Honoka'a Hospital and Skilled Nursing Facility

All Charges

Charge

Type

Setting

Price

PLT COMP 16H 3.5X194MM 4935-16

Facility

$1,530.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$856.80
Max. Negotiated Rate	$1,484.10
Rate for Payer: Cash Price	$918.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,071.00
Rate for Payer: Health Management Network Commercial	$1,300.50
Rate for Payer: Kaiser Permanente Commercial	$1,377.00
Rate for Payer: MDX Hawaii PPO	$1,484.10
Rate for Payer: University Health Alliance Commercial	$856.80

PLT COMP 16H 3.5X194MM 4935-16

Facility

$1,530.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$765.00
Max. Negotiated Rate	$1,484.10
Rate for Payer: AlohaCare Medicaid	$765.00
Rate for Payer: AlohaCare Medicare	$1,162.80
Rate for Payer: Cash Price	$918.00
Rate for Payer: Devoted Health Medicare	$1,285.20
Rate for Payer: Hawaii Medical Service Association Medicare	$1,162.80
Rate for Payer: Hawaii Western Management Group Commercial	$1,071.00
Rate for Payer: Health Management Network Commercial	$1,300.50
Rate for Payer: Humana Medicare	$1,162.80
Rate for Payer: Kaiser Permanente Commercial	$1,377.00
Rate for Payer: Kaiser Permanente Medicaid	$780.30
Rate for Payer: Kaiser Permanente Medicare	$1,162.80
Rate for Payer: MDX Hawaii PPO	$1,484.10
Rate for Payer: Ohana Health Plan Medicaid	$1,162.80
Rate for Payer: Ohana Health Plan Medicare	$1,162.80
Rate for Payer: UnitedHealthcare Medicare	$1,162.80
Rate for Payer: University Health Alliance Commercial	$856.80

PLT COMP 18H 3.5X217MM 4935-18

Facility

$1,719.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$962.64
Max. Negotiated Rate	$1,667.43
Rate for Payer: Cash Price	$1,031.40
Rate for Payer: Hawaii Western Management Group Commercial	$1,203.30
Rate for Payer: Health Management Network Commercial	$1,461.15
Rate for Payer: Kaiser Permanente Commercial	$1,547.10
Rate for Payer: MDX Hawaii PPO	$1,667.43
Rate for Payer: University Health Alliance Commercial	$962.64

PLT COMP 18H 3.5X217MM 4935-18

Facility

$1,719.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$859.50
Max. Negotiated Rate	$1,667.43
Rate for Payer: AlohaCare Medicaid	$859.50
Rate for Payer: AlohaCare Medicare	$1,306.44
Rate for Payer: Cash Price	$1,031.40
Rate for Payer: Devoted Health Medicare	$1,443.96
Rate for Payer: Hawaii Medical Service Association Medicare	$1,306.44
Rate for Payer: Hawaii Western Management Group Commercial	$1,203.30
Rate for Payer: Health Management Network Commercial	$1,461.15
Rate for Payer: Humana Medicare	$1,306.44
Rate for Payer: Kaiser Permanente Commercial	$1,547.10
Rate for Payer: Kaiser Permanente Medicaid	$876.69
Rate for Payer: Kaiser Permanente Medicare	$1,306.44
Rate for Payer: MDX Hawaii PPO	$1,667.43
Rate for Payer: Ohana Health Plan Medicaid	$1,306.44
Rate for Payer: Ohana Health Plan Medicare	$1,306.44
Rate for Payer: UnitedHealthcare Medicare	$1,306.44
Rate for Payer: University Health Alliance Commercial	$962.64

PLT COMP 20H 3.5X242MM 4935-20

Facility

$1,875.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,050.00
Max. Negotiated Rate	$1,818.75
Rate for Payer: Cash Price	$1,125.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,312.50
Rate for Payer: Health Management Network Commercial	$1,593.75
Rate for Payer: Kaiser Permanente Commercial	$1,687.50
Rate for Payer: MDX Hawaii PPO	$1,818.75
Rate for Payer: University Health Alliance Commercial	$1,050.00

