Hilo Benioff Medical Center

All Charges

Charge

Type

Setting

Price

ULTRASOUND ACCELERATED AND OTHER THROMBOLYSIS OF PERIPHERAL VASCULAR STRUCTURES WITH MCC

Facility

$96,016.95

Service Code	MSDRG 278
Min. Negotiated Rate	$63,311.37
Max. Negotiated Rate	$96,016.95
Rate for Payer: AlohaCare Medicare	$63,311.37
Rate for Payer: Devoted Health Medicare	$69,642.51
Rate for Payer: Hawaii Medical Service Association Commercial	$73,623.04
Rate for Payer: Hawaii Medical Service Association Medicare	$63,311.37
Rate for Payer: Humana Medicare	$63,311.37
Rate for Payer: Kaiser Permanente Commercial	$96,016.95
Rate for Payer: Kaiser Permanente Medicare	$63,311.37
Rate for Payer: Ohana Health Plan Medicare	$63,311.37
Rate for Payer: UnitedHealthcare Medicare	$63,311.37

ULTRASOUND ACCELERATED AND OTHER THROMBOLYSIS OF PERIPHERAL VASCULAR STRUCTURES WITHOUT MCC

Facility

$73,623.04

Service Code	MSDRG 279
Min. Negotiated Rate	$41,020.11
Max. Negotiated Rate	$73,623.04
Rate for Payer: AlohaCare Medicare	$41,020.11
Rate for Payer: Devoted Health Medicare	$45,122.12
Rate for Payer: Hawaii Medical Service Association Commercial	$73,623.04
Rate for Payer: Hawaii Medical Service Association Medicare	$41,020.11
Rate for Payer: Humana Medicare	$41,020.11
Rate for Payer: Kaiser Permanente Commercial	$62,210.40
Rate for Payer: Kaiser Permanente Medicare	$41,020.11
Rate for Payer: Ohana Health Plan Medicare	$41,020.11
Rate for Payer: UnitedHealthcare Medicare	$41,020.11

ULTRASOUND ACCELERATED AND OTHER THROMBOLYSIS WITH PRINCIPAL DIAGNOSIS PULMONARY EMBOLISM

Facility

$51,342.90

Service Code	MSDRG 173
Min. Negotiated Rate	$33,854.32
Max. Negotiated Rate	$51,342.90
Rate for Payer: AlohaCare Medicare	$33,854.32
Rate for Payer: Devoted Health Medicare	$37,239.75
Rate for Payer: Hawaii Medical Service Association Medicare	$33,854.32
Rate for Payer: Humana Medicare	$33,854.32
Rate for Payer: Kaiser Permanente Commercial	$51,342.90
Rate for Payer: Kaiser Permanente Medicare	$33,854.32
Rate for Payer: Ohana Health Plan Medicare	$33,854.32
Rate for Payer: UnitedHealthcare Medicare	$33,854.32

ULTRASOUND GUIDANCE FOR VASCULAR ACCESS REQUIRING ULTRASOUND EVALUATION OF POTENTIAL ACCESS SITES, DOCUMENTATION OF SELECTED VESSEL PATENCY, CONCURRENT REALTIME ULTRASOUND VISUALIZATION OF VASCULAR NEEDLE ENTRY, WITH PERMANENT RECORDING AND REPORTING (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)

Facility

$2,837.00

Service Code	CPT 76937
Hospital Revenue Code	360
Min. Negotiated Rate	$13.38
Max. Negotiated Rate	$2,837.00
Rate for Payer: Hawaii Medical Service Association ABD	$13.38
Rate for Payer: Hawaii Medical Service Association Non-ABD	$15.63
Rate for Payer: Kaiser Permanente Medicaid	$2,837.00
Rate for Payer: UnitedHealthcare Medicaid	$13.38
Rate for Payer: University Health Alliance Commercial	$69.04

ULTRATHANE SET MAC-LOC G30404

Facility

$565.00

Service Code	HCPCS C2627
Hospital Revenue Code	272
Min. Negotiated Rate	$480.25
Max. Negotiated Rate	$548.05
Rate for Payer: Cash Price	$339.00
Rate for Payer: Health Management Network Commercial	$480.25
Rate for Payer: MDX Hawaii PPO	$548.05

ULTRATHANE SET MAC-LOC G30404

Facility

$565.00

Service Code	HCPCS C2627
Hospital Revenue Code	272
Min. Negotiated Rate	$288.15
Max. Negotiated Rate	$548.05
Rate for Payer: Cash Price	$339.00
Rate for Payer: Hawaii Western Management Group Commercial	$536.75
Rate for Payer: Health Management Network Commercial	$480.25
Rate for Payer: Kaiser Permanente Commercial	$355.95
Rate for Payer: Kaiser Permanente Medicaid	$288.15
Rate for Payer: MDX Hawaii PPO	$548.05
Rate for Payer: University Health Alliance Commercial	$411.83

