Kau Hospital

All Charges

Charge

Type

Setting

Price

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

Facility

$5,988.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$3,353.28
Max. Negotiated Rate	$5,808.36
Rate for Payer: Cash Price	$3,592.80
Rate for Payer: Hawaii Western Management Group Commercial	$4,191.60
Rate for Payer: Health Management Network Commercial	$5,089.80
Rate for Payer: Kaiser Permanente Commercial	$5,389.20
Rate for Payer: MDX Hawaii PPO	$5,808.36
Rate for Payer: University Health Alliance Commercial	$3,353.28

TRI HA ACETAB 56MM #542-11-56F

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 56MM #542-11-56F

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 58MM 542-11-58G

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 58MM 542-11-58G

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 60MM 542-11-60G

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 60MM 542-11-60G

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 62MM 542-11-62H

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 62MM 542-11-62H

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 64MM 542-11-64H

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 64MM 542-11-64H

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 66MM 542-11-66I

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 66MM 542-11-66I

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 68MM 542-11-68I

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 68MM 542-11-68I

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 70MM 542-11-70J

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 70MM 542-11-70J

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 72MM 542-11-72J

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 72MM 542-11-72J

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

TRIHEXYPHENIDYL 2 MG TABLET [8166]

Facility

$1.00

Service Code	NDC 00591533501
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

TRIHEXYPHENIDYL 2 MG TABLET [8166]

Facility

$1.00

Service Code	NDC 00591533501
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

TRI-LUMEN FILTER ASM-EVAC1-BI

Facility

$420.00

Hospital Revenue Code	272
Min. Negotiated Rate	$130.20
Max. Negotiated Rate	$407.40
Rate for Payer: AlohaCare Medicaid	$210.00
Rate for Payer: AlohaCare Medicare	$130.20
Rate for Payer: Cash Price	$252.00
Rate for Payer: Devoted Health Medicare	$142.80
Rate for Payer: Hawaii Medical Service Association Medicare	$130.20
Rate for Payer: Hawaii Western Management Group Commercial	$399.00
Rate for Payer: Health Management Network Commercial	$357.00
Rate for Payer: Humana Medicare	$130.20
Rate for Payer: Kaiser Permanente Commercial	$378.00
Rate for Payer: Kaiser Permanente Medicaid	$214.20
Rate for Payer: Kaiser Permanente Medicare	$130.20
Rate for Payer: MDX Hawaii PPO	$407.40
Rate for Payer: Ohana Health Plan Medicaid	$130.20
Rate for Payer: Ohana Health Plan Medicare	$130.20
Rate for Payer: UnitedHealthcare Medicare	$130.20
Rate for Payer: University Health Alliance Commercial	$306.14

TRI-LUMEN FILTER ASM-EVAC1-BI

Facility

$420.00

Hospital Revenue Code	272
Min. Negotiated Rate	$357.00
Max. Negotiated Rate	$407.40
Rate for Payer: Cash Price	$252.00
Rate for Payer: Health Management Network Commercial	$357.00
Rate for Payer: Kaiser Permanente Commercial	$378.00
Rate for Payer: MDX Hawaii PPO	$407.40

TRIMETHOPRIM 100 MG TABLET [8182]

Facility

$9.00

Service Code	NDC 70954054110
Hospital Revenue Code	250
Min. Negotiated Rate	$7.65
Max. Negotiated Rate	$8.73
Rate for Payer: Cash Price	$5.40
Rate for Payer: Health Management Network Commercial	$7.65
Rate for Payer: Kaiser Permanente Commercial	$8.10
Rate for Payer: MDX Hawaii PPO	$8.73

TRIMETHOPRIM 100 MG TABLET [8182]

Facility

$9.00

Service Code	NDC 75907004301
Hospital Revenue Code	250
Min. Negotiated Rate	$7.65
Max. Negotiated Rate	$8.73
Rate for Payer: Cash Price	$5.40
Rate for Payer: Health Management Network Commercial	$7.65
Rate for Payer: Kaiser Permanente Commercial	$8.10
Rate for Payer: MDX Hawaii PPO	$8.73

Know your out-of-pocket cost for care.

All Charges