Hilo Benioff Medical Center

All Charges

Charge

Type

Setting

Price

SHEATH URETERAL ACCESS 12FRX45

Facility

$576.00

Service Code	HCPCS C1894
Hospital Revenue Code	272
Min. Negotiated Rate	$293.76
Max. Negotiated Rate	$558.72
Rate for Payer: Cash Price	$345.60
Rate for Payer: Hawaii Western Management Group Commercial	$547.20
Rate for Payer: Health Management Network Commercial	$489.60
Rate for Payer: Kaiser Permanente Commercial	$362.88
Rate for Payer: Kaiser Permanente Medicaid	$293.76
Rate for Payer: MDX Hawaii PPO	$558.72
Rate for Payer: University Health Alliance Commercial	$419.85

SHEATH URETERAL ACCESS 14FRX35

Facility

$576.00

Service Code	HCPCS C1894
Hospital Revenue Code	272
Min. Negotiated Rate	$489.60
Max. Negotiated Rate	$558.72
Rate for Payer: Cash Price	$345.60
Rate for Payer: Health Management Network Commercial	$489.60
Rate for Payer: MDX Hawaii PPO	$558.72

SHEATH URETERAL ACCESS 14FRX35

Facility

$576.00

Service Code	HCPCS C1894
Hospital Revenue Code	272
Min. Negotiated Rate	$293.76
Max. Negotiated Rate	$558.72
Rate for Payer: Cash Price	$345.60
Rate for Payer: Hawaii Western Management Group Commercial	$547.20
Rate for Payer: Health Management Network Commercial	$489.60
Rate for Payer: Kaiser Permanente Commercial	$362.88
Rate for Payer: Kaiser Permanente Medicaid	$293.76
Rate for Payer: MDX Hawaii PPO	$558.72
Rate for Payer: University Health Alliance Commercial	$419.85

SHEATH URETERAL ACCESS 14FRX45

Facility

$576.00

Service Code	HCPCS C1894
Hospital Revenue Code	272
Min. Negotiated Rate	$489.60
Max. Negotiated Rate	$558.72
Rate for Payer: Cash Price	$345.60
Rate for Payer: Health Management Network Commercial	$489.60
Rate for Payer: MDX Hawaii PPO	$558.72

SHEATH URETERAL ACCESS 14FRX45

Facility

$576.00

Service Code	HCPCS C1894
Hospital Revenue Code	272
Min. Negotiated Rate	$293.76
Max. Negotiated Rate	$558.72
Rate for Payer: Cash Price	$345.60
Rate for Payer: Hawaii Western Management Group Commercial	$547.20
Rate for Payer: Health Management Network Commercial	$489.60
Rate for Payer: Kaiser Permanente Commercial	$362.88
Rate for Payer: Kaiser Permanente Medicaid	$293.76
Rate for Payer: MDX Hawaii PPO	$558.72
Rate for Payer: University Health Alliance Commercial	$419.85

SHEATH URETERAL ACCESS SET

Facility

$424.00

Service Code	HCPCS C1894
Hospital Revenue Code	272
Min. Negotiated Rate	$360.40
Max. Negotiated Rate	$411.28
Rate for Payer: Cash Price	$254.40
Rate for Payer: Health Management Network Commercial	$360.40
Rate for Payer: MDX Hawaii PPO	$411.28

SHEATH URETERAL ACCESS SET

Facility

$424.00

Service Code	HCPCS C1894
Hospital Revenue Code	272
Min. Negotiated Rate	$216.24
Max. Negotiated Rate	$411.28
Rate for Payer: Cash Price	$254.40
Rate for Payer: Hawaii Western Management Group Commercial	$402.80
Rate for Payer: Health Management Network Commercial	$360.40
Rate for Payer: Kaiser Permanente Commercial	$267.12
Rate for Payer: Kaiser Permanente Medicaid	$216.24
Rate for Payer: MDX Hawaii PPO	$411.28
Rate for Payer: University Health Alliance Commercial	$309.05

SHELL 44MM #00-5001-044-00

Facility

$1,568.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$878.08
Max. Negotiated Rate	$1,520.96
Rate for Payer: Cash Price	$940.80
Rate for Payer: Hawaii Western Management Group Commercial	$1,097.60
Rate for Payer: Health Management Network Commercial	$1,332.80
Rate for Payer: MDX Hawaii PPO	$1,520.96
Rate for Payer: University Health Alliance Commercial	$878.08

SHELL 44MM #00-5001-044-00

Facility

$1,568.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$799.68
Max. Negotiated Rate	$1,520.96
Rate for Payer: Cash Price	$940.80
Rate for Payer: Hawaii Western Management Group Commercial	$1,097.60
Rate for Payer: Health Management Network Commercial	$1,332.80
Rate for Payer: Kaiser Permanente Commercial	$987.84
Rate for Payer: Kaiser Permanente Medicaid	$799.68
Rate for Payer: MDX Hawaii PPO	$1,520.96
Rate for Payer: University Health Alliance Commercial	$878.08

