Hilo Benioff Medical Center

All Charges

Charge

Type

Setting

Price

COMPONENT TIBIAL SIZE C RT

Facility

$3,800.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$1,938.00
Max. Negotiated Rate	$3,686.00
Rate for Payer: Cash Price	$2,280.00
Rate for Payer: Hawaii Western Management Group Commercial	$2,660.00
Rate for Payer: Health Management Network Commercial	$3,230.00
Rate for Payer: Kaiser Permanente Commercial	$2,394.00
Rate for Payer: Kaiser Permanente Medicaid	$1,938.00
Rate for Payer: MDX Hawaii PPO	$3,686.00
Rate for Payer: University Health Alliance Commercial	$2,128.00

COMPOSITE SYRINGE

Facility

$352.00

Hospital Revenue Code	272
Min. Negotiated Rate	$299.20
Max. Negotiated Rate	$341.44
Rate for Payer: Cash Price	$211.20
Rate for Payer: Health Management Network Commercial	$299.20
Rate for Payer: MDX Hawaii PPO	$341.44

COMPOSITE SYRINGE

Facility

$352.00

Hospital Revenue Code	272
Min. Negotiated Rate	$179.52
Max. Negotiated Rate	$341.44
Rate for Payer: Cash Price	$211.20
Rate for Payer: Hawaii Western Management Group Commercial	$334.40
Rate for Payer: Health Management Network Commercial	$299.20
Rate for Payer: Kaiser Permanente Commercial	$221.76
Rate for Payer: Kaiser Permanente Medicaid	$179.52
Rate for Payer: MDX Hawaii PPO	$341.44
Rate for Payer: University Health Alliance Commercial	$256.57

COMPOSITE SYRINGE 3GM 7211199

Facility

$217.00

Hospital Revenue Code	272
Min. Negotiated Rate	$184.45
Max. Negotiated Rate	$210.49
Rate for Payer: Cash Price	$130.20
Rate for Payer: Health Management Network Commercial	$184.45
Rate for Payer: MDX Hawaii PPO	$210.49

COMPOSITE SYRINGE 3GM 7211199

Facility

$217.00

Hospital Revenue Code	272
Min. Negotiated Rate	$110.67
Max. Negotiated Rate	$210.49
Rate for Payer: Cash Price	$130.20
Rate for Payer: Hawaii Western Management Group Commercial	$206.15
Rate for Payer: Health Management Network Commercial	$184.45
Rate for Payer: Kaiser Permanente Commercial	$136.71
Rate for Payer: Kaiser Permanente Medicaid	$110.67
Rate for Payer: MDX Hawaii PPO	$210.49
Rate for Payer: University Health Alliance Commercial	$158.17

COMPOSITE SYRINGE 3GM 7211318

Facility

$225.00

Hospital Revenue Code	272
Min. Negotiated Rate	$191.25
Max. Negotiated Rate	$218.25
Rate for Payer: Cash Price	$135.00
Rate for Payer: Health Management Network Commercial	$191.25
Rate for Payer: MDX Hawaii PPO	$218.25

COMPOSITE SYRINGE 3GM 7211318

Facility

$225.00

Hospital Revenue Code	272
Min. Negotiated Rate	$114.75
Max. Negotiated Rate	$218.25
Rate for Payer: Cash Price	$135.00
Rate for Payer: Hawaii Western Management Group Commercial	$213.75
Rate for Payer: Health Management Network Commercial	$191.25
Rate for Payer: Kaiser Permanente Commercial	$141.75
Rate for Payer: Kaiser Permanente Medicaid	$114.75
Rate for Payer: MDX Hawaii PPO	$218.25
Rate for Payer: University Health Alliance Commercial	$164.00

COMPOUNDING VEHICLE SUSPENSION SUGAR-FREE NO.20 ORAL [5851]

Facility

$55.00

Service Code	NDC 30316000000
Hospital Revenue Code	250
Min. Negotiated Rate	$46.75
Max. Negotiated Rate	$53.35
Rate for Payer: Cash Price	$33.00
Rate for Payer: Health Management Network Commercial	$46.75
Rate for Payer: MDX Hawaii PPO	$53.35

COMPOUNDING VEHICLE SUSPENSION SUGAR-FREE NO.20 ORAL [5851]

Facility

$55.00

Service Code	NDC 30316000000
Hospital Revenue Code	637
Min. Negotiated Rate	$28.05
Max. Negotiated Rate	$53.35
Rate for Payer: Cash Price	$33.00
Rate for Payer: Hawaii Western Management Group Commercial	$52.25
Rate for Payer: Health Management Network Commercial	$46.75
Rate for Payer: Kaiser Permanente Commercial	$34.65
Rate for Payer: Kaiser Permanente Medicaid	$28.05
Rate for Payer: MDX Hawaii PPO	$53.35
Rate for Payer: University Health Alliance Commercial	$40.09

COMPOUNDING VEHICLE SYRUP NO.23 [5852]

