Hilo Benioff Medical Center

All Charges

Charge

Type

Setting

Price

HALOPERIDOL LACTATE 2 MG/ML ORAL CONCENTRATE [3585]

Facility

$109.00

Service Code	NDC 00121058104
Hospital Revenue Code	250
Min. Negotiated Rate	$92.65
Max. Negotiated Rate	$105.73
Rate for Payer: Cash Price	$65.40
Rate for Payer: Health Management Network Commercial	$92.65
Rate for Payer: MDX Hawaii PPO	$105.73

HALOPERIDOL LACTATE 5 MG/ML INJECTION SOLUTION [3584]

Facility

$22.00

Service Code	HCPCS J1630
Hospital Revenue Code	250
Min. Negotiated Rate	$18.70
Max. Negotiated Rate	$21.34
Rate for Payer: Cash Price	$13.20
Rate for Payer: Cash Price	$3.60
Rate for Payer: Health Management Network Commercial	$5.10
Rate for Payer: Health Management Network Commercial	$18.70
Rate for Payer: MDX Hawaii PPO	$5.82
Rate for Payer: MDX Hawaii PPO	$21.34

HALOPERIDOL LACTATE 5 MG/ML INJECTION SOLUTION [3584]

Facility

$22.00

Service Code	HCPCS J1630
Hospital Revenue Code	636
Min. Negotiated Rate	$0.84
Max. Negotiated Rate	$21.34
Rate for Payer: Cash Price	$13.20
Rate for Payer: Cash Price	$3.60
Rate for Payer: Cash Price	$3.60
Rate for Payer: Cash Price	$13.20
Rate for Payer: Hawaii Medical Service Association ABD	$0.84
Rate for Payer: Hawaii Medical Service Association ABD	$0.84
Rate for Payer: Hawaii Medical Service Association Non-ABD	$0.84
Rate for Payer: Hawaii Medical Service Association Non-ABD	$0.84
Rate for Payer: Hawaii Western Management Group Commercial	$20.90
Rate for Payer: Hawaii Western Management Group Commercial	$5.70
Rate for Payer: Health Management Network Commercial	$5.10
Rate for Payer: Health Management Network Commercial	$18.70
Rate for Payer: Kaiser Permanente Commercial	$13.86
Rate for Payer: Kaiser Permanente Commercial	$3.78
Rate for Payer: Kaiser Permanente Medicaid	$3.06
Rate for Payer: Kaiser Permanente Medicaid	$11.22
Rate for Payer: MDX Hawaii PPO	$5.82
Rate for Payer: MDX Hawaii PPO	$21.34
Rate for Payer: UnitedHealthcare Medicaid	$13.20
Rate for Payer: UnitedHealthcare Medicaid	$3.60
Rate for Payer: University Health Alliance Commercial	$4.37
Rate for Payer: University Health Alliance Commercial	$16.04

HANDLE SHORT EGIA NEXT GEN

Facility

$384.00

Hospital Revenue Code	272
Min. Negotiated Rate	$326.40
Max. Negotiated Rate	$372.48
Rate for Payer: Cash Price	$230.40
Rate for Payer: Health Management Network Commercial	$326.40
Rate for Payer: MDX Hawaii PPO	$372.48

HANDLE SHORT EGIA NEXT GEN

Facility

$384.00

Hospital Revenue Code	272
Min. Negotiated Rate	$195.84
Max. Negotiated Rate	$372.48
Rate for Payer: Cash Price	$230.40
Rate for Payer: Hawaii Western Management Group Commercial	$364.80
Rate for Payer: Health Management Network Commercial	$326.40
Rate for Payer: Kaiser Permanente Commercial	$241.92
Rate for Payer: Kaiser Permanente Medicaid	$195.84
Rate for Payer: MDX Hawaii PPO	$372.48
Rate for Payer: University Health Alliance Commercial	$279.90

HAND OR WRIST PROCEDURES, EXCEPT MAJOR THUMB OR JOINT PROCEDURES WITH CC/MCC

Facility

$27,274.98

Service Code	MSDRG 513
Min. Negotiated Rate	$17,906.48
Max. Negotiated Rate	$27,274.98
Rate for Payer: AlohaCare Medicare	$17,906.48
Rate for Payer: Devoted Health Medicare	$19,697.13
Rate for Payer: Hawaii Medical Service Association Commercial	$27,274.98
Rate for Payer: Hawaii Medical Service Association Medicare	$17,906.48
Rate for Payer: Humana Medicare	$17,906.48
Rate for Payer: Kaiser Permanente Commercial	$27,156.67
Rate for Payer: Kaiser Permanente Medicare	$17,906.48
Rate for Payer: Ohana Health Plan Medicare	$17,906.48
Rate for Payer: UnitedHealthcare Medicare	$17,906.48

