Honoka'a Hospital and Skilled Nursing Facility

All Charges

Charge

Type

Setting

Price

PLATE LCP 14H 3.5X211 #239.945

Facility

$4,738.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$2,369.00
Max. Negotiated Rate	$4,595.86
Rate for Payer: AlohaCare Medicaid	$2,369.00
Rate for Payer: AlohaCare Medicare	$3,600.88
Rate for Payer: Cash Price	$2,842.80
Rate for Payer: Devoted Health Medicare	$3,979.92
Rate for Payer: Hawaii Medical Service Association Medicare	$3,600.88
Rate for Payer: Hawaii Western Management Group Commercial	$3,316.60
Rate for Payer: Health Management Network Commercial	$4,027.30
Rate for Payer: Humana Medicare	$3,600.88
Rate for Payer: Kaiser Permanente Commercial	$4,264.20
Rate for Payer: Kaiser Permanente Medicaid	$2,416.38
Rate for Payer: Kaiser Permanente Medicare	$3,600.88
Rate for Payer: MDX Hawaii PPO	$4,595.86
Rate for Payer: Ohana Health Plan Medicaid	$3,600.88
Rate for Payer: Ohana Health Plan Medicare	$3,600.88
Rate for Payer: UnitedHealthcare Medicare	$3,600.88
Rate for Payer: University Health Alliance Commercial	$2,653.28

PLATE LCP 16H 3.5X237 #239.946

Facility

$5,070.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$2,535.00
Max. Negotiated Rate	$4,917.90
Rate for Payer: AlohaCare Medicaid	$2,535.00
Rate for Payer: AlohaCare Medicare	$3,853.20
Rate for Payer: Cash Price	$3,042.00
Rate for Payer: Devoted Health Medicare	$4,258.80
Rate for Payer: Hawaii Medical Service Association Medicare	$3,853.20
Rate for Payer: Hawaii Western Management Group Commercial	$3,549.00
Rate for Payer: Health Management Network Commercial	$4,309.50
Rate for Payer: Humana Medicare	$3,853.20
Rate for Payer: Kaiser Permanente Commercial	$4,563.00
Rate for Payer: Kaiser Permanente Medicaid	$2,585.70
Rate for Payer: Kaiser Permanente Medicare	$3,853.20
Rate for Payer: MDX Hawaii PPO	$4,917.90
Rate for Payer: Ohana Health Plan Medicaid	$3,853.20
Rate for Payer: Ohana Health Plan Medicare	$3,853.20
Rate for Payer: UnitedHealthcare Medicare	$3,853.20
Rate for Payer: University Health Alliance Commercial	$2,839.20

PLATE LCP 16H 3.5X237 #239.946

Facility

$5,070.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$2,839.20
Max. Negotiated Rate	$4,917.90
Rate for Payer: Cash Price	$3,042.00
Rate for Payer: Hawaii Western Management Group Commercial	$3,549.00
Rate for Payer: Health Management Network Commercial	$4,309.50
Rate for Payer: Kaiser Permanente Commercial	$4,563.00
Rate for Payer: MDX Hawaii PPO	$4,917.90
Rate for Payer: University Health Alliance Commercial	$2,839.20

PLATE LCP 16H 3.5X237 #239.947

Facility

$5,070.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$2,839.20
Max. Negotiated Rate	$4,917.90
Rate for Payer: Cash Price	$3,042.00
Rate for Payer: Hawaii Western Management Group Commercial	$3,549.00
Rate for Payer: Health Management Network Commercial	$4,309.50
Rate for Payer: Kaiser Permanente Commercial	$4,563.00
Rate for Payer: MDX Hawaii PPO	$4,917.90
Rate for Payer: University Health Alliance Commercial	$2,839.20

PLATE LCP 16H 3.5X237 #239.947

Facility

$5,070.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$2,535.00
Max. Negotiated Rate	$4,917.90
Rate for Payer: AlohaCare Medicaid	$2,535.00
Rate for Payer: AlohaCare Medicare	$3,853.20
Rate for Payer: Cash Price	$3,042.00
Rate for Payer: Devoted Health Medicare	$4,258.80
Rate for Payer: Hawaii Medical Service Association Medicare	$3,853.20
Rate for Payer: Hawaii Western Management Group Commercial	$3,549.00
Rate for Payer: Health Management Network Commercial	$4,309.50
Rate for Payer: Humana Medicare	$3,853.20
Rate for Payer: Kaiser Permanente Commercial	$4,563.00
Rate for Payer: Kaiser Permanente Medicaid	$2,585.70
Rate for Payer: Kaiser Permanente Medicare	$3,853.20
Rate for Payer: MDX Hawaii PPO	$4,917.90
Rate for Payer: Ohana Health Plan Medicaid	$3,853.20
Rate for Payer: Ohana Health Plan Medicare	$3,853.20
Rate for Payer: UnitedHealthcare Medicare	$3,853.20
Rate for Payer: University Health Alliance Commercial	$2,839.20

