Hilo Benioff Medical Center

All Charges

Charge

Type

Setting

Price

OPEN TREATMENT OF PHALANGEAL SHAFT FRACTURE, PROXIMAL OR MIDDLE PHALANX, FINGER OR THUMB, INCLUDES INTERNAL FIXATION, WHEN PERFORMED, EACH

Facility

$10,679.55

Service Code	CPT 26735
Hospital Revenue Code	360
Min. Negotiated Rate	$456.03
Max. Negotiated Rate	$10,679.55
Rate for Payer: AlohaCare Medicaid	$3,865.36
Rate for Payer: AlohaCare Medicare	$3,865.36
Rate for Payer: Devoted Health Medicare	$4,251.90
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	$3,865.36
Rate for Payer: Hawaii Medical Service Association Non-ABD	$1,427.62
Rate for Payer: Humana Medicare	$3,865.36
Rate for Payer: Kaiser Permanente Medicaid	$2,837.00
Rate for Payer: Kaiser Permanente Medicare	$3,865.36
Rate for Payer: Ohana Health Plan Medicaid	$4,251.90
Rate for Payer: Ohana Health Plan Medicare	$3,865.36
Rate for Payer: UnitedHealthcare Medicaid	$456.03
Rate for Payer: UnitedHealthcare Medicare	$3,865.36
Rate for Payer: University Health Alliance Commercial	$10,679.55

OPEN TREATMENT OF PROXIMAL HUMERAL (SURGICAL OR ANATOMICAL NECK) FRACTURE, INCLUDES INTERNAL FIXATION, WHEN PERFORMED, INCLUDES REPAIR OF TUBEROSITY(S), WHEN PERFORMED;

Facility

$16,683.60

Service Code	CPT 23615
Hospital Revenue Code	360
Min. Negotiated Rate	$521.33
Max. Negotiated Rate	$16,683.60
Rate for Payer: AlohaCare Medicaid	$15,166.91
Rate for Payer: AlohaCare Medicare	$15,166.91
Rate for Payer: Devoted Health Medicare	$16,683.60
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	$15,166.91
Rate for Payer: Hawaii Medical Service Association Non-ABD	$2,294.85
Rate for Payer: Humana Medicare	$15,166.91
Rate for Payer: Kaiser Permanente Medicaid	$2,837.00
Rate for Payer: Kaiser Permanente Medicare	$15,166.91
Rate for Payer: Ohana Health Plan Medicaid	$16,683.60
Rate for Payer: Ohana Health Plan Medicare	$15,166.91
Rate for Payer: UnitedHealthcare Medicaid	$521.33
Rate for Payer: UnitedHealthcare Medicare	$15,166.91
Rate for Payer: University Health Alliance Commercial	$10,679.55

OPEN TREATMENT OF RADIAL AND ULNAR SHAFT FRACTURES, WITH INTERNAL FIXATION, WHEN PERFORMED; OF RADIUS AND ULNA

Facility

$13,778.00

Service Code	CPT 25575
Hospital Revenue Code	360
Min. Negotiated Rate	$521.33
Max. Negotiated Rate	$13,778.00
Rate for Payer: AlohaCare Medicaid	$8,572.09
Rate for Payer: AlohaCare Medicare	$8,572.09
Rate for Payer: Devoted Health Medicare	$9,429.30
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	$8,572.09
Rate for Payer: Hawaii Medical Service Association Non-ABD	$2,294.85
Rate for Payer: Humana Medicare	$8,572.09
Rate for Payer: Kaiser Permanente Medicaid	$2,837.00
Rate for Payer: Kaiser Permanente Medicare	$8,572.09
Rate for Payer: Ohana Health Plan Medicaid	$9,429.30
Rate for Payer: Ohana Health Plan Medicare	$8,572.09
Rate for Payer: UnitedHealthcare Medicaid	$521.33
Rate for Payer: UnitedHealthcare Medicare	$8,572.09
Rate for Payer: University Health Alliance Commercial	$6,743.44

