Kauai Veterans Memorial Hospital

All Charges

Charge

Type

Setting

Price

SPINE & PAIN: BOSTON SCIENTIFIC PRECISION M8 ADAPTER - 15CM

Facility

$2,180.00

Service Code	HCPCS C1883
Hospital Charge Code	8882389
Hospital Revenue Code	278
Min. Negotiated Rate	$1,220.80
Max. Negotiated Rate	$2,114.60
Rate for Payer: Cash Price	$1,417.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,526.00
Rate for Payer: Health Management Network Commercial	$1,853.00
Rate for Payer: Kaiser Permanente Commercial	$1,962.00
Rate for Payer: MDX Hawaii PPO	$2,114.60
Rate for Payer: University Health Alliance Commercial	$1,220.80

SPINE & PAIN: BOSTON SCIENTIFIC PRECISION M8 ADAPTER 55CM

Facility

$2,180.00

Service Code	HCPCS C1883
Hospital Charge Code	8882681
Hospital Revenue Code	278
Min. Negotiated Rate	$1,220.80
Max. Negotiated Rate	$2,114.60
Rate for Payer: Cash Price	$1,417.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,526.00
Rate for Payer: Health Management Network Commercial	$1,853.00
Rate for Payer: Kaiser Permanente Commercial	$1,962.00
Rate for Payer: MDX Hawaii PPO	$2,114.60
Rate for Payer: University Health Alliance Commercial	$1,220.80

SPINE & PAIN: BOSTON SCIENTIFIC PRECISION M8 ADAPTER 55CM

Facility

$2,180.00

Service Code	HCPCS C1883
Hospital Charge Code	8882681
Hospital Revenue Code	278
Min. Negotiated Rate	$1,090.00
Max. Negotiated Rate	$2,114.60
Rate for Payer: AlohaCare Medicaid	$1,090.00
Rate for Payer: AlohaCare Medicare	$1,090.00
Rate for Payer: Cash Price	$1,417.00
Rate for Payer: Devoted Health Medicare	$1,199.00
Rate for Payer: Hawaii Medical Service Association Medicare	$1,090.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,526.00
Rate for Payer: Health Management Network Commercial	$1,853.00
Rate for Payer: Humana Medicare	$1,090.00
Rate for Payer: Kaiser Permanente Commercial	$1,962.00
Rate for Payer: Kaiser Permanente Medicaid	$1,111.80
Rate for Payer: Kaiser Permanente Medicare	$1,090.00
Rate for Payer: MDX Hawaii PPO	$2,114.60
Rate for Payer: Ohana Health Plan Medicaid	$1,090.00
Rate for Payer: Ohana Health Plan Medicare	$1,090.00
Rate for Payer: UnitedHealthcare Medicare	$1,090.00
Rate for Payer: University Health Alliance Commercial	$1,220.80

SPINE & PAIN: BOSTON SCIENTIFIC PRECISION NOVI IMPLANTABLE PULSE GENERATOR (IPG)

Facility

$27,285.00

Service Code	HCPCS C1767
Hospital Charge Code	8882336
Hospital Revenue Code	278
Min. Negotiated Rate	$13,642.50
Max. Negotiated Rate	$26,466.45
Rate for Payer: AlohaCare Medicaid	$13,642.50
Rate for Payer: AlohaCare Medicare	$13,642.50
Rate for Payer: Cash Price	$17,735.25
Rate for Payer: Devoted Health Medicare	$15,006.75
Rate for Payer: Hawaii Medical Service Association Medicare	$13,642.50
Rate for Payer: Hawaii Western Management Group Commercial	$19,099.50
Rate for Payer: Health Management Network Commercial	$23,192.25
Rate for Payer: Humana Medicare	$13,642.50
Rate for Payer: Kaiser Permanente Commercial	$24,556.50
Rate for Payer: Kaiser Permanente Medicaid	$13,915.35
Rate for Payer: Kaiser Permanente Medicare	$13,642.50
Rate for Payer: MDX Hawaii PPO	$26,466.45
Rate for Payer: Ohana Health Plan Medicaid	$13,642.50
Rate for Payer: Ohana Health Plan Medicare	$13,642.50
Rate for Payer: UnitedHealthcare Medicare	$13,642.50
Rate for Payer: University Health Alliance Commercial	$15,279.60

SPINE & PAIN: BOSTON SCIENTIFIC PRECISION NOVI IMPLANTABLE PULSE GENERATOR (IPG)

