Kau Hospital

All Charges

Charge

Type

Setting

Price

KIT FOR PREPARATION OF TC-99M-MEDRONATE SODIUM 20 MG IV SOLUTION [98466]

Facility

$69.00

Service Code	HCPCS A9503
Hospital Revenue Code	343
Min. Negotiated Rate	$58.65
Max. Negotiated Rate	$66.93
Rate for Payer: Cash Price	$41.40
Rate for Payer: Health Management Network Commercial	$58.65
Rate for Payer: Kaiser Permanente Commercial	$62.10
Rate for Payer: MDX Hawaii PPO	$66.93

KIT FOR PREPARATION OF TC 99M-PENTETIC ACID 20 MG IV SOLUTION [109481]

Facility

$325.00

Service Code	HCPCS A9505
Hospital Revenue Code	343
Min. Negotiated Rate	$276.25
Max. Negotiated Rate	$315.25
Rate for Payer: Cash Price	$195.00
Rate for Payer: Health Management Network Commercial	$276.25
Rate for Payer: Kaiser Permanente Commercial	$292.50
Rate for Payer: MDX Hawaii PPO	$315.25

KIT FOR PREPARATION OF TC 99M-PENTETIC ACID 20 MG IV SOLUTION [109481]

Facility

$325.00

Service Code	HCPCS A9505
Hospital Revenue Code	343
Min. Negotiated Rate	$59.80
Max. Negotiated Rate	$315.25
Rate for Payer: AlohaCare Medicaid	$162.50
Rate for Payer: AlohaCare Medicare	$100.75
Rate for Payer: Cash Price	$195.00
Rate for Payer: Cash Price	$195.00
Rate for Payer: Devoted Health Medicare	$110.50
Rate for Payer: Hawaii Medical Service Association Medicare	$100.75
Rate for Payer: Hawaii Western Management Group Commercial	$308.75
Rate for Payer: Health Management Network Commercial	$276.25
Rate for Payer: Humana Medicare	$100.75
Rate for Payer: Kaiser Permanente Commercial	$292.50
Rate for Payer: Kaiser Permanente Medicaid	$165.75
Rate for Payer: Kaiser Permanente Medicare	$100.75
Rate for Payer: MDX Hawaii PPO	$315.25
Rate for Payer: Ohana Health Plan Medicaid	$100.75
Rate for Payer: Ohana Health Plan Medicare	$100.75
Rate for Payer: UnitedHealthcare Medicaid	$59.80
Rate for Payer: UnitedHealthcare Medicare	$100.75
Rate for Payer: University Health Alliance Commercial	$236.89

KIT FOR PREPARATION OF TC-99M-SODIUM OXIDRONATE 3.15 MG IV SOLUTION [209306]

Facility

$63.00

Service Code	HCPCS A9561
Hospital Revenue Code	343
Min. Negotiated Rate	$53.55
Max. Negotiated Rate	$61.11
Rate for Payer: Cash Price	$37.80
Rate for Payer: Health Management Network Commercial	$53.55
Rate for Payer: Kaiser Permanente Commercial	$56.70
Rate for Payer: MDX Hawaii PPO	$61.11

KIT FOR PREPARATION OF TC-99M-SODIUM OXIDRONATE 3.15 MG IV SOLUTION [209306]

Facility

$63.00

Service Code	HCPCS A9561
Hospital Revenue Code	343
Min. Negotiated Rate	$9.00
Max. Negotiated Rate	$61.11
Rate for Payer: AlohaCare Medicaid	$31.50
Rate for Payer: AlohaCare Medicare	$19.53
Rate for Payer: Cash Price	$37.80
Rate for Payer: Cash Price	$37.80
Rate for Payer: Devoted Health Medicare	$21.42
Rate for Payer: Hawaii Medical Service Association Medicare	$19.53
Rate for Payer: Hawaii Western Management Group Commercial	$59.85
Rate for Payer: Health Management Network Commercial	$53.55
Rate for Payer: Humana Medicare	$19.53
Rate for Payer: Kaiser Permanente Commercial	$56.70
Rate for Payer: Kaiser Permanente Medicaid	$32.13
Rate for Payer: Kaiser Permanente Medicare	$19.53
Rate for Payer: MDX Hawaii PPO	$61.11
Rate for Payer: Ohana Health Plan Medicaid	$19.53
Rate for Payer: Ohana Health Plan Medicare	$19.53
Rate for Payer: UnitedHealthcare Medicaid	$9.00
Rate for Payer: UnitedHealthcare Medicare	$19.53
Rate for Payer: University Health Alliance Commercial	$45.92

