Kau Hospital

All Charges

Charge

Type

Setting

Price

SURGICAL MESH WSM0710

Facility

$2,050.00

Service Code	HCPCS Q4166
Hospital Revenue Code	636
Min. Negotiated Rate	$1,742.50
Max. Negotiated Rate	$1,988.50
Rate for Payer: Cash Price	$1,230.00
Rate for Payer: Health Management Network Commercial	$1,742.50
Rate for Payer: Kaiser Permanente Commercial	$1,845.00
Rate for Payer: MDX Hawaii PPO	$1,988.50

SURGICAL MESH WSM0710

Facility

$2,050.00

Service Code	HCPCS Q4166
Hospital Revenue Code	636
Min. Negotiated Rate	$20.85
Max. Negotiated Rate	$1,988.50
Rate for Payer: AlohaCare Medicaid	$1,025.00
Rate for Payer: AlohaCare Medicare	$635.50
Rate for Payer: Cash Price	$1,230.00
Rate for Payer: Cash Price	$1,230.00
Rate for Payer: Devoted Health Medicare	$697.00
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	$635.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$20.85
Rate for Payer: Hawaii Western Management Group Commercial	$1,947.50
Rate for Payer: Health Management Network Commercial	$1,742.50
Rate for Payer: Humana Medicare	$635.50
Rate for Payer: Kaiser Permanente Commercial	$1,845.00
Rate for Payer: Kaiser Permanente Medicaid	$1,045.50
Rate for Payer: Kaiser Permanente Medicare	$635.50
Rate for Payer: MDX Hawaii PPO	$1,988.50
Rate for Payer: Ohana Health Plan Medicaid	$635.50
Rate for Payer: Ohana Health Plan Medicare	$635.50
Rate for Payer: UnitedHealthcare Medicaid	$1,230.00
Rate for Payer: UnitedHealthcare Medicare	$635.50
Rate for Payer: University Health Alliance Commercial	$1,494.24

SURGICAL POST BRA LG M5001-L

Facility

$106.00

Hospital Revenue Code	272
Min. Negotiated Rate	$32.86
Max. Negotiated Rate	$102.82
Rate for Payer: AlohaCare Medicaid	$53.00
Rate for Payer: AlohaCare Medicare	$32.86
Rate for Payer: Cash Price	$63.60
Rate for Payer: Devoted Health Medicare	$36.04
Rate for Payer: Hawaii Medical Service Association Medicare	$32.86
Rate for Payer: Hawaii Western Management Group Commercial	$100.70
Rate for Payer: Health Management Network Commercial	$90.10
Rate for Payer: Humana Medicare	$32.86
Rate for Payer: Kaiser Permanente Commercial	$95.40
Rate for Payer: Kaiser Permanente Medicaid	$54.06
Rate for Payer: Kaiser Permanente Medicare	$32.86
Rate for Payer: MDX Hawaii PPO	$102.82
Rate for Payer: Ohana Health Plan Medicaid	$32.86
Rate for Payer: Ohana Health Plan Medicare	$32.86
Rate for Payer: UnitedHealthcare Medicare	$32.86
Rate for Payer: University Health Alliance Commercial	$77.26

SURGICAL POST BRA LG M5001-L

Facility

$106.00

Hospital Revenue Code	272
Min. Negotiated Rate	$90.10
Max. Negotiated Rate	$102.82
Rate for Payer: Cash Price	$63.60
Rate for Payer: Health Management Network Commercial	$90.10
Rate for Payer: Kaiser Permanente Commercial	$95.40
Rate for Payer: MDX Hawaii PPO	$102.82

SURGICAL POST BRA MED M5001-M

Facility

$106.00

Hospital Revenue Code	272
Min. Negotiated Rate	$90.10
Max. Negotiated Rate	$102.82
Rate for Payer: Cash Price	$63.60
Rate for Payer: Health Management Network Commercial	$90.10
Rate for Payer: Kaiser Permanente Commercial	$95.40
Rate for Payer: MDX Hawaii PPO	$102.82

