Honoka'a Hospital and Skilled Nursing Facility

All Charges

Charge

Type

Setting

Price

PLT LCP 12H 4.5X229MM 226.622

Facility

$2,250.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,125.00
Max. Negotiated Rate	$2,182.50
Rate for Payer: AlohaCare Medicaid	$1,125.00
Rate for Payer: AlohaCare Medicare	$1,710.00
Rate for Payer: Cash Price	$1,350.00
Rate for Payer: Devoted Health Medicare	$1,890.00
Rate for Payer: Hawaii Medical Service Association Medicare	$1,710.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,575.00
Rate for Payer: Health Management Network Commercial	$1,912.50
Rate for Payer: Humana Medicare	$1,710.00
Rate for Payer: Kaiser Permanente Commercial	$2,025.00
Rate for Payer: Kaiser Permanente Medicaid	$1,147.50
Rate for Payer: Kaiser Permanente Medicare	$1,710.00
Rate for Payer: MDX Hawaii PPO	$2,182.50
Rate for Payer: Ohana Health Plan Medicaid	$1,710.00
Rate for Payer: Ohana Health Plan Medicare	$1,710.00
Rate for Payer: UnitedHealthcare Medicare	$1,710.00
Rate for Payer: University Health Alliance Commercial	$1,260.00

PLT LCP 13H 4.5X247MM 226.632

Facility

$2,652.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,485.12
Max. Negotiated Rate	$2,572.44
Rate for Payer: Cash Price	$1,591.20
Rate for Payer: Hawaii Western Management Group Commercial	$1,856.40
Rate for Payer: Health Management Network Commercial	$2,254.20
Rate for Payer: Kaiser Permanente Commercial	$2,386.80
Rate for Payer: MDX Hawaii PPO	$2,572.44
Rate for Payer: University Health Alliance Commercial	$1,485.12

PLT LCP 13H 4.5X247MM 226.632

Facility

$2,652.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,326.00
Max. Negotiated Rate	$2,572.44
Rate for Payer: AlohaCare Medicaid	$1,326.00
Rate for Payer: AlohaCare Medicare	$2,015.52
Rate for Payer: Cash Price	$1,591.20
Rate for Payer: Devoted Health Medicare	$2,227.68
Rate for Payer: Hawaii Medical Service Association Medicare	$2,015.52
Rate for Payer: Hawaii Western Management Group Commercial	$1,856.40
Rate for Payer: Health Management Network Commercial	$2,254.20
Rate for Payer: Humana Medicare	$2,015.52
Rate for Payer: Kaiser Permanente Commercial	$2,386.80
Rate for Payer: Kaiser Permanente Medicaid	$1,352.52
Rate for Payer: Kaiser Permanente Medicare	$2,015.52
Rate for Payer: MDX Hawaii PPO	$2,572.44
Rate for Payer: Ohana Health Plan Medicaid	$2,015.52
Rate for Payer: Ohana Health Plan Medicare	$2,015.52
Rate for Payer: UnitedHealthcare Medicare	$2,015.52
Rate for Payer: University Health Alliance Commercial	$1,485.12

PLT LCP 14H 4.5X265MM 226.642

Facility

$2,340.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,170.00
Max. Negotiated Rate	$2,269.80
Rate for Payer: AlohaCare Medicaid	$1,170.00
Rate for Payer: AlohaCare Medicare	$1,778.40
Rate for Payer: Cash Price	$1,404.00
Rate for Payer: Devoted Health Medicare	$1,965.60
Rate for Payer: Hawaii Medical Service Association Medicare	$1,778.40
Rate for Payer: Hawaii Western Management Group Commercial	$1,638.00
Rate for Payer: Health Management Network Commercial	$1,989.00
Rate for Payer: Humana Medicare	$1,778.40
Rate for Payer: Kaiser Permanente Commercial	$2,106.00
Rate for Payer: Kaiser Permanente Medicaid	$1,193.40
Rate for Payer: Kaiser Permanente Medicare	$1,778.40
Rate for Payer: MDX Hawaii PPO	$2,269.80
Rate for Payer: Ohana Health Plan Medicaid	$1,778.40
Rate for Payer: Ohana Health Plan Medicare	$1,778.40
Rate for Payer: UnitedHealthcare Medicare	$1,778.40
Rate for Payer: University Health Alliance Commercial	$1,310.40

