Kau Hospital

All Charges

Charge

Type

Setting

Price

SHEATH DRYSEAL 22X33CM DSF2233

Facility

$2,200.00

Service Code	HCPCS C1894
Hospital Revenue Code	272
Min. Negotiated Rate	$682.00
Max. Negotiated Rate	$2,134.00
Rate for Payer: AlohaCare Medicaid	$1,100.00
Rate for Payer: AlohaCare Medicare	$682.00
Rate for Payer: Cash Price	$1,320.00
Rate for Payer: Devoted Health Medicare	$748.00
Rate for Payer: Hawaii Medical Service Association Medicare	$682.00
Rate for Payer: Hawaii Western Management Group Commercial	$2,090.00
Rate for Payer: Health Management Network Commercial	$1,870.00
Rate for Payer: Humana Medicare	$682.00
Rate for Payer: Kaiser Permanente Commercial	$1,980.00
Rate for Payer: Kaiser Permanente Medicaid	$1,122.00
Rate for Payer: Kaiser Permanente Medicare	$682.00
Rate for Payer: MDX Hawaii PPO	$2,134.00
Rate for Payer: Ohana Health Plan Medicaid	$682.00
Rate for Payer: Ohana Health Plan Medicare	$682.00
Rate for Payer: UnitedHealthcare Medicare	$682.00
Rate for Payer: University Health Alliance Commercial	$1,603.58

SHEATH DRYSEAL 24X33CM DSF2433

Facility

$2,200.00

Service Code	HCPCS C1894
Hospital Revenue Code	272
Min. Negotiated Rate	$682.00
Max. Negotiated Rate	$2,134.00
Rate for Payer: AlohaCare Medicaid	$1,100.00
Rate for Payer: AlohaCare Medicare	$682.00
Rate for Payer: Cash Price	$1,320.00
Rate for Payer: Devoted Health Medicare	$748.00
Rate for Payer: Hawaii Medical Service Association Medicare	$682.00
Rate for Payer: Hawaii Western Management Group Commercial	$2,090.00
Rate for Payer: Health Management Network Commercial	$1,870.00
Rate for Payer: Humana Medicare	$682.00
Rate for Payer: Kaiser Permanente Commercial	$1,980.00
Rate for Payer: Kaiser Permanente Medicaid	$1,122.00
Rate for Payer: Kaiser Permanente Medicare	$682.00
Rate for Payer: MDX Hawaii PPO	$2,134.00
Rate for Payer: Ohana Health Plan Medicaid	$682.00
Rate for Payer: Ohana Health Plan Medicare	$682.00
Rate for Payer: UnitedHealthcare Medicare	$682.00
Rate for Payer: University Health Alliance Commercial	$1,603.58

SHEATH DRYSEAL 24X33CM DSF2433

Facility

$2,200.00

Service Code	HCPCS C1894
Hospital Revenue Code	272
Min. Negotiated Rate	$1,870.00
Max. Negotiated Rate	$2,134.00
Rate for Payer: Cash Price	$1,320.00
Rate for Payer: Health Management Network Commercial	$1,870.00
Rate for Payer: Kaiser Permanente Commercial	$1,980.00
Rate for Payer: MDX Hawaii PPO	$2,134.00

SHEATH D/S 12FRX28CM DSL1228

Facility

$963.00

Service Code	HCPCS C1894
Hospital Revenue Code	272
Min. Negotiated Rate	$298.53
Max. Negotiated Rate	$934.11
Rate for Payer: AlohaCare Medicaid	$481.50
Rate for Payer: AlohaCare Medicare	$298.53
Rate for Payer: Cash Price	$577.80
Rate for Payer: Devoted Health Medicare	$327.42
Rate for Payer: Hawaii Medical Service Association Medicare	$298.53
Rate for Payer: Hawaii Western Management Group Commercial	$914.85
Rate for Payer: Health Management Network Commercial	$818.55
Rate for Payer: Humana Medicare	$298.53
Rate for Payer: Kaiser Permanente Commercial	$866.70
Rate for Payer: Kaiser Permanente Medicaid	$491.13
Rate for Payer: Kaiser Permanente Medicare	$298.53
Rate for Payer: MDX Hawaii PPO	$934.11
Rate for Payer: Ohana Health Plan Medicaid	$298.53
Rate for Payer: Ohana Health Plan Medicare	$298.53
Rate for Payer: UnitedHealthcare Medicare	$298.53
Rate for Payer: University Health Alliance Commercial	$701.93

