Hilo Benioff Medical Center

All Charges

Charge

Type

Setting

Price

EXCLUDER ENDO AAA CXA260005

Facility

$10,004.00

Hospital Revenue Code	278
Min. Negotiated Rate	$5,602.24
Max. Negotiated Rate	$9,703.88
Rate for Payer: Cash Price	$6,002.40
Rate for Payer: Hawaii Western Management Group Commercial	$7,002.80
Rate for Payer: Health Management Network Commercial	$8,503.40
Rate for Payer: MDX Hawaii PPO	$9,703.88
Rate for Payer: University Health Alliance Commercial	$5,602.24

EXCLUDER ENDO AAA CXA260005

Facility

$10,004.00

Hospital Revenue Code	278
Min. Negotiated Rate	$5,102.04
Max. Negotiated Rate	$9,703.88
Rate for Payer: Cash Price	$6,002.40
Rate for Payer: Hawaii Western Management Group Commercial	$7,002.80
Rate for Payer: Health Management Network Commercial	$8,503.40
Rate for Payer: Kaiser Permanente Commercial	$6,302.52
Rate for Payer: Kaiser Permanente Medicaid	$5,102.04
Rate for Payer: MDX Hawaii PPO	$9,703.88
Rate for Payer: University Health Alliance Commercial	$5,602.24

EXCLUDER GORE CXT201412

Facility

$29,168.00

Hospital Revenue Code	278
Min. Negotiated Rate	$14,875.68
Max. Negotiated Rate	$28,292.96
Rate for Payer: Cash Price	$17,500.80
Rate for Payer: Hawaii Western Management Group Commercial	$20,417.60
Rate for Payer: Health Management Network Commercial	$24,792.80
Rate for Payer: Kaiser Permanente Commercial	$18,375.84
Rate for Payer: Kaiser Permanente Medicaid	$14,875.68
Rate for Payer: MDX Hawaii PPO	$28,292.96
Rate for Payer: University Health Alliance Commercial	$16,334.08

EXCLUDER GORE CXT201412

Facility

$29,168.00

Hospital Revenue Code	278
Min. Negotiated Rate	$16,334.08
Max. Negotiated Rate	$28,292.96
Rate for Payer: Cash Price	$17,500.80
Rate for Payer: Hawaii Western Management Group Commercial	$20,417.60
Rate for Payer: Health Management Network Commercial	$24,792.80
Rate for Payer: MDX Hawaii PPO	$28,292.96
Rate for Payer: University Health Alliance Commercial	$16,334.08

EXPANDER BREAST ALLOX2-FH15SE

Facility

$3,750.00

Service Code	HCPCS C1789
Hospital Revenue Code	278
Min. Negotiated Rate	$2,100.00
Max. Negotiated Rate	$3,637.50
Rate for Payer: Cash Price	$2,250.00
Rate for Payer: Hawaii Western Management Group Commercial	$2,625.00
Rate for Payer: Health Management Network Commercial	$3,187.50
Rate for Payer: MDX Hawaii PPO	$3,637.50
Rate for Payer: University Health Alliance Commercial	$2,100.00

EXPANDER BREAST ALLOX2-FH15SE

Facility

$3,750.00

Service Code	HCPCS C1789
Hospital Revenue Code	278
Min. Negotiated Rate	$1,912.50
Max. Negotiated Rate	$3,637.50
Rate for Payer: Cash Price	$2,250.00
Rate for Payer: Hawaii Western Management Group Commercial	$2,625.00
Rate for Payer: Health Management Network Commercial	$3,187.50
Rate for Payer: Kaiser Permanente Commercial	$2,362.50
Rate for Payer: Kaiser Permanente Medicaid	$1,912.50
Rate for Payer: MDX Hawaii PPO	$3,637.50
Rate for Payer: University Health Alliance Commercial	$2,100.00

