Hilo Benioff Medical Center

All Charges

Charge

Type

Setting

Price

INFLAMMATION OF THE MALE REPRODUCTIVE SYSTEM WITHOUT MCC

Facility

$13,993.20

Service Code	MSDRG 728
Min. Negotiated Rate	$9,226.80
Max. Negotiated Rate	$13,993.20
Rate for Payer: AlohaCare Medicare	$9,226.80
Rate for Payer: Devoted Health Medicare	$10,149.48
Rate for Payer: Hawaii Medical Service Association Commercial	$13,491.90
Rate for Payer: Hawaii Medical Service Association Medicare	$9,226.80
Rate for Payer: Humana Medicare	$9,226.80
Rate for Payer: Kaiser Permanente Commercial	$13,993.20
Rate for Payer: Kaiser Permanente Medicare	$9,226.80
Rate for Payer: Ohana Health Plan Medicare	$9,226.80
Rate for Payer: UnitedHealthcare Medicare	$9,226.80

INFLAMMATORY BOWEL DISEASE

Facility

$3,334.44

Service Code	APR-DRG 2451
Min. Negotiated Rate	$3,334.44
Max. Negotiated Rate	$3,334.44
Rate for Payer: AlohaCare Medicaid	$3,334.44
Rate for Payer: Hawaii Medical Service Association ABD	$3,334.44
Rate for Payer: Hawaii Medical Service Association Non-ABD	$3,334.44
Rate for Payer: Kaiser Permanente Medicaid	$3,334.44
Rate for Payer: Ohana Health Plan Medicaid	$3,334.44
Rate for Payer: UnitedHealthcare Medicaid	$3,334.44

INFLAMMATORY BOWEL DISEASE

Facility

$4,139.35

Service Code	APR-DRG 2452
Min. Negotiated Rate	$4,139.35
Max. Negotiated Rate	$4,139.35
Rate for Payer: AlohaCare Medicaid	$4,139.35
Rate for Payer: Hawaii Medical Service Association ABD	$4,139.35
Rate for Payer: Hawaii Medical Service Association Non-ABD	$4,139.35
Rate for Payer: Kaiser Permanente Medicaid	$4,139.35
Rate for Payer: Ohana Health Plan Medicaid	$4,139.35
Rate for Payer: UnitedHealthcare Medicaid	$4,139.35

INFLAMMATORY BOWEL DISEASE

Facility

$11,644.45

Service Code	APR-DRG 2454
Min. Negotiated Rate	$11,644.45
Max. Negotiated Rate	$11,644.45
Rate for Payer: AlohaCare Medicaid	$11,644.45
Rate for Payer: Hawaii Medical Service Association ABD	$11,644.45
Rate for Payer: Hawaii Medical Service Association Non-ABD	$11,644.45
Rate for Payer: Kaiser Permanente Medicaid	$11,644.45
Rate for Payer: Ohana Health Plan Medicaid	$11,644.45
Rate for Payer: UnitedHealthcare Medicaid	$11,644.45

INFLAMMATORY BOWEL DISEASE

Facility

$6,044.00

Service Code	APR-DRG 2453
Min. Negotiated Rate	$6,044.00
Max. Negotiated Rate	$6,044.00
Rate for Payer: AlohaCare Medicaid	$6,044.00
Rate for Payer: Hawaii Medical Service Association ABD	$6,044.00
Rate for Payer: Hawaii Medical Service Association Non-ABD	$6,044.00
Rate for Payer: Kaiser Permanente Medicaid	$6,044.00
Rate for Payer: Ohana Health Plan Medicaid	$6,044.00
Rate for Payer: UnitedHealthcare Medicaid	$6,044.00

INFLAMMATORY BOWEL DISEASE WITH CC

Facility

$19,898.12

Service Code	MSDRG 386
Min. Negotiated Rate	$11,104.69
Max. Negotiated Rate	$19,898.12
Rate for Payer: AlohaCare Medicare	$11,104.69
Rate for Payer: Devoted Health Medicare	$12,215.16
Rate for Payer: Hawaii Medical Service Association Commercial	$19,898.12
Rate for Payer: Hawaii Medical Service Association Medicare	$11,104.69
Rate for Payer: Humana Medicare	$11,104.69
Rate for Payer: Kaiser Permanente Commercial	$16,841.17
Rate for Payer: Kaiser Permanente Medicare	$11,104.69
Rate for Payer: Ohana Health Plan Medicare	$11,104.69
Rate for Payer: UnitedHealthcare Medicare	$11,104.69

