Hilo Benioff Medical Center

All Charges

Charge

Type

Setting

Price

REVASCULARIZATION, ENDOVASCULAR, OPEN OR PERCUTANEOUS, FEMORAL, POPLITEAL ARTERY(S), UNILATERAL; WITH TRANSLUMINAL ANGIOPLASTY

Facility

$13,923.44

Service Code	CPT 37224
Hospital Revenue Code	360
Min. Negotiated Rate	$290.08
Max. Negotiated Rate	$13,923.44
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 Non-ABD	$1,427.62
Rate for Payer: Kaiser Permanente Medicaid	$2,837.00
Rate for Payer: UnitedHealthcare Medicaid	$290.08
Rate for Payer: University Health Alliance Commercial	$13,923.44

REVASCULARIZATION, ENDOVASCULAR, OPEN OR PERCUTANEOUS, FEMORAL, POPLITEAL ARTERY(S), UNILATERAL; WITH TRANSLUMINAL STENT PLACEMENT(S), INCLUDES ANGIOPLASTY WITHIN THE SAME VESSEL, WHEN PERFORMED

Facility

$24,500.00

Service Code	CPT 37226
Hospital Revenue Code	360
Min. Negotiated Rate	$327.35
Max. Negotiated Rate	$24,500.00
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 Non-ABD	$1,427.62
Rate for Payer: Kaiser Permanente Medicaid	$2,837.00
Rate for Payer: UnitedHealthcare Medicaid	$327.35
Rate for Payer: University Health Alliance Commercial	$24,500.00

REVASCULARIZATION, ENDOVASCULAR, OPEN OR PERCUTANEOUS, ILIAC ARTERY, EACH ADDITIONAL IPSILATERAL ILIAC VESSEL; WITH TRANSLUMINAL STENT PLACEMENT(S), INCLUDES ANGIOPLASTY WITHIN THE SAME VESSEL, WHEN PERFORMED (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)

Facility

$2,837.00

Service Code	CPT 37223
Hospital Revenue Code	360
Min. Negotiated Rate	$135.74
Max. Negotiated Rate	$2,837.00
Rate for Payer: Kaiser Permanente Medicaid	$2,837.00
Rate for Payer: UnitedHealthcare Medicaid	$135.74

REVASCULARIZATION, ENDOVASCULAR, OPEN OR PERCUTANEOUS, ILIAC ARTERY, UNILATERAL, INITIAL VESSEL; WITH TRANSLUMINAL ANGIOPLASTY

Facility

$19,192.00

Service Code	CPT 37220
Hospital Revenue Code	360
Min. Negotiated Rate	$263.22
Max. Negotiated Rate	$19,192.00
Rate for Payer: Hawaii Medical Service Association ABD	$2,102.00
Rate for Payer: Hawaii Medical Service Association Commercial	$19,192.00
Rate for Payer: Hawaii Medical Service Association Non-ABD	$3,561.00
Rate for Payer: Kaiser Permanente Medicaid	$2,837.00
Rate for Payer: UnitedHealthcare Medicaid	$263.22
Rate for Payer: University Health Alliance Commercial	$16,700.00

REVASCULARIZATION, ENDOVASCULAR, OPEN OR PERCUTANEOUS, ILIAC ARTERY, UNILATERAL, INITIAL VESSEL; WITH TRANSLUMINAL ANGIOPLASTY

Facility

$19,192.00

Service Code	CPT 37220
Hospital Revenue Code	361
Min. Negotiated Rate	$263.22
Max. Negotiated Rate	$19,192.00
Rate for Payer: Hawaii Medical Service Association ABD	$2,102.00
Rate for Payer: Hawaii Medical Service Association Commercial	$19,192.00
Rate for Payer: Hawaii Medical Service Association Non-ABD	$3,561.00
Rate for Payer: Kaiser Permanente Medicaid	$2,837.00
Rate for Payer: UnitedHealthcare Medicaid	$263.22
Rate for Payer: University Health Alliance Commercial	$16,700.00

REVASCULARIZATION, ENDOVASCULAR, OPEN OR PERCUTANEOUS, ILIAC ARTERY, UNILATERAL, INITIAL VESSEL; WITH TRANSLUMINAL STENT PLACEMENT(S), INCLUDES ANGIOPLASTY WITHIN THE SAME VESSEL, WHEN PERFORMED

Facility

$20,300.00

Service Code	CPT 37221
Hospital Revenue Code	360
Min. Negotiated Rate	$321.35
Max. Negotiated Rate	$20,300.00
Rate for Payer: Hawaii Medical Service Association ABD	$2,102.00
Rate for Payer: Hawaii Medical Service Association Commercial	$19,192.00
Rate for Payer: Hawaii Medical Service Association Non-ABD	$3,561.00
Rate for Payer: Kaiser Permanente Medicaid	$2,837.00
Rate for Payer: UnitedHealthcare Medicaid	$321.35
Rate for Payer: University Health Alliance Commercial	$20,300.00

