Hilo Benioff Medical Center

All Charges

Charge

Type

Setting

Price

TOURNQ NS 30X4 5921-030-135NS

Facility

$129.00

Hospital Revenue Code	272
Min. Negotiated Rate	$109.65
Max. Negotiated Rate	$125.13
Rate for Payer: Cash Price	$77.40
Rate for Payer: Health Management Network Commercial	$109.65
Rate for Payer: MDX Hawaii PPO	$125.13

TOURNQ NS 30X4 5921-030-135NS

Facility

$129.00

Hospital Revenue Code	272
Min. Negotiated Rate	$65.79
Max. Negotiated Rate	$125.13
Rate for Payer: Cash Price	$77.40
Rate for Payer: Hawaii Western Management Group Commercial	$122.55
Rate for Payer: Health Management Network Commercial	$109.65
Rate for Payer: Kaiser Permanente Commercial	$81.27
Rate for Payer: Kaiser Permanente Medicaid	$65.79
Rate for Payer: MDX Hawaii PPO	$125.13
Rate for Payer: University Health Alliance Commercial	$94.03

TOURNQ NS 34X4 5921-034-135NS

Facility

$137.00

Hospital Revenue Code	272
Min. Negotiated Rate	$116.45
Max. Negotiated Rate	$132.89
Rate for Payer: Cash Price	$82.20
Rate for Payer: Health Management Network Commercial	$116.45
Rate for Payer: MDX Hawaii PPO	$132.89

TOURNQ NS 34X4 5921-034-135NS

Facility

$137.00

Hospital Revenue Code	272
Min. Negotiated Rate	$69.87
Max. Negotiated Rate	$132.89
Rate for Payer: Cash Price	$82.20
Rate for Payer: Hawaii Western Management Group Commercial	$130.15
Rate for Payer: Health Management Network Commercial	$116.45
Rate for Payer: Kaiser Permanente Commercial	$86.31
Rate for Payer: Kaiser Permanente Medicaid	$69.87
Rate for Payer: MDX Hawaii PPO	$132.89
Rate for Payer: University Health Alliance Commercial	$99.86

TOXIC EFFECTS OF NON-MEDICINAL SUBSTANCES

Facility

$2,479.96

Service Code	APR-DRG 8161
Min. Negotiated Rate	$2,479.96
Max. Negotiated Rate	$2,479.96
Rate for Payer: AlohaCare Medicaid	$2,479.96
Rate for Payer: Hawaii Medical Service Association ABD	$2,479.96
Rate for Payer: Hawaii Medical Service Association Non-ABD	$2,479.96
Rate for Payer: Kaiser Permanente Medicaid	$2,479.96
Rate for Payer: Ohana Health Plan Medicaid	$2,479.96
Rate for Payer: UnitedHealthcare Medicaid	$2,479.96

TOXIC EFFECTS OF NON-MEDICINAL SUBSTANCES

Facility

$7,640.77

Service Code	APR-DRG 8164
Min. Negotiated Rate	$7,640.77
Max. Negotiated Rate	$7,640.77
Rate for Payer: AlohaCare Medicaid	$7,640.77
Rate for Payer: Hawaii Medical Service Association ABD	$7,640.77
Rate for Payer: Hawaii Medical Service Association Non-ABD	$7,640.77
Rate for Payer: Kaiser Permanente Medicaid	$7,640.77
Rate for Payer: Ohana Health Plan Medicaid	$7,640.77
Rate for Payer: UnitedHealthcare Medicaid	$7,640.77

TOXIC EFFECTS OF NON-MEDICINAL SUBSTANCES

Facility

$3,918.88

Service Code	APR-DRG 8163
Min. Negotiated Rate	$3,918.88
Max. Negotiated Rate	$3,918.88
Rate for Payer: AlohaCare Medicaid	$3,918.88
Rate for Payer: Hawaii Medical Service Association ABD	$3,918.88
Rate for Payer: Hawaii Medical Service Association Non-ABD	$3,918.88
Rate for Payer: Kaiser Permanente Medicaid	$3,918.88
Rate for Payer: Ohana Health Plan Medicaid	$3,918.88
Rate for Payer: UnitedHealthcare Medicaid	$3,918.88

