Kau Hospital

All Charges

Charge

Type

Setting

Price

SIZER PROJECTION SZ10621-440HP

Facility

$260.00

Service Code	HCPCS C1789
Hospital Revenue Code	278
Min. Negotiated Rate	$80.60
Max. Negotiated Rate	$252.20
Rate for Payer: AlohaCare Medicaid	$130.00
Rate for Payer: AlohaCare Medicare	$80.60
Rate for Payer: Cash Price	$156.00
Rate for Payer: Devoted Health Medicare	$88.40
Rate for Payer: Hawaii Medical Service Association Medicare	$80.60
Rate for Payer: Hawaii Western Management Group Commercial	$182.00
Rate for Payer: Health Management Network Commercial	$221.00
Rate for Payer: Humana Medicare	$80.60
Rate for Payer: Kaiser Permanente Commercial	$234.00
Rate for Payer: Kaiser Permanente Medicaid	$132.60
Rate for Payer: Kaiser Permanente Medicare	$80.60
Rate for Payer: MDX Hawaii PPO	$252.20
Rate for Payer: Ohana Health Plan Medicaid	$80.60
Rate for Payer: Ohana Health Plan Medicare	$80.60
Rate for Payer: UnitedHealthcare Medicare	$80.60
Rate for Payer: University Health Alliance Commercial	$145.60

SIZER PROJECTION SZ10621-455MP

Facility

$260.00

Service Code	HCPCS C1789
Hospital Revenue Code	278
Min. Negotiated Rate	$80.60
Max. Negotiated Rate	$252.20
Rate for Payer: AlohaCare Medicaid	$130.00
Rate for Payer: AlohaCare Medicare	$80.60
Rate for Payer: Cash Price	$156.00
Rate for Payer: Devoted Health Medicare	$88.40
Rate for Payer: Hawaii Medical Service Association Medicare	$80.60
Rate for Payer: Hawaii Western Management Group Commercial	$182.00
Rate for Payer: Health Management Network Commercial	$221.00
Rate for Payer: Humana Medicare	$80.60
Rate for Payer: Kaiser Permanente Commercial	$234.00
Rate for Payer: Kaiser Permanente Medicaid	$132.60
Rate for Payer: Kaiser Permanente Medicare	$80.60
Rate for Payer: MDX Hawaii PPO	$252.20
Rate for Payer: Ohana Health Plan Medicaid	$80.60
Rate for Payer: Ohana Health Plan Medicare	$80.60
Rate for Payer: UnitedHealthcare Medicare	$80.60
Rate for Payer: University Health Alliance Commercial	$145.60

SIZER PROJECTION SZ10621-455MP

Facility

$260.00

Service Code	HCPCS C1789
Hospital Revenue Code	278
Min. Negotiated Rate	$145.60
Max. Negotiated Rate	$252.20
Rate for Payer: Cash Price	$156.00
Rate for Payer: Hawaii Western Management Group Commercial	$182.00
Rate for Payer: Health Management Network Commercial	$221.00
Rate for Payer: Kaiser Permanente Commercial	$234.00
Rate for Payer: MDX Hawaii PPO	$252.20
Rate for Payer: University Health Alliance Commercial	$145.60

SIZER RND 190ML GS10512-190MP

Facility

$844.00

Service Code	HCPCS C1789
Hospital Revenue Code	278
Min. Negotiated Rate	$261.64
Max. Negotiated Rate	$818.68
Rate for Payer: AlohaCare Medicaid	$422.00
Rate for Payer: AlohaCare Medicare	$261.64
Rate for Payer: Cash Price	$506.40
Rate for Payer: Devoted Health Medicare	$286.96
Rate for Payer: Hawaii Medical Service Association Medicare	$261.64
Rate for Payer: Hawaii Western Management Group Commercial	$590.80
Rate for Payer: Health Management Network Commercial	$717.40
Rate for Payer: Humana Medicare	$261.64
Rate for Payer: Kaiser Permanente Commercial	$759.60
Rate for Payer: Kaiser Permanente Medicaid	$430.44
Rate for Payer: Kaiser Permanente Medicare	$261.64
Rate for Payer: MDX Hawaii PPO	$818.68
Rate for Payer: Ohana Health Plan Medicaid	$261.64
Rate for Payer: Ohana Health Plan Medicare	$261.64
Rate for Payer: UnitedHealthcare Medicare	$261.64
Rate for Payer: University Health Alliance Commercial	$472.64

