Kauai Veterans Memorial Hospital

All Charges

Charge

Type

Setting

Price

Pain Mgmt Profile w/ Oxycodone and Alcohol FSI

Facility

$1,384.00

Service Code	HCPCS 80307
Hospital Charge Code	8729547
Hospital Revenue Code	301
Min. Negotiated Rate	$1,176.40
Max. Negotiated Rate	$1,342.48
Rate for Payer: Cash Price	$899.60
Rate for Payer: Health Management Network Commercial	$1,176.40
Rate for Payer: Kaiser Permanente Commercial	$1,245.60
Rate for Payer: MDX Hawaii PPO	$1,342.48

Pain Mgmt Prof w/ Oxy, Alcohol and Rfx Confirm FSI

Facility

$1,384.00

Service Code	HCPCS 80307
Hospital Charge Code	8729548
Hospital Revenue Code	301
Min. Negotiated Rate	$1,176.40
Max. Negotiated Rate	$1,342.48
Rate for Payer: Cash Price	$899.60
Rate for Payer: Health Management Network Commercial	$1,176.40
Rate for Payer: Kaiser Permanente Commercial	$1,245.60
Rate for Payer: MDX Hawaii PPO	$1,342.48

Pain Mgmt Prof w/ Oxy, Alcohol and Rfx Confirm FSI

Facility

$1,384.00

Service Code	HCPCS 80307
Hospital Charge Code	8729548
Hospital Revenue Code	301
Min. Negotiated Rate	$47.89
Max. Negotiated Rate	$1,342.48
Rate for Payer: AlohaCare Medicaid	$692.00
Rate for Payer: AlohaCare Medicare	$692.00
Rate for Payer: Cash Price	$899.60
Rate for Payer: Cash Price	$899.60
Rate for Payer: Devoted Health Medicare	$761.20
Rate for Payer: Hawaii Medical Service Association ABD	$59.38
Rate for Payer: Hawaii Medical Service Association Commercial	$77.67
Rate for Payer: Hawaii Medical Service Association Medicare	$692.00
Rate for Payer: Hawaii Medical Service Association Non-ABD	$59.38
Rate for Payer: Hawaii Western Management Group Commercial	$62.14
Rate for Payer: Health Management Network Commercial	$1,176.40
Rate for Payer: Humana Medicare	$692.00
Rate for Payer: Kaiser Permanente Commercial	$1,245.60
Rate for Payer: Kaiser Permanente Medicaid	$705.84
Rate for Payer: Kaiser Permanente Medicare	$692.00
Rate for Payer: MDX Hawaii PPO	$1,342.48
Rate for Payer: Ohana Health Plan Medicaid	$692.00
Rate for Payer: Ohana Health Plan Medicare	$692.00
Rate for Payer: UnitedHealthcare Medicaid	$47.89
Rate for Payer: UnitedHealthcare Medicare	$692.00
Rate for Payer: University Health Alliance Commercial	$147.65

PAIN & SPINE: AutoPlex System Cement Mixer W/ Vertaplex HV Cement

Facility

$2,625.00

Hospital Charge Code	11525539
Hospital Revenue Code	272
Min. Negotiated Rate	$2,231.25
Max. Negotiated Rate	$2,546.25
Rate for Payer: Cash Price	$1,706.25
Rate for Payer: Health Management Network Commercial	$2,231.25
Rate for Payer: Kaiser Permanente Commercial	$2,362.50
Rate for Payer: MDX Hawaii PPO	$2,546.25

