Samuel Mahelona Memorial Hospital

All Charges

Charge

Type

Setting

Price

OPTH:KNIFE SIDE PORT CLEAR CUT 1.2 MM

Facility

$114.00

Hospital Charge Code	8274248
Hospital Revenue Code	272
Min. Negotiated Rate	$96.90
Max. Negotiated Rate	$110.58
Rate for Payer: Cash Price	$74.10
Rate for Payer: Health Management Network Commercial	$96.90
Rate for Payer: Kaiser Permanente Commercial	$102.60
Rate for Payer: MDX Hawaii PPO	$110.58

OPTH:KNIFE SIDEPORT CLEAR CUT 1.5MM

Facility

$89.00

Hospital Charge Code	8274249
Hospital Revenue Code	272
Min. Negotiated Rate	$44.50
Max. Negotiated Rate	$86.33
Rate for Payer: AlohaCare Medicaid	$44.50
Rate for Payer: AlohaCare Medicare	$44.50
Rate for Payer: Cash Price	$57.85
Rate for Payer: Devoted Health Medicare	$48.95
Rate for Payer: Hawaii Medical Service Association Medicare	$44.50
Rate for Payer: Hawaii Western Management Group Commercial	$84.55
Rate for Payer: Health Management Network Commercial	$75.65
Rate for Payer: Humana Medicare	$44.50
Rate for Payer: Kaiser Permanente Commercial	$80.10
Rate for Payer: Kaiser Permanente Medicaid	$45.39
Rate for Payer: Kaiser Permanente Medicare	$44.50
Rate for Payer: MDX Hawaii PPO	$86.33
Rate for Payer: Ohana Health Plan Medicaid	$44.50
Rate for Payer: Ohana Health Plan Medicare	$44.50
Rate for Payer: UnitedHealthcare Medicare	$44.50
Rate for Payer: University Health Alliance Commercial	$64.87

OPTH:KNIFE SIDEPORT CLEAR CUT 1.5MM

Facility

$89.00

Hospital Charge Code	8274249
Hospital Revenue Code	272
Min. Negotiated Rate	$75.65
Max. Negotiated Rate	$86.33
Rate for Payer: Cash Price	$57.85
Rate for Payer: Health Management Network Commercial	$75.65
Rate for Payer: Kaiser Permanente Commercial	$80.10
Rate for Payer: MDX Hawaii PPO	$86.33

OPTH:KNIFE SLIT CLEAR CUT 2.75MM

Facility

$298.00

Hospital Charge Code	8274250
Hospital Revenue Code	272
Min. Negotiated Rate	$253.30
Max. Negotiated Rate	$289.06
Rate for Payer: Cash Price	$193.70
Rate for Payer: Health Management Network Commercial	$253.30
Rate for Payer: Kaiser Permanente Commercial	$268.20
Rate for Payer: MDX Hawaii PPO	$289.06

OPTH:KNIFE SLIT CLEAR CUT 2.75MM

Facility

$298.00

Hospital Charge Code	8274250
Hospital Revenue Code	272
Min. Negotiated Rate	$149.00
Max. Negotiated Rate	$289.06
Rate for Payer: AlohaCare Medicaid	$149.00
Rate for Payer: AlohaCare Medicare	$149.00
Rate for Payer: Cash Price	$193.70
Rate for Payer: Devoted Health Medicare	$163.90
Rate for Payer: Hawaii Medical Service Association Medicare	$149.00
Rate for Payer: Hawaii Western Management Group Commercial	$283.10
Rate for Payer: Health Management Network Commercial	$253.30
Rate for Payer: Humana Medicare	$149.00
Rate for Payer: Kaiser Permanente Commercial	$268.20
Rate for Payer: Kaiser Permanente Medicaid	$151.98
Rate for Payer: Kaiser Permanente Medicare	$149.00
Rate for Payer: MDX Hawaii PPO	$289.06
Rate for Payer: Ohana Health Plan Medicaid	$149.00
Rate for Payer: Ohana Health Plan Medicare	$149.00
Rate for Payer: UnitedHealthcare Medicare	$149.00
Rate for Payer: University Health Alliance Commercial	$217.21

