Kauai Veterans Memorial Hospital

All Charges

Charge

Type

Setting

Price

PAIN & SPINE: PROBE APSE050 REUSABLE SS 50MM 16-22G

Facility

$2,500.00

Hospital Charge Code	9586069
Hospital Revenue Code	272
Min. Negotiated Rate	$1,250.00
Max. Negotiated Rate	$2,425.00
Rate for Payer: AlohaCare Medicaid	$1,250.00
Rate for Payer: AlohaCare Medicare	$1,250.00
Rate for Payer: Cash Price	$1,625.00
Rate for Payer: Devoted Health Medicare	$1,375.00
Rate for Payer: Hawaii Medical Service Association Medicare	$1,250.00
Rate for Payer: Hawaii Western Management Group Commercial	$2,375.00
Rate for Payer: Health Management Network Commercial	$2,125.00
Rate for Payer: Humana Medicare	$1,250.00
Rate for Payer: Kaiser Permanente Commercial	$2,250.00
Rate for Payer: Kaiser Permanente Medicaid	$1,275.00
Rate for Payer: Kaiser Permanente Medicare	$1,250.00
Rate for Payer: MDX Hawaii PPO	$2,425.00
Rate for Payer: Ohana Health Plan Medicaid	$1,250.00
Rate for Payer: Ohana Health Plan Medicare	$1,250.00
Rate for Payer: UnitedHealthcare Medicare	$1,250.00
Rate for Payer: University Health Alliance Commercial	$1,822.25

PAIN & SPINE: PROBE APSE050 REUSABLE SS 50MM 16-22G

Facility

$2,500.00

Hospital Charge Code	9586069
Hospital Revenue Code	272
Min. Negotiated Rate	$2,125.00
Max. Negotiated Rate	$2,425.00
Rate for Payer: Cash Price	$1,625.00
Rate for Payer: Health Management Network Commercial	$2,125.00
Rate for Payer: Kaiser Permanente Commercial	$2,250.00
Rate for Payer: MDX Hawaii PPO	$2,425.00

PAIN & SPINE: PROBE APSN050 REUSE NITINOL 50MM 16-22G

Facility

$3,000.00

Hospital Charge Code	9586173
Hospital Revenue Code	272
Min. Negotiated Rate	$1,500.00
Max. Negotiated Rate	$2,910.00
Rate for Payer: AlohaCare Medicaid	$1,500.00
Rate for Payer: AlohaCare Medicare	$1,500.00
Rate for Payer: Cash Price	$1,950.00
Rate for Payer: Devoted Health Medicare	$1,650.00
Rate for Payer: Hawaii Medical Service Association Medicare	$1,500.00
Rate for Payer: Hawaii Western Management Group Commercial	$2,850.00
Rate for Payer: Health Management Network Commercial	$2,550.00
Rate for Payer: Humana Medicare	$1,500.00
Rate for Payer: Kaiser Permanente Commercial	$2,700.00
Rate for Payer: Kaiser Permanente Medicaid	$1,530.00
Rate for Payer: Kaiser Permanente Medicare	$1,500.00
Rate for Payer: MDX Hawaii PPO	$2,910.00
Rate for Payer: Ohana Health Plan Medicaid	$1,500.00
Rate for Payer: Ohana Health Plan Medicare	$1,500.00
Rate for Payer: UnitedHealthcare Medicare	$1,500.00
Rate for Payer: University Health Alliance Commercial	$2,186.70

PAIN & SPINE: PROBE APSN050 REUSE NITINOL 50MM 16-22G

Facility

$3,000.00

Hospital Charge Code	9586173
Hospital Revenue Code	272
Min. Negotiated Rate	$2,550.00
Max. Negotiated Rate	$2,910.00
Rate for Payer: Cash Price	$1,950.00
Rate for Payer: Health Management Network Commercial	$2,550.00
Rate for Payer: Kaiser Permanente Commercial	$2,700.00
Rate for Payer: MDX Hawaii PPO	$2,910.00

PAIN & SPINE: PROBE APSN100 REUSE NITINOL 100MM 16-22G

Facility

$3,000.00

Hospital Charge Code	9586174
Hospital Revenue Code	272
Min. Negotiated Rate	$2,550.00
Max. Negotiated Rate	$2,910.00
Rate for Payer: Cash Price	$1,950.00
Rate for Payer: Health Management Network Commercial	$2,550.00
Rate for Payer: Kaiser Permanente Commercial	$2,700.00
Rate for Payer: MDX Hawaii PPO	$2,910.00

