Kau Hospital

All Charges

Charge

Type

Setting

Price

STENT BILIARY 10F POLYMERIC

Facility

$504.00

Service Code	HCPCS C2625
Hospital Revenue Code	278
Min. Negotiated Rate	$156.24
Max. Negotiated Rate	$488.88
Rate for Payer: AlohaCare Medicaid	$252.00
Rate for Payer: AlohaCare Medicare	$156.24
Rate for Payer: Cash Price	$302.40
Rate for Payer: Devoted Health Medicare	$171.36
Rate for Payer: Hawaii Medical Service Association Medicare	$156.24
Rate for Payer: Hawaii Western Management Group Commercial	$352.80
Rate for Payer: Health Management Network Commercial	$428.40
Rate for Payer: Humana Medicare	$156.24
Rate for Payer: Kaiser Permanente Commercial	$453.60
Rate for Payer: Kaiser Permanente Medicaid	$257.04
Rate for Payer: Kaiser Permanente Medicare	$156.24
Rate for Payer: MDX Hawaii PPO	$488.88
Rate for Payer: Ohana Health Plan Medicaid	$156.24
Rate for Payer: Ohana Health Plan Medicare	$156.24
Rate for Payer: UnitedHealthcare Medicare	$156.24
Rate for Payer: University Health Alliance Commercial	$282.24

STENT BILIARY 10FX9

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 BILIARY 10FX9

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 BILIARY 10MM

Facility

$4,959.00

Service Code	HCPCS C1874
Hospital Revenue Code	278
Min. Negotiated Rate	$1,537.29
Max. Negotiated Rate	$4,810.23
Rate for Payer: AlohaCare Medicaid	$2,479.50
Rate for Payer: AlohaCare Medicare	$1,537.29
Rate for Payer: Cash Price	$2,975.40
Rate for Payer: Devoted Health Medicare	$1,686.06
Rate for Payer: Hawaii Medical Service Association Medicare	$1,537.29
Rate for Payer: Hawaii Western Management Group Commercial	$3,471.30
Rate for Payer: Health Management Network Commercial	$4,215.15
Rate for Payer: Humana Medicare	$1,537.29
Rate for Payer: Kaiser Permanente Commercial	$4,463.10
Rate for Payer: Kaiser Permanente Medicaid	$2,529.09
Rate for Payer: Kaiser Permanente Medicare	$1,537.29
Rate for Payer: MDX Hawaii PPO	$4,810.23
Rate for Payer: Ohana Health Plan Medicaid	$1,537.29
Rate for Payer: Ohana Health Plan Medicare	$1,537.29
Rate for Payer: UnitedHealthcare Medicare	$1,537.29
Rate for Payer: University Health Alliance Commercial	$2,777.04

STENT BILIARY 10MM

Facility

$4,959.00

Service Code	HCPCS C1874
Hospital Revenue Code	278
Min. Negotiated Rate	$2,777.04
Max. Negotiated Rate	$4,810.23
Rate for Payer: Cash Price	$2,975.40
Rate for Payer: Hawaii Western Management Group Commercial	$3,471.30
Rate for Payer: Health Management Network Commercial	$4,215.15
Rate for Payer: Kaiser Permanente Commercial	$4,463.10
Rate for Payer: MDX Hawaii PPO	$4,810.23
Rate for Payer: University Health Alliance Commercial	$2,777.04

STENT BILIARY 10X60

Facility

$4,984.00

Service Code	HCPCS C1874
Hospital Revenue Code	278
Min. Negotiated Rate	$1,545.04
Max. Negotiated Rate	$4,834.48
Rate for Payer: AlohaCare Medicaid	$2,492.00
Rate for Payer: AlohaCare Medicare	$1,545.04
Rate for Payer: Cash Price	$2,990.40
Rate for Payer: Devoted Health Medicare	$1,694.56
Rate for Payer: Hawaii Medical Service Association Medicare	$1,545.04
Rate for Payer: Hawaii Western Management Group Commercial	$3,488.80
Rate for Payer: Health Management Network Commercial	$4,236.40
Rate for Payer: Humana Medicare	$1,545.04
Rate for Payer: Kaiser Permanente Commercial	$4,485.60
Rate for Payer: Kaiser Permanente Medicaid	$2,541.84
Rate for Payer: Kaiser Permanente Medicare	$1,545.04
Rate for Payer: MDX Hawaii PPO	$4,834.48
Rate for Payer: Ohana Health Plan Medicaid	$1,545.04
Rate for Payer: Ohana Health Plan Medicare	$1,545.04
Rate for Payer: UnitedHealthcare Medicare	$1,545.04
Rate for Payer: University Health Alliance Commercial	$2,791.04

