Hilo Benioff Medical Center

All Charges

Charge

Type

Setting

Price

COLLAR MIAMI J PEDS

Facility

$188.00

Service Code	HCPCS L0174
Hospital Revenue Code	274
Min. Negotiated Rate	$105.28
Max. Negotiated Rate	$182.36
Rate for Payer: Cash Price	$112.80
Rate for Payer: Hawaii Western Management Group Commercial	$131.60
Rate for Payer: Health Management Network Commercial	$159.80
Rate for Payer: MDX Hawaii PPO	$182.36
Rate for Payer: University Health Alliance Commercial	$105.28

COLLAR MIAMI J PEDS

Facility

$188.00

Service Code	HCPCS L0174
Hospital Revenue Code	274
Min. Negotiated Rate	$95.88
Max. Negotiated Rate	$211.18
Rate for Payer: Cash Price	$112.80
Rate for Payer: Cash Price	$112.80
Rate for Payer: Hawaii Western Management Group Commercial	$131.60
Rate for Payer: Health Management Network Commercial	$159.80
Rate for Payer: Kaiser Permanente Commercial	$118.44
Rate for Payer: Kaiser Permanente Medicaid	$95.88
Rate for Payer: MDX Hawaii PPO	$182.36
Rate for Payer: UnitedHealthcare Medicaid	$211.18
Rate for Payer: University Health Alliance Commercial	$105.28

COLORECTAL CANCER SCREENING; COLONOSCOPY ON INDIVIDUAL AT HIGH RISK

Facility

$5,509.00

Service Code	CPT G0105
Hospital Revenue Code	360
Min. Negotiated Rate	$340.18
Max. Negotiated Rate	$5,509.00
Rate for Payer: AlohaCare Medicaid	$1,098.60
Rate for Payer: AlohaCare Medicare	$1,098.60
Rate for Payer: Devoted Health Medicare	$1,208.46
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	$1,098.60
Rate for Payer: Hawaii Medical Service Association Non-ABD	$1,028.67
Rate for Payer: Humana Medicare	$1,098.60
Rate for Payer: Kaiser Permanente Medicaid	$2,837.00
Rate for Payer: Kaiser Permanente Medicare	$1,098.60
Rate for Payer: Ohana Health Plan Medicaid	$1,208.46
Rate for Payer: Ohana Health Plan Medicare	$1,098.60
Rate for Payer: UnitedHealthcare Medicaid	$340.18
Rate for Payer: UnitedHealthcare Medicare	$1,098.60
Rate for Payer: University Health Alliance Commercial	$5,160.40

COLORECTAL CANCER SCREENING; COLONOSCOPY ON INDIVIDUAL NOT MEETING CRITERIA FOR HIGH RISK

Facility

$5,509.00

Service Code	CPT G0121
Hospital Revenue Code	360
Min. Negotiated Rate	$340.18
Max. Negotiated Rate	$5,509.00
Rate for Payer: AlohaCare Medicaid	$1,098.60
Rate for Payer: AlohaCare Medicare	$1,098.60
Rate for Payer: Devoted Health Medicare	$1,208.46
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	$1,098.60
Rate for Payer: Hawaii Medical Service Association Non-ABD	$1,028.67
Rate for Payer: Humana Medicare	$1,098.60
Rate for Payer: Kaiser Permanente Medicaid	$2,837.00
Rate for Payer: Kaiser Permanente Medicare	$1,098.60
Rate for Payer: Ohana Health Plan Medicaid	$1,208.46
Rate for Payer: Ohana Health Plan Medicare	$1,098.60
Rate for Payer: UnitedHealthcare Medicaid	$340.18
Rate for Payer: UnitedHealthcare Medicare	$1,098.60
Rate for Payer: University Health Alliance Commercial	$5,160.40

COLPOCLEISIS (LE FORT TYPE)

Facility

$6,500.58

Service Code	CPT 57120
Hospital Revenue Code	360
Min. Negotiated Rate	$456.03
Max. Negotiated Rate	$6,500.58
Rate for Payer: AlohaCare Medicaid	$5,909.62
Rate for Payer: AlohaCare Medicare	$5,909.62
Rate for Payer: Devoted Health Medicare	$6,500.58
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	$5,909.62
Rate for Payer: Hawaii Medical Service Association Non-ABD	$1,028.67
Rate for Payer: Humana Medicare	$5,909.62
Rate for Payer: Kaiser Permanente Medicaid	$2,837.00
Rate for Payer: Kaiser Permanente Medicare	$5,909.62
Rate for Payer: Ohana Health Plan Medicaid	$6,500.58
Rate for Payer: Ohana Health Plan Medicare	$5,909.62
Rate for Payer: UnitedHealthcare Medicaid	$456.03
Rate for Payer: UnitedHealthcare Medicare	$5,909.62

