Hilo Benioff Medical Center

All Charges

Charge

Type

Setting

Price

HC OB US FOLLOW-UP PER FETUS - US OB FOLLOW UP TRANSABDOMINAL APPROACH

Facility

$529.00

Service Code	HCPCS 76816
Hospital Charge Code	4027681601
Hospital Revenue Code	402
Min. Negotiated Rate	$36.81
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	$36.81
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	$39.59
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	$36.81
Rate for Payer: UnitedHealthcare Medicare	$123.50
Rate for Payer: University Health Alliance Commercial	$203.81

HC OB US FOLLOW-UP PER FETUS - US OB FOLLOW UP TRANSABDOMINAL APPROACH

Facility

$529.00

Service Code	HCPCS 76816
Hospital Charge Code	4027681601
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 LIMITED FETUS(S) - US OB LIMITED 1+ FETUSES

Facility

$529.00

Service Code	HCPCS 76815
Hospital Charge Code	4027681501
Hospital Revenue Code	402
Min. Negotiated Rate	$46.98
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	$46.98
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	$50.90
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	$46.98
Rate for Payer: UnitedHealthcare Medicare	$123.50
Rate for Payer: University Health Alliance Commercial	$183.63

HC OB US LIMITED FETUS(S) - US OB LIMITED 1+ FETUSES

Facility

$529.00

Service Code	HCPCS 76815
Hospital Charge Code	4027681501
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 OLIGOCLONAL IMMUNOGLOBULIN - OLIGOCLONAL BANDING

Facility

$230.00

Service Code	HCPCS 83916
Hospital Charge Code	3018391601
Hospital Revenue Code	301
Min. Negotiated Rate	$27.39
Max. Negotiated Rate	$223.10
Rate for Payer: AlohaCare Medicaid	$27.39
Rate for Payer: AlohaCare Medicare	$27.39
Rate for Payer: Cash Price	$138.00
Rate for Payer: Cash Price	$138.00
Rate for Payer: Devoted Health Medicare	$30.13
Rate for Payer: Hawaii Medical Service Association ABD	$27.79
Rate for Payer: Hawaii Medical Service Association Commercial	$34.24
Rate for Payer: Hawaii Medical Service Association Medicare	$27.39
Rate for Payer: Hawaii Medical Service Association Non-ABD	$29.18
Rate for Payer: Hawaii Western Management Group Commercial	$27.39
Rate for Payer: Health Management Network Commercial	$195.50
Rate for Payer: Humana Medicare	$27.39
Rate for Payer: Kaiser Permanente Commercial	$144.90
Rate for Payer: Kaiser Permanente Medicaid	$117.30
Rate for Payer: Kaiser Permanente Medicare	$27.39
Rate for Payer: MDX Hawaii PPO	$223.10
Rate for Payer: Ohana Health Plan Medicaid	$30.13
Rate for Payer: Ohana Health Plan Medicare	$27.39
Rate for Payer: UnitedHealthcare Medicaid	$27.79
Rate for Payer: UnitedHealthcare Medicare	$27.39
Rate for Payer: University Health Alliance Commercial	$51.97

HC OLIGOCLONAL IMMUNOGLOBULIN - OLIGOCLONAL BANDING

Facility

$230.00

Service Code	HCPCS 83916
Hospital Charge Code	3018391601
Hospital Revenue Code	301
Min. Negotiated Rate	$195.50
Max. Negotiated Rate	$223.10
Rate for Payer: Cash Price	$138.00
Rate for Payer: Health Management Network Commercial	$195.50
Rate for Payer: MDX Hawaii PPO	$223.10

