Honoka'a Hospital and Skilled Nursing Facility

All Charges

Charge

Type

Setting

Price

BIPOLAR 42MM 00-5001-042-00

Facility

$1,050.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$525.00
Max. Negotiated Rate	$1,018.50
Rate for Payer: AlohaCare Medicaid	$525.00
Rate for Payer: AlohaCare Medicare	$798.00
Rate for Payer: Cash Price	$630.00
Rate for Payer: Devoted Health Medicare	$882.00
Rate for Payer: Hawaii Medical Service Association Medicare	$798.00
Rate for Payer: Hawaii Western Management Group Commercial	$735.00
Rate for Payer: Health Management Network Commercial	$892.50
Rate for Payer: Humana Medicare	$798.00
Rate for Payer: Kaiser Permanente Commercial	$945.00
Rate for Payer: Kaiser Permanente Medicaid	$535.50
Rate for Payer: Kaiser Permanente Medicare	$798.00
Rate for Payer: MDX Hawaii PPO	$1,018.50
Rate for Payer: Ohana Health Plan Medicaid	$798.00
Rate for Payer: Ohana Health Plan Medicare	$798.00
Rate for Payer: UnitedHealthcare Medicare	$798.00
Rate for Payer: University Health Alliance Commercial	$588.00

BIPOLAR 42MM 00-5001-042-00

Facility

$1,050.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$588.00
Max. Negotiated Rate	$1,018.50
Rate for Payer: Cash Price	$630.00
Rate for Payer: Hawaii Western Management Group Commercial	$735.00
Rate for Payer: Health Management Network Commercial	$892.50
Rate for Payer: Kaiser Permanente Commercial	$945.00
Rate for Payer: MDX Hawaii PPO	$1,018.50
Rate for Payer: University Health Alliance Commercial	$588.00

BIPOLAR HIP #98-0001-006-00

Facility

$7,000.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$3,500.00
Max. Negotiated Rate	$6,790.00
Rate for Payer: AlohaCare Medicaid	$3,500.00
Rate for Payer: AlohaCare Medicare	$5,320.00
Rate for Payer: Cash Price	$4,200.00
Rate for Payer: Devoted Health Medicare	$5,880.00
Rate for Payer: Hawaii Medical Service Association Medicare	$5,320.00
Rate for Payer: Hawaii Western Management Group Commercial	$4,900.00
Rate for Payer: Health Management Network Commercial	$5,950.00
Rate for Payer: Humana Medicare	$5,320.00
Rate for Payer: Kaiser Permanente Commercial	$6,300.00
Rate for Payer: Kaiser Permanente Medicaid	$3,570.00
Rate for Payer: Kaiser Permanente Medicare	$5,320.00
Rate for Payer: MDX Hawaii PPO	$6,790.00
Rate for Payer: Ohana Health Plan Medicaid	$5,320.00
Rate for Payer: Ohana Health Plan Medicare	$5,320.00
Rate for Payer: UnitedHealthcare Medicare	$5,320.00
Rate for Payer: University Health Alliance Commercial	$3,920.00

BIPOLAR HIP #98-0001-006-00

Facility

$7,000.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$3,920.00
Max. Negotiated Rate	$6,790.00
Rate for Payer: Cash Price	$4,200.00
Rate for Payer: Hawaii Western Management Group Commercial	$4,900.00
Rate for Payer: Health Management Network Commercial	$5,950.00
Rate for Payer: Kaiser Permanente Commercial	$6,300.00
Rate for Payer: MDX Hawaii PPO	$6,790.00
Rate for Payer: University Health Alliance Commercial	$3,920.00

BIPOLAR LINER

Facility

$998.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$558.88
Max. Negotiated Rate	$968.06
Rate for Payer: Cash Price	$598.80
Rate for Payer: Hawaii Western Management Group Commercial	$698.60
Rate for Payer: Health Management Network Commercial	$848.30
Rate for Payer: Kaiser Permanente Commercial	$898.20
Rate for Payer: MDX Hawaii PPO	$968.06
Rate for Payer: University Health Alliance Commercial	$558.88