HAND OR WRIST PROCEDURES, EXCEPT MAJOR THUMB OR JOINT PROCEDURES WITHOUT CC/MCC

Facility

$18,854.68

Service Code	MSDRG 514
Min. Negotiated Rate	$11,627.90
Max. Negotiated Rate	$18,854.68
Rate for Payer: AlohaCare Medicare	$11,627.90
Rate for Payer: Devoted Health Medicare	$12,790.69
Rate for Payer: Hawaii Medical Service Association Commercial	$18,854.68
Rate for Payer: Hawaii Medical Service Association Medicare	$11,627.90
Rate for Payer: Humana Medicare	$11,627.90
Rate for Payer: Kaiser Permanente Commercial	$17,634.67
Rate for Payer: Kaiser Permanente Medicare	$11,627.90
Rate for Payer: Ohana Health Plan Medicare	$11,627.90
Rate for Payer: UnitedHealthcare Medicare	$11,627.90

HAND PROCEDURES FOR INJURIES

Facility

$30,401.40

Service Code	MSDRG 906
Min. Negotiated Rate	$22,342.45
Max. Negotiated Rate	$30,401.40
Rate for Payer: AlohaCare Medicare	$22,342.45
Rate for Payer: Devoted Health Medicare	$24,576.69
Rate for Payer: Hawaii Medical Service Association Commercial	$22,688.71
Rate for Payer: Hawaii Medical Service Association Medicare	$22,342.45
Rate for Payer: Humana Medicare	$22,342.45
Rate for Payer: Kaiser Permanente Commercial	$30,401.40
Rate for Payer: Kaiser Permanente Medicare	$22,342.45
Rate for Payer: Ohana Health Plan Medicare	$22,342.45
Rate for Payer: UnitedHealthcare Medicare	$22,342.45

HAND REST ORHTOSIS LEFT REG

Facility

$268.00

Service Code	HCPCS L3809
Hospital Revenue Code	274
Min. Negotiated Rate	$150.08
Max. Negotiated Rate	$259.96
Rate for Payer: Cash Price	$160.80
Rate for Payer: Hawaii Western Management Group Commercial	$187.60
Rate for Payer: Health Management Network Commercial	$227.80
Rate for Payer: MDX Hawaii PPO	$259.96
Rate for Payer: University Health Alliance Commercial	$150.08

HAND REST ORHTOSIS LEFT REG

Facility

$268.00

Service Code	HCPCS L3809
Hospital Revenue Code	274
Min. Negotiated Rate	$136.68
Max. Negotiated Rate	$259.96
Rate for Payer: Cash Price	$160.80
Rate for Payer: Cash Price	$160.80
Rate for Payer: Hawaii Western Management Group Commercial	$187.60
Rate for Payer: Health Management Network Commercial	$227.80
Rate for Payer: Kaiser Permanente Commercial	$168.84
Rate for Payer: Kaiser Permanente Medicaid	$136.68
Rate for Payer: MDX Hawaii PPO	$259.96
Rate for Payer: UnitedHealthcare Medicaid	$209.46
Rate for Payer: University Health Alliance Commercial	$150.08

HAND REST ORHTOSIS LEFT SM

Facility

$268.00

Service Code	HCPCS L3809
Hospital Revenue Code	274
Min. Negotiated Rate	$136.68
Max. Negotiated Rate	$259.96
Rate for Payer: Cash Price	$160.80
Rate for Payer: Cash Price	$160.80
Rate for Payer: Hawaii Western Management Group Commercial	$187.60
Rate for Payer: Health Management Network Commercial	$227.80
Rate for Payer: Kaiser Permanente Commercial	$168.84
Rate for Payer: Kaiser Permanente Medicaid	$136.68
Rate for Payer: MDX Hawaii PPO	$259.96
Rate for Payer: UnitedHealthcare Medicaid	$209.46
Rate for Payer: University Health Alliance Commercial	$150.08