SHEATH D/S 12FRX28CM DSL1228

Facility

$963.00

Service Code	HCPCS C1894
Hospital Revenue Code	272
Min. Negotiated Rate	$818.55
Max. Negotiated Rate	$934.11
Rate for Payer: Cash Price	$577.80
Rate for Payer: Health Management Network Commercial	$818.55
Rate for Payer: Kaiser Permanente Commercial	$866.70
Rate for Payer: MDX Hawaii PPO	$934.11

SHEATH D/S 16FRX28CM DSL1628

Facility

$963.00

Service Code	HCPCS C1894
Hospital Revenue Code	272
Min. Negotiated Rate	$298.53
Max. Negotiated Rate	$934.11
Rate for Payer: AlohaCare Medicaid	$481.50
Rate for Payer: AlohaCare Medicare	$298.53
Rate for Payer: Cash Price	$577.80
Rate for Payer: Devoted Health Medicare	$327.42
Rate for Payer: Hawaii Medical Service Association Medicare	$298.53
Rate for Payer: Hawaii Western Management Group Commercial	$914.85
Rate for Payer: Health Management Network Commercial	$818.55
Rate for Payer: Humana Medicare	$298.53
Rate for Payer: Kaiser Permanente Commercial	$866.70
Rate for Payer: Kaiser Permanente Medicaid	$491.13
Rate for Payer: Kaiser Permanente Medicare	$298.53
Rate for Payer: MDX Hawaii PPO	$934.11
Rate for Payer: Ohana Health Plan Medicaid	$298.53
Rate for Payer: Ohana Health Plan Medicare	$298.53
Rate for Payer: UnitedHealthcare Medicare	$298.53
Rate for Payer: University Health Alliance Commercial	$701.93

SHEATH D/S 16FRX28CM DSL1628

Facility

$963.00

Service Code	HCPCS C1894
Hospital Revenue Code	272
Min. Negotiated Rate	$818.55
Max. Negotiated Rate	$934.11
Rate for Payer: Cash Price	$577.80
Rate for Payer: Health Management Network Commercial	$818.55
Rate for Payer: Kaiser Permanente Commercial	$866.70
Rate for Payer: MDX Hawaii PPO	$934.11

SHEATH LAPAROSCOPIC 5MM CTS02

Facility

$225.00

Hospital Revenue Code	272
Min. Negotiated Rate	$191.25
Max. Negotiated Rate	$218.25
Rate for Payer: Cash Price	$135.00
Rate for Payer: Health Management Network Commercial	$191.25
Rate for Payer: Kaiser Permanente Commercial	$202.50
Rate for Payer: MDX Hawaii PPO	$218.25

SHEATH LAPAROSCOPIC 5MM CTS02

Facility

$225.00

Hospital Revenue Code	272
Min. Negotiated Rate	$69.75
Max. Negotiated Rate	$218.25
Rate for Payer: AlohaCare Medicaid	$112.50
Rate for Payer: AlohaCare Medicare	$69.75
Rate for Payer: Cash Price	$135.00
Rate for Payer: Devoted Health Medicare	$76.50
Rate for Payer: Hawaii Medical Service Association Medicare	$69.75
Rate for Payer: Hawaii Western Management Group Commercial	$213.75
Rate for Payer: Health Management Network Commercial	$191.25
Rate for Payer: Humana Medicare	$69.75
Rate for Payer: Kaiser Permanente Commercial	$202.50
Rate for Payer: Kaiser Permanente Medicaid	$114.75
Rate for Payer: Kaiser Permanente Medicare	$69.75
Rate for Payer: MDX Hawaii PPO	$218.25
Rate for Payer: Ohana Health Plan Medicaid	$69.75
Rate for Payer: Ohana Health Plan Medicare	$69.75
Rate for Payer: UnitedHealthcare Medicare	$69.75
Rate for Payer: University Health Alliance Commercial	$164.00

SHEATH RENAL CLEAR

Facility

$229.00

Service Code	HCPCS C1894
Hospital Revenue Code	272
Min. Negotiated Rate	$194.65
Max. Negotiated Rate	$222.13
Rate for Payer: Cash Price	$137.40
Rate for Payer: Health Management Network Commercial	$194.65
Rate for Payer: Kaiser Permanente Commercial	$206.10
Rate for Payer: MDX Hawaii PPO	$222.13

