Kau Hospital

All Charges

Charge

Type

Setting

Price

PILOCARPINE 2 % EYE DROPS [6280]

Facility

$285.00

Service Code	NDC 70069019101
Hospital Revenue Code	250
Min. Negotiated Rate	$242.25
Max. Negotiated Rate	$276.45
Rate for Payer: Cash Price	$171.00
Rate for Payer: Health Management Network Commercial	$242.25
Rate for Payer: Kaiser Permanente Commercial	$256.50
Rate for Payer: MDX Hawaii PPO	$276.45

PILOCARPINE 4 % EYE DROPS [6282]

Facility

$299.00

Service Code	NDC 70069020101
Hospital Revenue Code	250
Min. Negotiated Rate	$254.15
Max. Negotiated Rate	$290.03
Rate for Payer: Cash Price	$179.40
Rate for Payer: Health Management Network Commercial	$254.15
Rate for Payer: Kaiser Permanente Commercial	$269.10
Rate for Payer: MDX Hawaii PPO	$290.03

PILOCARPINE 4 % EYE DROPS [6282]

Facility

$318.00

Service Code	NDC 61314020615
Hospital Revenue Code	637
Min. Negotiated Rate	$98.58
Max. Negotiated Rate	$308.46
Rate for Payer: AlohaCare Medicaid	$159.00
Rate for Payer: AlohaCare Medicare	$98.58
Rate for Payer: Cash Price	$190.80
Rate for Payer: Devoted Health Medicare	$108.12
Rate for Payer: Hawaii Medical Service Association Medicare	$98.58
Rate for Payer: Hawaii Western Management Group Commercial	$302.10
Rate for Payer: Health Management Network Commercial	$270.30
Rate for Payer: Humana Medicare	$98.58
Rate for Payer: Kaiser Permanente Commercial	$286.20
Rate for Payer: Kaiser Permanente Medicaid	$162.18
Rate for Payer: Kaiser Permanente Medicare	$98.58
Rate for Payer: MDX Hawaii PPO	$308.46
Rate for Payer: Ohana Health Plan Medicaid	$98.58
Rate for Payer: Ohana Health Plan Medicare	$98.58
Rate for Payer: UnitedHealthcare Medicare	$98.58
Rate for Payer: University Health Alliance Commercial	$231.79

PILOCARPINE 4 % EYE DROPS [6282]

Facility

$318.00

Service Code	NDC 61314020615
Hospital Revenue Code	250
Min. Negotiated Rate	$270.30
Max. Negotiated Rate	$308.46
Rate for Payer: Cash Price	$190.80
Rate for Payer: Health Management Network Commercial	$270.30
Rate for Payer: Kaiser Permanente Commercial	$286.20
Rate for Payer: MDX Hawaii PPO	$308.46

PILOCARPINE 4 % EYE DROPS [6282]

Facility

$299.00

Service Code	NDC 70069020101
Hospital Revenue Code	637
Min. Negotiated Rate	$92.69
Max. Negotiated Rate	$290.03
Rate for Payer: AlohaCare Medicaid	$149.50
Rate for Payer: AlohaCare Medicare	$92.69
Rate for Payer: Cash Price	$179.40
Rate for Payer: Devoted Health Medicare	$101.66
Rate for Payer: Hawaii Medical Service Association Medicare	$92.69
Rate for Payer: Hawaii Western Management Group Commercial	$284.05
Rate for Payer: Health Management Network Commercial	$254.15
Rate for Payer: Humana Medicare	$92.69
Rate for Payer: Kaiser Permanente Commercial	$269.10
Rate for Payer: Kaiser Permanente Medicaid	$152.49
Rate for Payer: Kaiser Permanente Medicare	$92.69
Rate for Payer: MDX Hawaii PPO	$290.03
Rate for Payer: Ohana Health Plan Medicaid	$92.69
Rate for Payer: Ohana Health Plan Medicare	$92.69
Rate for Payer: UnitedHealthcare Medicare	$92.69
Rate for Payer: University Health Alliance Commercial	$217.94