COLPOPEXY, VAGINAL; EXTRA-PERITONEAL APPROACH (SACROSPINOUS, ILIOCOCCYGEUS)

Facility

$9,636.21

Service Code	CPT 57282
Hospital Revenue Code	360
Min. Negotiated Rate	$521.33
Max. Negotiated Rate	$9,636.21
Rate for Payer: AlohaCare Medicaid	$8,760.19
Rate for Payer: AlohaCare Medicare	$8,760.19
Rate for Payer: Devoted Health Medicare	$9,636.21
Rate for Payer: Hawaii Medical Service Association ABD	$848.00
Rate for Payer: Hawaii Medical Service Association Commercial	$8,270.00
Rate for Payer: Hawaii Medical Service Association Medicare	$8,760.19
Rate for Payer: Hawaii Medical Service Association Non-ABD	$1,427.62
Rate for Payer: Humana Medicare	$8,760.19
Rate for Payer: Kaiser Permanente Medicaid	$2,837.00
Rate for Payer: Kaiser Permanente Medicare	$8,760.19
Rate for Payer: Ohana Health Plan Medicaid	$9,636.21
Rate for Payer: Ohana Health Plan Medicare	$8,760.19
Rate for Payer: UnitedHealthcare Medicaid	$521.33
Rate for Payer: UnitedHealthcare Medicare	$8,760.19

COLPORRHAPHY, SUTURE OF INJURY OF VAGINA (NONOBSTETRICAL)

Facility

$5,509.00

Service Code	CPT 57200
Hospital Revenue Code	360
Min. Negotiated Rate	$456.03
Max. Negotiated Rate	$5,509.00
Rate for Payer: AlohaCare Medicaid	$3,824.16
Rate for Payer: AlohaCare Medicare	$3,824.16
Rate for Payer: Devoted Health Medicare	$4,206.58
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	$3,824.16
Rate for Payer: Hawaii Medical Service Association Non-ABD	$1,028.67
Rate for Payer: Humana Medicare	$3,824.16
Rate for Payer: Kaiser Permanente Medicaid	$2,837.00
Rate for Payer: Kaiser Permanente Medicare	$3,824.16
Rate for Payer: Ohana Health Plan Medicaid	$4,206.58
Rate for Payer: Ohana Health Plan Medicare	$3,824.16
Rate for Payer: UnitedHealthcare Medicaid	$456.03
Rate for Payer: UnitedHealthcare Medicare	$3,824.16
Rate for Payer: University Health Alliance Commercial	$4,035.20

COMBINED ANTERIOR AND POSTERIOR CERVICAL SPINAL FUSION WITH MCC

Facility

$155,415.60

Service Code	MSDRG 429
Min. Negotiated Rate	$102,477.48
Max. Negotiated Rate	$155,415.60
Rate for Payer: AlohaCare Medicare	$102,477.48
Rate for Payer: Devoted Health Medicare	$112,725.23
Rate for Payer: Hawaii Medical Service Association Commercial	$118,345.28
Rate for Payer: Hawaii Medical Service Association Medicare	$102,477.48
Rate for Payer: Humana Medicare	$102,477.48
Rate for Payer: Kaiser Permanente Commercial	$155,415.60
Rate for Payer: Kaiser Permanente Medicare	$102,477.48
Rate for Payer: Ohana Health Plan Medicare	$102,477.48
Rate for Payer: UnitedHealthcare Medicare	$102,477.48

COMBINED ANTERIOR AND POSTERIOR CERVICAL SPINAL FUSION WITHOUT MCC

Facility

$118,345.28

Service Code	MSDRG 430
Min. Negotiated Rate	$65,596.47
Max. Negotiated Rate	$118,345.28
Rate for Payer: AlohaCare Medicare	$65,596.47
Rate for Payer: Devoted Health Medicare	$72,156.12
Rate for Payer: Hawaii Medical Service Association Commercial	$118,345.28
Rate for Payer: Hawaii Medical Service Association Medicare	$65,596.47
Rate for Payer: Humana Medicare	$65,596.47
Rate for Payer: Kaiser Permanente Commercial	$99,482.48
Rate for Payer: Kaiser Permanente Medicare	$65,596.47
Rate for Payer: Ohana Health Plan Medicare	$65,596.47
Rate for Payer: UnitedHealthcare Medicare	$65,596.47

