Kau Hospital

All Charges

Charge

Type

Setting

Price

GORE PROPATEN 4-7X45 H470045A

Facility

$2,744.00

Service Code	HCPCS C1768
Hospital Revenue Code	278
Min. Negotiated Rate	$850.64
Max. Negotiated Rate	$2,661.68
Rate for Payer: AlohaCare Medicaid	$1,372.00
Rate for Payer: AlohaCare Medicare	$850.64
Rate for Payer: Cash Price	$1,646.40
Rate for Payer: Devoted Health Medicare	$932.96
Rate for Payer: Hawaii Medical Service Association Medicare	$850.64
Rate for Payer: Hawaii Western Management Group Commercial	$1,920.80
Rate for Payer: Health Management Network Commercial	$2,332.40
Rate for Payer: Humana Medicare	$850.64
Rate for Payer: Kaiser Permanente Commercial	$2,469.60
Rate for Payer: Kaiser Permanente Medicaid	$1,399.44
Rate for Payer: Kaiser Permanente Medicare	$850.64
Rate for Payer: MDX Hawaii PPO	$2,661.68
Rate for Payer: Ohana Health Plan Medicaid	$850.64
Rate for Payer: Ohana Health Plan Medicare	$850.64
Rate for Payer: UnitedHealthcare Medicare	$850.64
Rate for Payer: University Health Alliance Commercial	$1,536.64

GORE PROPATEN 4-7X45 H470045A

Facility

$2,744.00

Service Code	HCPCS C1768
Hospital Revenue Code	278
Min. Negotiated Rate	$1,536.64
Max. Negotiated Rate	$2,661.68
Rate for Payer: Cash Price	$1,646.40
Rate for Payer: Hawaii Western Management Group Commercial	$1,920.80
Rate for Payer: Health Management Network Commercial	$2,332.40
Rate for Payer: Kaiser Permanente Commercial	$2,469.60
Rate for Payer: MDX Hawaii PPO	$2,661.68
Rate for Payer: University Health Alliance Commercial	$1,536.64

GORE STRETCH 7X10 S0701

Facility

$668.00

Service Code	HCPCS C1768
Hospital Revenue Code	278
Min. Negotiated Rate	$374.08
Max. Negotiated Rate	$647.96
Rate for Payer: Cash Price	$400.80
Rate for Payer: Hawaii Western Management Group Commercial	$467.60
Rate for Payer: Health Management Network Commercial	$567.80
Rate for Payer: Kaiser Permanente Commercial	$601.20
Rate for Payer: MDX Hawaii PPO	$647.96
Rate for Payer: University Health Alliance Commercial	$374.08

GORE STRETCH 7X10 S0701

Facility

$668.00

Service Code	HCPCS C1768
Hospital Revenue Code	278
Min. Negotiated Rate	$207.08
Max. Negotiated Rate	$647.96
Rate for Payer: AlohaCare Medicaid	$334.00
Rate for Payer: AlohaCare Medicare	$207.08
Rate for Payer: Cash Price	$400.80
Rate for Payer: Devoted Health Medicare	$227.12
Rate for Payer: Hawaii Medical Service Association Medicare	$207.08
Rate for Payer: Hawaii Western Management Group Commercial	$467.60
Rate for Payer: Health Management Network Commercial	$567.80
Rate for Payer: Humana Medicare	$207.08
Rate for Payer: Kaiser Permanente Commercial	$601.20
Rate for Payer: Kaiser Permanente Medicaid	$340.68
Rate for Payer: Kaiser Permanente Medicare	$207.08
Rate for Payer: MDX Hawaii PPO	$647.96
Rate for Payer: Ohana Health Plan Medicaid	$207.08
Rate for Payer: Ohana Health Plan Medicare	$207.08
Rate for Payer: UnitedHealthcare Medicare	$207.08
Rate for Payer: University Health Alliance Commercial	$374.08

