Kau Hospital

All Charges

Charge

Type

Setting

Price

TRIDENT INSTX3/36MM 623-00-36G

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

TRIDENT INSTX3/36MM 623-00-36G

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

TRIDENT TITANM 52MM 702-04-52E

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

TRIDENT TITANM 52MM 702-04-52E

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

TRIDENT X3 INSERT 723-00-32C

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

TRIDENT X3 INSERT 723-00-32C

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

TRIFLURIDINE 1 % EYE DROPS [11595]

Facility

$613.00

Service Code	NDC 61314004475
Hospital Revenue Code	250
Min. Negotiated Rate	$521.05
Max. Negotiated Rate	$594.61
Rate for Payer: Cash Price	$367.80
Rate for Payer: Health Management Network Commercial	$521.05
Rate for Payer: Kaiser Permanente Commercial	$551.70
Rate for Payer: MDX Hawaii PPO	$594.61

TRIFLURIDINE 1 % EYE DROPS [11595]

Facility

$613.00

Service Code	NDC 61314004475
Hospital Revenue Code	637
Min. Negotiated Rate	$190.03
Max. Negotiated Rate	$594.61
Rate for Payer: AlohaCare Medicaid	$306.50
Rate for Payer: AlohaCare Medicare	$190.03
Rate for Payer: Cash Price	$367.80
Rate for Payer: Devoted Health Medicare	$208.42
Rate for Payer: Hawaii Medical Service Association Medicare	$190.03
Rate for Payer: Hawaii Western Management Group Commercial	$582.35
Rate for Payer: Health Management Network Commercial	$521.05
Rate for Payer: Humana Medicare	$190.03
Rate for Payer: Kaiser Permanente Commercial	$551.70
Rate for Payer: Kaiser Permanente Medicaid	$312.63
Rate for Payer: Kaiser Permanente Medicare	$190.03
Rate for Payer: MDX Hawaii PPO	$594.61
Rate for Payer: Ohana Health Plan Medicaid	$190.03
Rate for Payer: Ohana Health Plan Medicare	$190.03
Rate for Payer: UnitedHealthcare Medicare	$190.03
Rate for Payer: University Health Alliance Commercial	$446.82

TRIGEN L-P SCREW 5.0X35

Facility

$1,196.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$370.76
Max. Negotiated Rate	$1,160.12
Rate for Payer: AlohaCare Medicaid	$598.00
Rate for Payer: AlohaCare Medicare	$370.76
Rate for Payer: Cash Price	$717.60
Rate for Payer: Devoted Health Medicare	$406.64
Rate for Payer: Hawaii Medical Service Association Medicare	$370.76
Rate for Payer: Hawaii Western Management Group Commercial	$837.20
Rate for Payer: Health Management Network Commercial	$1,016.60
Rate for Payer: Humana Medicare	$370.76
Rate for Payer: Kaiser Permanente Commercial	$1,076.40
Rate for Payer: Kaiser Permanente Medicaid	$609.96
Rate for Payer: Kaiser Permanente Medicare	$370.76
Rate for Payer: MDX Hawaii PPO	$1,160.12
Rate for Payer: Ohana Health Plan Medicaid	$370.76
Rate for Payer: Ohana Health Plan Medicare	$370.76
Rate for Payer: UnitedHealthcare Medicare	$370.76
Rate for Payer: University Health Alliance Commercial	$669.76

TRIGEN L-P SCREW 5.0X35

Facility

$1,196.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$669.76
Max. Negotiated Rate	$1,160.12
Rate for Payer: Cash Price	$717.60
Rate for Payer: Hawaii Western Management Group Commercial	$837.20
Rate for Payer: Health Management Network Commercial	$1,016.60
Rate for Payer: Kaiser Permanente Commercial	$1,076.40
Rate for Payer: MDX Hawaii PPO	$1,160.12
Rate for Payer: University Health Alliance Commercial	$669.76

TRI HA ACETAB 40MM 542-11-40A

Facility

$5,814.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$1,802.34
Max. Negotiated Rate	$5,639.58
Rate for Payer: AlohaCare Medicaid	$2,907.00
Rate for Payer: AlohaCare Medicare	$1,802.34
Rate for Payer: Cash Price	$3,488.40
Rate for Payer: Devoted Health Medicare	$1,976.76
Rate for Payer: Hawaii Medical Service Association Medicare	$1,802.34
Rate for Payer: Hawaii Western Management Group Commercial	$4,069.80
Rate for Payer: Health Management Network Commercial	$4,941.90
Rate for Payer: Humana Medicare	$1,802.34
Rate for Payer: Kaiser Permanente Commercial	$5,232.60
Rate for Payer: Kaiser Permanente Medicaid	$2,965.14
Rate for Payer: Kaiser Permanente Medicare	$1,802.34
Rate for Payer: MDX Hawaii PPO	$5,639.58
Rate for Payer: Ohana Health Plan Medicaid	$1,802.34
Rate for Payer: Ohana Health Plan Medicare	$1,802.34
Rate for Payer: UnitedHealthcare Medicare	$1,802.34
Rate for Payer: University Health Alliance Commercial	$3,255.84

