Kau Hospital

All Charges

Charge

Type

Setting

Price

PLUG 16MM/25MM 32-8105-038-00

Facility

$727.00

Hospital Revenue Code	272
Min. Negotiated Rate	$225.37
Max. Negotiated Rate	$705.19
Rate for Payer: AlohaCare Medicaid	$363.50
Rate for Payer: AlohaCare Medicare	$225.37
Rate for Payer: Cash Price	$436.20
Rate for Payer: Devoted Health Medicare	$247.18
Rate for Payer: Hawaii Medical Service Association Medicare	$225.37
Rate for Payer: Hawaii Western Management Group Commercial	$690.65
Rate for Payer: Health Management Network Commercial	$617.95
Rate for Payer: Humana Medicare	$225.37
Rate for Payer: Kaiser Permanente Commercial	$654.30
Rate for Payer: Kaiser Permanente Medicaid	$370.77
Rate for Payer: Kaiser Permanente Medicare	$225.37
Rate for Payer: MDX Hawaii PPO	$705.19
Rate for Payer: Ohana Health Plan Medicaid	$225.37
Rate for Payer: Ohana Health Plan Medicare	$225.37
Rate for Payer: UnitedHealthcare Medicare	$225.37
Rate for Payer: University Health Alliance Commercial	$529.91

PLUG CABLE 5MM 661002S

Facility

$891.00

Hospital Revenue Code	272
Min. Negotiated Rate	$276.21
Max. Negotiated Rate	$864.27
Rate for Payer: AlohaCare Medicaid	$445.50
Rate for Payer: AlohaCare Medicare	$276.21
Rate for Payer: Cash Price	$534.60
Rate for Payer: Devoted Health Medicare	$302.94
Rate for Payer: Hawaii Medical Service Association Medicare	$276.21
Rate for Payer: Hawaii Western Management Group Commercial	$846.45
Rate for Payer: Health Management Network Commercial	$757.35
Rate for Payer: Humana Medicare	$276.21
Rate for Payer: Kaiser Permanente Commercial	$801.90
Rate for Payer: Kaiser Permanente Medicaid	$454.41
Rate for Payer: Kaiser Permanente Medicare	$276.21
Rate for Payer: MDX Hawaii PPO	$864.27
Rate for Payer: Ohana Health Plan Medicaid	$276.21
Rate for Payer: Ohana Health Plan Medicare	$276.21
Rate for Payer: UnitedHealthcare Medicare	$276.21
Rate for Payer: University Health Alliance Commercial	$649.45

PLUG CABLE 5MM 661002S

Facility

$891.00

Hospital Revenue Code	272
Min. Negotiated Rate	$757.35
Max. Negotiated Rate	$864.27
Rate for Payer: Cash Price	$534.60
Rate for Payer: Health Management Network Commercial	$757.35
Rate for Payer: Kaiser Permanente Commercial	$801.90
Rate for Payer: MDX Hawaii PPO	$864.27

PLUG LEAD BLIND 119602

Facility

$180.00

Hospital Revenue Code	272
Min. Negotiated Rate	$55.80
Max. Negotiated Rate	$174.60
Rate for Payer: AlohaCare Medicaid	$90.00
Rate for Payer: AlohaCare Medicare	$55.80
Rate for Payer: Cash Price	$108.00
Rate for Payer: Devoted Health Medicare	$61.20
Rate for Payer: Hawaii Medical Service Association Medicare	$55.80
Rate for Payer: Hawaii Western Management Group Commercial	$171.00
Rate for Payer: Health Management Network Commercial	$153.00
Rate for Payer: Humana Medicare	$55.80
Rate for Payer: Kaiser Permanente Commercial	$162.00
Rate for Payer: Kaiser Permanente Medicaid	$91.80
Rate for Payer: Kaiser Permanente Medicare	$55.80
Rate for Payer: MDX Hawaii PPO	$174.60
Rate for Payer: Ohana Health Plan Medicaid	$55.80
Rate for Payer: Ohana Health Plan Medicare	$55.80
Rate for Payer: UnitedHealthcare Medicare	$55.80
Rate for Payer: University Health Alliance Commercial	$131.20

PLUG LEAD BLIND 119602

Facility

$180.00

Hospital Revenue Code	272
Min. Negotiated Rate	$153.00
Max. Negotiated Rate	$174.60
Rate for Payer: Cash Price	$108.00
Rate for Payer: Health Management Network Commercial	$153.00
Rate for Payer: Kaiser Permanente Commercial	$162.00
Rate for Payer: MDX Hawaii PPO	$174.60

