Hilo Benioff Medical Center

All Charges

Charge

Type

Setting

Price

HC NURSERY LEVEL 1 DAILY

Facility

$1,875.00

Hospital Charge Code	1710000001
Hospital Revenue Code	171
Min. Negotiated Rate	$1,593.75
Max. Negotiated Rate	$2,250.00
Rate for Payer: Cash Price	$1,125.00
Rate for Payer: Cash Price	$1,125.00
Rate for Payer: Hawaii Western Management Group Commercial	$2,250.00
Rate for Payer: Health Management Network Commercial	$1,593.75
Rate for Payer: MDX Hawaii PPO	$1,818.75
Rate for Payer: University Health Alliance Commercial	$1,875.00

HC NURSERY LEVEL 2 DAILY

Facility

$2,500.00

Hospital Charge Code	1720000001
Hospital Revenue Code	172
Min. Negotiated Rate	$1,875.00
Max. Negotiated Rate	$2,425.00
Rate for Payer: Cash Price	$1,500.00
Rate for Payer: Cash Price	$1,500.00
Rate for Payer: Hawaii Western Management Group Commercial	$2,250.00
Rate for Payer: Health Management Network Commercial	$2,125.00
Rate for Payer: MDX Hawaii PPO	$2,425.00
Rate for Payer: University Health Alliance Commercial	$1,875.00

HC OB ROOM DAILY

Facility

$3,125.00

Hospital Charge Code	1220000001
Hospital Revenue Code	122
Min. Negotiated Rate	$2,656.25
Max. Negotiated Rate	$7,250.00
Rate for Payer: Cash Price	$1,875.00
Rate for Payer: Cash Price	$1,875.00
Rate for Payer: Hawaii Western Management Group Commercial	$7,250.00
Rate for Payer: Health Management Network Commercial	$2,656.25
Rate for Payer: MDX Hawaii PPO	$3,031.25
Rate for Payer: University Health Alliance Commercial	$5,923.00

HC OBSERVATION CARVE-OUT - GASTROINTESTINAL

Facility

$174.00

Service Code	HCPCS G0378
Hospital Charge Code	762G037803
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

HC OBSERVATION CARVE-OUT - GASTROINTESTINAL

Facility

$174.00

Service Code	HCPCS G0378
Hospital Charge Code	762G037803
Hospital Revenue Code	762
Min. Negotiated Rate	$147.90
Max. Negotiated Rate	$168.78
Rate for Payer: Cash Price	$104.40
Rate for Payer: Health Management Network Commercial	$147.90
Rate for Payer: MDX Hawaii PPO	$168.78

HC OBSERVATION CARVE-OUT - IV INFUSION ADMIN

Facility

$174.00

Service Code	HCPCS G0378
Hospital Charge Code	762G037808
Hospital Revenue Code	762
Min. Negotiated Rate	$147.90
Max. Negotiated Rate	$168.78
Rate for Payer: Cash Price	$104.40
Rate for Payer: Health Management Network Commercial	$147.90
Rate for Payer: MDX Hawaii PPO	$168.78

HC OBSERVATION CARVE-OUT - IV INFUSION ADMIN

Facility

$174.00

Service Code	HCPCS G0378
Hospital Charge Code	762G037808
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

HC OBSERVATION CARVE-OUT - RADIOLOGY

Facility

$174.00

Service Code	HCPCS G0378
Hospital Charge Code	762G037802
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

HC OBSERVATION CARVE-OUT - RADIOLOGY

Facility

$174.00

Service Code	HCPCS G0378
Hospital Charge Code	762G037802
Hospital Revenue Code	762
Min. Negotiated Rate	$147.90
Max. Negotiated Rate	$168.78
Rate for Payer: Cash Price	$104.40
Rate for Payer: Health Management Network Commercial	$147.90
Rate for Payer: MDX Hawaii PPO	$168.78

HC OBSERVATION CARVE-OUT - RESPIRATORY

Facility

$174.00

Service Code	HCPCS G0378
Hospital Charge Code	762G037805
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

