Hilo Benioff Medical Center

All Charges

Charge

Type

Setting

Price

TRACHEOSTOMY W MV 96+ HOURS W EXTENSIVE PROCEDURE

Facility

$34,495.67

Service Code	APR-DRG 0041
Min. Negotiated Rate	$34,495.67
Max. Negotiated Rate	$34,495.67
Rate for Payer: AlohaCare Medicaid	$34,495.67
Rate for Payer: Hawaii Medical Service Association ABD	$34,495.67
Rate for Payer: Hawaii Medical Service Association Non-ABD	$34,495.67
Rate for Payer: Kaiser Permanente Medicaid	$34,495.67
Rate for Payer: Ohana Health Plan Medicaid	$34,495.67
Rate for Payer: UnitedHealthcare Medicaid	$34,495.67

TRACHEOSTOMY W MV 96+ HOURS W EXTENSIVE PROCEDURE

Facility

$50,484.94

Service Code	APR-DRG 0043
Min. Negotiated Rate	$50,484.94
Max. Negotiated Rate	$50,484.94
Rate for Payer: AlohaCare Medicaid	$50,484.94
Rate for Payer: Hawaii Medical Service Association ABD	$50,484.94
Rate for Payer: Hawaii Medical Service Association Non-ABD	$50,484.94
Rate for Payer: Kaiser Permanente Medicaid	$50,484.94
Rate for Payer: Ohana Health Plan Medicaid	$50,484.94
Rate for Payer: UnitedHealthcare Medicaid	$50,484.94

TRACHEOSTOMY W MV 96+ HOURS W/O EXTENSIVE PROCEDURE

Facility

$46,150.55

Service Code	APR-DRG 0054
Min. Negotiated Rate	$46,150.55
Max. Negotiated Rate	$46,150.55
Rate for Payer: AlohaCare Medicaid	$46,150.55
Rate for Payer: Hawaii Medical Service Association ABD	$46,150.55
Rate for Payer: Hawaii Medical Service Association Non-ABD	$46,150.55
Rate for Payer: Kaiser Permanente Medicaid	$46,150.55
Rate for Payer: Ohana Health Plan Medicaid	$46,150.55
Rate for Payer: UnitedHealthcare Medicaid	$46,150.55

TRACHEOSTOMY W MV 96+ HOURS W/O EXTENSIVE PROCEDURE

Facility

$25,817.78

Service Code	APR-DRG 0051
Min. Negotiated Rate	$25,817.78
Max. Negotiated Rate	$25,817.78
Rate for Payer: AlohaCare Medicaid	$25,817.78
Rate for Payer: Hawaii Medical Service Association ABD	$25,817.78
Rate for Payer: Hawaii Medical Service Association Non-ABD	$25,817.78
Rate for Payer: Kaiser Permanente Medicaid	$25,817.78
Rate for Payer: Ohana Health Plan Medicaid	$25,817.78
Rate for Payer: UnitedHealthcare Medicaid	$25,817.78

TRACHEOSTOMY W MV 96+ HOURS W/O EXTENSIVE PROCEDURE

Facility

$35,526.92

Service Code	APR-DRG 0053
Min. Negotiated Rate	$35,526.92
Max. Negotiated Rate	$35,526.92
Rate for Payer: AlohaCare Medicaid	$35,526.92
Rate for Payer: Hawaii Medical Service Association ABD	$35,526.92
Rate for Payer: Hawaii Medical Service Association Non-ABD	$35,526.92
Rate for Payer: Kaiser Permanente Medicaid	$35,526.92
Rate for Payer: Ohana Health Plan Medicaid	$35,526.92
Rate for Payer: UnitedHealthcare Medicaid	$35,526.92

TRACHEOSTOMY W MV 96+ HOURS W/O EXTENSIVE PROCEDURE

Facility

$27,568.49

Service Code	APR-DRG 0052
Min. Negotiated Rate	$27,568.49
Max. Negotiated Rate	$27,568.49
Rate for Payer: AlohaCare Medicaid	$27,568.49
Rate for Payer: Hawaii Medical Service Association ABD	$27,568.49
Rate for Payer: Hawaii Medical Service Association Non-ABD	$27,568.49
Rate for Payer: Kaiser Permanente Medicaid	$27,568.49
Rate for Payer: Ohana Health Plan Medicaid	$27,568.49
Rate for Payer: UnitedHealthcare Medicaid	$27,568.49