HC OPEN/PERQ PLACEMENT INTRAVASCULAR STENT SAME 1ST

Facility

$45,131.00

Service Code	HCPCS 37238
Hospital Charge Code	3603723801
Hospital Revenue Code	360
Min. Negotiated Rate	$644.55
Max. Negotiated Rate	$43,777.07
Rate for Payer: AlohaCare Medicaid	$13,637.67
Rate for Payer: AlohaCare Medicare	$13,637.67
Rate for Payer: Cash Price	$27,078.60
Rate for Payer: Cash Price	$27,078.60
Rate for Payer: Cash Price	$27,078.60
Rate for Payer: Devoted Health Medicare	$15,001.44
Rate for Payer: Hawaii Medical Service Association ABD	$1,900.00
Rate for Payer: Hawaii Medical Service Association Commercial	$14,395.00
Rate for Payer: Hawaii Medical Service Association Medicare	$13,637.67
Rate for Payer: Hawaii Medical Service Association Non-ABD	$2,695.11
Rate for Payer: Health Management Network Commercial	$38,361.35
Rate for Payer: Humana Medicare	$13,637.67
Rate for Payer: Kaiser Permanente Commercial	$28,432.53
Rate for Payer: Kaiser Permanente Medicaid	$2,837.00
Rate for Payer: Kaiser Permanente Medicare	$13,637.67
Rate for Payer: MDX Hawaii PPO	$43,777.07
Rate for Payer: Ohana Health Plan Medicaid	$15,001.44
Rate for Payer: Ohana Health Plan Medicare	$13,637.67
Rate for Payer: UnitedHealthcare Medicaid	$644.55
Rate for Payer: UnitedHealthcare Medicare	$13,637.67
Rate for Payer: University Health Alliance Commercial	$13,923.44

HC OPEN/PERQ PLACEMENT INTRAVASCULAR STENT SAME 1ST

Facility

$45,131.00

Service Code	HCPCS 37238
Hospital Charge Code	3603723801
Hospital Revenue Code	360
Min. Negotiated Rate	$38,361.35
Max. Negotiated Rate	$43,777.07
Rate for Payer: Cash Price	$27,078.60
Rate for Payer: Health Management Network Commercial	$38,361.35
Rate for Payer: MDX Hawaii PPO	$43,777.07

HC OPEN TREATMENT OF CRANIOFACIAL SEPARATION (LEFORT III TYPE); COMPLICATED, MULTIPLE APPROACHES

Facility

$12,637.00

Service Code	HCPCS 21431
Hospital Charge Code	4502143101
Hospital Revenue Code	450
Min. Negotiated Rate	$520.00
Max. Negotiated Rate	$12,257.89
Rate for Payer: AlohaCare Medicaid	$6,993.36
Rate for Payer: AlohaCare Medicare	$6,993.36
Rate for Payer: Cash Price	$7,582.20
Rate for Payer: Cash Price	$7,582.20
Rate for Payer: Cash Price	$7,582.20
Rate for Payer: Cash Price	$7,582.20
Rate for Payer: Devoted Health Medicare	$7,692.70
Rate for Payer: Hawaii Medical Service Association ABD	$569.00
Rate for Payer: Hawaii Medical Service Association Commercial	$1,600.00
Rate for Payer: Hawaii Medical Service Association Medicare	$6,993.36
Rate for Payer: Hawaii Medical Service Association Non-ABD	$520.00
Rate for Payer: Hawaii Western Management Group Commercial	$12,005.15
Rate for Payer: Health Management Network Commercial	$10,741.45
Rate for Payer: Humana Medicare	$6,993.36
Rate for Payer: Kaiser Permanente Commercial	$7,961.31
Rate for Payer: Kaiser Permanente Medicaid	$937.50
Rate for Payer: Kaiser Permanente Medicare	$6,993.36
Rate for Payer: MDX Hawaii PPO	$12,257.89
Rate for Payer: Ohana Health Plan Medicaid	$7,692.70
Rate for Payer: Ohana Health Plan Medicare	$6,993.36
Rate for Payer: UnitedHealthcare Medicaid	$521.33
Rate for Payer: UnitedHealthcare Medicare	$6,993.36
Rate for Payer: University Health Alliance Commercial	$9,211.11

HC OPEN TREATMENT OF CRANIOFACIAL SEPARATION (LEFORT III TYPE); COMPLICATED, MULTIPLE APPROACHES

Facility

$12,637.00

Service Code	HCPCS 21431
Hospital Charge Code	4502143101
Hospital Revenue Code	450
Min. Negotiated Rate	$10,741.45
Max. Negotiated Rate	$12,257.89
Rate for Payer: Cash Price	$7,582.20
Rate for Payer: Health Management Network Commercial	$10,741.45
Rate for Payer: MDX Hawaii PPO	$12,257.89