HC OBSERVATION CARVE-OUT - RESPIRATORY

Facility

$174.00

Service Code	HCPCS G0378
Hospital Charge Code	762G037805
Hospital Revenue Code	762
Min. Negotiated Rate	$147.90
Max. Negotiated Rate	$168.78
Rate for Payer: Cash Price	$104.40
Rate for Payer: Health Management Network Commercial	$147.90
Rate for Payer: MDX Hawaii PPO	$168.78

HC OBSERVATION CARVE-OUT - SURGICAL

Facility

$174.00

Service Code	HCPCS G0378
Hospital Charge Code	762G037806
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

HC OBSERVATION CARVE-OUT - SURGICAL

Facility

$174.00

Service Code	HCPCS G0378
Hospital Charge Code	762G037806
Hospital Revenue Code	762
Min. Negotiated Rate	$147.90
Max. Negotiated Rate	$168.78
Rate for Payer: Cash Price	$104.40
Rate for Payer: Health Management Network Commercial	$147.90
Rate for Payer: MDX Hawaii PPO	$168.78

HC OBSERVATION HOURLY

Facility

$174.00

Service Code	HCPCS G0378
Hospital Charge Code	762G037801
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

HC OBSERVATION HOURLY

Facility

$174.00

Service Code	HCPCS G0378
Hospital Charge Code	762G037801
Hospital Revenue Code	762
Min. Negotiated Rate	$147.90
Max. Negotiated Rate	$168.78
Rate for Payer: Cash Price	$104.40
Rate for Payer: Health Management Network Commercial	$147.90
Rate for Payer: MDX Hawaii PPO	$168.78

HC OBSTRUCTIVE MATERIAL REMOVAL FROM GI TUBE

Facility

$4,664.00

Service Code	HCPCS 49460
Hospital Charge Code	3614946001
Hospital Revenue Code	361
Min. Negotiated Rate	$393.00
Max. Negotiated Rate	$4,524.08
Rate for Payer: AlohaCare Medicaid	$1,071.46
Rate for Payer: AlohaCare Medicare	$1,071.46
Rate for Payer: Cash Price	$2,798.40
Rate for Payer: Cash Price	$2,798.40
Rate for Payer: Cash Price	$2,798.40
Rate for Payer: Devoted Health Medicare	$1,178.61
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	$1,071.46
Rate for Payer: Hawaii Medical Service Association Non-ABD	$496.75
Rate for Payer: Health Management Network Commercial	$3,964.40
Rate for Payer: Humana Medicare	$1,071.46
Rate for Payer: Kaiser Permanente Commercial	$2,938.32
Rate for Payer: Kaiser Permanente Medicaid	$2,837.00
Rate for Payer: Kaiser Permanente Medicare	$1,071.46
Rate for Payer: MDX Hawaii PPO	$4,524.08
Rate for Payer: Ohana Health Plan Medicaid	$1,178.61
Rate for Payer: Ohana Health Plan Medicare	$1,071.46
Rate for Payer: UnitedHealthcare Medicaid	$456.03
Rate for Payer: UnitedHealthcare Medicare	$1,071.46
Rate for Payer: University Health Alliance Commercial	$3,399.59

HC OBSTRUCTIVE MATERIAL REMOVAL FROM GI TUBE

Facility

$4,664.00

Service Code	HCPCS 49460
Hospital Charge Code	3614946001
Hospital Revenue Code	361
Min. Negotiated Rate	$3,964.40
Max. Negotiated Rate	$4,524.08
Rate for Payer: Cash Price	$2,798.40
Rate for Payer: Health Management Network Commercial	$3,964.40
Rate for Payer: MDX Hawaii PPO	$4,524.08

