Hilo Benioff Medical Center

All Charges

Charge

Type

Setting

Price

ANTIBIOTIC BIOENVELOPE MED

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

ANTIHEMOPHILIC FACTOR VIII, FULL LENGTH 3,000 (+/-) UNIT IV SOLUTION [82525]

Facility

$7,259.00

Service Code	HCPCS J7192
Hospital Revenue Code	636
Min. Negotiated Rate	$6,170.15
Max. Negotiated Rate	$7,041.23
Rate for Payer: Cash Price	$4,355.40
Rate for Payer: Health Management Network Commercial	$6,170.15
Rate for Payer: MDX Hawaii PPO	$7,041.23

ANTIHEMOPHILIC FACTOR VIII, FULL LENGTH 3,000 (+/-) UNIT IV SOLUTION [82525]

Facility

$7,259.00

Service Code	HCPCS J7192
Hospital Revenue Code	636
Min. Negotiated Rate	$1.57
Max. Negotiated Rate	$7,041.23
Rate for Payer: AlohaCare Medicaid	$1.57
Rate for Payer: AlohaCare Medicare	$1.57
Rate for Payer: Cash Price	$4,355.40
Rate for Payer: Cash Price	$4,355.40
Rate for Payer: Devoted Health Medicare	$1.73
Rate for Payer: Hawaii Medical Service Association Commercial	$1.96
Rate for Payer: Hawaii Medical Service Association Medicare	$1.57
Rate for Payer: Hawaii Western Management Group Commercial	$6,896.05
Rate for Payer: Health Management Network Commercial	$6,170.15
Rate for Payer: Humana Medicare	$1.57
Rate for Payer: Kaiser Permanente Commercial	$4,573.17
Rate for Payer: Kaiser Permanente Medicaid	$3,702.09
Rate for Payer: Kaiser Permanente Medicare	$1.57
Rate for Payer: MDX Hawaii PPO	$7,041.23
Rate for Payer: Ohana Health Plan Medicaid	$1.73
Rate for Payer: Ohana Health Plan Medicare	$1.57
Rate for Payer: UnitedHealthcare Medicaid	$4,355.40
Rate for Payer: UnitedHealthcare Medicare	$1.57
Rate for Payer: University Health Alliance Commercial	$5,291.09

ANTIHEMOPHILIC FACTOR VIII, FULL LENGTH 4,000 (+/-) UNIT IV SOLUTION [117087]

Facility

$9,943.00

Service Code	HCPCS J7192
Hospital Revenue Code	636
Min. Negotiated Rate	$1.57
Max. Negotiated Rate	$9,644.71
Rate for Payer: AlohaCare Medicaid	$1.57
Rate for Payer: AlohaCare Medicare	$1.57
Rate for Payer: Cash Price	$5,965.80
Rate for Payer: Cash Price	$5,965.80
Rate for Payer: Devoted Health Medicare	$1.73
Rate for Payer: Hawaii Medical Service Association Commercial	$1.96
Rate for Payer: Hawaii Medical Service Association Medicare	$1.57
Rate for Payer: Hawaii Western Management Group Commercial	$9,445.85
Rate for Payer: Health Management Network Commercial	$8,451.55
Rate for Payer: Humana Medicare	$1.57
Rate for Payer: Kaiser Permanente Commercial	$6,264.09
Rate for Payer: Kaiser Permanente Medicaid	$5,070.93
Rate for Payer: Kaiser Permanente Medicare	$1.57
Rate for Payer: MDX Hawaii PPO	$9,644.71
Rate for Payer: Ohana Health Plan Medicaid	$1.73
Rate for Payer: Ohana Health Plan Medicare	$1.57
Rate for Payer: UnitedHealthcare Medicaid	$5,965.80
Rate for Payer: UnitedHealthcare Medicare	$1.57
Rate for Payer: University Health Alliance Commercial	$7,247.45

ANTIHEMOPHILIC FACTOR VIII, FULL LENGTH 4,000 (+/-) UNIT IV SOLUTION [117087]

Facility

$9,943.00

Service Code	HCPCS J7192
Hospital Revenue Code	636
Min. Negotiated Rate	$8,451.55
Max. Negotiated Rate	$9,644.71
Rate for Payer: Cash Price	$5,965.80
Rate for Payer: Health Management Network Commercial	$8,451.55
Rate for Payer: MDX Hawaii PPO	$9,644.71