GORE THIN 6MMX50CM HT064050A

Facility

$3,828.00

Service Code	HCPCS C1768
Hospital Revenue Code	278
Min. Negotiated Rate	$1,186.68
Max. Negotiated Rate	$3,713.16
Rate for Payer: AlohaCare Medicaid	$1,914.00
Rate for Payer: AlohaCare Medicare	$1,186.68
Rate for Payer: Cash Price	$2,296.80
Rate for Payer: Devoted Health Medicare	$1,301.52
Rate for Payer: Hawaii Medical Service Association Medicare	$1,186.68
Rate for Payer: Hawaii Western Management Group Commercial	$2,679.60
Rate for Payer: Health Management Network Commercial	$3,253.80
Rate for Payer: Humana Medicare	$1,186.68
Rate for Payer: Kaiser Permanente Commercial	$3,445.20
Rate for Payer: Kaiser Permanente Medicaid	$1,952.28
Rate for Payer: Kaiser Permanente Medicare	$1,186.68
Rate for Payer: MDX Hawaii PPO	$3,713.16
Rate for Payer: Ohana Health Plan Medicaid	$1,186.68
Rate for Payer: Ohana Health Plan Medicare	$1,186.68
Rate for Payer: UnitedHealthcare Medicare	$1,186.68
Rate for Payer: University Health Alliance Commercial	$2,143.68

GORE THIN 6MMX50CM HT064050A

Facility

$3,828.00

Service Code	HCPCS C1768
Hospital Revenue Code	278
Min. Negotiated Rate	$2,143.68
Max. Negotiated Rate	$3,713.16
Rate for Payer: Cash Price	$2,296.80
Rate for Payer: Hawaii Western Management Group Commercial	$2,679.60
Rate for Payer: Health Management Network Commercial	$3,253.80
Rate for Payer: Kaiser Permanente Commercial	$3,445.20
Rate for Payer: MDX Hawaii PPO	$3,713.16
Rate for Payer: University Health Alliance Commercial	$2,143.68

GORE THIN 6MMX80CM HT066080A

Facility

$5,884.00

Service Code	HCPCS C1768
Hospital Revenue Code	278
Min. Negotiated Rate	$1,824.04
Max. Negotiated Rate	$5,707.48
Rate for Payer: AlohaCare Medicaid	$2,942.00
Rate for Payer: AlohaCare Medicare	$1,824.04
Rate for Payer: Cash Price	$3,530.40
Rate for Payer: Devoted Health Medicare	$2,000.56
Rate for Payer: Hawaii Medical Service Association Medicare	$1,824.04
Rate for Payer: Hawaii Western Management Group Commercial	$4,118.80
Rate for Payer: Health Management Network Commercial	$5,001.40
Rate for Payer: Humana Medicare	$1,824.04
Rate for Payer: Kaiser Permanente Commercial	$5,295.60
Rate for Payer: Kaiser Permanente Medicaid	$3,000.84
Rate for Payer: Kaiser Permanente Medicare	$1,824.04
Rate for Payer: MDX Hawaii PPO	$5,707.48
Rate for Payer: Ohana Health Plan Medicaid	$1,824.04
Rate for Payer: Ohana Health Plan Medicare	$1,824.04
Rate for Payer: UnitedHealthcare Medicare	$1,824.04
Rate for Payer: University Health Alliance Commercial	$3,295.04

GORE THIN 6MMX80CM HT066080A

Facility

$5,884.00

Service Code	HCPCS C1768
Hospital Revenue Code	278
Min. Negotiated Rate	$3,295.04
Max. Negotiated Rate	$5,707.48
Rate for Payer: Cash Price	$3,530.40
Rate for Payer: Hawaii Western Management Group Commercial	$4,118.80
Rate for Payer: Health Management Network Commercial	$5,001.40
Rate for Payer: Kaiser Permanente Commercial	$5,295.60
Rate for Payer: MDX Hawaii PPO	$5,707.48
Rate for Payer: University Health Alliance Commercial	$3,295.04

GORE THIN 8MMX40CM HT083040A

Facility

$3,066.00

Service Code	HCPCS C1768
Hospital Revenue Code	278
Min. Negotiated Rate	$1,716.96
Max. Negotiated Rate	$2,974.02
Rate for Payer: Cash Price	$1,839.60
Rate for Payer: Hawaii Western Management Group Commercial	$2,146.20
Rate for Payer: Health Management Network Commercial	$2,606.10
Rate for Payer: Kaiser Permanente Commercial	$2,759.40
Rate for Payer: MDX Hawaii PPO	$2,974.02
Rate for Payer: University Health Alliance Commercial	$1,716.96

