Kau Hospital

All Charges

Charge

Type

Setting

Price

ARIPIPRAZOLE 5 MG TABLET [36438]

Facility

$75.00

Service Code	NDC 50268008815
Hospital Revenue Code	250
Min. Negotiated Rate	$63.75
Max. Negotiated Rate	$72.75
Rate for Payer: Cash Price	$45.00
Rate for Payer: Health Management Network Commercial	$63.75
Rate for Payer: Kaiser Permanente Commercial	$67.50
Rate for Payer: MDX Hawaii PPO	$72.75

ARIPIPRAZOLE 5 MG TABLET [36438]

Facility

$75.00

Service Code	NDC 50268008811
Hospital Revenue Code	637
Min. Negotiated Rate	$23.25
Max. Negotiated Rate	$72.75
Rate for Payer: AlohaCare Medicaid	$37.50
Rate for Payer: AlohaCare Medicare	$23.25
Rate for Payer: Cash Price	$45.00
Rate for Payer: Devoted Health Medicare	$25.50
Rate for Payer: Hawaii Medical Service Association Medicare	$23.25
Rate for Payer: Hawaii Western Management Group Commercial	$71.25
Rate for Payer: Health Management Network Commercial	$63.75
Rate for Payer: Humana Medicare	$23.25
Rate for Payer: Kaiser Permanente Commercial	$67.50
Rate for Payer: Kaiser Permanente Medicaid	$38.25
Rate for Payer: Kaiser Permanente Medicare	$23.25
Rate for Payer: MDX Hawaii PPO	$72.75
Rate for Payer: Ohana Health Plan Medicaid	$23.25
Rate for Payer: Ohana Health Plan Medicare	$23.25
Rate for Payer: UnitedHealthcare Medicare	$23.25
Rate for Payer: University Health Alliance Commercial	$54.67

ARIPIPRAZOLE 5 MG TABLET [36438]

Facility

$81.00

Service Code	NDC 67877043103
Hospital Revenue Code	637
Min. Negotiated Rate	$25.11
Max. Negotiated Rate	$78.57
Rate for Payer: AlohaCare Medicaid	$40.50
Rate for Payer: AlohaCare Medicare	$25.11
Rate for Payer: Cash Price	$48.60
Rate for Payer: Devoted Health Medicare	$27.54
Rate for Payer: Hawaii Medical Service Association Medicare	$25.11
Rate for Payer: Hawaii Western Management Group Commercial	$76.95
Rate for Payer: Health Management Network Commercial	$68.85
Rate for Payer: Humana Medicare	$25.11
Rate for Payer: Kaiser Permanente Commercial	$72.90
Rate for Payer: Kaiser Permanente Medicaid	$41.31
Rate for Payer: Kaiser Permanente Medicare	$25.11
Rate for Payer: MDX Hawaii PPO	$78.57
Rate for Payer: Ohana Health Plan Medicaid	$25.11
Rate for Payer: Ohana Health Plan Medicare	$25.11
Rate for Payer: UnitedHealthcare Medicare	$25.11
Rate for Payer: University Health Alliance Commercial	$59.04

ARIPIPRAZOLE 5 MG TABLET [36438]

Facility

$75.00

Service Code	NDC 50268008811
Hospital Revenue Code	250
Min. Negotiated Rate	$63.75
Max. Negotiated Rate	$72.75
Rate for Payer: Cash Price	$45.00
Rate for Payer: Health Management Network Commercial	$63.75
Rate for Payer: Kaiser Permanente Commercial	$67.50
Rate for Payer: MDX Hawaii PPO	$72.75

ARIPIPRAZOLE 5 MG TABLET [36438]

Facility

$75.00

Service Code	NDC 50268008815
Hospital Revenue Code	637
Min. Negotiated Rate	$23.25
Max. Negotiated Rate	$72.75
Rate for Payer: AlohaCare Medicaid	$37.50
Rate for Payer: AlohaCare Medicare	$23.25
Rate for Payer: Cash Price	$45.00
Rate for Payer: Devoted Health Medicare	$25.50
Rate for Payer: Hawaii Medical Service Association Medicare	$23.25
Rate for Payer: Hawaii Western Management Group Commercial	$71.25
Rate for Payer: Health Management Network Commercial	$63.75
Rate for Payer: Humana Medicare	$23.25
Rate for Payer: Kaiser Permanente Commercial	$67.50
Rate for Payer: Kaiser Permanente Medicaid	$38.25
Rate for Payer: Kaiser Permanente Medicare	$23.25
Rate for Payer: MDX Hawaii PPO	$72.75
Rate for Payer: Ohana Health Plan Medicaid	$23.25
Rate for Payer: Ohana Health Plan Medicare	$23.25
Rate for Payer: UnitedHealthcare Medicare	$23.25
Rate for Payer: University Health Alliance Commercial	$54.67

