Kau Hospital

All Charges

Charge

Type

Setting

Price

SUPERIOR CLAVICLE 8H RT 628028

Facility

$3,450.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,069.50
Max. Negotiated Rate	$3,346.50
Rate for Payer: AlohaCare Medicaid	$1,725.00
Rate for Payer: AlohaCare Medicare	$1,069.50
Rate for Payer: Cash Price	$2,070.00
Rate for Payer: Devoted Health Medicare	$1,173.00
Rate for Payer: Hawaii Medical Service Association Medicare	$1,069.50
Rate for Payer: Hawaii Western Management Group Commercial	$2,415.00
Rate for Payer: Health Management Network Commercial	$2,932.50
Rate for Payer: Humana Medicare	$1,069.50
Rate for Payer: Kaiser Permanente Commercial	$3,105.00
Rate for Payer: Kaiser Permanente Medicaid	$1,759.50
Rate for Payer: Kaiser Permanente Medicare	$1,069.50
Rate for Payer: MDX Hawaii PPO	$3,346.50
Rate for Payer: Ohana Health Plan Medicaid	$1,069.50
Rate for Payer: Ohana Health Plan Medicare	$1,069.50
Rate for Payer: UnitedHealthcare Medicare	$1,069.50
Rate for Payer: University Health Alliance Commercial	$1,932.00

SUPPORT FOREARM RIGHT

Facility

$119.00

Service Code	HCPCS L3908
Hospital Revenue Code	274
Min. Negotiated Rate	$66.64
Max. Negotiated Rate	$115.43
Rate for Payer: Cash Price	$71.40
Rate for Payer: Hawaii Western Management Group Commercial	$83.30
Rate for Payer: Health Management Network Commercial	$101.15
Rate for Payer: Kaiser Permanente Commercial	$107.10
Rate for Payer: MDX Hawaii PPO	$115.43
Rate for Payer: University Health Alliance Commercial	$66.64

SUPPORT FOREARM RIGHT

Facility

$119.00

Service Code	HCPCS L3908
Hospital Revenue Code	274
Min. Negotiated Rate	$36.89
Max. Negotiated Rate	$115.43
Rate for Payer: AlohaCare Medicaid	$59.50
Rate for Payer: AlohaCare Medicare	$36.89
Rate for Payer: Cash Price	$71.40
Rate for Payer: Cash Price	$71.40
Rate for Payer: Devoted Health Medicare	$40.46
Rate for Payer: Hawaii Medical Service Association Medicare	$36.89
Rate for Payer: Hawaii Western Management Group Commercial	$83.30
Rate for Payer: Health Management Network Commercial	$101.15
Rate for Payer: Humana Medicare	$36.89
Rate for Payer: Kaiser Permanente Commercial	$107.10
Rate for Payer: Kaiser Permanente Medicaid	$60.69
Rate for Payer: Kaiser Permanente Medicare	$36.89
Rate for Payer: MDX Hawaii PPO	$115.43
Rate for Payer: Ohana Health Plan Medicaid	$36.89
Rate for Payer: Ohana Health Plan Medicare	$36.89
Rate for Payer: UnitedHealthcare Medicaid	$49.46
Rate for Payer: UnitedHealthcare Medicare	$36.89
Rate for Payer: University Health Alliance Commercial	$66.64

SUREFORM 45 2.0 GRAY 48345M

Facility

$750.00

Hospital Revenue Code	272
Min. Negotiated Rate	$232.50
Max. Negotiated Rate	$727.50
Rate for Payer: AlohaCare Medicaid	$375.00
Rate for Payer: AlohaCare Medicare	$232.50
Rate for Payer: Cash Price	$450.00
Rate for Payer: Devoted Health Medicare	$255.00
Rate for Payer: Hawaii Medical Service Association Medicare	$232.50
Rate for Payer: Hawaii Western Management Group Commercial	$712.50
Rate for Payer: Health Management Network Commercial	$637.50
Rate for Payer: Humana Medicare	$232.50
Rate for Payer: Kaiser Permanente Commercial	$675.00
Rate for Payer: Kaiser Permanente Medicaid	$382.50
Rate for Payer: Kaiser Permanente Medicare	$232.50
Rate for Payer: MDX Hawaii PPO	$727.50
Rate for Payer: Ohana Health Plan Medicaid	$232.50
Rate for Payer: Ohana Health Plan Medicare	$232.50
Rate for Payer: UnitedHealthcare Medicare	$232.50
Rate for Payer: University Health Alliance Commercial	$546.67

