Kau Hospital

All Charges

Charge

Type

Setting

Price

ACCOLADE II SIZE 8 6720-0837

Facility

$5,780.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$3,236.80
Max. Negotiated Rate	$5,606.60
Rate for Payer: Cash Price	$3,468.00
Rate for Payer: Hawaii Western Management Group Commercial	$4,046.00
Rate for Payer: Health Management Network Commercial	$4,913.00
Rate for Payer: Kaiser Permanente Commercial	$5,202.00
Rate for Payer: MDX Hawaii PPO	$5,606.60
Rate for Payer: University Health Alliance Commercial	$3,236.80

ACCOLADE II SIZE 8 6720-0837

Facility

$5,780.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$1,791.80
Max. Negotiated Rate	$5,606.60
Rate for Payer: AlohaCare Medicaid	$2,890.00
Rate for Payer: AlohaCare Medicare	$1,791.80
Rate for Payer: Cash Price	$3,468.00
Rate for Payer: Devoted Health Medicare	$1,965.20
Rate for Payer: Hawaii Medical Service Association Medicare	$1,791.80
Rate for Payer: Hawaii Western Management Group Commercial	$4,046.00
Rate for Payer: Health Management Network Commercial	$4,913.00
Rate for Payer: Humana Medicare	$1,791.80
Rate for Payer: Kaiser Permanente Commercial	$5,202.00
Rate for Payer: Kaiser Permanente Medicaid	$2,947.80
Rate for Payer: Kaiser Permanente Medicare	$1,791.80
Rate for Payer: MDX Hawaii PPO	$5,606.60
Rate for Payer: Ohana Health Plan Medicaid	$1,791.80
Rate for Payer: Ohana Health Plan Medicare	$1,791.80
Rate for Payer: UnitedHealthcare Medicare	$1,791.80
Rate for Payer: University Health Alliance Commercial	$3,236.80

ACCOLADE II SZ5 6721-0535

Facility

$5,780.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$1,791.80
Max. Negotiated Rate	$5,606.60
Rate for Payer: AlohaCare Medicaid	$2,890.00
Rate for Payer: AlohaCare Medicare	$1,791.80
Rate for Payer: Cash Price	$3,468.00
Rate for Payer: Devoted Health Medicare	$1,965.20
Rate for Payer: Hawaii Medical Service Association Medicare	$1,791.80
Rate for Payer: Hawaii Western Management Group Commercial	$4,046.00
Rate for Payer: Health Management Network Commercial	$4,913.00
Rate for Payer: Humana Medicare	$1,791.80
Rate for Payer: Kaiser Permanente Commercial	$5,202.00
Rate for Payer: Kaiser Permanente Medicaid	$2,947.80
Rate for Payer: Kaiser Permanente Medicare	$1,791.80
Rate for Payer: MDX Hawaii PPO	$5,606.60
Rate for Payer: Ohana Health Plan Medicaid	$1,791.80
Rate for Payer: Ohana Health Plan Medicare	$1,791.80
Rate for Payer: UnitedHealthcare Medicare	$1,791.80
Rate for Payer: University Health Alliance Commercial	$3,236.80

ACCOLADE II SZ5 6721-0535

Facility

$5,780.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$3,236.80
Max. Negotiated Rate	$5,606.60
Rate for Payer: Cash Price	$3,468.00
Rate for Payer: Hawaii Western Management Group Commercial	$4,046.00
Rate for Payer: Health Management Network Commercial	$4,913.00
Rate for Payer: Kaiser Permanente Commercial	$5,202.00
Rate for Payer: MDX Hawaii PPO	$5,606.60
Rate for Payer: University Health Alliance Commercial	$3,236.80

ACCOLADE II SZ6 6721-0635

Facility

$5,780.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$1,791.80
Max. Negotiated Rate	$5,606.60
Rate for Payer: AlohaCare Medicaid	$2,890.00
Rate for Payer: AlohaCare Medicare	$1,791.80
Rate for Payer: Cash Price	$3,468.00
Rate for Payer: Devoted Health Medicare	$1,965.20
Rate for Payer: Hawaii Medical Service Association Medicare	$1,791.80
Rate for Payer: Hawaii Western Management Group Commercial	$4,046.00
Rate for Payer: Health Management Network Commercial	$4,913.00
Rate for Payer: Humana Medicare	$1,791.80
Rate for Payer: Kaiser Permanente Commercial	$5,202.00
Rate for Payer: Kaiser Permanente Medicaid	$2,947.80
Rate for Payer: Kaiser Permanente Medicare	$1,791.80
Rate for Payer: MDX Hawaii PPO	$5,606.60
Rate for Payer: Ohana Health Plan Medicaid	$1,791.80
Rate for Payer: Ohana Health Plan Medicare	$1,791.80
Rate for Payer: UnitedHealthcare Medicare	$1,791.80
Rate for Payer: University Health Alliance Commercial	$3,236.80

