Hilo Benioff Medical Center

All Charges

Charge

Type

Setting

Price

HIP SYS RESTORATION 6276-7-019

Facility

$6,428.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$3,278.28
Max. Negotiated Rate	$6,235.16
Rate for Payer: Cash Price	$3,856.80
Rate for Payer: Hawaii Western Management Group Commercial	$4,499.60
Rate for Payer: Health Management Network Commercial	$5,463.80
Rate for Payer: Kaiser Permanente Commercial	$4,049.64
Rate for Payer: Kaiser Permanente Medicaid	$3,278.28
Rate for Payer: MDX Hawaii PPO	$6,235.16
Rate for Payer: University Health Alliance Commercial	$3,599.68

HIP SYS RESTORATION 6276-7-019

Facility

$6,428.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$3,599.68
Max. Negotiated Rate	$6,235.16
Rate for Payer: Cash Price	$3,856.80
Rate for Payer: Hawaii Western Management Group Commercial	$4,499.60
Rate for Payer: Health Management Network Commercial	$5,463.80
Rate for Payer: MDX Hawaii PPO	$6,235.16
Rate for Payer: University Health Alliance Commercial	$3,599.68

HIP SYS RESTORATION 6276-7-418

Facility

$6,363.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$3,245.13
Max. Negotiated Rate	$6,172.11
Rate for Payer: Cash Price	$3,817.80
Rate for Payer: Hawaii Western Management Group Commercial	$4,454.10
Rate for Payer: Health Management Network Commercial	$5,408.55
Rate for Payer: Kaiser Permanente Commercial	$4,008.69
Rate for Payer: Kaiser Permanente Medicaid	$3,245.13
Rate for Payer: MDX Hawaii PPO	$6,172.11
Rate for Payer: University Health Alliance Commercial	$3,563.28

HIP SYS RESTORATION 6276-7-418

Facility

$6,363.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$3,563.28
Max. Negotiated Rate	$6,172.11
Rate for Payer: Cash Price	$3,817.80
Rate for Payer: Hawaii Western Management Group Commercial	$4,454.10
Rate for Payer: Health Management Network Commercial	$5,408.55
Rate for Payer: MDX Hawaii PPO	$6,172.11
Rate for Payer: University Health Alliance Commercial	$3,563.28

HIP SYS SZE 23MM 62726-1-123

Facility

$8,879.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$4,972.24
Max. Negotiated Rate	$8,612.63
Rate for Payer: Cash Price	$5,327.40
Rate for Payer: Hawaii Western Management Group Commercial	$6,215.30
Rate for Payer: Health Management Network Commercial	$7,547.15
Rate for Payer: MDX Hawaii PPO	$8,612.63
Rate for Payer: University Health Alliance Commercial	$4,972.24

HIP SYS SZE 23MM 62726-1-123

Facility

$8,879.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$4,528.29
Max. Negotiated Rate	$8,612.63
Rate for Payer: Cash Price	$5,327.40
Rate for Payer: Hawaii Western Management Group Commercial	$6,215.30
Rate for Payer: Health Management Network Commercial	$7,547.15
Rate for Payer: Kaiser Permanente Commercial	$5,593.77
Rate for Payer: Kaiser Permanente Medicaid	$4,528.29
Rate for Payer: MDX Hawaii PPO	$8,612.63
Rate for Payer: University Health Alliance Commercial	$4,972.24

HIP SYSYTEM 6276-7-022

Facility

$6,428.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$3,278.28
Max. Negotiated Rate	$6,235.16
Rate for Payer: Cash Price	$3,856.80
Rate for Payer: Hawaii Western Management Group Commercial	$4,499.60
Rate for Payer: Health Management Network Commercial	$5,463.80
Rate for Payer: Kaiser Permanente Commercial	$4,049.64
Rate for Payer: Kaiser Permanente Medicaid	$3,278.28
Rate for Payer: MDX Hawaii PPO	$6,235.16
Rate for Payer: University Health Alliance Commercial	$3,599.68

