Hilo Benioff Medical Center

All Charges

Charge

Type

Setting

Price

HC REDUCE TEMPOROMANDIBL DISLOC

Facility

$955.00

Service Code	HCPCS 21480
Hospital Charge Code	4502148001
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	$573.00
Rate for Payer: Cash Price	$573.00
Rate for Payer: Cash Price	$573.00
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	$907.25
Rate for Payer: Health Management Network Commercial	$811.75
Rate for Payer: Humana Medicare	$291.40
Rate for Payer: Kaiser Permanente Commercial	$601.65
Rate for Payer: Kaiser Permanente Medicaid	$937.50
Rate for Payer: Kaiser Permanente Medicare	$291.40
Rate for Payer: MDX Hawaii PPO	$926.35
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	$696.10

HC REDUCE TEMPOROMANDIBL DISLOC

Facility

$955.00

Service Code	HCPCS 21480
Hospital Charge Code	4502148001
Hospital Revenue Code	450
Min. Negotiated Rate	$811.75
Max. Negotiated Rate	$926.35
Rate for Payer: Cash Price	$573.00
Rate for Payer: Health Management Network Commercial	$811.75
Rate for Payer: MDX Hawaii PPO	$926.35

HC REFILL/MAINT, PORTABLE PUMP

Facility

$838.00

Service Code	HCPCS 96521
Hospital Charge Code	3359652101
Hospital Revenue Code	335
Min. Negotiated Rate	$101.13
Max. Negotiated Rate	$812.86
Rate for Payer: AlohaCare Medicaid	$251.28
Rate for Payer: AlohaCare Medicare	$251.28
Rate for Payer: Cash Price	$502.80
Rate for Payer: Cash Price	$502.80
Rate for Payer: Devoted Health Medicare	$276.41
Rate for Payer: Hawaii Medical Service Association Commercial	$314.10
Rate for Payer: Hawaii Medical Service Association Medicare	$251.28
Rate for Payer: Hawaii Western Management Group Commercial	$796.10
Rate for Payer: Health Management Network Commercial	$712.30
Rate for Payer: Humana Medicare	$251.28
Rate for Payer: Kaiser Permanente Commercial	$527.94
Rate for Payer: Kaiser Permanente Medicaid	$427.38
Rate for Payer: Kaiser Permanente Medicare	$251.28
Rate for Payer: MDX Hawaii PPO	$812.86
Rate for Payer: Ohana Health Plan Medicaid	$276.41
Rate for Payer: Ohana Health Plan Medicare	$251.28
Rate for Payer: UnitedHealthcare Medicaid	$101.13
Rate for Payer: UnitedHealthcare Medicare	$251.28
Rate for Payer: University Health Alliance Commercial	$610.82

HC REFILL/MAINT, PORTABLE PUMP

Facility

$838.00

Service Code	HCPCS 96521
Hospital Charge Code	3359652101
Hospital Revenue Code	335
Min. Negotiated Rate	$712.30
Max. Negotiated Rate	$812.86
Rate for Payer: Cash Price	$502.80
Rate for Payer: Health Management Network Commercial	$712.30
Rate for Payer: MDX Hawaii PPO	$812.86

HC REFILL/MAINT SYSTEMIC PUMP/RESVR

Facility

$838.00

Service Code	HCPCS 96522
Hospital Charge Code	3359652201
Hospital Revenue Code	335
Min. Negotiated Rate	$72.83
Max. Negotiated Rate	$812.86
Rate for Payer: AlohaCare Medicaid	$251.28
Rate for Payer: AlohaCare Medicare	$251.28
Rate for Payer: Cash Price	$502.80
Rate for Payer: Cash Price	$502.80
Rate for Payer: Devoted Health Medicare	$276.41
Rate for Payer: Hawaii Medical Service Association Commercial	$314.10
Rate for Payer: Hawaii Medical Service Association Medicare	$251.28
Rate for Payer: Hawaii Western Management Group Commercial	$796.10
Rate for Payer: Health Management Network Commercial	$712.30
Rate for Payer: Humana Medicare	$251.28
Rate for Payer: Kaiser Permanente Commercial	$527.94
Rate for Payer: Kaiser Permanente Medicaid	$427.38
Rate for Payer: Kaiser Permanente Medicare	$251.28
Rate for Payer: MDX Hawaii PPO	$812.86
Rate for Payer: Ohana Health Plan Medicaid	$276.41
Rate for Payer: Ohana Health Plan Medicare	$251.28
Rate for Payer: UnitedHealthcare Medicaid	$72.83
Rate for Payer: UnitedHealthcare Medicare	$251.28
Rate for Payer: University Health Alliance Commercial	$610.82