TOXIC EFFECTS OF NON-MEDICINAL SUBSTANCES

Facility

$2,936.55

Service Code	APR-DRG 8162
Min. Negotiated Rate	$2,936.55
Max. Negotiated Rate	$2,936.55
Rate for Payer: AlohaCare Medicaid	$2,936.55
Rate for Payer: Hawaii Medical Service Association ABD	$2,936.55
Rate for Payer: Hawaii Medical Service Association Non-ABD	$2,936.55
Rate for Payer: Kaiser Permanente Medicaid	$2,936.55
Rate for Payer: Ohana Health Plan Medicaid	$2,936.55
Rate for Payer: UnitedHealthcare Medicaid	$2,936.55

T-PLATE 2.0 6 HOLE MCT-6N

Facility

$1,663.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$931.28
Max. Negotiated Rate	$1,613.11
Rate for Payer: Cash Price	$997.80
Rate for Payer: Hawaii Western Management Group Commercial	$1,164.10
Rate for Payer: Health Management Network Commercial	$1,413.55
Rate for Payer: MDX Hawaii PPO	$1,613.11
Rate for Payer: University Health Alliance Commercial	$931.28

T-PLATE 2.0 6 HOLE MCT-6N

Facility

$1,663.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$848.13
Max. Negotiated Rate	$1,613.11
Rate for Payer: Cash Price	$997.80
Rate for Payer: Hawaii Western Management Group Commercial	$1,164.10
Rate for Payer: Health Management Network Commercial	$1,413.55
Rate for Payer: Kaiser Permanente Commercial	$1,047.69
Rate for Payer: Kaiser Permanente Medicaid	$848.13
Rate for Payer: MDX Hawaii PPO	$1,613.11
Rate for Payer: University Health Alliance Commercial	$931.28

T-PLATE 2.4 LCP 249.615

Facility

$2,525.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,414.00
Max. Negotiated Rate	$2,449.25
Rate for Payer: Cash Price	$1,515.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,767.50
Rate for Payer: Health Management Network Commercial	$2,146.25
Rate for Payer: MDX Hawaii PPO	$2,449.25
Rate for Payer: University Health Alliance Commercial	$1,414.00

T-PLATE 2.4 LCP 249.615

Facility

$2,525.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,287.75
Max. Negotiated Rate	$2,449.25
Rate for Payer: Cash Price	$1,515.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,767.50
Rate for Payer: Health Management Network Commercial	$2,146.25
Rate for Payer: Kaiser Permanente Commercial	$1,590.75
Rate for Payer: Kaiser Permanente Medicaid	$1,287.75
Rate for Payer: MDX Hawaii PPO	$2,449.25
Rate for Payer: University Health Alliance Commercial	$1,414.00

TRABECTEDIN 1 MG/20ML IV (WET SOLR VIAL) [430129413]

Facility

$4,928.00

Service Code	HCPCS J9352
Hospital Revenue Code	250
Min. Negotiated Rate	$4,188.80
Max. Negotiated Rate	$4,780.16
Rate for Payer: Cash Price	$2,956.80
Rate for Payer: Health Management Network Commercial	$4,188.80
Rate for Payer: MDX Hawaii PPO	$4,780.16

TRABECTEDIN 1 MG/20ML IV (WET SOLR VIAL) [430129413]