PAIN & SPINE: AutoPlex System Cement Mixer W/ Vertaplex HV Cement

Facility

$2,625.00

Hospital Charge Code	11525539
Hospital Revenue Code	272
Min. Negotiated Rate	$1,312.50
Max. Negotiated Rate	$2,546.25
Rate for Payer: AlohaCare Medicaid	$1,312.50
Rate for Payer: AlohaCare Medicare	$1,312.50
Rate for Payer: Cash Price	$1,706.25
Rate for Payer: Devoted Health Medicare	$1,443.75
Rate for Payer: Hawaii Medical Service Association Medicare	$1,312.50
Rate for Payer: Hawaii Western Management Group Commercial	$2,493.75
Rate for Payer: Health Management Network Commercial	$2,231.25
Rate for Payer: Humana Medicare	$1,312.50
Rate for Payer: Kaiser Permanente Commercial	$2,362.50
Rate for Payer: Kaiser Permanente Medicaid	$1,338.75
Rate for Payer: Kaiser Permanente Medicare	$1,312.50
Rate for Payer: MDX Hawaii PPO	$2,546.25
Rate for Payer: Ohana Health Plan Medicaid	$1,312.50
Rate for Payer: Ohana Health Plan Medicare	$1,312.50
Rate for Payer: UnitedHealthcare Medicare	$1,312.50
Rate for Payer: University Health Alliance Commercial	$1,913.36

PAIN & SPINE: BALLOON KYPHOPLASTY ESSENTIALS KIT

Facility

$7,030.00

Service Code	HCPCS C1062
Hospital Charge Code	10994942
Hospital Revenue Code	278
Min. Negotiated Rate	$3,936.80
Max. Negotiated Rate	$6,819.10
Rate for Payer: Cash Price	$4,569.50
Rate for Payer: Hawaii Western Management Group Commercial	$4,921.00
Rate for Payer: Health Management Network Commercial	$5,975.50
Rate for Payer: Kaiser Permanente Commercial	$6,327.00
Rate for Payer: MDX Hawaii PPO	$6,819.10
Rate for Payer: University Health Alliance Commercial	$3,936.80

PAIN & SPINE: BALLOON KYPHOPLASTY ESSENTIALS KIT

Facility

$7,030.00

Service Code	HCPCS C1062
Hospital Charge Code	10994942
Hospital Revenue Code	278
Min. Negotiated Rate	$3,515.00
Max. Negotiated Rate	$6,819.10
Rate for Payer: AlohaCare Medicaid	$3,515.00
Rate for Payer: AlohaCare Medicare	$3,515.00
Rate for Payer: Cash Price	$4,569.50
Rate for Payer: Devoted Health Medicare	$3,866.50
Rate for Payer: Hawaii Medical Service Association Medicare	$3,515.00
Rate for Payer: Hawaii Western Management Group Commercial	$4,921.00
Rate for Payer: Health Management Network Commercial	$5,975.50
Rate for Payer: Humana Medicare	$3,515.00
Rate for Payer: Kaiser Permanente Commercial	$6,327.00
Rate for Payer: Kaiser Permanente Medicaid	$3,585.30
Rate for Payer: Kaiser Permanente Medicare	$3,515.00
Rate for Payer: MDX Hawaii PPO	$6,819.10
Rate for Payer: Ohana Health Plan Medicaid	$3,515.00
Rate for Payer: Ohana Health Plan Medicare	$3,515.00
Rate for Payer: UnitedHealthcare Medicare	$3,515.00
Rate for Payer: University Health Alliance Commercial	$3,936.80

PAIN & SPINE BOOT ENS 375003 PAIN DISPOSABLE

Facility

$375.00

Hospital Charge Code	8806233
Hospital Revenue Code	272
Min. Negotiated Rate	$318.75
Max. Negotiated Rate	$363.75
Rate for Payer: Cash Price	$243.75
Rate for Payer: Health Management Network Commercial	$318.75
Rate for Payer: Kaiser Permanente Commercial	$337.50
Rate for Payer: MDX Hawaii PPO	$363.75

