Honoka'a Hospital and Skilled Nursing Facility

All Charges

Charge

Type

Setting

Price

PLT LCP TIB-L 16H 02.118.115S

Facility

$6,578.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$3,289.00
Max. Negotiated Rate	$6,380.66
Rate for Payer: AlohaCare Medicaid	$3,289.00
Rate for Payer: AlohaCare Medicare	$4,999.28
Rate for Payer: Cash Price	$3,946.80
Rate for Payer: Devoted Health Medicare	$5,525.52
Rate for Payer: Hawaii Medical Service Association Medicare	$4,999.28
Rate for Payer: Hawaii Western Management Group Commercial	$4,604.60
Rate for Payer: Health Management Network Commercial	$5,591.30
Rate for Payer: Humana Medicare	$4,999.28
Rate for Payer: Kaiser Permanente Commercial	$5,920.20
Rate for Payer: Kaiser Permanente Medicaid	$3,354.78
Rate for Payer: Kaiser Permanente Medicare	$4,999.28
Rate for Payer: MDX Hawaii PPO	$6,380.66
Rate for Payer: Ohana Health Plan Medicaid	$4,999.28
Rate for Payer: Ohana Health Plan Medicare	$4,999.28
Rate for Payer: UnitedHealthcare Medicare	$4,999.28
Rate for Payer: University Health Alliance Commercial	$3,683.68

PLT LCP TIB-L 16H 02.118.115S

Facility

$6,578.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$3,683.68
Max. Negotiated Rate	$6,380.66
Rate for Payer: Cash Price	$3,946.80
Rate for Payer: Hawaii Western Management Group Commercial	$4,604.60
Rate for Payer: Health Management Network Commercial	$5,591.30
Rate for Payer: Kaiser Permanente Commercial	$5,920.20
Rate for Payer: MDX Hawaii PPO	$6,380.66
Rate for Payer: University Health Alliance Commercial	$3,683.68

PLT LCP TIB-L 4H 02.118.103S

Facility

$5,016.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$2,808.96
Max. Negotiated Rate	$4,865.52
Rate for Payer: Cash Price	$3,009.60
Rate for Payer: Hawaii Western Management Group Commercial	$3,511.20
Rate for Payer: Health Management Network Commercial	$4,263.60
Rate for Payer: Kaiser Permanente Commercial	$4,514.40
Rate for Payer: MDX Hawaii PPO	$4,865.52
Rate for Payer: University Health Alliance Commercial	$2,808.96

PLT LCP TIB-L 4H 02.118.103S

Facility

$5,016.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$2,508.00
Max. Negotiated Rate	$4,865.52
Rate for Payer: AlohaCare Medicaid	$2,508.00
Rate for Payer: AlohaCare Medicare	$3,812.16
Rate for Payer: Cash Price	$3,009.60
Rate for Payer: Devoted Health Medicare	$4,213.44
Rate for Payer: Hawaii Medical Service Association Medicare	$3,812.16
Rate for Payer: Hawaii Western Management Group Commercial	$3,511.20
Rate for Payer: Health Management Network Commercial	$4,263.60
Rate for Payer: Humana Medicare	$3,812.16
Rate for Payer: Kaiser Permanente Commercial	$4,514.40
Rate for Payer: Kaiser Permanente Medicaid	$2,558.16
Rate for Payer: Kaiser Permanente Medicare	$3,812.16
Rate for Payer: MDX Hawaii PPO	$4,865.52
Rate for Payer: Ohana Health Plan Medicaid	$3,812.16
Rate for Payer: Ohana Health Plan Medicare	$3,812.16
Rate for Payer: UnitedHealthcare Medicare	$3,812.16
Rate for Payer: University Health Alliance Commercial	$2,808.96

PLT LCP TIB-L 4H "L"02.118.303

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-L 4H "L"02.118.303

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-L 6H 02.118.105S

Facility

$5,066.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$2,533.00
Max. Negotiated Rate	$4,914.02
Rate for Payer: AlohaCare Medicaid	$2,533.00
Rate for Payer: AlohaCare Medicare	$3,850.16
Rate for Payer: Cash Price	$3,039.60
Rate for Payer: Devoted Health Medicare	$4,255.44
Rate for Payer: Hawaii Medical Service Association Medicare	$3,850.16
Rate for Payer: Hawaii Western Management Group Commercial	$3,546.20
Rate for Payer: Health Management Network Commercial	$4,306.10
Rate for Payer: Humana Medicare	$3,850.16
Rate for Payer: Kaiser Permanente Commercial	$4,559.40
Rate for Payer: Kaiser Permanente Medicaid	$2,583.66
Rate for Payer: Kaiser Permanente Medicare	$3,850.16
Rate for Payer: MDX Hawaii PPO	$4,914.02
Rate for Payer: Ohana Health Plan Medicaid	$3,850.16
Rate for Payer: Ohana Health Plan Medicare	$3,850.16
Rate for Payer: UnitedHealthcare Medicare	$3,850.16
Rate for Payer: University Health Alliance Commercial	$2,836.96

