Hilo Benioff Medical Center

All Charges

Charge

Type

Setting

Price

INGEVITY + PACING LEAD 52CM

Facility

$1,414.00

Service Code	HCPCS C1898
Hospital Revenue Code	275
Min. Negotiated Rate	$721.14
Max. Negotiated Rate	$1,371.58
Rate for Payer: Cash Price	$848.40
Rate for Payer: Hawaii Western Management Group Commercial	$989.80
Rate for Payer: Health Management Network Commercial	$1,201.90
Rate for Payer: Kaiser Permanente Commercial	$890.82
Rate for Payer: Kaiser Permanente Medicaid	$721.14
Rate for Payer: MDX Hawaii PPO	$1,371.58
Rate for Payer: University Health Alliance Commercial	$791.84

INGUINAL AND FEMORAL HERNIA PROCEDURES WITH CC

Facility

$30,599.43

Service Code	MSDRG 351
Min. Negotiated Rate	$17,340.06
Max. Negotiated Rate	$30,599.43
Rate for Payer: AlohaCare Medicare	$17,340.06
Rate for Payer: Devoted Health Medicare	$19,074.07
Rate for Payer: Hawaii Medical Service Association Commercial	$30,599.43
Rate for Payer: Hawaii Medical Service Association Medicare	$17,340.06
Rate for Payer: Humana Medicare	$17,340.06
Rate for Payer: Kaiser Permanente Commercial	$26,297.62
Rate for Payer: Kaiser Permanente Medicare	$17,340.06
Rate for Payer: Ohana Health Plan Medicare	$17,340.06
Rate for Payer: UnitedHealthcare Medicare	$17,340.06

INGUINAL AND FEMORAL HERNIA PROCEDURES WITH MCC

Facility

$42,985.28

Service Code	MSDRG 350
Min. Negotiated Rate	$28,343.50
Max. Negotiated Rate	$42,985.28
Rate for Payer: AlohaCare Medicare	$28,343.50
Rate for Payer: Devoted Health Medicare	$31,177.85
Rate for Payer: Hawaii Medical Service Association Commercial	$38,000.56
Rate for Payer: Hawaii Medical Service Association Medicare	$28,343.50
Rate for Payer: Humana Medicare	$28,343.50
Rate for Payer: Kaiser Permanente Commercial	$42,985.28
Rate for Payer: Kaiser Permanente Medicare	$28,343.50
Rate for Payer: Ohana Health Plan Medicare	$28,343.50
Rate for Payer: UnitedHealthcare Medicare	$28,343.50

INGUINAL AND FEMORAL HERNIA PROCEDURES WITHOUT CC/MCC

Facility

$20,144.55

Service Code	MSDRG 352
Min. Negotiated Rate	$13,282.85
Max. Negotiated Rate	$20,144.55
Rate for Payer: AlohaCare Medicare	$13,282.85
Rate for Payer: Devoted Health Medicare	$14,611.14
Rate for Payer: Hawaii Medical Service Association Commercial	$15,821.43
Rate for Payer: Hawaii Medical Service Association Medicare	$13,282.85
Rate for Payer: Humana Medicare	$13,282.85
Rate for Payer: Kaiser Permanente Commercial	$20,144.55
Rate for Payer: Kaiser Permanente Medicare	$13,282.85
Rate for Payer: Ohana Health Plan Medicare	$13,282.85
Rate for Payer: UnitedHealthcare Medicare	$13,282.85

INGUINAL, FEMORAL & UMBILICAL HERNIA PROCEDURES

Facility

$8,260.44

Service Code	APR-DRG 2283
Min. Negotiated Rate	$8,260.44
Max. Negotiated Rate	$8,260.44
Rate for Payer: AlohaCare Medicaid	$8,260.44
Rate for Payer: Hawaii Medical Service Association ABD	$8,260.44
Rate for Payer: Hawaii Medical Service Association Non-ABD	$8,260.44
Rate for Payer: Kaiser Permanente Medicaid	$8,260.44
Rate for Payer: Ohana Health Plan Medicaid	$8,260.44
Rate for Payer: UnitedHealthcare Medicaid	$8,260.44

