Kau Hospital

All Charges

Charge

Type

Setting

Price

GLENOID PT HYBRID PT-113950

Facility

$1,050.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$588.00
Max. Negotiated Rate	$1,018.50
Rate for Payer: Cash Price	$630.00
Rate for Payer: Hawaii Western Management Group Commercial	$735.00
Rate for Payer: Health Management Network Commercial	$892.50
Rate for Payer: Kaiser Permanente Commercial	$945.00
Rate for Payer: MDX Hawaii PPO	$1,018.50
Rate for Payer: University Health Alliance Commercial	$588.00

GLENOID PT HYBRID PT-113950

Facility

$1,050.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$325.50
Max. Negotiated Rate	$1,018.50
Rate for Payer: AlohaCare Medicaid	$525.00
Rate for Payer: AlohaCare Medicare	$325.50
Rate for Payer: Cash Price	$630.00
Rate for Payer: Devoted Health Medicare	$357.00
Rate for Payer: Hawaii Medical Service Association Medicare	$325.50
Rate for Payer: Hawaii Western Management Group Commercial	$735.00
Rate for Payer: Health Management Network Commercial	$892.50
Rate for Payer: Humana Medicare	$325.50
Rate for Payer: Kaiser Permanente Commercial	$945.00
Rate for Payer: Kaiser Permanente Medicaid	$535.50
Rate for Payer: Kaiser Permanente Medicare	$325.50
Rate for Payer: MDX Hawaii PPO	$1,018.50
Rate for Payer: Ohana Health Plan Medicaid	$325.50
Rate for Payer: Ohana Health Plan Medicare	$325.50
Rate for Payer: UnitedHealthcare Medicare	$325.50
Rate for Payer: University Health Alliance Commercial	$588.00

GLENOID REVERSE AUGMENT DWJ505

Facility

$3,000.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$1,680.00
Max. Negotiated Rate	$2,910.00
Rate for Payer: Cash Price	$1,800.00
Rate for Payer: Hawaii Western Management Group Commercial	$2,100.00
Rate for Payer: Health Management Network Commercial	$2,550.00
Rate for Payer: Kaiser Permanente Commercial	$2,700.00
Rate for Payer: MDX Hawaii PPO	$2,910.00
Rate for Payer: University Health Alliance Commercial	$1,680.00

GLENOID REVERSE AUGMENT DWJ505

Facility

$3,000.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$930.00
Max. Negotiated Rate	$2,910.00
Rate for Payer: AlohaCare Medicaid	$1,500.00
Rate for Payer: AlohaCare Medicare	$930.00
Rate for Payer: Cash Price	$1,800.00
Rate for Payer: Devoted Health Medicare	$1,020.00
Rate for Payer: Hawaii Medical Service Association Medicare	$930.00
Rate for Payer: Hawaii Western Management Group Commercial	$2,100.00
Rate for Payer: Health Management Network Commercial	$2,550.00
Rate for Payer: Humana Medicare	$930.00
Rate for Payer: Kaiser Permanente Commercial	$2,700.00
Rate for Payer: Kaiser Permanente Medicaid	$1,530.00
Rate for Payer: Kaiser Permanente Medicare	$930.00
Rate for Payer: MDX Hawaii PPO	$2,910.00
Rate for Payer: Ohana Health Plan Medicaid	$930.00
Rate for Payer: Ohana Health Plan Medicare	$930.00
Rate for Payer: UnitedHealthcare Medicare	$930.00
Rate for Payer: University Health Alliance Commercial	$1,680.00

GLENOID SIZE 56 5542-P0056

Facility

$4,721.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$1,463.51
Max. Negotiated Rate	$4,579.37
Rate for Payer: AlohaCare Medicaid	$2,360.50
Rate for Payer: AlohaCare Medicare	$1,463.51
Rate for Payer: Cash Price	$2,832.60
Rate for Payer: Devoted Health Medicare	$1,605.14
Rate for Payer: Hawaii Medical Service Association Medicare	$1,463.51
Rate for Payer: Hawaii Western Management Group Commercial	$3,304.70
Rate for Payer: Health Management Network Commercial	$4,012.85
Rate for Payer: Humana Medicare	$1,463.51
Rate for Payer: Kaiser Permanente Commercial	$4,248.90
Rate for Payer: Kaiser Permanente Medicaid	$2,407.71
Rate for Payer: Kaiser Permanente Medicare	$1,463.51
Rate for Payer: MDX Hawaii PPO	$4,579.37
Rate for Payer: Ohana Health Plan Medicaid	$1,463.51
Rate for Payer: Ohana Health Plan Medicare	$1,463.51
Rate for Payer: UnitedHealthcare Medicare	$1,463.51
Rate for Payer: University Health Alliance Commercial	$2,643.76

