Hilo Benioff Medical Center

All Charges

Charge

Type

Setting

Price

CORONARY BYPASS WITHOUT CARDIAC CATHETERIZATION WITH MCC

Facility

$101,233.35

Service Code	MSDRG 235
Min. Negotiated Rate	$66,750.95
Max. Negotiated Rate	$101,233.35
Rate for Payer: AlohaCare Medicare	$66,750.95
Rate for Payer: Devoted Health Medicare	$73,426.04
Rate for Payer: Hawaii Medical Service Association Commercial	$99,514.87
Rate for Payer: Hawaii Medical Service Association Medicare	$66,750.95
Rate for Payer: Humana Medicare	$66,750.95
Rate for Payer: Kaiser Permanente Commercial	$101,233.35
Rate for Payer: Kaiser Permanente Medicare	$66,750.95
Rate for Payer: Ohana Health Plan Medicare	$66,750.95
Rate for Payer: UnitedHealthcare Medicare	$66,750.95

CORONARY BYPASS WITHOUT CARDIAC CATHETERIZATION WITHOUT MCC

Facility

$92,526.26

Service Code	MSDRG 236
Min. Negotiated Rate	$47,644.49
Max. Negotiated Rate	$92,526.26
Rate for Payer: AlohaCare Medicare	$47,644.49
Rate for Payer: Devoted Health Medicare	$52,408.94
Rate for Payer: Hawaii Medical Service Association Commercial	$92,526.26
Rate for Payer: Hawaii Medical Service Association Medicare	$47,644.49
Rate for Payer: Humana Medicare	$47,644.49
Rate for Payer: Kaiser Permanente Commercial	$72,256.80
Rate for Payer: Kaiser Permanente Medicare	$47,644.49
Rate for Payer: Ohana Health Plan Medicare	$47,644.49
Rate for Payer: UnitedHealthcare Medicare	$47,644.49

CORONARY BYPASS WITH PTCA WITH MCC

Facility

$145,415.77

Service Code	MSDRG 231
Min. Negotiated Rate	$95,883.84
Max. Negotiated Rate	$145,415.77
Rate for Payer: AlohaCare Medicare	$95,883.84
Rate for Payer: Devoted Health Medicare	$105,472.22
Rate for Payer: Hawaii Medical Service Association Commercial	$143,848.85
Rate for Payer: Hawaii Medical Service Association Medicare	$95,883.84
Rate for Payer: Humana Medicare	$95,883.84
Rate for Payer: Kaiser Permanente Commercial	$145,415.77
Rate for Payer: Kaiser Permanente Medicare	$95,883.84
Rate for Payer: Ohana Health Plan Medicare	$95,883.84
Rate for Payer: UnitedHealthcare Medicare	$95,883.84

CORONARY BYPASS WITH PTCA WITHOUT MCC

Facility

$143,848.85

Service Code	MSDRG 232
Min. Negotiated Rate	$68,957.55
Max. Negotiated Rate	$143,848.85
Rate for Payer: AlohaCare Medicare	$68,957.55
Rate for Payer: Devoted Health Medicare	$75,853.30
Rate for Payer: Hawaii Medical Service Association Commercial	$143,848.85
Rate for Payer: Hawaii Medical Service Association Medicare	$68,957.55
Rate for Payer: Humana Medicare	$68,957.55
Rate for Payer: Kaiser Permanente Commercial	$104,579.85
Rate for Payer: Kaiser Permanente Medicare	$68,957.55
Rate for Payer: Ohana Health Plan Medicare	$68,957.55
Rate for Payer: UnitedHealthcare Medicare	$68,957.55

CORONARY BYPASS W/O AMI OR COMPLEX PDX

Facility

$19,471.12

Service Code	APR-DRG 1662
Min. Negotiated Rate	$19,471.12
Max. Negotiated Rate	$19,471.12
Rate for Payer: AlohaCare Medicaid	$19,471.12
Rate for Payer: Hawaii Medical Service Association ABD	$19,471.12
Rate for Payer: Hawaii Medical Service Association Non-ABD	$19,471.12
Rate for Payer: Kaiser Permanente Medicaid	$19,471.12
Rate for Payer: Ohana Health Plan Medicaid	$19,471.12
Rate for Payer: UnitedHealthcare Medicaid	$19,471.12

