Honoka'a Hospital and Skilled Nursing Facility

All Charges

Charge

Type

Setting

Price

PLATE LCP-RT 10H 4.5MM 222.660

Facility

$4,786.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$2,680.16
Max. Negotiated Rate	$4,642.42
Rate for Payer: Cash Price	$2,871.60
Rate for Payer: Hawaii Western Management Group Commercial	$3,350.20
Rate for Payer: Health Management Network Commercial	$4,068.10
Rate for Payer: Kaiser Permanente Commercial	$4,307.40
Rate for Payer: MDX Hawaii PPO	$4,642.42
Rate for Payer: University Health Alliance Commercial	$2,680.16

PLATE LCP-RT 10H 4.5MM 222.660

Facility

$4,786.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$2,393.00
Max. Negotiated Rate	$4,642.42
Rate for Payer: AlohaCare Medicaid	$2,393.00
Rate for Payer: AlohaCare Medicare	$3,637.36
Rate for Payer: Cash Price	$2,871.60
Rate for Payer: Devoted Health Medicare	$4,020.24
Rate for Payer: Hawaii Medical Service Association Medicare	$3,637.36
Rate for Payer: Hawaii Western Management Group Commercial	$3,350.20
Rate for Payer: Health Management Network Commercial	$4,068.10
Rate for Payer: Humana Medicare	$3,637.36
Rate for Payer: Kaiser Permanente Commercial	$4,307.40
Rate for Payer: Kaiser Permanente Medicaid	$2,440.86
Rate for Payer: Kaiser Permanente Medicare	$3,637.36
Rate for Payer: MDX Hawaii PPO	$4,642.42
Rate for Payer: Ohana Health Plan Medicaid	$3,637.36
Rate for Payer: Ohana Health Plan Medicare	$3,637.36
Rate for Payer: UnitedHealthcare Medicare	$3,637.36
Rate for Payer: University Health Alliance Commercial	$2,680.16

PLATE LCP-RT 10H 4.5MM 240.042

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-RT 10H 4.5MM 240.042

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-RT 12H 4.5MM 222.662

Facility

$3,748.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$2,098.88
Max. Negotiated Rate	$3,635.56
Rate for Payer: Cash Price	$2,248.80
Rate for Payer: Hawaii Western Management Group Commercial	$2,623.60
Rate for Payer: Health Management Network Commercial	$3,185.80
Rate for Payer: Kaiser Permanente Commercial	$3,373.20
Rate for Payer: MDX Hawaii PPO	$3,635.56
Rate for Payer: University Health Alliance Commercial	$2,098.88

PLATE LCP-RT 12H 4.5MM 222.662

Facility

$3,748.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,874.00
Max. Negotiated Rate	$3,635.56
Rate for Payer: AlohaCare Medicaid	$1,874.00
Rate for Payer: AlohaCare Medicare	$2,848.48
Rate for Payer: Cash Price	$2,248.80
Rate for Payer: Devoted Health Medicare	$3,148.32
Rate for Payer: Hawaii Medical Service Association Medicare	$2,848.48
Rate for Payer: Hawaii Western Management Group Commercial	$2,623.60
Rate for Payer: Health Management Network Commercial	$3,185.80
Rate for Payer: Humana Medicare	$2,848.48
Rate for Payer: Kaiser Permanente Commercial	$3,373.20
Rate for Payer: Kaiser Permanente Medicaid	$1,911.48
Rate for Payer: Kaiser Permanente Medicare	$2,848.48
Rate for Payer: MDX Hawaii PPO	$3,635.56
Rate for Payer: Ohana Health Plan Medicaid	$2,848.48
Rate for Payer: Ohana Health Plan Medicare	$2,848.48
Rate for Payer: UnitedHealthcare Medicare	$2,848.48
Rate for Payer: University Health Alliance Commercial	$2,098.88

