Hilo Benioff Medical Center

All Charges

Charge

Type

Setting

Price

TRAUMATIC STUPOR AND COMA <1 HOUR WITH MCC

Facility

$59,621.56

Service Code	MSDRG 085
Min. Negotiated Rate	$25,841.17
Max. Negotiated Rate	$59,621.56
Rate for Payer: AlohaCare Medicare	$25,841.17
Rate for Payer: Devoted Health Medicare	$28,425.29
Rate for Payer: Hawaii Medical Service Association Commercial	$59,621.56
Rate for Payer: Hawaii Medical Service Association Medicare	$25,841.17
Rate for Payer: Humana Medicare	$25,841.17
Rate for Payer: Kaiser Permanente Commercial	$39,190.28
Rate for Payer: Kaiser Permanente Medicare	$25,841.17
Rate for Payer: Ohana Health Plan Medicare	$25,841.17
Rate for Payer: UnitedHealthcare Medicare	$25,841.17

TRAUMATIC STUPOR AND COMA >1 HOUR WITH MCC

Facility

$39,426.60

Service Code	MSDRG 082
Min. Negotiated Rate	$25,996.99
Max. Negotiated Rate	$39,426.60
Rate for Payer: AlohaCare Medicare	$25,996.99
Rate for Payer: Devoted Health Medicare	$28,596.69
Rate for Payer: Hawaii Medical Service Association Commercial	$38,655.74
Rate for Payer: Hawaii Medical Service Association Medicare	$25,996.99
Rate for Payer: Humana Medicare	$25,996.99
Rate for Payer: Kaiser Permanente Commercial	$39,426.60
Rate for Payer: Kaiser Permanente Medicare	$25,996.99
Rate for Payer: Ohana Health Plan Medicare	$25,996.99
Rate for Payer: UnitedHealthcare Medicare	$25,996.99

TRAUMATIC STUPOR AND COMA <1 HOUR WITHOUT CC/MCC

Facility

$15,778.58

Service Code	MSDRG 087
Min. Negotiated Rate	$10,404.04
Max. Negotiated Rate	$15,778.58
Rate for Payer: AlohaCare Medicare	$10,404.04
Rate for Payer: Devoted Health Medicare	$11,444.44
Rate for Payer: Hawaii Medical Service Association Commercial	$15,578.77
Rate for Payer: Hawaii Medical Service Association Medicare	$10,404.04
Rate for Payer: Humana Medicare	$10,404.04
Rate for Payer: Kaiser Permanente Commercial	$15,778.58
Rate for Payer: Kaiser Permanente Medicare	$10,404.04
Rate for Payer: Ohana Health Plan Medicare	$10,404.04
Rate for Payer: UnitedHealthcare Medicare	$10,404.04

TRAUMATIC STUPOR AND COMA >1 HOUR WITHOUT CC/MCC

Facility

$38,655.74

Service Code	MSDRG 084
Min. Negotiated Rate	$10,871.53
Max. Negotiated Rate	$38,655.74
Rate for Payer: AlohaCare Medicare	$10,871.53
Rate for Payer: Devoted Health Medicare	$11,958.68
Rate for Payer: Hawaii Medical Service Association Commercial	$38,655.74
Rate for Payer: Hawaii Medical Service Association Medicare	$10,871.53
Rate for Payer: Humana Medicare	$10,871.53
Rate for Payer: Kaiser Permanente Commercial	$16,487.55
Rate for Payer: Kaiser Permanente Medicare	$10,871.53
Rate for Payer: Ohana Health Plan Medicare	$10,871.53
Rate for Payer: UnitedHealthcare Medicare	$10,871.53