SUREFORM 45 2.0 GRAY 48345M

Facility

$750.00

Hospital Revenue Code	272
Min. Negotiated Rate	$637.50
Max. Negotiated Rate	$727.50
Rate for Payer: Cash Price	$450.00
Rate for Payer: Health Management Network Commercial	$637.50
Rate for Payer: Kaiser Permanente Commercial	$675.00
Rate for Payer: MDX Hawaii PPO	$727.50

SUREFORM 45 2.5 WHITE 48345W

Facility

$788.00

Hospital Revenue Code	272
Min. Negotiated Rate	$669.80
Max. Negotiated Rate	$764.36
Rate for Payer: Cash Price	$472.80
Rate for Payer: Health Management Network Commercial	$669.80
Rate for Payer: Kaiser Permanente Commercial	$709.20
Rate for Payer: MDX Hawaii PPO	$764.36

SUREFORM 45 2.5 WHITE 48345W

Facility

$788.00

Hospital Revenue Code	272
Min. Negotiated Rate	$244.28
Max. Negotiated Rate	$764.36
Rate for Payer: AlohaCare Medicaid	$394.00
Rate for Payer: AlohaCare Medicare	$244.28
Rate for Payer: Cash Price	$472.80
Rate for Payer: Devoted Health Medicare	$267.92
Rate for Payer: Hawaii Medical Service Association Medicare	$244.28
Rate for Payer: Hawaii Western Management Group Commercial	$748.60
Rate for Payer: Health Management Network Commercial	$669.80
Rate for Payer: Humana Medicare	$244.28
Rate for Payer: Kaiser Permanente Commercial	$709.20
Rate for Payer: Kaiser Permanente Medicaid	$401.88
Rate for Payer: Kaiser Permanente Medicare	$244.28
Rate for Payer: MDX Hawaii PPO	$764.36
Rate for Payer: Ohana Health Plan Medicaid	$244.28
Rate for Payer: Ohana Health Plan Medicare	$244.28
Rate for Payer: UnitedHealthcare Medicare	$244.28
Rate for Payer: University Health Alliance Commercial	$574.37

SUREFORM 45 3.5 BLUE 48345B

Facility

$750.00

Hospital Revenue Code	272
Min. Negotiated Rate	$232.50
Max. Negotiated Rate	$727.50
Rate for Payer: AlohaCare Medicaid	$375.00
Rate for Payer: AlohaCare Medicare	$232.50
Rate for Payer: Cash Price	$450.00
Rate for Payer: Devoted Health Medicare	$255.00
Rate for Payer: Hawaii Medical Service Association Medicare	$232.50
Rate for Payer: Hawaii Western Management Group Commercial	$712.50
Rate for Payer: Health Management Network Commercial	$637.50
Rate for Payer: Humana Medicare	$232.50
Rate for Payer: Kaiser Permanente Commercial	$675.00
Rate for Payer: Kaiser Permanente Medicaid	$382.50
Rate for Payer: Kaiser Permanente Medicare	$232.50
Rate for Payer: MDX Hawaii PPO	$727.50
Rate for Payer: Ohana Health Plan Medicaid	$232.50
Rate for Payer: Ohana Health Plan Medicare	$232.50
Rate for Payer: UnitedHealthcare Medicare	$232.50
Rate for Payer: University Health Alliance Commercial	$546.67

SUREFORM 45 3.5 BLUE 48345B

Facility

$750.00

Hospital Revenue Code	272
Min. Negotiated Rate	$637.50
Max. Negotiated Rate	$727.50
Rate for Payer: Cash Price	$450.00
Rate for Payer: Health Management Network Commercial	$637.50
Rate for Payer: Kaiser Permanente Commercial	$675.00
Rate for Payer: MDX Hawaii PPO	$727.50

SUREFORM 45 4.3 GREEN 48345G

Facility

$750.00

Hospital Revenue Code	272
Min. Negotiated Rate	$637.50
Max. Negotiated Rate	$727.50
Rate for Payer: Cash Price	$450.00
Rate for Payer: Health Management Network Commercial	$637.50
Rate for Payer: Kaiser Permanente Commercial	$675.00
Rate for Payer: MDX Hawaii PPO	$727.50

