Kauai Veterans Memorial Hospital

All Charges

Charge

Type

Setting

Price

SPINE & PAIN COOLIEF MULTI-COOLED RADIOFREQUENCY KIT

Facility

$3,820.00

Hospital Charge Code	9036217
Hospital Revenue Code	272
Min. Negotiated Rate	$1,910.00
Max. Negotiated Rate	$3,705.40
Rate for Payer: AlohaCare Medicaid	$1,910.00
Rate for Payer: AlohaCare Medicare	$1,910.00
Rate for Payer: Cash Price	$2,483.00
Rate for Payer: Devoted Health Medicare	$2,101.00
Rate for Payer: Hawaii Medical Service Association Medicare	$1,910.00
Rate for Payer: Hawaii Western Management Group Commercial	$3,629.00
Rate for Payer: Health Management Network Commercial	$3,247.00
Rate for Payer: Humana Medicare	$1,910.00
Rate for Payer: Kaiser Permanente Commercial	$3,438.00
Rate for Payer: Kaiser Permanente Medicaid	$1,948.20
Rate for Payer: Kaiser Permanente Medicare	$1,910.00
Rate for Payer: MDX Hawaii PPO	$3,705.40
Rate for Payer: Ohana Health Plan Medicaid	$1,910.00
Rate for Payer: Ohana Health Plan Medicare	$1,910.00
Rate for Payer: UnitedHealthcare Medicare	$1,910.00
Rate for Payer: University Health Alliance Commercial	$2,784.40

SPINE & PAIN COOLIEF MULTI-COOLED RADIOFREQUENCY MODULE

Facility

$4,000.00

Hospital Charge Code	9036240
Hospital Revenue Code	272
Min. Negotiated Rate	$3,400.00
Max. Negotiated Rate	$3,880.00
Rate for Payer: Cash Price	$2,600.00
Rate for Payer: Health Management Network Commercial	$3,400.00
Rate for Payer: Kaiser Permanente Commercial	$3,600.00
Rate for Payer: MDX Hawaii PPO	$3,880.00

SPINE & PAIN COOLIEF MULTI-COOLED RADIOFREQUENCY MODULE

Facility

$4,000.00

Hospital Charge Code	9036240
Hospital Revenue Code	272
Min. Negotiated Rate	$2,000.00
Max. Negotiated Rate	$3,880.00
Rate for Payer: AlohaCare Medicaid	$2,000.00
Rate for Payer: AlohaCare Medicare	$2,000.00
Rate for Payer: Cash Price	$2,600.00
Rate for Payer: Devoted Health Medicare	$2,200.00
Rate for Payer: Hawaii Medical Service Association Medicare	$2,000.00
Rate for Payer: Hawaii Western Management Group Commercial	$3,800.00
Rate for Payer: Health Management Network Commercial	$3,400.00
Rate for Payer: Humana Medicare	$2,000.00
Rate for Payer: Kaiser Permanente Commercial	$3,600.00
Rate for Payer: Kaiser Permanente Medicaid	$2,040.00
Rate for Payer: Kaiser Permanente Medicare	$2,000.00
Rate for Payer: MDX Hawaii PPO	$3,880.00
Rate for Payer: Ohana Health Plan Medicaid	$2,000.00
Rate for Payer: Ohana Health Plan Medicare	$2,000.00
Rate for Payer: UnitedHealthcare Medicare	$2,000.00
Rate for Payer: University Health Alliance Commercial	$2,915.60

SPINE & PAIN DISPERSIVE ELECTRODE

Facility

$149.00

Hospital Charge Code	9036241
Hospital Revenue Code	272
Min. Negotiated Rate	$126.65
Max. Negotiated Rate	$144.53
Rate for Payer: Cash Price	$96.85
Rate for Payer: Health Management Network Commercial	$126.65
Rate for Payer: Kaiser Permanente Commercial	$134.10
Rate for Payer: MDX Hawaii PPO	$144.53