ACCOLADE II SZ6 6721-0635

Facility

$5,780.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$3,236.80
Max. Negotiated Rate	$5,606.60
Rate for Payer: Cash Price	$3,468.00
Rate for Payer: Hawaii Western Management Group Commercial	$4,046.00
Rate for Payer: Health Management Network Commercial	$4,913.00
Rate for Payer: Kaiser Permanente Commercial	$5,202.00
Rate for Payer: MDX Hawaii PPO	$5,606.60
Rate for Payer: University Health Alliance Commercial	$3,236.80

ACCOLADE II SZE 4 6720-0435

Facility

$5,780.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$3,236.80
Max. Negotiated Rate	$5,606.60
Rate for Payer: Cash Price	$3,468.00
Rate for Payer: Hawaii Western Management Group Commercial	$4,046.00
Rate for Payer: Health Management Network Commercial	$4,913.00
Rate for Payer: Kaiser Permanente Commercial	$5,202.00
Rate for Payer: MDX Hawaii PPO	$5,606.60
Rate for Payer: University Health Alliance Commercial	$3,236.80

ACCOLADE II SZE 4 6720-0435

Facility

$5,780.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$1,791.80
Max. Negotiated Rate	$5,606.60
Rate for Payer: AlohaCare Medicaid	$2,890.00
Rate for Payer: AlohaCare Medicare	$1,791.80
Rate for Payer: Cash Price	$3,468.00
Rate for Payer: Devoted Health Medicare	$1,965.20
Rate for Payer: Hawaii Medical Service Association Medicare	$1,791.80
Rate for Payer: Hawaii Western Management Group Commercial	$4,046.00
Rate for Payer: Health Management Network Commercial	$4,913.00
Rate for Payer: Humana Medicare	$1,791.80
Rate for Payer: Kaiser Permanente Commercial	$5,202.00
Rate for Payer: Kaiser Permanente Medicaid	$2,947.80
Rate for Payer: Kaiser Permanente Medicare	$1,791.80
Rate for Payer: MDX Hawaii PPO	$5,606.60
Rate for Payer: Ohana Health Plan Medicaid	$1,791.80
Rate for Payer: Ohana Health Plan Medicare	$1,791.80
Rate for Payer: UnitedHealthcare Medicare	$1,791.80
Rate for Payer: University Health Alliance Commercial	$3,236.80

ACCOLADE II SZE 4 6721-0435

Facility

$5,839.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$3,269.84
Max. Negotiated Rate	$5,663.83
Rate for Payer: Cash Price	$3,503.40
Rate for Payer: Hawaii Western Management Group Commercial	$4,087.30
Rate for Payer: Health Management Network Commercial	$4,963.15
Rate for Payer: Kaiser Permanente Commercial	$5,255.10
Rate for Payer: MDX Hawaii PPO	$5,663.83
Rate for Payer: University Health Alliance Commercial	$3,269.84

ACCOLADE II SZE 4 6721-0435

Facility

$5,839.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$1,810.09
Max. Negotiated Rate	$5,663.83
Rate for Payer: AlohaCare Medicaid	$2,919.50
Rate for Payer: AlohaCare Medicare	$1,810.09
Rate for Payer: Cash Price	$3,503.40
Rate for Payer: Devoted Health Medicare	$1,985.26
Rate for Payer: Hawaii Medical Service Association Medicare	$1,810.09
Rate for Payer: Hawaii Western Management Group Commercial	$4,087.30
Rate for Payer: Health Management Network Commercial	$4,963.15
Rate for Payer: Humana Medicare	$1,810.09
Rate for Payer: Kaiser Permanente Commercial	$5,255.10
Rate for Payer: Kaiser Permanente Medicaid	$2,977.89
Rate for Payer: Kaiser Permanente Medicare	$1,810.09
Rate for Payer: MDX Hawaii PPO	$5,663.83
Rate for Payer: Ohana Health Plan Medicaid	$1,810.09
Rate for Payer: Ohana Health Plan Medicare	$1,810.09
Rate for Payer: UnitedHealthcare Medicare	$1,810.09
Rate for Payer: University Health Alliance Commercial	$3,269.84

