Kau Hospital

All Charges

Charge

Type

Setting

Price

SURGIMEND PRS THIN 606-004-104

Facility

$10,350.00

Service Code	HCPCS C9358
Hospital Revenue Code	278
Min. Negotiated Rate	$3,208.50
Max. Negotiated Rate	$10,039.50
Rate for Payer: AlohaCare Medicaid	$5,175.00
Rate for Payer: AlohaCare Medicare	$3,208.50
Rate for Payer: Cash Price	$6,210.00
Rate for Payer: Devoted Health Medicare	$3,519.00
Rate for Payer: Hawaii Medical Service Association Medicare	$3,208.50
Rate for Payer: Hawaii Western Management Group Commercial	$7,245.00
Rate for Payer: Health Management Network Commercial	$8,797.50
Rate for Payer: Humana Medicare	$3,208.50
Rate for Payer: Kaiser Permanente Commercial	$9,315.00
Rate for Payer: Kaiser Permanente Medicaid	$5,278.50
Rate for Payer: Kaiser Permanente Medicare	$3,208.50
Rate for Payer: MDX Hawaii PPO	$10,039.50
Rate for Payer: Ohana Health Plan Medicaid	$3,208.50
Rate for Payer: Ohana Health Plan Medicare	$3,208.50
Rate for Payer: UnitedHealthcare Medicare	$3,208.50
Rate for Payer: University Health Alliance Commercial	$5,796.00

SUT CHROMIC ENDO LOOP #0

Facility

$91.00

Hospital Revenue Code	272
Min. Negotiated Rate	$77.35
Max. Negotiated Rate	$88.27
Rate for Payer: Cash Price	$54.60
Rate for Payer: Health Management Network Commercial	$77.35
Rate for Payer: Kaiser Permanente Commercial	$81.90
Rate for Payer: MDX Hawaii PPO	$88.27

SUT CHROMIC ENDO LOOP #0

Facility

$91.00

Hospital Revenue Code	272
Min. Negotiated Rate	$28.21
Max. Negotiated Rate	$88.27
Rate for Payer: AlohaCare Medicaid	$45.50
Rate for Payer: AlohaCare Medicare	$28.21
Rate for Payer: Cash Price	$54.60
Rate for Payer: Devoted Health Medicare	$30.94
Rate for Payer: Hawaii Medical Service Association Medicare	$28.21
Rate for Payer: Hawaii Western Management Group Commercial	$86.45
Rate for Payer: Health Management Network Commercial	$77.35
Rate for Payer: Humana Medicare	$28.21
Rate for Payer: Kaiser Permanente Commercial	$81.90
Rate for Payer: Kaiser Permanente Medicaid	$46.41
Rate for Payer: Kaiser Permanente Medicare	$28.21
Rate for Payer: MDX Hawaii PPO	$88.27
Rate for Payer: Ohana Health Plan Medicaid	$28.21
Rate for Payer: Ohana Health Plan Medicare	$28.21
Rate for Payer: UnitedHealthcare Medicare	$28.21
Rate for Payer: University Health Alliance Commercial	$66.33

SUT CT CLOSURE SYSTEM

Facility

$590.00

Hospital Revenue Code	272
Min. Negotiated Rate	$182.90
Max. Negotiated Rate	$572.30
Rate for Payer: AlohaCare Medicaid	$295.00
Rate for Payer: AlohaCare Medicare	$182.90
Rate for Payer: Cash Price	$354.00
Rate for Payer: Devoted Health Medicare	$200.60
Rate for Payer: Hawaii Medical Service Association Medicare	$182.90
Rate for Payer: Hawaii Western Management Group Commercial	$560.50
Rate for Payer: Health Management Network Commercial	$501.50
Rate for Payer: Humana Medicare	$182.90
Rate for Payer: Kaiser Permanente Commercial	$531.00
Rate for Payer: Kaiser Permanente Medicaid	$300.90
Rate for Payer: Kaiser Permanente Medicare	$182.90
Rate for Payer: MDX Hawaii PPO	$572.30
Rate for Payer: Ohana Health Plan Medicaid	$182.90
Rate for Payer: Ohana Health Plan Medicare	$182.90
Rate for Payer: UnitedHealthcare Medicare	$182.90
Rate for Payer: University Health Alliance Commercial	$430.05