PLATE LCP 2H 4.5X44MM 224.521

Facility

$1,673.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$836.50
Max. Negotiated Rate	$1,622.81
Rate for Payer: AlohaCare Medicaid	$836.50
Rate for Payer: AlohaCare Medicare	$1,271.48
Rate for Payer: Cash Price	$1,003.80
Rate for Payer: Devoted Health Medicare	$1,405.32
Rate for Payer: Hawaii Medical Service Association Medicare	$1,271.48
Rate for Payer: Hawaii Western Management Group Commercial	$1,171.10
Rate for Payer: Health Management Network Commercial	$1,422.05
Rate for Payer: Humana Medicare	$1,271.48
Rate for Payer: Kaiser Permanente Commercial	$1,505.70
Rate for Payer: Kaiser Permanente Medicaid	$853.23
Rate for Payer: Kaiser Permanente Medicare	$1,271.48
Rate for Payer: MDX Hawaii PPO	$1,622.81
Rate for Payer: Ohana Health Plan Medicaid	$1,271.48
Rate for Payer: Ohana Health Plan Medicare	$1,271.48
Rate for Payer: UnitedHealthcare Medicare	$1,271.48
Rate for Payer: University Health Alliance Commercial	$936.88

PLATE LCP 2H 4.5X44MM 224.521

Facility

$1,673.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$936.88
Max. Negotiated Rate	$1,622.81
Rate for Payer: Cash Price	$1,003.80
Rate for Payer: Hawaii Western Management Group Commercial	$1,171.10
Rate for Payer: Health Management Network Commercial	$1,422.05
Rate for Payer: Kaiser Permanente Commercial	$1,505.70
Rate for Payer: MDX Hawaii PPO	$1,622.81
Rate for Payer: University Health Alliance Commercial	$936.88

PLATE LCP 3.5/10H/L 02.127.341

Facility

$4,263.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$2,387.28
Max. Negotiated Rate	$4,135.11
Rate for Payer: Cash Price	$2,557.80
Rate for Payer: Hawaii Western Management Group Commercial	$2,984.10
Rate for Payer: Health Management Network Commercial	$3,623.55
Rate for Payer: Kaiser Permanente Commercial	$3,836.70
Rate for Payer: MDX Hawaii PPO	$4,135.11
Rate for Payer: University Health Alliance Commercial	$2,387.28

PLATE LCP 3.5/10H/L 02.127.341

Facility

$4,263.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$2,131.50
Max. Negotiated Rate	$4,135.11
Rate for Payer: AlohaCare Medicaid	$2,131.50
Rate for Payer: AlohaCare Medicare	$3,239.88
Rate for Payer: Cash Price	$2,557.80
Rate for Payer: Devoted Health Medicare	$3,580.92
Rate for Payer: Hawaii Medical Service Association Medicare	$3,239.88
Rate for Payer: Hawaii Western Management Group Commercial	$2,984.10
Rate for Payer: Health Management Network Commercial	$3,623.55
Rate for Payer: Humana Medicare	$3,239.88
Rate for Payer: Kaiser Permanente Commercial	$3,836.70
Rate for Payer: Kaiser Permanente Medicaid	$2,174.13
Rate for Payer: Kaiser Permanente Medicare	$3,239.88
Rate for Payer: MDX Hawaii PPO	$4,135.11
Rate for Payer: Ohana Health Plan Medicaid	$3,239.88
Rate for Payer: Ohana Health Plan Medicare	$3,239.88
Rate for Payer: UnitedHealthcare Medicare	$3,239.88
Rate for Payer: University Health Alliance Commercial	$2,387.28

PLATE LCP 3.5/10H/R 02.127.240

Facility

$4,263.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$2,131.50
Max. Negotiated Rate	$4,135.11
Rate for Payer: AlohaCare Medicaid	$2,131.50
Rate for Payer: AlohaCare Medicare	$3,239.88
Rate for Payer: Cash Price	$2,557.80
Rate for Payer: Devoted Health Medicare	$3,580.92
Rate for Payer: Hawaii Medical Service Association Medicare	$3,239.88
Rate for Payer: Hawaii Western Management Group Commercial	$2,984.10
Rate for Payer: Health Management Network Commercial	$3,623.55
Rate for Payer: Humana Medicare	$3,239.88
Rate for Payer: Kaiser Permanente Commercial	$3,836.70
Rate for Payer: Kaiser Permanente Medicaid	$2,174.13
Rate for Payer: Kaiser Permanente Medicare	$3,239.88
Rate for Payer: MDX Hawaii PPO	$4,135.11
Rate for Payer: Ohana Health Plan Medicaid	$3,239.88
Rate for Payer: Ohana Health Plan Medicare	$3,239.88
Rate for Payer: UnitedHealthcare Medicare	$3,239.88
Rate for Payer: University Health Alliance Commercial	$2,387.28

