Kau Hospital

All Charges

Charge

Type

Setting

Price

SITAGLIPTIN PHOSPHATE 50 MG TABLET [77616]

Facility

$33.00

Service Code	NDC 00006011228
Hospital Revenue Code	637
Min. Negotiated Rate	$10.23
Max. Negotiated Rate	$32.01
Rate for Payer: AlohaCare Medicaid	$16.50
Rate for Payer: AlohaCare Medicare	$10.23
Rate for Payer: Cash Price	$19.80
Rate for Payer: Devoted Health Medicare	$11.22
Rate for Payer: Hawaii Medical Service Association Medicare	$10.23
Rate for Payer: Hawaii Western Management Group Commercial	$31.35
Rate for Payer: Health Management Network Commercial	$28.05
Rate for Payer: Humana Medicare	$10.23
Rate for Payer: Kaiser Permanente Commercial	$29.70
Rate for Payer: Kaiser Permanente Medicaid	$16.83
Rate for Payer: Kaiser Permanente Medicare	$10.23
Rate for Payer: MDX Hawaii PPO	$32.01
Rate for Payer: Ohana Health Plan Medicaid	$10.23
Rate for Payer: Ohana Health Plan Medicare	$10.23
Rate for Payer: UnitedHealthcare Medicare	$10.23
Rate for Payer: University Health Alliance Commercial	$24.05

SITAGLIPTIN PHOSPHATE 50 MG TABLET [77616]

Facility

$33.00

Service Code	NDC 00006011231
Hospital Revenue Code	637
Min. Negotiated Rate	$10.23
Max. Negotiated Rate	$32.01
Rate for Payer: AlohaCare Medicaid	$16.50
Rate for Payer: AlohaCare Medicare	$10.23
Rate for Payer: Cash Price	$19.80
Rate for Payer: Devoted Health Medicare	$11.22
Rate for Payer: Hawaii Medical Service Association Medicare	$10.23
Rate for Payer: Hawaii Western Management Group Commercial	$31.35
Rate for Payer: Health Management Network Commercial	$28.05
Rate for Payer: Humana Medicare	$10.23
Rate for Payer: Kaiser Permanente Commercial	$29.70
Rate for Payer: Kaiser Permanente Medicaid	$16.83
Rate for Payer: Kaiser Permanente Medicare	$10.23
Rate for Payer: MDX Hawaii PPO	$32.01
Rate for Payer: Ohana Health Plan Medicaid	$10.23
Rate for Payer: Ohana Health Plan Medicare	$10.23
Rate for Payer: UnitedHealthcare Medicare	$10.23
Rate for Payer: University Health Alliance Commercial	$24.05

SIZER GEL 325CC GS10621-325MP

Facility

$844.00

Service Code	HCPCS C1789
Hospital Revenue Code	278
Min. Negotiated Rate	$472.64
Max. Negotiated Rate	$818.68
Rate for Payer: Cash Price	$506.40
Rate for Payer: Hawaii Western Management Group Commercial	$590.80
Rate for Payer: Health Management Network Commercial	$717.40
Rate for Payer: Kaiser Permanente Commercial	$759.60
Rate for Payer: MDX Hawaii PPO	$818.68
Rate for Payer: University Health Alliance Commercial	$472.64

SIZER GEL 325CC GS10621-325MP

Facility

$844.00

Service Code	HCPCS C1789
Hospital Revenue Code	278
Min. Negotiated Rate	$261.64
Max. Negotiated Rate	$818.68
Rate for Payer: AlohaCare Medicaid	$422.00
Rate for Payer: AlohaCare Medicare	$261.64
Rate for Payer: Cash Price	$506.40
Rate for Payer: Devoted Health Medicare	$286.96
Rate for Payer: Hawaii Medical Service Association Medicare	$261.64
Rate for Payer: Hawaii Western Management Group Commercial	$590.80
Rate for Payer: Health Management Network Commercial	$717.40
Rate for Payer: Humana Medicare	$261.64
Rate for Payer: Kaiser Permanente Commercial	$759.60
Rate for Payer: Kaiser Permanente Medicaid	$430.44
Rate for Payer: Kaiser Permanente Medicare	$261.64
Rate for Payer: MDX Hawaii PPO	$818.68
Rate for Payer: Ohana Health Plan Medicaid	$261.64
Rate for Payer: Ohana Health Plan Medicare	$261.64
Rate for Payer: UnitedHealthcare Medicare	$261.64
Rate for Payer: University Health Alliance Commercial	$472.64

