Hilo Benioff Medical Center

All Charges

Charge

Type

Setting

Price

INTESTINAL OBSTRUCTION

Facility

$3,357.92

Service Code	APR-DRG 2472
Min. Negotiated Rate	$3,357.92
Max. Negotiated Rate	$3,357.92
Rate for Payer: AlohaCare Medicaid	$3,357.92
Rate for Payer: Hawaii Medical Service Association ABD	$3,357.92
Rate for Payer: Hawaii Medical Service Association Non-ABD	$3,357.92
Rate for Payer: Kaiser Permanente Medicaid	$3,357.92
Rate for Payer: Ohana Health Plan Medicaid	$3,357.92
Rate for Payer: UnitedHealthcare Medicaid	$3,357.92

INTRACRANIAL HEMORRHAGE

Facility

$5,788.31

Service Code	APR-DRG 0443
Min. Negotiated Rate	$5,788.31
Max. Negotiated Rate	$5,788.31
Rate for Payer: AlohaCare Medicaid	$5,788.31
Rate for Payer: Hawaii Medical Service Association ABD	$5,788.31
Rate for Payer: Hawaii Medical Service Association Non-ABD	$5,788.31
Rate for Payer: Kaiser Permanente Medicaid	$5,788.31
Rate for Payer: Ohana Health Plan Medicaid	$5,788.31
Rate for Payer: UnitedHealthcare Medicaid	$5,788.31

INTRACRANIAL HEMORRHAGE

Facility

$4,692.48

Service Code	APR-DRG 0442
Min. Negotiated Rate	$4,692.48
Max. Negotiated Rate	$4,692.48
Rate for Payer: AlohaCare Medicaid	$4,692.48
Rate for Payer: Hawaii Medical Service Association ABD	$4,692.48
Rate for Payer: Hawaii Medical Service Association Non-ABD	$4,692.48
Rate for Payer: Kaiser Permanente Medicaid	$4,692.48
Rate for Payer: Ohana Health Plan Medicaid	$4,692.48
Rate for Payer: UnitedHealthcare Medicaid	$4,692.48

INTRACRANIAL HEMORRHAGE

Facility

$7,397.47

Service Code	APR-DRG 0444
Min. Negotiated Rate	$7,397.47
Max. Negotiated Rate	$7,397.47
Rate for Payer: AlohaCare Medicaid	$7,397.47
Rate for Payer: Hawaii Medical Service Association ABD	$7,397.47
Rate for Payer: Hawaii Medical Service Association Non-ABD	$7,397.47
Rate for Payer: Kaiser Permanente Medicaid	$7,397.47
Rate for Payer: Ohana Health Plan Medicaid	$7,397.47
Rate for Payer: UnitedHealthcare Medicaid	$7,397.47

INTRACRANIAL HEMORRHAGE

Facility

$3,588.18

Service Code	APR-DRG 0441
Min. Negotiated Rate	$3,588.18
Max. Negotiated Rate	$3,588.18
Rate for Payer: AlohaCare Medicaid	$3,588.18
Rate for Payer: Hawaii Medical Service Association ABD	$3,588.18
Rate for Payer: Hawaii Medical Service Association Non-ABD	$3,588.18
Rate for Payer: Kaiser Permanente Medicaid	$3,588.18
Rate for Payer: Ohana Health Plan Medicaid	$3,588.18
Rate for Payer: UnitedHealthcare Medicaid	$3,588.18

INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION WITH CC OR TPA IN 24 HOURS

Facility

$35,234.23

Service Code	MSDRG 065
Min. Negotiated Rate	$11,491.40
Max. Negotiated Rate	$35,234.23
Rate for Payer: AlohaCare Medicare	$11,491.40
Rate for Payer: Devoted Health Medicare	$12,640.54
Rate for Payer: Hawaii Medical Service Association Commercial	$35,234.23
Rate for Payer: Hawaii Medical Service Association Medicare	$11,491.40
Rate for Payer: Humana Medicare	$11,491.40
Rate for Payer: Kaiser Permanente Commercial	$17,427.67
Rate for Payer: Kaiser Permanente Medicare	$11,491.40
Rate for Payer: Ohana Health Plan Medicare	$11,491.40
Rate for Payer: UnitedHealthcare Medicare	$11,491.40

INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION WITH MCC

Facility

$35,234.23

Service Code	MSDRG 064
Min. Negotiated Rate	$22,873.63
Max. Negotiated Rate	$35,234.23
Rate for Payer: AlohaCare Medicare	$22,873.63
Rate for Payer: Devoted Health Medicare	$25,160.99
Rate for Payer: Hawaii Medical Service Association Commercial	$35,234.23
Rate for Payer: Hawaii Medical Service Association Medicare	$22,873.63
Rate for Payer: Humana Medicare	$22,873.63
Rate for Payer: Kaiser Permanente Commercial	$34,689.75
Rate for Payer: Kaiser Permanente Medicare	$22,873.63
Rate for Payer: Ohana Health Plan Medicare	$22,873.63
Rate for Payer: UnitedHealthcare Medicare	$22,873.63

INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION WITHOUT CC/MCC

Facility

$35,234.23

Service Code	MSDRG 066
Min. Negotiated Rate	$7,784.54
Max. Negotiated Rate	$35,234.23
Rate for Payer: AlohaCare Medicare	$7,784.54
Rate for Payer: Devoted Health Medicare	$8,562.99
Rate for Payer: Hawaii Medical Service Association Commercial	$35,234.23
Rate for Payer: Hawaii Medical Service Association Medicare	$7,784.54
Rate for Payer: Humana Medicare	$7,784.54
Rate for Payer: Kaiser Permanente Commercial	$11,805.90
Rate for Payer: Kaiser Permanente Medicare	$7,784.54
Rate for Payer: Ohana Health Plan Medicare	$7,784.54
Rate for Payer: UnitedHealthcare Medicare	$7,784.54

INTRACRANIAL VASCULAR PROCEDURES WITH PRINCIPAL DIAGNOSIS HEMORRHAGE WITH CC

Facility

$251,128.83

Service Code	MSDRG 021
Min. Negotiated Rate	$10,400.00
Max. Negotiated Rate	$251,128.83
Rate for Payer: AlohaCare Medicare	$60,213.03
Rate for Payer: Devoted Health Medicare	$66,234.33
Rate for Payer: Hawaii Medical Service Association Commercial	$251,128.83
Rate for Payer: Hawaii Medical Service Association Medicare	$60,213.03
Rate for Payer: Humana Medicare	$60,213.03
Rate for Payer: Kaiser Permanente Commercial	$91,318.05
Rate for Payer: Kaiser Permanente Medicare	$60,213.03
Rate for Payer: Ohana Health Plan Medicare	$60,213.03
Rate for Payer: UnitedHealthcare Medicare	$60,213.03
Rate for Payer: University Health Alliance Commercial	$10,400.00

INTRACRANIAL VASCULAR PROCEDURES WITH PRINCIPAL DIAGNOSIS HEMORRHAGE WITH MCC

Facility

$251,128.83

Service Code	MSDRG 020
Min. Negotiated Rate	$10,400.00
Max. Negotiated Rate	$251,128.83
Rate for Payer: AlohaCare Medicare	$89,501.75
Rate for Payer: Devoted Health Medicare	$98,451.93
Rate for Payer: Hawaii Medical Service Association Commercial	$251,128.83
Rate for Payer: Hawaii Medical Service Association Medicare	$89,501.75
Rate for Payer: Humana Medicare	$89,501.75
Rate for Payer: Kaiser Permanente Commercial	$135,736.80
Rate for Payer: Kaiser Permanente Medicare	$89,501.75
Rate for Payer: Ohana Health Plan Medicare	$89,501.75
Rate for Payer: UnitedHealthcare Medicare	$89,501.75
Rate for Payer: University Health Alliance Commercial	$10,400.00

INTRACRANIAL VASCULAR PROCEDURES WITH PRINCIPAL DIAGNOSIS HEMORRHAGE WITHOUT CC/MCC

Facility

$251,128.83

Service Code	MSDRG 022
Min. Negotiated Rate	$10,400.00
Max. Negotiated Rate	$251,128.83
Rate for Payer: AlohaCare Medicare	$36,140.56
Rate for Payer: Devoted Health Medicare	$39,754.62
Rate for Payer: Hawaii Medical Service Association Commercial	$251,128.83
Rate for Payer: Hawaii Medical Service Association Medicare	$36,140.56
Rate for Payer: Humana Medicare	$36,140.56
Rate for Payer: Kaiser Permanente Commercial	$53,045.47
Rate for Payer: Kaiser Permanente Medicare	$36,140.56
Rate for Payer: Ohana Health Plan Medicare	$36,140.56
Rate for Payer: UnitedHealthcare Medicare	$36,140.56
Rate for Payer: University Health Alliance Commercial	$10,400.00