OPEN TREATMENT OF RADIAL SHAFT FRACTURE, INCLUDES INTERNAL FIXATION, WHEN PERFORMED

Facility

$9,429.30

Service Code	CPT 25515
Hospital Revenue Code	360
Min. Negotiated Rate	$521.33
Max. Negotiated Rate	$9,429.30
Rate for Payer: AlohaCare Medicaid	$8,572.09
Rate for Payer: AlohaCare Medicare	$8,572.09
Rate for Payer: Devoted Health Medicare	$9,429.30
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	$8,572.09
Rate for Payer: Hawaii Medical Service Association Non-ABD	$1,427.62
Rate for Payer: Humana Medicare	$8,572.09
Rate for Payer: Kaiser Permanente Medicaid	$2,837.00
Rate for Payer: Kaiser Permanente Medicare	$8,572.09
Rate for Payer: Ohana Health Plan Medicaid	$9,429.30
Rate for Payer: Ohana Health Plan Medicare	$8,572.09
Rate for Payer: UnitedHealthcare Medicaid	$521.33
Rate for Payer: UnitedHealthcare Medicare	$8,572.09
Rate for Payer: University Health Alliance Commercial	$6,743.44

OPEN TREATMENT OF TRIMALLEOLAR ANKLE FRACTURE, INCLUDES INTERNAL FIXATION, WHEN PERFORMED, MEDIAL AND/OR LATERAL MALLEOLUS; WITHOUT FIXATION OF POSTERIOR LIP

Facility

$9,429.30

Service Code	CPT 27822
Hospital Revenue Code	360
Min. Negotiated Rate	$521.33
Max. Negotiated Rate	$9,429.30
Rate for Payer: AlohaCare Medicaid	$8,572.09
Rate for Payer: AlohaCare Medicare	$8,572.09
Rate for Payer: Devoted Health Medicare	$9,429.30
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	$8,572.09
Rate for Payer: Hawaii Medical Service Association Non-ABD	$1,427.62
Rate for Payer: Humana Medicare	$8,572.09
Rate for Payer: Kaiser Permanente Medicaid	$2,837.00
Rate for Payer: Kaiser Permanente Medicare	$8,572.09
Rate for Payer: Ohana Health Plan Medicaid	$9,429.30
Rate for Payer: Ohana Health Plan Medicare	$8,572.09
Rate for Payer: UnitedHealthcare Medicaid	$521.33
Rate for Payer: UnitedHealthcare Medicare	$8,572.09
Rate for Payer: University Health Alliance Commercial	$6,743.44

OPEN TREATMENT OF ULNAR FRACTURE, PROXIMAL END (EG, OLECRANON OR CORONOID PROCESS[ES]), INCLUDES INTERNAL FIXATION, WHEN PERFORMED

Facility

$13,778.00

Service Code	CPT 24685
Hospital Revenue Code	360
Min. Negotiated Rate	$521.33
Max. Negotiated Rate	$13,778.00
Rate for Payer: AlohaCare Medicaid	$8,572.09
Rate for Payer: AlohaCare Medicare	$8,572.09
Rate for Payer: Devoted Health Medicare	$9,429.30
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	$8,572.09
Rate for Payer: Hawaii Medical Service Association Non-ABD	$2,294.85
Rate for Payer: Humana Medicare	$8,572.09
Rate for Payer: Kaiser Permanente Medicaid	$2,837.00
Rate for Payer: Kaiser Permanente Medicare	$8,572.09
Rate for Payer: Ohana Health Plan Medicaid	$9,429.30
Rate for Payer: Ohana Health Plan Medicare	$8,572.09
Rate for Payer: UnitedHealthcare Medicaid	$521.33
Rate for Payer: UnitedHealthcare Medicare	$8,572.09
Rate for Payer: University Health Alliance Commercial	$6,743.44

