Kau Hospital

All Charges

Charge

Type

Setting

Price

SHELL BPLR 55MM 00-5001-055-00

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

SHELL BPLR 55MM 00-5001-055-00

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

SHELL CLUSTER 50MM 702-1150D

Facility

$2,703.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$837.93
Max. Negotiated Rate	$2,621.91
Rate for Payer: AlohaCare Medicaid	$1,351.50
Rate for Payer: AlohaCare Medicare	$837.93
Rate for Payer: Cash Price	$1,621.80
Rate for Payer: Devoted Health Medicare	$919.02
Rate for Payer: Hawaii Medical Service Association Medicare	$837.93
Rate for Payer: Hawaii Western Management Group Commercial	$1,892.10
Rate for Payer: Health Management Network Commercial	$2,297.55
Rate for Payer: Humana Medicare	$837.93
Rate for Payer: Kaiser Permanente Commercial	$2,432.70
Rate for Payer: Kaiser Permanente Medicaid	$1,378.53
Rate for Payer: Kaiser Permanente Medicare	$837.93
Rate for Payer: MDX Hawaii PPO	$2,621.91
Rate for Payer: Ohana Health Plan Medicaid	$837.93
Rate for Payer: Ohana Health Plan Medicare	$837.93
Rate for Payer: UnitedHealthcare Medicare	$837.93
Rate for Payer: University Health Alliance Commercial	$1,513.68

SHELL CLUSTER 50MM 702-1150D

Facility

$2,703.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$1,513.68
Max. Negotiated Rate	$2,621.91
Rate for Payer: Cash Price	$1,621.80
Rate for Payer: Hawaii Western Management Group Commercial	$1,892.10
Rate for Payer: Health Management Network Commercial	$2,297.55
Rate for Payer: Kaiser Permanente Commercial	$2,432.70
Rate for Payer: MDX Hawaii PPO	$2,621.91
Rate for Payer: University Health Alliance Commercial	$1,513.68

SHELL CLUSTER 60MM 702-04-60G

Facility

$3,211.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$1,798.16
Max. Negotiated Rate	$3,114.67
Rate for Payer: Cash Price	$1,926.60
Rate for Payer: Hawaii Western Management Group Commercial	$2,247.70
Rate for Payer: Health Management Network Commercial	$2,729.35
Rate for Payer: Kaiser Permanente Commercial	$2,889.90
Rate for Payer: MDX Hawaii PPO	$3,114.67
Rate for Payer: University Health Alliance Commercial	$1,798.16

SHELL CLUSTER 60MM 702-04-60G

Facility

$3,211.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$995.41
Max. Negotiated Rate	$3,114.67
Rate for Payer: AlohaCare Medicaid	$1,605.50
Rate for Payer: AlohaCare Medicare	$995.41
Rate for Payer: Cash Price	$1,926.60
Rate for Payer: Devoted Health Medicare	$1,091.74
Rate for Payer: Hawaii Medical Service Association Medicare	$995.41
Rate for Payer: Hawaii Western Management Group Commercial	$2,247.70
Rate for Payer: Health Management Network Commercial	$2,729.35
Rate for Payer: Humana Medicare	$995.41
Rate for Payer: Kaiser Permanente Commercial	$2,889.90
Rate for Payer: Kaiser Permanente Medicaid	$1,637.61
Rate for Payer: Kaiser Permanente Medicare	$995.41
Rate for Payer: MDX Hawaii PPO	$3,114.67
Rate for Payer: Ohana Health Plan Medicaid	$995.41
Rate for Payer: Ohana Health Plan Medicare	$995.41
Rate for Payer: UnitedHealthcare Medicare	$995.41
Rate for Payer: University Health Alliance Commercial	$1,798.16