SPINE & PAIN DISPERSIVE ELECTRODE

Facility

$149.00

Hospital Charge Code	9036241
Hospital Revenue Code	272
Min. Negotiated Rate	$74.50
Max. Negotiated Rate	$144.53
Rate for Payer: AlohaCare Medicaid	$74.50
Rate for Payer: AlohaCare Medicare	$74.50
Rate for Payer: Cash Price	$96.85
Rate for Payer: Devoted Health Medicare	$81.95
Rate for Payer: Hawaii Medical Service Association Medicare	$74.50
Rate for Payer: Hawaii Western Management Group Commercial	$141.55
Rate for Payer: Health Management Network Commercial	$126.65
Rate for Payer: Humana Medicare	$74.50
Rate for Payer: Kaiser Permanente Commercial	$134.10
Rate for Payer: Kaiser Permanente Medicaid	$75.99
Rate for Payer: Kaiser Permanente Medicare	$74.50
Rate for Payer: MDX Hawaii PPO	$144.53
Rate for Payer: Ohana Health Plan Medicaid	$74.50
Rate for Payer: Ohana Health Plan Medicare	$74.50
Rate for Payer: UnitedHealthcare Medicare	$74.50
Rate for Payer: University Health Alliance Commercial	$108.61

SPINE & PAIN: SJM - EXTERNAL PULSE GENERATOR, 2 PORT HEADER (2 LEAD TRIAL KIT)

Facility

$4,000.00

Hospital Charge Code	8890598
Hospital Revenue Code	278
Min. Negotiated Rate	$2,240.00
Max. Negotiated Rate	$3,880.00
Rate for Payer: Cash Price	$2,600.00
Rate for Payer: Hawaii Western Management Group Commercial	$2,800.00
Rate for Payer: Health Management Network Commercial	$3,400.00
Rate for Payer: Kaiser Permanente Commercial	$3,600.00
Rate for Payer: MDX Hawaii PPO	$3,880.00
Rate for Payer: University Health Alliance Commercial	$2,240.00

SPINE & PAIN: SJM - EXTERNAL PULSE GENERATOR, 2 PORT HEADER (2 LEAD TRIAL KIT)

Facility

$4,000.00

Hospital Charge Code	8890598
Hospital Revenue Code	278
Min. Negotiated Rate	$2,000.00
Max. Negotiated Rate	$3,880.00
Rate for Payer: AlohaCare Medicaid	$2,000.00
Rate for Payer: AlohaCare Medicare	$2,000.00
Rate for Payer: Cash Price	$2,600.00
Rate for Payer: Devoted Health Medicare	$2,200.00
Rate for Payer: Hawaii Medical Service Association Medicare	$2,000.00
Rate for Payer: Hawaii Western Management Group Commercial	$2,800.00
Rate for Payer: Health Management Network Commercial	$3,400.00
Rate for Payer: Humana Medicare	$2,000.00
Rate for Payer: Kaiser Permanente Commercial	$3,600.00
Rate for Payer: Kaiser Permanente Medicaid	$2,040.00
Rate for Payer: Kaiser Permanente Medicare	$2,000.00
Rate for Payer: MDX Hawaii PPO	$3,880.00
Rate for Payer: Ohana Health Plan Medicaid	$2,000.00
Rate for Payer: Ohana Health Plan Medicare	$2,000.00
Rate for Payer: UnitedHealthcare Medicare	$2,000.00
Rate for Payer: University Health Alliance Commercial	$2,240.00

SPINE & PAIN: SJM - MULTILEAD TRIAL CABLE (2 LEAD TRIAL KIT)

Facility

$4,000.00

Hospital Charge Code	8890597
Hospital Revenue Code	278
Min. Negotiated Rate	$2,000.00
Max. Negotiated Rate	$3,880.00
Rate for Payer: AlohaCare Medicaid	$2,000.00
Rate for Payer: AlohaCare Medicare	$2,000.00
Rate for Payer: Cash Price	$2,600.00
Rate for Payer: Devoted Health Medicare	$2,200.00
Rate for Payer: Hawaii Medical Service Association Medicare	$2,000.00
Rate for Payer: Hawaii Western Management Group Commercial	$2,800.00
Rate for Payer: Health Management Network Commercial	$3,400.00
Rate for Payer: Humana Medicare	$2,000.00
Rate for Payer: Kaiser Permanente Commercial	$3,600.00
Rate for Payer: Kaiser Permanente Medicaid	$2,040.00
Rate for Payer: Kaiser Permanente Medicare	$2,000.00
Rate for Payer: MDX Hawaii PPO	$3,880.00
Rate for Payer: Ohana Health Plan Medicaid	$2,000.00
Rate for Payer: Ohana Health Plan Medicare	$2,000.00
Rate for Payer: UnitedHealthcare Medicare	$2,000.00
Rate for Payer: University Health Alliance Commercial	$2,240.00

