Hilo Benioff Medical Center

All Charges

Charge

Type

Setting

Price

REMOVAL (VIA SNARE/CAPTURE) AND REPLACEMENT OF INTERNALLY DWELLING URETERAL STENT VIA PERCUTANEOUS APPROACH, INCLUDING RADIOLOGICAL SUPERVISION AND INTERPRETATION

Facility

$8,270.00

Service Code	CPT 50382
Hospital Revenue Code	361
Min. Negotiated Rate	$456.03
Max. Negotiated Rate	$8,270.00
Rate for Payer: AlohaCare Medicaid	$2,469.46
Rate for Payer: AlohaCare Medicare	$2,469.46
Rate for Payer: Devoted Health Medicare	$2,716.41
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	$2,469.46
Rate for Payer: Hawaii Medical Service Association Non-ABD	$1,427.62
Rate for Payer: Humana Medicare	$2,469.46
Rate for Payer: Kaiser Permanente Medicaid	$2,837.00
Rate for Payer: Kaiser Permanente Medicare	$2,469.46
Rate for Payer: Ohana Health Plan Medicaid	$2,716.41
Rate for Payer: Ohana Health Plan Medicare	$2,469.46
Rate for Payer: UnitedHealthcare Medicaid	$456.03
Rate for Payer: UnitedHealthcare Medicare	$2,469.46

REMOVAL (VIA SNARE/CAPTURE) OF INTERNALLY DWELLING URETERAL STENT VIA TRANSURETHRAL APPROACH, WITHOUT USE OF CYSTOSCOPY, INCLUDING RADIOLOGICAL SUPERVISION AND INTERPRETATION

Facility

$5,509.00

Service Code	CPT 50386
Hospital Revenue Code	360
Min. Negotiated Rate	$456.03
Max. Negotiated Rate	$5,509.00
Rate for Payer: AlohaCare Medicaid	$2,469.46
Rate for Payer: AlohaCare Medicare	$2,469.46
Rate for Payer: Devoted Health Medicare	$2,716.41
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	$2,469.46
Rate for Payer: Hawaii Medical Service Association Non-ABD	$1,028.67
Rate for Payer: Humana Medicare	$2,469.46
Rate for Payer: Kaiser Permanente Medicaid	$2,837.00
Rate for Payer: Kaiser Permanente Medicare	$2,469.46
Rate for Payer: Ohana Health Plan Medicaid	$2,716.41
Rate for Payer: Ohana Health Plan Medicare	$2,469.46
Rate for Payer: UnitedHealthcare Medicaid	$456.03
Rate for Payer: UnitedHealthcare Medicare	$2,469.46

RENAL DIALYSIS ACCESS DEVICE PROCEDURES & VESSEL REPAIR

Facility

$11,273.96

Service Code	APR-DRG 4443
Min. Negotiated Rate	$11,273.96
Max. Negotiated Rate	$11,273.96
Rate for Payer: AlohaCare Medicaid	$11,273.96
Rate for Payer: Hawaii Medical Service Association ABD	$11,273.96
Rate for Payer: Hawaii Medical Service Association Non-ABD	$11,273.96
Rate for Payer: Kaiser Permanente Medicaid	$11,273.96
Rate for Payer: Ohana Health Plan Medicaid	$11,273.96
Rate for Payer: UnitedHealthcare Medicaid	$11,273.96

RENAL DIALYSIS ACCESS DEVICE PROCEDURES & VESSEL REPAIR

Facility

$21,412.30

Service Code	APR-DRG 4444
Min. Negotiated Rate	$21,412.30
Max. Negotiated Rate	$21,412.30
Rate for Payer: AlohaCare Medicaid	$21,412.30
Rate for Payer: Hawaii Medical Service Association ABD	$21,412.30
Rate for Payer: Hawaii Medical Service Association Non-ABD	$21,412.30
Rate for Payer: Kaiser Permanente Medicaid	$21,412.30
Rate for Payer: Ohana Health Plan Medicaid	$21,412.30
Rate for Payer: UnitedHealthcare Medicaid	$21,412.30

