Honoka'a Hospital and Skilled Nursing Facility

All Charges

Charge

Type

Setting

Price

PLATE-T 4H 84MM 240.14

Facility

$1,176.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$588.00
Max. Negotiated Rate	$1,140.72
Rate for Payer: AlohaCare Medicaid	$588.00
Rate for Payer: AlohaCare Medicare	$893.76
Rate for Payer: Cash Price	$705.60
Rate for Payer: Devoted Health Medicare	$987.84
Rate for Payer: Hawaii Medical Service Association Medicare	$893.76
Rate for Payer: Hawaii Western Management Group Commercial	$823.20
Rate for Payer: Health Management Network Commercial	$999.60
Rate for Payer: Humana Medicare	$893.76
Rate for Payer: Kaiser Permanente Commercial	$1,058.40
Rate for Payer: Kaiser Permanente Medicaid	$599.76
Rate for Payer: Kaiser Permanente Medicare	$893.76
Rate for Payer: MDX Hawaii PPO	$1,140.72
Rate for Payer: Ohana Health Plan Medicaid	$893.76
Rate for Payer: Ohana Health Plan Medicare	$893.76
Rate for Payer: UnitedHealthcare Medicare	$893.76
Rate for Payer: University Health Alliance Commercial	$658.56

PLATE T 5 HOLE 629778

Facility

$2,137.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,196.72
Max. Negotiated Rate	$2,072.89
Rate for Payer: Cash Price	$1,282.20
Rate for Payer: Hawaii Western Management Group Commercial	$1,495.90
Rate for Payer: Health Management Network Commercial	$1,816.45
Rate for Payer: Kaiser Permanente Commercial	$1,923.30
Rate for Payer: MDX Hawaii PPO	$2,072.89
Rate for Payer: University Health Alliance Commercial	$1,196.72

PLATE T 5 HOLE 629778

Facility

$2,137.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,068.50
Max. Negotiated Rate	$2,072.89
Rate for Payer: AlohaCare Medicaid	$1,068.50
Rate for Payer: AlohaCare Medicare	$1,624.12
Rate for Payer: Cash Price	$1,282.20
Rate for Payer: Devoted Health Medicare	$1,795.08
Rate for Payer: Hawaii Medical Service Association Medicare	$1,624.12
Rate for Payer: Hawaii Western Management Group Commercial	$1,495.90
Rate for Payer: Health Management Network Commercial	$1,816.45
Rate for Payer: Humana Medicare	$1,624.12
Rate for Payer: Kaiser Permanente Commercial	$1,923.30
Rate for Payer: Kaiser Permanente Medicaid	$1,089.87
Rate for Payer: Kaiser Permanente Medicare	$1,624.12
Rate for Payer: MDX Hawaii PPO	$2,072.89
Rate for Payer: Ohana Health Plan Medicaid	$1,624.12
Rate for Payer: Ohana Health Plan Medicare	$1,624.12
Rate for Payer: UnitedHealthcare Medicare	$1,624.12
Rate for Payer: University Health Alliance Commercial	$1,196.72

PLATE T-BONE SM 6HOLE 57-10140

Facility

$1,562.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$781.00
Max. Negotiated Rate	$1,515.14
Rate for Payer: AlohaCare Medicaid	$781.00
Rate for Payer: AlohaCare Medicare	$1,187.12
Rate for Payer: Cash Price	$937.20
Rate for Payer: Devoted Health Medicare	$1,312.08
Rate for Payer: Hawaii Medical Service Association Medicare	$1,187.12
Rate for Payer: Hawaii Western Management Group Commercial	$1,093.40
Rate for Payer: Health Management Network Commercial	$1,327.70
Rate for Payer: Humana Medicare	$1,187.12
Rate for Payer: Kaiser Permanente Commercial	$1,405.80
Rate for Payer: Kaiser Permanente Medicaid	$796.62
Rate for Payer: Kaiser Permanente Medicare	$1,187.12
Rate for Payer: MDX Hawaii PPO	$1,515.14
Rate for Payer: Ohana Health Plan Medicaid	$1,187.12
Rate for Payer: Ohana Health Plan Medicare	$1,187.12
Rate for Payer: UnitedHealthcare Medicare	$1,187.12
Rate for Payer: University Health Alliance Commercial	$874.72

