Hilo Benioff Medical Center

All Charges

Charge

Type

Setting

Price

MASTECTOMY FOR MALIGNANCY WITHOUT CC/MCC

Facility

$29,745.90

Service Code	MSDRG 583
Min. Negotiated Rate	$19,613.77
Max. Negotiated Rate	$29,745.90
Rate for Payer: AlohaCare Medicare	$19,613.77
Rate for Payer: Devoted Health Medicare	$21,575.15
Rate for Payer: Hawaii Medical Service Association Commercial	$23,392.42
Rate for Payer: Hawaii Medical Service Association Medicare	$19,613.77
Rate for Payer: Humana Medicare	$19,613.77
Rate for Payer: Kaiser Permanente Commercial	$29,745.90
Rate for Payer: Kaiser Permanente Medicare	$19,613.77
Rate for Payer: Ohana Health Plan Medicare	$19,613.77
Rate for Payer: UnitedHealthcare Medicare	$19,613.77

MASTECTOMY, MODIFIED RADICAL, INCLUDING AXILLARY LYMPH NODES, WITH OR WITHOUT PECTORALIS MINOR MUSCLE, BUT EXCLUDING PECTORALIS MAJOR MUSCLE

Facility

$24,500.00

Service Code	CPT 19307
Hospital Revenue Code	360
Min. Negotiated Rate	$521.33
Max. Negotiated Rate	$24,500.00
Rate for Payer: AlohaCare Medicaid	$7,844.33
Rate for Payer: AlohaCare Medicare	$7,844.33
Rate for Payer: Devoted Health Medicare	$8,628.76
Rate for Payer: Hawaii Medical Service Association ABD	$1,900.00
Rate for Payer: Hawaii Medical Service Association Commercial	$14,395.00
Rate for Payer: Hawaii Medical Service Association Medicare	$7,844.33
Rate for Payer: Hawaii Medical Service Association Non-ABD	$2,695.11
Rate for Payer: Humana Medicare	$7,844.33
Rate for Payer: Kaiser Permanente Medicaid	$2,837.00
Rate for Payer: Kaiser Permanente Medicare	$7,844.33
Rate for Payer: Ohana Health Plan Medicaid	$8,628.76
Rate for Payer: Ohana Health Plan Medicare	$7,844.33
Rate for Payer: UnitedHealthcare Medicaid	$521.33
Rate for Payer: UnitedHealthcare Medicare	$7,844.33
Rate for Payer: University Health Alliance Commercial	$24,500.00

MASTECTOMY, PARTIAL (EG, LUMPECTOMY, TYLECTOMY, QUADRANTECTOMY, SEGMENTECTOMY);

Facility

$8,270.00

Service Code	CPT 19301
Hospital Revenue Code	360
Min. Negotiated Rate	$456.03
Max. Negotiated Rate	$8,270.00
Rate for Payer: AlohaCare Medicaid	$4,625.48
Rate for Payer: AlohaCare Medicare	$4,625.48
Rate for Payer: Devoted Health Medicare	$5,088.03
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	$4,625.48
Rate for Payer: Hawaii Medical Service Association Non-ABD	$1,427.62
Rate for Payer: Humana Medicare	$4,625.48
Rate for Payer: Kaiser Permanente Medicaid	$2,837.00
Rate for Payer: Kaiser Permanente Medicare	$4,625.48
Rate for Payer: Ohana Health Plan Medicaid	$5,088.03
Rate for Payer: Ohana Health Plan Medicare	$4,625.48
Rate for Payer: UnitedHealthcare Medicaid	$456.03
Rate for Payer: UnitedHealthcare Medicare	$4,625.48
Rate for Payer: University Health Alliance Commercial	$6,743.44

MASTECTOMY PROCEDURES

Facility

$7,972.78

Service Code	APR-DRG 3622
Min. Negotiated Rate	$7,972.78
Max. Negotiated Rate	$7,972.78
Rate for Payer: AlohaCare Medicaid	$7,972.78
Rate for Payer: Hawaii Medical Service Association ABD	$7,972.78
Rate for Payer: Hawaii Medical Service Association Non-ABD	$7,972.78
Rate for Payer: Kaiser Permanente Medicaid	$7,972.78
Rate for Payer: Ohana Health Plan Medicaid	$7,972.78
Rate for Payer: UnitedHealthcare Medicaid	$7,972.78

MASTECTOMY PROCEDURES

Facility

$5,981.38

Service Code	APR-DRG 3621
Min. Negotiated Rate	$5,981.38
Max. Negotiated Rate	$5,981.38
Rate for Payer: AlohaCare Medicaid	$5,981.38
Rate for Payer: Hawaii Medical Service Association ABD	$5,981.38
Rate for Payer: Hawaii Medical Service Association Non-ABD	$5,981.38
Rate for Payer: Kaiser Permanente Medicaid	$5,981.38
Rate for Payer: Ohana Health Plan Medicaid	$5,981.38
Rate for Payer: UnitedHealthcare Medicaid	$5,981.38

