Kauai Veterans Memorial Hospital

All Charges

Charge

Type

Setting

Price

OPTH:DISP.EYE SHIELD CLEAR

Facility

$19.00

Hospital Charge Code	12818171
Hospital Revenue Code	272
Min. Negotiated Rate	$9.50
Max. Negotiated Rate	$18.43
Rate for Payer: AlohaCare Medicaid	$9.50
Rate for Payer: AlohaCare Medicare	$9.50
Rate for Payer: Cash Price	$12.35
Rate for Payer: Devoted Health Medicare	$10.45
Rate for Payer: Hawaii Medical Service Association Medicare	$9.50
Rate for Payer: Hawaii Western Management Group Commercial	$18.05
Rate for Payer: Health Management Network Commercial	$16.15
Rate for Payer: Humana Medicare	$9.50
Rate for Payer: Kaiser Permanente Commercial	$17.10
Rate for Payer: Kaiser Permanente Medicaid	$9.69
Rate for Payer: Kaiser Permanente Medicare	$9.50
Rate for Payer: MDX Hawaii PPO	$18.43
Rate for Payer: Ohana Health Plan Medicaid	$9.50
Rate for Payer: Ohana Health Plan Medicare	$9.50
Rate for Payer: UnitedHealthcare Medicare	$9.50
Rate for Payer: University Health Alliance Commercial	$13.85

OPTH:DISP.EYE SHIELD CLEAR

Facility

$19.00

Hospital Charge Code	12818171
Hospital Revenue Code	272
Min. Negotiated Rate	$16.15
Max. Negotiated Rate	$18.43
Rate for Payer: Cash Price	$12.35
Rate for Payer: Health Management Network Commercial	$16.15
Rate for Payer: Kaiser Permanente Commercial	$17.10
Rate for Payer: MDX Hawaii PPO	$18.43

OPTH:EYEHANCE DIB00

Facility

$582.00

Service Code	HCPCS V2630
Hospital Charge Code	9909045
Hospital Revenue Code	276
Min. Negotiated Rate	$197.46
Max. Negotiated Rate	$564.54
Rate for Payer: AlohaCare Medicaid	$342.00
Rate for Payer: AlohaCare Medicare	$291.00
Rate for Payer: Cash Price	$378.30
Rate for Payer: Cash Price	$378.30
Rate for Payer: Cash Price	$378.30
Rate for Payer: Devoted Health Medicare	$320.10
Rate for Payer: Hawaii Medical Service Association Medicare	$291.00
Rate for Payer: Hawaii Western Management Group Commercial	$407.40
Rate for Payer: Health Management Network Commercial	$494.70
Rate for Payer: Humana Medicare	$291.00
Rate for Payer: Kaiser Permanente Commercial	$523.80
Rate for Payer: Kaiser Permanente Medicaid	$296.82
Rate for Payer: Kaiser Permanente Medicare	$291.00
Rate for Payer: MDX Hawaii PPO	$564.54
Rate for Payer: Ohana Health Plan Medicaid	$291.00
Rate for Payer: Ohana Health Plan Medicare	$291.00
Rate for Payer: UnitedHealthcare Medicaid	$197.46
Rate for Payer: UnitedHealthcare Medicare	$291.00
Rate for Payer: University Health Alliance Commercial	$325.92

OPTH:EYEHANCE DIB00

Facility

$582.00

Service Code	HCPCS V2630
Hospital Charge Code	9909045
Hospital Revenue Code	276
Min. Negotiated Rate	$325.92
Max. Negotiated Rate	$564.54
Rate for Payer: Cash Price	$378.30
Rate for Payer: Hawaii Western Management Group Commercial	$407.40
Rate for Payer: Health Management Network Commercial	$494.70
Rate for Payer: Kaiser Permanente Commercial	$523.80
Rate for Payer: MDX Hawaii PPO	$564.54
Rate for Payer: University Health Alliance Commercial	$325.92

OPTH:EYEHANCE TORIC DIU150

Facility

$1,785.00

Service Code	HCPCS V2630
Hospital Charge Code	9909046
Hospital Revenue Code	276
Min. Negotiated Rate	$999.60
Max. Negotiated Rate	$1,731.45
Rate for Payer: Cash Price	$1,160.25
Rate for Payer: Hawaii Western Management Group Commercial	$1,249.50
Rate for Payer: Health Management Network Commercial	$1,517.25
Rate for Payer: Kaiser Permanente Commercial	$1,606.50
Rate for Payer: MDX Hawaii PPO	$1,731.45
Rate for Payer: University Health Alliance Commercial	$999.60

