Hilo Benioff Medical Center

All Charges

Charge

Type

Setting

Price

GASTRIC FUNDOPLICATION

Facility

$10,330.11

Service Code	APR-DRG 2323
Min. Negotiated Rate	$10,330.11
Max. Negotiated Rate	$10,330.11
Rate for Payer: AlohaCare Medicaid	$10,330.11
Rate for Payer: Hawaii Medical Service Association ABD	$10,330.11
Rate for Payer: Hawaii Medical Service Association Non-ABD	$10,330.11
Rate for Payer: Kaiser Permanente Medicaid	$10,330.11
Rate for Payer: Ohana Health Plan Medicaid	$10,330.11
Rate for Payer: UnitedHealthcare Medicaid	$10,330.11

GASTRIC FUNDOPLICATION

Facility

$7,747.75

Service Code	APR-DRG 2322
Min. Negotiated Rate	$7,747.75
Max. Negotiated Rate	$7,747.75
Rate for Payer: AlohaCare Medicaid	$7,747.75
Rate for Payer: Hawaii Medical Service Association ABD	$7,747.75
Rate for Payer: Hawaii Medical Service Association Non-ABD	$7,747.75
Rate for Payer: Kaiser Permanente Medicaid	$7,747.75
Rate for Payer: Ohana Health Plan Medicaid	$7,747.75
Rate for Payer: UnitedHealthcare Medicaid	$7,747.75

GASTROINTESTINAL HEMORRHAGE WITH CC

Facility

$21,863.67

Service Code	MSDRG 378
Min. Negotiated Rate	$11,154.74
Max. Negotiated Rate	$21,863.67
Rate for Payer: AlohaCare Medicare	$11,154.74
Rate for Payer: Devoted Health Medicare	$12,270.21
Rate for Payer: Hawaii Medical Service Association Commercial	$21,863.67
Rate for Payer: Hawaii Medical Service Association Medicare	$11,154.74
Rate for Payer: Humana Medicare	$11,154.74
Rate for Payer: Kaiser Permanente Commercial	$16,917.08
Rate for Payer: Kaiser Permanente Medicare	$11,154.74
Rate for Payer: Ohana Health Plan Medicare	$11,154.74
Rate for Payer: UnitedHealthcare Medicare	$11,154.74

GASTROINTESTINAL HEMORRHAGE WITH MCC

Facility

$31,533.00

Service Code	MSDRG 377
Min. Negotiated Rate	$20,792.15
Max. Negotiated Rate	$31,533.00
Rate for Payer: AlohaCare Medicare	$20,792.15
Rate for Payer: Devoted Health Medicare	$22,871.37
Rate for Payer: Hawaii Medical Service Association Commercial	$21,863.67
Rate for Payer: Hawaii Medical Service Association Medicare	$20,792.15
Rate for Payer: Humana Medicare	$20,792.15
Rate for Payer: Kaiser Permanente Commercial	$31,533.00
Rate for Payer: Kaiser Permanente Medicare	$20,792.15
Rate for Payer: Ohana Health Plan Medicare	$20,792.15
Rate for Payer: UnitedHealthcare Medicare	$20,792.15

GASTROINTESTINAL HEMORRHAGE WITHOUT CC/MCC

Facility

$16,767.81

Service Code	MSDRG 379
Min. Negotiated Rate	$7,170.33
Max. Negotiated Rate	$16,767.81
Rate for Payer: AlohaCare Medicare	$7,170.33
Rate for Payer: Devoted Health Medicare	$7,887.36
Rate for Payer: Hawaii Medical Service Association Commercial	$16,767.81
Rate for Payer: Hawaii Medical Service Association Medicare	$7,170.33
Rate for Payer: Humana Medicare	$7,170.33
Rate for Payer: Kaiser Permanente Commercial	$10,874.40
Rate for Payer: Kaiser Permanente Medicare	$7,170.33
Rate for Payer: Ohana Health Plan Medicare	$7,170.33
Rate for Payer: UnitedHealthcare Medicare	$7,170.33

