Hilo Benioff Medical Center

All Charges

Charge

Type

Setting

Price

ARTHROPLASTY, KNEE, CONDYLE AND PLATEAU; MEDIAL OR LATERAL COMPARTMENT

Facility

$20,300.00

Service Code	CPT 27446
Hospital Revenue Code	360
Min. Negotiated Rate	$644.55
Max. Negotiated Rate	$20,300.00
Rate for Payer: AlohaCare Medicaid	$15,166.91
Rate for Payer: AlohaCare Medicare	$15,166.91
Rate for Payer: Devoted Health Medicare	$16,683.60
Rate for Payer: Hawaii Medical Service Association ABD	$1,900.00
Rate for Payer: Hawaii Medical Service Association Commercial	$14,395.00
Rate for Payer: Hawaii Medical Service Association Medicare	$15,166.91
Rate for Payer: Hawaii Medical Service Association Non-ABD	$2,695.11
Rate for Payer: Humana Medicare	$15,166.91
Rate for Payer: Kaiser Permanente Medicaid	$2,837.00
Rate for Payer: Kaiser Permanente Medicare	$15,166.91
Rate for Payer: Ohana Health Plan Medicaid	$16,683.60
Rate for Payer: Ohana Health Plan Medicare	$15,166.91
Rate for Payer: UnitedHealthcare Medicaid	$644.55
Rate for Payer: UnitedHealthcare Medicare	$15,166.91
Rate for Payer: University Health Alliance Commercial	$20,300.00

ARTHROPLASTY, RADIAL HEAD; WITH IMPLANT

Facility

$16,683.60

Service Code	CPT 24366
Hospital Revenue Code	360
Min. Negotiated Rate	$644.55
Max. Negotiated Rate	$16,683.60
Rate for Payer: AlohaCare Medicaid	$15,166.91
Rate for Payer: AlohaCare Medicare	$15,166.91
Rate for Payer: Devoted Health Medicare	$16,683.60
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	$15,166.91
Rate for Payer: Hawaii Medical Service Association Non-ABD	$1,427.62
Rate for Payer: Humana Medicare	$15,166.91
Rate for Payer: Kaiser Permanente Medicaid	$2,837.00
Rate for Payer: Kaiser Permanente Medicare	$15,166.91
Rate for Payer: Ohana Health Plan Medicaid	$16,683.60
Rate for Payer: Ohana Health Plan Medicare	$15,166.91
Rate for Payer: UnitedHealthcare Medicaid	$644.55
Rate for Payer: UnitedHealthcare Medicare	$15,166.91
Rate for Payer: University Health Alliance Commercial	$11,157.19

ARTHROSCOPICALLY AIDED ANTERIOR CRUCIATE LIGAMENT REPAIR/AUGMENTATION OR RECONSTRUCTION

Facility

$14,395.00

Service Code	CPT 29888
Hospital Revenue Code	360
Min. Negotiated Rate	$521.33
Max. Negotiated Rate	$14,395.00
Rate for Payer: AlohaCare Medicaid	$8,572.09
Rate for Payer: AlohaCare Medicare	$8,572.09
Rate for Payer: Devoted Health Medicare	$9,429.30
Rate for Payer: Hawaii Medical Service Association ABD	$1,900.00
Rate for Payer: Hawaii Medical Service Association Commercial	$14,395.00
Rate for Payer: Hawaii Medical Service Association Medicare	$8,572.09
Rate for Payer: Hawaii Medical Service Association Non-ABD	$2,695.11
Rate for Payer: Humana Medicare	$8,572.09
Rate for Payer: Kaiser Permanente Medicaid	$2,837.00
Rate for Payer: Kaiser Permanente Medicare	$8,572.09
Rate for Payer: Ohana Health Plan Medicaid	$9,429.30
Rate for Payer: Ohana Health Plan Medicare	$8,572.09
Rate for Payer: UnitedHealthcare Medicaid	$521.33
Rate for Payer: UnitedHealthcare Medicare	$8,572.09
Rate for Payer: University Health Alliance Commercial	$6,743.44

ARTHROSCOPICALLY AIDED TREATMENT OF INTERCONDYLAR SPINE(S) AND/OR TUBEROSITY FRACTURE(S) OF THE KNEE, WITH OR WITHOUT MANIPULATION; WITH INTERNAL OR EXTERNAL FIXATION (INCLUDES ARTHROSCOPY)