ARIPIPRAZOLE 5 MG TABLET [36438]

Facility

$81.00

Service Code	NDC 67877043103
Hospital Revenue Code	250
Min. Negotiated Rate	$68.85
Max. Negotiated Rate	$78.57
Rate for Payer: Cash Price	$48.60
Rate for Payer: Health Management Network Commercial	$68.85
Rate for Payer: Kaiser Permanente Commercial	$72.90
Rate for Payer: MDX Hawaii PPO	$78.57

ARM SLEEVE SHLDR SUS AR-1651

Facility

$593.00

Hospital Revenue Code	271
Min. Negotiated Rate	$504.05
Max. Negotiated Rate	$575.21
Rate for Payer: Cash Price	$355.80
Rate for Payer: Health Management Network Commercial	$504.05
Rate for Payer: Kaiser Permanente Commercial	$533.70
Rate for Payer: MDX Hawaii PPO	$575.21

ARM SLEEVE SHLDR SUS AR-1651

Facility

$593.00

Hospital Revenue Code	271
Min. Negotiated Rate	$183.83
Max. Negotiated Rate	$575.21
Rate for Payer: AlohaCare Medicaid	$296.50
Rate for Payer: AlohaCare Medicare	$183.83
Rate for Payer: Cash Price	$355.80
Rate for Payer: Devoted Health Medicare	$201.62
Rate for Payer: Hawaii Medical Service Association Medicare	$183.83
Rate for Payer: Hawaii Western Management Group Commercial	$563.35
Rate for Payer: Health Management Network Commercial	$504.05
Rate for Payer: Humana Medicare	$183.83
Rate for Payer: Kaiser Permanente Commercial	$533.70
Rate for Payer: Kaiser Permanente Medicaid	$302.43
Rate for Payer: Kaiser Permanente Medicare	$183.83
Rate for Payer: MDX Hawaii PPO	$575.21
Rate for Payer: Ohana Health Plan Medicaid	$183.83
Rate for Payer: Ohana Health Plan Medicare	$183.83
Rate for Payer: UnitedHealthcare Medicare	$183.83
Rate for Payer: University Health Alliance Commercial	$432.24

ARSENIC TRIOXIDE 1 MG/ML INTRAVENOUS SOLUTION [29071]

Facility

$920.00

Service Code	HCPCS J9017
Hospital Revenue Code	250
Min. Negotiated Rate	$782.00
Max. Negotiated Rate	$892.40
Rate for Payer: Cash Price	$552.00
Rate for Payer: Cash Price	$270.00
Rate for Payer: Cash Price	$855.60
Rate for Payer: Health Management Network Commercial	$1,212.10
Rate for Payer: Health Management Network Commercial	$782.00
Rate for Payer: Health Management Network Commercial	$382.50
Rate for Payer: Kaiser Permanente Commercial	$405.00
Rate for Payer: Kaiser Permanente Commercial	$828.00
Rate for Payer: Kaiser Permanente Commercial	$1,283.40
Rate for Payer: MDX Hawaii PPO	$436.50
Rate for Payer: MDX Hawaii PPO	$1,383.22
Rate for Payer: MDX Hawaii PPO	$892.40

ARSENIC TRIOXIDE 1 MG/ML INTRAVENOUS SOLUTION [29071]

