Hilo Benioff Medical Center

All Charges

Charge

Type

Setting

Price

NERVE GRAFT 3MM DIAM 311270

Facility

$16,378.00

Service Code	HCPCS C1763
Hospital Revenue Code	278
Min. Negotiated Rate	$9,171.68
Max. Negotiated Rate	$15,886.66
Rate for Payer: Cash Price	$9,826.80
Rate for Payer: Hawaii Western Management Group Commercial	$11,464.60
Rate for Payer: Health Management Network Commercial	$13,921.30
Rate for Payer: MDX Hawaii PPO	$15,886.66
Rate for Payer: University Health Alliance Commercial	$9,171.68

NERVE PROTECTOR 2X15MM AGX215

Facility

$3,996.00

Service Code	HCPCS C1763
Hospital Revenue Code	278
Min. Negotiated Rate	$2,237.76
Max. Negotiated Rate	$3,876.12
Rate for Payer: Cash Price	$2,397.60
Rate for Payer: Hawaii Western Management Group Commercial	$2,797.20
Rate for Payer: Health Management Network Commercial	$3,396.60
Rate for Payer: MDX Hawaii PPO	$3,876.12
Rate for Payer: University Health Alliance Commercial	$2,237.76

NERVE PROTECTOR 2X15MM AGX215

Facility

$3,996.00

Service Code	HCPCS C1763
Hospital Revenue Code	278
Min. Negotiated Rate	$2,037.96
Max. Negotiated Rate	$3,876.12
Rate for Payer: Cash Price	$2,397.60
Rate for Payer: Hawaii Western Management Group Commercial	$2,797.20
Rate for Payer: Health Management Network Commercial	$3,396.60
Rate for Payer: Kaiser Permanente Commercial	$2,517.48
Rate for Payer: Kaiser Permanente Medicaid	$2,037.96
Rate for Payer: MDX Hawaii PPO	$3,876.12
Rate for Payer: University Health Alliance Commercial	$2,237.76

NERVE PROTECTOR 7X40MM AG0740

Facility

$5,670.00

Service Code	HCPCS C1763
Hospital Revenue Code	278
Min. Negotiated Rate	$2,891.70
Max. Negotiated Rate	$5,499.90
Rate for Payer: Cash Price	$3,402.00
Rate for Payer: Hawaii Western Management Group Commercial	$3,969.00
Rate for Payer: Health Management Network Commercial	$4,819.50
Rate for Payer: Kaiser Permanente Commercial	$3,572.10
Rate for Payer: Kaiser Permanente Medicaid	$2,891.70
Rate for Payer: MDX Hawaii PPO	$5,499.90
Rate for Payer: University Health Alliance Commercial	$3,175.20

NERVE PROTECTOR 7X40MM AG0740

Facility

$5,670.00

Service Code	HCPCS C1763
Hospital Revenue Code	278
Min. Negotiated Rate	$3,175.20
Max. Negotiated Rate	$5,499.90
Rate for Payer: Cash Price	$3,402.00
Rate for Payer: Hawaii Western Management Group Commercial	$3,969.00
Rate for Payer: Health Management Network Commercial	$4,819.50
Rate for Payer: MDX Hawaii PPO	$5,499.90
Rate for Payer: University Health Alliance Commercial	$3,175.20

NERVE PROTECTOR AG0340

Facility

$5,344.00

Service Code	HCPCS C1763
Hospital Revenue Code	278
Min. Negotiated Rate	$2,725.44
Max. Negotiated Rate	$5,183.68
Rate for Payer: Cash Price	$3,206.40
Rate for Payer: Hawaii Western Management Group Commercial	$3,740.80
Rate for Payer: Health Management Network Commercial	$4,542.40
Rate for Payer: Kaiser Permanente Commercial	$3,366.72
Rate for Payer: Kaiser Permanente Medicaid	$2,725.44
Rate for Payer: MDX Hawaii PPO	$5,183.68
Rate for Payer: University Health Alliance Commercial	$2,992.64

NERVE PROTECTOR AG0340

Facility

$5,344.00

Service Code	HCPCS C1763
Hospital Revenue Code	278
Min. Negotiated Rate	$2,992.64
Max. Negotiated Rate	$5,183.68
Rate for Payer: Cash Price	$3,206.40
Rate for Payer: Hawaii Western Management Group Commercial	$3,740.80
Rate for Payer: Health Management Network Commercial	$4,542.40
Rate for Payer: MDX Hawaii PPO	$5,183.68
Rate for Payer: University Health Alliance Commercial	$2,992.64

