Kau Hospital

All Charges

Charge

Type

Setting

Price

PSN ALL POLY PAT PLY 32MM

Facility

$1,575.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$882.00
Max. Negotiated Rate	$1,527.75
Rate for Payer: Cash Price	$945.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,102.50
Rate for Payer: Health Management Network Commercial	$1,338.75
Rate for Payer: Kaiser Permanente Commercial	$1,417.50
Rate for Payer: MDX Hawaii PPO	$1,527.75
Rate for Payer: University Health Alliance Commercial	$882.00

PSN ALL POLY PAT PLY 32MM

Facility

$1,575.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$488.25
Max. Negotiated Rate	$1,527.75
Rate for Payer: AlohaCare Medicaid	$787.50
Rate for Payer: AlohaCare Medicare	$488.25
Rate for Payer: Cash Price	$945.00
Rate for Payer: Devoted Health Medicare	$535.50
Rate for Payer: Hawaii Medical Service Association Medicare	$488.25
Rate for Payer: Hawaii Western Management Group Commercial	$1,102.50
Rate for Payer: Health Management Network Commercial	$1,338.75
Rate for Payer: Humana Medicare	$488.25
Rate for Payer: Kaiser Permanente Commercial	$1,417.50
Rate for Payer: Kaiser Permanente Medicaid	$803.25
Rate for Payer: Kaiser Permanente Medicare	$488.25
Rate for Payer: MDX Hawaii PPO	$1,527.75
Rate for Payer: Ohana Health Plan Medicaid	$488.25
Rate for Payer: Ohana Health Plan Medicare	$488.25
Rate for Payer: UnitedHealthcare Medicare	$488.25
Rate for Payer: University Health Alliance Commercial	$882.00

PSN ALL POLY PAT PLY 38MM

Facility

$1,350.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$756.00
Max. Negotiated Rate	$1,309.50
Rate for Payer: Cash Price	$810.00
Rate for Payer: Hawaii Western Management Group Commercial	$945.00
Rate for Payer: Health Management Network Commercial	$1,147.50
Rate for Payer: Kaiser Permanente Commercial	$1,215.00
Rate for Payer: MDX Hawaii PPO	$1,309.50
Rate for Payer: University Health Alliance Commercial	$756.00

PSN ALL POLY PAT PLY 38MM

Facility

$1,350.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$418.50
Max. Negotiated Rate	$1,309.50
Rate for Payer: AlohaCare Medicaid	$675.00
Rate for Payer: AlohaCare Medicare	$418.50
Rate for Payer: Cash Price	$810.00
Rate for Payer: Devoted Health Medicare	$459.00
Rate for Payer: Hawaii Medical Service Association Medicare	$418.50
Rate for Payer: Hawaii Western Management Group Commercial	$945.00
Rate for Payer: Health Management Network Commercial	$1,147.50
Rate for Payer: Humana Medicare	$418.50
Rate for Payer: Kaiser Permanente Commercial	$1,215.00
Rate for Payer: Kaiser Permanente Medicaid	$688.50
Rate for Payer: Kaiser Permanente Medicare	$418.50
Rate for Payer: MDX Hawaii PPO	$1,309.50
Rate for Payer: Ohana Health Plan Medicaid	$418.50
Rate for Payer: Ohana Health Plan Medicare	$418.50
Rate for Payer: UnitedHealthcare Medicare	$418.50
Rate for Payer: University Health Alliance Commercial	$756.00

PSN ALL POLY PAT VE 26MM DIA

Facility

$3,288.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$1,019.28
Max. Negotiated Rate	$3,189.36
Rate for Payer: AlohaCare Medicaid	$1,644.00
Rate for Payer: AlohaCare Medicare	$1,019.28
Rate for Payer: Cash Price	$1,972.80
Rate for Payer: Devoted Health Medicare	$1,117.92
Rate for Payer: Hawaii Medical Service Association Medicare	$1,019.28
Rate for Payer: Hawaii Western Management Group Commercial	$2,301.60
Rate for Payer: Health Management Network Commercial	$2,794.80
Rate for Payer: Humana Medicare	$1,019.28
Rate for Payer: Kaiser Permanente Commercial	$2,959.20
Rate for Payer: Kaiser Permanente Medicaid	$1,676.88
Rate for Payer: Kaiser Permanente Medicare	$1,019.28
Rate for Payer: MDX Hawaii PPO	$3,189.36
Rate for Payer: Ohana Health Plan Medicaid	$1,019.28
Rate for Payer: Ohana Health Plan Medicare	$1,019.28
Rate for Payer: UnitedHealthcare Medicare	$1,019.28
Rate for Payer: University Health Alliance Commercial	$1,841.28

