Hilo Benioff Medical Center

All Charges

Charge

Type

Setting

Price

UNLISTED LAPAROSCOPY PROCEDURE, URETER

Facility

$8,927.31

Service Code	CPT 50949
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, UTERUS

Facility

$8,927.31

Service Code	CPT 58578
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 PROCEDURE, ABDOMEN, MUSCULOSKELETAL SYSTEM

Facility

$2,837.00

Service Code	CPT 22999
Hospital Revenue Code	360
Min. Negotiated Rate	$291.40
Max. Negotiated Rate	$2,837.00
Rate for Payer: AlohaCare Medicaid	$291.40
Rate for Payer: AlohaCare Medicare	$291.40
Rate for Payer: Devoted Health Medicare	$320.54
Rate for Payer: Hawaii Medical Service Association Commercial	$364.25
Rate for Payer: Hawaii Medical Service Association Medicare	$291.40
Rate for Payer: Humana Medicare	$291.40
Rate for Payer: Kaiser Permanente Medicaid	$2,837.00
Rate for Payer: Kaiser Permanente Medicare	$291.40
Rate for Payer: Ohana Health Plan Medicaid	$320.54
Rate for Payer: Ohana Health Plan Medicare	$291.40
Rate for Payer: UnitedHealthcare Medicaid	$757.48
Rate for Payer: UnitedHealthcare Medicare	$291.40

UNLISTED PROCEDURE, DENTOALVEOLAR STRUCTURES

Facility

$2,837.00

Service Code	CPT 41899
Hospital Revenue Code	360
Min. Negotiated Rate	$35.12
Max. Negotiated Rate	$2,837.00
Rate for Payer: AlohaCare Medicaid	$279.80
Rate for Payer: AlohaCare Medicare	$279.80
Rate for Payer: Devoted Health Medicare	$307.78
Rate for Payer: Hawaii Medical Service Association Commercial	$349.75
Rate for Payer: Hawaii Medical Service Association Medicare	$279.80
Rate for Payer: Humana Medicare	$279.80
Rate for Payer: Kaiser Permanente Medicaid	$2,837.00
Rate for Payer: Kaiser Permanente Medicare	$279.80
Rate for Payer: Ohana Health Plan Medicaid	$307.78
Rate for Payer: Ohana Health Plan Medicare	$279.80
Rate for Payer: UnitedHealthcare Medicaid	$35.12
Rate for Payer: UnitedHealthcare Medicare	$279.80

UNLISTED PROCEDURE, MALE GENITAL SYSTEM

Facility

$2,837.00

Service Code	CPT 55899
Hospital Revenue Code	360
Min. Negotiated Rate	$245.62
Max. Negotiated Rate	$2,837.00
Rate for Payer: AlohaCare Medicaid	$295.16
Rate for Payer: AlohaCare Medicare	$295.16
Rate for Payer: Devoted Health Medicare	$324.68
Rate for Payer: Hawaii Medical Service Association Commercial	$368.95
Rate for Payer: Hawaii Medical Service Association Medicare	$295.16
Rate for Payer: Humana Medicare	$295.16
Rate for Payer: Kaiser Permanente Medicaid	$2,837.00
Rate for Payer: Kaiser Permanente Medicare	$295.16
Rate for Payer: Ohana Health Plan Medicaid	$324.68
Rate for Payer: Ohana Health Plan Medicare	$295.16
Rate for Payer: UnitedHealthcare Medicaid	$245.62
Rate for Payer: UnitedHealthcare Medicare	$295.16

UNLISTED PROCEDURE, MATERNITY CARE AND DELIVERY

Facility

$2,837.00

Service Code	CPT 59899
Hospital Revenue Code	361
Min. Negotiated Rate	$150.88
Max. Negotiated Rate	$2,837.00
Rate for Payer: AlohaCare Medicaid	$238.83
Rate for Payer: AlohaCare Medicare	$238.83
Rate for Payer: Devoted Health Medicare	$262.71
Rate for Payer: Hawaii Medical Service Association Commercial	$298.54
Rate for Payer: Hawaii Medical Service Association Medicare	$238.83
Rate for Payer: Humana Medicare	$238.83
Rate for Payer: Kaiser Permanente Medicaid	$2,837.00
Rate for Payer: Kaiser Permanente Medicare	$238.83
Rate for Payer: Ohana Health Plan Medicaid	$262.71
Rate for Payer: Ohana Health Plan Medicare	$238.83
Rate for Payer: UnitedHealthcare Medicaid	$150.88
Rate for Payer: UnitedHealthcare Medicare	$238.83

