Kauai Veterans Memorial Hospital

All Charges

Charge

Type

Setting

Price

PAIN & SPINE: MEDTRONIC SPINAL KYPHOPLASTY 10MM TRAY FIRST FRACTURE

Facility

$10,810.00

Service Code	HCPCS C1713
Hospital Charge Code	8848268
Hospital Revenue Code	278
Min. Negotiated Rate	$6,053.60
Max. Negotiated Rate	$10,485.70
Rate for Payer: Cash Price	$7,026.50
Rate for Payer: Hawaii Western Management Group Commercial	$7,567.00
Rate for Payer: Health Management Network Commercial	$9,188.50
Rate for Payer: Kaiser Permanente Commercial	$9,729.00
Rate for Payer: MDX Hawaii PPO	$10,485.70
Rate for Payer: University Health Alliance Commercial	$6,053.60

PAIN & SPINE: MEDTRONIC WIRELESS EXTERNAL NEUROSTIMULATOR

Facility

$2,145.00

Service Code	HCPCS L9900
Hospital Charge Code	8743134
Hospital Revenue Code	270
Min. Negotiated Rate	$1,072.50
Max. Negotiated Rate	$2,080.65
Rate for Payer: AlohaCare Medicaid	$1,072.50
Rate for Payer: AlohaCare Medicare	$1,072.50
Rate for Payer: Cash Price	$1,394.25
Rate for Payer: Devoted Health Medicare	$1,179.75
Rate for Payer: Hawaii Medical Service Association Medicare	$1,072.50
Rate for Payer: Hawaii Western Management Group Commercial	$2,037.75
Rate for Payer: Health Management Network Commercial	$1,823.25
Rate for Payer: Humana Medicare	$1,072.50
Rate for Payer: Kaiser Permanente Commercial	$1,930.50
Rate for Payer: Kaiser Permanente Medicaid	$1,093.95
Rate for Payer: Kaiser Permanente Medicare	$1,072.50
Rate for Payer: MDX Hawaii PPO	$2,080.65
Rate for Payer: Ohana Health Plan Medicaid	$1,072.50
Rate for Payer: Ohana Health Plan Medicare	$1,072.50
Rate for Payer: UnitedHealthcare Medicare	$1,072.50
Rate for Payer: University Health Alliance Commercial	$1,563.49

PAIN & SPINE: MEDTRONIC WIRELESS EXTERNAL NEUROSTIMULATOR

Facility

$2,145.00

Service Code	HCPCS L9900
Hospital Charge Code	8743134
Hospital Revenue Code	270
Min. Negotiated Rate	$1,823.25
Max. Negotiated Rate	$2,080.65
Rate for Payer: Cash Price	$1,394.25
Rate for Payer: Health Management Network Commercial	$1,823.25
Rate for Payer: Kaiser Permanente Commercial	$1,930.50
Rate for Payer: MDX Hawaii PPO	$2,080.65

PAIN & SPINE: MINUTEMAN INTERLAMINAR FUSION DEVICE-SIZE 10

Facility

$34,000.00

Service Code	HCPCS C1831
Hospital Charge Code	11117385
Hospital Revenue Code	278
Min. Negotiated Rate	$17,000.00
Max. Negotiated Rate	$32,980.00
Rate for Payer: AlohaCare Medicaid	$17,000.00
Rate for Payer: AlohaCare Medicare	$17,000.00
Rate for Payer: Cash Price	$22,100.00
Rate for Payer: Devoted Health Medicare	$18,700.00
Rate for Payer: Hawaii Medical Service Association Medicare	$17,000.00
Rate for Payer: Hawaii Western Management Group Commercial	$23,800.00
Rate for Payer: Health Management Network Commercial	$28,900.00
Rate for Payer: Humana Medicare	$17,000.00
Rate for Payer: Kaiser Permanente Commercial	$30,600.00
Rate for Payer: Kaiser Permanente Medicaid	$17,340.00
Rate for Payer: Kaiser Permanente Medicare	$17,000.00
Rate for Payer: MDX Hawaii PPO	$32,980.00
Rate for Payer: Ohana Health Plan Medicaid	$17,000.00
Rate for Payer: Ohana Health Plan Medicare	$17,000.00
Rate for Payer: UnitedHealthcare Medicare	$17,000.00
Rate for Payer: University Health Alliance Commercial	$19,040.00

