Kau Hospital

All Charges

Charge

Type

Setting

Price

PLT LCP 17H 4.5X318MM 226.672

Facility

$2,978.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,667.68
Max. Negotiated Rate	$2,888.66
Rate for Payer: Cash Price	$1,786.80
Rate for Payer: Hawaii Western Management Group Commercial	$2,084.60
Rate for Payer: Health Management Network Commercial	$2,531.30
Rate for Payer: Kaiser Permanente Commercial	$2,680.20
Rate for Payer: MDX Hawaii PPO	$2,888.66
Rate for Payer: University Health Alliance Commercial	$1,667.68

PLT LCP 17H 4.5X318MM 226.672

Facility

$2,978.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$923.18
Max. Negotiated Rate	$2,888.66
Rate for Payer: AlohaCare Medicaid	$1,489.00
Rate for Payer: AlohaCare Medicare	$923.18
Rate for Payer: Cash Price	$1,786.80
Rate for Payer: Devoted Health Medicare	$1,012.52
Rate for Payer: Hawaii Medical Service Association Medicare	$923.18
Rate for Payer: Hawaii Western Management Group Commercial	$2,084.60
Rate for Payer: Health Management Network Commercial	$2,531.30
Rate for Payer: Humana Medicare	$923.18
Rate for Payer: Kaiser Permanente Commercial	$2,680.20
Rate for Payer: Kaiser Permanente Medicaid	$1,518.78
Rate for Payer: Kaiser Permanente Medicare	$923.18
Rate for Payer: MDX Hawaii PPO	$2,888.66
Rate for Payer: Ohana Health Plan Medicaid	$923.18
Rate for Payer: Ohana Health Plan Medicare	$923.18
Rate for Payer: UnitedHealthcare Medicare	$923.18
Rate for Payer: University Health Alliance Commercial	$1,667.68

PLT LCP 18H 4.5X336MM 226.682

Facility

$3,246.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,006.26
Max. Negotiated Rate	$3,148.62
Rate for Payer: AlohaCare Medicaid	$1,623.00
Rate for Payer: AlohaCare Medicare	$1,006.26
Rate for Payer: Cash Price	$1,947.60
Rate for Payer: Devoted Health Medicare	$1,103.64
Rate for Payer: Hawaii Medical Service Association Medicare	$1,006.26
Rate for Payer: Hawaii Western Management Group Commercial	$2,272.20
Rate for Payer: Health Management Network Commercial	$2,759.10
Rate for Payer: Humana Medicare	$1,006.26
Rate for Payer: Kaiser Permanente Commercial	$2,921.40
Rate for Payer: Kaiser Permanente Medicaid	$1,655.46
Rate for Payer: Kaiser Permanente Medicare	$1,006.26
Rate for Payer: MDX Hawaii PPO	$3,148.62
Rate for Payer: Ohana Health Plan Medicaid	$1,006.26
Rate for Payer: Ohana Health Plan Medicare	$1,006.26
Rate for Payer: UnitedHealthcare Medicare	$1,006.26
Rate for Payer: University Health Alliance Commercial	$1,817.76

PLT LCP 18H 4.5X336MM 226.682

Facility

$3,246.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,817.76
Max. Negotiated Rate	$3,148.62
Rate for Payer: Cash Price	$1,947.60
Rate for Payer: Hawaii Western Management Group Commercial	$2,272.20
Rate for Payer: Health Management Network Commercial	$2,759.10
Rate for Payer: Kaiser Permanente Commercial	$2,921.40
Rate for Payer: MDX Hawaii PPO	$3,148.62
Rate for Payer: University Health Alliance Commercial	$1,817.76

PLT LCP-T 6H 4.5X115MM 240.161

Facility

$2,436.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$755.16
Max. Negotiated Rate	$2,362.92
Rate for Payer: AlohaCare Medicaid	$1,218.00
Rate for Payer: AlohaCare Medicare	$755.16
Rate for Payer: Cash Price	$1,461.60
Rate for Payer: Devoted Health Medicare	$828.24
Rate for Payer: Hawaii Medical Service Association Medicare	$755.16
Rate for Payer: Hawaii Western Management Group Commercial	$1,705.20
Rate for Payer: Health Management Network Commercial	$2,070.60
Rate for Payer: Humana Medicare	$755.16
Rate for Payer: Kaiser Permanente Commercial	$2,192.40
Rate for Payer: Kaiser Permanente Medicaid	$1,242.36
Rate for Payer: Kaiser Permanente Medicare	$755.16
Rate for Payer: MDX Hawaii PPO	$2,362.92
Rate for Payer: Ohana Health Plan Medicaid	$755.16
Rate for Payer: Ohana Health Plan Medicare	$755.16
Rate for Payer: UnitedHealthcare Medicare	$755.16
Rate for Payer: University Health Alliance Commercial	$1,364.16