INGUINAL, FEMORAL & UMBILICAL HERNIA PROCEDURES

Facility

$5,914.20

Service Code	APR-DRG 2282
Min. Negotiated Rate	$5,914.20
Max. Negotiated Rate	$5,914.20
Rate for Payer: AlohaCare Medicaid	$5,914.20
Rate for Payer: Hawaii Medical Service Association ABD	$5,914.20
Rate for Payer: Hawaii Medical Service Association Non-ABD	$5,914.20
Rate for Payer: Kaiser Permanente Medicaid	$5,914.20
Rate for Payer: Ohana Health Plan Medicaid	$5,914.20
Rate for Payer: UnitedHealthcare Medicaid	$5,914.20

INGUINAL, FEMORAL & UMBILICAL HERNIA PROCEDURES

Facility

$15,580.94

Service Code	APR-DRG 2284
Min. Negotiated Rate	$15,580.94
Max. Negotiated Rate	$15,580.94
Rate for Payer: AlohaCare Medicaid	$15,580.94
Rate for Payer: Hawaii Medical Service Association ABD	$15,580.94
Rate for Payer: Hawaii Medical Service Association Non-ABD	$15,580.94
Rate for Payer: Kaiser Permanente Medicaid	$15,580.94
Rate for Payer: Ohana Health Plan Medicaid	$15,580.94
Rate for Payer: UnitedHealthcare Medicaid	$15,580.94

INGUINAL, FEMORAL & UMBILICAL HERNIA PROCEDURES

Facility

$4,421.79

Service Code	APR-DRG 2281
Min. Negotiated Rate	$4,421.79
Max. Negotiated Rate	$4,421.79
Rate for Payer: AlohaCare Medicaid	$4,421.79
Rate for Payer: Hawaii Medical Service Association ABD	$4,421.79
Rate for Payer: Hawaii Medical Service Association Non-ABD	$4,421.79
Rate for Payer: Kaiser Permanente Medicaid	$4,421.79
Rate for Payer: Ohana Health Plan Medicaid	$4,421.79
Rate for Payer: UnitedHealthcare Medicaid	$4,421.79

INJECTION, INTRALESIONAL; UP TO AND INCLUDING 7 LESIONS

Facility

$2,837.00

Service Code	CPT 11900
Hospital Revenue Code	360
Min. Negotiated Rate	$19.80
Max. Negotiated Rate	$2,837.00
Rate for Payer: AlohaCare Medicaid	$237.02
Rate for Payer: AlohaCare Medicare	$237.02
Rate for Payer: Devoted Health Medicare	$260.72
Rate for Payer: Hawaii Medical Service Association Commercial	$296.27
Rate for Payer: Hawaii Medical Service Association Medicare	$237.02
Rate for Payer: Humana Medicare	$237.02
Rate for Payer: Kaiser Permanente Medicaid	$2,837.00
Rate for Payer: Kaiser Permanente Medicare	$237.02
Rate for Payer: Ohana Health Plan Medicaid	$260.72
Rate for Payer: Ohana Health Plan Medicare	$237.02
Rate for Payer: UnitedHealthcare Medicaid	$19.80
Rate for Payer: UnitedHealthcare Medicare	$237.02

INJECTION OF NON-COMPOUNDED FOAM SCLEROSANT WITH ULTRASOUND COMPRESSION MANEUVERS TO GUIDE DISPERSION OF THE INJECTATE, INCLUSIVE OF ALL IMAGING GUIDANCE AND MONITORING; MULTIPLE INCOMPETENT TRUNCAL VEINS (EG, GREAT SAPHENOUS VEIN, ACCESSORY SAPHENOUS VEIN), SAME LEG

