Hilo Benioff Medical Center

All Charges

Charge

Type

Setting

Price

HIV W MULTIPLE MAJOR HIV RELATED CONDITIONS

Facility

$4,444.62

Service Code	APR-DRG 8902
Min. Negotiated Rate	$4,444.62
Max. Negotiated Rate	$4,444.62
Rate for Payer: AlohaCare Medicaid	$4,444.62
Rate for Payer: Hawaii Medical Service Association ABD	$4,444.62
Rate for Payer: Hawaii Medical Service Association Non-ABD	$4,444.62
Rate for Payer: Kaiser Permanente Medicaid	$4,444.62
Rate for Payer: Ohana Health Plan Medicaid	$4,444.62
Rate for Payer: UnitedHealthcare Medicaid	$4,444.62

HIV W MULTIPLE MAJOR HIV RELATED CONDITIONS

Facility

$12,129.74

Service Code	APR-DRG 8904
Min. Negotiated Rate	$12,129.74
Max. Negotiated Rate	$12,129.74
Rate for Payer: AlohaCare Medicaid	$12,129.74
Rate for Payer: Hawaii Medical Service Association ABD	$12,129.74
Rate for Payer: Hawaii Medical Service Association Non-ABD	$12,129.74
Rate for Payer: Kaiser Permanente Medicaid	$12,129.74
Rate for Payer: Ohana Health Plan Medicaid	$12,129.74
Rate for Payer: UnitedHealthcare Medicaid	$12,129.74

HIV W MULTIPLE MAJOR HIV RELATED CONDITIONS

Facility

$6,340.78

Service Code	APR-DRG 8903
Min. Negotiated Rate	$6,340.78
Max. Negotiated Rate	$6,340.78
Rate for Payer: AlohaCare Medicaid	$6,340.78
Rate for Payer: Hawaii Medical Service Association ABD	$6,340.78
Rate for Payer: Hawaii Medical Service Association Non-ABD	$6,340.78
Rate for Payer: Kaiser Permanente Medicaid	$6,340.78
Rate for Payer: Ohana Health Plan Medicaid	$6,340.78
Rate for Payer: UnitedHealthcare Medicaid	$6,340.78

HIV W MULTIPLE SIGNIFICANT HIV RELATED CONDITIONS

Facility

$9,101.87

Service Code	APR-DRG 8934
Min. Negotiated Rate	$9,101.87
Max. Negotiated Rate	$9,101.87
Rate for Payer: AlohaCare Medicaid	$9,101.87
Rate for Payer: Hawaii Medical Service Association ABD	$9,101.87
Rate for Payer: Hawaii Medical Service Association Non-ABD	$9,101.87
Rate for Payer: Kaiser Permanente Medicaid	$9,101.87
Rate for Payer: Ohana Health Plan Medicaid	$9,101.87
Rate for Payer: UnitedHealthcare Medicaid	$9,101.87

HIV W MULTIPLE SIGNIFICANT HIV RELATED CONDITIONS

Facility

$4,042.16

Service Code	APR-DRG 8932
Min. Negotiated Rate	$4,042.16
Max. Negotiated Rate	$4,042.16
Rate for Payer: AlohaCare Medicaid	$4,042.16
Rate for Payer: Hawaii Medical Service Association ABD	$4,042.16
Rate for Payer: Hawaii Medical Service Association Non-ABD	$4,042.16
Rate for Payer: Kaiser Permanente Medicaid	$4,042.16
Rate for Payer: Ohana Health Plan Medicaid	$4,042.16
Rate for Payer: UnitedHealthcare Medicaid	$4,042.16

HIV W MULTIPLE SIGNIFICANT HIV RELATED CONDITIONS

Facility

$3,292.04

Service Code	APR-DRG 8931
Min. Negotiated Rate	$3,292.04
Max. Negotiated Rate	$3,292.04
Rate for Payer: AlohaCare Medicaid	$3,292.04
Rate for Payer: Hawaii Medical Service Association ABD	$3,292.04
Rate for Payer: Hawaii Medical Service Association Non-ABD	$3,292.04
Rate for Payer: Kaiser Permanente Medicaid	$3,292.04
Rate for Payer: Ohana Health Plan Medicaid	$3,292.04
Rate for Payer: UnitedHealthcare Medicaid	$3,292.04

