Samuel Mahelona Memorial Hospital

All Charges

Charge

Type

Setting

Price

OPTH IMPLANT IOL CCW0T7

Facility

$750.00

Service Code	HCPCS V2787
Hospital Charge Code	12667517
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 CCW0T8

Facility

$750.00

Service Code	HCPCS V2787
Hospital Charge Code	12667515
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 CCW0T8

Facility

$750.00

Service Code	HCPCS V2787
Hospital Charge Code	12667515
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 CCW0T9

Facility

$750.00

Service Code	HCPCS V2787
Hospital Charge Code	12667518
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 CCW0T9

Facility

$750.00

Service Code	HCPCS V2787
Hospital Charge Code	12667518
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 CCWET0

Facility

$1,500.00

Service Code	HCPCS V2788
Hospital Charge Code	12850855
Hospital Revenue Code	276
Min. Negotiated Rate	$750.00
Max. Negotiated Rate	$1,455.00
Rate for Payer: AlohaCare Medicaid	$750.00
Rate for Payer: AlohaCare Medicare	$750.00
Rate for Payer: Cash Price	$975.00
Rate for Payer: Devoted Health Medicare	$825.00
Rate for Payer: Hawaii Medical Service Association Medicare	$750.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,050.00
Rate for Payer: Health Management Network Commercial	$1,275.00
Rate for Payer: Humana Medicare	$750.00
Rate for Payer: Kaiser Permanente Commercial	$1,350.00
Rate for Payer: Kaiser Permanente Medicaid	$765.00
Rate for Payer: Kaiser Permanente Medicare	$750.00
Rate for Payer: MDX Hawaii PPO	$1,455.00
Rate for Payer: Ohana Health Plan Medicaid	$750.00
Rate for Payer: Ohana Health Plan Medicare	$750.00
Rate for Payer: UnitedHealthcare Medicare	$750.00
Rate for Payer: University Health Alliance Commercial	$840.00

OPTH:IMPLANT IOL CCWET0

Facility

$1,500.00

Service Code	HCPCS V2788
Hospital Charge Code	12850855
Hospital Revenue Code	276
Min. Negotiated Rate	$840.00
Max. Negotiated Rate	$1,455.00
Rate for Payer: Cash Price	$975.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,050.00
Rate for Payer: Health Management Network Commercial	$1,275.00
Rate for Payer: Kaiser Permanente Commercial	$1,350.00
Rate for Payer: MDX Hawaii PPO	$1,455.00
Rate for Payer: University Health Alliance Commercial	$840.00

OPTH IMPLANT IOL CCWET3

Facility

$1,500.00

Service Code	HCPCS V2788
Hospital Charge Code	10714137
Hospital Revenue Code	276
Min. Negotiated Rate	$750.00
Max. Negotiated Rate	$1,455.00
Rate for Payer: AlohaCare Medicaid	$750.00
Rate for Payer: AlohaCare Medicare	$750.00
Rate for Payer: Cash Price	$975.00
Rate for Payer: Devoted Health Medicare	$825.00
Rate for Payer: Hawaii Medical Service Association Medicare	$750.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,050.00
Rate for Payer: Health Management Network Commercial	$1,275.00
Rate for Payer: Humana Medicare	$750.00
Rate for Payer: Kaiser Permanente Commercial	$1,350.00
Rate for Payer: Kaiser Permanente Medicaid	$765.00
Rate for Payer: Kaiser Permanente Medicare	$750.00
Rate for Payer: MDX Hawaii PPO	$1,455.00
Rate for Payer: Ohana Health Plan Medicaid	$750.00
Rate for Payer: Ohana Health Plan Medicare	$750.00
Rate for Payer: UnitedHealthcare Medicare	$750.00
Rate for Payer: University Health Alliance Commercial	$840.00

