Honoka'a Hospital and Skilled Nursing Facility

All Charges

Charge

Type

Setting

Price

PLATE LCP 3.5/8H/LT 02.112.031

Facility

$3,160.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,580.00
Max. Negotiated Rate	$3,065.20
Rate for Payer: AlohaCare Medicaid	$1,580.00
Rate for Payer: AlohaCare Medicare	$2,401.60
Rate for Payer: Cash Price	$1,896.00
Rate for Payer: Devoted Health Medicare	$2,654.40
Rate for Payer: Hawaii Medical Service Association Medicare	$2,401.60
Rate for Payer: Hawaii Western Management Group Commercial	$2,212.00
Rate for Payer: Health Management Network Commercial	$2,686.00
Rate for Payer: Humana Medicare	$2,401.60
Rate for Payer: Kaiser Permanente Commercial	$2,844.00
Rate for Payer: Kaiser Permanente Medicaid	$1,611.60
Rate for Payer: Kaiser Permanente Medicare	$2,401.60
Rate for Payer: MDX Hawaii PPO	$3,065.20
Rate for Payer: Ohana Health Plan Medicaid	$2,401.60
Rate for Payer: Ohana Health Plan Medicare	$2,401.60
Rate for Payer: UnitedHealthcare Medicare	$2,401.60
Rate for Payer: University Health Alliance Commercial	$1,769.60

PLATE LCP 3.5/8H/LT 02.112.031

Facility

$3,160.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,769.60
Max. Negotiated Rate	$3,065.20
Rate for Payer: Cash Price	$1,896.00
Rate for Payer: Hawaii Western Management Group Commercial	$2,212.00
Rate for Payer: Health Management Network Commercial	$2,686.00
Rate for Payer: Kaiser Permanente Commercial	$2,844.00
Rate for Payer: MDX Hawaii PPO	$3,065.20
Rate for Payer: University Health Alliance Commercial	$1,769.60

PLATE LCP 3.5/8H/LT 02.112.085

Facility

$3,610.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,805.00
Max. Negotiated Rate	$3,501.70
Rate for Payer: AlohaCare Medicaid	$1,805.00
Rate for Payer: AlohaCare Medicare	$2,743.60
Rate for Payer: Cash Price	$2,166.00
Rate for Payer: Devoted Health Medicare	$3,032.40
Rate for Payer: Hawaii Medical Service Association Medicare	$2,743.60
Rate for Payer: Hawaii Western Management Group Commercial	$2,527.00
Rate for Payer: Health Management Network Commercial	$3,068.50
Rate for Payer: Humana Medicare	$2,743.60
Rate for Payer: Kaiser Permanente Commercial	$3,249.00
Rate for Payer: Kaiser Permanente Medicaid	$1,841.10
Rate for Payer: Kaiser Permanente Medicare	$2,743.60
Rate for Payer: MDX Hawaii PPO	$3,501.70
Rate for Payer: Ohana Health Plan Medicaid	$2,743.60
Rate for Payer: Ohana Health Plan Medicare	$2,743.60
Rate for Payer: UnitedHealthcare Medicare	$2,743.60
Rate for Payer: University Health Alliance Commercial	$2,021.60

PLATE LCP 3.5/8H/LT 02.112.085

Facility

$3,610.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$2,021.60
Max. Negotiated Rate	$3,501.70
Rate for Payer: Cash Price	$2,166.00
Rate for Payer: Hawaii Western Management Group Commercial	$2,527.00
Rate for Payer: Health Management Network Commercial	$3,068.50
Rate for Payer: Kaiser Permanente Commercial	$3,249.00
Rate for Payer: MDX Hawaii PPO	$3,501.70
Rate for Payer: University Health Alliance Commercial	$2,021.60