PLATE T-BONE SM 6HOLE 57-10140

Facility

$1,562.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$874.72
Max. Negotiated Rate	$1,515.14
Rate for Payer: Cash Price	$937.20
Rate for Payer: Hawaii Western Management Group Commercial	$1,093.40
Rate for Payer: Health Management Network Commercial	$1,327.70
Rate for Payer: Kaiser Permanente Commercial	$1,405.80
Rate for Payer: MDX Hawaii PPO	$1,515.14
Rate for Payer: University Health Alliance Commercial	$874.72

PLATE THIN 3-HOLE/88MM 241.83

Facility

$914.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$457.00
Max. Negotiated Rate	$886.58
Rate for Payer: AlohaCare Medicaid	$457.00
Rate for Payer: AlohaCare Medicare	$694.64
Rate for Payer: Cash Price	$548.40
Rate for Payer: Devoted Health Medicare	$767.76
Rate for Payer: Hawaii Medical Service Association Medicare	$694.64
Rate for Payer: Hawaii Western Management Group Commercial	$639.80
Rate for Payer: Health Management Network Commercial	$776.90
Rate for Payer: Humana Medicare	$694.64
Rate for Payer: Kaiser Permanente Commercial	$822.60
Rate for Payer: Kaiser Permanente Medicaid	$466.14
Rate for Payer: Kaiser Permanente Medicare	$694.64
Rate for Payer: MDX Hawaii PPO	$886.58
Rate for Payer: Ohana Health Plan Medicaid	$694.64
Rate for Payer: Ohana Health Plan Medicare	$694.64
Rate for Payer: UnitedHealthcare Medicare	$694.64
Rate for Payer: University Health Alliance Commercial	$511.84

PLATE THIN 3-HOLE/88MM 241.83

Facility

$914.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$511.84
Max. Negotiated Rate	$886.58
Rate for Payer: Cash Price	$548.40
Rate for Payer: Hawaii Western Management Group Commercial	$639.80
Rate for Payer: Health Management Network Commercial	$776.90
Rate for Payer: Kaiser Permanente Commercial	$822.60
Rate for Payer: MDX Hawaii PPO	$886.58
Rate for Payer: University Health Alliance Commercial	$511.84

PLATE TIB 4HOLE RT 2347-07-04

Facility

$2,328.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,303.68
Max. Negotiated Rate	$2,258.16
Rate for Payer: Cash Price	$1,396.80
Rate for Payer: Hawaii Western Management Group Commercial	$1,629.60
Rate for Payer: Health Management Network Commercial	$1,978.80
Rate for Payer: Kaiser Permanente Commercial	$2,095.20
Rate for Payer: MDX Hawaii PPO	$2,258.16
Rate for Payer: University Health Alliance Commercial	$1,303.68

PLATE TIB 4HOLE RT 2347-07-04

Facility

$2,328.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,164.00
Max. Negotiated Rate	$2,258.16
Rate for Payer: AlohaCare Medicaid	$1,164.00
Rate for Payer: AlohaCare Medicare	$1,769.28
Rate for Payer: Cash Price	$1,396.80
Rate for Payer: Devoted Health Medicare	$1,955.52
Rate for Payer: Hawaii Medical Service Association Medicare	$1,769.28
Rate for Payer: Hawaii Western Management Group Commercial	$1,629.60
Rate for Payer: Health Management Network Commercial	$1,978.80
Rate for Payer: Humana Medicare	$1,769.28
Rate for Payer: Kaiser Permanente Commercial	$2,095.20
Rate for Payer: Kaiser Permanente Medicaid	$1,187.28
Rate for Payer: Kaiser Permanente Medicare	$1,769.28
Rate for Payer: MDX Hawaii PPO	$2,258.16
Rate for Payer: Ohana Health Plan Medicaid	$1,769.28
Rate for Payer: Ohana Health Plan Medicare	$1,769.28
Rate for Payer: UnitedHealthcare Medicare	$1,769.28
Rate for Payer: University Health Alliance Commercial	$1,303.68

PLATE TIBIA 189MM 10H

Facility

$6,772.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$3,386.00
Max. Negotiated Rate	$6,568.84
Rate for Payer: AlohaCare Medicaid	$3,386.00
Rate for Payer: AlohaCare Medicare	$5,146.72
Rate for Payer: Cash Price	$4,063.20
Rate for Payer: Devoted Health Medicare	$5,688.48
Rate for Payer: Hawaii Medical Service Association Medicare	$5,146.72
Rate for Payer: Hawaii Western Management Group Commercial	$4,740.40
Rate for Payer: Health Management Network Commercial	$5,756.20
Rate for Payer: Humana Medicare	$5,146.72
Rate for Payer: Kaiser Permanente Commercial	$6,094.80
Rate for Payer: Kaiser Permanente Medicaid	$3,453.72
Rate for Payer: Kaiser Permanente Medicare	$5,146.72
Rate for Payer: MDX Hawaii PPO	$6,568.84
Rate for Payer: Ohana Health Plan Medicaid	$5,146.72
Rate for Payer: Ohana Health Plan Medicare	$5,146.72
Rate for Payer: UnitedHealthcare Medicare	$5,146.72
Rate for Payer: University Health Alliance Commercial	$3,792.32

