Kau Hospital

All Charges

Charge

Type

Setting

Price

SERTRALINE 25 MG TABLET [19882]

Facility

$2.00

Service Code	NDC 60687023111
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

SERTRALINE 25 MG TABLET [19882]

Facility

$2.00

Service Code	NDC 60687023111
Hospital Revenue Code	637
Min. Negotiated Rate	$0.62
Max. Negotiated Rate	$1.94
Rate for Payer: AlohaCare Medicaid	$1.00
Rate for Payer: AlohaCare Medicare	$0.62
Rate for Payer: Cash Price	$1.20
Rate for Payer: Devoted Health Medicare	$0.68
Rate for Payer: Hawaii Medical Service Association Medicare	$0.62
Rate for Payer: Hawaii Western Management Group Commercial	$1.90
Rate for Payer: Health Management Network Commercial	$1.70
Rate for Payer: Humana Medicare	$0.62
Rate for Payer: Kaiser Permanente Commercial	$1.80
Rate for Payer: Kaiser Permanente Medicaid	$1.02
Rate for Payer: Kaiser Permanente Medicare	$0.62
Rate for Payer: MDX Hawaii PPO	$1.94
Rate for Payer: Ohana Health Plan Medicaid	$0.62
Rate for Payer: Ohana Health Plan Medicare	$0.62
Rate for Payer: UnitedHealthcare Medicare	$0.62
Rate for Payer: University Health Alliance Commercial	$1.46

SERTRALINE 25 MG TABLET [19882]

Facility

$2.00

Service Code	NDC 60687023101
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

SERTRALINE 50 MG TABLET [11351]

Facility

$2.00

Service Code	NDC 60687024201
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

SERTRALINE 50 MG TABLET [11351]

Facility

$2.00

Service Code	NDC 60687024211
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

SERTRALINE 50 MG TABLET [11351]

Facility

$2.00

Service Code	NDC 60687024201
Hospital Revenue Code	637
Min. Negotiated Rate	$0.62
Max. Negotiated Rate	$1.94
Rate for Payer: AlohaCare Medicaid	$1.00
Rate for Payer: AlohaCare Medicare	$0.62
Rate for Payer: Cash Price	$1.20
Rate for Payer: Devoted Health Medicare	$0.68
Rate for Payer: Hawaii Medical Service Association Medicare	$0.62
Rate for Payer: Hawaii Western Management Group Commercial	$1.90
Rate for Payer: Health Management Network Commercial	$1.70
Rate for Payer: Humana Medicare	$0.62
Rate for Payer: Kaiser Permanente Commercial	$1.80
Rate for Payer: Kaiser Permanente Medicaid	$1.02
Rate for Payer: Kaiser Permanente Medicare	$0.62
Rate for Payer: MDX Hawaii PPO	$1.94
Rate for Payer: Ohana Health Plan Medicaid	$0.62
Rate for Payer: Ohana Health Plan Medicare	$0.62
Rate for Payer: UnitedHealthcare Medicare	$0.62
Rate for Payer: University Health Alliance Commercial	$1.46

SERTRALINE 50 MG TABLET [11351]

Facility

$2.00

Service Code	NDC 60687024211
Hospital Revenue Code	637
Min. Negotiated Rate	$0.62
Max. Negotiated Rate	$1.94
Rate for Payer: AlohaCare Medicaid	$1.00
Rate for Payer: AlohaCare Medicare	$0.62
Rate for Payer: Cash Price	$1.20
Rate for Payer: Devoted Health Medicare	$0.68
Rate for Payer: Hawaii Medical Service Association Medicare	$0.62
Rate for Payer: Hawaii Western Management Group Commercial	$1.90
Rate for Payer: Health Management Network Commercial	$1.70
Rate for Payer: Humana Medicare	$0.62
Rate for Payer: Kaiser Permanente Commercial	$1.80
Rate for Payer: Kaiser Permanente Medicaid	$1.02
Rate for Payer: Kaiser Permanente Medicare	$0.62
Rate for Payer: MDX Hawaii PPO	$1.94
Rate for Payer: Ohana Health Plan Medicaid	$0.62
Rate for Payer: Ohana Health Plan Medicare	$0.62
Rate for Payer: UnitedHealthcare Medicare	$0.62
Rate for Payer: University Health Alliance Commercial	$1.46