AO DRIVER SHAFT

Facility

$578.00

Hospital Revenue Code	272
Min. Negotiated Rate	$491.30
Max. Negotiated Rate	$560.66
Rate for Payer: Cash Price	$346.80
Rate for Payer: Health Management Network Commercial	$491.30
Rate for Payer: MDX Hawaii PPO	$560.66

AO DRIVER SHAFT

Facility

$578.00

Hospital Revenue Code	272
Min. Negotiated Rate	$294.78
Max. Negotiated Rate	$560.66
Rate for Payer: Cash Price	$346.80
Rate for Payer: Hawaii Western Management Group Commercial	$549.10
Rate for Payer: Health Management Network Commercial	$491.30
Rate for Payer: Kaiser Permanente Commercial	$364.14
Rate for Payer: Kaiser Permanente Medicaid	$294.78
Rate for Payer: MDX Hawaii PPO	$560.66
Rate for Payer: University Health Alliance Commercial	$421.30

AORTIC AND HEART ASSIST PROCEDURES EXCEPT PULSATION BALLOON WITH MCC

Facility

$118,643.77

Service Code	MSDRG 268
Min. Negotiated Rate	$78,230.99
Max. Negotiated Rate	$118,643.77
Rate for Payer: AlohaCare Medicare	$78,230.99
Rate for Payer: Devoted Health Medicare	$86,054.09
Rate for Payer: Hawaii Medical Service Association Commercial	$113,928.87
Rate for Payer: Hawaii Medical Service Association Medicare	$78,230.99
Rate for Payer: Humana Medicare	$78,230.99
Rate for Payer: Kaiser Permanente Commercial	$118,643.77
Rate for Payer: Kaiser Permanente Medicare	$78,230.99
Rate for Payer: Ohana Health Plan Medicare	$78,230.99
Rate for Payer: UnitedHealthcare Medicare	$78,230.99

AORTIC AND HEART ASSIST PROCEDURES EXCEPT PULSATION BALLOON WITHOUT MCC

Facility

$98,325.83

Service Code	MSDRG 269
Min. Negotiated Rate	$48,035.75
Max. Negotiated Rate	$98,325.83
Rate for Payer: AlohaCare Medicare	$48,035.75
Rate for Payer: Devoted Health Medicare	$52,839.32
Rate for Payer: Hawaii Medical Service Association Commercial	$98,325.83
Rate for Payer: Hawaii Medical Service Association Medicare	$48,035.75
Rate for Payer: Humana Medicare	$48,035.75
Rate for Payer: Kaiser Permanente Commercial	$72,850.20
Rate for Payer: Kaiser Permanente Medicare	$48,035.75
Rate for Payer: Ohana Health Plan Medicare	$48,035.75
Rate for Payer: UnitedHealthcare Medicare	$48,035.75

AORTIC EXTEN ENDO 23MMX3.3CM

Facility

$7,754.00

Service Code	HCPCS C1768
Hospital Revenue Code	278
Min. Negotiated Rate	$3,954.54
Max. Negotiated Rate	$7,521.38
Rate for Payer: Cash Price	$4,652.40
Rate for Payer: Hawaii Western Management Group Commercial	$5,427.80
Rate for Payer: Health Management Network Commercial	$6,590.90
Rate for Payer: Kaiser Permanente Commercial	$4,885.02
Rate for Payer: Kaiser Permanente Medicaid	$3,954.54
Rate for Payer: MDX Hawaii PPO	$7,521.38
Rate for Payer: University Health Alliance Commercial	$4,342.24

AORTIC EXTEN ENDO 23MMX3.3CM

Facility

$7,754.00

Service Code	HCPCS C1768
Hospital Revenue Code	278
Min. Negotiated Rate	$4,342.24
Max. Negotiated Rate	$7,521.38
Rate for Payer: Cash Price	$4,652.40
Rate for Payer: Hawaii Western Management Group Commercial	$5,427.80
Rate for Payer: Health Management Network Commercial	$6,590.90
Rate for Payer: MDX Hawaii PPO	$7,521.38
Rate for Payer: University Health Alliance Commercial	$4,342.24

