Kau Hospital

All Charges

Charge

Type

Setting

Price

GOSERELIN 3.6 MG SUBCUTANEOUS IMPLANT [10137]

Facility

$1,849.00

Service Code	HCPCS J9202
Hospital Revenue Code	637
Min. Negotiated Rate	$550.61
Max. Negotiated Rate	$1,793.53
Rate for Payer: AlohaCare Medicaid	$924.50
Rate for Payer: AlohaCare Medicare	$573.19
Rate for Payer: Cash Price	$1,109.40
Rate for Payer: Cash Price	$1,109.40
Rate for Payer: Devoted Health Medicare	$628.66
Rate for Payer: Hawaii Medical Service Association ABD	$734.15
Rate for Payer: Hawaii Medical Service Association Medicare	$573.19
Rate for Payer: Hawaii Medical Service Association Non-ABD	$734.15
Rate for Payer: Hawaii Western Management Group Commercial	$1,756.55
Rate for Payer: Health Management Network Commercial	$1,571.65
Rate for Payer: Humana Medicare	$573.19
Rate for Payer: Kaiser Permanente Commercial	$1,664.10
Rate for Payer: Kaiser Permanente Medicaid	$942.99
Rate for Payer: Kaiser Permanente Medicare	$573.19
Rate for Payer: MDX Hawaii PPO	$1,793.53
Rate for Payer: Ohana Health Plan Medicaid	$573.19
Rate for Payer: Ohana Health Plan Medicare	$573.19
Rate for Payer: UnitedHealthcare Medicaid	$550.61
Rate for Payer: UnitedHealthcare Medicare	$573.19
Rate for Payer: University Health Alliance Commercial	$1,347.74

GRAFT AMNIC MEMBRANE 1.5X2

Facility

$1,725.00

Service Code	HCPCS V2787
Hospital Revenue Code	276
Min. Negotiated Rate	$966.00
Max. Negotiated Rate	$1,673.25
Rate for Payer: Cash Price	$1,035.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,207.50
Rate for Payer: Health Management Network Commercial	$1,466.25
Rate for Payer: Kaiser Permanente Commercial	$1,552.50
Rate for Payer: MDX Hawaii PPO	$1,673.25
Rate for Payer: University Health Alliance Commercial	$966.00

GRAFT AMNIC MEMBRANE 1.5X2

Facility

$1,725.00

Service Code	HCPCS V2787
Hospital Revenue Code	276
Min. Negotiated Rate	$534.75
Max. Negotiated Rate	$1,673.25
Rate for Payer: AlohaCare Medicaid	$862.50
Rate for Payer: AlohaCare Medicare	$534.75
Rate for Payer: Cash Price	$1,035.00
Rate for Payer: Devoted Health Medicare	$586.50
Rate for Payer: Hawaii Medical Service Association Medicare	$534.75
Rate for Payer: Hawaii Western Management Group Commercial	$1,207.50
Rate for Payer: Health Management Network Commercial	$1,466.25
Rate for Payer: Humana Medicare	$534.75
Rate for Payer: Kaiser Permanente Commercial	$1,552.50
Rate for Payer: Kaiser Permanente Medicaid	$879.75
Rate for Payer: Kaiser Permanente Medicare	$534.75
Rate for Payer: MDX Hawaii PPO	$1,673.25
Rate for Payer: Ohana Health Plan Medicaid	$534.75
Rate for Payer: Ohana Health Plan Medicare	$534.75
Rate for Payer: UnitedHealthcare Medicare	$534.75
Rate for Payer: University Health Alliance Commercial	$966.00

GRAFT COLLAGEN 6MMX39CM AG735

Facility

$3,638.00

Service Code	HCPCS C1768
Hospital Revenue Code	278
Min. Negotiated Rate	$2,037.28
Max. Negotiated Rate	$3,528.86
Rate for Payer: Cash Price	$2,182.80
Rate for Payer: Hawaii Western Management Group Commercial	$2,546.60
Rate for Payer: Health Management Network Commercial	$3,092.30
Rate for Payer: Kaiser Permanente Commercial	$3,274.20
Rate for Payer: MDX Hawaii PPO	$3,528.86
Rate for Payer: University Health Alliance Commercial	$2,037.28

