Kau Hospital

All Charges

Charge

Type

Setting

Price

PR SPLINT SUPPLIES MISC

Professional

Both

$10.00

Service Code	HCPCS Q4051
Min. Negotiated Rate	$8.50
Max. Negotiated Rate	$8.50
Rate for Payer: Cash Price	$6.00
Rate for Payer: Health Management Network Commercial	$8.50

PR SPLT AGRFT F/S/N/H/F/G/M/DGT 1ST 100 SQCM/</1%

Professional

Both

$1,606.46

Service Code	HCPCS 15120
Min. Negotiated Rate	$476.32
Max. Negotiated Rate	$1,365.49
Rate for Payer: AlohaCare Medicaid	$709.84
Rate for Payer: AlohaCare Medicare	$623.47
Rate for Payer: Cash Price	$963.88
Rate for Payer: Cash Price	$963.88
Rate for Payer: Devoted Health Medicare	$685.82
Rate for Payer: Hawaii Medical Service Association ABD	$709.84
Rate for Payer: Hawaii Medical Service Association Commercial	$1,094.54
Rate for Payer: Hawaii Medical Service Association Medicare	$623.47
Rate for Payer: Hawaii Medical Service Association Non-ABD	$709.84
Rate for Payer: Hawaii Western Management Group Commercial	$476.32
Rate for Payer: Health Management Network Commercial	$1,365.49
Rate for Payer: Kaiser Permanente Commercial	$748.16
Rate for Payer: Kaiser Permanente Medicaid	$748.16
Rate for Payer: Kaiser Permanente Medicare	$748.16
Rate for Payer: Ohana Health Plan Medicaid	$709.84
Rate for Payer: Ohana Health Plan Medicare	$623.47
Rate for Payer: UnitedHealthcare Medicaid	$709.84
Rate for Payer: UnitedHealthcare Medicare	$623.47
Rate for Payer: University Health Alliance Commercial	$809.96

PR SPLT AGRFT F/S/N/H/F/G/M/DGT EA 100 SQCM/EA 1%

Professional

Both

$410.66

Service Code	HCPCS 15121
Min. Negotiated Rate	$118.83
Max. Negotiated Rate	$349.06
Rate for Payer: AlohaCare Medicaid	$132.18
Rate for Payer: AlohaCare Medicare	$118.83
Rate for Payer: Cash Price	$246.40
Rate for Payer: Cash Price	$246.40
Rate for Payer: Devoted Health Medicare	$130.71
Rate for Payer: Hawaii Medical Service Association ABD	$132.18
Rate for Payer: Hawaii Medical Service Association Commercial	$220.56
Rate for Payer: Hawaii Medical Service Association Medicare	$118.83
Rate for Payer: Hawaii Medical Service Association Non-ABD	$132.18
Rate for Payer: Hawaii Western Management Group Commercial	$163.54
Rate for Payer: Health Management Network Commercial	$349.06
Rate for Payer: Kaiser Permanente Commercial	$142.60
Rate for Payer: Kaiser Permanente Medicaid	$142.60
Rate for Payer: Kaiser Permanente Medicare	$142.60
Rate for Payer: Ohana Health Plan Medicaid	$132.18
Rate for Payer: Ohana Health Plan Medicare	$118.83
Rate for Payer: UnitedHealthcare Medicaid	$132.18
Rate for Payer: UnitedHealthcare Medicare	$118.83
Rate for Payer: University Health Alliance Commercial	$157.78

