Samuel Mahelona Memorial Hospital

All Charges

Charge

Type

Setting

Price

OPTH IMPLANT IOL TECNIS MULTIFOCAL ZMB00

Facility

$1,500.00

Service Code	HCPCS V2788
Hospital Charge Code	8419463
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 TECNIS TORIC ZXT

Facility

$1,500.00

Service Code	HCPCS V2788
Hospital Charge Code	8419476
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 TECNIS TORIC ZXT

Facility

$1,500.00

Service Code	HCPCS V2788
Hospital Charge Code	8419476
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 TFNT00

Facility

$1,500.00

Service Code	HCPCS V2788 GY
Hospital Charge Code	8811146
Hospital Revenue Code	276
Min. Negotiated Rate	$750.00
Max. Negotiated Rate	$1,455.00
Rate for Payer: UnitedHealthcare Medicare	$750.00
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: University Health Alliance Commercial	$840.00

OPTH IMPLANT IOL TFNT00

Facility

$1,500.00

Service Code	HCPCS V2788 GY
Hospital Charge Code	8811146
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 TFNT30

Facility

$1,500.00

Service Code	HCPCS V2788
Hospital Charge Code	8855903
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 TFNT30

Facility

$1,500.00

Service Code	HCPCS V2788
Hospital Charge Code	8855903
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 TFNT40

Facility

$1,500.00

Service Code	HCPCS V2788
Hospital Charge Code	8855904
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 TFNT40

Facility

$1,500.00

Service Code	HCPCS V2788
Hospital Charge Code	8855904
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 TFNT50

Facility

$1,500.00

Service Code	HCPCS V2788
Hospital Charge Code	8855905
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 TFNT50

Facility

$1,500.00

Service Code	HCPCS V2788
Hospital Charge Code	8855905
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 TFNT60

Facility

$1,500.00

Service Code	HCPCS V2788
Hospital Charge Code	8855906
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 TFNT60

Facility

$1,500.00

Service Code	HCPCS V2788
Hospital Charge Code	8855906
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 TORIC MULTIFOCAL ZXR00

Facility

$1,500.00

Service Code	HCPCS V2788
Hospital Charge Code	8419478
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 TORIC MULTIFOCAL ZXR00

Facility

$1,500.00

Service Code	HCPCS V2788
Hospital Charge Code	8419478
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 TORIC MULTIFOCAL ZXT150

Facility

$1,500.00

Service Code	HCPCS V2787
Hospital Charge Code	8419479
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 TORIC MULTIFOCAL ZXT150

Facility

$1,500.00

Service Code	HCPCS V2787
Hospital Charge Code	8419479
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 TORIC MULTIFOCAL ZXT225

Facility

$1,500.00

Service Code	HCPCS V2788
Hospital Charge Code	8419477
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 TORIC MULTIFOCAL ZXT225

Facility

$1,500.00

Service Code	HCPCS V2788
Hospital Charge Code	8419477
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 TORIC MULTIFOCAL ZXT300

Facility

$1,500.00

Service Code	HCPCS V2788
Hospital Charge Code	8419480
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 TORIC MULTIFOCAL ZXT300

Facility

$1,500.00

Service Code	HCPCS V2788
Hospital Charge Code	8419480
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 TORIC MULTIFOCAL ZXT375

Facility

$1,500.00

Service Code	HCPCS V2788
Hospital Charge Code	8419481
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 TORIC MULTIFOCAL ZXT375

Facility

$1,500.00

Service Code	HCPCS V2788
Hospital Charge Code	8419481
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 ZXW225

Facility

$1,500.00

Service Code	HCPCS V2787
Hospital Charge Code	10466216
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 ZXW225

Facility

$1,500.00

Service Code	HCPCS V2787
Hospital Charge Code	10466216
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

Know your out-of-pocket cost for care.

All Charges