OPTH:LENS MULTIFOCAL TORIC

Facility

$1,733.00

Service Code	HCPCS V2788
Hospital Charge Code	8879042
Hospital Revenue Code	276
Min. Negotiated Rate	$866.50
Max. Negotiated Rate	$1,681.01
Rate for Payer: AlohaCare Medicaid	$866.50
Rate for Payer: AlohaCare Medicare	$866.50
Rate for Payer: Cash Price	$1,126.45
Rate for Payer: Devoted Health Medicare	$953.15
Rate for Payer: Hawaii Medical Service Association Medicare	$866.50
Rate for Payer: Hawaii Western Management Group Commercial	$1,213.10
Rate for Payer: Health Management Network Commercial	$1,473.05
Rate for Payer: Humana Medicare	$866.50
Rate for Payer: Kaiser Permanente Commercial	$1,559.70
Rate for Payer: Kaiser Permanente Medicaid	$883.83
Rate for Payer: Kaiser Permanente Medicare	$866.50
Rate for Payer: MDX Hawaii PPO	$1,681.01
Rate for Payer: Ohana Health Plan Medicaid	$866.50
Rate for Payer: Ohana Health Plan Medicare	$866.50
Rate for Payer: UnitedHealthcare Medicare	$866.50
Rate for Payer: University Health Alliance Commercial	$970.48

OPTH:LENS MULTIFOCAL TORIC

Facility

$1,733.00

Service Code	HCPCS V2788
Hospital Charge Code	8879042
Hospital Revenue Code	276
Min. Negotiated Rate	$970.48
Max. Negotiated Rate	$1,681.01
Rate for Payer: Cash Price	$1,126.45
Rate for Payer: Hawaii Western Management Group Commercial	$1,213.10
Rate for Payer: Health Management Network Commercial	$1,473.05
Rate for Payer: Kaiser Permanente Commercial	$1,559.70
Rate for Payer: MDX Hawaii PPO	$1,681.01
Rate for Payer: University Health Alliance Commercial	$970.48

OPTH:MALYUGIN RING 2.0 6.25 MM

Facility

$532.00

Hospital Charge Code	8274251
Hospital Revenue Code	272
Min. Negotiated Rate	$266.00
Max. Negotiated Rate	$516.04
Rate for Payer: AlohaCare Medicaid	$266.00
Rate for Payer: AlohaCare Medicare	$266.00
Rate for Payer: Cash Price	$345.80
Rate for Payer: Devoted Health Medicare	$292.60
Rate for Payer: Hawaii Medical Service Association Medicare	$266.00
Rate for Payer: Hawaii Western Management Group Commercial	$505.40
Rate for Payer: Health Management Network Commercial	$452.20
Rate for Payer: Humana Medicare	$266.00
Rate for Payer: Kaiser Permanente Commercial	$478.80
Rate for Payer: Kaiser Permanente Medicaid	$271.32
Rate for Payer: Kaiser Permanente Medicare	$266.00
Rate for Payer: MDX Hawaii PPO	$516.04
Rate for Payer: Ohana Health Plan Medicaid	$266.00
Rate for Payer: Ohana Health Plan Medicare	$266.00
Rate for Payer: UnitedHealthcare Medicare	$266.00
Rate for Payer: University Health Alliance Commercial	$387.77

OPTH:MALYUGIN RING 2.0 6.25 MM

Facility

$532.00

Hospital Charge Code	8274251
Hospital Revenue Code	272
Min. Negotiated Rate	$452.20
Max. Negotiated Rate	$516.04
Rate for Payer: Cash Price	$345.80
Rate for Payer: Health Management Network Commercial	$452.20
Rate for Payer: Kaiser Permanente Commercial	$478.80
Rate for Payer: MDX Hawaii PPO	$516.04

