Kau Hospital

All Charges

Charge

Type

Setting

Price

PLATE LCP 3.5/6H/RT 02.112.080

Facility

$2,486.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,392.16
Max. Negotiated Rate	$2,411.42
Rate for Payer: Cash Price	$1,491.60
Rate for Payer: Hawaii Western Management Group Commercial	$1,740.20
Rate for Payer: Health Management Network Commercial	$2,113.10
Rate for Payer: Kaiser Permanente Commercial	$2,237.40
Rate for Payer: MDX Hawaii PPO	$2,411.42
Rate for Payer: University Health Alliance Commercial	$1,392.16

PLATE LCP 3.5/6H/RT 02.112.080

Facility

$2,486.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$770.66
Max. Negotiated Rate	$2,411.42
Rate for Payer: AlohaCare Medicaid	$1,243.00
Rate for Payer: AlohaCare Medicare	$770.66
Rate for Payer: Cash Price	$1,491.60
Rate for Payer: Devoted Health Medicare	$845.24
Rate for Payer: Hawaii Medical Service Association Medicare	$770.66
Rate for Payer: Hawaii Western Management Group Commercial	$1,740.20
Rate for Payer: Health Management Network Commercial	$2,113.10
Rate for Payer: Humana Medicare	$770.66
Rate for Payer: Kaiser Permanente Commercial	$2,237.40
Rate for Payer: Kaiser Permanente Medicaid	$1,267.86
Rate for Payer: Kaiser Permanente Medicare	$770.66
Rate for Payer: MDX Hawaii PPO	$2,411.42
Rate for Payer: Ohana Health Plan Medicaid	$770.66
Rate for Payer: Ohana Health Plan Medicare	$770.66
Rate for Payer: UnitedHealthcare Medicare	$770.66
Rate for Payer: University Health Alliance Commercial	$1,392.16

PLATE LCP 3.5/7H/LT 02.112.019

Facility

$3,084.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,727.04
Max. Negotiated Rate	$2,991.48
Rate for Payer: Cash Price	$1,850.40
Rate for Payer: Hawaii Western Management Group Commercial	$2,158.80
Rate for Payer: Health Management Network Commercial	$2,621.40
Rate for Payer: Kaiser Permanente Commercial	$2,775.60
Rate for Payer: MDX Hawaii PPO	$2,991.48
Rate for Payer: University Health Alliance Commercial	$1,727.04

PLATE LCP 3.5/7H/LT 02.112.019

Facility

$3,084.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$956.04
Max. Negotiated Rate	$2,991.48
Rate for Payer: AlohaCare Medicaid	$1,542.00
Rate for Payer: AlohaCare Medicare	$956.04
Rate for Payer: Cash Price	$1,850.40
Rate for Payer: Devoted Health Medicare	$1,048.56
Rate for Payer: Hawaii Medical Service Association Medicare	$956.04
Rate for Payer: Hawaii Western Management Group Commercial	$2,158.80
Rate for Payer: Health Management Network Commercial	$2,621.40
Rate for Payer: Humana Medicare	$956.04
Rate for Payer: Kaiser Permanente Commercial	$2,775.60
Rate for Payer: Kaiser Permanente Medicaid	$1,572.84
Rate for Payer: Kaiser Permanente Medicare	$956.04
Rate for Payer: MDX Hawaii PPO	$2,991.48
Rate for Payer: Ohana Health Plan Medicaid	$956.04
Rate for Payer: Ohana Health Plan Medicare	$956.04
Rate for Payer: UnitedHealthcare Medicare	$956.04
Rate for Payer: University Health Alliance Commercial	$1,727.04

PLATE LCP 3.5/7H/LT 02.112.029

Facility

$2,219.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$687.89
Max. Negotiated Rate	$2,152.43
Rate for Payer: AlohaCare Medicaid	$1,109.50
Rate for Payer: AlohaCare Medicare	$687.89
Rate for Payer: Cash Price	$1,331.40
Rate for Payer: Devoted Health Medicare	$754.46
Rate for Payer: Hawaii Medical Service Association Medicare	$687.89
Rate for Payer: Hawaii Western Management Group Commercial	$1,553.30
Rate for Payer: Health Management Network Commercial	$1,886.15
Rate for Payer: Humana Medicare	$687.89
Rate for Payer: Kaiser Permanente Commercial	$1,997.10
Rate for Payer: Kaiser Permanente Medicaid	$1,131.69
Rate for Payer: Kaiser Permanente Medicare	$687.89
Rate for Payer: MDX Hawaii PPO	$2,152.43
Rate for Payer: Ohana Health Plan Medicaid	$687.89
Rate for Payer: Ohana Health Plan Medicare	$687.89
Rate for Payer: UnitedHealthcare Medicare	$687.89
Rate for Payer: University Health Alliance Commercial	$1,242.64

