Hilo Benioff Medical Center

All Charges

Charge

Type

Setting

Price

AMPUTATION OF LOWER LIMB FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS WITHOUT CC/MCC

Facility

$73,307.59

Service Code	MSDRG 618
Min. Negotiated Rate	$16,132.11
Max. Negotiated Rate	$73,307.59
Rate for Payer: AlohaCare Medicare	$16,132.11
Rate for Payer: Devoted Health Medicare	$17,745.32
Rate for Payer: Hawaii Medical Service Association Commercial	$73,307.59
Rate for Payer: Hawaii Medical Service Association Medicare	$16,132.11
Rate for Payer: Humana Medicare	$16,132.11
Rate for Payer: Kaiser Permanente Commercial	$24,465.67
Rate for Payer: Kaiser Permanente Medicare	$16,132.11
Rate for Payer: Ohana Health Plan Medicare	$16,132.11
Rate for Payer: UnitedHealthcare Medicare	$16,132.11

AMPUTATION, TOE; METATARSOPHALANGEAL JOINT

Facility

$5,509.00

Service Code	CPT 28820
Hospital Revenue Code	360
Min. Negotiated Rate	$456.03
Max. Negotiated Rate	$5,509.00
Rate for Payer: AlohaCare Medicaid	$3,865.36
Rate for Payer: AlohaCare Medicare	$3,865.36
Rate for Payer: Devoted Health Medicare	$4,251.90
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	$3,865.36
Rate for Payer: Hawaii Medical Service Association Non-ABD	$1,028.67
Rate for Payer: Humana Medicare	$3,865.36
Rate for Payer: Kaiser Permanente Medicaid	$2,837.00
Rate for Payer: Kaiser Permanente Medicare	$3,865.36
Rate for Payer: Ohana Health Plan Medicaid	$4,251.90
Rate for Payer: Ohana Health Plan Medicare	$3,865.36
Rate for Payer: UnitedHealthcare Medicaid	$456.03
Rate for Payer: UnitedHealthcare Medicare	$3,865.36
Rate for Payer: University Health Alliance Commercial	$5,160.40

AMS 700 ACCESSORY KIT 72401850

Facility

$2,970.00

Hospital Revenue Code	272
Min. Negotiated Rate	$2,524.50
Max. Negotiated Rate	$2,880.90
Rate for Payer: Cash Price	$1,782.00
Rate for Payer: Health Management Network Commercial	$2,524.50
Rate for Payer: MDX Hawaii PPO	$2,880.90

AMS 700 ACCESSORY KIT 72401850

Facility

$2,970.00

Hospital Revenue Code	272
Min. Negotiated Rate	$1,514.70
Max. Negotiated Rate	$2,880.90
Rate for Payer: Cash Price	$1,782.00
Rate for Payer: Hawaii Western Management Group Commercial	$2,821.50
Rate for Payer: Health Management Network Commercial	$2,524.50
Rate for Payer: Kaiser Permanente Commercial	$1,871.10
Rate for Payer: Kaiser Permanente Medicaid	$1,514.70
Rate for Payer: MDX Hawaii PPO	$2,880.90
Rate for Payer: University Health Alliance Commercial	$2,164.83

AMS CONCEAL RESERVR 720185-01

Facility

$6,345.00

Service Code	HCPCS C1813
Hospital Revenue Code	278
Min. Negotiated Rate	$3,235.95
Max. Negotiated Rate	$6,154.65
Rate for Payer: Cash Price	$3,807.00
Rate for Payer: Hawaii Western Management Group Commercial	$4,441.50
Rate for Payer: Health Management Network Commercial	$5,393.25
Rate for Payer: Kaiser Permanente Commercial	$3,997.35
Rate for Payer: Kaiser Permanente Medicaid	$3,235.95
Rate for Payer: MDX Hawaii PPO	$6,154.65
Rate for Payer: University Health Alliance Commercial	$3,553.20