PSN ALL POLY PAT VE 26MM DIA

Facility

$3,288.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$1,841.28
Max. Negotiated Rate	$3,189.36
Rate for Payer: Cash Price	$1,972.80
Rate for Payer: Hawaii Western Management Group Commercial	$2,301.60
Rate for Payer: Health Management Network Commercial	$2,794.80
Rate for Payer: Kaiser Permanente Commercial	$2,959.20
Rate for Payer: MDX Hawaii PPO	$3,189.36
Rate for Payer: University Health Alliance Commercial	$1,841.28

PSN ALL POLY PAT VE 29MM DIA

Facility

$3,288.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$1,841.28
Max. Negotiated Rate	$3,189.36
Rate for Payer: Cash Price	$1,972.80
Rate for Payer: Hawaii Western Management Group Commercial	$2,301.60
Rate for Payer: Health Management Network Commercial	$2,794.80
Rate for Payer: Kaiser Permanente Commercial	$2,959.20
Rate for Payer: MDX Hawaii PPO	$3,189.36
Rate for Payer: University Health Alliance Commercial	$1,841.28

PSN ALL POLY PAT VE 29MM DIA

Facility

$3,288.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$1,019.28
Max. Negotiated Rate	$3,189.36
Rate for Payer: AlohaCare Medicaid	$1,644.00
Rate for Payer: AlohaCare Medicare	$1,019.28
Rate for Payer: Cash Price	$1,972.80
Rate for Payer: Devoted Health Medicare	$1,117.92
Rate for Payer: Hawaii Medical Service Association Medicare	$1,019.28
Rate for Payer: Hawaii Western Management Group Commercial	$2,301.60
Rate for Payer: Health Management Network Commercial	$2,794.80
Rate for Payer: Humana Medicare	$1,019.28
Rate for Payer: Kaiser Permanente Commercial	$2,959.20
Rate for Payer: Kaiser Permanente Medicaid	$1,676.88
Rate for Payer: Kaiser Permanente Medicare	$1,019.28
Rate for Payer: MDX Hawaii PPO	$3,189.36
Rate for Payer: Ohana Health Plan Medicaid	$1,019.28
Rate for Payer: Ohana Health Plan Medicare	$1,019.28
Rate for Payer: UnitedHealthcare Medicare	$1,019.28
Rate for Payer: University Health Alliance Commercial	$1,841.28

PSN ALL POLY PAT VE 32MM DIA

Facility

$3,288.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$1,841.28
Max. Negotiated Rate	$3,189.36
Rate for Payer: Cash Price	$1,972.80
Rate for Payer: Hawaii Western Management Group Commercial	$2,301.60
Rate for Payer: Health Management Network Commercial	$2,794.80
Rate for Payer: Kaiser Permanente Commercial	$2,959.20
Rate for Payer: MDX Hawaii PPO	$3,189.36
Rate for Payer: University Health Alliance Commercial	$1,841.28

PSN ALL POLY PAT VE 32MM DIA

Facility

$3,288.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$1,019.28
Max. Negotiated Rate	$3,189.36
Rate for Payer: AlohaCare Medicaid	$1,644.00
Rate for Payer: AlohaCare Medicare	$1,019.28
Rate for Payer: Cash Price	$1,972.80
Rate for Payer: Devoted Health Medicare	$1,117.92
Rate for Payer: Hawaii Medical Service Association Medicare	$1,019.28
Rate for Payer: Hawaii Western Management Group Commercial	$2,301.60
Rate for Payer: Health Management Network Commercial	$2,794.80
Rate for Payer: Humana Medicare	$1,019.28
Rate for Payer: Kaiser Permanente Commercial	$2,959.20
Rate for Payer: Kaiser Permanente Medicaid	$1,676.88
Rate for Payer: Kaiser Permanente Medicare	$1,019.28
Rate for Payer: MDX Hawaii PPO	$3,189.36
Rate for Payer: Ohana Health Plan Medicaid	$1,019.28
Rate for Payer: Ohana Health Plan Medicare	$1,019.28
Rate for Payer: UnitedHealthcare Medicare	$1,019.28
Rate for Payer: University Health Alliance Commercial	$1,841.28