GRAFT COLLAGEN 6MMX39CM AG735

Facility

$3,638.00

Service Code	HCPCS C1768
Hospital Revenue Code	278
Min. Negotiated Rate	$1,127.78
Max. Negotiated Rate	$3,528.86
Rate for Payer: AlohaCare Medicaid	$1,819.00
Rate for Payer: AlohaCare Medicare	$1,127.78
Rate for Payer: Cash Price	$2,182.80
Rate for Payer: Devoted Health Medicare	$1,236.92
Rate for Payer: Hawaii Medical Service Association Medicare	$1,127.78
Rate for Payer: Hawaii Western Management Group Commercial	$2,546.60
Rate for Payer: Health Management Network Commercial	$3,092.30
Rate for Payer: Humana Medicare	$1,127.78
Rate for Payer: Kaiser Permanente Commercial	$3,274.20
Rate for Payer: Kaiser Permanente Medicaid	$1,855.38
Rate for Payer: Kaiser Permanente Medicare	$1,127.78
Rate for Payer: MDX Hawaii PPO	$3,528.86
Rate for Payer: Ohana Health Plan Medicaid	$1,127.78
Rate for Payer: Ohana Health Plan Medicare	$1,127.78
Rate for Payer: UnitedHealthcare Medicare	$1,127.78
Rate for Payer: University Health Alliance Commercial	$2,037.28

GRAFT COLLAGEN 6MMX40CM AG740

Facility

$4,718.00

Service Code	HCPCS C1768
Hospital Revenue Code	278
Min. Negotiated Rate	$2,642.08
Max. Negotiated Rate	$4,576.46
Rate for Payer: Cash Price	$2,830.80
Rate for Payer: Hawaii Western Management Group Commercial	$3,302.60
Rate for Payer: Health Management Network Commercial	$4,010.30
Rate for Payer: Kaiser Permanente Commercial	$4,246.20
Rate for Payer: MDX Hawaii PPO	$4,576.46
Rate for Payer: University Health Alliance Commercial	$2,642.08

GRAFT COLLAGEN 6MMX40CM AG740

Facility

$4,718.00

Service Code	HCPCS C1768
Hospital Revenue Code	278
Min. Negotiated Rate	$1,462.58
Max. Negotiated Rate	$4,576.46
Rate for Payer: AlohaCare Medicaid	$2,359.00
Rate for Payer: AlohaCare Medicare	$1,462.58
Rate for Payer: Cash Price	$2,830.80
Rate for Payer: Devoted Health Medicare	$1,604.12
Rate for Payer: Hawaii Medical Service Association Medicare	$1,462.58
Rate for Payer: Hawaii Western Management Group Commercial	$3,302.60
Rate for Payer: Health Management Network Commercial	$4,010.30
Rate for Payer: Humana Medicare	$1,462.58
Rate for Payer: Kaiser Permanente Commercial	$4,246.20
Rate for Payer: Kaiser Permanente Medicaid	$2,406.18
Rate for Payer: Kaiser Permanente Medicare	$1,462.58
Rate for Payer: MDX Hawaii PPO	$4,576.46
Rate for Payer: Ohana Health Plan Medicaid	$1,462.58
Rate for Payer: Ohana Health Plan Medicare	$1,462.58
Rate for Payer: UnitedHealthcare Medicare	$1,462.58
Rate for Payer: University Health Alliance Commercial	$2,642.08

GRAFT CONTRLT LEG 16MMX11.5CM

Facility

$11,540.00

Service Code	HCPCS C1768
Hospital Revenue Code	278
Min. Negotiated Rate	$3,577.40
Max. Negotiated Rate	$11,193.80
Rate for Payer: AlohaCare Medicaid	$5,770.00
Rate for Payer: AlohaCare Medicare	$3,577.40
Rate for Payer: Cash Price	$6,924.00
Rate for Payer: Devoted Health Medicare	$3,923.60
Rate for Payer: Hawaii Medical Service Association Medicare	$3,577.40
Rate for Payer: Hawaii Western Management Group Commercial	$8,078.00
Rate for Payer: Health Management Network Commercial	$9,809.00
Rate for Payer: Humana Medicare	$3,577.40
Rate for Payer: Kaiser Permanente Commercial	$10,386.00
Rate for Payer: Kaiser Permanente Medicaid	$5,885.40
Rate for Payer: Kaiser Permanente Medicare	$3,577.40
Rate for Payer: MDX Hawaii PPO	$11,193.80
Rate for Payer: Ohana Health Plan Medicaid	$3,577.40
Rate for Payer: Ohana Health Plan Medicare	$3,577.40
Rate for Payer: UnitedHealthcare Medicare	$3,577.40
Rate for Payer: University Health Alliance Commercial	$6,462.40

