Kauai Veterans Memorial Hospital

All Charges

Charge

Type

Setting

Price

OPTH:SUTURE POLYSORB 8-0 SE-140-8 L-2748K

Facility

$208.00

Hospital Charge Code	8274321
Hospital Revenue Code	272
Min. Negotiated Rate	$104.00
Max. Negotiated Rate	$201.76
Rate for Payer: AlohaCare Medicaid	$104.00
Rate for Payer: AlohaCare Medicare	$104.00
Rate for Payer: Cash Price	$135.20
Rate for Payer: Devoted Health Medicare	$114.40
Rate for Payer: Hawaii Medical Service Association Medicare	$104.00
Rate for Payer: Hawaii Western Management Group Commercial	$197.60
Rate for Payer: Health Management Network Commercial	$176.80
Rate for Payer: Humana Medicare	$104.00
Rate for Payer: Kaiser Permanente Commercial	$187.20
Rate for Payer: Kaiser Permanente Medicaid	$106.08
Rate for Payer: Kaiser Permanente Medicare	$104.00
Rate for Payer: MDX Hawaii PPO	$201.76
Rate for Payer: Ohana Health Plan Medicaid	$104.00
Rate for Payer: Ohana Health Plan Medicare	$104.00
Rate for Payer: UnitedHealthcare Medicare	$104.00
Rate for Payer: University Health Alliance Commercial	$151.61

OPTH:SUTURE PROLENE 4-0 RB-1 8871H

Facility

$34.00

Hospital Charge Code	8274381
Hospital Revenue Code	272
Min. Negotiated Rate	$28.90
Max. Negotiated Rate	$32.98
Rate for Payer: Cash Price	$22.10
Rate for Payer: Health Management Network Commercial	$28.90
Rate for Payer: Kaiser Permanente Commercial	$30.60
Rate for Payer: MDX Hawaii PPO	$32.98

OPTH:SUTURE PROLENE 4-0 RB-1 8871H

Facility

$34.00

Hospital Charge Code	8274381
Hospital Revenue Code	272
Min. Negotiated Rate	$17.00
Max. Negotiated Rate	$32.98
Rate for Payer: AlohaCare Medicaid	$17.00
Rate for Payer: AlohaCare Medicare	$17.00
Rate for Payer: Cash Price	$22.10
Rate for Payer: Devoted Health Medicare	$18.70
Rate for Payer: Hawaii Medical Service Association Medicare	$17.00
Rate for Payer: Hawaii Western Management Group Commercial	$32.30
Rate for Payer: Health Management Network Commercial	$28.90
Rate for Payer: Humana Medicare	$17.00
Rate for Payer: Kaiser Permanente Commercial	$30.60
Rate for Payer: Kaiser Permanente Medicaid	$17.34
Rate for Payer: Kaiser Permanente Medicare	$17.00
Rate for Payer: MDX Hawaii PPO	$32.98
Rate for Payer: Ohana Health Plan Medicaid	$17.00
Rate for Payer: Ohana Health Plan Medicare	$17.00
Rate for Payer: UnitedHealthcare Medicare	$17.00
Rate for Payer: University Health Alliance Commercial	$24.78

OPTH:SUTURE PROLENE 9-0 STC-9

Facility

$532.00

Hospital Charge Code	8274322
Hospital Revenue Code	272
Min. Negotiated Rate	$266.00
Max. Negotiated Rate	$516.04
Rate for Payer: AlohaCare Medicaid	$266.00
Rate for Payer: AlohaCare Medicare	$266.00
Rate for Payer: Cash Price	$345.80
Rate for Payer: Devoted Health Medicare	$292.60
Rate for Payer: Hawaii Medical Service Association Medicare	$266.00
Rate for Payer: Hawaii Western Management Group Commercial	$505.40
Rate for Payer: Health Management Network Commercial	$452.20
Rate for Payer: Humana Medicare	$266.00
Rate for Payer: Kaiser Permanente Commercial	$478.80
Rate for Payer: Kaiser Permanente Medicaid	$271.32
Rate for Payer: Kaiser Permanente Medicare	$266.00
Rate for Payer: MDX Hawaii PPO	$516.04
Rate for Payer: Ohana Health Plan Medicaid	$266.00
Rate for Payer: Ohana Health Plan Medicare	$266.00
Rate for Payer: UnitedHealthcare Medicare	$266.00
Rate for Payer: University Health Alliance Commercial	$387.77

