Kau Hospital

All Charges

Charge

Type

Setting

Price

PLATE LCP-RT 14H 4.5MM 222.664

Facility

$5,147.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$2,882.32
Max. Negotiated Rate	$4,992.59
Rate for Payer: Cash Price	$3,088.20
Rate for Payer: Hawaii Western Management Group Commercial	$3,602.90
Rate for Payer: Health Management Network Commercial	$4,374.95
Rate for Payer: Kaiser Permanente Commercial	$4,632.30
Rate for Payer: MDX Hawaii PPO	$4,992.59
Rate for Payer: University Health Alliance Commercial	$2,882.32

PLATE LCP-RT 14H 4.5MM 240.046

Facility

$4,426.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,372.06
Max. Negotiated Rate	$4,293.22
Rate for Payer: AlohaCare Medicaid	$2,213.00
Rate for Payer: AlohaCare Medicare	$1,372.06
Rate for Payer: Cash Price	$2,655.60
Rate for Payer: Devoted Health Medicare	$1,504.84
Rate for Payer: Hawaii Medical Service Association Medicare	$1,372.06
Rate for Payer: Hawaii Western Management Group Commercial	$3,098.20
Rate for Payer: Health Management Network Commercial	$3,762.10
Rate for Payer: Humana Medicare	$1,372.06
Rate for Payer: Kaiser Permanente Commercial	$3,983.40
Rate for Payer: Kaiser Permanente Medicaid	$2,257.26
Rate for Payer: Kaiser Permanente Medicare	$1,372.06
Rate for Payer: MDX Hawaii PPO	$4,293.22
Rate for Payer: Ohana Health Plan Medicaid	$1,372.06
Rate for Payer: Ohana Health Plan Medicare	$1,372.06
Rate for Payer: UnitedHealthcare Medicare	$1,372.06
Rate for Payer: University Health Alliance Commercial	$2,478.56

PLATE LCP-RT 14H 4.5MM 240.046

Facility

$4,426.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$2,478.56
Max. Negotiated Rate	$4,293.22
Rate for Payer: Cash Price	$2,655.60
Rate for Payer: Hawaii Western Management Group Commercial	$3,098.20
Rate for Payer: Health Management Network Commercial	$3,762.10
Rate for Payer: Kaiser Permanente Commercial	$3,983.40
Rate for Payer: MDX Hawaii PPO	$4,293.22
Rate for Payer: University Health Alliance Commercial	$2,478.56

PLATE LCP-RT 16H 4.5MM 222.666

Facility

$5,250.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$2,940.00
Max. Negotiated Rate	$5,092.50
Rate for Payer: Cash Price	$3,150.00
Rate for Payer: Hawaii Western Management Group Commercial	$3,675.00
Rate for Payer: Health Management Network Commercial	$4,462.50
Rate for Payer: Kaiser Permanente Commercial	$4,725.00
Rate for Payer: MDX Hawaii PPO	$5,092.50
Rate for Payer: University Health Alliance Commercial	$2,940.00

PLATE LCP-RT 16H 4.5MM 222.666

Facility

$5,250.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,627.50
Max. Negotiated Rate	$5,092.50
Rate for Payer: AlohaCare Medicaid	$2,625.00
Rate for Payer: AlohaCare Medicare	$1,627.50
Rate for Payer: Cash Price	$3,150.00
Rate for Payer: Devoted Health Medicare	$1,785.00
Rate for Payer: Hawaii Medical Service Association Medicare	$1,627.50
Rate for Payer: Hawaii Western Management Group Commercial	$3,675.00
Rate for Payer: Health Management Network Commercial	$4,462.50
Rate for Payer: Humana Medicare	$1,627.50
Rate for Payer: Kaiser Permanente Commercial	$4,725.00
Rate for Payer: Kaiser Permanente Medicaid	$2,677.50
Rate for Payer: Kaiser Permanente Medicare	$1,627.50
Rate for Payer: MDX Hawaii PPO	$5,092.50
Rate for Payer: Ohana Health Plan Medicaid	$1,627.50
Rate for Payer: Ohana Health Plan Medicare	$1,627.50
Rate for Payer: UnitedHealthcare Medicare	$1,627.50
Rate for Payer: University Health Alliance Commercial	$2,940.00

