Hilo Benioff Medical Center

All Charges

Charge

Type

Setting

Price

CIRCUMCISION, SURGICAL EXCISION OTHER THAN CLAMP, DEVICE, OR DORSAL SLIT; OLDER THAN 28 DAYS OF AGE

Facility

$5,509.00

Service Code	CPT 54161
Hospital Revenue Code	360
Min. Negotiated Rate	$456.03
Max. Negotiated Rate	$5,509.00
Rate for Payer: AlohaCare Medicaid	$2,469.46
Rate for Payer: AlohaCare Medicare	$2,469.46
Rate for Payer: Devoted Health Medicare	$2,716.41
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	$2,469.46
Rate for Payer: Hawaii Medical Service Association Non-ABD	$1,028.67
Rate for Payer: Humana Medicare	$2,469.46
Rate for Payer: Kaiser Permanente Medicaid	$2,837.00
Rate for Payer: Kaiser Permanente Medicare	$2,469.46
Rate for Payer: Ohana Health Plan Medicaid	$2,716.41
Rate for Payer: Ohana Health Plan Medicare	$2,469.46
Rate for Payer: UnitedHealthcare Medicaid	$456.03
Rate for Payer: UnitedHealthcare Medicare	$2,469.46
Rate for Payer: University Health Alliance Commercial	$5,160.40

CIRRHOSIS AND ALCOHOLIC HEPATITIS WITH CC

Facility

$42,319.90

Service Code	MSDRG 433
Min. Negotiated Rate	$12,013.48
Max. Negotiated Rate	$42,319.90
Rate for Payer: AlohaCare Medicare	$12,013.48
Rate for Payer: Devoted Health Medicare	$13,214.83
Rate for Payer: Hawaii Medical Service Association Commercial	$42,319.90
Rate for Payer: Hawaii Medical Service Association Medicare	$12,013.48
Rate for Payer: Humana Medicare	$12,013.48
Rate for Payer: Kaiser Permanente Commercial	$18,219.45
Rate for Payer: Kaiser Permanente Medicare	$12,013.48
Rate for Payer: Ohana Health Plan Medicare	$12,013.48
Rate for Payer: UnitedHealthcare Medicare	$12,013.48

CIRRHOSIS AND ALCOHOLIC HEPATITIS WITH MCC

Facility

$42,319.90

Service Code	MSDRG 432
Min. Negotiated Rate	$22,386.81
Max. Negotiated Rate	$42,319.90
Rate for Payer: AlohaCare Medicare	$22,386.81
Rate for Payer: Devoted Health Medicare	$24,625.49
Rate for Payer: Hawaii Medical Service Association Commercial	$42,319.90
Rate for Payer: Hawaii Medical Service Association Medicare	$22,386.81
Rate for Payer: Humana Medicare	$22,386.81
Rate for Payer: Kaiser Permanente Commercial	$33,951.45
Rate for Payer: Kaiser Permanente Medicare	$22,386.81
Rate for Payer: Ohana Health Plan Medicare	$22,386.81
Rate for Payer: UnitedHealthcare Medicare	$22,386.81

CIRRHOSIS AND ALCOHOLIC HEPATITIS WITHOUT CC/MCC

Facility

$42,319.90

Service Code	MSDRG 434
Min. Negotiated Rate	$8,104.15
Max. Negotiated Rate	$42,319.90
Rate for Payer: AlohaCare Medicare	$8,104.15
Rate for Payer: Devoted Health Medicare	$8,914.57
Rate for Payer: Hawaii Medical Service Association Commercial	$42,319.90
Rate for Payer: Hawaii Medical Service Association Medicare	$8,104.15
Rate for Payer: Humana Medicare	$8,104.15
Rate for Payer: Kaiser Permanente Commercial	$12,290.62
Rate for Payer: Kaiser Permanente Medicare	$8,104.15
Rate for Payer: Ohana Health Plan Medicare	$8,104.15
Rate for Payer: UnitedHealthcare Medicare	$8,104.15

CISATRACURIUM 2 MG/ML INTRAVENOUS SOLUTION [119149]

Facility

$30.00

Service Code	NDC 71288071206
Hospital Revenue Code	250
Min. Negotiated Rate	$25.50
Max. Negotiated Rate	$29.10
Rate for Payer: Cash Price	$18.00
Rate for Payer: Health Management Network Commercial	$25.50
Rate for Payer: MDX Hawaii PPO	$29.10

