Kau Hospital

All Charges

Charge

Type

Setting

Price

PERSONA FEM PS POR STD SZ8 L

Facility

$7,400.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$2,294.00
Max. Negotiated Rate	$7,178.00
Rate for Payer: AlohaCare Medicaid	$3,700.00
Rate for Payer: AlohaCare Medicaid	$9,987.00
Rate for Payer: AlohaCare Medicare	$2,294.00
Rate for Payer: AlohaCare Medicare	$6,191.94
Rate for Payer: Cash Price	$11,984.40
Rate for Payer: Cash Price	$4,440.00
Rate for Payer: Devoted Health Medicare	$6,791.16
Rate for Payer: Devoted Health Medicare	$2,516.00
Rate for Payer: Hawaii Medical Service Association Medicare	$6,191.94
Rate for Payer: Hawaii Medical Service Association Medicare	$2,294.00
Rate for Payer: Hawaii Western Management Group Commercial	$13,981.80
Rate for Payer: Hawaii Western Management Group Commercial	$5,180.00
Rate for Payer: Health Management Network Commercial	$6,290.00
Rate for Payer: Health Management Network Commercial	$16,977.90
Rate for Payer: Humana Medicare	$2,294.00
Rate for Payer: Humana Medicare	$6,191.94
Rate for Payer: Kaiser Permanente Commercial	$17,976.60
Rate for Payer: Kaiser Permanente Commercial	$6,660.00
Rate for Payer: Kaiser Permanente Medicaid	$10,186.74
Rate for Payer: Kaiser Permanente Medicaid	$3,774.00
Rate for Payer: Kaiser Permanente Medicare	$2,294.00
Rate for Payer: Kaiser Permanente Medicare	$6,191.94
Rate for Payer: MDX Hawaii PPO	$19,374.78
Rate for Payer: MDX Hawaii PPO	$7,178.00
Rate for Payer: Ohana Health Plan Medicaid	$2,294.00
Rate for Payer: Ohana Health Plan Medicaid	$6,191.94
Rate for Payer: Ohana Health Plan Medicare	$2,294.00
Rate for Payer: Ohana Health Plan Medicare	$6,191.94
Rate for Payer: UnitedHealthcare Medicare	$6,191.94
Rate for Payer: UnitedHealthcare Medicare	$2,294.00
Rate for Payer: University Health Alliance Commercial	$4,144.00
Rate for Payer: University Health Alliance Commercial	$11,185.44

PERSONA FEM PS POR STD SZ8 L

Facility

$19,974.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$11,185.44
Max. Negotiated Rate	$19,374.78
Rate for Payer: Cash Price	$11,984.40
Rate for Payer: Cash Price	$4,440.00
Rate for Payer: Hawaii Western Management Group Commercial	$5,180.00
Rate for Payer: Hawaii Western Management Group Commercial	$13,981.80
Rate for Payer: Health Management Network Commercial	$6,290.00
Rate for Payer: Health Management Network Commercial	$16,977.90
Rate for Payer: Kaiser Permanente Commercial	$6,660.00
Rate for Payer: Kaiser Permanente Commercial	$17,976.60
Rate for Payer: MDX Hawaii PPO	$7,178.00
Rate for Payer: MDX Hawaii PPO	$19,374.78
Rate for Payer: University Health Alliance Commercial	$4,144.00
Rate for Payer: University Health Alliance Commercial	$11,185.44

