Hilo Benioff Medical Center

All Charges

Charge

Type

Setting

Price

BACTERIAL & TUBERCULOUS INFECTIONS OF NERVOUS SYSTEM

Facility

$19,910.10

Service Code	APR-DRG 0494
Min. Negotiated Rate	$19,910.10
Max. Negotiated Rate	$19,910.10
Rate for Payer: AlohaCare Medicaid	$19,910.10
Rate for Payer: Hawaii Medical Service Association ABD	$19,910.10
Rate for Payer: Hawaii Medical Service Association Non-ABD	$19,910.10
Rate for Payer: Kaiser Permanente Medicaid	$19,910.10
Rate for Payer: Ohana Health Plan Medicaid	$19,910.10
Rate for Payer: UnitedHealthcare Medicaid	$19,910.10

BACTERIAL & TUBERCULOUS INFECTIONS OF NERVOUS SYSTEM

Facility

$5,697.64

Service Code	APR-DRG 0491
Min. Negotiated Rate	$5,697.64
Max. Negotiated Rate	$5,697.64
Rate for Payer: AlohaCare Medicaid	$5,697.64
Rate for Payer: Hawaii Medical Service Association ABD	$5,697.64
Rate for Payer: Hawaii Medical Service Association Non-ABD	$5,697.64
Rate for Payer: Kaiser Permanente Medicaid	$5,697.64
Rate for Payer: Ohana Health Plan Medicaid	$5,697.64
Rate for Payer: UnitedHealthcare Medicaid	$5,697.64

BAG 15MM ENDO CATCH

Facility

$397.00

Hospital Revenue Code	272
Min. Negotiated Rate	$337.45
Max. Negotiated Rate	$385.09
Rate for Payer: Cash Price	$238.20
Rate for Payer: Health Management Network Commercial	$337.45
Rate for Payer: MDX Hawaii PPO	$385.09

BAG 15MM ENDO CATCH

Facility

$397.00

Hospital Revenue Code	272
Min. Negotiated Rate	$202.47
Max. Negotiated Rate	$385.09
Rate for Payer: Cash Price	$238.20
Rate for Payer: Hawaii Western Management Group Commercial	$377.15
Rate for Payer: Health Management Network Commercial	$337.45
Rate for Payer: Kaiser Permanente Commercial	$250.11
Rate for Payer: Kaiser Permanente Medicaid	$202.47
Rate for Payer: MDX Hawaii PPO	$385.09
Rate for Payer: University Health Alliance Commercial	$289.37

BAG HYPERINFLATION 1/2L

Facility

$81.00

Hospital Revenue Code	272
Min. Negotiated Rate	$41.31
Max. Negotiated Rate	$78.57
Rate for Payer: Cash Price	$48.60
Rate for Payer: Hawaii Western Management Group Commercial	$76.95
Rate for Payer: Health Management Network Commercial	$68.85
Rate for Payer: Kaiser Permanente Commercial	$51.03
Rate for Payer: Kaiser Permanente Medicaid	$41.31
Rate for Payer: MDX Hawaii PPO	$78.57
Rate for Payer: University Health Alliance Commercial	$59.04

BAG HYPERINFLATION 1/2L

Facility

$81.00

Hospital Revenue Code	272
Min. Negotiated Rate	$68.85
Max. Negotiated Rate	$78.57
Rate for Payer: Cash Price	$48.60
Rate for Payer: Health Management Network Commercial	$68.85
Rate for Payer: MDX Hawaii PPO	$78.57

BAG RETRIEVAL ENDO

Facility

$118.00

Hospital Revenue Code	272
Min. Negotiated Rate	$60.18
Max. Negotiated Rate	$114.46
Rate for Payer: Cash Price	$70.80
Rate for Payer: Hawaii Western Management Group Commercial	$112.10
Rate for Payer: Health Management Network Commercial	$100.30
Rate for Payer: Kaiser Permanente Commercial	$74.34
Rate for Payer: Kaiser Permanente Medicaid	$60.18
Rate for Payer: MDX Hawaii PPO	$114.46
Rate for Payer: University Health Alliance Commercial	$86.01

BAG RETRIEVAL ENDO

Facility

$118.00

Hospital Revenue Code	272
Min. Negotiated Rate	$100.30
Max. Negotiated Rate	$114.46
Rate for Payer: Cash Price	$70.80
Rate for Payer: Health Management Network Commercial	$100.30
Rate for Payer: MDX Hawaii PPO	$114.46

BAG UROLOGY DRAIN

Facility

$101.00

Service Code	HCPCS A4649
Hospital Revenue Code	272
Min. Negotiated Rate	$85.85
Max. Negotiated Rate	$97.97
Rate for Payer: Cash Price	$60.60
Rate for Payer: Health Management Network Commercial	$85.85
Rate for Payer: MDX Hawaii PPO	$97.97