PAIN & SPINE: MINUTEMAN INTERLAMINAR FUSION DEVICE-SIZE 10

Facility

$34,000.00

Service Code	HCPCS C1831
Hospital Charge Code	11117385
Hospital Revenue Code	278
Min. Negotiated Rate	$19,040.00
Max. Negotiated Rate	$32,980.00
Rate for Payer: Cash Price	$22,100.00
Rate for Payer: Hawaii Western Management Group Commercial	$23,800.00
Rate for Payer: Health Management Network Commercial	$28,900.00
Rate for Payer: Kaiser Permanente Commercial	$30,600.00
Rate for Payer: MDX Hawaii PPO	$32,980.00
Rate for Payer: University Health Alliance Commercial	$19,040.00

PAIN & SPINE:PAINTEQ LINQ SI JOINT ALLOGRAFT SPACER 22MM

Facility

$25,000.00

Hospital Charge Code	11808916
Hospital Revenue Code	278
Min. Negotiated Rate	$12,500.00
Max. Negotiated Rate	$24,250.00
Rate for Payer: AlohaCare Medicaid	$12,500.00
Rate for Payer: AlohaCare Medicare	$12,500.00
Rate for Payer: Cash Price	$16,250.00
Rate for Payer: Devoted Health Medicare	$13,750.00
Rate for Payer: Hawaii Medical Service Association Medicare	$12,500.00
Rate for Payer: Hawaii Western Management Group Commercial	$17,500.00
Rate for Payer: Health Management Network Commercial	$21,250.00
Rate for Payer: Humana Medicare	$12,500.00
Rate for Payer: Kaiser Permanente Commercial	$22,500.00
Rate for Payer: Kaiser Permanente Medicaid	$12,750.00
Rate for Payer: Kaiser Permanente Medicare	$12,500.00
Rate for Payer: MDX Hawaii PPO	$24,250.00
Rate for Payer: Ohana Health Plan Medicaid	$12,500.00
Rate for Payer: Ohana Health Plan Medicare	$12,500.00
Rate for Payer: UnitedHealthcare Medicare	$12,500.00
Rate for Payer: University Health Alliance Commercial	$14,000.00

PAIN & SPINE:PAINTEQ LINQ SI JOINT ALLOGRAFT SPACER 22MM

Facility

$25,000.00

Hospital Charge Code	11808916
Hospital Revenue Code	278
Min. Negotiated Rate	$14,000.00
Max. Negotiated Rate	$24,250.00
Rate for Payer: Cash Price	$16,250.00
Rate for Payer: Hawaii Western Management Group Commercial	$17,500.00
Rate for Payer: Health Management Network Commercial	$21,250.00
Rate for Payer: Kaiser Permanente Commercial	$22,500.00
Rate for Payer: MDX Hawaii PPO	$24,250.00
Rate for Payer: University Health Alliance Commercial	$14,000.00

