Hilo Benioff Medical Center

All Charges

Charge

Type

Setting

Price

HEAD HUMERAL 44/17 AR-9144-17P

Facility

$5,000.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$2,550.00
Max. Negotiated Rate	$4,850.00
Rate for Payer: Cash Price	$3,000.00
Rate for Payer: Hawaii Western Management Group Commercial	$3,500.00
Rate for Payer: Health Management Network Commercial	$4,250.00
Rate for Payer: Kaiser Permanente Commercial	$3,150.00
Rate for Payer: Kaiser Permanente Medicaid	$2,550.00
Rate for Payer: MDX Hawaii PPO	$4,850.00
Rate for Payer: University Health Alliance Commercial	$2,800.00

HEAD HUMERAL 44/17 AR-9144-17P

Facility

$5,000.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$2,800.00
Max. Negotiated Rate	$4,850.00
Rate for Payer: Cash Price	$3,000.00
Rate for Payer: Hawaii Western Management Group Commercial	$3,500.00
Rate for Payer: Health Management Network Commercial	$4,250.00
Rate for Payer: MDX Hawaii PPO	$4,850.00
Rate for Payer: University Health Alliance Commercial	$2,800.00

HEAD HUMERAL X36-12

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

HEAD HUMERAL X36-12

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

HEAD HUMERAL X38-13

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

HEAD HUMERAL X38-13

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

HEAD PROLINE EVOLVE 496H018

Facility

$3,846.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$2,153.76
Max. Negotiated Rate	$3,730.62
Rate for Payer: Cash Price	$2,307.60
Rate for Payer: Hawaii Western Management Group Commercial	$2,692.20
Rate for Payer: Health Management Network Commercial	$3,269.10
Rate for Payer: MDX Hawaii PPO	$3,730.62
Rate for Payer: University Health Alliance Commercial	$2,153.76

HEAD PROLINE EVOLVE 496H018

Facility

$3,846.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$1,961.46
Max. Negotiated Rate	$3,730.62
Rate for Payer: Cash Price	$2,307.60
Rate for Payer: Hawaii Western Management Group Commercial	$2,692.20
Rate for Payer: Health Management Network Commercial	$3,269.10
Rate for Payer: Kaiser Permanente Commercial	$2,422.98
Rate for Payer: Kaiser Permanente Medicaid	$1,961.46
Rate for Payer: MDX Hawaii PPO	$3,730.62
Rate for Payer: University Health Alliance Commercial	$2,153.76

HEAD RADIAL 09.405.580S

Facility

$8,625.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$4,830.00
Max. Negotiated Rate	$8,366.25
Rate for Payer: Cash Price	$5,175.00
Rate for Payer: Hawaii Western Management Group Commercial	$6,037.50
Rate for Payer: Health Management Network Commercial	$7,331.25
Rate for Payer: MDX Hawaii PPO	$8,366.25
Rate for Payer: University Health Alliance Commercial	$4,830.00

HEAD RADIAL 09.405.580S

Facility

$8,625.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$4,398.75
Max. Negotiated Rate	$8,366.25
Rate for Payer: Cash Price	$5,175.00
Rate for Payer: Hawaii Western Management Group Commercial	$6,037.50
Rate for Payer: Health Management Network Commercial	$7,331.25
Rate for Payer: Kaiser Permanente Commercial	$5,433.75
Rate for Payer: Kaiser Permanente Medicaid	$4,398.75
Rate for Payer: MDX Hawaii PPO	$8,366.25
Rate for Payer: University Health Alliance Commercial	$4,830.00

HEAD TRAUMA W COMA >1 HR OR HEMORRHAGE

Facility

$7,261.15

Service Code	APR-DRG 0553
Min. Negotiated Rate	$7,261.15
Max. Negotiated Rate	$7,261.15
Rate for Payer: AlohaCare Medicaid	$7,261.15
Rate for Payer: Hawaii Medical Service Association ABD	$7,261.15
Rate for Payer: Hawaii Medical Service Association Non-ABD	$7,261.15
Rate for Payer: Kaiser Permanente Medicaid	$7,261.15
Rate for Payer: Ohana Health Plan Medicaid	$7,261.15
Rate for Payer: UnitedHealthcare Medicaid	$7,261.15