BAG UROLOGY DRAIN

Facility

$101.00

Service Code	HCPCS A4649
Hospital Revenue Code	272
Min. Negotiated Rate	$51.51
Max. Negotiated Rate	$97.97
Rate for Payer: Cash Price	$60.60
Rate for Payer: Hawaii Western Management Group Commercial	$95.95
Rate for Payer: Health Management Network Commercial	$85.85
Rate for Payer: Kaiser Permanente Commercial	$63.63
Rate for Payer: Kaiser Permanente Medicaid	$51.51
Rate for Payer: MDX Hawaii PPO	$97.97
Rate for Payer: University Health Alliance Commercial	$73.62

BALANCED SALT SOLUTION COMBINATION NO.1 INTRAOCULAR IRRIGATION [834]

Facility

$186.00

Service Code	NDC 00065080050
Hospital Revenue Code	250
Min. Negotiated Rate	$158.10
Max. Negotiated Rate	$180.42
Rate for Payer: Cash Price	$111.60
Rate for Payer: Health Management Network Commercial	$158.10
Rate for Payer: MDX Hawaii PPO	$180.42

BALANCED SALT SOLUTION COMBINATION NO.2 INTRAOCULAR IRRIGATION [37578]

Facility

$38.00

Service Code	NDC 00065079515
Hospital Revenue Code	250
Min. Negotiated Rate	$32.30
Max. Negotiated Rate	$36.86
Rate for Payer: Cash Price	$22.80
Rate for Payer: Health Management Network Commercial	$32.30
Rate for Payer: MDX Hawaii PPO	$36.86

BALANCED SALT SOLUTION COMBINATION NO.2 INTRAOCULAR IRRIGATION [37578]

Facility

$38.00

Service Code	NDC 00065079515
Hospital Revenue Code	637
Min. Negotiated Rate	$19.38
Max. Negotiated Rate	$36.86
Rate for Payer: Cash Price	$22.80
Rate for Payer: Hawaii Western Management Group Commercial	$36.10
Rate for Payer: Health Management Network Commercial	$32.30
Rate for Payer: Kaiser Permanente Commercial	$23.94
Rate for Payer: Kaiser Permanente Medicaid	$19.38
Rate for Payer: MDX Hawaii PPO	$36.86
Rate for Payer: University Health Alliance Commercial	$27.70

BALANCED SALT SOLUTION NON-SURGICAL NO.3 EYE WASH [2999]

Facility

$84.00

Service Code	NDC 00065053001
Hospital Revenue Code	250
Min. Negotiated Rate	$71.40
Max. Negotiated Rate	$81.48
Rate for Payer: Cash Price	$50.40
Rate for Payer: Health Management Network Commercial	$71.40
Rate for Payer: MDX Hawaii PPO	$81.48

BALANCED SALT SOLUTION NON-SURGICAL NO.3 EYE WASH [2999]

Facility

$84.00

Service Code	NDC 00065053001
Hospital Revenue Code	637
Min. Negotiated Rate	$42.84
Max. Negotiated Rate	$81.48
Rate for Payer: Cash Price	$50.40
Rate for Payer: Hawaii Western Management Group Commercial	$79.80
Rate for Payer: Health Management Network Commercial	$71.40
Rate for Payer: Kaiser Permanente Commercial	$52.92
Rate for Payer: Kaiser Permanente Medicaid	$42.84
Rate for Payer: MDX Hawaii PPO	$81.48
Rate for Payer: University Health Alliance Commercial	$61.23

BALLOON 2.5X20 AGENT DCB

Facility

$12,350.00

Service Code	HCPCS C9610
Hospital Revenue Code	272
Min. Negotiated Rate	$10,497.50
Max. Negotiated Rate	$11,979.50
Rate for Payer: Cash Price	$7,410.00
Rate for Payer: Health Management Network Commercial	$10,497.50
Rate for Payer: MDX Hawaii PPO	$11,979.50

BALLOON 2.5X20 AGENT DCB

Facility

$12,350.00

Service Code	HCPCS C9610
Hospital Revenue Code	272
Min. Negotiated Rate	$6,298.50
Max. Negotiated Rate	$11,979.50
Rate for Payer: Cash Price	$7,410.00
Rate for Payer: Hawaii Western Management Group Commercial	$11,732.50
Rate for Payer: Health Management Network Commercial	$10,497.50
Rate for Payer: Kaiser Permanente Commercial	$7,780.50
Rate for Payer: Kaiser Permanente Medicaid	$6,298.50
Rate for Payer: MDX Hawaii PPO	$11,979.50
Rate for Payer: University Health Alliance Commercial	$9,001.92

