Honoka'a Hospital and Skilled Nursing Facility

All Charges

Charge

Type

Setting

Price

PLATE LT10H 3.5X187 02.112.523

Facility

$3,324.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,662.00
Max. Negotiated Rate	$3,224.28
Rate for Payer: AlohaCare Medicaid	$1,662.00
Rate for Payer: AlohaCare Medicare	$2,526.24
Rate for Payer: Cash Price	$1,994.40
Rate for Payer: Devoted Health Medicare	$2,792.16
Rate for Payer: Hawaii Medical Service Association Medicare	$2,526.24
Rate for Payer: Hawaii Western Management Group Commercial	$2,326.80
Rate for Payer: Health Management Network Commercial	$2,825.40
Rate for Payer: Humana Medicare	$2,526.24
Rate for Payer: Kaiser Permanente Commercial	$2,991.60
Rate for Payer: Kaiser Permanente Medicaid	$1,695.24
Rate for Payer: Kaiser Permanente Medicare	$2,526.24
Rate for Payer: MDX Hawaii PPO	$3,224.28
Rate for Payer: Ohana Health Plan Medicaid	$2,526.24
Rate for Payer: Ohana Health Plan Medicare	$2,526.24
Rate for Payer: UnitedHealthcare Medicare	$2,526.24
Rate for Payer: University Health Alliance Commercial	$1,861.44

PLATE LT10H 3.5X187 02.112.523

Facility

$3,324.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,861.44
Max. Negotiated Rate	$3,224.28
Rate for Payer: Cash Price	$1,994.40
Rate for Payer: Hawaii Western Management Group Commercial	$2,326.80
Rate for Payer: Health Management Network Commercial	$2,825.40
Rate for Payer: Kaiser Permanente Commercial	$2,991.60
Rate for Payer: MDX Hawaii PPO	$3,224.28
Rate for Payer: University Health Alliance Commercial	$1,861.44

PLATE LT 4H 3.5X109 02.112.511

Facility

$3,221.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,803.76
Max. Negotiated Rate	$3,124.37
Rate for Payer: Cash Price	$1,932.60
Rate for Payer: Hawaii Western Management Group Commercial	$2,254.70
Rate for Payer: Health Management Network Commercial	$2,737.85
Rate for Payer: Kaiser Permanente Commercial	$2,898.90
Rate for Payer: MDX Hawaii PPO	$3,124.37
Rate for Payer: University Health Alliance Commercial	$1,803.76

PLATE LT 4H 3.5X109 02.112.511

Facility

$3,221.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,610.50
Max. Negotiated Rate	$3,124.37
Rate for Payer: AlohaCare Medicaid	$1,610.50
Rate for Payer: AlohaCare Medicare	$2,447.96
Rate for Payer: Cash Price	$1,932.60
Rate for Payer: Devoted Health Medicare	$2,705.64
Rate for Payer: Hawaii Medical Service Association Medicare	$2,447.96
Rate for Payer: Hawaii Western Management Group Commercial	$2,254.70
Rate for Payer: Health Management Network Commercial	$2,737.85
Rate for Payer: Humana Medicare	$2,447.96
Rate for Payer: Kaiser Permanente Commercial	$2,898.90
Rate for Payer: Kaiser Permanente Medicaid	$1,642.71
Rate for Payer: Kaiser Permanente Medicare	$2,447.96
Rate for Payer: MDX Hawaii PPO	$3,124.37
Rate for Payer: Ohana Health Plan Medicaid	$2,447.96
Rate for Payer: Ohana Health Plan Medicare	$2,447.96
Rate for Payer: UnitedHealthcare Medicare	$2,447.96
Rate for Payer: University Health Alliance Commercial	$1,803.76

PLATE LT 8H 3.5X161 02.112.519

Facility

$4,766.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$2,383.00
Max. Negotiated Rate	$4,623.02
Rate for Payer: AlohaCare Medicaid	$2,383.00
Rate for Payer: AlohaCare Medicare	$3,622.16
Rate for Payer: Cash Price	$2,859.60
Rate for Payer: Devoted Health Medicare	$4,003.44
Rate for Payer: Hawaii Medical Service Association Medicare	$3,622.16
Rate for Payer: Hawaii Western Management Group Commercial	$3,336.20
Rate for Payer: Health Management Network Commercial	$4,051.10
Rate for Payer: Humana Medicare	$3,622.16
Rate for Payer: Kaiser Permanente Commercial	$4,289.40
Rate for Payer: Kaiser Permanente Medicaid	$2,430.66
Rate for Payer: Kaiser Permanente Medicare	$3,622.16
Rate for Payer: MDX Hawaii PPO	$4,623.02
Rate for Payer: Ohana Health Plan Medicaid	$3,622.16
Rate for Payer: Ohana Health Plan Medicare	$3,622.16
Rate for Payer: UnitedHealthcare Medicare	$3,622.16
Rate for Payer: University Health Alliance Commercial	$2,668.96