PLATE LCP-RT 12H 4.5MM 240.044

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-RT 12H 4.5MM 240.044

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-RT 14H 4.5MM 222.664

Facility

$5,147.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$2,573.50
Max. Negotiated Rate	$4,992.59
Rate for Payer: AlohaCare Medicaid	$2,573.50
Rate for Payer: AlohaCare Medicare	$3,911.72
Rate for Payer: Cash Price	$3,088.20
Rate for Payer: Devoted Health Medicare	$4,323.48
Rate for Payer: Hawaii Medical Service Association Medicare	$3,911.72
Rate for Payer: Hawaii Western Management Group Commercial	$3,602.90
Rate for Payer: Health Management Network Commercial	$4,374.95
Rate for Payer: Humana Medicare	$3,911.72
Rate for Payer: Kaiser Permanente Commercial	$4,632.30
Rate for Payer: Kaiser Permanente Medicaid	$2,624.97
Rate for Payer: Kaiser Permanente Medicare	$3,911.72
Rate for Payer: MDX Hawaii PPO	$4,992.59
Rate for Payer: Ohana Health Plan Medicaid	$3,911.72
Rate for Payer: Ohana Health Plan Medicare	$3,911.72
Rate for Payer: UnitedHealthcare Medicare	$3,911.72
Rate for Payer: University Health Alliance Commercial	$2,882.32

PLATE LCP-RT 14H 4.5MM 222.664

Facility

$5,147.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$2,882.32
Max. Negotiated Rate	$4,992.59
Rate for Payer: Cash Price	$3,088.20
Rate for Payer: Hawaii Western Management Group Commercial	$3,602.90
Rate for Payer: Health Management Network Commercial	$4,374.95
Rate for Payer: Kaiser Permanente Commercial	$4,632.30
Rate for Payer: MDX Hawaii PPO	$4,992.59
Rate for Payer: University Health Alliance Commercial	$2,882.32

PLATE LCP-RT 14H 4.5MM 240.046

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-RT 14H 4.5MM 240.046

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-RT 16H 4.5MM 222.666

Facility

$5,250.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$2,625.00
Max. Negotiated Rate	$5,092.50
Rate for Payer: AlohaCare Medicaid	$2,625.00
Rate for Payer: AlohaCare Medicare	$3,990.00
Rate for Payer: Cash Price	$3,150.00
Rate for Payer: Devoted Health Medicare	$4,410.00
Rate for Payer: Hawaii Medical Service Association Medicare	$3,990.00
Rate for Payer: Hawaii Western Management Group Commercial	$3,675.00
Rate for Payer: Health Management Network Commercial	$4,462.50
Rate for Payer: Humana Medicare	$3,990.00
Rate for Payer: Kaiser Permanente Commercial	$4,725.00
Rate for Payer: Kaiser Permanente Medicaid	$2,677.50
Rate for Payer: Kaiser Permanente Medicare	$3,990.00
Rate for Payer: MDX Hawaii PPO	$5,092.50
Rate for Payer: Ohana Health Plan Medicaid	$3,990.00
Rate for Payer: Ohana Health Plan Medicare	$3,990.00
Rate for Payer: UnitedHealthcare Medicare	$3,990.00
Rate for Payer: University Health Alliance Commercial	$2,940.00

PLATE LCP-RT 16H 4.5MM 222.666

Facility

$5,250.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$2,940.00
Max. Negotiated Rate	$5,092.50
Rate for Payer: Cash Price	$3,150.00
Rate for Payer: Hawaii Western Management Group Commercial	$3,675.00
Rate for Payer: Health Management Network Commercial	$4,462.50
Rate for Payer: Kaiser Permanente Commercial	$4,725.00
Rate for Payer: MDX Hawaii PPO	$5,092.50
Rate for Payer: University Health Alliance Commercial	$2,940.00

