Kau Hospital

All Charges

Charge

Type

Setting

Price

ULTRASLING UNISX LRG 11-0445-4

Facility

$239.00

Service Code	HCPCS L3670
Hospital Revenue Code	274
Min. Negotiated Rate	$133.84
Max. Negotiated Rate	$231.83
Rate for Payer: Cash Price	$143.40
Rate for Payer: Hawaii Western Management Group Commercial	$167.30
Rate for Payer: Health Management Network Commercial	$203.15
Rate for Payer: Kaiser Permanente Commercial	$215.10
Rate for Payer: MDX Hawaii PPO	$231.83
Rate for Payer: University Health Alliance Commercial	$133.84

ULTRASLING UNISX MED 11-0445-3

Facility

$239.00

Service Code	HCPCS L3670
Hospital Revenue Code	274
Min. Negotiated Rate	$133.84
Max. Negotiated Rate	$231.83
Rate for Payer: Cash Price	$143.40
Rate for Payer: Hawaii Western Management Group Commercial	$167.30
Rate for Payer: Health Management Network Commercial	$203.15
Rate for Payer: Kaiser Permanente Commercial	$215.10
Rate for Payer: MDX Hawaii PPO	$231.83
Rate for Payer: University Health Alliance Commercial	$133.84

ULTRASLING UNISX MED 11-0445-3

Facility

$239.00

Service Code	HCPCS L3670
Hospital Revenue Code	274
Min. Negotiated Rate	$74.09
Max. Negotiated Rate	$231.83
Rate for Payer: AlohaCare Medicaid	$119.50
Rate for Payer: AlohaCare Medicare	$74.09
Rate for Payer: Cash Price	$143.40
Rate for Payer: Cash Price	$143.40
Rate for Payer: Devoted Health Medicare	$81.26
Rate for Payer: Hawaii Medical Service Association Medicare	$74.09
Rate for Payer: Hawaii Western Management Group Commercial	$167.30
Rate for Payer: Health Management Network Commercial	$203.15
Rate for Payer: Humana Medicare	$74.09
Rate for Payer: Kaiser Permanente Commercial	$215.10
Rate for Payer: Kaiser Permanente Medicaid	$121.89
Rate for Payer: Kaiser Permanente Medicare	$74.09
Rate for Payer: MDX Hawaii PPO	$231.83
Rate for Payer: Ohana Health Plan Medicaid	$74.09
Rate for Payer: Ohana Health Plan Medicare	$74.09
Rate for Payer: UnitedHealthcare Medicaid	$84.70
Rate for Payer: UnitedHealthcare Medicare	$74.09
Rate for Payer: University Health Alliance Commercial	$133.84

ULTRASOUND ACCELERATED AND OTHER THROMBOLYSIS OF PERIPHERAL VASCULAR STRUCTURES WITH MCC

Facility

$71,911.87

Service Code	MSDRG 278
Min. Negotiated Rate	$71,911.87
Max. Negotiated Rate	$71,911.87
Rate for Payer: Hawaii Medical Service Association Commercial	$71,911.87

ULTRASOUND ACCELERATED AND OTHER THROMBOLYSIS OF PERIPHERAL VASCULAR STRUCTURES WITHOUT MCC

Facility

$71,911.87

Service Code	MSDRG 279
Min. Negotiated Rate	$71,911.87
Max. Negotiated Rate	$71,911.87
Rate for Payer: Hawaii Medical Service Association Commercial	$71,911.87

ULTRATHANE SET MAC-LOC G30404

Facility

$565.00

Service Code	HCPCS C2627
Hospital Revenue Code	272
Min. Negotiated Rate	$480.25
Max. Negotiated Rate	$548.05
Rate for Payer: Cash Price	$339.00
Rate for Payer: Health Management Network Commercial	$480.25
Rate for Payer: Kaiser Permanente Commercial	$508.50
Rate for Payer: MDX Hawaii PPO	$548.05