SHEATH RENAL CLEAR

Facility

$229.00

Service Code	HCPCS C1894
Hospital Revenue Code	272
Min. Negotiated Rate	$70.99
Max. Negotiated Rate	$222.13
Rate for Payer: AlohaCare Medicaid	$114.50
Rate for Payer: AlohaCare Medicare	$70.99
Rate for Payer: Cash Price	$137.40
Rate for Payer: Devoted Health Medicare	$77.86
Rate for Payer: Hawaii Medical Service Association Medicare	$70.99
Rate for Payer: Hawaii Western Management Group Commercial	$217.55
Rate for Payer: Health Management Network Commercial	$194.65
Rate for Payer: Humana Medicare	$70.99
Rate for Payer: Kaiser Permanente Commercial	$206.10
Rate for Payer: Kaiser Permanente Medicaid	$116.79
Rate for Payer: Kaiser Permanente Medicare	$70.99
Rate for Payer: MDX Hawaii PPO	$222.13
Rate for Payer: Ohana Health Plan Medicaid	$70.99
Rate for Payer: Ohana Health Plan Medicare	$70.99
Rate for Payer: UnitedHealthcare Medicare	$70.99
Rate for Payer: University Health Alliance Commercial	$166.92

SHEATH SET NAVI URETH ACCESS

Facility

$424.00

Service Code	HCPCS C1894
Hospital Revenue Code	272
Min. Negotiated Rate	$131.44
Max. Negotiated Rate	$411.28
Rate for Payer: AlohaCare Medicaid	$212.00
Rate for Payer: AlohaCare Medicare	$131.44
Rate for Payer: Cash Price	$254.40
Rate for Payer: Devoted Health Medicare	$144.16
Rate for Payer: Hawaii Medical Service Association Medicare	$131.44
Rate for Payer: Hawaii Western Management Group Commercial	$402.80
Rate for Payer: Health Management Network Commercial	$360.40
Rate for Payer: Humana Medicare	$131.44
Rate for Payer: Kaiser Permanente Commercial	$381.60
Rate for Payer: Kaiser Permanente Medicaid	$216.24
Rate for Payer: Kaiser Permanente Medicare	$131.44
Rate for Payer: MDX Hawaii PPO	$411.28
Rate for Payer: Ohana Health Plan Medicaid	$131.44
Rate for Payer: Ohana Health Plan Medicare	$131.44
Rate for Payer: UnitedHealthcare Medicare	$131.44
Rate for Payer: University Health Alliance Commercial	$309.05

SHEATH SET NAVI URETH ACCESS

Facility

$424.00

Service Code	HCPCS C1894
Hospital Revenue Code	272
Min. Negotiated Rate	$360.40
Max. Negotiated Rate	$411.28
Rate for Payer: Cash Price	$254.40
Rate for Payer: Health Management Network Commercial	$360.40
Rate for Payer: Kaiser Permanente Commercial	$381.60
Rate for Payer: MDX Hawaii PPO	$411.28

SHEATH URETERAL ACCESS 12FRX35

Facility

$576.00

Service Code	HCPCS C1894
Hospital Revenue Code	272
Min. Negotiated Rate	$489.60
Max. Negotiated Rate	$558.72
Rate for Payer: Cash Price	$345.60
Rate for Payer: Health Management Network Commercial	$489.60
Rate for Payer: Kaiser Permanente Commercial	$518.40
Rate for Payer: MDX Hawaii PPO	$558.72

SHEATH URETERAL ACCESS 12FRX35

Facility

$576.00

Service Code	HCPCS C1894
Hospital Revenue Code	272
Min. Negotiated Rate	$178.56
Max. Negotiated Rate	$558.72
Rate for Payer: AlohaCare Medicaid	$288.00
Rate for Payer: AlohaCare Medicare	$178.56
Rate for Payer: Cash Price	$345.60
Rate for Payer: Devoted Health Medicare	$195.84
Rate for Payer: Hawaii Medical Service Association Medicare	$178.56
Rate for Payer: Hawaii Western Management Group Commercial	$547.20
Rate for Payer: Health Management Network Commercial	$489.60
Rate for Payer: Humana Medicare	$178.56
Rate for Payer: Kaiser Permanente Commercial	$518.40
Rate for Payer: Kaiser Permanente Medicaid	$293.76
Rate for Payer: Kaiser Permanente Medicare	$178.56
Rate for Payer: MDX Hawaii PPO	$558.72
Rate for Payer: Ohana Health Plan Medicaid	$178.56
Rate for Payer: Ohana Health Plan Medicare	$178.56
Rate for Payer: UnitedHealthcare Medicare	$178.56
Rate for Payer: University Health Alliance Commercial	$419.85

