Hilo Benioff Medical Center

All Charges

Charge

Type

Setting

Price

PEPTIC ULCER & GASTRITIS

Facility

$11,628.79

Service Code	APR-DRG 2414
Min. Negotiated Rate	$11,628.79
Max. Negotiated Rate	$11,628.79
Rate for Payer: AlohaCare Medicaid	$11,628.79
Rate for Payer: Hawaii Medical Service Association ABD	$11,628.79
Rate for Payer: Hawaii Medical Service Association Non-ABD	$11,628.79
Rate for Payer: Kaiser Permanente Medicaid	$11,628.79
Rate for Payer: Ohana Health Plan Medicaid	$11,628.79
Rate for Payer: UnitedHealthcare Medicaid	$11,628.79

PEPTIC ULCER & GASTRITIS

Facility

$3,340.31

Service Code	APR-DRG 2411
Min. Negotiated Rate	$3,340.31
Max. Negotiated Rate	$3,340.31
Rate for Payer: AlohaCare Medicaid	$3,340.31
Rate for Payer: Hawaii Medical Service Association ABD	$3,340.31
Rate for Payer: Hawaii Medical Service Association Non-ABD	$3,340.31
Rate for Payer: Kaiser Permanente Medicaid	$3,340.31
Rate for Payer: Ohana Health Plan Medicaid	$3,340.31
Rate for Payer: UnitedHealthcare Medicaid	$3,340.31

PERC 2.4 INSERT KIT #AR-1934PI

Facility

$977.00

Hospital Revenue Code	272
Min. Negotiated Rate	$498.27
Max. Negotiated Rate	$947.69
Rate for Payer: Cash Price	$586.20
Rate for Payer: Hawaii Western Management Group Commercial	$928.15
Rate for Payer: Health Management Network Commercial	$830.45
Rate for Payer: Kaiser Permanente Commercial	$615.51
Rate for Payer: Kaiser Permanente Medicaid	$498.27
Rate for Payer: MDX Hawaii PPO	$947.69
Rate for Payer: University Health Alliance Commercial	$712.14

PERC 2.4 INSERT KIT #AR-1934PI

Facility

$977.00

Hospital Revenue Code	272
Min. Negotiated Rate	$830.45
Max. Negotiated Rate	$947.69
Rate for Payer: Cash Price	$586.20
Rate for Payer: Health Management Network Commercial	$830.45
Rate for Payer: MDX Hawaii PPO	$947.69

PERCEPTA CRTP MRI US

Facility

$34,000.00

Service Code	HCPCS C2621
Hospital Revenue Code	275
Min. Negotiated Rate	$19,040.00
Max. Negotiated Rate	$32,980.00
Rate for Payer: Cash Price	$20,400.00
Rate for Payer: Hawaii Western Management Group Commercial	$23,800.00
Rate for Payer: Health Management Network Commercial	$28,900.00
Rate for Payer: MDX Hawaii PPO	$32,980.00
Rate for Payer: University Health Alliance Commercial	$19,040.00

PERCEPTA CRTP MRI US

Facility

$34,000.00

Service Code	HCPCS C2621
Hospital Revenue Code	275
Min. Negotiated Rate	$17,340.00
Max. Negotiated Rate	$32,980.00
Rate for Payer: Cash Price	$20,400.00
Rate for Payer: Hawaii Western Management Group Commercial	$23,800.00
Rate for Payer: Health Management Network Commercial	$28,900.00
Rate for Payer: Kaiser Permanente Commercial	$21,420.00
Rate for Payer: Kaiser Permanente Medicaid	$17,340.00
Rate for Payer: MDX Hawaii PPO	$32,980.00
Rate for Payer: University Health Alliance Commercial	$19,040.00

PERCIVA ICD DF4

Facility

$28,368.00

Service Code	HCPCS C1721
Hospital Revenue Code	275
Min. Negotiated Rate	$14,467.68
Max. Negotiated Rate	$27,516.96
Rate for Payer: Cash Price	$17,020.80
Rate for Payer: Hawaii Western Management Group Commercial	$19,857.60
Rate for Payer: Health Management Network Commercial	$24,112.80
Rate for Payer: Kaiser Permanente Commercial	$17,871.84
Rate for Payer: Kaiser Permanente Medicaid	$14,467.68
Rate for Payer: MDX Hawaii PPO	$27,516.96
Rate for Payer: University Health Alliance Commercial	$15,886.08

PERCIVA ICD DF4

Facility

$28,368.00

Service Code	HCPCS C1721
Hospital Revenue Code	275
Min. Negotiated Rate	$15,886.08
Max. Negotiated Rate	$27,516.96
Rate for Payer: Cash Price	$17,020.80
Rate for Payer: Hawaii Western Management Group Commercial	$19,857.60
Rate for Payer: Health Management Network Commercial	$24,112.80
Rate for Payer: MDX Hawaii PPO	$27,516.96
Rate for Payer: University Health Alliance Commercial	$15,886.08

