Hilo Benioff Medical Center

All Charges

Charge

Type

Setting

Price

TYMPANOPLASTY WITH ANTROTOMY OR MASTOIDOTOMY (INCLUDING CANALPLASTY, ATTICOTOMY, MIDDLE EAR SURGERY, AND/OR TYMPANIC MEMBRANE REPAIR); WITH OSSICULAR CHAIN RECONSTRUCTION AND SYNTHETIC PROSTHESIS (EG, PARTIAL OSSICULAR REPLACEMENT PROSTHESIS [PORP], TOTAL OSSICULAR REPLACEMENT PROSTHESIS [TORP])

Facility

$16,700.00

Service Code	CPT 69637
Hospital Revenue Code	360
Min. Negotiated Rate	$521.33
Max. Negotiated Rate	$16,700.00
Rate for Payer: AlohaCare Medicaid	$6,993.36
Rate for Payer: AlohaCare Medicare	$6,993.36
Rate for Payer: Devoted Health Medicare	$7,692.70
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	$6,993.36
Rate for Payer: Hawaii Medical Service Association Non-ABD	$2,695.11
Rate for Payer: Humana Medicare	$6,993.36
Rate for Payer: Kaiser Permanente Medicaid	$2,837.00
Rate for Payer: Kaiser Permanente Medicare	$6,993.36
Rate for Payer: Ohana Health Plan Medicaid	$7,692.70
Rate for Payer: Ohana Health Plan Medicare	$6,993.36
Rate for Payer: UnitedHealthcare Medicaid	$521.33
Rate for Payer: UnitedHealthcare Medicare	$6,993.36
Rate for Payer: University Health Alliance Commercial	$16,700.00

TYMPANOPLASTY WITH MASTOIDECTOMY (INCLUDING CANALPLASTY, MIDDLE EAR SURGERY, TYMPANIC MEMBRANE REPAIR); WITH OSSICULAR CHAIN RECONSTRUCTION

Facility

$16,700.00

Service Code	CPT 69642
Hospital Revenue Code	360
Min. Negotiated Rate	$521.33
Max. Negotiated Rate	$16,700.00
Rate for Payer: AlohaCare Medicaid	$6,993.36
Rate for Payer: AlohaCare Medicare	$6,993.36
Rate for Payer: Devoted Health Medicare	$7,692.70
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	$6,993.36
Rate for Payer: Hawaii Medical Service Association Non-ABD	$2,695.11
Rate for Payer: Humana Medicare	$6,993.36
Rate for Payer: Kaiser Permanente Medicaid	$2,837.00
Rate for Payer: Kaiser Permanente Medicare	$6,993.36
Rate for Payer: Ohana Health Plan Medicaid	$7,692.70
Rate for Payer: Ohana Health Plan Medicare	$6,993.36
Rate for Payer: UnitedHealthcare Medicaid	$521.33
Rate for Payer: UnitedHealthcare Medicare	$6,993.36
Rate for Payer: University Health Alliance Commercial	$16,700.00

TYMPANOPLASTY WITH MASTOIDECTOMY (INCLUDING CANALPLASTY, MIDDLE EAR SURGERY, TYMPANIC MEMBRANE REPAIR); WITHOUT OSSICULAR CHAIN RECONSTRUCTION