REVASCULARIZATION, ENDOVASCULAR, OPEN OR PERCUTANEOUS, LOWER EXTREMITY ARTERY(IES), EXCEPT TIBIAL/PERONEAL; WITH INTRAVASCULAR LITHOTRIPSY, INCLUDES ANGIOPLASTY WITHIN THE SAME VESSEL(S), WHEN PERFORMED

Facility

$24,500.00

Service Code	CPT C9764
Hospital Revenue Code	481
Min. Negotiated Rate	$521.33
Max. Negotiated Rate	$24,500.00
Rate for Payer: AlohaCare Medicaid	$13,637.67
Rate for Payer: AlohaCare Medicare	$13,637.67
Rate for Payer: Devoted Health Medicare	$15,001.44
Rate for Payer: Hawaii Medical Service Association Commercial	$17,047.09
Rate for Payer: Hawaii Medical Service Association Medicare	$13,637.67
Rate for Payer: Humana Medicare	$13,637.67
Rate for Payer: Kaiser Permanente Medicare	$13,637.67
Rate for Payer: Ohana Health Plan Medicaid	$15,001.44
Rate for Payer: Ohana Health Plan Medicare	$13,637.67
Rate for Payer: UnitedHealthcare Medicaid	$521.33
Rate for Payer: UnitedHealthcare Medicare	$13,637.67
Rate for Payer: University Health Alliance Commercial	$24,500.00

REVASCULARIZATION, ENDOVASCULAR, OPEN OR PERCUTANEOUS, TIBIAL/PERONEAL ARTERY, UNILATERAL, EACH ADDITIONAL VESSEL; WITH TRANSLUMINAL ANGIOPLASTY (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)

Facility

$2,837.00

Service Code	CPT 37232
Hospital Revenue Code	360
Min. Negotiated Rate	$127.92
Max. Negotiated Rate	$2,837.00
Rate for Payer: Kaiser Permanente Medicaid	$2,837.00
Rate for Payer: UnitedHealthcare Medicaid	$127.92

REVASCULARIZATION, ENDOVASCULAR, OPEN OR PERCUTANEOUS, TIBIAL, PERONEAL ARTERY, UNILATERAL, INITIAL VESSEL; WITH ATHERECTOMY, INCLUDES ANGIOPLASTY WITHIN THE SAME VESSEL, WHEN PERFORMED

Facility

$19,192.00

Service Code	CPT 37229
Hospital Revenue Code	360
Min. Negotiated Rate	$456.98
Max. Negotiated Rate	$19,192.00
Rate for Payer: Hawaii Medical Service Association ABD	$2,102.00
Rate for Payer: Hawaii Medical Service Association Commercial	$19,192.00
Rate for Payer: Hawaii Medical Service Association Non-ABD	$3,561.00
Rate for Payer: Kaiser Permanente Medicaid	$2,837.00
Rate for Payer: UnitedHealthcare Medicaid	$456.98

REVASCULARIZATION, ENDOVASCULAR, OPEN OR PERCUTANEOUS, TIBIAL, PERONEAL ARTERY, UNILATERAL, INITIAL VESSEL; WITH TRANSLUMINAL ANGIOPLASTY

Facility

$19,192.00

Service Code	CPT 37228
Hospital Revenue Code	360
Min. Negotiated Rate	$353.98
Max. Negotiated Rate	$19,192.00
Rate for Payer: Hawaii Medical Service Association ABD	$2,102.00
Rate for Payer: Hawaii Medical Service Association Commercial	$19,192.00
Rate for Payer: Hawaii Medical Service Association Non-ABD	$3,561.00
Rate for Payer: Kaiser Permanente Medicaid	$2,837.00
Rate for Payer: UnitedHealthcare Medicaid	$353.98
Rate for Payer: University Health Alliance Commercial	$13,923.44

REVASCULARIZATION, ENDOVASCULAR, OPEN OR PERCUTANEOUS, TIBIAL, PERONEAL ARTERY, UNILATERAL, INITIAL VESSEL; WITH TRANSLUMINAL STENT PLACEMENT(S), INCLUDES ANGIOPLASTY WITHIN THE SAME VESSEL, WHEN PERFORMED

Facility

$19,192.00

Service Code	CPT 37230
Hospital Revenue Code	360
Min. Negotiated Rate	$442.57
Max. Negotiated Rate	$19,192.00
Rate for Payer: Hawaii Medical Service Association ABD	$2,102.00
Rate for Payer: Hawaii Medical Service Association Commercial	$19,192.00
Rate for Payer: Hawaii Medical Service Association Non-ABD	$3,561.00
Rate for Payer: Kaiser Permanente Medicaid	$2,837.00
Rate for Payer: UnitedHealthcare Medicaid	$442.57

