Hilo Benioff Medical Center

All Charges

Charge

Type

Setting

Price

TEMNO ACT 22X15 BIOSPY

Facility

$240.00

Hospital Revenue Code	272
Min. Negotiated Rate	$204.00
Max. Negotiated Rate	$232.80
Rate for Payer: Cash Price	$144.00
Rate for Payer: Health Management Network Commercial	$204.00
Rate for Payer: MDX Hawaii PPO	$232.80

TEMNO ACT 22X15 BIOSPY

Facility

$240.00

Hospital Revenue Code	272
Min. Negotiated Rate	$122.40
Max. Negotiated Rate	$232.80
Rate for Payer: Cash Price	$144.00
Rate for Payer: Hawaii Western Management Group Commercial	$228.00
Rate for Payer: Health Management Network Commercial	$204.00
Rate for Payer: Kaiser Permanente Commercial	$151.20
Rate for Payer: Kaiser Permanente Medicaid	$122.40
Rate for Payer: MDX Hawaii PPO	$232.80
Rate for Payer: University Health Alliance Commercial	$174.94

TEMPLATE CALCANEAL KIT M224

Facility

$977.00

Hospital Revenue Code	272
Min. Negotiated Rate	$830.45
Max. Negotiated Rate	$947.69
Rate for Payer: Cash Price	$586.20
Rate for Payer: Health Management Network Commercial	$830.45
Rate for Payer: MDX Hawaii PPO	$947.69

TEMPLATE CALCANEAL KIT M224

Facility

$977.00

Hospital Revenue Code	272
Min. Negotiated Rate	$498.27
Max. Negotiated Rate	$947.69
Rate for Payer: Cash Price	$586.20
Rate for Payer: Hawaii Western Management Group Commercial	$928.15
Rate for Payer: Health Management Network Commercial	$830.45
Rate for Payer: Kaiser Permanente Commercial	$615.51
Rate for Payer: Kaiser Permanente Medicaid	$498.27
Rate for Payer: MDX Hawaii PPO	$947.69
Rate for Payer: University Health Alliance Commercial	$712.14

TEMPLATE MINIRAIL KIT M225

Facility

$591.00

Hospital Revenue Code	272
Min. Negotiated Rate	$301.41
Max. Negotiated Rate	$573.27
Rate for Payer: Cash Price	$354.60
Rate for Payer: Hawaii Western Management Group Commercial	$561.45
Rate for Payer: Health Management Network Commercial	$502.35
Rate for Payer: Kaiser Permanente Commercial	$372.33
Rate for Payer: Kaiser Permanente Medicaid	$301.41
Rate for Payer: MDX Hawaii PPO	$573.27
Rate for Payer: University Health Alliance Commercial	$430.78

TEMPLATE MINIRAIL KIT M225

Facility

$591.00

Hospital Revenue Code	272
Min. Negotiated Rate	$502.35
Max. Negotiated Rate	$573.27
Rate for Payer: Cash Price	$354.60
Rate for Payer: Health Management Network Commercial	$502.35
Rate for Payer: MDX Hawaii PPO	$573.27

TENACIO ACCESSORY KIT

Facility

$2,970.00

Service Code	HCPCS C1813
Hospital Revenue Code	278
Min. Negotiated Rate	$1,663.20
Max. Negotiated Rate	$2,880.90
Rate for Payer: Cash Price	$1,782.00
Rate for Payer: Hawaii Western Management Group Commercial	$2,079.00
Rate for Payer: Health Management Network Commercial	$2,524.50
Rate for Payer: MDX Hawaii PPO	$2,880.90
Rate for Payer: University Health Alliance Commercial	$1,663.20

TENACIO ACCESSORY KIT

Facility

$2,970.00

Service Code	HCPCS C1813
Hospital Revenue Code	278
Min. Negotiated Rate	$1,514.70
Max. Negotiated Rate	$2,880.90
Rate for Payer: Cash Price	$1,782.00
Rate for Payer: Hawaii Western Management Group Commercial	$2,079.00
Rate for Payer: Health Management Network Commercial	$2,524.50
Rate for Payer: Kaiser Permanente Commercial	$1,871.10
Rate for Payer: Kaiser Permanente Medicaid	$1,514.70
Rate for Payer: MDX Hawaii PPO	$2,880.90
Rate for Payer: University Health Alliance Commercial	$1,663.20

