Honoka'a Hospital and Skilled Nursing Facility

All Charges

Charge

Type

Setting

Price

PLT LCP TIB-R 6H "L"02.118.304

Facility

$2,610.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,461.60
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-R 8H 02.118.106S

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-R 8H 02.118.106S

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 RECON 6H/70MM 1179-05-06

Facility

$1,384.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$775.04
Max. Negotiated Rate	$1,342.48
Rate for Payer: Cash Price	$830.40
Rate for Payer: Hawaii Western Management Group Commercial	$968.80
Rate for Payer: Health Management Network Commercial	$1,176.40
Rate for Payer: Kaiser Permanente Commercial	$1,245.60
Rate for Payer: MDX Hawaii PPO	$1,342.48
Rate for Payer: University Health Alliance Commercial	$775.04

PLT RECON 6H/70MM 1179-05-06

Facility

$1,384.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$692.00
Max. Negotiated Rate	$1,342.48
Rate for Payer: AlohaCare Medicaid	$692.00
Rate for Payer: AlohaCare Medicare	$1,051.84
Rate for Payer: Cash Price	$830.40
Rate for Payer: Devoted Health Medicare	$1,162.56
Rate for Payer: Hawaii Medical Service Association Medicare	$1,051.84
Rate for Payer: Hawaii Western Management Group Commercial	$968.80
Rate for Payer: Health Management Network Commercial	$1,176.40
Rate for Payer: Humana Medicare	$1,051.84
Rate for Payer: Kaiser Permanente Commercial	$1,245.60
Rate for Payer: Kaiser Permanente Medicaid	$705.84
Rate for Payer: Kaiser Permanente Medicare	$1,051.84
Rate for Payer: MDX Hawaii PPO	$1,342.48
Rate for Payer: Ohana Health Plan Medicaid	$1,051.84
Rate for Payer: Ohana Health Plan Medicare	$1,051.84
Rate for Payer: UnitedHealthcare Medicare	$1,051.84
Rate for Payer: University Health Alliance Commercial	$775.04

PLT RECON 7H/82MM 1179-05-07

Facility

$1,384.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$692.00
Max. Negotiated Rate	$1,342.48
Rate for Payer: AlohaCare Medicaid	$692.00
Rate for Payer: AlohaCare Medicare	$1,051.84
Rate for Payer: Cash Price	$830.40
Rate for Payer: Devoted Health Medicare	$1,162.56
Rate for Payer: Hawaii Medical Service Association Medicare	$1,051.84
Rate for Payer: Hawaii Western Management Group Commercial	$968.80
Rate for Payer: Health Management Network Commercial	$1,176.40
Rate for Payer: Humana Medicare	$1,051.84
Rate for Payer: Kaiser Permanente Commercial	$1,245.60
Rate for Payer: Kaiser Permanente Medicaid	$705.84
Rate for Payer: Kaiser Permanente Medicare	$1,051.84
Rate for Payer: MDX Hawaii PPO	$1,342.48
Rate for Payer: Ohana Health Plan Medicaid	$1,051.84
Rate for Payer: Ohana Health Plan Medicare	$1,051.84
Rate for Payer: UnitedHealthcare Medicare	$1,051.84
Rate for Payer: University Health Alliance Commercial	$775.04

PLT RECON 7H/82MM 1179-05-07

Facility

$1,384.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$775.04
Max. Negotiated Rate	$1,342.48
Rate for Payer: Cash Price	$830.40
Rate for Payer: Hawaii Western Management Group Commercial	$968.80
Rate for Payer: Health Management Network Commercial	$1,176.40
Rate for Payer: Kaiser Permanente Commercial	$1,245.60
Rate for Payer: MDX Hawaii PPO	$1,342.48
Rate for Payer: University Health Alliance Commercial	$775.04

PLT TU 1/3 10H/121M 4935-10-03

Facility

$288.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$161.28
Max. Negotiated Rate	$279.36
Rate for Payer: Cash Price	$172.80
Rate for Payer: Hawaii Western Management Group Commercial	$201.60
Rate for Payer: Health Management Network Commercial	$244.80
Rate for Payer: Kaiser Permanente Commercial	$259.20
Rate for Payer: MDX Hawaii PPO	$279.36
Rate for Payer: University Health Alliance Commercial	$161.28

