Honoka'a Hospital and Skilled Nursing Facility

All Charges

Charge

Type

Setting

Price

CEMENT BONE HYDROSET XT 897010

Facility

$11,307.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$5,653.50
Max. Negotiated Rate	$10,967.79
Rate for Payer: AlohaCare Medicaid	$5,653.50
Rate for Payer: AlohaCare Medicare	$8,593.32
Rate for Payer: Cash Price	$6,784.20
Rate for Payer: Devoted Health Medicare	$9,497.88
Rate for Payer: Hawaii Medical Service Association Medicare	$8,593.32
Rate for Payer: Hawaii Western Management Group Commercial	$7,914.90
Rate for Payer: Health Management Network Commercial	$9,610.95
Rate for Payer: Humana Medicare	$8,593.32
Rate for Payer: Kaiser Permanente Commercial	$10,176.30
Rate for Payer: Kaiser Permanente Medicaid	$5,766.57
Rate for Payer: Kaiser Permanente Medicare	$8,593.32
Rate for Payer: MDX Hawaii PPO	$10,967.79
Rate for Payer: Ohana Health Plan Medicaid	$8,593.32
Rate for Payer: Ohana Health Plan Medicare	$8,593.32
Rate for Payer: UnitedHealthcare Medicare	$8,593.32
Rate for Payer: University Health Alliance Commercial	$6,331.92

CEMENT BONE HYDROSET XT 897010

Facility

$11,307.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$6,331.92
Max. Negotiated Rate	$10,967.79
Rate for Payer: Cash Price	$6,784.20
Rate for Payer: Hawaii Western Management Group Commercial	$7,914.90
Rate for Payer: Health Management Network Commercial	$9,610.95
Rate for Payer: Kaiser Permanente Commercial	$10,176.30
Rate for Payer: MDX Hawaii PPO	$10,967.79
Rate for Payer: University Health Alliance Commercial	$6,331.92

CEMENT BONE MIXER

Facility

$230.00

Hospital Revenue Code	272
Min. Negotiated Rate	$115.00
Max. Negotiated Rate	$223.10
Rate for Payer: AlohaCare Medicaid	$115.00
Rate for Payer: AlohaCare Medicare	$174.80
Rate for Payer: Cash Price	$138.00
Rate for Payer: Devoted Health Medicare	$193.20
Rate for Payer: Hawaii Medical Service Association Medicare	$174.80
Rate for Payer: Hawaii Western Management Group Commercial	$218.50
Rate for Payer: Health Management Network Commercial	$195.50
Rate for Payer: Humana Medicare	$174.80
Rate for Payer: Kaiser Permanente Commercial	$207.00
Rate for Payer: Kaiser Permanente Medicaid	$117.30
Rate for Payer: Kaiser Permanente Medicare	$174.80
Rate for Payer: MDX Hawaii PPO	$223.10
Rate for Payer: Ohana Health Plan Medicaid	$174.80
Rate for Payer: Ohana Health Plan Medicare	$174.80
Rate for Payer: UnitedHealthcare Medicare	$174.80
Rate for Payer: University Health Alliance Commercial	$167.65

CEMENT BONE MIXER

Facility

$230.00

Hospital Revenue Code	272
Min. Negotiated Rate	$195.50
Max. Negotiated Rate	$223.10
Rate for Payer: Cash Price	$138.00
Rate for Payer: Health Management Network Commercial	$195.50
Rate for Payer: Kaiser Permanente Commercial	$207.00
Rate for Payer: MDX Hawaii PPO	$223.10

CEMENT BONE SIMPLX 6191-1-001

Facility

$309.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$154.50
Max. Negotiated Rate	$299.73
Rate for Payer: AlohaCare Medicaid	$154.50
Rate for Payer: AlohaCare Medicare	$234.84
Rate for Payer: Cash Price	$185.40
Rate for Payer: Devoted Health Medicare	$259.56
Rate for Payer: Hawaii Medical Service Association Medicare	$234.84
Rate for Payer: Hawaii Western Management Group Commercial	$216.30
Rate for Payer: Health Management Network Commercial	$262.65
Rate for Payer: Humana Medicare	$234.84
Rate for Payer: Kaiser Permanente Commercial	$278.10
Rate for Payer: Kaiser Permanente Medicaid	$157.59
Rate for Payer: Kaiser Permanente Medicare	$234.84
Rate for Payer: MDX Hawaii PPO	$299.73
Rate for Payer: Ohana Health Plan Medicaid	$234.84
Rate for Payer: Ohana Health Plan Medicare	$234.84
Rate for Payer: UnitedHealthcare Medicare	$234.84
Rate for Payer: University Health Alliance Commercial	$173.04