PLATE LT 8H 3.5X161 02.112.519

Facility

$4,766.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$2,668.96
Max. Negotiated Rate	$4,623.02
Rate for Payer: Cash Price	$2,859.60
Rate for Payer: Hawaii Western Management Group Commercial	$3,336.20
Rate for Payer: Health Management Network Commercial	$4,051.10
Rate for Payer: Kaiser Permanente Commercial	$4,289.40
Rate for Payer: MDX Hawaii PPO	$4,623.02
Rate for Payer: University Health Alliance Commercial	$2,668.96

PLATE MANDI 4H 1.0 04.503.707

Facility

$1,662.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$930.72
Max. Negotiated Rate	$1,612.14
Rate for Payer: Cash Price	$997.20
Rate for Payer: Hawaii Western Management Group Commercial	$1,163.40
Rate for Payer: Health Management Network Commercial	$1,412.70
Rate for Payer: Kaiser Permanente Commercial	$1,495.80
Rate for Payer: MDX Hawaii PPO	$1,612.14
Rate for Payer: University Health Alliance Commercial	$930.72

PLATE MANDI 4H 1.0 04.503.707

Facility

$1,662.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$831.00
Max. Negotiated Rate	$1,612.14
Rate for Payer: AlohaCare Medicaid	$831.00
Rate for Payer: AlohaCare Medicare	$1,263.12
Rate for Payer: Cash Price	$997.20
Rate for Payer: Devoted Health Medicare	$1,396.08
Rate for Payer: Hawaii Medical Service Association Medicare	$1,263.12
Rate for Payer: Hawaii Western Management Group Commercial	$1,163.40
Rate for Payer: Health Management Network Commercial	$1,412.70
Rate for Payer: Humana Medicare	$1,263.12
Rate for Payer: Kaiser Permanente Commercial	$1,495.80
Rate for Payer: Kaiser Permanente Medicaid	$847.62
Rate for Payer: Kaiser Permanente Medicare	$1,263.12
Rate for Payer: MDX Hawaii PPO	$1,612.14
Rate for Payer: Ohana Health Plan Medicaid	$1,263.12
Rate for Payer: Ohana Health Plan Medicare	$1,263.12
Rate for Payer: UnitedHealthcare Medicare	$1,263.12
Rate for Payer: University Health Alliance Commercial	$930.72

PLATE MATRIX 20 H 03.503.174

Facility

$540.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$270.00
Max. Negotiated Rate	$523.80
Rate for Payer: AlohaCare Medicaid	$270.00
Rate for Payer: AlohaCare Medicare	$410.40
Rate for Payer: Cash Price	$324.00
Rate for Payer: Devoted Health Medicare	$453.60
Rate for Payer: Hawaii Medical Service Association Medicare	$410.40
Rate for Payer: Hawaii Western Management Group Commercial	$378.00
Rate for Payer: Health Management Network Commercial	$459.00
Rate for Payer: Humana Medicare	$410.40
Rate for Payer: Kaiser Permanente Commercial	$486.00
Rate for Payer: Kaiser Permanente Medicaid	$275.40
Rate for Payer: Kaiser Permanente Medicare	$410.40
Rate for Payer: MDX Hawaii PPO	$523.80
Rate for Payer: Ohana Health Plan Medicaid	$410.40
Rate for Payer: Ohana Health Plan Medicare	$410.40
Rate for Payer: UnitedHealthcare Medicare	$410.40
Rate for Payer: University Health Alliance Commercial	$302.40

PLATE MATRIX 20 H 03.503.174

Facility

$540.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$302.40
Max. Negotiated Rate	$523.80
Rate for Payer: Cash Price	$324.00
Rate for Payer: Hawaii Western Management Group Commercial	$378.00
Rate for Payer: Health Management Network Commercial	$459.00
Rate for Payer: Kaiser Permanente Commercial	$486.00
Rate for Payer: MDX Hawaii PPO	$523.80
Rate for Payer: University Health Alliance Commercial	$302.40