PLT COMP 20H 3.5X242MM 4935-20

Facility

$1,875.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$937.50
Max. Negotiated Rate	$1,818.75
Rate for Payer: AlohaCare Medicaid	$937.50
Rate for Payer: AlohaCare Medicare	$1,425.00
Rate for Payer: Cash Price	$1,125.00
Rate for Payer: Devoted Health Medicare	$1,575.00
Rate for Payer: Hawaii Medical Service Association Medicare	$1,425.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,312.50
Rate for Payer: Health Management Network Commercial	$1,593.75
Rate for Payer: Humana Medicare	$1,425.00
Rate for Payer: Kaiser Permanente Commercial	$1,687.50
Rate for Payer: Kaiser Permanente Medicaid	$956.25
Rate for Payer: Kaiser Permanente Medicare	$1,425.00
Rate for Payer: MDX Hawaii PPO	$1,818.75
Rate for Payer: Ohana Health Plan Medicaid	$1,425.00
Rate for Payer: Ohana Health Plan Medicare	$1,425.00
Rate for Payer: UnitedHealthcare Medicare	$1,425.00
Rate for Payer: University Health Alliance Commercial	$1,050.00

PLT COMP 22H 3.5X265MM 4935-22

Facility

$2,034.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,017.00
Max. Negotiated Rate	$1,972.98
Rate for Payer: AlohaCare Medicaid	$1,017.00
Rate for Payer: AlohaCare Medicare	$1,545.84
Rate for Payer: Cash Price	$1,220.40
Rate for Payer: Devoted Health Medicare	$1,708.56
Rate for Payer: Hawaii Medical Service Association Medicare	$1,545.84
Rate for Payer: Hawaii Western Management Group Commercial	$1,423.80
Rate for Payer: Health Management Network Commercial	$1,728.90
Rate for Payer: Humana Medicare	$1,545.84
Rate for Payer: Kaiser Permanente Commercial	$1,830.60
Rate for Payer: Kaiser Permanente Medicaid	$1,037.34
Rate for Payer: Kaiser Permanente Medicare	$1,545.84
Rate for Payer: MDX Hawaii PPO	$1,972.98
Rate for Payer: Ohana Health Plan Medicaid	$1,545.84
Rate for Payer: Ohana Health Plan Medicare	$1,545.84
Rate for Payer: UnitedHealthcare Medicare	$1,545.84
Rate for Payer: University Health Alliance Commercial	$1,139.04

PLT COMP 22H 3.5X265MM 4935-22

Facility

$2,034.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,139.04
Max. Negotiated Rate	$1,972.98
Rate for Payer: Cash Price	$1,220.40
Rate for Payer: Hawaii Western Management Group Commercial	$1,423.80
Rate for Payer: Health Management Network Commercial	$1,728.90
Rate for Payer: Kaiser Permanente Commercial	$1,830.60
Rate for Payer: MDX Hawaii PPO	$1,972.98
Rate for Payer: University Health Alliance Commercial	$1,139.04

PLT COMP 2H 3.5X25MM 4935-02

Facility

$394.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$220.64
Max. Negotiated Rate	$382.18
Rate for Payer: Cash Price	$236.40
Rate for Payer: Hawaii Western Management Group Commercial	$275.80
Rate for Payer: Health Management Network Commercial	$334.90
Rate for Payer: Kaiser Permanente Commercial	$354.60
Rate for Payer: MDX Hawaii PPO	$382.18
Rate for Payer: University Health Alliance Commercial	$220.64

PLT COMP 2H 3.5X25MM 4935-02

Facility

$394.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$197.00
Max. Negotiated Rate	$382.18
Rate for Payer: AlohaCare Medicaid	$197.00
Rate for Payer: AlohaCare Medicare	$299.44
Rate for Payer: Cash Price	$236.40
Rate for Payer: Devoted Health Medicare	$330.96
Rate for Payer: Hawaii Medical Service Association Medicare	$299.44
Rate for Payer: Hawaii Western Management Group Commercial	$275.80
Rate for Payer: Health Management Network Commercial	$334.90
Rate for Payer: Humana Medicare	$299.44
Rate for Payer: Kaiser Permanente Commercial	$354.60
Rate for Payer: Kaiser Permanente Medicaid	$200.94
Rate for Payer: Kaiser Permanente Medicare	$299.44
Rate for Payer: MDX Hawaii PPO	$382.18
Rate for Payer: Ohana Health Plan Medicaid	$299.44
Rate for Payer: Ohana Health Plan Medicare	$299.44
Rate for Payer: UnitedHealthcare Medicare	$299.44
Rate for Payer: University Health Alliance Commercial	$220.64

