Kau Hospital

All Charges

Charge

Type

Setting

Price

CHG VENOGRAPHY RENAL BILATERAL SELECTIVE RS&I

Professional

Both

$293.00

Service Code	HCPCS 75833
Min. Negotiated Rate	$94.99
Max. Negotiated Rate	$636.14
Rate for Payer: AlohaCare Medicaid	$94.99
Rate for Payer: AlohaCare Medicare	$167.38
Rate for Payer: Cash Price	$175.80
Rate for Payer: Cash Price	$175.80
Rate for Payer: Devoted Health Medicare	$184.12
Rate for Payer: Hawaii Medical Service Association Medicare	$167.38
Rate for Payer: Hawaii Western Management Group Commercial	$636.14
Rate for Payer: Health Management Network Commercial	$249.05
Rate for Payer: Kaiser Permanente Commercial	$200.86
Rate for Payer: Kaiser Permanente Medicaid	$200.86
Rate for Payer: Kaiser Permanente Medicare	$200.86
Rate for Payer: Ohana Health Plan Medicaid	$94.99
Rate for Payer: Ohana Health Plan Medicare	$167.38
Rate for Payer: UnitedHealthcare Medicaid	$94.99
Rate for Payer: UnitedHealthcare Medicare	$167.38

CHG VENOGRAPHY RENAL BILATERAL SELECTIVE RS&I

Professional

Both

$178.00

Service Code	HCPCS 75833 TC
Min. Negotiated Rate	$94.99
Max. Negotiated Rate	$636.14
Rate for Payer: AlohaCare Medicaid	$94.99
Rate for Payer: AlohaCare Medicare	$96.09
Rate for Payer: Cash Price	$106.80
Rate for Payer: Cash Price	$106.80
Rate for Payer: Devoted Health Medicare	$105.70
Rate for Payer: Hawaii Medical Service Association Medicare	$96.09
Rate for Payer: Hawaii Western Management Group Commercial	$636.14
Rate for Payer: Health Management Network Commercial	$151.30
Rate for Payer: Kaiser Permanente Commercial	$115.31
Rate for Payer: Kaiser Permanente Medicaid	$115.31
Rate for Payer: Kaiser Permanente Medicare	$115.31
Rate for Payer: Ohana Health Plan Medicaid	$94.99
Rate for Payer: Ohana Health Plan Medicare	$96.09
Rate for Payer: UnitedHealthcare Medicaid	$94.99
Rate for Payer: UnitedHealthcare Medicare	$96.09

CHG VENOGRAPHY RENAL UNILATERAL SELECTIVE RS&I

Professional

Both

$87.00

Service Code	HCPCS 75831 26
Min. Negotiated Rate	$50.21
Max. Negotiated Rate	$616.67
Rate for Payer: AlohaCare Medicaid	$77.47
Rate for Payer: AlohaCare Medicare	$50.21
Rate for Payer: Cash Price	$52.20
Rate for Payer: Cash Price	$52.20
Rate for Payer: Devoted Health Medicare	$55.23
Rate for Payer: Hawaii Medical Service Association Medicare	$50.21
Rate for Payer: Hawaii Western Management Group Commercial	$616.67
Rate for Payer: Health Management Network Commercial	$73.95
Rate for Payer: Kaiser Permanente Commercial	$60.25
Rate for Payer: Kaiser Permanente Medicaid	$60.25
Rate for Payer: Kaiser Permanente Medicare	$60.25
Rate for Payer: Ohana Health Plan Medicaid	$77.47
Rate for Payer: Ohana Health Plan Medicare	$50.21
Rate for Payer: UnitedHealthcare Medicaid	$77.47
Rate for Payer: UnitedHealthcare Medicare	$50.21