OPTH:EYEHANCE TORIC DIU150

Facility

$1,785.00

Service Code	HCPCS V2630
Hospital Charge Code	9909046
Hospital Revenue Code	276
Min. Negotiated Rate	$197.46
Max. Negotiated Rate	$1,731.45
Rate for Payer: AlohaCare Medicaid	$342.00
Rate for Payer: AlohaCare Medicare	$892.50
Rate for Payer: Cash Price	$1,160.25
Rate for Payer: Cash Price	$1,160.25
Rate for Payer: Cash Price	$1,160.25
Rate for Payer: Devoted Health Medicare	$981.75
Rate for Payer: Hawaii Medical Service Association Medicare	$892.50
Rate for Payer: Hawaii Western Management Group Commercial	$1,249.50
Rate for Payer: Health Management Network Commercial	$1,517.25
Rate for Payer: Humana Medicare	$892.50
Rate for Payer: Kaiser Permanente Commercial	$1,606.50
Rate for Payer: Kaiser Permanente Medicaid	$910.35
Rate for Payer: Kaiser Permanente Medicare	$892.50
Rate for Payer: MDX Hawaii PPO	$1,731.45
Rate for Payer: Ohana Health Plan Medicaid	$892.50
Rate for Payer: Ohana Health Plan Medicare	$892.50
Rate for Payer: UnitedHealthcare Medicaid	$197.46
Rate for Payer: UnitedHealthcare Medicare	$892.50
Rate for Payer: University Health Alliance Commercial	$999.60

OPTH:EYEHANCE TORIC DIU225

Facility

$1,785.00

Service Code	HCPCS V2630
Hospital Charge Code	9909047
Hospital Revenue Code	276
Min. Negotiated Rate	$999.60
Max. Negotiated Rate	$1,731.45
Rate for Payer: Cash Price	$1,160.25
Rate for Payer: Hawaii Western Management Group Commercial	$1,249.50
Rate for Payer: Health Management Network Commercial	$1,517.25
Rate for Payer: Kaiser Permanente Commercial	$1,606.50
Rate for Payer: MDX Hawaii PPO	$1,731.45
Rate for Payer: University Health Alliance Commercial	$999.60

OPTH:EYEHANCE TORIC DIU225

Facility

$1,785.00

Service Code	HCPCS V2630
Hospital Charge Code	9909047
Hospital Revenue Code	276
Min. Negotiated Rate	$197.46
Max. Negotiated Rate	$1,731.45
Rate for Payer: AlohaCare Medicaid	$342.00
Rate for Payer: AlohaCare Medicare	$892.50
Rate for Payer: Cash Price	$1,160.25
Rate for Payer: Cash Price	$1,160.25
Rate for Payer: Cash Price	$1,160.25
Rate for Payer: Devoted Health Medicare	$981.75
Rate for Payer: Hawaii Medical Service Association Medicare	$892.50
Rate for Payer: Hawaii Western Management Group Commercial	$1,249.50
Rate for Payer: Health Management Network Commercial	$1,517.25
Rate for Payer: Humana Medicare	$892.50
Rate for Payer: Kaiser Permanente Commercial	$1,606.50
Rate for Payer: Kaiser Permanente Medicaid	$910.35
Rate for Payer: Kaiser Permanente Medicare	$892.50
Rate for Payer: MDX Hawaii PPO	$1,731.45
Rate for Payer: Ohana Health Plan Medicaid	$892.50
Rate for Payer: Ohana Health Plan Medicare	$892.50
Rate for Payer: UnitedHealthcare Medicaid	$197.46
Rate for Payer: UnitedHealthcare Medicare	$892.50
Rate for Payer: University Health Alliance Commercial	$999.60

