Hilo Benioff Medical Center

All Charges

Charge

Type

Setting

Price

KNEE IMMOBILIZER, TROM COOL

Facility

$356.00

Service Code	HCPCS L1830
Hospital Revenue Code	274
Min. Negotiated Rate	$87.51
Max. Negotiated Rate	$345.32
Rate for Payer: Cash Price	$213.60
Rate for Payer: Cash Price	$213.60
Rate for Payer: Hawaii Western Management Group Commercial	$249.20
Rate for Payer: Health Management Network Commercial	$302.60
Rate for Payer: Kaiser Permanente Commercial	$224.28
Rate for Payer: Kaiser Permanente Medicaid	$181.56
Rate for Payer: MDX Hawaii PPO	$345.32
Rate for Payer: UnitedHealthcare Medicaid	$87.51
Rate for Payer: University Health Alliance Commercial	$199.36

KNEE JOINT REPLACEMENT

Facility

$9,210.80

Service Code	APR-DRG 3022
Min. Negotiated Rate	$9,210.80
Max. Negotiated Rate	$9,210.80
Rate for Payer: AlohaCare Medicaid	$9,210.80
Rate for Payer: Hawaii Medical Service Association ABD	$9,210.80
Rate for Payer: Hawaii Medical Service Association Non-ABD	$9,210.80
Rate for Payer: Kaiser Permanente Medicaid	$9,210.80
Rate for Payer: Ohana Health Plan Medicaid	$9,210.80
Rate for Payer: UnitedHealthcare Medicaid	$9,210.80

KNEE JOINT REPLACEMENT

Facility

$12,183.23

Service Code	APR-DRG 3023
Min. Negotiated Rate	$12,183.23
Max. Negotiated Rate	$12,183.23
Rate for Payer: AlohaCare Medicaid	$12,183.23
Rate for Payer: Hawaii Medical Service Association ABD	$12,183.23
Rate for Payer: Hawaii Medical Service Association Non-ABD	$12,183.23
Rate for Payer: Kaiser Permanente Medicaid	$12,183.23
Rate for Payer: Ohana Health Plan Medicaid	$12,183.23
Rate for Payer: UnitedHealthcare Medicaid	$12,183.23

KNEE JOINT REPLACEMENT

Facility

$8,538.31

Service Code	APR-DRG 3021
Min. Negotiated Rate	$8,538.31
Max. Negotiated Rate	$8,538.31
Rate for Payer: AlohaCare Medicaid	$8,538.31
Rate for Payer: Hawaii Medical Service Association ABD	$8,538.31
Rate for Payer: Hawaii Medical Service Association Non-ABD	$8,538.31
Rate for Payer: Kaiser Permanente Medicaid	$8,538.31
Rate for Payer: Ohana Health Plan Medicaid	$8,538.31
Rate for Payer: UnitedHealthcare Medicaid	$8,538.31

KNEE JOINT REPLACEMENT

Facility

$18,056.33

Service Code	APR-DRG 3024
Min. Negotiated Rate	$18,056.33
Max. Negotiated Rate	$18,056.33
Rate for Payer: AlohaCare Medicaid	$18,056.33
Rate for Payer: Hawaii Medical Service Association ABD	$18,056.33
Rate for Payer: Hawaii Medical Service Association Non-ABD	$18,056.33
Rate for Payer: Kaiser Permanente Medicaid	$18,056.33
Rate for Payer: Ohana Health Plan Medicaid	$18,056.33
Rate for Payer: UnitedHealthcare Medicaid	$18,056.33

KNEE LEFT SZ6 42-5580-006-01

Facility

$4,410.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$2,249.10
Max. Negotiated Rate	$4,277.70
Rate for Payer: Cash Price	$2,646.00
Rate for Payer: Hawaii Western Management Group Commercial	$3,087.00
Rate for Payer: Health Management Network Commercial	$3,748.50
Rate for Payer: Kaiser Permanente Commercial	$2,778.30
Rate for Payer: Kaiser Permanente Medicaid	$2,249.10
Rate for Payer: MDX Hawaii PPO	$4,277.70
Rate for Payer: University Health Alliance Commercial	$2,469.60