SHELL CUP 45MM 00-5001-45-00

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 CUP 45MM 00-5001-45-00

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

SHELL HEMI 64MM 509-02-64G

Facility

$11,560.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$6,473.60
Max. Negotiated Rate	$11,213.20
Rate for Payer: Cash Price	$6,936.00
Rate for Payer: Hawaii Western Management Group Commercial	$8,092.00
Rate for Payer: Health Management Network Commercial	$9,826.00
Rate for Payer: Kaiser Permanente Commercial	$10,404.00
Rate for Payer: MDX Hawaii PPO	$11,213.20
Rate for Payer: University Health Alliance Commercial	$6,473.60

SHELL HEMI 64MM 509-02-64G

Facility

$11,560.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$3,583.60
Max. Negotiated Rate	$11,213.20
Rate for Payer: AlohaCare Medicaid	$5,780.00
Rate for Payer: AlohaCare Medicare	$3,583.60
Rate for Payer: Cash Price	$6,936.00
Rate for Payer: Devoted Health Medicare	$3,930.40
Rate for Payer: Hawaii Medical Service Association Medicare	$3,583.60
Rate for Payer: Hawaii Western Management Group Commercial	$8,092.00
Rate for Payer: Health Management Network Commercial	$9,826.00
Rate for Payer: Humana Medicare	$3,583.60
Rate for Payer: Kaiser Permanente Commercial	$10,404.00
Rate for Payer: Kaiser Permanente Medicaid	$5,895.60
Rate for Payer: Kaiser Permanente Medicare	$3,583.60
Rate for Payer: MDX Hawaii PPO	$11,213.20
Rate for Payer: Ohana Health Plan Medicaid	$3,583.60
Rate for Payer: Ohana Health Plan Medicare	$3,583.60
Rate for Payer: UnitedHealthcare Medicare	$3,583.60
Rate for Payer: University Health Alliance Commercial	$6,473.60

SHOULDER CRYO/CUFF 12A01

Facility

$205.00

Hospital Revenue Code	272
Min. Negotiated Rate	$174.25
Max. Negotiated Rate	$198.85
Rate for Payer: Cash Price	$123.00
Rate for Payer: Health Management Network Commercial	$174.25
Rate for Payer: Kaiser Permanente Commercial	$184.50
Rate for Payer: MDX Hawaii PPO	$198.85

SHOULDER CRYO/CUFF 12A01

Facility

$205.00

Hospital Revenue Code	272
Min. Negotiated Rate	$63.55
Max. Negotiated Rate	$198.85
Rate for Payer: AlohaCare Medicaid	$102.50
Rate for Payer: AlohaCare Medicare	$63.55
Rate for Payer: Cash Price	$123.00
Rate for Payer: Devoted Health Medicare	$69.70
Rate for Payer: Hawaii Medical Service Association Medicare	$63.55
Rate for Payer: Hawaii Western Management Group Commercial	$194.75
Rate for Payer: Health Management Network Commercial	$174.25
Rate for Payer: Humana Medicare	$63.55
Rate for Payer: Kaiser Permanente Commercial	$184.50
Rate for Payer: Kaiser Permanente Medicaid	$104.55
Rate for Payer: Kaiser Permanente Medicare	$63.55
Rate for Payer: MDX Hawaii PPO	$198.85
Rate for Payer: Ohana Health Plan Medicaid	$63.55
Rate for Payer: Ohana Health Plan Medicare	$63.55
Rate for Payer: UnitedHealthcare Medicare	$63.55
Rate for Payer: University Health Alliance Commercial	$149.42

SHOULDER, ELBOW OR FOREARM PROCEDURES, EXCEPT MAJOR JOINT PROCEDURES WITH CC

Facility

$23,180.56

Service Code	MSDRG 511
Min. Negotiated Rate	$23,180.56
Max. Negotiated Rate	$23,180.56
Rate for Payer: Hawaii Medical Service Association Commercial	$23,180.56

SHOULDER, ELBOW OR FOREARM PROCEDURES, EXCEPT MAJOR JOINT PROCEDURES WITH MCC

Facility

$23,180.56

Service Code	MSDRG 510
Min. Negotiated Rate	$23,180.56
Max. Negotiated Rate	$23,180.56
Rate for Payer: Hawaii Medical Service Association Commercial	$23,180.56

