Hilo Benioff Medical Center

All Charges

Charge

Type

Setting

Price

ADAPTER LATITUDE 3G USB 6295

Facility

$746.00

Hospital Revenue Code	271
Min. Negotiated Rate	$380.46
Max. Negotiated Rate	$723.62
Rate for Payer: Cash Price	$447.60
Rate for Payer: Hawaii Western Management Group Commercial	$708.70
Rate for Payer: Health Management Network Commercial	$634.10
Rate for Payer: Kaiser Permanente Commercial	$469.98
Rate for Payer: Kaiser Permanente Medicaid	$380.46
Rate for Payer: MDX Hawaii PPO	$723.62
Rate for Payer: University Health Alliance Commercial	$543.76

ADAPTER S1S HIP NEC STD 431186

Facility

$1,663.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$931.28
Max. Negotiated Rate	$1,613.11
Rate for Payer: Cash Price	$997.80
Rate for Payer: Hawaii Western Management Group Commercial	$1,164.10
Rate for Payer: Health Management Network Commercial	$1,413.55
Rate for Payer: MDX Hawaii PPO	$1,613.11
Rate for Payer: University Health Alliance Commercial	$931.28

ADAPTER S1S HIP NEC STD 431186

Facility

$1,663.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$848.13
Max. Negotiated Rate	$1,613.11
Rate for Payer: Cash Price	$997.80
Rate for Payer: Hawaii Western Management Group Commercial	$1,164.10
Rate for Payer: Health Management Network Commercial	$1,413.55
Rate for Payer: Kaiser Permanente Commercial	$1,047.69
Rate for Payer: Kaiser Permanente Medicaid	$848.13
Rate for Payer: MDX Hawaii PPO	$1,613.11
Rate for Payer: University Health Alliance Commercial	$931.28

ADAPTER SLEEVE C-TAPE 19-0325T

Facility

$768.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$430.08
Max. Negotiated Rate	$744.96
Rate for Payer: Cash Price	$460.80
Rate for Payer: Hawaii Western Management Group Commercial	$537.60
Rate for Payer: Health Management Network Commercial	$652.80
Rate for Payer: MDX Hawaii PPO	$744.96
Rate for Payer: University Health Alliance Commercial	$430.08

ADAPTER SLEEVE C-TAPE 19-0325T

Facility

$768.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$391.68
Max. Negotiated Rate	$744.96
Rate for Payer: Cash Price	$460.80
Rate for Payer: Hawaii Western Management Group Commercial	$537.60
Rate for Payer: Health Management Network Commercial	$652.80
Rate for Payer: Kaiser Permanente Commercial	$483.84
Rate for Payer: Kaiser Permanente Medicaid	$391.68
Rate for Payer: MDX Hawaii PPO	$744.96
Rate for Payer: University Health Alliance Commercial	$430.08

ADENOIDECTOMY, PRIMARY; AGE 12 OR OVER

Facility

$10,679.55

Service Code	CPT 42831
Hospital Revenue Code	360
Min. Negotiated Rate	$456.03
Max. Negotiated Rate	$10,679.55
Rate for Payer: AlohaCare Medicaid	$3,916.70
Rate for Payer: AlohaCare Medicare	$3,916.70
Rate for Payer: Devoted Health Medicare	$4,308.37
Rate for Payer: Hawaii Medical Service Association ABD	$695.00
Rate for Payer: Hawaii Medical Service Association Commercial	$5,509.00
Rate for Payer: Hawaii Medical Service Association Medicare	$3,916.70
Rate for Payer: Hawaii Medical Service Association Non-ABD	$1,028.67
Rate for Payer: Humana Medicare	$3,916.70
Rate for Payer: Kaiser Permanente Medicaid	$2,837.00
Rate for Payer: Kaiser Permanente Medicare	$3,916.70
Rate for Payer: Ohana Health Plan Medicaid	$4,308.37
Rate for Payer: Ohana Health Plan Medicare	$3,916.70
Rate for Payer: UnitedHealthcare Medicaid	$456.03
Rate for Payer: UnitedHealthcare Medicare	$3,916.70
Rate for Payer: University Health Alliance Commercial	$10,679.55