ULTRATHANE SET MAC-LOC G30404

Facility

$565.00

Service Code	HCPCS C2627
Hospital Revenue Code	272
Min. Negotiated Rate	$175.15
Max. Negotiated Rate	$548.05
Rate for Payer: AlohaCare Medicaid	$282.50
Rate for Payer: AlohaCare Medicare	$175.15
Rate for Payer: Cash Price	$339.00
Rate for Payer: Devoted Health Medicare	$192.10
Rate for Payer: Hawaii Medical Service Association Medicare	$175.15
Rate for Payer: Hawaii Western Management Group Commercial	$536.75
Rate for Payer: Health Management Network Commercial	$480.25
Rate for Payer: Humana Medicare	$175.15
Rate for Payer: Kaiser Permanente Commercial	$508.50
Rate for Payer: Kaiser Permanente Medicaid	$288.15
Rate for Payer: Kaiser Permanente Medicare	$175.15
Rate for Payer: MDX Hawaii PPO	$548.05
Rate for Payer: Ohana Health Plan Medicaid	$175.15
Rate for Payer: Ohana Health Plan Medicare	$175.15
Rate for Payer: UnitedHealthcare Medicare	$175.15
Rate for Payer: University Health Alliance Commercial	$411.83

UMECLIDINIUM 62.5 MCG-VILANTEROL 25 MCG/ACTUATION POWDR FOR INHALATION [188073]

Facility

$424.00

Service Code	NDC 00173086906
Hospital Revenue Code	637
Min. Negotiated Rate	$131.44
Max. Negotiated Rate	$411.28
Rate for Payer: AlohaCare Medicaid	$212.00
Rate for Payer: AlohaCare Medicare	$131.44
Rate for Payer: Cash Price	$254.40
Rate for Payer: Devoted Health Medicare	$144.16
Rate for Payer: Hawaii Medical Service Association Medicare	$131.44
Rate for Payer: Hawaii Western Management Group Commercial	$402.80
Rate for Payer: Health Management Network Commercial	$360.40
Rate for Payer: Humana Medicare	$131.44
Rate for Payer: Kaiser Permanente Commercial	$381.60
Rate for Payer: Kaiser Permanente Medicaid	$216.24
Rate for Payer: Kaiser Permanente Medicare	$131.44
Rate for Payer: MDX Hawaii PPO	$411.28
Rate for Payer: Ohana Health Plan Medicaid	$131.44
Rate for Payer: Ohana Health Plan Medicare	$131.44
Rate for Payer: UnitedHealthcare Medicare	$131.44
Rate for Payer: University Health Alliance Commercial	$309.05

UMECLIDINIUM 62.5 MCG-VILANTEROL 25 MCG/ACTUATION POWDR FOR INHALATION [188073]

Facility

$424.00

Service Code	NDC 00173086906
Hospital Revenue Code	250
Min. Negotiated Rate	$360.40
Max. Negotiated Rate	$411.28
Rate for Payer: Cash Price	$254.40
Rate for Payer: Health Management Network Commercial	$360.40
Rate for Payer: Kaiser Permanente Commercial	$381.60
Rate for Payer: MDX Hawaii PPO	$411.28

UNCOMPLICATED PEPTIC ULCER WITH MCC

Facility

$19,625.26

Service Code	MSDRG 383
Min. Negotiated Rate	$19,625.26
Max. Negotiated Rate	$19,625.26
Rate for Payer: Hawaii Medical Service Association Commercial	$19,625.26

UNCOMPLICATED PEPTIC ULCER WITHOUT MCC

Facility

$19,625.26

Service Code	MSDRG 384
Min. Negotiated Rate	$19,625.26
Max. Negotiated Rate	$19,625.26
Rate for Payer: Hawaii Medical Service Association Commercial	$19,625.26

UNILATERAL KIT W/PDS 0 ES0528

Facility

$2,940.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,646.40
Max. Negotiated Rate	$2,851.80
Rate for Payer: Cash Price	$1,764.00
Rate for Payer: Hawaii Western Management Group Commercial	$2,058.00
Rate for Payer: Health Management Network Commercial	$2,499.00
Rate for Payer: Kaiser Permanente Commercial	$2,646.00
Rate for Payer: MDX Hawaii PPO	$2,851.80
Rate for Payer: University Health Alliance Commercial	$1,646.40

UNILATERAL KIT W/PDS 0 ES0528

Facility

$2,940.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$911.40
Max. Negotiated Rate	$2,851.80
Rate for Payer: AlohaCare Medicaid	$1,470.00
Rate for Payer: AlohaCare Medicare	$911.40
Rate for Payer: Cash Price	$1,764.00
Rate for Payer: Devoted Health Medicare	$999.60
Rate for Payer: Hawaii Medical Service Association Medicare	$911.40
Rate for Payer: Hawaii Western Management Group Commercial	$2,058.00
Rate for Payer: Health Management Network Commercial	$2,499.00
Rate for Payer: Humana Medicare	$911.40
Rate for Payer: Kaiser Permanente Commercial	$2,646.00
Rate for Payer: Kaiser Permanente Medicaid	$1,499.40
Rate for Payer: Kaiser Permanente Medicare	$911.40
Rate for Payer: MDX Hawaii PPO	$2,851.80
Rate for Payer: Ohana Health Plan Medicaid	$911.40
Rate for Payer: Ohana Health Plan Medicare	$911.40
Rate for Payer: UnitedHealthcare Medicare	$911.40
Rate for Payer: University Health Alliance Commercial	$1,646.40

