Hilo Benioff Medical Center

All Charges

Charge

Type

Setting

Price

AMPICILLIN-SULBACTAM IVPB 3 G IN 100 ML NS ADD-A-VIAL (SIMPLE) [4080112]

Facility

$42.00

Service Code	HCPCS J0295
Hospital Revenue Code	250
Min. Negotiated Rate	$35.70
Max. Negotiated Rate	$40.74
Rate for Payer: Cash Price	$25.20
Rate for Payer: Health Management Network Commercial	$35.70
Rate for Payer: MDX Hawaii PPO	$40.74

AMPICILLIN-SULBACTAM IVPB 3 G IN 100 ML NS ADD-A-VIAL (SIMPLE) [4080112]

Facility

$42.00

Service Code	HCPCS J0295
Hospital Revenue Code	636
Min. Negotiated Rate	$1.49
Max. Negotiated Rate	$40.74
Rate for Payer: Cash Price	$25.20
Rate for Payer: Cash Price	$25.20
Rate for Payer: Hawaii Medical Service Association ABD	$1.49
Rate for Payer: Hawaii Medical Service Association Non-ABD	$1.49
Rate for Payer: Hawaii Western Management Group Commercial	$39.90
Rate for Payer: Health Management Network Commercial	$35.70
Rate for Payer: Kaiser Permanente Commercial	$26.46
Rate for Payer: Kaiser Permanente Medicaid	$21.42
Rate for Payer: MDX Hawaii PPO	$40.74
Rate for Payer: UnitedHealthcare Medicaid	$25.20
Rate for Payer: University Health Alliance Commercial	$30.61

AMPLATZ SHORT TAPER EX 035X260

Facility

$234.00

Service Code	HCPCS C1769
Hospital Revenue Code	272
Min. Negotiated Rate	$119.34
Max. Negotiated Rate	$226.98
Rate for Payer: Cash Price	$140.40
Rate for Payer: Hawaii Western Management Group Commercial	$222.30
Rate for Payer: Health Management Network Commercial	$198.90
Rate for Payer: Kaiser Permanente Commercial	$147.42
Rate for Payer: Kaiser Permanente Medicaid	$119.34
Rate for Payer: MDX Hawaii PPO	$226.98
Rate for Payer: University Health Alliance Commercial	$170.56

AMPLATZ SHORT TAPER EX 035X260

Facility

$234.00

Service Code	HCPCS C1769
Hospital Revenue Code	272
Min. Negotiated Rate	$198.90
Max. Negotiated Rate	$226.98
Rate for Payer: Cash Price	$140.40
Rate for Payer: Health Management Network Commercial	$198.90
Rate for Payer: MDX Hawaii PPO	$226.98

AMPLATZ SUPER STIFF 035X260

Facility

$144.00

Service Code	HCPCS C1769
Hospital Revenue Code	272
Min. Negotiated Rate	$122.40
Max. Negotiated Rate	$139.68
Rate for Payer: Cash Price	$86.40
Rate for Payer: Health Management Network Commercial	$122.40
Rate for Payer: MDX Hawaii PPO	$139.68

AMPLATZ SUPER STIFF 035X260

Facility

$144.00

Service Code	HCPCS C1769
Hospital Revenue Code	272
Min. Negotiated Rate	$73.44
Max. Negotiated Rate	$139.68
Rate for Payer: Cash Price	$86.40
Rate for Payer: Hawaii Western Management Group Commercial	$136.80
Rate for Payer: Health Management Network Commercial	$122.40
Rate for Payer: Kaiser Permanente Commercial	$90.72
Rate for Payer: Kaiser Permanente Medicaid	$73.44
Rate for Payer: MDX Hawaii PPO	$139.68
Rate for Payer: University Health Alliance Commercial	$104.96

AMPLATZ URETERAL 8.5FRX20

Facility

$441.00

Service Code	HCPCS C2625
Hospital Revenue Code	272
Min. Negotiated Rate	$374.85
Max. Negotiated Rate	$427.77
Rate for Payer: Cash Price	$264.60
Rate for Payer: Health Management Network Commercial	$374.85
Rate for Payer: MDX Hawaii PPO	$427.77