TRAUMA TO THE SKIN, SUBCUTANEOUS TISSUE AND BREAST WITH MCC

Facility

$25,393.72

Service Code	MSDRG 604
Min. Negotiated Rate	$16,744.04
Max. Negotiated Rate	$25,393.72
Rate for Payer: AlohaCare Medicare	$16,744.04
Rate for Payer: Devoted Health Medicare	$18,418.44
Rate for Payer: Hawaii Medical Service Association Commercial	$18,345.10
Rate for Payer: Hawaii Medical Service Association Medicare	$16,744.04
Rate for Payer: Humana Medicare	$16,744.04
Rate for Payer: Kaiser Permanente Commercial	$25,393.72
Rate for Payer: Kaiser Permanente Medicare	$16,744.04
Rate for Payer: Ohana Health Plan Medicare	$16,744.04
Rate for Payer: UnitedHealthcare Medicare	$16,744.04

TRAUMA TO THE SKIN, SUBCUTANEOUS TISSUE AND BREAST WITHOUT MCC

Facility

$15,801.00

Service Code	MSDRG 605
Min. Negotiated Rate	$10,418.82
Max. Negotiated Rate	$15,801.00
Rate for Payer: AlohaCare Medicare	$10,418.82
Rate for Payer: Devoted Health Medicare	$11,460.70
Rate for Payer: Hawaii Medical Service Association Commercial	$15,069.19
Rate for Payer: Hawaii Medical Service Association Medicare	$10,418.82
Rate for Payer: Humana Medicare	$10,418.82
Rate for Payer: Kaiser Permanente Commercial	$15,801.00
Rate for Payer: Kaiser Permanente Medicare	$10,418.82
Rate for Payer: Ohana Health Plan Medicare	$10,418.82
Rate for Payer: UnitedHealthcare Medicare	$10,418.82

TRAY CATHETER UMBILICAL

Facility

$203.00

Service Code	HCPCS C1751
Hospital Revenue Code	272
Min. Negotiated Rate	$172.55
Max. Negotiated Rate	$196.91
Rate for Payer: Cash Price	$121.80
Rate for Payer: Health Management Network Commercial	$172.55
Rate for Payer: MDX Hawaii PPO	$196.91

TRAY CATHETER UMBILICAL

Facility

$203.00

Service Code	HCPCS C1751
Hospital Revenue Code	272
Min. Negotiated Rate	$103.53
Max. Negotiated Rate	$196.91
Rate for Payer: Cash Price	$121.80
Rate for Payer: Hawaii Western Management Group Commercial	$192.85
Rate for Payer: Health Management Network Commercial	$172.55
Rate for Payer: Kaiser Permanente Commercial	$127.89
Rate for Payer: Kaiser Permanente Medicaid	$103.53
Rate for Payer: MDX Hawaii PPO	$196.91
Rate for Payer: University Health Alliance Commercial	$147.97

TRAY CATH TEMPERATURE SENSING

Facility

$166.00

Hospital Revenue Code	272
Min. Negotiated Rate	$141.10
Max. Negotiated Rate	$161.02
Rate for Payer: Cash Price	$99.60
Rate for Payer: Health Management Network Commercial	$141.10
Rate for Payer: MDX Hawaii PPO	$161.02

TRAY CATH TEMPERATURE SENSING

Facility

$166.00

Hospital Revenue Code	272
Min. Negotiated Rate	$84.66
Max. Negotiated Rate	$161.02
Rate for Payer: Cash Price	$99.60
Rate for Payer: Hawaii Western Management Group Commercial	$157.70
Rate for Payer: Health Management Network Commercial	$141.10
Rate for Payer: Kaiser Permanente Commercial	$104.58
Rate for Payer: Kaiser Permanente Medicaid	$84.66
Rate for Payer: MDX Hawaii PPO	$161.02
Rate for Payer: University Health Alliance Commercial	$121.00

TRAY CHEST TUBE THALQUIK 18F

Facility

$678.00

Service Code	HCPCS C1729
Hospital Revenue Code	272
Min. Negotiated Rate	$576.30
Max. Negotiated Rate	$657.66
Rate for Payer: Cash Price	$406.80
Rate for Payer: Health Management Network Commercial	$576.30
Rate for Payer: MDX Hawaii PPO	$657.66