GASTROINTESTINAL OBSTRUCTION WITH CC

Facility

$17,059.00

Service Code	MSDRG 389
Min. Negotiated Rate	$8,983.37
Max. Negotiated Rate	$17,059.00
Rate for Payer: AlohaCare Medicare	$8,983.37
Rate for Payer: Devoted Health Medicare	$9,881.71
Rate for Payer: Hawaii Medical Service Association Commercial	$17,059.00
Rate for Payer: Hawaii Medical Service Association Medicare	$8,983.37
Rate for Payer: Humana Medicare	$8,983.37
Rate for Payer: Kaiser Permanente Commercial	$13,624.05
Rate for Payer: Kaiser Permanente Medicare	$8,983.37
Rate for Payer: Ohana Health Plan Medicare	$8,983.37
Rate for Payer: UnitedHealthcare Medicare	$8,983.37

GASTROINTESTINAL OBSTRUCTION WITH MCC

Facility

$25,474.80

Service Code	MSDRG 388
Min. Negotiated Rate	$16,797.51
Max. Negotiated Rate	$25,474.80
Rate for Payer: UnitedHealthcare Medicare	$16,797.51
Rate for Payer: AlohaCare Medicare	$16,797.51
Rate for Payer: Devoted Health Medicare	$18,477.26
Rate for Payer: Hawaii Medical Service Association Commercial	$19,218.67
Rate for Payer: Hawaii Medical Service Association Medicare	$16,797.51
Rate for Payer: Humana Medicare	$16,797.51
Rate for Payer: Kaiser Permanente Commercial	$25,474.80
Rate for Payer: Kaiser Permanente Medicare	$16,797.51
Rate for Payer: Ohana Health Plan Medicare	$16,797.51

GASTROINTESTINAL OBSTRUCTION WITHOUT CC/MCC

Facility

$13,588.96

Service Code	MSDRG 390
Min. Negotiated Rate	$6,187.59
Max. Negotiated Rate	$13,588.96
Rate for Payer: AlohaCare Medicare	$6,187.59
Rate for Payer: Devoted Health Medicare	$6,806.35
Rate for Payer: Hawaii Medical Service Association Commercial	$13,588.96
Rate for Payer: Hawaii Medical Service Association Medicare	$6,187.59
Rate for Payer: Humana Medicare	$6,187.59
Rate for Payer: Kaiser Permanente Commercial	$9,384.00
Rate for Payer: Kaiser Permanente Medicare	$6,187.59
Rate for Payer: Ohana Health Plan Medicare	$6,187.59
Rate for Payer: UnitedHealthcare Medicare	$6,187.59

GASTROINTESTINAL VASCULAR INSUFFICIENCY

Facility

$3,981.50

Service Code	APR-DRG 2462
Min. Negotiated Rate	$3,981.50
Max. Negotiated Rate	$3,981.50
Rate for Payer: AlohaCare Medicaid	$3,981.50
Rate for Payer: Hawaii Medical Service Association ABD	$3,981.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$3,981.50
Rate for Payer: Kaiser Permanente Medicaid	$3,981.50
Rate for Payer: Ohana Health Plan Medicaid	$3,981.50
Rate for Payer: UnitedHealthcare Medicaid	$3,981.50

GASTROINTESTINAL VASCULAR INSUFFICIENCY

Facility

$5,728.30

Service Code	APR-DRG 2463
Min. Negotiated Rate	$5,728.30
Max. Negotiated Rate	$5,728.30
Rate for Payer: AlohaCare Medicaid	$5,728.30
Rate for Payer: Hawaii Medical Service Association ABD	$5,728.30
Rate for Payer: Hawaii Medical Service Association Non-ABD	$5,728.30
Rate for Payer: Kaiser Permanente Medicaid	$5,728.30
Rate for Payer: Ohana Health Plan Medicaid	$5,728.30
Rate for Payer: UnitedHealthcare Medicaid	$5,728.30

