Kau Hospital

All Charges

Charge

Type

Setting

Price

TRAY CHEST TUBE THALQUIK 18F

Facility

$678.00

Service Code	HCPCS C1729
Hospital Revenue Code	272
Min. Negotiated Rate	$576.30
Max. Negotiated Rate	$657.66
Rate for Payer: Cash Price	$406.80
Rate for Payer: Health Management Network Commercial	$576.30
Rate for Payer: Kaiser Permanente Commercial	$610.20
Rate for Payer: MDX Hawaii PPO	$657.66

TRAY CHEST TUBE THALQUIK 28F

Facility

$682.00

Service Code	HCPCS C1729
Hospital Revenue Code	272
Min. Negotiated Rate	$211.42
Max. Negotiated Rate	$661.54
Rate for Payer: AlohaCare Medicaid	$341.00
Rate for Payer: AlohaCare Medicare	$211.42
Rate for Payer: Cash Price	$409.20
Rate for Payer: Devoted Health Medicare	$231.88
Rate for Payer: Hawaii Medical Service Association Medicare	$211.42
Rate for Payer: Hawaii Western Management Group Commercial	$647.90
Rate for Payer: Health Management Network Commercial	$579.70
Rate for Payer: Humana Medicare	$211.42
Rate for Payer: Kaiser Permanente Commercial	$613.80
Rate for Payer: Kaiser Permanente Medicaid	$347.82
Rate for Payer: Kaiser Permanente Medicare	$211.42
Rate for Payer: MDX Hawaii PPO	$661.54
Rate for Payer: Ohana Health Plan Medicaid	$211.42
Rate for Payer: Ohana Health Plan Medicare	$211.42
Rate for Payer: UnitedHealthcare Medicare	$211.42
Rate for Payer: University Health Alliance Commercial	$497.11

TRAY CHEST TUBE THALQUIK 28F

Facility

$682.00

Service Code	HCPCS C1729
Hospital Revenue Code	272
Min. Negotiated Rate	$579.70
Max. Negotiated Rate	$661.54
Rate for Payer: Cash Price	$409.20
Rate for Payer: Health Management Network Commercial	$579.70
Rate for Payer: Kaiser Permanente Commercial	$613.80
Rate for Payer: MDX Hawaii PPO	$661.54

TRAY FIXED T3-I4 L 02.12.T314L

Facility

$3,600.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$1,116.00
Max. Negotiated Rate	$3,492.00
Rate for Payer: AlohaCare Medicaid	$1,800.00
Rate for Payer: AlohaCare Medicare	$1,116.00
Rate for Payer: Cash Price	$2,160.00
Rate for Payer: Devoted Health Medicare	$1,224.00
Rate for Payer: Hawaii Medical Service Association Medicare	$1,116.00
Rate for Payer: Hawaii Western Management Group Commercial	$2,520.00
Rate for Payer: Health Management Network Commercial	$3,060.00
Rate for Payer: Humana Medicare	$1,116.00
Rate for Payer: Kaiser Permanente Commercial	$3,240.00
Rate for Payer: Kaiser Permanente Medicaid	$1,836.00
Rate for Payer: Kaiser Permanente Medicare	$1,116.00
Rate for Payer: MDX Hawaii PPO	$3,492.00
Rate for Payer: Ohana Health Plan Medicaid	$1,116.00
Rate for Payer: Ohana Health Plan Medicare	$1,116.00
Rate for Payer: UnitedHealthcare Medicare	$1,116.00
Rate for Payer: University Health Alliance Commercial	$2,016.00

TRAY FIXED T3-I4 L 02.12.T314L

Facility

$3,600.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$2,016.00
Max. Negotiated Rate	$3,492.00
Rate for Payer: Cash Price	$2,160.00
Rate for Payer: Hawaii Western Management Group Commercial	$2,520.00
Rate for Payer: Health Management Network Commercial	$3,060.00
Rate for Payer: Kaiser Permanente Commercial	$3,240.00
Rate for Payer: MDX Hawaii PPO	$3,492.00
Rate for Payer: University Health Alliance Commercial	$2,016.00

TRAY FOLEY W/UROMETER 14FR

Facility

$119.00

Hospital Revenue Code	272
Min. Negotiated Rate	$101.15
Max. Negotiated Rate	$115.43
Rate for Payer: Cash Price	$71.40
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

