Hilo Benioff Medical Center

All Charges

Charge

Type

Setting

Price

SPLINT INTRANASAL

Facility

$340.00

Hospital Revenue Code	272
Min. Negotiated Rate	$289.00
Max. Negotiated Rate	$329.80
Rate for Payer: Cash Price	$204.00
Rate for Payer: Health Management Network Commercial	$289.00
Rate for Payer: MDX Hawaii PPO	$329.80

SPLINT NASAL FIRM 4CM

Facility

$562.00

Hospital Revenue Code	272
Min. Negotiated Rate	$477.70
Max. Negotiated Rate	$545.14
Rate for Payer: Cash Price	$337.20
Rate for Payer: Health Management Network Commercial	$477.70
Rate for Payer: MDX Hawaii PPO	$545.14

SPLINT NASAL FIRM 4CM

Facility

$562.00

Hospital Revenue Code	272
Min. Negotiated Rate	$286.62
Max. Negotiated Rate	$545.14
Rate for Payer: Cash Price	$337.20
Rate for Payer: Hawaii Western Management Group Commercial	$533.90
Rate for Payer: Health Management Network Commercial	$477.70
Rate for Payer: Kaiser Permanente Commercial	$354.06
Rate for Payer: Kaiser Permanente Medicaid	$286.62
Rate for Payer: MDX Hawaii PPO	$545.14
Rate for Payer: University Health Alliance Commercial	$409.64

SPLINT NASAL MED

Facility

$184.00

Hospital Revenue Code	272
Min. Negotiated Rate	$156.40
Max. Negotiated Rate	$178.48
Rate for Payer: Cash Price	$110.40
Rate for Payer: Health Management Network Commercial	$156.40
Rate for Payer: MDX Hawaii PPO	$178.48

SPLINT NASAL MED

Facility

$184.00

Hospital Revenue Code	272
Min. Negotiated Rate	$93.84
Max. Negotiated Rate	$178.48
Rate for Payer: Cash Price	$110.40
Rate for Payer: Hawaii Western Management Group Commercial	$174.80
Rate for Payer: Health Management Network Commercial	$156.40
Rate for Payer: Kaiser Permanente Commercial	$115.92
Rate for Payer: Kaiser Permanente Medicaid	$93.84
Rate for Payer: MDX Hawaii PPO	$178.48
Rate for Payer: University Health Alliance Commercial	$134.12

SPLIT-THICKNESS AUTOGRAFT, FACE, SCALP, EYELIDS, MOUTH, NECK, EARS, ORBITS, GENITALIA, HANDS, FEET, AND/OR MULTIPLE DIGITS; FIRST 100 SQ CM OR LESS, OR 1% OF BODY AREA OF INFANTS AND CHILDREN (EXCEPT 15050)

Facility

$8,270.00

Service Code	CPT 15120
Hospital Revenue Code	360
Min. Negotiated Rate	$456.03
Max. Negotiated Rate	$8,270.00
Rate for Payer: AlohaCare Medicaid	$4,186.36
Rate for Payer: AlohaCare Medicare	$4,186.36
Rate for Payer: Devoted Health Medicare	$4,605.00
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 Medicare	$4,186.36
Rate for Payer: Hawaii Medical Service Association Non-ABD	$1,427.62
Rate for Payer: Humana Medicare	$4,186.36
Rate for Payer: Kaiser Permanente Medicaid	$2,837.00
Rate for Payer: Kaiser Permanente Medicare	$4,186.36
Rate for Payer: Ohana Health Plan Medicaid	$4,605.00
Rate for Payer: Ohana Health Plan Medicare	$4,186.36
Rate for Payer: UnitedHealthcare Medicaid	$456.03
Rate for Payer: UnitedHealthcare Medicare	$4,186.36
Rate for Payer: University Health Alliance Commercial	$5,160.40