BALLOON 2.5X30 AGENT DCB

Facility

$12,350.00

Service Code	HCPCS C9610
Hospital Revenue Code	272
Min. Negotiated Rate	$10,497.50
Max. Negotiated Rate	$11,979.50
Rate for Payer: Cash Price	$7,410.00
Rate for Payer: Health Management Network Commercial	$10,497.50
Rate for Payer: MDX Hawaii PPO	$11,979.50

BALLOON 2.5X30 AGENT DCB

Facility

$12,350.00

Service Code	HCPCS C9610
Hospital Revenue Code	272
Min. Negotiated Rate	$6,298.50
Max. Negotiated Rate	$11,979.50
Rate for Payer: Cash Price	$7,410.00
Rate for Payer: Hawaii Western Management Group Commercial	$11,732.50
Rate for Payer: Health Management Network Commercial	$10,497.50
Rate for Payer: Kaiser Permanente Commercial	$7,780.50
Rate for Payer: Kaiser Permanente Medicaid	$6,298.50
Rate for Payer: MDX Hawaii PPO	$11,979.50
Rate for Payer: University Health Alliance Commercial	$9,001.92

BALLOON 2X12 AGENT DCB

Facility

$12,350.00

Service Code	HCPCS C9610
Hospital Revenue Code	272
Min. Negotiated Rate	$10,497.50
Max. Negotiated Rate	$11,979.50
Rate for Payer: Cash Price	$7,410.00
Rate for Payer: Health Management Network Commercial	$10,497.50
Rate for Payer: MDX Hawaii PPO	$11,979.50

BALLOON 2X12 AGENT DCB

Facility

$12,350.00

Service Code	HCPCS C9610
Hospital Revenue Code	272
Min. Negotiated Rate	$6,298.50
Max. Negotiated Rate	$11,979.50
Rate for Payer: Cash Price	$7,410.00
Rate for Payer: Hawaii Western Management Group Commercial	$11,732.50
Rate for Payer: Health Management Network Commercial	$10,497.50
Rate for Payer: Kaiser Permanente Commercial	$7,780.50
Rate for Payer: Kaiser Permanente Medicaid	$6,298.50
Rate for Payer: MDX Hawaii PPO	$11,979.50
Rate for Payer: University Health Alliance Commercial	$9,001.92

BALLOON 2X15 AGENT DCB

Facility

$12,350.00

Service Code	HCPCS C9610
Hospital Revenue Code	272
Min. Negotiated Rate	$10,497.50
Max. Negotiated Rate	$11,979.50
Rate for Payer: Cash Price	$7,410.00
Rate for Payer: Health Management Network Commercial	$10,497.50
Rate for Payer: MDX Hawaii PPO	$11,979.50

BALLOON 2X15 AGENT DCB

Facility

$12,350.00

Service Code	HCPCS C9610
Hospital Revenue Code	272
Min. Negotiated Rate	$6,298.50
Max. Negotiated Rate	$11,979.50
Rate for Payer: Cash Price	$7,410.00
Rate for Payer: Hawaii Western Management Group Commercial	$11,732.50
Rate for Payer: Health Management Network Commercial	$10,497.50
Rate for Payer: Kaiser Permanente Commercial	$7,780.50
Rate for Payer: Kaiser Permanente Medicaid	$6,298.50
Rate for Payer: MDX Hawaii PPO	$11,979.50
Rate for Payer: University Health Alliance Commercial	$9,001.92

BALLOON 3.5X20 AGENT DCB

Facility

$12,350.00

Service Code	HCPCS C9610
Hospital Revenue Code	272
Min. Negotiated Rate	$6,298.50
Max. Negotiated Rate	$11,979.50
Rate for Payer: Cash Price	$7,410.00
Rate for Payer: Hawaii Western Management Group Commercial	$11,732.50
Rate for Payer: Health Management Network Commercial	$10,497.50
Rate for Payer: Kaiser Permanente Commercial	$7,780.50
Rate for Payer: Kaiser Permanente Medicaid	$6,298.50
Rate for Payer: MDX Hawaii PPO	$11,979.50
Rate for Payer: University Health Alliance Commercial	$9,001.92

BALLOON 3.5X20 AGENT DCB

Facility

$12,350.00

Service Code	HCPCS C9610
Hospital Revenue Code	272
Min. Negotiated Rate	$10,497.50
Max. Negotiated Rate	$11,979.50
Rate for Payer: Cash Price	$7,410.00
Rate for Payer: Health Management Network Commercial	$10,497.50
Rate for Payer: MDX Hawaii PPO	$11,979.50

Know your out-of-pocket cost for care.

All Charges