OPTH:EYEHANCE TORIC DIU300

Facility

$1,785.00

Service Code	HCPCS V2630
Hospital Charge Code	9909048
Hospital Revenue Code	276
Min. Negotiated Rate	$999.60
Max. Negotiated Rate	$1,731.45
Rate for Payer: Cash Price	$1,160.25
Rate for Payer: Hawaii Western Management Group Commercial	$1,249.50
Rate for Payer: Health Management Network Commercial	$1,517.25
Rate for Payer: Kaiser Permanente Commercial	$1,606.50
Rate for Payer: MDX Hawaii PPO	$1,731.45
Rate for Payer: University Health Alliance Commercial	$999.60

OPTH:EYEHANCE TORIC DIU300

Facility

$1,785.00

Service Code	HCPCS V2630
Hospital Charge Code	9909048
Hospital Revenue Code	276
Min. Negotiated Rate	$197.46
Max. Negotiated Rate	$1,731.45
Rate for Payer: AlohaCare Medicaid	$342.00
Rate for Payer: AlohaCare Medicare	$892.50
Rate for Payer: Cash Price	$1,160.25
Rate for Payer: Cash Price	$1,160.25
Rate for Payer: Cash Price	$1,160.25
Rate for Payer: Devoted Health Medicare	$981.75
Rate for Payer: Hawaii Medical Service Association Medicare	$892.50
Rate for Payer: Hawaii Western Management Group Commercial	$1,249.50
Rate for Payer: Health Management Network Commercial	$1,517.25
Rate for Payer: Humana Medicare	$892.50
Rate for Payer: Kaiser Permanente Commercial	$1,606.50
Rate for Payer: Kaiser Permanente Medicaid	$910.35
Rate for Payer: Kaiser Permanente Medicare	$892.50
Rate for Payer: MDX Hawaii PPO	$1,731.45
Rate for Payer: Ohana Health Plan Medicaid	$892.50
Rate for Payer: Ohana Health Plan Medicare	$892.50
Rate for Payer: UnitedHealthcare Medicaid	$197.46
Rate for Payer: UnitedHealthcare Medicare	$892.50
Rate for Payer: University Health Alliance Commercial	$999.60

OPTH:EYEHANCE TORIC DIU375

Facility

$1,785.00

Service Code	HCPCS V2630
Hospital Charge Code	9909049
Hospital Revenue Code	276
Min. Negotiated Rate	$999.60
Max. Negotiated Rate	$1,731.45
Rate for Payer: Cash Price	$1,160.25
Rate for Payer: Hawaii Western Management Group Commercial	$1,249.50
Rate for Payer: Health Management Network Commercial	$1,517.25
Rate for Payer: Kaiser Permanente Commercial	$1,606.50
Rate for Payer: MDX Hawaii PPO	$1,731.45
Rate for Payer: University Health Alliance Commercial	$999.60

OPTH:EYEHANCE TORIC DIU375

Facility

$1,785.00

Service Code	HCPCS V2630
Hospital Charge Code	9909049
Hospital Revenue Code	276
Min. Negotiated Rate	$197.46
Max. Negotiated Rate	$1,731.45
Rate for Payer: AlohaCare Medicaid	$342.00
Rate for Payer: AlohaCare Medicare	$892.50
Rate for Payer: Cash Price	$1,160.25
Rate for Payer: Cash Price	$1,160.25
Rate for Payer: Cash Price	$1,160.25
Rate for Payer: Devoted Health Medicare	$981.75
Rate for Payer: Hawaii Medical Service Association Medicare	$892.50
Rate for Payer: Hawaii Western Management Group Commercial	$1,249.50
Rate for Payer: Health Management Network Commercial	$1,517.25
Rate for Payer: Humana Medicare	$892.50
Rate for Payer: Kaiser Permanente Commercial	$1,606.50
Rate for Payer: Kaiser Permanente Medicaid	$910.35
Rate for Payer: Kaiser Permanente Medicare	$892.50
Rate for Payer: MDX Hawaii PPO	$1,731.45
Rate for Payer: Ohana Health Plan Medicaid	$892.50
Rate for Payer: Ohana Health Plan Medicare	$892.50
Rate for Payer: UnitedHealthcare Medicaid	$197.46
Rate for Payer: UnitedHealthcare Medicare	$892.50
Rate for Payer: University Health Alliance Commercial	$999.60