OPTH:SUTURE PROLENE 9-0 STC-9

Facility

$532.00

Hospital Charge Code	8274322
Hospital Revenue Code	272
Min. Negotiated Rate	$452.20
Max. Negotiated Rate	$516.04
Rate for Payer: Cash Price	$345.80
Rate for Payer: Health Management Network Commercial	$452.20
Rate for Payer: Kaiser Permanente Commercial	$478.80
Rate for Payer: MDX Hawaii PPO	$516.04

OPTH:SUTURE SOFSILK 6-0 HE-7

Facility

$49.00

Hospital Charge Code	8274323
Hospital Revenue Code	272
Min. Negotiated Rate	$41.65
Max. Negotiated Rate	$47.53
Rate for Payer: Cash Price	$31.85
Rate for Payer: Health Management Network Commercial	$41.65
Rate for Payer: Kaiser Permanente Commercial	$44.10
Rate for Payer: MDX Hawaii PPO	$47.53

OPTH:SUTURE SOFSILK 6-0 HE-7

Facility

$49.00

Hospital Charge Code	8274323
Hospital Revenue Code	272
Min. Negotiated Rate	$24.50
Max. Negotiated Rate	$47.53
Rate for Payer: AlohaCare Medicaid	$24.50
Rate for Payer: AlohaCare Medicare	$24.50
Rate for Payer: Cash Price	$31.85
Rate for Payer: Devoted Health Medicare	$26.95
Rate for Payer: Hawaii Medical Service Association Medicare	$24.50
Rate for Payer: Hawaii Western Management Group Commercial	$46.55
Rate for Payer: Health Management Network Commercial	$41.65
Rate for Payer: Humana Medicare	$24.50
Rate for Payer: Kaiser Permanente Commercial	$44.10
Rate for Payer: Kaiser Permanente Medicaid	$24.99
Rate for Payer: Kaiser Permanente Medicare	$24.50
Rate for Payer: MDX Hawaii PPO	$47.53
Rate for Payer: Ohana Health Plan Medicaid	$24.50
Rate for Payer: Ohana Health Plan Medicare	$24.50
Rate for Payer: UnitedHealthcare Medicare	$24.50
Rate for Payer: University Health Alliance Commercial	$35.72

OPTH:SUTURE SOFSILK 6-0, SE-140-8 S-1732K

Facility

$118.00

Hospital Charge Code	8274324
Hospital Revenue Code	272
Min. Negotiated Rate	$100.30
Max. Negotiated Rate	$114.46
Rate for Payer: Cash Price	$76.70
Rate for Payer: Health Management Network Commercial	$100.30
Rate for Payer: Kaiser Permanente Commercial	$106.20
Rate for Payer: MDX Hawaii PPO	$114.46

OPTH:SUTURE SOFSILK 6-0, SE-140-8 S-1732K

Facility

$118.00

Hospital Charge Code	8274324
Hospital Revenue Code	272
Min. Negotiated Rate	$59.00
Max. Negotiated Rate	$114.46
Rate for Payer: AlohaCare Medicaid	$59.00
Rate for Payer: AlohaCare Medicare	$59.00
Rate for Payer: Cash Price	$76.70
Rate for Payer: Devoted Health Medicare	$64.90
Rate for Payer: Hawaii Medical Service Association Medicare	$59.00
Rate for Payer: Hawaii Western Management Group Commercial	$112.10
Rate for Payer: Health Management Network Commercial	$100.30
Rate for Payer: Humana Medicare	$59.00
Rate for Payer: Kaiser Permanente Commercial	$106.20
Rate for Payer: Kaiser Permanente Medicaid	$60.18
Rate for Payer: Kaiser Permanente Medicare	$59.00
Rate for Payer: MDX Hawaii PPO	$114.46
Rate for Payer: Ohana Health Plan Medicaid	$59.00
Rate for Payer: Ohana Health Plan Medicare	$59.00
Rate for Payer: UnitedHealthcare Medicare	$59.00
Rate for Payer: University Health Alliance Commercial	$86.01

