Samuel Mahelona Memorial Hospital

All Charges

Charge

Type

Setting

Price

OPTH:SYNERGY TORIC DFW150

Facility

$2,985.00

Service Code	HCPCS V2630
Hospital Charge Code	9909054
Hospital Revenue Code	276
Min. Negotiated Rate	$197.46
Max. Negotiated Rate	$2,895.45
Rate for Payer: AlohaCare Medicaid	$1,492.50
Rate for Payer: AlohaCare Medicare	$1,492.50
Rate for Payer: Cash Price	$1,940.25
Rate for Payer: Cash Price	$1,940.25
Rate for Payer: Devoted Health Medicare	$1,641.75
Rate for Payer: Hawaii Medical Service Association Medicare	$1,492.50
Rate for Payer: Hawaii Western Management Group Commercial	$2,089.50
Rate for Payer: Health Management Network Commercial	$2,537.25
Rate for Payer: Humana Medicare	$1,492.50
Rate for Payer: Kaiser Permanente Commercial	$2,686.50
Rate for Payer: Kaiser Permanente Medicaid	$1,522.35
Rate for Payer: Kaiser Permanente Medicare	$1,492.50
Rate for Payer: MDX Hawaii PPO	$2,895.45
Rate for Payer: Ohana Health Plan Medicaid	$1,492.50
Rate for Payer: Ohana Health Plan Medicare	$1,492.50
Rate for Payer: UnitedHealthcare Medicaid	$197.46
Rate for Payer: UnitedHealthcare Medicare	$1,492.50
Rate for Payer: University Health Alliance Commercial	$1,671.60

OPTH:SYNERGY TORIC DFW150

Facility

$2,985.00

Service Code	HCPCS V2630
Hospital Charge Code	9909054
Hospital Revenue Code	276
Min. Negotiated Rate	$1,671.60
Max. Negotiated Rate	$2,895.45
Rate for Payer: Cash Price	$1,940.25
Rate for Payer: Hawaii Western Management Group Commercial	$2,089.50
Rate for Payer: Health Management Network Commercial	$2,537.25
Rate for Payer: Kaiser Permanente Commercial	$2,686.50
Rate for Payer: MDX Hawaii PPO	$2,895.45
Rate for Payer: University Health Alliance Commercial	$1,671.60

OPTH:SYNERGY TORIC DFW225

Facility

$2,985.00

Service Code	HCPCS V2630
Hospital Charge Code	9909082
Hospital Revenue Code	276
Min. Negotiated Rate	$1,671.60
Max. Negotiated Rate	$2,895.45
Rate for Payer: Cash Price	$1,940.25
Rate for Payer: Hawaii Western Management Group Commercial	$2,089.50
Rate for Payer: Health Management Network Commercial	$2,537.25
Rate for Payer: Kaiser Permanente Commercial	$2,686.50
Rate for Payer: MDX Hawaii PPO	$2,895.45
Rate for Payer: University Health Alliance Commercial	$1,671.60

OPTH:SYNERGY TORIC DFW225

Facility

$2,985.00

Service Code	HCPCS V2630
Hospital Charge Code	9909082
Hospital Revenue Code	276
Min. Negotiated Rate	$197.46
Max. Negotiated Rate	$2,895.45
Rate for Payer: AlohaCare Medicaid	$1,492.50
Rate for Payer: AlohaCare Medicare	$1,492.50
Rate for Payer: Cash Price	$1,940.25
Rate for Payer: Cash Price	$1,940.25
Rate for Payer: Devoted Health Medicare	$1,641.75
Rate for Payer: Hawaii Medical Service Association Medicare	$1,492.50
Rate for Payer: Hawaii Western Management Group Commercial	$2,089.50
Rate for Payer: Health Management Network Commercial	$2,537.25
Rate for Payer: Humana Medicare	$1,492.50
Rate for Payer: Kaiser Permanente Commercial	$2,686.50
Rate for Payer: Kaiser Permanente Medicaid	$1,522.35
Rate for Payer: Kaiser Permanente Medicare	$1,492.50
Rate for Payer: MDX Hawaii PPO	$2,895.45
Rate for Payer: Ohana Health Plan Medicaid	$1,492.50
Rate for Payer: Ohana Health Plan Medicare	$1,492.50
Rate for Payer: UnitedHealthcare Medicaid	$197.46
Rate for Payer: UnitedHealthcare Medicare	$1,492.50
Rate for Payer: University Health Alliance Commercial	$1,671.60

