Hilo Benioff Medical Center

All Charges

Charge

Type

Setting

Price

DISTAL ATTACHMENT 11.35MM

Facility

$127.00

Hospital Revenue Code	272
Min. Negotiated Rate	$107.95
Max. Negotiated Rate	$123.19
Rate for Payer: Cash Price	$76.20
Rate for Payer: Health Management Network Commercial	$107.95
Rate for Payer: MDX Hawaii PPO	$123.19

DISTAL ATTACHMENT 11.8MM

Facility

$128.00

Hospital Revenue Code	272
Min. Negotiated Rate	$108.80
Max. Negotiated Rate	$124.16
Rate for Payer: Cash Price	$76.80
Rate for Payer: Health Management Network Commercial	$108.80
Rate for Payer: MDX Hawaii PPO	$124.16

DISTAL ATTACHMENT 11.8MM

Facility

$128.00

Hospital Revenue Code	272
Min. Negotiated Rate	$65.28
Max. Negotiated Rate	$124.16
Rate for Payer: Cash Price	$76.80
Rate for Payer: Hawaii Western Management Group Commercial	$121.60
Rate for Payer: Health Management Network Commercial	$108.80
Rate for Payer: Kaiser Permanente Commercial	$80.64
Rate for Payer: Kaiser Permanente Medicaid	$65.28
Rate for Payer: MDX Hawaii PPO	$124.16
Rate for Payer: University Health Alliance Commercial	$93.30

DISTAL ATTACHMENT 12.4MM

Facility

$134.00

Hospital Revenue Code	272
Min. Negotiated Rate	$113.90
Max. Negotiated Rate	$129.98
Rate for Payer: Cash Price	$80.40
Rate for Payer: Health Management Network Commercial	$113.90
Rate for Payer: MDX Hawaii PPO	$129.98

DISTAL ATTACHMENT 12.4MM

Facility

$134.00

Hospital Revenue Code	272
Min. Negotiated Rate	$68.34
Max. Negotiated Rate	$129.98
Rate for Payer: Cash Price	$80.40
Rate for Payer: Hawaii Western Management Group Commercial	$127.30
Rate for Payer: Health Management Network Commercial	$113.90
Rate for Payer: Kaiser Permanente Commercial	$84.42
Rate for Payer: Kaiser Permanente Medicaid	$68.34
Rate for Payer: MDX Hawaii PPO	$129.98
Rate for Payer: University Health Alliance Commercial	$97.67

DISTAL ATTACHMENT 13.4MM

Facility

$134.00

Hospital Revenue Code	272
Min. Negotiated Rate	$68.34
Max. Negotiated Rate	$129.98
Rate for Payer: Cash Price	$80.40
Rate for Payer: Hawaii Western Management Group Commercial	$127.30
Rate for Payer: Health Management Network Commercial	$113.90
Rate for Payer: Kaiser Permanente Commercial	$84.42
Rate for Payer: Kaiser Permanente Medicaid	$68.34
Rate for Payer: MDX Hawaii PPO	$129.98
Rate for Payer: University Health Alliance Commercial	$97.67

DISTAL ATTACHMENT 13.4MM

Facility

$134.00

Hospital Revenue Code	272
Min. Negotiated Rate	$113.90
Max. Negotiated Rate	$129.98
Rate for Payer: Cash Price	$80.40
Rate for Payer: Health Management Network Commercial	$113.90
Rate for Payer: MDX Hawaii PPO	$129.98

DISTAL ATTACHMENT 15MM

Facility

$128.00

Hospital Revenue Code	272
Min. Negotiated Rate	$65.28
Max. Negotiated Rate	$124.16
Rate for Payer: Cash Price	$76.80
Rate for Payer: Hawaii Western Management Group Commercial	$121.60
Rate for Payer: Health Management Network Commercial	$108.80
Rate for Payer: Kaiser Permanente Commercial	$80.64
Rate for Payer: Kaiser Permanente Medicaid	$65.28
Rate for Payer: MDX Hawaii PPO	$124.16
Rate for Payer: University Health Alliance Commercial	$93.30

DISTAL ATTACHMENT 15MM

Facility

$128.00

Hospital Revenue Code	272
Min. Negotiated Rate	$108.80
Max. Negotiated Rate	$124.16
Rate for Payer: Cash Price	$76.80
Rate for Payer: Health Management Network Commercial	$108.80
Rate for Payer: MDX Hawaii PPO	$124.16