PERSONA FEM PS POR STD SZ8 R

Facility

$7,400.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$2,294.00
Max. Negotiated Rate	$7,178.00
Rate for Payer: AlohaCare Medicaid	$3,700.00
Rate for Payer: AlohaCare Medicaid	$9,987.00
Rate for Payer: AlohaCare Medicare	$2,294.00
Rate for Payer: AlohaCare Medicare	$6,191.94
Rate for Payer: Cash Price	$11,984.40
Rate for Payer: Cash Price	$4,440.00
Rate for Payer: Devoted Health Medicare	$6,791.16
Rate for Payer: Devoted Health Medicare	$2,516.00
Rate for Payer: Hawaii Medical Service Association Medicare	$6,191.94
Rate for Payer: Hawaii Medical Service Association Medicare	$2,294.00
Rate for Payer: Hawaii Western Management Group Commercial	$13,981.80
Rate for Payer: Hawaii Western Management Group Commercial	$5,180.00
Rate for Payer: Health Management Network Commercial	$6,290.00
Rate for Payer: Health Management Network Commercial	$16,977.90
Rate for Payer: Humana Medicare	$2,294.00
Rate for Payer: Humana Medicare	$6,191.94
Rate for Payer: Kaiser Permanente Commercial	$17,976.60
Rate for Payer: Kaiser Permanente Commercial	$6,660.00
Rate for Payer: Kaiser Permanente Medicaid	$10,186.74
Rate for Payer: Kaiser Permanente Medicaid	$3,774.00
Rate for Payer: Kaiser Permanente Medicare	$2,294.00
Rate for Payer: Kaiser Permanente Medicare	$6,191.94
Rate for Payer: MDX Hawaii PPO	$19,374.78
Rate for Payer: MDX Hawaii PPO	$7,178.00
Rate for Payer: Ohana Health Plan Medicaid	$2,294.00
Rate for Payer: Ohana Health Plan Medicaid	$6,191.94
Rate for Payer: Ohana Health Plan Medicare	$2,294.00
Rate for Payer: Ohana Health Plan Medicare	$6,191.94
Rate for Payer: UnitedHealthcare Medicare	$6,191.94
Rate for Payer: UnitedHealthcare Medicare	$2,294.00
Rate for Payer: University Health Alliance Commercial	$4,144.00
Rate for Payer: University Health Alliance Commercial	$11,185.44

PERSONA FEM PS POR STD SZ8 R

Facility

$19,974.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$11,185.44
Max. Negotiated Rate	$19,374.78
Rate for Payer: Cash Price	$11,984.40
Rate for Payer: Cash Price	$4,440.00
Rate for Payer: Hawaii Western Management Group Commercial	$5,180.00
Rate for Payer: Hawaii Western Management Group Commercial	$13,981.80
Rate for Payer: Health Management Network Commercial	$6,290.00
Rate for Payer: Health Management Network Commercial	$16,977.90
Rate for Payer: Kaiser Permanente Commercial	$6,660.00
Rate for Payer: Kaiser Permanente Commercial	$17,976.60
Rate for Payer: MDX Hawaii PPO	$7,178.00
Rate for Payer: MDX Hawaii PPO	$19,374.78
Rate for Payer: University Health Alliance Commercial	$4,144.00
Rate for Payer: University Health Alliance Commercial	$11,185.44

PERSONA FEM PS POR STD SZ9 L

Facility

$9,310.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$2,886.10
Max. Negotiated Rate	$9,030.70
Rate for Payer: AlohaCare Medicaid	$4,655.00
Rate for Payer: AlohaCare Medicaid	$9,987.00
Rate for Payer: AlohaCare Medicare	$2,886.10
Rate for Payer: AlohaCare Medicare	$6,191.94
Rate for Payer: Cash Price	$11,984.40
Rate for Payer: Cash Price	$5,586.00
Rate for Payer: Devoted Health Medicare	$6,791.16
Rate for Payer: Devoted Health Medicare	$3,165.40
Rate for Payer: Hawaii Medical Service Association Medicare	$6,191.94
Rate for Payer: Hawaii Medical Service Association Medicare	$2,886.10
Rate for Payer: Hawaii Western Management Group Commercial	$13,981.80
Rate for Payer: Hawaii Western Management Group Commercial	$6,517.00
Rate for Payer: Health Management Network Commercial	$7,913.50
Rate for Payer: Health Management Network Commercial	$16,977.90
Rate for Payer: Humana Medicare	$2,886.10
Rate for Payer: Humana Medicare	$6,191.94
Rate for Payer: Kaiser Permanente Commercial	$17,976.60
Rate for Payer: Kaiser Permanente Commercial	$8,379.00
Rate for Payer: Kaiser Permanente Medicaid	$10,186.74
Rate for Payer: Kaiser Permanente Medicaid	$4,748.10
Rate for Payer: Kaiser Permanente Medicare	$2,886.10
Rate for Payer: Kaiser Permanente Medicare	$6,191.94
Rate for Payer: MDX Hawaii PPO	$19,374.78
Rate for Payer: MDX Hawaii PPO	$9,030.70
Rate for Payer: Ohana Health Plan Medicaid	$2,886.10
Rate for Payer: Ohana Health Plan Medicaid	$6,191.94
Rate for Payer: Ohana Health Plan Medicare	$2,886.10
Rate for Payer: Ohana Health Plan Medicare	$6,191.94
Rate for Payer: UnitedHealthcare Medicare	$6,191.94
Rate for Payer: UnitedHealthcare Medicare	$2,886.10
Rate for Payer: University Health Alliance Commercial	$5,213.60
Rate for Payer: University Health Alliance Commercial	$11,185.44

