Hilo Benioff Medical Center

All Charges

Charge

Type

Setting

Price

RECHARGER 97755

Facility

$3,400.00

Service Code	HCPCS C1820
Hospital Revenue Code	278
Min. Negotiated Rate	$1,734.00
Max. Negotiated Rate	$3,298.00
Rate for Payer: Cash Price	$2,040.00
Rate for Payer: Hawaii Western Management Group Commercial	$2,380.00
Rate for Payer: Health Management Network Commercial	$2,890.00
Rate for Payer: Kaiser Permanente Commercial	$2,142.00
Rate for Payer: Kaiser Permanente Medicaid	$1,734.00
Rate for Payer: MDX Hawaii PPO	$3,298.00
Rate for Payer: University Health Alliance Commercial	$1,904.00

RECHARGER 97755

Facility

$3,400.00

Service Code	HCPCS C1820
Hospital Revenue Code	278
Min. Negotiated Rate	$1,904.00
Max. Negotiated Rate	$3,298.00
Rate for Payer: Cash Price	$2,040.00
Rate for Payer: Hawaii Western Management Group Commercial	$2,380.00
Rate for Payer: Health Management Network Commercial	$2,890.00
Rate for Payer: MDX Hawaii PPO	$3,298.00
Rate for Payer: University Health Alliance Commercial	$1,904.00

RECIP BLADE, HEAVY 277-96-327

Facility

$215.00

Hospital Revenue Code	272
Min. Negotiated Rate	$182.75
Max. Negotiated Rate	$208.55
Rate for Payer: Cash Price	$129.00
Rate for Payer: Health Management Network Commercial	$182.75
Rate for Payer: MDX Hawaii PPO	$208.55

RECIP BLADE, HEAVY 277-96-327

Facility

$215.00

Hospital Revenue Code	272
Min. Negotiated Rate	$109.65
Max. Negotiated Rate	$208.55
Rate for Payer: Cash Price	$129.00
Rate for Payer: Hawaii Western Management Group Commercial	$204.25
Rate for Payer: Health Management Network Commercial	$182.75
Rate for Payer: Kaiser Permanente Commercial	$135.45
Rate for Payer: Kaiser Permanente Medicaid	$109.65
Rate for Payer: MDX Hawaii PPO	$208.55
Rate for Payer: University Health Alliance Commercial	$156.71

RECONSTRUCTION OF DISLOCATING PATELLA; (EG, HAUSER TYPE PROCEDURE)

Facility

$13,778.00

Service Code	CPT 27420
Hospital Revenue Code	360
Min. Negotiated Rate	$521.33
Max. Negotiated Rate	$13,778.00
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	$1,149.00
Rate for Payer: Hawaii Medical Service Association Commercial	$13,778.00
Rate for Payer: Hawaii Medical Service Association Medicare	$8,572.09
Rate for Payer: Hawaii Medical Service Association Non-ABD	$2,294.85
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	$521.33
Rate for Payer: UnitedHealthcare Medicare	$8,572.09
Rate for Payer: University Health Alliance Commercial	$6,743.44

RECONSTRUCTION OF POLYDACTYLOUS DIGIT, SOFT TISSUE AND BONE

Facility

$11,157.19

Service Code	CPT 26587
Hospital Revenue Code	360
Min. Negotiated Rate	$456.03
Max. Negotiated Rate	$11,157.19
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	$11,157.19

RECTAL RESECTION WITH CC

Facility

$72,919.33

Service Code	MSDRG 333
Min. Negotiated Rate	$26,640.80
Max. Negotiated Rate	$72,919.33
Rate for Payer: AlohaCare Medicare	$26,640.80
Rate for Payer: Devoted Health Medicare	$29,304.88
Rate for Payer: Hawaii Medical Service Association Commercial	$72,919.33
Rate for Payer: Hawaii Medical Service Association Medicare	$26,640.80
Rate for Payer: Humana Medicare	$26,640.80
Rate for Payer: Kaiser Permanente Commercial	$40,402.95
Rate for Payer: Kaiser Permanente Medicare	$26,640.80
Rate for Payer: Ohana Health Plan Medicare	$26,640.80
Rate for Payer: UnitedHealthcare Medicare	$26,640.80