COMBINED ANTEROPOSTERIOR COLPORRHAPHY, INCLUDING CYSTOURETHROSCOPY, WHEN PERFORMED;

Facility

$11,157.19

Service Code	CPT 57260
Hospital Revenue Code	360
Min. Negotiated Rate	$456.03
Max. Negotiated Rate	$11,157.19
Rate for Payer: AlohaCare Medicaid	$5,909.62
Rate for Payer: AlohaCare Medicare	$5,909.62
Rate for Payer: Devoted Health Medicare	$6,500.58
Rate for Payer: Hawaii Medical Service Association ABD	$848.00
Rate for Payer: Hawaii Medical Service Association Commercial	$8,270.00
Rate for Payer: Hawaii Medical Service Association Medicare	$5,909.62
Rate for Payer: Hawaii Medical Service Association Non-ABD	$1,427.62
Rate for Payer: Humana Medicare	$5,909.62
Rate for Payer: Kaiser Permanente Medicaid	$2,837.00
Rate for Payer: Kaiser Permanente Medicare	$5,909.62
Rate for Payer: Ohana Health Plan Medicaid	$6,500.58
Rate for Payer: Ohana Health Plan Medicare	$5,909.62
Rate for Payer: UnitedHealthcare Medicaid	$456.03
Rate for Payer: UnitedHealthcare Medicare	$5,909.62
Rate for Payer: University Health Alliance Commercial	$11,157.19

COMBINED ANTEROPOSTERIOR COLPORRHAPHY, INCLUDING CYSTOURETHROSCOPY, WHEN PERFORMED; WITH ENTEROCELE REPAIR

Facility

$16,700.00

Service Code	CPT 57265
Hospital Revenue Code	360
Min. Negotiated Rate	$521.33
Max. Negotiated Rate	$16,700.00
Rate for Payer: AlohaCare Medicaid	$5,909.62
Rate for Payer: AlohaCare Medicare	$5,909.62
Rate for Payer: Devoted Health Medicare	$6,500.58
Rate for Payer: Hawaii Medical Service Association ABD	$848.00
Rate for Payer: Hawaii Medical Service Association Commercial	$8,270.00
Rate for Payer: Hawaii Medical Service Association Medicare	$5,909.62
Rate for Payer: Hawaii Medical Service Association Non-ABD	$1,427.62
Rate for Payer: Humana Medicare	$5,909.62
Rate for Payer: Kaiser Permanente Medicaid	$2,837.00
Rate for Payer: Kaiser Permanente Medicare	$5,909.62
Rate for Payer: Ohana Health Plan Medicaid	$6,500.58
Rate for Payer: Ohana Health Plan Medicare	$5,909.62
Rate for Payer: UnitedHealthcare Medicaid	$521.33
Rate for Payer: UnitedHealthcare Medicare	$5,909.62
Rate for Payer: University Health Alliance Commercial	$16,700.00

COMPACT VAC MIX SYSTEM

Facility

$998.00

Hospital Revenue Code	272
Min. Negotiated Rate	$508.98
Max. Negotiated Rate	$968.06
Rate for Payer: Cash Price	$598.80
Rate for Payer: Hawaii Western Management Group Commercial	$948.10
Rate for Payer: Health Management Network Commercial	$848.30
Rate for Payer: Kaiser Permanente Commercial	$628.74
Rate for Payer: Kaiser Permanente Medicaid	$508.98
Rate for Payer: MDX Hawaii PPO	$968.06
Rate for Payer: University Health Alliance Commercial	$727.44

COMPACT VAC MIX SYSTEM

Facility

$998.00

Hospital Revenue Code	272
Min. Negotiated Rate	$848.30
Max. Negotiated Rate	$968.06
Rate for Payer: Cash Price	$598.80
Rate for Payer: Health Management Network Commercial	$848.30
Rate for Payer: MDX Hawaii PPO	$968.06