TENDON ANCHOR 8 2504-1

Facility

$2,700.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,377.00
Max. Negotiated Rate	$2,619.00
Rate for Payer: Cash Price	$1,620.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,890.00
Rate for Payer: Health Management Network Commercial	$2,295.00
Rate for Payer: Kaiser Permanente Commercial	$1,701.00
Rate for Payer: Kaiser Permanente Medicaid	$1,377.00
Rate for Payer: MDX Hawaii PPO	$2,619.00
Rate for Payer: University Health Alliance Commercial	$1,512.00

TENDON ANCHOR 8 2504-1

Facility

$2,700.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,512.00
Max. Negotiated Rate	$2,619.00
Rate for Payer: Cash Price	$1,620.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,890.00
Rate for Payer: Health Management Network Commercial	$2,295.00
Rate for Payer: MDX Hawaii PPO	$2,619.00
Rate for Payer: University Health Alliance Commercial	$1,512.00

TENDON GRACILIS SSG-002

Facility

$2,350.00

Service Code	HCPCS C1762
Hospital Revenue Code	278
Min. Negotiated Rate	$1,198.50
Max. Negotiated Rate	$2,279.50
Rate for Payer: Cash Price	$1,410.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,645.00
Rate for Payer: Health Management Network Commercial	$1,997.50
Rate for Payer: Kaiser Permanente Commercial	$1,480.50
Rate for Payer: Kaiser Permanente Medicaid	$1,198.50
Rate for Payer: MDX Hawaii PPO	$2,279.50
Rate for Payer: University Health Alliance Commercial	$1,316.00

TENDON GRACILIS SSG-002

Facility

$2,350.00

Service Code	HCPCS C1762
Hospital Revenue Code	278
Min. Negotiated Rate	$1,316.00
Max. Negotiated Rate	$2,279.50
Rate for Payer: Cash Price	$1,410.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,645.00
Rate for Payer: Health Management Network Commercial	$1,997.50
Rate for Payer: MDX Hawaii PPO	$2,279.50
Rate for Payer: University Health Alliance Commercial	$1,316.00

TENDONITIS, MYOSITIS AND BURSITIS WITH MCC

Facility

$25,649.03

Service Code	MSDRG 557
Min. Negotiated Rate	$16,912.39
Max. Negotiated Rate	$25,649.03
Rate for Payer: AlohaCare Medicare	$16,912.39
Rate for Payer: Devoted Health Medicare	$18,603.63
Rate for Payer: Hawaii Medical Service Association Commercial	$20,237.84
Rate for Payer: Hawaii Medical Service Association Medicare	$16,912.39
Rate for Payer: Humana Medicare	$16,912.39
Rate for Payer: Kaiser Permanente Commercial	$25,649.03
Rate for Payer: Kaiser Permanente Medicare	$16,912.39
Rate for Payer: Ohana Health Plan Medicare	$16,912.39
Rate for Payer: UnitedHealthcare Medicare	$16,912.39

TENDONITIS, MYOSITIS AND BURSITIS WITHOUT MCC

Facility

$20,237.84

Service Code	MSDRG 558
Min. Negotiated Rate	$10,159.49
Max. Negotiated Rate	$20,237.84
Rate for Payer: AlohaCare Medicare	$10,159.49
Rate for Payer: Devoted Health Medicare	$11,175.44
Rate for Payer: Hawaii Medical Service Association Commercial	$20,237.84
Rate for Payer: Hawaii Medical Service Association Medicare	$10,159.49
Rate for Payer: Humana Medicare	$10,159.49
Rate for Payer: Kaiser Permanente Commercial	$15,407.70
Rate for Payer: Kaiser Permanente Medicare	$10,159.49
Rate for Payer: Ohana Health Plan Medicare	$10,159.49
Rate for Payer: UnitedHealthcare Medicare	$10,159.49

TENDON, MUSCLE & OTHER SOFT TISSUE PROCEDURES

Facility

$6,660.40

Service Code	APR-DRG 3172
Min. Negotiated Rate	$6,660.40
Max. Negotiated Rate	$6,660.40
Rate for Payer: AlohaCare Medicaid	$6,660.40
Rate for Payer: Hawaii Medical Service Association ABD	$6,660.40
Rate for Payer: Hawaii Medical Service Association Non-ABD	$6,660.40
Rate for Payer: Kaiser Permanente Medicaid	$6,660.40
Rate for Payer: Ohana Health Plan Medicaid	$6,660.40
Rate for Payer: UnitedHealthcare Medicaid	$6,660.40