Facility

$27,285.00

Service Code	HCPCS C1767
Hospital Charge Code	8882336
Hospital Revenue Code	278
Min. Negotiated Rate	$15,279.60
Max. Negotiated Rate	$26,466.45
Rate for Payer: Cash Price	$17,735.25
Rate for Payer: Hawaii Western Management Group Commercial	$19,099.50
Rate for Payer: Health Management Network Commercial	$23,192.25
Rate for Payer: Kaiser Permanente Commercial	$24,556.50
Rate for Payer: MDX Hawaii PPO	$26,466.45
Rate for Payer: University Health Alliance Commercial	$15,279.60

SPINE & PAIN: BOSTON SCIENTIFIC PRECISION OR CABLE

Facility

$1,050.00

Hospital Charge Code	9458962
Hospital Revenue Code	272
Min. Negotiated Rate	$525.00
Max. Negotiated Rate	$1,018.50
Rate for Payer: AlohaCare Medicaid	$525.00
Rate for Payer: AlohaCare Medicare	$525.00
Rate for Payer: Cash Price	$682.50
Rate for Payer: Devoted Health Medicare	$577.50
Rate for Payer: Hawaii Medical Service Association Medicare	$525.00
Rate for Payer: Hawaii Western Management Group Commercial	$997.50
Rate for Payer: Health Management Network Commercial	$892.50
Rate for Payer: Humana Medicare	$525.00
Rate for Payer: Kaiser Permanente Commercial	$945.00
Rate for Payer: Kaiser Permanente Medicaid	$535.50
Rate for Payer: Kaiser Permanente Medicare	$525.00
Rate for Payer: MDX Hawaii PPO	$1,018.50
Rate for Payer: Ohana Health Plan Medicaid	$525.00
Rate for Payer: Ohana Health Plan Medicare	$525.00
Rate for Payer: UnitedHealthcare Medicare	$525.00
Rate for Payer: University Health Alliance Commercial	$765.35

SPINE & PAIN: BOSTON SCIENTIFIC PRECISION OR CABLE

Facility

$1,050.00

Hospital Charge Code	9458962
Hospital Revenue Code	272
Min. Negotiated Rate	$892.50
Max. Negotiated Rate	$1,018.50
Rate for Payer: Cash Price	$682.50
Rate for Payer: Health Management Network Commercial	$892.50
Rate for Payer: Kaiser Permanente Commercial	$945.00
Rate for Payer: MDX Hawaii PPO	$1,018.50

SPINE & PAIN: BOSTON SCIENTIFIC PRECISION PATIENT PROGRAMMER KIT

Facility

$3,000.00

Service Code	HCPCS C1787
Hospital Charge Code	8882393
Hospital Revenue Code	278
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	$2,100.00
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	$1,680.00

SPINE & PAIN: BOSTON SCIENTIFIC PRECISION PATIENT PROGRAMMER KIT

Facility

$3,000.00

Service Code	HCPCS C1787
Hospital Charge Code	8882393
Hospital Revenue Code	278
Min. Negotiated Rate	$1,680.00
Max. Negotiated Rate	$2,910.00
Rate for Payer: Cash Price	$1,950.00
Rate for Payer: Hawaii Western Management Group Commercial	$2,100.00
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
Rate for Payer: University Health Alliance Commercial	$1,680.00

SPINE & PAIN: BOSTON SCIENTIFIC PRECISION PATIENT TRIAL KIT

Facility

$432.00

Hospital Charge Code	8882397
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

SPINE & PAIN: BOSTON SCIENTIFIC PRECISION PATIENT TRIAL KIT

Facility

$432.00

Hospital Charge Code	8882397
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