CORONARY BYPASS W/O AMI OR COMPLEX PDX

Facility

$17,706.71

Service Code	APR-DRG 1661
Min. Negotiated Rate	$17,706.71
Max. Negotiated Rate	$17,706.71
Rate for Payer: AlohaCare Medicaid	$17,706.71
Rate for Payer: Hawaii Medical Service Association ABD	$17,706.71
Rate for Payer: Hawaii Medical Service Association Non-ABD	$17,706.71
Rate for Payer: Kaiser Permanente Medicaid	$17,706.71
Rate for Payer: Ohana Health Plan Medicaid	$17,706.71
Rate for Payer: UnitedHealthcare Medicaid	$17,706.71

CORONARY BYPASS W/O AMI OR COMPLEX PDX

Facility

$23,154.53

Service Code	APR-DRG 1663
Min. Negotiated Rate	$23,154.53
Max. Negotiated Rate	$23,154.53
Rate for Payer: AlohaCare Medicaid	$23,154.53
Rate for Payer: Hawaii Medical Service Association ABD	$23,154.53
Rate for Payer: Hawaii Medical Service Association Non-ABD	$23,154.53
Rate for Payer: Kaiser Permanente Medicaid	$23,154.53
Rate for Payer: Ohana Health Plan Medicaid	$23,154.53
Rate for Payer: UnitedHealthcare Medicaid	$23,154.53

CORONARY BYPASS W/O AMI OR COMPLEX PDX

Facility

$34,344.34

Service Code	APR-DRG 1664
Min. Negotiated Rate	$34,344.34
Max. Negotiated Rate	$34,344.34
Rate for Payer: AlohaCare Medicaid	$34,344.34
Rate for Payer: Hawaii Medical Service Association ABD	$34,344.34
Rate for Payer: Hawaii Medical Service Association Non-ABD	$34,344.34
Rate for Payer: Kaiser Permanente Medicaid	$34,344.34
Rate for Payer: Ohana Health Plan Medicaid	$34,344.34
Rate for Payer: UnitedHealthcare Medicaid	$34,344.34

CORONARY INTRAVASCULAR LITHOTRIPSY WITH INTRALUMINAL DEVICE WITH MCC

Facility

$74,647.65

Service Code	MSDRG 323
Min. Negotiated Rate	$41,446.33
Max. Negotiated Rate	$74,647.65
Rate for Payer: AlohaCare Medicare	$49,220.96
Rate for Payer: Devoted Health Medicare	$54,143.06
Rate for Payer: Hawaii Medical Service Association Commercial	$41,446.33
Rate for Payer: Hawaii Medical Service Association Medicare	$49,220.96
Rate for Payer: Humana Medicare	$49,220.96
Rate for Payer: Kaiser Permanente Commercial	$74,647.65
Rate for Payer: Kaiser Permanente Medicare	$49,220.96
Rate for Payer: Ohana Health Plan Medicare	$49,220.96
Rate for Payer: UnitedHealthcare Medicare	$49,220.96

CORONARY INTRAVASCULAR LITHOTRIPSY WITH INTRALUMINAL DEVICE WITHOUT MCC

Facility

$54,354.75

Service Code	MSDRG 324
Min. Negotiated Rate	$35,840.27
Max. Negotiated Rate	$54,354.75
Rate for Payer: AlohaCare Medicare	$35,840.27
Rate for Payer: Devoted Health Medicare	$39,424.30
Rate for Payer: Hawaii Medical Service Association Commercial	$41,446.33
Rate for Payer: Hawaii Medical Service Association Medicare	$35,840.27
Rate for Payer: Humana Medicare	$35,840.27
Rate for Payer: Kaiser Permanente Commercial	$54,354.75
Rate for Payer: Kaiser Permanente Medicare	$35,840.27
Rate for Payer: Ohana Health Plan Medicare	$35,840.27
Rate for Payer: UnitedHealthcare Medicare	$35,840.27