HEAD TRAUMA W COMA >1 HR OR HEMORRHAGE

Facility

$13,685.91

Service Code	APR-DRG 0554
Min. Negotiated Rate	$13,685.91
Max. Negotiated Rate	$13,685.91
Rate for Payer: AlohaCare Medicaid	$13,685.91
Rate for Payer: Hawaii Medical Service Association ABD	$13,685.91
Rate for Payer: Hawaii Medical Service Association Non-ABD	$13,685.91
Rate for Payer: Kaiser Permanente Medicaid	$13,685.91
Rate for Payer: Ohana Health Plan Medicaid	$13,685.91
Rate for Payer: UnitedHealthcare Medicaid	$13,685.91

HEAD TRAUMA W COMA >1 HR OR HEMORRHAGE

Facility

$4,988.29

Service Code	APR-DRG 0552
Min. Negotiated Rate	$4,988.29
Max. Negotiated Rate	$4,988.29
Rate for Payer: AlohaCare Medicaid	$4,988.29
Rate for Payer: Hawaii Medical Service Association ABD	$4,988.29
Rate for Payer: Hawaii Medical Service Association Non-ABD	$4,988.29
Rate for Payer: Kaiser Permanente Medicaid	$4,988.29
Rate for Payer: Ohana Health Plan Medicaid	$4,988.29
Rate for Payer: UnitedHealthcare Medicaid	$4,988.29

HEAD TRAUMA W COMA >1 HR OR HEMORRHAGE

Facility

$3,664.33

Service Code	APR-DRG 0551
Min. Negotiated Rate	$3,664.33
Max. Negotiated Rate	$3,664.33
Rate for Payer: AlohaCare Medicaid	$3,664.33
Rate for Payer: Hawaii Medical Service Association ABD	$3,664.33
Rate for Payer: Hawaii Medical Service Association Non-ABD	$3,664.33
Rate for Payer: Kaiser Permanente Medicaid	$3,664.33
Rate for Payer: Ohana Health Plan Medicaid	$3,664.33
Rate for Payer: UnitedHealthcare Medicaid	$3,664.33

HEALICOIL RG DILATOR 72203951

Facility

$875.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$446.25
Max. Negotiated Rate	$848.75
Rate for Payer: Cash Price	$525.00
Rate for Payer: Hawaii Western Management Group Commercial	$612.50
Rate for Payer: Health Management Network Commercial	$743.75
Rate for Payer: Kaiser Permanente Commercial	$551.25
Rate for Payer: Kaiser Permanente Medicaid	$446.25
Rate for Payer: MDX Hawaii PPO	$848.75
Rate for Payer: University Health Alliance Commercial	$490.00

HEALICOIL RG DILATOR 72203951

Facility

$875.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$490.00
Max. Negotiated Rate	$848.75
Rate for Payer: Cash Price	$525.00
Rate for Payer: Hawaii Western Management Group Commercial	$612.50
Rate for Payer: Health Management Network Commercial	$743.75
Rate for Payer: MDX Hawaii PPO	$848.75
Rate for Payer: University Health Alliance Commercial	$490.00

HEALICOIL RSB SA 4.75 72203697

Facility

$1,663.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$848.13
Max. Negotiated Rate	$1,613.11
Rate for Payer: Cash Price	$997.80
Rate for Payer: Hawaii Western Management Group Commercial	$1,164.10
Rate for Payer: Health Management Network Commercial	$1,413.55
Rate for Payer: Kaiser Permanente Commercial	$1,047.69
Rate for Payer: Kaiser Permanente Medicaid	$848.13
Rate for Payer: MDX Hawaii PPO	$1,613.11
Rate for Payer: University Health Alliance Commercial	$931.28

HEALICOIL RSB SA 4.75 72203697

Facility

$1,663.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$931.28
Max. Negotiated Rate	$1,613.11
Rate for Payer: Cash Price	$997.80
Rate for Payer: Hawaii Western Management Group Commercial	$1,164.10
Rate for Payer: Health Management Network Commercial	$1,413.55
Rate for Payer: MDX Hawaii PPO	$1,613.11
Rate for Payer: University Health Alliance Commercial	$931.28

HEART FAILURE

Facility

$3,532.73

Service Code	APR-DRG 1942
Min. Negotiated Rate	$3,532.73
Max. Negotiated Rate	$3,532.73
Rate for Payer: AlohaCare Medicaid	$3,532.73
Rate for Payer: Hawaii Medical Service Association ABD	$3,532.73
Rate for Payer: Hawaii Medical Service Association Non-ABD	$3,532.73
Rate for Payer: Kaiser Permanente Medicaid	$3,532.73
Rate for Payer: Ohana Health Plan Medicaid	$3,532.73
Rate for Payer: UnitedHealthcare Medicaid	$3,532.73