INFLAMMATORY BOWEL DISEASE WITH MCC

Facility

$27,294.67

Service Code	MSDRG 385
Min. Negotiated Rate	$17,997.48
Max. Negotiated Rate	$27,294.67
Rate for Payer: AlohaCare Medicare	$17,997.48
Rate for Payer: Devoted Health Medicare	$19,797.23
Rate for Payer: Hawaii Medical Service Association Commercial	$19,898.12
Rate for Payer: Hawaii Medical Service Association Medicare	$17,997.48
Rate for Payer: Humana Medicare	$17,997.48
Rate for Payer: Kaiser Permanente Commercial	$27,294.67
Rate for Payer: Kaiser Permanente Medicare	$17,997.48
Rate for Payer: Ohana Health Plan Medicare	$17,997.48
Rate for Payer: UnitedHealthcare Medicare	$17,997.48

INFLAMMATORY BOWEL DISEASE WITHOUT CC/MCC

Facility

$19,898.12

Service Code	MSDRG 387
Min. Negotiated Rate	$7,749.28
Max. Negotiated Rate	$19,898.12
Rate for Payer: AlohaCare Medicare	$7,749.28
Rate for Payer: Devoted Health Medicare	$8,524.21
Rate for Payer: Hawaii Medical Service Association Commercial	$19,898.12
Rate for Payer: Hawaii Medical Service Association Medicare	$7,749.28
Rate for Payer: Humana Medicare	$7,749.28
Rate for Payer: Kaiser Permanente Commercial	$11,752.42
Rate for Payer: Kaiser Permanente Medicare	$7,749.28
Rate for Payer: Ohana Health Plan Medicare	$7,749.28
Rate for Payer: UnitedHealthcare Medicare	$7,749.28

INFLATION DEVICE COOK G34903

Facility

$235.00

Hospital Revenue Code	272
Min. Negotiated Rate	$119.85
Max. Negotiated Rate	$227.95
Rate for Payer: Cash Price	$141.00
Rate for Payer: Hawaii Western Management Group Commercial	$223.25
Rate for Payer: Health Management Network Commercial	$199.75
Rate for Payer: Kaiser Permanente Commercial	$148.05
Rate for Payer: Kaiser Permanente Medicaid	$119.85
Rate for Payer: MDX Hawaii PPO	$227.95
Rate for Payer: University Health Alliance Commercial	$171.29

INFLATION DEVICE COOK G34903

Facility

$235.00

Hospital Revenue Code	272
Min. Negotiated Rate	$199.75
Max. Negotiated Rate	$227.95
Rate for Payer: Cash Price	$141.00
Rate for Payer: Health Management Network Commercial	$199.75
Rate for Payer: MDX Hawaii PPO	$227.95

INFLIXIMAB-DYYB 100 MG/10ML IV (WET SOLR VIAL) [430134057]

Facility

$1,636.00

Service Code	HCPCS Q5103
Hospital Revenue Code	250
Min. Negotiated Rate	$1,390.60
Max. Negotiated Rate	$1,586.92
Rate for Payer: Cash Price	$981.60
Rate for Payer: Health Management Network Commercial	$1,390.60
Rate for Payer: MDX Hawaii PPO	$1,586.92

INFLIXIMAB-DYYB 100 MG/10ML IV (WET SOLR VIAL) [430134057]

Facility

$1,636.00

Service Code	HCPCS Q5103
Hospital Revenue Code	636
Min. Negotiated Rate	$19.68
Max. Negotiated Rate	$1,586.92
Rate for Payer: AlohaCare Medicaid	$26.04
Rate for Payer: AlohaCare Medicare	$26.04
Rate for Payer: Cash Price	$981.60
Rate for Payer: Cash Price	$981.60
Rate for Payer: Devoted Health Medicare	$28.64
Rate for Payer: Hawaii Medical Service Association ABD	$19.68
Rate for Payer: Hawaii Medical Service Association Commercial	$32.55
Rate for Payer: Hawaii Medical Service Association Medicare	$26.04
Rate for Payer: Hawaii Medical Service Association Non-ABD	$19.68
Rate for Payer: Hawaii Western Management Group Commercial	$1,554.20
Rate for Payer: Health Management Network Commercial	$1,390.60
Rate for Payer: Humana Medicare	$26.04
Rate for Payer: Kaiser Permanente Commercial	$1,030.68
Rate for Payer: Kaiser Permanente Medicaid	$834.36
Rate for Payer: Kaiser Permanente Medicare	$26.04
Rate for Payer: MDX Hawaii PPO	$1,586.92
Rate for Payer: Ohana Health Plan Medicaid	$28.64
Rate for Payer: Ohana Health Plan Medicare	$26.04
Rate for Payer: UnitedHealthcare Medicaid	$981.60
Rate for Payer: UnitedHealthcare Medicare	$26.04
Rate for Payer: University Health Alliance Commercial	$1,192.48