COMPLEX AORTIC ARCH PROCEDURES

Facility

$197,962.03

Service Code	MSDRG 209
Min. Negotiated Rate	$128,742.92
Max. Negotiated Rate	$197,962.03
Rate for Payer: AlohaCare Medicare	$128,742.92
Rate for Payer: Devoted Health Medicare	$141,617.21
Rate for Payer: Hawaii Medical Service Association Commercial	$197,962.03
Rate for Payer: Hawaii Medical Service Association Medicare	$128,742.92
Rate for Payer: Humana Medicare	$128,742.92
Rate for Payer: Kaiser Permanente Commercial	$195,249.30
Rate for Payer: Kaiser Permanente Medicare	$128,742.92
Rate for Payer: Ohana Health Plan Medicare	$128,742.92
Rate for Payer: UnitedHealthcare Medicare	$128,742.92

COMPLICATED PEPTIC ULCER WITH CC

Facility

$24,363.06

Service Code	MSDRG 381
Min. Negotiated Rate	$12,324.00
Max. Negotiated Rate	$24,363.06
Rate for Payer: AlohaCare Medicare	$12,324.00
Rate for Payer: Devoted Health Medicare	$13,556.40
Rate for Payer: Hawaii Medical Service Association Commercial	$24,363.06
Rate for Payer: Hawaii Medical Service Association Medicare	$12,324.00
Rate for Payer: Humana Medicare	$12,324.00
Rate for Payer: Kaiser Permanente Commercial	$18,690.38
Rate for Payer: Kaiser Permanente Medicare	$12,324.00
Rate for Payer: Ohana Health Plan Medicare	$12,324.00
Rate for Payer: UnitedHealthcare Medicare	$12,324.00

COMPLICATED PEPTIC ULCER WITH MCC

Facility

$33,847.95

Service Code	MSDRG 380
Min. Negotiated Rate	$22,318.56
Max. Negotiated Rate	$33,847.95
Rate for Payer: AlohaCare Medicare	$22,318.56
Rate for Payer: Devoted Health Medicare	$24,550.42
Rate for Payer: Hawaii Medical Service Association Commercial	$24,363.06
Rate for Payer: Hawaii Medical Service Association Medicare	$22,318.56
Rate for Payer: Humana Medicare	$22,318.56
Rate for Payer: Kaiser Permanente Commercial	$33,847.95
Rate for Payer: Kaiser Permanente Medicare	$22,318.56
Rate for Payer: Ohana Health Plan Medicare	$22,318.56
Rate for Payer: UnitedHealthcare Medicare	$22,318.56

COMPLICATED PEPTIC ULCER WITHOUT CC/MCC

Facility

$24,363.06

Service Code	MSDRG 382
Min. Negotiated Rate	$9,106.23
Max. Negotiated Rate	$24,363.06
Rate for Payer: AlohaCare Medicare	$9,106.23
Rate for Payer: Devoted Health Medicare	$10,016.85
Rate for Payer: Hawaii Medical Service Association Commercial	$24,363.06
Rate for Payer: Hawaii Medical Service Association Medicare	$9,106.23
Rate for Payer: Humana Medicare	$9,106.23
Rate for Payer: Kaiser Permanente Commercial	$13,810.35
Rate for Payer: Kaiser Permanente Medicare	$9,106.23
Rate for Payer: Ohana Health Plan Medicare	$9,106.23
Rate for Payer: UnitedHealthcare Medicare	$9,106.23

COMPLICATIONS OF TREATMENT WITH CC

Facility

$28,488.28

Service Code	MSDRG 920
Min. Negotiated Rate	$11,400.41
Max. Negotiated Rate	$28,488.28
Rate for Payer: AlohaCare Medicare	$11,400.41
Rate for Payer: Devoted Health Medicare	$12,540.45
Rate for Payer: Hawaii Medical Service Association Commercial	$28,488.28
Rate for Payer: Hawaii Medical Service Association Medicare	$11,400.41
Rate for Payer: Humana Medicare	$11,400.41
Rate for Payer: Kaiser Permanente Commercial	$17,289.67
Rate for Payer: Kaiser Permanente Medicare	$11,400.41
Rate for Payer: Ohana Health Plan Medicare	$11,400.41
Rate for Payer: UnitedHealthcare Medicare	$11,400.41