GORE THIN 8MMX40CM HT083040A

Facility

$3,066.00

Service Code	HCPCS C1768
Hospital Revenue Code	278
Min. Negotiated Rate	$950.46
Max. Negotiated Rate	$2,974.02
Rate for Payer: AlohaCare Medicaid	$1,533.00
Rate for Payer: AlohaCare Medicare	$950.46
Rate for Payer: Cash Price	$1,839.60
Rate for Payer: Devoted Health Medicare	$1,042.44
Rate for Payer: Hawaii Medical Service Association Medicare	$950.46
Rate for Payer: Hawaii Western Management Group Commercial	$2,146.20
Rate for Payer: Health Management Network Commercial	$2,606.10
Rate for Payer: Humana Medicare	$950.46
Rate for Payer: Kaiser Permanente Commercial	$2,759.40
Rate for Payer: Kaiser Permanente Medicaid	$1,563.66
Rate for Payer: Kaiser Permanente Medicare	$950.46
Rate for Payer: MDX Hawaii PPO	$2,974.02
Rate for Payer: Ohana Health Plan Medicaid	$950.46
Rate for Payer: Ohana Health Plan Medicare	$950.46
Rate for Payer: UnitedHealthcare Medicare	$950.46
Rate for Payer: University Health Alliance Commercial	$1,716.96

GORE THIN 8MMX50CM HT084050A

Facility

$3,622.00

Service Code	HCPCS C1768
Hospital Revenue Code	278
Min. Negotiated Rate	$2,028.32
Max. Negotiated Rate	$3,513.34
Rate for Payer: Cash Price	$2,173.20
Rate for Payer: Hawaii Western Management Group Commercial	$2,535.40
Rate for Payer: Health Management Network Commercial	$3,078.70
Rate for Payer: Kaiser Permanente Commercial	$3,259.80
Rate for Payer: MDX Hawaii PPO	$3,513.34
Rate for Payer: University Health Alliance Commercial	$2,028.32

GORE THIN 8MMX50CM HT084050A

Facility

$3,622.00

Service Code	HCPCS C1768
Hospital Revenue Code	278
Min. Negotiated Rate	$1,122.82
Max. Negotiated Rate	$3,513.34
Rate for Payer: AlohaCare Medicaid	$1,811.00
Rate for Payer: AlohaCare Medicare	$1,122.82
Rate for Payer: Cash Price	$2,173.20
Rate for Payer: Devoted Health Medicare	$1,231.48
Rate for Payer: Hawaii Medical Service Association Medicare	$1,122.82
Rate for Payer: Hawaii Western Management Group Commercial	$2,535.40
Rate for Payer: Health Management Network Commercial	$3,078.70
Rate for Payer: Humana Medicare	$1,122.82
Rate for Payer: Kaiser Permanente Commercial	$3,259.80
Rate for Payer: Kaiser Permanente Medicaid	$1,847.22
Rate for Payer: Kaiser Permanente Medicare	$1,122.82
Rate for Payer: MDX Hawaii PPO	$3,513.34
Rate for Payer: Ohana Health Plan Medicaid	$1,122.82
Rate for Payer: Ohana Health Plan Medicare	$1,122.82
Rate for Payer: UnitedHealthcare Medicare	$1,122.82
Rate for Payer: University Health Alliance Commercial	$2,028.32

GORE THIN 8MMX80CM HT087080A

Facility

$6,062.00

Service Code	HCPCS C1768
Hospital Revenue Code	278
Min. Negotiated Rate	$1,879.22
Max. Negotiated Rate	$5,880.14
Rate for Payer: AlohaCare Medicaid	$3,031.00
Rate for Payer: AlohaCare Medicare	$1,879.22
Rate for Payer: Cash Price	$3,637.20
Rate for Payer: Devoted Health Medicare	$2,061.08
Rate for Payer: Hawaii Medical Service Association Medicare	$1,879.22
Rate for Payer: Hawaii Western Management Group Commercial	$4,243.40
Rate for Payer: Health Management Network Commercial	$5,152.70
Rate for Payer: Humana Medicare	$1,879.22
Rate for Payer: Kaiser Permanente Commercial	$5,455.80
Rate for Payer: Kaiser Permanente Medicaid	$3,091.62
Rate for Payer: Kaiser Permanente Medicare	$1,879.22
Rate for Payer: MDX Hawaii PPO	$5,880.14
Rate for Payer: Ohana Health Plan Medicaid	$1,879.22
Rate for Payer: Ohana Health Plan Medicare	$1,879.22
Rate for Payer: UnitedHealthcare Medicare	$1,879.22
Rate for Payer: University Health Alliance Commercial	$3,394.72