PERCUTANEOUS AND OTHER INTRACARDIAC PROCEDURES WITH MCC

Facility

$71,164.88

Service Code	MSDRG 273
Min. Negotiated Rate	$46,924.49
Max. Negotiated Rate	$71,164.88
Rate for Payer: AlohaCare Medicare	$46,924.49
Rate for Payer: Devoted Health Medicare	$51,616.94
Rate for Payer: Hawaii Medical Service Association Commercial	$54,671.30
Rate for Payer: Hawaii Medical Service Association Medicare	$46,924.49
Rate for Payer: Humana Medicare	$46,924.49
Rate for Payer: Kaiser Permanente Commercial	$71,164.88
Rate for Payer: Kaiser Permanente Medicare	$46,924.49
Rate for Payer: Ohana Health Plan Medicare	$46,924.49
Rate for Payer: UnitedHealthcare Medicare	$46,924.49

PERCUTANEOUS AND OTHER INTRACARDIAC PROCEDURES WITHOUT MCC

Facility

$56,781.82

Service Code	MSDRG 274
Min. Negotiated Rate	$37,440.63
Max. Negotiated Rate	$56,781.82
Rate for Payer: AlohaCare Medicare	$37,440.63
Rate for Payer: Devoted Health Medicare	$41,184.69
Rate for Payer: Hawaii Medical Service Association Commercial	$38,485.88
Rate for Payer: Hawaii Medical Service Association Medicare	$37,440.63
Rate for Payer: Humana Medicare	$37,440.63
Rate for Payer: Kaiser Permanente Commercial	$56,781.82
Rate for Payer: Kaiser Permanente Medicare	$37,440.63
Rate for Payer: Ohana Health Plan Medicare	$37,440.63
Rate for Payer: UnitedHealthcare Medicare	$37,440.63

PERCUTANEOUS CARDIAC INTERVENTION W AMI

Facility

$19,444.38

Service Code	APR-DRG 1744
Min. Negotiated Rate	$19,444.38
Max. Negotiated Rate	$19,444.38
Rate for Payer: AlohaCare Medicaid	$19,444.38
Rate for Payer: Hawaii Medical Service Association ABD	$19,444.38
Rate for Payer: Hawaii Medical Service Association Non-ABD	$19,444.38
Rate for Payer: Kaiser Permanente Medicaid	$19,444.38
Rate for Payer: Ohana Health Plan Medicaid	$19,444.38
Rate for Payer: UnitedHealthcare Medicaid	$19,444.38

PERCUTANEOUS CARDIAC INTERVENTION W AMI

Facility

$10,776.27

Service Code	APR-DRG 1741
Min. Negotiated Rate	$10,776.27
Max. Negotiated Rate	$10,776.27
Rate for Payer: AlohaCare Medicaid	$10,776.27
Rate for Payer: Hawaii Medical Service Association ABD	$10,776.27
Rate for Payer: Hawaii Medical Service Association Non-ABD	$10,776.27
Rate for Payer: Kaiser Permanente Medicaid	$10,776.27
Rate for Payer: Ohana Health Plan Medicaid	$10,776.27
Rate for Payer: UnitedHealthcare Medicaid	$10,776.27

PERCUTANEOUS CARDIAC INTERVENTION W AMI

Facility

$14,152.45

Service Code	APR-DRG 1743
Min. Negotiated Rate	$14,152.45
Max. Negotiated Rate	$14,152.45
Rate for Payer: AlohaCare Medicaid	$14,152.45
Rate for Payer: Hawaii Medical Service Association ABD	$14,152.45
Rate for Payer: Hawaii Medical Service Association Non-ABD	$14,152.45
Rate for Payer: Kaiser Permanente Medicaid	$14,152.45
Rate for Payer: Ohana Health Plan Medicaid	$14,152.45
Rate for Payer: UnitedHealthcare Medicaid	$14,152.45

PERCUTANEOUS CARDIAC INTERVENTION W AMI

Facility

$11,552.48

Service Code	APR-DRG 1742
Min. Negotiated Rate	$11,552.48
Max. Negotiated Rate	$11,552.48
Rate for Payer: AlohaCare Medicaid	$11,552.48
Rate for Payer: Hawaii Medical Service Association ABD	$11,552.48
Rate for Payer: Hawaii Medical Service Association Non-ABD	$11,552.48
Rate for Payer: Kaiser Permanente Medicaid	$11,552.48
Rate for Payer: Ohana Health Plan Medicaid	$11,552.48
Rate for Payer: UnitedHealthcare Medicaid	$11,552.48

