Honoka'a Hospital and Skilled Nursing Facility

All Charges

Charge

Type

Setting

Price

PLATE LCP TIB-R 12H 02.118.010

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-R 12H 02.118.010

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-R 12H 02.118.210

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

PLATE LCP TIB-R 12H 02.118.210

Facility

$5,406.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$2,703.00
Max. Negotiated Rate	$5,243.82
Rate for Payer: Kaiser Permanente Medicare	$4,108.56
Rate for Payer: AlohaCare Medicaid	$2,703.00
Rate for Payer: AlohaCare Medicare	$4,108.56
Rate for Payer: Cash Price	$3,243.60
Rate for Payer: Devoted Health Medicare	$4,541.04
Rate for Payer: Hawaii Medical Service Association Medicare	$4,108.56
Rate for Payer: Hawaii Western Management Group Commercial	$3,784.20
Rate for Payer: Health Management Network Commercial	$4,595.10
Rate for Payer: Humana Medicare	$4,108.56
Rate for Payer: Kaiser Permanente Commercial	$4,865.40
Rate for Payer: Kaiser Permanente Medicaid	$2,757.06
Rate for Payer: MDX Hawaii PPO	$5,243.82
Rate for Payer: Ohana Health Plan Medicaid	$4,108.56
Rate for Payer: Ohana Health Plan Medicare	$4,108.56
Rate for Payer: UnitedHealthcare Medicare	$4,108.56
Rate for Payer: University Health Alliance Commercial	$3,027.36

PLATE LCP TIB-R 14H 02.118.012

Facility

$5,828.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$3,263.68
Max. Negotiated Rate	$5,653.16
Rate for Payer: Cash Price	$3,496.80
Rate for Payer: Hawaii Western Management Group Commercial	$4,079.60
Rate for Payer: Health Management Network Commercial	$4,953.80
Rate for Payer: Kaiser Permanente Commercial	$5,245.20
Rate for Payer: MDX Hawaii PPO	$5,653.16
Rate for Payer: University Health Alliance Commercial	$3,263.68

PLATE LCP TIB-R 14H 02.118.012

Facility

$5,828.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$2,914.00
Max. Negotiated Rate	$5,653.16
Rate for Payer: AlohaCare Medicaid	$2,914.00
Rate for Payer: AlohaCare Medicare	$4,429.28
Rate for Payer: Cash Price	$3,496.80
Rate for Payer: Devoted Health Medicare	$4,895.52
Rate for Payer: Hawaii Medical Service Association Medicare	$4,429.28
Rate for Payer: Hawaii Western Management Group Commercial	$4,079.60
Rate for Payer: Health Management Network Commercial	$4,953.80
Rate for Payer: Humana Medicare	$4,429.28
Rate for Payer: Kaiser Permanente Commercial	$5,245.20
Rate for Payer: Kaiser Permanente Medicaid	$2,972.28
Rate for Payer: Kaiser Permanente Medicare	$4,429.28
Rate for Payer: MDX Hawaii PPO	$5,653.16
Rate for Payer: Ohana Health Plan Medicaid	$4,429.28
Rate for Payer: Ohana Health Plan Medicare	$4,429.28
Rate for Payer: UnitedHealthcare Medicare	$4,429.28
Rate for Payer: University Health Alliance Commercial	$3,263.68

PLATE LCP TIB-R 14H 02.118.212

Facility

$6,034.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$3,017.00
Max. Negotiated Rate	$5,852.98
Rate for Payer: AlohaCare Medicaid	$3,017.00
Rate for Payer: AlohaCare Medicare	$4,585.84
Rate for Payer: Cash Price	$3,620.40
Rate for Payer: Devoted Health Medicare	$5,068.56
Rate for Payer: Hawaii Medical Service Association Medicare	$4,585.84
Rate for Payer: Hawaii Western Management Group Commercial	$4,223.80
Rate for Payer: Health Management Network Commercial	$5,128.90
Rate for Payer: Humana Medicare	$4,585.84
Rate for Payer: Kaiser Permanente Commercial	$5,430.60
Rate for Payer: Kaiser Permanente Medicaid	$3,077.34
Rate for Payer: Kaiser Permanente Medicare	$4,585.84
Rate for Payer: MDX Hawaii PPO	$5,852.98
Rate for Payer: Ohana Health Plan Medicaid	$4,585.84
Rate for Payer: Ohana Health Plan Medicare	$4,585.84
Rate for Payer: UnitedHealthcare Medicare	$4,585.84
Rate for Payer: University Health Alliance Commercial	$3,379.04