OPEN TREATMENT OF ULNAR SHAFT FRACTURE, INCLUDES INTERNAL FIXATION, WHEN PERFORMED

Facility

$9,429.30

Service Code	CPT 25545
Hospital Revenue Code	360
Min. Negotiated Rate	$521.33
Max. Negotiated Rate	$9,429.30
Rate for Payer: AlohaCare Medicaid	$8,572.09
Rate for Payer: AlohaCare Medicare	$8,572.09
Rate for Payer: Devoted Health Medicare	$9,429.30
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	$8,572.09
Rate for Payer: Hawaii Medical Service Association Non-ABD	$1,427.62
Rate for Payer: Humana Medicare	$8,572.09
Rate for Payer: Kaiser Permanente Medicaid	$2,837.00
Rate for Payer: Kaiser Permanente Medicare	$8,572.09
Rate for Payer: Ohana Health Plan Medicaid	$9,429.30
Rate for Payer: Ohana Health Plan Medicare	$8,572.09
Rate for Payer: UnitedHealthcare Medicaid	$521.33
Rate for Payer: UnitedHealthcare Medicare	$8,572.09
Rate for Payer: University Health Alliance Commercial	$6,743.44

OPIOID ABUSE & DEPENDENCE

Facility

$1,633.01

Service Code	APR-DRG 7731
Min. Negotiated Rate	$1,633.01
Max. Negotiated Rate	$1,633.01
Rate for Payer: AlohaCare Medicaid	$1,633.01
Rate for Payer: Hawaii Medical Service Association ABD	$1,633.01
Rate for Payer: Hawaii Medical Service Association Non-ABD	$1,633.01
Rate for Payer: Kaiser Permanente Medicaid	$1,633.01
Rate for Payer: Ohana Health Plan Medicaid	$1,633.01
Rate for Payer: UnitedHealthcare Medicaid	$1,633.01

OPIOID ABUSE & DEPENDENCE

Facility

$2,478.39

Service Code	APR-DRG 7732
Min. Negotiated Rate	$2,478.39
Max. Negotiated Rate	$2,478.39
Rate for Payer: AlohaCare Medicaid	$2,478.39
Rate for Payer: Hawaii Medical Service Association ABD	$2,478.39
Rate for Payer: Hawaii Medical Service Association Non-ABD	$2,478.39
Rate for Payer: Kaiser Permanente Medicaid	$2,478.39
Rate for Payer: Ohana Health Plan Medicaid	$2,478.39
Rate for Payer: UnitedHealthcare Medicaid	$2,478.39

OPIOID ABUSE & DEPENDENCE

Facility

$10,904.47

Service Code	APR-DRG 7734
Min. Negotiated Rate	$10,904.47
Max. Negotiated Rate	$10,904.47
Rate for Payer: AlohaCare Medicaid	$10,904.47
Rate for Payer: Hawaii Medical Service Association ABD	$10,904.47
Rate for Payer: Hawaii Medical Service Association Non-ABD	$10,904.47
Rate for Payer: Kaiser Permanente Medicaid	$10,904.47
Rate for Payer: Ohana Health Plan Medicaid	$10,904.47
Rate for Payer: UnitedHealthcare Medicaid	$10,904.47

OPIOID ABUSE & DEPENDENCE

Facility

$4,604.98

Service Code	APR-DRG 7733
Min. Negotiated Rate	$4,604.98
Max. Negotiated Rate	$4,604.98
Rate for Payer: AlohaCare Medicaid	$4,604.98
Rate for Payer: Hawaii Medical Service Association ABD	$4,604.98
Rate for Payer: Hawaii Medical Service Association Non-ABD	$4,604.98
Rate for Payer: Kaiser Permanente Medicaid	$4,604.98
Rate for Payer: Ohana Health Plan Medicaid	$4,604.98
Rate for Payer: UnitedHealthcare Medicaid	$4,604.98

OPTISEAL VALVED INTROD 6X13

Facility

$910.00

Service Code	HCPCS C1892
Hospital Revenue Code	272
Min. Negotiated Rate	$464.10
Max. Negotiated Rate	$882.70
Rate for Payer: Cash Price	$546.00
Rate for Payer: Hawaii Western Management Group Commercial	$864.50
Rate for Payer: Health Management Network Commercial	$773.50
Rate for Payer: Kaiser Permanente Commercial	$573.30
Rate for Payer: Kaiser Permanente Medicaid	$464.10
Rate for Payer: MDX Hawaii PPO	$882.70
Rate for Payer: University Health Alliance Commercial	$663.30