SPINE & PAIN: SJM - MULTILEAD TRIAL CABLE (2 LEAD TRIAL KIT)

Facility

$4,000.00

Hospital Charge Code	8890597
Hospital Revenue Code	278
Min. Negotiated Rate	$2,240.00
Max. Negotiated Rate	$3,880.00
Rate for Payer: Cash Price	$2,600.00
Rate for Payer: Hawaii Western Management Group Commercial	$2,800.00
Rate for Payer: Health Management Network Commercial	$3,400.00
Rate for Payer: Kaiser Permanente Commercial	$3,600.00
Rate for Payer: MDX Hawaii PPO	$3,880.00
Rate for Payer: University Health Alliance Commercial	$2,240.00

SPINE & PAIN: SJM - OCTRODE (2 LEAD TRIAL KIT)

Facility

$4,000.00

Service Code	HCPCS C1897
Hospital Charge Code	8890596
Hospital Revenue Code	278
Min. Negotiated Rate	$2,240.00
Max. Negotiated Rate	$3,880.00
Rate for Payer: Cash Price	$2,600.00
Rate for Payer: Hawaii Western Management Group Commercial	$2,800.00
Rate for Payer: Health Management Network Commercial	$3,400.00
Rate for Payer: Kaiser Permanente Commercial	$3,600.00
Rate for Payer: MDX Hawaii PPO	$3,880.00
Rate for Payer: University Health Alliance Commercial	$2,240.00

SPINE & PAIN: SJM - OCTRODE (2 LEAD TRIAL KIT)

Facility

$4,000.00

Service Code	HCPCS C1897
Hospital Charge Code	8890596
Hospital Revenue Code	278
Min. Negotiated Rate	$2,000.00
Max. Negotiated Rate	$3,880.00
Rate for Payer: AlohaCare Medicaid	$2,000.00
Rate for Payer: AlohaCare Medicare	$2,000.00
Rate for Payer: Cash Price	$2,600.00
Rate for Payer: Devoted Health Medicare	$2,200.00
Rate for Payer: Hawaii Medical Service Association Medicare	$2,000.00
Rate for Payer: Hawaii Western Management Group Commercial	$2,800.00
Rate for Payer: Health Management Network Commercial	$3,400.00
Rate for Payer: Humana Medicare	$2,000.00
Rate for Payer: Kaiser Permanente Commercial	$3,600.00
Rate for Payer: Kaiser Permanente Medicaid	$2,040.00
Rate for Payer: Kaiser Permanente Medicare	$2,000.00
Rate for Payer: MDX Hawaii PPO	$3,880.00
Rate for Payer: Ohana Health Plan Medicaid	$2,000.00
Rate for Payer: Ohana Health Plan Medicare	$2,000.00
Rate for Payer: UnitedHealthcare Medicare	$2,000.00
Rate for Payer: University Health Alliance Commercial	$2,240.00

SPINE & PAIN: SJM - SWIFT-LOCK

Facility

$525.00

Hospital Charge Code	8890599
Hospital Revenue Code	272
Min. Negotiated Rate	$446.25
Max. Negotiated Rate	$509.25
Rate for Payer: Cash Price	$341.25
Rate for Payer: Health Management Network Commercial	$446.25
Rate for Payer: Kaiser Permanente Commercial	$472.50
Rate for Payer: MDX Hawaii PPO	$509.25

SPINE & PAIN: SJM - SWIFT-LOCK

Facility

$525.00

Hospital Charge Code	8890599
Hospital Revenue Code	272
Min. Negotiated Rate	$262.50
Max. Negotiated Rate	$509.25
Rate for Payer: AlohaCare Medicaid	$262.50
Rate for Payer: AlohaCare Medicare	$262.50
Rate for Payer: Cash Price	$341.25
Rate for Payer: Devoted Health Medicare	$288.75
Rate for Payer: Hawaii Medical Service Association Medicare	$262.50
Rate for Payer: Hawaii Western Management Group Commercial	$498.75
Rate for Payer: Health Management Network Commercial	$446.25
Rate for Payer: Humana Medicare	$262.50
Rate for Payer: Kaiser Permanente Commercial	$472.50
Rate for Payer: Kaiser Permanente Medicaid	$267.75
Rate for Payer: Kaiser Permanente Medicare	$262.50
Rate for Payer: MDX Hawaii PPO	$509.25
Rate for Payer: Ohana Health Plan Medicaid	$262.50
Rate for Payer: Ohana Health Plan Medicare	$262.50
Rate for Payer: UnitedHealthcare Medicare	$262.50
Rate for Payer: University Health Alliance Commercial	$382.67

