Kau Hospital

All Charges

Charge

Type

Setting

Price

STENT 7FRX22CM URO DBL PIG

Facility

$473.00

Service Code	HCPCS C2617
Hospital Revenue Code	278
Min. Negotiated Rate	$264.88
Max. Negotiated Rate	$458.81
Rate for Payer: Cash Price	$283.80
Rate for Payer: Hawaii Western Management Group Commercial	$331.10
Rate for Payer: Health Management Network Commercial	$402.05
Rate for Payer: Kaiser Permanente Commercial	$425.70
Rate for Payer: MDX Hawaii PPO	$458.81
Rate for Payer: University Health Alliance Commercial	$264.88

STENT 7FRX22CM URO DBL PIG

Facility

$473.00

Service Code	HCPCS C2617
Hospital Revenue Code	278
Min. Negotiated Rate	$146.63
Max. Negotiated Rate	$458.81
Rate for Payer: AlohaCare Medicaid	$236.50
Rate for Payer: AlohaCare Medicare	$146.63
Rate for Payer: Cash Price	$283.80
Rate for Payer: Devoted Health Medicare	$160.82
Rate for Payer: Hawaii Medical Service Association Medicare	$146.63
Rate for Payer: Hawaii Western Management Group Commercial	$331.10
Rate for Payer: Health Management Network Commercial	$402.05
Rate for Payer: Humana Medicare	$146.63
Rate for Payer: Kaiser Permanente Commercial	$425.70
Rate for Payer: Kaiser Permanente Medicaid	$241.23
Rate for Payer: Kaiser Permanente Medicare	$146.63
Rate for Payer: MDX Hawaii PPO	$458.81
Rate for Payer: Ohana Health Plan Medicaid	$146.63
Rate for Payer: Ohana Health Plan Medicare	$146.63
Rate for Payer: UnitedHealthcare Medicare	$146.63
Rate for Payer: University Health Alliance Commercial	$264.88

STENT 7FRX24CM URO DBL PIG

Facility

$473.00

Service Code	HCPCS C2617
Hospital Revenue Code	278
Min. Negotiated Rate	$264.88
Max. Negotiated Rate	$458.81
Rate for Payer: Cash Price	$283.80
Rate for Payer: Hawaii Western Management Group Commercial	$331.10
Rate for Payer: Health Management Network Commercial	$402.05
Rate for Payer: Kaiser Permanente Commercial	$425.70
Rate for Payer: MDX Hawaii PPO	$458.81
Rate for Payer: University Health Alliance Commercial	$264.88

STENT 7FRX24CM URO DBL PIG

Facility

$473.00

Service Code	HCPCS C2617
Hospital Revenue Code	278
Min. Negotiated Rate	$146.63
Max. Negotiated Rate	$458.81
Rate for Payer: AlohaCare Medicaid	$236.50
Rate for Payer: AlohaCare Medicare	$146.63
Rate for Payer: Cash Price	$283.80
Rate for Payer: Devoted Health Medicare	$160.82
Rate for Payer: Hawaii Medical Service Association Medicare	$146.63
Rate for Payer: Hawaii Western Management Group Commercial	$331.10
Rate for Payer: Health Management Network Commercial	$402.05
Rate for Payer: Humana Medicare	$146.63
Rate for Payer: Kaiser Permanente Commercial	$425.70
Rate for Payer: Kaiser Permanente Medicaid	$241.23
Rate for Payer: Kaiser Permanente Medicare	$146.63
Rate for Payer: MDX Hawaii PPO	$458.81
Rate for Payer: Ohana Health Plan Medicaid	$146.63
Rate for Payer: Ohana Health Plan Medicare	$146.63
Rate for Payer: UnitedHealthcare Medicare	$146.63
Rate for Payer: University Health Alliance Commercial	$264.88