OPTH:EYEHANCE TORIC DIU450

Facility

$1,785.00

Service Code	HCPCS V2630
Hospital Charge Code	9909050
Hospital Revenue Code	276
Min. Negotiated Rate	$999.60
Max. Negotiated Rate	$1,731.45
Rate for Payer: Cash Price	$1,160.25
Rate for Payer: Hawaii Western Management Group Commercial	$1,249.50
Rate for Payer: Health Management Network Commercial	$1,517.25
Rate for Payer: Kaiser Permanente Commercial	$1,606.50
Rate for Payer: MDX Hawaii PPO	$1,731.45
Rate for Payer: University Health Alliance Commercial	$999.60

OPTH:EYEHANCE TORIC DIU450

Facility

$1,785.00

Service Code	HCPCS V2630
Hospital Charge Code	9909050
Hospital Revenue Code	276
Min. Negotiated Rate	$197.46
Max. Negotiated Rate	$1,731.45
Rate for Payer: AlohaCare Medicaid	$342.00
Rate for Payer: AlohaCare Medicare	$892.50
Rate for Payer: Cash Price	$1,160.25
Rate for Payer: Cash Price	$1,160.25
Rate for Payer: Cash Price	$1,160.25
Rate for Payer: Devoted Health Medicare	$981.75
Rate for Payer: Hawaii Medical Service Association Medicare	$892.50
Rate for Payer: Hawaii Western Management Group Commercial	$1,249.50
Rate for Payer: Health Management Network Commercial	$1,517.25
Rate for Payer: Humana Medicare	$892.50
Rate for Payer: Kaiser Permanente Commercial	$1,606.50
Rate for Payer: Kaiser Permanente Medicaid	$910.35
Rate for Payer: Kaiser Permanente Medicare	$892.50
Rate for Payer: MDX Hawaii PPO	$1,731.45
Rate for Payer: Ohana Health Plan Medicaid	$892.50
Rate for Payer: Ohana Health Plan Medicare	$892.50
Rate for Payer: UnitedHealthcare Medicaid	$197.46
Rate for Payer: UnitedHealthcare Medicare	$892.50
Rate for Payer: University Health Alliance Commercial	$999.60

OPTH:EYEHANCE TORIC DIU525

Facility

$1,785.00

Hospital Charge Code	9909051
Hospital Revenue Code	276
Min. Negotiated Rate	$999.60
Max. Negotiated Rate	$1,731.45
Rate for Payer: Cash Price	$1,160.25
Rate for Payer: Hawaii Western Management Group Commercial	$1,249.50
Rate for Payer: Health Management Network Commercial	$1,517.25
Rate for Payer: Kaiser Permanente Commercial	$1,606.50
Rate for Payer: MDX Hawaii PPO	$1,731.45
Rate for Payer: University Health Alliance Commercial	$999.60

OPTH:EYEHANCE TORIC DIU525

Facility

$1,785.00

Hospital Charge Code	9909051
Hospital Revenue Code	276
Min. Negotiated Rate	$892.50
Max. Negotiated Rate	$1,731.45
Rate for Payer: AlohaCare Medicaid	$892.50
Rate for Payer: AlohaCare Medicare	$892.50
Rate for Payer: Cash Price	$1,160.25
Rate for Payer: Devoted Health Medicare	$981.75
Rate for Payer: Hawaii Medical Service Association Medicare	$892.50
Rate for Payer: Hawaii Western Management Group Commercial	$1,249.50
Rate for Payer: Health Management Network Commercial	$1,517.25
Rate for Payer: Humana Medicare	$892.50
Rate for Payer: Kaiser Permanente Commercial	$1,606.50
Rate for Payer: Kaiser Permanente Medicaid	$910.35
Rate for Payer: Kaiser Permanente Medicare	$892.50
Rate for Payer: MDX Hawaii PPO	$1,731.45
Rate for Payer: Ohana Health Plan Medicaid	$892.50
Rate for Payer: Ohana Health Plan Medicare	$892.50
Rate for Payer: UnitedHealthcare Medicare	$892.50
Rate for Payer: University Health Alliance Commercial	$999.60

