Kau Hospital

All Charges

Charge

Type

Setting

Price

TIBIAL COMPONENT #5 5534-A-516

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

TIBIAL COMPONENT #5 5534-A-516

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

TIBIAL COMPONENT SIZE B RIGHT

Facility

$3,800.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$2,128.00
Max. Negotiated Rate	$3,686.00
Rate for Payer: Cash Price	$2,280.00
Rate for Payer: Hawaii Western Management Group Commercial	$2,660.00
Rate for Payer: Health Management Network Commercial	$3,230.00
Rate for Payer: Kaiser Permanente Commercial	$3,420.00
Rate for Payer: MDX Hawaii PPO	$3,686.00
Rate for Payer: University Health Alliance Commercial	$2,128.00

TIBIAL COMPONENT SIZE B RIGHT

Facility

$3,800.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$1,178.00
Max. Negotiated Rate	$3,686.00
Rate for Payer: AlohaCare Medicaid	$1,900.00
Rate for Payer: AlohaCare Medicare	$1,178.00
Rate for Payer: Cash Price	$2,280.00
Rate for Payer: Devoted Health Medicare	$1,292.00
Rate for Payer: Hawaii Medical Service Association Medicare	$1,178.00
Rate for Payer: Hawaii Western Management Group Commercial	$2,660.00
Rate for Payer: Health Management Network Commercial	$3,230.00
Rate for Payer: Humana Medicare	$1,178.00
Rate for Payer: Kaiser Permanente Commercial	$3,420.00
Rate for Payer: Kaiser Permanente Medicaid	$1,938.00
Rate for Payer: Kaiser Permanente Medicare	$1,178.00
Rate for Payer: MDX Hawaii PPO	$3,686.00
Rate for Payer: Ohana Health Plan Medicaid	$1,178.00
Rate for Payer: Ohana Health Plan Medicare	$1,178.00
Rate for Payer: UnitedHealthcare Medicare	$1,178.00
Rate for Payer: University Health Alliance Commercial	$2,128.00

TIBIAL COMPONE SZ 4 5536-B-400

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

TIBIAL COMPONE SZ 4 5536-B-400

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

TIBIA LCP 3.5X105 02.120.704S

Facility

$2,440.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$756.40
Max. Negotiated Rate	$2,366.80
Rate for Payer: AlohaCare Medicaid	$1,220.00
Rate for Payer: AlohaCare Medicare	$756.40
Rate for Payer: Cash Price	$1,464.00
Rate for Payer: Devoted Health Medicare	$829.60
Rate for Payer: Hawaii Medical Service Association Medicare	$756.40
Rate for Payer: Hawaii Western Management Group Commercial	$1,708.00
Rate for Payer: Health Management Network Commercial	$2,074.00
Rate for Payer: Humana Medicare	$756.40
Rate for Payer: Kaiser Permanente Commercial	$2,196.00
Rate for Payer: Kaiser Permanente Medicaid	$1,244.40
Rate for Payer: Kaiser Permanente Medicare	$756.40
Rate for Payer: MDX Hawaii PPO	$2,366.80
Rate for Payer: Ohana Health Plan Medicaid	$756.40
Rate for Payer: Ohana Health Plan Medicare	$756.40
Rate for Payer: UnitedHealthcare Medicare	$756.40
Rate for Payer: University Health Alliance Commercial	$1,366.40

TIBIA LCP 3.5X105 02.120.704S

Facility

$2,440.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,366.40
Max. Negotiated Rate	$2,366.80
Rate for Payer: Cash Price	$1,464.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,708.00
Rate for Payer: Health Management Network Commercial	$2,074.00
Rate for Payer: Kaiser Permanente Commercial	$2,196.00
Rate for Payer: MDX Hawaii PPO	$2,366.80
Rate for Payer: University Health Alliance Commercial	$1,366.40

TIBIAL HINGE 5612-0-005

Facility

$11,373.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$6,368.88
Max. Negotiated Rate	$11,031.81
Rate for Payer: Cash Price	$6,823.80
Rate for Payer: Hawaii Western Management Group Commercial	$7,961.10
Rate for Payer: Health Management Network Commercial	$9,667.05
Rate for Payer: Kaiser Permanente Commercial	$10,235.70
Rate for Payer: MDX Hawaii PPO	$11,031.81
Rate for Payer: University Health Alliance Commercial	$6,368.88

