Honoka'a Hospital and Skilled Nursing Facility

All Charges

Charge

Type

Setting

Price

TRIDEN II TRITANIUM 702-04-62G

Facility

$3,244.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$1,622.00
Max. Negotiated Rate	$3,146.68
Rate for Payer: AlohaCare Medicaid	$1,622.00
Rate for Payer: AlohaCare Medicare	$2,465.44
Rate for Payer: Cash Price	$1,946.40
Rate for Payer: Devoted Health Medicare	$2,724.96
Rate for Payer: Hawaii Medical Service Association Medicare	$2,465.44
Rate for Payer: Hawaii Western Management Group Commercial	$2,270.80
Rate for Payer: Health Management Network Commercial	$2,757.40
Rate for Payer: Humana Medicare	$2,465.44
Rate for Payer: Kaiser Permanente Commercial	$2,919.60
Rate for Payer: Kaiser Permanente Medicaid	$1,654.44
Rate for Payer: Kaiser Permanente Medicare	$2,465.44
Rate for Payer: MDX Hawaii PPO	$3,146.68
Rate for Payer: Ohana Health Plan Medicaid	$2,465.44
Rate for Payer: Ohana Health Plan Medicare	$2,465.44
Rate for Payer: UnitedHealthcare Medicare	$2,465.44
Rate for Payer: University Health Alliance Commercial	$1,816.64

TRIDEN II TRITANIUM 702-04-62G

Facility

$3,244.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$1,816.64
Max. Negotiated Rate	$3,146.68
Rate for Payer: Cash Price	$1,946.40
Rate for Payer: Hawaii Western Management Group Commercial	$2,270.80
Rate for Payer: Health Management Network Commercial	$2,757.40
Rate for Payer: Kaiser Permanente Commercial	$2,919.60
Rate for Payer: MDX Hawaii PPO	$3,146.68
Rate for Payer: University Health Alliance Commercial	$1,816.64

TRIDENT ACETABULAR 690-00-22D

Facility

$6,105.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$3,052.50
Max. Negotiated Rate	$5,921.85
Rate for Payer: AlohaCare Medicaid	$3,052.50
Rate for Payer: AlohaCare Medicare	$4,639.80
Rate for Payer: Cash Price	$3,663.00
Rate for Payer: Devoted Health Medicare	$5,128.20
Rate for Payer: Hawaii Medical Service Association Medicare	$4,639.80
Rate for Payer: Hawaii Western Management Group Commercial	$4,273.50
Rate for Payer: Health Management Network Commercial	$5,189.25
Rate for Payer: Humana Medicare	$4,639.80
Rate for Payer: Kaiser Permanente Commercial	$5,494.50
Rate for Payer: Kaiser Permanente Medicaid	$3,113.55
Rate for Payer: Kaiser Permanente Medicare	$4,639.80
Rate for Payer: MDX Hawaii PPO	$5,921.85
Rate for Payer: Ohana Health Plan Medicaid	$4,639.80
Rate for Payer: Ohana Health Plan Medicare	$4,639.80
Rate for Payer: UnitedHealthcare Medicare	$4,639.80
Rate for Payer: University Health Alliance Commercial	$3,418.80

TRIDENT ACETABULAR 690-00-22D

Facility

$6,105.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$3,418.80
Max. Negotiated Rate	$5,921.85
Rate for Payer: Cash Price	$3,663.00
Rate for Payer: Hawaii Western Management Group Commercial	$4,273.50
Rate for Payer: Health Management Network Commercial	$5,189.25
Rate for Payer: Kaiser Permanente Commercial	$5,494.50
Rate for Payer: MDX Hawaii PPO	$5,921.85
Rate for Payer: University Health Alliance Commercial	$3,418.80