OPTH:MALYUGIN RING 6.25 (2.0)

Facility

$547.00

Hospital Charge Code	11808917
Hospital Revenue Code	272
Min. Negotiated Rate	$464.95
Max. Negotiated Rate	$530.59
Rate for Payer: Cash Price	$355.55
Rate for Payer: Health Management Network Commercial	$464.95
Rate for Payer: Kaiser Permanente Commercial	$492.30
Rate for Payer: MDX Hawaii PPO	$530.59

OPTH:MALYUGIN RING 6.25 (2.0)

Facility

$547.00

Hospital Charge Code	11808917
Hospital Revenue Code	272
Min. Negotiated Rate	$273.50
Max. Negotiated Rate	$530.59
Rate for Payer: AlohaCare Medicaid	$273.50
Rate for Payer: AlohaCare Medicare	$273.50
Rate for Payer: Cash Price	$355.55
Rate for Payer: Devoted Health Medicare	$300.85
Rate for Payer: Hawaii Medical Service Association Medicare	$273.50
Rate for Payer: Hawaii Western Management Group Commercial	$519.65
Rate for Payer: Health Management Network Commercial	$464.95
Rate for Payer: Humana Medicare	$273.50
Rate for Payer: Kaiser Permanente Commercial	$492.30
Rate for Payer: Kaiser Permanente Medicaid	$278.97
Rate for Payer: Kaiser Permanente Medicare	$273.50
Rate for Payer: MDX Hawaii PPO	$530.59
Rate for Payer: Ohana Health Plan Medicaid	$273.50
Rate for Payer: Ohana Health Plan Medicare	$273.50
Rate for Payer: UnitedHealthcare Medicare	$273.50
Rate for Payer: University Health Alliance Commercial	$398.71

OPTH:MALYUGIN RINGS 2.0 7.0 MM

Facility

$562.00

Hospital Charge Code	8274252
Hospital Revenue Code	272
Min. Negotiated Rate	$281.00
Max. Negotiated Rate	$545.14
Rate for Payer: AlohaCare Medicaid	$281.00
Rate for Payer: AlohaCare Medicare	$281.00
Rate for Payer: Cash Price	$365.30
Rate for Payer: Devoted Health Medicare	$309.10
Rate for Payer: Hawaii Medical Service Association Medicare	$281.00
Rate for Payer: Hawaii Western Management Group Commercial	$533.90
Rate for Payer: Health Management Network Commercial	$477.70
Rate for Payer: Humana Medicare	$281.00
Rate for Payer: Kaiser Permanente Commercial	$505.80
Rate for Payer: Kaiser Permanente Medicaid	$286.62
Rate for Payer: Kaiser Permanente Medicare	$281.00
Rate for Payer: MDX Hawaii PPO	$545.14
Rate for Payer: Ohana Health Plan Medicaid	$281.00
Rate for Payer: Ohana Health Plan Medicare	$281.00
Rate for Payer: UnitedHealthcare Medicare	$281.00
Rate for Payer: University Health Alliance Commercial	$409.64

OPTH:MALYUGIN RINGS 2.0 7.0 MM

Facility

$562.00

Hospital Charge Code	8274252
Hospital Revenue Code	272
Min. Negotiated Rate	$477.70
Max. Negotiated Rate	$545.14
Rate for Payer: Cash Price	$365.30
Rate for Payer: Health Management Network Commercial	$477.70
Rate for Payer: Kaiser Permanente Commercial	$505.80
Rate for Payer: MDX Hawaii PPO	$545.14

OPTH:MILOOP

Facility

$563.00

Hospital Charge Code	12646773
Hospital Revenue Code	272
Min. Negotiated Rate	$478.55
Max. Negotiated Rate	$546.11
Rate for Payer: Cash Price	$365.95
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

OPTH:MILOOP

Facility

$563.00

Hospital Charge Code	12646773
Hospital Revenue Code	272
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	$534.85
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	$410.37

