Samuel Mahelona Memorial Hospital

All Charges

Charge

Type

Setting

Price

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: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: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:HYDRUS MICROSTENT

Facility

$4,400.00

Service Code	HCPCS C1783
Hospital Charge Code	10309147
Hospital Revenue Code	278
Min. Negotiated Rate	$2,464.00
Max. Negotiated Rate	$4,268.00
Rate for Payer: Cash Price	$2,860.00
Rate for Payer: Hawaii Western Management Group Commercial	$3,080.00
Rate for Payer: Health Management Network Commercial	$3,740.00
Rate for Payer: Kaiser Permanente Commercial	$3,960.00
Rate for Payer: MDX Hawaii PPO	$4,268.00
Rate for Payer: University Health Alliance Commercial	$2,464.00

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

OPTH IMPLANT CORNEA HUMAN

Facility

$7,200.00

Service Code	HCPCS V2785
Hospital Charge Code	8348101
Hospital Revenue Code	278
Min. Negotiated Rate	$4,032.00
Max. Negotiated Rate	$6,984.00
Rate for Payer: Cash Price	$4,680.00
Rate for Payer: Hawaii Western Management Group Commercial	$5,040.00
Rate for Payer: Health Management Network Commercial	$6,120.00
Rate for Payer: Kaiser Permanente Commercial	$6,480.00
Rate for Payer: MDX Hawaii PPO	$6,984.00
Rate for Payer: University Health Alliance Commercial	$4,032.00

OPTH IMPLANT CORNEA HUMAN

Facility

$7,200.00

Service Code	HCPCS V2785
Hospital Charge Code	8348101
Hospital Revenue Code	278
Min. Negotiated Rate	$3,600.00
Max. Negotiated Rate	$6,984.00
Rate for Payer: AlohaCare Medicaid	$3,600.00
Rate for Payer: AlohaCare Medicare	$3,600.00
Rate for Payer: Cash Price	$4,680.00
Rate for Payer: Devoted Health Medicare	$3,960.00
Rate for Payer: Hawaii Medical Service Association Medicare	$3,600.00
Rate for Payer: Hawaii Western Management Group Commercial	$5,040.00
Rate for Payer: Health Management Network Commercial	$6,120.00
Rate for Payer: Humana Medicare	$3,600.00
Rate for Payer: Kaiser Permanente Commercial	$6,480.00
Rate for Payer: Kaiser Permanente Medicaid	$3,672.00
Rate for Payer: Kaiser Permanente Medicare	$3,600.00
Rate for Payer: MDX Hawaii PPO	$6,984.00
Rate for Payer: Ohana Health Plan Medicaid	$3,600.00
Rate for Payer: Ohana Health Plan Medicare	$3,600.00
Rate for Payer: UnitedHealthcare Medicare	$3,600.00
Rate for Payer: University Health Alliance Commercial	$4,032.00

OPTH IMPLANT enVISTA ASPIRE

Facility

$469.00

Service Code	HCPCS V2787
Hospital Charge Code	13156194
Hospital Revenue Code	276
Min. Negotiated Rate	$262.64
Max. Negotiated Rate	$454.93
Rate for Payer: Cash Price	$304.85
Rate for Payer: Hawaii Western Management Group Commercial	$328.30
Rate for Payer: Health Management Network Commercial	$398.65
Rate for Payer: Kaiser Permanente Commercial	$422.10
Rate for Payer: MDX Hawaii PPO	$454.93
Rate for Payer: University Health Alliance Commercial	$262.64

OPTH IMPLANT enVISTA ASPIRE

Facility

$469.00

Service Code	HCPCS V2787
Hospital Charge Code	13156194
Hospital Revenue Code	276
Min. Negotiated Rate	$234.50
Max. Negotiated Rate	$454.93
Rate for Payer: AlohaCare Medicaid	$234.50
Rate for Payer: AlohaCare Medicare	$234.50
Rate for Payer: Cash Price	$304.85
Rate for Payer: Devoted Health Medicare	$257.95
Rate for Payer: Hawaii Medical Service Association Medicare	$234.50
Rate for Payer: Hawaii Western Management Group Commercial	$328.30
Rate for Payer: Health Management Network Commercial	$398.65
Rate for Payer: Humana Medicare	$234.50
Rate for Payer: Kaiser Permanente Commercial	$422.10
Rate for Payer: Kaiser Permanente Medicaid	$239.19
Rate for Payer: Kaiser Permanente Medicare	$234.50
Rate for Payer: MDX Hawaii PPO	$454.93
Rate for Payer: Ohana Health Plan Medicaid	$234.50
Rate for Payer: Ohana Health Plan Medicare	$234.50
Rate for Payer: UnitedHealthcare Medicare	$234.50
Rate for Payer: University Health Alliance Commercial	$262.64