PLATE LCP 3.5/7H/LT 02.112.029

Facility

$2,219.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,242.64
Max. Negotiated Rate	$2,152.43
Rate for Payer: Cash Price	$1,331.40
Rate for Payer: Hawaii Western Management Group Commercial	$1,553.30
Rate for Payer: Health Management Network Commercial	$1,886.15
Rate for Payer: Kaiser Permanente Commercial	$1,997.10
Rate for Payer: MDX Hawaii PPO	$2,152.43
Rate for Payer: University Health Alliance Commercial	$1,242.64

PLATE LCP 3.5/7H/LT 02.112.083

Facility

$2,219.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,242.64
Max. Negotiated Rate	$2,152.43
Rate for Payer: Cash Price	$1,331.40
Rate for Payer: Hawaii Western Management Group Commercial	$1,553.30
Rate for Payer: Health Management Network Commercial	$1,886.15
Rate for Payer: Kaiser Permanente Commercial	$1,997.10
Rate for Payer: MDX Hawaii PPO	$2,152.43
Rate for Payer: University Health Alliance Commercial	$1,242.64

PLATE LCP 3.5/7H/LT 02.112.083

Facility

$2,219.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$687.89
Max. Negotiated Rate	$2,152.43
Rate for Payer: AlohaCare Medicaid	$1,109.50
Rate for Payer: AlohaCare Medicare	$687.89
Rate for Payer: Cash Price	$1,331.40
Rate for Payer: Devoted Health Medicare	$754.46
Rate for Payer: Hawaii Medical Service Association Medicare	$687.89
Rate for Payer: Hawaii Western Management Group Commercial	$1,553.30
Rate for Payer: Health Management Network Commercial	$1,886.15
Rate for Payer: Humana Medicare	$687.89
Rate for Payer: Kaiser Permanente Commercial	$1,997.10
Rate for Payer: Kaiser Permanente Medicaid	$1,131.69
Rate for Payer: Kaiser Permanente Medicare	$687.89
Rate for Payer: MDX Hawaii PPO	$2,152.43
Rate for Payer: Ohana Health Plan Medicaid	$687.89
Rate for Payer: Ohana Health Plan Medicare	$687.89
Rate for Payer: UnitedHealthcare Medicare	$687.89
Rate for Payer: University Health Alliance Commercial	$1,242.64

PLATE LCP 3.5/7H/RT 02.112.028

Facility

$2,573.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,440.88
Max. Negotiated Rate	$2,495.81
Rate for Payer: Cash Price	$1,543.80
Rate for Payer: Hawaii Western Management Group Commercial	$1,801.10
Rate for Payer: Health Management Network Commercial	$2,187.05
Rate for Payer: Kaiser Permanente Commercial	$2,315.70
Rate for Payer: MDX Hawaii PPO	$2,495.81
Rate for Payer: University Health Alliance Commercial	$1,440.88

PLATE LCP 3.5/7H/RT 02.112.028

Facility

$2,573.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$797.63
Max. Negotiated Rate	$2,495.81
Rate for Payer: AlohaCare Medicaid	$1,286.50
Rate for Payer: AlohaCare Medicare	$797.63
Rate for Payer: Cash Price	$1,543.80
Rate for Payer: Devoted Health Medicare	$874.82
Rate for Payer: Hawaii Medical Service Association Medicare	$797.63
Rate for Payer: Hawaii Western Management Group Commercial	$1,801.10
Rate for Payer: Health Management Network Commercial	$2,187.05
Rate for Payer: Humana Medicare	$797.63
Rate for Payer: Kaiser Permanente Commercial	$2,315.70
Rate for Payer: Kaiser Permanente Medicaid	$1,312.23
Rate for Payer: Kaiser Permanente Medicare	$797.63
Rate for Payer: MDX Hawaii PPO	$2,495.81
Rate for Payer: Ohana Health Plan Medicaid	$797.63
Rate for Payer: Ohana Health Plan Medicare	$797.63
Rate for Payer: UnitedHealthcare Medicare	$797.63
Rate for Payer: University Health Alliance Commercial	$1,440.88