HIP SYSYTEM 6276-7-022

Facility

$6,428.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$3,599.68
Max. Negotiated Rate	$6,235.16
Rate for Payer: Cash Price	$3,856.80
Rate for Payer: Hawaii Western Management Group Commercial	$4,499.60
Rate for Payer: Health Management Network Commercial	$5,463.80
Rate for Payer: MDX Hawaii PPO	$6,235.16
Rate for Payer: University Health Alliance Commercial	$3,599.68

HI-TORQUE BALANCE 014X190

Facility

$1,488.00

Service Code	HCPCS C1769
Hospital Revenue Code	272
Min. Negotiated Rate	$758.88
Max. Negotiated Rate	$1,443.36
Rate for Payer: Cash Price	$892.80
Rate for Payer: Hawaii Western Management Group Commercial	$1,413.60
Rate for Payer: Health Management Network Commercial	$1,264.80
Rate for Payer: Kaiser Permanente Commercial	$937.44
Rate for Payer: Kaiser Permanente Medicaid	$758.88
Rate for Payer: MDX Hawaii PPO	$1,443.36
Rate for Payer: University Health Alliance Commercial	$1,084.60

HI-TORQUE BALANCE 014X190

Facility

$1,488.00

Service Code	HCPCS C1769
Hospital Revenue Code	272
Min. Negotiated Rate	$1,264.80
Max. Negotiated Rate	$1,443.36
Rate for Payer: Cash Price	$892.80
Rate for Payer: Health Management Network Commercial	$1,264.80
Rate for Payer: MDX Hawaii PPO	$1,443.36

HI-TORQUE PILOT 50 STRT 300

Facility

$360.00

Service Code	HCPCS C1769
Hospital Revenue Code	272
Min. Negotiated Rate	$183.60
Max. Negotiated Rate	$349.20
Rate for Payer: Cash Price	$216.00
Rate for Payer: Hawaii Western Management Group Commercial	$342.00
Rate for Payer: Health Management Network Commercial	$306.00
Rate for Payer: Kaiser Permanente Commercial	$226.80
Rate for Payer: Kaiser Permanente Medicaid	$183.60
Rate for Payer: MDX Hawaii PPO	$349.20
Rate for Payer: University Health Alliance Commercial	$262.40

HI-TORQUE PILOT 50 STRT 300

Facility

$360.00

Service Code	HCPCS C1769
Hospital Revenue Code	272
Min. Negotiated Rate	$306.00
Max. Negotiated Rate	$349.20
Rate for Payer: Cash Price	$216.00
Rate for Payer: Health Management Network Commercial	$306.00
Rate for Payer: MDX Hawaii PPO	$349.20

HI VIS HIP BURR 4.0 #7220312

Facility

$426.00

Hospital Revenue Code	272
Min. Negotiated Rate	$362.10
Max. Negotiated Rate	$413.22
Rate for Payer: Cash Price	$255.60
Rate for Payer: Health Management Network Commercial	$362.10
Rate for Payer: MDX Hawaii PPO	$413.22

HI VIS HIP BURR 4.0 #7220312

Facility

$426.00

Hospital Revenue Code	272
Min. Negotiated Rate	$217.26
Max. Negotiated Rate	$413.22
Rate for Payer: Cash Price	$255.60
Rate for Payer: Hawaii Western Management Group Commercial	$404.70
Rate for Payer: Health Management Network Commercial	$362.10
Rate for Payer: Kaiser Permanente Commercial	$268.38
Rate for Payer: Kaiser Permanente Medicaid	$217.26
Rate for Payer: MDX Hawaii PPO	$413.22
Rate for Payer: University Health Alliance Commercial	$310.51

HIV WITH EXTENSIVE O.R. PROCEDURES WITH MCC

Facility

$105,592.43

Service Code	MSDRG 969
Min. Negotiated Rate	$69,625.22
Max. Negotiated Rate	$105,592.43
Rate for Payer: AlohaCare Medicare	$69,625.22
Rate for Payer: Devoted Health Medicare	$76,587.74
Rate for Payer: Hawaii Medical Service Association Commercial	$101,431.88
Rate for Payer: Hawaii Medical Service Association Medicare	$69,625.22
Rate for Payer: Humana Medicare	$69,625.22
Rate for Payer: Kaiser Permanente Commercial	$105,592.43
Rate for Payer: Kaiser Permanente Medicare	$69,625.22
Rate for Payer: Ohana Health Plan Medicare	$69,625.22
Rate for Payer: UnitedHealthcare Medicare	$69,625.22

