Hilo Benioff Medical Center

All Charges

Charge

Type

Setting

Price

CELL SAVER PROCEDURE KIT 04362

Facility

$532.00

Hospital Revenue Code	272
Min. Negotiated Rate	$452.20
Max. Negotiated Rate	$516.04
Rate for Payer: Cash Price	$319.20
Rate for Payer: Health Management Network Commercial	$452.20
Rate for Payer: MDX Hawaii PPO	$516.04

CELL SAVER PROCEDURE KIT 04362

Facility

$532.00

Hospital Revenue Code	272
Min. Negotiated Rate	$271.32
Max. Negotiated Rate	$516.04
Rate for Payer: Cash Price	$319.20
Rate for Payer: Hawaii Western Management Group Commercial	$505.40
Rate for Payer: Health Management Network Commercial	$452.20
Rate for Payer: Kaiser Permanente Commercial	$335.16
Rate for Payer: Kaiser Permanente Medicaid	$271.32
Rate for Payer: MDX Hawaii PPO	$516.04
Rate for Payer: University Health Alliance Commercial	$387.77

CELLULITIS & OTHER SKIN INFECTIONS

Facility

$3,133.54

Service Code	APR-DRG 3832
Min. Negotiated Rate	$3,133.54
Max. Negotiated Rate	$3,133.54
Rate for Payer: AlohaCare Medicaid	$3,133.54
Rate for Payer: Hawaii Medical Service Association ABD	$3,133.54
Rate for Payer: Hawaii Medical Service Association Non-ABD	$3,133.54
Rate for Payer: Kaiser Permanente Medicaid	$3,133.54
Rate for Payer: Ohana Health Plan Medicaid	$3,133.54
Rate for Payer: UnitedHealthcare Medicaid	$3,133.54

CELLULITIS & OTHER SKIN INFECTIONS

Facility

$2,300.58

Service Code	APR-DRG 3831
Min. Negotiated Rate	$2,300.58
Max. Negotiated Rate	$2,300.58
Rate for Payer: AlohaCare Medicaid	$2,300.58
Rate for Payer: Hawaii Medical Service Association ABD	$2,300.58
Rate for Payer: Hawaii Medical Service Association Non-ABD	$2,300.58
Rate for Payer: Kaiser Permanente Medicaid	$2,300.58
Rate for Payer: Ohana Health Plan Medicaid	$2,300.58
Rate for Payer: UnitedHealthcare Medicaid	$2,300.58

CELLULITIS & OTHER SKIN INFECTIONS

Facility

$8,710.51

Service Code	APR-DRG 3834
Min. Negotiated Rate	$8,710.51
Max. Negotiated Rate	$8,710.51
Rate for Payer: AlohaCare Medicaid	$8,710.51
Rate for Payer: Hawaii Medical Service Association ABD	$8,710.51
Rate for Payer: Hawaii Medical Service Association Non-ABD	$8,710.51
Rate for Payer: Kaiser Permanente Medicaid	$8,710.51
Rate for Payer: Ohana Health Plan Medicaid	$8,710.51
Rate for Payer: UnitedHealthcare Medicaid	$8,710.51

CELLULITIS & OTHER SKIN INFECTIONS

Facility

$4,604.42

Service Code	APR-DRG 3833
Min. Negotiated Rate	$4,604.42
Max. Negotiated Rate	$4,604.42
Rate for Payer: AlohaCare Medicaid	$4,604.42
Rate for Payer: Hawaii Medical Service Association ABD	$4,604.42
Rate for Payer: Hawaii Medical Service Association Non-ABD	$4,604.42
Rate for Payer: Kaiser Permanente Medicaid	$4,604.42
Rate for Payer: Ohana Health Plan Medicaid	$4,604.42
Rate for Payer: UnitedHealthcare Medicaid	$4,604.42

CELLULITIS WITH MCC

Facility

$24,557.19

Service Code	MSDRG 602
Min. Negotiated Rate	$16,166.21
Max. Negotiated Rate	$24,557.19
Rate for Payer: AlohaCare Medicare	$16,166.21
Rate for Payer: Devoted Health Medicare	$17,782.83
Rate for Payer: Hawaii Medical Service Association Commercial	$24,557.19
Rate for Payer: Hawaii Medical Service Association Medicare	$16,166.21
Rate for Payer: Humana Medicare	$16,166.21
Rate for Payer: Kaiser Permanente Commercial	$24,517.42
Rate for Payer: Kaiser Permanente Medicare	$16,166.21
Rate for Payer: Ohana Health Plan Medicare	$16,166.21
Rate for Payer: UnitedHealthcare Medicare	$16,166.21

