Hilo Benioff Medical Center

All Charges

Charge

Type

Setting

Price

RESPIRATORY SYSTEM DIAGNOSIS W VENTILATOR SUPPORT 96+ HOURS

Facility

$21,088.77

Service Code	APR-DRG 1303
Min. Negotiated Rate	$21,088.77
Max. Negotiated Rate	$21,088.77
Rate for Payer: AlohaCare Medicaid	$21,088.77
Rate for Payer: Hawaii Medical Service Association ABD	$21,088.77
Rate for Payer: Hawaii Medical Service Association Non-ABD	$21,088.77
Rate for Payer: Kaiser Permanente Medicaid	$21,088.77
Rate for Payer: Ohana Health Plan Medicaid	$21,088.77
Rate for Payer: UnitedHealthcare Medicaid	$21,088.77

RESTORATION MODULAR 6276-7-017

Facility

$6,363.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$3,563.28
Max. Negotiated Rate	$6,172.11
Rate for Payer: Cash Price	$3,817.80
Rate for Payer: Hawaii Western Management Group Commercial	$4,454.10
Rate for Payer: Health Management Network Commercial	$5,408.55
Rate for Payer: MDX Hawaii PPO	$6,172.11
Rate for Payer: University Health Alliance Commercial	$3,563.28

RESTORATION MODULAR 6276-7-017

Facility

$6,363.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$3,245.13
Max. Negotiated Rate	$6,172.11
Rate for Payer: Cash Price	$3,817.80
Rate for Payer: Hawaii Western Management Group Commercial	$4,454.10
Rate for Payer: Health Management Network Commercial	$5,408.55
Rate for Payer: Kaiser Permanente Commercial	$4,008.69
Rate for Payer: Kaiser Permanente Medicaid	$3,245.13
Rate for Payer: MDX Hawaii PPO	$6,172.11
Rate for Payer: University Health Alliance Commercial	$3,563.28

RESTORATION MODULAR 6276-7-018

Facility

$6,363.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$3,563.28
Max. Negotiated Rate	$6,172.11
Rate for Payer: Cash Price	$3,817.80
Rate for Payer: Hawaii Western Management Group Commercial	$4,454.10
Rate for Payer: Health Management Network Commercial	$5,408.55
Rate for Payer: MDX Hawaii PPO	$6,172.11
Rate for Payer: University Health Alliance Commercial	$3,563.28

RESTORATION MODULAR 6276-7-018

Facility

$6,363.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$3,245.13
Max. Negotiated Rate	$6,172.11
Rate for Payer: Cash Price	$3,817.80
Rate for Payer: Hawaii Western Management Group Commercial	$4,454.10
Rate for Payer: Health Management Network Commercial	$5,408.55
Rate for Payer: Kaiser Permanente Commercial	$4,008.69
Rate for Payer: Kaiser Permanente Medicaid	$3,245.13
Rate for Payer: MDX Hawaii PPO	$6,172.11
Rate for Payer: University Health Alliance Commercial	$3,563.28

RESTORATION MODULAR HIP SYSTEM

Facility

$8,879.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$4,972.24
Max. Negotiated Rate	$8,612.63
Rate for Payer: Cash Price	$5,327.40
Rate for Payer: Hawaii Western Management Group Commercial	$6,215.30
Rate for Payer: Health Management Network Commercial	$7,547.15
Rate for Payer: MDX Hawaii PPO	$8,612.63
Rate for Payer: University Health Alliance Commercial	$4,972.24

RESTORATION MODULAR HIP SYSTEM

Facility

$8,879.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$4,528.29
Max. Negotiated Rate	$8,612.63
Rate for Payer: Cash Price	$5,327.40
Rate for Payer: Hawaii Western Management Group Commercial	$6,215.30
Rate for Payer: Health Management Network Commercial	$7,547.15
Rate for Payer: Kaiser Permanente Commercial	$5,593.77
Rate for Payer: Kaiser Permanente Medicaid	$4,528.29
Rate for Payer: MDX Hawaii PPO	$8,612.63
Rate for Payer: University Health Alliance Commercial	$4,972.24

RESTORELLE Y SMARTMESH 501430

Facility

$3,762.00

Service Code	HCPCS C1781
Hospital Revenue Code	278
Min. Negotiated Rate	$2,106.72
Max. Negotiated Rate	$3,649.14
Rate for Payer: Cash Price	$2,257.20
Rate for Payer: Hawaii Western Management Group Commercial	$2,633.40
Rate for Payer: Health Management Network Commercial	$3,197.70
Rate for Payer: MDX Hawaii PPO	$3,649.14
Rate for Payer: University Health Alliance Commercial	$2,106.72