PLUS STENT GRAFT BLN CATH

Facility

$1,698.00

Service Code	HCPCS C1726
Hospital Revenue Code	272
Min. Negotiated Rate	$526.38
Max. Negotiated Rate	$1,647.06
Rate for Payer: AlohaCare Medicaid	$849.00
Rate for Payer: AlohaCare Medicare	$526.38
Rate for Payer: Cash Price	$1,018.80
Rate for Payer: Devoted Health Medicare	$577.32
Rate for Payer: Hawaii Medical Service Association Medicare	$526.38
Rate for Payer: Hawaii Western Management Group Commercial	$1,613.10
Rate for Payer: Health Management Network Commercial	$1,443.30
Rate for Payer: Humana Medicare	$526.38
Rate for Payer: Kaiser Permanente Commercial	$1,528.20
Rate for Payer: Kaiser Permanente Medicaid	$865.98
Rate for Payer: Kaiser Permanente Medicare	$526.38
Rate for Payer: MDX Hawaii PPO	$1,647.06
Rate for Payer: Ohana Health Plan Medicaid	$526.38
Rate for Payer: Ohana Health Plan Medicare	$526.38
Rate for Payer: UnitedHealthcare Medicare	$526.38
Rate for Payer: University Health Alliance Commercial	$1,237.67

PLUS STENT GRAFT BLN CATH

Facility

$1,698.00

Service Code	HCPCS C1726
Hospital Revenue Code	272
Min. Negotiated Rate	$1,443.30
Max. Negotiated Rate	$1,647.06
Rate for Payer: Cash Price	$1,018.80
Rate for Payer: Health Management Network Commercial	$1,443.30
Rate for Payer: Kaiser Permanente Commercial	$1,528.20
Rate for Payer: MDX Hawaii PPO	$1,647.06

PNEUMOCOCCAL 20-VALENT CONJ VACCINE-DIP CRM (PF) 0.5 ML IM SYRINGE [180721]

Facility

$495.00

Service Code	NDC 00005200010
Hospital Revenue Code	250
Min. Negotiated Rate	$420.75
Max. Negotiated Rate	$480.15
Rate for Payer: Cash Price	$297.00
Rate for Payer: Health Management Network Commercial	$420.75
Rate for Payer: Kaiser Permanente Commercial	$445.50
Rate for Payer: MDX Hawaii PPO	$480.15

PNEUMOCOCCAL 20-VALENT CONJ VACCINE-DIP CRM (PF) 0.5 ML IM SYRINGE [180721]

Facility

$510.00

Service Code	NDC 00005200002
Hospital Revenue Code	250
Min. Negotiated Rate	$433.50
Max. Negotiated Rate	$494.70
Rate for Payer: Cash Price	$306.00
Rate for Payer: Health Management Network Commercial	$433.50
Rate for Payer: Kaiser Permanente Commercial	$459.00
Rate for Payer: MDX Hawaii PPO	$494.70

PNEUMOCOCCAL 20-VALENT CONJ VACCINE-DIP CRM (PF) 0.5 ML IM SYRINGE [180721]

Facility

$510.00

Service Code	NDC 00005200001
Hospital Revenue Code	250
Min. Negotiated Rate	$433.50
Max. Negotiated Rate	$494.70
Rate for Payer: Cash Price	$306.00
Rate for Payer: Health Management Network Commercial	$433.50
Rate for Payer: Kaiser Permanente Commercial	$459.00
Rate for Payer: MDX Hawaii PPO	$494.70

PNEUMOPERITONEUNM NDL PN120

Facility

$232.00

Hospital Revenue Code	272
Min. Negotiated Rate	$197.20
Max. Negotiated Rate	$225.04
Rate for Payer: Cash Price	$139.20
Rate for Payer: Health Management Network Commercial	$197.20
Rate for Payer: Kaiser Permanente Commercial	$208.80
Rate for Payer: MDX Hawaii PPO	$225.04