COMPLICATIONS OF TREATMENT WITH MCC

Facility

$31,581.30

Service Code	MSDRG 919
Min. Negotiated Rate	$20,823.99
Max. Negotiated Rate	$31,581.30
Rate for Payer: AlohaCare Medicare	$20,823.99
Rate for Payer: Devoted Health Medicare	$22,906.39
Rate for Payer: Hawaii Medical Service Association Commercial	$28,488.28
Rate for Payer: Hawaii Medical Service Association Medicare	$20,823.99
Rate for Payer: Humana Medicare	$20,823.99
Rate for Payer: Kaiser Permanente Commercial	$31,581.30
Rate for Payer: Kaiser Permanente Medicare	$20,823.99
Rate for Payer: Ohana Health Plan Medicare	$20,823.99
Rate for Payer: UnitedHealthcare Medicare	$20,823.99

COMPLICATIONS OF TREATMENT WITHOUT CC/MCC

Facility

$16,136.89

Service Code	MSDRG 921
Min. Negotiated Rate	$7,830.03
Max. Negotiated Rate	$16,136.89
Rate for Payer: AlohaCare Medicare	$7,830.03
Rate for Payer: Devoted Health Medicare	$8,613.03
Rate for Payer: Hawaii Medical Service Association Commercial	$16,136.89
Rate for Payer: Hawaii Medical Service Association Medicare	$7,830.03
Rate for Payer: Humana Medicare	$7,830.03
Rate for Payer: Kaiser Permanente Commercial	$11,874.90
Rate for Payer: Kaiser Permanente Medicare	$7,830.03
Rate for Payer: Ohana Health Plan Medicare	$7,830.03
Rate for Payer: UnitedHealthcare Medicare	$7,830.03

COMPNENT KIT ACCESSRY HERO1003

Facility

$1,120.00

Hospital Revenue Code	272
Min. Negotiated Rate	$571.20
Max. Negotiated Rate	$1,086.40
Rate for Payer: Cash Price	$672.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,064.00
Rate for Payer: Health Management Network Commercial	$952.00
Rate for Payer: Kaiser Permanente Commercial	$705.60
Rate for Payer: Kaiser Permanente Medicaid	$571.20
Rate for Payer: MDX Hawaii PPO	$1,086.40
Rate for Payer: University Health Alliance Commercial	$816.37

COMPNENT KIT ACCESSRY HERO1003

Facility

$1,120.00

Hospital Revenue Code	272
Min. Negotiated Rate	$952.00
Max. Negotiated Rate	$1,086.40
Rate for Payer: Cash Price	$672.00
Rate for Payer: Health Management Network Commercial	$952.00
Rate for Payer: MDX Hawaii PPO	$1,086.40

COMPONENT FEMORAL SIZE 8

Facility

$8,400.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$4,284.00
Max. Negotiated Rate	$8,148.00
Rate for Payer: Cash Price	$5,040.00
Rate for Payer: Hawaii Western Management Group Commercial	$5,880.00
Rate for Payer: Health Management Network Commercial	$7,140.00
Rate for Payer: Kaiser Permanente Commercial	$5,292.00
Rate for Payer: Kaiser Permanente Medicaid	$4,284.00
Rate for Payer: MDX Hawaii PPO	$8,148.00
Rate for Payer: University Health Alliance Commercial	$4,704.00

COMPONENT FEMORAL SIZE 8

Facility

$8,400.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$4,704.00
Max. Negotiated Rate	$8,148.00
Rate for Payer: Cash Price	$5,040.00
Rate for Payer: Hawaii Western Management Group Commercial	$5,880.00
Rate for Payer: Health Management Network Commercial	$7,140.00
Rate for Payer: MDX Hawaii PPO	$8,148.00
Rate for Payer: University Health Alliance Commercial	$4,704.00

COMPONENT TIBIAL SIZE C RT

Facility

$3,800.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$1,938.00
Max. Negotiated Rate	$3,686.00
Rate for Payer: Cash Price	$2,280.00
Rate for Payer: Hawaii Western Management Group Commercial	$2,660.00
Rate for Payer: Health Management Network Commercial	$3,230.00
Rate for Payer: Kaiser Permanente Commercial	$2,394.00
Rate for Payer: Kaiser Permanente Medicaid	$1,938.00
Rate for Payer: MDX Hawaii PPO	$3,686.00
Rate for Payer: University Health Alliance Commercial	$2,128.00

Know your out-of-pocket cost for care.

All Charges