Kau Hospital

All Charges

Charge

Type

Setting

Price

INSERT POLYETHYLENE 723-00-36F

Facility

$2,703.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$837.93
Max. Negotiated Rate	$2,621.91
Rate for Payer: AlohaCare Medicaid	$1,351.50
Rate for Payer: AlohaCare Medicare	$837.93
Rate for Payer: Cash Price	$1,621.80
Rate for Payer: Devoted Health Medicare	$919.02
Rate for Payer: Hawaii Medical Service Association Medicare	$837.93
Rate for Payer: Hawaii Western Management Group Commercial	$1,892.10
Rate for Payer: Health Management Network Commercial	$2,297.55
Rate for Payer: Humana Medicare	$837.93
Rate for Payer: Kaiser Permanente Commercial	$2,432.70
Rate for Payer: Kaiser Permanente Medicaid	$1,378.53
Rate for Payer: Kaiser Permanente Medicare	$837.93
Rate for Payer: MDX Hawaii PPO	$2,621.91
Rate for Payer: Ohana Health Plan Medicaid	$837.93
Rate for Payer: Ohana Health Plan Medicare	$837.93
Rate for Payer: UnitedHealthcare Medicare	$837.93
Rate for Payer: University Health Alliance Commercial	$1,513.68

INSERT POLYETHYLENE 723-00-36F

Facility

$2,703.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$1,513.68
Max. Negotiated Rate	$2,621.91
Rate for Payer: Cash Price	$1,621.80
Rate for Payer: Hawaii Western Management Group Commercial	$1,892.10
Rate for Payer: Health Management Network Commercial	$2,297.55
Rate for Payer: Kaiser Permanente Commercial	$2,432.70
Rate for Payer: MDX Hawaii PPO	$2,621.91
Rate for Payer: University Health Alliance Commercial	$1,513.68

INSERT RETENTIVE REV DWF364B

Facility

$5,976.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$3,346.56
Max. Negotiated Rate	$5,796.72
Rate for Payer: Cash Price	$3,585.60
Rate for Payer: Hawaii Western Management Group Commercial	$4,183.20
Rate for Payer: Health Management Network Commercial	$5,079.60
Rate for Payer: Kaiser Permanente Commercial	$5,378.40
Rate for Payer: MDX Hawaii PPO	$5,796.72
Rate for Payer: University Health Alliance Commercial	$3,346.56

INSERT RETENTIVE REV DWF364B

Facility

$5,976.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$1,852.56
Max. Negotiated Rate	$5,796.72
Rate for Payer: AlohaCare Medicaid	$2,988.00
Rate for Payer: AlohaCare Medicare	$1,852.56
Rate for Payer: Cash Price	$3,585.60
Rate for Payer: Devoted Health Medicare	$2,031.84
Rate for Payer: Hawaii Medical Service Association Medicare	$1,852.56
Rate for Payer: Hawaii Western Management Group Commercial	$4,183.20
Rate for Payer: Health Management Network Commercial	$5,079.60
Rate for Payer: Humana Medicare	$1,852.56
Rate for Payer: Kaiser Permanente Commercial	$5,378.40
Rate for Payer: Kaiser Permanente Medicaid	$3,047.76
Rate for Payer: Kaiser Permanente Medicare	$1,852.56
Rate for Payer: MDX Hawaii PPO	$5,796.72
Rate for Payer: Ohana Health Plan Medicaid	$1,852.56
Rate for Payer: Ohana Health Plan Medicare	$1,852.56
Rate for Payer: UnitedHealthcare Medicare	$1,852.56
Rate for Payer: University Health Alliance Commercial	$3,346.56

INSERT REVERSED +3MM

Facility

$2,768.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$1,550.08
Max. Negotiated Rate	$2,684.96
Rate for Payer: Cash Price	$1,660.80
Rate for Payer: Hawaii Western Management Group Commercial	$1,937.60
Rate for Payer: Health Management Network Commercial	$2,352.80
Rate for Payer: Kaiser Permanente Commercial	$2,491.20
Rate for Payer: MDX Hawaii PPO	$2,684.96
Rate for Payer: University Health Alliance Commercial	$1,550.08