Facility

$13,778.00

Service Code	CPT 29851
Hospital Revenue Code	360
Min. Negotiated Rate	$521.33
Max. Negotiated Rate	$13,778.00
Rate for Payer: AlohaCare Medicaid	$1,899.59
Rate for Payer: AlohaCare Medicare	$1,899.59
Rate for Payer: Devoted Health Medicare	$2,089.55
Rate for Payer: Hawaii Medical Service Association ABD	$1,149.00
Rate for Payer: Hawaii Medical Service Association Commercial	$13,778.00
Rate for Payer: Hawaii Medical Service Association Medicare	$1,899.59
Rate for Payer: Hawaii Medical Service Association Non-ABD	$2,294.85
Rate for Payer: Humana Medicare	$1,899.59
Rate for Payer: Kaiser Permanente Medicaid	$2,837.00
Rate for Payer: Kaiser Permanente Medicare	$1,899.59
Rate for Payer: Ohana Health Plan Medicaid	$2,089.55
Rate for Payer: Ohana Health Plan Medicare	$1,899.59
Rate for Payer: UnitedHealthcare Medicaid	$521.33
Rate for Payer: UnitedHealthcare Medicare	$1,899.59
Rate for Payer: University Health Alliance Commercial	$10,679.55

ARTHROSCOPY, ELBOW, SURGICAL; DEBRIDEMENT, EXTENSIVE

Facility

$13,778.00

Service Code	CPT 29838
Hospital Revenue Code	360
Min. Negotiated Rate	$456.03
Max. Negotiated Rate	$13,778.00
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	$1,149.00
Rate for Payer: Hawaii Medical Service Association Commercial	$13,778.00
Rate for Payer: Hawaii Medical Service Association Medicare	$3,865.36
Rate for Payer: Hawaii Medical Service Association Non-ABD	$2,294.85
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	$6,743.44

ARTHROSCOPY, KNEE, SURGICAL; ABRASION ARTHROPLASTY (INCLUDES CHONDROPLASTY WHERE NECESSARY) OR MULTIPLE DRILLING OR MICROFRACTURE

Facility

$8,270.00

Service Code	CPT 29879
Hospital Revenue Code	360
Min. Negotiated Rate	$456.03
Max. Negotiated Rate	$8,270.00
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	$848.00
Rate for Payer: Hawaii Medical Service Association Commercial	$8,270.00
Rate for Payer: Hawaii Medical Service Association Medicare	$3,865.36
Rate for Payer: Hawaii Medical Service Association Non-ABD	$1,427.62
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	$6,743.44

ARTHROSCOPY, KNEE, SURGICAL; WITH MENISCECTOMY (MEDIAL AND LATERAL, INCLUDING ANY MENISCAL SHAVING) INCLUDING DEBRIDEMENT/SHAVING OF ARTICULAR CARTILAGE (CHONDROPLASTY), SAME OR SEPARATE COMPARTMENT(S), WHEN PERFORMED

Facility

$10,679.55

Service Code	CPT 29880
Hospital Revenue Code	360
Min. Negotiated Rate	$456.03
Max. Negotiated Rate	$10,679.55
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	$848.00
Rate for Payer: Hawaii Medical Service Association Commercial	$8,270.00
Rate for Payer: Hawaii Medical Service Association Medicare	$3,865.36
Rate for Payer: Hawaii Medical Service Association Non-ABD	$1,427.62
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	$10,679.55

ARTHROSCOPY, KNEE, SURGICAL; WITH MENISCECTOMY (MEDIAL OR LATERAL, INCLUDING ANY MENISCAL SHAVING) INCLUDING DEBRIDEMENT/SHAVING OF ARTICULAR CARTILAGE (CHONDROPLASTY), SAME OR SEPARATE COMPARTMENT(S), WHEN PERFORMED

Facility

$10,679.55

Service Code	CPT 29881
Hospital Revenue Code	360
Min. Negotiated Rate	$456.03
Max. Negotiated Rate	$10,679.55
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	$848.00
Rate for Payer: Hawaii Medical Service Association Commercial	$8,270.00
Rate for Payer: Hawaii Medical Service Association Medicare	$3,865.36
Rate for Payer: Hawaii Medical Service Association Non-ABD	$1,427.62
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	$10,679.55

ARTHROSCOPY, KNEE, SURGICAL; WITH MENISCUS REPAIR (MEDIAL AND LATERAL)