UNIVERS GLENO 36+4 AR-9504S-04

Facility

$4,200.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$1,302.00
Max. Negotiated Rate	$4,074.00
Rate for Payer: AlohaCare Medicaid	$2,100.00
Rate for Payer: AlohaCare Medicare	$1,302.00
Rate for Payer: Cash Price	$2,520.00
Rate for Payer: Devoted Health Medicare	$1,428.00
Rate for Payer: Hawaii Medical Service Association Medicare	$1,302.00
Rate for Payer: Hawaii Western Management Group Commercial	$2,940.00
Rate for Payer: Health Management Network Commercial	$3,570.00
Rate for Payer: Humana Medicare	$1,302.00
Rate for Payer: Kaiser Permanente Commercial	$3,780.00
Rate for Payer: Kaiser Permanente Medicaid	$2,142.00
Rate for Payer: Kaiser Permanente Medicare	$1,302.00
Rate for Payer: MDX Hawaii PPO	$4,074.00
Rate for Payer: Ohana Health Plan Medicaid	$1,302.00
Rate for Payer: Ohana Health Plan Medicare	$1,302.00
Rate for Payer: UnitedHealthcare Medicare	$1,302.00
Rate for Payer: University Health Alliance Commercial	$2,352.00

UNIVERS GLENO 36+4 AR-9504S-04

Facility

$4,200.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$2,352.00
Max. Negotiated Rate	$4,074.00
Rate for Payer: Cash Price	$2,520.00
Rate for Payer: Hawaii Western Management Group Commercial	$2,940.00
Rate for Payer: Health Management Network Commercial	$3,570.00
Rate for Payer: Kaiser Permanente Commercial	$3,780.00
Rate for Payer: MDX Hawaii PPO	$4,074.00
Rate for Payer: University Health Alliance Commercial	$2,352.00

UNIV HEAD 26X41 #UH1-41-26

Facility

$2,408.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$746.48
Max. Negotiated Rate	$2,335.76
Rate for Payer: AlohaCare Medicaid	$1,204.00
Rate for Payer: AlohaCare Medicare	$746.48
Rate for Payer: Cash Price	$1,444.80
Rate for Payer: Devoted Health Medicare	$818.72
Rate for Payer: Hawaii Medical Service Association Medicare	$746.48
Rate for Payer: Hawaii Western Management Group Commercial	$1,685.60
Rate for Payer: Health Management Network Commercial	$2,046.80
Rate for Payer: Humana Medicare	$746.48
Rate for Payer: Kaiser Permanente Commercial	$2,167.20
Rate for Payer: Kaiser Permanente Medicaid	$1,228.08
Rate for Payer: Kaiser Permanente Medicare	$746.48
Rate for Payer: MDX Hawaii PPO	$2,335.76
Rate for Payer: Ohana Health Plan Medicaid	$746.48
Rate for Payer: Ohana Health Plan Medicare	$746.48
Rate for Payer: UnitedHealthcare Medicare	$746.48
Rate for Payer: University Health Alliance Commercial	$1,348.48

UNIV HEAD 26X41 #UH1-41-26

Facility

$2,408.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$1,348.48
Max. Negotiated Rate	$2,335.76
Rate for Payer: Cash Price	$1,444.80
Rate for Payer: Hawaii Western Management Group Commercial	$1,685.60
Rate for Payer: Health Management Network Commercial	$2,046.80
Rate for Payer: Kaiser Permanente Commercial	$2,167.20
Rate for Payer: MDX Hawaii PPO	$2,335.76
Rate for Payer: University Health Alliance Commercial	$1,348.48

UNIV HEAD 26X42 #UH1-42-26

Facility

$2,408.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$1,348.48
Max. Negotiated Rate	$2,335.76
Rate for Payer: Cash Price	$1,444.80
Rate for Payer: Hawaii Western Management Group Commercial	$1,685.60
Rate for Payer: Health Management Network Commercial	$2,046.80
Rate for Payer: Kaiser Permanente Commercial	$2,167.20
Rate for Payer: MDX Hawaii PPO	$2,335.76
Rate for Payer: University Health Alliance Commercial	$1,348.48