SHOULDER, ELBOW OR FOREARM PROCEDURES, EXCEPT MAJOR JOINT PROCEDURES WITHOUT CC/MCC

Facility

$21,782.14

Service Code	MSDRG 512
Min. Negotiated Rate	$21,782.14
Max. Negotiated Rate	$21,782.14
Rate for Payer: Hawaii Medical Service Association Commercial	$21,782.14

SHOULDER FLEX SYS DWG146

Facility

$8,306.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$4,651.36
Max. Negotiated Rate	$8,056.82
Rate for Payer: Cash Price	$4,983.60
Rate for Payer: Hawaii Western Management Group Commercial	$5,814.20
Rate for Payer: Health Management Network Commercial	$7,060.10
Rate for Payer: Kaiser Permanente Commercial	$7,475.40
Rate for Payer: MDX Hawaii PPO	$8,056.82
Rate for Payer: University Health Alliance Commercial	$4,651.36

SHOULDER FLEX SYS DWG146

Facility

$8,306.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$2,574.86
Max. Negotiated Rate	$8,056.82
Rate for Payer: AlohaCare Medicaid	$4,153.00
Rate for Payer: AlohaCare Medicare	$2,574.86
Rate for Payer: Cash Price	$4,983.60
Rate for Payer: Devoted Health Medicare	$2,824.04
Rate for Payer: Hawaii Medical Service Association Medicare	$2,574.86
Rate for Payer: Hawaii Western Management Group Commercial	$5,814.20
Rate for Payer: Health Management Network Commercial	$7,060.10
Rate for Payer: Humana Medicare	$2,574.86
Rate for Payer: Kaiser Permanente Commercial	$7,475.40
Rate for Payer: Kaiser Permanente Medicaid	$4,236.06
Rate for Payer: Kaiser Permanente Medicare	$2,574.86
Rate for Payer: MDX Hawaii PPO	$8,056.82
Rate for Payer: Ohana Health Plan Medicaid	$2,574.86
Rate for Payer: Ohana Health Plan Medicare	$2,574.86
Rate for Payer: UnitedHealthcare Medicare	$2,574.86
Rate for Payer: University Health Alliance Commercial	$4,651.36

SHOULDER STABILIZER KIT

Facility

$332.00

Hospital Revenue Code	272
Min. Negotiated Rate	$282.20
Max. Negotiated Rate	$322.04
Rate for Payer: Cash Price	$199.20
Rate for Payer: Health Management Network Commercial	$282.20
Rate for Payer: Kaiser Permanente Commercial	$298.80
Rate for Payer: MDX Hawaii PPO	$322.04

SHOULDER STABILIZER KIT

Facility

$332.00

Hospital Revenue Code	272
Min. Negotiated Rate	$102.92
Max. Negotiated Rate	$322.04
Rate for Payer: AlohaCare Medicaid	$166.00
Rate for Payer: AlohaCare Medicare	$102.92
Rate for Payer: Cash Price	$199.20
Rate for Payer: Devoted Health Medicare	$112.88
Rate for Payer: Hawaii Medical Service Association Medicare	$102.92
Rate for Payer: Hawaii Western Management Group Commercial	$315.40
Rate for Payer: Health Management Network Commercial	$282.20
Rate for Payer: Humana Medicare	$102.92
Rate for Payer: Kaiser Permanente Commercial	$298.80
Rate for Payer: Kaiser Permanente Medicaid	$169.32
Rate for Payer: Kaiser Permanente Medicare	$102.92
Rate for Payer: MDX Hawaii PPO	$322.04
Rate for Payer: Ohana Health Plan Medicaid	$102.92
Rate for Payer: Ohana Health Plan Medicare	$102.92
Rate for Payer: UnitedHealthcare Medicare	$102.92
Rate for Payer: University Health Alliance Commercial	$241.99