OPTH IMPLANT enVISTA ASPIRE TORIC +1.25D CYL

Facility

$1,575.00

Service Code	HCPCS V2787
Hospital Charge Code	13165753
Hospital Revenue Code	276
Min. Negotiated Rate	$882.00
Max. Negotiated Rate	$1,527.75
Rate for Payer: Cash Price	$1,023.75
Rate for Payer: Hawaii Western Management Group Commercial	$1,102.50
Rate for Payer: Health Management Network Commercial	$1,338.75
Rate for Payer: Kaiser Permanente Commercial	$1,417.50
Rate for Payer: MDX Hawaii PPO	$1,527.75
Rate for Payer: University Health Alliance Commercial	$882.00

OPTH IMPLANT enVISTA ASPIRE TORIC +1.25D CYL

Facility

$1,575.00

Service Code	HCPCS V2787
Hospital Charge Code	13165753
Hospital Revenue Code	276
Min. Negotiated Rate	$787.50
Max. Negotiated Rate	$1,527.75
Rate for Payer: AlohaCare Medicaid	$787.50
Rate for Payer: AlohaCare Medicare	$787.50
Rate for Payer: Cash Price	$1,023.75
Rate for Payer: Devoted Health Medicare	$866.25
Rate for Payer: Hawaii Medical Service Association Medicare	$787.50
Rate for Payer: Hawaii Western Management Group Commercial	$1,102.50
Rate for Payer: Health Management Network Commercial	$1,338.75
Rate for Payer: Humana Medicare	$787.50
Rate for Payer: Kaiser Permanente Commercial	$1,417.50
Rate for Payer: Kaiser Permanente Medicaid	$803.25
Rate for Payer: Kaiser Permanente Medicare	$787.50
Rate for Payer: MDX Hawaii PPO	$1,527.75
Rate for Payer: Ohana Health Plan Medicaid	$787.50
Rate for Payer: Ohana Health Plan Medicare	$787.50
Rate for Payer: UnitedHealthcare Medicare	$787.50
Rate for Payer: University Health Alliance Commercial	$882.00

OPTH IMPLANT enVISTA ASPIRE TORIC +1.50D CYL

Facility

$1,575.00

Service Code	HCPCS V2787
Hospital Charge Code	13165754
Hospital Revenue Code	276
Min. Negotiated Rate	$787.50
Max. Negotiated Rate	$1,527.75
Rate for Payer: AlohaCare Medicaid	$787.50
Rate for Payer: AlohaCare Medicare	$787.50
Rate for Payer: Cash Price	$1,023.75
Rate for Payer: Devoted Health Medicare	$866.25
Rate for Payer: Hawaii Medical Service Association Medicare	$787.50
Rate for Payer: Hawaii Western Management Group Commercial	$1,102.50
Rate for Payer: Health Management Network Commercial	$1,338.75
Rate for Payer: Humana Medicare	$787.50
Rate for Payer: Kaiser Permanente Commercial	$1,417.50
Rate for Payer: Kaiser Permanente Medicaid	$803.25
Rate for Payer: Kaiser Permanente Medicare	$787.50
Rate for Payer: MDX Hawaii PPO	$1,527.75
Rate for Payer: Ohana Health Plan Medicaid	$787.50
Rate for Payer: Ohana Health Plan Medicare	$787.50
Rate for Payer: UnitedHealthcare Medicare	$787.50
Rate for Payer: University Health Alliance Commercial	$882.00

