Kau Hospital

All Charges

Charge

Type

Setting

Price

IBUPROFEN TABLETS (MOTRIN) 400 MG (TAKE HOME) [4080368]

Facility

$15.00

Service Code	NDC 00004080156
Hospital Revenue Code	253
Min. Negotiated Rate	$12.75
Max. Negotiated Rate	$14.55
Rate for Payer: Cash Price	$9.00
Rate for Payer: Health Management Network Commercial	$12.75
Rate for Payer: Kaiser Permanente Commercial	$13.50
Rate for Payer: MDX Hawaii PPO	$14.55

IBUPROFEN TABLETS (MOTRIN) 400 MG (TAKE HOME) [4080368]

Facility

$15.00

Service Code	NDC 00004080156
Hospital Revenue Code	253
Min. Negotiated Rate	$4.65
Max. Negotiated Rate	$14.55
Rate for Payer: AlohaCare Medicaid	$7.50
Rate for Payer: AlohaCare Medicare	$4.65
Rate for Payer: Cash Price	$9.00
Rate for Payer: Devoted Health Medicare	$5.10
Rate for Payer: Hawaii Medical Service Association Medicare	$4.65
Rate for Payer: Hawaii Western Management Group Commercial	$14.25
Rate for Payer: Health Management Network Commercial	$12.75
Rate for Payer: Humana Medicare	$4.65
Rate for Payer: Kaiser Permanente Commercial	$13.50
Rate for Payer: Kaiser Permanente Medicaid	$7.65
Rate for Payer: Kaiser Permanente Medicare	$4.65
Rate for Payer: MDX Hawaii PPO	$14.55
Rate for Payer: Ohana Health Plan Medicaid	$4.65
Rate for Payer: Ohana Health Plan Medicare	$4.65
Rate for Payer: UnitedHealthcare Medicare	$4.65
Rate for Payer: University Health Alliance Commercial	$10.93

ICATIBANT 30 MG/3 ML SUBCUTANEOUS SYRINGE [191015]

Facility

$13,209.00

Service Code	HCPCS J1744
Hospital Revenue Code	250
Min. Negotiated Rate	$11,227.65
Max. Negotiated Rate	$12,812.73
Rate for Payer: Cash Price	$7,925.40
Rate for Payer: Health Management Network Commercial	$11,227.65
Rate for Payer: Kaiser Permanente Commercial	$11,888.10
Rate for Payer: MDX Hawaii PPO	$12,812.73

ICD EVERA MRI XT DDMB1D1

Facility

$43,890.00

Service Code	HCPCS C1721
Hospital Revenue Code	275
Min. Negotiated Rate	$13,605.90
Max. Negotiated Rate	$42,573.30
Rate for Payer: AlohaCare Medicaid	$21,945.00
Rate for Payer: AlohaCare Medicare	$13,605.90
Rate for Payer: Cash Price	$26,334.00
Rate for Payer: Devoted Health Medicare	$14,922.60
Rate for Payer: Hawaii Medical Service Association Medicare	$13,605.90
Rate for Payer: Hawaii Western Management Group Commercial	$30,723.00
Rate for Payer: Health Management Network Commercial	$37,306.50
Rate for Payer: Humana Medicare	$13,605.90
Rate for Payer: Kaiser Permanente Commercial	$39,501.00
Rate for Payer: Kaiser Permanente Medicaid	$22,383.90
Rate for Payer: Kaiser Permanente Medicare	$13,605.90
Rate for Payer: MDX Hawaii PPO	$42,573.30
Rate for Payer: Ohana Health Plan Medicaid	$13,605.90
Rate for Payer: Ohana Health Plan Medicare	$13,605.90
Rate for Payer: UnitedHealthcare Medicare	$13,605.90
Rate for Payer: University Health Alliance Commercial	$24,578.40

ICD EVERA MRI XT DDMB1D1

Facility

$43,890.00

Service Code	HCPCS C1721
Hospital Revenue Code	275
Min. Negotiated Rate	$24,578.40
Max. Negotiated Rate	$42,573.30
Rate for Payer: Cash Price	$26,334.00
Rate for Payer: Hawaii Western Management Group Commercial	$30,723.00
Rate for Payer: Health Management Network Commercial	$37,306.50
Rate for Payer: Kaiser Permanente Commercial	$39,501.00
Rate for Payer: MDX Hawaii PPO	$42,573.30
Rate for Payer: University Health Alliance Commercial	$24,578.40