INSERT REVERSED +3MM

Facility

$2,768.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$858.08
Max. Negotiated Rate	$2,684.96
Rate for Payer: AlohaCare Medicaid	$1,384.00
Rate for Payer: AlohaCare Medicare	$858.08
Rate for Payer: Cash Price	$1,660.80
Rate for Payer: Devoted Health Medicare	$941.12
Rate for Payer: Hawaii Medical Service Association Medicare	$858.08
Rate for Payer: Hawaii Western Management Group Commercial	$1,937.60
Rate for Payer: Health Management Network Commercial	$2,352.80
Rate for Payer: Humana Medicare	$858.08
Rate for Payer: Kaiser Permanente Commercial	$2,491.20
Rate for Payer: Kaiser Permanente Medicaid	$1,411.68
Rate for Payer: Kaiser Permanente Medicare	$858.08
Rate for Payer: MDX Hawaii PPO	$2,684.96
Rate for Payer: Ohana Health Plan Medicaid	$858.08
Rate for Payer: Ohana Health Plan Medicare	$858.08
Rate for Payer: UnitedHealthcare Medicare	$858.08
Rate for Payer: University Health Alliance Commercial	$1,550.08

INSERT REVERSED THICKNESS +9MM

Facility

$3,530.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$1,976.80
Max. Negotiated Rate	$3,424.10
Rate for Payer: Cash Price	$2,118.00
Rate for Payer: Hawaii Western Management Group Commercial	$2,471.00
Rate for Payer: Health Management Network Commercial	$3,000.50
Rate for Payer: Kaiser Permanente Commercial	$3,177.00
Rate for Payer: MDX Hawaii PPO	$3,424.10
Rate for Payer: University Health Alliance Commercial	$1,976.80

INSERT REVERSED THICKNESS +9MM

Facility

$3,530.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$1,094.30
Max. Negotiated Rate	$3,424.10
Rate for Payer: AlohaCare Medicaid	$1,765.00
Rate for Payer: AlohaCare Medicare	$1,094.30
Rate for Payer: Cash Price	$2,118.00
Rate for Payer: Devoted Health Medicare	$1,200.20
Rate for Payer: Hawaii Medical Service Association Medicare	$1,094.30
Rate for Payer: Hawaii Western Management Group Commercial	$2,471.00
Rate for Payer: Health Management Network Commercial	$3,000.50
Rate for Payer: Humana Medicare	$1,094.30
Rate for Payer: Kaiser Permanente Commercial	$3,177.00
Rate for Payer: Kaiser Permanente Medicaid	$1,800.30
Rate for Payer: Kaiser Permanente Medicare	$1,094.30
Rate for Payer: MDX Hawaii PPO	$3,424.10
Rate for Payer: Ohana Health Plan Medicaid	$1,094.30
Rate for Payer: Ohana Health Plan Medicare	$1,094.30
Rate for Payer: UnitedHealthcare Medicare	$1,094.30
Rate for Payer: University Health Alliance Commercial	$1,976.80

INSERT REVERSE THCK +6 DWF391B

Facility

$2,768.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$858.08
Max. Negotiated Rate	$2,684.96
Rate for Payer: AlohaCare Medicaid	$1,384.00
Rate for Payer: AlohaCare Medicare	$858.08
Rate for Payer: Cash Price	$1,660.80
Rate for Payer: Devoted Health Medicare	$941.12
Rate for Payer: Hawaii Medical Service Association Medicare	$858.08
Rate for Payer: Hawaii Western Management Group Commercial	$1,937.60
Rate for Payer: Health Management Network Commercial	$2,352.80
Rate for Payer: Humana Medicare	$858.08
Rate for Payer: Kaiser Permanente Commercial	$2,491.20
Rate for Payer: Kaiser Permanente Medicaid	$1,411.68
Rate for Payer: Kaiser Permanente Medicare	$858.08
Rate for Payer: MDX Hawaii PPO	$2,684.96
Rate for Payer: Ohana Health Plan Medicaid	$858.08
Rate for Payer: Ohana Health Plan Medicare	$858.08
Rate for Payer: UnitedHealthcare Medicare	$858.08
Rate for Payer: University Health Alliance Commercial	$1,550.08

INSERT REVERSE THCK +6 DWF391B

Facility

$2,768.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$1,550.08
Max. Negotiated Rate	$2,684.96
Rate for Payer: Cash Price	$1,660.80
Rate for Payer: Hawaii Western Management Group Commercial	$1,937.60
Rate for Payer: Health Management Network Commercial	$2,352.80
Rate for Payer: Kaiser Permanente Commercial	$2,491.20
Rate for Payer: MDX Hawaii PPO	$2,684.96
Rate for Payer: University Health Alliance Commercial	$1,550.08