HC OB US < 14 WKS ADDL FETUS - US OB < 14 WEEKS EACH ADDITIONAL GEST

Facility

$430.00

Service Code	HCPCS 76802
Hospital Charge Code	4027680201
Hospital Revenue Code	402
Min. Negotiated Rate	$28.71
Max. Negotiated Rate	$417.10
Rate for Payer: Cash Price	$258.00
Rate for Payer: Cash Price	$258.00
Rate for Payer: Hawaii Medical Service Association ABD	$28.71
Rate for Payer: Hawaii Medical Service Association Non-ABD	$34.28
Rate for Payer: Hawaii Western Management Group Commercial	$408.50
Rate for Payer: Health Management Network Commercial	$365.50
Rate for Payer: Kaiser Permanente Commercial	$270.90
Rate for Payer: Kaiser Permanente Medicaid	$219.30
Rate for Payer: MDX Hawaii PPO	$417.10
Rate for Payer: UnitedHealthcare Medicaid	$28.71
Rate for Payer: University Health Alliance Commercial	$152.61

HC OB US < 14 WKS ADDL FETUS - US OB < 14 WEEKS EACH ADDITIONAL GEST

Facility

$430.00

Service Code	HCPCS 76802
Hospital Charge Code	4027680201
Hospital Revenue Code	402
Min. Negotiated Rate	$365.50
Max. Negotiated Rate	$417.10
Rate for Payer: Cash Price	$258.00
Rate for Payer: Health Management Network Commercial	$365.50
Rate for Payer: MDX Hawaii PPO	$417.10

HC OB US < 14 WKS SINGLE FETUS - US OB < 14 WEEKS SINGLE OR FIRST GEST

Facility

$529.00

Service Code	HCPCS 76801
Hospital Charge Code	4027680101
Hospital Revenue Code	402
Min. Negotiated Rate	$55.49
Max. Negotiated Rate	$513.13
Rate for Payer: AlohaCare Medicaid	$123.50
Rate for Payer: AlohaCare Medicare	$123.50
Rate for Payer: Cash Price	$317.40
Rate for Payer: Cash Price	$317.40
Rate for Payer: Devoted Health Medicare	$135.85
Rate for Payer: Hawaii Medical Service Association ABD	$55.49
Rate for Payer: Hawaii Medical Service Association Commercial	$154.38
Rate for Payer: Hawaii Medical Service Association Medicare	$123.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$66.25
Rate for Payer: Hawaii Western Management Group Commercial	$123.50
Rate for Payer: Health Management Network Commercial	$449.65
Rate for Payer: Humana Medicare	$123.50
Rate for Payer: Kaiser Permanente Commercial	$333.27
Rate for Payer: Kaiser Permanente Medicaid	$269.79
Rate for Payer: Kaiser Permanente Medicare	$123.50
Rate for Payer: MDX Hawaii PPO	$513.13
Rate for Payer: Ohana Health Plan Medicaid	$135.85
Rate for Payer: Ohana Health Plan Medicare	$123.50
Rate for Payer: UnitedHealthcare Medicaid	$55.49
Rate for Payer: UnitedHealthcare Medicare	$123.50
Rate for Payer: University Health Alliance Commercial	$265.83

HC OB US < 14 WKS SINGLE FETUS - US OB < 14 WEEKS SINGLE OR FIRST GEST

Facility

$529.00

Service Code	HCPCS 76801
Hospital Charge Code	4027680101
Hospital Revenue Code	402
Min. Negotiated Rate	$449.65
Max. Negotiated Rate	$513.13
Rate for Payer: Cash Price	$317.40
Rate for Payer: Health Management Network Commercial	$449.65
Rate for Payer: MDX Hawaii PPO	$513.13