STENT BILIARY 10X60

Facility

$4,984.00

Service Code	HCPCS C1874
Hospital Revenue Code	278
Min. Negotiated Rate	$2,791.04
Max. Negotiated Rate	$4,834.48
Rate for Payer: Cash Price	$2,990.40
Rate for Payer: Hawaii Western Management Group Commercial	$3,488.80
Rate for Payer: Health Management Network Commercial	$4,236.40
Rate for Payer: Kaiser Permanente Commercial	$4,485.60
Rate for Payer: MDX Hawaii PPO	$4,834.48
Rate for Payer: University Health Alliance Commercial	$2,791.04

STENT BILIARY 10X80

Facility

$4,984.00

Service Code	HCPCS C1874
Hospital Revenue Code	278
Min. Negotiated Rate	$1,545.04
Max. Negotiated Rate	$4,834.48
Rate for Payer: AlohaCare Medicaid	$2,492.00
Rate for Payer: AlohaCare Medicare	$1,545.04
Rate for Payer: Cash Price	$2,990.40
Rate for Payer: Devoted Health Medicare	$1,694.56
Rate for Payer: Hawaii Medical Service Association Medicare	$1,545.04
Rate for Payer: Hawaii Western Management Group Commercial	$3,488.80
Rate for Payer: Health Management Network Commercial	$4,236.40
Rate for Payer: Humana Medicare	$1,545.04
Rate for Payer: Kaiser Permanente Commercial	$4,485.60
Rate for Payer: Kaiser Permanente Medicaid	$2,541.84
Rate for Payer: Kaiser Permanente Medicare	$1,545.04
Rate for Payer: MDX Hawaii PPO	$4,834.48
Rate for Payer: Ohana Health Plan Medicaid	$1,545.04
Rate for Payer: Ohana Health Plan Medicare	$1,545.04
Rate for Payer: UnitedHealthcare Medicare	$1,545.04
Rate for Payer: University Health Alliance Commercial	$2,791.04

STENT BILIARY 10X80

Facility

$4,984.00

Service Code	HCPCS C1874
Hospital Revenue Code	278
Min. Negotiated Rate	$2,791.04
Max. Negotiated Rate	$4,834.48
Rate for Payer: Cash Price	$2,990.40
Rate for Payer: Hawaii Western Management Group Commercial	$3,488.80
Rate for Payer: Health Management Network Commercial	$4,236.40
Rate for Payer: Kaiser Permanente Commercial	$4,485.60
Rate for Payer: MDX Hawaii PPO	$4,834.48
Rate for Payer: University Health Alliance Commercial	$2,791.04

STENT BILIARY 7FX9

Facility

$2,123.00

Service Code	HCPCS C2625
Hospital Revenue Code	278
Min. Negotiated Rate	$658.13
Max. Negotiated Rate	$2,059.31
Rate for Payer: AlohaCare Medicaid	$1,061.50
Rate for Payer: AlohaCare Medicare	$658.13
Rate for Payer: Cash Price	$1,273.80
Rate for Payer: Devoted Health Medicare	$721.82
Rate for Payer: Hawaii Medical Service Association Medicare	$658.13
Rate for Payer: Hawaii Western Management Group Commercial	$1,486.10
Rate for Payer: Health Management Network Commercial	$1,804.55
Rate for Payer: Humana Medicare	$658.13
Rate for Payer: Kaiser Permanente Commercial	$1,910.70
Rate for Payer: Kaiser Permanente Medicaid	$1,082.73
Rate for Payer: Kaiser Permanente Medicare	$658.13
Rate for Payer: MDX Hawaii PPO	$2,059.31
Rate for Payer: Ohana Health Plan Medicaid	$658.13
Rate for Payer: Ohana Health Plan Medicare	$658.13
Rate for Payer: UnitedHealthcare Medicare	$658.13
Rate for Payer: University Health Alliance Commercial	$1,188.88

STENT BILIARY 7FX9

Facility

$2,123.00

Service Code	HCPCS C2625
Hospital Revenue Code	278
Min. Negotiated Rate	$1,188.88
Max. Negotiated Rate	$2,059.31
Rate for Payer: Cash Price	$1,273.80
Rate for Payer: Hawaii Western Management Group Commercial	$1,486.10
Rate for Payer: Health Management Network Commercial	$1,804.55
Rate for Payer: Kaiser Permanente Commercial	$1,910.70
Rate for Payer: MDX Hawaii PPO	$2,059.31
Rate for Payer: University Health Alliance Commercial	$1,188.88