Facility

$8,270.00

Service Code	CPT 29883
Hospital Revenue Code	360
Min. Negotiated Rate	$456.03
Max. Negotiated Rate	$8,270.00
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	$848.00
Rate for Payer: Hawaii Medical Service Association Commercial	$8,270.00
Rate for Payer: Hawaii Medical Service Association Medicare	$3,865.36
Rate for Payer: Hawaii Medical Service Association Non-ABD	$1,427.62
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	$6,743.44

ARTHROSCOPY, KNEE, SURGICAL; WITH MENISCUS REPAIR (MEDIAL OR LATERAL)

Facility

$13,778.00

Service Code	CPT 29882
Hospital Revenue Code	360
Min. Negotiated Rate	$456.03
Max. Negotiated Rate	$13,778.00
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	$1,149.00
Rate for Payer: Hawaii Medical Service Association Commercial	$13,778.00
Rate for Payer: Hawaii Medical Service Association Medicare	$3,865.36
Rate for Payer: Hawaii Medical Service Association Non-ABD	$2,294.85
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	$6,743.44

ARTHROSCOPY, SHOULDER, SURGICAL; BICEPS TENODESIS

Facility

$24,500.00

Service Code	CPT 29828
Hospital Revenue Code	360
Min. Negotiated Rate	$521.33
Max. Negotiated Rate	$24,500.00
Rate for Payer: AlohaCare Medicaid	$8,572.09
Rate for Payer: AlohaCare Medicare	$8,572.09
Rate for Payer: Devoted Health Medicare	$9,429.30
Rate for Payer: Hawaii Medical Service Association ABD	$1,149.00
Rate for Payer: Hawaii Medical Service Association Commercial	$13,778.00
Rate for Payer: Hawaii Medical Service Association Medicare	$8,572.09
Rate for Payer: Hawaii Medical Service Association Non-ABD	$2,294.85
Rate for Payer: Humana Medicare	$8,572.09
Rate for Payer: Kaiser Permanente Medicaid	$2,837.00
Rate for Payer: Kaiser Permanente Medicare	$8,572.09
Rate for Payer: Ohana Health Plan Medicaid	$9,429.30
Rate for Payer: Ohana Health Plan Medicare	$8,572.09
Rate for Payer: UnitedHealthcare Medicaid	$521.33
Rate for Payer: UnitedHealthcare Medicare	$8,572.09
Rate for Payer: University Health Alliance Commercial	$24,500.00

ARTHROSCOPY, SHOULDER, SURGICAL; DEBRIDEMENT, EXTENSIVE, 3 OR MORE DISCRETE STRUCTURES (EG, HUMERAL BONE, HUMERAL ARTICULAR CARTILAGE, GLENOID BONE, GLENOID ARTICULAR CARTILAGE, BICEPS TENDON, BICEPS ANCHOR COMPLEX, LABRUM, ARTICULAR CAPSULE, ARTICULAR SIDE OF THE ROTATOR CUFF, BURSAL SIDE OF THE ROTATOR CUFF, SUBACROMIAL BURSA, FOREIGN BODY[IES])

Facility

$13,778.00

Service Code	CPT 29823
Hospital Revenue Code	360
Min. Negotiated Rate	$521.33
Max. Negotiated Rate	$13,778.00
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	$1,149.00
Rate for Payer: Hawaii Medical Service Association Commercial	$13,778.00
Rate for Payer: Hawaii Medical Service Association Medicare	$3,865.36
Rate for Payer: Hawaii Medical Service Association Non-ABD	$2,294.85
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	$521.33
Rate for Payer: UnitedHealthcare Medicare	$3,865.36
Rate for Payer: University Health Alliance Commercial	$6,743.44

ARTHROSCOPY, SHOULDER, SURGICAL; DEBRIDEMENT, LIMITED, 1 OR 2 DISCRETE STRUCTURES (EG, HUMERAL BONE, HUMERAL ARTICULAR CARTILAGE, GLENOID BONE, GLENOID ARTICULAR CARTILAGE, BICEPS TENDON, BICEPS ANCHOR COMPLEX, LABRUM, ARTICULAR CAPSULE, ARTICULAR SIDE OF THE ROTATOR CUFF, BURSAL SIDE OF THE ROTATOR CUFF, SUBACROMIAL BURSA, FOREIGN BODY[IES])