EXPANDER SKIN GRAFT 1.5-1

Facility

$230.00

Service Code	HCPCS C1781
Hospital Revenue Code	278
Min. Negotiated Rate	$117.30
Max. Negotiated Rate	$223.10
Rate for Payer: Cash Price	$138.00
Rate for Payer: Hawaii Western Management Group Commercial	$161.00
Rate for Payer: Health Management Network Commercial	$195.50
Rate for Payer: Kaiser Permanente Commercial	$144.90
Rate for Payer: Kaiser Permanente Medicaid	$117.30
Rate for Payer: MDX Hawaii PPO	$223.10
Rate for Payer: University Health Alliance Commercial	$128.80

EXPANDER SKIN GRAFT 1.5-1

Facility

$230.00

Service Code	HCPCS C1781
Hospital Revenue Code	278
Min. Negotiated Rate	$128.80
Max. Negotiated Rate	$223.10
Rate for Payer: Cash Price	$138.00
Rate for Payer: Hawaii Western Management Group Commercial	$161.00
Rate for Payer: Health Management Network Commercial	$195.50
Rate for Payer: MDX Hawaii PPO	$223.10
Rate for Payer: University Health Alliance Commercial	$128.80

EXPANDER TISSUE ALLOX2-FH13SE

Facility

$3,750.00

Service Code	HCPCS C1789
Hospital Revenue Code	278
Min. Negotiated Rate	$1,912.50
Max. Negotiated Rate	$3,637.50
Rate for Payer: Cash Price	$2,250.00
Rate for Payer: Hawaii Western Management Group Commercial	$2,625.00
Rate for Payer: Health Management Network Commercial	$3,187.50
Rate for Payer: Kaiser Permanente Commercial	$2,362.50
Rate for Payer: Kaiser Permanente Medicaid	$1,912.50
Rate for Payer: MDX Hawaii PPO	$3,637.50
Rate for Payer: University Health Alliance Commercial	$2,100.00

EXPANDER TISSUE ALLOX2-FH13SE

Facility

$3,750.00

Service Code	HCPCS C1789
Hospital Revenue Code	278
Min. Negotiated Rate	$2,100.00
Max. Negotiated Rate	$3,637.50
Rate for Payer: Cash Price	$2,250.00
Rate for Payer: Hawaii Western Management Group Commercial	$2,625.00
Rate for Payer: Health Management Network Commercial	$3,187.50
Rate for Payer: MDX Hawaii PPO	$3,637.50
Rate for Payer: University Health Alliance Commercial	$2,100.00

EXPLORATION OF PENETRATING WOUND (SEPARATE PROCEDURE); EXTREMITY

Facility

$5,509.00

Service Code	CPT 20103
Hospital Revenue Code	360
Min. Negotiated Rate	$340.18
Max. Negotiated Rate	$5,509.00
Rate for Payer: AlohaCare Medicaid	$1,951.11
Rate for Payer: AlohaCare Medicare	$1,951.11
Rate for Payer: Devoted Health Medicare	$2,146.22
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	$1,951.11
Rate for Payer: Hawaii Medical Service Association Non-ABD	$1,028.67
Rate for Payer: Humana Medicare	$1,951.11
Rate for Payer: Kaiser Permanente Medicaid	$2,837.00
Rate for Payer: Kaiser Permanente Medicare	$1,951.11
Rate for Payer: Ohana Health Plan Medicaid	$2,146.22
Rate for Payer: Ohana Health Plan Medicare	$1,951.11
Rate for Payer: UnitedHealthcare Medicaid	$340.18
Rate for Payer: UnitedHealthcare Medicare	$1,951.11

EXSUP STRT TIP GUIDEWIRE 9X330

Facility

$1,120.00

Service Code	HCPCS C1769
Hospital Revenue Code	272
Min. Negotiated Rate	$952.00
Max. Negotiated Rate	$1,086.40
Rate for Payer: Cash Price	$672.00
Rate for Payer: Health Management Network Commercial	$952.00
Rate for Payer: MDX Hawaii PPO	$1,086.40