PLT COMP 3H 3.5X37MM 4935-03

Facility

$420.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$235.20
Max. Negotiated Rate	$407.40
Rate for Payer: Cash Price	$252.00
Rate for Payer: Hawaii Western Management Group Commercial	$294.00
Rate for Payer: Health Management Network Commercial	$357.00
Rate for Payer: Kaiser Permanente Commercial	$378.00
Rate for Payer: MDX Hawaii PPO	$407.40
Rate for Payer: University Health Alliance Commercial	$235.20

PLT COMP 3H 3.5X37MM 4935-03

Facility

$420.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$210.00
Max. Negotiated Rate	$407.40
Rate for Payer: AlohaCare Medicaid	$210.00
Rate for Payer: AlohaCare Medicare	$319.20
Rate for Payer: Cash Price	$252.00
Rate for Payer: Devoted Health Medicare	$352.80
Rate for Payer: Hawaii Medical Service Association Medicare	$319.20
Rate for Payer: Hawaii Western Management Group Commercial	$294.00
Rate for Payer: Health Management Network Commercial	$357.00
Rate for Payer: Humana Medicare	$319.20
Rate for Payer: Kaiser Permanente Commercial	$378.00
Rate for Payer: Kaiser Permanente Medicaid	$214.20
Rate for Payer: Kaiser Permanente Medicare	$319.20
Rate for Payer: MDX Hawaii PPO	$407.40
Rate for Payer: Ohana Health Plan Medicaid	$319.20
Rate for Payer: Ohana Health Plan Medicare	$319.20
Rate for Payer: UnitedHealthcare Medicare	$319.20
Rate for Payer: University Health Alliance Commercial	$235.20

PLT COMP 4H 3.5X49MM 4935-04

Facility

$446.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$223.00
Max. Negotiated Rate	$432.62
Rate for Payer: AlohaCare Medicaid	$223.00
Rate for Payer: AlohaCare Medicare	$338.96
Rate for Payer: Cash Price	$267.60
Rate for Payer: Devoted Health Medicare	$374.64
Rate for Payer: Hawaii Medical Service Association Medicare	$338.96
Rate for Payer: Hawaii Western Management Group Commercial	$312.20
Rate for Payer: Health Management Network Commercial	$379.10
Rate for Payer: Humana Medicare	$338.96
Rate for Payer: Kaiser Permanente Commercial	$401.40
Rate for Payer: Kaiser Permanente Medicaid	$227.46
Rate for Payer: Kaiser Permanente Medicare	$338.96
Rate for Payer: MDX Hawaii PPO	$432.62
Rate for Payer: Ohana Health Plan Medicaid	$338.96
Rate for Payer: Ohana Health Plan Medicare	$338.96
Rate for Payer: UnitedHealthcare Medicare	$338.96
Rate for Payer: University Health Alliance Commercial	$249.76

PLT COMP 4H 3.5X49MM 4935-04

Facility

$446.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$249.76
Max. Negotiated Rate	$432.62
Rate for Payer: Cash Price	$267.60
Rate for Payer: Hawaii Western Management Group Commercial	$312.20
Rate for Payer: Health Management Network Commercial	$379.10
Rate for Payer: Kaiser Permanente Commercial	$401.40
Rate for Payer: MDX Hawaii PPO	$432.62
Rate for Payer: University Health Alliance Commercial	$249.76

