Hilo Benioff Medical Center

All Charges

Charge

Type

Setting

Price

ACTIVATED CHARCOAL 25 GRAM/120 ML ORAL SUSPENSION [202413]

Facility

$75.00

Service Code	NDC 66689020204
Hospital Revenue Code	250
Min. Negotiated Rate	$63.75
Max. Negotiated Rate	$72.75
Rate for Payer: Cash Price	$45.00
Rate for Payer: Health Management Network Commercial	$63.75
Rate for Payer: MDX Hawaii PPO	$72.75

ACTIVATED CHARCOAL 25 GRAM/120 ML ORAL SUSPENSION [202413]

Facility

$75.00

Service Code	NDC 66689020204
Hospital Revenue Code	637
Min. Negotiated Rate	$38.25
Max. Negotiated Rate	$72.75
Rate for Payer: Cash Price	$45.00
Rate for Payer: Hawaii Western Management Group Commercial	$71.25
Rate for Payer: Health Management Network Commercial	$63.75
Rate for Payer: Kaiser Permanente Commercial	$47.25
Rate for Payer: Kaiser Permanente Medicaid	$38.25
Rate for Payer: MDX Hawaii PPO	$72.75
Rate for Payer: University Health Alliance Commercial	$54.67

ACTIVATED CHARCOAL 50 GRAM/240 ML ORAL SUSPENSION [27099]

Facility

$60.00

Service Code	NDC 00574052176
Hospital Revenue Code	250
Min. Negotiated Rate	$51.00
Max. Negotiated Rate	$58.20
Rate for Payer: Cash Price	$36.00
Rate for Payer: Health Management Network Commercial	$51.00
Rate for Payer: MDX Hawaii PPO	$58.20

ACTIVATED CHARCOAL 50 GRAM/240 ML ORAL SUSPENSION [27099]

Facility

$60.00

Service Code	NDC 00574052176
Hospital Revenue Code	637
Min. Negotiated Rate	$30.60
Max. Negotiated Rate	$58.20
Rate for Payer: Cash Price	$36.00
Rate for Payer: Hawaii Western Management Group Commercial	$57.00
Rate for Payer: Health Management Network Commercial	$51.00
Rate for Payer: Kaiser Permanente Commercial	$37.80
Rate for Payer: Kaiser Permanente Medicaid	$30.60
Rate for Payer: MDX Hawaii PPO	$58.20
Rate for Payer: University Health Alliance Commercial	$43.73

ACUITY CORONARY EXTEN HOOK 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

ACUITY CORONARY EXTEN HOOK 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

ACUITY CORONARY HOOK 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

ACUITY CORONARY HOOK 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

ACUITY CORONARY SINUS 7F IC130

Facility

$919.00

Service Code	HCPCS C1887
Hospital Revenue Code	272
Min. Negotiated Rate	$781.15
Max. Negotiated Rate	$891.43
Rate for Payer: Cash Price	$551.40
Rate for Payer: Health Management Network Commercial	$781.15
Rate for Payer: MDX Hawaii PPO	$891.43

ACUITY CORONARY SINUS 7F IC130

Facility

$919.00

Service Code	HCPCS C1887
Hospital Revenue Code	272
Min. Negotiated Rate	$468.69
Max. Negotiated Rate	$891.43
Rate for Payer: Cash Price	$551.40
Rate for Payer: Hawaii Western Management Group Commercial	$873.05
Rate for Payer: Health Management Network Commercial	$781.15
Rate for Payer: Kaiser Permanente Commercial	$578.97
Rate for Payer: Kaiser Permanente Medicaid	$468.69
Rate for Payer: MDX Hawaii PPO	$891.43
Rate for Payer: University Health Alliance Commercial	$669.86

ACUITY CORONARY SINUS 7F IC90

Facility

$919.00

Service Code	HCPCS C1887
Hospital Revenue Code	272
Min. Negotiated Rate	$781.15
Max. Negotiated Rate	$891.43
Rate for Payer: Cash Price	$551.40
Rate for Payer: Health Management Network Commercial	$781.15
Rate for Payer: MDX Hawaii PPO	$891.43