STENT 7FRX26CM URO DBL PIG

Facility

$473.00

Service Code	HCPCS C2617
Hospital Revenue Code	278
Min. Negotiated Rate	$146.63
Max. Negotiated Rate	$458.81
Rate for Payer: AlohaCare Medicaid	$236.50
Rate for Payer: AlohaCare Medicare	$146.63
Rate for Payer: Cash Price	$283.80
Rate for Payer: Devoted Health Medicare	$160.82
Rate for Payer: Hawaii Medical Service Association Medicare	$146.63
Rate for Payer: Hawaii Western Management Group Commercial	$331.10
Rate for Payer: Health Management Network Commercial	$402.05
Rate for Payer: Humana Medicare	$146.63
Rate for Payer: Kaiser Permanente Commercial	$425.70
Rate for Payer: Kaiser Permanente Medicaid	$241.23
Rate for Payer: Kaiser Permanente Medicare	$146.63
Rate for Payer: MDX Hawaii PPO	$458.81
Rate for Payer: Ohana Health Plan Medicaid	$146.63
Rate for Payer: Ohana Health Plan Medicare	$146.63
Rate for Payer: UnitedHealthcare Medicare	$146.63
Rate for Payer: University Health Alliance Commercial	$264.88

STENT 7FRX26CM URO DBL PIG

Facility

$473.00

Service Code	HCPCS C2617
Hospital Revenue Code	278
Min. Negotiated Rate	$264.88
Max. Negotiated Rate	$458.81
Rate for Payer: Cash Price	$283.80
Rate for Payer: Hawaii Western Management Group Commercial	$331.10
Rate for Payer: Health Management Network Commercial	$402.05
Rate for Payer: Kaiser Permanente Commercial	$425.70
Rate for Payer: MDX Hawaii PPO	$458.81
Rate for Payer: University Health Alliance Commercial	$264.88

STENT 7X10 ZIMMON BILIARY

Facility

$518.00

Service Code	HCPCS C2625
Hospital Revenue Code	278
Min. Negotiated Rate	$160.58
Max. Negotiated Rate	$502.46
Rate for Payer: AlohaCare Medicaid	$259.00
Rate for Payer: AlohaCare Medicare	$160.58
Rate for Payer: Cash Price	$310.80
Rate for Payer: Devoted Health Medicare	$176.12
Rate for Payer: Hawaii Medical Service Association Medicare	$160.58
Rate for Payer: Hawaii Western Management Group Commercial	$362.60
Rate for Payer: Health Management Network Commercial	$440.30
Rate for Payer: Humana Medicare	$160.58
Rate for Payer: Kaiser Permanente Commercial	$466.20
Rate for Payer: Kaiser Permanente Medicaid	$264.18
Rate for Payer: Kaiser Permanente Medicare	$160.58
Rate for Payer: MDX Hawaii PPO	$502.46
Rate for Payer: Ohana Health Plan Medicaid	$160.58
Rate for Payer: Ohana Health Plan Medicare	$160.58
Rate for Payer: UnitedHealthcare Medicare	$160.58
Rate for Payer: University Health Alliance Commercial	$290.08

STENT 7X10 ZIMMON BILIARY

Facility

$518.00

Service Code	HCPCS C2625
Hospital Revenue Code	278
Min. Negotiated Rate	$290.08
Max. Negotiated Rate	$502.46
Rate for Payer: Cash Price	$310.80
Rate for Payer: Hawaii Western Management Group Commercial	$362.60
Rate for Payer: Health Management Network Commercial	$440.30
Rate for Payer: Kaiser Permanente Commercial	$466.20
Rate for Payer: MDX Hawaii PPO	$502.46
Rate for Payer: University Health Alliance Commercial	$290.08