Facility

$13,778.00

Service Code	CPT 29822
Hospital Revenue Code	360
Min. Negotiated Rate	$456.03
Max. Negotiated Rate	$13,778.00
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	$1,149.00
Rate for Payer: Hawaii Medical Service Association Commercial	$13,778.00
Rate for Payer: Hawaii Medical Service Association Medicare	$3,865.36
Rate for Payer: Hawaii Medical Service Association Non-ABD	$2,294.85
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	$6,743.44

ARTHROSCOPY, SHOULDER, SURGICAL; DECOMPRESSION OF SUBACROMIAL SPACE WITH PARTIAL ACROMIOPLASTY, WITH CORACOACROMIAL LIGAMENT (IE, ARCH) RELEASE, WHEN PERFORMED (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)

Facility

$2,837.00

Service Code	CPT 29826
Hospital Revenue Code	360
Min. Negotiated Rate	$575.82
Max. Negotiated Rate	$2,837.00
Rate for Payer: Kaiser Permanente Medicaid	$2,837.00
Rate for Payer: UnitedHealthcare Medicaid	$575.82

ARTHROSCOPY, SHOULDER, SURGICAL; DISTAL CLAVICULECTOMY INCLUDING DISTAL ARTICULAR SURFACE (MUMFORD PROCEDURE)

Facility

$13,778.00

Service Code	CPT 29824
Hospital Revenue Code	360
Min. Negotiated Rate	$521.33
Max. Negotiated Rate	$13,778.00
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	$1,149.00
Rate for Payer: Hawaii Medical Service Association Commercial	$13,778.00
Rate for Payer: Hawaii Medical Service Association Medicare	$3,865.36
Rate for Payer: Hawaii Medical Service Association Non-ABD	$2,294.85
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	$521.33
Rate for Payer: UnitedHealthcare Medicare	$3,865.36
Rate for Payer: University Health Alliance Commercial	$11,157.19

ARTHROSCOPY, SHOULDER, SURGICAL; WITH ROTATOR CUFF REPAIR

Facility

$14,395.00

Service Code	CPT 29827
Hospital Revenue Code	360
Min. Negotiated Rate	$521.33
Max. Negotiated Rate	$14,395.00
Rate for Payer: AlohaCare Medicaid	$8,572.09
Rate for Payer: AlohaCare Medicare	$8,572.09
Rate for Payer: Devoted Health Medicare	$9,429.30
Rate for Payer: Hawaii Medical Service Association ABD	$1,900.00
Rate for Payer: Hawaii Medical Service Association Commercial	$14,395.00
Rate for Payer: Hawaii Medical Service Association Medicare	$8,572.09
Rate for Payer: Hawaii Medical Service Association Non-ABD	$2,695.11
Rate for Payer: Humana Medicare	$8,572.09
Rate for Payer: Kaiser Permanente Medicaid	$2,837.00
Rate for Payer: Kaiser Permanente Medicare	$8,572.09
Rate for Payer: Ohana Health Plan Medicaid	$9,429.30
Rate for Payer: Ohana Health Plan Medicare	$8,572.09
Rate for Payer: UnitedHealthcare Medicaid	$521.33
Rate for Payer: UnitedHealthcare Medicare	$8,572.09
Rate for Payer: University Health Alliance Commercial	$11,157.19

ARTHROSCOPY TUBING #AR-6410

Facility

$240.00

Hospital Revenue Code	272
Min. Negotiated Rate	$204.00
Max. Negotiated Rate	$232.80
Rate for Payer: Cash Price	$144.00
Rate for Payer: Health Management Network Commercial	$204.00
Rate for Payer: MDX Hawaii PPO	$232.80

ARTHROSCOPY TUBING #AR-6410

Facility

$240.00

Hospital Revenue Code	272
Min. Negotiated Rate	$122.40
Max. Negotiated Rate	$232.80
Rate for Payer: Cash Price	$144.00
Rate for Payer: Hawaii Western Management Group Commercial	$228.00
Rate for Payer: Health Management Network Commercial	$204.00
Rate for Payer: Kaiser Permanente Commercial	$151.20
Rate for Payer: Kaiser Permanente Medicaid	$122.40
Rate for Payer: MDX Hawaii PPO	$232.80
Rate for Payer: University Health Alliance Commercial	$174.94