NERVOUS SYSTEM MALIGNANCY

Facility

$5,413.25

Service Code	APR-DRG 0413
Min. Negotiated Rate	$5,413.25
Max. Negotiated Rate	$5,413.25
Rate for Payer: AlohaCare Medicaid	$5,413.25
Rate for Payer: Hawaii Medical Service Association ABD	$5,413.25
Rate for Payer: Hawaii Medical Service Association Non-ABD	$5,413.25
Rate for Payer: Kaiser Permanente Medicaid	$5,413.25
Rate for Payer: Ohana Health Plan Medicaid	$5,413.25
Rate for Payer: UnitedHealthcare Medicaid	$5,413.25

NERVOUS SYSTEM MALIGNANCY

Facility

$8,099.98

Service Code	APR-DRG 0414
Min. Negotiated Rate	$8,099.98
Max. Negotiated Rate	$8,099.98
Rate for Payer: AlohaCare Medicaid	$8,099.98
Rate for Payer: Hawaii Medical Service Association ABD	$8,099.98
Rate for Payer: Hawaii Medical Service Association Non-ABD	$8,099.98
Rate for Payer: Kaiser Permanente Medicaid	$8,099.98
Rate for Payer: Ohana Health Plan Medicaid	$8,099.98
Rate for Payer: UnitedHealthcare Medicaid	$8,099.98

NERVOUS SYSTEM MALIGNANCY

Facility

$4,139.35

Service Code	APR-DRG 0412
Min. Negotiated Rate	$4,139.35
Max. Negotiated Rate	$4,139.35
Rate for Payer: AlohaCare Medicaid	$4,139.35
Rate for Payer: Hawaii Medical Service Association ABD	$4,139.35
Rate for Payer: Hawaii Medical Service Association Non-ABD	$4,139.35
Rate for Payer: Kaiser Permanente Medicaid	$4,139.35
Rate for Payer: Ohana Health Plan Medicaid	$4,139.35
Rate for Payer: UnitedHealthcare Medicaid	$4,139.35

NERVOUS SYSTEM MALIGNANCY

Facility

$3,732.33

Service Code	APR-DRG 0411
Min. Negotiated Rate	$3,732.33
Max. Negotiated Rate	$3,732.33
Rate for Payer: AlohaCare Medicaid	$3,732.33
Rate for Payer: Hawaii Medical Service Association ABD	$3,732.33
Rate for Payer: Hawaii Medical Service Association Non-ABD	$3,732.33
Rate for Payer: Kaiser Permanente Medicaid	$3,732.33
Rate for Payer: Ohana Health Plan Medicaid	$3,732.33
Rate for Payer: UnitedHealthcare Medicaid	$3,732.33

NERVOUS SYSTEM NEOPLASMS WITH MCC

Facility

$26,339.03

Service Code	MSDRG 054
Min. Negotiated Rate	$17,367.34
Max. Negotiated Rate	$26,339.03
Rate for Payer: AlohaCare Medicare	$17,367.34
Rate for Payer: Devoted Health Medicare	$19,104.07
Rate for Payer: Hawaii Medical Service Association Commercial	$24,484.39
Rate for Payer: Hawaii Medical Service Association Medicare	$17,367.34
Rate for Payer: Humana Medicare	$17,367.34
Rate for Payer: Kaiser Permanente Commercial	$26,339.03
Rate for Payer: Kaiser Permanente Medicare	$17,367.34
Rate for Payer: Ohana Health Plan Medicare	$17,367.34
Rate for Payer: UnitedHealthcare Medicare	$17,367.34

NERVOUS SYSTEM NEOPLASMS WITHOUT MCC

Facility

$24,241.73

Service Code	MSDRG 055
Min. Negotiated Rate	$11,597.19
Max. Negotiated Rate	$24,241.73
Rate for Payer: AlohaCare Medicare	$11,597.19
Rate for Payer: Devoted Health Medicare	$12,756.91
Rate for Payer: Hawaii Medical Service Association Commercial	$24,241.73
Rate for Payer: Hawaii Medical Service Association Medicare	$11,597.19
Rate for Payer: Humana Medicare	$11,597.19
Rate for Payer: Kaiser Permanente Commercial	$17,588.10
Rate for Payer: Kaiser Permanente Medicare	$11,597.19
Rate for Payer: Ohana Health Plan Medicare	$11,597.19
Rate for Payer: UnitedHealthcare Medicare	$11,597.19