OPTH IMPLANT IOL CCWET3

Facility

$1,500.00

Service Code	HCPCS V2788
Hospital Charge Code	10714137
Hospital Revenue Code	276
Min. Negotiated Rate	$840.00
Max. Negotiated Rate	$1,455.00
Rate for Payer: Cash Price	$975.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,050.00
Rate for Payer: Health Management Network Commercial	$1,275.00
Rate for Payer: Kaiser Permanente Commercial	$1,350.00
Rate for Payer: MDX Hawaii PPO	$1,455.00
Rate for Payer: University Health Alliance Commercial	$840.00

OPTH IMPLANT IOL CCWET4

Facility

$2,030.00

Service Code	HCPCS V2788
Hospital Charge Code	13044385
Hospital Revenue Code	276
Min. Negotiated Rate	$1,136.80
Max. Negotiated Rate	$1,969.10
Rate for Payer: Cash Price	$1,319.50
Rate for Payer: Hawaii Western Management Group Commercial	$1,421.00
Rate for Payer: Health Management Network Commercial	$1,725.50
Rate for Payer: Kaiser Permanente Commercial	$1,827.00
Rate for Payer: MDX Hawaii PPO	$1,969.10
Rate for Payer: University Health Alliance Commercial	$1,136.80

OPTH IMPLANT IOL CCWET4

Facility

$2,030.00

Service Code	HCPCS V2788
Hospital Charge Code	13044385
Hospital Revenue Code	276
Min. Negotiated Rate	$1,015.00
Max. Negotiated Rate	$1,969.10
Rate for Payer: AlohaCare Medicaid	$1,015.00
Rate for Payer: AlohaCare Medicare	$1,015.00
Rate for Payer: Cash Price	$1,319.50
Rate for Payer: Devoted Health Medicare	$1,116.50
Rate for Payer: Hawaii Medical Service Association Medicare	$1,015.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,421.00
Rate for Payer: Health Management Network Commercial	$1,725.50
Rate for Payer: Humana Medicare	$1,015.00
Rate for Payer: Kaiser Permanente Commercial	$1,827.00
Rate for Payer: Kaiser Permanente Medicaid	$1,035.30
Rate for Payer: Kaiser Permanente Medicare	$1,015.00
Rate for Payer: MDX Hawaii PPO	$1,969.10
Rate for Payer: Ohana Health Plan Medicaid	$1,015.00
Rate for Payer: Ohana Health Plan Medicare	$1,015.00
Rate for Payer: UnitedHealthcare Medicare	$1,015.00
Rate for Payer: University Health Alliance Commercial	$1,136.80

OPTH IMPLANT IOL CCWET6

Facility

$1,500.00

Service Code	HCPCS V2788
Hospital Charge Code	12273865
Hospital Revenue Code	276
Min. Negotiated Rate	$750.00
Max. Negotiated Rate	$1,455.00
Rate for Payer: AlohaCare Medicaid	$750.00
Rate for Payer: AlohaCare Medicare	$750.00
Rate for Payer: Cash Price	$975.00
Rate for Payer: Devoted Health Medicare	$825.00
Rate for Payer: Hawaii Medical Service Association Medicare	$750.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,050.00
Rate for Payer: Health Management Network Commercial	$1,275.00
Rate for Payer: Humana Medicare	$750.00
Rate for Payer: Kaiser Permanente Commercial	$1,350.00
Rate for Payer: Kaiser Permanente Medicaid	$765.00
Rate for Payer: Kaiser Permanente Medicare	$750.00
Rate for Payer: MDX Hawaii PPO	$1,455.00
Rate for Payer: Ohana Health Plan Medicaid	$750.00
Rate for Payer: Ohana Health Plan Medicare	$750.00
Rate for Payer: UnitedHealthcare Medicare	$750.00
Rate for Payer: University Health Alliance Commercial	$840.00

