Kauai Veterans Memorial Hospital

All Charges

Charge

Type

Setting

Price

SPINE & PAIN: BOSTON SCIENTIFIC HEX WRENCH

Facility

$300.00

Hospital Charge Code	8882686
Hospital Revenue Code	272
Min. Negotiated Rate	$255.00
Max. Negotiated Rate	$291.00
Rate for Payer: Cash Price	$195.00
Rate for Payer: Health Management Network Commercial	$255.00
Rate for Payer: Kaiser Permanente Commercial	$270.00
Rate for Payer: MDX Hawaii PPO	$291.00

SPINE & PAIN: BOSTON SCIENTIFIC HEX WRENCH

Facility

$300.00

Hospital Charge Code	8882686
Hospital Revenue Code	272
Min. Negotiated Rate	$150.00
Max. Negotiated Rate	$291.00
Rate for Payer: AlohaCare Medicaid	$150.00
Rate for Payer: AlohaCare Medicare	$150.00
Rate for Payer: Cash Price	$195.00
Rate for Payer: Devoted Health Medicare	$165.00
Rate for Payer: Hawaii Medical Service Association Medicare	$150.00
Rate for Payer: Hawaii Western Management Group Commercial	$285.00
Rate for Payer: Health Management Network Commercial	$255.00
Rate for Payer: Humana Medicare	$150.00
Rate for Payer: Kaiser Permanente Commercial	$270.00
Rate for Payer: Kaiser Permanente Medicaid	$153.00
Rate for Payer: Kaiser Permanente Medicare	$150.00
Rate for Payer: MDX Hawaii PPO	$291.00
Rate for Payer: Ohana Health Plan Medicaid	$150.00
Rate for Payer: Ohana Health Plan Medicare	$150.00
Rate for Payer: UnitedHealthcare Medicare	$150.00
Rate for Payer: University Health Alliance Commercial	$218.67

SPINE & PAIN: BOSTON SCIENTIFIC HEX WRENCH 3

Facility

$200.00

Hospital Charge Code	8882687
Hospital Revenue Code	272
Min. Negotiated Rate	$100.00
Max. Negotiated Rate	$194.00
Rate for Payer: AlohaCare Medicaid	$100.00
Rate for Payer: AlohaCare Medicare	$100.00
Rate for Payer: Cash Price	$130.00
Rate for Payer: Devoted Health Medicare	$110.00
Rate for Payer: Hawaii Medical Service Association Medicare	$100.00
Rate for Payer: Hawaii Western Management Group Commercial	$190.00
Rate for Payer: Health Management Network Commercial	$170.00
Rate for Payer: Humana Medicare	$100.00
Rate for Payer: Kaiser Permanente Commercial	$180.00
Rate for Payer: Kaiser Permanente Medicaid	$102.00
Rate for Payer: Kaiser Permanente Medicare	$100.00
Rate for Payer: MDX Hawaii PPO	$194.00
Rate for Payer: Ohana Health Plan Medicaid	$100.00
Rate for Payer: Ohana Health Plan Medicare	$100.00
Rate for Payer: UnitedHealthcare Medicare	$100.00
Rate for Payer: University Health Alliance Commercial	$145.78

SPINE & PAIN: BOSTON SCIENTIFIC HEX WRENCH 3

Facility

$200.00

Hospital Charge Code	8882687
Hospital Revenue Code	272
Min. Negotiated Rate	$170.00
Max. Negotiated Rate	$194.00
Rate for Payer: Cash Price	$130.00
Rate for Payer: Health Management Network Commercial	$170.00
Rate for Payer: Kaiser Permanente Commercial	$180.00
Rate for Payer: MDX Hawaii PPO	$194.00

