Honoka'a Hospital and Skilled Nursing Facility

All Charges

Charge

Type

Setting

Price

TRI HA ACETAB 46MM #542-11-46D

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

TRI HA ACETAB 46MM #542-11-46D

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

TRI HA ACETAB 48MM #542-11-48D

Facility

$6,108.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$3,420.48
Max. Negotiated Rate	$5,924.76
Rate for Payer: Cash Price	$3,664.80
Rate for Payer: Hawaii Western Management Group Commercial	$4,275.60
Rate for Payer: Health Management Network Commercial	$5,191.80
Rate for Payer: Kaiser Permanente Commercial	$5,497.20
Rate for Payer: MDX Hawaii PPO	$5,924.76
Rate for Payer: University Health Alliance Commercial	$3,420.48

TRI HA ACETAB 48MM #542-11-48D

Facility

$6,108.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$3,054.00
Max. Negotiated Rate	$5,924.76
Rate for Payer: AlohaCare Medicaid	$3,054.00
Rate for Payer: AlohaCare Medicare	$4,642.08
Rate for Payer: Cash Price	$3,664.80
Rate for Payer: Devoted Health Medicare	$5,130.72
Rate for Payer: Hawaii Medical Service Association Medicare	$4,642.08
Rate for Payer: Hawaii Western Management Group Commercial	$4,275.60
Rate for Payer: Health Management Network Commercial	$5,191.80
Rate for Payer: Humana Medicare	$4,642.08
Rate for Payer: Kaiser Permanente Commercial	$5,497.20
Rate for Payer: Kaiser Permanente Medicaid	$3,115.08
Rate for Payer: Kaiser Permanente Medicare	$4,642.08
Rate for Payer: MDX Hawaii PPO	$5,924.76
Rate for Payer: Ohana Health Plan Medicaid	$4,642.08
Rate for Payer: Ohana Health Plan Medicare	$4,642.08
Rate for Payer: UnitedHealthcare Medicare	$4,642.08
Rate for Payer: University Health Alliance Commercial	$3,420.48

TRI HA ACETAB 50MM #542-11-50E

Facility

$6,108.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$3,420.48
Max. Negotiated Rate	$5,924.76
Rate for Payer: Cash Price	$3,664.80
Rate for Payer: Hawaii Western Management Group Commercial	$4,275.60
Rate for Payer: Health Management Network Commercial	$5,191.80
Rate for Payer: Kaiser Permanente Commercial	$5,497.20
Rate for Payer: MDX Hawaii PPO	$5,924.76
Rate for Payer: University Health Alliance Commercial	$3,420.48

TRI HA ACETAB 50MM #542-11-50E

Facility

$6,108.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$3,054.00
Max. Negotiated Rate	$5,924.76
Rate for Payer: Kaiser Permanente Medicare	$4,642.08
Rate for Payer: AlohaCare Medicaid	$3,054.00
Rate for Payer: AlohaCare Medicare	$4,642.08
Rate for Payer: Cash Price	$3,664.80
Rate for Payer: Devoted Health Medicare	$5,130.72
Rate for Payer: Hawaii Medical Service Association Medicare	$4,642.08
Rate for Payer: Hawaii Western Management Group Commercial	$4,275.60
Rate for Payer: Health Management Network Commercial	$5,191.80
Rate for Payer: Humana Medicare	$4,642.08
Rate for Payer: Kaiser Permanente Commercial	$5,497.20
Rate for Payer: Kaiser Permanente Medicaid	$3,115.08
Rate for Payer: MDX Hawaii PPO	$5,924.76
Rate for Payer: Ohana Health Plan Medicaid	$4,642.08
Rate for Payer: Ohana Health Plan Medicare	$4,642.08
Rate for Payer: UnitedHealthcare Medicare	$4,642.08
Rate for Payer: University Health Alliance Commercial	$3,420.48

TRI HA ACETAB 52MM #542-11-52E

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

TRI HA ACETAB 52MM #542-11-52E

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

TRI HA ACETAB 54MM #542-11-54F

Facility

$5,988.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$3,353.28
Max. Negotiated Rate	$5,808.36
Rate for Payer: Cash Price	$3,592.80
Rate for Payer: Hawaii Western Management Group Commercial	$4,191.60
Rate for Payer: Health Management Network Commercial	$5,089.80
Rate for Payer: Kaiser Permanente Commercial	$5,389.20
Rate for Payer: MDX Hawaii PPO	$5,808.36
Rate for Payer: University Health Alliance Commercial	$3,353.28