SIZER GEL 355CC GS10621-355MP

Facility

$844.00

Service Code	HCPCS C1789
Hospital Revenue Code	278
Min. Negotiated Rate	$472.64
Max. Negotiated Rate	$818.68
Rate for Payer: Cash Price	$506.40
Rate for Payer: Hawaii Western Management Group Commercial	$590.80
Rate for Payer: Health Management Network Commercial	$717.40
Rate for Payer: Kaiser Permanente Commercial	$759.60
Rate for Payer: MDX Hawaii PPO	$818.68
Rate for Payer: University Health Alliance Commercial	$472.64

SIZER GEL 355CC GS10621-355MP

Facility

$844.00

Service Code	HCPCS C1789
Hospital Revenue Code	278
Min. Negotiated Rate	$261.64
Max. Negotiated Rate	$818.68
Rate for Payer: AlohaCare Medicaid	$422.00
Rate for Payer: AlohaCare Medicare	$261.64
Rate for Payer: Cash Price	$506.40
Rate for Payer: Devoted Health Medicare	$286.96
Rate for Payer: Hawaii Medical Service Association Medicare	$261.64
Rate for Payer: Hawaii Western Management Group Commercial	$590.80
Rate for Payer: Health Management Network Commercial	$717.40
Rate for Payer: Humana Medicare	$261.64
Rate for Payer: Kaiser Permanente Commercial	$759.60
Rate for Payer: Kaiser Permanente Medicaid	$430.44
Rate for Payer: Kaiser Permanente Medicare	$261.64
Rate for Payer: MDX Hawaii PPO	$818.68
Rate for Payer: Ohana Health Plan Medicaid	$261.64
Rate for Payer: Ohana Health Plan Medicare	$261.64
Rate for Payer: UnitedHealthcare Medicare	$261.64
Rate for Payer: University Health Alliance Commercial	$472.64

SIZER GEL 385CC GS10621-385MP

Facility

$844.00

Service Code	HCPCS C1789
Hospital Revenue Code	278
Min. Negotiated Rate	$261.64
Max. Negotiated Rate	$818.68
Rate for Payer: AlohaCare Medicaid	$422.00
Rate for Payer: AlohaCare Medicare	$261.64
Rate for Payer: Cash Price	$506.40
Rate for Payer: Devoted Health Medicare	$286.96
Rate for Payer: Hawaii Medical Service Association Medicare	$261.64
Rate for Payer: Hawaii Western Management Group Commercial	$590.80
Rate for Payer: Health Management Network Commercial	$717.40
Rate for Payer: Humana Medicare	$261.64
Rate for Payer: Kaiser Permanente Commercial	$759.60
Rate for Payer: Kaiser Permanente Medicaid	$430.44
Rate for Payer: Kaiser Permanente Medicare	$261.64
Rate for Payer: MDX Hawaii PPO	$818.68
Rate for Payer: Ohana Health Plan Medicaid	$261.64
Rate for Payer: Ohana Health Plan Medicare	$261.64
Rate for Payer: UnitedHealthcare Medicare	$261.64
Rate for Payer: University Health Alliance Commercial	$472.64