HEART FAILURE

Facility

$2,730.43

Service Code	APR-DRG 1941
Min. Negotiated Rate	$2,730.43
Max. Negotiated Rate	$2,730.43
Rate for Payer: AlohaCare Medicaid	$2,730.43
Rate for Payer: Hawaii Medical Service Association ABD	$2,730.43
Rate for Payer: Hawaii Medical Service Association Non-ABD	$2,730.43
Rate for Payer: Kaiser Permanente Medicaid	$2,730.43
Rate for Payer: Ohana Health Plan Medicaid	$2,730.43
Rate for Payer: UnitedHealthcare Medicaid	$2,730.43

HEART FAILURE

Facility

$7,394.86

Service Code	APR-DRG 1944
Min. Negotiated Rate	$7,394.86
Max. Negotiated Rate	$7,394.86
Rate for Payer: AlohaCare Medicaid	$7,394.86
Rate for Payer: Hawaii Medical Service Association ABD	$7,394.86
Rate for Payer: Hawaii Medical Service Association Non-ABD	$7,394.86
Rate for Payer: Kaiser Permanente Medicaid	$7,394.86
Rate for Payer: Ohana Health Plan Medicaid	$7,394.86
Rate for Payer: UnitedHealthcare Medicaid	$7,394.86

HEART FAILURE

Facility

$4,941.65

Service Code	APR-DRG 1943
Min. Negotiated Rate	$4,941.65
Max. Negotiated Rate	$4,941.65
Rate for Payer: AlohaCare Medicaid	$4,941.65
Rate for Payer: Hawaii Medical Service Association ABD	$4,941.65
Rate for Payer: Hawaii Medical Service Association Non-ABD	$4,941.65
Rate for Payer: Kaiser Permanente Medicaid	$4,941.65
Rate for Payer: Ohana Health Plan Medicaid	$4,941.65
Rate for Payer: UnitedHealthcare Medicaid	$4,941.65

HEART FAILURE AND SHOCK WITH CC

Facility

$29,192.00

Service Code	MSDRG 292
Min. Negotiated Rate	$9,656.75
Max. Negotiated Rate	$29,192.00
Rate for Payer: AlohaCare Medicare	$9,656.75
Rate for Payer: Devoted Health Medicare	$10,622.42
Rate for Payer: Hawaii Medical Service Association Commercial	$29,192.00
Rate for Payer: Hawaii Medical Service Association Medicare	$9,656.75
Rate for Payer: Humana Medicare	$9,656.75
Rate for Payer: Kaiser Permanente Commercial	$14,645.25
Rate for Payer: Kaiser Permanente Medicare	$9,656.75
Rate for Payer: Ohana Health Plan Medicare	$9,656.75
Rate for Payer: UnitedHealthcare Medicare	$9,656.75

HEART FAILURE AND SHOCK WITH MCC

Facility

$29,192.00

Service Code	MSDRG 291
Min. Negotiated Rate	$14,602.27
Max. Negotiated Rate	$29,192.00
Rate for Payer: AlohaCare Medicare	$14,602.27
Rate for Payer: Devoted Health Medicare	$16,062.50
Rate for Payer: Hawaii Medical Service Association Commercial	$29,192.00
Rate for Payer: Hawaii Medical Service Association Medicare	$14,602.27
Rate for Payer: Humana Medicare	$14,602.27
Rate for Payer: Kaiser Permanente Commercial	$22,145.55
Rate for Payer: Kaiser Permanente Medicare	$14,602.27
Rate for Payer: Ohana Health Plan Medicare	$14,602.27
Rate for Payer: UnitedHealthcare Medicare	$14,602.27

HEART FAILURE AND SHOCK WITHOUT CC/MCC

Facility

$29,192.00

Service Code	MSDRG 293
Min. Negotiated Rate	$6,437.82
Max. Negotiated Rate	$29,192.00
Rate for Payer: AlohaCare Medicare	$6,437.82
Rate for Payer: Devoted Health Medicare	$7,081.60
Rate for Payer: Hawaii Medical Service Association Commercial	$29,192.00
Rate for Payer: Hawaii Medical Service Association Medicare	$6,437.82
Rate for Payer: Humana Medicare	$6,437.82
Rate for Payer: Kaiser Permanente Commercial	$9,763.50
Rate for Payer: Kaiser Permanente Medicare	$6,437.82
Rate for Payer: Ohana Health Plan Medicare	$6,437.82
Rate for Payer: UnitedHealthcare Medicare	$6,437.82

Know your out-of-pocket cost for care.

All Charges