RENAL DIALYSIS ACCESS DEVICE PROCEDURES & VESSEL REPAIR

Facility

$7,287.89

Service Code	APR-DRG 4442
Min. Negotiated Rate	$7,287.89
Max. Negotiated Rate	$7,287.89
Rate for Payer: AlohaCare Medicaid	$7,287.89
Rate for Payer: Hawaii Medical Service Association ABD	$7,287.89
Rate for Payer: Hawaii Medical Service Association Non-ABD	$7,287.89
Rate for Payer: Kaiser Permanente Medicaid	$7,287.89
Rate for Payer: Ohana Health Plan Medicaid	$7,287.89
Rate for Payer: UnitedHealthcare Medicaid	$7,287.89

RENAL DIALYSIS ACCESS DEVICE PROCEDURES & VESSEL REPAIR

Facility

$5,211.69

Service Code	APR-DRG 4441
Min. Negotiated Rate	$5,211.69
Max. Negotiated Rate	$5,211.69
Rate for Payer: AlohaCare Medicaid	$5,211.69
Rate for Payer: Hawaii Medical Service Association ABD	$5,211.69
Rate for Payer: Hawaii Medical Service Association Non-ABD	$5,211.69
Rate for Payer: Kaiser Permanente Medicaid	$5,211.69
Rate for Payer: Ohana Health Plan Medicaid	$5,211.69
Rate for Payer: UnitedHealthcare Medicaid	$5,211.69

RENAL ENDOSCOPY THROUGH ESTABLISHED NEPHROSTOMY OR PYELOSTOMY, WITH OR WITHOUT IRRIGATION, INSTILLATION, OR URETEROPYELOGRAPHY, EXCLUSIVE OF RADIOLOGIC SERVICE; WITH REMOVAL OF FOREIGN BODY OR CALCULUS

Facility

$8,270.00

Service Code	CPT 50561
Hospital Revenue Code	360
Min. Negotiated Rate	$456.03
Max. Negotiated Rate	$8,270.00
Rate for Payer: AlohaCare Medicaid	$6,334.13
Rate for Payer: AlohaCare Medicare	$6,334.13
Rate for Payer: Devoted Health Medicare	$6,967.54
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	$6,334.13
Rate for Payer: Hawaii Medical Service Association Non-ABD	$1,427.62
Rate for Payer: Humana Medicare	$6,334.13
Rate for Payer: Kaiser Permanente Medicaid	$2,837.00
Rate for Payer: Kaiser Permanente Medicare	$6,334.13
Rate for Payer: Ohana Health Plan Medicaid	$6,967.54
Rate for Payer: Ohana Health Plan Medicare	$6,334.13
Rate for Payer: UnitedHealthcare Medicaid	$456.03
Rate for Payer: UnitedHealthcare Medicare	$6,334.13

RENAL ENDOSCOPY THROUGH NEPHROTOMY OR PYELOTOMY, WITH OR WITHOUT IRRIGATION, INSTILLATION, OR URETEROPYELOGRAPHY, EXCLUSIVE OF RADIOLOGIC SERVICE; WITH ENDOPYELOTOMY (INCLUDES CYSTOSCOPY, URETEROSCOPY, DILATION OF URETER AND URETERAL PELVIC JUNCTION, INCISION OF URETERAL PELVIC JUNCTION AND INSERTION OF ENDOPYELOTOMY STENT)

Facility

$8,270.00

Service Code	CPT 50575
Hospital Revenue Code	360
Min. Negotiated Rate	$521.33
Max. Negotiated Rate	$8,270.00
Rate for Payer: AlohaCare Medicaid	$6,334.13
Rate for Payer: AlohaCare Medicare	$6,334.13
Rate for Payer: Devoted Health Medicare	$6,967.54
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	$6,334.13
Rate for Payer: Hawaii Medical Service Association Non-ABD	$1,427.62
Rate for Payer: Humana Medicare	$6,334.13
Rate for Payer: Kaiser Permanente Medicaid	$2,837.00
Rate for Payer: Kaiser Permanente Medicare	$6,334.13
Rate for Payer: Ohana Health Plan Medicaid	$6,967.54
Rate for Payer: Ohana Health Plan Medicare	$6,334.13
Rate for Payer: UnitedHealthcare Medicaid	$521.33
Rate for Payer: UnitedHealthcare Medicare	$6,334.13