SIZER GEL 385CC GS10621-385MP

Facility

$844.00

Service Code	HCPCS C1789
Hospital Revenue Code	278
Min. Negotiated Rate	$472.64
Max. Negotiated Rate	$818.68
Rate for Payer: Cash Price	$506.40
Rate for Payer: Hawaii Western Management Group Commercial	$590.80
Rate for Payer: Health Management Network Commercial	$717.40
Rate for Payer: Kaiser Permanente Commercial	$759.60
Rate for Payer: MDX Hawaii PPO	$818.68
Rate for Payer: University Health Alliance Commercial	$472.64

SIZER GEL 415CC GS10621-415MP

Facility

$844.00

Service Code	HCPCS C1789
Hospital Revenue Code	278
Min. Negotiated Rate	$261.64
Max. Negotiated Rate	$818.68
Rate for Payer: AlohaCare Medicaid	$422.00
Rate for Payer: AlohaCare Medicare	$261.64
Rate for Payer: Cash Price	$506.40
Rate for Payer: Devoted Health Medicare	$286.96
Rate for Payer: Hawaii Medical Service Association Medicare	$261.64
Rate for Payer: Hawaii Western Management Group Commercial	$590.80
Rate for Payer: Health Management Network Commercial	$717.40
Rate for Payer: Humana Medicare	$261.64
Rate for Payer: Kaiser Permanente Commercial	$759.60
Rate for Payer: Kaiser Permanente Medicaid	$430.44
Rate for Payer: Kaiser Permanente Medicare	$261.64
Rate for Payer: MDX Hawaii PPO	$818.68
Rate for Payer: Ohana Health Plan Medicaid	$261.64
Rate for Payer: Ohana Health Plan Medicare	$261.64
Rate for Payer: UnitedHealthcare Medicare	$261.64
Rate for Payer: University Health Alliance Commercial	$472.64

SIZER GEL 415CC GS10621-415MP

Facility

$844.00

Service Code	HCPCS C1789
Hospital Revenue Code	278
Min. Negotiated Rate	$472.64
Max. Negotiated Rate	$818.68
Rate for Payer: Cash Price	$506.40
Rate for Payer: Hawaii Western Management Group Commercial	$590.80
Rate for Payer: Health Management Network Commercial	$717.40
Rate for Payer: Kaiser Permanente Commercial	$759.60
Rate for Payer: MDX Hawaii PPO	$818.68
Rate for Payer: University Health Alliance Commercial	$472.64

SIZER GEL 445CC GS10621-455MP

Facility

$844.00

Service Code	HCPCS C1789
Hospital Revenue Code	278
Min. Negotiated Rate	$261.64
Max. Negotiated Rate	$818.68
Rate for Payer: AlohaCare Medicaid	$422.00
Rate for Payer: AlohaCare Medicare	$261.64
Rate for Payer: Cash Price	$506.40
Rate for Payer: Devoted Health Medicare	$286.96
Rate for Payer: Hawaii Medical Service Association Medicare	$261.64
Rate for Payer: Hawaii Western Management Group Commercial	$590.80
Rate for Payer: Health Management Network Commercial	$717.40
Rate for Payer: Humana Medicare	$261.64
Rate for Payer: Kaiser Permanente Commercial	$759.60
Rate for Payer: Kaiser Permanente Medicaid	$430.44
Rate for Payer: Kaiser Permanente Medicare	$261.64
Rate for Payer: MDX Hawaii PPO	$818.68
Rate for Payer: Ohana Health Plan Medicaid	$261.64
Rate for Payer: Ohana Health Plan Medicare	$261.64
Rate for Payer: UnitedHealthcare Medicare	$261.64
Rate for Payer: University Health Alliance Commercial	$472.64

SIZER GEL 445CC GS10621-455MP

Facility

$844.00

Service Code	HCPCS C1789
Hospital Revenue Code	278
Min. Negotiated Rate	$472.64
Max. Negotiated Rate	$818.68
Rate for Payer: Cash Price	$506.40
Rate for Payer: Hawaii Western Management Group Commercial	$590.80
Rate for Payer: Health Management Network Commercial	$717.40
Rate for Payer: Kaiser Permanente Commercial	$759.60
Rate for Payer: MDX Hawaii PPO	$818.68
Rate for Payer: University Health Alliance Commercial	$472.64