ACUITY CORONARY SINUS 7F IC90

Facility

$919.00

Service Code	HCPCS C1887
Hospital Revenue Code	272
Min. Negotiated Rate	$468.69
Max. Negotiated Rate	$891.43
Rate for Payer: Cash Price	$551.40
Rate for Payer: Hawaii Western Management Group Commercial	$873.05
Rate for Payer: Health Management Network Commercial	$781.15
Rate for Payer: Kaiser Permanente Commercial	$578.97
Rate for Payer: Kaiser Permanente Medicaid	$468.69
Rate for Payer: MDX Hawaii PPO	$891.43
Rate for Payer: University Health Alliance Commercial	$669.86

ACUITY CORONARY WIDE 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

ACUITY CORONARY WIDE 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

ACUITY WHISPER VIEW .014X190

Facility

$525.00

Service Code	HCPCS C1769
Hospital Revenue Code	272
Min. Negotiated Rate	$267.75
Max. Negotiated Rate	$509.25
Rate for Payer: Cash Price	$315.00
Rate for Payer: Hawaii Western Management Group Commercial	$498.75
Rate for Payer: Health Management Network Commercial	$446.25
Rate for Payer: Kaiser Permanente Commercial	$330.75
Rate for Payer: Kaiser Permanente Medicaid	$267.75
Rate for Payer: MDX Hawaii PPO	$509.25
Rate for Payer: University Health Alliance Commercial	$382.67

ACUITY WHISPER VIEW .014X190

Facility

$525.00

Service Code	HCPCS C1769
Hospital Revenue Code	272
Min. Negotiated Rate	$446.25
Max. Negotiated Rate	$509.25
Rate for Payer: Cash Price	$315.00
Rate for Payer: Health Management Network Commercial	$446.25
Rate for Payer: MDX Hawaii PPO	$509.25

ACUSEAL #ECH460045A

Facility

$3,108.00

Service Code	HCPCS C1768
Hospital Revenue Code	278
Min. Negotiated Rate	$1,740.48
Max. Negotiated Rate	$3,014.76
Rate for Payer: Cash Price	$1,864.80
Rate for Payer: Hawaii Western Management Group Commercial	$2,175.60
Rate for Payer: Health Management Network Commercial	$2,641.80
Rate for Payer: MDX Hawaii PPO	$3,014.76
Rate for Payer: University Health Alliance Commercial	$1,740.48

ACUSEAL #ECH460045A

Facility

$3,108.00

Service Code	HCPCS C1768
Hospital Revenue Code	278
Min. Negotiated Rate	$1,585.08
Max. Negotiated Rate	$3,014.76
Rate for Payer: Cash Price	$1,864.80
Rate for Payer: Hawaii Western Management Group Commercial	$2,175.60
Rate for Payer: Health Management Network Commercial	$2,641.80
Rate for Payer: Kaiser Permanente Commercial	$1,958.04
Rate for Payer: Kaiser Permanente Medicaid	$1,585.08
Rate for Payer: MDX Hawaii PPO	$3,014.76
Rate for Payer: University Health Alliance Commercial	$1,740.48

ACUTE ADJUSTMENT REACTION AND PSYCHOSOCIAL DYSFUNCTION

Facility

$16,563.45

Service Code	MSDRG 880
Min. Negotiated Rate	$10,921.56
Max. Negotiated Rate	$16,563.45
Rate for Payer: AlohaCare Medicare	$10,921.56
Rate for Payer: Devoted Health Medicare	$12,013.72
Rate for Payer: Hawaii Medical Service Association Commercial	$11,938.87
Rate for Payer: Hawaii Medical Service Association Medicare	$10,921.56
Rate for Payer: Humana Medicare	$10,921.56
Rate for Payer: Kaiser Permanente Commercial	$16,563.45
Rate for Payer: Kaiser Permanente Medicare	$10,921.56
Rate for Payer: Ohana Health Plan Medicare	$10,921.56
Rate for Payer: UnitedHealthcare Medicare	$10,921.56

ACUTE AND SUBACUTE ENDOCARDITIS WITH CC

Facility

$49,138.65

Service Code	MSDRG 289
Min. Negotiated Rate	$19,414.72
Max. Negotiated Rate	$49,138.65
Rate for Payer: AlohaCare Medicare	$19,414.72
Rate for Payer: Devoted Health Medicare	$21,356.19
Rate for Payer: Hawaii Medical Service Association Commercial	$49,138.65
Rate for Payer: Hawaii Medical Service Association Medicare	$19,414.72
Rate for Payer: Humana Medicare	$19,414.72
Rate for Payer: Kaiser Permanente Commercial	$29,444.03
Rate for Payer: Kaiser Permanente Medicare	$19,414.72
Rate for Payer: Ohana Health Plan Medicare	$19,414.72
Rate for Payer: UnitedHealthcare Medicare	$19,414.72