PR SPLT AGRFT T/A/L 1ST 100 SQCM/</1% BDY INFT/CHLD

Professional

Both

$1,696.03

Service Code	HCPCS 15100
Min. Negotiated Rate	$532.74
Max. Negotiated Rate	$1,441.63
Rate for Payer: AlohaCare Medicaid	$735.82
Rate for Payer: AlohaCare Medicare	$671.05
Rate for Payer: Cash Price	$1,017.62
Rate for Payer: Cash Price	$1,017.62
Rate for Payer: Devoted Health Medicare	$738.15
Rate for Payer: Hawaii Medical Service Association ABD	$735.82
Rate for Payer: Hawaii Medical Service Association Commercial	$1,139.64
Rate for Payer: Hawaii Medical Service Association Medicare	$671.05
Rate for Payer: Hawaii Medical Service Association Non-ABD	$735.82
Rate for Payer: Hawaii Western Management Group Commercial	$532.74
Rate for Payer: Health Management Network Commercial	$1,441.63
Rate for Payer: Kaiser Permanente Commercial	$805.26
Rate for Payer: Kaiser Permanente Medicaid	$805.26
Rate for Payer: Kaiser Permanente Medicare	$805.26
Rate for Payer: Ohana Health Plan Medicaid	$735.82
Rate for Payer: Ohana Health Plan Medicare	$671.05
Rate for Payer: UnitedHealthcare Medicaid	$735.82
Rate for Payer: UnitedHealthcare Medicare	$671.05
Rate for Payer: University Health Alliance Commercial	$843.33

PR SPLT AGRFT T/A/L EA ADD 100 SQCM/EA 1% INFT/CHLD

Professional

Both

$374.90

Service Code	HCPCS 15101
Min. Negotiated Rate	$99.54
Max. Negotiated Rate	$318.67
Rate for Payer: AlohaCare Medicaid	$110.25
Rate for Payer: AlohaCare Medicare	$99.54
Rate for Payer: Cash Price	$224.94
Rate for Payer: Cash Price	$224.94
Rate for Payer: Devoted Health Medicare	$109.49
Rate for Payer: Hawaii Medical Service Association ABD	$110.25
Rate for Payer: Hawaii Medical Service Association Commercial	$176.01
Rate for Payer: Hawaii Medical Service Association Medicare	$99.54
Rate for Payer: Hawaii Medical Service Association Non-ABD	$110.25
Rate for Payer: Hawaii Western Management Group Commercial	$119.08
Rate for Payer: Health Management Network Commercial	$318.67
Rate for Payer: Kaiser Permanente Commercial	$119.45
Rate for Payer: Kaiser Permanente Medicaid	$119.45
Rate for Payer: Kaiser Permanente Medicare	$119.45
Rate for Payer: Ohana Health Plan Medicaid	$110.25
Rate for Payer: Ohana Health Plan Medicare	$99.54
Rate for Payer: UnitedHealthcare Medicaid	$110.25
Rate for Payer: UnitedHealthcare Medicare	$99.54
Rate for Payer: University Health Alliance Commercial	$130.25

PR SPMTRY W/VC EXPIRATORY FLO W/WO MXML VOL VNTJ

Professional

Both

$15.00

Service Code	HCPCS 94010 26
Min. Negotiated Rate	$8.53
Max. Negotiated Rate	$33.23
Rate for Payer: AlohaCare Medicaid	$30.13
Rate for Payer: AlohaCare Medicare	$8.53
Rate for Payer: Cash Price	$9.00
Rate for Payer: Cash Price	$9.00
Rate for Payer: Devoted Health Medicare	$9.38
Rate for Payer: Hawaii Medical Service Association Medicare	$8.53
Rate for Payer: Hawaii Western Management Group Commercial	$33.23
Rate for Payer: Health Management Network Commercial	$12.75
Rate for Payer: Kaiser Permanente Commercial	$10.24
Rate for Payer: Kaiser Permanente Medicaid	$10.24
Rate for Payer: Kaiser Permanente Medicare	$10.24
Rate for Payer: Ohana Health Plan Medicaid	$30.13
Rate for Payer: Ohana Health Plan Medicare	$8.53
Rate for Payer: UnitedHealthcare Medicaid	$30.13
Rate for Payer: UnitedHealthcare Medicare	$8.53