INTRAOCULAR PROCEDURES WITH CC/MCC

Facility

$31,189.72

Service Code	MSDRG 116
Min. Negotiated Rate	$10,400.00
Max. Negotiated Rate	$31,189.72
Rate for Payer: AlohaCare Medicare	$20,565.79
Rate for Payer: Devoted Health Medicare	$22,622.37
Rate for Payer: Hawaii Medical Service Association Commercial	$18,951.75
Rate for Payer: Hawaii Medical Service Association Medicare	$20,565.79
Rate for Payer: Humana Medicare	$20,565.79
Rate for Payer: Kaiser Permanente Commercial	$31,189.72
Rate for Payer: Kaiser Permanente Medicare	$20,565.79
Rate for Payer: Ohana Health Plan Medicare	$20,565.79
Rate for Payer: UnitedHealthcare Medicare	$20,565.79
Rate for Payer: University Health Alliance Commercial	$10,400.00

INTRAOCULAR PROCEDURES WITHOUT CC/MCC

Facility

$18,781.88

Service Code	MSDRG 117
Min. Negotiated Rate	$10,400.00
Max. Negotiated Rate	$18,781.88
Rate for Payer: AlohaCare Medicare	$12,339.93
Rate for Payer: Devoted Health Medicare	$13,573.92
Rate for Payer: Hawaii Medical Service Association Commercial	$18,781.88
Rate for Payer: Hawaii Medical Service Association Medicare	$12,339.93
Rate for Payer: Humana Medicare	$12,339.93
Rate for Payer: Kaiser Permanente Commercial	$18,714.53
Rate for Payer: Kaiser Permanente Medicare	$12,339.93
Rate for Payer: Ohana Health Plan Medicare	$12,339.93
Rate for Payer: UnitedHealthcare Medicare	$12,339.93
Rate for Payer: University Health Alliance Commercial	$10,400.00

INTRAOPERATIVE IDENTIFICATION (EG, MAPPING) OF SENTINEL LYMPH NODE(S) INCLUDES INJECTION OF NON-RADIOACTIVE DYE, WHEN PERFORMED (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)

Facility

$2,837.00

Service Code	CPT 38900
Hospital Revenue Code	360
Min. Negotiated Rate	$83.03
Max. Negotiated Rate	$2,837.00
Rate for Payer: Kaiser Permanente Medicaid	$2,837.00
Rate for Payer: UnitedHealthcare Medicaid	$83.03

INTRAUTERINE PRESSURE CATHETER

Facility

$232.00

Hospital Revenue Code	272
Min. Negotiated Rate	$197.20
Max. Negotiated Rate	$225.04
Rate for Payer: Cash Price	$139.20
Rate for Payer: Health Management Network Commercial	$197.20
Rate for Payer: MDX Hawaii PPO	$225.04

INTRAUTERINE PRESSURE CATHETER

Facility

$232.00

Hospital Revenue Code	272
Min. Negotiated Rate	$118.32
Max. Negotiated Rate	$225.04
Rate for Payer: Cash Price	$139.20
Rate for Payer: Hawaii Western Management Group Commercial	$220.40
Rate for Payer: Health Management Network Commercial	$197.20
Rate for Payer: Kaiser Permanente Commercial	$146.16
Rate for Payer: Kaiser Permanente Medicaid	$118.32
Rate for Payer: MDX Hawaii PPO	$225.04
Rate for Payer: University Health Alliance Commercial	$169.10

INTRO 10FR SAFESHEATH

Facility

$260.00

Service Code	HCPCS C1894
Hospital Revenue Code	272
Min. Negotiated Rate	$132.60
Max. Negotiated Rate	$252.20
Rate for Payer: Cash Price	$156.00
Rate for Payer: Hawaii Western Management Group Commercial	$247.00
Rate for Payer: Health Management Network Commercial	$221.00
Rate for Payer: Kaiser Permanente Commercial	$163.80
Rate for Payer: Kaiser Permanente Medicaid	$132.60
Rate for Payer: MDX Hawaii PPO	$252.20
Rate for Payer: University Health Alliance Commercial	$189.51