PLATE LCP 3.5/10H/R 02.127.240

Facility

$4,263.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$2,387.28
Max. Negotiated Rate	$4,135.11
Rate for Payer: Cash Price	$2,557.80
Rate for Payer: Hawaii Western Management Group Commercial	$2,984.10
Rate for Payer: Health Management Network Commercial	$3,623.55
Rate for Payer: Kaiser Permanente Commercial	$3,836.70
Rate for Payer: MDX Hawaii PPO	$4,135.11
Rate for Payer: University Health Alliance Commercial	$2,387.28

PLATE LCP 3.5/10H/R 02.127.340

Facility

$4,263.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$2,387.28
Max. Negotiated Rate	$4,135.11
Rate for Payer: Cash Price	$2,557.80
Rate for Payer: Hawaii Western Management Group Commercial	$2,984.10
Rate for Payer: Health Management Network Commercial	$3,623.55
Rate for Payer: Kaiser Permanente Commercial	$3,836.70
Rate for Payer: MDX Hawaii PPO	$4,135.11
Rate for Payer: University Health Alliance Commercial	$2,387.28

PLATE LCP 3.5/10H/R 02.127.340

Facility

$4,263.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$2,131.50
Max. Negotiated Rate	$4,135.11
Rate for Payer: AlohaCare Medicaid	$2,131.50
Rate for Payer: AlohaCare Medicare	$3,239.88
Rate for Payer: Cash Price	$2,557.80
Rate for Payer: Devoted Health Medicare	$3,580.92
Rate for Payer: Hawaii Medical Service Association Medicare	$3,239.88
Rate for Payer: Hawaii Western Management Group Commercial	$2,984.10
Rate for Payer: Health Management Network Commercial	$3,623.55
Rate for Payer: Humana Medicare	$3,239.88
Rate for Payer: Kaiser Permanente Commercial	$3,836.70
Rate for Payer: Kaiser Permanente Medicaid	$2,174.13
Rate for Payer: Kaiser Permanente Medicare	$3,239.88
Rate for Payer: MDX Hawaii PPO	$4,135.11
Rate for Payer: Ohana Health Plan Medicaid	$3,239.88
Rate for Payer: Ohana Health Plan Medicare	$3,239.88
Rate for Payer: UnitedHealthcare Medicare	$3,239.88
Rate for Payer: University Health Alliance Commercial	$2,387.28

PLATE LCP 3.5/12H/L 02.127.251

Facility

$4,755.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$2,377.50
Max. Negotiated Rate	$4,612.35
Rate for Payer: AlohaCare Medicaid	$2,377.50
Rate for Payer: AlohaCare Medicare	$3,613.80
Rate for Payer: Cash Price	$2,853.00
Rate for Payer: Devoted Health Medicare	$3,994.20
Rate for Payer: Hawaii Medical Service Association Medicare	$3,613.80
Rate for Payer: Hawaii Western Management Group Commercial	$3,328.50
Rate for Payer: Health Management Network Commercial	$4,041.75
Rate for Payer: Humana Medicare	$3,613.80
Rate for Payer: Kaiser Permanente Commercial	$4,279.50
Rate for Payer: Kaiser Permanente Medicaid	$2,425.05
Rate for Payer: Kaiser Permanente Medicare	$3,613.80
Rate for Payer: MDX Hawaii PPO	$4,612.35
Rate for Payer: Ohana Health Plan Medicaid	$3,613.80
Rate for Payer: Ohana Health Plan Medicare	$3,613.80
Rate for Payer: UnitedHealthcare Medicare	$3,613.80
Rate for Payer: University Health Alliance Commercial	$2,662.80

PLATE LCP 3.5/12H/L 02.127.251

Facility

$4,755.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$2,662.80
Max. Negotiated Rate	$4,612.35
Rate for Payer: Cash Price	$2,853.00
Rate for Payer: Hawaii Western Management Group Commercial	$3,328.50
Rate for Payer: Health Management Network Commercial	$4,041.75
Rate for Payer: Kaiser Permanente Commercial	$4,279.50
Rate for Payer: MDX Hawaii PPO	$4,612.35
Rate for Payer: University Health Alliance Commercial	$2,662.80