PLT LCP 14H 4.5X265MM 226.642

Facility

$2,340.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,310.40
Max. Negotiated Rate	$2,269.80
Rate for Payer: Cash Price	$1,404.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,638.00
Rate for Payer: Health Management Network Commercial	$1,989.00
Rate for Payer: Kaiser Permanente Commercial	$2,106.00
Rate for Payer: MDX Hawaii PPO	$2,269.80
Rate for Payer: University Health Alliance Commercial	$1,310.40

PLT LCP 15H 4.5X282MM 226.652

Facility

$2,598.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,454.88
Max. Negotiated Rate	$2,520.06
Rate for Payer: Cash Price	$1,558.80
Rate for Payer: Hawaii Western Management Group Commercial	$1,818.60
Rate for Payer: Health Management Network Commercial	$2,208.30
Rate for Payer: Kaiser Permanente Commercial	$2,338.20
Rate for Payer: MDX Hawaii PPO	$2,520.06
Rate for Payer: University Health Alliance Commercial	$1,454.88

PLT LCP 15H 4.5X282MM 226.652

Facility

$2,598.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,299.00
Max. Negotiated Rate	$2,520.06
Rate for Payer: AlohaCare Medicaid	$1,299.00
Rate for Payer: AlohaCare Medicare	$1,974.48
Rate for Payer: Cash Price	$1,558.80
Rate for Payer: Devoted Health Medicare	$2,182.32
Rate for Payer: Hawaii Medical Service Association Medicare	$1,974.48
Rate for Payer: Hawaii Western Management Group Commercial	$1,818.60
Rate for Payer: Health Management Network Commercial	$2,208.30
Rate for Payer: Humana Medicare	$1,974.48
Rate for Payer: Kaiser Permanente Commercial	$2,338.20
Rate for Payer: Kaiser Permanente Medicaid	$1,324.98
Rate for Payer: Kaiser Permanente Medicare	$1,974.48
Rate for Payer: MDX Hawaii PPO	$2,520.06
Rate for Payer: Ohana Health Plan Medicaid	$1,974.48
Rate for Payer: Ohana Health Plan Medicare	$1,974.48
Rate for Payer: UnitedHealthcare Medicare	$1,974.48
Rate for Payer: University Health Alliance Commercial	$1,454.88

PLT LCP 16H 4.5X300MM 226.662

Facility

$2,256.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,128.00
Max. Negotiated Rate	$2,188.32
Rate for Payer: AlohaCare Medicaid	$1,128.00
Rate for Payer: AlohaCare Medicare	$1,714.56
Rate for Payer: Cash Price	$1,353.60
Rate for Payer: Devoted Health Medicare	$1,895.04
Rate for Payer: Hawaii Medical Service Association Medicare	$1,714.56
Rate for Payer: Hawaii Western Management Group Commercial	$1,579.20
Rate for Payer: Health Management Network Commercial	$1,917.60
Rate for Payer: Humana Medicare	$1,714.56
Rate for Payer: Kaiser Permanente Commercial	$2,030.40
Rate for Payer: Kaiser Permanente Medicaid	$1,150.56
Rate for Payer: Kaiser Permanente Medicare	$1,714.56
Rate for Payer: MDX Hawaii PPO	$2,188.32
Rate for Payer: Ohana Health Plan Medicaid	$1,714.56
Rate for Payer: Ohana Health Plan Medicare	$1,714.56
Rate for Payer: UnitedHealthcare Medicare	$1,714.56
Rate for Payer: University Health Alliance Commercial	$1,263.36

PLT LCP 16H 4.5X300MM 226.662

Facility

$2,256.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,263.36
Max. Negotiated Rate	$2,188.32
Rate for Payer: Cash Price	$1,353.60
Rate for Payer: Hawaii Western Management Group Commercial	$1,579.20
Rate for Payer: Health Management Network Commercial	$1,917.60
Rate for Payer: Kaiser Permanente Commercial	$2,030.40
Rate for Payer: MDX Hawaii PPO	$2,188.32
Rate for Payer: University Health Alliance Commercial	$1,263.36

PLT LCP 17H 4.5X318MM 226.672

Facility

$2,978.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,667.68
Max. Negotiated Rate	$2,888.66
Rate for Payer: MDX Hawaii PPO	$2,888.66
Rate for Payer: Cash Price	$1,786.80
Rate for Payer: Hawaii Western Management Group Commercial	$2,084.60
Rate for Payer: Health Management Network Commercial	$2,531.30
Rate for Payer: Kaiser Permanente Commercial	$2,680.20
Rate for Payer: University Health Alliance Commercial	$1,667.68