SET BANDER URETHERAL 6X75

Facility

$389.00

Service Code	HCPCS C2625
Hospital Revenue Code	278
Min. Negotiated Rate	$120.59
Max. Negotiated Rate	$377.33
Rate for Payer: AlohaCare Medicaid	$194.50
Rate for Payer: AlohaCare Medicare	$120.59
Rate for Payer: Cash Price	$233.40
Rate for Payer: Devoted Health Medicare	$132.26
Rate for Payer: Hawaii Medical Service Association Medicare	$120.59
Rate for Payer: Hawaii Western Management Group Commercial	$272.30
Rate for Payer: Health Management Network Commercial	$330.65
Rate for Payer: Humana Medicare	$120.59
Rate for Payer: Kaiser Permanente Commercial	$350.10
Rate for Payer: Kaiser Permanente Medicaid	$198.39
Rate for Payer: Kaiser Permanente Medicare	$120.59
Rate for Payer: MDX Hawaii PPO	$377.33
Rate for Payer: Ohana Health Plan Medicaid	$120.59
Rate for Payer: Ohana Health Plan Medicare	$120.59
Rate for Payer: UnitedHealthcare Medicare	$120.59
Rate for Payer: University Health Alliance Commercial	$217.84

SET BANDER URETHERAL 6X75

Facility

$389.00

Service Code	HCPCS C2625
Hospital Revenue Code	278
Min. Negotiated Rate	$217.84
Max. Negotiated Rate	$377.33
Rate for Payer: Cash Price	$233.40
Rate for Payer: Hawaii Western Management Group Commercial	$272.30
Rate for Payer: Health Management Network Commercial	$330.65
Rate for Payer: Kaiser Permanente Commercial	$350.10
Rate for Payer: MDX Hawaii PPO	$377.33
Rate for Payer: University Health Alliance Commercial	$217.84

SET BLADDER EVACUATOR

Facility

$116.00

Hospital Revenue Code	272
Min. Negotiated Rate	$98.60
Max. Negotiated Rate	$112.52
Rate for Payer: Cash Price	$69.60
Rate for Payer: Health Management Network Commercial	$98.60
Rate for Payer: Kaiser Permanente Commercial	$104.40
Rate for Payer: MDX Hawaii PPO	$112.52

SET BLADDER EVACUATOR

Facility

$116.00

Hospital Revenue Code	272
Min. Negotiated Rate	$35.96
Max. Negotiated Rate	$112.52
Rate for Payer: AlohaCare Medicaid	$58.00
Rate for Payer: AlohaCare Medicare	$35.96
Rate for Payer: Cash Price	$69.60
Rate for Payer: Devoted Health Medicare	$39.44
Rate for Payer: Hawaii Medical Service Association Medicare	$35.96
Rate for Payer: Hawaii Western Management Group Commercial	$110.20
Rate for Payer: Health Management Network Commercial	$98.60
Rate for Payer: Humana Medicare	$35.96
Rate for Payer: Kaiser Permanente Commercial	$104.40
Rate for Payer: Kaiser Permanente Medicaid	$59.16
Rate for Payer: Kaiser Permanente Medicare	$35.96
Rate for Payer: MDX Hawaii PPO	$112.52
Rate for Payer: Ohana Health Plan Medicaid	$35.96
Rate for Payer: Ohana Health Plan Medicare	$35.96
Rate for Payer: UnitedHealthcare Medicare	$35.96
Rate for Payer: University Health Alliance Commercial	$84.55

