Samuel Mahelona Memorial Hospital

All Charges

Charge

Type

Setting

Price

OPTH IMPLANT enVISTA ENVY TORIC +3.00D CYL

Facility

$2,600.00

Service Code	HCPCS V2787
Hospital Charge Code	13271039
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 +3.00D CYL

Facility

$2,600.00

Service Code	HCPCS V2787
Hospital Charge Code	13271039
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 +5.00D CYL

Facility

$2,600.00

Service Code	HCPCS V2787
Hospital Charge Code	13271066
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 +5.00D CYL

Facility

$2,600.00

Service Code	HCPCS V2787
Hospital Charge Code	13271066
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 IOL ANTERIOR MA60AC

Facility

$300.00

Service Code	HCPCS V2632
Hospital Charge Code	8419466
Hospital Revenue Code	276
Min. Negotiated Rate	$150.00
Max. Negotiated Rate	$311.40
Rate for Payer: AlohaCare Medicaid	$150.00
Rate for Payer: AlohaCare Medicare	$150.00
Rate for Payer: Cash Price	$195.00
Rate for Payer: Cash Price	$195.00
Rate for Payer: Devoted Health Medicare	$165.00
Rate for Payer: Hawaii Medical Service Association Medicare	$150.00
Rate for Payer: Hawaii Western Management Group Commercial	$210.00
Rate for Payer: Health Management Network Commercial	$255.00
Rate for Payer: Humana Medicare	$150.00
Rate for Payer: Kaiser Permanente Commercial	$270.00
Rate for Payer: Kaiser Permanente Medicaid	$153.00
Rate for Payer: Kaiser Permanente Medicare	$150.00
Rate for Payer: MDX Hawaii PPO	$291.00
Rate for Payer: Ohana Health Plan Medicaid	$150.00
Rate for Payer: Ohana Health Plan Medicare	$150.00
Rate for Payer: UnitedHealthcare Medicaid	$311.40
Rate for Payer: UnitedHealthcare Medicare	$150.00
Rate for Payer: University Health Alliance Commercial	$168.00

OPTH IMPLANT IOL ANTERIOR MA60AC

Facility

$300.00

Service Code	HCPCS V2632
Hospital Charge Code	8419466
Hospital Revenue Code	276
Min. Negotiated Rate	$168.00
Max. Negotiated Rate	$291.00
Rate for Payer: Cash Price	$195.00
Rate for Payer: Hawaii Western Management Group Commercial	$210.00
Rate for Payer: Health Management Network Commercial	$255.00
Rate for Payer: Kaiser Permanente Commercial	$270.00
Rate for Payer: MDX Hawaii PPO	$291.00
Rate for Payer: University Health Alliance Commercial	$168.00

OPTH IMPLANT IOL ANTERIOR MN60AC

Facility

$300.00

Service Code	HCPCS V2632
Hospital Charge Code	8419467
Hospital Revenue Code	276
Min. Negotiated Rate	$150.00
Max. Negotiated Rate	$311.40
Rate for Payer: AlohaCare Medicaid	$150.00
Rate for Payer: AlohaCare Medicare	$150.00
Rate for Payer: Cash Price	$195.00
Rate for Payer: Cash Price	$195.00
Rate for Payer: Devoted Health Medicare	$165.00
Rate for Payer: Hawaii Medical Service Association Medicare	$150.00
Rate for Payer: Hawaii Western Management Group Commercial	$210.00
Rate for Payer: Health Management Network Commercial	$255.00
Rate for Payer: Humana Medicare	$150.00
Rate for Payer: Kaiser Permanente Commercial	$270.00
Rate for Payer: Kaiser Permanente Medicaid	$153.00
Rate for Payer: Kaiser Permanente Medicare	$150.00
Rate for Payer: MDX Hawaii PPO	$291.00
Rate for Payer: Ohana Health Plan Medicaid	$150.00
Rate for Payer: Ohana Health Plan Medicare	$150.00
Rate for Payer: UnitedHealthcare Medicaid	$311.40
Rate for Payer: UnitedHealthcare Medicare	$150.00
Rate for Payer: University Health Alliance Commercial	$168.00