STENT 7X4 ZIMMON BILIARY

Facility

$570.00

Service Code	HCPCS C2625
Hospital Revenue Code	278
Min. Negotiated Rate	$319.20
Max. Negotiated Rate	$552.90
Rate for Payer: Cash Price	$342.00
Rate for Payer: Hawaii Western Management Group Commercial	$399.00
Rate for Payer: Health Management Network Commercial	$484.50
Rate for Payer: Kaiser Permanente Commercial	$513.00
Rate for Payer: MDX Hawaii PPO	$552.90
Rate for Payer: University Health Alliance Commercial	$319.20

STENT 7X4 ZIMMON BILIARY

Facility

$570.00

Service Code	HCPCS C2625
Hospital Revenue Code	278
Min. Negotiated Rate	$176.70
Max. Negotiated Rate	$552.90
Rate for Payer: AlohaCare Medicaid	$285.00
Rate for Payer: AlohaCare Medicare	$176.70
Rate for Payer: Cash Price	$342.00
Rate for Payer: Devoted Health Medicare	$193.80
Rate for Payer: Hawaii Medical Service Association Medicare	$176.70
Rate for Payer: Hawaii Western Management Group Commercial	$399.00
Rate for Payer: Health Management Network Commercial	$484.50
Rate for Payer: Humana Medicare	$176.70
Rate for Payer: Kaiser Permanente Commercial	$513.00
Rate for Payer: Kaiser Permanente Medicaid	$290.70
Rate for Payer: Kaiser Permanente Medicare	$176.70
Rate for Payer: MDX Hawaii PPO	$552.90
Rate for Payer: Ohana Health Plan Medicaid	$176.70
Rate for Payer: Ohana Health Plan Medicare	$176.70
Rate for Payer: UnitedHealthcare Medicare	$176.70
Rate for Payer: University Health Alliance Commercial	$319.20

STENT 7X5 ADVANIX BILIARY RX

Facility

$490.00

Service Code	HCPCS C2625
Hospital Revenue Code	278
Min. Negotiated Rate	$151.90
Max. Negotiated Rate	$475.30
Rate for Payer: AlohaCare Medicaid	$245.00
Rate for Payer: AlohaCare Medicare	$151.90
Rate for Payer: Cash Price	$294.00
Rate for Payer: Devoted Health Medicare	$166.60
Rate for Payer: Hawaii Medical Service Association Medicare	$151.90
Rate for Payer: Hawaii Western Management Group Commercial	$343.00
Rate for Payer: Health Management Network Commercial	$416.50
Rate for Payer: Humana Medicare	$151.90
Rate for Payer: Kaiser Permanente Commercial	$441.00
Rate for Payer: Kaiser Permanente Medicaid	$249.90
Rate for Payer: Kaiser Permanente Medicare	$151.90
Rate for Payer: MDX Hawaii PPO	$475.30
Rate for Payer: Ohana Health Plan Medicaid	$151.90
Rate for Payer: Ohana Health Plan Medicare	$151.90
Rate for Payer: UnitedHealthcare Medicare	$151.90
Rate for Payer: University Health Alliance Commercial	$274.40

STENT 7X5 ADVANIX BILIARY RX

Facility

$490.00

Service Code	HCPCS C2625
Hospital Revenue Code	278
Min. Negotiated Rate	$274.40
Max. Negotiated Rate	$475.30
Rate for Payer: Cash Price	$294.00
Rate for Payer: Hawaii Western Management Group Commercial	$343.00
Rate for Payer: Health Management Network Commercial	$416.50
Rate for Payer: Kaiser Permanente Commercial	$441.00
Rate for Payer: MDX Hawaii PPO	$475.30
Rate for Payer: University Health Alliance Commercial	$274.40