BIPOLAR LINER

Facility

$998.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$499.00
Max. Negotiated Rate	$968.06
Rate for Payer: AlohaCare Medicaid	$499.00
Rate for Payer: AlohaCare Medicare	$758.48
Rate for Payer: Cash Price	$598.80
Rate for Payer: Devoted Health Medicare	$838.32
Rate for Payer: Hawaii Medical Service Association Medicare	$758.48
Rate for Payer: Hawaii Western Management Group Commercial	$698.60
Rate for Payer: Health Management Network Commercial	$848.30
Rate for Payer: Humana Medicare	$758.48
Rate for Payer: Kaiser Permanente Commercial	$898.20
Rate for Payer: Kaiser Permanente Medicaid	$508.98
Rate for Payer: Kaiser Permanente Medicare	$758.48
Rate for Payer: MDX Hawaii PPO	$968.06
Rate for Payer: Ohana Health Plan Medicaid	$758.48
Rate for Payer: Ohana Health Plan Medicare	$758.48
Rate for Payer: UnitedHealthcare Medicare	$758.48
Rate for Payer: University Health Alliance Commercial	$558.88

BIPOLAR LINER #00-5001-047-28

Facility

$750.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$375.00
Max. Negotiated Rate	$727.50
Rate for Payer: AlohaCare Medicaid	$375.00
Rate for Payer: AlohaCare Medicare	$570.00
Rate for Payer: Cash Price	$450.00
Rate for Payer: Devoted Health Medicare	$630.00
Rate for Payer: Hawaii Medical Service Association Medicare	$570.00
Rate for Payer: Hawaii Western Management Group Commercial	$525.00
Rate for Payer: Health Management Network Commercial	$637.50
Rate for Payer: Humana Medicare	$570.00
Rate for Payer: Kaiser Permanente Commercial	$675.00
Rate for Payer: Kaiser Permanente Medicaid	$382.50
Rate for Payer: Kaiser Permanente Medicare	$570.00
Rate for Payer: MDX Hawaii PPO	$727.50
Rate for Payer: Ohana Health Plan Medicaid	$570.00
Rate for Payer: Ohana Health Plan Medicare	$570.00
Rate for Payer: UnitedHealthcare Medicare	$570.00
Rate for Payer: University Health Alliance Commercial	$420.00

BIPOLAR LINER #00-5001-047-28

Facility

$750.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$420.00
Max. Negotiated Rate	$727.50
Rate for Payer: Cash Price	$450.00
Rate for Payer: Hawaii Western Management Group Commercial	$525.00
Rate for Payer: Health Management Network Commercial	$637.50
Rate for Payer: Kaiser Permanente Commercial	$675.00
Rate for Payer: MDX Hawaii PPO	$727.50
Rate for Payer: University Health Alliance Commercial	$420.00

BIPOLAR LINER 28X53/54/55

Facility

$875.00

Service Code	HCPCS C1776
Hospital Revenue Code	272
Min. Negotiated Rate	$743.75
Max. Negotiated Rate	$848.75
Rate for Payer: Cash Price	$525.00
Rate for Payer: Health Management Network Commercial	$743.75
Rate for Payer: Kaiser Permanente Commercial	$787.50
Rate for Payer: MDX Hawaii PPO	$848.75

BIPOLAR LINER 28X53/54/55

Facility

$875.00

Service Code	HCPCS C1776
Hospital Revenue Code	272
Min. Negotiated Rate	$437.50
Max. Negotiated Rate	$848.75
Rate for Payer: AlohaCare Medicaid	$437.50
Rate for Payer: AlohaCare Medicare	$665.00
Rate for Payer: Cash Price	$525.00
Rate for Payer: Devoted Health Medicare	$735.00
Rate for Payer: Hawaii Medical Service Association Medicare	$665.00
Rate for Payer: Hawaii Western Management Group Commercial	$831.25
Rate for Payer: Health Management Network Commercial	$743.75
Rate for Payer: Humana Medicare	$665.00
Rate for Payer: Kaiser Permanente Commercial	$787.50
Rate for Payer: Kaiser Permanente Medicaid	$446.25
Rate for Payer: Kaiser Permanente Medicare	$665.00
Rate for Payer: MDX Hawaii PPO	$848.75
Rate for Payer: Ohana Health Plan Medicaid	$665.00
Rate for Payer: Ohana Health Plan Medicare	$665.00
Rate for Payer: UnitedHealthcare Medicare	$665.00
Rate for Payer: University Health Alliance Commercial	$637.79