PLT COMP 5H 3.5X61MM 4935-05

Facility

$750.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$375.00
Max. Negotiated Rate	$727.50
Rate for Payer: AlohaCare Medicaid	$375.00
Rate for Payer: AlohaCare Medicare	$570.00
Rate for Payer: Cash Price	$450.00
Rate for Payer: Devoted Health Medicare	$630.00
Rate for Payer: Hawaii Medical Service Association Medicare	$570.00
Rate for Payer: Hawaii Western Management Group Commercial	$525.00
Rate for Payer: Health Management Network Commercial	$637.50
Rate for Payer: Humana Medicare	$570.00
Rate for Payer: Kaiser Permanente Commercial	$675.00
Rate for Payer: Kaiser Permanente Medicaid	$382.50
Rate for Payer: Kaiser Permanente Medicare	$570.00
Rate for Payer: MDX Hawaii PPO	$727.50
Rate for Payer: Ohana Health Plan Medicaid	$570.00
Rate for Payer: Ohana Health Plan Medicare	$570.00
Rate for Payer: UnitedHealthcare Medicare	$570.00
Rate for Payer: University Health Alliance Commercial	$420.00

PLT COMP 5H 3.5X61MM 4935-05

Facility

$750.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$420.00
Max. Negotiated Rate	$727.50
Rate for Payer: Cash Price	$450.00
Rate for Payer: Hawaii Western Management Group Commercial	$525.00
Rate for Payer: Health Management Network Commercial	$637.50
Rate for Payer: Kaiser Permanente Commercial	$675.00
Rate for Payer: MDX Hawaii PPO	$727.50
Rate for Payer: University Health Alliance Commercial	$420.00

PLT COMP 8H 3.5X97MM 4935-08

Facility

$531.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$265.50
Max. Negotiated Rate	$515.07
Rate for Payer: AlohaCare Medicaid	$265.50
Rate for Payer: AlohaCare Medicare	$403.56
Rate for Payer: Cash Price	$318.60
Rate for Payer: Devoted Health Medicare	$446.04
Rate for Payer: Hawaii Medical Service Association Medicare	$403.56
Rate for Payer: Hawaii Western Management Group Commercial	$371.70
Rate for Payer: Health Management Network Commercial	$451.35
Rate for Payer: Humana Medicare	$403.56
Rate for Payer: Kaiser Permanente Commercial	$477.90
Rate for Payer: Kaiser Permanente Medicaid	$270.81
Rate for Payer: Kaiser Permanente Medicare	$403.56
Rate for Payer: MDX Hawaii PPO	$515.07
Rate for Payer: Ohana Health Plan Medicaid	$403.56
Rate for Payer: Ohana Health Plan Medicare	$403.56
Rate for Payer: UnitedHealthcare Medicare	$403.56
Rate for Payer: University Health Alliance Commercial	$297.36

PLT COMP 8H 3.5X97MM 4935-08

Facility

$531.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$297.36
Max. Negotiated Rate	$515.07
Rate for Payer: Cash Price	$318.60
Rate for Payer: Hawaii Western Management Group Commercial	$371.70
Rate for Payer: Health Management Network Commercial	$451.35
Rate for Payer: Kaiser Permanente Commercial	$477.90
Rate for Payer: MDX Hawaii PPO	$515.07
Rate for Payer: University Health Alliance Commercial	$297.36

PLT COMP 9H 3.5X109MM 4935-09

Facility

$863.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$483.28
Max. Negotiated Rate	$837.11
Rate for Payer: Cash Price	$517.80
Rate for Payer: Hawaii Western Management Group Commercial	$604.10
Rate for Payer: Health Management Network Commercial	$733.55
Rate for Payer: Kaiser Permanente Commercial	$776.70
Rate for Payer: MDX Hawaii PPO	$837.11
Rate for Payer: University Health Alliance Commercial	$483.28

PLT COMP 9H 3.5X109MM 4935-09

Facility

$863.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$431.50
Max. Negotiated Rate	$837.11
Rate for Payer: AlohaCare Medicaid	$431.50
Rate for Payer: AlohaCare Medicare	$655.88
Rate for Payer: Cash Price	$517.80
Rate for Payer: Devoted Health Medicare	$724.92
Rate for Payer: Hawaii Medical Service Association Medicare	$655.88
Rate for Payer: Hawaii Western Management Group Commercial	$604.10
Rate for Payer: Health Management Network Commercial	$733.55
Rate for Payer: Humana Medicare	$655.88
Rate for Payer: Kaiser Permanente Commercial	$776.70
Rate for Payer: Kaiser Permanente Medicaid	$440.13
Rate for Payer: Kaiser Permanente Medicare	$655.88
Rate for Payer: MDX Hawaii PPO	$837.11
Rate for Payer: Ohana Health Plan Medicaid	$655.88
Rate for Payer: Ohana Health Plan Medicare	$655.88
Rate for Payer: UnitedHealthcare Medicare	$655.88
Rate for Payer: University Health Alliance Commercial	$483.28