MASTECTOMY PROCEDURES

Facility

$9,428.66

Service Code	APR-DRG 3623
Min. Negotiated Rate	$9,428.66
Max. Negotiated Rate	$9,428.66
Rate for Payer: AlohaCare Medicaid	$9,428.66
Rate for Payer: Hawaii Medical Service Association ABD	$9,428.66
Rate for Payer: Hawaii Medical Service Association Non-ABD	$9,428.66
Rate for Payer: Kaiser Permanente Medicaid	$9,428.66
Rate for Payer: Ohana Health Plan Medicaid	$9,428.66
Rate for Payer: UnitedHealthcare Medicaid	$9,428.66

MASTECTOMY PROCEDURES

Facility

$18,139.82

Service Code	APR-DRG 3624
Min. Negotiated Rate	$18,139.82
Max. Negotiated Rate	$18,139.82
Rate for Payer: AlohaCare Medicaid	$18,139.82
Rate for Payer: Hawaii Medical Service Association ABD	$18,139.82
Rate for Payer: Hawaii Medical Service Association Non-ABD	$18,139.82
Rate for Payer: Kaiser Permanente Medicaid	$18,139.82
Rate for Payer: Ohana Health Plan Medicaid	$18,139.82
Rate for Payer: UnitedHealthcare Medicaid	$18,139.82

MASTECTOMY, SIMPLE, COMPLETE

Facility

$13,778.00

Service Code	CPT 19303
Hospital Revenue Code	360
Min. Negotiated Rate	$456.03
Max. Negotiated Rate	$13,778.00
Rate for Payer: AlohaCare Medicaid	$7,844.33
Rate for Payer: AlohaCare Medicare	$7,844.33
Rate for Payer: Devoted Health Medicare	$8,628.76
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	$7,844.33
Rate for Payer: Hawaii Medical Service Association Non-ABD	$2,294.85
Rate for Payer: Humana Medicare	$7,844.33
Rate for Payer: Kaiser Permanente Medicaid	$2,837.00
Rate for Payer: Kaiser Permanente Medicare	$7,844.33
Rate for Payer: Ohana Health Plan Medicaid	$8,628.76
Rate for Payer: Ohana Health Plan Medicare	$7,844.33
Rate for Payer: UnitedHealthcare Medicaid	$456.03
Rate for Payer: UnitedHealthcare Medicare	$7,844.33
Rate for Payer: University Health Alliance Commercial	$10,679.55

MASTOIDECTOMY; COMPLETE

Facility

$16,700.00

Service Code	CPT 69502
Hospital Revenue Code	360
Min. Negotiated Rate	$456.03
Max. Negotiated Rate	$16,700.00
Rate for Payer: AlohaCare Medicaid	$6,993.36
Rate for Payer: AlohaCare Medicare	$6,993.36
Rate for Payer: Devoted Health Medicare	$7,692.70
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	$6,993.36
Rate for Payer: Hawaii Medical Service Association Non-ABD	$1,427.62
Rate for Payer: Humana Medicare	$6,993.36
Rate for Payer: Kaiser Permanente Medicaid	$2,837.00
Rate for Payer: Kaiser Permanente Medicare	$6,993.36
Rate for Payer: Ohana Health Plan Medicaid	$7,692.70
Rate for Payer: Ohana Health Plan Medicare	$6,993.36
Rate for Payer: UnitedHealthcare Medicaid	$456.03
Rate for Payer: UnitedHealthcare Medicare	$6,993.36
Rate for Payer: University Health Alliance Commercial	$16,700.00

MASTOPEXY

Facility

$10,679.55

Service Code	CPT 19316
Hospital Revenue Code	360
Min. Negotiated Rate	$456.03
Max. Negotiated Rate	$10,679.55
Rate for Payer: AlohaCare Medicaid	$7,844.33
Rate for Payer: AlohaCare Medicare	$7,844.33
Rate for Payer: Devoted Health Medicare	$8,628.76
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	$7,844.33
Rate for Payer: Hawaii Medical Service Association Non-ABD	$1,028.67
Rate for Payer: Humana Medicare	$7,844.33
Rate for Payer: Kaiser Permanente Medicaid	$2,837.00
Rate for Payer: Kaiser Permanente Medicare	$7,844.33
Rate for Payer: Ohana Health Plan Medicaid	$8,628.76
Rate for Payer: Ohana Health Plan Medicare	$7,844.33
Rate for Payer: UnitedHealthcare Medicaid	$456.03
Rate for Payer: UnitedHealthcare Medicare	$7,844.33
Rate for Payer: University Health Alliance Commercial	$10,679.55

