Honoka'a Hospital and Skilled Nursing Facility

All Charges

Charge

Type

Setting

Price

TIBIAL AUGMENT 5545-A-402

Facility

$2,123.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$1,061.50
Max. Negotiated Rate	$2,059.31
Rate for Payer: AlohaCare Medicaid	$1,061.50
Rate for Payer: AlohaCare Medicare	$1,613.48
Rate for Payer: Cash Price	$1,273.80
Rate for Payer: Devoted Health Medicare	$1,783.32
Rate for Payer: Hawaii Medical Service Association Medicare	$1,613.48
Rate for Payer: Hawaii Western Management Group Commercial	$1,486.10
Rate for Payer: Health Management Network Commercial	$1,804.55
Rate for Payer: Humana Medicare	$1,613.48
Rate for Payer: Kaiser Permanente Commercial	$1,910.70
Rate for Payer: Kaiser Permanente Medicaid	$1,082.73
Rate for Payer: Kaiser Permanente Medicare	$1,613.48
Rate for Payer: MDX Hawaii PPO	$2,059.31
Rate for Payer: Ohana Health Plan Medicaid	$1,613.48
Rate for Payer: Ohana Health Plan Medicare	$1,613.48
Rate for Payer: UnitedHealthcare Medicare	$1,613.48
Rate for Payer: University Health Alliance Commercial	$1,188.88

TIBIAL AUGMENT 5545-A-402

Facility

$2,123.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$1,188.88
Max. Negotiated Rate	$2,059.31
Rate for Payer: Cash Price	$1,273.80
Rate for Payer: Hawaii Western Management Group Commercial	$1,486.10
Rate for Payer: Health Management Network Commercial	$1,804.55
Rate for Payer: Kaiser Permanente Commercial	$1,910.70
Rate for Payer: MDX Hawaii PPO	$2,059.31
Rate for Payer: University Health Alliance Commercial	$1,188.88

TIBIAL AUGMENT 5545-A-601

Facility

$2,123.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$1,061.50
Max. Negotiated Rate	$2,059.31
Rate for Payer: AlohaCare Medicaid	$1,061.50
Rate for Payer: AlohaCare Medicare	$1,613.48
Rate for Payer: Cash Price	$1,273.80
Rate for Payer: Devoted Health Medicare	$1,783.32
Rate for Payer: Hawaii Medical Service Association Medicare	$1,613.48
Rate for Payer: Hawaii Western Management Group Commercial	$1,486.10
Rate for Payer: Health Management Network Commercial	$1,804.55
Rate for Payer: Humana Medicare	$1,613.48
Rate for Payer: Kaiser Permanente Commercial	$1,910.70
Rate for Payer: Kaiser Permanente Medicaid	$1,082.73
Rate for Payer: Kaiser Permanente Medicare	$1,613.48
Rate for Payer: MDX Hawaii PPO	$2,059.31
Rate for Payer: Ohana Health Plan Medicaid	$1,613.48
Rate for Payer: Ohana Health Plan Medicare	$1,613.48
Rate for Payer: UnitedHealthcare Medicare	$1,613.48
Rate for Payer: University Health Alliance Commercial	$1,188.88

TIBIAL AUGMENT 5545-A-601

Facility

$2,123.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$1,188.88
Max. Negotiated Rate	$2,059.31
Rate for Payer: Cash Price	$1,273.80
Rate for Payer: Hawaii Western Management Group Commercial	$1,486.10
Rate for Payer: Health Management Network Commercial	$1,804.55
Rate for Payer: Kaiser Permanente Commercial	$1,910.70
Rate for Payer: MDX Hawaii PPO	$2,059.31
Rate for Payer: University Health Alliance Commercial	$1,188.88

TIBIAL AUGMENT 5545-A-602

Facility

$2,123.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$1,061.50
Max. Negotiated Rate	$2,059.31
Rate for Payer: AlohaCare Medicaid	$1,061.50
Rate for Payer: AlohaCare Medicare	$1,613.48
Rate for Payer: Cash Price	$1,273.80
Rate for Payer: Devoted Health Medicare	$1,783.32
Rate for Payer: Hawaii Medical Service Association Medicare	$1,613.48
Rate for Payer: Hawaii Western Management Group Commercial	$1,486.10
Rate for Payer: Health Management Network Commercial	$1,804.55
Rate for Payer: Humana Medicare	$1,613.48
Rate for Payer: Kaiser Permanente Commercial	$1,910.70
Rate for Payer: Kaiser Permanente Medicaid	$1,082.73
Rate for Payer: Kaiser Permanente Medicare	$1,613.48
Rate for Payer: MDX Hawaii PPO	$2,059.31
Rate for Payer: Ohana Health Plan Medicaid	$1,613.48
Rate for Payer: Ohana Health Plan Medicare	$1,613.48
Rate for Payer: UnitedHealthcare Medicare	$1,613.48
Rate for Payer: University Health Alliance Commercial	$1,188.88

