Hilo Benioff Medical Center

All Charges

Charge

Type

Setting

Price

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

APPENDECTOMY WITHOUT COMPLEX PRINCIPAL DIAGNOSIS

Facility

$4,214.36

Service Code	APR-DRG 2341
Min. Negotiated Rate	$4,214.36
Max. Negotiated Rate	$4,214.36
Rate for Payer: AlohaCare Medicaid	$4,214.36
Rate for Payer: Hawaii Medical Service Association ABD	$4,214.36
Rate for Payer: Hawaii Medical Service Association Non-ABD	$4,214.36
Rate for Payer: Kaiser Permanente Medicaid	$4,214.36
Rate for Payer: Ohana Health Plan Medicaid	$4,214.36
Rate for Payer: UnitedHealthcare Medicaid	$4,214.36

APPENDECTOMY WITHOUT COMPLEX PRINCIPAL DIAGNOSIS

Facility

$14,088.53

Service Code	APR-DRG 2344
Min. Negotiated Rate	$14,088.53
Max. Negotiated Rate	$14,088.53
Rate for Payer: AlohaCare Medicaid	$14,088.53
Rate for Payer: Hawaii Medical Service Association ABD	$14,088.53
Rate for Payer: Hawaii Medical Service Association Non-ABD	$14,088.53
Rate for Payer: Kaiser Permanente Medicaid	$14,088.53
Rate for Payer: Ohana Health Plan Medicaid	$14,088.53
Rate for Payer: UnitedHealthcare Medicaid	$14,088.53

APPENDECTOMY WITHOUT COMPLEX PRINCIPAL DIAGNOSIS

Facility

$5,733.51

Service Code	APR-DRG 2342
Min. Negotiated Rate	$5,733.51
Max. Negotiated Rate	$5,733.51
Rate for Payer: AlohaCare Medicaid	$5,733.51
Rate for Payer: Hawaii Medical Service Association ABD	$5,733.51
Rate for Payer: Hawaii Medical Service Association Non-ABD	$5,733.51
Rate for Payer: Kaiser Permanente Medicaid	$5,733.51
Rate for Payer: Ohana Health Plan Medicaid	$5,733.51
Rate for Payer: UnitedHealthcare Medicaid	$5,733.51

APPENDECTOMY WITHOUT COMPLEX PRINCIPAL DIAGNOSIS

Facility

$8,419.59

Service Code	APR-DRG 2343
Min. Negotiated Rate	$8,419.59
Max. Negotiated Rate	$8,419.59
Rate for Payer: AlohaCare Medicaid	$8,419.59
Rate for Payer: Hawaii Medical Service Association ABD	$8,419.59
Rate for Payer: Hawaii Medical Service Association Non-ABD	$8,419.59
Rate for Payer: Kaiser Permanente Medicaid	$8,419.59
Rate for Payer: Ohana Health Plan Medicaid	$8,419.59
Rate for Payer: UnitedHealthcare Medicaid	$8,419.59

APPENDIX PROCEDURES WITH CC

Facility

$32,443.64

Service Code	MSDRG 398
Min. Negotiated Rate	$17,216.09
Max. Negotiated Rate	$32,443.64
Rate for Payer: AlohaCare Medicare	$17,216.09
Rate for Payer: Devoted Health Medicare	$18,937.70
Rate for Payer: Hawaii Medical Service Association Commercial	$32,443.64
Rate for Payer: Hawaii Medical Service Association Medicare	$17,216.09
Rate for Payer: Humana Medicare	$17,216.09
Rate for Payer: Kaiser Permanente Commercial	$26,109.60
Rate for Payer: Kaiser Permanente Medicare	$17,216.09
Rate for Payer: Ohana Health Plan Medicare	$17,216.09
Rate for Payer: UnitedHealthcare Medicare	$17,216.09

APPENDIX PROCEDURES WITH MCC

Facility

$41,312.03

Service Code	MSDRG 397
Min. Negotiated Rate	$27,240.20
Max. Negotiated Rate	$41,312.03
Rate for Payer: AlohaCare Medicare	$27,240.20
Rate for Payer: Devoted Health Medicare	$29,964.22
Rate for Payer: Hawaii Medical Service Association Commercial	$35,137.17
Rate for Payer: Hawaii Medical Service Association Medicare	$27,240.20
Rate for Payer: Humana Medicare	$27,240.20
Rate for Payer: Kaiser Permanente Commercial	$41,312.03
Rate for Payer: Kaiser Permanente Medicare	$27,240.20
Rate for Payer: Ohana Health Plan Medicare	$27,240.20
Rate for Payer: UnitedHealthcare Medicare	$27,240.20

