Hilo Benioff Medical Center

All Charges

Charge

Type

Setting

Price

SHOULDER, ELBOW OR FOREARM PROCEDURES, EXCEPT MAJOR JOINT PROCEDURES WITH CC

Facility

$35,869.65

Service Code	MSDRG 511
Min. Negotiated Rate	$23,651.62
Max. Negotiated Rate	$35,869.65
Rate for Payer: AlohaCare Medicare	$23,651.62
Rate for Payer: Devoted Health Medicare	$26,016.78
Rate for Payer: Hawaii Medical Service Association Commercial	$23,732.15
Rate for Payer: Hawaii Medical Service Association Medicare	$23,651.62
Rate for Payer: Humana Medicare	$23,651.62
Rate for Payer: Kaiser Permanente Commercial	$35,869.65
Rate for Payer: Kaiser Permanente Medicare	$23,651.62
Rate for Payer: Ohana Health Plan Medicare	$23,651.62
Rate for Payer: UnitedHealthcare Medicare	$23,651.62

SHOULDER, ELBOW OR FOREARM PROCEDURES, EXCEPT MAJOR JOINT PROCEDURES WITH MCC

Facility

$52,103.62

Service Code	MSDRG 510
Min. Negotiated Rate	$23,732.15
Max. Negotiated Rate	$52,103.62
Rate for Payer: AlohaCare Medicare	$34,355.95
Rate for Payer: Devoted Health Medicare	$37,791.54
Rate for Payer: Hawaii Medical Service Association Commercial	$23,732.15
Rate for Payer: Hawaii Medical Service Association Medicare	$34,355.95
Rate for Payer: Humana Medicare	$34,355.95
Rate for Payer: Kaiser Permanente Commercial	$52,103.62
Rate for Payer: Kaiser Permanente Medicare	$34,355.95
Rate for Payer: Ohana Health Plan Medicare	$34,355.95
Rate for Payer: UnitedHealthcare Medicare	$34,355.95

SHOULDER, ELBOW OR FOREARM PROCEDURES, EXCEPT MAJOR JOINT PROCEDURES WITHOUT CC/MCC

Facility

$28,555.65

Service Code	MSDRG 512
Min. Negotiated Rate	$18,828.94
Max. Negotiated Rate	$28,555.65
Rate for Payer: AlohaCare Medicare	$18,828.94
Rate for Payer: Devoted Health Medicare	$20,711.83
Rate for Payer: Hawaii Medical Service Association Commercial	$22,300.45
Rate for Payer: Hawaii Medical Service Association Medicare	$18,828.94
Rate for Payer: Humana Medicare	$18,828.94
Rate for Payer: Kaiser Permanente Commercial	$28,555.65
Rate for Payer: Kaiser Permanente Medicare	$18,828.94
Rate for Payer: Ohana Health Plan Medicare	$18,828.94
Rate for Payer: UnitedHealthcare Medicare	$18,828.94

SHOULDER FLEX SYS DWG146

Facility

$8,306.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$4,236.06
Max. Negotiated Rate	$8,056.82
Rate for Payer: Cash Price	$4,983.60
Rate for Payer: Hawaii Western Management Group Commercial	$5,814.20
Rate for Payer: Health Management Network Commercial	$7,060.10
Rate for Payer: Kaiser Permanente Commercial	$5,232.78
Rate for Payer: Kaiser Permanente Medicaid	$4,236.06
Rate for Payer: MDX Hawaii PPO	$8,056.82
Rate for Payer: University Health Alliance Commercial	$4,651.36

SHOULDER FLEX SYS DWG146

Facility

$8,306.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$4,651.36
Max. Negotiated Rate	$8,056.82
Rate for Payer: Cash Price	$4,983.60
Rate for Payer: Hawaii Western Management Group Commercial	$5,814.20
Rate for Payer: Health Management Network Commercial	$7,060.10
Rate for Payer: MDX Hawaii PPO	$8,056.82
Rate for Payer: University Health Alliance Commercial	$4,651.36

SHOULDER STABILIZER KIT

Facility

$332.00

Hospital Revenue Code	272
Min. Negotiated Rate	$169.32
Max. Negotiated Rate	$322.04
Rate for Payer: Cash Price	$199.20
Rate for Payer: Hawaii Western Management Group Commercial	$315.40
Rate for Payer: Health Management Network Commercial	$282.20
Rate for Payer: Kaiser Permanente Commercial	$209.16
Rate for Payer: Kaiser Permanente Medicaid	$169.32
Rate for Payer: MDX Hawaii PPO	$322.04
Rate for Payer: University Health Alliance Commercial	$241.99