GRAFT CONTRLT LEG 16MMX11.5CM

Facility

$11,540.00

Service Code	HCPCS C1768
Hospital Revenue Code	278
Min. Negotiated Rate	$6,462.40
Max. Negotiated Rate	$11,193.80
Rate for Payer: Cash Price	$6,924.00
Rate for Payer: Hawaii Western Management Group Commercial	$8,078.00
Rate for Payer: Health Management Network Commercial	$9,809.00
Rate for Payer: Kaiser Permanente Commercial	$10,386.00
Rate for Payer: MDX Hawaii PPO	$11,193.80
Rate for Payer: University Health Alliance Commercial	$6,462.40

GRAFT GRACILIS FGRACILIS

Facility

$2,315.00

Service Code	HCPCS C1762
Hospital Revenue Code	278
Min. Negotiated Rate	$1,296.40
Max. Negotiated Rate	$2,245.55
Rate for Payer: Cash Price	$1,389.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,620.50
Rate for Payer: Health Management Network Commercial	$1,967.75
Rate for Payer: Kaiser Permanente Commercial	$2,083.50
Rate for Payer: MDX Hawaii PPO	$2,245.55
Rate for Payer: University Health Alliance Commercial	$1,296.40

GRAFT GRACILIS FGRACILIS

Facility

$2,315.00

Service Code	HCPCS C1762
Hospital Revenue Code	278
Min. Negotiated Rate	$717.65
Max. Negotiated Rate	$2,245.55
Rate for Payer: AlohaCare Medicaid	$1,157.50
Rate for Payer: AlohaCare Medicare	$717.65
Rate for Payer: Cash Price	$1,389.00
Rate for Payer: Devoted Health Medicare	$787.10
Rate for Payer: Hawaii Medical Service Association Medicare	$717.65
Rate for Payer: Hawaii Western Management Group Commercial	$1,620.50
Rate for Payer: Health Management Network Commercial	$1,967.75
Rate for Payer: Humana Medicare	$717.65
Rate for Payer: Kaiser Permanente Commercial	$2,083.50
Rate for Payer: Kaiser Permanente Medicaid	$1,180.65
Rate for Payer: Kaiser Permanente Medicare	$717.65
Rate for Payer: MDX Hawaii PPO	$2,245.55
Rate for Payer: Ohana Health Plan Medicaid	$717.65
Rate for Payer: Ohana Health Plan Medicare	$717.65
Rate for Payer: UnitedHealthcare Medicare	$717.65
Rate for Payer: University Health Alliance Commercial	$1,296.40

GRAFT HEPARIN 6X40 ECH060040A

Facility

$2,712.00

Service Code	HCPCS C1768
Hospital Revenue Code	278
Min. Negotiated Rate	$840.72
Max. Negotiated Rate	$2,630.64
Rate for Payer: AlohaCare Medicaid	$1,356.00
Rate for Payer: AlohaCare Medicare	$840.72
Rate for Payer: Cash Price	$1,627.20
Rate for Payer: Devoted Health Medicare	$922.08
Rate for Payer: Hawaii Medical Service Association Medicare	$840.72
Rate for Payer: Hawaii Western Management Group Commercial	$1,898.40
Rate for Payer: Health Management Network Commercial	$2,305.20
Rate for Payer: Humana Medicare	$840.72
Rate for Payer: Kaiser Permanente Commercial	$2,440.80
Rate for Payer: Kaiser Permanente Medicaid	$1,383.12
Rate for Payer: Kaiser Permanente Medicare	$840.72
Rate for Payer: MDX Hawaii PPO	$2,630.64
Rate for Payer: Ohana Health Plan Medicaid	$840.72
Rate for Payer: Ohana Health Plan Medicare	$840.72
Rate for Payer: UnitedHealthcare Medicare	$840.72
Rate for Payer: University Health Alliance Commercial	$1,518.72

