Hilo Benioff Medical Center

All Charges

Charge

Type

Setting

Price

PERCUTANEOUS INST AR-1934PI-30

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

PERCUTANEOUS INST AR-1934PI-30

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

PERCUTANEOUS INTRA & EXTRACRANIAL VASCULAR PROCEDURES

Facility

$24,921.55

Service Code	APR-DRG 0304
Min. Negotiated Rate	$24,921.55
Max. Negotiated Rate	$24,921.55
Rate for Payer: AlohaCare Medicaid	$24,921.55
Rate for Payer: Hawaii Medical Service Association ABD	$24,921.55
Rate for Payer: Hawaii Medical Service Association Non-ABD	$24,921.55
Rate for Payer: Kaiser Permanente Medicaid	$24,921.55
Rate for Payer: Ohana Health Plan Medicaid	$24,921.55
Rate for Payer: UnitedHealthcare Medicaid	$24,921.55

PERCUTANEOUS INTRA & EXTRACRANIAL VASCULAR PROCEDURES

Facility

$12,566.77

Service Code	APR-DRG 0302
Min. Negotiated Rate	$12,566.77
Max. Negotiated Rate	$12,566.77
Rate for Payer: AlohaCare Medicaid	$12,566.77
Rate for Payer: Hawaii Medical Service Association ABD	$12,566.77
Rate for Payer: Hawaii Medical Service Association Non-ABD	$12,566.77
Rate for Payer: Kaiser Permanente Medicaid	$12,566.77
Rate for Payer: Ohana Health Plan Medicaid	$12,566.77
Rate for Payer: UnitedHealthcare Medicaid	$12,566.77

PERCUTANEOUS INTRA & EXTRACRANIAL VASCULAR PROCEDURES

Facility

$9,503.02

Service Code	APR-DRG 0301
Min. Negotiated Rate	$9,503.02
Max. Negotiated Rate	$9,503.02
Rate for Payer: AlohaCare Medicaid	$9,503.02
Rate for Payer: Hawaii Medical Service Association ABD	$9,503.02
Rate for Payer: Hawaii Medical Service Association Non-ABD	$9,503.02
Rate for Payer: Kaiser Permanente Medicaid	$9,503.02
Rate for Payer: Ohana Health Plan Medicaid	$9,503.02
Rate for Payer: UnitedHealthcare Medicaid	$9,503.02

PERCUTANEOUS INTRA & EXTRACRANIAL VASCULAR PROCEDURES

Facility

$18,600.98

Service Code	APR-DRG 0303
Min. Negotiated Rate	$18,600.98
Max. Negotiated Rate	$18,600.98
Rate for Payer: AlohaCare Medicaid	$18,600.98
Rate for Payer: Hawaii Medical Service Association ABD	$18,600.98
Rate for Payer: Hawaii Medical Service Association Non-ABD	$18,600.98
Rate for Payer: Kaiser Permanente Medicaid	$18,600.98
Rate for Payer: Ohana Health Plan Medicaid	$18,600.98
Rate for Payer: UnitedHealthcare Medicaid	$18,600.98

PERCUTANEOUS NEPHROLITHOTOMY OR PYELOLITHOTOMY, LITHOTRIPSY, STONE EXTRACTION, ANTEGRADE URETEROSCOPY, ANTEGRADE STENT PLACEMENT AND NEPHROSTOMY TUBE PLACEMENT, WHEN PERFORMED, INCLUDING IMAGING GUIDANCE; COMPLEX (EG, STONE[S] > 2 CM, BRANCHING STONES, STONES IN MULTIPLE LOCATIONS, URETER STONES, COMPLICATED ANATOMY)