CORONARY INTRAVASCULAR LITHOTRIPSY WITHOUT INTRALUMINAL DEVICE

Facility

$55,379.40

Service Code	MSDRG 325
Min. Negotiated Rate	$36,515.89
Max. Negotiated Rate	$55,379.40
Rate for Payer: AlohaCare Medicare	$36,515.89
Rate for Payer: Devoted Health Medicare	$40,167.48
Rate for Payer: Hawaii Medical Service Association Commercial	$39,019.73
Rate for Payer: Hawaii Medical Service Association Medicare	$36,515.89
Rate for Payer: Humana Medicare	$36,515.89
Rate for Payer: Kaiser Permanente Commercial	$55,379.40
Rate for Payer: Kaiser Permanente Medicare	$36,515.89
Rate for Payer: Ohana Health Plan Medicare	$36,515.89
Rate for Payer: UnitedHealthcare Medicare	$36,515.89

CORONOID PLATE, RT 131218500

Facility

$2,660.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,489.60
Max. Negotiated Rate	$2,580.20
Rate for Payer: Cash Price	$1,596.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,862.00
Rate for Payer: Health Management Network Commercial	$2,261.00
Rate for Payer: MDX Hawaii PPO	$2,580.20
Rate for Payer: University Health Alliance Commercial	$1,489.60

CORONOID PLATE, RT 131218500

Facility

$2,660.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,356.60
Max. Negotiated Rate	$2,580.20
Rate for Payer: Cash Price	$1,596.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,862.00
Rate for Payer: Health Management Network Commercial	$2,261.00
Rate for Payer: Kaiser Permanente Commercial	$1,675.80
Rate for Payer: Kaiser Permanente Medicaid	$1,356.60
Rate for Payer: MDX Hawaii PPO	$2,580.20
Rate for Payer: University Health Alliance Commercial	$1,489.60

CORTILOC GLENOID DWK405LA25S

Facility

$9,960.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$5,577.60
Max. Negotiated Rate	$9,661.20
Rate for Payer: Cash Price	$5,976.00
Rate for Payer: Hawaii Western Management Group Commercial	$6,972.00
Rate for Payer: Health Management Network Commercial	$8,466.00
Rate for Payer: MDX Hawaii PPO	$9,661.20
Rate for Payer: University Health Alliance Commercial	$5,577.60

CORTILOC GLENOID DWK405LA25S

Facility

$9,960.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$5,079.60
Max. Negotiated Rate	$9,661.20
Rate for Payer: Cash Price	$5,976.00
Rate for Payer: Hawaii Western Management Group Commercial	$6,972.00
Rate for Payer: Health Management Network Commercial	$8,466.00
Rate for Payer: Kaiser Permanente Commercial	$6,274.80
Rate for Payer: Kaiser Permanente Medicaid	$5,079.60
Rate for Payer: MDX Hawaii PPO	$9,661.20
Rate for Payer: University Health Alliance Commercial	$5,577.60

CORTILOC PEGGED GLENOID DWE421

Facility

$6,906.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$3,522.06
Max. Negotiated Rate	$6,698.82
Rate for Payer: Cash Price	$4,143.60
Rate for Payer: Hawaii Western Management Group Commercial	$4,834.20
Rate for Payer: Health Management Network Commercial	$5,870.10
Rate for Payer: Kaiser Permanente Commercial	$4,350.78
Rate for Payer: Kaiser Permanente Medicaid	$3,522.06
Rate for Payer: MDX Hawaii PPO	$6,698.82
Rate for Payer: University Health Alliance Commercial	$3,867.36

CORTILOC PEGGED GLENOID DWE421

Facility

$6,906.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$3,867.36
Max. Negotiated Rate	$6,698.82
Rate for Payer: Cash Price	$4,143.60
Rate for Payer: Hawaii Western Management Group Commercial	$4,834.20
Rate for Payer: Health Management Network Commercial	$5,870.10
Rate for Payer: MDX Hawaii PPO	$6,698.82
Rate for Payer: University Health Alliance Commercial	$3,867.36

CORTILOC PEG GLENOID DWE433

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

CORTILOC PEG GLENOID DWE433

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

COSTAL CARTILAGE SM 450030

Facility

$2,997.00

Service Code	HCPCS C1762
Hospital Revenue Code	278
Min. Negotiated Rate	$1,528.47
Max. Negotiated Rate	$2,907.09
Rate for Payer: Cash Price	$1,798.20
Rate for Payer: Hawaii Western Management Group Commercial	$2,097.90
Rate for Payer: Health Management Network Commercial	$2,547.45
Rate for Payer: Kaiser Permanente Commercial	$1,888.11
Rate for Payer: Kaiser Permanente Medicaid	$1,528.47
Rate for Payer: MDX Hawaii PPO	$2,907.09
Rate for Payer: University Health Alliance Commercial	$1,678.32