TRIDENT CUP 3/36MM 623-00-36I

Facility

$5,696.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$2,848.00
Max. Negotiated Rate	$5,525.12
Rate for Payer: AlohaCare Medicaid	$2,848.00
Rate for Payer: AlohaCare Medicare	$4,328.96
Rate for Payer: Cash Price	$3,417.60
Rate for Payer: Devoted Health Medicare	$4,784.64
Rate for Payer: Hawaii Medical Service Association Medicare	$4,328.96
Rate for Payer: Hawaii Western Management Group Commercial	$3,987.20
Rate for Payer: Health Management Network Commercial	$4,841.60
Rate for Payer: Humana Medicare	$4,328.96
Rate for Payer: Kaiser Permanente Commercial	$5,126.40
Rate for Payer: Kaiser Permanente Medicaid	$2,904.96
Rate for Payer: Kaiser Permanente Medicare	$4,328.96
Rate for Payer: MDX Hawaii PPO	$5,525.12
Rate for Payer: Ohana Health Plan Medicaid	$4,328.96
Rate for Payer: Ohana Health Plan Medicare	$4,328.96
Rate for Payer: UnitedHealthcare Medicare	$4,328.96
Rate for Payer: University Health Alliance Commercial	$3,189.76

TRIDENT CUP 3/36MM 623-00-36I

Facility

$5,696.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$3,189.76
Max. Negotiated Rate	$5,525.12
Rate for Payer: Cash Price	$3,417.60
Rate for Payer: Hawaii Western Management Group Commercial	$3,987.20
Rate for Payer: Health Management Network Commercial	$4,841.60
Rate for Payer: Kaiser Permanente Commercial	$5,126.40
Rate for Payer: MDX Hawaii PPO	$5,525.12
Rate for Payer: University Health Alliance Commercial	$3,189.76

TRIDENT CUP 3/36MM 623-00-36J

Facility

$5,696.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$3,189.76
Max. Negotiated Rate	$5,525.12
Rate for Payer: Cash Price	$3,417.60
Rate for Payer: Hawaii Western Management Group Commercial	$3,987.20
Rate for Payer: Health Management Network Commercial	$4,841.60
Rate for Payer: Kaiser Permanente Commercial	$5,126.40
Rate for Payer: MDX Hawaii PPO	$5,525.12
Rate for Payer: University Health Alliance Commercial	$3,189.76

TRIDENT CUP 3/36MM 623-00-36J

Facility

$5,696.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$2,848.00
Max. Negotiated Rate	$5,525.12
Rate for Payer: AlohaCare Medicaid	$2,848.00
Rate for Payer: AlohaCare Medicare	$4,328.96
Rate for Payer: Cash Price	$3,417.60
Rate for Payer: Devoted Health Medicare	$4,784.64
Rate for Payer: Hawaii Medical Service Association Medicare	$4,328.96
Rate for Payer: Hawaii Western Management Group Commercial	$3,987.20
Rate for Payer: Health Management Network Commercial	$4,841.60
Rate for Payer: Humana Medicare	$4,328.96
Rate for Payer: Kaiser Permanente Commercial	$5,126.40
Rate for Payer: Kaiser Permanente Medicaid	$2,904.96
Rate for Payer: Kaiser Permanente Medicare	$4,328.96
Rate for Payer: MDX Hawaii PPO	$5,525.12
Rate for Payer: Ohana Health Plan Medicaid	$4,328.96
Rate for Payer: Ohana Health Plan Medicare	$4,328.96
Rate for Payer: UnitedHealthcare Medicare	$4,328.96
Rate for Payer: University Health Alliance Commercial	$3,189.76