OPTH:NEEDLE, PERIBULBAR

Facility

$31.00

Hospital Charge Code	8274285
Hospital Revenue Code	272
Min. Negotiated Rate	$15.50
Max. Negotiated Rate	$30.07
Rate for Payer: AlohaCare Medicaid	$15.50
Rate for Payer: AlohaCare Medicare	$15.50
Rate for Payer: Cash Price	$20.15
Rate for Payer: Devoted Health Medicare	$17.05
Rate for Payer: Hawaii Medical Service Association Medicare	$15.50
Rate for Payer: Hawaii Western Management Group Commercial	$29.45
Rate for Payer: Health Management Network Commercial	$26.35
Rate for Payer: Humana Medicare	$15.50
Rate for Payer: Kaiser Permanente Commercial	$27.90
Rate for Payer: Kaiser Permanente Medicaid	$15.81
Rate for Payer: Kaiser Permanente Medicare	$15.50
Rate for Payer: MDX Hawaii PPO	$30.07
Rate for Payer: Ohana Health Plan Medicaid	$15.50
Rate for Payer: Ohana Health Plan Medicare	$15.50
Rate for Payer: UnitedHealthcare Medicare	$15.50
Rate for Payer: University Health Alliance Commercial	$22.60

OPTH:NEEDLE, PERIBULBAR

Facility

$31.00

Hospital Charge Code	8274285
Hospital Revenue Code	272
Min. Negotiated Rate	$26.35
Max. Negotiated Rate	$30.07
Rate for Payer: Cash Price	$20.15
Rate for Payer: Health Management Network Commercial	$26.35
Rate for Payer: Kaiser Permanente Commercial	$27.90
Rate for Payer: MDX Hawaii PPO	$30.07

OPTH OMNI SURGICAL SYSTEM

Facility

$3,724.00

Hospital Charge Code	9243325
Hospital Revenue Code	272
Min. Negotiated Rate	$3,165.40
Max. Negotiated Rate	$3,612.28
Rate for Payer: Cash Price	$2,420.60
Rate for Payer: Health Management Network Commercial	$3,165.40
Rate for Payer: Kaiser Permanente Commercial	$3,351.60
Rate for Payer: MDX Hawaii PPO	$3,612.28

OPTH OMNI SURGICAL SYSTEM

Facility

$3,724.00

Hospital Charge Code	9243325
Hospital Revenue Code	272
Min. Negotiated Rate	$1,862.00
Max. Negotiated Rate	$3,612.28
Rate for Payer: AlohaCare Medicaid	$1,862.00
Rate for Payer: AlohaCare Medicare	$1,862.00
Rate for Payer: Cash Price	$2,420.60
Rate for Payer: Devoted Health Medicare	$2,048.20
Rate for Payer: Hawaii Medical Service Association Medicare	$1,862.00
Rate for Payer: Hawaii Western Management Group Commercial	$3,537.80
Rate for Payer: Health Management Network Commercial	$3,165.40
Rate for Payer: Humana Medicare	$1,862.00
Rate for Payer: Kaiser Permanente Commercial	$3,351.60
Rate for Payer: Kaiser Permanente Medicaid	$1,899.24
Rate for Payer: Kaiser Permanente Medicare	$1,862.00
Rate for Payer: MDX Hawaii PPO	$3,612.28
Rate for Payer: Ohana Health Plan Medicaid	$1,862.00
Rate for Payer: Ohana Health Plan Medicare	$1,862.00
Rate for Payer: UnitedHealthcare Medicare	$1,862.00
Rate for Payer: University Health Alliance Commercial	$2,714.42