SET COMMON DUCT EXPLORATION

Facility

$2,020.00

Service Code	HCPCS C1726
Hospital Revenue Code	272
Min. Negotiated Rate	$1,717.00
Max. Negotiated Rate	$1,959.40
Rate for Payer: Cash Price	$1,212.00
Rate for Payer: Health Management Network Commercial	$1,717.00
Rate for Payer: Kaiser Permanente Commercial	$1,818.00
Rate for Payer: MDX Hawaii PPO	$1,959.40

SET COMMON DUCT EXPLORATION

Facility

$2,020.00

Service Code	HCPCS C1726
Hospital Revenue Code	272
Min. Negotiated Rate	$626.20
Max. Negotiated Rate	$1,959.40
Rate for Payer: AlohaCare Medicaid	$1,010.00
Rate for Payer: AlohaCare Medicare	$626.20
Rate for Payer: Cash Price	$1,212.00
Rate for Payer: Devoted Health Medicare	$686.80
Rate for Payer: Hawaii Medical Service Association Medicare	$626.20
Rate for Payer: Hawaii Western Management Group Commercial	$1,919.00
Rate for Payer: Health Management Network Commercial	$1,717.00
Rate for Payer: Humana Medicare	$626.20
Rate for Payer: Kaiser Permanente Commercial	$1,818.00
Rate for Payer: Kaiser Permanente Medicaid	$1,030.20
Rate for Payer: Kaiser Permanente Medicare	$626.20
Rate for Payer: MDX Hawaii PPO	$1,959.40
Rate for Payer: Ohana Health Plan Medicaid	$626.20
Rate for Payer: Ohana Health Plan Medicare	$626.20
Rate for Payer: UnitedHealthcare Medicare	$626.20
Rate for Payer: University Health Alliance Commercial	$1,472.38

SET CRYOTHERAPY

Facility

$4,343.00

Service Code	HCPCS C2618
Hospital Revenue Code	272
Min. Negotiated Rate	$3,691.55
Max. Negotiated Rate	$4,212.71
Rate for Payer: Cash Price	$2,605.80
Rate for Payer: Health Management Network Commercial	$3,691.55
Rate for Payer: Kaiser Permanente Commercial	$3,908.70
Rate for Payer: MDX Hawaii PPO	$4,212.71

SET CRYOTHERAPY

Facility

$4,343.00

Service Code	HCPCS C2618
Hospital Revenue Code	272
Min. Negotiated Rate	$1,346.33
Max. Negotiated Rate	$4,212.71
Rate for Payer: AlohaCare Medicaid	$2,171.50
Rate for Payer: AlohaCare Medicare	$1,346.33
Rate for Payer: Cash Price	$2,605.80
Rate for Payer: Devoted Health Medicare	$1,476.62
Rate for Payer: Hawaii Medical Service Association Medicare	$1,346.33
Rate for Payer: Hawaii Western Management Group Commercial	$4,125.85
Rate for Payer: Health Management Network Commercial	$3,691.55
Rate for Payer: Humana Medicare	$1,346.33
Rate for Payer: Kaiser Permanente Commercial	$3,908.70
Rate for Payer: Kaiser Permanente Medicaid	$2,214.93
Rate for Payer: Kaiser Permanente Medicare	$1,346.33
Rate for Payer: MDX Hawaii PPO	$4,212.71
Rate for Payer: Ohana Health Plan Medicaid	$1,346.33
Rate for Payer: Ohana Health Plan Medicare	$1,346.33
Rate for Payer: UnitedHealthcare Medicare	$1,346.33
Rate for Payer: University Health Alliance Commercial	$3,165.61