Facility

$1,426.00

Service Code	HCPCS J9017
Hospital Revenue Code	636
Min. Negotiated Rate	$5.86
Max. Negotiated Rate	$1,383.22
Rate for Payer: AlohaCare Medicaid	$713.00
Rate for Payer: AlohaCare Medicaid	$460.00
Rate for Payer: AlohaCare Medicaid	$225.00
Rate for Payer: AlohaCare Medicare	$139.50
Rate for Payer: AlohaCare Medicare	$442.06
Rate for Payer: AlohaCare Medicare	$285.20
Rate for Payer: Cash Price	$270.00
Rate for Payer: Cash Price	$552.00
Rate for Payer: Cash Price	$270.00
Rate for Payer: Cash Price	$855.60
Rate for Payer: Cash Price	$855.60
Rate for Payer: Cash Price	$552.00
Rate for Payer: Devoted Health Medicare	$484.84
Rate for Payer: Devoted Health Medicare	$312.80
Rate for Payer: Devoted Health Medicare	$153.00
Rate for Payer: Hawaii Medical Service Association ABD	$5.86
Rate for Payer: Hawaii Medical Service Association ABD	$5.86
Rate for Payer: Hawaii Medical Service Association ABD	$5.86
Rate for Payer: Hawaii Medical Service Association Medicare	$442.06
Rate for Payer: Hawaii Medical Service Association Medicare	$285.20
Rate for Payer: Hawaii Medical Service Association Medicare	$139.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$5.86
Rate for Payer: Hawaii Medical Service Association Non-ABD	$5.86
Rate for Payer: Hawaii Medical Service Association Non-ABD	$5.86
Rate for Payer: Hawaii Western Management Group Commercial	$427.50
Rate for Payer: Hawaii Western Management Group Commercial	$1,354.70
Rate for Payer: Hawaii Western Management Group Commercial	$874.00
Rate for Payer: Health Management Network Commercial	$782.00
Rate for Payer: Health Management Network Commercial	$1,212.10
Rate for Payer: Health Management Network Commercial	$382.50
Rate for Payer: Humana Medicare	$442.06
Rate for Payer: Humana Medicare	$139.50
Rate for Payer: Humana Medicare	$285.20
Rate for Payer: Kaiser Permanente Commercial	$1,283.40
Rate for Payer: Kaiser Permanente Commercial	$405.00
Rate for Payer: Kaiser Permanente Commercial	$828.00
Rate for Payer: Kaiser Permanente Medicaid	$469.20
Rate for Payer: Kaiser Permanente Medicaid	$229.50
Rate for Payer: Kaiser Permanente Medicaid	$727.26
Rate for Payer: Kaiser Permanente Medicare	$442.06
Rate for Payer: Kaiser Permanente Medicare	$139.50
Rate for Payer: Kaiser Permanente Medicare	$285.20
Rate for Payer: MDX Hawaii PPO	$892.40
Rate for Payer: MDX Hawaii PPO	$436.50
Rate for Payer: MDX Hawaii PPO	$1,383.22
Rate for Payer: Ohana Health Plan Medicaid	$139.50
Rate for Payer: Ohana Health Plan Medicaid	$442.06
Rate for Payer: Ohana Health Plan Medicaid	$285.20
Rate for Payer: Ohana Health Plan Medicare	$139.50
Rate for Payer: Ohana Health Plan Medicare	$442.06
Rate for Payer: Ohana Health Plan Medicare	$285.20
Rate for Payer: UnitedHealthcare Medicaid	$270.00
Rate for Payer: UnitedHealthcare Medicaid	$855.60
Rate for Payer: UnitedHealthcare Medicaid	$552.00
Rate for Payer: UnitedHealthcare Medicare	$139.50
Rate for Payer: UnitedHealthcare Medicare	$442.06
Rate for Payer: UnitedHealthcare Medicare	$285.20
Rate for Payer: University Health Alliance Commercial	$1,039.41
Rate for Payer: University Health Alliance Commercial	$328.00
Rate for Payer: University Health Alliance Commercial	$670.59

ART COMP OVOMOT 8HMC2-5046-A

Facility

$15,252.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$8,541.12
Max. Negotiated Rate	$14,794.44
Rate for Payer: Cash Price	$9,151.20
Rate for Payer: Hawaii Western Management Group Commercial	$10,676.40
Rate for Payer: Health Management Network Commercial	$12,964.20
Rate for Payer: Kaiser Permanente Commercial	$13,726.80
Rate for Payer: MDX Hawaii PPO	$14,794.44
Rate for Payer: University Health Alliance Commercial	$8,541.12