ACCOLADE II SZE5 6720-0535

Facility

$5,780.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$3,236.80
Max. Negotiated Rate	$5,606.60
Rate for Payer: Cash Price	$3,468.00
Rate for Payer: Hawaii Western Management Group Commercial	$4,046.00
Rate for Payer: Health Management Network Commercial	$4,913.00
Rate for Payer: Kaiser Permanente Commercial	$5,202.00
Rate for Payer: MDX Hawaii PPO	$5,606.60
Rate for Payer: University Health Alliance Commercial	$3,236.80

ACCOLADE II SZE5 6720-0535

Facility

$5,780.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$1,791.80
Max. Negotiated Rate	$5,606.60
Rate for Payer: AlohaCare Medicaid	$2,890.00
Rate for Payer: AlohaCare Medicare	$1,791.80
Rate for Payer: Cash Price	$3,468.00
Rate for Payer: Devoted Health Medicare	$1,965.20
Rate for Payer: Hawaii Medical Service Association Medicare	$1,791.80
Rate for Payer: Hawaii Western Management Group Commercial	$4,046.00
Rate for Payer: Health Management Network Commercial	$4,913.00
Rate for Payer: Humana Medicare	$1,791.80
Rate for Payer: Kaiser Permanente Commercial	$5,202.00
Rate for Payer: Kaiser Permanente Medicaid	$2,947.80
Rate for Payer: Kaiser Permanente Medicare	$1,791.80
Rate for Payer: MDX Hawaii PPO	$5,606.60
Rate for Payer: Ohana Health Plan Medicaid	$1,791.80
Rate for Payer: Ohana Health Plan Medicare	$1,791.80
Rate for Payer: UnitedHealthcare Medicare	$1,791.80
Rate for Payer: University Health Alliance Commercial	$3,236.80

ACCOLADE MRI DR IS-1 L311

Facility

$8,064.00

Service Code	HCPCS C1785
Hospital Revenue Code	275
Min. Negotiated Rate	$2,499.84
Max. Negotiated Rate	$7,822.08
Rate for Payer: AlohaCare Medicaid	$4,032.00
Rate for Payer: AlohaCare Medicare	$2,499.84
Rate for Payer: Cash Price	$4,838.40
Rate for Payer: Devoted Health Medicare	$2,741.76
Rate for Payer: Hawaii Medical Service Association Medicare	$2,499.84
Rate for Payer: Hawaii Western Management Group Commercial	$5,644.80
Rate for Payer: Health Management Network Commercial	$6,854.40
Rate for Payer: Humana Medicare	$2,499.84
Rate for Payer: Kaiser Permanente Commercial	$7,257.60
Rate for Payer: Kaiser Permanente Medicaid	$4,112.64
Rate for Payer: Kaiser Permanente Medicare	$2,499.84
Rate for Payer: MDX Hawaii PPO	$7,822.08
Rate for Payer: Ohana Health Plan Medicaid	$2,499.84
Rate for Payer: Ohana Health Plan Medicare	$2,499.84
Rate for Payer: UnitedHealthcare Medicare	$2,499.84
Rate for Payer: University Health Alliance Commercial	$4,515.84

ACCOLADE MRI DR IS-1 L311

Facility

$8,064.00

Service Code	HCPCS C1785
Hospital Revenue Code	275
Min. Negotiated Rate	$4,515.84
Max. Negotiated Rate	$7,822.08
Rate for Payer: Cash Price	$4,838.40
Rate for Payer: Hawaii Western Management Group Commercial	$5,644.80
Rate for Payer: Health Management Network Commercial	$6,854.40
Rate for Payer: Kaiser Permanente Commercial	$7,257.60
Rate for Payer: MDX Hawaii PPO	$7,822.08
Rate for Payer: University Health Alliance Commercial	$4,515.84

ACETABULAR LINER 1221-36-056

Facility

$4,078.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$2,283.68
Max. Negotiated Rate	$3,955.66
Rate for Payer: Cash Price	$2,446.80
Rate for Payer: Hawaii Western Management Group Commercial	$2,854.60
Rate for Payer: Health Management Network Commercial	$3,466.30
Rate for Payer: Kaiser Permanente Commercial	$3,670.20
Rate for Payer: MDX Hawaii PPO	$3,955.66
Rate for Payer: University Health Alliance Commercial	$2,283.68

