Hilo Benioff Medical Center

All Charges

Charge

Type

Setting

Price

GRAFTING OF AUTOLOGOUS FAT HARVESTED BY LIPOSUCTION TECHNIQUE TO TRUNK, BREASTS, SCALP, ARMS, AND/OR LEGS; EACH ADDITIONAL 50 CC INJECTATE, OR PART THEREOF (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)

Facility

$4,035.20

Service Code	CPT 15772
Hospital Revenue Code	360
Min. Negotiated Rate	$147.27
Max. Negotiated Rate	$4,035.20
Rate for Payer: Kaiser Permanente Medicaid	$2,837.00
Rate for Payer: UnitedHealthcare Medicaid	$147.27
Rate for Payer: University Health Alliance Commercial	$4,035.20

GRAFTING OF AUTOLOGOUS SOFT TISSUE, OTHER, HARVESTED BY DIRECT EXCISION (EG, FAT, DERMIS, FASCIA)

Facility

$5,232.95

Service Code	CPT 15769
Hospital Revenue Code	360
Min. Negotiated Rate	$456.03
Max. Negotiated Rate	$5,232.95
Rate for Payer: AlohaCare Medicaid	$4,186.36
Rate for Payer: AlohaCare Medicare	$4,186.36
Rate for Payer: Devoted Health Medicare	$4,605.00
Rate for Payer: Hawaii Medical Service Association Commercial	$5,232.95
Rate for Payer: Hawaii Medical Service Association Medicare	$4,186.36
Rate for Payer: Humana Medicare	$4,186.36
Rate for Payer: Kaiser Permanente Medicaid	$2,837.00
Rate for Payer: Kaiser Permanente Medicare	$4,186.36
Rate for Payer: Ohana Health Plan Medicaid	$4,605.00
Rate for Payer: Ohana Health Plan Medicare	$4,186.36
Rate for Payer: UnitedHealthcare Medicaid	$456.03
Rate for Payer: UnitedHealthcare Medicare	$4,186.36

GRAFT LEG 12MMX10CM PXC121000

Facility

$4,510.00

Service Code	HCPCS C1768
Hospital Revenue Code	278
Min. Negotiated Rate	$2,300.10
Max. Negotiated Rate	$4,374.70
Rate for Payer: Cash Price	$2,706.00
Rate for Payer: Hawaii Western Management Group Commercial	$3,157.00
Rate for Payer: Health Management Network Commercial	$3,833.50
Rate for Payer: Kaiser Permanente Commercial	$2,841.30
Rate for Payer: Kaiser Permanente Medicaid	$2,300.10
Rate for Payer: MDX Hawaii PPO	$4,374.70
Rate for Payer: University Health Alliance Commercial	$2,525.60

GRAFT LEG 12MMX10CM PXC121000

Facility

$4,510.00

Service Code	HCPCS C1768
Hospital Revenue Code	278
Min. Negotiated Rate	$2,525.60
Max. Negotiated Rate	$4,374.70
Rate for Payer: Cash Price	$2,706.00
Rate for Payer: Hawaii Western Management Group Commercial	$3,157.00
Rate for Payer: Health Management Network Commercial	$3,833.50
Rate for Payer: MDX Hawaii PPO	$4,374.70
Rate for Payer: University Health Alliance Commercial	$2,525.60

GRAFT LEG 12MMX12CM PXC121200

Facility

$9,020.00

Service Code	HCPCS C1768
Hospital Revenue Code	278
Min. Negotiated Rate	$5,051.20
Max. Negotiated Rate	$8,749.40
Rate for Payer: Cash Price	$5,412.00
Rate for Payer: Hawaii Western Management Group Commercial	$6,314.00
Rate for Payer: Health Management Network Commercial	$7,667.00
Rate for Payer: MDX Hawaii PPO	$8,749.40
Rate for Payer: University Health Alliance Commercial	$5,051.20