PAIN & SPINE: PROBE APSN100 REUSE NITINOL 100MM 16-22G

Facility

$3,000.00

Hospital Charge Code	9586174
Hospital Revenue Code	272
Min. Negotiated Rate	$1,500.00
Max. Negotiated Rate	$2,910.00
Rate for Payer: AlohaCare Medicaid	$1,500.00
Rate for Payer: AlohaCare Medicare	$1,500.00
Rate for Payer: Cash Price	$1,950.00
Rate for Payer: Devoted Health Medicare	$1,650.00
Rate for Payer: Hawaii Medical Service Association Medicare	$1,500.00
Rate for Payer: Hawaii Western Management Group Commercial	$2,850.00
Rate for Payer: Health Management Network Commercial	$2,550.00
Rate for Payer: Humana Medicare	$1,500.00
Rate for Payer: Kaiser Permanente Commercial	$2,700.00
Rate for Payer: Kaiser Permanente Medicaid	$1,530.00
Rate for Payer: Kaiser Permanente Medicare	$1,500.00
Rate for Payer: MDX Hawaii PPO	$2,910.00
Rate for Payer: Ohana Health Plan Medicaid	$1,500.00
Rate for Payer: Ohana Health Plan Medicare	$1,500.00
Rate for Payer: UnitedHealthcare Medicare	$1,500.00
Rate for Payer: University Health Alliance Commercial	$2,186.70

PAIN & SPINE: PROBE APSN150 REUSE NITINOL 150MM 16-22G

Facility

$3,000.00

Hospital Charge Code	9586291
Hospital Revenue Code	272
Min. Negotiated Rate	$2,550.00
Max. Negotiated Rate	$2,910.00
Rate for Payer: Cash Price	$1,950.00
Rate for Payer: Health Management Network Commercial	$2,550.00
Rate for Payer: Kaiser Permanente Commercial	$2,700.00
Rate for Payer: MDX Hawaii PPO	$2,910.00

PAIN & SPINE: PROBE APSN150 REUSE NITINOL 150MM 16-22G

Facility

$3,000.00

Hospital Charge Code	9586291
Hospital Revenue Code	272
Min. Negotiated Rate	$1,500.00
Max. Negotiated Rate	$2,910.00
Rate for Payer: AlohaCare Medicaid	$1,500.00
Rate for Payer: AlohaCare Medicare	$1,500.00
Rate for Payer: Cash Price	$1,950.00
Rate for Payer: Devoted Health Medicare	$1,650.00
Rate for Payer: Hawaii Medical Service Association Medicare	$1,500.00
Rate for Payer: Hawaii Western Management Group Commercial	$2,850.00
Rate for Payer: Health Management Network Commercial	$2,550.00
Rate for Payer: Humana Medicare	$1,500.00
Rate for Payer: Kaiser Permanente Commercial	$2,700.00
Rate for Payer: Kaiser Permanente Medicaid	$1,530.00
Rate for Payer: Kaiser Permanente Medicare	$1,500.00
Rate for Payer: MDX Hawaii PPO	$2,910.00
Rate for Payer: Ohana Health Plan Medicaid	$1,500.00
Rate for Payer: Ohana Health Plan Medicare	$1,500.00
Rate for Payer: UnitedHealthcare Medicare	$1,500.00
Rate for Payer: University Health Alliance Commercial	$2,186.70

PAIN & SPINE: PROBE APSR0150 REUABLE SS 150MM 16-22G

Facility

$2,500.00

Hospital Charge Code	9586172
Hospital Revenue Code	272
Min. Negotiated Rate	$2,125.00
Max. Negotiated Rate	$2,425.00
Rate for Payer: Cash Price	$1,625.00
Rate for Payer: Health Management Network Commercial	$2,125.00
Rate for Payer: Kaiser Permanente Commercial	$2,250.00
Rate for Payer: MDX Hawaii PPO	$2,425.00