GRAFT HEPARIN 6X40 ECH060040A

Facility

$2,712.00

Service Code	HCPCS C1768
Hospital Revenue Code	278
Min. Negotiated Rate	$1,518.72
Max. Negotiated Rate	$2,630.64
Rate for Payer: Cash Price	$1,627.20
Rate for Payer: Hawaii Western Management Group Commercial	$1,898.40
Rate for Payer: Health Management Network Commercial	$2,305.20
Rate for Payer: Kaiser Permanente Commercial	$2,440.80
Rate for Payer: MDX Hawaii PPO	$2,630.64
Rate for Payer: University Health Alliance Commercial	$1,518.72

GRAFT HERO 1000 SUPERHERO

Facility

$8,800.00

Service Code	HCPCS C1750
Hospital Revenue Code	278
Min. Negotiated Rate	$2,728.00
Max. Negotiated Rate	$8,536.00
Rate for Payer: AlohaCare Medicaid	$4,400.00
Rate for Payer: AlohaCare Medicare	$2,728.00
Rate for Payer: Cash Price	$5,280.00
Rate for Payer: Devoted Health Medicare	$2,992.00
Rate for Payer: Hawaii Medical Service Association Medicare	$2,728.00
Rate for Payer: Hawaii Western Management Group Commercial	$6,160.00
Rate for Payer: Health Management Network Commercial	$7,480.00
Rate for Payer: Humana Medicare	$2,728.00
Rate for Payer: Kaiser Permanente Commercial	$7,920.00
Rate for Payer: Kaiser Permanente Medicaid	$4,488.00
Rate for Payer: Kaiser Permanente Medicare	$2,728.00
Rate for Payer: MDX Hawaii PPO	$8,536.00
Rate for Payer: Ohana Health Plan Medicaid	$2,728.00
Rate for Payer: Ohana Health Plan Medicare	$2,728.00
Rate for Payer: UnitedHealthcare Medicare	$2,728.00
Rate for Payer: University Health Alliance Commercial	$4,928.00

GRAFT HERO 1000 SUPERHERO

Facility

$8,800.00

Service Code	HCPCS C1750
Hospital Revenue Code	278
Min. Negotiated Rate	$4,928.00
Max. Negotiated Rate	$8,536.00
Rate for Payer: Cash Price	$5,280.00
Rate for Payer: Hawaii Western Management Group Commercial	$6,160.00
Rate for Payer: Health Management Network Commercial	$7,480.00
Rate for Payer: Kaiser Permanente Commercial	$7,920.00
Rate for Payer: MDX Hawaii PPO	$8,536.00
Rate for Payer: University Health Alliance Commercial	$4,928.00

GRAFT ILIAC CREST WEDGE BONE

Facility

$2,070.00

Service Code	HCPCS C1762
Hospital Revenue Code	278
Min. Negotiated Rate	$641.70
Max. Negotiated Rate	$2,007.90
Rate for Payer: AlohaCare Medicaid	$1,035.00
Rate for Payer: AlohaCare Medicare	$641.70
Rate for Payer: Cash Price	$1,242.00
Rate for Payer: Devoted Health Medicare	$703.80
Rate for Payer: Hawaii Medical Service Association Medicare	$641.70
Rate for Payer: Hawaii Western Management Group Commercial	$1,449.00
Rate for Payer: Health Management Network Commercial	$1,759.50
Rate for Payer: Humana Medicare	$641.70
Rate for Payer: Kaiser Permanente Commercial	$1,863.00
Rate for Payer: Kaiser Permanente Medicaid	$1,055.70
Rate for Payer: Kaiser Permanente Medicare	$641.70
Rate for Payer: MDX Hawaii PPO	$2,007.90
Rate for Payer: Ohana Health Plan Medicaid	$641.70
Rate for Payer: Ohana Health Plan Medicare	$641.70
Rate for Payer: UnitedHealthcare Medicare	$641.70
Rate for Payer: University Health Alliance Commercial	$1,159.20

