Kau Hospital

All Charges

Charge

Type

Setting

Price

PLT COMP 2H 3.5X25MM 4935-02

Facility

$394.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$220.64
Max. Negotiated Rate	$382.18
Rate for Payer: Cash Price	$236.40
Rate for Payer: Hawaii Western Management Group Commercial	$275.80
Rate for Payer: Health Management Network Commercial	$334.90
Rate for Payer: Kaiser Permanente Commercial	$354.60
Rate for Payer: MDX Hawaii PPO	$382.18
Rate for Payer: University Health Alliance Commercial	$220.64

PLT COMP 3H 3.5X37MM 4935-03

Facility

$420.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$130.20
Max. Negotiated Rate	$407.40
Rate for Payer: AlohaCare Medicaid	$210.00
Rate for Payer: AlohaCare Medicare	$130.20
Rate for Payer: Cash Price	$252.00
Rate for Payer: Devoted Health Medicare	$142.80
Rate for Payer: Hawaii Medical Service Association Medicare	$130.20
Rate for Payer: Hawaii Western Management Group Commercial	$294.00
Rate for Payer: Health Management Network Commercial	$357.00
Rate for Payer: Humana Medicare	$130.20
Rate for Payer: Kaiser Permanente Commercial	$378.00
Rate for Payer: Kaiser Permanente Medicaid	$214.20
Rate for Payer: Kaiser Permanente Medicare	$130.20
Rate for Payer: MDX Hawaii PPO	$407.40
Rate for Payer: Ohana Health Plan Medicaid	$130.20
Rate for Payer: Ohana Health Plan Medicare	$130.20
Rate for Payer: UnitedHealthcare Medicare	$130.20
Rate for Payer: University Health Alliance Commercial	$235.20

PLT COMP 3H 3.5X37MM 4935-03

Facility

$420.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$235.20
Max. Negotiated Rate	$407.40
Rate for Payer: Cash Price	$252.00
Rate for Payer: Hawaii Western Management Group Commercial	$294.00
Rate for Payer: Health Management Network Commercial	$357.00
Rate for Payer: Kaiser Permanente Commercial	$378.00
Rate for Payer: MDX Hawaii PPO	$407.40
Rate for Payer: University Health Alliance Commercial	$235.20

PLT COMP 4H 3.5X49MM 4935-04

Facility

$446.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$249.76
Max. Negotiated Rate	$432.62
Rate for Payer: Cash Price	$267.60
Rate for Payer: Hawaii Western Management Group Commercial	$312.20
Rate for Payer: Health Management Network Commercial	$379.10
Rate for Payer: Kaiser Permanente Commercial	$401.40
Rate for Payer: MDX Hawaii PPO	$432.62
Rate for Payer: University Health Alliance Commercial	$249.76

PLT COMP 4H 3.5X49MM 4935-04

Facility

$446.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$138.26
Max. Negotiated Rate	$432.62
Rate for Payer: AlohaCare Medicaid	$223.00
Rate for Payer: AlohaCare Medicare	$138.26
Rate for Payer: Cash Price	$267.60
Rate for Payer: Devoted Health Medicare	$151.64
Rate for Payer: Hawaii Medical Service Association Medicare	$138.26
Rate for Payer: Hawaii Western Management Group Commercial	$312.20
Rate for Payer: Health Management Network Commercial	$379.10
Rate for Payer: Humana Medicare	$138.26
Rate for Payer: Kaiser Permanente Commercial	$401.40
Rate for Payer: Kaiser Permanente Medicaid	$227.46
Rate for Payer: Kaiser Permanente Medicare	$138.26
Rate for Payer: MDX Hawaii PPO	$432.62
Rate for Payer: Ohana Health Plan Medicaid	$138.26
Rate for Payer: Ohana Health Plan Medicare	$138.26
Rate for Payer: UnitedHealthcare Medicare	$138.26
Rate for Payer: University Health Alliance Commercial	$249.76

