Hilo Benioff Medical Center

All Charges

Charge

Type

Setting

Price

LIVER TRANSPLANT &/OR INTESTINAL TRANSPLANT

Facility

$40,912.12

Service Code	APR-DRG 0011
Min. Negotiated Rate	$40,912.12
Max. Negotiated Rate	$40,912.12
Rate for Payer: AlohaCare Medicaid	$40,912.12
Rate for Payer: Hawaii Medical Service Association ABD	$40,912.12
Rate for Payer: Hawaii Medical Service Association Non-ABD	$40,912.12
Rate for Payer: Kaiser Permanente Medicaid	$40,912.12
Rate for Payer: Ohana Health Plan Medicaid	$40,912.12
Rate for Payer: UnitedHealthcare Medicaid	$40,912.12

LIVER TRANSPLANT &/OR INTESTINAL TRANSPLANT

Facility

$41,192.60

Service Code	APR-DRG 0012
Min. Negotiated Rate	$41,192.60
Max. Negotiated Rate	$41,192.60
Rate for Payer: AlohaCare Medicaid	$41,192.60
Rate for Payer: Hawaii Medical Service Association ABD	$41,192.60
Rate for Payer: Hawaii Medical Service Association Non-ABD	$41,192.60
Rate for Payer: Kaiser Permanente Medicaid	$41,192.60
Rate for Payer: Ohana Health Plan Medicaid	$41,192.60
Rate for Payer: UnitedHealthcare Medicaid	$41,192.60

LIVER TRANSPLANT &/OR INTESTINAL TRANSPLANT

Facility

$82,638.28

Service Code	APR-DRG 0014
Min. Negotiated Rate	$82,638.28
Max. Negotiated Rate	$82,638.28
Rate for Payer: AlohaCare Medicaid	$82,638.28
Rate for Payer: Hawaii Medical Service Association ABD	$82,638.28
Rate for Payer: Hawaii Medical Service Association Non-ABD	$82,638.28
Rate for Payer: Kaiser Permanente Medicaid	$82,638.28
Rate for Payer: Ohana Health Plan Medicaid	$82,638.28
Rate for Payer: UnitedHealthcare Medicaid	$82,638.28

LIVER TRANSPLANT &/OR INTESTINAL TRANSPLANT

Facility

$49,918.76

Service Code	APR-DRG 0013
Min. Negotiated Rate	$49,918.76
Max. Negotiated Rate	$49,918.76
Rate for Payer: AlohaCare Medicaid	$49,918.76
Rate for Payer: Hawaii Medical Service Association ABD	$49,918.76
Rate for Payer: Hawaii Medical Service Association Non-ABD	$49,918.76
Rate for Payer: Kaiser Permanente Medicaid	$49,918.76
Rate for Payer: Ohana Health Plan Medicaid	$49,918.76
Rate for Payer: UnitedHealthcare Medicaid	$49,918.76

LIVER TRANSPLANT WITH MCC OR INTESTINAL TRANSPLANT

Facility

$367,144.58

Service Code	MSDRG 005
Min. Negotiated Rate	$10,400.00
Max. Negotiated Rate	$367,144.58
Rate for Payer: AlohaCare Medicare	$117,274.26
Rate for Payer: Devoted Health Medicare	$129,001.69
Rate for Payer: Hawaii Medical Service Association Commercial	$367,144.58
Rate for Payer: Hawaii Medical Service Association Medicare	$117,274.26
Rate for Payer: Kaiser Permanente Commercial	$177,856.12
Rate for Payer: Kaiser Permanente Medicare	$117,274.26
Rate for Payer: Ohana Health Plan Medicare	$117,274.26
Rate for Payer: UnitedHealthcare Medicare	$117,274.26
Rate for Payer: University Health Alliance Commercial	$10,400.00