CHG VENOGRAPHY RENAL UNILATERAL SELECTIVE RS&I

Professional

Both

$224.00

Service Code	HCPCS 75831
Min. Negotiated Rate	$77.47
Max. Negotiated Rate	$616.67
Rate for Payer: AlohaCare Medicaid	$77.47
Rate for Payer: AlohaCare Medicare	$128.07
Rate for Payer: Cash Price	$134.40
Rate for Payer: Cash Price	$134.40
Rate for Payer: Devoted Health Medicare	$140.88
Rate for Payer: Hawaii Medical Service Association Medicare	$128.07
Rate for Payer: Hawaii Western Management Group Commercial	$616.67
Rate for Payer: Health Management Network Commercial	$190.40
Rate for Payer: Kaiser Permanente Commercial	$153.68
Rate for Payer: Kaiser Permanente Medicaid	$153.68
Rate for Payer: Kaiser Permanente Medicare	$153.68
Rate for Payer: Ohana Health Plan Medicaid	$77.47
Rate for Payer: Ohana Health Plan Medicare	$128.07
Rate for Payer: UnitedHealthcare Medicaid	$77.47
Rate for Payer: UnitedHealthcare Medicare	$128.07

CHG VENOGRAPHY RENAL UNILATERAL SELECTIVE RS&I

Professional

Both

$137.00

Service Code	HCPCS 75831 TC
Min. Negotiated Rate	$77.47
Max. Negotiated Rate	$616.67
Rate for Payer: AlohaCare Medicaid	$77.47
Rate for Payer: AlohaCare Medicare	$77.86
Rate for Payer: Cash Price	$82.20
Rate for Payer: Cash Price	$82.20
Rate for Payer: Devoted Health Medicare	$85.65
Rate for Payer: Hawaii Medical Service Association Medicare	$77.86
Rate for Payer: Hawaii Western Management Group Commercial	$616.67
Rate for Payer: Health Management Network Commercial	$116.45
Rate for Payer: Kaiser Permanente Commercial	$93.43
Rate for Payer: Kaiser Permanente Medicaid	$93.43
Rate for Payer: Kaiser Permanente Medicare	$93.43
Rate for Payer: Ohana Health Plan Medicaid	$77.47
Rate for Payer: Ohana Health Plan Medicare	$77.86
Rate for Payer: UnitedHealthcare Medicaid	$77.47
Rate for Payer: UnitedHealthcare Medicare	$77.86

CHG VENOGRAPHY VENOUS SINUS/JUGULAR CATH RS&I

Professional

Both

$364.00

Service Code	HCPCS 75860
Min. Negotiated Rate	$81.60
Max. Negotiated Rate	$616.76
Rate for Payer: AlohaCare Medicaid	$81.60
Rate for Payer: AlohaCare Medicare	$139.85
Rate for Payer: Cash Price	$218.40
Rate for Payer: Cash Price	$218.40
Rate for Payer: Devoted Health Medicare	$153.84
Rate for Payer: Hawaii Medical Service Association Medicare	$139.85
Rate for Payer: Hawaii Western Management Group Commercial	$616.76
Rate for Payer: Health Management Network Commercial	$309.40
Rate for Payer: Kaiser Permanente Commercial	$167.82
Rate for Payer: Kaiser Permanente Medicaid	$167.82
Rate for Payer: Kaiser Permanente Medicare	$167.82
Rate for Payer: Ohana Health Plan Medicaid	$81.60
Rate for Payer: Ohana Health Plan Medicare	$139.85
Rate for Payer: UnitedHealthcare Medicaid	$81.60
Rate for Payer: UnitedHealthcare Medicare	$139.85

CHG VENOGRAPHY VENOUS SINUS/JUGULAR CATH RS&I

Professional

Both

$270.00

Service Code	HCPCS 75860 TC
Min. Negotiated Rate	$81.60
Max. Negotiated Rate	$616.76
Rate for Payer: AlohaCare Medicaid	$81.60
Rate for Payer: AlohaCare Medicare	$86.21
Rate for Payer: Cash Price	$162.00
Rate for Payer: Cash Price	$162.00
Rate for Payer: Devoted Health Medicare	$94.83
Rate for Payer: Hawaii Medical Service Association Medicare	$86.21
Rate for Payer: Hawaii Western Management Group Commercial	$616.76
Rate for Payer: Health Management Network Commercial	$229.50
Rate for Payer: Kaiser Permanente Commercial	$103.45
Rate for Payer: Kaiser Permanente Medicaid	$103.45
Rate for Payer: Kaiser Permanente Medicare	$103.45
Rate for Payer: Ohana Health Plan Medicaid	$81.60
Rate for Payer: Ohana Health Plan Medicare	$86.21
Rate for Payer: UnitedHealthcare Medicaid	$81.60
Rate for Payer: UnitedHealthcare Medicare	$86.21