UMECLIDINIUM 62.5 MCG-VILANTEROL 25 MCG/ACTUATION POWDR FOR INHALATION [188073]

Facility

$424.00

Service Code	NDC 00173086906
Hospital Revenue Code	250
Min. Negotiated Rate	$360.40
Max. Negotiated Rate	$411.28
Rate for Payer: Cash Price	$254.40
Rate for Payer: Health Management Network Commercial	$360.40
Rate for Payer: MDX Hawaii PPO	$411.28

UMECLIDINIUM 62.5 MCG-VILANTEROL 25 MCG/ACTUATION POWDR FOR INHALATION [188073]

Facility

$424.00

Service Code	NDC 00173086906
Hospital Revenue Code	637
Min. Negotiated Rate	$216.24
Max. Negotiated Rate	$411.28
Rate for Payer: Cash Price	$254.40
Rate for Payer: Hawaii Western Management Group Commercial	$402.80
Rate for Payer: Health Management Network Commercial	$360.40
Rate for Payer: Kaiser Permanente Commercial	$267.12
Rate for Payer: Kaiser Permanente Medicaid	$216.24
Rate for Payer: MDX Hawaii PPO	$411.28
Rate for Payer: University Health Alliance Commercial	$309.05

UNCOMPLICATED PEPTIC ULCER WITH MCC

Facility

$23,817.08

Service Code	MSDRG 383
Min. Negotiated Rate	$15,704.43
Max. Negotiated Rate	$23,817.08
Rate for Payer: AlohaCare Medicare	$15,704.43
Rate for Payer: Devoted Health Medicare	$17,274.87
Rate for Payer: Hawaii Medical Service Association Commercial	$20,092.25
Rate for Payer: Hawaii Medical Service Association Medicare	$15,704.43
Rate for Payer: Humana Medicare	$15,704.43
Rate for Payer: Kaiser Permanente Commercial	$23,817.08
Rate for Payer: Kaiser Permanente Medicare	$15,704.43
Rate for Payer: Ohana Health Plan Medicare	$15,704.43
Rate for Payer: UnitedHealthcare Medicare	$15,704.43

UNCOMPLICATED PEPTIC ULCER WITHOUT MCC

Facility

$20,092.25

Service Code	MSDRG 384
Min. Negotiated Rate	$9,722.71
Max. Negotiated Rate	$20,092.25
Rate for Payer: AlohaCare Medicare	$9,722.71
Rate for Payer: Devoted Health Medicare	$10,694.98
Rate for Payer: Hawaii Medical Service Association Commercial	$20,092.25
Rate for Payer: Hawaii Medical Service Association Medicare	$9,722.71
Rate for Payer: Humana Medicare	$9,722.71
Rate for Payer: Kaiser Permanente Commercial	$14,745.30
Rate for Payer: Kaiser Permanente Medicare	$9,722.71
Rate for Payer: Ohana Health Plan Medicare	$9,722.71
Rate for Payer: UnitedHealthcare Medicare	$9,722.71

UNILATERAL KIT W/PDS 0 ES0528

Facility

$2,940.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,646.40
Max. Negotiated Rate	$2,851.80
Rate for Payer: Cash Price	$1,764.00
Rate for Payer: Hawaii Western Management Group Commercial	$2,058.00
Rate for Payer: Health Management Network Commercial	$2,499.00
Rate for Payer: MDX Hawaii PPO	$2,851.80
Rate for Payer: University Health Alliance Commercial	$1,646.40

UNILATERAL KIT W/PDS 0 ES0528

Facility

$2,940.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,499.40
Max. Negotiated Rate	$2,851.80
Rate for Payer: Cash Price	$1,764.00
Rate for Payer: Hawaii Western Management Group Commercial	$2,058.00
Rate for Payer: Health Management Network Commercial	$2,499.00
Rate for Payer: Kaiser Permanente Commercial	$1,852.20
Rate for Payer: Kaiser Permanente Medicaid	$1,499.40
Rate for Payer: MDX Hawaii PPO	$2,851.80
Rate for Payer: University Health Alliance Commercial	$1,646.40

UNIVERS GLENO 36+4 AR-9504S-04

Facility

$4,200.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$2,142.00
Max. Negotiated Rate	$4,074.00
Rate for Payer: Cash Price	$2,520.00
Rate for Payer: Hawaii Western Management Group Commercial	$2,940.00
Rate for Payer: Health Management Network Commercial	$3,570.00
Rate for Payer: Kaiser Permanente Commercial	$2,646.00
Rate for Payer: Kaiser Permanente Medicaid	$2,142.00
Rate for Payer: MDX Hawaii PPO	$4,074.00
Rate for Payer: University Health Alliance Commercial	$2,352.00