AMS CONCEAL RESERVR 720185-01

Facility

$6,345.00

Service Code	HCPCS C1813
Hospital Revenue Code	278
Min. Negotiated Rate	$3,553.20
Max. Negotiated Rate	$6,154.65
Rate for Payer: Cash Price	$3,807.00
Rate for Payer: Hawaii Western Management Group Commercial	$4,441.50
Rate for Payer: Health Management Network Commercial	$5,393.25
Rate for Payer: MDX Hawaii PPO	$6,154.65
Rate for Payer: University Health Alliance Commercial	$3,553.20

ANAL AND STOMAL PROCEDURES WITH CC

Facility

$23,416.69

Service Code	MSDRG 348
Min. Negotiated Rate	$14,886.62
Max. Negotiated Rate	$23,416.69
Rate for Payer: AlohaCare Medicare	$14,886.62
Rate for Payer: Devoted Health Medicare	$16,375.28
Rate for Payer: Hawaii Medical Service Association Commercial	$23,416.69
Rate for Payer: Hawaii Medical Service Association Medicare	$14,886.62
Rate for Payer: Humana Medicare	$14,886.62
Rate for Payer: Kaiser Permanente Commercial	$22,576.80
Rate for Payer: Kaiser Permanente Medicare	$14,886.62
Rate for Payer: Ohana Health Plan Medicare	$14,886.62
Rate for Payer: UnitedHealthcare Medicare	$14,886.62

ANAL AND STOMAL PROCEDURES WITH MCC

Facility

$39,599.10

Service Code	MSDRG 347
Min. Negotiated Rate	$26,110.75
Max. Negotiated Rate	$39,599.10
Rate for Payer: AlohaCare Medicare	$26,110.75
Rate for Payer: Devoted Health Medicare	$28,721.83
Rate for Payer: Hawaii Medical Service Association Commercial	$29,192.00
Rate for Payer: Hawaii Medical Service Association Medicare	$26,110.75
Rate for Payer: Humana Medicare	$26,110.75
Rate for Payer: Kaiser Permanente Commercial	$39,599.10
Rate for Payer: Kaiser Permanente Medicare	$26,110.75
Rate for Payer: Ohana Health Plan Medicare	$26,110.75
Rate for Payer: UnitedHealthcare Medicare	$26,110.75

ANAL AND STOMAL PROCEDURES WITHOUT CC/MCC

Facility

$15,017.85

Service Code	MSDRG 349
Min. Negotiated Rate	$9,902.44
Max. Negotiated Rate	$15,017.85
Rate for Payer: AlohaCare Medicare	$9,902.44
Rate for Payer: Devoted Health Medicare	$10,892.68
Rate for Payer: Hawaii Medical Service Association Commercial	$14,535.33
Rate for Payer: Hawaii Medical Service Association Medicare	$9,902.44
Rate for Payer: Humana Medicare	$9,902.44
Rate for Payer: Kaiser Permanente Commercial	$15,017.85
Rate for Payer: Kaiser Permanente Medicare	$9,902.44
Rate for Payer: Ohana Health Plan Medicare	$9,902.44
Rate for Payer: UnitedHealthcare Medicare	$9,902.44

ANAL PROCEDURES

Facility

$4,529.41

Service Code	APR-DRG 2261
Min. Negotiated Rate	$4,529.41
Max. Negotiated Rate	$4,529.41
Rate for Payer: AlohaCare Medicaid	$4,529.41
Rate for Payer: Hawaii Medical Service Association ABD	$4,529.41
Rate for Payer: Hawaii Medical Service Association Non-ABD	$4,529.41
Rate for Payer: Kaiser Permanente Medicaid	$4,529.41
Rate for Payer: Ohana Health Plan Medicaid	$4,529.41
Rate for Payer: UnitedHealthcare Medicaid	$4,529.41

ANAL PROCEDURES

Facility

$6,000.30

Service Code	APR-DRG 2262
Min. Negotiated Rate	$6,000.30
Max. Negotiated Rate	$6,000.30
Rate for Payer: AlohaCare Medicaid	$6,000.30
Rate for Payer: Hawaii Medical Service Association ABD	$6,000.30
Rate for Payer: Hawaii Medical Service Association Non-ABD	$6,000.30
Rate for Payer: Kaiser Permanente Medicaid	$6,000.30
Rate for Payer: Ohana Health Plan Medicaid	$6,000.30
Rate for Payer: UnitedHealthcare Medicaid	$6,000.30