SPINE & PAIN: BOSTON SCIENTIFIC PRECISION S8 ADAPTER 15CM

Facility

$2,180.00

Service Code	HCPCS C1883
Hospital Charge Code	8882682
Hospital Revenue Code	278
Min. Negotiated Rate	$1,090.00
Max. Negotiated Rate	$2,114.60
Rate for Payer: AlohaCare Medicaid	$1,090.00
Rate for Payer: AlohaCare Medicare	$1,090.00
Rate for Payer: Cash Price	$1,417.00
Rate for Payer: Devoted Health Medicare	$1,199.00
Rate for Payer: Hawaii Medical Service Association Medicare	$1,090.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,526.00
Rate for Payer: Health Management Network Commercial	$1,853.00
Rate for Payer: Humana Medicare	$1,090.00
Rate for Payer: Kaiser Permanente Commercial	$1,962.00
Rate for Payer: Kaiser Permanente Medicaid	$1,111.80
Rate for Payer: Kaiser Permanente Medicare	$1,090.00
Rate for Payer: MDX Hawaii PPO	$2,114.60
Rate for Payer: Ohana Health Plan Medicaid	$1,090.00
Rate for Payer: Ohana Health Plan Medicare	$1,090.00
Rate for Payer: UnitedHealthcare Medicare	$1,090.00
Rate for Payer: University Health Alliance Commercial	$1,220.80

SPINE & PAIN: BOSTON SCIENTIFIC PRECISION S8 ADAPTER 15CM

Facility

$2,180.00

Service Code	HCPCS C1883
Hospital Charge Code	8882682
Hospital Revenue Code	278
Min. Negotiated Rate	$1,220.80
Max. Negotiated Rate	$2,114.60
Rate for Payer: Cash Price	$1,417.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,526.00
Rate for Payer: Health Management Network Commercial	$1,853.00
Rate for Payer: Kaiser Permanente Commercial	$1,962.00
Rate for Payer: MDX Hawaii PPO	$2,114.60
Rate for Payer: University Health Alliance Commercial	$1,220.80

SPINE & PAIN: BOSTON SCIENTIFIC SPECTRA 2 FT 2X16 OR CABLE AND EXT

Facility

$1,800.00

Hospital Charge Code	8882685
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

SPINE & PAIN: BOSTON SCIENTIFIC SPECTRA 2 FT 2X16 OR CABLE AND EXT

Facility

$1,800.00

Hospital Charge Code	8882685
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

SPINE & PAIN: BOSTON SCIENTIFIC SPECTRA 2 FT 2X8 OR CABLE AND EXT

Facility

$7.00

Hospital Charge Code	8882684
Hospital Revenue Code	272
Min. Negotiated Rate	$5.95
Max. Negotiated Rate	$6.79
Rate for Payer: Cash Price	$4.55
Rate for Payer: Health Management Network Commercial	$5.95
Rate for Payer: Kaiser Permanente Commercial	$6.30
Rate for Payer: MDX Hawaii PPO	$6.79

SPINE & PAIN: BOSTON SCIENTIFIC SPECTRA 2 FT 2X8 OR CABLE AND EXT

Facility

$7.00

Hospital Charge Code	8882684
Hospital Revenue Code	272
Min. Negotiated Rate	$3.50
Max. Negotiated Rate	$6.79
Rate for Payer: AlohaCare Medicaid	$3.50
Rate for Payer: AlohaCare Medicare	$3.50
Rate for Payer: Cash Price	$4.55
Rate for Payer: Devoted Health Medicare	$3.85
Rate for Payer: Hawaii Medical Service Association Medicare	$3.50
Rate for Payer: Hawaii Western Management Group Commercial	$6.65
Rate for Payer: Health Management Network Commercial	$5.95
Rate for Payer: Humana Medicare	$3.50
Rate for Payer: Kaiser Permanente Commercial	$6.30
Rate for Payer: Kaiser Permanente Medicaid	$3.57
Rate for Payer: Kaiser Permanente Medicare	$3.50
Rate for Payer: MDX Hawaii PPO	$6.79
Rate for Payer: Ohana Health Plan Medicaid	$3.50
Rate for Payer: Ohana Health Plan Medicare	$3.50
Rate for Payer: UnitedHealthcare Medicare	$3.50
Rate for Payer: University Health Alliance Commercial	$5.10

SPINE & PAIN: BOSTON SCIENTIFIC SPECTRA PATIENT PROGRAMMER KIT

Facility

$3,580.00

Service Code	HCPCS C1787
Hospital Charge Code	8882394
Hospital Revenue Code	278
Min. Negotiated Rate	$2,004.80
Max. Negotiated Rate	$3,472.60
Rate for Payer: Cash Price	$2,327.00
Rate for Payer: Hawaii Western Management Group Commercial	$2,506.00
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
Rate for Payer: University Health Alliance Commercial	$2,004.80

SPINE & PAIN: BOSTON SCIENTIFIC SPECTRA PATIENT PROGRAMMER KIT

Facility

$3,580.00

Service Code	HCPCS C1787
Hospital Charge Code	8882394
Hospital Revenue Code	278
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	$2,506.00
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	$2,004.80