SHEATH URETERAL ACCESS 12FRX45

Facility

$576.00

Service Code	HCPCS C1894
Hospital Revenue Code	272
Min. Negotiated Rate	$489.60
Max. Negotiated Rate	$558.72
Rate for Payer: Cash Price	$345.60
Rate for Payer: Health Management Network Commercial	$489.60
Rate for Payer: Kaiser Permanente Commercial	$518.40
Rate for Payer: MDX Hawaii PPO	$558.72

SHEATH URETERAL ACCESS 12FRX45

Facility

$576.00

Service Code	HCPCS C1894
Hospital Revenue Code	272
Min. Negotiated Rate	$178.56
Max. Negotiated Rate	$558.72
Rate for Payer: AlohaCare Medicaid	$288.00
Rate for Payer: AlohaCare Medicare	$178.56
Rate for Payer: Cash Price	$345.60
Rate for Payer: Devoted Health Medicare	$195.84
Rate for Payer: Hawaii Medical Service Association Medicare	$178.56
Rate for Payer: Hawaii Western Management Group Commercial	$547.20
Rate for Payer: Health Management Network Commercial	$489.60
Rate for Payer: Humana Medicare	$178.56
Rate for Payer: Kaiser Permanente Commercial	$518.40
Rate for Payer: Kaiser Permanente Medicaid	$293.76
Rate for Payer: Kaiser Permanente Medicare	$178.56
Rate for Payer: MDX Hawaii PPO	$558.72
Rate for Payer: Ohana Health Plan Medicaid	$178.56
Rate for Payer: Ohana Health Plan Medicare	$178.56
Rate for Payer: UnitedHealthcare Medicare	$178.56
Rate for Payer: University Health Alliance Commercial	$419.85

SHEATH URETERAL ACCESS 14FRX35

Facility

$576.00

Service Code	HCPCS C1894
Hospital Revenue Code	272
Min. Negotiated Rate	$489.60
Max. Negotiated Rate	$558.72
Rate for Payer: Cash Price	$345.60
Rate for Payer: Health Management Network Commercial	$489.60
Rate for Payer: Kaiser Permanente Commercial	$518.40
Rate for Payer: MDX Hawaii PPO	$558.72

SHEATH URETERAL ACCESS 14FRX35

Facility

$576.00

Service Code	HCPCS C1894
Hospital Revenue Code	272
Min. Negotiated Rate	$178.56
Max. Negotiated Rate	$558.72
Rate for Payer: AlohaCare Medicaid	$288.00
Rate for Payer: AlohaCare Medicare	$178.56
Rate for Payer: Cash Price	$345.60
Rate for Payer: Devoted Health Medicare	$195.84
Rate for Payer: Hawaii Medical Service Association Medicare	$178.56
Rate for Payer: Hawaii Western Management Group Commercial	$547.20
Rate for Payer: Health Management Network Commercial	$489.60
Rate for Payer: Humana Medicare	$178.56
Rate for Payer: Kaiser Permanente Commercial	$518.40
Rate for Payer: Kaiser Permanente Medicaid	$293.76
Rate for Payer: Kaiser Permanente Medicare	$178.56
Rate for Payer: MDX Hawaii PPO	$558.72
Rate for Payer: Ohana Health Plan Medicaid	$178.56
Rate for Payer: Ohana Health Plan Medicare	$178.56
Rate for Payer: UnitedHealthcare Medicare	$178.56
Rate for Payer: University Health Alliance Commercial	$419.85

SHEATH URETERAL ACCESS 14FRX45

Facility

$576.00

Service Code	HCPCS C1894
Hospital Revenue Code	272
Min. Negotiated Rate	$489.60
Max. Negotiated Rate	$558.72
Rate for Payer: Cash Price	$345.60
Rate for Payer: Health Management Network Commercial	$489.60
Rate for Payer: Kaiser Permanente Commercial	$518.40
Rate for Payer: MDX Hawaii PPO	$558.72