ICEFORCE CRYO NEEDLE

Facility

$3,790.00

Service Code	HCPCS C2618
Hospital Revenue Code	272
Min. Negotiated Rate	$1,174.90
Max. Negotiated Rate	$3,676.30
Rate for Payer: AlohaCare Medicaid	$1,895.00
Rate for Payer: AlohaCare Medicare	$1,174.90
Rate for Payer: Cash Price	$2,274.00
Rate for Payer: Devoted Health Medicare	$1,288.60
Rate for Payer: Hawaii Medical Service Association Medicare	$1,174.90
Rate for Payer: Hawaii Western Management Group Commercial	$3,600.50
Rate for Payer: Health Management Network Commercial	$3,221.50
Rate for Payer: Humana Medicare	$1,174.90
Rate for Payer: Kaiser Permanente Commercial	$3,411.00
Rate for Payer: Kaiser Permanente Medicaid	$1,932.90
Rate for Payer: Kaiser Permanente Medicare	$1,174.90
Rate for Payer: MDX Hawaii PPO	$3,676.30
Rate for Payer: Ohana Health Plan Medicaid	$1,174.90
Rate for Payer: Ohana Health Plan Medicare	$1,174.90
Rate for Payer: UnitedHealthcare Medicare	$1,174.90
Rate for Payer: University Health Alliance Commercial	$2,762.53

ICEFORCE CRYO NEEDLE

Facility

$3,790.00

Service Code	HCPCS C2618
Hospital Revenue Code	272
Min. Negotiated Rate	$3,221.50
Max. Negotiated Rate	$3,676.30
Rate for Payer: Cash Price	$2,274.00
Rate for Payer: Health Management Network Commercial	$3,221.50
Rate for Payer: Kaiser Permanente Commercial	$3,411.00
Rate for Payer: MDX Hawaii PPO	$3,676.30

ICEPEARL CRYO NEEDLE

Facility

$3,790.00

Service Code	HCPCS C2618
Hospital Revenue Code	272
Min. Negotiated Rate	$1,174.90
Max. Negotiated Rate	$3,676.30
Rate for Payer: AlohaCare Medicaid	$1,895.00
Rate for Payer: AlohaCare Medicare	$1,174.90
Rate for Payer: Cash Price	$2,274.00
Rate for Payer: Devoted Health Medicare	$1,288.60
Rate for Payer: Hawaii Medical Service Association Medicare	$1,174.90
Rate for Payer: Hawaii Western Management Group Commercial	$3,600.50
Rate for Payer: Health Management Network Commercial	$3,221.50
Rate for Payer: Humana Medicare	$1,174.90
Rate for Payer: Kaiser Permanente Commercial	$3,411.00
Rate for Payer: Kaiser Permanente Medicaid	$1,932.90
Rate for Payer: Kaiser Permanente Medicare	$1,174.90
Rate for Payer: MDX Hawaii PPO	$3,676.30
Rate for Payer: Ohana Health Plan Medicaid	$1,174.90
Rate for Payer: Ohana Health Plan Medicare	$1,174.90
Rate for Payer: UnitedHealthcare Medicare	$1,174.90
Rate for Payer: University Health Alliance Commercial	$2,762.53

ICEPEARL CRYO NEEDLE

Facility

$3,790.00

Service Code	HCPCS C2618
Hospital Revenue Code	272
Min. Negotiated Rate	$3,221.50
Max. Negotiated Rate	$3,676.30
Rate for Payer: Cash Price	$2,274.00
Rate for Payer: Health Management Network Commercial	$3,221.50
Rate for Payer: Kaiser Permanente Commercial	$3,411.00
Rate for Payer: MDX Hawaii PPO	$3,676.30

ICEROD CRYO NEEDLE

Facility

$3,790.00

Service Code	HCPCS C2618
Hospital Revenue Code	272
Min. Negotiated Rate	$3,221.50
Max. Negotiated Rate	$3,676.30
Rate for Payer: Cash Price	$2,274.00
Rate for Payer: Health Management Network Commercial	$3,221.50
Rate for Payer: Kaiser Permanente Commercial	$3,411.00
Rate for Payer: MDX Hawaii PPO	$3,676.30