PIN 4.5 POSITIONING #298.803S

Facility

$815.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$252.65
Max. Negotiated Rate	$790.55
Rate for Payer: AlohaCare Medicaid	$407.50
Rate for Payer: AlohaCare Medicare	$252.65
Rate for Payer: Cash Price	$489.00
Rate for Payer: Devoted Health Medicare	$277.10
Rate for Payer: Hawaii Medical Service Association Medicare	$252.65
Rate for Payer: Hawaii Western Management Group Commercial	$570.50
Rate for Payer: Health Management Network Commercial	$692.75
Rate for Payer: Humana Medicare	$252.65
Rate for Payer: Kaiser Permanente Commercial	$733.50
Rate for Payer: Kaiser Permanente Medicaid	$415.65
Rate for Payer: Kaiser Permanente Medicare	$252.65
Rate for Payer: MDX Hawaii PPO	$790.55
Rate for Payer: Ohana Health Plan Medicaid	$252.65
Rate for Payer: Ohana Health Plan Medicare	$252.65
Rate for Payer: UnitedHealthcare Medicare	$252.65
Rate for Payer: University Health Alliance Commercial	$456.40

PIN 4.5 POSITIONING #298.803S

Facility

$815.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$456.40
Max. Negotiated Rate	$790.55
Rate for Payer: Cash Price	$489.00
Rate for Payer: Hawaii Western Management Group Commercial	$570.50
Rate for Payer: Health Management Network Commercial	$692.75
Rate for Payer: Kaiser Permanente Commercial	$733.50
Rate for Payer: MDX Hawaii PPO	$790.55
Rate for Payer: University Health Alliance Commercial	$456.40

PIN 5018-5-150

Facility

$631.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$353.36
Max. Negotiated Rate	$612.07
Rate for Payer: Cash Price	$378.60
Rate for Payer: Hawaii Western Management Group Commercial	$441.70
Rate for Payer: Health Management Network Commercial	$536.35
Rate for Payer: Kaiser Permanente Commercial	$567.90
Rate for Payer: MDX Hawaii PPO	$612.07
Rate for Payer: University Health Alliance Commercial	$353.36

PIN 5018-5-150

Facility

$631.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$195.61
Max. Negotiated Rate	$612.07
Rate for Payer: AlohaCare Medicaid	$315.50
Rate for Payer: AlohaCare Medicare	$195.61
Rate for Payer: Cash Price	$378.60
Rate for Payer: Devoted Health Medicare	$214.54
Rate for Payer: Hawaii Medical Service Association Medicare	$195.61
Rate for Payer: Hawaii Western Management Group Commercial	$441.70
Rate for Payer: Health Management Network Commercial	$536.35
Rate for Payer: Humana Medicare	$195.61
Rate for Payer: Kaiser Permanente Commercial	$567.90
Rate for Payer: Kaiser Permanente Medicaid	$321.81
Rate for Payer: Kaiser Permanente Medicare	$195.61
Rate for Payer: MDX Hawaii PPO	$612.07
Rate for Payer: Ohana Health Plan Medicaid	$195.61
Rate for Payer: Ohana Health Plan Medicare	$195.61
Rate for Payer: UnitedHealthcare Medicare	$195.61
Rate for Payer: University Health Alliance Commercial	$353.36

PIN 5X250 APEX HALF 5018-7-250

Facility

$852.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$477.12
Max. Negotiated Rate	$826.44
Rate for Payer: Cash Price	$511.20
Rate for Payer: Hawaii Western Management Group Commercial	$596.40
Rate for Payer: Health Management Network Commercial	$724.20
Rate for Payer: Kaiser Permanente Commercial	$766.80
Rate for Payer: MDX Hawaii PPO	$826.44
Rate for Payer: University Health Alliance Commercial	$477.12