SIZER GEL 535CC GS10621-535HP

Facility

$844.00

Service Code	HCPCS C1789
Hospital Revenue Code	278
Min. Negotiated Rate	$261.64
Max. Negotiated Rate	$818.68
Rate for Payer: AlohaCare Medicaid	$422.00
Rate for Payer: AlohaCare Medicare	$261.64
Rate for Payer: Cash Price	$506.40
Rate for Payer: Devoted Health Medicare	$286.96
Rate for Payer: Hawaii Medical Service Association Medicare	$261.64
Rate for Payer: Hawaii Western Management Group Commercial	$590.80
Rate for Payer: Health Management Network Commercial	$717.40
Rate for Payer: Humana Medicare	$261.64
Rate for Payer: Kaiser Permanente Commercial	$759.60
Rate for Payer: Kaiser Permanente Medicaid	$430.44
Rate for Payer: Kaiser Permanente Medicare	$261.64
Rate for Payer: MDX Hawaii PPO	$818.68
Rate for Payer: Ohana Health Plan Medicaid	$261.64
Rate for Payer: Ohana Health Plan Medicare	$261.64
Rate for Payer: UnitedHealthcare Medicare	$261.64
Rate for Payer: University Health Alliance Commercial	$472.64

SIZER GEL 535CC GS10621-535HP

Facility

$844.00

Service Code	HCPCS C1789
Hospital Revenue Code	278
Min. Negotiated Rate	$472.64
Max. Negotiated Rate	$818.68
Rate for Payer: Cash Price	$506.40
Rate for Payer: Hawaii Western Management Group Commercial	$590.80
Rate for Payer: Health Management Network Commercial	$717.40
Rate for Payer: Kaiser Permanente Commercial	$759.60
Rate for Payer: MDX Hawaii PPO	$818.68
Rate for Payer: University Health Alliance Commercial	$472.64

SIZER GEL 650CC GS10621-650HP

Facility

$844.00

Service Code	HCPCS C1789
Hospital Revenue Code	278
Min. Negotiated Rate	$472.64
Max. Negotiated Rate	$818.68
Rate for Payer: Cash Price	$506.40
Rate for Payer: Hawaii Western Management Group Commercial	$590.80
Rate for Payer: Health Management Network Commercial	$717.40
Rate for Payer: Kaiser Permanente Commercial	$759.60
Rate for Payer: MDX Hawaii PPO	$818.68
Rate for Payer: University Health Alliance Commercial	$472.64

SIZER GEL 650CC GS10621-650HP

Facility

$844.00

Service Code	HCPCS C1789
Hospital Revenue Code	278
Min. Negotiated Rate	$261.64
Max. Negotiated Rate	$818.68
Rate for Payer: AlohaCare Medicaid	$422.00
Rate for Payer: AlohaCare Medicare	$261.64
Rate for Payer: Cash Price	$506.40
Rate for Payer: Devoted Health Medicare	$286.96
Rate for Payer: Hawaii Medical Service Association Medicare	$261.64
Rate for Payer: Hawaii Western Management Group Commercial	$590.80
Rate for Payer: Health Management Network Commercial	$717.40
Rate for Payer: Humana Medicare	$261.64
Rate for Payer: Kaiser Permanente Commercial	$759.60
Rate for Payer: Kaiser Permanente Medicaid	$430.44
Rate for Payer: Kaiser Permanente Medicare	$261.64
Rate for Payer: MDX Hawaii PPO	$818.68
Rate for Payer: Ohana Health Plan Medicaid	$261.64
Rate for Payer: Ohana Health Plan Medicare	$261.64
Rate for Payer: UnitedHealthcare Medicare	$261.64
Rate for Payer: University Health Alliance Commercial	$472.64