PLATE TIBIA 189MM 10H

Facility

$6,772.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$3,792.32
Max. Negotiated Rate	$6,568.84
Rate for Payer: Cash Price	$4,063.20
Rate for Payer: Hawaii Western Management Group Commercial	$4,740.40
Rate for Payer: Health Management Network Commercial	$5,756.20
Rate for Payer: Kaiser Permanente Commercial	$6,094.80
Rate for Payer: MDX Hawaii PPO	$6,568.84
Rate for Payer: University Health Alliance Commercial	$3,792.32

PLATE TIBIA3.5MM SM 02.127.241

Facility

$4,263.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$2,387.28
Max. Negotiated Rate	$4,135.11
Rate for Payer: Cash Price	$2,557.80
Rate for Payer: Hawaii Western Management Group Commercial	$2,984.10
Rate for Payer: Health Management Network Commercial	$3,623.55
Rate for Payer: Kaiser Permanente Commercial	$3,836.70
Rate for Payer: MDX Hawaii PPO	$4,135.11
Rate for Payer: University Health Alliance Commercial	$2,387.28

PLATE TIBIA3.5MM SM 02.127.241

Facility

$4,263.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$2,131.50
Max. Negotiated Rate	$4,135.11
Rate for Payer: AlohaCare Medicaid	$2,131.50
Rate for Payer: AlohaCare Medicare	$3,239.88
Rate for Payer: Cash Price	$2,557.80
Rate for Payer: Devoted Health Medicare	$3,580.92
Rate for Payer: Hawaii Medical Service Association Medicare	$3,239.88
Rate for Payer: Hawaii Western Management Group Commercial	$2,984.10
Rate for Payer: Health Management Network Commercial	$3,623.55
Rate for Payer: Humana Medicare	$3,239.88
Rate for Payer: Kaiser Permanente Commercial	$3,836.70
Rate for Payer: Kaiser Permanente Medicaid	$2,174.13
Rate for Payer: Kaiser Permanente Medicare	$3,239.88
Rate for Payer: MDX Hawaii PPO	$4,135.11
Rate for Payer: Ohana Health Plan Medicaid	$3,239.88
Rate for Payer: Ohana Health Plan Medicare	$3,239.88
Rate for Payer: UnitedHealthcare Medicare	$3,239.88
Rate for Payer: University Health Alliance Commercial	$2,387.28

PLATE TIBIAL 4H 121MM 627334

Facility

$3,712.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$2,078.72
Max. Negotiated Rate	$3,600.64
Rate for Payer: Cash Price	$2,227.20
Rate for Payer: Hawaii Western Management Group Commercial	$2,598.40
Rate for Payer: Health Management Network Commercial	$3,155.20
Rate for Payer: Kaiser Permanente Commercial	$3,340.80
Rate for Payer: MDX Hawaii PPO	$3,600.64
Rate for Payer: University Health Alliance Commercial	$2,078.72

PLATE TIBIAL 4H 121MM 627334

Facility

$3,712.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,856.00
Max. Negotiated Rate	$3,600.64
Rate for Payer: AlohaCare Medicaid	$1,856.00
Rate for Payer: AlohaCare Medicare	$2,821.12
Rate for Payer: Cash Price	$2,227.20
Rate for Payer: Devoted Health Medicare	$3,118.08
Rate for Payer: Hawaii Medical Service Association Medicare	$2,821.12
Rate for Payer: Hawaii Western Management Group Commercial	$2,598.40
Rate for Payer: Health Management Network Commercial	$3,155.20
Rate for Payer: Humana Medicare	$2,821.12
Rate for Payer: Kaiser Permanente Commercial	$3,340.80
Rate for Payer: Kaiser Permanente Medicaid	$1,893.12
Rate for Payer: Kaiser Permanente Medicare	$2,821.12
Rate for Payer: MDX Hawaii PPO	$3,600.64
Rate for Payer: Ohana Health Plan Medicaid	$2,821.12
Rate for Payer: Ohana Health Plan Medicare	$2,821.12
Rate for Payer: UnitedHealthcare Medicare	$2,821.12
Rate for Payer: University Health Alliance Commercial	$2,078.72