PLATE LCP 3.5/8H/LT 02.127.231

Facility

$4,215.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$2,107.50
Max. Negotiated Rate	$4,088.55
Rate for Payer: AlohaCare Medicaid	$2,107.50
Rate for Payer: AlohaCare Medicare	$3,203.40
Rate for Payer: Cash Price	$2,529.00
Rate for Payer: Devoted Health Medicare	$3,540.60
Rate for Payer: Hawaii Medical Service Association Medicare	$3,203.40
Rate for Payer: Hawaii Western Management Group Commercial	$2,950.50
Rate for Payer: Health Management Network Commercial	$3,582.75
Rate for Payer: Humana Medicare	$3,203.40
Rate for Payer: Kaiser Permanente Commercial	$3,793.50
Rate for Payer: Kaiser Permanente Medicaid	$2,149.65
Rate for Payer: Kaiser Permanente Medicare	$3,203.40
Rate for Payer: MDX Hawaii PPO	$4,088.55
Rate for Payer: Ohana Health Plan Medicaid	$3,203.40
Rate for Payer: Ohana Health Plan Medicare	$3,203.40
Rate for Payer: UnitedHealthcare Medicare	$3,203.40
Rate for Payer: University Health Alliance Commercial	$2,360.40

PLATE LCP 3.5/8H/LT 02.127.231

Facility

$4,215.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$2,360.40
Max. Negotiated Rate	$4,088.55
Rate for Payer: Cash Price	$2,529.00
Rate for Payer: Hawaii Western Management Group Commercial	$2,950.50
Rate for Payer: Health Management Network Commercial	$3,582.75
Rate for Payer: Kaiser Permanente Commercial	$3,793.50
Rate for Payer: MDX Hawaii PPO	$4,088.55
Rate for Payer: University Health Alliance Commercial	$2,360.40

PLATE LCP 3.5/8H/R 02.127.330

Facility

$4,215.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$2,107.50
Max. Negotiated Rate	$4,088.55
Rate for Payer: AlohaCare Medicaid	$2,107.50
Rate for Payer: AlohaCare Medicare	$3,203.40
Rate for Payer: Cash Price	$2,529.00
Rate for Payer: Devoted Health Medicare	$3,540.60
Rate for Payer: Hawaii Medical Service Association Medicare	$3,203.40
Rate for Payer: Hawaii Western Management Group Commercial	$2,950.50
Rate for Payer: Health Management Network Commercial	$3,582.75
Rate for Payer: Humana Medicare	$3,203.40
Rate for Payer: Kaiser Permanente Commercial	$3,793.50
Rate for Payer: Kaiser Permanente Medicaid	$2,149.65
Rate for Payer: Kaiser Permanente Medicare	$3,203.40
Rate for Payer: MDX Hawaii PPO	$4,088.55
Rate for Payer: Ohana Health Plan Medicaid	$3,203.40
Rate for Payer: Ohana Health Plan Medicare	$3,203.40
Rate for Payer: UnitedHealthcare Medicare	$3,203.40
Rate for Payer: University Health Alliance Commercial	$2,360.40

PLATE LCP 3.5/8H/R 02.127.330

Facility

$4,215.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$2,360.40
Max. Negotiated Rate	$4,088.55
Rate for Payer: Cash Price	$2,529.00
Rate for Payer: Hawaii Western Management Group Commercial	$2,950.50
Rate for Payer: Health Management Network Commercial	$3,582.75
Rate for Payer: Kaiser Permanente Commercial	$3,793.50
Rate for Payer: MDX Hawaii PPO	$4,088.55
Rate for Payer: University Health Alliance Commercial	$2,360.40

PLATE LCP 3.5/8H/RT 02.112.020

Facility

$3,160.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,580.00
Max. Negotiated Rate	$3,065.20
Rate for Payer: AlohaCare Medicaid	$1,580.00
Rate for Payer: AlohaCare Medicare	$2,401.60
Rate for Payer: Cash Price	$1,896.00
Rate for Payer: Devoted Health Medicare	$2,654.40
Rate for Payer: Hawaii Medical Service Association Medicare	$2,401.60
Rate for Payer: Hawaii Western Management Group Commercial	$2,212.00
Rate for Payer: Health Management Network Commercial	$2,686.00
Rate for Payer: Humana Medicare	$2,401.60
Rate for Payer: Kaiser Permanente Commercial	$2,844.00
Rate for Payer: Kaiser Permanente Medicaid	$1,611.60
Rate for Payer: Kaiser Permanente Medicare	$2,401.60
Rate for Payer: MDX Hawaii PPO	$3,065.20
Rate for Payer: Ohana Health Plan Medicaid	$2,401.60
Rate for Payer: Ohana Health Plan Medicare	$2,401.60
Rate for Payer: UnitedHealthcare Medicare	$2,401.60
Rate for Payer: University Health Alliance Commercial	$1,769.60