SPINE & PAIN: BOSTON SCIENTIFIC INFINION CX LEAD KIT - 50 CM

Facility

$15,000.00

Service Code	HCPCS C1778
Hospital Charge Code	8882383
Hospital Revenue Code	278
Min. Negotiated Rate	$7,500.00
Max. Negotiated Rate	$14,550.00
Rate for Payer: AlohaCare Medicaid	$7,500.00
Rate for Payer: AlohaCare Medicare	$7,500.00
Rate for Payer: Cash Price	$9,750.00
Rate for Payer: Devoted Health Medicare	$8,250.00
Rate for Payer: Hawaii Medical Service Association Medicare	$7,500.00
Rate for Payer: Hawaii Western Management Group Commercial	$10,500.00
Rate for Payer: Health Management Network Commercial	$12,750.00
Rate for Payer: Humana Medicare	$7,500.00
Rate for Payer: Kaiser Permanente Commercial	$13,500.00
Rate for Payer: Kaiser Permanente Medicaid	$7,650.00
Rate for Payer: Kaiser Permanente Medicare	$7,500.00
Rate for Payer: MDX Hawaii PPO	$14,550.00
Rate for Payer: Ohana Health Plan Medicaid	$7,500.00
Rate for Payer: Ohana Health Plan Medicare	$7,500.00
Rate for Payer: UnitedHealthcare Medicare	$7,500.00
Rate for Payer: University Health Alliance Commercial	$8,400.00

SPINE & PAIN: BOSTON SCIENTIFIC INFINION CX LEAD KIT - 50 CM

Facility

$15,000.00

Service Code	HCPCS C1778
Hospital Charge Code	8882383
Hospital Revenue Code	278
Min. Negotiated Rate	$8,400.00
Max. Negotiated Rate	$14,550.00
Rate for Payer: Cash Price	$9,750.00
Rate for Payer: Hawaii Western Management Group Commercial	$10,500.00
Rate for Payer: Health Management Network Commercial	$12,750.00
Rate for Payer: Kaiser Permanente Commercial	$13,500.00
Rate for Payer: MDX Hawaii PPO	$14,550.00
Rate for Payer: University Health Alliance Commercial	$8,400.00

SPINE & PAIN: BOSTON SCIENTIFIC INFINION CX LEAD KIT - 70 CM

Facility

$15,000.00

Service Code	HCPCS C1778
Hospital Charge Code	8882384
Hospital Revenue Code	278
Min. Negotiated Rate	$8,400.00
Max. Negotiated Rate	$14,550.00
Rate for Payer: Cash Price	$9,750.00
Rate for Payer: Hawaii Western Management Group Commercial	$10,500.00
Rate for Payer: Health Management Network Commercial	$12,750.00
Rate for Payer: Kaiser Permanente Commercial	$13,500.00
Rate for Payer: MDX Hawaii PPO	$14,550.00
Rate for Payer: University Health Alliance Commercial	$8,400.00

SPINE & PAIN: BOSTON SCIENTIFIC INFINION CX LEAD KIT - 70 CM

Facility

$15,000.00

Service Code	HCPCS C1778
Hospital Charge Code	8882384
Hospital Revenue Code	278
Min. Negotiated Rate	$7,500.00
Max. Negotiated Rate	$14,550.00
Rate for Payer: AlohaCare Medicaid	$7,500.00
Rate for Payer: AlohaCare Medicare	$7,500.00
Rate for Payer: Cash Price	$9,750.00
Rate for Payer: Devoted Health Medicare	$8,250.00
Rate for Payer: Hawaii Medical Service Association Medicare	$7,500.00
Rate for Payer: Hawaii Western Management Group Commercial	$10,500.00
Rate for Payer: Health Management Network Commercial	$12,750.00
Rate for Payer: Humana Medicare	$7,500.00
Rate for Payer: Kaiser Permanente Commercial	$13,500.00
Rate for Payer: Kaiser Permanente Medicaid	$7,650.00
Rate for Payer: Kaiser Permanente Medicare	$7,500.00
Rate for Payer: MDX Hawaii PPO	$14,550.00
Rate for Payer: Ohana Health Plan Medicaid	$7,500.00
Rate for Payer: Ohana Health Plan Medicare	$7,500.00
Rate for Payer: UnitedHealthcare Medicare	$7,500.00
Rate for Payer: University Health Alliance Commercial	$8,400.00