SHOULDER STABILIZER KIT

Facility

$332.00

Hospital Revenue Code	272
Min. Negotiated Rate	$282.20
Max. Negotiated Rate	$322.04
Rate for Payer: Cash Price	$199.20
Rate for Payer: Health Management Network Commercial	$282.20
Rate for Payer: MDX Hawaii PPO	$322.04

SHOULDER SUSPENSION MPR-SS-KIT

Facility

$183.00

Hospital Revenue Code	272
Min. Negotiated Rate	$155.55
Max. Negotiated Rate	$177.51
Rate for Payer: Cash Price	$109.80
Rate for Payer: Health Management Network Commercial	$155.55
Rate for Payer: MDX Hawaii PPO	$177.51

SHOULDER SUSPENSION MPR-SS-KIT

Facility

$183.00

Hospital Revenue Code	272
Min. Negotiated Rate	$93.33
Max. Negotiated Rate	$177.51
Rate for Payer: Cash Price	$109.80
Rate for Payer: Hawaii Western Management Group Commercial	$173.85
Rate for Payer: Health Management Network Commercial	$155.55
Rate for Payer: Kaiser Permanente Commercial	$115.29
Rate for Payer: Kaiser Permanente Medicaid	$93.33
Rate for Payer: MDX Hawaii PPO	$177.51
Rate for Payer: University Health Alliance Commercial	$133.39

SHOULDER, UPPER ARM & FOREARM PROCEDURES EXCEPT JOINT REPLACEMENT

Facility

$17,446.45

Service Code	APR-DRG 3154
Min. Negotiated Rate	$17,446.45
Max. Negotiated Rate	$17,446.45
Rate for Payer: AlohaCare Medicaid	$17,446.45
Rate for Payer: Hawaii Medical Service Association ABD	$17,446.45
Rate for Payer: Hawaii Medical Service Association Non-ABD	$17,446.45
Rate for Payer: Kaiser Permanente Medicaid	$17,446.45
Rate for Payer: Ohana Health Plan Medicaid	$17,446.45
Rate for Payer: UnitedHealthcare Medicaid	$17,446.45

SHOULDER, UPPER ARM & FOREARM PROCEDURES EXCEPT JOINT REPLACEMENT

Facility

$4,481.14

Service Code	APR-DRG 3151
Min. Negotiated Rate	$4,481.14
Max. Negotiated Rate	$4,481.14
Rate for Payer: AlohaCare Medicaid	$4,481.14
Rate for Payer: Hawaii Medical Service Association ABD	$4,481.14
Rate for Payer: Hawaii Medical Service Association Non-ABD	$4,481.14
Rate for Payer: Kaiser Permanente Medicaid	$4,481.14
Rate for Payer: Ohana Health Plan Medicaid	$4,481.14
Rate for Payer: UnitedHealthcare Medicaid	$4,481.14

SHOULDER, UPPER ARM & FOREARM PROCEDURES EXCEPT JOINT REPLACEMENT

Facility

$7,357.68

Service Code	APR-DRG 3152
Min. Negotiated Rate	$7,357.68
Max. Negotiated Rate	$7,357.68
Rate for Payer: AlohaCare Medicaid	$7,357.68
Rate for Payer: Hawaii Medical Service Association ABD	$7,357.68
Rate for Payer: Hawaii Medical Service Association Non-ABD	$7,357.68
Rate for Payer: Kaiser Permanente Medicaid	$7,357.68
Rate for Payer: Ohana Health Plan Medicaid	$7,357.68
Rate for Payer: UnitedHealthcare Medicaid	$7,357.68

SHOULDER, UPPER ARM & FOREARM PROCEDURES EXCEPT JOINT REPLACEMENT

Facility

$10,724.74

Service Code	APR-DRG 3153
Min. Negotiated Rate	$10,724.74
Max. Negotiated Rate	$10,724.74
Rate for Payer: AlohaCare Medicaid	$10,724.74
Rate for Payer: Hawaii Medical Service Association ABD	$10,724.74
Rate for Payer: Hawaii Medical Service Association Non-ABD	$10,724.74
Rate for Payer: Kaiser Permanente Medicaid	$10,724.74
Rate for Payer: Ohana Health Plan Medicaid	$10,724.74
Rate for Payer: UnitedHealthcare Medicaid	$10,724.74