SURGICAL POST BRA MED M5001-M

Facility

$106.00

Hospital Revenue Code	272
Min. Negotiated Rate	$32.86
Max. Negotiated Rate	$102.82
Rate for Payer: AlohaCare Medicaid	$53.00
Rate for Payer: AlohaCare Medicare	$32.86
Rate for Payer: Cash Price	$63.60
Rate for Payer: Devoted Health Medicare	$36.04
Rate for Payer: Hawaii Medical Service Association Medicare	$32.86
Rate for Payer: Hawaii Western Management Group Commercial	$100.70
Rate for Payer: Health Management Network Commercial	$90.10
Rate for Payer: Humana Medicare	$32.86
Rate for Payer: Kaiser Permanente Commercial	$95.40
Rate for Payer: Kaiser Permanente Medicaid	$54.06
Rate for Payer: Kaiser Permanente Medicare	$32.86
Rate for Payer: MDX Hawaii PPO	$102.82
Rate for Payer: Ohana Health Plan Medicaid	$32.86
Rate for Payer: Ohana Health Plan Medicare	$32.86
Rate for Payer: UnitedHealthcare Medicare	$32.86
Rate for Payer: University Health Alliance Commercial	$77.26

SURGICAL POST BRA XLG M5001-XL

Facility

$106.00

Hospital Revenue Code	272
Min. Negotiated Rate	$32.86
Max. Negotiated Rate	$102.82
Rate for Payer: AlohaCare Medicaid	$53.00
Rate for Payer: AlohaCare Medicare	$32.86
Rate for Payer: Cash Price	$63.60
Rate for Payer: Devoted Health Medicare	$36.04
Rate for Payer: Hawaii Medical Service Association Medicare	$32.86
Rate for Payer: Hawaii Western Management Group Commercial	$100.70
Rate for Payer: Health Management Network Commercial	$90.10
Rate for Payer: Humana Medicare	$32.86
Rate for Payer: Kaiser Permanente Commercial	$95.40
Rate for Payer: Kaiser Permanente Medicaid	$54.06
Rate for Payer: Kaiser Permanente Medicare	$32.86
Rate for Payer: MDX Hawaii PPO	$102.82
Rate for Payer: Ohana Health Plan Medicaid	$32.86
Rate for Payer: Ohana Health Plan Medicare	$32.86
Rate for Payer: UnitedHealthcare Medicare	$32.86
Rate for Payer: University Health Alliance Commercial	$77.26

SURGICAL POST BRA XLG M5001-XL

Facility

$106.00

Hospital Revenue Code	272
Min. Negotiated Rate	$90.10
Max. Negotiated Rate	$102.82
Rate for Payer: Cash Price	$63.60
Rate for Payer: Health Management Network Commercial	$90.10
Rate for Payer: Kaiser Permanente Commercial	$95.40
Rate for Payer: MDX Hawaii PPO	$102.82

SURGICEL APPLICATOR 3123SPEA

Facility

$133.00

Hospital Revenue Code	272
Min. Negotiated Rate	$41.23
Max. Negotiated Rate	$129.01
Rate for Payer: AlohaCare Medicaid	$66.50
Rate for Payer: AlohaCare Medicare	$41.23
Rate for Payer: Cash Price	$79.80
Rate for Payer: Devoted Health Medicare	$45.22
Rate for Payer: Hawaii Medical Service Association Medicare	$41.23
Rate for Payer: Hawaii Western Management Group Commercial	$126.35
Rate for Payer: Health Management Network Commercial	$113.05
Rate for Payer: Humana Medicare	$41.23
Rate for Payer: Kaiser Permanente Commercial	$119.70
Rate for Payer: Kaiser Permanente Medicaid	$67.83
Rate for Payer: Kaiser Permanente Medicare	$41.23
Rate for Payer: MDX Hawaii PPO	$129.01
Rate for Payer: Ohana Health Plan Medicaid	$41.23
Rate for Payer: Ohana Health Plan Medicare	$41.23
Rate for Payer: UnitedHealthcare Medicare	$41.23
Rate for Payer: University Health Alliance Commercial	$96.94

SURGICEL APPLICATOR 3123SPEA

Facility

$133.00

Hospital Revenue Code	272
Min. Negotiated Rate	$113.05
Max. Negotiated Rate	$129.01
Rate for Payer: Cash Price	$79.80
Rate for Payer: Health Management Network Commercial	$113.05
Rate for Payer: Kaiser Permanente Commercial	$119.70
Rate for Payer: MDX Hawaii PPO	$129.01