Facility

$19,192.00

Service Code	CPT 69641
Hospital Revenue Code	360
Min. Negotiated Rate	$521.33
Max. Negotiated Rate	$19,192.00
Rate for Payer: AlohaCare Medicaid	$6,993.36
Rate for Payer: AlohaCare Medicare	$6,993.36
Rate for Payer: Devoted Health Medicare	$7,692.70
Rate for Payer: Hawaii Medical Service Association ABD	$2,102.00
Rate for Payer: Hawaii Medical Service Association Commercial	$19,192.00
Rate for Payer: Hawaii Medical Service Association Medicare	$6,993.36
Rate for Payer: Hawaii Medical Service Association Non-ABD	$3,561.00
Rate for Payer: Humana Medicare	$6,993.36
Rate for Payer: Kaiser Permanente Medicaid	$2,837.00
Rate for Payer: Kaiser Permanente Medicare	$6,993.36
Rate for Payer: Ohana Health Plan Medicaid	$7,692.70
Rate for Payer: Ohana Health Plan Medicare	$6,993.36
Rate for Payer: UnitedHealthcare Medicaid	$521.33
Rate for Payer: UnitedHealthcare Medicare	$6,993.36
Rate for Payer: University Health Alliance Commercial	$16,700.00

TYMPANOPLASTY WITHOUT MASTOIDECTOMY (INCLUDING CANALPLASTY, ATTICOTOMY AND/OR MIDDLE EAR SURGERY), INITIAL OR REVISION; WITH OSSICULAR CHAIN RECONSTRUCTION (EG, POSTFENESTRATION)

Facility

$13,778.00

Service Code	CPT 69632
Hospital Revenue Code	360
Min. Negotiated Rate	$521.33
Max. Negotiated Rate	$13,778.00
Rate for Payer: AlohaCare Medicaid	$6,993.36
Rate for Payer: AlohaCare Medicare	$6,993.36
Rate for Payer: Devoted Health Medicare	$7,692.70
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	$6,993.36
Rate for Payer: Hawaii Medical Service Association Non-ABD	$2,294.85
Rate for Payer: Humana Medicare	$6,993.36
Rate for Payer: Kaiser Permanente Medicaid	$2,837.00
Rate for Payer: Kaiser Permanente Medicare	$6,993.36
Rate for Payer: Ohana Health Plan Medicaid	$7,692.70
Rate for Payer: Ohana Health Plan Medicare	$6,993.36
Rate for Payer: UnitedHealthcare Medicaid	$521.33
Rate for Payer: UnitedHealthcare Medicare	$6,993.36
Rate for Payer: University Health Alliance Commercial	$11,157.19

TYMPANOPLASTY WITHOUT MASTOIDECTOMY (INCLUDING CANALPLASTY, ATTICOTOMY AND/OR MIDDLE EAR SURGERY), INITIAL OR REVISION; WITHOUT OSSICULAR CHAIN RECONSTRUCTION

Facility

$13,778.00

Service Code	CPT 69631
Hospital Revenue Code	360
Min. Negotiated Rate	$521.33
Max. Negotiated Rate	$13,778.00
Rate for Payer: AlohaCare Medicaid	$6,993.36
Rate for Payer: AlohaCare Medicare	$6,993.36
Rate for Payer: Devoted Health Medicare	$7,692.70
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	$6,993.36
Rate for Payer: Hawaii Medical Service Association Non-ABD	$2,294.85
Rate for Payer: Humana Medicare	$6,993.36
Rate for Payer: Kaiser Permanente Medicaid	$2,837.00
Rate for Payer: Kaiser Permanente Medicare	$6,993.36
Rate for Payer: Ohana Health Plan Medicaid	$7,692.70
Rate for Payer: Ohana Health Plan Medicare	$6,993.36
Rate for Payer: UnitedHealthcare Medicaid	$521.33
Rate for Payer: UnitedHealthcare Medicare	$6,993.36
Rate for Payer: University Health Alliance Commercial	$11,157.19

