Samuel Mahelona Memorial Hospital

All Charges

Charge

Type

Setting

Price

OPTH IMPLANT IOL ZXW300

Facility

$1,500.00

Service Code	HCPCS V2787
Hospital Charge Code	10466217
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 ZXW300

Facility

$1,500.00

Service Code	HCPCS V2787
Hospital Charge Code	10466217
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 PXCWT3

Facility

$2,130.00

Service Code	HCPCS V2787
Hospital Charge Code	13382200
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 PXCWT3

Facility

$2,130.00

Service Code	HCPCS V2787
Hospital Charge Code	13382200
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 SOFTPORT

Facility

$469.00

Service Code	HCPCS V2632
Hospital Charge Code	13046208
Hospital Revenue Code	276
Min. Negotiated Rate	$262.64
Max. Negotiated Rate	$454.93
Rate for Payer: Cash Price	$304.85
Rate for Payer: Hawaii Western Management Group Commercial	$328.30
Rate for Payer: Health Management Network Commercial	$398.65
Rate for Payer: Kaiser Permanente Commercial	$422.10
Rate for Payer: MDX Hawaii PPO	$454.93
Rate for Payer: University Health Alliance Commercial	$262.64

OPTH IMPLANT SOFTPORT

Facility

$469.00

Service Code	HCPCS V2632
Hospital Charge Code	13046208
Hospital Revenue Code	276
Min. Negotiated Rate	$234.50
Max. Negotiated Rate	$454.93
Rate for Payer: AlohaCare Medicaid	$234.50
Rate for Payer: AlohaCare Medicare	$234.50
Rate for Payer: Cash Price	$304.85
Rate for Payer: Cash Price	$304.85
Rate for Payer: Devoted Health Medicare	$257.95
Rate for Payer: Hawaii Medical Service Association Medicare	$234.50
Rate for Payer: Hawaii Western Management Group Commercial	$328.30
Rate for Payer: Health Management Network Commercial	$398.65
Rate for Payer: Humana Medicare	$234.50
Rate for Payer: Kaiser Permanente Commercial	$422.10
Rate for Payer: Kaiser Permanente Medicaid	$239.19
Rate for Payer: Kaiser Permanente Medicare	$234.50
Rate for Payer: MDX Hawaii PPO	$454.93
Rate for Payer: Ohana Health Plan Medicaid	$234.50
Rate for Payer: Ohana Health Plan Medicare	$234.50
Rate for Payer: UnitedHealthcare Medicaid	$311.40
Rate for Payer: UnitedHealthcare Medicare	$234.50
Rate for Payer: University Health Alliance Commercial	$262.64

OPTH INTREPID MICRO-COAXIAL SYSTEM 0.3MM POLYMER I/A

Facility

$109.00

Hospital Charge Code	9227346
Hospital Revenue Code	272
Min. Negotiated Rate	$92.65
Max. Negotiated Rate	$105.73
Rate for Payer: Cash Price	$70.85
Rate for Payer: Health Management Network Commercial	$92.65
Rate for Payer: Kaiser Permanente Commercial	$98.10
Rate for Payer: MDX Hawaii PPO	$105.73

OPTH INTREPID MICRO-COAXIAL SYSTEM 0.3MM POLYMER I/A

Facility

$109.00

Hospital Charge Code	9227346
Hospital Revenue Code	272
Min. Negotiated Rate	$54.50
Max. Negotiated Rate	$105.73
Rate for Payer: AlohaCare Medicaid	$54.50
Rate for Payer: AlohaCare Medicare	$54.50
Rate for Payer: Cash Price	$70.85
Rate for Payer: Devoted Health Medicare	$59.95
Rate for Payer: Hawaii Medical Service Association Medicare	$54.50
Rate for Payer: Hawaii Western Management Group Commercial	$103.55
Rate for Payer: Health Management Network Commercial	$92.65
Rate for Payer: Humana Medicare	$54.50
Rate for Payer: Kaiser Permanente Commercial	$98.10
Rate for Payer: Kaiser Permanente Medicaid	$55.59
Rate for Payer: Kaiser Permanente Medicare	$54.50
Rate for Payer: MDX Hawaii PPO	$105.73
Rate for Payer: Ohana Health Plan Medicaid	$54.50
Rate for Payer: Ohana Health Plan Medicare	$54.50
Rate for Payer: UnitedHealthcare Medicare	$54.50
Rate for Payer: University Health Alliance Commercial	$79.45