PR SPMTRY W/VC EXPIRATORY FLO W/WO MXML VOL VNTJ

Professional

Both

$71.00

Service Code	HCPCS 94010 TC
Min. Negotiated Rate	$24.12
Max. Negotiated Rate	$60.35
Rate for Payer: AlohaCare Medicaid	$30.13
Rate for Payer: AlohaCare Medicare	$24.12
Rate for Payer: Cash Price	$42.60
Rate for Payer: Cash Price	$42.60
Rate for Payer: Devoted Health Medicare	$26.53
Rate for Payer: Hawaii Medical Service Association Medicare	$24.12
Rate for Payer: Hawaii Western Management Group Commercial	$33.23
Rate for Payer: Health Management Network Commercial	$60.35
Rate for Payer: Kaiser Permanente Commercial	$28.94
Rate for Payer: Kaiser Permanente Medicaid	$28.94
Rate for Payer: Kaiser Permanente Medicare	$28.94
Rate for Payer: Ohana Health Plan Medicaid	$30.13
Rate for Payer: Ohana Health Plan Medicare	$24.12
Rate for Payer: UnitedHealthcare Medicaid	$30.13
Rate for Payer: UnitedHealthcare Medicare	$24.12

PR SPMTRY W/VC EXPIRATORY FLO W/WO MXML VOL VNTJ

Professional

Both

$86.00

Service Code	HCPCS 94010
Min. Negotiated Rate	$30.13
Max. Negotiated Rate	$73.10
Rate for Payer: AlohaCare Medicaid	$30.13
Rate for Payer: AlohaCare Medicare	$32.65
Rate for Payer: Cash Price	$51.60
Rate for Payer: Cash Price	$51.60
Rate for Payer: Devoted Health Medicare	$35.91
Rate for Payer: Hawaii Medical Service Association Medicare	$32.65
Rate for Payer: Hawaii Western Management Group Commercial	$33.23
Rate for Payer: Health Management Network Commercial	$73.10
Rate for Payer: Kaiser Permanente Commercial	$39.18
Rate for Payer: Kaiser Permanente Medicaid	$39.18
Rate for Payer: Kaiser Permanente Medicare	$39.18
Rate for Payer: Ohana Health Plan Medicaid	$30.13
Rate for Payer: Ohana Health Plan Medicare	$32.65
Rate for Payer: UnitedHealthcare Medicaid	$30.13
Rate for Payer: UnitedHealthcare Medicare	$32.65

PR SPORTS CARDIO CONSULT

Professional

Both

$100.00

Service Code	HCPCS 98364
Min. Negotiated Rate	$85.00
Max. Negotiated Rate	$85.00
Rate for Payer: Cash Price	$60.00
Rate for Payer: Health Management Network Commercial	$85.00

PR SPORTS CARDIO CT CALCIUM SCORE

Professional

Both

$99.00

Service Code	HCPCS 98363
Min. Negotiated Rate	$84.15
Max. Negotiated Rate	$84.15
Rate for Payer: Cash Price	$59.40
Rate for Payer: Health Management Network Commercial	$84.15

PR SPORTS CARDIO ECG APPL REC & INT

Professional

Both

$250.00

Service Code	HCPCS 98367
Min. Negotiated Rate	$212.50
Max. Negotiated Rate	$212.50
Rate for Payer: Cash Price	$150.00
Rate for Payer: Health Management Network Commercial	$212.50

PR SPORTS CARDIO ECHO

Professional

Both

$150.00

Service Code	HCPCS 98361
Min. Negotiated Rate	$127.50
Max. Negotiated Rate	$127.50
Rate for Payer: Cash Price	$90.00
Rate for Payer: Health Management Network Commercial	$127.50

PR SPORTS CARDIOLOGY EKG

Professional

Both

$49.00

Service Code	HCPCS 98399
Min. Negotiated Rate	$41.65
Max. Negotiated Rate	$41.65
Rate for Payer: Cash Price	$29.40
Rate for Payer: Health Management Network Commercial	$41.65

PR SPORTS CARDIO TREADMILL STRESS

Professional

Both

$150.00

Service Code	HCPCS 98362
Min. Negotiated Rate	$127.50
Max. Negotiated Rate	$127.50
Rate for Payer: Cash Price	$90.00
Rate for Payer: Health Management Network Commercial	$127.50

