Kau Hospital

All Charges

Charge

Type

Setting

Price

SAFESHEATH 8X23

Facility

$563.00

Service Code	HCPCS C1892
Hospital Revenue Code	272
Min. Negotiated Rate	$478.55
Max. Negotiated Rate	$546.11
Rate for Payer: Cash Price	$337.80
Rate for Payer: Health Management Network Commercial	$478.55
Rate for Payer: Kaiser Permanente Commercial	$506.70
Rate for Payer: MDX Hawaii PPO	$546.11

SAFESHEATH 8X23

Facility

$563.00

Service Code	HCPCS C1892
Hospital Revenue Code	272
Min. Negotiated Rate	$174.53
Max. Negotiated Rate	$546.11
Rate for Payer: AlohaCare Medicaid	$281.50
Rate for Payer: AlohaCare Medicare	$174.53
Rate for Payer: Cash Price	$337.80
Rate for Payer: Devoted Health Medicare	$191.42
Rate for Payer: Hawaii Medical Service Association Medicare	$174.53
Rate for Payer: Hawaii Western Management Group Commercial	$534.85
Rate for Payer: Health Management Network Commercial	$478.55
Rate for Payer: Humana Medicare	$174.53
Rate for Payer: Kaiser Permanente Commercial	$506.70
Rate for Payer: Kaiser Permanente Medicaid	$287.13
Rate for Payer: Kaiser Permanente Medicare	$174.53
Rate for Payer: MDX Hawaii PPO	$546.11
Rate for Payer: Ohana Health Plan Medicaid	$174.53
Rate for Payer: Ohana Health Plan Medicare	$174.53
Rate for Payer: UnitedHealthcare Medicare	$174.53
Rate for Payer: University Health Alliance Commercial	$410.37

SAFESHEATH II SS6 398339

Facility

$236.00

Service Code	HCPCS C1892
Hospital Revenue Code	272
Min. Negotiated Rate	$200.60
Max. Negotiated Rate	$228.92
Rate for Payer: Cash Price	$141.60
Rate for Payer: Health Management Network Commercial	$200.60
Rate for Payer: Kaiser Permanente Commercial	$212.40
Rate for Payer: MDX Hawaii PPO	$228.92

SAFESHEATH II SS6 398339

Facility

$236.00

Service Code	HCPCS C1892
Hospital Revenue Code	272
Min. Negotiated Rate	$73.16
Max. Negotiated Rate	$228.92
Rate for Payer: AlohaCare Medicaid	$118.00
Rate for Payer: AlohaCare Medicare	$73.16
Rate for Payer: Cash Price	$141.60
Rate for Payer: Devoted Health Medicare	$80.24
Rate for Payer: Hawaii Medical Service Association Medicare	$73.16
Rate for Payer: Hawaii Western Management Group Commercial	$224.20
Rate for Payer: Health Management Network Commercial	$200.60
Rate for Payer: Humana Medicare	$73.16
Rate for Payer: Kaiser Permanente Commercial	$212.40
Rate for Payer: Kaiser Permanente Medicaid	$120.36
Rate for Payer: Kaiser Permanente Medicare	$73.16
Rate for Payer: MDX Hawaii PPO	$228.92
Rate for Payer: Ohana Health Plan Medicaid	$73.16
Rate for Payer: Ohana Health Plan Medicare	$73.16
Rate for Payer: UnitedHealthcare Medicare	$73.16
Rate for Payer: University Health Alliance Commercial	$172.02

SAFESHEATH II SS8 398343

Facility

$236.00

Service Code	HCPCS C1892
Hospital Revenue Code	272
Min. Negotiated Rate	$73.16
Max. Negotiated Rate	$228.92
Rate for Payer: AlohaCare Medicaid	$118.00
Rate for Payer: AlohaCare Medicare	$73.16
Rate for Payer: Cash Price	$141.60
Rate for Payer: Devoted Health Medicare	$80.24
Rate for Payer: Hawaii Medical Service Association Medicare	$73.16
Rate for Payer: Hawaii Western Management Group Commercial	$224.20
Rate for Payer: Health Management Network Commercial	$200.60
Rate for Payer: Humana Medicare	$73.16
Rate for Payer: Kaiser Permanente Commercial	$212.40
Rate for Payer: Kaiser Permanente Medicaid	$120.36
Rate for Payer: Kaiser Permanente Medicare	$73.16
Rate for Payer: MDX Hawaii PPO	$228.92
Rate for Payer: Ohana Health Plan Medicaid	$73.16
Rate for Payer: Ohana Health Plan Medicare	$73.16
Rate for Payer: UnitedHealthcare Medicare	$73.16
Rate for Payer: University Health Alliance Commercial	$172.02