APPENDIX PROCEDURES WITHOUT CC/MCC

Facility

$24,217.47

Service Code	MSDRG 399
Min. Negotiated Rate	$13,020.12
Max. Negotiated Rate	$24,217.47
Rate for Payer: AlohaCare Medicare	$13,020.12
Rate for Payer: Devoted Health Medicare	$14,322.13
Rate for Payer: Hawaii Medical Service Association Commercial	$24,217.47
Rate for Payer: Hawaii Medical Service Association Medicare	$13,020.12
Rate for Payer: Humana Medicare	$13,020.12
Rate for Payer: Kaiser Permanente Commercial	$19,746.08
Rate for Payer: Kaiser Permanente Medicare	$13,020.12
Rate for Payer: Ohana Health Plan Medicare	$13,020.12
Rate for Payer: UnitedHealthcare Medicare	$13,020.12

APPLICATION OF LOW COST SKIN SUBSTITUTE GRAFT TO FACE, SCALP, EYELIDS, MOUTH, NECK, EARS, ORBITS, GENITALIA, HANDS, FEET, AND/OR MULTIPLE DIGITS, TOTAL WOUND SURFACE AREA UP TO 100 SQ CM; FIRST 25 SQ CM OR LESS WOUND SURFACE AREA

Facility

$2,837.00

Service Code	CPT C5275
Hospital Revenue Code	360
Min. Negotiated Rate	$459.10
Max. Negotiated Rate	$2,837.00
Rate for Payer: Kaiser Permanente Medicaid	$2,837.00
Rate for Payer: UnitedHealthcare Medicaid	$459.10

APPLICATION OF LOW COST SKIN SUBSTITUTE GRAFT TO TRUNK, ARMS, LEGS, TOTAL WOUND SURFACE AREA GREATER THAN OR EQUAL TO 100 SQ CM; EACH ADDITIONAL 100 SQ CM WOUND SURFACE AREA, OR PART THEREOF, OR EACH ADDITIONAL 1% OF BODY AREA OF INFANTS AND CHILDREN, OR PART THEREOF (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)

Facility

$2,837.00

Service Code	CPT C5274
Hospital Revenue Code	360
Min. Negotiated Rate	$2,837.00
Max. Negotiated Rate	$2,837.00
Rate for Payer: Kaiser Permanente Medicaid	$2,837.00

APPLICATION OF LOW COST SKIN SUBSTITUTE GRAFT TO TRUNK, ARMS, LEGS, TOTAL WOUND SURFACE AREA GREATER THAN OR EQUAL TO 100 SQ CM; FIRST 100 SQ CM WOUND SURFACE AREA, OR 1% OF BODY AREA OF INFANTS AND CHILDREN

Facility

$2,837.00

Service Code	CPT C5273
Hospital Revenue Code	360
Min. Negotiated Rate	$1.00
Max. Negotiated Rate	$2,837.00
Rate for Payer: Kaiser Permanente Medicaid	$2,837.00
Rate for Payer: UnitedHealthcare Medicaid	$1.00

APPLICATION OF LOW COST SKIN SUBSTITUTE GRAFT TO TRUNK, ARMS, LEGS, TOTAL WOUND SURFACE AREA UP TO 100 SQ CM; EACH ADDITIONAL 25 SQ CM WOUND SURFACE AREA, OR PART THEREOF (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)

Facility

$2,837.00

Service Code	CPT C5272
Hospital Revenue Code	360
Min. Negotiated Rate	$2,837.00
Max. Negotiated Rate	$2,837.00
Rate for Payer: Kaiser Permanente Medicaid	$2,837.00

APPLICATION OF LOW COST SKIN SUBSTITUTE GRAFT TO TRUNK, ARMS, LEGS, TOTAL WOUND SURFACE AREA UP TO 100 SQ CM; FIRST 25 SQ CM OR LESS WOUND SURFACE AREA