HC REFILL/MAINT SYSTEMIC PUMP/RESVR

Facility

$838.00

Service Code	HCPCS 96522
Hospital Charge Code	3359652201
Hospital Revenue Code	335
Min. Negotiated Rate	$712.30
Max. Negotiated Rate	$812.86
Rate for Payer: Cash Price	$502.80
Rate for Payer: Health Management Network Commercial	$712.30
Rate for Payer: MDX Hawaii PPO	$812.86

HC REGIONAL ANESTHESIA TIME - EACH INCREMENTAL 1 MINUTE

Facility

$30.00

Hospital Charge Code	3700000004
Hospital Revenue Code	370
Min. Negotiated Rate	$15.30
Max. Negotiated Rate	$29.10
Rate for Payer: Cash Price	$18.00
Rate for Payer: Hawaii Western Management Group Commercial	$28.50
Rate for Payer: Health Management Network Commercial	$25.50
Rate for Payer: Kaiser Permanente Commercial	$18.90
Rate for Payer: Kaiser Permanente Medicaid	$15.30
Rate for Payer: MDX Hawaii PPO	$29.10
Rate for Payer: University Health Alliance Commercial	$21.87

HC REGIONAL ANESTHESIA TIME - EACH INCREMENTAL 1 MINUTE

Facility

$30.00

Hospital Charge Code	3700000004
Hospital Revenue Code	370
Min. Negotiated Rate	$25.50
Max. Negotiated Rate	$29.10
Rate for Payer: Cash Price	$18.00
Rate for Payer: Health Management Network Commercial	$25.50
Rate for Payer: MDX Hawaii PPO	$29.10

HC REGIONAL ANESTHESIA TIME - INITIAL BASE CHARGE

Facility

$559.00

Hospital Charge Code	3700000003
Hospital Revenue Code	370
Min. Negotiated Rate	$285.09
Max. Negotiated Rate	$542.23
Rate for Payer: Cash Price	$335.40
Rate for Payer: Hawaii Western Management Group Commercial	$531.05
Rate for Payer: Health Management Network Commercial	$475.15
Rate for Payer: Kaiser Permanente Commercial	$352.17
Rate for Payer: Kaiser Permanente Medicaid	$285.09
Rate for Payer: MDX Hawaii PPO	$542.23
Rate for Payer: University Health Alliance Commercial	$407.46

HC REGIONAL ANESTHESIA TIME - INITIAL BASE CHARGE

Facility

$559.00

Hospital Charge Code	3700000003
Hospital Revenue Code	370
Min. Negotiated Rate	$475.15
Max. Negotiated Rate	$542.23
Rate for Payer: Cash Price	$335.40
Rate for Payer: Health Management Network Commercial	$475.15
Rate for Payer: MDX Hawaii PPO	$542.23

HC REMOVAL BILIARY DRG CATHETER REQ FLUOR GID RS&I

Facility

$3,731.00

Service Code	HCPCS 47537
Hospital Charge Code	3614753701
Hospital Revenue Code	361
Min. Negotiated Rate	$456.03
Max. Negotiated Rate	$5,509.00
Rate for Payer: AlohaCare Medicaid	$1,071.46
Rate for Payer: AlohaCare Medicare	$1,071.46
Rate for Payer: Cash Price	$2,238.60
Rate for Payer: Cash Price	$2,238.60
Rate for Payer: Cash Price	$2,238.60
Rate for Payer: Devoted Health Medicare	$1,178.61
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	$1,071.46
Rate for Payer: Hawaii Medical Service Association Non-ABD	$1,028.67
Rate for Payer: Health Management Network Commercial	$3,171.35
Rate for Payer: Humana Medicare	$1,071.46
Rate for Payer: Kaiser Permanente Commercial	$2,350.53
Rate for Payer: Kaiser Permanente Medicaid	$2,837.00
Rate for Payer: Kaiser Permanente Medicare	$1,071.46
Rate for Payer: MDX Hawaii PPO	$3,619.07
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	$2,719.53