OPTH IMPLANT IOL ANTERIOR MN60AC

Facility

$300.00

Service Code	HCPCS V2632
Hospital Charge Code	8419467
Hospital Revenue Code	276
Min. Negotiated Rate	$168.00
Max. Negotiated Rate	$291.00
Rate for Payer: Cash Price	$195.00
Rate for Payer: Hawaii Western Management Group Commercial	$210.00
Rate for Payer: Health Management Network Commercial	$255.00
Rate for Payer: Kaiser Permanente Commercial	$270.00
Rate for Payer: MDX Hawaii PPO	$291.00
Rate for Payer: University Health Alliance Commercial	$168.00

OPTH IMPLANT IOL ANTERIOR MTA3U0

Facility

$300.00

Service Code	HCPCS V2630
Hospital Charge Code	8419468
Hospital Revenue Code	276
Min. Negotiated Rate	$168.00
Max. Negotiated Rate	$291.00
Rate for Payer: Cash Price	$195.00
Rate for Payer: Hawaii Western Management Group Commercial	$210.00
Rate for Payer: Health Management Network Commercial	$255.00
Rate for Payer: Kaiser Permanente Commercial	$270.00
Rate for Payer: MDX Hawaii PPO	$291.00
Rate for Payer: University Health Alliance Commercial	$168.00

OPTH IMPLANT IOL ANTERIOR MTA3U0

Facility

$300.00

Service Code	HCPCS V2630
Hospital Charge Code	8419468
Hospital Revenue Code	276
Min. Negotiated Rate	$150.00
Max. Negotiated Rate	$291.00
Rate for Payer: AlohaCare Medicaid	$150.00
Rate for Payer: AlohaCare Medicare	$150.00
Rate for Payer: Cash Price	$195.00
Rate for Payer: Cash Price	$195.00
Rate for Payer: Devoted Health Medicare	$165.00
Rate for Payer: Hawaii Medical Service Association Medicare	$150.00
Rate for Payer: Hawaii Western Management Group Commercial	$210.00
Rate for Payer: Health Management Network Commercial	$255.00
Rate for Payer: Humana Medicare	$150.00
Rate for Payer: Kaiser Permanente Commercial	$270.00
Rate for Payer: Kaiser Permanente Medicaid	$153.00
Rate for Payer: Kaiser Permanente Medicare	$150.00
Rate for Payer: MDX Hawaii PPO	$291.00
Rate for Payer: Ohana Health Plan Medicaid	$150.00
Rate for Payer: Ohana Health Plan Medicare	$150.00
Rate for Payer: UnitedHealthcare Medicaid	$197.46
Rate for Payer: UnitedHealthcare Medicare	$150.00
Rate for Payer: University Health Alliance Commercial	$168.00

OPTH IMPLANT IOL ANTERIOR MTA4U0

Facility

$375.00

Service Code	HCPCS V2632
Hospital Charge Code	13271070
Hospital Revenue Code	276
Min. Negotiated Rate	$187.50
Max. Negotiated Rate	$363.75
Rate for Payer: AlohaCare Medicaid	$187.50
Rate for Payer: AlohaCare Medicare	$187.50
Rate for Payer: Cash Price	$243.75
Rate for Payer: Cash Price	$243.75
Rate for Payer: Devoted Health Medicare	$206.25
Rate for Payer: Hawaii Medical Service Association Medicare	$187.50
Rate for Payer: Hawaii Western Management Group Commercial	$262.50
Rate for Payer: Health Management Network Commercial	$318.75
Rate for Payer: Humana Medicare	$187.50
Rate for Payer: Kaiser Permanente Commercial	$337.50
Rate for Payer: Kaiser Permanente Medicaid	$191.25
Rate for Payer: Kaiser Permanente Medicare	$187.50
Rate for Payer: MDX Hawaii PPO	$363.75
Rate for Payer: Ohana Health Plan Medicaid	$187.50
Rate for Payer: Ohana Health Plan Medicare	$187.50
Rate for Payer: UnitedHealthcare Medicaid	$311.40
Rate for Payer: UnitedHealthcare Medicare	$187.50
Rate for Payer: University Health Alliance Commercial	$210.00