OPTH:EYEHANCE TORIC DIU600

Facility

$1,785.00

Hospital Charge Code	9909052
Hospital Revenue Code	276
Min. Negotiated Rate	$999.60
Max. Negotiated Rate	$1,731.45
Rate for Payer: Cash Price	$1,160.25
Rate for Payer: Hawaii Western Management Group Commercial	$1,249.50
Rate for Payer: Health Management Network Commercial	$1,517.25
Rate for Payer: Kaiser Permanente Commercial	$1,606.50
Rate for Payer: MDX Hawaii PPO	$1,731.45
Rate for Payer: University Health Alliance Commercial	$999.60

OPTH:EYEHANCE TORIC DIU600

Facility

$1,785.00

Hospital Charge Code	9909052
Hospital Revenue Code	276
Min. Negotiated Rate	$892.50
Max. Negotiated Rate	$1,731.45
Rate for Payer: AlohaCare Medicaid	$892.50
Rate for Payer: AlohaCare Medicare	$892.50
Rate for Payer: Cash Price	$1,160.25
Rate for Payer: Devoted Health Medicare	$981.75
Rate for Payer: Hawaii Medical Service Association Medicare	$892.50
Rate for Payer: Hawaii Western Management Group Commercial	$1,249.50
Rate for Payer: Health Management Network Commercial	$1,517.25
Rate for Payer: Humana Medicare	$892.50
Rate for Payer: Kaiser Permanente Commercial	$1,606.50
Rate for Payer: Kaiser Permanente Medicaid	$910.35
Rate for Payer: Kaiser Permanente Medicare	$892.50
Rate for Payer: MDX Hawaii PPO	$1,731.45
Rate for Payer: Ohana Health Plan Medicaid	$892.50
Rate for Payer: Ohana Health Plan Medicare	$892.50
Rate for Payer: UnitedHealthcare Medicare	$892.50
Rate for Payer: University Health Alliance Commercial	$999.60

OPTH:FLOSEAL NEXT GEN W/ RECOTHRO, 5ML, 6/CASE

Facility

$885.00

Service Code	HCPCS C1760
Hospital Charge Code	10994944
Hospital Revenue Code	272
Min. Negotiated Rate	$752.25
Max. Negotiated Rate	$858.45
Rate for Payer: Cash Price	$575.25
Rate for Payer: Health Management Network Commercial	$752.25
Rate for Payer: Kaiser Permanente Commercial	$796.50
Rate for Payer: MDX Hawaii PPO	$858.45

OPTH:FLOSEAL NEXT GEN W/ RECOTHRO, 5ML, 6/CASE

Facility

$885.00

Service Code	HCPCS C1760
Hospital Charge Code	10994944
Hospital Revenue Code	272
Min. Negotiated Rate	$442.50
Max. Negotiated Rate	$858.45
Rate for Payer: AlohaCare Medicaid	$442.50
Rate for Payer: AlohaCare Medicare	$442.50
Rate for Payer: Cash Price	$575.25
Rate for Payer: Devoted Health Medicare	$486.75
Rate for Payer: Hawaii Medical Service Association Medicare	$442.50
Rate for Payer: Hawaii Western Management Group Commercial	$840.75
Rate for Payer: Health Management Network Commercial	$752.25
Rate for Payer: Humana Medicare	$442.50
Rate for Payer: Kaiser Permanente Commercial	$796.50
Rate for Payer: Kaiser Permanente Medicaid	$451.35
Rate for Payer: Kaiser Permanente Medicare	$442.50
Rate for Payer: MDX Hawaii PPO	$858.45
Rate for Payer: Ohana Health Plan Medicaid	$442.50
Rate for Payer: Ohana Health Plan Medicare	$442.50
Rate for Payer: UnitedHealthcare Medicare	$442.50
Rate for Payer: University Health Alliance Commercial	$645.08

OPTH:HYDRODISSECTION CANNULA 27G

Facility

$62.00

Hospital Charge Code	8274283
Hospital Revenue Code	272
Min. Negotiated Rate	$52.70
Max. Negotiated Rate	$60.14
Rate for Payer: Cash Price	$40.30
Rate for Payer: Health Management Network Commercial	$52.70
Rate for Payer: Kaiser Permanente Commercial	$55.80
Rate for Payer: MDX Hawaii PPO	$60.14