SAFESHEATH II SS8 398343

Facility

$236.00

Service Code	HCPCS C1892
Hospital Revenue Code	272
Min. Negotiated Rate	$200.60
Max. Negotiated Rate	$228.92
Rate for Payer: Cash Price	$141.60
Rate for Payer: Health Management Network Commercial	$200.60
Rate for Payer: Kaiser Permanente Commercial	$212.40
Rate for Payer: MDX Hawaii PPO	$228.92

SAFETY PEG KIT 20FR

Facility

$586.00

Hospital Revenue Code	272
Min. Negotiated Rate	$181.66
Max. Negotiated Rate	$568.42
Rate for Payer: AlohaCare Medicaid	$293.00
Rate for Payer: AlohaCare Medicare	$181.66
Rate for Payer: Cash Price	$351.60
Rate for Payer: Devoted Health Medicare	$199.24
Rate for Payer: Hawaii Medical Service Association Medicare	$181.66
Rate for Payer: Hawaii Western Management Group Commercial	$556.70
Rate for Payer: Health Management Network Commercial	$498.10
Rate for Payer: Humana Medicare	$181.66
Rate for Payer: Kaiser Permanente Commercial	$527.40
Rate for Payer: Kaiser Permanente Medicaid	$298.86
Rate for Payer: Kaiser Permanente Medicare	$181.66
Rate for Payer: MDX Hawaii PPO	$568.42
Rate for Payer: Ohana Health Plan Medicaid	$181.66
Rate for Payer: Ohana Health Plan Medicare	$181.66
Rate for Payer: UnitedHealthcare Medicare	$181.66
Rate for Payer: University Health Alliance Commercial	$427.14

SAFETY PEG KIT 20FR

Facility

$586.00

Hospital Revenue Code	272
Min. Negotiated Rate	$498.10
Max. Negotiated Rate	$568.42
Rate for Payer: Cash Price	$351.60
Rate for Payer: Health Management Network Commercial	$498.10
Rate for Payer: Kaiser Permanente Commercial	$527.40
Rate for Payer: MDX Hawaii PPO	$568.42

SALINE BREAST SIZER SZHP68500

Facility

$175.00

Service Code	HCPCS C1789
Hospital Revenue Code	278
Min. Negotiated Rate	$54.25
Max. Negotiated Rate	$169.75
Rate for Payer: AlohaCare Medicaid	$87.50
Rate for Payer: AlohaCare Medicare	$54.25
Rate for Payer: Cash Price	$105.00
Rate for Payer: Devoted Health Medicare	$59.50
Rate for Payer: Hawaii Medical Service Association Medicare	$54.25
Rate for Payer: Hawaii Western Management Group Commercial	$122.50
Rate for Payer: Health Management Network Commercial	$148.75
Rate for Payer: Humana Medicare	$54.25
Rate for Payer: Kaiser Permanente Commercial	$157.50
Rate for Payer: Kaiser Permanente Medicaid	$89.25
Rate for Payer: Kaiser Permanente Medicare	$54.25
Rate for Payer: MDX Hawaii PPO	$169.75
Rate for Payer: Ohana Health Plan Medicaid	$54.25
Rate for Payer: Ohana Health Plan Medicare	$54.25
Rate for Payer: UnitedHealthcare Medicare	$54.25
Rate for Payer: University Health Alliance Commercial	$98.00

SALINE BREAST SIZER SZHP68500

Facility

$175.00

Service Code	HCPCS C1789
Hospital Revenue Code	278
Min. Negotiated Rate	$98.00
Max. Negotiated Rate	$169.75
Rate for Payer: Cash Price	$105.00
Rate for Payer: Hawaii Western Management Group Commercial	$122.50
Rate for Payer: Health Management Network Commercial	$148.75
Rate for Payer: Kaiser Permanente Commercial	$157.50
Rate for Payer: MDX Hawaii PPO	$169.75
Rate for Payer: University Health Alliance Commercial	$98.00