BIPOLAR LINER 40/41MM OD X22MM

Facility

$875.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$437.50
Max. Negotiated Rate	$848.75
Rate for Payer: AlohaCare Medicaid	$437.50
Rate for Payer: AlohaCare Medicare	$665.00
Rate for Payer: Cash Price	$525.00
Rate for Payer: Devoted Health Medicare	$735.00
Rate for Payer: Hawaii Medical Service Association Medicare	$665.00
Rate for Payer: Hawaii Western Management Group Commercial	$612.50
Rate for Payer: Health Management Network Commercial	$743.75
Rate for Payer: Humana Medicare	$665.00
Rate for Payer: Kaiser Permanente Commercial	$787.50
Rate for Payer: Kaiser Permanente Medicaid	$446.25
Rate for Payer: Kaiser Permanente Medicare	$665.00
Rate for Payer: MDX Hawaii PPO	$848.75
Rate for Payer: Ohana Health Plan Medicaid	$665.00
Rate for Payer: Ohana Health Plan Medicare	$665.00
Rate for Payer: UnitedHealthcare Medicare	$665.00
Rate for Payer: University Health Alliance Commercial	$490.00

BIPOLAR LINER 40/41MM OD X22MM

Facility

$875.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$490.00
Max. Negotiated Rate	$848.75
Rate for Payer: Cash Price	$525.00
Rate for Payer: Hawaii Western Management Group Commercial	$612.50
Rate for Payer: Health Management Network Commercial	$743.75
Rate for Payer: Kaiser Permanente Commercial	$787.50
Rate for Payer: MDX Hawaii PPO	$848.75
Rate for Payer: University Health Alliance Commercial	$490.00

BIPOLAR LINER 40MM OD X 26MM

Facility

$875.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$437.50
Max. Negotiated Rate	$848.75
Rate for Payer: AlohaCare Medicaid	$437.50
Rate for Payer: AlohaCare Medicare	$665.00
Rate for Payer: Cash Price	$525.00
Rate for Payer: Devoted Health Medicare	$735.00
Rate for Payer: Hawaii Medical Service Association Medicare	$665.00
Rate for Payer: Hawaii Western Management Group Commercial	$612.50
Rate for Payer: Health Management Network Commercial	$743.75
Rate for Payer: Humana Medicare	$665.00
Rate for Payer: Kaiser Permanente Commercial	$787.50
Rate for Payer: Kaiser Permanente Medicaid	$446.25
Rate for Payer: Kaiser Permanente Medicare	$665.00
Rate for Payer: MDX Hawaii PPO	$848.75
Rate for Payer: Ohana Health Plan Medicaid	$665.00
Rate for Payer: Ohana Health Plan Medicare	$665.00
Rate for Payer: UnitedHealthcare Medicare	$665.00
Rate for Payer: University Health Alliance Commercial	$490.00

BIPOLAR LINER 40MM OD X 26MM

Facility

$875.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$490.00
Max. Negotiated Rate	$848.75
Rate for Payer: Cash Price	$525.00
Rate for Payer: Hawaii Western Management Group Commercial	$612.50
Rate for Payer: Health Management Network Commercial	$743.75
Rate for Payer: Kaiser Permanente Commercial	$787.50
Rate for Payer: MDX Hawaii PPO	$848.75
Rate for Payer: University Health Alliance Commercial	$490.00

BIPOLAR LINER 42/43 OD X 22MM

Facility

$875.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$437.50
Max. Negotiated Rate	$848.75
Rate for Payer: AlohaCare Medicaid	$437.50
Rate for Payer: AlohaCare Medicare	$665.00
Rate for Payer: Cash Price	$525.00
Rate for Payer: Devoted Health Medicare	$735.00
Rate for Payer: Hawaii Medical Service Association Medicare	$665.00
Rate for Payer: Hawaii Western Management Group Commercial	$612.50
Rate for Payer: Health Management Network Commercial	$743.75
Rate for Payer: Humana Medicare	$665.00
Rate for Payer: Kaiser Permanente Commercial	$787.50
Rate for Payer: Kaiser Permanente Medicaid	$446.25
Rate for Payer: Kaiser Permanente Medicare	$665.00
Rate for Payer: MDX Hawaii PPO	$848.75
Rate for Payer: Ohana Health Plan Medicaid	$665.00
Rate for Payer: Ohana Health Plan Medicare	$665.00
Rate for Payer: UnitedHealthcare Medicare	$665.00
Rate for Payer: University Health Alliance Commercial	$490.00