HIV WITH EXTENSIVE O.R. PROCEDURES WITHOUT MCC

Facility

$101,431.88

Service Code	MSDRG 970
Min. Negotiated Rate	$29,998.45
Max. Negotiated Rate	$101,431.88
Rate for Payer: AlohaCare Medicare	$29,998.45
Rate for Payer: Devoted Health Medicare	$32,998.29
Rate for Payer: Hawaii Medical Service Association Commercial	$101,431.88
Rate for Payer: Hawaii Medical Service Association Medicare	$29,998.45
Rate for Payer: Humana Medicare	$29,998.45
Rate for Payer: Kaiser Permanente Commercial	$45,495.15
Rate for Payer: Kaiser Permanente Medicare	$29,998.45
Rate for Payer: Ohana Health Plan Medicare	$29,998.45
Rate for Payer: UnitedHealthcare Medicare	$29,998.45

HIV WITH MAJOR RELATED CONDITION WITH CC

Facility

$59,014.91

Service Code	MSDRG 975
Min. Negotiated Rate	$14,729.66
Max. Negotiated Rate	$59,014.91
Rate for Payer: AlohaCare Medicare	$14,729.66
Rate for Payer: Devoted Health Medicare	$16,202.63
Rate for Payer: Hawaii Medical Service Association Commercial	$59,014.91
Rate for Payer: Hawaii Medical Service Association Medicare	$14,729.66
Rate for Payer: Humana Medicare	$14,729.66
Rate for Payer: Kaiser Permanente Commercial	$22,338.75
Rate for Payer: Kaiser Permanente Medicare	$14,729.66
Rate for Payer: Ohana Health Plan Medicare	$14,729.66
Rate for Payer: UnitedHealthcare Medicare	$14,729.66

HIV WITH MAJOR RELATED CONDITION WITH MCC

Facility

$59,014.91

Service Code	MSDRG 974
Min. Negotiated Rate	$32,826.10
Max. Negotiated Rate	$59,014.91
Rate for Payer: AlohaCare Medicare	$32,826.10
Rate for Payer: Devoted Health Medicare	$36,108.71
Rate for Payer: Hawaii Medical Service Association Commercial	$59,014.91
Rate for Payer: Hawaii Medical Service Association Medicare	$32,826.10
Rate for Payer: Humana Medicare	$32,826.10
Rate for Payer: Kaiser Permanente Commercial	$49,783.50
Rate for Payer: Kaiser Permanente Medicare	$32,826.10
Rate for Payer: Ohana Health Plan Medicare	$32,826.10
Rate for Payer: UnitedHealthcare Medicare	$32,826.10

HIV WITH MAJOR RELATED CONDITION WITHOUT CC/MCC

Facility

$59,014.91

Service Code	MSDRG 976
Min. Negotiated Rate	$10,267.53
Max. Negotiated Rate	$59,014.91
Rate for Payer: AlohaCare Medicare	$10,267.53
Rate for Payer: Devoted Health Medicare	$11,294.28
Rate for Payer: Hawaii Medical Service Association Commercial	$59,014.91
Rate for Payer: Hawaii Medical Service Association Medicare	$10,267.53
Rate for Payer: Humana Medicare	$10,267.53
Rate for Payer: Kaiser Permanente Commercial	$15,430.12
Rate for Payer: Kaiser Permanente Medicare	$10,267.53
Rate for Payer: Ohana Health Plan Medicare	$10,267.53
Rate for Payer: UnitedHealthcare Medicare	$10,267.53