SUREFORM 45 4.3 GREEN 48345G

Facility

$750.00

Hospital Revenue Code	272
Min. Negotiated Rate	$232.50
Max. Negotiated Rate	$727.50
Rate for Payer: AlohaCare Medicaid	$375.00
Rate for Payer: AlohaCare Medicare	$232.50
Rate for Payer: Cash Price	$450.00
Rate for Payer: Devoted Health Medicare	$255.00
Rate for Payer: Hawaii Medical Service Association Medicare	$232.50
Rate for Payer: Hawaii Western Management Group Commercial	$712.50
Rate for Payer: Health Management Network Commercial	$637.50
Rate for Payer: Humana Medicare	$232.50
Rate for Payer: Kaiser Permanente Commercial	$675.00
Rate for Payer: Kaiser Permanente Medicaid	$382.50
Rate for Payer: Kaiser Permanente Medicare	$232.50
Rate for Payer: MDX Hawaii PPO	$727.50
Rate for Payer: Ohana Health Plan Medicaid	$232.50
Rate for Payer: Ohana Health Plan Medicare	$232.50
Rate for Payer: UnitedHealthcare Medicare	$232.50
Rate for Payer: University Health Alliance Commercial	$546.67

SUREFORM 45 4.6 BLACK 48345T

Facility

$750.00

Hospital Revenue Code	272
Min. Negotiated Rate	$637.50
Max. Negotiated Rate	$727.50
Rate for Payer: Cash Price	$450.00
Rate for Payer: Health Management Network Commercial	$637.50
Rate for Payer: Kaiser Permanente Commercial	$675.00
Rate for Payer: MDX Hawaii PPO	$727.50

SUREFORM 45 4.6 BLACK 48345T

Facility

$750.00

Hospital Revenue Code	272
Min. Negotiated Rate	$232.50
Max. Negotiated Rate	$727.50
Rate for Payer: AlohaCare Medicaid	$375.00
Rate for Payer: AlohaCare Medicare	$232.50
Rate for Payer: Cash Price	$450.00
Rate for Payer: Devoted Health Medicare	$255.00
Rate for Payer: Hawaii Medical Service Association Medicare	$232.50
Rate for Payer: Hawaii Western Management Group Commercial	$712.50
Rate for Payer: Health Management Network Commercial	$637.50
Rate for Payer: Humana Medicare	$232.50
Rate for Payer: Kaiser Permanente Commercial	$675.00
Rate for Payer: Kaiser Permanente Medicaid	$382.50
Rate for Payer: Kaiser Permanente Medicare	$232.50
Rate for Payer: MDX Hawaii PPO	$727.50
Rate for Payer: Ohana Health Plan Medicaid	$232.50
Rate for Payer: Ohana Health Plan Medicare	$232.50
Rate for Payer: UnitedHealthcare Medicare	$232.50
Rate for Payer: University Health Alliance Commercial	$546.67

SUREFORM 60 2.5 WHITE 48360W

Facility

$863.00

Hospital Revenue Code	272
Min. Negotiated Rate	$733.55
Max. Negotiated Rate	$837.11
Rate for Payer: Cash Price	$517.80
Rate for Payer: Health Management Network Commercial	$733.55
Rate for Payer: Kaiser Permanente Commercial	$776.70
Rate for Payer: MDX Hawaii PPO	$837.11

SUREFORM 60 2.5 WHITE 48360W

Facility

$863.00

Hospital Revenue Code	272
Min. Negotiated Rate	$267.53
Max. Negotiated Rate	$837.11
Rate for Payer: AlohaCare Medicaid	$431.50
Rate for Payer: AlohaCare Medicare	$267.53
Rate for Payer: Cash Price	$517.80
Rate for Payer: Devoted Health Medicare	$293.42
Rate for Payer: Hawaii Medical Service Association Medicare	$267.53
Rate for Payer: Hawaii Western Management Group Commercial	$819.85
Rate for Payer: Health Management Network Commercial	$733.55
Rate for Payer: Humana Medicare	$267.53
Rate for Payer: Kaiser Permanente Commercial	$776.70
Rate for Payer: Kaiser Permanente Medicaid	$440.13
Rate for Payer: Kaiser Permanente Medicare	$267.53
Rate for Payer: MDX Hawaii PPO	$837.11
Rate for Payer: Ohana Health Plan Medicaid	$267.53
Rate for Payer: Ohana Health Plan Medicare	$267.53
Rate for Payer: UnitedHealthcare Medicare	$267.53
Rate for Payer: University Health Alliance Commercial	$629.04