BIPOLAR LINER 42/43 OD X 22MM

Facility

$875.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$490.00
Max. Negotiated Rate	$848.75
Rate for Payer: Cash Price	$525.00
Rate for Payer: Hawaii Western Management Group Commercial	$612.50
Rate for Payer: Health Management Network Commercial	$743.75
Rate for Payer: Kaiser Permanente Commercial	$787.50
Rate for Payer: MDX Hawaii PPO	$848.75
Rate for Payer: University Health Alliance Commercial	$490.00

BIPOLAR LINER 42MM OD X 26MM

Facility

$875.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$490.00
Max. Negotiated Rate	$848.75
Rate for Payer: Cash Price	$525.00
Rate for Payer: Hawaii Western Management Group Commercial	$612.50
Rate for Payer: Health Management Network Commercial	$743.75
Rate for Payer: Kaiser Permanente Commercial	$787.50
Rate for Payer: MDX Hawaii PPO	$848.75
Rate for Payer: University Health Alliance Commercial	$490.00

BIPOLAR LINER 42MM OD X 26MM

Facility

$875.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$437.50
Max. Negotiated Rate	$848.75
Rate for Payer: AlohaCare Medicaid	$437.50
Rate for Payer: AlohaCare Medicare	$665.00
Rate for Payer: Cash Price	$525.00
Rate for Payer: Devoted Health Medicare	$735.00
Rate for Payer: Hawaii Medical Service Association Medicare	$665.00
Rate for Payer: Hawaii Western Management Group Commercial	$612.50
Rate for Payer: Health Management Network Commercial	$743.75
Rate for Payer: Humana Medicare	$665.00
Rate for Payer: Kaiser Permanente Commercial	$787.50
Rate for Payer: Kaiser Permanente Medicaid	$446.25
Rate for Payer: Kaiser Permanente Medicare	$665.00
Rate for Payer: MDX Hawaii PPO	$848.75
Rate for Payer: Ohana Health Plan Medicaid	$665.00
Rate for Payer: Ohana Health Plan Medicare	$665.00
Rate for Payer: UnitedHealthcare Medicare	$665.00
Rate for Payer: University Health Alliance Commercial	$490.00

BIPOLAR LINER 44MM OD X 22MM

Facility

$875.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$437.50
Max. Negotiated Rate	$848.75
Rate for Payer: AlohaCare Medicaid	$437.50
Rate for Payer: AlohaCare Medicare	$665.00
Rate for Payer: Cash Price	$525.00
Rate for Payer: Devoted Health Medicare	$735.00
Rate for Payer: Hawaii Medical Service Association Medicare	$665.00
Rate for Payer: Hawaii Western Management Group Commercial	$612.50
Rate for Payer: Health Management Network Commercial	$743.75
Rate for Payer: Humana Medicare	$665.00
Rate for Payer: Kaiser Permanente Commercial	$787.50
Rate for Payer: Kaiser Permanente Medicaid	$446.25
Rate for Payer: Kaiser Permanente Medicare	$665.00
Rate for Payer: MDX Hawaii PPO	$848.75
Rate for Payer: Ohana Health Plan Medicaid	$665.00
Rate for Payer: Ohana Health Plan Medicare	$665.00
Rate for Payer: UnitedHealthcare Medicare	$665.00
Rate for Payer: University Health Alliance Commercial	$490.00

BIPOLAR LINER 44MM OD X 22MM

Facility

$875.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$490.00
Max. Negotiated Rate	$848.75
Rate for Payer: Cash Price	$525.00
Rate for Payer: Hawaii Western Management Group Commercial	$612.50
Rate for Payer: Health Management Network Commercial	$743.75
Rate for Payer: Kaiser Permanente Commercial	$787.50
Rate for Payer: MDX Hawaii PPO	$848.75
Rate for Payer: University Health Alliance Commercial	$490.00