INSERT REV THICK +3MM DWP1363

Facility

$2,768.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$1,550.08
Max. Negotiated Rate	$2,684.96
Rate for Payer: Cash Price	$1,660.80
Rate for Payer: Hawaii Western Management Group Commercial	$1,937.60
Rate for Payer: Health Management Network Commercial	$2,352.80
Rate for Payer: Kaiser Permanente Commercial	$2,491.20
Rate for Payer: MDX Hawaii PPO	$2,684.96
Rate for Payer: University Health Alliance Commercial	$1,550.08

INSERT REV THICK +3MM DWP1363

Facility

$2,768.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$858.08
Max. Negotiated Rate	$2,684.96
Rate for Payer: AlohaCare Medicaid	$1,384.00
Rate for Payer: AlohaCare Medicare	$858.08
Rate for Payer: Cash Price	$1,660.80
Rate for Payer: Devoted Health Medicare	$941.12
Rate for Payer: Hawaii Medical Service Association Medicare	$858.08
Rate for Payer: Hawaii Western Management Group Commercial	$1,937.60
Rate for Payer: Health Management Network Commercial	$2,352.80
Rate for Payer: Humana Medicare	$858.08
Rate for Payer: Kaiser Permanente Commercial	$2,491.20
Rate for Payer: Kaiser Permanente Medicaid	$1,411.68
Rate for Payer: Kaiser Permanente Medicare	$858.08
Rate for Payer: MDX Hawaii PPO	$2,684.96
Rate for Payer: Ohana Health Plan Medicaid	$858.08
Rate for Payer: Ohana Health Plan Medicare	$858.08
Rate for Payer: UnitedHealthcare Medicare	$858.08
Rate for Payer: University Health Alliance Commercial	$1,550.08

INSERT STABILIZER 5537-G-316-E

Facility

$4,903.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$1,519.93
Max. Negotiated Rate	$4,755.91
Rate for Payer: AlohaCare Medicaid	$2,451.50
Rate for Payer: AlohaCare Medicare	$1,519.93
Rate for Payer: Cash Price	$2,941.80
Rate for Payer: Devoted Health Medicare	$1,667.02
Rate for Payer: Hawaii Medical Service Association Medicare	$1,519.93
Rate for Payer: Hawaii Western Management Group Commercial	$3,432.10
Rate for Payer: Health Management Network Commercial	$4,167.55
Rate for Payer: Humana Medicare	$1,519.93
Rate for Payer: Kaiser Permanente Commercial	$4,412.70
Rate for Payer: Kaiser Permanente Medicaid	$2,500.53
Rate for Payer: Kaiser Permanente Medicare	$1,519.93
Rate for Payer: MDX Hawaii PPO	$4,755.91
Rate for Payer: Ohana Health Plan Medicaid	$1,519.93
Rate for Payer: Ohana Health Plan Medicare	$1,519.93
Rate for Payer: UnitedHealthcare Medicare	$1,519.93
Rate for Payer: University Health Alliance Commercial	$2,745.68

INSERT STABILIZER 5537-G-316-E

Facility

$4,903.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$2,745.68
Max. Negotiated Rate	$4,755.91
Rate for Payer: Cash Price	$2,941.80
Rate for Payer: Hawaii Western Management Group Commercial	$3,432.10
Rate for Payer: Health Management Network Commercial	$4,167.55
Rate for Payer: Kaiser Permanente Commercial	$4,412.70
Rate for Payer: MDX Hawaii PPO	$4,755.91
Rate for Payer: University Health Alliance Commercial	$2,745.68

INSERT TB 5531-G-613-E

Facility

$2,676.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$829.56
Max. Negotiated Rate	$2,595.72
Rate for Payer: AlohaCare Medicaid	$1,338.00
Rate for Payer: AlohaCare Medicare	$829.56
Rate for Payer: Cash Price	$1,605.60
Rate for Payer: Devoted Health Medicare	$909.84
Rate for Payer: Hawaii Medical Service Association Medicare	$829.56
Rate for Payer: Hawaii Western Management Group Commercial	$1,873.20
Rate for Payer: Health Management Network Commercial	$2,274.60
Rate for Payer: Humana Medicare	$829.56
Rate for Payer: Kaiser Permanente Commercial	$2,408.40
Rate for Payer: Kaiser Permanente Medicaid	$1,364.76
Rate for Payer: Kaiser Permanente Medicare	$829.56
Rate for Payer: MDX Hawaii PPO	$2,595.72
Rate for Payer: Ohana Health Plan Medicaid	$829.56
Rate for Payer: Ohana Health Plan Medicare	$829.56
Rate for Payer: UnitedHealthcare Medicare	$829.56
Rate for Payer: University Health Alliance Commercial	$1,498.56

