Samuel Mahelona Memorial Hospital

All Charges

Charge

Type

Setting

Price

OPTH IMPLANT IOL PROMO SV25T0

Facility

$300.00

Service Code	HCPCS V2788
Hospital Charge Code	8419482
Hospital Revenue Code	276
Min. Negotiated Rate	$150.00
Max. Negotiated Rate	$291.00
Rate for Payer: Kaiser Permanente Medicare	$150.00
Rate for Payer: AlohaCare Medicaid	$150.00
Rate for Payer: AlohaCare Medicare	$150.00
Rate for Payer: Cash Price	$195.00
Rate for Payer: 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: 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 Medicare	$150.00
Rate for Payer: University Health Alliance Commercial	$168.00

OPTH IMPLANT IOL PXYAT0

Facility

$2,130.00

Service Code	HCPCS V2788
Hospital Charge Code	13044300
Hospital Revenue Code	276
Min. Negotiated Rate	$1,065.00
Max. Negotiated Rate	$2,066.10
Rate for Payer: AlohaCare Medicaid	$1,065.00
Rate for Payer: AlohaCare Medicare	$1,065.00
Rate for Payer: Cash Price	$1,384.50
Rate for Payer: Devoted Health Medicare	$1,171.50
Rate for Payer: Hawaii Medical Service Association Medicare	$1,065.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,491.00
Rate for Payer: Health Management Network Commercial	$1,810.50
Rate for Payer: Humana Medicare	$1,065.00
Rate for Payer: Kaiser Permanente Commercial	$1,917.00
Rate for Payer: Kaiser Permanente Medicaid	$1,086.30
Rate for Payer: Kaiser Permanente Medicare	$1,065.00
Rate for Payer: MDX Hawaii PPO	$2,066.10
Rate for Payer: Ohana Health Plan Medicaid	$1,065.00
Rate for Payer: Ohana Health Plan Medicare	$1,065.00
Rate for Payer: UnitedHealthcare Medicare	$1,065.00
Rate for Payer: University Health Alliance Commercial	$1,192.80

OPTH IMPLANT IOL PXYAT0

Facility

$2,130.00

Service Code	HCPCS V2788
Hospital Charge Code	13044300
Hospital Revenue Code	276
Min. Negotiated Rate	$1,192.80
Max. Negotiated Rate	$2,066.10
Rate for Payer: Cash Price	$1,384.50
Rate for Payer: Hawaii Western Management Group Commercial	$1,491.00
Rate for Payer: Health Management Network Commercial	$1,810.50
Rate for Payer: Kaiser Permanente Commercial	$1,917.00
Rate for Payer: MDX Hawaii PPO	$2,066.10
Rate for Payer: University Health Alliance Commercial	$1,192.80

OPTH IMPLANT IOL PXYAT0 (TRIAL)

Facility

$563.00

Service Code	HCPCS V2788
Hospital Charge Code	13045105
Hospital Revenue Code	276
Min. Negotiated Rate	$315.28
Max. Negotiated Rate	$546.11
Rate for Payer: Cash Price	$365.95
Rate for Payer: Hawaii Western Management Group Commercial	$394.10
Rate for Payer: Health Management Network Commercial	$478.55
Rate for Payer: Kaiser Permanente Commercial	$506.70
Rate for Payer: MDX Hawaii PPO	$546.11
Rate for Payer: University Health Alliance Commercial	$315.28

OPTH IMPLANT IOL PXYAT0 (TRIAL)

Facility

$563.00

Service Code	HCPCS V2788
Hospital Charge Code	13045105
Hospital Revenue Code	276
Min. Negotiated Rate	$281.50
Max. Negotiated Rate	$546.11
Rate for Payer: AlohaCare Medicaid	$281.50
Rate for Payer: AlohaCare Medicare	$281.50
Rate for Payer: Cash Price	$365.95
Rate for Payer: Devoted Health Medicare	$309.65
Rate for Payer: Hawaii Medical Service Association Medicare	$281.50
Rate for Payer: Hawaii Western Management Group Commercial	$394.10
Rate for Payer: Health Management Network Commercial	$478.55
Rate for Payer: Humana Medicare	$281.50
Rate for Payer: Kaiser Permanente Commercial	$506.70
Rate for Payer: Kaiser Permanente Medicaid	$287.13
Rate for Payer: Kaiser Permanente Medicare	$281.50
Rate for Payer: MDX Hawaii PPO	$546.11
Rate for Payer: Ohana Health Plan Medicaid	$281.50
Rate for Payer: Ohana Health Plan Medicare	$281.50
Rate for Payer: UnitedHealthcare Medicare	$281.50
Rate for Payer: University Health Alliance Commercial	$315.28