PERSONA FEM PS POR STD SZ9 L

Facility

$19,974.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$11,185.44
Max. Negotiated Rate	$19,374.78
Rate for Payer: Cash Price	$11,984.40
Rate for Payer: Cash Price	$5,586.00
Rate for Payer: Hawaii Western Management Group Commercial	$6,517.00
Rate for Payer: Hawaii Western Management Group Commercial	$13,981.80
Rate for Payer: Health Management Network Commercial	$7,913.50
Rate for Payer: Health Management Network Commercial	$16,977.90
Rate for Payer: Kaiser Permanente Commercial	$8,379.00
Rate for Payer: Kaiser Permanente Commercial	$17,976.60
Rate for Payer: MDX Hawaii PPO	$9,030.70
Rate for Payer: MDX Hawaii PPO	$19,374.78
Rate for Payer: University Health Alliance Commercial	$5,213.60
Rate for Payer: University Health Alliance Commercial	$11,185.44

PERSONA FEM PS POR STD SZ9 R

Facility

$7,400.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$2,294.00
Max. Negotiated Rate	$7,178.00
Rate for Payer: AlohaCare Medicaid	$3,700.00
Rate for Payer: AlohaCare Medicaid	$9,987.00
Rate for Payer: AlohaCare Medicare	$2,294.00
Rate for Payer: AlohaCare Medicare	$6,191.94
Rate for Payer: Cash Price	$11,984.40
Rate for Payer: Cash Price	$4,440.00
Rate for Payer: Devoted Health Medicare	$6,791.16
Rate for Payer: Devoted Health Medicare	$2,516.00
Rate for Payer: Hawaii Medical Service Association Medicare	$6,191.94
Rate for Payer: Hawaii Medical Service Association Medicare	$2,294.00
Rate for Payer: Hawaii Western Management Group Commercial	$13,981.80
Rate for Payer: Hawaii Western Management Group Commercial	$5,180.00
Rate for Payer: Health Management Network Commercial	$6,290.00
Rate for Payer: Health Management Network Commercial	$16,977.90
Rate for Payer: Humana Medicare	$2,294.00
Rate for Payer: Humana Medicare	$6,191.94
Rate for Payer: Kaiser Permanente Commercial	$17,976.60
Rate for Payer: Kaiser Permanente Commercial	$6,660.00
Rate for Payer: Kaiser Permanente Medicaid	$10,186.74
Rate for Payer: Kaiser Permanente Medicaid	$3,774.00
Rate for Payer: Kaiser Permanente Medicare	$2,294.00
Rate for Payer: Kaiser Permanente Medicare	$6,191.94
Rate for Payer: MDX Hawaii PPO	$19,374.78
Rate for Payer: MDX Hawaii PPO	$7,178.00
Rate for Payer: Ohana Health Plan Medicaid	$2,294.00
Rate for Payer: Ohana Health Plan Medicaid	$6,191.94
Rate for Payer: Ohana Health Plan Medicare	$2,294.00
Rate for Payer: Ohana Health Plan Medicare	$6,191.94
Rate for Payer: UnitedHealthcare Medicare	$6,191.94
Rate for Payer: UnitedHealthcare Medicare	$2,294.00
Rate for Payer: University Health Alliance Commercial	$4,144.00
Rate for Payer: University Health Alliance Commercial	$11,185.44

