Kau Hospital

All Charges

Charge

Type

Setting

Price

MATRIXMAND 1.5 DB 03.503.408

Facility

$1,131.00

Hospital Revenue Code	272
Min. Negotiated Rate	$961.35
Max. Negotiated Rate	$1,097.07
Rate for Payer: Cash Price	$678.60
Rate for Payer: Health Management Network Commercial	$961.35
Rate for Payer: Kaiser Permanente Commercial	$1,017.90
Rate for Payer: MDX Hawaii PPO	$1,097.07

MATRIXMIDFACE 4M 04.503.204.01

Facility

$806.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$451.36
Max. Negotiated Rate	$781.82
Rate for Payer: Cash Price	$483.60
Rate for Payer: Hawaii Western Management Group Commercial	$564.20
Rate for Payer: Health Management Network Commercial	$685.10
Rate for Payer: Kaiser Permanente Commercial	$725.40
Rate for Payer: MDX Hawaii PPO	$781.82
Rate for Payer: University Health Alliance Commercial	$451.36

MATRIXMIDFACE 4M 04.503.204.01

Facility

$806.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$249.86
Max. Negotiated Rate	$781.82
Rate for Payer: AlohaCare Medicaid	$403.00
Rate for Payer: AlohaCare Medicare	$249.86
Rate for Payer: Cash Price	$483.60
Rate for Payer: Devoted Health Medicare	$274.04
Rate for Payer: Hawaii Medical Service Association Medicare	$249.86
Rate for Payer: Hawaii Western Management Group Commercial	$564.20
Rate for Payer: Health Management Network Commercial	$685.10
Rate for Payer: Humana Medicare	$249.86
Rate for Payer: Kaiser Permanente Commercial	$725.40
Rate for Payer: Kaiser Permanente Medicaid	$411.06
Rate for Payer: Kaiser Permanente Medicare	$249.86
Rate for Payer: MDX Hawaii PPO	$781.82
Rate for Payer: Ohana Health Plan Medicaid	$249.86
Rate for Payer: Ohana Health Plan Medicare	$249.86
Rate for Payer: UnitedHealthcare Medicare	$249.86
Rate for Payer: University Health Alliance Commercial	$451.36

MATRIXMIDFACE OBL 04.503.355

Facility

$2,148.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,202.88
Max. Negotiated Rate	$2,083.56
Rate for Payer: Cash Price	$1,288.80
Rate for Payer: Hawaii Western Management Group Commercial	$1,503.60
Rate for Payer: Health Management Network Commercial	$1,825.80
Rate for Payer: Kaiser Permanente Commercial	$1,933.20
Rate for Payer: MDX Hawaii PPO	$2,083.56
Rate for Payer: University Health Alliance Commercial	$1,202.88

MATRIXMIDFACE OBL 04.503.355

Facility

$2,148.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$665.88
Max. Negotiated Rate	$2,083.56
Rate for Payer: AlohaCare Medicaid	$1,074.00
Rate for Payer: AlohaCare Medicare	$665.88
Rate for Payer: Cash Price	$1,288.80
Rate for Payer: Devoted Health Medicare	$730.32
Rate for Payer: Hawaii Medical Service Association Medicare	$665.88
Rate for Payer: Hawaii Western Management Group Commercial	$1,503.60
Rate for Payer: Health Management Network Commercial	$1,825.80
Rate for Payer: Humana Medicare	$665.88
Rate for Payer: Kaiser Permanente Commercial	$1,933.20
Rate for Payer: Kaiser Permanente Medicaid	$1,095.48
Rate for Payer: Kaiser Permanente Medicare	$665.88
Rate for Payer: MDX Hawaii PPO	$2,083.56
Rate for Payer: Ohana Health Plan Medicaid	$665.88
Rate for Payer: Ohana Health Plan Medicare	$665.88
Rate for Payer: UnitedHealthcare Medicare	$665.88
Rate for Payer: University Health Alliance Commercial	$1,202.88

MATRIXMIDFACE OBL LT 3X4 HOLES

Facility

$2,301.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,288.56
Max. Negotiated Rate	$2,231.97
Rate for Payer: Cash Price	$1,380.60
Rate for Payer: Hawaii Western Management Group Commercial	$1,610.70
Rate for Payer: Health Management Network Commercial	$1,955.85
Rate for Payer: Kaiser Permanente Commercial	$2,070.90
Rate for Payer: MDX Hawaii PPO	$2,231.97
Rate for Payer: University Health Alliance Commercial	$1,288.56