GRAFT LEG 12MMX12CM PXC121200

Facility

$9,020.00

Service Code	HCPCS C1768
Hospital Revenue Code	278
Min. Negotiated Rate	$4,600.20
Max. Negotiated Rate	$8,749.40
Rate for Payer: Cash Price	$5,412.00
Rate for Payer: Hawaii Western Management Group Commercial	$6,314.00
Rate for Payer: Health Management Network Commercial	$7,667.00
Rate for Payer: Kaiser Permanente Commercial	$5,682.60
Rate for Payer: Kaiser Permanente Medicaid	$4,600.20
Rate for Payer: MDX Hawaii PPO	$8,749.40
Rate for Payer: University Health Alliance Commercial	$5,051.20

GRAFT LEG 12MMX14CM PXC121400

Facility

$9,246.00

Service Code	HCPCS C1768
Hospital Revenue Code	278
Min. Negotiated Rate	$4,715.46
Max. Negotiated Rate	$8,968.62
Rate for Payer: Cash Price	$5,547.60
Rate for Payer: Hawaii Western Management Group Commercial	$6,472.20
Rate for Payer: Health Management Network Commercial	$7,859.10
Rate for Payer: Kaiser Permanente Commercial	$5,824.98
Rate for Payer: Kaiser Permanente Medicaid	$4,715.46
Rate for Payer: MDX Hawaii PPO	$8,968.62
Rate for Payer: University Health Alliance Commercial	$5,177.76

GRAFT LEG 12MMX14CM PXC121400

Facility

$9,246.00

Service Code	HCPCS C1768
Hospital Revenue Code	278
Min. Negotiated Rate	$5,177.76
Max. Negotiated Rate	$8,968.62
Rate for Payer: Cash Price	$5,547.60
Rate for Payer: Hawaii Western Management Group Commercial	$6,472.20
Rate for Payer: Health Management Network Commercial	$7,859.10
Rate for Payer: MDX Hawaii PPO	$8,968.62
Rate for Payer: University Health Alliance Commercial	$5,177.76

GRAFT LEG 16X13.5CM PLC161400

Facility

$11,540.00

Service Code	HCPCS C1768
Hospital Revenue Code	278
Min. Negotiated Rate	$6,462.40
Max. Negotiated Rate	$11,193.80
Rate for Payer: Cash Price	$6,924.00
Rate for Payer: Hawaii Western Management Group Commercial	$8,078.00
Rate for Payer: Health Management Network Commercial	$9,809.00
Rate for Payer: MDX Hawaii PPO	$11,193.80
Rate for Payer: University Health Alliance Commercial	$6,462.40

GRAFT LEG 16X13.5CM PLC161400

Facility

$11,540.00

Service Code	HCPCS C1768
Hospital Revenue Code	278
Min. Negotiated Rate	$5,885.40
Max. Negotiated Rate	$11,193.80
Rate for Payer: Cash Price	$6,924.00
Rate for Payer: Hawaii Western Management Group Commercial	$8,078.00
Rate for Payer: Health Management Network Commercial	$9,809.00
Rate for Payer: Kaiser Permanente Commercial	$7,270.20
Rate for Payer: Kaiser Permanente Medicaid	$5,885.40
Rate for Payer: MDX Hawaii PPO	$11,193.80
Rate for Payer: University Health Alliance Commercial	$6,462.40

GRAFT LEG 18X11.5CM PLC181200

Facility

$10,670.00

Hospital Revenue Code	278
Min. Negotiated Rate	$5,441.70
Max. Negotiated Rate	$10,349.90
Rate for Payer: Cash Price	$6,402.00
Rate for Payer: Hawaii Western Management Group Commercial	$7,469.00
Rate for Payer: Health Management Network Commercial	$9,069.50
Rate for Payer: Kaiser Permanente Commercial	$6,722.10
Rate for Payer: Kaiser Permanente Medicaid	$5,441.70
Rate for Payer: MDX Hawaii PPO	$10,349.90
Rate for Payer: University Health Alliance Commercial	$5,975.20

GRAFT LEG 18X11.5CM PLC181200

Facility

$10,670.00

Hospital Revenue Code	278
Min. Negotiated Rate	$5,975.20
Max. Negotiated Rate	$10,349.90
Rate for Payer: Cash Price	$6,402.00
Rate for Payer: Hawaii Western Management Group Commercial	$7,469.00
Rate for Payer: Health Management Network Commercial	$9,069.50
Rate for Payer: MDX Hawaii PPO	$10,349.90
Rate for Payer: University Health Alliance Commercial	$5,975.20