SHELL BPLR 55MM 00-5001-055-00

Facility

$1,050.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$588.00
Max. Negotiated Rate	$1,018.50
Rate for Payer: Cash Price	$630.00
Rate for Payer: Hawaii Western Management Group Commercial	$735.00
Rate for Payer: Health Management Network Commercial	$892.50
Rate for Payer: MDX Hawaii PPO	$1,018.50
Rate for Payer: University Health Alliance Commercial	$588.00

SHELL BPLR 55MM 00-5001-055-00

Facility

$1,050.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$535.50
Max. Negotiated Rate	$1,018.50
Rate for Payer: Cash Price	$630.00
Rate for Payer: Hawaii Western Management Group Commercial	$735.00
Rate for Payer: Health Management Network Commercial	$892.50
Rate for Payer: Kaiser Permanente Commercial	$661.50
Rate for Payer: Kaiser Permanente Medicaid	$535.50
Rate for Payer: MDX Hawaii PPO	$1,018.50
Rate for Payer: University Health Alliance Commercial	$588.00

SHELL CLUSTER 50MM 702-1150D

Facility

$2,703.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$1,513.68
Max. Negotiated Rate	$2,621.91
Rate for Payer: Cash Price	$1,621.80
Rate for Payer: Hawaii Western Management Group Commercial	$1,892.10
Rate for Payer: Health Management Network Commercial	$2,297.55
Rate for Payer: MDX Hawaii PPO	$2,621.91
Rate for Payer: University Health Alliance Commercial	$1,513.68

SHELL CLUSTER 50MM 702-1150D

Facility

$2,703.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$1,378.53
Max. Negotiated Rate	$2,621.91
Rate for Payer: Cash Price	$1,621.80
Rate for Payer: Hawaii Western Management Group Commercial	$1,892.10
Rate for Payer: Health Management Network Commercial	$2,297.55
Rate for Payer: Kaiser Permanente Commercial	$1,702.89
Rate for Payer: Kaiser Permanente Medicaid	$1,378.53
Rate for Payer: MDX Hawaii PPO	$2,621.91
Rate for Payer: University Health Alliance Commercial	$1,513.68

SHELL CLUSTER 60MM 702-04-60G

Facility

$3,211.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$1,798.16
Max. Negotiated Rate	$3,114.67
Rate for Payer: Cash Price	$1,926.60
Rate for Payer: Hawaii Western Management Group Commercial	$2,247.70
Rate for Payer: Health Management Network Commercial	$2,729.35
Rate for Payer: MDX Hawaii PPO	$3,114.67
Rate for Payer: University Health Alliance Commercial	$1,798.16

SHELL CLUSTER 60MM 702-04-60G

Facility

$3,211.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$1,637.61
Max. Negotiated Rate	$3,114.67
Rate for Payer: Cash Price	$1,926.60
Rate for Payer: Hawaii Western Management Group Commercial	$2,247.70
Rate for Payer: Health Management Network Commercial	$2,729.35
Rate for Payer: Kaiser Permanente Commercial	$2,022.93
Rate for Payer: Kaiser Permanente Medicaid	$1,637.61
Rate for Payer: MDX Hawaii PPO	$3,114.67
Rate for Payer: University Health Alliance Commercial	$1,798.16

SHELL CUP 45MM 00-5001-45-00

Facility

$1,568.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$878.08
Max. Negotiated Rate	$1,520.96
Rate for Payer: Cash Price	$940.80
Rate for Payer: Hawaii Western Management Group Commercial	$1,097.60
Rate for Payer: Health Management Network Commercial	$1,332.80
Rate for Payer: MDX Hawaii PPO	$1,520.96
Rate for Payer: University Health Alliance Commercial	$878.08

SHELL CUP 45MM 00-5001-45-00

Facility

$1,568.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$799.68
Max. Negotiated Rate	$1,520.96
Rate for Payer: Cash Price	$940.80
Rate for Payer: Hawaii Western Management Group Commercial	$1,097.60
Rate for Payer: Health Management Network Commercial	$1,332.80
Rate for Payer: Kaiser Permanente Commercial	$987.84
Rate for Payer: Kaiser Permanente Medicaid	$799.68
Rate for Payer: MDX Hawaii PPO	$1,520.96
Rate for Payer: University Health Alliance Commercial	$878.08