RECTAL RESECTION WITH MCC

Facility

$72,919.33

Service Code	MSDRG 332
Min. Negotiated Rate	$41,182.78
Max. Negotiated Rate	$72,919.33
Rate for Payer: AlohaCare Medicare	$41,182.78
Rate for Payer: Devoted Health Medicare	$45,301.06
Rate for Payer: Hawaii Medical Service Association Commercial	$72,919.33
Rate for Payer: Hawaii Medical Service Association Medicare	$41,182.78
Rate for Payer: Humana Medicare	$41,182.78
Rate for Payer: Kaiser Permanente Commercial	$62,457.07
Rate for Payer: Kaiser Permanente Medicare	$41,182.78
Rate for Payer: Ohana Health Plan Medicare	$41,182.78
Rate for Payer: UnitedHealthcare Medicare	$41,182.78

RECTAL RESECTION WITHOUT CC/MCC

Facility

$34,894.51

Service Code	MSDRG 334
Min. Negotiated Rate	$18,629.90
Max. Negotiated Rate	$34,894.51
Rate for Payer: AlohaCare Medicare	$18,629.90
Rate for Payer: Devoted Health Medicare	$20,492.89
Rate for Payer: Hawaii Medical Service Association Commercial	$34,894.51
Rate for Payer: Hawaii Medical Service Association Medicare	$18,629.90
Rate for Payer: Humana Medicare	$18,629.90
Rate for Payer: Kaiser Permanente Commercial	$28,253.78
Rate for Payer: Kaiser Permanente Medicare	$18,629.90
Rate for Payer: Ohana Health Plan Medicare	$18,629.90
Rate for Payer: UnitedHealthcare Medicare	$18,629.90

RED BLOOD CELL DISORDERS WITH MCC

Facility

$31,788.46

Service Code	MSDRG 811
Min. Negotiated Rate	$15,972.87
Max. Negotiated Rate	$31,788.46
Rate for Payer: AlohaCare Medicare	$15,972.87
Rate for Payer: Devoted Health Medicare	$17,570.16
Rate for Payer: Hawaii Medical Service Association Commercial	$31,788.46
Rate for Payer: Hawaii Medical Service Association Medicare	$15,972.87
Rate for Payer: Humana Medicare	$15,972.87
Rate for Payer: Kaiser Permanente Commercial	$24,224.17
Rate for Payer: Kaiser Permanente Medicare	$15,972.87
Rate for Payer: Ohana Health Plan Medicare	$15,972.87
Rate for Payer: UnitedHealthcare Medicare	$15,972.87

RED BLOOD CELL DISORDERS WITHOUT MCC

Facility

$17,034.73

Service Code	MSDRG 812
Min. Negotiated Rate	$10,443.84
Max. Negotiated Rate	$17,034.73
Rate for Payer: AlohaCare Medicare	$10,443.84
Rate for Payer: Devoted Health Medicare	$11,488.22
Rate for Payer: Hawaii Medical Service Association Commercial	$17,034.73
Rate for Payer: Hawaii Medical Service Association Medicare	$10,443.84
Rate for Payer: Humana Medicare	$10,443.84
Rate for Payer: Kaiser Permanente Commercial	$15,838.95
Rate for Payer: Kaiser Permanente Medicare	$10,443.84
Rate for Payer: Ohana Health Plan Medicare	$10,443.84
Rate for Payer: UnitedHealthcare Medicare	$10,443.84

REDUCTION OF TORSION OF TESTIS, SURGICAL, WITH OR WITHOUT FIXATION OF CONTRALATERAL TESTIS

Facility

$10,679.55

Service Code	CPT 54600
Hospital Revenue Code	360
Min. Negotiated Rate	$456.03
Max. Negotiated Rate	$10,679.55
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	$848.00
Rate for Payer: Hawaii Medical Service Association Commercial	$8,270.00
Rate for Payer: Hawaii Medical Service Association Medicare	$4,164.22
Rate for Payer: Hawaii Medical Service Association Non-ABD	$1,427.62
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	$456.03
Rate for Payer: UnitedHealthcare Medicare	$4,164.22
Rate for Payer: University Health Alliance Commercial	$10,679.55

REGADENOSON 0.4 MG/5 ML INTRAVENOUS SYRINGE [91408]

