Samuel Mahelona Memorial Hospital

All Charges

Charge

Type

Setting

Price

OPTH ANGLED MICRO-NEEDLE ELECTRODE E1653

Facility

$130.00

Hospital Charge Code	9024307
Hospital Revenue Code	272
Min. Negotiated Rate	$110.50
Max. Negotiated Rate	$126.10
Rate for Payer: Cash Price	$84.50
Rate for Payer: Health Management Network Commercial	$110.50
Rate for Payer: Kaiser Permanente Commercial	$117.00
Rate for Payer: MDX Hawaii PPO	$126.10

OPTH: ANTERIOR CHAMBER CANNULA 27G

Facility

$52.00

Hospital Charge Code	9024305
Hospital Revenue Code	272
Min. Negotiated Rate	$44.20
Max. Negotiated Rate	$50.44
Rate for Payer: Cash Price	$33.80
Rate for Payer: Health Management Network Commercial	$44.20
Rate for Payer: Kaiser Permanente Commercial	$46.80
Rate for Payer: MDX Hawaii PPO	$50.44

OPTH: ANTERIOR CHAMBER CANNULA 27G

Facility

$52.00

Hospital Charge Code	9024305
Hospital Revenue Code	272
Min. Negotiated Rate	$26.00
Max. Negotiated Rate	$50.44
Rate for Payer: AlohaCare Medicaid	$26.00
Rate for Payer: AlohaCare Medicare	$26.00
Rate for Payer: Cash Price	$33.80
Rate for Payer: Devoted Health Medicare	$28.60
Rate for Payer: Hawaii Medical Service Association Medicare	$26.00
Rate for Payer: Hawaii Western Management Group Commercial	$49.40
Rate for Payer: Health Management Network Commercial	$44.20
Rate for Payer: Humana Medicare	$26.00
Rate for Payer: Kaiser Permanente Commercial	$46.80
Rate for Payer: Kaiser Permanente Medicaid	$26.52
Rate for Payer: Kaiser Permanente Medicare	$26.00
Rate for Payer: MDX Hawaii PPO	$50.44
Rate for Payer: Ohana Health Plan Medicaid	$26.00
Rate for Payer: Ohana Health Plan Medicare	$26.00
Rate for Payer: UnitedHealthcare Medicare	$26.00
Rate for Payer: University Health Alliance Commercial	$37.90

OPTH:ARTISS FROZEN ADHESIVE

Facility

$919.00

Service Code	HCPCS C9250
Hospital Charge Code	10598169
Hospital Revenue Code	636
Min. Negotiated Rate	$781.15
Max. Negotiated Rate	$891.43
Rate for Payer: Cash Price	$597.35
Rate for Payer: Health Management Network Commercial	$781.15
Rate for Payer: Kaiser Permanente Commercial	$827.10
Rate for Payer: MDX Hawaii PPO	$891.43

OPTH:ARTISS FROZEN ADHESIVE

Facility

$919.00

Service Code	HCPCS C9250
Hospital Charge Code	10598169
Hospital Revenue Code	636
Min. Negotiated Rate	$179.62
Max. Negotiated Rate	$891.43
Rate for Payer: AlohaCare Medicaid	$459.50
Rate for Payer: AlohaCare Medicare	$459.50
Rate for Payer: Cash Price	$597.35
Rate for Payer: Cash Price	$597.35
Rate for Payer: Devoted Health Medicare	$505.45
Rate for Payer: Hawaii Medical Service Association Commercial	$179.62
Rate for Payer: Hawaii Medical Service Association Medicare	$459.50
Rate for Payer: Hawaii Western Management Group Commercial	$873.05
Rate for Payer: Health Management Network Commercial	$781.15
Rate for Payer: Humana Medicare	$459.50
Rate for Payer: Kaiser Permanente Commercial	$827.10
Rate for Payer: Kaiser Permanente Medicaid	$468.69
Rate for Payer: Kaiser Permanente Medicare	$459.50
Rate for Payer: MDX Hawaii PPO	$891.43
Rate for Payer: Ohana Health Plan Medicaid	$459.50
Rate for Payer: Ohana Health Plan Medicare	$459.50
Rate for Payer: UnitedHealthcare Medicaid	$551.40
Rate for Payer: UnitedHealthcare Medicare	$459.50
Rate for Payer: University Health Alliance Commercial	$514.64