GLENOID SIZE 56 5542-P0056

Facility

$4,721.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$2,643.76
Max. Negotiated Rate	$4,579.37
Rate for Payer: Cash Price	$2,832.60
Rate for Payer: Hawaii Western Management Group Commercial	$3,304.70
Rate for Payer: Health Management Network Commercial	$4,012.85
Rate for Payer: Kaiser Permanente Commercial	$4,248.90
Rate for Payer: MDX Hawaii PPO	$4,579.37
Rate for Payer: University Health Alliance Commercial	$2,643.76

GLENOID SZ44 TSA-X3 5542-P-004

Facility

$4,721.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$1,463.51
Max. Negotiated Rate	$4,579.37
Rate for Payer: AlohaCare Medicaid	$2,360.50
Rate for Payer: AlohaCare Medicare	$1,463.51
Rate for Payer: Cash Price	$2,832.60
Rate for Payer: Devoted Health Medicare	$1,605.14
Rate for Payer: Hawaii Medical Service Association Medicare	$1,463.51
Rate for Payer: Hawaii Western Management Group Commercial	$3,304.70
Rate for Payer: Health Management Network Commercial	$4,012.85
Rate for Payer: Humana Medicare	$1,463.51
Rate for Payer: Kaiser Permanente Commercial	$4,248.90
Rate for Payer: Kaiser Permanente Medicaid	$2,407.71
Rate for Payer: Kaiser Permanente Medicare	$1,463.51
Rate for Payer: MDX Hawaii PPO	$4,579.37
Rate for Payer: Ohana Health Plan Medicaid	$1,463.51
Rate for Payer: Ohana Health Plan Medicare	$1,463.51
Rate for Payer: UnitedHealthcare Medicare	$1,463.51
Rate for Payer: University Health Alliance Commercial	$2,643.76

GLENOID SZ44 TSA-X3 5542-P-004

Facility

$4,721.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$2,643.76
Max. Negotiated Rate	$4,579.37
Rate for Payer: Cash Price	$2,832.60
Rate for Payer: Hawaii Western Management Group Commercial	$3,304.70
Rate for Payer: Health Management Network Commercial	$4,012.85
Rate for Payer: Kaiser Permanente Commercial	$4,248.90
Rate for Payer: MDX Hawaii PPO	$4,579.37
Rate for Payer: University Health Alliance Commercial	$2,643.76

GLENOSPHER 36X2MM 5573-2E-3602

Facility

$4,000.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$1,240.00
Max. Negotiated Rate	$3,880.00
Rate for Payer: AlohaCare Medicaid	$2,000.00
Rate for Payer: AlohaCare Medicare	$1,240.00
Rate for Payer: Cash Price	$2,400.00
Rate for Payer: Devoted Health Medicare	$1,360.00
Rate for Payer: Hawaii Medical Service Association Medicare	$1,240.00
Rate for Payer: Hawaii Western Management Group Commercial	$2,800.00
Rate for Payer: Health Management Network Commercial	$3,400.00
Rate for Payer: Humana Medicare	$1,240.00
Rate for Payer: Kaiser Permanente Commercial	$3,600.00
Rate for Payer: Kaiser Permanente Medicaid	$2,040.00
Rate for Payer: Kaiser Permanente Medicare	$1,240.00
Rate for Payer: MDX Hawaii PPO	$3,880.00
Rate for Payer: Ohana Health Plan Medicaid	$1,240.00
Rate for Payer: Ohana Health Plan Medicare	$1,240.00
Rate for Payer: UnitedHealthcare Medicare	$1,240.00
Rate for Payer: University Health Alliance Commercial	$2,240.00

GLENOSPHER 36X2MM 5573-2E-3602

Facility

$4,000.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$2,240.00
Max. Negotiated Rate	$3,880.00
Rate for Payer: Cash Price	$2,400.00
Rate for Payer: Hawaii Western Management Group Commercial	$2,800.00
Rate for Payer: Health Management Network Commercial	$3,400.00
Rate for Payer: Kaiser Permanente Commercial	$3,600.00
Rate for Payer: MDX Hawaii PPO	$3,880.00
Rate for Payer: University Health Alliance Commercial	$2,240.00