HC REMOVAL BILIARY DRG CATHETER REQ FLUOR GID RS&I

Facility

$3,731.00

Service Code	HCPCS 47537
Hospital Charge Code	3614753701
Hospital Revenue Code	361
Min. Negotiated Rate	$3,171.35
Max. Negotiated Rate	$3,619.07
Rate for Payer: Cash Price	$2,238.60
Rate for Payer: Health Management Network Commercial	$3,171.35
Rate for Payer: MDX Hawaii PPO	$3,619.07

HC REMOVAL BILIARY DUCT &/GLBLDR CALCULI PERQ RS&I

Facility

$627.00

Service Code	HCPCS 47544
Hospital Charge Code	3614754401
Hospital Revenue Code	361
Min. Negotiated Rate	$150.14
Max. Negotiated Rate	$2,837.00
Rate for Payer: Cash Price	$376.20
Rate for Payer: Cash Price	$376.20
Rate for Payer: Cash Price	$376.20
Rate for Payer: Health Management Network Commercial	$532.95
Rate for Payer: Kaiser Permanente Commercial	$395.01
Rate for Payer: Kaiser Permanente Medicaid	$2,837.00
Rate for Payer: MDX Hawaii PPO	$608.19
Rate for Payer: UnitedHealthcare Medicaid	$150.14
Rate for Payer: University Health Alliance Commercial	$457.02

HC REMOVAL BILIARY DUCT &/GLBLDR CALCULI PERQ RS&I

Facility

$627.00

Service Code	HCPCS 47544
Hospital Charge Code	3614754401
Hospital Revenue Code	361
Min. Negotiated Rate	$532.95
Max. Negotiated Rate	$608.19
Rate for Payer: Cash Price	$376.20
Rate for Payer: Health Management Network Commercial	$532.95
Rate for Payer: MDX Hawaii PPO	$608.19

HC REMOVAL IMPACTED CERUMEN INSTRUMENTATION UNILAT

Facility

$236.00

Service Code	HCPCS 69210
Hospital Charge Code	7616921001
Hospital Revenue Code	761
Min. Negotiated Rate	$22.98
Max. Negotiated Rate	$5,160.40
Rate for Payer: AlohaCare Medicaid	$69.69
Rate for Payer: AlohaCare Medicare	$69.69
Rate for Payer: Cash Price	$141.60
Rate for Payer: Cash Price	$141.60
Rate for Payer: Cash Price	$141.60
Rate for Payer: Devoted Health Medicare	$76.66
Rate for Payer: Hawaii Medical Service Association Commercial	$87.11
Rate for Payer: Hawaii Medical Service Association Medicare	$69.69
Rate for Payer: Hawaii Western Management Group Commercial	$224.20
Rate for Payer: Health Management Network Commercial	$200.60
Rate for Payer: Humana Medicare	$69.69
Rate for Payer: Kaiser Permanente Commercial	$148.68
Rate for Payer: Kaiser Permanente Medicaid	$120.36
Rate for Payer: Kaiser Permanente Medicare	$69.69
Rate for Payer: MDX Hawaii PPO	$228.92
Rate for Payer: Ohana Health Plan Medicaid	$76.66
Rate for Payer: Ohana Health Plan Medicare	$69.69
Rate for Payer: UnitedHealthcare Medicaid	$22.98
Rate for Payer: UnitedHealthcare Medicare	$69.69
Rate for Payer: University Health Alliance Commercial	$5,160.40

HC REMOVAL IMPACTED CERUMEN INSTRUMENTATION UNILAT

Facility

$236.00

Service Code	HCPCS 69210
Hospital Charge Code	7616921001
Hospital Revenue Code	761
Min. Negotiated Rate	$200.60
Max. Negotiated Rate	$228.92
Rate for Payer: Cash Price	$141.60
Rate for Payer: Health Management Network Commercial	$200.60
Rate for Payer: MDX Hawaii PPO	$228.92

