Hilo Benioff Medical Center

All Charges

Charge

Type

Setting

Price

SPEEDGRAFT JRF 10MM #SPD-001

Facility

$4,650.00

Service Code	HCPCS C1762
Hospital Revenue Code	278
Min. Negotiated Rate	$2,371.50
Max. Negotiated Rate	$4,510.50
Rate for Payer: Cash Price	$2,790.00
Rate for Payer: Hawaii Western Management Group Commercial	$3,255.00
Rate for Payer: Health Management Network Commercial	$3,952.50
Rate for Payer: Kaiser Permanente Commercial	$2,929.50
Rate for Payer: Kaiser Permanente Medicaid	$2,371.50
Rate for Payer: MDX Hawaii PPO	$4,510.50
Rate for Payer: University Health Alliance Commercial	$2,604.00

SPHERE FEMUR LT 4+ 02.12.0024L

Facility

$4,000.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$2,240.00
Max. Negotiated Rate	$3,880.00
Rate for Payer: Cash Price	$2,400.00
Rate for Payer: Hawaii Western Management Group Commercial	$2,800.00
Rate for Payer: Health Management Network Commercial	$3,400.00
Rate for Payer: MDX Hawaii PPO	$3,880.00
Rate for Payer: University Health Alliance Commercial	$2,240.00

SPHERE FEMUR LT 4+ 02.12.0024L

Facility

$4,000.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$2,040.00
Max. Negotiated Rate	$3,880.00
Rate for Payer: Cash Price	$2,400.00
Rate for Payer: Hawaii Western Management Group Commercial	$2,800.00
Rate for Payer: Health Management Network Commercial	$3,400.00
Rate for Payer: Kaiser Permanente Commercial	$2,520.00
Rate for Payer: Kaiser Permanente Medicaid	$2,040.00
Rate for Payer: MDX Hawaii PPO	$3,880.00
Rate for Payer: University Health Alliance Commercial	$2,240.00

SPHERE FEMUR RT 5+ 02.12.0025R

Facility

$4,000.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$2,240.00
Max. Negotiated Rate	$3,880.00
Rate for Payer: Cash Price	$2,400.00
Rate for Payer: Hawaii Western Management Group Commercial	$2,800.00
Rate for Payer: Health Management Network Commercial	$3,400.00
Rate for Payer: MDX Hawaii PPO	$3,880.00
Rate for Payer: University Health Alliance Commercial	$2,240.00

SPHERE FEMUR RT 5+ 02.12.0025R

Facility

$4,000.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$2,040.00
Max. Negotiated Rate	$3,880.00
Rate for Payer: Cash Price	$2,400.00
Rate for Payer: Hawaii Western Management Group Commercial	$2,800.00
Rate for Payer: Health Management Network Commercial	$3,400.00
Rate for Payer: Kaiser Permanente Commercial	$2,520.00
Rate for Payer: Kaiser Permanente Medicaid	$2,040.00
Rate for Payer: MDX Hawaii PPO	$3,880.00
Rate for Payer: University Health Alliance Commercial	$2,240.00

SPHERE TIB 10MM 02.12.0410CRL

Facility

$2,400.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$1,344.00
Max. Negotiated Rate	$2,328.00
Rate for Payer: Cash Price	$1,440.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,680.00
Rate for Payer: Health Management Network Commercial	$2,040.00
Rate for Payer: MDX Hawaii PPO	$2,328.00
Rate for Payer: University Health Alliance Commercial	$1,344.00

SPHERE TIB 10MM 02.12.0410CRL

Facility

$2,400.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$1,224.00
Max. Negotiated Rate	$2,328.00
Rate for Payer: Cash Price	$1,440.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,680.00
Rate for Payer: Health Management Network Commercial	$2,040.00
Rate for Payer: Kaiser Permanente Commercial	$1,512.00
Rate for Payer: Kaiser Permanente Medicaid	$1,224.00
Rate for Payer: MDX Hawaii PPO	$2,328.00
Rate for Payer: University Health Alliance Commercial	$1,344.00

SPHERE TIB 10 S4 02.12.0410CRR

Facility

$2,400.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$1,224.00
Max. Negotiated Rate	$2,328.00
Rate for Payer: Cash Price	$1,440.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,680.00
Rate for Payer: Health Management Network Commercial	$2,040.00
Rate for Payer: Kaiser Permanente Commercial	$1,512.00
Rate for Payer: Kaiser Permanente Medicaid	$1,224.00
Rate for Payer: MDX Hawaii PPO	$2,328.00
Rate for Payer: University Health Alliance Commercial	$1,344.00