GLENOSPHERE 32X6MM 5573-C-3202

Facility

$4,000.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$1,240.00
Max. Negotiated Rate	$3,880.00
Rate for Payer: AlohaCare Medicaid	$2,000.00
Rate for Payer: AlohaCare Medicare	$1,240.00
Rate for Payer: Cash Price	$2,400.00
Rate for Payer: Devoted Health Medicare	$1,360.00
Rate for Payer: Hawaii Medical Service Association Medicare	$1,240.00
Rate for Payer: Hawaii Western Management Group Commercial	$2,800.00
Rate for Payer: Health Management Network Commercial	$3,400.00
Rate for Payer: Humana Medicare	$1,240.00
Rate for Payer: Kaiser Permanente Commercial	$3,600.00
Rate for Payer: Kaiser Permanente Medicaid	$2,040.00
Rate for Payer: Kaiser Permanente Medicare	$1,240.00
Rate for Payer: MDX Hawaii PPO	$3,880.00
Rate for Payer: Ohana Health Plan Medicaid	$1,240.00
Rate for Payer: Ohana Health Plan Medicare	$1,240.00
Rate for Payer: UnitedHealthcare Medicare	$1,240.00
Rate for Payer: University Health Alliance Commercial	$2,240.00

GLENOSPHERE 32X6MM 5573-C-3202

Facility

$4,000.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$2,240.00
Max. Negotiated Rate	$3,880.00
Rate for Payer: Cash Price	$2,400.00
Rate for Payer: Hawaii Western Management Group Commercial	$2,800.00
Rate for Payer: Health Management Network Commercial	$3,400.00
Rate for Payer: Kaiser Permanente Commercial	$3,600.00
Rate for Payer: MDX Hawaii PPO	$3,880.00
Rate for Payer: University Health Alliance Commercial	$2,240.00

GLENOSPHERE 36X2MM 5573-C-3602

Facility

$4,000.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$1,240.00
Max. Negotiated Rate	$3,880.00
Rate for Payer: AlohaCare Medicaid	$2,000.00
Rate for Payer: AlohaCare Medicare	$1,240.00
Rate for Payer: Cash Price	$2,400.00
Rate for Payer: Devoted Health Medicare	$1,360.00
Rate for Payer: Hawaii Medical Service Association Medicare	$1,240.00
Rate for Payer: Hawaii Western Management Group Commercial	$2,800.00
Rate for Payer: Health Management Network Commercial	$3,400.00
Rate for Payer: Humana Medicare	$1,240.00
Rate for Payer: Kaiser Permanente Commercial	$3,600.00
Rate for Payer: Kaiser Permanente Medicaid	$2,040.00
Rate for Payer: Kaiser Permanente Medicare	$1,240.00
Rate for Payer: MDX Hawaii PPO	$3,880.00
Rate for Payer: Ohana Health Plan Medicaid	$1,240.00
Rate for Payer: Ohana Health Plan Medicare	$1,240.00
Rate for Payer: UnitedHealthcare Medicare	$1,240.00
Rate for Payer: University Health Alliance Commercial	$2,240.00

GLENOSPHERE 36X2MM 5573-C-3602

Facility

$4,000.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$2,240.00
Max. Negotiated Rate	$3,880.00
Rate for Payer: Cash Price	$2,400.00
Rate for Payer: Hawaii Western Management Group Commercial	$2,800.00
Rate for Payer: Health Management Network Commercial	$3,400.00
Rate for Payer: Kaiser Permanente Commercial	$3,600.00
Rate for Payer: MDX Hawaii PPO	$3,880.00
Rate for Payer: University Health Alliance Commercial	$2,240.00

GLENOSPHERE COCR + TI6AI4V

Facility

$9,558.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$5,352.48
Max. Negotiated Rate	$9,271.26
Rate for Payer: Cash Price	$5,734.80
Rate for Payer: Hawaii Western Management Group Commercial	$6,690.60
Rate for Payer: Health Management Network Commercial	$8,124.30
Rate for Payer: Kaiser Permanente Commercial	$8,602.20
Rate for Payer: MDX Hawaii PPO	$9,271.26
Rate for Payer: University Health Alliance Commercial	$5,352.48

