Hilo Benioff Medical Center

All Charges

Charge

Type

Setting

Price

TRANSCAROTID SYS SR-200-NPS

Facility

$7,500.00

Service Code	HCPCS C1884
Hospital Revenue Code	272
Min. Negotiated Rate	$3,825.00
Max. Negotiated Rate	$7,275.00
Rate for Payer: Cash Price	$4,500.00
Rate for Payer: Hawaii Western Management Group Commercial	$7,125.00
Rate for Payer: Health Management Network Commercial	$6,375.00
Rate for Payer: Kaiser Permanente Commercial	$4,725.00
Rate for Payer: Kaiser Permanente Medicaid	$3,825.00
Rate for Payer: MDX Hawaii PPO	$7,275.00
Rate for Payer: University Health Alliance Commercial	$5,466.75

TRANSCAROTID SYS SR-200-NPS

Facility

$7,500.00

Service Code	HCPCS C1884
Hospital Revenue Code	272
Min. Negotiated Rate	$6,375.00
Max. Negotiated Rate	$7,275.00
Rate for Payer: Cash Price	$4,500.00
Rate for Payer: Health Management Network Commercial	$6,375.00
Rate for Payer: MDX Hawaii PPO	$7,275.00

TRANSCATHETER PLACEMENT OF AN INTRAVASCULAR STENT(S) (EXCEPT LOWER EXTREMITY ARTERY(S) FOR OCCLUSIVE DISEASE, CERVICAL CAROTID, EXTRACRANIAL VERTEBRAL OR INTRATHORACIC CAROTID, INTRACRANIAL, OR CORONARY), OPEN OR PERCUTANEOUS, INCLUDING RADIOLOGICAL SUPERVISION AND INTERPRETATION AND INCLUDING ALL ANGIOPLASTY WITHIN THE SAME VESSEL, WHEN PERFORMED; INITIAL ARTERY

Facility

$15,001.44

Service Code	CPT 37236
Hospital Revenue Code	360
Min. Negotiated Rate	$644.55
Max. Negotiated Rate	$15,001.44
Rate for Payer: AlohaCare Medicaid	$13,637.67
Rate for Payer: AlohaCare Medicare	$13,637.67
Rate for Payer: Devoted Health Medicare	$15,001.44
Rate for Payer: Hawaii Medical Service Association ABD	$1,900.00
Rate for Payer: Hawaii Medical Service Association Commercial	$14,395.00
Rate for Payer: Hawaii Medical Service Association Medicare	$13,637.67
Rate for Payer: Hawaii Medical Service Association Non-ABD	$2,695.11
Rate for Payer: Humana Medicare	$13,637.67
Rate for Payer: Kaiser Permanente Medicaid	$2,837.00
Rate for Payer: Kaiser Permanente Medicare	$13,637.67
Rate for Payer: Ohana Health Plan Medicaid	$15,001.44
Rate for Payer: Ohana Health Plan Medicare	$13,637.67
Rate for Payer: UnitedHealthcare Medicaid	$644.55
Rate for Payer: UnitedHealthcare Medicare	$13,637.67

TRANSCATHETER PLACEMENT OF AN INTRAVASCULAR STENT(S), OPEN OR PERCUTANEOUS, INCLUDING RADIOLOGICAL SUPERVISION AND INTERPRETATION AND INCLUDING ANGIOPLASTY WITHIN THE SAME VESSEL, WHEN PERFORMED; EACH ADDITIONAL VEIN (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)

Facility

$2,837.00

Service Code	CPT 37239
Hospital Revenue Code	360
Min. Negotiated Rate	$521.33
Max. Negotiated Rate	$2,837.00
Rate for Payer: Kaiser Permanente Medicaid	$2,837.00
Rate for Payer: UnitedHealthcare Medicaid	$521.33

TRANSFIXATN PIN 6X225MM 294.50

Facility

$641.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$358.96
Max. Negotiated Rate	$621.77
Rate for Payer: Cash Price	$384.60
Rate for Payer: Hawaii Western Management Group Commercial	$448.70
Rate for Payer: Health Management Network Commercial	$544.85
Rate for Payer: MDX Hawaii PPO	$621.77
Rate for Payer: University Health Alliance Commercial	$358.96

TRANSFIXATN PIN 6X225MM 294.50

Facility

$641.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$326.91
Max. Negotiated Rate	$621.77
Rate for Payer: Cash Price	$384.60
Rate for Payer: Hawaii Western Management Group Commercial	$448.70
Rate for Payer: Health Management Network Commercial	$544.85
Rate for Payer: Kaiser Permanente Commercial	$403.83
Rate for Payer: Kaiser Permanente Medicaid	$326.91
Rate for Payer: MDX Hawaii PPO	$621.77
Rate for Payer: University Health Alliance Commercial	$358.96