OPTH:I-RING PUPIL EXPANDER

Facility

$786.00

Hospital Charge Code	8274244
Hospital Revenue Code	272
Min. Negotiated Rate	$393.00
Max. Negotiated Rate	$762.42
Rate for Payer: AlohaCare Medicaid	$393.00
Rate for Payer: AlohaCare Medicare	$393.00
Rate for Payer: Cash Price	$510.90
Rate for Payer: Devoted Health Medicare	$432.30
Rate for Payer: Hawaii Medical Service Association Medicare	$393.00
Rate for Payer: Hawaii Western Management Group Commercial	$746.70
Rate for Payer: Health Management Network Commercial	$668.10
Rate for Payer: Humana Medicare	$393.00
Rate for Payer: Kaiser Permanente Commercial	$707.40
Rate for Payer: Kaiser Permanente Medicaid	$400.86
Rate for Payer: Kaiser Permanente Medicare	$393.00
Rate for Payer: MDX Hawaii PPO	$762.42
Rate for Payer: Ohana Health Plan Medicaid	$393.00
Rate for Payer: Ohana Health Plan Medicare	$393.00
Rate for Payer: UnitedHealthcare Medicare	$393.00
Rate for Payer: University Health Alliance Commercial	$572.92

OPTH:I-RING PUPIL EXPANDER

Facility

$786.00

Hospital Charge Code	8274244
Hospital Revenue Code	272
Min. Negotiated Rate	$668.10
Max. Negotiated Rate	$762.42
Rate for Payer: Cash Price	$510.90
Rate for Payer: Health Management Network Commercial	$668.10
Rate for Payer: Kaiser Permanente Commercial	$707.40
Rate for Payer: MDX Hawaii PPO	$762.42

OPTH:IRRIGATING ANTERIOR CHAMBER CANNULA 30G

Facility

$52.00

Hospital Charge Code	8274284
Hospital Revenue Code	272
Min. Negotiated Rate	$44.20
Max. Negotiated Rate	$50.44
Rate for Payer: Cash Price	$33.80
Rate for Payer: Health Management Network Commercial	$44.20
Rate for Payer: Kaiser Permanente Commercial	$46.80
Rate for Payer: MDX Hawaii PPO	$50.44

OPTH:IRRIGATING ANTERIOR CHAMBER CANNULA 30G

Facility

$52.00

Hospital Charge Code	8274284
Hospital Revenue Code	272
Min. Negotiated Rate	$26.00
Max. Negotiated Rate	$50.44
Rate for Payer: AlohaCare Medicaid	$26.00
Rate for Payer: AlohaCare Medicare	$26.00
Rate for Payer: Cash Price	$33.80
Rate for Payer: Devoted Health Medicare	$28.60
Rate for Payer: Hawaii Medical Service Association Medicare	$26.00
Rate for Payer: Hawaii Western Management Group Commercial	$49.40
Rate for Payer: Health Management Network Commercial	$44.20
Rate for Payer: Humana Medicare	$26.00
Rate for Payer: Kaiser Permanente Commercial	$46.80
Rate for Payer: Kaiser Permanente Medicaid	$26.52
Rate for Payer: Kaiser Permanente Medicare	$26.00
Rate for Payer: MDX Hawaii PPO	$50.44
Rate for Payer: Ohana Health Plan Medicaid	$26.00
Rate for Payer: Ohana Health Plan Medicare	$26.00
Rate for Payer: UnitedHealthcare Medicare	$26.00
Rate for Payer: University Health Alliance Commercial	$37.90

OPTH:IRRIGATION; BSS 15CC

Facility

$42.00

Hospital Charge Code	8274377
Hospital Revenue Code	250
Min. Negotiated Rate	$35.70
Max. Negotiated Rate	$40.74
Rate for Payer: Cash Price	$27.30
Rate for Payer: Health Management Network Commercial	$35.70
Rate for Payer: Kaiser Permanente Commercial	$37.80
Rate for Payer: MDX Hawaii PPO	$40.74