PLT LCDCP 14H 4.5X250MM 226.64

Facility

$1,470.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$735.00
Max. Negotiated Rate	$1,425.90
Rate for Payer: AlohaCare Medicaid	$735.00
Rate for Payer: AlohaCare Medicare	$1,117.20
Rate for Payer: Cash Price	$882.00
Rate for Payer: Devoted Health Medicare	$1,234.80
Rate for Payer: Hawaii Medical Service Association Medicare	$1,117.20
Rate for Payer: Hawaii Western Management Group Commercial	$1,029.00
Rate for Payer: Health Management Network Commercial	$1,249.50
Rate for Payer: Humana Medicare	$1,117.20
Rate for Payer: Kaiser Permanente Commercial	$1,323.00
Rate for Payer: Kaiser Permanente Medicaid	$749.70
Rate for Payer: Kaiser Permanente Medicare	$1,117.20
Rate for Payer: MDX Hawaii PPO	$1,425.90
Rate for Payer: Ohana Health Plan Medicaid	$1,117.20
Rate for Payer: Ohana Health Plan Medicare	$1,117.20
Rate for Payer: UnitedHealthcare Medicare	$1,117.20
Rate for Payer: University Health Alliance Commercial	$823.20

PLT LCDCP 14H 4.5X250MM 226.64

Facility

$1,470.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$823.20
Max. Negotiated Rate	$1,425.90
Rate for Payer: Cash Price	$882.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,029.00
Rate for Payer: Health Management Network Commercial	$1,249.50
Rate for Payer: Kaiser Permanente Commercial	$1,323.00
Rate for Payer: MDX Hawaii PPO	$1,425.90
Rate for Payer: University Health Alliance Commercial	$823.20

PLT LCP 10H 1/3T 117MM 241.401

Facility

$1,082.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$541.00
Max. Negotiated Rate	$1,049.54
Rate for Payer: AlohaCare Medicaid	$541.00
Rate for Payer: AlohaCare Medicare	$822.32
Rate for Payer: Cash Price	$649.20
Rate for Payer: Devoted Health Medicare	$908.88
Rate for Payer: Hawaii Medical Service Association Medicare	$822.32
Rate for Payer: Hawaii Western Management Group Commercial	$757.40
Rate for Payer: Health Management Network Commercial	$919.70
Rate for Payer: Humana Medicare	$822.32
Rate for Payer: Kaiser Permanente Commercial	$973.80
Rate for Payer: Kaiser Permanente Medicaid	$551.82
Rate for Payer: Kaiser Permanente Medicare	$822.32
Rate for Payer: MDX Hawaii PPO	$1,049.54
Rate for Payer: Ohana Health Plan Medicaid	$822.32
Rate for Payer: Ohana Health Plan Medicare	$822.32
Rate for Payer: UnitedHealthcare Medicare	$822.32
Rate for Payer: University Health Alliance Commercial	$605.92

PLT LCP 10H 1/3T 117MM 241.401

Facility

$1,082.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$605.92
Max. Negotiated Rate	$1,049.54
Rate for Payer: Cash Price	$649.20
Rate for Payer: Hawaii Western Management Group Commercial	$757.40
Rate for Payer: Health Management Network Commercial	$919.70
Rate for Payer: Kaiser Permanente Commercial	$973.80
Rate for Payer: MDX Hawaii PPO	$1,049.54
Rate for Payer: University Health Alliance Commercial	$605.92

PLT LCP 12H 4.5X229MM 226.622

Facility

$2,250.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,260.00
Max. Negotiated Rate	$2,182.50
Rate for Payer: Cash Price	$1,350.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,575.00
Rate for Payer: Health Management Network Commercial	$1,912.50
Rate for Payer: Kaiser Permanente Commercial	$2,025.00
Rate for Payer: MDX Hawaii PPO	$2,182.50
Rate for Payer: University Health Alliance Commercial	$1,260.00

Know your out-of-pocket cost for care.

All Charges