GRAFT ILIAC CREST WEDGE BONE

Facility

$2,070.00

Service Code	HCPCS C1762
Hospital Revenue Code	278
Min. Negotiated Rate	$1,159.20
Max. Negotiated Rate	$2,007.90
Rate for Payer: Cash Price	$1,242.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,449.00
Rate for Payer: Health Management Network Commercial	$1,759.50
Rate for Payer: Kaiser Permanente Commercial	$1,863.00
Rate for Payer: MDX Hawaii PPO	$2,007.90
Rate for Payer: University Health Alliance Commercial	$1,159.20

GRAFT LEG 12MMX10CM PXC121000

Facility

$4,510.00

Service Code	HCPCS C1768
Hospital Revenue Code	278
Min. Negotiated Rate	$2,525.60
Max. Negotiated Rate	$4,374.70
Rate for Payer: Cash Price	$2,706.00
Rate for Payer: Hawaii Western Management Group Commercial	$3,157.00
Rate for Payer: Health Management Network Commercial	$3,833.50
Rate for Payer: Kaiser Permanente Commercial	$4,059.00
Rate for Payer: MDX Hawaii PPO	$4,374.70
Rate for Payer: University Health Alliance Commercial	$2,525.60

GRAFT LEG 12MMX10CM PXC121000

Facility

$4,510.00

Service Code	HCPCS C1768
Hospital Revenue Code	278
Min. Negotiated Rate	$1,398.10
Max. Negotiated Rate	$4,374.70
Rate for Payer: AlohaCare Medicaid	$2,255.00
Rate for Payer: AlohaCare Medicare	$1,398.10
Rate for Payer: Cash Price	$2,706.00
Rate for Payer: Devoted Health Medicare	$1,533.40
Rate for Payer: Hawaii Medical Service Association Medicare	$1,398.10
Rate for Payer: Hawaii Western Management Group Commercial	$3,157.00
Rate for Payer: Health Management Network Commercial	$3,833.50
Rate for Payer: Humana Medicare	$1,398.10
Rate for Payer: Kaiser Permanente Commercial	$4,059.00
Rate for Payer: Kaiser Permanente Medicaid	$2,300.10
Rate for Payer: Kaiser Permanente Medicare	$1,398.10
Rate for Payer: MDX Hawaii PPO	$4,374.70
Rate for Payer: Ohana Health Plan Medicaid	$1,398.10
Rate for Payer: Ohana Health Plan Medicare	$1,398.10
Rate for Payer: UnitedHealthcare Medicare	$1,398.10
Rate for Payer: University Health Alliance Commercial	$2,525.60

GRAFT LEG 12MMX12CM PXC121200

Facility

$9,020.00

Service Code	HCPCS C1768
Hospital Revenue Code	278
Min. Negotiated Rate	$5,051.20
Max. Negotiated Rate	$8,749.40
Rate for Payer: Cash Price	$5,412.00
Rate for Payer: Hawaii Western Management Group Commercial	$6,314.00
Rate for Payer: Health Management Network Commercial	$7,667.00
Rate for Payer: Kaiser Permanente Commercial	$8,118.00
Rate for Payer: MDX Hawaii PPO	$8,749.40
Rate for Payer: University Health Alliance Commercial	$5,051.20

GRAFT LEG 12MMX12CM PXC121200

Facility

$9,020.00

Service Code	HCPCS C1768
Hospital Revenue Code	278
Min. Negotiated Rate	$2,796.20
Max. Negotiated Rate	$8,749.40
Rate for Payer: AlohaCare Medicaid	$4,510.00
Rate for Payer: AlohaCare Medicare	$2,796.20
Rate for Payer: Cash Price	$5,412.00
Rate for Payer: Devoted Health Medicare	$3,066.80
Rate for Payer: Hawaii Medical Service Association Medicare	$2,796.20
Rate for Payer: Hawaii Western Management Group Commercial	$6,314.00
Rate for Payer: Health Management Network Commercial	$7,667.00
Rate for Payer: Humana Medicare	$2,796.20
Rate for Payer: Kaiser Permanente Commercial	$8,118.00
Rate for Payer: Kaiser Permanente Medicaid	$4,600.20
Rate for Payer: Kaiser Permanente Medicare	$2,796.20
Rate for Payer: MDX Hawaii PPO	$8,749.40
Rate for Payer: Ohana Health Plan Medicaid	$2,796.20
Rate for Payer: Ohana Health Plan Medicare	$2,796.20
Rate for Payer: UnitedHealthcare Medicare	$2,796.20
Rate for Payer: University Health Alliance Commercial	$5,051.20