CISATRACURIUM 2 MG/ML INTRAVENOUS SOLUTION [119149]

Facility

$30.00

Service Code	NDC 71288071205
Hospital Revenue Code	250
Min. Negotiated Rate	$25.50
Max. Negotiated Rate	$29.10
Rate for Payer: Cash Price	$18.00
Rate for Payer: Health Management Network Commercial	$25.50
Rate for Payer: MDX Hawaii PPO	$29.10

CISPLATIN 1 MG/ML INTRAVENOUS SOLUTION [88376]

Facility

$2.00

Service Code	HCPCS J9060
Hospital Revenue Code	250
Min. Negotiated Rate	$1.70
Max. Negotiated Rate	$1.94
Rate for Payer: Cash Price	$1.20
Rate for Payer: Cash Price	$100.80
Rate for Payer: Cash Price	$91.20
Rate for Payer: Cash Price	$34.20
Rate for Payer: Cash Price	$77.40
Rate for Payer: Health Management Network Commercial	$142.80
Rate for Payer: Health Management Network Commercial	$109.65
Rate for Payer: Health Management Network Commercial	$129.20
Rate for Payer: Health Management Network Commercial	$1.70
Rate for Payer: Health Management Network Commercial	$48.45
Rate for Payer: MDX Hawaii PPO	$55.29
Rate for Payer: MDX Hawaii PPO	$1.94
Rate for Payer: MDX Hawaii PPO	$125.13
Rate for Payer: MDX Hawaii PPO	$162.96
Rate for Payer: MDX Hawaii PPO	$147.44

CISPLATIN 1 MG/ML INTRAVENOUS SOLUTION [88376]

Facility

$2.00

Service Code	HCPCS J9060
Hospital Revenue Code	636
Min. Negotiated Rate	$1.02
Max. Negotiated Rate	$1.95
Rate for Payer: Cash Price	$1.20
Rate for Payer: Cash Price	$77.40
Rate for Payer: Cash Price	$100.80
Rate for Payer: Cash Price	$77.40
Rate for Payer: Cash Price	$34.20
Rate for Payer: Cash Price	$91.20
Rate for Payer: Cash Price	$91.20
Rate for Payer: Cash Price	$34.20
Rate for Payer: Cash Price	$1.20
Rate for Payer: Cash Price	$100.80
Rate for Payer: Hawaii Medical Service Association ABD	$1.95
Rate for Payer: Hawaii Medical Service Association ABD	$1.95
Rate for Payer: Hawaii Medical Service Association ABD	$1.95
Rate for Payer: Hawaii Medical Service Association ABD	$1.95
Rate for Payer: Hawaii Medical Service Association ABD	$1.95
Rate for Payer: Hawaii Medical Service Association Non-ABD	$1.95
Rate for Payer: Hawaii Medical Service Association Non-ABD	$1.95
Rate for Payer: Hawaii Medical Service Association Non-ABD	$1.95
Rate for Payer: Hawaii Medical Service Association Non-ABD	$1.95
Rate for Payer: Hawaii Medical Service Association Non-ABD	$1.95
Rate for Payer: Hawaii Western Management Group Commercial	$144.40
Rate for Payer: Hawaii Western Management Group Commercial	$1.90
Rate for Payer: Hawaii Western Management Group Commercial	$54.15
Rate for Payer: Hawaii Western Management Group Commercial	$159.60
Rate for Payer: Hawaii Western Management Group Commercial	$122.55
Rate for Payer: Health Management Network Commercial	$129.20
Rate for Payer: Health Management Network Commercial	$48.45
Rate for Payer: Health Management Network Commercial	$109.65
Rate for Payer: Health Management Network Commercial	$142.80
Rate for Payer: Health Management Network Commercial	$1.70
Rate for Payer: Kaiser Permanente Commercial	$105.84
Rate for Payer: Kaiser Permanente Commercial	$35.91
Rate for Payer: Kaiser Permanente Commercial	$81.27
Rate for Payer: Kaiser Permanente Commercial	$95.76
Rate for Payer: Kaiser Permanente Commercial	$1.26
Rate for Payer: Kaiser Permanente Medicaid	$77.52
Rate for Payer: Kaiser Permanente Medicaid	$1.02
Rate for Payer: Kaiser Permanente Medicaid	$65.79
Rate for Payer: Kaiser Permanente Medicaid	$29.07
Rate for Payer: Kaiser Permanente Medicaid	$85.68
Rate for Payer: MDX Hawaii PPO	$162.96
Rate for Payer: MDX Hawaii PPO	$55.29
Rate for Payer: MDX Hawaii PPO	$1.94
Rate for Payer: MDX Hawaii PPO	$125.13
Rate for Payer: MDX Hawaii PPO	$147.44
Rate for Payer: UnitedHealthcare Medicaid	$100.80
Rate for Payer: UnitedHealthcare Medicaid	$1.20
Rate for Payer: UnitedHealthcare Medicaid	$77.40
Rate for Payer: UnitedHealthcare Medicaid	$91.20
Rate for Payer: UnitedHealthcare Medicaid	$34.20
Rate for Payer: University Health Alliance Commercial	$110.79
Rate for Payer: University Health Alliance Commercial	$122.46
Rate for Payer: University Health Alliance Commercial	$1.46
Rate for Payer: University Health Alliance Commercial	$41.55
Rate for Payer: University Health Alliance Commercial	$94.03

