Hilo Benioff Medical Center

All Charges

Charge

Type

Setting

Price

INSERTION OF SUBCUTANEOUS EXTENSION TO INTRAPERITONEAL CANNULA OR CATHETER WITH REMOTE CHEST EXIT SITE (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)

Facility

$2,837.00

Service Code	CPT 49435
Hospital Revenue Code	360
Min. Negotiated Rate	$456.03
Max. Negotiated Rate	$2,837.00
Rate for Payer: Kaiser Permanente Medicaid	$2,837.00
Rate for Payer: UnitedHealthcare Medicaid	$456.03

INSERTION OF TEMPORARY INDWELLING BLADDER CATHETER; COMPLICATED (EG, ALTERED ANATOMY, FRACTURED CATHETER/BALLOON)

Facility

$2,837.00

Service Code	CPT 51703
Hospital Revenue Code	360
Min. Negotiated Rate	$58.37
Max. Negotiated Rate	$2,837.00
Rate for Payer: AlohaCare Medicaid	$152.01
Rate for Payer: AlohaCare Medicare	$152.01
Rate for Payer: Devoted Health Medicare	$167.21
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	$152.01
Rate for Payer: Hawaii Medical Service Association Non-ABD	$496.75
Rate for Payer: Humana Medicare	$152.01
Rate for Payer: Kaiser Permanente Medicaid	$2,837.00
Rate for Payer: Kaiser Permanente Medicare	$152.01
Rate for Payer: Ohana Health Plan Medicaid	$167.21
Rate for Payer: Ohana Health Plan Medicare	$152.01
Rate for Payer: UnitedHealthcare Medicaid	$58.37
Rate for Payer: UnitedHealthcare Medicare	$152.01

INSERTION OF TUNNELED CENTRALLY INSERTED CENTRAL VENOUS ACCESS DEVICE, WITH SUBCUTANEOUS PORT; AGE 5 YEARS OR OLDER

Facility

$8,270.00

Service Code	CPT 36561
Hospital Revenue Code	360
Min. Negotiated Rate	$456.03
Max. Negotiated Rate	$8,270.00
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	$848.00
Rate for Payer: Hawaii Medical Service Association Commercial	$8,270.00
Rate for Payer: Hawaii Medical Service Association Medicare	$3,730.07
Rate for Payer: Hawaii Medical Service Association Non-ABD	$1,427.62
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	$456.03
Rate for Payer: UnitedHealthcare Medicare	$3,730.07
Rate for Payer: University Health Alliance Commercial	$6,743.44

INSERTION OF TUNNELED CENTRALLY INSERTED CENTRAL VENOUS ACCESS DEVICE WITH SUBCUTANEOUS PUMP

Facility

$8,270.00

Service Code	CPT 36563
Hospital Revenue Code	360
Min. Negotiated Rate	$521.33
Max. Negotiated Rate	$8,270.00
Rate for Payer: AlohaCare Medicaid	$6,573.58
Rate for Payer: AlohaCare Medicare	$6,573.58
Rate for Payer: Devoted Health Medicare	$7,230.94
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	$6,573.58
Rate for Payer: Hawaii Medical Service Association Non-ABD	$1,427.62
Rate for Payer: Humana Medicare	$6,573.58
Rate for Payer: Kaiser Permanente Medicaid	$2,837.00
Rate for Payer: Kaiser Permanente Medicare	$6,573.58
Rate for Payer: Ohana Health Plan Medicaid	$7,230.94
Rate for Payer: Ohana Health Plan Medicare	$6,573.58
Rate for Payer: UnitedHealthcare Medicaid	$521.33
Rate for Payer: UnitedHealthcare Medicare	$6,573.58
Rate for Payer: University Health Alliance Commercial	$6,743.44

INSERTION OF TUNNELED CENTRALLY INSERTED CENTRAL VENOUS CATHETER, WITHOUT SUBCUTANEOUS PORT OR PUMP; AGE 5 YEARS OR OLDER

Facility

$5,509.00

Service Code	CPT 36558
Hospital Revenue Code	360
Min. Negotiated Rate	$456.03
Max. Negotiated Rate	$5,509.00
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	$695.00
Rate for Payer: Hawaii Medical Service Association Commercial	$5,509.00
Rate for Payer: Hawaii Medical Service Association Medicare	$3,730.07
Rate for Payer: Hawaii Medical Service Association Non-ABD	$1,028.67
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	$456.03
Rate for Payer: UnitedHealthcare Medicare	$3,730.07
Rate for Payer: University Health Alliance Commercial	$5,160.40

INSERTION OR REPLACEMENT OF BREAST IMPLANT ON SEPARATE DAY FROM MASTECTOMY

Facility

$13,778.00

Service Code	CPT 19342
Hospital Revenue Code	360
Min. Negotiated Rate	$521.33
Max. Negotiated Rate	$13,778.00
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	$1,149.00
Rate for Payer: Hawaii Medical Service Association Commercial	$13,778.00
Rate for Payer: Hawaii Medical Service Association Medicare	$9,655.59
Rate for Payer: Hawaii Medical Service Association Non-ABD	$2,294.85
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	$6,743.44