SPINE & PAIN: BOSTON SCIENTIFIC INFINION LEAD KIT - 50 CM

Facility

$9,380.00

Service Code	HCPCS C1778
Hospital Charge Code	8882381
Hospital Revenue Code	278
Min. Negotiated Rate	$5,252.80
Max. Negotiated Rate	$9,098.60
Rate for Payer: Cash Price	$6,097.00
Rate for Payer: Hawaii Western Management Group Commercial	$6,566.00
Rate for Payer: Health Management Network Commercial	$7,973.00
Rate for Payer: Kaiser Permanente Commercial	$8,442.00
Rate for Payer: MDX Hawaii PPO	$9,098.60
Rate for Payer: University Health Alliance Commercial	$5,252.80

SPINE & PAIN: BOSTON SCIENTIFIC INFINION LEAD KIT - 50 CM

Facility

$9,380.00

Service Code	HCPCS C1778
Hospital Charge Code	8882381
Hospital Revenue Code	278
Min. Negotiated Rate	$4,690.00
Max. Negotiated Rate	$9,098.60
Rate for Payer: AlohaCare Medicaid	$4,690.00
Rate for Payer: AlohaCare Medicare	$4,690.00
Rate for Payer: Cash Price	$6,097.00
Rate for Payer: Devoted Health Medicare	$5,159.00
Rate for Payer: Hawaii Medical Service Association Medicare	$4,690.00
Rate for Payer: Hawaii Western Management Group Commercial	$6,566.00
Rate for Payer: Health Management Network Commercial	$7,973.00
Rate for Payer: Humana Medicare	$4,690.00
Rate for Payer: Kaiser Permanente Commercial	$8,442.00
Rate for Payer: Kaiser Permanente Medicaid	$4,783.80
Rate for Payer: Kaiser Permanente Medicare	$4,690.00
Rate for Payer: MDX Hawaii PPO	$9,098.60
Rate for Payer: Ohana Health Plan Medicaid	$4,690.00
Rate for Payer: Ohana Health Plan Medicare	$4,690.00
Rate for Payer: UnitedHealthcare Medicare	$4,690.00
Rate for Payer: University Health Alliance Commercial	$5,252.80

SPINE & PAIN: BOSTON SCIENTIFIC INFINION LEAD KIT - 70 CM

Facility

$9,380.00

Service Code	HCPCS C1778
Hospital Charge Code	8882382
Hospital Revenue Code	278
Min. Negotiated Rate	$4,690.00
Max. Negotiated Rate	$9,098.60
Rate for Payer: AlohaCare Medicaid	$4,690.00
Rate for Payer: AlohaCare Medicare	$4,690.00
Rate for Payer: Cash Price	$6,097.00
Rate for Payer: Devoted Health Medicare	$5,159.00
Rate for Payer: Hawaii Medical Service Association Medicare	$4,690.00
Rate for Payer: Hawaii Western Management Group Commercial	$6,566.00
Rate for Payer: Health Management Network Commercial	$7,973.00
Rate for Payer: Humana Medicare	$4,690.00
Rate for Payer: Kaiser Permanente Commercial	$8,442.00
Rate for Payer: Kaiser Permanente Medicaid	$4,783.80
Rate for Payer: Kaiser Permanente Medicare	$4,690.00
Rate for Payer: MDX Hawaii PPO	$9,098.60
Rate for Payer: Ohana Health Plan Medicaid	$4,690.00
Rate for Payer: Ohana Health Plan Medicare	$4,690.00
Rate for Payer: UnitedHealthcare Medicare	$4,690.00
Rate for Payer: University Health Alliance Commercial	$5,252.80

SPINE & PAIN: BOSTON SCIENTIFIC INFINION LEAD KIT - 70 CM

Facility

$9,380.00

Service Code	HCPCS C1778
Hospital Charge Code	8882382
Hospital Revenue Code	278
Min. Negotiated Rate	$5,252.80
Max. Negotiated Rate	$9,098.60
Rate for Payer: MDX Hawaii PPO	$9,098.60
Rate for Payer: Cash Price	$6,097.00
Rate for Payer: Hawaii Western Management Group Commercial	$6,566.00
Rate for Payer: Health Management Network Commercial	$7,973.00
Rate for Payer: Kaiser Permanente Commercial	$8,442.00
Rate for Payer: University Health Alliance Commercial	$5,252.80