PR SPORTS PHYSICAL EST PT

Professional

Both

$75.00

Service Code	HCPCS 98366
Min. Negotiated Rate	$63.75
Max. Negotiated Rate	$63.75
Rate for Payer: Cash Price	$45.00
Rate for Payer: Health Management Network Commercial	$63.75

PR SPORTS PHYSICAL NEW PT

Professional

Both

$125.00

Service Code	HCPCS 98365
Min. Negotiated Rate	$106.25
Max. Negotiated Rate	$106.25
Rate for Payer: Cash Price	$75.00
Rate for Payer: Health Management Network Commercial	$106.25

PR STAB PHLEBT VARICOSE VEINS 1 XTR 10-20 STAB INCS

Professional

Both

$751.73

Service Code	HCPCS 37765
Min. Negotiated Rate	$237.40
Max. Negotiated Rate	$661.57
Rate for Payer: AlohaCare Medicaid	$260.07
Rate for Payer: AlohaCare Medicare	$237.40
Rate for Payer: Cash Price	$451.04
Rate for Payer: Cash Price	$451.04
Rate for Payer: Devoted Health Medicare	$261.14
Rate for Payer: Hawaii Medical Service Association ABD	$260.07
Rate for Payer: Hawaii Medical Service Association Commercial	$661.57
Rate for Payer: Hawaii Medical Service Association Medicare	$237.40
Rate for Payer: Hawaii Medical Service Association Non-ABD	$260.07
Rate for Payer: Hawaii Western Management Group Commercial	$445.38
Rate for Payer: Health Management Network Commercial	$638.97
Rate for Payer: Kaiser Permanente Commercial	$284.88
Rate for Payer: Kaiser Permanente Medicaid	$284.88
Rate for Payer: Kaiser Permanente Medicare	$284.88
Rate for Payer: Ohana Health Plan Medicaid	$260.07
Rate for Payer: Ohana Health Plan Medicare	$237.40
Rate for Payer: UnitedHealthcare Medicaid	$260.07
Rate for Payer: UnitedHealthcare Medicare	$237.40
Rate for Payer: University Health Alliance Commercial	$400.00

PR STANDARDIZED COGNITIVE PERFORMANCE TESTING

Professional

Both

$189.77

Service Code	HCPCS 96125
Min. Negotiated Rate	$107.81
Max. Negotiated Rate	$161.30
Rate for Payer: AlohaCare Medicaid	$107.81
Rate for Payer: AlohaCare Medicare	$108.44
Rate for Payer: Cash Price	$113.86
Rate for Payer: Cash Price	$113.86
Rate for Payer: Devoted Health Medicare	$119.28
Rate for Payer: Hawaii Medical Service Association Medicare	$108.44
Rate for Payer: Hawaii Western Management Group Commercial	$121.99
Rate for Payer: Health Management Network Commercial	$161.30
Rate for Payer: Kaiser Permanente Commercial	$130.13
Rate for Payer: Kaiser Permanente Medicaid	$130.13
Rate for Payer: Kaiser Permanente Medicare	$130.13
Rate for Payer: Ohana Health Plan Medicaid	$107.81
Rate for Payer: Ohana Health Plan Medicare	$108.44
Rate for Payer: UnitedHealthcare Medicaid	$107.81
Rate for Payer: UnitedHealthcare Medicare	$108.44

PR STAPEDECTOMY/STAPEDOTOMY

Professional

Both

$1,643.00

Service Code	HCPCS 69660
Min. Negotiated Rate	$190.84
Max. Negotiated Rate	$1,396.55
Rate for Payer: AlohaCare Medicaid	$972.22
Rate for Payer: AlohaCare Medicare	$845.46
Rate for Payer: Cash Price	$985.80
Rate for Payer: Cash Price	$985.80
Rate for Payer: Devoted Health Medicare	$930.01
Rate for Payer: Hawaii Medical Service Association Medicare	$845.46
Rate for Payer: Hawaii Western Management Group Commercial	$190.84
Rate for Payer: Health Management Network Commercial	$1,396.55
Rate for Payer: Kaiser Permanente Commercial	$1,014.55
Rate for Payer: Kaiser Permanente Medicaid	$1,014.55
Rate for Payer: Kaiser Permanente Medicare	$1,014.55
Rate for Payer: Ohana Health Plan Medicaid	$972.22
Rate for Payer: Ohana Health Plan Medicare	$845.46
Rate for Payer: UnitedHealthcare Medicaid	$972.22
Rate for Payer: UnitedHealthcare Medicare	$845.46