PLT COMP 5H 3.5X61MM 4935-05

Facility

$750.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$232.50
Max. Negotiated Rate	$727.50
Rate for Payer: AlohaCare Medicaid	$375.00
Rate for Payer: AlohaCare Medicare	$232.50
Rate for Payer: Cash Price	$450.00
Rate for Payer: Devoted Health Medicare	$255.00
Rate for Payer: Hawaii Medical Service Association Medicare	$232.50
Rate for Payer: Hawaii Western Management Group Commercial	$525.00
Rate for Payer: Health Management Network Commercial	$637.50
Rate for Payer: Humana Medicare	$232.50
Rate for Payer: Kaiser Permanente Commercial	$675.00
Rate for Payer: Kaiser Permanente Medicaid	$382.50
Rate for Payer: Kaiser Permanente Medicare	$232.50
Rate for Payer: MDX Hawaii PPO	$727.50
Rate for Payer: Ohana Health Plan Medicaid	$232.50
Rate for Payer: Ohana Health Plan Medicare	$232.50
Rate for Payer: UnitedHealthcare Medicare	$232.50
Rate for Payer: University Health Alliance Commercial	$420.00

PLT COMP 5H 3.5X61MM 4935-05

Facility

$750.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$420.00
Max. Negotiated Rate	$727.50
Rate for Payer: Cash Price	$450.00
Rate for Payer: Hawaii Western Management Group Commercial	$525.00
Rate for Payer: Health Management Network Commercial	$637.50
Rate for Payer: Kaiser Permanente Commercial	$675.00
Rate for Payer: MDX Hawaii PPO	$727.50
Rate for Payer: University Health Alliance Commercial	$420.00

PLT COMP 8H 3.5X97MM 4935-08

Facility

$531.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$164.61
Max. Negotiated Rate	$515.07
Rate for Payer: AlohaCare Medicaid	$265.50
Rate for Payer: AlohaCare Medicare	$164.61
Rate for Payer: Cash Price	$318.60
Rate for Payer: Devoted Health Medicare	$180.54
Rate for Payer: Hawaii Medical Service Association Medicare	$164.61
Rate for Payer: Hawaii Western Management Group Commercial	$371.70
Rate for Payer: Health Management Network Commercial	$451.35
Rate for Payer: Humana Medicare	$164.61
Rate for Payer: Kaiser Permanente Commercial	$477.90
Rate for Payer: Kaiser Permanente Medicaid	$270.81
Rate for Payer: Kaiser Permanente Medicare	$164.61
Rate for Payer: MDX Hawaii PPO	$515.07
Rate for Payer: Ohana Health Plan Medicaid	$164.61
Rate for Payer: Ohana Health Plan Medicare	$164.61
Rate for Payer: UnitedHealthcare Medicare	$164.61
Rate for Payer: University Health Alliance Commercial	$297.36

PLT COMP 8H 3.5X97MM 4935-08

Facility

$531.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$297.36
Max. Negotiated Rate	$515.07
Rate for Payer: Cash Price	$318.60
Rate for Payer: Hawaii Western Management Group Commercial	$371.70
Rate for Payer: Health Management Network Commercial	$451.35
Rate for Payer: Kaiser Permanente Commercial	$477.90
Rate for Payer: MDX Hawaii PPO	$515.07
Rate for Payer: University Health Alliance Commercial	$297.36

PLT COMP 9H 3.5X109MM 4935-09

Facility

$863.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$483.28
Max. Negotiated Rate	$837.11
Rate for Payer: Cash Price	$517.80
Rate for Payer: Hawaii Western Management Group Commercial	$604.10
Rate for Payer: Health Management Network Commercial	$733.55
Rate for Payer: Kaiser Permanente Commercial	$776.70
Rate for Payer: MDX Hawaii PPO	$837.11
Rate for Payer: University Health Alliance Commercial	$483.28

PLT COMP 9H 3.5X109MM 4935-09

Facility

$863.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$267.53
Max. Negotiated Rate	$837.11
Rate for Payer: AlohaCare Medicaid	$431.50
Rate for Payer: AlohaCare Medicare	$267.53
Rate for Payer: Cash Price	$517.80
Rate for Payer: Devoted Health Medicare	$293.42
Rate for Payer: Hawaii Medical Service Association Medicare	$267.53
Rate for Payer: Hawaii Western Management Group Commercial	$604.10
Rate for Payer: Health Management Network Commercial	$733.55
Rate for Payer: Humana Medicare	$267.53
Rate for Payer: Kaiser Permanente Commercial	$776.70
Rate for Payer: Kaiser Permanente Medicaid	$440.13
Rate for Payer: Kaiser Permanente Medicare	$267.53
Rate for Payer: MDX Hawaii PPO	$837.11
Rate for Payer: Ohana Health Plan Medicaid	$267.53
Rate for Payer: Ohana Health Plan Medicare	$267.53
Rate for Payer: UnitedHealthcare Medicare	$267.53
Rate for Payer: University Health Alliance Commercial	$483.28

