Hilo Benioff Medical Center

All Charges

Charge

Type

Setting

Price

INSERT ADM/MDM X3 1236-2-854

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 BEARING 5532-G-413-E

Facility

$2,676.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$1,498.56
Max. Negotiated Rate	$2,595.72
Rate for Payer: Cash Price	$1,605.60
Rate for Payer: Hawaii Western Management Group Commercial	$1,873.20
Rate for Payer: Health Management Network Commercial	$2,274.60
Rate for Payer: MDX Hawaii PPO	$2,595.72
Rate for Payer: University Health Alliance Commercial	$1,498.56

INSERT BEARING 5532-G-413-E

Facility

$2,676.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$1,364.76
Max. Negotiated Rate	$2,595.72
Rate for Payer: Cash Price	$1,605.60
Rate for Payer: Hawaii Western Management Group Commercial	$1,873.20
Rate for Payer: Health Management Network Commercial	$2,274.60
Rate for Payer: Kaiser Permanente Commercial	$1,685.88
Rate for Payer: Kaiser Permanente Medicaid	$1,364.76
Rate for Payer: MDX Hawaii PPO	$2,595.72
Rate for Payer: University Health Alliance Commercial	$1,498.56

INSERT CR SZ 6 6MM 1516-20-606

Facility

$3,000.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$1,530.00
Max. Negotiated Rate	$2,910.00
Rate for Payer: Cash Price	$1,800.00
Rate for Payer: Hawaii Western Management Group Commercial	$2,100.00
Rate for Payer: Health Management Network Commercial	$2,550.00
Rate for Payer: Kaiser Permanente Commercial	$1,890.00
Rate for Payer: Kaiser Permanente Medicaid	$1,530.00
Rate for Payer: MDX Hawaii PPO	$2,910.00
Rate for Payer: University Health Alliance Commercial	$1,680.00

INSERT CR SZ 6 6MM 1516-20-606

Facility

$3,000.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$1,680.00
Max. Negotiated Rate	$2,910.00
Rate for Payer: Cash Price	$1,800.00
Rate for Payer: Hawaii Western Management Group Commercial	$2,100.00
Rate for Payer: Health Management Network Commercial	$2,550.00
Rate for Payer: MDX Hawaii PPO	$2,910.00
Rate for Payer: University Health Alliance Commercial	$1,680.00

INSERT E-VITALIZ SZ6 166-7613

Facility

$8,550.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$4,360.50
Max. Negotiated Rate	$8,293.50
Rate for Payer: Cash Price	$5,130.00
Rate for Payer: Hawaii Western Management Group Commercial	$5,985.00
Rate for Payer: Health Management Network Commercial	$7,267.50
Rate for Payer: Kaiser Permanente Commercial	$5,386.50
Rate for Payer: Kaiser Permanente Medicaid	$4,360.50
Rate for Payer: MDX Hawaii PPO	$8,293.50
Rate for Payer: University Health Alliance Commercial	$4,788.00

INSERT E-VITALIZ SZ6 166-7613

Facility

$8,550.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$4,788.00
Max. Negotiated Rate	$8,293.50
Rate for Payer: Cash Price	$5,130.00
Rate for Payer: Hawaii Western Management Group Commercial	$5,985.00
Rate for Payer: Health Management Network Commercial	$7,267.50
Rate for Payer: MDX Hawaii PPO	$8,293.50
Rate for Payer: University Health Alliance Commercial	$4,788.00

INSERT E-VITALIZ SZ7 166-5712

Facility

$8,550.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$4,360.50
Max. Negotiated Rate	$8,293.50
Rate for Payer: Cash Price	$5,130.00
Rate for Payer: Hawaii Western Management Group Commercial	$5,985.00
Rate for Payer: Health Management Network Commercial	$7,267.50
Rate for Payer: Kaiser Permanente Commercial	$5,386.50
Rate for Payer: Kaiser Permanente Medicaid	$4,360.50
Rate for Payer: MDX Hawaii PPO	$8,293.50
Rate for Payer: University Health Alliance Commercial	$4,788.00