GRAFT LEG 12MMX14CM PXC121400

Facility

$9,246.00

Service Code	HCPCS C1768
Hospital Revenue Code	278
Min. Negotiated Rate	$2,866.26
Max. Negotiated Rate	$8,968.62
Rate for Payer: AlohaCare Medicaid	$4,623.00
Rate for Payer: AlohaCare Medicare	$2,866.26
Rate for Payer: Cash Price	$5,547.60
Rate for Payer: Devoted Health Medicare	$3,143.64
Rate for Payer: Hawaii Medical Service Association Medicare	$2,866.26
Rate for Payer: Hawaii Western Management Group Commercial	$6,472.20
Rate for Payer: Health Management Network Commercial	$7,859.10
Rate for Payer: Humana Medicare	$2,866.26
Rate for Payer: Kaiser Permanente Commercial	$8,321.40
Rate for Payer: Kaiser Permanente Medicaid	$4,715.46
Rate for Payer: Kaiser Permanente Medicare	$2,866.26
Rate for Payer: MDX Hawaii PPO	$8,968.62
Rate for Payer: Ohana Health Plan Medicaid	$2,866.26
Rate for Payer: Ohana Health Plan Medicare	$2,866.26
Rate for Payer: UnitedHealthcare Medicare	$2,866.26
Rate for Payer: University Health Alliance Commercial	$5,177.76

GRAFT LEG 12MMX14CM PXC121400

Facility

$9,246.00

Service Code	HCPCS C1768
Hospital Revenue Code	278
Min. Negotiated Rate	$5,177.76
Max. Negotiated Rate	$8,968.62
Rate for Payer: Cash Price	$5,547.60
Rate for Payer: Hawaii Western Management Group Commercial	$6,472.20
Rate for Payer: Health Management Network Commercial	$7,859.10
Rate for Payer: Kaiser Permanente Commercial	$8,321.40
Rate for Payer: MDX Hawaii PPO	$8,968.62
Rate for Payer: University Health Alliance Commercial	$5,177.76

GRAFT LEG 16X13.5CM PLC161400

Facility

$11,540.00

Service Code	HCPCS C1768
Hospital Revenue Code	278
Min. Negotiated Rate	$3,577.40
Max. Negotiated Rate	$11,193.80
Rate for Payer: AlohaCare Medicaid	$5,770.00
Rate for Payer: AlohaCare Medicare	$3,577.40
Rate for Payer: Cash Price	$6,924.00
Rate for Payer: Devoted Health Medicare	$3,923.60
Rate for Payer: Hawaii Medical Service Association Medicare	$3,577.40
Rate for Payer: Hawaii Western Management Group Commercial	$8,078.00
Rate for Payer: Health Management Network Commercial	$9,809.00
Rate for Payer: Humana Medicare	$3,577.40
Rate for Payer: Kaiser Permanente Commercial	$10,386.00
Rate for Payer: Kaiser Permanente Medicaid	$5,885.40
Rate for Payer: Kaiser Permanente Medicare	$3,577.40
Rate for Payer: MDX Hawaii PPO	$11,193.80
Rate for Payer: Ohana Health Plan Medicaid	$3,577.40
Rate for Payer: Ohana Health Plan Medicare	$3,577.40
Rate for Payer: UnitedHealthcare Medicare	$3,577.40
Rate for Payer: University Health Alliance Commercial	$6,462.40

GRAFT LEG 16X13.5CM PLC161400

Facility

$11,540.00

Service Code	HCPCS C1768
Hospital Revenue Code	278
Min. Negotiated Rate	$6,462.40
Max. Negotiated Rate	$11,193.80
Rate for Payer: Cash Price	$6,924.00
Rate for Payer: Hawaii Western Management Group Commercial	$8,078.00
Rate for Payer: Health Management Network Commercial	$9,809.00
Rate for Payer: Kaiser Permanente Commercial	$10,386.00
Rate for Payer: MDX Hawaii PPO	$11,193.80
Rate for Payer: University Health Alliance Commercial	$6,462.40

Know your out-of-pocket cost for care.

All Charges