SIZER RND 190ML GS10512-190MP

Facility

$844.00

Service Code	HCPCS C1789
Hospital Revenue Code	278
Min. Negotiated Rate	$472.64
Max. Negotiated Rate	$818.68
Rate for Payer: Cash Price	$506.40
Rate for Payer: Hawaii Western Management Group Commercial	$590.80
Rate for Payer: Health Management Network Commercial	$717.40
Rate for Payer: Kaiser Permanente Commercial	$759.60
Rate for Payer: MDX Hawaii PPO	$818.68
Rate for Payer: University Health Alliance Commercial	$472.64

SIZER RND 255CC SZ10621-255MP

Facility

$175.00

Service Code	HCPCS C1789
Hospital Revenue Code	278
Min. Negotiated Rate	$54.25
Max. Negotiated Rate	$169.75
Rate for Payer: AlohaCare Medicaid	$87.50
Rate for Payer: AlohaCare Medicare	$54.25
Rate for Payer: Cash Price	$105.00
Rate for Payer: Devoted Health Medicare	$59.50
Rate for Payer: Hawaii Medical Service Association Medicare	$54.25
Rate for Payer: Hawaii Western Management Group Commercial	$122.50
Rate for Payer: Health Management Network Commercial	$148.75
Rate for Payer: Humana Medicare	$54.25
Rate for Payer: Kaiser Permanente Commercial	$157.50
Rate for Payer: Kaiser Permanente Medicaid	$89.25
Rate for Payer: Kaiser Permanente Medicare	$54.25
Rate for Payer: MDX Hawaii PPO	$169.75
Rate for Payer: Ohana Health Plan Medicaid	$54.25
Rate for Payer: Ohana Health Plan Medicare	$54.25
Rate for Payer: UnitedHealthcare Medicare	$54.25
Rate for Payer: University Health Alliance Commercial	$98.00

SIZER RND 255CC SZ10621-255MP

Facility

$175.00

Service Code	HCPCS C1789
Hospital Revenue Code	278
Min. Negotiated Rate	$98.00
Max. Negotiated Rate	$169.75
Rate for Payer: Cash Price	$105.00
Rate for Payer: Hawaii Western Management Group Commercial	$122.50
Rate for Payer: Health Management Network Commercial	$148.75
Rate for Payer: Kaiser Permanente Commercial	$157.50
Rate for Payer: MDX Hawaii PPO	$169.75
Rate for Payer: University Health Alliance Commercial	$98.00

SIZER RND 355CC SZ10621-355MP

Facility

$260.00

Service Code	HCPCS C1789
Hospital Revenue Code	278
Min. Negotiated Rate	$80.60
Max. Negotiated Rate	$252.20
Rate for Payer: AlohaCare Medicaid	$130.00
Rate for Payer: AlohaCare Medicare	$80.60
Rate for Payer: Cash Price	$156.00
Rate for Payer: Devoted Health Medicare	$88.40
Rate for Payer: Hawaii Medical Service Association Medicare	$80.60
Rate for Payer: Hawaii Western Management Group Commercial	$182.00
Rate for Payer: Health Management Network Commercial	$221.00
Rate for Payer: Humana Medicare	$80.60
Rate for Payer: Kaiser Permanente Commercial	$234.00
Rate for Payer: Kaiser Permanente Medicaid	$132.60
Rate for Payer: Kaiser Permanente Medicare	$80.60
Rate for Payer: MDX Hawaii PPO	$252.20
Rate for Payer: Ohana Health Plan Medicaid	$80.60
Rate for Payer: Ohana Health Plan Medicare	$80.60
Rate for Payer: UnitedHealthcare Medicare	$80.60
Rate for Payer: University Health Alliance Commercial	$145.60