TRI HA ACETAB 54MM #542-11-54F

Facility

$5,988.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$2,994.00
Max. Negotiated Rate	$5,808.36
Rate for Payer: AlohaCare Medicaid	$2,994.00
Rate for Payer: AlohaCare Medicare	$4,550.88
Rate for Payer: Cash Price	$3,592.80
Rate for Payer: Devoted Health Medicare	$5,029.92
Rate for Payer: Hawaii Medical Service Association Medicare	$4,550.88
Rate for Payer: Hawaii Western Management Group Commercial	$4,191.60
Rate for Payer: Health Management Network Commercial	$5,089.80
Rate for Payer: Humana Medicare	$4,550.88
Rate for Payer: Kaiser Permanente Commercial	$5,389.20
Rate for Payer: Kaiser Permanente Medicaid	$3,053.88
Rate for Payer: Kaiser Permanente Medicare	$4,550.88
Rate for Payer: MDX Hawaii PPO	$5,808.36
Rate for Payer: Ohana Health Plan Medicaid	$4,550.88
Rate for Payer: Ohana Health Plan Medicare	$4,550.88
Rate for Payer: UnitedHealthcare Medicare	$4,550.88
Rate for Payer: University Health Alliance Commercial	$3,353.28

TRI HA ACETAB 56MM #542-11-56F

Facility

$6,108.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$3,420.48
Max. Negotiated Rate	$5,924.76
Rate for Payer: Cash Price	$3,664.80
Rate for Payer: Hawaii Western Management Group Commercial	$4,275.60
Rate for Payer: Health Management Network Commercial	$5,191.80
Rate for Payer: Kaiser Permanente Commercial	$5,497.20
Rate for Payer: MDX Hawaii PPO	$5,924.76
Rate for Payer: University Health Alliance Commercial	$3,420.48

TRI HA ACETAB 56MM #542-11-56F

Facility

$6,108.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$3,054.00
Max. Negotiated Rate	$5,924.76
Rate for Payer: AlohaCare Medicaid	$3,054.00
Rate for Payer: AlohaCare Medicare	$4,642.08
Rate for Payer: Cash Price	$3,664.80
Rate for Payer: Devoted Health Medicare	$5,130.72
Rate for Payer: Hawaii Medical Service Association Medicare	$4,642.08
Rate for Payer: Hawaii Western Management Group Commercial	$4,275.60
Rate for Payer: Health Management Network Commercial	$5,191.80
Rate for Payer: Humana Medicare	$4,642.08
Rate for Payer: Kaiser Permanente Commercial	$5,497.20
Rate for Payer: Kaiser Permanente Medicaid	$3,115.08
Rate for Payer: Kaiser Permanente Medicare	$4,642.08
Rate for Payer: MDX Hawaii PPO	$5,924.76
Rate for Payer: Ohana Health Plan Medicaid	$4,642.08
Rate for Payer: Ohana Health Plan Medicare	$4,642.08
Rate for Payer: UnitedHealthcare Medicare	$4,642.08
Rate for Payer: University Health Alliance Commercial	$3,420.48

TRI HA ACETAB 58MM 542-11-58G

Facility

$5,814.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$3,255.84
Max. Negotiated Rate	$5,639.58
Rate for Payer: Cash Price	$3,488.40
Rate for Payer: Hawaii Western Management Group Commercial	$4,069.80
Rate for Payer: Health Management Network Commercial	$4,941.90
Rate for Payer: Kaiser Permanente Commercial	$5,232.60
Rate for Payer: MDX Hawaii PPO	$5,639.58
Rate for Payer: University Health Alliance Commercial	$3,255.84

TRI HA ACETAB 58MM 542-11-58G

Facility

$5,814.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$2,907.00
Max. Negotiated Rate	$5,639.58
Rate for Payer: AlohaCare Medicaid	$2,907.00
Rate for Payer: AlohaCare Medicare	$4,418.64
Rate for Payer: Cash Price	$3,488.40
Rate for Payer: Devoted Health Medicare	$4,883.76
Rate for Payer: Hawaii Medical Service Association Medicare	$4,418.64
Rate for Payer: Hawaii Western Management Group Commercial	$4,069.80
Rate for Payer: Health Management Network Commercial	$4,941.90
Rate for Payer: Humana Medicare	$4,418.64
Rate for Payer: Kaiser Permanente Commercial	$5,232.60
Rate for Payer: Kaiser Permanente Medicaid	$2,965.14
Rate for Payer: Kaiser Permanente Medicare	$4,418.64
Rate for Payer: MDX Hawaii PPO	$5,639.58
Rate for Payer: Ohana Health Plan Medicaid	$4,418.64
Rate for Payer: Ohana Health Plan Medicare	$4,418.64
Rate for Payer: UnitedHealthcare Medicare	$4,418.64
Rate for Payer: University Health Alliance Commercial	$3,255.84