PLT TU 1/3 10H/121M 4935-10-03

Facility

$288.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$144.00
Max. Negotiated Rate	$279.36
Rate for Payer: AlohaCare Medicaid	$144.00
Rate for Payer: AlohaCare Medicare	$218.88
Rate for Payer: Cash Price	$172.80
Rate for Payer: Devoted Health Medicare	$241.92
Rate for Payer: Hawaii Medical Service Association Medicare	$218.88
Rate for Payer: Hawaii Western Management Group Commercial	$201.60
Rate for Payer: Health Management Network Commercial	$244.80
Rate for Payer: Humana Medicare	$218.88
Rate for Payer: Kaiser Permanente Commercial	$259.20
Rate for Payer: Kaiser Permanente Medicaid	$146.88
Rate for Payer: Kaiser Permanente Medicare	$218.88
Rate for Payer: MDX Hawaii PPO	$279.36
Rate for Payer: Ohana Health Plan Medicaid	$218.88
Rate for Payer: Ohana Health Plan Medicare	$218.88
Rate for Payer: UnitedHealthcare Medicare	$218.88
Rate for Payer: University Health Alliance Commercial	$161.28

PLT TU 1/3 2H/25MM 4935-02-03

Facility

$488.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$273.28
Max. Negotiated Rate	$473.36
Rate for Payer: Cash Price	$292.80
Rate for Payer: Hawaii Western Management Group Commercial	$341.60
Rate for Payer: Health Management Network Commercial	$414.80
Rate for Payer: Kaiser Permanente Commercial	$439.20
Rate for Payer: MDX Hawaii PPO	$473.36
Rate for Payer: University Health Alliance Commercial	$273.28

PLT TU 1/3 2H/25MM 4935-02-03

Facility

$488.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$244.00
Max. Negotiated Rate	$473.36
Rate for Payer: AlohaCare Medicaid	$244.00
Rate for Payer: AlohaCare Medicare	$370.88
Rate for Payer: Cash Price	$292.80
Rate for Payer: Devoted Health Medicare	$409.92
Rate for Payer: Hawaii Medical Service Association Medicare	$370.88
Rate for Payer: Hawaii Western Management Group Commercial	$341.60
Rate for Payer: Health Management Network Commercial	$414.80
Rate for Payer: Humana Medicare	$370.88
Rate for Payer: Kaiser Permanente Commercial	$439.20
Rate for Payer: Kaiser Permanente Medicaid	$248.88
Rate for Payer: Kaiser Permanente Medicare	$370.88
Rate for Payer: MDX Hawaii PPO	$473.36
Rate for Payer: Ohana Health Plan Medicaid	$370.88
Rate for Payer: Ohana Health Plan Medicare	$370.88
Rate for Payer: UnitedHealthcare Medicare	$370.88
Rate for Payer: University Health Alliance Commercial	$273.28

PLT TU 1/3 6H/73MM 4935-06-03

Facility

$525.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$262.50
Max. Negotiated Rate	$509.25
Rate for Payer: AlohaCare Medicaid	$262.50
Rate for Payer: AlohaCare Medicare	$399.00
Rate for Payer: Cash Price	$315.00
Rate for Payer: Devoted Health Medicare	$441.00
Rate for Payer: Hawaii Medical Service Association Medicare	$399.00
Rate for Payer: Hawaii Western Management Group Commercial	$367.50
Rate for Payer: Health Management Network Commercial	$446.25
Rate for Payer: Humana Medicare	$399.00
Rate for Payer: Kaiser Permanente Commercial	$472.50
Rate for Payer: Kaiser Permanente Medicaid	$267.75
Rate for Payer: Kaiser Permanente Medicare	$399.00
Rate for Payer: MDX Hawaii PPO	$509.25
Rate for Payer: Ohana Health Plan Medicaid	$399.00
Rate for Payer: Ohana Health Plan Medicare	$399.00
Rate for Payer: UnitedHealthcare Medicare	$399.00
Rate for Payer: University Health Alliance Commercial	$294.00

PLT TU 1/3 6H/73MM 4935-06-03

Facility

$525.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$294.00
Max. Negotiated Rate	$509.25
Rate for Payer: Cash Price	$315.00
Rate for Payer: Hawaii Western Management Group Commercial	$367.50
Rate for Payer: Health Management Network Commercial	$446.25
Rate for Payer: Kaiser Permanente Commercial	$472.50
Rate for Payer: MDX Hawaii PPO	$509.25
Rate for Payer: University Health Alliance Commercial	$294.00

PLT TU 1/3 9H/109MM 4935-09-03

Facility

$450.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$225.00
Max. Negotiated Rate	$436.50
Rate for Payer: AlohaCare Medicaid	$225.00
Rate for Payer: AlohaCare Medicare	$342.00
Rate for Payer: Cash Price	$270.00
Rate for Payer: Devoted Health Medicare	$378.00
Rate for Payer: Hawaii Medical Service Association Medicare	$342.00
Rate for Payer: Hawaii Western Management Group Commercial	$315.00
Rate for Payer: Health Management Network Commercial	$382.50
Rate for Payer: Humana Medicare	$342.00
Rate for Payer: Kaiser Permanente Commercial	$405.00
Rate for Payer: Kaiser Permanente Medicaid	$229.50
Rate for Payer: Kaiser Permanente Medicare	$342.00
Rate for Payer: MDX Hawaii PPO	$436.50
Rate for Payer: Ohana Health Plan Medicaid	$342.00
Rate for Payer: Ohana Health Plan Medicare	$342.00
Rate for Payer: UnitedHealthcare Medicare	$342.00
Rate for Payer: University Health Alliance Commercial	$252.00