TYMPANOSTOMY (REQUIRING INSERTION OF VENTILATING TUBE), GENERAL ANESTHESIA

Facility

$6,743.44

Service Code	CPT 69436
Hospital Revenue Code	360
Min. Negotiated Rate	$456.03
Max. Negotiated Rate	$6,743.44
Rate for Payer: AlohaCare Medicaid	$1,832.96
Rate for Payer: AlohaCare Medicare	$1,832.96
Rate for Payer: Devoted Health Medicare	$2,016.26
Rate for Payer: Hawaii Medical Service Association ABD	$695.00
Rate for Payer: Hawaii Medical Service Association Commercial	$5,509.00
Rate for Payer: Hawaii Medical Service Association Medicare	$1,832.96
Rate for Payer: Hawaii Medical Service Association Non-ABD	$1,028.67
Rate for Payer: Humana Medicare	$1,832.96
Rate for Payer: Kaiser Permanente Medicaid	$2,837.00
Rate for Payer: Kaiser Permanente Medicare	$1,832.96
Rate for Payer: Ohana Health Plan Medicaid	$2,016.26
Rate for Payer: Ohana Health Plan Medicare	$1,832.96
Rate for Payer: UnitedHealthcare Medicaid	$456.03
Rate for Payer: UnitedHealthcare Medicare	$1,832.96
Rate for Payer: University Health Alliance Commercial	$6,743.44

UCL SYSTEM INTER BRACE AR-7715

Facility

$2,476.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,386.56
Max. Negotiated Rate	$2,401.72
Rate for Payer: Cash Price	$1,485.60
Rate for Payer: Hawaii Western Management Group Commercial	$1,733.20
Rate for Payer: Health Management Network Commercial	$2,104.60
Rate for Payer: MDX Hawaii PPO	$2,401.72
Rate for Payer: University Health Alliance Commercial	$1,386.56

UCL SYSTEM INTER BRACE AR-7715

Facility

$2,476.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,262.76
Max. Negotiated Rate	$2,401.72
Rate for Payer: Cash Price	$1,485.60
Rate for Payer: Hawaii Western Management Group Commercial	$1,733.20
Rate for Payer: Health Management Network Commercial	$2,104.60
Rate for Payer: Kaiser Permanente Commercial	$1,559.88
Rate for Payer: Kaiser Permanente Medicaid	$1,262.76
Rate for Payer: MDX Hawaii PPO	$2,401.72
Rate for Payer: University Health Alliance Commercial	$1,386.56

UHR BIPOLAR 28X44MM UH1-44-28

Facility

$2,408.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$1,228.08
Max. Negotiated Rate	$2,335.76
Rate for Payer: Cash Price	$1,444.80
Rate for Payer: Hawaii Western Management Group Commercial	$1,685.60
Rate for Payer: Health Management Network Commercial	$2,046.80
Rate for Payer: Kaiser Permanente Commercial	$1,517.04
Rate for Payer: Kaiser Permanente Medicaid	$1,228.08
Rate for Payer: MDX Hawaii PPO	$2,335.76
Rate for Payer: University Health Alliance Commercial	$1,348.48

UHR BIPOLAR 28X44MM UH1-44-28

Facility

$2,408.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$1,348.48
Max. Negotiated Rate	$2,335.76
Rate for Payer: Cash Price	$1,444.80
Rate for Payer: Hawaii Western Management Group Commercial	$1,685.60
Rate for Payer: Health Management Network Commercial	$2,046.80
Rate for Payer: MDX Hawaii PPO	$2,335.76
Rate for Payer: University Health Alliance Commercial	$1,348.48

UHR BIPOLAR 28X45MM UH1-45-28

Facility

$2,408.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$1,348.48
Max. Negotiated Rate	$2,335.76
Rate for Payer: Cash Price	$1,444.80
Rate for Payer: Hawaii Western Management Group Commercial	$1,685.60
Rate for Payer: Health Management Network Commercial	$2,046.80
Rate for Payer: MDX Hawaii PPO	$2,335.76
Rate for Payer: University Health Alliance Commercial	$1,348.48