SIZER GEL RND GS10621-505MP

Facility

$844.00

Service Code	HCPCS C1789
Hospital Revenue Code	278
Min. Negotiated Rate	$472.64
Max. Negotiated Rate	$818.68
Rate for Payer: Cash Price	$506.40
Rate for Payer: Hawaii Western Management Group Commercial	$590.80
Rate for Payer: Health Management Network Commercial	$717.40
Rate for Payer: Kaiser Permanente Commercial	$759.60
Rate for Payer: MDX Hawaii PPO	$818.68
Rate for Payer: University Health Alliance Commercial	$472.64

SIZER GEL RND GS10621-505MP

Facility

$844.00

Service Code	HCPCS C1789
Hospital Revenue Code	278
Min. Negotiated Rate	$261.64
Max. Negotiated Rate	$818.68
Rate for Payer: AlohaCare Medicaid	$422.00
Rate for Payer: AlohaCare Medicare	$261.64
Rate for Payer: Cash Price	$506.40
Rate for Payer: Devoted Health Medicare	$286.96
Rate for Payer: Hawaii Medical Service Association Medicare	$261.64
Rate for Payer: Hawaii Western Management Group Commercial	$590.80
Rate for Payer: Health Management Network Commercial	$717.40
Rate for Payer: Humana Medicare	$261.64
Rate for Payer: Kaiser Permanente Commercial	$759.60
Rate for Payer: Kaiser Permanente Medicaid	$430.44
Rate for Payer: Kaiser Permanente Medicare	$261.64
Rate for Payer: MDX Hawaii PPO	$818.68
Rate for Payer: Ohana Health Plan Medicaid	$261.64
Rate for Payer: Ohana Health Plan Medicare	$261.64
Rate for Payer: UnitedHealthcare Medicare	$261.64
Rate for Payer: University Health Alliance Commercial	$472.64

SIZER HANDLE 7205-30-301

Facility

$341.00

Hospital Revenue Code	272
Min. Negotiated Rate	$105.71
Max. Negotiated Rate	$330.77
Rate for Payer: AlohaCare Medicaid	$170.50
Rate for Payer: AlohaCare Medicare	$105.71
Rate for Payer: Cash Price	$204.60
Rate for Payer: Devoted Health Medicare	$115.94
Rate for Payer: Hawaii Medical Service Association Medicare	$105.71
Rate for Payer: Hawaii Western Management Group Commercial	$323.95
Rate for Payer: Health Management Network Commercial	$289.85
Rate for Payer: Humana Medicare	$105.71
Rate for Payer: Kaiser Permanente Commercial	$306.90
Rate for Payer: Kaiser Permanente Medicaid	$173.91
Rate for Payer: Kaiser Permanente Medicare	$105.71
Rate for Payer: MDX Hawaii PPO	$330.77
Rate for Payer: Ohana Health Plan Medicaid	$105.71
Rate for Payer: Ohana Health Plan Medicare	$105.71
Rate for Payer: UnitedHealthcare Medicare	$105.71
Rate for Payer: University Health Alliance Commercial	$248.55

SIZER HANDLE 7205-30-301

Facility

$341.00

Hospital Revenue Code	272
Min. Negotiated Rate	$289.85
Max. Negotiated Rate	$330.77
Rate for Payer: Cash Price	$204.60
Rate for Payer: Health Management Network Commercial	$289.85
Rate for Payer: Kaiser Permanente Commercial	$306.90
Rate for Payer: MDX Hawaii PPO	$330.77

SIZER NATRELLE 110 SSZ-L110

Facility

$690.00

Service Code	HCPCS C1789
Hospital Revenue Code	278
Min. Negotiated Rate	$386.40
Max. Negotiated Rate	$669.30
Rate for Payer: Cash Price	$414.00
Rate for Payer: Hawaii Western Management Group Commercial	$483.00
Rate for Payer: Health Management Network Commercial	$586.50
Rate for Payer: Kaiser Permanente Commercial	$621.00
Rate for Payer: MDX Hawaii PPO	$669.30
Rate for Payer: University Health Alliance Commercial	$386.40