RENAL FAILURE WITH CC

Facility

$30,720.76

Service Code	MSDRG 683
Min. Negotiated Rate	$9,961.57
Max. Negotiated Rate	$30,720.76
Rate for Payer: AlohaCare Medicare	$9,961.57
Rate for Payer: Devoted Health Medicare	$10,957.73
Rate for Payer: Hawaii Medical Service Association Commercial	$30,720.76
Rate for Payer: Hawaii Medical Service Association Medicare	$9,961.57
Rate for Payer: Humana Medicare	$9,961.57
Rate for Payer: Kaiser Permanente Commercial	$15,107.55
Rate for Payer: Kaiser Permanente Medicare	$9,961.57
Rate for Payer: Ohana Health Plan Medicare	$9,961.57
Rate for Payer: UnitedHealthcare Medicare	$9,961.57

RENAL FAILURE WITH MCC

Facility

$30,720.76

Service Code	MSDRG 682
Min. Negotiated Rate	$16,845.27
Max. Negotiated Rate	$30,720.76
Rate for Payer: AlohaCare Medicare	$16,845.27
Rate for Payer: Devoted Health Medicare	$18,529.80
Rate for Payer: Hawaii Medical Service Association Commercial	$30,720.76
Rate for Payer: Hawaii Medical Service Association Medicare	$16,845.27
Rate for Payer: Humana Medicare	$16,845.27
Rate for Payer: Kaiser Permanente Commercial	$25,547.25
Rate for Payer: Kaiser Permanente Medicare	$16,845.27
Rate for Payer: Ohana Health Plan Medicare	$16,845.27
Rate for Payer: UnitedHealthcare Medicare	$16,845.27

RENAL FAILURE WITHOUT CC/MCC

Facility

$30,720.76

Service Code	MSDRG 684
Min. Negotiated Rate	$6,827.95
Max. Negotiated Rate	$30,720.76
Rate for Payer: AlohaCare Medicare	$6,827.95
Rate for Payer: Devoted Health Medicare	$7,510.74
Rate for Payer: Hawaii Medical Service Association Commercial	$30,720.76
Rate for Payer: Hawaii Medical Service Association Medicare	$6,827.95
Rate for Payer: Humana Medicare	$6,827.95
Rate for Payer: Kaiser Permanente Commercial	$10,355.17
Rate for Payer: Kaiser Permanente Medicare	$6,827.95
Rate for Payer: Ohana Health Plan Medicare	$6,827.95
Rate for Payer: UnitedHealthcare Medicare	$6,827.95

RENEGADE HI-FLO 20X135

Facility

$1,009.00

Service Code	HCPCS C1887
Hospital Revenue Code	272
Min. Negotiated Rate	$514.59
Max. Negotiated Rate	$978.73
Rate for Payer: Cash Price	$605.40
Rate for Payer: Hawaii Western Management Group Commercial	$958.55
Rate for Payer: Health Management Network Commercial	$857.65
Rate for Payer: Kaiser Permanente Commercial	$635.67
Rate for Payer: Kaiser Permanente Medicaid	$514.59
Rate for Payer: MDX Hawaii PPO	$978.73
Rate for Payer: University Health Alliance Commercial	$735.46

RENEGADE HI-FLO 20X135

Facility

$1,009.00

Service Code	HCPCS C1887
Hospital Revenue Code	272
Min. Negotiated Rate	$857.65
Max. Negotiated Rate	$978.73
Rate for Payer: Cash Price	$605.40
Rate for Payer: Health Management Network Commercial	$857.65
Rate for Payer: MDX Hawaii PPO	$978.73