PAIN & SPINE PROBE APSC01 50MM 10MM ENHANCED

Facility

$1,860.00

Hospital Charge Code	9586297
Hospital Revenue Code	272
Min. Negotiated Rate	$930.00
Max. Negotiated Rate	$1,804.20
Rate for Payer: AlohaCare Medicaid	$930.00
Rate for Payer: AlohaCare Medicare	$930.00
Rate for Payer: Cash Price	$1,209.00
Rate for Payer: Devoted Health Medicare	$1,023.00
Rate for Payer: Hawaii Medical Service Association Medicare	$930.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,767.00
Rate for Payer: Health Management Network Commercial	$1,581.00
Rate for Payer: Humana Medicare	$930.00
Rate for Payer: Kaiser Permanente Commercial	$1,674.00
Rate for Payer: Kaiser Permanente Medicaid	$948.60
Rate for Payer: Kaiser Permanente Medicare	$930.00
Rate for Payer: MDX Hawaii PPO	$1,804.20
Rate for Payer: Ohana Health Plan Medicaid	$930.00
Rate for Payer: Ohana Health Plan Medicare	$930.00
Rate for Payer: UnitedHealthcare Medicare	$930.00
Rate for Payer: University Health Alliance Commercial	$1,355.75

PAIN & SPINE PROBE APSC01 50MM 10MM ENHANCED

Facility

$1,860.00

Hospital Charge Code	9586297
Hospital Revenue Code	272
Min. Negotiated Rate	$1,581.00
Max. Negotiated Rate	$1,804.20
Rate for Payer: Cash Price	$1,209.00
Rate for Payer: Health Management Network Commercial	$1,581.00
Rate for Payer: Kaiser Permanente Commercial	$1,674.00
Rate for Payer: MDX Hawaii PPO	$1,804.20

PAIN & SPINE: PROBE APSC02 100MM 10MM ENHANCED

Facility

$1,860.00

Hospital Charge Code	9586298
Hospital Revenue Code	272
Min. Negotiated Rate	$930.00
Max. Negotiated Rate	$1,804.20
Rate for Payer: AlohaCare Medicaid	$930.00
Rate for Payer: AlohaCare Medicare	$930.00
Rate for Payer: Cash Price	$1,209.00
Rate for Payer: Devoted Health Medicare	$1,023.00
Rate for Payer: Hawaii Medical Service Association Medicare	$930.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,767.00
Rate for Payer: Health Management Network Commercial	$1,581.00
Rate for Payer: Humana Medicare	$930.00
Rate for Payer: Kaiser Permanente Commercial	$1,674.00
Rate for Payer: Kaiser Permanente Medicaid	$948.60
Rate for Payer: Kaiser Permanente Medicare	$930.00
Rate for Payer: MDX Hawaii PPO	$1,804.20
Rate for Payer: Ohana Health Plan Medicaid	$930.00
Rate for Payer: Ohana Health Plan Medicare	$930.00
Rate for Payer: UnitedHealthcare Medicare	$930.00
Rate for Payer: University Health Alliance Commercial	$1,355.75

PAIN & SPINE: PROBE APSC02 100MM 10MM ENHANCED

Facility

$1,860.00

Hospital Charge Code	9586298
Hospital Revenue Code	272
Min. Negotiated Rate	$1,581.00
Max. Negotiated Rate	$1,804.20
Rate for Payer: Cash Price	$1,209.00
Rate for Payer: Health Management Network Commercial	$1,581.00
Rate for Payer: Kaiser Permanente Commercial	$1,674.00
Rate for Payer: MDX Hawaii PPO	$1,804.20

PAIN & SPINE: PROBE APSC03 150MM 10MM ENHANCED

Facility

$1,860.00

Hospital Charge Code	9586299
Hospital Revenue Code	272
Min. Negotiated Rate	$1,581.00
Max. Negotiated Rate	$1,804.20
Rate for Payer: Cash Price	$1,209.00
Rate for Payer: Health Management Network Commercial	$1,581.00
Rate for Payer: Kaiser Permanente Commercial	$1,674.00
Rate for Payer: MDX Hawaii PPO	$1,804.20