PLT TU 1/3 9H/109MM 4935-09-03

Facility

$450.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$252.00
Max. Negotiated Rate	$436.50
Rate for Payer: Cash Price	$270.00
Rate for Payer: Hawaii Western Management Group Commercial	$315.00
Rate for Payer: Health Management Network Commercial	$382.50
Rate for Payer: Kaiser Permanente Commercial	$405.00
Rate for Payer: MDX Hawaii PPO	$436.50
Rate for Payer: University Health Alliance Commercial	$252.00

PLT VO ANG LT/3H/7PEG VPPL-3-7

Facility

$2,595.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,453.20
Max. Negotiated Rate	$2,517.15
Rate for Payer: Cash Price	$1,557.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,816.50
Rate for Payer: Health Management Network Commercial	$2,205.75
Rate for Payer: Kaiser Permanente Commercial	$2,335.50
Rate for Payer: MDX Hawaii PPO	$2,517.15
Rate for Payer: University Health Alliance Commercial	$1,453.20

PLT VO ANG LT/3H/7PEG VPPL-3-7

Facility

$2,595.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,297.50
Max. Negotiated Rate	$2,517.15
Rate for Payer: AlohaCare Medicaid	$1,297.50
Rate for Payer: AlohaCare Medicare	$1,972.20
Rate for Payer: Cash Price	$1,557.00
Rate for Payer: Devoted Health Medicare	$2,179.80
Rate for Payer: Hawaii Medical Service Association Medicare	$1,972.20
Rate for Payer: Hawaii Western Management Group Commercial	$1,816.50
Rate for Payer: Health Management Network Commercial	$2,205.75
Rate for Payer: Humana Medicare	$1,972.20
Rate for Payer: Kaiser Permanente Commercial	$2,335.50
Rate for Payer: Kaiser Permanente Medicaid	$1,323.45
Rate for Payer: Kaiser Permanente Medicare	$1,972.20
Rate for Payer: MDX Hawaii PPO	$2,517.15
Rate for Payer: Ohana Health Plan Medicaid	$1,972.20
Rate for Payer: Ohana Health Plan Medicare	$1,972.20
Rate for Payer: UnitedHealthcare Medicare	$1,972.20
Rate for Payer: University Health Alliance Commercial	$1,453.20

PLT VO ANG/LT/5H/7PEG VPPL-5-7

Facility

$2,000.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,120.00
Max. Negotiated Rate	$1,940.00
Rate for Payer: Cash Price	$1,200.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,400.00
Rate for Payer: Health Management Network Commercial	$1,700.00
Rate for Payer: Kaiser Permanente Commercial	$1,800.00
Rate for Payer: MDX Hawaii PPO	$1,940.00
Rate for Payer: University Health Alliance Commercial	$1,120.00

PLT VO ANG/LT/5H/7PEG VPPL-5-7

Facility

$2,000.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,000.00
Max. Negotiated Rate	$1,940.00
Rate for Payer: AlohaCare Medicaid	$1,000.00
Rate for Payer: AlohaCare Medicare	$1,520.00
Rate for Payer: Cash Price	$1,200.00
Rate for Payer: Devoted Health Medicare	$1,680.00
Rate for Payer: Hawaii Medical Service Association Medicare	$1,520.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,400.00
Rate for Payer: Health Management Network Commercial	$1,700.00
Rate for Payer: Humana Medicare	$1,520.00
Rate for Payer: Kaiser Permanente Commercial	$1,800.00
Rate for Payer: Kaiser Permanente Medicaid	$1,020.00
Rate for Payer: Kaiser Permanente Medicare	$1,520.00
Rate for Payer: MDX Hawaii PPO	$1,940.00
Rate for Payer: Ohana Health Plan Medicaid	$1,520.00
Rate for Payer: Ohana Health Plan Medicare	$1,520.00
Rate for Payer: UnitedHealthcare Medicare	$1,520.00
Rate for Payer: University Health Alliance Commercial	$1,120.00

PLT VO ANG/RT/3H/7PEG VPPR-3-7

Facility

$2,595.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,453.20
Max. Negotiated Rate	$2,517.15
Rate for Payer: Cash Price	$1,557.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,816.50
Rate for Payer: Health Management Network Commercial	$2,205.75
Rate for Payer: Kaiser Permanente Commercial	$2,335.50
Rate for Payer: MDX Hawaii PPO	$2,517.15
Rate for Payer: University Health Alliance Commercial	$1,453.20