GRAFT LEG 18X13.5CM PLC181400

Facility

$10,156.00

Service Code	HCPCS C1768
Hospital Revenue Code	278
Min. Negotiated Rate	$5,179.56
Max. Negotiated Rate	$9,851.32
Rate for Payer: Cash Price	$6,093.60
Rate for Payer: Hawaii Western Management Group Commercial	$7,109.20
Rate for Payer: Health Management Network Commercial	$8,632.60
Rate for Payer: Kaiser Permanente Commercial	$6,398.28
Rate for Payer: Kaiser Permanente Medicaid	$5,179.56
Rate for Payer: MDX Hawaii PPO	$9,851.32
Rate for Payer: University Health Alliance Commercial	$5,687.36

GRAFT LEG 18X13.5CM PLC181400

Facility

$10,156.00

Service Code	HCPCS C1768
Hospital Revenue Code	278
Min. Negotiated Rate	$5,687.36
Max. Negotiated Rate	$9,851.32
Rate for Payer: Cash Price	$6,093.60
Rate for Payer: Hawaii Western Management Group Commercial	$7,109.20
Rate for Payer: Health Management Network Commercial	$8,632.60
Rate for Payer: MDX Hawaii PPO	$9,851.32
Rate for Payer: University Health Alliance Commercial	$5,687.36

GRAFT LEG 18X9.5CM PLC181000

Facility

$9,956.00

Service Code	HCPCS C1768
Hospital Revenue Code	278
Min. Negotiated Rate	$5,575.36
Max. Negotiated Rate	$9,657.32
Rate for Payer: Cash Price	$5,973.60
Rate for Payer: Hawaii Western Management Group Commercial	$6,969.20
Rate for Payer: Health Management Network Commercial	$8,462.60
Rate for Payer: MDX Hawaii PPO	$9,657.32
Rate for Payer: University Health Alliance Commercial	$5,575.36

GRAFT LEG 18X9.5CM PLC181000

Facility

$9,956.00

Service Code	HCPCS C1768
Hospital Revenue Code	278
Min. Negotiated Rate	$5,077.56
Max. Negotiated Rate	$9,657.32
Rate for Payer: Cash Price	$5,973.60
Rate for Payer: Hawaii Western Management Group Commercial	$6,969.20
Rate for Payer: Health Management Network Commercial	$8,462.60
Rate for Payer: Kaiser Permanente Commercial	$6,272.28
Rate for Payer: Kaiser Permanente Medicaid	$5,077.56
Rate for Payer: MDX Hawaii PPO	$9,657.32
Rate for Payer: University Health Alliance Commercial	$5,575.36

GRAFT LEG 20X11.5CM PLC201200

Facility

$11,540.00

Service Code	HCPCS C1768
Hospital Revenue Code	278
Min. Negotiated Rate	$6,462.40
Max. Negotiated Rate	$11,193.80
Rate for Payer: Cash Price	$6,924.00
Rate for Payer: Hawaii Western Management Group Commercial	$8,078.00
Rate for Payer: Health Management Network Commercial	$9,809.00
Rate for Payer: MDX Hawaii PPO	$11,193.80
Rate for Payer: University Health Alliance Commercial	$6,462.40

GRAFT LEG 20X11.5CM PLC201200

Facility

$11,540.00

Service Code	HCPCS C1768
Hospital Revenue Code	278
Min. Negotiated Rate	$5,885.40
Max. Negotiated Rate	$11,193.80
Rate for Payer: Cash Price	$6,924.00
Rate for Payer: Hawaii Western Management Group Commercial	$8,078.00
Rate for Payer: Health Management Network Commercial	$9,809.00
Rate for Payer: Kaiser Permanente Commercial	$7,270.20
Rate for Payer: Kaiser Permanente Medicaid	$5,885.40
Rate for Payer: MDX Hawaii PPO	$11,193.80
Rate for Payer: University Health Alliance Commercial	$6,462.40