PAIN & SPINE BOOT ENS 375003 PAIN DISPOSABLE

Facility

$375.00

Hospital Charge Code	8806233
Hospital Revenue Code	272
Min. Negotiated Rate	$187.50
Max. Negotiated Rate	$363.75
Rate for Payer: AlohaCare Medicaid	$187.50
Rate for Payer: AlohaCare Medicare	$187.50
Rate for Payer: Cash Price	$243.75
Rate for Payer: Devoted Health Medicare	$206.25
Rate for Payer: Hawaii Medical Service Association Medicare	$187.50
Rate for Payer: Hawaii Western Management Group Commercial	$356.25
Rate for Payer: Health Management Network Commercial	$318.75
Rate for Payer: Humana Medicare	$187.50
Rate for Payer: Kaiser Permanente Commercial	$337.50
Rate for Payer: Kaiser Permanente Medicaid	$191.25
Rate for Payer: Kaiser Permanente Medicare	$187.50
Rate for Payer: MDX Hawaii PPO	$363.75
Rate for Payer: Ohana Health Plan Medicaid	$187.50
Rate for Payer: Ohana Health Plan Medicare	$187.50
Rate for Payer: UnitedHealthcare Medicare	$187.50
Rate for Payer: University Health Alliance Commercial	$273.34

PAIN & SPINE: BOSTON SCIENTIFIC AVISTA MRI SAFE LEAD KIT 70 CM

Facility

$9,240.00

Service Code	HCPCS C1778
Hospital Charge Code	9452706
Hospital Revenue Code	278
Min. Negotiated Rate	$4,620.00
Max. Negotiated Rate	$8,962.80
Rate for Payer: AlohaCare Medicaid	$4,620.00
Rate for Payer: AlohaCare Medicare	$4,620.00
Rate for Payer: Cash Price	$6,006.00
Rate for Payer: Devoted Health Medicare	$5,082.00
Rate for Payer: Hawaii Medical Service Association Medicare	$4,620.00
Rate for Payer: Hawaii Western Management Group Commercial	$6,468.00
Rate for Payer: Health Management Network Commercial	$7,854.00
Rate for Payer: Humana Medicare	$4,620.00
Rate for Payer: Kaiser Permanente Commercial	$8,316.00
Rate for Payer: Kaiser Permanente Medicaid	$4,712.40
Rate for Payer: Kaiser Permanente Medicare	$4,620.00
Rate for Payer: MDX Hawaii PPO	$8,962.80
Rate for Payer: Ohana Health Plan Medicaid	$4,620.00
Rate for Payer: Ohana Health Plan Medicare	$4,620.00
Rate for Payer: UnitedHealthcare Medicare	$4,620.00
Rate for Payer: University Health Alliance Commercial	$5,174.40

PAIN & SPINE: BOSTON SCIENTIFIC AVISTA MRI SAFE LEAD KIT 70 CM

Facility

$9,240.00

Service Code	HCPCS C1778
Hospital Charge Code	9452706
Hospital Revenue Code	278
Min. Negotiated Rate	$5,174.40
Max. Negotiated Rate	$8,962.80
Rate for Payer: Cash Price	$6,006.00
Rate for Payer: Hawaii Western Management Group Commercial	$6,468.00
Rate for Payer: Health Management Network Commercial	$7,854.00
Rate for Payer: Kaiser Permanente Commercial	$8,316.00
Rate for Payer: MDX Hawaii PPO	$8,962.80
Rate for Payer: University Health Alliance Commercial	$5,174.40

PAIN & SPINE: BOSTON SCIENTIFIC FIXATE TISSUE BAND (DUAL PACK)

Facility

$3,580.00

Hospital Charge Code	8882333
Hospital Revenue Code	272
Min. Negotiated Rate	$1,790.00
Max. Negotiated Rate	$3,472.60
Rate for Payer: AlohaCare Medicaid	$1,790.00
Rate for Payer: AlohaCare Medicare	$1,790.00
Rate for Payer: Cash Price	$2,327.00
Rate for Payer: Devoted Health Medicare	$1,969.00
Rate for Payer: Hawaii Medical Service Association Medicare	$1,790.00
Rate for Payer: Hawaii Western Management Group Commercial	$3,401.00
Rate for Payer: Health Management Network Commercial	$3,043.00
Rate for Payer: Humana Medicare	$1,790.00
Rate for Payer: Kaiser Permanente Commercial	$3,222.00
Rate for Payer: Kaiser Permanente Medicaid	$1,825.80
Rate for Payer: Kaiser Permanente Medicare	$1,790.00
Rate for Payer: MDX Hawaii PPO	$3,472.60
Rate for Payer: Ohana Health Plan Medicaid	$1,790.00
Rate for Payer: Ohana Health Plan Medicare	$1,790.00
Rate for Payer: UnitedHealthcare Medicare	$1,790.00
Rate for Payer: University Health Alliance Commercial	$2,609.46