Facility

$77.00

Service Code	NDC 30416000000
Hospital Revenue Code	250
Min. Negotiated Rate	$65.45
Max. Negotiated Rate	$74.69
Rate for Payer: Cash Price	$46.20
Rate for Payer: Health Management Network Commercial	$65.45
Rate for Payer: MDX Hawaii PPO	$74.69

COMPOUNDING VEHICLE SYRUP NO.23 [5852]

Facility

$77.00

Service Code	NDC 30416000000
Hospital Revenue Code	637
Min. Negotiated Rate	$39.27
Max. Negotiated Rate	$74.69
Rate for Payer: Cash Price	$46.20
Rate for Payer: Hawaii Western Management Group Commercial	$73.15
Rate for Payer: Health Management Network Commercial	$65.45
Rate for Payer: Kaiser Permanente Commercial	$48.51
Rate for Payer: Kaiser Permanente Medicaid	$39.27
Rate for Payer: MDX Hawaii PPO	$74.69
Rate for Payer: University Health Alliance Commercial	$56.13

COMPR SCD FOOT CUFF LG

Facility

$90.00

Hospital Revenue Code	272
Min. Negotiated Rate	$45.90
Max. Negotiated Rate	$87.30
Rate for Payer: Cash Price	$54.00
Rate for Payer: Hawaii Western Management Group Commercial	$85.50
Rate for Payer: Health Management Network Commercial	$76.50
Rate for Payer: Kaiser Permanente Commercial	$56.70
Rate for Payer: Kaiser Permanente Medicaid	$45.90
Rate for Payer: MDX Hawaii PPO	$87.30
Rate for Payer: University Health Alliance Commercial	$65.60

COMPR SCD FOOT CUFF LG

Facility

$90.00

Hospital Revenue Code	272
Min. Negotiated Rate	$76.50
Max. Negotiated Rate	$87.30
Rate for Payer: Cash Price	$54.00
Rate for Payer: Health Management Network Commercial	$76.50
Rate for Payer: MDX Hawaii PPO	$87.30

COMPR SCD FOOT CUFF REG

Facility

$94.00

Hospital Revenue Code	271
Min. Negotiated Rate	$47.94
Max. Negotiated Rate	$91.18
Rate for Payer: Cash Price	$56.40
Rate for Payer: Hawaii Western Management Group Commercial	$89.30
Rate for Payer: Health Management Network Commercial	$79.90
Rate for Payer: Kaiser Permanente Commercial	$59.22
Rate for Payer: Kaiser Permanente Medicaid	$47.94
Rate for Payer: MDX Hawaii PPO	$91.18
Rate for Payer: University Health Alliance Commercial	$68.52

COMPR SCD FOOT CUFF REG

Facility

$94.00

Hospital Revenue Code	271
Min. Negotiated Rate	$79.90
Max. Negotiated Rate	$91.18
Rate for Payer: Cash Price	$56.40
Rate for Payer: Health Management Network Commercial	$79.90
Rate for Payer: MDX Hawaii PPO	$91.18

COMP RVS TRAY CO 44MM #115370

Facility

$1,845.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$940.95
Max. Negotiated Rate	$1,789.65
Rate for Payer: Cash Price	$1,107.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,291.50
Rate for Payer: Health Management Network Commercial	$1,568.25
Rate for Payer: Kaiser Permanente Commercial	$1,162.35
Rate for Payer: Kaiser Permanente Medicaid	$940.95
Rate for Payer: MDX Hawaii PPO	$1,789.65
Rate for Payer: University Health Alliance Commercial	$1,033.20

COMP RVS TRAY CO 44MM #115370

Facility

$1,845.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$1,033.20
Max. Negotiated Rate	$1,789.65
Rate for Payer: Cash Price	$1,107.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,291.50
Rate for Payer: Health Management Network Commercial	$1,568.25
Rate for Payer: MDX Hawaii PPO	$1,789.65
Rate for Payer: University Health Alliance Commercial	$1,033.20

COMP WIRE MEDIUM 824299104

Facility

$280.00

Service Code	HCPCS C1713
Hospital Revenue Code	272
Min. Negotiated Rate	$238.00
Max. Negotiated Rate	$271.60
Rate for Payer: Cash Price	$168.00
Rate for Payer: Health Management Network Commercial	$238.00
Rate for Payer: MDX Hawaii PPO	$271.60

COMP WIRE MEDIUM 824299104

Facility

$280.00

Service Code	HCPCS C1713
Hospital Revenue Code	272
Min. Negotiated Rate	$142.80
Max. Negotiated Rate	$271.60
Rate for Payer: Cash Price	$168.00
Rate for Payer: Hawaii Western Management Group Commercial	$266.00
Rate for Payer: Health Management Network Commercial	$238.00
Rate for Payer: Kaiser Permanente Commercial	$176.40
Rate for Payer: Kaiser Permanente Medicaid	$142.80
Rate for Payer: MDX Hawaii PPO	$271.60
Rate for Payer: University Health Alliance Commercial	$204.09