ACETABULAR LINER 1221-36-056

Facility

$4,078.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$1,264.18
Max. Negotiated Rate	$3,955.66
Rate for Payer: AlohaCare Medicaid	$2,039.00
Rate for Payer: AlohaCare Medicare	$1,264.18
Rate for Payer: Cash Price	$2,446.80
Rate for Payer: Devoted Health Medicare	$1,386.52
Rate for Payer: Hawaii Medical Service Association Medicare	$1,264.18
Rate for Payer: Hawaii Western Management Group Commercial	$2,854.60
Rate for Payer: Health Management Network Commercial	$3,466.30
Rate for Payer: Humana Medicare	$1,264.18
Rate for Payer: Kaiser Permanente Commercial	$3,670.20
Rate for Payer: Kaiser Permanente Medicaid	$2,079.78
Rate for Payer: Kaiser Permanente Medicare	$1,264.18
Rate for Payer: MDX Hawaii PPO	$3,955.66
Rate for Payer: Ohana Health Plan Medicaid	$1,264.18
Rate for Payer: Ohana Health Plan Medicare	$1,264.18
Rate for Payer: UnitedHealthcare Medicare	$1,264.18
Rate for Payer: University Health Alliance Commercial	$2,283.68

ACETABULAR LINER 36MM 30103606

Facility

$2,000.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$1,120.00
Max. Negotiated Rate	$1,940.00
Rate for Payer: Cash Price	$1,200.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,400.00
Rate for Payer: Health Management Network Commercial	$1,700.00
Rate for Payer: Kaiser Permanente Commercial	$1,800.00
Rate for Payer: MDX Hawaii PPO	$1,940.00
Rate for Payer: University Health Alliance Commercial	$1,120.00

ACETABULAR LINER 36MM 30103606

Facility

$2,000.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$620.00
Max. Negotiated Rate	$1,940.00
Rate for Payer: AlohaCare Medicaid	$1,000.00
Rate for Payer: AlohaCare Medicare	$620.00
Rate for Payer: Cash Price	$1,200.00
Rate for Payer: Devoted Health Medicare	$680.00
Rate for Payer: Hawaii Medical Service Association Medicare	$620.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,400.00
Rate for Payer: Health Management Network Commercial	$1,700.00
Rate for Payer: Humana Medicare	$620.00
Rate for Payer: Kaiser Permanente Commercial	$1,800.00
Rate for Payer: Kaiser Permanente Medicaid	$1,020.00
Rate for Payer: Kaiser Permanente Medicare	$620.00
Rate for Payer: MDX Hawaii PPO	$1,940.00
Rate for Payer: Ohana Health Plan Medicaid	$620.00
Rate for Payer: Ohana Health Plan Medicare	$620.00
Rate for Payer: UnitedHealthcare Medicare	$620.00
Rate for Payer: University Health Alliance Commercial	$1,120.00

ACETABULAR SHELL 1217-32-056

Facility

$6,392.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$3,579.52
Max. Negotiated Rate	$6,200.24
Rate for Payer: Cash Price	$3,835.20
Rate for Payer: Hawaii Western Management Group Commercial	$4,474.40
Rate for Payer: Health Management Network Commercial	$5,433.20
Rate for Payer: Kaiser Permanente Commercial	$5,752.80
Rate for Payer: MDX Hawaii PPO	$6,200.24
Rate for Payer: University Health Alliance Commercial	$3,579.52

ACETABULAR SHELL 1217-32-056

Facility

$6,392.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$1,981.52
Max. Negotiated Rate	$6,200.24
Rate for Payer: AlohaCare Medicaid	$3,196.00
Rate for Payer: AlohaCare Medicare	$1,981.52
Rate for Payer: Cash Price	$3,835.20
Rate for Payer: Devoted Health Medicare	$2,173.28
Rate for Payer: Hawaii Medical Service Association Medicare	$1,981.52
Rate for Payer: Hawaii Western Management Group Commercial	$4,474.40
Rate for Payer: Health Management Network Commercial	$5,433.20
Rate for Payer: Humana Medicare	$1,981.52
Rate for Payer: Kaiser Permanente Commercial	$5,752.80
Rate for Payer: Kaiser Permanente Medicaid	$3,259.92
Rate for Payer: Kaiser Permanente Medicare	$1,981.52
Rate for Payer: MDX Hawaii PPO	$6,200.24
Rate for Payer: Ohana Health Plan Medicaid	$1,981.52
Rate for Payer: Ohana Health Plan Medicare	$1,981.52
Rate for Payer: UnitedHealthcare Medicare	$1,981.52
Rate for Payer: University Health Alliance Commercial	$3,579.52

ACETABULAR SHELL 50 709-04-50D

Facility

$6,283.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$3,518.48
Max. Negotiated Rate	$6,094.51
Rate for Payer: Cash Price	$3,769.80
Rate for Payer: Hawaii Western Management Group Commercial	$4,398.10
Rate for Payer: Health Management Network Commercial	$5,340.55
Rate for Payer: Kaiser Permanente Commercial	$5,654.70
Rate for Payer: MDX Hawaii PPO	$6,094.51
Rate for Payer: University Health Alliance Commercial	$3,518.48

