Kau Hospital

All Charges

Charge

Type

Setting

Price

PLT LCP TIB-L 6H "L"02.118.305

Facility

$2,610.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$809.10
Max. Negotiated Rate	$2,531.70
Rate for Payer: AlohaCare Medicaid	$1,305.00
Rate for Payer: AlohaCare Medicare	$809.10
Rate for Payer: Cash Price	$1,566.00
Rate for Payer: Devoted Health Medicare	$887.40
Rate for Payer: Hawaii Medical Service Association Medicare	$809.10
Rate for Payer: Hawaii Western Management Group Commercial	$1,827.00
Rate for Payer: Health Management Network Commercial	$2,218.50
Rate for Payer: Humana Medicare	$809.10
Rate for Payer: Kaiser Permanente Commercial	$2,349.00
Rate for Payer: Kaiser Permanente Medicaid	$1,331.10
Rate for Payer: Kaiser Permanente Medicare	$809.10
Rate for Payer: MDX Hawaii PPO	$2,531.70
Rate for Payer: Ohana Health Plan Medicaid	$809.10
Rate for Payer: Ohana Health Plan Medicare	$809.10
Rate for Payer: UnitedHealthcare Medicare	$809.10
Rate for Payer: University Health Alliance Commercial	$1,461.60

PLT LCP TIB-L 8H 02.118.107S

Facility

$5,116.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,585.96
Max. Negotiated Rate	$4,962.52
Rate for Payer: AlohaCare Medicaid	$2,558.00
Rate for Payer: AlohaCare Medicare	$1,585.96
Rate for Payer: Cash Price	$3,069.60
Rate for Payer: Devoted Health Medicare	$1,739.44
Rate for Payer: Hawaii Medical Service Association Medicare	$1,585.96
Rate for Payer: Hawaii Western Management Group Commercial	$3,581.20
Rate for Payer: Health Management Network Commercial	$4,348.60
Rate for Payer: Humana Medicare	$1,585.96
Rate for Payer: Kaiser Permanente Commercial	$4,604.40
Rate for Payer: Kaiser Permanente Medicaid	$2,609.16
Rate for Payer: Kaiser Permanente Medicare	$1,585.96
Rate for Payer: MDX Hawaii PPO	$4,962.52
Rate for Payer: Ohana Health Plan Medicaid	$1,585.96
Rate for Payer: Ohana Health Plan Medicare	$1,585.96
Rate for Payer: UnitedHealthcare Medicare	$1,585.96
Rate for Payer: University Health Alliance Commercial	$2,864.96

PLT LCP TIB-L 8H 02.118.107S

Facility

$5,116.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$2,864.96
Max. Negotiated Rate	$4,962.52
Rate for Payer: Cash Price	$3,069.60
Rate for Payer: Hawaii Western Management Group Commercial	$3,581.20
Rate for Payer: Health Management Network Commercial	$4,348.60
Rate for Payer: Kaiser Permanente Commercial	$4,604.40
Rate for Payer: MDX Hawaii PPO	$4,962.52
Rate for Payer: University Health Alliance Commercial	$2,864.96

PLT LCP TIB-R 12H 02.118.110S

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-R 12H 02.118.110S

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-R 16H 02.118.014

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-R 16H 02.118.014

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-R 16H 02.118.114S

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-R 16H 02.118.114S

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-R 4H 02.118.102S

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-R 4H 02.118.102S

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-R 4H "L"02.118.302

Facility

$2,510.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$778.10
Max. Negotiated Rate	$2,434.70
Rate for Payer: AlohaCare Medicaid	$1,255.00
Rate for Payer: AlohaCare Medicare	$778.10
Rate for Payer: Cash Price	$1,506.00
Rate for Payer: Devoted Health Medicare	$853.40
Rate for Payer: Hawaii Medical Service Association Medicare	$778.10
Rate for Payer: Hawaii Western Management Group Commercial	$1,757.00
Rate for Payer: Health Management Network Commercial	$2,133.50
Rate for Payer: Humana Medicare	$778.10
Rate for Payer: Kaiser Permanente Commercial	$2,259.00
Rate for Payer: Kaiser Permanente Medicaid	$1,280.10
Rate for Payer: Kaiser Permanente Medicare	$778.10
Rate for Payer: MDX Hawaii PPO	$2,434.70
Rate for Payer: Ohana Health Plan Medicaid	$778.10
Rate for Payer: Ohana Health Plan Medicare	$778.10
Rate for Payer: UnitedHealthcare Medicare	$778.10
Rate for Payer: University Health Alliance Commercial	$1,405.60