PIN 5X250 APEX HALF 5018-7-250

Facility

$852.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$264.12
Max. Negotiated Rate	$826.44
Rate for Payer: AlohaCare Medicaid	$426.00
Rate for Payer: AlohaCare Medicare	$264.12
Rate for Payer: Cash Price	$511.20
Rate for Payer: Devoted Health Medicare	$289.68
Rate for Payer: Hawaii Medical Service Association Medicare	$264.12
Rate for Payer: Hawaii Western Management Group Commercial	$596.40
Rate for Payer: Health Management Network Commercial	$724.20
Rate for Payer: Humana Medicare	$264.12
Rate for Payer: Kaiser Permanente Commercial	$766.80
Rate for Payer: Kaiser Permanente Medicaid	$434.52
Rate for Payer: Kaiser Permanente Medicare	$264.12
Rate for Payer: MDX Hawaii PPO	$826.44
Rate for Payer: Ohana Health Plan Medicaid	$264.12
Rate for Payer: Ohana Health Plan Medicare	$264.12
Rate for Payer: UnitedHealthcare Medicare	$264.12
Rate for Payer: University Health Alliance Commercial	$477.12

PIN 5X25 APEX HALF 5018-6-200

Facility

$547.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$306.32
Max. Negotiated Rate	$530.59
Rate for Payer: Cash Price	$328.20
Rate for Payer: Hawaii Western Management Group Commercial	$382.90
Rate for Payer: Health Management Network Commercial	$464.95
Rate for Payer: Kaiser Permanente Commercial	$492.30
Rate for Payer: MDX Hawaii PPO	$530.59
Rate for Payer: University Health Alliance Commercial	$306.32

PIN 5X25 APEX HALF 5018-6-200

Facility

$547.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$169.57
Max. Negotiated Rate	$530.59
Rate for Payer: AlohaCare Medicaid	$273.50
Rate for Payer: AlohaCare Medicare	$169.57
Rate for Payer: Cash Price	$328.20
Rate for Payer: Devoted Health Medicare	$185.98
Rate for Payer: Hawaii Medical Service Association Medicare	$169.57
Rate for Payer: Hawaii Western Management Group Commercial	$382.90
Rate for Payer: Health Management Network Commercial	$464.95
Rate for Payer: Humana Medicare	$169.57
Rate for Payer: Kaiser Permanente Commercial	$492.30
Rate for Payer: Kaiser Permanente Medicaid	$278.97
Rate for Payer: Kaiser Permanente Medicare	$169.57
Rate for Payer: MDX Hawaii PPO	$530.59
Rate for Payer: Ohana Health Plan Medicaid	$169.57
Rate for Payer: Ohana Health Plan Medicare	$169.57
Rate for Payer: UnitedHealthcare Medicare	$169.57
Rate for Payer: University Health Alliance Commercial	$306.32

PIN APEX 5MM 5018-6-150

Facility

$631.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$195.61
Max. Negotiated Rate	$612.07
Rate for Payer: AlohaCare Medicaid	$315.50
Rate for Payer: AlohaCare Medicare	$195.61
Rate for Payer: Cash Price	$378.60
Rate for Payer: Devoted Health Medicare	$214.54
Rate for Payer: Hawaii Medical Service Association Medicare	$195.61
Rate for Payer: Hawaii Western Management Group Commercial	$441.70
Rate for Payer: Health Management Network Commercial	$536.35
Rate for Payer: Humana Medicare	$195.61
Rate for Payer: Kaiser Permanente Commercial	$567.90
Rate for Payer: Kaiser Permanente Medicaid	$321.81
Rate for Payer: Kaiser Permanente Medicare	$195.61
Rate for Payer: MDX Hawaii PPO	$612.07
Rate for Payer: Ohana Health Plan Medicaid	$195.61
Rate for Payer: Ohana Health Plan Medicare	$195.61
Rate for Payer: UnitedHealthcare Medicare	$195.61
Rate for Payer: University Health Alliance Commercial	$353.36

PIN APEX 5MM 5018-6-150

Facility

$631.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$353.36
Max. Negotiated Rate	$612.07
Rate for Payer: Cash Price	$378.60
Rate for Payer: Hawaii Western Management Group Commercial	$441.70
Rate for Payer: Health Management Network Commercial	$536.35
Rate for Payer: Kaiser Permanente Commercial	$567.90
Rate for Payer: MDX Hawaii PPO	$612.07
Rate for Payer: University Health Alliance Commercial	$353.36

