Hilo Benioff Medical Center

All Charges

Charge

Type

Setting

Price

PERFORATOR DISP 14/11 200-241

Facility

$791.00

Hospital Revenue Code	272
Min. Negotiated Rate	$403.41
Max. Negotiated Rate	$767.27
Rate for Payer: Cash Price	$474.60
Rate for Payer: Hawaii Western Management Group Commercial	$751.45
Rate for Payer: Health Management Network Commercial	$672.35
Rate for Payer: Kaiser Permanente Commercial	$498.33
Rate for Payer: Kaiser Permanente Medicaid	$403.41
Rate for Payer: MDX Hawaii PPO	$767.27
Rate for Payer: University Health Alliance Commercial	$576.56

PERFORATOR DISP 14/11 200-241

Facility

$791.00

Hospital Revenue Code	272
Min. Negotiated Rate	$672.35
Max. Negotiated Rate	$767.27
Rate for Payer: Cash Price	$474.60
Rate for Payer: Health Management Network Commercial	$672.35
Rate for Payer: MDX Hawaii PPO	$767.27

PERFORM ANOTOM GLENOID DWE403

Facility

$4,628.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$2,591.68
Max. Negotiated Rate	$4,489.16
Rate for Payer: Cash Price	$2,776.80
Rate for Payer: Hawaii Western Management Group Commercial	$3,239.60
Rate for Payer: Health Management Network Commercial	$3,933.80
Rate for Payer: MDX Hawaii PPO	$4,489.16
Rate for Payer: University Health Alliance Commercial	$2,591.68

PERFORM ANOTOM GLENOID DWE403

Facility

$4,628.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$2,360.28
Max. Negotiated Rate	$4,489.16
Rate for Payer: Cash Price	$2,776.80
Rate for Payer: Hawaii Western Management Group Commercial	$3,239.60
Rate for Payer: Health Management Network Commercial	$3,933.80
Rate for Payer: Kaiser Permanente Commercial	$2,915.64
Rate for Payer: Kaiser Permanente Medicaid	$2,360.28
Rate for Payer: MDX Hawaii PPO	$4,489.16
Rate for Payer: University Health Alliance Commercial	$2,591.68

PERFORM HUMERAL SYSTEM DWP2420

Facility

$2,768.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$1,411.68
Max. Negotiated Rate	$2,684.96
Rate for Payer: Cash Price	$1,660.80
Rate for Payer: Hawaii Western Management Group Commercial	$1,937.60
Rate for Payer: Health Management Network Commercial	$2,352.80
Rate for Payer: Kaiser Permanente Commercial	$1,743.84
Rate for Payer: Kaiser Permanente Medicaid	$1,411.68
Rate for Payer: MDX Hawaii PPO	$2,684.96
Rate for Payer: University Health Alliance Commercial	$1,550.08

PERFORM HUMERAL SYSTEM DWP2420

Facility

$2,768.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$1,550.08
Max. Negotiated Rate	$2,684.96
Rate for Payer: Cash Price	$1,660.80
Rate for Payer: Hawaii Western Management Group Commercial	$1,937.60
Rate for Payer: Health Management Network Commercial	$2,352.80
Rate for Payer: MDX Hawaii PPO	$2,684.96
Rate for Payer: University Health Alliance Commercial	$1,550.08

PERFORM HUMERAL SYSTEM DWX3SS

Facility

$10,762.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$6,026.72
Max. Negotiated Rate	$10,439.14
Rate for Payer: Cash Price	$6,457.20
Rate for Payer: Hawaii Western Management Group Commercial	$7,533.40
Rate for Payer: Health Management Network Commercial	$9,147.70
Rate for Payer: MDX Hawaii PPO	$10,439.14
Rate for Payer: University Health Alliance Commercial	$6,026.72

PERFORM HUMERAL SYSTEM DWX3SS

Facility

$10,762.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$5,488.62
Max. Negotiated Rate	$10,439.14
Rate for Payer: Cash Price	$6,457.20
Rate for Payer: Hawaii Western Management Group Commercial	$7,533.40
Rate for Payer: Health Management Network Commercial	$9,147.70
Rate for Payer: Kaiser Permanente Commercial	$6,780.06
Rate for Payer: Kaiser Permanente Medicaid	$5,488.62
Rate for Payer: MDX Hawaii PPO	$10,439.14
Rate for Payer: University Health Alliance Commercial	$6,026.72