SUT CT CLOSURE SYSTEM

Facility

$590.00

Hospital Revenue Code	272
Min. Negotiated Rate	$501.50
Max. Negotiated Rate	$572.30
Rate for Payer: Cash Price	$354.00
Rate for Payer: Health Management Network Commercial	$501.50
Rate for Payer: Kaiser Permanente Commercial	$531.00
Rate for Payer: MDX Hawaii PPO	$572.30

SUT ENDO 2-0 POLYSORB 48IN

Facility

$124.00

Hospital Revenue Code	272
Min. Negotiated Rate	$105.40
Max. Negotiated Rate	$120.28
Rate for Payer: Cash Price	$74.40
Rate for Payer: Health Management Network Commercial	$105.40
Rate for Payer: Kaiser Permanente Commercial	$111.60
Rate for Payer: MDX Hawaii PPO	$120.28

SUT ENDO 2-0 POLYSORB 48IN

Facility

$124.00

Hospital Revenue Code	272
Min. Negotiated Rate	$38.44
Max. Negotiated Rate	$120.28
Rate for Payer: AlohaCare Medicaid	$62.00
Rate for Payer: AlohaCare Medicare	$38.44
Rate for Payer: Cash Price	$74.40
Rate for Payer: Devoted Health Medicare	$42.16
Rate for Payer: Hawaii Medical Service Association Medicare	$38.44
Rate for Payer: Hawaii Western Management Group Commercial	$117.80
Rate for Payer: Health Management Network Commercial	$105.40
Rate for Payer: Humana Medicare	$38.44
Rate for Payer: Kaiser Permanente Commercial	$111.60
Rate for Payer: Kaiser Permanente Medicaid	$63.24
Rate for Payer: Kaiser Permanente Medicare	$38.44
Rate for Payer: MDX Hawaii PPO	$120.28
Rate for Payer: Ohana Health Plan Medicaid	$38.44
Rate for Payer: Ohana Health Plan Medicare	$38.44
Rate for Payer: UnitedHealthcare Medicare	$38.44
Rate for Payer: University Health Alliance Commercial	$90.38

SUTLASSO CURVE LT AR-4068-25TL

Facility

$551.00

Hospital Revenue Code	272
Min. Negotiated Rate	$170.81
Max. Negotiated Rate	$534.47
Rate for Payer: AlohaCare Medicaid	$275.50
Rate for Payer: AlohaCare Medicare	$170.81
Rate for Payer: Cash Price	$330.60
Rate for Payer: Devoted Health Medicare	$187.34
Rate for Payer: Hawaii Medical Service Association Medicare	$170.81
Rate for Payer: Hawaii Western Management Group Commercial	$523.45
Rate for Payer: Health Management Network Commercial	$468.35
Rate for Payer: Humana Medicare	$170.81
Rate for Payer: Kaiser Permanente Commercial	$495.90
Rate for Payer: Kaiser Permanente Medicaid	$281.01
Rate for Payer: Kaiser Permanente Medicare	$170.81
Rate for Payer: MDX Hawaii PPO	$534.47
Rate for Payer: Ohana Health Plan Medicaid	$170.81
Rate for Payer: Ohana Health Plan Medicare	$170.81
Rate for Payer: UnitedHealthcare Medicare	$170.81
Rate for Payer: University Health Alliance Commercial	$401.62

SUTLASSO CURVE LT AR-4068-25TL

Facility

$551.00

Hospital Revenue Code	272
Min. Negotiated Rate	$468.35
Max. Negotiated Rate	$534.47
Rate for Payer: Cash Price	$330.60
Rate for Payer: Health Management Network Commercial	$468.35
Rate for Payer: Kaiser Permanente Commercial	$495.90
Rate for Payer: MDX Hawaii PPO	$534.47

SUT LIGASURE PDS ENDOLOOP

Facility

$600.00

Hospital Revenue Code	272
Min. Negotiated Rate	$186.00
Max. Negotiated Rate	$582.00
Rate for Payer: AlohaCare Medicaid	$300.00
Rate for Payer: AlohaCare Medicare	$186.00
Rate for Payer: Cash Price	$360.00
Rate for Payer: Devoted Health Medicare	$204.00
Rate for Payer: Hawaii Medical Service Association Medicare	$186.00
Rate for Payer: Hawaii Western Management Group Commercial	$570.00
Rate for Payer: Health Management Network Commercial	$510.00
Rate for Payer: Humana Medicare	$186.00
Rate for Payer: Kaiser Permanente Commercial	$540.00
Rate for Payer: Kaiser Permanente Medicaid	$306.00
Rate for Payer: Kaiser Permanente Medicare	$186.00
Rate for Payer: MDX Hawaii PPO	$582.00
Rate for Payer: Ohana Health Plan Medicaid	$186.00
Rate for Payer: Ohana Health Plan Medicare	$186.00
Rate for Payer: UnitedHealthcare Medicare	$186.00
Rate for Payer: University Health Alliance Commercial	$437.34

