Honoka'a Hospital and Skilled Nursing Facility

All Charges

Charge

Type

Setting

Price

PLATE LCP FIB-R 6H 02.118.406

Facility

$2,020.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,010.00
Max. Negotiated Rate	$1,959.40
Rate for Payer: AlohaCare Medicaid	$1,010.00
Rate for Payer: AlohaCare Medicare	$1,535.20
Rate for Payer: Cash Price	$1,212.00
Rate for Payer: Devoted Health Medicare	$1,696.80
Rate for Payer: Hawaii Medical Service Association Medicare	$1,535.20
Rate for Payer: Hawaii Western Management Group Commercial	$1,414.00
Rate for Payer: Health Management Network Commercial	$1,717.00
Rate for Payer: Humana Medicare	$1,535.20
Rate for Payer: Kaiser Permanente Commercial	$1,818.00
Rate for Payer: Kaiser Permanente Medicaid	$1,030.20
Rate for Payer: Kaiser Permanente Medicare	$1,535.20
Rate for Payer: MDX Hawaii PPO	$1,959.40
Rate for Payer: Ohana Health Plan Medicaid	$1,535.20
Rate for Payer: Ohana Health Plan Medicare	$1,535.20
Rate for Payer: UnitedHealthcare Medicare	$1,535.20
Rate for Payer: University Health Alliance Commercial	$1,131.20

PLATE LCP FIB-R 7H 02.118.408

Facility

$2,116.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,058.00
Max. Negotiated Rate	$2,052.52
Rate for Payer: AlohaCare Medicaid	$1,058.00
Rate for Payer: AlohaCare Medicare	$1,608.16
Rate for Payer: Cash Price	$1,269.60
Rate for Payer: Devoted Health Medicare	$1,777.44
Rate for Payer: Hawaii Medical Service Association Medicare	$1,608.16
Rate for Payer: Hawaii Western Management Group Commercial	$1,481.20
Rate for Payer: Health Management Network Commercial	$1,798.60
Rate for Payer: Humana Medicare	$1,608.16
Rate for Payer: Kaiser Permanente Commercial	$1,904.40
Rate for Payer: Kaiser Permanente Medicaid	$1,079.16
Rate for Payer: Kaiser Permanente Medicare	$1,608.16
Rate for Payer: MDX Hawaii PPO	$2,052.52
Rate for Payer: Ohana Health Plan Medicaid	$1,608.16
Rate for Payer: Ohana Health Plan Medicare	$1,608.16
Rate for Payer: UnitedHealthcare Medicare	$1,608.16
Rate for Payer: University Health Alliance Commercial	$1,184.96

PLATE LCP FIB-R 7H 02.118.408

Facility

$2,116.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,184.96
Max. Negotiated Rate	$2,052.52
Rate for Payer: Cash Price	$1,269.60
Rate for Payer: Hawaii Western Management Group Commercial	$1,481.20
Rate for Payer: Health Management Network Commercial	$1,798.60
Rate for Payer: Kaiser Permanente Commercial	$1,904.40
Rate for Payer: MDX Hawaii PPO	$2,052.52
Rate for Payer: University Health Alliance Commercial	$1,184.96

PLATE LCP-LT 10H 4.5MM 222.661

Facility

$3,709.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,854.50
Max. Negotiated Rate	$3,597.73
Rate for Payer: AlohaCare Medicaid	$1,854.50
Rate for Payer: AlohaCare Medicare	$2,818.84
Rate for Payer: Cash Price	$2,225.40
Rate for Payer: Devoted Health Medicare	$3,115.56
Rate for Payer: Hawaii Medical Service Association Medicare	$2,818.84
Rate for Payer: Hawaii Western Management Group Commercial	$2,596.30
Rate for Payer: Health Management Network Commercial	$3,152.65
Rate for Payer: Humana Medicare	$2,818.84
Rate for Payer: Kaiser Permanente Commercial	$3,338.10
Rate for Payer: Kaiser Permanente Medicaid	$1,891.59
Rate for Payer: Kaiser Permanente Medicare	$2,818.84
Rate for Payer: MDX Hawaii PPO	$3,597.73
Rate for Payer: Ohana Health Plan Medicaid	$2,818.84
Rate for Payer: Ohana Health Plan Medicare	$2,818.84
Rate for Payer: UnitedHealthcare Medicare	$2,818.84
Rate for Payer: University Health Alliance Commercial	$2,077.04