PLATE LCP 3.5/8H/RT 02.112.020

Facility

$3,160.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,769.60
Max. Negotiated Rate	$3,065.20
Rate for Payer: Cash Price	$1,896.00
Rate for Payer: Hawaii Western Management Group Commercial	$2,212.00
Rate for Payer: Health Management Network Commercial	$2,686.00
Rate for Payer: Kaiser Permanente Commercial	$2,844.00
Rate for Payer: MDX Hawaii PPO	$3,065.20
Rate for Payer: University Health Alliance Commercial	$1,769.60

PLATE LCP 3.5/8H/RT 02.112.030

Facility

$2,277.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,275.12
Max. Negotiated Rate	$2,208.69
Rate for Payer: Cash Price	$1,366.20
Rate for Payer: Hawaii Western Management Group Commercial	$1,593.90
Rate for Payer: Health Management Network Commercial	$1,935.45
Rate for Payer: Kaiser Permanente Commercial	$2,049.30
Rate for Payer: MDX Hawaii PPO	$2,208.69
Rate for Payer: University Health Alliance Commercial	$1,275.12

PLATE LCP 3.5/8H/RT 02.112.030

Facility

$2,277.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,138.50
Max. Negotiated Rate	$2,208.69
Rate for Payer: AlohaCare Medicaid	$1,138.50
Rate for Payer: AlohaCare Medicare	$1,730.52
Rate for Payer: Cash Price	$1,366.20
Rate for Payer: Devoted Health Medicare	$1,912.68
Rate for Payer: Hawaii Medical Service Association Medicare	$1,730.52
Rate for Payer: Hawaii Western Management Group Commercial	$1,593.90
Rate for Payer: Health Management Network Commercial	$1,935.45
Rate for Payer: Humana Medicare	$1,730.52
Rate for Payer: Kaiser Permanente Commercial	$2,049.30
Rate for Payer: Kaiser Permanente Medicaid	$1,161.27
Rate for Payer: Kaiser Permanente Medicare	$1,730.52
Rate for Payer: MDX Hawaii PPO	$2,208.69
Rate for Payer: Ohana Health Plan Medicaid	$1,730.52
Rate for Payer: Ohana Health Plan Medicare	$1,730.52
Rate for Payer: UnitedHealthcare Medicare	$1,730.52
Rate for Payer: University Health Alliance Commercial	$1,275.12

PLATE LCP 3.5/8H/RT 02.112.084

Facility

$3,160.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,769.60
Max. Negotiated Rate	$3,065.20
Rate for Payer: Cash Price	$1,896.00
Rate for Payer: Hawaii Western Management Group Commercial	$2,212.00
Rate for Payer: Health Management Network Commercial	$2,686.00
Rate for Payer: Kaiser Permanente Commercial	$2,844.00
Rate for Payer: MDX Hawaii PPO	$3,065.20
Rate for Payer: University Health Alliance Commercial	$1,769.60

PLATE LCP 3.5/8H/RT 02.112.084

Facility

$3,160.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,580.00
Max. Negotiated Rate	$3,065.20
Rate for Payer: AlohaCare Medicaid	$1,580.00
Rate for Payer: AlohaCare Medicare	$2,401.60
Rate for Payer: Cash Price	$1,896.00
Rate for Payer: Devoted Health Medicare	$2,654.40
Rate for Payer: Hawaii Medical Service Association Medicare	$2,401.60
Rate for Payer: Hawaii Western Management Group Commercial	$2,212.00
Rate for Payer: Health Management Network Commercial	$2,686.00
Rate for Payer: Humana Medicare	$2,401.60
Rate for Payer: Kaiser Permanente Commercial	$2,844.00
Rate for Payer: Kaiser Permanente Medicaid	$1,611.60
Rate for Payer: Kaiser Permanente Medicare	$2,401.60
Rate for Payer: MDX Hawaii PPO	$3,065.20
Rate for Payer: Ohana Health Plan Medicaid	$2,401.60
Rate for Payer: Ohana Health Plan Medicare	$2,401.60
Rate for Payer: UnitedHealthcare Medicare	$2,401.60
Rate for Payer: University Health Alliance Commercial	$1,769.60