MATRIXMIDFACE OBL LT 3X4 HOLES

Facility

$2,301.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$713.31
Max. Negotiated Rate	$2,231.97
Rate for Payer: AlohaCare Medicaid	$1,150.50
Rate for Payer: AlohaCare Medicare	$713.31
Rate for Payer: Cash Price	$1,380.60
Rate for Payer: Devoted Health Medicare	$782.34
Rate for Payer: Hawaii Medical Service Association Medicare	$713.31
Rate for Payer: Hawaii Western Management Group Commercial	$1,610.70
Rate for Payer: Health Management Network Commercial	$1,955.85
Rate for Payer: Humana Medicare	$713.31
Rate for Payer: Kaiser Permanente Commercial	$2,070.90
Rate for Payer: Kaiser Permanente Medicaid	$1,173.51
Rate for Payer: Kaiser Permanente Medicare	$713.31
Rate for Payer: MDX Hawaii PPO	$2,231.97
Rate for Payer: Ohana Health Plan Medicaid	$713.31
Rate for Payer: Ohana Health Plan Medicare	$713.31
Rate for Payer: UnitedHealthcare Medicare	$713.31
Rate for Payer: University Health Alliance Commercial	$1,288.56

MATRIXMIDFACE RIM 04.503.373

Facility

$2,556.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$792.36
Max. Negotiated Rate	$2,479.32
Rate for Payer: AlohaCare Medicaid	$1,278.00
Rate for Payer: AlohaCare Medicare	$792.36
Rate for Payer: Cash Price	$1,533.60
Rate for Payer: Devoted Health Medicare	$869.04
Rate for Payer: Hawaii Medical Service Association Medicare	$792.36
Rate for Payer: Hawaii Western Management Group Commercial	$1,789.20
Rate for Payer: Health Management Network Commercial	$2,172.60
Rate for Payer: Humana Medicare	$792.36
Rate for Payer: Kaiser Permanente Commercial	$2,300.40
Rate for Payer: Kaiser Permanente Medicaid	$1,303.56
Rate for Payer: Kaiser Permanente Medicare	$792.36
Rate for Payer: MDX Hawaii PPO	$2,479.32
Rate for Payer: Ohana Health Plan Medicaid	$792.36
Rate for Payer: Ohana Health Plan Medicare	$792.36
Rate for Payer: UnitedHealthcare Medicare	$792.36
Rate for Payer: University Health Alliance Commercial	$1,431.36

MATRIXMIDFACE RIM 04.503.373

Facility

$2,556.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,431.36
Max. Negotiated Rate	$2,479.32
Rate for Payer: Cash Price	$1,533.60
Rate for Payer: Hawaii Western Management Group Commercial	$1,789.20
Rate for Payer: Health Management Network Commercial	$2,172.60
Rate for Payer: Kaiser Permanente Commercial	$2,300.40
Rate for Payer: MDX Hawaii PPO	$2,479.32
Rate for Payer: University Health Alliance Commercial	$1,431.36

MATRIX WOUND THIN 4X10 54101T

Facility

$17,483.00

Service Code	HCPCS Q4108
Hospital Revenue Code	636
Min. Negotiated Rate	$49.12
Max. Negotiated Rate	$16,958.51
Rate for Payer: AlohaCare Medicaid	$8,741.50
Rate for Payer: AlohaCare Medicare	$5,419.73
Rate for Payer: Cash Price	$10,489.80
Rate for Payer: Cash Price	$10,489.80
Rate for Payer: Devoted Health Medicare	$5,944.22
Rate for Payer: Hawaii Medical Service Association ABD	$49.12
Rate for Payer: Hawaii Medical Service Association Commercial	$158.93
Rate for Payer: Hawaii Medical Service Association Medicare	$5,419.73
Rate for Payer: Hawaii Medical Service Association Non-ABD	$49.12
Rate for Payer: Hawaii Western Management Group Commercial	$16,608.85
Rate for Payer: Health Management Network Commercial	$14,860.55
Rate for Payer: Humana Medicare	$5,419.73
Rate for Payer: Kaiser Permanente Commercial	$15,734.70
Rate for Payer: Kaiser Permanente Medicaid	$8,916.33
Rate for Payer: Kaiser Permanente Medicare	$5,419.73
Rate for Payer: MDX Hawaii PPO	$16,958.51
Rate for Payer: Ohana Health Plan Medicaid	$5,419.73
Rate for Payer: Ohana Health Plan Medicare	$5,419.73
Rate for Payer: UnitedHealthcare Medicaid	$10,489.80
Rate for Payer: UnitedHealthcare Medicare	$5,419.73
Rate for Payer: University Health Alliance Commercial	$12,743.36