CHG VENOGRAPHY VENOUS SINUS/JUGULAR CATH RS&I

Professional

Both

$94.00

Service Code	HCPCS 75860 26
Min. Negotiated Rate	$53.63
Max. Negotiated Rate	$616.76
Rate for Payer: AlohaCare Medicaid	$81.60
Rate for Payer: AlohaCare Medicare	$53.63
Rate for Payer: Cash Price	$56.40
Rate for Payer: Cash Price	$56.40
Rate for Payer: Devoted Health Medicare	$58.99
Rate for Payer: Hawaii Medical Service Association Medicare	$53.63
Rate for Payer: Hawaii Western Management Group Commercial	$616.76
Rate for Payer: Health Management Network Commercial	$79.90
Rate for Payer: Kaiser Permanente Commercial	$64.36
Rate for Payer: Kaiser Permanente Medicaid	$64.36
Rate for Payer: Kaiser Permanente Medicare	$64.36
Rate for Payer: Ohana Health Plan Medicaid	$81.60
Rate for Payer: Ohana Health Plan Medicare	$53.63
Rate for Payer: UnitedHealthcare Medicaid	$81.60
Rate for Payer: UnitedHealthcare Medicare	$53.63

CHLORDIAZEPOXIDE 10 MG CAPSULE [1622]

Facility

$2.00

Service Code	NDC 00555003302
Hospital Revenue Code	250
Min. Negotiated Rate	$1.70
Max. Negotiated Rate	$1.94
Rate for Payer: Cash Price	$1.20
Rate for Payer: Health Management Network Commercial	$1.70
Rate for Payer: Kaiser Permanente Commercial	$1.80
Rate for Payer: MDX Hawaii PPO	$1.94

CHLORDIAZEPOXIDE 10 MG CAPSULE [1622]

Facility

$2.00

Service Code	NDC 00555003302
Hospital Revenue Code	637
Min. Negotiated Rate	$0.62
Max. Negotiated Rate	$1.94
Rate for Payer: AlohaCare Medicaid	$1.00
Rate for Payer: AlohaCare Medicare	$0.62
Rate for Payer: Cash Price	$1.20
Rate for Payer: Devoted Health Medicare	$0.68
Rate for Payer: Hawaii Medical Service Association Medicare	$0.62
Rate for Payer: Hawaii Western Management Group Commercial	$1.90
Rate for Payer: Health Management Network Commercial	$1.70
Rate for Payer: Humana Medicare	$0.62
Rate for Payer: Kaiser Permanente Commercial	$1.80
Rate for Payer: Kaiser Permanente Medicaid	$1.02
Rate for Payer: Kaiser Permanente Medicare	$0.62
Rate for Payer: MDX Hawaii PPO	$1.94
Rate for Payer: Ohana Health Plan Medicaid	$0.62
Rate for Payer: Ohana Health Plan Medicare	$0.62
Rate for Payer: UnitedHealthcare Medicare	$0.62
Rate for Payer: University Health Alliance Commercial	$1.46

CHLORDIAZEPOXIDE 25 MG CAPSULE [1623]

Facility

$3.00

Service Code	NDC 51079014120
Hospital Revenue Code	637
Min. Negotiated Rate	$0.93
Max. Negotiated Rate	$2.91
Rate for Payer: AlohaCare Medicaid	$1.50
Rate for Payer: AlohaCare Medicare	$0.93
Rate for Payer: Cash Price	$1.80
Rate for Payer: Devoted Health Medicare	$1.02
Rate for Payer: Hawaii Medical Service Association Medicare	$0.93
Rate for Payer: Hawaii Western Management Group Commercial	$2.85
Rate for Payer: Health Management Network Commercial	$2.55
Rate for Payer: Humana Medicare	$0.93
Rate for Payer: Kaiser Permanente Commercial	$2.70
Rate for Payer: Kaiser Permanente Medicaid	$1.53
Rate for Payer: Kaiser Permanente Medicare	$0.93
Rate for Payer: MDX Hawaii PPO	$2.91
Rate for Payer: Ohana Health Plan Medicaid	$0.93
Rate for Payer: Ohana Health Plan Medicare	$0.93
Rate for Payer: UnitedHealthcare Medicare	$0.93
Rate for Payer: University Health Alliance Commercial	$2.19