PLATE LCP 3.5/8H/RT 02.127.230

Facility

$4,215.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$2,360.40
Max. Negotiated Rate	$4,088.55
Rate for Payer: Cash Price	$2,529.00
Rate for Payer: Hawaii Western Management Group Commercial	$2,950.50
Rate for Payer: Health Management Network Commercial	$3,582.75
Rate for Payer: Kaiser Permanente Commercial	$3,793.50
Rate for Payer: MDX Hawaii PPO	$4,088.55
Rate for Payer: University Health Alliance Commercial	$2,360.40

PLATE LCP 3.5/8H/RT 02.127.230

Facility

$4,215.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$2,107.50
Max. Negotiated Rate	$4,088.55
Rate for Payer: AlohaCare Medicaid	$2,107.50
Rate for Payer: AlohaCare Medicare	$3,203.40
Rate for Payer: Cash Price	$2,529.00
Rate for Payer: Devoted Health Medicare	$3,540.60
Rate for Payer: Hawaii Medical Service Association Medicare	$3,203.40
Rate for Payer: Hawaii Western Management Group Commercial	$2,950.50
Rate for Payer: Health Management Network Commercial	$3,582.75
Rate for Payer: Humana Medicare	$3,203.40
Rate for Payer: Kaiser Permanente Commercial	$3,793.50
Rate for Payer: Kaiser Permanente Medicaid	$2,149.65
Rate for Payer: Kaiser Permanente Medicare	$3,203.40
Rate for Payer: MDX Hawaii PPO	$4,088.55
Rate for Payer: Ohana Health Plan Medicaid	$3,203.40
Rate for Payer: Ohana Health Plan Medicare	$3,203.40
Rate for Payer: UnitedHealthcare Medicare	$3,203.40
Rate for Payer: University Health Alliance Commercial	$2,360.40

PLATE LCP 3.5 CLAVICLE HOOK

Facility

$2,662.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,490.72
Max. Negotiated Rate	$2,582.14
Rate for Payer: Cash Price	$1,597.20
Rate for Payer: Cash Price	$1,552.80
Rate for Payer: Cash Price	$1,484.40
Rate for Payer: Cash Price	$1,664.40
Rate for Payer: Cash Price	$1,797.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,941.80
Rate for Payer: Hawaii Western Management Group Commercial	$1,731.80
Rate for Payer: Hawaii Western Management Group Commercial	$1,811.60
Rate for Payer: Hawaii Western Management Group Commercial	$1,863.40
Rate for Payer: Hawaii Western Management Group Commercial	$2,096.50
Rate for Payer: Health Management Network Commercial	$2,357.90
Rate for Payer: Health Management Network Commercial	$2,545.75
Rate for Payer: Health Management Network Commercial	$2,102.90
Rate for Payer: Health Management Network Commercial	$2,199.80
Rate for Payer: Health Management Network Commercial	$2,262.70
Rate for Payer: Kaiser Permanente Commercial	$2,329.20
Rate for Payer: Kaiser Permanente Commercial	$2,226.60
Rate for Payer: Kaiser Permanente Commercial	$2,395.80
Rate for Payer: Kaiser Permanente Commercial	$2,496.60
Rate for Payer: Kaiser Permanente Commercial	$2,695.50
Rate for Payer: MDX Hawaii PPO	$2,510.36
Rate for Payer: MDX Hawaii PPO	$2,399.78
Rate for Payer: MDX Hawaii PPO	$2,582.14
Rate for Payer: MDX Hawaii PPO	$2,690.78
Rate for Payer: MDX Hawaii PPO	$2,905.15
Rate for Payer: University Health Alliance Commercial	$1,490.72
Rate for Payer: University Health Alliance Commercial	$1,449.28
Rate for Payer: University Health Alliance Commercial	$1,385.44
Rate for Payer: University Health Alliance Commercial	$1,677.20
Rate for Payer: University Health Alliance Commercial	$1,553.44