SPHERE TIB 10 S4 02.12.0410CRR

Facility

$2,400.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$1,344.00
Max. Negotiated Rate	$2,328.00
Rate for Payer: Cash Price	$1,440.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,680.00
Rate for Payer: Health Management Network Commercial	$2,040.00
Rate for Payer: MDX Hawaii PPO	$2,328.00
Rate for Payer: University Health Alliance Commercial	$1,344.00

SPINAL DISORDERS AND INJURIES WITH CC/MCC

Facility

$35,404.09

Service Code	MSDRG 052
Min. Negotiated Rate	$20,602.17
Max. Negotiated Rate	$35,404.09
Rate for Payer: AlohaCare Medicare	$20,602.17
Rate for Payer: Devoted Health Medicare	$22,662.39
Rate for Payer: Hawaii Medical Service Association Commercial	$35,404.09
Rate for Payer: Hawaii Medical Service Association Medicare	$20,602.17
Rate for Payer: Humana Medicare	$20,602.17
Rate for Payer: Kaiser Permanente Commercial	$30,718.80
Rate for Payer: Kaiser Permanente Medicare	$20,602.17
Rate for Payer: Ohana Health Plan Medicare	$20,602.17
Rate for Payer: UnitedHealthcare Medicare	$20,602.17

SPINAL DISORDERS AND INJURIES WITHOUT CC/MCC

Facility

$35,404.09

Service Code	MSDRG 053
Min. Negotiated Rate	$11,137.68
Max. Negotiated Rate	$35,404.09
Rate for Payer: AlohaCare Medicare	$11,137.68
Rate for Payer: Devoted Health Medicare	$12,251.45
Rate for Payer: Hawaii Medical Service Association Commercial	$35,404.09
Rate for Payer: Hawaii Medical Service Association Medicare	$11,137.68
Rate for Payer: Humana Medicare	$11,137.68
Rate for Payer: Kaiser Permanente Commercial	$16,891.20
Rate for Payer: Kaiser Permanente Medicare	$11,137.68
Rate for Payer: Ohana Health Plan Medicare	$11,137.68
Rate for Payer: UnitedHealthcare Medicare	$11,137.68

SPINAL DISORDERS & INJURIES

Facility

$5,621.98

Service Code	APR-DRG 0402
Min. Negotiated Rate	$5,621.98
Max. Negotiated Rate	$5,621.98
Rate for Payer: AlohaCare Medicaid	$5,621.98
Rate for Payer: Hawaii Medical Service Association ABD	$5,621.98
Rate for Payer: Hawaii Medical Service Association Non-ABD	$5,621.98
Rate for Payer: Kaiser Permanente Medicaid	$5,621.98
Rate for Payer: Ohana Health Plan Medicaid	$5,621.98
Rate for Payer: UnitedHealthcare Medicaid	$5,621.98

SPINAL DISORDERS & INJURIES

Facility

$8,141.72

Service Code	APR-DRG 0403
Min. Negotiated Rate	$8,141.72
Max. Negotiated Rate	$8,141.72
Rate for Payer: AlohaCare Medicaid	$8,141.72
Rate for Payer: Hawaii Medical Service Association ABD	$8,141.72
Rate for Payer: Hawaii Medical Service Association Non-ABD	$8,141.72
Rate for Payer: Kaiser Permanente Medicaid	$8,141.72
Rate for Payer: Ohana Health Plan Medicaid	$8,141.72
Rate for Payer: UnitedHealthcare Medicaid	$8,141.72

SPINAL DISORDERS & INJURIES

Facility

$13,173.39

Service Code	APR-DRG 0404
Min. Negotiated Rate	$13,173.39
Max. Negotiated Rate	$13,173.39
Rate for Payer: AlohaCare Medicaid	$13,173.39
Rate for Payer: Hawaii Medical Service Association ABD	$13,173.39
Rate for Payer: Hawaii Medical Service Association Non-ABD	$13,173.39
Rate for Payer: Kaiser Permanente Medicaid	$13,173.39
Rate for Payer: Ohana Health Plan Medicaid	$13,173.39
Rate for Payer: UnitedHealthcare Medicaid	$13,173.39