PLATE LCP-RT 18H 4.5MM 222.668

Facility

$5,356.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,660.36
Max. Negotiated Rate	$5,195.32
Rate for Payer: AlohaCare Medicaid	$2,678.00
Rate for Payer: AlohaCare Medicare	$1,660.36
Rate for Payer: Cash Price	$3,213.60
Rate for Payer: Devoted Health Medicare	$1,821.04
Rate for Payer: Hawaii Medical Service Association Medicare	$1,660.36
Rate for Payer: Hawaii Western Management Group Commercial	$3,749.20
Rate for Payer: Health Management Network Commercial	$4,552.60
Rate for Payer: Humana Medicare	$1,660.36
Rate for Payer: Kaiser Permanente Commercial	$4,820.40
Rate for Payer: Kaiser Permanente Medicaid	$2,731.56
Rate for Payer: Kaiser Permanente Medicare	$1,660.36
Rate for Payer: MDX Hawaii PPO	$5,195.32
Rate for Payer: Ohana Health Plan Medicaid	$1,660.36
Rate for Payer: Ohana Health Plan Medicare	$1,660.36
Rate for Payer: UnitedHealthcare Medicare	$1,660.36
Rate for Payer: University Health Alliance Commercial	$2,999.36

PLATE LCP-RT 18H 4.5MM 222.668

Facility

$5,356.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$2,999.36
Max. Negotiated Rate	$5,195.32
Rate for Payer: Cash Price	$3,213.60
Rate for Payer: Hawaii Western Management Group Commercial	$3,749.20
Rate for Payer: Health Management Network Commercial	$4,552.60
Rate for Payer: Kaiser Permanente Commercial	$4,820.40
Rate for Payer: MDX Hawaii PPO	$5,195.32
Rate for Payer: University Health Alliance Commercial	$2,999.36

PLATE LCP-RT 8H 4.5MM 240.040

Facility

$4,584.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$2,567.04
Max. Negotiated Rate	$4,446.48
Rate for Payer: Cash Price	$2,750.40
Rate for Payer: Hawaii Western Management Group Commercial	$3,208.80
Rate for Payer: Health Management Network Commercial	$3,896.40
Rate for Payer: Kaiser Permanente Commercial	$4,125.60
Rate for Payer: MDX Hawaii PPO	$4,446.48
Rate for Payer: University Health Alliance Commercial	$2,567.04

PLATE LCP-RT 8H 4.5MM 240.040

Facility

$4,584.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,421.04
Max. Negotiated Rate	$4,446.48
Rate for Payer: AlohaCare Medicaid	$2,292.00
Rate for Payer: AlohaCare Medicare	$1,421.04
Rate for Payer: Cash Price	$2,750.40
Rate for Payer: Devoted Health Medicare	$1,558.56
Rate for Payer: Hawaii Medical Service Association Medicare	$1,421.04
Rate for Payer: Hawaii Western Management Group Commercial	$3,208.80
Rate for Payer: Health Management Network Commercial	$3,896.40
Rate for Payer: Humana Medicare	$1,421.04
Rate for Payer: Kaiser Permanente Commercial	$4,125.60
Rate for Payer: Kaiser Permanente Medicaid	$2,337.84
Rate for Payer: Kaiser Permanente Medicare	$1,421.04
Rate for Payer: MDX Hawaii PPO	$4,446.48
Rate for Payer: Ohana Health Plan Medicaid	$1,421.04
Rate for Payer: Ohana Health Plan Medicare	$1,421.04
Rate for Payer: UnitedHealthcare Medicare	$1,421.04
Rate for Payer: University Health Alliance Commercial	$2,567.04

PLATE LCP TIB-L 10H 02.118.009

Facility

$4,478.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$2,507.68
Max. Negotiated Rate	$4,343.66
Rate for Payer: Cash Price	$2,686.80
Rate for Payer: Hawaii Western Management Group Commercial	$3,134.60
Rate for Payer: Health Management Network Commercial	$3,806.30
Rate for Payer: Kaiser Permanente Commercial	$4,030.20
Rate for Payer: MDX Hawaii PPO	$4,343.66
Rate for Payer: University Health Alliance Commercial	$2,507.68