Facility

$24,500.00

Service Code	CPT 50081
Hospital Revenue Code	360
Min. Negotiated Rate	$521.33
Max. Negotiated Rate	$24,500.00
Rate for Payer: AlohaCare Medicaid	$11,183.16
Rate for Payer: AlohaCare Medicare	$11,183.16
Rate for Payer: Devoted Health Medicare	$12,301.48
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	$11,183.16
Rate for Payer: Hawaii Medical Service Association Non-ABD	$2,695.11
Rate for Payer: Humana Medicare	$11,183.16
Rate for Payer: Kaiser Permanente Medicaid	$2,837.00
Rate for Payer: Kaiser Permanente Medicare	$11,183.16
Rate for Payer: Ohana Health Plan Medicaid	$12,301.48
Rate for Payer: Ohana Health Plan Medicare	$11,183.16
Rate for Payer: UnitedHealthcare Medicaid	$521.33
Rate for Payer: UnitedHealthcare Medicare	$11,183.16
Rate for Payer: University Health Alliance Commercial	$24,500.00

PERCUTANEOUS NEPHROLITHOTOMY OR PYELOLITHOTOMY, LITHOTRIPSY, STONE EXTRACTION, ANTEGRADE URETEROSCOPY, ANTEGRADE STENT PLACEMENT AND NEPHROSTOMY TUBE PLACEMENT, WHEN PERFORMED, INCLUDING IMAGING GUIDANCE; SIMPLE (EG, STONE[S] UP TO 2 CM IN SINGLE LOCATION OF KIDNEY OR RENAL PELVIS, NONBRANCHING STONES)

Facility

$20,300.00

Service Code	CPT 50080
Hospital Revenue Code	361
Min. Negotiated Rate	$521.33
Max. Negotiated Rate	$20,300.00
Rate for Payer: AlohaCare Medicaid	$11,183.16
Rate for Payer: AlohaCare Medicare	$11,183.16
Rate for Payer: Devoted Health Medicare	$12,301.48
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	$11,183.16
Rate for Payer: Hawaii Medical Service Association Non-ABD	$2,695.11
Rate for Payer: Humana Medicare	$11,183.16
Rate for Payer: Kaiser Permanente Medicaid	$2,837.00
Rate for Payer: Kaiser Permanente Medicare	$11,183.16
Rate for Payer: Ohana Health Plan Medicaid	$12,301.48
Rate for Payer: Ohana Health Plan Medicare	$11,183.16
Rate for Payer: UnitedHealthcare Medicaid	$521.33
Rate for Payer: UnitedHealthcare Medicare	$11,183.16
Rate for Payer: University Health Alliance Commercial	$20,300.00

PERCUTANEOUS NEPHROLITHOTOMY OR PYELOLITHOTOMY, LITHOTRIPSY, STONE EXTRACTION, ANTEGRADE URETEROSCOPY, ANTEGRADE STENT PLACEMENT AND NEPHROSTOMY TUBE PLACEMENT, WHEN PERFORMED, INCLUDING IMAGING GUIDANCE; SIMPLE (EG, STONE[S] UP TO 2 CM IN SINGLE LOCATION OF KIDNEY OR RENAL PELVIS, NONBRANCHING STONES)

Facility

$20,300.00

Service Code	CPT 50080
Hospital Revenue Code	360
Min. Negotiated Rate	$521.33
Max. Negotiated Rate	$20,300.00
Rate for Payer: AlohaCare Medicaid	$11,183.16
Rate for Payer: AlohaCare Medicare	$11,183.16
Rate for Payer: Devoted Health Medicare	$12,301.48
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	$11,183.16
Rate for Payer: Hawaii Medical Service Association Non-ABD	$2,695.11
Rate for Payer: Humana Medicare	$11,183.16
Rate for Payer: Kaiser Permanente Medicaid	$2,837.00
Rate for Payer: Kaiser Permanente Medicare	$11,183.16
Rate for Payer: Ohana Health Plan Medicaid	$12,301.48
Rate for Payer: Ohana Health Plan Medicare	$11,183.16
Rate for Payer: UnitedHealthcare Medicaid	$521.33
Rate for Payer: UnitedHealthcare Medicare	$11,183.16
Rate for Payer: University Health Alliance Commercial	$20,300.00