OPTH:SUTURE SRGPROII 4-0 30 BL CV-23 VP871X-2

Facility

$17.00

Hospital Charge Code	8274382
Hospital Revenue Code	272
Min. Negotiated Rate	$14.45
Max. Negotiated Rate	$16.49
Rate for Payer: Cash Price	$11.05
Rate for Payer: Health Management Network Commercial	$14.45
Rate for Payer: Kaiser Permanente Commercial	$15.30
Rate for Payer: MDX Hawaii PPO	$16.49

OPTH:SUTURE SRGPROII 4-0 30 BL CV-23 VP871X-2

Facility

$17.00

Hospital Charge Code	8274382
Hospital Revenue Code	272
Min. Negotiated Rate	$8.50
Max. Negotiated Rate	$16.49
Rate for Payer: AlohaCare Medicaid	$8.50
Rate for Payer: AlohaCare Medicare	$8.50
Rate for Payer: Cash Price	$11.05
Rate for Payer: Devoted Health Medicare	$9.35
Rate for Payer: Hawaii Medical Service Association Medicare	$8.50
Rate for Payer: Hawaii Western Management Group Commercial	$16.15
Rate for Payer: Health Management Network Commercial	$14.45
Rate for Payer: Humana Medicare	$8.50
Rate for Payer: Kaiser Permanente Commercial	$15.30
Rate for Payer: Kaiser Permanente Medicaid	$8.67
Rate for Payer: Kaiser Permanente Medicare	$8.50
Rate for Payer: MDX Hawaii PPO	$16.49
Rate for Payer: Ohana Health Plan Medicaid	$8.50
Rate for Payer: Ohana Health Plan Medicare	$8.50
Rate for Payer: UnitedHealthcare Medicare	$8.50
Rate for Payer: University Health Alliance Commercial	$12.39

OPTH:SUTURE VICRYL 4-0 RB-1 J214H

Facility

$15.00

Hospital Charge Code	8274374
Hospital Revenue Code	272
Min. Negotiated Rate	$12.75
Max. Negotiated Rate	$14.55
Rate for Payer: Cash Price	$9.75
Rate for Payer: Health Management Network Commercial	$12.75
Rate for Payer: Kaiser Permanente Commercial	$13.50
Rate for Payer: MDX Hawaii PPO	$14.55

OPTH:SUTURE VICRYL 4-0 RB-1 J214H

Facility

$15.00

Hospital Charge Code	8274374
Hospital Revenue Code	272
Min. Negotiated Rate	$7.50
Max. Negotiated Rate	$14.55
Rate for Payer: AlohaCare Medicaid	$7.50
Rate for Payer: AlohaCare Medicare	$7.50
Rate for Payer: Cash Price	$9.75
Rate for Payer: Devoted Health Medicare	$8.25
Rate for Payer: Hawaii Medical Service Association Medicare	$7.50
Rate for Payer: Hawaii Western Management Group Commercial	$14.25
Rate for Payer: Health Management Network Commercial	$12.75
Rate for Payer: Humana Medicare	$7.50
Rate for Payer: Kaiser Permanente Commercial	$13.50
Rate for Payer: Kaiser Permanente Medicaid	$7.65
Rate for Payer: Kaiser Permanente Medicare	$7.50
Rate for Payer: MDX Hawaii PPO	$14.55
Rate for Payer: Ohana Health Plan Medicaid	$7.50
Rate for Payer: Ohana Health Plan Medicare	$7.50
Rate for Payer: UnitedHealthcare Medicare	$7.50
Rate for Payer: University Health Alliance Commercial	$10.93