PLT LCP 17H 4.5X318MM 226.672

Facility

$2,978.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,489.00
Max. Negotiated Rate	$2,888.66
Rate for Payer: AlohaCare Medicaid	$1,489.00
Rate for Payer: AlohaCare Medicare	$2,263.28
Rate for Payer: Cash Price	$1,786.80
Rate for Payer: Devoted Health Medicare	$2,501.52
Rate for Payer: Hawaii Medical Service Association Medicare	$2,263.28
Rate for Payer: Hawaii Western Management Group Commercial	$2,084.60
Rate for Payer: Health Management Network Commercial	$2,531.30
Rate for Payer: Humana Medicare	$2,263.28
Rate for Payer: Kaiser Permanente Commercial	$2,680.20
Rate for Payer: Kaiser Permanente Medicaid	$1,518.78
Rate for Payer: Kaiser Permanente Medicare	$2,263.28
Rate for Payer: MDX Hawaii PPO	$2,888.66
Rate for Payer: Ohana Health Plan Medicaid	$2,263.28
Rate for Payer: Ohana Health Plan Medicare	$2,263.28
Rate for Payer: UnitedHealthcare Medicare	$2,263.28
Rate for Payer: University Health Alliance Commercial	$1,667.68

PLT LCP 18H 4.5X336MM 226.682

Facility

$3,246.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,817.76
Max. Negotiated Rate	$3,148.62
Rate for Payer: Cash Price	$1,947.60
Rate for Payer: Hawaii Western Management Group Commercial	$2,272.20
Rate for Payer: Health Management Network Commercial	$2,759.10
Rate for Payer: Kaiser Permanente Commercial	$2,921.40
Rate for Payer: MDX Hawaii PPO	$3,148.62
Rate for Payer: University Health Alliance Commercial	$1,817.76

PLT LCP 18H 4.5X336MM 226.682

Facility

$3,246.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,623.00
Max. Negotiated Rate	$3,148.62
Rate for Payer: AlohaCare Medicaid	$1,623.00
Rate for Payer: AlohaCare Medicare	$2,466.96
Rate for Payer: Cash Price	$1,947.60
Rate for Payer: Devoted Health Medicare	$2,726.64
Rate for Payer: Hawaii Medical Service Association Medicare	$2,466.96
Rate for Payer: Hawaii Western Management Group Commercial	$2,272.20
Rate for Payer: Health Management Network Commercial	$2,759.10
Rate for Payer: Humana Medicare	$2,466.96
Rate for Payer: Kaiser Permanente Commercial	$2,921.40
Rate for Payer: Kaiser Permanente Medicaid	$1,655.46
Rate for Payer: Kaiser Permanente Medicare	$2,466.96
Rate for Payer: MDX Hawaii PPO	$3,148.62
Rate for Payer: Ohana Health Plan Medicaid	$2,466.96
Rate for Payer: Ohana Health Plan Medicare	$2,466.96
Rate for Payer: UnitedHealthcare Medicare	$2,466.96
Rate for Payer: University Health Alliance Commercial	$1,817.76

PLT LCP-T 6H 4.5X115MM 240.161

Facility

$2,436.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,218.00
Max. Negotiated Rate	$2,362.92
Rate for Payer: AlohaCare Medicaid	$1,218.00
Rate for Payer: AlohaCare Medicare	$1,851.36
Rate for Payer: Cash Price	$1,461.60
Rate for Payer: Devoted Health Medicare	$2,046.24
Rate for Payer: Hawaii Medical Service Association Medicare	$1,851.36
Rate for Payer: Hawaii Western Management Group Commercial	$1,705.20
Rate for Payer: Health Management Network Commercial	$2,070.60
Rate for Payer: Humana Medicare	$1,851.36
Rate for Payer: Kaiser Permanente Commercial	$2,192.40
Rate for Payer: Kaiser Permanente Medicaid	$1,242.36
Rate for Payer: Kaiser Permanente Medicare	$1,851.36
Rate for Payer: MDX Hawaii PPO	$2,362.92
Rate for Payer: Ohana Health Plan Medicaid	$1,851.36
Rate for Payer: Ohana Health Plan Medicare	$1,851.36
Rate for Payer: UnitedHealthcare Medicare	$1,851.36
Rate for Payer: University Health Alliance Commercial	$1,364.16

PLT LCP-T 6H 4.5X115MM 240.161

Facility

$2,436.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,364.16
Max. Negotiated Rate	$2,362.92
Rate for Payer: Cash Price	$1,461.60
Rate for Payer: Hawaii Western Management Group Commercial	$1,705.20
Rate for Payer: Health Management Network Commercial	$2,070.60
Rate for Payer: Kaiser Permanente Commercial	$2,192.40
Rate for Payer: MDX Hawaii PPO	$2,362.92
Rate for Payer: University Health Alliance Commercial	$1,364.16