PLT LCP-T 6H 4.5X115MM 240.161

Facility

$2,436.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,364.16
Max. Negotiated Rate	$2,362.92
Rate for Payer: Cash Price	$1,461.60
Rate for Payer: Hawaii Western Management Group Commercial	$1,705.20
Rate for Payer: Health Management Network Commercial	$2,070.60
Rate for Payer: Kaiser Permanente Commercial	$2,192.40
Rate for Payer: MDX Hawaii PPO	$2,362.92
Rate for Payer: University Health Alliance Commercial	$1,364.16

PLT LCP-T 8H 4.5X147MM 240.181

Facility

$2,364.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,323.84
Max. Negotiated Rate	$2,293.08
Rate for Payer: Cash Price	$1,418.40
Rate for Payer: Hawaii Western Management Group Commercial	$1,654.80
Rate for Payer: Health Management Network Commercial	$2,009.40
Rate for Payer: Kaiser Permanente Commercial	$2,127.60
Rate for Payer: MDX Hawaii PPO	$2,293.08
Rate for Payer: University Health Alliance Commercial	$1,323.84

PLT LCP-T 8H 4.5X147MM 240.181

Facility

$2,364.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$732.84
Max. Negotiated Rate	$2,293.08
Rate for Payer: AlohaCare Medicaid	$1,182.00
Rate for Payer: AlohaCare Medicare	$732.84
Rate for Payer: Cash Price	$1,418.40
Rate for Payer: Devoted Health Medicare	$803.76
Rate for Payer: Hawaii Medical Service Association Medicare	$732.84
Rate for Payer: Hawaii Western Management Group Commercial	$1,654.80
Rate for Payer: Health Management Network Commercial	$2,009.40
Rate for Payer: Humana Medicare	$732.84
Rate for Payer: Kaiser Permanente Commercial	$2,127.60
Rate for Payer: Kaiser Permanente Medicaid	$1,205.64
Rate for Payer: Kaiser Permanente Medicare	$732.84
Rate for Payer: MDX Hawaii PPO	$2,293.08
Rate for Payer: Ohana Health Plan Medicaid	$732.84
Rate for Payer: Ohana Health Plan Medicare	$732.84
Rate for Payer: UnitedHealthcare Medicare	$732.84
Rate for Payer: University Health Alliance Commercial	$1,323.84

PLT LCP TIB 4H "T" 02.118.306

Facility

$2,110.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,181.60
Max. Negotiated Rate	$2,046.70
Rate for Payer: Cash Price	$1,266.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,477.00
Rate for Payer: Health Management Network Commercial	$1,793.50
Rate for Payer: Kaiser Permanente Commercial	$1,899.00
Rate for Payer: MDX Hawaii PPO	$2,046.70
Rate for Payer: University Health Alliance Commercial	$1,181.60

PLT LCP TIB 4H "T" 02.118.306

Facility

$2,110.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$654.10
Max. Negotiated Rate	$2,046.70
Rate for Payer: AlohaCare Medicaid	$1,055.00
Rate for Payer: AlohaCare Medicare	$654.10
Rate for Payer: Cash Price	$1,266.00
Rate for Payer: Devoted Health Medicare	$717.40
Rate for Payer: Hawaii Medical Service Association Medicare	$654.10
Rate for Payer: Hawaii Western Management Group Commercial	$1,477.00
Rate for Payer: Health Management Network Commercial	$1,793.50
Rate for Payer: Humana Medicare	$654.10
Rate for Payer: Kaiser Permanente Commercial	$1,899.00
Rate for Payer: Kaiser Permanente Medicaid	$1,076.10
Rate for Payer: Kaiser Permanente Medicare	$654.10
Rate for Payer: MDX Hawaii PPO	$2,046.70
Rate for Payer: Ohana Health Plan Medicaid	$654.10
Rate for Payer: Ohana Health Plan Medicare	$654.10
Rate for Payer: UnitedHealthcare Medicare	$654.10
Rate for Payer: University Health Alliance Commercial	$1,181.60