SET IRRIG SIMPULSE SYSTEM

Facility

$210.00

Hospital Revenue Code	272
Min. Negotiated Rate	$65.10
Max. Negotiated Rate	$203.70
Rate for Payer: AlohaCare Medicaid	$105.00
Rate for Payer: AlohaCare Medicare	$65.10
Rate for Payer: Cash Price	$126.00
Rate for Payer: Devoted Health Medicare	$71.40
Rate for Payer: Hawaii Medical Service Association Medicare	$65.10
Rate for Payer: Hawaii Western Management Group Commercial	$199.50
Rate for Payer: Health Management Network Commercial	$178.50
Rate for Payer: Humana Medicare	$65.10
Rate for Payer: Kaiser Permanente Commercial	$189.00
Rate for Payer: Kaiser Permanente Medicaid	$107.10
Rate for Payer: Kaiser Permanente Medicare	$65.10
Rate for Payer: MDX Hawaii PPO	$203.70
Rate for Payer: Ohana Health Plan Medicaid	$65.10
Rate for Payer: Ohana Health Plan Medicare	$65.10
Rate for Payer: UnitedHealthcare Medicare	$65.10
Rate for Payer: University Health Alliance Commercial	$153.07

SET IRRIG SIMPULSE SYSTEM

Facility

$210.00

Hospital Revenue Code	272
Min. Negotiated Rate	$178.50
Max. Negotiated Rate	$203.70
Rate for Payer: Cash Price	$126.00
Rate for Payer: Health Management Network Commercial	$178.50
Rate for Payer: Kaiser Permanente Commercial	$189.00
Rate for Payer: MDX Hawaii PPO	$203.70

SET MINI CAP PD

Facility

$278.00

Hospital Revenue Code	272
Min. Negotiated Rate	$86.18
Max. Negotiated Rate	$269.66
Rate for Payer: AlohaCare Medicaid	$139.00
Rate for Payer: AlohaCare Medicare	$86.18
Rate for Payer: Cash Price	$166.80
Rate for Payer: Devoted Health Medicare	$94.52
Rate for Payer: Hawaii Medical Service Association Medicare	$86.18
Rate for Payer: Hawaii Western Management Group Commercial	$264.10
Rate for Payer: Health Management Network Commercial	$236.30
Rate for Payer: Humana Medicare	$86.18
Rate for Payer: Kaiser Permanente Commercial	$250.20
Rate for Payer: Kaiser Permanente Medicaid	$141.78
Rate for Payer: Kaiser Permanente Medicare	$86.18
Rate for Payer: MDX Hawaii PPO	$269.66
Rate for Payer: Ohana Health Plan Medicaid	$86.18
Rate for Payer: Ohana Health Plan Medicare	$86.18
Rate for Payer: UnitedHealthcare Medicare	$86.18
Rate for Payer: University Health Alliance Commercial	$202.63

SET MINI CAP PD

Facility

$278.00

Hospital Revenue Code	272
Min. Negotiated Rate	$236.30
Max. Negotiated Rate	$269.66
Rate for Payer: Cash Price	$166.80
Rate for Payer: Health Management Network Commercial	$236.30
Rate for Payer: Kaiser Permanente Commercial	$250.20
Rate for Payer: MDX Hawaii PPO	$269.66

SET NIGHT DRAINAGE CONTAINER

Facility

$143.00

Hospital Revenue Code	274
Min. Negotiated Rate	$80.08
Max. Negotiated Rate	$138.71
Rate for Payer: Cash Price	$85.80
Rate for Payer: Hawaii Western Management Group Commercial	$100.10
Rate for Payer: Health Management Network Commercial	$121.55
Rate for Payer: Kaiser Permanente Commercial	$128.70
Rate for Payer: MDX Hawaii PPO	$138.71
Rate for Payer: University Health Alliance Commercial	$80.08