CHLORDIAZEPOXIDE 25 MG CAPSULE [1623]

Facility

$3.00

Service Code	NDC 60687080711
Hospital Revenue Code	250
Min. Negotiated Rate	$2.55
Max. Negotiated Rate	$2.91
Rate for Payer: Cash Price	$1.80
Rate for Payer: Health Management Network Commercial	$2.55
Rate for Payer: Kaiser Permanente Commercial	$2.70
Rate for Payer: MDX Hawaii PPO	$2.91

CHLORDIAZEPOXIDE 25 MG CAPSULE [1623]

Facility

$3.00

Service Code	NDC 60687080701
Hospital Revenue Code	637
Min. Negotiated Rate	$0.93
Max. Negotiated Rate	$2.91
Rate for Payer: AlohaCare Medicaid	$1.50
Rate for Payer: AlohaCare Medicare	$0.93
Rate for Payer: Cash Price	$1.80
Rate for Payer: Devoted Health Medicare	$1.02
Rate for Payer: Hawaii Medical Service Association Medicare	$0.93
Rate for Payer: Hawaii Western Management Group Commercial	$2.85
Rate for Payer: Health Management Network Commercial	$2.55
Rate for Payer: Humana Medicare	$0.93
Rate for Payer: Kaiser Permanente Commercial	$2.70
Rate for Payer: Kaiser Permanente Medicaid	$1.53
Rate for Payer: Kaiser Permanente Medicare	$0.93
Rate for Payer: MDX Hawaii PPO	$2.91
Rate for Payer: Ohana Health Plan Medicaid	$0.93
Rate for Payer: Ohana Health Plan Medicare	$0.93
Rate for Payer: UnitedHealthcare Medicare	$0.93
Rate for Payer: University Health Alliance Commercial	$2.19

CHLORDIAZEPOXIDE 25 MG CAPSULE [1623]

Facility

$3.00

Service Code	NDC 60687080701
Hospital Revenue Code	250
Min. Negotiated Rate	$2.55
Max. Negotiated Rate	$2.91
Rate for Payer: Cash Price	$1.80
Rate for Payer: Health Management Network Commercial	$2.55
Rate for Payer: Kaiser Permanente Commercial	$2.70
Rate for Payer: MDX Hawaii PPO	$2.91

CHLORDIAZEPOXIDE 25 MG CAPSULE [1623]

Facility

$2.00

Service Code	NDC 00555015902
Hospital Revenue Code	637
Min. Negotiated Rate	$0.62
Max. Negotiated Rate	$1.94
Rate for Payer: AlohaCare Medicaid	$1.00
Rate for Payer: AlohaCare Medicare	$0.62
Rate for Payer: Cash Price	$1.20
Rate for Payer: Devoted Health Medicare	$0.68
Rate for Payer: Hawaii Medical Service Association Medicare	$0.62
Rate for Payer: Hawaii Western Management Group Commercial	$1.90
Rate for Payer: Health Management Network Commercial	$1.70
Rate for Payer: Humana Medicare	$0.62
Rate for Payer: Kaiser Permanente Commercial	$1.80
Rate for Payer: Kaiser Permanente Medicaid	$1.02
Rate for Payer: Kaiser Permanente Medicare	$0.62
Rate for Payer: MDX Hawaii PPO	$1.94
Rate for Payer: Ohana Health Plan Medicaid	$0.62
Rate for Payer: Ohana Health Plan Medicare	$0.62
Rate for Payer: UnitedHealthcare Medicare	$0.62
Rate for Payer: University Health Alliance Commercial	$1.46

CHLORDIAZEPOXIDE 25 MG CAPSULE [1623]

