Hilo Benioff Medical Center

All Charges

Charge

Type

Setting

Price

AEQUALIS ASCEND FLEX DWF602B

Facility

$8,762.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$4,906.72
Max. Negotiated Rate	$8,499.14
Rate for Payer: Cash Price	$5,257.20
Rate for Payer: Hawaii Western Management Group Commercial	$6,133.40
Rate for Payer: Health Management Network Commercial	$7,447.70
Rate for Payer: MDX Hawaii PPO	$8,499.14
Rate for Payer: University Health Alliance Commercial	$4,906.72

AEQUALIS ASCEND FLEX DWF602B

Facility

$8,762.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$4,468.62
Max. Negotiated Rate	$8,499.14
Rate for Payer: Cash Price	$5,257.20
Rate for Payer: Hawaii Western Management Group Commercial	$6,133.40
Rate for Payer: Health Management Network Commercial	$7,447.70
Rate for Payer: Kaiser Permanente Commercial	$5,520.06
Rate for Payer: Kaiser Permanente Medicaid	$4,468.62
Rate for Payer: MDX Hawaii PPO	$8,499.14
Rate for Payer: University Health Alliance Commercial	$4,906.72

AEQUALIS ASCEND FLEX DWF604B

Facility

$8,762.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$4,468.62
Max. Negotiated Rate	$8,499.14
Rate for Payer: Cash Price	$5,257.20
Rate for Payer: Hawaii Western Management Group Commercial	$6,133.40
Rate for Payer: Health Management Network Commercial	$7,447.70
Rate for Payer: Kaiser Permanente Commercial	$5,520.06
Rate for Payer: Kaiser Permanente Medicaid	$4,468.62
Rate for Payer: MDX Hawaii PPO	$8,499.14
Rate for Payer: University Health Alliance Commercial	$4,906.72

AEQUALIS ASCEND FLEX DWF604B

Facility

$8,762.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$4,906.72
Max. Negotiated Rate	$8,499.14
Rate for Payer: Cash Price	$5,257.20
Rate for Payer: Hawaii Western Management Group Commercial	$6,133.40
Rate for Payer: Health Management Network Commercial	$7,447.70
Rate for Payer: MDX Hawaii PPO	$8,499.14
Rate for Payer: University Health Alliance Commercial	$4,906.72

AEQUALIS ASCEND FLEX DWF607B

Facility

$11,368.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$6,366.08
Max. Negotiated Rate	$11,026.96
Rate for Payer: Cash Price	$6,820.80
Rate for Payer: Hawaii Western Management Group Commercial	$7,957.60
Rate for Payer: Health Management Network Commercial	$9,662.80
Rate for Payer: MDX Hawaii PPO	$11,026.96
Rate for Payer: University Health Alliance Commercial	$6,366.08

AEQUALIS ASCEND FLEX DWF607B

Facility

$11,368.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$5,797.68
Max. Negotiated Rate	$11,026.96
Rate for Payer: Cash Price	$6,820.80
Rate for Payer: Hawaii Western Management Group Commercial	$7,957.60
Rate for Payer: Health Management Network Commercial	$9,662.80
Rate for Payer: Kaiser Permanente Commercial	$7,161.84
Rate for Payer: Kaiser Permanente Medicaid	$5,797.68
Rate for Payer: MDX Hawaii PPO	$11,026.96
Rate for Payer: University Health Alliance Commercial	$6,366.08

AEQUALIS PERFORM+ DWE413

Facility

$4,628.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$2,360.28
Max. Negotiated Rate	$4,489.16
Rate for Payer: Cash Price	$2,776.80
Rate for Payer: Hawaii Western Management Group Commercial	$3,239.60
Rate for Payer: Health Management Network Commercial	$3,933.80
Rate for Payer: Kaiser Permanente Commercial	$2,915.64
Rate for Payer: Kaiser Permanente Medicaid	$2,360.28
Rate for Payer: MDX Hawaii PPO	$4,489.16
Rate for Payer: University Health Alliance Commercial	$2,591.68

AEQUALIS PERFORM+ DWE413

Facility

$4,628.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$2,591.68
Max. Negotiated Rate	$4,489.16
Rate for Payer: Cash Price	$2,776.80
Rate for Payer: Hawaii Western Management Group Commercial	$3,239.60
Rate for Payer: Health Management Network Commercial	$3,933.80
Rate for Payer: MDX Hawaii PPO	$4,489.16
Rate for Payer: University Health Alliance Commercial	$2,591.68

AEQUALIS PERFORM DWE422

Facility

$6,394.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$3,580.64
Max. Negotiated Rate	$6,202.18
Rate for Payer: Cash Price	$3,836.40
Rate for Payer: Hawaii Western Management Group Commercial	$4,475.80
Rate for Payer: Health Management Network Commercial	$5,434.90
Rate for Payer: MDX Hawaii PPO	$6,202.18
Rate for Payer: University Health Alliance Commercial	$3,580.64