SPLIT-THICKNESS AUTOGRAFT, TRUNK, ARMS, LEGS; EACH ADDITIONAL 100 SQ CM, OR EACH ADDITIONAL 1% OF BODY AREA OF INFANTS AND CHILDREN, OR PART THEREOF (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)

Facility

$2,837.00

Service Code	CPT 15101
Hospital Revenue Code	360
Min. Negotiated Rate	$88.76
Max. Negotiated Rate	$2,837.00
Rate for Payer: Kaiser Permanente Medicaid	$2,837.00
Rate for Payer: UnitedHealthcare Medicaid	$88.76

SPLIT-THICKNESS AUTOGRAFT, TRUNK, ARMS, LEGS; FIRST 100 SQ CM OR LESS, OR 1% OF BODY AREA OF INFANTS AND CHILDREN (EXCEPT 15050)

Facility

$5,509.00

Service Code	CPT 15100
Hospital Revenue Code	360
Min. Negotiated Rate	$456.03
Max. Negotiated Rate	$5,509.00
Rate for Payer: AlohaCare Medicaid	$2,437.45
Rate for Payer: AlohaCare Medicare	$2,437.45
Rate for Payer: Devoted Health Medicare	$2,681.20
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	$2,437.45
Rate for Payer: Hawaii Medical Service Association Non-ABD	$1,028.67
Rate for Payer: Humana Medicare	$2,437.45
Rate for Payer: Kaiser Permanente Medicaid	$2,837.00
Rate for Payer: Kaiser Permanente Medicare	$2,437.45
Rate for Payer: Ohana Health Plan Medicaid	$2,681.20
Rate for Payer: Ohana Health Plan Medicare	$2,437.45
Rate for Payer: UnitedHealthcare Medicaid	$456.03
Rate for Payer: UnitedHealthcare Medicare	$2,437.45
Rate for Payer: University Health Alliance Commercial	$5,160.40

SPONGE ENDO PEANUT

Facility

$88.00

Hospital Revenue Code	272
Min. Negotiated Rate	$44.88
Max. Negotiated Rate	$85.36
Rate for Payer: Cash Price	$52.80
Rate for Payer: Hawaii Western Management Group Commercial	$83.60
Rate for Payer: Health Management Network Commercial	$74.80
Rate for Payer: Kaiser Permanente Commercial	$55.44
Rate for Payer: Kaiser Permanente Medicaid	$44.88
Rate for Payer: MDX Hawaii PPO	$85.36
Rate for Payer: University Health Alliance Commercial	$64.14

SPONGE ENDO PEANUT

Facility

$88.00

Hospital Revenue Code	272
Min. Negotiated Rate	$74.80
Max. Negotiated Rate	$85.36
Rate for Payer: Cash Price	$52.80
Rate for Payer: Health Management Network Commercial	$74.80
Rate for Payer: MDX Hawaii PPO	$85.36

SPONGE NEURO .25X.25

Facility

$67.00

Hospital Revenue Code	272
Min. Negotiated Rate	$56.95
Max. Negotiated Rate	$64.99
Rate for Payer: Cash Price	$40.20
Rate for Payer: Health Management Network Commercial	$56.95
Rate for Payer: MDX Hawaii PPO	$64.99

SPONGE NEURO .25X.25

Facility

$67.00

Hospital Revenue Code	272
Min. Negotiated Rate	$34.17
Max. Negotiated Rate	$64.99
Rate for Payer: Cash Price	$40.20
Rate for Payer: Hawaii Western Management Group Commercial	$63.65
Rate for Payer: Health Management Network Commercial	$56.95
Rate for Payer: Kaiser Permanente Commercial	$42.21
Rate for Payer: Kaiser Permanente Medicaid	$34.17
Rate for Payer: MDX Hawaii PPO	$64.99
Rate for Payer: University Health Alliance Commercial	$48.84