HAND REST ORHTOSIS LEFT SM

Facility

$268.00

Service Code	HCPCS L3809
Hospital Revenue Code	274
Min. Negotiated Rate	$150.08
Max. Negotiated Rate	$259.96
Rate for Payer: Cash Price	$160.80
Rate for Payer: Hawaii Western Management Group Commercial	$187.60
Rate for Payer: Health Management Network Commercial	$227.80
Rate for Payer: MDX Hawaii PPO	$259.96
Rate for Payer: University Health Alliance Commercial	$150.08

HAND REST ORHTOSIS RIGHT REG

Facility

$268.00

Service Code	HCPCS L3809
Hospital Revenue Code	274
Min. Negotiated Rate	$150.08
Max. Negotiated Rate	$259.96
Rate for Payer: Cash Price	$160.80
Rate for Payer: Hawaii Western Management Group Commercial	$187.60
Rate for Payer: Health Management Network Commercial	$227.80
Rate for Payer: MDX Hawaii PPO	$259.96
Rate for Payer: University Health Alliance Commercial	$150.08

HAND REST ORHTOSIS RIGHT REG

Facility

$268.00

Service Code	HCPCS L3809
Hospital Revenue Code	274
Min. Negotiated Rate	$136.68
Max. Negotiated Rate	$259.96
Rate for Payer: Cash Price	$160.80
Rate for Payer: Cash Price	$160.80
Rate for Payer: Hawaii Western Management Group Commercial	$187.60
Rate for Payer: Health Management Network Commercial	$227.80
Rate for Payer: Kaiser Permanente Commercial	$168.84
Rate for Payer: Kaiser Permanente Medicaid	$136.68
Rate for Payer: MDX Hawaii PPO	$259.96
Rate for Payer: UnitedHealthcare Medicaid	$209.46
Rate for Payer: University Health Alliance Commercial	$150.08

HAND REST ORHTOSIS RIGHT SM

Facility

$268.00

Service Code	HCPCS L3809
Hospital Revenue Code	274
Min. Negotiated Rate	$150.08
Max. Negotiated Rate	$259.96
Rate for Payer: Cash Price	$160.80
Rate for Payer: Hawaii Western Management Group Commercial	$187.60
Rate for Payer: Health Management Network Commercial	$227.80
Rate for Payer: MDX Hawaii PPO	$259.96
Rate for Payer: University Health Alliance Commercial	$150.08

HAND REST ORHTOSIS RIGHT SM

Facility

$268.00

Service Code	HCPCS L3809
Hospital Revenue Code	274
Min. Negotiated Rate	$136.68
Max. Negotiated Rate	$259.96
Rate for Payer: Cash Price	$160.80
Rate for Payer: Cash Price	$160.80
Rate for Payer: Hawaii Western Management Group Commercial	$187.60
Rate for Payer: Health Management Network Commercial	$227.80
Rate for Payer: Kaiser Permanente Commercial	$168.84
Rate for Payer: Kaiser Permanente Medicaid	$136.68
Rate for Payer: MDX Hawaii PPO	$259.96
Rate for Payer: UnitedHealthcare Medicaid	$209.46
Rate for Payer: University Health Alliance Commercial	$150.08

HAND & WRIST PROCEDURES

Facility

$8,585.27

Service Code	APR-DRG 3163
Min. Negotiated Rate	$8,585.27
Max. Negotiated Rate	$8,585.27
Rate for Payer: AlohaCare Medicaid	$8,585.27
Rate for Payer: Hawaii Medical Service Association ABD	$8,585.27
Rate for Payer: Hawaii Medical Service Association Non-ABD	$8,585.27
Rate for Payer: Kaiser Permanente Medicaid	$8,585.27
Rate for Payer: Ohana Health Plan Medicaid	$8,585.27
Rate for Payer: UnitedHealthcare Medicaid	$8,585.27

HAND & WRIST PROCEDURES

Facility

$4,423.74

Service Code	APR-DRG 3161
Min. Negotiated Rate	$4,423.74
Max. Negotiated Rate	$4,423.74
Rate for Payer: AlohaCare Medicaid	$4,423.74
Rate for Payer: Hawaii Medical Service Association ABD	$4,423.74
Rate for Payer: Hawaii Medical Service Association Non-ABD	$4,423.74
Rate for Payer: Kaiser Permanente Medicaid	$4,423.74
Rate for Payer: Ohana Health Plan Medicaid	$4,423.74
Rate for Payer: UnitedHealthcare Medicaid	$4,423.74