SIZER RND 355CC SZ10621-355MP

Facility

$260.00

Service Code	HCPCS C1789
Hospital Revenue Code	278
Min. Negotiated Rate	$145.60
Max. Negotiated Rate	$252.20
Rate for Payer: Cash Price	$156.00
Rate for Payer: Hawaii Western Management Group Commercial	$182.00
Rate for Payer: Health Management Network Commercial	$221.00
Rate for Payer: Kaiser Permanente Commercial	$234.00
Rate for Payer: MDX Hawaii PPO	$252.20
Rate for Payer: University Health Alliance Commercial	$145.60

SIZER RND BREAST SZ10621-215MP

Facility

$260.00

Service Code	HCPCS C1789
Hospital Revenue Code	278
Min. Negotiated Rate	$145.60
Max. Negotiated Rate	$252.20
Rate for Payer: Cash Price	$156.00
Rate for Payer: Hawaii Western Management Group Commercial	$182.00
Rate for Payer: Health Management Network Commercial	$221.00
Rate for Payer: Kaiser Permanente Commercial	$234.00
Rate for Payer: MDX Hawaii PPO	$252.20
Rate for Payer: University Health Alliance Commercial	$145.60

SIZER RND BREAST SZ10621-215MP

Facility

$260.00

Service Code	HCPCS C1789
Hospital Revenue Code	278
Min. Negotiated Rate	$80.60
Max. Negotiated Rate	$252.20
Rate for Payer: AlohaCare Medicaid	$130.00
Rate for Payer: AlohaCare Medicare	$80.60
Rate for Payer: Cash Price	$156.00
Rate for Payer: Devoted Health Medicare	$88.40
Rate for Payer: Hawaii Medical Service Association Medicare	$80.60
Rate for Payer: Hawaii Western Management Group Commercial	$182.00
Rate for Payer: Health Management Network Commercial	$221.00
Rate for Payer: Humana Medicare	$80.60
Rate for Payer: Kaiser Permanente Commercial	$234.00
Rate for Payer: Kaiser Permanente Medicaid	$132.60
Rate for Payer: Kaiser Permanente Medicare	$80.60
Rate for Payer: MDX Hawaii PPO	$252.20
Rate for Payer: Ohana Health Plan Medicaid	$80.60
Rate for Payer: Ohana Health Plan Medicare	$80.60
Rate for Payer: UnitedHealthcare Medicare	$80.60
Rate for Payer: University Health Alliance Commercial	$145.60

SIZER RND GS10621-285MP

Facility

$844.00

Service Code	HCPCS C1789
Hospital Revenue Code	278
Min. Negotiated Rate	$261.64
Max. Negotiated Rate	$818.68
Rate for Payer: AlohaCare Medicaid	$422.00
Rate for Payer: AlohaCare Medicare	$261.64
Rate for Payer: Cash Price	$506.40
Rate for Payer: Devoted Health Medicare	$286.96
Rate for Payer: Hawaii Medical Service Association Medicare	$261.64
Rate for Payer: Hawaii Western Management Group Commercial	$590.80
Rate for Payer: Health Management Network Commercial	$717.40
Rate for Payer: Humana Medicare	$261.64
Rate for Payer: Kaiser Permanente Commercial	$759.60
Rate for Payer: Kaiser Permanente Medicaid	$430.44
Rate for Payer: Kaiser Permanente Medicare	$261.64
Rate for Payer: MDX Hawaii PPO	$818.68
Rate for Payer: Ohana Health Plan Medicaid	$261.64
Rate for Payer: Ohana Health Plan Medicare	$261.64
Rate for Payer: UnitedHealthcare Medicare	$261.64
Rate for Payer: University Health Alliance Commercial	$472.64