Facility

$451.00

Service Code	HCPCS J2785
Hospital Revenue Code	636
Min. Negotiated Rate	$2.89
Max. Negotiated Rate	$437.47
Rate for Payer: Cash Price	$270.60
Rate for Payer: Cash Price	$270.60
Rate for Payer: Cash Price	$278.40
Rate for Payer: Cash Price	$278.40
Rate for Payer: Hawaii Medical Service Association ABD	$2.89
Rate for Payer: Hawaii Medical Service Association ABD	$2.89
Rate for Payer: Hawaii Medical Service Association Non-ABD	$2.89
Rate for Payer: Hawaii Medical Service Association Non-ABD	$2.89
Rate for Payer: Hawaii Western Management Group Commercial	$428.45
Rate for Payer: Hawaii Western Management Group Commercial	$440.80
Rate for Payer: Health Management Network Commercial	$394.40
Rate for Payer: Health Management Network Commercial	$383.35
Rate for Payer: Kaiser Permanente Commercial	$292.32
Rate for Payer: Kaiser Permanente Commercial	$284.13
Rate for Payer: Kaiser Permanente Medicaid	$230.01
Rate for Payer: Kaiser Permanente Medicaid	$236.64
Rate for Payer: MDX Hawaii PPO	$450.08
Rate for Payer: MDX Hawaii PPO	$437.47
Rate for Payer: UnitedHealthcare Medicaid	$270.60
Rate for Payer: UnitedHealthcare Medicaid	$278.40
Rate for Payer: University Health Alliance Commercial	$338.21
Rate for Payer: University Health Alliance Commercial	$328.73

REGADENOSON 0.4 MG/5 ML INTRAVENOUS SYRINGE [91408]

Facility

$464.00

Service Code	HCPCS J2785
Hospital Revenue Code	250
Min. Negotiated Rate	$394.40
Max. Negotiated Rate	$450.08
Rate for Payer: Cash Price	$278.40
Rate for Payer: Cash Price	$270.60
Rate for Payer: Health Management Network Commercial	$383.35
Rate for Payer: Health Management Network Commercial	$394.40
Rate for Payer: MDX Hawaii PPO	$437.47
Rate for Payer: MDX Hawaii PPO	$450.08

REHABILITATION

Facility

$5,844.40

Service Code	APR-DRG 8601
Min. Negotiated Rate	$5,844.40
Max. Negotiated Rate	$5,844.40
Rate for Payer: AlohaCare Medicaid	$5,844.40
Rate for Payer: Hawaii Medical Service Association ABD	$5,844.40
Rate for Payer: Hawaii Medical Service Association Non-ABD	$5,844.40
Rate for Payer: Kaiser Permanente Medicaid	$5,844.40
Rate for Payer: Ohana Health Plan Medicaid	$5,844.40
Rate for Payer: UnitedHealthcare Medicaid	$5,844.40

REHABILITATION

Facility

$8,666.80

Service Code	APR-DRG 8603
Min. Negotiated Rate	$8,666.80
Max. Negotiated Rate	$8,666.80
Rate for Payer: AlohaCare Medicaid	$8,666.80
Rate for Payer: Hawaii Medical Service Association ABD	$8,666.80
Rate for Payer: Hawaii Medical Service Association Non-ABD	$8,666.80
Rate for Payer: Kaiser Permanente Medicaid	$8,666.80
Rate for Payer: Ohana Health Plan Medicaid	$8,666.80
Rate for Payer: UnitedHealthcare Medicaid	$8,666.80

REHABILITATION

Facility

$11,395.28

Service Code	APR-DRG 8604
Min. Negotiated Rate	$11,395.28
Max. Negotiated Rate	$11,395.28
Rate for Payer: AlohaCare Medicaid	$11,395.28
Rate for Payer: Hawaii Medical Service Association ABD	$11,395.28
Rate for Payer: Hawaii Medical Service Association Non-ABD	$11,395.28
Rate for Payer: Kaiser Permanente Medicaid	$11,395.28
Rate for Payer: Ohana Health Plan Medicaid	$11,395.28
Rate for Payer: UnitedHealthcare Medicaid	$11,395.28

REHABILITATION

Facility

$6,361.01

Service Code	APR-DRG 8602
Min. Negotiated Rate	$6,361.01
Max. Negotiated Rate	$6,361.01
Rate for Payer: AlohaCare Medicaid	$6,361.01
Rate for Payer: Hawaii Medical Service Association ABD	$6,361.01
Rate for Payer: Hawaii Medical Service Association Non-ABD	$6,361.01
Rate for Payer: Kaiser Permanente Medicaid	$6,361.01
Rate for Payer: Ohana Health Plan Medicaid	$6,361.01
Rate for Payer: UnitedHealthcare Medicaid	$6,361.01