PR STAPEDECTOMY/STAPEDOTOMY W/FOOTPLATE DRILL OUT

Professional

Both

$2,137.00

Service Code	HCPCS 69661
Min. Negotiated Rate	$973.44
Max. Negotiated Rate	$1,816.45
Rate for Payer: AlohaCare Medicaid	$1,264.59
Rate for Payer: AlohaCare Medicare	$1,097.18
Rate for Payer: Cash Price	$1,282.20
Rate for Payer: Cash Price	$1,282.20
Rate for Payer: Devoted Health Medicare	$1,206.90
Rate for Payer: Hawaii Medical Service Association Medicare	$1,097.18
Rate for Payer: Hawaii Western Management Group Commercial	$973.44
Rate for Payer: Health Management Network Commercial	$1,816.45
Rate for Payer: Kaiser Permanente Commercial	$1,316.62
Rate for Payer: Kaiser Permanente Medicaid	$1,316.62
Rate for Payer: Kaiser Permanente Medicare	$1,316.62
Rate for Payer: Ohana Health Plan Medicaid	$1,264.59
Rate for Payer: Ohana Health Plan Medicare	$1,097.18
Rate for Payer: UnitedHealthcare Medicaid	$1,264.59
Rate for Payer: UnitedHealthcare Medicare	$1,097.18

PR STENGER TEST PURE TONE

Professional

Both

$236.00

Service Code	HCPCS 92565
Min. Negotiated Rate	$13.00
Max. Negotiated Rate	$200.60
Rate for Payer: AlohaCare Medicaid	$23.90
Rate for Payer: AlohaCare Medicare	$25.26
Rate for Payer: Cash Price	$141.60
Rate for Payer: Cash Price	$141.60
Rate for Payer: Devoted Health Medicare	$27.79
Rate for Payer: Hawaii Medical Service Association Medicare	$25.26
Rate for Payer: Hawaii Western Management Group Commercial	$13.00
Rate for Payer: Health Management Network Commercial	$200.60
Rate for Payer: Kaiser Permanente Commercial	$30.31
Rate for Payer: Kaiser Permanente Medicaid	$30.31
Rate for Payer: Kaiser Permanente Medicare	$30.31
Rate for Payer: Ohana Health Plan Medicaid	$23.90
Rate for Payer: Ohana Health Plan Medicare	$25.26
Rate for Payer: UnitedHealthcare Medicaid	$23.90
Rate for Payer: UnitedHealthcare Medicare	$25.26

PR STENGER TEST SPEECH

Professional

Both

$2,112.00

Service Code	HCPCS 92577
Min. Negotiated Rate	$18.94
Max. Negotiated Rate	$1,795.20
Rate for Payer: AlohaCare Medicaid	$25.05
Rate for Payer: AlohaCare Medicare	$25.64
Rate for Payer: Cash Price	$1,267.20
Rate for Payer: Cash Price	$1,267.20
Rate for Payer: Devoted Health Medicare	$28.20
Rate for Payer: Hawaii Medical Service Association Medicare	$25.64
Rate for Payer: Hawaii Western Management Group Commercial	$18.94
Rate for Payer: Health Management Network Commercial	$1,795.20
Rate for Payer: Kaiser Permanente Commercial	$30.77
Rate for Payer: Kaiser Permanente Medicaid	$30.77
Rate for Payer: Kaiser Permanente Medicare	$30.77
Rate for Payer: Ohana Health Plan Medicaid	$25.05
Rate for Payer: Ohana Health Plan Medicare	$25.64
Rate for Payer: UnitedHealthcare Medicaid	$25.05
Rate for Payer: UnitedHealthcare Medicare	$25.64