INSERT TB 5531-G-613-E

Facility

$2,676.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$1,498.56
Max. Negotiated Rate	$2,595.72
Rate for Payer: Cash Price	$1,605.60
Rate for Payer: Hawaii Western Management Group Commercial	$1,873.20
Rate for Payer: Health Management Network Commercial	$2,274.60
Rate for Payer: Kaiser Permanente Commercial	$2,408.40
Rate for Payer: MDX Hawaii PPO	$2,595.72
Rate for Payer: University Health Alliance Commercial	$1,498.56

INSERT TB 5532-G-612-E

Facility

$2,676.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$829.56
Max. Negotiated Rate	$2,595.72
Rate for Payer: AlohaCare Medicaid	$1,338.00
Rate for Payer: AlohaCare Medicare	$829.56
Rate for Payer: Cash Price	$1,605.60
Rate for Payer: Devoted Health Medicare	$909.84
Rate for Payer: Hawaii Medical Service Association Medicare	$829.56
Rate for Payer: Hawaii Western Management Group Commercial	$1,873.20
Rate for Payer: Health Management Network Commercial	$2,274.60
Rate for Payer: Humana Medicare	$829.56
Rate for Payer: Kaiser Permanente Commercial	$2,408.40
Rate for Payer: Kaiser Permanente Medicaid	$1,364.76
Rate for Payer: Kaiser Permanente Medicare	$829.56
Rate for Payer: MDX Hawaii PPO	$2,595.72
Rate for Payer: Ohana Health Plan Medicaid	$829.56
Rate for Payer: Ohana Health Plan Medicare	$829.56
Rate for Payer: UnitedHealthcare Medicare	$829.56
Rate for Payer: University Health Alliance Commercial	$1,498.56

INSERT TB 5532-G-612-E

Facility

$2,676.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$1,498.56
Max. Negotiated Rate	$2,595.72
Rate for Payer: Cash Price	$1,605.60
Rate for Payer: Hawaii Western Management Group Commercial	$1,873.20
Rate for Payer: Health Management Network Commercial	$2,274.60
Rate for Payer: Kaiser Permanente Commercial	$2,408.40
Rate for Payer: MDX Hawaii PPO	$2,595.72
Rate for Payer: University Health Alliance Commercial	$1,498.56

INSERT TB CS 5531-G-110-E

Facility

$2,676.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$1,498.56
Max. Negotiated Rate	$2,595.72
Rate for Payer: Cash Price	$1,605.60
Rate for Payer: Hawaii Western Management Group Commercial	$1,873.20
Rate for Payer: Health Management Network Commercial	$2,274.60
Rate for Payer: Kaiser Permanente Commercial	$2,408.40
Rate for Payer: MDX Hawaii PPO	$2,595.72
Rate for Payer: University Health Alliance Commercial	$1,498.56

INSERT TB CS 5531-G-110-E

Facility

$2,676.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$829.56
Max. Negotiated Rate	$2,595.72
Rate for Payer: AlohaCare Medicaid	$1,338.00
Rate for Payer: AlohaCare Medicare	$829.56
Rate for Payer: Cash Price	$1,605.60
Rate for Payer: Devoted Health Medicare	$909.84
Rate for Payer: Hawaii Medical Service Association Medicare	$829.56
Rate for Payer: Hawaii Western Management Group Commercial	$1,873.20
Rate for Payer: Health Management Network Commercial	$2,274.60
Rate for Payer: Humana Medicare	$829.56
Rate for Payer: Kaiser Permanente Commercial	$2,408.40
Rate for Payer: Kaiser Permanente Medicaid	$1,364.76
Rate for Payer: Kaiser Permanente Medicare	$829.56
Rate for Payer: MDX Hawaii PPO	$2,595.72
Rate for Payer: Ohana Health Plan Medicaid	$829.56
Rate for Payer: Ohana Health Plan Medicare	$829.56
Rate for Payer: UnitedHealthcare Medicare	$829.56
Rate for Payer: University Health Alliance Commercial	$1,498.56