SPINE & PAIN: BOSTON SCIENTIFIC SPECTRA PATIENT TRIAL KIT

Facility

$431.00

Hospital Charge Code	8882398
Hospital Revenue Code	272
Min. Negotiated Rate	$366.35
Max. Negotiated Rate	$418.07
Rate for Payer: Cash Price	$280.15
Rate for Payer: Health Management Network Commercial	$366.35
Rate for Payer: Kaiser Permanente Commercial	$387.90
Rate for Payer: MDX Hawaii PPO	$418.07

SPINE & PAIN: BOSTON SCIENTIFIC SPECTRA PATIENT TRIAL KIT

Facility

$431.00

Hospital Charge Code	8882398
Hospital Revenue Code	272
Min. Negotiated Rate	$215.50
Max. Negotiated Rate	$418.07
Rate for Payer: AlohaCare Medicaid	$215.50
Rate for Payer: AlohaCare Medicare	$215.50
Rate for Payer: Cash Price	$280.15
Rate for Payer: Devoted Health Medicare	$237.05
Rate for Payer: Hawaii Medical Service Association Medicare	$215.50
Rate for Payer: Hawaii Western Management Group Commercial	$409.45
Rate for Payer: Health Management Network Commercial	$366.35
Rate for Payer: Humana Medicare	$215.50
Rate for Payer: Kaiser Permanente Commercial	$387.90
Rate for Payer: Kaiser Permanente Medicaid	$219.81
Rate for Payer: Kaiser Permanente Medicare	$215.50
Rate for Payer: MDX Hawaii PPO	$418.07
Rate for Payer: Ohana Health Plan Medicaid	$215.50
Rate for Payer: Ohana Health Plan Medicare	$215.50
Rate for Payer: UnitedHealthcare Medicare	$215.50
Rate for Payer: University Health Alliance Commercial	$314.16

SPINE & PAIN: BOSTON SCIENTIFIC SPECTRA SPARE PORT PLUGS

Facility

$300.00

Hospital Charge Code	8882392
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 SPECTRA SPARE PORT PLUGS

Facility

$300.00

Hospital Charge Code	8882392
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 ST LINEAR TRIAL LEAD WITH PRELOADED 0.014 STYLET 50 CM

Facility

$2,000.00

Service Code	HCPCS C1897
Hospital Charge Code	9456260
Hospital Revenue Code	278
Min. Negotiated Rate	$1,120.00
Max. Negotiated Rate	$1,940.00
Rate for Payer: Cash Price	$1,300.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,400.00
Rate for Payer: Health Management Network Commercial	$1,700.00
Rate for Payer: Kaiser Permanente Commercial	$1,800.00
Rate for Payer: MDX Hawaii PPO	$1,940.00
Rate for Payer: University Health Alliance Commercial	$1,120.00

SPINE & PAIN: BOSTON SCIENTIFIC ST LINEAR TRIAL LEAD WITH PRELOADED 0.014 STYLET 50 CM

Facility

$2,000.00

Service Code	HCPCS C1897
Hospital Charge Code	9456260
Hospital Revenue Code	278
Min. Negotiated Rate	$1,000.00
Max. Negotiated Rate	$1,940.00
Rate for Payer: AlohaCare Medicaid	$1,000.00
Rate for Payer: AlohaCare Medicare	$1,000.00
Rate for Payer: Cash Price	$1,300.00
Rate for Payer: Devoted Health Medicare	$1,100.00
Rate for Payer: Hawaii Medical Service Association Medicare	$1,000.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,400.00
Rate for Payer: Health Management Network Commercial	$1,700.00
Rate for Payer: Humana Medicare	$1,000.00
Rate for Payer: Kaiser Permanente Commercial	$1,800.00
Rate for Payer: Kaiser Permanente Medicaid	$1,020.00
Rate for Payer: Kaiser Permanente Medicare	$1,000.00
Rate for Payer: MDX Hawaii PPO	$1,940.00
Rate for Payer: Ohana Health Plan Medicaid	$1,000.00
Rate for Payer: Ohana Health Plan Medicare	$1,000.00
Rate for Payer: UnitedHealthcare Medicare	$1,000.00
Rate for Payer: University Health Alliance Commercial	$1,120.00

Know your out-of-pocket cost for care.

All Charges