PERSONA FEM PS POR STD SZ9 R

Facility

$19,974.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$11,185.44
Max. Negotiated Rate	$19,374.78
Rate for Payer: Cash Price	$11,984.40
Rate for Payer: Cash Price	$4,440.00
Rate for Payer: Hawaii Western Management Group Commercial	$5,180.00
Rate for Payer: Hawaii Western Management Group Commercial	$13,981.80
Rate for Payer: Health Management Network Commercial	$6,290.00
Rate for Payer: Health Management Network Commercial	$16,977.90
Rate for Payer: Kaiser Permanente Commercial	$6,660.00
Rate for Payer: Kaiser Permanente Commercial	$17,976.60
Rate for Payer: MDX Hawaii PPO	$7,178.00
Rate for Payer: MDX Hawaii PPO	$19,374.78
Rate for Payer: University Health Alliance Commercial	$4,144.00
Rate for Payer: University Health Alliance Commercial	$11,185.44

PERSONA KNEE 4 42-5580-004-02

Facility

$5,400.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$3,024.00
Max. Negotiated Rate	$5,238.00
Rate for Payer: Cash Price	$3,240.00
Rate for Payer: Hawaii Western Management Group Commercial	$3,780.00
Rate for Payer: Health Management Network Commercial	$4,590.00
Rate for Payer: Kaiser Permanente Commercial	$4,860.00
Rate for Payer: MDX Hawaii PPO	$5,238.00
Rate for Payer: University Health Alliance Commercial	$3,024.00

PERSONA KNEE 4 42-5580-004-02

Facility

$5,400.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$1,674.00
Max. Negotiated Rate	$5,238.00
Rate for Payer: AlohaCare Medicaid	$2,700.00
Rate for Payer: AlohaCare Medicare	$1,674.00
Rate for Payer: Cash Price	$3,240.00
Rate for Payer: Devoted Health Medicare	$1,836.00
Rate for Payer: Hawaii Medical Service Association Medicare	$1,674.00
Rate for Payer: Hawaii Western Management Group Commercial	$3,780.00
Rate for Payer: Health Management Network Commercial	$4,590.00
Rate for Payer: Humana Medicare	$1,674.00
Rate for Payer: Kaiser Permanente Commercial	$4,860.00
Rate for Payer: Kaiser Permanente Medicaid	$2,754.00
Rate for Payer: Kaiser Permanente Medicare	$1,674.00
Rate for Payer: MDX Hawaii PPO	$5,238.00
Rate for Payer: Ohana Health Plan Medicaid	$1,674.00
Rate for Payer: Ohana Health Plan Medicare	$1,674.00
Rate for Payer: UnitedHealthcare Medicare	$1,674.00
Rate for Payer: University Health Alliance Commercial	$3,024.00

PERSONA LF SZ 2 42-5580-002-01

Facility

$4,410.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$2,469.60
Max. Negotiated Rate	$4,277.70
Rate for Payer: Cash Price	$2,646.00
Rate for Payer: Hawaii Western Management Group Commercial	$3,087.00
Rate for Payer: Health Management Network Commercial	$3,748.50
Rate for Payer: Kaiser Permanente Commercial	$3,969.00
Rate for Payer: MDX Hawaii PPO	$4,277.70
Rate for Payer: University Health Alliance Commercial	$2,469.60