OPTH:SYNERGY TORIC DFW300

Facility

$2,985.00

Service Code	HCPCS V2630
Hospital Charge Code	9909083
Hospital Revenue Code	276
Min. Negotiated Rate	$1,671.60
Max. Negotiated Rate	$2,895.45
Rate for Payer: Cash Price	$1,940.25
Rate for Payer: Hawaii Western Management Group Commercial	$2,089.50
Rate for Payer: Health Management Network Commercial	$2,537.25
Rate for Payer: Kaiser Permanente Commercial	$2,686.50
Rate for Payer: MDX Hawaii PPO	$2,895.45
Rate for Payer: University Health Alliance Commercial	$1,671.60

OPTH:SYNERGY TORIC DFW300

Facility

$2,985.00

Service Code	HCPCS V2630
Hospital Charge Code	9909083
Hospital Revenue Code	276
Min. Negotiated Rate	$197.46
Max. Negotiated Rate	$2,895.45
Rate for Payer: AlohaCare Medicaid	$1,492.50
Rate for Payer: AlohaCare Medicare	$1,492.50
Rate for Payer: Cash Price	$1,940.25
Rate for Payer: Cash Price	$1,940.25
Rate for Payer: Devoted Health Medicare	$1,641.75
Rate for Payer: Hawaii Medical Service Association Medicare	$1,492.50
Rate for Payer: Hawaii Western Management Group Commercial	$2,089.50
Rate for Payer: Health Management Network Commercial	$2,537.25
Rate for Payer: Humana Medicare	$1,492.50
Rate for Payer: Kaiser Permanente Commercial	$2,686.50
Rate for Payer: Kaiser Permanente Medicaid	$1,522.35
Rate for Payer: Kaiser Permanente Medicare	$1,492.50
Rate for Payer: MDX Hawaii PPO	$2,895.45
Rate for Payer: Ohana Health Plan Medicaid	$1,492.50
Rate for Payer: Ohana Health Plan Medicare	$1,492.50
Rate for Payer: UnitedHealthcare Medicaid	$197.46
Rate for Payer: UnitedHealthcare Medicare	$1,492.50
Rate for Payer: University Health Alliance Commercial	$1,671.60

OPTH:SYNERGY TORIC DFW375

Facility

$2,985.00

Service Code	HCPCS V2630
Hospital Charge Code	9909084
Hospital Revenue Code	276
Min. Negotiated Rate	$197.46
Max. Negotiated Rate	$2,895.45
Rate for Payer: AlohaCare Medicaid	$1,492.50
Rate for Payer: AlohaCare Medicare	$1,492.50
Rate for Payer: Cash Price	$1,940.25
Rate for Payer: Cash Price	$1,940.25
Rate for Payer: Devoted Health Medicare	$1,641.75
Rate for Payer: Hawaii Medical Service Association Medicare	$1,492.50
Rate for Payer: Hawaii Western Management Group Commercial	$2,089.50
Rate for Payer: Health Management Network Commercial	$2,537.25
Rate for Payer: Humana Medicare	$1,492.50
Rate for Payer: Kaiser Permanente Commercial	$2,686.50
Rate for Payer: Kaiser Permanente Medicaid	$1,522.35
Rate for Payer: Kaiser Permanente Medicare	$1,492.50
Rate for Payer: MDX Hawaii PPO	$2,895.45
Rate for Payer: Ohana Health Plan Medicaid	$1,492.50
Rate for Payer: Ohana Health Plan Medicare	$1,492.50
Rate for Payer: UnitedHealthcare Medicaid	$197.46
Rate for Payer: UnitedHealthcare Medicare	$1,492.50
Rate for Payer: University Health Alliance Commercial	$1,671.60