LIVER TRANSPLANT WITHOUT MCC

Facility

$367,144.58

Service Code	MSDRG 006
Min. Negotiated Rate	$10,400.00
Max. Negotiated Rate	$367,144.58
Rate for Payer: AlohaCare Medicare	$52,742.42
Rate for Payer: Devoted Health Medicare	$58,016.66
Rate for Payer: Hawaii Medical Service Association Commercial	$367,144.58
Rate for Payer: Hawaii Medical Service Association Medicare	$52,742.42
Rate for Payer: Kaiser Permanente Commercial	$79,988.25
Rate for Payer: Kaiser Permanente Medicare	$52,742.42
Rate for Payer: Ohana Health Plan Medicare	$52,742.42
Rate for Payer: UnitedHealthcare Medicare	$52,742.42
Rate for Payer: University Health Alliance Commercial	$10,400.00

LOCAL EXCISION AND REMOVAL OF INTERNAL FIXATION DEVICES EXCEPT HIP AND FEMUR WITH CC

Facility

$36,399.00

Service Code	MSDRG 496
Min. Negotiated Rate	$20,518.01
Max. Negotiated Rate	$36,399.00
Rate for Payer: AlohaCare Medicare	$20,518.01
Rate for Payer: Devoted Health Medicare	$22,569.81
Rate for Payer: Hawaii Medical Service Association Commercial	$36,399.00
Rate for Payer: Hawaii Medical Service Association Medicare	$20,518.01
Rate for Payer: Humana Medicare	$20,518.01
Rate for Payer: Kaiser Permanente Commercial	$31,117.28
Rate for Payer: Kaiser Permanente Medicare	$20,518.01
Rate for Payer: Ohana Health Plan Medicare	$20,518.01
Rate for Payer: UnitedHealthcare Medicare	$20,518.01

LOCAL EXCISION AND REMOVAL OF INTERNAL FIXATION DEVICES EXCEPT HIP AND FEMUR WITH MCC

Facility

$62,543.32

Service Code	MSDRG 495
Min. Negotiated Rate	$39,189.59
Max. Negotiated Rate	$62,543.32
Rate for Payer: AlohaCare Medicare	$41,239.64
Rate for Payer: Devoted Health Medicare	$45,363.60
Rate for Payer: Hawaii Medical Service Association Commercial	$39,189.59
Rate for Payer: Hawaii Medical Service Association Medicare	$41,239.64
Rate for Payer: Humana Medicare	$41,239.64
Rate for Payer: Kaiser Permanente Commercial	$62,543.32
Rate for Payer: Kaiser Permanente Medicare	$41,239.64
Rate for Payer: Ohana Health Plan Medicare	$41,239.64
Rate for Payer: UnitedHealthcare Medicare	$41,239.64

LOCAL EXCISION AND REMOVAL OF INTERNAL FIXATION DEVICES EXCEPT HIP AND FEMUR WITHOUT CC/MCC

Facility

$25,260.91

Service Code	MSDRG 497
Min. Negotiated Rate	$13,743.52
Max. Negotiated Rate	$25,260.91
Rate for Payer: AlohaCare Medicare	$13,743.52
Rate for Payer: Devoted Health Medicare	$15,117.87
Rate for Payer: Hawaii Medical Service Association Commercial	$25,260.91
Rate for Payer: Hawaii Medical Service Association Medicare	$13,743.52
Rate for Payer: Humana Medicare	$13,743.52
Rate for Payer: Kaiser Permanente Commercial	$19,866.83
Rate for Payer: Kaiser Permanente Medicare	$13,743.52
Rate for Payer: Ohana Health Plan Medicare	$13,743.52
Rate for Payer: UnitedHealthcare Medicare	$13,743.52

LOCAL EXCISION AND REMOVAL OF INTERNAL FIXATION DEVICES OF HIP AND FEMUR WITH CC/MCC

Facility

$52,039.80

Service Code	MSDRG 498
Min. Negotiated Rate	$34,313.86
Max. Negotiated Rate	$52,039.80
Rate for Payer: AlohaCare Medicare	$34,313.86
Rate for Payer: Devoted Health Medicare	$37,745.25
Rate for Payer: Hawaii Medical Service Association Commercial	$43,994.26
Rate for Payer: Hawaii Medical Service Association Medicare	$34,313.86
Rate for Payer: Humana Medicare	$34,313.86
Rate for Payer: Kaiser Permanente Commercial	$52,039.80
Rate for Payer: Kaiser Permanente Medicare	$34,313.86
Rate for Payer: Ohana Health Plan Medicare	$34,313.86
Rate for Payer: UnitedHealthcare Medicare	$34,313.86