TRAY FOLEY W/UROMETER 14FR

Facility

$119.00

Hospital Revenue Code	272
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: Devoted Health Medicare	$40.46
Rate for Payer: Hawaii Medical Service Association Medicare	$36.89
Rate for Payer: Hawaii Western Management Group Commercial	$113.05
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 Medicare	$36.89
Rate for Payer: University Health Alliance Commercial	$86.74

TRAY FOLEY W/UROMETER 16FR

Facility

$119.00

Hospital Revenue Code	272
Min. Negotiated Rate	$101.15
Max. Negotiated Rate	$115.43
Rate for Payer: Cash Price	$71.40
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

TRAY FOLEY W/UROMETER 16FR

Facility

$119.00

Hospital Revenue Code	272
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: Devoted Health Medicare	$40.46
Rate for Payer: Hawaii Medical Service Association Medicare	$36.89
Rate for Payer: Hawaii Western Management Group Commercial	$113.05
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 Medicare	$36.89
Rate for Payer: University Health Alliance Commercial	$86.74

TRAY INTRODUCER PERCUT TRACH

Facility

$1,431.00

Service Code	HCPCS C1769
Hospital Revenue Code	272
Min. Negotiated Rate	$443.61
Max. Negotiated Rate	$1,388.07
Rate for Payer: AlohaCare Medicaid	$715.50
Rate for Payer: AlohaCare Medicare	$443.61
Rate for Payer: Cash Price	$858.60
Rate for Payer: Devoted Health Medicare	$486.54
Rate for Payer: Hawaii Medical Service Association Medicare	$443.61
Rate for Payer: Hawaii Western Management Group Commercial	$1,359.45
Rate for Payer: Health Management Network Commercial	$1,216.35
Rate for Payer: Humana Medicare	$443.61
Rate for Payer: Kaiser Permanente Commercial	$1,287.90
Rate for Payer: Kaiser Permanente Medicaid	$729.81
Rate for Payer: Kaiser Permanente Medicare	$443.61
Rate for Payer: MDX Hawaii PPO	$1,388.07
Rate for Payer: Ohana Health Plan Medicaid	$443.61
Rate for Payer: Ohana Health Plan Medicare	$443.61
Rate for Payer: UnitedHealthcare Medicare	$443.61
Rate for Payer: University Health Alliance Commercial	$1,043.06

TRAY INTRODUCER PERCUT TRACH

Facility

$1,431.00

Service Code	HCPCS C1769
Hospital Revenue Code	272
Min. Negotiated Rate	$1,216.35
Max. Negotiated Rate	$1,388.07
Rate for Payer: Cash Price	$858.60
Rate for Payer: Health Management Network Commercial	$1,216.35
Rate for Payer: Kaiser Permanente Commercial	$1,287.90
Rate for Payer: MDX Hawaii PPO	$1,388.07

TRAY LF MEDIAL TIB SZ F 154775

Facility

$3,300.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$1,023.00
Max. Negotiated Rate	$3,201.00
Rate for Payer: AlohaCare Medicaid	$1,650.00
Rate for Payer: AlohaCare Medicare	$1,023.00
Rate for Payer: Cash Price	$1,980.00
Rate for Payer: Devoted Health Medicare	$1,122.00
Rate for Payer: Hawaii Medical Service Association Medicare	$1,023.00
Rate for Payer: Hawaii Western Management Group Commercial	$2,310.00
Rate for Payer: Health Management Network Commercial	$2,805.00
Rate for Payer: Humana Medicare	$1,023.00
Rate for Payer: Kaiser Permanente Commercial	$2,970.00
Rate for Payer: Kaiser Permanente Medicaid	$1,683.00
Rate for Payer: Kaiser Permanente Medicare	$1,023.00
Rate for Payer: MDX Hawaii PPO	$3,201.00
Rate for Payer: Ohana Health Plan Medicaid	$1,023.00
Rate for Payer: Ohana Health Plan Medicare	$1,023.00
Rate for Payer: UnitedHealthcare Medicare	$1,023.00
Rate for Payer: University Health Alliance Commercial	$1,848.00

