Kau Hospital

All Charges

Charge

Type

Setting

Price

BIPOLAR LINER 47MM OD X 26MM

Facility

$875.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$271.25
Max. Negotiated Rate	$848.75
Rate for Payer: AlohaCare Medicaid	$437.50
Rate for Payer: AlohaCare Medicare	$271.25
Rate for Payer: Cash Price	$525.00
Rate for Payer: Devoted Health Medicare	$297.50
Rate for Payer: Hawaii Medical Service Association Medicare	$271.25
Rate for Payer: Hawaii Western Management Group Commercial	$612.50
Rate for Payer: Health Management Network Commercial	$743.75
Rate for Payer: Humana Medicare	$271.25
Rate for Payer: Kaiser Permanente Commercial	$787.50
Rate for Payer: Kaiser Permanente Medicaid	$446.25
Rate for Payer: Kaiser Permanente Medicare	$271.25
Rate for Payer: MDX Hawaii PPO	$848.75
Rate for Payer: Ohana Health Plan Medicaid	$271.25
Rate for Payer: Ohana Health Plan Medicare	$271.25
Rate for Payer: UnitedHealthcare Medicare	$271.25
Rate for Payer: University Health Alliance Commercial	$490.00

BIPOLAR LINER 47MM OD X 32MM

Facility

$875.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$490.00
Max. Negotiated Rate	$848.75
Rate for Payer: Cash Price	$525.00
Rate for Payer: Hawaii Western Management Group Commercial	$612.50
Rate for Payer: Health Management Network Commercial	$743.75
Rate for Payer: Kaiser Permanente Commercial	$787.50
Rate for Payer: MDX Hawaii PPO	$848.75
Rate for Payer: University Health Alliance Commercial	$490.00

BIPOLAR LINER 47MM OD X 32MM

Facility

$875.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$271.25
Max. Negotiated Rate	$848.75
Rate for Payer: AlohaCare Medicaid	$437.50
Rate for Payer: AlohaCare Medicare	$271.25
Rate for Payer: Cash Price	$525.00
Rate for Payer: Devoted Health Medicare	$297.50
Rate for Payer: Hawaii Medical Service Association Medicare	$271.25
Rate for Payer: Hawaii Western Management Group Commercial	$612.50
Rate for Payer: Health Management Network Commercial	$743.75
Rate for Payer: Humana Medicare	$271.25
Rate for Payer: Kaiser Permanente Commercial	$787.50
Rate for Payer: Kaiser Permanente Medicaid	$446.25
Rate for Payer: Kaiser Permanente Medicare	$271.25
Rate for Payer: MDX Hawaii PPO	$848.75
Rate for Payer: Ohana Health Plan Medicaid	$271.25
Rate for Payer: Ohana Health Plan Medicare	$271.25
Rate for Payer: UnitedHealthcare Medicare	$271.25
Rate for Payer: University Health Alliance Commercial	$490.00

BIPOLAR LINER 50/51/52MMODX28M

Facility

$875.00

Service Code	HCPCS C1776
Hospital Revenue Code	272
Min. Negotiated Rate	$743.75
Max. Negotiated Rate	$848.75
Rate for Payer: Cash Price	$525.00
Rate for Payer: Health Management Network Commercial	$743.75
Rate for Payer: Kaiser Permanente Commercial	$787.50
Rate for Payer: MDX Hawaii PPO	$848.75

BIPOLAR LINER 50/51/52MMODX28M

Facility

$875.00

Service Code	HCPCS C1776
Hospital Revenue Code	272
Min. Negotiated Rate	$271.25
Max. Negotiated Rate	$848.75
Rate for Payer: AlohaCare Medicaid	$437.50
Rate for Payer: AlohaCare Medicare	$271.25
Rate for Payer: Cash Price	$525.00
Rate for Payer: Devoted Health Medicare	$297.50
Rate for Payer: Hawaii Medical Service Association Medicare	$271.25
Rate for Payer: Hawaii Western Management Group Commercial	$831.25
Rate for Payer: Health Management Network Commercial	$743.75
Rate for Payer: Humana Medicare	$271.25
Rate for Payer: Kaiser Permanente Commercial	$787.50
Rate for Payer: Kaiser Permanente Medicaid	$446.25
Rate for Payer: Kaiser Permanente Medicare	$271.25
Rate for Payer: MDX Hawaii PPO	$848.75
Rate for Payer: Ohana Health Plan Medicaid	$271.25
Rate for Payer: Ohana Health Plan Medicare	$271.25
Rate for Payer: UnitedHealthcare Medicare	$271.25
Rate for Payer: University Health Alliance Commercial	$637.79