OPTH:IRRIGATION; BSS 15CC

Facility

$42.00

Hospital Charge Code	8274377
Hospital Revenue Code	250
Min. Negotiated Rate	$21.00
Max. Negotiated Rate	$40.74
Rate for Payer: AlohaCare Medicaid	$21.00
Rate for Payer: AlohaCare Medicare	$21.00
Rate for Payer: Cash Price	$27.30
Rate for Payer: Devoted Health Medicare	$23.10
Rate for Payer: Hawaii Medical Service Association Medicare	$21.00
Rate for Payer: Hawaii Western Management Group Commercial	$39.90
Rate for Payer: Health Management Network Commercial	$35.70
Rate for Payer: Humana Medicare	$21.00
Rate for Payer: Kaiser Permanente Commercial	$37.80
Rate for Payer: Kaiser Permanente Medicaid	$21.42
Rate for Payer: Kaiser Permanente Medicare	$21.00
Rate for Payer: MDX Hawaii PPO	$40.74
Rate for Payer: Ohana Health Plan Medicaid	$21.00
Rate for Payer: Ohana Health Plan Medicare	$21.00
Rate for Payer: UnitedHealthcare Medicaid	$25.20
Rate for Payer: UnitedHealthcare Medicare	$21.00
Rate for Payer: University Health Alliance Commercial	$30.61

OPTH:I-STENT GLAUCOMA IMPLANT LEFT

Facility

$4,850.00

Service Code	HCPCS C1783
Hospital Charge Code	8274164
Hospital Revenue Code	278
Min. Negotiated Rate	$2,425.00
Max. Negotiated Rate	$4,704.50
Rate for Payer: AlohaCare Medicaid	$2,425.00
Rate for Payer: AlohaCare Medicare	$2,425.00
Rate for Payer: Cash Price	$3,152.50
Rate for Payer: Devoted Health Medicare	$2,667.50
Rate for Payer: Hawaii Medical Service Association Medicare	$2,425.00
Rate for Payer: Hawaii Western Management Group Commercial	$3,395.00
Rate for Payer: Health Management Network Commercial	$4,122.50
Rate for Payer: Humana Medicare	$2,425.00
Rate for Payer: Kaiser Permanente Commercial	$4,365.00
Rate for Payer: Kaiser Permanente Medicaid	$2,473.50
Rate for Payer: Kaiser Permanente Medicare	$2,425.00
Rate for Payer: MDX Hawaii PPO	$4,704.50
Rate for Payer: Ohana Health Plan Medicaid	$2,425.00
Rate for Payer: Ohana Health Plan Medicare	$2,425.00
Rate for Payer: UnitedHealthcare Medicare	$2,425.00
Rate for Payer: University Health Alliance Commercial	$2,716.00

OPTH:I-STENT GLAUCOMA IMPLANT LEFT

Facility

$4,850.00

Service Code	HCPCS C1783
Hospital Charge Code	8274164
Hospital Revenue Code	278
Min. Negotiated Rate	$2,716.00
Max. Negotiated Rate	$4,704.50
Rate for Payer: Cash Price	$3,152.50
Rate for Payer: Hawaii Western Management Group Commercial	$3,395.00
Rate for Payer: Health Management Network Commercial	$4,122.50
Rate for Payer: Kaiser Permanente Commercial	$4,365.00
Rate for Payer: MDX Hawaii PPO	$4,704.50
Rate for Payer: University Health Alliance Commercial	$2,716.00

OPTH:I-STENT GLAUCOMA IMPLANT RIGHT

Facility

$4,850.00

Service Code	HCPCS C1783
Hospital Charge Code	8274165
Hospital Revenue Code	278
Min. Negotiated Rate	$2,716.00
Max. Negotiated Rate	$4,704.50
Rate for Payer: Cash Price	$3,152.50
Rate for Payer: Hawaii Western Management Group Commercial	$3,395.00
Rate for Payer: Health Management Network Commercial	$4,122.50
Rate for Payer: Kaiser Permanente Commercial	$4,365.00
Rate for Payer: MDX Hawaii PPO	$4,704.50
Rate for Payer: University Health Alliance Commercial	$2,716.00

