Hilo Benioff Medical Center

All Charges

Charge

Type

Setting

Price

PARTIAL THICKNESS BURNS W/O SKIN GRAFT

Facility

$3,021.35

Service Code	APR-DRG 8442
Min. Negotiated Rate	$3,021.35
Max. Negotiated Rate	$3,021.35
Rate for Payer: AlohaCare Medicaid	$3,021.35
Rate for Payer: Hawaii Medical Service Association ABD	$3,021.35
Rate for Payer: Hawaii Medical Service Association Non-ABD	$3,021.35
Rate for Payer: Kaiser Permanente Medicaid	$3,021.35
Rate for Payer: Ohana Health Plan Medicaid	$3,021.35
Rate for Payer: UnitedHealthcare Medicaid	$3,021.35

PARTIAL THICKNESS BURNS W/O SKIN GRAFT

Facility

$5,008.84

Service Code	APR-DRG 8443
Min. Negotiated Rate	$5,008.84
Max. Negotiated Rate	$5,008.84
Rate for Payer: AlohaCare Medicaid	$5,008.84
Rate for Payer: Hawaii Medical Service Association ABD	$5,008.84
Rate for Payer: Hawaii Medical Service Association Non-ABD	$5,008.84
Rate for Payer: Kaiser Permanente Medicaid	$5,008.84
Rate for Payer: Ohana Health Plan Medicaid	$5,008.84
Rate for Payer: UnitedHealthcare Medicaid	$5,008.84

PARTIAL THICKNESS BURNS W/O SKIN GRAFT

Facility

$1,942.48

Service Code	APR-DRG 8441
Min. Negotiated Rate	$1,942.48
Max. Negotiated Rate	$1,942.48
Rate for Payer: AlohaCare Medicaid	$1,942.48
Rate for Payer: Hawaii Medical Service Association ABD	$1,942.48
Rate for Payer: Hawaii Medical Service Association Non-ABD	$1,942.48
Rate for Payer: Kaiser Permanente Medicaid	$1,942.48
Rate for Payer: Ohana Health Plan Medicaid	$1,942.48
Rate for Payer: UnitedHealthcare Medicaid	$1,942.48

PARTIAL THICKNESS BURNS W/O SKIN GRAFT

Facility

$11,559.65

Service Code	APR-DRG 8444
Min. Negotiated Rate	$11,559.65
Max. Negotiated Rate	$11,559.65
Rate for Payer: AlohaCare Medicaid	$11,559.65
Rate for Payer: Hawaii Medical Service Association ABD	$11,559.65
Rate for Payer: Hawaii Medical Service Association Non-ABD	$11,559.65
Rate for Payer: Kaiser Permanente Medicaid	$11,559.65
Rate for Payer: Ohana Health Plan Medicaid	$11,559.65
Rate for Payer: UnitedHealthcare Medicaid	$11,559.65

PATCH WITTMANN EWP 2040

Facility

$16,200.00

Hospital Revenue Code	272
Min. Negotiated Rate	$8,262.00
Max. Negotiated Rate	$15,714.00
Rate for Payer: Cash Price	$9,720.00
Rate for Payer: Hawaii Western Management Group Commercial	$15,390.00
Rate for Payer: Health Management Network Commercial	$13,770.00
Rate for Payer: Kaiser Permanente Commercial	$10,206.00
Rate for Payer: Kaiser Permanente Medicaid	$8,262.00
Rate for Payer: MDX Hawaii PPO	$15,714.00
Rate for Payer: University Health Alliance Commercial	$11,808.18

PATCH WITTMANN EWP 2040

Facility

$16,200.00

Hospital Revenue Code	272
Min. Negotiated Rate	$13,770.00
Max. Negotiated Rate	$15,714.00
Rate for Payer: Cash Price	$9,720.00
Rate for Payer: Health Management Network Commercial	$13,770.00
Rate for Payer: MDX Hawaii PPO	$15,714.00

PATELLA 36X10MM X3 5550-G-360

Facility

$3,628.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$1,850.28
Max. Negotiated Rate	$3,519.16
Rate for Payer: Cash Price	$2,176.80
Rate for Payer: Hawaii Western Management Group Commercial	$2,539.60
Rate for Payer: Health Management Network Commercial	$3,083.80
Rate for Payer: Kaiser Permanente Commercial	$2,285.64
Rate for Payer: Kaiser Permanente Medicaid	$1,850.28
Rate for Payer: MDX Hawaii PPO	$3,519.16
Rate for Payer: University Health Alliance Commercial	$2,031.68