OPTH:CAPSULAR TENSION RING

Facility

$832.00

Hospital Charge Code	8274163
Hospital Revenue Code	272
Min. Negotiated Rate	$707.20
Max. Negotiated Rate	$807.04
Rate for Payer: Cash Price	$540.80
Rate for Payer: Health Management Network Commercial	$707.20
Rate for Payer: Kaiser Permanente Commercial	$748.80
Rate for Payer: MDX Hawaii PPO	$807.04

OPTH:CAPSULAR TENSION RING

Facility

$832.00

Hospital Charge Code	8274163
Hospital Revenue Code	272
Min. Negotiated Rate	$416.00
Max. Negotiated Rate	$807.04
Rate for Payer: AlohaCare Medicaid	$416.00
Rate for Payer: AlohaCare Medicare	$416.00
Rate for Payer: Cash Price	$540.80
Rate for Payer: Devoted Health Medicare	$457.60
Rate for Payer: Hawaii Medical Service Association Medicare	$416.00
Rate for Payer: Hawaii Western Management Group Commercial	$790.40
Rate for Payer: Health Management Network Commercial	$707.20
Rate for Payer: Humana Medicare	$416.00
Rate for Payer: Kaiser Permanente Commercial	$748.80
Rate for Payer: Kaiser Permanente Medicaid	$424.32
Rate for Payer: Kaiser Permanente Medicare	$416.00
Rate for Payer: MDX Hawaii PPO	$807.04
Rate for Payer: Ohana Health Plan Medicaid	$416.00
Rate for Payer: Ohana Health Plan Medicare	$416.00
Rate for Payer: UnitedHealthcare Medicare	$416.00
Rate for Payer: University Health Alliance Commercial	$606.44

OPTH:CAPSULAR TENSION RING CTR10L

Facility

$563.00

Service Code	HCPCS L8610
Hospital Charge Code	10558757
Hospital Revenue Code	272
Min. Negotiated Rate	$44.09
Max. Negotiated Rate	$546.11
Rate for Payer: AlohaCare Medicaid	$281.50
Rate for Payer: AlohaCare Medicare	$281.50
Rate for Payer: Cash Price	$365.95
Rate for Payer: Cash Price	$365.95
Rate for Payer: Devoted Health Medicare	$309.65
Rate for Payer: Hawaii Medical Service Association Medicare	$281.50
Rate for Payer: Hawaii Western Management Group Commercial	$534.85
Rate for Payer: Health Management Network Commercial	$478.55
Rate for Payer: Humana Medicare	$281.50
Rate for Payer: Kaiser Permanente Commercial	$506.70
Rate for Payer: Kaiser Permanente Medicaid	$287.13
Rate for Payer: Kaiser Permanente Medicare	$281.50
Rate for Payer: MDX Hawaii PPO	$546.11
Rate for Payer: Ohana Health Plan Medicaid	$281.50
Rate for Payer: Ohana Health Plan Medicare	$281.50
Rate for Payer: UnitedHealthcare Medicaid	$44.09
Rate for Payer: UnitedHealthcare Medicare	$281.50
Rate for Payer: University Health Alliance Commercial	$410.37

OPTH:CAPSULAR TENSION RING CTR10L

Facility

$563.00

Service Code	HCPCS L8610
Hospital Charge Code	10558757
Hospital Revenue Code	272
Min. Negotiated Rate	$478.55
Max. Negotiated Rate	$546.11
Rate for Payer: Cash Price	$365.95
Rate for Payer: Health Management Network Commercial	$478.55
Rate for Payer: Kaiser Permanente Commercial	$506.70
Rate for Payer: MDX Hawaii PPO	$546.11

OPTH:CAPSULAR TENSION RING CTR10R

Facility

$450.00

Service Code	HCPCS L8610
Hospital Charge Code	10558756
Hospital Revenue Code	272
Min. Negotiated Rate	$382.50
Max. Negotiated Rate	$436.50
Rate for Payer: Cash Price	$292.50
Rate for Payer: Health Management Network Commercial	$382.50
Rate for Payer: Kaiser Permanente Commercial	$405.00
Rate for Payer: MDX Hawaii PPO	$436.50

