Hilo Benioff Medical Center

All Charges

Charge

Type

Setting

Price

ANKLE FIXATION SYS WASHER AFSW

Facility

$394.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$200.94
Max. Negotiated Rate	$382.18
Rate for Payer: Cash Price	$236.40
Rate for Payer: Hawaii Western Management Group Commercial	$275.80
Rate for Payer: Health Management Network Commercial	$334.90
Rate for Payer: Kaiser Permanente Commercial	$248.22
Rate for Payer: Kaiser Permanente Medicaid	$200.94
Rate for Payer: MDX Hawaii PPO	$382.18
Rate for Payer: University Health Alliance Commercial	$220.64

ANKLE FIXATION SYS WASHER AFSW

Facility

$394.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$220.64
Max. Negotiated Rate	$382.18
Rate for Payer: Cash Price	$236.40
Rate for Payer: Hawaii Western Management Group Commercial	$275.80
Rate for Payer: Health Management Network Commercial	$334.90
Rate for Payer: MDX Hawaii PPO	$382.18
Rate for Payer: University Health Alliance Commercial	$220.64

ANKLE HOOK PLATE 6H HOOK-6

Facility

$2,130.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,192.80
Max. Negotiated Rate	$2,066.10
Rate for Payer: Cash Price	$1,278.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,491.00
Rate for Payer: Health Management Network Commercial	$1,810.50
Rate for Payer: MDX Hawaii PPO	$2,066.10
Rate for Payer: University Health Alliance Commercial	$1,192.80

ANKLE HOOK PLATE 6H HOOK-6

Facility

$2,130.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,086.30
Max. Negotiated Rate	$2,066.10
Rate for Payer: Cash Price	$1,278.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,491.00
Rate for Payer: Health Management Network Commercial	$1,810.50
Rate for Payer: Kaiser Permanente Commercial	$1,341.90
Rate for Payer: Kaiser Permanente Medicaid	$1,086.30
Rate for Payer: MDX Hawaii PPO	$2,066.10
Rate for Payer: University Health Alliance Commercial	$1,192.80

ANKLE HOOK PLATE HOOK-4

Facility

$2,000.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,020.00
Max. Negotiated Rate	$1,940.00
Rate for Payer: Cash Price	$1,200.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,400.00
Rate for Payer: Health Management Network Commercial	$1,700.00
Rate for Payer: Kaiser Permanente Commercial	$1,260.00
Rate for Payer: Kaiser Permanente Medicaid	$1,020.00
Rate for Payer: MDX Hawaii PPO	$1,940.00
Rate for Payer: University Health Alliance Commercial	$1,120.00

ANKLE HOOK PLATE HOOK-4

Facility

$2,000.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,120.00
Max. Negotiated Rate	$1,940.00
Rate for Payer: Cash Price	$1,200.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,400.00
Rate for Payer: Health Management Network Commercial	$1,700.00
Rate for Payer: MDX Hawaii PPO	$1,940.00
Rate for Payer: University Health Alliance Commercial	$1,120.00

ANKLE RECONS KIT AR-1675BC-CP

Facility

$3,500.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,960.00
Max. Negotiated Rate	$3,395.00
Rate for Payer: Cash Price	$2,100.00
Rate for Payer: Hawaii Western Management Group Commercial	$2,450.00
Rate for Payer: Health Management Network Commercial	$2,975.00
Rate for Payer: MDX Hawaii PPO	$3,395.00
Rate for Payer: University Health Alliance Commercial	$1,960.00

ANKLE RECONS KIT AR-1675BC-CP

Facility

$3,500.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,785.00
Max. Negotiated Rate	$3,395.00
Rate for Payer: Cash Price	$2,100.00
Rate for Payer: Hawaii Western Management Group Commercial	$2,450.00
Rate for Payer: Health Management Network Commercial	$2,975.00
Rate for Payer: Kaiser Permanente Commercial	$2,205.00
Rate for Payer: Kaiser Permanente Medicaid	$1,785.00
Rate for Payer: MDX Hawaii PPO	$3,395.00
Rate for Payer: University Health Alliance Commercial	$1,960.00