ICEROD CRYO NEEDLE

Facility

$3,790.00

Service Code	HCPCS C2618
Hospital Revenue Code	272
Min. Negotiated Rate	$1,174.90
Max. Negotiated Rate	$3,676.30
Rate for Payer: AlohaCare Medicaid	$1,895.00
Rate for Payer: AlohaCare Medicare	$1,174.90
Rate for Payer: Cash Price	$2,274.00
Rate for Payer: Devoted Health Medicare	$1,288.60
Rate for Payer: Hawaii Medical Service Association Medicare	$1,174.90
Rate for Payer: Hawaii Western Management Group Commercial	$3,600.50
Rate for Payer: Health Management Network Commercial	$3,221.50
Rate for Payer: Humana Medicare	$1,174.90
Rate for Payer: Kaiser Permanente Commercial	$3,411.00
Rate for Payer: Kaiser Permanente Medicaid	$1,932.90
Rate for Payer: Kaiser Permanente Medicare	$1,174.90
Rate for Payer: MDX Hawaii PPO	$3,676.30
Rate for Payer: Ohana Health Plan Medicaid	$1,174.90
Rate for Payer: Ohana Health Plan Medicare	$1,174.90
Rate for Payer: UnitedHealthcare Medicare	$1,174.90
Rate for Payer: University Health Alliance Commercial	$2,762.53

ICOSAPENT ETHYL 1 GRAM CAPSULE [119049]

Facility

$16.00

Service Code	NDC 60687076411
Hospital Revenue Code	250
Min. Negotiated Rate	$13.60
Max. Negotiated Rate	$15.52
Rate for Payer: Cash Price	$9.60
Rate for Payer: Health Management Network Commercial	$13.60
Rate for Payer: Kaiser Permanente Commercial	$14.40
Rate for Payer: MDX Hawaii PPO	$15.52

ICOSAPENT ETHYL 1 GRAM CAPSULE [119049]

Facility

$12.00

Service Code	NDC 00054050823
Hospital Revenue Code	637
Min. Negotiated Rate	$3.72
Max. Negotiated Rate	$11.64
Rate for Payer: AlohaCare Medicaid	$6.00
Rate for Payer: AlohaCare Medicare	$3.72
Rate for Payer: Cash Price	$7.20
Rate for Payer: Devoted Health Medicare	$4.08
Rate for Payer: Hawaii Medical Service Association Medicare	$3.72
Rate for Payer: Hawaii Western Management Group Commercial	$11.40
Rate for Payer: Health Management Network Commercial	$10.20
Rate for Payer: Humana Medicare	$3.72
Rate for Payer: Kaiser Permanente Commercial	$10.80
Rate for Payer: Kaiser Permanente Medicaid	$6.12
Rate for Payer: Kaiser Permanente Medicare	$3.72
Rate for Payer: MDX Hawaii PPO	$11.64
Rate for Payer: Ohana Health Plan Medicaid	$3.72
Rate for Payer: Ohana Health Plan Medicare	$3.72
Rate for Payer: UnitedHealthcare Medicare	$3.72
Rate for Payer: University Health Alliance Commercial	$8.75

ICOSAPENT ETHYL 1 GRAM CAPSULE [119049]

Facility

$16.00

Service Code	NDC 60687076411
Hospital Revenue Code	637
Min. Negotiated Rate	$4.96
Max. Negotiated Rate	$15.52
Rate for Payer: AlohaCare Medicaid	$8.00
Rate for Payer: AlohaCare Medicare	$4.96
Rate for Payer: Cash Price	$9.60
Rate for Payer: Devoted Health Medicare	$5.44
Rate for Payer: Hawaii Medical Service Association Medicare	$4.96
Rate for Payer: Hawaii Western Management Group Commercial	$15.20
Rate for Payer: Health Management Network Commercial	$13.60
Rate for Payer: Humana Medicare	$4.96
Rate for Payer: Kaiser Permanente Commercial	$14.40
Rate for Payer: Kaiser Permanente Medicaid	$8.16
Rate for Payer: Kaiser Permanente Medicare	$4.96
Rate for Payer: MDX Hawaii PPO	$15.52
Rate for Payer: Ohana Health Plan Medicaid	$4.96
Rate for Payer: Ohana Health Plan Medicare	$4.96
Rate for Payer: UnitedHealthcare Medicare	$4.96
Rate for Payer: University Health Alliance Commercial	$11.66