ACUTE AND SUBACUTE ENDOCARDITIS WITH MCC

Facility

$49,138.65

Service Code	MSDRG 288
Min. Negotiated Rate	$30,781.02
Max. Negotiated Rate	$49,138.65
Rate for Payer: AlohaCare Medicare	$30,781.02
Rate for Payer: Devoted Health Medicare	$33,859.12
Rate for Payer: Hawaii Medical Service Association Commercial	$49,138.65
Rate for Payer: Hawaii Medical Service Association Medicare	$30,781.02
Rate for Payer: Humana Medicare	$30,781.02
Rate for Payer: Kaiser Permanente Commercial	$46,681.95
Rate for Payer: Kaiser Permanente Medicare	$30,781.02
Rate for Payer: Ohana Health Plan Medicare	$30,781.02
Rate for Payer: UnitedHealthcare Medicare	$30,781.02

ACUTE AND SUBACUTE ENDOCARDITIS WITHOUT CC/MCC

Facility

$49,138.65

Service Code	MSDRG 290
Min. Negotiated Rate	$10,574.66
Max. Negotiated Rate	$49,138.65
Rate for Payer: AlohaCare Medicare	$10,574.66
Rate for Payer: Devoted Health Medicare	$11,632.13
Rate for Payer: Hawaii Medical Service Association Commercial	$49,138.65
Rate for Payer: Hawaii Medical Service Association Medicare	$10,574.66
Rate for Payer: Humana Medicare	$10,574.66
Rate for Payer: Kaiser Permanente Commercial	$16,037.33
Rate for Payer: Kaiser Permanente Medicare	$10,574.66
Rate for Payer: Ohana Health Plan Medicare	$10,574.66
Rate for Payer: UnitedHealthcare Medicare	$10,574.66

ACUTE ANXIETY & DELIRIUM STATES

Facility

$3,758.84

Service Code	APR-DRG 7563
Min. Negotiated Rate	$3,758.84
Max. Negotiated Rate	$3,758.84
Rate for Payer: AlohaCare Medicaid	$3,758.84
Rate for Payer: Hawaii Medical Service Association ABD	$3,758.84
Rate for Payer: Hawaii Medical Service Association Non-ABD	$3,758.84
Rate for Payer: Kaiser Permanente Medicaid	$3,758.84
Rate for Payer: Ohana Health Plan Medicaid	$3,758.84
Rate for Payer: UnitedHealthcare Medicaid	$3,758.84

ACUTE ANXIETY & DELIRIUM STATES

Facility

$3,610.32

Service Code	APR-DRG 7562
Min. Negotiated Rate	$3,610.32
Max. Negotiated Rate	$3,610.32
Rate for Payer: AlohaCare Medicaid	$3,610.32
Rate for Payer: Hawaii Medical Service Association ABD	$3,610.32
Rate for Payer: Hawaii Medical Service Association Non-ABD	$3,610.32
Rate for Payer: Kaiser Permanente Medicaid	$3,610.32
Rate for Payer: Ohana Health Plan Medicaid	$3,610.32
Rate for Payer: UnitedHealthcare Medicaid	$3,610.32

ACUTE ANXIETY & DELIRIUM STATES

Facility

$3,003.47

Service Code	APR-DRG 7561
Min. Negotiated Rate	$3,003.47
Max. Negotiated Rate	$3,003.47
Rate for Payer: AlohaCare Medicaid	$3,003.47
Rate for Payer: Hawaii Medical Service Association ABD	$3,003.47
Rate for Payer: Hawaii Medical Service Association Non-ABD	$3,003.47
Rate for Payer: Kaiser Permanente Medicaid	$3,003.47
Rate for Payer: Ohana Health Plan Medicaid	$3,003.47
Rate for Payer: UnitedHealthcare Medicaid	$3,003.47

Know your out-of-pocket cost for care.

All Charges