KNEE LEFT SZ6 42-5580-006-01

Facility

$4,410.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$2,469.60
Max. Negotiated Rate	$4,277.70
Rate for Payer: Cash Price	$2,646.00
Rate for Payer: Hawaii Western Management Group Commercial	$3,087.00
Rate for Payer: Health Management Network Commercial	$3,748.50
Rate for Payer: MDX Hawaii PPO	$4,277.70
Rate for Payer: University Health Alliance Commercial	$2,469.60

KNEE LEFT SZH 42-5380-008-01

Facility

$2,940.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$1,646.40
Max. Negotiated Rate	$2,851.80
Rate for Payer: Cash Price	$1,764.00
Rate for Payer: Hawaii Western Management Group Commercial	$2,058.00
Rate for Payer: Health Management Network Commercial	$2,499.00
Rate for Payer: MDX Hawaii PPO	$2,851.80
Rate for Payer: University Health Alliance Commercial	$1,646.40

KNEE LEFT SZH 42-5380-008-01

Facility

$2,940.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$1,499.40
Max. Negotiated Rate	$2,851.80
Rate for Payer: Cash Price	$1,764.00
Rate for Payer: Hawaii Western Management Group Commercial	$2,058.00
Rate for Payer: Health Management Network Commercial	$2,499.00
Rate for Payer: Kaiser Permanente Commercial	$1,852.20
Rate for Payer: Kaiser Permanente Medicaid	$1,499.40
Rate for Payer: MDX Hawaii PPO	$2,851.80
Rate for Payer: University Health Alliance Commercial	$1,646.40

KNEE & LOWER LEG PROCEDURES EXCEPT FOOT

Facility

$11,847.96

Service Code	APR-DRG 3133
Min. Negotiated Rate	$11,847.96
Max. Negotiated Rate	$11,847.96
Rate for Payer: AlohaCare Medicaid	$11,847.96
Rate for Payer: Hawaii Medical Service Association ABD	$11,847.96
Rate for Payer: Hawaii Medical Service Association Non-ABD	$11,847.96
Rate for Payer: Kaiser Permanente Medicaid	$11,847.96
Rate for Payer: Ohana Health Plan Medicaid	$11,847.96
Rate for Payer: UnitedHealthcare Medicaid	$11,847.96

KNEE & LOWER LEG PROCEDURES EXCEPT FOOT

Facility

$19,296.31

Service Code	APR-DRG 3134
Min. Negotiated Rate	$19,296.31
Max. Negotiated Rate	$19,296.31
Rate for Payer: AlohaCare Medicaid	$19,296.31
Rate for Payer: Hawaii Medical Service Association ABD	$19,296.31
Rate for Payer: Hawaii Medical Service Association Non-ABD	$19,296.31
Rate for Payer: Kaiser Permanente Medicaid	$19,296.31
Rate for Payer: Ohana Health Plan Medicaid	$19,296.31
Rate for Payer: UnitedHealthcare Medicaid	$19,296.31

KNEE & LOWER LEG PROCEDURES EXCEPT FOOT

Facility

$8,535.04

Service Code	APR-DRG 3132
Min. Negotiated Rate	$8,535.04
Max. Negotiated Rate	$8,535.04
Rate for Payer: AlohaCare Medicaid	$8,535.04
Rate for Payer: Hawaii Medical Service Association ABD	$8,535.04
Rate for Payer: Hawaii Medical Service Association Non-ABD	$8,535.04
Rate for Payer: Kaiser Permanente Medicaid	$8,535.04
Rate for Payer: Ohana Health Plan Medicaid	$8,535.04
Rate for Payer: UnitedHealthcare Medicaid	$8,535.04

KNEE & LOWER LEG PROCEDURES EXCEPT FOOT

Facility

$6,589.95

Service Code	APR-DRG 3131
Min. Negotiated Rate	$6,589.95
Max. Negotiated Rate	$6,589.95
Rate for Payer: AlohaCare Medicaid	$6,589.95
Rate for Payer: Hawaii Medical Service Association ABD	$6,589.95
Rate for Payer: Hawaii Medical Service Association Non-ABD	$6,589.95
Rate for Payer: Kaiser Permanente Medicaid	$6,589.95
Rate for Payer: Ohana Health Plan Medicaid	$6,589.95
Rate for Payer: UnitedHealthcare Medicaid	$6,589.95