SIZER RND GS10621-285MP

Facility

$844.00

Service Code	HCPCS C1789
Hospital Revenue Code	278
Min. Negotiated Rate	$472.64
Max. Negotiated Rate	$818.68
Rate for Payer: Cash Price	$506.40
Rate for Payer: Hawaii Western Management Group Commercial	$590.80
Rate for Payer: Health Management Network Commercial	$717.40
Rate for Payer: Kaiser Permanente Commercial	$759.60
Rate for Payer: MDX Hawaii PPO	$818.68
Rate for Payer: University Health Alliance Commercial	$472.64

SIZER RND GS10621-700HP

Facility

$844.00

Service Code	HCPCS C1789
Hospital Revenue Code	278
Min. Negotiated Rate	$261.64
Max. Negotiated Rate	$818.68
Rate for Payer: AlohaCare Medicaid	$422.00
Rate for Payer: AlohaCare Medicare	$261.64
Rate for Payer: Cash Price	$506.40
Rate for Payer: Devoted Health Medicare	$286.96
Rate for Payer: Hawaii Medical Service Association Medicare	$261.64
Rate for Payer: Hawaii Western Management Group Commercial	$590.80
Rate for Payer: Health Management Network Commercial	$717.40
Rate for Payer: Humana Medicare	$261.64
Rate for Payer: Kaiser Permanente Commercial	$759.60
Rate for Payer: Kaiser Permanente Medicaid	$430.44
Rate for Payer: Kaiser Permanente Medicare	$261.64
Rate for Payer: MDX Hawaii PPO	$818.68
Rate for Payer: Ohana Health Plan Medicaid	$261.64
Rate for Payer: Ohana Health Plan Medicare	$261.64
Rate for Payer: UnitedHealthcare Medicare	$261.64
Rate for Payer: University Health Alliance Commercial	$472.64

SIZER RND GS10621-700HP

Facility

$844.00

Service Code	HCPCS C1789
Hospital Revenue Code	278
Min. Negotiated Rate	$472.64
Max. Negotiated Rate	$818.68
Rate for Payer: Cash Price	$506.40
Rate for Payer: Hawaii Western Management Group Commercial	$590.80
Rate for Payer: Health Management Network Commercial	$717.40
Rate for Payer: Kaiser Permanente Commercial	$759.60
Rate for Payer: MDX Hawaii PPO	$818.68
Rate for Payer: University Health Alliance Commercial	$472.64

SIZER RND SILICONE 470CC

Facility

$844.00

Service Code	HCPCS C1789
Hospital Revenue Code	278
Min. Negotiated Rate	$472.64
Max. Negotiated Rate	$818.68
Rate for Payer: Cash Price	$506.40
Rate for Payer: Hawaii Western Management Group Commercial	$590.80
Rate for Payer: Health Management Network Commercial	$717.40
Rate for Payer: Kaiser Permanente Commercial	$759.60
Rate for Payer: MDX Hawaii PPO	$818.68
Rate for Payer: University Health Alliance Commercial	$472.64

SIZER RND SILICONE 470CC

Facility

$844.00

Service Code	HCPCS C1789
Hospital Revenue Code	278
Min. Negotiated Rate	$261.64
Max. Negotiated Rate	$818.68
Rate for Payer: AlohaCare Medicaid	$422.00
Rate for Payer: AlohaCare Medicare	$261.64
Rate for Payer: Cash Price	$506.40
Rate for Payer: Devoted Health Medicare	$286.96
Rate for Payer: Hawaii Medical Service Association Medicare	$261.64
Rate for Payer: Hawaii Western Management Group Commercial	$590.80
Rate for Payer: Health Management Network Commercial	$717.40
Rate for Payer: Humana Medicare	$261.64
Rate for Payer: Kaiser Permanente Commercial	$759.60
Rate for Payer: Kaiser Permanente Medicaid	$430.44
Rate for Payer: Kaiser Permanente Medicare	$261.64
Rate for Payer: MDX Hawaii PPO	$818.68
Rate for Payer: Ohana Health Plan Medicaid	$261.64
Rate for Payer: Ohana Health Plan Medicare	$261.64
Rate for Payer: UnitedHealthcare Medicare	$261.64
Rate for Payer: University Health Alliance Commercial	$472.64