REHABILITATION WITH CC/MCC

Facility

$26,713.35

Service Code	MSDRG 945
Min. Negotiated Rate	$9,997.59
Max. Negotiated Rate	$26,713.35
Rate for Payer: AlohaCare Medicare	$17,614.18
Rate for Payer: Devoted Health Medicare	$19,375.60
Rate for Payer: Hawaii Medical Service Association Commercial	$9,997.59
Rate for Payer: Hawaii Medical Service Association Medicare	$17,614.18
Rate for Payer: Humana Medicare	$17,614.18
Rate for Payer: Kaiser Permanente Commercial	$26,713.35
Rate for Payer: Kaiser Permanente Medicare	$17,614.18
Rate for Payer: Ohana Health Plan Medicare	$17,614.18
Rate for Payer: UnitedHealthcare Medicare	$17,614.18

REHABILITATION WITHOUT CC/MCC

Facility

$19,782.30

Service Code	MSDRG 946
Min. Negotiated Rate	$9,997.59
Max. Negotiated Rate	$19,782.30
Rate for Payer: AlohaCare Medicare	$13,044.01
Rate for Payer: Devoted Health Medicare	$14,348.41
Rate for Payer: Hawaii Medical Service Association Commercial	$9,997.59
Rate for Payer: Hawaii Medical Service Association Medicare	$13,044.01
Rate for Payer: Humana Medicare	$13,044.01
Rate for Payer: Kaiser Permanente Commercial	$19,782.30
Rate for Payer: Kaiser Permanente Medicare	$13,044.01
Rate for Payer: Ohana Health Plan Medicare	$13,044.01
Rate for Payer: UnitedHealthcare Medicare	$13,044.01

REINSERTION OF RUPTURED BICEPS OR TRICEPS TENDON, DISTAL, WITH OR WITHOUT TENDON GRAFT

Facility

$9,429.30

Service Code	CPT 24342
Hospital Revenue Code	360
Min. Negotiated Rate	$521.33
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	$521.33
Rate for Payer: UnitedHealthcare Medicare	$8,572.09
Rate for Payer: University Health Alliance Commercial	$6,743.44

RELIANCE 4 FRONT COIL 64CM

Facility

$6,208.00

Service Code	HCPCS C1895
Hospital Revenue Code	278
Min. Negotiated Rate	$3,476.48
Max. Negotiated Rate	$6,021.76
Rate for Payer: Cash Price	$3,724.80
Rate for Payer: Hawaii Western Management Group Commercial	$4,345.60
Rate for Payer: Health Management Network Commercial	$5,276.80
Rate for Payer: MDX Hawaii PPO	$6,021.76
Rate for Payer: University Health Alliance Commercial	$3,476.48

RELIANCE 4 FRONT COIL 64CM

Facility

$6,208.00

Service Code	HCPCS C1895
Hospital Revenue Code	278
Min. Negotiated Rate	$3,166.08
Max. Negotiated Rate	$6,021.76
Rate for Payer: Cash Price	$3,724.80
Rate for Payer: Hawaii Western Management Group Commercial	$4,345.60
Rate for Payer: Health Management Network Commercial	$5,276.80
Rate for Payer: Kaiser Permanente Commercial	$3,911.04
Rate for Payer: Kaiser Permanente Medicaid	$3,166.08
Rate for Payer: MDX Hawaii PPO	$6,021.76
Rate for Payer: University Health Alliance Commercial	$3,476.48

RELIANCE LEAD 59CM

Facility

$6,208.00

Service Code	HCPCS C1777
Hospital Revenue Code	278
Min. Negotiated Rate	$3,166.08
Max. Negotiated Rate	$6,021.76
Rate for Payer: Cash Price	$3,724.80
Rate for Payer: Hawaii Western Management Group Commercial	$4,345.60
Rate for Payer: Health Management Network Commercial	$5,276.80
Rate for Payer: Kaiser Permanente Commercial	$3,911.04
Rate for Payer: Kaiser Permanente Medicaid	$3,166.08
Rate for Payer: MDX Hawaii PPO	$6,021.76
Rate for Payer: University Health Alliance Commercial	$3,476.48

RELIANCE LEAD 59CM

Facility

$6,208.00

Service Code	HCPCS C1777
Hospital Revenue Code	278
Min. Negotiated Rate	$3,476.48
Max. Negotiated Rate	$6,021.76
Rate for Payer: Cash Price	$3,724.80
Rate for Payer: Hawaii Western Management Group Commercial	$4,345.60
Rate for Payer: Health Management Network Commercial	$5,276.80
Rate for Payer: MDX Hawaii PPO	$6,021.76
Rate for Payer: University Health Alliance Commercial	$3,476.48

Know your out-of-pocket cost for care.

All Charges