PLT LCP-T 8H 4.5X147MM 240.181

Facility

$2,364.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,323.84
Max. Negotiated Rate	$2,293.08
Rate for Payer: Cash Price	$1,418.40
Rate for Payer: Hawaii Western Management Group Commercial	$1,654.80
Rate for Payer: Health Management Network Commercial	$2,009.40
Rate for Payer: Kaiser Permanente Commercial	$2,127.60
Rate for Payer: MDX Hawaii PPO	$2,293.08
Rate for Payer: University Health Alliance Commercial	$1,323.84

PLT LCP-T 8H 4.5X147MM 240.181

Facility

$2,364.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,182.00
Max. Negotiated Rate	$2,293.08
Rate for Payer: AlohaCare Medicaid	$1,182.00
Rate for Payer: AlohaCare Medicare	$1,796.64
Rate for Payer: Cash Price	$1,418.40
Rate for Payer: Devoted Health Medicare	$1,985.76
Rate for Payer: Hawaii Medical Service Association Medicare	$1,796.64
Rate for Payer: Hawaii Western Management Group Commercial	$1,654.80
Rate for Payer: Health Management Network Commercial	$2,009.40
Rate for Payer: Humana Medicare	$1,796.64
Rate for Payer: Kaiser Permanente Commercial	$2,127.60
Rate for Payer: Kaiser Permanente Medicaid	$1,205.64
Rate for Payer: Kaiser Permanente Medicare	$1,796.64
Rate for Payer: MDX Hawaii PPO	$2,293.08
Rate for Payer: Ohana Health Plan Medicaid	$1,796.64
Rate for Payer: Ohana Health Plan Medicare	$1,796.64
Rate for Payer: UnitedHealthcare Medicare	$1,796.64
Rate for Payer: University Health Alliance Commercial	$1,323.84

PLT LCP TIB 4H "T" 02.118.306

Facility

$2,110.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,181.60
Max. Negotiated Rate	$2,046.70
Rate for Payer: Cash Price	$1,266.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,477.00
Rate for Payer: Health Management Network Commercial	$1,793.50
Rate for Payer: Kaiser Permanente Commercial	$1,899.00
Rate for Payer: MDX Hawaii PPO	$2,046.70
Rate for Payer: University Health Alliance Commercial	$1,181.60

PLT LCP TIB 4H "T" 02.118.306

Facility

$2,110.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,055.00
Max. Negotiated Rate	$2,046.70
Rate for Payer: AlohaCare Medicaid	$1,055.00
Rate for Payer: AlohaCare Medicare	$1,603.60
Rate for Payer: Cash Price	$1,266.00
Rate for Payer: Devoted Health Medicare	$1,772.40
Rate for Payer: Hawaii Medical Service Association Medicare	$1,603.60
Rate for Payer: Hawaii Western Management Group Commercial	$1,477.00
Rate for Payer: Health Management Network Commercial	$1,793.50
Rate for Payer: Humana Medicare	$1,603.60
Rate for Payer: Kaiser Permanente Commercial	$1,899.00
Rate for Payer: Kaiser Permanente Medicaid	$1,076.10
Rate for Payer: Kaiser Permanente Medicare	$1,603.60
Rate for Payer: MDX Hawaii PPO	$2,046.70
Rate for Payer: Ohana Health Plan Medicaid	$1,603.60
Rate for Payer: Ohana Health Plan Medicare	$1,603.60
Rate for Payer: UnitedHealthcare Medicare	$1,603.60
Rate for Payer: University Health Alliance Commercial	$1,181.60

PLT LCP TIB 6H "T" 02.118.207

Facility

$2,196.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,098.00
Max. Negotiated Rate	$2,130.12
Rate for Payer: AlohaCare Medicaid	$1,098.00
Rate for Payer: AlohaCare Medicare	$1,668.96
Rate for Payer: Cash Price	$1,317.60
Rate for Payer: Devoted Health Medicare	$1,844.64
Rate for Payer: Hawaii Medical Service Association Medicare	$1,668.96
Rate for Payer: Hawaii Western Management Group Commercial	$1,537.20
Rate for Payer: Health Management Network Commercial	$1,866.60
Rate for Payer: Humana Medicare	$1,668.96
Rate for Payer: Kaiser Permanente Commercial	$1,976.40
Rate for Payer: Kaiser Permanente Medicaid	$1,119.96
Rate for Payer: Kaiser Permanente Medicare	$1,668.96
Rate for Payer: MDX Hawaii PPO	$2,130.12
Rate for Payer: Ohana Health Plan Medicaid	$1,668.96
Rate for Payer: Ohana Health Plan Medicare	$1,668.96
Rate for Payer: UnitedHealthcare Medicare	$1,668.96
Rate for Payer: University Health Alliance Commercial	$1,229.76

