Kau Hospital

All Charges

Charge

Type

Setting

Price

GLYCERIN (CHILD) RECTAL SUPPOSITORY [76974]

Facility

$1.00

Service Code	NDC 46122022263
Hospital Revenue Code	250
Min. Negotiated Rate	$0.85
Max. Negotiated Rate	$0.97
Rate for Payer: Cash Price	$0.60
Rate for Payer: Health Management Network Commercial	$0.85
Rate for Payer: Kaiser Permanente Commercial	$0.90
Rate for Payer: MDX Hawaii PPO	$0.97

GLYCERIN (CHILD) RECTAL SUPPOSITORY [76974]

Facility

$1.00

Service Code	NDC 46122022263
Hospital Revenue Code	637
Min. Negotiated Rate	$0.31
Max. Negotiated Rate	$0.97
Rate for Payer: AlohaCare Medicaid	$0.50
Rate for Payer: AlohaCare Medicare	$0.31
Rate for Payer: Cash Price	$0.60
Rate for Payer: Devoted Health Medicare	$0.34
Rate for Payer: Hawaii Medical Service Association Medicare	$0.31
Rate for Payer: Hawaii Western Management Group Commercial	$0.95
Rate for Payer: Health Management Network Commercial	$0.85
Rate for Payer: Humana Medicare	$0.31
Rate for Payer: Kaiser Permanente Commercial	$0.90
Rate for Payer: Kaiser Permanente Medicaid	$0.51
Rate for Payer: Kaiser Permanente Medicare	$0.31
Rate for Payer: MDX Hawaii PPO	$0.97
Rate for Payer: Ohana Health Plan Medicaid	$0.31
Rate for Payer: Ohana Health Plan Medicare	$0.31
Rate for Payer: UnitedHealthcare Medicare	$0.31
Rate for Payer: University Health Alliance Commercial	$0.73

GLYCERIN (CHILD) RECTAL SUPPOSITORY [76974]

Facility

$1.00

Service Code	NDC 42512000000
Hospital Revenue Code	637
Min. Negotiated Rate	$0.31
Max. Negotiated Rate	$0.97
Rate for Payer: AlohaCare Medicaid	$0.50
Rate for Payer: AlohaCare Medicare	$0.31
Rate for Payer: Cash Price	$0.60
Rate for Payer: Devoted Health Medicare	$0.34
Rate for Payer: Hawaii Medical Service Association Medicare	$0.31
Rate for Payer: Hawaii Western Management Group Commercial	$0.95
Rate for Payer: Health Management Network Commercial	$0.85
Rate for Payer: Humana Medicare	$0.31
Rate for Payer: Kaiser Permanente Commercial	$0.90
Rate for Payer: Kaiser Permanente Medicaid	$0.51
Rate for Payer: Kaiser Permanente Medicare	$0.31
Rate for Payer: MDX Hawaii PPO	$0.97
Rate for Payer: Ohana Health Plan Medicaid	$0.31
Rate for Payer: Ohana Health Plan Medicare	$0.31
Rate for Payer: UnitedHealthcare Medicare	$0.31
Rate for Payer: University Health Alliance Commercial	$0.73

GLYCOPYRROLATE 0.2 MG/ML INJECTION SOLUTION [3497]

Facility

$12.00

Service Code	HCPCS J1596
Hospital Revenue Code	250
Min. Negotiated Rate	$10.20
Max. Negotiated Rate	$11.64
Rate for Payer: Cash Price	$7.20
Rate for Payer: Cash Price	$4.20
Rate for Payer: Health Management Network Commercial	$10.20
Rate for Payer: Health Management Network Commercial	$5.95
Rate for Payer: Kaiser Permanente Commercial	$10.80
Rate for Payer: Kaiser Permanente Commercial	$6.30
Rate for Payer: MDX Hawaii PPO	$6.79
Rate for Payer: MDX Hawaii PPO	$11.64

GLYCOPYRROLATE 0.2 MG/ML INJECTION SOLUTION [3497]