GASTROINTESTINAL VASCULAR INSUFFICIENCY

Facility

$3,262.04

Service Code	APR-DRG 2461
Min. Negotiated Rate	$3,262.04
Max. Negotiated Rate	$3,262.04
Rate for Payer: AlohaCare Medicaid	$3,262.04
Rate for Payer: Hawaii Medical Service Association ABD	$3,262.04
Rate for Payer: Hawaii Medical Service Association Non-ABD	$3,262.04
Rate for Payer: Kaiser Permanente Medicaid	$3,262.04
Rate for Payer: Ohana Health Plan Medicaid	$3,262.04
Rate for Payer: UnitedHealthcare Medicaid	$3,262.04

GASTROINTESTINAL VASCULAR INSUFFICIENCY

Facility

$9,053.60

Service Code	APR-DRG 2464
Min. Negotiated Rate	$9,053.60
Max. Negotiated Rate	$9,053.60
Rate for Payer: AlohaCare Medicaid	$9,053.60
Rate for Payer: Hawaii Medical Service Association ABD	$9,053.60
Rate for Payer: Hawaii Medical Service Association Non-ABD	$9,053.60
Rate for Payer: Kaiser Permanente Medicaid	$9,053.60
Rate for Payer: Ohana Health Plan Medicaid	$9,053.60
Rate for Payer: UnitedHealthcare Medicaid	$9,053.60

GAUGE MOLDED OTOLOGIC SIZER

Facility

$86.00

Hospital Revenue Code	272
Min. Negotiated Rate	$73.10
Max. Negotiated Rate	$83.42
Rate for Payer: Cash Price	$51.60
Rate for Payer: Health Management Network Commercial	$73.10
Rate for Payer: MDX Hawaii PPO	$83.42

GAUGE MOLDED OTOLOGIC SIZER

Facility

$86.00

Hospital Revenue Code	272
Min. Negotiated Rate	$43.86
Max. Negotiated Rate	$83.42
Rate for Payer: Cash Price	$51.60
Rate for Payer: Hawaii Western Management Group Commercial	$81.70
Rate for Payer: Health Management Network Commercial	$73.10
Rate for Payer: Kaiser Permanente Commercial	$54.18
Rate for Payer: Kaiser Permanente Medicaid	$43.86
Rate for Payer: MDX Hawaii PPO	$83.42
Rate for Payer: University Health Alliance Commercial	$62.69

GDNG CATH W/ SD HLS 7FR XB3.5

Facility

$240.00

Service Code	HCPCS C1725
Hospital Revenue Code	272
Min. Negotiated Rate	$204.00
Max. Negotiated Rate	$232.80
Rate for Payer: Cash Price	$144.00
Rate for Payer: Health Management Network Commercial	$204.00
Rate for Payer: MDX Hawaii PPO	$232.80

GDNG CATH W/ SD HLS 7FR XB3.5

Facility

$240.00

Service Code	HCPCS C1725
Hospital Revenue Code	272
Min. Negotiated Rate	$122.40
Max. Negotiated Rate	$232.80
Rate for Payer: Cash Price	$144.00
Rate for Payer: Hawaii Western Management Group Commercial	$228.00
Rate for Payer: Health Management Network Commercial	$204.00
Rate for Payer: Kaiser Permanente Commercial	$151.20
Rate for Payer: Kaiser Permanente Medicaid	$122.40
Rate for Payer: MDX Hawaii PPO	$232.80
Rate for Payer: University Health Alliance Commercial	$174.94

GELATIN SPONGE,ABSORBABLE-PORCINE SKIN 100 CM TOPICAL SPONGE [28022]

Facility

$111.00

Service Code	NDC 00009035301
Hospital Revenue Code	250
Min. Negotiated Rate	$94.35
Max. Negotiated Rate	$107.67
Rate for Payer: Cash Price	$66.60
Rate for Payer: Health Management Network Commercial	$94.35
Rate for Payer: MDX Hawaii PPO	$107.67

GELATIN SPONGE,ABSORBABLE-PORCINE SKIN 100 TOPICAL SPONGE [28025]