UNLISTED PROCEDURE, NOSE

Facility

$2,837.00

Service Code	CPT 30999
Hospital Revenue Code	360
Min. Negotiated Rate	$174.17
Max. Negotiated Rate	$2,837.00
Rate for Payer: AlohaCare Medicaid	$279.80
Rate for Payer: AlohaCare Medicare	$279.80
Rate for Payer: Devoted Health Medicare	$307.78
Rate for Payer: Hawaii Medical Service Association Commercial	$349.75
Rate for Payer: Hawaii Medical Service Association Medicare	$279.80
Rate for Payer: Humana Medicare	$279.80
Rate for Payer: Kaiser Permanente Medicaid	$2,837.00
Rate for Payer: Kaiser Permanente Medicare	$279.80
Rate for Payer: Ohana Health Plan Medicaid	$307.78
Rate for Payer: Ohana Health Plan Medicare	$279.80
Rate for Payer: UnitedHealthcare Medicaid	$174.17
Rate for Payer: UnitedHealthcare Medicare	$279.80

UNLISTED PROCEDURE, TRACHEA, BRONCHI

Facility

$2,837.00

Service Code	CPT 31899
Hospital Revenue Code	360
Min. Negotiated Rate	$145.61
Max. Negotiated Rate	$2,837.00
Rate for Payer: AlohaCare Medicaid	$235.80
Rate for Payer: AlohaCare Medicare	$235.80
Rate for Payer: Devoted Health Medicare	$259.38
Rate for Payer: Hawaii Medical Service Association Commercial	$294.75
Rate for Payer: Hawaii Medical Service Association Medicare	$235.80
Rate for Payer: Humana Medicare	$235.80
Rate for Payer: Kaiser Permanente Medicaid	$2,837.00
Rate for Payer: Kaiser Permanente Medicare	$235.80
Rate for Payer: Ohana Health Plan Medicaid	$259.38
Rate for Payer: Ohana Health Plan Medicare	$235.80
Rate for Payer: UnitedHealthcare Medicaid	$145.61
Rate for Payer: UnitedHealthcare Medicare	$235.80

UPPER LIMB AND TOE AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS WITH CC

Facility

$37,515.24

Service Code	MSDRG 256
Min. Negotiated Rate	$19,312.35
Max. Negotiated Rate	$37,515.24
Rate for Payer: AlohaCare Medicare	$19,312.35
Rate for Payer: Devoted Health Medicare	$21,243.58
Rate for Payer: Hawaii Medical Service Association Commercial	$37,515.24
Rate for Payer: Hawaii Medical Service Association Medicare	$19,312.35
Rate for Payer: Humana Medicare	$19,312.35
Rate for Payer: Kaiser Permanente Commercial	$29,288.78
Rate for Payer: Kaiser Permanente Medicare	$19,312.35
Rate for Payer: Ohana Health Plan Medicare	$19,312.35
Rate for Payer: UnitedHealthcare Medicare	$19,312.35

UPPER LIMB AND TOE AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS WITH MCC

Facility

$46,530.15

Service Code	MSDRG 255
Min. Negotiated Rate	$30,680.92
Max. Negotiated Rate	$46,530.15
Rate for Payer: AlohaCare Medicare	$30,680.92
Rate for Payer: Devoted Health Medicare	$33,749.01
Rate for Payer: Hawaii Medical Service Association Commercial	$37,515.24
Rate for Payer: Hawaii Medical Service Association Medicare	$30,680.92
Rate for Payer: Humana Medicare	$30,680.92
Rate for Payer: Kaiser Permanente Commercial	$46,530.15
Rate for Payer: Kaiser Permanente Medicare	$30,680.92
Rate for Payer: Ohana Health Plan Medicare	$30,680.92
Rate for Payer: UnitedHealthcare Medicare	$30,680.92