HAND & WRIST PROCEDURES

Facility

$5,828.09

Service Code	APR-DRG 3162
Min. Negotiated Rate	$5,828.09
Max. Negotiated Rate	$5,828.09
Rate for Payer: AlohaCare Medicaid	$5,828.09
Rate for Payer: Hawaii Medical Service Association ABD	$5,828.09
Rate for Payer: Hawaii Medical Service Association Non-ABD	$5,828.09
Rate for Payer: Kaiser Permanente Medicaid	$5,828.09
Rate for Payer: Ohana Health Plan Medicaid	$5,828.09
Rate for Payer: UnitedHealthcare Medicaid	$5,828.09

HAND & WRIST PROCEDURES

Facility

$15,952.74

Service Code	APR-DRG 3164
Min. Negotiated Rate	$15,952.74
Max. Negotiated Rate	$15,952.74
Rate for Payer: AlohaCare Medicaid	$15,952.74
Rate for Payer: Hawaii Medical Service Association ABD	$15,952.74
Rate for Payer: Hawaii Medical Service Association Non-ABD	$15,952.74
Rate for Payer: Kaiser Permanente Medicaid	$15,952.74
Rate for Payer: Ohana Health Plan Medicaid	$15,952.74
Rate for Payer: UnitedHealthcare Medicaid	$15,952.74

HARMONIC ACE 8MM IS4000 480275

Facility

$1,717.00

Hospital Revenue Code	272
Min. Negotiated Rate	$1,459.45
Max. Negotiated Rate	$1,665.49
Rate for Payer: Cash Price	$1,030.20
Rate for Payer: Health Management Network Commercial	$1,459.45
Rate for Payer: MDX Hawaii PPO	$1,665.49

HARMONIC ACE 8MM IS4000 480275

Facility

$1,717.00

Hospital Revenue Code	272
Min. Negotiated Rate	$875.67
Max. Negotiated Rate	$1,665.49
Rate for Payer: Cash Price	$1,030.20
Rate for Payer: Hawaii Western Management Group Commercial	$1,631.15
Rate for Payer: Health Management Network Commercial	$1,459.45
Rate for Payer: Kaiser Permanente Commercial	$1,081.71
Rate for Payer: Kaiser Permanente Medicaid	$875.67
Rate for Payer: MDX Hawaii PPO	$1,665.49
Rate for Payer: University Health Alliance Commercial	$1,251.52

HARVESTER QUADPRO AR-2386-10

Facility

$1,562.00

Hospital Revenue Code	272
Min. Negotiated Rate	$796.62
Max. Negotiated Rate	$1,515.14
Rate for Payer: Cash Price	$937.20
Rate for Payer: Hawaii Western Management Group Commercial	$1,483.90
Rate for Payer: Health Management Network Commercial	$1,327.70
Rate for Payer: Kaiser Permanente Commercial	$984.06
Rate for Payer: Kaiser Permanente Medicaid	$796.62
Rate for Payer: MDX Hawaii PPO	$1,515.14
Rate for Payer: University Health Alliance Commercial	$1,138.54

HARVESTER QUADPRO AR-2386-10

Facility

$1,562.00

Hospital Revenue Code	272
Min. Negotiated Rate	$1,327.70
Max. Negotiated Rate	$1,515.14
Rate for Payer: Cash Price	$937.20
Rate for Payer: Health Management Network Commercial	$1,327.70
Rate for Payer: MDX Hawaii PPO	$1,515.14

HB OBSERVATION CARVE-OUT - CARDIOLOGY

Facility

$174.00

Service Code	HCPCS G0378
Hospital Charge Code	762G037804
Hospital Revenue Code	762
Min. Negotiated Rate	$88.74
Max. Negotiated Rate	$1,200.00
Rate for Payer: Cash Price	$104.40
Rate for Payer: Cash Price	$104.40
Rate for Payer: Hawaii Medical Service Association Commercial	$1,200.00
Rate for Payer: Hawaii Western Management Group Commercial	$165.30
Rate for Payer: Health Management Network Commercial	$147.90
Rate for Payer: Kaiser Permanente Commercial	$109.62
Rate for Payer: Kaiser Permanente Medicaid	$88.74
Rate for Payer: MDX Hawaii PPO	$168.78
Rate for Payer: University Health Alliance Commercial	$126.83

Know your out-of-pocket cost for care.

All Charges