TRAY LF MEDIAL TIB SZ F 154775

Facility

$3,300.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$1,848.00
Max. Negotiated Rate	$3,201.00
Rate for Payer: Cash Price	$1,980.00
Rate for Payer: Hawaii Western Management Group Commercial	$2,310.00
Rate for Payer: Health Management Network Commercial	$2,805.00
Rate for Payer: Kaiser Permanente Commercial	$2,970.00
Rate for Payer: MDX Hawaii PPO	$3,201.00
Rate for Payer: University Health Alliance Commercial	$1,848.00

TRAY REVERSED TI6AI4V DWF510

Facility

$2,000.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$620.00
Max. Negotiated Rate	$1,940.00
Rate for Payer: AlohaCare Medicaid	$1,000.00
Rate for Payer: AlohaCare Medicare	$620.00
Rate for Payer: Cash Price	$1,200.00
Rate for Payer: Devoted Health Medicare	$680.00
Rate for Payer: Hawaii Medical Service Association Medicare	$620.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,400.00
Rate for Payer: Health Management Network Commercial	$1,700.00
Rate for Payer: Humana Medicare	$620.00
Rate for Payer: Kaiser Permanente Commercial	$1,800.00
Rate for Payer: Kaiser Permanente Medicaid	$1,020.00
Rate for Payer: Kaiser Permanente Medicare	$620.00
Rate for Payer: MDX Hawaii PPO	$1,940.00
Rate for Payer: Ohana Health Plan Medicaid	$620.00
Rate for Payer: Ohana Health Plan Medicare	$620.00
Rate for Payer: UnitedHealthcare Medicare	$620.00
Rate for Payer: University Health Alliance Commercial	$1,120.00

TRAY REVERSED TI6AI4V DWF510

Facility

$2,000.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$1,120.00
Max. Negotiated Rate	$1,940.00
Rate for Payer: Cash Price	$1,200.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,400.00
Rate for Payer: Health Management Network Commercial	$1,700.00
Rate for Payer: Kaiser Permanente Commercial	$1,800.00
Rate for Payer: MDX Hawaii PPO	$1,940.00
Rate for Payer: University Health Alliance Commercial	$1,120.00

TRAY REVERSED TI6AI4V DWF520

Facility

$5,506.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$3,083.36
Max. Negotiated Rate	$5,340.82
Rate for Payer: Cash Price	$3,303.60
Rate for Payer: Hawaii Western Management Group Commercial	$3,854.20
Rate for Payer: Health Management Network Commercial	$4,680.10
Rate for Payer: Kaiser Permanente Commercial	$4,955.40
Rate for Payer: MDX Hawaii PPO	$5,340.82
Rate for Payer: University Health Alliance Commercial	$3,083.36

TRAY REVERSED TI6AI4V DWF520

Facility

$5,506.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$1,706.86
Max. Negotiated Rate	$5,340.82
Rate for Payer: AlohaCare Medicaid	$2,753.00
Rate for Payer: AlohaCare Medicare	$1,706.86
Rate for Payer: Cash Price	$3,303.60
Rate for Payer: Devoted Health Medicare	$1,872.04
Rate for Payer: Hawaii Medical Service Association Medicare	$1,706.86
Rate for Payer: Hawaii Western Management Group Commercial	$3,854.20
Rate for Payer: Health Management Network Commercial	$4,680.10
Rate for Payer: Humana Medicare	$1,706.86
Rate for Payer: Kaiser Permanente Commercial	$4,955.40
Rate for Payer: Kaiser Permanente Medicaid	$2,808.06
Rate for Payer: Kaiser Permanente Medicare	$1,706.86
Rate for Payer: MDX Hawaii PPO	$5,340.82
Rate for Payer: Ohana Health Plan Medicaid	$1,706.86
Rate for Payer: Ohana Health Plan Medicare	$1,706.86
Rate for Payer: UnitedHealthcare Medicare	$1,706.86
Rate for Payer: University Health Alliance Commercial	$3,083.36

