Hilo Benioff Medical Center

All Charges

Charge

Type

Setting

Price

HETASTARCH 6 % IN 0.9 % SODIUM CHLORIDE INTRAVENOUS SOLUTION [25174]

Facility

$179.00

Service Code	NDC 00409724803
Hospital Revenue Code	250
Min. Negotiated Rate	$152.15
Max. Negotiated Rate	$173.63
Rate for Payer: Cash Price	$107.40
Rate for Payer: Health Management Network Commercial	$152.15
Rate for Payer: MDX Hawaii PPO	$173.63

HETASTARCH 6 % IN 0.9 % SODIUM CHLORIDE INTRAVENOUS SOLUTION [25174]

Facility

$179.00

Service Code	NDC 00409724813
Hospital Revenue Code	250
Min. Negotiated Rate	$152.15
Max. Negotiated Rate	$173.63
Rate for Payer: Cash Price	$107.40
Rate for Payer: Health Management Network Commercial	$152.15
Rate for Payer: MDX Hawaii PPO	$173.63

HEX DRIVE CANNULATE AR-7000-13

Facility

$1,213.00

Hospital Revenue Code	272
Min. Negotiated Rate	$1,031.05
Max. Negotiated Rate	$1,176.61
Rate for Payer: Cash Price	$727.80
Rate for Payer: Health Management Network Commercial	$1,031.05
Rate for Payer: MDX Hawaii PPO	$1,176.61

HEX DRIVE CANNULATE AR-7000-13

Facility

$1,213.00

Hospital Revenue Code	272
Min. Negotiated Rate	$618.63
Max. Negotiated Rate	$1,176.61
Rate for Payer: Cash Price	$727.80
Rate for Payer: Hawaii Western Management Group Commercial	$1,152.35
Rate for Payer: Health Management Network Commercial	$1,031.05
Rate for Payer: Kaiser Permanente Commercial	$764.19
Rate for Payer: Kaiser Permanente Medicaid	$618.63
Rate for Payer: MDX Hawaii PPO	$1,176.61
Rate for Payer: University Health Alliance Commercial	$884.16

HEX WRENCH 442-2

Facility

$180.00

Hospital Revenue Code	272
Min. Negotiated Rate	$153.00
Max. Negotiated Rate	$174.60
Rate for Payer: Cash Price	$108.00
Rate for Payer: Health Management Network Commercial	$153.00
Rate for Payer: MDX Hawaii PPO	$174.60

HEX WRENCH 442-2

Facility

$180.00

Hospital Revenue Code	272
Min. Negotiated Rate	$91.80
Max. Negotiated Rate	$174.60
Rate for Payer: Cash Price	$108.00
Rate for Payer: Hawaii Western Management Group Commercial	$171.00
Rate for Payer: Health Management Network Commercial	$153.00
Rate for Payer: Kaiser Permanente Commercial	$113.40
Rate for Payer: Kaiser Permanente Medicaid	$91.80
Rate for Payer: MDX Hawaii PPO	$174.60
Rate for Payer: University Health Alliance Commercial	$131.20

HIP AND FEMUR PROCEDURES EXCEPT MAJOR JOINT WITH CC

Facility

$49,672.50

Service Code	MSDRG 481
Min. Negotiated Rate	$23,823.39
Max. Negotiated Rate	$49,672.50
Rate for Payer: AlohaCare Medicare	$23,823.39
Rate for Payer: Devoted Health Medicare	$26,205.73
Rate for Payer: Hawaii Medical Service Association Commercial	$49,672.50
Rate for Payer: Hawaii Medical Service Association Medicare	$23,823.39
Rate for Payer: Humana Medicare	$23,823.39
Rate for Payer: Kaiser Permanente Commercial	$36,130.12
Rate for Payer: Kaiser Permanente Medicare	$23,823.39
Rate for Payer: Ohana Health Plan Medicare	$23,823.39
Rate for Payer: UnitedHealthcare Medicare	$23,823.39

HIP AND FEMUR PROCEDURES EXCEPT MAJOR JOINT WITH MCC

Facility

$50,934.33

Service Code	MSDRG 480
Min. Negotiated Rate	$33,125.25
Max. Negotiated Rate	$50,934.33
Rate for Payer: AlohaCare Medicare	$33,125.25
Rate for Payer: Devoted Health Medicare	$36,437.78
Rate for Payer: Hawaii Medical Service Association Commercial	$50,934.33
Rate for Payer: Hawaii Medical Service Association Medicare	$33,125.25
Rate for Payer: Humana Medicare	$33,125.25
Rate for Payer: Kaiser Permanente Commercial	$50,237.18
Rate for Payer: Kaiser Permanente Medicare	$33,125.25
Rate for Payer: Ohana Health Plan Medicare	$33,125.25
Rate for Payer: UnitedHealthcare Medicare	$33,125.25