GLENOSPHERE COCR + TI6AI4V

Facility

$9,558.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$2,962.98
Max. Negotiated Rate	$9,271.26
Rate for Payer: AlohaCare Medicaid	$4,779.00
Rate for Payer: AlohaCare Medicare	$2,962.98
Rate for Payer: Cash Price	$5,734.80
Rate for Payer: Devoted Health Medicare	$3,249.72
Rate for Payer: Hawaii Medical Service Association Medicare	$2,962.98
Rate for Payer: Hawaii Western Management Group Commercial	$6,690.60
Rate for Payer: Health Management Network Commercial	$8,124.30
Rate for Payer: Humana Medicare	$2,962.98
Rate for Payer: Kaiser Permanente Commercial	$8,602.20
Rate for Payer: Kaiser Permanente Medicaid	$4,874.58
Rate for Payer: Kaiser Permanente Medicare	$2,962.98
Rate for Payer: MDX Hawaii PPO	$9,271.26
Rate for Payer: Ohana Health Plan Medicaid	$2,962.98
Rate for Payer: Ohana Health Plan Medicare	$2,962.98
Rate for Payer: UnitedHealthcare Medicare	$2,962.98
Rate for Payer: University Health Alliance Commercial	$5,352.48

GLENOSPHERE DWJ1017301

Facility

$6,028.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$3,375.68
Max. Negotiated Rate	$5,847.16
Rate for Payer: Cash Price	$3,616.80
Rate for Payer: Hawaii Western Management Group Commercial	$4,219.60
Rate for Payer: Health Management Network Commercial	$5,123.80
Rate for Payer: Kaiser Permanente Commercial	$5,425.20
Rate for Payer: MDX Hawaii PPO	$5,847.16
Rate for Payer: University Health Alliance Commercial	$3,375.68

GLENOSPHERE DWJ1017301

Facility

$6,028.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$1,868.68
Max. Negotiated Rate	$5,847.16
Rate for Payer: AlohaCare Medicaid	$3,014.00
Rate for Payer: AlohaCare Medicare	$1,868.68
Rate for Payer: Cash Price	$3,616.80
Rate for Payer: Devoted Health Medicare	$2,049.52
Rate for Payer: Hawaii Medical Service Association Medicare	$1,868.68
Rate for Payer: Hawaii Western Management Group Commercial	$4,219.60
Rate for Payer: Health Management Network Commercial	$5,123.80
Rate for Payer: Humana Medicare	$1,868.68
Rate for Payer: Kaiser Permanente Commercial	$5,425.20
Rate for Payer: Kaiser Permanente Medicaid	$3,074.28
Rate for Payer: Kaiser Permanente Medicare	$1,868.68
Rate for Payer: MDX Hawaii PPO	$5,847.16
Rate for Payer: Ohana Health Plan Medicaid	$1,868.68
Rate for Payer: Ohana Health Plan Medicare	$1,868.68
Rate for Payer: UnitedHealthcare Medicare	$1,868.68
Rate for Payer: University Health Alliance Commercial	$3,375.68

GLENOSPHERE RVS SHDR STD 36M

Facility

$1,845.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$1,033.20
Max. Negotiated Rate	$1,789.65
Rate for Payer: Cash Price	$1,107.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,291.50
Rate for Payer: Health Management Network Commercial	$1,568.25
Rate for Payer: Kaiser Permanente Commercial	$1,660.50
Rate for Payer: MDX Hawaii PPO	$1,789.65
Rate for Payer: University Health Alliance Commercial	$1,033.20

GLENOSPHERE RVS SHDR STD 36M

Facility

$1,845.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$571.95
Max. Negotiated Rate	$1,789.65
Rate for Payer: AlohaCare Medicaid	$922.50
Rate for Payer: AlohaCare Medicare	$571.95
Rate for Payer: Cash Price	$1,107.00
Rate for Payer: Devoted Health Medicare	$627.30
Rate for Payer: Hawaii Medical Service Association Medicare	$571.95
Rate for Payer: Hawaii Western Management Group Commercial	$1,291.50
Rate for Payer: Health Management Network Commercial	$1,568.25
Rate for Payer: Humana Medicare	$571.95
Rate for Payer: Kaiser Permanente Commercial	$1,660.50
Rate for Payer: Kaiser Permanente Medicaid	$940.95
Rate for Payer: Kaiser Permanente Medicare	$571.95
Rate for Payer: MDX Hawaii PPO	$1,789.65
Rate for Payer: Ohana Health Plan Medicaid	$571.95
Rate for Payer: Ohana Health Plan Medicare	$571.95
Rate for Payer: UnitedHealthcare Medicare	$571.95
Rate for Payer: University Health Alliance Commercial	$1,033.20