PIN APEX S/D HALF 5018-5-120

Facility

$631.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$353.36
Max. Negotiated Rate	$612.07
Rate for Payer: Cash Price	$378.60
Rate for Payer: Hawaii Western Management Group Commercial	$441.70
Rate for Payer: Health Management Network Commercial	$536.35
Rate for Payer: Kaiser Permanente Commercial	$567.90
Rate for Payer: MDX Hawaii PPO	$612.07
Rate for Payer: University Health Alliance Commercial	$353.36

PIN APEX S/D HALF 5018-5-120

Facility

$631.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$195.61
Max. Negotiated Rate	$612.07
Rate for Payer: AlohaCare Medicaid	$315.50
Rate for Payer: AlohaCare Medicare	$195.61
Rate for Payer: Cash Price	$378.60
Rate for Payer: Devoted Health Medicare	$214.54
Rate for Payer: Hawaii Medical Service Association Medicare	$195.61
Rate for Payer: Hawaii Western Management Group Commercial	$441.70
Rate for Payer: Health Management Network Commercial	$536.35
Rate for Payer: Humana Medicare	$195.61
Rate for Payer: Kaiser Permanente Commercial	$567.90
Rate for Payer: Kaiser Permanente Medicaid	$321.81
Rate for Payer: Kaiser Permanente Medicare	$195.61
Rate for Payer: MDX Hawaii PPO	$612.07
Rate for Payer: Ohana Health Plan Medicaid	$195.61
Rate for Payer: Ohana Health Plan Medicare	$195.61
Rate for Payer: UnitedHealthcare Medicare	$195.61
Rate for Payer: University Health Alliance Commercial	$353.36

PIN APEX SELF-DRILL 5018-5-200

Facility

$631.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$195.61
Max. Negotiated Rate	$612.07
Rate for Payer: AlohaCare Medicaid	$315.50
Rate for Payer: AlohaCare Medicare	$195.61
Rate for Payer: Cash Price	$378.60
Rate for Payer: Devoted Health Medicare	$214.54
Rate for Payer: Hawaii Medical Service Association Medicare	$195.61
Rate for Payer: Hawaii Western Management Group Commercial	$441.70
Rate for Payer: Health Management Network Commercial	$536.35
Rate for Payer: Humana Medicare	$195.61
Rate for Payer: Kaiser Permanente Commercial	$567.90
Rate for Payer: Kaiser Permanente Medicaid	$321.81
Rate for Payer: Kaiser Permanente Medicare	$195.61
Rate for Payer: MDX Hawaii PPO	$612.07
Rate for Payer: Ohana Health Plan Medicaid	$195.61
Rate for Payer: Ohana Health Plan Medicare	$195.61
Rate for Payer: UnitedHealthcare Medicare	$195.61
Rate for Payer: University Health Alliance Commercial	$353.36

PIN APEX SELF-DRILL 5018-5-200

Facility

$631.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$353.36
Max. Negotiated Rate	$612.07
Rate for Payer: Cash Price	$378.60
Rate for Payer: Hawaii Western Management Group Commercial	$441.70
Rate for Payer: Health Management Network Commercial	$536.35
Rate for Payer: Kaiser Permanente Commercial	$567.90
Rate for Payer: MDX Hawaii PPO	$612.07
Rate for Payer: University Health Alliance Commercial	$353.36

PIN AXIS 2.5X40 IJS-EAP-25400

Facility

$1,127.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$631.12
Max. Negotiated Rate	$1,093.19
Rate for Payer: Cash Price	$676.20
Rate for Payer: Hawaii Western Management Group Commercial	$788.90
Rate for Payer: Health Management Network Commercial	$957.95
Rate for Payer: Kaiser Permanente Commercial	$1,014.30
Rate for Payer: MDX Hawaii PPO	$1,093.19
Rate for Payer: University Health Alliance Commercial	$631.12