PLATE LCP 3.5 CLAVICLE HOOK

Facility

$2,774.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,387.00
Max. Negotiated Rate	$2,690.78
Rate for Payer: AlohaCare Medicaid	$1,387.00
Rate for Payer: AlohaCare Medicaid	$1,331.00
Rate for Payer: AlohaCare Medicaid	$1,497.50
Rate for Payer: AlohaCare Medicaid	$1,294.00
Rate for Payer: AlohaCare Medicaid	$1,237.00
Rate for Payer: AlohaCare Medicare	$1,880.24
Rate for Payer: AlohaCare Medicare	$2,023.12
Rate for Payer: AlohaCare Medicare	$2,108.24
Rate for Payer: AlohaCare Medicare	$2,276.20
Rate for Payer: AlohaCare Medicare	$1,966.88
Rate for Payer: Cash Price	$1,664.40
Rate for Payer: Cash Price	$1,597.20
Rate for Payer: Cash Price	$1,552.80
Rate for Payer: Cash Price	$1,484.40
Rate for Payer: Cash Price	$1,797.00
Rate for Payer: Devoted Health Medicare	$2,236.08
Rate for Payer: Devoted Health Medicare	$2,173.92
Rate for Payer: Devoted Health Medicare	$2,515.80
Rate for Payer: Devoted Health Medicare	$2,330.16
Rate for Payer: Devoted Health Medicare	$2,078.16
Rate for Payer: Hawaii Medical Service Association Medicare	$1,880.24
Rate for Payer: Hawaii Medical Service Association Medicare	$2,276.20
Rate for Payer: Hawaii Medical Service Association Medicare	$1,966.88
Rate for Payer: Hawaii Medical Service Association Medicare	$2,108.24
Rate for Payer: Hawaii Medical Service Association Medicare	$2,023.12
Rate for Payer: Hawaii Western Management Group Commercial	$2,096.50
Rate for Payer: Hawaii Western Management Group Commercial	$1,731.80
Rate for Payer: Hawaii Western Management Group Commercial	$1,811.60
Rate for Payer: Hawaii Western Management Group Commercial	$1,863.40
Rate for Payer: Hawaii Western Management Group Commercial	$1,941.80
Rate for Payer: Health Management Network Commercial	$2,357.90
Rate for Payer: Health Management Network Commercial	$2,102.90
Rate for Payer: Health Management Network Commercial	$2,262.70
Rate for Payer: Health Management Network Commercial	$2,199.80
Rate for Payer: Health Management Network Commercial	$2,545.75
Rate for Payer: Humana Medicare	$1,880.24
Rate for Payer: Humana Medicare	$1,966.88
Rate for Payer: Humana Medicare	$2,023.12
Rate for Payer: Humana Medicare	$2,108.24
Rate for Payer: Humana Medicare	$2,276.20
Rate for Payer: Kaiser Permanente Commercial	$2,329.20
Rate for Payer: Kaiser Permanente Commercial	$2,695.50
Rate for Payer: Kaiser Permanente Commercial	$2,226.60
Rate for Payer: Kaiser Permanente Commercial	$2,395.80
Rate for Payer: Kaiser Permanente Commercial	$2,496.60
Rate for Payer: Kaiser Permanente Medicaid	$1,261.74
Rate for Payer: Kaiser Permanente Medicaid	$1,319.88
Rate for Payer: Kaiser Permanente Medicaid	$1,357.62
Rate for Payer: Kaiser Permanente Medicaid	$1,414.74
Rate for Payer: Kaiser Permanente Medicaid	$1,527.45
Rate for Payer: Kaiser Permanente Medicare	$1,880.24
Rate for Payer: Kaiser Permanente Medicare	$2,108.24
Rate for Payer: Kaiser Permanente Medicare	$2,023.12
Rate for Payer: Kaiser Permanente Medicare	$1,966.88
Rate for Payer: Kaiser Permanente Medicare	$2,276.20
Rate for Payer: MDX Hawaii PPO	$2,399.78
Rate for Payer: MDX Hawaii PPO	$2,582.14
Rate for Payer: MDX Hawaii PPO	$2,510.36
Rate for Payer: MDX Hawaii PPO	$2,905.15
Rate for Payer: MDX Hawaii PPO	$2,690.78
Rate for Payer: Ohana Health Plan Medicaid	$2,023.12
Rate for Payer: Ohana Health Plan Medicaid	$1,880.24
Rate for Payer: Ohana Health Plan Medicaid	$2,108.24
Rate for Payer: Ohana Health Plan Medicaid	$2,276.20
Rate for Payer: Ohana Health Plan Medicaid	$1,966.88
Rate for Payer: Ohana Health Plan Medicare	$2,108.24
Rate for Payer: Ohana Health Plan Medicare	$2,276.20
Rate for Payer: Ohana Health Plan Medicare	$1,966.88
Rate for Payer: Ohana Health Plan Medicare	$1,880.24
Rate for Payer: Ohana Health Plan Medicare	$2,023.12
Rate for Payer: UnitedHealthcare Medicare	$1,966.88
Rate for Payer: UnitedHealthcare Medicare	$2,276.20
Rate for Payer: UnitedHealthcare Medicare	$2,023.12
Rate for Payer: UnitedHealthcare Medicare	$1,880.24
Rate for Payer: UnitedHealthcare Medicare	$2,108.24
Rate for Payer: University Health Alliance Commercial	$1,553.44
Rate for Payer: University Health Alliance Commercial	$1,490.72
Rate for Payer: University Health Alliance Commercial	$1,677.20
Rate for Payer: University Health Alliance Commercial	$1,385.44
Rate for Payer: University Health Alliance Commercial	$1,449.28