HC OPEN TREATMENT OF GREATER TROCHANTERIC FRACTURE; WITH INTERNAL FIXATION

Facility

$935.00

Service Code	HCPCS 27246
Hospital Charge Code	4502724601
Hospital Revenue Code	450
Min. Negotiated Rate	$291.40
Max. Negotiated Rate	$2,536.00
Rate for Payer: AlohaCare Medicaid	$291.40
Rate for Payer: AlohaCare Medicare	$291.40
Rate for Payer: Cash Price	$561.00
Rate for Payer: Cash Price	$561.00
Rate for Payer: Cash Price	$561.00
Rate for Payer: Devoted Health Medicare	$320.54
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	$291.40
Rate for Payer: Hawaii Medical Service Association Non-ABD	$496.75
Rate for Payer: Hawaii Western Management Group Commercial	$888.25
Rate for Payer: Health Management Network Commercial	$794.75
Rate for Payer: Humana Medicare	$291.40
Rate for Payer: Kaiser Permanente Commercial	$589.05
Rate for Payer: Kaiser Permanente Medicaid	$937.50
Rate for Payer: Kaiser Permanente Medicare	$291.40
Rate for Payer: MDX Hawaii PPO	$906.95
Rate for Payer: Ohana Health Plan Medicaid	$320.54
Rate for Payer: Ohana Health Plan Medicare	$291.40
Rate for Payer: UnitedHealthcare Medicare	$291.40
Rate for Payer: University Health Alliance Commercial	$681.52

HC OPEN TREATMENT OF GREATER TROCHANTERIC FRACTURE; WITH INTERNAL FIXATION

Facility

$935.00

Service Code	HCPCS 27246
Hospital Charge Code	4502724601
Hospital Revenue Code	450
Min. Negotiated Rate	$794.75
Max. Negotiated Rate	$906.95
Rate for Payer: Cash Price	$561.00
Rate for Payer: Health Management Network Commercial	$794.75
Rate for Payer: MDX Hawaii PPO	$906.95

HC OPEN TREATMENT OF HUMERAL CONDYLAR FRACTURE, MEDIAL OR LATERAL, WITH INTERNAL FIXATION

Facility

$935.00

Service Code	HCPCS 24576
Hospital Charge Code	4502457601
Hospital Revenue Code	450
Min. Negotiated Rate	$291.40
Max. Negotiated Rate	$2,536.00
Rate for Payer: AlohaCare Medicaid	$291.40
Rate for Payer: AlohaCare Medicare	$291.40
Rate for Payer: Cash Price	$561.00
Rate for Payer: Cash Price	$561.00
Rate for Payer: Cash Price	$561.00
Rate for Payer: Devoted Health Medicare	$320.54
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	$291.40
Rate for Payer: Hawaii Medical Service Association Non-ABD	$496.75
Rate for Payer: Hawaii Western Management Group Commercial	$888.25
Rate for Payer: Health Management Network Commercial	$794.75
Rate for Payer: Humana Medicare	$291.40
Rate for Payer: Kaiser Permanente Commercial	$589.05
Rate for Payer: Kaiser Permanente Medicaid	$937.50
Rate for Payer: Kaiser Permanente Medicare	$291.40
Rate for Payer: MDX Hawaii PPO	$906.95
Rate for Payer: Ohana Health Plan Medicaid	$320.54
Rate for Payer: Ohana Health Plan Medicare	$291.40
Rate for Payer: UnitedHealthcare Medicare	$291.40
Rate for Payer: University Health Alliance Commercial	$681.52

HC OPEN TREATMENT OF HUMERAL CONDYLAR FRACTURE, MEDIAL OR LATERAL, WITH INTERNAL FIXATION

Facility

$935.00

Service Code	HCPCS 24576
Hospital Charge Code	4502457601
Hospital Revenue Code	450
Min. Negotiated Rate	$794.75
Max. Negotiated Rate	$906.95
Rate for Payer: Cash Price	$561.00
Rate for Payer: Health Management Network Commercial	$794.75
Rate for Payer: MDX Hawaii PPO	$906.95