AEQUALIS PERFORM DWE422

Facility

$6,394.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$3,260.94
Max. Negotiated Rate	$6,202.18
Rate for Payer: Cash Price	$3,836.40
Rate for Payer: Hawaii Western Management Group Commercial	$4,475.80
Rate for Payer: Health Management Network Commercial	$5,434.90
Rate for Payer: Kaiser Permanente Commercial	$4,028.22
Rate for Payer: Kaiser Permanente Medicaid	$3,260.94
Rate for Payer: MDX Hawaii PPO	$6,202.18
Rate for Payer: University Health Alliance Commercial	$3,580.64

AEQUALIS PERFORM DWJ014

Facility

$6,028.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$3,074.28
Max. Negotiated Rate	$5,847.16
Rate for Payer: Cash Price	$3,616.80
Rate for Payer: Hawaii Western Management Group Commercial	$4,219.60
Rate for Payer: Health Management Network Commercial	$5,123.80
Rate for Payer: Kaiser Permanente Commercial	$3,797.64
Rate for Payer: Kaiser Permanente Medicaid	$3,074.28
Rate for Payer: MDX Hawaii PPO	$5,847.16
Rate for Payer: University Health Alliance Commercial	$3,375.68

AEQUALIS PERFORM DWJ014

Facility

$6,028.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$3,375.68
Max. Negotiated Rate	$5,847.16
Rate for Payer: Cash Price	$3,616.80
Rate for Payer: Hawaii Western Management Group Commercial	$4,219.60
Rate for Payer: Health Management Network Commercial	$5,123.80
Rate for Payer: MDX Hawaii PPO	$5,847.16
Rate for Payer: University Health Alliance Commercial	$3,375.68

AEQUALIS PERFORM DWJ513

Facility

$7,356.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$4,119.36
Max. Negotiated Rate	$7,135.32
Rate for Payer: Cash Price	$4,413.60
Rate for Payer: Hawaii Western Management Group Commercial	$5,149.20
Rate for Payer: Health Management Network Commercial	$6,252.60
Rate for Payer: MDX Hawaii PPO	$7,135.32
Rate for Payer: University Health Alliance Commercial	$4,119.36

AEQUALIS PERFORM DWJ513

Facility

$7,356.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$3,751.56
Max. Negotiated Rate	$7,135.32
Rate for Payer: Cash Price	$4,413.60
Rate for Payer: Hawaii Western Management Group Commercial	$5,149.20
Rate for Payer: Health Management Network Commercial	$6,252.60
Rate for Payer: Kaiser Permanente Commercial	$4,634.28
Rate for Payer: Kaiser Permanente Medicaid	$3,751.56
Rate for Payer: MDX Hawaii PPO	$7,135.32
Rate for Payer: University Health Alliance Commercial	$4,119.36

AEQUALIS PERFORM REV DWJ401

Facility

$3,208.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$1,796.48
Max. Negotiated Rate	$3,111.76
Rate for Payer: Cash Price	$1,924.80
Rate for Payer: Hawaii Western Management Group Commercial	$2,245.60
Rate for Payer: Health Management Network Commercial	$2,726.80
Rate for Payer: MDX Hawaii PPO	$3,111.76
Rate for Payer: University Health Alliance Commercial	$1,796.48

AEQUALIS PERFORM REV DWJ401

Facility

$3,208.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$1,636.08
Max. Negotiated Rate	$3,111.76
Rate for Payer: Cash Price	$1,924.80
Rate for Payer: Hawaii Western Management Group Commercial	$2,245.60
Rate for Payer: Health Management Network Commercial	$2,726.80
Rate for Payer: Kaiser Permanente Commercial	$2,021.04
Rate for Payer: Kaiser Permanente Medicaid	$1,636.08
Rate for Payer: MDX Hawaii PPO	$3,111.76
Rate for Payer: University Health Alliance Commercial	$1,796.48

AEQUALIS SCREW DRILL BT MWJ126

Facility

$454.00

Service Code	HCPCS C1776
Hospital Revenue Code	272
Min. Negotiated Rate	$385.90
Max. Negotiated Rate	$440.38
Rate for Payer: Cash Price	$272.40
Rate for Payer: Health Management Network Commercial	$385.90
Rate for Payer: MDX Hawaii PPO	$440.38

AEQUALIS SCREW DRILL BT MWJ126

Facility

$454.00

Service Code	HCPCS C1776
Hospital Revenue Code	272
Min. Negotiated Rate	$231.54
Max. Negotiated Rate	$440.38
Rate for Payer: Cash Price	$272.40
Rate for Payer: Hawaii Western Management Group Commercial	$431.30
Rate for Payer: Health Management Network Commercial	$385.90
Rate for Payer: Kaiser Permanente Commercial	$286.02
Rate for Payer: Kaiser Permanente Medicaid	$231.54
Rate for Payer: MDX Hawaii PPO	$440.38
Rate for Payer: University Health Alliance Commercial	$330.92