PAIN & SPINE: BOSTON SCIENTIFIC FIXATE TISSUE BAND (DUAL PACK)

Facility

$3,580.00

Hospital Charge Code	8882333
Hospital Revenue Code	272
Min. Negotiated Rate	$3,043.00
Max. Negotiated Rate	$3,472.60
Rate for Payer: Cash Price	$2,327.00
Rate for Payer: Health Management Network Commercial	$3,043.00
Rate for Payer: Kaiser Permanente Commercial	$3,222.00
Rate for Payer: MDX Hawaii PPO	$3,472.60

PAIN & SPINE: BOSTON SCIENTIFIC FIXATE TISSUE BAND (SINGLE PACK)

Facility

$1,800.00

Hospital Charge Code	8813157
Hospital Revenue Code	272
Min. Negotiated Rate	$900.00
Max. Negotiated Rate	$1,746.00
Rate for Payer: AlohaCare Medicaid	$900.00
Rate for Payer: AlohaCare Medicare	$900.00
Rate for Payer: Cash Price	$1,170.00
Rate for Payer: Devoted Health Medicare	$990.00
Rate for Payer: Hawaii Medical Service Association Medicare	$900.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,710.00
Rate for Payer: Health Management Network Commercial	$1,530.00
Rate for Payer: Humana Medicare	$900.00
Rate for Payer: Kaiser Permanente Commercial	$1,620.00
Rate for Payer: Kaiser Permanente Medicaid	$918.00
Rate for Payer: Kaiser Permanente Medicare	$900.00
Rate for Payer: MDX Hawaii PPO	$1,746.00
Rate for Payer: Ohana Health Plan Medicaid	$900.00
Rate for Payer: Ohana Health Plan Medicare	$900.00
Rate for Payer: UnitedHealthcare Medicare	$900.00
Rate for Payer: University Health Alliance Commercial	$1,312.02

PAIN & SPINE: BOSTON SCIENTIFIC FIXATE TISSUE BAND (SINGLE PACK)

Facility

$1,800.00

Hospital Charge Code	8813157
Hospital Revenue Code	272
Min. Negotiated Rate	$1,530.00
Max. Negotiated Rate	$1,746.00
Rate for Payer: Cash Price	$1,170.00
Rate for Payer: Health Management Network Commercial	$1,530.00
Rate for Payer: Kaiser Permanente Commercial	$1,620.00
Rate for Payer: MDX Hawaii PPO	$1,746.00

PAIN & SPINE: BOSTON SCIENTIFIC LINEAR 3-4 LEAD 50CM

Facility

$6,160.00

Service Code	HCPCS C1778
Hospital Charge Code	8882340
Hospital Revenue Code	278
Min. Negotiated Rate	$3,080.00
Max. Negotiated Rate	$5,975.20
Rate for Payer: AlohaCare Medicaid	$3,080.00
Rate for Payer: AlohaCare Medicare	$3,080.00
Rate for Payer: Cash Price	$4,004.00
Rate for Payer: Devoted Health Medicare	$3,388.00
Rate for Payer: Hawaii Medical Service Association Medicare	$3,080.00
Rate for Payer: Hawaii Western Management Group Commercial	$4,312.00
Rate for Payer: Health Management Network Commercial	$5,236.00
Rate for Payer: Humana Medicare	$3,080.00
Rate for Payer: Kaiser Permanente Commercial	$5,544.00
Rate for Payer: Kaiser Permanente Medicaid	$3,141.60
Rate for Payer: Kaiser Permanente Medicare	$3,080.00
Rate for Payer: MDX Hawaii PPO	$5,975.20
Rate for Payer: Ohana Health Plan Medicaid	$3,080.00
Rate for Payer: Ohana Health Plan Medicare	$3,080.00
Rate for Payer: UnitedHealthcare Medicare	$3,080.00
Rate for Payer: University Health Alliance Commercial	$3,449.60

