Hilo Benioff Medical Center

All Charges

Charge

Type

Setting

Price

URINARY STONES & ACQUIRED UPPER URINARY TRACT OBSTRUCTION

Facility

$5,527.40

Service Code	APR-DRG 4653
Min. Negotiated Rate	$5,527.40
Max. Negotiated Rate	$5,527.40
Rate for Payer: AlohaCare Medicaid	$5,527.40
Rate for Payer: Hawaii Medical Service Association ABD	$5,527.40
Rate for Payer: Hawaii Medical Service Association Non-ABD	$5,527.40
Rate for Payer: Kaiser Permanente Medicaid	$5,527.40
Rate for Payer: Ohana Health Plan Medicaid	$5,527.40
Rate for Payer: UnitedHealthcare Medicaid	$5,527.40

URINARY STONES WITH MCC

Facility

$23,192.62

Service Code	MSDRG 693
Min. Negotiated Rate	$12,836.71
Max. Negotiated Rate	$23,192.62
Rate for Payer: AlohaCare Medicare	$15,292.69
Rate for Payer: Devoted Health Medicare	$16,821.96
Rate for Payer: Hawaii Medical Service Association Commercial	$12,836.71
Rate for Payer: Hawaii Medical Service Association Medicare	$15,292.69
Rate for Payer: Humana Medicare	$15,292.69
Rate for Payer: Kaiser Permanente Commercial	$23,192.62
Rate for Payer: Kaiser Permanente Medicare	$15,292.69
Rate for Payer: Ohana Health Plan Medicare	$15,292.69
Rate for Payer: UnitedHealthcare Medicare	$15,292.69

URINARY STONES WITHOUT MCC

Facility

$13,484.33

Service Code	MSDRG 694
Min. Negotiated Rate	$8,891.25
Max. Negotiated Rate	$13,484.33
Rate for Payer: AlohaCare Medicare	$8,891.25
Rate for Payer: Devoted Health Medicare	$9,780.38
Rate for Payer: Hawaii Medical Service Association Commercial	$11,987.40
Rate for Payer: Hawaii Medical Service Association Medicare	$8,891.25
Rate for Payer: Humana Medicare	$8,891.25
Rate for Payer: Kaiser Permanente Commercial	$13,484.33
Rate for Payer: Kaiser Permanente Medicare	$8,891.25
Rate for Payer: Ohana Health Plan Medicare	$8,891.25
Rate for Payer: UnitedHealthcare Medicare	$8,891.25

UROMAX CATH KIT M0062251210

Facility

$938.00

Service Code	HCPCS C1726
Hospital Revenue Code	272
Min. Negotiated Rate	$797.30
Max. Negotiated Rate	$909.86
Rate for Payer: Cash Price	$562.80
Rate for Payer: Health Management Network Commercial	$797.30
Rate for Payer: MDX Hawaii PPO	$909.86

UROMAX CATH KIT M0062251210

Facility

$938.00

Service Code	HCPCS C1726
Hospital Revenue Code	272
Min. Negotiated Rate	$478.38
Max. Negotiated Rate	$909.86
Rate for Payer: Cash Price	$562.80
Rate for Payer: Hawaii Western Management Group Commercial	$891.10
Rate for Payer: Health Management Network Commercial	$797.30
Rate for Payer: Kaiser Permanente Commercial	$590.94
Rate for Payer: Kaiser Permanente Medicaid	$478.38
Rate for Payer: MDX Hawaii PPO	$909.86
Rate for Payer: University Health Alliance Commercial	$683.71

UROMAX ULTRA BALLOON KIT

Facility

$883.00

Service Code	HCPCS C1726
Hospital Revenue Code	272
Min. Negotiated Rate	$750.55
Max. Negotiated Rate	$856.51
Rate for Payer: Cash Price	$529.80
Rate for Payer: Health Management Network Commercial	$750.55
Rate for Payer: MDX Hawaii PPO	$856.51