CEMENT BONE SIMPLX 6191-1-001

Facility

$309.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$173.04
Max. Negotiated Rate	$299.73
Rate for Payer: Cash Price	$185.40
Rate for Payer: Hawaii Western Management Group Commercial	$216.30
Rate for Payer: Health Management Network Commercial	$262.65
Rate for Payer: Kaiser Permanente Commercial	$278.10
Rate for Payer: MDX Hawaii PPO	$299.73
Rate for Payer: University Health Alliance Commercial	$173.04

CEMENTED KIT DWD014

Facility

$713.00

Service Code	HCPCS C1776
Hospital Revenue Code	272
Min. Negotiated Rate	$606.05
Max. Negotiated Rate	$691.61
Rate for Payer: Cash Price	$427.80
Rate for Payer: Health Management Network Commercial	$606.05
Rate for Payer: Kaiser Permanente Commercial	$641.70
Rate for Payer: MDX Hawaii PPO	$691.61

CEMENTED KIT DWD014

Facility

$713.00

Service Code	HCPCS C1776
Hospital Revenue Code	272
Min. Negotiated Rate	$356.50
Max. Negotiated Rate	$691.61
Rate for Payer: AlohaCare Medicaid	$356.50
Rate for Payer: AlohaCare Medicare	$541.88
Rate for Payer: Cash Price	$427.80
Rate for Payer: Devoted Health Medicare	$598.92
Rate for Payer: Hawaii Medical Service Association Medicare	$541.88
Rate for Payer: Hawaii Western Management Group Commercial	$677.35
Rate for Payer: Health Management Network Commercial	$606.05
Rate for Payer: Humana Medicare	$541.88
Rate for Payer: Kaiser Permanente Commercial	$641.70
Rate for Payer: Kaiser Permanente Medicaid	$363.63
Rate for Payer: Kaiser Permanente Medicare	$541.88
Rate for Payer: MDX Hawaii PPO	$691.61
Rate for Payer: Ohana Health Plan Medicaid	$541.88
Rate for Payer: Ohana Health Plan Medicare	$541.88
Rate for Payer: UnitedHealthcare Medicare	$541.88
Rate for Payer: University Health Alliance Commercial	$519.71

CEMENTED STEMLESS 5200-00-036

Facility

$15,097.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$8,454.32
Max. Negotiated Rate	$14,644.09
Rate for Payer: Cash Price	$9,058.20
Rate for Payer: Hawaii Western Management Group Commercial	$10,567.90
Rate for Payer: Health Management Network Commercial	$12,832.45
Rate for Payer: Kaiser Permanente Commercial	$13,587.30
Rate for Payer: MDX Hawaii PPO	$14,644.09
Rate for Payer: University Health Alliance Commercial	$8,454.32

CEMENTED STEMLESS 5200-00-036

Facility

$15,097.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$7,548.50
Max. Negotiated Rate	$14,644.09
Rate for Payer: AlohaCare Medicaid	$7,548.50
Rate for Payer: AlohaCare Medicare	$11,473.72
Rate for Payer: Cash Price	$9,058.20
Rate for Payer: Devoted Health Medicare	$12,681.48
Rate for Payer: Hawaii Medical Service Association Medicare	$11,473.72
Rate for Payer: Hawaii Western Management Group Commercial	$10,567.90
Rate for Payer: Health Management Network Commercial	$12,832.45
Rate for Payer: Humana Medicare	$11,473.72
Rate for Payer: Kaiser Permanente Commercial	$13,587.30
Rate for Payer: Kaiser Permanente Medicaid	$7,699.47
Rate for Payer: Kaiser Permanente Medicare	$11,473.72
Rate for Payer: MDX Hawaii PPO	$14,644.09
Rate for Payer: Ohana Health Plan Medicaid	$11,473.72
Rate for Payer: Ohana Health Plan Medicare	$11,473.72
Rate for Payer: UnitedHealthcare Medicare	$11,473.72
Rate for Payer: University Health Alliance Commercial	$8,454.32