SURGICEL POWDER 3.0GM 3013SP

Facility

$2,248.00

Hospital Revenue Code	272
Min. Negotiated Rate	$1,910.80
Max. Negotiated Rate	$2,180.56
Rate for Payer: Cash Price	$1,348.80
Rate for Payer: Health Management Network Commercial	$1,910.80
Rate for Payer: Kaiser Permanente Commercial	$2,023.20
Rate for Payer: MDX Hawaii PPO	$2,180.56

SURGICEL POWDER 3.0GM 3013SP

Facility

$2,248.00

Hospital Revenue Code	272
Min. Negotiated Rate	$696.88
Max. Negotiated Rate	$2,180.56
Rate for Payer: AlohaCare Medicaid	$1,124.00
Rate for Payer: AlohaCare Medicare	$696.88
Rate for Payer: Cash Price	$1,348.80
Rate for Payer: Devoted Health Medicare	$764.32
Rate for Payer: Hawaii Medical Service Association Medicare	$696.88
Rate for Payer: Hawaii Western Management Group Commercial	$2,135.60
Rate for Payer: Health Management Network Commercial	$1,910.80
Rate for Payer: Humana Medicare	$696.88
Rate for Payer: Kaiser Permanente Commercial	$2,023.20
Rate for Payer: Kaiser Permanente Medicaid	$1,146.48
Rate for Payer: Kaiser Permanente Medicare	$696.88
Rate for Payer: MDX Hawaii PPO	$2,180.56
Rate for Payer: Ohana Health Plan Medicaid	$696.88
Rate for Payer: Ohana Health Plan Medicare	$696.88
Rate for Payer: UnitedHealthcare Medicare	$696.88
Rate for Payer: University Health Alliance Commercial	$1,638.57

SURGICEL SNOW 2X4IN 2082

Facility

$596.00

Hospital Revenue Code	272
Min. Negotiated Rate	$506.60
Max. Negotiated Rate	$578.12
Rate for Payer: Cash Price	$357.60
Rate for Payer: Health Management Network Commercial	$506.60
Rate for Payer: Kaiser Permanente Commercial	$536.40
Rate for Payer: MDX Hawaii PPO	$578.12

SURGICEL SNOW 2X4IN 2082

Facility

$596.00

Hospital Revenue Code	272
Min. Negotiated Rate	$184.76
Max. Negotiated Rate	$578.12
Rate for Payer: AlohaCare Medicaid	$298.00
Rate for Payer: AlohaCare Medicare	$184.76
Rate for Payer: Cash Price	$357.60
Rate for Payer: Devoted Health Medicare	$202.64
Rate for Payer: Hawaii Medical Service Association Medicare	$184.76
Rate for Payer: Hawaii Western Management Group Commercial	$566.20
Rate for Payer: Health Management Network Commercial	$506.60
Rate for Payer: Humana Medicare	$184.76
Rate for Payer: Kaiser Permanente Commercial	$536.40
Rate for Payer: Kaiser Permanente Medicaid	$303.96
Rate for Payer: Kaiser Permanente Medicare	$184.76
Rate for Payer: MDX Hawaii PPO	$578.12
Rate for Payer: Ohana Health Plan Medicaid	$184.76
Rate for Payer: Ohana Health Plan Medicare	$184.76
Rate for Payer: UnitedHealthcare Medicare	$184.76
Rate for Payer: University Health Alliance Commercial	$434.42

SURGICLIP PREMIUM

Facility

$215.00

Hospital Revenue Code	272
Min. Negotiated Rate	$66.65
Max. Negotiated Rate	$208.55
Rate for Payer: AlohaCare Medicaid	$107.50
Rate for Payer: AlohaCare Medicare	$66.65
Rate for Payer: Cash Price	$129.00
Rate for Payer: Devoted Health Medicare	$73.10
Rate for Payer: Hawaii Medical Service Association Medicare	$66.65
Rate for Payer: Hawaii Western Management Group Commercial	$204.25
Rate for Payer: Health Management Network Commercial	$182.75
Rate for Payer: Humana Medicare	$66.65
Rate for Payer: Kaiser Permanente Commercial	$193.50
Rate for Payer: Kaiser Permanente Medicaid	$109.65
Rate for Payer: Kaiser Permanente Medicare	$66.65
Rate for Payer: MDX Hawaii PPO	$208.55
Rate for Payer: Ohana Health Plan Medicaid	$66.65
Rate for Payer: Ohana Health Plan Medicare	$66.65
Rate for Payer: UnitedHealthcare Medicare	$66.65
Rate for Payer: University Health Alliance Commercial	$156.71