CONCOMITANT AORTIC AND MITRAL VALVE PROCEDURES

Facility

$187,578.23

Service Code	MSDRG 212
Min. Negotiated Rate	$123,684.78
Max. Negotiated Rate	$187,578.23
Rate for Payer: AlohaCare Medicare	$123,684.78
Rate for Payer: Devoted Health Medicare	$136,053.26
Rate for Payer: Hawaii Medical Service Association Commercial	$130,575.35
Rate for Payer: Hawaii Medical Service Association Medicare	$123,684.78
Rate for Payer: Humana Medicare	$123,684.78
Rate for Payer: Kaiser Permanente Commercial	$187,578.23
Rate for Payer: Kaiser Permanente Medicare	$123,684.78
Rate for Payer: Ohana Health Plan Medicare	$123,684.78
Rate for Payer: UnitedHealthcare Medicare	$123,684.78

CONCOMITANT LEFT ATRIAL APPENDAGE CLOSURE AND CARDIAC ABLATION

Facility

$115,342.12

Service Code	MSDRG 317
Min. Negotiated Rate	$76,053.96
Max. Negotiated Rate	$115,342.12
Rate for Payer: AlohaCare Medicare	$76,053.96
Rate for Payer: Devoted Health Medicare	$83,659.36
Rate for Payer: Hawaii Medical Service Association Medicare	$76,053.96
Rate for Payer: Humana Medicare	$76,053.96
Rate for Payer: Kaiser Permanente Commercial	$115,342.12
Rate for Payer: Kaiser Permanente Medicare	$76,053.96
Rate for Payer: Ohana Health Plan Medicare	$76,053.96
Rate for Payer: UnitedHealthcare Medicare	$76,053.96

CONCUSSION, CLOSED SKULL FX NOS,UNCOMPLICATED INTRACRANIAL INJURY, COMA < 1 HR OR NO COMA

Facility

$9,641.96

Service Code	APR-DRG 0574
Min. Negotiated Rate	$9,641.96
Max. Negotiated Rate	$9,641.96
Rate for Payer: AlohaCare Medicaid	$9,641.96
Rate for Payer: Hawaii Medical Service Association ABD	$9,641.96
Rate for Payer: Hawaii Medical Service Association Non-ABD	$9,641.96
Rate for Payer: Kaiser Permanente Medicaid	$9,641.96
Rate for Payer: Ohana Health Plan Medicaid	$9,641.96
Rate for Payer: UnitedHealthcare Medicaid	$9,641.96

CONCUSSION, CLOSED SKULL FX NOS,UNCOMPLICATED INTRACRANIAL INJURY, COMA < 1 HR OR NO COMA

Facility

$2,532.79

Service Code	APR-DRG 0571
Min. Negotiated Rate	$2,532.79
Max. Negotiated Rate	$2,532.79
Rate for Payer: Ohana Health Plan Medicaid	$2,532.79
Rate for Payer: AlohaCare Medicaid	$2,532.79
Rate for Payer: Hawaii Medical Service Association ABD	$2,532.79
Rate for Payer: Hawaii Medical Service Association Non-ABD	$2,532.79
Rate for Payer: Kaiser Permanente Medicaid	$2,532.79
Rate for Payer: UnitedHealthcare Medicaid	$2,532.79

CONCUSSION, CLOSED SKULL FX NOS,UNCOMPLICATED INTRACRANIAL INJURY, COMA < 1 HR OR NO COMA

Facility

$5,578.93

Service Code	APR-DRG 0573
Min. Negotiated Rate	$5,578.93
Max. Negotiated Rate	$5,578.93
Rate for Payer: AlohaCare Medicaid	$5,578.93
Rate for Payer: Hawaii Medical Service Association ABD	$5,578.93
Rate for Payer: Hawaii Medical Service Association Non-ABD	$5,578.93
Rate for Payer: Kaiser Permanente Medicaid	$5,578.93
Rate for Payer: Ohana Health Plan Medicaid	$5,578.93
Rate for Payer: UnitedHealthcare Medicaid	$5,578.93

CONCUSSION, CLOSED SKULL FX NOS,UNCOMPLICATED INTRACRANIAL INJURY, COMA < 1 HR OR NO COMA

Facility

$3,904.53

Service Code	APR-DRG 0572
Min. Negotiated Rate	$3,904.53
Max. Negotiated Rate	$3,904.53
Rate for Payer: AlohaCare Medicaid	$3,904.53
Rate for Payer: Hawaii Medical Service Association ABD	$3,904.53
Rate for Payer: Hawaii Medical Service Association Non-ABD	$3,904.53
Rate for Payer: Kaiser Permanente Medicaid	$3,904.53
Rate for Payer: Ohana Health Plan Medicaid	$3,904.53
Rate for Payer: UnitedHealthcare Medicaid	$3,904.53

Know your out-of-pocket cost for care.

All Charges