INTRO 10FR SAFESHEATH

Facility

$260.00

Service Code	HCPCS C1894
Hospital Revenue Code	272
Min. Negotiated Rate	$221.00
Max. Negotiated Rate	$252.20
Rate for Payer: Cash Price	$156.00
Rate for Payer: Health Management Network Commercial	$221.00
Rate for Payer: MDX Hawaii PPO	$252.20

INTRO 9FR SAFESHEATH

Facility

$260.00

Service Code	HCPCS C1894
Hospital Revenue Code	272
Min. Negotiated Rate	$221.00
Max. Negotiated Rate	$252.20
Rate for Payer: Cash Price	$156.00
Rate for Payer: Health Management Network Commercial	$221.00
Rate for Payer: MDX Hawaii PPO	$252.20

INTRO 9FR SAFESHEATH

Facility

$260.00

Service Code	HCPCS C1894
Hospital Revenue Code	272
Min. Negotiated Rate	$132.60
Max. Negotiated Rate	$252.20
Rate for Payer: Cash Price	$156.00
Rate for Payer: Hawaii Western Management Group Commercial	$247.00
Rate for Payer: Health Management Network Commercial	$221.00
Rate for Payer: Kaiser Permanente Commercial	$163.80
Rate for Payer: Kaiser Permanente Medicaid	$132.60
Rate for Payer: MDX Hawaii PPO	$252.20
Rate for Payer: University Health Alliance Commercial	$189.51

INTROD 4FR MICRO SET STIFF

Facility

$259.00

Service Code	HCPCS C1769
Hospital Revenue Code	272
Min. Negotiated Rate	$132.09
Max. Negotiated Rate	$251.23
Rate for Payer: Cash Price	$155.40
Rate for Payer: Hawaii Western Management Group Commercial	$246.05
Rate for Payer: Health Management Network Commercial	$220.15
Rate for Payer: Kaiser Permanente Commercial	$163.17
Rate for Payer: Kaiser Permanente Medicaid	$132.09
Rate for Payer: MDX Hawaii PPO	$251.23
Rate for Payer: University Health Alliance Commercial	$188.79

INTROD 4FR MICRO SET STIFF

Facility

$259.00

Service Code	HCPCS C1769
Hospital Revenue Code	272
Min. Negotiated Rate	$220.15
Max. Negotiated Rate	$251.23
Rate for Payer: Cash Price	$155.40
Rate for Payer: Health Management Network Commercial	$220.15
Rate for Payer: MDX Hawaii PPO	$251.23

INTROD 6FX45CM FLEXOR CHECKFLO

Facility

$310.00

Service Code	HCPCS C1894
Hospital Revenue Code	272
Min. Negotiated Rate	$158.10
Max. Negotiated Rate	$300.70
Rate for Payer: Cash Price	$186.00
Rate for Payer: Hawaii Western Management Group Commercial	$294.50
Rate for Payer: Health Management Network Commercial	$263.50
Rate for Payer: Kaiser Permanente Commercial	$195.30
Rate for Payer: Kaiser Permanente Medicaid	$158.10
Rate for Payer: MDX Hawaii PPO	$300.70
Rate for Payer: University Health Alliance Commercial	$225.96

INTROD 6FX45CM FLEXOR CHECKFLO

Facility

$310.00

Service Code	HCPCS C1894
Hospital Revenue Code	272
Min. Negotiated Rate	$263.50
Max. Negotiated Rate	$300.70
Rate for Payer: Cash Price	$186.00
Rate for Payer: Health Management Network Commercial	$263.50
Rate for Payer: MDX Hawaii PPO	$300.70

INTROD PERCUTANEOUS TRACH

Facility

$1,712.00

Service Code	HCPCS C1769
Hospital Revenue Code	272
Min. Negotiated Rate	$1,455.20
Max. Negotiated Rate	$1,660.64
Rate for Payer: Cash Price	$1,027.20
Rate for Payer: Health Management Network Commercial	$1,455.20
Rate for Payer: MDX Hawaii PPO	$1,660.64

Know your out-of-pocket cost for care.

All Charges