OPTH:SUTURE VICRYL 6-0 S-29 J556G

Facility

$116.00

Hospital Charge Code	8274326
Hospital Revenue Code	272
Min. Negotiated Rate	$58.00
Max. Negotiated Rate	$112.52
Rate for Payer: AlohaCare Medicaid	$58.00
Rate for Payer: AlohaCare Medicare	$58.00
Rate for Payer: Cash Price	$75.40
Rate for Payer: Devoted Health Medicare	$63.80
Rate for Payer: Hawaii Medical Service Association Medicare	$58.00
Rate for Payer: Hawaii Western Management Group Commercial	$110.20
Rate for Payer: Health Management Network Commercial	$98.60
Rate for Payer: Humana Medicare	$58.00
Rate for Payer: Kaiser Permanente Commercial	$104.40
Rate for Payer: Kaiser Permanente Medicaid	$59.16
Rate for Payer: Kaiser Permanente Medicare	$58.00
Rate for Payer: MDX Hawaii PPO	$112.52
Rate for Payer: Ohana Health Plan Medicaid	$58.00
Rate for Payer: Ohana Health Plan Medicare	$58.00
Rate for Payer: UnitedHealthcare Medicare	$58.00
Rate for Payer: University Health Alliance Commercial	$84.55

OPTH:SUTURE VICRYL 6-0 S-29 J556G

Facility

$116.00

Hospital Charge Code	8274326
Hospital Revenue Code	272
Min. Negotiated Rate	$98.60
Max. Negotiated Rate	$112.52
Rate for Payer: Cash Price	$75.40
Rate for Payer: Health Management Network Commercial	$98.60
Rate for Payer: Kaiser Permanente Commercial	$104.40
Rate for Payer: MDX Hawaii PPO	$112.52

OPTH:SUTURE VICRYL 8-0 TG148-8

Facility

$131.00

Hospital Charge Code	8274327
Hospital Revenue Code	272
Min. Negotiated Rate	$65.50
Max. Negotiated Rate	$127.07
Rate for Payer: AlohaCare Medicaid	$65.50
Rate for Payer: AlohaCare Medicare	$65.50
Rate for Payer: Cash Price	$85.15
Rate for Payer: Devoted Health Medicare	$72.05
Rate for Payer: Hawaii Medical Service Association Medicare	$65.50
Rate for Payer: Hawaii Western Management Group Commercial	$124.45
Rate for Payer: Health Management Network Commercial	$111.35
Rate for Payer: Humana Medicare	$65.50
Rate for Payer: Kaiser Permanente Commercial	$117.90
Rate for Payer: Kaiser Permanente Medicaid	$66.81
Rate for Payer: Kaiser Permanente Medicare	$65.50
Rate for Payer: MDX Hawaii PPO	$127.07
Rate for Payer: Ohana Health Plan Medicaid	$65.50
Rate for Payer: Ohana Health Plan Medicare	$65.50
Rate for Payer: UnitedHealthcare Medicare	$65.50
Rate for Payer: University Health Alliance Commercial	$95.49

OPTH:SUTURE VICRYL 8-0 TG148-8

Facility

$131.00

Hospital Charge Code	8274327
Hospital Revenue Code	272
Min. Negotiated Rate	$111.35
Max. Negotiated Rate	$127.07
Rate for Payer: Cash Price	$85.15
Rate for Payer: Health Management Network Commercial	$111.35
Rate for Payer: Kaiser Permanente Commercial	$117.90
Rate for Payer: MDX Hawaii PPO	$127.07

OPTH:SUTURE VICRYL 9-0, CS140-6 V950G

Facility

$113.00

Hospital Charge Code	8274353
Hospital Revenue Code	272
Min. Negotiated Rate	$96.05
Max. Negotiated Rate	$109.61
Rate for Payer: Cash Price	$73.45
Rate for Payer: Health Management Network Commercial	$96.05
Rate for Payer: Kaiser Permanente Commercial	$101.70
Rate for Payer: MDX Hawaii PPO	$109.61