KIT FOR PREPARATION OF TC 99M-SODIUM THIOSULFATE 2 MG SOLUTION [171666]

Facility

$119.00

Service Code	HCPCS A9541
Hospital Revenue Code	343
Min. Negotiated Rate	$101.15
Max. Negotiated Rate	$115.43
Rate for Payer: Cash Price	$71.40
Rate for Payer: Health Management Network Commercial	$101.15
Rate for Payer: Kaiser Permanente Commercial	$107.10
Rate for Payer: MDX Hawaii PPO	$115.43

KIT FOR PREPARATION OF TC 99M-SODIUM THIOSULFATE 2 MG SOLUTION [171666]

Facility

$119.00

Service Code	HCPCS A9541
Hospital Revenue Code	343
Min. Negotiated Rate	$36.89
Max. Negotiated Rate	$115.43
Rate for Payer: AlohaCare Medicaid	$59.50
Rate for Payer: AlohaCare Medicare	$36.89
Rate for Payer: Cash Price	$71.40
Rate for Payer: Devoted Health Medicare	$40.46
Rate for Payer: Hawaii Medical Service Association Medicare	$36.89
Rate for Payer: Hawaii Western Management Group Commercial	$113.05
Rate for Payer: Health Management Network Commercial	$101.15
Rate for Payer: Humana Medicare	$36.89
Rate for Payer: Kaiser Permanente Commercial	$107.10
Rate for Payer: Kaiser Permanente Medicaid	$60.69
Rate for Payer: Kaiser Permanente Medicare	$36.89
Rate for Payer: MDX Hawaii PPO	$115.43
Rate for Payer: Ohana Health Plan Medicaid	$36.89
Rate for Payer: Ohana Health Plan Medicare	$36.89
Rate for Payer: UnitedHealthcare Medicare	$36.89
Rate for Payer: University Health Alliance Commercial	$86.74

KIT FOR PREPARATION TC-99M-SUCCIMER 1 MG INTRAVENOUS SOLUTION [98464]

Facility

$282.00

Service Code	NDC 17156052501
Hospital Revenue Code	343
Min. Negotiated Rate	$87.42
Max. Negotiated Rate	$273.54
Rate for Payer: AlohaCare Medicaid	$141.00
Rate for Payer: AlohaCare Medicare	$87.42
Rate for Payer: Cash Price	$169.20
Rate for Payer: Devoted Health Medicare	$95.88
Rate for Payer: Hawaii Medical Service Association Medicare	$87.42
Rate for Payer: Hawaii Western Management Group Commercial	$267.90
Rate for Payer: Health Management Network Commercial	$239.70
Rate for Payer: Humana Medicare	$87.42
Rate for Payer: Kaiser Permanente Commercial	$253.80
Rate for Payer: Kaiser Permanente Medicaid	$143.82
Rate for Payer: Kaiser Permanente Medicare	$87.42
Rate for Payer: MDX Hawaii PPO	$273.54
Rate for Payer: Ohana Health Plan Medicaid	$87.42
Rate for Payer: Ohana Health Plan Medicare	$87.42
Rate for Payer: UnitedHealthcare Medicare	$87.42
Rate for Payer: University Health Alliance Commercial	$205.55

KIT FOR PREPARATION TC-99M-SUCCIMER 1 MG INTRAVENOUS SOLUTION [98464]

Facility

$282.00

Service Code	NDC 17156052501
Hospital Revenue Code	343
Min. Negotiated Rate	$239.70
Max. Negotiated Rate	$273.54
Rate for Payer: Cash Price	$169.20
Rate for Payer: Health Management Network Commercial	$239.70
Rate for Payer: Kaiser Permanente Commercial	$253.80
Rate for Payer: MDX Hawaii PPO	$273.54

KIT FOR PREP TC-99M-MERTIATIDE (BETIATIDE) 1 MG INTRAVENOUS SOLUTION [208743]

Facility

$809.00

Service Code	HCPCS A9562
Hospital Revenue Code	343
Min. Negotiated Rate	$250.79
Max. Negotiated Rate	$784.73
Rate for Payer: AlohaCare Medicaid	$404.50
Rate for Payer: AlohaCare Medicare	$250.79
Rate for Payer: Cash Price	$485.40
Rate for Payer: Devoted Health Medicare	$275.06
Rate for Payer: Hawaii Medical Service Association Medicare	$250.79
Rate for Payer: Hawaii Western Management Group Commercial	$768.55
Rate for Payer: Health Management Network Commercial	$687.65
Rate for Payer: Humana Medicare	$250.79
Rate for Payer: Kaiser Permanente Commercial	$728.10
Rate for Payer: Kaiser Permanente Medicaid	$412.59
Rate for Payer: Kaiser Permanente Medicare	$250.79
Rate for Payer: MDX Hawaii PPO	$784.73
Rate for Payer: Ohana Health Plan Medicaid	$250.79
Rate for Payer: Ohana Health Plan Medicare	$250.79
Rate for Payer: UnitedHealthcare Medicare	$250.79
Rate for Payer: University Health Alliance Commercial	$589.68