PLT LCDCP 14H 4.5X250MM 226.64

Facility

$1,470.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$455.70
Max. Negotiated Rate	$1,425.90
Rate for Payer: AlohaCare Medicaid	$735.00
Rate for Payer: AlohaCare Medicare	$455.70
Rate for Payer: Cash Price	$882.00
Rate for Payer: Devoted Health Medicare	$499.80
Rate for Payer: Hawaii Medical Service Association Medicare	$455.70
Rate for Payer: Hawaii Western Management Group Commercial	$1,029.00
Rate for Payer: Health Management Network Commercial	$1,249.50
Rate for Payer: Humana Medicare	$455.70
Rate for Payer: Kaiser Permanente Commercial	$1,323.00
Rate for Payer: Kaiser Permanente Medicaid	$749.70
Rate for Payer: Kaiser Permanente Medicare	$455.70
Rate for Payer: MDX Hawaii PPO	$1,425.90
Rate for Payer: Ohana Health Plan Medicaid	$455.70
Rate for Payer: Ohana Health Plan Medicare	$455.70
Rate for Payer: UnitedHealthcare Medicare	$455.70
Rate for Payer: University Health Alliance Commercial	$823.20

PLT LCDCP 14H 4.5X250MM 226.64

Facility

$1,470.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$823.20
Max. Negotiated Rate	$1,425.90
Rate for Payer: Cash Price	$882.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,029.00
Rate for Payer: Health Management Network Commercial	$1,249.50
Rate for Payer: Kaiser Permanente Commercial	$1,323.00
Rate for Payer: MDX Hawaii PPO	$1,425.90
Rate for Payer: University Health Alliance Commercial	$823.20

PLT LCP 10H 1/3T 117MM 241.401

Facility

$1,082.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$605.92
Max. Negotiated Rate	$1,049.54
Rate for Payer: Cash Price	$649.20
Rate for Payer: Hawaii Western Management Group Commercial	$757.40
Rate for Payer: Health Management Network Commercial	$919.70
Rate for Payer: Kaiser Permanente Commercial	$973.80
Rate for Payer: MDX Hawaii PPO	$1,049.54
Rate for Payer: University Health Alliance Commercial	$605.92

PLT LCP 10H 1/3T 117MM 241.401

Facility

$1,082.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$335.42
Max. Negotiated Rate	$1,049.54
Rate for Payer: AlohaCare Medicaid	$541.00
Rate for Payer: AlohaCare Medicare	$335.42
Rate for Payer: Cash Price	$649.20
Rate for Payer: Devoted Health Medicare	$367.88
Rate for Payer: Hawaii Medical Service Association Medicare	$335.42
Rate for Payer: Hawaii Western Management Group Commercial	$757.40
Rate for Payer: Health Management Network Commercial	$919.70
Rate for Payer: Humana Medicare	$335.42
Rate for Payer: Kaiser Permanente Commercial	$973.80
Rate for Payer: Kaiser Permanente Medicaid	$551.82
Rate for Payer: Kaiser Permanente Medicare	$335.42
Rate for Payer: MDX Hawaii PPO	$1,049.54
Rate for Payer: Ohana Health Plan Medicaid	$335.42
Rate for Payer: Ohana Health Plan Medicare	$335.42
Rate for Payer: UnitedHealthcare Medicare	$335.42
Rate for Payer: University Health Alliance Commercial	$605.92

PLT LCP 12H 4.5X229MM 226.622

Facility

$2,250.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,260.00
Max. Negotiated Rate	$2,182.50
Rate for Payer: Cash Price	$1,350.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,575.00
Rate for Payer: Health Management Network Commercial	$1,912.50
Rate for Payer: Kaiser Permanente Commercial	$2,025.00
Rate for Payer: MDX Hawaii PPO	$2,182.50
Rate for Payer: University Health Alliance Commercial	$1,260.00