SHUNT PRUITT-INA 2013-10

Facility

$2,098.00

Service Code	HCPCS C1889
Hospital Revenue Code	278
Min. Negotiated Rate	$1,174.88
Max. Negotiated Rate	$2,035.06
Rate for Payer: Cash Price	$1,258.80
Rate for Payer: Hawaii Western Management Group Commercial	$1,468.60
Rate for Payer: Health Management Network Commercial	$1,783.30
Rate for Payer: MDX Hawaii PPO	$2,035.06
Rate for Payer: University Health Alliance Commercial	$1,174.88

SHUNT PRUITT-INA 2013-10

Facility

$2,098.00

Service Code	HCPCS C1889
Hospital Revenue Code	278
Min. Negotiated Rate	$1,069.98
Max. Negotiated Rate	$2,035.06
Rate for Payer: Cash Price	$1,258.80
Rate for Payer: Hawaii Western Management Group Commercial	$1,468.60
Rate for Payer: Health Management Network Commercial	$1,783.30
Rate for Payer: Kaiser Permanente Commercial	$1,321.74
Rate for Payer: Kaiser Permanente Medicaid	$1,069.98
Rate for Payer: MDX Hawaii PPO	$2,035.06
Rate for Payer: University Health Alliance Commercial	$1,174.88

SICKLE CELL ANEMIA CRISIS

Facility

$3,825.60

Service Code	APR-DRG 6622
Min. Negotiated Rate	$3,825.60
Max. Negotiated Rate	$3,825.60
Rate for Payer: AlohaCare Medicaid	$3,825.60
Rate for Payer: Hawaii Medical Service Association ABD	$3,825.60
Rate for Payer: Hawaii Medical Service Association Non-ABD	$3,825.60
Rate for Payer: Kaiser Permanente Medicaid	$3,825.60
Rate for Payer: Ohana Health Plan Medicaid	$3,825.60
Rate for Payer: UnitedHealthcare Medicaid	$3,825.60

SICKLE CELL ANEMIA CRISIS

Facility

$5,460.21

Service Code	APR-DRG 6623
Min. Negotiated Rate	$5,460.21
Max. Negotiated Rate	$5,460.21
Rate for Payer: AlohaCare Medicaid	$5,460.21
Rate for Payer: Hawaii Medical Service Association ABD	$5,460.21
Rate for Payer: Hawaii Medical Service Association Non-ABD	$5,460.21
Rate for Payer: Kaiser Permanente Medicaid	$5,460.21
Rate for Payer: Ohana Health Plan Medicaid	$5,460.21
Rate for Payer: UnitedHealthcare Medicaid	$5,460.21

SICKLE CELL ANEMIA CRISIS

Facility

$11,285.04

Service Code	APR-DRG 6624
Min. Negotiated Rate	$11,285.04
Max. Negotiated Rate	$11,285.04
Rate for Payer: AlohaCare Medicaid	$11,285.04
Rate for Payer: Hawaii Medical Service Association ABD	$11,285.04
Rate for Payer: Hawaii Medical Service Association Non-ABD	$11,285.04
Rate for Payer: Kaiser Permanente Medicaid	$11,285.04
Rate for Payer: Ohana Health Plan Medicaid	$11,285.04
Rate for Payer: UnitedHealthcare Medicaid	$11,285.04

SICKLE CELL ANEMIA CRISIS

Facility

$2,849.80

Service Code	APR-DRG 6621
Min. Negotiated Rate	$2,849.80
Max. Negotiated Rate	$2,849.80
Rate for Payer: AlohaCare Medicaid	$2,849.80
Rate for Payer: Hawaii Medical Service Association ABD	$2,849.80
Rate for Payer: Hawaii Medical Service Association Non-ABD	$2,849.80
Rate for Payer: Kaiser Permanente Medicaid	$2,849.80
Rate for Payer: Ohana Health Plan Medicaid	$2,849.80
Rate for Payer: UnitedHealthcare Medicaid	$2,849.80

SIGMOIDOSCOPY, FLEXIBLE; WITH REMOVAL OF TUMOR(S), POLYP(S), OR OTHER LESION(S) BY SNARE TECHNIQUE

Facility

$5,509.00

Service Code	CPT 45338
Hospital Revenue Code	360
Min. Negotiated Rate	$456.03
Max. Negotiated Rate	$5,509.00
Rate for Payer: AlohaCare Medicaid	$1,413.65
Rate for Payer: AlohaCare Medicare	$1,413.65
Rate for Payer: Devoted Health Medicare	$1,555.02
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	$1,413.65
Rate for Payer: Hawaii Medical Service Association Non-ABD	$1,028.67
Rate for Payer: Humana Medicare	$1,413.65
Rate for Payer: Kaiser Permanente Medicaid	$2,837.00
Rate for Payer: Kaiser Permanente Medicare	$1,413.65
Rate for Payer: Ohana Health Plan Medicaid	$1,555.02
Rate for Payer: Ohana Health Plan Medicare	$1,413.65
Rate for Payer: UnitedHealthcare Medicaid	$456.03
Rate for Payer: UnitedHealthcare Medicare	$1,413.65