PERCUTANEOUS CARDIAC INTERVENTION W/O AMI

Facility

$11,891.01

Service Code	APR-DRG 1752
Min. Negotiated Rate	$11,891.01
Max. Negotiated Rate	$11,891.01
Rate for Payer: AlohaCare Medicaid	$11,891.01
Rate for Payer: Hawaii Medical Service Association ABD	$11,891.01
Rate for Payer: Hawaii Medical Service Association Non-ABD	$11,891.01
Rate for Payer: Kaiser Permanente Medicaid	$11,891.01
Rate for Payer: Ohana Health Plan Medicaid	$11,891.01
Rate for Payer: UnitedHealthcare Medicaid	$11,891.01

PERCUTANEOUS CARDIAC INTERVENTION W/O AMI

Facility

$14,513.82

Service Code	APR-DRG 1753
Min. Negotiated Rate	$14,513.82
Max. Negotiated Rate	$14,513.82
Rate for Payer: AlohaCare Medicaid	$14,513.82
Rate for Payer: Hawaii Medical Service Association ABD	$14,513.82
Rate for Payer: Hawaii Medical Service Association Non-ABD	$14,513.82
Rate for Payer: Kaiser Permanente Medicaid	$14,513.82
Rate for Payer: Ohana Health Plan Medicaid	$14,513.82
Rate for Payer: UnitedHealthcare Medicaid	$14,513.82

PERCUTANEOUS CARDIAC INTERVENTION W/O AMI

Facility

$21,750.83

Service Code	APR-DRG 1754
Min. Negotiated Rate	$21,750.83
Max. Negotiated Rate	$21,750.83
Rate for Payer: AlohaCare Medicaid	$21,750.83
Rate for Payer: Hawaii Medical Service Association ABD	$21,750.83
Rate for Payer: Hawaii Medical Service Association Non-ABD	$21,750.83
Rate for Payer: Kaiser Permanente Medicaid	$21,750.83
Rate for Payer: Ohana Health Plan Medicaid	$21,750.83
Rate for Payer: UnitedHealthcare Medicaid	$21,750.83

PERCUTANEOUS CARDIAC INTERVENTION W/O AMI

Facility

$10,848.67

Service Code	APR-DRG 1751
Min. Negotiated Rate	$10,848.67
Max. Negotiated Rate	$10,848.67
Rate for Payer: AlohaCare Medicaid	$10,848.67
Rate for Payer: Hawaii Medical Service Association ABD	$10,848.67
Rate for Payer: Hawaii Medical Service Association Non-ABD	$10,848.67
Rate for Payer: Kaiser Permanente Medicaid	$10,848.67
Rate for Payer: Ohana Health Plan Medicaid	$10,848.67
Rate for Payer: UnitedHealthcare Medicaid	$10,848.67

PERCUTANEOUS CARDIOVASCULAR PROCEDURES WITH INTRALUMINAL DEVICE WITH MCC OR 4+ ARTERIES/INTRALUMINAL DEVICES

Facility

$58,408.26

Service Code	MSDRG 321
Min. Negotiated Rate	$30,947.08
Max. Negotiated Rate	$58,408.26
Rate for Payer: AlohaCare Medicare	$30,947.08
Rate for Payer: Devoted Health Medicare	$34,041.79
Rate for Payer: Hawaii Medical Service Association Commercial	$58,408.26
Rate for Payer: Hawaii Medical Service Association Medicare	$30,947.08
Rate for Payer: Humana Medicare	$30,947.08
Rate for Payer: Kaiser Permanente Commercial	$46,933.80
Rate for Payer: Kaiser Permanente Medicare	$30,947.08
Rate for Payer: Ohana Health Plan Medicare	$30,947.08
Rate for Payer: UnitedHealthcare Medicare	$30,947.08

PERCUTANEOUS CARDIOVASCULAR PROCEDURES WITH INTRALUMINAL DEVICE WITHOUT MCC

Facility

$41,446.33

Service Code	MSDRG 322
Min. Negotiated Rate	$20,052.82
Max. Negotiated Rate	$41,446.33
Rate for Payer: AlohaCare Medicare	$20,052.82
Rate for Payer: Devoted Health Medicare	$22,058.10
Rate for Payer: Hawaii Medical Service Association Commercial	$41,446.33
Rate for Payer: Hawaii Medical Service Association Medicare	$20,052.82
Rate for Payer: Humana Medicare	$20,052.82
Rate for Payer: Kaiser Permanente Commercial	$30,411.75
Rate for Payer: Kaiser Permanente Medicare	$20,052.82
Rate for Payer: Ohana Health Plan Medicare	$20,052.82
Rate for Payer: UnitedHealthcare Medicare	$20,052.82