PLT LCP TIB 6H "T" 02.118.207

Facility

$2,196.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,229.76
Max. Negotiated Rate	$2,130.12
Rate for Payer: Cash Price	$1,317.60
Rate for Payer: Hawaii Western Management Group Commercial	$1,537.20
Rate for Payer: Health Management Network Commercial	$1,866.60
Rate for Payer: Kaiser Permanente Commercial	$1,976.40
Rate for Payer: MDX Hawaii PPO	$2,130.12
Rate for Payer: University Health Alliance Commercial	$1,229.76

PLT LCP TIB 6H "T" 02.118.207

Facility

$2,196.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$680.76
Max. Negotiated Rate	$2,130.12
Rate for Payer: AlohaCare Medicaid	$1,098.00
Rate for Payer: AlohaCare Medicare	$680.76
Rate for Payer: Cash Price	$1,317.60
Rate for Payer: Devoted Health Medicare	$746.64
Rate for Payer: Hawaii Medical Service Association Medicare	$680.76
Rate for Payer: Hawaii Western Management Group Commercial	$1,537.20
Rate for Payer: Health Management Network Commercial	$1,866.60
Rate for Payer: Humana Medicare	$680.76
Rate for Payer: Kaiser Permanente Commercial	$1,976.40
Rate for Payer: Kaiser Permanente Medicaid	$1,119.96
Rate for Payer: Kaiser Permanente Medicare	$680.76
Rate for Payer: MDX Hawaii PPO	$2,130.12
Rate for Payer: Ohana Health Plan Medicaid	$680.76
Rate for Payer: Ohana Health Plan Medicare	$680.76
Rate for Payer: UnitedHealthcare Medicare	$680.76
Rate for Payer: University Health Alliance Commercial	$1,229.76

PLT LCP TIB-L 12H 02.118.111S

Facility

$5,374.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$3,009.44
Max. Negotiated Rate	$5,212.78
Rate for Payer: Cash Price	$3,224.40
Rate for Payer: Hawaii Western Management Group Commercial	$3,761.80
Rate for Payer: Health Management Network Commercial	$4,567.90
Rate for Payer: Kaiser Permanente Commercial	$4,836.60
Rate for Payer: MDX Hawaii PPO	$5,212.78
Rate for Payer: University Health Alliance Commercial	$3,009.44

PLT LCP TIB-L 12H 02.118.111S

Facility

$5,374.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,665.94
Max. Negotiated Rate	$5,212.78
Rate for Payer: AlohaCare Medicaid	$2,687.00
Rate for Payer: AlohaCare Medicare	$1,665.94
Rate for Payer: Cash Price	$3,224.40
Rate for Payer: Devoted Health Medicare	$1,827.16
Rate for Payer: Hawaii Medical Service Association Medicare	$1,665.94
Rate for Payer: Hawaii Western Management Group Commercial	$3,761.80
Rate for Payer: Health Management Network Commercial	$4,567.90
Rate for Payer: Humana Medicare	$1,665.94
Rate for Payer: Kaiser Permanente Commercial	$4,836.60
Rate for Payer: Kaiser Permanente Medicaid	$2,740.74
Rate for Payer: Kaiser Permanente Medicare	$1,665.94
Rate for Payer: MDX Hawaii PPO	$5,212.78
Rate for Payer: Ohana Health Plan Medicaid	$1,665.94
Rate for Payer: Ohana Health Plan Medicare	$1,665.94
Rate for Payer: UnitedHealthcare Medicare	$1,665.94
Rate for Payer: University Health Alliance Commercial	$3,009.44

PLT LCP TIB-L 16H 02.118.015

Facility

$5,972.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,851.32
Max. Negotiated Rate	$5,792.84
Rate for Payer: AlohaCare Medicaid	$2,986.00
Rate for Payer: AlohaCare Medicare	$1,851.32
Rate for Payer: Cash Price	$3,583.20
Rate for Payer: Devoted Health Medicare	$2,030.48
Rate for Payer: Hawaii Medical Service Association Medicare	$1,851.32
Rate for Payer: Hawaii Western Management Group Commercial	$4,180.40
Rate for Payer: Health Management Network Commercial	$5,076.20
Rate for Payer: Humana Medicare	$1,851.32
Rate for Payer: Kaiser Permanente Commercial	$5,374.80
Rate for Payer: Kaiser Permanente Medicaid	$3,045.72
Rate for Payer: Kaiser Permanente Medicare	$1,851.32
Rate for Payer: MDX Hawaii PPO	$5,792.84
Rate for Payer: Ohana Health Plan Medicaid	$1,851.32
Rate for Payer: Ohana Health Plan Medicare	$1,851.32
Rate for Payer: UnitedHealthcare Medicare	$1,851.32
Rate for Payer: University Health Alliance Commercial	$3,344.32