TRANSFUSION, BLOOD OR BLOOD COMPONENTS

Facility

$2,837.00

Service Code	CPT 36430
Hospital Revenue Code	360
Min. Negotiated Rate	$33.38
Max. Negotiated Rate	$2,837.00
Rate for Payer: Kaiser Permanente Medicaid	$2,837.00
Rate for Payer: AlohaCare Medicaid	$521.18
Rate for Payer: AlohaCare Medicare	$521.18
Rate for Payer: Devoted Health Medicare	$573.30
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	$521.18
Rate for Payer: Hawaii Medical Service Association Non-ABD	$496.75
Rate for Payer: Humana Medicare	$521.18
Rate for Payer: Kaiser Permanente Medicare	$521.18
Rate for Payer: Ohana Health Plan Medicaid	$573.30
Rate for Payer: Ohana Health Plan Medicare	$521.18
Rate for Payer: UnitedHealthcare Medicaid	$33.38
Rate for Payer: UnitedHealthcare Medicare	$521.18

TRANSIENT ISCHEMIA

Facility

$3,697.11

Service Code	APR-DRG 0472
Min. Negotiated Rate	$3,697.11
Max. Negotiated Rate	$3,697.11
Rate for Payer: AlohaCare Medicaid	$3,697.11
Rate for Payer: Hawaii Medical Service Association ABD	$3,697.11
Rate for Payer: Hawaii Medical Service Association Non-ABD	$3,697.11
Rate for Payer: Kaiser Permanente Medicaid	$3,697.11
Rate for Payer: Ohana Health Plan Medicaid	$3,697.11
Rate for Payer: UnitedHealthcare Medicaid	$3,697.11

TRANSIENT ISCHEMIA

Facility

$4,695.74

Service Code	APR-DRG 0473
Min. Negotiated Rate	$4,695.74
Max. Negotiated Rate	$4,695.74
Rate for Payer: AlohaCare Medicaid	$4,695.74
Rate for Payer: Hawaii Medical Service Association ABD	$4,695.74
Rate for Payer: Hawaii Medical Service Association Non-ABD	$4,695.74
Rate for Payer: Kaiser Permanente Medicaid	$4,695.74
Rate for Payer: Ohana Health Plan Medicaid	$4,695.74
Rate for Payer: UnitedHealthcare Medicaid	$4,695.74

TRANSIENT ISCHEMIA

Facility

$3,299.22

Service Code	APR-DRG 0471
Min. Negotiated Rate	$3,299.22
Max. Negotiated Rate	$3,299.22
Rate for Payer: AlohaCare Medicaid	$3,299.22
Rate for Payer: Hawaii Medical Service Association ABD	$3,299.22
Rate for Payer: Hawaii Medical Service Association Non-ABD	$3,299.22
Rate for Payer: Kaiser Permanente Medicaid	$3,299.22
Rate for Payer: Ohana Health Plan Medicaid	$3,299.22
Rate for Payer: UnitedHealthcare Medicaid	$3,299.22

TRANSIENT ISCHEMIA

Facility

$7,464.66

Service Code	APR-DRG 0474
Min. Negotiated Rate	$7,464.66
Max. Negotiated Rate	$7,464.66
Rate for Payer: AlohaCare Medicaid	$7,464.66
Rate for Payer: Hawaii Medical Service Association ABD	$7,464.66
Rate for Payer: Hawaii Medical Service Association Non-ABD	$7,464.66
Rate for Payer: Kaiser Permanente Medicaid	$7,464.66
Rate for Payer: Ohana Health Plan Medicaid	$7,464.66
Rate for Payer: UnitedHealthcare Medicaid	$7,464.66

TRANSIENT ISCHEMIA WITHOUT THROMBOLYTIC

Facility

$17,884.04

Service Code	MSDRG 069
Min. Negotiated Rate	$9,085.76
Max. Negotiated Rate	$17,884.04
Rate for Payer: AlohaCare Medicare	$9,085.76
Rate for Payer: Devoted Health Medicare	$9,994.34
Rate for Payer: Hawaii Medical Service Association Commercial	$17,884.04
Rate for Payer: Hawaii Medical Service Association Medicare	$9,085.76
Rate for Payer: Humana Medicare	$9,085.76
Rate for Payer: Kaiser Permanente Commercial	$13,779.30
Rate for Payer: Kaiser Permanente Medicare	$9,085.76
Rate for Payer: Ohana Health Plan Medicare	$9,085.76
Rate for Payer: UnitedHealthcare Medicare	$9,085.76

TRANSPEC SPECIMEN DEVICE

Facility

$249.00

Hospital Revenue Code	272
Min. Negotiated Rate	$211.65
Max. Negotiated Rate	$241.53
Rate for Payer: Cash Price	$149.40
Rate for Payer: Health Management Network Commercial	$211.65
Rate for Payer: MDX Hawaii PPO	$241.53