PLATE LCP TIB-L 10H 02.118.009

Facility

$4,478.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,388.18
Max. Negotiated Rate	$4,343.66
Rate for Payer: AlohaCare Medicaid	$2,239.00
Rate for Payer: AlohaCare Medicare	$1,388.18
Rate for Payer: Cash Price	$2,686.80
Rate for Payer: Devoted Health Medicare	$1,522.52
Rate for Payer: Hawaii Medical Service Association Medicare	$1,388.18
Rate for Payer: Hawaii Western Management Group Commercial	$3,134.60
Rate for Payer: Health Management Network Commercial	$3,806.30
Rate for Payer: Humana Medicare	$1,388.18
Rate for Payer: Kaiser Permanente Commercial	$4,030.20
Rate for Payer: Kaiser Permanente Medicaid	$2,283.78
Rate for Payer: Kaiser Permanente Medicare	$1,388.18
Rate for Payer: MDX Hawaii PPO	$4,343.66
Rate for Payer: Ohana Health Plan Medicaid	$1,388.18
Rate for Payer: Ohana Health Plan Medicare	$1,388.18
Rate for Payer: UnitedHealthcare Medicare	$1,388.18
Rate for Payer: University Health Alliance Commercial	$2,507.68

PLATE LCP TIB-L 10H 02.118.209

Facility

$4,764.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,476.84
Max. Negotiated Rate	$4,621.08
Rate for Payer: AlohaCare Medicaid	$2,382.00
Rate for Payer: AlohaCare Medicare	$1,476.84
Rate for Payer: Cash Price	$2,858.40
Rate for Payer: Devoted Health Medicare	$1,619.76
Rate for Payer: Hawaii Medical Service Association Medicare	$1,476.84
Rate for Payer: Hawaii Western Management Group Commercial	$3,334.80
Rate for Payer: Health Management Network Commercial	$4,049.40
Rate for Payer: Humana Medicare	$1,476.84
Rate for Payer: Kaiser Permanente Commercial	$4,287.60
Rate for Payer: Kaiser Permanente Medicaid	$2,429.64
Rate for Payer: Kaiser Permanente Medicare	$1,476.84
Rate for Payer: MDX Hawaii PPO	$4,621.08
Rate for Payer: Ohana Health Plan Medicaid	$1,476.84
Rate for Payer: Ohana Health Plan Medicare	$1,476.84
Rate for Payer: UnitedHealthcare Medicare	$1,476.84
Rate for Payer: University Health Alliance Commercial	$2,667.84

PLATE LCP TIB-L 10H 02.118.209

Facility

$4,764.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$2,667.84
Max. Negotiated Rate	$4,621.08
Rate for Payer: Cash Price	$2,858.40
Rate for Payer: Hawaii Western Management Group Commercial	$3,334.80
Rate for Payer: Health Management Network Commercial	$4,049.40
Rate for Payer: Kaiser Permanente Commercial	$4,287.60
Rate for Payer: MDX Hawaii PPO	$4,621.08
Rate for Payer: University Health Alliance Commercial	$2,667.84

PLATE LCP TIB-L 12H 02.118.011

Facility

$5,226.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$2,926.56
Max. Negotiated Rate	$5,069.22
Rate for Payer: Cash Price	$3,135.60
Rate for Payer: Hawaii Western Management Group Commercial	$3,658.20
Rate for Payer: Health Management Network Commercial	$4,442.10
Rate for Payer: Kaiser Permanente Commercial	$4,703.40
Rate for Payer: MDX Hawaii PPO	$5,069.22
Rate for Payer: University Health Alliance Commercial	$2,926.56

PLATE LCP TIB-L 12H 02.118.011

Facility

$5,226.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,620.06
Max. Negotiated Rate	$5,069.22
Rate for Payer: AlohaCare Medicaid	$2,613.00
Rate for Payer: AlohaCare Medicare	$1,620.06
Rate for Payer: Cash Price	$3,135.60
Rate for Payer: Devoted Health Medicare	$1,776.84
Rate for Payer: Hawaii Medical Service Association Medicare	$1,620.06
Rate for Payer: Hawaii Western Management Group Commercial	$3,658.20
Rate for Payer: Health Management Network Commercial	$4,442.10
Rate for Payer: Humana Medicare	$1,620.06
Rate for Payer: Kaiser Permanente Commercial	$4,703.40
Rate for Payer: Kaiser Permanente Medicaid	$2,665.26
Rate for Payer: Kaiser Permanente Medicare	$1,620.06
Rate for Payer: MDX Hawaii PPO	$5,069.22
Rate for Payer: Ohana Health Plan Medicaid	$1,620.06
Rate for Payer: Ohana Health Plan Medicare	$1,620.06
Rate for Payer: UnitedHealthcare Medicare	$1,620.06
Rate for Payer: University Health Alliance Commercial	$2,926.56

