Samuel Mahelona Memorial Hospital

All Charges

Charge

Type

Setting

Price

OPTH: CRESCENT KNIFE ANGLED BEVEL UP

Facility

$153.00

Hospital Charge Code	8274246
Hospital Revenue Code	272
Min. Negotiated Rate	$130.05
Max. Negotiated Rate	$148.41
Rate for Payer: Cash Price	$99.45
Rate for Payer: Health Management Network Commercial	$130.05
Rate for Payer: Kaiser Permanente Commercial	$137.70
Rate for Payer: MDX Hawaii PPO	$148.41

OPTH: CRESCENT KNIFE ANGLED BEVEL UP

Facility

$153.00

Hospital Charge Code	8274246
Hospital Revenue Code	272
Min. Negotiated Rate	$76.50
Max. Negotiated Rate	$148.41
Rate for Payer: AlohaCare Medicaid	$76.50
Rate for Payer: AlohaCare Medicare	$76.50
Rate for Payer: Cash Price	$99.45
Rate for Payer: Devoted Health Medicare	$84.15
Rate for Payer: Hawaii Medical Service Association Medicare	$76.50
Rate for Payer: Hawaii Western Management Group Commercial	$145.35
Rate for Payer: Health Management Network Commercial	$130.05
Rate for Payer: Humana Medicare	$76.50
Rate for Payer: Kaiser Permanente Commercial	$137.70
Rate for Payer: Kaiser Permanente Medicaid	$78.03
Rate for Payer: Kaiser Permanente Medicare	$76.50
Rate for Payer: MDX Hawaii PPO	$148.41
Rate for Payer: Ohana Health Plan Medicaid	$76.50
Rate for Payer: Ohana Health Plan Medicare	$76.50
Rate for Payer: UnitedHealthcare Medicare	$76.50
Rate for Payer: University Health Alliance Commercial	$111.52

OPTH:CYSTITOME 25G FORMED

Facility

$49.00

Hospital Charge Code	8274282
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:CYSTITOME 25G FORMED

Facility

$49.00

Hospital Charge Code	8274282
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: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: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: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 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	$291.00
Rate for Payer: AlohaCare Medicare	$291.00
Rate for Payer: Cash Price	$378.30
Rate for Payer: Cash Price	$378.30
Rate for Payer: 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 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	$892.50
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: 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 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 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	$892.50
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: 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	$197.46
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: 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 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	$892.50
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: 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 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	$892.50
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: 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	$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: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: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: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

Know your out-of-pocket cost for care.

All Charges