PLT LCP TIB-R 4H "L"02.118.302

Facility

$2,510.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,405.60
Max. Negotiated Rate	$2,434.70
Rate for Payer: Cash Price	$1,506.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,757.00
Rate for Payer: Health Management Network Commercial	$2,133.50
Rate for Payer: Kaiser Permanente Commercial	$2,259.00
Rate for Payer: MDX Hawaii PPO	$2,434.70
Rate for Payer: University Health Alliance Commercial	$1,405.60

PLT LCP TIB-R 6H 02.118.104S

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-R 6H 02.118.104S

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-R 6H "L"02.118.304

Facility

$2,610.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$809.10
Max. Negotiated Rate	$2,531.70
Rate for Payer: AlohaCare Medicaid	$1,305.00
Rate for Payer: AlohaCare Medicare	$809.10
Rate for Payer: Cash Price	$1,566.00
Rate for Payer: Devoted Health Medicare	$887.40
Rate for Payer: Hawaii Medical Service Association Medicare	$809.10
Rate for Payer: Hawaii Western Management Group Commercial	$1,827.00
Rate for Payer: Health Management Network Commercial	$2,218.50
Rate for Payer: Humana Medicare	$809.10
Rate for Payer: Kaiser Permanente Commercial	$2,349.00
Rate for Payer: Kaiser Permanente Medicaid	$1,331.10
Rate for Payer: Kaiser Permanente Medicare	$809.10
Rate for Payer: MDX Hawaii PPO	$2,531.70
Rate for Payer: Ohana Health Plan Medicaid	$809.10
Rate for Payer: Ohana Health Plan Medicare	$809.10
Rate for Payer: UnitedHealthcare Medicare	$809.10
Rate for Payer: University Health Alliance Commercial	$1,461.60

PLT LCP TIB-R 6H "L"02.118.304

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

PLT LCP TIB-R 8H 02.118.106S

Facility

$5,116.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$2,864.96
Max. Negotiated Rate	$4,962.52
Rate for Payer: Cash Price	$3,069.60
Rate for Payer: Hawaii Western Management Group Commercial	$3,581.20
Rate for Payer: Health Management Network Commercial	$4,348.60
Rate for Payer: Kaiser Permanente Commercial	$4,604.40
Rate for Payer: MDX Hawaii PPO	$4,962.52
Rate for Payer: University Health Alliance Commercial	$2,864.96

PLT LCP TIB-R 8H 02.118.106S

Facility

$5,116.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,585.96
Max. Negotiated Rate	$4,962.52
Rate for Payer: AlohaCare Medicaid	$2,558.00
Rate for Payer: AlohaCare Medicare	$1,585.96
Rate for Payer: Cash Price	$3,069.60
Rate for Payer: Devoted Health Medicare	$1,739.44
Rate for Payer: Hawaii Medical Service Association Medicare	$1,585.96
Rate for Payer: Hawaii Western Management Group Commercial	$3,581.20
Rate for Payer: Health Management Network Commercial	$4,348.60
Rate for Payer: Humana Medicare	$1,585.96
Rate for Payer: Kaiser Permanente Commercial	$4,604.40
Rate for Payer: Kaiser Permanente Medicaid	$2,609.16
Rate for Payer: Kaiser Permanente Medicare	$1,585.96
Rate for Payer: MDX Hawaii PPO	$4,962.52
Rate for Payer: Ohana Health Plan Medicaid	$1,585.96
Rate for Payer: Ohana Health Plan Medicare	$1,585.96
Rate for Payer: UnitedHealthcare Medicare	$1,585.96
Rate for Payer: University Health Alliance Commercial	$2,864.96

PLT RECON 6H/70MM 1179-05-06

Facility

$1,384.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$775.04
Max. Negotiated Rate	$1,342.48
Rate for Payer: Cash Price	$830.40
Rate for Payer: Hawaii Western Management Group Commercial	$968.80
Rate for Payer: Health Management Network Commercial	$1,176.40
Rate for Payer: Kaiser Permanente Commercial	$1,245.60
Rate for Payer: MDX Hawaii PPO	$1,342.48
Rate for Payer: University Health Alliance Commercial	$775.04