Facility

$4,928.00

Service Code	HCPCS J9352
Hospital Revenue Code	636
Min. Negotiated Rate	$383.07
Max. Negotiated Rate	$4,780.16
Rate for Payer: AlohaCare Medicaid	$391.07
Rate for Payer: AlohaCare Medicare	$391.07
Rate for Payer: Cash Price	$2,956.80
Rate for Payer: Cash Price	$2,956.80
Rate for Payer: Devoted Health Medicare	$430.18
Rate for Payer: Hawaii Medical Service Association ABD	$383.07
Rate for Payer: Hawaii Medical Service Association Commercial	$488.84
Rate for Payer: Hawaii Medical Service Association Medicare	$391.07
Rate for Payer: Hawaii Medical Service Association Non-ABD	$383.07
Rate for Payer: Hawaii Western Management Group Commercial	$4,681.60
Rate for Payer: Health Management Network Commercial	$4,188.80
Rate for Payer: Humana Medicare	$391.07
Rate for Payer: Kaiser Permanente Commercial	$3,104.64
Rate for Payer: Kaiser Permanente Medicaid	$2,513.28
Rate for Payer: Kaiser Permanente Medicare	$391.07
Rate for Payer: MDX Hawaii PPO	$4,780.16
Rate for Payer: Ohana Health Plan Medicaid	$430.18
Rate for Payer: Ohana Health Plan Medicare	$391.07
Rate for Payer: UnitedHealthcare Medicaid	$2,956.80
Rate for Payer: UnitedHealthcare Medicare	$391.07
Rate for Payer: University Health Alliance Commercial	$3,592.02

TRABECTEDIN 1 MG INTRAVENOUS SOLUTION [129413]

Facility

$4,928.00

Service Code	HCPCS J9352
Hospital Revenue Code	636
Min. Negotiated Rate	$383.07
Max. Negotiated Rate	$4,780.16
Rate for Payer: AlohaCare Medicaid	$391.07
Rate for Payer: AlohaCare Medicaid	$391.07
Rate for Payer: AlohaCare Medicare	$391.07
Rate for Payer: AlohaCare Medicare	$391.07
Rate for Payer: Cash Price	$4,624.80
Rate for Payer: Cash Price	$2,956.80
Rate for Payer: Cash Price	$2,956.80
Rate for Payer: Cash Price	$4,624.80
Rate for Payer: Devoted Health Medicare	$430.18
Rate for Payer: Devoted Health Medicare	$430.18
Rate for Payer: Hawaii Medical Service Association ABD	$383.07
Rate for Payer: Hawaii Medical Service Association ABD	$383.07
Rate for Payer: Hawaii Medical Service Association Commercial	$488.84
Rate for Payer: Hawaii Medical Service Association Commercial	$488.84
Rate for Payer: Hawaii Medical Service Association Medicare	$391.07
Rate for Payer: Hawaii Medical Service Association Medicare	$391.07
Rate for Payer: Hawaii Medical Service Association Non-ABD	$383.07
Rate for Payer: Hawaii Medical Service Association Non-ABD	$383.07
Rate for Payer: Hawaii Western Management Group Commercial	$4,681.60
Rate for Payer: Hawaii Western Management Group Commercial	$7,322.60
Rate for Payer: Health Management Network Commercial	$6,551.80
Rate for Payer: Health Management Network Commercial	$4,188.80
Rate for Payer: Humana Medicare	$391.07
Rate for Payer: Humana Medicare	$391.07
Rate for Payer: Kaiser Permanente Commercial	$4,856.04
Rate for Payer: Kaiser Permanente Commercial	$3,104.64
Rate for Payer: Kaiser Permanente Medicaid	$2,513.28
Rate for Payer: Kaiser Permanente Medicaid	$3,931.08
Rate for Payer: Kaiser Permanente Medicare	$391.07
Rate for Payer: Kaiser Permanente Medicare	$391.07
Rate for Payer: MDX Hawaii PPO	$7,476.76
Rate for Payer: MDX Hawaii PPO	$4,780.16
Rate for Payer: Ohana Health Plan Medicaid	$430.18
Rate for Payer: Ohana Health Plan Medicaid	$430.18
Rate for Payer: Ohana Health Plan Medicare	$391.07
Rate for Payer: Ohana Health Plan Medicare	$391.07
Rate for Payer: UnitedHealthcare Medicaid	$2,956.80
Rate for Payer: UnitedHealthcare Medicaid	$4,624.80
Rate for Payer: UnitedHealthcare Medicare	$391.07
Rate for Payer: UnitedHealthcare Medicare	$391.07
Rate for Payer: University Health Alliance Commercial	$5,618.36
Rate for Payer: University Health Alliance Commercial	$3,592.02

TRABECTEDIN 1 MG INTRAVENOUS SOLUTION [129413]