OPTH IMPLANT IOL CCWET6

Facility

$1,500.00

Service Code	HCPCS V2788
Hospital Charge Code	12273865
Hospital Revenue Code	276
Min. Negotiated Rate	$840.00
Max. Negotiated Rate	$1,455.00
Rate for Payer: Cash Price	$975.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,050.00
Rate for Payer: Health Management Network Commercial	$1,275.00
Rate for Payer: Kaiser Permanente Commercial	$1,350.00
Rate for Payer: MDX Hawaii PPO	$1,455.00
Rate for Payer: University Health Alliance Commercial	$840.00

OPTH IMPLANT IOL CCWTT0

Facility

$1,500.00

Service Code	HCPCS V2788
Hospital Charge Code	10714138
Hospital Revenue Code	276
Min. Negotiated Rate	$750.00
Max. Negotiated Rate	$1,455.00
Rate for Payer: AlohaCare Medicaid	$750.00
Rate for Payer: AlohaCare Medicare	$750.00
Rate for Payer: Cash Price	$975.00
Rate for Payer: Devoted Health Medicare	$825.00
Rate for Payer: Hawaii Medical Service Association Medicare	$750.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,050.00
Rate for Payer: Health Management Network Commercial	$1,275.00
Rate for Payer: Humana Medicare	$750.00
Rate for Payer: Kaiser Permanente Commercial	$1,350.00
Rate for Payer: Kaiser Permanente Medicaid	$765.00
Rate for Payer: Kaiser Permanente Medicare	$750.00
Rate for Payer: MDX Hawaii PPO	$1,455.00
Rate for Payer: Ohana Health Plan Medicaid	$750.00
Rate for Payer: Ohana Health Plan Medicare	$750.00
Rate for Payer: UnitedHealthcare Medicare	$750.00
Rate for Payer: University Health Alliance Commercial	$840.00

OPTH IMPLANT IOL CCWTT0

Facility

$1,500.00

Service Code	HCPCS V2788
Hospital Charge Code	10714138
Hospital Revenue Code	276
Min. Negotiated Rate	$840.00
Max. Negotiated Rate	$1,455.00
Rate for Payer: Cash Price	$975.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,050.00
Rate for Payer: Health Management Network Commercial	$1,275.00
Rate for Payer: Kaiser Permanente Commercial	$1,350.00
Rate for Payer: MDX Hawaii PPO	$1,455.00
Rate for Payer: University Health Alliance Commercial	$840.00

OPTH IMPLANT IOL CCWTT3

Facility

$1,500.00

Service Code	HCPCS V2788
Hospital Charge Code	12684516
Hospital Revenue Code	276
Min. Negotiated Rate	$840.00
Max. Negotiated Rate	$1,455.00
Rate for Payer: Cash Price	$975.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,050.00
Rate for Payer: Health Management Network Commercial	$1,275.00
Rate for Payer: Kaiser Permanente Commercial	$1,350.00
Rate for Payer: MDX Hawaii PPO	$1,455.00
Rate for Payer: University Health Alliance Commercial	$840.00

OPTH IMPLANT IOL CCWTT3

Facility

$1,500.00

Service Code	HCPCS V2788
Hospital Charge Code	12684516
Hospital Revenue Code	276
Min. Negotiated Rate	$750.00
Max. Negotiated Rate	$1,455.00
Rate for Payer: AlohaCare Medicaid	$750.00
Rate for Payer: AlohaCare Medicare	$750.00
Rate for Payer: Cash Price	$975.00
Rate for Payer: Devoted Health Medicare	$825.00
Rate for Payer: Hawaii Medical Service Association Medicare	$750.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,050.00
Rate for Payer: Health Management Network Commercial	$1,275.00
Rate for Payer: Humana Medicare	$750.00
Rate for Payer: Kaiser Permanente Commercial	$1,350.00
Rate for Payer: Kaiser Permanente Medicaid	$765.00
Rate for Payer: Kaiser Permanente Medicare	$750.00
Rate for Payer: MDX Hawaii PPO	$1,455.00
Rate for Payer: Ohana Health Plan Medicaid	$750.00
Rate for Payer: Ohana Health Plan Medicare	$750.00
Rate for Payer: UnitedHealthcare Medicare	$750.00
Rate for Payer: University Health Alliance Commercial	$840.00