OPTH:SYNERGY TORIC DFW375

Facility

$2,985.00

Service Code	HCPCS V2630
Hospital Charge Code	9909084
Hospital Revenue Code	276
Min. Negotiated Rate	$1,671.60
Max. Negotiated Rate	$2,895.45
Rate for Payer: Cash Price	$1,940.25
Rate for Payer: Hawaii Western Management Group Commercial	$2,089.50
Rate for Payer: Health Management Network Commercial	$2,537.25
Rate for Payer: Kaiser Permanente Commercial	$2,686.50
Rate for Payer: MDX Hawaii PPO	$2,895.45
Rate for Payer: University Health Alliance Commercial	$1,671.60

OPTH:VACUMN TERPHINE 7.5 MM

Facility

$332.00

Hospital Charge Code	8274177
Hospital Revenue Code	272
Min. Negotiated Rate	$282.20
Max. Negotiated Rate	$322.04
Rate for Payer: Cash Price	$215.80
Rate for Payer: Health Management Network Commercial	$282.20
Rate for Payer: Kaiser Permanente Commercial	$298.80
Rate for Payer: MDX Hawaii PPO	$322.04

OPTH:VACUMN TERPHINE 7.5 MM

Facility

$332.00

Hospital Charge Code	8274177
Hospital Revenue Code	272
Min. Negotiated Rate	$166.00
Max. Negotiated Rate	$322.04
Rate for Payer: AlohaCare Medicaid	$166.00
Rate for Payer: AlohaCare Medicare	$166.00
Rate for Payer: Cash Price	$215.80
Rate for Payer: Devoted Health Medicare	$182.60
Rate for Payer: Hawaii Medical Service Association Medicare	$166.00
Rate for Payer: Hawaii Western Management Group Commercial	$315.40
Rate for Payer: Health Management Network Commercial	$282.20
Rate for Payer: Humana Medicare	$166.00
Rate for Payer: Kaiser Permanente Commercial	$298.80
Rate for Payer: Kaiser Permanente Medicaid	$169.32
Rate for Payer: Kaiser Permanente Medicare	$166.00
Rate for Payer: MDX Hawaii PPO	$322.04
Rate for Payer: Ohana Health Plan Medicaid	$166.00
Rate for Payer: Ohana Health Plan Medicare	$166.00
Rate for Payer: UnitedHealthcare Medicare	$166.00
Rate for Payer: University Health Alliance Commercial	$241.99

OPTH:VACUMN TERPHINE 7.75 MM

Facility

$312.00

Hospital Charge Code	8274178
Hospital Revenue Code	272
Min. Negotiated Rate	$265.20
Max. Negotiated Rate	$302.64
Rate for Payer: Cash Price	$202.80
Rate for Payer: Health Management Network Commercial	$265.20
Rate for Payer: Kaiser Permanente Commercial	$280.80
Rate for Payer: MDX Hawaii PPO	$302.64

OPTH:VACUMN TERPHINE 7.75 MM

Facility

$312.00

Hospital Charge Code	8274178
Hospital Revenue Code	272
Min. Negotiated Rate	$156.00
Max. Negotiated Rate	$302.64
Rate for Payer: AlohaCare Medicaid	$156.00
Rate for Payer: AlohaCare Medicare	$156.00
Rate for Payer: Cash Price	$202.80
Rate for Payer: Devoted Health Medicare	$171.60
Rate for Payer: Hawaii Medical Service Association Medicare	$156.00
Rate for Payer: Hawaii Western Management Group Commercial	$296.40
Rate for Payer: Health Management Network Commercial	$265.20
Rate for Payer: Humana Medicare	$156.00
Rate for Payer: Kaiser Permanente Commercial	$280.80
Rate for Payer: Kaiser Permanente Medicaid	$159.12
Rate for Payer: Kaiser Permanente Medicare	$156.00
Rate for Payer: MDX Hawaii PPO	$302.64
Rate for Payer: Ohana Health Plan Medicaid	$156.00
Rate for Payer: Ohana Health Plan Medicare	$156.00
Rate for Payer: UnitedHealthcare Medicare	$156.00
Rate for Payer: University Health Alliance Commercial	$227.42