KNEE PROCEDURES WITHOUT PRINCIPAL DIAGNOSIS OF INFECTION WITH CC/MCC

Facility

$26,282.10

Service Code	MSDRG 488
Min. Negotiated Rate	$20,119.92
Max. Negotiated Rate	$26,282.10
Rate for Payer: AlohaCare Medicare	$20,119.92
Rate for Payer: Devoted Health Medicare	$22,131.91
Rate for Payer: Hawaii Medical Service Association Commercial	$25,527.83
Rate for Payer: Hawaii Medical Service Association Medicare	$20,119.92
Rate for Payer: Humana Medicare	$20,119.92
Rate for Payer: Kaiser Permanente Commercial	$26,282.10
Rate for Payer: Kaiser Permanente Medicare	$20,119.92
Rate for Payer: Ohana Health Plan Medicare	$20,119.92
Rate for Payer: UnitedHealthcare Medicare	$20,119.92

KNEE PROCEDURES WITHOUT PRINCIPAL DIAGNOSIS OF INFECTION WITHOUT CC/MCC

Facility

$25,527.83

Service Code	MSDRG 489
Min. Negotiated Rate	$12,702.77
Max. Negotiated Rate	$25,527.83
Rate for Payer: AlohaCare Medicare	$12,702.77
Rate for Payer: Devoted Health Medicare	$13,973.05
Rate for Payer: Hawaii Medical Service Association Commercial	$25,527.83
Rate for Payer: Hawaii Medical Service Association Medicare	$12,702.77
Rate for Payer: Humana Medicare	$12,702.77
Rate for Payer: Kaiser Permanente Commercial	$19,264.80
Rate for Payer: Kaiser Permanente Medicare	$12,702.77
Rate for Payer: Ohana Health Plan Medicare	$12,702.77
Rate for Payer: UnitedHealthcare Medicare	$12,702.77

KNEE PROCEDURES WITH PRINCIPAL DIAGNOSIS OF INFECTION WITH CC

Facility

$45,207.56

Service Code	MSDRG 486
Min. Negotiated Rate	$23,784.71
Max. Negotiated Rate	$45,207.56
Rate for Payer: AlohaCare Medicare	$23,784.71
Rate for Payer: Devoted Health Medicare	$26,163.18
Rate for Payer: Hawaii Medical Service Association Commercial	$45,207.56
Rate for Payer: Hawaii Medical Service Association Medicare	$23,784.71
Rate for Payer: Humana Medicare	$23,784.71
Rate for Payer: Kaiser Permanente Commercial	$36,071.47
Rate for Payer: Kaiser Permanente Medicare	$23,784.71
Rate for Payer: Ohana Health Plan Medicare	$23,784.71
Rate for Payer: UnitedHealthcare Medicare	$23,784.71

KNEE PROCEDURES WITH PRINCIPAL DIAGNOSIS OF INFECTION WITH MCC

Facility

$55,667.47

Service Code	MSDRG 485
Min. Negotiated Rate	$36,705.86
Max. Negotiated Rate	$55,667.47
Rate for Payer: AlohaCare Medicare	$36,705.86
Rate for Payer: Devoted Health Medicare	$40,376.45
Rate for Payer: Hawaii Medical Service Association Commercial	$45,207.56
Rate for Payer: Hawaii Medical Service Association Medicare	$36,705.86
Rate for Payer: Humana Medicare	$36,705.86
Rate for Payer: Kaiser Permanente Commercial	$55,667.47
Rate for Payer: Kaiser Permanente Medicare	$36,705.86
Rate for Payer: Ohana Health Plan Medicare	$36,705.86
Rate for Payer: UnitedHealthcare Medicare	$36,705.86

KNEE PROCEDURES WITH PRINCIPAL DIAGNOSIS OF INFECTION WITHOUT CC/MCC

Facility

$32,298.05

Service Code	MSDRG 487
Min. Negotiated Rate	$17,814.37
Max. Negotiated Rate	$32,298.05
Rate for Payer: AlohaCare Medicare	$17,814.37
Rate for Payer: Devoted Health Medicare	$19,595.81
Rate for Payer: Hawaii Medical Service Association Commercial	$32,298.05
Rate for Payer: Hawaii Medical Service Association Medicare	$17,814.37
Rate for Payer: Humana Medicare	$17,814.37
Rate for Payer: Kaiser Permanente Commercial	$27,016.95
Rate for Payer: Kaiser Permanente Medicare	$17,814.37
Rate for Payer: Ohana Health Plan Medicare	$17,814.37
Rate for Payer: UnitedHealthcare Medicare	$17,814.37