SHOULDER SUSPENSION MPR-SS-KIT

Facility

$183.00

Hospital Revenue Code	272
Min. Negotiated Rate	$56.73
Max. Negotiated Rate	$177.51
Rate for Payer: AlohaCare Medicaid	$91.50
Rate for Payer: AlohaCare Medicare	$56.73
Rate for Payer: Cash Price	$109.80
Rate for Payer: Devoted Health Medicare	$62.22
Rate for Payer: Hawaii Medical Service Association Medicare	$56.73
Rate for Payer: Hawaii Western Management Group Commercial	$173.85
Rate for Payer: Health Management Network Commercial	$155.55
Rate for Payer: Humana Medicare	$56.73
Rate for Payer: Kaiser Permanente Commercial	$164.70
Rate for Payer: Kaiser Permanente Medicaid	$93.33
Rate for Payer: Kaiser Permanente Medicare	$56.73
Rate for Payer: MDX Hawaii PPO	$177.51
Rate for Payer: Ohana Health Plan Medicaid	$56.73
Rate for Payer: Ohana Health Plan Medicare	$56.73
Rate for Payer: UnitedHealthcare Medicare	$56.73
Rate for Payer: University Health Alliance Commercial	$133.39

SHOULDER SUSPENSION MPR-SS-KIT

Facility

$183.00

Hospital Revenue Code	272
Min. Negotiated Rate	$155.55
Max. Negotiated Rate	$177.51
Rate for Payer: Cash Price	$109.80
Rate for Payer: Health Management Network Commercial	$155.55
Rate for Payer: Kaiser Permanente Commercial	$164.70
Rate for Payer: MDX Hawaii PPO	$177.51

SHUNT PRUITT-INA 2013-10

Facility

$2,098.00

Service Code	HCPCS C1889
Hospital Revenue Code	278
Min. Negotiated Rate	$650.38
Max. Negotiated Rate	$2,035.06
Rate for Payer: AlohaCare Medicaid	$1,049.00
Rate for Payer: AlohaCare Medicare	$650.38
Rate for Payer: Cash Price	$1,258.80
Rate for Payer: Devoted Health Medicare	$713.32
Rate for Payer: Hawaii Medical Service Association Medicare	$650.38
Rate for Payer: Hawaii Western Management Group Commercial	$1,468.60
Rate for Payer: Health Management Network Commercial	$1,783.30
Rate for Payer: Humana Medicare	$650.38
Rate for Payer: Kaiser Permanente Commercial	$1,888.20
Rate for Payer: Kaiser Permanente Medicaid	$1,069.98
Rate for Payer: Kaiser Permanente Medicare	$650.38
Rate for Payer: MDX Hawaii PPO	$2,035.06
Rate for Payer: Ohana Health Plan Medicaid	$650.38
Rate for Payer: Ohana Health Plan Medicare	$650.38
Rate for Payer: UnitedHealthcare Medicare	$650.38
Rate for Payer: University Health Alliance Commercial	$1,174.88

SHUNT PRUITT-INA 2013-10

Facility

$2,098.00

Service Code	HCPCS C1889
Hospital Revenue Code	278
Min. Negotiated Rate	$1,174.88
Max. Negotiated Rate	$2,035.06
Rate for Payer: Cash Price	$1,258.80
Rate for Payer: Hawaii Western Management Group Commercial	$1,468.60
Rate for Payer: Health Management Network Commercial	$1,783.30
Rate for Payer: Kaiser Permanente Commercial	$1,888.20
Rate for Payer: MDX Hawaii PPO	$2,035.06
Rate for Payer: University Health Alliance Commercial	$1,174.88

SIGNS AND SYMPTOMS OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH MCC

Facility

$10,499.99

Service Code	MSDRG 555
Min. Negotiated Rate	$10,499.99
Max. Negotiated Rate	$10,499.99
Rate for Payer: Hawaii Medical Service Association Commercial	$10,499.99

SIGNS AND SYMPTOMS OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITHOUT MCC

Facility

$10,499.99

Service Code	MSDRG 556
Min. Negotiated Rate	$10,499.99
Max. Negotiated Rate	$10,499.99
Rate for Payer: Hawaii Medical Service Association Commercial	$10,499.99

Know your out-of-pocket cost for care.

All Charges