TIBIAL HINGE 5612-0-005

Facility

$11,373.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$3,525.63
Max. Negotiated Rate	$11,031.81
Rate for Payer: AlohaCare Medicaid	$5,686.50
Rate for Payer: AlohaCare Medicare	$3,525.63
Rate for Payer: Cash Price	$6,823.80
Rate for Payer: Devoted Health Medicare	$3,866.82
Rate for Payer: Hawaii Medical Service Association Medicare	$3,525.63
Rate for Payer: Hawaii Western Management Group Commercial	$7,961.10
Rate for Payer: Health Management Network Commercial	$9,667.05
Rate for Payer: Humana Medicare	$3,525.63
Rate for Payer: Kaiser Permanente Commercial	$10,235.70
Rate for Payer: Kaiser Permanente Medicaid	$5,800.23
Rate for Payer: Kaiser Permanente Medicare	$3,525.63
Rate for Payer: MDX Hawaii PPO	$11,031.81
Rate for Payer: Ohana Health Plan Medicaid	$3,525.63
Rate for Payer: Ohana Health Plan Medicare	$3,525.63
Rate for Payer: UnitedHealthcare Medicare	$3,525.63
Rate for Payer: University Health Alliance Commercial	$6,368.88

TIBIAL INSERT 5531-G-311-E

Facility

$2,676.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$829.56
Max. Negotiated Rate	$2,595.72
Rate for Payer: AlohaCare Medicaid	$1,338.00
Rate for Payer: AlohaCare Medicare	$829.56
Rate for Payer: Cash Price	$1,605.60
Rate for Payer: Devoted Health Medicare	$909.84
Rate for Payer: Hawaii Medical Service Association Medicare	$829.56
Rate for Payer: Hawaii Western Management Group Commercial	$1,873.20
Rate for Payer: Health Management Network Commercial	$2,274.60
Rate for Payer: Humana Medicare	$829.56
Rate for Payer: Kaiser Permanente Commercial	$2,408.40
Rate for Payer: Kaiser Permanente Medicaid	$1,364.76
Rate for Payer: Kaiser Permanente Medicare	$829.56
Rate for Payer: MDX Hawaii PPO	$2,595.72
Rate for Payer: Ohana Health Plan Medicaid	$829.56
Rate for Payer: Ohana Health Plan Medicare	$829.56
Rate for Payer: UnitedHealthcare Medicare	$829.56
Rate for Payer: University Health Alliance Commercial	$1,498.56

TIBIAL INSERT 5531-G-311-E

Facility

$2,676.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$1,498.56
Max. Negotiated Rate	$2,595.72
Rate for Payer: Cash Price	$1,605.60
Rate for Payer: Hawaii Western Management Group Commercial	$1,873.20
Rate for Payer: Health Management Network Commercial	$2,274.60
Rate for Payer: Kaiser Permanente Commercial	$2,408.40
Rate for Payer: MDX Hawaii PPO	$2,595.72
Rate for Payer: University Health Alliance Commercial	$1,498.56

TIBIAL INSERT 5537-G-413-E

Facility

$4,903.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$2,745.68
Max. Negotiated Rate	$4,755.91
Rate for Payer: Cash Price	$2,941.80
Rate for Payer: Hawaii Western Management Group Commercial	$3,432.10
Rate for Payer: Health Management Network Commercial	$4,167.55
Rate for Payer: Kaiser Permanente Commercial	$4,412.70
Rate for Payer: MDX Hawaii PPO	$4,755.91
Rate for Payer: University Health Alliance Commercial	$2,745.68