OPTH:VACUMN TERPHINE 8.5MM

Facility

$332.00

Hospital Charge Code	8274180
Hospital Revenue Code	272
Min. Negotiated Rate	$166.00
Max. Negotiated Rate	$322.04
Rate for Payer: AlohaCare Medicaid	$166.00
Rate for Payer: AlohaCare Medicare	$166.00
Rate for Payer: Cash Price	$215.80
Rate for Payer: Devoted Health Medicare	$182.60
Rate for Payer: Hawaii Medical Service Association Medicare	$166.00
Rate for Payer: Hawaii Western Management Group Commercial	$315.40
Rate for Payer: Health Management Network Commercial	$282.20
Rate for Payer: Humana Medicare	$166.00
Rate for Payer: Kaiser Permanente Commercial	$298.80
Rate for Payer: Kaiser Permanente Medicaid	$169.32
Rate for Payer: Kaiser Permanente Medicare	$166.00
Rate for Payer: MDX Hawaii PPO	$322.04
Rate for Payer: Ohana Health Plan Medicaid	$166.00
Rate for Payer: Ohana Health Plan Medicare	$166.00
Rate for Payer: UnitedHealthcare Medicare	$166.00
Rate for Payer: University Health Alliance Commercial	$241.99

OPTH:VACUMN TERPHINE 8.5MM

Facility

$332.00

Hospital Charge Code	8274180
Hospital Revenue Code	272
Min. Negotiated Rate	$282.20
Max. Negotiated Rate	$322.04
Rate for Payer: Cash Price	$215.80
Rate for Payer: Health Management Network Commercial	$282.20
Rate for Payer: Kaiser Permanente Commercial	$298.80
Rate for Payer: MDX Hawaii PPO	$322.04

OPTH:VACUMN TERPHINE 9.0MM

Facility

$296.00

Hospital Charge Code	8274181
Hospital Revenue Code	272
Min. Negotiated Rate	$251.60
Max. Negotiated Rate	$287.12
Rate for Payer: Cash Price	$192.40
Rate for Payer: Health Management Network Commercial	$251.60
Rate for Payer: Kaiser Permanente Commercial	$266.40
Rate for Payer: MDX Hawaii PPO	$287.12

OPTH:VACUMN TERPHINE 9.0MM

Facility

$296.00

Hospital Charge Code	8274181
Hospital Revenue Code	272
Min. Negotiated Rate	$148.00
Max. Negotiated Rate	$287.12
Rate for Payer: AlohaCare Medicaid	$148.00
Rate for Payer: AlohaCare Medicare	$148.00
Rate for Payer: Cash Price	$192.40
Rate for Payer: Devoted Health Medicare	$162.80
Rate for Payer: Hawaii Medical Service Association Medicare	$148.00
Rate for Payer: Hawaii Western Management Group Commercial	$281.20
Rate for Payer: Health Management Network Commercial	$251.60
Rate for Payer: Humana Medicare	$148.00
Rate for Payer: Kaiser Permanente Commercial	$266.40
Rate for Payer: Kaiser Permanente Medicaid	$150.96
Rate for Payer: Kaiser Permanente Medicare	$148.00
Rate for Payer: MDX Hawaii PPO	$287.12
Rate for Payer: Ohana Health Plan Medicaid	$148.00
Rate for Payer: Ohana Health Plan Medicare	$148.00
Rate for Payer: UnitedHealthcare Medicare	$148.00
Rate for Payer: University Health Alliance Commercial	$215.75

OPTH VISCOAT 0.5ML ALCON

Facility

$258.00

Hospital Charge Code	9077882
Hospital Revenue Code	272
Min. Negotiated Rate	$219.30
Max. Negotiated Rate	$250.26
Rate for Payer: Cash Price	$167.70
Rate for Payer: Health Management Network Commercial	$219.30
Rate for Payer: Kaiser Permanente Commercial	$232.20
Rate for Payer: MDX Hawaii PPO	$250.26