SURGICLIP PREMIUM

Facility

$215.00

Hospital Revenue Code	272
Min. Negotiated Rate	$182.75
Max. Negotiated Rate	$208.55
Rate for Payer: Cash Price	$129.00
Rate for Payer: Health Management Network Commercial	$182.75
Rate for Payer: Kaiser Permanente Commercial	$193.50
Rate for Payer: MDX Hawaii PPO	$208.55

SURGICLIP PREMIUM LG

Facility

$207.00

Hospital Revenue Code	272
Min. Negotiated Rate	$64.17
Max. Negotiated Rate	$200.79
Rate for Payer: AlohaCare Medicaid	$103.50
Rate for Payer: AlohaCare Medicare	$64.17
Rate for Payer: Cash Price	$124.20
Rate for Payer: Devoted Health Medicare	$70.38
Rate for Payer: Hawaii Medical Service Association Medicare	$64.17
Rate for Payer: Hawaii Western Management Group Commercial	$196.65
Rate for Payer: Health Management Network Commercial	$175.95
Rate for Payer: Humana Medicare	$64.17
Rate for Payer: Kaiser Permanente Commercial	$186.30
Rate for Payer: Kaiser Permanente Medicaid	$105.57
Rate for Payer: Kaiser Permanente Medicare	$64.17
Rate for Payer: MDX Hawaii PPO	$200.79
Rate for Payer: Ohana Health Plan Medicaid	$64.17
Rate for Payer: Ohana Health Plan Medicare	$64.17
Rate for Payer: UnitedHealthcare Medicare	$64.17
Rate for Payer: University Health Alliance Commercial	$150.88

SURGICLIP PREMIUM LG

Facility

$207.00

Hospital Revenue Code	272
Min. Negotiated Rate	$175.95
Max. Negotiated Rate	$200.79
Rate for Payer: Cash Price	$124.20
Rate for Payer: Health Management Network Commercial	$175.95
Rate for Payer: Kaiser Permanente Commercial	$186.30
Rate for Payer: MDX Hawaii PPO	$200.79

SURGICLIP PREMIUM SM

Facility

$240.00

Hospital Revenue Code	272
Min. Negotiated Rate	$74.40
Max. Negotiated Rate	$232.80
Rate for Payer: AlohaCare Medicaid	$120.00
Rate for Payer: AlohaCare Medicare	$74.40
Rate for Payer: Cash Price	$144.00
Rate for Payer: Devoted Health Medicare	$81.60
Rate for Payer: Hawaii Medical Service Association Medicare	$74.40
Rate for Payer: Hawaii Western Management Group Commercial	$228.00
Rate for Payer: Health Management Network Commercial	$204.00
Rate for Payer: Humana Medicare	$74.40
Rate for Payer: Kaiser Permanente Commercial	$216.00
Rate for Payer: Kaiser Permanente Medicaid	$122.40
Rate for Payer: Kaiser Permanente Medicare	$74.40
Rate for Payer: MDX Hawaii PPO	$232.80
Rate for Payer: Ohana Health Plan Medicaid	$74.40
Rate for Payer: Ohana Health Plan Medicare	$74.40
Rate for Payer: UnitedHealthcare Medicare	$74.40
Rate for Payer: University Health Alliance Commercial	$174.94

SURGICLIP PREMIUM SM

Facility

$240.00

Hospital Revenue Code	272
Min. Negotiated Rate	$204.00
Max. Negotiated Rate	$232.80
Rate for Payer: Cash Price	$144.00
Rate for Payer: Health Management Network Commercial	$204.00
Rate for Payer: Kaiser Permanente Commercial	$216.00
Rate for Payer: MDX Hawaii PPO	$232.80