OPTH IMPLANT IOL ANTERIOR MTA4U0

Facility

$375.00

Service Code	HCPCS V2632
Hospital Charge Code	13271070
Hospital Revenue Code	276
Min. Negotiated Rate	$210.00
Max. Negotiated Rate	$363.75
Rate for Payer: Cash Price	$243.75
Rate for Payer: Hawaii Western Management Group Commercial	$262.50
Rate for Payer: Health Management Network Commercial	$318.75
Rate for Payer: Kaiser Permanente Commercial	$337.50
Rate for Payer: MDX Hawaii PPO	$363.75
Rate for Payer: University Health Alliance Commercial	$210.00

OPTH IMPLANT IOL AR40e

Facility

$340.00

Service Code	HCPCS V2632
Hospital Charge Code	13271068
Hospital Revenue Code	276
Min. Negotiated Rate	$170.00
Max. Negotiated Rate	$329.80
Rate for Payer: AlohaCare Medicaid	$170.00
Rate for Payer: AlohaCare Medicare	$170.00
Rate for Payer: Cash Price	$221.00
Rate for Payer: Cash Price	$221.00
Rate for Payer: Devoted Health Medicare	$187.00
Rate for Payer: Hawaii Medical Service Association Medicare	$170.00
Rate for Payer: Hawaii Western Management Group Commercial	$238.00
Rate for Payer: Health Management Network Commercial	$289.00
Rate for Payer: Humana Medicare	$170.00
Rate for Payer: Kaiser Permanente Commercial	$306.00
Rate for Payer: Kaiser Permanente Medicaid	$173.40
Rate for Payer: Kaiser Permanente Medicare	$170.00
Rate for Payer: MDX Hawaii PPO	$329.80
Rate for Payer: Ohana Health Plan Medicaid	$170.00
Rate for Payer: Ohana Health Plan Medicare	$170.00
Rate for Payer: UnitedHealthcare Medicaid	$311.40
Rate for Payer: UnitedHealthcare Medicare	$170.00
Rate for Payer: University Health Alliance Commercial	$190.40

OPTH IMPLANT IOL AR40e

Facility

$340.00

Service Code	HCPCS V2632
Hospital Charge Code	13271068
Hospital Revenue Code	276
Min. Negotiated Rate	$190.40
Max. Negotiated Rate	$329.80
Rate for Payer: Cash Price	$221.00
Rate for Payer: Hawaii Western Management Group Commercial	$238.00
Rate for Payer: Health Management Network Commercial	$289.00
Rate for Payer: Kaiser Permanente Commercial	$306.00
Rate for Payer: MDX Hawaii PPO	$329.80
Rate for Payer: University Health Alliance Commercial	$190.40

OPTH IMPLANT IOL CCA0T0

Facility

$300.00

Service Code	HCPCS V2632
Hospital Charge Code	12566964
Hospital Revenue Code	276
Min. Negotiated Rate	$168.00
Max. Negotiated Rate	$291.00
Rate for Payer: Cash Price	$195.00
Rate for Payer: Hawaii Western Management Group Commercial	$210.00
Rate for Payer: Health Management Network Commercial	$255.00
Rate for Payer: Kaiser Permanente Commercial	$270.00
Rate for Payer: MDX Hawaii PPO	$291.00
Rate for Payer: University Health Alliance Commercial	$168.00

OPTH IMPLANT IOL CCA0T0

Facility

$300.00

Service Code	HCPCS V2632
Hospital Charge Code	12566964
Hospital Revenue Code	276
Min. Negotiated Rate	$150.00
Max. Negotiated Rate	$311.40
Rate for Payer: AlohaCare Medicaid	$150.00
Rate for Payer: AlohaCare Medicare	$150.00
Rate for Payer: Cash Price	$195.00
Rate for Payer: Cash Price	$195.00
Rate for Payer: Devoted Health Medicare	$165.00
Rate for Payer: Hawaii Medical Service Association Medicare	$150.00
Rate for Payer: Hawaii Western Management Group Commercial	$210.00
Rate for Payer: Health Management Network Commercial	$255.00
Rate for Payer: Humana Medicare	$150.00
Rate for Payer: Kaiser Permanente Commercial	$270.00
Rate for Payer: Kaiser Permanente Medicaid	$153.00
Rate for Payer: Kaiser Permanente Medicare	$150.00
Rate for Payer: MDX Hawaii PPO	$291.00
Rate for Payer: Ohana Health Plan Medicaid	$150.00
Rate for Payer: Ohana Health Plan Medicare	$150.00
Rate for Payer: UnitedHealthcare Medicaid	$311.40
Rate for Payer: UnitedHealthcare Medicare	$150.00
Rate for Payer: University Health Alliance Commercial	$168.00