SPRAINS, STRAINS, AND DISLOCATIONS OF HIP, PELVIS AND THIGH WITH CC/MCC

Facility

$25,503.57

Service Code	MSDRG 537
Min. Negotiated Rate	$10,854.45
Max. Negotiated Rate	$25,503.57
Rate for Payer: AlohaCare Medicare	$10,854.45
Rate for Payer: Devoted Health Medicare	$11,939.90
Rate for Payer: Hawaii Medical Service Association Commercial	$25,503.57
Rate for Payer: Hawaii Medical Service Association Medicare	$10,854.45
Rate for Payer: Humana Medicare	$10,854.45
Rate for Payer: Kaiser Permanente Commercial	$16,461.67
Rate for Payer: Kaiser Permanente Medicare	$10,854.45
Rate for Payer: Ohana Health Plan Medicare	$10,854.45
Rate for Payer: UnitedHealthcare Medicare	$10,854.45

SPRAINS, STRAINS, AND DISLOCATIONS OF HIP, PELVIS AND THIGH WITHOUT CC/MCC

Facility

$25,503.57

Service Code	MSDRG 538
Min. Negotiated Rate	$8,192.88
Max. Negotiated Rate	$25,503.57
Rate for Payer: AlohaCare Medicare	$8,192.88
Rate for Payer: Devoted Health Medicare	$9,012.17
Rate for Payer: Hawaii Medical Service Association Commercial	$25,503.57
Rate for Payer: Hawaii Medical Service Association Medicare	$8,192.88
Rate for Payer: Humana Medicare	$8,192.88
Rate for Payer: Kaiser Permanente Commercial	$12,425.17
Rate for Payer: Kaiser Permanente Medicare	$8,192.88
Rate for Payer: Ohana Health Plan Medicare	$8,192.88
Rate for Payer: UnitedHealthcare Medicare	$8,192.88

SPRAY SETS FOR TISSEEL/ARTISS

Facility

$259.00

Hospital Revenue Code	272
Min. Negotiated Rate	$132.09
Max. Negotiated Rate	$251.23
Rate for Payer: Cash Price	$155.40
Rate for Payer: Hawaii Western Management Group Commercial	$246.05
Rate for Payer: Health Management Network Commercial	$220.15
Rate for Payer: Kaiser Permanente Commercial	$163.17
Rate for Payer: Kaiser Permanente Medicaid	$132.09
Rate for Payer: MDX Hawaii PPO	$251.23
Rate for Payer: University Health Alliance Commercial	$188.79

SPRAY SETS FOR TISSEEL/ARTISS

Facility

$259.00

Hospital Revenue Code	272
Min. Negotiated Rate	$220.15
Max. Negotiated Rate	$251.23
Rate for Payer: Cash Price	$155.40
Rate for Payer: Health Management Network Commercial	$220.15
Rate for Payer: MDX Hawaii PPO	$251.23

SROM MODULAR HIP SYS 55-0534

Facility

$4,310.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$2,198.10
Max. Negotiated Rate	$4,180.70
Rate for Payer: Cash Price	$2,586.00
Rate for Payer: Hawaii Western Management Group Commercial	$3,017.00
Rate for Payer: Health Management Network Commercial	$3,663.50
Rate for Payer: Kaiser Permanente Commercial	$2,715.30
Rate for Payer: Kaiser Permanente Medicaid	$2,198.10
Rate for Payer: MDX Hawaii PPO	$4,180.70
Rate for Payer: University Health Alliance Commercial	$2,413.60

SROM MODULAR HIP SYS 55-0534

Facility

$4,310.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$2,413.60
Max. Negotiated Rate	$4,180.70
Rate for Payer: Cash Price	$2,586.00
Rate for Payer: Hawaii Western Management Group Commercial	$3,017.00
Rate for Payer: Health Management Network Commercial	$3,663.50
Rate for Payer: MDX Hawaii PPO	$4,180.70
Rate for Payer: University Health Alliance Commercial	$2,413.60