TRAY CHEST TUBE THALQUIK 18F

Facility

$678.00

Service Code	HCPCS C1729
Hospital Revenue Code	272
Min. Negotiated Rate	$345.78
Max. Negotiated Rate	$657.66
Rate for Payer: Cash Price	$406.80
Rate for Payer: Hawaii Western Management Group Commercial	$644.10
Rate for Payer: Health Management Network Commercial	$576.30
Rate for Payer: Kaiser Permanente Commercial	$427.14
Rate for Payer: Kaiser Permanente Medicaid	$345.78
Rate for Payer: MDX Hawaii PPO	$657.66
Rate for Payer: University Health Alliance Commercial	$494.19

TRAY CHEST TUBE THALQUIK 28F

Facility

$682.00

Service Code	HCPCS C1729
Hospital Revenue Code	272
Min. Negotiated Rate	$347.82
Max. Negotiated Rate	$661.54
Rate for Payer: Cash Price	$409.20
Rate for Payer: Hawaii Western Management Group Commercial	$647.90
Rate for Payer: Health Management Network Commercial	$579.70
Rate for Payer: Kaiser Permanente Commercial	$429.66
Rate for Payer: Kaiser Permanente Medicaid	$347.82
Rate for Payer: MDX Hawaii PPO	$661.54
Rate for Payer: University Health Alliance Commercial	$497.11

TRAY CHEST TUBE THALQUIK 28F

Facility

$682.00

Service Code	HCPCS C1729
Hospital Revenue Code	272
Min. Negotiated Rate	$579.70
Max. Negotiated Rate	$661.54
Rate for Payer: Cash Price	$409.20
Rate for Payer: Health Management Network Commercial	$579.70
Rate for Payer: MDX Hawaii PPO	$661.54

TRAY FIXED T3-I4 L 02.12.T314L

Facility

$3,600.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$1,836.00
Max. Negotiated Rate	$3,492.00
Rate for Payer: Cash Price	$2,160.00
Rate for Payer: Hawaii Western Management Group Commercial	$2,520.00
Rate for Payer: Health Management Network Commercial	$3,060.00
Rate for Payer: Kaiser Permanente Commercial	$2,268.00
Rate for Payer: Kaiser Permanente Medicaid	$1,836.00
Rate for Payer: MDX Hawaii PPO	$3,492.00
Rate for Payer: University Health Alliance Commercial	$2,016.00

TRAY FIXED T3-I4 L 02.12.T314L

Facility

$3,600.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$2,016.00
Max. Negotiated Rate	$3,492.00
Rate for Payer: Cash Price	$2,160.00
Rate for Payer: Hawaii Western Management Group Commercial	$2,520.00
Rate for Payer: Health Management Network Commercial	$3,060.00
Rate for Payer: MDX Hawaii PPO	$3,492.00
Rate for Payer: University Health Alliance Commercial	$2,016.00

TRAY FOLEY W/UROMETER 14FR

Facility

$119.00

Hospital Revenue Code	272
Min. Negotiated Rate	$60.69
Max. Negotiated Rate	$115.43
Rate for Payer: Cash Price	$71.40
Rate for Payer: Hawaii Western Management Group Commercial	$113.05
Rate for Payer: Health Management Network Commercial	$101.15
Rate for Payer: Kaiser Permanente Commercial	$74.97
Rate for Payer: Kaiser Permanente Medicaid	$60.69
Rate for Payer: MDX Hawaii PPO	$115.43
Rate for Payer: University Health Alliance Commercial	$86.74

TRAY FOLEY W/UROMETER 14FR

Facility

$119.00

Hospital Revenue Code	272
Min. Negotiated Rate	$101.15
Max. Negotiated Rate	$115.43
Rate for Payer: Cash Price	$71.40
Rate for Payer: Health Management Network Commercial	$101.15
Rate for Payer: MDX Hawaii PPO	$115.43

