Kau Hospital

All Charges

Charge

Type

Setting

Price

GEL SIZER 350CC

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

GEL SIZER 350CC

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

GEL SIZER 350CC GS10512-350MP

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

GEL SIZER 350CC GS10512-350MP

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

GEL SIZER 410CC GS10512-410MP

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

GEL SIZER 410CC GS10512-410MP

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

GEL SIZER 525CC GS10621-525MP

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

GEL SIZER 525CC GS10621-525MP

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

GEL SIZER 565CC GS10621-565HP

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

GEL SIZER 565CC GS10621-565HP

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

GEL SIZER 575CC GS10621-575MP

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

GEL SIZER 575CC GS10621-575MP

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

GEL SIZER 695CC GS10621-695MP

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

GEL SIZER 695CC GS10621-695MP

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

GEL SIZER GS10621-505HP

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

GEL SIZER GS10621-505HP

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

GEL SIZER RND GS10621-385HP

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

GEL SIZER RND GS10621-385HP

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

GEL SIZER RND GS10621-415HP

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

GEL SIZER RND GS10621-415HP

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

GEL SIZER RND GS10621-440HP

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

GEL SIZER RND GS10621-440HP

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

GEL SIZER RND GS10621-470HP

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

GEL SIZER RND GS10621-470HP

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

GEL THERAHONEY WOUND GEL 1.5

Facility

$66.00

Hospital Revenue Code	272
Min. Negotiated Rate	$56.10
Max. Negotiated Rate	$64.02
Rate for Payer: Cash Price	$39.60
Rate for Payer: Health Management Network Commercial	$56.10
Rate for Payer: Kaiser Permanente Commercial	$59.40
Rate for Payer: MDX Hawaii PPO	$64.02

Know your out-of-pocket cost for care.

All Charges