SPINE & PAIN STIMPOD PRECISION NERVE LOCATING DEVICE

Facility

$2,250.00

Hospital Charge Code	9199409
Hospital Revenue Code	272
Min. Negotiated Rate	$1,125.00
Max. Negotiated Rate	$2,182.50
Rate for Payer: AlohaCare Medicaid	$1,125.00
Rate for Payer: AlohaCare Medicare	$1,125.00
Rate for Payer: Cash Price	$1,462.50
Rate for Payer: Devoted Health Medicare	$1,237.50
Rate for Payer: Hawaii Medical Service Association Medicare	$1,125.00
Rate for Payer: Hawaii Western Management Group Commercial	$2,137.50
Rate for Payer: Health Management Network Commercial	$1,912.50
Rate for Payer: Humana Medicare	$1,125.00
Rate for Payer: Kaiser Permanente Commercial	$2,025.00
Rate for Payer: Kaiser Permanente Medicaid	$1,147.50
Rate for Payer: Kaiser Permanente Medicare	$1,125.00
Rate for Payer: MDX Hawaii PPO	$2,182.50
Rate for Payer: Ohana Health Plan Medicaid	$1,125.00
Rate for Payer: Ohana Health Plan Medicare	$1,125.00
Rate for Payer: UnitedHealthcare Medicare	$1,125.00
Rate for Payer: University Health Alliance Commercial	$1,640.03

SPINE & PAIN STIMPOD PRECISION NERVE LOCATING DEVICE

Facility

$2,250.00

Hospital Charge Code	9199409
Hospital Revenue Code	272
Min. Negotiated Rate	$1,912.50
Max. Negotiated Rate	$2,182.50
Rate for Payer: Cash Price	$1,462.50
Rate for Payer: Health Management Network Commercial	$1,912.50
Rate for Payer: Kaiser Permanente Commercial	$2,025.00
Rate for Payer: MDX Hawaii PPO	$2,182.50

SPINE & PAIN STIM ROUTER CLINICIAN KIT

Facility

$5,000.00

Hospital Charge Code	9199408
Hospital Revenue Code	272
Min. Negotiated Rate	$4,250.00
Max. Negotiated Rate	$4,850.00
Rate for Payer: Cash Price	$3,250.00
Rate for Payer: Health Management Network Commercial	$4,250.00
Rate for Payer: Kaiser Permanente Commercial	$4,500.00
Rate for Payer: MDX Hawaii PPO	$4,850.00

SPINE & PAIN STIM ROUTER CLINICIAN KIT

Facility

$5,000.00

Hospital Charge Code	9199408
Hospital Revenue Code	272
Min. Negotiated Rate	$2,500.00
Max. Negotiated Rate	$4,850.00
Rate for Payer: AlohaCare Medicaid	$2,500.00
Rate for Payer: AlohaCare Medicare	$2,500.00
Rate for Payer: Cash Price	$3,250.00
Rate for Payer: Devoted Health Medicare	$2,750.00
Rate for Payer: Hawaii Medical Service Association Medicare	$2,500.00
Rate for Payer: Hawaii Western Management Group Commercial	$4,750.00
Rate for Payer: Health Management Network Commercial	$4,250.00
Rate for Payer: Humana Medicare	$2,500.00
Rate for Payer: Kaiser Permanente Commercial	$4,500.00
Rate for Payer: Kaiser Permanente Medicaid	$2,550.00
Rate for Payer: Kaiser Permanente Medicare	$2,500.00
Rate for Payer: MDX Hawaii PPO	$4,850.00
Rate for Payer: Ohana Health Plan Medicaid	$2,500.00
Rate for Payer: Ohana Health Plan Medicare	$2,500.00
Rate for Payer: UnitedHealthcare Medicare	$2,500.00
Rate for Payer: University Health Alliance Commercial	$3,644.50