OPTH VISCOAT 0.5ML ALCON

Facility

$258.00

Hospital Charge Code	9077882
Hospital Revenue Code	272
Min. Negotiated Rate	$129.00
Max. Negotiated Rate	$250.26
Rate for Payer: AlohaCare Medicaid	$129.00
Rate for Payer: AlohaCare Medicare	$129.00
Rate for Payer: Cash Price	$167.70
Rate for Payer: Devoted Health Medicare	$141.90
Rate for Payer: Hawaii Medical Service Association Medicare	$129.00
Rate for Payer: Hawaii Western Management Group Commercial	$245.10
Rate for Payer: Health Management Network Commercial	$219.30
Rate for Payer: Humana Medicare	$129.00
Rate for Payer: Kaiser Permanente Commercial	$232.20
Rate for Payer: Kaiser Permanente Medicaid	$131.58
Rate for Payer: Kaiser Permanente Medicare	$129.00
Rate for Payer: MDX Hawaii PPO	$250.26
Rate for Payer: Ohana Health Plan Medicaid	$129.00
Rate for Payer: Ohana Health Plan Medicare	$129.00
Rate for Payer: UnitedHealthcare Medicare	$129.00
Rate for Payer: University Health Alliance Commercial	$188.06

OPTH:VITRECTOMY, ANTERIOR 23G

Facility

$1,019.00

Hospital Charge Code	8274183
Hospital Revenue Code	272
Min. Negotiated Rate	$866.15
Max. Negotiated Rate	$988.43
Rate for Payer: Cash Price	$662.35
Rate for Payer: Health Management Network Commercial	$866.15
Rate for Payer: Kaiser Permanente Commercial	$917.10
Rate for Payer: MDX Hawaii PPO	$988.43

OPTH:VITRECTOMY, ANTERIOR 23G

Facility

$1,019.00

Hospital Charge Code	8274183
Hospital Revenue Code	272
Min. Negotiated Rate	$509.50
Max. Negotiated Rate	$988.43
Rate for Payer: AlohaCare Medicaid	$509.50
Rate for Payer: AlohaCare Medicare	$509.50
Rate for Payer: Cash Price	$662.35
Rate for Payer: Devoted Health Medicare	$560.45
Rate for Payer: Hawaii Medical Service Association Medicare	$509.50
Rate for Payer: Hawaii Western Management Group Commercial	$968.05
Rate for Payer: Health Management Network Commercial	$866.15
Rate for Payer: Humana Medicare	$509.50
Rate for Payer: Kaiser Permanente Commercial	$917.10
Rate for Payer: Kaiser Permanente Medicaid	$519.69
Rate for Payer: Kaiser Permanente Medicare	$509.50
Rate for Payer: MDX Hawaii PPO	$988.43
Rate for Payer: Ohana Health Plan Medicaid	$509.50
Rate for Payer: Ohana Health Plan Medicare	$509.50
Rate for Payer: UnitedHealthcare Medicare	$509.50
Rate for Payer: University Health Alliance Commercial	$742.75

ORBITAL PROCEDURES WITH CC/MCC

Facility

$19,103.81

Service Code	MSDRG 113
Min. Negotiated Rate	$10,400.00
Max. Negotiated Rate	$19,103.81
Rate for Payer: Hawaii Medical Service Association Commercial	$19,103.81
Rate for Payer: University Health Alliance Commercial	$10,400.00

ORBITAL PROCEDURES WITHOUT CC/MCC

Facility

$19,103.81

Service Code	MSDRG 114
Min. Negotiated Rate	$10,400.00
Max. Negotiated Rate	$19,103.81
Rate for Payer: Hawaii Medical Service Association Commercial	$19,103.81
Rate for Payer: University Health Alliance Commercial	$10,400.00

ORGANIC DISTURBANCES AND INTELLECTUAL DISABILITY

Facility

$25,669.27

Service Code	MSDRG 884
Min. Negotiated Rate	$25,669.27
Max. Negotiated Rate	$25,669.27
Rate for Payer: Hawaii Medical Service Association Commercial	$25,669.27

O.R. PROCEDURES FOR OBESITY WITH CC

Facility

$51,717.76

Service Code	MSDRG 620
Min. Negotiated Rate	$51,717.76
Max. Negotiated Rate	$51,717.76
Rate for Payer: Hawaii Medical Service Association Commercial	$51,717.76

O.R. PROCEDURES FOR OBESITY WITH MCC

Facility

$51,717.76

Service Code	MSDRG 619
Min. Negotiated Rate	$51,717.76
Max. Negotiated Rate	$51,717.76
Rate for Payer: Hawaii Medical Service Association Commercial	$51,717.76

Know your out-of-pocket cost for care.

All Charges