PERFORM REVERSE GLENOID DWJ012

Facility

$6,028.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$3,375.68
Max. Negotiated Rate	$5,847.16
Rate for Payer: Cash Price	$3,616.80
Rate for Payer: Hawaii Western Management Group Commercial	$4,219.60
Rate for Payer: Health Management Network Commercial	$5,123.80
Rate for Payer: MDX Hawaii PPO	$5,847.16
Rate for Payer: University Health Alliance Commercial	$3,375.68

PERFORM REVERSE GLENOID DWJ012

Facility

$6,028.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$3,074.28
Max. Negotiated Rate	$5,847.16
Rate for Payer: Cash Price	$3,616.80
Rate for Payer: Hawaii Western Management Group Commercial	$4,219.60
Rate for Payer: Health Management Network Commercial	$5,123.80
Rate for Payer: Kaiser Permanente Commercial	$3,797.64
Rate for Payer: Kaiser Permanente Medicaid	$3,074.28
Rate for Payer: MDX Hawaii PPO	$5,847.16
Rate for Payer: University Health Alliance Commercial	$3,375.68

PERI-IMPLANT CAPSULECTOMY, BREAST, COMPLETE, INCLUDING REMOVAL OF ALL INTRACAPSULAR CONTENTS

Facility

$10,679.55

Service Code	CPT 19371
Hospital Revenue Code	360
Min. Negotiated Rate	$456.03
Max. Negotiated Rate	$10,679.55
Rate for Payer: AlohaCare Medicaid	$4,625.48
Rate for Payer: AlohaCare Medicare	$4,625.48
Rate for Payer: Devoted Health Medicare	$5,088.03
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	$4,625.48
Rate for Payer: Hawaii Medical Service Association Non-ABD	$1,427.62
Rate for Payer: Humana Medicare	$4,625.48
Rate for Payer: Kaiser Permanente Medicaid	$2,837.00
Rate for Payer: Kaiser Permanente Medicare	$4,625.48
Rate for Payer: Ohana Health Plan Medicaid	$5,088.03
Rate for Payer: Ohana Health Plan Medicare	$4,625.48
Rate for Payer: UnitedHealthcare Medicaid	$456.03
Rate for Payer: UnitedHealthcare Medicare	$4,625.48
Rate for Payer: University Health Alliance Commercial	$10,679.55

PERINEAL PAD SUPINE 72200634

Facility

$354.00

Hospital Revenue Code	272
Min. Negotiated Rate	$180.54
Max. Negotiated Rate	$343.38
Rate for Payer: Cash Price	$212.40
Rate for Payer: Hawaii Western Management Group Commercial	$336.30
Rate for Payer: Health Management Network Commercial	$300.90
Rate for Payer: Kaiser Permanente Commercial	$223.02
Rate for Payer: Kaiser Permanente Medicaid	$180.54
Rate for Payer: MDX Hawaii PPO	$343.38
Rate for Payer: University Health Alliance Commercial	$258.03

PERINEAL PAD SUPINE 72200634

Facility

$354.00

Hospital Revenue Code	272
Min. Negotiated Rate	$300.90
Max. Negotiated Rate	$343.38
Rate for Payer: Cash Price	$212.40
Rate for Payer: Health Management Network Commercial	$300.90
Rate for Payer: MDX Hawaii PPO	$343.38

PERIPHERAL, CRANIAL & AUTONOMIC NERVE DISORDERS

Facility

$4,789.67

Service Code	APR-DRG 0483
Min. Negotiated Rate	$4,789.67
Max. Negotiated Rate	$4,789.67
Rate for Payer: AlohaCare Medicaid	$4,789.67
Rate for Payer: Hawaii Medical Service Association ABD	$4,789.67
Rate for Payer: Hawaii Medical Service Association Non-ABD	$4,789.67
Rate for Payer: Kaiser Permanente Medicaid	$4,789.67
Rate for Payer: Ohana Health Plan Medicaid	$4,789.67
Rate for Payer: UnitedHealthcare Medicaid	$4,789.67