SIZER RND SILICONE 510CC

Facility

$844.00

Service Code	HCPCS C1789
Hospital Revenue Code	278
Min. Negotiated Rate	$472.64
Max. Negotiated Rate	$818.68
Rate for Payer: Cash Price	$506.40
Rate for Payer: Hawaii Western Management Group Commercial	$590.80
Rate for Payer: Health Management Network Commercial	$717.40
Rate for Payer: Kaiser Permanente Commercial	$759.60
Rate for Payer: MDX Hawaii PPO	$818.68
Rate for Payer: University Health Alliance Commercial	$472.64

SIZER RND SILICONE 510CC

Facility

$844.00

Service Code	HCPCS C1789
Hospital Revenue Code	278
Min. Negotiated Rate	$261.64
Max. Negotiated Rate	$818.68
Rate for Payer: AlohaCare Medicaid	$422.00
Rate for Payer: AlohaCare Medicare	$261.64
Rate for Payer: Cash Price	$506.40
Rate for Payer: Devoted Health Medicare	$286.96
Rate for Payer: Hawaii Medical Service Association Medicare	$261.64
Rate for Payer: Hawaii Western Management Group Commercial	$590.80
Rate for Payer: Health Management Network Commercial	$717.40
Rate for Payer: Humana Medicare	$261.64
Rate for Payer: Kaiser Permanente Commercial	$759.60
Rate for Payer: Kaiser Permanente Medicaid	$430.44
Rate for Payer: Kaiser Permanente Medicare	$261.64
Rate for Payer: MDX Hawaii PPO	$818.68
Rate for Payer: Ohana Health Plan Medicaid	$261.64
Rate for Payer: Ohana Health Plan Medicare	$261.64
Rate for Payer: UnitedHealthcare Medicare	$261.64
Rate for Payer: University Health Alliance Commercial	$472.64

SIZER RND SILI GS10610-500LP

Facility

$844.00

Service Code	HCPCS C1789
Hospital Revenue Code	278
Min. Negotiated Rate	$261.64
Max. Negotiated Rate	$818.68
Rate for Payer: AlohaCare Medicaid	$422.00
Rate for Payer: AlohaCare Medicare	$261.64
Rate for Payer: Cash Price	$506.40
Rate for Payer: Devoted Health Medicare	$286.96
Rate for Payer: Hawaii Medical Service Association Medicare	$261.64
Rate for Payer: Hawaii Western Management Group Commercial	$590.80
Rate for Payer: Health Management Network Commercial	$717.40
Rate for Payer: Humana Medicare	$261.64
Rate for Payer: Kaiser Permanente Commercial	$759.60
Rate for Payer: Kaiser Permanente Medicaid	$430.44
Rate for Payer: Kaiser Permanente Medicare	$261.64
Rate for Payer: MDX Hawaii PPO	$818.68
Rate for Payer: Ohana Health Plan Medicaid	$261.64
Rate for Payer: Ohana Health Plan Medicare	$261.64
Rate for Payer: UnitedHealthcare Medicare	$261.64
Rate for Payer: University Health Alliance Commercial	$472.64

SIZER RND SILI GS10610-500LP

Facility

$844.00

Service Code	HCPCS C1789
Hospital Revenue Code	278
Min. Negotiated Rate	$472.64
Max. Negotiated Rate	$818.68
Rate for Payer: Cash Price	$506.40
Rate for Payer: Hawaii Western Management Group Commercial	$590.80
Rate for Payer: Health Management Network Commercial	$717.40
Rate for Payer: Kaiser Permanente Commercial	$759.60
Rate for Payer: MDX Hawaii PPO	$818.68
Rate for Payer: University Health Alliance Commercial	$472.64