ICOSAPENT ETHYL 1 GRAM CAPSULE [119049]

Facility

$13.00

Service Code	NDC 52937000120
Hospital Revenue Code	637
Min. Negotiated Rate	$4.03
Max. Negotiated Rate	$12.61
Rate for Payer: AlohaCare Medicaid	$6.50
Rate for Payer: AlohaCare Medicare	$4.03
Rate for Payer: Cash Price	$7.80
Rate for Payer: Devoted Health Medicare	$4.42
Rate for Payer: Hawaii Medical Service Association Medicare	$4.03
Rate for Payer: Hawaii Western Management Group Commercial	$12.35
Rate for Payer: Health Management Network Commercial	$11.05
Rate for Payer: Humana Medicare	$4.03
Rate for Payer: Kaiser Permanente Commercial	$11.70
Rate for Payer: Kaiser Permanente Medicaid	$6.63
Rate for Payer: Kaiser Permanente Medicare	$4.03
Rate for Payer: MDX Hawaii PPO	$12.61
Rate for Payer: Ohana Health Plan Medicaid	$4.03
Rate for Payer: Ohana Health Plan Medicare	$4.03
Rate for Payer: UnitedHealthcare Medicare	$4.03
Rate for Payer: University Health Alliance Commercial	$9.48

ICOSAPENT ETHYL 1 GRAM CAPSULE [119049]

Facility

$13.00

Service Code	NDC 52937000120
Hospital Revenue Code	250
Min. Negotiated Rate	$11.05
Max. Negotiated Rate	$12.61
Rate for Payer: Cash Price	$7.80
Rate for Payer: Health Management Network Commercial	$11.05
Rate for Payer: Kaiser Permanente Commercial	$11.70
Rate for Payer: MDX Hawaii PPO	$12.61

ICOSAPENT ETHYL 1 GRAM CAPSULE [119049]

Facility

$12.00

Service Code	NDC 00054050823
Hospital Revenue Code	250
Min. Negotiated Rate	$10.20
Max. Negotiated Rate	$11.64
Rate for Payer: Cash Price	$7.20
Rate for Payer: Health Management Network Commercial	$10.20
Rate for Payer: Kaiser Permanente Commercial	$10.80
Rate for Payer: MDX Hawaii PPO	$11.64

IDARUCIZUMAB 2.5 GRAM/50 ML INTRAVENOUS SOLUTION [130445]

Facility

$6,123.00

Service Code	HCPCS J3490
Hospital Revenue Code	637
Min. Negotiated Rate	$1,898.13
Max. Negotiated Rate	$5,939.31
Rate for Payer: AlohaCare Medicaid	$3,061.50
Rate for Payer: AlohaCare Medicare	$1,898.13
Rate for Payer: Cash Price	$3,673.80
Rate for Payer: Devoted Health Medicare	$2,081.82
Rate for Payer: Hawaii Medical Service Association Medicare	$1,898.13
Rate for Payer: Hawaii Western Management Group Commercial	$5,816.85
Rate for Payer: Health Management Network Commercial	$5,204.55
Rate for Payer: Humana Medicare	$1,898.13
Rate for Payer: Kaiser Permanente Commercial	$5,510.70
Rate for Payer: Kaiser Permanente Medicaid	$3,122.73
Rate for Payer: Kaiser Permanente Medicare	$1,898.13
Rate for Payer: MDX Hawaii PPO	$5,939.31
Rate for Payer: Ohana Health Plan Medicaid	$1,898.13
Rate for Payer: Ohana Health Plan Medicare	$1,898.13
Rate for Payer: UnitedHealthcare Medicare	$1,898.13
Rate for Payer: University Health Alliance Commercial	$4,463.05

IDARUCIZUMAB 2.5 GRAM/50 ML INTRAVENOUS SOLUTION [130445]

