Kauai Veterans Memorial Hospital

All Charges

Charge

Type

Setting

Price

SPINE & PAIN: BOSTON SCIENTIFIC LEAD BLANKS

Facility

$300.00

Hospital Charge Code	8882701
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 LINEAR 3-4 LEAD 70CM

Facility

$6,160.00

Service Code	HCPCS C1778
Hospital Charge Code	8882341
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

SPINE & PAIN: BOSTON SCIENTIFIC LINEAR 3-4 LEAD 70CM

Facility

$6,160.00

Service Code	HCPCS C1778
Hospital Charge Code	8882341
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

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

Facility

$3,630.00

Service Code	HCPCS C1897
Hospital Charge Code	9456262
Hospital Revenue Code	278
Min. Negotiated Rate	$1,815.00
Max. Negotiated Rate	$3,521.10
Rate for Payer: AlohaCare Medicaid	$1,815.00
Rate for Payer: AlohaCare Medicare	$1,815.00
Rate for Payer: Cash Price	$2,359.50
Rate for Payer: Devoted Health Medicare	$1,996.50
Rate for Payer: Hawaii Medical Service Association Medicare	$1,815.00
Rate for Payer: Hawaii Western Management Group Commercial	$2,541.00
Rate for Payer: Health Management Network Commercial	$3,085.50
Rate for Payer: Humana Medicare	$1,815.00
Rate for Payer: Kaiser Permanente Commercial	$3,267.00
Rate for Payer: Kaiser Permanente Medicaid	$1,851.30
Rate for Payer: Kaiser Permanente Medicare	$1,815.00
Rate for Payer: MDX Hawaii PPO	$3,521.10
Rate for Payer: Ohana Health Plan Medicaid	$1,815.00
Rate for Payer: Ohana Health Plan Medicare	$1,815.00
Rate for Payer: UnitedHealthcare Medicare	$1,815.00
Rate for Payer: University Health Alliance Commercial	$2,032.80

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

Facility

$3,630.00

Service Code	HCPCS C1897
Hospital Charge Code	9456262
Hospital Revenue Code	278
Min. Negotiated Rate	$2,032.80
Max. Negotiated Rate	$3,521.10
Rate for Payer: Cash Price	$2,359.50
Rate for Payer: Hawaii Western Management Group Commercial	$2,541.00
Rate for Payer: Health Management Network Commercial	$3,085.50
Rate for Payer: Kaiser Permanente Commercial	$3,267.00
Rate for Payer: MDX Hawaii PPO	$3,521.10
Rate for Payer: University Health Alliance Commercial	$2,032.80

SPINE & PAIN: BOSTON SCIENTIFIC LINEAR 3-6 LEAD 30CM

Facility

$6,160.00

Service Code	HCPCS C1778
Hospital Charge Code	8882342
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

SPINE & PAIN: BOSTON SCIENTIFIC LINEAR 3-6 LEAD 30CM

Facility

$6,160.00

Service Code	HCPCS C1778
Hospital Charge Code	8882342
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

SPINE & PAIN: BOSTON SCIENTIFIC LINEAR 3-6 LEAD 50CM

Facility

$6,160.00

Service Code	HCPCS C1778
Hospital Charge Code	8882379
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

SPINE & PAIN: BOSTON SCIENTIFIC LINEAR 3-6 LEAD 50CM

Facility

$6,160.00

Service Code	HCPCS C1778
Hospital Charge Code	8882379
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

SPINE & PAIN: BOSTON SCIENTIFIC LINEAR 3-6 LEAD 70CM

Facility

$6,160.00

Service Code	HCPCS C1778
Hospital Charge Code	8882380
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

SPINE & PAIN: BOSTON SCIENTIFIC LINEAR 3-6 LEAD 70CM

Facility

$6,160.00

Service Code	HCPCS C1778
Hospital Charge Code	8882380
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

SPINE & PAIN: BOSTON SCIENTIFIC LINEAR 3-6 TRIAL LEAD 50 CM

Facility

$3,630.00

Service Code	HCPCS C1897
Hospital Charge Code	9456263
Hospital Revenue Code	278
Min. Negotiated Rate	$2,032.80
Max. Negotiated Rate	$3,521.10
Rate for Payer: Cash Price	$2,359.50
Rate for Payer: Hawaii Western Management Group Commercial	$2,541.00
Rate for Payer: Health Management Network Commercial	$3,085.50
Rate for Payer: Kaiser Permanente Commercial	$3,267.00
Rate for Payer: MDX Hawaii PPO	$3,521.10
Rate for Payer: University Health Alliance Commercial	$2,032.80