INSERTION, REVISION & REPLACEMENTS OF PACEMAKER & OTHER CARDIAC DEVICES

Facility

$8,431.33

Service Code	APR-DRG 1761
Min. Negotiated Rate	$8,431.33
Max. Negotiated Rate	$8,431.33
Rate for Payer: AlohaCare Medicaid	$8,431.33
Rate for Payer: Hawaii Medical Service Association ABD	$8,431.33
Rate for Payer: Hawaii Medical Service Association Non-ABD	$8,431.33
Rate for Payer: Kaiser Permanente Medicaid	$8,431.33
Rate for Payer: Ohana Health Plan Medicaid	$8,431.33
Rate for Payer: UnitedHealthcare Medicaid	$8,431.33

INSERTION, REVISION & REPLACEMENTS OF PACEMAKER & OTHER CARDIAC DEVICES

Facility

$10,169.65

Service Code	APR-DRG 1762
Min. Negotiated Rate	$10,169.65
Max. Negotiated Rate	$10,169.65
Rate for Payer: AlohaCare Medicaid	$10,169.65
Rate for Payer: Hawaii Medical Service Association ABD	$10,169.65
Rate for Payer: Hawaii Medical Service Association Non-ABD	$10,169.65
Rate for Payer: Kaiser Permanente Medicaid	$10,169.65
Rate for Payer: Ohana Health Plan Medicaid	$10,169.65
Rate for Payer: UnitedHealthcare Medicaid	$10,169.65

INSERTION, REVISION & REPLACEMENTS OF PACEMAKER & OTHER CARDIAC DEVICES

Facility

$26,170.66

Service Code	APR-DRG 1764
Min. Negotiated Rate	$26,170.66
Max. Negotiated Rate	$26,170.66
Rate for Payer: AlohaCare Medicaid	$26,170.66
Rate for Payer: Hawaii Medical Service Association ABD	$26,170.66
Rate for Payer: Hawaii Medical Service Association Non-ABD	$26,170.66
Rate for Payer: Kaiser Permanente Medicaid	$26,170.66
Rate for Payer: Ohana Health Plan Medicaid	$26,170.66
Rate for Payer: UnitedHealthcare Medicaid	$26,170.66

INSERTION, REVISION & REPLACEMENTS OF PACEMAKER & OTHER CARDIAC DEVICES

Facility

$15,427.66

Service Code	APR-DRG 1763
Min. Negotiated Rate	$15,427.66
Max. Negotiated Rate	$15,427.66
Rate for Payer: AlohaCare Medicaid	$15,427.66
Rate for Payer: Hawaii Medical Service Association ABD	$15,427.66
Rate for Payer: Hawaii Medical Service Association Non-ABD	$15,427.66
Rate for Payer: Kaiser Permanente Medicaid	$15,427.66
Rate for Payer: Ohana Health Plan Medicaid	$15,427.66
Rate for Payer: UnitedHealthcare Medicaid	$15,427.66

INSERT JOURNEY II BSC XLPE

Facility

$4,038.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$2,059.38
Max. Negotiated Rate	$3,916.86
Rate for Payer: Cash Price	$2,422.80
Rate for Payer: Hawaii Western Management Group Commercial	$2,826.60
Rate for Payer: Health Management Network Commercial	$3,432.30
Rate for Payer: Kaiser Permanente Commercial	$2,543.94
Rate for Payer: Kaiser Permanente Medicaid	$2,059.38
Rate for Payer: MDX Hawaii PPO	$3,916.86
Rate for Payer: University Health Alliance Commercial	$2,261.28

INSERT JOURNEY II BSC XLPE

Facility

$4,038.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$2,261.28
Max. Negotiated Rate	$3,916.86
Rate for Payer: Cash Price	$2,422.80
Rate for Payer: Hawaii Western Management Group Commercial	$2,826.60
Rate for Payer: Health Management Network Commercial	$3,432.30
Rate for Payer: MDX Hawaii PPO	$3,916.86
Rate for Payer: University Health Alliance Commercial	$2,261.28

INSERT MDM X3 1236-2-244

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 MDM X3 1236-2-244

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 POLYEHTYLENE 723-00-36E

Facility

$2,703.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$1,378.53
Max. Negotiated Rate	$2,621.91
Rate for Payer: Cash Price	$1,621.80
Rate for Payer: Hawaii Western Management Group Commercial	$1,892.10
Rate for Payer: Health Management Network Commercial	$2,297.55
Rate for Payer: Kaiser Permanente Commercial	$1,702.89
Rate for Payer: Kaiser Permanente Medicaid	$1,378.53
Rate for Payer: MDX Hawaii PPO	$2,621.91
Rate for Payer: University Health Alliance Commercial	$1,513.68

INSERT POLYEHTYLENE 723-00-36E

Facility

$2,703.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$1,513.68
Max. Negotiated Rate	$2,621.91
Rate for Payer: Cash Price	$1,621.80
Rate for Payer: Hawaii Western Management Group Commercial	$1,892.10
Rate for Payer: Health Management Network Commercial	$2,297.55
Rate for Payer: MDX Hawaii PPO	$2,621.91
Rate for Payer: University Health Alliance Commercial	$1,513.68