Facility

$2,837.00

Service Code	CPT C5271
Hospital Revenue Code	360
Min. Negotiated Rate	$459.10
Max. Negotiated Rate	$2,837.00
Rate for Payer: Kaiser Permanente Medicaid	$2,837.00
Rate for Payer: UnitedHealthcare Medicaid	$459.10

APPLICATION OF SKIN SUBSTITUTE GRAFT TO FACE, SCALP, EYELIDS, MOUTH, NECK, EARS, ORBITS, GENITALIA, HANDS, FEET, AND/OR MULTIPLE DIGITS, TOTAL WOUND SURFACE AREA GREATER THAN OR EQUAL TO 100 SQ CM; EACH ADDITIONAL 100 SQ CM WOUND SURFACE AREA, OR PART THEREOF, OR EACH ADDITIONAL 1% OF BODY AREA OF INFANTS AND CHILDREN, OR PART THEREOF (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)

Facility

$2,837.00

Service Code	CPT 15278
Hospital Revenue Code	360
Min. Negotiated Rate	$33.59
Max. Negotiated Rate	$2,837.00
Rate for Payer: Kaiser Permanente Medicaid	$2,837.00
Rate for Payer: UnitedHealthcare Medicaid	$33.59

Facility

$2,837.00

Service Code	CPT 15277
Hospital Revenue Code	360
Min. Negotiated Rate	$393.00
Max. Negotiated Rate	$2,837.00
Rate for Payer: AlohaCare Medicaid	$2,437.45
Rate for Payer: AlohaCare Medicare	$2,437.45
Rate for Payer: Devoted Health Medicare	$2,681.20
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	$2,437.45
Rate for Payer: Hawaii Medical Service Association Non-ABD	$496.75
Rate for Payer: Humana Medicare	$2,437.45
Rate for Payer: Kaiser Permanente Medicaid	$2,837.00
Rate for Payer: Kaiser Permanente Medicare	$2,437.45
Rate for Payer: Ohana Health Plan Medicaid	$2,681.20
Rate for Payer: Ohana Health Plan Medicare	$2,437.45
Rate for Payer: UnitedHealthcare Medicaid	$456.03
Rate for Payer: UnitedHealthcare Medicare	$2,437.45

APPLICATION OF SKIN SUBSTITUTE GRAFT TO FACE, SCALP, EYELIDS, MOUTH, NECK, EARS, ORBITS, GENITALIA, HANDS, FEET, AND/OR MULTIPLE DIGITS, TOTAL WOUND SURFACE AREA UP TO 100 SQ CM; EACH ADDITIONAL 25 SQ CM WOUND SURFACE AREA, OR PART THEREOF (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)

Facility

$2,837.00

Service Code	CPT 15276
Hospital Revenue Code	360
Min. Negotiated Rate	$15.08
Max. Negotiated Rate	$2,837.00
Rate for Payer: Kaiser Permanente Medicaid	$2,837.00
Rate for Payer: UnitedHealthcare Medicaid	$15.08

Facility

$8,270.00

Service Code	CPT 15275
Hospital Revenue Code	360
Min. Negotiated Rate	$456.03
Max. Negotiated Rate	$8,270.00
Rate for Payer: AlohaCare Medicaid	$873.10
Rate for Payer: AlohaCare Medicare	$873.10
Rate for Payer: Devoted Health Medicare	$960.41
Rate for Payer: Hawaii Medical Service Association ABD	$848.00
Rate for Payer: Hawaii Medical Service Association Commercial	$8,270.00
Rate for Payer: Hawaii Medical Service Association Medicare	$873.10
Rate for Payer: Hawaii Medical Service Association Non-ABD	$1,427.62
Rate for Payer: Humana Medicare	$873.10
Rate for Payer: Kaiser Permanente Medicaid	$2,837.00
Rate for Payer: Kaiser Permanente Medicare	$873.10
Rate for Payer: Ohana Health Plan Medicaid	$960.41
Rate for Payer: Ohana Health Plan Medicare	$873.10
Rate for Payer: UnitedHealthcare Medicaid	$456.03
Rate for Payer: UnitedHealthcare Medicare	$873.10

APPLICATION OF SKIN SUBSTITUTE GRAFT TO TRUNK, ARMS, LEGS, TOTAL WOUND SURFACE AREA GREATER THAN OR EQUAL TO 100 SQ CM; EACH ADDITIONAL 100 SQ CM WOUND SURFACE AREA, OR PART THEREOF, OR EACH ADDITIONAL 1% OF BODY AREA OF INFANTS AND CHILDREN, OR PART THEREOF (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)