SPINE & PAIN: BOSTON SCIENTIFIC LINEAR 3-6 TRIAL LEAD 50 CM

Facility

$3,630.00

Service Code	HCPCS C1897
Hospital Charge Code	9456263
Hospital Revenue Code	278
Min. Negotiated Rate	$1,815.00
Max. Negotiated Rate	$3,521.10
Rate for Payer: AlohaCare Medicaid	$1,815.00
Rate for Payer: AlohaCare Medicare	$1,815.00
Rate for Payer: Cash Price	$2,359.50
Rate for Payer: Devoted Health Medicare	$1,996.50
Rate for Payer: Hawaii Medical Service Association Medicare	$1,815.00
Rate for Payer: Hawaii Western Management Group Commercial	$2,541.00
Rate for Payer: Health Management Network Commercial	$3,085.50
Rate for Payer: Humana Medicare	$1,815.00
Rate for Payer: Kaiser Permanente Commercial	$3,267.00
Rate for Payer: Kaiser Permanente Medicaid	$1,851.30
Rate for Payer: Kaiser Permanente Medicare	$1,815.00
Rate for Payer: MDX Hawaii PPO	$3,521.10
Rate for Payer: Ohana Health Plan Medicaid	$1,815.00
Rate for Payer: Ohana Health Plan Medicare	$1,815.00
Rate for Payer: UnitedHealthcare Medicare	$1,815.00
Rate for Payer: University Health Alliance Commercial	$2,032.80

SPINE & PAIN: BOSTON SCIENTIFIC LINEAR ST LEAD KIT 70 CM

Facility

$3,800.00

Service Code	HCPCS C1897
Hospital Charge Code	9468258
Hospital Revenue Code	278
Min. Negotiated Rate	$1,900.00
Max. Negotiated Rate	$3,686.00
Rate for Payer: AlohaCare Medicaid	$1,900.00
Rate for Payer: AlohaCare Medicare	$1,900.00
Rate for Payer: Cash Price	$2,470.00
Rate for Payer: Devoted Health Medicare	$2,090.00
Rate for Payer: Hawaii Medical Service Association Medicare	$1,900.00
Rate for Payer: Hawaii Western Management Group Commercial	$2,660.00
Rate for Payer: Health Management Network Commercial	$3,230.00
Rate for Payer: Humana Medicare	$1,900.00
Rate for Payer: Kaiser Permanente Commercial	$3,420.00
Rate for Payer: Kaiser Permanente Medicaid	$1,938.00
Rate for Payer: Kaiser Permanente Medicare	$1,900.00
Rate for Payer: MDX Hawaii PPO	$3,686.00
Rate for Payer: Ohana Health Plan Medicaid	$1,900.00
Rate for Payer: Ohana Health Plan Medicare	$1,900.00
Rate for Payer: UnitedHealthcare Medicare	$1,900.00
Rate for Payer: University Health Alliance Commercial	$2,128.00

SPINE & PAIN: BOSTON SCIENTIFIC LINEAR ST LEAD KIT 70 CM

Facility

$3,800.00

Service Code	HCPCS C1897
Hospital Charge Code	9468258
Hospital Revenue Code	278
Min. Negotiated Rate	$2,128.00
Max. Negotiated Rate	$3,686.00
Rate for Payer: Cash Price	$2,470.00
Rate for Payer: Hawaii Western Management Group Commercial	$2,660.00
Rate for Payer: Health Management Network Commercial	$3,230.00
Rate for Payer: Kaiser Permanente Commercial	$3,420.00
Rate for Payer: MDX Hawaii PPO	$3,686.00
Rate for Payer: University Health Alliance Commercial	$2,128.00