PLATE TIBIAL 6HOLE 336-4006

Facility

$3,528.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,975.68
Max. Negotiated Rate	$3,422.16
Rate for Payer: Cash Price	$2,116.80
Rate for Payer: Hawaii Western Management Group Commercial	$2,469.60
Rate for Payer: Health Management Network Commercial	$2,998.80
Rate for Payer: Kaiser Permanente Commercial	$3,175.20
Rate for Payer: MDX Hawaii PPO	$3,422.16
Rate for Payer: University Health Alliance Commercial	$1,975.68

PLATE TIBIAL 6HOLE 336-4006

Facility

$3,528.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,764.00
Max. Negotiated Rate	$3,422.16
Rate for Payer: AlohaCare Medicaid	$1,764.00
Rate for Payer: AlohaCare Medicare	$2,681.28
Rate for Payer: Cash Price	$2,116.80
Rate for Payer: Devoted Health Medicare	$2,963.52
Rate for Payer: Hawaii Medical Service Association Medicare	$2,681.28
Rate for Payer: Hawaii Western Management Group Commercial	$2,469.60
Rate for Payer: Health Management Network Commercial	$2,998.80
Rate for Payer: Humana Medicare	$2,681.28
Rate for Payer: Kaiser Permanente Commercial	$3,175.20
Rate for Payer: Kaiser Permanente Medicaid	$1,799.28
Rate for Payer: Kaiser Permanente Medicare	$2,681.28
Rate for Payer: MDX Hawaii PPO	$3,422.16
Rate for Payer: Ohana Health Plan Medicaid	$2,681.28
Rate for Payer: Ohana Health Plan Medicare	$2,681.28
Rate for Payer: UnitedHealthcare Medicare	$2,681.28
Rate for Payer: University Health Alliance Commercial	$1,975.68

PLATE TIBIAL LEFT 4MM 6H

Facility

$3,414.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,911.84
Max. Negotiated Rate	$3,311.58
Rate for Payer: Cash Price	$2,048.40
Rate for Payer: Hawaii Western Management Group Commercial	$2,389.80
Rate for Payer: Health Management Network Commercial	$2,901.90
Rate for Payer: Kaiser Permanente Commercial	$3,072.60
Rate for Payer: MDX Hawaii PPO	$3,311.58
Rate for Payer: University Health Alliance Commercial	$1,911.84

PLATE TIBIAL LEFT 4MM 6H

Facility

$3,414.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,707.00
Max. Negotiated Rate	$3,311.58
Rate for Payer: AlohaCare Medicaid	$1,707.00
Rate for Payer: AlohaCare Medicare	$2,594.64
Rate for Payer: Cash Price	$2,048.40
Rate for Payer: Devoted Health Medicare	$2,867.76
Rate for Payer: Hawaii Medical Service Association Medicare	$2,594.64
Rate for Payer: Hawaii Western Management Group Commercial	$2,389.80
Rate for Payer: Health Management Network Commercial	$2,901.90
Rate for Payer: Humana Medicare	$2,594.64
Rate for Payer: Kaiser Permanente Commercial	$3,072.60
Rate for Payer: Kaiser Permanente Medicaid	$1,741.14
Rate for Payer: Kaiser Permanente Medicare	$2,594.64
Rate for Payer: MDX Hawaii PPO	$3,311.58
Rate for Payer: Ohana Health Plan Medicaid	$2,594.64
Rate for Payer: Ohana Health Plan Medicare	$2,594.64
Rate for Payer: UnitedHealthcare Medicare	$2,594.64
Rate for Payer: University Health Alliance Commercial	$1,911.84

PLATE TIBIAL LF DISTAL 627404

Facility

$4,686.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$2,624.16
Max. Negotiated Rate	$4,545.42
Rate for Payer: Cash Price	$2,811.60
Rate for Payer: Hawaii Western Management Group Commercial	$3,280.20
Rate for Payer: Health Management Network Commercial	$3,983.10
Rate for Payer: Kaiser Permanente Commercial	$4,217.40
Rate for Payer: MDX Hawaii PPO	$4,545.42
Rate for Payer: University Health Alliance Commercial	$2,624.16