UNIVERS GLENO 36+4 AR-9504S-04

Facility

$4,200.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$2,352.00
Max. Negotiated Rate	$4,074.00
Rate for Payer: Cash Price	$2,520.00
Rate for Payer: Hawaii Western Management Group Commercial	$2,940.00
Rate for Payer: Health Management Network Commercial	$3,570.00
Rate for Payer: MDX Hawaii PPO	$4,074.00
Rate for Payer: University Health Alliance Commercial	$2,352.00

UNIV HEAD 26X41 #UH1-41-26

Facility

$2,408.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$1,348.48
Max. Negotiated Rate	$2,335.76
Rate for Payer: Cash Price	$1,444.80
Rate for Payer: Hawaii Western Management Group Commercial	$1,685.60
Rate for Payer: Health Management Network Commercial	$2,046.80
Rate for Payer: MDX Hawaii PPO	$2,335.76
Rate for Payer: University Health Alliance Commercial	$1,348.48

UNIV HEAD 26X41 #UH1-41-26

Facility

$2,408.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$1,228.08
Max. Negotiated Rate	$2,335.76
Rate for Payer: Cash Price	$1,444.80
Rate for Payer: Hawaii Western Management Group Commercial	$1,685.60
Rate for Payer: Health Management Network Commercial	$2,046.80
Rate for Payer: Kaiser Permanente Commercial	$1,517.04
Rate for Payer: Kaiser Permanente Medicaid	$1,228.08
Rate for Payer: MDX Hawaii PPO	$2,335.76
Rate for Payer: University Health Alliance Commercial	$1,348.48

UNIV HEAD 26X42 #UH1-42-26

Facility

$2,408.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$1,228.08
Max. Negotiated Rate	$2,335.76
Rate for Payer: Cash Price	$1,444.80
Rate for Payer: Hawaii Western Management Group Commercial	$1,685.60
Rate for Payer: Health Management Network Commercial	$2,046.80
Rate for Payer: Kaiser Permanente Commercial	$1,517.04
Rate for Payer: Kaiser Permanente Medicaid	$1,228.08
Rate for Payer: MDX Hawaii PPO	$2,335.76
Rate for Payer: University Health Alliance Commercial	$1,348.48

UNIV HEAD 26X42 #UH1-42-26

Facility

$2,408.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$1,348.48
Max. Negotiated Rate	$2,335.76
Rate for Payer: Cash Price	$1,444.80
Rate for Payer: Hawaii Western Management Group Commercial	$1,685.60
Rate for Payer: Health Management Network Commercial	$2,046.80
Rate for Payer: MDX Hawaii PPO	$2,335.76
Rate for Payer: University Health Alliance Commercial	$1,348.48

UNIV HEAD 26X43 #UH1-43-26

Facility

$2,408.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$1,228.08
Max. Negotiated Rate	$2,335.76
Rate for Payer: Cash Price	$1,444.80
Rate for Payer: Hawaii Western Management Group Commercial	$1,685.60
Rate for Payer: Health Management Network Commercial	$2,046.80
Rate for Payer: Kaiser Permanente Commercial	$1,517.04
Rate for Payer: Kaiser Permanente Medicaid	$1,228.08
Rate for Payer: MDX Hawaii PPO	$2,335.76
Rate for Payer: University Health Alliance Commercial	$1,348.48

UNIV HEAD 26X43 #UH1-43-26

Facility

$2,408.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$1,348.48
Max. Negotiated Rate	$2,335.76
Rate for Payer: Cash Price	$1,444.80
Rate for Payer: Hawaii Western Management Group Commercial	$1,685.60
Rate for Payer: Health Management Network Commercial	$2,046.80
Rate for Payer: MDX Hawaii PPO	$2,335.76
Rate for Payer: University Health Alliance Commercial	$1,348.48

UNLISTED LAPAROSCOPY PROCEDURE, ABDOMEN, PERITONEUM AND OMENTUM

Facility

$8,927.31

Service Code	CPT 49329
Hospital Revenue Code	360
Min. Negotiated Rate	$521.33
Max. Negotiated Rate	$8,927.31
Rate for Payer: AlohaCare Medicaid	$7,141.85
Rate for Payer: AlohaCare Medicare	$7,141.85
Rate for Payer: Devoted Health Medicare	$7,856.03
Rate for Payer: Hawaii Medical Service Association Commercial	$8,927.31
Rate for Payer: Hawaii Medical Service Association Medicare	$7,141.85
Rate for Payer: Humana Medicare	$7,141.85
Rate for Payer: Kaiser Permanente Medicaid	$2,837.00
Rate for Payer: Kaiser Permanente Medicare	$7,141.85
Rate for Payer: Ohana Health Plan Medicaid	$7,856.03
Rate for Payer: Ohana Health Plan Medicare	$7,141.85
Rate for Payer: UnitedHealthcare Medicaid	$521.33
Rate for Payer: UnitedHealthcare Medicare	$7,141.85