Facility

$3.00

Service Code	NDC 60687080711
Hospital Revenue Code	637
Min. Negotiated Rate	$0.93
Max. Negotiated Rate	$2.91
Rate for Payer: AlohaCare Medicaid	$1.50
Rate for Payer: AlohaCare Medicare	$0.93
Rate for Payer: Cash Price	$1.80
Rate for Payer: Devoted Health Medicare	$1.02
Rate for Payer: Hawaii Medical Service Association Medicare	$0.93
Rate for Payer: Hawaii Western Management Group Commercial	$2.85
Rate for Payer: Health Management Network Commercial	$2.55
Rate for Payer: Humana Medicare	$0.93
Rate for Payer: Kaiser Permanente Commercial	$2.70
Rate for Payer: Kaiser Permanente Medicaid	$1.53
Rate for Payer: Kaiser Permanente Medicare	$0.93
Rate for Payer: MDX Hawaii PPO	$2.91
Rate for Payer: Ohana Health Plan Medicaid	$0.93
Rate for Payer: Ohana Health Plan Medicare	$0.93
Rate for Payer: UnitedHealthcare Medicare	$0.93
Rate for Payer: University Health Alliance Commercial	$2.19

CHLORDIAZEPOXIDE 25 MG CAPSULE [1623]

Facility

$3.00

Service Code	NDC 51079014120
Hospital Revenue Code	250
Min. Negotiated Rate	$2.55
Max. Negotiated Rate	$2.91
Rate for Payer: Cash Price	$1.80
Rate for Payer: Health Management Network Commercial	$2.55
Rate for Payer: Kaiser Permanente Commercial	$2.70
Rate for Payer: MDX Hawaii PPO	$2.91

CHLORDIAZEPOXIDE 25 MG CAPSULE [1623]

Facility

$2.00

Service Code	NDC 00555015902
Hospital Revenue Code	250
Min. Negotiated Rate	$1.70
Max. Negotiated Rate	$1.94
Rate for Payer: Cash Price	$1.20
Rate for Payer: Health Management Network Commercial	$1.70
Rate for Payer: Kaiser Permanente Commercial	$1.80
Rate for Payer: MDX Hawaii PPO	$1.94

CHLORHEXIDINE GLUCONATE 0.12 % MOUTHWASH [9516]

Facility

$497.00

Service Code	NDC 00116200116
Hospital Revenue Code	637
Min. Negotiated Rate	$154.07
Max. Negotiated Rate	$482.09
Rate for Payer: AlohaCare Medicaid	$248.50
Rate for Payer: AlohaCare Medicare	$154.07
Rate for Payer: Cash Price	$298.20
Rate for Payer: Devoted Health Medicare	$168.98
Rate for Payer: Hawaii Medical Service Association Medicare	$154.07
Rate for Payer: Hawaii Western Management Group Commercial	$472.15
Rate for Payer: Health Management Network Commercial	$422.45
Rate for Payer: Humana Medicare	$154.07
Rate for Payer: Kaiser Permanente Commercial	$447.30
Rate for Payer: Kaiser Permanente Medicaid	$253.47
Rate for Payer: Kaiser Permanente Medicare	$154.07
Rate for Payer: MDX Hawaii PPO	$482.09
Rate for Payer: Ohana Health Plan Medicaid	$154.07
Rate for Payer: Ohana Health Plan Medicare	$154.07
Rate for Payer: UnitedHealthcare Medicare	$154.07
Rate for Payer: University Health Alliance Commercial	$362.26

CHLORHEXIDINE GLUCONATE 0.12 % MOUTHWASH [9516]

Facility

$32.00

Service Code	NDC 00126027216
Hospital Revenue Code	637
Min. Negotiated Rate	$9.92
Max. Negotiated Rate	$31.04
Rate for Payer: AlohaCare Medicaid	$16.00
Rate for Payer: AlohaCare Medicare	$9.92
Rate for Payer: Cash Price	$19.20
Rate for Payer: Devoted Health Medicare	$10.88
Rate for Payer: Hawaii Medical Service Association Medicare	$9.92
Rate for Payer: Hawaii Western Management Group Commercial	$30.40
Rate for Payer: Health Management Network Commercial	$27.20
Rate for Payer: Humana Medicare	$9.92
Rate for Payer: Kaiser Permanente Commercial	$28.80
Rate for Payer: Kaiser Permanente Medicaid	$16.32
Rate for Payer: Kaiser Permanente Medicare	$9.92
Rate for Payer: MDX Hawaii PPO	$31.04
Rate for Payer: Ohana Health Plan Medicaid	$9.92
Rate for Payer: Ohana Health Plan Medicare	$9.92
Rate for Payer: UnitedHealthcare Medicare	$9.92
Rate for Payer: University Health Alliance Commercial	$23.32