TRANSPEC SPECIMEN DEVICE

Facility

$249.00

Hospital Revenue Code	272
Min. Negotiated Rate	$126.99
Max. Negotiated Rate	$241.53
Rate for Payer: Cash Price	$149.40
Rate for Payer: Hawaii Western Management Group Commercial	$236.55
Rate for Payer: Health Management Network Commercial	$211.65
Rate for Payer: Kaiser Permanente Commercial	$156.87
Rate for Payer: Kaiser Permanente Medicaid	$126.99
Rate for Payer: MDX Hawaii PPO	$241.53
Rate for Payer: University Health Alliance Commercial	$181.50

TRANSTIBIAL KIT #AR-1897S

Facility

$889.00

Hospital Revenue Code	272
Min. Negotiated Rate	$453.39
Max. Negotiated Rate	$862.33
Rate for Payer: Cash Price	$533.40
Rate for Payer: Hawaii Western Management Group Commercial	$844.55
Rate for Payer: Health Management Network Commercial	$755.65
Rate for Payer: Kaiser Permanente Commercial	$560.07
Rate for Payer: Kaiser Permanente Medicaid	$453.39
Rate for Payer: MDX Hawaii PPO	$862.33
Rate for Payer: University Health Alliance Commercial	$647.99

TRANSTIBIAL KIT #AR-1897S

Facility

$889.00

Hospital Revenue Code	272
Min. Negotiated Rate	$755.65
Max. Negotiated Rate	$862.33
Rate for Payer: Cash Price	$533.40
Rate for Payer: Health Management Network Commercial	$755.65
Rate for Payer: MDX Hawaii PPO	$862.33

TRANSURETHRAL ELECTROSURGICAL RESECTION OF PROSTATE, INCLUDING CONTROL OF POSTOPERATIVE BLEEDING, COMPLETE (VASECTOMY, MEATOTOMY, CYSTOURETHROSCOPY, URETHRAL CALIBRATION AND/OR DILATION, AND INTERNAL URETHROTOMY ARE INCLUDED)

Facility

$13,778.00

Service Code	CPT 52601
Hospital Revenue Code	360
Min. Negotiated Rate	$521.33
Max. Negotiated Rate	$13,778.00
Rate for Payer: AlohaCare Medicaid	$6,334.13
Rate for Payer: AlohaCare Medicare	$6,334.13
Rate for Payer: Devoted Health Medicare	$6,967.54
Rate for Payer: Hawaii Medical Service Association ABD	$1,149.00
Rate for Payer: Hawaii Medical Service Association Commercial	$13,778.00
Rate for Payer: Hawaii Medical Service Association Medicare	$6,334.13
Rate for Payer: Hawaii Medical Service Association Non-ABD	$2,294.85
Rate for Payer: Humana Medicare	$6,334.13
Rate for Payer: Kaiser Permanente Medicaid	$2,837.00
Rate for Payer: Kaiser Permanente Medicare	$6,334.13
Rate for Payer: Ohana Health Plan Medicaid	$6,967.54
Rate for Payer: Ohana Health Plan Medicare	$6,334.13
Rate for Payer: UnitedHealthcare Medicaid	$521.33
Rate for Payer: UnitedHealthcare Medicare	$6,334.13
Rate for Payer: University Health Alliance Commercial	$10,679.55

TRANSURETHRAL PROCEDURES WITH CC

Facility

$26,772.00

Service Code	MSDRG 669
Min. Negotiated Rate	$17,652.84
Max. Negotiated Rate	$26,772.00
Rate for Payer: AlohaCare Medicare	$17,652.84
Rate for Payer: Devoted Health Medicare	$19,418.12
Rate for Payer: Hawaii Medical Service Association Commercial	$21,669.54
Rate for Payer: Hawaii Medical Service Association Medicare	$17,652.84
Rate for Payer: Humana Medicare	$17,652.84
Rate for Payer: Kaiser Permanente Commercial	$26,772.00
Rate for Payer: Kaiser Permanente Medicare	$17,652.84
Rate for Payer: Ohana Health Plan Medicare	$17,652.84
Rate for Payer: UnitedHealthcare Medicare	$17,652.84

TRANSURETHRAL PROCEDURES WITH MCC

Facility

$50,370.00

Service Code	MSDRG 668
Min. Negotiated Rate	$21,669.54
Max. Negotiated Rate	$50,370.00
Rate for Payer: AlohaCare Medicare	$33,212.82
Rate for Payer: Devoted Health Medicare	$36,534.10
Rate for Payer: Hawaii Medical Service Association Commercial	$21,669.54
Rate for Payer: Hawaii Medical Service Association Medicare	$33,212.82
Rate for Payer: Humana Medicare	$33,212.82
Rate for Payer: Kaiser Permanente Commercial	$50,370.00
Rate for Payer: Kaiser Permanente Medicare	$33,212.82
Rate for Payer: Ohana Health Plan Medicare	$33,212.82
Rate for Payer: UnitedHealthcare Medicare	$33,212.82