PAIN & SPINE: PROBE APSC03 150MM 10MM ENHANCED

Facility

$1,860.00

Hospital Charge Code	9586299
Hospital Revenue Code	272
Min. Negotiated Rate	$930.00
Max. Negotiated Rate	$1,804.20
Rate for Payer: AlohaCare Medicaid	$930.00
Rate for Payer: AlohaCare Medicare	$930.00
Rate for Payer: Cash Price	$1,209.00
Rate for Payer: Devoted Health Medicare	$1,023.00
Rate for Payer: Hawaii Medical Service Association Medicare	$930.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,767.00
Rate for Payer: Health Management Network Commercial	$1,581.00
Rate for Payer: Humana Medicare	$930.00
Rate for Payer: Kaiser Permanente Commercial	$1,674.00
Rate for Payer: Kaiser Permanente Medicaid	$948.60
Rate for Payer: Kaiser Permanente Medicare	$930.00
Rate for Payer: MDX Hawaii PPO	$1,804.20
Rate for Payer: Ohana Health Plan Medicaid	$930.00
Rate for Payer: Ohana Health Plan Medicare	$930.00
Rate for Payer: UnitedHealthcare Medicare	$930.00
Rate for Payer: University Health Alliance Commercial	$1,355.75

PAIN & SPINE: PROBE APSC04 50MM 12MM ENHANCED

Facility

$1,860.00

Hospital Charge Code	9586300
Hospital Revenue Code	272
Min. Negotiated Rate	$930.00
Max. Negotiated Rate	$1,804.20
Rate for Payer: AlohaCare Medicaid	$930.00
Rate for Payer: AlohaCare Medicare	$930.00
Rate for Payer: Cash Price	$1,209.00
Rate for Payer: Devoted Health Medicare	$1,023.00
Rate for Payer: Hawaii Medical Service Association Medicare	$930.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,767.00
Rate for Payer: Health Management Network Commercial	$1,581.00
Rate for Payer: Humana Medicare	$930.00
Rate for Payer: Kaiser Permanente Commercial	$1,674.00
Rate for Payer: Kaiser Permanente Medicaid	$948.60
Rate for Payer: Kaiser Permanente Medicare	$930.00
Rate for Payer: MDX Hawaii PPO	$1,804.20
Rate for Payer: Ohana Health Plan Medicaid	$930.00
Rate for Payer: Ohana Health Plan Medicare	$930.00
Rate for Payer: UnitedHealthcare Medicare	$930.00
Rate for Payer: University Health Alliance Commercial	$1,355.75

PAIN & SPINE: PROBE APSC04 50MM 12MM ENHANCED

Facility

$1,860.00

Hospital Charge Code	9586300
Hospital Revenue Code	272
Min. Negotiated Rate	$1,581.00
Max. Negotiated Rate	$1,804.20
Rate for Payer: Cash Price	$1,209.00
Rate for Payer: Health Management Network Commercial	$1,581.00
Rate for Payer: Kaiser Permanente Commercial	$1,674.00
Rate for Payer: MDX Hawaii PPO	$1,804.20

PAIN & SPINE: PROBE APSC05 100MM 12MM ENHANCED

Facility

$1,860.00

Hospital Charge Code	9583513
Hospital Revenue Code	272
Min. Negotiated Rate	$1,581.00
Max. Negotiated Rate	$1,804.20
Rate for Payer: Cash Price	$1,209.00
Rate for Payer: Health Management Network Commercial	$1,581.00
Rate for Payer: Kaiser Permanente Commercial	$1,674.00
Rate for Payer: MDX Hawaii PPO	$1,804.20

PAIN & SPINE: PROBE APSC05 100MM 12MM ENHANCED

Facility

$1,860.00

Hospital Charge Code	9583513
Hospital Revenue Code	272
Min. Negotiated Rate	$930.00
Max. Negotiated Rate	$1,804.20
Rate for Payer: AlohaCare Medicaid	$930.00
Rate for Payer: AlohaCare Medicare	$930.00
Rate for Payer: Cash Price	$1,209.00
Rate for Payer: Devoted Health Medicare	$1,023.00
Rate for Payer: Hawaii Medical Service Association Medicare	$930.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,767.00
Rate for Payer: Health Management Network Commercial	$1,581.00
Rate for Payer: Humana Medicare	$930.00
Rate for Payer: Kaiser Permanente Commercial	$1,674.00
Rate for Payer: Kaiser Permanente Medicaid	$948.60
Rate for Payer: Kaiser Permanente Medicare	$930.00
Rate for Payer: MDX Hawaii PPO	$1,804.20
Rate for Payer: Ohana Health Plan Medicaid	$930.00
Rate for Payer: Ohana Health Plan Medicare	$930.00
Rate for Payer: UnitedHealthcare Medicare	$930.00
Rate for Payer: University Health Alliance Commercial	$1,355.75