GORE THIN 8MMX80CM HT087080A

Facility

$6,062.00

Service Code	HCPCS C1768
Hospital Revenue Code	278
Min. Negotiated Rate	$3,394.72
Max. Negotiated Rate	$5,880.14
Rate for Payer: Cash Price	$3,637.20
Rate for Payer: Hawaii Western Management Group Commercial	$4,243.40
Rate for Payer: Health Management Network Commercial	$5,152.70
Rate for Payer: Kaiser Permanente Commercial	$5,455.80
Rate for Payer: MDX Hawaii PPO	$5,880.14
Rate for Payer: University Health Alliance Commercial	$3,394.72

GORE T-IPSI 12/12CM RLT231212

Facility

$22,000.00

Service Code	HCPCS C1768
Hospital Revenue Code	278
Min. Negotiated Rate	$6,820.00
Max. Negotiated Rate	$21,340.00
Rate for Payer: AlohaCare Medicaid	$11,000.00
Rate for Payer: AlohaCare Medicare	$6,820.00
Rate for Payer: Cash Price	$13,200.00
Rate for Payer: Devoted Health Medicare	$7,480.00
Rate for Payer: Hawaii Medical Service Association Medicare	$6,820.00
Rate for Payer: Hawaii Western Management Group Commercial	$15,400.00
Rate for Payer: Health Management Network Commercial	$18,700.00
Rate for Payer: Humana Medicare	$6,820.00
Rate for Payer: Kaiser Permanente Commercial	$19,800.00
Rate for Payer: Kaiser Permanente Medicaid	$11,220.00
Rate for Payer: Kaiser Permanente Medicare	$6,820.00
Rate for Payer: MDX Hawaii PPO	$21,340.00
Rate for Payer: Ohana Health Plan Medicaid	$6,820.00
Rate for Payer: Ohana Health Plan Medicare	$6,820.00
Rate for Payer: UnitedHealthcare Medicare	$6,820.00
Rate for Payer: University Health Alliance Commercial	$12,320.00

GORE T-IPSI 12/12CM RLT231212

Facility

$22,000.00

Service Code	HCPCS C1768
Hospital Revenue Code	278
Min. Negotiated Rate	$12,320.00
Max. Negotiated Rate	$21,340.00
Rate for Payer: Cash Price	$13,200.00
Rate for Payer: Hawaii Western Management Group Commercial	$15,400.00
Rate for Payer: Health Management Network Commercial	$18,700.00
Rate for Payer: Kaiser Permanente Commercial	$19,800.00
Rate for Payer: MDX Hawaii PPO	$21,340.00
Rate for Payer: University Health Alliance Commercial	$12,320.00

GORE T-IPSI 12/12CM RLT261212

Facility

$22,000.00

Service Code	HCPCS C1768
Hospital Revenue Code	278
Min. Negotiated Rate	$6,820.00
Max. Negotiated Rate	$21,340.00
Rate for Payer: AlohaCare Medicaid	$11,000.00
Rate for Payer: AlohaCare Medicare	$6,820.00
Rate for Payer: Cash Price	$13,200.00
Rate for Payer: Devoted Health Medicare	$7,480.00
Rate for Payer: Hawaii Medical Service Association Medicare	$6,820.00
Rate for Payer: Hawaii Western Management Group Commercial	$15,400.00
Rate for Payer: Health Management Network Commercial	$18,700.00
Rate for Payer: Humana Medicare	$6,820.00
Rate for Payer: Kaiser Permanente Commercial	$19,800.00
Rate for Payer: Kaiser Permanente Medicaid	$11,220.00
Rate for Payer: Kaiser Permanente Medicare	$6,820.00
Rate for Payer: MDX Hawaii PPO	$21,340.00
Rate for Payer: Ohana Health Plan Medicaid	$6,820.00
Rate for Payer: Ohana Health Plan Medicare	$6,820.00
Rate for Payer: UnitedHealthcare Medicare	$6,820.00
Rate for Payer: University Health Alliance Commercial	$12,320.00