PLATE LCP 3.5/7H/RT 02.112.082

Facility

$2,219.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,242.64
Max. Negotiated Rate	$2,152.43
Rate for Payer: Cash Price	$1,331.40
Rate for Payer: Hawaii Western Management Group Commercial	$1,553.30
Rate for Payer: Health Management Network Commercial	$1,886.15
Rate for Payer: Kaiser Permanente Commercial	$1,997.10
Rate for Payer: MDX Hawaii PPO	$2,152.43
Rate for Payer: University Health Alliance Commercial	$1,242.64

PLATE LCP 3.5/7H/RT 02.112.082

Facility

$2,219.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$687.89
Max. Negotiated Rate	$2,152.43
Rate for Payer: AlohaCare Medicaid	$1,109.50
Rate for Payer: AlohaCare Medicare	$687.89
Rate for Payer: Cash Price	$1,331.40
Rate for Payer: Devoted Health Medicare	$754.46
Rate for Payer: Hawaii Medical Service Association Medicare	$687.89
Rate for Payer: Hawaii Western Management Group Commercial	$1,553.30
Rate for Payer: Health Management Network Commercial	$1,886.15
Rate for Payer: Humana Medicare	$687.89
Rate for Payer: Kaiser Permanente Commercial	$1,997.10
Rate for Payer: Kaiser Permanente Medicaid	$1,131.69
Rate for Payer: Kaiser Permanente Medicare	$687.89
Rate for Payer: MDX Hawaii PPO	$2,152.43
Rate for Payer: Ohana Health Plan Medicaid	$687.89
Rate for Payer: Ohana Health Plan Medicare	$687.89
Rate for Payer: UnitedHealthcare Medicare	$687.89
Rate for Payer: University Health Alliance Commercial	$1,242.64

PLATE LCP 3.5/8H/L 02.127.331

Facility

$4,215.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,306.65
Max. Negotiated Rate	$4,088.55
Rate for Payer: AlohaCare Medicaid	$2,107.50
Rate for Payer: AlohaCare Medicare	$1,306.65
Rate for Payer: Cash Price	$2,529.00
Rate for Payer: Devoted Health Medicare	$1,433.10
Rate for Payer: Hawaii Medical Service Association Medicare	$1,306.65
Rate for Payer: Hawaii Western Management Group Commercial	$2,950.50
Rate for Payer: Health Management Network Commercial	$3,582.75
Rate for Payer: Humana Medicare	$1,306.65
Rate for Payer: Kaiser Permanente Commercial	$3,793.50
Rate for Payer: Kaiser Permanente Medicaid	$2,149.65
Rate for Payer: Kaiser Permanente Medicare	$1,306.65
Rate for Payer: MDX Hawaii PPO	$4,088.55
Rate for Payer: Ohana Health Plan Medicaid	$1,306.65
Rate for Payer: Ohana Health Plan Medicare	$1,306.65
Rate for Payer: UnitedHealthcare Medicare	$1,306.65
Rate for Payer: University Health Alliance Commercial	$2,360.40

PLATE LCP 3.5/8H/L 02.127.331

Facility

$4,215.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$2,360.40
Max. Negotiated Rate	$4,088.55
Rate for Payer: Cash Price	$2,529.00
Rate for Payer: Hawaii Western Management Group Commercial	$2,950.50
Rate for Payer: Health Management Network Commercial	$3,582.75
Rate for Payer: Kaiser Permanente Commercial	$3,793.50
Rate for Payer: MDX Hawaii PPO	$4,088.55
Rate for Payer: University Health Alliance Commercial	$2,360.40

PLATE LCP 3.5/8H/LT 02.112.021

Facility

$3,160.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$979.60
Max. Negotiated Rate	$3,065.20
Rate for Payer: AlohaCare Medicaid	$1,580.00
Rate for Payer: AlohaCare Medicare	$979.60
Rate for Payer: Cash Price	$1,896.00
Rate for Payer: Devoted Health Medicare	$1,074.40
Rate for Payer: Hawaii Medical Service Association Medicare	$979.60
Rate for Payer: Hawaii Western Management Group Commercial	$2,212.00
Rate for Payer: Health Management Network Commercial	$2,686.00
Rate for Payer: Humana Medicare	$979.60
Rate for Payer: Kaiser Permanente Commercial	$2,844.00
Rate for Payer: Kaiser Permanente Medicaid	$1,611.60
Rate for Payer: Kaiser Permanente Medicare	$979.60
Rate for Payer: MDX Hawaii PPO	$3,065.20
Rate for Payer: Ohana Health Plan Medicaid	$979.60
Rate for Payer: Ohana Health Plan Medicare	$979.60
Rate for Payer: UnitedHealthcare Medicare	$979.60
Rate for Payer: University Health Alliance Commercial	$1,769.60

