Hilo Benioff Medical Center

All Charges

Charge

Type

Setting

Price

PLASTIC OPERATION ON PENIS TO CORRECT ANGULATION

Facility

$6,743.44

Service Code	CPT 54360
Hospital Revenue Code	360
Min. Negotiated Rate	$521.33
Max. Negotiated Rate	$6,743.44
Rate for Payer: AlohaCare Medicaid	$4,164.22
Rate for Payer: AlohaCare Medicare	$4,164.22
Rate for Payer: Devoted Health Medicare	$4,580.64
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	$4,164.22
Rate for Payer: Hawaii Medical Service Association Non-ABD	$1,028.67
Rate for Payer: Humana Medicare	$4,164.22
Rate for Payer: Kaiser Permanente Medicaid	$2,837.00
Rate for Payer: Kaiser Permanente Medicare	$4,164.22
Rate for Payer: Ohana Health Plan Medicaid	$4,580.64
Rate for Payer: Ohana Health Plan Medicare	$4,164.22
Rate for Payer: UnitedHealthcare Medicaid	$521.33
Rate for Payer: UnitedHealthcare Medicare	$4,164.22
Rate for Payer: University Health Alliance Commercial	$6,743.44

PLASTIC REPAIR OF INTROITUS

Facility

$8,270.00

Service Code	CPT 56800
Hospital Revenue Code	360
Min. Negotiated Rate	$456.03
Max. Negotiated Rate	$8,270.00
Rate for Payer: AlohaCare Medicaid	$3,824.16
Rate for Payer: AlohaCare Medicare	$3,824.16
Rate for Payer: Devoted Health Medicare	$4,206.58
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	$3,824.16
Rate for Payer: Hawaii Medical Service Association Non-ABD	$1,427.62
Rate for Payer: Humana Medicare	$3,824.16
Rate for Payer: Kaiser Permanente Medicaid	$2,837.00
Rate for Payer: Kaiser Permanente Medicare	$3,824.16
Rate for Payer: Ohana Health Plan Medicaid	$4,206.58
Rate for Payer: Ohana Health Plan Medicare	$3,824.16
Rate for Payer: UnitedHealthcare Medicaid	$456.03
Rate for Payer: UnitedHealthcare Medicare	$3,824.16
Rate for Payer: University Health Alliance Commercial	$6,743.44

PLAT DHS 135D/6H/110MM 281.160

Facility

$2,430.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,360.80
Max. Negotiated Rate	$2,357.10
Rate for Payer: Cash Price	$1,458.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,701.00
Rate for Payer: Health Management Network Commercial	$2,065.50
Rate for Payer: MDX Hawaii PPO	$2,357.10
Rate for Payer: University Health Alliance Commercial	$1,360.80

PLAT DHS 135D/6H/110MM 281.160

Facility

$2,430.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,239.30
Max. Negotiated Rate	$2,357.10
Rate for Payer: Cash Price	$1,458.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,701.00
Rate for Payer: Health Management Network Commercial	$2,065.50
Rate for Payer: Kaiser Permanente Commercial	$1,530.90
Rate for Payer: Kaiser Permanente Medicaid	$1,239.30
Rate for Payer: MDX Hawaii PPO	$2,357.10
Rate for Payer: University Health Alliance Commercial	$1,360.80

PLAT DHS 140D 6H 110MM 281.260

Facility

$2,430.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,360.80
Max. Negotiated Rate	$2,357.10
Rate for Payer: Cash Price	$1,458.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,701.00
Rate for Payer: Health Management Network Commercial	$2,065.50
Rate for Payer: MDX Hawaii PPO	$2,357.10
Rate for Payer: University Health Alliance Commercial	$1,360.80

PLAT DHS 140D 6H 110MM 281.260

Facility

$2,430.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,239.30
Max. Negotiated Rate	$2,357.10
Rate for Payer: Cash Price	$1,458.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,701.00
Rate for Payer: Health Management Network Commercial	$2,065.50
Rate for Payer: Kaiser Permanente Commercial	$1,530.90
Rate for Payer: Kaiser Permanente Medicaid	$1,239.30
Rate for Payer: MDX Hawaii PPO	$2,357.10
Rate for Payer: University Health Alliance Commercial	$1,360.80

PLAT DHS 145D/6H/110MM 281.360

Facility

$2,001.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,120.56
Max. Negotiated Rate	$1,940.97
Rate for Payer: Cash Price	$1,200.60
Rate for Payer: Hawaii Western Management Group Commercial	$1,400.70
Rate for Payer: Health Management Network Commercial	$1,700.85
Rate for Payer: MDX Hawaii PPO	$1,940.97
Rate for Payer: University Health Alliance Commercial	$1,120.56