BIPOLAR LINER 50MM OD X 22MM

Facility

$875.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$490.00
Max. Negotiated Rate	$848.75
Rate for Payer: Cash Price	$525.00
Rate for Payer: Hawaii Western Management Group Commercial	$612.50
Rate for Payer: Health Management Network Commercial	$743.75
Rate for Payer: Kaiser Permanente Commercial	$787.50
Rate for Payer: MDX Hawaii PPO	$848.75
Rate for Payer: University Health Alliance Commercial	$490.00

BIPOLAR LINER 50MM OD X 22MM

Facility

$875.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$271.25
Max. Negotiated Rate	$848.75
Rate for Payer: AlohaCare Medicaid	$437.50
Rate for Payer: AlohaCare Medicare	$271.25
Rate for Payer: Cash Price	$525.00
Rate for Payer: Devoted Health Medicare	$297.50
Rate for Payer: Hawaii Medical Service Association Medicare	$271.25
Rate for Payer: Hawaii Western Management Group Commercial	$612.50
Rate for Payer: Health Management Network Commercial	$743.75
Rate for Payer: Humana Medicare	$271.25
Rate for Payer: Kaiser Permanente Commercial	$787.50
Rate for Payer: Kaiser Permanente Medicaid	$446.25
Rate for Payer: Kaiser Permanente Medicare	$271.25
Rate for Payer: MDX Hawaii PPO	$848.75
Rate for Payer: Ohana Health Plan Medicaid	$271.25
Rate for Payer: Ohana Health Plan Medicare	$271.25
Rate for Payer: UnitedHealthcare Medicare	$271.25
Rate for Payer: University Health Alliance Commercial	$490.00

BIPOLAR SHELL #00-5001-048-00

Facility

$1,050.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$588.00
Max. Negotiated Rate	$1,018.50
Rate for Payer: Cash Price	$630.00
Rate for Payer: Hawaii Western Management Group Commercial	$735.00
Rate for Payer: Health Management Network Commercial	$892.50
Rate for Payer: Kaiser Permanente Commercial	$945.00
Rate for Payer: MDX Hawaii PPO	$1,018.50
Rate for Payer: University Health Alliance Commercial	$588.00

BIPOLAR SHELL #00-5001-048-00

Facility

$1,050.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$325.50
Max. Negotiated Rate	$1,018.50
Rate for Payer: AlohaCare Medicaid	$525.00
Rate for Payer: AlohaCare Medicare	$325.50
Rate for Payer: Cash Price	$630.00
Rate for Payer: Devoted Health Medicare	$357.00
Rate for Payer: Hawaii Medical Service Association Medicare	$325.50
Rate for Payer: Hawaii Western Management Group Commercial	$735.00
Rate for Payer: Health Management Network Commercial	$892.50
Rate for Payer: Humana Medicare	$325.50
Rate for Payer: Kaiser Permanente Commercial	$945.00
Rate for Payer: Kaiser Permanente Medicaid	$535.50
Rate for Payer: Kaiser Permanente Medicare	$325.50
Rate for Payer: MDX Hawaii PPO	$1,018.50
Rate for Payer: Ohana Health Plan Medicaid	$325.50
Rate for Payer: Ohana Health Plan Medicare	$325.50
Rate for Payer: UnitedHealthcare Medicare	$325.50
Rate for Payer: University Health Alliance Commercial	$588.00

BIPOLAR SHELL 43MM OD

Facility

$1,050.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$588.00
Max. Negotiated Rate	$1,018.50
Rate for Payer: Cash Price	$630.00
Rate for Payer: Hawaii Western Management Group Commercial	$735.00
Rate for Payer: Health Management Network Commercial	$892.50
Rate for Payer: Kaiser Permanente Commercial	$945.00
Rate for Payer: MDX Hawaii PPO	$1,018.50
Rate for Payer: University Health Alliance Commercial	$588.00