HC REMOVAL IMPACTED CERUMEN IRRIGATION/LVG UNILAT

Facility

$236.00

Service Code	HCPCS 69209
Hospital Charge Code	7616920901
Hospital Revenue Code	761
Min. Negotiated Rate	$18.16
Max. Negotiated Rate	$228.92
Rate for Payer: AlohaCare Medicaid	$69.69
Rate for Payer: AlohaCare Medicare	$69.69
Rate for Payer: Cash Price	$141.60
Rate for Payer: Cash Price	$141.60
Rate for Payer: Devoted Health Medicare	$76.66
Rate for Payer: Hawaii Medical Service Association Commercial	$87.11
Rate for Payer: Hawaii Medical Service Association Medicare	$69.69
Rate for Payer: Hawaii Western Management Group Commercial	$224.20
Rate for Payer: Health Management Network Commercial	$200.60
Rate for Payer: Humana Medicare	$69.69
Rate for Payer: Kaiser Permanente Commercial	$148.68
Rate for Payer: Kaiser Permanente Medicaid	$120.36
Rate for Payer: Kaiser Permanente Medicare	$69.69
Rate for Payer: MDX Hawaii PPO	$228.92
Rate for Payer: Ohana Health Plan Medicaid	$76.66
Rate for Payer: Ohana Health Plan Medicare	$69.69
Rate for Payer: UnitedHealthcare Medicaid	$18.16
Rate for Payer: UnitedHealthcare Medicare	$69.69
Rate for Payer: University Health Alliance Commercial	$172.02

HC REMOVAL IMPACTED CERUMEN IRRIGATION/LVG UNILAT

Facility

$236.00

Service Code	HCPCS 69209
Hospital Charge Code	7616920901
Hospital Revenue Code	761
Min. Negotiated Rate	$200.60
Max. Negotiated Rate	$228.92
Rate for Payer: Cash Price	$141.60
Rate for Payer: Health Management Network Commercial	$200.60
Rate for Payer: MDX Hawaii PPO	$228.92

HC REMOVAL OF EMBEDDED FOREIGN BODY, EYELID

Facility

$1,190.00

Service Code	HCPCS 67938
Hospital Charge Code	4506793801
Hospital Revenue Code	450
Min. Negotiated Rate	$374.96
Max. Negotiated Rate	$5,509.00
Rate for Payer: AlohaCare Medicaid	$374.96
Rate for Payer: AlohaCare Medicare	$374.96
Rate for Payer: Cash Price	$714.00
Rate for Payer: Cash Price	$714.00
Rate for Payer: Cash Price	$714.00
Rate for Payer: Devoted Health Medicare	$412.46
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	$374.96
Rate for Payer: Hawaii Medical Service Association Non-ABD	$1,028.67
Rate for Payer: Hawaii Western Management Group Commercial	$1,130.50
Rate for Payer: Health Management Network Commercial	$1,011.50
Rate for Payer: Humana Medicare	$374.96
Rate for Payer: Kaiser Permanente Commercial	$749.70
Rate for Payer: Kaiser Permanente Medicaid	$937.50
Rate for Payer: Kaiser Permanente Medicare	$374.96
Rate for Payer: MDX Hawaii PPO	$1,154.30
Rate for Payer: Ohana Health Plan Medicaid	$412.46
Rate for Payer: Ohana Health Plan Medicare	$374.96
Rate for Payer: UnitedHealthcare Medicare	$374.96
Rate for Payer: University Health Alliance Commercial	$867.39

HC REMOVAL OF EMBEDDED FOREIGN BODY, EYELID

Facility

$1,190.00

Service Code	HCPCS 67938
Hospital Charge Code	4506793801
Hospital Revenue Code	450
Min. Negotiated Rate	$1,011.50
Max. Negotiated Rate	$1,154.30
Rate for Payer: Cash Price	$714.00
Rate for Payer: Health Management Network Commercial	$1,011.50
Rate for Payer: MDX Hawaii PPO	$1,154.30

HC REMOVAL OF EMBEDDED FOREIGN BODY FROM DENTOALVEOLAR STRUCTURES; SOFT TISSUES

Facility

$5,772.00

Service Code	HCPCS 41805
Hospital Charge Code	4504180501
Hospital Revenue Code	450
Min. Negotiated Rate	$393.00
Max. Negotiated Rate	$5,598.84
Rate for Payer: AlohaCare Medicaid	$1,832.96
Rate for Payer: AlohaCare Medicare	$1,832.96
Rate for Payer: Cash Price	$3,463.20
Rate for Payer: Cash Price	$3,463.20
Rate for Payer: Cash Price	$3,463.20
Rate for Payer: Devoted Health Medicare	$2,016.26
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	$1,832.96
Rate for Payer: Hawaii Medical Service Association Non-ABD	$496.75
Rate for Payer: Hawaii Western Management Group Commercial	$5,483.40
Rate for Payer: Health Management Network Commercial	$4,906.20
Rate for Payer: Humana Medicare	$1,832.96
Rate for Payer: Kaiser Permanente Commercial	$3,636.36
Rate for Payer: Kaiser Permanente Medicaid	$937.50
Rate for Payer: Kaiser Permanente Medicare	$1,832.96
Rate for Payer: MDX Hawaii PPO	$5,598.84
Rate for Payer: Ohana Health Plan Medicaid	$2,016.26
Rate for Payer: Ohana Health Plan Medicare	$1,832.96
Rate for Payer: UnitedHealthcare Medicaid	$456.03
Rate for Payer: UnitedHealthcare Medicare	$1,832.96
Rate for Payer: University Health Alliance Commercial	$4,207.21