HIV W MULTIPLE SIGNIFICANT HIV RELATED CONDITIONS

Facility

$5,477.17

Service Code	APR-DRG 8933
Min. Negotiated Rate	$5,477.17
Max. Negotiated Rate	$5,477.17
Rate for Payer: AlohaCare Medicaid	$5,477.17
Rate for Payer: Hawaii Medical Service Association ABD	$5,477.17
Rate for Payer: Hawaii Medical Service Association Non-ABD	$5,477.17
Rate for Payer: Kaiser Permanente Medicaid	$5,477.17
Rate for Payer: Ohana Health Plan Medicaid	$5,477.17
Rate for Payer: UnitedHealthcare Medicaid	$5,477.17

HIV W ONE SIGNIF HIV COND OR W/O SIGNIF RELATED COND

Facility

$5,770.69

Service Code	APR-DRG 8944
Min. Negotiated Rate	$5,770.69
Max. Negotiated Rate	$5,770.69
Rate for Payer: AlohaCare Medicaid	$5,770.69
Rate for Payer: Hawaii Medical Service Association ABD	$5,770.69
Rate for Payer: Hawaii Medical Service Association Non-ABD	$5,770.69
Rate for Payer: Kaiser Permanente Medicaid	$5,770.69
Rate for Payer: Ohana Health Plan Medicaid	$5,770.69
Rate for Payer: UnitedHealthcare Medicaid	$5,770.69

HIV W ONE SIGNIF HIV COND OR W/O SIGNIF RELATED COND

Facility

$4,711.40

Service Code	APR-DRG 8943
Min. Negotiated Rate	$4,711.40
Max. Negotiated Rate	$4,711.40
Rate for Payer: AlohaCare Medicaid	$4,711.40
Rate for Payer: Hawaii Medical Service Association ABD	$4,711.40
Rate for Payer: Hawaii Medical Service Association Non-ABD	$4,711.40
Rate for Payer: Kaiser Permanente Medicaid	$4,711.40
Rate for Payer: Ohana Health Plan Medicaid	$4,711.40
Rate for Payer: UnitedHealthcare Medicaid	$4,711.40

HIV W ONE SIGNIF HIV COND OR W/O SIGNIF RELATED COND

Facility

$3,436.85

Service Code	APR-DRG 8942
Min. Negotiated Rate	$3,436.85
Max. Negotiated Rate	$3,436.85
Rate for Payer: AlohaCare Medicaid	$3,436.85
Rate for Payer: Hawaii Medical Service Association ABD	$3,436.85
Rate for Payer: Hawaii Medical Service Association Non-ABD	$3,436.85
Rate for Payer: Kaiser Permanente Medicaid	$3,436.85
Rate for Payer: Ohana Health Plan Medicaid	$3,436.85
Rate for Payer: UnitedHealthcare Medicaid	$3,436.85

HIV W ONE SIGNIF HIV COND OR W/O SIGNIF RELATED COND

Facility

$2,976.34

Service Code	APR-DRG 8941
Min. Negotiated Rate	$2,976.34
Max. Negotiated Rate	$2,976.34
Rate for Payer: AlohaCare Medicaid	$2,976.34
Rate for Payer: Hawaii Medical Service Association ABD	$2,976.34
Rate for Payer: Hawaii Medical Service Association Non-ABD	$2,976.34
Rate for Payer: Kaiser Permanente Medicaid	$2,976.34
Rate for Payer: Ohana Health Plan Medicaid	$2,976.34
Rate for Payer: UnitedHealthcare Medicaid	$2,976.34