GRAFT LEG 20X13.5CM PLC201400

Facility

$9,020.00

Service Code	HCPCS C1768
Hospital Revenue Code	278
Min. Negotiated Rate	$5,051.20
Max. Negotiated Rate	$8,749.40
Rate for Payer: Cash Price	$5,412.00
Rate for Payer: Hawaii Western Management Group Commercial	$6,314.00
Rate for Payer: Health Management Network Commercial	$7,667.00
Rate for Payer: MDX Hawaii PPO	$8,749.40
Rate for Payer: University Health Alliance Commercial	$5,051.20

GRAFT LEG 20X13.5CM PLC201400

Facility

$9,020.00

Service Code	HCPCS C1768
Hospital Revenue Code	278
Min. Negotiated Rate	$4,600.20
Max. Negotiated Rate	$8,749.40
Rate for Payer: Cash Price	$5,412.00
Rate for Payer: Hawaii Western Management Group Commercial	$6,314.00
Rate for Payer: Health Management Network Commercial	$7,667.00
Rate for Payer: Kaiser Permanente Commercial	$5,682.60
Rate for Payer: Kaiser Permanente Medicaid	$4,600.20
Rate for Payer: MDX Hawaii PPO	$8,749.40
Rate for Payer: University Health Alliance Commercial	$5,051.20

GRAFT LEG 20X9.5CM PLC201000

Facility

$11,540.00

Hospital Revenue Code	278
Min. Negotiated Rate	$6,462.40
Max. Negotiated Rate	$11,193.80
Rate for Payer: Cash Price	$6,924.00
Rate for Payer: Hawaii Western Management Group Commercial	$8,078.00
Rate for Payer: Health Management Network Commercial	$9,809.00
Rate for Payer: MDX Hawaii PPO	$11,193.80
Rate for Payer: University Health Alliance Commercial	$6,462.40

GRAFT LEG 20X9.5CM PLC201000

Facility

$11,540.00

Hospital Revenue Code	278
Min. Negotiated Rate	$5,885.40
Max. Negotiated Rate	$11,193.80
Rate for Payer: Cash Price	$6,924.00
Rate for Payer: Hawaii Western Management Group Commercial	$8,078.00
Rate for Payer: Health Management Network Commercial	$9,809.00
Rate for Payer: Kaiser Permanente Commercial	$7,270.20
Rate for Payer: Kaiser Permanente Medicaid	$5,885.40
Rate for Payer: MDX Hawaii PPO	$11,193.80
Rate for Payer: University Health Alliance Commercial	$6,462.40

GRAFT LEG 23X10CM PLC231000

Facility

$9,020.00

Service Code	HCPCS C1768
Hospital Revenue Code	278
Min. Negotiated Rate	$4,600.20
Max. Negotiated Rate	$8,749.40
Rate for Payer: Cash Price	$5,412.00
Rate for Payer: Hawaii Western Management Group Commercial	$6,314.00
Rate for Payer: Health Management Network Commercial	$7,667.00
Rate for Payer: Kaiser Permanente Commercial	$5,682.60
Rate for Payer: Kaiser Permanente Medicaid	$4,600.20
Rate for Payer: MDX Hawaii PPO	$8,749.40
Rate for Payer: University Health Alliance Commercial	$5,051.20

GRAFT LEG 23X10CM PLC231000

Facility

$9,020.00

Service Code	HCPCS C1768
Hospital Revenue Code	278
Min. Negotiated Rate	$5,051.20
Max. Negotiated Rate	$8,749.40
Rate for Payer: Cash Price	$5,412.00
Rate for Payer: Hawaii Western Management Group Commercial	$6,314.00
Rate for Payer: Health Management Network Commercial	$7,667.00
Rate for Payer: MDX Hawaii PPO	$8,749.40
Rate for Payer: University Health Alliance Commercial	$5,051.20

GRAFT LEG 23X12CM PLC231200

Facility

$10,156.00

Service Code	HCPCS C1768
Hospital Revenue Code	278
Min. Negotiated Rate	$5,687.36
Max. Negotiated Rate	$9,851.32
Rate for Payer: Cash Price	$6,093.60
Rate for Payer: Hawaii Western Management Group Commercial	$7,109.20
Rate for Payer: Health Management Network Commercial	$8,632.60
Rate for Payer: MDX Hawaii PPO	$9,851.32
Rate for Payer: University Health Alliance Commercial	$5,687.36

Know your out-of-pocket cost for care.

All Charges