PERCUTANEOUS SKELETAL FIXATION OF CARPOMETACARPAL DISLOCATION, OTHER THAN THUMB, WITH MANIPULATION, EACH JOINT

Facility

$5,509.00

Service Code	CPT 26676
Hospital Revenue Code	360
Min. Negotiated Rate	$456.03
Max. Negotiated Rate	$5,509.00
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	$695.00
Rate for Payer: Hawaii Medical Service Association Commercial	$5,509.00
Rate for Payer: Hawaii Medical Service Association Medicare	$3,865.36
Rate for Payer: Hawaii Medical Service Association Non-ABD	$1,028.67
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	$5,160.40

PERCUTANEOUS SKELETAL FIXATION OF DISTAL RADIAL FRACTURE OR EPIPHYSEAL SEPARATION

Facility

$8,270.00

Service Code	CPT 25606
Hospital Revenue Code	360
Min. Negotiated Rate	$456.03
Max. Negotiated Rate	$8,270.00
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	$6,743.44

PERCUTANEOUS SKELETAL FIXATION OF HUMERAL EPICONDYLAR FRACTURE, MEDIAL OR LATERAL, WITH MANIPULATION

Facility

$8,270.00

Service Code	CPT 24566
Hospital Revenue Code	360
Min. Negotiated Rate	$456.03
Max. Negotiated Rate	$8,270.00
Rate for Payer: AlohaCare Medicaid	$1,899.59
Rate for Payer: AlohaCare Medicare	$1,899.59
Rate for Payer: Devoted Health Medicare	$2,089.55
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	$1,899.59
Rate for Payer: Hawaii Medical Service Association Non-ABD	$1,427.62
Rate for Payer: Humana Medicare	$1,899.59
Rate for Payer: Kaiser Permanente Medicaid	$2,837.00
Rate for Payer: Kaiser Permanente Medicare	$1,899.59
Rate for Payer: Ohana Health Plan Medicaid	$2,089.55
Rate for Payer: Ohana Health Plan Medicare	$1,899.59
Rate for Payer: UnitedHealthcare Medicaid	$456.03
Rate for Payer: UnitedHealthcare Medicare	$1,899.59
Rate for Payer: University Health Alliance Commercial	$5,160.40

PERCUTANEOUS SKELETAL FIXATION OF INTERPHALANGEAL JOINT DISLOCATION, SINGLE, WITH MANIPULATION

Facility

$5,509.00

Service Code	CPT 26776
Hospital Revenue Code	360
Min. Negotiated Rate	$456.03
Max. Negotiated Rate	$5,509.00
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	$695.00
Rate for Payer: Hawaii Medical Service Association Commercial	$5,509.00
Rate for Payer: Hawaii Medical Service Association Medicare	$3,865.36
Rate for Payer: Hawaii Medical Service Association Non-ABD	$1,028.67
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	$5,160.40

PERCUTANEOUS SKELETAL FIXATION OF METACARPAL FRACTURE, EACH BONE

Facility

$10,679.55

Service Code	CPT 26608
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	$695.00
Rate for Payer: Hawaii Medical Service Association Commercial	$5,509.00
Rate for Payer: Hawaii Medical Service Association Medicare	$3,865.36
Rate for Payer: Hawaii Medical Service Association Non-ABD	$1,028.67
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

PERCUTANEOUS SKELETAL FIXATION OF METACARPOPHALANGEAL DISLOCATION, SINGLE, WITH MANIPULATION

Facility

$5,509.00

Service Code	CPT 26706
Hospital Revenue Code	360
Min. Negotiated Rate	$456.03
Max. Negotiated Rate	$5,509.00
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	$695.00
Rate for Payer: Hawaii Medical Service Association Commercial	$5,509.00
Rate for Payer: Hawaii Medical Service Association Medicare	$3,865.36
Rate for Payer: Hawaii Medical Service Association Non-ABD	$1,028.67
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

PERCUTANEOUS SKELETAL FIXATION OF SUPRACONDYLAR OR TRANSCONDYLAR HUMERAL FRACTURE, WITH OR WITHOUT INTERCONDYLAR EXTENSION