BIPOLAR LINER 44MM OD X 26MM

Facility

$875.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$437.50
Max. Negotiated Rate	$848.75
Rate for Payer: AlohaCare Medicaid	$437.50
Rate for Payer: AlohaCare Medicare	$665.00
Rate for Payer: Cash Price	$525.00
Rate for Payer: Devoted Health Medicare	$735.00
Rate for Payer: Hawaii Medical Service Association Medicare	$665.00
Rate for Payer: Hawaii Western Management Group Commercial	$612.50
Rate for Payer: Health Management Network Commercial	$743.75
Rate for Payer: Humana Medicare	$665.00
Rate for Payer: Kaiser Permanente Commercial	$787.50
Rate for Payer: Kaiser Permanente Medicaid	$446.25
Rate for Payer: Kaiser Permanente Medicare	$665.00
Rate for Payer: MDX Hawaii PPO	$848.75
Rate for Payer: Ohana Health Plan Medicaid	$665.00
Rate for Payer: Ohana Health Plan Medicare	$665.00
Rate for Payer: UnitedHealthcare Medicare	$665.00
Rate for Payer: University Health Alliance Commercial	$490.00

BIPOLAR LINER 44MM OD X 26MM

Facility

$875.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$490.00
Max. Negotiated Rate	$848.75
Rate for Payer: Cash Price	$525.00
Rate for Payer: Hawaii Western Management Group Commercial	$612.50
Rate for Payer: Health Management Network Commercial	$743.75
Rate for Payer: Kaiser Permanente Commercial	$787.50
Rate for Payer: MDX Hawaii PPO	$848.75
Rate for Payer: University Health Alliance Commercial	$490.00

BIPOLAR LINER 47MM OD X 22MM

Facility

$875.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$490.00
Max. Negotiated Rate	$848.75
Rate for Payer: Cash Price	$525.00
Rate for Payer: Hawaii Western Management Group Commercial	$612.50
Rate for Payer: Health Management Network Commercial	$743.75
Rate for Payer: Kaiser Permanente Commercial	$787.50
Rate for Payer: MDX Hawaii PPO	$848.75
Rate for Payer: University Health Alliance Commercial	$490.00

BIPOLAR LINER 47MM OD X 22MM

Facility

$875.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$437.50
Max. Negotiated Rate	$848.75
Rate for Payer: AlohaCare Medicaid	$437.50
Rate for Payer: AlohaCare Medicare	$665.00
Rate for Payer: Cash Price	$525.00
Rate for Payer: Devoted Health Medicare	$735.00
Rate for Payer: Hawaii Medical Service Association Medicare	$665.00
Rate for Payer: Hawaii Western Management Group Commercial	$612.50
Rate for Payer: Health Management Network Commercial	$743.75
Rate for Payer: Humana Medicare	$665.00
Rate for Payer: Kaiser Permanente Commercial	$787.50
Rate for Payer: Kaiser Permanente Medicaid	$446.25
Rate for Payer: Kaiser Permanente Medicare	$665.00
Rate for Payer: MDX Hawaii PPO	$848.75
Rate for Payer: Ohana Health Plan Medicaid	$665.00
Rate for Payer: Ohana Health Plan Medicare	$665.00
Rate for Payer: UnitedHealthcare Medicare	$665.00
Rate for Payer: University Health Alliance Commercial	$490.00

BIPOLAR LINER 47MM OD X 26MM

Facility

$875.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$437.50
Max. Negotiated Rate	$848.75
Rate for Payer: AlohaCare Medicaid	$437.50
Rate for Payer: AlohaCare Medicare	$665.00
Rate for Payer: Cash Price	$525.00
Rate for Payer: Devoted Health Medicare	$735.00
Rate for Payer: Hawaii Medical Service Association Medicare	$665.00
Rate for Payer: Hawaii Western Management Group Commercial	$612.50
Rate for Payer: Health Management Network Commercial	$743.75
Rate for Payer: Humana Medicare	$665.00
Rate for Payer: Kaiser Permanente Commercial	$787.50
Rate for Payer: Kaiser Permanente Medicaid	$446.25
Rate for Payer: Kaiser Permanente Medicare	$665.00
Rate for Payer: MDX Hawaii PPO	$848.75
Rate for Payer: Ohana Health Plan Medicaid	$665.00
Rate for Payer: Ohana Health Plan Medicare	$665.00
Rate for Payer: UnitedHealthcare Medicare	$665.00
Rate for Payer: University Health Alliance Commercial	$490.00

Know your out-of-pocket cost for care.

All Charges