TENDON, MUSCLE & OTHER SOFT TISSUE PROCEDURES

Facility

$5,157.55

Service Code	APR-DRG 3171
Min. Negotiated Rate	$5,157.55
Max. Negotiated Rate	$5,157.55
Rate for Payer: AlohaCare Medicaid	$5,157.55
Rate for Payer: Hawaii Medical Service Association ABD	$5,157.55
Rate for Payer: Hawaii Medical Service Association Non-ABD	$5,157.55
Rate for Payer: Kaiser Permanente Medicaid	$5,157.55
Rate for Payer: Ohana Health Plan Medicaid	$5,157.55
Rate for Payer: UnitedHealthcare Medicaid	$5,157.55

TENDON, MUSCLE & OTHER SOFT TISSUE PROCEDURES

Facility

$18,647.29

Service Code	APR-DRG 3174
Min. Negotiated Rate	$18,647.29
Max. Negotiated Rate	$18,647.29
Rate for Payer: AlohaCare Medicaid	$18,647.29
Rate for Payer: Hawaii Medical Service Association ABD	$18,647.29
Rate for Payer: Hawaii Medical Service Association Non-ABD	$18,647.29
Rate for Payer: Kaiser Permanente Medicaid	$18,647.29
Rate for Payer: Ohana Health Plan Medicaid	$18,647.29
Rate for Payer: UnitedHealthcare Medicaid	$18,647.29

TENDON, MUSCLE & OTHER SOFT TISSUE PROCEDURES

Facility

$9,949.18

Service Code	APR-DRG 3173
Min. Negotiated Rate	$9,949.18
Max. Negotiated Rate	$9,949.18
Rate for Payer: AlohaCare Medicaid	$9,949.18
Rate for Payer: Hawaii Medical Service Association ABD	$9,949.18
Rate for Payer: Hawaii Medical Service Association Non-ABD	$9,949.18
Rate for Payer: Kaiser Permanente Medicaid	$9,949.18
Rate for Payer: Ohana Health Plan Medicaid	$9,949.18
Rate for Payer: UnitedHealthcare Medicaid	$9,949.18

TENDON SHEATH INCISION (EG, FOR TRIGGER FINGER)

Facility

$5,509.00

Service Code	CPT 26055
Hospital Revenue Code	360
Min. Negotiated Rate	$456.03
Max. Negotiated Rate	$5,509.00
Rate for Payer: AlohaCare Medicaid	$1,899.59
Rate for Payer: AlohaCare Medicare	$1,899.59
Rate for Payer: Devoted Health Medicare	$2,089.55
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	$1,899.59
Rate for Payer: Hawaii Medical Service Association Non-ABD	$1,028.67
Rate for Payer: Humana Medicare	$1,899.59
Rate for Payer: Kaiser Permanente Medicaid	$2,837.00
Rate for Payer: Kaiser Permanente Medicare	$1,899.59
Rate for Payer: Ohana Health Plan Medicaid	$2,089.55
Rate for Payer: Ohana Health Plan Medicare	$1,899.59
Rate for Payer: UnitedHealthcare Medicaid	$456.03
Rate for Payer: UnitedHealthcare Medicare	$1,899.59
Rate for Payer: University Health Alliance Commercial	$5,160.40

TENECTEPLASE 25 MG INTRAVENOUS SOLUTION [237629]

Facility

$10,457.00

Service Code	HCPCS J3101
Hospital Revenue Code	250
Min. Negotiated Rate	$8,888.45
Max. Negotiated Rate	$10,143.29
Rate for Payer: Cash Price	$6,274.20
Rate for Payer: Health Management Network Commercial	$8,888.45
Rate for Payer: MDX Hawaii PPO	$10,143.29

TENECTEPLASE 25 MG INTRAVENOUS SOLUTION [237629]