PERSONA LF SZ 2 42-5580-002-01

Facility

$4,410.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$1,367.10
Max. Negotiated Rate	$4,277.70
Rate for Payer: AlohaCare Medicaid	$2,205.00
Rate for Payer: AlohaCare Medicare	$1,367.10
Rate for Payer: Cash Price	$2,646.00
Rate for Payer: Devoted Health Medicare	$1,499.40
Rate for Payer: Hawaii Medical Service Association Medicare	$1,367.10
Rate for Payer: Hawaii Western Management Group Commercial	$3,087.00
Rate for Payer: Health Management Network Commercial	$3,748.50
Rate for Payer: Humana Medicare	$1,367.10
Rate for Payer: Kaiser Permanente Commercial	$3,969.00
Rate for Payer: Kaiser Permanente Medicaid	$2,249.10
Rate for Payer: Kaiser Permanente Medicare	$1,367.10
Rate for Payer: MDX Hawaii PPO	$4,277.70
Rate for Payer: Ohana Health Plan Medicaid	$1,367.10
Rate for Payer: Ohana Health Plan Medicare	$1,367.10
Rate for Payer: UnitedHealthcare Medicare	$1,367.10
Rate for Payer: University Health Alliance Commercial	$2,469.60

PERSONA LFT 4MM 42-5580-004-01

Facility

$3,350.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$1,876.00
Max. Negotiated Rate	$3,249.50
Rate for Payer: Cash Price	$2,010.00
Rate for Payer: Hawaii Western Management Group Commercial	$2,345.00
Rate for Payer: Health Management Network Commercial	$2,847.50
Rate for Payer: Kaiser Permanente Commercial	$3,015.00
Rate for Payer: MDX Hawaii PPO	$3,249.50
Rate for Payer: University Health Alliance Commercial	$1,876.00

PERSONA LFT 4MM 42-5580-004-01

Facility

$3,350.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$1,038.50
Max. Negotiated Rate	$3,249.50
Rate for Payer: AlohaCare Medicaid	$1,675.00
Rate for Payer: AlohaCare Medicare	$1,038.50
Rate for Payer: Cash Price	$2,010.00
Rate for Payer: Devoted Health Medicare	$1,139.00
Rate for Payer: Hawaii Medical Service Association Medicare	$1,038.50
Rate for Payer: Hawaii Western Management Group Commercial	$2,345.00
Rate for Payer: Health Management Network Commercial	$2,847.50
Rate for Payer: Humana Medicare	$1,038.50
Rate for Payer: Kaiser Permanente Commercial	$3,015.00
Rate for Payer: Kaiser Permanente Medicaid	$1,708.50
Rate for Payer: Kaiser Permanente Medicare	$1,038.50
Rate for Payer: MDX Hawaii PPO	$3,249.50
Rate for Payer: Ohana Health Plan Medicaid	$1,038.50
Rate for Payer: Ohana Health Plan Medicare	$1,038.50
Rate for Payer: UnitedHealthcare Medicare	$1,038.50
Rate for Payer: University Health Alliance Commercial	$1,876.00

PERSONA RIGHT J 42-5380-009-02

Facility

$2,940.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$911.40
Max. Negotiated Rate	$2,851.80
Rate for Payer: AlohaCare Medicaid	$1,470.00
Rate for Payer: AlohaCare Medicare	$911.40
Rate for Payer: Cash Price	$1,764.00
Rate for Payer: Devoted Health Medicare	$999.60
Rate for Payer: Hawaii Medical Service Association Medicare	$911.40
Rate for Payer: Hawaii Western Management Group Commercial	$2,058.00
Rate for Payer: Health Management Network Commercial	$2,499.00
Rate for Payer: Humana Medicare	$911.40
Rate for Payer: Kaiser Permanente Commercial	$2,646.00
Rate for Payer: Kaiser Permanente Medicaid	$1,499.40
Rate for Payer: Kaiser Permanente Medicare	$911.40
Rate for Payer: MDX Hawaii PPO	$2,851.80
Rate for Payer: Ohana Health Plan Medicaid	$911.40
Rate for Payer: Ohana Health Plan Medicare	$911.40
Rate for Payer: UnitedHealthcare Medicare	$911.40
Rate for Payer: University Health Alliance Commercial	$1,646.40