OPTH IMPLANT enVISTA ASPIRE TORIC +1.50D CYL

Facility

$1,575.00

Service Code	HCPCS V2787
Hospital Charge Code	13165754
Hospital Revenue Code	276
Min. Negotiated Rate	$882.00
Max. Negotiated Rate	$1,527.75
Rate for Payer: Cash Price	$1,023.75
Rate for Payer: Hawaii Western Management Group Commercial	$1,102.50
Rate for Payer: Health Management Network Commercial	$1,338.75
Rate for Payer: Kaiser Permanente Commercial	$1,417.50
Rate for Payer: MDX Hawaii PPO	$1,527.75
Rate for Payer: University Health Alliance Commercial	$882.00

OPTH IMPLANT enVISTA ASPIRE TORIC +2.00D CYL

Facility

$1,575.00

Service Code	HCPCS V2787
Hospital Charge Code	13165752
Hospital Revenue Code	276
Min. Negotiated Rate	$882.00
Max. Negotiated Rate	$1,527.75
Rate for Payer: Cash Price	$1,023.75
Rate for Payer: Hawaii Western Management Group Commercial	$1,102.50
Rate for Payer: Health Management Network Commercial	$1,338.75
Rate for Payer: Kaiser Permanente Commercial	$1,417.50
Rate for Payer: MDX Hawaii PPO	$1,527.75
Rate for Payer: University Health Alliance Commercial	$882.00

OPTH IMPLANT enVISTA ASPIRE TORIC +2.00D CYL

Facility

$1,575.00

Service Code	HCPCS V2787
Hospital Charge Code	13165752
Hospital Revenue Code	276
Min. Negotiated Rate	$787.50
Max. Negotiated Rate	$1,527.75
Rate for Payer: AlohaCare Medicaid	$787.50
Rate for Payer: AlohaCare Medicare	$787.50
Rate for Payer: Cash Price	$1,023.75
Rate for Payer: Devoted Health Medicare	$866.25
Rate for Payer: Hawaii Medical Service Association Medicare	$787.50
Rate for Payer: Hawaii Western Management Group Commercial	$1,102.50
Rate for Payer: Health Management Network Commercial	$1,338.75
Rate for Payer: Humana Medicare	$787.50
Rate for Payer: Kaiser Permanente Commercial	$1,417.50
Rate for Payer: Kaiser Permanente Medicaid	$803.25
Rate for Payer: Kaiser Permanente Medicare	$787.50
Rate for Payer: MDX Hawaii PPO	$1,527.75
Rate for Payer: Ohana Health Plan Medicaid	$787.50
Rate for Payer: Ohana Health Plan Medicare	$787.50
Rate for Payer: UnitedHealthcare Medicare	$787.50
Rate for Payer: University Health Alliance Commercial	$882.00

OPTH IMPLANT enVISTA ASPIRE TORIC +4.25D CYL

Facility

$1,575.00

Service Code	HCPCS V2787
Hospital Charge Code	13156193
Hospital Revenue Code	276
Min. Negotiated Rate	$882.00
Max. Negotiated Rate	$1,527.75
Rate for Payer: Cash Price	$1,023.75
Rate for Payer: Hawaii Western Management Group Commercial	$1,102.50
Rate for Payer: Health Management Network Commercial	$1,338.75
Rate for Payer: Kaiser Permanente Commercial	$1,417.50
Rate for Payer: MDX Hawaii PPO	$1,527.75
Rate for Payer: University Health Alliance Commercial	$882.00

OPTH IMPLANT enVISTA ASPIRE TORIC +4.25D CYL

Facility

$1,575.00

Service Code	HCPCS V2787
Hospital Charge Code	13156193
Hospital Revenue Code	276
Min. Negotiated Rate	$787.50
Max. Negotiated Rate	$1,527.75
Rate for Payer: AlohaCare Medicaid	$787.50
Rate for Payer: AlohaCare Medicare	$787.50
Rate for Payer: Cash Price	$1,023.75
Rate for Payer: Devoted Health Medicare	$866.25
Rate for Payer: Hawaii Medical Service Association Medicare	$787.50
Rate for Payer: Hawaii Western Management Group Commercial	$1,102.50
Rate for Payer: Health Management Network Commercial	$1,338.75
Rate for Payer: Humana Medicare	$787.50
Rate for Payer: Kaiser Permanente Commercial	$1,417.50
Rate for Payer: Kaiser Permanente Medicaid	$803.25
Rate for Payer: Kaiser Permanente Medicare	$787.50
Rate for Payer: MDX Hawaii PPO	$1,527.75
Rate for Payer: Ohana Health Plan Medicaid	$787.50
Rate for Payer: Ohana Health Plan Medicare	$787.50
Rate for Payer: UnitedHealthcare Medicare	$787.50
Rate for Payer: University Health Alliance Commercial	$882.00