HC REMOVAL OF EMBEDDED FOREIGN BODY FROM DENTOALVEOLAR STRUCTURES; SOFT TISSUES

Facility

$5,772.00

Service Code	HCPCS 41805
Hospital Charge Code	4504180501
Hospital Revenue Code	450
Min. Negotiated Rate	$4,906.20
Max. Negotiated Rate	$5,598.84
Rate for Payer: Cash Price	$3,463.20
Rate for Payer: Health Management Network Commercial	$4,906.20
Rate for Payer: MDX Hawaii PPO	$5,598.84

HC REMOVAL OF EMBEDDED FOREIGN BODY, VESTIBULE OF MOUTH; COMPLICATED

Facility

$1,984.00

Service Code	HCPCS 40805
Hospital Charge Code	4504080501
Hospital Revenue Code	450
Min. Negotiated Rate	$637.13
Max. Negotiated Rate	$8,270.00
Rate for Payer: AlohaCare Medicaid	$637.13
Rate for Payer: AlohaCare Medicare	$637.13
Rate for Payer: Cash Price	$1,190.40
Rate for Payer: Cash Price	$1,190.40
Rate for Payer: Cash Price	$1,190.40
Rate for Payer: Devoted Health Medicare	$700.84
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	$637.13
Rate for Payer: Hawaii Medical Service Association Non-ABD	$1,427.62
Rate for Payer: Hawaii Western Management Group Commercial	$1,884.80
Rate for Payer: Health Management Network Commercial	$1,686.40
Rate for Payer: Humana Medicare	$637.13
Rate for Payer: Kaiser Permanente Commercial	$1,249.92
Rate for Payer: Kaiser Permanente Medicaid	$937.50
Rate for Payer: Kaiser Permanente Medicare	$637.13
Rate for Payer: MDX Hawaii PPO	$1,924.48
Rate for Payer: Ohana Health Plan Medicaid	$700.84
Rate for Payer: Ohana Health Plan Medicare	$637.13
Rate for Payer: UnitedHealthcare Medicare	$637.13
Rate for Payer: University Health Alliance Commercial	$1,446.14

HC REMOVAL OF EMBEDDED FOREIGN BODY, VESTIBULE OF MOUTH; COMPLICATED

Facility

$1,984.00

Service Code	HCPCS 40805
Hospital Charge Code	4504080501
Hospital Revenue Code	450
Min. Negotiated Rate	$1,686.40
Max. Negotiated Rate	$1,924.48
Rate for Payer: Cash Price	$1,190.40
Rate for Payer: Health Management Network Commercial	$1,686.40
Rate for Payer: MDX Hawaii PPO	$1,924.48

HC REMOVAL OF EMBEDDED FOREIGN BODY, VESTIBULE OF MOUTH; SIMPLE

Facility

$3,731.00

Service Code	HCPCS 40804
Hospital Charge Code	4504080401
Hospital Revenue Code	450
Min. Negotiated Rate	$456.03
Max. Negotiated Rate	$3,619.07
Rate for Payer: AlohaCare Medicaid	$1,071.46
Rate for Payer: AlohaCare Medicare	$1,071.46
Rate for Payer: Cash Price	$2,238.60
Rate for Payer: Cash Price	$2,238.60
Rate for Payer: Cash Price	$2,238.60
Rate for Payer: Cash Price	$2,238.60
Rate for Payer: Devoted Health Medicare	$1,178.61
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	$1,071.46
Rate for Payer: Hawaii Medical Service Association Non-ABD	$520.00
Rate for Payer: Hawaii Western Management Group Commercial	$3,544.45
Rate for Payer: Health Management Network Commercial	$3,171.35
Rate for Payer: Humana Medicare	$1,071.46
Rate for Payer: Kaiser Permanente Commercial	$2,350.53
Rate for Payer: Kaiser Permanente Medicaid	$937.50
Rate for Payer: Kaiser Permanente Medicare	$1,071.46
Rate for Payer: MDX Hawaii PPO	$3,619.07
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	$2,719.53

Know your out-of-pocket cost for care.

All Charges