PERSONA RIGHT J 42-5380-009-02

Facility

$2,940.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$1,646.40
Max. Negotiated Rate	$2,851.80
Rate for Payer: Cash Price	$1,764.00
Rate for Payer: Hawaii Western Management Group Commercial	$2,058.00
Rate for Payer: Health Management Network Commercial	$2,499.00
Rate for Payer: Kaiser Permanente Commercial	$2,646.00
Rate for Payer: MDX Hawaii PPO	$2,851.80
Rate for Payer: University Health Alliance Commercial	$1,646.40

PERSONA SZ G 42-5380-007-01

Facility

$2,940.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$911.40
Max. Negotiated Rate	$2,851.80
Rate for Payer: AlohaCare Medicaid	$1,470.00
Rate for Payer: AlohaCare Medicare	$911.40
Rate for Payer: Cash Price	$1,764.00
Rate for Payer: Devoted Health Medicare	$999.60
Rate for Payer: Hawaii Medical Service Association Medicare	$911.40
Rate for Payer: Hawaii Western Management Group Commercial	$2,058.00
Rate for Payer: Health Management Network Commercial	$2,499.00
Rate for Payer: Humana Medicare	$911.40
Rate for Payer: Kaiser Permanente Commercial	$2,646.00
Rate for Payer: Kaiser Permanente Medicaid	$1,499.40
Rate for Payer: Kaiser Permanente Medicare	$911.40
Rate for Payer: MDX Hawaii PPO	$2,851.80
Rate for Payer: Ohana Health Plan Medicaid	$911.40
Rate for Payer: Ohana Health Plan Medicare	$911.40
Rate for Payer: UnitedHealthcare Medicare	$911.40
Rate for Payer: University Health Alliance Commercial	$1,646.40

PERSONA SZ G 42-5380-007-01

Facility

$2,940.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$1,646.40
Max. Negotiated Rate	$2,851.80
Rate for Payer: Cash Price	$1,764.00
Rate for Payer: Hawaii Western Management Group Commercial	$2,058.00
Rate for Payer: Health Management Network Commercial	$2,499.00
Rate for Payer: Kaiser Permanente Commercial	$2,646.00
Rate for Payer: MDX Hawaii PPO	$2,851.80
Rate for Payer: University Health Alliance Commercial	$1,646.40

PERSONA SZG 8 42-5182-007-08

Facility

$2,520.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$781.20
Max. Negotiated Rate	$2,444.40
Rate for Payer: AlohaCare Medicaid	$1,260.00
Rate for Payer: AlohaCare Medicare	$781.20
Rate for Payer: Cash Price	$1,512.00
Rate for Payer: Devoted Health Medicare	$856.80
Rate for Payer: Hawaii Medical Service Association Medicare	$781.20
Rate for Payer: Hawaii Western Management Group Commercial	$1,764.00
Rate for Payer: Health Management Network Commercial	$2,142.00
Rate for Payer: Humana Medicare	$781.20
Rate for Payer: Kaiser Permanente Commercial	$2,268.00
Rate for Payer: Kaiser Permanente Medicaid	$1,285.20
Rate for Payer: Kaiser Permanente Medicare	$781.20
Rate for Payer: MDX Hawaii PPO	$2,444.40
Rate for Payer: Ohana Health Plan Medicaid	$781.20
Rate for Payer: Ohana Health Plan Medicare	$781.20
Rate for Payer: UnitedHealthcare Medicare	$781.20
Rate for Payer: University Health Alliance Commercial	$1,411.20

PERSONA SZG 8 42-5182-007-08

Facility

$2,520.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$1,411.20
Max. Negotiated Rate	$2,444.40
Rate for Payer: Cash Price	$1,512.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,764.00
Rate for Payer: Health Management Network Commercial	$2,142.00
Rate for Payer: Kaiser Permanente Commercial	$2,268.00
Rate for Payer: MDX Hawaii PPO	$2,444.40
Rate for Payer: University Health Alliance Commercial	$1,411.20