RESTORELLE Y SMARTMESH 501430

Facility

$3,762.00

Service Code	HCPCS C1781
Hospital Revenue Code	278
Min. Negotiated Rate	$1,918.62
Max. Negotiated Rate	$3,649.14
Rate for Payer: Cash Price	$2,257.20
Rate for Payer: Hawaii Western Management Group Commercial	$2,633.40
Rate for Payer: Health Management Network Commercial	$3,197.70
Rate for Payer: Kaiser Permanente Commercial	$2,370.06
Rate for Payer: Kaiser Permanente Medicaid	$1,918.62
Rate for Payer: MDX Hawaii PPO	$3,649.14
Rate for Payer: University Health Alliance Commercial	$2,106.72

RETAINER VISCERA CENTER SPINE

Facility

$221.00

Hospital Revenue Code	272
Min. Negotiated Rate	$112.71
Max. Negotiated Rate	$214.37
Rate for Payer: Cash Price	$132.60
Rate for Payer: Hawaii Western Management Group Commercial	$209.95
Rate for Payer: Health Management Network Commercial	$187.85
Rate for Payer: Kaiser Permanente Commercial	$139.23
Rate for Payer: Kaiser Permanente Medicaid	$112.71
Rate for Payer: MDX Hawaii PPO	$214.37
Rate for Payer: University Health Alliance Commercial	$161.09

RETAINER VISCERA CENTER SPINE

Facility

$221.00

Hospital Revenue Code	272
Min. Negotiated Rate	$187.85
Max. Negotiated Rate	$214.37
Rate for Payer: Cash Price	$132.60
Rate for Payer: Health Management Network Commercial	$187.85
Rate for Payer: MDX Hawaii PPO	$214.37

RETAIN FEMORAL SZ.5 5517-F-501

Facility

$15,986.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$8,952.16
Max. Negotiated Rate	$15,506.42
Rate for Payer: Cash Price	$9,591.60
Rate for Payer: Hawaii Western Management Group Commercial	$11,190.20
Rate for Payer: Health Management Network Commercial	$13,588.10
Rate for Payer: MDX Hawaii PPO	$15,506.42
Rate for Payer: University Health Alliance Commercial	$8,952.16

RETAIN FEMORAL SZ.5 5517-F-501

Facility

$15,986.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$8,152.86
Max. Negotiated Rate	$15,506.42
Rate for Payer: Cash Price	$9,591.60
Rate for Payer: Hawaii Western Management Group Commercial	$11,190.20
Rate for Payer: Health Management Network Commercial	$13,588.10
Rate for Payer: Kaiser Permanente Commercial	$10,071.18
Rate for Payer: Kaiser Permanente Medicaid	$8,152.86
Rate for Payer: MDX Hawaii PPO	$15,506.42
Rate for Payer: University Health Alliance Commercial	$8,952.16

RETICULOENDOTHELIAL AND IMMUNITY DISORDERS WITH CC

Facility

$17,491.50

Service Code	MSDRG 815
Min. Negotiated Rate	$11,533.49
Max. Negotiated Rate	$17,491.50
Rate for Payer: AlohaCare Medicare	$11,533.49
Rate for Payer: Devoted Health Medicare	$12,686.84
Rate for Payer: Hawaii Medical Service Association Commercial	$16,355.28
Rate for Payer: Hawaii Medical Service Association Medicare	$11,533.49
Rate for Payer: Humana Medicare	$11,533.49
Rate for Payer: Kaiser Permanente Commercial	$17,491.50
Rate for Payer: Kaiser Permanente Medicare	$11,533.49
Rate for Payer: Ohana Health Plan Medicare	$11,533.49
Rate for Payer: UnitedHealthcare Medicare	$11,533.49

RETICULOENDOTHELIAL AND IMMUNITY DISORDERS WITH MCC

Facility

$36,685.57

Service Code	MSDRG 814
Min. Negotiated Rate	$16,355.28
Max. Negotiated Rate	$36,685.57
Rate for Payer: AlohaCare Medicare	$24,189.63
Rate for Payer: Devoted Health Medicare	$26,608.59
Rate for Payer: Hawaii Medical Service Association Commercial	$16,355.28
Rate for Payer: Hawaii Medical Service Association Medicare	$24,189.63
Rate for Payer: Humana Medicare	$24,189.63
Rate for Payer: Kaiser Permanente Commercial	$36,685.57
Rate for Payer: Kaiser Permanente Medicare	$24,189.63
Rate for Payer: Ohana Health Plan Medicare	$24,189.63
Rate for Payer: UnitedHealthcare Medicare	$24,189.63

RETICULOENDOTHELIAL AND IMMUNITY DISORDERS WITHOUT CC/MCC

Facility

$11,963.14

Service Code	MSDRG 816
Min. Negotiated Rate	$7,188.54
Max. Negotiated Rate	$11,963.14
Rate for Payer: AlohaCare Medicare	$7,188.54
Rate for Payer: Devoted Health Medicare	$7,907.39
Rate for Payer: Hawaii Medical Service Association Commercial	$11,963.14
Rate for Payer: Hawaii Medical Service Association Medicare	$7,188.54
Rate for Payer: Humana Medicare	$7,188.54
Rate for Payer: Kaiser Permanente Commercial	$10,902.00
Rate for Payer: Kaiser Permanente Medicare	$7,188.54
Rate for Payer: Ohana Health Plan Medicare	$7,188.54
Rate for Payer: UnitedHealthcare Medicare	$7,188.54