PLATE LCP TIB-R 14H 02.118.212

Facility

$6,034.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$3,379.04
Max. Negotiated Rate	$5,852.98
Rate for Payer: Cash Price	$3,620.40
Rate for Payer: Hawaii Western Management Group Commercial	$4,223.80
Rate for Payer: Health Management Network Commercial	$5,128.90
Rate for Payer: Kaiser Permanente Commercial	$5,430.60
Rate for Payer: MDX Hawaii PPO	$5,852.98
Rate for Payer: University Health Alliance Commercial	$3,379.04

PLATE LCP TIB-R 16H 02.118.214

Facility

$6,370.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$3,185.00
Max. Negotiated Rate	$6,178.90
Rate for Payer: AlohaCare Medicaid	$3,185.00
Rate for Payer: AlohaCare Medicare	$4,841.20
Rate for Payer: Cash Price	$3,822.00
Rate for Payer: Devoted Health Medicare	$5,350.80
Rate for Payer: Hawaii Medical Service Association Medicare	$4,841.20
Rate for Payer: Hawaii Western Management Group Commercial	$4,459.00
Rate for Payer: Health Management Network Commercial	$5,414.50
Rate for Payer: Humana Medicare	$4,841.20
Rate for Payer: Kaiser Permanente Commercial	$5,733.00
Rate for Payer: Kaiser Permanente Medicaid	$3,248.70
Rate for Payer: Kaiser Permanente Medicare	$4,841.20
Rate for Payer: MDX Hawaii PPO	$6,178.90
Rate for Payer: Ohana Health Plan Medicaid	$4,841.20
Rate for Payer: Ohana Health Plan Medicare	$4,841.20
Rate for Payer: UnitedHealthcare Medicare	$4,841.20
Rate for Payer: University Health Alliance Commercial	$3,567.20

PLATE LCP TIB-R 16H 02.118.214

Facility

$6,370.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$3,567.20
Max. Negotiated Rate	$6,178.90
Rate for Payer: Cash Price	$3,822.00
Rate for Payer: Hawaii Western Management Group Commercial	$4,459.00
Rate for Payer: Health Management Network Commercial	$5,414.50
Rate for Payer: Kaiser Permanente Commercial	$5,733.00
Rate for Payer: MDX Hawaii PPO	$6,178.90
Rate for Payer: University Health Alliance Commercial	$3,567.20

PLATE LCP TIB-R 18H 02.118.216

Facility

$6,488.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$3,244.00
Max. Negotiated Rate	$6,293.36
Rate for Payer: AlohaCare Medicaid	$3,244.00
Rate for Payer: AlohaCare Medicare	$4,930.88
Rate for Payer: Cash Price	$3,892.80
Rate for Payer: Devoted Health Medicare	$5,449.92
Rate for Payer: Hawaii Medical Service Association Medicare	$4,930.88
Rate for Payer: Hawaii Western Management Group Commercial	$4,541.60
Rate for Payer: Health Management Network Commercial	$5,514.80
Rate for Payer: Humana Medicare	$4,930.88
Rate for Payer: Kaiser Permanente Commercial	$5,839.20
Rate for Payer: Kaiser Permanente Medicaid	$3,308.88
Rate for Payer: Kaiser Permanente Medicare	$4,930.88
Rate for Payer: MDX Hawaii PPO	$6,293.36
Rate for Payer: Ohana Health Plan Medicaid	$4,930.88
Rate for Payer: Ohana Health Plan Medicare	$4,930.88
Rate for Payer: UnitedHealthcare Medicare	$4,930.88
Rate for Payer: University Health Alliance Commercial	$3,633.28

