Kau Hospital

All Charges

Charge

Type

Setting

Price

GUIDE WIRE 1.25X150MM 900.722

Facility

$186.00

Service Code	HCPCS C1769
Hospital Revenue Code	272
Min. Negotiated Rate	$57.66
Max. Negotiated Rate	$180.42
Rate for Payer: AlohaCare Medicaid	$93.00
Rate for Payer: AlohaCare Medicare	$57.66
Rate for Payer: Cash Price	$111.60
Rate for Payer: Devoted Health Medicare	$63.24
Rate for Payer: Hawaii Medical Service Association Medicare	$57.66
Rate for Payer: Hawaii Western Management Group Commercial	$176.70
Rate for Payer: Health Management Network Commercial	$158.10
Rate for Payer: Humana Medicare	$57.66
Rate for Payer: Kaiser Permanente Commercial	$167.40
Rate for Payer: Kaiser Permanente Medicaid	$94.86
Rate for Payer: Kaiser Permanente Medicare	$57.66
Rate for Payer: MDX Hawaii PPO	$180.42
Rate for Payer: Ohana Health Plan Medicaid	$57.66
Rate for Payer: Ohana Health Plan Medicare	$57.66
Rate for Payer: UnitedHealthcare Medicare	$57.66
Rate for Payer: University Health Alliance Commercial	$135.58

GUIDE WIRE 1.25X150MM 900.722

Facility

$186.00

Service Code	HCPCS C1769
Hospital Revenue Code	272
Min. Negotiated Rate	$158.10
Max. Negotiated Rate	$180.42
Rate for Payer: Cash Price	$111.60
Rate for Payer: Health Management Network Commercial	$158.10
Rate for Payer: Kaiser Permanente Commercial	$167.40
Rate for Payer: MDX Hawaii PPO	$180.42

GUIDEWIRE 1.35MM AR-5050-01

Facility

$215.00

Hospital Revenue Code	272
Min. Negotiated Rate	$66.65
Max. Negotiated Rate	$208.55
Rate for Payer: AlohaCare Medicaid	$107.50
Rate for Payer: AlohaCare Medicare	$66.65
Rate for Payer: Cash Price	$129.00
Rate for Payer: Devoted Health Medicare	$73.10
Rate for Payer: Hawaii Medical Service Association Medicare	$66.65
Rate for Payer: Hawaii Western Management Group Commercial	$204.25
Rate for Payer: Health Management Network Commercial	$182.75
Rate for Payer: Humana Medicare	$66.65
Rate for Payer: Kaiser Permanente Commercial	$193.50
Rate for Payer: Kaiser Permanente Medicaid	$109.65
Rate for Payer: Kaiser Permanente Medicare	$66.65
Rate for Payer: MDX Hawaii PPO	$208.55
Rate for Payer: Ohana Health Plan Medicaid	$66.65
Rate for Payer: Ohana Health Plan Medicare	$66.65
Rate for Payer: UnitedHealthcare Medicare	$66.65
Rate for Payer: University Health Alliance Commercial	$156.71

GUIDEWIRE 1.35MM AR-5050-01

Facility

$215.00

Hospital Revenue Code	272
Min. Negotiated Rate	$182.75
Max. Negotiated Rate	$208.55
Rate for Payer: Cash Price	$129.00
Rate for Payer: Health Management Network Commercial	$182.75
Rate for Payer: Kaiser Permanente Commercial	$193.50
Rate for Payer: MDX Hawaii PPO	$208.55

GUIDE WIRE, 1.35MM AR-8943-01

Facility

$120.00

Hospital Revenue Code	272
Min. Negotiated Rate	$102.00
Max. Negotiated Rate	$116.40
Rate for Payer: Cash Price	$72.00
Rate for Payer: Health Management Network Commercial	$102.00
Rate for Payer: Kaiser Permanente Commercial	$108.00
Rate for Payer: MDX Hawaii PPO	$116.40