LOCAL EXCISION AND REMOVAL OF INTERNAL FIXATION DEVICES OF HIP AND FEMUR WITHOUT CC/MCC

Facility

$43,994.26

Service Code	MSDRG 499
Min. Negotiated Rate	$22,916.85
Max. Negotiated Rate	$43,994.26
Rate for Payer: AlohaCare Medicare	$22,916.85
Rate for Payer: Devoted Health Medicare	$25,208.53
Rate for Payer: Hawaii Medical Service Association Commercial	$43,994.26
Rate for Payer: Hawaii Medical Service Association Medicare	$22,916.85
Rate for Payer: Humana Medicare	$22,916.85
Rate for Payer: Kaiser Permanente Commercial	$34,755.30
Rate for Payer: Kaiser Permanente Medicare	$22,916.85
Rate for Payer: Ohana Health Plan Medicare	$22,916.85
Rate for Payer: UnitedHealthcare Medicare	$22,916.85

LOCKING PLATE 2.3MM 57-15340

Facility

$1,729.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$881.79
Max. Negotiated Rate	$1,677.13
Rate for Payer: Cash Price	$1,037.40
Rate for Payer: Hawaii Western Management Group Commercial	$1,210.30
Rate for Payer: Health Management Network Commercial	$1,469.65
Rate for Payer: Kaiser Permanente Commercial	$1,089.27
Rate for Payer: Kaiser Permanente Medicaid	$881.79
Rate for Payer: MDX Hawaii PPO	$1,677.13
Rate for Payer: University Health Alliance Commercial	$968.24

LOCKING PLATE 2.3MM 57-15340

Facility

$1,729.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$968.24
Max. Negotiated Rate	$1,677.13
Rate for Payer: Cash Price	$1,037.40
Rate for Payer: Hawaii Western Management Group Commercial	$1,210.30
Rate for Payer: Health Management Network Commercial	$1,469.65
Rate for Payer: MDX Hawaii PPO	$1,677.13
Rate for Payer: University Health Alliance Commercial	$968.24

LONG ARMED GUIDE ACCUCUT 19510

Facility

$469.00

Hospital Revenue Code	272
Min. Negotiated Rate	$239.19
Max. Negotiated Rate	$454.93
Rate for Payer: Cash Price	$281.40
Rate for Payer: Hawaii Western Management Group Commercial	$445.55
Rate for Payer: Health Management Network Commercial	$398.65
Rate for Payer: Kaiser Permanente Commercial	$295.47
Rate for Payer: Kaiser Permanente Medicaid	$239.19
Rate for Payer: MDX Hawaii PPO	$454.93
Rate for Payer: University Health Alliance Commercial	$341.85

LONG ARMED GUIDE ACCUCUT 19510

Facility

$469.00

Hospital Revenue Code	272
Min. Negotiated Rate	$398.65
Max. Negotiated Rate	$454.93
Rate for Payer: Cash Price	$281.40
Rate for Payer: Health Management Network Commercial	$398.65
Rate for Payer: MDX Hawaii PPO	$454.93

LOOP ELECTRODE 20MMX12MM

Facility

$94.00

Hospital Revenue Code	272
Min. Negotiated Rate	$47.94
Max. Negotiated Rate	$91.18
Rate for Payer: Cash Price	$56.40
Rate for Payer: Hawaii Western Management Group Commercial	$89.30
Rate for Payer: Health Management Network Commercial	$79.90
Rate for Payer: Kaiser Permanente Commercial	$59.22
Rate for Payer: Kaiser Permanente Medicaid	$47.94
Rate for Payer: MDX Hawaii PPO	$91.18
Rate for Payer: University Health Alliance Commercial	$68.52

LOOP ELECTRODE 20MMX12MM

Facility

$94.00

Hospital Revenue Code	272
Min. Negotiated Rate	$79.90
Max. Negotiated Rate	$91.18
Rate for Payer: Cash Price	$56.40
Rate for Payer: Health Management Network Commercial	$79.90
Rate for Payer: MDX Hawaii PPO	$91.18