Facility

$4,928.00

Service Code	HCPCS J9352
Hospital Revenue Code	250
Min. Negotiated Rate	$4,188.80
Max. Negotiated Rate	$4,780.16
Rate for Payer: Cash Price	$2,956.80
Rate for Payer: Cash Price	$4,624.80
Rate for Payer: Health Management Network Commercial	$6,551.80
Rate for Payer: Health Management Network Commercial	$4,188.80
Rate for Payer: MDX Hawaii PPO	$4,780.16
Rate for Payer: MDX Hawaii PPO	$7,476.76

TRACE ELEMENTS ZN 3 MG-CU 0.3 MG-MN 55 MCG-SE 60 MCG/ML IV SOLUTION [174502]

Facility

$85.00

Service Code	NDC 00517930501
Hospital Revenue Code	250
Min. Negotiated Rate	$72.25
Max. Negotiated Rate	$82.45
Rate for Payer: Cash Price	$51.00
Rate for Payer: Health Management Network Commercial	$72.25
Rate for Payer: MDX Hawaii PPO	$82.45

TRACE ELEMENTS ZN 3 MG-CU 0.3 MG-MN 55 MCG-SE 60 MCG/ML IV SOLUTION [174502]

Facility

$85.00

Service Code	NDC 00517930525
Hospital Revenue Code	250
Min. Negotiated Rate	$72.25
Max. Negotiated Rate	$82.45
Rate for Payer: Cash Price	$51.00
Rate for Payer: Health Management Network Commercial	$72.25
Rate for Payer: MDX Hawaii PPO	$82.45

TRACHEOSTOMA REVISION; SIMPLE, WITHOUT FLAP ROTATION

Facility

$5,509.00

Service Code	CPT 31613
Hospital Revenue Code	360
Min. Negotiated Rate	$456.03
Max. Negotiated Rate	$5,509.00
Rate for Payer: AlohaCare Medicaid	$3,916.70
Rate for Payer: AlohaCare Medicare	$3,916.70
Rate for Payer: Devoted Health Medicare	$4,308.37
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	$3,916.70
Rate for Payer: Hawaii Medical Service Association Non-ABD	$1,028.67
Rate for Payer: Humana Medicare	$3,916.70
Rate for Payer: Kaiser Permanente Medicaid	$2,837.00
Rate for Payer: Kaiser Permanente Medicare	$3,916.70
Rate for Payer: Ohana Health Plan Medicaid	$4,308.37
Rate for Payer: Ohana Health Plan Medicare	$3,916.70
Rate for Payer: UnitedHealthcare Medicaid	$456.03
Rate for Payer: UnitedHealthcare Medicare	$3,916.70
Rate for Payer: University Health Alliance Commercial	$5,160.40

TRACHEOSTOMY FOR FACE, MOUTH AND NECK DIAGNOSES OR LARYNGECTOMY WITH CC

Facility

$85,100.86

Service Code	MSDRG 012
Min. Negotiated Rate	$10,400.00
Max. Negotiated Rate	$85,100.86
Rate for Payer: AlohaCare Medicare	$47,953.87
Rate for Payer: Devoted Health Medicare	$52,749.26
Rate for Payer: Hawaii Medical Service Association Commercial	$85,100.86
Rate for Payer: Hawaii Medical Service Association Medicare	$47,953.87
Rate for Payer: Humana Medicare	$47,953.87
Rate for Payer: Kaiser Permanente Commercial	$72,726.00
Rate for Payer: Kaiser Permanente Medicare	$47,953.87
Rate for Payer: Ohana Health Plan Medicare	$47,953.87
Rate for Payer: UnitedHealthcare Medicare	$47,953.87
Rate for Payer: University Health Alliance Commercial	$10,400.00