PLT LCP TIB-L 6H 02.118.105S

Facility

$5,066.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$2,836.96
Max. Negotiated Rate	$4,914.02
Rate for Payer: Cash Price	$3,039.60
Rate for Payer: Hawaii Western Management Group Commercial	$3,546.20
Rate for Payer: Health Management Network Commercial	$4,306.10
Rate for Payer: Kaiser Permanente Commercial	$4,559.40
Rate for Payer: MDX Hawaii PPO	$4,914.02
Rate for Payer: University Health Alliance Commercial	$2,836.96

PLT LCP TIB-L 6H "L"02.118.305

Facility

$2,610.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,461.60
Max. Negotiated Rate	$2,531.70
Rate for Payer: Cash Price	$1,566.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,827.00
Rate for Payer: Health Management Network Commercial	$2,218.50
Rate for Payer: Kaiser Permanente Commercial	$2,349.00
Rate for Payer: MDX Hawaii PPO	$2,531.70
Rate for Payer: University Health Alliance Commercial	$1,461.60

PLT LCP TIB-L 6H "L"02.118.305

Facility

$2,610.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,305.00
Max. Negotiated Rate	$2,531.70
Rate for Payer: AlohaCare Medicaid	$1,305.00
Rate for Payer: AlohaCare Medicare	$1,983.60
Rate for Payer: Cash Price	$1,566.00
Rate for Payer: Devoted Health Medicare	$2,192.40
Rate for Payer: Hawaii Medical Service Association Medicare	$1,983.60
Rate for Payer: Hawaii Western Management Group Commercial	$1,827.00
Rate for Payer: Health Management Network Commercial	$2,218.50
Rate for Payer: Humana Medicare	$1,983.60
Rate for Payer: Kaiser Permanente Commercial	$2,349.00
Rate for Payer: Kaiser Permanente Medicaid	$1,331.10
Rate for Payer: Kaiser Permanente Medicare	$1,983.60
Rate for Payer: MDX Hawaii PPO	$2,531.70
Rate for Payer: Ohana Health Plan Medicaid	$1,983.60
Rate for Payer: Ohana Health Plan Medicare	$1,983.60
Rate for Payer: UnitedHealthcare Medicare	$1,983.60
Rate for Payer: University Health Alliance Commercial	$1,461.60

PLT LCP TIB-L 8H 02.118.107S

Facility

$5,116.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$2,864.96
Max. Negotiated Rate	$4,962.52
Rate for Payer: Cash Price	$3,069.60
Rate for Payer: Hawaii Western Management Group Commercial	$3,581.20
Rate for Payer: Health Management Network Commercial	$4,348.60
Rate for Payer: Kaiser Permanente Commercial	$4,604.40
Rate for Payer: MDX Hawaii PPO	$4,962.52
Rate for Payer: University Health Alliance Commercial	$2,864.96

PLT LCP TIB-L 8H 02.118.107S

Facility

$5,116.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$2,558.00
Max. Negotiated Rate	$4,962.52
Rate for Payer: AlohaCare Medicaid	$2,558.00
Rate for Payer: AlohaCare Medicare	$3,888.16
Rate for Payer: Cash Price	$3,069.60
Rate for Payer: Devoted Health Medicare	$4,297.44
Rate for Payer: Hawaii Medical Service Association Medicare	$3,888.16
Rate for Payer: Hawaii Western Management Group Commercial	$3,581.20
Rate for Payer: Health Management Network Commercial	$4,348.60
Rate for Payer: Humana Medicare	$3,888.16
Rate for Payer: Kaiser Permanente Commercial	$4,604.40
Rate for Payer: Kaiser Permanente Medicaid	$2,609.16
Rate for Payer: Kaiser Permanente Medicare	$3,888.16
Rate for Payer: MDX Hawaii PPO	$4,962.52
Rate for Payer: Ohana Health Plan Medicaid	$3,888.16
Rate for Payer: Ohana Health Plan Medicare	$3,888.16
Rate for Payer: UnitedHealthcare Medicare	$3,888.16
Rate for Payer: University Health Alliance Commercial	$2,864.96