CLADRIBINE 10 MG/10 ML INTRAVENOUS SOLUTION [131501]

Facility

$555.00

Service Code	HCPCS J9065
Hospital Revenue Code	250
Min. Negotiated Rate	$471.75
Max. Negotiated Rate	$538.35
Rate for Payer: Cash Price	$333.00
Rate for Payer: Cash Price	$450.00
Rate for Payer: Health Management Network Commercial	$471.75
Rate for Payer: Health Management Network Commercial	$637.50
Rate for Payer: MDX Hawaii PPO	$538.35
Rate for Payer: MDX Hawaii PPO	$727.50

CLADRIBINE 10 MG/10 ML INTRAVENOUS SOLUTION [131501]

Facility

$750.00

Service Code	HCPCS J9065
Hospital Revenue Code	636
Min. Negotiated Rate	$8.73
Max. Negotiated Rate	$727.50
Rate for Payer: AlohaCare Medicaid	$8.73
Rate for Payer: AlohaCare Medicaid	$8.73
Rate for Payer: AlohaCare Medicare	$8.73
Rate for Payer: AlohaCare Medicare	$8.73
Rate for Payer: Cash Price	$450.00
Rate for Payer: Cash Price	$450.00
Rate for Payer: Cash Price	$333.00
Rate for Payer: Cash Price	$333.00
Rate for Payer: Devoted Health Medicare	$9.60
Rate for Payer: Devoted Health Medicare	$9.60
Rate for Payer: Hawaii Medical Service Association ABD	$9.73
Rate for Payer: Hawaii Medical Service Association ABD	$9.73
Rate for Payer: Hawaii Medical Service Association Commercial	$10.91
Rate for Payer: Hawaii Medical Service Association Commercial	$10.91
Rate for Payer: Hawaii Medical Service Association Medicare	$8.73
Rate for Payer: Hawaii Medical Service Association Medicare	$8.73
Rate for Payer: Hawaii Medical Service Association Non-ABD	$9.73
Rate for Payer: Hawaii Medical Service Association Non-ABD	$9.73
Rate for Payer: Hawaii Western Management Group Commercial	$527.25
Rate for Payer: Hawaii Western Management Group Commercial	$712.50
Rate for Payer: Health Management Network Commercial	$471.75
Rate for Payer: Health Management Network Commercial	$637.50
Rate for Payer: Humana Medicare	$8.73
Rate for Payer: Humana Medicare	$8.73
Rate for Payer: Kaiser Permanente Commercial	$349.65
Rate for Payer: Kaiser Permanente Commercial	$472.50
Rate for Payer: Kaiser Permanente Medicaid	$382.50
Rate for Payer: Kaiser Permanente Medicaid	$283.05
Rate for Payer: Kaiser Permanente Medicare	$8.73
Rate for Payer: Kaiser Permanente Medicare	$8.73
Rate for Payer: MDX Hawaii PPO	$727.50
Rate for Payer: MDX Hawaii PPO	$538.35
Rate for Payer: Ohana Health Plan Medicaid	$9.60
Rate for Payer: Ohana Health Plan Medicaid	$9.60
Rate for Payer: Ohana Health Plan Medicare	$8.73
Rate for Payer: Ohana Health Plan Medicare	$8.73
Rate for Payer: UnitedHealthcare Medicaid	$450.00
Rate for Payer: UnitedHealthcare Medicaid	$333.00
Rate for Payer: UnitedHealthcare Medicare	$8.73
Rate for Payer: UnitedHealthcare Medicare	$8.73
Rate for Payer: University Health Alliance Commercial	$546.67
Rate for Payer: University Health Alliance Commercial	$404.54