HMRL RADIUS 52X17MM 5552-S-521

Facility

$6,838.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$3,829.28
Max. Negotiated Rate	$6,632.86
Rate for Payer: Cash Price	$4,102.80
Rate for Payer: Hawaii Western Management Group Commercial	$4,786.60
Rate for Payer: Health Management Network Commercial	$5,812.30
Rate for Payer: MDX Hawaii PPO	$6,632.86
Rate for Payer: University Health Alliance Commercial	$3,829.28

HMRL RADIUS 52X17MM 5552-S-521

Facility

$6,838.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$3,487.38
Max. Negotiated Rate	$6,632.86
Rate for Payer: Cash Price	$4,102.80
Rate for Payer: Hawaii Western Management Group Commercial	$4,786.60
Rate for Payer: Health Management Network Commercial	$5,812.30
Rate for Payer: Kaiser Permanente Commercial	$4,307.94
Rate for Payer: Kaiser Permanente Medicaid	$3,487.38
Rate for Payer: MDX Hawaii PPO	$6,632.86
Rate for Payer: University Health Alliance Commercial	$3,829.28

HOOPLATE LCP PROXI FEM 4.5MM

Facility

$4,572.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$2,331.72
Max. Negotiated Rate	$4,434.84
Rate for Payer: Cash Price	$2,743.20
Rate for Payer: Hawaii Western Management Group Commercial	$3,200.40
Rate for Payer: Health Management Network Commercial	$3,886.20
Rate for Payer: Kaiser Permanente Commercial	$2,880.36
Rate for Payer: Kaiser Permanente Medicaid	$2,331.72
Rate for Payer: MDX Hawaii PPO	$4,434.84
Rate for Payer: University Health Alliance Commercial	$2,560.32

HOOPLATE LCP PROXI FEM 4.5MM

Facility

$4,572.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$2,560.32
Max. Negotiated Rate	$4,434.84
Rate for Payer: Cash Price	$2,743.20
Rate for Payer: Hawaii Western Management Group Commercial	$3,200.40
Rate for Payer: Health Management Network Commercial	$3,886.20
Rate for Payer: MDX Hawaii PPO	$4,434.84
Rate for Payer: University Health Alliance Commercial	$2,560.32

HSC+ 285CC 10721-285MP

Facility

$2,850.00

Service Code	HCPCS C1789
Hospital Revenue Code	278
Min. Negotiated Rate	$1,596.00
Max. Negotiated Rate	$2,764.50
Rate for Payer: Cash Price	$1,710.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,995.00
Rate for Payer: Health Management Network Commercial	$2,422.50
Rate for Payer: MDX Hawaii PPO	$2,764.50
Rate for Payer: University Health Alliance Commercial	$1,596.00

HSC+ 285CC 10721-285MP

Facility

$2,850.00

Service Code	HCPCS C1789
Hospital Revenue Code	278
Min. Negotiated Rate	$1,453.50
Max. Negotiated Rate	$2,764.50
Rate for Payer: Cash Price	$1,710.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,995.00
Rate for Payer: Health Management Network Commercial	$2,422.50
Rate for Payer: Kaiser Permanente Commercial	$1,795.50
Rate for Payer: Kaiser Permanente Medicaid	$1,453.50
Rate for Payer: MDX Hawaii PPO	$2,764.50
Rate for Payer: University Health Alliance Commercial	$1,596.00

HSC GEL BREAST 440 10621-440HP

Facility

$2,085.00

Service Code	HCPCS C1789
Hospital Revenue Code	278
Min. Negotiated Rate	$1,167.60
Max. Negotiated Rate	$2,022.45
Rate for Payer: Cash Price	$1,251.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,459.50
Rate for Payer: Health Management Network Commercial	$1,772.25
Rate for Payer: MDX Hawaii PPO	$2,022.45
Rate for Payer: University Health Alliance Commercial	$1,167.60