PAIN & SPINE: BOSTON SCIENTIFIC LINEAR 3-4 LEAD 50CM

Facility

$6,160.00

Service Code	HCPCS C1778
Hospital Charge Code	8882340
Hospital Revenue Code	278
Min. Negotiated Rate	$3,449.60
Max. Negotiated Rate	$5,975.20
Rate for Payer: Cash Price	$4,004.00
Rate for Payer: Hawaii Western Management Group Commercial	$4,312.00
Rate for Payer: Health Management Network Commercial	$5,236.00
Rate for Payer: Kaiser Permanente Commercial	$5,544.00
Rate for Payer: MDX Hawaii PPO	$5,975.20
Rate for Payer: University Health Alliance Commercial	$3,449.60

PAIN & SPINE: BOSTON SCIENTIFIC PATIENT TRIAL KIT

Facility

$432.00

Hospital Charge Code	9558775
Hospital Revenue Code	272
Min. Negotiated Rate	$216.00
Max. Negotiated Rate	$419.04
Rate for Payer: AlohaCare Medicaid	$216.00
Rate for Payer: AlohaCare Medicare	$216.00
Rate for Payer: Cash Price	$280.80
Rate for Payer: Devoted Health Medicare	$237.60
Rate for Payer: Hawaii Medical Service Association Medicare	$216.00
Rate for Payer: Hawaii Western Management Group Commercial	$410.40
Rate for Payer: Health Management Network Commercial	$367.20
Rate for Payer: Humana Medicare	$216.00
Rate for Payer: Kaiser Permanente Commercial	$388.80
Rate for Payer: Kaiser Permanente Medicaid	$220.32
Rate for Payer: Kaiser Permanente Medicare	$216.00
Rate for Payer: MDX Hawaii PPO	$419.04
Rate for Payer: Ohana Health Plan Medicaid	$216.00
Rate for Payer: Ohana Health Plan Medicare	$216.00
Rate for Payer: UnitedHealthcare Medicare	$216.00
Rate for Payer: University Health Alliance Commercial	$314.88

PAIN & SPINE: BOSTON SCIENTIFIC PATIENT TRIAL KIT

Facility

$432.00

Hospital Charge Code	9558775
Hospital Revenue Code	272
Min. Negotiated Rate	$367.20
Max. Negotiated Rate	$419.04
Rate for Payer: Cash Price	$280.80
Rate for Payer: Health Management Network Commercial	$367.20
Rate for Payer: Kaiser Permanente Commercial	$388.80
Rate for Payer: MDX Hawaii PPO	$419.04

PAIN & SPINE CABLE 355531 MULTI LEAD TRIALING

Facility

$750.00

Service Code	HCPCS C1897
Hospital Charge Code	8806215
Hospital Revenue Code	278
Min. Negotiated Rate	$420.00
Max. Negotiated Rate	$727.50
Rate for Payer: Cash Price	$487.50
Rate for Payer: Hawaii Western Management Group Commercial	$525.00
Rate for Payer: Health Management Network Commercial	$637.50
Rate for Payer: Kaiser Permanente Commercial	$675.00
Rate for Payer: MDX Hawaii PPO	$727.50
Rate for Payer: University Health Alliance Commercial	$420.00

PAIN & SPINE CABLE 355531 MULTI LEAD TRIALING

Facility

$750.00

Service Code	HCPCS C1897
Hospital Charge Code	8806215
Hospital Revenue Code	278
Min. Negotiated Rate	$375.00
Max. Negotiated Rate	$727.50
Rate for Payer: AlohaCare Medicaid	$375.00
Rate for Payer: AlohaCare Medicare	$375.00
Rate for Payer: Cash Price	$487.50
Rate for Payer: Devoted Health Medicare	$412.50
Rate for Payer: Hawaii Medical Service Association Medicare	$375.00
Rate for Payer: Hawaii Western Management Group Commercial	$525.00
Rate for Payer: Health Management Network Commercial	$637.50
Rate for Payer: Humana Medicare	$375.00
Rate for Payer: Kaiser Permanente Commercial	$675.00
Rate for Payer: Kaiser Permanente Medicaid	$382.50
Rate for Payer: Kaiser Permanente Medicare	$375.00
Rate for Payer: MDX Hawaii PPO	$727.50
Rate for Payer: Ohana Health Plan Medicaid	$375.00
Rate for Payer: Ohana Health Plan Medicare	$375.00
Rate for Payer: UnitedHealthcare Medicare	$375.00
Rate for Payer: University Health Alliance Commercial	$420.00