GUIDE WIRE, 1.35MM AR-8943-01

Facility

$120.00

Hospital Revenue Code	272
Min. Negotiated Rate	$37.20
Max. Negotiated Rate	$116.40
Rate for Payer: AlohaCare Medicaid	$60.00
Rate for Payer: AlohaCare Medicare	$37.20
Rate for Payer: Cash Price	$72.00
Rate for Payer: Devoted Health Medicare	$40.80
Rate for Payer: Hawaii Medical Service Association Medicare	$37.20
Rate for Payer: Hawaii Western Management Group Commercial	$114.00
Rate for Payer: Health Management Network Commercial	$102.00
Rate for Payer: Humana Medicare	$37.20
Rate for Payer: Kaiser Permanente Commercial	$108.00
Rate for Payer: Kaiser Permanente Medicaid	$61.20
Rate for Payer: Kaiser Permanente Medicare	$37.20
Rate for Payer: MDX Hawaii PPO	$116.40
Rate for Payer: Ohana Health Plan Medicaid	$37.20
Rate for Payer: Ohana Health Plan Medicare	$37.20
Rate for Payer: UnitedHealthcare Medicare	$37.20
Rate for Payer: University Health Alliance Commercial	$87.47

GUIDEWIRE 1.35X150 AR-8943-38

Facility

$126.00

Hospital Revenue Code	272
Min. Negotiated Rate	$39.06
Max. Negotiated Rate	$122.22
Rate for Payer: AlohaCare Medicaid	$63.00
Rate for Payer: AlohaCare Medicare	$39.06
Rate for Payer: Cash Price	$75.60
Rate for Payer: Devoted Health Medicare	$42.84
Rate for Payer: Hawaii Medical Service Association Medicare	$39.06
Rate for Payer: Hawaii Western Management Group Commercial	$119.70
Rate for Payer: Health Management Network Commercial	$107.10
Rate for Payer: Humana Medicare	$39.06
Rate for Payer: Kaiser Permanente Commercial	$113.40
Rate for Payer: Kaiser Permanente Medicaid	$64.26
Rate for Payer: Kaiser Permanente Medicare	$39.06
Rate for Payer: MDX Hawaii PPO	$122.22
Rate for Payer: Ohana Health Plan Medicaid	$39.06
Rate for Payer: Ohana Health Plan Medicare	$39.06
Rate for Payer: UnitedHealthcare Medicare	$39.06
Rate for Payer: University Health Alliance Commercial	$91.84

GUIDEWIRE 1.35X150 AR-8943-38

Facility

$126.00

Hospital Revenue Code	272
Min. Negotiated Rate	$107.10
Max. Negotiated Rate	$122.22
Rate for Payer: Cash Price	$75.60
Rate for Payer: Health Management Network Commercial	$107.10
Rate for Payer: Kaiser Permanente Commercial	$113.40
Rate for Payer: MDX Hawaii PPO	$122.22

GUIDEWIRE 1.6 01-1050-0039

Facility

$200.00

Service Code	HCPCS C1769
Hospital Revenue Code	272
Min. Negotiated Rate	$62.00
Max. Negotiated Rate	$194.00
Rate for Payer: AlohaCare Medicaid	$100.00
Rate for Payer: AlohaCare Medicare	$62.00
Rate for Payer: Cash Price	$120.00
Rate for Payer: Devoted Health Medicare	$68.00
Rate for Payer: Hawaii Medical Service Association Medicare	$62.00
Rate for Payer: Hawaii Western Management Group Commercial	$190.00
Rate for Payer: Health Management Network Commercial	$170.00
Rate for Payer: Humana Medicare	$62.00
Rate for Payer: Kaiser Permanente Commercial	$180.00
Rate for Payer: Kaiser Permanente Medicaid	$102.00
Rate for Payer: Kaiser Permanente Medicare	$62.00
Rate for Payer: MDX Hawaii PPO	$194.00
Rate for Payer: Ohana Health Plan Medicaid	$62.00
Rate for Payer: Ohana Health Plan Medicare	$62.00
Rate for Payer: UnitedHealthcare Medicare	$62.00
Rate for Payer: University Health Alliance Commercial	$145.78

GUIDEWIRE 1.6 01-1050-0039

Facility

$200.00

Service Code	HCPCS C1769
Hospital Revenue Code	272
Min. Negotiated Rate	$170.00
Max. Negotiated Rate	$194.00
Rate for Payer: Cash Price	$120.00
Rate for Payer: Health Management Network Commercial	$170.00
Rate for Payer: Kaiser Permanente Commercial	$180.00
Rate for Payer: MDX Hawaii PPO	$194.00