SPINAL DISORDERS & INJURIES

Facility

$4,924.69

Service Code	APR-DRG 0401
Min. Negotiated Rate	$4,924.69
Max. Negotiated Rate	$4,924.69
Rate for Payer: AlohaCare Medicaid	$4,924.69
Rate for Payer: Hawaii Medical Service Association ABD	$4,924.69
Rate for Payer: Hawaii Medical Service Association Non-ABD	$4,924.69
Rate for Payer: Kaiser Permanente Medicaid	$4,924.69
Rate for Payer: Ohana Health Plan Medicaid	$4,924.69
Rate for Payer: UnitedHealthcare Medicaid	$4,924.69

SPINAL FUSION EXCEPT CERVICAL WITH SPINAL CURVATURE, MALIGNANCY, INFECTION OR EXTENSIVE FUSIONS WITH CC

Facility

$140,548.67

Service Code	MSDRG 457
Min. Negotiated Rate	$67,825.82
Max. Negotiated Rate	$140,548.67
Rate for Payer: AlohaCare Medicare	$67,825.82
Rate for Payer: Devoted Health Medicare	$74,608.40
Rate for Payer: Hawaii Medical Service Association Commercial	$140,548.67
Rate for Payer: Hawaii Medical Service Association Medicare	$67,825.82
Rate for Payer: Humana Medicare	$67,825.82
Rate for Payer: Kaiser Permanente Commercial	$102,863.48
Rate for Payer: Kaiser Permanente Medicare	$67,825.82
Rate for Payer: Ohana Health Plan Medicare	$67,825.82
Rate for Payer: UnitedHealthcare Medicare	$67,825.82

SPINAL FUSION EXCEPT CERVICAL WITH SPINAL CURVATURE, MALIGNANCY, INFECTION OR EXTENSIVE FUSIONS WITH MCC

Facility

$144,958.65

Service Code	MSDRG 456
Min. Negotiated Rate	$95,582.42
Max. Negotiated Rate	$144,958.65
Rate for Payer: AlohaCare Medicare	$95,582.42
Rate for Payer: Devoted Health Medicare	$105,140.66
Rate for Payer: Hawaii Medical Service Association Commercial	$140,548.67
Rate for Payer: Hawaii Medical Service Association Medicare	$95,582.42
Rate for Payer: Humana Medicare	$95,582.42
Rate for Payer: Kaiser Permanente Commercial	$144,958.65
Rate for Payer: Kaiser Permanente Medicare	$95,582.42
Rate for Payer: Ohana Health Plan Medicare	$95,582.42
Rate for Payer: UnitedHealthcare Medicare	$95,582.42

SPINAL FUSION EXCEPT CERVICAL WITH SPINAL CURVATURE, MALIGNANCY, INFECTION OR EXTENSIVE FUSIONS WITHOUT CC/MCC

Facility

$140,548.67

Service Code	MSDRG 458
Min. Negotiated Rate	$47,460.21
Max. Negotiated Rate	$140,548.67
Rate for Payer: AlohaCare Medicare	$47,460.21
Rate for Payer: Devoted Health Medicare	$52,206.23
Rate for Payer: Hawaii Medical Service Association Commercial	$140,548.67
Rate for Payer: Hawaii Medical Service Association Medicare	$47,460.21
Rate for Payer: Humana Medicare	$47,460.21
Rate for Payer: Kaiser Permanente Commercial	$71,977.35
Rate for Payer: Kaiser Permanente Medicare	$47,460.21
Rate for Payer: Ohana Health Plan Medicare	$47,460.21
Rate for Payer: UnitedHealthcare Medicare	$47,460.21

SPINAL PROCEDURES

Facility

$17,156.84

Service Code	APR-DRG 0233
Min. Negotiated Rate	$17,156.84
Max. Negotiated Rate	$17,156.84
Rate for Payer: AlohaCare Medicaid	$17,156.84
Rate for Payer: Hawaii Medical Service Association ABD	$17,156.84
Rate for Payer: Hawaii Medical Service Association Non-ABD	$17,156.84
Rate for Payer: Kaiser Permanente Medicaid	$17,156.84
Rate for Payer: Ohana Health Plan Medicaid	$17,156.84
Rate for Payer: UnitedHealthcare Medicaid	$17,156.84

SPINAL PROCEDURES

Facility

$7,699.48

Service Code	APR-DRG 0231
Min. Negotiated Rate	$7,699.48
Max. Negotiated Rate	$7,699.48
Rate for Payer: AlohaCare Medicaid	$7,699.48
Rate for Payer: Hawaii Medical Service Association ABD	$7,699.48
Rate for Payer: Hawaii Medical Service Association Non-ABD	$7,699.48
Rate for Payer: Kaiser Permanente Medicaid	$7,699.48
Rate for Payer: Ohana Health Plan Medicaid	$7,699.48
Rate for Payer: UnitedHealthcare Medicaid	$7,699.48