OPTH IMPLANT IOL PXYAT3

Facility

$2,130.00

Service Code	HCPCS V2788
Hospital Charge Code	13044301
Hospital Revenue Code	276
Min. Negotiated Rate	$1,192.80
Max. Negotiated Rate	$2,066.10
Rate for Payer: Cash Price	$1,384.50
Rate for Payer: Hawaii Western Management Group Commercial	$1,491.00
Rate for Payer: Health Management Network Commercial	$1,810.50
Rate for Payer: Kaiser Permanente Commercial	$1,917.00
Rate for Payer: MDX Hawaii PPO	$2,066.10
Rate for Payer: University Health Alliance Commercial	$1,192.80

OPTH IMPLANT IOL PXYAT3

Facility

$2,130.00

Service Code	HCPCS V2788
Hospital Charge Code	13044301
Hospital Revenue Code	276
Min. Negotiated Rate	$1,065.00
Max. Negotiated Rate	$2,066.10
Rate for Payer: AlohaCare Medicaid	$1,065.00
Rate for Payer: AlohaCare Medicare	$1,065.00
Rate for Payer: Cash Price	$1,384.50
Rate for Payer: Devoted Health Medicare	$1,171.50
Rate for Payer: Hawaii Medical Service Association Medicare	$1,065.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,491.00
Rate for Payer: Health Management Network Commercial	$1,810.50
Rate for Payer: Humana Medicare	$1,065.00
Rate for Payer: Kaiser Permanente Commercial	$1,917.00
Rate for Payer: Kaiser Permanente Medicaid	$1,086.30
Rate for Payer: Kaiser Permanente Medicare	$1,065.00
Rate for Payer: MDX Hawaii PPO	$2,066.10
Rate for Payer: Ohana Health Plan Medicaid	$1,065.00
Rate for Payer: Ohana Health Plan Medicare	$1,065.00
Rate for Payer: UnitedHealthcare Medicare	$1,065.00
Rate for Payer: University Health Alliance Commercial	$1,192.80

OPTH IMPLANT IOL PXYAT3 (TRIAL)

Facility

$563.00

Service Code	HCPCS V2788
Hospital Charge Code	13045106
Hospital Revenue Code	276
Min. Negotiated Rate	$315.28
Max. Negotiated Rate	$546.11
Rate for Payer: Cash Price	$365.95
Rate for Payer: Hawaii Western Management Group Commercial	$394.10
Rate for Payer: Health Management Network Commercial	$478.55
Rate for Payer: Kaiser Permanente Commercial	$506.70
Rate for Payer: MDX Hawaii PPO	$546.11
Rate for Payer: University Health Alliance Commercial	$315.28

OPTH IMPLANT IOL PXYAT3 (TRIAL)

Facility

$563.00

Service Code	HCPCS V2788
Hospital Charge Code	13045106
Hospital Revenue Code	276
Min. Negotiated Rate	$281.50
Max. Negotiated Rate	$546.11
Rate for Payer: AlohaCare Medicaid	$281.50
Rate for Payer: AlohaCare Medicare	$281.50
Rate for Payer: Cash Price	$365.95
Rate for Payer: Devoted Health Medicare	$309.65
Rate for Payer: Hawaii Medical Service Association Medicare	$281.50
Rate for Payer: Hawaii Western Management Group Commercial	$394.10
Rate for Payer: Health Management Network Commercial	$478.55
Rate for Payer: Humana Medicare	$281.50
Rate for Payer: Kaiser Permanente Commercial	$506.70
Rate for Payer: Kaiser Permanente Medicaid	$287.13
Rate for Payer: Kaiser Permanente Medicare	$281.50
Rate for Payer: MDX Hawaii PPO	$546.11
Rate for Payer: Ohana Health Plan Medicaid	$281.50
Rate for Payer: Ohana Health Plan Medicare	$281.50
Rate for Payer: UnitedHealthcare Medicare	$281.50
Rate for Payer: University Health Alliance Commercial	$315.28