GUIDEWIRE 1.60MM 01-1010-007

Facility

$272.00

Service Code	HCPCS C1769
Hospital Revenue Code	272
Min. Negotiated Rate	$231.20
Max. Negotiated Rate	$263.84
Rate for Payer: Cash Price	$163.20
Rate for Payer: Health Management Network Commercial	$231.20
Rate for Payer: Kaiser Permanente Commercial	$244.80
Rate for Payer: MDX Hawaii PPO	$263.84

GUIDEWIRE 1.60MM 01-1010-007

Facility

$272.00

Service Code	HCPCS C1769
Hospital Revenue Code	272
Min. Negotiated Rate	$84.32
Max. Negotiated Rate	$263.84
Rate for Payer: AlohaCare Medicaid	$136.00
Rate for Payer: AlohaCare Medicare	$84.32
Rate for Payer: Cash Price	$163.20
Rate for Payer: Devoted Health Medicare	$92.48
Rate for Payer: Hawaii Medical Service Association Medicare	$84.32
Rate for Payer: Hawaii Western Management Group Commercial	$258.40
Rate for Payer: Health Management Network Commercial	$231.20
Rate for Payer: Humana Medicare	$84.32
Rate for Payer: Kaiser Permanente Commercial	$244.80
Rate for Payer: Kaiser Permanente Medicaid	$138.72
Rate for Payer: Kaiser Permanente Medicare	$84.32
Rate for Payer: MDX Hawaii PPO	$263.84
Rate for Payer: Ohana Health Plan Medicaid	$84.32
Rate for Payer: Ohana Health Plan Medicare	$84.32
Rate for Payer: UnitedHealthcare Medicare	$84.32
Rate for Payer: University Health Alliance Commercial	$198.26

GUIDE WIRE 1.6MM 220MM TROCAR

Facility

$408.00

Service Code	HCPCS C1769
Hospital Revenue Code	272
Min. Negotiated Rate	$346.80
Max. Negotiated Rate	$395.76
Rate for Payer: Cash Price	$244.80
Rate for Payer: Health Management Network Commercial	$346.80
Rate for Payer: Kaiser Permanente Commercial	$367.20
Rate for Payer: MDX Hawaii PPO	$395.76

GUIDE WIRE 1.6MM 220MM TROCAR

Facility

$408.00

Service Code	HCPCS C1769
Hospital Revenue Code	272
Min. Negotiated Rate	$126.48
Max. Negotiated Rate	$395.76
Rate for Payer: AlohaCare Medicaid	$204.00
Rate for Payer: AlohaCare Medicare	$126.48
Rate for Payer: Cash Price	$244.80
Rate for Payer: Devoted Health Medicare	$138.72
Rate for Payer: Hawaii Medical Service Association Medicare	$126.48
Rate for Payer: Hawaii Western Management Group Commercial	$387.60
Rate for Payer: Health Management Network Commercial	$346.80
Rate for Payer: Humana Medicare	$126.48
Rate for Payer: Kaiser Permanente Commercial	$367.20
Rate for Payer: Kaiser Permanente Medicaid	$208.08
Rate for Payer: Kaiser Permanente Medicare	$126.48
Rate for Payer: MDX Hawaii PPO	$395.76
Rate for Payer: Ohana Health Plan Medicaid	$126.48
Rate for Payer: Ohana Health Plan Medicare	$126.48
Rate for Payer: UnitedHealthcare Medicare	$126.48
Rate for Payer: University Health Alliance Commercial	$297.39

GUIDE WIRE 1.6X200 02.113.001

Facility

$224.00

Service Code	HCPCS C1769
Hospital Revenue Code	272
Min. Negotiated Rate	$69.44
Max. Negotiated Rate	$217.28
Rate for Payer: AlohaCare Medicaid	$112.00
Rate for Payer: AlohaCare Medicare	$69.44
Rate for Payer: Cash Price	$134.40
Rate for Payer: Devoted Health Medicare	$76.16
Rate for Payer: Hawaii Medical Service Association Medicare	$69.44
Rate for Payer: Hawaii Western Management Group Commercial	$212.80
Rate for Payer: Health Management Network Commercial	$190.40
Rate for Payer: Humana Medicare	$69.44
Rate for Payer: Kaiser Permanente Commercial	$201.60
Rate for Payer: Kaiser Permanente Medicaid	$114.24
Rate for Payer: Kaiser Permanente Medicare	$69.44
Rate for Payer: MDX Hawaii PPO	$217.28
Rate for Payer: Ohana Health Plan Medicaid	$69.44
Rate for Payer: Ohana Health Plan Medicare	$69.44
Rate for Payer: UnitedHealthcare Medicare	$69.44
Rate for Payer: University Health Alliance Commercial	$163.27