PR STENT PLMT CENTRAL DIAYLSIS SEG PFRMD DIAL CIR

Professional

Both

$2,714.37

Service Code	HCPCS 36908
Min. Negotiated Rate	$174.79
Max. Negotiated Rate	$3,108.56
Rate for Payer: AlohaCare Medicaid	$195.66
Rate for Payer: AlohaCare Medicare	$174.79
Rate for Payer: Cash Price	$1,628.62
Rate for Payer: Cash Price	$1,628.62
Rate for Payer: Devoted Health Medicare	$192.27
Rate for Payer: Hawaii Medical Service Association ABD	$195.66
Rate for Payer: Hawaii Medical Service Association Commercial	$312.15
Rate for Payer: Hawaii Medical Service Association Medicare	$174.79
Rate for Payer: Hawaii Medical Service Association Non-ABD	$195.66
Rate for Payer: Hawaii Western Management Group Commercial	$3,108.56
Rate for Payer: Health Management Network Commercial	$2,307.21
Rate for Payer: Kaiser Permanente Commercial	$209.75
Rate for Payer: Kaiser Permanente Medicaid	$209.75
Rate for Payer: Kaiser Permanente Medicare	$209.75
Rate for Payer: Ohana Health Plan Medicaid	$195.66
Rate for Payer: Ohana Health Plan Medicare	$174.79
Rate for Payer: UnitedHealthcare Medicaid	$195.66
Rate for Payer: UnitedHealthcare Medicare	$174.79
Rate for Payer: University Health Alliance Commercial	$274.29

PR STERILE WATER/SALINE, 10 ML

Professional

Both

$2.00

Service Code	HCPCS A4216
Min. Negotiated Rate	$0.60
Max. Negotiated Rate	$1.70
Rate for Payer: AlohaCare Medicaid	$0.60
Rate for Payer: AlohaCare Medicare	$0.97
Rate for Payer: Cash Price	$1.20
Rate for Payer: Cash Price	$1.20
Rate for Payer: Devoted Health Medicare	$1.07
Rate for Payer: Hawaii Medical Service Association Medicare	$0.97
Rate for Payer: Health Management Network Commercial	$1.70
Rate for Payer: Kaiser Permanente Commercial	$1.16
Rate for Payer: Kaiser Permanente Medicaid	$1.16
Rate for Payer: Kaiser Permanente Medicare	$1.16
Rate for Payer: Ohana Health Plan Medicaid	$0.60
Rate for Payer: Ohana Health Plan Medicare	$0.97
Rate for Payer: UnitedHealthcare Medicaid	$0.60
Rate for Payer: UnitedHealthcare Medicare	$0.97

PR STOT/TOT HYSTERECTOMY AFTER CESAREAN DELIVERY

Professional

Both

$779.00

Service Code	HCPCS 59525
Min. Negotiated Rate	$396.75
Max. Negotiated Rate	$662.15
Rate for Payer: AlohaCare Medicaid	$458.70
Rate for Payer: AlohaCare Medicare	$396.75
Rate for Payer: Cash Price	$467.40
Rate for Payer: Cash Price	$467.40
Rate for Payer: Devoted Health Medicare	$436.43
Rate for Payer: Hawaii Medical Service Association Medicare	$396.75
Rate for Payer: Hawaii Western Management Group Commercial	$468.78
Rate for Payer: Health Management Network Commercial	$662.15
Rate for Payer: Kaiser Permanente Commercial	$476.10
Rate for Payer: Kaiser Permanente Medicaid	$476.10
Rate for Payer: Kaiser Permanente Medicare	$476.10
Rate for Payer: Ohana Health Plan Medicaid	$458.70
Rate for Payer: Ohana Health Plan Medicare	$396.75
Rate for Payer: UnitedHealthcare Medicaid	$458.70
Rate for Payer: UnitedHealthcare Medicare	$396.75

Know your out-of-pocket cost for care.

All Charges