PLAT DHS 145D/6H/110MM 281.360

Facility

$2,001.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,020.51
Max. Negotiated Rate	$1,940.97
Rate for Payer: Cash Price	$1,200.60
Rate for Payer: Hawaii Western Management Group Commercial	$1,400.70
Rate for Payer: Health Management Network Commercial	$1,700.85
Rate for Payer: Kaiser Permanente Commercial	$1,260.63
Rate for Payer: Kaiser Permanente Medicaid	$1,020.51
Rate for Payer: MDX Hawaii PPO	$1,940.97
Rate for Payer: University Health Alliance Commercial	$1,120.56

PLATE 10 HOLE 629550S

Facility

$2,060.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,153.60
Max. Negotiated Rate	$1,998.20
Rate for Payer: Cash Price	$1,236.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,442.00
Rate for Payer: Health Management Network Commercial	$1,751.00
Rate for Payer: MDX Hawaii PPO	$1,998.20
Rate for Payer: University Health Alliance Commercial	$1,153.60

PLATE 10 HOLE 629550S

Facility

$2,060.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,050.60
Max. Negotiated Rate	$1,998.20
Rate for Payer: Cash Price	$1,236.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,442.00
Rate for Payer: Health Management Network Commercial	$1,751.00
Rate for Payer: Kaiser Permanente Commercial	$1,297.80
Rate for Payer: Kaiser Permanente Medicaid	$1,050.60
Rate for Payer: MDX Hawaii PPO	$1,998.20
Rate for Payer: University Health Alliance Commercial	$1,153.60

PLATE 126MM 10H

Facility

$2,225.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,246.00
Max. Negotiated Rate	$2,158.25
Rate for Payer: Cash Price	$1,335.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,557.50
Rate for Payer: Health Management Network Commercial	$1,891.25
Rate for Payer: MDX Hawaii PPO	$2,158.25
Rate for Payer: University Health Alliance Commercial	$1,246.00

PLATE 126MM 10H

Facility

$2,225.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,134.75
Max. Negotiated Rate	$2,158.25
Rate for Payer: Cash Price	$1,335.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,557.50
Rate for Payer: Health Management Network Commercial	$1,891.25
Rate for Payer: Kaiser Permanente Commercial	$1,401.75
Rate for Payer: Kaiser Permanente Medicaid	$1,134.75
Rate for Payer: MDX Hawaii PPO	$2,158.25
Rate for Payer: University Health Alliance Commercial	$1,246.00

PLATE 1/3 10-HOLE/121MM 241.40

Facility

$310.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$173.60
Max. Negotiated Rate	$300.70
Rate for Payer: Cash Price	$186.00
Rate for Payer: Hawaii Western Management Group Commercial	$217.00
Rate for Payer: Health Management Network Commercial	$263.50
Rate for Payer: MDX Hawaii PPO	$300.70
Rate for Payer: University Health Alliance Commercial	$173.60

PLATE 1/3 10-HOLE/121MM 241.40

Facility

$310.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$158.10
Max. Negotiated Rate	$300.70
Rate for Payer: Cash Price	$186.00
Rate for Payer: Hawaii Western Management Group Commercial	$217.00
Rate for Payer: Health Management Network Commercial	$263.50
Rate for Payer: Kaiser Permanente Commercial	$195.30
Rate for Payer: Kaiser Permanente Medicaid	$158.10
Rate for Payer: MDX Hawaii PPO	$300.70
Rate for Payer: University Health Alliance Commercial	$173.60

PLATE 1/3 2-HOLE/25MM 241.32

Facility

$381.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$194.31
Max. Negotiated Rate	$369.57
Rate for Payer: Cash Price	$228.60
Rate for Payer: Hawaii Western Management Group Commercial	$266.70
Rate for Payer: Health Management Network Commercial	$323.85
Rate for Payer: Kaiser Permanente Commercial	$240.03
Rate for Payer: Kaiser Permanente Medicaid	$194.31
Rate for Payer: MDX Hawaii PPO	$369.57
Rate for Payer: University Health Alliance Commercial	$213.36

PLATE 1/3 2-HOLE/25MM 241.32

Facility

$381.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$213.36
Max. Negotiated Rate	$369.57
Rate for Payer: Cash Price	$228.60
Rate for Payer: Hawaii Western Management Group Commercial	$266.70
Rate for Payer: Health Management Network Commercial	$323.85
Rate for Payer: MDX Hawaii PPO	$369.57
Rate for Payer: University Health Alliance Commercial	$213.36