SHELL HEMI 64MM 509-02-64G

Facility

$11,560.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$6,473.60
Max. Negotiated Rate	$11,213.20
Rate for Payer: Cash Price	$6,936.00
Rate for Payer: Hawaii Western Management Group Commercial	$8,092.00
Rate for Payer: Health Management Network Commercial	$9,826.00
Rate for Payer: MDX Hawaii PPO	$11,213.20
Rate for Payer: University Health Alliance Commercial	$6,473.60

SHELL HEMI 64MM 509-02-64G

Facility

$11,560.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$5,895.60
Max. Negotiated Rate	$11,213.20
Rate for Payer: Cash Price	$6,936.00
Rate for Payer: Hawaii Western Management Group Commercial	$8,092.00
Rate for Payer: Health Management Network Commercial	$9,826.00
Rate for Payer: Kaiser Permanente Commercial	$7,282.80
Rate for Payer: Kaiser Permanente Medicaid	$5,895.60
Rate for Payer: MDX Hawaii PPO	$11,213.20
Rate for Payer: University Health Alliance Commercial	$6,473.60

SHOULDER CRYO/CUFF 12A01

Facility

$205.00

Hospital Revenue Code	272
Min. Negotiated Rate	$104.55
Max. Negotiated Rate	$198.85
Rate for Payer: Cash Price	$123.00
Rate for Payer: Hawaii Western Management Group Commercial	$194.75
Rate for Payer: Health Management Network Commercial	$174.25
Rate for Payer: Kaiser Permanente Commercial	$129.15
Rate for Payer: Kaiser Permanente Medicaid	$104.55
Rate for Payer: MDX Hawaii PPO	$198.85
Rate for Payer: University Health Alliance Commercial	$149.42

SHOULDER CRYO/CUFF 12A01

Facility

$205.00

Hospital Revenue Code	272
Min. Negotiated Rate	$174.25
Max. Negotiated Rate	$198.85
Rate for Payer: Cash Price	$123.00
Rate for Payer: Health Management Network Commercial	$174.25
Rate for Payer: MDX Hawaii PPO	$198.85

SHOULDER & ELBOW JOINT REPLACEMENT

Facility

$9,734.58

Service Code	APR-DRG 3221
Min. Negotiated Rate	$9,734.58
Max. Negotiated Rate	$9,734.58
Rate for Payer: AlohaCare Medicaid	$9,734.58
Rate for Payer: Hawaii Medical Service Association ABD	$9,734.58
Rate for Payer: Hawaii Medical Service Association Non-ABD	$9,734.58
Rate for Payer: Kaiser Permanente Medicaid	$9,734.58
Rate for Payer: Ohana Health Plan Medicaid	$9,734.58
Rate for Payer: UnitedHealthcare Medicaid	$9,734.58

SHOULDER & ELBOW JOINT REPLACEMENT

Facility

$10,581.24

Service Code	APR-DRG 3222
Min. Negotiated Rate	$10,581.24
Max. Negotiated Rate	$10,581.24
Rate for Payer: AlohaCare Medicaid	$10,581.24
Rate for Payer: Hawaii Medical Service Association ABD	$10,581.24
Rate for Payer: Hawaii Medical Service Association Non-ABD	$10,581.24
Rate for Payer: Kaiser Permanente Medicaid	$10,581.24
Rate for Payer: Ohana Health Plan Medicaid	$10,581.24
Rate for Payer: UnitedHealthcare Medicaid	$10,581.24

SHOULDER & ELBOW JOINT REPLACEMENT

Facility

$18,772.53

Service Code	APR-DRG 3224
Min. Negotiated Rate	$18,772.53
Max. Negotiated Rate	$18,772.53
Rate for Payer: AlohaCare Medicaid	$18,772.53
Rate for Payer: Hawaii Medical Service Association ABD	$18,772.53
Rate for Payer: Hawaii Medical Service Association Non-ABD	$18,772.53
Rate for Payer: Kaiser Permanente Medicaid	$18,772.53
Rate for Payer: Ohana Health Plan Medicaid	$18,772.53
Rate for Payer: UnitedHealthcare Medicaid	$18,772.53

SHOULDER & ELBOW JOINT REPLACEMENT

Facility

$13,359.94

Service Code	APR-DRG 3223
Min. Negotiated Rate	$13,359.94
Max. Negotiated Rate	$13,359.94
Rate for Payer: AlohaCare Medicaid	$13,359.94
Rate for Payer: Hawaii Medical Service Association ABD	$13,359.94
Rate for Payer: Hawaii Medical Service Association Non-ABD	$13,359.94
Rate for Payer: Kaiser Permanente Medicaid	$13,359.94
Rate for Payer: Ohana Health Plan Medicaid	$13,359.94
Rate for Payer: UnitedHealthcare Medicaid	$13,359.94

Know your out-of-pocket cost for care.

All Charges