HC OPEN TREATMENT OF HUMERAL SHAFT FRACTURE; WITH PLATE/SCREWS, WITH OR WITHOUT CERCLAGE

Facility

$935.00

Service Code	HCPCS 24560
Hospital Charge Code	4502456001
Hospital Revenue Code	450
Min. Negotiated Rate	$291.40
Max. Negotiated Rate	$1,600.00
Rate for Payer: AlohaCare Medicaid	$291.40
Rate for Payer: AlohaCare Medicare	$291.40
Rate for Payer: Cash Price	$561.00
Rate for Payer: Cash Price	$561.00
Rate for Payer: Cash Price	$561.00
Rate for Payer: Cash Price	$561.00
Rate for Payer: Devoted Health Medicare	$320.54
Rate for Payer: Hawaii Medical Service Association ABD	$569.00
Rate for Payer: Hawaii Medical Service Association Commercial	$1,600.00
Rate for Payer: Hawaii Medical Service Association Medicare	$291.40
Rate for Payer: Hawaii Medical Service Association Non-ABD	$520.00
Rate for Payer: Hawaii Western Management Group Commercial	$888.25
Rate for Payer: Health Management Network Commercial	$794.75
Rate for Payer: Humana Medicare	$291.40
Rate for Payer: Kaiser Permanente Commercial	$589.05
Rate for Payer: Kaiser Permanente Medicaid	$937.50
Rate for Payer: Kaiser Permanente Medicare	$291.40
Rate for Payer: MDX Hawaii PPO	$906.95
Rate for Payer: Ohana Health Plan Medicaid	$320.54
Rate for Payer: Ohana Health Plan Medicare	$291.40
Rate for Payer: UnitedHealthcare Medicare	$291.40
Rate for Payer: University Health Alliance Commercial	$681.52

HC OPEN TREATMENT OF HUMERAL SHAFT FRACTURE; WITH PLATE/SCREWS, WITH OR WITHOUT CERCLAGE

Facility

$935.00

Service Code	HCPCS 24560
Hospital Charge Code	4502456001
Hospital Revenue Code	450
Min. Negotiated Rate	$794.75
Max. Negotiated Rate	$906.95
Rate for Payer: Cash Price	$561.00
Rate for Payer: Health Management Network Commercial	$794.75
Rate for Payer: MDX Hawaii PPO	$906.95

HC OPEN TREATMENT OF PALATAL OR MAXILLARY FRACTURE (LEFORT I TYPE); COMPLICATED, MULTIPLE APPROACHES

Facility

$12,637.00

Service Code	HCPCS 21421
Hospital Charge Code	4502142101
Hospital Revenue Code	450
Min. Negotiated Rate	$456.03
Max. Negotiated Rate	$12,257.89
Rate for Payer: AlohaCare Medicaid	$3,916.70
Rate for Payer: AlohaCare Medicare	$3,916.70
Rate for Payer: Cash Price	$7,582.20
Rate for Payer: Cash Price	$7,582.20
Rate for Payer: Cash Price	$7,582.20
Rate for Payer: Devoted Health Medicare	$4,308.37
Rate for Payer: Hawaii Medical Service Association ABD	$695.00
Rate for Payer: Hawaii Medical Service Association Commercial	$5,509.00
Rate for Payer: Hawaii Medical Service Association Medicare	$3,916.70
Rate for Payer: Hawaii Medical Service Association Non-ABD	$1,028.67
Rate for Payer: Hawaii Western Management Group Commercial	$12,005.15
Rate for Payer: Health Management Network Commercial	$10,741.45
Rate for Payer: Humana Medicare	$3,916.70
Rate for Payer: Kaiser Permanente Commercial	$7,961.31
Rate for Payer: Kaiser Permanente Medicaid	$937.50
Rate for Payer: Kaiser Permanente Medicare	$3,916.70
Rate for Payer: MDX Hawaii PPO	$12,257.89
Rate for Payer: Ohana Health Plan Medicaid	$4,308.37
Rate for Payer: Ohana Health Plan Medicare	$3,916.70
Rate for Payer: UnitedHealthcare Medicaid	$456.03
Rate for Payer: UnitedHealthcare Medicare	$3,916.70
Rate for Payer: University Health Alliance Commercial	$10,679.55