SHEATH URETERAL ACCESS 14FRX45

Facility

$576.00

Service Code	HCPCS C1894
Hospital Revenue Code	272
Min. Negotiated Rate	$178.56
Max. Negotiated Rate	$558.72
Rate for Payer: AlohaCare Medicaid	$288.00
Rate for Payer: AlohaCare Medicare	$178.56
Rate for Payer: Cash Price	$345.60
Rate for Payer: Devoted Health Medicare	$195.84
Rate for Payer: Hawaii Medical Service Association Medicare	$178.56
Rate for Payer: Hawaii Western Management Group Commercial	$547.20
Rate for Payer: Health Management Network Commercial	$489.60
Rate for Payer: Humana Medicare	$178.56
Rate for Payer: Kaiser Permanente Commercial	$518.40
Rate for Payer: Kaiser Permanente Medicaid	$293.76
Rate for Payer: Kaiser Permanente Medicare	$178.56
Rate for Payer: MDX Hawaii PPO	$558.72
Rate for Payer: Ohana Health Plan Medicaid	$178.56
Rate for Payer: Ohana Health Plan Medicare	$178.56
Rate for Payer: UnitedHealthcare Medicare	$178.56
Rate for Payer: University Health Alliance Commercial	$419.85

SHEATH URETERAL ACCESS SET

Facility

$424.00

Service Code	HCPCS C1894
Hospital Revenue Code	272
Min. Negotiated Rate	$131.44
Max. Negotiated Rate	$411.28
Rate for Payer: AlohaCare Medicaid	$212.00
Rate for Payer: AlohaCare Medicare	$131.44
Rate for Payer: Cash Price	$254.40
Rate for Payer: Devoted Health Medicare	$144.16
Rate for Payer: Hawaii Medical Service Association Medicare	$131.44
Rate for Payer: Hawaii Western Management Group Commercial	$402.80
Rate for Payer: Health Management Network Commercial	$360.40
Rate for Payer: Humana Medicare	$131.44
Rate for Payer: Kaiser Permanente Commercial	$381.60
Rate for Payer: Kaiser Permanente Medicaid	$216.24
Rate for Payer: Kaiser Permanente Medicare	$131.44
Rate for Payer: MDX Hawaii PPO	$411.28
Rate for Payer: Ohana Health Plan Medicaid	$131.44
Rate for Payer: Ohana Health Plan Medicare	$131.44
Rate for Payer: UnitedHealthcare Medicare	$131.44
Rate for Payer: University Health Alliance Commercial	$309.05

SHEATH URETERAL ACCESS SET

Facility

$424.00

Service Code	HCPCS C1894
Hospital Revenue Code	272
Min. Negotiated Rate	$360.40
Max. Negotiated Rate	$411.28
Rate for Payer: Cash Price	$254.40
Rate for Payer: Health Management Network Commercial	$360.40
Rate for Payer: Kaiser Permanente Commercial	$381.60
Rate for Payer: MDX Hawaii PPO	$411.28

SHELL 44MM #00-5001-044-00

Facility

$1,568.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$878.08
Max. Negotiated Rate	$1,520.96
Rate for Payer: Cash Price	$940.80
Rate for Payer: Hawaii Western Management Group Commercial	$1,097.60
Rate for Payer: Health Management Network Commercial	$1,332.80
Rate for Payer: Kaiser Permanente Commercial	$1,411.20
Rate for Payer: MDX Hawaii PPO	$1,520.96
Rate for Payer: University Health Alliance Commercial	$878.08

SHELL 44MM #00-5001-044-00

Facility

$1,568.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$486.08
Max. Negotiated Rate	$1,520.96
Rate for Payer: AlohaCare Medicaid	$784.00
Rate for Payer: AlohaCare Medicare	$486.08
Rate for Payer: Cash Price	$940.80
Rate for Payer: Devoted Health Medicare	$533.12
Rate for Payer: Hawaii Medical Service Association Medicare	$486.08
Rate for Payer: Hawaii Western Management Group Commercial	$1,097.60
Rate for Payer: Health Management Network Commercial	$1,332.80
Rate for Payer: Humana Medicare	$486.08
Rate for Payer: Kaiser Permanente Commercial	$1,411.20
Rate for Payer: Kaiser Permanente Medicaid	$799.68
Rate for Payer: Kaiser Permanente Medicare	$486.08
Rate for Payer: MDX Hawaii PPO	$1,520.96
Rate for Payer: Ohana Health Plan Medicaid	$486.08
Rate for Payer: Ohana Health Plan Medicare	$486.08
Rate for Payer: UnitedHealthcare Medicare	$486.08
Rate for Payer: University Health Alliance Commercial	$878.08

Know your out-of-pocket cost for care.

All Charges