RETRACT ENDO PADDLE 12MM

Facility

$1,024.00

Hospital Revenue Code	272
Min. Negotiated Rate	$870.40
Max. Negotiated Rate	$993.28
Rate for Payer: Cash Price	$614.40
Rate for Payer: Health Management Network Commercial	$870.40
Rate for Payer: MDX Hawaii PPO	$993.28

RETRACT ENDO PADDLE 12MM

Facility

$1,024.00

Hospital Revenue Code	272
Min. Negotiated Rate	$522.24
Max. Negotiated Rate	$993.28
Rate for Payer: Cash Price	$614.40
Rate for Payer: Hawaii Western Management Group Commercial	$972.80
Rate for Payer: Health Management Network Commercial	$870.40
Rate for Payer: Kaiser Permanente Commercial	$645.12
Rate for Payer: Kaiser Permanente Medicaid	$522.24
Rate for Payer: MDX Hawaii PPO	$993.28
Rate for Payer: University Health Alliance Commercial	$746.39

RETRACTOR ALEXIS-O LG

Facility

$344.00

Hospital Revenue Code	272
Min. Negotiated Rate	$292.40
Max. Negotiated Rate	$333.68
Rate for Payer: Cash Price	$206.40
Rate for Payer: Health Management Network Commercial	$292.40
Rate for Payer: MDX Hawaii PPO	$333.68

RETRACTOR ALEXIS-O LG

Facility

$344.00

Hospital Revenue Code	272
Min. Negotiated Rate	$175.44
Max. Negotiated Rate	$333.68
Rate for Payer: Cash Price	$206.40
Rate for Payer: Hawaii Western Management Group Commercial	$326.80
Rate for Payer: Health Management Network Commercial	$292.40
Rate for Payer: Kaiser Permanente Commercial	$216.72
Rate for Payer: Kaiser Permanente Medicaid	$175.44
Rate for Payer: MDX Hawaii PPO	$333.68
Rate for Payer: University Health Alliance Commercial	$250.74

RETRACTOR ALEXIS-O MED

Facility

$248.00

Hospital Revenue Code	272
Min. Negotiated Rate	$126.48
Max. Negotiated Rate	$240.56
Rate for Payer: Cash Price	$148.80
Rate for Payer: Hawaii Western Management Group Commercial	$235.60
Rate for Payer: Health Management Network Commercial	$210.80
Rate for Payer: Kaiser Permanente Commercial	$156.24
Rate for Payer: Kaiser Permanente Medicaid	$126.48
Rate for Payer: MDX Hawaii PPO	$240.56
Rate for Payer: University Health Alliance Commercial	$180.77

RETRACTOR ALEXIS-O MED

Facility

$248.00

Hospital Revenue Code	272
Min. Negotiated Rate	$210.80
Max. Negotiated Rate	$240.56
Rate for Payer: Cash Price	$148.80
Rate for Payer: Health Management Network Commercial	$210.80
Rate for Payer: MDX Hawaii PPO	$240.56

RETRACTOR ALEXIS-O SM

Facility

$248.00

Hospital Revenue Code	272
Min. Negotiated Rate	$210.80
Max. Negotiated Rate	$240.56
Rate for Payer: Cash Price	$148.80
Rate for Payer: Health Management Network Commercial	$210.80
Rate for Payer: MDX Hawaii PPO	$240.56

RETRACTOR ALEXIS-O SM

Facility

$248.00

Hospital Revenue Code	272
Min. Negotiated Rate	$126.48
Max. Negotiated Rate	$240.56
Rate for Payer: Cash Price	$148.80
Rate for Payer: Hawaii Western Management Group Commercial	$235.60
Rate for Payer: Health Management Network Commercial	$210.80
Rate for Payer: Kaiser Permanente Commercial	$156.24
Rate for Payer: Kaiser Permanente Medicaid	$126.48
Rate for Payer: MDX Hawaii PPO	$240.56
Rate for Payer: University Health Alliance Commercial	$180.77

RETRACTOR ALEXIS-O XLG

Facility

$413.00

Hospital Revenue Code	272
Min. Negotiated Rate	$210.63
Max. Negotiated Rate	$400.61
Rate for Payer: Cash Price	$247.80
Rate for Payer: Hawaii Western Management Group Commercial	$392.35
Rate for Payer: Health Management Network Commercial	$351.05
Rate for Payer: Kaiser Permanente Commercial	$260.19
Rate for Payer: Kaiser Permanente Medicaid	$210.63
Rate for Payer: MDX Hawaii PPO	$400.61
Rate for Payer: University Health Alliance Commercial	$301.04

Know your out-of-pocket cost for care.

All Charges