PLATE LCP 3.5M 02.112.042

Facility

$2,277.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,138.50
Max. Negotiated Rate	$2,208.69
Rate for Payer: AlohaCare Medicaid	$1,138.50
Rate for Payer: AlohaCare Medicare	$1,730.52
Rate for Payer: Cash Price	$1,366.20
Rate for Payer: Devoted Health Medicare	$1,912.68
Rate for Payer: Hawaii Medical Service Association Medicare	$1,730.52
Rate for Payer: Hawaii Western Management Group Commercial	$1,593.90
Rate for Payer: Health Management Network Commercial	$1,935.45
Rate for Payer: Humana Medicare	$1,730.52
Rate for Payer: Kaiser Permanente Commercial	$2,049.30
Rate for Payer: Kaiser Permanente Medicaid	$1,161.27
Rate for Payer: Kaiser Permanente Medicare	$1,730.52
Rate for Payer: MDX Hawaii PPO	$2,208.69
Rate for Payer: Ohana Health Plan Medicaid	$1,730.52
Rate for Payer: Ohana Health Plan Medicare	$1,730.52
Rate for Payer: UnitedHealthcare Medicare	$1,730.52
Rate for Payer: University Health Alliance Commercial	$1,275.12

PLATE LCP 3.5M 02.112.042

Facility

$2,277.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,275.12
Max. Negotiated Rate	$2,208.69
Rate for Payer: Cash Price	$1,366.20
Rate for Payer: Hawaii Western Management Group Commercial	$1,593.90
Rate for Payer: Health Management Network Commercial	$1,935.45
Rate for Payer: Kaiser Permanente Commercial	$2,049.30
Rate for Payer: MDX Hawaii PPO	$2,208.69
Rate for Payer: University Health Alliance Commercial	$1,275.12

PLATE LCP 3.5X86MM RT 236.502

Facility

$2,073.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,160.88
Max. Negotiated Rate	$2,010.81
Rate for Payer: Cash Price	$1,243.80
Rate for Payer: Hawaii Western Management Group Commercial	$1,451.10
Rate for Payer: Health Management Network Commercial	$1,762.05
Rate for Payer: Kaiser Permanente Commercial	$1,865.70
Rate for Payer: MDX Hawaii PPO	$2,010.81
Rate for Payer: University Health Alliance Commercial	$1,160.88