ANORECTAL EXAM, SURGICAL, REQUIRING ANESTHESIA (GENERAL, SPINAL, OR EPIDURAL), DIAGNOSTIC

Facility

$3,606.91

Service Code	CPT 45990
Hospital Revenue Code	360
Min. Negotiated Rate	$393.00
Max. Negotiated Rate	$3,606.91
Rate for Payer: AlohaCare Medicaid	$3,279.01
Rate for Payer: AlohaCare Medicare	$3,279.01
Rate for Payer: Devoted Health Medicare	$3,606.91
Rate for Payer: Hawaii Medical Service Association ABD	$393.00
Rate for Payer: Hawaii Medical Service Association Commercial	$2,536.00
Rate for Payer: Hawaii Medical Service Association Medicare	$3,279.01
Rate for Payer: Hawaii Medical Service Association Non-ABD	$496.75
Rate for Payer: Humana Medicare	$3,279.01
Rate for Payer: Kaiser Permanente Medicaid	$2,837.00
Rate for Payer: Kaiser Permanente Medicare	$3,279.01
Rate for Payer: Ohana Health Plan Medicaid	$3,606.91
Rate for Payer: Ohana Health Plan Medicare	$3,279.01
Rate for Payer: UnitedHealthcare Medicaid	$456.03
Rate for Payer: UnitedHealthcare Medicare	$3,279.01

ANOSCOPY; DIAGNOSTIC, INCLUDING COLLECTION OF SPECIMEN(S) BY BRUSHING OR WASHING, WHEN PERFORMED (SEPARATE PROCEDURE)

Facility

$2,837.00

Service Code	CPT 46600
Hospital Revenue Code	360
Min. Negotiated Rate	$20.92
Max. Negotiated Rate	$2,837.00
Rate for Payer: AlohaCare Medicaid	$157.18
Rate for Payer: AlohaCare Medicare	$157.18
Rate for Payer: Devoted Health Medicare	$172.90
Rate for Payer: Hawaii Medical Service Association Commercial	$196.47
Rate for Payer: Hawaii Medical Service Association Medicare	$157.18
Rate for Payer: Humana Medicare	$157.18
Rate for Payer: Kaiser Permanente Medicaid	$2,837.00
Rate for Payer: Kaiser Permanente Medicare	$157.18
Rate for Payer: Ohana Health Plan Medicaid	$172.90
Rate for Payer: Ohana Health Plan Medicare	$157.18
Rate for Payer: UnitedHealthcare Medicaid	$20.92
Rate for Payer: UnitedHealthcare Medicare	$157.18

ANOXIC & OTHER SEVERE BRAIN DAMAGE

Facility

$5,923.33

Service Code	APR-DRG 0593
Min. Negotiated Rate	$5,923.33
Max. Negotiated Rate	$5,923.33
Rate for Payer: AlohaCare Medicaid	$5,923.33
Rate for Payer: Hawaii Medical Service Association ABD	$5,923.33
Rate for Payer: Hawaii Medical Service Association Non-ABD	$5,923.33
Rate for Payer: Kaiser Permanente Medicaid	$5,923.33
Rate for Payer: Ohana Health Plan Medicaid	$5,923.33
Rate for Payer: UnitedHealthcare Medicaid	$5,923.33

ANOXIC & OTHER SEVERE BRAIN DAMAGE

Facility

$9,882.65

Service Code	APR-DRG 0594
Min. Negotiated Rate	$9,882.65
Max. Negotiated Rate	$9,882.65
Rate for Payer: AlohaCare Medicaid	$9,882.65
Rate for Payer: Hawaii Medical Service Association ABD	$9,882.65
Rate for Payer: Hawaii Medical Service Association Non-ABD	$9,882.65
Rate for Payer: Kaiser Permanente Medicaid	$9,882.65
Rate for Payer: Ohana Health Plan Medicaid	$9,882.65
Rate for Payer: UnitedHealthcare Medicaid	$9,882.65