HIP AND FEMUR PROCEDURES EXCEPT MAJOR JOINT WITHOUT CC/MCC

Facility

$35,792.35

Service Code	MSDRG 482
Min. Negotiated Rate	$18,551.41
Max. Negotiated Rate	$35,792.35
Rate for Payer: AlohaCare Medicare	$18,551.41
Rate for Payer: Devoted Health Medicare	$20,406.55
Rate for Payer: Hawaii Medical Service Association Commercial	$35,792.35
Rate for Payer: Hawaii Medical Service Association Medicare	$18,551.41
Rate for Payer: Humana Medicare	$18,551.41
Rate for Payer: Kaiser Permanente Commercial	$28,134.75
Rate for Payer: Kaiser Permanente Medicare	$18,551.41
Rate for Payer: Ohana Health Plan Medicare	$18,551.41
Rate for Payer: UnitedHealthcare Medicare	$18,551.41

HIP CRYO CUFF 14A01

Facility

$181.00

Hospital Revenue Code	272
Min. Negotiated Rate	$92.31
Max. Negotiated Rate	$175.57
Rate for Payer: Cash Price	$108.60
Rate for Payer: Hawaii Western Management Group Commercial	$171.95
Rate for Payer: Health Management Network Commercial	$153.85
Rate for Payer: Kaiser Permanente Commercial	$114.03
Rate for Payer: Kaiser Permanente Medicaid	$92.31
Rate for Payer: MDX Hawaii PPO	$175.57
Rate for Payer: University Health Alliance Commercial	$131.93

HIP CRYO CUFF 14A01

Facility

$181.00

Hospital Revenue Code	272
Min. Negotiated Rate	$153.85
Max. Negotiated Rate	$175.57
Rate for Payer: Cash Price	$108.60
Rate for Payer: Health Management Network Commercial	$153.85
Rate for Payer: MDX Hawaii PPO	$175.57

HIP & FEMUR FRACTURE REPAIR

Facility

$8,457.42

Service Code	APR-DRG 3082
Min. Negotiated Rate	$8,457.42
Max. Negotiated Rate	$8,457.42
Rate for Payer: AlohaCare Medicaid	$8,457.42
Rate for Payer: Hawaii Medical Service Association ABD	$8,457.42
Rate for Payer: Hawaii Medical Service Association Non-ABD	$8,457.42
Rate for Payer: Kaiser Permanente Medicaid	$8,457.42
Rate for Payer: Ohana Health Plan Medicaid	$8,457.42
Rate for Payer: UnitedHealthcare Medicaid	$8,457.42

HIP & FEMUR FRACTURE REPAIR

Facility

$7,104.60

Service Code	APR-DRG 3081
Min. Negotiated Rate	$7,104.60
Max. Negotiated Rate	$7,104.60
Rate for Payer: AlohaCare Medicaid	$7,104.60
Rate for Payer: Hawaii Medical Service Association ABD	$7,104.60
Rate for Payer: Hawaii Medical Service Association Non-ABD	$7,104.60
Rate for Payer: Kaiser Permanente Medicaid	$7,104.60
Rate for Payer: Ohana Health Plan Medicaid	$7,104.60
Rate for Payer: UnitedHealthcare Medicaid	$7,104.60

HIP & FEMUR FRACTURE REPAIR

Facility

$15,825.54

Service Code	APR-DRG 3084
Min. Negotiated Rate	$15,825.54
Max. Negotiated Rate	$15,825.54
Rate for Payer: AlohaCare Medicaid	$15,825.54
Rate for Payer: Hawaii Medical Service Association ABD	$15,825.54
Rate for Payer: Hawaii Medical Service Association Non-ABD	$15,825.54
Rate for Payer: Kaiser Permanente Medicaid	$15,825.54
Rate for Payer: Ohana Health Plan Medicaid	$15,825.54
Rate for Payer: UnitedHealthcare Medicaid	$15,825.54

HIP & FEMUR FRACTURE REPAIR

Facility

$10,886.50

Service Code	APR-DRG 3083
Min. Negotiated Rate	$10,886.50
Max. Negotiated Rate	$10,886.50
Rate for Payer: AlohaCare Medicaid	$10,886.50
Rate for Payer: Hawaii Medical Service Association ABD	$10,886.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$10,886.50
Rate for Payer: Kaiser Permanente Medicaid	$10,886.50
Rate for Payer: Ohana Health Plan Medicaid	$10,886.50
Rate for Payer: UnitedHealthcare Medicaid	$10,886.50

HIP JOINT REPLACEMENT

Facility

$17,452.32

Service Code	APR-DRG 3014
Min. Negotiated Rate	$17,452.32
Max. Negotiated Rate	$17,452.32
Rate for Payer: AlohaCare Medicaid	$17,452.32
Rate for Payer: Hawaii Medical Service Association ABD	$17,452.32
Rate for Payer: Hawaii Medical Service Association Non-ABD	$17,452.32
Rate for Payer: Kaiser Permanente Medicaid	$17,452.32
Rate for Payer: Ohana Health Plan Medicaid	$17,452.32
Rate for Payer: UnitedHealthcare Medicaid	$17,452.32