GUIDE WIRE 1.6X200 02.113.001

Facility

$224.00

Service Code	HCPCS C1769
Hospital Revenue Code	272
Min. Negotiated Rate	$190.40
Max. Negotiated Rate	$217.28
Rate for Payer: Cash Price	$134.40
Rate for Payer: Health Management Network Commercial	$190.40
Rate for Payer: Kaiser Permanente Commercial	$201.60
Rate for Payer: MDX Hawaii PPO	$217.28

GUIDEWIRE 1806-0083S

Facility

$732.00

Service Code	HCPCS C1769
Hospital Revenue Code	272
Min. Negotiated Rate	$226.92
Max. Negotiated Rate	$710.04
Rate for Payer: AlohaCare Medicaid	$366.00
Rate for Payer: AlohaCare Medicare	$226.92
Rate for Payer: Cash Price	$439.20
Rate for Payer: Devoted Health Medicare	$248.88
Rate for Payer: Hawaii Medical Service Association Medicare	$226.92
Rate for Payer: Hawaii Western Management Group Commercial	$695.40
Rate for Payer: Health Management Network Commercial	$622.20
Rate for Payer: Humana Medicare	$226.92
Rate for Payer: Kaiser Permanente Commercial	$658.80
Rate for Payer: Kaiser Permanente Medicaid	$373.32
Rate for Payer: Kaiser Permanente Medicare	$226.92
Rate for Payer: MDX Hawaii PPO	$710.04
Rate for Payer: Ohana Health Plan Medicaid	$226.92
Rate for Payer: Ohana Health Plan Medicare	$226.92
Rate for Payer: UnitedHealthcare Medicare	$226.92
Rate for Payer: University Health Alliance Commercial	$533.55

GUIDEWIRE 1806-0083S

Facility

$732.00

Service Code	HCPCS C1769
Hospital Revenue Code	272
Min. Negotiated Rate	$622.20
Max. Negotiated Rate	$710.04
Rate for Payer: Cash Price	$439.20
Rate for Payer: Health Management Network Commercial	$622.20
Rate for Payer: Kaiser Permanente Commercial	$658.80
Rate for Payer: MDX Hawaii PPO	$710.04

GUIDEWIRE 2.0, 240MM

Facility

$204.00

Service Code	HCPCS C1769
Hospital Revenue Code	272
Min. Negotiated Rate	$63.24
Max. Negotiated Rate	$197.88
Rate for Payer: AlohaCare Medicaid	$102.00
Rate for Payer: AlohaCare Medicare	$63.24
Rate for Payer: Cash Price	$122.40
Rate for Payer: Devoted Health Medicare	$69.36
Rate for Payer: Hawaii Medical Service Association Medicare	$63.24
Rate for Payer: Hawaii Western Management Group Commercial	$193.80
Rate for Payer: Health Management Network Commercial	$173.40
Rate for Payer: Humana Medicare	$63.24
Rate for Payer: Kaiser Permanente Commercial	$183.60
Rate for Payer: Kaiser Permanente Medicaid	$104.04
Rate for Payer: Kaiser Permanente Medicare	$63.24
Rate for Payer: MDX Hawaii PPO	$197.88
Rate for Payer: Ohana Health Plan Medicaid	$63.24
Rate for Payer: Ohana Health Plan Medicare	$63.24
Rate for Payer: UnitedHealthcare Medicare	$63.24
Rate for Payer: University Health Alliance Commercial	$148.70