PATELLA 36X10MM X3 5550-G-360

Facility

$3,628.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$2,031.68
Max. Negotiated Rate	$3,519.16
Rate for Payer: Cash Price	$2,176.80
Rate for Payer: Hawaii Western Management Group Commercial	$2,539.60
Rate for Payer: Health Management Network Commercial	$3,083.80
Rate for Payer: MDX Hawaii PPO	$3,519.16
Rate for Payer: University Health Alliance Commercial	$2,031.68

PATELLA 38X42X11MM 5551-T-381

Facility

$956.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$535.36
Max. Negotiated Rate	$927.32
Rate for Payer: Cash Price	$573.60
Rate for Payer: Hawaii Western Management Group Commercial	$669.20
Rate for Payer: Health Management Network Commercial	$812.60
Rate for Payer: MDX Hawaii PPO	$927.32
Rate for Payer: University Health Alliance Commercial	$535.36

PATELLA 38X42X11MM 5551-T-381

Facility

$956.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$487.56
Max. Negotiated Rate	$927.32
Rate for Payer: Cash Price	$573.60
Rate for Payer: Hawaii Western Management Group Commercial	$669.20
Rate for Payer: Health Management Network Commercial	$812.60
Rate for Payer: Kaiser Permanente Commercial	$602.28
Rate for Payer: Kaiser Permanente Medicaid	$487.56
Rate for Payer: MDX Hawaii PPO	$927.32
Rate for Payer: University Health Alliance Commercial	$535.36

PATELLA A32X10MM 5552-L-320

Facility

$2,317.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$1,181.67
Max. Negotiated Rate	$2,247.49
Rate for Payer: Cash Price	$1,390.20
Rate for Payer: Hawaii Western Management Group Commercial	$1,621.90
Rate for Payer: Health Management Network Commercial	$1,969.45
Rate for Payer: Kaiser Permanente Commercial	$1,459.71
Rate for Payer: Kaiser Permanente Medicaid	$1,181.67
Rate for Payer: MDX Hawaii PPO	$2,247.49
Rate for Payer: University Health Alliance Commercial	$1,297.52

PATELLA A32X10MM 5552-L-320

Facility

$2,317.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$1,297.52
Max. Negotiated Rate	$2,247.49
Rate for Payer: Cash Price	$1,390.20
Rate for Payer: Hawaii Western Management Group Commercial	$1,621.90
Rate for Payer: Health Management Network Commercial	$1,969.45
Rate for Payer: MDX Hawaii PPO	$2,247.49
Rate for Payer: University Health Alliance Commercial	$1,297.52

PATELLA ASYMETRIC 5551-G-299-E

Facility

$2,317.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$1,297.52
Max. Negotiated Rate	$2,247.49
Rate for Payer: Cash Price	$1,390.20
Rate for Payer: Hawaii Western Management Group Commercial	$1,621.90
Rate for Payer: Health Management Network Commercial	$1,969.45
Rate for Payer: MDX Hawaii PPO	$2,247.49
Rate for Payer: University Health Alliance Commercial	$1,297.52

PATELLA ASYMETRIC 5551-G-299-E

Facility

$2,317.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$1,181.67
Max. Negotiated Rate	$2,247.49
Rate for Payer: Cash Price	$1,390.20
Rate for Payer: Hawaii Western Management Group Commercial	$1,621.90
Rate for Payer: Health Management Network Commercial	$1,969.45
Rate for Payer: Kaiser Permanente Commercial	$1,459.71
Rate for Payer: Kaiser Permanente Medicaid	$1,181.67
Rate for Payer: MDX Hawaii PPO	$2,247.49
Rate for Payer: University Health Alliance Commercial	$1,297.52

PATELLA DOME 35MM 1518-20-035

Facility

$1,650.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$841.50
Max. Negotiated Rate	$1,600.50
Rate for Payer: Cash Price	$990.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,155.00
Rate for Payer: Health Management Network Commercial	$1,402.50
Rate for Payer: Kaiser Permanente Commercial	$1,039.50
Rate for Payer: Kaiser Permanente Medicaid	$841.50
Rate for Payer: MDX Hawaii PPO	$1,600.50
Rate for Payer: University Health Alliance Commercial	$924.00

PATELLA DOME 35MM 1518-20-035

Facility

$1,650.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$924.00
Max. Negotiated Rate	$1,600.50
Rate for Payer: Cash Price	$990.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,155.00
Rate for Payer: Health Management Network Commercial	$1,402.50
Rate for Payer: MDX Hawaii PPO	$1,600.50
Rate for Payer: University Health Alliance Commercial	$924.00