PLT LCP 12H 4.5X229MM 226.622

Facility

$2,250.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$697.50
Max. Negotiated Rate	$2,182.50
Rate for Payer: AlohaCare Medicaid	$1,125.00
Rate for Payer: AlohaCare Medicare	$697.50
Rate for Payer: Cash Price	$1,350.00
Rate for Payer: Devoted Health Medicare	$765.00
Rate for Payer: Hawaii Medical Service Association Medicare	$697.50
Rate for Payer: Hawaii Western Management Group Commercial	$1,575.00
Rate for Payer: Health Management Network Commercial	$1,912.50
Rate for Payer: Humana Medicare	$697.50
Rate for Payer: Kaiser Permanente Commercial	$2,025.00
Rate for Payer: Kaiser Permanente Medicaid	$1,147.50
Rate for Payer: Kaiser Permanente Medicare	$697.50
Rate for Payer: MDX Hawaii PPO	$2,182.50
Rate for Payer: Ohana Health Plan Medicaid	$697.50
Rate for Payer: Ohana Health Plan Medicare	$697.50
Rate for Payer: UnitedHealthcare Medicare	$697.50
Rate for Payer: University Health Alliance Commercial	$1,260.00

PLT LCP 13H 4.5X247MM 226.632

Facility

$2,652.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,485.12
Max. Negotiated Rate	$2,572.44
Rate for Payer: Cash Price	$1,591.20
Rate for Payer: Hawaii Western Management Group Commercial	$1,856.40
Rate for Payer: Health Management Network Commercial	$2,254.20
Rate for Payer: Kaiser Permanente Commercial	$2,386.80
Rate for Payer: MDX Hawaii PPO	$2,572.44
Rate for Payer: University Health Alliance Commercial	$1,485.12

PLT LCP 13H 4.5X247MM 226.632

Facility

$2,652.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$822.12
Max. Negotiated Rate	$2,572.44
Rate for Payer: AlohaCare Medicaid	$1,326.00
Rate for Payer: AlohaCare Medicare	$822.12
Rate for Payer: Cash Price	$1,591.20
Rate for Payer: Devoted Health Medicare	$901.68
Rate for Payer: Hawaii Medical Service Association Medicare	$822.12
Rate for Payer: Hawaii Western Management Group Commercial	$1,856.40
Rate for Payer: Health Management Network Commercial	$2,254.20
Rate for Payer: Humana Medicare	$822.12
Rate for Payer: Kaiser Permanente Commercial	$2,386.80
Rate for Payer: Kaiser Permanente Medicaid	$1,352.52
Rate for Payer: Kaiser Permanente Medicare	$822.12
Rate for Payer: MDX Hawaii PPO	$2,572.44
Rate for Payer: Ohana Health Plan Medicaid	$822.12
Rate for Payer: Ohana Health Plan Medicare	$822.12
Rate for Payer: UnitedHealthcare Medicare	$822.12
Rate for Payer: University Health Alliance Commercial	$1,485.12

PLT LCP 14H 4.5X265MM 226.642

Facility

$2,340.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,310.40
Max. Negotiated Rate	$2,269.80
Rate for Payer: Cash Price	$1,404.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,638.00
Rate for Payer: Health Management Network Commercial	$1,989.00
Rate for Payer: Kaiser Permanente Commercial	$2,106.00
Rate for Payer: MDX Hawaii PPO	$2,269.80
Rate for Payer: University Health Alliance Commercial	$1,310.40