NEUROLOGICAL EYE DISORDERS

Facility

$17,034.73

Service Code	MSDRG 123
Min. Negotiated Rate	$9,083.47
Max. Negotiated Rate	$17,034.73
Rate for Payer: AlohaCare Medicare	$9,083.47
Rate for Payer: Devoted Health Medicare	$9,991.82
Rate for Payer: Hawaii Medical Service Association Commercial	$17,034.73
Rate for Payer: Hawaii Medical Service Association Medicare	$9,083.47
Rate for Payer: Humana Medicare	$9,083.47
Rate for Payer: Kaiser Permanente Commercial	$13,775.85
Rate for Payer: Kaiser Permanente Medicare	$9,083.47
Rate for Payer: Ohana Health Plan Medicare	$9,083.47
Rate for Payer: UnitedHealthcare Medicare	$9,083.47

NEUROPLASTY AND/OR TRANSPOSITION; MEDIAN NERVE AT CARPAL TUNNEL

Facility

$5,509.00

Service Code	CPT 64721
Hospital Revenue Code	360
Min. Negotiated Rate	$456.03
Max. Negotiated Rate	$5,509.00
Rate for Payer: AlohaCare Medicaid	$2,306.84
Rate for Payer: AlohaCare Medicare	$2,306.84
Rate for Payer: Devoted Health Medicare	$2,537.52
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	$2,306.84
Rate for Payer: Hawaii Medical Service Association Non-ABD	$1,028.67
Rate for Payer: Humana Medicare	$2,306.84
Rate for Payer: Kaiser Permanente Medicaid	$2,837.00
Rate for Payer: Kaiser Permanente Medicare	$2,306.84
Rate for Payer: Ohana Health Plan Medicaid	$2,537.52
Rate for Payer: Ohana Health Plan Medicare	$2,306.84
Rate for Payer: UnitedHealthcare Medicaid	$456.03
Rate for Payer: UnitedHealthcare Medicare	$2,306.84
Rate for Payer: University Health Alliance Commercial	$5,160.40

NEUROPLASTY AND/OR TRANSPOSITION; ULNAR NERVE AT ELBOW

Facility

$8,270.00

Service Code	CPT 64718
Hospital Revenue Code	360
Min. Negotiated Rate	$456.03
Max. Negotiated Rate	$8,270.00
Rate for Payer: AlohaCare Medicaid	$2,306.84
Rate for Payer: AlohaCare Medicare	$2,306.84
Rate for Payer: Devoted Health Medicare	$2,537.52
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	$2,306.84
Rate for Payer: Hawaii Medical Service Association Non-ABD	$1,427.62
Rate for Payer: Humana Medicare	$2,306.84
Rate for Payer: Kaiser Permanente Medicaid	$2,837.00
Rate for Payer: Kaiser Permanente Medicare	$2,306.84
Rate for Payer: Ohana Health Plan Medicaid	$2,537.52
Rate for Payer: Ohana Health Plan Medicare	$2,306.84
Rate for Payer: UnitedHealthcare Medicaid	$456.03
Rate for Payer: UnitedHealthcare Medicare	$2,306.84
Rate for Payer: University Health Alliance Commercial	$5,160.40

NEUROPLASTY AND/OR TRANSPOSITION; ULNAR NERVE AT WRIST

Facility

$8,270.00

Service Code	CPT 64719
Hospital Revenue Code	360
Min. Negotiated Rate	$456.03
Max. Negotiated Rate	$8,270.00
Rate for Payer: AlohaCare Medicaid	$2,306.84
Rate for Payer: AlohaCare Medicare	$2,306.84
Rate for Payer: Devoted Health Medicare	$2,537.52
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	$2,306.84
Rate for Payer: Hawaii Medical Service Association Non-ABD	$1,427.62
Rate for Payer: Humana Medicare	$2,306.84
Rate for Payer: Kaiser Permanente Medicaid	$2,837.00
Rate for Payer: Kaiser Permanente Medicare	$2,306.84
Rate for Payer: Ohana Health Plan Medicaid	$2,537.52
Rate for Payer: Ohana Health Plan Medicare	$2,306.84
Rate for Payer: UnitedHealthcare Medicaid	$456.03
Rate for Payer: UnitedHealthcare Medicare	$2,306.84
Rate for Payer: University Health Alliance Commercial	$5,160.40

NEUROPLASTY, MAJOR PERIPHERAL NERVE, ARM OR LEG, OPEN; OTHER THAN SPECIFIED

Facility

$8,270.00

Service Code	CPT 64708
Hospital Revenue Code	360
Min. Negotiated Rate	$456.03
Max. Negotiated Rate	$8,270.00
Rate for Payer: AlohaCare Medicaid	$2,306.84
Rate for Payer: AlohaCare Medicare	$2,306.84
Rate for Payer: Devoted Health Medicare	$2,537.52
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	$2,306.84
Rate for Payer: Hawaii Medical Service Association Non-ABD	$1,427.62
Rate for Payer: Humana Medicare	$2,306.84
Rate for Payer: Kaiser Permanente Medicaid	$2,837.00
Rate for Payer: Kaiser Permanente Medicare	$2,306.84
Rate for Payer: Ohana Health Plan Medicaid	$2,537.52
Rate for Payer: Ohana Health Plan Medicare	$2,306.84
Rate for Payer: UnitedHealthcare Medicaid	$456.03
Rate for Payer: UnitedHealthcare Medicare	$2,306.84
Rate for Payer: University Health Alliance Commercial	$5,160.40