SPINE & PAIN: BOSTON SCIENTIFIC LINEAR ST LEAD WITH PRELOADED ENHANCED STYLET - 50CM

Facility

$3,800.00

Service Code	HCPCS C1778
Hospital Charge Code	8882338
Hospital Revenue Code	278
Min. Negotiated Rate	$2,128.00
Max. Negotiated Rate	$3,686.00
Rate for Payer: Cash Price	$2,470.00
Rate for Payer: Hawaii Western Management Group Commercial	$2,660.00
Rate for Payer: Health Management Network Commercial	$3,230.00
Rate for Payer: Kaiser Permanente Commercial	$3,420.00
Rate for Payer: MDX Hawaii PPO	$3,686.00
Rate for Payer: University Health Alliance Commercial	$2,128.00

SPINE & PAIN: BOSTON SCIENTIFIC LINEAR ST LEAD WITH PRELOADED ENHANCED STYLET - 50CM

Facility

$3,800.00

Service Code	HCPCS C1778
Hospital Charge Code	8882338
Hospital Revenue Code	278
Min. Negotiated Rate	$1,900.00
Max. Negotiated Rate	$3,686.00
Rate for Payer: AlohaCare Medicaid	$1,900.00
Rate for Payer: AlohaCare Medicare	$1,900.00
Rate for Payer: Cash Price	$2,470.00
Rate for Payer: Devoted Health Medicare	$2,090.00
Rate for Payer: Hawaii Medical Service Association Medicare	$1,900.00
Rate for Payer: Hawaii Western Management Group Commercial	$2,660.00
Rate for Payer: Health Management Network Commercial	$3,230.00
Rate for Payer: Humana Medicare	$1,900.00
Rate for Payer: Kaiser Permanente Commercial	$3,420.00
Rate for Payer: Kaiser Permanente Medicaid	$1,938.00
Rate for Payer: Kaiser Permanente Medicare	$1,900.00
Rate for Payer: MDX Hawaii PPO	$3,686.00
Rate for Payer: Ohana Health Plan Medicaid	$1,900.00
Rate for Payer: Ohana Health Plan Medicare	$1,900.00
Rate for Payer: UnitedHealthcare Medicare	$1,900.00
Rate for Payer: University Health Alliance Commercial	$2,128.00

SPINE & PAIN: BOSTON SCIENTIFIC LINEAR ST LEAD WITH PRELOADED ENHANCED STYLET - 70 CM

Facility

$6,160.00

Service Code	HCPCS C1778
Hospital Charge Code	8882339
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

SPINE & PAIN: BOSTON SCIENTIFIC LINEAR ST LEAD WITH PRELOADED ENHANCED STYLET - 70 CM

Facility

$6,160.00

Service Code	HCPCS C1778
Hospital Charge Code	8882339
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

SPINE & PAIN: BOSTON SCIENTIFIC LONG TUNNELING TOOL (35 CM)

Facility

$392.00

Hospital Charge Code	8882698
Hospital Revenue Code	272
Min. Negotiated Rate	$333.20
Max. Negotiated Rate	$380.24
Rate for Payer: Cash Price	$254.80
Rate for Payer: Health Management Network Commercial	$333.20
Rate for Payer: Kaiser Permanente Commercial	$352.80
Rate for Payer: MDX Hawaii PPO	$380.24

SPINE & PAIN: BOSTON SCIENTIFIC LONG TUNNELING TOOL (35 CM)

Facility

$392.00

Hospital Charge Code	8882698
Hospital Revenue Code	272
Min. Negotiated Rate	$196.00
Max. Negotiated Rate	$380.24
Rate for Payer: AlohaCare Medicaid	$196.00
Rate for Payer: AlohaCare Medicare	$196.00
Rate for Payer: Cash Price	$254.80
Rate for Payer: Devoted Health Medicare	$215.60
Rate for Payer: Hawaii Medical Service Association Medicare	$196.00
Rate for Payer: Hawaii Western Management Group Commercial	$372.40
Rate for Payer: Health Management Network Commercial	$333.20
Rate for Payer: Humana Medicare	$196.00
Rate for Payer: Kaiser Permanente Commercial	$352.80
Rate for Payer: Kaiser Permanente Medicaid	$199.92
Rate for Payer: Kaiser Permanente Medicare	$196.00
Rate for Payer: MDX Hawaii PPO	$380.24
Rate for Payer: Ohana Health Plan Medicaid	$196.00
Rate for Payer: Ohana Health Plan Medicare	$196.00
Rate for Payer: UnitedHealthcare Medicare	$196.00
Rate for Payer: University Health Alliance Commercial	$285.73