TIBIAL AUGMENT 5545-A-602

Facility

$2,123.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$1,188.88
Max. Negotiated Rate	$2,059.31
Rate for Payer: Cash Price	$1,273.80
Rate for Payer: Hawaii Western Management Group Commercial	$1,486.10
Rate for Payer: Health Management Network Commercial	$1,804.55
Rate for Payer: Kaiser Permanente Commercial	$1,910.70
Rate for Payer: MDX Hawaii PPO	$2,059.31
Rate for Payer: University Health Alliance Commercial	$1,188.88

TIBIAL AUGMENT #5 5546-A-502

Facility

$2,173.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$1,086.50
Max. Negotiated Rate	$2,107.81
Rate for Payer: AlohaCare Medicaid	$1,086.50
Rate for Payer: AlohaCare Medicare	$1,651.48
Rate for Payer: Cash Price	$1,303.80
Rate for Payer: Devoted Health Medicare	$1,825.32
Rate for Payer: Hawaii Medical Service Association Medicare	$1,651.48
Rate for Payer: Hawaii Western Management Group Commercial	$1,521.10
Rate for Payer: Health Management Network Commercial	$1,847.05
Rate for Payer: Humana Medicare	$1,651.48
Rate for Payer: Kaiser Permanente Commercial	$1,955.70
Rate for Payer: Kaiser Permanente Medicaid	$1,108.23
Rate for Payer: Kaiser Permanente Medicare	$1,651.48
Rate for Payer: MDX Hawaii PPO	$2,107.81
Rate for Payer: Ohana Health Plan Medicaid	$1,651.48
Rate for Payer: Ohana Health Plan Medicare	$1,651.48
Rate for Payer: UnitedHealthcare Medicare	$1,651.48
Rate for Payer: University Health Alliance Commercial	$1,216.88

TIBIAL AUGMENT #5 5546-A-502

Facility

$2,173.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$1,216.88
Max. Negotiated Rate	$2,107.81
Rate for Payer: Cash Price	$1,303.80
Rate for Payer: Hawaii Western Management Group Commercial	$1,521.10
Rate for Payer: Health Management Network Commercial	$1,847.05
Rate for Payer: Kaiser Permanente Commercial	$1,955.70
Rate for Payer: MDX Hawaii PPO	$2,107.81
Rate for Payer: University Health Alliance Commercial	$1,216.88

TIBIAL AUGMENT HALF BLK SIZE 3

Facility

$2,229.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$1,114.50
Max. Negotiated Rate	$2,162.13
Rate for Payer: AlohaCare Medicaid	$1,114.50
Rate for Payer: AlohaCare Medicare	$1,694.04
Rate for Payer: Cash Price	$1,337.40
Rate for Payer: Devoted Health Medicare	$1,872.36
Rate for Payer: Hawaii Medical Service Association Medicare	$1,694.04
Rate for Payer: Hawaii Western Management Group Commercial	$1,560.30
Rate for Payer: Health Management Network Commercial	$1,894.65
Rate for Payer: Humana Medicare	$1,694.04
Rate for Payer: Kaiser Permanente Commercial	$2,006.10
Rate for Payer: Kaiser Permanente Medicaid	$1,136.79
Rate for Payer: Kaiser Permanente Medicare	$1,694.04
Rate for Payer: MDX Hawaii PPO	$2,162.13
Rate for Payer: Ohana Health Plan Medicaid	$1,694.04
Rate for Payer: Ohana Health Plan Medicare	$1,694.04
Rate for Payer: UnitedHealthcare Medicare	$1,694.04
Rate for Payer: University Health Alliance Commercial	$1,248.24

TIBIAL AUGMENT HALF BLK SIZE 3

Facility

$2,229.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$1,248.24
Max. Negotiated Rate	$2,162.13
Rate for Payer: Cash Price	$1,337.40
Rate for Payer: Hawaii Western Management Group Commercial	$1,560.30
Rate for Payer: Health Management Network Commercial	$1,894.65
Rate for Payer: Kaiser Permanente Commercial	$2,006.10
Rate for Payer: MDX Hawaii PPO	$2,162.13
Rate for Payer: University Health Alliance Commercial	$1,248.24