SPINE & PAIN: BOSTON SCIENTIFIC INFINION TRIAL LEAD KIT - 50 CM

Facility

$7,800.00

Service Code	HCPCS C1897
Hospital Charge Code	8882385
Hospital Revenue Code	278
Min. Negotiated Rate	$3,900.00
Max. Negotiated Rate	$7,566.00
Rate for Payer: AlohaCare Medicaid	$3,900.00
Rate for Payer: AlohaCare Medicare	$3,900.00
Rate for Payer: Cash Price	$5,070.00
Rate for Payer: Devoted Health Medicare	$4,290.00
Rate for Payer: Hawaii Medical Service Association Medicare	$3,900.00
Rate for Payer: Hawaii Western Management Group Commercial	$5,460.00
Rate for Payer: Health Management Network Commercial	$6,630.00
Rate for Payer: Humana Medicare	$3,900.00
Rate for Payer: Kaiser Permanente Commercial	$7,020.00
Rate for Payer: Kaiser Permanente Medicaid	$3,978.00
Rate for Payer: Kaiser Permanente Medicare	$3,900.00
Rate for Payer: MDX Hawaii PPO	$7,566.00
Rate for Payer: Ohana Health Plan Medicaid	$3,900.00
Rate for Payer: Ohana Health Plan Medicare	$3,900.00
Rate for Payer: UnitedHealthcare Medicare	$3,900.00
Rate for Payer: University Health Alliance Commercial	$4,368.00

SPINE & PAIN: BOSTON SCIENTIFIC INFINION TRIAL LEAD KIT - 50 CM

Facility

$7,800.00

Service Code	HCPCS C1897
Hospital Charge Code	8882385
Hospital Revenue Code	278
Min. Negotiated Rate	$4,368.00
Max. Negotiated Rate	$7,566.00
Rate for Payer: Cash Price	$5,070.00
Rate for Payer: Hawaii Western Management Group Commercial	$5,460.00
Rate for Payer: Health Management Network Commercial	$6,630.00
Rate for Payer: Kaiser Permanente Commercial	$7,020.00
Rate for Payer: MDX Hawaii PPO	$7,566.00
Rate for Payer: University Health Alliance Commercial	$4,368.00

SPINE & PAIN: BOSTON SCIENTIFIC INSERTION NEEDLE

Facility

$807.00

Hospital Charge Code	8882688
Hospital Revenue Code	272
Min. Negotiated Rate	$685.95
Max. Negotiated Rate	$782.79
Rate for Payer: Cash Price	$524.55
Rate for Payer: Health Management Network Commercial	$685.95
Rate for Payer: Kaiser Permanente Commercial	$726.30
Rate for Payer: MDX Hawaii PPO	$782.79

SPINE & PAIN: BOSTON SCIENTIFIC INSERTION NEEDLE

Facility

$807.00

Hospital Charge Code	8882688
Hospital Revenue Code	272
Min. Negotiated Rate	$403.50
Max. Negotiated Rate	$782.79
Rate for Payer: AlohaCare Medicaid	$403.50
Rate for Payer: AlohaCare Medicare	$403.50
Rate for Payer: Cash Price	$524.55
Rate for Payer: Devoted Health Medicare	$443.85
Rate for Payer: Hawaii Medical Service Association Medicare	$403.50
Rate for Payer: Hawaii Western Management Group Commercial	$766.65
Rate for Payer: Health Management Network Commercial	$685.95
Rate for Payer: Humana Medicare	$403.50
Rate for Payer: Kaiser Permanente Commercial	$726.30
Rate for Payer: Kaiser Permanente Medicaid	$411.57
Rate for Payer: Kaiser Permanente Medicare	$403.50
Rate for Payer: MDX Hawaii PPO	$782.79
Rate for Payer: Ohana Health Plan Medicaid	$403.50
Rate for Payer: Ohana Health Plan Medicare	$403.50
Rate for Payer: UnitedHealthcare Medicare	$403.50
Rate for Payer: University Health Alliance Commercial	$588.22