PSN ALL POLY PAT VE 35MM DIA

Facility

$3,288.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$1,019.28
Max. Negotiated Rate	$3,189.36
Rate for Payer: AlohaCare Medicaid	$1,644.00
Rate for Payer: AlohaCare Medicare	$1,019.28
Rate for Payer: Cash Price	$1,972.80
Rate for Payer: Devoted Health Medicare	$1,117.92
Rate for Payer: Hawaii Medical Service Association Medicare	$1,019.28
Rate for Payer: Hawaii Western Management Group Commercial	$2,301.60
Rate for Payer: Health Management Network Commercial	$2,794.80
Rate for Payer: Humana Medicare	$1,019.28
Rate for Payer: Kaiser Permanente Commercial	$2,959.20
Rate for Payer: Kaiser Permanente Medicaid	$1,676.88
Rate for Payer: Kaiser Permanente Medicare	$1,019.28
Rate for Payer: MDX Hawaii PPO	$3,189.36
Rate for Payer: Ohana Health Plan Medicaid	$1,019.28
Rate for Payer: Ohana Health Plan Medicare	$1,019.28
Rate for Payer: UnitedHealthcare Medicare	$1,019.28
Rate for Payer: University Health Alliance Commercial	$1,841.28

PSN ALL POLY PAT VE 35MM DIA

Facility

$3,288.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$1,841.28
Max. Negotiated Rate	$3,189.36
Rate for Payer: Cash Price	$1,972.80
Rate for Payer: Hawaii Western Management Group Commercial	$2,301.60
Rate for Payer: Health Management Network Commercial	$2,794.80
Rate for Payer: Kaiser Permanente Commercial	$2,959.20
Rate for Payer: MDX Hawaii PPO	$3,189.36
Rate for Payer: University Health Alliance Commercial	$1,841.28

PSN ALL POLY PAT VE 38MM DIA

Facility

$3,288.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$1,019.28
Max. Negotiated Rate	$3,189.36
Rate for Payer: AlohaCare Medicaid	$1,644.00
Rate for Payer: AlohaCare Medicare	$1,019.28
Rate for Payer: Cash Price	$1,972.80
Rate for Payer: Devoted Health Medicare	$1,117.92
Rate for Payer: Hawaii Medical Service Association Medicare	$1,019.28
Rate for Payer: Hawaii Western Management Group Commercial	$2,301.60
Rate for Payer: Health Management Network Commercial	$2,794.80
Rate for Payer: Humana Medicare	$1,019.28
Rate for Payer: Kaiser Permanente Commercial	$2,959.20
Rate for Payer: Kaiser Permanente Medicaid	$1,676.88
Rate for Payer: Kaiser Permanente Medicare	$1,019.28
Rate for Payer: MDX Hawaii PPO	$3,189.36
Rate for Payer: Ohana Health Plan Medicaid	$1,019.28
Rate for Payer: Ohana Health Plan Medicare	$1,019.28
Rate for Payer: UnitedHealthcare Medicare	$1,019.28
Rate for Payer: University Health Alliance Commercial	$1,841.28

PSN ALL POLY PAT VE 38MM DIA

Facility

$3,288.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$1,841.28
Max. Negotiated Rate	$3,189.36
Rate for Payer: Cash Price	$1,972.80
Rate for Payer: Hawaii Western Management Group Commercial	$2,301.60
Rate for Payer: Health Management Network Commercial	$2,794.80
Rate for Payer: Kaiser Permanente Commercial	$2,959.20
Rate for Payer: MDX Hawaii PPO	$3,189.36
Rate for Payer: University Health Alliance Commercial	$1,841.28

PSN ALL POLY PAT VE 41MM DIA

Facility

$3,288.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$1,841.28
Max. Negotiated Rate	$3,189.36
Rate for Payer: Cash Price	$1,972.80
Rate for Payer: Hawaii Western Management Group Commercial	$2,301.60
Rate for Payer: Health Management Network Commercial	$2,794.80
Rate for Payer: Kaiser Permanente Commercial	$2,959.20
Rate for Payer: MDX Hawaii PPO	$3,189.36
Rate for Payer: University Health Alliance Commercial	$1,841.28