UROMAX ULTRA BALLOON KIT

Facility

$883.00

Service Code	HCPCS C1726
Hospital Revenue Code	272
Min. Negotiated Rate	$450.33
Max. Negotiated Rate	$856.51
Rate for Payer: Cash Price	$529.80
Rate for Payer: Hawaii Western Management Group Commercial	$838.85
Rate for Payer: Health Management Network Commercial	$750.55
Rate for Payer: Kaiser Permanente Commercial	$556.29
Rate for Payer: Kaiser Permanente Medicaid	$450.33
Rate for Payer: MDX Hawaii PPO	$856.51
Rate for Payer: University Health Alliance Commercial	$643.62

URSODIOL 300 MG CAPSULE [11624]

Facility

$23.00

Service Code	NDC 60687010001
Hospital Revenue Code	250
Min. Negotiated Rate	$19.55
Max. Negotiated Rate	$22.31
Rate for Payer: Cash Price	$13.80
Rate for Payer: Health Management Network Commercial	$19.55
Rate for Payer: MDX Hawaii PPO	$22.31

URSODIOL 300 MG CAPSULE [11624]

Facility

$23.00

Service Code	NDC 60687010011
Hospital Revenue Code	637
Min. Negotiated Rate	$11.73
Max. Negotiated Rate	$22.31
Rate for Payer: Cash Price	$13.80
Rate for Payer: Hawaii Western Management Group Commercial	$21.85
Rate for Payer: Health Management Network Commercial	$19.55
Rate for Payer: Kaiser Permanente Commercial	$14.49
Rate for Payer: Kaiser Permanente Medicaid	$11.73
Rate for Payer: MDX Hawaii PPO	$22.31
Rate for Payer: University Health Alliance Commercial	$16.76

URSODIOL 300 MG CAPSULE [11624]

Facility

$23.00

Service Code	NDC 60687010001
Hospital Revenue Code	637
Min. Negotiated Rate	$11.73
Max. Negotiated Rate	$22.31
Rate for Payer: Cash Price	$13.80
Rate for Payer: Hawaii Western Management Group Commercial	$21.85
Rate for Payer: Health Management Network Commercial	$19.55
Rate for Payer: Kaiser Permanente Commercial	$14.49
Rate for Payer: Kaiser Permanente Medicaid	$11.73
Rate for Payer: MDX Hawaii PPO	$22.31
Rate for Payer: University Health Alliance Commercial	$16.76

URSODIOL 300 MG CAPSULE [11624]

Facility

$23.00

Service Code	NDC 60687010011
Hospital Revenue Code	250
Min. Negotiated Rate	$19.55
Max. Negotiated Rate	$22.31
Rate for Payer: Cash Price	$13.80
Rate for Payer: Health Management Network Commercial	$19.55
Rate for Payer: MDX Hawaii PPO	$22.31

UTERINE & ADNEXA PROCEDURES FOR LEIOMYOMA

Facility

$10,070.50

Service Code	APR-DRG 5193
Min. Negotiated Rate	$10,070.50
Max. Negotiated Rate	$10,070.50
Rate for Payer: AlohaCare Medicaid	$10,070.50
Rate for Payer: Hawaii Medical Service Association ABD	$10,070.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$10,070.50
Rate for Payer: Kaiser Permanente Medicaid	$10,070.50
Rate for Payer: Ohana Health Plan Medicaid	$10,070.50
Rate for Payer: UnitedHealthcare Medicaid	$10,070.50

UTERINE & ADNEXA PROCEDURES FOR LEIOMYOMA

Facility

$6,078.57

Service Code	APR-DRG 5192
Min. Negotiated Rate	$6,078.57
Max. Negotiated Rate	$6,078.57
Rate for Payer: AlohaCare Medicaid	$6,078.57
Rate for Payer: Hawaii Medical Service Association ABD	$6,078.57
Rate for Payer: Hawaii Medical Service Association Non-ABD	$6,078.57
Rate for Payer: Kaiser Permanente Medicaid	$6,078.57
Rate for Payer: Ohana Health Plan Medicaid	$6,078.57
Rate for Payer: UnitedHealthcare Medicaid	$6,078.57

UTERINE & ADNEXA PROCEDURES FOR LEIOMYOMA

Facility

$4,803.37

Service Code	APR-DRG 5191
Min. Negotiated Rate	$4,803.37
Max. Negotiated Rate	$4,803.37
Rate for Payer: AlohaCare Medicaid	$4,803.37
Rate for Payer: Hawaii Medical Service Association ABD	$4,803.37
Rate for Payer: Hawaii Medical Service Association Non-ABD	$4,803.37
Rate for Payer: Kaiser Permanente Medicaid	$4,803.37
Rate for Payer: Ohana Health Plan Medicaid	$4,803.37
Rate for Payer: UnitedHealthcare Medicaid	$4,803.37