SPINE & PAIN STIM ROUTER ELECTRODE SET

Facility

$150.00

Service Code	HCPCS C1883
Hospital Charge Code	9199411
Hospital Revenue Code	278
Min. Negotiated Rate	$75.00
Max. Negotiated Rate	$145.50
Rate for Payer: AlohaCare Medicaid	$75.00
Rate for Payer: AlohaCare Medicare	$75.00
Rate for Payer: Cash Price	$97.50
Rate for Payer: Devoted Health Medicare	$82.50
Rate for Payer: Hawaii Medical Service Association Medicare	$75.00
Rate for Payer: Hawaii Western Management Group Commercial	$105.00
Rate for Payer: Health Management Network Commercial	$127.50
Rate for Payer: Humana Medicare	$75.00
Rate for Payer: Kaiser Permanente Commercial	$135.00
Rate for Payer: Kaiser Permanente Medicaid	$76.50
Rate for Payer: Kaiser Permanente Medicare	$75.00
Rate for Payer: MDX Hawaii PPO	$145.50
Rate for Payer: Ohana Health Plan Medicaid	$75.00
Rate for Payer: Ohana Health Plan Medicare	$75.00
Rate for Payer: UnitedHealthcare Medicare	$75.00
Rate for Payer: University Health Alliance Commercial	$84.00

SPINE & PAIN STIM ROUTER ELECTRODE SET

Facility

$150.00

Service Code	HCPCS C1883
Hospital Charge Code	9199411
Hospital Revenue Code	278
Min. Negotiated Rate	$84.00
Max. Negotiated Rate	$145.50
Rate for Payer: Cash Price	$97.50
Rate for Payer: Hawaii Western Management Group Commercial	$105.00
Rate for Payer: Health Management Network Commercial	$127.50
Rate for Payer: Kaiser Permanente Commercial	$135.00
Rate for Payer: MDX Hawaii PPO	$145.50
Rate for Payer: University Health Alliance Commercial	$84.00

SPINE & PAIN STIM ROUTER IMPLANTABLE LEAD & INTRODUCER KIT

Facility

$4,250.00

Service Code	HCPCS C1778
Hospital Charge Code	9199407
Hospital Revenue Code	278
Min. Negotiated Rate	$2,125.00
Max. Negotiated Rate	$4,122.50
Rate for Payer: AlohaCare Medicaid	$2,125.00
Rate for Payer: AlohaCare Medicare	$2,125.00
Rate for Payer: Cash Price	$2,762.50
Rate for Payer: Devoted Health Medicare	$2,337.50
Rate for Payer: Hawaii Medical Service Association Medicare	$2,125.00
Rate for Payer: Hawaii Western Management Group Commercial	$2,975.00
Rate for Payer: Health Management Network Commercial	$3,612.50
Rate for Payer: Humana Medicare	$2,125.00
Rate for Payer: Kaiser Permanente Commercial	$3,825.00
Rate for Payer: Kaiser Permanente Medicaid	$2,167.50
Rate for Payer: Kaiser Permanente Medicare	$2,125.00
Rate for Payer: MDX Hawaii PPO	$4,122.50
Rate for Payer: Ohana Health Plan Medicaid	$2,125.00
Rate for Payer: Ohana Health Plan Medicare	$2,125.00
Rate for Payer: UnitedHealthcare Medicare	$2,125.00
Rate for Payer: University Health Alliance Commercial	$2,380.00

SPINE & PAIN STIM ROUTER IMPLANTABLE LEAD & INTRODUCER KIT

Facility

$4,250.00

Service Code	HCPCS C1778
Hospital Charge Code	9199407
Hospital Revenue Code	278
Min. Negotiated Rate	$2,380.00
Max. Negotiated Rate	$4,122.50
Rate for Payer: Cash Price	$2,762.50
Rate for Payer: Hawaii Western Management Group Commercial	$2,975.00
Rate for Payer: Health Management Network Commercial	$3,612.50
Rate for Payer: Kaiser Permanente Commercial	$3,825.00
Rate for Payer: MDX Hawaii PPO	$4,122.50
Rate for Payer: University Health Alliance Commercial	$2,380.00