OPTH IMPLANT IOL CCWTT4

Facility

$1,500.00

Service Code	HCPCS V2788
Hospital Charge Code	12684515
Hospital Revenue Code	276
Min. Negotiated Rate	$750.00
Max. Negotiated Rate	$1,455.00
Rate for Payer: AlohaCare Medicaid	$750.00
Rate for Payer: AlohaCare Medicare	$750.00
Rate for Payer: Cash Price	$975.00
Rate for Payer: Devoted Health Medicare	$825.00
Rate for Payer: Hawaii Medical Service Association Medicare	$750.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,050.00
Rate for Payer: Health Management Network Commercial	$1,275.00
Rate for Payer: Humana Medicare	$750.00
Rate for Payer: Kaiser Permanente Commercial	$1,350.00
Rate for Payer: Kaiser Permanente Medicaid	$765.00
Rate for Payer: Kaiser Permanente Medicare	$750.00
Rate for Payer: MDX Hawaii PPO	$1,455.00
Rate for Payer: Ohana Health Plan Medicaid	$750.00
Rate for Payer: Ohana Health Plan Medicare	$750.00
Rate for Payer: UnitedHealthcare Medicare	$750.00
Rate for Payer: University Health Alliance Commercial	$840.00

OPTH IMPLANT IOL CCWTT4

Facility

$1,500.00

Service Code	HCPCS V2788
Hospital Charge Code	12684515
Hospital Revenue Code	276
Min. Negotiated Rate	$840.00
Max. Negotiated Rate	$1,455.00
Rate for Payer: Cash Price	$975.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,050.00
Rate for Payer: Health Management Network Commercial	$1,275.00
Rate for Payer: Kaiser Permanente Commercial	$1,350.00
Rate for Payer: MDX Hawaii PPO	$1,455.00
Rate for Payer: University Health Alliance Commercial	$840.00

OPTH IMPLANT IOL CCWTT5

Facility

$1,500.00

Service Code	HCPCS V2788
Hospital Charge Code	12684518
Hospital Revenue Code	276
Min. Negotiated Rate	$840.00
Max. Negotiated Rate	$1,455.00
Rate for Payer: Cash Price	$975.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,050.00
Rate for Payer: Health Management Network Commercial	$1,275.00
Rate for Payer: Kaiser Permanente Commercial	$1,350.00
Rate for Payer: MDX Hawaii PPO	$1,455.00
Rate for Payer: University Health Alliance Commercial	$840.00

OPTH IMPLANT IOL CCWTT5

Facility

$1,500.00

Service Code	HCPCS V2788
Hospital Charge Code	12684518
Hospital Revenue Code	276
Min. Negotiated Rate	$750.00
Max. Negotiated Rate	$1,455.00
Rate for Payer: AlohaCare Medicaid	$750.00
Rate for Payer: AlohaCare Medicare	$750.00
Rate for Payer: Cash Price	$975.00
Rate for Payer: Devoted Health Medicare	$825.00
Rate for Payer: Hawaii Medical Service Association Medicare	$750.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,050.00
Rate for Payer: Health Management Network Commercial	$1,275.00
Rate for Payer: Humana Medicare	$750.00
Rate for Payer: Kaiser Permanente Commercial	$1,350.00
Rate for Payer: Kaiser Permanente Medicaid	$765.00
Rate for Payer: Kaiser Permanente Medicare	$750.00
Rate for Payer: MDX Hawaii PPO	$1,455.00
Rate for Payer: Ohana Health Plan Medicaid	$750.00
Rate for Payer: Ohana Health Plan Medicare	$750.00
Rate for Payer: UnitedHealthcare Medicare	$750.00
Rate for Payer: University Health Alliance Commercial	$840.00