SIGNS AND SYMPTOMS OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH MCC

Facility

$22,801.05

Service Code	MSDRG 555
Min. Negotiated Rate	$10,749.84
Max. Negotiated Rate	$22,801.05
Rate for Payer: AlohaCare Medicare	$15,034.47
Rate for Payer: Devoted Health Medicare	$16,537.92
Rate for Payer: Hawaii Medical Service Association Commercial	$10,749.84
Rate for Payer: Hawaii Medical Service Association Medicare	$15,034.47
Rate for Payer: Humana Medicare	$15,034.47
Rate for Payer: Kaiser Permanente Commercial	$22,801.05
Rate for Payer: Kaiser Permanente Medicare	$15,034.47
Rate for Payer: Ohana Health Plan Medicare	$15,034.47
Rate for Payer: UnitedHealthcare Medicare	$15,034.47

SIGNS AND SYMPTOMS OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITHOUT MCC

Facility

$14,327.85

Service Code	MSDRG 556
Min. Negotiated Rate	$9,447.47
Max. Negotiated Rate	$14,327.85
Rate for Payer: AlohaCare Medicare	$9,447.47
Rate for Payer: Devoted Health Medicare	$10,392.22
Rate for Payer: Hawaii Medical Service Association Commercial	$10,749.84
Rate for Payer: Hawaii Medical Service Association Medicare	$9,447.47
Rate for Payer: Humana Medicare	$9,447.47
Rate for Payer: Kaiser Permanente Commercial	$14,327.85
Rate for Payer: Kaiser Permanente Medicare	$9,447.47
Rate for Payer: Ohana Health Plan Medicare	$9,447.47
Rate for Payer: UnitedHealthcare Medicare	$9,447.47

SIGNS AND SYMPTOMS WITH MCC

Facility

$21,897.15

Service Code	MSDRG 947
Min. Negotiated Rate	$14,438.46
Max. Negotiated Rate	$21,897.15
Rate for Payer: AlohaCare Medicare	$14,438.46
Rate for Payer: Devoted Health Medicare	$15,882.31
Rate for Payer: Hawaii Medical Service Association Commercial	$14,729.46
Rate for Payer: Hawaii Medical Service Association Medicare	$14,438.46
Rate for Payer: Humana Medicare	$14,438.46
Rate for Payer: Kaiser Permanente Commercial	$21,897.15
Rate for Payer: Kaiser Permanente Medicare	$14,438.46
Rate for Payer: Ohana Health Plan Medicare	$14,438.46
Rate for Payer: UnitedHealthcare Medicare	$14,438.46

SIGNS AND SYMPTOMS WITHOUT MCC

Facility

$14,001.48

Service Code	MSDRG 948
Min. Negotiated Rate	$9,105.08
Max. Negotiated Rate	$14,001.48
Rate for Payer: AlohaCare Medicare	$9,105.08
Rate for Payer: Devoted Health Medicare	$10,015.59
Rate for Payer: Hawaii Medical Service Association Commercial	$14,001.48
Rate for Payer: Hawaii Medical Service Association Medicare	$9,105.08
Rate for Payer: Humana Medicare	$9,105.08
Rate for Payer: Kaiser Permanente Commercial	$13,808.62
Rate for Payer: Kaiser Permanente Medicare	$9,105.08
Rate for Payer: Ohana Health Plan Medicare	$9,105.08
Rate for Payer: UnitedHealthcare Medicare	$9,105.08

SIGNS, SYMPTOMS & OTHER FACTORS INFLUENCING HEALTH STATUS

Facility

$3,102.88

Service Code	APR-DRG 8612
Min. Negotiated Rate	$3,102.88
Max. Negotiated Rate	$3,102.88
Rate for Payer: AlohaCare Medicaid	$3,102.88
Rate for Payer: Hawaii Medical Service Association ABD	$3,102.88
Rate for Payer: Hawaii Medical Service Association Non-ABD	$3,102.88
Rate for Payer: Kaiser Permanente Medicaid	$3,102.88
Rate for Payer: Ohana Health Plan Medicaid	$3,102.88
Rate for Payer: UnitedHealthcare Medicaid	$3,102.88

Know your out-of-pocket cost for care.

All Charges