INSERT E-VITALIZ SZ7 166-5712

Facility

$8,550.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$4,788.00
Max. Negotiated Rate	$8,293.50
Rate for Payer: Cash Price	$5,130.00
Rate for Payer: Hawaii Western Management Group Commercial	$5,985.00
Rate for Payer: Health Management Network Commercial	$7,267.50
Rate for Payer: MDX Hawaii PPO	$8,293.50
Rate for Payer: University Health Alliance Commercial	$4,788.00

INSERT HINGE TRIATH 5612-P-511

Facility

$5,870.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$2,993.70
Max. Negotiated Rate	$5,693.90
Rate for Payer: Cash Price	$3,522.00
Rate for Payer: Hawaii Western Management Group Commercial	$4,109.00
Rate for Payer: Health Management Network Commercial	$4,989.50
Rate for Payer: Kaiser Permanente Commercial	$3,698.10
Rate for Payer: Kaiser Permanente Medicaid	$2,993.70
Rate for Payer: MDX Hawaii PPO	$5,693.90
Rate for Payer: University Health Alliance Commercial	$3,287.20

INSERT HINGE TRIATH 5612-P-511

Facility

$5,870.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$3,287.20
Max. Negotiated Rate	$5,693.90
Rate for Payer: Cash Price	$3,522.00
Rate for Payer: Hawaii Western Management Group Commercial	$4,109.00
Rate for Payer: Health Management Network Commercial	$4,989.50
Rate for Payer: MDX Hawaii PPO	$5,693.90
Rate for Payer: University Health Alliance Commercial	$3,287.20

INSERT HUMERAL X3 5571-C-3608

Facility

$3,200.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$1,632.00
Max. Negotiated Rate	$3,104.00
Rate for Payer: Cash Price	$1,920.00
Rate for Payer: Hawaii Western Management Group Commercial	$2,240.00
Rate for Payer: Health Management Network Commercial	$2,720.00
Rate for Payer: Kaiser Permanente Commercial	$2,016.00
Rate for Payer: Kaiser Permanente Medicaid	$1,632.00
Rate for Payer: MDX Hawaii PPO	$3,104.00
Rate for Payer: University Health Alliance Commercial	$1,792.00

INSERT HUMERAL X3 5571-C-3608

Facility

$3,200.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$1,792.00
Max. Negotiated Rate	$3,104.00
Rate for Payer: Cash Price	$1,920.00
Rate for Payer: Hawaii Western Management Group Commercial	$2,240.00
Rate for Payer: Health Management Network Commercial	$2,720.00
Rate for Payer: MDX Hawaii PPO	$3,104.00
Rate for Payer: University Health Alliance Commercial	$1,792.00

INSERT HUMERL 32X4 5571-S-3204

Facility

$3,200.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$1,632.00
Max. Negotiated Rate	$3,104.00
Rate for Payer: Cash Price	$1,920.00
Rate for Payer: Hawaii Western Management Group Commercial	$2,240.00
Rate for Payer: Health Management Network Commercial	$2,720.00
Rate for Payer: Kaiser Permanente Commercial	$2,016.00
Rate for Payer: Kaiser Permanente Medicaid	$1,632.00
Rate for Payer: MDX Hawaii PPO	$3,104.00
Rate for Payer: University Health Alliance Commercial	$1,792.00

INSERT HUMERL 32X4 5571-S-3204

Facility

$3,200.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$1,792.00
Max. Negotiated Rate	$3,104.00
Rate for Payer: Cash Price	$1,920.00
Rate for Payer: Hawaii Western Management Group Commercial	$2,240.00
Rate for Payer: Health Management Network Commercial	$2,720.00
Rate for Payer: MDX Hawaii PPO	$3,104.00
Rate for Payer: University Health Alliance Commercial	$1,792.00