PAIN & SPINE: CANNULA AC0001 50MM 16G 10MM CS

Facility

$563.00

Hospital Charge Code	9589766
Hospital Revenue Code	272
Min. Negotiated Rate	$281.50
Max. Negotiated Rate	$546.11
Rate for Payer: AlohaCare Medicaid	$281.50
Rate for Payer: AlohaCare Medicare	$281.50
Rate for Payer: Cash Price	$365.95
Rate for Payer: Devoted Health Medicare	$309.65
Rate for Payer: Hawaii Medical Service Association Medicare	$281.50
Rate for Payer: Hawaii Western Management Group Commercial	$534.85
Rate for Payer: Health Management Network Commercial	$478.55
Rate for Payer: Humana Medicare	$281.50
Rate for Payer: Kaiser Permanente Commercial	$506.70
Rate for Payer: Kaiser Permanente Medicaid	$287.13
Rate for Payer: Kaiser Permanente Medicare	$281.50
Rate for Payer: MDX Hawaii PPO	$546.11
Rate for Payer: Ohana Health Plan Medicaid	$281.50
Rate for Payer: Ohana Health Plan Medicare	$281.50
Rate for Payer: UnitedHealthcare Medicare	$281.50
Rate for Payer: University Health Alliance Commercial	$410.37

PAIN & SPINE: CANNULA AC0001 50MM 16G 10MM CS

Facility

$563.00

Hospital Charge Code	9589766
Hospital Revenue Code	272
Min. Negotiated Rate	$478.55
Max. Negotiated Rate	$546.11
Rate for Payer: Cash Price	$365.95
Rate for Payer: Health Management Network Commercial	$478.55
Rate for Payer: Kaiser Permanente Commercial	$506.70
Rate for Payer: MDX Hawaii PPO	$546.11

PAIN & SPINE: CANNULA AC0002 100MM 16G 10MM CS

Facility

$563.00

Hospital Charge Code	9589767
Hospital Revenue Code	272
Min. Negotiated Rate	$478.55
Max. Negotiated Rate	$546.11
Rate for Payer: Cash Price	$365.95
Rate for Payer: Health Management Network Commercial	$478.55
Rate for Payer: Kaiser Permanente Commercial	$506.70
Rate for Payer: MDX Hawaii PPO	$546.11

PAIN & SPINE: CANNULA AC0002 100MM 16G 10MM CS

Facility

$563.00

Hospital Charge Code	9589767
Hospital Revenue Code	272
Min. Negotiated Rate	$281.50
Max. Negotiated Rate	$546.11
Rate for Payer: AlohaCare Medicaid	$281.50
Rate for Payer: AlohaCare Medicare	$281.50
Rate for Payer: Cash Price	$365.95
Rate for Payer: Devoted Health Medicare	$309.65
Rate for Payer: Hawaii Medical Service Association Medicare	$281.50
Rate for Payer: Hawaii Western Management Group Commercial	$534.85
Rate for Payer: Health Management Network Commercial	$478.55
Rate for Payer: Humana Medicare	$281.50
Rate for Payer: Kaiser Permanente Commercial	$506.70
Rate for Payer: Kaiser Permanente Medicaid	$287.13
Rate for Payer: Kaiser Permanente Medicare	$281.50
Rate for Payer: MDX Hawaii PPO	$546.11
Rate for Payer: Ohana Health Plan Medicaid	$281.50
Rate for Payer: Ohana Health Plan Medicare	$281.50
Rate for Payer: UnitedHealthcare Medicare	$281.50
Rate for Payer: University Health Alliance Commercial	$410.37

Know your out-of-pocket cost for care.

All Charges