AMPLATZ URETERAL 8.5FRX20

Facility

$441.00

Service Code	HCPCS C2625
Hospital Revenue Code	272
Min. Negotiated Rate	$224.91
Max. Negotiated Rate	$427.77
Rate for Payer: Cash Price	$264.60
Rate for Payer: Hawaii Western Management Group Commercial	$418.95
Rate for Payer: Health Management Network Commercial	$374.85
Rate for Payer: Kaiser Permanente Commercial	$277.83
Rate for Payer: Kaiser Permanente Medicaid	$224.91
Rate for Payer: MDX Hawaii PPO	$427.77
Rate for Payer: University Health Alliance Commercial	$321.44

AMPLATZ URETERAL 8.5FRX22

Facility

$441.00

Service Code	HCPCS C2625
Hospital Revenue Code	272
Min. Negotiated Rate	$374.85
Max. Negotiated Rate	$427.77
Rate for Payer: Cash Price	$264.60
Rate for Payer: Health Management Network Commercial	$374.85
Rate for Payer: MDX Hawaii PPO	$427.77

AMPLATZ URETERAL 8.5FRX22

Facility

$441.00

Service Code	HCPCS C2625
Hospital Revenue Code	272
Min. Negotiated Rate	$224.91
Max. Negotiated Rate	$427.77
Rate for Payer: Cash Price	$264.60
Rate for Payer: Hawaii Western Management Group Commercial	$418.95
Rate for Payer: Health Management Network Commercial	$374.85
Rate for Payer: Kaiser Permanente Commercial	$277.83
Rate for Payer: Kaiser Permanente Medicaid	$224.91
Rate for Payer: MDX Hawaii PPO	$427.77
Rate for Payer: University Health Alliance Commercial	$321.44

AMPLATZ URETERAL 8.5FRX24

Facility

$441.00

Service Code	HCPCS C2625
Hospital Revenue Code	272
Min. Negotiated Rate	$224.91
Max. Negotiated Rate	$427.77
Rate for Payer: Cash Price	$264.60
Rate for Payer: Hawaii Western Management Group Commercial	$418.95
Rate for Payer: Health Management Network Commercial	$374.85
Rate for Payer: Kaiser Permanente Commercial	$277.83
Rate for Payer: Kaiser Permanente Medicaid	$224.91
Rate for Payer: MDX Hawaii PPO	$427.77
Rate for Payer: University Health Alliance Commercial	$321.44

AMPLATZ URETERAL 8.5FRX24

Facility

$441.00

Service Code	HCPCS C2625
Hospital Revenue Code	272
Min. Negotiated Rate	$374.85
Max. Negotiated Rate	$427.77
Rate for Payer: Cash Price	$264.60
Rate for Payer: Health Management Network Commercial	$374.85
Rate for Payer: MDX Hawaii PPO	$427.77

AMPUTATION, FINGER OR THUMB, PRIMARY OR SECONDARY, ANY JOINT OR PHALANX, SINGLE, INCLUDING NEURECTOMIES; WITH DIRECT CLOSURE

Facility

$5,509.00

Service Code	CPT 26951
Hospital Revenue Code	360
Min. Negotiated Rate	$456.03
Max. Negotiated Rate	$5,509.00
Rate for Payer: AlohaCare Medicaid	$3,865.36
Rate for Payer: AlohaCare Medicare	$3,865.36
Rate for Payer: Devoted Health Medicare	$4,251.90
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	$3,865.36
Rate for Payer: Hawaii Medical Service Association Non-ABD	$1,028.67
Rate for Payer: Humana Medicare	$3,865.36
Rate for Payer: Kaiser Permanente Medicaid	$2,837.00
Rate for Payer: Kaiser Permanente Medicare	$3,865.36
Rate for Payer: Ohana Health Plan Medicaid	$4,251.90
Rate for Payer: Ohana Health Plan Medicare	$3,865.36
Rate for Payer: UnitedHealthcare Medicaid	$456.03
Rate for Payer: UnitedHealthcare Medicare	$3,865.36
Rate for Payer: University Health Alliance Commercial	$5,160.40

AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS EXCEPT UPPER LIMB AND TOE WITH CC

Facility

$82,722.79

Service Code	MSDRG 240
Min. Negotiated Rate	$32,422.31
Max. Negotiated Rate	$82,722.79
Rate for Payer: AlohaCare Medicare	$32,422.31
Rate for Payer: Devoted Health Medicare	$35,664.54
Rate for Payer: Hawaii Medical Service Association Commercial	$82,722.79
Rate for Payer: Hawaii Medical Service Association Medicare	$32,422.31
Rate for Payer: Humana Medicare	$32,422.31
Rate for Payer: Kaiser Permanente Commercial	$49,171.12
Rate for Payer: Kaiser Permanente Medicare	$32,422.31
Rate for Payer: Ohana Health Plan Medicare	$32,422.31
Rate for Payer: UnitedHealthcare Medicare	$32,422.31

AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS EXCEPT UPPER LIMB AND TOE WITH MCC

Facility

$84,899.32

Service Code	MSDRG 239
Min. Negotiated Rate	$55,980.68
Max. Negotiated Rate	$84,899.32
Rate for Payer: AlohaCare Medicare	$55,980.68
Rate for Payer: Devoted Health Medicare	$61,578.75
Rate for Payer: Hawaii Medical Service Association Commercial	$82,722.79
Rate for Payer: Hawaii Medical Service Association Medicare	$55,980.68
Rate for Payer: Humana Medicare	$55,980.68
Rate for Payer: Kaiser Permanente Commercial	$84,899.32
Rate for Payer: Kaiser Permanente Medicare	$55,980.68
Rate for Payer: Ohana Health Plan Medicare	$55,980.68
Rate for Payer: UnitedHealthcare Medicare	$55,980.68

AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS EXCEPT UPPER LIMB AND TOE WITHOUT CC/MCC

Facility

$82,722.79

Service Code	MSDRG 241
Min. Negotiated Rate	$15,746.52
Max. Negotiated Rate	$82,722.79
Rate for Payer: AlohaCare Medicare	$15,746.52
Rate for Payer: Devoted Health Medicare	$17,321.17
Rate for Payer: Hawaii Medical Service Association Commercial	$82,722.79
Rate for Payer: Hawaii Medical Service Association Medicare	$15,746.52
Rate for Payer: Humana Medicare	$15,746.52
Rate for Payer: Kaiser Permanente Commercial	$23,880.90
Rate for Payer: Kaiser Permanente Medicare	$15,746.52
Rate for Payer: Ohana Health Plan Medicare	$15,746.52
Rate for Payer: UnitedHealthcare Medicare	$15,746.52

AMPUTATION FOR MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DISORDERS WITH CC

Facility

$41,664.72

Service Code	MSDRG 475
Min. Negotiated Rate	$25,884.39
Max. Negotiated Rate	$41,664.72
Rate for Payer: AlohaCare Medicare	$25,884.39
Rate for Payer: Devoted Health Medicare	$28,472.83
Rate for Payer: Hawaii Medical Service Association Commercial	$41,664.72
Rate for Payer: Hawaii Medical Service Association Medicare	$25,884.39
Rate for Payer: Humana Medicare	$25,884.39
Rate for Payer: Kaiser Permanente Commercial	$39,255.82
Rate for Payer: Kaiser Permanente Medicare	$25,884.39
Rate for Payer: Ohana Health Plan Medicare	$25,884.39
Rate for Payer: UnitedHealthcare Medicare	$25,884.39

AMPUTATION FOR MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DISORDERS WITH MCC

Facility

$74,052.52

Service Code	MSDRG 474
Min. Negotiated Rate	$41,664.72
Max. Negotiated Rate	$74,052.52
Rate for Payer: AlohaCare Medicare	$48,828.55
Rate for Payer: Devoted Health Medicare	$53,711.40
Rate for Payer: Hawaii Medical Service Association Commercial	$41,664.72
Rate for Payer: Hawaii Medical Service Association Medicare	$48,828.55
Rate for Payer: Humana Medicare	$48,828.55
Rate for Payer: Kaiser Permanente Commercial	$74,052.52
Rate for Payer: Kaiser Permanente Medicare	$48,828.55
Rate for Payer: Ohana Health Plan Medicare	$48,828.55
Rate for Payer: UnitedHealthcare Medicare	$48,828.55

AMPUTATION FOR MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DISORDERS WITHOUT CC/MCC

Facility

$41,664.72

Service Code	MSDRG 476
Min. Negotiated Rate	$13,423.90
Max. Negotiated Rate	$41,664.72
Rate for Payer: AlohaCare Medicare	$13,423.90
Rate for Payer: Devoted Health Medicare	$14,766.29
Rate for Payer: Hawaii Medical Service Association Commercial	$41,664.72
Rate for Payer: Hawaii Medical Service Association Medicare	$13,423.90
Rate for Payer: Humana Medicare	$13,423.90
Rate for Payer: Kaiser Permanente Commercial	$20,358.45
Rate for Payer: Kaiser Permanente Medicare	$13,423.90
Rate for Payer: Ohana Health Plan Medicare	$13,423.90
Rate for Payer: UnitedHealthcare Medicare	$13,423.90