TRIDENT CUP 3/36MM 623-10-36E

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

TRIDENT CUP 3/36MM 623-10-36E

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

TRIDENT CUP 3/36MM 623-10-36I

Facility

$5,696.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$2,848.00
Max. Negotiated Rate	$5,525.12
Rate for Payer: AlohaCare Medicaid	$2,848.00
Rate for Payer: AlohaCare Medicare	$4,328.96
Rate for Payer: Cash Price	$3,417.60
Rate for Payer: Devoted Health Medicare	$4,784.64
Rate for Payer: Hawaii Medical Service Association Medicare	$4,328.96
Rate for Payer: Hawaii Western Management Group Commercial	$3,987.20
Rate for Payer: Health Management Network Commercial	$4,841.60
Rate for Payer: Humana Medicare	$4,328.96
Rate for Payer: Kaiser Permanente Commercial	$5,126.40
Rate for Payer: Kaiser Permanente Medicaid	$2,904.96
Rate for Payer: Kaiser Permanente Medicare	$4,328.96
Rate for Payer: MDX Hawaii PPO	$5,525.12
Rate for Payer: Ohana Health Plan Medicaid	$4,328.96
Rate for Payer: Ohana Health Plan Medicare	$4,328.96
Rate for Payer: UnitedHealthcare Medicare	$4,328.96
Rate for Payer: University Health Alliance Commercial	$3,189.76

TRIDENT CUP 3/36MM 623-10-36I

Facility

$5,696.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$3,189.76
Max. Negotiated Rate	$5,525.12
Rate for Payer: Cash Price	$3,417.60
Rate for Payer: Hawaii Western Management Group Commercial	$3,987.20
Rate for Payer: Health Management Network Commercial	$4,841.60
Rate for Payer: Kaiser Permanente Commercial	$5,126.40
Rate for Payer: MDX Hawaii PPO	$5,525.12
Rate for Payer: University Health Alliance Commercial	$3,189.76

TRIDENT CUP 3/36MM 623-10-36J

Facility

$5,696.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$3,189.76
Max. Negotiated Rate	$5,525.12
Rate for Payer: Cash Price	$3,417.60
Rate for Payer: Hawaii Western Management Group Commercial	$3,987.20
Rate for Payer: Health Management Network Commercial	$4,841.60
Rate for Payer: Kaiser Permanente Commercial	$5,126.40
Rate for Payer: MDX Hawaii PPO	$5,525.12
Rate for Payer: University Health Alliance Commercial	$3,189.76

TRIDENT CUP 3/36MM 623-10-36J

Facility

$5,696.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$2,848.00
Max. Negotiated Rate	$5,525.12
Rate for Payer: AlohaCare Medicaid	$2,848.00
Rate for Payer: AlohaCare Medicare	$4,328.96
Rate for Payer: Cash Price	$3,417.60
Rate for Payer: Devoted Health Medicare	$4,784.64
Rate for Payer: Hawaii Medical Service Association Medicare	$4,328.96
Rate for Payer: Hawaii Western Management Group Commercial	$3,987.20
Rate for Payer: Health Management Network Commercial	$4,841.60
Rate for Payer: Humana Medicare	$4,328.96
Rate for Payer: Kaiser Permanente Commercial	$5,126.40
Rate for Payer: Kaiser Permanente Medicaid	$2,904.96
Rate for Payer: Kaiser Permanente Medicare	$4,328.96
Rate for Payer: MDX Hawaii PPO	$5,525.12
Rate for Payer: Ohana Health Plan Medicaid	$4,328.96
Rate for Payer: Ohana Health Plan Medicare	$4,328.96
Rate for Payer: UnitedHealthcare Medicare	$4,328.96
Rate for Payer: University Health Alliance Commercial	$3,189.76

TRIDENT II 702-04-46C

Facility

$3,211.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$1,605.50
Max. Negotiated Rate	$3,114.67
Rate for Payer: AlohaCare Medicaid	$1,605.50
Rate for Payer: AlohaCare Medicare	$2,440.36
Rate for Payer: Cash Price	$1,926.60
Rate for Payer: Devoted Health Medicare	$2,697.24
Rate for Payer: Hawaii Medical Service Association Medicare	$2,440.36
Rate for Payer: Hawaii Western Management Group Commercial	$2,247.70
Rate for Payer: Health Management Network Commercial	$2,729.35
Rate for Payer: Humana Medicare	$2,440.36
Rate for Payer: Kaiser Permanente Commercial	$2,889.90
Rate for Payer: Kaiser Permanente Medicaid	$1,637.61
Rate for Payer: Kaiser Permanente Medicare	$2,440.36
Rate for Payer: MDX Hawaii PPO	$3,114.67
Rate for Payer: Ohana Health Plan Medicaid	$2,440.36
Rate for Payer: Ohana Health Plan Medicare	$2,440.36
Rate for Payer: UnitedHealthcare Medicare	$2,440.36
Rate for Payer: University Health Alliance Commercial	$1,798.16