OPTH PATCH SCLERAL

Facility

$963.00

Hospital Charge Code	8348090
Hospital Revenue Code	278
Min. Negotiated Rate	$481.50
Max. Negotiated Rate	$934.11
Rate for Payer: AlohaCare Medicaid	$481.50
Rate for Payer: AlohaCare Medicare	$481.50
Rate for Payer: Cash Price	$625.95
Rate for Payer: Devoted Health Medicare	$529.65
Rate for Payer: Hawaii Medical Service Association Medicare	$481.50
Rate for Payer: Hawaii Western Management Group Commercial	$674.10
Rate for Payer: Health Management Network Commercial	$818.55
Rate for Payer: Humana Medicare	$481.50
Rate for Payer: Kaiser Permanente Commercial	$866.70
Rate for Payer: Kaiser Permanente Medicaid	$491.13
Rate for Payer: Kaiser Permanente Medicare	$481.50
Rate for Payer: MDX Hawaii PPO	$934.11
Rate for Payer: Ohana Health Plan Medicaid	$481.50
Rate for Payer: Ohana Health Plan Medicare	$481.50
Rate for Payer: UnitedHealthcare Medicare	$481.50
Rate for Payer: University Health Alliance Commercial	$539.28

OPTH PATCH SCLERAL

Facility

$963.00

Hospital Charge Code	8348090
Hospital Revenue Code	278
Min. Negotiated Rate	$539.28
Max. Negotiated Rate	$934.11
Rate for Payer: Cash Price	$625.95
Rate for Payer: Hawaii Western Management Group Commercial	$674.10
Rate for Payer: Health Management Network Commercial	$818.55
Rate for Payer: Kaiser Permanente Commercial	$866.70
Rate for Payer: MDX Hawaii PPO	$934.11
Rate for Payer: University Health Alliance Commercial	$539.28

OPTH PERICARDIUM PATCH

Facility

$963.00

Hospital Charge Code	8348089
Hospital Revenue Code	278
Min. Negotiated Rate	$539.28
Max. Negotiated Rate	$934.11
Rate for Payer: Cash Price	$625.95
Rate for Payer: Hawaii Western Management Group Commercial	$674.10
Rate for Payer: Health Management Network Commercial	$818.55
Rate for Payer: Kaiser Permanente Commercial	$866.70
Rate for Payer: MDX Hawaii PPO	$934.11
Rate for Payer: University Health Alliance Commercial	$539.28

OPTH PERICARDIUM PATCH

Facility

$963.00

Hospital Charge Code	8348089
Hospital Revenue Code	278
Min. Negotiated Rate	$481.50
Max. Negotiated Rate	$934.11
Rate for Payer: AlohaCare Medicaid	$481.50
Rate for Payer: AlohaCare Medicare	$481.50
Rate for Payer: Cash Price	$625.95
Rate for Payer: Devoted Health Medicare	$529.65
Rate for Payer: Hawaii Medical Service Association Medicare	$481.50
Rate for Payer: Hawaii Western Management Group Commercial	$674.10
Rate for Payer: Health Management Network Commercial	$818.55
Rate for Payer: Humana Medicare	$481.50
Rate for Payer: Kaiser Permanente Commercial	$866.70
Rate for Payer: Kaiser Permanente Medicaid	$491.13
Rate for Payer: Kaiser Permanente Medicare	$481.50
Rate for Payer: MDX Hawaii PPO	$934.11
Rate for Payer: Ohana Health Plan Medicaid	$481.50
Rate for Payer: Ohana Health Plan Medicare	$481.50
Rate for Payer: UnitedHealthcare Medicare	$481.50
Rate for Payer: University Health Alliance Commercial	$539.28

OPTH:(PERSONALIZED VISION PROGRAM) IMPLANT TECNIS MULTIFOCAL LENS

Facility

$563.00

Service Code	HCPCS V2632
Hospital Charge Code	8546277
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: 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 Medicaid	$311.40
Rate for Payer: UnitedHealthcare Medicare	$281.50
Rate for Payer: University Health Alliance Commercial	$315.28

OPTH:(PERSONALIZED VISION PROGRAM) IMPLANT TECNIS MULTIFOCAL LENS

Facility

$563.00

Service Code	HCPCS V2632
Hospital Charge Code	8546277
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

Know your out-of-pocket cost for care.

All Charges