ANAL PROCEDURES

Facility

$16,032.32

Service Code	APR-DRG 2264
Min. Negotiated Rate	$16,032.32
Max. Negotiated Rate	$16,032.32
Rate for Payer: AlohaCare Medicaid	$16,032.32
Rate for Payer: Hawaii Medical Service Association ABD	$16,032.32
Rate for Payer: Hawaii Medical Service Association Non-ABD	$16,032.32
Rate for Payer: Kaiser Permanente Medicaid	$16,032.32
Rate for Payer: Ohana Health Plan Medicaid	$16,032.32
Rate for Payer: UnitedHealthcare Medicaid	$16,032.32

ANAL PROCEDURES

Facility

$8,280.00

Service Code	APR-DRG 2263
Min. Negotiated Rate	$8,280.00
Max. Negotiated Rate	$8,280.00
Rate for Payer: AlohaCare Medicaid	$8,280.00
Rate for Payer: Hawaii Medical Service Association ABD	$8,280.00
Rate for Payer: Hawaii Medical Service Association Non-ABD	$8,280.00
Rate for Payer: Kaiser Permanente Medicaid	$8,280.00
Rate for Payer: Ohana Health Plan Medicaid	$8,280.00
Rate for Payer: UnitedHealthcare Medicaid	$8,280.00

ANATOMIC ADAPTER 5120-00-110

Facility

$2,246.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$1,145.46
Max. Negotiated Rate	$2,178.62
Rate for Payer: Cash Price	$1,347.60
Rate for Payer: Hawaii Western Management Group Commercial	$1,572.20
Rate for Payer: Health Management Network Commercial	$1,909.10
Rate for Payer: Kaiser Permanente Commercial	$1,414.98
Rate for Payer: Kaiser Permanente Medicaid	$1,145.46
Rate for Payer: MDX Hawaii PPO	$2,178.62
Rate for Payer: University Health Alliance Commercial	$1,257.76

ANATOMIC ADAPTER 5120-00-110

Facility

$2,246.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$1,257.76
Max. Negotiated Rate	$2,178.62
Rate for Payer: Cash Price	$1,347.60
Rate for Payer: Hawaii Western Management Group Commercial	$1,572.20
Rate for Payer: Health Management Network Commercial	$1,909.10
Rate for Payer: MDX Hawaii PPO	$2,178.62
Rate for Payer: University Health Alliance Commercial	$1,257.76

ANATOMICAL SHOULDER HUMERAL

Facility

$4,600.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$2,576.00
Max. Negotiated Rate	$4,462.00
Rate for Payer: Cash Price	$2,760.00
Rate for Payer: Hawaii Western Management Group Commercial	$3,220.00
Rate for Payer: Health Management Network Commercial	$3,910.00
Rate for Payer: MDX Hawaii PPO	$4,462.00
Rate for Payer: University Health Alliance Commercial	$2,576.00

ANATOMICAL SHOULDER HUMERAL

Facility

$4,600.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$2,346.00
Max. Negotiated Rate	$4,462.00
Rate for Payer: Cash Price	$2,760.00
Rate for Payer: Hawaii Western Management Group Commercial	$3,220.00
Rate for Payer: Health Management Network Commercial	$3,910.00
Rate for Payer: Kaiser Permanente Commercial	$2,898.00
Rate for Payer: Kaiser Permanente Medicaid	$2,346.00
Rate for Payer: MDX Hawaii PPO	$4,462.00
Rate for Payer: University Health Alliance Commercial	$2,576.00

ANATOMICAL SHOULDER REMV HEAD

Facility

$4,600.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$2,576.00
Max. Negotiated Rate	$4,462.00
Rate for Payer: Cash Price	$2,760.00
Rate for Payer: Hawaii Western Management Group Commercial	$3,220.00
Rate for Payer: Health Management Network Commercial	$3,910.00
Rate for Payer: MDX Hawaii PPO	$4,462.00
Rate for Payer: University Health Alliance Commercial	$2,576.00