GORE T-IPSI 12/12CM RLT261212

Facility

$22,000.00

Service Code	HCPCS C1768
Hospital Revenue Code	278
Min. Negotiated Rate	$12,320.00
Max. Negotiated Rate	$21,340.00
Rate for Payer: Cash Price	$13,200.00
Rate for Payer: Hawaii Western Management Group Commercial	$15,400.00
Rate for Payer: Health Management Network Commercial	$18,700.00
Rate for Payer: Kaiser Permanente Commercial	$19,800.00
Rate for Payer: MDX Hawaii PPO	$21,340.00
Rate for Payer: University Health Alliance Commercial	$12,320.00

GORE T-IPSI 12/12CM RLT281212

Facility

$22,000.00

Service Code	HCPCS C1768
Hospital Revenue Code	278
Min. Negotiated Rate	$6,820.00
Max. Negotiated Rate	$21,340.00
Rate for Payer: AlohaCare Medicaid	$11,000.00
Rate for Payer: AlohaCare Medicare	$6,820.00
Rate for Payer: Cash Price	$13,200.00
Rate for Payer: Devoted Health Medicare	$7,480.00
Rate for Payer: Hawaii Medical Service Association Medicare	$6,820.00
Rate for Payer: Hawaii Western Management Group Commercial	$15,400.00
Rate for Payer: Health Management Network Commercial	$18,700.00
Rate for Payer: Humana Medicare	$6,820.00
Rate for Payer: Kaiser Permanente Commercial	$19,800.00
Rate for Payer: Kaiser Permanente Medicaid	$11,220.00
Rate for Payer: Kaiser Permanente Medicare	$6,820.00
Rate for Payer: MDX Hawaii PPO	$21,340.00
Rate for Payer: Ohana Health Plan Medicaid	$6,820.00
Rate for Payer: Ohana Health Plan Medicare	$6,820.00
Rate for Payer: UnitedHealthcare Medicare	$6,820.00
Rate for Payer: University Health Alliance Commercial	$12,320.00

GORE T-IPSI 12/12CM RLT281212

Facility

$22,000.00

Service Code	HCPCS C1768
Hospital Revenue Code	278
Min. Negotiated Rate	$12,320.00
Max. Negotiated Rate	$21,340.00
Rate for Payer: Cash Price	$13,200.00
Rate for Payer: Hawaii Western Management Group Commercial	$15,400.00
Rate for Payer: Health Management Network Commercial	$18,700.00
Rate for Payer: Kaiser Permanente Commercial	$19,800.00
Rate for Payer: MDX Hawaii PPO	$21,340.00
Rate for Payer: University Health Alliance Commercial	$12,320.00

GORE T-IPSI 12/14CM RLT231214

Facility

$22,000.00

Service Code	HCPCS C1768
Hospital Revenue Code	278
Min. Negotiated Rate	$12,320.00
Max. Negotiated Rate	$21,340.00
Rate for Payer: Cash Price	$13,200.00
Rate for Payer: Hawaii Western Management Group Commercial	$15,400.00
Rate for Payer: Health Management Network Commercial	$18,700.00
Rate for Payer: Kaiser Permanente Commercial	$19,800.00
Rate for Payer: MDX Hawaii PPO	$21,340.00
Rate for Payer: University Health Alliance Commercial	$12,320.00