PLATE LCP-RT 18H 4.5MM 222.668

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-RT 18H 4.5MM 222.668

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-RT 8H 4.5MM 240.040

Facility

$4,584.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$2,567.04
Max. Negotiated Rate	$4,446.48
Rate for Payer: MDX Hawaii PPO	$4,446.48
Rate for Payer: Cash Price	$2,750.40
Rate for Payer: Hawaii Western Management Group Commercial	$3,208.80
Rate for Payer: Health Management Network Commercial	$3,896.40
Rate for Payer: Kaiser Permanente Commercial	$4,125.60
Rate for Payer: University Health Alliance Commercial	$2,567.04

PLATE LCP-RT 8H 4.5MM 240.040

Facility

$4,584.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$2,292.00
Max. Negotiated Rate	$4,446.48
Rate for Payer: AlohaCare Medicaid	$2,292.00
Rate for Payer: AlohaCare Medicare	$3,483.84
Rate for Payer: Cash Price	$2,750.40
Rate for Payer: Devoted Health Medicare	$3,850.56
Rate for Payer: Hawaii Medical Service Association Medicare	$3,483.84
Rate for Payer: Hawaii Western Management Group Commercial	$3,208.80
Rate for Payer: Health Management Network Commercial	$3,896.40
Rate for Payer: Humana Medicare	$3,483.84
Rate for Payer: Kaiser Permanente Commercial	$4,125.60
Rate for Payer: Kaiser Permanente Medicaid	$2,337.84
Rate for Payer: Kaiser Permanente Medicare	$3,483.84
Rate for Payer: MDX Hawaii PPO	$4,446.48
Rate for Payer: Ohana Health Plan Medicaid	$3,483.84
Rate for Payer: Ohana Health Plan Medicare	$3,483.84
Rate for Payer: UnitedHealthcare Medicare	$3,483.84
Rate for Payer: University Health Alliance Commercial	$2,567.04

PLATE LCP TIB-L 10H 02.118.009

Facility

$4,478.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$2,507.68
Max. Negotiated Rate	$4,343.66
Rate for Payer: Cash Price	$2,686.80
Rate for Payer: Hawaii Western Management Group Commercial	$3,134.60
Rate for Payer: Health Management Network Commercial	$3,806.30
Rate for Payer: Kaiser Permanente Commercial	$4,030.20
Rate for Payer: MDX Hawaii PPO	$4,343.66
Rate for Payer: University Health Alliance Commercial	$2,507.68

PLATE LCP TIB-L 10H 02.118.009

Facility

$4,478.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$2,239.00
Max. Negotiated Rate	$4,343.66
Rate for Payer: AlohaCare Medicaid	$2,239.00
Rate for Payer: AlohaCare Medicare	$3,403.28
Rate for Payer: Cash Price	$2,686.80
Rate for Payer: Devoted Health Medicare	$3,761.52
Rate for Payer: Hawaii Medical Service Association Medicare	$3,403.28
Rate for Payer: Hawaii Western Management Group Commercial	$3,134.60
Rate for Payer: Health Management Network Commercial	$3,806.30
Rate for Payer: Humana Medicare	$3,403.28
Rate for Payer: Kaiser Permanente Commercial	$4,030.20
Rate for Payer: Kaiser Permanente Medicaid	$2,283.78
Rate for Payer: Kaiser Permanente Medicare	$3,403.28
Rate for Payer: MDX Hawaii PPO	$4,343.66
Rate for Payer: Ohana Health Plan Medicaid	$3,403.28
Rate for Payer: Ohana Health Plan Medicare	$3,403.28
Rate for Payer: UnitedHealthcare Medicare	$3,403.28
Rate for Payer: University Health Alliance Commercial	$2,507.68

PLATE LCP TIB-L 10H 02.118.209

Facility

$4,764.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$2,667.84
Max. Negotiated Rate	$4,621.08
Rate for Payer: Cash Price	$2,858.40
Rate for Payer: Hawaii Western Management Group Commercial	$3,334.80
Rate for Payer: Health Management Network Commercial	$4,049.40
Rate for Payer: Kaiser Permanente Commercial	$4,287.60
Rate for Payer: MDX Hawaii PPO	$4,621.08
Rate for Payer: University Health Alliance Commercial	$2,667.84