PERIPHERAL, CRANIAL & AUTONOMIC NERVE DISORDERS

Facility

$3,166.80

Service Code	APR-DRG 0481
Min. Negotiated Rate	$3,166.80
Max. Negotiated Rate	$3,166.80
Rate for Payer: AlohaCare Medicaid	$3,166.80
Rate for Payer: Hawaii Medical Service Association ABD	$3,166.80
Rate for Payer: Hawaii Medical Service Association Non-ABD	$3,166.80
Rate for Payer: Kaiser Permanente Medicaid	$3,166.80
Rate for Payer: Ohana Health Plan Medicaid	$3,166.80
Rate for Payer: UnitedHealthcare Medicaid	$3,166.80

PERIPHERAL, CRANIAL & AUTONOMIC NERVE DISORDERS

Facility

$3,615.57

Service Code	APR-DRG 0482
Min. Negotiated Rate	$3,615.57
Max. Negotiated Rate	$3,615.57
Rate for Payer: AlohaCare Medicaid	$3,615.57
Rate for Payer: Hawaii Medical Service Association ABD	$3,615.57
Rate for Payer: Hawaii Medical Service Association Non-ABD	$3,615.57
Rate for Payer: Kaiser Permanente Medicaid	$3,615.57
Rate for Payer: Ohana Health Plan Medicaid	$3,615.57
Rate for Payer: UnitedHealthcare Medicaid	$3,615.57

PERIPHERAL, CRANIAL & AUTONOMIC NERVE DISORDERS

Facility

$9,668.70

Service Code	APR-DRG 0484
Min. Negotiated Rate	$9,668.70
Max. Negotiated Rate	$9,668.70
Rate for Payer: AlohaCare Medicaid	$9,668.70
Rate for Payer: Hawaii Medical Service Association ABD	$9,668.70
Rate for Payer: Hawaii Medical Service Association Non-ABD	$9,668.70
Rate for Payer: Kaiser Permanente Medicaid	$9,668.70
Rate for Payer: Ohana Health Plan Medicaid	$9,668.70
Rate for Payer: UnitedHealthcare Medicaid	$9,668.70

PERIPHERAL, CRANIAL NERVE AND OTHER NERVOUS SYSTEM PROCEDURES WITH CC OR PERIPHERAL NEUROSTIMULATOR

Facility

$59,475.97

Service Code	MSDRG 041
Min. Negotiated Rate	$10,400.00
Max. Negotiated Rate	$59,475.97
Rate for Payer: AlohaCare Medicare	$25,008.57
Rate for Payer: Devoted Health Medicare	$27,509.43
Rate for Payer: Hawaii Medical Service Association Commercial	$59,475.97
Rate for Payer: Hawaii Medical Service Association Medicare	$25,008.57
Rate for Payer: Humana Medicare	$25,008.57
Rate for Payer: Kaiser Permanente Commercial	$37,927.57
Rate for Payer: Kaiser Permanente Medicare	$25,008.57
Rate for Payer: Ohana Health Plan Medicare	$25,008.57
Rate for Payer: UnitedHealthcare Medicare	$25,008.57
Rate for Payer: University Health Alliance Commercial	$10,400.00

PERIPHERAL, CRANIAL NERVE AND OTHER NERVOUS SYSTEM PROCEDURES WITH MCC

Facility

$67,629.34

Service Code	MSDRG 040
Min. Negotiated Rate	$10,400.00
Max. Negotiated Rate	$67,629.34
Rate for Payer: Devoted Health Medicare	$48,310.11
Rate for Payer: AlohaCare Medicare	$43,918.28
Rate for Payer: Hawaii Medical Service Association Commercial	$67,629.34
Rate for Payer: Hawaii Medical Service Association Medicare	$43,918.28
Rate for Payer: Humana Medicare	$43,918.28
Rate for Payer: Kaiser Permanente Commercial	$66,605.70
Rate for Payer: Kaiser Permanente Medicare	$43,918.28
Rate for Payer: Ohana Health Plan Medicare	$43,918.28
Rate for Payer: UnitedHealthcare Medicare	$43,918.28
Rate for Payer: University Health Alliance Commercial	$10,400.00