TRANSURETHRAL PROCEDURES WITHOUT CC/MCC

Facility

$19,218.67

Service Code	MSDRG 670
Min. Negotiated Rate	$11,116.07
Max. Negotiated Rate	$19,218.67
Rate for Payer: AlohaCare Medicare	$11,116.07
Rate for Payer: Devoted Health Medicare	$12,227.68
Rate for Payer: Hawaii Medical Service Association Commercial	$19,218.67
Rate for Payer: Hawaii Medical Service Association Medicare	$11,116.07
Rate for Payer: Humana Medicare	$11,116.07
Rate for Payer: Kaiser Permanente Commercial	$16,858.42
Rate for Payer: Kaiser Permanente Medicare	$11,116.07
Rate for Payer: Ohana Health Plan Medicare	$11,116.07
Rate for Payer: UnitedHealthcare Medicare	$11,116.07

TRANSURETHRAL PROSTATECTOMY

Facility

$8,358.93

Service Code	APR-DRG 4823
Min. Negotiated Rate	$8,358.93
Max. Negotiated Rate	$8,358.93
Rate for Payer: AlohaCare Medicaid	$8,358.93
Rate for Payer: Hawaii Medical Service Association ABD	$8,358.93
Rate for Payer: Hawaii Medical Service Association Non-ABD	$8,358.93
Rate for Payer: Kaiser Permanente Medicaid	$8,358.93
Rate for Payer: Ohana Health Plan Medicaid	$8,358.93
Rate for Payer: UnitedHealthcare Medicaid	$8,358.93

TRANSURETHRAL PROSTATECTOMY

Facility

$14,656.01

Service Code	APR-DRG 4824
Min. Negotiated Rate	$14,656.01
Max. Negotiated Rate	$14,656.01
Rate for Payer: AlohaCare Medicaid	$14,656.01
Rate for Payer: Hawaii Medical Service Association ABD	$14,656.01
Rate for Payer: Hawaii Medical Service Association Non-ABD	$14,656.01
Rate for Payer: Kaiser Permanente Medicaid	$14,656.01
Rate for Payer: Ohana Health Plan Medicaid	$14,656.01
Rate for Payer: UnitedHealthcare Medicaid	$14,656.01

TRANSURETHRAL PROSTATECTOMY

Facility

$4,657.26

Service Code	APR-DRG 4822
Min. Negotiated Rate	$4,657.26
Max. Negotiated Rate	$4,657.26
Rate for Payer: AlohaCare Medicaid	$4,657.26
Rate for Payer: Hawaii Medical Service Association ABD	$4,657.26
Rate for Payer: Hawaii Medical Service Association Non-ABD	$4,657.26
Rate for Payer: Kaiser Permanente Medicaid	$4,657.26
Rate for Payer: Ohana Health Plan Medicaid	$4,657.26
Rate for Payer: UnitedHealthcare Medicaid	$4,657.26

TRANSURETHRAL PROSTATECTOMY

Facility

$3,855.61

Service Code	APR-DRG 4821
Min. Negotiated Rate	$3,855.61
Max. Negotiated Rate	$3,855.61
Rate for Payer: AlohaCare Medicaid	$3,855.61
Rate for Payer: Hawaii Medical Service Association ABD	$3,855.61
Rate for Payer: Hawaii Medical Service Association Non-ABD	$3,855.61
Rate for Payer: Kaiser Permanente Medicaid	$3,855.61
Rate for Payer: Ohana Health Plan Medicaid	$3,855.61
Rate for Payer: UnitedHealthcare Medicaid	$3,855.61

TRANSURETHRAL PROSTATECTOMY WITH CC/MCC

Facility

$25,933.65

Service Code	MSDRG 713
Min. Negotiated Rate	$17,100.05
Max. Negotiated Rate	$25,933.65
Rate for Payer: AlohaCare Medicare	$17,100.05
Rate for Payer: Devoted Health Medicare	$18,810.06
Rate for Payer: Hawaii Medical Service Association Commercial	$18,102.44
Rate for Payer: Hawaii Medical Service Association Medicare	$17,100.05
Rate for Payer: Humana Medicare	$17,100.05
Rate for Payer: Kaiser Permanente Commercial	$25,933.65
Rate for Payer: Kaiser Permanente Medicare	$17,100.05
Rate for Payer: Ohana Health Plan Medicare	$17,100.05
Rate for Payer: UnitedHealthcare Medicare	$17,100.05

Know your out-of-pocket cost for care.

All Charges