KIT FOR PREP TC-99M-MERTIATIDE (BETIATIDE) 1 MG INTRAVENOUS SOLUTION [208743]

Facility

$809.00

Service Code	HCPCS A9562
Hospital Revenue Code	343
Min. Negotiated Rate	$687.65
Max. Negotiated Rate	$784.73
Rate for Payer: Cash Price	$485.40
Rate for Payer: Health Management Network Commercial	$687.65
Rate for Payer: Kaiser Permanente Commercial	$728.10
Rate for Payer: MDX Hawaii PPO	$784.73

KIT FOR TC 99M-LABELED RED BLOOD CELLS INTRAVENOUS SOLUTION [205836]

Facility

$235.00

Service Code	NDC 69945006820
Hospital Revenue Code	343
Min. Negotiated Rate	$199.75
Max. Negotiated Rate	$227.95
Rate for Payer: Cash Price	$141.00
Rate for Payer: Health Management Network Commercial	$199.75
Rate for Payer: Kaiser Permanente Commercial	$211.50
Rate for Payer: MDX Hawaii PPO	$227.95

KIT FOR TC 99M-LABELED RED BLOOD CELLS INTRAVENOUS SOLUTION [205836]

Facility

$235.00

Service Code	NDC 69945006820
Hospital Revenue Code	343
Min. Negotiated Rate	$72.85
Max. Negotiated Rate	$227.95
Rate for Payer: AlohaCare Medicaid	$117.50
Rate for Payer: AlohaCare Medicare	$72.85
Rate for Payer: Cash Price	$141.00
Rate for Payer: Devoted Health Medicare	$79.90
Rate for Payer: Hawaii Medical Service Association Medicare	$72.85
Rate for Payer: Hawaii Western Management Group Commercial	$223.25
Rate for Payer: Health Management Network Commercial	$199.75
Rate for Payer: Humana Medicare	$72.85
Rate for Payer: Kaiser Permanente Commercial	$211.50
Rate for Payer: Kaiser Permanente Medicaid	$119.85
Rate for Payer: Kaiser Permanente Medicare	$72.85
Rate for Payer: MDX Hawaii PPO	$227.95
Rate for Payer: Ohana Health Plan Medicaid	$72.85
Rate for Payer: Ohana Health Plan Medicare	$72.85
Rate for Payer: UnitedHealthcare Medicare	$72.85
Rate for Payer: University Health Alliance Commercial	$171.29

KIT FOR THE PREPARATION OF TC-99M-MEBROFENIN 45 MG IV SOLUTION [103948]

Facility

$153.00

Service Code	HCPCS A9537
Hospital Revenue Code	343
Min. Negotiated Rate	$47.43
Max. Negotiated Rate	$148.41
Rate for Payer: AlohaCare Medicaid	$76.50
Rate for Payer: AlohaCare Medicare	$47.43
Rate for Payer: Cash Price	$91.80
Rate for Payer: Devoted Health Medicare	$52.02
Rate for Payer: Hawaii Medical Service Association Medicare	$47.43
Rate for Payer: Hawaii Western Management Group Commercial	$145.35
Rate for Payer: Health Management Network Commercial	$130.05
Rate for Payer: Humana Medicare	$47.43
Rate for Payer: Kaiser Permanente Commercial	$137.70
Rate for Payer: Kaiser Permanente Medicaid	$78.03
Rate for Payer: Kaiser Permanente Medicare	$47.43
Rate for Payer: MDX Hawaii PPO	$148.41
Rate for Payer: Ohana Health Plan Medicaid	$47.43
Rate for Payer: Ohana Health Plan Medicare	$47.43
Rate for Payer: UnitedHealthcare Medicare	$47.43
Rate for Payer: University Health Alliance Commercial	$111.52

KIT FOR THE PREPARATION OF TC-99M-MEBROFENIN 45 MG IV SOLUTION [103948]