PLT RECON 6H/70MM 1179-05-06

Facility

$1,384.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$429.04
Max. Negotiated Rate	$1,342.48
Rate for Payer: AlohaCare Medicaid	$692.00
Rate for Payer: AlohaCare Medicare	$429.04
Rate for Payer: Cash Price	$830.40
Rate for Payer: Devoted Health Medicare	$470.56
Rate for Payer: Hawaii Medical Service Association Medicare	$429.04
Rate for Payer: Hawaii Western Management Group Commercial	$968.80
Rate for Payer: Health Management Network Commercial	$1,176.40
Rate for Payer: Humana Medicare	$429.04
Rate for Payer: Kaiser Permanente Commercial	$1,245.60
Rate for Payer: Kaiser Permanente Medicaid	$705.84
Rate for Payer: Kaiser Permanente Medicare	$429.04
Rate for Payer: MDX Hawaii PPO	$1,342.48
Rate for Payer: Ohana Health Plan Medicaid	$429.04
Rate for Payer: Ohana Health Plan Medicare	$429.04
Rate for Payer: UnitedHealthcare Medicare	$429.04
Rate for Payer: University Health Alliance Commercial	$775.04

PLT RECON 7H/82MM 1179-05-07

Facility

$1,384.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$775.04
Max. Negotiated Rate	$1,342.48
Rate for Payer: Cash Price	$830.40
Rate for Payer: Hawaii Western Management Group Commercial	$968.80
Rate for Payer: Health Management Network Commercial	$1,176.40
Rate for Payer: Kaiser Permanente Commercial	$1,245.60
Rate for Payer: MDX Hawaii PPO	$1,342.48
Rate for Payer: University Health Alliance Commercial	$775.04

PLT RECON 7H/82MM 1179-05-07

Facility

$1,384.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$429.04
Max. Negotiated Rate	$1,342.48
Rate for Payer: AlohaCare Medicaid	$692.00
Rate for Payer: AlohaCare Medicare	$429.04
Rate for Payer: Cash Price	$830.40
Rate for Payer: Devoted Health Medicare	$470.56
Rate for Payer: Hawaii Medical Service Association Medicare	$429.04
Rate for Payer: Hawaii Western Management Group Commercial	$968.80
Rate for Payer: Health Management Network Commercial	$1,176.40
Rate for Payer: Humana Medicare	$429.04
Rate for Payer: Kaiser Permanente Commercial	$1,245.60
Rate for Payer: Kaiser Permanente Medicaid	$705.84
Rate for Payer: Kaiser Permanente Medicare	$429.04
Rate for Payer: MDX Hawaii PPO	$1,342.48
Rate for Payer: Ohana Health Plan Medicaid	$429.04
Rate for Payer: Ohana Health Plan Medicare	$429.04
Rate for Payer: UnitedHealthcare Medicare	$429.04
Rate for Payer: University Health Alliance Commercial	$775.04

PLT TU 1/3 10H/121M 4935-10-03

Facility

$288.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$89.28
Max. Negotiated Rate	$279.36
Rate for Payer: AlohaCare Medicaid	$144.00
Rate for Payer: AlohaCare Medicare	$89.28
Rate for Payer: Cash Price	$172.80
Rate for Payer: Devoted Health Medicare	$97.92
Rate for Payer: Hawaii Medical Service Association Medicare	$89.28
Rate for Payer: Hawaii Western Management Group Commercial	$201.60
Rate for Payer: Health Management Network Commercial	$244.80
Rate for Payer: Humana Medicare	$89.28
Rate for Payer: Kaiser Permanente Commercial	$259.20
Rate for Payer: Kaiser Permanente Medicaid	$146.88
Rate for Payer: Kaiser Permanente Medicare	$89.28
Rate for Payer: MDX Hawaii PPO	$279.36
Rate for Payer: Ohana Health Plan Medicaid	$89.28
Rate for Payer: Ohana Health Plan Medicare	$89.28
Rate for Payer: UnitedHealthcare Medicare	$89.28
Rate for Payer: University Health Alliance Commercial	$161.28

PLT TU 1/3 10H/121M 4935-10-03

Facility

$288.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$161.28
Max. Negotiated Rate	$279.36
Rate for Payer: Cash Price	$172.80
Rate for Payer: Hawaii Western Management Group Commercial	$201.60
Rate for Payer: Health Management Network Commercial	$244.80
Rate for Payer: Kaiser Permanente Commercial	$259.20
Rate for Payer: MDX Hawaii PPO	$279.36
Rate for Payer: University Health Alliance Commercial	$161.28

Know your out-of-pocket cost for care.

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