OPTH IMPLANT IOL CCW0T3

Facility

$750.00

Service Code	HCPCS V2787
Hospital Charge Code	12667512
Hospital Revenue Code	276
Min. Negotiated Rate	$420.00
Max. Negotiated Rate	$727.50
Rate for Payer: Cash Price	$487.50
Rate for Payer: Hawaii Western Management Group Commercial	$525.00
Rate for Payer: Health Management Network Commercial	$637.50
Rate for Payer: Kaiser Permanente Commercial	$675.00
Rate for Payer: MDX Hawaii PPO	$727.50
Rate for Payer: University Health Alliance Commercial	$420.00

OPTH IMPLANT IOL CCW0T3

Facility

$750.00

Service Code	HCPCS V2787
Hospital Charge Code	12667512
Hospital Revenue Code	276
Min. Negotiated Rate	$375.00
Max. Negotiated Rate	$727.50
Rate for Payer: AlohaCare Medicaid	$375.00
Rate for Payer: AlohaCare Medicare	$375.00
Rate for Payer: Cash Price	$487.50
Rate for Payer: Devoted Health Medicare	$412.50
Rate for Payer: Hawaii Medical Service Association Medicare	$375.00
Rate for Payer: Hawaii Western Management Group Commercial	$525.00
Rate for Payer: Health Management Network Commercial	$637.50
Rate for Payer: Humana Medicare	$375.00
Rate for Payer: Kaiser Permanente Commercial	$675.00
Rate for Payer: Kaiser Permanente Medicaid	$382.50
Rate for Payer: Kaiser Permanente Medicare	$375.00
Rate for Payer: MDX Hawaii PPO	$727.50
Rate for Payer: Ohana Health Plan Medicaid	$375.00
Rate for Payer: Ohana Health Plan Medicare	$375.00
Rate for Payer: UnitedHealthcare Medicare	$375.00
Rate for Payer: University Health Alliance Commercial	$420.00

OPTH IMPLANT IOL CCW0T4

Facility

$750.00

Service Code	HCPCS V2787
Hospital Charge Code	12667513
Hospital Revenue Code	276
Min. Negotiated Rate	$420.00
Max. Negotiated Rate	$727.50
Rate for Payer: Cash Price	$487.50
Rate for Payer: Hawaii Western Management Group Commercial	$525.00
Rate for Payer: Health Management Network Commercial	$637.50
Rate for Payer: Kaiser Permanente Commercial	$675.00
Rate for Payer: MDX Hawaii PPO	$727.50
Rate for Payer: University Health Alliance Commercial	$420.00

OPTH IMPLANT IOL CCW0T4

Facility

$750.00

Service Code	HCPCS V2787
Hospital Charge Code	12667513
Hospital Revenue Code	276
Min. Negotiated Rate	$375.00
Max. Negotiated Rate	$727.50
Rate for Payer: AlohaCare Medicaid	$375.00
Rate for Payer: AlohaCare Medicare	$375.00
Rate for Payer: Cash Price	$487.50
Rate for Payer: Devoted Health Medicare	$412.50
Rate for Payer: Hawaii Medical Service Association Medicare	$375.00
Rate for Payer: Hawaii Western Management Group Commercial	$525.00
Rate for Payer: Health Management Network Commercial	$637.50
Rate for Payer: Humana Medicare	$375.00
Rate for Payer: Kaiser Permanente Commercial	$675.00
Rate for Payer: Kaiser Permanente Medicaid	$382.50
Rate for Payer: Kaiser Permanente Medicare	$375.00
Rate for Payer: MDX Hawaii PPO	$727.50
Rate for Payer: Ohana Health Plan Medicaid	$375.00
Rate for Payer: Ohana Health Plan Medicare	$375.00
Rate for Payer: UnitedHealthcare Medicare	$375.00
Rate for Payer: University Health Alliance Commercial	$420.00