SPINE & PAIN: BOSTON SCIENTIFIC MED-A SURGICAL MEDICAL ADHESIVE

Facility

$280.00

Hospital Charge Code	9459071
Hospital Revenue Code	272
Min. Negotiated Rate	$140.00
Max. Negotiated Rate	$271.60
Rate for Payer: AlohaCare Medicaid	$140.00
Rate for Payer: AlohaCare Medicare	$140.00
Rate for Payer: Cash Price	$182.00
Rate for Payer: Devoted Health Medicare	$154.00
Rate for Payer: Hawaii Medical Service Association Medicare	$140.00
Rate for Payer: Hawaii Western Management Group Commercial	$266.00
Rate for Payer: Health Management Network Commercial	$238.00
Rate for Payer: Humana Medicare	$140.00
Rate for Payer: Kaiser Permanente Commercial	$252.00
Rate for Payer: Kaiser Permanente Medicaid	$142.80
Rate for Payer: Kaiser Permanente Medicare	$140.00
Rate for Payer: MDX Hawaii PPO	$271.60
Rate for Payer: Ohana Health Plan Medicaid	$140.00
Rate for Payer: Ohana Health Plan Medicare	$140.00
Rate for Payer: UnitedHealthcare Medicare	$140.00
Rate for Payer: University Health Alliance Commercial	$204.09

SPINE & PAIN: BOSTON SCIENTIFIC MED-A SURGICAL MEDICAL ADHESIVE

Facility

$280.00

Hospital Charge Code	9459071
Hospital Revenue Code	272
Min. Negotiated Rate	$238.00
Max. Negotiated Rate	$271.60
Rate for Payer: Cash Price	$182.00
Rate for Payer: Health Management Network Commercial	$238.00
Rate for Payer: Kaiser Permanente Commercial	$252.00
Rate for Payer: MDX Hawaii PPO	$271.60

SPINE & PAIN: BOSTON SCIENTIFIC MONTAGE MRI SAFE IMPLANTABLE PULSE GENERATOR

Facility

$28,285.00

Service Code	HCPCS C1820
Hospital Charge Code	8882337
Hospital Revenue Code	278
Min. Negotiated Rate	$15,839.60
Max. Negotiated Rate	$27,436.45
Rate for Payer: Cash Price	$18,385.25
Rate for Payer: Hawaii Western Management Group Commercial	$19,799.50
Rate for Payer: Health Management Network Commercial	$24,042.25
Rate for Payer: Kaiser Permanente Commercial	$25,456.50
Rate for Payer: MDX Hawaii PPO	$27,436.45
Rate for Payer: University Health Alliance Commercial	$15,839.60

SPINE & PAIN: BOSTON SCIENTIFIC MONTAGE MRI SAFE IMPLANTABLE PULSE GENERATOR

Facility

$28,285.00

Service Code	HCPCS C1820
Hospital Charge Code	8882337
Hospital Revenue Code	278
Min. Negotiated Rate	$14,142.50
Max. Negotiated Rate	$27,436.45
Rate for Payer: AlohaCare Medicaid	$14,142.50
Rate for Payer: AlohaCare Medicare	$14,142.50
Rate for Payer: Cash Price	$18,385.25
Rate for Payer: Devoted Health Medicare	$15,556.75
Rate for Payer: Hawaii Medical Service Association Medicare	$14,142.50
Rate for Payer: Hawaii Western Management Group Commercial	$19,799.50
Rate for Payer: Health Management Network Commercial	$24,042.25
Rate for Payer: Humana Medicare	$14,142.50
Rate for Payer: Kaiser Permanente Commercial	$25,456.50
Rate for Payer: Kaiser Permanente Medicaid	$14,425.35
Rate for Payer: Kaiser Permanente Medicare	$14,142.50
Rate for Payer: MDX Hawaii PPO	$27,436.45
Rate for Payer: Ohana Health Plan Medicaid	$14,142.50
Rate for Payer: Ohana Health Plan Medicare	$14,142.50
Rate for Payer: UnitedHealthcare Medicare	$14,142.50
Rate for Payer: University Health Alliance Commercial	$15,839.60

Know your out-of-pocket cost for care.

All Charges