Hilo Benioff Medical Center

All Charges

Charge

Type

Setting

Price

CHAMBER ILIVIA NEO DUAL 429529

Facility

$38,500.00

Service Code	HCPCS C1721
Hospital Revenue Code	275
Min. Negotiated Rate	$19,635.00
Max. Negotiated Rate	$37,345.00
Rate for Payer: Cash Price	$23,100.00
Rate for Payer: Hawaii Western Management Group Commercial	$26,950.00
Rate for Payer: Health Management Network Commercial	$32,725.00
Rate for Payer: Kaiser Permanente Commercial	$24,255.00
Rate for Payer: Kaiser Permanente Medicaid	$19,635.00
Rate for Payer: MDX Hawaii PPO	$37,345.00
Rate for Payer: University Health Alliance Commercial	$21,560.00

CHANGE OF CYSTOSTOMY TUBE; SIMPLE

Facility

$2,837.00

Service Code	CPT 51705
Hospital Revenue Code	360
Min. Negotiated Rate	$49.55
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 ABD	$393.00
Rate for Payer: Hawaii Medical Service Association Commercial	$2,536.00
Rate for Payer: Hawaii Medical Service Association Medicare	$295.16
Rate for Payer: Hawaii Medical Service Association Non-ABD	$496.75
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	$49.55
Rate for Payer: UnitedHealthcare Medicare	$295.16

CHEMOTHERAPY FOR ACUTE LEUKEMIA

Facility

$9,457.36

Service Code	APR-DRG 6953
Min. Negotiated Rate	$9,457.36
Max. Negotiated Rate	$9,457.36
Rate for Payer: AlohaCare Medicaid	$9,457.36
Rate for Payer: Hawaii Medical Service Association ABD	$9,457.36
Rate for Payer: Hawaii Medical Service Association Non-ABD	$9,457.36
Rate for Payer: Kaiser Permanente Medicaid	$9,457.36
Rate for Payer: Ohana Health Plan Medicaid	$9,457.36
Rate for Payer: UnitedHealthcare Medicaid	$9,457.36

CHEMOTHERAPY FOR ACUTE LEUKEMIA

Facility

$3,908.44

Service Code	APR-DRG 6951
Min. Negotiated Rate	$3,908.44
Max. Negotiated Rate	$3,908.44
Rate for Payer: AlohaCare Medicaid	$3,908.44
Rate for Payer: Hawaii Medical Service Association ABD	$3,908.44
Rate for Payer: Hawaii Medical Service Association Non-ABD	$3,908.44
Rate for Payer: Kaiser Permanente Medicaid	$3,908.44
Rate for Payer: Ohana Health Plan Medicaid	$3,908.44
Rate for Payer: UnitedHealthcare Medicaid	$3,908.44

CHEMOTHERAPY FOR ACUTE LEUKEMIA

Facility

$4,500.06

Service Code	APR-DRG 6952
Min. Negotiated Rate	$4,500.06
Max. Negotiated Rate	$4,500.06
Rate for Payer: AlohaCare Medicaid	$4,500.06
Rate for Payer: Hawaii Medical Service Association ABD	$4,500.06
Rate for Payer: Hawaii Medical Service Association Non-ABD	$4,500.06
Rate for Payer: Kaiser Permanente Medicaid	$4,500.06
Rate for Payer: Ohana Health Plan Medicaid	$4,500.06
Rate for Payer: UnitedHealthcare Medicaid	$4,500.06

CHEMOTHERAPY FOR ACUTE LEUKEMIA

Facility

$27,886.80

Service Code	APR-DRG 6954
Min. Negotiated Rate	$27,886.80
Max. Negotiated Rate	$27,886.80
Rate for Payer: AlohaCare Medicaid	$27,886.80
Rate for Payer: Hawaii Medical Service Association ABD	$27,886.80
Rate for Payer: Hawaii Medical Service Association Non-ABD	$27,886.80
Rate for Payer: Kaiser Permanente Medicaid	$27,886.80
Rate for Payer: Ohana Health Plan Medicaid	$27,886.80
Rate for Payer: UnitedHealthcare Medicaid	$27,886.80