PLATE LCP-LT 10H 4.5MM 222.661

Facility

$3,709.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$2,077.04
Max. Negotiated Rate	$3,597.73
Rate for Payer: Cash Price	$2,225.40
Rate for Payer: Hawaii Western Management Group Commercial	$2,596.30
Rate for Payer: Health Management Network Commercial	$3,152.65
Rate for Payer: Kaiser Permanente Commercial	$3,338.10
Rate for Payer: MDX Hawaii PPO	$3,597.73
Rate for Payer: University Health Alliance Commercial	$2,077.04

PLATE LCP-LT 10H 4.5MM 240.043

Facility

$4,328.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$2,164.00
Max. Negotiated Rate	$4,198.16
Rate for Payer: AlohaCare Medicaid	$2,164.00
Rate for Payer: AlohaCare Medicare	$3,289.28
Rate for Payer: Cash Price	$2,596.80
Rate for Payer: Devoted Health Medicare	$3,635.52
Rate for Payer: Hawaii Medical Service Association Medicare	$3,289.28
Rate for Payer: Hawaii Western Management Group Commercial	$3,029.60
Rate for Payer: Health Management Network Commercial	$3,678.80
Rate for Payer: Humana Medicare	$3,289.28
Rate for Payer: Kaiser Permanente Commercial	$3,895.20
Rate for Payer: Kaiser Permanente Medicaid	$2,207.28
Rate for Payer: Kaiser Permanente Medicare	$3,289.28
Rate for Payer: MDX Hawaii PPO	$4,198.16
Rate for Payer: Ohana Health Plan Medicaid	$3,289.28
Rate for Payer: Ohana Health Plan Medicare	$3,289.28
Rate for Payer: UnitedHealthcare Medicare	$3,289.28
Rate for Payer: University Health Alliance Commercial	$2,423.68

PLATE LCP-LT 10H 4.5MM 240.043

Facility

$4,328.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$2,423.68
Max. Negotiated Rate	$4,198.16
Rate for Payer: Cash Price	$2,596.80
Rate for Payer: Hawaii Western Management Group Commercial	$3,029.60
Rate for Payer: Health Management Network Commercial	$3,678.80
Rate for Payer: Kaiser Permanente Commercial	$3,895.20
Rate for Payer: MDX Hawaii PPO	$4,198.16
Rate for Payer: University Health Alliance Commercial	$2,423.68

PLATE LCP-LT 12H 4.5MM 222.663

Facility

$5,221.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$2,923.76
Max. Negotiated Rate	$5,064.37
Rate for Payer: Cash Price	$3,132.60
Rate for Payer: Hawaii Western Management Group Commercial	$3,654.70
Rate for Payer: Health Management Network Commercial	$4,437.85
Rate for Payer: Kaiser Permanente Commercial	$4,698.90
Rate for Payer: MDX Hawaii PPO	$5,064.37
Rate for Payer: University Health Alliance Commercial	$2,923.76

PLATE LCP-LT 12H 4.5MM 222.663

Facility

$5,221.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$2,610.50
Max. Negotiated Rate	$5,064.37
Rate for Payer: AlohaCare Medicaid	$2,610.50
Rate for Payer: AlohaCare Medicare	$3,967.96
Rate for Payer: Cash Price	$3,132.60
Rate for Payer: Devoted Health Medicare	$4,385.64
Rate for Payer: Hawaii Medical Service Association Medicare	$3,967.96
Rate for Payer: Hawaii Western Management Group Commercial	$3,654.70
Rate for Payer: Health Management Network Commercial	$4,437.85
Rate for Payer: Humana Medicare	$3,967.96
Rate for Payer: Kaiser Permanente Commercial	$4,698.90
Rate for Payer: Kaiser Permanente Medicaid	$2,662.71
Rate for Payer: Kaiser Permanente Medicare	$3,967.96
Rate for Payer: MDX Hawaii PPO	$5,064.37
Rate for Payer: Ohana Health Plan Medicaid	$3,967.96
Rate for Payer: Ohana Health Plan Medicare	$3,967.96
Rate for Payer: UnitedHealthcare Medicare	$3,967.96
Rate for Payer: University Health Alliance Commercial	$2,923.76

PLATE LCP-LT 12H 4.5MM 240.045

Facility

$4,380.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$2,452.80
Max. Negotiated Rate	$4,248.60
Rate for Payer: Cash Price	$2,628.00
Rate for Payer: Hawaii Western Management Group Commercial	$3,066.00
Rate for Payer: Health Management Network Commercial	$3,723.00
Rate for Payer: Kaiser Permanente Commercial	$3,942.00
Rate for Payer: MDX Hawaii PPO	$4,248.60
Rate for Payer: University Health Alliance Commercial	$2,452.80