OPTH:I-STENT GLAUCOMA IMPLANT RIGHT

Facility

$4,850.00

Service Code	HCPCS C1783
Hospital Charge Code	8274165
Hospital Revenue Code	278
Min. Negotiated Rate	$2,425.00
Max. Negotiated Rate	$4,704.50
Rate for Payer: AlohaCare Medicaid	$2,425.00
Rate for Payer: AlohaCare Medicare	$2,425.00
Rate for Payer: Cash Price	$3,152.50
Rate for Payer: Devoted Health Medicare	$2,667.50
Rate for Payer: Hawaii Medical Service Association Medicare	$2,425.00
Rate for Payer: Hawaii Western Management Group Commercial	$3,395.00
Rate for Payer: Health Management Network Commercial	$4,122.50
Rate for Payer: Humana Medicare	$2,425.00
Rate for Payer: Kaiser Permanente Commercial	$4,365.00
Rate for Payer: Kaiser Permanente Medicaid	$2,473.50
Rate for Payer: Kaiser Permanente Medicare	$2,425.00
Rate for Payer: MDX Hawaii PPO	$4,704.50
Rate for Payer: Ohana Health Plan Medicaid	$2,425.00
Rate for Payer: Ohana Health Plan Medicare	$2,425.00
Rate for Payer: UnitedHealthcare Medicare	$2,425.00
Rate for Payer: University Health Alliance Commercial	$2,716.00

OPTH:KNIFE 15 DEGREE

Facility

$34.00

Hospital Charge Code	8274340
Hospital Revenue Code	272
Min. Negotiated Rate	$17.00
Max. Negotiated Rate	$32.98
Rate for Payer: AlohaCare Medicaid	$17.00
Rate for Payer: AlohaCare Medicare	$17.00
Rate for Payer: Cash Price	$22.10
Rate for Payer: Devoted Health Medicare	$18.70
Rate for Payer: Hawaii Medical Service Association Medicare	$17.00
Rate for Payer: Hawaii Western Management Group Commercial	$32.30
Rate for Payer: Health Management Network Commercial	$28.90
Rate for Payer: Humana Medicare	$17.00
Rate for Payer: Kaiser Permanente Commercial	$30.60
Rate for Payer: Kaiser Permanente Medicaid	$17.34
Rate for Payer: Kaiser Permanente Medicare	$17.00
Rate for Payer: MDX Hawaii PPO	$32.98
Rate for Payer: Ohana Health Plan Medicaid	$17.00
Rate for Payer: Ohana Health Plan Medicare	$17.00
Rate for Payer: UnitedHealthcare Medicare	$17.00
Rate for Payer: University Health Alliance Commercial	$24.78

OPTH:KNIFE 15 DEGREE

Facility

$34.00

Hospital Charge Code	8274340
Hospital Revenue Code	272
Min. Negotiated Rate	$28.90
Max. Negotiated Rate	$32.98
Rate for Payer: Cash Price	$22.10
Rate for Payer: Health Management Network Commercial	$28.90
Rate for Payer: Kaiser Permanente Commercial	$30.60
Rate for Payer: MDX Hawaii PPO	$32.98

OPTH KNIFE SCLERAL POCKET 1.0 MM

Facility

$110.00

Hospital Charge Code	8348102
Hospital Revenue Code	272
Min. Negotiated Rate	$93.50
Max. Negotiated Rate	$106.70
Rate for Payer: Cash Price	$71.50
Rate for Payer: Health Management Network Commercial	$93.50
Rate for Payer: Kaiser Permanente Commercial	$99.00
Rate for Payer: MDX Hawaii PPO	$106.70