OPTH IMPLANT IOL CCW0T5

Facility

$750.00

Service Code	HCPCS V2787
Hospital Charge Code	12667516
Hospital Revenue Code	276
Min. Negotiated Rate	$420.00
Max. Negotiated Rate	$727.50
Rate for Payer: Cash Price	$487.50
Rate for Payer: Hawaii Western Management Group Commercial	$525.00
Rate for Payer: Health Management Network Commercial	$637.50
Rate for Payer: Kaiser Permanente Commercial	$675.00
Rate for Payer: MDX Hawaii PPO	$727.50
Rate for Payer: University Health Alliance Commercial	$420.00

OPTH IMPLANT IOL CCW0T5

Facility

$750.00

Service Code	HCPCS V2787
Hospital Charge Code	12667516
Hospital Revenue Code	276
Min. Negotiated Rate	$375.00
Max. Negotiated Rate	$727.50
Rate for Payer: AlohaCare Medicaid	$375.00
Rate for Payer: AlohaCare Medicare	$375.00
Rate for Payer: Cash Price	$487.50
Rate for Payer: Devoted Health Medicare	$412.50
Rate for Payer: Hawaii Medical Service Association Medicare	$375.00
Rate for Payer: Hawaii Western Management Group Commercial	$525.00
Rate for Payer: Health Management Network Commercial	$637.50
Rate for Payer: Humana Medicare	$375.00
Rate for Payer: Kaiser Permanente Commercial	$675.00
Rate for Payer: Kaiser Permanente Medicaid	$382.50
Rate for Payer: Kaiser Permanente Medicare	$375.00
Rate for Payer: MDX Hawaii PPO	$727.50
Rate for Payer: Ohana Health Plan Medicaid	$375.00
Rate for Payer: Ohana Health Plan Medicare	$375.00
Rate for Payer: UnitedHealthcare Medicare	$375.00
Rate for Payer: University Health Alliance Commercial	$420.00

OPTH IMPLANT IOL CCW0T6

Facility

$750.00

Service Code	HCPCS V2787
Hospital Charge Code	12667514
Hospital Revenue Code	276
Min. Negotiated Rate	$420.00
Max. Negotiated Rate	$727.50
Rate for Payer: Cash Price	$487.50
Rate for Payer: Hawaii Western Management Group Commercial	$525.00
Rate for Payer: Health Management Network Commercial	$637.50
Rate for Payer: Kaiser Permanente Commercial	$675.00
Rate for Payer: MDX Hawaii PPO	$727.50
Rate for Payer: University Health Alliance Commercial	$420.00

OPTH IMPLANT IOL CCW0T6

Facility

$750.00

Service Code	HCPCS V2787
Hospital Charge Code	12667514
Hospital Revenue Code	276
Min. Negotiated Rate	$375.00
Max. Negotiated Rate	$727.50
Rate for Payer: AlohaCare Medicaid	$375.00
Rate for Payer: AlohaCare Medicare	$375.00
Rate for Payer: Cash Price	$487.50
Rate for Payer: Devoted Health Medicare	$412.50
Rate for Payer: Hawaii Medical Service Association Medicare	$375.00
Rate for Payer: Hawaii Western Management Group Commercial	$525.00
Rate for Payer: Health Management Network Commercial	$637.50
Rate for Payer: Humana Medicare	$375.00
Rate for Payer: Kaiser Permanente Commercial	$675.00
Rate for Payer: Kaiser Permanente Medicaid	$382.50
Rate for Payer: Kaiser Permanente Medicare	$375.00
Rate for Payer: MDX Hawaii PPO	$727.50
Rate for Payer: Ohana Health Plan Medicaid	$375.00
Rate for Payer: Ohana Health Plan Medicare	$375.00
Rate for Payer: UnitedHealthcare Medicare	$375.00
Rate for Payer: University Health Alliance Commercial	$420.00

OPTH IMPLANT IOL CCW0T7

Facility

$750.00

Service Code	HCPCS V2787
Hospital Charge Code	12667517
Hospital Revenue Code	276
Min. Negotiated Rate	$420.00
Max. Negotiated Rate	$727.50
Rate for Payer: Cash Price	$487.50
Rate for Payer: Hawaii Western Management Group Commercial	$525.00
Rate for Payer: Health Management Network Commercial	$637.50
Rate for Payer: Kaiser Permanente Commercial	$675.00
Rate for Payer: MDX Hawaii PPO	$727.50
Rate for Payer: University Health Alliance Commercial	$420.00

Know your out-of-pocket cost for care.

All Charges