Negotiated Rate	$5,872.38
Rate for Payer: AlohaCare Medicaid	$3,027.00
Rate for Payer: AlohaCare Medicare	$4,601.04
Rate for Payer: Cash Price	$3,632.40
Rate for Payer: Devoted Health Medicare	$5,085.36
Rate for Payer: Hawaii Medical Service Association Medicare	$4,601.04
Rate for Payer: Hawaii Western Management Group Commercial	$4,237.80
Rate for Payer: Health Management Network Commercial	$5,145.90
Rate for Payer: Humana Medicare	$4,601.04
Rate for Payer: Kaiser Permanente Commercial	$5,448.60
Rate for Payer: Kaiser Permanente Medicaid	$3,087.54
Rate for Payer: Kaiser Permanente Medicare	$4,601.04
Rate for Payer: MDX Hawaii PPO	$5,872.38
Rate for Payer: Ohana Health Plan Medicaid	$4,601.04
Rate for Payer: Ohana Health Plan Medicare	$4,601.04
Rate for Payer: UnitedHealthcare Medicare	$4,601.04
Rate for Payer: University Health Alliance Commercial	$3,390.24

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