AFTERCARE, MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH CC

Facility

$19,425.22

Service Code	MSDRG 560
Min. Negotiated Rate	$12,808.55
Max. Negotiated Rate	$19,425.22
Rate for Payer: AlohaCare Medicare	$12,808.55
Rate for Payer: Devoted Health Medicare	$14,089.41
Rate for Payer: Hawaii Medical Service Association Commercial	$16,961.93
Rate for Payer: Hawaii Medical Service Association Medicare	$12,808.55
Rate for Payer: Humana Medicare	$12,808.55
Rate for Payer: Kaiser Permanente Commercial	$19,425.22
Rate for Payer: Kaiser Permanente Medicare	$12,808.55
Rate for Payer: Ohana Health Plan Medicare	$12,808.55
Rate for Payer: UnitedHealthcare Medicare	$12,808.55

AFTERCARE, MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH MCC

Facility

$32,169.53

Service Code	MSDRG 559
Min. Negotiated Rate	$16,961.93
Max. Negotiated Rate	$32,169.53
Rate for Payer: AlohaCare Medicare	$21,211.86
Rate for Payer: Devoted Health Medicare	$23,333.05
Rate for Payer: Hawaii Medical Service Association Commercial	$16,961.93
Rate for Payer: Hawaii Medical Service Association Medicare	$21,211.86
Rate for Payer: Humana Medicare	$21,211.86
Rate for Payer: Kaiser Permanente Commercial	$32,169.53
Rate for Payer: Kaiser Permanente Medicare	$21,211.86
Rate for Payer: Ohana Health Plan Medicare	$21,211.86
Rate for Payer: UnitedHealthcare Medicare	$21,211.86

AFTERCARE, MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITHOUT CC/MCC

Facility

$16,961.93

Service Code	MSDRG 561
Min. Negotiated Rate	$9,143.76
Max. Negotiated Rate	$16,961.93
Rate for Payer: AlohaCare Medicare	$9,143.76
Rate for Payer: Devoted Health Medicare	$10,058.14
Rate for Payer: Hawaii Medical Service Association Commercial	$16,961.93
Rate for Payer: Hawaii Medical Service Association Medicare	$9,143.76
Rate for Payer: Humana Medicare	$9,143.76
Rate for Payer: Kaiser Permanente Commercial	$13,867.27
Rate for Payer: Kaiser Permanente Medicare	$9,143.76
Rate for Payer: Ohana Health Plan Medicare	$9,143.76
Rate for Payer: UnitedHealthcare Medicare	$9,143.76

AFTERCARE WITH CC/MCC

Facility

$20,522.33

Service Code	MSDRG 949
Min. Negotiated Rate	$13,531.96
Max. Negotiated Rate	$20,522.33
Rate for Payer: AlohaCare Medicare	$13,531.96
Rate for Payer: Devoted Health Medicare	$14,885.16
Rate for Payer: Hawaii Medical Service Association Commercial	$18,029.64
Rate for Payer: Hawaii Medical Service Association Medicare	$13,531.96
Rate for Payer: Humana Medicare	$13,531.96
Rate for Payer: Kaiser Permanente Commercial	$20,522.33
Rate for Payer: Kaiser Permanente Medicare	$13,531.96
Rate for Payer: Ohana Health Plan Medicare	$13,531.96
Rate for Payer: UnitedHealthcare Medicare	$13,531.96

AFTERCARE WITHOUT CC/MCC

Facility

$10,827.83

Service Code	MSDRG 950
Min. Negotiated Rate	$5,338.52
Max. Negotiated Rate	$10,827.83
Rate for Payer: AlohaCare Medicare	$7,139.63
Rate for Payer: Devoted Health Medicare	$7,853.59
Rate for Payer: Hawaii Medical Service Association Commercial	$5,338.52
Rate for Payer: Hawaii Medical Service Association Medicare	$7,139.63
Rate for Payer: Humana Medicare	$7,139.63
Rate for Payer: Kaiser Permanente Commercial	$10,827.83
Rate for Payer: Kaiser Permanente Medicare	$7,139.63
Rate for Payer: Ohana Health Plan Medicare	$7,139.63
Rate for Payer: UnitedHealthcare Medicare	$7,139.63

AGENT DCB 2.5X15

Facility

$12,350.00

Service Code	HCPCS C9610
Hospital Revenue Code	272
Min. Negotiated Rate	$6,298.50
Max. Negotiated Rate	$11,979.50
Rate for Payer: Cash Price	$7,410.00
Rate for Payer: Hawaii Western Management Group Commercial	$11,732.50
Rate for Payer: Health Management Network Commercial	$10,497.50
Rate for Payer: Kaiser Permanente Commercial	$7,780.50
Rate for Payer: Kaiser Permanente Medicaid	$6,298.50
Rate for Payer: MDX Hawaii PPO	$11,979.50
Rate for Payer: University Health Alliance Commercial	$9,001.92

AGENT DCB 2.5X15

Facility

$12,350.00

Service Code	HCPCS C9610
Hospital Revenue Code	272
Min. Negotiated Rate	$10,497.50
Max. Negotiated Rate	$11,979.50
Rate for Payer: Cash Price	$7,410.00
Rate for Payer: Health Management Network Commercial	$10,497.50
Rate for Payer: MDX Hawaii PPO	$11,979.50

Know your out-of-pocket cost for care.

All Charges