TIBIAL BEARING 5MM 1516-40-605

Facility

$3,000.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$1,500.00
Max. Negotiated Rate	$2,910.00
Rate for Payer: AlohaCare Medicaid	$1,500.00
Rate for Payer: AlohaCare Medicare	$2,280.00
Rate for Payer: Cash Price	$1,800.00
Rate for Payer: Devoted Health Medicare	$2,520.00
Rate for Payer: Hawaii Medical Service Association Medicare	$2,280.00
Rate for Payer: Hawaii Western Management Group Commercial	$2,100.00
Rate for Payer: Health Management Network Commercial	$2,550.00
Rate for Payer: Humana Medicare	$2,280.00
Rate for Payer: Kaiser Permanente Commercial	$2,700.00
Rate for Payer: Kaiser Permanente Medicaid	$1,530.00
Rate for Payer: Kaiser Permanente Medicare	$2,280.00
Rate for Payer: MDX Hawaii PPO	$2,910.00
Rate for Payer: Ohana Health Plan Medicaid	$2,280.00
Rate for Payer: Ohana Health Plan Medicare	$2,280.00
Rate for Payer: UnitedHealthcare Medicare	$2,280.00
Rate for Payer: University Health Alliance Commercial	$1,680.00

TIBIAL BEARING 5MM 1516-40-605

Facility

$3,000.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$1,680.00
Max. Negotiated Rate	$2,910.00
Rate for Payer: Cash Price	$1,800.00
Rate for Payer: Hawaii Western Management Group Commercial	$2,100.00
Rate for Payer: Health Management Network Commercial	$2,550.00
Rate for Payer: Kaiser Permanente Commercial	$2,700.00
Rate for Payer: MDX Hawaii PPO	$2,910.00
Rate for Payer: University Health Alliance Commercial	$1,680.00

TIBIAL BEARING INS 5531-G-609

Facility

$7,716.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$4,320.96
Max. Negotiated Rate	$7,484.52
Rate for Payer: Cash Price	$4,629.60
Rate for Payer: Hawaii Western Management Group Commercial	$5,401.20
Rate for Payer: Health Management Network Commercial	$6,558.60
Rate for Payer: Kaiser Permanente Commercial	$6,944.40
Rate for Payer: MDX Hawaii PPO	$7,484.52
Rate for Payer: University Health Alliance Commercial	$4,320.96

TIBIAL BEARING INS 5531-G-609

Facility

$7,716.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$3,858.00
Max. Negotiated Rate	$7,484.52
Rate for Payer: AlohaCare Medicaid	$3,858.00
Rate for Payer: AlohaCare Medicare	$5,864.16
Rate for Payer: Cash Price	$4,629.60
Rate for Payer: Devoted Health Medicare	$6,481.44
Rate for Payer: Hawaii Medical Service Association Medicare	$5,864.16
Rate for Payer: Hawaii Western Management Group Commercial	$5,401.20
Rate for Payer: Health Management Network Commercial	$6,558.60
Rate for Payer: Humana Medicare	$5,864.16
Rate for Payer: Kaiser Permanente Commercial	$6,944.40
Rate for Payer: Kaiser Permanente Medicaid	$3,935.16
Rate for Payer: Kaiser Permanente Medicare	$5,864.16
Rate for Payer: MDX Hawaii PPO	$7,484.52
Rate for Payer: Ohana Health Plan Medicaid	$5,864.16
Rate for Payer: Ohana Health Plan Medicare	$5,864.16
Rate for Payer: UnitedHealthcare Medicare	$5,864.16
Rate for Payer: University Health Alliance Commercial	$4,320.96

TIBIAL BEARING SZ5 1506-70-005

Facility

$3,400.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$1,904.00
Max. Negotiated Rate	$3,298.00
Rate for Payer: Cash Price	$2,040.00
Rate for Payer: Hawaii Western Management Group Commercial	$2,380.00
Rate for Payer: Health Management Network Commercial	$2,890.00
Rate for Payer: Kaiser Permanente Commercial	$3,060.00
Rate for Payer: MDX Hawaii PPO	$3,298.00
Rate for Payer: University Health Alliance Commercial	$1,904.00