PLATE LCP TIB-R 18H 02.118.216

Facility

$6,488.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$3,633.28
Max. Negotiated Rate	$6,293.36
Rate for Payer: Cash Price	$3,892.80
Rate for Payer: Hawaii Western Management Group Commercial	$4,541.60
Rate for Payer: Health Management Network Commercial	$5,514.80
Rate for Payer: Kaiser Permanente Commercial	$5,839.20
Rate for Payer: MDX Hawaii PPO	$6,293.36
Rate for Payer: University Health Alliance Commercial	$3,633.28

PLATE LCP TIB-R 4H 02.118.002

Facility

$3,685.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$2,063.60
Max. Negotiated Rate	$3,574.45
Rate for Payer: Cash Price	$2,211.00
Rate for Payer: Hawaii Western Management Group Commercial	$2,579.50
Rate for Payer: Health Management Network Commercial	$3,132.25
Rate for Payer: Kaiser Permanente Commercial	$3,316.50
Rate for Payer: MDX Hawaii PPO	$3,574.45
Rate for Payer: University Health Alliance Commercial	$2,063.60

PLATE LCP TIB-R 4H 02.118.002

Facility

$3,685.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,842.50
Max. Negotiated Rate	$3,574.45
Rate for Payer: AlohaCare Medicaid	$1,842.50
Rate for Payer: AlohaCare Medicare	$2,800.60
Rate for Payer: Cash Price	$2,211.00
Rate for Payer: Devoted Health Medicare	$3,095.40
Rate for Payer: Hawaii Medical Service Association Medicare	$2,800.60
Rate for Payer: Hawaii Western Management Group Commercial	$2,579.50
Rate for Payer: Health Management Network Commercial	$3,132.25
Rate for Payer: Humana Medicare	$2,800.60
Rate for Payer: Kaiser Permanente Commercial	$3,316.50
Rate for Payer: Kaiser Permanente Medicaid	$1,879.35
Rate for Payer: Kaiser Permanente Medicare	$2,800.60
Rate for Payer: MDX Hawaii PPO	$3,574.45
Rate for Payer: Ohana Health Plan Medicaid	$2,800.60
Rate for Payer: Ohana Health Plan Medicare	$2,800.60
Rate for Payer: UnitedHealthcare Medicare	$2,800.60
Rate for Payer: University Health Alliance Commercial	$2,063.60

PLATE LCP TIB-R 4H 02.118.202

Facility

$4,616.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$2,584.96
Max. Negotiated Rate	$4,477.52
Rate for Payer: Cash Price	$2,769.60
Rate for Payer: Hawaii Western Management Group Commercial	$3,231.20
Rate for Payer: Health Management Network Commercial	$3,923.60
Rate for Payer: Kaiser Permanente Commercial	$4,154.40
Rate for Payer: MDX Hawaii PPO	$4,477.52
Rate for Payer: University Health Alliance Commercial	$2,584.96

PLATE LCP TIB-R 4H 02.118.202

Facility

$4,616.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$2,308.00
Max. Negotiated Rate	$4,477.52
Rate for Payer: AlohaCare Medicaid	$2,308.00
Rate for Payer: AlohaCare Medicare	$3,508.16
Rate for Payer: Cash Price	$2,769.60
Rate for Payer: Devoted Health Medicare	$3,877.44
Rate for Payer: Hawaii Medical Service Association Medicare	$3,508.16
Rate for Payer: Hawaii Western Management Group Commercial	$3,231.20
Rate for Payer: Health Management Network Commercial	$3,923.60
Rate for Payer: Humana Medicare	$3,508.16
Rate for Payer: Kaiser Permanente Commercial	$4,154.40
Rate for Payer: Kaiser Permanente Medicaid	$2,354.16
Rate for Payer: Kaiser Permanente Medicare	$3,508.16
Rate for Payer: MDX Hawaii PPO	$4,477.52
Rate for Payer: Ohana Health Plan Medicaid	$3,508.16
Rate for Payer: Ohana Health Plan Medicare	$3,508.16
Rate for Payer: UnitedHealthcare Medicare	$3,508.16
Rate for Payer: University Health Alliance Commercial	$2,584.96