OPTH IMPLANT enVISTA ENVY

Facility

$2,000.00

Service Code	HCPCS V2787
Hospital Charge Code	13287343
Hospital Revenue Code	276
Min. Negotiated Rate	$1,120.00
Max. Negotiated Rate	$1,940.00
Rate for Payer: Cash Price	$1,300.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,400.00
Rate for Payer: Health Management Network Commercial	$1,700.00
Rate for Payer: Kaiser Permanente Commercial	$1,800.00
Rate for Payer: MDX Hawaii PPO	$1,940.00
Rate for Payer: University Health Alliance Commercial	$1,120.00

OPTH IMPLANT enVISTA ENVY

Facility

$2,000.00

Service Code	HCPCS V2787
Hospital Charge Code	13287343
Hospital Revenue Code	276
Min. Negotiated Rate	$1,000.00
Max. Negotiated Rate	$1,940.00
Rate for Payer: AlohaCare Medicaid	$1,000.00
Rate for Payer: AlohaCare Medicare	$1,000.00
Rate for Payer: Cash Price	$1,300.00
Rate for Payer: Devoted Health Medicare	$1,100.00
Rate for Payer: Hawaii Medical Service Association Medicare	$1,000.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,400.00
Rate for Payer: Health Management Network Commercial	$1,700.00
Rate for Payer: Humana Medicare	$1,000.00
Rate for Payer: Kaiser Permanente Commercial	$1,800.00
Rate for Payer: Kaiser Permanente Medicaid	$1,020.00
Rate for Payer: Kaiser Permanente Medicare	$1,000.00
Rate for Payer: MDX Hawaii PPO	$1,940.00
Rate for Payer: Ohana Health Plan Medicaid	$1,000.00
Rate for Payer: Ohana Health Plan Medicare	$1,000.00
Rate for Payer: UnitedHealthcare Medicare	$1,000.00
Rate for Payer: University Health Alliance Commercial	$1,120.00

OPTH IMPLANT enVISTA ENVY TORIC +1.25D CYL

Facility

$2,000.00

Service Code	HCPCS V2787
Hospital Charge Code	13271037
Hospital Revenue Code	276
Min. Negotiated Rate	$1,000.00
Max. Negotiated Rate	$1,940.00
Rate for Payer: AlohaCare Medicaid	$1,000.00
Rate for Payer: AlohaCare Medicare	$1,000.00
Rate for Payer: Cash Price	$1,300.00
Rate for Payer: Devoted Health Medicare	$1,100.00
Rate for Payer: Hawaii Medical Service Association Medicare	$1,000.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,400.00
Rate for Payer: Health Management Network Commercial	$1,700.00
Rate for Payer: Humana Medicare	$1,000.00
Rate for Payer: Kaiser Permanente Commercial	$1,800.00
Rate for Payer: Kaiser Permanente Medicaid	$1,020.00
Rate for Payer: Kaiser Permanente Medicare	$1,000.00
Rate for Payer: MDX Hawaii PPO	$1,940.00
Rate for Payer: Ohana Health Plan Medicaid	$1,000.00
Rate for Payer: Ohana Health Plan Medicare	$1,000.00
Rate for Payer: UnitedHealthcare Medicare	$1,000.00
Rate for Payer: University Health Alliance Commercial	$1,120.00

OPTH IMPLANT enVISTA ENVY TORIC +1.25D CYL

Facility

$2,000.00

Service Code	HCPCS V2787
Hospital Charge Code	13271037
Hospital Revenue Code	276
Min. Negotiated Rate	$1,120.00
Max. Negotiated Rate	$1,940.00
Rate for Payer: Cash Price	$1,300.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,400.00
Rate for Payer: Health Management Network Commercial	$1,700.00
Rate for Payer: Kaiser Permanente Commercial	$1,800.00
Rate for Payer: MDX Hawaii PPO	$1,940.00
Rate for Payer: University Health Alliance Commercial	$1,120.00