ART COMP OVOMOT 8HMC2-5046-A

Facility

$15,252.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$4,728.12
Max. Negotiated Rate	$14,794.44
Rate for Payer: AlohaCare Medicaid	$7,626.00
Rate for Payer: AlohaCare Medicare	$4,728.12
Rate for Payer: Cash Price	$9,151.20
Rate for Payer: Devoted Health Medicare	$5,185.68
Rate for Payer: Hawaii Medical Service Association Medicare	$4,728.12
Rate for Payer: Hawaii Western Management Group Commercial	$10,676.40
Rate for Payer: Health Management Network Commercial	$12,964.20
Rate for Payer: Humana Medicare	$4,728.12
Rate for Payer: Kaiser Permanente Commercial	$13,726.80
Rate for Payer: Kaiser Permanente Medicaid	$7,778.52
Rate for Payer: Kaiser Permanente Medicare	$4,728.12
Rate for Payer: MDX Hawaii PPO	$14,794.44
Rate for Payer: Ohana Health Plan Medicaid	$4,728.12
Rate for Payer: Ohana Health Plan Medicare	$4,728.12
Rate for Payer: UnitedHealthcare Medicare	$4,728.12
Rate for Payer: University Health Alliance Commercial	$8,541.12

ARTERY SHUNT KIT 8888577775

Facility

$156.00

Service Code	HCPCS C1889
Hospital Revenue Code	272
Min. Negotiated Rate	$48.36
Max. Negotiated Rate	$151.32
Rate for Payer: AlohaCare Medicaid	$78.00
Rate for Payer: AlohaCare Medicare	$48.36
Rate for Payer: Cash Price	$93.60
Rate for Payer: Devoted Health Medicare	$53.04
Rate for Payer: Hawaii Medical Service Association Medicare	$48.36
Rate for Payer: Hawaii Western Management Group Commercial	$148.20
Rate for Payer: Health Management Network Commercial	$132.60
Rate for Payer: Humana Medicare	$48.36
Rate for Payer: Kaiser Permanente Commercial	$140.40
Rate for Payer: Kaiser Permanente Medicaid	$79.56
Rate for Payer: Kaiser Permanente Medicare	$48.36
Rate for Payer: MDX Hawaii PPO	$151.32
Rate for Payer: Ohana Health Plan Medicaid	$48.36
Rate for Payer: Ohana Health Plan Medicare	$48.36
Rate for Payer: UnitedHealthcare Medicare	$48.36
Rate for Payer: University Health Alliance Commercial	$113.71

ARTERY SHUNT KIT 8888577775

Facility

$156.00

Service Code	HCPCS C1889
Hospital Revenue Code	272
Min. Negotiated Rate	$132.60
Max. Negotiated Rate	$151.32
Rate for Payer: Cash Price	$93.60
Rate for Payer: Health Management Network Commercial	$132.60
Rate for Payer: Kaiser Permanente Commercial	$140.40
Rate for Payer: MDX Hawaii PPO	$151.32

ARTHROSCOPY TUBING #AR-6410

Facility

$240.00

Hospital Revenue Code	272
Min. Negotiated Rate	$204.00
Max. Negotiated Rate	$232.80
Rate for Payer: Cash Price	$144.00
Rate for Payer: Health Management Network Commercial	$204.00
Rate for Payer: Kaiser Permanente Commercial	$216.00
Rate for Payer: MDX Hawaii PPO	$232.80

ARTHROSCOPY TUBING #AR-6410

Facility

$240.00

Hospital Revenue Code	272
Min. Negotiated Rate	$74.40
Max. Negotiated Rate	$232.80
Rate for Payer: AlohaCare Medicaid	$120.00
Rate for Payer: AlohaCare Medicare	$74.40
Rate for Payer: Cash Price	$144.00
Rate for Payer: Devoted Health Medicare	$81.60
Rate for Payer: Hawaii Medical Service Association Medicare	$74.40
Rate for Payer: Hawaii Western Management Group Commercial	$228.00
Rate for Payer: Health Management Network Commercial	$204.00
Rate for Payer: Humana Medicare	$74.40
Rate for Payer: Kaiser Permanente Commercial	$216.00
Rate for Payer: Kaiser Permanente Medicaid	$122.40
Rate for Payer: Kaiser Permanente Medicare	$74.40
Rate for Payer: MDX Hawaii PPO	$232.80
Rate for Payer: Ohana Health Plan Medicaid	$74.40
Rate for Payer: Ohana Health Plan Medicare	$74.40
Rate for Payer: UnitedHealthcare Medicare	$74.40
Rate for Payer: University Health Alliance Commercial	$174.94