PLATE LCP TIB-L 10H 02.118.209

Facility

$4,764.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$2,382.00
Max. Negotiated Rate	$4,621.08
Rate for Payer: AlohaCare Medicaid	$2,382.00
Rate for Payer: AlohaCare Medicare	$3,620.64
Rate for Payer: Cash Price	$2,858.40
Rate for Payer: Devoted Health Medicare	$4,001.76
Rate for Payer: Hawaii Medical Service Association Medicare	$3,620.64
Rate for Payer: Hawaii Western Management Group Commercial	$3,334.80
Rate for Payer: Health Management Network Commercial	$4,049.40
Rate for Payer: Humana Medicare	$3,620.64
Rate for Payer: Kaiser Permanente Commercial	$4,287.60
Rate for Payer: Kaiser Permanente Medicaid	$2,429.64
Rate for Payer: Kaiser Permanente Medicare	$3,620.64
Rate for Payer: MDX Hawaii PPO	$4,621.08
Rate for Payer: Ohana Health Plan Medicaid	$3,620.64
Rate for Payer: Ohana Health Plan Medicare	$3,620.64
Rate for Payer: UnitedHealthcare Medicare	$3,620.64
Rate for Payer: University Health Alliance Commercial	$2,667.84

PLATE LCP TIB-L 12H 02.118.011

Facility

$5,226.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$2,926.56
Max. Negotiated Rate	$5,069.22
Rate for Payer: Cash Price	$3,135.60
Rate for Payer: Hawaii Western Management Group Commercial	$3,658.20
Rate for Payer: Health Management Network Commercial	$4,442.10
Rate for Payer: Kaiser Permanente Commercial	$4,703.40
Rate for Payer: MDX Hawaii PPO	$5,069.22
Rate for Payer: University Health Alliance Commercial	$2,926.56

PLATE LCP TIB-L 12H 02.118.011

Facility

$5,226.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$2,613.00
Max. Negotiated Rate	$5,069.22
Rate for Payer: AlohaCare Medicaid	$2,613.00
Rate for Payer: AlohaCare Medicare	$3,971.76
Rate for Payer: Cash Price	$3,135.60
Rate for Payer: Devoted Health Medicare	$4,389.84
Rate for Payer: Hawaii Medical Service Association Medicare	$3,971.76
Rate for Payer: Hawaii Western Management Group Commercial	$3,658.20
Rate for Payer: Health Management Network Commercial	$4,442.10
Rate for Payer: Humana Medicare	$3,971.76
Rate for Payer: Kaiser Permanente Commercial	$4,703.40
Rate for Payer: Kaiser Permanente Medicaid	$2,665.26
Rate for Payer: Kaiser Permanente Medicare	$3,971.76
Rate for Payer: MDX Hawaii PPO	$5,069.22
Rate for Payer: Ohana Health Plan Medicaid	$3,971.76
Rate for Payer: Ohana Health Plan Medicare	$3,971.76
Rate for Payer: UnitedHealthcare Medicare	$3,971.76
Rate for Payer: University Health Alliance Commercial	$2,926.56

PLATE LCP TIB-L 12H 02.118.211

Facility

$5,406.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$3,027.36
Max. Negotiated Rate	$5,243.82
Rate for Payer: Cash Price	$3,243.60
Rate for Payer: Hawaii Western Management Group Commercial	$3,784.20
Rate for Payer: Health Management Network Commercial	$4,595.10
Rate for Payer: Kaiser Permanente Commercial	$4,865.40
Rate for Payer: MDX Hawaii PPO	$5,243.82
Rate for Payer: University Health Alliance Commercial	$3,027.36

Know your out-of-pocket cost for care.

All Charges