SALINE SIZER SZ10621-470HP

Facility

$175.00

Service Code	HCPCS C1789
Hospital Revenue Code	278
Min. Negotiated Rate	$54.25
Max. Negotiated Rate	$169.75
Rate for Payer: AlohaCare Medicaid	$87.50
Rate for Payer: AlohaCare Medicare	$54.25
Rate for Payer: Cash Price	$105.00
Rate for Payer: Devoted Health Medicare	$59.50
Rate for Payer: Hawaii Medical Service Association Medicare	$54.25
Rate for Payer: Hawaii Western Management Group Commercial	$122.50
Rate for Payer: Health Management Network Commercial	$148.75
Rate for Payer: Humana Medicare	$54.25
Rate for Payer: Kaiser Permanente Commercial	$157.50
Rate for Payer: Kaiser Permanente Medicaid	$89.25
Rate for Payer: Kaiser Permanente Medicare	$54.25
Rate for Payer: MDX Hawaii PPO	$169.75
Rate for Payer: Ohana Health Plan Medicaid	$54.25
Rate for Payer: Ohana Health Plan Medicare	$54.25
Rate for Payer: UnitedHealthcare Medicare	$54.25
Rate for Payer: University Health Alliance Commercial	$98.00

SALINE SIZER SZ10621-470HP

Facility

$175.00

Service Code	HCPCS C1789
Hospital Revenue Code	278
Min. Negotiated Rate	$98.00
Max. Negotiated Rate	$169.75
Rate for Payer: Cash Price	$105.00
Rate for Payer: Hawaii Western Management Group Commercial	$122.50
Rate for Payer: Health Management Network Commercial	$148.75
Rate for Payer: Kaiser Permanente Commercial	$157.50
Rate for Payer: MDX Hawaii PPO	$169.75
Rate for Payer: University Health Alliance Commercial	$98.00

SALIVARY GLAND PROCEDURES

Facility

$21,758.44

Service Code	MSDRG 139
Min. Negotiated Rate	$21,758.44
Max. Negotiated Rate	$21,758.44
Rate for Payer: Hawaii Medical Service Association Commercial	$21,758.44

SAW BLADE 13MM 6113-127-100

Facility

$253.00

Hospital Revenue Code	272
Min. Negotiated Rate	$215.05
Max. Negotiated Rate	$245.41
Rate for Payer: Cash Price	$151.80
Rate for Payer: Health Management Network Commercial	$215.05
Rate for Payer: Kaiser Permanente Commercial	$227.70
Rate for Payer: MDX Hawaii PPO	$245.41

SAW BLADE 13MM 6113-127-100

Facility

$253.00

Hospital Revenue Code	272
Min. Negotiated Rate	$78.43
Max. Negotiated Rate	$245.41
Rate for Payer: AlohaCare Medicaid	$126.50
Rate for Payer: AlohaCare Medicare	$78.43
Rate for Payer: Cash Price	$151.80
Rate for Payer: Devoted Health Medicare	$86.02
Rate for Payer: Hawaii Medical Service Association Medicare	$78.43
Rate for Payer: Hawaii Western Management Group Commercial	$240.35
Rate for Payer: Health Management Network Commercial	$215.05
Rate for Payer: Humana Medicare	$78.43
Rate for Payer: Kaiser Permanente Commercial	$227.70
Rate for Payer: Kaiser Permanente Medicaid	$129.03
Rate for Payer: Kaiser Permanente Medicare	$78.43
Rate for Payer: MDX Hawaii PPO	$245.41
Rate for Payer: Ohana Health Plan Medicaid	$78.43
Rate for Payer: Ohana Health Plan Medicare	$78.43
Rate for Payer: UnitedHealthcare Medicare	$78.43
Rate for Payer: University Health Alliance Commercial	$184.41