HC OB US >/= 14 WKS SNGL FETUS - US OB 14+ WEEKS SINGLE OR FIRST GEST

Facility

$529.00

Service Code	HCPCS 76805
Hospital Charge Code	4027680501
Hospital Revenue Code	402
Min. Negotiated Rate	$61.23
Max. Negotiated Rate	$513.13
Rate for Payer: AlohaCare Medicaid	$123.50
Rate for Payer: AlohaCare Medicare	$123.50
Rate for Payer: Cash Price	$317.40
Rate for Payer: Cash Price	$317.40
Rate for Payer: Devoted Health Medicare	$135.85
Rate for Payer: Hawaii Medical Service Association ABD	$61.23
Rate for Payer: Hawaii Medical Service Association Commercial	$154.38
Rate for Payer: Hawaii Medical Service Association Medicare	$123.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$75.32
Rate for Payer: Hawaii Western Management Group Commercial	$123.50
Rate for Payer: Health Management Network Commercial	$449.65
Rate for Payer: Humana Medicare	$123.50
Rate for Payer: Kaiser Permanente Commercial	$333.27
Rate for Payer: Kaiser Permanente Medicaid	$269.79
Rate for Payer: Kaiser Permanente Medicare	$123.50
Rate for Payer: MDX Hawaii PPO	$513.13
Rate for Payer: Ohana Health Plan Medicaid	$135.85
Rate for Payer: Ohana Health Plan Medicare	$123.50
Rate for Payer: UnitedHealthcare Medicaid	$61.23
Rate for Payer: UnitedHealthcare Medicare	$123.50
Rate for Payer: University Health Alliance Commercial	$287.45

HC OB US >/= 14 WKS SNGL FETUS - US OB 14+ WEEKS SINGLE OR FIRST GEST

Facility

$529.00

Service Code	HCPCS 76805
Hospital Charge Code	4027680501
Hospital Revenue Code	402
Min. Negotiated Rate	$449.65
Max. Negotiated Rate	$513.13
Rate for Payer: Cash Price	$317.40
Rate for Payer: Health Management Network Commercial	$449.65
Rate for Payer: MDX Hawaii PPO	$513.13

HC OB US DETAILED SNGL FETUS - US OB DETAIL FETAL ANAT SING OR 1ST GEST

Facility

$1,203.00

Service Code	HCPCS 76811
Hospital Charge Code	4027681101
Hospital Revenue Code	402
Min. Negotiated Rate	$112.44
Max. Negotiated Rate	$1,166.91
Rate for Payer: AlohaCare Medicaid	$281.87
Rate for Payer: AlohaCare Medicare	$281.87
Rate for Payer: Cash Price	$721.80
Rate for Payer: Cash Price	$721.80
Rate for Payer: Devoted Health Medicare	$310.06
Rate for Payer: Hawaii Medical Service Association ABD	$112.44
Rate for Payer: Hawaii Medical Service Association Commercial	$352.34
Rate for Payer: Hawaii Medical Service Association Medicare	$281.87
Rate for Payer: Hawaii Medical Service Association Non-ABD	$131.50
Rate for Payer: Hawaii Western Management Group Commercial	$281.87
Rate for Payer: Health Management Network Commercial	$1,022.55
Rate for Payer: Humana Medicare	$281.87
Rate for Payer: Kaiser Permanente Commercial	$757.89
Rate for Payer: Kaiser Permanente Medicaid	$613.53
Rate for Payer: Kaiser Permanente Medicare	$281.87
Rate for Payer: MDX Hawaii PPO	$1,166.91
Rate for Payer: Ohana Health Plan Medicaid	$310.06
Rate for Payer: Ohana Health Plan Medicare	$281.87
Rate for Payer: UnitedHealthcare Medicaid	$112.44
Rate for Payer: UnitedHealthcare Medicare	$281.87
Rate for Payer: University Health Alliance Commercial	$436.01

HC OB US DETAILED SNGL FETUS - US OB DETAIL FETAL ANAT SING OR 1ST GEST

Facility

$1,203.00

Service Code	HCPCS 76811
Hospital Charge Code	4027681101
Hospital Revenue Code	402
Min. Negotiated Rate	$1,022.55
Max. Negotiated Rate	$1,166.91
Rate for Payer: Cash Price	$721.80
Rate for Payer: Health Management Network Commercial	$1,022.55
Rate for Payer: MDX Hawaii PPO	$1,166.91

Know your out-of-pocket cost for care.

All Charges