PLT LCP TIB-L 16H 02.118.015

Facility

$5,972.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$3,344.32
Max. Negotiated Rate	$5,792.84
Rate for Payer: Cash Price	$3,583.20
Rate for Payer: Hawaii Western Management Group Commercial	$4,180.40
Rate for Payer: Health Management Network Commercial	$5,076.20
Rate for Payer: Kaiser Permanente Commercial	$5,374.80
Rate for Payer: MDX Hawaii PPO	$5,792.84
Rate for Payer: University Health Alliance Commercial	$3,344.32

PLT LCP TIB-L 16H 02.118.115S

Facility

$6,578.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$2,039.18
Max. Negotiated Rate	$6,380.66
Rate for Payer: AlohaCare Medicaid	$3,289.00
Rate for Payer: AlohaCare Medicare	$2,039.18
Rate for Payer: Cash Price	$3,946.80
Rate for Payer: Devoted Health Medicare	$2,236.52
Rate for Payer: Hawaii Medical Service Association Medicare	$2,039.18
Rate for Payer: Hawaii Western Management Group Commercial	$4,604.60
Rate for Payer: Health Management Network Commercial	$5,591.30
Rate for Payer: Humana Medicare	$2,039.18
Rate for Payer: Kaiser Permanente Commercial	$5,920.20
Rate for Payer: Kaiser Permanente Medicaid	$3,354.78
Rate for Payer: Kaiser Permanente Medicare	$2,039.18
Rate for Payer: MDX Hawaii PPO	$6,380.66
Rate for Payer: Ohana Health Plan Medicaid	$2,039.18
Rate for Payer: Ohana Health Plan Medicare	$2,039.18
Rate for Payer: UnitedHealthcare Medicare	$2,039.18
Rate for Payer: University Health Alliance Commercial	$3,683.68

PLT LCP TIB-L 16H 02.118.115S

Facility

$6,578.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$3,683.68
Max. Negotiated Rate	$6,380.66
Rate for Payer: Cash Price	$3,946.80
Rate for Payer: Hawaii Western Management Group Commercial	$4,604.60
Rate for Payer: Health Management Network Commercial	$5,591.30
Rate for Payer: Kaiser Permanente Commercial	$5,920.20
Rate for Payer: MDX Hawaii PPO	$6,380.66
Rate for Payer: University Health Alliance Commercial	$3,683.68

PLT LCP TIB-L 4H 02.118.103S

Facility

$5,016.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,554.96
Max. Negotiated Rate	$4,865.52
Rate for Payer: AlohaCare Medicaid	$2,508.00
Rate for Payer: AlohaCare Medicare	$1,554.96
Rate for Payer: Cash Price	$3,009.60
Rate for Payer: Devoted Health Medicare	$1,705.44
Rate for Payer: Hawaii Medical Service Association Medicare	$1,554.96
Rate for Payer: Hawaii Western Management Group Commercial	$3,511.20
Rate for Payer: Health Management Network Commercial	$4,263.60
Rate for Payer: Humana Medicare	$1,554.96
Rate for Payer: Kaiser Permanente Commercial	$4,514.40
Rate for Payer: Kaiser Permanente Medicaid	$2,558.16
Rate for Payer: Kaiser Permanente Medicare	$1,554.96
Rate for Payer: MDX Hawaii PPO	$4,865.52
Rate for Payer: Ohana Health Plan Medicaid	$1,554.96
Rate for Payer: Ohana Health Plan Medicare	$1,554.96
Rate for Payer: UnitedHealthcare Medicare	$1,554.96
Rate for Payer: University Health Alliance Commercial	$2,808.96