PAIN & SPINE: PROBE APSR0150 REUABLE SS 150MM 16-22G

Facility

$2,500.00

Hospital Charge Code	9586172
Hospital Revenue Code	272
Min. Negotiated Rate	$1,250.00
Max. Negotiated Rate	$2,425.00
Rate for Payer: AlohaCare Medicaid	$1,250.00
Rate for Payer: AlohaCare Medicare	$1,250.00
Rate for Payer: Cash Price	$1,625.00
Rate for Payer: Devoted Health Medicare	$1,375.00
Rate for Payer: Hawaii Medical Service Association Medicare	$1,250.00
Rate for Payer: Hawaii Western Management Group Commercial	$2,375.00
Rate for Payer: Health Management Network Commercial	$2,125.00
Rate for Payer: Humana Medicare	$1,250.00
Rate for Payer: Kaiser Permanente Commercial	$2,250.00
Rate for Payer: Kaiser Permanente Medicaid	$1,275.00
Rate for Payer: Kaiser Permanente Medicare	$1,250.00
Rate for Payer: MDX Hawaii PPO	$2,425.00
Rate for Payer: Ohana Health Plan Medicaid	$1,250.00
Rate for Payer: Ohana Health Plan Medicare	$1,250.00
Rate for Payer: UnitedHealthcare Medicare	$1,250.00
Rate for Payer: University Health Alliance Commercial	$1,822.25

PAIN & SPINE: PROBE APSR100 REUSABLE SS 100MM 16-22G

Facility

$2,500.00

Hospital Charge Code	9586171
Hospital Revenue Code	272
Min. Negotiated Rate	$1,250.00
Max. Negotiated Rate	$2,425.00
Rate for Payer: AlohaCare Medicaid	$1,250.00
Rate for Payer: AlohaCare Medicare	$1,250.00
Rate for Payer: Cash Price	$1,625.00
Rate for Payer: Devoted Health Medicare	$1,375.00
Rate for Payer: Hawaii Medical Service Association Medicare	$1,250.00
Rate for Payer: Hawaii Western Management Group Commercial	$2,375.00
Rate for Payer: Health Management Network Commercial	$2,125.00
Rate for Payer: Humana Medicare	$1,250.00
Rate for Payer: Kaiser Permanente Commercial	$2,250.00
Rate for Payer: Kaiser Permanente Medicaid	$1,275.00
Rate for Payer: Kaiser Permanente Medicare	$1,250.00
Rate for Payer: MDX Hawaii PPO	$2,425.00
Rate for Payer: Ohana Health Plan Medicaid	$1,250.00
Rate for Payer: Ohana Health Plan Medicare	$1,250.00
Rate for Payer: UnitedHealthcare Medicare	$1,250.00
Rate for Payer: University Health Alliance Commercial	$1,822.25

PAIN & SPINE: PROBE APSR100 REUSABLE SS 100MM 16-22G

Facility

$2,500.00

Hospital Charge Code	9586171
Hospital Revenue Code	272
Min. Negotiated Rate	$2,125.00
Max. Negotiated Rate	$2,425.00
Rate for Payer: Cash Price	$1,625.00
Rate for Payer: Health Management Network Commercial	$2,125.00
Rate for Payer: Kaiser Permanente Commercial	$2,250.00
Rate for Payer: MDX Hawaii PPO	$2,425.00

PAIN & SPINE PROGRAMMER 97740 PATIENT MRICS

Facility

$2,985.00

Service Code	HCPCS C1787
Hospital Charge Code	8806214
Hospital Revenue Code	278
Min. Negotiated Rate	$1,492.50
Max. Negotiated Rate	$2,895.45
Rate for Payer: AlohaCare Medicaid	$1,492.50
Rate for Payer: AlohaCare Medicare	$1,492.50
Rate for Payer: Cash Price	$1,940.25
Rate for Payer: Devoted Health Medicare	$1,641.75
Rate for Payer: Hawaii Medical Service Association Medicare	$1,492.50
Rate for Payer: Hawaii Western Management Group Commercial	$2,089.50
Rate for Payer: Health Management Network Commercial	$2,537.25
Rate for Payer: Humana Medicare	$1,492.50
Rate for Payer: Kaiser Permanente Commercial	$2,686.50
Rate for Payer: Kaiser Permanente Medicaid	$1,522.35
Rate for Payer: Kaiser Permanente Medicare	$1,492.50
Rate for Payer: MDX Hawaii PPO	$2,895.45
Rate for Payer: Ohana Health Plan Medicaid	$1,492.50
Rate for Payer: Ohana Health Plan Medicare	$1,492.50
Rate for Payer: UnitedHealthcare Medicare	$1,492.50
Rate for Payer: University Health Alliance Commercial	$1,671.60