MATCHSTICK 3.0MM 5220-107-530

Facility

$434.00

Hospital Revenue Code	272
Min. Negotiated Rate	$221.34
Max. Negotiated Rate	$420.98
Rate for Payer: Cash Price	$260.40
Rate for Payer: Hawaii Western Management Group Commercial	$412.30
Rate for Payer: Health Management Network Commercial	$368.90
Rate for Payer: Kaiser Permanente Commercial	$273.42
Rate for Payer: Kaiser Permanente Medicaid	$221.34
Rate for Payer: MDX Hawaii PPO	$420.98
Rate for Payer: University Health Alliance Commercial	$316.34

MATCHSTICK 3.0MM 5220-107-530

Facility

$434.00

Hospital Revenue Code	272
Min. Negotiated Rate	$368.90
Max. Negotiated Rate	$420.98
Rate for Payer: Cash Price	$260.40
Rate for Payer: Health Management Network Commercial	$368.90
Rate for Payer: MDX Hawaii PPO	$420.98

MATRIXMAND 1.5 DB 03.503.408

Facility

$1,131.00

Hospital Revenue Code	272
Min. Negotiated Rate	$961.35
Max. Negotiated Rate	$1,097.07
Rate for Payer: Cash Price	$678.60
Rate for Payer: Health Management Network Commercial	$961.35
Rate for Payer: MDX Hawaii PPO	$1,097.07

MATRIXMAND 1.5 DB 03.503.408

Facility

$1,131.00

Hospital Revenue Code	272
Min. Negotiated Rate	$576.81
Max. Negotiated Rate	$1,097.07
Rate for Payer: Cash Price	$678.60
Rate for Payer: Hawaii Western Management Group Commercial	$1,074.45
Rate for Payer: Health Management Network Commercial	$961.35
Rate for Payer: Kaiser Permanente Commercial	$712.53
Rate for Payer: Kaiser Permanente Medicaid	$576.81
Rate for Payer: MDX Hawaii PPO	$1,097.07
Rate for Payer: University Health Alliance Commercial	$824.39

MATRIXMIDFACE 4M 04.503.204.01

Facility

$806.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$451.36
Max. Negotiated Rate	$781.82
Rate for Payer: Cash Price	$483.60
Rate for Payer: Hawaii Western Management Group Commercial	$564.20
Rate for Payer: Health Management Network Commercial	$685.10
Rate for Payer: MDX Hawaii PPO	$781.82
Rate for Payer: University Health Alliance Commercial	$451.36

MATRIXMIDFACE 4M 04.503.204.01

Facility

$806.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$411.06
Max. Negotiated Rate	$781.82
Rate for Payer: Cash Price	$483.60
Rate for Payer: Hawaii Western Management Group Commercial	$564.20
Rate for Payer: Health Management Network Commercial	$685.10
Rate for Payer: Kaiser Permanente Commercial	$507.78
Rate for Payer: Kaiser Permanente Medicaid	$411.06
Rate for Payer: MDX Hawaii PPO	$781.82
Rate for Payer: University Health Alliance Commercial	$451.36

MATRIXMIDFACE OBL 04.503.355

Facility

$2,148.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,095.48
Max. Negotiated Rate	$2,083.56
Rate for Payer: Cash Price	$1,288.80
Rate for Payer: Hawaii Western Management Group Commercial	$1,503.60
Rate for Payer: Health Management Network Commercial	$1,825.80
Rate for Payer: Kaiser Permanente Commercial	$1,353.24
Rate for Payer: Kaiser Permanente Medicaid	$1,095.48
Rate for Payer: MDX Hawaii PPO	$2,083.56
Rate for Payer: University Health Alliance Commercial	$1,202.88

MATRIXMIDFACE OBL 04.503.355

Facility

$2,148.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,202.88
Max. Negotiated Rate	$2,083.56
Rate for Payer: Cash Price	$1,288.80
Rate for Payer: Hawaii Western Management Group Commercial	$1,503.60
Rate for Payer: Health Management Network Commercial	$1,825.80
Rate for Payer: MDX Hawaii PPO	$2,083.56
Rate for Payer: University Health Alliance Commercial	$1,202.88

MATRIXMIDFACE OBL LT 3X4 HOLES

Facility

$2,301.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,288.56
Max. Negotiated Rate	$2,231.97
Rate for Payer: Cash Price	$1,380.60
Rate for Payer: Hawaii Western Management Group Commercial	$1,610.70
Rate for Payer: Health Management Network Commercial	$1,955.85
Rate for Payer: MDX Hawaii PPO	$2,231.97
Rate for Payer: University Health Alliance Commercial	$1,288.56