PLT LCP TIB-L 4H 02.118.103S

Facility

$5,016.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$2,808.96
Max. Negotiated Rate	$4,865.52
Rate for Payer: Cash Price	$3,009.60
Rate for Payer: Hawaii Western Management Group Commercial	$3,511.20
Rate for Payer: Health Management Network Commercial	$4,263.60
Rate for Payer: Kaiser Permanente Commercial	$4,514.40
Rate for Payer: MDX Hawaii PPO	$4,865.52
Rate for Payer: University Health Alliance Commercial	$2,808.96

PLT LCP TIB-L 4H "L"02.118.303

Facility

$2,110.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,181.60
Max. Negotiated Rate	$2,046.70
Rate for Payer: Cash Price	$1,266.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,477.00
Rate for Payer: Health Management Network Commercial	$1,793.50
Rate for Payer: Kaiser Permanente Commercial	$1,899.00
Rate for Payer: MDX Hawaii PPO	$2,046.70
Rate for Payer: University Health Alliance Commercial	$1,181.60

PLT LCP TIB-L 4H "L"02.118.303

Facility

$2,110.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$654.10
Max. Negotiated Rate	$2,046.70
Rate for Payer: AlohaCare Medicaid	$1,055.00
Rate for Payer: AlohaCare Medicare	$654.10
Rate for Payer: Cash Price	$1,266.00
Rate for Payer: Devoted Health Medicare	$717.40
Rate for Payer: Hawaii Medical Service Association Medicare	$654.10
Rate for Payer: Hawaii Western Management Group Commercial	$1,477.00
Rate for Payer: Health Management Network Commercial	$1,793.50
Rate for Payer: Humana Medicare	$654.10
Rate for Payer: Kaiser Permanente Commercial	$1,899.00
Rate for Payer: Kaiser Permanente Medicaid	$1,076.10
Rate for Payer: Kaiser Permanente Medicare	$654.10
Rate for Payer: MDX Hawaii PPO	$2,046.70
Rate for Payer: Ohana Health Plan Medicaid	$654.10
Rate for Payer: Ohana Health Plan Medicare	$654.10
Rate for Payer: UnitedHealthcare Medicare	$654.10
Rate for Payer: University Health Alliance Commercial	$1,181.60

PLT LCP TIB-L 6H 02.118.105S

Facility

$5,066.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,570.46
Max. Negotiated Rate	$4,914.02
Rate for Payer: AlohaCare Medicaid	$2,533.00
Rate for Payer: AlohaCare Medicare	$1,570.46
Rate for Payer: Cash Price	$3,039.60
Rate for Payer: Devoted Health Medicare	$1,722.44
Rate for Payer: Hawaii Medical Service Association Medicare	$1,570.46
Rate for Payer: Hawaii Western Management Group Commercial	$3,546.20
Rate for Payer: Health Management Network Commercial	$4,306.10
Rate for Payer: Humana Medicare	$1,570.46
Rate for Payer: Kaiser Permanente Commercial	$4,559.40
Rate for Payer: Kaiser Permanente Medicaid	$2,583.66
Rate for Payer: Kaiser Permanente Medicare	$1,570.46
Rate for Payer: MDX Hawaii PPO	$4,914.02
Rate for Payer: Ohana Health Plan Medicaid	$1,570.46
Rate for Payer: Ohana Health Plan Medicare	$1,570.46
Rate for Payer: UnitedHealthcare Medicare	$1,570.46
Rate for Payer: University Health Alliance Commercial	$2,836.96

PLT LCP TIB-L 6H 02.118.105S

Facility

$5,066.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$2,836.96
Max. Negotiated Rate	$4,914.02
Rate for Payer: Cash Price	$3,039.60
Rate for Payer: Hawaii Western Management Group Commercial	$3,546.20
Rate for Payer: Health Management Network Commercial	$4,306.10
Rate for Payer: Kaiser Permanente Commercial	$4,559.40
Rate for Payer: MDX Hawaii PPO	$4,914.02
Rate for Payer: University Health Alliance Commercial	$2,836.96

PLT LCP TIB-L 6H "L"02.118.305

Facility

$2,610.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,461.60
Max. Negotiated Rate	$2,531.70
Rate for Payer: Cash Price	$1,566.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,827.00
Rate for Payer: Health Management Network Commercial	$2,218.50
Rate for Payer: Kaiser Permanente Commercial	$2,349.00
Rate for Payer: MDX Hawaii PPO	$2,531.70
Rate for Payer: University Health Alliance Commercial	$1,461.60

Know your out-of-pocket cost for care.

All Charges