PSN ALL POLY PAT VE 41MM DIA

Facility

$3,288.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$1,019.28
Max. Negotiated Rate	$3,189.36
Rate for Payer: AlohaCare Medicaid	$1,644.00
Rate for Payer: AlohaCare Medicare	$1,019.28
Rate for Payer: Cash Price	$1,972.80
Rate for Payer: Devoted Health Medicare	$1,117.92
Rate for Payer: Hawaii Medical Service Association Medicare	$1,019.28
Rate for Payer: Hawaii Western Management Group Commercial	$2,301.60
Rate for Payer: Health Management Network Commercial	$2,794.80
Rate for Payer: Humana Medicare	$1,019.28
Rate for Payer: Kaiser Permanente Commercial	$2,959.20
Rate for Payer: Kaiser Permanente Medicaid	$1,676.88
Rate for Payer: Kaiser Permanente Medicare	$1,019.28
Rate for Payer: MDX Hawaii PPO	$3,189.36
Rate for Payer: Ohana Health Plan Medicaid	$1,019.28
Rate for Payer: Ohana Health Plan Medicare	$1,019.28
Rate for Payer: UnitedHealthcare Medicare	$1,019.28
Rate for Payer: University Health Alliance Commercial	$1,841.28

PSN ASF 4-11 RT 42-5212-005-13

Facility

$2,000.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$620.00
Max. Negotiated Rate	$1,940.00
Rate for Payer: AlohaCare Medicaid	$1,000.00
Rate for Payer: AlohaCare Medicare	$620.00
Rate for Payer: Cash Price	$1,200.00
Rate for Payer: Devoted Health Medicare	$680.00
Rate for Payer: Hawaii Medical Service Association Medicare	$620.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,400.00
Rate for Payer: Health Management Network Commercial	$1,700.00
Rate for Payer: Humana Medicare	$620.00
Rate for Payer: Kaiser Permanente Commercial	$1,800.00
Rate for Payer: Kaiser Permanente Medicaid	$1,020.00
Rate for Payer: Kaiser Permanente Medicare	$620.00
Rate for Payer: MDX Hawaii PPO	$1,940.00
Rate for Payer: Ohana Health Plan Medicaid	$620.00
Rate for Payer: Ohana Health Plan Medicare	$620.00
Rate for Payer: UnitedHealthcare Medicare	$620.00
Rate for Payer: University Health Alliance Commercial	$1,120.00

PSN ASF 4-11 RT 42-5212-005-13

Facility

$2,000.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$1,120.00
Max. Negotiated Rate	$1,940.00
Rate for Payer: Cash Price	$1,200.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,400.00
Rate for Payer: Health Management Network Commercial	$1,700.00
Rate for Payer: Kaiser Permanente Commercial	$1,800.00
Rate for Payer: MDX Hawaii PPO	$1,940.00
Rate for Payer: University Health Alliance Commercial	$1,120.00

PSN ASF CR 10MM PLY L 3-11EF

Facility

$2,000.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$1,120.00
Max. Negotiated Rate	$1,940.00
Rate for Payer: Cash Price	$1,200.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,400.00
Rate for Payer: Health Management Network Commercial	$1,700.00
Rate for Payer: Kaiser Permanente Commercial	$1,800.00
Rate for Payer: MDX Hawaii PPO	$1,940.00
Rate for Payer: University Health Alliance Commercial	$1,120.00

PSN ASF CR 10MM PLY L 3-11EF

Facility

$2,000.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$620.00
Max. Negotiated Rate	$1,940.00
Rate for Payer: AlohaCare Medicaid	$1,000.00
Rate for Payer: AlohaCare Medicare	$620.00
Rate for Payer: Cash Price	$1,200.00
Rate for Payer: Devoted Health Medicare	$680.00
Rate for Payer: Hawaii Medical Service Association Medicare	$620.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,400.00
Rate for Payer: Health Management Network Commercial	$1,700.00
Rate for Payer: Humana Medicare	$620.00
Rate for Payer: Kaiser Permanente Commercial	$1,800.00
Rate for Payer: Kaiser Permanente Medicaid	$1,020.00
Rate for Payer: Kaiser Permanente Medicare	$620.00
Rate for Payer: MDX Hawaii PPO	$1,940.00
Rate for Payer: Ohana Health Plan Medicaid	$620.00
Rate for Payer: Ohana Health Plan Medicare	$620.00
Rate for Payer: UnitedHealthcare Medicare	$620.00
Rate for Payer: University Health Alliance Commercial	$1,120.00