OPTH IMPLANT IOL PXYWT0

Facility

$2,130.00

Service Code	HCPCS V2788
Hospital Charge Code	13155533
Hospital Revenue Code	276
Min. Negotiated Rate	$1,192.80
Max. Negotiated Rate	$2,066.10
Rate for Payer: Cash Price	$1,384.50
Rate for Payer: Hawaii Western Management Group Commercial	$1,491.00
Rate for Payer: Health Management Network Commercial	$1,810.50
Rate for Payer: Kaiser Permanente Commercial	$1,917.00
Rate for Payer: MDX Hawaii PPO	$2,066.10
Rate for Payer: University Health Alliance Commercial	$1,192.80

OPTH IMPLANT IOL PXYWT0

Facility

$2,130.00

Service Code	HCPCS V2788
Hospital Charge Code	13155533
Hospital Revenue Code	276
Min. Negotiated Rate	$1,065.00
Max. Negotiated Rate	$2,066.10
Rate for Payer: AlohaCare Medicaid	$1,065.00
Rate for Payer: AlohaCare Medicare	$1,065.00
Rate for Payer: Cash Price	$1,384.50
Rate for Payer: Devoted Health Medicare	$1,171.50
Rate for Payer: Hawaii Medical Service Association Medicare	$1,065.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,491.00
Rate for Payer: Health Management Network Commercial	$1,810.50
Rate for Payer: Humana Medicare	$1,065.00
Rate for Payer: Kaiser Permanente Commercial	$1,917.00
Rate for Payer: Kaiser Permanente Medicaid	$1,086.30
Rate for Payer: Kaiser Permanente Medicare	$1,065.00
Rate for Payer: MDX Hawaii PPO	$2,066.10
Rate for Payer: Ohana Health Plan Medicaid	$1,065.00
Rate for Payer: Ohana Health Plan Medicare	$1,065.00
Rate for Payer: UnitedHealthcare Medicare	$1,065.00
Rate for Payer: University Health Alliance Commercial	$1,192.80

OPTH IMPLANT IOL RESTOR MULTIFOCAL MN60D3

Facility

$1,500.00

Service Code	HCPCS V2788 GY
Hospital Charge Code	8419473
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 RESTOR MULTIFOCAL MN60D3

Facility

$1,500.00

Service Code	HCPCS V2788 GY
Hospital Charge Code	8419473
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 RESTOR SN6AD3

Facility

$1,500.00

Service Code	HCPCS V2788
Hospital Charge Code	8419474
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 RESTOR SN6AD3

Facility

$1,500.00

Service Code	HCPCS V2788
Hospital Charge Code	8419474
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 RESTOR SND1T4

Facility

$1,500.00

Service Code	HCPCS V2788
Hospital Charge Code	8500795
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 RESTOR SND1T4

Facility

$1,500.00

Service Code	HCPCS V2788
Hospital Charge Code	8500795
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 SN60AT

Facility

$300.00

Service Code	HCPCS V2632
Hospital Charge Code	8419483
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 SN60AT

Facility

$300.00

Service Code	HCPCS V2632
Hospital Charge Code	8419483
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 SN60WF

Facility

$300.00

Service Code	HCPCS V2632
Hospital Charge Code	8352176
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 SN60WF

Facility

$300.00

Service Code	HCPCS V2632
Hospital Charge Code	8352176
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 SN6AD1

Facility

$1,500.00

Service Code	HCPCS V2788
Hospital Charge Code	8352177
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 SN6AD1

Facility

$1,500.00

Service Code	HCPCS V2788
Hospital Charge Code	8352177
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 SN6AT3

Facility

$750.00

Service Code	HCPCS V2787
Hospital Charge Code	8419470
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 SN6AT3

Facility

$750.00

Service Code	HCPCS V2787
Hospital Charge Code	8419470
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

Know your out-of-pocket cost for care.

All Charges