GORE T-IPSI 12/14CM RLT231214

Facility

$22,000.00

Service Code	HCPCS C1768
Hospital Revenue Code	278
Min. Negotiated Rate	$6,820.00
Max. Negotiated Rate	$21,340.00
Rate for Payer: AlohaCare Medicaid	$11,000.00
Rate for Payer: AlohaCare Medicare	$6,820.00
Rate for Payer: Cash Price	$13,200.00
Rate for Payer: Devoted Health Medicare	$7,480.00
Rate for Payer: Hawaii Medical Service Association Medicare	$6,820.00
Rate for Payer: Hawaii Western Management Group Commercial	$15,400.00
Rate for Payer: Health Management Network Commercial	$18,700.00
Rate for Payer: Humana Medicare	$6,820.00
Rate for Payer: Kaiser Permanente Commercial	$19,800.00
Rate for Payer: Kaiser Permanente Medicaid	$11,220.00
Rate for Payer: Kaiser Permanente Medicare	$6,820.00
Rate for Payer: MDX Hawaii PPO	$21,340.00
Rate for Payer: Ohana Health Plan Medicaid	$6,820.00
Rate for Payer: Ohana Health Plan Medicare	$6,820.00
Rate for Payer: UnitedHealthcare Medicare	$6,820.00
Rate for Payer: University Health Alliance Commercial	$12,320.00

GORE T-IPSI 12/14CM RLT261214

Facility

$22,550.00

Service Code	HCPCS C1768
Hospital Revenue Code	278
Min. Negotiated Rate	$6,990.50
Max. Negotiated Rate	$21,873.50
Rate for Payer: AlohaCare Medicaid	$11,275.00
Rate for Payer: AlohaCare Medicare	$6,990.50
Rate for Payer: Cash Price	$13,530.00
Rate for Payer: Devoted Health Medicare	$7,667.00
Rate for Payer: Hawaii Medical Service Association Medicare	$6,990.50
Rate for Payer: Hawaii Western Management Group Commercial	$15,785.00
Rate for Payer: Health Management Network Commercial	$19,167.50
Rate for Payer: Humana Medicare	$6,990.50
Rate for Payer: Kaiser Permanente Commercial	$20,295.00
Rate for Payer: Kaiser Permanente Medicaid	$11,500.50
Rate for Payer: Kaiser Permanente Medicare	$6,990.50
Rate for Payer: MDX Hawaii PPO	$21,873.50
Rate for Payer: Ohana Health Plan Medicaid	$6,990.50
Rate for Payer: Ohana Health Plan Medicare	$6,990.50
Rate for Payer: UnitedHealthcare Medicare	$6,990.50
Rate for Payer: University Health Alliance Commercial	$12,628.00

GORE T-IPSI 12/14CM RLT261214

Facility

$22,550.00

Service Code	HCPCS C1768
Hospital Revenue Code	278
Min. Negotiated Rate	$12,628.00
Max. Negotiated Rate	$21,873.50
Rate for Payer: Cash Price	$13,530.00
Rate for Payer: Hawaii Western Management Group Commercial	$15,785.00
Rate for Payer: Health Management Network Commercial	$19,167.50
Rate for Payer: Kaiser Permanente Commercial	$20,295.00
Rate for Payer: MDX Hawaii PPO	$21,873.50
Rate for Payer: University Health Alliance Commercial	$12,628.00

GORE T-IPSI 12/14CM RLT281214

Facility

$22,000.00

Service Code	HCPCS C1768
Hospital Revenue Code	278
Min. Negotiated Rate	$6,820.00
Max. Negotiated Rate	$21,340.00
Rate for Payer: AlohaCare Medicaid	$11,000.00
Rate for Payer: AlohaCare Medicare	$6,820.00
Rate for Payer: Cash Price	$13,200.00
Rate for Payer: Devoted Health Medicare	$7,480.00
Rate for Payer: Hawaii Medical Service Association Medicare	$6,820.00
Rate for Payer: Hawaii Western Management Group Commercial	$15,400.00
Rate for Payer: Health Management Network Commercial	$18,700.00
Rate for Payer: Humana Medicare	$6,820.00
Rate for Payer: Kaiser Permanente Commercial	$19,800.00
Rate for Payer: Kaiser Permanente Medicaid	$11,220.00
Rate for Payer: Kaiser Permanente Medicare	$6,820.00
Rate for Payer: MDX Hawaii PPO	$21,340.00
Rate for Payer: Ohana Health Plan Medicaid	$6,820.00
Rate for Payer: Ohana Health Plan Medicare	$6,820.00
Rate for Payer: UnitedHealthcare Medicare	$6,820.00
Rate for Payer: University Health Alliance Commercial	$12,320.00

Know your out-of-pocket cost for care.

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