BIPOLAR SHELL 43MM OD

Facility

$1,050.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$325.50
Max. Negotiated Rate	$1,018.50
Rate for Payer: AlohaCare Medicaid	$525.00
Rate for Payer: AlohaCare Medicare	$325.50
Rate for Payer: Cash Price	$630.00
Rate for Payer: Devoted Health Medicare	$357.00
Rate for Payer: Hawaii Medical Service Association Medicare	$325.50
Rate for Payer: Hawaii Western Management Group Commercial	$735.00
Rate for Payer: Health Management Network Commercial	$892.50
Rate for Payer: Humana Medicare	$325.50
Rate for Payer: Kaiser Permanente Commercial	$945.00
Rate for Payer: Kaiser Permanente Medicaid	$535.50
Rate for Payer: Kaiser Permanente Medicare	$325.50
Rate for Payer: MDX Hawaii PPO	$1,018.50
Rate for Payer: Ohana Health Plan Medicaid	$325.50
Rate for Payer: Ohana Health Plan Medicare	$325.50
Rate for Payer: UnitedHealthcare Medicare	$325.50
Rate for Payer: University Health Alliance Commercial	$588.00

BIPOLAR SHELL 46MM OD

Facility

$1,050.00

Service Code	HCPCS C1776
Hospital Revenue Code	272
Min. Negotiated Rate	$325.50
Max. Negotiated Rate	$1,018.50
Rate for Payer: AlohaCare Medicaid	$525.00
Rate for Payer: AlohaCare Medicare	$325.50
Rate for Payer: Cash Price	$630.00
Rate for Payer: Devoted Health Medicare	$357.00
Rate for Payer: Hawaii Medical Service Association Medicare	$325.50
Rate for Payer: Hawaii Western Management Group Commercial	$997.50
Rate for Payer: Health Management Network Commercial	$892.50
Rate for Payer: Humana Medicare	$325.50
Rate for Payer: Kaiser Permanente Commercial	$945.00
Rate for Payer: Kaiser Permanente Medicaid	$535.50
Rate for Payer: Kaiser Permanente Medicare	$325.50
Rate for Payer: MDX Hawaii PPO	$1,018.50
Rate for Payer: Ohana Health Plan Medicaid	$325.50
Rate for Payer: Ohana Health Plan Medicare	$325.50
Rate for Payer: UnitedHealthcare Medicare	$325.50
Rate for Payer: University Health Alliance Commercial	$765.35

BIPOLAR SHELL 46MM OD

Facility

$1,050.00

Service Code	HCPCS C1776
Hospital Revenue Code	272
Min. Negotiated Rate	$892.50
Max. Negotiated Rate	$1,018.50
Rate for Payer: Cash Price	$630.00
Rate for Payer: Health Management Network Commercial	$892.50
Rate for Payer: Kaiser Permanente Commercial	$945.00
Rate for Payer: MDX Hawaii PPO	$1,018.50

BIPOLAR SHELL, 52MM

Facility

$2,090.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$1,170.40
Max. Negotiated Rate	$2,027.30
Rate for Payer: Cash Price	$1,254.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,463.00
Rate for Payer: Health Management Network Commercial	$1,776.50
Rate for Payer: Kaiser Permanente Commercial	$1,881.00
Rate for Payer: MDX Hawaii PPO	$2,027.30
Rate for Payer: University Health Alliance Commercial	$1,170.40

BIPOLAR SHELL, 52MM

Facility

$2,090.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$647.90
Max. Negotiated Rate	$2,027.30
Rate for Payer: AlohaCare Medicaid	$1,045.00
Rate for Payer: AlohaCare Medicare	$647.90
Rate for Payer: Cash Price	$1,254.00
Rate for Payer: Devoted Health Medicare	$710.60
Rate for Payer: Hawaii Medical Service Association Medicare	$647.90
Rate for Payer: Hawaii Western Management Group Commercial	$1,463.00
Rate for Payer: Health Management Network Commercial	$1,776.50
Rate for Payer: Humana Medicare	$647.90
Rate for Payer: Kaiser Permanente Commercial	$1,881.00
Rate for Payer: Kaiser Permanente Medicaid	$1,065.90
Rate for Payer: Kaiser Permanente Medicare	$647.90
Rate for Payer: MDX Hawaii PPO	$2,027.30
Rate for Payer: Ohana Health Plan Medicaid	$647.90
Rate for Payer: Ohana Health Plan Medicare	$647.90
Rate for Payer: UnitedHealthcare Medicare	$647.90
Rate for Payer: University Health Alliance Commercial	$1,170.40