Facility

$9,429.30

Service Code	CPT 24538
Hospital Revenue Code	360
Min. Negotiated Rate	$456.03
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	$456.03
Rate for Payer: UnitedHealthcare Medicare	$8,572.09
Rate for Payer: University Health Alliance Commercial	$5,160.40

PERCUTANEOUS SKELETAL FIXATION OF UNSTABLE PHALANGEAL SHAFT FRACTURE, PROXIMAL OR MIDDLE PHALANX, FINGER OR THUMB, WITH MANIPULATION, EACH

Facility

$16,700.00

Service Code	CPT 26727
Hospital Revenue Code	360
Min. Negotiated Rate	$456.03
Max. Negotiated Rate	$16,700.00
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	$695.00
Rate for Payer: Hawaii Medical Service Association Commercial	$5,509.00
Rate for Payer: Hawaii Medical Service Association Medicare	$3,865.36
Rate for Payer: Hawaii Medical Service Association Non-ABD	$1,028.67
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	$16,700.00

PERCUTANEOUS STRUCTURAL CARDIAC PROCEDURES

Facility

$27,803.96

Service Code	APR-DRG 1833
Min. Negotiated Rate	$27,803.96
Max. Negotiated Rate	$27,803.96
Rate for Payer: AlohaCare Medicaid	$27,803.96
Rate for Payer: Hawaii Medical Service Association ABD	$27,803.96
Rate for Payer: Hawaii Medical Service Association Non-ABD	$27,803.96
Rate for Payer: Kaiser Permanente Medicaid	$27,803.96
Rate for Payer: Ohana Health Plan Medicaid	$27,803.96
Rate for Payer: UnitedHealthcare Medicaid	$27,803.96

PERCUTANEOUS STRUCTURAL CARDIAC PROCEDURES

Facility

$23,902.04

Service Code	APR-DRG 1832
Min. Negotiated Rate	$23,902.04
Max. Negotiated Rate	$23,902.04
Rate for Payer: AlohaCare Medicaid	$23,902.04
Rate for Payer: Hawaii Medical Service Association ABD	$23,902.04
Rate for Payer: Hawaii Medical Service Association Non-ABD	$23,902.04
Rate for Payer: Kaiser Permanente Medicaid	$23,902.04
Rate for Payer: Ohana Health Plan Medicaid	$23,902.04
Rate for Payer: UnitedHealthcare Medicaid	$23,902.04

PERCUTANEOUS STRUCTURAL CARDIAC PROCEDURES

Facility

$22,337.88

Service Code	APR-DRG 1831
Min. Negotiated Rate	$22,337.88
Max. Negotiated Rate	$22,337.88
Rate for Payer: AlohaCare Medicaid	$22,337.88
Rate for Payer: Hawaii Medical Service Association ABD	$22,337.88
Rate for Payer: Hawaii Medical Service Association Non-ABD	$22,337.88
Rate for Payer: Kaiser Permanente Medicaid	$22,337.88
Rate for Payer: Ohana Health Plan Medicaid	$22,337.88
Rate for Payer: UnitedHealthcare Medicaid	$22,337.88

PERCUTANEOUS STRUCTURAL CARDIAC PROCEDURES

Facility

$38,928.54

Service Code	APR-DRG 1834
Min. Negotiated Rate	$38,928.54
Max. Negotiated Rate	$38,928.54
Rate for Payer: AlohaCare Medicaid	$38,928.54
Rate for Payer: Hawaii Medical Service Association ABD	$38,928.54
Rate for Payer: Hawaii Medical Service Association Non-ABD	$38,928.54
Rate for Payer: Kaiser Permanente Medicaid	$38,928.54
Rate for Payer: Ohana Health Plan Medicaid	$38,928.54
Rate for Payer: UnitedHealthcare Medicaid	$38,928.54

PERCUTANEOUS TRANSCATHETER PLACEMENT OF INTRACORONARY STENT(S), WITH CORONARY ANGIOPLASTY WHEN PERFORMED, SINGLE MAJOR CORONARY ARTERY AND/OR ITS BRANCH(ES); 1 LESION INVOLVING 1 OR MORE CORONARY SEGMENTS