ADENOIDECTOMY, PRIMARY; YOUNGER THAN AGE 12

Facility

$10,679.55

Service Code	CPT 42830
Hospital Revenue Code	360
Min. Negotiated Rate	$456.03
Max. Negotiated Rate	$10,679.55
Rate for Payer: AlohaCare Medicaid	$3,916.70
Rate for Payer: AlohaCare Medicare	$3,916.70
Rate for Payer: Devoted Health Medicare	$4,308.37
Rate for Payer: Hawaii Medical Service Association ABD	$695.00
Rate for Payer: Hawaii Medical Service Association Commercial	$5,509.00
Rate for Payer: Hawaii Medical Service Association Medicare	$3,916.70
Rate for Payer: Hawaii Medical Service Association Non-ABD	$1,028.67
Rate for Payer: Humana Medicare	$3,916.70
Rate for Payer: Kaiser Permanente Medicaid	$2,837.00
Rate for Payer: Kaiser Permanente Medicare	$3,916.70
Rate for Payer: Ohana Health Plan Medicaid	$4,308.37
Rate for Payer: Ohana Health Plan Medicare	$3,916.70
Rate for Payer: UnitedHealthcare Medicaid	$456.03
Rate for Payer: UnitedHealthcare Medicare	$3,916.70
Rate for Payer: University Health Alliance Commercial	$10,679.55

ADENOSINE 3 MG/ML INTRAVENOUS SOLUTION [38703]

Facility

$27.00

Service Code	HCPCS J0153
Hospital Revenue Code	250
Min. Negotiated Rate	$22.95
Max. Negotiated Rate	$26.19
Rate for Payer: Cash Price	$16.20
Rate for Payer: Health Management Network Commercial	$22.95
Rate for Payer: MDX Hawaii PPO	$26.19

ADENOSINE 3 MG/ML INTRAVENOUS SOLUTION [38703]

Facility

$27.00

Service Code	HCPCS J0153
Hospital Revenue Code	636
Min. Negotiated Rate	$0.46
Max. Negotiated Rate	$26.19
Rate for Payer: Cash Price	$16.20
Rate for Payer: Cash Price	$16.20
Rate for Payer: Hawaii Medical Service Association ABD	$0.46
Rate for Payer: Hawaii Medical Service Association Non-ABD	$0.46
Rate for Payer: Hawaii Western Management Group Commercial	$25.65
Rate for Payer: Health Management Network Commercial	$22.95
Rate for Payer: Kaiser Permanente Commercial	$17.01
Rate for Payer: Kaiser Permanente Medicaid	$13.77
Rate for Payer: MDX Hawaii PPO	$26.19
Rate for Payer: UnitedHealthcare Medicaid	$16.20
Rate for Payer: University Health Alliance Commercial	$19.68

ADENOSINE (DIAGNOSTIC) 3 MG/ML INTRAVENOUS SOLUTION [8975]

Facility

$706.00

Service Code	HCPCS J0153
Hospital Revenue Code	250
Min. Negotiated Rate	$600.10
Max. Negotiated Rate	$684.82
Rate for Payer: Cash Price	$423.60
Rate for Payer: Health Management Network Commercial	$600.10
Rate for Payer: MDX Hawaii PPO	$684.82

ADENOSINE (DIAGNOSTIC) 3 MG/ML INTRAVENOUS SOLUTION [8975]

Facility

$706.00

Service Code	HCPCS J0153
Hospital Revenue Code	636
Min. Negotiated Rate	$0.46
Max. Negotiated Rate	$684.82
Rate for Payer: Cash Price	$423.60
Rate for Payer: Cash Price	$423.60
Rate for Payer: Hawaii Medical Service Association ABD	$0.46
Rate for Payer: Hawaii Medical Service Association Non-ABD	$0.46
Rate for Payer: Hawaii Western Management Group Commercial	$670.70
Rate for Payer: Health Management Network Commercial	$600.10
Rate for Payer: Kaiser Permanente Commercial	$444.78
Rate for Payer: Kaiser Permanente Medicaid	$360.06
Rate for Payer: MDX Hawaii PPO	$684.82
Rate for Payer: UnitedHealthcare Medicaid	$423.60
Rate for Payer: University Health Alliance Commercial	$514.60

ADHES LIQUIBAND DOME TIP

Facility

$104.00

Hospital Revenue Code	272
Min. Negotiated Rate	$88.40
Max. Negotiated Rate	$100.88
Rate for Payer: Cash Price	$62.40
Rate for Payer: Health Management Network Commercial	$88.40
Rate for Payer: MDX Hawaii PPO	$100.88