INFLIXIMAB-DYYB 100 MG INTRAVENOUS SOLUTION [134057]

Facility

$1,636.00

Service Code	HCPCS Q5103
Hospital Revenue Code	250
Min. Negotiated Rate	$1,390.60
Max. Negotiated Rate	$1,586.92
Rate for Payer: Cash Price	$981.60
Rate for Payer: Health Management Network Commercial	$1,390.60
Rate for Payer: MDX Hawaii PPO	$1,586.92

INFLIXIMAB-DYYB 100 MG INTRAVENOUS SOLUTION [134057]

Facility

$1,636.00

Service Code	HCPCS Q5103
Hospital Revenue Code	636
Min. Negotiated Rate	$19.68
Max. Negotiated Rate	$1,586.92
Rate for Payer: AlohaCare Medicaid	$26.04
Rate for Payer: AlohaCare Medicare	$26.04
Rate for Payer: Cash Price	$981.60
Rate for Payer: Cash Price	$981.60
Rate for Payer: Devoted Health Medicare	$28.64
Rate for Payer: Hawaii Medical Service Association ABD	$19.68
Rate for Payer: Hawaii Medical Service Association Commercial	$32.55
Rate for Payer: Hawaii Medical Service Association Medicare	$26.04
Rate for Payer: Hawaii Medical Service Association Non-ABD	$19.68
Rate for Payer: Hawaii Western Management Group Commercial	$1,554.20
Rate for Payer: Health Management Network Commercial	$1,390.60
Rate for Payer: Humana Medicare	$26.04
Rate for Payer: Kaiser Permanente Commercial	$1,030.68
Rate for Payer: Kaiser Permanente Medicaid	$834.36
Rate for Payer: Kaiser Permanente Medicare	$26.04
Rate for Payer: MDX Hawaii PPO	$1,586.92
Rate for Payer: Ohana Health Plan Medicaid	$28.64
Rate for Payer: Ohana Health Plan Medicare	$26.04
Rate for Payer: UnitedHealthcare Medicaid	$981.60
Rate for Payer: UnitedHealthcare Medicare	$26.04
Rate for Payer: University Health Alliance Commercial	$1,192.48

INGENIO DR IS-1 GENERATOR

Facility

$12,310.00

Service Code	HCPCS C1785
Hospital Revenue Code	275
Min. Negotiated Rate	$6,278.10
Max. Negotiated Rate	$11,940.70
Rate for Payer: Cash Price	$7,386.00
Rate for Payer: Hawaii Western Management Group Commercial	$8,617.00
Rate for Payer: Health Management Network Commercial	$10,463.50
Rate for Payer: Kaiser Permanente Commercial	$7,755.30
Rate for Payer: Kaiser Permanente Medicaid	$6,278.10
Rate for Payer: MDX Hawaii PPO	$11,940.70
Rate for Payer: University Health Alliance Commercial	$6,893.60

INGENIO DR IS-1 GENERATOR

Facility

$12,310.00

Service Code	HCPCS C1785
Hospital Revenue Code	275
Min. Negotiated Rate	$6,893.60
Max. Negotiated Rate	$11,940.70
Rate for Payer: Cash Price	$7,386.00
Rate for Payer: Hawaii Western Management Group Commercial	$8,617.00
Rate for Payer: Health Management Network Commercial	$10,463.50
Rate for Payer: MDX Hawaii PPO	$11,940.70
Rate for Payer: University Health Alliance Commercial	$6,893.60

INGEVITY LEAD 45CM

Facility

$1,302.00

Service Code	HCPCS C1898
Hospital Revenue Code	275
Min. Negotiated Rate	$729.12
Max. Negotiated Rate	$1,262.94
Rate for Payer: Cash Price	$781.20
Rate for Payer: Hawaii Western Management Group Commercial	$911.40
Rate for Payer: Health Management Network Commercial	$1,106.70
Rate for Payer: MDX Hawaii PPO	$1,262.94
Rate for Payer: University Health Alliance Commercial	$729.12