OPTH KNIFE SCLERAL POCKET 1.0 MM

Facility

$110.00

Hospital Charge Code	8348102
Hospital Revenue Code	272
Min. Negotiated Rate	$55.00
Max. Negotiated Rate	$106.70
Rate for Payer: AlohaCare Medicaid	$55.00
Rate for Payer: AlohaCare Medicare	$55.00
Rate for Payer: Cash Price	$71.50
Rate for Payer: Devoted Health Medicare	$60.50
Rate for Payer: Hawaii Medical Service Association Medicare	$55.00
Rate for Payer: Hawaii Western Management Group Commercial	$104.50
Rate for Payer: Health Management Network Commercial	$93.50
Rate for Payer: Humana Medicare	$55.00
Rate for Payer: Kaiser Permanente Commercial	$99.00
Rate for Payer: Kaiser Permanente Medicaid	$56.10
Rate for Payer: Kaiser Permanente Medicare	$55.00
Rate for Payer: MDX Hawaii PPO	$106.70
Rate for Payer: Ohana Health Plan Medicaid	$55.00
Rate for Payer: Ohana Health Plan Medicare	$55.00
Rate for Payer: UnitedHealthcare Medicare	$55.00
Rate for Payer: University Health Alliance Commercial	$80.18

OPTH:KNIFE SIDE PORT CLEAR CUT 1.0 MM

Facility

$98.00

Hospital Charge Code	8274247
Hospital Revenue Code	272
Min. Negotiated Rate	$49.00
Max. Negotiated Rate	$95.06
Rate for Payer: AlohaCare Medicaid	$49.00
Rate for Payer: AlohaCare Medicare	$49.00
Rate for Payer: Cash Price	$63.70
Rate for Payer: Devoted Health Medicare	$53.90
Rate for Payer: Hawaii Medical Service Association Medicare	$49.00
Rate for Payer: Hawaii Western Management Group Commercial	$93.10
Rate for Payer: Health Management Network Commercial	$83.30
Rate for Payer: Humana Medicare	$49.00
Rate for Payer: Kaiser Permanente Commercial	$88.20
Rate for Payer: Kaiser Permanente Medicaid	$49.98
Rate for Payer: Kaiser Permanente Medicare	$49.00
Rate for Payer: MDX Hawaii PPO	$95.06
Rate for Payer: Ohana Health Plan Medicaid	$49.00
Rate for Payer: Ohana Health Plan Medicare	$49.00
Rate for Payer: UnitedHealthcare Medicare	$49.00
Rate for Payer: University Health Alliance Commercial	$71.43

OPTH:KNIFE SIDE PORT CLEAR CUT 1.0 MM

Facility

$98.00

Hospital Charge Code	8274247
Hospital Revenue Code	272
Min. Negotiated Rate	$83.30
Max. Negotiated Rate	$95.06
Rate for Payer: Cash Price	$63.70
Rate for Payer: Health Management Network Commercial	$83.30
Rate for Payer: Kaiser Permanente Commercial	$88.20
Rate for Payer: MDX Hawaii PPO	$95.06

OPTH:KNIFE SIDE PORT CLEAR CUT 1.2 MM

Facility

$114.00

Hospital Charge Code	8274248
Hospital Revenue Code	272
Min. Negotiated Rate	$57.00
Max. Negotiated Rate	$110.58
Rate for Payer: AlohaCare Medicaid	$57.00
Rate for Payer: AlohaCare Medicare	$57.00
Rate for Payer: Cash Price	$74.10
Rate for Payer: Devoted Health Medicare	$62.70
Rate for Payer: Hawaii Medical Service Association Medicare	$57.00
Rate for Payer: Hawaii Western Management Group Commercial	$108.30
Rate for Payer: Health Management Network Commercial	$96.90
Rate for Payer: Humana Medicare	$57.00
Rate for Payer: Kaiser Permanente Commercial	$102.60
Rate for Payer: Kaiser Permanente Medicaid	$58.14
Rate for Payer: Kaiser Permanente Medicare	$57.00
Rate for Payer: MDX Hawaii PPO	$110.58
Rate for Payer: Ohana Health Plan Medicaid	$57.00
Rate for Payer: Ohana Health Plan Medicare	$57.00
Rate for Payer: UnitedHealthcare Medicare	$57.00
Rate for Payer: University Health Alliance Commercial	$83.09

Know your out-of-pocket cost for care.

All Charges