TRIDENT II 702-04-46C

Facility

$3,211.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$1,798.16
Max. Negotiated Rate	$3,114.67
Rate for Payer: Cash Price	$1,926.60
Rate for Payer: Hawaii Western Management Group Commercial	$2,247.70
Rate for Payer: Health Management Network Commercial	$2,729.35
Rate for Payer: Kaiser Permanente Commercial	$2,889.90
Rate for Payer: MDX Hawaii PPO	$3,114.67
Rate for Payer: University Health Alliance Commercial	$1,798.16

TRIDENT II SHELL 702-04-56F

Facility

$3,244.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$1,816.64
Max. Negotiated Rate	$3,146.68
Rate for Payer: Cash Price	$1,946.40
Rate for Payer: Hawaii Western Management Group Commercial	$2,270.80
Rate for Payer: Health Management Network Commercial	$2,757.40
Rate for Payer: Kaiser Permanente Commercial	$2,919.60
Rate for Payer: MDX Hawaii PPO	$3,146.68
Rate for Payer: University Health Alliance Commercial	$1,816.64

TRIDENT II SHELL 702-04-56F

Facility

$3,244.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$1,622.00
Max. Negotiated Rate	$3,146.68
Rate for Payer: AlohaCare Medicaid	$1,622.00
Rate for Payer: AlohaCare Medicare	$2,465.44
Rate for Payer: Cash Price	$1,946.40
Rate for Payer: Devoted Health Medicare	$2,724.96
Rate for Payer: Hawaii Medical Service Association Medicare	$2,465.44
Rate for Payer: Hawaii Western Management Group Commercial	$2,270.80
Rate for Payer: Health Management Network Commercial	$2,757.40
Rate for Payer: Humana Medicare	$2,465.44
Rate for Payer: Kaiser Permanente Commercial	$2,919.60
Rate for Payer: Kaiser Permanente Medicaid	$1,654.44
Rate for Payer: Kaiser Permanente Medicare	$2,465.44
Rate for Payer: MDX Hawaii PPO	$3,146.68
Rate for Payer: Ohana Health Plan Medicaid	$2,465.44
Rate for Payer: Ohana Health Plan Medicare	$2,465.44
Rate for Payer: UnitedHealthcare Medicare	$2,465.44
Rate for Payer: University Health Alliance Commercial	$1,816.64

TRIDENT II TRI 54MM 702-04-54E

Facility

$3,244.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$1,816.64
Max. Negotiated Rate	$3,146.68
Rate for Payer: Cash Price	$1,946.40
Rate for Payer: Hawaii Western Management Group Commercial	$2,270.80
Rate for Payer: Health Management Network Commercial	$2,757.40
Rate for Payer: Kaiser Permanente Commercial	$2,919.60
Rate for Payer: MDX Hawaii PPO	$3,146.68
Rate for Payer: University Health Alliance Commercial	$1,816.64

TRIDENT II TRI 54MM 702-04-54E

Facility

$3,244.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$1,622.00
Max. Negotiated Rate	$3,146.68
Rate for Payer: AlohaCare Medicaid	$1,622.00
Rate for Payer: AlohaCare Medicare	$2,465.44
Rate for Payer: Cash Price	$1,946.40
Rate for Payer: Devoted Health Medicare	$2,724.96
Rate for Payer: Hawaii Medical Service Association Medicare	$2,465.44
Rate for Payer: Hawaii Western Management Group Commercial	$2,270.80
Rate for Payer: Health Management Network Commercial	$2,757.40
Rate for Payer: Humana Medicare	$2,465.44
Rate for Payer: Kaiser Permanente Commercial	$2,919.60
Rate for Payer: Kaiser Permanente Medicaid	$1,654.44
Rate for Payer: Kaiser Permanente Medicare	$2,465.44
Rate for Payer: MDX Hawaii PPO	$3,146.68
Rate for Payer: Ohana Health Plan Medicaid	$2,465.44
Rate for Payer: Ohana Health Plan Medicare	$2,465.44
Rate for Payer: UnitedHealthcare Medicare	$2,465.44
Rate for Payer: University Health Alliance Commercial	$1,816.64