OPTH:HYDRODISSECTION CANNULA 27G

Facility

$62.00

Hospital Charge Code	8274283
Hospital Revenue Code	272
Min. Negotiated Rate	$31.00
Max. Negotiated Rate	$60.14
Rate for Payer: AlohaCare Medicaid	$31.00
Rate for Payer: AlohaCare Medicare	$31.00
Rate for Payer: Cash Price	$40.30
Rate for Payer: Devoted Health Medicare	$34.10
Rate for Payer: Hawaii Medical Service Association Medicare	$31.00
Rate for Payer: Hawaii Western Management Group Commercial	$58.90
Rate for Payer: Health Management Network Commercial	$52.70
Rate for Payer: Humana Medicare	$31.00
Rate for Payer: Kaiser Permanente Commercial	$55.80
Rate for Payer: Kaiser Permanente Medicaid	$31.62
Rate for Payer: Kaiser Permanente Medicare	$31.00
Rate for Payer: MDX Hawaii PPO	$60.14
Rate for Payer: Ohana Health Plan Medicaid	$31.00
Rate for Payer: Ohana Health Plan Medicare	$31.00
Rate for Payer: UnitedHealthcare Medicare	$31.00
Rate for Payer: University Health Alliance Commercial	$45.19

OPTH:HYDRODISSECTOR 27G CHANG

Facility

$32.00

Hospital Charge Code	12850853
Hospital Revenue Code	272
Min. Negotiated Rate	$16.00
Max. Negotiated Rate	$31.04
Rate for Payer: AlohaCare Medicaid	$16.00
Rate for Payer: AlohaCare Medicare	$16.00
Rate for Payer: Cash Price	$20.80
Rate for Payer: Devoted Health Medicare	$17.60
Rate for Payer: Hawaii Medical Service Association Medicare	$16.00
Rate for Payer: Hawaii Western Management Group Commercial	$30.40
Rate for Payer: Health Management Network Commercial	$27.20
Rate for Payer: Humana Medicare	$16.00
Rate for Payer: Kaiser Permanente Commercial	$28.80
Rate for Payer: Kaiser Permanente Medicaid	$16.32
Rate for Payer: Kaiser Permanente Medicare	$16.00
Rate for Payer: MDX Hawaii PPO	$31.04
Rate for Payer: Ohana Health Plan Medicaid	$16.00
Rate for Payer: Ohana Health Plan Medicare	$16.00
Rate for Payer: UnitedHealthcare Medicare	$16.00
Rate for Payer: University Health Alliance Commercial	$23.32

OPTH:HYDRODISSECTOR 27G CHANG

Facility

$32.00

Hospital Charge Code	12850853
Hospital Revenue Code	272
Min. Negotiated Rate	$27.20
Max. Negotiated Rate	$31.04
Rate for Payer: Cash Price	$20.80
Rate for Payer: Health Management Network Commercial	$27.20
Rate for Payer: Kaiser Permanente Commercial	$28.80
Rate for Payer: MDX Hawaii PPO	$31.04

OPTH:HYDRUS MICROSTENT

Facility

$4,400.00

Service Code	HCPCS C1783
Hospital Charge Code	10309147
Hospital Revenue Code	278
Min. Negotiated Rate	$2,200.00
Max. Negotiated Rate	$4,268.00
Rate for Payer: AlohaCare Medicaid	$2,200.00
Rate for Payer: AlohaCare Medicare	$2,200.00
Rate for Payer: Cash Price	$2,860.00
Rate for Payer: Devoted Health Medicare	$2,420.00
Rate for Payer: Hawaii Medical Service Association Medicare	$2,200.00
Rate for Payer: Hawaii Western Management Group Commercial	$3,080.00
Rate for Payer: Health Management Network Commercial	$3,740.00
Rate for Payer: Humana Medicare	$2,200.00
Rate for Payer: Kaiser Permanente Commercial	$3,960.00
Rate for Payer: Kaiser Permanente Medicaid	$2,244.00
Rate for Payer: Kaiser Permanente Medicare	$2,200.00
Rate for Payer: MDX Hawaii PPO	$4,268.00
Rate for Payer: Ohana Health Plan Medicaid	$2,200.00
Rate for Payer: Ohana Health Plan Medicare	$2,200.00
Rate for Payer: UnitedHealthcare Medicare	$2,200.00
Rate for Payer: University Health Alliance Commercial	$2,464.00

Know your out-of-pocket cost for care.

All Charges