SPINE & PAIN: BOSTON SCIENTIFIC INSERTION NEEDLE 5

Facility

$807.00

Hospital Charge Code	8882689
Hospital Revenue Code	272
Min. Negotiated Rate	$403.50
Max. Negotiated Rate	$782.79
Rate for Payer: AlohaCare Medicaid	$403.50
Rate for Payer: AlohaCare Medicare	$403.50
Rate for Payer: Cash Price	$524.55
Rate for Payer: Devoted Health Medicare	$443.85
Rate for Payer: Hawaii Medical Service Association Medicare	$403.50
Rate for Payer: Hawaii Western Management Group Commercial	$766.65
Rate for Payer: Health Management Network Commercial	$685.95
Rate for Payer: Humana Medicare	$403.50
Rate for Payer: Kaiser Permanente Commercial	$726.30
Rate for Payer: Kaiser Permanente Medicaid	$411.57
Rate for Payer: Kaiser Permanente Medicare	$403.50
Rate for Payer: MDX Hawaii PPO	$782.79
Rate for Payer: Ohana Health Plan Medicaid	$403.50
Rate for Payer: Ohana Health Plan Medicare	$403.50
Rate for Payer: UnitedHealthcare Medicare	$403.50
Rate for Payer: University Health Alliance Commercial	$588.22

SPINE & PAIN: BOSTON SCIENTIFIC INSERTION NEEDLE 5

Facility

$807.00

Hospital Charge Code	8882689
Hospital Revenue Code	272
Min. Negotiated Rate	$685.95
Max. Negotiated Rate	$782.79
Rate for Payer: Cash Price	$524.55
Rate for Payer: Health Management Network Commercial	$685.95
Rate for Payer: Kaiser Permanente Commercial	$726.30
Rate for Payer: MDX Hawaii PPO	$782.79

SPINE & PAIN: BOSTON SCIENTIFIC INSERTION NEEDLE 6.5

Facility

$807.00

Hospital Charge Code	8882690
Hospital Revenue Code	272
Min. Negotiated Rate	$403.50
Max. Negotiated Rate	$782.79
Rate for Payer: AlohaCare Medicaid	$403.50
Rate for Payer: AlohaCare Medicare	$403.50
Rate for Payer: Cash Price	$524.55
Rate for Payer: Devoted Health Medicare	$443.85
Rate for Payer: Hawaii Medical Service Association Medicare	$403.50
Rate for Payer: Hawaii Western Management Group Commercial	$766.65
Rate for Payer: Health Management Network Commercial	$685.95
Rate for Payer: Humana Medicare	$403.50
Rate for Payer: Kaiser Permanente Commercial	$726.30
Rate for Payer: Kaiser Permanente Medicaid	$411.57
Rate for Payer: Kaiser Permanente Medicare	$403.50
Rate for Payer: MDX Hawaii PPO	$782.79
Rate for Payer: Ohana Health Plan Medicaid	$403.50
Rate for Payer: Ohana Health Plan Medicare	$403.50
Rate for Payer: UnitedHealthcare Medicare	$403.50
Rate for Payer: University Health Alliance Commercial	$588.22

SPINE & PAIN: BOSTON SCIENTIFIC INSERTION NEEDLE 6.5

Facility

$807.00

Hospital Charge Code	8882690
Hospital Revenue Code	272
Min. Negotiated Rate	$685.95
Max. Negotiated Rate	$782.79
Rate for Payer: Cash Price	$524.55
Rate for Payer: Health Management Network Commercial	$685.95
Rate for Payer: Kaiser Permanente Commercial	$726.30
Rate for Payer: MDX Hawaii PPO	$782.79