PLT LCP TIB-R 12H 02.118.110S

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-R 12H 02.118.110S

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-R 16H 02.118.014

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-R 16H 02.118.014

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

PLT LCP TIB-R 16H 02.118.114S

Facility

$6,578.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$3,683.68
Max. Negotiated Rate	$6,380.66
Rate for Payer: Cash Price	$3,946.80
Rate for Payer: Hawaii Western Management Group Commercial	$4,604.60
Rate for Payer: Health Management Network Commercial	$5,591.30
Rate for Payer: Kaiser Permanente Commercial	$5,920.20
Rate for Payer: MDX Hawaii PPO	$6,380.66
Rate for Payer: University Health Alliance Commercial	$3,683.68

PLT LCP TIB-R 16H 02.118.114S

Facility

$6,578.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$3,289.00
Max. Negotiated Rate	$6,380.66
Rate for Payer: AlohaCare Medicaid	$3,289.00
Rate for Payer: AlohaCare Medicare	$4,999.28
Rate for Payer: Cash Price	$3,946.80
Rate for Payer: Devoted Health Medicare	$5,525.52
Rate for Payer: Hawaii Medical Service Association Medicare	$4,999.28
Rate for Payer: Hawaii Western Management Group Commercial	$4,604.60
Rate for Payer: Health Management Network Commercial	$5,591.30
Rate for Payer: Humana Medicare	$4,999.28
Rate for Payer: Kaiser Permanente Commercial	$5,920.20
Rate for Payer: Kaiser Permanente Medicaid	$3,354.78
Rate for Payer: Kaiser Permanente Medicare	$4,999.28
Rate for Payer: MDX Hawaii PPO	$6,380.66
Rate for Payer: Ohana Health Plan Medicaid	$4,999.28
Rate for Payer: Ohana Health Plan Medicare	$4,999.28
Rate for Payer: UnitedHealthcare Medicare	$4,999.28
Rate for Payer: University Health Alliance Commercial	$3,683.68

PLT LCP TIB-R 4H 02.118.102S

Facility

$5,016.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$2,808.96
Max. Negotiated Rate	$4,865.52
Rate for Payer: Cash Price	$3,009.60
Rate for Payer: Hawaii Western Management Group Commercial	$3,511.20
Rate for Payer: Health Management Network Commercial	$4,263.60
Rate for Payer: Kaiser Permanente Commercial	$4,514.40
Rate for Payer: MDX Hawaii PPO	$4,865.52
Rate for Payer: University Health Alliance Commercial	$2,808.96

PLT LCP TIB-R 4H 02.118.102S

Facility

$5,016.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$2,508.00
Max. Negotiated Rate	$4,865.52
Rate for Payer: AlohaCare Medicaid	$2,508.00
Rate for Payer: AlohaCare Medicare	$3,812.16
Rate for Payer: Cash Price	$3,009.60
Rate for Payer: Devoted Health Medicare	$4,213.44
Rate for Payer: Hawaii Medical Service Association Medicare	$3,812.16
Rate for Payer: Hawaii Western Management Group Commercial	$3,511.20
Rate for Payer: Health Management Network Commercial	$4,263.60
Rate for Payer: Humana Medicare	$3,812.16
Rate for Payer: Kaiser Permanente Commercial	$4,514.40
Rate for Payer: Kaiser Permanente Medicaid	$2,558.16
Rate for Payer: Kaiser Permanente Medicare	$3,812.16
Rate for Payer: MDX Hawaii PPO	$4,865.52
Rate for Payer: Ohana Health Plan Medicaid	$3,812.16
Rate for Payer: Ohana Health Plan Medicare	$3,812.16
Rate for Payer: UnitedHealthcare Medicare	$3,812.16
Rate for Payer: University Health Alliance Commercial	$2,808.96

PLT LCP TIB-R 4H "L"02.118.302

Facility

$2,510.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,405.60
Max. Negotiated Rate	$2,434.70
Rate for Payer: Cash Price	$1,506.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,757.00
Rate for Payer: Health Management Network Commercial	$2,133.50
Rate for Payer: Kaiser Permanente Commercial	$2,259.00
Rate for Payer: MDX Hawaii PPO	$2,434.70
Rate for Payer: University Health Alliance Commercial	$1,405.60