TRACHEOTOMY TUBE CHANGE PRIOR TO ESTABLISHMENT OF FISTULA TRACT

Facility

$2,837.00

Service Code	CPT 31502
Hospital Revenue Code	360
Min. Negotiated Rate	$32.14
Max. Negotiated Rate	$2,837.00
Rate for Payer: AlohaCare Medicaid	$279.80
Rate for Payer: AlohaCare Medicare	$279.80
Rate for Payer: Devoted Health Medicare	$307.78
Rate for Payer: Hawaii Medical Service Association ABD	$393.00
Rate for Payer: Hawaii Medical Service Association Commercial	$2,536.00
Rate for Payer: Hawaii Medical Service Association Medicare	$279.80
Rate for Payer: Hawaii Medical Service Association Non-ABD	$496.75
Rate for Payer: Humana Medicare	$279.80
Rate for Payer: Kaiser Permanente Medicaid	$2,837.00
Rate for Payer: Kaiser Permanente Medicare	$279.80
Rate for Payer: Ohana Health Plan Medicaid	$307.78
Rate for Payer: Ohana Health Plan Medicare	$279.80
Rate for Payer: UnitedHealthcare Medicaid	$32.14
Rate for Payer: UnitedHealthcare Medicare	$279.80

TRACH PERC INTROD 8.0MM

Facility

$1,560.00

Service Code	HCPCS C1769
Hospital Revenue Code	272
Min. Negotiated Rate	$1,326.00
Max. Negotiated Rate	$1,513.20
Rate for Payer: Cash Price	$936.00
Rate for Payer: Health Management Network Commercial	$1,326.00
Rate for Payer: MDX Hawaii PPO	$1,513.20

TRACH PERC INTROD 8.0MM

Facility

$1,560.00

Service Code	HCPCS C1769
Hospital Revenue Code	272
Min. Negotiated Rate	$795.60
Max. Negotiated Rate	$1,513.20
Rate for Payer: Cash Price	$936.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,482.00
Rate for Payer: Health Management Network Commercial	$1,326.00
Rate for Payer: Kaiser Permanente Commercial	$982.80
Rate for Payer: Kaiser Permanente Medicaid	$795.60
Rate for Payer: MDX Hawaii PPO	$1,513.20
Rate for Payer: University Health Alliance Commercial	$1,137.08

TRACH SHILEY 8XLT CUFF

Facility

$259.00

Hospital Revenue Code	272
Min. Negotiated Rate	$132.09
Max. Negotiated Rate	$251.23
Rate for Payer: Cash Price	$155.40
Rate for Payer: Hawaii Western Management Group Commercial	$246.05
Rate for Payer: Health Management Network Commercial	$220.15
Rate for Payer: Kaiser Permanente Commercial	$163.17
Rate for Payer: Kaiser Permanente Medicaid	$132.09
Rate for Payer: MDX Hawaii PPO	$251.23
Rate for Payer: University Health Alliance Commercial	$188.79

TRACH SHILEY 8XLT CUFF

Facility

$259.00

Hospital Revenue Code	272
Min. Negotiated Rate	$220.15
Max. Negotiated Rate	$251.23
Rate for Payer: Cash Price	$155.40
Rate for Payer: Health Management Network Commercial	$220.15
Rate for Payer: MDX Hawaii PPO	$251.23

TRACH TUBE 6.0MM BIVONA

Facility

$735.00

Hospital Revenue Code	272
Min. Negotiated Rate	$624.75
Max. Negotiated Rate	$712.95
Rate for Payer: Cash Price	$441.00
Rate for Payer: Health Management Network Commercial	$624.75
Rate for Payer: MDX Hawaii PPO	$712.95

TRACH TUBE 6.0MM BIVONA

Facility

$735.00

Hospital Revenue Code	272
Min. Negotiated Rate	$374.85
Max. Negotiated Rate	$712.95
Rate for Payer: Cash Price	$441.00
Rate for Payer: Hawaii Western Management Group Commercial	$698.25
Rate for Payer: Health Management Network Commercial	$624.75
Rate for Payer: Kaiser Permanente Commercial	$463.05
Rate for Payer: Kaiser Permanente Medicaid	$374.85
Rate for Payer: MDX Hawaii PPO	$712.95
Rate for Payer: University Health Alliance Commercial	$535.74

TRACH TUBE 7.0MM BIVONA

Facility

$735.00

Hospital Revenue Code	272
Min. Negotiated Rate	$374.85
Max. Negotiated Rate	$712.95
Rate for Payer: Cash Price	$441.00
Rate for Payer: Hawaii Western Management Group Commercial	$698.25
Rate for Payer: Health Management Network Commercial	$624.75
Rate for Payer: Kaiser Permanente Commercial	$463.05
Rate for Payer: Kaiser Permanente Medicaid	$374.85
Rate for Payer: MDX Hawaii PPO	$712.95
Rate for Payer: University Health Alliance Commercial	$535.74

TRACH TUBE 7.0MM BIVONA

Facility

$735.00

Hospital Revenue Code	272
Min. Negotiated Rate	$624.75
Max. Negotiated Rate	$712.95
Rate for Payer: Cash Price	$441.00
Rate for Payer: Health Management Network Commercial	$624.75
Rate for Payer: MDX Hawaii PPO	$712.95