Facility

$2,837.00

Service Code	CPT 36466
Hospital Revenue Code	360
Min. Negotiated Rate	$393.00
Max. Negotiated Rate	$2,837.00
Rate for Payer: AlohaCare Medicaid	$2,437.45
Rate for Payer: AlohaCare Medicare	$2,437.45
Rate for Payer: Devoted Health Medicare	$2,681.20
Rate for Payer: Hawaii Medical Service Association ABD	$393.00
Rate for Payer: Hawaii Medical Service Association Commercial	$2,536.00
Rate for Payer: Hawaii Medical Service Association Medicare	$2,437.45
Rate for Payer: Hawaii Medical Service Association Non-ABD	$496.75
Rate for Payer: Humana Medicare	$2,437.45
Rate for Payer: Kaiser Permanente Medicaid	$2,837.00
Rate for Payer: Kaiser Permanente Medicare	$2,437.45
Rate for Payer: Ohana Health Plan Medicaid	$2,681.20
Rate for Payer: Ohana Health Plan Medicare	$2,437.45
Rate for Payer: UnitedHealthcare Medicaid	$456.03
Rate for Payer: UnitedHealthcare Medicare	$2,437.45

INJECTION PROCEDURE FOR HIP ARTHROGRAPHY; WITH ANESTHESIA

Facility

$2,837.00

Service Code	CPT 27095
Hospital Revenue Code	360
Min. Negotiated Rate	$65.12
Max. Negotiated Rate	$2,837.00
Rate for Payer: Hawaii Medical Service Association ABD	$393.00
Rate for Payer: Hawaii Medical Service Association Commercial	$2,536.00
Rate for Payer: Hawaii Medical Service Association Non-ABD	$496.75
Rate for Payer: Kaiser Permanente Medicaid	$2,837.00
Rate for Payer: UnitedHealthcare Medicaid	$65.12

INJECTION PROCEDURE FOR RETROGRADE URETHROCYSTOGRAPHY

Facility

$2,837.00

Service Code	CPT 51610
Hospital Revenue Code	360
Min. Negotiated Rate	$40.43
Max. Negotiated Rate	$2,837.00
Rate for Payer: Kaiser Permanente Medicaid	$2,837.00
Rate for Payer: UnitedHealthcare Medicaid	$40.43

INJECTION PROCEDURE; LYMPHANGIOGRAPHY

Facility

$2,837.00

Service Code	CPT 38790
Hospital Revenue Code	361
Min. Negotiated Rate	$67.38
Max. Negotiated Rate	$2,837.00
Rate for Payer: Kaiser Permanente Medicaid	$2,837.00
Rate for Payer: UnitedHealthcare Medicaid	$67.38

INJECTION PROCEDURE; RADIOACTIVE TRACER FOR IDENTIFICATION OF SENTINEL NODE

Facility

$2,837.00

Service Code	CPT 38792
Hospital Revenue Code	360
Min. Negotiated Rate	$27.71
Max. Negotiated Rate	$2,837.00
Rate for Payer: AlohaCare Medicaid	$472.27
Rate for Payer: AlohaCare Medicare	$472.27
Rate for Payer: Devoted Health Medicare	$519.50
Rate for Payer: Hawaii Medical Service Association ABD	$393.00
Rate for Payer: Hawaii Medical Service Association Commercial	$2,536.00
Rate for Payer: Hawaii Medical Service Association Medicare	$472.27
Rate for Payer: Hawaii Medical Service Association Non-ABD	$496.75
Rate for Payer: Humana Medicare	$472.27
Rate for Payer: Kaiser Permanente Medicaid	$2,837.00
Rate for Payer: Kaiser Permanente Medicare	$472.27
Rate for Payer: Ohana Health Plan Medicaid	$519.50
Rate for Payer: Ohana Health Plan Medicare	$472.27
Rate for Payer: UnitedHealthcare Medicaid	$27.71
Rate for Payer: UnitedHealthcare Medicare	$472.27

INJECTION(S), DIAGNOSTIC OR THERAPEUTIC AGENT, PARAVERTEBRAL FACET (ZYGAPOPHYSEAL) JOINT (OR NERVES INNERVATING THAT JOINT) WITH IMAGE GUIDANCE (FLUOROSCOPY OR CT), LUMBAR OR SACRAL; SINGLE LEVEL