PNEUMOPERITONEUNM NDL PN120

Facility

$232.00

Hospital Revenue Code	272
Min. Negotiated Rate	$71.92
Max. Negotiated Rate	$225.04
Rate for Payer: AlohaCare Medicaid	$116.00
Rate for Payer: AlohaCare Medicare	$71.92
Rate for Payer: Cash Price	$139.20
Rate for Payer: Devoted Health Medicare	$78.88
Rate for Payer: Hawaii Medical Service Association Medicare	$71.92
Rate for Payer: Hawaii Western Management Group Commercial	$220.40
Rate for Payer: Health Management Network Commercial	$197.20
Rate for Payer: Humana Medicare	$71.92
Rate for Payer: Kaiser Permanente Commercial	$208.80
Rate for Payer: Kaiser Permanente Medicaid	$118.32
Rate for Payer: Kaiser Permanente Medicare	$71.92
Rate for Payer: MDX Hawaii PPO	$225.04
Rate for Payer: Ohana Health Plan Medicaid	$71.92
Rate for Payer: Ohana Health Plan Medicare	$71.92
Rate for Payer: UnitedHealthcare Medicare	$71.92
Rate for Payer: University Health Alliance Commercial	$169.10

PNEUMOTHORAX WITH CC

Facility

$17,373.57

Service Code	MSDRG 200
Min. Negotiated Rate	$17,373.57
Max. Negotiated Rate	$17,373.57
Rate for Payer: Hawaii Medical Service Association Commercial	$17,373.57

PNEUMOTHORAX WITH MCC

Facility

$18,321.65

Service Code	MSDRG 199
Min. Negotiated Rate	$18,321.65
Max. Negotiated Rate	$18,321.65
Rate for Payer: Hawaii Medical Service Association Commercial	$18,321.65

PNEUMOTHORAX WITHOUT CC/MCC

Facility

$13,770.86

Service Code	MSDRG 201
Min. Negotiated Rate	$13,770.86
Max. Negotiated Rate	$13,770.86
Rate for Payer: Hawaii Medical Service Association Commercial	$13,770.86

POISONING AND TOXIC EFFECTS OF DRUGS WITH MCC

Facility

$20,597.04

Service Code	MSDRG 917
Min. Negotiated Rate	$20,597.04
Max. Negotiated Rate	$20,597.04
Rate for Payer: Hawaii Medical Service Association Commercial	$20,597.04

POISONING AND TOXIC EFFECTS OF DRUGS WITHOUT MCC

Facility

$15,714.43

Service Code	MSDRG 918
Min. Negotiated Rate	$15,714.43
Max. Negotiated Rate	$15,714.43
Rate for Payer: Hawaii Medical Service Association Commercial	$15,714.43

POLATUZUMAB VEDOTIN-PIIQ 140 MG/7ML IV (WET SOLR VIAL) [430168184]

Facility

$22,834.00

Service Code	HCPCS J9309
Hospital Revenue Code	250
Min. Negotiated Rate	$19,408.90
Max. Negotiated Rate	$22,148.98
Rate for Payer: Cash Price	$13,700.40
Rate for Payer: Health Management Network Commercial	$19,408.90
Rate for Payer: Kaiser Permanente Commercial	$20,550.60
Rate for Payer: MDX Hawaii PPO	$22,148.98

POLATUZUMAB VEDOTIN-PIIQ 140 MG/7ML IV (WET SOLR VIAL) [430168184]

Facility

$22,834.00

Service Code	HCPCS J9309
Hospital Revenue Code	636
Min. Negotiated Rate	$136.23
Max. Negotiated Rate	$22,148.98
Rate for Payer: AlohaCare Medicaid	$11,417.00
Rate for Payer: AlohaCare Medicare	$7,078.54
Rate for Payer: Cash Price	$13,700.40
Rate for Payer: Cash Price	$13,700.40
Rate for Payer: Devoted Health Medicare	$7,763.56
Rate for Payer: Hawaii Medical Service Association ABD	$136.23
Rate for Payer: Hawaii Medical Service Association Commercial	$171.54
Rate for Payer: Hawaii Medical Service Association Medicare	$7,078.54
Rate for Payer: Hawaii Medical Service Association Non-ABD	$136.23
Rate for Payer: Hawaii Western Management Group Commercial	$21,692.30
Rate for Payer: Health Management Network Commercial	$19,408.90
Rate for Payer: Humana Medicare	$7,078.54
Rate for Payer: Kaiser Permanente Commercial	$20,550.60
Rate for Payer: Kaiser Permanente Medicaid	$11,645.34
Rate for Payer: Kaiser Permanente Medicare	$7,078.54
Rate for Payer: MDX Hawaii PPO	$22,148.98
Rate for Payer: Ohana Health Plan Medicaid	$7,078.54
Rate for Payer: Ohana Health Plan Medicare	$7,078.54
Rate for Payer: UnitedHealthcare Medicaid	$13,700.40
Rate for Payer: UnitedHealthcare Medicare	$7,078.54
Rate for Payer: University Health Alliance Commercial	$16,643.70