STENT COLON WALLFLEX 25X90

Facility

$5,075.00

Service Code	HCPCS C1876
Hospital Revenue Code	278
Min. Negotiated Rate	$1,573.25
Max. Negotiated Rate	$4,922.75
Rate for Payer: AlohaCare Medicaid	$2,537.50
Rate for Payer: AlohaCare Medicare	$1,573.25
Rate for Payer: Cash Price	$3,045.00
Rate for Payer: Devoted Health Medicare	$1,725.50
Rate for Payer: Hawaii Medical Service Association Medicare	$1,573.25
Rate for Payer: Hawaii Western Management Group Commercial	$3,552.50
Rate for Payer: Health Management Network Commercial	$4,313.75
Rate for Payer: Humana Medicare	$1,573.25
Rate for Payer: Kaiser Permanente Commercial	$4,567.50
Rate for Payer: Kaiser Permanente Medicaid	$2,588.25
Rate for Payer: Kaiser Permanente Medicare	$1,573.25
Rate for Payer: MDX Hawaii PPO	$4,922.75
Rate for Payer: Ohana Health Plan Medicaid	$1,573.25
Rate for Payer: Ohana Health Plan Medicare	$1,573.25
Rate for Payer: UnitedHealthcare Medicare	$1,573.25
Rate for Payer: University Health Alliance Commercial	$2,842.00

STENT COLON WALLFLEX 25X90

Facility

$5,075.00

Service Code	HCPCS C1876
Hospital Revenue Code	278
Min. Negotiated Rate	$2,842.00
Max. Negotiated Rate	$4,922.75
Rate for Payer: Cash Price	$3,045.00
Rate for Payer: Hawaii Western Management Group Commercial	$3,552.50
Rate for Payer: Health Management Network Commercial	$4,313.75
Rate for Payer: Kaiser Permanente Commercial	$4,567.50
Rate for Payer: MDX Hawaii PPO	$4,922.75
Rate for Payer: University Health Alliance Commercial	$2,842.00

STENT CONTOUR 4.8FX22-30CM

Facility

$419.00

Service Code	HCPCS C2617
Hospital Revenue Code	278
Min. Negotiated Rate	$129.89
Max. Negotiated Rate	$406.43
Rate for Payer: AlohaCare Medicaid	$209.50
Rate for Payer: AlohaCare Medicare	$129.89
Rate for Payer: Cash Price	$251.40
Rate for Payer: Devoted Health Medicare	$142.46
Rate for Payer: Hawaii Medical Service Association Medicare	$129.89
Rate for Payer: Hawaii Western Management Group Commercial	$293.30
Rate for Payer: Health Management Network Commercial	$356.15
Rate for Payer: Humana Medicare	$129.89
Rate for Payer: Kaiser Permanente Commercial	$377.10
Rate for Payer: Kaiser Permanente Medicaid	$213.69
Rate for Payer: Kaiser Permanente Medicare	$129.89
Rate for Payer: MDX Hawaii PPO	$406.43
Rate for Payer: Ohana Health Plan Medicaid	$129.89
Rate for Payer: Ohana Health Plan Medicare	$129.89
Rate for Payer: UnitedHealthcare Medicare	$129.89
Rate for Payer: University Health Alliance Commercial	$234.64

STENT CONTOUR 4.8FX22-30CM

Facility

$419.00

Service Code	HCPCS C2617
Hospital Revenue Code	278
Min. Negotiated Rate	$234.64
Max. Negotiated Rate	$406.43
Rate for Payer: Cash Price	$251.40
Rate for Payer: Hawaii Western Management Group Commercial	$293.30
Rate for Payer: Health Management Network Commercial	$356.15
Rate for Payer: Kaiser Permanente Commercial	$377.10
Rate for Payer: MDX Hawaii PPO	$406.43
Rate for Payer: University Health Alliance Commercial	$234.64

STENT CONTOUR VL URETERAL

Facility

$415.00

Service Code	HCPCS C2617
Hospital Revenue Code	278
Min. Negotiated Rate	$232.40
Max. Negotiated Rate	$402.55
Rate for Payer: Cash Price	$249.00
Rate for Payer: Hawaii Western Management Group Commercial	$290.50
Rate for Payer: Health Management Network Commercial	$352.75
Rate for Payer: Kaiser Permanente Commercial	$373.50
Rate for Payer: MDX Hawaii PPO	$402.55
Rate for Payer: University Health Alliance Commercial	$232.40