Facility

$4,035.20

Service Code	CPT 64493
Hospital Revenue Code	361
Min. Negotiated Rate	$340.18
Max. Negotiated Rate	$4,035.20
Rate for Payer: AlohaCare Medicaid	$1,044.87
Rate for Payer: AlohaCare Medicare	$1,044.87
Rate for Payer: Devoted Health Medicare	$1,149.36
Rate for Payer: Hawaii Medical Service Association ABD	$393.00
Rate for Payer: Hawaii Medical Service Association Commercial	$2,536.00
Rate for Payer: Hawaii Medical Service Association Medicare	$1,044.87
Rate for Payer: Hawaii Medical Service Association Non-ABD	$496.75
Rate for Payer: Humana Medicare	$1,044.87
Rate for Payer: Kaiser Permanente Medicaid	$2,837.00
Rate for Payer: Kaiser Permanente Medicare	$1,044.87
Rate for Payer: Ohana Health Plan Medicaid	$1,149.36
Rate for Payer: Ohana Health Plan Medicare	$1,044.87
Rate for Payer: UnitedHealthcare Medicaid	$340.18
Rate for Payer: UnitedHealthcare Medicare	$1,044.87
Rate for Payer: University Health Alliance Commercial	$4,035.20

INJECTION(S), OF DIAGNOSTIC OR THERAPEUTIC SUBSTANCE(S) (EG, ANESTHETIC, ANTISPASMODIC, OPIOID, STEROID, OTHER SOLUTION), NOT INCLUDING NEUROLYTIC SUBSTANCES, INCLUDING NEEDLE OR CATHETER PLACEMENT, INTERLAMINAR EPIDURAL OR SUBARACHNOID, LUMBAR OR SACRAL (CAUDAL); WITH IMAGING GUIDANCE (IE, FLUOROSCOPY OR CT)

Facility

$4,035.20

Service Code	CPT 62323
Hospital Revenue Code	361
Min. Negotiated Rate	$340.18
Max. Negotiated Rate	$4,035.20
Rate for Payer: AlohaCare Medicaid	$833.89
Rate for Payer: AlohaCare Medicare	$833.89
Rate for Payer: Devoted Health Medicare	$917.28
Rate for Payer: Hawaii Medical Service Association ABD	$393.00
Rate for Payer: Hawaii Medical Service Association Commercial	$2,536.00
Rate for Payer: Hawaii Medical Service Association Medicare	$833.89
Rate for Payer: Hawaii Medical Service Association Non-ABD	$496.75
Rate for Payer: Humana Medicare	$833.89
Rate for Payer: Kaiser Permanente Medicaid	$2,837.00
Rate for Payer: Kaiser Permanente Medicare	$833.89
Rate for Payer: Ohana Health Plan Medicaid	$917.28
Rate for Payer: Ohana Health Plan Medicare	$833.89
Rate for Payer: UnitedHealthcare Medicaid	$340.18
Rate for Payer: UnitedHealthcare Medicare	$833.89
Rate for Payer: University Health Alliance Commercial	$4,035.20

INLINE TL CANN ASSM 51-10430

Facility

$1,244.00

Hospital Revenue Code	272
Min. Negotiated Rate	$634.44
Max. Negotiated Rate	$1,206.68
Rate for Payer: Cash Price	$746.40
Rate for Payer: Hawaii Western Management Group Commercial	$1,181.80
Rate for Payer: Health Management Network Commercial	$1,057.40
Rate for Payer: Kaiser Permanente Commercial	$783.72
Rate for Payer: Kaiser Permanente Medicaid	$634.44
Rate for Payer: MDX Hawaii PPO	$1,206.68
Rate for Payer: University Health Alliance Commercial	$906.75

INLINE TL CANN ASSM 51-10430

Facility

$1,244.00

Hospital Revenue Code	272
Min. Negotiated Rate	$1,057.40
Max. Negotiated Rate	$1,206.68
Rate for Payer: Cash Price	$746.40
Rate for Payer: Health Management Network Commercial	$1,057.40
Rate for Payer: MDX Hawaii PPO	$1,206.68