PLATE LCP 3.5X86MM RT 236.502

Facility

$2,073.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,036.50
Max. Negotiated Rate	$2,010.81
Rate for Payer: AlohaCare Medicaid	$1,036.50
Rate for Payer: AlohaCare Medicare	$1,575.48
Rate for Payer: Cash Price	$1,243.80
Rate for Payer: Devoted Health Medicare	$1,741.32
Rate for Payer: Hawaii Medical Service Association Medicare	$1,575.48
Rate for Payer: Hawaii Western Management Group Commercial	$1,451.10
Rate for Payer: Health Management Network Commercial	$1,762.05
Rate for Payer: Humana Medicare	$1,575.48
Rate for Payer: Kaiser Permanente Commercial	$1,865.70
Rate for Payer: Kaiser Permanente Medicaid	$1,057.23
Rate for Payer: Kaiser Permanente Medicare	$1,575.48
Rate for Payer: MDX Hawaii PPO	$2,010.81
Rate for Payer: Ohana Health Plan Medicaid	$1,575.48
Rate for Payer: Ohana Health Plan Medicare	$1,575.48
Rate for Payer: UnitedHealthcare Medicare	$1,575.48
Rate for Payer: University Health Alliance Commercial	$1,160.88

PLATE LCP 3H 3.5X90MM 241.901

Facility

$3,409.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,704.50
Max. Negotiated Rate	$3,306.73
Rate for Payer: AlohaCare Medicaid	$1,704.50
Rate for Payer: AlohaCare Medicare	$2,590.84
Rate for Payer: Cash Price	$2,045.40
Rate for Payer: Devoted Health Medicare	$2,863.56
Rate for Payer: Hawaii Medical Service Association Medicare	$2,590.84
Rate for Payer: Hawaii Western Management Group Commercial	$2,386.30
Rate for Payer: Health Management Network Commercial	$2,897.65
Rate for Payer: Humana Medicare	$2,590.84
Rate for Payer: Kaiser Permanente Commercial	$3,068.10
Rate for Payer: Kaiser Permanente Medicaid	$1,738.59
Rate for Payer: Kaiser Permanente Medicare	$2,590.84
Rate for Payer: MDX Hawaii PPO	$3,306.73
Rate for Payer: Ohana Health Plan Medicaid	$2,590.84
Rate for Payer: Ohana Health Plan Medicare	$2,590.84
Rate for Payer: UnitedHealthcare Medicare	$2,590.84
Rate for Payer: University Health Alliance Commercial	$1,909.04

PLATE LCP 3H 3.5X90MM 241.901

Facility

$3,409.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,909.04
Max. Negotiated Rate	$3,306.73
Rate for Payer: Cash Price	$2,045.40
Rate for Payer: Hawaii Western Management Group Commercial	$2,386.30
Rate for Payer: Health Management Network Commercial	$2,897.65
Rate for Payer: Kaiser Permanente Commercial	$3,068.10
Rate for Payer: MDX Hawaii PPO	$3,306.73
Rate for Payer: University Health Alliance Commercial	$1,909.04

PLATE LCP 3H 4.5X62MM 224.531

Facility

$1,694.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$847.00
Max. Negotiated Rate	$1,643.18
Rate for Payer: Kaiser Permanente Medicare	$1,287.44
Rate for Payer: AlohaCare Medicaid	$847.00
Rate for Payer: AlohaCare Medicare	$1,287.44
Rate for Payer: Cash Price	$1,016.40
Rate for Payer: Devoted Health Medicare	$1,422.96
Rate for Payer: Hawaii Medical Service Association Medicare	$1,287.44
Rate for Payer: Hawaii Western Management Group Commercial	$1,185.80
Rate for Payer: Health Management Network Commercial	$1,439.90
Rate for Payer: Humana Medicare	$1,287.44
Rate for Payer: Kaiser Permanente Commercial	$1,524.60
Rate for Payer: Kaiser Permanente Medicaid	$863.94
Rate for Payer: MDX Hawaii PPO	$1,643.18
Rate for Payer: Ohana Health Plan Medicaid	$1,287.44
Rate for Payer: Ohana Health Plan Medicare	$1,287.44
Rate for Payer: UnitedHealthcare Medicare	$1,287.44
Rate for Payer: University Health Alliance Commercial	$948.64

Know your out-of-pocket cost for care.

All Charges