STENT CONTOUR VL URETERAL

Facility

$415.00

Service Code	HCPCS C2617
Hospital Revenue Code	278
Min. Negotiated Rate	$128.65
Max. Negotiated Rate	$402.55
Rate for Payer: AlohaCare Medicaid	$207.50
Rate for Payer: AlohaCare Medicare	$128.65
Rate for Payer: Cash Price	$249.00
Rate for Payer: Devoted Health Medicare	$141.10
Rate for Payer: Hawaii Medical Service Association Medicare	$128.65
Rate for Payer: Hawaii Western Management Group Commercial	$290.50
Rate for Payer: Health Management Network Commercial	$352.75
Rate for Payer: Humana Medicare	$128.65
Rate for Payer: Kaiser Permanente Commercial	$373.50
Rate for Payer: Kaiser Permanente Medicaid	$211.65
Rate for Payer: Kaiser Permanente Medicare	$128.65
Rate for Payer: MDX Hawaii PPO	$402.55
Rate for Payer: Ohana Health Plan Medicaid	$128.65
Rate for Payer: Ohana Health Plan Medicare	$128.65
Rate for Payer: UnitedHealthcare Medicare	$128.65
Rate for Payer: University Health Alliance Commercial	$232.40

STENT COTTON HUIB 10X12

Facility

$284.00

Service Code	HCPCS C2617
Hospital Revenue Code	278
Min. Negotiated Rate	$159.04
Max. Negotiated Rate	$275.48
Rate for Payer: Cash Price	$170.40
Rate for Payer: Hawaii Western Management Group Commercial	$198.80
Rate for Payer: Health Management Network Commercial	$241.40
Rate for Payer: Kaiser Permanente Commercial	$255.60
Rate for Payer: MDX Hawaii PPO	$275.48
Rate for Payer: University Health Alliance Commercial	$159.04

STENT COTTON HUIB 10X12

Facility

$284.00

Service Code	HCPCS C2617
Hospital Revenue Code	278
Min. Negotiated Rate	$88.04
Max. Negotiated Rate	$275.48
Rate for Payer: AlohaCare Medicaid	$142.00
Rate for Payer: AlohaCare Medicare	$88.04
Rate for Payer: Cash Price	$170.40
Rate for Payer: Devoted Health Medicare	$96.56
Rate for Payer: Hawaii Medical Service Association Medicare	$88.04
Rate for Payer: Hawaii Western Management Group Commercial	$198.80
Rate for Payer: Health Management Network Commercial	$241.40
Rate for Payer: Humana Medicare	$88.04
Rate for Payer: Kaiser Permanente Commercial	$255.60
Rate for Payer: Kaiser Permanente Medicaid	$144.84
Rate for Payer: Kaiser Permanente Medicare	$88.04
Rate for Payer: MDX Hawaii PPO	$275.48
Rate for Payer: Ohana Health Plan Medicaid	$88.04
Rate for Payer: Ohana Health Plan Medicare	$88.04
Rate for Payer: UnitedHealthcare Medicare	$88.04
Rate for Payer: University Health Alliance Commercial	$159.04

STENT COTTON HUIB 10X15

Facility

$284.00

Service Code	HCPCS C2617
Hospital Revenue Code	278
Min. Negotiated Rate	$88.04
Max. Negotiated Rate	$275.48
Rate for Payer: AlohaCare Medicaid	$142.00
Rate for Payer: AlohaCare Medicare	$88.04
Rate for Payer: Cash Price	$170.40
Rate for Payer: Devoted Health Medicare	$96.56
Rate for Payer: Hawaii Medical Service Association Medicare	$88.04
Rate for Payer: Hawaii Western Management Group Commercial	$198.80
Rate for Payer: Health Management Network Commercial	$241.40
Rate for Payer: Humana Medicare	$88.04
Rate for Payer: Kaiser Permanente Commercial	$255.60
Rate for Payer: Kaiser Permanente Medicaid	$144.84
Rate for Payer: Kaiser Permanente Medicare	$88.04
Rate for Payer: MDX Hawaii PPO	$275.48
Rate for Payer: Ohana Health Plan Medicaid	$88.04
Rate for Payer: Ohana Health Plan Medicare	$88.04
Rate for Payer: UnitedHealthcare Medicare	$88.04
Rate for Payer: University Health Alliance Commercial	$159.04