UPPER LIMB AND TOE AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS WITHOUT CC/MCC

Facility

$37,515.24

Service Code	MSDRG 257
Min. Negotiated Rate	$12,422.97
Max. Negotiated Rate	$37,515.24
Rate for Payer: AlohaCare Medicare	$12,422.97
Rate for Payer: Devoted Health Medicare	$13,665.27
Rate for Payer: Hawaii Medical Service Association Commercial	$37,515.24
Rate for Payer: Hawaii Medical Service Association Medicare	$12,422.97
Rate for Payer: Humana Medicare	$12,422.97
Rate for Payer: Kaiser Permanente Commercial	$18,840.45
Rate for Payer: Kaiser Permanente Medicare	$12,422.97
Rate for Payer: Ohana Health Plan Medicare	$12,422.97
Rate for Payer: UnitedHealthcare Medicare	$12,422.97

UREA 15 GRAM ORAL POWDER PACKET [137170]

Facility

$16.00

Service Code	NDC 00011000000
Hospital Revenue Code	250
Min. Negotiated Rate	$13.60
Max. Negotiated Rate	$15.52
Rate for Payer: Cash Price	$9.60
Rate for Payer: Health Management Network Commercial	$13.60
Rate for Payer: MDX Hawaii PPO	$15.52

UREA 15 GRAM ORAL POWDER PACKET [137170]

Facility

$16.00

Service Code	NDC 00011000000
Hospital Revenue Code	637
Min. Negotiated Rate	$8.16
Max. Negotiated Rate	$15.52
Rate for Payer: Cash Price	$9.60
Rate for Payer: Hawaii Western Management Group Commercial	$15.20
Rate for Payer: Health Management Network Commercial	$13.60
Rate for Payer: Kaiser Permanente Commercial	$10.08
Rate for Payer: Kaiser Permanente Medicaid	$8.16
Rate for Payer: MDX Hawaii PPO	$15.52
Rate for Payer: University Health Alliance Commercial	$11.66

URETERAL ENDOSCOPY THROUGH ESTABLISHED URETEROSTOMY, WITH OR WITHOUT IRRIGATION, INSTILLATION, OR URETEROPYELOGRAPHY, EXCLUSIVE OF RADIOLOGIC SERVICE; WITH REMOVAL OF FOREIGN BODY OR CALCULUS

Facility

$13,778.00

Service Code	CPT 50961
Hospital Revenue Code	361
Min. Negotiated Rate	$456.03
Max. Negotiated Rate	$13,778.00
Rate for Payer: AlohaCare Medicaid	$6,334.13
Rate for Payer: AlohaCare Medicare	$6,334.13
Rate for Payer: Devoted Health Medicare	$6,967.54
Rate for Payer: Hawaii Medical Service Association ABD	$1,149.00
Rate for Payer: Hawaii Medical Service Association Commercial	$13,778.00
Rate for Payer: Hawaii Medical Service Association Medicare	$6,334.13
Rate for Payer: Hawaii Medical Service Association Non-ABD	$2,294.85
Rate for Payer: Humana Medicare	$6,334.13
Rate for Payer: Kaiser Permanente Medicaid	$2,837.00
Rate for Payer: Kaiser Permanente Medicare	$6,334.13
Rate for Payer: Ohana Health Plan Medicaid	$6,967.54
Rate for Payer: Ohana Health Plan Medicare	$6,334.13
Rate for Payer: UnitedHealthcare Medicaid	$456.03
Rate for Payer: UnitedHealthcare Medicare	$6,334.13

URETHRAL PROCEDURES WITH CC/MCC

Facility

$36,350.47

Service Code	MSDRG 671
Min. Negotiated Rate	$20,416.79
Max. Negotiated Rate	$36,350.47
Rate for Payer: AlohaCare Medicare	$20,416.79
Rate for Payer: Devoted Health Medicare	$22,458.47
Rate for Payer: Hawaii Medical Service Association Commercial	$36,350.47
Rate for Payer: Hawaii Medical Service Association Medicare	$20,416.79
Rate for Payer: Humana Medicare	$20,416.79
Rate for Payer: Kaiser Permanente Commercial	$30,963.75
Rate for Payer: Kaiser Permanente Medicare	$20,416.79
Rate for Payer: Ohana Health Plan Medicare	$20,416.79
Rate for Payer: UnitedHealthcare Medicare	$20,416.79