REVERSED GLENOID DWJ013

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

REVERSED GLENOID DWJ013

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

REVERSED INSERT DWF421B

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

REVERSED INSERT DWF421B

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

REVISION OF HIP OR KNEE REPLACEMENT WITH CC

Facility

$60,833.85

Service Code	MSDRG 467
Min. Negotiated Rate	$40,112.44
Max. Negotiated Rate	$60,833.85
Rate for Payer: AlohaCare Medicare	$40,112.44
Rate for Payer: Devoted Health Medicare	$44,123.68
Rate for Payer: Hawaii Medical Service Association Commercial	$57,922.94
Rate for Payer: Hawaii Medical Service Association Medicare	$40,112.44
Rate for Payer: Humana Medicare	$40,112.44
Rate for Payer: Kaiser Permanente Commercial	$60,833.85
Rate for Payer: Kaiser Permanente Medicare	$40,112.44
Rate for Payer: Ohana Health Plan Medicare	$40,112.44
Rate for Payer: UnitedHealthcare Medicare	$40,112.44

REVISION OF HIP OR KNEE REPLACEMENT WITH MCC

Facility

$89,793.15

Service Code	MSDRG 466
Min. Negotiated Rate	$57,922.94
Max. Negotiated Rate	$89,793.15
Rate for Payer: AlohaCare Medicare	$59,207.54
Rate for Payer: Devoted Health Medicare	$65,128.29
Rate for Payer: Hawaii Medical Service Association Commercial	$57,922.94
Rate for Payer: Hawaii Medical Service Association Medicare	$59,207.54
Rate for Payer: Humana Medicare	$59,207.54
Rate for Payer: Kaiser Permanente Commercial	$89,793.15
Rate for Payer: Kaiser Permanente Medicare	$59,207.54
Rate for Payer: Ohana Health Plan Medicare	$59,207.54
Rate for Payer: UnitedHealthcare Medicare	$59,207.54

REVISION OF HIP OR KNEE REPLACEMENT WITHOUT CC/MCC

Facility

$57,922.94

Service Code	MSDRG 468
Min. Negotiated Rate	$31,256.47
Max. Negotiated Rate	$57,922.94
Rate for Payer: AlohaCare Medicare	$31,256.47
Rate for Payer: Devoted Health Medicare	$34,382.12
Rate for Payer: Hawaii Medical Service Association Commercial	$57,922.94
Rate for Payer: Hawaii Medical Service Association Medicare	$31,256.47
Rate for Payer: Humana Medicare	$31,256.47
Rate for Payer: Kaiser Permanente Commercial	$47,403.00
Rate for Payer: Kaiser Permanente Medicare	$31,256.47
Rate for Payer: Ohana Health Plan Medicare	$31,256.47
Rate for Payer: UnitedHealthcare Medicare	$31,256.47

REVISION OF PERI-IMPLANT CAPSULE, BREAST, INCLUDING CAPSULOTOMY, CAPSULORRHAPHY, AND/OR PARTIAL CAPSULECTOMY

Facility

$13,778.00

Service Code	CPT 19370
Hospital Revenue Code	360
Min. Negotiated Rate	$456.03
Max. Negotiated Rate	$13,778.00
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	$1,149.00
Rate for Payer: Hawaii Medical Service Association Commercial	$13,778.00
Rate for Payer: Hawaii Medical Service Association Medicare	$4,625.48
Rate for Payer: Hawaii Medical Service Association Non-ABD	$2,294.85
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

REVISION OF RECONSTRUCTED BREAST (EG, SIGNIFICANT REMOVAL OF TISSUE, RE-ADVANCEMENT AND/OR RE-INSET OF FLAPS IN AUTOLOGOUS RECONSTRUCTION OR SIGNIFICANT CAPSULAR REVISION COMBINED WITH SOFT TISSUE EXCISION IN IMPLANT-BASED RECONSTRUCTION)

Facility

$13,778.00

Service Code	CPT 19380
Hospital Revenue Code	360
Min. Negotiated Rate	$521.33
Max. Negotiated Rate	$13,778.00
Rate for Payer: AlohaCare Medicaid	$7,844.33
Rate for Payer: AlohaCare Medicare	$7,844.33
Rate for Payer: Devoted Health Medicare	$8,628.76
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	$7,844.33
Rate for Payer: Hawaii Medical Service Association Non-ABD	$2,294.85
Rate for Payer: Humana Medicare	$7,844.33
Rate for Payer: Kaiser Permanente Medicaid	$2,837.00
Rate for Payer: Kaiser Permanente Medicare	$7,844.33
Rate for Payer: Ohana Health Plan Medicaid	$8,628.76
Rate for Payer: Ohana Health Plan Medicare	$7,844.33
Rate for Payer: UnitedHealthcare Medicaid	$521.33
Rate for Payer: UnitedHealthcare Medicare	$7,844.33
Rate for Payer: University Health Alliance Commercial	$11,157.19