UTERINE & ADNEXA PROCEDURES FOR LEIOMYOMA

Facility

$19,052.36

Service Code	APR-DRG 5194
Min. Negotiated Rate	$19,052.36
Max. Negotiated Rate	$19,052.36
Rate for Payer: AlohaCare Medicaid	$19,052.36
Rate for Payer: Hawaii Medical Service Association ABD	$19,052.36
Rate for Payer: Hawaii Medical Service Association Non-ABD	$19,052.36
Rate for Payer: Kaiser Permanente Medicaid	$19,052.36
Rate for Payer: Ohana Health Plan Medicaid	$19,052.36
Rate for Payer: UnitedHealthcare Medicaid	$19,052.36

UTERINE & ADNEXA PROCEDURES FOR NON-MALIGNANCY EXCEPT LEIOMYOMA

Facility

$17,248.81

Service Code	APR-DRG 5134
Min. Negotiated Rate	$17,248.81
Max. Negotiated Rate	$17,248.81
Rate for Payer: AlohaCare Medicaid	$17,248.81
Rate for Payer: Hawaii Medical Service Association ABD	$17,248.81
Rate for Payer: Hawaii Medical Service Association Non-ABD	$17,248.81
Rate for Payer: Kaiser Permanente Medicaid	$17,248.81
Rate for Payer: Ohana Health Plan Medicaid	$17,248.81
Rate for Payer: UnitedHealthcare Medicaid	$17,248.81

UTERINE & ADNEXA PROCEDURES FOR NON-MALIGNANCY EXCEPT LEIOMYOMA

Facility

$9,369.96

Service Code	APR-DRG 5133
Min. Negotiated Rate	$9,369.96
Max. Negotiated Rate	$9,369.96
Rate for Payer: AlohaCare Medicaid	$9,369.96
Rate for Payer: Hawaii Medical Service Association ABD	$9,369.96
Rate for Payer: Hawaii Medical Service Association Non-ABD	$9,369.96
Rate for Payer: Kaiser Permanente Medicaid	$9,369.96
Rate for Payer: Ohana Health Plan Medicaid	$9,369.96
Rate for Payer: UnitedHealthcare Medicaid	$9,369.96

UTERINE & ADNEXA PROCEDURES FOR NON-MALIGNANCY EXCEPT LEIOMYOMA

Facility

$6,145.10

Service Code	APR-DRG 5132
Min. Negotiated Rate	$6,145.10
Max. Negotiated Rate	$6,145.10
Rate for Payer: AlohaCare Medicaid	$6,145.10
Rate for Payer: Hawaii Medical Service Association ABD	$6,145.10
Rate for Payer: Hawaii Medical Service Association Non-ABD	$6,145.10
Rate for Payer: Kaiser Permanente Medicaid	$6,145.10
Rate for Payer: Ohana Health Plan Medicaid	$6,145.10
Rate for Payer: UnitedHealthcare Medicaid	$6,145.10

UTERINE & ADNEXA PROCEDURES FOR NON-MALIGNANCY EXCEPT LEIOMYOMA

Facility

$5,051.89

Service Code	APR-DRG 5131
Min. Negotiated Rate	$5,051.89
Max. Negotiated Rate	$5,051.89
Rate for Payer: AlohaCare Medicaid	$5,051.89
Rate for Payer: Hawaii Medical Service Association ABD	$5,051.89
Rate for Payer: Hawaii Medical Service Association Non-ABD	$5,051.89
Rate for Payer: Kaiser Permanente Medicaid	$5,051.89
Rate for Payer: Ohana Health Plan Medicaid	$5,051.89
Rate for Payer: UnitedHealthcare Medicaid	$5,051.89