PAIN & SPINE PROGRAMMER 97740 PATIENT MRICS

Facility

$2,985.00

Service Code	HCPCS C1787
Hospital Charge Code	8806214
Hospital Revenue Code	278
Min. Negotiated Rate	$1,671.60
Max. Negotiated Rate	$2,895.45
Rate for Payer: Cash Price	$1,940.25
Rate for Payer: Hawaii Western Management Group Commercial	$2,089.50
Rate for Payer: Health Management Network Commercial	$2,537.25
Rate for Payer: Kaiser Permanente Commercial	$2,686.50
Rate for Payer: MDX Hawaii PPO	$2,895.45
Rate for Payer: University Health Alliance Commercial	$1,671.60

PAIN & SPINE PUMP 8637-20 SYNCH II PR PCC=32

Facility

$21,280.00

Service Code	HCPCS C1772
Hospital Charge Code	8805344
Hospital Revenue Code	278
Min. Negotiated Rate	$10,640.00
Max. Negotiated Rate	$20,641.60
Rate for Payer: AlohaCare Medicaid	$10,640.00
Rate for Payer: AlohaCare Medicare	$10,640.00
Rate for Payer: Cash Price	$13,832.00
Rate for Payer: Devoted Health Medicare	$11,704.00
Rate for Payer: Hawaii Medical Service Association Medicare	$10,640.00
Rate for Payer: Hawaii Western Management Group Commercial	$14,896.00
Rate for Payer: Health Management Network Commercial	$18,088.00
Rate for Payer: Humana Medicare	$10,640.00
Rate for Payer: Kaiser Permanente Commercial	$19,152.00
Rate for Payer: Kaiser Permanente Medicaid	$10,852.80
Rate for Payer: Kaiser Permanente Medicare	$10,640.00
Rate for Payer: MDX Hawaii PPO	$20,641.60
Rate for Payer: Ohana Health Plan Medicaid	$10,640.00
Rate for Payer: Ohana Health Plan Medicare	$10,640.00
Rate for Payer: UnitedHealthcare Medicare	$10,640.00
Rate for Payer: University Health Alliance Commercial	$11,916.80

PAIN & SPINE PUMP 8637-20 SYNCH II PR PCC=32

Facility

$21,280.00

Service Code	HCPCS C1772
Hospital Charge Code	8805344
Hospital Revenue Code	278
Min. Negotiated Rate	$11,916.80
Max. Negotiated Rate	$20,641.60
Rate for Payer: Cash Price	$13,832.00
Rate for Payer: Hawaii Western Management Group Commercial	$14,896.00
Rate for Payer: Health Management Network Commercial	$18,088.00
Rate for Payer: Kaiser Permanente Commercial	$19,152.00
Rate for Payer: MDX Hawaii PPO	$20,641.60
Rate for Payer: University Health Alliance Commercial	$11,916.80

PAIN & SPINE PUMP 8637-40 SYNCH II PR PCC=32

Facility

$21,280.00

Service Code	HCPCS C1772
Hospital Charge Code	8805345
Hospital Revenue Code	278
Min. Negotiated Rate	$11,916.80
Max. Negotiated Rate	$20,641.60
Rate for Payer: Cash Price	$13,832.00
Rate for Payer: Hawaii Western Management Group Commercial	$14,896.00
Rate for Payer: Health Management Network Commercial	$18,088.00
Rate for Payer: Kaiser Permanente Commercial	$19,152.00
Rate for Payer: MDX Hawaii PPO	$20,641.60
Rate for Payer: University Health Alliance Commercial	$11,916.80