Facility

$2,837.00

Service Code	CPT 15274
Hospital Revenue Code	360
Min. Negotiated Rate	$27.19
Max. Negotiated Rate	$2,837.00
Rate for Payer: Kaiser Permanente Medicaid	$2,837.00
Rate for Payer: UnitedHealthcare Medicaid	$27.19

APPLICATION OF SKIN SUBSTITUTE GRAFT TO TRUNK, ARMS, LEGS, TOTAL WOUND SURFACE AREA GREATER THAN OR EQUAL TO 100 SQ CM; FIRST 100 SQ CM WOUND SURFACE AREA, OR 1% OF BODY AREA OF INFANTS AND CHILDREN

Facility

$2,837.00

Service Code	CPT 15273
Hospital Revenue Code	360
Min. Negotiated Rate	$393.00
Max. Negotiated Rate	$2,837.00
Rate for Payer: AlohaCare Medicaid	$2,437.45
Rate for Payer: AlohaCare Medicare	$2,437.45
Rate for Payer: Devoted Health Medicare	$2,681.20
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	$2,437.45
Rate for Payer: Hawaii Medical Service Association Non-ABD	$496.75
Rate for Payer: Humana Medicare	$2,437.45
Rate for Payer: Kaiser Permanente Medicaid	$2,837.00
Rate for Payer: Kaiser Permanente Medicare	$2,437.45
Rate for Payer: Ohana Health Plan Medicaid	$2,681.20
Rate for Payer: Ohana Health Plan Medicare	$2,437.45
Rate for Payer: UnitedHealthcare Medicaid	$456.03
Rate for Payer: UnitedHealthcare Medicare	$2,437.45

APPLICATOR ENDOSCOPIC

Facility

$316.00

Hospital Revenue Code	272
Min. Negotiated Rate	$268.60
Max. Negotiated Rate	$306.52
Rate for Payer: Cash Price	$189.60
Rate for Payer: Health Management Network Commercial	$268.60
Rate for Payer: MDX Hawaii PPO	$306.52

APPLICATOR ENDOSCOPIC

Facility

$316.00

Hospital Revenue Code	272
Min. Negotiated Rate	$161.16
Max. Negotiated Rate	$306.52
Rate for Payer: Cash Price	$189.60
Rate for Payer: Hawaii Western Management Group Commercial	$300.20
Rate for Payer: Health Management Network Commercial	$268.60
Rate for Payer: Kaiser Permanente Commercial	$199.08
Rate for Payer: Kaiser Permanente Medicaid	$161.16
Rate for Payer: MDX Hawaii PPO	$306.52
Rate for Payer: University Health Alliance Commercial	$230.33

APRACLONIDINE 0.5 % EYE DROPS [9119]

Facility

$217.00

Service Code	NDC 61314066505
Hospital Revenue Code	250
Min. Negotiated Rate	$184.45
Max. Negotiated Rate	$210.49
Rate for Payer: Cash Price	$130.20
Rate for Payer: Health Management Network Commercial	$184.45
Rate for Payer: MDX Hawaii PPO	$210.49

APRACLONIDINE 0.5 % EYE DROPS [9119]

Facility

$217.00

Service Code	NDC 61314066505
Hospital Revenue Code	637
Min. Negotiated Rate	$110.67
Max. Negotiated Rate	$210.49
Rate for Payer: Cash Price	$130.20
Rate for Payer: Hawaii Western Management Group Commercial	$206.15
Rate for Payer: Health Management Network Commercial	$184.45
Rate for Payer: Kaiser Permanente Commercial	$136.71
Rate for Payer: Kaiser Permanente Medicaid	$110.67
Rate for Payer: MDX Hawaii PPO	$210.49
Rate for Payer: University Health Alliance Commercial	$158.17

AQUAMANTYS MALLEABLE BIPOLAR

Facility

$1,885.00

Hospital Revenue Code	272
Min. Negotiated Rate	$1,602.25
Max. Negotiated Rate	$1,828.45
Rate for Payer: Cash Price	$1,131.00
Rate for Payer: Health Management Network Commercial	$1,602.25
Rate for Payer: MDX Hawaii PPO	$1,828.45

Know your out-of-pocket cost for care.

All Charges