TRI HA ACETAB 60MM 542-11-60G

Facility

$5,814.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$3,255.84
Max. Negotiated Rate	$5,639.58
Rate for Payer: Cash Price	$3,488.40
Rate for Payer: Hawaii Western Management Group Commercial	$4,069.80
Rate for Payer: Health Management Network Commercial	$4,941.90
Rate for Payer: Kaiser Permanente Commercial	$5,232.60
Rate for Payer: MDX Hawaii PPO	$5,639.58
Rate for Payer: University Health Alliance Commercial	$3,255.84

TRI HA ACETAB 60MM 542-11-60G

Facility

$5,814.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$2,907.00
Max. Negotiated Rate	$5,639.58
Rate for Payer: AlohaCare Medicaid	$2,907.00
Rate for Payer: AlohaCare Medicare	$4,418.64
Rate for Payer: Cash Price	$3,488.40
Rate for Payer: Devoted Health Medicare	$4,883.76
Rate for Payer: Hawaii Medical Service Association Medicare	$4,418.64
Rate for Payer: Hawaii Western Management Group Commercial	$4,069.80
Rate for Payer: Health Management Network Commercial	$4,941.90
Rate for Payer: Humana Medicare	$4,418.64
Rate for Payer: Kaiser Permanente Commercial	$5,232.60
Rate for Payer: Kaiser Permanente Medicaid	$2,965.14
Rate for Payer: Kaiser Permanente Medicare	$4,418.64
Rate for Payer: MDX Hawaii PPO	$5,639.58
Rate for Payer: Ohana Health Plan Medicaid	$4,418.64
Rate for Payer: Ohana Health Plan Medicare	$4,418.64
Rate for Payer: UnitedHealthcare Medicare	$4,418.64
Rate for Payer: University Health Alliance Commercial	$3,255.84

TRI HA ACETAB 62MM 542-11-62H

Facility

$5,814.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$3,255.84
Max. Negotiated Rate	$5,639.58
Rate for Payer: Cash Price	$3,488.40
Rate for Payer: Hawaii Western Management Group Commercial	$4,069.80
Rate for Payer: Health Management Network Commercial	$4,941.90
Rate for Payer: Kaiser Permanente Commercial	$5,232.60
Rate for Payer: MDX Hawaii PPO	$5,639.58
Rate for Payer: University Health Alliance Commercial	$3,255.84

TRI HA ACETAB 62MM 542-11-62H

Facility

$5,814.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$2,907.00
Max. Negotiated Rate	$5,639.58
Rate for Payer: AlohaCare Medicaid	$2,907.00
Rate for Payer: AlohaCare Medicare	$4,418.64
Rate for Payer: Cash Price	$3,488.40
Rate for Payer: Devoted Health Medicare	$4,883.76
Rate for Payer: Hawaii Medical Service Association Medicare	$4,418.64
Rate for Payer: Hawaii Western Management Group Commercial	$4,069.80
Rate for Payer: Health Management Network Commercial	$4,941.90
Rate for Payer: Humana Medicare	$4,418.64
Rate for Payer: Kaiser Permanente Commercial	$5,232.60
Rate for Payer: Kaiser Permanente Medicaid	$2,965.14
Rate for Payer: Kaiser Permanente Medicare	$4,418.64
Rate for Payer: MDX Hawaii PPO	$5,639.58
Rate for Payer: Ohana Health Plan Medicaid	$4,418.64
Rate for Payer: Ohana Health Plan Medicare	$4,418.64
Rate for Payer: UnitedHealthcare Medicare	$4,418.64
Rate for Payer: University Health Alliance Commercial	$3,255.84

TRI HA ACETAB 64MM 542-11-64H

Facility

$5,814.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$2,907.00
Max. Negotiated Rate	$5,639.58
Rate for Payer: AlohaCare Medicaid	$2,907.00
Rate for Payer: AlohaCare Medicare	$4,418.64
Rate for Payer: Cash Price	$3,488.40
Rate for Payer: Devoted Health Medicare	$4,883.76
Rate for Payer: Hawaii Medical Service Association Medicare	$4,418.64
Rate for Payer: Hawaii Western Management Group Commercial	$4,069.80
Rate for Payer: Health Management Network Commercial	$4,941.90
Rate for Payer: Humana Medicare	$4,418.64
Rate for Payer: Kaiser Permanente Commercial	$5,232.60
Rate for Payer: Kaiser Permanente Medicaid	$2,965.14
Rate for Payer: Kaiser Permanente Medicare	$4,418.64
Rate for Payer: MDX Hawaii PPO	$5,639.58
Rate for Payer: Ohana Health Plan Medicaid	$4,418.64
Rate for Payer: Ohana Health Plan Medicare	$4,418.64
Rate for Payer: UnitedHealthcare Medicare	$4,418.64
Rate for Payer: University Health Alliance Commercial	$3,255.84