STENT 7X7 ZIMMON BILIARY

Facility

$570.00

Service Code	HCPCS C2625
Hospital Revenue Code	278
Min. Negotiated Rate	$176.70
Max. Negotiated Rate	$552.90
Rate for Payer: AlohaCare Medicaid	$285.00
Rate for Payer: AlohaCare Medicare	$176.70
Rate for Payer: Cash Price	$342.00
Rate for Payer: Devoted Health Medicare	$193.80
Rate for Payer: Hawaii Medical Service Association Medicare	$176.70
Rate for Payer: Hawaii Western Management Group Commercial	$399.00
Rate for Payer: Health Management Network Commercial	$484.50
Rate for Payer: Humana Medicare	$176.70
Rate for Payer: Kaiser Permanente Commercial	$513.00
Rate for Payer: Kaiser Permanente Medicaid	$290.70
Rate for Payer: Kaiser Permanente Medicare	$176.70
Rate for Payer: MDX Hawaii PPO	$552.90
Rate for Payer: Ohana Health Plan Medicaid	$176.70
Rate for Payer: Ohana Health Plan Medicare	$176.70
Rate for Payer: UnitedHealthcare Medicare	$176.70
Rate for Payer: University Health Alliance Commercial	$319.20

STENT 7X7 ZIMMON BILIARY

Facility

$570.00

Service Code	HCPCS C2625
Hospital Revenue Code	278
Min. Negotiated Rate	$319.20
Max. Negotiated Rate	$552.90
Rate for Payer: Cash Price	$342.00
Rate for Payer: Hawaii Western Management Group Commercial	$399.00
Rate for Payer: Health Management Network Commercial	$484.50
Rate for Payer: Kaiser Permanente Commercial	$513.00
Rate for Payer: MDX Hawaii PPO	$552.90
Rate for Payer: University Health Alliance Commercial	$319.20

STENT 8.5X7 ADVANIX BILIARY RX

Facility

$490.00

Service Code	HCPCS C2625
Hospital Revenue Code	278
Min. Negotiated Rate	$151.90
Max. Negotiated Rate	$475.30
Rate for Payer: AlohaCare Medicaid	$245.00
Rate for Payer: AlohaCare Medicare	$151.90
Rate for Payer: Cash Price	$294.00
Rate for Payer: Devoted Health Medicare	$166.60
Rate for Payer: Hawaii Medical Service Association Medicare	$151.90
Rate for Payer: Hawaii Western Management Group Commercial	$343.00
Rate for Payer: Health Management Network Commercial	$416.50
Rate for Payer: Humana Medicare	$151.90
Rate for Payer: Kaiser Permanente Commercial	$441.00
Rate for Payer: Kaiser Permanente Medicaid	$249.90
Rate for Payer: Kaiser Permanente Medicare	$151.90
Rate for Payer: MDX Hawaii PPO	$475.30
Rate for Payer: Ohana Health Plan Medicaid	$151.90
Rate for Payer: Ohana Health Plan Medicare	$151.90
Rate for Payer: UnitedHealthcare Medicare	$151.90
Rate for Payer: University Health Alliance Commercial	$274.40

STENT 8.5X7 ADVANIX BILIARY RX

Facility

$490.00

Service Code	HCPCS C2625
Hospital Revenue Code	278
Min. Negotiated Rate	$274.40
Max. Negotiated Rate	$475.30
Rate for Payer: Cash Price	$294.00
Rate for Payer: Hawaii Western Management Group Commercial	$343.00
Rate for Payer: Health Management Network Commercial	$416.50
Rate for Payer: Kaiser Permanente Commercial	$441.00
Rate for Payer: MDX Hawaii PPO	$475.30
Rate for Payer: University Health Alliance Commercial	$274.40