UNLISTED LAPAROSCOPY PROCEDURE, BLADDER

Facility

$8,927.31

Service Code	CPT 51999
Hospital Revenue Code	360
Min. Negotiated Rate	$521.33
Max. Negotiated Rate	$8,927.31
Rate for Payer: AlohaCare Medicaid	$7,141.85
Rate for Payer: AlohaCare Medicare	$7,141.85
Rate for Payer: Devoted Health Medicare	$7,856.03
Rate for Payer: Hawaii Medical Service Association Commercial	$8,927.31
Rate for Payer: Hawaii Medical Service Association Medicare	$7,141.85
Rate for Payer: Humana Medicare	$7,141.85
Rate for Payer: Kaiser Permanente Medicaid	$2,837.00
Rate for Payer: Kaiser Permanente Medicare	$7,141.85
Rate for Payer: Ohana Health Plan Medicaid	$7,856.03
Rate for Payer: Ohana Health Plan Medicare	$7,141.85
Rate for Payer: UnitedHealthcare Medicaid	$521.33
Rate for Payer: UnitedHealthcare Medicare	$7,141.85

UNLISTED LAPAROSCOPY PROCEDURE, HERNIOPLASTY, HERNIORRHAPHY, HERNIOTOMY

Facility

$8,927.31

Service Code	CPT 49659
Hospital Revenue Code	360
Min. Negotiated Rate	$521.33
Max. Negotiated Rate	$8,927.31
Rate for Payer: AlohaCare Medicaid	$7,141.85
Rate for Payer: AlohaCare Medicare	$7,141.85
Rate for Payer: Devoted Health Medicare	$7,856.03
Rate for Payer: Hawaii Medical Service Association Commercial	$8,927.31
Rate for Payer: Hawaii Medical Service Association Medicare	$7,141.85
Rate for Payer: Humana Medicare	$7,141.85
Rate for Payer: Kaiser Permanente Medicaid	$2,837.00
Rate for Payer: Kaiser Permanente Medicare	$7,141.85
Rate for Payer: Ohana Health Plan Medicaid	$7,856.03
Rate for Payer: Ohana Health Plan Medicare	$7,141.85
Rate for Payer: UnitedHealthcare Medicaid	$521.33
Rate for Payer: UnitedHealthcare Medicare	$7,141.85

UNLISTED LAPAROSCOPY PROCEDURE, INTESTINE (EXCEPT RECTUM)

Facility

$13,923.44

Service Code	CPT 44238
Hospital Revenue Code	360
Min. Negotiated Rate	$521.33
Max. Negotiated Rate	$13,923.44
Rate for Payer: AlohaCare Medicaid	$7,141.85
Rate for Payer: AlohaCare Medicare	$7,141.85
Rate for Payer: Devoted Health Medicare	$7,856.03
Rate for Payer: Hawaii Medical Service Association Commercial	$8,927.31
Rate for Payer: Hawaii Medical Service Association Medicare	$7,141.85
Rate for Payer: Humana Medicare	$7,141.85
Rate for Payer: Kaiser Permanente Medicaid	$2,837.00
Rate for Payer: Kaiser Permanente Medicare	$7,141.85
Rate for Payer: Ohana Health Plan Medicaid	$7,856.03
Rate for Payer: Ohana Health Plan Medicare	$7,141.85
Rate for Payer: UnitedHealthcare Medicaid	$521.33
Rate for Payer: UnitedHealthcare Medicare	$7,141.85
Rate for Payer: University Health Alliance Commercial	$13,923.44

UNLISTED LAPAROSCOPY PROCEDURE, OVIDUCT, OVARY

Facility

$8,927.31

Service Code	CPT 58679
Hospital Revenue Code	360
Min. Negotiated Rate	$521.33
Max. Negotiated Rate	$8,927.31
Rate for Payer: AlohaCare Medicaid	$7,141.85
Rate for Payer: AlohaCare Medicare	$7,141.85
Rate for Payer: Devoted Health Medicare	$7,856.03
Rate for Payer: Hawaii Medical Service Association Commercial	$8,927.31
Rate for Payer: Hawaii Medical Service Association Medicare	$7,141.85
Rate for Payer: Humana Medicare	$7,141.85
Rate for Payer: Kaiser Permanente Medicaid	$2,837.00
Rate for Payer: Kaiser Permanente Medicare	$7,141.85
Rate for Payer: Ohana Health Plan Medicaid	$7,856.03
Rate for Payer: Ohana Health Plan Medicare	$7,141.85
Rate for Payer: UnitedHealthcare Medicaid	$521.33
Rate for Payer: UnitedHealthcare Medicare	$7,141.85

Know your out-of-pocket cost for care.

All Charges