SUREFORM 60 3.5 BLUE 48360B

Facility

$906.00

Hospital Revenue Code	272
Min. Negotiated Rate	$280.86
Max. Negotiated Rate	$878.82
Rate for Payer: AlohaCare Medicaid	$453.00
Rate for Payer: AlohaCare Medicare	$280.86
Rate for Payer: Cash Price	$543.60
Rate for Payer: Devoted Health Medicare	$308.04
Rate for Payer: Hawaii Medical Service Association Medicare	$280.86
Rate for Payer: Hawaii Western Management Group Commercial	$860.70
Rate for Payer: Health Management Network Commercial	$770.10
Rate for Payer: Humana Medicare	$280.86
Rate for Payer: Kaiser Permanente Commercial	$815.40
Rate for Payer: Kaiser Permanente Medicaid	$462.06
Rate for Payer: Kaiser Permanente Medicare	$280.86
Rate for Payer: MDX Hawaii PPO	$878.82
Rate for Payer: Ohana Health Plan Medicaid	$280.86
Rate for Payer: Ohana Health Plan Medicare	$280.86
Rate for Payer: UnitedHealthcare Medicare	$280.86
Rate for Payer: University Health Alliance Commercial	$660.38

SUREFORM 60 3.5 BLUE 48360B

Facility

$906.00

Hospital Revenue Code	272
Min. Negotiated Rate	$770.10
Max. Negotiated Rate	$878.82
Rate for Payer: Cash Price	$543.60
Rate for Payer: Health Management Network Commercial	$770.10
Rate for Payer: Kaiser Permanente Commercial	$815.40
Rate for Payer: MDX Hawaii PPO	$878.82

SUREFORM 60 4.3 GREEN 48360G

Facility

$863.00

Hospital Revenue Code	272
Min. Negotiated Rate	$267.53
Max. Negotiated Rate	$837.11
Rate for Payer: AlohaCare Medicaid	$431.50
Rate for Payer: AlohaCare Medicare	$267.53
Rate for Payer: Cash Price	$517.80
Rate for Payer: Devoted Health Medicare	$293.42
Rate for Payer: Hawaii Medical Service Association Medicare	$267.53
Rate for Payer: Hawaii Western Management Group Commercial	$819.85
Rate for Payer: Health Management Network Commercial	$733.55
Rate for Payer: Humana Medicare	$267.53
Rate for Payer: Kaiser Permanente Commercial	$776.70
Rate for Payer: Kaiser Permanente Medicaid	$440.13
Rate for Payer: Kaiser Permanente Medicare	$267.53
Rate for Payer: MDX Hawaii PPO	$837.11
Rate for Payer: Ohana Health Plan Medicaid	$267.53
Rate for Payer: Ohana Health Plan Medicare	$267.53
Rate for Payer: UnitedHealthcare Medicare	$267.53
Rate for Payer: University Health Alliance Commercial	$629.04

SUREFORM 60 4.3 GREEN 48360G

Facility

$863.00

Hospital Revenue Code	272
Min. Negotiated Rate	$733.55
Max. Negotiated Rate	$837.11
Rate for Payer: Cash Price	$517.80
Rate for Payer: Health Management Network Commercial	$733.55
Rate for Payer: Kaiser Permanente Commercial	$776.70
Rate for Payer: MDX Hawaii PPO	$837.11

SURFACE ART TIB 42-5121-008-10

Facility

$2,850.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$1,596.00
Max. Negotiated Rate	$2,764.50
Rate for Payer: Cash Price	$1,710.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,995.00
Rate for Payer: Health Management Network Commercial	$2,422.50
Rate for Payer: Kaiser Permanente Commercial	$2,565.00
Rate for Payer: MDX Hawaii PPO	$2,764.50
Rate for Payer: University Health Alliance Commercial	$1,596.00

SURFACE ART TIB 42-5121-008-10

Facility

$2,850.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$883.50
Max. Negotiated Rate	$2,764.50
Rate for Payer: AlohaCare Medicaid	$1,425.00
Rate for Payer: AlohaCare Medicare	$883.50
Rate for Payer: Cash Price	$1,710.00
Rate for Payer: Devoted Health Medicare	$969.00
Rate for Payer: Hawaii Medical Service Association Medicare	$883.50
Rate for Payer: Hawaii Western Management Group Commercial	$1,995.00
Rate for Payer: Health Management Network Commercial	$2,422.50
Rate for Payer: Humana Medicare	$883.50
Rate for Payer: Kaiser Permanente Commercial	$2,565.00
Rate for Payer: Kaiser Permanente Medicaid	$1,453.50
Rate for Payer: Kaiser Permanente Medicare	$883.50
Rate for Payer: MDX Hawaii PPO	$2,764.50
Rate for Payer: Ohana Health Plan Medicaid	$883.50
Rate for Payer: Ohana Health Plan Medicare	$883.50
Rate for Payer: UnitedHealthcare Medicare	$883.50
Rate for Payer: University Health Alliance Commercial	$1,596.00