ADHES LIQUIBAND DOME TIP

Facility

$104.00

Hospital Revenue Code	272
Min. Negotiated Rate	$53.04
Max. Negotiated Rate	$100.88
Rate for Payer: Cash Price	$62.40
Rate for Payer: Hawaii Western Management Group Commercial	$98.80
Rate for Payer: Health Management Network Commercial	$88.40
Rate for Payer: Kaiser Permanente Commercial	$65.52
Rate for Payer: Kaiser Permanente Medicaid	$53.04
Rate for Payer: MDX Hawaii PPO	$100.88
Rate for Payer: University Health Alliance Commercial	$75.81

ADJACENT TISSUE TRANSFER OR REARRANGEMENT, ANY AREA; DEFECT 30.1 SQ CM TO 60.0 SQ CM

Facility

$8,270.00

Service Code	CPT 14301
Hospital Revenue Code	360
Min. Negotiated Rate	$456.03
Max. Negotiated Rate	$8,270.00
Rate for Payer: AlohaCare Medicaid	$4,186.36
Rate for Payer: AlohaCare Medicare	$4,186.36
Rate for Payer: Devoted Health Medicare	$4,605.00
Rate for Payer: Hawaii Medical Service Association ABD	$848.00
Rate for Payer: Hawaii Medical Service Association Commercial	$8,270.00
Rate for Payer: Hawaii Medical Service Association Medicare	$4,186.36
Rate for Payer: Hawaii Medical Service Association Non-ABD	$1,427.62
Rate for Payer: Humana Medicare	$4,186.36
Rate for Payer: Kaiser Permanente Medicaid	$2,837.00
Rate for Payer: Kaiser Permanente Medicare	$4,186.36
Rate for Payer: Ohana Health Plan Medicaid	$4,605.00
Rate for Payer: Ohana Health Plan Medicare	$4,186.36
Rate for Payer: UnitedHealthcare Medicaid	$456.03
Rate for Payer: UnitedHealthcare Medicare	$4,186.36
Rate for Payer: University Health Alliance Commercial	$6,743.44

ADJACENT TISSUE TRANSFER OR REARRANGEMENT, ANY AREA; EACH ADDITIONAL 30.0 SQ CM, OR PART THEREOF (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)

Facility

$2,837.00

Service Code	CPT 14302
Hospital Revenue Code	360
Min. Negotiated Rate	$109.64
Max. Negotiated Rate	$2,837.00
Rate for Payer: Kaiser Permanente Medicaid	$2,837.00
Rate for Payer: UnitedHealthcare Medicaid	$109.64

ADJACENT TISSUE TRANSFER OR REARRANGEMENT, EYELIDS, NOSE, EARS AND/OR LIPS; DEFECT 10.1 SQ CM TO 30.0 SQ CM

Facility

$8,270.00

Service Code	CPT 14061
Hospital Revenue Code	360
Min. Negotiated Rate	$456.03
Max. Negotiated Rate	$8,270.00
Rate for Payer: AlohaCare Medicaid	$2,437.45
Rate for Payer: AlohaCare Medicare	$2,437.45
Rate for Payer: Devoted Health Medicare	$2,681.20
Rate for Payer: Hawaii Medical Service Association ABD	$848.00
Rate for Payer: Hawaii Medical Service Association Commercial	$8,270.00
Rate for Payer: Hawaii Medical Service Association Medicare	$2,437.45
Rate for Payer: Hawaii Medical Service Association Non-ABD	$1,427.62
Rate for Payer: Humana Medicare	$2,437.45
Rate for Payer: Kaiser Permanente Medicaid	$2,837.00
Rate for Payer: Kaiser Permanente Medicare	$2,437.45
Rate for Payer: Ohana Health Plan Medicaid	$2,681.20
Rate for Payer: Ohana Health Plan Medicare	$2,437.45
Rate for Payer: UnitedHealthcare Medicaid	$456.03
Rate for Payer: UnitedHealthcare Medicare	$2,437.45
Rate for Payer: University Health Alliance Commercial	$6,743.44

ADJACENT TISSUE TRANSFER OR REARRANGEMENT, FOREHEAD, CHEEKS, CHIN, MOUTH, NECK, AXILLAE, GENITALIA, HANDS AND/OR FEET; DEFECT 10.1 SQ CM TO 30.0 SQ CM