MATRIX WOUND THIN 4X10 54101T

Facility

$17,483.00

Service Code	HCPCS Q4108
Hospital Revenue Code	636
Min. Negotiated Rate	$14,860.55
Max. Negotiated Rate	$16,958.51
Rate for Payer: Cash Price	$10,489.80
Rate for Payer: Health Management Network Commercial	$14,860.55
Rate for Payer: Kaiser Permanente Commercial	$15,734.70
Rate for Payer: MDX Hawaii PPO	$16,958.51

MDM LINER 46MM 626-00-46F

Facility

$3,344.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$1,036.64
Max. Negotiated Rate	$3,243.68
Rate for Payer: AlohaCare Medicaid	$1,672.00
Rate for Payer: AlohaCare Medicare	$1,036.64
Rate for Payer: Cash Price	$2,006.40
Rate for Payer: Devoted Health Medicare	$1,136.96
Rate for Payer: Hawaii Medical Service Association Medicare	$1,036.64
Rate for Payer: Hawaii Western Management Group Commercial	$2,340.80
Rate for Payer: Health Management Network Commercial	$2,842.40
Rate for Payer: Humana Medicare	$1,036.64
Rate for Payer: Kaiser Permanente Commercial	$3,009.60
Rate for Payer: Kaiser Permanente Medicaid	$1,705.44
Rate for Payer: Kaiser Permanente Medicare	$1,036.64
Rate for Payer: MDX Hawaii PPO	$3,243.68
Rate for Payer: Ohana Health Plan Medicaid	$1,036.64
Rate for Payer: Ohana Health Plan Medicare	$1,036.64
Rate for Payer: UnitedHealthcare Medicare	$1,036.64
Rate for Payer: University Health Alliance Commercial	$1,872.64

MDM LINER 46MM 626-00-46F

Facility

$3,344.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$1,872.64
Max. Negotiated Rate	$3,243.68
Rate for Payer: Cash Price	$2,006.40
Rate for Payer: Hawaii Western Management Group Commercial	$2,340.80
Rate for Payer: Health Management Network Commercial	$2,842.40
Rate for Payer: Kaiser Permanente Commercial	$3,009.60
Rate for Payer: MDX Hawaii PPO	$3,243.68
Rate for Payer: University Health Alliance Commercial	$1,872.64

MDM LINER CEMENTIES 626-00-48G

Facility

$4,271.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$1,324.01
Max. Negotiated Rate	$4,142.87
Rate for Payer: AlohaCare Medicaid	$2,135.50
Rate for Payer: AlohaCare Medicare	$1,324.01
Rate for Payer: Cash Price	$2,562.60
Rate for Payer: Devoted Health Medicare	$1,452.14
Rate for Payer: Hawaii Medical Service Association Medicare	$1,324.01
Rate for Payer: Hawaii Western Management Group Commercial	$2,989.70
Rate for Payer: Health Management Network Commercial	$3,630.35
Rate for Payer: Humana Medicare	$1,324.01
Rate for Payer: Kaiser Permanente Commercial	$3,843.90
Rate for Payer: Kaiser Permanente Medicaid	$2,178.21
Rate for Payer: Kaiser Permanente Medicare	$1,324.01
Rate for Payer: MDX Hawaii PPO	$4,142.87
Rate for Payer: Ohana Health Plan Medicaid	$1,324.01
Rate for Payer: Ohana Health Plan Medicare	$1,324.01
Rate for Payer: UnitedHealthcare Medicare	$1,324.01
Rate for Payer: University Health Alliance Commercial	$2,391.76

MDM LINER CEMENTIES 626-00-48G

Facility

$4,271.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$2,391.76
Max. Negotiated Rate	$4,142.87
Rate for Payer: Cash Price	$2,562.60
Rate for Payer: Hawaii Western Management Group Commercial	$2,989.70
Rate for Payer: Health Management Network Commercial	$3,630.35
Rate for Payer: Kaiser Permanente Commercial	$3,843.90
Rate for Payer: MDX Hawaii PPO	$4,142.87
Rate for Payer: University Health Alliance Commercial	$2,391.76

MEASLES,MUMPS,RUBELLA VACCINE LIVE(PF)1,000-12,500TCID50/0.5 ML SUBCUT [168883]