PIN AXIS 2.5X40 IJS-EAP-25400

Facility

$1,127.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$349.37
Max. Negotiated Rate	$1,093.19
Rate for Payer: AlohaCare Medicaid	$563.50
Rate for Payer: AlohaCare Medicare	$349.37
Rate for Payer: Cash Price	$676.20
Rate for Payer: Devoted Health Medicare	$383.18
Rate for Payer: Hawaii Medical Service Association Medicare	$349.37
Rate for Payer: Hawaii Western Management Group Commercial	$788.90
Rate for Payer: Health Management Network Commercial	$957.95
Rate for Payer: Humana Medicare	$349.37
Rate for Payer: Kaiser Permanente Commercial	$1,014.30
Rate for Payer: Kaiser Permanente Medicaid	$574.77
Rate for Payer: Kaiser Permanente Medicare	$349.37
Rate for Payer: MDX Hawaii PPO	$1,093.19
Rate for Payer: Ohana Health Plan Medicaid	$349.37
Rate for Payer: Ohana Health Plan Medicare	$349.37
Rate for Payer: UnitedHealthcare Medicare	$349.37
Rate for Payer: University Health Alliance Commercial	$631.12

PIN CLAMP 10 HOLES 4921-2-060

Facility

$2,456.00

Hospital Revenue Code	272
Min. Negotiated Rate	$2,087.60
Max. Negotiated Rate	$2,382.32
Rate for Payer: Cash Price	$1,473.60
Rate for Payer: Health Management Network Commercial	$2,087.60
Rate for Payer: Kaiser Permanente Commercial	$2,210.40
Rate for Payer: MDX Hawaii PPO	$2,382.32

PIN CLAMP 10 HOLES 4921-2-060

Facility

$2,456.00

Hospital Revenue Code	272
Min. Negotiated Rate	$761.36
Max. Negotiated Rate	$2,382.32
Rate for Payer: AlohaCare Medicaid	$1,228.00
Rate for Payer: AlohaCare Medicare	$761.36
Rate for Payer: Cash Price	$1,473.60
Rate for Payer: Devoted Health Medicare	$835.04
Rate for Payer: Hawaii Medical Service Association Medicare	$761.36
Rate for Payer: Hawaii Western Management Group Commercial	$2,333.20
Rate for Payer: Health Management Network Commercial	$2,087.60
Rate for Payer: Humana Medicare	$761.36
Rate for Payer: Kaiser Permanente Commercial	$2,210.40
Rate for Payer: Kaiser Permanente Medicaid	$1,252.56
Rate for Payer: Kaiser Permanente Medicare	$761.36
Rate for Payer: MDX Hawaii PPO	$2,382.32
Rate for Payer: Ohana Health Plan Medicaid	$761.36
Rate for Payer: Ohana Health Plan Medicare	$761.36
Rate for Payer: UnitedHealthcare Medicare	$761.36
Rate for Payer: University Health Alliance Commercial	$1,790.18

PIN CLAMP 4922-2-240

Facility

$2,452.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$760.12
Max. Negotiated Rate	$2,378.44
Rate for Payer: AlohaCare Medicaid	$1,226.00
Rate for Payer: AlohaCare Medicare	$760.12
Rate for Payer: Cash Price	$1,471.20
Rate for Payer: Devoted Health Medicare	$833.68
Rate for Payer: Hawaii Medical Service Association Medicare	$760.12
Rate for Payer: Hawaii Western Management Group Commercial	$1,716.40
Rate for Payer: Health Management Network Commercial	$2,084.20
Rate for Payer: Humana Medicare	$760.12
Rate for Payer: Kaiser Permanente Commercial	$2,206.80
Rate for Payer: Kaiser Permanente Medicaid	$1,250.52
Rate for Payer: Kaiser Permanente Medicare	$760.12
Rate for Payer: MDX Hawaii PPO	$2,378.44
Rate for Payer: Ohana Health Plan Medicaid	$760.12
Rate for Payer: Ohana Health Plan Medicare	$760.12
Rate for Payer: UnitedHealthcare Medicare	$760.12
Rate for Payer: University Health Alliance Commercial	$1,373.12

PIN CLAMP 4922-2-240

Facility

$2,452.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,373.12
Max. Negotiated Rate	$2,378.44
Rate for Payer: Cash Price	$1,471.20
Rate for Payer: Hawaii Western Management Group Commercial	$1,716.40
Rate for Payer: Health Management Network Commercial	$2,084.20
Rate for Payer: Kaiser Permanente Commercial	$2,206.80
Rate for Payer: MDX Hawaii PPO	$2,378.44
Rate for Payer: University Health Alliance Commercial	$1,373.12

Know your out-of-pocket cost for care.

All Charges