PLATE MATRIX 2X2 H 04.503.723

Facility

$2,558.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,432.48
Max. Negotiated Rate	$2,481.26
Rate for Payer: Cash Price	$1,534.80
Rate for Payer: Hawaii Western Management Group Commercial	$1,790.60
Rate for Payer: Health Management Network Commercial	$2,174.30
Rate for Payer: Kaiser Permanente Commercial	$2,302.20
Rate for Payer: MDX Hawaii PPO	$2,481.26
Rate for Payer: University Health Alliance Commercial	$1,432.48

PLATE MATRIX 2X2 H 04.503.723

Facility

$2,558.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,279.00
Max. Negotiated Rate	$2,481.26
Rate for Payer: AlohaCare Medicaid	$1,279.00
Rate for Payer: AlohaCare Medicare	$1,944.08
Rate for Payer: Cash Price	$1,534.80
Rate for Payer: Devoted Health Medicare	$2,148.72
Rate for Payer: Hawaii Medical Service Association Medicare	$1,944.08
Rate for Payer: Hawaii Western Management Group Commercial	$1,790.60
Rate for Payer: Health Management Network Commercial	$2,174.30
Rate for Payer: Humana Medicare	$1,944.08
Rate for Payer: Kaiser Permanente Commercial	$2,302.20
Rate for Payer: Kaiser Permanente Medicaid	$1,304.58
Rate for Payer: Kaiser Permanente Medicare	$1,944.08
Rate for Payer: MDX Hawaii PPO	$2,481.26
Rate for Payer: Ohana Health Plan Medicaid	$1,944.08
Rate for Payer: Ohana Health Plan Medicare	$1,944.08
Rate for Payer: UnitedHealthcare Medicare	$1,944.08
Rate for Payer: University Health Alliance Commercial	$1,432.48

PLATE MATRIX 3X3 04.503.704

Facility

$2,040.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,020.00
Max. Negotiated Rate	$1,978.80
Rate for Payer: AlohaCare Medicaid	$1,020.00
Rate for Payer: AlohaCare Medicare	$1,550.40
Rate for Payer: Cash Price	$1,224.00
Rate for Payer: Devoted Health Medicare	$1,713.60
Rate for Payer: Hawaii Medical Service Association Medicare	$1,550.40
Rate for Payer: Hawaii Western Management Group Commercial	$1,428.00
Rate for Payer: Health Management Network Commercial	$1,734.00
Rate for Payer: Humana Medicare	$1,550.40
Rate for Payer: Kaiser Permanente Commercial	$1,836.00
Rate for Payer: Kaiser Permanente Medicaid	$1,040.40
Rate for Payer: Kaiser Permanente Medicare	$1,550.40
Rate for Payer: MDX Hawaii PPO	$1,978.80
Rate for Payer: Ohana Health Plan Medicaid	$1,550.40
Rate for Payer: Ohana Health Plan Medicare	$1,550.40
Rate for Payer: UnitedHealthcare Medicare	$1,550.40
Rate for Payer: University Health Alliance Commercial	$1,142.40

PLATE MATRIX 3X3 04.503.704

Facility

$2,040.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,142.40
Max. Negotiated Rate	$1,978.80
Rate for Payer: Cash Price	$1,224.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,428.00
Rate for Payer: Health Management Network Commercial	$1,734.00
Rate for Payer: Kaiser Permanente Commercial	$1,836.00
Rate for Payer: MDX Hawaii PPO	$1,978.80
Rate for Payer: University Health Alliance Commercial	$1,142.40

PLATE MATRIXMIDFACE 04.503.346

Facility

$2,892.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,619.52
Max. Negotiated Rate	$2,805.24
Rate for Payer: Cash Price	$1,735.20
Rate for Payer: Hawaii Western Management Group Commercial	$2,024.40
Rate for Payer: Health Management Network Commercial	$2,458.20
Rate for Payer: Kaiser Permanente Commercial	$2,602.80
Rate for Payer: MDX Hawaii PPO	$2,805.24
Rate for Payer: University Health Alliance Commercial	$1,619.52