INSERT HUM S36/+3 AR-9503S-03

Facility

$2,030.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$1,136.80
Max. Negotiated Rate	$1,969.10
Rate for Payer: Cash Price	$1,218.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,421.00
Rate for Payer: Health Management Network Commercial	$1,725.50
Rate for Payer: MDX Hawaii PPO	$1,969.10
Rate for Payer: University Health Alliance Commercial	$1,136.80

INSERT HUM S36/+3 AR-9503S-03

Facility

$2,030.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$1,035.30
Max. Negotiated Rate	$1,969.10
Rate for Payer: Cash Price	$1,218.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,421.00
Rate for Payer: Health Management Network Commercial	$1,725.50
Rate for Payer: Kaiser Permanente Commercial	$1,278.90
Rate for Payer: Kaiser Permanente Medicaid	$1,035.30
Rate for Payer: MDX Hawaii PPO	$1,969.10
Rate for Payer: University Health Alliance Commercial	$1,136.80

INSERTION, DRUG-DELIVERY IMPLANT (IE, BIORESORBABLE, BIODEGRADABLE, NON-BIODEGRADABLE)

Facility

$4,035.20

Service Code	CPT 11981
Hospital Revenue Code	360
Min. Negotiated Rate	$82.56
Max. Negotiated Rate	$4,035.20
Rate for Payer: AlohaCare Medicaid	$157.18
Rate for Payer: AlohaCare Medicare	$157.18
Rate for Payer: Devoted Health Medicare	$172.90
Rate for Payer: Hawaii Medical Service Association Commercial	$196.47
Rate for Payer: Hawaii Medical Service Association Medicare	$157.18
Rate for Payer: Humana Medicare	$157.18
Rate for Payer: Kaiser Permanente Medicaid	$2,837.00
Rate for Payer: Kaiser Permanente Medicare	$157.18
Rate for Payer: Ohana Health Plan Medicaid	$172.90
Rate for Payer: Ohana Health Plan Medicare	$157.18
Rate for Payer: UnitedHealthcare Medicaid	$82.56
Rate for Payer: UnitedHealthcare Medicare	$157.18
Rate for Payer: University Health Alliance Commercial	$4,035.20

INSERTION KIT AR-3610PK-3

Facility

$886.00

Service Code	HCPCS C1713
Hospital Revenue Code	272
Min. Negotiated Rate	$753.10
Max. Negotiated Rate	$859.42
Rate for Payer: Cash Price	$531.60
Rate for Payer: Health Management Network Commercial	$753.10
Rate for Payer: MDX Hawaii PPO	$859.42

INSERTION KIT AR-3610PK-3

Facility

$886.00

Service Code	HCPCS C1713
Hospital Revenue Code	272
Min. Negotiated Rate	$451.86
Max. Negotiated Rate	$859.42
Rate for Payer: Cash Price	$531.60
Rate for Payer: Hawaii Western Management Group Commercial	$841.70
Rate for Payer: Health Management Network Commercial	$753.10
Rate for Payer: Kaiser Permanente Commercial	$558.18
Rate for Payer: Kaiser Permanente Medicaid	$451.86
Rate for Payer: MDX Hawaii PPO	$859.42
Rate for Payer: University Health Alliance Commercial	$645.81

INSERTION OF BREAST IMPLANT ON SAME DAY OF MASTECTOMY (IE, IMMEDIATE)

Facility

$10,621.15

Service Code	CPT 19340
Hospital Revenue Code	360
Min. Negotiated Rate	$521.33
Max. Negotiated Rate	$10,621.15
Rate for Payer: AlohaCare Medicaid	$9,655.59
Rate for Payer: AlohaCare Medicare	$9,655.59
Rate for Payer: Devoted Health Medicare	$10,621.15
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	$9,655.59
Rate for Payer: Hawaii Medical Service Association Non-ABD	$1,427.62
Rate for Payer: Humana Medicare	$9,655.59
Rate for Payer: Kaiser Permanente Medicaid	$2,837.00
Rate for Payer: Kaiser Permanente Medicare	$9,655.59
Rate for Payer: Ohana Health Plan Medicaid	$10,621.15
Rate for Payer: Ohana Health Plan Medicare	$9,655.59
Rate for Payer: UnitedHealthcare Medicaid	$521.33
Rate for Payer: UnitedHealthcare Medicare	$9,655.59
Rate for Payer: University Health Alliance Commercial	$5,160.40