CELLULITIS WITHOUT MCC

Facility

$16,525.15

Service Code	MSDRG 603
Min. Negotiated Rate	$9,905.83
Max. Negotiated Rate	$16,525.15
Rate for Payer: AlohaCare Medicare	$9,905.83
Rate for Payer: Devoted Health Medicare	$10,896.41
Rate for Payer: Hawaii Medical Service Association Commercial	$16,525.15
Rate for Payer: Hawaii Medical Service Association Medicare	$9,905.83
Rate for Payer: Humana Medicare	$9,905.83
Rate for Payer: Kaiser Permanente Commercial	$15,023.02
Rate for Payer: Kaiser Permanente Medicare	$9,905.83
Rate for Payer: Ohana Health Plan Medicare	$9,905.83
Rate for Payer: UnitedHealthcare Medicare	$9,905.83

CEMENT AUTOMIX RELYX 7770454

Facility

$326.00

Service Code	HCPCS C1734
Hospital Revenue Code	278
Min. Negotiated Rate	$182.56
Max. Negotiated Rate	$316.22
Rate for Payer: Cash Price	$195.60
Rate for Payer: Hawaii Western Management Group Commercial	$228.20
Rate for Payer: Health Management Network Commercial	$277.10
Rate for Payer: MDX Hawaii PPO	$316.22
Rate for Payer: University Health Alliance Commercial	$182.56

CEMENT AUTOMIX RELYX 7770454

Facility

$326.00

Service Code	HCPCS C1734
Hospital Revenue Code	278
Min. Negotiated Rate	$166.26
Max. Negotiated Rate	$316.22
Rate for Payer: Cash Price	$195.60
Rate for Payer: Hawaii Western Management Group Commercial	$228.20
Rate for Payer: Health Management Network Commercial	$277.10
Rate for Payer: Kaiser Permanente Commercial	$205.38
Rate for Payer: Kaiser Permanente Medicaid	$166.26
Rate for Payer: MDX Hawaii PPO	$316.22
Rate for Payer: University Health Alliance Commercial	$182.56

CEMENT BONE 0306-573-000

Facility

$392.00

Hospital Revenue Code	272
Min. Negotiated Rate	$333.20
Max. Negotiated Rate	$380.24
Rate for Payer: Cash Price	$235.20
Rate for Payer: Health Management Network Commercial	$333.20
Rate for Payer: MDX Hawaii PPO	$380.24

CEMENT BONE 0306-573-000

Facility

$392.00

Hospital Revenue Code	272
Min. Negotiated Rate	$199.92
Max. Negotiated Rate	$380.24
Rate for Payer: Cash Price	$235.20
Rate for Payer: Hawaii Western Management Group Commercial	$372.40
Rate for Payer: Health Management Network Commercial	$333.20
Rate for Payer: Kaiser Permanente Commercial	$246.96
Rate for Payer: Kaiser Permanente Medicaid	$199.92
Rate for Payer: MDX Hawaii PPO	$380.24
Rate for Payer: University Health Alliance Commercial	$285.73

CEMENT BONE 40GM 6197-9-010

Facility

$6,100.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$3,111.00
Max. Negotiated Rate	$5,917.00
Rate for Payer: Cash Price	$3,660.00
Rate for Payer: Hawaii Western Management Group Commercial	$4,270.00
Rate for Payer: Health Management Network Commercial	$5,185.00
Rate for Payer: Kaiser Permanente Commercial	$3,843.00
Rate for Payer: Kaiser Permanente Medicaid	$3,111.00
Rate for Payer: MDX Hawaii PPO	$5,917.00
Rate for Payer: University Health Alliance Commercial	$3,416.00

CEMENT BONE 40GM 6197-9-010

Facility

$6,100.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$3,416.00
Max. Negotiated Rate	$5,917.00
Rate for Payer: Cash Price	$3,660.00
Rate for Payer: Hawaii Western Management Group Commercial	$4,270.00
Rate for Payer: Health Management Network Commercial	$5,185.00
Rate for Payer: MDX Hawaii PPO	$5,917.00
Rate for Payer: University Health Alliance Commercial	$3,416.00

CEMENT BONE HYDROSET XT 897005

Facility

$5,939.00

Service Code	HCPCS C1734
Hospital Revenue Code	278
Min. Negotiated Rate	$3,325.84
Max. Negotiated Rate	$5,760.83
Rate for Payer: Cash Price	$3,563.40
Rate for Payer: Hawaii Western Management Group Commercial	$4,157.30
Rate for Payer: Health Management Network Commercial	$5,048.15
Rate for Payer: MDX Hawaii PPO	$5,760.83
Rate for Payer: University Health Alliance Commercial	$3,325.84