TRI HA ACETAB 40MM 542-11-40A

Facility

$5,814.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$3,255.84
Max. Negotiated Rate	$5,639.58
Rate for Payer: Cash Price	$3,488.40
Rate for Payer: Hawaii Western Management Group Commercial	$4,069.80
Rate for Payer: Health Management Network Commercial	$4,941.90
Rate for Payer: Kaiser Permanente Commercial	$5,232.60
Rate for Payer: MDX Hawaii PPO	$5,639.58
Rate for Payer: University Health Alliance Commercial	$3,255.84

TRI HA ACETAB 42MM 542-11-42B

Facility

$5,814.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$3,255.84
Max. Negotiated Rate	$5,639.58
Rate for Payer: Cash Price	$3,488.40
Rate for Payer: Hawaii Western Management Group Commercial	$4,069.80
Rate for Payer: Health Management Network Commercial	$4,941.90
Rate for Payer: Kaiser Permanente Commercial	$5,232.60
Rate for Payer: MDX Hawaii PPO	$5,639.58
Rate for Payer: University Health Alliance Commercial	$3,255.84

TRI HA ACETAB 42MM 542-11-42B

Facility

$5,814.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$1,802.34
Max. Negotiated Rate	$5,639.58
Rate for Payer: AlohaCare Medicaid	$2,907.00
Rate for Payer: AlohaCare Medicare	$1,802.34
Rate for Payer: Cash Price	$3,488.40
Rate for Payer: Devoted Health Medicare	$1,976.76
Rate for Payer: Hawaii Medical Service Association Medicare	$1,802.34
Rate for Payer: Hawaii Western Management Group Commercial	$4,069.80
Rate for Payer: Health Management Network Commercial	$4,941.90
Rate for Payer: Humana Medicare	$1,802.34
Rate for Payer: Kaiser Permanente Commercial	$5,232.60
Rate for Payer: Kaiser Permanente Medicaid	$2,965.14
Rate for Payer: Kaiser Permanente Medicare	$1,802.34
Rate for Payer: MDX Hawaii PPO	$5,639.58
Rate for Payer: Ohana Health Plan Medicaid	$1,802.34
Rate for Payer: Ohana Health Plan Medicare	$1,802.34
Rate for Payer: UnitedHealthcare Medicare	$1,802.34
Rate for Payer: University Health Alliance Commercial	$3,255.84

TRI HA ACETAB 44MM 542-11-44C

Facility

$5,814.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$3,255.84
Max. Negotiated Rate	$5,639.58
Rate for Payer: Cash Price	$3,488.40
Rate for Payer: Hawaii Western Management Group Commercial	$4,069.80
Rate for Payer: Health Management Network Commercial	$4,941.90
Rate for Payer: Kaiser Permanente Commercial	$5,232.60
Rate for Payer: MDX Hawaii PPO	$5,639.58
Rate for Payer: University Health Alliance Commercial	$3,255.84

TRI HA ACETAB 44MM 542-11-44C

Facility

$5,814.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$1,802.34
Max. Negotiated Rate	$5,639.58
Rate for Payer: AlohaCare Medicaid	$2,907.00
Rate for Payer: AlohaCare Medicare	$1,802.34
Rate for Payer: Cash Price	$3,488.40
Rate for Payer: Devoted Health Medicare	$1,976.76
Rate for Payer: Hawaii Medical Service Association Medicare	$1,802.34
Rate for Payer: Hawaii Western Management Group Commercial	$4,069.80
Rate for Payer: Health Management Network Commercial	$4,941.90
Rate for Payer: Humana Medicare	$1,802.34
Rate for Payer: Kaiser Permanente Commercial	$5,232.60
Rate for Payer: Kaiser Permanente Medicaid	$2,965.14
Rate for Payer: Kaiser Permanente Medicare	$1,802.34
Rate for Payer: MDX Hawaii PPO	$5,639.58
Rate for Payer: Ohana Health Plan Medicaid	$1,802.34
Rate for Payer: Ohana Health Plan Medicare	$1,802.34
Rate for Payer: UnitedHealthcare Medicare	$1,802.34
Rate for Payer: University Health Alliance Commercial	$3,255.84