HC OPEN TREATMENT OF PALATAL OR MAXILLARY FRACTURE (LEFORT I TYPE); COMPLICATED, MULTIPLE APPROACHES

Facility

$12,637.00

Service Code	HCPCS 21421
Hospital Charge Code	4502142101
Hospital Revenue Code	450
Min. Negotiated Rate	$10,741.45
Max. Negotiated Rate	$12,257.89
Rate for Payer: Cash Price	$7,582.20
Rate for Payer: Health Management Network Commercial	$10,741.45
Rate for Payer: MDX Hawaii PPO	$12,257.89

HC OR ACUITY ADD'L 15 MIN

Facility

$621.00

Hospital Charge Code	3600000006
Hospital Revenue Code	360
Min. Negotiated Rate	$391.23
Max. Negotiated Rate	$2,837.00
Rate for Payer: Cash Price	$372.60
Rate for Payer: Cash Price	$372.60
Rate for Payer: Health Management Network Commercial	$527.85
Rate for Payer: Kaiser Permanente Commercial	$391.23
Rate for Payer: Kaiser Permanente Medicaid	$2,837.00
Rate for Payer: MDX Hawaii PPO	$602.37
Rate for Payer: University Health Alliance Commercial	$452.65

HC OR ACUITY ADD'L 15 MIN

Facility

$621.00

Hospital Charge Code	3600000006
Hospital Revenue Code	360
Min. Negotiated Rate	$527.85
Max. Negotiated Rate	$602.37
Rate for Payer: Cash Price	$372.60
Rate for Payer: Health Management Network Commercial	$527.85
Rate for Payer: MDX Hawaii PPO	$602.37

HC OR ACUITY LEVEL 1 BASE 30MIN

Facility

$2,356.00

Hospital Charge Code	3600000001
Hospital Revenue Code	360
Min. Negotiated Rate	$2,002.60
Max. Negotiated Rate	$2,285.32
Rate for Payer: Cash Price	$1,413.60
Rate for Payer: Health Management Network Commercial	$2,002.60
Rate for Payer: MDX Hawaii PPO	$2,285.32

HC OR ACUITY LEVEL 1 BASE 30MIN

Facility

$2,356.00

Hospital Charge Code	3600000001
Hospital Revenue Code	360
Min. Negotiated Rate	$1,484.28
Max. Negotiated Rate	$2,837.00
Rate for Payer: Cash Price	$1,413.60
Rate for Payer: Cash Price	$1,413.60
Rate for Payer: Health Management Network Commercial	$2,002.60
Rate for Payer: Kaiser Permanente Commercial	$1,484.28
Rate for Payer: Kaiser Permanente Medicaid	$2,837.00
Rate for Payer: MDX Hawaii PPO	$2,285.32
Rate for Payer: University Health Alliance Commercial	$1,717.29

HC OR ACUITY LEVEL 2 BASE 30MIN

Facility

$3,545.00

Hospital Charge Code	3600000002
Hospital Revenue Code	360
Min. Negotiated Rate	$2,233.35
Max. Negotiated Rate	$3,438.65
Rate for Payer: Cash Price	$2,127.00
Rate for Payer: Cash Price	$2,127.00
Rate for Payer: Health Management Network Commercial	$3,013.25
Rate for Payer: Kaiser Permanente Commercial	$2,233.35
Rate for Payer: Kaiser Permanente Medicaid	$2,837.00
Rate for Payer: MDX Hawaii PPO	$3,438.65
Rate for Payer: University Health Alliance Commercial	$2,583.95

HC OR ACUITY LEVEL 2 BASE 30MIN

Facility

$3,545.00

Hospital Charge Code	3600000002
Hospital Revenue Code	360
Min. Negotiated Rate	$3,013.25
Max. Negotiated Rate	$3,438.65
Rate for Payer: Cash Price	$2,127.00
Rate for Payer: Health Management Network Commercial	$3,013.25
Rate for Payer: MDX Hawaii PPO	$3,438.65

HC OR ACUITY LEVEL 3 BASE 30MIN

Facility

$4,980.00

Hospital Charge Code	3600000003
Hospital Revenue Code	360
Min. Negotiated Rate	$4,233.00
Max. Negotiated Rate	$4,830.60
Rate for Payer: Cash Price	$2,988.00
Rate for Payer: Health Management Network Commercial	$4,233.00
Rate for Payer: MDX Hawaii PPO	$4,830.60

Know your out-of-pocket cost for care.

All Charges