DISTAL CLAVICLE RT AR-2656DR

Facility

$2,834.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,587.04
Max. Negotiated Rate	$2,748.98
Rate for Payer: Cash Price	$1,700.40
Rate for Payer: Hawaii Western Management Group Commercial	$1,983.80
Rate for Payer: Health Management Network Commercial	$2,408.90
Rate for Payer: MDX Hawaii PPO	$2,748.98
Rate for Payer: University Health Alliance Commercial	$1,587.04

DISTAL CLAVICLE RT AR-2656DR

Facility

$2,834.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,445.34
Max. Negotiated Rate	$2,748.98
Rate for Payer: Cash Price	$1,700.40
Rate for Payer: Hawaii Western Management Group Commercial	$1,983.80
Rate for Payer: Health Management Network Commercial	$2,408.90
Rate for Payer: Kaiser Permanente Commercial	$1,785.42
Rate for Payer: Kaiser Permanente Medicaid	$1,445.34
Rate for Payer: MDX Hawaii PPO	$2,748.98
Rate for Payer: University Health Alliance Commercial	$1,587.04

DISTAL FIBULA LCK AR-8943DR-05

Facility

$2,175.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,218.00
Max. Negotiated Rate	$2,109.75
Rate for Payer: Cash Price	$1,305.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,522.50
Rate for Payer: Health Management Network Commercial	$1,848.75
Rate for Payer: MDX Hawaii PPO	$2,109.75
Rate for Payer: University Health Alliance Commercial	$1,218.00

DISTAL FIBULA LCK AR-8943DR-05

Facility

$2,175.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,109.25
Max. Negotiated Rate	$2,109.75
Rate for Payer: Cash Price	$1,305.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,522.50
Rate for Payer: Health Management Network Commercial	$1,848.75
Rate for Payer: Kaiser Permanente Commercial	$1,370.25
Rate for Payer: Kaiser Permanente Medicaid	$1,109.25
Rate for Payer: MDX Hawaii PPO	$2,109.75
Rate for Payer: University Health Alliance Commercial	$1,218.00

DISTAL LATERAL FIB LCKIN PLATE

Facility

$2,480.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,264.80
Max. Negotiated Rate	$2,405.60
Rate for Payer: Cash Price	$1,488.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,736.00
Rate for Payer: Health Management Network Commercial	$2,108.00
Rate for Payer: Kaiser Permanente Commercial	$1,562.40
Rate for Payer: Kaiser Permanente Medicaid	$1,264.80
Rate for Payer: MDX Hawaii PPO	$2,405.60
Rate for Payer: University Health Alliance Commercial	$1,388.80

DISTAL LATERAL FIB LCKIN PLATE

Facility

$2,480.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,388.80
Max. Negotiated Rate	$2,405.60
Rate for Payer: Cash Price	$1,488.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,736.00
Rate for Payer: Health Management Network Commercial	$2,108.00
Rate for Payer: MDX Hawaii PPO	$2,405.60
Rate for Payer: University Health Alliance Commercial	$1,388.80

DISTAL REVASCULARIZATION AND INTERVAL LIGATION (DRIL), UPPER EXTREMITY HEMODIALYSIS ACCESS (STEAL SYNDROME)

Facility

$7,230.94

Service Code	CPT 36838
Hospital Revenue Code	360
Min. Negotiated Rate	$521.33
Max. Negotiated Rate	$7,230.94
Rate for Payer: AlohaCare Medicaid	$6,573.58
Rate for Payer: AlohaCare Medicare	$6,573.58
Rate for Payer: Devoted Health Medicare	$7,230.94
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	$6,573.58
Rate for Payer: Hawaii Medical Service Association Non-ABD	$1,028.67
Rate for Payer: Humana Medicare	$6,573.58
Rate for Payer: Kaiser Permanente Medicaid	$2,837.00
Rate for Payer: Kaiser Permanente Medicare	$6,573.58
Rate for Payer: Ohana Health Plan Medicaid	$7,230.94
Rate for Payer: Ohana Health Plan Medicare	$6,573.58
Rate for Payer: UnitedHealthcare Medicaid	$521.33
Rate for Payer: UnitedHealthcare Medicare	$6,573.58

DISTRACTOR TL 100MM 50-10140

Facility

$1,559.00

Hospital Revenue Code	272
Min. Negotiated Rate	$1,325.15
Max. Negotiated Rate	$1,512.23
Rate for Payer: Cash Price	$935.40
Rate for Payer: Health Management Network Commercial	$1,325.15
Rate for Payer: MDX Hawaii PPO	$1,512.23