CEMENT FEMUR LFTS6 02.12.0006L

Facility

$4,000.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$2,000.00
Max. Negotiated Rate	$3,880.00
Rate for Payer: AlohaCare Medicaid	$2,000.00
Rate for Payer: AlohaCare Medicare	$3,040.00
Rate for Payer: Cash Price	$2,400.00
Rate for Payer: Devoted Health Medicare	$3,360.00
Rate for Payer: Hawaii Medical Service Association Medicare	$3,040.00
Rate for Payer: Hawaii Western Management Group Commercial	$2,800.00
Rate for Payer: Health Management Network Commercial	$3,400.00
Rate for Payer: Humana Medicare	$3,040.00
Rate for Payer: Kaiser Permanente Commercial	$3,600.00
Rate for Payer: Kaiser Permanente Medicaid	$2,040.00
Rate for Payer: Kaiser Permanente Medicare	$3,040.00
Rate for Payer: MDX Hawaii PPO	$3,880.00
Rate for Payer: Ohana Health Plan Medicaid	$3,040.00
Rate for Payer: Ohana Health Plan Medicare	$3,040.00
Rate for Payer: UnitedHealthcare Medicare	$3,040.00
Rate for Payer: University Health Alliance Commercial	$2,240.00

CEMENT FEMUR LFTS6 02.12.0006L

Facility

$4,000.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$2,240.00
Max. Negotiated Rate	$3,880.00
Rate for Payer: Cash Price	$2,400.00
Rate for Payer: Hawaii Western Management Group Commercial	$2,800.00
Rate for Payer: Health Management Network Commercial	$3,400.00
Rate for Payer: Kaiser Permanente Commercial	$3,600.00
Rate for Payer: MDX Hawaii PPO	$3,880.00
Rate for Payer: University Health Alliance Commercial	$2,240.00

CEMENT GLENOID AS 01.04214.370

Facility

$4,400.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$2,464.00
Max. Negotiated Rate	$4,268.00
Rate for Payer: Cash Price	$2,640.00
Rate for Payer: Hawaii Western Management Group Commercial	$3,080.00
Rate for Payer: Health Management Network Commercial	$3,740.00
Rate for Payer: Kaiser Permanente Commercial	$3,960.00
Rate for Payer: MDX Hawaii PPO	$4,268.00
Rate for Payer: University Health Alliance Commercial	$2,464.00

CEMENT GLENOID AS 01.04214.370

Facility

$4,400.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$2,200.00
Max. Negotiated Rate	$4,268.00
Rate for Payer: AlohaCare Medicaid	$2,200.00
Rate for Payer: AlohaCare Medicare	$3,344.00
Rate for Payer: Cash Price	$2,640.00
Rate for Payer: Devoted Health Medicare	$3,696.00
Rate for Payer: Hawaii Medical Service Association Medicare	$3,344.00
Rate for Payer: Hawaii Western Management Group Commercial	$3,080.00
Rate for Payer: Health Management Network Commercial	$3,740.00
Rate for Payer: Humana Medicare	$3,344.00
Rate for Payer: Kaiser Permanente Commercial	$3,960.00
Rate for Payer: Kaiser Permanente Medicaid	$2,244.00
Rate for Payer: Kaiser Permanente Medicare	$3,344.00
Rate for Payer: MDX Hawaii PPO	$4,268.00
Rate for Payer: Ohana Health Plan Medicaid	$3,344.00
Rate for Payer: Ohana Health Plan Medicare	$3,344.00
Rate for Payer: UnitedHealthcare Medicare	$3,344.00
Rate for Payer: University Health Alliance Commercial	$2,464.00

CEMENT GLENOID AS 01.04214.400

Facility

$4,400.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$2,200.00
Max. Negotiated Rate	$4,268.00
Rate for Payer: AlohaCare Medicaid	$2,200.00
Rate for Payer: AlohaCare Medicare	$3,344.00
Rate for Payer: Cash Price	$2,640.00
Rate for Payer: Devoted Health Medicare	$3,696.00
Rate for Payer: Hawaii Medical Service Association Medicare	$3,344.00
Rate for Payer: Hawaii Western Management Group Commercial	$3,080.00
Rate for Payer: Health Management Network Commercial	$3,740.00
Rate for Payer: Humana Medicare	$3,344.00
Rate for Payer: Kaiser Permanente Commercial	$3,960.00
Rate for Payer: Kaiser Permanente Medicaid	$2,244.00
Rate for Payer: Kaiser Permanente Medicare	$3,344.00
Rate for Payer: MDX Hawaii PPO	$4,268.00
Rate for Payer: Ohana Health Plan Medicaid	$3,344.00
Rate for Payer: Ohana Health Plan Medicare	$3,344.00
Rate for Payer: UnitedHealthcare Medicare	$3,344.00
Rate for Payer: University Health Alliance Commercial	$2,464.00

CEMENT GLENOID AS 01.04214.400

Facility

$4,400.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$2,464.00
Max. Negotiated Rate	$4,268.00
Rate for Payer: Cash Price	$2,640.00
Rate for Payer: Hawaii Western Management Group Commercial	$3,080.00
Rate for Payer: Health Management Network Commercial	$3,740.00
Rate for Payer: Kaiser Permanente Commercial	$3,960.00
Rate for Payer: MDX Hawaii PPO	$4,268.00
Rate for Payer: University Health Alliance Commercial	$2,464.00