TRACH TUBE BIVONA 8 SILICONE

Facility

$713.00

Hospital Revenue Code	272
Min. Negotiated Rate	$606.05
Max. Negotiated Rate	$691.61
Rate for Payer: Cash Price	$427.80
Rate for Payer: Health Management Network Commercial	$606.05
Rate for Payer: MDX Hawaii PPO	$691.61

TRACH TUBE BIVONA 8 SILICONE

Facility

$713.00

Hospital Revenue Code	272
Min. Negotiated Rate	$363.63
Max. Negotiated Rate	$691.61
Rate for Payer: Cash Price	$427.80
Rate for Payer: Hawaii Western Management Group Commercial	$677.35
Rate for Payer: Health Management Network Commercial	$606.05
Rate for Payer: Kaiser Permanente Commercial	$449.19
Rate for Payer: Kaiser Permanente Medicaid	$363.63
Rate for Payer: MDX Hawaii PPO	$691.61
Rate for Payer: University Health Alliance Commercial	$519.71

TRACH TUBE CUFF 6.5

Facility

$192.00

Hospital Revenue Code	272
Min. Negotiated Rate	$163.20
Max. Negotiated Rate	$186.24
Rate for Payer: Cash Price	$115.20
Rate for Payer: Health Management Network Commercial	$163.20
Rate for Payer: MDX Hawaii PPO	$186.24

TRACH TUBE CUFF 6.5

Facility

$192.00

Hospital Revenue Code	272
Min. Negotiated Rate	$97.92
Max. Negotiated Rate	$186.24
Rate for Payer: Cash Price	$115.20
Rate for Payer: Hawaii Western Management Group Commercial	$182.40
Rate for Payer: Health Management Network Commercial	$163.20
Rate for Payer: Kaiser Permanente Commercial	$120.96
Rate for Payer: Kaiser Permanente Medicaid	$97.92
Rate for Payer: MDX Hawaii PPO	$186.24
Rate for Payer: University Health Alliance Commercial	$139.95

TRACH TUBE CUFF 7.5

Facility

$192.00

Hospital Revenue Code	272
Min. Negotiated Rate	$97.92
Max. Negotiated Rate	$186.24
Rate for Payer: Cash Price	$115.20
Rate for Payer: Hawaii Western Management Group Commercial	$182.40
Rate for Payer: Health Management Network Commercial	$163.20
Rate for Payer: Kaiser Permanente Commercial	$120.96
Rate for Payer: Kaiser Permanente Medicaid	$97.92
Rate for Payer: MDX Hawaii PPO	$186.24
Rate for Payer: University Health Alliance Commercial	$139.95

TRACH TUBE CUFF 7.5

Facility

$192.00

Hospital Revenue Code	272
Min. Negotiated Rate	$163.20
Max. Negotiated Rate	$186.24
Rate for Payer: Cash Price	$115.20
Rate for Payer: Health Management Network Commercial	$163.20
Rate for Payer: MDX Hawaii PPO	$186.24

TRACH TUBE CUFF 8.5

Facility

$192.00

Hospital Revenue Code	272
Min. Negotiated Rate	$97.92
Max. Negotiated Rate	$186.24
Rate for Payer: Cash Price	$115.20
Rate for Payer: Hawaii Western Management Group Commercial	$182.40
Rate for Payer: Health Management Network Commercial	$163.20
Rate for Payer: Kaiser Permanente Commercial	$120.96
Rate for Payer: Kaiser Permanente Medicaid	$97.92
Rate for Payer: MDX Hawaii PPO	$186.24
Rate for Payer: University Health Alliance Commercial	$139.95

TRACH TUBE CUFF 8.5

Facility

$192.00

Hospital Revenue Code	272
Min. Negotiated Rate	$163.20
Max. Negotiated Rate	$186.24
Rate for Payer: Cash Price	$115.20
Rate for Payer: Health Management Network Commercial	$163.20
Rate for Payer: MDX Hawaii PPO	$186.24

TRACH TUBE CUFFED

Facility

$259.00

Hospital Revenue Code	272
Min. Negotiated Rate	$132.09
Max. Negotiated Rate	$251.23
Rate for Payer: Cash Price	$155.40
Rate for Payer: Hawaii Western Management Group Commercial	$246.05
Rate for Payer: Health Management Network Commercial	$220.15
Rate for Payer: Kaiser Permanente Commercial	$163.17
Rate for Payer: Kaiser Permanente Medicaid	$132.09
Rate for Payer: MDX Hawaii PPO	$251.23
Rate for Payer: University Health Alliance Commercial	$188.79

TRACH TUBE CUFFED

Facility

$259.00

Hospital Revenue Code	272
Min. Negotiated Rate	$220.15
Max. Negotiated Rate	$251.23
Rate for Payer: Cash Price	$155.40
Rate for Payer: Health Management Network Commercial	$220.15
Rate for Payer: MDX Hawaii PPO	$251.23

Know your out-of-pocket cost for care.

All Charges