AORTIC EXTEN ENDO 26MMX3.3CM

Facility

$6,350.00

Service Code	HCPCS C1768
Hospital Revenue Code	278
Min. Negotiated Rate	$3,238.50
Max. Negotiated Rate	$6,159.50
Rate for Payer: Cash Price	$3,810.00
Rate for Payer: Hawaii Western Management Group Commercial	$4,445.00
Rate for Payer: Health Management Network Commercial	$5,397.50
Rate for Payer: Kaiser Permanente Commercial	$4,000.50
Rate for Payer: Kaiser Permanente Medicaid	$3,238.50
Rate for Payer: MDX Hawaii PPO	$6,159.50
Rate for Payer: University Health Alliance Commercial	$3,556.00

AORTIC EXTEN ENDO 26MMX3.3CM

Facility

$6,350.00

Service Code	HCPCS C1768
Hospital Revenue Code	278
Min. Negotiated Rate	$3,556.00
Max. Negotiated Rate	$6,159.50
Rate for Payer: Cash Price	$3,810.00
Rate for Payer: Hawaii Western Management Group Commercial	$4,445.00
Rate for Payer: Health Management Network Commercial	$5,397.50
Rate for Payer: MDX Hawaii PPO	$6,159.50
Rate for Payer: University Health Alliance Commercial	$3,556.00

AORTIC EXTEN ENDO 28.5MMX3.3CM

Facility

$6,350.00

Service Code	HCPCS C1768
Hospital Revenue Code	278
Min. Negotiated Rate	$3,238.50
Max. Negotiated Rate	$6,159.50
Rate for Payer: Cash Price	$3,810.00
Rate for Payer: Hawaii Western Management Group Commercial	$4,445.00
Rate for Payer: Health Management Network Commercial	$5,397.50
Rate for Payer: Kaiser Permanente Commercial	$4,000.50
Rate for Payer: Kaiser Permanente Medicaid	$3,238.50
Rate for Payer: MDX Hawaii PPO	$6,159.50
Rate for Payer: University Health Alliance Commercial	$3,556.00

AORTIC EXTEN ENDO 28.5MMX3.3CM

Facility

$6,350.00

Service Code	HCPCS C1768
Hospital Revenue Code	278
Min. Negotiated Rate	$3,556.00
Max. Negotiated Rate	$6,159.50
Rate for Payer: Cash Price	$3,810.00
Rate for Payer: Hawaii Western Management Group Commercial	$4,445.00
Rate for Payer: Health Management Network Commercial	$5,397.50
Rate for Payer: MDX Hawaii PPO	$6,159.50
Rate for Payer: University Health Alliance Commercial	$3,556.00

AORTIC EXTEN ENDO 32MMX4.5CM

Facility

$6,350.00

Service Code	HCPCS C1768
Hospital Revenue Code	278
Min. Negotiated Rate	$3,556.00
Max. Negotiated Rate	$6,159.50
Rate for Payer: Cash Price	$3,810.00
Rate for Payer: Hawaii Western Management Group Commercial	$4,445.00
Rate for Payer: Health Management Network Commercial	$5,397.50
Rate for Payer: MDX Hawaii PPO	$6,159.50
Rate for Payer: University Health Alliance Commercial	$3,556.00

AORTIC EXTEN ENDO 32MMX4.5CM

Facility

$6,350.00

Service Code	HCPCS C1768
Hospital Revenue Code	278
Min. Negotiated Rate	$3,238.50
Max. Negotiated Rate	$6,159.50
Rate for Payer: Cash Price	$3,810.00
Rate for Payer: Hawaii Western Management Group Commercial	$4,445.00
Rate for Payer: Health Management Network Commercial	$5,397.50
Rate for Payer: Kaiser Permanente Commercial	$4,000.50
Rate for Payer: Kaiser Permanente Medicaid	$3,238.50
Rate for Payer: MDX Hawaii PPO	$6,159.50
Rate for Payer: University Health Alliance Commercial	$3,556.00

AORTIC EXTEN ENDO 36MMX4.5CM

Facility

$6,350.00

Service Code	HCPCS C1768
Hospital Revenue Code	278
Min. Negotiated Rate	$3,238.50
Max. Negotiated Rate	$6,159.50
Rate for Payer: Cash Price	$3,810.00
Rate for Payer: Hawaii Western Management Group Commercial	$4,445.00
Rate for Payer: Health Management Network Commercial	$5,397.50
Rate for Payer: Kaiser Permanente Commercial	$4,000.50
Rate for Payer: Kaiser Permanente Medicaid	$3,238.50
Rate for Payer: MDX Hawaii PPO	$6,159.50
Rate for Payer: University Health Alliance Commercial	$3,556.00