HIP JOINT REPLACEMENT

Facility

$12,241.93

Service Code	APR-DRG 3013
Min. Negotiated Rate	$12,241.93
Max. Negotiated Rate	$12,241.93
Rate for Payer: AlohaCare Medicaid	$12,241.93
Rate for Payer: Hawaii Medical Service Association ABD	$12,241.93
Rate for Payer: Hawaii Medical Service Association Non-ABD	$12,241.93
Rate for Payer: Kaiser Permanente Medicaid	$12,241.93
Rate for Payer: Ohana Health Plan Medicaid	$12,241.93
Rate for Payer: UnitedHealthcare Medicaid	$12,241.93

HIP JOINT REPLACEMENT

Facility

$9,492.59

Service Code	APR-DRG 3012
Min. Negotiated Rate	$9,492.59
Max. Negotiated Rate	$9,492.59
Rate for Payer: AlohaCare Medicaid	$9,492.59
Rate for Payer: Hawaii Medical Service Association ABD	$9,492.59
Rate for Payer: Hawaii Medical Service Association Non-ABD	$9,492.59
Rate for Payer: Kaiser Permanente Medicaid	$9,492.59
Rate for Payer: Ohana Health Plan Medicaid	$9,492.59
Rate for Payer: UnitedHealthcare Medicaid	$9,492.59

HIP JOINT REPLACEMENT

Facility

$8,791.39

Service Code	APR-DRG 3011
Min. Negotiated Rate	$8,791.39
Max. Negotiated Rate	$8,791.39
Rate for Payer: AlohaCare Medicaid	$8,791.39
Rate for Payer: Hawaii Medical Service Association ABD	$8,791.39
Rate for Payer: Hawaii Medical Service Association Non-ABD	$8,791.39
Rate for Payer: Kaiser Permanente Medicaid	$8,791.39
Rate for Payer: Ohana Health Plan Medicaid	$8,791.39
Rate for Payer: UnitedHealthcare Medicaid	$8,791.39

HIP LINER 36X54 00-8751-011-36

Facility

$2,800.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$1,428.00
Max. Negotiated Rate	$2,716.00
Rate for Payer: Cash Price	$1,680.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,960.00
Rate for Payer: Health Management Network Commercial	$2,380.00
Rate for Payer: Kaiser Permanente Commercial	$1,764.00
Rate for Payer: Kaiser Permanente Medicaid	$1,428.00
Rate for Payer: MDX Hawaii PPO	$2,716.00
Rate for Payer: University Health Alliance Commercial	$1,568.00

HIP LINER 36X54 00-8751-011-36

Facility

$2,800.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$1,568.00
Max. Negotiated Rate	$2,716.00
Rate for Payer: Cash Price	$1,680.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,960.00
Rate for Payer: Health Management Network Commercial	$2,380.00
Rate for Payer: MDX Hawaii PPO	$2,716.00
Rate for Payer: University Health Alliance Commercial	$1,568.00

HIP LINER 36X56 00-8751-012-36

Facility

$2,800.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$1,428.00
Max. Negotiated Rate	$2,716.00
Rate for Payer: Cash Price	$1,680.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,960.00
Rate for Payer: Health Management Network Commercial	$2,380.00
Rate for Payer: Kaiser Permanente Commercial	$1,764.00
Rate for Payer: Kaiser Permanente Medicaid	$1,428.00
Rate for Payer: MDX Hawaii PPO	$2,716.00
Rate for Payer: University Health Alliance Commercial	$1,568.00

HIP LINER 36X56 00-8751-012-36

Facility

$2,800.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$1,568.00
Max. Negotiated Rate	$2,716.00
Rate for Payer: Cash Price	$1,680.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,960.00
Rate for Payer: Health Management Network Commercial	$2,380.00
Rate for Payer: MDX Hawaii PPO	$2,716.00
Rate for Payer: University Health Alliance Commercial	$1,568.00

HIP LINER 36X60 00-8751-014-36

Facility

$2,800.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$1,568.00
Max. Negotiated Rate	$2,716.00
Rate for Payer: Cash Price	$1,680.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,960.00
Rate for Payer: Health Management Network Commercial	$2,380.00
Rate for Payer: MDX Hawaii PPO	$2,716.00
Rate for Payer: University Health Alliance Commercial	$1,568.00

HIP LINER 36X60 00-8751-014-36

Facility

$2,800.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$1,428.00
Max. Negotiated Rate	$2,716.00
Rate for Payer: Cash Price	$1,680.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,960.00
Rate for Payer: Health Management Network Commercial	$2,380.00
Rate for Payer: Kaiser Permanente Commercial	$1,764.00
Rate for Payer: Kaiser Permanente Medicaid	$1,428.00
Rate for Payer: MDX Hawaii PPO	$2,716.00
Rate for Payer: University Health Alliance Commercial	$1,568.00

Know your out-of-pocket cost for care.

All Charges