PLATE LCP TIB-R 6H 02.118.004

Facility

$3,726.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$2,086.56
Max. Negotiated Rate	$3,614.22
Rate for Payer: Cash Price	$2,235.60
Rate for Payer: Hawaii Western Management Group Commercial	$2,608.20
Rate for Payer: Health Management Network Commercial	$3,167.10
Rate for Payer: Kaiser Permanente Commercial	$3,353.40
Rate for Payer: MDX Hawaii PPO	$3,614.22
Rate for Payer: University Health Alliance Commercial	$2,086.56

PLATE LCP TIB-R 6H 02.118.004

Facility

$3,726.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,863.00
Max. Negotiated Rate	$3,614.22
Rate for Payer: AlohaCare Medicaid	$1,863.00
Rate for Payer: AlohaCare Medicare	$2,831.76
Rate for Payer: Cash Price	$2,235.60
Rate for Payer: Devoted Health Medicare	$3,129.84
Rate for Payer: Hawaii Medical Service Association Medicare	$2,831.76
Rate for Payer: Hawaii Western Management Group Commercial	$2,608.20
Rate for Payer: Health Management Network Commercial	$3,167.10
Rate for Payer: Humana Medicare	$2,831.76
Rate for Payer: Kaiser Permanente Commercial	$3,353.40
Rate for Payer: Kaiser Permanente Medicaid	$1,900.26
Rate for Payer: Kaiser Permanente Medicare	$2,831.76
Rate for Payer: MDX Hawaii PPO	$3,614.22
Rate for Payer: Ohana Health Plan Medicaid	$2,831.76
Rate for Payer: Ohana Health Plan Medicare	$2,831.76
Rate for Payer: UnitedHealthcare Medicare	$2,831.76
Rate for Payer: University Health Alliance Commercial	$2,086.56

PLATE LCP TIB-R 6H 02.118.204

Facility

$3,966.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$2,220.96
Max. Negotiated Rate	$3,847.02
Rate for Payer: Cash Price	$2,379.60
Rate for Payer: Hawaii Western Management Group Commercial	$2,776.20
Rate for Payer: Health Management Network Commercial	$3,371.10
Rate for Payer: Kaiser Permanente Commercial	$3,569.40
Rate for Payer: MDX Hawaii PPO	$3,847.02
Rate for Payer: University Health Alliance Commercial	$2,220.96

PLATE LCP TIB-R 6H 02.118.204

Facility

$3,966.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,983.00
Max. Negotiated Rate	$3,847.02
Rate for Payer: AlohaCare Medicaid	$1,983.00
Rate for Payer: AlohaCare Medicare	$3,014.16
Rate for Payer: Cash Price	$2,379.60
Rate for Payer: Devoted Health Medicare	$3,331.44
Rate for Payer: Hawaii Medical Service Association Medicare	$3,014.16
Rate for Payer: Hawaii Western Management Group Commercial	$2,776.20
Rate for Payer: Health Management Network Commercial	$3,371.10
Rate for Payer: Humana Medicare	$3,014.16
Rate for Payer: Kaiser Permanente Commercial	$3,569.40
Rate for Payer: Kaiser Permanente Medicaid	$2,022.66
Rate for Payer: Kaiser Permanente Medicare	$3,014.16
Rate for Payer: MDX Hawaii PPO	$3,847.02
Rate for Payer: Ohana Health Plan Medicaid	$3,014.16
Rate for Payer: Ohana Health Plan Medicare	$3,014.16
Rate for Payer: UnitedHealthcare Medicare	$3,014.16
Rate for Payer: University Health Alliance Commercial	$2,220.96

PLATE LCP TIB-R 8H 02.118.006

Facility

$4,432.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$2,481.92
Max. Negotiated Rate	$4,299.04
Rate for Payer: Cash Price	$2,659.20
Rate for Payer: Hawaii Western Management Group Commercial	$3,102.40
Rate for Payer: Health Management Network Commercial	$3,767.20
Rate for Payer: Kaiser Permanente Commercial	$3,988.80
Rate for Payer: MDX Hawaii PPO	$4,299.04
Rate for Payer: University Health Alliance Commercial	$2,481.92