TRAY TIBIAL RT SZ4 02.07.1204R

Facility

$3,600.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$1,116.00
Max. Negotiated Rate	$3,492.00
Rate for Payer: AlohaCare Medicaid	$1,800.00
Rate for Payer: AlohaCare Medicare	$1,116.00
Rate for Payer: Cash Price	$2,160.00
Rate for Payer: Devoted Health Medicare	$1,224.00
Rate for Payer: Hawaii Medical Service Association Medicare	$1,116.00
Rate for Payer: Hawaii Western Management Group Commercial	$2,520.00
Rate for Payer: Health Management Network Commercial	$3,060.00
Rate for Payer: Humana Medicare	$1,116.00
Rate for Payer: Kaiser Permanente Commercial	$3,240.00
Rate for Payer: Kaiser Permanente Medicaid	$1,836.00
Rate for Payer: Kaiser Permanente Medicare	$1,116.00
Rate for Payer: MDX Hawaii PPO	$3,492.00
Rate for Payer: Ohana Health Plan Medicaid	$1,116.00
Rate for Payer: Ohana Health Plan Medicare	$1,116.00
Rate for Payer: UnitedHealthcare Medicare	$1,116.00
Rate for Payer: University Health Alliance Commercial	$2,016.00

TRAY TIBIAL RT SZ4 02.07.1204R

Facility

$3,600.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$2,016.00
Max. Negotiated Rate	$3,492.00
Rate for Payer: Cash Price	$2,160.00
Rate for Payer: Hawaii Western Management Group Commercial	$2,520.00
Rate for Payer: Health Management Network Commercial	$3,060.00
Rate for Payer: Kaiser Permanente Commercial	$3,240.00
Rate for Payer: MDX Hawaii PPO	$3,492.00
Rate for Payer: University Health Alliance Commercial	$2,016.00

TRAY TIBIAL SIZE A LF 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

TRAY TIBIAL SIZE A LF 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

TRAZODONE 100 MG TABLET [8083]

Facility

$1.00

Service Code	NDC 60687045411
Hospital Revenue Code	637
Min. Negotiated Rate	$0.31
Max. Negotiated Rate	$0.97
Rate for Payer: AlohaCare Medicaid	$0.50
Rate for Payer: AlohaCare Medicare	$0.31
Rate for Payer: Cash Price	$0.60
Rate for Payer: Devoted Health Medicare	$0.34
Rate for Payer: Hawaii Medical Service Association Medicare	$0.31
Rate for Payer: Hawaii Western Management Group Commercial	$0.95
Rate for Payer: Health Management Network Commercial	$0.85
Rate for Payer: Humana Medicare	$0.31
Rate for Payer: Kaiser Permanente Commercial	$0.90
Rate for Payer: Kaiser Permanente Medicaid	$0.51
Rate for Payer: Kaiser Permanente Medicare	$0.31
Rate for Payer: MDX Hawaii PPO	$0.97
Rate for Payer: Ohana Health Plan Medicaid	$0.31
Rate for Payer: Ohana Health Plan Medicare	$0.31
Rate for Payer: UnitedHealthcare Medicare	$0.31
Rate for Payer: University Health Alliance Commercial	$0.73

TRAZODONE 100 MG TABLET [8083]

Facility

$1.00

Service Code	NDC 00904686961
Hospital Revenue Code	250
Min. Negotiated Rate	$0.85
Max. Negotiated Rate	$0.97
Rate for Payer: Cash Price	$0.60
Rate for Payer: Health Management Network Commercial	$0.85
Rate for Payer: Kaiser Permanente Commercial	$0.90
Rate for Payer: MDX Hawaii PPO	$0.97

TRAZODONE 100 MG TABLET [8083]

Facility

$1.00

Service Code	NDC 60687045411
Hospital Revenue Code	250
Min. Negotiated Rate	$0.85
Max. Negotiated Rate	$0.97
Rate for Payer: Cash Price	$0.60
Rate for Payer: Health Management Network Commercial	$0.85
Rate for Payer: Kaiser Permanente Commercial	$0.90
Rate for Payer: MDX Hawaii PPO	$0.97

TRAZODONE 100 MG TABLET [8083]

Facility

$1.00

Service Code	NDC 60687045401
Hospital Revenue Code	250
Min. Negotiated Rate	$0.85
Max. Negotiated Rate	$0.97
Rate for Payer: Cash Price	$0.60
Rate for Payer: Health Management Network Commercial	$0.85
Rate for Payer: Kaiser Permanente Commercial	$0.90
Rate for Payer: MDX Hawaii PPO	$0.97

Know your out-of-pocket cost for care.

All Charges