CEMENT RESTRICT MED B000-0240

Facility

$542.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$271.00
Max. Negotiated Rate	$525.74
Rate for Payer: AlohaCare Medicaid	$271.00
Rate for Payer: AlohaCare Medicare	$411.92
Rate for Payer: Cash Price	$325.20
Rate for Payer: Devoted Health Medicare	$455.28
Rate for Payer: Hawaii Medical Service Association Medicare	$411.92
Rate for Payer: Hawaii Western Management Group Commercial	$379.40
Rate for Payer: Health Management Network Commercial	$460.70
Rate for Payer: Humana Medicare	$411.92
Rate for Payer: Kaiser Permanente Commercial	$487.80
Rate for Payer: Kaiser Permanente Medicaid	$276.42
Rate for Payer: Kaiser Permanente Medicare	$411.92
Rate for Payer: MDX Hawaii PPO	$525.74
Rate for Payer: Ohana Health Plan Medicaid	$411.92
Rate for Payer: Ohana Health Plan Medicare	$411.92
Rate for Payer: UnitedHealthcare Medicare	$411.92
Rate for Payer: University Health Alliance Commercial	$303.52

CEMENT RESTRICT MED B000-0240

Facility

$542.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$303.52
Max. Negotiated Rate	$525.74
Rate for Payer: Cash Price	$325.20
Rate for Payer: Hawaii Western Management Group Commercial	$379.40
Rate for Payer: Health Management Network Commercial	$460.70
Rate for Payer: Kaiser Permanente Commercial	$487.80
Rate for Payer: MDX Hawaii PPO	$525.74
Rate for Payer: University Health Alliance Commercial	$303.52

CEMENT RESTRICTOR

Facility

$1,068.00

Service Code	HCPCS C1889
Hospital Revenue Code	278
Min. Negotiated Rate	$598.08
Max. Negotiated Rate	$1,035.96
Rate for Payer: Cash Price	$640.80
Rate for Payer: Hawaii Western Management Group Commercial	$747.60
Rate for Payer: Health Management Network Commercial	$907.80
Rate for Payer: Kaiser Permanente Commercial	$961.20
Rate for Payer: MDX Hawaii PPO	$1,035.96
Rate for Payer: University Health Alliance Commercial	$598.08

CEMENT RESTRICTOR

Facility

$1,068.00

Service Code	HCPCS C1889
Hospital Revenue Code	278
Min. Negotiated Rate	$534.00
Max. Negotiated Rate	$1,035.96
Rate for Payer: AlohaCare Medicaid	$534.00
Rate for Payer: AlohaCare Medicare	$811.68
Rate for Payer: Cash Price	$640.80
Rate for Payer: Devoted Health Medicare	$897.12
Rate for Payer: Hawaii Medical Service Association Medicare	$811.68
Rate for Payer: Hawaii Western Management Group Commercial	$747.60
Rate for Payer: Health Management Network Commercial	$907.80
Rate for Payer: Humana Medicare	$811.68
Rate for Payer: Kaiser Permanente Commercial	$961.20
Rate for Payer: Kaiser Permanente Medicaid	$544.68
Rate for Payer: Kaiser Permanente Medicare	$811.68
Rate for Payer: MDX Hawaii PPO	$1,035.96
Rate for Payer: Ohana Health Plan Medicaid	$811.68
Rate for Payer: Ohana Health Plan Medicare	$811.68
Rate for Payer: UnitedHealthcare Medicare	$811.68
Rate for Payer: University Health Alliance Commercial	$598.08

CEMENT TIBIAL TRAY 02.07.1205L

Facility

$3,600.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$2,016.00
Max. Negotiated Rate	$3,492.00
Rate for Payer: Cash Price	$2,160.00
Rate for Payer: Hawaii Western Management Group Commercial	$2,520.00
Rate for Payer: Health Management Network Commercial	$3,060.00
Rate for Payer: Kaiser Permanente Commercial	$3,240.00
Rate for Payer: MDX Hawaii PPO	$3,492.00
Rate for Payer: University Health Alliance Commercial	$2,016.00