UHR BIPOLAR 28X45MM UH1-45-28

Facility

$2,408.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$1,228.08
Max. Negotiated Rate	$2,335.76
Rate for Payer: Cash Price	$1,444.80
Rate for Payer: Hawaii Western Management Group Commercial	$1,685.60
Rate for Payer: Health Management Network Commercial	$2,046.80
Rate for Payer: Kaiser Permanente Commercial	$1,517.04
Rate for Payer: Kaiser Permanente Medicaid	$1,228.08
Rate for Payer: MDX Hawaii PPO	$2,335.76
Rate for Payer: University Health Alliance Commercial	$1,348.48

UHR BIPOLAR 28X46MM UH1-46-28

Facility

$2,408.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$1,228.08
Max. Negotiated Rate	$2,335.76
Rate for Payer: Cash Price	$1,444.80
Rate for Payer: Hawaii Western Management Group Commercial	$1,685.60
Rate for Payer: Health Management Network Commercial	$2,046.80
Rate for Payer: Kaiser Permanente Commercial	$1,517.04
Rate for Payer: Kaiser Permanente Medicaid	$1,228.08
Rate for Payer: MDX Hawaii PPO	$2,335.76
Rate for Payer: University Health Alliance Commercial	$1,348.48

UHR BIPOLAR 28X46MM UH1-46-28

Facility

$2,408.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$1,348.48
Max. Negotiated Rate	$2,335.76
Rate for Payer: Cash Price	$1,444.80
Rate for Payer: Hawaii Western Management Group Commercial	$1,685.60
Rate for Payer: Health Management Network Commercial	$2,046.80
Rate for Payer: MDX Hawaii PPO	$2,335.76
Rate for Payer: University Health Alliance Commercial	$1,348.48

UHR BIPOLAR 28X47MM UH1-47-28

Facility

$2,408.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$1,348.48
Max. Negotiated Rate	$2,335.76
Rate for Payer: Cash Price	$1,444.80
Rate for Payer: Hawaii Western Management Group Commercial	$1,685.60
Rate for Payer: Health Management Network Commercial	$2,046.80
Rate for Payer: MDX Hawaii PPO	$2,335.76
Rate for Payer: University Health Alliance Commercial	$1,348.48

UHR BIPOLAR 28X47MM UH1-47-28

Facility

$2,408.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$1,228.08
Max. Negotiated Rate	$2,335.76
Rate for Payer: Cash Price	$1,444.80
Rate for Payer: Hawaii Western Management Group Commercial	$1,685.60
Rate for Payer: Health Management Network Commercial	$2,046.80
Rate for Payer: Kaiser Permanente Commercial	$1,517.04
Rate for Payer: Kaiser Permanente Medicaid	$1,228.08
Rate for Payer: MDX Hawaii PPO	$2,335.76
Rate for Payer: University Health Alliance Commercial	$1,348.48

UHR BIPOLAR 28X48MM UH1-48-28

Facility

$2,433.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$1,362.48
Max. Negotiated Rate	$2,360.01
Rate for Payer: Cash Price	$1,459.80
Rate for Payer: Hawaii Western Management Group Commercial	$1,703.10
Rate for Payer: Health Management Network Commercial	$2,068.05
Rate for Payer: MDX Hawaii PPO	$2,360.01
Rate for Payer: University Health Alliance Commercial	$1,362.48

UHR BIPOLAR 28X48MM UH1-48-28

Facility

$2,433.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$1,240.83
Max. Negotiated Rate	$2,360.01
Rate for Payer: Cash Price	$1,459.80
Rate for Payer: Hawaii Western Management Group Commercial	$1,703.10
Rate for Payer: Health Management Network Commercial	$2,068.05
Rate for Payer: Kaiser Permanente Commercial	$1,532.79
Rate for Payer: Kaiser Permanente Medicaid	$1,240.83
Rate for Payer: MDX Hawaii PPO	$2,360.01
Rate for Payer: University Health Alliance Commercial	$1,362.48