ANOXIC & OTHER SEVERE BRAIN DAMAGE

Facility

$3,637.10

Service Code	APR-DRG 0591
Min. Negotiated Rate	$3,637.10
Max. Negotiated Rate	$3,637.10
Rate for Payer: AlohaCare Medicaid	$3,637.10
Rate for Payer: Hawaii Medical Service Association ABD	$3,637.10
Rate for Payer: Hawaii Medical Service Association Non-ABD	$3,637.10
Rate for Payer: Kaiser Permanente Medicaid	$3,637.10
Rate for Payer: Ohana Health Plan Medicaid	$3,637.10
Rate for Payer: UnitedHealthcare Medicaid	$3,637.10

ANOXIC & OTHER SEVERE BRAIN DAMAGE

Facility

$4,638.99

Service Code	APR-DRG 0592
Min. Negotiated Rate	$4,638.99
Max. Negotiated Rate	$4,638.99
Rate for Payer: AlohaCare Medicaid	$4,638.99
Rate for Payer: Hawaii Medical Service Association ABD	$4,638.99
Rate for Payer: Hawaii Medical Service Association Non-ABD	$4,638.99
Rate for Payer: Kaiser Permanente Medicaid	$4,638.99
Rate for Payer: Ohana Health Plan Medicaid	$4,638.99
Rate for Payer: UnitedHealthcare Medicaid	$4,638.99

ANTEPARTUM W/O O.R. PROCEDURE

Facility

$2,127.08

Service Code	APR-DRG 5662
Min. Negotiated Rate	$2,127.08
Max. Negotiated Rate	$2,127.08
Rate for Payer: AlohaCare Medicaid	$2,127.08
Rate for Payer: Hawaii Medical Service Association ABD	$2,127.08
Rate for Payer: Hawaii Medical Service Association Non-ABD	$2,127.08
Rate for Payer: Kaiser Permanente Medicaid	$2,127.08
Rate for Payer: Ohana Health Plan Medicaid	$2,127.08
Rate for Payer: UnitedHealthcare Medicaid	$2,127.08

ANTEPARTUM W/O O.R. PROCEDURE

Facility

$1,785.93

Service Code	APR-DRG 5661
Min. Negotiated Rate	$1,785.93
Max. Negotiated Rate	$1,785.93
Rate for Payer: AlohaCare Medicaid	$1,785.93
Rate for Payer: Hawaii Medical Service Association ABD	$1,785.93
Rate for Payer: Hawaii Medical Service Association Non-ABD	$1,785.93
Rate for Payer: Kaiser Permanente Medicaid	$1,785.93
Rate for Payer: Ohana Health Plan Medicaid	$1,785.93
Rate for Payer: UnitedHealthcare Medicaid	$1,785.93

ANTEPARTUM W/O O.R. PROCEDURE

Facility

$2,932.64

Service Code	APR-DRG 5663
Min. Negotiated Rate	$2,932.64
Max. Negotiated Rate	$2,932.64
Rate for Payer: AlohaCare Medicaid	$2,932.64
Rate for Payer: Hawaii Medical Service Association ABD	$2,932.64
Rate for Payer: Hawaii Medical Service Association Non-ABD	$2,932.64
Rate for Payer: Kaiser Permanente Medicaid	$2,932.64
Rate for Payer: Ohana Health Plan Medicaid	$2,932.64
Rate for Payer: UnitedHealthcare Medicaid	$2,932.64

ANTEPARTUM W/O O.R. PROCEDURE

Facility

$6,238.38

Service Code	APR-DRG 5664
Min. Negotiated Rate	$6,238.38
Max. Negotiated Rate	$6,238.38
Rate for Payer: AlohaCare Medicaid	$6,238.38
Rate for Payer: Hawaii Medical Service Association ABD	$6,238.38
Rate for Payer: Hawaii Medical Service Association Non-ABD	$6,238.38
Rate for Payer: Kaiser Permanente Medicaid	$6,238.38
Rate for Payer: Ohana Health Plan Medicaid	$6,238.38
Rate for Payer: UnitedHealthcare Medicaid	$6,238.38

ANTEPARTUM W O.R. PROCEDURE

Facility

$14,528.82

Service Code	APR-DRG 5474
Min. Negotiated Rate	$14,528.82
Max. Negotiated Rate	$14,528.82
Rate for Payer: AlohaCare Medicaid	$14,528.82
Rate for Payer: Hawaii Medical Service Association ABD	$14,528.82
Rate for Payer: Hawaii Medical Service Association Non-ABD	$14,528.82
Rate for Payer: Kaiser Permanente Medicaid	$14,528.82
Rate for Payer: Ohana Health Plan Medicaid	$14,528.82
Rate for Payer: UnitedHealthcare Medicaid	$14,528.82