PERIPHERAL, CRANIAL NERVE AND OTHER NERVOUS SYSTEM PROCEDURES WITHOUT CC/MCC

Facility

$51,298.32

Service Code	MSDRG 042
Min. Negotiated Rate	$10,400.00
Max. Negotiated Rate	$51,298.32
Rate for Payer: AlohaCare Medicare	$19,651.30
Rate for Payer: Devoted Health Medicare	$21,616.43
Rate for Payer: Hawaii Medical Service Association Commercial	$51,298.32
Rate for Payer: Hawaii Medical Service Association Medicare	$19,651.30
Rate for Payer: Humana Medicare	$19,651.30
Rate for Payer: Kaiser Permanente Commercial	$29,802.83
Rate for Payer: Kaiser Permanente Medicare	$19,651.30
Rate for Payer: Ohana Health Plan Medicare	$19,651.30
Rate for Payer: UnitedHealthcare Medicare	$19,651.30
Rate for Payer: University Health Alliance Commercial	$10,400.00

PERIPHERAL & OTHER VASCULAR DISORDERS

Facility

$8,260.44

Service Code	APR-DRG 1974
Min. Negotiated Rate	$8,260.44
Max. Negotiated Rate	$8,260.44
Rate for Payer: AlohaCare Medicaid	$8,260.44
Rate for Payer: Hawaii Medical Service Association ABD	$8,260.44
Rate for Payer: Hawaii Medical Service Association Non-ABD	$8,260.44
Rate for Payer: Kaiser Permanente Medicaid	$8,260.44
Rate for Payer: Ohana Health Plan Medicaid	$8,260.44
Rate for Payer: UnitedHealthcare Medicaid	$8,260.44

PERIPHERAL & OTHER VASCULAR DISORDERS

Facility

$2,565.41

Service Code	APR-DRG 1971
Min. Negotiated Rate	$2,565.41
Max. Negotiated Rate	$2,565.41
Rate for Payer: AlohaCare Medicaid	$2,565.41
Rate for Payer: Hawaii Medical Service Association ABD	$2,565.41
Rate for Payer: Hawaii Medical Service Association Non-ABD	$2,565.41
Rate for Payer: Kaiser Permanente Medicaid	$2,565.41
Rate for Payer: Ohana Health Plan Medicaid	$2,565.41
Rate for Payer: UnitedHealthcare Medicaid	$2,565.41

PERIPHERAL & OTHER VASCULAR DISORDERS

Facility

$3,381.40

Service Code	APR-DRG 1972
Min. Negotiated Rate	$3,381.40
Max. Negotiated Rate	$3,381.40
Rate for Payer: AlohaCare Medicaid	$3,381.40
Rate for Payer: Hawaii Medical Service Association ABD	$3,381.40
Rate for Payer: Hawaii Medical Service Association Non-ABD	$3,381.40
Rate for Payer: Kaiser Permanente Medicaid	$3,381.40
Rate for Payer: Ohana Health Plan Medicaid	$3,381.40
Rate for Payer: UnitedHealthcare Medicaid	$3,381.40

PERIPHERAL & OTHER VASCULAR DISORDERS

Facility

$4,674.87

Service Code	APR-DRG 1973
Min. Negotiated Rate	$4,674.87
Max. Negotiated Rate	$4,674.87
Rate for Payer: AlohaCare Medicaid	$4,674.87
Rate for Payer: Hawaii Medical Service Association ABD	$4,674.87
Rate for Payer: Hawaii Medical Service Association Non-ABD	$4,674.87
Rate for Payer: Kaiser Permanente Medicaid	$4,674.87
Rate for Payer: Ohana Health Plan Medicaid	$4,674.87
Rate for Payer: UnitedHealthcare Medicaid	$4,674.87

PERIPHERAL VASCULAR DISORDERS WITH CC

Facility

$25,115.31

Service Code	MSDRG 300
Min. Negotiated Rate	$12,142.02
Max. Negotiated Rate	$25,115.31
Rate for Payer: AlohaCare Medicare	$12,142.02
Rate for Payer: Devoted Health Medicare	$13,356.22
Rate for Payer: Hawaii Medical Service Association Commercial	$25,115.31
Rate for Payer: Hawaii Medical Service Association Medicare	$12,142.02
Rate for Payer: Humana Medicare	$12,142.02
Rate for Payer: Kaiser Permanente Commercial	$18,414.38
Rate for Payer: Kaiser Permanente Medicare	$12,142.02
Rate for Payer: Ohana Health Plan Medicare	$12,142.02
Rate for Payer: UnitedHealthcare Medicare	$12,142.02

Know your out-of-pocket cost for care.

All Charges