STENT COTTON HUIB 10X15

Facility

$284.00

Service Code	HCPCS C2617
Hospital Revenue Code	278
Min. Negotiated Rate	$159.04
Max. Negotiated Rate	$275.48
Rate for Payer: Cash Price	$170.40
Rate for Payer: Hawaii Western Management Group Commercial	$198.80
Rate for Payer: Health Management Network Commercial	$241.40
Rate for Payer: Kaiser Permanente Commercial	$255.60
Rate for Payer: MDX Hawaii PPO	$275.48
Rate for Payer: University Health Alliance Commercial	$159.04

STENT COTTON HUIB 10X5

Facility

$312.00

Service Code	HCPCS C2617
Hospital Revenue Code	278
Min. Negotiated Rate	$96.72
Max. Negotiated Rate	$302.64
Rate for Payer: AlohaCare Medicaid	$156.00
Rate for Payer: AlohaCare Medicare	$96.72
Rate for Payer: Cash Price	$187.20
Rate for Payer: Devoted Health Medicare	$106.08
Rate for Payer: Hawaii Medical Service Association Medicare	$96.72
Rate for Payer: Hawaii Western Management Group Commercial	$218.40
Rate for Payer: Health Management Network Commercial	$265.20
Rate for Payer: Humana Medicare	$96.72
Rate for Payer: Kaiser Permanente Commercial	$280.80
Rate for Payer: Kaiser Permanente Medicaid	$159.12
Rate for Payer: Kaiser Permanente Medicare	$96.72
Rate for Payer: MDX Hawaii PPO	$302.64
Rate for Payer: Ohana Health Plan Medicaid	$96.72
Rate for Payer: Ohana Health Plan Medicare	$96.72
Rate for Payer: UnitedHealthcare Medicare	$96.72
Rate for Payer: University Health Alliance Commercial	$174.72

STENT COTTON HUIB 10X5

Facility

$312.00

Service Code	HCPCS C2617
Hospital Revenue Code	278
Min. Negotiated Rate	$174.72
Max. Negotiated Rate	$302.64
Rate for Payer: Cash Price	$187.20
Rate for Payer: Hawaii Western Management Group Commercial	$218.40
Rate for Payer: Health Management Network Commercial	$265.20
Rate for Payer: Kaiser Permanente Commercial	$280.80
Rate for Payer: MDX Hawaii PPO	$302.64
Rate for Payer: University Health Alliance Commercial	$174.72

STENT COTTON HUIB 10X7

Facility

$312.00

Service Code	HCPCS C2617
Hospital Revenue Code	278
Min. Negotiated Rate	$96.72
Max. Negotiated Rate	$302.64
Rate for Payer: AlohaCare Medicaid	$156.00
Rate for Payer: AlohaCare Medicare	$96.72
Rate for Payer: Cash Price	$187.20
Rate for Payer: Devoted Health Medicare	$106.08
Rate for Payer: Hawaii Medical Service Association Medicare	$96.72
Rate for Payer: Hawaii Western Management Group Commercial	$218.40
Rate for Payer: Health Management Network Commercial	$265.20
Rate for Payer: Humana Medicare	$96.72
Rate for Payer: Kaiser Permanente Commercial	$280.80
Rate for Payer: Kaiser Permanente Medicaid	$159.12
Rate for Payer: Kaiser Permanente Medicare	$96.72
Rate for Payer: MDX Hawaii PPO	$302.64
Rate for Payer: Ohana Health Plan Medicaid	$96.72
Rate for Payer: Ohana Health Plan Medicare	$96.72
Rate for Payer: UnitedHealthcare Medicare	$96.72
Rate for Payer: University Health Alliance Commercial	$174.72

STENT COTTON HUIB 10X7

Facility

$312.00

Service Code	HCPCS C2617
Hospital Revenue Code	278
Min. Negotiated Rate	$174.72
Max. Negotiated Rate	$302.64
Rate for Payer: Cash Price	$187.20
Rate for Payer: Hawaii Western Management Group Commercial	$218.40
Rate for Payer: Health Management Network Commercial	$265.20
Rate for Payer: Kaiser Permanente Commercial	$280.80
Rate for Payer: MDX Hawaii PPO	$302.64
Rate for Payer: University Health Alliance Commercial	$174.72

Know your out-of-pocket cost for care.

All Charges