HIV WITH OR WITHOUT OTHER RELATED CONDITION

Facility

$42,416.97

Service Code	MSDRG 977
Min. Negotiated Rate	$14,760.37
Max. Negotiated Rate	$42,416.97
Rate for Payer: AlohaCare Medicare	$14,760.37
Rate for Payer: Devoted Health Medicare	$16,236.41
Rate for Payer: Hawaii Medical Service Association Commercial	$42,416.97
Rate for Payer: Hawaii Medical Service Association Medicare	$14,760.37
Rate for Payer: Humana Medicare	$14,760.37
Rate for Payer: Kaiser Permanente Commercial	$21,866.10
Rate for Payer: Kaiser Permanente Medicare	$14,760.37
Rate for Payer: Ohana Health Plan Medicare	$14,760.37
Rate for Payer: UnitedHealthcare Medicare	$14,760.37

HIV W MAJOR HIV RELATED CONDITION

Facility

$3,624.05

Service Code	APR-DRG 8922
Min. Negotiated Rate	$3,624.05
Max. Negotiated Rate	$3,624.05
Rate for Payer: AlohaCare Medicaid	$3,624.05
Rate for Payer: Hawaii Medical Service Association ABD	$3,624.05
Rate for Payer: Hawaii Medical Service Association Non-ABD	$3,624.05
Rate for Payer: Kaiser Permanente Medicaid	$3,624.05
Rate for Payer: Ohana Health Plan Medicaid	$3,624.05
Rate for Payer: UnitedHealthcare Medicaid	$3,624.05

HIV W MAJOR HIV RELATED CONDITION

Facility

$2,988.73

Service Code	APR-DRG 8921
Min. Negotiated Rate	$2,988.73
Max. Negotiated Rate	$2,988.73
Rate for Payer: AlohaCare Medicaid	$2,988.73
Rate for Payer: Hawaii Medical Service Association ABD	$2,988.73
Rate for Payer: Hawaii Medical Service Association Non-ABD	$2,988.73
Rate for Payer: Kaiser Permanente Medicaid	$2,988.73
Rate for Payer: Ohana Health Plan Medicaid	$2,988.73
Rate for Payer: UnitedHealthcare Medicaid	$2,988.73

HIV W MAJOR HIV RELATED CONDITION

Facility

$5,054.49

Service Code	APR-DRG 8923
Min. Negotiated Rate	$5,054.49
Max. Negotiated Rate	$5,054.49
Rate for Payer: AlohaCare Medicaid	$5,054.49
Rate for Payer: Hawaii Medical Service Association ABD	$5,054.49
Rate for Payer: Hawaii Medical Service Association Non-ABD	$5,054.49
Rate for Payer: Kaiser Permanente Medicaid	$5,054.49
Rate for Payer: Ohana Health Plan Medicaid	$5,054.49
Rate for Payer: UnitedHealthcare Medicaid	$5,054.49

HIV W MAJOR HIV RELATED CONDITION

Facility

$8,217.39

Service Code	APR-DRG 8924
Min. Negotiated Rate	$8,217.39
Max. Negotiated Rate	$8,217.39
Rate for Payer: AlohaCare Medicaid	$8,217.39
Rate for Payer: Hawaii Medical Service Association ABD	$8,217.39
Rate for Payer: Hawaii Medical Service Association Non-ABD	$8,217.39
Rate for Payer: Kaiser Permanente Medicaid	$8,217.39
Rate for Payer: Ohana Health Plan Medicaid	$8,217.39
Rate for Payer: UnitedHealthcare Medicaid	$8,217.39

HIV W MULTIPLE MAJOR HIV RELATED CONDITIONS

Facility

$4,434.18

Service Code	APR-DRG 8901
Min. Negotiated Rate	$4,434.18
Max. Negotiated Rate	$4,434.18
Rate for Payer: AlohaCare Medicaid	$4,434.18
Rate for Payer: Hawaii Medical Service Association ABD	$4,434.18
Rate for Payer: Hawaii Medical Service Association Non-ABD	$4,434.18
Rate for Payer: Kaiser Permanente Medicaid	$4,434.18
Rate for Payer: Ohana Health Plan Medicaid	$4,434.18
Rate for Payer: UnitedHealthcare Medicaid	$4,434.18

Know your out-of-pocket cost for care.

All Charges