POLATUZUMAB VEDOTIN-PIIQ 140 MG INTRAVENOUS SOLUTION [168184]

Facility

$12,848.00

Service Code	HCPCS J9309
Hospital Revenue Code	636
Min. Negotiated Rate	$136.23
Max. Negotiated Rate	$12,462.56
Rate for Payer: AlohaCare Medicaid	$6,424.00
Rate for Payer: AlohaCare Medicaid	$11,417.00
Rate for Payer: AlohaCare Medicare	$7,078.54
Rate for Payer: AlohaCare Medicare	$3,982.88
Rate for Payer: Cash Price	$7,708.80
Rate for Payer: Cash Price	$7,708.80
Rate for Payer: Cash Price	$13,700.40
Rate for Payer: Cash Price	$13,700.40
Rate for Payer: Devoted Health Medicare	$4,368.32
Rate for Payer: Devoted Health Medicare	$7,763.56
Rate for Payer: Hawaii Medical Service Association ABD	$136.23
Rate for Payer: Hawaii Medical Service Association ABD	$136.23
Rate for Payer: Hawaii Medical Service Association Commercial	$171.54
Rate for Payer: Hawaii Medical Service Association Commercial	$171.54
Rate for Payer: Hawaii Medical Service Association Medicare	$3,982.88
Rate for Payer: Hawaii Medical Service Association Medicare	$7,078.54
Rate for Payer: Hawaii Medical Service Association Non-ABD	$136.23
Rate for Payer: Hawaii Medical Service Association Non-ABD	$136.23
Rate for Payer: Hawaii Western Management Group Commercial	$12,205.60
Rate for Payer: Hawaii Western Management Group Commercial	$21,692.30
Rate for Payer: Health Management Network Commercial	$10,920.80
Rate for Payer: Health Management Network Commercial	$19,408.90
Rate for Payer: Humana Medicare	$3,982.88
Rate for Payer: Humana Medicare	$7,078.54
Rate for Payer: Kaiser Permanente Commercial	$11,563.20
Rate for Payer: Kaiser Permanente Commercial	$20,550.60
Rate for Payer: Kaiser Permanente Medicaid	$6,552.48
Rate for Payer: Kaiser Permanente Medicaid	$11,645.34
Rate for Payer: Kaiser Permanente Medicare	$3,982.88
Rate for Payer: Kaiser Permanente Medicare	$7,078.54
Rate for Payer: MDX Hawaii PPO	$12,462.56
Rate for Payer: MDX Hawaii PPO	$22,148.98
Rate for Payer: Ohana Health Plan Medicaid	$7,078.54
Rate for Payer: Ohana Health Plan Medicaid	$3,982.88
Rate for Payer: Ohana Health Plan Medicare	$3,982.88
Rate for Payer: Ohana Health Plan Medicare	$7,078.54
Rate for Payer: UnitedHealthcare Medicaid	$7,708.80
Rate for Payer: UnitedHealthcare Medicaid	$13,700.40
Rate for Payer: UnitedHealthcare Medicare	$7,078.54
Rate for Payer: UnitedHealthcare Medicare	$3,982.88
Rate for Payer: University Health Alliance Commercial	$9,364.91
Rate for Payer: University Health Alliance Commercial	$16,643.70

POLATUZUMAB VEDOTIN-PIIQ 140 MG INTRAVENOUS SOLUTION [168184]

Facility

$12,848.00

Service Code	HCPCS J9309
Hospital Revenue Code	250
Min. Negotiated Rate	$10,920.80
Max. Negotiated Rate	$12,462.56
Rate for Payer: Cash Price	$7,708.80
Rate for Payer: Cash Price	$13,700.40
Rate for Payer: Health Management Network Commercial	$19,408.90
Rate for Payer: Health Management Network Commercial	$10,920.80
Rate for Payer: Kaiser Permanente Commercial	$11,563.20
Rate for Payer: Kaiser Permanente Commercial	$20,550.60
Rate for Payer: MDX Hawaii PPO	$12,462.56
Rate for Payer: MDX Hawaii PPO	$22,148.98