SPINE & PAIN: BOSTON SCIENTIFIC INTRODUCER KIT

Facility

$360.00

Hospital Charge Code	9459072
Hospital Revenue Code	272
Min. Negotiated Rate	$180.00
Max. Negotiated Rate	$349.20
Rate for Payer: AlohaCare Medicaid	$180.00
Rate for Payer: AlohaCare Medicare	$180.00
Rate for Payer: Cash Price	$234.00
Rate for Payer: Devoted Health Medicare	$198.00
Rate for Payer: Hawaii Medical Service Association Medicare	$180.00
Rate for Payer: Hawaii Western Management Group Commercial	$342.00
Rate for Payer: Health Management Network Commercial	$306.00
Rate for Payer: Humana Medicare	$180.00
Rate for Payer: Kaiser Permanente Commercial	$324.00
Rate for Payer: Kaiser Permanente Medicaid	$183.60
Rate for Payer: Kaiser Permanente Medicare	$180.00
Rate for Payer: MDX Hawaii PPO	$349.20
Rate for Payer: Ohana Health Plan Medicaid	$180.00
Rate for Payer: Ohana Health Plan Medicare	$180.00
Rate for Payer: UnitedHealthcare Medicare	$180.00
Rate for Payer: University Health Alliance Commercial	$262.40

SPINE & PAIN: BOSTON SCIENTIFIC INTRODUCER KIT

Facility

$360.00

Hospital Charge Code	9459072
Hospital Revenue Code	272
Min. Negotiated Rate	$306.00
Max. Negotiated Rate	$349.20
Rate for Payer: Cash Price	$234.00
Rate for Payer: Health Management Network Commercial	$306.00
Rate for Payer: Kaiser Permanente Commercial	$324.00
Rate for Payer: MDX Hawaii PPO	$349.20

SPINE & PAIN: BOSTON SCIENTIFIC IPG PORT PLUG

Facility

$300.00

Hospital Charge Code	8882391
Hospital Revenue Code	272
Min. Negotiated Rate	$150.00
Max. Negotiated Rate	$291.00
Rate for Payer: AlohaCare Medicaid	$150.00
Rate for Payer: AlohaCare Medicare	$150.00
Rate for Payer: Cash Price	$195.00
Rate for Payer: Devoted Health Medicare	$165.00
Rate for Payer: Hawaii Medical Service Association Medicare	$150.00
Rate for Payer: Hawaii Western Management Group Commercial	$285.00
Rate for Payer: Health Management Network Commercial	$255.00
Rate for Payer: Humana Medicare	$150.00
Rate for Payer: Kaiser Permanente Commercial	$270.00
Rate for Payer: Kaiser Permanente Medicaid	$153.00
Rate for Payer: Kaiser Permanente Medicare	$150.00
Rate for Payer: MDX Hawaii PPO	$291.00
Rate for Payer: Ohana Health Plan Medicaid	$150.00
Rate for Payer: Ohana Health Plan Medicare	$150.00
Rate for Payer: UnitedHealthcare Medicare	$150.00
Rate for Payer: University Health Alliance Commercial	$218.67

SPINE & PAIN: BOSTON SCIENTIFIC IPG PORT PLUG

Facility

$300.00

Hospital Charge Code	8882391
Hospital Revenue Code	272
Min. Negotiated Rate	$255.00
Max. Negotiated Rate	$291.00
Rate for Payer: Cash Price	$195.00
Rate for Payer: Health Management Network Commercial	$255.00
Rate for Payer: Kaiser Permanente Commercial	$270.00
Rate for Payer: MDX Hawaii PPO	$291.00

SPINE & PAIN: BOSTON SCIENTIFIC LEAD BLANKS

Facility

$300.00

Hospital Charge Code	8882701
Hospital Revenue Code	272
Min. Negotiated Rate	$255.00
Max. Negotiated Rate	$291.00
Rate for Payer: Cash Price	$195.00
Rate for Payer: Health Management Network Commercial	$255.00
Rate for Payer: Kaiser Permanente Commercial	$270.00
Rate for Payer: MDX Hawaii PPO	$291.00

Know your out-of-pocket cost for care.

All Charges