PLATE TIBIAL LF DISTAL 627404

Facility

$4,686.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$2,343.00
Max. Negotiated Rate	$4,545.42
Rate for Payer: AlohaCare Medicaid	$2,343.00
Rate for Payer: AlohaCare Medicare	$3,561.36
Rate for Payer: Cash Price	$2,811.60
Rate for Payer: Devoted Health Medicare	$3,936.24
Rate for Payer: Hawaii Medical Service Association Medicare	$3,561.36
Rate for Payer: Hawaii Western Management Group Commercial	$3,280.20
Rate for Payer: Health Management Network Commercial	$3,983.10
Rate for Payer: Humana Medicare	$3,561.36
Rate for Payer: Kaiser Permanente Commercial	$4,217.40
Rate for Payer: Kaiser Permanente Medicaid	$2,389.86
Rate for Payer: Kaiser Permanente Medicare	$3,561.36
Rate for Payer: MDX Hawaii PPO	$4,545.42
Rate for Payer: Ohana Health Plan Medicaid	$3,561.36
Rate for Payer: Ohana Health Plan Medicare	$3,561.36
Rate for Payer: UnitedHealthcare Medicare	$3,561.36
Rate for Payer: University Health Alliance Commercial	$2,624.16

PLATE TIBIAL RT 8H 627338

Facility

$5,204.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$2,602.00
Max. Negotiated Rate	$5,047.88
Rate for Payer: AlohaCare Medicaid	$2,602.00
Rate for Payer: AlohaCare Medicare	$3,955.04
Rate for Payer: Cash Price	$3,122.40
Rate for Payer: Devoted Health Medicare	$4,371.36
Rate for Payer: Hawaii Medical Service Association Medicare	$3,955.04
Rate for Payer: Hawaii Western Management Group Commercial	$3,642.80
Rate for Payer: Health Management Network Commercial	$4,423.40
Rate for Payer: Humana Medicare	$3,955.04
Rate for Payer: Kaiser Permanente Commercial	$4,683.60
Rate for Payer: Kaiser Permanente Medicaid	$2,654.04
Rate for Payer: Kaiser Permanente Medicare	$3,955.04
Rate for Payer: MDX Hawaii PPO	$5,047.88
Rate for Payer: Ohana Health Plan Medicaid	$3,955.04
Rate for Payer: Ohana Health Plan Medicare	$3,955.04
Rate for Payer: UnitedHealthcare Medicare	$3,955.04
Rate for Payer: University Health Alliance Commercial	$2,914.24

PLATE TIBIAL RT 8H 627338

Facility

$5,204.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$2,914.24
Max. Negotiated Rate	$5,047.88
Rate for Payer: Cash Price	$3,122.40
Rate for Payer: Hawaii Western Management Group Commercial	$3,642.80
Rate for Payer: Health Management Network Commercial	$4,423.40
Rate for Payer: Kaiser Permanente Commercial	$4,683.60
Rate for Payer: MDX Hawaii PPO	$5,047.88
Rate for Payer: University Health Alliance Commercial	$2,914.24

PLATE TIBIAL RT DISTAL 627440

Facility

$3,787.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$2,120.72
Max. Negotiated Rate	$3,673.39
Rate for Payer: Cash Price	$2,272.20
Rate for Payer: Hawaii Western Management Group Commercial	$2,650.90
Rate for Payer: Health Management Network Commercial	$3,218.95
Rate for Payer: Kaiser Permanente Commercial	$3,408.30
Rate for Payer: MDX Hawaii PPO	$3,673.39
Rate for Payer: University Health Alliance Commercial	$2,120.72

PLATE TIBIAL RT DISTAL 627440

Facility

$3,787.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,893.50
Max. Negotiated Rate	$3,673.39
Rate for Payer: AlohaCare Medicaid	$1,893.50
Rate for Payer: AlohaCare Medicare	$2,878.12
Rate for Payer: Cash Price	$2,272.20
Rate for Payer: Devoted Health Medicare	$3,181.08
Rate for Payer: Hawaii Medical Service Association Medicare	$2,878.12
Rate for Payer: Hawaii Western Management Group Commercial	$2,650.90
Rate for Payer: Health Management Network Commercial	$3,218.95
Rate for Payer: Humana Medicare	$2,878.12
Rate for Payer: Kaiser Permanente Commercial	$3,408.30
Rate for Payer: Kaiser Permanente Medicaid	$1,931.37
Rate for Payer: Kaiser Permanente Medicare	$2,878.12
Rate for Payer: MDX Hawaii PPO	$3,673.39
Rate for Payer: Ohana Health Plan Medicaid	$2,878.12
Rate for Payer: Ohana Health Plan Medicare	$2,878.12
Rate for Payer: UnitedHealthcare Medicare	$2,878.12
Rate for Payer: University Health Alliance Commercial	$2,120.72

Know your out-of-pocket cost for care.

All Charges