PAIN & SPINE PUMP 8637-40 SYNCH II PR PCC=32

Facility

$21,280.00

Service Code	HCPCS C1772
Hospital Charge Code	8805345
Hospital Revenue Code	278
Min. Negotiated Rate	$10,640.00
Max. Negotiated Rate	$20,641.60
Rate for Payer: AlohaCare Medicaid	$10,640.00
Rate for Payer: AlohaCare Medicare	$10,640.00
Rate for Payer: Cash Price	$13,832.00
Rate for Payer: Devoted Health Medicare	$11,704.00
Rate for Payer: Hawaii Medical Service Association Medicare	$10,640.00
Rate for Payer: Hawaii Western Management Group Commercial	$14,896.00
Rate for Payer: Health Management Network Commercial	$18,088.00
Rate for Payer: Humana Medicare	$10,640.00
Rate for Payer: Kaiser Permanente Commercial	$19,152.00
Rate for Payer: Kaiser Permanente Medicaid	$10,852.80
Rate for Payer: Kaiser Permanente Medicare	$10,640.00
Rate for Payer: MDX Hawaii PPO	$20,641.60
Rate for Payer: Ohana Health Plan Medicaid	$10,640.00
Rate for Payer: Ohana Health Plan Medicare	$10,640.00
Rate for Payer: UnitedHealthcare Medicare	$10,640.00
Rate for Payer: University Health Alliance Commercial	$11,916.80

PAIN & SPINE: SpineJack Case Kit 4.2MM

Facility

$7,497.00

Service Code	HCPCS C1062
Hospital Charge Code	11511784
Hospital Revenue Code	278
Min. Negotiated Rate	$3,748.50
Max. Negotiated Rate	$7,272.09
Rate for Payer: AlohaCare Medicaid	$3,748.50
Rate for Payer: AlohaCare Medicare	$3,748.50
Rate for Payer: Cash Price	$4,873.05
Rate for Payer: Devoted Health Medicare	$4,123.35
Rate for Payer: Hawaii Medical Service Association Medicare	$3,748.50
Rate for Payer: Hawaii Western Management Group Commercial	$5,247.90
Rate for Payer: Health Management Network Commercial	$6,372.45
Rate for Payer: Humana Medicare	$3,748.50
Rate for Payer: Kaiser Permanente Commercial	$6,747.30
Rate for Payer: Kaiser Permanente Medicaid	$3,823.47
Rate for Payer: Kaiser Permanente Medicare	$3,748.50
Rate for Payer: MDX Hawaii PPO	$7,272.09
Rate for Payer: Ohana Health Plan Medicaid	$3,748.50
Rate for Payer: Ohana Health Plan Medicare	$3,748.50
Rate for Payer: UnitedHealthcare Medicare	$3,748.50
Rate for Payer: University Health Alliance Commercial	$4,198.32

PAIN & SPINE: SpineJack Case Kit 4.2MM

Facility

$7,497.00

Service Code	HCPCS C1062
Hospital Charge Code	11511784
Hospital Revenue Code	278
Min. Negotiated Rate	$4,198.32
Max. Negotiated Rate	$7,272.09
Rate for Payer: Cash Price	$4,873.05
Rate for Payer: Hawaii Western Management Group Commercial	$5,247.90
Rate for Payer: Health Management Network Commercial	$6,372.45
Rate for Payer: Kaiser Permanente Commercial	$6,747.30
Rate for Payer: MDX Hawaii PPO	$7,272.09
Rate for Payer: University Health Alliance Commercial	$4,198.32

PAIN & SPINE: SpineJack Case Kit 5.0MM

Facility

$7,497.00

Service Code	HCPCS C1062
Hospital Charge Code	11511785
Hospital Revenue Code	278
Min. Negotiated Rate	$4,198.32
Max. Negotiated Rate	$7,272.09
Rate for Payer: Cash Price	$4,873.05
Rate for Payer: Hawaii Western Management Group Commercial	$5,247.90
Rate for Payer: Health Management Network Commercial	$6,372.45
Rate for Payer: Kaiser Permanente Commercial	$6,747.30
Rate for Payer: MDX Hawaii PPO	$7,272.09
Rate for Payer: University Health Alliance Commercial	$4,198.32