TRACHEOSTOMY FOR FACE, MOUTH AND NECK DIAGNOSES OR LARYNGECTOMY WITH MCC

Facility

$94,083.23

Service Code	MSDRG 011
Min. Negotiated Rate	$10,400.00
Max. Negotiated Rate	$94,083.23
Rate for Payer: AlohaCare Medicare	$62,036.32
Rate for Payer: Devoted Health Medicare	$68,239.95
Rate for Payer: Hawaii Medical Service Association Commercial	$85,100.86
Rate for Payer: Hawaii Medical Service Association Medicare	$62,036.32
Rate for Payer: Humana Medicare	$62,036.32
Rate for Payer: Kaiser Permanente Commercial	$94,083.23
Rate for Payer: Kaiser Permanente Medicare	$62,036.32
Rate for Payer: Ohana Health Plan Medicare	$62,036.32
Rate for Payer: UnitedHealthcare Medicare	$62,036.32
Rate for Payer: University Health Alliance Commercial	$10,400.00

TRACHEOSTOMY FOR FACE, MOUTH AND NECK DIAGNOSES OR LARYNGECTOMY WITHOUT CC/MCC

Facility

$85,100.86

Service Code	MSDRG 013
Min. Negotiated Rate	$10,400.00
Max. Negotiated Rate	$85,100.86
Rate for Payer: AlohaCare Medicare	$32,778.33
Rate for Payer: Devoted Health Medicare	$36,056.16
Rate for Payer: Hawaii Medical Service Association Commercial	$85,100.86
Rate for Payer: Hawaii Medical Service Association Medicare	$32,778.33
Rate for Payer: Humana Medicare	$32,778.33
Rate for Payer: Kaiser Permanente Commercial	$49,711.05
Rate for Payer: Kaiser Permanente Medicare	$32,778.33
Rate for Payer: Ohana Health Plan Medicare	$32,778.33
Rate for Payer: UnitedHealthcare Medicare	$32,778.33
Rate for Payer: University Health Alliance Commercial	$10,400.00

TRACHEOSTOMY WITH MV >96 HOURS OR PRINCIPAL DIAGNOSIS EXCEPT FACE, MOUTH AND NECK WITHOUT MAJOR O.R. PROCEDURES

Facility

$414,220.62

Service Code	MSDRG 004
Min. Negotiated Rate	$10,400.00
Max. Negotiated Rate	$414,220.62
Rate for Payer: AlohaCare Medicare	$157,549.37
Rate for Payer: Devoted Health Medicare	$173,304.31
Rate for Payer: Hawaii Medical Service Association Commercial	$414,220.62
Rate for Payer: Hawaii Medical Service Association Medicare	$157,549.37
Rate for Payer: Humana Medicare	$157,549.37
Rate for Payer: Kaiser Permanente Commercial	$238,936.65
Rate for Payer: Kaiser Permanente Medicare	$157,549.37
Rate for Payer: Ohana Health Plan Medicare	$157,549.37
Rate for Payer: UnitedHealthcare Medicare	$157,549.37
Rate for Payer: University Health Alliance Commercial	$10,400.00

TRACHEOSTOMY W MV 96+ HOURS W EXTENSIVE PROCEDURE

Facility

$72,168.58

Service Code	APR-DRG 0044
Min. Negotiated Rate	$72,168.58
Max. Negotiated Rate	$72,168.58
Rate for Payer: AlohaCare Medicaid	$72,168.58
Rate for Payer: Hawaii Medical Service Association ABD	$72,168.58
Rate for Payer: Hawaii Medical Service Association Non-ABD	$72,168.58
Rate for Payer: Kaiser Permanente Medicaid	$72,168.58
Rate for Payer: Ohana Health Plan Medicaid	$72,168.58
Rate for Payer: UnitedHealthcare Medicaid	$72,168.58

TRACHEOSTOMY W MV 96+ HOURS W EXTENSIVE PROCEDURE

Facility

$38,408.03

Service Code	APR-DRG 0042
Min. Negotiated Rate	$38,408.03
Max. Negotiated Rate	$38,408.03
Rate for Payer: AlohaCare Medicaid	$38,408.03
Rate for Payer: Hawaii Medical Service Association ABD	$38,408.03
Rate for Payer: Hawaii Medical Service Association Non-ABD	$38,408.03
Rate for Payer: Kaiser Permanente Medicaid	$38,408.03
Rate for Payer: Ohana Health Plan Medicaid	$38,408.03
Rate for Payer: UnitedHealthcare Medicaid	$38,408.03

Know your out-of-pocket cost for care.

All Charges