Facility

$176.00

Service Code	HCPCS 90710
Hospital Revenue Code	250
Min. Negotiated Rate	$149.60
Max. Negotiated Rate	$170.72
Rate for Payer: Cash Price	$105.60
Rate for Payer: Health Management Network Commercial	$149.60
Rate for Payer: Kaiser Permanente Commercial	$158.40
Rate for Payer: MDX Hawaii PPO	$170.72

MEASLES,MUMPS,RUBELLA VACCINE LIVE(PF)1,000-12,500TCID50/0.5 ML SUBCUT [168883]

Facility

$176.00

Service Code	HCPCS 90710
Hospital Revenue Code	636
Min. Negotiated Rate	$54.56
Max. Negotiated Rate	$299.87
Rate for Payer: AlohaCare Medicaid	$88.00
Rate for Payer: AlohaCare Medicare	$54.56
Rate for Payer: Cash Price	$105.60
Rate for Payer: Cash Price	$105.60
Rate for Payer: Devoted Health Medicare	$59.84
Rate for Payer: Hawaii Medical Service Association ABD	$299.87
Rate for Payer: Hawaii Medical Service Association Medicare	$54.56
Rate for Payer: Hawaii Medical Service Association Non-ABD	$299.87
Rate for Payer: Hawaii Western Management Group Commercial	$167.20
Rate for Payer: Health Management Network Commercial	$149.60
Rate for Payer: Humana Medicare	$54.56
Rate for Payer: Kaiser Permanente Commercial	$158.40
Rate for Payer: Kaiser Permanente Medicaid	$89.76
Rate for Payer: Kaiser Permanente Medicare	$54.56
Rate for Payer: MDX Hawaii PPO	$170.72
Rate for Payer: Ohana Health Plan Medicaid	$54.56
Rate for Payer: Ohana Health Plan Medicare	$54.56
Rate for Payer: UnitedHealthcare Medicaid	$105.60
Rate for Payer: UnitedHealthcare Medicare	$54.56
Rate for Payer: University Health Alliance Commercial	$128.29

MECLIZINE 12.5 MG TABLET [12024]

Facility

$3.00

Service Code	NDC 50268052215
Hospital Revenue Code	637
Min. Negotiated Rate	$0.93
Max. Negotiated Rate	$2.91
Rate for Payer: AlohaCare Medicaid	$1.50
Rate for Payer: AlohaCare Medicare	$0.93
Rate for Payer: Cash Price	$1.80
Rate for Payer: Devoted Health Medicare	$1.02
Rate for Payer: Hawaii Medical Service Association Medicare	$0.93
Rate for Payer: Hawaii Western Management Group Commercial	$2.85
Rate for Payer: Health Management Network Commercial	$2.55
Rate for Payer: Humana Medicare	$0.93
Rate for Payer: Kaiser Permanente Commercial	$2.70
Rate for Payer: Kaiser Permanente Medicaid	$1.53
Rate for Payer: Kaiser Permanente Medicare	$0.93
Rate for Payer: MDX Hawaii PPO	$2.91
Rate for Payer: Ohana Health Plan Medicaid	$0.93
Rate for Payer: Ohana Health Plan Medicare	$0.93
Rate for Payer: UnitedHealthcare Medicare	$0.93
Rate for Payer: University Health Alliance Commercial	$2.19

MECLIZINE 12.5 MG TABLET [12024]

Facility

$3.00

Service Code	NDC 60687077511
Hospital Revenue Code	637
Min. Negotiated Rate	$0.93
Max. Negotiated Rate	$2.91
Rate for Payer: AlohaCare Medicaid	$1.50
Rate for Payer: AlohaCare Medicare	$0.93
Rate for Payer: Cash Price	$1.80
Rate for Payer: Devoted Health Medicare	$1.02
Rate for Payer: Hawaii Medical Service Association Medicare	$0.93
Rate for Payer: Hawaii Western Management Group Commercial	$2.85
Rate for Payer: Health Management Network Commercial	$2.55
Rate for Payer: Humana Medicare	$0.93
Rate for Payer: Kaiser Permanente Commercial	$2.70
Rate for Payer: Kaiser Permanente Medicaid	$1.53
Rate for Payer: Kaiser Permanente Medicare	$0.93
Rate for Payer: MDX Hawaii PPO	$2.91
Rate for Payer: Ohana Health Plan Medicaid	$0.93
Rate for Payer: Ohana Health Plan Medicare	$0.93
Rate for Payer: UnitedHealthcare Medicare	$0.93
Rate for Payer: University Health Alliance Commercial	$2.19