PAIN & SPINE: PROBE APSC06 150MM 12MM ENHANCED

Facility

$1,860.00

Hospital Charge Code	9586301
Hospital Revenue Code	272
Min. Negotiated Rate	$1,581.00
Max. Negotiated Rate	$1,804.20
Rate for Payer: Cash Price	$1,209.00
Rate for Payer: Health Management Network Commercial	$1,581.00
Rate for Payer: Kaiser Permanente Commercial	$1,674.00
Rate for Payer: MDX Hawaii PPO	$1,804.20

PAIN & SPINE: PROBE APSC06 150MM 12MM ENHANCED

Facility

$1,860.00

Hospital Charge Code	9586301
Hospital Revenue Code	272
Min. Negotiated Rate	$930.00
Max. Negotiated Rate	$1,804.20
Rate for Payer: AlohaCare Medicaid	$930.00
Rate for Payer: AlohaCare Medicare	$930.00
Rate for Payer: Cash Price	$1,209.00
Rate for Payer: Devoted Health Medicare	$1,023.00
Rate for Payer: Hawaii Medical Service Association Medicare	$930.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,767.00
Rate for Payer: Health Management Network Commercial	$1,581.00
Rate for Payer: Humana Medicare	$930.00
Rate for Payer: Kaiser Permanente Commercial	$1,674.00
Rate for Payer: Kaiser Permanente Medicaid	$948.60
Rate for Payer: Kaiser Permanente Medicare	$930.00
Rate for Payer: MDX Hawaii PPO	$1,804.20
Rate for Payer: Ohana Health Plan Medicaid	$930.00
Rate for Payer: Ohana Health Plan Medicare	$930.00
Rate for Payer: UnitedHealthcare Medicare	$930.00
Rate for Payer: University Health Alliance Commercial	$1,355.75

PAIN & SPINE: PROBE APSD050 SINGLE USE SS 50MM 16-22G

Facility

$488.00

Hospital Charge Code	9586302
Hospital Revenue Code	272
Min. Negotiated Rate	$244.00
Max. Negotiated Rate	$473.36
Rate for Payer: AlohaCare Medicaid	$244.00
Rate for Payer: AlohaCare Medicare	$244.00
Rate for Payer: Cash Price	$317.20
Rate for Payer: Devoted Health Medicare	$268.40
Rate for Payer: Hawaii Medical Service Association Medicare	$244.00
Rate for Payer: Hawaii Western Management Group Commercial	$463.60
Rate for Payer: Health Management Network Commercial	$414.80
Rate for Payer: Humana Medicare	$244.00
Rate for Payer: Kaiser Permanente Commercial	$439.20
Rate for Payer: Kaiser Permanente Medicaid	$248.88
Rate for Payer: Kaiser Permanente Medicare	$244.00
Rate for Payer: MDX Hawaii PPO	$473.36
Rate for Payer: Ohana Health Plan Medicaid	$244.00
Rate for Payer: Ohana Health Plan Medicare	$244.00
Rate for Payer: UnitedHealthcare Medicare	$244.00
Rate for Payer: University Health Alliance Commercial	$355.70

PAIN & SPINE: PROBE APSD050 SINGLE USE SS 50MM 16-22G

Facility

$488.00

Hospital Charge Code	9586302
Hospital Revenue Code	272
Min. Negotiated Rate	$414.80
Max. Negotiated Rate	$473.36
Rate for Payer: Cash Price	$317.20
Rate for Payer: Health Management Network Commercial	$414.80
Rate for Payer: Kaiser Permanente Commercial	$439.20
Rate for Payer: MDX Hawaii PPO	$473.36