AORTIC EXTEN ENDO 36MMX4.5CM

Facility

$6,350.00

Service Code	HCPCS C1768
Hospital Revenue Code	278
Min. Negotiated Rate	$3,556.00
Max. Negotiated Rate	$6,159.50
Rate for Payer: Cash Price	$3,810.00
Rate for Payer: Hawaii Western Management Group Commercial	$4,445.00
Rate for Payer: Health Management Network Commercial	$5,397.50
Rate for Payer: MDX Hawaii PPO	$6,159.50
Rate for Payer: University Health Alliance Commercial	$3,556.00

APIXABAN 2.5 MG TABLET [119040]

Facility

$31.00

Service Code	NDC 00003089331
Hospital Revenue Code	250
Min. Negotiated Rate	$26.35
Max. Negotiated Rate	$30.07
Rate for Payer: Cash Price	$18.60
Rate for Payer: Health Management Network Commercial	$26.35
Rate for Payer: MDX Hawaii PPO	$30.07

APIXABAN 2.5 MG TABLET [119040]

Facility

$31.00

Service Code	NDC 00003089331
Hospital Revenue Code	637
Min. Negotiated Rate	$15.81
Max. Negotiated Rate	$30.07
Rate for Payer: Cash Price	$18.60
Rate for Payer: Hawaii Western Management Group Commercial	$29.45
Rate for Payer: Health Management Network Commercial	$26.35
Rate for Payer: Kaiser Permanente Commercial	$19.53
Rate for Payer: Kaiser Permanente Medicaid	$15.81
Rate for Payer: MDX Hawaii PPO	$30.07
Rate for Payer: University Health Alliance Commercial	$22.60

APIXABAN 5 MG TABLET [119614]

Facility

$31.00

Service Code	NDC 00003089431
Hospital Revenue Code	250
Min. Negotiated Rate	$26.35
Max. Negotiated Rate	$30.07
Rate for Payer: Cash Price	$18.60
Rate for Payer: Health Management Network Commercial	$26.35
Rate for Payer: MDX Hawaii PPO	$30.07

APIXABAN 5 MG TABLET [119614]

Facility

$31.00

Service Code	NDC 00003089431
Hospital Revenue Code	637
Min. Negotiated Rate	$15.81
Max. Negotiated Rate	$30.07
Rate for Payer: Cash Price	$18.60
Rate for Payer: Hawaii Western Management Group Commercial	$29.45
Rate for Payer: Health Management Network Commercial	$26.35
Rate for Payer: Kaiser Permanente Commercial	$19.53
Rate for Payer: Kaiser Permanente Medicaid	$15.81
Rate for Payer: MDX Hawaii PPO	$30.07
Rate for Payer: University Health Alliance Commercial	$22.60

APPENDECTOMY WITH COMPLEX PRINCIPAL DIAGNOSIS

Facility

$17,288.60

Service Code	APR-DRG 2334
Min. Negotiated Rate	$17,288.60
Max. Negotiated Rate	$17,288.60
Rate for Payer: AlohaCare Medicaid	$17,288.60
Rate for Payer: Hawaii Medical Service Association ABD	$17,288.60
Rate for Payer: Hawaii Medical Service Association Non-ABD	$17,288.60
Rate for Payer: Kaiser Permanente Medicaid	$17,288.60
Rate for Payer: Ohana Health Plan Medicaid	$17,288.60
Rate for Payer: UnitedHealthcare Medicaid	$17,288.60

APPENDECTOMY WITH COMPLEX PRINCIPAL DIAGNOSIS

Facility

$5,798.74

Service Code	APR-DRG 2331
Min. Negotiated Rate	$5,798.74
Max. Negotiated Rate	$5,798.74
Rate for Payer: AlohaCare Medicaid	$5,798.74
Rate for Payer: Hawaii Medical Service Association ABD	$5,798.74
Rate for Payer: Hawaii Medical Service Association Non-ABD	$5,798.74
Rate for Payer: Kaiser Permanente Medicaid	$5,798.74
Rate for Payer: Ohana Health Plan Medicaid	$5,798.74
Rate for Payer: UnitedHealthcare Medicaid	$5,798.74

Know your out-of-pocket cost for care.

All Charges