Facility

$6,123.00

Service Code	HCPCS J3490
Hospital Revenue Code	250
Min. Negotiated Rate	$5,204.55
Max. Negotiated Rate	$5,939.31
Rate for Payer: Cash Price	$3,673.80
Rate for Payer: Health Management Network Commercial	$5,204.55
Rate for Payer: Kaiser Permanente Commercial	$5,510.70
Rate for Payer: MDX Hawaii PPO	$5,939.31

IDURSULFASE 6 MG/3 ML INTRAVENOUS SOLUTION [76878]

Facility

$4,376.00

Service Code	HCPCS J1743
Hospital Revenue Code	636
Min. Negotiated Rate	$558.56
Max. Negotiated Rate	$4,244.72
Rate for Payer: AlohaCare Medicaid	$2,188.00
Rate for Payer: AlohaCare Medicare	$1,356.56
Rate for Payer: Cash Price	$2,625.60
Rate for Payer: Cash Price	$2,625.60
Rate for Payer: Devoted Health Medicare	$1,487.84
Rate for Payer: Hawaii Medical Service Association ABD	$558.56
Rate for Payer: Hawaii Medical Service Association Commercial	$697.77
Rate for Payer: Hawaii Medical Service Association Medicare	$1,356.56
Rate for Payer: Hawaii Medical Service Association Non-ABD	$558.56
Rate for Payer: Hawaii Western Management Group Commercial	$4,157.20
Rate for Payer: Health Management Network Commercial	$3,719.60
Rate for Payer: Humana Medicare	$1,356.56
Rate for Payer: Kaiser Permanente Commercial	$3,938.40
Rate for Payer: Kaiser Permanente Medicaid	$2,231.76
Rate for Payer: Kaiser Permanente Medicare	$1,356.56
Rate for Payer: MDX Hawaii PPO	$4,244.72
Rate for Payer: Ohana Health Plan Medicaid	$1,356.56
Rate for Payer: Ohana Health Plan Medicare	$1,356.56
Rate for Payer: UnitedHealthcare Medicaid	$2,625.60
Rate for Payer: UnitedHealthcare Medicare	$1,356.56
Rate for Payer: University Health Alliance Commercial	$3,189.67

IDURSULFASE 6 MG/3 ML INTRAVENOUS SOLUTION [76878]

Facility

$4,376.00

Service Code	HCPCS J1743
Hospital Revenue Code	250
Min. Negotiated Rate	$3,719.60
Max. Negotiated Rate	$4,244.72
Rate for Payer: Cash Price	$2,625.60
Rate for Payer: Health Management Network Commercial	$3,719.60
Rate for Payer: Kaiser Permanente Commercial	$3,938.40
Rate for Payer: MDX Hawaii PPO	$4,244.72

IFOSFAMIDE 3 G/60ML IV (WET SOLR VIAL) [43010249]

Facility

$194.00

Service Code	HCPCS J9208
Hospital Revenue Code	636
Min. Negotiated Rate	$23.50
Max. Negotiated Rate	$188.18
Rate for Payer: AlohaCare Medicaid	$97.00
Rate for Payer: AlohaCare Medicaid	$57.50
Rate for Payer: AlohaCare Medicare	$35.65
Rate for Payer: AlohaCare Medicare	$60.14
Rate for Payer: Cash Price	$69.00
Rate for Payer: Cash Price	$69.00
Rate for Payer: Cash Price	$116.40
Rate for Payer: Cash Price	$116.40
Rate for Payer: Devoted Health Medicare	$39.10
Rate for Payer: Devoted Health Medicare	$65.96
Rate for Payer: Hawaii Medical Service Association ABD	$23.50
Rate for Payer: Hawaii Medical Service Association ABD	$23.50
Rate for Payer: Hawaii Medical Service Association Medicare	$35.65
Rate for Payer: Hawaii Medical Service Association Medicare	$60.14
Rate for Payer: Hawaii Medical Service Association Non-ABD	$23.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$23.50
Rate for Payer: Hawaii Western Management Group Commercial	$109.25
Rate for Payer: Hawaii Western Management Group Commercial	$184.30
Rate for Payer: Health Management Network Commercial	$97.75
Rate for Payer: Health Management Network Commercial	$164.90
Rate for Payer: Humana Medicare	$35.65
Rate for Payer: Humana Medicare	$60.14
Rate for Payer: Kaiser Permanente Commercial	$174.60
Rate for Payer: Kaiser Permanente Commercial	$103.50
Rate for Payer: Kaiser Permanente Medicaid	$58.65
Rate for Payer: Kaiser Permanente Medicaid	$98.94
Rate for Payer: Kaiser Permanente Medicare	$35.65
Rate for Payer: Kaiser Permanente Medicare	$60.14
Rate for Payer: MDX Hawaii PPO	$111.55
Rate for Payer: MDX Hawaii PPO	$188.18
Rate for Payer: Ohana Health Plan Medicaid	$60.14
Rate for Payer: Ohana Health Plan Medicaid	$35.65
Rate for Payer: Ohana Health Plan Medicare	$35.65
Rate for Payer: Ohana Health Plan Medicare	$60.14
Rate for Payer: UnitedHealthcare Medicaid	$69.00
Rate for Payer: UnitedHealthcare Medicaid	$116.40
Rate for Payer: UnitedHealthcare Medicare	$60.14
Rate for Payer: UnitedHealthcare Medicare	$35.65
Rate for Payer: University Health Alliance Commercial	$83.82
Rate for Payer: University Health Alliance Commercial	$141.41