TIBIAL INSERT 5537-G-413-E

Facility

$4,903.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$1,519.93
Max. Negotiated Rate	$4,755.91
Rate for Payer: AlohaCare Medicaid	$2,451.50
Rate for Payer: AlohaCare Medicare	$1,519.93
Rate for Payer: Cash Price	$2,941.80
Rate for Payer: Devoted Health Medicare	$1,667.02
Rate for Payer: Hawaii Medical Service Association Medicare	$1,519.93
Rate for Payer: Hawaii Western Management Group Commercial	$3,432.10
Rate for Payer: Health Management Network Commercial	$4,167.55
Rate for Payer: Humana Medicare	$1,519.93
Rate for Payer: Kaiser Permanente Commercial	$4,412.70
Rate for Payer: Kaiser Permanente Medicaid	$2,500.53
Rate for Payer: Kaiser Permanente Medicare	$1,519.93
Rate for Payer: MDX Hawaii PPO	$4,755.91
Rate for Payer: Ohana Health Plan Medicaid	$1,519.93
Rate for Payer: Ohana Health Plan Medicare	$1,519.93
Rate for Payer: UnitedHealthcare Medicare	$1,519.93
Rate for Payer: University Health Alliance Commercial	$2,745.68

TIBIAL INSERT 5537-G-809-E

Facility

$4,903.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$1,519.93
Max. Negotiated Rate	$4,755.91
Rate for Payer: AlohaCare Medicaid	$2,451.50
Rate for Payer: AlohaCare Medicare	$1,519.93
Rate for Payer: Cash Price	$2,941.80
Rate for Payer: Devoted Health Medicare	$1,667.02
Rate for Payer: Hawaii Medical Service Association Medicare	$1,519.93
Rate for Payer: Hawaii Western Management Group Commercial	$3,432.10
Rate for Payer: Health Management Network Commercial	$4,167.55
Rate for Payer: Humana Medicare	$1,519.93
Rate for Payer: Kaiser Permanente Commercial	$4,412.70
Rate for Payer: Kaiser Permanente Medicaid	$2,500.53
Rate for Payer: Kaiser Permanente Medicare	$1,519.93
Rate for Payer: MDX Hawaii PPO	$4,755.91
Rate for Payer: Ohana Health Plan Medicaid	$1,519.93
Rate for Payer: Ohana Health Plan Medicare	$1,519.93
Rate for Payer: UnitedHealthcare Medicare	$1,519.93
Rate for Payer: University Health Alliance Commercial	$2,745.68

TIBIAL INSERT 5537-G-809-E

Facility

$4,903.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$2,745.68
Max. Negotiated Rate	$4,755.91
Rate for Payer: Cash Price	$2,941.80
Rate for Payer: Hawaii Western Management Group Commercial	$3,432.10
Rate for Payer: Health Management Network Commercial	$4,167.55
Rate for Payer: Kaiser Permanente Commercial	$4,412.70
Rate for Payer: MDX Hawaii PPO	$4,755.91
Rate for Payer: University Health Alliance Commercial	$2,745.68

TIBIAL INSERTS5L 02.12.0510CRL

Facility

$2,400.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$1,344.00
Max. Negotiated Rate	$2,328.00
Rate for Payer: Cash Price	$1,440.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,680.00
Rate for Payer: Health Management Network Commercial	$2,040.00
Rate for Payer: Kaiser Permanente Commercial	$2,160.00
Rate for Payer: MDX Hawaii PPO	$2,328.00
Rate for Payer: University Health Alliance Commercial	$1,344.00

TIBIAL INSERTS5L 02.12.0510CRL

Facility

$2,400.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$744.00
Max. Negotiated Rate	$2,328.00
Rate for Payer: AlohaCare Medicaid	$1,200.00
Rate for Payer: AlohaCare Medicare	$744.00
Rate for Payer: Cash Price	$1,440.00
Rate for Payer: Devoted Health Medicare	$816.00
Rate for Payer: Hawaii Medical Service Association Medicare	$744.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,680.00
Rate for Payer: Health Management Network Commercial	$2,040.00
Rate for Payer: Humana Medicare	$744.00
Rate for Payer: Kaiser Permanente Commercial	$2,160.00
Rate for Payer: Kaiser Permanente Medicaid	$1,224.00
Rate for Payer: Kaiser Permanente Medicare	$744.00
Rate for Payer: MDX Hawaii PPO	$2,328.00
Rate for Payer: Ohana Health Plan Medicaid	$744.00
Rate for Payer: Ohana Health Plan Medicare	$744.00
Rate for Payer: UnitedHealthcare Medicare	$744.00
Rate for Payer: University Health Alliance Commercial	$1,344.00