GUIDEWIRE 2.0, 240MM

Facility

$204.00

Service Code	HCPCS C1769
Hospital Revenue Code	272
Min. Negotiated Rate	$173.40
Max. Negotiated Rate	$197.88
Rate for Payer: Cash Price	$122.40
Rate for Payer: Health Management Network Commercial	$173.40
Rate for Payer: Kaiser Permanente Commercial	$183.60
Rate for Payer: MDX Hawaii PPO	$197.88

GUIDEWIRE 2.0X230MM 292.652

Facility

$238.00

Service Code	HCPCS C1769
Hospital Revenue Code	272
Min. Negotiated Rate	$73.78
Max. Negotiated Rate	$230.86
Rate for Payer: AlohaCare Medicaid	$119.00
Rate for Payer: AlohaCare Medicare	$73.78
Rate for Payer: Cash Price	$142.80
Rate for Payer: Devoted Health Medicare	$80.92
Rate for Payer: Hawaii Medical Service Association Medicare	$73.78
Rate for Payer: Hawaii Western Management Group Commercial	$226.10
Rate for Payer: Health Management Network Commercial	$202.30
Rate for Payer: Humana Medicare	$73.78
Rate for Payer: Kaiser Permanente Commercial	$214.20
Rate for Payer: Kaiser Permanente Medicaid	$121.38
Rate for Payer: Kaiser Permanente Medicare	$73.78
Rate for Payer: MDX Hawaii PPO	$230.86
Rate for Payer: Ohana Health Plan Medicaid	$73.78
Rate for Payer: Ohana Health Plan Medicare	$73.78
Rate for Payer: UnitedHealthcare Medicare	$73.78
Rate for Payer: University Health Alliance Commercial	$173.48

GUIDEWIRE 2.0X230MM 292.652

Facility

$238.00

Service Code	HCPCS C1769
Hospital Revenue Code	272
Min. Negotiated Rate	$202.30
Max. Negotiated Rate	$230.86
Rate for Payer: Cash Price	$142.80
Rate for Payer: Health Management Network Commercial	$202.30
Rate for Payer: Kaiser Permanente Commercial	$214.20
Rate for Payer: MDX Hawaii PPO	$230.86

GUIDEWIRE 2.2 150L 03.333.001

Facility

$348.00

Service Code	HCPCS C1769
Hospital Revenue Code	272
Min. Negotiated Rate	$107.88
Max. Negotiated Rate	$337.56
Rate for Payer: AlohaCare Medicaid	$174.00
Rate for Payer: AlohaCare Medicare	$107.88
Rate for Payer: Cash Price	$208.80
Rate for Payer: Devoted Health Medicare	$118.32
Rate for Payer: Hawaii Medical Service Association Medicare	$107.88
Rate for Payer: Hawaii Western Management Group Commercial	$330.60
Rate for Payer: Health Management Network Commercial	$295.80
Rate for Payer: Humana Medicare	$107.88
Rate for Payer: Kaiser Permanente Commercial	$313.20
Rate for Payer: Kaiser Permanente Medicaid	$177.48
Rate for Payer: Kaiser Permanente Medicare	$107.88
Rate for Payer: MDX Hawaii PPO	$337.56
Rate for Payer: Ohana Health Plan Medicaid	$107.88
Rate for Payer: Ohana Health Plan Medicare	$107.88
Rate for Payer: UnitedHealthcare Medicare	$107.88
Rate for Payer: University Health Alliance Commercial	$253.66

GUIDEWIRE 2.2 150L 03.333.001

Facility

$348.00

Service Code	HCPCS C1769
Hospital Revenue Code	272
Min. Negotiated Rate	$295.80
Max. Negotiated Rate	$337.56
Rate for Payer: Cash Price	$208.80
Rate for Payer: Health Management Network Commercial	$295.80
Rate for Payer: Kaiser Permanente Commercial	$313.20
Rate for Payer: MDX Hawaii PPO	$337.56

GUIDE WIRE 2.5MMX220MM DWD017

Facility

$435.00

Service Code	HCPCS C1769
Hospital Revenue Code	272
Min. Negotiated Rate	$369.75
Max. Negotiated Rate	$421.95
Rate for Payer: Cash Price	$261.00
Rate for Payer: Health Management Network Commercial	$369.75
Rate for Payer: Kaiser Permanente Commercial	$391.50
Rate for Payer: MDX Hawaii PPO	$421.95

Know your out-of-pocket cost for care.

All Charges