SAWBLADE OXFORD #506269

Facility

$2,550.00

Hospital Revenue Code	272
Min. Negotiated Rate	$2,167.50
Max. Negotiated Rate	$2,473.50
Rate for Payer: Cash Price	$1,530.00
Rate for Payer: Health Management Network Commercial	$2,167.50
Rate for Payer: Kaiser Permanente Commercial	$2,295.00
Rate for Payer: MDX Hawaii PPO	$2,473.50

SAWBLADE OXFORD #506269

Facility

$2,550.00

Hospital Revenue Code	272
Min. Negotiated Rate	$790.50
Max. Negotiated Rate	$2,473.50
Rate for Payer: AlohaCare Medicaid	$1,275.00
Rate for Payer: AlohaCare Medicare	$790.50
Rate for Payer: Cash Price	$1,530.00
Rate for Payer: Devoted Health Medicare	$867.00
Rate for Payer: Hawaii Medical Service Association Medicare	$790.50
Rate for Payer: Hawaii Western Management Group Commercial	$2,422.50
Rate for Payer: Health Management Network Commercial	$2,167.50
Rate for Payer: Humana Medicare	$790.50
Rate for Payer: Kaiser Permanente Commercial	$2,295.00
Rate for Payer: Kaiser Permanente Medicaid	$1,300.50
Rate for Payer: Kaiser Permanente Medicare	$790.50
Rate for Payer: MDX Hawaii PPO	$2,473.50
Rate for Payer: Ohana Health Plan Medicaid	$790.50
Rate for Payer: Ohana Health Plan Medicare	$790.50
Rate for Payer: UnitedHealthcare Medicare	$790.50
Rate for Payer: University Health Alliance Commercial	$1,858.69

SCALPEL TISSUE HARMONIC HAR9F

Facility

$1,103.00

Hospital Revenue Code	272
Min. Negotiated Rate	$341.93
Max. Negotiated Rate	$1,069.91
Rate for Payer: AlohaCare Medicaid	$551.50
Rate for Payer: AlohaCare Medicare	$341.93
Rate for Payer: Cash Price	$661.80
Rate for Payer: Devoted Health Medicare	$375.02
Rate for Payer: Hawaii Medical Service Association Medicare	$341.93
Rate for Payer: Hawaii Western Management Group Commercial	$1,047.85
Rate for Payer: Health Management Network Commercial	$937.55
Rate for Payer: Humana Medicare	$341.93
Rate for Payer: Kaiser Permanente Commercial	$992.70
Rate for Payer: Kaiser Permanente Medicaid	$562.53
Rate for Payer: Kaiser Permanente Medicare	$341.93
Rate for Payer: MDX Hawaii PPO	$1,069.91
Rate for Payer: Ohana Health Plan Medicaid	$341.93
Rate for Payer: Ohana Health Plan Medicare	$341.93
Rate for Payer: UnitedHealthcare Medicare	$341.93
Rate for Payer: University Health Alliance Commercial	$803.98

SCALPEL TISSUE HARMONIC HAR9F

Facility

$1,103.00

Hospital Revenue Code	272
Min. Negotiated Rate	$937.55
Max. Negotiated Rate	$1,069.91
Rate for Payer: Cash Price	$661.80
Rate for Payer: Health Management Network Commercial	$937.55
Rate for Payer: Kaiser Permanente Commercial	$992.70
Rate for Payer: MDX Hawaii PPO	$1,069.91

SCANLAN INSRT GRN SM 9009-18

Facility

$257.00

Service Code	HCPCS C1894
Hospital Revenue Code	272
Min. Negotiated Rate	$218.45
Max. Negotiated Rate	$249.29
Rate for Payer: Cash Price	$154.20
Rate for Payer: Health Management Network Commercial	$218.45
Rate for Payer: Kaiser Permanente Commercial	$231.30
Rate for Payer: MDX Hawaii PPO	$249.29