PATELLA DOME 41MM 1518-20-041

Facility

$1,650.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$841.50
Max. Negotiated Rate	$1,600.50
Rate for Payer: Cash Price	$990.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,155.00
Rate for Payer: Health Management Network Commercial	$1,402.50
Rate for Payer: Kaiser Permanente Commercial	$1,039.50
Rate for Payer: Kaiser Permanente Medicaid	$841.50
Rate for Payer: MDX Hawaii PPO	$1,600.50
Rate for Payer: University Health Alliance Commercial	$924.00

PATELLA DOME 41MM 1518-20-041

Facility

$1,650.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$924.00
Max. Negotiated Rate	$1,600.50
Rate for Payer: Cash Price	$990.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,155.00
Rate for Payer: Health Management Network Commercial	$1,402.50
Rate for Payer: MDX Hawaii PPO	$1,600.50
Rate for Payer: University Health Alliance Commercial	$924.00

PATELLA RESURFACE 02.07.0035RP

Facility

$1,575.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$803.25
Max. Negotiated Rate	$1,527.75
Rate for Payer: Cash Price	$945.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,102.50
Rate for Payer: Health Management Network Commercial	$1,338.75
Rate for Payer: Kaiser Permanente Commercial	$992.25
Rate for Payer: Kaiser Permanente Medicaid	$803.25
Rate for Payer: MDX Hawaii PPO	$1,527.75
Rate for Payer: University Health Alliance Commercial	$882.00

PATELLA RESURFACE 02.07.0035RP

Facility

$1,575.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$882.00
Max. Negotiated Rate	$1,527.75
Rate for Payer: Cash Price	$945.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,102.50
Rate for Payer: Health Management Network Commercial	$1,338.75
Rate for Payer: MDX Hawaii PPO	$1,527.75
Rate for Payer: University Health Alliance Commercial	$882.00

PATELLA RESURF S2 02.07.0034RP

Facility

$1,575.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$803.25
Max. Negotiated Rate	$1,527.75
Rate for Payer: Cash Price	$945.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,102.50
Rate for Payer: Health Management Network Commercial	$1,338.75
Rate for Payer: Kaiser Permanente Commercial	$992.25
Rate for Payer: Kaiser Permanente Medicaid	$803.25
Rate for Payer: MDX Hawaii PPO	$1,527.75
Rate for Payer: University Health Alliance Commercial	$882.00

PATELLA RESURF S2 02.07.0034RP

Facility

$1,575.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$882.00
Max. Negotiated Rate	$1,527.75
Rate for Payer: Cash Price	$945.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,102.50
Rate for Payer: Health Management Network Commercial	$1,338.75
Rate for Payer: MDX Hawaii PPO	$1,527.75
Rate for Payer: University Health Alliance Commercial	$882.00

PATELLA RESURF S4 02.07.0036RP

Facility

$1,050.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$588.00
Max. Negotiated Rate	$1,018.50
Rate for Payer: Cash Price	$630.00
Rate for Payer: Hawaii Western Management Group Commercial	$735.00
Rate for Payer: Health Management Network Commercial	$892.50
Rate for Payer: MDX Hawaii PPO	$1,018.50
Rate for Payer: University Health Alliance Commercial	$588.00

PATELLA RESURF S4 02.07.0036RP

Facility

$1,050.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$535.50
Max. Negotiated Rate	$1,018.50
Rate for Payer: Cash Price	$630.00
Rate for Payer: Hawaii Western Management Group Commercial	$735.00
Rate for Payer: Health Management Network Commercial	$892.50
Rate for Payer: Kaiser Permanente Commercial	$661.50
Rate for Payer: Kaiser Permanente Medicaid	$535.50
Rate for Payer: MDX Hawaii PPO	$1,018.50
Rate for Payer: University Health Alliance Commercial	$588.00

PATELLA S39X11MM X3 5550-G-391

Facility

$3,628.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$1,850.28
Max. Negotiated Rate	$3,519.16
Rate for Payer: Cash Price	$2,176.80
Rate for Payer: Hawaii Western Management Group Commercial	$2,539.60
Rate for Payer: Health Management Network Commercial	$3,083.80
Rate for Payer: Kaiser Permanente Commercial	$2,285.64
Rate for Payer: Kaiser Permanente Medicaid	$1,850.28
Rate for Payer: MDX Hawaii PPO	$3,519.16
Rate for Payer: University Health Alliance Commercial	$2,031.68

Know your out-of-pocket cost for care.

All Charges