Facility

$8,270.00

Service Code	CPT 14041
Hospital Revenue Code	360
Min. Negotiated Rate	$456.03
Max. Negotiated Rate	$8,270.00
Rate for Payer: AlohaCare Medicaid	$2,437.45
Rate for Payer: AlohaCare Medicare	$2,437.45
Rate for Payer: Devoted Health Medicare	$2,681.20
Rate for Payer: Hawaii Medical Service Association ABD	$848.00
Rate for Payer: Hawaii Medical Service Association Commercial	$8,270.00
Rate for Payer: Hawaii Medical Service Association Medicare	$2,437.45
Rate for Payer: Hawaii Medical Service Association Non-ABD	$1,427.62
Rate for Payer: Humana Medicare	$2,437.45
Rate for Payer: Kaiser Permanente Medicaid	$2,837.00
Rate for Payer: Kaiser Permanente Medicare	$2,437.45
Rate for Payer: Ohana Health Plan Medicaid	$2,681.20
Rate for Payer: Ohana Health Plan Medicare	$2,437.45
Rate for Payer: UnitedHealthcare Medicaid	$456.03
Rate for Payer: UnitedHealthcare Medicare	$2,437.45
Rate for Payer: University Health Alliance Commercial	$6,743.44

ADJACENT TISSUE TRANSFER OR REARRANGEMENT, FOREHEAD, CHEEKS, CHIN, MOUTH, NECK, AXILLAE, GENITALIA, HANDS AND/OR FEET; DEFECT 10 SQ CM OR LESS

Facility

$8,270.00

Service Code	CPT 14040
Hospital Revenue Code	360
Min. Negotiated Rate	$456.03
Max. Negotiated Rate	$8,270.00
Rate for Payer: AlohaCare Medicaid	$2,437.45
Rate for Payer: AlohaCare Medicare	$2,437.45
Rate for Payer: Devoted Health Medicare	$2,681.20
Rate for Payer: Hawaii Medical Service Association ABD	$848.00
Rate for Payer: Hawaii Medical Service Association Commercial	$8,270.00
Rate for Payer: Hawaii Medical Service Association Medicare	$2,437.45
Rate for Payer: Hawaii Medical Service Association Non-ABD	$1,427.62
Rate for Payer: Humana Medicare	$2,437.45
Rate for Payer: Kaiser Permanente Medicaid	$2,837.00
Rate for Payer: Kaiser Permanente Medicare	$2,437.45
Rate for Payer: Ohana Health Plan Medicaid	$2,681.20
Rate for Payer: Ohana Health Plan Medicare	$2,437.45
Rate for Payer: UnitedHealthcare Medicaid	$456.03
Rate for Payer: UnitedHealthcare Medicare	$2,437.45
Rate for Payer: University Health Alliance Commercial	$5,160.40

ADJACENT TISSUE TRANSFER OR REARRANGEMENT, SCALP, ARMS AND/OR LEGS; DEFECT 10.1 SQ CM TO 30.0 SQ CM

Facility

$6,743.44

Service Code	CPT 14021
Hospital Revenue Code	360
Min. Negotiated Rate	$456.03
Max. Negotiated Rate	$6,743.44
Rate for Payer: AlohaCare Medicaid	$2,437.45
Rate for Payer: AlohaCare Medicare	$2,437.45
Rate for Payer: Devoted Health Medicare	$2,681.20
Rate for Payer: Hawaii Medical Service Association ABD	$695.00
Rate for Payer: Hawaii Medical Service Association Commercial	$5,509.00
Rate for Payer: Hawaii Medical Service Association Medicare	$2,437.45
Rate for Payer: Hawaii Medical Service Association Non-ABD	$1,028.67
Rate for Payer: Humana Medicare	$2,437.45
Rate for Payer: Kaiser Permanente Medicaid	$2,837.00
Rate for Payer: Kaiser Permanente Medicare	$2,437.45
Rate for Payer: Ohana Health Plan Medicaid	$2,681.20
Rate for Payer: Ohana Health Plan Medicare	$2,437.45
Rate for Payer: UnitedHealthcare Medicaid	$456.03
Rate for Payer: UnitedHealthcare Medicare	$2,437.45
Rate for Payer: University Health Alliance Commercial	$6,743.44