SURFACE TIBIAL 42-5221-009-10

Facility

$2,850.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$1,596.00
Max. Negotiated Rate	$2,764.50
Rate for Payer: Cash Price	$1,710.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,995.00
Rate for Payer: Health Management Network Commercial	$2,422.50
Rate for Payer: Kaiser Permanente Commercial	$2,565.00
Rate for Payer: MDX Hawaii PPO	$2,764.50
Rate for Payer: University Health Alliance Commercial	$1,596.00

SURFACE TIBIAL 42-5221-009-10

Facility

$2,850.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$883.50
Max. Negotiated Rate	$2,764.50
Rate for Payer: AlohaCare Medicaid	$1,425.00
Rate for Payer: AlohaCare Medicare	$883.50
Rate for Payer: Cash Price	$1,710.00
Rate for Payer: Devoted Health Medicare	$969.00
Rate for Payer: Hawaii Medical Service Association Medicare	$883.50
Rate for Payer: Hawaii Western Management Group Commercial	$1,995.00
Rate for Payer: Health Management Network Commercial	$2,422.50
Rate for Payer: Humana Medicare	$883.50
Rate for Payer: Kaiser Permanente Commercial	$2,565.00
Rate for Payer: Kaiser Permanente Medicaid	$1,453.50
Rate for Payer: Kaiser Permanente Medicare	$883.50
Rate for Payer: MDX Hawaii PPO	$2,764.50
Rate for Payer: Ohana Health Plan Medicaid	$883.50
Rate for Payer: Ohana Health Plan Medicare	$883.50
Rate for Payer: UnitedHealthcare Medicare	$883.50
Rate for Payer: University Health Alliance Commercial	$1,596.00

SURGICAL MESH/TISSUE WSM1015

Facility

$3,690.00

Service Code	HCPCS Q4166
Hospital Revenue Code	636
Min. Negotiated Rate	$20.85
Max. Negotiated Rate	$3,579.30
Rate for Payer: AlohaCare Medicaid	$1,845.00
Rate for Payer: AlohaCare Medicare	$1,143.90
Rate for Payer: Cash Price	$2,214.00
Rate for Payer: Cash Price	$2,214.00
Rate for Payer: Devoted Health Medicare	$1,254.60
Rate for Payer: Hawaii Medical Service Association ABD	$20.85
Rate for Payer: Hawaii Medical Service Association Commercial	$158.93
Rate for Payer: Hawaii Medical Service Association Medicare	$1,143.90
Rate for Payer: Hawaii Medical Service Association Non-ABD	$20.85
Rate for Payer: Hawaii Western Management Group Commercial	$3,505.50
Rate for Payer: Health Management Network Commercial	$3,136.50
Rate for Payer: Humana Medicare	$1,143.90
Rate for Payer: Kaiser Permanente Commercial	$3,321.00
Rate for Payer: Kaiser Permanente Medicaid	$1,881.90
Rate for Payer: Kaiser Permanente Medicare	$1,143.90
Rate for Payer: MDX Hawaii PPO	$3,579.30
Rate for Payer: Ohana Health Plan Medicaid	$1,143.90
Rate for Payer: Ohana Health Plan Medicare	$1,143.90
Rate for Payer: UnitedHealthcare Medicaid	$2,214.00
Rate for Payer: UnitedHealthcare Medicare	$1,143.90
Rate for Payer: University Health Alliance Commercial	$2,689.64

SURGICAL MESH/TISSUE WSM1015

Facility

$3,690.00

Service Code	HCPCS Q4166
Hospital Revenue Code	636
Min. Negotiated Rate	$3,136.50
Max. Negotiated Rate	$3,579.30
Rate for Payer: Cash Price	$2,214.00
Rate for Payer: Health Management Network Commercial	$3,136.50
Rate for Payer: Kaiser Permanente Commercial	$3,321.00
Rate for Payer: MDX Hawaii PPO	$3,579.30

Know your out-of-pocket cost for care.

All Charges