INNER VISION 50FR TIP 1465-50

Facility

$450.00

Hospital Revenue Code	272
Min. Negotiated Rate	$382.50
Max. Negotiated Rate	$436.50
Rate for Payer: Cash Price	$270.00
Rate for Payer: Health Management Network Commercial	$382.50
Rate for Payer: MDX Hawaii PPO	$436.50

INNER VISION 50FR TIP 1465-50

Facility

$450.00

Hospital Revenue Code	272
Min. Negotiated Rate	$229.50
Max. Negotiated Rate	$436.50
Rate for Payer: Cash Price	$270.00
Rate for Payer: Hawaii Western Management Group Commercial	$427.50
Rate for Payer: Health Management Network Commercial	$382.50
Rate for Payer: Kaiser Permanente Commercial	$283.50
Rate for Payer: Kaiser Permanente Medicaid	$229.50
Rate for Payer: MDX Hawaii PPO	$436.50
Rate for Payer: University Health Alliance Commercial	$328.00

INSERT ACETABULAR 7236-2-848

Facility

$3,211.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$1,798.16
Max. Negotiated Rate	$3,114.67
Rate for Payer: Cash Price	$1,926.60
Rate for Payer: Hawaii Western Management Group Commercial	$2,247.70
Rate for Payer: Health Management Network Commercial	$2,729.35
Rate for Payer: MDX Hawaii PPO	$3,114.67
Rate for Payer: University Health Alliance Commercial	$1,798.16

INSERT ACETABULAR 7236-2-848

Facility

$3,211.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$1,637.61
Max. Negotiated Rate	$3,114.67
Rate for Payer: Cash Price	$1,926.60
Rate for Payer: Hawaii Western Management Group Commercial	$2,247.70
Rate for Payer: Health Management Network Commercial	$2,729.35
Rate for Payer: Kaiser Permanente Commercial	$2,022.93
Rate for Payer: Kaiser Permanente Medicaid	$1,637.61
Rate for Payer: MDX Hawaii PPO	$3,114.67
Rate for Payer: University Health Alliance Commercial	$1,798.16

INSERT ADM MDM X3 1236-2-852

Facility

$3,244.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$1,654.44
Max. Negotiated Rate	$3,146.68
Rate for Payer: Cash Price	$1,946.40
Rate for Payer: Hawaii Western Management Group Commercial	$2,270.80
Rate for Payer: Health Management Network Commercial	$2,757.40
Rate for Payer: Kaiser Permanente Commercial	$2,043.72
Rate for Payer: Kaiser Permanente Medicaid	$1,654.44
Rate for Payer: MDX Hawaii PPO	$3,146.68
Rate for Payer: University Health Alliance Commercial	$1,816.64

INSERT ADM MDM X3 1236-2-852

Facility

$3,244.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$1,816.64
Max. Negotiated Rate	$3,146.68
Rate for Payer: Cash Price	$1,946.40
Rate for Payer: Hawaii Western Management Group Commercial	$2,270.80
Rate for Payer: Health Management Network Commercial	$2,757.40
Rate for Payer: MDX Hawaii PPO	$3,146.68
Rate for Payer: University Health Alliance Commercial	$1,816.64

INSERT ADM/MDM X3 1236-2-854

Facility

$3,244.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$1,654.44
Max. Negotiated Rate	$3,146.68
Rate for Payer: Cash Price	$1,946.40
Rate for Payer: Hawaii Western Management Group Commercial	$2,270.80
Rate for Payer: Health Management Network Commercial	$2,757.40
Rate for Payer: Kaiser Permanente Commercial	$2,043.72
Rate for Payer: Kaiser Permanente Medicaid	$1,654.44
Rate for Payer: MDX Hawaii PPO	$3,146.68
Rate for Payer: University Health Alliance Commercial	$1,816.64

Know your out-of-pocket cost for care.

All Charges