SPINAL PROCEDURES

Facility

$9,957.66

Service Code	APR-DRG 0232
Min. Negotiated Rate	$9,957.66
Max. Negotiated Rate	$9,957.66
Rate for Payer: AlohaCare Medicaid	$9,957.66
Rate for Payer: Hawaii Medical Service Association ABD	$9,957.66
Rate for Payer: Hawaii Medical Service Association Non-ABD	$9,957.66
Rate for Payer: Kaiser Permanente Medicaid	$9,957.66
Rate for Payer: Ohana Health Plan Medicaid	$9,957.66
Rate for Payer: UnitedHealthcare Medicaid	$9,957.66

SPINAL PROCEDURES

Facility

$30,052.36

Service Code	APR-DRG 0234
Min. Negotiated Rate	$30,052.36
Max. Negotiated Rate	$30,052.36
Rate for Payer: AlohaCare Medicaid	$30,052.36
Rate for Payer: Hawaii Medical Service Association ABD	$30,052.36
Rate for Payer: Hawaii Medical Service Association Non-ABD	$30,052.36
Rate for Payer: Kaiser Permanente Medicaid	$30,052.36
Rate for Payer: Ohana Health Plan Medicaid	$30,052.36
Rate for Payer: UnitedHealthcare Medicaid	$30,052.36

SPINAL PROCEDURES WITH CC OR SPINAL NEUROSTIMULATORS

Facility

$72,870.80

Service Code	MSDRG 029
Min. Negotiated Rate	$10,400.00
Max. Negotiated Rate	$72,870.80
Rate for Payer: AlohaCare Medicare	$38,804.42
Rate for Payer: Devoted Health Medicare	$42,684.86
Rate for Payer: Hawaii Medical Service Association Commercial	$72,870.80
Rate for Payer: Hawaii Medical Service Association Medicare	$38,804.42
Rate for Payer: Humana Medicare	$38,804.42
Rate for Payer: Kaiser Permanente Commercial	$58,850.10
Rate for Payer: Kaiser Permanente Medicare	$38,804.42
Rate for Payer: Ohana Health Plan Medicare	$38,804.42
Rate for Payer: UnitedHealthcare Medicare	$38,804.42
Rate for Payer: University Health Alliance Commercial	$10,400.00

SPINAL PROCEDURES WITH MCC

Facility

$103,643.18

Service Code	MSDRG 028
Min. Negotiated Rate	$10,400.00
Max. Negotiated Rate	$103,643.18
Rate for Payer: AlohaCare Medicare	$68,339.95
Rate for Payer: Devoted Health Medicare	$75,173.95
Rate for Payer: Hawaii Medical Service Association Commercial	$88,085.58
Rate for Payer: Hawaii Medical Service Association Medicare	$68,339.95
Rate for Payer: Humana Medicare	$68,339.95
Rate for Payer: Kaiser Permanente Commercial	$103,643.18
Rate for Payer: Kaiser Permanente Medicare	$68,339.95
Rate for Payer: Ohana Health Plan Medicare	$68,339.95
Rate for Payer: UnitedHealthcare Medicare	$68,339.95
Rate for Payer: University Health Alliance Commercial	$10,400.00

SPINAL PROCEDURES WITHOUT CC/MCC

Facility

$48,313.61

Service Code	MSDRG 030
Min. Negotiated Rate	$10,400.00
Max. Negotiated Rate	$48,313.61
Rate for Payer: AlohaCare Medicare	$24,968.76
Rate for Payer: Devoted Health Medicare	$27,465.64
Rate for Payer: Hawaii Medical Service Association Commercial	$48,313.61
Rate for Payer: Hawaii Medical Service Association Medicare	$24,968.76
Rate for Payer: Humana Medicare	$24,968.76
Rate for Payer: Kaiser Permanente Commercial	$37,867.20
Rate for Payer: Kaiser Permanente Medicare	$24,968.76
Rate for Payer: Ohana Health Plan Medicare	$24,968.76
Rate for Payer: UnitedHealthcare Medicare	$24,968.76
Rate for Payer: University Health Alliance Commercial	$10,400.00

Know your out-of-pocket cost for care.

All Charges