PLT LCP TIB 6H "T" 02.118.207

Facility

$2,196.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,229.76
Max. Negotiated Rate	$2,130.12
Rate for Payer: Cash Price	$1,317.60
Rate for Payer: Hawaii Western Management Group Commercial	$1,537.20
Rate for Payer: Health Management Network Commercial	$1,866.60
Rate for Payer: Kaiser Permanente Commercial	$1,976.40
Rate for Payer: MDX Hawaii PPO	$2,130.12
Rate for Payer: University Health Alliance Commercial	$1,229.76

PLT LCP TIB-L 12H 02.118.111S

Facility

$5,374.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$3,009.44
Max. Negotiated Rate	$5,212.78
Rate for Payer: Cash Price	$3,224.40
Rate for Payer: Hawaii Western Management Group Commercial	$3,761.80
Rate for Payer: Health Management Network Commercial	$4,567.90
Rate for Payer: Kaiser Permanente Commercial	$4,836.60
Rate for Payer: MDX Hawaii PPO	$5,212.78
Rate for Payer: University Health Alliance Commercial	$3,009.44

PLT LCP TIB-L 12H 02.118.111S

Facility

$5,374.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$2,687.00
Max. Negotiated Rate	$5,212.78
Rate for Payer: AlohaCare Medicaid	$2,687.00
Rate for Payer: AlohaCare Medicare	$4,084.24
Rate for Payer: Cash Price	$3,224.40
Rate for Payer: Devoted Health Medicare	$4,514.16
Rate for Payer: Hawaii Medical Service Association Medicare	$4,084.24
Rate for Payer: Hawaii Western Management Group Commercial	$3,761.80
Rate for Payer: Health Management Network Commercial	$4,567.90
Rate for Payer: Humana Medicare	$4,084.24
Rate for Payer: Kaiser Permanente Commercial	$4,836.60
Rate for Payer: Kaiser Permanente Medicaid	$2,740.74
Rate for Payer: Kaiser Permanente Medicare	$4,084.24
Rate for Payer: MDX Hawaii PPO	$5,212.78
Rate for Payer: Ohana Health Plan Medicaid	$4,084.24
Rate for Payer: Ohana Health Plan Medicare	$4,084.24
Rate for Payer: UnitedHealthcare Medicare	$4,084.24
Rate for Payer: University Health Alliance Commercial	$3,009.44

PLT LCP TIB-L 16H 02.118.015

Facility

$5,972.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$2,986.00
Max. Negotiated Rate	$5,792.84
Rate for Payer: AlohaCare Medicaid	$2,986.00
Rate for Payer: AlohaCare Medicare	$4,538.72
Rate for Payer: Cash Price	$3,583.20
Rate for Payer: Devoted Health Medicare	$5,016.48
Rate for Payer: Hawaii Medical Service Association Medicare	$4,538.72
Rate for Payer: Hawaii Western Management Group Commercial	$4,180.40
Rate for Payer: Health Management Network Commercial	$5,076.20
Rate for Payer: Humana Medicare	$4,538.72
Rate for Payer: Kaiser Permanente Commercial	$5,374.80
Rate for Payer: Kaiser Permanente Medicaid	$3,045.72
Rate for Payer: Kaiser Permanente Medicare	$4,538.72
Rate for Payer: MDX Hawaii PPO	$5,792.84
Rate for Payer: Ohana Health Plan Medicaid	$4,538.72
Rate for Payer: Ohana Health Plan Medicare	$4,538.72
Rate for Payer: UnitedHealthcare Medicare	$4,538.72
Rate for Payer: University Health Alliance Commercial	$3,344.32

PLT LCP TIB-L 16H 02.118.015

Facility

$5,972.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$3,344.32
Max. Negotiated Rate	$5,792.84
Rate for Payer: Cash Price	$3,583.20
Rate for Payer: Hawaii Western Management Group Commercial	$4,180.40
Rate for Payer: Health Management Network Commercial	$5,076.20
Rate for Payer: Kaiser Permanente Commercial	$5,374.80
Rate for Payer: MDX Hawaii PPO	$5,792.84
Rate for Payer: University Health Alliance Commercial	$3,344.32

Know your out-of-pocket cost for care.

All Charges