IFOSFAMIDE 3 G/60ML IV (WET SOLR VIAL) [43010249]

Facility

$115.00

Service Code	HCPCS J9208
Hospital Revenue Code	250
Min. Negotiated Rate	$97.75
Max. Negotiated Rate	$111.55
Rate for Payer: Cash Price	$69.00
Rate for Payer: Cash Price	$116.40
Rate for Payer: Health Management Network Commercial	$164.90
Rate for Payer: Health Management Network Commercial	$97.75
Rate for Payer: Kaiser Permanente Commercial	$103.50
Rate for Payer: Kaiser Permanente Commercial	$174.60
Rate for Payer: MDX Hawaii PPO	$111.55
Rate for Payer: MDX Hawaii PPO	$188.18

IFOSFAMIDE 3 GRAM INTRAVENOUS SOLUTION [10249]

Facility

$194.00

Service Code	HCPCS J9208
Hospital Revenue Code	636
Min. Negotiated Rate	$23.50
Max. Negotiated Rate	$188.18
Rate for Payer: AlohaCare Medicaid	$97.00
Rate for Payer: AlohaCare Medicare	$60.14
Rate for Payer: Cash Price	$116.40
Rate for Payer: Cash Price	$116.40
Rate for Payer: Devoted Health Medicare	$65.96
Rate for Payer: Hawaii Medical Service Association ABD	$23.50
Rate for Payer: Hawaii Medical Service Association Medicare	$60.14
Rate for Payer: Hawaii Medical Service Association Non-ABD	$23.50
Rate for Payer: Hawaii Western Management Group Commercial	$184.30
Rate for Payer: Health Management Network Commercial	$164.90
Rate for Payer: Humana Medicare	$60.14
Rate for Payer: Kaiser Permanente Commercial	$174.60
Rate for Payer: Kaiser Permanente Medicaid	$98.94
Rate for Payer: Kaiser Permanente Medicare	$60.14
Rate for Payer: MDX Hawaii PPO	$188.18
Rate for Payer: Ohana Health Plan Medicaid	$60.14
Rate for Payer: Ohana Health Plan Medicare	$60.14
Rate for Payer: UnitedHealthcare Medicaid	$116.40
Rate for Payer: UnitedHealthcare Medicare	$60.14
Rate for Payer: University Health Alliance Commercial	$141.41

IFOSFAMIDE 3 GRAM INTRAVENOUS SOLUTION [10249]

Facility

$194.00

Service Code	HCPCS J9208
Hospital Revenue Code	250
Min. Negotiated Rate	$164.90
Max. Negotiated Rate	$188.18
Rate for Payer: Cash Price	$116.40
Rate for Payer: Health Management Network Commercial	$164.90
Rate for Payer: Kaiser Permanente Commercial	$174.60
Rate for Payer: MDX Hawaii PPO	$188.18

Know your out-of-pocket cost for care.

All Charges