Facility

$153.00

Service Code	HCPCS A9537
Hospital Revenue Code	343
Min. Negotiated Rate	$130.05
Max. Negotiated Rate	$148.41
Rate for Payer: Cash Price	$91.80
Rate for Payer: Health Management Network Commercial	$130.05
Rate for Payer: Kaiser Permanente Commercial	$137.70
Rate for Payer: MDX Hawaii PPO	$148.41

KIT FOR THE PREP OF TC-99M-TILMANOCEPT 250 MCG SOLUTION FOR INJECTION [190429]

Facility

$2,385.00

Service Code	HCPCS A9520
Hospital Revenue Code	343
Min. Negotiated Rate	$739.35
Max. Negotiated Rate	$2,313.45
Rate for Payer: AlohaCare Medicaid	$1,192.50
Rate for Payer: AlohaCare Medicare	$739.35
Rate for Payer: Cash Price	$1,431.00
Rate for Payer: Devoted Health Medicare	$810.90
Rate for Payer: Hawaii Medical Service Association Medicare	$739.35
Rate for Payer: Hawaii Western Management Group Commercial	$2,265.75
Rate for Payer: Health Management Network Commercial	$2,027.25
Rate for Payer: Humana Medicare	$739.35
Rate for Payer: Kaiser Permanente Commercial	$2,146.50
Rate for Payer: Kaiser Permanente Medicaid	$1,216.35
Rate for Payer: Kaiser Permanente Medicare	$739.35
Rate for Payer: MDX Hawaii PPO	$2,313.45
Rate for Payer: Ohana Health Plan Medicaid	$739.35
Rate for Payer: Ohana Health Plan Medicare	$739.35
Rate for Payer: UnitedHealthcare Medicare	$739.35
Rate for Payer: University Health Alliance Commercial	$1,738.43

KIT FOR THE PREP OF TC-99M-TILMANOCEPT 250 MCG SOLUTION FOR INJECTION [190429]

Facility

$2,385.00

Service Code	HCPCS A9520
Hospital Revenue Code	343
Min. Negotiated Rate	$2,027.25
Max. Negotiated Rate	$2,313.45
Rate for Payer: Cash Price	$1,431.00
Rate for Payer: Health Management Network Commercial	$2,027.25
Rate for Payer: Kaiser Permanente Commercial	$2,146.50
Rate for Payer: MDX Hawaii PPO	$2,313.45

KIT INFERIOR GLENOID G000-0100

Facility

$2,637.00

Hospital Revenue Code	272
Min. Negotiated Rate	$2,241.45
Max. Negotiated Rate	$2,557.89
Rate for Payer: Cash Price	$1,582.20
Rate for Payer: Health Management Network Commercial	$2,241.45
Rate for Payer: Kaiser Permanente Commercial	$2,373.30
Rate for Payer: MDX Hawaii PPO	$2,557.89

KIT INFERIOR GLENOID G000-0100

Facility

$2,637.00

Hospital Revenue Code	272
Min. Negotiated Rate	$817.47
Max. Negotiated Rate	$2,557.89
Rate for Payer: AlohaCare Medicaid	$1,318.50
Rate for Payer: AlohaCare Medicare	$817.47
Rate for Payer: Cash Price	$1,582.20
Rate for Payer: Devoted Health Medicare	$896.58
Rate for Payer: Hawaii Medical Service Association Medicare	$817.47
Rate for Payer: Hawaii Western Management Group Commercial	$2,505.15
Rate for Payer: Health Management Network Commercial	$2,241.45
Rate for Payer: Humana Medicare	$817.47
Rate for Payer: Kaiser Permanente Commercial	$2,373.30
Rate for Payer: Kaiser Permanente Medicaid	$1,344.87
Rate for Payer: Kaiser Permanente Medicare	$817.47
Rate for Payer: MDX Hawaii PPO	$2,557.89
Rate for Payer: Ohana Health Plan Medicaid	$817.47
Rate for Payer: Ohana Health Plan Medicare	$817.47
Rate for Payer: UnitedHealthcare Medicare	$817.47
Rate for Payer: University Health Alliance Commercial	$1,922.11

KIT IN-LINE INJECTION HOUSING

Facility

$130.00

Hospital Revenue Code	272
Min. Negotiated Rate	$110.50
Max. Negotiated Rate	$126.10
Rate for Payer: Cash Price	$78.00
Rate for Payer: Health Management Network Commercial	$110.50
Rate for Payer: Kaiser Permanente Commercial	$117.00
Rate for Payer: MDX Hawaii PPO	$126.10