CHEMOTHERAPY WITH ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS OR WITH HIGH DOSE CHEMOTHERAPY AGENT WITH MCC

Facility

$82,874.18

Service Code	MSDRG 837
Min. Negotiated Rate	$54,645.34
Max. Negotiated Rate	$82,874.18
Rate for Payer: AlohaCare Medicare	$54,645.34
Rate for Payer: Devoted Health Medicare	$60,109.87
Rate for Payer: Hawaii Medical Service Association Commercial	$59,354.64
Rate for Payer: Hawaii Medical Service Association Medicare	$54,645.34
Rate for Payer: Humana Medicare	$54,645.34
Rate for Payer: Kaiser Permanente Commercial	$82,874.18
Rate for Payer: Kaiser Permanente Medicare	$54,645.34
Rate for Payer: Ohana Health Plan Medicare	$54,645.34
Rate for Payer: UnitedHealthcare Medicare	$54,645.34

CHEMOTHERAPY WITH ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS WITH CC OR HIGH DOSE CHEMOTHERAPY AGENT

Facility

$59,354.64

Service Code	MSDRG 838
Min. Negotiated Rate	$23,742.62
Max. Negotiated Rate	$59,354.64
Rate for Payer: AlohaCare Medicare	$23,742.62
Rate for Payer: Devoted Health Medicare	$26,116.88
Rate for Payer: Hawaii Medical Service Association Commercial	$59,354.64
Rate for Payer: Hawaii Medical Service Association Medicare	$23,742.62
Rate for Payer: Humana Medicare	$23,742.62
Rate for Payer: Kaiser Permanente Commercial	$36,007.65
Rate for Payer: Kaiser Permanente Medicare	$23,742.62
Rate for Payer: Ohana Health Plan Medicare	$23,742.62
Rate for Payer: UnitedHealthcare Medicare	$23,742.62

CHEMOTHERAPY WITH ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS WITHOUT CC/MCC

Facility

$59,354.64

Service Code	MSDRG 839
Min. Negotiated Rate	$16,423.28
Max. Negotiated Rate	$59,354.64
Rate for Payer: AlohaCare Medicare	$16,423.28
Rate for Payer: Devoted Health Medicare	$18,065.61
Rate for Payer: Hawaii Medical Service Association Commercial	$59,354.64
Rate for Payer: Hawaii Medical Service Association Medicare	$16,423.28
Rate for Payer: Humana Medicare	$16,423.28
Rate for Payer: Kaiser Permanente Commercial	$24,907.28
Rate for Payer: Kaiser Permanente Medicare	$16,423.28
Rate for Payer: Ohana Health Plan Medicare	$16,423.28
Rate for Payer: UnitedHealthcare Medicare	$16,423.28

CHEMOTHERAPY WITHOUT ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS WITH CC

Facility

$22,566.45

Service Code	MSDRG 847
Min. Negotiated Rate	$14,879.81
Max. Negotiated Rate	$22,566.45
Rate for Payer: AlohaCare Medicare	$14,879.81
Rate for Payer: Devoted Health Medicare	$16,367.79
Rate for Payer: Hawaii Medical Service Association Commercial	$18,951.75
Rate for Payer: Hawaii Medical Service Association Medicare	$14,879.81
Rate for Payer: Humana Medicare	$14,879.81
Rate for Payer: Kaiser Permanente Commercial	$22,566.45
Rate for Payer: Kaiser Permanente Medicare	$14,879.81
Rate for Payer: Ohana Health Plan Medicare	$14,879.81
Rate for Payer: UnitedHealthcare Medicare	$14,879.81

CHEMOTHERAPY WITHOUT ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS WITH MCC

Facility

$44,720.62

Service Code	MSDRG 846
Min. Negotiated Rate	$18,951.75
Max. Negotiated Rate	$44,720.62
Rate for Payer: AlohaCare Medicare	$29,487.75
Rate for Payer: Devoted Health Medicare	$32,436.53
Rate for Payer: Hawaii Medical Service Association Commercial	$18,951.75
Rate for Payer: Hawaii Medical Service Association Medicare	$29,487.75
Rate for Payer: Humana Medicare	$29,487.75
Rate for Payer: Kaiser Permanente Commercial	$44,720.62
Rate for Payer: Kaiser Permanente Medicare	$29,487.75
Rate for Payer: Ohana Health Plan Medicare	$29,487.75
Rate for Payer: UnitedHealthcare Medicare	$29,487.75

CHEMOTHERAPY WITHOUT ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS WITHOUT CC/MCC