ARTICULAR GLENOID G203-2015-W

Facility

$4,550.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$2,548.00
Max. Negotiated Rate	$4,413.50
Rate for Payer: Cash Price	$2,730.00
Rate for Payer: Hawaii Western Management Group Commercial	$3,185.00
Rate for Payer: Health Management Network Commercial	$3,867.50
Rate for Payer: Kaiser Permanente Commercial	$4,095.00
Rate for Payer: MDX Hawaii PPO	$4,413.50
Rate for Payer: University Health Alliance Commercial	$2,548.00

ARTICULAR GLENOID G203-2015-W

Facility

$4,550.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$1,410.50
Max. Negotiated Rate	$4,413.50
Rate for Payer: AlohaCare Medicaid	$2,275.00
Rate for Payer: AlohaCare Medicare	$1,410.50
Rate for Payer: Cash Price	$2,730.00
Rate for Payer: Devoted Health Medicare	$1,547.00
Rate for Payer: Hawaii Medical Service Association Medicare	$1,410.50
Rate for Payer: Hawaii Western Management Group Commercial	$3,185.00
Rate for Payer: Health Management Network Commercial	$3,867.50
Rate for Payer: Humana Medicare	$1,410.50
Rate for Payer: Kaiser Permanente Commercial	$4,095.00
Rate for Payer: Kaiser Permanente Medicaid	$2,320.50
Rate for Payer: Kaiser Permanente Medicare	$1,410.50
Rate for Payer: MDX Hawaii PPO	$4,413.50
Rate for Payer: Ohana Health Plan Medicaid	$1,410.50
Rate for Payer: Ohana Health Plan Medicare	$1,410.50
Rate for Payer: UnitedHealthcare Medicare	$1,410.50
Rate for Payer: University Health Alliance Commercial	$2,548.00

ASAHI SION BLACK 300CM STRT

Facility

$525.00

Service Code	HCPCS C1769
Hospital Revenue Code	272
Min. Negotiated Rate	$162.75
Max. Negotiated Rate	$509.25
Rate for Payer: AlohaCare Medicaid	$262.50
Rate for Payer: AlohaCare Medicare	$162.75
Rate for Payer: Cash Price	$315.00
Rate for Payer: Devoted Health Medicare	$178.50
Rate for Payer: Hawaii Medical Service Association Medicare	$162.75
Rate for Payer: Hawaii Western Management Group Commercial	$498.75
Rate for Payer: Health Management Network Commercial	$446.25
Rate for Payer: Humana Medicare	$162.75
Rate for Payer: Kaiser Permanente Commercial	$472.50
Rate for Payer: Kaiser Permanente Medicaid	$267.75
Rate for Payer: Kaiser Permanente Medicare	$162.75
Rate for Payer: MDX Hawaii PPO	$509.25
Rate for Payer: Ohana Health Plan Medicaid	$162.75
Rate for Payer: Ohana Health Plan Medicare	$162.75
Rate for Payer: UnitedHealthcare Medicare	$162.75
Rate for Payer: University Health Alliance Commercial	$382.67

ASAHI SION BLACK 300CM STRT

Facility

$525.00

Service Code	HCPCS C1769
Hospital Revenue Code	272
Min. Negotiated Rate	$446.25
Max. Negotiated Rate	$509.25
Rate for Payer: Cash Price	$315.00
Rate for Payer: Health Management Network Commercial	$446.25
Rate for Payer: Kaiser Permanente Commercial	$472.50
Rate for Payer: MDX Hawaii PPO	$509.25

ASCORBIC ACID (VITAMIN C) 250 MG TABLET [663]

Facility

$1.00

Service Code	NDC 00100000000
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

ASCORBIC ACID (VITAMIN C) 250 MG TABLET [663]

Facility

$1.00

Service Code	NDC 86015000000
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

ASCORBIC ACID (VITAMIN C) 250 MG TABLET [663]

Facility

$1.00

Service Code	NDC 86015000000
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

ASCORBIC ACID (VITAMIN C) 250 MG TABLET [663]

Facility

$1.00

Service Code	NDC 00100000000
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

ASCORBIC ACID (VITAMIN C) 250 MG TABLET [663]

Facility

$1.00

Service Code	NDC 86011000000
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

Know your out-of-pocket cost for care.

All Charges