ANATOMICAL SHOULDER REMV HEAD

Facility

$4,600.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$2,346.00
Max. Negotiated Rate	$4,462.00
Rate for Payer: Cash Price	$2,760.00
Rate for Payer: Hawaii Western Management Group Commercial	$3,220.00
Rate for Payer: Health Management Network Commercial	$3,910.00
Rate for Payer: Kaiser Permanente Commercial	$2,898.00
Rate for Payer: Kaiser Permanente Medicaid	$2,346.00
Rate for Payer: MDX Hawaii PPO	$4,462.00
Rate for Payer: University Health Alliance Commercial	$2,576.00

ANATOMIC GLENOID 5100-26-500

Facility

$8,436.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$4,724.16
Max. Negotiated Rate	$8,182.92
Rate for Payer: Cash Price	$5,061.60
Rate for Payer: Hawaii Western Management Group Commercial	$5,905.20
Rate for Payer: Health Management Network Commercial	$7,170.60
Rate for Payer: MDX Hawaii PPO	$8,182.92
Rate for Payer: University Health Alliance Commercial	$4,724.16

ANATOMIC GLENOID 5100-26-500

Facility

$8,436.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$4,302.36
Max. Negotiated Rate	$8,182.92
Rate for Payer: Cash Price	$5,061.60
Rate for Payer: Hawaii Western Management Group Commercial	$5,905.20
Rate for Payer: Health Management Network Commercial	$7,170.60
Rate for Payer: Kaiser Permanente Commercial	$5,314.68
Rate for Payer: Kaiser Permanente Medicaid	$4,302.36
Rate for Payer: MDX Hawaii PPO	$8,182.92
Rate for Payer: University Health Alliance Commercial	$4,724.16

ANATOMIC LEFT MEDIAL 159541

Facility

$2,400.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$1,344.00
Max. Negotiated Rate	$2,328.00
Rate for Payer: Cash Price	$1,440.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,680.00
Rate for Payer: Health Management Network Commercial	$2,040.00
Rate for Payer: MDX Hawaii PPO	$2,328.00
Rate for Payer: University Health Alliance Commercial	$1,344.00

ANATOMIC LEFT MEDIAL 159541

Facility

$2,400.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$1,224.00
Max. Negotiated Rate	$2,328.00
Rate for Payer: Cash Price	$1,440.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,680.00
Rate for Payer: Health Management Network Commercial	$2,040.00
Rate for Payer: Kaiser Permanente Commercial	$1,512.00
Rate for Payer: Kaiser Permanente Medicaid	$1,224.00
Rate for Payer: MDX Hawaii PPO	$2,328.00
Rate for Payer: University Health Alliance Commercial	$1,344.00

ANCHOR 2.6 FIBER AR-3632SP

Facility

$4,148.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$2,115.48
Max. Negotiated Rate	$4,023.56
Rate for Payer: Cash Price	$2,488.80
Rate for Payer: Hawaii Western Management Group Commercial	$2,903.60
Rate for Payer: Health Management Network Commercial	$3,525.80
Rate for Payer: Kaiser Permanente Commercial	$2,613.24
Rate for Payer: Kaiser Permanente Medicaid	$2,115.48
Rate for Payer: MDX Hawaii PPO	$4,023.56
Rate for Payer: University Health Alliance Commercial	$2,322.88

ANCHOR 2.6 FIBER AR-3632SP

Facility

$4,148.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$2,322.88
Max. Negotiated Rate	$4,023.56
Rate for Payer: Cash Price	$2,488.80
Rate for Payer: Hawaii Western Management Group Commercial	$2,903.60
Rate for Payer: Health Management Network Commercial	$3,525.80
Rate for Payer: MDX Hawaii PPO	$4,023.56
Rate for Payer: University Health Alliance Commercial	$2,322.88

Know your out-of-pocket cost for care.

All Charges