KIT IN-LINE INJECTION HOUSING

Facility

$130.00

Hospital Revenue Code	272
Min. Negotiated Rate	$40.30
Max. Negotiated Rate	$126.10
Rate for Payer: AlohaCare Medicaid	$65.00
Rate for Payer: AlohaCare Medicare	$40.30
Rate for Payer: Cash Price	$78.00
Rate for Payer: Devoted Health Medicare	$44.20
Rate for Payer: Hawaii Medical Service Association Medicare	$40.30
Rate for Payer: Hawaii Western Management Group Commercial	$123.50
Rate for Payer: Health Management Network Commercial	$110.50
Rate for Payer: Humana Medicare	$40.30
Rate for Payer: Kaiser Permanente Commercial	$117.00
Rate for Payer: Kaiser Permanente Medicaid	$66.30
Rate for Payer: Kaiser Permanente Medicare	$40.30
Rate for Payer: MDX Hawaii PPO	$126.10
Rate for Payer: Ohana Health Plan Medicaid	$40.30
Rate for Payer: Ohana Health Plan Medicare	$40.30
Rate for Payer: UnitedHealthcare Medicare	$40.30
Rate for Payer: University Health Alliance Commercial	$94.76

KIT INTERSTIM REVISION 3560031

Facility

$1,452.00

Hospital Revenue Code	272
Min. Negotiated Rate	$1,234.20
Max. Negotiated Rate	$1,408.44
Rate for Payer: Cash Price	$871.20
Rate for Payer: Health Management Network Commercial	$1,234.20
Rate for Payer: Kaiser Permanente Commercial	$1,306.80
Rate for Payer: MDX Hawaii PPO	$1,408.44

KIT INTERSTIM REVISION 3560031

Facility

$1,452.00

Hospital Revenue Code	272
Min. Negotiated Rate	$450.12
Max. Negotiated Rate	$1,408.44
Rate for Payer: AlohaCare Medicaid	$726.00
Rate for Payer: AlohaCare Medicare	$450.12
Rate for Payer: Cash Price	$871.20
Rate for Payer: Devoted Health Medicare	$493.68
Rate for Payer: Hawaii Medical Service Association Medicare	$450.12
Rate for Payer: Hawaii Western Management Group Commercial	$1,379.40
Rate for Payer: Health Management Network Commercial	$1,234.20
Rate for Payer: Humana Medicare	$450.12
Rate for Payer: Kaiser Permanente Commercial	$1,306.80
Rate for Payer: Kaiser Permanente Medicaid	$740.52
Rate for Payer: Kaiser Permanente Medicare	$450.12
Rate for Payer: MDX Hawaii PPO	$1,408.44
Rate for Payer: Ohana Health Plan Medicaid	$450.12
Rate for Payer: Ohana Health Plan Medicare	$450.12
Rate for Payer: UnitedHealthcare Medicare	$450.12
Rate for Payer: University Health Alliance Commercial	$1,058.36

KIT IV CATH 2 LUMEN

Facility

$170.00

Service Code	HCPCS C1751
Hospital Revenue Code	272
Min. Negotiated Rate	$144.50
Max. Negotiated Rate	$164.90
Rate for Payer: Cash Price	$102.00
Rate for Payer: Health Management Network Commercial	$144.50
Rate for Payer: Kaiser Permanente Commercial	$153.00
Rate for Payer: MDX Hawaii PPO	$164.90

KIT IV CATH 2 LUMEN

Facility

$170.00

Service Code	HCPCS C1751
Hospital Revenue Code	272
Min. Negotiated Rate	$52.70
Max. Negotiated Rate	$164.90
Rate for Payer: AlohaCare Medicaid	$85.00
Rate for Payer: AlohaCare Medicare	$52.70
Rate for Payer: Cash Price	$102.00
Rate for Payer: Devoted Health Medicare	$57.80
Rate for Payer: Hawaii Medical Service Association Medicare	$52.70
Rate for Payer: Hawaii Western Management Group Commercial	$161.50
Rate for Payer: Health Management Network Commercial	$144.50
Rate for Payer: Humana Medicare	$52.70
Rate for Payer: Kaiser Permanente Commercial	$153.00
Rate for Payer: Kaiser Permanente Medicaid	$86.70
Rate for Payer: Kaiser Permanente Medicare	$52.70
Rate for Payer: MDX Hawaii PPO	$164.90
Rate for Payer: Ohana Health Plan Medicaid	$52.70
Rate for Payer: Ohana Health Plan Medicare	$52.70
Rate for Payer: UnitedHealthcare Medicare	$52.70
Rate for Payer: University Health Alliance Commercial	$123.91

Know your out-of-pocket cost for care.

All Charges