STENT 8FR URETERAL SOFT

Facility

$254.00

Service Code	HCPCS C2617
Hospital Revenue Code	278
Min. Negotiated Rate	$78.74
Max. Negotiated Rate	$246.38
Rate for Payer: AlohaCare Medicaid	$127.00
Rate for Payer: AlohaCare Medicare	$78.74
Rate for Payer: Cash Price	$152.40
Rate for Payer: Devoted Health Medicare	$86.36
Rate for Payer: Hawaii Medical Service Association Medicare	$78.74
Rate for Payer: Hawaii Western Management Group Commercial	$177.80
Rate for Payer: Health Management Network Commercial	$215.90
Rate for Payer: Humana Medicare	$78.74
Rate for Payer: Kaiser Permanente Commercial	$228.60
Rate for Payer: Kaiser Permanente Medicaid	$129.54
Rate for Payer: Kaiser Permanente Medicare	$78.74
Rate for Payer: MDX Hawaii PPO	$246.38
Rate for Payer: Ohana Health Plan Medicaid	$78.74
Rate for Payer: Ohana Health Plan Medicare	$78.74
Rate for Payer: UnitedHealthcare Medicare	$78.74
Rate for Payer: University Health Alliance Commercial	$142.24

STENT 8FR URETERAL SOFT

Facility

$254.00

Service Code	HCPCS C2617
Hospital Revenue Code	278
Min. Negotiated Rate	$142.24
Max. Negotiated Rate	$246.38
Rate for Payer: Cash Price	$152.40
Rate for Payer: Hawaii Western Management Group Commercial	$177.80
Rate for Payer: Health Management Network Commercial	$215.90
Rate for Payer: Kaiser Permanente Commercial	$228.60
Rate for Payer: MDX Hawaii PPO	$246.38
Rate for Payer: University Health Alliance Commercial	$142.24

STENT 8X20 FLEXIMA URETERAL

Facility

$581.00

Service Code	HCPCS C2625
Hospital Revenue Code	278
Min. Negotiated Rate	$325.36
Max. Negotiated Rate	$563.57
Rate for Payer: Cash Price	$348.60
Rate for Payer: Hawaii Western Management Group Commercial	$406.70
Rate for Payer: Health Management Network Commercial	$493.85
Rate for Payer: Kaiser Permanente Commercial	$522.90
Rate for Payer: MDX Hawaii PPO	$563.57
Rate for Payer: University Health Alliance Commercial	$325.36

STENT 8X20 FLEXIMA URETERAL

Facility

$581.00

Service Code	HCPCS C2625
Hospital Revenue Code	278
Min. Negotiated Rate	$180.11
Max. Negotiated Rate	$563.57
Rate for Payer: AlohaCare Medicaid	$290.50
Rate for Payer: AlohaCare Medicare	$180.11
Rate for Payer: Cash Price	$348.60
Rate for Payer: Devoted Health Medicare	$197.54
Rate for Payer: Hawaii Medical Service Association Medicare	$180.11
Rate for Payer: Hawaii Western Management Group Commercial	$406.70
Rate for Payer: Health Management Network Commercial	$493.85
Rate for Payer: Humana Medicare	$180.11
Rate for Payer: Kaiser Permanente Commercial	$522.90
Rate for Payer: Kaiser Permanente Medicaid	$296.31
Rate for Payer: Kaiser Permanente Medicare	$180.11
Rate for Payer: MDX Hawaii PPO	$563.57
Rate for Payer: Ohana Health Plan Medicaid	$180.11
Rate for Payer: Ohana Health Plan Medicare	$180.11
Rate for Payer: UnitedHealthcare Medicare	$180.11
Rate for Payer: University Health Alliance Commercial	$325.36

STENT AGILE 18MM 5.9

Facility

$5,800.00

Service Code	HCPCS C1874
Hospital Revenue Code	278
Min. Negotiated Rate	$1,798.00
Max. Negotiated Rate	$5,626.00
Rate for Payer: AlohaCare Medicaid	$2,900.00
Rate for Payer: AlohaCare Medicare	$1,798.00
Rate for Payer: Cash Price	$3,480.00
Rate for Payer: Devoted Health Medicare	$1,972.00
Rate for Payer: Hawaii Medical Service Association Medicare	$1,798.00
Rate for Payer: Hawaii Western Management Group Commercial	$4,060.00
Rate for Payer: Health Management Network Commercial	$4,930.00
Rate for Payer: Humana Medicare	$1,798.00
Rate for Payer: Kaiser Permanente Commercial	$5,220.00
Rate for Payer: Kaiser Permanente Medicaid	$2,958.00
Rate for Payer: Kaiser Permanente Medicare	$1,798.00
Rate for Payer: MDX Hawaii PPO	$5,626.00
Rate for Payer: Ohana Health Plan Medicaid	$1,798.00
Rate for Payer: Ohana Health Plan Medicare	$1,798.00
Rate for Payer: UnitedHealthcare Medicare	$1,798.00
Rate for Payer: University Health Alliance Commercial	$3,248.00