OPTH:CAPSULAR TENSION RING CTR10R

Facility

$450.00

Service Code	HCPCS L8610
Hospital Charge Code	10558756
Hospital Revenue Code	272
Min. Negotiated Rate	$44.09
Max. Negotiated Rate	$436.50
Rate for Payer: AlohaCare Medicaid	$225.00
Rate for Payer: AlohaCare Medicare	$225.00
Rate for Payer: Cash Price	$292.50
Rate for Payer: Cash Price	$292.50
Rate for Payer: Devoted Health Medicare	$247.50
Rate for Payer: Hawaii Medical Service Association Medicare	$225.00
Rate for Payer: Hawaii Western Management Group Commercial	$427.50
Rate for Payer: Health Management Network Commercial	$382.50
Rate for Payer: Humana Medicare	$225.00
Rate for Payer: Kaiser Permanente Commercial	$405.00
Rate for Payer: Kaiser Permanente Medicaid	$229.50
Rate for Payer: Kaiser Permanente Medicare	$225.00
Rate for Payer: MDX Hawaii PPO	$436.50
Rate for Payer: Ohana Health Plan Medicaid	$225.00
Rate for Payer: Ohana Health Plan Medicare	$225.00
Rate for Payer: UnitedHealthcare Medicaid	$44.09
Rate for Payer: UnitedHealthcare Medicare	$225.00
Rate for Payer: University Health Alliance Commercial	$328.00

OPTH:CARTRIDGES, MONARCH II, CARTRIDGE B

Facility

$133.00

Hospital Charge Code	8274278
Hospital Revenue Code	272
Min. Negotiated Rate	$66.50
Max. Negotiated Rate	$129.01
Rate for Payer: AlohaCare Medicaid	$66.50
Rate for Payer: AlohaCare Medicare	$66.50
Rate for Payer: Cash Price	$86.45
Rate for Payer: Devoted Health Medicare	$73.15
Rate for Payer: Hawaii Medical Service Association Medicare	$66.50
Rate for Payer: Hawaii Western Management Group Commercial	$126.35
Rate for Payer: Health Management Network Commercial	$113.05
Rate for Payer: Humana Medicare	$66.50
Rate for Payer: Kaiser Permanente Commercial	$119.70
Rate for Payer: Kaiser Permanente Medicaid	$67.83
Rate for Payer: Kaiser Permanente Medicare	$66.50
Rate for Payer: MDX Hawaii PPO	$129.01
Rate for Payer: Ohana Health Plan Medicaid	$66.50
Rate for Payer: Ohana Health Plan Medicare	$66.50
Rate for Payer: UnitedHealthcare Medicare	$66.50
Rate for Payer: University Health Alliance Commercial	$96.94

OPTH:CARTRIDGES, MONARCH II, CARTRIDGE B

Facility

$133.00

Hospital Charge Code	8274278
Hospital Revenue Code	272
Min. Negotiated Rate	$113.05
Max. Negotiated Rate	$129.01
Rate for Payer: Cash Price	$86.45
Rate for Payer: Health Management Network Commercial	$113.05
Rate for Payer: Kaiser Permanente Commercial	$119.70
Rate for Payer: MDX Hawaii PPO	$129.01

OPTH:CARTRIDGES, MONARCH III, CARTRIDGE C

Facility

$133.00

Hospital Charge Code	8274279
Hospital Revenue Code	272
Min. Negotiated Rate	$66.50
Max. Negotiated Rate	$129.01
Rate for Payer: AlohaCare Medicaid	$66.50
Rate for Payer: AlohaCare Medicare	$66.50
Rate for Payer: Cash Price	$86.45
Rate for Payer: Devoted Health Medicare	$73.15
Rate for Payer: Hawaii Medical Service Association Medicare	$66.50
Rate for Payer: Hawaii Western Management Group Commercial	$126.35
Rate for Payer: Health Management Network Commercial	$113.05
Rate for Payer: Humana Medicare	$66.50
Rate for Payer: Kaiser Permanente Commercial	$119.70
Rate for Payer: Kaiser Permanente Medicaid	$67.83
Rate for Payer: Kaiser Permanente Medicare	$66.50
Rate for Payer: MDX Hawaii PPO	$129.01
Rate for Payer: Ohana Health Plan Medicaid	$66.50
Rate for Payer: Ohana Health Plan Medicare	$66.50
Rate for Payer: UnitedHealthcare Medicare	$66.50
Rate for Payer: University Health Alliance Commercial	$96.94

OPTH:CARTRIDGES, MONARCH III, CARTRIDGE C

Facility

$133.00

Hospital Charge Code	8274279
Hospital Revenue Code	272
Min. Negotiated Rate	$113.05
Max. Negotiated Rate	$129.01
Rate for Payer: Cash Price	$86.45
Rate for Payer: Health Management Network Commercial	$113.05
Rate for Payer: Kaiser Permanente Commercial	$119.70
Rate for Payer: MDX Hawaii PPO	$129.01