NEUROSES EXCEPT DEPRESSIVE

Facility

$18,523.05

Service Code	MSDRG 882
Min. Negotiated Rate	$9,754.93
Max. Negotiated Rate	$18,523.05
Rate for Payer: AlohaCare Medicare	$12,213.69
Rate for Payer: Devoted Health Medicare	$13,435.06
Rate for Payer: Hawaii Medical Service Association Commercial	$9,754.93
Rate for Payer: Hawaii Medical Service Association Medicare	$12,213.69
Rate for Payer: Humana Medicare	$12,213.69
Rate for Payer: Kaiser Permanente Commercial	$18,523.05
Rate for Payer: Kaiser Permanente Medicare	$12,213.69
Rate for Payer: Ohana Health Plan Medicare	$12,213.69
Rate for Payer: UnitedHealthcare Medicare	$12,213.69

NEUROSTIMULATOR EXTERNL 353101

Facility

$1,470.00

Service Code	HCPCS C1787
Hospital Revenue Code	272
Min. Negotiated Rate	$1,249.50
Max. Negotiated Rate	$1,425.90
Rate for Payer: Cash Price	$882.00
Rate for Payer: Health Management Network Commercial	$1,249.50
Rate for Payer: MDX Hawaii PPO	$1,425.90

NEUROSTIMULATOR EXTERNL 353101

Facility

$1,470.00

Service Code	HCPCS C1787
Hospital Revenue Code	272
Min. Negotiated Rate	$749.70
Max. Negotiated Rate	$1,425.90
Rate for Payer: Cash Price	$882.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,396.50
Rate for Payer: Health Management Network Commercial	$1,249.50
Rate for Payer: Kaiser Permanente Commercial	$926.10
Rate for Payer: Kaiser Permanente Medicaid	$749.70
Rate for Payer: MDX Hawaii PPO	$1,425.90
Rate for Payer: University Health Alliance Commercial	$1,071.48

NEVIRAPINE 50 MG/5 ML ORAL SUSPENSION [24119]

Facility

$285.00

Service Code	NDC 65862005724
Hospital Revenue Code	250
Min. Negotiated Rate	$242.25
Max. Negotiated Rate	$276.45
Rate for Payer: Cash Price	$171.00
Rate for Payer: Health Management Network Commercial	$242.25
Rate for Payer: MDX Hawaii PPO	$276.45

NEVIRAPINE 50 MG/5 ML ORAL SUSPENSION [24119]

Facility

$285.00

Service Code	NDC 65862005724
Hospital Revenue Code	637
Min. Negotiated Rate	$145.35
Max. Negotiated Rate	$276.45
Rate for Payer: Cash Price	$171.00
Rate for Payer: Hawaii Western Management Group Commercial	$270.75
Rate for Payer: Health Management Network Commercial	$242.25
Rate for Payer: Kaiser Permanente Commercial	$179.55
Rate for Payer: Kaiser Permanente Medicaid	$145.35
Rate for Payer: MDX Hawaii PPO	$276.45
Rate for Payer: University Health Alliance Commercial	$207.74

NEXGEN 12X155MM STR 5988-11-12

Facility

$2,239.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$1,253.84
Max. Negotiated Rate	$2,171.83
Rate for Payer: Cash Price	$1,343.40
Rate for Payer: Hawaii Western Management Group Commercial	$1,567.30
Rate for Payer: Health Management Network Commercial	$1,903.15
Rate for Payer: MDX Hawaii PPO	$2,171.83
Rate for Payer: University Health Alliance Commercial	$1,253.84

NEXGEN 12X155MM STR 5988-11-12

Facility

$2,239.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$1,141.89
Max. Negotiated Rate	$2,171.83
Rate for Payer: Cash Price	$1,343.40
Rate for Payer: Hawaii Western Management Group Commercial	$1,567.30
Rate for Payer: Health Management Network Commercial	$1,903.15
Rate for Payer: Kaiser Permanente Commercial	$1,410.57
Rate for Payer: Kaiser Permanente Medicaid	$1,141.89
Rate for Payer: MDX Hawaii PPO	$2,171.83
Rate for Payer: University Health Alliance Commercial	$1,253.84

Know your out-of-pocket cost for care.

All Charges