PLATE LCP 3.5/8H/LT 02.112.021

Facility

$3,160.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,769.60
Max. Negotiated Rate	$3,065.20
Rate for Payer: Cash Price	$1,896.00
Rate for Payer: Hawaii Western Management Group Commercial	$2,212.00
Rate for Payer: Health Management Network Commercial	$2,686.00
Rate for Payer: Kaiser Permanente Commercial	$2,844.00
Rate for Payer: MDX Hawaii PPO	$3,065.20
Rate for Payer: University Health Alliance Commercial	$1,769.60

PLATE LCP 3.5/8H/LT 02.112.031

Facility

$3,160.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,769.60
Max. Negotiated Rate	$3,065.20
Rate for Payer: Cash Price	$1,896.00
Rate for Payer: Hawaii Western Management Group Commercial	$2,212.00
Rate for Payer: Health Management Network Commercial	$2,686.00
Rate for Payer: Kaiser Permanente Commercial	$2,844.00
Rate for Payer: MDX Hawaii PPO	$3,065.20
Rate for Payer: University Health Alliance Commercial	$1,769.60

PLATE LCP 3.5/8H/LT 02.112.031

Facility

$3,160.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$979.60
Max. Negotiated Rate	$3,065.20
Rate for Payer: AlohaCare Medicaid	$1,580.00
Rate for Payer: AlohaCare Medicare	$979.60
Rate for Payer: Cash Price	$1,896.00
Rate for Payer: Devoted Health Medicare	$1,074.40
Rate for Payer: Hawaii Medical Service Association Medicare	$979.60
Rate for Payer: Hawaii Western Management Group Commercial	$2,212.00
Rate for Payer: Health Management Network Commercial	$2,686.00
Rate for Payer: Humana Medicare	$979.60
Rate for Payer: Kaiser Permanente Commercial	$2,844.00
Rate for Payer: Kaiser Permanente Medicaid	$1,611.60
Rate for Payer: Kaiser Permanente Medicare	$979.60
Rate for Payer: MDX Hawaii PPO	$3,065.20
Rate for Payer: Ohana Health Plan Medicaid	$979.60
Rate for Payer: Ohana Health Plan Medicare	$979.60
Rate for Payer: UnitedHealthcare Medicare	$979.60
Rate for Payer: University Health Alliance Commercial	$1,769.60

PLATE LCP 3.5/8H/LT 02.112.085

Facility

$3,610.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,119.10
Max. Negotiated Rate	$3,501.70
Rate for Payer: AlohaCare Medicaid	$1,805.00
Rate for Payer: AlohaCare Medicare	$1,119.10
Rate for Payer: Cash Price	$2,166.00
Rate for Payer: Devoted Health Medicare	$1,227.40
Rate for Payer: Hawaii Medical Service Association Medicare	$1,119.10
Rate for Payer: Hawaii Western Management Group Commercial	$2,527.00
Rate for Payer: Health Management Network Commercial	$3,068.50
Rate for Payer: Humana Medicare	$1,119.10
Rate for Payer: Kaiser Permanente Commercial	$3,249.00
Rate for Payer: Kaiser Permanente Medicaid	$1,841.10
Rate for Payer: Kaiser Permanente Medicare	$1,119.10
Rate for Payer: MDX Hawaii PPO	$3,501.70
Rate for Payer: Ohana Health Plan Medicaid	$1,119.10
Rate for Payer: Ohana Health Plan Medicare	$1,119.10
Rate for Payer: UnitedHealthcare Medicare	$1,119.10
Rate for Payer: University Health Alliance Commercial	$2,021.60

PLATE LCP 3.5/8H/LT 02.112.085

Facility

$3,610.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$2,021.60
Max. Negotiated Rate	$3,501.70
Rate for Payer: Cash Price	$2,166.00
Rate for Payer: Hawaii Western Management Group Commercial	$2,527.00
Rate for Payer: Health Management Network Commercial	$3,068.50
Rate for Payer: Kaiser Permanente Commercial	$3,249.00
Rate for Payer: MDX Hawaii PPO	$3,501.70
Rate for Payer: University Health Alliance Commercial	$2,021.60