OPTH:CARTRIDGES, MONARCH III, CARTRIDGE D

Facility

$133.00

Hospital Charge Code	8274280
Hospital Revenue Code	272
Min. Negotiated Rate	$66.50
Max. Negotiated Rate	$129.01
Rate for Payer: AlohaCare Medicaid	$66.50
Rate for Payer: AlohaCare Medicare	$66.50
Rate for Payer: Cash Price	$86.45
Rate for Payer: Devoted Health Medicare	$73.15
Rate for Payer: Hawaii Medical Service Association Medicare	$66.50
Rate for Payer: Hawaii Western Management Group Commercial	$126.35
Rate for Payer: Health Management Network Commercial	$113.05
Rate for Payer: Humana Medicare	$66.50
Rate for Payer: Kaiser Permanente Commercial	$119.70
Rate for Payer: Kaiser Permanente Medicaid	$67.83
Rate for Payer: Kaiser Permanente Medicare	$66.50
Rate for Payer: MDX Hawaii PPO	$129.01
Rate for Payer: Ohana Health Plan Medicaid	$66.50
Rate for Payer: Ohana Health Plan Medicare	$66.50
Rate for Payer: UnitedHealthcare Medicare	$66.50
Rate for Payer: University Health Alliance Commercial	$96.94

OPTH:CARTRIDGES, MONARCH III, CARTRIDGE D

Facility

$133.00

Hospital Charge Code	8274280
Hospital Revenue Code	272
Min. Negotiated Rate	$113.05
Max. Negotiated Rate	$129.01
Rate for Payer: Cash Price	$86.45
Rate for Payer: Health Management Network Commercial	$113.05
Rate for Payer: Kaiser Permanente Commercial	$119.70
Rate for Payer: MDX Hawaii PPO	$129.01

OPTH:CAUTERY; BIPOLAR CORD DISPOSABLE

Facility

$171.00

Hospital Charge Code	8274438
Hospital Revenue Code	272
Min. Negotiated Rate	$145.35
Max. Negotiated Rate	$165.87
Rate for Payer: Cash Price	$111.15
Rate for Payer: Health Management Network Commercial	$145.35
Rate for Payer: Kaiser Permanente Commercial	$153.90
Rate for Payer: MDX Hawaii PPO	$165.87

OPTH:CAUTERY; BIPOLAR CORD DISPOSABLE

Facility

$171.00

Hospital Charge Code	8274438
Hospital Revenue Code	272
Min. Negotiated Rate	$85.50
Max. Negotiated Rate	$165.87
Rate for Payer: AlohaCare Medicaid	$85.50
Rate for Payer: AlohaCare Medicare	$85.50
Rate for Payer: Cash Price	$111.15
Rate for Payer: Devoted Health Medicare	$94.05
Rate for Payer: Hawaii Medical Service Association Medicare	$85.50
Rate for Payer: Hawaii Western Management Group Commercial	$162.45
Rate for Payer: Health Management Network Commercial	$145.35
Rate for Payer: Humana Medicare	$85.50
Rate for Payer: Kaiser Permanente Commercial	$153.90
Rate for Payer: Kaiser Permanente Medicaid	$87.21
Rate for Payer: Kaiser Permanente Medicare	$85.50
Rate for Payer: MDX Hawaii PPO	$165.87
Rate for Payer: Ohana Health Plan Medicaid	$85.50
Rate for Payer: Ohana Health Plan Medicare	$85.50
Rate for Payer: UnitedHealthcare Medicare	$85.50
Rate for Payer: University Health Alliance Commercial	$124.64

OPTH CAUTERY WET FIELD BRUSH

Facility

$77.00

Hospital Charge Code	8274281
Hospital Revenue Code	272
Min. Negotiated Rate	$38.50
Max. Negotiated Rate	$74.69
Rate for Payer: AlohaCare Medicaid	$38.50
Rate for Payer: AlohaCare Medicare	$38.50
Rate for Payer: Cash Price	$50.05
Rate for Payer: Devoted Health Medicare	$42.35
Rate for Payer: Hawaii Medical Service Association Medicare	$38.50
Rate for Payer: Hawaii Western Management Group Commercial	$73.15
Rate for Payer: Health Management Network Commercial	$65.45
Rate for Payer: Humana Medicare	$38.50
Rate for Payer: Kaiser Permanente Commercial	$69.30
Rate for Payer: Kaiser Permanente Medicaid	$39.27
Rate for Payer: Kaiser Permanente Medicare	$38.50
Rate for Payer: MDX Hawaii PPO	$74.69
Rate for Payer: Ohana Health Plan Medicaid	$38.50
Rate for Payer: Ohana Health Plan Medicare	$38.50
Rate for Payer: UnitedHealthcare Medicare	$38.50
Rate for Payer: University Health Alliance Commercial	$56.13