PAIN & SPINE: SpineJack Case Kit 5.0MM

Facility

$7,497.00

Service Code	HCPCS C1062
Hospital Charge Code	11511785
Hospital Revenue Code	278
Min. Negotiated Rate	$3,748.50
Max. Negotiated Rate	$7,272.09
Rate for Payer: AlohaCare Medicaid	$3,748.50
Rate for Payer: AlohaCare Medicare	$3,748.50
Rate for Payer: Cash Price	$4,873.05
Rate for Payer: Devoted Health Medicare	$4,123.35
Rate for Payer: Hawaii Medical Service Association Medicare	$3,748.50
Rate for Payer: Hawaii Western Management Group Commercial	$5,247.90
Rate for Payer: Health Management Network Commercial	$6,372.45
Rate for Payer: Humana Medicare	$3,748.50
Rate for Payer: Kaiser Permanente Commercial	$6,747.30
Rate for Payer: Kaiser Permanente Medicaid	$3,823.47
Rate for Payer: Kaiser Permanente Medicare	$3,748.50
Rate for Payer: MDX Hawaii PPO	$7,272.09
Rate for Payer: Ohana Health Plan Medicaid	$3,748.50
Rate for Payer: Ohana Health Plan Medicare	$3,748.50
Rate for Payer: UnitedHealthcare Medicare	$3,748.50
Rate for Payer: University Health Alliance Commercial	$4,198.32

PAIN & SPINE: SpineJack Case Kit 5.8MM

Facility

$7,497.00

Service Code	HCPCS C1062
Hospital Charge Code	11511783
Hospital Revenue Code	278
Min. Negotiated Rate	$3,748.50
Max. Negotiated Rate	$7,272.09
Rate for Payer: AlohaCare Medicaid	$3,748.50
Rate for Payer: AlohaCare Medicare	$3,748.50
Rate for Payer: Cash Price	$4,873.05
Rate for Payer: Devoted Health Medicare	$4,123.35
Rate for Payer: Hawaii Medical Service Association Medicare	$3,748.50
Rate for Payer: Hawaii Western Management Group Commercial	$5,247.90
Rate for Payer: Health Management Network Commercial	$6,372.45
Rate for Payer: Humana Medicare	$3,748.50
Rate for Payer: Kaiser Permanente Commercial	$6,747.30
Rate for Payer: Kaiser Permanente Medicaid	$3,823.47
Rate for Payer: Kaiser Permanente Medicare	$3,748.50
Rate for Payer: MDX Hawaii PPO	$7,272.09
Rate for Payer: Ohana Health Plan Medicaid	$3,748.50
Rate for Payer: Ohana Health Plan Medicare	$3,748.50
Rate for Payer: UnitedHealthcare Medicare	$3,748.50
Rate for Payer: University Health Alliance Commercial	$4,198.32

PAIN & SPINE: SpineJack Case Kit 5.8MM

Facility

$7,497.00

Service Code	HCPCS C1062
Hospital Charge Code	11511783
Hospital Revenue Code	278
Min. Negotiated Rate	$4,198.32
Max. Negotiated Rate	$7,272.09
Rate for Payer: Cash Price	$4,873.05
Rate for Payer: Hawaii Western Management Group Commercial	$5,247.90
Rate for Payer: Health Management Network Commercial	$6,372.45
Rate for Payer: Kaiser Permanente Commercial	$6,747.30
Rate for Payer: MDX Hawaii PPO	$7,272.09
Rate for Payer: University Health Alliance Commercial	$4,198.32

PAIN & SPINE: THERMOGARD

Facility

$188.00

Hospital Charge Code	9337527
Hospital Revenue Code	272
Min. Negotiated Rate	$94.00
Max. Negotiated Rate	$182.36
Rate for Payer: AlohaCare Medicaid	$94.00
Rate for Payer: AlohaCare Medicare	$94.00
Rate for Payer: Cash Price	$122.20
Rate for Payer: Devoted Health Medicare	$103.40
Rate for Payer: Hawaii Medical Service Association Medicare	$94.00
Rate for Payer: Hawaii Western Management Group Commercial	$178.60
Rate for Payer: Health Management Network Commercial	$159.80
Rate for Payer: Humana Medicare	$94.00
Rate for Payer: Kaiser Permanente Commercial	$169.20
Rate for Payer: Kaiser Permanente Medicaid	$95.88
Rate for Payer: Kaiser Permanente Medicare	$94.00
Rate for Payer: MDX Hawaii PPO	$182.36
Rate for Payer: Ohana Health Plan Medicaid	$94.00
Rate for Payer: Ohana Health Plan Medicare	$94.00
Rate for Payer: UnitedHealthcare Medicare	$94.00
Rate for Payer: University Health Alliance Commercial	$137.03

Know your out-of-pocket cost for care.

All Charges