UHR BIPOLAR 28X49MM UH1-49-28

Facility

$2,408.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$1,348.48
Max. Negotiated Rate	$2,335.76
Rate for Payer: Cash Price	$1,444.80
Rate for Payer: Hawaii Western Management Group Commercial	$1,685.60
Rate for Payer: Health Management Network Commercial	$2,046.80
Rate for Payer: MDX Hawaii PPO	$2,335.76
Rate for Payer: University Health Alliance Commercial	$1,348.48

UHR BIPOLAR 28X49MM UH1-49-28

Facility

$2,408.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$1,228.08
Max. Negotiated Rate	$2,335.76
Rate for Payer: Cash Price	$1,444.80
Rate for Payer: Hawaii Western Management Group Commercial	$1,685.60
Rate for Payer: Health Management Network Commercial	$2,046.80
Rate for Payer: Kaiser Permanente Commercial	$1,517.04
Rate for Payer: Kaiser Permanente Medicaid	$1,228.08
Rate for Payer: MDX Hawaii PPO	$2,335.76
Rate for Payer: University Health Alliance Commercial	$1,348.48

UHR BIPOLAR 28X50MM UH1-50-28

Facility

$2,408.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$1,348.48
Max. Negotiated Rate	$2,335.76
Rate for Payer: Cash Price	$1,444.80
Rate for Payer: Hawaii Western Management Group Commercial	$1,685.60
Rate for Payer: Health Management Network Commercial	$2,046.80
Rate for Payer: MDX Hawaii PPO	$2,335.76
Rate for Payer: University Health Alliance Commercial	$1,348.48

UHR BIPOLAR 28X50MM UH1-50-28

Facility

$2,408.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$1,228.08
Max. Negotiated Rate	$2,335.76
Rate for Payer: Cash Price	$1,444.80
Rate for Payer: Hawaii Western Management Group Commercial	$1,685.60
Rate for Payer: Health Management Network Commercial	$2,046.80
Rate for Payer: Kaiser Permanente Commercial	$1,517.04
Rate for Payer: Kaiser Permanente Medicaid	$1,228.08
Rate for Payer: MDX Hawaii PPO	$2,335.76
Rate for Payer: University Health Alliance Commercial	$1,348.48

UHR BIPOLAR 28X51MM UH1-51-28

Facility

$2,408.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$1,228.08
Max. Negotiated Rate	$2,335.76
Rate for Payer: Cash Price	$1,444.80
Rate for Payer: Hawaii Western Management Group Commercial	$1,685.60
Rate for Payer: Health Management Network Commercial	$2,046.80
Rate for Payer: Kaiser Permanente Commercial	$1,517.04
Rate for Payer: Kaiser Permanente Medicaid	$1,228.08
Rate for Payer: MDX Hawaii PPO	$2,335.76
Rate for Payer: University Health Alliance Commercial	$1,348.48

UHR BIPOLAR 28X51MM UH1-51-28

Facility

$2,408.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$1,348.48
Max. Negotiated Rate	$2,335.76
Rate for Payer: Cash Price	$1,444.80
Rate for Payer: Hawaii Western Management Group Commercial	$1,685.60
Rate for Payer: Health Management Network Commercial	$2,046.80
Rate for Payer: MDX Hawaii PPO	$2,335.76
Rate for Payer: University Health Alliance Commercial	$1,348.48

UHR BIPOLAR 28X52MM UH1-52-28

Facility

$2,433.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$1,240.83
Max. Negotiated Rate	$2,360.01
Rate for Payer: Cash Price	$1,459.80
Rate for Payer: Hawaii Western Management Group Commercial	$1,703.10
Rate for Payer: Health Management Network Commercial	$2,068.05
Rate for Payer: Kaiser Permanente Commercial	$1,532.79
Rate for Payer: Kaiser Permanente Medicaid	$1,240.83
Rate for Payer: MDX Hawaii PPO	$2,360.01
Rate for Payer: University Health Alliance Commercial	$1,362.48

Know your out-of-pocket cost for care.

All Charges