POLATUZUMAB VEDOTIN-PIIQ 30 MG INTRAVENOUS SOLUTION [174859]

Facility

$5,286.00

Service Code	HCPCS J9309
Hospital Revenue Code	636
Min. Negotiated Rate	$136.23
Max. Negotiated Rate	$5,127.42
Rate for Payer: AlohaCare Medicaid	$2,643.00
Rate for Payer: AlohaCare Medicare	$1,638.66
Rate for Payer: Cash Price	$3,171.60
Rate for Payer: Cash Price	$3,171.60
Rate for Payer: Devoted Health Medicare	$1,797.24
Rate for Payer: Hawaii Medical Service Association ABD	$136.23
Rate for Payer: Hawaii Medical Service Association Commercial	$171.54
Rate for Payer: Hawaii Medical Service Association Medicare	$1,638.66
Rate for Payer: Hawaii Medical Service Association Non-ABD	$136.23
Rate for Payer: Hawaii Western Management Group Commercial	$5,021.70
Rate for Payer: Health Management Network Commercial	$4,493.10
Rate for Payer: Humana Medicare	$1,638.66
Rate for Payer: Kaiser Permanente Commercial	$4,757.40
Rate for Payer: Kaiser Permanente Medicaid	$2,695.86
Rate for Payer: Kaiser Permanente Medicare	$1,638.66
Rate for Payer: MDX Hawaii PPO	$5,127.42
Rate for Payer: Ohana Health Plan Medicaid	$1,638.66
Rate for Payer: Ohana Health Plan Medicare	$1,638.66
Rate for Payer: UnitedHealthcare Medicaid	$3,171.60
Rate for Payer: UnitedHealthcare Medicare	$1,638.66
Rate for Payer: University Health Alliance Commercial	$3,852.97

POLATUZUMAB VEDOTIN-PIIQ 30 MG INTRAVENOUS SOLUTION [174859]

Facility

$5,286.00

Service Code	HCPCS J9309
Hospital Revenue Code	250
Min. Negotiated Rate	$4,493.10
Max. Negotiated Rate	$5,127.42
Rate for Payer: Cash Price	$3,171.60
Rate for Payer: Health Management Network Commercial	$4,493.10
Rate for Payer: Kaiser Permanente Commercial	$4,757.40
Rate for Payer: MDX Hawaii PPO	$5,127.42

POLYETHYLENE GLYCOL 3350 17 GRAM ORAL POWDER PACKET [25424]

Facility

$6.00

Service Code	NDC 00904693176
Hospital Revenue Code	637
Min. Negotiated Rate	$1.86
Max. Negotiated Rate	$5.82
Rate for Payer: AlohaCare Medicaid	$3.00
Rate for Payer: AlohaCare Medicare	$1.86
Rate for Payer: Cash Price	$3.60
Rate for Payer: Devoted Health Medicare	$2.04
Rate for Payer: Hawaii Medical Service Association Medicare	$1.86
Rate for Payer: Hawaii Western Management Group Commercial	$5.70
Rate for Payer: Health Management Network Commercial	$5.10
Rate for Payer: Humana Medicare	$1.86
Rate for Payer: Kaiser Permanente Commercial	$5.40
Rate for Payer: Kaiser Permanente Medicaid	$3.06
Rate for Payer: Kaiser Permanente Medicare	$1.86
Rate for Payer: MDX Hawaii PPO	$5.82
Rate for Payer: Ohana Health Plan Medicaid	$1.86
Rate for Payer: Ohana Health Plan Medicare	$1.86
Rate for Payer: UnitedHealthcare Medicare	$1.86
Rate for Payer: University Health Alliance Commercial	$4.37

POLYETHYLENE GLYCOL 3350 17 GRAM ORAL POWDER PACKET [25424]

Facility

$6.00

Service Code	NDC 62559015730
Hospital Revenue Code	250
Min. Negotiated Rate	$5.10
Max. Negotiated Rate	$5.82
Rate for Payer: Cash Price	$3.60
Rate for Payer: Health Management Network Commercial	$5.10
Rate for Payer: Kaiser Permanente Commercial	$5.40
Rate for Payer: MDX Hawaii PPO	$5.82

Know your out-of-pocket cost for care.

All Charges