AMPUTATION OF LOWER LIMB EXCEPT TOES

Facility

$11,121.98

Service Code	APR-DRG 3053
Min. Negotiated Rate	$11,121.98
Max. Negotiated Rate	$11,121.98
Rate for Payer: AlohaCare Medicaid	$11,121.98
Rate for Payer: Hawaii Medical Service Association ABD	$11,121.98
Rate for Payer: Hawaii Medical Service Association Non-ABD	$11,121.98
Rate for Payer: Kaiser Permanente Medicaid	$11,121.98
Rate for Payer: Ohana Health Plan Medicaid	$11,121.98
Rate for Payer: UnitedHealthcare Medicaid	$11,121.98

AMPUTATION OF LOWER LIMB EXCEPT TOES

Facility

$21,614.50

Service Code	APR-DRG 3054
Min. Negotiated Rate	$21,614.50
Max. Negotiated Rate	$21,614.50
Rate for Payer: AlohaCare Medicaid	$21,614.50
Rate for Payer: Hawaii Medical Service Association ABD	$21,614.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$21,614.50
Rate for Payer: Kaiser Permanente Medicaid	$21,614.50
Rate for Payer: Ohana Health Plan Medicaid	$21,614.50
Rate for Payer: UnitedHealthcare Medicaid	$21,614.50

AMPUTATION OF LOWER LIMB EXCEPT TOES

Facility

$5,271.70

Service Code	APR-DRG 3051
Min. Negotiated Rate	$5,271.70
Max. Negotiated Rate	$5,271.70
Rate for Payer: AlohaCare Medicaid	$5,271.70
Rate for Payer: Hawaii Medical Service Association ABD	$5,271.70
Rate for Payer: Hawaii Medical Service Association Non-ABD	$5,271.70
Rate for Payer: Kaiser Permanente Medicaid	$5,271.70
Rate for Payer: Ohana Health Plan Medicaid	$5,271.70
Rate for Payer: UnitedHealthcare Medicaid	$5,271.70

AMPUTATION OF LOWER LIMB EXCEPT TOES

Facility

$7,139.17

Service Code	APR-DRG 3052
Min. Negotiated Rate	$7,139.17
Max. Negotiated Rate	$7,139.17
Rate for Payer: AlohaCare Medicaid	$7,139.17
Rate for Payer: Hawaii Medical Service Association ABD	$7,139.17
Rate for Payer: Hawaii Medical Service Association Non-ABD	$7,139.17
Rate for Payer: Kaiser Permanente Medicaid	$7,139.17
Rate for Payer: Ohana Health Plan Medicaid	$7,139.17
Rate for Payer: UnitedHealthcare Medicaid	$7,139.17

AMPUTATION OF LOWER LIMB FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS WITH CC

Facility

$73,307.59

Service Code	MSDRG 617
Min. Negotiated Rate	$21,273.26
Max. Negotiated Rate	$73,307.59
Rate for Payer: AlohaCare Medicare	$21,273.26
Rate for Payer: Devoted Health Medicare	$23,400.59
Rate for Payer: Hawaii Medical Service Association Commercial	$73,307.59
Rate for Payer: Hawaii Medical Service Association Medicare	$21,273.26
Rate for Payer: Humana Medicare	$21,273.26
Rate for Payer: Kaiser Permanente Commercial	$32,262.67
Rate for Payer: Kaiser Permanente Medicare	$21,273.26
Rate for Payer: Ohana Health Plan Medicare	$21,273.26
Rate for Payer: UnitedHealthcare Medicare	$21,273.26

AMPUTATION OF LOWER LIMB FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS WITH MCC

Facility

$73,307.59

Service Code	MSDRG 616
Min. Negotiated Rate	$39,666.59
Max. Negotiated Rate	$73,307.59
Rate for Payer: AlohaCare Medicare	$39,666.59
Rate for Payer: Devoted Health Medicare	$43,633.25
Rate for Payer: Hawaii Medical Service Association Commercial	$73,307.59
Rate for Payer: Hawaii Medical Service Association Medicare	$39,666.59
Rate for Payer: Humana Medicare	$39,666.59
Rate for Payer: Kaiser Permanente Commercial	$60,157.65
Rate for Payer: Kaiser Permanente Medicare	$39,666.59
Rate for Payer: Ohana Health Plan Medicare	$39,666.59
Rate for Payer: UnitedHealthcare Medicare	$39,666.59

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