Facility

$18,951.75

Service Code	MSDRG 848
Min. Negotiated Rate	$9,661.30
Max. Negotiated Rate	$18,951.75
Rate for Payer: AlohaCare Medicare	$9,661.30
Rate for Payer: Devoted Health Medicare	$10,627.43
Rate for Payer: Hawaii Medical Service Association Commercial	$18,951.75
Rate for Payer: Hawaii Medical Service Association Medicare	$9,661.30
Rate for Payer: Humana Medicare	$9,661.30
Rate for Payer: Kaiser Permanente Commercial	$14,652.15
Rate for Payer: Kaiser Permanente Medicare	$9,661.30
Rate for Payer: Ohana Health Plan Medicare	$9,661.30
Rate for Payer: UnitedHealthcare Medicare	$9,661.30

CHEST PAIN

Facility

$2,594.11

Service Code	APR-DRG 2031
Min. Negotiated Rate	$2,594.11
Max. Negotiated Rate	$2,594.11
Rate for Payer: AlohaCare Medicaid	$2,594.11
Rate for Payer: Hawaii Medical Service Association ABD	$2,594.11
Rate for Payer: Hawaii Medical Service Association Non-ABD	$2,594.11
Rate for Payer: Kaiser Permanente Medicaid	$2,594.11
Rate for Payer: Ohana Health Plan Medicaid	$2,594.11
Rate for Payer: UnitedHealthcare Medicaid	$2,594.11

CHEST PAIN

Facility

$3,721.89

Service Code	APR-DRG 2033
Min. Negotiated Rate	$3,721.89
Max. Negotiated Rate	$3,721.89
Rate for Payer: AlohaCare Medicaid	$3,721.89
Rate for Payer: Hawaii Medical Service Association ABD	$3,721.89
Rate for Payer: Hawaii Medical Service Association Non-ABD	$3,721.89
Rate for Payer: Kaiser Permanente Medicaid	$3,721.89
Rate for Payer: Ohana Health Plan Medicaid	$3,721.89
Rate for Payer: UnitedHealthcare Medicaid	$3,721.89

CHEST PAIN

Facility

$3,018.74

Service Code	APR-DRG 2032
Min. Negotiated Rate	$3,018.74
Max. Negotiated Rate	$3,018.74
Rate for Payer: AlohaCare Medicaid	$3,018.74
Rate for Payer: Hawaii Medical Service Association ABD	$3,018.74
Rate for Payer: Hawaii Medical Service Association Non-ABD	$3,018.74
Rate for Payer: Kaiser Permanente Medicaid	$3,018.74
Rate for Payer: Ohana Health Plan Medicaid	$3,018.74
Rate for Payer: UnitedHealthcare Medicaid	$3,018.74

CHEST PAIN

Facility

$5,256.05

Service Code	APR-DRG 2034
Min. Negotiated Rate	$5,256.05
Max. Negotiated Rate	$5,256.05
Rate for Payer: AlohaCare Medicaid	$5,256.05
Rate for Payer: Hawaii Medical Service Association ABD	$5,256.05
Rate for Payer: Hawaii Medical Service Association Non-ABD	$5,256.05
Rate for Payer: Kaiser Permanente Medicaid	$5,256.05
Rate for Payer: Ohana Health Plan Medicaid	$5,256.05
Rate for Payer: UnitedHealthcare Medicaid	$5,256.05

CHEST PAIN

Facility

$12,420.00

Service Code	MSDRG 313
Min. Negotiated Rate	$8,189.47
Max. Negotiated Rate	$12,420.00
Rate for Payer: AlohaCare Medicare	$8,189.47
Rate for Payer: Devoted Health Medicare	$9,008.42
Rate for Payer: Hawaii Medical Service Association Commercial	$11,720.48
Rate for Payer: Hawaii Medical Service Association Medicare	$8,189.47
Rate for Payer: Humana Medicare	$8,189.47
Rate for Payer: Kaiser Permanente Commercial	$12,420.00
Rate for Payer: Kaiser Permanente Medicare	$8,189.47
Rate for Payer: Ohana Health Plan Medicare	$8,189.47
Rate for Payer: UnitedHealthcare Medicare	$8,189.47

CHG 3D RENDERING W/INTERP&POSTPROC DIFF WORK STATION

Professional

Both

$222.00

Service Code	HCPCS 76377
Min. Negotiated Rate	$50.53
Max. Negotiated Rate	$188.71
Rate for Payer: AlohaCare Medicaid	$50.53
Rate for Payer: AlohaCare Medicare	$84.80
Rate for Payer: Cash Price	$133.20
Rate for Payer: Cash Price	$133.20
Rate for Payer: Devoted Health Medicare	$93.28
Rate for Payer: Hawaii Medical Service Association Medicare	$84.80
Rate for Payer: Hawaii Western Management Group Commercial	$188.71
Rate for Payer: Health Management Network Commercial	$188.70
Rate for Payer: Kaiser Permanente Commercial	$101.76
Rate for Payer: Kaiser Permanente Medicaid	$101.76
Rate for Payer: Kaiser Permanente Medicare	$101.76
Rate for Payer: Ohana Health Plan Medicaid	$50.53
Rate for Payer: Ohana Health Plan Medicare	$84.80
Rate for Payer: UnitedHealthcare Medicaid	$50.53
Rate for Payer: UnitedHealthcare Medicare	$84.80