HSC GEL BREAST 440 10621-440HP

Facility

$2,085.00

Service Code	HCPCS C1789
Hospital Revenue Code	278
Min. Negotiated Rate	$1,063.35
Max. Negotiated Rate	$2,022.45
Rate for Payer: Cash Price	$1,251.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,459.50
Rate for Payer: Health Management Network Commercial	$1,772.25
Rate for Payer: Kaiser Permanente Commercial	$1,313.55
Rate for Payer: Kaiser Permanente Medicaid	$1,063.35
Rate for Payer: MDX Hawaii PPO	$2,022.45
Rate for Payer: University Health Alliance Commercial	$1,167.60

HSC GEL BREAST LF 10621-470HP

Facility

$2,250.00

Service Code	HCPCS C1789
Hospital Revenue Code	278
Min. Negotiated Rate	$1,147.50
Max. Negotiated Rate	$2,182.50
Rate for Payer: Cash Price	$1,350.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,575.00
Rate for Payer: Health Management Network Commercial	$1,912.50
Rate for Payer: Kaiser Permanente Commercial	$1,417.50
Rate for Payer: Kaiser Permanente Medicaid	$1,147.50
Rate for Payer: MDX Hawaii PPO	$2,182.50
Rate for Payer: University Health Alliance Commercial	$1,260.00

HSC GEL BREAST LF 10621-470HP

Facility

$2,250.00

Service Code	HCPCS C1789
Hospital Revenue Code	278
Min. Negotiated Rate	$1,260.00
Max. Negotiated Rate	$2,182.50
Rate for Payer: Cash Price	$1,350.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,575.00
Rate for Payer: Health Management Network Commercial	$1,912.50
Rate for Payer: MDX Hawaii PPO	$2,182.50
Rate for Payer: University Health Alliance Commercial	$1,260.00

HSC+ RND HI RT 10721-565HP

Facility

$2,850.00

Service Code	HCPCS C1789
Hospital Revenue Code	278
Min. Negotiated Rate	$1,596.00
Max. Negotiated Rate	$2,764.50
Rate for Payer: Cash Price	$1,710.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,995.00
Rate for Payer: Health Management Network Commercial	$2,422.50
Rate for Payer: MDX Hawaii PPO	$2,764.50
Rate for Payer: University Health Alliance Commercial	$1,596.00

HSC+ RND HI RT 10721-565HP

Facility

$2,850.00

Service Code	HCPCS C1789
Hospital Revenue Code	278
Min. Negotiated Rate	$1,453.50
Max. Negotiated Rate	$2,764.50
Rate for Payer: Cash Price	$1,710.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,995.00
Rate for Payer: Health Management Network Commercial	$2,422.50
Rate for Payer: Kaiser Permanente Commercial	$1,795.50
Rate for Payer: Kaiser Permanente Medicaid	$1,453.50
Rate for Payer: MDX Hawaii PPO	$2,764.50
Rate for Payer: University Health Alliance Commercial	$1,596.00

HSC+ SMOOTH RND 10721-325MP

Facility

$2,850.00

Service Code	HCPCS C1789
Hospital Revenue Code	278
Min. Negotiated Rate	$1,453.50
Max. Negotiated Rate	$2,764.50
Rate for Payer: Cash Price	$1,710.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,995.00
Rate for Payer: Health Management Network Commercial	$2,422.50
Rate for Payer: Kaiser Permanente Commercial	$1,795.50
Rate for Payer: Kaiser Permanente Medicaid	$1,453.50
Rate for Payer: MDX Hawaii PPO	$2,764.50
Rate for Payer: University Health Alliance Commercial	$1,596.00

HSC+ SMOOTH RND 10721-325MP

Facility

$2,850.00

Service Code	HCPCS C1789
Hospital Revenue Code	278
Min. Negotiated Rate	$1,596.00
Max. Negotiated Rate	$2,764.50
Rate for Payer: Cash Price	$1,710.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,995.00
Rate for Payer: Health Management Network Commercial	$2,422.50
Rate for Payer: MDX Hawaii PPO	$2,764.50
Rate for Payer: University Health Alliance Commercial	$1,596.00

Know your out-of-pocket cost for care.

All Charges