ANTEPARTUM W O.R. PROCEDURE

Facility

$3,151.80

Service Code	APR-DRG 5471
Min. Negotiated Rate	$3,151.80
Max. Negotiated Rate	$3,151.80
Rate for Payer: AlohaCare Medicaid	$3,151.80
Rate for Payer: Hawaii Medical Service Association ABD	$3,151.80
Rate for Payer: Hawaii Medical Service Association Non-ABD	$3,151.80
Rate for Payer: Kaiser Permanente Medicaid	$3,151.80
Rate for Payer: Ohana Health Plan Medicaid	$3,151.80
Rate for Payer: UnitedHealthcare Medicaid	$3,151.80

ANTEPARTUM W O.R. PROCEDURE

Facility

$4,098.91

Service Code	APR-DRG 5472
Min. Negotiated Rate	$4,098.91
Max. Negotiated Rate	$4,098.91
Rate for Payer: AlohaCare Medicaid	$4,098.91
Rate for Payer: Hawaii Medical Service Association ABD	$4,098.91
Rate for Payer: Hawaii Medical Service Association Non-ABD	$4,098.91
Rate for Payer: Kaiser Permanente Medicaid	$4,098.91
Rate for Payer: Ohana Health Plan Medicaid	$4,098.91
Rate for Payer: UnitedHealthcare Medicaid	$4,098.91

ANTEPARTUM W O.R. PROCEDURE

Facility

$5,948.11

Service Code	APR-DRG 5473
Min. Negotiated Rate	$5,948.11
Max. Negotiated Rate	$5,948.11
Rate for Payer: AlohaCare Medicaid	$5,948.11
Rate for Payer: Hawaii Medical Service Association ABD	$5,948.11
Rate for Payer: Hawaii Medical Service Association Non-ABD	$5,948.11
Rate for Payer: Kaiser Permanente Medicaid	$5,948.11
Rate for Payer: Ohana Health Plan Medicaid	$5,948.11
Rate for Payer: UnitedHealthcare Medicaid	$5,948.11

ANTIBIOTIC BIOENVELOPE LRG

Facility

$2,985.00

Service Code	HCPCS C1781
Hospital Revenue Code	278
Min. Negotiated Rate	$1,522.35
Max. Negotiated Rate	$2,895.45
Rate for Payer: Cash Price	$1,791.00
Rate for Payer: Hawaii Western Management Group Commercial	$2,089.50
Rate for Payer: Health Management Network Commercial	$2,537.25
Rate for Payer: Kaiser Permanente Commercial	$1,880.55
Rate for Payer: Kaiser Permanente Medicaid	$1,522.35
Rate for Payer: MDX Hawaii PPO	$2,895.45
Rate for Payer: University Health Alliance Commercial	$1,671.60

ANTIBIOTIC BIOENVELOPE LRG

Facility

$2,985.00

Service Code	HCPCS C1781
Hospital Revenue Code	278
Min. Negotiated Rate	$1,671.60
Max. Negotiated Rate	$2,895.45
Rate for Payer: Cash Price	$1,791.00
Rate for Payer: Hawaii Western Management Group Commercial	$2,089.50
Rate for Payer: Health Management Network Commercial	$2,537.25
Rate for Payer: MDX Hawaii PPO	$2,895.45
Rate for Payer: University Health Alliance Commercial	$1,671.60

ANTIBIOTIC BIOENVELOPE MED

Facility

$2,985.00

Service Code	HCPCS C1781
Hospital Revenue Code	278
Min. Negotiated Rate	$1,671.60
Max. Negotiated Rate	$2,895.45
Rate for Payer: Cash Price	$1,791.00
Rate for Payer: Hawaii Western Management Group Commercial	$2,089.50
Rate for Payer: Health Management Network Commercial	$2,537.25
Rate for Payer: MDX Hawaii PPO	$2,895.45
Rate for Payer: University Health Alliance Commercial	$1,671.60

Know your out-of-pocket cost for care.

All Charges