MATRIXMIDFACE OBL LT 3X4 HOLES

Facility

$2,301.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,173.51
Max. Negotiated Rate	$2,231.97
Rate for Payer: Cash Price	$1,380.60
Rate for Payer: Hawaii Western Management Group Commercial	$1,610.70
Rate for Payer: Health Management Network Commercial	$1,955.85
Rate for Payer: Kaiser Permanente Commercial	$1,449.63
Rate for Payer: Kaiser Permanente Medicaid	$1,173.51
Rate for Payer: MDX Hawaii PPO	$2,231.97
Rate for Payer: University Health Alliance Commercial	$1,288.56

MATRIXMIDFACE RIM 04.503.373

Facility

$2,556.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,303.56
Max. Negotiated Rate	$2,479.32
Rate for Payer: Cash Price	$1,533.60
Rate for Payer: Hawaii Western Management Group Commercial	$1,789.20
Rate for Payer: Health Management Network Commercial	$2,172.60
Rate for Payer: Kaiser Permanente Commercial	$1,610.28
Rate for Payer: Kaiser Permanente Medicaid	$1,303.56
Rate for Payer: MDX Hawaii PPO	$2,479.32
Rate for Payer: University Health Alliance Commercial	$1,431.36

MATRIXMIDFACE RIM 04.503.373

Facility

$2,556.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,431.36
Max. Negotiated Rate	$2,479.32
Rate for Payer: Cash Price	$1,533.60
Rate for Payer: Hawaii Western Management Group Commercial	$1,789.20
Rate for Payer: Health Management Network Commercial	$2,172.60
Rate for Payer: MDX Hawaii PPO	$2,479.32
Rate for Payer: University Health Alliance Commercial	$1,431.36

MATRIX WOUND THIN 4X10 54101T

Facility

$17,483.00

Service Code	HCPCS Q4108
Hospital Revenue Code	636
Min. Negotiated Rate	$14,860.55
Max. Negotiated Rate	$16,958.51
Rate for Payer: Cash Price	$10,489.80
Rate for Payer: Health Management Network Commercial	$14,860.55
Rate for Payer: MDX Hawaii PPO	$16,958.51

MATRIX WOUND THIN 4X10 54101T

Facility

$17,483.00

Service Code	HCPCS Q4108
Hospital Revenue Code	636
Min. Negotiated Rate	$49.12
Max. Negotiated Rate	$16,958.51
Rate for Payer: AlohaCare Medicaid	$147.01
Rate for Payer: AlohaCare Medicare	$147.01
Rate for Payer: Cash Price	$10,489.80
Rate for Payer: Cash Price	$10,489.80
Rate for Payer: Devoted Health Medicare	$161.71
Rate for Payer: Hawaii Medical Service Association ABD	$49.12
Rate for Payer: Hawaii Medical Service Association Commercial	$183.76
Rate for Payer: Hawaii Medical Service Association Medicare	$147.01
Rate for Payer: Hawaii Medical Service Association Non-ABD	$49.12
Rate for Payer: Hawaii Western Management Group Commercial	$16,608.85
Rate for Payer: Health Management Network Commercial	$14,860.55
Rate for Payer: Humana Medicare	$147.01
Rate for Payer: Kaiser Permanente Commercial	$11,014.29
Rate for Payer: Kaiser Permanente Medicaid	$8,916.33
Rate for Payer: Kaiser Permanente Medicare	$147.01
Rate for Payer: MDX Hawaii PPO	$16,958.51
Rate for Payer: Ohana Health Plan Medicaid	$161.71
Rate for Payer: Ohana Health Plan Medicare	$147.01
Rate for Payer: UnitedHealthcare Medicaid	$10,489.80
Rate for Payer: UnitedHealthcare Medicare	$147.01
Rate for Payer: University Health Alliance Commercial	$12,743.36

MDM LINER 46MM 626-00-46F

Facility

$3,344.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$1,705.44
Max. Negotiated Rate	$3,243.68
Rate for Payer: Cash Price	$2,006.40
Rate for Payer: Hawaii Western Management Group Commercial	$2,340.80
Rate for Payer: Health Management Network Commercial	$2,842.40
Rate for Payer: Kaiser Permanente Commercial	$2,106.72
Rate for Payer: Kaiser Permanente Medicaid	$1,705.44
Rate for Payer: MDX Hawaii PPO	$3,243.68
Rate for Payer: University Health Alliance Commercial	$1,872.64

Know your out-of-pocket cost for care.

All Charges