TRIDENT II TRI 58MM 702-04-58F

Facility

$3,211.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$1,798.16
Max. Negotiated Rate	$3,114.67
Rate for Payer: Cash Price	$1,926.60
Rate for Payer: Hawaii Western Management Group Commercial	$2,247.70
Rate for Payer: Health Management Network Commercial	$2,729.35
Rate for Payer: Kaiser Permanente Commercial	$2,889.90
Rate for Payer: MDX Hawaii PPO	$3,114.67
Rate for Payer: University Health Alliance Commercial	$1,798.16

TRIDENT II TRI 58MM 702-04-58F

Facility

$3,211.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$1,605.50
Max. Negotiated Rate	$3,114.67
Rate for Payer: AlohaCare Medicaid	$1,605.50
Rate for Payer: AlohaCare Medicare	$2,440.36
Rate for Payer: Cash Price	$1,926.60
Rate for Payer: Devoted Health Medicare	$2,697.24
Rate for Payer: Hawaii Medical Service Association Medicare	$2,440.36
Rate for Payer: Hawaii Western Management Group Commercial	$2,247.70
Rate for Payer: Health Management Network Commercial	$2,729.35
Rate for Payer: Humana Medicare	$2,440.36
Rate for Payer: Kaiser Permanente Commercial	$2,889.90
Rate for Payer: Kaiser Permanente Medicaid	$1,637.61
Rate for Payer: Kaiser Permanente Medicare	$2,440.36
Rate for Payer: MDX Hawaii PPO	$3,114.67
Rate for Payer: Ohana Health Plan Medicaid	$2,440.36
Rate for Payer: Ohana Health Plan Medicare	$2,440.36
Rate for Payer: UnitedHealthcare Medicare	$2,440.36
Rate for Payer: University Health Alliance Commercial	$1,798.16

TRIDENT INSERT 36M #623-00-36E

Facility

$2,703.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$1,513.68
Max. Negotiated Rate	$2,621.91
Rate for Payer: Cash Price	$1,621.80
Rate for Payer: Hawaii Western Management Group Commercial	$1,892.10
Rate for Payer: Health Management Network Commercial	$2,297.55
Rate for Payer: Kaiser Permanente Commercial	$2,432.70
Rate for Payer: MDX Hawaii PPO	$2,621.91
Rate for Payer: University Health Alliance Commercial	$1,513.68

TRIDENT INSERT 36M #623-00-36E

Facility

$2,703.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$1,351.50
Max. Negotiated Rate	$2,621.91
Rate for Payer: AlohaCare Medicaid	$1,351.50
Rate for Payer: AlohaCare Medicare	$2,054.28
Rate for Payer: Cash Price	$1,621.80
Rate for Payer: Devoted Health Medicare	$2,270.52
Rate for Payer: Hawaii Medical Service Association Medicare	$2,054.28
Rate for Payer: Hawaii Western Management Group Commercial	$1,892.10
Rate for Payer: Health Management Network Commercial	$2,297.55
Rate for Payer: Humana Medicare	$2,054.28
Rate for Payer: Kaiser Permanente Commercial	$2,432.70
Rate for Payer: Kaiser Permanente Medicaid	$1,378.53
Rate for Payer: Kaiser Permanente Medicare	$2,054.28
Rate for Payer: MDX Hawaii PPO	$2,621.91
Rate for Payer: Ohana Health Plan Medicaid	$2,054.28
Rate for Payer: Ohana Health Plan Medicare	$2,054.28
Rate for Payer: UnitedHealthcare Medicare	$2,054.28
Rate for Payer: University Health Alliance Commercial	$1,513.68

TRIDENT INSTX3/32MM 623-00-32C

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

Know your out-of-pocket cost for care.

All Charges