SURGIFOAM SPONGE 8X12.5

Facility

$170.00

Hospital Revenue Code	272
Min. Negotiated Rate	$144.50
Max. Negotiated Rate	$164.90
Rate for Payer: Cash Price	$102.00
Rate for Payer: Health Management Network Commercial	$144.50
Rate for Payer: Kaiser Permanente Commercial	$153.00
Rate for Payer: MDX Hawaii PPO	$164.90

SURGIFOAM SPONGE 8X12.5

Facility

$170.00

Hospital Revenue Code	272
Min. Negotiated Rate	$52.70
Max. Negotiated Rate	$164.90
Rate for Payer: AlohaCare Medicaid	$85.00
Rate for Payer: AlohaCare Medicare	$52.70
Rate for Payer: Cash Price	$102.00
Rate for Payer: Devoted Health Medicare	$57.80
Rate for Payer: Hawaii Medical Service Association Medicare	$52.70
Rate for Payer: Hawaii Western Management Group Commercial	$161.50
Rate for Payer: Health Management Network Commercial	$144.50
Rate for Payer: Humana Medicare	$52.70
Rate for Payer: Kaiser Permanente Commercial	$153.00
Rate for Payer: Kaiser Permanente Medicaid	$86.70
Rate for Payer: Kaiser Permanente Medicare	$52.70
Rate for Payer: MDX Hawaii PPO	$164.90
Rate for Payer: Ohana Health Plan Medicaid	$52.70
Rate for Payer: Ohana Health Plan Medicare	$52.70
Rate for Payer: UnitedHealthcare Medicare	$52.70
Rate for Payer: University Health Alliance Commercial	$123.91

SURGIMEND PRS 8X16 606-004-108

Facility

$5,888.00

Service Code	HCPCS C9358
Hospital Revenue Code	278
Min. Negotiated Rate	$3,297.28
Max. Negotiated Rate	$5,711.36
Rate for Payer: Cash Price	$3,532.80
Rate for Payer: Hawaii Western Management Group Commercial	$4,121.60
Rate for Payer: Health Management Network Commercial	$5,004.80
Rate for Payer: Kaiser Permanente Commercial	$5,299.20
Rate for Payer: MDX Hawaii PPO	$5,711.36
Rate for Payer: University Health Alliance Commercial	$3,297.28

SURGIMEND PRS 8X16 606-004-108

Facility

$5,888.00

Service Code	HCPCS C9358
Hospital Revenue Code	278
Min. Negotiated Rate	$1,825.28
Max. Negotiated Rate	$5,711.36
Rate for Payer: AlohaCare Medicaid	$2,944.00
Rate for Payer: AlohaCare Medicare	$1,825.28
Rate for Payer: Cash Price	$3,532.80
Rate for Payer: Devoted Health Medicare	$2,001.92
Rate for Payer: Hawaii Medical Service Association Medicare	$1,825.28
Rate for Payer: Hawaii Western Management Group Commercial	$4,121.60
Rate for Payer: Health Management Network Commercial	$5,004.80
Rate for Payer: Humana Medicare	$1,825.28
Rate for Payer: Kaiser Permanente Commercial	$5,299.20
Rate for Payer: Kaiser Permanente Medicaid	$3,002.88
Rate for Payer: Kaiser Permanente Medicare	$1,825.28
Rate for Payer: MDX Hawaii PPO	$5,711.36
Rate for Payer: Ohana Health Plan Medicaid	$1,825.28
Rate for Payer: Ohana Health Plan Medicare	$1,825.28
Rate for Payer: UnitedHealthcare Medicare	$1,825.28
Rate for Payer: University Health Alliance Commercial	$3,297.28

SURGIMEND PRS THIN 606-004-104

Facility

$10,350.00

Service Code	HCPCS C9358
Hospital Revenue Code	278
Min. Negotiated Rate	$5,796.00
Max. Negotiated Rate	$10,039.50
Rate for Payer: Cash Price	$6,210.00
Rate for Payer: Hawaii Western Management Group Commercial	$7,245.00
Rate for Payer: Health Management Network Commercial	$8,797.50
Rate for Payer: Kaiser Permanente Commercial	$9,315.00
Rate for Payer: MDX Hawaii PPO	$10,039.50
Rate for Payer: University Health Alliance Commercial	$5,796.00

Know your out-of-pocket cost for care.

All Charges