PLATE LCP-LT 12H 4.5MM 240.045

Facility

$4,380.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$2,190.00
Max. Negotiated Rate	$4,248.60
Rate for Payer: AlohaCare Medicaid	$2,190.00
Rate for Payer: AlohaCare Medicare	$3,328.80
Rate for Payer: Cash Price	$2,628.00
Rate for Payer: Devoted Health Medicare	$3,679.20
Rate for Payer: Hawaii Medical Service Association Medicare	$3,328.80
Rate for Payer: Hawaii Western Management Group Commercial	$3,066.00
Rate for Payer: Health Management Network Commercial	$3,723.00
Rate for Payer: Humana Medicare	$3,328.80
Rate for Payer: Kaiser Permanente Commercial	$3,942.00
Rate for Payer: Kaiser Permanente Medicaid	$2,233.80
Rate for Payer: Kaiser Permanente Medicare	$3,328.80
Rate for Payer: MDX Hawaii PPO	$4,248.60
Rate for Payer: Ohana Health Plan Medicaid	$3,328.80
Rate for Payer: Ohana Health Plan Medicare	$3,328.80
Rate for Payer: UnitedHealthcare Medicare	$3,328.80
Rate for Payer: University Health Alliance Commercial	$2,452.80

PLATE LCP-LT 14H 4.5MM 222.665

Facility

$5,148.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$2,882.88
Max. Negotiated Rate	$4,993.56
Rate for Payer: Cash Price	$3,088.80
Rate for Payer: Hawaii Western Management Group Commercial	$3,603.60
Rate for Payer: Health Management Network Commercial	$4,375.80
Rate for Payer: Kaiser Permanente Commercial	$4,633.20
Rate for Payer: MDX Hawaii PPO	$4,993.56
Rate for Payer: University Health Alliance Commercial	$2,882.88

PLATE LCP-LT 14H 4.5MM 222.665

Facility

$5,148.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$2,574.00
Max. Negotiated Rate	$4,993.56
Rate for Payer: AlohaCare Medicaid	$2,574.00
Rate for Payer: AlohaCare Medicare	$3,912.48
Rate for Payer: Cash Price	$3,088.80
Rate for Payer: Devoted Health Medicare	$4,324.32
Rate for Payer: Hawaii Medical Service Association Medicare	$3,912.48
Rate for Payer: Hawaii Western Management Group Commercial	$3,603.60
Rate for Payer: Health Management Network Commercial	$4,375.80
Rate for Payer: Humana Medicare	$3,912.48
Rate for Payer: Kaiser Permanente Commercial	$4,633.20
Rate for Payer: Kaiser Permanente Medicaid	$2,625.48
Rate for Payer: Kaiser Permanente Medicare	$3,912.48
Rate for Payer: MDX Hawaii PPO	$4,993.56
Rate for Payer: Ohana Health Plan Medicaid	$3,912.48
Rate for Payer: Ohana Health Plan Medicare	$3,912.48
Rate for Payer: UnitedHealthcare Medicare	$3,912.48
Rate for Payer: University Health Alliance Commercial	$2,882.88

PLATE LCP-LT 14H 4.5MM 240.047

Facility

$4,426.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$2,213.00
Max. Negotiated Rate	$4,293.22
Rate for Payer: AlohaCare Medicaid	$2,213.00
Rate for Payer: AlohaCare Medicare	$3,363.76
Rate for Payer: Cash Price	$2,655.60
Rate for Payer: Devoted Health Medicare	$3,717.84
Rate for Payer: Hawaii Medical Service Association Medicare	$3,363.76
Rate for Payer: Hawaii Western Management Group Commercial	$3,098.20
Rate for Payer: Health Management Network Commercial	$3,762.10
Rate for Payer: Humana Medicare	$3,363.76
Rate for Payer: Kaiser Permanente Commercial	$3,983.40
Rate for Payer: Kaiser Permanente Medicaid	$2,257.26
Rate for Payer: Kaiser Permanente Medicare	$3,363.76
Rate for Payer: MDX Hawaii PPO	$4,293.22
Rate for Payer: Ohana Health Plan Medicaid	$3,363.76
Rate for Payer: Ohana Health Plan Medicare	$3,363.76
Rate for Payer: UnitedHealthcare Medicare	$3,363.76
Rate for Payer: University Health Alliance Commercial	$2,478.56

PLATE LCP-LT 14H 4.5MM 240.047

Facility

$4,426.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$2,478.56
Max. Negotiated Rate	$4,293.22
Rate for Payer: Cash Price	$2,655.60
Rate for Payer: Hawaii Western Management Group Commercial	$3,098.20
Rate for Payer: Health Management Network Commercial	$3,762.10
Rate for Payer: Kaiser Permanente Commercial	$3,983.40
Rate for Payer: MDX Hawaii PPO	$4,293.22
Rate for Payer: University Health Alliance Commercial	$2,478.56