OPTH IMPLANT enVISTA ENVY TORIC +2.00D CYL

Facility

$2,600.00

Service Code	HCPCS V2787
Hospital Charge Code	13271041
Hospital Revenue Code	276
Min. Negotiated Rate	$1,300.00
Max. Negotiated Rate	$2,522.00
Rate for Payer: AlohaCare Medicaid	$1,300.00
Rate for Payer: AlohaCare Medicare	$1,300.00
Rate for Payer: Cash Price	$1,690.00
Rate for Payer: Devoted Health Medicare	$1,430.00
Rate for Payer: Hawaii Medical Service Association Medicare	$1,300.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,820.00
Rate for Payer: Health Management Network Commercial	$2,210.00
Rate for Payer: Humana Medicare	$1,300.00
Rate for Payer: Kaiser Permanente Commercial	$2,340.00
Rate for Payer: Kaiser Permanente Medicaid	$1,326.00
Rate for Payer: Kaiser Permanente Medicare	$1,300.00
Rate for Payer: MDX Hawaii PPO	$2,522.00
Rate for Payer: Ohana Health Plan Medicaid	$1,300.00
Rate for Payer: Ohana Health Plan Medicare	$1,300.00
Rate for Payer: UnitedHealthcare Medicare	$1,300.00
Rate for Payer: University Health Alliance Commercial	$1,456.00

OPTH IMPLANT enVISTA ENVY TORIC +2.00D CYL

Facility

$2,600.00

Service Code	HCPCS V2787
Hospital Charge Code	13271041
Hospital Revenue Code	276
Min. Negotiated Rate	$1,456.00
Max. Negotiated Rate	$2,522.00
Rate for Payer: Cash Price	$1,690.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,820.00
Rate for Payer: Health Management Network Commercial	$2,210.00
Rate for Payer: Kaiser Permanente Commercial	$2,340.00
Rate for Payer: MDX Hawaii PPO	$2,522.00
Rate for Payer: University Health Alliance Commercial	$1,456.00

OPTH IMPLANT enVISTA ENVY TORIC +2.50D CYL

Facility

$2,600.00

Service Code	HCPCS V2787
Hospital Charge Code	13271042
Hospital Revenue Code	276
Min. Negotiated Rate	$1,456.00
Max. Negotiated Rate	$2,522.00
Rate for Payer: Cash Price	$1,690.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,820.00
Rate for Payer: Health Management Network Commercial	$2,210.00
Rate for Payer: Kaiser Permanente Commercial	$2,340.00
Rate for Payer: MDX Hawaii PPO	$2,522.00
Rate for Payer: University Health Alliance Commercial	$1,456.00

OPTH IMPLANT enVISTA ENVY TORIC +2.50D CYL

Facility

$2,600.00

Service Code	HCPCS V2787
Hospital Charge Code	13271042
Hospital Revenue Code	276
Min. Negotiated Rate	$1,300.00
Max. Negotiated Rate	$2,522.00
Rate for Payer: AlohaCare Medicaid	$1,300.00
Rate for Payer: AlohaCare Medicare	$1,300.00
Rate for Payer: Cash Price	$1,690.00
Rate for Payer: Devoted Health Medicare	$1,430.00
Rate for Payer: Hawaii Medical Service Association Medicare	$1,300.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,820.00
Rate for Payer: Health Management Network Commercial	$2,210.00
Rate for Payer: Humana Medicare	$1,300.00
Rate for Payer: Kaiser Permanente Commercial	$2,340.00
Rate for Payer: Kaiser Permanente Medicaid	$1,326.00
Rate for Payer: Kaiser Permanente Medicare	$1,300.00
Rate for Payer: MDX Hawaii PPO	$2,522.00
Rate for Payer: Ohana Health Plan Medicaid	$1,300.00
Rate for Payer: Ohana Health Plan Medicare	$1,300.00
Rate for Payer: UnitedHealthcare Medicare	$1,300.00
Rate for Payer: University Health Alliance Commercial	$1,456.00

Know your out-of-pocket cost for care.

All Charges