CLAMP 4.0MM ADJUST DR #390.051

Facility

$2,967.00

Hospital Revenue Code	272
Min. Negotiated Rate	$1,513.17
Max. Negotiated Rate	$2,877.99
Rate for Payer: Cash Price	$1,780.20
Rate for Payer: Hawaii Western Management Group Commercial	$2,818.65
Rate for Payer: Health Management Network Commercial	$2,521.95
Rate for Payer: Kaiser Permanente Commercial	$1,869.21
Rate for Payer: Kaiser Permanente Medicaid	$1,513.17
Rate for Payer: MDX Hawaii PPO	$2,877.99
Rate for Payer: University Health Alliance Commercial	$2,162.65

CLAMP 4.0MM ADJUST DR #390.051

Facility

$2,967.00

Hospital Revenue Code	272
Min. Negotiated Rate	$2,521.95
Max. Negotiated Rate	$2,877.99
Rate for Payer: Cash Price	$1,780.20
Rate for Payer: Health Management Network Commercial	$2,521.95
Rate for Payer: MDX Hawaii PPO	$2,877.99

CLAMP 8MM/11MM COMBO #390.037

Facility

$2,092.00

Service Code	HCPCS C1713
Hospital Revenue Code	272
Min. Negotiated Rate	$1,778.20
Max. Negotiated Rate	$2,029.24
Rate for Payer: Cash Price	$1,255.20
Rate for Payer: Health Management Network Commercial	$1,778.20
Rate for Payer: MDX Hawaii PPO	$2,029.24

CLAMP 8MM/11MM COMBO #390.037

Facility

$2,092.00

Service Code	HCPCS C1713
Hospital Revenue Code	272
Min. Negotiated Rate	$1,066.92
Max. Negotiated Rate	$2,029.24
Rate for Payer: Cash Price	$1,255.20
Rate for Payer: Hawaii Western Management Group Commercial	$1,987.40
Rate for Payer: Health Management Network Commercial	$1,778.20
Rate for Payer: Kaiser Permanente Commercial	$1,317.96
Rate for Payer: Kaiser Permanente Medicaid	$1,066.92
Rate for Payer: MDX Hawaii PPO	$2,029.24
Rate for Payer: University Health Alliance Commercial	$1,524.86

CLAMP COMBINATION LRG 390.005

Facility

$2,524.00

Hospital Revenue Code	272
Min. Negotiated Rate	$1,287.24
Max. Negotiated Rate	$2,448.28
Rate for Payer: Cash Price	$1,514.40
Rate for Payer: Hawaii Western Management Group Commercial	$2,397.80
Rate for Payer: Health Management Network Commercial	$2,145.40
Rate for Payer: Kaiser Permanente Commercial	$1,590.12
Rate for Payer: Kaiser Permanente Medicaid	$1,287.24
Rate for Payer: MDX Hawaii PPO	$2,448.28
Rate for Payer: University Health Alliance Commercial	$1,839.74

CLAMP COMBINATION LRG 390.005

Facility

$2,524.00

Hospital Revenue Code	272
Min. Negotiated Rate	$2,145.40
Max. Negotiated Rate	$2,448.28
Rate for Payer: Cash Price	$1,514.40
Rate for Payer: Health Management Network Commercial	$2,145.40
Rate for Payer: MDX Hawaii PPO	$2,448.28

CLAMP COMBINATION MED 390.031

Facility

$2,054.00

Hospital Revenue Code	272
Min. Negotiated Rate	$1,745.90
Max. Negotiated Rate	$1,992.38
Rate for Payer: Cash Price	$1,232.40
Rate for Payer: Health Management Network Commercial	$1,745.90
Rate for Payer: MDX Hawaii PPO	$1,992.38