Facility

$111.00

Service Code	NDC 00009034201
Hospital Revenue Code	250
Min. Negotiated Rate	$94.35
Max. Negotiated Rate	$107.67
Rate for Payer: Cash Price	$66.60
Rate for Payer: Health Management Network Commercial	$94.35
Rate for Payer: MDX Hawaii PPO	$107.67

GELATIN SPONGE,ABSORBABLE-PORCINE SKIN 12 MM-7 MM TOPICAL SPONGE [28018]

Facility

$29.00

Service Code	NDC 00009031508
Hospital Revenue Code	250
Min. Negotiated Rate	$24.65
Max. Negotiated Rate	$28.13
Rate for Payer: Cash Price	$17.40
Rate for Payer: Health Management Network Commercial	$24.65
Rate for Payer: MDX Hawaii PPO	$28.13

GELPOINT MINI CNGL3

Facility

$2,250.00

Hospital Revenue Code	272
Min. Negotiated Rate	$1,912.50
Max. Negotiated Rate	$2,182.50
Rate for Payer: Cash Price	$1,350.00
Rate for Payer: Health Management Network Commercial	$1,912.50
Rate for Payer: MDX Hawaii PPO	$2,182.50

GELPOINT MINI CNGL3

Facility

$2,250.00

Hospital Revenue Code	272
Min. Negotiated Rate	$1,147.50
Max. Negotiated Rate	$2,182.50
Rate for Payer: Cash Price	$1,350.00
Rate for Payer: Hawaii Western Management Group Commercial	$2,137.50
Rate for Payer: Health Management Network Commercial	$1,912.50
Rate for Payer: Kaiser Permanente Commercial	$1,417.50
Rate for Payer: Kaiser Permanente Medicaid	$1,147.50
Rate for Payer: MDX Hawaii PPO	$2,182.50
Rate for Payer: University Health Alliance Commercial	$1,640.03

GELPOINT TRANSANAL ACC CNO11

Facility

$2,625.00

Hospital Revenue Code	272
Min. Negotiated Rate	$1,338.75
Max. Negotiated Rate	$2,546.25
Rate for Payer: Cash Price	$1,575.00
Rate for Payer: Hawaii Western Management Group Commercial	$2,493.75
Rate for Payer: Health Management Network Commercial	$2,231.25
Rate for Payer: Kaiser Permanente Commercial	$1,653.75
Rate for Payer: Kaiser Permanente Medicaid	$1,338.75
Rate for Payer: MDX Hawaii PPO	$2,546.25
Rate for Payer: University Health Alliance Commercial	$1,913.36

GELPOINT TRANSANAL ACC CNO11

Facility

$2,625.00

Hospital Revenue Code	272
Min. Negotiated Rate	$2,231.25
Max. Negotiated Rate	$2,546.25
Rate for Payer: Cash Price	$1,575.00
Rate for Payer: Health Management Network Commercial	$2,231.25
Rate for Payer: MDX Hawaii PPO	$2,546.25

GELPORT LAPAROSCOPIC SYS C8XX2

Facility

$2,100.00

Hospital Revenue Code	272
Min. Negotiated Rate	$1,785.00
Max. Negotiated Rate	$2,037.00
Rate for Payer: Cash Price	$1,260.00
Rate for Payer: Health Management Network Commercial	$1,785.00
Rate for Payer: MDX Hawaii PPO	$2,037.00

GELPORT LAPAROSCOPIC SYS C8XX2

Facility

$2,100.00

Hospital Revenue Code	272
Min. Negotiated Rate	$1,071.00
Max. Negotiated Rate	$2,037.00
Rate for Payer: Cash Price	$1,260.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,995.00
Rate for Payer: Health Management Network Commercial	$1,785.00
Rate for Payer: Kaiser Permanente Commercial	$1,323.00
Rate for Payer: Kaiser Permanente Medicaid	$1,071.00
Rate for Payer: MDX Hawaii PPO	$2,037.00
Rate for Payer: University Health Alliance Commercial	$1,530.69

Know your out-of-pocket cost for care.

All Charges