GLIDEWIRE .25ANGL M0066802021

Facility

$183.00

Service Code	HCPCS C1769
Hospital Revenue Code	272
Min. Negotiated Rate	$56.73
Max. Negotiated Rate	$177.51
Rate for Payer: AlohaCare Medicaid	$91.50
Rate for Payer: AlohaCare Medicare	$56.73
Rate for Payer: Cash Price	$109.80
Rate for Payer: Devoted Health Medicare	$62.22
Rate for Payer: Hawaii Medical Service Association Medicare	$56.73
Rate for Payer: Hawaii Western Management Group Commercial	$173.85
Rate for Payer: Health Management Network Commercial	$155.55
Rate for Payer: Humana Medicare	$56.73
Rate for Payer: Kaiser Permanente Commercial	$164.70
Rate for Payer: Kaiser Permanente Medicaid	$93.33
Rate for Payer: Kaiser Permanente Medicare	$56.73
Rate for Payer: MDX Hawaii PPO	$177.51
Rate for Payer: Ohana Health Plan Medicaid	$56.73
Rate for Payer: Ohana Health Plan Medicare	$56.73
Rate for Payer: UnitedHealthcare Medicare	$56.73
Rate for Payer: University Health Alliance Commercial	$133.39

GLIDEWIRE .25ANGL M0066802021

Facility

$183.00

Service Code	HCPCS C1769
Hospital Revenue Code	272
Min. Negotiated Rate	$155.55
Max. Negotiated Rate	$177.51
Rate for Payer: Cash Price	$109.80
Rate for Payer: Health Management Network Commercial	$155.55
Rate for Payer: Kaiser Permanente Commercial	$164.70
Rate for Payer: MDX Hawaii PPO	$177.51

GLIDEWIRE STIFF ANG 35X260

Facility

$277.00

Service Code	HCPCS C1769
Hospital Revenue Code	272
Min. Negotiated Rate	$85.87
Max. Negotiated Rate	$268.69
Rate for Payer: AlohaCare Medicaid	$138.50
Rate for Payer: AlohaCare Medicare	$85.87
Rate for Payer: Cash Price	$166.20
Rate for Payer: Devoted Health Medicare	$94.18
Rate for Payer: Hawaii Medical Service Association Medicare	$85.87
Rate for Payer: Hawaii Western Management Group Commercial	$263.15
Rate for Payer: Health Management Network Commercial	$235.45
Rate for Payer: Humana Medicare	$85.87
Rate for Payer: Kaiser Permanente Commercial	$249.30
Rate for Payer: Kaiser Permanente Medicaid	$141.27
Rate for Payer: Kaiser Permanente Medicare	$85.87
Rate for Payer: MDX Hawaii PPO	$268.69
Rate for Payer: Ohana Health Plan Medicaid	$85.87
Rate for Payer: Ohana Health Plan Medicare	$85.87
Rate for Payer: UnitedHealthcare Medicare	$85.87
Rate for Payer: University Health Alliance Commercial	$201.91

GLIDEWIRE STIFF ANG 35X260

Facility

$277.00

Service Code	HCPCS C1769
Hospital Revenue Code	272
Min. Negotiated Rate	$235.45
Max. Negotiated Rate	$268.69
Rate for Payer: Cash Price	$166.20
Rate for Payer: Health Management Network Commercial	$235.45
Rate for Payer: Kaiser Permanente Commercial	$249.30
Rate for Payer: MDX Hawaii PPO	$268.69

GLIDEWIRE STRAIGHT 0.25

Facility

$183.00

Service Code	HCPCS C1769
Hospital Revenue Code	272
Min. Negotiated Rate	$155.55
Max. Negotiated Rate	$177.51
Rate for Payer: Cash Price	$109.80
Rate for Payer: Health Management Network Commercial	$155.55
Rate for Payer: Kaiser Permanente Commercial	$164.70
Rate for Payer: MDX Hawaii PPO	$177.51

Know your out-of-pocket cost for care.

All Charges