CLAMP COMBINATION MED 390.031

Facility

$2,054.00

Hospital Revenue Code	272
Min. Negotiated Rate	$1,047.54
Max. Negotiated Rate	$1,992.38
Rate for Payer: Cash Price	$1,232.40
Rate for Payer: Hawaii Western Management Group Commercial	$1,951.30
Rate for Payer: Health Management Network Commercial	$1,745.90
Rate for Payer: Kaiser Permanente Commercial	$1,294.02
Rate for Payer: Kaiser Permanente Medicaid	$1,047.54
Rate for Payer: MDX Hawaii PPO	$1,992.38
Rate for Payer: University Health Alliance Commercial	$1,497.16

CLAMP COVER MINIFIXATOR M138

Facility

$270.00

Hospital Revenue Code	272
Min. Negotiated Rate	$137.70
Max. Negotiated Rate	$261.90
Rate for Payer: Cash Price	$162.00
Rate for Payer: Hawaii Western Management Group Commercial	$256.50
Rate for Payer: Health Management Network Commercial	$229.50
Rate for Payer: Kaiser Permanente Commercial	$170.10
Rate for Payer: Kaiser Permanente Medicaid	$137.70
Rate for Payer: MDX Hawaii PPO	$261.90
Rate for Payer: University Health Alliance Commercial	$196.80

CLAMP COVER MINIFIXATOR M138

Facility

$270.00

Hospital Revenue Code	272
Min. Negotiated Rate	$229.50
Max. Negotiated Rate	$261.90
Rate for Payer: Cash Price	$162.00
Rate for Payer: Health Management Network Commercial	$229.50
Rate for Payer: MDX Hawaii PPO	$261.90

CLAMP COVER MINIRAIL M203

Facility

$288.00

Hospital Revenue Code	272
Min. Negotiated Rate	$146.88
Max. Negotiated Rate	$279.36
Rate for Payer: Cash Price	$172.80
Rate for Payer: Hawaii Western Management Group Commercial	$273.60
Rate for Payer: Health Management Network Commercial	$244.80
Rate for Payer: Kaiser Permanente Commercial	$181.44
Rate for Payer: Kaiser Permanente Medicaid	$146.88
Rate for Payer: MDX Hawaii PPO	$279.36
Rate for Payer: University Health Alliance Commercial	$209.92

CLAMP COVER MINIRAIL M203

Facility

$288.00

Hospital Revenue Code	272
Min. Negotiated Rate	$244.80
Max. Negotiated Rate	$279.36
Rate for Payer: Cash Price	$172.80
Rate for Payer: Health Management Network Commercial	$244.80
Rate for Payer: MDX Hawaii PPO	$279.36

CLAMP DYNAMIZATION LRG 390.006

Facility

$713.00

Hospital Revenue Code	272
Min. Negotiated Rate	$606.05
Max. Negotiated Rate	$691.61
Rate for Payer: Cash Price	$427.80
Rate for Payer: Health Management Network Commercial	$606.05
Rate for Payer: MDX Hawaii PPO	$691.61

CLAMP DYNAMIZATION LRG 390.006

Facility

$713.00

Hospital Revenue Code	272
Min. Negotiated Rate	$363.63
Max. Negotiated Rate	$691.61
Rate for Payer: Cash Price	$427.80
Rate for Payer: Hawaii Western Management Group Commercial	$677.35
Rate for Payer: Health Management Network Commercial	$606.05
Rate for Payer: Kaiser Permanente Commercial	$449.19
Rate for Payer: Kaiser Permanente Medicaid	$363.63
Rate for Payer: MDX Hawaii PPO	$691.61
Rate for Payer: University Health Alliance Commercial	$519.71

CLAMP MED PIN 4-POS 390.026

Facility

$2,193.00

Hospital Revenue Code	272
Min. Negotiated Rate	$1,864.05
Max. Negotiated Rate	$2,127.21
Rate for Payer: Cash Price	$1,315.80
Rate for Payer: Health Management Network Commercial	$1,864.05
Rate for Payer: MDX Hawaii PPO	$2,127.21

Know your out-of-pocket cost for care.

All Charges