CHG 3D RENDERING W/INTERP&POSTPROC DIFF WORK STATION

Professional

Both

$66.00

Service Code	HCPCS 76377 26
Min. Negotiated Rate	$37.70
Max. Negotiated Rate	$188.71
Rate for Payer: AlohaCare Medicaid	$50.53
Rate for Payer: AlohaCare Medicare	$37.70
Rate for Payer: Cash Price	$39.60
Rate for Payer: Cash Price	$39.60
Rate for Payer: Devoted Health Medicare	$41.47
Rate for Payer: Hawaii Medical Service Association Medicare	$37.70
Rate for Payer: Hawaii Western Management Group Commercial	$188.71
Rate for Payer: Health Management Network Commercial	$56.10
Rate for Payer: Kaiser Permanente Commercial	$45.24
Rate for Payer: Kaiser Permanente Medicaid	$45.24
Rate for Payer: Kaiser Permanente Medicare	$45.24
Rate for Payer: Ohana Health Plan Medicaid	$50.53
Rate for Payer: Ohana Health Plan Medicare	$37.70
Rate for Payer: UnitedHealthcare Medicaid	$50.53
Rate for Payer: UnitedHealthcare Medicare	$37.70

CHG 3D RENDERING W/INTERP&POSTPROC DIFF WORK STATION

Professional

Both

$156.00

Service Code	HCPCS 76377 TC
Min. Negotiated Rate	$47.10
Max. Negotiated Rate	$188.71
Rate for Payer: AlohaCare Medicaid	$50.53
Rate for Payer: AlohaCare Medicare	$47.10
Rate for Payer: Cash Price	$93.60
Rate for Payer: Cash Price	$93.60
Rate for Payer: Devoted Health Medicare	$51.81
Rate for Payer: Hawaii Medical Service Association Medicare	$47.10
Rate for Payer: Hawaii Western Management Group Commercial	$188.71
Rate for Payer: Health Management Network Commercial	$132.60
Rate for Payer: Kaiser Permanente Commercial	$56.52
Rate for Payer: Kaiser Permanente Medicaid	$56.52
Rate for Payer: Kaiser Permanente Medicare	$56.52
Rate for Payer: Ohana Health Plan Medicaid	$50.53
Rate for Payer: Ohana Health Plan Medicare	$47.10
Rate for Payer: UnitedHealthcare Medicaid	$50.53
Rate for Payer: UnitedHealthcare Medicare	$47.10

CHG 3D RENDERING W/INTERP & POSTPROCESS SUPERVISION

Professional

Both

$17.00

Service Code	HCPCS 76376 26
Min. Negotiated Rate	$9.53
Max. Negotiated Rate	$150.85
Rate for Payer: AlohaCare Medicaid	$16.38
Rate for Payer: AlohaCare Medicare	$9.53
Rate for Payer: Cash Price	$10.20
Rate for Payer: Cash Price	$10.20
Rate for Payer: Devoted Health Medicare	$10.48
Rate for Payer: Hawaii Medical Service Association Medicare	$9.53
Rate for Payer: Hawaii Western Management Group Commercial	$150.85
Rate for Payer: Health Management Network Commercial	$14.45
Rate for Payer: Kaiser Permanente Commercial	$11.44
Rate for Payer: Kaiser Permanente Medicaid	$11.44
Rate for Payer: Kaiser Permanente Medicare	$11.44
Rate for Payer: Ohana Health Plan Medicaid	$16.38
Rate for Payer: Ohana Health Plan Medicare	$9.53
Rate for Payer: UnitedHealthcare Medicaid	$16.38
Rate for Payer: UnitedHealthcare Medicare	$9.53