PLATE LCP-LT 16H 4.5MM 222.667

Facility

$4,031.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$2,015.50
Max. Negotiated Rate	$3,910.07
Rate for Payer: AlohaCare Medicaid	$2,015.50
Rate for Payer: AlohaCare Medicare	$3,063.56
Rate for Payer: Cash Price	$2,418.60
Rate for Payer: Devoted Health Medicare	$3,386.04
Rate for Payer: Hawaii Medical Service Association Medicare	$3,063.56
Rate for Payer: Hawaii Western Management Group Commercial	$2,821.70
Rate for Payer: Health Management Network Commercial	$3,426.35
Rate for Payer: Humana Medicare	$3,063.56
Rate for Payer: Kaiser Permanente Commercial	$3,627.90
Rate for Payer: Kaiser Permanente Medicaid	$2,055.81
Rate for Payer: Kaiser Permanente Medicare	$3,063.56
Rate for Payer: MDX Hawaii PPO	$3,910.07
Rate for Payer: Ohana Health Plan Medicaid	$3,063.56
Rate for Payer: Ohana Health Plan Medicare	$3,063.56
Rate for Payer: UnitedHealthcare Medicare	$3,063.56
Rate for Payer: University Health Alliance Commercial	$2,257.36

PLATE LCP-LT 16H 4.5MM 222.667

Facility

$4,031.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$2,257.36
Max. Negotiated Rate	$3,910.07
Rate for Payer: Cash Price	$2,418.60
Rate for Payer: Hawaii Western Management Group Commercial	$2,821.70
Rate for Payer: Health Management Network Commercial	$3,426.35
Rate for Payer: Kaiser Permanente Commercial	$3,627.90
Rate for Payer: MDX Hawaii PPO	$3,910.07
Rate for Payer: University Health Alliance Commercial	$2,257.36

PLATE LCP-LT 18H 4.5MM 222.669

Facility

$5,356.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$2,678.00
Max. Negotiated Rate	$5,195.32
Rate for Payer: AlohaCare Medicaid	$2,678.00
Rate for Payer: AlohaCare Medicare	$4,070.56
Rate for Payer: Cash Price	$3,213.60
Rate for Payer: Devoted Health Medicare	$4,499.04
Rate for Payer: Hawaii Medical Service Association Medicare	$4,070.56
Rate for Payer: Hawaii Western Management Group Commercial	$3,749.20
Rate for Payer: Health Management Network Commercial	$4,552.60
Rate for Payer: Humana Medicare	$4,070.56
Rate for Payer: Kaiser Permanente Commercial	$4,820.40
Rate for Payer: Kaiser Permanente Medicaid	$2,731.56
Rate for Payer: Kaiser Permanente Medicare	$4,070.56
Rate for Payer: MDX Hawaii PPO	$5,195.32
Rate for Payer: Ohana Health Plan Medicaid	$4,070.56
Rate for Payer: Ohana Health Plan Medicare	$4,070.56
Rate for Payer: UnitedHealthcare Medicare	$4,070.56
Rate for Payer: University Health Alliance Commercial	$2,999.36

PLATE LCP-LT 18H 4.5MM 222.669

Facility

$5,356.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$2,999.36
Max. Negotiated Rate	$5,195.32
Rate for Payer: Cash Price	$3,213.60
Rate for Payer: Hawaii Western Management Group Commercial	$3,749.20
Rate for Payer: Health Management Network Commercial	$4,552.60
Rate for Payer: Kaiser Permanente Commercial	$4,820.40
Rate for Payer: MDX Hawaii PPO	$5,195.32
Rate for Payer: University Health Alliance Commercial	$2,999.36

PLATE LCP-LT 8H 4.5MM 240.041

Facility

$4,284.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$2,399.04
Max. Negotiated Rate	$4,155.48
Rate for Payer: Cash Price	$2,570.40
Rate for Payer: Hawaii Western Management Group Commercial	$2,998.80
Rate for Payer: Health Management Network Commercial	$3,641.40
Rate for Payer: Kaiser Permanente Commercial	$3,855.60
Rate for Payer: MDX Hawaii PPO	$4,155.48
Rate for Payer: University Health Alliance Commercial	$2,399.04