SROM TOTAL HIP SYS 52.3420

Facility

$8,873.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$4,525.23
Max. Negotiated Rate	$8,606.81
Rate for Payer: Cash Price	$5,323.80
Rate for Payer: Hawaii Western Management Group Commercial	$6,211.10
Rate for Payer: Health Management Network Commercial	$7,542.05
Rate for Payer: Kaiser Permanente Commercial	$5,589.99
Rate for Payer: Kaiser Permanente Medicaid	$4,525.23
Rate for Payer: MDX Hawaii PPO	$8,606.81
Rate for Payer: University Health Alliance Commercial	$4,968.88

SROM TOTAL HIP SYS 52.3420

Facility

$8,873.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$4,968.88
Max. Negotiated Rate	$8,606.81
Rate for Payer: Cash Price	$5,323.80
Rate for Payer: Hawaii Western Management Group Commercial	$6,211.10
Rate for Payer: Health Management Network Commercial	$7,542.05
Rate for Payer: MDX Hawaii PPO	$8,606.81
Rate for Payer: University Health Alliance Commercial	$4,968.88

SSPC NXT 2.5 DELIVERY CATH 9F

Facility

$1,733.00

Service Code	HCPCS C1887
Hospital Revenue Code	272
Min. Negotiated Rate	$1,473.05
Max. Negotiated Rate	$1,681.01
Rate for Payer: Cash Price	$1,039.80
Rate for Payer: Health Management Network Commercial	$1,473.05
Rate for Payer: MDX Hawaii PPO	$1,681.01

SSPC NXT 2.5 DELIVERY CATH 9F

Facility

$1,733.00

Service Code	HCPCS C1887
Hospital Revenue Code	272
Min. Negotiated Rate	$883.83
Max. Negotiated Rate	$1,681.01
Rate for Payer: Cash Price	$1,039.80
Rate for Payer: Hawaii Western Management Group Commercial	$1,646.35
Rate for Payer: Health Management Network Commercial	$1,473.05
Rate for Payer: Kaiser Permanente Commercial	$1,091.79
Rate for Payer: Kaiser Permanente Medicaid	$883.83
Rate for Payer: MDX Hawaii PPO	$1,681.01
Rate for Payer: University Health Alliance Commercial	$1,263.18

SSPC NXT Y DELIVERY CATH

Facility

$1,733.00

Service Code	HCPCS C1887
Hospital Revenue Code	272
Min. Negotiated Rate	$883.83
Max. Negotiated Rate	$1,681.01
Rate for Payer: Cash Price	$1,039.80
Rate for Payer: Hawaii Western Management Group Commercial	$1,646.35
Rate for Payer: Health Management Network Commercial	$1,473.05
Rate for Payer: Kaiser Permanente Commercial	$1,091.79
Rate for Payer: Kaiser Permanente Medicaid	$883.83
Rate for Payer: MDX Hawaii PPO	$1,681.01
Rate for Payer: University Health Alliance Commercial	$1,263.18

SSPC NXT Y DELIVERY CATH

Facility

$1,733.00

Service Code	HCPCS C1887
Hospital Revenue Code	272
Min. Negotiated Rate	$1,473.05
Max. Negotiated Rate	$1,681.01
Rate for Payer: Cash Price	$1,039.80
Rate for Payer: Health Management Network Commercial	$1,473.05
Rate for Payer: MDX Hawaii PPO	$1,681.01

STABILIZER FEMORAL 5512-F-201

Facility

$12,283.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$6,878.48
Max. Negotiated Rate	$11,914.51
Rate for Payer: Cash Price	$7,369.80
Rate for Payer: Hawaii Western Management Group Commercial	$8,598.10
Rate for Payer: Health Management Network Commercial	$10,440.55
Rate for Payer: MDX Hawaii PPO	$11,914.51
Rate for Payer: University Health Alliance Commercial	$6,878.48

Know your out-of-pocket cost for care.

All Charges