PLATE LCP TIB-R 8H 02.118.006

Facility

$4,432.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$2,216.00
Max. Negotiated Rate	$4,299.04
Rate for Payer: AlohaCare Medicaid	$2,216.00
Rate for Payer: AlohaCare Medicare	$3,368.32
Rate for Payer: Cash Price	$2,659.20
Rate for Payer: Devoted Health Medicare	$3,722.88
Rate for Payer: Hawaii Medical Service Association Medicare	$3,368.32
Rate for Payer: Hawaii Western Management Group Commercial	$3,102.40
Rate for Payer: Health Management Network Commercial	$3,767.20
Rate for Payer: Humana Medicare	$3,368.32
Rate for Payer: Kaiser Permanente Commercial	$3,988.80
Rate for Payer: Kaiser Permanente Medicaid	$2,260.32
Rate for Payer: Kaiser Permanente Medicare	$3,368.32
Rate for Payer: MDX Hawaii PPO	$4,299.04
Rate for Payer: Ohana Health Plan Medicaid	$3,368.32
Rate for Payer: Ohana Health Plan Medicare	$3,368.32
Rate for Payer: UnitedHealthcare Medicare	$3,368.32
Rate for Payer: University Health Alliance Commercial	$2,481.92

PLATE LCP TIB-R 8H 02.118.206

Facility

$4,009.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$2,004.50
Max. Negotiated Rate	$3,888.73
Rate for Payer: AlohaCare Medicaid	$2,004.50
Rate for Payer: AlohaCare Medicare	$3,046.84
Rate for Payer: Cash Price	$2,405.40
Rate for Payer: Devoted Health Medicare	$3,367.56
Rate for Payer: Hawaii Medical Service Association Medicare	$3,046.84
Rate for Payer: Hawaii Western Management Group Commercial	$2,806.30
Rate for Payer: Health Management Network Commercial	$3,407.65
Rate for Payer: Humana Medicare	$3,046.84
Rate for Payer: Kaiser Permanente Commercial	$3,608.10
Rate for Payer: Kaiser Permanente Medicaid	$2,044.59
Rate for Payer: Kaiser Permanente Medicare	$3,046.84
Rate for Payer: MDX Hawaii PPO	$3,888.73
Rate for Payer: Ohana Health Plan Medicaid	$3,046.84
Rate for Payer: Ohana Health Plan Medicare	$3,046.84
Rate for Payer: UnitedHealthcare Medicare	$3,046.84
Rate for Payer: University Health Alliance Commercial	$2,245.04

PLATE LCP TIB-R 8H 02.118.206

Facility

$4,009.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$2,245.04
Max. Negotiated Rate	$3,888.73
Rate for Payer: Cash Price	$2,405.40
Rate for Payer: Hawaii Western Management Group Commercial	$2,806.30
Rate for Payer: Health Management Network Commercial	$3,407.65
Rate for Payer: Kaiser Permanente Commercial	$3,608.10
Rate for Payer: MDX Hawaii PPO	$3,888.73
Rate for Payer: University Health Alliance Commercial	$2,245.04

PLATE LEFT 3H 74MM 2358-108-03

Facility

$2,820.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,410.00
Max. Negotiated Rate	$2,735.40
Rate for Payer: AlohaCare Medicaid	$1,410.00
Rate for Payer: AlohaCare Medicare	$2,143.20
Rate for Payer: Cash Price	$1,692.00
Rate for Payer: Devoted Health Medicare	$2,368.80
Rate for Payer: Hawaii Medical Service Association Medicare	$2,143.20
Rate for Payer: Hawaii Western Management Group Commercial	$1,974.00
Rate for Payer: Health Management Network Commercial	$2,397.00
Rate for Payer: Humana Medicare	$2,143.20
Rate for Payer: Kaiser Permanente Commercial	$2,538.00
Rate for Payer: Kaiser Permanente Medicaid	$1,438.20
Rate for Payer: Kaiser Permanente Medicare	$2,143.20
Rate for Payer: MDX Hawaii PPO	$2,735.40
Rate for Payer: Ohana Health Plan Medicaid	$2,143.20
Rate for Payer: Ohana Health Plan Medicare	$2,143.20
Rate for Payer: UnitedHealthcare Medicare	$2,143.20
Rate for Payer: University Health Alliance Commercial	$1,579.20

Know your out-of-pocket cost for care.

All Charges