CEMENT BONE HYDROSET XT 897005

Facility

$5,939.00

Service Code	HCPCS C1734
Hospital Revenue Code	278
Min. Negotiated Rate	$3,028.89
Max. Negotiated Rate	$5,760.83
Rate for Payer: Cash Price	$3,563.40
Rate for Payer: Hawaii Western Management Group Commercial	$4,157.30
Rate for Payer: Health Management Network Commercial	$5,048.15
Rate for Payer: Kaiser Permanente Commercial	$3,741.57
Rate for Payer: Kaiser Permanente Medicaid	$3,028.89
Rate for Payer: MDX Hawaii PPO	$5,760.83
Rate for Payer: University Health Alliance Commercial	$3,325.84

CEMENT BONE HYDROSET XT 897010

Facility

$11,307.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$6,331.92
Max. Negotiated Rate	$10,967.79
Rate for Payer: Cash Price	$6,784.20
Rate for Payer: Hawaii Western Management Group Commercial	$7,914.90
Rate for Payer: Health Management Network Commercial	$9,610.95
Rate for Payer: MDX Hawaii PPO	$10,967.79
Rate for Payer: University Health Alliance Commercial	$6,331.92

CEMENT BONE HYDROSET XT 897010

Facility

$11,307.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$5,766.57
Max. Negotiated Rate	$10,967.79
Rate for Payer: Cash Price	$6,784.20
Rate for Payer: Hawaii Western Management Group Commercial	$7,914.90
Rate for Payer: Health Management Network Commercial	$9,610.95
Rate for Payer: Kaiser Permanente Commercial	$7,123.41
Rate for Payer: Kaiser Permanente Medicaid	$5,766.57
Rate for Payer: MDX Hawaii PPO	$10,967.79
Rate for Payer: University Health Alliance Commercial	$6,331.92

CEMENT BONE MIXER

Facility

$230.00

Hospital Revenue Code	272
Min. Negotiated Rate	$117.30
Max. Negotiated Rate	$223.10
Rate for Payer: Cash Price	$138.00
Rate for Payer: Hawaii Western Management Group Commercial	$218.50
Rate for Payer: Health Management Network Commercial	$195.50
Rate for Payer: Kaiser Permanente Commercial	$144.90
Rate for Payer: Kaiser Permanente Medicaid	$117.30
Rate for Payer: MDX Hawaii PPO	$223.10
Rate for Payer: University Health Alliance Commercial	$167.65

CEMENT BONE MIXER

Facility

$230.00

Hospital Revenue Code	272
Min. Negotiated Rate	$195.50
Max. Negotiated Rate	$223.10
Rate for Payer: Cash Price	$138.00
Rate for Payer: Health Management Network Commercial	$195.50
Rate for Payer: MDX Hawaii PPO	$223.10

CEMENT BONE SIMPLX 6191-1-001

Facility

$309.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$173.04
Max. Negotiated Rate	$299.73
Rate for Payer: Cash Price	$185.40
Rate for Payer: Hawaii Western Management Group Commercial	$216.30
Rate for Payer: Health Management Network Commercial	$262.65
Rate for Payer: MDX Hawaii PPO	$299.73
Rate for Payer: University Health Alliance Commercial	$173.04

CEMENT BONE SIMPLX 6191-1-001

Facility

$309.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$157.59
Max. Negotiated Rate	$299.73
Rate for Payer: Cash Price	$185.40
Rate for Payer: Hawaii Western Management Group Commercial	$216.30
Rate for Payer: Health Management Network Commercial	$262.65
Rate for Payer: Kaiser Permanente Commercial	$194.67
Rate for Payer: Kaiser Permanente Medicaid	$157.59
Rate for Payer: MDX Hawaii PPO	$299.73
Rate for Payer: University Health Alliance Commercial	$173.04

CEMENTED KIT DWD014

Facility

$713.00

Service Code	HCPCS C1776
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

CEMENTED KIT DWD014

Facility

$713.00

Service Code	HCPCS C1776
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

CEMENTED STEMLESS 5200-00-036

Facility

$15,097.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$7,699.47
Max. Negotiated Rate	$14,644.09
Rate for Payer: Cash Price	$9,058.20
Rate for Payer: Hawaii Western Management Group Commercial	$10,567.90
Rate for Payer: Health Management Network Commercial	$12,832.45
Rate for Payer: Kaiser Permanente Commercial	$9,511.11
Rate for Payer: Kaiser Permanente Medicaid	$7,699.47
Rate for Payer: MDX Hawaii PPO	$14,644.09
Rate for Payer: University Health Alliance Commercial	$8,454.32

Know your out-of-pocket cost for care.

All Charges