LOOP PASSING XBRAID TT 1.4MM

Facility

$492.00

Hospital Revenue Code	272
Min. Negotiated Rate	$250.92
Max. Negotiated Rate	$477.24
Rate for Payer: Cash Price	$295.20
Rate for Payer: Hawaii Western Management Group Commercial	$467.40
Rate for Payer: Health Management Network Commercial	$418.20
Rate for Payer: Kaiser Permanente Commercial	$309.96
Rate for Payer: Kaiser Permanente Medicaid	$250.92
Rate for Payer: MDX Hawaii PPO	$477.24
Rate for Payer: University Health Alliance Commercial	$358.62

LOOP PASSING XBRAID TT 1.4MM

Facility

$492.00

Hospital Revenue Code	272
Min. Negotiated Rate	$418.20
Max. Negotiated Rate	$477.24
Rate for Payer: Cash Price	$295.20
Rate for Payer: Health Management Network Commercial	$418.20
Rate for Payer: MDX Hawaii PPO	$477.24

LOPERAMIDE 1 MG/7.5 ML ORAL LIQUID [173371]

Facility

$16.00

Service Code	NDC 00904683620
Hospital Revenue Code	250
Min. Negotiated Rate	$13.60
Max. Negotiated Rate	$15.52
Rate for Payer: Cash Price	$9.60
Rate for Payer: Health Management Network Commercial	$13.60
Rate for Payer: MDX Hawaii PPO	$15.52

LOPERAMIDE 1 MG/7.5 ML ORAL LIQUID [173371]

Facility

$16.00

Service Code	NDC 00904683620
Hospital Revenue Code	637
Min. Negotiated Rate	$8.16
Max. Negotiated Rate	$15.52
Rate for Payer: Cash Price	$9.60
Rate for Payer: Hawaii Western Management Group Commercial	$15.20
Rate for Payer: Health Management Network Commercial	$13.60
Rate for Payer: Kaiser Permanente Commercial	$10.08
Rate for Payer: Kaiser Permanente Medicaid	$8.16
Rate for Payer: MDX Hawaii PPO	$15.52
Rate for Payer: University Health Alliance Commercial	$11.66

LOPERAMIDE 2 MG CAPSULE [4560]

Facility

$4.00

Service Code	NDC 51079069020
Hospital Revenue Code	637
Min. Negotiated Rate	$2.04
Max. Negotiated Rate	$3.88
Rate for Payer: Cash Price	$2.40
Rate for Payer: Hawaii Western Management Group Commercial	$3.80
Rate for Payer: Health Management Network Commercial	$3.40
Rate for Payer: Kaiser Permanente Commercial	$2.52
Rate for Payer: Kaiser Permanente Medicaid	$2.04
Rate for Payer: MDX Hawaii PPO	$3.88
Rate for Payer: University Health Alliance Commercial	$2.92

LOPERAMIDE 2 MG CAPSULE [4560]

Facility

$4.00

Service Code	NDC 51079069020
Hospital Revenue Code	250
Min. Negotiated Rate	$3.40
Max. Negotiated Rate	$3.88
Rate for Payer: Cash Price	$2.40
Rate for Payer: Health Management Network Commercial	$3.40
Rate for Payer: MDX Hawaii PPO	$3.88

LOPERAMIDE 2 MG CAPSULE [4560]

Facility

$4.00

Service Code	NDC 51079069001
Hospital Revenue Code	250
Min. Negotiated Rate	$3.40
Max. Negotiated Rate	$3.88
Rate for Payer: Cash Price	$2.40
Rate for Payer: Health Management Network Commercial	$3.40
Rate for Payer: MDX Hawaii PPO	$3.88

LOPERAMIDE 2 MG CAPSULE [4560]

Facility

$4.00

Service Code	NDC 60687022901
Hospital Revenue Code	250
Min. Negotiated Rate	$3.40
Max. Negotiated Rate	$3.88
Rate for Payer: Cash Price	$2.40
Rate for Payer: Health Management Network Commercial	$3.40
Rate for Payer: MDX Hawaii PPO	$3.88

Know your out-of-pocket cost for care.

All Charges