CHLORHEXIDINE GLUCONATE 0.12 % MOUTHWASH [9516]

Facility

$497.00

Service Code	NDC 00116200116
Hospital Revenue Code	250
Min. Negotiated Rate	$422.45
Max. Negotiated Rate	$482.09
Rate for Payer: Cash Price	$298.20
Rate for Payer: Health Management Network Commercial	$422.45
Rate for Payer: Kaiser Permanente Commercial	$447.30
Rate for Payer: MDX Hawaii PPO	$482.09

CHLORHEXIDINE GLUCONATE 0.12 % MOUTHWASH [9516]

Facility

$8.00

Service Code	NDC 63739005274
Hospital Revenue Code	250
Min. Negotiated Rate	$6.80
Max. Negotiated Rate	$7.76
Rate for Payer: Cash Price	$4.80
Rate for Payer: Health Management Network Commercial	$6.80
Rate for Payer: Kaiser Permanente Commercial	$7.20
Rate for Payer: MDX Hawaii PPO	$7.76

CHLORHEXIDINE GLUCONATE 0.12 % MOUTHWASH [9516]

Facility

$8.00

Service Code	NDC 63739005274
Hospital Revenue Code	637
Min. Negotiated Rate	$2.48
Max. Negotiated Rate	$7.76
Rate for Payer: AlohaCare Medicaid	$4.00
Rate for Payer: AlohaCare Medicare	$2.48
Rate for Payer: Cash Price	$4.80
Rate for Payer: Devoted Health Medicare	$2.72
Rate for Payer: Hawaii Medical Service Association Medicare	$2.48
Rate for Payer: Hawaii Western Management Group Commercial	$7.60
Rate for Payer: Health Management Network Commercial	$6.80
Rate for Payer: Humana Medicare	$2.48
Rate for Payer: Kaiser Permanente Commercial	$7.20
Rate for Payer: Kaiser Permanente Medicaid	$4.08
Rate for Payer: Kaiser Permanente Medicare	$2.48
Rate for Payer: MDX Hawaii PPO	$7.76
Rate for Payer: Ohana Health Plan Medicaid	$2.48
Rate for Payer: Ohana Health Plan Medicare	$2.48
Rate for Payer: UnitedHealthcare Medicare	$2.48
Rate for Payer: University Health Alliance Commercial	$5.83

CHLORHEXIDINE GLUCONATE 0.12 % MOUTHWASH [9516]

Facility

$8.00

Service Code	NDC 69339013817
Hospital Revenue Code	250
Min. Negotiated Rate	$6.80
Max. Negotiated Rate	$7.76
Rate for Payer: Cash Price	$4.80
Rate for Payer: Health Management Network Commercial	$6.80
Rate for Payer: Kaiser Permanente Commercial	$7.20
Rate for Payer: MDX Hawaii PPO	$7.76

CHLORHEXIDINE GLUCONATE 0.12 % MOUTHWASH [9516]

Facility

$42.00

Service Code	NDC 16571012848
Hospital Revenue Code	637
Min. Negotiated Rate	$13.02
Max. Negotiated Rate	$40.74
Rate for Payer: AlohaCare Medicaid	$21.00
Rate for Payer: AlohaCare Medicare	$13.02
Rate for Payer: Cash Price	$25.20
Rate for Payer: Devoted Health Medicare	$14.28
Rate for Payer: Hawaii Medical Service Association Medicare	$13.02
Rate for Payer: Hawaii Western Management Group Commercial	$39.90
Rate for Payer: Health Management Network Commercial	$35.70
Rate for Payer: Humana Medicare	$13.02
Rate for Payer: Kaiser Permanente Commercial	$37.80
Rate for Payer: Kaiser Permanente Medicaid	$21.42
Rate for Payer: Kaiser Permanente Medicare	$13.02
Rate for Payer: MDX Hawaii PPO	$40.74
Rate for Payer: Ohana Health Plan Medicaid	$13.02
Rate for Payer: Ohana Health Plan Medicare	$13.02
Rate for Payer: UnitedHealthcare Medicare	$13.02
Rate for Payer: University Health Alliance Commercial	$30.61

Know your out-of-pocket cost for care.

All Charges