PLATE 1/3 3-HOLE/37MM 241.33

Facility

$389.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$217.84
Max. Negotiated Rate	$377.33
Rate for Payer: Cash Price	$233.40
Rate for Payer: Hawaii Western Management Group Commercial	$272.30
Rate for Payer: Health Management Network Commercial	$330.65
Rate for Payer: MDX Hawaii PPO	$377.33
Rate for Payer: University Health Alliance Commercial	$217.84

PLATE 1/3 3-HOLE/37MM 241.33

Facility

$389.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$198.39
Max. Negotiated Rate	$377.33
Rate for Payer: Cash Price	$233.40
Rate for Payer: Hawaii Western Management Group Commercial	$272.30
Rate for Payer: Health Management Network Commercial	$330.65
Rate for Payer: Kaiser Permanente Commercial	$245.07
Rate for Payer: Kaiser Permanente Medicaid	$198.39
Rate for Payer: MDX Hawaii PPO	$377.33
Rate for Payer: University Health Alliance Commercial	$217.84

PLATE 1/3 8-HOLE/97MM 241.38

Facility

$450.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$252.00
Max. Negotiated Rate	$436.50
Rate for Payer: Cash Price	$270.00
Rate for Payer: Hawaii Western Management Group Commercial	$315.00
Rate for Payer: Health Management Network Commercial	$382.50
Rate for Payer: MDX Hawaii PPO	$436.50
Rate for Payer: University Health Alliance Commercial	$252.00

PLATE 1/3 8-HOLE/97MM 241.38

Facility

$450.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$229.50
Max. Negotiated Rate	$436.50
Rate for Payer: Cash Price	$270.00
Rate for Payer: Hawaii Western Management Group Commercial	$315.00
Rate for Payer: Health Management Network Commercial	$382.50
Rate for Payer: Kaiser Permanente Commercial	$283.50
Rate for Payer: Kaiser Permanente Medicaid	$229.50
Rate for Payer: MDX Hawaii PPO	$436.50
Rate for Payer: University Health Alliance Commercial	$252.00

PLATE 1/3 9-HOLE/109MM 241.39

Facility

$543.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$276.93
Max. Negotiated Rate	$526.71
Rate for Payer: Cash Price	$325.80
Rate for Payer: Hawaii Western Management Group Commercial	$380.10
Rate for Payer: Health Management Network Commercial	$461.55
Rate for Payer: Kaiser Permanente Commercial	$342.09
Rate for Payer: Kaiser Permanente Medicaid	$276.93
Rate for Payer: MDX Hawaii PPO	$526.71
Rate for Payer: University Health Alliance Commercial	$304.08

PLATE 1/3 9-HOLE/109MM 241.39

Facility

$543.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$304.08
Max. Negotiated Rate	$526.71
Rate for Payer: Cash Price	$325.80
Rate for Payer: Hawaii Western Management Group Commercial	$380.10
Rate for Payer: Health Management Network Commercial	$461.55
Rate for Payer: MDX Hawaii PPO	$526.71
Rate for Payer: University Health Alliance Commercial	$304.08

PLATE 1/3 TUBULAR 10H 626680

Facility

$1,848.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$942.48
Max. Negotiated Rate	$1,792.56
Rate for Payer: Cash Price	$1,108.80
Rate for Payer: Hawaii Western Management Group Commercial	$1,293.60
Rate for Payer: Health Management Network Commercial	$1,570.80
Rate for Payer: Kaiser Permanente Commercial	$1,164.24
Rate for Payer: Kaiser Permanente Medicaid	$942.48
Rate for Payer: MDX Hawaii PPO	$1,792.56
Rate for Payer: University Health Alliance Commercial	$1,034.88

PLATE 1/3 TUBULAR 10H 626680

Facility

$1,848.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,034.88
Max. Negotiated Rate	$1,792.56
Rate for Payer: Cash Price	$1,108.80
Rate for Payer: Hawaii Western Management Group Commercial	$1,293.60
Rate for Payer: Health Management Network Commercial	$1,570.80
Rate for Payer: MDX Hawaii PPO	$1,792.56
Rate for Payer: University Health Alliance Commercial	$1,034.88

PLATE 1/3 TUBULAR 83 7H 626677

Facility

$1,608.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$900.48
Max. Negotiated Rate	$1,559.76
Rate for Payer: Cash Price	$964.80
Rate for Payer: Hawaii Western Management Group Commercial	$1,125.60
Rate for Payer: Health Management Network Commercial	$1,366.80
Rate for Payer: MDX Hawaii PPO	$1,559.76
Rate for Payer: University Health Alliance Commercial	$900.48

Know your out-of-pocket cost for care.

All Charges