Facility

$12.00

Service Code	HCPCS J1596
Hospital Revenue Code	636
Min. Negotiated Rate	$0.43
Max. Negotiated Rate	$11.64
Rate for Payer: AlohaCare Medicaid	$6.00
Rate for Payer: AlohaCare Medicaid	$3.50
Rate for Payer: AlohaCare Medicare	$2.17
Rate for Payer: AlohaCare Medicare	$3.72
Rate for Payer: Cash Price	$4.20
Rate for Payer: Cash Price	$7.20
Rate for Payer: Cash Price	$7.20
Rate for Payer: Cash Price	$4.20
Rate for Payer: Devoted Health Medicare	$4.08
Rate for Payer: Devoted Health Medicare	$2.38
Rate for Payer: Hawaii Medical Service Association ABD	$0.43
Rate for Payer: Hawaii Medical Service Association ABD	$0.43
Rate for Payer: Hawaii Medical Service Association Medicare	$2.17
Rate for Payer: Hawaii Medical Service Association Medicare	$3.72
Rate for Payer: Hawaii Medical Service Association Non-ABD	$0.43
Rate for Payer: Hawaii Medical Service Association Non-ABD	$0.43
Rate for Payer: Hawaii Western Management Group Commercial	$11.40
Rate for Payer: Hawaii Western Management Group Commercial	$6.65
Rate for Payer: Health Management Network Commercial	$5.95
Rate for Payer: Health Management Network Commercial	$10.20
Rate for Payer: Humana Medicare	$3.72
Rate for Payer: Humana Medicare	$2.17
Rate for Payer: Kaiser Permanente Commercial	$10.80
Rate for Payer: Kaiser Permanente Commercial	$6.30
Rate for Payer: Kaiser Permanente Medicaid	$3.57
Rate for Payer: Kaiser Permanente Medicaid	$6.12
Rate for Payer: Kaiser Permanente Medicare	$3.72
Rate for Payer: Kaiser Permanente Medicare	$2.17
Rate for Payer: MDX Hawaii PPO	$11.64
Rate for Payer: MDX Hawaii PPO	$6.79
Rate for Payer: Ohana Health Plan Medicaid	$2.17
Rate for Payer: Ohana Health Plan Medicaid	$3.72
Rate for Payer: Ohana Health Plan Medicare	$3.72
Rate for Payer: Ohana Health Plan Medicare	$2.17
Rate for Payer: UnitedHealthcare Medicaid	$4.20
Rate for Payer: UnitedHealthcare Medicaid	$7.20
Rate for Payer: UnitedHealthcare Medicare	$3.72
Rate for Payer: UnitedHealthcare Medicare	$2.17
Rate for Payer: University Health Alliance Commercial	$8.75
Rate for Payer: University Health Alliance Commercial	$5.10

GORE DRYSEAL SHEATH 12FRX45CM

Facility

$2,271.00

Service Code	HCPCS C1894
Hospital Revenue Code	272
Min. Negotiated Rate	$1,930.35
Max. Negotiated Rate	$2,202.87
Rate for Payer: Cash Price	$1,362.60
Rate for Payer: Health Management Network Commercial	$1,930.35
Rate for Payer: Kaiser Permanente Commercial	$2,043.90
Rate for Payer: MDX Hawaii PPO	$2,202.87

GORE DRYSEAL SHEATH 12FRX45CM

Facility

$2,271.00

Service Code	HCPCS C1894
Hospital Revenue Code	272
Min. Negotiated Rate	$704.01
Max. Negotiated Rate	$2,202.87
Rate for Payer: AlohaCare Medicaid	$1,135.50
Rate for Payer: AlohaCare Medicare	$704.01
Rate for Payer: Cash Price	$1,362.60
Rate for Payer: Devoted Health Medicare	$772.14
Rate for Payer: Hawaii Medical Service Association Medicare	$704.01
Rate for Payer: Hawaii Western Management Group Commercial	$2,157.45
Rate for Payer: Health Management Network Commercial	$1,930.35
Rate for Payer: Humana Medicare	$704.01
Rate for Payer: Kaiser Permanente Commercial	$2,043.90
Rate for Payer: Kaiser Permanente Medicaid	$1,158.21
Rate for Payer: Kaiser Permanente Medicare	$704.01
Rate for Payer: MDX Hawaii PPO	$2,202.87
Rate for Payer: Ohana Health Plan Medicaid	$704.01
Rate for Payer: Ohana Health Plan Medicare	$704.01
Rate for Payer: UnitedHealthcare Medicare	$704.01
Rate for Payer: University Health Alliance Commercial	$1,655.33