PAIN & SPINE: PROBE APSD100 SINGLE USE SS 100MM 16-22G

Facility

$488.00

Hospital Charge Code	9586332
Hospital Revenue Code	272
Min. Negotiated Rate	$244.00
Max. Negotiated Rate	$473.36
Rate for Payer: AlohaCare Medicaid	$244.00
Rate for Payer: AlohaCare Medicare	$244.00
Rate for Payer: Cash Price	$317.20
Rate for Payer: Devoted Health Medicare	$268.40
Rate for Payer: Hawaii Medical Service Association Medicare	$244.00
Rate for Payer: Hawaii Western Management Group Commercial	$463.60
Rate for Payer: Health Management Network Commercial	$414.80
Rate for Payer: Humana Medicare	$244.00
Rate for Payer: Kaiser Permanente Commercial	$439.20
Rate for Payer: Kaiser Permanente Medicaid	$248.88
Rate for Payer: Kaiser Permanente Medicare	$244.00
Rate for Payer: MDX Hawaii PPO	$473.36
Rate for Payer: Ohana Health Plan Medicaid	$244.00
Rate for Payer: Ohana Health Plan Medicare	$244.00
Rate for Payer: UnitedHealthcare Medicare	$244.00
Rate for Payer: University Health Alliance Commercial	$355.70

PAIN & SPINE: PROBE APSD100 SINGLE USE SS 100MM 16-22G

Facility

$488.00

Hospital Charge Code	9586332
Hospital Revenue Code	272
Min. Negotiated Rate	$414.80
Max. Negotiated Rate	$473.36
Rate for Payer: Cash Price	$317.20
Rate for Payer: Health Management Network Commercial	$414.80
Rate for Payer: Kaiser Permanente Commercial	$439.20
Rate for Payer: MDX Hawaii PPO	$473.36

PAIN & SPINE: PROBE APSD150 SINGLE USE SS 150MM 16-22G

Facility

$488.00

Hospital Charge Code	9586333
Hospital Revenue Code	272
Min. Negotiated Rate	$414.80
Max. Negotiated Rate	$473.36
Rate for Payer: Cash Price	$317.20
Rate for Payer: Health Management Network Commercial	$414.80
Rate for Payer: Kaiser Permanente Commercial	$439.20
Rate for Payer: MDX Hawaii PPO	$473.36

PAIN & SPINE: PROBE APSD150 SINGLE USE SS 150MM 16-22G

Facility

$488.00

Hospital Charge Code	9586333
Hospital Revenue Code	272
Min. Negotiated Rate	$244.00
Max. Negotiated Rate	$473.36
Rate for Payer: AlohaCare Medicaid	$244.00
Rate for Payer: AlohaCare Medicare	$244.00
Rate for Payer: Cash Price	$317.20
Rate for Payer: Devoted Health Medicare	$268.40
Rate for Payer: Hawaii Medical Service Association Medicare	$244.00
Rate for Payer: Hawaii Western Management Group Commercial	$463.60
Rate for Payer: Health Management Network Commercial	$414.80
Rate for Payer: Humana Medicare	$244.00
Rate for Payer: Kaiser Permanente Commercial	$439.20
Rate for Payer: Kaiser Permanente Medicaid	$248.88
Rate for Payer: Kaiser Permanente Medicare	$244.00
Rate for Payer: MDX Hawaii PPO	$473.36
Rate for Payer: Ohana Health Plan Medicaid	$244.00
Rate for Payer: Ohana Health Plan Medicare	$244.00
Rate for Payer: UnitedHealthcare Medicare	$244.00
Rate for Payer: University Health Alliance Commercial	$355.70

Know your out-of-pocket cost for care.

All Charges