STENT AGILE 18MM 5.9

Facility

$5,800.00

Service Code	HCPCS C1874
Hospital Revenue Code	278
Min. Negotiated Rate	$3,248.00
Max. Negotiated Rate	$5,626.00
Rate for Payer: Cash Price	$3,480.00
Rate for Payer: Hawaii Western Management Group Commercial	$4,060.00
Rate for Payer: Health Management Network Commercial	$4,930.00
Rate for Payer: Kaiser Permanente Commercial	$5,220.00
Rate for Payer: MDX Hawaii PPO	$5,626.00
Rate for Payer: University Health Alliance Commercial	$3,248.00

STENT AGILE 18MM 9.7

Facility

$5,800.00

Service Code	HCPCS C1874
Hospital Revenue Code	278
Min. Negotiated Rate	$3,248.00
Max. Negotiated Rate	$5,626.00
Rate for Payer: Cash Price	$3,480.00
Rate for Payer: Hawaii Western Management Group Commercial	$4,060.00
Rate for Payer: Health Management Network Commercial	$4,930.00
Rate for Payer: Kaiser Permanente Commercial	$5,220.00
Rate for Payer: MDX Hawaii PPO	$5,626.00
Rate for Payer: University Health Alliance Commercial	$3,248.00

STENT AGILE 18MM 9.7

Facility

$5,800.00

Service Code	HCPCS C1874
Hospital Revenue Code	278
Min. Negotiated Rate	$1,798.00
Max. Negotiated Rate	$5,626.00
Rate for Payer: AlohaCare Medicaid	$2,900.00
Rate for Payer: AlohaCare Medicare	$1,798.00
Rate for Payer: Cash Price	$3,480.00
Rate for Payer: Devoted Health Medicare	$1,972.00
Rate for Payer: Hawaii Medical Service Association Medicare	$1,798.00
Rate for Payer: Hawaii Western Management Group Commercial	$4,060.00
Rate for Payer: Health Management Network Commercial	$4,930.00
Rate for Payer: Humana Medicare	$1,798.00
Rate for Payer: Kaiser Permanente Commercial	$5,220.00
Rate for Payer: Kaiser Permanente Medicaid	$2,958.00
Rate for Payer: Kaiser Permanente Medicare	$1,798.00
Rate for Payer: MDX Hawaii PPO	$5,626.00
Rate for Payer: Ohana Health Plan Medicaid	$1,798.00
Rate for Payer: Ohana Health Plan Medicare	$1,798.00
Rate for Payer: UnitedHealthcare Medicare	$1,798.00
Rate for Payer: University Health Alliance Commercial	$3,248.00

STENT BILIARY 10F POLYMERIC

Facility

$504.00

Service Code	HCPCS C2625
Hospital Revenue Code	278
Min. Negotiated Rate	$282.24
Max. Negotiated Rate	$488.88
Rate for Payer: Cash Price	$302.40
Rate for Payer: Hawaii Western Management Group Commercial	$352.80
Rate for Payer: Health Management Network Commercial	$428.40
Rate for Payer: Kaiser Permanente Commercial	$453.60
Rate for Payer: MDX Hawaii PPO	$488.88
Rate for Payer: University Health Alliance Commercial	$282.24

Know your out-of-pocket cost for care.

All Charges