SET NIGHT DRAINAGE CONTAINER

Facility

$143.00

Hospital Revenue Code	274
Min. Negotiated Rate	$44.33
Max. Negotiated Rate	$138.71
Rate for Payer: AlohaCare Medicaid	$71.50
Rate for Payer: AlohaCare Medicare	$44.33
Rate for Payer: Cash Price	$85.80
Rate for Payer: Devoted Health Medicare	$48.62
Rate for Payer: Hawaii Medical Service Association Medicare	$44.33
Rate for Payer: Hawaii Western Management Group Commercial	$100.10
Rate for Payer: Health Management Network Commercial	$121.55
Rate for Payer: Humana Medicare	$44.33
Rate for Payer: Kaiser Permanente Commercial	$128.70
Rate for Payer: Kaiser Permanente Medicaid	$72.93
Rate for Payer: Kaiser Permanente Medicare	$44.33
Rate for Payer: MDX Hawaii PPO	$138.71
Rate for Payer: Ohana Health Plan Medicaid	$44.33
Rate for Payer: Ohana Health Plan Medicare	$44.33
Rate for Payer: UnitedHealthcare Medicare	$44.33
Rate for Payer: University Health Alliance Commercial	$80.08

SET TUBE DECLOG

Facility

$248.00

Service Code	HCPCS C1889
Hospital Revenue Code	272
Min. Negotiated Rate	$76.88
Max. Negotiated Rate	$240.56
Rate for Payer: AlohaCare Medicaid	$124.00
Rate for Payer: AlohaCare Medicare	$76.88
Rate for Payer: Cash Price	$148.80
Rate for Payer: Devoted Health Medicare	$84.32
Rate for Payer: Hawaii Medical Service Association Medicare	$76.88
Rate for Payer: Hawaii Western Management Group Commercial	$235.60
Rate for Payer: Health Management Network Commercial	$210.80
Rate for Payer: Humana Medicare	$76.88
Rate for Payer: Kaiser Permanente Commercial	$223.20
Rate for Payer: Kaiser Permanente Medicaid	$126.48
Rate for Payer: Kaiser Permanente Medicare	$76.88
Rate for Payer: MDX Hawaii PPO	$240.56
Rate for Payer: Ohana Health Plan Medicaid	$76.88
Rate for Payer: Ohana Health Plan Medicare	$76.88
Rate for Payer: UnitedHealthcare Medicare	$76.88
Rate for Payer: University Health Alliance Commercial	$180.77

SET TUBE DECLOG

Facility

$248.00

Service Code	HCPCS C1889
Hospital Revenue Code	272
Min. Negotiated Rate	$210.80
Max. Negotiated Rate	$240.56
Rate for Payer: Cash Price	$148.80
Rate for Payer: Health Management Network Commercial	$210.80
Rate for Payer: Kaiser Permanente Commercial	$223.20
Rate for Payer: MDX Hawaii PPO	$240.56

SET WOUND IRRIGATION

Facility

$87.00

Hospital Revenue Code	272
Min. Negotiated Rate	$26.97
Max. Negotiated Rate	$84.39
Rate for Payer: AlohaCare Medicaid	$43.50
Rate for Payer: AlohaCare Medicare	$26.97
Rate for Payer: Cash Price	$52.20
Rate for Payer: Devoted Health Medicare	$29.58
Rate for Payer: Hawaii Medical Service Association Medicare	$26.97
Rate for Payer: Hawaii Western Management Group Commercial	$82.65
Rate for Payer: Health Management Network Commercial	$73.95
Rate for Payer: Humana Medicare	$26.97
Rate for Payer: Kaiser Permanente Commercial	$78.30
Rate for Payer: Kaiser Permanente Medicaid	$44.37
Rate for Payer: Kaiser Permanente Medicare	$26.97
Rate for Payer: MDX Hawaii PPO	$84.39
Rate for Payer: Ohana Health Plan Medicaid	$26.97
Rate for Payer: Ohana Health Plan Medicare	$26.97
Rate for Payer: UnitedHealthcare Medicare	$26.97
Rate for Payer: University Health Alliance Commercial	$63.41

SET WOUND IRRIGATION

Facility

$87.00

Hospital Revenue Code	272
Min. Negotiated Rate	$73.95
Max. Negotiated Rate	$84.39
Rate for Payer: Cash Price	$52.20
Rate for Payer: Health Management Network Commercial	$73.95
Rate for Payer: Kaiser Permanente Commercial	$78.30
Rate for Payer: MDX Hawaii PPO	$84.39

Know your out-of-pocket cost for care.

All Charges