PLATE LCP 3.5/8H/LT 02.127.231

Facility

$4,215.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$2,360.40
Max. Negotiated Rate	$4,088.55
Rate for Payer: Cash Price	$2,529.00
Rate for Payer: Hawaii Western Management Group Commercial	$2,950.50
Rate for Payer: Health Management Network Commercial	$3,582.75
Rate for Payer: Kaiser Permanente Commercial	$3,793.50
Rate for Payer: MDX Hawaii PPO	$4,088.55
Rate for Payer: University Health Alliance Commercial	$2,360.40

PLATE LCP 3.5/8H/LT 02.127.231

Facility

$4,215.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,306.65
Max. Negotiated Rate	$4,088.55
Rate for Payer: AlohaCare Medicaid	$2,107.50
Rate for Payer: AlohaCare Medicare	$1,306.65
Rate for Payer: Cash Price	$2,529.00
Rate for Payer: Devoted Health Medicare	$1,433.10
Rate for Payer: Hawaii Medical Service Association Medicare	$1,306.65
Rate for Payer: Hawaii Western Management Group Commercial	$2,950.50
Rate for Payer: Health Management Network Commercial	$3,582.75
Rate for Payer: Humana Medicare	$1,306.65
Rate for Payer: Kaiser Permanente Commercial	$3,793.50
Rate for Payer: Kaiser Permanente Medicaid	$2,149.65
Rate for Payer: Kaiser Permanente Medicare	$1,306.65
Rate for Payer: MDX Hawaii PPO	$4,088.55
Rate for Payer: Ohana Health Plan Medicaid	$1,306.65
Rate for Payer: Ohana Health Plan Medicare	$1,306.65
Rate for Payer: UnitedHealthcare Medicare	$1,306.65
Rate for Payer: University Health Alliance Commercial	$2,360.40

PLATE LCP 3.5/8H/R 02.127.330

Facility

$4,215.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$2,360.40
Max. Negotiated Rate	$4,088.55
Rate for Payer: Cash Price	$2,529.00
Rate for Payer: Hawaii Western Management Group Commercial	$2,950.50
Rate for Payer: Health Management Network Commercial	$3,582.75
Rate for Payer: Kaiser Permanente Commercial	$3,793.50
Rate for Payer: MDX Hawaii PPO	$4,088.55
Rate for Payer: University Health Alliance Commercial	$2,360.40

PLATE LCP 3.5/8H/R 02.127.330

Facility

$4,215.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,306.65
Max. Negotiated Rate	$4,088.55
Rate for Payer: AlohaCare Medicaid	$2,107.50
Rate for Payer: AlohaCare Medicare	$1,306.65
Rate for Payer: Cash Price	$2,529.00
Rate for Payer: Devoted Health Medicare	$1,433.10
Rate for Payer: Hawaii Medical Service Association Medicare	$1,306.65
Rate for Payer: Hawaii Western Management Group Commercial	$2,950.50
Rate for Payer: Health Management Network Commercial	$3,582.75
Rate for Payer: Humana Medicare	$1,306.65
Rate for Payer: Kaiser Permanente Commercial	$3,793.50
Rate for Payer: Kaiser Permanente Medicaid	$2,149.65
Rate for Payer: Kaiser Permanente Medicare	$1,306.65
Rate for Payer: MDX Hawaii PPO	$4,088.55
Rate for Payer: Ohana Health Plan Medicaid	$1,306.65
Rate for Payer: Ohana Health Plan Medicare	$1,306.65
Rate for Payer: UnitedHealthcare Medicare	$1,306.65
Rate for Payer: University Health Alliance Commercial	$2,360.40

PLATE LCP 3.5/8H/RT 02.112.020

Facility

$3,160.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,769.60
Max. Negotiated Rate	$3,065.20
Rate for Payer: Cash Price	$1,896.00
Rate for Payer: Hawaii Western Management Group Commercial	$2,212.00
Rate for Payer: Health Management Network Commercial	$2,686.00
Rate for Payer: Kaiser Permanente Commercial	$2,844.00
Rate for Payer: MDX Hawaii PPO	$3,065.20
Rate for Payer: University Health Alliance Commercial	$1,769.60

Know your out-of-pocket cost for care.

All Charges