INSERTION OF INFLATABLE URETHRAL/BLADDER NECK SPHINCTER, INCLUDING PLACEMENT OF PUMP, RESERVOIR, AND CUFF

Facility

$26,933.17

Service Code	CPT 53445
Hospital Revenue Code	360
Min. Negotiated Rate	$644.55
Max. Negotiated Rate	$26,933.17
Rate for Payer: AlohaCare Medicaid	$24,484.70
Rate for Payer: AlohaCare Medicare	$24,484.70
Rate for Payer: Devoted Health Medicare	$26,933.17
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	$24,484.70
Rate for Payer: Hawaii Medical Service Association Non-ABD	$2,294.85
Rate for Payer: Humana Medicare	$24,484.70
Rate for Payer: Kaiser Permanente Medicaid	$2,837.00
Rate for Payer: Kaiser Permanente Medicare	$24,484.70
Rate for Payer: Ohana Health Plan Medicaid	$26,933.17
Rate for Payer: Ohana Health Plan Medicare	$24,484.70
Rate for Payer: UnitedHealthcare Medicaid	$644.55
Rate for Payer: UnitedHealthcare Medicare	$24,484.70

INSERTION OF INTRAUTERINE DEVICE (IUD)

Facility

$4,035.20

Service Code	CPT 58300
Hospital Revenue Code	360
Min. Negotiated Rate	$51.59
Max. Negotiated Rate	$4,035.20
Rate for Payer: Kaiser Permanente Medicaid	$2,837.00
Rate for Payer: UnitedHealthcare Medicaid	$51.59
Rate for Payer: University Health Alliance Commercial	$4,035.20

INSERTION OF NON-TUNNELED CENTRALLY INSERTED CENTRAL VENOUS CATHETER; AGE 5 YEARS OR OLDER

Facility

$4,103.08

Service Code	CPT 36556
Hospital Revenue Code	360
Min. Negotiated Rate	$340.18
Max. Negotiated Rate	$4,103.08
Rate for Payer: AlohaCare Medicaid	$3,730.07
Rate for Payer: AlohaCare Medicare	$3,730.07
Rate for Payer: Devoted Health Medicare	$4,103.08
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	$3,730.07
Rate for Payer: Hawaii Medical Service Association Non-ABD	$496.75
Rate for Payer: Humana Medicare	$3,730.07
Rate for Payer: Kaiser Permanente Medicaid	$2,837.00
Rate for Payer: Kaiser Permanente Medicare	$3,730.07
Rate for Payer: Ohana Health Plan Medicaid	$4,103.08
Rate for Payer: Ohana Health Plan Medicare	$3,730.07
Rate for Payer: UnitedHealthcare Medicaid	$340.18
Rate for Payer: UnitedHealthcare Medicare	$3,730.07

INSERTION OF PACING ELECTRODE, CARDIAC VENOUS SYSTEM, FOR LEFT VENTRICULAR PACING, AT TIME OF INSERTION OF IMPLANTABLE DEFIBRILLATOR OR PACEMAKER PULSE GENERATOR (EG, FOR UPGRADE TO DUAL CHAMBER SYSTEM) (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)

Facility

$2,837.00

Service Code	CPT 33225
Hospital Revenue Code	361
Min. Negotiated Rate	$644.55
Max. Negotiated Rate	$2,837.00
Rate for Payer: Kaiser Permanente Medicaid	$2,837.00
Rate for Payer: UnitedHealthcare Medicaid	$644.55

Know your out-of-pocket cost for care.

All Charges