TIBIAL BEARING SZ5 1506-70-005

Facility

$3,400.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$1,700.00
Max. Negotiated Rate	$3,298.00
Rate for Payer: AlohaCare Medicaid	$1,700.00
Rate for Payer: AlohaCare Medicare	$2,584.00
Rate for Payer: Cash Price	$2,040.00
Rate for Payer: Devoted Health Medicare	$2,856.00
Rate for Payer: Hawaii Medical Service Association Medicare	$2,584.00
Rate for Payer: Hawaii Western Management Group Commercial	$2,380.00
Rate for Payer: Health Management Network Commercial	$2,890.00
Rate for Payer: Humana Medicare	$2,584.00
Rate for Payer: Kaiser Permanente Commercial	$3,060.00
Rate for Payer: Kaiser Permanente Medicaid	$1,734.00
Rate for Payer: Kaiser Permanente Medicare	$2,584.00
Rate for Payer: MDX Hawaii PPO	$3,298.00
Rate for Payer: Ohana Health Plan Medicaid	$2,584.00
Rate for Payer: Ohana Health Plan Medicare	$2,584.00
Rate for Payer: UnitedHealthcare Medicare	$2,584.00
Rate for Payer: University Health Alliance Commercial	$1,904.00

TIBIAL BEARING SZ6 1506-70-006

Facility

$3,400.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$1,700.00
Max. Negotiated Rate	$3,298.00
Rate for Payer: AlohaCare Medicaid	$1,700.00
Rate for Payer: AlohaCare Medicare	$2,584.00
Rate for Payer: Cash Price	$2,040.00
Rate for Payer: Devoted Health Medicare	$2,856.00
Rate for Payer: Hawaii Medical Service Association Medicare	$2,584.00
Rate for Payer: Hawaii Western Management Group Commercial	$2,380.00
Rate for Payer: Health Management Network Commercial	$2,890.00
Rate for Payer: Humana Medicare	$2,584.00
Rate for Payer: Kaiser Permanente Commercial	$3,060.00
Rate for Payer: Kaiser Permanente Medicaid	$1,734.00
Rate for Payer: Kaiser Permanente Medicare	$2,584.00
Rate for Payer: MDX Hawaii PPO	$3,298.00
Rate for Payer: Ohana Health Plan Medicaid	$2,584.00
Rate for Payer: Ohana Health Plan Medicare	$2,584.00
Rate for Payer: UnitedHealthcare Medicare	$2,584.00
Rate for Payer: University Health Alliance Commercial	$1,904.00

TIBIAL BEARING SZ6 1506-70-006

Facility

$3,400.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$1,904.00
Max. Negotiated Rate	$3,298.00
Rate for Payer: Cash Price	$2,040.00
Rate for Payer: Hawaii Western Management Group Commercial	$2,380.00
Rate for Payer: Health Management Network Commercial	$2,890.00
Rate for Payer: Kaiser Permanente Commercial	$3,060.00
Rate for Payer: MDX Hawaii PPO	$3,298.00
Rate for Payer: University Health Alliance Commercial	$1,904.00

TIBIAL BEARING X3 5532-G-511-E

Facility

$2,676.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$1,498.56
Max. Negotiated Rate	$2,595.72
Rate for Payer: Cash Price	$1,605.60
Rate for Payer: Hawaii Western Management Group Commercial	$1,873.20
Rate for Payer: Health Management Network Commercial	$2,274.60
Rate for Payer: Kaiser Permanente Commercial	$2,408.40
Rate for Payer: MDX Hawaii PPO	$2,595.72
Rate for Payer: University Health Alliance Commercial	$1,498.56

TIBIAL BEARING X3 5532-G-511-E

Facility

$2,676.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$1,338.00
Max. Negotiated Rate	$2,595.72
Rate for Payer: AlohaCare Medicaid	$1,338.00
Rate for Payer: AlohaCare Medicare	$2,033.76
Rate for Payer: Cash Price	$1,605.60
Rate for Payer: Devoted Health Medicare	$2,247.84
Rate for Payer: Hawaii Medical Service Association Medicare	$2,033.76
Rate for Payer: Hawaii Western Management Group Commercial	$1,873.20
Rate for Payer: Health Management Network Commercial	$2,274.60
Rate for Payer: Humana Medicare	$2,033.76
Rate for Payer: Kaiser Permanente Commercial	$2,408.40
Rate for Payer: Kaiser Permanente Medicaid	$1,364.76
Rate for Payer: Kaiser Permanente Medicare	$2,033.76
Rate for Payer: MDX Hawaii PPO	$2,595.72
Rate for Payer: Ohana Health Plan Medicaid	$2,033.76
Rate for Payer: Ohana Health Plan Medicare	$2,033.76
Rate for Payer: UnitedHealthcare Medicare	$2,033.76
Rate for Payer: University Health Alliance Commercial	$1,498.56