TRI HA ACETAB 64MM 542-11-64H

Facility

$5,814.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$3,255.84
Max. Negotiated Rate	$5,639.58
Rate for Payer: Cash Price	$3,488.40
Rate for Payer: Hawaii Western Management Group Commercial	$4,069.80
Rate for Payer: Health Management Network Commercial	$4,941.90
Rate for Payer: Kaiser Permanente Commercial	$5,232.60
Rate for Payer: MDX Hawaii PPO	$5,639.58
Rate for Payer: University Health Alliance Commercial	$3,255.84

TRI HA ACETAB 66MM 542-11-66I

Facility

$5,814.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$3,255.84
Max. Negotiated Rate	$5,639.58
Rate for Payer: Cash Price	$3,488.40
Rate for Payer: Hawaii Western Management Group Commercial	$4,069.80
Rate for Payer: Health Management Network Commercial	$4,941.90
Rate for Payer: Kaiser Permanente Commercial	$5,232.60
Rate for Payer: MDX Hawaii PPO	$5,639.58
Rate for Payer: University Health Alliance Commercial	$3,255.84

TRI HA ACETAB 66MM 542-11-66I

Facility

$5,814.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$2,907.00
Max. Negotiated Rate	$5,639.58
Rate for Payer: AlohaCare Medicaid	$2,907.00
Rate for Payer: AlohaCare Medicare	$4,418.64
Rate for Payer: Cash Price	$3,488.40
Rate for Payer: Devoted Health Medicare	$4,883.76
Rate for Payer: Hawaii Medical Service Association Medicare	$4,418.64
Rate for Payer: Hawaii Western Management Group Commercial	$4,069.80
Rate for Payer: Health Management Network Commercial	$4,941.90
Rate for Payer: Humana Medicare	$4,418.64
Rate for Payer: Kaiser Permanente Commercial	$5,232.60
Rate for Payer: Kaiser Permanente Medicaid	$2,965.14
Rate for Payer: Kaiser Permanente Medicare	$4,418.64
Rate for Payer: MDX Hawaii PPO	$5,639.58
Rate for Payer: Ohana Health Plan Medicaid	$4,418.64
Rate for Payer: Ohana Health Plan Medicare	$4,418.64
Rate for Payer: UnitedHealthcare Medicare	$4,418.64
Rate for Payer: University Health Alliance Commercial	$3,255.84

TRI HA ACETAB 68MM 542-11-68I

Facility

$5,814.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$3,255.84
Max. Negotiated Rate	$5,639.58
Rate for Payer: Cash Price	$3,488.40
Rate for Payer: Hawaii Western Management Group Commercial	$4,069.80
Rate for Payer: Health Management Network Commercial	$4,941.90
Rate for Payer: Kaiser Permanente Commercial	$5,232.60
Rate for Payer: MDX Hawaii PPO	$5,639.58
Rate for Payer: University Health Alliance Commercial	$3,255.84

TRI HA ACETAB 68MM 542-11-68I

Facility

$5,814.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$2,907.00
Max. Negotiated Rate	$5,639.58
Rate for Payer: AlohaCare Medicaid	$2,907.00
Rate for Payer: AlohaCare Medicare	$4,418.64
Rate for Payer: Cash Price	$3,488.40
Rate for Payer: Devoted Health Medicare	$4,883.76
Rate for Payer: Hawaii Medical Service Association Medicare	$4,418.64
Rate for Payer: Hawaii Western Management Group Commercial	$4,069.80
Rate for Payer: Health Management Network Commercial	$4,941.90
Rate for Payer: Humana Medicare	$4,418.64
Rate for Payer: Kaiser Permanente Commercial	$5,232.60
Rate for Payer: Kaiser Permanente Medicaid	$2,965.14
Rate for Payer: Kaiser Permanente Medicare	$4,418.64
Rate for Payer: MDX Hawaii PPO	$5,639.58
Rate for Payer: Ohana Health Plan Medicaid	$4,418.64
Rate for Payer: Ohana Health Plan Medicare	$4,418.64
Rate for Payer: UnitedHealthcare Medicare	$4,418.64
Rate for Payer: University Health Alliance Commercial	$3,255.84

TRI HA ACETAB 70MM 542-11-70J

Facility

$5,814.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$3,255.84
Max. Negotiated Rate	$5,639.58
Rate for Payer: Cash Price	$3,488.40
Rate for Payer: Hawaii Western Management Group Commercial	$4,069.80
Rate for Payer: Health Management Network Commercial	$4,941.90
Rate for Payer: Kaiser Permanente Commercial	$5,232.60
Rate for Payer: MDX Hawaii PPO	$5,639.58
Rate for Payer: University Health Alliance Commercial	$3,255.84

Know your out-of-pocket cost for care.

All Charges