PLT LCP TIB-R 4H "L"02.118.302

Facility

$2,510.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,255.00
Max. Negotiated Rate	$2,434.70
Rate for Payer: Kaiser Permanente Medicare	$1,907.60
Rate for Payer: AlohaCare Medicaid	$1,255.00
Rate for Payer: AlohaCare Medicare	$1,907.60
Rate for Payer: Cash Price	$1,506.00
Rate for Payer: Devoted Health Medicare	$2,108.40
Rate for Payer: Hawaii Medical Service Association Medicare	$1,907.60
Rate for Payer: Hawaii Western Management Group Commercial	$1,757.00
Rate for Payer: Health Management Network Commercial	$2,133.50
Rate for Payer: Humana Medicare	$1,907.60
Rate for Payer: Kaiser Permanente Commercial	$2,259.00
Rate for Payer: Kaiser Permanente Medicaid	$1,280.10
Rate for Payer: MDX Hawaii PPO	$2,434.70
Rate for Payer: Ohana Health Plan Medicaid	$1,907.60
Rate for Payer: Ohana Health Plan Medicare	$1,907.60
Rate for Payer: UnitedHealthcare Medicare	$1,907.60
Rate for Payer: University Health Alliance Commercial	$1,405.60

PLT LCP TIB-R 6H 02.118.104S

Facility

$5,066.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$2,533.00
Max. Negotiated Rate	$4,914.02
Rate for Payer: AlohaCare Medicaid	$2,533.00
Rate for Payer: AlohaCare Medicare	$3,850.16
Rate for Payer: Cash Price	$3,039.60
Rate for Payer: Devoted Health Medicare	$4,255.44
Rate for Payer: Hawaii Medical Service Association Medicare	$3,850.16
Rate for Payer: Hawaii Western Management Group Commercial	$3,546.20
Rate for Payer: Health Management Network Commercial	$4,306.10
Rate for Payer: Humana Medicare	$3,850.16
Rate for Payer: Kaiser Permanente Commercial	$4,559.40
Rate for Payer: Kaiser Permanente Medicaid	$2,583.66
Rate for Payer: Kaiser Permanente Medicare	$3,850.16
Rate for Payer: MDX Hawaii PPO	$4,914.02
Rate for Payer: Ohana Health Plan Medicaid	$3,850.16
Rate for Payer: Ohana Health Plan Medicare	$3,850.16
Rate for Payer: UnitedHealthcare Medicare	$3,850.16
Rate for Payer: University Health Alliance Commercial	$2,836.96

PLT LCP TIB-R 6H 02.118.104S

Facility

$5,066.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$2,836.96
Max. Negotiated Rate	$4,914.02
Rate for Payer: Cash Price	$3,039.60
Rate for Payer: Hawaii Western Management Group Commercial	$3,546.20
Rate for Payer: Health Management Network Commercial	$4,306.10
Rate for Payer: Kaiser Permanente Commercial	$4,559.40
Rate for Payer: MDX Hawaii PPO	$4,914.02
Rate for Payer: University Health Alliance Commercial	$2,836.96

PLT LCP TIB-R 6H "L"02.118.304

Facility

$2,610.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,305.00
Max. Negotiated Rate	$2,531.70
Rate for Payer: AlohaCare Medicaid	$1,305.00
Rate for Payer: AlohaCare Medicare	$1,983.60
Rate for Payer: Cash Price	$1,566.00
Rate for Payer: Devoted Health Medicare	$2,192.40
Rate for Payer: Hawaii Medical Service Association Medicare	$1,983.60
Rate for Payer: Hawaii Western Management Group Commercial	$1,827.00
Rate for Payer: Health Management Network Commercial	$2,218.50
Rate for Payer: Humana Medicare	$1,983.60
Rate for Payer: Kaiser Permanente Commercial	$2,349.00
Rate for Payer: Kaiser Permanente Medicaid	$1,331.10
Rate for Payer: Kaiser Permanente Medicare	$1,983.60
Rate for Payer: MDX Hawaii PPO	$2,531.70
Rate for Payer: Ohana Health Plan Medicaid	$1,983.60
Rate for Payer: Ohana Health Plan Medicare	$1,983.60
Rate for Payer: UnitedHealthcare Medicare	$1,983.60
Rate for Payer: University Health Alliance Commercial	$1,461.60

Know your out-of-pocket cost for care.

All Charges