Samuel Mahelona Memorial Hospital

All Charges

Charge

Type

Setting

Price

OPTH IMPLANT IOL CNW0T3

Facility

$750.00

Service Code	HCPCS V2787
Hospital Charge Code	10590843
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 CNW0T3

Facility

$750.00

Service Code	HCPCS V2787
Hospital Charge Code	10590843
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 CNW0T4

Facility

$750.00

Service Code	HCPCS V2787
Hospital Charge Code	10590844
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 CNW0T4

Facility

$750.00

Service Code	HCPCS V2787
Hospital Charge Code	10590844
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 CNW0T5

Facility

$750.00

Service Code	HCPCS V2787
Hospital Charge Code	10590845
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 CNW0T5

Facility

$750.00

Service Code	HCPCS V2787
Hospital Charge Code	10590845
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 CNW0T6

Facility

$750.00

Service Code	HCPCS V2787
Hospital Charge Code	10590842
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 CNW0T6

Facility

$750.00

Service Code	HCPCS V2787
Hospital Charge Code	10590842
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 CNW0T7

Facility

$750.00

Service Code	HCPCS V2787
Hospital Charge Code	12566965
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 CNW0T7

Facility

$750.00

Service Code	HCPCS V2787
Hospital Charge Code	12566965
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 CNW0T8

Facility

$750.00

Service Code	HCPCS V2787
Hospital Charge Code	12566966
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 CNW0T8

Facility

$750.00

Service Code	HCPCS V2787
Hospital Charge Code	12566966
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 CNW0T9

Facility

$750.00

Service Code	HCPCS V2787
Hospital Charge Code	12566967
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 CNW0T9

Facility

$750.00

Service Code	HCPCS V2787
Hospital Charge Code	12566967
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 CNWET0

Facility

$1,500.00

Service Code	HCPCS V2788
Hospital Charge Code	10254771
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 CNWET0

Facility

$1,500.00

Service Code	HCPCS V2788
Hospital Charge Code	10254771
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 CNWET3

Facility

$1,500.00

Service Code	HCPCS V2788
Hospital Charge Code	10254778
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 CNWET3

Facility

$1,500.00

Service Code	HCPCS V2788
Hospital Charge Code	10254778
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 CNWET4

Facility

$1,500.00

Service Code	HCPCS V2788
Hospital Charge Code	10254772
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 CNWET4

Facility

$1,500.00

Service Code	HCPCS V2788
Hospital Charge Code	10254772
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 CNWET5

Facility

$1,500.00

Service Code	HCPCS V2788
Hospital Charge Code	10254779
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 CNWET5

Facility

$1,500.00

Service Code	HCPCS V2788
Hospital Charge Code	10254779
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 CNWET6

Facility

$1,500.00

Service Code	HCPCS V2788
Hospital Charge Code	10254773
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 CNWET6

Facility

$1,500.00

Service Code	HCPCS V2788
Hospital Charge Code	10254773
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 CNWTT0

Facility

$1,500.00

Service Code	HCPCS V2788
Hospital Charge Code	10254774
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