INSERT TB SIZE 5 5532-G-510-E

Facility

$2,676.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$829.56
Max. Negotiated Rate	$2,595.72
Rate for Payer: AlohaCare Medicaid	$1,338.00
Rate for Payer: AlohaCare Medicare	$829.56
Rate for Payer: Cash Price	$1,605.60
Rate for Payer: Devoted Health Medicare	$909.84
Rate for Payer: Hawaii Medical Service Association Medicare	$829.56
Rate for Payer: Hawaii Western Management Group Commercial	$1,873.20
Rate for Payer: Health Management Network Commercial	$2,274.60
Rate for Payer: Humana Medicare	$829.56
Rate for Payer: Kaiser Permanente Commercial	$2,408.40
Rate for Payer: Kaiser Permanente Medicaid	$1,364.76
Rate for Payer: Kaiser Permanente Medicare	$829.56
Rate for Payer: MDX Hawaii PPO	$2,595.72
Rate for Payer: Ohana Health Plan Medicaid	$829.56
Rate for Payer: Ohana Health Plan Medicare	$829.56
Rate for Payer: UnitedHealthcare Medicare	$829.56
Rate for Payer: University Health Alliance Commercial	$1,498.56

INSERT TB SIZE 5 5532-G-510-E

Facility

$2,676.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$1,498.56
Max. Negotiated Rate	$2,595.72
Rate for Payer: Cash Price	$1,605.60
Rate for Payer: Hawaii Western Management Group Commercial	$1,873.20
Rate for Payer: Health Management Network Commercial	$2,274.60
Rate for Payer: Kaiser Permanente Commercial	$2,408.40
Rate for Payer: MDX Hawaii PPO	$2,595.72
Rate for Payer: University Health Alliance Commercial	$1,498.56

INSERT TB SZ2 9MM 5531-G-209-E

Facility

$2,676.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$1,498.56
Max. Negotiated Rate	$2,595.72
Rate for Payer: Cash Price	$1,605.60
Rate for Payer: Hawaii Western Management Group Commercial	$1,873.20
Rate for Payer: Health Management Network Commercial	$2,274.60
Rate for Payer: Kaiser Permanente Commercial	$2,408.40
Rate for Payer: MDX Hawaii PPO	$2,595.72
Rate for Payer: University Health Alliance Commercial	$1,498.56

INSERT TB SZ2 9MM 5531-G-209-E

Facility

$2,676.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$829.56
Max. Negotiated Rate	$2,595.72
Rate for Payer: AlohaCare Medicaid	$1,338.00
Rate for Payer: AlohaCare Medicare	$829.56
Rate for Payer: Cash Price	$1,605.60
Rate for Payer: Devoted Health Medicare	$909.84
Rate for Payer: Hawaii Medical Service Association Medicare	$829.56
Rate for Payer: Hawaii Western Management Group Commercial	$1,873.20
Rate for Payer: Health Management Network Commercial	$2,274.60
Rate for Payer: Humana Medicare	$829.56
Rate for Payer: Kaiser Permanente Commercial	$2,408.40
Rate for Payer: Kaiser Permanente Medicaid	$1,364.76
Rate for Payer: Kaiser Permanente Medicare	$829.56
Rate for Payer: MDX Hawaii PPO	$2,595.72
Rate for Payer: Ohana Health Plan Medicaid	$829.56
Rate for Payer: Ohana Health Plan Medicare	$829.56
Rate for Payer: UnitedHealthcare Medicare	$829.56
Rate for Payer: University Health Alliance Commercial	$1,498.56

INSERT TB X3 5531-G-316-E

Facility

$2,676.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$1,498.56
Max. Negotiated Rate	$2,595.72
Rate for Payer: Cash Price	$1,605.60
Rate for Payer: Hawaii Western Management Group Commercial	$1,873.20
Rate for Payer: Health Management Network Commercial	$2,274.60
Rate for Payer: Kaiser Permanente Commercial	$2,408.40
Rate for Payer: MDX Hawaii PPO	$2,595.72
Rate for Payer: University Health Alliance Commercial	$1,498.56

Know your out-of-pocket cost for care.

All Charges