OPTISEAL VALVED INTROD 6X13

Facility

$910.00

Service Code	HCPCS C1892
Hospital Revenue Code	272
Min. Negotiated Rate	$773.50
Max. Negotiated Rate	$882.70
Rate for Payer: Cash Price	$546.00
Rate for Payer: Health Management Network Commercial	$773.50
Rate for Payer: MDX Hawaii PPO	$882.70

OPTISEAL VALVED INTROD 6X25

Facility

$910.00

Service Code	HCPCS C1892
Hospital Revenue Code	272
Min. Negotiated Rate	$773.50
Max. Negotiated Rate	$882.70
Rate for Payer: Cash Price	$546.00
Rate for Payer: Health Management Network Commercial	$773.50
Rate for Payer: MDX Hawaii PPO	$882.70

OPTISEAL VALVED INTROD 6X25

Facility

$910.00

Service Code	HCPCS C1892
Hospital Revenue Code	272
Min. Negotiated Rate	$464.10
Max. Negotiated Rate	$882.70
Rate for Payer: Cash Price	$546.00
Rate for Payer: Hawaii Western Management Group Commercial	$864.50
Rate for Payer: Health Management Network Commercial	$773.50
Rate for Payer: Kaiser Permanente Commercial	$573.30
Rate for Payer: Kaiser Permanente Medicaid	$464.10
Rate for Payer: MDX Hawaii PPO	$882.70
Rate for Payer: University Health Alliance Commercial	$663.30

OPTISEAL VALVED INTROD 8X13

Facility

$910.00

Service Code	HCPCS C1892
Hospital Revenue Code	272
Min. Negotiated Rate	$773.50
Max. Negotiated Rate	$882.70
Rate for Payer: Cash Price	$546.00
Rate for Payer: Health Management Network Commercial	$773.50
Rate for Payer: MDX Hawaii PPO	$882.70

OPTISEAL VALVED INTROD 8X13

Facility

$910.00

Service Code	HCPCS C1892
Hospital Revenue Code	272
Min. Negotiated Rate	$464.10
Max. Negotiated Rate	$882.70
Rate for Payer: Cash Price	$546.00
Rate for Payer: Hawaii Western Management Group Commercial	$864.50
Rate for Payer: Health Management Network Commercial	$773.50
Rate for Payer: Kaiser Permanente Commercial	$573.30
Rate for Payer: Kaiser Permanente Medicaid	$464.10
Rate for Payer: MDX Hawaii PPO	$882.70
Rate for Payer: University Health Alliance Commercial	$663.30

OPTISEAL VALVED INTROD 9X13

Facility

$910.00

Service Code	HCPCS C1894
Hospital Revenue Code	272
Min. Negotiated Rate	$773.50
Max. Negotiated Rate	$882.70
Rate for Payer: Cash Price	$546.00
Rate for Payer: Health Management Network Commercial	$773.50
Rate for Payer: MDX Hawaii PPO	$882.70

OPTISEAL VALVED INTROD 9X13

Facility

$910.00

Service Code	HCPCS C1894
Hospital Revenue Code	272
Min. Negotiated Rate	$464.10
Max. Negotiated Rate	$882.70
Rate for Payer: Cash Price	$546.00
Rate for Payer: Hawaii Western Management Group Commercial	$864.50
Rate for Payer: Health Management Network Commercial	$773.50
Rate for Payer: Kaiser Permanente Commercial	$573.30
Rate for Payer: Kaiser Permanente Medicaid	$464.10
Rate for Payer: MDX Hawaii PPO	$882.70
Rate for Payer: University Health Alliance Commercial	$663.30

OPTITORQUE TIGER 6F 4X100

Facility

$225.00

Service Code	HCPCS C1887
Hospital Revenue Code	272
Min. Negotiated Rate	$191.25
Max. Negotiated Rate	$218.25
Rate for Payer: Cash Price	$135.00
Rate for Payer: Health Management Network Commercial	$191.25
Rate for Payer: MDX Hawaii PPO	$218.25