PSN ASF CR 10MM PLY L 3-9CD

Facility

$2,000.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$620.00
Max. Negotiated Rate	$1,940.00
Rate for Payer: AlohaCare Medicaid	$1,000.00
Rate for Payer: AlohaCare Medicare	$620.00
Rate for Payer: Cash Price	$1,200.00
Rate for Payer: Devoted Health Medicare	$680.00
Rate for Payer: Hawaii Medical Service Association Medicare	$620.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,400.00
Rate for Payer: Health Management Network Commercial	$1,700.00
Rate for Payer: Humana Medicare	$620.00
Rate for Payer: Kaiser Permanente Commercial	$1,800.00
Rate for Payer: Kaiser Permanente Medicaid	$1,020.00
Rate for Payer: Kaiser Permanente Medicare	$620.00
Rate for Payer: MDX Hawaii PPO	$1,940.00
Rate for Payer: Ohana Health Plan Medicaid	$620.00
Rate for Payer: Ohana Health Plan Medicare	$620.00
Rate for Payer: UnitedHealthcare Medicare	$620.00
Rate for Payer: University Health Alliance Commercial	$1,120.00

PSN ASF CR 10MM PLY L 3-9CD

Facility

$2,000.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$1,120.00
Max. Negotiated Rate	$1,940.00
Rate for Payer: Cash Price	$1,200.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,400.00
Rate for Payer: Health Management Network Commercial	$1,700.00
Rate for Payer: Kaiser Permanente Commercial	$1,800.00
Rate for Payer: MDX Hawaii PPO	$1,940.00
Rate for Payer: University Health Alliance Commercial	$1,120.00

PSN ASF CR 10MM PLY L 7-12GH

Facility

$2,000.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$1,120.00
Max. Negotiated Rate	$1,940.00
Rate for Payer: Cash Price	$1,200.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,400.00
Rate for Payer: Health Management Network Commercial	$1,700.00
Rate for Payer: Kaiser Permanente Commercial	$1,800.00
Rate for Payer: MDX Hawaii PPO	$1,940.00
Rate for Payer: University Health Alliance Commercial	$1,120.00

PSN ASF CR 10MM PLY L 7-12GH

Facility

$2,000.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$620.00
Max. Negotiated Rate	$1,940.00
Rate for Payer: AlohaCare Medicaid	$1,000.00
Rate for Payer: AlohaCare Medicare	$620.00
Rate for Payer: Cash Price	$1,200.00
Rate for Payer: Devoted Health Medicare	$680.00
Rate for Payer: Hawaii Medical Service Association Medicare	$620.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,400.00
Rate for Payer: Health Management Network Commercial	$1,700.00
Rate for Payer: Humana Medicare	$620.00
Rate for Payer: Kaiser Permanente Commercial	$1,800.00
Rate for Payer: Kaiser Permanente Medicaid	$1,020.00
Rate for Payer: Kaiser Permanente Medicare	$620.00
Rate for Payer: MDX Hawaii PPO	$1,940.00
Rate for Payer: Ohana Health Plan Medicaid	$620.00
Rate for Payer: Ohana Health Plan Medicare	$620.00
Rate for Payer: UnitedHealthcare Medicare	$620.00
Rate for Payer: University Health Alliance Commercial	$1,120.00

PSN ASF CR 10MM PLY L 9-12J

Facility

$2,000.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$620.00
Max. Negotiated Rate	$1,940.00
Rate for Payer: AlohaCare Medicaid	$1,000.00
Rate for Payer: AlohaCare Medicare	$620.00
Rate for Payer: Cash Price	$1,200.00
Rate for Payer: Devoted Health Medicare	$680.00
Rate for Payer: Hawaii Medical Service Association Medicare	$620.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,400.00
Rate for Payer: Health Management Network Commercial	$1,700.00
Rate for Payer: Humana Medicare	$620.00
Rate for Payer: Kaiser Permanente Commercial	$1,800.00
Rate for Payer: Kaiser Permanente Medicaid	$1,020.00
Rate for Payer: Kaiser Permanente Medicare	$620.00
Rate for Payer: MDX Hawaii PPO	$1,940.00
Rate for Payer: Ohana Health Plan Medicaid	$620.00
Rate for Payer: Ohana Health Plan Medicare	$620.00
Rate for Payer: UnitedHealthcare Medicare	$620.00
Rate for Payer: University Health Alliance Commercial	$1,120.00

Know your out-of-pocket cost for care.

All Charges