BIPOLAR SHELL, 55MM

Facility

$2,272.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$1,272.32
Max. Negotiated Rate	$2,203.84
Rate for Payer: Cash Price	$1,363.20
Rate for Payer: Hawaii Western Management Group Commercial	$1,590.40
Rate for Payer: Health Management Network Commercial	$1,931.20
Rate for Payer: Kaiser Permanente Commercial	$2,044.80
Rate for Payer: MDX Hawaii PPO	$2,203.84
Rate for Payer: University Health Alliance Commercial	$1,272.32

BIPOLAR SHELL, 55MM

Facility

$2,272.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$704.32
Max. Negotiated Rate	$2,203.84
Rate for Payer: AlohaCare Medicaid	$1,136.00
Rate for Payer: AlohaCare Medicare	$704.32
Rate for Payer: Cash Price	$1,363.20
Rate for Payer: Devoted Health Medicare	$772.48
Rate for Payer: Hawaii Medical Service Association Medicare	$704.32
Rate for Payer: Hawaii Western Management Group Commercial	$1,590.40
Rate for Payer: Health Management Network Commercial	$1,931.20
Rate for Payer: Humana Medicare	$704.32
Rate for Payer: Kaiser Permanente Commercial	$2,044.80
Rate for Payer: Kaiser Permanente Medicaid	$1,158.72
Rate for Payer: Kaiser Permanente Medicare	$704.32
Rate for Payer: MDX Hawaii PPO	$2,203.84
Rate for Payer: Ohana Health Plan Medicaid	$704.32
Rate for Payer: Ohana Health Plan Medicare	$704.32
Rate for Payer: UnitedHealthcare Medicare	$704.32
Rate for Payer: University Health Alliance Commercial	$1,272.32

BIPOLAR SMALL SHELL 49MM

Facility

$2,278.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$706.18
Max. Negotiated Rate	$2,209.66
Rate for Payer: AlohaCare Medicaid	$1,139.00
Rate for Payer: AlohaCare Medicare	$706.18
Rate for Payer: Cash Price	$1,366.80
Rate for Payer: Devoted Health Medicare	$774.52
Rate for Payer: Hawaii Medical Service Association Medicare	$706.18
Rate for Payer: Hawaii Western Management Group Commercial	$1,594.60
Rate for Payer: Health Management Network Commercial	$1,936.30
Rate for Payer: Humana Medicare	$706.18
Rate for Payer: Kaiser Permanente Commercial	$2,050.20
Rate for Payer: Kaiser Permanente Medicaid	$1,161.78
Rate for Payer: Kaiser Permanente Medicare	$706.18
Rate for Payer: MDX Hawaii PPO	$2,209.66
Rate for Payer: Ohana Health Plan Medicaid	$706.18
Rate for Payer: Ohana Health Plan Medicare	$706.18
Rate for Payer: UnitedHealthcare Medicare	$706.18
Rate for Payer: University Health Alliance Commercial	$1,275.68

BIPOLAR SMALL SHELL 49MM

Facility

$2,278.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$1,275.68
Max. Negotiated Rate	$2,209.66
Rate for Payer: Cash Price	$1,366.80
Rate for Payer: Hawaii Western Management Group Commercial	$1,594.60
Rate for Payer: Health Management Network Commercial	$1,936.30
Rate for Payer: Kaiser Permanente Commercial	$2,050.20
Rate for Payer: MDX Hawaii PPO	$2,209.66
Rate for Payer: University Health Alliance Commercial	$1,275.68

BIPOLR SHELL 47 00-5001-047-00

Facility

$1,225.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$686.00
Max. Negotiated Rate	$1,188.25
Rate for Payer: Cash Price	$735.00
Rate for Payer: Hawaii Western Management Group Commercial	$857.50
Rate for Payer: Health Management Network Commercial	$1,041.25
Rate for Payer: Kaiser Permanente Commercial	$1,102.50
Rate for Payer: MDX Hawaii PPO	$1,188.25
Rate for Payer: University Health Alliance Commercial	$686.00