DISTRACTOR TL 100MM 50-10140

Facility

$1,559.00

Hospital Revenue Code	272
Min. Negotiated Rate	$795.09
Max. Negotiated Rate	$1,512.23
Rate for Payer: Cash Price	$935.40
Rate for Payer: Hawaii Western Management Group Commercial	$1,481.05
Rate for Payer: Health Management Network Commercial	$1,325.15
Rate for Payer: Kaiser Permanente Commercial	$982.17
Rate for Payer: Kaiser Permanente Medicaid	$795.09
Rate for Payer: MDX Hawaii PPO	$1,512.23
Rate for Payer: University Health Alliance Commercial	$1,136.36

DISTRACTOR TL 150MM 50-10150

Facility

$1,733.00

Hospital Revenue Code	272
Min. Negotiated Rate	$1,473.05
Max. Negotiated Rate	$1,681.01
Rate for Payer: Cash Price	$1,039.80
Rate for Payer: Health Management Network Commercial	$1,473.05
Rate for Payer: MDX Hawaii PPO	$1,681.01

DISTRACTOR TL 150MM 50-10150

Facility

$1,733.00

Hospital Revenue Code	272
Min. Negotiated Rate	$883.83
Max. Negotiated Rate	$1,681.01
Rate for Payer: Cash Price	$1,039.80
Rate for Payer: Hawaii Western Management Group Commercial	$1,646.35
Rate for Payer: Health Management Network Commercial	$1,473.05
Rate for Payer: Kaiser Permanente Commercial	$1,091.79
Rate for Payer: Kaiser Permanente Medicaid	$883.83
Rate for Payer: MDX Hawaii PPO	$1,681.01
Rate for Payer: University Health Alliance Commercial	$1,263.18

DISTRACTOR TL 150MM 51-10470

Facility

$2,835.00

Hospital Revenue Code	272
Min. Negotiated Rate	$1,445.85
Max. Negotiated Rate	$2,749.95
Rate for Payer: Cash Price	$1,701.00
Rate for Payer: Hawaii Western Management Group Commercial	$2,693.25
Rate for Payer: Health Management Network Commercial	$2,409.75
Rate for Payer: Kaiser Permanente Commercial	$1,786.05
Rate for Payer: Kaiser Permanente Medicaid	$1,445.85
Rate for Payer: MDX Hawaii PPO	$2,749.95
Rate for Payer: University Health Alliance Commercial	$2,066.43

DISTRACTOR TL 150MM 51-10470

Facility

$2,835.00

Hospital Revenue Code	272
Min. Negotiated Rate	$2,409.75
Max. Negotiated Rate	$2,749.95
Rate for Payer: Cash Price	$1,701.00
Rate for Payer: Health Management Network Commercial	$2,409.75
Rate for Payer: MDX Hawaii PPO	$2,749.95

DISTRACTOR TL 200MM 50-10160

Facility

$1,634.00

Hospital Revenue Code	272
Min. Negotiated Rate	$1,388.90
Max. Negotiated Rate	$1,584.98
Rate for Payer: Cash Price	$980.40
Rate for Payer: Health Management Network Commercial	$1,388.90
Rate for Payer: MDX Hawaii PPO	$1,584.98

DISTRACTOR TL 200MM 50-10160

Facility

$1,634.00

Hospital Revenue Code	272
Min. Negotiated Rate	$833.34
Max. Negotiated Rate	$1,584.98
Rate for Payer: Cash Price	$980.40
Rate for Payer: Hawaii Western Management Group Commercial	$1,552.30
Rate for Payer: Health Management Network Commercial	$1,388.90
Rate for Payer: Kaiser Permanente Commercial	$1,029.42
Rate for Payer: Kaiser Permanente Medicaid	$833.34
Rate for Payer: MDX Hawaii PPO	$1,584.98
Rate for Payer: University Health Alliance Commercial	$1,191.02

DISTRACTOR TL 70MM 50-11010

Facility

$1,386.00

Hospital Revenue Code	272
Min. Negotiated Rate	$706.86
Max. Negotiated Rate	$1,344.42
Rate for Payer: Cash Price	$831.60
Rate for Payer: Hawaii Western Management Group Commercial	$1,316.70
Rate for Payer: Health Management Network Commercial	$1,178.10
Rate for Payer: Kaiser Permanente Commercial	$873.18
Rate for Payer: Kaiser Permanente Medicaid	$706.86
Rate for Payer: MDX Hawaii PPO	$1,344.42
Rate for Payer: University Health Alliance Commercial	$1,010.26

Know your out-of-pocket cost for care.

All Charges