INSERT POLYETHYLENE 723-00-36F

Facility

$2,703.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$1,378.53
Max. Negotiated Rate	$2,621.91
Rate for Payer: Cash Price	$1,621.80
Rate for Payer: Hawaii Western Management Group Commercial	$1,892.10
Rate for Payer: Health Management Network Commercial	$2,297.55
Rate for Payer: Kaiser Permanente Commercial	$1,702.89
Rate for Payer: Kaiser Permanente Medicaid	$1,378.53
Rate for Payer: MDX Hawaii PPO	$2,621.91
Rate for Payer: University Health Alliance Commercial	$1,513.68

INSERT POLYETHYLENE 723-00-36F

Facility

$2,703.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$1,513.68
Max. Negotiated Rate	$2,621.91
Rate for Payer: Cash Price	$1,621.80
Rate for Payer: Hawaii Western Management Group Commercial	$1,892.10
Rate for Payer: Health Management Network Commercial	$2,297.55
Rate for Payer: MDX Hawaii PPO	$2,621.91
Rate for Payer: University Health Alliance Commercial	$1,513.68

INSERT RETENTIVE REV DWF364B

Facility

$5,976.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$3,346.56
Max. Negotiated Rate	$5,796.72
Rate for Payer: Cash Price	$3,585.60
Rate for Payer: Hawaii Western Management Group Commercial	$4,183.20
Rate for Payer: Health Management Network Commercial	$5,079.60
Rate for Payer: MDX Hawaii PPO	$5,796.72
Rate for Payer: University Health Alliance Commercial	$3,346.56

INSERT RETENTIVE REV DWF364B

Facility

$5,976.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$3,047.76
Max. Negotiated Rate	$5,796.72
Rate for Payer: Cash Price	$3,585.60
Rate for Payer: Hawaii Western Management Group Commercial	$4,183.20
Rate for Payer: Health Management Network Commercial	$5,079.60
Rate for Payer: Kaiser Permanente Commercial	$3,764.88
Rate for Payer: Kaiser Permanente Medicaid	$3,047.76
Rate for Payer: MDX Hawaii PPO	$5,796.72
Rate for Payer: University Health Alliance Commercial	$3,346.56

INSERT REVERSED +3MM

Facility

$2,768.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$1,550.08
Max. Negotiated Rate	$2,684.96
Rate for Payer: Cash Price	$1,660.80
Rate for Payer: Hawaii Western Management Group Commercial	$1,937.60
Rate for Payer: Health Management Network Commercial	$2,352.80
Rate for Payer: MDX Hawaii PPO	$2,684.96
Rate for Payer: University Health Alliance Commercial	$1,550.08

INSERT REVERSED +3MM

Facility

$2,768.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$1,411.68
Max. Negotiated Rate	$2,684.96
Rate for Payer: Cash Price	$1,660.80
Rate for Payer: Hawaii Western Management Group Commercial	$1,937.60
Rate for Payer: Health Management Network Commercial	$2,352.80
Rate for Payer: Kaiser Permanente Commercial	$1,743.84
Rate for Payer: Kaiser Permanente Medicaid	$1,411.68
Rate for Payer: MDX Hawaii PPO	$2,684.96
Rate for Payer: University Health Alliance Commercial	$1,550.08

INSERT REVERSED THICKNESS +9MM

Facility

$3,530.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$1,800.30
Max. Negotiated Rate	$3,424.10
Rate for Payer: Cash Price	$2,118.00
Rate for Payer: Hawaii Western Management Group Commercial	$2,471.00
Rate for Payer: Health Management Network Commercial	$3,000.50
Rate for Payer: Kaiser Permanente Commercial	$2,223.90
Rate for Payer: Kaiser Permanente Medicaid	$1,800.30
Rate for Payer: MDX Hawaii PPO	$3,424.10
Rate for Payer: University Health Alliance Commercial	$1,976.80

INSERT REVERSED THICKNESS +9MM

Facility

$3,530.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$1,976.80
Max. Negotiated Rate	$3,424.10
Rate for Payer: Cash Price	$2,118.00
Rate for Payer: Hawaii Western Management Group Commercial	$2,471.00
Rate for Payer: Health Management Network Commercial	$3,000.50
Rate for Payer: MDX Hawaii PPO	$3,424.10
Rate for Payer: University Health Alliance Commercial	$1,976.80

INSERT REVERSE THCK +6 DWF391B

Facility

$2,768.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$1,550.08
Max. Negotiated Rate	$2,684.96
Rate for Payer: Cash Price	$1,660.80
Rate for Payer: Hawaii Western Management Group Commercial	$1,937.60
Rate for Payer: Health Management Network Commercial	$2,352.80
Rate for Payer: MDX Hawaii PPO	$2,684.96
Rate for Payer: University Health Alliance Commercial	$1,550.08

Know your out-of-pocket cost for care.

All Charges