UTERINE & ADNEXA PROCEDURES FOR NON-OVARIAN & NON-ADNEXAL MALIG

Facility

$11,543.35

Service Code	APR-DRG 5123
Min. Negotiated Rate	$11,543.35
Max. Negotiated Rate	$11,543.35
Rate for Payer: AlohaCare Medicaid	$11,543.35
Rate for Payer: Hawaii Medical Service Association ABD	$11,543.35
Rate for Payer: Hawaii Medical Service Association Non-ABD	$11,543.35
Rate for Payer: Kaiser Permanente Medicaid	$11,543.35
Rate for Payer: Ohana Health Plan Medicaid	$11,543.35
Rate for Payer: UnitedHealthcare Medicaid	$11,543.35

UTERINE & ADNEXA PROCEDURES FOR NON-OVARIAN & NON-ADNEXAL MALIG

Facility

$7,514.23

Service Code	APR-DRG 5122
Min. Negotiated Rate	$7,514.23
Max. Negotiated Rate	$7,514.23
Rate for Payer: AlohaCare Medicaid	$7,514.23
Rate for Payer: Hawaii Medical Service Association ABD	$7,514.23
Rate for Payer: Hawaii Medical Service Association Non-ABD	$7,514.23
Rate for Payer: Kaiser Permanente Medicaid	$7,514.23
Rate for Payer: Ohana Health Plan Medicaid	$7,514.23
Rate for Payer: UnitedHealthcare Medicaid	$7,514.23

UTERINE & ADNEXA PROCEDURES FOR NON-OVARIAN & NON-ADNEXAL MALIG

Facility

$20,429.97

Service Code	APR-DRG 5124
Min. Negotiated Rate	$20,429.97
Max. Negotiated Rate	$20,429.97
Rate for Payer: AlohaCare Medicaid	$20,429.97
Rate for Payer: Hawaii Medical Service Association ABD	$20,429.97
Rate for Payer: Hawaii Medical Service Association Non-ABD	$20,429.97
Rate for Payer: Kaiser Permanente Medicaid	$20,429.97
Rate for Payer: Ohana Health Plan Medicaid	$20,429.97
Rate for Payer: UnitedHealthcare Medicaid	$20,429.97

UTERINE & ADNEXA PROCEDURES FOR NON-OVARIAN & NON-ADNEXAL MALIG

Facility

$6,292.52

Service Code	APR-DRG 5121
Min. Negotiated Rate	$6,292.52
Max. Negotiated Rate	$6,292.52
Rate for Payer: AlohaCare Medicaid	$6,292.52
Rate for Payer: Hawaii Medical Service Association ABD	$6,292.52
Rate for Payer: Hawaii Medical Service Association Non-ABD	$6,292.52
Rate for Payer: Kaiser Permanente Medicaid	$6,292.52
Rate for Payer: Ohana Health Plan Medicaid	$6,292.52
Rate for Payer: UnitedHealthcare Medicaid	$6,292.52

UTERINE & ADNEXA PROCEDURES FOR OVARIAN & ADNEXAL MALIGNANCY

Facility

$25,122.45

Service Code	APR-DRG 5114
Min. Negotiated Rate	$25,122.45
Max. Negotiated Rate	$25,122.45
Rate for Payer: AlohaCare Medicaid	$25,122.45
Rate for Payer: Hawaii Medical Service Association ABD	$25,122.45
Rate for Payer: Hawaii Medical Service Association Non-ABD	$25,122.45
Rate for Payer: Kaiser Permanente Medicaid	$25,122.45
Rate for Payer: Ohana Health Plan Medicaid	$25,122.45
Rate for Payer: UnitedHealthcare Medicaid	$25,122.45

UTERINE & ADNEXA PROCEDURES FOR OVARIAN & ADNEXAL MALIGNANCY

Facility

$7,196.57

Service Code	APR-DRG 5111
Min. Negotiated Rate	$7,196.57
Max. Negotiated Rate	$7,196.57
Rate for Payer: AlohaCare Medicaid	$7,196.57
Rate for Payer: Hawaii Medical Service Association ABD	$7,196.57
Rate for Payer: Hawaii Medical Service Association Non-ABD	$7,196.57
Rate for Payer: Kaiser Permanente Medicaid	$7,196.57
Rate for Payer: Ohana Health Plan Medicaid	$7,196.57
Rate for Payer: UnitedHealthcare Medicaid	$7,196.57

Know your out-of-pocket cost for care.

All Charges