TIBIAL BEARING XS 4MM L 160791

Facility

$2,850.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$1,425.00
Max. Negotiated Rate	$2,764.50
Rate for Payer: AlohaCare Medicaid	$1,425.00
Rate for Payer: AlohaCare Medicare	$2,166.00
Rate for Payer: Cash Price	$1,710.00
Rate for Payer: Devoted Health Medicare	$2,394.00
Rate for Payer: Hawaii Medical Service Association Medicare	$2,166.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,995.00
Rate for Payer: Health Management Network Commercial	$2,422.50
Rate for Payer: Humana Medicare	$2,166.00
Rate for Payer: Kaiser Permanente Commercial	$2,565.00
Rate for Payer: Kaiser Permanente Medicaid	$1,453.50
Rate for Payer: Kaiser Permanente Medicare	$2,166.00
Rate for Payer: MDX Hawaii PPO	$2,764.50
Rate for Payer: Ohana Health Plan Medicaid	$2,166.00
Rate for Payer: Ohana Health Plan Medicare	$2,166.00
Rate for Payer: UnitedHealthcare Medicare	$2,166.00
Rate for Payer: University Health Alliance Commercial	$1,596.00

TIBIAL BEARING XS 4MM L 160791

Facility

$2,850.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$1,596.00
Max. Negotiated Rate	$2,764.50
Rate for Payer: Cash Price	$1,710.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,995.00
Rate for Payer: Health Management Network Commercial	$2,422.50
Rate for Payer: Kaiser Permanente Commercial	$2,565.00
Rate for Payer: MDX Hawaii PPO	$2,764.50
Rate for Payer: University Health Alliance Commercial	$1,596.00

TIBIAL BEARNG 10MM 1516-20-610

Facility

$3,000.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$1,680.00
Max. Negotiated Rate	$2,910.00
Rate for Payer: Cash Price	$1,800.00
Rate for Payer: Hawaii Western Management Group Commercial	$2,100.00
Rate for Payer: Health Management Network Commercial	$2,550.00
Rate for Payer: Kaiser Permanente Commercial	$2,700.00
Rate for Payer: MDX Hawaii PPO	$2,910.00
Rate for Payer: University Health Alliance Commercial	$1,680.00

TIBIAL BEARNG 10MM 1516-20-610

Facility

$3,000.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$1,500.00
Max. Negotiated Rate	$2,910.00
Rate for Payer: AlohaCare Medicaid	$1,500.00
Rate for Payer: AlohaCare Medicare	$2,280.00
Rate for Payer: Cash Price	$1,800.00
Rate for Payer: Devoted Health Medicare	$2,520.00
Rate for Payer: Hawaii Medical Service Association Medicare	$2,280.00
Rate for Payer: Hawaii Western Management Group Commercial	$2,100.00
Rate for Payer: Health Management Network Commercial	$2,550.00
Rate for Payer: Humana Medicare	$2,280.00
Rate for Payer: Kaiser Permanente Commercial	$2,700.00
Rate for Payer: Kaiser Permanente Medicaid	$1,530.00
Rate for Payer: Kaiser Permanente Medicare	$2,280.00
Rate for Payer: MDX Hawaii PPO	$2,910.00
Rate for Payer: Ohana Health Plan Medicaid	$2,280.00
Rate for Payer: Ohana Health Plan Medicare	$2,280.00
Rate for Payer: UnitedHealthcare Medicare	$2,280.00
Rate for Payer: University Health Alliance Commercial	$1,680.00

TIBIAL BEARNG SZ4 5531-G-411-E

Facility

$2,676.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$1,498.56
Max. Negotiated Rate	$2,595.72
Rate for Payer: Cash Price	$1,605.60
Rate for Payer: Hawaii Western Management Group Commercial	$1,873.20
Rate for Payer: Health Management Network Commercial	$2,274.60
Rate for Payer: Kaiser Permanente Commercial	$2,408.40
Rate for Payer: MDX Hawaii PPO	$2,595.72
Rate for Payer: University Health Alliance Commercial	$1,498.56

Know your out-of-pocket cost for care.

All Charges