TIBIAL INSERT SZ#7 5532-G-711

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

TIBIAL INSERT SZ#7 5532-G-711

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

TIBIAL S5R 10MM 02.12.0510CRR

Facility

$2,400.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$744.00
Max. Negotiated Rate	$2,328.00
Rate for Payer: AlohaCare Medicaid	$1,200.00
Rate for Payer: AlohaCare Medicare	$744.00
Rate for Payer: Cash Price	$1,440.00
Rate for Payer: Devoted Health Medicare	$816.00
Rate for Payer: Hawaii Medical Service Association Medicare	$744.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,680.00
Rate for Payer: Health Management Network Commercial	$2,040.00
Rate for Payer: Humana Medicare	$744.00
Rate for Payer: Kaiser Permanente Commercial	$2,160.00
Rate for Payer: Kaiser Permanente Medicaid	$1,224.00
Rate for Payer: Kaiser Permanente Medicare	$744.00
Rate for Payer: MDX Hawaii PPO	$2,328.00
Rate for Payer: Ohana Health Plan Medicaid	$744.00
Rate for Payer: Ohana Health Plan Medicare	$744.00
Rate for Payer: UnitedHealthcare Medicare	$744.00
Rate for Payer: University Health Alliance Commercial	$1,344.00

TIBIAL S5R 10MM 02.12.0510CRR

Facility

$2,400.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$1,344.00
Max. Negotiated Rate	$2,328.00
Rate for Payer: Cash Price	$1,440.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,680.00
Rate for Payer: Health Management Network Commercial	$2,040.00
Rate for Payer: Kaiser Permanente Commercial	$2,160.00
Rate for Payer: MDX Hawaii PPO	$2,328.00
Rate for Payer: University Health Alliance Commercial	$1,344.00

TIBIAL SIZE A RT MEDIAL

Facility

$3,800.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$2,128.00
Max. Negotiated Rate	$3,686.00
Rate for Payer: Cash Price	$2,280.00
Rate for Payer: Hawaii Western Management Group Commercial	$2,660.00
Rate for Payer: Health Management Network Commercial	$3,230.00
Rate for Payer: Kaiser Permanente Commercial	$3,420.00
Rate for Payer: MDX Hawaii PPO	$3,686.00
Rate for Payer: University Health Alliance Commercial	$2,128.00

TIBIAL SIZE A RT MEDIAL

Facility

$3,800.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$1,178.00
Max. Negotiated Rate	$3,686.00
Rate for Payer: AlohaCare Medicaid	$1,900.00
Rate for Payer: AlohaCare Medicare	$1,178.00
Rate for Payer: Cash Price	$2,280.00
Rate for Payer: Devoted Health Medicare	$1,292.00
Rate for Payer: Hawaii Medical Service Association Medicare	$1,178.00
Rate for Payer: Hawaii Western Management Group Commercial	$2,660.00
Rate for Payer: Health Management Network Commercial	$3,230.00
Rate for Payer: Humana Medicare	$1,178.00
Rate for Payer: Kaiser Permanente Commercial	$3,420.00
Rate for Payer: Kaiser Permanente Medicaid	$1,938.00
Rate for Payer: Kaiser Permanente Medicare	$1,178.00
Rate for Payer: MDX Hawaii PPO	$3,686.00
Rate for Payer: Ohana Health Plan Medicaid	$1,178.00
Rate for Payer: Ohana Health Plan Medicare	$1,178.00
Rate for Payer: UnitedHealthcare Medicare	$1,178.00
Rate for Payer: University Health Alliance Commercial	$2,128.00

TIBIAL SIZE D LEFT

Facility

$3,800.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$2,128.00
Max. Negotiated Rate	$3,686.00
Rate for Payer: Cash Price	$2,280.00
Rate for Payer: Hawaii Western Management Group Commercial	$2,660.00
Rate for Payer: Health Management Network Commercial	$3,230.00
Rate for Payer: Kaiser Permanente Commercial	$3,420.00
Rate for Payer: MDX Hawaii PPO	$3,686.00
Rate for Payer: University Health Alliance Commercial	$2,128.00

Know your out-of-pocket cost for care.

All Charges