SUT LIGASURE PDS ENDOLOOP

Facility

$600.00

Hospital Revenue Code	272
Min. Negotiated Rate	$510.00
Max. Negotiated Rate	$582.00
Rate for Payer: Cash Price	$360.00
Rate for Payer: Health Management Network Commercial	$510.00
Rate for Payer: Kaiser Permanente Commercial	$540.00
Rate for Payer: MDX Hawaii PPO	$582.00

SUT POLYSORB ENDO LOOP #0

Facility

$136.00

Hospital Revenue Code	272
Min. Negotiated Rate	$115.60
Max. Negotiated Rate	$131.92
Rate for Payer: Cash Price	$81.60
Rate for Payer: Health Management Network Commercial	$115.60
Rate for Payer: Kaiser Permanente Commercial	$122.40
Rate for Payer: MDX Hawaii PPO	$131.92

SUT POLYSORB ENDO LOOP #0

Facility

$136.00

Hospital Revenue Code	272
Min. Negotiated Rate	$42.16
Max. Negotiated Rate	$131.92
Rate for Payer: AlohaCare Medicaid	$68.00
Rate for Payer: AlohaCare Medicare	$42.16
Rate for Payer: Cash Price	$81.60
Rate for Payer: Devoted Health Medicare	$46.24
Rate for Payer: Hawaii Medical Service Association Medicare	$42.16
Rate for Payer: Hawaii Western Management Group Commercial	$129.20
Rate for Payer: Health Management Network Commercial	$115.60
Rate for Payer: Humana Medicare	$42.16
Rate for Payer: Kaiser Permanente Commercial	$122.40
Rate for Payer: Kaiser Permanente Medicaid	$69.36
Rate for Payer: Kaiser Permanente Medicare	$42.16
Rate for Payer: MDX Hawaii PPO	$131.92
Rate for Payer: Ohana Health Plan Medicaid	$42.16
Rate for Payer: Ohana Health Plan Medicare	$42.16
Rate for Payer: UnitedHealthcare Medicare	$42.16
Rate for Payer: University Health Alliance Commercial	$99.13

SUTURE ANCHOR 2.4X8.5MM

Facility

$1,562.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$874.72
Max. Negotiated Rate	$1,515.14
Rate for Payer: Cash Price	$937.20
Rate for Payer: Hawaii Western Management Group Commercial	$1,093.40
Rate for Payer: Health Management Network Commercial	$1,327.70
Rate for Payer: Kaiser Permanente Commercial	$1,405.80
Rate for Payer: MDX Hawaii PPO	$1,515.14
Rate for Payer: University Health Alliance Commercial	$874.72

SUTURE ANCHOR 2.4X8.5MM

Facility

$1,562.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$484.22
Max. Negotiated Rate	$1,515.14
Rate for Payer: AlohaCare Medicaid	$781.00
Rate for Payer: AlohaCare Medicare	$484.22
Rate for Payer: Cash Price	$937.20
Rate for Payer: Devoted Health Medicare	$531.08
Rate for Payer: Hawaii Medical Service Association Medicare	$484.22
Rate for Payer: Hawaii Western Management Group Commercial	$1,093.40
Rate for Payer: Health Management Network Commercial	$1,327.70
Rate for Payer: Humana Medicare	$484.22
Rate for Payer: Kaiser Permanente Commercial	$1,405.80
Rate for Payer: Kaiser Permanente Medicaid	$796.62
Rate for Payer: Kaiser Permanente Medicare	$484.22
Rate for Payer: MDX Hawaii PPO	$1,515.14
Rate for Payer: Ohana Health Plan Medicaid	$484.22
Rate for Payer: Ohana Health Plan Medicare	$484.22
Rate for Payer: UnitedHealthcare Medicare	$484.22
Rate for Payer: University Health Alliance Commercial	$874.72