GORE DRYSEAL SHEATH 12FX33CM

Facility

$2,448.00

Service Code	HCPCS C1894
Hospital Revenue Code	272
Min. Negotiated Rate	$758.88
Max. Negotiated Rate	$2,374.56
Rate for Payer: AlohaCare Medicaid	$1,224.00
Rate for Payer: AlohaCare Medicare	$758.88
Rate for Payer: Cash Price	$1,468.80
Rate for Payer: Devoted Health Medicare	$832.32
Rate for Payer: Hawaii Medical Service Association Medicare	$758.88
Rate for Payer: Hawaii Western Management Group Commercial	$2,325.60
Rate for Payer: Health Management Network Commercial	$2,080.80
Rate for Payer: Humana Medicare	$758.88
Rate for Payer: Kaiser Permanente Commercial	$2,203.20
Rate for Payer: Kaiser Permanente Medicaid	$1,248.48
Rate for Payer: Kaiser Permanente Medicare	$758.88
Rate for Payer: MDX Hawaii PPO	$2,374.56
Rate for Payer: Ohana Health Plan Medicaid	$758.88
Rate for Payer: Ohana Health Plan Medicare	$758.88
Rate for Payer: UnitedHealthcare Medicare	$758.88
Rate for Payer: University Health Alliance Commercial	$1,784.35

GORE DRYSEAL SHEATH 12FX33CM

Facility

$2,448.00

Service Code	HCPCS C1894
Hospital Revenue Code	272
Min. Negotiated Rate	$2,080.80
Max. Negotiated Rate	$2,374.56
Rate for Payer: Cash Price	$1,468.80
Rate for Payer: Health Management Network Commercial	$2,080.80
Rate for Payer: Kaiser Permanente Commercial	$2,203.20
Rate for Payer: MDX Hawaii PPO	$2,374.56

GORE DRYSEAL SHEATH 14FRX33CM

Facility

$1,548.00

Service Code	HCPCS C1894
Hospital Revenue Code	272
Min. Negotiated Rate	$479.88
Max. Negotiated Rate	$1,501.56
Rate for Payer: AlohaCare Medicaid	$774.00
Rate for Payer: AlohaCare Medicare	$479.88
Rate for Payer: Cash Price	$928.80
Rate for Payer: Devoted Health Medicare	$526.32
Rate for Payer: Hawaii Medical Service Association Medicare	$479.88
Rate for Payer: Hawaii Western Management Group Commercial	$1,470.60
Rate for Payer: Health Management Network Commercial	$1,315.80
Rate for Payer: Humana Medicare	$479.88
Rate for Payer: Kaiser Permanente Commercial	$1,393.20
Rate for Payer: Kaiser Permanente Medicaid	$789.48
Rate for Payer: Kaiser Permanente Medicare	$479.88
Rate for Payer: MDX Hawaii PPO	$1,501.56
Rate for Payer: Ohana Health Plan Medicaid	$479.88
Rate for Payer: Ohana Health Plan Medicare	$479.88
Rate for Payer: UnitedHealthcare Medicare	$479.88
Rate for Payer: University Health Alliance Commercial	$1,128.34

GORE DRYSEAL SHEATH 14FRX33CM

Facility

$1,548.00

Service Code	HCPCS C1894
Hospital Revenue Code	272
Min. Negotiated Rate	$1,315.80
Max. Negotiated Rate	$1,501.56
Rate for Payer: Cash Price	$928.80
Rate for Payer: Health Management Network Commercial	$1,315.80
Rate for Payer: Kaiser Permanente Commercial	$1,393.20
Rate for Payer: MDX Hawaii PPO	$1,501.56