SPINE & PAIN STIMROUTER USER KIT

Facility

$5,000.00

Service Code	HCPCS C1889
Hospital Charge Code	9199410
Hospital Revenue Code	278
Min. Negotiated Rate	$2,500.00
Max. Negotiated Rate	$4,850.00
Rate for Payer: AlohaCare Medicaid	$2,500.00
Rate for Payer: AlohaCare Medicare	$2,500.00
Rate for Payer: Cash Price	$3,250.00
Rate for Payer: Devoted Health Medicare	$2,750.00
Rate for Payer: Hawaii Medical Service Association Medicare	$2,500.00
Rate for Payer: Hawaii Western Management Group Commercial	$3,500.00
Rate for Payer: Health Management Network Commercial	$4,250.00
Rate for Payer: Humana Medicare	$2,500.00
Rate for Payer: Kaiser Permanente Commercial	$4,500.00
Rate for Payer: Kaiser Permanente Medicaid	$2,550.00
Rate for Payer: Kaiser Permanente Medicare	$2,500.00
Rate for Payer: MDX Hawaii PPO	$4,850.00
Rate for Payer: Ohana Health Plan Medicaid	$2,500.00
Rate for Payer: Ohana Health Plan Medicare	$2,500.00
Rate for Payer: UnitedHealthcare Medicare	$2,500.00
Rate for Payer: University Health Alliance Commercial	$2,800.00

SPINE & PAIN STIMROUTER USER KIT

Facility

$5,000.00

Service Code	HCPCS C1889
Hospital Charge Code	9199410
Hospital Revenue Code	278
Min. Negotiated Rate	$2,800.00
Max. Negotiated Rate	$4,850.00
Rate for Payer: Cash Price	$3,250.00
Rate for Payer: Hawaii Western Management Group Commercial	$3,500.00
Rate for Payer: Health Management Network Commercial	$4,250.00
Rate for Payer: Kaiser Permanente Commercial	$4,500.00
Rate for Payer: MDX Hawaii PPO	$4,850.00
Rate for Payer: University Health Alliance Commercial	$2,800.00

SPINE & PAIN: VERTIFLEX INDIRECT DECOMPRESSION IMPLANT 10MM

Facility

$10,500.00

Service Code	HCPCS C1821
Hospital Charge Code	8879097
Hospital Revenue Code	278
Min. Negotiated Rate	$5,250.00
Max. Negotiated Rate	$10,185.00
Rate for Payer: AlohaCare Medicaid	$5,250.00
Rate for Payer: AlohaCare Medicare	$5,250.00
Rate for Payer: Cash Price	$6,825.00
Rate for Payer: Devoted Health Medicare	$5,775.00
Rate for Payer: Hawaii Medical Service Association Medicare	$5,250.00
Rate for Payer: Hawaii Western Management Group Commercial	$7,350.00
Rate for Payer: Health Management Network Commercial	$8,925.00
Rate for Payer: Humana Medicare	$5,250.00
Rate for Payer: Kaiser Permanente Commercial	$9,450.00
Rate for Payer: Kaiser Permanente Medicaid	$5,355.00
Rate for Payer: Kaiser Permanente Medicare	$5,250.00
Rate for Payer: MDX Hawaii PPO	$10,185.00
Rate for Payer: Ohana Health Plan Medicaid	$5,250.00
Rate for Payer: Ohana Health Plan Medicare	$5,250.00
Rate for Payer: UnitedHealthcare Medicare	$5,250.00
Rate for Payer: University Health Alliance Commercial	$5,880.00

SPINE & PAIN: VERTIFLEX INDIRECT DECOMPRESSION IMPLANT 10MM

Facility

$10,500.00

Service Code	HCPCS C1821
Hospital Charge Code	8879097
Hospital Revenue Code	278
Min. Negotiated Rate	$5,880.00
Max. Negotiated Rate	$10,185.00
Rate for Payer: Cash Price	$6,825.00
Rate for Payer: Hawaii Western Management Group Commercial	$7,350.00
Rate for Payer: Health Management Network Commercial	$8,925.00
Rate for Payer: Kaiser Permanente Commercial	$9,450.00
Rate for Payer: MDX Hawaii PPO	$10,185.00
Rate for Payer: University Health Alliance Commercial	$5,880.00

Know your out-of-pocket cost for care.

All Charges