URETHRAL PROCEDURES WITHOUT CC/MCC

Facility

$36,350.47

Service Code	MSDRG 672
Min. Negotiated Rate	$12,278.52
Max. Negotiated Rate	$36,350.47
Rate for Payer: AlohaCare Medicare	$12,278.52
Rate for Payer: Devoted Health Medicare	$13,506.37
Rate for Payer: Hawaii Medical Service Association Commercial	$36,350.47
Rate for Payer: Hawaii Medical Service Association Medicare	$12,278.52
Rate for Payer: Humana Medicare	$12,278.52
Rate for Payer: Kaiser Permanente Commercial	$18,621.38
Rate for Payer: Kaiser Permanente Medicare	$12,278.52
Rate for Payer: Ohana Health Plan Medicare	$12,278.52
Rate for Payer: UnitedHealthcare Medicare	$12,278.52

URETHRAL STRICTURE

Facility

$18,592.05

Service Code	MSDRG 697
Min. Negotiated Rate	$5,314.25
Max. Negotiated Rate	$18,592.05
Rate for Payer: AlohaCare Medicare	$12,259.16
Rate for Payer: Devoted Health Medicare	$13,485.08
Rate for Payer: Hawaii Medical Service Association Commercial	$5,314.25
Rate for Payer: Hawaii Medical Service Association Medicare	$12,259.16
Rate for Payer: Humana Medicare	$12,259.16
Rate for Payer: Kaiser Permanente Commercial	$18,592.05
Rate for Payer: Kaiser Permanente Medicare	$12,259.16
Rate for Payer: Ohana Health Plan Medicare	$12,259.16
Rate for Payer: UnitedHealthcare Medicare	$12,259.16

URETHRAL & TRANSURETHRAL PROCEDURES

Facility

$8,479.60

Service Code	APR-DRG 4463
Min. Negotiated Rate	$8,479.60
Max. Negotiated Rate	$8,479.60
Rate for Payer: AlohaCare Medicaid	$8,479.60
Rate for Payer: Hawaii Medical Service Association ABD	$8,479.60
Rate for Payer: Hawaii Medical Service Association Non-ABD	$8,479.60
Rate for Payer: Kaiser Permanente Medicaid	$8,479.60
Rate for Payer: Ohana Health Plan Medicaid	$8,479.60
Rate for Payer: UnitedHealthcare Medicaid	$8,479.60

URETHRAL & TRANSURETHRAL PROCEDURES

Facility

$4,336.34

Service Code	APR-DRG 4461
Min. Negotiated Rate	$4,336.34
Max. Negotiated Rate	$4,336.34
Rate for Payer: AlohaCare Medicaid	$4,336.34
Rate for Payer: Hawaii Medical Service Association ABD	$4,336.34
Rate for Payer: Hawaii Medical Service Association Non-ABD	$4,336.34
Rate for Payer: Kaiser Permanente Medicaid	$4,336.34
Rate for Payer: Ohana Health Plan Medicaid	$4,336.34
Rate for Payer: UnitedHealthcare Medicaid	$4,336.34

URETHRAL & TRANSURETHRAL PROCEDURES

Facility

$5,448.47

Service Code	APR-DRG 4462
Min. Negotiated Rate	$5,448.47
Max. Negotiated Rate	$5,448.47
Rate for Payer: AlohaCare Medicaid	$5,448.47
Rate for Payer: Hawaii Medical Service Association ABD	$5,448.47
Rate for Payer: Hawaii Medical Service Association Non-ABD	$5,448.47
Rate for Payer: Kaiser Permanente Medicaid	$5,448.47
Rate for Payer: Ohana Health Plan Medicaid	$5,448.47
Rate for Payer: UnitedHealthcare Medicaid	$5,448.47