GORE DRYSEAL SHEATH 15FRX33CM

Facility

$2,448.00

Service Code	HCPCS C1894
Hospital Revenue Code	272
Min. Negotiated Rate	$758.88
Max. Negotiated Rate	$2,374.56
Rate for Payer: AlohaCare Medicaid	$1,224.00
Rate for Payer: AlohaCare Medicare	$758.88
Rate for Payer: Cash Price	$1,468.80
Rate for Payer: Devoted Health Medicare	$832.32
Rate for Payer: Hawaii Medical Service Association Medicare	$758.88
Rate for Payer: Hawaii Western Management Group Commercial	$2,325.60
Rate for Payer: Health Management Network Commercial	$2,080.80
Rate for Payer: Humana Medicare	$758.88
Rate for Payer: Kaiser Permanente Commercial	$2,203.20
Rate for Payer: Kaiser Permanente Medicaid	$1,248.48
Rate for Payer: Kaiser Permanente Medicare	$758.88
Rate for Payer: MDX Hawaii PPO	$2,374.56
Rate for Payer: Ohana Health Plan Medicaid	$758.88
Rate for Payer: Ohana Health Plan Medicare	$758.88
Rate for Payer: UnitedHealthcare Medicare	$758.88
Rate for Payer: University Health Alliance Commercial	$1,784.35

GORE DRYSEAL SHEATH 15FRX33CM

Facility

$2,448.00

Service Code	HCPCS C1894
Hospital Revenue Code	272
Min. Negotiated Rate	$2,080.80
Max. Negotiated Rate	$2,374.56
Rate for Payer: Cash Price	$1,468.80
Rate for Payer: Health Management Network Commercial	$2,080.80
Rate for Payer: Kaiser Permanente Commercial	$2,203.20
Rate for Payer: MDX Hawaii PPO	$2,374.56

GORE DRYSEAL SHEATH 16FRX33CM

Facility

$2,400.00

Service Code	HCPCS C1894
Hospital Revenue Code	272
Min. Negotiated Rate	$2,040.00
Max. Negotiated Rate	$2,328.00
Rate for Payer: Cash Price	$1,440.00
Rate for Payer: Health Management Network Commercial	$2,040.00
Rate for Payer: Kaiser Permanente Commercial	$2,160.00
Rate for Payer: MDX Hawaii PPO	$2,328.00

GORE DRYSEAL SHEATH 16FRX33CM

Facility

$2,400.00

Service Code	HCPCS C1894
Hospital Revenue Code	272
Min. Negotiated Rate	$744.00
Max. Negotiated Rate	$2,328.00
Rate for Payer: AlohaCare Medicaid	$1,200.00
Rate for Payer: AlohaCare Medicare	$744.00
Rate for Payer: Cash Price	$1,440.00
Rate for Payer: Devoted Health Medicare	$816.00
Rate for Payer: Hawaii Medical Service Association Medicare	$744.00
Rate for Payer: Hawaii Western Management Group Commercial	$2,280.00
Rate for Payer: Health Management Network Commercial	$2,040.00
Rate for Payer: Humana Medicare	$744.00
Rate for Payer: Kaiser Permanente Commercial	$2,160.00
Rate for Payer: Kaiser Permanente Medicaid	$1,224.00
Rate for Payer: Kaiser Permanente Medicare	$744.00
Rate for Payer: MDX Hawaii PPO	$2,328.00
Rate for Payer: Ohana Health Plan Medicaid	$744.00
Rate for Payer: Ohana Health Plan Medicare	$744.00
Rate for Payer: UnitedHealthcare Medicare	$744.00
Rate for Payer: University Health Alliance Commercial	$1,749.36

GORE DRYSEAL SHEATH 18FRX28CM

Facility

$1,155.00

Service Code	HCPCS C1894
Hospital Revenue Code	272
Min. Negotiated Rate	$358.05
Max. Negotiated Rate	$1,120.35
Rate for Payer: AlohaCare Medicaid	$577.50
Rate for Payer: AlohaCare Medicare	$358.05
Rate for Payer: Cash Price	$693.00
Rate for Payer: Devoted Health Medicare	$392.70
Rate for Payer: Hawaii Medical Service Association Medicare	$358.05
Rate for Payer: Hawaii Western Management Group Commercial	$1,097.25
Rate for Payer: Health Management Network Commercial	$981.75
Rate for Payer: Humana Medicare	$358.05
Rate for Payer: Kaiser Permanente Commercial	$1,039.50
Rate for Payer: Kaiser Permanente Medicaid	$589.05
Rate for Payer: Kaiser Permanente Medicare	$358.05
Rate for Payer: MDX Hawaii PPO	$1,120.35
Rate for Payer: Ohana Health Plan Medicaid	$358.05
Rate for Payer: Ohana Health Plan Medicare	$358.05
Rate for Payer: UnitedHealthcare Medicare	$358.05
Rate for Payer: University Health Alliance Commercial	$841.88