UNIV HEAD 26X42 #UH1-42-26

Facility

$2,408.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$746.48
Max. Negotiated Rate	$2,335.76
Rate for Payer: AlohaCare Medicaid	$1,204.00
Rate for Payer: AlohaCare Medicare	$746.48
Rate for Payer: Cash Price	$1,444.80
Rate for Payer: Devoted Health Medicare	$818.72
Rate for Payer: Hawaii Medical Service Association Medicare	$746.48
Rate for Payer: Hawaii Western Management Group Commercial	$1,685.60
Rate for Payer: Health Management Network Commercial	$2,046.80
Rate for Payer: Humana Medicare	$746.48
Rate for Payer: Kaiser Permanente Commercial	$2,167.20
Rate for Payer: Kaiser Permanente Medicaid	$1,228.08
Rate for Payer: Kaiser Permanente Medicare	$746.48
Rate for Payer: MDX Hawaii PPO	$2,335.76
Rate for Payer: Ohana Health Plan Medicaid	$746.48
Rate for Payer: Ohana Health Plan Medicare	$746.48
Rate for Payer: UnitedHealthcare Medicare	$746.48
Rate for Payer: University Health Alliance Commercial	$1,348.48

UNIV HEAD 26X43 #UH1-43-26

Facility

$2,408.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$1,348.48
Max. Negotiated Rate	$2,335.76
Rate for Payer: Cash Price	$1,444.80
Rate for Payer: Hawaii Western Management Group Commercial	$1,685.60
Rate for Payer: Health Management Network Commercial	$2,046.80
Rate for Payer: Kaiser Permanente Commercial	$2,167.20
Rate for Payer: MDX Hawaii PPO	$2,335.76
Rate for Payer: University Health Alliance Commercial	$1,348.48

UNIV HEAD 26X43 #UH1-43-26

Facility

$2,408.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$746.48
Max. Negotiated Rate	$2,335.76
Rate for Payer: AlohaCare Medicaid	$1,204.00
Rate for Payer: AlohaCare Medicare	$746.48
Rate for Payer: Cash Price	$1,444.80
Rate for Payer: Devoted Health Medicare	$818.72
Rate for Payer: Hawaii Medical Service Association Medicare	$746.48
Rate for Payer: Hawaii Western Management Group Commercial	$1,685.60
Rate for Payer: Health Management Network Commercial	$2,046.80
Rate for Payer: Humana Medicare	$746.48
Rate for Payer: Kaiser Permanente Commercial	$2,167.20
Rate for Payer: Kaiser Permanente Medicaid	$1,228.08
Rate for Payer: Kaiser Permanente Medicare	$746.48
Rate for Payer: MDX Hawaii PPO	$2,335.76
Rate for Payer: Ohana Health Plan Medicaid	$746.48
Rate for Payer: Ohana Health Plan Medicare	$746.48
Rate for Payer: UnitedHealthcare Medicare	$746.48
Rate for Payer: University Health Alliance Commercial	$1,348.48

UPPER LIMB AND TOE AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS WITH CC

Facility

$36,643.29

Service Code	MSDRG 256
Min. Negotiated Rate	$36,643.29
Max. Negotiated Rate	$36,643.29
Rate for Payer: Hawaii Medical Service Association Commercial	$36,643.29

UPPER LIMB AND TOE AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS WITH MCC

Facility

$36,643.29

Service Code	MSDRG 255
Min. Negotiated Rate	$36,643.29
Max. Negotiated Rate	$36,643.29
Rate for Payer: Hawaii Medical Service Association Commercial	$36,643.29

UPPER LIMB AND TOE AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS WITHOUT CC/MCC

Facility

$36,643.29

Service Code	MSDRG 257
Min. Negotiated Rate	$36,643.29
Max. Negotiated Rate	$36,643.29
Rate for Payer: Hawaii Medical Service Association Commercial	$36,643.29

UREA 15 GRAM ORAL POWDER PACKET [137170]

Facility

$16.00

Service Code	NDC 00011000000
Hospital Revenue Code	250
Min. Negotiated Rate	$13.60
Max. Negotiated Rate	$15.52
Rate for Payer: Cash Price	$9.60
Rate for Payer: Health Management Network Commercial	$13.60
Rate for Payer: Kaiser Permanente Commercial	$14.40
Rate for Payer: MDX Hawaii PPO	$15.52

Know your out-of-pocket cost for care.

All Charges