SCANLAN INSRT GRN SM 9009-18

Facility

$257.00

Service Code	HCPCS C1894
Hospital Revenue Code	272
Min. Negotiated Rate	$79.67
Max. Negotiated Rate	$249.29
Rate for Payer: AlohaCare Medicaid	$128.50
Rate for Payer: AlohaCare Medicare	$79.67
Rate for Payer: Cash Price	$154.20
Rate for Payer: Devoted Health Medicare	$87.38
Rate for Payer: Hawaii Medical Service Association Medicare	$79.67
Rate for Payer: Hawaii Western Management Group Commercial	$244.15
Rate for Payer: Health Management Network Commercial	$218.45
Rate for Payer: Humana Medicare	$79.67
Rate for Payer: Kaiser Permanente Commercial	$231.30
Rate for Payer: Kaiser Permanente Medicaid	$131.07
Rate for Payer: Kaiser Permanente Medicare	$79.67
Rate for Payer: MDX Hawaii PPO	$249.29
Rate for Payer: Ohana Health Plan Medicaid	$79.67
Rate for Payer: Ohana Health Plan Medicare	$79.67
Rate for Payer: UnitedHealthcare Medicare	$79.67
Rate for Payer: University Health Alliance Commercial	$187.33

SCANLAN INSRT YEL SM 9009-23

Facility

$218.00

Service Code	HCPCS C1894
Hospital Revenue Code	272
Min. Negotiated Rate	$185.30
Max. Negotiated Rate	$211.46
Rate for Payer: Cash Price	$130.80
Rate for Payer: Health Management Network Commercial	$185.30
Rate for Payer: Kaiser Permanente Commercial	$196.20
Rate for Payer: MDX Hawaii PPO	$211.46

SCANLAN INSRT YEL SM 9009-23

Facility

$218.00

Service Code	HCPCS C1894
Hospital Revenue Code	272
Min. Negotiated Rate	$67.58
Max. Negotiated Rate	$211.46
Rate for Payer: AlohaCare Medicaid	$109.00
Rate for Payer: AlohaCare Medicare	$67.58
Rate for Payer: Cash Price	$130.80
Rate for Payer: Devoted Health Medicare	$74.12
Rate for Payer: Hawaii Medical Service Association Medicare	$67.58
Rate for Payer: Hawaii Western Management Group Commercial	$207.10
Rate for Payer: Health Management Network Commercial	$185.30
Rate for Payer: Humana Medicare	$67.58
Rate for Payer: Kaiser Permanente Commercial	$196.20
Rate for Payer: Kaiser Permanente Medicaid	$111.18
Rate for Payer: Kaiser Permanente Medicare	$67.58
Rate for Payer: MDX Hawaii PPO	$211.46
Rate for Payer: Ohana Health Plan Medicaid	$67.58
Rate for Payer: Ohana Health Plan Medicare	$67.58
Rate for Payer: UnitedHealthcare Medicare	$67.58
Rate for Payer: University Health Alliance Commercial	$158.90

SCARF GUIDE ACCUCUT 19511

Facility

$469.00

Hospital Revenue Code	272
Min. Negotiated Rate	$398.65
Max. Negotiated Rate	$454.93
Rate for Payer: Cash Price	$281.40
Rate for Payer: Health Management Network Commercial	$398.65
Rate for Payer: Kaiser Permanente Commercial	$422.10
Rate for Payer: MDX Hawaii PPO	$454.93

SCARF GUIDE ACCUCUT 19511

Facility

$469.00

Hospital Revenue Code	272
Min. Negotiated Rate	$145.39
Max. Negotiated Rate	$454.93
Rate for Payer: AlohaCare Medicaid	$234.50
Rate for Payer: AlohaCare Medicare	$145.39
Rate for Payer: Cash Price	$281.40
Rate for Payer: Devoted Health Medicare	$159.46
Rate for Payer: Hawaii Medical Service Association Medicare	$145.39
Rate for Payer: Hawaii Western Management Group Commercial	$445.55
Rate for Payer: Health Management Network Commercial	$398.65
Rate for Payer: Humana Medicare	$145.39
Rate for Payer: Kaiser Permanente Commercial	$422.10
Rate for Payer: Kaiser Permanente Medicaid	$239.19
Rate for Payer: Kaiser Permanente Medicare	$145.39
Rate for Payer: MDX Hawaii PPO	$454.93
Rate for Payer: Ohana Health Plan Medicaid	$145.39
Rate for Payer: Ohana Health Plan Medicare	$145.39
Rate for Payer: UnitedHealthcare Medicare	$145.39
Rate for Payer: University Health Alliance Commercial	$341.85

Know your out-of-pocket cost for care.

All Charges