SUTURE ANCHOR 4.75 72203704

Facility

$1,663.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$515.53
Max. Negotiated Rate	$1,613.11
Rate for Payer: AlohaCare Medicaid	$831.50
Rate for Payer: AlohaCare Medicare	$515.53
Rate for Payer: Cash Price	$997.80
Rate for Payer: Devoted Health Medicare	$565.42
Rate for Payer: Hawaii Medical Service Association Medicare	$515.53
Rate for Payer: Hawaii Western Management Group Commercial	$1,164.10
Rate for Payer: Health Management Network Commercial	$1,413.55
Rate for Payer: Humana Medicare	$515.53
Rate for Payer: Kaiser Permanente Commercial	$1,496.70
Rate for Payer: Kaiser Permanente Medicaid	$848.13
Rate for Payer: Kaiser Permanente Medicare	$515.53
Rate for Payer: MDX Hawaii PPO	$1,613.11
Rate for Payer: Ohana Health Plan Medicaid	$515.53
Rate for Payer: Ohana Health Plan Medicare	$515.53
Rate for Payer: UnitedHealthcare Medicare	$515.53
Rate for Payer: University Health Alliance Commercial	$931.28

SUTURE ANCHOR 4.75 72203704

Facility

$1,663.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$931.28
Max. Negotiated Rate	$1,613.11
Rate for Payer: Cash Price	$997.80
Rate for Payer: Hawaii Western Management Group Commercial	$1,164.10
Rate for Payer: Health Management Network Commercial	$1,413.55
Rate for Payer: Kaiser Permanente Commercial	$1,496.70
Rate for Payer: MDX Hawaii PPO	$1,613.11
Rate for Payer: University Health Alliance Commercial	$931.28

SUTURE ANCHOR 4.75 72203705

Facility

$1,663.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$931.28
Max. Negotiated Rate	$1,613.11
Rate for Payer: Cash Price	$997.80
Rate for Payer: Hawaii Western Management Group Commercial	$1,164.10
Rate for Payer: Health Management Network Commercial	$1,413.55
Rate for Payer: Kaiser Permanente Commercial	$1,496.70
Rate for Payer: MDX Hawaii PPO	$1,613.11
Rate for Payer: University Health Alliance Commercial	$931.28

SUTURE ANCHOR 4.75 72203705

Facility

$1,663.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$515.53
Max. Negotiated Rate	$1,613.11
Rate for Payer: AlohaCare Medicaid	$831.50
Rate for Payer: AlohaCare Medicare	$515.53
Rate for Payer: Cash Price	$997.80
Rate for Payer: Devoted Health Medicare	$565.42
Rate for Payer: Hawaii Medical Service Association Medicare	$515.53
Rate for Payer: Hawaii Western Management Group Commercial	$1,164.10
Rate for Payer: Health Management Network Commercial	$1,413.55
Rate for Payer: Humana Medicare	$515.53
Rate for Payer: Kaiser Permanente Commercial	$1,496.70
Rate for Payer: Kaiser Permanente Medicaid	$848.13
Rate for Payer: Kaiser Permanente Medicare	$515.53
Rate for Payer: MDX Hawaii PPO	$1,613.11
Rate for Payer: Ohana Health Plan Medicaid	$515.53
Rate for Payer: Ohana Health Plan Medicare	$515.53
Rate for Payer: UnitedHealthcare Medicare	$515.53
Rate for Payer: University Health Alliance Commercial	$931.28

SUTURE ANCHOR 4.75M 3910847021

Facility

$1,835.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$568.85
Max. Negotiated Rate	$1,779.95
Rate for Payer: AlohaCare Medicaid	$917.50
Rate for Payer: AlohaCare Medicare	$568.85
Rate for Payer: Cash Price	$1,101.00
Rate for Payer: Devoted Health Medicare	$623.90
Rate for Payer: Hawaii Medical Service Association Medicare	$568.85
Rate for Payer: Hawaii Western Management Group Commercial	$1,284.50
Rate for Payer: Health Management Network Commercial	$1,559.75
Rate for Payer: Humana Medicare	$568.85
Rate for Payer: Kaiser Permanente Commercial	$1,651.50
Rate for Payer: Kaiser Permanente Medicaid	$935.85
Rate for Payer: Kaiser Permanente Medicare	$568.85
Rate for Payer: MDX Hawaii PPO	$1,779.95
Rate for Payer: Ohana Health Plan Medicaid	$568.85
Rate for Payer: Ohana Health Plan Medicare	$568.85
Rate for Payer: UnitedHealthcare Medicare	$568.85
Rate for Payer: University Health Alliance Commercial	$1,027.60