OPTH:SUTURE VICRYL 9-0, CS140-6 V950G

Facility

$113.00

Hospital Charge Code	8274353
Hospital Revenue Code	272
Min. Negotiated Rate	$56.50
Max. Negotiated Rate	$109.61
Rate for Payer: AlohaCare Medicaid	$56.50
Rate for Payer: AlohaCare Medicare	$56.50
Rate for Payer: Cash Price	$73.45
Rate for Payer: Devoted Health Medicare	$62.15
Rate for Payer: Hawaii Medical Service Association Medicare	$56.50
Rate for Payer: Hawaii Western Management Group Commercial	$107.35
Rate for Payer: Health Management Network Commercial	$96.05
Rate for Payer: Humana Medicare	$56.50
Rate for Payer: Kaiser Permanente Commercial	$101.70
Rate for Payer: Kaiser Permanente Medicaid	$57.63
Rate for Payer: Kaiser Permanente Medicare	$56.50
Rate for Payer: MDX Hawaii PPO	$109.61
Rate for Payer: Ohana Health Plan Medicaid	$56.50
Rate for Payer: Ohana Health Plan Medicare	$56.50
Rate for Payer: UnitedHealthcare Medicare	$56.50
Rate for Payer: University Health Alliance Commercial	$82.37

OPTH:SYNERGY DFR00V

Facility

$2,985.00

Service Code	HCPCS V2630
Hospital Charge Code	9909053
Hospital Revenue Code	276
Min. Negotiated Rate	$197.46
Max. Negotiated Rate	$2,895.45
Rate for Payer: AlohaCare Medicaid	$342.00
Rate for Payer: AlohaCare Medicare	$1,492.50
Rate for Payer: Cash Price	$1,940.25
Rate for Payer: Cash Price	$1,940.25
Rate for Payer: Cash Price	$1,940.25
Rate for Payer: Devoted Health Medicare	$1,641.75
Rate for Payer: Hawaii Medical Service Association Medicare	$1,492.50
Rate for Payer: Hawaii Western Management Group Commercial	$2,089.50
Rate for Payer: Health Management Network Commercial	$2,537.25
Rate for Payer: Humana Medicare	$1,492.50
Rate for Payer: Kaiser Permanente Commercial	$2,686.50
Rate for Payer: Kaiser Permanente Medicaid	$1,522.35
Rate for Payer: Kaiser Permanente Medicare	$1,492.50
Rate for Payer: MDX Hawaii PPO	$2,895.45
Rate for Payer: Ohana Health Plan Medicaid	$1,492.50
Rate for Payer: Ohana Health Plan Medicare	$1,492.50
Rate for Payer: UnitedHealthcare Medicaid	$197.46
Rate for Payer: UnitedHealthcare Medicare	$1,492.50
Rate for Payer: University Health Alliance Commercial	$1,671.60

OPTH:SYNERGY DFR00V

Facility

$2,985.00

Service Code	HCPCS V2630
Hospital Charge Code	9909053
Hospital Revenue Code	276
Min. Negotiated Rate	$1,671.60
Max. Negotiated Rate	$2,895.45
Rate for Payer: Cash Price	$1,940.25
Rate for Payer: Hawaii Western Management Group Commercial	$2,089.50
Rate for Payer: Health Management Network Commercial	$2,537.25
Rate for Payer: Kaiser Permanente Commercial	$2,686.50
Rate for Payer: MDX Hawaii PPO	$2,895.45
Rate for Payer: University Health Alliance Commercial	$1,671.60

OPTH:SYNERGY TORIC DFW150

Facility

$2,985.00

Service Code	HCPCS V2630
Hospital Charge Code	9909054
Hospital Revenue Code	276
Min. Negotiated Rate	$1,671.60
Max. Negotiated Rate	$2,895.45
Rate for Payer: Cash Price	$1,940.25
Rate for Payer: Hawaii Western Management Group Commercial	$2,089.50
Rate for Payer: Health Management Network Commercial	$2,537.25
Rate for Payer: Kaiser Permanente Commercial	$2,686.50
Rate for Payer: MDX Hawaii PPO	$2,895.45
Rate for Payer: University Health Alliance Commercial	$1,671.60