REPAIR BLOOD VESSEL, DIRECT; UPPER EXTREMITY

Facility

$8,270.00

Service Code	CPT 35206
Hospital Revenue Code	360
Min. Negotiated Rate	$456.03
Max. Negotiated Rate	$8,270.00
Rate for Payer: AlohaCare Medicaid	$3,730.07
Rate for Payer: AlohaCare Medicare	$3,730.07
Rate for Payer: Devoted Health Medicare	$4,103.08
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	$3,730.07
Rate for Payer: Hawaii Medical Service Association Non-ABD	$1,427.62
Rate for Payer: Humana Medicare	$3,730.07
Rate for Payer: Kaiser Permanente Medicaid	$2,837.00
Rate for Payer: Kaiser Permanente Medicare	$3,730.07
Rate for Payer: Ohana Health Plan Medicaid	$4,103.08
Rate for Payer: Ohana Health Plan Medicare	$3,730.07
Rate for Payer: UnitedHealthcare Medicaid	$456.03
Rate for Payer: UnitedHealthcare Medicare	$3,730.07

REPAIR BLOOD VESSEL WITH GRAFT OTHER THAN VEIN; UPPER EXTREMITY

Facility

$8,216.98

Service Code	CPT 35266
Hospital Revenue Code	360
Min. Negotiated Rate	$521.33
Max. Negotiated Rate	$8,216.98
Rate for Payer: AlohaCare Medicaid	$6,573.58
Rate for Payer: AlohaCare Medicare	$6,573.58
Rate for Payer: Devoted Health Medicare	$7,230.94
Rate for Payer: Hawaii Medical Service Association Commercial	$8,216.98
Rate for Payer: Hawaii Medical Service Association Medicare	$6,573.58
Rate for Payer: Humana Medicare	$6,573.58
Rate for Payer: Kaiser Permanente Medicaid	$2,837.00
Rate for Payer: Kaiser Permanente Medicare	$6,573.58
Rate for Payer: Ohana Health Plan Medicaid	$7,230.94
Rate for Payer: Ohana Health Plan Medicare	$6,573.58
Rate for Payer: UnitedHealthcare Medicaid	$521.33
Rate for Payer: UnitedHealthcare Medicare	$6,573.58

REPAIR, COMPLEX, EYELIDS, NOSE, EARS AND/OR LIPS; 1.1 CM TO 2.5 CM

Facility

$2,837.00

Service Code	CPT 13151
Hospital Revenue Code	360
Min. Negotiated Rate	$190.43
Max. Negotiated Rate	$2,837.00
Rate for Payer: AlohaCare Medicaid	$873.10
Rate for Payer: AlohaCare Medicare	$873.10
Rate for Payer: Devoted Health Medicare	$960.41
Rate for Payer: Hawaii Medical Service Association Commercial	$1,091.38
Rate for Payer: Hawaii Medical Service Association Medicare	$873.10
Rate for Payer: Humana Medicare	$873.10
Rate for Payer: Kaiser Permanente Medicaid	$2,837.00
Rate for Payer: Kaiser Permanente Medicare	$873.10
Rate for Payer: Ohana Health Plan Medicaid	$960.41
Rate for Payer: Ohana Health Plan Medicare	$873.10
Rate for Payer: UnitedHealthcare Medicaid	$190.43
Rate for Payer: UnitedHealthcare Medicare	$873.10