SUTURE ANCHOR 4.75M 3910847021

Facility

$1,835.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,027.60
Max. Negotiated Rate	$1,779.95
Rate for Payer: Cash Price	$1,101.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,284.50
Rate for Payer: Health Management Network Commercial	$1,559.75
Rate for Payer: Kaiser Permanente Commercial	$1,651.50
Rate for Payer: MDX Hawaii PPO	$1,779.95
Rate for Payer: University Health Alliance Commercial	$1,027.60

SUTURE ANCHOR 5.5 72203708

Facility

$1,663.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$515.53
Max. Negotiated Rate	$1,613.11
Rate for Payer: AlohaCare Medicaid	$831.50
Rate for Payer: AlohaCare Medicare	$515.53
Rate for Payer: Cash Price	$997.80
Rate for Payer: Devoted Health Medicare	$565.42
Rate for Payer: Hawaii Medical Service Association Medicare	$515.53
Rate for Payer: Hawaii Western Management Group Commercial	$1,164.10
Rate for Payer: Health Management Network Commercial	$1,413.55
Rate for Payer: Humana Medicare	$515.53
Rate for Payer: Kaiser Permanente Commercial	$1,496.70
Rate for Payer: Kaiser Permanente Medicaid	$848.13
Rate for Payer: Kaiser Permanente Medicare	$515.53
Rate for Payer: MDX Hawaii PPO	$1,613.11
Rate for Payer: Ohana Health Plan Medicaid	$515.53
Rate for Payer: Ohana Health Plan Medicare	$515.53
Rate for Payer: UnitedHealthcare Medicare	$515.53
Rate for Payer: University Health Alliance Commercial	$931.28

SUTURE ANCHOR 5.5 72203708

Facility

$1,663.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$931.28
Max. Negotiated Rate	$1,613.11
Rate for Payer: Cash Price	$997.80
Rate for Payer: Hawaii Western Management Group Commercial	$1,164.10
Rate for Payer: Health Management Network Commercial	$1,413.55
Rate for Payer: Kaiser Permanente Commercial	$1,496.70
Rate for Payer: MDX Hawaii PPO	$1,613.11
Rate for Payer: University Health Alliance Commercial	$931.28

SUTURE ANCHOR 5.5 72203801

Facility

$1,663.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$515.53
Max. Negotiated Rate	$1,613.11
Rate for Payer: AlohaCare Medicaid	$831.50
Rate for Payer: AlohaCare Medicare	$515.53
Rate for Payer: Cash Price	$997.80
Rate for Payer: Devoted Health Medicare	$565.42
Rate for Payer: Hawaii Medical Service Association Medicare	$515.53
Rate for Payer: Hawaii Western Management Group Commercial	$1,164.10
Rate for Payer: Health Management Network Commercial	$1,413.55
Rate for Payer: Humana Medicare	$515.53
Rate for Payer: Kaiser Permanente Commercial	$1,496.70
Rate for Payer: Kaiser Permanente Medicaid	$848.13
Rate for Payer: Kaiser Permanente Medicare	$515.53
Rate for Payer: MDX Hawaii PPO	$1,613.11
Rate for Payer: Ohana Health Plan Medicaid	$515.53
Rate for Payer: Ohana Health Plan Medicare	$515.53
Rate for Payer: UnitedHealthcare Medicare	$515.53
Rate for Payer: University Health Alliance Commercial	$931.28

SUTURE ANCHOR 5.5 72203801

Facility

$1,663.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$931.28
Max. Negotiated Rate	$1,613.11
Rate for Payer: Cash Price	$997.80
Rate for Payer: Hawaii Western Management Group Commercial	$1,164.10
Rate for Payer: Health Management Network Commercial	$1,413.55
Rate for Payer: Kaiser Permanente Commercial	$1,496.70
Rate for Payer: MDX Hawaii PPO	$1,613.11
Rate for Payer: University Health Alliance Commercial	$931.28

Know your out-of-pocket cost for care.

All Charges