PLT VO ANG/RT/3H/7PEG VPPR-3-7

Facility

$2,595.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,297.50
Max. Negotiated Rate	$2,517.15
Rate for Payer: AlohaCare Medicaid	$1,297.50
Rate for Payer: AlohaCare Medicare	$1,972.20
Rate for Payer: Cash Price	$1,557.00
Rate for Payer: Devoted Health Medicare	$2,179.80
Rate for Payer: Hawaii Medical Service Association Medicare	$1,972.20
Rate for Payer: Hawaii Western Management Group Commercial	$1,816.50
Rate for Payer: Health Management Network Commercial	$2,205.75
Rate for Payer: Humana Medicare	$1,972.20
Rate for Payer: Kaiser Permanente Commercial	$2,335.50
Rate for Payer: Kaiser Permanente Medicaid	$1,323.45
Rate for Payer: Kaiser Permanente Medicare	$1,972.20
Rate for Payer: MDX Hawaii PPO	$2,517.15
Rate for Payer: Ohana Health Plan Medicaid	$1,972.20
Rate for Payer: Ohana Health Plan Medicare	$1,972.20
Rate for Payer: UnitedHealthcare Medicare	$1,972.20
Rate for Payer: University Health Alliance Commercial	$1,453.20

PLT VO ANG/RT/5H/7PEG VPPR-5-7

Facility

$2,000.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,000.00
Max. Negotiated Rate	$1,940.00
Rate for Payer: AlohaCare Medicaid	$1,000.00
Rate for Payer: AlohaCare Medicare	$1,520.00
Rate for Payer: Cash Price	$1,200.00
Rate for Payer: Devoted Health Medicare	$1,680.00
Rate for Payer: Hawaii Medical Service Association Medicare	$1,520.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,400.00
Rate for Payer: Health Management Network Commercial	$1,700.00
Rate for Payer: Humana Medicare	$1,520.00
Rate for Payer: Kaiser Permanente Commercial	$1,800.00
Rate for Payer: Kaiser Permanente Medicaid	$1,020.00
Rate for Payer: Kaiser Permanente Medicare	$1,520.00
Rate for Payer: MDX Hawaii PPO	$1,940.00
Rate for Payer: Ohana Health Plan Medicaid	$1,520.00
Rate for Payer: Ohana Health Plan Medicare	$1,520.00
Rate for Payer: UnitedHealthcare Medicare	$1,520.00
Rate for Payer: University Health Alliance Commercial	$1,120.00

PLT VO ANG/RT/5H/7PEG VPPR-5-7

Facility

$2,000.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,120.00
Max. Negotiated Rate	$1,940.00
Rate for Payer: Cash Price	$1,200.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,400.00
Rate for Payer: Health Management Network Commercial	$1,700.00
Rate for Payer: Kaiser Permanente Commercial	$1,800.00
Rate for Payer: MDX Hawaii PPO	$1,940.00
Rate for Payer: University Health Alliance Commercial	$1,120.00

PLT VOL LT/11H/7PEG VLBPL-11-7

Facility

$5,310.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$2,973.60
Max. Negotiated Rate	$5,150.70
Rate for Payer: Cash Price	$3,186.00
Rate for Payer: Hawaii Western Management Group Commercial	$3,717.00
Rate for Payer: Health Management Network Commercial	$4,513.50
Rate for Payer: Kaiser Permanente Commercial	$4,779.00
Rate for Payer: MDX Hawaii PPO	$5,150.70
Rate for Payer: University Health Alliance Commercial	$2,973.60

PLT VOL LT/11H/7PEG VLBPL-11-7

Facility

$5,310.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$2,655.00
Max. Negotiated Rate	$5,150.70
Rate for Payer: AlohaCare Medicaid	$2,655.00
Rate for Payer: AlohaCare Medicare	$4,035.60
Rate for Payer: Cash Price	$3,186.00
Rate for Payer: Devoted Health Medicare	$4,460.40
Rate for Payer: Hawaii Medical Service Association Medicare	$4,035.60
Rate for Payer: Hawaii Western Management Group Commercial	$3,717.00
Rate for Payer: Health Management Network Commercial	$4,513.50
Rate for Payer: Humana Medicare	$4,035.60
Rate for Payer: Kaiser Permanente Commercial	$4,779.00
Rate for Payer: Kaiser Permanente Medicaid	$2,708.10
Rate for Payer: Kaiser Permanente Medicare	$4,035.60
Rate for Payer: MDX Hawaii PPO	$5,150.70
Rate for Payer: Ohana Health Plan Medicaid	$4,035.60
Rate for Payer: Ohana Health Plan Medicare	$4,035.60
Rate for Payer: UnitedHealthcare Medicare	$4,035.60
Rate for Payer: University Health Alliance Commercial	$2,973.60

Know your out-of-pocket cost for care.

All Charges