PLATE MATRIXMIDFACE 04.503.346

Facility

$2,892.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,446.00
Max. Negotiated Rate	$2,805.24
Rate for Payer: AlohaCare Medicaid	$1,446.00
Rate for Payer: AlohaCare Medicare	$2,197.92
Rate for Payer: Cash Price	$1,735.20
Rate for Payer: Devoted Health Medicare	$2,429.28
Rate for Payer: Hawaii Medical Service Association Medicare	$2,197.92
Rate for Payer: Hawaii Western Management Group Commercial	$2,024.40
Rate for Payer: Health Management Network Commercial	$2,458.20
Rate for Payer: Humana Medicare	$2,197.92
Rate for Payer: Kaiser Permanente Commercial	$2,602.80
Rate for Payer: Kaiser Permanente Medicaid	$1,474.92
Rate for Payer: Kaiser Permanente Medicare	$2,197.92
Rate for Payer: MDX Hawaii PPO	$2,805.24
Rate for Payer: Ohana Health Plan Medicaid	$2,197.92
Rate for Payer: Ohana Health Plan Medicare	$2,197.92
Rate for Payer: UnitedHealthcare Medicare	$2,197.92
Rate for Payer: University Health Alliance Commercial	$1,619.52

PLATE MATRX 12H 1.5 04.503.717

Facility

$2,770.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,385.00
Max. Negotiated Rate	$2,686.90
Rate for Payer: AlohaCare Medicaid	$1,385.00
Rate for Payer: AlohaCare Medicare	$2,105.20
Rate for Payer: Cash Price	$1,662.00
Rate for Payer: Devoted Health Medicare	$2,326.80
Rate for Payer: Hawaii Medical Service Association Medicare	$2,105.20
Rate for Payer: Hawaii Western Management Group Commercial	$1,939.00
Rate for Payer: Health Management Network Commercial	$2,354.50
Rate for Payer: Humana Medicare	$2,105.20
Rate for Payer: Kaiser Permanente Commercial	$2,493.00
Rate for Payer: Kaiser Permanente Medicaid	$1,412.70
Rate for Payer: Kaiser Permanente Medicare	$2,105.20
Rate for Payer: MDX Hawaii PPO	$2,686.90
Rate for Payer: Ohana Health Plan Medicaid	$2,105.20
Rate for Payer: Ohana Health Plan Medicare	$2,105.20
Rate for Payer: UnitedHealthcare Medicare	$2,105.20
Rate for Payer: University Health Alliance Commercial	$1,551.20

PLATE MATRX 12H 1.5 04.503.717

Facility

$2,770.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,551.20
Max. Negotiated Rate	$2,686.90
Rate for Payer: Cash Price	$1,662.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,939.00
Rate for Payer: Health Management Network Commercial	$2,354.50
Rate for Payer: Kaiser Permanente Commercial	$2,493.00
Rate for Payer: MDX Hawaii PPO	$2,686.90
Rate for Payer: University Health Alliance Commercial	$1,551.20

PLATE MED DIST 6H RT 627436

Facility

$4,824.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$2,701.44
Max. Negotiated Rate	$4,679.28
Rate for Payer: Cash Price	$2,894.40
Rate for Payer: Hawaii Western Management Group Commercial	$3,376.80
Rate for Payer: Health Management Network Commercial	$4,100.40
Rate for Payer: Kaiser Permanente Commercial	$4,341.60
Rate for Payer: MDX Hawaii PPO	$4,679.28
Rate for Payer: University Health Alliance Commercial	$2,701.44

PLATE MED DIST 6H RT 627436

Facility

$4,824.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$2,412.00
Max. Negotiated Rate	$4,679.28
Rate for Payer: AlohaCare Medicaid	$2,412.00
Rate for Payer: AlohaCare Medicare	$3,666.24
Rate for Payer: Cash Price	$2,894.40
Rate for Payer: Devoted Health Medicare	$4,052.16
Rate for Payer: Hawaii Medical Service Association Medicare	$3,666.24
Rate for Payer: Hawaii Western Management Group Commercial	$3,376.80
Rate for Payer: Health Management Network Commercial	$4,100.40
Rate for Payer: Humana Medicare	$3,666.24
Rate for Payer: Kaiser Permanente Commercial	$4,341.60
Rate for Payer: Kaiser Permanente Medicaid	$2,460.24
Rate for Payer: Kaiser Permanente Medicare	$3,666.24
Rate for Payer: MDX Hawaii PPO	$4,679.28
Rate for Payer: Ohana Health Plan Medicaid	$3,666.24
Rate for Payer: Ohana Health Plan Medicare	$3,666.24
Rate for Payer: UnitedHealthcare Medicare	$3,666.24
Rate for Payer: University Health Alliance Commercial	$2,701.44

PLATE MEDIAL DIST HUM 2.7/3.5

Facility

$3,042.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,703.52
Max. Negotiated Rate	$2,950.74
Rate for Payer: Cash Price	$1,825.20
Rate for Payer: Hawaii Western Management Group Commercial	$2,129.40
Rate for Payer: Health Management Network Commercial	$2,585.70
Rate for Payer: Kaiser Permanente Commercial	$2,737.80
Rate for Payer: MDX Hawaii PPO	$2,950.74
Rate for Payer: University Health Alliance Commercial	$1,703.52