CHG 3D RENDERING W/INTERP & POSTPROCESS SUPERVISION

Professional

Both

$60.00

Service Code	HCPCS 76376 TC
Min. Negotiated Rate	$16.38
Max. Negotiated Rate	$150.85
Rate for Payer: AlohaCare Medicaid	$16.38
Rate for Payer: AlohaCare Medicare	$18.04
Rate for Payer: Cash Price	$36.00
Rate for Payer: Cash Price	$36.00
Rate for Payer: Devoted Health Medicare	$19.84
Rate for Payer: Hawaii Medical Service Association Medicare	$18.04
Rate for Payer: Hawaii Western Management Group Commercial	$150.85
Rate for Payer: Health Management Network Commercial	$51.00
Rate for Payer: Kaiser Permanente Commercial	$21.65
Rate for Payer: Kaiser Permanente Medicaid	$21.65
Rate for Payer: Kaiser Permanente Medicare	$21.65
Rate for Payer: Ohana Health Plan Medicaid	$16.38
Rate for Payer: Ohana Health Plan Medicare	$18.04
Rate for Payer: UnitedHealthcare Medicaid	$16.38
Rate for Payer: UnitedHealthcare Medicare	$18.04

CHG 3D RENDERING W/INTERP & POSTPROCESS SUPERVISION

Professional

Both

$77.00

Service Code	HCPCS 76376
Min. Negotiated Rate	$16.38
Max. Negotiated Rate	$150.85
Rate for Payer: AlohaCare Medicaid	$16.38
Rate for Payer: AlohaCare Medicare	$27.57
Rate for Payer: Cash Price	$46.20
Rate for Payer: Cash Price	$46.20
Rate for Payer: Devoted Health Medicare	$30.33
Rate for Payer: Hawaii Medical Service Association Medicare	$27.57
Rate for Payer: Hawaii Western Management Group Commercial	$150.85
Rate for Payer: Health Management Network Commercial	$65.45
Rate for Payer: Kaiser Permanente Commercial	$33.08
Rate for Payer: Kaiser Permanente Medicaid	$33.08
Rate for Payer: Kaiser Permanente Medicare	$33.08
Rate for Payer: Ohana Health Plan Medicaid	$16.38
Rate for Payer: Ohana Health Plan Medicare	$27.57
Rate for Payer: UnitedHealthcare Medicaid	$16.38
Rate for Payer: UnitedHealthcare Medicare	$27.57

CHG ANGIOGRAPHY EXTREMITY BILATERAL RS&I

Professional

Both

$421.00

Service Code	HCPCS 75716
Min. Negotiated Rate	$103.42
Max. Negotiated Rate	$626.28
Rate for Payer: AlohaCare Medicaid	$103.42
Rate for Payer: AlohaCare Medicare	$171.87
Rate for Payer: Cash Price	$252.60
Rate for Payer: Cash Price	$252.60
Rate for Payer: Devoted Health Medicare	$189.06
Rate for Payer: Hawaii Medical Service Association Medicare	$171.87
Rate for Payer: Hawaii Western Management Group Commercial	$626.28
Rate for Payer: Health Management Network Commercial	$357.85
Rate for Payer: Kaiser Permanente Commercial	$206.24
Rate for Payer: Kaiser Permanente Medicaid	$206.24
Rate for Payer: Kaiser Permanente Medicare	$206.24
Rate for Payer: Ohana Health Plan Medicaid	$103.42
Rate for Payer: Ohana Health Plan Medicare	$171.87
Rate for Payer: UnitedHealthcare Medicaid	$103.42
Rate for Payer: UnitedHealthcare Medicare	$171.87

CHG ANGIOGRAPHY EXTREMITY BILATERAL RS&I

Professional

Both

$264.00

Service Code	HCPCS 75716 TC
Min. Negotiated Rate	$82.04
Max. Negotiated Rate	$626.28
Rate for Payer: AlohaCare Medicaid	$103.42
Rate for Payer: AlohaCare Medicare	$82.04
Rate for Payer: Cash Price	$158.40
Rate for Payer: Cash Price	$158.40
Rate for Payer: Devoted Health Medicare	$90.24
Rate for Payer: Hawaii Medical Service Association Medicare	$82.04
Rate for Payer: Hawaii Western Management Group Commercial	$626.28
Rate for Payer: Health Management Network Commercial	$224.40
Rate for Payer: Kaiser Permanente Commercial	$98.45
Rate for Payer: Kaiser Permanente Medicaid	$98.45
Rate for Payer: Kaiser Permanente Medicare	$98.45
Rate for Payer: Ohana Health Plan Medicaid	$103.42
Rate for Payer: Ohana Health Plan Medicare	$82.04
Rate for Payer: UnitedHealthcare Medicaid	$103.42
Rate for Payer: UnitedHealthcare Medicare	$82.04

Know your out-of-pocket cost for care.

All Charges