COSTAL CARTILAGE SM 450030

Facility

$2,997.00

Service Code	HCPCS C1762
Hospital Revenue Code	278
Min. Negotiated Rate	$1,678.32
Max. Negotiated Rate	$2,907.09
Rate for Payer: Cash Price	$1,798.20
Rate for Payer: Hawaii Western Management Group Commercial	$2,097.90
Rate for Payer: Health Management Network Commercial	$2,547.45
Rate for Payer: MDX Hawaii PPO	$2,907.09
Rate for Payer: University Health Alliance Commercial	$1,678.32

COSYNTROPIN 0.25 MG SOLUTION FOR INJECTION [9686]

Facility

$192.00

Service Code	HCPCS J0834
Hospital Revenue Code	250
Min. Negotiated Rate	$163.20
Max. Negotiated Rate	$186.24
Rate for Payer: Cash Price	$115.20
Rate for Payer: Cash Price	$115.80
Rate for Payer: Health Management Network Commercial	$163.20
Rate for Payer: Health Management Network Commercial	$164.05
Rate for Payer: MDX Hawaii PPO	$186.24
Rate for Payer: MDX Hawaii PPO	$187.21

COSYNTROPIN 0.25 MG SOLUTION FOR INJECTION [9686]

Facility

$192.00

Service Code	HCPCS J0834
Hospital Revenue Code	636
Min. Negotiated Rate	$28.02
Max. Negotiated Rate	$186.24
Rate for Payer: Cash Price	$115.20
Rate for Payer: Cash Price	$115.80
Rate for Payer: Cash Price	$115.20
Rate for Payer: Cash Price	$115.80
Rate for Payer: Hawaii Medical Service Association ABD	$28.02
Rate for Payer: Hawaii Medical Service Association ABD	$28.02
Rate for Payer: Hawaii Medical Service Association Non-ABD	$28.02
Rate for Payer: Hawaii Medical Service Association Non-ABD	$28.02
Rate for Payer: Hawaii Western Management Group Commercial	$183.35
Rate for Payer: Hawaii Western Management Group Commercial	$182.40
Rate for Payer: Health Management Network Commercial	$164.05
Rate for Payer: Health Management Network Commercial	$163.20
Rate for Payer: Kaiser Permanente Commercial	$121.59
Rate for Payer: Kaiser Permanente Commercial	$120.96
Rate for Payer: Kaiser Permanente Medicaid	$97.92
Rate for Payer: Kaiser Permanente Medicaid	$98.43
Rate for Payer: MDX Hawaii PPO	$186.24
Rate for Payer: MDX Hawaii PPO	$187.21
Rate for Payer: UnitedHealthcare Medicaid	$115.80
Rate for Payer: UnitedHealthcare Medicaid	$115.20
Rate for Payer: University Health Alliance Commercial	$139.95
Rate for Payer: University Health Alliance Commercial	$140.68

COUNTERSINK 1.7MM HSINK-1.7

Facility

$630.00

Hospital Revenue Code	272
Min. Negotiated Rate	$535.50
Max. Negotiated Rate	$611.10
Rate for Payer: Cash Price	$378.00
Rate for Payer: Health Management Network Commercial	$535.50
Rate for Payer: MDX Hawaii PPO	$611.10

COUNTERSINK 1.7MM HSINK-1.7

Facility

$630.00

Hospital Revenue Code	272
Min. Negotiated Rate	$321.30
Max. Negotiated Rate	$611.10
Rate for Payer: Cash Price	$378.00
Rate for Payer: Hawaii Western Management Group Commercial	$598.50
Rate for Payer: Health Management Network Commercial	$535.50
Rate for Payer: Kaiser Permanente Commercial	$396.90
Rate for Payer: Kaiser Permanente Medicaid	$321.30
Rate for Payer: MDX Hawaii PPO	$611.10
Rate for Payer: University Health Alliance Commercial	$459.21

Know your out-of-pocket cost for care.

All Charges