PLATE MEDIAL DIST HUM 2.7/3.5

Facility

$3,042.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,521.00
Max. Negotiated Rate	$2,950.74
Rate for Payer: AlohaCare Medicaid	$1,521.00
Rate for Payer: AlohaCare Medicare	$2,311.92
Rate for Payer: Cash Price	$1,825.20
Rate for Payer: Devoted Health Medicare	$2,555.28
Rate for Payer: Hawaii Medical Service Association Medicare	$2,311.92
Rate for Payer: Hawaii Western Management Group Commercial	$2,129.40
Rate for Payer: Health Management Network Commercial	$2,585.70
Rate for Payer: Humana Medicare	$2,311.92
Rate for Payer: Kaiser Permanente Commercial	$2,737.80
Rate for Payer: Kaiser Permanente Medicaid	$1,551.42
Rate for Payer: Kaiser Permanente Medicare	$2,311.92
Rate for Payer: MDX Hawaii PPO	$2,950.74
Rate for Payer: Ohana Health Plan Medicaid	$2,311.92
Rate for Payer: Ohana Health Plan Medicare	$2,311.92
Rate for Payer: UnitedHealthcare Medicare	$2,311.92
Rate for Payer: University Health Alliance Commercial	$1,703.52

PLATE MESH 56MM CALC 336-3530

Facility

$2,667.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,493.52
Max. Negotiated Rate	$2,586.99
Rate for Payer: Cash Price	$1,600.20
Rate for Payer: Hawaii Western Management Group Commercial	$1,866.90
Rate for Payer: Health Management Network Commercial	$2,266.95
Rate for Payer: Kaiser Permanente Commercial	$2,400.30
Rate for Payer: MDX Hawaii PPO	$2,586.99
Rate for Payer: University Health Alliance Commercial	$1,493.52

PLATE MESH 56MM CALC 336-3530

Facility

$2,667.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,333.50
Max. Negotiated Rate	$2,586.99
Rate for Payer: AlohaCare Medicaid	$1,333.50
Rate for Payer: AlohaCare Medicare	$2,026.92
Rate for Payer: Cash Price	$1,600.20
Rate for Payer: Devoted Health Medicare	$2,240.28
Rate for Payer: Hawaii Medical Service Association Medicare	$2,026.92
Rate for Payer: Hawaii Western Management Group Commercial	$1,866.90
Rate for Payer: Health Management Network Commercial	$2,266.95
Rate for Payer: Humana Medicare	$2,026.92
Rate for Payer: Kaiser Permanente Commercial	$2,400.30
Rate for Payer: Kaiser Permanente Medicaid	$1,360.17
Rate for Payer: Kaiser Permanente Medicare	$2,026.92
Rate for Payer: MDX Hawaii PPO	$2,586.99
Rate for Payer: Ohana Health Plan Medicaid	$2,026.92
Rate for Payer: Ohana Health Plan Medicare	$2,026.92
Rate for Payer: UnitedHealthcare Medicare	$2,026.92
Rate for Payer: University Health Alliance Commercial	$1,493.52

PLATE MESH 65MM CALC 336-3531

Facility

$2,667.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,333.50
Max. Negotiated Rate	$2,586.99
Rate for Payer: AlohaCare Medicaid	$1,333.50
Rate for Payer: AlohaCare Medicare	$2,026.92
Rate for Payer: Cash Price	$1,600.20
Rate for Payer: Devoted Health Medicare	$2,240.28
Rate for Payer: Hawaii Medical Service Association Medicare	$2,026.92
Rate for Payer: Hawaii Western Management Group Commercial	$1,866.90
Rate for Payer: Health Management Network Commercial	$2,266.95
Rate for Payer: Humana Medicare	$2,026.92
Rate for Payer: Kaiser Permanente Commercial	$2,400.30
Rate for Payer: Kaiser Permanente Medicaid	$1,360.17
Rate for Payer: Kaiser Permanente Medicare	$2,026.92
Rate for Payer: MDX Hawaii PPO	$2,586.99
Rate for Payer: Ohana Health Plan Medicaid	$2,026.92
Rate for Payer: Ohana Health Plan Medicare	$2,026.92
Rate for Payer: UnitedHealthcare Medicare	$2,026.92
Rate for Payer: University Health Alliance Commercial	$1,493.52

Know your out-of-pocket cost for care.

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