MECLIZINE 12.5 MG TABLET [12024]

Facility

$3.00

Service Code	NDC 50268052211
Hospital Revenue Code	637
Min. Negotiated Rate	$0.93
Max. Negotiated Rate	$2.91
Rate for Payer: AlohaCare Medicaid	$1.50
Rate for Payer: AlohaCare Medicare	$0.93
Rate for Payer: Cash Price	$1.80
Rate for Payer: Devoted Health Medicare	$1.02
Rate for Payer: Hawaii Medical Service Association Medicare	$0.93
Rate for Payer: Hawaii Western Management Group Commercial	$2.85
Rate for Payer: Health Management Network Commercial	$2.55
Rate for Payer: Humana Medicare	$0.93
Rate for Payer: Kaiser Permanente Commercial	$2.70
Rate for Payer: Kaiser Permanente Medicaid	$1.53
Rate for Payer: Kaiser Permanente Medicare	$0.93
Rate for Payer: MDX Hawaii PPO	$2.91
Rate for Payer: Ohana Health Plan Medicaid	$0.93
Rate for Payer: Ohana Health Plan Medicare	$0.93
Rate for Payer: UnitedHealthcare Medicare	$0.93
Rate for Payer: University Health Alliance Commercial	$2.19

MECLIZINE 12.5 MG TABLET [12024]

Facility

$3.00

Service Code	NDC 60687077565
Hospital Revenue Code	250
Min. Negotiated Rate	$2.55
Max. Negotiated Rate	$2.91
Rate for Payer: Cash Price	$1.80
Rate for Payer: Health Management Network Commercial	$2.55
Rate for Payer: Kaiser Permanente Commercial	$2.70
Rate for Payer: MDX Hawaii PPO	$2.91

MECLIZINE 12.5 MG TABLET [12024]

Facility

$3.00

Service Code	NDC 60687077511
Hospital Revenue Code	250
Min. Negotiated Rate	$2.55
Max. Negotiated Rate	$2.91
Rate for Payer: Cash Price	$1.80
Rate for Payer: Health Management Network Commercial	$2.55
Rate for Payer: Kaiser Permanente Commercial	$2.70
Rate for Payer: MDX Hawaii PPO	$2.91

MECLIZINE 12.5 MG TABLET [12024]

Facility

$3.00

Service Code	NDC 50268052211
Hospital Revenue Code	250
Min. Negotiated Rate	$2.55
Max. Negotiated Rate	$2.91
Rate for Payer: Cash Price	$1.80
Rate for Payer: Health Management Network Commercial	$2.55
Rate for Payer: Kaiser Permanente Commercial	$2.70
Rate for Payer: MDX Hawaii PPO	$2.91

MECLIZINE 12.5 MG TABLET [12024]

Facility

$3.00

Service Code	NDC 60687077565
Hospital Revenue Code	637
Min. Negotiated Rate	$0.93
Max. Negotiated Rate	$2.91
Rate for Payer: AlohaCare Medicaid	$1.50
Rate for Payer: AlohaCare Medicare	$0.93
Rate for Payer: Cash Price	$1.80
Rate for Payer: Devoted Health Medicare	$1.02
Rate for Payer: Hawaii Medical Service Association Medicare	$0.93
Rate for Payer: Hawaii Western Management Group Commercial	$2.85
Rate for Payer: Health Management Network Commercial	$2.55
Rate for Payer: Humana Medicare	$0.93
Rate for Payer: Kaiser Permanente Commercial	$2.70
Rate for Payer: Kaiser Permanente Medicaid	$1.53
Rate for Payer: Kaiser Permanente Medicare	$0.93
Rate for Payer: MDX Hawaii PPO	$2.91
Rate for Payer: Ohana Health Plan Medicaid	$0.93
Rate for Payer: Ohana Health Plan Medicare	$0.93
Rate for Payer: UnitedHealthcare Medicare	$0.93
Rate for Payer: University Health Alliance Commercial	$2.19

MECLIZINE 12.5 MG TABLET [12024]

Facility

$3.00

Service Code	NDC 50268052215
Hospital Revenue Code	250
Min. Negotiated Rate	$2.55
Max. Negotiated Rate	$2.91
Rate for Payer: Cash Price	$1.80
Rate for Payer: Health Management Network Commercial	$2.55
Rate for Payer: Kaiser Permanente Commercial	$2.70
Rate for Payer: MDX Hawaii PPO	$2.91

Know your out-of-pocket cost for care.

All Charges