EXSUP STRT TIP GUIDEWIRE 9X330

Facility

$1,120.00

Service Code	HCPCS C1769
Hospital Revenue Code	272
Min. Negotiated Rate	$571.20
Max. Negotiated Rate	$1,086.40
Rate for Payer: Cash Price	$672.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,064.00
Rate for Payer: Health Management Network Commercial	$952.00
Rate for Payer: Kaiser Permanente Commercial	$705.60
Rate for Payer: Kaiser Permanente Medicaid	$571.20
Rate for Payer: MDX Hawaii PPO	$1,086.40
Rate for Payer: University Health Alliance Commercial	$816.37

EXTENDER TL 100MM 51-10220

Facility

$743.00

Hospital Revenue Code	272
Min. Negotiated Rate	$631.55
Max. Negotiated Rate	$720.71
Rate for Payer: Cash Price	$445.80
Rate for Payer: Health Management Network Commercial	$631.55
Rate for Payer: MDX Hawaii PPO	$720.71

EXTENDER TL 100MM 51-10220

Facility

$743.00

Hospital Revenue Code	272
Min. Negotiated Rate	$378.93
Max. Negotiated Rate	$720.71
Rate for Payer: Cash Price	$445.80
Rate for Payer: Hawaii Western Management Group Commercial	$705.85
Rate for Payer: Health Management Network Commercial	$631.55
Rate for Payer: Kaiser Permanente Commercial	$468.09
Rate for Payer: Kaiser Permanente Medicaid	$378.93
Rate for Payer: MDX Hawaii PPO	$720.71
Rate for Payer: University Health Alliance Commercial	$541.57

EXTENSION PERCUTANEOUS 3560022

Facility

$929.00

Service Code	HCPCS C1883
Hospital Revenue Code	278
Min. Negotiated Rate	$473.79
Max. Negotiated Rate	$901.13
Rate for Payer: Cash Price	$557.40
Rate for Payer: Hawaii Western Management Group Commercial	$650.30
Rate for Payer: Health Management Network Commercial	$789.65
Rate for Payer: Kaiser Permanente Commercial	$585.27
Rate for Payer: Kaiser Permanente Medicaid	$473.79
Rate for Payer: MDX Hawaii PPO	$901.13
Rate for Payer: University Health Alliance Commercial	$520.24

EXTENSION PERCUTANEOUS 3560022

Facility

$929.00

Service Code	HCPCS C1883
Hospital Revenue Code	278
Min. Negotiated Rate	$520.24
Max. Negotiated Rate	$901.13
Rate for Payer: Cash Price	$557.40
Rate for Payer: Hawaii Western Management Group Commercial	$650.30
Rate for Payer: Health Management Network Commercial	$789.65
Rate for Payer: MDX Hawaii PPO	$901.13
Rate for Payer: University Health Alliance Commercial	$520.24

EXTENSIVE 3RD DEGREE BURNS W/O SKIN GRAFT

Facility

$10,805.62

Service Code	APR-DRG 8434
Min. Negotiated Rate	$10,805.62
Max. Negotiated Rate	$10,805.62
Rate for Payer: AlohaCare Medicaid	$10,805.62
Rate for Payer: Hawaii Medical Service Association ABD	$10,805.62
Rate for Payer: Hawaii Medical Service Association Non-ABD	$10,805.62
Rate for Payer: Kaiser Permanente Medicaid	$10,805.62
Rate for Payer: Ohana Health Plan Medicaid	$10,805.62
Rate for Payer: UnitedHealthcare Medicaid	$10,805.62

EXTENSIVE 3RD DEGREE BURNS W/O SKIN GRAFT

Facility

$2,848.49

Service Code	APR-DRG 8431
Min. Negotiated Rate	$2,848.49
Max. Negotiated Rate	$2,848.49
Rate for Payer: AlohaCare Medicaid	$2,848.49
Rate for Payer: Hawaii Medical Service Association ABD	$2,848.49
Rate for Payer: Hawaii Medical Service Association Non-ABD	$2,848.49
Rate for Payer: Kaiser Permanente Medicaid	$2,848.49
Rate for Payer: Ohana Health Plan Medicaid	$2,848.49
Rate for Payer: UnitedHealthcare Medicaid	$2,848.49