PLATE LCP 3.5/12H/L 02.127.351

Facility

$4,755.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$2,662.80
Max. Negotiated Rate	$4,612.35
Rate for Payer: Cash Price	$2,853.00
Rate for Payer: Hawaii Western Management Group Commercial	$3,328.50
Rate for Payer: Health Management Network Commercial	$4,041.75
Rate for Payer: Kaiser Permanente Commercial	$4,279.50
Rate for Payer: MDX Hawaii PPO	$4,612.35
Rate for Payer: University Health Alliance Commercial	$2,662.80

PLATE LCP 3.5/12H/L 02.127.351

Facility

$4,755.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$2,377.50
Max. Negotiated Rate	$4,612.35
Rate for Payer: AlohaCare Medicaid	$2,377.50
Rate for Payer: AlohaCare Medicare	$3,613.80
Rate for Payer: Cash Price	$2,853.00
Rate for Payer: Devoted Health Medicare	$3,994.20
Rate for Payer: Hawaii Medical Service Association Medicare	$3,613.80
Rate for Payer: Hawaii Western Management Group Commercial	$3,328.50
Rate for Payer: Health Management Network Commercial	$4,041.75
Rate for Payer: Humana Medicare	$3,613.80
Rate for Payer: Kaiser Permanente Commercial	$4,279.50
Rate for Payer: Kaiser Permanente Medicaid	$2,425.05
Rate for Payer: Kaiser Permanente Medicare	$3,613.80
Rate for Payer: MDX Hawaii PPO	$4,612.35
Rate for Payer: Ohana Health Plan Medicaid	$3,613.80
Rate for Payer: Ohana Health Plan Medicare	$3,613.80
Rate for Payer: UnitedHealthcare Medicare	$3,613.80
Rate for Payer: University Health Alliance Commercial	$2,662.80

PLATE LCP 3.5/12H/R 02.127.250

Facility

$4,755.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$2,662.80
Max. Negotiated Rate	$4,612.35
Rate for Payer: Cash Price	$2,853.00
Rate for Payer: Hawaii Western Management Group Commercial	$3,328.50
Rate for Payer: Health Management Network Commercial	$4,041.75
Rate for Payer: Kaiser Permanente Commercial	$4,279.50
Rate for Payer: MDX Hawaii PPO	$4,612.35
Rate for Payer: University Health Alliance Commercial	$2,662.80

PLATE LCP 3.5/12H/R 02.127.250

Facility

$4,755.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$2,377.50
Max. Negotiated Rate	$4,612.35
Rate for Payer: AlohaCare Medicaid	$2,377.50
Rate for Payer: AlohaCare Medicare	$3,613.80
Rate for Payer: Cash Price	$2,853.00
Rate for Payer: Devoted Health Medicare	$3,994.20
Rate for Payer: Hawaii Medical Service Association Medicare	$3,613.80
Rate for Payer: Hawaii Western Management Group Commercial	$3,328.50
Rate for Payer: Health Management Network Commercial	$4,041.75
Rate for Payer: Humana Medicare	$3,613.80
Rate for Payer: Kaiser Permanente Commercial	$4,279.50
Rate for Payer: Kaiser Permanente Medicaid	$2,425.05
Rate for Payer: Kaiser Permanente Medicare	$3,613.80
Rate for Payer: MDX Hawaii PPO	$4,612.35
Rate for Payer: Ohana Health Plan Medicaid	$3,613.80
Rate for Payer: Ohana Health Plan Medicare	$3,613.80
Rate for Payer: UnitedHealthcare Medicare	$3,613.80
Rate for Payer: University Health Alliance Commercial	$2,662.80

PLATE LCP 3.5/14H/L 02.127.261

Facility

$4,964.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$2,779.84
Max. Negotiated Rate	$4,815.08
Rate for Payer: Cash Price	$2,978.40
Rate for Payer: Hawaii Western Management Group Commercial	$3,474.80
Rate for Payer: Health Management Network Commercial	$4,219.40
Rate for Payer: Kaiser Permanente Commercial	$4,467.60
Rate for Payer: MDX Hawaii PPO	$4,815.08
Rate for Payer: University Health Alliance Commercial	$2,779.84