PLATE LCP TIB-L 12H 02.118.211

Facility

$5,406.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,675.86
Max. Negotiated Rate	$5,243.82
Rate for Payer: AlohaCare Medicaid	$2,703.00
Rate for Payer: AlohaCare Medicare	$1,675.86
Rate for Payer: Cash Price	$3,243.60
Rate for Payer: Devoted Health Medicare	$1,838.04
Rate for Payer: Hawaii Medical Service Association Medicare	$1,675.86
Rate for Payer: Hawaii Western Management Group Commercial	$3,784.20
Rate for Payer: Health Management Network Commercial	$4,595.10
Rate for Payer: Humana Medicare	$1,675.86
Rate for Payer: Kaiser Permanente Commercial	$4,865.40
Rate for Payer: Kaiser Permanente Medicaid	$2,757.06
Rate for Payer: Kaiser Permanente Medicare	$1,675.86
Rate for Payer: MDX Hawaii PPO	$5,243.82
Rate for Payer: Ohana Health Plan Medicaid	$1,675.86
Rate for Payer: Ohana Health Plan Medicare	$1,675.86
Rate for Payer: UnitedHealthcare Medicare	$1,675.86
Rate for Payer: University Health Alliance Commercial	$3,027.36

PLATE LCP TIB-L 12H 02.118.211

Facility

$5,406.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$3,027.36
Max. Negotiated Rate	$5,243.82
Rate for Payer: Cash Price	$3,243.60
Rate for Payer: Hawaii Western Management Group Commercial	$3,784.20
Rate for Payer: Health Management Network Commercial	$4,595.10
Rate for Payer: Kaiser Permanente Commercial	$4,865.40
Rate for Payer: MDX Hawaii PPO	$5,243.82
Rate for Payer: University Health Alliance Commercial	$3,027.36

PLATE LCP TIB-L 14H 02.118.013

Facility

$5,828.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,806.68
Max. Negotiated Rate	$5,653.16
Rate for Payer: AlohaCare Medicaid	$2,914.00
Rate for Payer: AlohaCare Medicare	$1,806.68
Rate for Payer: Cash Price	$3,496.80
Rate for Payer: Devoted Health Medicare	$1,981.52
Rate for Payer: Hawaii Medical Service Association Medicare	$1,806.68
Rate for Payer: Hawaii Western Management Group Commercial	$4,079.60
Rate for Payer: Health Management Network Commercial	$4,953.80
Rate for Payer: Humana Medicare	$1,806.68
Rate for Payer: Kaiser Permanente Commercial	$5,245.20
Rate for Payer: Kaiser Permanente Medicaid	$2,972.28
Rate for Payer: Kaiser Permanente Medicare	$1,806.68
Rate for Payer: MDX Hawaii PPO	$5,653.16
Rate for Payer: Ohana Health Plan Medicaid	$1,806.68
Rate for Payer: Ohana Health Plan Medicare	$1,806.68
Rate for Payer: UnitedHealthcare Medicare	$1,806.68
Rate for Payer: University Health Alliance Commercial	$3,263.68

PLATE LCP TIB-L 14H 02.118.013

Facility

$5,828.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$3,263.68
Max. Negotiated Rate	$5,653.16
Rate for Payer: Cash Price	$3,496.80
Rate for Payer: Hawaii Western Management Group Commercial	$4,079.60
Rate for Payer: Health Management Network Commercial	$4,953.80
Rate for Payer: Kaiser Permanente Commercial	$5,245.20
Rate for Payer: MDX Hawaii PPO	$5,653.16
Rate for Payer: University Health Alliance Commercial	$3,263.68

PLATE LCP TIB-L 14H 02.118.213

Facility

$6,034.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,870.54
Max. Negotiated Rate	$5,852.98
Rate for Payer: AlohaCare Medicaid	$3,017.00
Rate for Payer: AlohaCare Medicare	$1,870.54
Rate for Payer: Cash Price	$3,620.40
Rate for Payer: Devoted Health Medicare	$2,051.56
Rate for Payer: Hawaii Medical Service Association Medicare	$1,870.54
Rate for Payer: Hawaii Western Management Group Commercial	$4,223.80
Rate for Payer: Health Management Network Commercial	$5,128.90
Rate for Payer: Humana Medicare	$1,870.54
Rate for Payer: Kaiser Permanente Commercial	$5,430.60
Rate for Payer: Kaiser Permanente Medicaid	$3,077.34
Rate for Payer: Kaiser Permanente Medicare	$1,870.54
Rate for Payer: MDX Hawaii PPO	$5,852.98
Rate for Payer: Ohana Health Plan Medicaid	$1,870.54
Rate for Payer: Ohana Health Plan Medicare	$1,870.54
Rate for Payer: UnitedHealthcare Medicare	$1,870.54
Rate for Payer: University Health Alliance Commercial	$3,379.04