EXTENSIVE 3RD DEGREE BURNS W/O SKIN GRAFT

Facility

$4,963.18

Service Code	APR-DRG 8433
Min. Negotiated Rate	$4,963.18
Max. Negotiated Rate	$4,963.18
Rate for Payer: AlohaCare Medicaid	$4,963.18
Rate for Payer: Hawaii Medical Service Association ABD	$4,963.18
Rate for Payer: Hawaii Medical Service Association Non-ABD	$4,963.18
Rate for Payer: Kaiser Permanente Medicaid	$4,963.18
Rate for Payer: Ohana Health Plan Medicaid	$4,963.18
Rate for Payer: UnitedHealthcare Medicaid	$4,963.18

EXTENSIVE 3RD DEGREE BURNS W/O SKIN GRAFT

Facility

$3,526.86

Service Code	APR-DRG 8432
Min. Negotiated Rate	$3,526.86
Max. Negotiated Rate	$3,526.86
Rate for Payer: AlohaCare Medicaid	$3,526.86
Rate for Payer: Hawaii Medical Service Association ABD	$3,526.86
Rate for Payer: Hawaii Medical Service Association Non-ABD	$3,526.86
Rate for Payer: Kaiser Permanente Medicaid	$3,526.86
Rate for Payer: Ohana Health Plan Medicaid	$3,526.86
Rate for Payer: UnitedHealthcare Medicaid	$3,526.86

EXTENSIVE 3RD DEGREE BURNS W SKIN GRAFT

Facility

$19,503.08

Service Code	APR-DRG 8412
Min. Negotiated Rate	$19,503.08
Max. Negotiated Rate	$19,503.08
Rate for Payer: AlohaCare Medicaid	$19,503.08
Rate for Payer: Hawaii Medical Service Association ABD	$19,503.08
Rate for Payer: Hawaii Medical Service Association Non-ABD	$19,503.08
Rate for Payer: Kaiser Permanente Medicaid	$19,503.08
Rate for Payer: Ohana Health Plan Medicaid	$19,503.08
Rate for Payer: UnitedHealthcare Medicaid	$19,503.08

EXTENSIVE 3RD DEGREE BURNS W SKIN GRAFT

Facility

$17,134.01

Service Code	APR-DRG 8411
Min. Negotiated Rate	$17,134.01
Max. Negotiated Rate	$17,134.01
Rate for Payer: AlohaCare Medicaid	$17,134.01
Rate for Payer: Hawaii Medical Service Association ABD	$17,134.01
Rate for Payer: Hawaii Medical Service Association Non-ABD	$17,134.01
Rate for Payer: Kaiser Permanente Medicaid	$17,134.01
Rate for Payer: Ohana Health Plan Medicaid	$17,134.01
Rate for Payer: UnitedHealthcare Medicaid	$17,134.01

EXTENSIVE 3RD DEGREE BURNS W SKIN GRAFT

Facility

$39,923.92

Service Code	APR-DRG 8413
Min. Negotiated Rate	$39,923.92
Max. Negotiated Rate	$39,923.92
Rate for Payer: AlohaCare Medicaid	$39,923.92
Rate for Payer: Hawaii Medical Service Association ABD	$39,923.92
Rate for Payer: Hawaii Medical Service Association Non-ABD	$39,923.92
Rate for Payer: Kaiser Permanente Medicaid	$39,923.92
Rate for Payer: Ohana Health Plan Medicaid	$39,923.92
Rate for Payer: UnitedHealthcare Medicaid	$39,923.92

EXTENSIVE 3RD DEGREE BURNS W SKIN GRAFT

Facility

$82,430.20

Service Code	APR-DRG 8414
Min. Negotiated Rate	$82,430.20
Max. Negotiated Rate	$82,430.20
Rate for Payer: AlohaCare Medicaid	$82,430.20
Rate for Payer: Hawaii Medical Service Association ABD	$82,430.20
Rate for Payer: Hawaii Medical Service Association Non-ABD	$82,430.20
Rate for Payer: Kaiser Permanente Medicaid	$82,430.20
Rate for Payer: Ohana Health Plan Medicaid	$82,430.20
Rate for Payer: UnitedHealthcare Medicaid	$82,430.20

Know your out-of-pocket cost for care.

All Charges