SIZER NATRELLE 110 SSZ-L110

Facility

$690.00

Service Code	HCPCS C1789
Hospital Revenue Code	278
Min. Negotiated Rate	$213.90
Max. Negotiated Rate	$669.30
Rate for Payer: AlohaCare Medicaid	$345.00
Rate for Payer: AlohaCare Medicare	$213.90
Rate for Payer: Cash Price	$414.00
Rate for Payer: Devoted Health Medicare	$234.60
Rate for Payer: Hawaii Medical Service Association Medicare	$213.90
Rate for Payer: Hawaii Western Management Group Commercial	$483.00
Rate for Payer: Health Management Network Commercial	$586.50
Rate for Payer: Humana Medicare	$213.90
Rate for Payer: Kaiser Permanente Commercial	$621.00
Rate for Payer: Kaiser Permanente Medicaid	$351.90
Rate for Payer: Kaiser Permanente Medicare	$213.90
Rate for Payer: MDX Hawaii PPO	$669.30
Rate for Payer: Ohana Health Plan Medicaid	$213.90
Rate for Payer: Ohana Health Plan Medicare	$213.90
Rate for Payer: UnitedHealthcare Medicare	$213.90
Rate for Payer: University Health Alliance Commercial	$386.40

SIZER NATRELLE 125 SSZ-LP125

Facility

$690.00

Service Code	HCPCS C1789
Hospital Revenue Code	278
Min. Negotiated Rate	$386.40
Max. Negotiated Rate	$669.30
Rate for Payer: Cash Price	$414.00
Rate for Payer: Hawaii Western Management Group Commercial	$483.00
Rate for Payer: Health Management Network Commercial	$586.50
Rate for Payer: Kaiser Permanente Commercial	$621.00
Rate for Payer: MDX Hawaii PPO	$669.30
Rate for Payer: University Health Alliance Commercial	$386.40

SIZER NATRELLE 125 SSZ-LP125

Facility

$690.00

Service Code	HCPCS C1789
Hospital Revenue Code	278
Min. Negotiated Rate	$213.90
Max. Negotiated Rate	$669.30
Rate for Payer: AlohaCare Medicaid	$345.00
Rate for Payer: AlohaCare Medicare	$213.90
Rate for Payer: Cash Price	$414.00
Rate for Payer: Devoted Health Medicare	$234.60
Rate for Payer: Hawaii Medical Service Association Medicare	$213.90
Rate for Payer: Hawaii Western Management Group Commercial	$483.00
Rate for Payer: Health Management Network Commercial	$586.50
Rate for Payer: Humana Medicare	$213.90
Rate for Payer: Kaiser Permanente Commercial	$621.00
Rate for Payer: Kaiser Permanente Medicaid	$351.90
Rate for Payer: Kaiser Permanente Medicare	$213.90
Rate for Payer: MDX Hawaii PPO	$669.30
Rate for Payer: Ohana Health Plan Medicaid	$213.90
Rate for Payer: Ohana Health Plan Medicare	$213.90
Rate for Payer: UnitedHealthcare Medicare	$213.90
Rate for Payer: University Health Alliance Commercial	$386.40

SIZER PROJECTION SZ10621-440HP

Facility

$260.00

Service Code	HCPCS C1789
Hospital Revenue Code	278
Min. Negotiated Rate	$145.60
Max. Negotiated Rate	$252.20
Rate for Payer: Cash Price	$156.00
Rate for Payer: Hawaii Western Management Group Commercial	$182.00
Rate for Payer: Health Management Network Commercial	$221.00
Rate for Payer: Kaiser Permanente Commercial	$234.00
Rate for Payer: MDX Hawaii PPO	$252.20
Rate for Payer: University Health Alliance Commercial	$145.60

Know your out-of-pocket cost for care.

All Charges