REVISION, OPEN, ARTERIOVENOUS FISTULA; WITHOUT THROMBECTOMY, AUTOGENOUS OR NONAUTOGENOUS DIALYSIS GRAFT (SEPARATE PROCEDURE)

Facility

$13,778.00

Service Code	CPT 36832
Hospital Revenue Code	360
Min. Negotiated Rate	$521.33
Max. Negotiated Rate	$13,778.00
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 ABD	$1,149.00
Rate for Payer: Hawaii Medical Service Association Commercial	$13,778.00
Rate for Payer: Hawaii Medical Service Association Medicare	$6,573.58
Rate for Payer: Hawaii Medical Service Association Non-ABD	$2,294.85
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
Rate for Payer: University Health Alliance Commercial	$10,679.55

REVISION, OPEN, ARTERIOVENOUS FISTULA; WITH THROMBECTOMY, AUTOGENOUS OR NONAUTOGENOUS DIALYSIS GRAFT (SEPARATE PROCEDURE)

Facility

$10,679.55

Service Code	CPT 36833
Hospital Revenue Code	360
Min. Negotiated Rate	$521.33
Max. Negotiated Rate	$10,679.55
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 ABD	$848.00
Rate for Payer: Hawaii Medical Service Association Commercial	$8,270.00
Rate for Payer: Hawaii Medical Service Association Medicare	$6,573.58
Rate for Payer: Hawaii Medical Service Association Non-ABD	$1,427.62
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
Rate for Payer: University Health Alliance Commercial	$10,679.55

REVISION OR REMOVAL OF PERIPHERAL NEUROSTIMULATOR ELECTRODE ARRAY

Facility

$5,509.00

Service Code	CPT 64585
Hospital Revenue Code	360
Min. Negotiated Rate	$456.03
Max. Negotiated Rate	$5,509.00
Rate for Payer: AlohaCare Medicaid	$4,130.11
Rate for Payer: AlohaCare Medicare	$4,130.11
Rate for Payer: Devoted Health Medicare	$4,543.12
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	$4,130.11
Rate for Payer: Hawaii Medical Service Association Non-ABD	$1,028.67
Rate for Payer: Humana Medicare	$4,130.11
Rate for Payer: Kaiser Permanente Medicaid	$2,837.00
Rate for Payer: Kaiser Permanente Medicare	$4,130.11
Rate for Payer: Ohana Health Plan Medicaid	$4,543.12
Rate for Payer: Ohana Health Plan Medicare	$4,130.11
Rate for Payer: UnitedHealthcare Medicaid	$456.03
Rate for Payer: UnitedHealthcare Medicare	$4,130.11
Rate for Payer: University Health Alliance Commercial	$4,035.20

REVISION OR REMOVAL OF PERIPHERAL, SACRAL, OR GASTRIC NEUROSTIMULATOR PULSE GENERATOR OR RECEIVER, WITH DETACHABLE CONNECTION TO ELECTRODE ARRAY

Facility

$5,509.00

Service Code	CPT 64595
Hospital Revenue Code	360
Min. Negotiated Rate	$456.03
Max. Negotiated Rate	$5,509.00
Rate for Payer: AlohaCare Medicaid	$4,130.11
Rate for Payer: AlohaCare Medicare	$4,130.11
Rate for Payer: Devoted Health Medicare	$4,543.12
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	$4,130.11
Rate for Payer: Hawaii Medical Service Association Non-ABD	$1,028.67
Rate for Payer: Humana Medicare	$4,130.11
Rate for Payer: Kaiser Permanente Medicaid	$2,837.00
Rate for Payer: Kaiser Permanente Medicare	$4,130.11
Rate for Payer: Ohana Health Plan Medicaid	$4,543.12
Rate for Payer: Ohana Health Plan Medicare	$4,130.11
Rate for Payer: UnitedHealthcare Medicaid	$456.03
Rate for Payer: UnitedHealthcare Medicare	$4,130.11
Rate for Payer: University Health Alliance Commercial	$4,035.20

RFX HUMERAL 10X123MM 5568-0010

Facility

$8,462.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$4,738.72
Max. Negotiated Rate	$8,208.14
Rate for Payer: Cash Price	$5,077.20
Rate for Payer: Hawaii Western Management Group Commercial	$5,923.40
Rate for Payer: Health Management Network Commercial	$7,192.70
Rate for Payer: MDX Hawaii PPO	$8,208.14
Rate for Payer: University Health Alliance Commercial	$4,738.72

Know your out-of-pocket cost for care.

All Charges