PLATE LCP 3.5/14H/L 02.127.261

Facility

$4,964.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$2,482.00
Max. Negotiated Rate	$4,815.08
Rate for Payer: AlohaCare Medicaid	$2,482.00
Rate for Payer: AlohaCare Medicare	$3,772.64
Rate for Payer: Cash Price	$2,978.40
Rate for Payer: Devoted Health Medicare	$4,169.76
Rate for Payer: Hawaii Medical Service Association Medicare	$3,772.64
Rate for Payer: Hawaii Western Management Group Commercial	$3,474.80
Rate for Payer: Health Management Network Commercial	$4,219.40
Rate for Payer: Humana Medicare	$3,772.64
Rate for Payer: Kaiser Permanente Commercial	$4,467.60
Rate for Payer: Kaiser Permanente Medicaid	$2,531.64
Rate for Payer: Kaiser Permanente Medicare	$3,772.64
Rate for Payer: MDX Hawaii PPO	$4,815.08
Rate for Payer: Ohana Health Plan Medicaid	$3,772.64
Rate for Payer: Ohana Health Plan Medicare	$3,772.64
Rate for Payer: UnitedHealthcare Medicare	$3,772.64
Rate for Payer: University Health Alliance Commercial	$2,779.84

PLATE LCP 3.5/14H/L 02.127.361

Facility

$4,964.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$2,482.00
Max. Negotiated Rate	$4,815.08
Rate for Payer: AlohaCare Medicaid	$2,482.00
Rate for Payer: AlohaCare Medicare	$3,772.64
Rate for Payer: Cash Price	$2,978.40
Rate for Payer: Devoted Health Medicare	$4,169.76
Rate for Payer: Hawaii Medical Service Association Medicare	$3,772.64
Rate for Payer: Hawaii Western Management Group Commercial	$3,474.80
Rate for Payer: Health Management Network Commercial	$4,219.40
Rate for Payer: Humana Medicare	$3,772.64
Rate for Payer: Kaiser Permanente Commercial	$4,467.60
Rate for Payer: Kaiser Permanente Medicaid	$2,531.64
Rate for Payer: Kaiser Permanente Medicare	$3,772.64
Rate for Payer: MDX Hawaii PPO	$4,815.08
Rate for Payer: Ohana Health Plan Medicaid	$3,772.64
Rate for Payer: Ohana Health Plan Medicare	$3,772.64
Rate for Payer: UnitedHealthcare Medicare	$3,772.64
Rate for Payer: University Health Alliance Commercial	$2,779.84

PLATE LCP 3.5/14H/L 02.127.361

Facility

$4,964.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$2,779.84
Max. Negotiated Rate	$4,815.08
Rate for Payer: Cash Price	$2,978.40
Rate for Payer: Hawaii Western Management Group Commercial	$3,474.80
Rate for Payer: Health Management Network Commercial	$4,219.40
Rate for Payer: Kaiser Permanente Commercial	$4,467.60
Rate for Payer: MDX Hawaii PPO	$4,815.08
Rate for Payer: University Health Alliance Commercial	$2,779.84

PLATE LCP 3.5/14H/R 02.127.260

Facility

$4,964.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$2,779.84
Max. Negotiated Rate	$4,815.08
Rate for Payer: Cash Price	$2,978.40
Rate for Payer: Hawaii Western Management Group Commercial	$3,474.80
Rate for Payer: Health Management Network Commercial	$4,219.40
Rate for Payer: Kaiser Permanente Commercial	$4,467.60
Rate for Payer: MDX Hawaii PPO	$4,815.08
Rate for Payer: University Health Alliance Commercial	$2,779.84

PLATE LCP 3.5/14H/R 02.127.260

Facility

$4,964.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$2,482.00
Max. Negotiated Rate	$4,815.08
Rate for Payer: AlohaCare Medicaid	$2,482.00
Rate for Payer: AlohaCare Medicare	$3,772.64
Rate for Payer: Cash Price	$2,978.40
Rate for Payer: Devoted Health Medicare	$4,169.76
Rate for Payer: Hawaii Medical Service Association Medicare	$3,772.64
Rate for Payer: Hawaii Western Management Group Commercial	$3,474.80
Rate for Payer: Health Management Network Commercial	$4,219.40
Rate for Payer: Humana Medicare	$3,772.64
Rate for Payer: Kaiser Permanente Commercial	$4,467.60
Rate for Payer: Kaiser Permanente Medicaid	$2,531.64
Rate for Payer: Kaiser Permanente Medicare	$3,772.64
Rate for Payer: MDX Hawaii PPO	$4,815.08
Rate for Payer: Ohana Health Plan Medicaid	$3,772.64
Rate for Payer: Ohana Health Plan Medicare	$3,772.64
Rate for Payer: UnitedHealthcare Medicare	$3,772.64
Rate for Payer: University Health Alliance Commercial	$2,779.84

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