SIZER SALINE RND 510CC SZ68510

Facility

$175.00

Service Code	HCPCS C1789
Hospital Revenue Code	278
Min. Negotiated Rate	$98.00
Max. Negotiated Rate	$169.75
Rate for Payer: Cash Price	$105.00
Rate for Payer: Hawaii Western Management Group Commercial	$122.50
Rate for Payer: Health Management Network Commercial	$148.75
Rate for Payer: Kaiser Permanente Commercial	$157.50
Rate for Payer: MDX Hawaii PPO	$169.75
Rate for Payer: University Health Alliance Commercial	$98.00

SIZER SALINE RND 510CC SZ68510

Facility

$175.00

Service Code	HCPCS C1789
Hospital Revenue Code	278
Min. Negotiated Rate	$54.25
Max. Negotiated Rate	$169.75
Rate for Payer: AlohaCare Medicaid	$87.50
Rate for Payer: AlohaCare Medicare	$54.25
Rate for Payer: Cash Price	$105.00
Rate for Payer: Devoted Health Medicare	$59.50
Rate for Payer: Hawaii Medical Service Association Medicare	$54.25
Rate for Payer: Hawaii Western Management Group Commercial	$122.50
Rate for Payer: Health Management Network Commercial	$148.75
Rate for Payer: Humana Medicare	$54.25
Rate for Payer: Kaiser Permanente Commercial	$157.50
Rate for Payer: Kaiser Permanente Medicaid	$89.25
Rate for Payer: Kaiser Permanente Medicare	$54.25
Rate for Payer: MDX Hawaii PPO	$169.75
Rate for Payer: Ohana Health Plan Medicaid	$54.25
Rate for Payer: Ohana Health Plan Medicare	$54.25
Rate for Payer: UnitedHealthcare Medicare	$54.25
Rate for Payer: University Health Alliance Commercial	$98.00

SIZER SALINE RND SZ10621-235MP

Facility

$260.00

Service Code	HCPCS C1789
Hospital Revenue Code	278
Min. Negotiated Rate	$80.60
Max. Negotiated Rate	$252.20
Rate for Payer: AlohaCare Medicaid	$130.00
Rate for Payer: AlohaCare Medicare	$80.60
Rate for Payer: Cash Price	$156.00
Rate for Payer: Devoted Health Medicare	$88.40
Rate for Payer: Hawaii Medical Service Association Medicare	$80.60
Rate for Payer: Hawaii Western Management Group Commercial	$182.00
Rate for Payer: Health Management Network Commercial	$221.00
Rate for Payer: Humana Medicare	$80.60
Rate for Payer: Kaiser Permanente Commercial	$234.00
Rate for Payer: Kaiser Permanente Medicaid	$132.60
Rate for Payer: Kaiser Permanente Medicare	$80.60
Rate for Payer: MDX Hawaii PPO	$252.20
Rate for Payer: Ohana Health Plan Medicaid	$80.60
Rate for Payer: Ohana Health Plan Medicare	$80.60
Rate for Payer: UnitedHealthcare Medicare	$80.60
Rate for Payer: University Health Alliance Commercial	$145.60

SIZER SALINE RND SZ10621-235MP

Facility

$260.00

Service Code	HCPCS C1789
Hospital Revenue Code	278
Min. Negotiated Rate	$145.60
Max. Negotiated Rate	$252.20
Rate for Payer: Cash Price	$156.00
Rate for Payer: Hawaii Western Management Group Commercial	$182.00
Rate for Payer: Health Management Network Commercial	$221.00
Rate for Payer: Kaiser Permanente Commercial	$234.00
Rate for Payer: MDX Hawaii PPO	$252.20
Rate for Payer: University Health Alliance Commercial	$145.60

Know your out-of-pocket cost for care.

All Charges