TRI HA ACETAB 46MM #542-11-46D

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

TRI HA ACETAB 46MM #542-11-46D

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

TRI HA ACETAB 48MM #542-11-48D

Facility

$6,108.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$1,893.48
Max. Negotiated Rate	$5,924.76
Rate for Payer: AlohaCare Medicaid	$3,054.00
Rate for Payer: AlohaCare Medicare	$1,893.48
Rate for Payer: Cash Price	$3,664.80
Rate for Payer: Devoted Health Medicare	$2,076.72
Rate for Payer: Hawaii Medical Service Association Medicare	$1,893.48
Rate for Payer: Hawaii Western Management Group Commercial	$4,275.60
Rate for Payer: Health Management Network Commercial	$5,191.80
Rate for Payer: Humana Medicare	$1,893.48
Rate for Payer: Kaiser Permanente Commercial	$5,497.20
Rate for Payer: Kaiser Permanente Medicaid	$3,115.08
Rate for Payer: Kaiser Permanente Medicare	$1,893.48
Rate for Payer: MDX Hawaii PPO	$5,924.76
Rate for Payer: Ohana Health Plan Medicaid	$1,893.48
Rate for Payer: Ohana Health Plan Medicare	$1,893.48
Rate for Payer: UnitedHealthcare Medicare	$1,893.48
Rate for Payer: University Health Alliance Commercial	$3,420.48

TRI HA ACETAB 48MM #542-11-48D

Facility

$6,108.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$3,420.48
Max. Negotiated Rate	$5,924.76
Rate for Payer: Cash Price	$3,664.80
Rate for Payer: Hawaii Western Management Group Commercial	$4,275.60
Rate for Payer: Health Management Network Commercial	$5,191.80
Rate for Payer: Kaiser Permanente Commercial	$5,497.20
Rate for Payer: MDX Hawaii PPO	$5,924.76
Rate for Payer: University Health Alliance Commercial	$3,420.48

TRI HA ACETAB 50MM #542-11-50E

Facility

$6,108.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$1,893.48
Max. Negotiated Rate	$5,924.76
Rate for Payer: AlohaCare Medicaid	$3,054.00
Rate for Payer: AlohaCare Medicare	$1,893.48
Rate for Payer: Cash Price	$3,664.80
Rate for Payer: Devoted Health Medicare	$2,076.72
Rate for Payer: Hawaii Medical Service Association Medicare	$1,893.48
Rate for Payer: Hawaii Western Management Group Commercial	$4,275.60
Rate for Payer: Health Management Network Commercial	$5,191.80
Rate for Payer: Humana Medicare	$1,893.48
Rate for Payer: Kaiser Permanente Commercial	$5,497.20
Rate for Payer: Kaiser Permanente Medicaid	$3,115.08
Rate for Payer: Kaiser Permanente Medicare	$1,893.48
Rate for Payer: MDX Hawaii PPO	$5,924.76
Rate for Payer: Ohana Health Plan Medicaid	$1,893.48
Rate for Payer: Ohana Health Plan Medicare	$1,893.48
Rate for Payer: UnitedHealthcare Medicare	$1,893.48
Rate for Payer: University Health Alliance Commercial	$3,420.48

TRI HA ACETAB 50MM #542-11-50E

Facility

$6,108.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$3,420.48
Max. Negotiated Rate	$5,924.76
Rate for Payer: Cash Price	$3,664.80
Rate for Payer: Hawaii Western Management Group Commercial	$4,275.60
Rate for Payer: Health Management Network Commercial	$5,191.80
Rate for Payer: Kaiser Permanente Commercial	$5,497.20
Rate for Payer: MDX Hawaii PPO	$5,924.76
Rate for Payer: University Health Alliance Commercial	$3,420.48

TRI HA ACETAB 52MM #542-11-52E

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

TRI HA ACETAB 52MM #542-11-52E

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

TRI HA ACETAB 54MM #542-11-54F

Facility

$5,988.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$1,856.28
Max. Negotiated Rate	$5,808.36
Rate for Payer: AlohaCare Medicaid	$2,994.00
Rate for Payer: AlohaCare Medicare	$1,856.28
Rate for Payer: Cash Price	$3,592.80
Rate for Payer: Devoted Health Medicare	$2,035.92
Rate for Payer: Hawaii Medical Service Association Medicare	$1,856.28
Rate for Payer: Hawaii Western Management Group Commercial	$4,191.60
Rate for Payer: Health Management Network Commercial	$5,089.80
Rate for Payer: Humana Medicare	$1,856.28
Rate for Payer: Kaiser Permanente Commercial	$5,389.20
Rate for Payer: Kaiser Permanente Medicaid	$3,053.88
Rate for Payer: Kaiser Permanente Medicare	$1,856.28
Rate for Payer: MDX Hawaii PPO	$5,808.36
Rate for Payer: Ohana Health Plan Medicaid	$1,856.28
Rate for Payer: Ohana Health Plan Medicare	$1,856.28
Rate for Payer: UnitedHealthcare Medicare	$1,856.28
Rate for Payer: University Health Alliance Commercial	$3,353.28

Know your out-of-pocket cost for care.

All Charges