ARTHROTOMY, WITH EXPLORATION, DRAINAGE, OR REMOVAL OF LOOSE OR FOREIGN BODY; INTERPHALANGEAL JOINT, EACH

Facility

$10,679.55

Service Code	CPT 26080
Hospital Revenue Code	360
Min. Negotiated Rate	$456.03
Max. Negotiated Rate	$10,679.55
Rate for Payer: AlohaCare Medicaid	$1,899.59
Rate for Payer: AlohaCare Medicare	$1,899.59
Rate for Payer: Devoted Health Medicare	$2,089.55
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	$1,899.59
Rate for Payer: Hawaii Medical Service Association Non-ABD	$1,028.67
Rate for Payer: Humana Medicare	$1,899.59
Rate for Payer: Kaiser Permanente Medicaid	$2,837.00
Rate for Payer: Kaiser Permanente Medicare	$1,899.59
Rate for Payer: Ohana Health Plan Medicaid	$2,089.55
Rate for Payer: Ohana Health Plan Medicare	$1,899.59
Rate for Payer: UnitedHealthcare Medicaid	$456.03
Rate for Payer: UnitedHealthcare Medicare	$1,899.59
Rate for Payer: University Health Alliance Commercial	$10,679.55

ARTHROTOMY, WITH EXPLORATION, DRAINAGE, OR REMOVAL OF LOOSE OR FOREIGN BODY; METACARPOPHALANGEAL JOINT, EACH

Facility

$10,679.55

Service Code	CPT 26075
Hospital Revenue Code	360
Min. Negotiated Rate	$456.03
Max. Negotiated Rate	$10,679.55
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	$10,679.55

ARTICULAR GLENOID G203-2015-W

Facility

$4,550.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$2,548.00
Max. Negotiated Rate	$4,413.50
Rate for Payer: Cash Price	$2,730.00
Rate for Payer: Hawaii Western Management Group Commercial	$3,185.00
Rate for Payer: Health Management Network Commercial	$3,867.50
Rate for Payer: MDX Hawaii PPO	$4,413.50
Rate for Payer: University Health Alliance Commercial	$2,548.00

ARTICULAR GLENOID G203-2015-W

Facility

$4,550.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$2,320.50
Max. Negotiated Rate	$4,413.50
Rate for Payer: Cash Price	$2,730.00
Rate for Payer: Hawaii Western Management Group Commercial	$3,185.00
Rate for Payer: Health Management Network Commercial	$3,867.50
Rate for Payer: Kaiser Permanente Commercial	$2,866.50
Rate for Payer: Kaiser Permanente Medicaid	$2,320.50
Rate for Payer: MDX Hawaii PPO	$4,413.50
Rate for Payer: University Health Alliance Commercial	$2,548.00

ASAHI SION BLACK 300CM STRT

Facility

$525.00

Service Code	HCPCS C1769
Hospital Revenue Code	272
Min. Negotiated Rate	$267.75
Max. Negotiated Rate	$509.25
Rate for Payer: Cash Price	$315.00
Rate for Payer: Hawaii Western Management Group Commercial	$498.75
Rate for Payer: Health Management Network Commercial	$446.25
Rate for Payer: Kaiser Permanente Commercial	$330.75
Rate for Payer: Kaiser Permanente Medicaid	$267.75
Rate for Payer: MDX Hawaii PPO	$509.25
Rate for Payer: University Health Alliance Commercial	$382.67

ASAHI SION BLACK 300CM STRT

Facility

$525.00

Service Code	HCPCS C1769
Hospital Revenue Code	272
Min. Negotiated Rate	$446.25
Max. Negotiated Rate	$509.25
Rate for Payer: Cash Price	$315.00
Rate for Payer: Health Management Network Commercial	$446.25
Rate for Payer: MDX Hawaii PPO	$509.25

ASCORBIC ACID (VITAMIN C) 250 MG TABLET [663]

Facility

$1.00

Service Code	NDC 00100000000
Hospital Revenue Code	637
Min. Negotiated Rate	$0.51
Max. Negotiated Rate	$0.97
Rate for Payer: Cash Price	$0.60
Rate for Payer: Hawaii Western Management Group Commercial	$0.95
Rate for Payer: Health Management Network Commercial	$0.85
Rate for Payer: Kaiser Permanente Commercial	$0.63
Rate for Payer: Kaiser Permanente Medicaid	$0.51
Rate for Payer: MDX Hawaii PPO	$0.97
Rate for Payer: University Health Alliance Commercial	$0.73

Know your out-of-pocket cost for care.

All Charges