REPAIR, COMPLEX, EYELIDS, NOSE, EARS AND/OR LIPS; 2.6 CM TO 7.5 CM

Facility

$6,743.44

Service Code	CPT 13152
Hospital Revenue Code	360
Min. Negotiated Rate	$279.51
Max. Negotiated Rate	$6,743.44
Rate for Payer: AlohaCare Medicaid	$873.10
Rate for Payer: AlohaCare Medicare	$873.10
Rate for Payer: Devoted Health Medicare	$960.41
Rate for Payer: Hawaii Medical Service Association Commercial	$1,091.38
Rate for Payer: Hawaii Medical Service Association Medicare	$873.10
Rate for Payer: Humana Medicare	$873.10
Rate for Payer: Kaiser Permanente Medicaid	$2,837.00
Rate for Payer: Kaiser Permanente Medicare	$873.10
Rate for Payer: Ohana Health Plan Medicaid	$960.41
Rate for Payer: Ohana Health Plan Medicare	$873.10
Rate for Payer: UnitedHealthcare Medicaid	$279.51
Rate for Payer: UnitedHealthcare Medicare	$873.10
Rate for Payer: University Health Alliance Commercial	$6,743.44

REPAIR, COMPLEX, FOREHEAD, CHEEKS, CHIN, MOUTH, NECK, AXILLAE, GENITALIA, HANDS AND/OR FEET; 1.1 CM TO 2.5 CM

Facility

$2,837.00

Service Code	CPT 13131
Hospital Revenue Code	360
Min. Negotiated Rate	$159.07
Max. Negotiated Rate	$2,837.00
Rate for Payer: AlohaCare Medicaid	$480.23
Rate for Payer: AlohaCare Medicare	$480.23
Rate for Payer: Devoted Health Medicare	$528.25
Rate for Payer: Hawaii Medical Service Association Commercial	$600.29
Rate for Payer: Hawaii Medical Service Association Medicare	$480.23
Rate for Payer: Humana Medicare	$480.23
Rate for Payer: Kaiser Permanente Medicaid	$2,837.00
Rate for Payer: Kaiser Permanente Medicare	$480.23
Rate for Payer: Ohana Health Plan Medicaid	$528.25
Rate for Payer: Ohana Health Plan Medicare	$480.23
Rate for Payer: UnitedHealthcare Medicaid	$159.07
Rate for Payer: UnitedHealthcare Medicare	$480.23

REPAIR, COMPLEX, FOREHEAD, CHEEKS, CHIN, MOUTH, NECK, AXILLAE, GENITALIA, HANDS AND/OR FEET; 2.6 CM TO 7.5 CM

Facility

$10,679.55

Service Code	CPT 13132
Hospital Revenue Code	360
Min. Negotiated Rate	$252.72
Max. Negotiated Rate	$10,679.55
Rate for Payer: AlohaCare Medicaid	$480.23
Rate for Payer: AlohaCare Medicare	$480.23
Rate for Payer: Devoted Health Medicare	$528.25
Rate for Payer: Hawaii Medical Service Association Commercial	$600.29
Rate for Payer: Hawaii Medical Service Association Medicare	$480.23
Rate for Payer: Humana Medicare	$480.23
Rate for Payer: Kaiser Permanente Medicaid	$2,837.00
Rate for Payer: Kaiser Permanente Medicare	$480.23
Rate for Payer: Ohana Health Plan Medicaid	$528.25
Rate for Payer: Ohana Health Plan Medicare	$480.23
Rate for Payer: UnitedHealthcare Medicaid	$252.72
Rate for Payer: UnitedHealthcare Medicare	$480.23
Rate for Payer: University Health Alliance Commercial	$10,679.55

REPAIR, COMPLEX, FOREHEAD, CHEEKS, CHIN, MOUTH, NECK, AXILLAE, GENITALIA, HANDS AND/OR FEET; EACH ADDITIONAL 5 CM OR LESS (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)

Facility

$2,837.00

Service Code	CPT 13133
Hospital Revenue Code	360
Min. Negotiated Rate	$92.13
Max. Negotiated Rate	$2,837.00
Rate for Payer: Kaiser Permanente Medicaid	$2,837.00
Rate for Payer: UnitedHealthcare Medicaid	$92.13