INGEVITY LEAD 45CM

Facility

$1,302.00

Service Code	HCPCS C1898
Hospital Revenue Code	275
Min. Negotiated Rate	$664.02
Max. Negotiated Rate	$1,262.94
Rate for Payer: Cash Price	$781.20
Rate for Payer: Hawaii Western Management Group Commercial	$911.40
Rate for Payer: Health Management Network Commercial	$1,106.70
Rate for Payer: Kaiser Permanente Commercial	$820.26
Rate for Payer: Kaiser Permanente Medicaid	$664.02
Rate for Payer: MDX Hawaii PPO	$1,262.94
Rate for Payer: University Health Alliance Commercial	$729.12

INGEVITY LEAD 59CM

Facility

$1,302.00

Service Code	HCPCS C1898
Hospital Revenue Code	275
Min. Negotiated Rate	$664.02
Max. Negotiated Rate	$1,262.94
Rate for Payer: Cash Price	$781.20
Rate for Payer: Hawaii Western Management Group Commercial	$911.40
Rate for Payer: Health Management Network Commercial	$1,106.70
Rate for Payer: Kaiser Permanente Commercial	$820.26
Rate for Payer: Kaiser Permanente Medicaid	$664.02
Rate for Payer: MDX Hawaii PPO	$1,262.94
Rate for Payer: University Health Alliance Commercial	$729.12

INGEVITY LEAD 59CM

Facility

$1,302.00

Service Code	HCPCS C1898
Hospital Revenue Code	275
Min. Negotiated Rate	$729.12
Max. Negotiated Rate	$1,262.94
Rate for Payer: Cash Price	$781.20
Rate for Payer: Hawaii Western Management Group Commercial	$911.40
Rate for Payer: Health Management Network Commercial	$1,106.70
Rate for Payer: MDX Hawaii PPO	$1,262.94
Rate for Payer: University Health Alliance Commercial	$729.12

INGEVITY MRI 59CM 7742

Facility

$1,875.00

Service Code	HCPCS C1898
Hospital Revenue Code	275
Min. Negotiated Rate	$1,050.00
Max. Negotiated Rate	$1,818.75
Rate for Payer: Cash Price	$1,125.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,312.50
Rate for Payer: Health Management Network Commercial	$1,593.75
Rate for Payer: MDX Hawaii PPO	$1,818.75
Rate for Payer: University Health Alliance Commercial	$1,050.00

INGEVITY MRI 59CM 7742

Facility

$1,875.00

Service Code	HCPCS C1898
Hospital Revenue Code	275
Min. Negotiated Rate	$956.25
Max. Negotiated Rate	$1,818.75
Rate for Payer: Cash Price	$1,125.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,312.50
Rate for Payer: Health Management Network Commercial	$1,593.75
Rate for Payer: Kaiser Permanente Commercial	$1,181.25
Rate for Payer: Kaiser Permanente Medicaid	$956.25
Rate for Payer: MDX Hawaii PPO	$1,818.75
Rate for Payer: University Health Alliance Commercial	$1,050.00

INGEVITY MRI FIX 52CM 7741

Facility

$1,875.00

Service Code	HCPCS C1898
Hospital Revenue Code	275
Min. Negotiated Rate	$956.25
Max. Negotiated Rate	$1,818.75
Rate for Payer: Cash Price	$1,125.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,312.50
Rate for Payer: Health Management Network Commercial	$1,593.75
Rate for Payer: Kaiser Permanente Commercial	$1,181.25
Rate for Payer: Kaiser Permanente Medicaid	$956.25
Rate for Payer: MDX Hawaii PPO	$1,818.75
Rate for Payer: University Health Alliance Commercial	$1,050.00

INGEVITY MRI FIX 52CM 7741

Facility

$1,875.00

Service Code	HCPCS C1898
Hospital Revenue Code	275
Min. Negotiated Rate	$1,050.00
Max. Negotiated Rate	$1,818.75
Rate for Payer: Cash Price	$1,125.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,312.50
Rate for Payer: Health Management Network Commercial	$1,593.75
Rate for Payer: MDX Hawaii PPO	$1,818.75
Rate for Payer: University Health Alliance Commercial	$1,050.00

INGEVITY + PACING LEAD 52CM

Facility

$1,414.00

Service Code	HCPCS C1898
Hospital Revenue Code	275
Min. Negotiated Rate	$791.84
Max. Negotiated Rate	$1,371.58
Rate for Payer: Cash Price	$848.40
Rate for Payer: Hawaii Western Management Group Commercial	$989.80
Rate for Payer: Health Management Network Commercial	$1,201.90
Rate for Payer: MDX Hawaii PPO	$1,371.58
Rate for Payer: University Health Alliance Commercial	$791.84

Know your out-of-pocket cost for care.

All Charges