PLT LCP 14H 4.5X265MM 226.642

Facility

$2,340.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$725.40
Max. Negotiated Rate	$2,269.80
Rate for Payer: AlohaCare Medicaid	$1,170.00
Rate for Payer: AlohaCare Medicare	$725.40
Rate for Payer: Cash Price	$1,404.00
Rate for Payer: Devoted Health Medicare	$795.60
Rate for Payer: Hawaii Medical Service Association Medicare	$725.40
Rate for Payer: Hawaii Western Management Group Commercial	$1,638.00
Rate for Payer: Health Management Network Commercial	$1,989.00
Rate for Payer: Humana Medicare	$725.40
Rate for Payer: Kaiser Permanente Commercial	$2,106.00
Rate for Payer: Kaiser Permanente Medicaid	$1,193.40
Rate for Payer: Kaiser Permanente Medicare	$725.40
Rate for Payer: MDX Hawaii PPO	$2,269.80
Rate for Payer: Ohana Health Plan Medicaid	$725.40
Rate for Payer: Ohana Health Plan Medicare	$725.40
Rate for Payer: UnitedHealthcare Medicare	$725.40
Rate for Payer: University Health Alliance Commercial	$1,310.40

PLT LCP 15H 4.5X282MM 226.652

Facility

$2,598.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,454.88
Max. Negotiated Rate	$2,520.06
Rate for Payer: Cash Price	$1,558.80
Rate for Payer: Hawaii Western Management Group Commercial	$1,818.60
Rate for Payer: Health Management Network Commercial	$2,208.30
Rate for Payer: Kaiser Permanente Commercial	$2,338.20
Rate for Payer: MDX Hawaii PPO	$2,520.06
Rate for Payer: University Health Alliance Commercial	$1,454.88

PLT LCP 15H 4.5X282MM 226.652

Facility

$2,598.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$805.38
Max. Negotiated Rate	$2,520.06
Rate for Payer: AlohaCare Medicaid	$1,299.00
Rate for Payer: AlohaCare Medicare	$805.38
Rate for Payer: Cash Price	$1,558.80
Rate for Payer: Devoted Health Medicare	$883.32
Rate for Payer: Hawaii Medical Service Association Medicare	$805.38
Rate for Payer: Hawaii Western Management Group Commercial	$1,818.60
Rate for Payer: Health Management Network Commercial	$2,208.30
Rate for Payer: Humana Medicare	$805.38
Rate for Payer: Kaiser Permanente Commercial	$2,338.20
Rate for Payer: Kaiser Permanente Medicaid	$1,324.98
Rate for Payer: Kaiser Permanente Medicare	$805.38
Rate for Payer: MDX Hawaii PPO	$2,520.06
Rate for Payer: Ohana Health Plan Medicaid	$805.38
Rate for Payer: Ohana Health Plan Medicare	$805.38
Rate for Payer: UnitedHealthcare Medicare	$805.38
Rate for Payer: University Health Alliance Commercial	$1,454.88

PLT LCP 16H 4.5X300MM 226.662

Facility

$2,256.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$699.36
Max. Negotiated Rate	$2,188.32
Rate for Payer: AlohaCare Medicaid	$1,128.00
Rate for Payer: AlohaCare Medicare	$699.36
Rate for Payer: Cash Price	$1,353.60
Rate for Payer: Devoted Health Medicare	$767.04
Rate for Payer: Hawaii Medical Service Association Medicare	$699.36
Rate for Payer: Hawaii Western Management Group Commercial	$1,579.20
Rate for Payer: Health Management Network Commercial	$1,917.60
Rate for Payer: Humana Medicare	$699.36
Rate for Payer: Kaiser Permanente Commercial	$2,030.40
Rate for Payer: Kaiser Permanente Medicaid	$1,150.56
Rate for Payer: Kaiser Permanente Medicare	$699.36
Rate for Payer: MDX Hawaii PPO	$2,188.32
Rate for Payer: Ohana Health Plan Medicaid	$699.36
Rate for Payer: Ohana Health Plan Medicare	$699.36
Rate for Payer: UnitedHealthcare Medicare	$699.36
Rate for Payer: University Health Alliance Commercial	$1,263.36

PLT LCP 16H 4.5X300MM 226.662

Facility

$2,256.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,263.36
Max. Negotiated Rate	$2,188.32
Rate for Payer: Cash Price	$1,353.60
Rate for Payer: Hawaii Western Management Group Commercial	$1,579.20
Rate for Payer: Health Management Network Commercial	$1,917.60
Rate for Payer: Kaiser Permanente Commercial	$2,030.40
Rate for Payer: MDX Hawaii PPO	$2,188.32
Rate for Payer: University Health Alliance Commercial	$1,263.36

Know your out-of-pocket cost for care.

All Charges