ADJUSTMENT DISORDERS & NEUROSES EXCEPT DEPRESSIVE DIAGNOSES

Facility

$7,344.41

Service Code	APR-DRG 7554
Min. Negotiated Rate	$7,344.41
Max. Negotiated Rate	$7,344.41
Rate for Payer: AlohaCare Medicaid	$7,344.41
Rate for Payer: Hawaii Medical Service Association ABD	$7,344.41
Rate for Payer: Hawaii Medical Service Association Non-ABD	$7,344.41
Rate for Payer: Kaiser Permanente Medicaid	$7,344.41
Rate for Payer: Ohana Health Plan Medicaid	$7,344.41
Rate for Payer: UnitedHealthcare Medicaid	$7,344.41

ADJUSTMENT DISORDERS & NEUROSES EXCEPT DEPRESSIVE DIAGNOSES

Facility

$2,358.37

Service Code	APR-DRG 7551
Min. Negotiated Rate	$2,358.37
Max. Negotiated Rate	$2,358.37
Rate for Payer: AlohaCare Medicaid	$2,358.37
Rate for Payer: Hawaii Medical Service Association ABD	$2,358.37
Rate for Payer: Hawaii Medical Service Association Non-ABD	$2,358.37
Rate for Payer: Kaiser Permanente Medicaid	$2,358.37
Rate for Payer: Ohana Health Plan Medicaid	$2,358.37
Rate for Payer: UnitedHealthcare Medicaid	$2,358.37

ADJUSTMENT DISORDERS & NEUROSES EXCEPT DEPRESSIVE DIAGNOSES

Facility

$4,226.17

Service Code	APR-DRG 7553
Min. Negotiated Rate	$4,226.17
Max. Negotiated Rate	$4,226.17
Rate for Payer: AlohaCare Medicaid	$4,226.17
Rate for Payer: Hawaii Medical Service Association ABD	$4,226.17
Rate for Payer: Hawaii Medical Service Association Non-ABD	$4,226.17
Rate for Payer: Kaiser Permanente Medicaid	$4,226.17
Rate for Payer: Ohana Health Plan Medicaid	$4,226.17
Rate for Payer: UnitedHealthcare Medicaid	$4,226.17

ADJUSTMENT DISORDERS & NEUROSES EXCEPT DEPRESSIVE DIAGNOSES

Facility

$3,188.75

Service Code	APR-DRG 7552
Min. Negotiated Rate	$3,188.75
Max. Negotiated Rate	$3,188.75
Rate for Payer: AlohaCare Medicaid	$3,188.75
Rate for Payer: Hawaii Medical Service Association ABD	$3,188.75
Rate for Payer: Hawaii Medical Service Association Non-ABD	$3,188.75
Rate for Payer: Kaiser Permanente Medicaid	$3,188.75
Rate for Payer: Ohana Health Plan Medicaid	$3,188.75
Rate for Payer: UnitedHealthcare Medicaid	$3,188.75

ADMINISTRATION OF INFLUENZA VIRUS VACCINE

Facility

$2,837.00

Service Code	CPT G0008
Hospital Revenue Code	360
Min. Negotiated Rate	$34.61
Max. Negotiated Rate	$2,837.00
Rate for Payer: AlohaCare Medicaid	$55.32
Rate for Payer: AlohaCare Medicare	$55.32
Rate for Payer: Devoted Health Medicare	$60.85
Rate for Payer: Hawaii Medical Service Association Commercial	$69.15
Rate for Payer: Hawaii Medical Service Association Medicare	$55.32
Rate for Payer: Humana Medicare	$55.32
Rate for Payer: Kaiser Permanente Medicaid	$2,837.00
Rate for Payer: Kaiser Permanente Medicare	$55.32
Rate for Payer: Ohana Health Plan Medicaid	$60.85
Rate for Payer: Ohana Health Plan Medicare	$55.32
Rate for Payer: UnitedHealthcare Medicaid	$34.61
Rate for Payer: UnitedHealthcare Medicare	$55.32

ADOLESCENT TAN 13MM DIA. RIGHT

Facility

$6,776.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$3,794.56
Max. Negotiated Rate	$6,572.72
Rate for Payer: Cash Price	$4,065.60
Rate for Payer: Hawaii Western Management Group Commercial	$4,743.20
Rate for Payer: Health Management Network Commercial	$5,759.60
Rate for Payer: MDX Hawaii PPO	$6,572.72
Rate for Payer: University Health Alliance Commercial	$3,794.56

Know your out-of-pocket cost for care.

All Charges