URETHRAL & TRANSURETHRAL PROCEDURES

Facility

$15,006.94

Service Code	APR-DRG 4464
Min. Negotiated Rate	$15,006.94
Max. Negotiated Rate	$15,006.94
Rate for Payer: AlohaCare Medicaid	$15,006.94
Rate for Payer: Hawaii Medical Service Association ABD	$15,006.94
Rate for Payer: Hawaii Medical Service Association Non-ABD	$15,006.94
Rate for Payer: Kaiser Permanente Medicaid	$15,006.94
Rate for Payer: Ohana Health Plan Medicaid	$15,006.94
Rate for Payer: UnitedHealthcare Medicaid	$15,006.94

URETHROPLASTY FOR SECOND STAGE HYPOSPADIAS REPAIR (INCLUDING URINARY DIVERSION); LESS THAN 3 CM

Facility

$7,917.66

Service Code	CPT 54308
Hospital Revenue Code	360
Min. Negotiated Rate	$521.33
Max. Negotiated Rate	$7,917.66
Rate for Payer: AlohaCare Medicaid	$6,334.13
Rate for Payer: AlohaCare Medicare	$6,334.13
Rate for Payer: Devoted Health Medicare	$6,967.54
Rate for Payer: Hawaii Medical Service Association Commercial	$7,917.66
Rate for Payer: Hawaii Medical Service Association Medicare	$6,334.13
Rate for Payer: Humana Medicare	$6,334.13
Rate for Payer: Kaiser Permanente Medicaid	$2,837.00
Rate for Payer: Kaiser Permanente Medicare	$6,334.13
Rate for Payer: Ohana Health Plan Medicaid	$6,967.54
Rate for Payer: Ohana Health Plan Medicare	$6,334.13
Rate for Payer: UnitedHealthcare Medicaid	$521.33
Rate for Payer: UnitedHealthcare Medicare	$6,334.13
Rate for Payer: University Health Alliance Commercial	$6,743.44

URINARY STONES & ACQUIRED UPPER URINARY TRACT OBSTRUCTION

Facility

$9,666.75

Service Code	APR-DRG 4654
Min. Negotiated Rate	$9,666.75
Max. Negotiated Rate	$9,666.75
Rate for Payer: AlohaCare Medicaid	$9,666.75
Rate for Payer: Hawaii Medical Service Association ABD	$9,666.75
Rate for Payer: Hawaii Medical Service Association Non-ABD	$9,666.75
Rate for Payer: Kaiser Permanente Medicaid	$9,666.75
Rate for Payer: Ohana Health Plan Medicaid	$9,666.75
Rate for Payer: UnitedHealthcare Medicaid	$9,666.75

URINARY STONES & ACQUIRED UPPER URINARY TRACT OBSTRUCTION

Facility

$3,431.63

Service Code	APR-DRG 4652
Min. Negotiated Rate	$3,431.63
Max. Negotiated Rate	$3,431.63
Rate for Payer: AlohaCare Medicaid	$3,431.63
Rate for Payer: Hawaii Medical Service Association ABD	$3,431.63
Rate for Payer: Hawaii Medical Service Association Non-ABD	$3,431.63
Rate for Payer: Kaiser Permanente Medicaid	$3,431.63
Rate for Payer: Ohana Health Plan Medicaid	$3,431.63
Rate for Payer: UnitedHealthcare Medicaid	$3,431.63

URINARY STONES & ACQUIRED UPPER URINARY TRACT OBSTRUCTION

Facility

$2,846.54

Service Code	APR-DRG 4651
Min. Negotiated Rate	$2,846.54
Max. Negotiated Rate	$2,846.54
Rate for Payer: AlohaCare Medicaid	$2,846.54
Rate for Payer: Hawaii Medical Service Association ABD	$2,846.54
Rate for Payer: Hawaii Medical Service Association Non-ABD	$2,846.54
Rate for Payer: Kaiser Permanente Medicaid	$2,846.54
Rate for Payer: Ohana Health Plan Medicaid	$2,846.54
Rate for Payer: UnitedHealthcare Medicaid	$2,846.54

Know your out-of-pocket cost for care.

All Charges