PLATE LCP-LT 8H 4.5MM 240.041

Facility

$4,284.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$2,142.00
Max. Negotiated Rate	$4,155.48
Rate for Payer: AlohaCare Medicaid	$2,142.00
Rate for Payer: AlohaCare Medicare	$3,255.84
Rate for Payer: Cash Price	$2,570.40
Rate for Payer: Devoted Health Medicare	$3,598.56
Rate for Payer: Hawaii Medical Service Association Medicare	$3,255.84
Rate for Payer: Hawaii Western Management Group Commercial	$2,998.80
Rate for Payer: Health Management Network Commercial	$3,641.40
Rate for Payer: Humana Medicare	$3,255.84
Rate for Payer: Kaiser Permanente Commercial	$3,855.60
Rate for Payer: Kaiser Permanente Medicaid	$2,184.84
Rate for Payer: Kaiser Permanente Medicare	$3,255.84
Rate for Payer: MDX Hawaii PPO	$4,155.48
Rate for Payer: Ohana Health Plan Medicaid	$3,255.84
Rate for Payer: Ohana Health Plan Medicare	$3,255.84
Rate for Payer: UnitedHealthcare Medicare	$3,255.84
Rate for Payer: University Health Alliance Commercial	$2,399.04

PLATE LCP PERIART PROX 3.5

Facility

$4,066.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$2,276.96
Max. Negotiated Rate	$3,944.02
Rate for Payer: Cash Price	$2,439.60
Rate for Payer: Hawaii Western Management Group Commercial	$2,846.20
Rate for Payer: Health Management Network Commercial	$3,456.10
Rate for Payer: Kaiser Permanente Commercial	$3,659.40
Rate for Payer: MDX Hawaii PPO	$3,944.02
Rate for Payer: University Health Alliance Commercial	$2,276.96

PLATE LCP PERIART PROX 3.5

Facility

$4,066.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$2,033.00
Max. Negotiated Rate	$3,944.02
Rate for Payer: AlohaCare Medicaid	$2,033.00
Rate for Payer: AlohaCare Medicare	$3,090.16
Rate for Payer: Cash Price	$2,439.60
Rate for Payer: Devoted Health Medicare	$3,415.44
Rate for Payer: Hawaii Medical Service Association Medicare	$3,090.16
Rate for Payer: Hawaii Western Management Group Commercial	$2,846.20
Rate for Payer: Health Management Network Commercial	$3,456.10
Rate for Payer: Humana Medicare	$3,090.16
Rate for Payer: Kaiser Permanente Commercial	$3,659.40
Rate for Payer: Kaiser Permanente Medicaid	$2,073.66
Rate for Payer: Kaiser Permanente Medicare	$3,090.16
Rate for Payer: MDX Hawaii PPO	$3,944.02
Rate for Payer: Ohana Health Plan Medicaid	$3,090.16
Rate for Payer: Ohana Health Plan Medicare	$3,090.16
Rate for Payer: UnitedHealthcare Medicare	$3,090.16
Rate for Payer: University Health Alliance Commercial	$2,276.96

PLATE LCP PROXI TIB 3.5MM

Facility

$3,836.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,918.00
Max. Negotiated Rate	$3,720.92
Rate for Payer: AlohaCare Medicaid	$1,918.00
Rate for Payer: AlohaCare Medicare	$2,915.36
Rate for Payer: Cash Price	$2,301.60
Rate for Payer: Devoted Health Medicare	$3,222.24
Rate for Payer: Hawaii Medical Service Association Medicare	$2,915.36
Rate for Payer: Hawaii Western Management Group Commercial	$2,685.20
Rate for Payer: Health Management Network Commercial	$3,260.60
Rate for Payer: Humana Medicare	$2,915.36
Rate for Payer: Kaiser Permanente Commercial	$3,452.40
Rate for Payer: Kaiser Permanente Medicaid	$1,956.36
Rate for Payer: Kaiser Permanente Medicare	$2,915.36
Rate for Payer: MDX Hawaii PPO	$3,720.92
Rate for Payer: Ohana Health Plan Medicaid	$2,915.36
Rate for Payer: Ohana Health Plan Medicare	$2,915.36
Rate for Payer: UnitedHealthcare Medicare	$2,915.36
Rate for Payer: University Health Alliance Commercial	$2,148.16

PLATE LCP PROXI TIB 3.5MM

Facility

$3,836.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$2,148.16
Max. Negotiated Rate	$3,720.92
Rate for Payer: Cash Price	$2,301.60
Rate for Payer: Hawaii Western Management Group Commercial	$2,685.20
Rate for Payer: Health Management Network Commercial	$3,260.60
Rate for Payer: Kaiser Permanente Commercial	$3,452.40
Rate for Payer: MDX Hawaii PPO	$3,720.92
Rate for Payer: University Health Alliance Commercial	$2,148.16

Know your out-of-pocket cost for care.

All Charges