Facility

$24,500.00

Service Code	CPT 92928
Hospital Revenue Code	481
Min. Negotiated Rate	$521.33
Max. Negotiated Rate	$24,500.00
Rate for Payer: AlohaCare Medicaid	$13,637.67
Rate for Payer: AlohaCare Medicare	$13,637.67
Rate for Payer: Devoted Health Medicare	$15,001.44
Rate for Payer: Hawaii Medical Service Association ABD	$2,102.00
Rate for Payer: Hawaii Medical Service Association Commercial	$19,192.00
Rate for Payer: Hawaii Medical Service Association Medicare	$13,637.67
Rate for Payer: Hawaii Medical Service Association Non-ABD	$3,561.00
Rate for Payer: Humana Medicare	$13,637.67
Rate for Payer: Kaiser Permanente Medicare	$13,637.67
Rate for Payer: Ohana Health Plan Medicaid	$15,001.44
Rate for Payer: Ohana Health Plan Medicare	$13,637.67
Rate for Payer: UnitedHealthcare Medicaid	$521.33
Rate for Payer: UnitedHealthcare Medicare	$13,637.67
Rate for Payer: University Health Alliance Commercial	$24,500.00

PERCUTANEOUS TRANSLUMINAL CORONARY ATHERECTOMY, WITH INTRACORONARY STENT, WITH CORONARY ANGIOPLASTY WHEN PERFORMED, SINGLE MAJOR CORONARY ARTERY AND/OR ITS BRANCH(ES)

Facility

$23,821.58

Service Code	CPT 92933
Hospital Revenue Code	481
Min. Negotiated Rate	$521.33
Max. Negotiated Rate	$23,821.58
Rate for Payer: AlohaCare Medicaid	$21,655.98
Rate for Payer: AlohaCare Medicare	$21,655.98
Rate for Payer: Devoted Health Medicare	$23,821.58
Rate for Payer: Hawaii Medical Service Association ABD	$2,102.00
Rate for Payer: Hawaii Medical Service Association Commercial	$19,192.00
Rate for Payer: Hawaii Medical Service Association Medicare	$21,655.98
Rate for Payer: Hawaii Medical Service Association Non-ABD	$3,561.00
Rate for Payer: Humana Medicare	$21,655.98
Rate for Payer: Kaiser Permanente Medicare	$21,655.98
Rate for Payer: Ohana Health Plan Medicaid	$23,821.58
Rate for Payer: Ohana Health Plan Medicare	$21,655.98
Rate for Payer: UnitedHealthcare Medicaid	$521.33
Rate for Payer: UnitedHealthcare Medicare	$21,655.98

PERFIX PLUG SMALL 0112950

Facility

$1,057.00

Service Code	HCPCS C1781
Hospital Revenue Code	278
Min. Negotiated Rate	$539.07
Max. Negotiated Rate	$1,025.29
Rate for Payer: Cash Price	$634.20
Rate for Payer: Hawaii Western Management Group Commercial	$739.90
Rate for Payer: Health Management Network Commercial	$898.45
Rate for Payer: Kaiser Permanente Commercial	$665.91
Rate for Payer: Kaiser Permanente Medicaid	$539.07
Rate for Payer: MDX Hawaii PPO	$1,025.29
Rate for Payer: University Health Alliance Commercial	$591.92

PERFIX PLUG SMALL 0112950

Facility

$1,057.00

Service Code	HCPCS C1781
Hospital Revenue Code	278
Min. Negotiated Rate	$591.92
Max. Negotiated Rate	$1,025.29
Rate for Payer: Cash Price	$634.20
Rate for Payer: Hawaii Western Management Group Commercial	$739.90
Rate for Payer: Health Management Network Commercial	$898.45
Rate for Payer: MDX Hawaii PPO	$1,025.29
Rate for Payer: University Health Alliance Commercial	$591.92

Know your out-of-pocket cost for care.

All Charges