BIPOLR SHELL 47 00-5001-047-00

Facility

$1,225.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$379.75
Max. Negotiated Rate	$1,188.25
Rate for Payer: AlohaCare Medicaid	$612.50
Rate for Payer: AlohaCare Medicare	$379.75
Rate for Payer: Cash Price	$735.00
Rate for Payer: Devoted Health Medicare	$416.50
Rate for Payer: Hawaii Medical Service Association Medicare	$379.75
Rate for Payer: Hawaii Western Management Group Commercial	$857.50
Rate for Payer: Health Management Network Commercial	$1,041.25
Rate for Payer: Humana Medicare	$379.75
Rate for Payer: Kaiser Permanente Commercial	$1,102.50
Rate for Payer: Kaiser Permanente Medicaid	$624.75
Rate for Payer: Kaiser Permanente Medicare	$379.75
Rate for Payer: MDX Hawaii PPO	$1,188.25
Rate for Payer: Ohana Health Plan Medicaid	$379.75
Rate for Payer: Ohana Health Plan Medicare	$379.75
Rate for Payer: UnitedHealthcare Medicare	$379.75
Rate for Payer: University Health Alliance Commercial	$686.00

BISACODYL 10 MG RECTAL SUPPOSITORY [1080]

Facility

$2.00

Service Code	NDC 00574705012
Hospital Revenue Code	250
Min. Negotiated Rate	$1.70
Max. Negotiated Rate	$1.94
Rate for Payer: Cash Price	$1.20
Rate for Payer: Health Management Network Commercial	$1.70
Rate for Payer: Kaiser Permanente Commercial	$1.80
Rate for Payer: MDX Hawaii PPO	$1.94

BISACODYL 10 MG RECTAL SUPPOSITORY [1080]

Facility

$1.00

Service Code	NDC 71399846002
Hospital Revenue Code	637
Min. Negotiated Rate	$0.31
Max. Negotiated Rate	$0.97
Rate for Payer: AlohaCare Medicaid	$0.50
Rate for Payer: AlohaCare Medicare	$0.31
Rate for Payer: Cash Price	$0.60
Rate for Payer: Devoted Health Medicare	$0.34
Rate for Payer: Hawaii Medical Service Association Medicare	$0.31
Rate for Payer: Hawaii Western Management Group Commercial	$0.95
Rate for Payer: Health Management Network Commercial	$0.85
Rate for Payer: Humana Medicare	$0.31
Rate for Payer: Kaiser Permanente Commercial	$0.90
Rate for Payer: Kaiser Permanente Medicaid	$0.51
Rate for Payer: Kaiser Permanente Medicare	$0.31
Rate for Payer: MDX Hawaii PPO	$0.97
Rate for Payer: Ohana Health Plan Medicaid	$0.31
Rate for Payer: Ohana Health Plan Medicare	$0.31
Rate for Payer: UnitedHealthcare Medicare	$0.31
Rate for Payer: University Health Alliance Commercial	$0.73

BISACODYL 10 MG RECTAL SUPPOSITORY [1080]

Facility

$1.00

Service Code	NDC 45802071030
Hospital Revenue Code	637
Min. Negotiated Rate	$0.31
Max. Negotiated Rate	$0.97
Rate for Payer: AlohaCare Medicaid	$0.50
Rate for Payer: AlohaCare Medicare	$0.31
Rate for Payer: Cash Price	$0.60
Rate for Payer: Devoted Health Medicare	$0.34
Rate for Payer: Hawaii Medical Service Association Medicare	$0.31
Rate for Payer: Hawaii Western Management Group Commercial	$0.95
Rate for Payer: Health Management Network Commercial	$0.85
Rate for Payer: Humana Medicare	$0.31
Rate for Payer: Kaiser Permanente Commercial	$0.90
Rate for Payer: Kaiser Permanente Medicaid	$0.51
Rate for Payer: Kaiser Permanente Medicare	$0.31
Rate for Payer: MDX Hawaii PPO	$0.97
Rate for Payer: Ohana Health Plan Medicaid	$0.31
Rate for Payer: Ohana Health Plan Medicare	$0.31
Rate for Payer: UnitedHealthcare Medicare	$0.31
Rate for Payer: University Health Alliance Commercial	$0.73

BISACODYL 10 MG RECTAL SUPPOSITORY [1080]

Facility

$1.00

Service Code	NDC 71399846002
Hospital Revenue Code	250
Min. Negotiated Rate	$0.85
Max. Negotiated Rate	$0.97
Rate for Payer: Cash Price	$0.60
Rate for Payer: Health Management Network Commercial	$0.85
Rate for Payer: Kaiser Permanente Commercial	$0.90
Rate for Payer: MDX Hawaii PPO	$0.97

Know your out-of-pocket cost for care.

All Charges