OPTH CAUTERY WET FIELD BRUSH

Facility

$77.00

Hospital Charge Code	8274281
Hospital Revenue Code	272
Min. Negotiated Rate	$65.45
Max. Negotiated Rate	$74.69
Rate for Payer: Cash Price	$50.05
Rate for Payer: Health Management Network Commercial	$65.45
Rate for Payer: Kaiser Permanente Commercial	$69.30
Rate for Payer: MDX Hawaii PPO	$74.69

OPTH:CORNEAL VACUUM BLADE TREPHINE 7.25 MM

Facility

$312.00

Hospital Charge Code	8274182
Hospital Revenue Code	272
Min. Negotiated Rate	$265.20
Max. Negotiated Rate	$302.64
Rate for Payer: Cash Price	$202.80
Rate for Payer: Health Management Network Commercial	$265.20
Rate for Payer: Kaiser Permanente Commercial	$280.80
Rate for Payer: MDX Hawaii PPO	$302.64

OPTH:CORNEAL VACUUM BLADE TREPHINE 7.25 MM

Facility

$312.00

Hospital Charge Code	8274182
Hospital Revenue Code	272
Min. Negotiated Rate	$156.00
Max. Negotiated Rate	$302.64
Rate for Payer: AlohaCare Medicaid	$156.00
Rate for Payer: AlohaCare Medicare	$156.00
Rate for Payer: Cash Price	$202.80
Rate for Payer: Devoted Health Medicare	$171.60
Rate for Payer: Hawaii Medical Service Association Medicare	$156.00
Rate for Payer: Hawaii Western Management Group Commercial	$296.40
Rate for Payer: Health Management Network Commercial	$265.20
Rate for Payer: Humana Medicare	$156.00
Rate for Payer: Kaiser Permanente Commercial	$280.80
Rate for Payer: Kaiser Permanente Medicaid	$159.12
Rate for Payer: Kaiser Permanente Medicare	$156.00
Rate for Payer: MDX Hawaii PPO	$302.64
Rate for Payer: Ohana Health Plan Medicaid	$156.00
Rate for Payer: Ohana Health Plan Medicare	$156.00
Rate for Payer: UnitedHealthcare Medicare	$156.00
Rate for Payer: University Health Alliance Commercial	$227.42

OPTH:CORNEAL VACUUM TREPHINE 8.0MM

Facility

$332.00

Hospital Charge Code	8274179
Hospital Revenue Code	272
Min. Negotiated Rate	$166.00
Max. Negotiated Rate	$322.04
Rate for Payer: AlohaCare Medicaid	$166.00
Rate for Payer: AlohaCare Medicare	$166.00
Rate for Payer: Cash Price	$215.80
Rate for Payer: Devoted Health Medicare	$182.60
Rate for Payer: Hawaii Medical Service Association Medicare	$166.00
Rate for Payer: Hawaii Western Management Group Commercial	$315.40
Rate for Payer: Health Management Network Commercial	$282.20
Rate for Payer: Humana Medicare	$166.00
Rate for Payer: Kaiser Permanente Commercial	$298.80
Rate for Payer: Kaiser Permanente Medicaid	$169.32
Rate for Payer: Kaiser Permanente Medicare	$166.00
Rate for Payer: MDX Hawaii PPO	$322.04
Rate for Payer: Ohana Health Plan Medicaid	$166.00
Rate for Payer: Ohana Health Plan Medicare	$166.00
Rate for Payer: UnitedHealthcare Medicare	$166.00
Rate for Payer: University Health Alliance Commercial	$241.99

OPTH:CORNEAL VACUUM TREPHINE 8.0MM

Facility

$332.00

Hospital Charge Code	8274179
Hospital Revenue Code	272
Min. Negotiated Rate	$282.20
Max. Negotiated Rate	$322.04
Rate for Payer: Cash Price	$215.80
Rate for Payer: Health Management Network Commercial	$282.20
Rate for Payer: Kaiser Permanente Commercial	$298.80
Rate for Payer: MDX Hawaii PPO	$322.04

Know your out-of-pocket cost for care.

All Charges