KNEE SYS SZ/3 L 42-5182-005-08

Facility

$2,661.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$1,357.11
Max. Negotiated Rate	$2,581.17
Rate for Payer: Cash Price	$1,596.60
Rate for Payer: Hawaii Western Management Group Commercial	$1,862.70
Rate for Payer: Health Management Network Commercial	$2,261.85
Rate for Payer: Kaiser Permanente Commercial	$1,676.43
Rate for Payer: Kaiser Permanente Medicaid	$1,357.11
Rate for Payer: MDX Hawaii PPO	$2,581.17
Rate for Payer: University Health Alliance Commercial	$1,490.16

KNEE SYS SZ/3 L 42-5182-005-08

Facility

$2,661.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$1,490.16
Max. Negotiated Rate	$2,581.17
Rate for Payer: Cash Price	$1,596.60
Rate for Payer: Hawaii Western Management Group Commercial	$1,862.70
Rate for Payer: Health Management Network Commercial	$2,261.85
Rate for Payer: MDX Hawaii PPO	$2,581.17
Rate for Payer: University Health Alliance Commercial	$1,490.16

KNEE SYS SZ/E L 42-5380-005-01

Facility

$3,350.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$1,708.50
Max. Negotiated Rate	$3,249.50
Rate for Payer: Cash Price	$2,010.00
Rate for Payer: Hawaii Western Management Group Commercial	$2,345.00
Rate for Payer: Health Management Network Commercial	$2,847.50
Rate for Payer: Kaiser Permanente Commercial	$2,110.50
Rate for Payer: Kaiser Permanente Medicaid	$1,708.50
Rate for Payer: MDX Hawaii PPO	$3,249.50
Rate for Payer: University Health Alliance Commercial	$1,876.00

KNEE SYS SZ/E L 42-5380-005-01

Facility

$3,350.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$1,876.00
Max. Negotiated Rate	$3,249.50
Rate for Payer: Cash Price	$2,010.00
Rate for Payer: Hawaii Western Management Group Commercial	$2,345.00
Rate for Payer: Health Management Network Commercial	$2,847.50
Rate for Payer: MDX Hawaii PPO	$3,249.50
Rate for Payer: University Health Alliance Commercial	$1,876.00

KNEE SYSTEM PARTIAL RT 159532

Facility

$3,300.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$1,848.00
Max. Negotiated Rate	$3,201.00
Rate for Payer: Cash Price	$1,980.00
Rate for Payer: Hawaii Western Management Group Commercial	$2,310.00
Rate for Payer: Health Management Network Commercial	$2,805.00
Rate for Payer: MDX Hawaii PPO	$3,201.00
Rate for Payer: University Health Alliance Commercial	$1,848.00

KNEE SYSTEM PARTIAL RT 159532

Facility

$3,300.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$1,683.00
Max. Negotiated Rate	$3,201.00
Rate for Payer: Cash Price	$1,980.00
Rate for Payer: Hawaii Western Management Group Commercial	$2,310.00
Rate for Payer: Health Management Network Commercial	$2,805.00
Rate for Payer: Kaiser Permanente Commercial	$2,079.00
Rate for Payer: Kaiser Permanente Medicaid	$1,683.00
Rate for Payer: MDX Hawaii PPO	$3,201.00
Rate for Payer: University Health Alliance Commercial	$1,848.00

KNEE SZH 9MM 42-5182-008-09

Facility

$2,520.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$1,411.20
Max. Negotiated Rate	$2,444.40
Rate for Payer: Cash Price	$1,512.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,764.00
Rate for Payer: Health Management Network Commercial	$2,142.00
Rate for Payer: MDX Hawaii PPO	$2,444.40
Rate for Payer: University Health Alliance Commercial	$1,411.20

Know your out-of-pocket cost for care.

All Charges