GORE DRYSEAL SHEATH 18FRX28CM

Facility

$1,155.00

Service Code	HCPCS C1894
Hospital Revenue Code	272
Min. Negotiated Rate	$981.75
Max. Negotiated Rate	$1,120.35
Rate for Payer: Cash Price	$693.00
Rate for Payer: Health Management Network Commercial	$981.75
Rate for Payer: Kaiser Permanente Commercial	$1,039.50
Rate for Payer: MDX Hawaii PPO	$1,120.35

GORE DRYSEAL SHEATH 18FRX33CM

Facility

$2,200.00

Service Code	HCPCS C1894
Hospital Revenue Code	272
Min. Negotiated Rate	$1,870.00
Max. Negotiated Rate	$2,134.00
Rate for Payer: Cash Price	$1,320.00
Rate for Payer: Health Management Network Commercial	$1,870.00
Rate for Payer: Kaiser Permanente Commercial	$1,980.00
Rate for Payer: MDX Hawaii PPO	$2,134.00

GORE DRYSEAL SHEATH 18FRX33CM

Facility

$2,200.00

Service Code	HCPCS C1894
Hospital Revenue Code	272
Min. Negotiated Rate	$682.00
Max. Negotiated Rate	$2,134.00
Rate for Payer: AlohaCare Medicaid	$1,100.00
Rate for Payer: AlohaCare Medicare	$682.00
Rate for Payer: Cash Price	$1,320.00
Rate for Payer: Devoted Health Medicare	$748.00
Rate for Payer: Hawaii Medical Service Association Medicare	$682.00
Rate for Payer: Hawaii Western Management Group Commercial	$2,090.00
Rate for Payer: Health Management Network Commercial	$1,870.00
Rate for Payer: Humana Medicare	$682.00
Rate for Payer: Kaiser Permanente Commercial	$1,980.00
Rate for Payer: Kaiser Permanente Medicaid	$1,122.00
Rate for Payer: Kaiser Permanente Medicare	$682.00
Rate for Payer: MDX Hawaii PPO	$2,134.00
Rate for Payer: Ohana Health Plan Medicaid	$682.00
Rate for Payer: Ohana Health Plan Medicare	$682.00
Rate for Payer: UnitedHealthcare Medicare	$682.00
Rate for Payer: University Health Alliance Commercial	$1,603.58

GORE ERLY CANN GRFT ECH470045A

Facility

$2,960.00

Service Code	HCPCS C1768
Hospital Revenue Code	278
Min. Negotiated Rate	$917.60
Max. Negotiated Rate	$2,871.20
Rate for Payer: AlohaCare Medicaid	$1,480.00
Rate for Payer: AlohaCare Medicare	$917.60
Rate for Payer: Cash Price	$1,776.00
Rate for Payer: Devoted Health Medicare	$1,006.40
Rate for Payer: Hawaii Medical Service Association Medicare	$917.60
Rate for Payer: Hawaii Western Management Group Commercial	$2,072.00
Rate for Payer: Health Management Network Commercial	$2,516.00
Rate for Payer: Humana Medicare	$917.60
Rate for Payer: Kaiser Permanente Commercial	$2,664.00
Rate for Payer: Kaiser Permanente Medicaid	$1,509.60
Rate for Payer: Kaiser Permanente Medicare	$917.60
Rate for Payer: MDX Hawaii PPO	$2,871.20
Rate for Payer: Ohana Health Plan Medicaid	$917.60
Rate for Payer: Ohana Health Plan Medicare	$917.60
Rate for Payer: UnitedHealthcare Medicare	$917.60
Rate for Payer: University Health Alliance Commercial	$1,657.60

GORE ERLY CANN GRFT ECH470045A

Facility

$2,960.00

Service Code	HCPCS C1768
Hospital Revenue Code	278
Min. Negotiated Rate	$1,657.60
Max. Negotiated Rate	$2,871.20
Rate for Payer: Cash Price	$1,776.00
Rate for Payer: Hawaii Western Management Group Commercial	$2,072.00
Rate for Payer: Health Management Network Commercial	$2,516.00
Rate for Payer: Kaiser Permanente Commercial	$2,664.00
Rate for Payer: MDX Hawaii PPO	$2,871.20
Rate for Payer: University Health Alliance Commercial	$1,657.60