ACETABULAR SHELL 50 709-04-50D

Facility

$6,283.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$1,947.73
Max. Negotiated Rate	$6,094.51
Rate for Payer: AlohaCare Medicaid	$3,141.50
Rate for Payer: AlohaCare Medicare	$1,947.73
Rate for Payer: Cash Price	$3,769.80
Rate for Payer: Devoted Health Medicare	$2,136.22
Rate for Payer: Hawaii Medical Service Association Medicare	$1,947.73
Rate for Payer: Hawaii Western Management Group Commercial	$4,398.10
Rate for Payer: Health Management Network Commercial	$5,340.55
Rate for Payer: Humana Medicare	$1,947.73
Rate for Payer: Kaiser Permanente Commercial	$5,654.70
Rate for Payer: Kaiser Permanente Medicaid	$3,204.33
Rate for Payer: Kaiser Permanente Medicare	$1,947.73
Rate for Payer: MDX Hawaii PPO	$6,094.51
Rate for Payer: Ohana Health Plan Medicaid	$1,947.73
Rate for Payer: Ohana Health Plan Medicare	$1,947.73
Rate for Payer: UnitedHealthcare Medicare	$1,947.73
Rate for Payer: University Health Alliance Commercial	$3,518.48

ACETABULAR SHELL 709-04-48D

Facility

$6,283.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$1,947.73
Max. Negotiated Rate	$6,094.51
Rate for Payer: AlohaCare Medicaid	$3,141.50
Rate for Payer: AlohaCare Medicare	$1,947.73
Rate for Payer: Cash Price	$3,769.80
Rate for Payer: Devoted Health Medicare	$2,136.22
Rate for Payer: Hawaii Medical Service Association Medicare	$1,947.73
Rate for Payer: Hawaii Western Management Group Commercial	$4,398.10
Rate for Payer: Health Management Network Commercial	$5,340.55
Rate for Payer: Humana Medicare	$1,947.73
Rate for Payer: Kaiser Permanente Commercial	$5,654.70
Rate for Payer: Kaiser Permanente Medicaid	$3,204.33
Rate for Payer: Kaiser Permanente Medicare	$1,947.73
Rate for Payer: MDX Hawaii PPO	$6,094.51
Rate for Payer: Ohana Health Plan Medicaid	$1,947.73
Rate for Payer: Ohana Health Plan Medicare	$1,947.73
Rate for Payer: UnitedHealthcare Medicare	$1,947.73
Rate for Payer: University Health Alliance Commercial	$3,518.48

ACETABULAR SHELL 709-04-48D

Facility

$6,283.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$3,518.48
Max. Negotiated Rate	$6,094.51
Rate for Payer: Cash Price	$3,769.80
Rate for Payer: Hawaii Western Management Group Commercial	$4,398.10
Rate for Payer: Health Management Network Commercial	$5,340.55
Rate for Payer: Kaiser Permanente Commercial	$5,654.70
Rate for Payer: MDX Hawaii PPO	$6,094.51
Rate for Payer: University Health Alliance Commercial	$3,518.48

ACETABULAR WEDGE 5096-4615

Facility

$4,378.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,357.18
Max. Negotiated Rate	$4,246.66
Rate for Payer: AlohaCare Medicaid	$2,189.00
Rate for Payer: AlohaCare Medicare	$1,357.18
Rate for Payer: Cash Price	$2,626.80
Rate for Payer: Devoted Health Medicare	$1,488.52
Rate for Payer: Hawaii Medical Service Association Medicare	$1,357.18
Rate for Payer: Hawaii Western Management Group Commercial	$3,064.60
Rate for Payer: Health Management Network Commercial	$3,721.30
Rate for Payer: Humana Medicare	$1,357.18
Rate for Payer: Kaiser Permanente Commercial	$3,940.20
Rate for Payer: Kaiser Permanente Medicaid	$2,232.78
Rate for Payer: Kaiser Permanente Medicare	$1,357.18
Rate for Payer: MDX Hawaii PPO	$4,246.66
Rate for Payer: Ohana Health Plan Medicaid	$1,357.18
Rate for Payer: Ohana Health Plan Medicare	$1,357.18
Rate for Payer: UnitedHealthcare Medicare	$1,357.18
Rate for Payer: University Health Alliance Commercial	$2,451.68

Know your out-of-pocket cost for care.

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