TRAY FOLEY W/UROMETER 16FR

Facility

$119.00

Hospital Revenue Code	272
Min. Negotiated Rate	$101.15
Max. Negotiated Rate	$115.43
Rate for Payer: Cash Price	$71.40
Rate for Payer: Health Management Network Commercial	$101.15
Rate for Payer: MDX Hawaii PPO	$115.43

TRAY FOLEY W/UROMETER 16FR

Facility

$119.00

Hospital Revenue Code	272
Min. Negotiated Rate	$60.69
Max. Negotiated Rate	$115.43
Rate for Payer: Cash Price	$71.40
Rate for Payer: Hawaii Western Management Group Commercial	$113.05
Rate for Payer: Health Management Network Commercial	$101.15
Rate for Payer: Kaiser Permanente Commercial	$74.97
Rate for Payer: Kaiser Permanente Medicaid	$60.69
Rate for Payer: MDX Hawaii PPO	$115.43
Rate for Payer: University Health Alliance Commercial	$86.74

TRAY INTRODUCER PERCUT TRACH

Facility

$1,431.00

Service Code	HCPCS C1769
Hospital Revenue Code	272
Min. Negotiated Rate	$1,216.35
Max. Negotiated Rate	$1,388.07
Rate for Payer: Cash Price	$858.60
Rate for Payer: Health Management Network Commercial	$1,216.35
Rate for Payer: MDX Hawaii PPO	$1,388.07

TRAY INTRODUCER PERCUT TRACH

Facility

$1,431.00

Service Code	HCPCS C1769
Hospital Revenue Code	272
Min. Negotiated Rate	$729.81
Max. Negotiated Rate	$1,388.07
Rate for Payer: Cash Price	$858.60
Rate for Payer: Hawaii Western Management Group Commercial	$1,359.45
Rate for Payer: Health Management Network Commercial	$1,216.35
Rate for Payer: Kaiser Permanente Commercial	$901.53
Rate for Payer: Kaiser Permanente Medicaid	$729.81
Rate for Payer: MDX Hawaii PPO	$1,388.07
Rate for Payer: University Health Alliance Commercial	$1,043.06

TRAY LF MEDIAL TIB SZ F 154775

Facility

$3,300.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$1,848.00
Max. Negotiated Rate	$3,201.00
Rate for Payer: Cash Price	$1,980.00
Rate for Payer: Hawaii Western Management Group Commercial	$2,310.00
Rate for Payer: Health Management Network Commercial	$2,805.00
Rate for Payer: MDX Hawaii PPO	$3,201.00
Rate for Payer: University Health Alliance Commercial	$1,848.00

TRAY LF MEDIAL TIB SZ F 154775

Facility

$3,300.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$1,683.00
Max. Negotiated Rate	$3,201.00
Rate for Payer: Cash Price	$1,980.00
Rate for Payer: Hawaii Western Management Group Commercial	$2,310.00
Rate for Payer: Health Management Network Commercial	$2,805.00
Rate for Payer: Kaiser Permanente Commercial	$2,079.00
Rate for Payer: Kaiser Permanente Medicaid	$1,683.00
Rate for Payer: MDX Hawaii PPO	$3,201.00
Rate for Payer: University Health Alliance Commercial	$1,848.00

TRAY REVERSED TI6AI4V DWF510

Facility

$2,000.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$1,120.00
Max. Negotiated Rate	$1,940.00
Rate for Payer: Cash Price	$1,200.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,400.00
Rate for Payer: Health Management Network Commercial	$1,700.00
Rate for Payer: MDX Hawaii PPO	$1,940.00
Rate for Payer: University Health Alliance Commercial	$1,120.00

Know your out-of-pocket cost for care.

All Charges