OPTH:SYNERGY TORIC DFW150

Facility

$2,985.00

Service Code	HCPCS V2630
Hospital Charge Code	9909054
Hospital Revenue Code	276
Min. Negotiated Rate	$197.46
Max. Negotiated Rate	$2,895.45
Rate for Payer: AlohaCare Medicaid	$342.00
Rate for Payer: AlohaCare Medicare	$1,492.50
Rate for Payer: Cash Price	$1,940.25
Rate for Payer: Cash Price	$1,940.25
Rate for Payer: Cash Price	$1,940.25
Rate for Payer: Devoted Health Medicare	$1,641.75
Rate for Payer: Hawaii Medical Service Association Medicare	$1,492.50
Rate for Payer: Hawaii Western Management Group Commercial	$2,089.50
Rate for Payer: Health Management Network Commercial	$2,537.25
Rate for Payer: Humana Medicare	$1,492.50
Rate for Payer: Kaiser Permanente Commercial	$2,686.50
Rate for Payer: Kaiser Permanente Medicaid	$1,522.35
Rate for Payer: Kaiser Permanente Medicare	$1,492.50
Rate for Payer: MDX Hawaii PPO	$2,895.45
Rate for Payer: Ohana Health Plan Medicaid	$1,492.50
Rate for Payer: Ohana Health Plan Medicare	$1,492.50
Rate for Payer: UnitedHealthcare Medicaid	$197.46
Rate for Payer: UnitedHealthcare Medicare	$1,492.50
Rate for Payer: University Health Alliance Commercial	$1,671.60

OPTH:SYNERGY TORIC DFW225

Facility

$2,985.00

Service Code	HCPCS V2630
Hospital Charge Code	9909082
Hospital Revenue Code	276
Min. Negotiated Rate	$197.46
Max. Negotiated Rate	$2,895.45
Rate for Payer: AlohaCare Medicaid	$342.00
Rate for Payer: AlohaCare Medicare	$1,492.50
Rate for Payer: Cash Price	$1,940.25
Rate for Payer: Cash Price	$1,940.25
Rate for Payer: Cash Price	$1,940.25
Rate for Payer: Devoted Health Medicare	$1,641.75
Rate for Payer: Hawaii Medical Service Association Medicare	$1,492.50
Rate for Payer: Hawaii Western Management Group Commercial	$2,089.50
Rate for Payer: Health Management Network Commercial	$2,537.25
Rate for Payer: Humana Medicare	$1,492.50
Rate for Payer: Kaiser Permanente Commercial	$2,686.50
Rate for Payer: Kaiser Permanente Medicaid	$1,522.35
Rate for Payer: Kaiser Permanente Medicare	$1,492.50
Rate for Payer: MDX Hawaii PPO	$2,895.45
Rate for Payer: Ohana Health Plan Medicaid	$1,492.50
Rate for Payer: Ohana Health Plan Medicare	$1,492.50
Rate for Payer: UnitedHealthcare Medicaid	$197.46
Rate for Payer: UnitedHealthcare Medicare	$1,492.50
Rate for Payer: University Health Alliance Commercial	$1,671.60

OPTH:SYNERGY TORIC DFW225

Facility

$2,985.00

Service Code	HCPCS V2630
Hospital Charge Code	9909082
Hospital Revenue Code	276
Min. Negotiated Rate	$1,671.60
Max. Negotiated Rate	$2,895.45
Rate for Payer: Cash Price	$1,940.25
Rate for Payer: Hawaii Western Management Group Commercial	$2,089.50
Rate for Payer: Health Management Network Commercial	$2,537.25
Rate for Payer: Kaiser Permanente Commercial	$2,686.50
Rate for Payer: MDX Hawaii PPO	$2,895.45
Rate for Payer: University Health Alliance Commercial	$1,671.60

Know your out-of-pocket cost for care.

All Charges