PERCUTANEOUS CARDIOVASCULAR PROCEDURES WITHOUT INTRALUMINAL DEVICE WITH MCC

Facility

$49,138.65

Service Code	MSDRG 250
Min. Negotiated Rate	$24,824.32
Max. Negotiated Rate	$49,138.65
Rate for Payer: AlohaCare Medicare	$24,824.32
Rate for Payer: Devoted Health Medicare	$27,306.75
Rate for Payer: Hawaii Medical Service Association Commercial	$49,138.65
Rate for Payer: Hawaii Medical Service Association Medicare	$24,824.32
Rate for Payer: Humana Medicare	$24,824.32
Rate for Payer: Kaiser Permanente Commercial	$37,648.12
Rate for Payer: Kaiser Permanente Medicare	$24,824.32
Rate for Payer: Ohana Health Plan Medicare	$24,824.32
Rate for Payer: UnitedHealthcare Medicare	$24,824.32

PERCUTANEOUS CARDIOVASCULAR PROCEDURES WITHOUT INTRALUMINAL DEVICE WITHOUT MCC

Facility

$36,593.13

Service Code	MSDRG 251
Min. Negotiated Rate	$16,998.82
Max. Negotiated Rate	$36,593.13
Rate for Payer: AlohaCare Medicare	$16,998.82
Rate for Payer: Devoted Health Medicare	$18,698.70
Rate for Payer: Hawaii Medical Service Association Commercial	$36,593.13
Rate for Payer: Hawaii Medical Service Association Medicare	$16,998.82
Rate for Payer: Humana Medicare	$16,998.82
Rate for Payer: Kaiser Permanente Commercial	$25,780.12
Rate for Payer: Kaiser Permanente Medicare	$16,998.82
Rate for Payer: Ohana Health Plan Medicare	$16,998.82
Rate for Payer: UnitedHealthcare Medicare	$16,998.82

PERCUTANEOUS CORONARY ATHERECTOMY WITH INTRALUMINAL DEVICE WITH MCC

Facility

$59,315.85

Service Code	MSDRG 359
Min. Negotiated Rate	$39,111.51
Max. Negotiated Rate	$59,315.85
Rate for Payer: AlohaCare Medicare	$39,111.51
Rate for Payer: Devoted Health Medicare	$43,022.66
Rate for Payer: Hawaii Medical Service Association Commercial	$58,408.26
Rate for Payer: Hawaii Medical Service Association Medicare	$39,111.51
Rate for Payer: Humana Medicare	$39,111.51
Rate for Payer: Kaiser Permanente Commercial	$59,315.85
Rate for Payer: Kaiser Permanente Medicare	$39,111.51
Rate for Payer: Ohana Health Plan Medicare	$39,111.51
Rate for Payer: UnitedHealthcare Medicare	$39,111.51

PERCUTANEOUS CORONARY ATHERECTOMY WITH INTRALUMINAL DEVICE WITHOUT MCC

Facility

$41,646.68

Service Code	MSDRG 360
Min. Negotiated Rate	$27,460.87
Max. Negotiated Rate	$41,646.68
Rate for Payer: AlohaCare Medicare	$27,460.87
Rate for Payer: Devoted Health Medicare	$30,206.96
Rate for Payer: Hawaii Medical Service Association Commercial	$41,446.33
Rate for Payer: Hawaii Medical Service Association Medicare	$27,460.87
Rate for Payer: Humana Medicare	$27,460.87
Rate for Payer: Kaiser Permanente Commercial	$41,646.68
Rate for Payer: Kaiser Permanente Medicare	$27,460.87
Rate for Payer: Ohana Health Plan Medicare	$27,460.87
Rate for Payer: UnitedHealthcare Medicare	$27,460.87

PERCUTANEOUS CORONARY ATHERECTOMY WITHOUT INTRALUMINAL DEVICE

Facility

$49,138.65

Service Code	MSDRG 318
Min. Negotiated Rate	$27,550.72
Max. Negotiated Rate	$49,138.65
Rate for Payer: AlohaCare Medicare	$27,550.72
Rate for Payer: Devoted Health Medicare	$30,305.79
Rate for Payer: Hawaii Medical Service Association Commercial	$49,138.65
Rate for Payer: Hawaii Medical Service Association Medicare	$27,550.72
Rate for Payer: Humana Medicare	$27,550.72
Rate for Payer: Kaiser Permanente Commercial	$41,782.95
Rate for Payer: Kaiser Permanente Medicare	$27,550.72
Rate for Payer: Ohana Health Plan Medicare	$27,550.72
Rate for Payer: UnitedHealthcare Medicare	$27,550.72

Know your out-of-pocket cost for care.

All Charges