PERSONA TIB STM 5 DEG SZ E L

Facility

$2,600.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$1,456.00
Max. Negotiated Rate	$2,522.00
Rate for Payer: Cash Price	$1,560.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,820.00
Rate for Payer: Health Management Network Commercial	$2,210.00
Rate for Payer: Kaiser Permanente Commercial	$2,340.00
Rate for Payer: MDX Hawaii PPO	$2,522.00
Rate for Payer: University Health Alliance Commercial	$1,456.00

PERSONA TIB STM 5 DEG SZ E L

Facility

$2,600.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$806.00
Max. Negotiated Rate	$2,522.00
Rate for Payer: AlohaCare Medicaid	$1,300.00
Rate for Payer: AlohaCare Medicare	$806.00
Rate for Payer: Cash Price	$1,560.00
Rate for Payer: Devoted Health Medicare	$884.00
Rate for Payer: Hawaii Medical Service Association Medicare	$806.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,820.00
Rate for Payer: Health Management Network Commercial	$2,210.00
Rate for Payer: Humana Medicare	$806.00
Rate for Payer: Kaiser Permanente Commercial	$2,340.00
Rate for Payer: Kaiser Permanente Medicaid	$1,326.00
Rate for Payer: Kaiser Permanente Medicare	$806.00
Rate for Payer: MDX Hawaii PPO	$2,522.00
Rate for Payer: Ohana Health Plan Medicaid	$806.00
Rate for Payer: Ohana Health Plan Medicare	$806.00
Rate for Payer: UnitedHealthcare Medicare	$806.00
Rate for Payer: University Health Alliance Commercial	$1,456.00

PERSONA TIB STM 5 DEG SZ E R

Facility

$2,000.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$1,120.00
Max. Negotiated Rate	$1,940.00
Rate for Payer: Cash Price	$1,200.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,400.00
Rate for Payer: Health Management Network Commercial	$1,700.00
Rate for Payer: Kaiser Permanente Commercial	$1,800.00
Rate for Payer: MDX Hawaii PPO	$1,940.00
Rate for Payer: University Health Alliance Commercial	$1,120.00

PERSONA TIB STM 5 DEG SZ E R

Facility

$2,000.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$620.00
Max. Negotiated Rate	$1,940.00
Rate for Payer: AlohaCare Medicaid	$1,000.00
Rate for Payer: AlohaCare Medicare	$620.00
Rate for Payer: Cash Price	$1,200.00
Rate for Payer: Devoted Health Medicare	$680.00
Rate for Payer: Hawaii Medical Service Association Medicare	$620.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,400.00
Rate for Payer: Health Management Network Commercial	$1,700.00
Rate for Payer: Humana Medicare	$620.00
Rate for Payer: Kaiser Permanente Commercial	$1,800.00
Rate for Payer: Kaiser Permanente Medicaid	$1,020.00
Rate for Payer: Kaiser Permanente Medicare	$620.00
Rate for Payer: MDX Hawaii PPO	$1,940.00
Rate for Payer: Ohana Health Plan Medicaid	$620.00
Rate for Payer: Ohana Health Plan Medicare	$620.00
Rate for Payer: UnitedHealthcare Medicare	$620.00
Rate for Payer: University Health Alliance Commercial	$1,120.00

PERSONA TIB STM 5 DEG SZ H, L

Facility

$2,000.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,120.00
Max. Negotiated Rate	$1,940.00
Rate for Payer: Cash Price	$1,200.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,400.00
Rate for Payer: Health Management Network Commercial	$1,700.00
Rate for Payer: Kaiser Permanente Commercial	$1,800.00
Rate for Payer: MDX Hawaii PPO	$1,940.00
Rate for Payer: University Health Alliance Commercial	$1,120.00

Know your out-of-pocket cost for care.

All Charges