CEMENT TIBIAL TRAY 02.07.1205L

Facility

$3,600.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$1,800.00
Max. Negotiated Rate	$3,492.00
Rate for Payer: AlohaCare Medicaid	$1,800.00
Rate for Payer: AlohaCare Medicare	$2,736.00
Rate for Payer: Cash Price	$2,160.00
Rate for Payer: Devoted Health Medicare	$3,024.00
Rate for Payer: Hawaii Medical Service Association Medicare	$2,736.00
Rate for Payer: Hawaii Western Management Group Commercial	$2,520.00
Rate for Payer: Health Management Network Commercial	$3,060.00
Rate for Payer: Humana Medicare	$2,736.00
Rate for Payer: Kaiser Permanente Commercial	$3,240.00
Rate for Payer: Kaiser Permanente Medicaid	$1,836.00
Rate for Payer: Kaiser Permanente Medicare	$2,736.00
Rate for Payer: MDX Hawaii PPO	$3,492.00
Rate for Payer: Ohana Health Plan Medicaid	$2,736.00
Rate for Payer: Ohana Health Plan Medicare	$2,736.00
Rate for Payer: UnitedHealthcare Medicare	$2,736.00
Rate for Payer: University Health Alliance Commercial	$2,016.00

CEMIPLIMAB-RWLC 50 MG/ML INTRAVENOUS SOLUTION [164576]

Facility

$14,102.00

Service Code	HCPCS J9119
Hospital Revenue Code	636
Min. Negotiated Rate	$28.70
Max. Negotiated Rate	$13,678.94
Rate for Payer: AlohaCare Medicaid	$7,051.00
Rate for Payer: AlohaCare Medicare	$10,717.52
Rate for Payer: Cash Price	$8,461.20
Rate for Payer: Cash Price	$8,461.20
Rate for Payer: Devoted Health Medicare	$11,845.68
Rate for Payer: Hawaii Medical Service Association ABD	$28.70
Rate for Payer: Hawaii Medical Service Association Commercial	$37.20
Rate for Payer: Hawaii Medical Service Association Medicare	$10,717.52
Rate for Payer: Hawaii Medical Service Association Non-ABD	$28.70
Rate for Payer: Hawaii Western Management Group Commercial	$13,396.90
Rate for Payer: Health Management Network Commercial	$11,986.70
Rate for Payer: Humana Medicare	$10,717.52
Rate for Payer: Kaiser Permanente Commercial	$12,691.80
Rate for Payer: Kaiser Permanente Medicaid	$7,192.02
Rate for Payer: Kaiser Permanente Medicare	$10,717.52
Rate for Payer: MDX Hawaii PPO	$13,678.94
Rate for Payer: Ohana Health Plan Medicaid	$10,717.52
Rate for Payer: Ohana Health Plan Medicare	$10,717.52
Rate for Payer: UnitedHealthcare Medicaid	$8,461.20
Rate for Payer: UnitedHealthcare Medicare	$10,717.52
Rate for Payer: University Health Alliance Commercial	$10,278.95

CEMIPLIMAB-RWLC 50 MG/ML INTRAVENOUS SOLUTION [164576]

Facility

$14,102.00

Service Code	HCPCS J9119
Hospital Revenue Code	250
Min. Negotiated Rate	$11,986.70
Max. Negotiated Rate	$13,678.94
Rate for Payer: Cash Price	$8,461.20
Rate for Payer: Health Management Network Commercial	$11,986.70
Rate for Payer: Kaiser Permanente Commercial	$12,691.80
Rate for Payer: MDX Hawaii PPO	$13,678.94

CENTERPOINT DELIVERY CATH 6.5F

Facility

$1,733.00

Service Code	HCPCS C1887
Hospital Revenue Code	272
Min. Negotiated Rate	$866.50
Max. Negotiated Rate	$1,681.01
Rate for Payer: AlohaCare Medicaid	$866.50
Rate for Payer: AlohaCare Medicare	$1,317.08
Rate for Payer: Cash Price	$1,039.80
Rate for Payer: Devoted Health Medicare	$1,455.72
Rate for Payer: Hawaii Medical Service Association Medicare	$1,317.08
Rate for Payer: Hawaii Western Management Group Commercial	$1,646.35
Rate for Payer: Health Management Network Commercial	$1,473.05
Rate for Payer: Humana Medicare	$1,317.08
Rate for Payer: Kaiser Permanente Commercial	$1,559.70
Rate for Payer: Kaiser Permanente Medicaid	$883.83
Rate for Payer: Kaiser Permanente Medicare	$1,317.08
Rate for Payer: MDX Hawaii PPO	$1,681.01
Rate for Payer: Ohana Health Plan Medicaid	$1,317.08
Rate for Payer: Ohana Health Plan Medicare	$1,317.08
Rate for Payer: UnitedHealthcare Medicare	$1,317.08
Rate for Payer: University Health Alliance Commercial	$1,263.18

Know your out-of-pocket cost for care.

All Charges