OPTITORQUE TIGER 6F 4X100

Facility

$225.00

Service Code	HCPCS C1887
Hospital Revenue Code	272
Min. Negotiated Rate	$114.75
Max. Negotiated Rate	$218.25
Rate for Payer: Cash Price	$135.00
Rate for Payer: Hawaii Western Management Group Commercial	$213.75
Rate for Payer: Health Management Network Commercial	$191.25
Rate for Payer: Kaiser Permanente Commercial	$141.75
Rate for Payer: Kaiser Permanente Medicaid	$114.75
Rate for Payer: MDX Hawaii PPO	$218.25
Rate for Payer: University Health Alliance Commercial	$164.00

ORBITAL PROCEDURES WITH CC/MCC

Facility

$40,556.47

Service Code	MSDRG 113
Min. Negotiated Rate	$10,400.00
Max. Negotiated Rate	$40,556.47
Rate for Payer: AlohaCare Medicare	$26,742.01
Rate for Payer: Devoted Health Medicare	$29,416.21
Rate for Payer: Hawaii Medical Service Association Commercial	$19,558.40
Rate for Payer: Hawaii Medical Service Association Medicare	$26,742.01
Rate for Payer: Humana Medicare	$26,742.01
Rate for Payer: Kaiser Permanente Commercial	$40,556.47
Rate for Payer: Kaiser Permanente Medicare	$26,742.01
Rate for Payer: Ohana Health Plan Medicare	$26,742.01
Rate for Payer: UnitedHealthcare Medicare	$26,742.01
Rate for Payer: University Health Alliance Commercial	$10,400.00

ORBITAL PROCEDURES WITHOUT CC/MCC

Facility

$23,339.25

Service Code	MSDRG 114
Min. Negotiated Rate	$10,400.00
Max. Negotiated Rate	$23,339.25
Rate for Payer: AlohaCare Medicare	$15,389.37
Rate for Payer: Devoted Health Medicare	$16,928.31
Rate for Payer: Hawaii Medical Service Association Commercial	$19,558.40
Rate for Payer: Hawaii Medical Service Association Medicare	$15,389.37
Rate for Payer: Humana Medicare	$15,389.37
Rate for Payer: Kaiser Permanente Commercial	$23,339.25
Rate for Payer: Kaiser Permanente Medicare	$15,389.37
Rate for Payer: Ohana Health Plan Medicare	$15,389.37
Rate for Payer: UnitedHealthcare Medicare	$15,389.37
Rate for Payer: University Health Alliance Commercial	$10,400.00

ORBIT & EYE PROCEDURES

Facility

$6,076.61

Service Code	APR-DRG 0732
Min. Negotiated Rate	$6,076.61
Max. Negotiated Rate	$6,076.61
Rate for Payer: AlohaCare Medicaid	$6,076.61
Rate for Payer: Hawaii Medical Service Association ABD	$6,076.61
Rate for Payer: Hawaii Medical Service Association Non-ABD	$6,076.61
Rate for Payer: Kaiser Permanente Medicaid	$6,076.61
Rate for Payer: Ohana Health Plan Medicaid	$6,076.61
Rate for Payer: UnitedHealthcare Medicaid	$6,076.61

ORBIT & EYE PROCEDURES

Facility

$18,806.45

Service Code	APR-DRG 0734
Min. Negotiated Rate	$18,806.45
Max. Negotiated Rate	$18,806.45
Rate for Payer: AlohaCare Medicaid	$18,806.45
Rate for Payer: Hawaii Medical Service Association ABD	$18,806.45
Rate for Payer: Hawaii Medical Service Association Non-ABD	$18,806.45
Rate for Payer: Kaiser Permanente Medicaid	$18,806.45
Rate for Payer: Ohana Health Plan Medicaid	$18,806.45
Rate for Payer: UnitedHealthcare Medicaid	$18,806.45

Know your out-of-pocket cost for care.

All Charges