PLATE LCP TIB-L 14H 02.118.213

Facility

$6,034.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$3,379.04
Max. Negotiated Rate	$5,852.98
Rate for Payer: Cash Price	$3,620.40
Rate for Payer: Hawaii Western Management Group Commercial	$4,223.80
Rate for Payer: Health Management Network Commercial	$5,128.90
Rate for Payer: Kaiser Permanente Commercial	$5,430.60
Rate for Payer: MDX Hawaii PPO	$5,852.98
Rate for Payer: University Health Alliance Commercial	$3,379.04

PLATE LCP TIB-L 16H 02.118.215

Facility

$6,370.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,974.70
Max. Negotiated Rate	$6,178.90
Rate for Payer: AlohaCare Medicaid	$3,185.00
Rate for Payer: AlohaCare Medicare	$1,974.70
Rate for Payer: Cash Price	$3,822.00
Rate for Payer: Devoted Health Medicare	$2,165.80
Rate for Payer: Hawaii Medical Service Association Medicare	$1,974.70
Rate for Payer: Hawaii Western Management Group Commercial	$4,459.00
Rate for Payer: Health Management Network Commercial	$5,414.50
Rate for Payer: Humana Medicare	$1,974.70
Rate for Payer: Kaiser Permanente Commercial	$5,733.00
Rate for Payer: Kaiser Permanente Medicaid	$3,248.70
Rate for Payer: Kaiser Permanente Medicare	$1,974.70
Rate for Payer: MDX Hawaii PPO	$6,178.90
Rate for Payer: Ohana Health Plan Medicaid	$1,974.70
Rate for Payer: Ohana Health Plan Medicare	$1,974.70
Rate for Payer: UnitedHealthcare Medicare	$1,974.70
Rate for Payer: University Health Alliance Commercial	$3,567.20

PLATE LCP TIB-L 16H 02.118.215

Facility

$6,370.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$3,567.20
Max. Negotiated Rate	$6,178.90
Rate for Payer: Cash Price	$3,822.00
Rate for Payer: Hawaii Western Management Group Commercial	$4,459.00
Rate for Payer: Health Management Network Commercial	$5,414.50
Rate for Payer: Kaiser Permanente Commercial	$5,733.00
Rate for Payer: MDX Hawaii PPO	$6,178.90
Rate for Payer: University Health Alliance Commercial	$3,567.20

PLATE LCP TIB-L 18H 02.118.217

Facility

$6,488.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$3,633.28
Max. Negotiated Rate	$6,293.36
Rate for Payer: Cash Price	$3,892.80
Rate for Payer: Hawaii Western Management Group Commercial	$4,541.60
Rate for Payer: Health Management Network Commercial	$5,514.80
Rate for Payer: Kaiser Permanente Commercial	$5,839.20
Rate for Payer: MDX Hawaii PPO	$6,293.36
Rate for Payer: University Health Alliance Commercial	$3,633.28

PLATE LCP TIB-L 18H 02.118.217

Facility

$6,488.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$2,011.28
Max. Negotiated Rate	$6,293.36
Rate for Payer: AlohaCare Medicaid	$3,244.00
Rate for Payer: AlohaCare Medicare	$2,011.28
Rate for Payer: Cash Price	$3,892.80
Rate for Payer: Devoted Health Medicare	$2,205.92
Rate for Payer: Hawaii Medical Service Association Medicare	$2,011.28
Rate for Payer: Hawaii Western Management Group Commercial	$4,541.60
Rate for Payer: Health Management Network Commercial	$5,514.80
Rate for Payer: Humana Medicare	$2,011.28
Rate for Payer: Kaiser Permanente Commercial	$5,839.20
Rate for Payer: Kaiser Permanente Medicaid	$3,308.88
Rate for Payer: Kaiser Permanente Medicare	$2,011.28
Rate for Payer: MDX Hawaii PPO	$6,293.36
Rate for Payer: Ohana Health Plan Medicaid	$2,011.28
Rate for Payer: Ohana Health Plan Medicare	$2,011.28
Rate for Payer: UnitedHealthcare Medicare	$2,011.28
Rate for Payer: University Health Alliance Commercial	$3,633.28

Know your out-of-pocket cost for care.

All Charges