OPTH IMPLANT IOL CCWTT6

Facility

$1,500.00

Service Code	HCPCS V2788
Hospital Charge Code	12684517
Hospital Revenue Code	276
Min. Negotiated Rate	$840.00
Max. Negotiated Rate	$1,455.00
Rate for Payer: Cash Price	$975.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,050.00
Rate for Payer: Health Management Network Commercial	$1,275.00
Rate for Payer: Kaiser Permanente Commercial	$1,350.00
Rate for Payer: MDX Hawaii PPO	$1,455.00
Rate for Payer: University Health Alliance Commercial	$840.00

OPTH IMPLANT IOL CCWTT6

Facility

$1,500.00

Service Code	HCPCS V2788
Hospital Charge Code	12684517
Hospital Revenue Code	276
Min. Negotiated Rate	$750.00
Max. Negotiated Rate	$1,455.00
Rate for Payer: AlohaCare Medicaid	$750.00
Rate for Payer: AlohaCare Medicare	$750.00
Rate for Payer: Cash Price	$975.00
Rate for Payer: Devoted Health Medicare	$825.00
Rate for Payer: Hawaii Medical Service Association Medicare	$750.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,050.00
Rate for Payer: Health Management Network Commercial	$1,275.00
Rate for Payer: Humana Medicare	$750.00
Rate for Payer: Kaiser Permanente Commercial	$1,350.00
Rate for Payer: Kaiser Permanente Medicaid	$765.00
Rate for Payer: Kaiser Permanente Medicare	$750.00
Rate for Payer: MDX Hawaii PPO	$1,455.00
Rate for Payer: Ohana Health Plan Medicaid	$750.00
Rate for Payer: Ohana Health Plan Medicare	$750.00
Rate for Payer: UnitedHealthcare Medicare	$750.00
Rate for Payer: University Health Alliance Commercial	$840.00

OPTH IMPLANT IOL CNW0T0

Facility

$1,500.00

Service Code	HCPCS V2787
Hospital Charge Code	12684510
Hospital Revenue Code	276
Min. Negotiated Rate	$840.00
Max. Negotiated Rate	$1,455.00
Rate for Payer: Cash Price	$975.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,050.00
Rate for Payer: Health Management Network Commercial	$1,275.00
Rate for Payer: Kaiser Permanente Commercial	$1,350.00
Rate for Payer: MDX Hawaii PPO	$1,455.00
Rate for Payer: University Health Alliance Commercial	$840.00

OPTH IMPLANT IOL CNW0T0

Facility

$1,500.00

Service Code	HCPCS V2787
Hospital Charge Code	12684510
Hospital Revenue Code	276
Min. Negotiated Rate	$750.00
Max. Negotiated Rate	$1,455.00
Rate for Payer: AlohaCare Medicaid	$750.00
Rate for Payer: AlohaCare Medicare	$750.00
Rate for Payer: Cash Price	$975.00
Rate for Payer: Devoted Health Medicare	$825.00
Rate for Payer: Hawaii Medical Service Association Medicare	$750.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,050.00
Rate for Payer: Health Management Network Commercial	$1,275.00
Rate for Payer: Humana Medicare	$750.00
Rate for Payer: Kaiser Permanente Commercial	$1,350.00
Rate for Payer: Kaiser Permanente Medicaid	$765.00
Rate for Payer: Kaiser Permanente Medicare	$750.00
Rate for Payer: MDX Hawaii PPO	$1,455.00
Rate for Payer: Ohana Health Plan Medicaid	$750.00
Rate for Payer: Ohana Health Plan Medicare	$750.00
Rate for Payer: UnitedHealthcare Medicare	$750.00
Rate for Payer: University Health Alliance Commercial	$840.00

Know your out-of-pocket cost for care.

All Charges