GORE GRAFT 12X50CM SBT1202D

Facility

$2,892.00

Service Code	HCPCS C1768
Hospital Revenue Code	278
Min. Negotiated Rate	$896.52
Max. Negotiated Rate	$2,805.24
Rate for Payer: AlohaCare Medicaid	$1,446.00
Rate for Payer: AlohaCare Medicare	$896.52
Rate for Payer: Cash Price	$1,735.20
Rate for Payer: Devoted Health Medicare	$983.28
Rate for Payer: Hawaii Medical Service Association Medicare	$896.52
Rate for Payer: Hawaii Western Management Group Commercial	$2,024.40
Rate for Payer: Health Management Network Commercial	$2,458.20
Rate for Payer: Humana Medicare	$896.52
Rate for Payer: Kaiser Permanente Commercial	$2,602.80
Rate for Payer: Kaiser Permanente Medicaid	$1,474.92
Rate for Payer: Kaiser Permanente Medicare	$896.52
Rate for Payer: MDX Hawaii PPO	$2,805.24
Rate for Payer: Ohana Health Plan Medicaid	$896.52
Rate for Payer: Ohana Health Plan Medicare	$896.52
Rate for Payer: UnitedHealthcare Medicare	$896.52
Rate for Payer: University Health Alliance Commercial	$1,619.52

GORE GRAFT 12X50CM SBT1202D

Facility

$2,892.00

Service Code	HCPCS C1768
Hospital Revenue Code	278
Min. Negotiated Rate	$1,619.52
Max. Negotiated Rate	$2,805.24
Rate for Payer: Cash Price	$1,735.20
Rate for Payer: Hawaii Western Management Group Commercial	$2,024.40
Rate for Payer: Health Management Network Commercial	$2,458.20
Rate for Payer: Kaiser Permanente Commercial	$2,602.80
Rate for Payer: MDX Hawaii PPO	$2,805.24
Rate for Payer: University Health Alliance Commercial	$1,619.52

GORE INTERING 4-7X45 IRS47045L

Facility

$1,947.00

Service Code	HCPCS C1768
Hospital Revenue Code	278
Min. Negotiated Rate	$603.57
Max. Negotiated Rate	$1,888.59
Rate for Payer: AlohaCare Medicaid	$973.50
Rate for Payer: AlohaCare Medicare	$603.57
Rate for Payer: Cash Price	$1,168.20
Rate for Payer: Devoted Health Medicare	$661.98
Rate for Payer: Hawaii Medical Service Association Medicare	$603.57
Rate for Payer: Hawaii Western Management Group Commercial	$1,362.90
Rate for Payer: Health Management Network Commercial	$1,654.95
Rate for Payer: Humana Medicare	$603.57
Rate for Payer: Kaiser Permanente Commercial	$1,752.30
Rate for Payer: Kaiser Permanente Medicaid	$992.97
Rate for Payer: Kaiser Permanente Medicare	$603.57
Rate for Payer: MDX Hawaii PPO	$1,888.59
Rate for Payer: Ohana Health Plan Medicaid	$603.57
Rate for Payer: Ohana Health Plan Medicare	$603.57
Rate for Payer: UnitedHealthcare Medicare	$603.57
Rate for Payer: University Health Alliance Commercial	$1,090.32

GORE INTERING 4-7X45 IRS47045L

Facility

$1,947.00

Service Code	HCPCS C1768
Hospital Revenue Code	278
Min. Negotiated Rate	$1,090.32
Max. Negotiated Rate	$1,888.59
Rate for Payer: Cash Price	$1,168.20
Rate for Payer: Hawaii Western Management Group Commercial	$1,362.90
Rate for Payer: Health Management Network Commercial	$1,654.95
Rate for Payer: Kaiser Permanente Commercial	$1,752.30
Rate for Payer: MDX Hawaii PPO	$1,888.59
Rate for Payer: University Health Alliance Commercial	$1,090.32

Know your out-of-pocket cost for care.

All Charges