Facility

$10,457.00

Service Code	HCPCS J3101
Hospital Revenue Code	636
Min. Negotiated Rate	$171.94
Max. Negotiated Rate	$10,143.29
Rate for Payer: AlohaCare Medicaid	$197.44
Rate for Payer: AlohaCare Medicare	$197.44
Rate for Payer: Cash Price	$6,274.20
Rate for Payer: Cash Price	$6,274.20
Rate for Payer: Devoted Health Medicare	$217.18
Rate for Payer: Hawaii Medical Service Association ABD	$171.94
Rate for Payer: Hawaii Medical Service Association Commercial	$246.80
Rate for Payer: Hawaii Medical Service Association Medicare	$197.44
Rate for Payer: Hawaii Medical Service Association Non-ABD	$171.94
Rate for Payer: Hawaii Western Management Group Commercial	$9,934.15
Rate for Payer: Health Management Network Commercial	$8,888.45
Rate for Payer: Humana Medicare	$197.44
Rate for Payer: Kaiser Permanente Commercial	$6,587.91
Rate for Payer: Kaiser Permanente Medicaid	$5,333.07
Rate for Payer: Kaiser Permanente Medicare	$197.44
Rate for Payer: MDX Hawaii PPO	$10,143.29
Rate for Payer: Ohana Health Plan Medicaid	$217.18
Rate for Payer: Ohana Health Plan Medicare	$197.44
Rate for Payer: UnitedHealthcare Medicaid	$6,274.20
Rate for Payer: UnitedHealthcare Medicare	$197.44
Rate for Payer: University Health Alliance Commercial	$7,622.11

TENECTEPLASE 50 MG INTRAVENOUS SOLUTION [206762]

Facility

$10,457.00

Service Code	HCPCS J3101
Hospital Revenue Code	250
Min. Negotiated Rate	$8,888.45
Max. Negotiated Rate	$10,143.29
Rate for Payer: Cash Price	$6,274.20
Rate for Payer: Health Management Network Commercial	$8,888.45
Rate for Payer: MDX Hawaii PPO	$10,143.29

TENECTEPLASE 50 MG INTRAVENOUS SOLUTION [206762]

Facility

$10,457.00

Service Code	HCPCS J3101
Hospital Revenue Code	636
Min. Negotiated Rate	$171.94
Max. Negotiated Rate	$10,143.29
Rate for Payer: AlohaCare Medicaid	$197.44
Rate for Payer: AlohaCare Medicare	$197.44
Rate for Payer: Cash Price	$6,274.20
Rate for Payer: Cash Price	$6,274.20
Rate for Payer: Devoted Health Medicare	$217.18
Rate for Payer: Hawaii Medical Service Association ABD	$171.94
Rate for Payer: Hawaii Medical Service Association Commercial	$246.80
Rate for Payer: Hawaii Medical Service Association Medicare	$197.44
Rate for Payer: Hawaii Medical Service Association Non-ABD	$171.94
Rate for Payer: Hawaii Western Management Group Commercial	$9,934.15
Rate for Payer: Health Management Network Commercial	$8,888.45
Rate for Payer: Humana Medicare	$197.44
Rate for Payer: Kaiser Permanente Commercial	$6,587.91
Rate for Payer: Kaiser Permanente Medicaid	$5,333.07
Rate for Payer: Kaiser Permanente Medicare	$197.44
Rate for Payer: MDX Hawaii PPO	$10,143.29
Rate for Payer: Ohana Health Plan Medicaid	$217.18
Rate for Payer: Ohana Health Plan Medicare	$197.44
Rate for Payer: UnitedHealthcare Medicaid	$6,274.20
Rate for Payer: UnitedHealthcare Medicare	$197.44
Rate for Payer: University Health Alliance Commercial	$7,622.11

TENMO ACT 20X11 BIOPSY

Facility

$234.00

Hospital Revenue Code	272
Min. Negotiated Rate	$198.90
Max. Negotiated Rate	$226.98
Rate for Payer: Cash Price	$140.40
Rate for Payer: Health Management Network Commercial	$198.90
Rate for Payer: MDX Hawaii PPO	$226.98

TENMO ACT 20X11 BIOPSY

Facility

$234.00

Hospital Revenue Code	272
Min. Negotiated Rate	$119.34
Max. Negotiated Rate	$226.98
Rate for Payer: Cash Price	$140.40
Rate for Payer: Hawaii Western Management Group Commercial	$222.30
Rate for Payer: Health Management Network Commercial	$198.90
Rate for Payer: Kaiser Permanente Commercial	$147.42
Rate for Payer: Kaiser Permanente Medicaid	$119.34
Rate for Payer: MDX Hawaii PPO	$226.98
Rate for Payer: University Health Alliance Commercial	$170.56

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