REPAIR, COMPLEX, SCALP, ARMS, AND/OR LEGS; 2.6 CM TO 7.5 CM

Facility

$5,160.40

Service Code	CPT 13121
Hospital Revenue Code	360
Min. Negotiated Rate	$179.03
Max. Negotiated Rate	$5,160.40
Rate for Payer: AlohaCare Medicaid	$480.23
Rate for Payer: AlohaCare Medicare	$480.23
Rate for Payer: Devoted Health Medicare	$528.25
Rate for Payer: Hawaii Medical Service Association Commercial	$600.29
Rate for Payer: Hawaii Medical Service Association Medicare	$480.23
Rate for Payer: Humana Medicare	$480.23
Rate for Payer: Kaiser Permanente Medicaid	$2,837.00
Rate for Payer: Kaiser Permanente Medicare	$480.23
Rate for Payer: Ohana Health Plan Medicaid	$528.25
Rate for Payer: Ohana Health Plan Medicare	$480.23
Rate for Payer: UnitedHealthcare Medicaid	$179.03
Rate for Payer: UnitedHealthcare Medicare	$480.23
Rate for Payer: University Health Alliance Commercial	$5,160.40

REPAIR, COMPLEX, SCALP, ARMS, AND/OR LEGS; EACH ADDITIONAL 5 CM OR LESS (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)

Facility

$2,837.00

Service Code	CPT 13122
Hospital Revenue Code	360
Min. Negotiated Rate	$60.73
Max. Negotiated Rate	$2,837.00
Rate for Payer: Kaiser Permanente Medicaid	$2,837.00
Rate for Payer: UnitedHealthcare Medicaid	$60.73

REPAIR, COMPLEX, TRUNK; 1.1 CM TO 2.5 CM

Facility

$2,837.00

Service Code	CPT 13100
Hospital Revenue Code	360
Min. Negotiated Rate	$134.38
Max. Negotiated Rate	$2,837.00
Rate for Payer: AlohaCare Medicaid	$873.10
Rate for Payer: AlohaCare Medicare	$873.10
Rate for Payer: Devoted Health Medicare	$960.41
Rate for Payer: Hawaii Medical Service Association Commercial	$1,091.38
Rate for Payer: Hawaii Medical Service Association Medicare	$873.10
Rate for Payer: Humana Medicare	$873.10
Rate for Payer: Kaiser Permanente Medicaid	$2,837.00
Rate for Payer: Kaiser Permanente Medicare	$873.10
Rate for Payer: Ohana Health Plan Medicaid	$960.41
Rate for Payer: Ohana Health Plan Medicare	$873.10
Rate for Payer: UnitedHealthcare Medicaid	$134.38
Rate for Payer: UnitedHealthcare Medicare	$873.10

REPAIR, COMPLEX, TRUNK; 2.6 CM TO 7.5 CM

Facility

$2,837.00

Service Code	CPT 13101
Hospital Revenue Code	360
Min. Negotiated Rate	$162.04
Max. Negotiated Rate	$2,837.00
Rate for Payer: AlohaCare Medicaid	$873.10
Rate for Payer: AlohaCare Medicare	$873.10
Rate for Payer: Devoted Health Medicare	$960.41
Rate for Payer: Hawaii Medical Service Association Commercial	$1,091.38
Rate for Payer: Hawaii Medical Service Association Medicare	$873.10
Rate for Payer: Humana Medicare	$873.10
Rate for Payer: Kaiser Permanente Medicaid	$2,837.00
Rate for Payer: Kaiser Permanente Medicare	$873.10
Rate for Payer: Ohana Health Plan Medicaid	$960.41
Rate for Payer: Ohana Health Plan Medicare	$873.10
Rate for Payer: UnitedHealthcare Medicaid	$162.04
Rate for Payer: UnitedHealthcare Medicare	$873.10

REPAIR, COMPLEX, TRUNK; EACH ADDITIONAL 5 CM OR LESS (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)

Facility

$2,837.00

Service Code	CPT 13102
Hospital Revenue Code	360
Min. Negotiated Rate	$52.41
Max. Negotiated Rate	$2,837.00
Rate for Payer: Kaiser Permanente Medicaid	$2,837.00
Rate for Payer: UnitedHealthcare Medicaid	$52.41

Know your out-of-pocket cost for care.

All Charges